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Home My WebLink About02-0444 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRIS8URG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT DIANNE L KOLLAS 850 KIEHL DRIVE LEMOYNE, PA 17043 nn_u_ fold ESTATE INFORMATION: SSN: 176-32-5009 FILE NUMBER: 2102-0444 DECEDENT NAME: BLAZETIC JOHN P DATE OF PAYMENT: 05/03/2002 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 08/03/2001 NO. CD 001147 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $15,202.61 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: DIANNE L KOLLAS CHECK# 5867 SEAL INITIALS: SK RECEIVED BY: REGISTER OF WILLS $15,202.61 MARY C. LEWIS REGISTER OF WILLS 1lE't<15IXIEXII43l .. .. (': './ . -- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPl 280601 HARRISBURG, PA 17128.(J601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY w ... z:::!5~ ufu woo :c"'-' u.... ~ I 7 -to J - J' FILE NUMBER _-.4... COUNTY COOE YEAR ~.dJ/.'L"-- NU_ ~ Z W C W (J W C DECEDENTS NAME (lASl FIRST, AND MIDDLE INITIAL) JOHN P. BLAZETIC SOCIAL SECURITY NUMBER 176-32-5009 : DATE OF BIRTH (MM-llD-YEAR) ! 08105/13 DATE OF DEATH (MM-DD-YEAR) 08/03/01 TIllS RETURN MUST BE FILED IN DUPLICATE WITH TIlE REGISTER OF WillS SOCIAL SECURITY NUMBER 176-32-5009 (IF APPLICABLE) SURVMNG SPOUSE'S NAME (lAST. FIRST, AND MIDDLE INITIAL) N/A I!J 1. Original Return o 4. Umited Estate D 6. Decedent Died Testate (Abdl copy of WI) o 9_ Uligalion Proceeds Received o 2. Supplemental Return D 4a. Future Interest Compromise (dill ltcl8llt1 alllr 12-12.a2) D 7. Decedent Maintained a Uving Trust (AIladl copy of TRIll) D 10. Spousal Poverty Credit (daII of dIIIt1 bIlween 12.31-91 n 14.95) o 3. RemaindefRelum(dllttddtalhpriorkl12-1U2) o 5. FedemI Estate Tax Return Required 8. Tolal Number of Safe Deposit Boxes o 11. Election 10 tax under Sec. 9113(A) 1".'''''01 !i w D ~ .. ill '" ~ u ~;^ .IlICOHElD~~IIJ;' Ilr.tATJON;SHOULD BEDI COMPLETE MAILING ADDRESS 1104 FERNWOOD AVENUE, SUITE 204 CAMP Hill, PA 17011-6912 " ISt$ECltlOlliMI.IU BE COlli -Ad;l;lOR!lE$f!()NDENC ' NAME SAMUEL M. BARBUSH, CPA FIRM NAME 1"_1 BARBUSH AND HOFFMAN, CPA'S TElEPHONE NUMBER (717) 761-2801 z o ~ :J ~ ii: c( (J W Ill:: 1. Real Estale (ScheduieA) (1) 2. Stocks and Bonds (Schedule B) (2) 3. CIose~ He~ CoIporation. Partnership or Sole-Proprietorship (3) 4. Mortgages & Noles Recewable (Scheduie D) (4) 5. Cosh, Bank Deposits & MisceHaneous Personal Properly (5) (Schedule E) 6_ Jointly Owned Property (Schedule F) (6) o Separate Billing Requested 7. Inter-Vwos Transfers & MisceUaneous Non-Probale Property (7) (Schedule G or L) 8. Total GroI' As..ts (total Lines 1-7) 9. Funeral Expenses & Adn;nistrative Costs (Schedule H) (9) 10. Debts of Decedent. Mortgage Uabilities. & Uens (Scheduie I) (10) 11. Total Deduction. (total lines 9 & 10) 12. N.t Valu. of Estate (Line 8 minus Line 11) 13. Chalilabie and Governmental BequestslSec9113 Truslsforwl1ich an_lotaxhasnotbeen made (Schedule J) 14. NetValul Subjed to Tax (Line 12 minus line 13) , ........~ I }:>..." . . ---OFFICIA(usE'oIliLv -I ! c:i "-.' -, -c. I W 353,084.16 .,1 353,084.16 (8) 11,822.26 3,426.18 (11) (121 (13) 15,248.44 337,835.72 (14) 337,835.72 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o !;( .... :J Q. == o (J ~ 15. Amount of line 14 taxable at the spousal tax rate. or transfers under Sec. 9116 (a)(1.2) x.O_ (15) 16. Amount of Une 14 taxable at Mneal rate 337,835.72 x.O~ (16) 17. Arnooot of Une 14 taxable at sibling rate x.12 (17) 18. Amount of Une 14 taxable at collateral rate x.15 (16) 19. Tax Du. (19) 15,202.61 15,202.61 CHECK HERE IF YOU ARE REQUESTING A REFUNO OF AN OVERPAYMENT 20.0 .. BE.SUQTO'ANSWER'-"'liQUesnOl'lSON'REVERSE-.S1P~Pl!'lEC:llECl<',MATH',",.<:", ;; ... . Decedent's Complete Address: STREET ADDRESS 850 KIEHL DRIVE CITY lEMOYNE I STATE I ZIP 17043 PA Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2. Credits/Payments A Spousal Poverty Credij B. Prior Payments C. Discount 15,202.61 Total Credits (A+ B + C) (2) 0.00 3. Interest/Penalty if applicable D.lnterest E. Penalty Totallnlerest/Penalty ( 0 + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enler the d~rence. 