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HomeMy WebLinkAbout07-18-14 J 1505610143 Ex(02.11) REV-1500 OFFICIAL USE ONLY PA Department of Revenue Pennsylvania ca,my code Year File Number Bureau of Individual Taxes PO 60x.280601 INHERITANCE TAX RETURN 21 13 1222 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 09 22 2013 12 27 1926 Decedent's Last Name Suffix Decedent's First Name MI SOUCY RENE (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 ❑ 1. Original Return 2. Supplemental Return ❑ 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate ❑ 4a.Future Interest cn—lse ❑ 5. Federal Estate Tax Return Required (date of dealh eftw 2.12.82) ® g Decedent Pied testate 7 Maims=a Uving Trust g, Total Number of Safe Deposit Boxes (AaaNint Died vest) ❑ Adadl o/Tryst) PO 9. Litigation Pmoeeds ReceNed 10.S I Poverty Credit 1Patea f Death ❑ ( ) ❑ e seer,1YJ1-51 arM i 1-85 11.Election to tax under Sec.91 A (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number EDWARD P SEEBER 717 533 3280 ry REGISTER OF USE O LY 17-M First Line of Address rr � SUITE C400 aD °"J " Second Line of Address C70' 3 �7 –'r� 555 GETTYSBURG PIKE o }np City or Post Office DATERILED State ZIP Code , MECRANICSBURG PA 17055 Correspondent's e-mail address: eps(cDisdc.com UUnde nettles of.pedury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, is nett aild conplete.DeVaration of preparer other than the personal representative Is based on all Information of which preparer has any knowledge. SI NATURE f)F PERSON ESPONSI LE FOR FILING RETURN DAT Mace. Jennifer E. Soucy (S1( ADORE � 321 Sou view DriveMechanicsbur EPA 17055 SIGNATURE F PREPARER OTNER THAN REPRESENTATIVE / DATE Edward P Seeber ADDRESS Suite C-4000555 Gettysburg PikeEMechanicsburg EPA 17055 Side 1 1505610143 1505610143 a� J 1505610243 REV-1500 EX Decedent's Social Security Number Dare em's Name: SOUCY, Rene 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. - . 15 , 964 . 81 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. -. 7. Inter-Vivos Transfers&Miscellaneous h{oq Probate Property , (Schedule G) u Separate Billing Requested............ 7, 5 , 433 . 78 8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 21 , 398 . 59 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 12 ,271 . 36 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 9, 485 . 06 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 21 , 756. 42 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. -357 . 83 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. -357 . 83 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.00 15. 0 . 00 16. Amount of Line 14 taxable 0 . 00 16. 0 . 00 at lineal rate X .045 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.1 5 0 . 00 18. 0 . 00 19. TAX DUE................................................................................................................ 19. 0 . 00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 J REV-1500 EX Page 3 file Number 214 34 222 Decedent's Complete Address: DECEDENTS NAME Soucy, Rene STREET ADDRESS 940 Walnut Bottom Road CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1, Tax Due(Page 2,Line 19) (1} 0.00 2, Credits/Payments A. Prior Payments S. Discount Total Credits(A +B) (2) 3. Interest (3) 4, If Line 2 is greater than Line I+Line 3,enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2ELine 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) 0.00 Make Check Pa able to: REGISTER OF WILLSCAGENT. 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:....... ................................. ....... 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?............................................................ Nx 2. If death occurred after Dec. 12, 1962, did decedent transfer property within one year of death without receiving adequate oonsiderafion?.........................._........................................................................................ ❑ 51 3. Did decedent own an"in trust fog' or payable upon death bank account or security at his or her death?....... ❑ ❑x 4. Did decedent awn an individual retirement account,annuity,or other non-probate property which contains a beneficiary designation?.....................................................................................„ ❑ ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YESLYOU 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)It)), 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 adaptive 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 rested in[72 P.S.§9116(a)(1)]. • The tax rate Im 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 SerAion 102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. Rev-1 608 EX-(11.10) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE - INHERITANCETAXRETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Soucy, Rene 21-13-1222 IrrJUde Ote s of l2g'albn and,me Cato khe Ixaceeds were racoiveE 7 at0 estate. All property Myow,roC wiM tM daM of eu,vivorshlp must bo ClecloeeC on sclroCWO F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Santander Checking Account No. 1421088827-valued per bank statement 2,660.38 2 Santander Checking Account No. 1661224474-valued per bank statement 5,176.84 3 American General Life-life insurance policy no.