The URL can be used to link to this page

Home My WebLink About06-04-14 (3) _. _ _ _ _ _ � REV-1500 1505610143 ��az_„> � OFFICIAL USE ONLY PA Department of Revenue pennsylvania counry code veu Fib Number Bureau of Indfvtdual Taxes �^"�"�"� Po Box.2soso� INHERITANCE TAX RETURN 21 13 012 5 8 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Sodal Security Number Date of Death Date of Birth 09 09 2013 08 09 1950 Decedent's Last Name Sufflx DecedenYs First Name M� GROHOL PATRICIA A (If Applicable)Enter Surviving Spouse's Informatlon Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Soctal Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Retum 0 2. SuPPlemental Retum � 3.�main�;R�t 2►(Date of Death � 4. Umked Estate � qa,Pwure iMerest Carpomtae � 5. Federal Estate Tax Retum Requlred (dete c(deelh aftx t 2-t2-82) � g. Decedenl dsd Testate � 7. �^��LMng Trual 8. Total Number of Safe Depostt Boxes (qtlach Copy af yylA) � 9. Litlgatlon Proceeds ReceNed � 10.be�Nv�12 31�1 a�ndttl--a5)f oeath ❑ 1 t.�Aaaar,8�ule O Sec.9113(A) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONPIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numl�r, CHARLBS L HOL3WORTH E3Q 412 6cS3 255� � � G p jr� � REGIST�OFty111�,yL3�ONkjh = " i .�-3 ;�. I_._ -} i r~ _ t;� � � First Line of Addresa f ; . ... - , . ¢�.., � 5801 HROWN3VILLB ROAD '�=' �'� Em7 � �"�° r.� c;, ;� � Second Line of Address `•`' �' � '�� N r�' -_i �— $�1TE FILED � � City or Post Office State ZIP Code PITT3BURGH PA 15236 CorrespondenYse-mailaddreas: hOISWOtth.law(a�acba.Org U es of perJury,l declare that I have exam this retum,inclu�ng accompanyinq schedules and statements,and to fhe bast oT my knowledge and belfef, fl Uue, and comPlete.Declaratlan of prePa than tha personal rePreaentaNve b based on aN IrrfortnaUon of whlch preparer has arryl knowledga. S OF PERSON RES �LE FIUNG �� ' Jacqueline J.Ayers ��a � � noo 31 Hillcrest Circle,Wexford, PA 15090 SIGNA7URE OF PREPAR�OTHER TFiAN REPRESENTATIVE �TE Charles L Holsworth Esq aoo�ss Holsworth, Sander and Associates, P.C. 5801 Brownsville Road, Pittsburgh, PA 15236 Side 1 � 1505610143 15D561D143 � - J 15D5610243 REV-1500 EX DecedenYs Sodal Security Number o�m'aName: GROHOL� PATRICIA ANN RECAPITULATION 1. Real Eshdte(Schadule A).......................................................................................... 1. 2. stiodcs and Bonds(schedule B)............................................................................... 2. 3. Gosely Held Corporadon,Partnership or Sole-Prop�ietorship(Schedule C).......... 3. 4. Mortgages&Notss Receivable(Schedule D).......................................................... 4. 5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 1 9 , 6 4 3 . 6 9 8. Joindy Owned Property(Schedule F) ❑ Separete Billing Requested............. 6. 7. Inter-Vlvos Transfers&Miscellaneous Non-Probate Property (Schedule G) 0 Separete Bflling Requested............. 7. 8. Total Gross Asseta(total Unes 1 through 7).......................................................... 8. 19 , 6 4 3 . 6 9 9. Funeral Expenses and AdminisfraUve Costs Schedule H ........................ 9. 5 , 10 3 . 2 6 � )............ 10. Debts of Decedent,Morlgage LlabiUdes and Llens(Schedule I)............................. 10. 3 , 0 5 6 . 1 3 11. Total Deductions(totai Lines 9 and 10).................................................................. 11. 8 , 159 . 39 12. Net Value of Eatate(Line 8 minus Line 11)............................................................. 12 11 , 484 . 30 �3, Charftable and Govemmentel Bequests/Sec 9113 Tnasts for which an electlon to tax has not been made(Schedule J)................................................. 