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) 0.00 0.00 15,202.61 A. Enter the interest on the tax due. (SA) B. Enler the total of Line 5 + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT _~ l~: W~;r!.i 15,202.61 ,,;!Ii 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 [K] b. retain the righl to designate who shall use the property transferred or its income; ............................................ 0 [K] c. retain a reversionary interest; or.......................................................................................................................... 0 [K] d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [K] 2. If death occurred aller December 12, 1982. did decedent transfer property within one year of death without reoeiving adequate consideration? .............................................................................................................. 0 [K] 3. Did deoedent own an 'in trust for" or payable upon death bank account or security at his or her death?.............. 0 [K] 4. Did decedent own an Individual Retirement Aa:oun~ annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 [K] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Underpenallies at per;.y,1 d8dare Ihall have exami'led lt1isretum. incIudf1g lICOtIIl198I,ying schedules BOO statements. and 10 the beslofmy knowledge and be~ef, it is true, COf1'8Ct and complete. 0lIdarati0n of preparer other than the personal represenl8tive ilbasldon II informaIIonofwhlch preparerhas any knowledge. SIGNATUR F F:ERSON RESPONSIBLE F FI NG DATE ti./:J - d 3- 0 "2........ ADDRESS 850 KIEHL DRIVE, lEMOYNE, PA 1 043 SIGNATU E OF PREPARER OTHER THAN REPRESENTATIVE ~. DATE ADDRESS BARBUSH AND HOFFMAN CPA'S, 1104 FERNWOOD AVENUE, SUITE 204, CAMP Hill, PA 17011-6912 For dales of death on or after July 1, 1994 and before January 1, 1995. the tax rale 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)l. For dates of death on or after January 1, 1995, the tax rate imposed on the nel value of transfers to or for the use of the surviving spouse is 0% 172 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemnt a transfer to a surviving spouse from tax, and Ihe statutory requirements for disclosure of assets and filing a lax retum are still applicable even if the suNiving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The lax rate imposed on the net value of transfers from a deceased chid twenty..,n. years of age or younger at death to or for the use of a natural parent, an adoptive paren~ or a stapparent of the child is 0% 172 P.S. ~9116(a)(1.2)]. The lax rale imposed on the Del value of transfers to or for the use of the deoedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) 172 P.S. ~9116(a)(1)1. The tax rale imposed on Ihe net value of lransfers to or for the use of the deoedeot's siblings is 12% 172 P.S. ~9116(a)(1.3)1. A sibling is defined, under Section 9102, as an individual who has at leasl one parent in common with the deoeden~ whether by blood or adoption. .. , ,~ - REV.1509 EX+ (6-98) . COMMONWEALlli OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENt DECEDENT SCHEDULE F JOINTLy-oWNED PROPERTY ESTATE OF JOHN P. BLAZETIC FILE NUMBER If an auet was made joint within on. year of the d.c.dent's date of death, It must b. reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. DIANNE L. KOLLAS 850 KIEHL DRIVE lEMOYNE, P A 17043 DAUGHTER 8. C. JOINTlY-OWNED PROPERTY: LEmR DA'" DESCRIPTION OF PROPERTY OOF DATE Of DEATH ''''" FORJOlNT MAIlE INCLUDe NAME OF FINANCIAL INSTITUTION AND BANKACCOUHT NUMBER OR SIMIlAR DATE OF DEATH DECO'S VALUE OF ""MeER TENANT )OINT lOENTlFYING NUMBER. ATTACH DEED FOR JOINTlY-HELD .N:I:IESTAn:.