HomeMy WebLinkAbout03-30-05
REV-jSOO EX i' (6-00j
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128.{)601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENrs NAME (LAST, FIRST, AND MIDDLE INITIAL)
MELLOTT ELIZABETH B.
DAlE OF DEATH {MM-DO-Year}
DATE OF BIRTH {MM-OO-Year)
~ 1. Original Return
o 4. Limited Estate
lXl 6. Decedent Died Testate (AllachcopyofWll)
o 9. Litigation Proceeds Rece~ed
o 2. Supplemental Return
o 4a. Future Interest Compromise ldale o/death after 12-12-82)
o 7. Decedent Maintained a Living Trust (AlIa::hcopyofTrusO
o 10. Spousal Poverty Credit (date of death betfien 12-31-91 and 1-1-95)
OFFICIAL USE ONLY
FILE NUMBER
2 L-.Q.2_QQl.9...d.
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
1 62- 2 2 - 1 454
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (dateofdeathpl'iorlo12-1:J..82)
o 5. Federal Estate Tax Return Required
fL 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Altach Sch 0)
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02/22/2004 11/27/1926
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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COMPLETE MAILING ADDRESS
3211 North Front Street
NAME
David H. Martineau Es uire
FIRM NAME (I! APJlIic"""l
Metz er Wickersham Knauss & Erb P.C.
TELEPHONE NUMBER
717 238-8187
Harrisbur
P.O. Box 5300
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (SeIledule B) (2)
3. Closely Held Corporation, Partnership or Sole.Proprietorshlp (3)
4. Mortgages & Notes Receivable (SeIledule D) (4)
5. Cash, Bank Deposits & Miscellaneous PelSOnaI Property (5)
(Schedule E)
6. Jointly OWned PlOperty (Schedule F) (6)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Admin~trative Cos~ (Schedule H) (9)
10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject!o lax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of line 14 taxable at the spousal tax
rate. ollranslers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of line 14 taxable at sibling rate
18. Amount of line 14 taxable at collateral rate
19. Tax Due
X_(15)
X _(16)
X .12 (17)
X .15 (18)
(19)
>> BESIIRETO'
~-9~S"()N.REYER
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
IJEA/WiRECHE
20. 0
PA 17110-0300
OFFICIAL USE ONLY
1 ,299.48
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0.00
(8)
1 ,299.48
6,021.48
2,661.86
(11)
(12)
(13)
8,683.34
-7,383.86
(14)
-7,383.86
Decedent's omPlete ress:
STREET ADDRESS
107 Marco Circle
CllY I STATE I ZIP
Shippensburg PA 17257
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Add
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Totai Credits (A + B + C) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check 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: ........................................................................... 0 IRI
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 IRI
c. retain a reversionary interest; or .............."...................................................................................... 0 00
d. receive the promise for iife of either payments, benefits or care? ............................................................. 0 IRI
2. If death occurred after December 12, 1982. did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................. 0 IRI
3. Did decedent own an 'in trustfo( or payable upon death bank account or security at his or her death? ................. 0 IRI
4. Did decedenl own an Individual Rellrement Account. annuity. or ather non-probate property which
contains a beneficiary designation? ....................................................................................................... 0 IRI
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined this return, jncludin~ 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 alllnformalion of which preparer has any knowledge.
SI ERSON RESP FOR FILlN RETURN DAT
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1 5 Goodhart Road
ippensburQ
SIGNAV~:;~~~RESE~VE
ADDiltSS 3211 North Front Street, PO Box 5300
HarrisburQ
PA 17257
DATE
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PA 17110-0300
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For dates at death on or after July " 1994 and before January 1. 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
172 P.S. ~9116 (a) (1.1) (I)].
For dates of death on or after January " 1995, the lax rale imposed on Ihe nel value oftransfers to or for the use of the surviving spouse Is 0% 172 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 stii! applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July " 2000:
The tax rate imposed on the nel vaiue of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a naturai parent. an adoptive parent,
or a stepparent of the chiid is 0% 172 P.S. ~9116(a)(1.2)J.
The tax rate imposed on the net value of transfers to or for the use at the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) 172 P.S. ~9116(a)(I)J.
The lax raleimposed on the nel vaiue of transfers to orforthe use of the decedent's siblings is 12% 172 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"1502 EX + (6.98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MELLOTT ELIZABETH B.
