HomeMy WebLinkAbout08-04-14 1505610105
REV-1500 EX(02-a)(FI)
PA Department of Revenue penns"ylvarda OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 28o6o1 INHERITANCE TAX RETURN (—n F-13]
Harrisburg,PA 19128-o6o1 RESIDENT DECEDENT I
ENTER DECEDENT INFORMATION BELOW
Social Security Number_ _ Date of Death MMDDYYYY Date of Birth MMDDYYYY
Yu� 11/04/2013 112/16/1926
Decedent's Last Name Suffix Decedent's First Name MI
I Peters Vrolan
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix _iI 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)
m 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust 0 B. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Litigation Proceeds Received C=:) 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule 0)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name _ Daytime Telephone Number
�Patric�-is Haywood (717) 300-3653
i REGISTER OF WILLS USE ONLY
First Line of Address
1 126 Milky Way p
Second Line of Address C G r�
7
City Or Post Office Stale ZIP Code_ FILED G
�Shlpperlsburg —� L— A PA17257
Correspondent's e-mail address:patrlcia.haywood @gmall.com
Under penalties of penury.I declare that 1 have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. -
$IG(JpifURE OF PERSON RESPPNSIBLE FOR FILING RETURN DATE
ADDRESS
126 Milky Way, Shippensburg, PA 17257
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
-1 1505610205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name: Vivian J. Peters
RECAPITULATION
1. Real Estate(Schedule A). ................. ..... ..... ................. 1. j
t
2. Stocks and Bonds(Schedule B) ... ....... ................ ........ ..... 2. �
i
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. L
1
4. Mortgages and Notes Receivable(Schedule D)................... ........
4. 1
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. ; 23,420.44 j
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property '--- 'Y- �
(Schedule G) O Separate Billing Requested........ 7.
8. Total Gross Assets(total Lines 1 through 7).. ................ ........... 8. - 23,420.44
9. Funeral Expenses and Administrative Costs(Schedule H).................. 9. • 13,627.33
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I). .............. 10. r 1,471.53
11. Total Deductions(total Lines 9 and 10)............................... .. 11. 15,098.86
12. Net Value of Estate(Line 8 minus Line 11) .. .............. .. ............ 12. 8,321.58
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. +I- 8,321.58
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 j-
(a)(1.2)X.0_ 7 15.
16. Amount of Line 14 taxable
at lineal rate x.0 45 8,321.58 : 16.1 374.47
17. Amount of Line 14 taxable 1
at sibling rate X.12 ` 17.i
18. Amount of Line 14 taxable 1
at collateral rate X.15 II + - 18. i
19. TAX DUE ....... .......... ..... .. ............................. .... 19.1 374.47
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side'2
L 1505610205 1505610205 J
REV•1500 EX(Fl) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
Vivian J. Peters
STREETADDRESS
Green Ridge Village
210 Big Spring Rd
CITY STATE ZIP
Newviile PA 17241
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 374.47
2. CreditsMaymenls
A.Prior Payments
S.Discount
Total Credits(A+S} (2) 0.00
3. Interest
(3) 0.00
4. If tine 2 is greater than Line 1 +tine 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) 374.47
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.......................................................................................... ❑ 0
b. retain the right to designate who shall use the property transferred or Its income ............................._............. ❑ ■
c. retain a reversionary interest.............................................................................................................................. ❑ E
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ E
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?.............. ❑ 0
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 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(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.
REV-iSo8 EX+(o8-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Vivian J. Peters
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. Checking account-M&T Bank ADctfx 9857728480 10,546.61
2. Prepaid funeral account-NGL Insurance Group 12,873.83
TOTAL(Also enter on Line 5, Recapitulation) $ 23,420.44
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (08-13)
pennsytvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Vivian J. Peters
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Fogelsanger-Bricker Funeral Home-funeral service,casket,grave opening,obituary notices,clergy fee, 12,873-83
flowers
2. Wagoner's Memorials-grave marker and installation 625.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 0.00
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees:
0-00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
0.00
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 128.50
5. Accountant Fees: 0.00
6. Tax Return Preparer Fees: 0.00
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 13,627.33
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+ (12-12)
[ 1� pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Vivian J. Peters
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 Green Ridge Village nursing home 1,471.53
TOTAL(Also enter on Line 10, Recapitulation) $ 1,471.53
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
pennsylvania SCHEDULE 7
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Vivian J. Peters
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. Patricia Haywood, 126 Milky Way,Shippensburg,PA 17257 daughter 1/3
2. Suzanne Hoch,665 Walnut Bottom Rd, Shippensburg,PA 17257 daughter 1/3
3. Jeffrey Peters, 549 E.Liberty St, Chambersburg, PA 17201 son 1/3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS 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
If more space is needed,use additional sheets of paper of the same size.
i
I
I
_, 11-T1-T C% J. PETERS, of S'ii. -'_ _v�_- --'' :.ou-1tY,
€ Pennsylvania, declare this to be my las: :;_ c y �=_-eSv revoke
all prior mills and codicils.
1. I direct that all my just debts, funeral expenses, grave-
marker and administrative expenses shall be paid from my residuary
estate as soon as practicable after my death.
2. I direct that all inheritance, estate, transfer, success-
ion and death taxes of any kind whatsoever which may be payable by
reason of my death shall be paid out of my residuary estate. !
3. I direct that my entire estate be distributed as follows:
I I
I
A. I leave my entire estate of whatever nature and wherever
situate to be divided equally among my three children, E
Patricia A. Haywood, Suzanne J. Hoch and Jeffrey L. Peters. f
B. Should any of my children predecease me, then that share
shall pass equally to his or her children.
