HomeMy WebLinkAbout07-24-14 1 1505610105
J REV-1500 Ex(w-11)(Fl) j
Pennsylvania
OFFICIAL USE ONLY
PA Department of Revenue P enns Y
Bureau of Individual Taxes `° County Code Year File Number
PO BOX 28o6o1 INHERITANCE TAX RETURN
Harrisburg,PA 17126-o6o1 RESIDENT DECEDENT 13
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
10/02/2013 10/19/1922
Decedent's Last Name Suffix Decedent's First Name MI
Dersin Doris . L
(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
OD 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4. Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
of 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and i-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED,ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Peter R. Henninger, Jr. (717) 533-7113
REGISTERGF WILLS USE LY
�C_— 1
First Line of Address _ 03 � !
7, -o
339 West Governor Road E (
v3
Second Line of Address C7 L ='6
Suite 201 pct�]] s rn
ALED
City or Post Office State ZIP Code
Hershey - I PA 17033
Correspondent's e-mail address:
Under penalties of perjury.I declare that I have examined this return,including accompanying schedules and statements,and tothe best of my knowledge and belief.
I is true,correct and complete.Declaration of preparer other than the personal representative Is based on all Information of which preparer has any knowledge.
SIGNf+ R ER,TiON RESPONSIBLE FOR FILING RETURN _77.Z/
ADDRESS
2062 Southpoint Drive, Hummelstown, PA 17036
SIGNATURE OF PREPARE r�WAyJ/REPRESENTATIVE 7 i T/E
ADDRESS ����
339 W. Governor Road, Suite 201, Hershey, PA 17033
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105
V`J
1505610205
REV-1500 EX(Fl)
Decedent's Social Security Number
Decedent's Name: Doris L. Dersin
RECAPITULATION
1. Real Estate(Schedule A). . . .. . . . . ... ..... . . . . .. .. . . . .. . . . . ........ . . . 1. 1 0.00 +
2. Stocks and Bonds (Schedule B) . . . .. . .. ... . . . . .. .. . . .. . . . . ..... ... . . . 2 .._ __ 0.00 1
Et i
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . ... . 3. ! 0.001
4. Mortgages and Notes Receivable(Schedule D) . ... . . . . .. . . . . ....... . . . . . . 4. 0.001
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. .. . .. 5 ' 7 453 28
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property .. !
(Schedule G) O Separate Billing Requested.. . . ... . 7 87,971.15 t
8. Total Gross Assets(total Lines 1 through 7).. . . .. . ....... . . . . .. . . . . .. .. . 8. 95,424.43
1
9. Funeral Expenses and Administrative Costs(Schedule H).... . . . . .. . . . . .. .. . 9. 14,465.81
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). . . .. . . . . .. . 10. ; 1,904.03 1,
11, Total Deductions(total Lines 9 and 10). . . .. .. . . ...._.. . . . . .. . . . . ...... 11. 16,369.84
12. Net Value of Estate(Line 8 minus Line 11) . .. . . .. ........ . . . . .. . . . . . ... . 12. 79,054.59
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . ..... .... . . . . .. . . . . ... 13. 0.00 i
14. Net Value Subject to Tax(Line 12 minus Line 13) ....... . . . . .. . . . . .. .. . . . 14. 79,054.59
TAX CALCULATION-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.0_ 15.�- 0.001
16. Amount of Line 14 taxable
at lineal rate x.0 45 i6.j 79,054.59
17. Amount of Line 14 taxable
at sibling rate X .12 i 17. 0.00
..�._.m�.._.__
18. Amount of Line 14 taxable
at collateral rate X.15 _ 18.j 0.001
19. TAX DUE . . . ..... . .. . . . . .. . . . . ... .. ... 3,557.46
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610205
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: a L 13 -
DECEDENTS NAME
Doris L. Dersin
STREETADDRESS
801 N. Hanover Street
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 3,557.46
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+B) (2) 0.00
3. Interest
(3) 6.41
4. If 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 tine 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 3,563.87
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.......................................................................................... ❑ E
b. retain the right to designate who shall use the propedy transferred or its income............................................ ❑ 0
c. retain a reversionary interest .............................................................................................................................. ❑ 0
d. receive the promise for fife of either payments,benefits or care?...................................................................... ❑
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 security at his or her death?.............. ❑
4. Did decedent own 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 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 dales of death on or after Jan. 1, 1995, the lax 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)(it)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
fling 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(a)(l fl.
• 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.