All Teal property owned solely OT as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real nro..'" which i. iointi'l-owned with rinht of ,u!'I"OlShin must be dillclosed on Schedule F.
SCHEDULE A
REAL ESTATE
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 1, Recapll"'a';o") $
(If more space is needed. insert additional sheets of the same size)
REV..1503 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
MELLOTT ELIZABETH B
FilE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV..1504 EX + (6-98)
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COMMONWEALTH OF PENN$YL VANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF
MELLOTT ELIZABETH B.
FILE NUMBER
Schedule C-1 or C-2 (including all supporting infonnation) must be attached for each closely-held corporation/partnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting infonnation to be submitted for sole-proprietorships.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enteron line 3. Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1505 EX + (6-98)
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SCHEDULE C-1
CLOSEL Y.HELD CORPORATE
STOCK INFORMATION REPORT
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MELLOTT ELIZABETH B.
FILE NUMBER
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
1. Name of Corporation
Address
City
2. Federal Employer I.D. Number
3. Type of Business
State
Zip Code
ProductJService
4.
Preferred
$
$
Common
Provide all rights and restrictions pertaining to each class of stock.
5. Was the decedent employed by the Corporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Yes 0 No
If yes. Position Annual Salary $ Time Devoted to Business
6. WastheCorporationindebledlothedecedent?...................................... 0 Yes 0 No
If yes, provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? ............... 0 Yes 0 No
if yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
8. Did the decedent sell or transfer stock in this company within one year prior 10 death or wilhin two years
if the date of death was prior to 12-31-82?
DYes 0 No if yes, 0 Transfer 0 Sale NumberolShares
Transferee or Purchaser Consideration $ Date
Attach a separate sheet for additional transfers and/or sales.
9. Was there a written shareholder's agreement in effect at the time of the decedent's death? . . . . . . . . . . . . 0 Yes 0 No
If yes, provide a copy of the agreement.
10. Was the decedent's stock sold? ................................................. 0 Yes 0 No
If yes, provide a copy of the agreement of sale, etc.
11. Was the corporation dissolved or liquidated after the decedent's death ? ....................... 0 Yes 0 No
if yes, provide a breakdown of distributions received by the estate, including dales and amounts received.
12. Did the corporation have an interest in other corporations or partnerships? . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No
if yes, report the necessary information on a separate sheet, including a Schedule C-l or C-2 for each interest.
THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete copies of financial statements or Federal Corporate Income Tax retums (Form 1120) for the year of dealh and 4 preceding years.
C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent.
E. List of officers, their salaries, bonuses and any other benefits received from the corporation.
F. Statemenl 01 dividends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
(If more space is needed, insert additional sheets of1he same size)
REV~1506 EX + (9-00)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
ESTATE OF
MELLOTT ELIZABETH B.
FILE NUMBER
1. Name of Partnership
Address
Date Business Commenced
Business Reporting Year
City State
2. Federal Employer 1.0, Number
3. Type of Business Product/Service
4, Decedent was a 0 Generai 0 Limited partner. If decedent was a iimited partner. provide initial investment $
Zip Code
5,
A.
B.
C.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted lathe decedent? ................................0 Yes 0 No
If yes, provide amounl of indebtedness $
B. Was there life insurance payabie to the partnership upon the death oft he decedent? ........ 0 Yes 0 No
If yes, Cash Surrender Vaiue $ Nel proceeds payable $
Owner of the poiicy
9. Did the decedent seil or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior 10 12-31-82?
o Ves 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold
Transferee or Purchaser Consideration $ Date
Attach a separate sheet for additional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time of the decedent's death? . . . . . . . 0 Ves 0 No
If yes, provide a copy of Ihe agreement
11. Was the decedent's partnership interest sold? .................................. 0 Ves 0 No
if yes, provide a copy of the agreement of sale, etc.
12, Wasthepartnershipdissolvedoriiquidatedafterlhedecedent'sdeath?...,............ 0 Ves 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Waslhe decedent related to any of the partners? ...................,............ 0 Ves 0 No
If yes, explain
14. Did the partnership have an inlerestin other corporations or partnersh ips?................ 0 Ves 0 No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each inlerest.
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedent's partnership interest.
B. Complele copies of financial statements or Federal Partnership i\\Come Tax relurns (Form 1(65) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s, If real estate appraisals have
been secured, attach copies.
