HomeMy WebLinkAbout09-12-14 REV-1500 EX(02-11) 1505610143
' OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County code Year File Number
Bureau of Individual Taxes Oo.TMEM tv A.M..
PO 60X.280601 INHERITANCE TAX RETURN 21 14 0413
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
02 25 2014 11 20 1940
Decedent's Last Name Suffix Decedent's First Name MI
HENDRICKS RICHARD I
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
HENDRICKS RACHEL E
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
DX IN APPROPRIATE OVALS BELOW
D 1. Original Return ❑ 2. Supplemental Return ❑ 3. Remainder Return(Date of Death
Prior to 12-13-82)
A. LimMed Estate ❑ qa.Future Interest Carexomise 5" Federal Estate Tax Return Required
(date ofpoleath after 12-12$2)
❑ 6' Decedent tacCpy of Will) ❑ �' (AltacheGOpy of Trust)Living Treat ^�" 8. Total Number of Safe Deposit Boxes
-g" Litigation Proceeds Received ❑ 1D.h e�en128�1-�f ana�7`��86 Death ❑ ti_Election to tax under Sec_8113(A)
(Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
HEATHER D ROYER (717) 234 2401 .j
ry
o -
REGISTER OF VftLtY$E ONrna M O
rTl
First Line of Address 7J n„ r-- --I C.7
r" H-+
4431 N FRONT STREET 3RD ?'„ � [v 70
C) o
Second Line of Address c.-.= c� � `1"I -TI `
c> CD n
r:7 Ca c
DATE,FILED
M
City or Post Office State ZIP Cade r-s to f
HARRISBURG PA 17110 Y ca
Correspondent's e-mail address: hroyer[alsaslip.com
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,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATUR PETS N`RE P SiBLE kQR FILI RETURN DATE
Rachel E. Hendricks - !T
ADDRESS
208 Sensate Avenue,Camp Hilt PA 17011
SIGN N DATE T R
ather D Royer
ADDRESZ
4431 N. Front Street, 3rd Floor, Harrisburg, PA
Side 1
1505610143 1505610143 J
1505612243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name. Hendricks, Richard Irvin
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2. 8, 498 . 16
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 54 ,306 . 31
6.; Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) u Separate Billing Requested............ 7. 112 , 629 . 26
8, .Total Gross Assets (total Lines 1 through 7)........................................................ 8. 175 ,433 . 73
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 14 ,822 . 95
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 97. 70
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 14, 926 . 65
12. Net Value of Estate(Line 8 minus Line 11)... - - .. ..... . 12. 160 ,513 . 08
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. 160 ,513 . 08
TAX COMPUTATION-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.00 136, 571 . 17 15. 0 . 00
16. Am Line 14 taxable 23 941 . 91 16. 1 077 - 39
at lineal neal ra rate X .045 � r
17. Amount of Line 14 taxable
at sibling rate X .12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE...................................... 19. 1 ,077 . 39
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21-14-0413
Decedent's Complete Address:
DECEDENT'S NAME
Hendricks, Richard Irvin
STREETADDRESS
406 High Street
CITY STATE ZIP
Summerdale PA 17093
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 1,077.39
2, Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +B) (2) 0.00
3. Interest (3)
4. If Line 2 is,greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT. (4)
-Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 1,077.39
Make Check Pa able 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;...... ............................................___... ❑ x
b, retain the right to designate who shall use the property transferred or its income:.................................. � x
c. retain a reversionary interest:or.........._.............................._............................._......_............................ � x
d. receive the promise for life of either payments,benefits or care?............................................................ FAI
2 If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?...................................-............................................................................... 0
3. Did decedent awn 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 of 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 172 P.S.§9116(a)(1.1)(i)).
For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
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 sfill 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)(12)).
• 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)1.
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent 172 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.
Re,1503 E%+(6-98)
SCHEDULE E
STOCKS & BONDS
COMMONWEALTHOFPENNSYLVANA
INHERITANCE TAR RETURN
RESIDENTDECEDENT
ESTATE OF FILE NUMBER
Hendricks, Richard Irvin 21-14-0413
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 444 shares of Manulife Financial-444 Shares of Manulife 19.14 8,498.16
Financial Corporation stock
2/25/14 High: $19.23 Low:$19.05=Mean: $19.14
TOTAL(Also enter on Line 2, Recapitulation) 8,498.16
(If more space is needed,additional pages of the same size)
Copyright(c)2002 form software only The Lackner Group, Inc. - Form PA-1500 Schedule B(Rev.6-98)
Rev-1508 EX+tdi 10)
SCHEDULE E
Pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hendricks, Richard Irvin 21-14-0413
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Cash-Money in safe deposit box deposited to Riverview Bank checking account 37,800.00
2 Riverview Bank-Checking Account#417718 4,449.17
3 Riverview Bank Money Market Account-Money Market Account#226397110 6,409.31
4 Automobile-Value per sale of 2009 Chevrolet Impala 5,000.00
5 Automobile-Value per sale of 1994 Jeep 300.00
