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Home My WebLink About07-21-14 (2) �f 1 1505610101 REV-1500 EX(ar.ra) PA Department of Revenue pew r sytvania OFFICIAL USE ONLY Bureau of Individual Taxes County Cade Year File Number PD Box INHERITANCE TAX RETURN Harrisburg,rg,PA PA 1 7128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY � 0 9 1 1 2 0 1 3 101111191119 2 0 Decedent's Last Name Suffix Decedent's First Name MI o a n I I I I I I I JTn ® MI il 11 dj rl el di rI I I 1] (If Applicable)Enter Surviving Spouse's Information Below ' Spouse's Last Name Suffix Spouse's am First Name MI ® �-I I I I I rrrn ❑ 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 O 2.Supplemental Return O 3, Remainder Return(date or death 't f, prior to 12-13-82) .. p 4.Limited Estate p 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required G r 7 f death after 12-12.82) O 6. Decedent Died Testate C= 7.Decedent Maintained a Living Trust S. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9.Litigation Proceeds Received C3 10.Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A) r "' between 12.31.91 and 1-1.95) (Attach Sch.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name + Daytime ��Telephone�Number n t h A o n e c F r7 -)- ; REGISTER OF WILLS USE ONLY 0 First line of address C) r x� , 1111! 3 t t t W Second tine of address L tV �C5, U f � 7 V P O o 5 8 c7 �p City or Post Once State `ZIP Code - ' 1 LED .P r O S P A 1 7. 0 0 7 0 3. 5 o ��-,:� f q Correspondent's e-mail address: Under penalties of perjury.I declare that I have examined this retum.Including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declamtton of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATLIRE OF PERSO RESP SIBLE FOR FILI RETURN DATE n�4L�� "Wo�rJ Lf9rr7/�sc1efQo 7'/7'/� DsT,o ed, 7 r i SIGNA E OF EP ER OTHE T N R PR E THE DATE ADD ESS P EAS£ USE ORIGINAL FO ONLY Side 1 1505610101 1505610101 j 1505610105 t REV-1500 EX Decedent's social Security Number r �' oecedent's Name: Mildred V. Homan RECAPITULATION 0 • 0 0 1. Real Estate(Schedule A). ................ 1. . 0 • 0 0 2. Stocks and Bonds(Schedule B) . ........ ........ ...................... 2. 3. Closely Held Corporacon,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0 . 00 4. Mortgages and Notes Receivable(Schedule D)...... ............... ...... 4. 0 • 0 p • 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 17 _ 0 p 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ... .... 6. 4 4 r 0 5 . 0 3 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property , + - - (Schedule G) p Separate Billing Requested,....... 7. = 3 a ' 0 • 0 0 ' & Total Gross Assets(total Lines 1 through 7). ........ ...... 8. 4 4 r 5 0 5 •'0 3 9. Funeral Expenses and Administrative Costs(Schedule H). ....... 9. '? . , � 0 3 '3 1 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) ...... ........ 10. A 0 •0 p 11. Total Deductions(total Lines 9 and 10)...............y.I..........1.... 11. 0 3 .3 1 12. Not Value of Estate(Line a minus Line ti) ..... ........ ...••..... 12. 3 4 r;�9 0 1 •? 2 ....... 13. Charitable and Governmental BequeststSec 9113 Trusts for which 0 •0 0 an election to lax has not been made(Schedule J) ........................ 53. 14. Net Value Subject to Tax(Line 12 minus Line 13) .... ..... ............... 14. 3 4 i;;J 0 1 •7 2 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 15 (a)(1.2)X.0- 'yam 16. Amount of Line 14 taxable $ at lineal rate x.045 3 4 1 9 0 1 . 7 2 16, 1 5 7 :0 • 5 sat 17. Amount of Line 14 taxable 17 at sibling rate X.12 r 18. Amount of Line 14 taxable at collateral rate X.15 i8. 