I 4. I appoint my daughter, Patricia A. Haywood, as Executrix
i of this my last Will. If she should predecease me or cease to act
in such capacity, I name Suzanne J. Hoch to so serve.
i
5. The Executrix of this Will shall have the power to distri-
bute my estate in kind or in cash, or partly in either.
i
6. I direct that no Executrix acting under this Will shall be
required to enter bond in any jurisdiction.
i
IN ITNESS WHEREOF, I have hereunto set my hand this AJI�_day
of ` , 1992.
1
VIVIAN J. .jPETERS
s
kJ,W OFFICES OF
!HEN J. HOGG
IOUTHER STREET
ILISLE. PA 17013
The preceding instrurent ccnS_s_ -
_ _ c° ___ y e ::-z
was on the day and date hereof signed, published ant decia by _
VIVIAN J. PETERS, as and for her last Will in the presence of us,
who at her request, in her presence and in the presence of each
other have subscribed our names as witnesses hereto.
LAW OFFICES OF
EPHEN J. HOGG
E.LOUTHER STREET
:ARLISLE. PA 17013
rte--.- =>T-�••fl:•-
County of Cumberland
I, VIVIAN J. PETERS, the testatrix whose name is signed to the
attached or foregoing instrument, having been duly qualified accord-
ing to law, do hereby acknowledge that I signed and executed the in-
strument as my last Will; that I signed it willingly and as my free
and voluntary act for the purposes therein expressed.
VIVIAN J. PETERS
Sworn to or affirmed and acknowledged before me by VIVIAN J.
PETERS, the testatrix, this / day of p,t ).1, 1992.
fd' .ary Pi?61ic/Akforney
AFFIDAVIT
Commonwealth of Pennsylvania
ss
County of Cumberland
We, f•*-E 5F_Ic- J, LEI-15S and lltS411 Cl6 4-dF-V' ,
the witnesses whose names are signed to the attached or foregoing in-
strument, being duly qualified according to law, do depose and say that
we were present and saw the testatrix sign and execute the instrument
as her last Will; that the testatrix signed willingly and executed it
as her free and voluntary act for the purposes therein expressed; that
each subscribing witness in the hearing and sight of the testatrix
signed the Will as a witness; and that to the best of our knowledge the
testatrix was at that time 18 or more years of age, of sound mind and
under no constraint or undue influence.
Swo n to or affirmed and subscribed to before me by witnesses, .
this day of ti 1992.
i Z
Notary Public/Attorney
LAW OFFICES OF
;TEPHEN J. HOGG
t01 E.LOUTHER STREET
CARLISLE, PA 17013 '
inn
;ACCOUNT Nli ACCCIUNT TYPE;� 'STATEMENT PERIOiD PAGE .:':
9857728480 MST CLASSIC CHECKING WJINTEREST OCT.16-MOV.15,2013 1 OF 1
00 0 06822" NM 017
000000049 FIDS1549D01711151311 06 001000 44513
i VIVIAN J PETERS
PATRICIA HAYWOOD, GUARDIAN
126 MILKY WAY c \
SHIPPENSBURG PA 17257 \l�
INTEREST EARNED FOR STATEMENT PERIOD 0.06 REET OFFICE
INTEREST PAID YEAR TO DATE 1.50
ACCOUNT SUMMARY
':8A AMCE �:- !I'N`NER ADDI'II4N5 :Ct1ECKS PAID
.. -. TBAL`TIONS- INTEREST PD :>. B
ND. AMOUNT NO. AMOUNT NO. AMOUNT
4,233.18 UN 5 1,313. 5 0 0.O0 1 O 1 0.00 1 0.08 10,546.61
ACCOUNT ACTIVITY
PAST .:. >. :;% _ TS,It1.T.ERE& £.ELKS S;AT ILY
aA#E. . .7tkAAtdnAC3:I4Nt ESCRIPXSm1 . :? S:`[iTiiER .I ION$ :;SU$Y1EAtT:Z
10-16-13 BEGINNING BALANCE 09,233.18
-25-13 AMERIPRISE FINC AMP PAYOUT 29.70 91262.88
--1 N-J-HEINZ EMP--RE—PAVMEW--- .- -_ ._.___.._.57-.43__
-)A--01-13 US TREASURY 312 XXCIV SERV 783.86
1-13 SSA TREAS 310 XXSOC SEC 413.00 10,517.17
11-05-13 AMERIPRISE FINC AMP PAYOUT 29.36 10,546.53
I1-15-13 INTEREST PAYMENT 8.08 10,546.61
ENDING BALANCE 010,546.61
ANNUAL PERCENTAGE YIELD EARNED - 0.00 X
SAVE MONEY ON GIFTS AND MORE AT MAJOR RETAILERS THIS HOLIDAY SEASON. FIND OUT
NOW TO GET ADDITIONAL SAVINGS BY USING YOUR MST VISA DEBIT CARD OR MST VISA
CREDIT CARD AT MORE THAN 5O RETAILERS WHEN YOU VISIT MTB.CO"/SHOPPING.
FOR CUSTOMER SERVICE QUESTIONS, PLEASE CALL 1-800-724-2440. MEMBER FDIC.
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PreBill 0-30 t t >90 BALANCE 1
" $1,471.53
Date Description Units Rate'^ (Credit)i') Payments Balance ��
_ .
Balance Forward $2,253.63
10/28/13 10/28/13 Pad Promise Reg 15 Blue 1 -$52.50 -$52.50
10130/13 10/30113 Toothettes 1 -$0.45 -$0.45
10/31/13 10/13113 Oxygen Daily 7 -$8.50 -$59.50
11/01/13 11/03/13 Patient Liability -$669.65
Total Balance Due Ir $1,471.53
FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
GREEN RIDGE VILLAGE Vivian J Peters 161595GRV