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HomeMy WebLinkAbout01-22-14 1505610101 REV-1500 rR OFFICIAL USE ONLY w PA Department of Revenue Pennsylvania Bureau of Individual Taxes County Code Year X_ File Number PO Box zso601 INHERITANCE TAX RETURN Harrisburg PA 17128-0601 RESIDENT DECEDENT Z ENTER DECEDENT INFORMATION BELOW 41, 1 '.,.. p. 4 7 ✓ Decedent's Last Name Suffix Decedent's First Name MI GLEME11T5 ® LLoyA (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name r Suffix Spouse's First Name MI GLOMENT S ® 9414 ,f/ C S Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1.Original Return O 2.Supplemental Return C=D 3. Remainder Return(date of death prior to 12-13-82) O '4. Limited Estate - O 4a.Future Interest Compromise(date of (=3 5. Federal Estate Tax Return Required death after 12-12-82) ®• 6.Decedent Died Testate O 7. Decedent Maintained a Living Trust D 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O it. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.0) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name - Daytime Telephone Number CHAkLES E SN / ELDS ! ! I 7 � 7 766, o oq 1 RE�T�OF WILL$USE d&YO min z --I � First line of address :;0 p t— Iv M rTi (' LO U EQ oQ D rZrn ry � ° v cn Pr 0 0 -o -n -n Second line of address ' ° n a 3 :C- 't n O T _ C7 .A City or Post Office State ZIP Code "BATE FILE r— O in Mj7FjA /4Al CSBuRG/ © i17o5�51k97j3Fj u, Correspondent's e-mall address: Ce3�fields j Comeazt. ne Under penalties of perjury,l declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief. it Is true,correct and complete.Declaregon of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN AT E OF PERSON RESPONSIBLE FOR FILING RET fP DATE ADDRESS K'R/}NCES L. CLEMEN%S 39 FeXAd/14 Sr . C2 rip,S le,� A# /70/S SIGNATURE 6�� DATE ADDRESS C//,f .S �, /rc2.os ( C/ouSer Rd., `l'IeC1ia/l�ds kr�, P/r< /7055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J 1505610105 J REV-1500 EX /f Decedent's Name: Lloyd W, Cle m en t5 RECAPITULATION n 1. Real Estate(Schedule A). ............. ... ....................... 1. �•�rY�! h _ I 2. Stocks and Bonds(Schedule B) ............ ........................... 2. -I-D ,j(��' 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. �• .p o 4. Mortgages and Notes Receivable(Schedule D)........................... 4. .I Q Q 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. - - -- 6. Jointly Owned Property(Schedule F) p Separate Billing Requested ....... 6. .'0 - 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. i o], 8. Total Gross Assets(total Lines 1 through 7)................ ............. 8. _ 8775= (z3 9. Funeral Expenses and Administrative Costs(Schedule H)............... .... 9. / /t( � ��• �. 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) ... ........... 10. , p O 11. Total Deductions(total Lines 9 and 10)..... ........ ......... ....... .... 11. _. III .:. � 12. Net Value of Estate(Line 8 minus Line 11) .. ......... ........ ........... 12. / 713 b Q IZA/i _ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which -- - - 1 an election to tax has not been-made(Schedule J) ..........:............. 13: - ' 00 14. Net Value Subject to Tax(Line 12 minus Line 13) .. .... ........ .......... 14. ( 27 -9J6 O •I � TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 �7 (a)(1.2)X.OD- l / 361O -:4 15. 16. Amount of Line 14 taxable } O D at lineal rate X.0 W 1, ��OHO 16. 17. Amount of Line 14 taxable at sibling rate X.12 » Q O 17.18. Amount of Line 14taxable iiu - Ay at collateral rate X.15 j 18. •. D 19. TAX DUE .... ............ ........... ..:............ ...I...; ... ..:.... 19. •OQ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT , - O r ' Side 2 1505610105 1505610105 REV-1560 EX,Page 3 Fite Number Decedent's Complete Address: DECEDENT'S NAME L toy rt( ik) G'rlE JeAto STREET ADDRESS - CITY STATE 21P {,,lt�`l i.'$fG f (•.Sf%YC�'��r.' /u�jo, .� 1�'�"g' 17D l.S Tax Payments and Credits: 1, Tax Due(Page 2,Line 19) 2. Credits/Payments A.Prior Payments ... B.Discount p Total Credits(A+B) (2) 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) Q 5. If Line 1 +Line 3 is greater then Line 2,enter the difference.This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;..............._.................................................................... ❑ 5 b. retain the right to designate who shall use the property transferred or its income;...........................-.............. ❑ K c. retain a reversionary interest;or.............................................-........................................................................... ❑ d. receive the promise for life of either payments,benefits or care?................_......._........................__............. ❑ IM 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?........................................................................................................._... ❑ [A 3. Did decedent own an'in trust for'or payable-upon-death bank account or security at his or her death?.............. 