19. TAX DUE .. ................. ...................................... i9. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT \ - O Side 2 1505610105 1505610105 �,,� REV-Ygbg EX+(ol-io) - - - - pennsylvania SCHEDULE F DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY j RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Mildred V. Haman If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. John W. Homan . 486 West Old York Road Son Carlisle, PA 17015-7503 B. Ruby M. Homan 3363 Ritner Highway Daughter Newville, PA 17241 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 DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FORJOINTLY HEM REAL ESTATE, VALUE OF ASSET INTEREST DECEDENT'S INTEREST I. A. 2/5/03 American Funds 1 ,876. 73 50% 938 . 37 44. 984 shrs The Growth Fund of America - A Fund #05 2. A 2/5/03 American Funds 31481 .30 50% 1 ,740.65 177. 346 shrs The Income Fund of America - A Fund #06 3. A 2/5/03 American Funds 4,908.81 50% 2, 454.41 246. 674 shrs Capital World Bond Fund A Fund #31 4;... A 2/5/03 American Funds 1 , 674.01 50% 837.01 39. 678 shrs Capital World Growth and Income Fund - A Fund #33 5`. B 10/24/ )2 Orrstown Bank Checking Acct. 13, 474 .50 50% 6,737.25 6-. B 10/28/ )2 Orrstown Bank Certificate of 3,272.90 50% 1 ,636.45 - Deposit Account #5030068295 7. C 4/1 /11 Reliance Standard Life Ins . Co. 30, 448.25 50% 15, 224 . 13 Annuity #K500001503 8. C 5/2/11 Reliance Standard Life Ins. Co 29, 873. 53 .50% 14,936.76 Annuity #K500001504 With regard to the annuities, see attached annuity applications and annual reports . z TOTAL (Also enter on Line 6, Recapitulation) $ 44 505.03 If more space is needed, use additional sheets of paper of the same size. REV-1511 Ex+(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Mildred V. Homan 21 — Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Fogelsanger-Bricker Funeral Home, Inc. $9, 103 . 31 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: - Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: z. Attorney Fees: Anthony L. DeLuca, Esquire 500 . 00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP 2 Relationship of Claimant to Decedent - - - 4. Probate Fees: S. Accountant Fees: 6. Tax Return Preparer Fees: 7. t TOTAL(Also enter on Line 9, Recapitulation) $ 9, 603. 31 If more space is needed,use additional sheets of paper of the same size. W �Q.R 13:56 11172490296 ^y G ANNUITY APPLICATION Adminicfratiye Office:2001 Market Street,Suite 1500, Philadelphia, PA 19103 i,,ire iaxunnn'c...... :l's 800-351-7500 Home Office:Chico o IL PROPOSED//u • • Name: O/'1'i0A /1'l%X rPoJ _ , ❑Male OFemale D Trust Birth(Trust Date: /-/9-20 Address: yRd IaJ. Old yerl( Kd_rrn r-1. SSNITIN: / Telephone: 7/ 7- �.y9 6 Y3 Email: If Owner,or Joint Owner Were persons and not U.S.citizens,explain residency In Special Remarks Section Name: 11.0mOA� J d hr1 111, Q(,Male O Female O Trust Birth(rust irate: b�d-aa leer K tndanaeefT7daS q Address: ' l � Rd C' X/,7/9A PAI X70/ SSNmN: Telephone: 7 b3 Email: Name. 0Aa4 LTOhiI r•�Male O Female Birth Date: 6--16-58 iee! J FV'M/ I� �t J. //� a Address: �6 1-f/- Gl' - IriOK Ra QoP�3/e P# /70/S SSN: / _Telephone: 93 Email: Name: ❑Male ❑Female Birth Date: feel FM M.L Address: Si =-. r�. a• BENEFICIARY INFORMATION �Complefe ill fields) Primary Beneficiary (( Percent of Benefit:boa Name: ffeM0rl O Male,3(Fenri O Trust Birth/Trust Date: 7 6 - __ i Feei ��T—n^Tn,aL O�.E_ nntfem seal PeBeam,eldocumem) Address: - - W. 04 d - C Ca-Ci r Pi- SSN/TIN: / Relationship to Owner. O Primary Beneficiary O Contingent Beneficiary Percent of Benefit Mama: O Male O Female 0 Trust BirthlTrust Date: LBBt rIIT we ar nuv..v.....n....