6 Trailer-Value per sale-1997 Light Trailer 100.00
7 United HealthCare Services, Inc. -Health Insurance Refund 41.70
8 Verizon Wireless-Refund for overpayment of invoice 206.13
TOTAL(Also enter on Line 5, Recapitulation) 54,306.31
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10)
Rev-1510 EX+(0809)
SCHEDULE G
Pennsylvania INTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hendricks; Richard Irvin 21-14-0413
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REVA 500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE NAME TRANSFER. ATTACH THEIR COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 Riverview Bank-Time Deposit-IRA#9400223 112,629.26 112,629.26
Beneficiary: Wife, Rachel Hendricks
TOTAL(Also enter on Line 7, Recapitulation) 112,629.26
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule G(Rev. 08-09)
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
Hendricks, Richard Irvin 21-14-0413
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. - FUNERAL EXPENSES:
See continuation schedule(s) attached 4,151.65
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid
2. Attorney's Fees Smigel,Anderson & Sacks, LLP 8,500.00
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State -Zic
RelationshiD of Claimant to Decedent
4. Probate Fees 253.50
5. Accountant's Fees 920.00
6. .Tax Return Preparer's Fees
7. Other Administrative Costs 997.80
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 14,822.95
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULEH
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Hendricks, Richard Irvin 21-14-0413
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Hetrick Bitner Funeral Home-Funeral - 4,151.65
H-A 4,151.65
Other Administrative Costs
2 AAA-Notary fee for sale of trailer. 5.00
3 Cumberland Law Journal -Legal advertisement 75.00
4 Dumpster Rental Unlimited-Dumpster to clean out house. 631.80
5 Duty's Lock,Safe and Security, Inc. -Enter safe at home. 63.60
6 The Sentinel-Legal Advertising 222.40
- H-137 997.80
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev.6-98)
Rev-1512 EX*(1208) �p
SCHEDULE i
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hendricks, Richard Irvin 21-14-0413
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 Mechanicsburg Area Meals on Wheels-February meals 56.00
2 United HealthCare Services, Inc. -Payment for insurance 41.70
TOTAL(Also enter on Line 10, Recapitulation) 97.70
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
• REV-1513 EX.(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hendricks, Richard Irvin 21-14-0413
NUMBER NAME AND ADDRESS OF DECEDENT RELATIONSHIP TO SHARE ESTATE AMOUNT ESTATE
PERSON(S)RECEIVING PROPERTY Do Not List Trutees (Words)ds) ($$$$$)
g. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec. 9116(a)(1.2)]
Jason Hendricks Son One-fourth of
3538 Citation Road Fifty(50%)
Cheyenne,WY 82009 percent of Estate
Joshua Hendricks Son One-Fourth of
208 Senate Avenue Fifty(50%)
Apt. 208 Percent of Estate
Camp Hill, PA 17011
Michael Hendricks Son One-Fourth of
134 Kenney Drive Fifty(50%)
Sewickley, PA 15143 Percent of Estate
Rachel E Hendricks Spouse One half(50%)of
208 Senate Avenue the Estate
Apt. 208
Camp Hill, PA 17011
Richard Hendricks Son One-Fourth of
71 Vine Street Fifty(50%)
Ambridge, PA 15003 Percent of Estate
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II• A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Inc. I Form PA-1500 Schedule J(Rev.01-10)
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R' ����E�V BANK �c.C`o
r AND ITS OPERATING DIVISIONS
200 Feon4 S¢ree¢,PO Box B,Marysville,PA 17063
www.riverviewbankpa.com
May 22,2014
Smigel,Anderson;&Sacks LLP - - REi Estate of Richard I Hendricks
4431 North Front Street DOD: 2/25/2014
Harrisburg PA 17110
AccountNumber(s) 322636 . 417718 226397110
Type of Account Checking Checking Money Market
Date Opened October 31, 1980 February 6,2003 February 13,2013
Principal Balance at date of death $613.82 $4,449.17 $6,409.31
Interest Rate N/A
N/A 0.5980%
Accrued Interest not
disbursed as of date of death $1.58
Maturity Date
Primary Owner of Account Richard I Hendricks Richard I Hendricks Richard I Hendricks
Name of Joint Owner(s),if any Rachel Hendricks
Beneficiary,if any
Date Joint Ownership was
Established October 31, 1980
If within I year of death of
Decedent could prior Account
Be traced into a prior Joint
Account in existence over
I year prior to death of
Decedent
Halifax Bank Marysville Bank
300 Markey Street 200 Front Street
PO Box PO Box
Halifax Bank Halifax,PA 17032 AViUeMarysville,PA 17053
www.hatifaxbankpa.com www.marysvillebankpa.com
ICI 1Ig�T�IE�T BAN K
.1y AND ITS OPERATING DIVISIONS
200 Fron85¢reeY,PO Box B,Marysville,PA 17053
www.riverviewban kpa.com
Smigel,.Anderson, &Sacks LLP-
4431 North Front Street state RE: E of Richard I Hendricks
Harrisburg PA 17110 DOD: Estate 014
Account Number(s) 9400223
Type of Account Time Deposit-IRA
Date Opened July 21, 1997
Principal Balance at date of death $112,629.26
Interest Rate 1.9800%
Accrued Interest not
disbursed as of date of death $30.55
Maturity Date
Primary Owner of Account Richard I Hendricks
Name of Joint Owner(s),if any
Beneficiary,if any Rachel Hendricks
Date Joint Ownership was
Established
If within 1 year of death of
Decedent could prior Account
Be traced into a prior Joint
Account in existence over
1 year prior to death of
Decedent
Box#222 Marysville Bank,500 South State St,Marysville PA 17053
Safe Deposit Box(s)and Location
By:
Christina e'ders
Halifax Bank Marysville Bank
300 Market Street 200 Front street
_ ,�; PO Box A - PO Box B
HaUfaxBank Halifax,PA 17032 4VIUeMarysville,PA 17053
www.halifaxbankpa.com www.marysvillebankpa.com