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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONlY ~
L
FIlE NUMBER
L.. ..L -_ ..c... 2- _ .5.. .Q.. i.
COUNTY CODE VENt HUMBER
SOCIAl SECURITY NUMBER
3 6 5 - 2 4 - 7 2 4 3
THIS RffilRN MUST BE FllflllN OOPllCATE WITH THE
REGISTER OF WilLS
SOC~lSECURlTYNUMBER
o 3. RemainderRetum (dale 01 deal;h plbtl 12.13-82)
o 5. Federal Eslate Tax Return Required
_ B. Total Number of Safe Depes, Bo,es
o 11. Eleclionto tax under See. 9113{A)_'Sc,oJ
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 260601
HARRISBURG. PA 1712~1
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DECEDENTS NAME (lAST. FIRST. AND MIDlJLE INITiAl)
Novak Eileen B
DATE Of DEA TN (llM.DD. Year,
DATE OF BIRTH (MM.Do.y...)
NAME
Marielle F Hazen
FIRM NAME I~ Ap~-J
Jan L Brown & Associates
TELEPHONE NUMBER
717-541-5550
Harrisbur
845 Sir Thomas Court Suite 12
~r
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PA 17109
OFFICIAL USE ONLY'
02/26/2002 0410911926
(IF APPlICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST. AND MiDDlE INITIAL)
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u"'lS
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"",...
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~
00 1. Original Retum
o 4. Limited Estate
o 6. Decedent Died Testate _'''''r~WlI
o 9. Litigalion Proceeds ReceWed
o 2. Supplemental Retum
o 4a. Future Interest Compromise (dale of death after 12.12-82j
o 7. Decedent Maintained a LIW1g T rusf__ ""r~T""'i
o 10. SpousaJ Poverty Credit jdaleofdeall be\Ween 12-31.S1 andl.1.95j
10
;"-,
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I
27,659.991 .;0,
)
(8)
27,659.99
1. Real EsIate (Sdledule A)
2, Stocks and Bonds (Sdledule B)
3. Closely Held Corporalion, Parln...hip or SO/e.PropJletorship
4. Mo/tgages & Notes Receivable (Sdledule D)
5. Cash, Bank Depesils & Miscellaneous Personal Property
(Schedule E)
6. Jainllr Owned property (Schedule F)
o Separafe Billing Requested
7.lnfBf-Vwos TIllns/elll & Miscellaneous Noo.Probafe Property
(Sdledule G or L)
8. Total Gros. A..ots (total Unes H)
g, FUneral Expenses & Ad_live Cosls (Schedule H)
10, DebIs of Decedent, Mortgage liabilities, & Liens (Schedule I)
11. ToIal Deduction. (total Lines 9 & 10)
12. NeI V."'" of Estate (line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 TrusIs for which an eleclion '" fax has not been
made (Schedule J)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(9)
(10)
14. NoIV.lu. Subjoctlo Tax (Une 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, ortransfe!s under See. 9116 (a}(1.2)
X _(15)
18,710.29 X .045 (16)
X .12 (17)
X .15 (18)
(19)
8,949.70
(11)
(12)
(13)
8,949.70
18,710.29
16. Amount of Line 14 taxable aflineal rate
17, Amount 01 Line 14 faxableatsibJing rate
18. Amounl of Line 14 taxable at collateral rate
19. Tax Du.
20.0
CHECK HERE IF YOU ARE REOUESTlNG A REFUND OF AN OVERPAYMENT
(14)
18,710.29
841.96
841.96
"
Decedent's ComDlete Address:
STREET AOORESS
9 Pinetree Drive
CITY I STATE I ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Oue (Page' Une 19)
2. CreditS/Payments
A. Spousal Poverty Credit
B. Pnor Payments
C. Discount
(1)
841.96
4210
Total Credits (A +8+C)
(2)
42.10
3, Inte<estIPenally if appJJcable
D,lnlerest
E. Penally
T otallnteresUPenalty ( 0 + E ) (3)
4. If Une 2 is greater than Une 1 + Une 3, enter the differerwe. This is lhe OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Une 1 ... Une 3 is greater than Une 2, enter the difference, This is the TAX DUE. (5)
A, Enter the interest on the tax due. (5A)
B. Enter the total of Une 5 + 5A. This is the BALANCE DUE. (58)
Make Check to: REGISTER OF AGENT
799.86
799.86
PlEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1, Did decedent make a lransfer and: Yes No
a. retain the use or income of the property transferred; ........................................................................... 0 00
b. retain the nght to designate who shall use the property transferred or its income; ........................................ 0 00
c. retain a reversionary interest; or ...................................................................................................... 0 00
d. receive the promise for life of either payments, benefits or care? .................................,........................... 0 00
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
withoul receiving adequate consideration?........................:..................................................................... 0 00
3. Did decedent own an 'in trustfor' or payable upon death bank accounl or~rity at his or her death? ................. 0 00
4. Did decedent own an Individual Retirement Account, ann~ity, or other non-probate property which
contains a beneficiary designation? ............................................................................,.......,.................. 0 00
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
:)-
ADDRESS
PA 17055
DATE
PA 17109
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For dates of death on or after July 1, 1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S, ~9116 (a) (1.1) (iJl.