-..:.w=-. -o-. ........ —••—,��® Address: SSN/TIN: Relationship to Owner: O Primary Beneficiary ❑Contingent Beneficiary Percent of Benefit: Name; ._---- Legit Flret MI. 1HTnm,rpm2daflntend kettnpeofTruetdocvrnetN rr Address: SSN/TIN: Relationship to Owner: �*4r;;;n*SC„-.flcJ ry n 4^tin- ent Rene"Jons Percent of Benefit:_ Name: O Male O Female 0 Trust Birth/Trust Date: Leel Gfe( ML (M TNet pehCe filel&G bat peg00tTNet depate6mj Address: SSN(TIN: Relationship to Owner: O Frimary t7enenciary a Contingent:Beneficiary Vie;cer, Name: ❑Male O Female O Trust Birth/Trust Date: ' Lest Fin M.L (a T=tmoddefm aidenl+ .fTr Mn .mm Address: SSN/TIN: _ _ Relationship to Owner: Identify any additional beneficiaries in the Special Remarks section of the application. rr RSL.8361.0107-PA Page 1 of 4 g?g7ggpn2o5 rg G03 ANNUITY APPLICATION WifiNce STONDfifiA Administrative Office:2001 Market$treat,Suits 1500,Philadelphia,PA 19103 i __._� ssrnrftrre,y;., _ Rf.�•35111 71=00 Home Office:Chlcai= IL • •124 i1f FAUN M / O Male Female 0 Trust Birth/Trust Date: tart o ms Mhv .l 2Y + J Telephone:-7/'7 Email: or Joint Owner Were persons and not U.S.citizens,explain residency in Special Remarks Section a : dM} t 1. 1✓ . t, 0 14alfi Fuitiiiiv O rust Jsrnnr J rust Data: rtn MJ. mT aodd�lm ie•tmnWTNndoamnQ 0 < C !7l ) Telephone: 7l 2 t,49-R6 Y3 Email: A 6 /91. d Male Female Birth Date: _ Telephone; / 3Yy- 6 Email: O Male 0 Female Birth Date: :aw rsaF Telephone; Fmeilr 3+•nefiaary Percent of Benefit: /aa 1fi apt S41 /LI ale 0 Female 0 Trust BirthlTrust Date: 6 .26°SB �, .r cm µt. MiN�pan�sine+eiectRepererNxammem> Relationship to Owner: S o n Beneficiary 0 Contingent Beneficiary Percent of Benefit: 0 Male 0 Femate O Trust BirthtTnast Date: Relationship to Owner. Beneficiary L1 Contingent Beneficiary Percent of Benefrf: JR {tE TNn,vmtdefraa+tl bu teeao'TNCCmaTTfd ° Relationship to Owner. Beneficiary 0 Contingent Beneficiary Percent of Benefit; 0 Male 0 Female 0 Trust Birthfl'rust pate: .a. >:m ray Mzn,n.Pu+ex�nev�toegmrraaooausra Raiallonship to Owner, _ ...:,icGe;a:y `:<aeriiaeert S ny;tti •; Pa=r".al,west": - t O Male 0 Female 0 Trust Birth/Trust Date: .e FTU .r. (rFTNStuo+ttlotma#pa:maaoiTNMtbnrt:xa} Relationship to Owner: .-y aw1lonal beneficiaries in the Special Remarks section of the application. v�A Page 1 of4 r ( RELIANCE STANDARD LIFE INSURANCE COMPANY A MEMBER OF THE TOKIO MARINE GROUP Annual Report 2_001 Market Street, Suite .!500 iy ! t i..i L�^ ` Philadelphia, PA 19103 800.351.7500 Singh: Premium Deferred www.reliancestandard.co111 Equity Indexed Annuity Contract Owner(s): - Policy Number K500001503 MILDRED V. HOMAN JOHN W. HOMAN Issue Date 04101/20 1 1 486 W OLD YORK ROAD Statement Date 04/01/2013 CARLISLE, PA 17015 Date Prepared 0410112013 Annuity Plan KEYSTONE-5 Tax Status NON-QUALIFIED Annuitant(s) JOHN W.iiOMAN This is an lmporiant Docurnent-please keep Mfg statement with your policy! Annuity Value The Annuity VstuB is equal to the beunrgq annuity value, fce,s any'Nithdrawal or Beginning Annuity Value $2f3,998.33 surecr dc.rs(;ncluvsng PCre*res),plus any Withdrawals credited Fixed or 1ndrx Strategy lnic:rost GLWR Rider Charge NIA Interest Crediting • Fixed Interest Stra?egy • Annual Point-To-faint, Capped $1,449,92 • Annual Point-To-Point, Participation Rate $0.00 • Annual Monthly Average, Capped $0.00 • Annual Monthly Average, Participation Rate $0.00 Ending Annuity Value $30,449.25 Guaranteed Minimum Value F`/ease,ever to Yout Policy Conhact for the Mhritnoro Annuity Val,ic and guaranteed