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HomeMy WebLinkAbout03-25-14 .J 1505610140 REVREV_1 500 EX (02-11)(FI) -1 OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 3 0 .7 9 8 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 7 0 5 2 0 1 3 0 2 1 8 1 9 3 2 Decedent's Last Name Suffix Decedent's First Name MI O ' B R I E N D 0 L 0 R E S T (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WITS FILL IN APPROPRIATE OVALS BELOW Q 1.Original Return El 2.Supplemental Return 3.Remainder Return(Date of Death Prior to 12-13-82) A.Limited Estate 4a.Future Interest Compromise(date of 5.Federal Estate Tax Return Required death after 12.12-82) © 6.Decedent Died Testate 7.Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) 9.Litigation Proceeds Received [j 10.Spousal Poverty Credit(Date of Death El 11.Election to Tax under Sec.9113(A) Between 12-31.91 and 1-1-95) (Attach Schedule O) CORRESPONDENT•THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Tele8one Numbef� M U R R E L W A L T E R S I I I E S Q 7 1 72609 7 :16r ' ro REGt - RTiF WILLS _ ONLY rn rhD rn r First Line of Address W A L T E R S & G A L L O W A Y , P L L { q � Second Line of Address r 5 4 E M A I N S T R E E T co City or Post Office State ZIP Code DATE FILED M E C H A N I C S B U R G P A 1 7 0 5 5 Correspondent's e-mail address: rinuf relaWalfersgallOWBV.cOfri Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, It is true,correct and complete.Declaration of preparer other than the personal representative Is based on Sit information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIbLE FOR FILING RETURN ,+• DAT E ../,I ADDRESS _AUSTIN O 'BRIEN, JR• , 202 ZfMMONS RD MECHANICSBURG PA 17055 SIGNATURE OF PREPARER O E H R RE f li/E DATE ADDRESS MURREL R. WA I 54�-E• MAIN ST MECHANICSBURG PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J 1505610240 REV-1500 EX(Fl) Decedent's Social Security Number Decedent's Name: DOLORES T . OrBRIEN RECAPITULATION 1. Real Estate(Schedule A) . . . . .. . . . . . . . . . . .. . .. . .. . .. . . . . .. . . . .. . . . .. 1. 2. Stocks and Bonds(Schedule B) . .. . .. . . . . .. . .. .. . . . . . .. . . . . . . . .. . .. . . 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . .. .. 3. 4. - Mortgages and Notes Receivable(Schedule D) . . . . .. . .. . . .. . .. .. .. . . ... . 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. . .. .. 5. 3 9 0 0 1 • 3 8 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . .. . .. 6. 7. Inter-Vivos Transfers&Miscellaneous N -Probate Property (Schedule G) Separate Billing Requested . . . . .. . 7. 8. Total Gross Assets(total Lines 1 through 7) . .. . .. . .. . . . . .. . .. . . .. . ... . 8. 3 9 0 0 1 • 3 8 9. Funeral Expenses and Administrative Costs(Schedule H) ... . .. . .. .. .. . .. .. 9. 9 7 1 1 . 1 5 10. Debts of Decedent,Mortgage Liabilities,and Liens Schedule 10. - 1 0 7 1 . 9 2 11. Total Deductions(total Lines 9 and 10) . .. . .. . .. . .. . . . . . .. . . . .. .. . .. .. 11. 1 0 7 8 3 . 0 7 12. Net Value of Estate(Line 8 minus Line 11) . . . . .. . .. . .. . . .. . . . .. .. . .. .. 12. .2 8 2 1 8 . 3 1 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . .. . . . . . .. . . . .. .. . .. .. 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) . .. . . .. . .. . .. .. .. . .. .. 14. .2 8 2 1 8 . 3 1 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)x.0 _ 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate X.045 2 8 2 1 8 . 3 1 16. 1 2 6 9 . 8 2 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE . .. . .. .. .. . .. . . . . .. . . . . .. . .. .. . . . . .. . . . . . . . .. .. .. . .. .. 19. 1 2 6 9 . 