11 I� 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? .....................................................................................-................................. ® ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are stilt applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REVi5S9 EX•11 SI) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE RESIDENT EC RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF / ^ -}. FILE NUMBER Include the proceeds of litigabon and the date the proceeds were received by the estate.All property jointly-awned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. aoo2 5v/ Cber(3lbf 151ozer �-5 6sje. 00 a- ,Zoo3 6h1G `rrucK )&.3, X81. oD TOTAL(Also enter online 5,Recapitulation) $ 0 (It more space is needed,insert additional sheets of the same size) REV-1510 EX+ (08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVO$ TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER uoyd W. NemenTs 21-/1/- This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE ITEM INCLUDE THE NAME OF THE TRANSFEREE THEIR RELATIONSHIP TO DECEDENT AND NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF AGDDGaLE) VALUE 1. InF % /3ank, many i 7_'RA Arcmi n" v �9 9�fo 63 9 9"7';4P.63 /oo —0— Vo, D/f72207gRg parable >'� Aiunee L. elements, 1v Vv 4d TOTAL(Also enter on Line 7, Recapitulation) $ ga 9q, 63 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX,(10-06) _ SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT - ESTATE OF L loyal G/. Clc/ne4 f5 FILE NUMBER [7 Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: Auer Oftf0e hdn 4*d r&&V9eM1 vivo, 5/2 e. ADMINISTRATIVE COSTS: 1. Personal Representatives Commissions p r Nameof Personal Representative(s) _ FrA�,-e S, �• C�eraenr5 GJLY;Yee/ Street Address 39 �'D k&)2ll "N-- _ city ('Ar/a It-, State AA Zip Year(s)Commission Paid: ec LL / ,G� / 2. Attorney Fees LAIAY�6C F. �/1/B�e�S � (G77d,'1k1 W;117GA) . 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation) Claimant LJ ? I V6 cl Street Address City State Lic _- Relationship of Claimant to Decedent _ 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. �'il:v,� Fee r Re�,.sfer /�1;3/s js- no TOTAL(Also enter on line 9,Recapitulation) (If more space is needed,insert additional sheets of the same size) REV-1513 EX+ (11-08) - pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RENRN - RESIDENT DECEDENT ESTATE OF L10yW w. C/emen7s FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under - Sec.2116(a)(1.2).] 1 Fra hots L. C(emen*s w,'�„� /DD� 3r1 �XQi1na Dr P4 17o is (a /rN a as C'orreet Copy l+�•%/ tmr/ f/e a1fr�,dant (oa%B:/ are q-4,Aa /K1`G7�') ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBURONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,insert additional sheets of the same size. LAST WILL AND TESTAMENT OF LLOYD W. CLEMENTS I, LLOYD W. CLEMENTS, of the Township of Silver Spring, County of Cumberland and State of Pennsylvania, being of sound and dis- posing mind, memory and understanding, do make, publish and declare this my Last Will and Testament. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. I give, devise and bequeath all the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, to my wife, Frances L. Clements, absolutely and unconditionally. 3. In the event that my wife, Frances L. Clements, should prede- cease me or should she die at about the same time as I do, such as in an accident common to both of us, then in such event, I give and bequeath my entire estate, real, personal and mixed, and wheresoever situate , to my two children, to wit, Lloyd W. Clements, Jr. and Kathy L. Clements, share and share alike. LASTLY, I nominate, constitute and appoint my wife, Frances L. Clements, Executrix of this my Last Will and Testament, and in the event my said wife should predecease me or should she be un- willing or unable to serve in such capacity for any reason, then in such event, I-nominate, constitute and appoint my two children, to wit, Lloyd W. Clements, Jr. and Kathy L. Clements, Co-Executors of this my Last Will and Testament in her place and stead. -1- Q ° -uni w N a o p 0 ON o = o Q O N T O 00 U N = N CMO E V J z d C; N N( V O U) 0 _Y�j�.�,i o — 17 cli .0 /�/ N o z Q Z D LV n 'p p d E (Zv w ¢ ►- -i 3 Cl) U) D l IL m Qa w � OQ CE: Q =_ w p U O m U)IrU) p mw0 H . �t LL a: X U o f U) N N O rn M 1 C3 O O � O i ftl ti fL O M1 CHARLES E. SHIELDS, III ATTORNEY-AT-LAW 6 CLOUSER ROAD Corner of Trindle and Clouser Roads MECHANICSBURG,PA 17055 GEORGE M.HOUCK TELEPHONE (717) 766-0209 (1912-1991) FAX (717) 795-7473 January 21, 2014 Register of Wills Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Lloyd W.Clements No.21-14- Dear Register of Wills: Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Lloyd W. Clements Estate as well as Check No. 1601 in the amount of$15.00 for the filing fee. As we have not probated this Estate, I am also enclosing a death certificate. Thank you for your kind attention to this matter. Very truly yours, U.�-�/��� Charles E. Shields, III Attorney-At-Law x CES/mjj r rn cm-� Enclosures m z m = � 10 M rn M N � ca 3> N ;:0 c> d z . ;` -v -n -n C'> Z) n a r r m Y l