HomeMy WebLinkAbout04-09-14 (2) J 1505610143
REV-1500 EX(02-11) �'
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPART"ENT OF REVENaE
PO BOX.280601 INHERITANCE TAX RETURN 21 13 1179
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
10 28 2013 07 23 1952
Decedent's Last Name Suffix Decedents First Name MI
UPDYRE ARLEEN E
(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
0 1. Original Return 2. Supplemental Return 3. Remainder Return(Date of Death
Prior to 12-13-82)
4. Limited Estate 4a.Future Interest Compromise 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
El 8 Decedent Died Testate 7 Dettcedenaiofta�nse a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) Copy
9. Litigation Proceeds Received 10.Spousal P2-3 vCredilt(Dale of Death 11.Election to tax under Sec.9113(A)
beM1Veen 12-31 91 and -1-95) (Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
DAVID J LENOX 717 2751, 7175
Vn� N
REGISTtR,l WILl 011 ,
M --�sr G? CS
First Line of Address _ m
n
8 TRISTAN DRIVE SUITE 3 z rn :;3 0
Second Line of Address p (.b
DAME FILED—
City or Post Office State ZIP Code
DILLSBURG PA 17019 D fV T
Correspondent's e-mail address: Iaw(FDdavidilenox comcastbiz net
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.
SIGNAT OF PERSON RESPO IBLE FOR (LING RETURN OATS
/�/�/y7 S�i� ADS/ Karen B. Rhoads
ADDRESS
533 S inho Rd. Yo k Haven PA 17370
SI6 ATURE 0 PR PAR 0TH HAN REPRESENTATWE /?A3E
David J. Lenox (/ /
ADDRESS /
8 Tristan Drive, Suite 3, Dillsburg, PA
L
1505610143 Side 1 1505610143
1505610243
REV-1500 EX
Decedent's Social Security Number
oecedefs Name. Updyke, Arleen E.
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&Notes Receivable(Schedule D)........................................................ 4.
5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 29, 320 . 86
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Ioq-Probate Property
(Schedule G) u Separate Billing Requested............ 7,
8, Total Gross Assets(total Lines t through 7)........................................................ 8. 29, 320 . 86
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 8 , 997 . 59
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 4 , 808 . 89
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 13 , 806. 48
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 15 , 514 . 38
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. 15 , 514 . 38
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 15 0 . 00
(a)(1.2)X.00
16. Amount of Line 14 taxable
at lineal rate X .045 15,514 . 38 16. 698 . 15
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................................................................................................................ 19. 698 . 15
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
L 1505610243 1505610243
REV-1500 EX Page 3 File Number 21-13-1179
Decedent's Complete Address:
DECEDENTS NAME
Updyke, Arleen E.
STREETADDRESS
8280 Lisburn Rd.,Apt. 410
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 698.15
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +B) (2) 0.00
3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 698. 15
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;or............................................................................................................... x
d. receive the promise for life of either payments,benefits or care?............................................................ x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ 0
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ Q
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?.................................................................................................................. ❑ 2
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 January 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[72 P.S.§9116(a)(1)).