- VAlUE OF ASSET 'NTEREST DECEDENT'S IKl(P.EST 1- A. 06/01/93 COMMERCE BANK 63,387.73 50 31,693.87 CHECKING ACCOUNT # 0512097791 2 A 06101/93 SAN ANTONIO CREDIT UNION 110,476.74 50 55,238.37 ACCOUNT # 32370587 3 A 06/01/93 TUCKER ANTHONY 125,000.00 50 62,500.00 ACCOUNT # DSH-OOOIII-58 PATRIOT BANK, POTTSTOWN, PA CERTIFICATE OF DEPOSIT 4 A 06/01/93 TUCKER ANTHONY 14,243.00 50 7,121.50 ACCOUNT # DSH-OOOI11-58 FREEDOM CASH MANAGEMENT FUND 5 A 06101/93 BANK OF AMERICA 15,367.21 50 7,683.61 CHECKING ACCOUNT # 747134-010-8 6 A 06/01/93 BANK OF AMERICA 204,918.35 50 102,459.18 ACCOUNT #6621343173 7 A 06/01/93 COMMERCE BANK 172,775.25 50 86,387.63 ACCOUNT # 41058732 TOTAL (Also enter on line 6, Recapitulation) $ 353,084.16 (If mOle space is needed, insert additional sheets of the same siZe) - .. - REV.15" EX+ (12.99). COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF JOHN P. BLAZETIC FILE NUMBER ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. FUNERAL DIRECTOR 3,364.00 2 CEMETERY 8,090.36 3 REPAST 137.88 4 FLOWERS 192.92 B. AOMINISTRATIVE COSTS: ,. Personal Representative's Commissions Name of Personal Representative(s) Social Sealnly Number(sVElN NUmber of Personal Represenlatiore(s) Street Address City State_~p Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as dalmanl's, attach explanation) Claimant Street Address City Stale_~p Relationship ot Claimant to Decedent 4. Probate Fees 5. Ac:oounlarot'sFees 6. Tax Rerum Preparer's Fees 7. CAPITAL STORAGE 37.10 TOTAL (Also enter on line 9, Recapitulalion) $ 11,822.26 Oebtl of dec.dent mUlt be reported on Schedule I. (If more space is needed, insert additional sheets of the same size) . .. . . - REV-1512 ex... (6-98) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE UABILITIES, & UENS COMMONWEAl.TH OF PENNSYlVANIA Itf-lERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JOHN p, BlAZETIC FILE NUMBER Include unr.imburstd medical expenses. ITEM NUMBER DESCRIPTION 1. MANOR CARE HEALTH SERVICES VALUE AT DATE OF DEATH 2 OAKWOOD CENTER RADIATION ONCOLOGY 3,373.00 53.18 TOTAL (Also enter on line 10. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 3,426.18 \, ?7-/6--li' BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z8D6Dl HARRISBURG, PA 171Z8-D6Dl COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF DETERMINATION AND ASSESSMENT OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN '* REV-~S5 EX AFP 101-\)2) SAMUEL M BARBUSH BARBUSH S HOFFMAN 1104 FERNWOOD AVE 2041..... CAMP HILL PA 1 fl:ol!l\: '02 J .,' 1 0 .\ '-, /-, r Ui nl" ;,-\ . 'I') 1\1 , \ '-' . ,..1'-, DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 06-10-2002 BLAZETIC 08-03-2001 21 02-0444 CUMBERLAND 201 JOHN P Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR FILES .... REV:48Y-EX--AFP-Toi":.-ozi-----..-NOiicE-OFDETERMiNATioN-AND-ASSESSMENT----------------------- ----- OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN .. ESTATE OF BLAZETIC JOHN P FILE NO.21 02-0444 ESTATE TAX DETERMINATION ACN 201 DATE 06-10-2002 1. Credit For State Death Taxes as Verified .00 2. Pennsylvania Inheritance Tax Assessed (Excluding Discount and/or Interest) 15.202.61 3. Inheritance Tax Assessed by Other States or Territories of the United States (Excluding Discount and/or Interest) .00 4. Total Inheritance Tax Assessed 15.202.61 5. Pennsylvania Estate Tax Due .00 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 -IF PAID AFTER THIS DATE, SEE REVERSE SIDE (IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) "v /~6/-)p BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG, PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUMBER '\ D:Dd COUNTY ACN 06-10-2002 BLAZETIC 08-03-2001 21 02-0444 CUMBERLAND 101 '02 JUiJ 1 7 SAMUEL M BARBUSH BARBUSH & HOFFMAN 1104 FERNWOOD AVE 204 L CAMP HILL P A 17l{lJ.l: *' REY-15Q7 EX AFP [Ul-02l JOHN P Amount Remitted ) CHANGED U) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 .00 353,084.16 .00 (8) MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV=iS'4-j-E3f-AFP--foY=02Y-riioYicE--OF-YNHEifiiAifCE-Y-A'X-APPRA-isEi'-EriiT~--AL1-oWAiicE-cfR-------------- --- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BLAZETIC JOHN P FILE NO. 21 02-0444 ACN 101 DATE 06-10-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Amount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: NOTE: (9) UO) 11,822.26 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 353,084.16 15.248 44 337,835.72 .00 337,835.72 00 = 045 = 12 = 15 = .00 15,202.61 .00 .00 15,202.61 3.426.18 Ul) (2) (3) (4) .00 X 337,835.72 X .00 X .00 X (9)= ~..._n. n____. l+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-03-2002 CDOO1147 .00 15,202.61 TOTAL TAX CREDIT 15,202.61 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)