HomeMy WebLinkAbout09-02-14 1505611101
REV-15001 -"' ' .'
- OFFICIAL USE ONLY
PA Department of Revenue pennsylvattia
Bureau of Individual Taxes County Code Year File Number
PO BO
u zs0601 INHERITANCE TAX RETURN 4' r �j 4 f�� �" �"
Harrisburg PA 17128-0601 RESIDENT DECEDENT }T/-!� fT3 �(J!f_D��L
ENTER DECEDENT INFORMATION BELOW
Date of Death MMDDYYYY Date of Birth MMDDYYYY
106 t 9 s
Decedent's Last Name Suffix Decedent's First Name MI
(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
C=
11 Original Return NP 2.Supplemental Return C= 3. Remainder Return(Date of Death
Prior to 12.13-82)
C= 4.Limited Estate C3 4a.Future Interest Compromise(date of C= 5. Federal Estate Tax Return Required
death after 12-12-82)
C= 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust _. 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
C= 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death G7 11. Election to Tax under Sec.9113(A)
Between 12-31.91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name _ Daytime Telephone Number
i P �'••�M-r!' "N{.'7Vl�M`-�-� rim 1r- f�'-�M +�-
- ^ v REGIST C.'bWiLLS US ONL
StdU
First tine of Address _ rn ;
Tjr f nfl3 le o a z �v rrr
Second Line of Address CD C -r7 ?I 'n
City or Post Office State yZIP Code DATE FI
e'cih,a r\11 C 5 b# x�js rP
_ ._ . . _ --
Correspondent's e-mail address:_ Non on e '
Under penalties of perjury,I declare that i have examined this return,Including accompanying schedules and statements,and to the best of my knowledge and belief.
It is true,coned and complete.Oedmatlon of praparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU OF PERSON RESPOr SIB fORFILIN ETU N DATI�
ADDR J_I^tL� E i J �dl� i`�� 7 ' 8cG la 1
�77 ! Y3 t G SAr�O 124 f C73
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505611101 1505611101 J �Q1
}
1505611201
REV-1500 EX i
RECAPITULATION
1. Real Estate(Schedule A). .. `...�. ` ti<,/
Y 1 ! t �R� V 4� 1 r-A
2. Stocks and Bonds Schedule B }
{ ) ....................................... z. 17.40.0.
{/1IF
1 Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ..... 3. �.i i,/�0:I
ry1 !yf
4, Mortgages and Notes Receivable(Schedule D)........ .......... 1....•_
......... 4. � 6+1QQ
O / r
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. ... .. 5. 1�, 2�C+�t(,i� i �.�
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6.
7, tnter•Vivos Transfers&Miscellaneous Non-Probate Property - *�y( f-- u�(
(Schedule G) C= Separate Billing Requested....... . 7. `h. i�ho -}-CS, /3,�-7yr1t
8. Total Gross Assets(total Lines 1 through 7)... ........ .......... ........ 8. LJ__ -1-h 5 �1�'•C_-T�Q�
9. Funeral Expenses and Administrative Costs(Schedule H).............. .... . 9!1 U l wo{•V o)i
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). .. .... ... ..1 . 10. ��,6 C) 4
11. Total Deductions(total Lines 9 and 10)... ...... ......... _4W��, Orb
12, Net Value of Estate Line 8 minus Line 11 .... . ... . ... .... ... . .. ....... . 12.
13. Charitable and Govemmentai Bequests/Sec 9113 Trusts for which kJ - --- - ---1 f�-(-
an etactlon to tax bas not been made(Schedule J) ...... + ........ 13. , � � �•6joQ
f1 .........
P'+ 14.,Net Value Subject to Tax(Line 12 minus Line 13) .. .... ... . ... . .. ... .... . 14. DOG Sl6S`3r,
0 TAX CALCULATION' SEE INSTRUCTIONS FOR APPLICABLE RATES
t'15.-Amount of Line 14 taxable
t,t at the•spousal tax rate,or
is . transfers under Sec.9116 �� 1 !''�^''11
e- t(a)(1.2)X.0 '� 1f '15.
i16. .Amount bf Line 14 taxable
tD at lineal rate X.0- 16. -F v
17' Amount of Line 14 taxable Y ---^t��-y1 � '
at sibling rate X.12
JA a�•_12•
18. Amount of Line 14 taxable
at collateral rate X.15`- • .18. :1 p l9. 1,/. yb
19. TAX DUE . .. ..............._......._. ....^,......................`Y9. , i �_.._ 4 -! `l � DQ
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ry. , � Cj
r -
Side 2
1505611201 1505611201
REV-1508 EX+(11-10)
Pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS St MISC.