• The fax 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.(11-10)
SCHEDULE E
Pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Updyke,Arleen E. 21-13-1179
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlybwoed with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 2006 Nissan Sentra: 3,467.50
2 Capital Blue Cross(refund): 194.10
3 Citizens Bank checking Account: 4,385.59
4 Comcast(refund): 45.19
5 Hartford IRA(payable to Estate of Arleen E. Updyke): 18,260.02
6 Interstate Realty Mgt.(apartment refunds): 775.04
7 Liberty Mutual Insurance(disability pay): 1,740.60
8 Misc. personal property: 250.00
9 Social Security Refund: 188.12
10 State Farm (car insurance refund): 14.70
TOTAL(Also enter on Line 5, Recapitulation) 29.320.86
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10)
REV-0511 EX-(1009)
Pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
RESIDENT DECEDENT ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Updyke, Arleen E. 21-13-1179
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s)attached 3,637.59
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid
2. Attorney's Fees David J. Lenox 1,200.00
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zio
Relationship of Claimant to Decedent
4. Probate Fees 128.50
5. Accountant's Fees
6. Tax Return Preparers Fees 158.00
7. Other Administrative Costs 3,873.50
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 8,997.59
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Updyke Arleen E. 21-13-1179
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Neill Funeral Home, Inc.: 3.637.59
H-A 3,637.59
Other Administrative Costs
2 Cumberland Law Journal(advertise estate), 75.00
3 Federal Income Tax paid on The Hartford Annuity: 1,826.00
4 James Holter, Esquire(consultation): 50.00
5 State Income Tax paid on The Hartford Annuity: 1,826.00
6 The News-Chronicle(advertise estate): 96.50
H-67 3,873.50
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12-08)
SCHEDULE I
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Updyke, Arleen E. 21-13-1179
Report debts incumed by the decedent prior to death that remained unpaid at the date of death,including unmimbumed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 AT&T(phone): 89.38
2 Bonnie K.Miller,Treasurer(tax): 16.50
3 Capital One(credit card): 281.06
4 Care Credit-GE Capital Retail Bank(credit card): 800.00
5 Citizens Bank(payoff): 2,815.93
6 Fashion Bug(credit card): 352.29
7 PP&L(electric): 84.50
8 Roaman's (credit card) 169.96
9 State Farm Insurance(car): 199.25
TOTAL(Also enter on Line 10, Recapitulation) 4,808.89
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 EX.(0110(
pennsylvania SCHEDULE J
DEPARTMENT Of REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
U d ke,Arleen E. 21-13-1179
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER pERSON(S}RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not I ist Trustee")j TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)1
Karen B.Rhoads Daughter 15,514.38
553 Steinhour Rd.
York Haven, PA 17370
Total 15,514.38
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART it-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
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CLAW OFFICE'ADOR°S3'„% ✓. -^"
GROUP .BENEFITS: " CLAIMS ""' - ' CHECK NUMBER "' CHECK GATE
P.O.' BOX' 1525 _Liberty 29700788 Y 12/10/13
DOVER, NH 03821 mutuiL E
1-800-210-0268 EXT. 38535 CHECK AMOUNT BLOCK NUMBER. }
•._-.,.
$***1740 60 000108:
CLAIM NU MBERi...cb,.. �,
0000436133
EMPLOYEE NAME POLICY NUMBER LOCATION NAME
UPDYKE,ARLEEN GF3-810-252761-01 HERSHEY MEDICAL CENTER
CUSTOMER NAME ANALYST ID
GEISINGER HEALTH SYSTEM N0000733
EXPLANATION OF BENEFIT (EOB) STATEMENT
PAYMENT DATE: 12/10/13 PAYMENT TYPE: LTD PAYEE: EMPLOYEE
PAYMENT PAYMENT GROSS ADJ. GROSS (FICA (F.I.T. (S.I.T. (OTHER NET
FROM THRU BENEFIT (OFFSETS) BENEFIT WITHHOLD.] WITHHOLD.) WITHHOLD.) DEDUCTIONS) PAYMENT
10/01/13 10/28/13 $ 1,740.60 $ .00 $ 1,740.60 5 .00 $ .00 5 .00 $ .00 $ 1,740.60
NET CHECK AMOUNT: $ 11740.60
OFFSET(S]-DETAIL - OTHER DEOUCTION(S)-DETAIL
PERIOD PERIOD PERIOD PERIOD
DESCRIPTION FROM THRU AMOUNT DESCRIPTION FROM THRU AMOUNT
i
MEMO: FINAL LTD BENEFIT PAYMENT
TAX REPORTING INFORMATION
FOR THIS PAYMENT ONLY E
THIS PAYMENT THIS PAYMENT
ADJUSTED GROSS BENEFIT: $ 1,740.60 OASDI WITHHOLDING: 5 .00 EMPLOYEE STATE: PA
BENEFIT TAX X: 0.00 MEDICARE WITHHOLDING: $ .00
FEDERAL WITHHOLDING: $ .00
OASDI TAXABLE WAGES: $ .00 STATE WITHHOLDING: $ .00
MEDICARE TAXABLE WAGES: $ .00 OTHER DEDUCTIONS: $ .00
FEDERAL TAXABLE WAGES: $ .00
FEDERAL (EXCLUDABLE) TAXABLE WAGES: $ 1,740.60 NET PAID: $ 1,740.60
STATE TAXABLE WAGES: 5 .00
PLEASE T IS O ty T DESIGNED TO CO PLLETE NDIIV DUAL TAX RETURNS AND SO ONLY.