D. Any other information relating 10 the valuation of the decedent's partnership interest.
REV-1507 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
MELLOTT ELIZABETH B.
FILE NUMBER
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX... (6.98)
'*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MELLOTT ELIZABETH B
FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate.
All proporty jolntly-ownod with right of survivorship must be disclosed on Schedulo F.
ITEM
NUMBER
1.
DESCRIPTION
Orrstown Bank, PO Box 250, Shippensburg, PA 17257
Checking Account No. 526665
VALUE AT DATE
OF DEATH
1,299.48
TOTAL (Also enter on line 5, Recapitulation) $
(If more space IS needed, Insert additional sheets of the same size)
1 299.48
REV-1509 EX + (6-98)
*
SCHEDULE F
JOINTL Y.OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MELLOTT ELIZABETH B
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
FILE NUMBER
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
B
c
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY.HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, Insert additional sheets of the same size)
REV.1510 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MELLOTT ELIZABETH B.
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV.1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY
ITEM INClUDETHE~EDFTHETRANSFEREE.THEIRRELATlON5HIPTODECEDENTAND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH ACOPV OF THE DEEO FOR REAl ESTATE VALUE OF ASSET INTEREST VALUE
(IFAPPUCABLE)
1. 1968 Murlett Mobile Home - transferred to Rick Rhodes on 800.00 100. 800.00 0.00
January 8, 2004 - value bound upon sale price
2. 1992 Oldsmobile Cutlas Siera Sedan, 180,000 miles- 1,175.00 100. 1,175.00 0.00
transferred to Rick Rhodes on January 5, 2004
TOTAL (Also enter on line 7 Recapitulation) $ 0.00
(If more space is needed, insert additional sheets of the same size)
REV.1511 EX + (12-99)
*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MELLOTT ELIZABETH B.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
Debts of decedent must be reported on Schedule I.
FILE NUMBER
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Fogelsanger-Bricker Funeral Home, Inc. 5,696.48
B. ADMINISTRATIVE COSTS:
!. Personal Representative's Commissions
Name of Personal Representative (s)
Social Secunty Numbe~')/EIN Number of Personal RepresentaUve(,)
Street Address
City State Zip
Year(s) Commission Paid:
2. AUomey Feas Metzger, Wickersham, Knauss & Erb, P.C. (estimated) 300.00
3. Family Exemption: (If decedenfs address is not the same as c1aimanfs, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountanfs Fees
6. Tax Return Preparer's Fees
7. Fee to file PA Inheritance Tax Return 25.00
TOTAL (Also enter on line 9, Recapitulation) $ 6021.48
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (6-98)
*
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MELLOTT. ELIZABETH B.
FILE NUMBER
Include un reimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1. Shippensburg Health Care Center
VALUE AT DATE
OF DEATH
2,661.86
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
2661.86
REV'1513EX'<.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
"~II rlT 1:::1 '....A........"T"H R
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
1. TAXABLE DISTRIBUTIONS [indude OU~ht s~usal d~tribu1ions, and transfers under
See.gI16(a (1.)]
1.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
n. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
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, insert addnional sheets of the same size)
REV-1514 EX + (6-9B)
*
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on Rev.1500 Cover Sheet
FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MELLOTT ELIZABETH B
This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89,
actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Will 0 Intervivos Deed of Trust 0 Other
OLile or OTenn 01 Years
OLileor o Term 01 Years
OLile or OTenn 01 Years
1. Value of fund from which life estate is payable. .............................................. $
2. Actuarial factor per appropriate table. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interest table rate - D 31/2% D 6% D 10% D Variable Rate %
3. Value 01 life estate (Line 1 multiplied by Line 2) .......................................... $
OLileor o Term 01 Years
DLife or DTerm of Years
DLifeor DTermofYears
1. Value of fund from which annuity is payable. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $
2. Check appropriate block below and enter corresponding (number) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frequency 01 payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12)
o Quarterly(4) 0 Semi-annually (2) 0 Annually (1) OOther()
3. Amount 01 payout per period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
4. Aggregate annual payment, Line 2 multiplied by Line 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Annuity Factor (see instructions)
Interest table rate - D 31/2% D 6% D 10% D Variable Rate %
6. Adjustment Factor (see instructions~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period
payout is at end of period, calculation is ; Line 4 x Line 5 x Line 6 ............................ $
If using variable rate and period payout is at beginning of period, calculation is :
(Line 4 x Line 5 x Line 6) + Line.3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
NOTE The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through
G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15, 16 and 17.