For dales of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or forthe use of the surviving spouse Is 0% [72 P,S. ~9116 (al (1,1) (ii)].
The statute does not exempI a Iransfer 10 a surviving spouse from tax, and the statutory requirements for disclosure of assels and flling a tax relum are still appiicable 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 twenty-one 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% [72 P,S. ~9116(a)(1 ,2J1.
The tax rate imposed on the nel value of transfers to or for the use oflhe decedent's lineal beneficianes is 4,5%, except as noted in 72 P,S. ~9116(1.2) [72 P,S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers 10 or for the use of the decadent's siblings is 12% [72 P,S, ~9116(a)(1.3)], A sibling is defined, under Seciion 9102, as an
inrlivirlual who has at least one parent in common with the decedent, whether by blood or adoption,
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REV''''''''''''.
COMMONWEAL ~ 01' PENNSYLVANIA
INHrnT ANCE TAX RETURN
RESIOENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
FflE NUMBER
Novak Eileen B
"an ..let was mad. joint wfthin on. yar 01111. decedenfl date of death, ~ must be ..ported on Schedule G.
SURV!VING JOINT TENANT(S) NAME
AOORESS
RELATlONSIflP TO DECEDENT
A. Carol A Holubowicz
9 Pinetree Dr
Mechanicsburg PA 17055
dau9hter
B
c
JOINTLy-oWNEO PROPERTY:
LEITER CATE QESCRlPTION OF PROPERTY I %Of CATE OF DEA~
ITEM FOR JOINT MAOE Include name offinillCial institution and bri a:count numberor sitNlw idefltifying number. Atta:h CATE OF DEATH DECO'S VALUE 01'
NUMBER TENANT JOINT deed for joinlly_rea_. VALUE 01' ASSET INTEREST DECEDENfS INTEREST
1. A. 5/1990 Waypoint Bank 2,449.34 50. 1,224.67
Certificate of Deposit; Account 5521732222
2 A 4/1990 Waypoint Bank 2,471.93 50. 1,235 97
Certificate of Deposit; Account 527170319
3 A 1/1992 Members 1st Federal Credit Union 45,065.05 50. 22,532.53
Savings Account 124383-00
4 A 1/1992 Members 1st Federal Credit Union 3,456.84 50. 1,728.42
Checking Account 124383-11
5 A 1/01 Waypoint Financial Corp 1,876.80 50. 938.40
115 shs @ $16.32 share
TOTAL (Also enter on line 6, Recapitulation) $ 27 e::9.9f
..
III more space IS needed, Insert additional sheets of the same Size)
I'
""~l1EX.(..n.
COMMONWEALTH (IF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT OECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
Novak Eileen B
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1- Malpezzi Funeral Home 6,474.70
2 Diocese of Harrisburg, Office of Catholic Cemeteries; marker 1,225.00
3 Funeral dinner 250.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of P....nal Rep""""'latiYe (s)
Social Security Number(s) I EIN Number of POlSOnal Representallve(s)
Street Address
City Slale Zip
Yea~s) Commission Paid:
2. Attorney Fees Jan L Brown & Associates 1,000.00
3. Family Exemp/ioll: (ff decedenrs address is not the same as claimants, attach explanalion)
Claimanl
Street Address
City Stale Zip
Relationship of Claimant to Decedent
4. Probale Fees
5. Accountanfs Fees
6. Tax Return Prepa....s Feas
7.
TOTAL (Also enter on line 9, Recapitulation) $ 8949.70
..
(If more space IS needed, Insert addttlonal sheets of the same size)
'''''!I'"''
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Attachment to REV -1500
Decedent's Name: Novak, Eileen B.