13. 14. Net Value Subject to Tax(Line 12 minus Une 13)..................... ........................ 14. 1 1 , 4 8 4 . 3 0 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Llne 14 taxable at ifie spousal tax rate,or fransfers under Sec.9116 (ax1.2)X.00 15. 18. Amount of Une 14 taxable �6 at lin�i rate X •�5 17. Amount of Line 14 taxable ��. 1 , 3 7 8 . 12 at sibling rate X .12 11 , 4 8 4 . 3 0 1 S. Amount of Une 14 taxable at collateral rate X .15 �8' 19. TAX DUE................................................................................................................... 19. 1 . 3 7 8 . 1 2 20. FlLL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. � Sid@ 2 � 1505610243 1505610243 � _ _ _ __ REV 1500 EX Page 3 File Number 21 - 13 - 01258 Decedent's Complete Address: Grohol, Patricia Ann STREET ADDRESS 4119 Nantucket Drive cmr srA� ziP Mechianicsburg PA 17050 Tax Payments and Credits: (�) 1,378.12 1. Tax Due(Page 2,Line 19) 2. CreditslPayments A. Prior Payments B. Disoount Total Credits(A +g) (2> 0.00 3. Interest (3) 0.0 0 4. If Une 2 is greater than Line 1 +Une 3,enter�e 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 Une 2,enter the difference. This is the TAX DUE. {5) ��3 7 8.�2 Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLaCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of fhe properly transferred:.................................................................................. b. reta(n the right to designate who shall use the property transferred or its income:.................................... c. retain e reversbnary interest;or.................................................................................................................. d. receive the promise for Iife of either payments,beneflts or care?.............................................................. 2. If death occuned after Dec. 12, 1982, did decedent transfer property within one year of death witliout a ❑ receivingadequate oonsideradon?....................................................................................................................... 3. Did decedent own an 9n trust for' or payable upon death bank account or secu�ity at his or her death?......... ❑ ❑ 4. Oid decedent own an tndividual retlrement account,annuity,or other non-probate propeity which containsa beneflciary deslgnatlon?...................................................................................................................... ❑ ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FlLE IT A3 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 fs 3 percent[72 P.S.§91�s�a)(1.1)(i)]. (72 P S§9116(a(1 1)ti)]QrThe s�fute doe�s nat exemptt a Uapnsserto a seurvivfngl spous�e from ta�x,and tlie statut fry requirernen�f�or disdo�sureont assets and flling a tax m are stlll applicable even if the surviving spouse is the only beneflciary. For dates of death on or after Juy 1,2000: •The tax rate Imposed o�the net value of fransfers 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.§9118(a)(1.2)]. •The tax rate Imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiarfes is 4.5 percent,exc�pt as noted in [72 P.S.§9116(a)(1)1• •The tax rate Imposed on the net value of transfers tp or for the use of ihe decedenYs siblings is 12 percent[72 P.S. 9116(a)(1.3). A sibling is defined under Sectlon 9102,as an fndividual who has at least one parent in«�mmmon with the decedent,w�ether by bl or adoption. � pennsylvania SCHEDULE E DEPARTA�ENTOFREVENUE CASH BANK DEPOSITS AND MISC. INHER(TANCE TAX RETURN � R�sio�TO�cEO�"T PERSONAL PROPERTY FlLE NUMBER ESTATE OF Grohol, Patricia Ann 21 - 13-01258 Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of survtvorship must be discloaed on schedule F. ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 The Hartford-�nal long term disability check 44�.51 2 PSECU check -Account #0211XXXXXX-money remaining in acxount 11,350.46 3 Capital Blue Cross/Vanguard -401 k, plan No 090370 7,852•72 TOTAL(Also enter on Line 5, Recapitulatlon) 19,643.69 REV-1511 EX+(10-09) pennsylvania n�'�p�/�� y��+H�`�ww' r DEPARTbENT OF REVENUE �-y"G��Fy,.G/�rGIw7G�7 FY�ID INHERITANCE TAX RENRN �� RE3IDENT DECEDENT FlLE NUMBER ESTATE oF Grohol, Patricia Ann 21 -13-01258 Decedent's debts must be reported on Schedule I. ��M DESCRIPTION AMOUNT NUMBER FUNERAL EXPENSES: A. 1 John F. Slater Fune�al Home, Inc. 2�g84•22 B. ADMINISTRATIVE COSTS: �, Personal Representative's Commissfons Name of Personal Represenhadve(s) Street Address City State Zlp Year(s)Commission Paid 2. Htbmeys Fees Holsworth, Sander and Associates, P.C. 2,000.00 3, Famlly ExempUon: (If decedent's address is not the same as claimanYs,attach explanadon) Clafmant Street Address City State Zip Relatlonshfp of Claimant to Decedent 4. Probate Fees Allegheny County Dept.of Court Records-swearing in 25.00 Cumberland County Register of Wilis-probating 128.50 5. AccountanYs Fees 8. Tax Retum Preparer's Fees 7, Other Administradve Costs � Advertising Estate-Cumberland Law Journal 75.OU See attached 190.54 TOTAL(Also enter on Iine 9,Recapitulation) 5,103.26 Sdiedule H Ft,r�eral E�e��s& COMMONVYEALTH OF PENJSYLVANIA A.,L.�.��JOW� INHERITANCE TAX RETIIRN �.x,a�■ RESIDENT DECEDENT FILE NUMBER ESTATE OF Grohol, Patricia Ann 21 -13-01258 2 Advertising Estate-Sentinel newspaper 190.54 Page 2 of Schedule H � pennsylvania SCHEDULE 1 pEpqRT1u�NTOFREVENUE DEBTS OF DECEDENT, MORTGAGE INHERITANCE TAX RETURN RESIDENTDECEDENT LtABiLITIES & LIENS FILE NUMBER ESTATE OF Grohol, Patricia Ann 21 - 13-01258 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. NUM ER DESCRIPTION AMOUNT 1 Ceftic Healthcare, Inc. -medical bill, patient ID#55205 156.77 2 DCM Services, LLC-unpaid Verizon bill, account#2229428 185.98 3 IRS-installment agreement, remaining money owed (Notice CP521, Social Security 1,095.55 #3*-3-2178(estimated) 4 Capita) One credit card, account#4444*5504, reference#20170352 1,617.83 TOTAL(Also enter on Llne 10�Recapitulation) 3,056.13 � REV-1513 FJ(+(01•10) � pennsylvania SCHEDULE J DEPARTF�ENT OF REVENUE INHERITANCE TAX RETURN BEN EFICIARI ES RESIDENT DECEDENT ESTATE OF FlLE NUMBER Grohol, Patricia Ann 21 - 13-01258 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER �►E AND ADDRESS OF PERSON(S) DECEDENT (Words) ($�S) RECEIVING PROPERTY Do Not Lis!Trusbe(s) I� TAXABLE DISTRIBUTIONS[indude outright spousal distributions,and transfers under Sec.9118(aj(1.2)] 1 Jacqueline J.Ayers sister 1/3 of remaining 831 Hilicrest Circle estate W Exford PA 15090 2 John J. Grohol, III brother 1/3 of remaining 110 Wordsworth Avenue estate Altoona PA 16602 3 Arden Shroyer sister 1/3 of remaining 1300 Parkhills Avenue estate State College, PA 16803 Enter dollar amounffi for distribuUons shown above on Unes 15 through 18 on Rev 1500 cover sheet,as appropriate. II NON-TAXABLE DISTRIBUTIONS: � 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-TAXABIE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 �o d cr -_� � � � ; , _ , i , , � y � _,... � � � � � O / n� I � �/�/ � � Q �C � � f � �� Q / W -� � 2 °� � � � �,. r � m 'V '(� � :� � '°=�' � � � m W a C3 � :�, Q � �� ^ � � � � � � ,/ n � Y 'V' � C � � � i � . %� N � � J � s.� � � � �' ° o � � � r � � � � c.� � � or g � � �- � � X < y � � �� 2[�Z O � . � .. .. . . r � �.� � � � �, ; � � � �.� � ��a= � � o � � � m .�+ ��., � � � z�o� - -� ��.