INHERHANCE DE ED NENRN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Sar��ra k G af! 191 ( 2 113 _d II
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 DESCRIFIION
Of DEATH
i . r`'�e n,bers Is+ federal C�edl`f 1��,� or, 2g, (Otis.ob
TOTAL(Also enter on Line 5, Recapitulation) $ 2 0 r lg-7S,06
If more space is needed,use additional sheets of paper of the same size.
CORRECTED(if checked)
PAYERS name,street address,City,state,2IP code and kJephmne rurtm 1 Gress disbburon OMB No.1545ot19 Distributions From
MEMBERS 1ST FEDERAL CREDIT UNION $ 28,64546 20 Peruslons,
5000 LOUISE DRIVE P.O.BOX 40 28 Taxable amount 2 Annunt or
Retirement or
MECHANICSBURG,PA 17055 $ 28,645.06 Form 1099-R Profit-Sharing
Plans,IRAs,
2b Taxable amount Trial Insurance
(800)283-2328 kwtdatrrmxrea distribution Contracts,eta
-PAYER'S Feder KWffxabM mutter RECtPIENi'S identifxatlon number 3 Ca hol gain(included in box 4 Federal none tax Copy g withheld 23-1360906 XXX-XX-3056 $ ODD $ 5,729.01 Reportthis
te1,
RECIRENTS carne,address firth ing apt rut.),my,scale wo ZIP code S FmPieyee roMnlwibns a NM umuar¢ed apPredatlan income er your
W /Designated Roth coadbutious »ompoyersaer+aric Federal fax
or insurance premiums r return.Hthis forth
$ 0.00 $ 0.00 shows Fangs}
income tax
KENNETH W GUTSHALL y Diaa,bwso, jmrvSEp, a or withheld lnbox4.
RENEE FOR SANDRA K GUTSHALL 1as
4724 E TRINDLE RD code(S) SIMPLE attach this copy
4 X $ 0.00 % to your return.
MECNANICSBURG, PA 17050 g This information
lmlllorlllruslrlrllrrnrllrrllorullrlrlurlrlrlulrllnl 9° told utioBiheor 9b Torts a is being furnished
to the Internal
% $ 0.00 Revenue Service.
12 State tax withheld 13 StatetPaym,star,up. 14 Stater irrbution
0.00 - . $ ,o
-- 10 AmmmtalluabfemlRRwlthin5years 11 iM yearofdosig.Roth contrib. $ $
$ 0.00 15taraltaxwitldisM 1s Namoofkrably 17 Local distributlon
Account nuriber(seo instructions) $ 0,00 $
XXXXXXX024 $ $
Form109$-R Substitute Form (Keep for your records.) cos .1m.gov/rormm9lir Depadmert of the Treasury-mtemat Revenuo Service
Instructions for Recipient
Ganemily,distributions from pensions,armufies,profit-shadn9 and retirement plans Box 2a.This pad of the distribution is generally taxable.If them is no entry in this
(including section 457 state and local government Plans).IRAs,Insurance oxltracts, box,the payer may not have OR the facts needed to figure the taxable amount in that
etc.,are reported to recipients en Form 1099-R. case,the first box in box 2b should be checked.You may ward to get me of the free
Qualified plans.if your annifir starting date is after 1997,you must use the publications from the IRS to help you figure the taxable amount.See Additional
simplified method to figure your taxable amount if your payer did not show the taxable information m the back of Copy 2.For an IRA distribution,see IRAs and Roth IRAs
amount in box 2a.See the instructions for Form 1040 or 1040A. on this page.For a direct rollover,other than from a qualified plan to a Roth IRA,taro
IRAs.For distributions from a traditional Individual retirement arrangement QRA), should be sham,and you must ender zero(-0-)on the"Taxable amount"line of your
siMMed employee pension(SEP),a savings incentive match plan for employees tax return.
(SIMPLE),generally the payer is not requited to compute the taxable amount Sea If this is a total distnlruton from a qualified plan and you were loom before January
the Form 1040 or 104GA instructions to determine the taxable amount.If you are at 2,1936(or you are the beneficiary of someone bom before January 2.1936),you
tried age TO V2,you must take minimum distributions from your IRA(other than a may be eligible for the 10-year tax option.Sae the Form 4972 instructions for mom
Roth IRA).If you do not.you may be subject to a 50%excise tau on the amount that information.
should have been distributed.Sao Pub.590 for more information on IRAs. if you are an eligible retired public safety officer who elected to exclude from
Roth IRAs.For distributions from a Roth IRA,generally the payer 6s not required to income distributions from your eligible plan used to pay certain insurance premiums,
compute the taxable amount You must compute any taxable amount on Form 6606. the amount shown in box 2a has not been reduced by the exclusion amount.Sea the
An amount shown in box 2a may be taxable earnings on an excess contribution. Instructors;for Form 1040 or 1040A for more information.