REV.15o3 E%+(8-v)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Doris L. Dersin 21-13-1248
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1' None 0.00
TOTAL(Also enter on Line 2, Recapitulation) $ 0.00
If more space is needed,insert additional sheets of the same size
REV-1504 EX+(9-12)
SCHEDULE C
pennsylvania
DEPARTMENT OF REVENUE CLOSELY-HELD CORPORATION,
INHERITANCE TAX RETURN PARTNERSHIP OR
RESIDENT DECEDENT SOLE-PROPRIETORSHIP
ESTATE OF FILE NUMBER
Doris L. Dersin 21-13-1248
Schedule C-1 or C-2 (including all supporting information)must be attached for each closely-held corporation/partnership interest of the decedent,
other than a sole-proprietorship.See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM NUMBER VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
None 0.00
TOTAL(Also enter on line 3, Recapitulation) $ 0.00
(If more space is needed,insert additional sheets of the same size)
REV-150:EX+ (04-13)
pennsylvania SCHEDULE D
DEPARTMENT OF REVENUE MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDEM
ESTATE OF FILE NUMBER
Doris L. Dersin 21-13-1248
All property jointly owned with right of survivorship must he disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 None I 0.00
i
TOTAL(Also enter on Line 4,Recapitulation) $ 0.00
(If more space is needed,insert additional sheets of the same size.)
REV-1508 EX+(08-v)
-i pennsytvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDE14T
ESTATE OF: FILE NUMBER:
Doris L. Dersin 21-13-1248
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. M&T Bank-Checking Account No.45147899 1,100.06
2. Conseco Life Insurance Company-Insurance Refund 237.00
3. Vanguard Account No.9949088605-replacement checks annuity 251.51
4. First Clearing, LLC-Wells Fargo IRA Distributions 973.28
5. Riversource Life Insurance Co.-annuity payments 722.20
6. MFS Govemment.Securities Fund-TOD account dividends 179.51
7, Conseco Life Insurance Company-Insurance refund 389.73
8, Oppenheimer Funds-IRA dividends 14.39
9. Church of God Home-Long Term Care refund 3,585.60
TOTAL(Also enter on Line S, Recapitulation) $ 7,453.28
If more space is needed,use additional sheets of paper of the same size.
REV-1509 EX+(01-10)
ispennsylvania SCHEDULE F
DEPARTMENT OINTLY-OWNED PROPERTY
INHERITANCE ANCE TAX RETURN OF REVENUE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Doris L. Dersin 21-13-1248
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.
B.
C.
JOINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY % 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 FOR JOINTLY HELD REAL ESTATE, VALUE OF ASSET INTEREST DECEDENTS INTEREST
1. A. NONE
TOTAL(Also enter on Line 6, Recapitulation) $ 0.00
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+(08-09)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Doris L. Derain 21-13-1248
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECUS EXCLUSION TAXABLE
ITEM
MB INCLUDE ME NAME DN THE. ATACHAE,THEIR RELATIONSHIP FOR STATE AND
NUMBER THE DATE OF TRANSFER. Aracn ACOVr DETnEOEeo FOR Rent ESTATE. VALUE OF ASSET INTEREST pE APaucnelEl VALUE
I. Allstate Life Insurance Company-fixed Annuity Contract No.GA17245402 45,900.60 100 N/A 45,900.60
Transferees-Eric A.Joseph-Grandson
Lance M.Joseph-Grandson
Jessica L.Dersin-Granddaughter
DOT-12/15/14
2 Oppenheimer IRA Account#002302800599170 660.39 100 N/A 66039
Transferees-Eric A.Joseph-Grandson
Lance M.Joseph-Grandson
Jessica L. Dersin-Granddaughter DOT-07/01/14
3 MFS Government Security Fund-A-Acct#9896341627 19,721.78 100 . N/A 19,721.78
Transferees-Eric A.Joseph-Grandson
Lance M.Joseph-Grandson
Jessica L.Dersin-Granddaughter- DOT-07/01/14
4. Wells Fargo IRA-Account#2766-2947 14,676.66 100 N/A 14,676.66
Transferees-Eric A.Joseph-Grandson
Lance M.Joseph-Grandson
Jessica L.Dersin-Granddaughter- DOT-07/01/14
5 Vanguard Pennsylvania Long Term Account No.9949088605 7,011.72 100 N/A 7,011.72
Transferees-Eric A.Joseph-Grandson
Lance M.Joseph-Grandson
Jessica L.Dersin-Granddaughter- DOT-07/01/14
TOTAL(Also enter on Line 7, Recapitulation) $ 87,971.15
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+ (03-13)
Yffpennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Doris L. Dersin 21-13-1248
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Birger A. Freeberg Funeral Home, Inc. 7,812.41 -
2. Moshamon Valley Floral 397.50
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s) -
Street Address
City State ZIP
Year(s)Commission Paid:
i. Attorney Fees: Jones & Henninger, P.C. 5,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City _. _State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 358.50
5. Accountant Fees:
6. Tax Return Preparer Fees: Reserve 500.00
7. Cumberland Law Journal-Estate Ad 75.00
8. Carlisle Sentinel-Estate Ad 222.40
9. Reserve for additional probate fees 100.00
TOTAL(Also enter on Line 9, Recapitulation) $ 14,465.81
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+ (12-12)
pennsytvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Doris L. Dersin 21-13-1248
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Riversource Life Insurance-request of overpaid annuity 1,002.05
2. Alert Pharmacy-medical bills 316.98
3. Frederick County Fire&Rescue-ambulance bill 560.00
4. Wells Fargo-estate D.O.D.valuation 25.00
TOTAL(Also enter on Line 10, Recapitulation) $ 1,904.03
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+ (01-10)
pennsytvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Doris L. Dersin 21-13-1248
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
I. Eric Joseph,2062 Southpoint Dr.,Hummelstown,PA 17036 Grandson 1/3
2. Lance Joseph,2062 Southpoint Dr.,Hummelstown, PA 17036 Grandson 1/3
3. Jessica Dersin,2703 Loch Haven Dr.,Ijamsville,MD 21754 Granddaughter 1/3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
it NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0.00
If more space is needed,use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
KNOW ALL MEN BY THESE PRESENTS, that I, DORIS L. DERSIN, widow, of
RR1, Box 416, Houtzdale, Clearfield County, Pennsylvania 16651, being of
sound and disposing mind, memory and understanding, do hereby make, publish
and declare this as and for my Last Will and Testament, hereby revoking and
making null and void any and all former Wills and/or Codicils heretofore by
me made.