8 2 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505610240 1505610240 REV-1500 EX(Fl) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME DOLORES T. O'BRIEN STREET ADDRESS 335 WESLEY DRIVE, APT. 409 CITY STATE ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 1,269.82 2. Credits/Payments A.Prior Payments 1,200.00 B.Discount 60.00 Total Credits(A+B) (2) 1.260.00 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) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 9,82 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 ...................................................................... ❑ I] b. retain the right to designate who shall use the properly transferred or its income ............................... ❑ ❑ c. retain a reversionary interest ..................................................................................................... ❑ ❑x d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ ❑X 2. If death occurred after December 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ ❑X 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ ❑X 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. ❑ ❑X 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 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 still 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 f/2 P.S.§9116(a)(1)I. • 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. REV 1508 EX-(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: DOLORES T. O'BRIEN 21 13 0798 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MEMBERS 1ST FEDERAL CREDIT UNION 4,495.85 CHECKING &SAVINGS 2 MEMBERS 1ST FEDERAL CREDIT UNION 32,099.58 CD 3. BETHANY TOWERS 730.23 RENT REFUND - $185.00 SECURITY DEPOSIT REFUND - $532.23 4. ERIE INSURANCE COMPANY 40.00 RENTER'S INSURANCE REFUND 4. HOLY SPIRIT HOSPITAL 33.72 DEPOSIT REFUND 6. AUTOMOBILE 1,100.00 1997 BUICK CENTURY NET SALE PRICE 7. U.S.TREASURY 502.00 2013 INCOME TAX REFUND TOTAL(Also enter on Line 5,Recapitulation) $ 39 001.38 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(08-13) - pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND RESIDENT ED RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER DOLORES T. O'BRIEN 21 13 0798 Decedent's debts must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MALPEZZI FUNERAL HOME, MECHANICSBURG, PA 6,447.00 2. LUNCHEON MEAL 94.45 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) AUSTIN O'BRIEN.JR. 1,500.00 Street Address 202 SIMMONS ROAD City MECHANICSBURG State PA ZIP 17055 Year(s)Commission Paid: 2013 2, Attorney Fees: MURREL R. WALTERS, III, ESQUIRE 1,450.00 3. Family Exemption:(If decedent's address is not the same as claimants,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS 173.50 6 Accountant Fees, 6. Tax Return Preparer Fees: 7. TEMPORARY CHECKS 2.00 8. POSTAGE 9,20 9. DEPARTMENT OF MOTOR VEHICLES- REPLACE CAR TITLE 35.00 TOTAL(Also enter on Line 9,Recapitulation) $ 9,711.15 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES& LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER DOLORES T. O'BRIEN 21 13 0798 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. VISA 94.79 CREDIT CARD 2. PINNACLE HEALTH 25.00 MEDICAL 3. ORTHOPEDIC INSTITUTE 151.95 MEDICAL 4. HOLY SPIRIT HOSPITAL 375.00 MEDICAL 5. AMERICAN HOME PATIENT 158.34 MEDICAL-OXYGEN 6. HARRISBURG GASTROENTEROLOGY 144.84 MEDICAL 7. PER CAPITA TAX 36.00 8. ERIE INSURANCE 86.00 AUTO TOTAL(Also enter on Line 10,Recapitulation) $ 1 071.92 If more space is needed, insert additional sheets of the same size. REV-1513 EX-(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: DOLORES T. O'BRIEN 21 13 0798 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 outd 9 ht spousal distributions and transfers under Sec.916(a)(1.2).] 1. STEPHANIE HOWER Lineal 1750 HUNT GLEN DRIVE DAUPHIN, PA 17018 2. REGINA SCHNEIDER Lineal 124 TWIN HILLS ROAD,APT 14 DILLSBURG, PA 17019 3. REBECCA MORROW Lineal 819 MT.AIRY ROAD COLLEGEVILLE, PA 19426 4. SHANNON O'BRIEN Lineal 39 ADELIA STREET MIDDLETOWN, PA 17057 5. CHRISTOPHER O'BRIEN Lineal 1245 N. MARTIN ROAD JANESVILLE,WI 53546 6. JOSHUA SIEBEL Lineal 334 N. RANDALL STREET JANESVILLE,WI 53546 7. BRIAN SIEBEL Lineal 1812 RUGBY ROAD JANESVILLE,WI 53546 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 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent DOLORES T. O'BRIEN 21 13 0798 Decedent's Name Page 1 File Number Schedule J - Beneficiaries - 1 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustees OF ESTATE I TAXABLE DISTRIBUTIONS lindude outn'ght spousal distributions and transfers under Sec.9116(a)(1.2).J 8. IAN O'BRIEN Lineal 7125 SALEM PARK CIRCLE MECHANICSBURG, PA 17055 9. MACKENZIE O'BRIEN Lineal 202 SIMMONS ROAD MECHANICSBURG, PA 17055 10. KENDRA O'BRIEN Lineal 202 SIMMONS ROAD MECHANICSBURG, PA 17055 11. STEVEN WHITE Lineal 897 FM 21 PITTSBURGH,TX 75686 12. RONALD WHITE Lineal 1726 LAFOY LANE LONGVIEW, TX 75604