Loans treated as distributions.If you borrow money from a qualified plan,section Box 2b.if the first box is checked,the payer was unable to determine the taxable
403(b)plan,agovernmental section 457(b)plan,you may have to treat the loan as a amount,and box 2a should be blank,except for an IRA It is your responsibility to
distribution and include all or part of the amount borrowed in your income.There are deter nkle the taxable anwunt If the second box is checked,the distribution was a
exceptions to this rule.If your Barr is taxable,Code L will be shown in box 7.See total distribution that dosed out your aocourt
Pub.575. Box 3.If you received a luxnp,sum distribution from a qualified plan and were bom
Recipient's Identification number.For your protection,this Torn may shove only the before January 2,1936(or you are the beneficiary of someone born before January
List four dghs of your social security number(SSN),individual taxpayer identification 2,1936),you may be able to elect to beat this amount as a capital gain on Form
number(ITIN),or adoption taxpayer identification number LATIN),However,the . 4972(not on Schedule_D(Form 1040)),See the Form 4972;nstructims.For a
— -- issuer her reported your completa ich ntifrce0on number to the IRS and;whata-- - charitable gift annuity,report as a long-term kapitalgain as°explained in the
applicable,to state and/or local governments. - instructions for Farm 6949.
Account number.May show an account or other unique number the payer assigned Box 4.Shows federal income tax withheld.Include this amount on your income tax
to distinguish your account. return as tax withheld,and if tux 4 shows an amount(other man zero),attach Copy B
Box 1.Shows the total amount you received this year.The amount may have been a to your return.Generally,if you will receive payments next year that are not eligible
direct rollover,a transfer a conversion to a Roth IRA,a recharadertzed IRA rollover detabutons,you can change your withholding or eyed not to have income
contribution;or you may have received it as periodic payments,as nonperiodic tax withheld by giving the payer Form W4P,
paymatts,or as a tae#d)stribtaion.Report the arraunt on Form 1040 or 1040A can Box 5.Generally,this shows the employee's investment in the contract(after-tax
the line for"IRA distributions"w"Pensions and annuities"(or the Me fa"taxable contributions),if any,recovered tax free this year the portion that is your basis in a
amount"),and on Farm 8606,as applicable.However,if this is a lu n"um designated Roth account;the pad of premiums paid on commercial annuities or
distdbubom see Form 4972.if you have not reached minlmen retirement age,report insurance rxtmracts recovered tau free;or the nontaxable pan of a charitable gift
your disability payments on the line for'Wager,salaries,Ups,etc."on your tax return. annuity.This box does not show any IRA contributions.If the amount shown is your
Also report on fiat titre permia..ibiewit drawats from eligible automatic cormbutim basis in a designated Roth account,the yea you first made contributions to that
arrangements and corrective distributions of excess deferrals,excess contributions, account may be entered in box 11.
or excess aggregate contributions except it you are self-employed. Box 6.if you received a lump-sum distribution from a qualified plan that includes
if a lire insurance,annuity,qualified long-term care,or endowment c antmetwas securities of the employer's company,the net umraUzed appreciation(NUA)(arry
transferred tax free to another trustee or contract issuer,an amount will be shown in increase In value of such securities while in the trust)is taxed only when you sell the
this box and Code 6 will be shown In bock 7.if a charge a payment was made against securities unless you choose to include it in your grass income this year.See Pub.
the cash value of an annuity contact or the cash surrender value of a life insurance 575 and the Form 4972 instructions.If you did not receive a lump-sum distribution,
contract fa the purchase of qualified Long-term rare assurance,an amount will be the amount shown is the NUA attributable to employee contributions,which is not
shown in this box and Code W will be shown in box 7,You need not report there taxed until you sell the securities.
amounts our you tax reborn.
(Continued on the bottom of Copy C)
l 13 — d c. t
E] CORRECTED (if checked)
'PAYER'S name,steel address,lily,slate.ZIP code and telephone number 1 Gross dishimban OMB No.1545-0119 Distributions From
MEMBERS 1ST FEDERAL CREDIT UNION $ 28,845 2013 Pensions,
5000 LOUISE DRIVE P.O. BOX 40 2a Taxable amount Annuities,
MECHANICSBURG,PA 17055 $ 26,645.06 Form 1099-R Profit-Sharing
Plans,IRAs,
2b Taxable amount Trial Insurance
(600)263-2326 node son ed distibution IN Contracts,etc.