SHOULD NOT BE USED FOR THAT PURPOSE.
CAREFULLY DETACH CHECK BEFORE DEPOSITING�RETAIN STATEMENT FOR YOUR RECORDS
Go paperless! Sign up for electronic document
delivery at www.thehartford.com/edelivery or call
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HARTFORD
01100095201 M80.405 "AUTO T4 0 2238 17370-9535 IACL 0-P00952 Date: December 9, 2013
11141'14hitlll'd'IrllPlll'ulrllllhlhirlllllll"I'lul'
ARLEEN UPDYKE Contract Number: 000000000/712426723
BENEFICIARY OF CATHERINE WATKI Type of Contract: IRA
553 STEINHOUR RD
YORK HAVEN PA 17370-9535
Owner Name: Arleen Updyke
Annuitant Name: Arleen Updyke
Your Director Select Outlook variable annuity financial
confirmation
The total value of your annuity on December 9, 2013 is $0.00
Full Surrender.- Death Proceeds
Trade Date: December 9, 2013
Unit
Investment Choice(s) Units Value Amount
Htfd Div&Grwth HLS -2,392.186 2:156669 -$5,159.15
Htfd Gbl Grwth HLS -311366 1.087616 -$338.65
Htfd HiYield HLS -364.370 1.989815 -$725.03
Htfd MidCap Val HLS -338.366 2.493494 -$843.71
Htfd Small Co HLS -328.266 2.686002 -$881.72
Htfd Ttl Return Bond HLS -1,977.985 1.774715 -$3,51036
Htfd US Gov Sec HLS -3,181.981 1.173519 -$3,734.12
WFargoAdvVT Intl Eqty -243.496 1923338 -$468.33
WFargoAdvVT Omega Grwth 1,559.049 1.667007 42,598.95
PAGE I OF 3
0110009520000001.0001606--1312101AC000253
Details of your surrender
Your net surrender will be distributed separately.
Gross Surrender Amount $18,260.02
Withholding
Federal Income Tax -$1,826.00
PA State Income Tax -$1,826.00
Net Surrender Amount $14,608.02
The Taxable Amount for this surrender is $18,260.02
The Taxable Amount provided is for it formational proposes only. In the case of an I.R.C. section 1035
exchange, Direct Transfer, or Direct Rollover, Hartford Life will not report the Taxable Amount
provided as taxable to the IRS. For custodian accounts, the Taxable Amount provided may be different
than the taxable amount determined and reported to the IRS by the custodian. Hartford Life recommends
consulting with a qualified tax advisor regarding the tax consequences of your transaction.
If federal taxes are withheld, state tax withholding may be applicable for certain states based on the
owner's state of residence. Please contact your tax advisor for questions on tax withholding.
Payee Information
Payee Name: Estate of A Updyke
This confirmation should be retained with your Contract. Please contact us if your address
changes.
Please promptly report any inaccuracy or discrepancy in your account to us and your brokerage
firm. Any oral communications should be re-confirmed in writing to further protect your rights,
including rights under the Securities Investor Protection Corporation (SIPC).
Under the terms of the Contract, if the contract value falls below the required minimum as the
result of a partial surrender, we will close your Contract and return to you any surrender value.
Reinstatements are not allowed.
We are issuing this confirmation statement on behalf of the selling broker-dealer. Hartford Life
and Annuity Innsnrance Company - Issuer; Hartford Securities Distribution Company, Inc. -
Principal Underwriter.
712426723 PAGE 2 OF 3
m i nnnaso.nnnnnn vnnn 1 era..i 0 v t OIAC.00n 953
OFFICIAL CHECK
j� 500790922-�
Citizens Bank x60
Q November 06 2013
I **** $4,385.59 *WW* DOLLARS c
C
+ * Estate of Arleen E. Updyke
MEMO: NON-NEGOTIABLE
C
' PAYMENT
OF
' SAVE THIS RECORD • '
This Official Check may not be rcPl, for 90 dnyI after the issue dnie if lost or stolen.:
WE CANNOT GIVE INFORMATION OR SEARCH RECORDS UNLESS THIS COPY IS PRESENTED '
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