HomeMy WebLinkAbout05-13-14 _ _ _
� 150561�143
REV-1500 EX(02-71)
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania Counry Code Year File Number
Bureau of Individual Taxes �P�TMENTOFREVENUE
Po BOx.28oso� INHERITANCE TAX RETURN 21 13 0934
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
08 15 2013 10 27 1934
DecedenYs Last Name Suffix DecedenYs First Name MI
WERT JOHANNA E
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Sociai Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Retum � 2. Supplemental Return � 3. Remainder Retum(Date of Death
Priorto 12-13-82)
� 4. Limited Estate � 4a.Future Interest Compromise � 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
a 6 Decedent Died Testate � 7. (Ana�cr,eGOM81of Trust a�iving Tn,st � 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) PY )
� 9. Litigation Proceeds Received � ���be�tween12 31�J1 a dic(Da95�f Death � ��.Election to tax under Sec.9113(A)
T (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JESSICA FISHER GREENE ESQ 717 697 3223
,_,
REGISTER(�FjNILLS USE�ILY �p
.� -rr
�Q � C'�3
First Line of Address �`�.�'.- , � ` ��;
� �- . '---;
555 GETTYSBURG PIKE �'`�'_ � _ ��
�r.r=,� .
Second Line of Address �'�,'";f�, --� ;-' `-,
n�°,3 - _`,,. _ -`r1
STE C100 C>c=�� ' �,� `^ �
City or Post Office State ZIP Code DAT tt�ED • ��
MECHANICSBURG PA 17055 ��
CorrespondenYs e-mail address: jessicaCa)_kevstoneelderlaw.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 OF PERSON RESPONSIBIE FOR FI�,ING RETURN DATE
f /
� � a h�� _ 1';��,, Terri L. Kelly �� ��'
ADDRE S
37 Grevstone Road, Carlisle, PA 17013
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
���f�y,�� ���r.� Jessica F. Greene, Esq � � 'J�y
ADDR ,
555 Gettysburg Pike , Mechanicsburg, PA
Side 1
� 150561D143 1505610143 J
� 1505610243
REV-1500 EX
DecedenYs Social Security Number
DecedenYsName: Wert, Johanna E.
RECAPITULATION
1. Reai 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 8�Miscellaneous Personal Property(Schedule E)............... 5. 12 5, 7 72 . 2�
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous I�q Probate Property
(Schedule G) LJ Separate Billing Requested............ 7.
g. Total Gross Assets(total Lines 1 through 7)........................................................ g. 125, 772 .20
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 21, 9�� . �1
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 1,7 98 . 71
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 23, 698 . 72
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 102 , �73 . 48
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. 102 , �73 . 4 8
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 �5 O . 0�
(a)(1.2)X.00
16. Amount of Line 14 taxable 102 , 073 . 48 �s. 4 ,593 . 31
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. � . ��
18. Amount of Line 14 taxable
at collaterai rate X.15 � . 0� 18. 0 . �0
19. TAX DUE................................................................................................................ 19. 4 ,5 93 . 31
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
L 1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-13-0934
Decedent's Complete Address:
DECEDENT'S NAME
Wert,Johanna E.
STREET ADDRESS
335 Wesley Drive
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 4,593.31
2. Credits/Payments
A. Prior Payments 4,832.98
B. Discount 229.67
- Total Credits(A +g) (2) 5,062.65
3. Interest (3)
4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 469.34
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)
Make Check Pa able 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:.................................. ❑ �x
c. retain a reversionary interest;or............................................................................................................... ❑ �
d. receive the promise for Iife 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?.................................................................................................................... ❑ ❑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?.................................................................................................................. ❑ 0
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 retum 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 decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)J.
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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
INHERITANCETAXRETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Wert,Johanna E. 21-13-0934
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property join8yowned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Members First Federal Credit Union Checking 2,386.24
2 Members First Federal Credit Union Money Management Account 123,173.34
3 Members First Federal Credit Union Regular Savings 5.12
4 Personal Property in Apartment 100.00
5 Bethany Towers Rent Refund 31.00
6 Bethany Towers Rent Refund 64.09
7 Comcast cable bill refund 12.41
TOTAL(Also enter on Line 5, Recapitulation) 125,772.20
(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-1511 E7C+��0-09) gCHEDULE H
pennsylvania
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
RESIDENNDEC ENT URN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Wert,Johanna E. 21-13-0934
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
N MB
q, FUNERAL EXPENSES:
See continuation schedule(s)attached 9,272.84
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid Waived
2, Attorney's Fees Keystone Elder Law P.C. 12,000.00
3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zio
Relationship of Claimant to Decedent
4. Probate Fees 358.50
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 268.67
See continuation schedule(s)attached
TOTAL(Also enter on line 9,Recapitulation) 21,900.01
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
Wert,Johanna E. 21-13-0934
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex en nses
1 Ewing Brothers Funeral Home 8,947.84
2 Gingrich Memorials,additional engraving on stone 160.00
3 Gingrich Memorials,engraving on stone 165.00
H-A 9,272.84
Other Administrative Costs
4 Cumberland County Bar Journal Estate Notice Publication Fee 75.00
5 Deluxe Checks for Estate 14.75
6 Sentinel Estate Publication Fee 178.92
H-67 268.67
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Wert,Johanna E. 21-13-0934
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 Apria Healthcare 35.47
2 Apria Pharmacy Network 67,�g
3 Bethany Towers final month's rent 672.00
4 Comcast cable utility bill 10.69
5 Dr.George Branscum M.D.Medical Bill 77.61
6 Dunham�Dunham Medical Bill 33.31
7 Messiah Life Ways, Emergency Call System (07/01/13-07/31/13) 32.00
8 Messiah Life Ways,Final Bill 15.45
9 Millenium Pharmacy 245.94
10 Quantum Imaging 9.76
11 Sarah Todd Home-room and board,final bill 560.00
12 Verizon phone utility bill 41.15
13 Verizon phone utility final bill 11.29
14 Walnut Bottom Family Practice 27.94
15 Weis Pharmacy 18.32
TOTAL(Also enter on Line 70, Recapitulation) 1,798.71
(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-1573 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Wert,Johanna E. 21-13-0934
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT �ords) ($$$)
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
Terri L. Kelly Daughter 51,036.74
37 Greystone Road
Carlisle, PA 17013
Sandy L. Parks Daughter 51,036.74
69 Greystone Road
Carlisle, PA 17013
Total 102,073.48
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
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 II-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)