Social Security No.: 365-24-7243
Eileen B. Novak designated her daughter, Carol A. Holubowicz, as beneficiary of her
pension benefits with Pinnacle Health. As of the date of her death, decedent was entitled to 58
more monthly payments. Her daughter and designated beneficiary, Carol A. Holubowicz, is now
entitled to those monthly payments. However, Carol A. Holubowicz does not have the right to
withdraw any funds other than the designated monthly payments, She cannot assign the benefits
of this pension plan; and upon her death, all benefits cease. As such, the value of this pension
plan has not been included on the return. We are attaching a letter from Price Waterhouse
Coopers setting out the present value of the monthly payments.
.". ,
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<::',-21-0:: 7: '9':'~~;
I . . . OS/20/2002 H: 20 FAX
: 23, -;':':O?-'3
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GHRS
I4!I002
fRJCEWAlERHOLJsf@JPERS I
May 20, 2002
I
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f"th::t:waterhouseCoopen UP
Two (:(.lmmerce SqiJil1l, SQlte llOO
20D1 MarkClt S(r~t
Phj!adelphia fA 19J03-7042
ToI.phon. (2671 HO 3000
faolmile 1267) 330 33-00
Private & Confidential
Mli. Faye Krupcr
Pinnacle Health System
205 South Front Street
Brady Hall Building - 2nd F100e
P,O. Box 8700
Harrisb\IIg, P A 171 05-8700
Re: Eileen Novak
Dear Faye:
As requested, for inheritance tax purposes, we have calculated the prescJlt value of the
mn~;n;ng pel15ion payments to Ms. Eileen Novak's beneficiary,
On January I, 1997, Ms. Novak elected to J10Ceive a monthly retinlmc:nt benefit of
$119,16 payable from the Pinnacle Health System Pl!tI$ion Plan fur her life, guaranteed
for 120 months. On FebIll8ty 26, 2002, Ms. Novak passed away after receiving only 62
payments. As a result, her beneficiary is entitled to the remaining 58 mon&ly payments,
Based on this infonnation, w= have detc:rmined the p~nt value as of Match 1, 2002 of
the remaining 58 payments to be $6, I 13 .54,
The present valtl.e was calculated under the 1lIeScribed table and interest rate (5.42%) as
defined by the IRC Section 20.2031-7.
Please call Brian Evitts (267-330-3199) or me (267-330-3233) if you have any questions
or need lIdditional information.
Sincerely,
~~v/P77~
Debbie Goldsman
Consultant
G:iRq\Rd\Phs\Db\l...ettets'NOYftk.!loc
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128-0601
REV-1162 EX{ll-96l
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HAZEN MARIELLE F
845 SIR THOMAS COURT
HARRISBURG, PA 17109
nn-n-fold
ESTATE INFORMATION: SSN: 365-24-7243
FILE NUMBER: 2102-0509
DECEDENT NAME: NOVAK EILEEN B
DATE OF PAYMENT: OS/23/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 02/26/2002
NO. CD 001205
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $799.86
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I
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I
TOTAL AMOUNT PAID:
REMARKS: MARIELLE HAZEN
CHECK# 5980
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
$799.86
MARY C. LEWIS
REGISTER OF WILLS
/7-6(:- <I
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLDWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
MARIELLE F HAZEN
JAN L BROWN & ASSOCS
845 SIR THOMAS CT lZ
HBG PA ,V109
_i.)
, ,
07-08-2002
NOVAK
02-26-2002
21 02-0509
CUMBERLAND
101
'*'
(f
1-/
REV-1S47 EX 'FP (Ol-02l
EILEEN
B
AllIount Rellitted
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=is4j-iiniFP-filFiiiff-Ncffici--oj:-YNHiifiTANcr'fAin-pPRAisii.fENi':--iiLioWAiofcE-cfR"------------m--
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF NOVAK EILEEN B FILE NO. 21 02-0509 ACN 101 DATE 07-08-2002
TAX RETURN WAS: I X) ACCEPTED AS FILED
) CHANGED
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 OJ
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule f)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
.00
27.659.99
.00
(S)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Ad.. Costs/Misc. Expenses (Schedule HJ
10. Debts/Mortgage Liabilities/Liens (Schedule Il
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
NOTE: IT an assessment was issued previously, lines
reTlect Tigures that include the total oT ALL
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.
(9)
(10)
8,949.70
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
27,659.99
8.949 70
18,710.29
.00
18,710.29
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00
841.96
.00
.00
841.96
.
RECEIPT [+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
05-23-2002 CDOO1205 42.10 799.86
TOTAL TAX CREDIT 841.96
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
.00
Ill)
(12)
(13)
(14)
.OOXOO=
18,710.29 X 045 =
.00x12=
.00X15=
(19)=
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
I IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)