*0569-payable to the Estate from late wife 1,632.00. (check received on 7/10/14) 4 Geisinger Health Plan-payment for Holy Spirit-medical provider 1,303.00 5 Social Security-monthly payment 301.00 6 The Woods-refund of security deposit 1,378.59 7 US Treasury-2013 income tax refund 3,513.00 TOTAL(Also enter on Line 5,Recapitulation) 15,964.81 (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) ROV•1610 EX*(09419) SCHEDULE G pennsylvania INTER-VIVOS TRANSFERS AND DEPARTMENT OF REVENUE INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Soucy, Rene 21-13-1222 This sMddule must be ro plate i and Tiled if the answer to any of Westions 1 tMOUgh 4 on page area or the REV-1 SOD is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECDS EXCLUSION TAXABLE NUMBER 7HE 6A E OFT ARANSFF ATTACH A CORELATIONSHIP Y FE ED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPIxnaLE} VALUE 1 Parthemore Funeral Home&Cremation Services Inc.- 5,433.78 100.000% 0.00 5,433.78 prepaid funeral TOTAL(Also enter on line 7,Recapitulation) 5,433.78 (If more space is needed,additional pages of the same size) Copyright(c)2009 form software only The Lackner Group,Inc. Form PA4500 Schedule G(Rev.08-09) REV-1511 EX-(IM) - Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHEArTANCE TAX REWDENT DECEDENT RETURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER SoucyCRene 21-13-1222 Decedent's debts must be reported on Schedule 1. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s)attached 6177.94 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zia Year(s)Commission Paid 2. Attorney's Fees JSDC Law Offices 5000.00 3. Famity Exemption: (If decedent's address is not the same as caimant's,attach explanation) Claimant Street Address City State Zio Relationst io of Claimant to Decedent ,L Probate Fees 328.50 See continuation schedules)attached 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. OtherAdmimstrative Costs 564.92 See Continuation schedule(s) attached TOTAL(Also enter on fine 9CRecapitulation) 12(271.36 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 Soucy, Rene 21-13-1222 ITEM NUMBER DESCRIPTION AMOUNT Funeral 1 BJs-food for funeral reception 341.81 2 Joanne Fabrics -display at funeral 12.69 3 Oldtowne Florist-funeral flowers 38.16 4 Parthemore Funeral Home&Cremation Services Inc.-funeral services 5,311.04 5 Premier Catering-food for funeral reception 127.00 6 Rolling Green Cemetery-grave opening 225.00 7 Route 15 Beverage-drinks for funeral reception 166.11 8 Wine&Spirits-drinks for funeral reception 56.13 H-A 6,277.94 Probate Fees 9 Register of Wills,Cumberland County-probate fee 108.50 10 Register of Wills,Cumberland County-reservation for additional probate fee 190.00 11 Register of Wills, Cumberland County-filing fee for Supplemental Return&Inventory 30.00 H-B4 328.50 Other Administrative Costs 12 Cumberland Law Journal-estate notice publication fee 75.00 Copyright(c)2002 forth software only The Lackner Group,Inc. Forth PA-1500 Schedule H(Rev.6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Soucy, Rene 21-13-1222 ITEM NUMBER DESCRIPTION AMOUNT - 13 JSDC Law Offices-reservation for estate administration closing costs 300.00 14 Santander -check fee 10.00 15 The Sentinel-estate notice publication fee 179.92 H-137 564.92 Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98) Rev-1512 U.(12-N) .. SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, 1 " INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Soucy, Rene 21-13-1222 Report debt,Imurted by the decadent prim to death that Mm Ined unpaid at the data of death,including unrelm med medical expenaee. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Camp Hill Emergency Physicians-unreimbursed medical bill 1,303.00 2 Community LifeTeam Inc-unreimbursed ambulance bill 105.20 3 Darryl Guistwite, DO-unreimbursed medical bill 318.75 4 Heartland Care Partners PA -unreimbursed medical bill 118.00 5 Heartland Care Partners PA -unreimbursed medical bill 150.00 6 Heartland Pharmacy of PA-unreimbursed pharmacy bill 45.41 7 Holy Spirit Hospital -unreimbursed hospital bill 1,006.40 8 HSH-unreimbursed hospital bill 120.15 9 Kantor&Tkatch Assoc PC-unreimbursed medical bill 331.00 10 Manor Care-unreimbursed nursing home bill 4,483.59 11 Orthopedic Institute of PA-unreimbursed medical bill 53.35 12 Orthopedic Institute of PA-unreimbursed medical bill 10,91 13 Peril Diagnostics Inc.-unreimbursed medical bill 182.00 14 Pinnacle Health Hospitals-unreimbursed medical bill 100.00 15 Quantum Imaging&Therapeutic Associates-unreimbursed medical bill 142.74 16 Spartan Pharmacy-unreimbursed pharmacy bill 23.56 17 State Collection Service Inc. -unreimbursed medical bill 991.00 TOTAL(Also enter on Line 10, Recapitulation) 9,485.06 (If more space is deeded,additional pages of the Same size) Copyright(c)2008 form software only The Lackner Group,Inc. Forth PA-1500 Schedule I(Rev. 12-08) REV-ISU EX.(01-10) - pennsylvania' SCHEDULE J • DEPARTMENT OF REVENUE -- - INHERMANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Souc Rene 21-13-1222 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$) I• TAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.91 16 a 1.2 Joshua S. Kopp,Jr. Grandson 9.596%of FEGLI 1090 Yocumtown Road,Apt 1 life insurance Etters, PA 17319 proceeds Joshua S. Kopp,Sr. Son 6.734%,of FEGLI 2550 Old Trail Road, Lot 28 life insurance York Haven, PA 17370 proceeds Peyton Kopp Granddaughter 9.596%,of FEGLI 2550 Old Trail Road, Lot 28 life insurance York Haven, PA 17370 proceeds Timothy R. Kopp Stepchild 6.734%,of FEGLI 118 Paddington Way NE life insurance Leesburg,VA 20176 proceeds Jennifer E.Soucy Daughter 67.34%,of FEGLI 321 Southview Drive life insurance Mechanicsburg, PA 17055 proceeds&100%, of the residue Total Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 1500 cover sheet as 1 DID 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 SHEE Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)