(If more space is needed, insert additional sheets of the same size)
REV.1644 EX + (3-64) INHERITANCE TAX
'*
SCHEDULE'L'
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT OR INVASION
INHERITANCE TAX RETURN
RESIDENT DECEDENT OF TRUST PRINCIPAL FILE NUMBER
I. Estate of ..", I nTT '" '7 """TH R
(last Name) (First Name) (Middle Initial)
This schedule is appropriate only for estates of decedents dying an or before December 12, 1982.
This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisi
of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal.
II. Remainder Prepayment:
A. Election to prepay filed with the Register of Wills on
(attach copy of election) (Date)
B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income
or Annuitant(s) of election or annuity is payable
C. Assets: Complete Schedule L- 1
1. Reo I Estate $
2. Stocks and Bonds $
3. Closely Held Stock/Partnership $
4. Mortgages and Notes $
5. Cash/Misc. Personal Properly $
6. Total from Schedule L-1 $
D. Credits: Complete Schedule L-2
1. Unpaid Liabilities $
2. Unpaid Bequests $
3. Value of Unincludable Assets $
4. Total from Schedule L-2 $
E. Total value of trust assets (Line C-6 minus Line 0-4) $
F. Remainder factor (see Table I or Table II in Instruction Booklet)
G. Taxable Remainder value (Line E x Line F) $
(Also enter on Line 7, Recapitulation)
III. Invasion of Corpus:
A. Invasion of corpus
(Month, Day, Year)
B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income
or Annuitant(s) corpus consumed or annuity is payable
C. Corpus consumed $
D. Remainder factor (see Table I or Table" in Instruction booklet) $
E. Taxable value of corpus consumed (Line C x Line 0) $
(Also enter on Line 7, Recapitulation)
ons
REV_1645 EX + (3-84) INHERITANCE TAX
SCHEDULE L-l
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT -ASSETS- FILE NUMBER
I. Estelte of MELLOTT ELl7ABETH B.
{Las1 Name) IF\n1 Name) {Middle Initial)
II. Item No. Oeser; ption Vellue
A. Real Estate (please describe)
Total value of real estate $
(include an Section II, Line C-' on Schedule Ll
B. Stocks and Bonds (please list)
Total value of stocks and bonds $
!include on Section II, Line C-2 on Schedule L)
C. Closely Held Stock/Partnership (attach Schedule C-' and/or C-2)
(please list)
Total value of Closely Held/Partnership $
!include on Section II, Line C-3 on Schedule Ll
D. Mortgages and Notes (please list)
Total value of Mortgages and Notes $
(include on Section II, Line C-4 on Schedule L\
E. Cash and Miscellaneous Personal Property (please list)
Total value of Cash/Misc. Pers. Property $
(include on Section II Line C-5 on Schedule Ll
III. TOTAL IAlso enter on Section II, Line C-6 on Schedule L) $
(If more space is needed, attach additional 8V2 x 11 sheets.)
REV.1646 EX + (3-84) INHERITANCE TAX
'* SCHEDULE L-2
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN -CREDITS- FILE NUMBER
RESIDENT DECEDENT
I. Estate of "'" I ()TT '" 17 IR
(Last Name) {First Name) (Middle Initial)
II. Item No. Description Amount
A. Unpaid Liabilities Claimed against Original Estate, and payable from assets
reported on Schedule L- 1 (please list)
Total unpaid liabilities $
(include on Section II, Line D-l on Schedule II
B. Unpaid Bequests payable Iram assets reported an Schedule L-l (please list)
Total unpaid bequests $
(include on Section II, Line D-2 on Schedule Ll
C. Value 01 assets reported on Schedule L-l (other than unpaid bequests listed under
"B" above) that are not included lor tax purposes or that do not lorm a part
01 the trust.
Computation as follows:
Total unincludable assets $
(include on Section II, Line D-3 on Schedule L)
III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $
(If more space is needed, attach additional 81/2 x 11 sheets.)
REV.t647EX>*
SCHEDULE M
FUTURE INTEREST COMPROMISE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Check Box 4a on Rev.1500 Cover Sheet
FILE NUMBER
ESTATE OF
MELLOTT ELIZABETH B.