PAYER'S Federal identification number RECIPIENTS identification number 3 Capital gain(unduded in box 4 Fedaral income tax
23-1360906 179-12-3056
?e) withheld Copy C
y. $ 0.00 $ 5,729.01 For Recipients
RECIPIENTS mama,address(bduding apL oo.),dy,stale and ZIP wde 5 Employee contributions 6 Net urxearaetl apProtlafion Records
/Designated Roth contributions bamplolefaecanitim
or insurance premiums
KENNETH W GUTSHALL $ 0.00 $ 0.00
BENEF FOR SANDRA K GUTSHALL 7 Disbbution IRAMEP/ 8 Other
4724 E TRINDLE RD COs) SIMPLE
MECHANICSBURG, PA 17050 4 0 $ 0.00 %
sa Yaurpercentage of 9b Total This information
n9 aIa���I U I II II II I a I'I II I III I II a I I)I I�I I�I��II total distribution co,bubbWors� is being furnished
to the Internal
% $ 0.00 Revenue Service.
12 State tax withheld 13 Stara/Payers state no. 14 State distribution
$ Ooo - $
10 Amount allocable to IRR w iltin 5 years It lstyearoffesig.RObmnlnb. $ $
$ 0.00 15Lacelta,wilhheld 16 Name oftocably 17 Loral d¢tnbution
Account number(see insbutions) $ 0.00 $
)DOODO X024 $ $
Form 1099-R Substitute Form (Keep for your records.) w Jragov/fonn1o99r DepartnentofMeTreasury-InernalRevenueService
Instructions for Recipient (conanued)
Box 7.The following codes identify the distribution you received.For more Box&If you received an annuity contract as part of a distribution,the value of the
information on these distributions,see the instructions for your tax return.Also, contract is shown,It is not taxable when you receive it and should not be included in
certain distributors may be subject to an additional 10%tax See the instructions for boxes 1 and 2a.When you receive periodic payments from the annuity contract,they
Form 5329. are taxable at that time.If the distribution is made to more than one person,the
percentage of the annuity contract distributed to you is also shown.
1-Early distribution,no known exception(in most cases,under age 591/2). You will need this information if you use the 10-year tax option(Form 4972).If
2-Early distribution,exception applies(under age 591/2). charges were made for qualified long-tens care insurance contracts under combined
3-Disability. arrangements,the amount of the reduction in the investment(but not below zero)in
4-Death. the annuity or life insurance contract is reported here.
5-Prohibited transaction. Box 9a.If a total distribution was made to more than one person,the percentage
6-Section 1035 exchange(a tax-file exchange of life insurance,annuity,qualified you received is shown.
long-term rare insurance,or endowment contracts). Box 9b.For a life annuity from a qualified plan or from a section 403(b)plan(with
7-Normal distribution. after-tax contributions),an amount may be shown for the employee's total
8-Excess wrdributions plus eamings/excess deferrals(and/or earnings)taxable in investment in the contract It is used to compute the taxable part of the distribution.
2013. See Pub.575.
9-Cost of wment life insurance protection. Box 10.If an amount is reported in this box,we the instructions for Form 5329 and
A-May be eligible for 10-year tax option(see Form 4972). Pub.575.
B-Designated Roth account distribution. Box 11.The 1st year you made a contribution to the designated Rath account
Note.If Code B is in box 7 and an amount is reported in box 10,see the instructions reported on this form is shown in this box.
for Form 5329. Boxes 12-17.If state or local income tax was withheld from the distribution,boxes
D-Annuity payments from nonqualified annuities that may be subject to tax under 14 and 17 may show the part of the distribution subject to state andlor local tax.
section 1411.
E-Distributions under Employee Plans Compliance Resolution System(EPCRS). Future developments.For the latest information about developments related to
F-Charitable gift annuity. Form 1099-R and its instructions,such as legislation enacted after they were
G-Direct rollover W a distribution(other than a designated Roth account distribution) published,go to www.h&gowform1099r.
