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Home My WebLink About03-25-14 1505610140 REV-1500 EX (02-11)(FI) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number PO Box 280601 2 1 1 4 0 0 4 0 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 1 0 3 2 0 1 4 0 9 2 1 1 9 6 6 Decedent's Last Name Suffix Decedent's First Name MI P 0 T T E I G E R B R I A N R (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 WILLS FILL IN APPROPRIATE OVALS BELOW ❑X 1.Original Return 2.Supplemental Return 3.Remainder Return(Date of Death Prior to 12-13-82) 4.Limited Estate ❑ 4a. Future Interest Compromise(date of 5.Federal Estate Tax Return Required death after 12-12-82) QX 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 10.Spousal Poverty Credit(Date of Death 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 Telephone Number M U R R E L W A L T E R S I I I E S Q 7 1 6 9 -F—� 4 6 fa 0 rn t REMTO OF WILLMSE @&). S , Fn 70 a Fn Z fo � � First Line of Address r— >" r N n'c rn W A L T E R S 8 G A L L O W A Y P L L C °; , ono Second Line of Address C> C -n 3 5 4 E M A I N S T R E E T = w m` City r Post Office � DATE FILE0 Y State ZIP Code 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: murrel(MWaltersfaallOWaY.Com 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 all information of which preparer has any knowledge. SIGNATURE 0 PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS KEITH A POTTEIGE , 1624 TRINDLE RD CARLISLE PA 17015 SIGNATURE OF PRE!,R OTH H N REP ENTATIVE DAATE ADDRESS Y 7 M U R R E L R E S III, 54 E . MAIN ST MECHANICSBURG PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J 4/Y 1505610240 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: BRIAN R . POTTEIGER 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. 6 4 5 6 , 3 3 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . .. . .. 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested . .. . .. . 7. 8. Total Gross Assets(total Lines 1 through 7) . . . . .. . .. . .. . .. . . . . . .. . .. . . 8. 6 4 5 6 • 3 3 9. Funeral Expenses and Administrative Costs(Schedule H) .. . . . . . . . . . . . . . . . . 9. 4 6 9 6 . 1 4 10. Debts of Decedent, Mortgage Liabilities,and Liens Schedule I 10. 3 6 7 8 . 0 5 11. Total Deductions(total Lines 9 and 10) . .. . . . . . . .. . .. . .. . . . . . .. . . .. . .. 11. 8 3 7 4 . 1 9 12. Net Value of Estate(Line 8 minus Line 11) . . . .. . .. . .. . .. . .. . . .. . .. . . .. 12. - 1 9 1 7 . 8 6 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. - 1 9 1 7 . 8 6 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 _ 0 . 0 0 16, 0 . 0 0 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. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505610240 1505610240 J REV-1500 EX(FI) Page File Number Decedent's Complete Address: 21 14 0040 DECEDENTS NAME BRIAN R. POTTEIGER STREETADDRESS 67 FAIRFIELD STREET CITY STATE ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credils/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0.00 3. Interest 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. (3) Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. It Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 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 ...................................................................... ❑ ❑X b. retain the right to designate who shall use the property transferred or its income ............................... ❑ c. retain a reversionary interest ..................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ Q 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ ❑ 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?.................................................................................................. ❑ 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 p2 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. REV-1508 EXa(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: BRIAN R. POTTEIGER 21 14 0040 Include the proceeds of litigation and the date the proceeds were received by the estate. All propertyJointly 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 2,088.59 CHECKING 2. MEMBERS 1ST FEDERAL CREDIT UNION 260.74 SAVINGS 3. 2002 DODGE DURANGO 4,107.00 KELLEY BLUE BOOK-FAIR CONDITION TOTAL(Also enter on Line 5,Recapitulation) $ 6 456.33 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX-(08-13) pennsylvania SCHEDULE H DEPARTWENTOF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER BRIAN R. POTTEIGER 21 14 0040 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. EWING BROTHERS FUNERAL HOME,CARLISLE, PA 3,362.64 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions', 1. Name(s)of Personal Representative(s) KEITH A. POTTEIGER Street Address 1524 W.TRINDLE ROAD city CARLISLE state PA zip 17015 Year(s)Commission Paid: (RENOUNCED) 2, Attorney Fees: MURREL R.WALTERS, Ile 1,200.00 3. Family Exemption:(if decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City state ZIP Relationship of Claimant to Decedent 4. Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS 133.50 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. I TOTAL(Also enter on Line 9,Recapitulation) S 4,696.14 U move 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 BRIAN R. POTTEIGER 21 14 0040 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 194.19 CREDIT CARD 2. LOWE'S 109.25 CREDIT CARD 3. WALMART 184.55 CREDIT CARD 4. TARGET 510.63 CREDIT CARD 5. LIBERTY MEDICAL SUPPLY 26.88 MEDICAL 6. PINNACLE HEALTH CARDIOVASCULAR 2.55 MEDICAL 7 MEMBERS 1ST F.C.U. 2,650.00 PERSONAL LOAN JOINTLY WITH MARGARET POTTEIGER ONE HALF BALANCE OF$5300. TOTAL(Also enter on Line 10,Recapitulation) $ 3,678.05 If more space is needed, Insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES 114HERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: BRIAN R. POTTEIGER 21 14 0040 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 ountht spousal distnbutions and transfer sunder Sec.9118(a)(1.2).j 1. KEITH A. POTTEIGER Sibling 1524 W.TRINDLE ROAD CARLISLE, PA 17015 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE, 11. 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.