Minimum Value Beginning Value: $28,031,72 definilio's- Ending Value: $28,452.20 Cash Surrender Value(as of stefemeni date) $28,53-0101 The CashSurrerdor Value is the greaterof wilier the ending Annuify,Valuo or ending Guaranfeed Next Policy Year Surrender Charge Rate: 7.00 Minsnurn VnNta, ltx=aurrc-ndet charges i „r o RELIRNCE STRNMIRD Life Insurance Company n Annual Report 2001 Market Street, Suite 1500 1 Philadelphia, PA 19103 800.351.7500 Single Premium Deferred www.reliancestandard.com Equity Indexed Annuity Contract Owner(s): Policy Number K500001504 MILDRED V. HOMAN RUBY M. HOMAN Issue Date 05/02/2011 486 W OLD YORK ROAD Statement Date 05/02/2012 CARLISLE, PA 17015 Date Prepared 05/02/2012 Annuity Plan KEYSTONE-5 Tax Status NON-QUALIFIED Annuitant(s) RUBY M. HOMAN This is an Important Document—Please keep this statement with your policy! Summary Values Detail for Contract year ending on 0510212012: Annuity Value The Annuity Value is equal to the beginning annuity value,less any withdrawal or Beginning Annuity Value $27,617.46 surrenders(including penalties),plus any Withdrawals ($.00) credited Fixed or Index Strategy Interest GLW B Rider Charge N/A Interest Crediting • Fixed Interest Strategy $0.00 • Annual Point-To-Point, Capped $833.52 o Annual Point-To-Point, Participation Rate $0.00 • Annual Monthly Average, Capped $0.00 • Annual Monthly Average, Participation Rate $0.00 Ending Annuity Value $28,450.98 Guaranteed Minimum Value Please refer to your Policy Contract for the Minimum Annuity Value and Guaranteed Minimum Value Beginning Value: $27,617.46 definitions. Ending Value: $28,031.72 Cash Surrender Value(as of statement date) $26,402.51 The Cash Surrender Value is the greater of either the ending Annuity Value or ending Guaranteed Next Policy Year Surrender Charge Rate: 8.00% Minimum Value,less surrender charges 1 of 3 REV-1500 EX Page 3 Fite Number Decedent's Complete Address: 21 - DECEDENT'S NAME _ Mildred V. Homan STREETAODRESS— — --- ---- -- ---- _, 3363 Ritner Highway--_— —_—_--_— ---__ CITY ----- ------ ---- —� STATE -- Newville, PA 17291 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) $1 , 570.58 2. Credits/Payments A.Prior Payments --B.Discount _ 0.00 Total Credits(A+B} (2) 3. Interest (3) 5 a1 5 4, 9 Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill In oval on Page 2,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) $1 ,5 75.,33 Make check payable 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;........ ......-................ ............. ❑ b, retain the right to designate who shall use the property transferred or its income;.........................._............... ❑ c. retain a reversionary interest;or..............................................................:..........__........................................... ❑ IN d. receive the promise for life of either payments,benefits or care?...................................................................... Il ER 2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ 3. Did decedent own an"in trust for"or payable-upon-death bank account or secudty at his or her death?.............. ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ IN 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 Jan. 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 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 decedent's lineal beneficiaries is 4.5 percent, except as. noted in 72 P.S.§9116(12)[72 P.S.§9116(a)(1)). , • The tax rate imposed 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 Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.