to a qualified plan,a section 403(b)plan,a governmental section 457(b)plan,or an
IRA
H-Direct rollover of a designated Roth account distribution to a Roth IRA Additional Information.You may want to see:
J-Early distribution from a Roth IRA,no known exception(in most cases,under age
59 112). Form W-4P,Withholding Certificate for Pension or Annuity Payments,
L-Loans treated as distibutions. - Form 4972,Tax on Lump-Sum Distributions,
N-Rechamcterized IRA contribution made for 2013 and recharacterized in 2013. Form 5329,Additional Taxes on Qualified Plans(Including IRAs)and Other Tax-
P-Excess contributions plus earnings/excess deferrals(and/or earnings)taxable in Favored Accounts,
2012. Form 8606,Nondeductible IRAs,
Q-Qualified distribution from a Roth IRA Pub.560,Retirement Plans for Small Business(SEP,SIMPLE,and Qualified
R-Recharac(erized IRA contribution made for 2012 and rechamcter zed in 2013. Plans),
S-Eady distribution from a SIMPLE IRA in first 2 years,no known exception(under Pub.571,Tax-Sheltered Annuity Plans(403(b)Plans),
age 591/2). Pub.675,Pension and Annuity Income,
T-Roth IRA distribution,exception applies. Pub.590,Individual Retirement Arrangements(IRAs),
U-Dividend distribution from ESOP under sec.404(k).Note.This distribution is not Pub.721,Tax Guide to U.S.Civil Service Retirement Benefits,
eligible for rollover. Pub.939,General Rule for Pensions and Annuities,
W-Charges or payments for purchasing qualified long-term care insurance contracts Pub.969,Health Savings Accounts and Other Tax-Favored Health Plans.
under combined arrangements.
If the IRA/SEP/SIMPLE box is checked,you have received a traditional IRA,SEP, -
or SIMPLE distribution.
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
sarl&r a K GLAtsl�ot ll 2113 - Nall
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.
ITEM DESCRIPTION OF PROPERTY
INCWDE THE RANE OF THE TRANSFEREE,THER RELATIONSHIP TO DKEDEwr MD DATE OF DEATH % DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. AT(ACH A COPY OF THE DEED RM REAL ESTATE, VALUE OF ASSET INTEREST IFmPua VALUE
' V)enne.+k bJ . GcA 'skA d ( , P44er _1�4_I2L(,Gb
2.
r")G i rt�sf CON PcZn
y LLC
TOTAL(Also enter on Line 7, Recapitulation) $
If more space is needed,use additional sheets of paper of the same size.
ING 4 1
00002
IMPORTANT NOTICE
NOTIFICATION OF CLOSURE
ING's Financial Lifeline
August 11, 2014
KENNETH W GUTSHALL
4724 EAST TRINDLE RD
MECHANICSBURG, PA 17050
Dear Accountholder :
Per your request, your Account## 81300072010253 has been fully redeemed and closed. A check for
the outstanding balance and remaining Interest in the amount of $27,724.60 will be sent separately to
--the registered-address-for-this-Account.---.---
If you have any questions, please call 1.800-625.7440 Monday- Friday from 8:00 AM TO 7:00 PM ET.
Sincerely,
ING's Financial Lifeline
\O PAYER3®.-O ,dd=ftsf W,md ZIPevde - frtehmted)
Bqq' MG 7Ydst COmp2Ly,LLC _ _ CORMCM OMB No.15454119 Distributions From
s y
FBO-CAMP HH.L ANIMAL HOSPITAL i a.>Qaam� Copy B Peos�Retir�l og
a .71717th Sheet,Suite 1380 9,163.74 PmfitSbarigg Plans,
iY a Denver,Co S8202
- tRAs,Inanrance
- 9,163.74 Porm 1099=R C,== ,w,
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75-31864 SRR-RR-1718 R
2013
3 vc SFm,Ndxrmbmmvim�resm® 6rmrmisa�ppic'um'om laiMtdmmde s0� ❑
$ : 1,832.71 4
RHr19QTt'S,mme.meet (tee0.d�aptm�tlry mm.aOd ZlP evde 9 0d _ .9a Yaor% IDTa Tmlq=CQ*R
DE[.ORES GUTSHALL s x rend olm. s s
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MECHANICSBURG,PA 17850 PA s
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If you have questions about your payment,Please call your employer or plan administrator.'
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m FBOe CAMP H11.L ANn4AL HOSPITAti - . t cmRemaaa(m, - For,Reciplenl's . _ - ReGtcment cr
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Denver,CO 80202 - € -
.9;163.74 =: Form 1099-R ��"pc.
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0 o TAX INFORMATION - RETAIN FOR YOUR FIGS$
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['�`�"�❑CORRECTED 0,MB No. 1545-0119 Dislributi n From
MG Trust Compmy,LLC Pensions.Ammrties,
_ FBO:CAMP HHd.ANIMAL HOSPITAL _ -l omsamnrodm Copy 2 Retirement or
71717th Street,Suite 1300 ra 9,14,r.-.. profitShming Plans.
�. Deaver,C980202 .,_. 9.163.74. Form los9-R Cootrirssaetc.
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