This Schedule is appropriate only for estates of decedents dying after December 12,1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in
possession and enjoyment cannot be established with certainty,
Indicate below the type of instrument which created the future interest and attach a copy to the tax return,
o Will 0 Trust 0 Other
I. Beneficiaries
NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
1,
2,
3,
4,
5.
n. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within
9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse
exercises such withdrawal right.
o Unlimited right of withdrawal o Limited right of withdrawal
ID. Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1, Amount of Future Interest "" ".,..".",.".,..,.,..,.", ",.",."..,.".$
2, Value of Line 1 exempt from tax as amount passing to charities, etc,
(also include as part of total shown on Line 13 of Cover Sheet) , . , , . ,$
3, Value of Line 1 passing to spouse at appropriate tax rate
Check One 06%, 03%, 00% "..,.".,.".,,$
(also include as part of total shown on Line 15 of Cover Sheet)
4, Value of Line 1 taxable at lineal rate
Check One 06%, 04.5% ,."..",." "..,." ,,$
(aiso include as part of total shown on Line 16 of Cover Sheet)
5, Vaiue of Line 1 taxable at sibling rate (12%)
(also include as part of total shown on Line 17 of Cover Sheet) ,.",,$
6, Value of Line 1 taxable at collateral rate (15%)
(also include as part of total shown on Line 18 of Cover Sheet) "".,$
7, Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) "" "" ""."." ".$
(If more space is needed, insert additional sheets of the same size)
ROV-l648 EX (11-9_
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX DIVISION (AVAILABLE FOR DATES OF DEATH 01/01/92 to 12/31/94)
ESTATE OF I FILE NUMBER
MELLOTT ELIZABETH B. .
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet.
SCHEDULE N
SPOUSAL POVERTY CREDIT
PART I - CALCULATION OF GROSS ESTATE
PARTII - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies 01 Federal Individual Icome
Tax Return for decedent and spouse)
Income: ,. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19
a. Spouse ............................. la. 2a. 3a.
b. Decedent ......................... lb. 2b. 3b.
c. Joint ................................. lc. 2e. 3c.
d. Tax Exempt Income ......... ld. 2d. 3d.
e. Other Income not
listed above ..................... Ie. 2e. 3e.
I. Total................................. ]f. 21. 31.
1. Taxable Assets total from line 8 (cover sheet) ......................................................................................
2. Insurance Proceeds on Life of Decedent ..............................................................................................
3. Retirement Benefits ...... ........... ... ..... ... ... ........ ........... ... ... ................ ..... ... ........ .......... ... ...... ......... ... .... .....
4. Joint Assets with Spouse ........ '" ..... ... ........ ... ..... ...... ... ... ....... ......... ..... ... ... ..... ........... ........ ... ... ... ...........
5. PA Lottery Winnings. .............. ........ ..... ... ... ........... ... ......... ....... ................ ... ................ ............ ... ... .... .....
6a. Other Nontaxable Assets: List (Attach schedule if necessary)..
6a.
6b.
6e.
6d.
6. SUBTOTAL (Lines 6a, b, e, d) ...........................................................................................................,..
7. Total Gross Assets (Add lines Ilhru 6) ...............................................................................................
B. Total Actual Liabilities ........... ... ... ..... ..... ..... ... ........ ......... ....... ...... ........... ... ... ..... ..... ... ...... ............ .... ......
9. Net Value of Estate (Subtract line 8 from line 7) ...................................................................................
$OOOSTOTh tfDl thdlftftPrl
4. Average Joint Exemption Income Calculation
4a. Add Joint Exemption Income from above:
(11)
+ (21)
+ (31)
4b. Average Joint Exemption Income......... ... ........ ............... .... ...... ... .....,.. ... ..... ... ... ..... ..... ... ...... .... ... .... ....... ....
If line 4(b) is greater then $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part Ill.
1.
1 299.48
2.
3.
4.
6.
7.
1 299.48
8.
9.
1,299.48
=
(+3)
PART III - CALCULATION OF SPOUSAL POVERTY CREOIT FOR RESIDENT AND NONRESIDENT ESTATES
1. Insert amount of taxable transfers to spouse or $100,000, whichever is less .....................................
2. Multiply by credit percentage (see instructions) ....................................................................................
3. This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculaUon of total credits on line 18 of the cover sheet. ........................ ....................................
4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate ...... ............... ...................................................................
5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet ..........