FIRST: I do direct my Executor hereinafter named to pay all my just debts
and funeral expenses as soon as may be found convenient after my decease.
SECOND: I do direct my Executor to pay all State and Federal transfer
inheritance and estate taxes on property passing by this, my Last Will and
I Testament, from my residuary estate.
THIRD: I do give, devise and bequeath the rest, residue and remainder of
�i my estate, real, personal, or mixed, and wheresoever situate to my �
ii grandchildren, ERIC JOSEPH and LANCE JOSEPH, both currently residing in
itHummelstown, Pennsylvania, and to JESSICA DERSIN, currently residing in j
jIjamsville, Maryland, in equal shares, share and share alike,
ii I£ any child named herein shall predecease me, their share shall
i
go to their parents, or parent, then living, at my death.
I
FOURTH: I give, confer and grant unto my Executor the authority to sell,
I
convey, exchange, partition or otherwise dispose of any real or personal
H
it property of which I may die seized or possessed or which may at any time
form part of my estate, at public or private sale, for such purposes and
i
upon such terms, and in such manner, at such prices as he may determine. I
i
LASTLY: I nominate, constitute and appoint MURYL E. DERSIN, II, of
Ijamsville, Maryland, as Executor of this, my Last Will and Testament.
Should MURYL E. DERSIN, II, predecease me or be otherwise unable to serve in
this capacity, I nominate, constitute and appoint DENISE E. JOSEPH, of
Hummelstown, Pennsylvania, as Alternate Executrix.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on this,
the 2nd page of my Last Will and Testament, the preceding page hereof being
identified by my initials contained in the margin thereof, all done the
d' ay of i 1999.
r
(SEAL)
DORIS L. DERSIN
SIGNED, SEALED, PUBLISHED and DECLARED by the above named
Testatrix as and for her Last Will and Testament, in the presence of us,
who, at her request, in her presence, and in the presence of each other,
have hereunto subscribed our names as witnesses.
i
i
-2-
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CLEARFIELD
I, DORIS L. DERSIN, Testatrix, whose name is signed to the attached
or foregoing instrument, having been duly qualified according to law, do
hereby acknowledge that I signed it willingly, and that I signed it as my
free and voluntary act for the purposes therein contained.
A�
r
� '9� _
DORIS L. 'DERSIN
Sworn or affirmed to nd acknowledged before me by DORIS L. DERSIN, the
Testatrix, this � ay of 1999.
Notary Public
My commission expires:
NOTARIAL SEAL
Ronald E.Archer,Notary Public
Houeda a Faro,Old foun
j COMMONWEALTH OF PENNSYLVANIA: M Lemmissior.Ex^ves March 23,2001
§ .
COUNTY OF CLEARFIELD
We, Peggy Swanson and Tamara S. Stodart, the witnesses whose names
f are signed to the attached or foregoing instrument, being duly qualified
I according to law, do depose and say that we were present and saw Testatrix,
DORIS L. DERSIN, sign and execute the instrument as her Last Will; that
DORIS L. DERSIN signed willingly and that DORIS L. DERSIN 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
I that to the best of our knowledge, the Testatrix was at the time eighteen
(18) years or more of age, of sound mind and under no constraint or
influence.
ure
Signatu
Sworn or affirmed to and subscribed to before me by Peggy Swanson and Tamara
S. Stodart, witnesses, this ay of 1999.
Notary Public
My commission expires: III
NOTARIAL SEAL
Ronald E.Archer,Notary Public
Houadale Dam,Ofd County
M ommission Expires March 82001