,.
2.
3.
4.
5.
R"''''''''''''''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 0
ELECTION UNDER SEC. 9113(A)
SPOUSAL DISTRIBUTIONS
ESTATE OF FILE NUMBER
MELLOTT ELIZABETH B
Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act.
If the election applies to more than one trust or similar arrangement, a separate form must be fiied for each trust.
This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc,),
If a trust or similar arrangement meets the requirements of Section 9113(A), and:
a, The trust or similar arrangement is listed on Schedule 0, and
b, The value of the trust or similar arrangement is entered in whole pr in part as an asset on Schedule 0,
then the transferors personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or
similar property treated as a taxable transfer in this estate, If iess than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the
personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to
the amount of the trust or similar arranqement included as a taxable asset on Schedule 0, The denominator is eQuai to the total value of the trust or similar arranqement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's
survivin s use under a Section 9113 A trust or similar arran ement.
DESCRIPTION VALUE
Part A Total $
PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made,
DESCRIPTION VALUE
Part B Total
(If more space is needed, insert additional sheets of the same size)
---
.. LAST WILL AND TESTAMENT
I, ELI ZABETH B. MELLOTT, being of sound mind, memory and
understanding, do make, publish and declare this my Last will and
Testament, hereby revoking all prior wills and codicils made at any
time before by me.
FIRST: I direct that all my funeral expenses and just debts
be paid as soon as practical after my death.
SECOND: I direct that all my property be it real, mixed or
personal, wherever situate be sold and after payment of the
expenses set forth above, the remaining proceeds be divided equally
among my children, Donald E. Adams, Gary L. Rhoads and Rick D.
Rhoades, share and share alike, per "stirpes.
THIRD: I nominate, constitute and appoint, Rick D. Rhoades,
as the Executor of this my Last will and Testament.
IN WITNESS WHEREOF, I, ELIZABETH B. MELLOTT, to this my Last
will and Testament, set my hand and seal, this
I~ day of
August, 1994.
'1--~ L~~~)
Ehz fth . Me 1 t
Sworn to and SUbscribed, declared and
published !='y ELIZABETH B. MELLOTT, a~ \ ~ 0----=:)
her Last WJ.ll and Testament, and so ~
done in the presence of we the .
witnesses, who sign at her request, ~ ~.
and in her presence, and in the ~ /
presence of each other. ~~
./
,-uMU~~~I\L'.L'.t1 u.r .t'.tiNN:;;~L~~1:1:"";.;r.~~ ,,;,;,,~,,"",:"..,;;'<i'M~'
:SS
f
COUNTY OF CUMBERLAND
I, ELIZABETH B. MELLOTT, whose name is signed to the foregoing
instrument, having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instrument as my Last
will and Testament; and that I signed it willingly; and that I
signed it as my free and voluntary act for the purpose therein
expressed.
~.k'~/~ S0-</~~
E i eth B. Mellott
Sworn to and acknowledged, before me,
b ELIZABETH B. MELLOTT, the Testatrix,
n's \~ day o~ A gust, 1994.
NOTARIAL SEAl.
DAWN MARIE SHOOP. Notary pub~~
Sh' nsburg. cumberland CounlY.
M~mmlsslon Expires Feb, 5,1996
COMMONWEALTH OF PENNSYLVANIA:
:SS
COUNTY OF CUMBERLAND
We, H. Anthony Adams and Sharon Coleman Adams, the witnesses
whose names are signed to the foregoing instrument, being duly
qualified according to law, do depose and say that we saw the
Testatrix sign and execute the instrument as her Last will and
Testament; that she signed willingly and that ,she executed it as
her free and voluntary act for the purposes therein expressed; that
each of us in the hearing and sight of the Testatrix signed the
will as witnesses, and that to the best of our knowledge and the
Testatrix was at the time at least eighteen (18) or more years of
age and of sound mind and under no constraint or undue influence.
~ ~ - f20L -
HIAd~ ~
~Sharon Coleman Adams
Sworn to and SUbscribed before me by,
H. Anthony Adams and Sharon Coleman Adams,
the 'tnesses, this /;)...... day of August, 1994.
r----;ii:;'l"ARIAL SEAL
I Di,xn MARIE SHOOP. Notary Public
Is"'p,,,,"'Ob'''9' Cumberland CounlY. PA
Mf wnlmisslon Expires Feb, 5, 1996