HomeMy WebLinkAbout10-03-14 (2) REV-1500Ex(°2_"'
1505610143
`LLi OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOx.280601 INHERITANCE TAX RETURN 2 1 13 1053
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
06 13 2001 08 10 1928
Decedent's Last Name Suffix Decedent's First Name MI
OWENS RAYMOND F
(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
® 1. Original Return ❑ 2. Supplemental Return ❑ 3,Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a.Future Interest Compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
❑ g Decedent Died Testate ❑ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
❑ 9. Litigation Proceeds Received ❑ 1 o.Spousal Poverty Credit(Date of Death ❑ 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
NORA F BLAIR 717 541 1428
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REGIS-[�R OF WILLIE ONNL`at
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c o M C->
First Line of Address
5440 JONESTOWN ROAD _T_
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Second Line of Address ,- U+ f
PO BOX 6 2 1 6 r �= -n `*t
City or Post Office State ZIP CodeDAE FILED rE n
.. :.Z1 N r"" i's'1
HARRISBURG PA 171120216
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Correspondent's e-mail address: NFBLAW@comcast.net
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.
SIG ATU .E.OF 19 RESPONSIBLE FOR ILING RETURN DATE
Lisa A. Owens
` ADD S
1A 0.10Depot Road, New Cumberland, PA 17070
SIGN E OF PREPARE ETHER N R N DATE
Nora F Blair
ADD SS
5440 Jonestown Road, Harrisburg, PA 171120216
Side 1
1505610143 1505610143
N 1505610293
N
eEv'1n0VEX
Decedent's Social Security Number
Decedent's Name: 0VVENS, RAYMOND F
RECAPITULATION
1, Real Estate(Schedule A)t..... ............. .............. ...........__ .......................... 55 , 475 . OO
o. Stocks and Bonds(Schedule B).......................................................................... u.
3. Closely Held Corporation, Partnership n,Sole-Proprietorship(Schedule C)--- 3.
4. Mortgages&Notes Receivable(Schedule D)................ .........................—........ 4.
5, Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)—...... ' o,
K Jointly Owned Property(Schedule F) [] Separate Billing Requested— ....... 6. 3 ^ 000 ^ 00
7, Inter-VivooTransfers&Miscellaneous Non-Probate Property
(Schedule G) [] GeporateEi||ingRequeoted---- r.
8, Total Gross Assets(total Lines 1through 7>...... ........... ........................... ........ 8. 58 , 475 . 00
10, Debts ufDecedent,Mortgage Liabilities and Liens(Schedule 1)....-------- 18 2 , 37I ~ 79
11. Total Deductions(total Lines 9and 10). ............................................................ 11. _ 19 , 1I5 . 41 '
' 12. Net Value mfEstate(Line 0minus Line 11} .......... ........... ......... — ....... ............ 12. 39 ° 35g ^ 59
13, Charitable and Governmental Bequests/Sec 8113Trusts for which
an election to tax has not been made(Schedule J........... ........... ...................... 13.
14` Net Value Subject moTax(Lmo1zminus Line 1o)..... —...... ...... .... 14� 39 ^ 359 . 5g
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15� Amount ovLine 14taxable
at the spousal tax rate,or
transfers under Sec.9118
(o)(1.2)x.00 15.
16 Amount ofLine 14 taxable
at lineal rate X _— 3 9 , 359 . 59 16. I , 771 . 18
17. Amount ofLine/4taxable
ausibling rate x .12 17.
18. Amount ofLine 14taxable
atcollateral rate n 15 18.
19, TAX DUE ----- ....—........... --- ............ ..................... ........................ 19. 1 , 77I . 18
20. FILL|mTHE OVAL|FYOU ARE REQUESTING 4REFUND OpxmOVERPAYMENT. F—1
L�
Side 2
N 1505610243 1505610243 N
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REV-1500 EX Page 3 File Number 21 - 13 - 1053
Decedent's Complete Address:
DECEDENT'S NAME
Owens, Raymond F
STREET ADDRESS Yu
5223 Windsor Boulvard
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 1,771.18
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits(A +B) (2) 0.00
3. Interest
(3) 1,083.10
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 theTAX DUE C5) 2,854.28
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;................................ ❑ ❑x
F-1 c. retain a reversionary interest;or............................................................................................................ 0
d. receive the promise for life of either payments,benefits or careZ.......................................................... ❑
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receivingadequate considerationZ................................................................................................................ ❑ C
3. Did decedent own an"in trust for' or payable upon death bank account or security at his or her death3....... ❑ E
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 RETUR
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 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
[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 21ears 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)(11.2)].
•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)1. 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.
� pennsylvania
iB I SCHEDULE A
: DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Owens, Raymond F 21 - 13 - 1053
All real property owned solely or as a tenant in common must be reported at fair market valud:air market value is defined as the price
at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having
reasonable knowledge of the relevant facts.Real property which is jointly-owned with right of survivorship must be disclosed on
schedule F.
Attach a copy of the settlement sheet if the property has been sold.
Include a copy of the deed showing decedent's interest if owned as tenant in common.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 5223 Windsor Boulevard, Mechanicsburg, Pennsylvania. Property is jointly owned as tenants 55,475.00
in common with decedent's ex-wife Mary Lee Owens--Assessed value as of 2001 was 110,950
TOTAL(Also enter on Line 1, Recapitulation) 55,475.00
REV-1509 EX+(01-10)
-. pennsylvania
DEPARTMENT OF REVENUE SCHEDULE F
INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF Owens, Raymond F FILE NUMBER
21 - 13 - 1053
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
Mary Lee Owens 5223 Windsor Boulvard Ex-Wife
A Mechanicsburg, PA 17055
JOINTLY OWNED PROPERTY:
LETTER DATE C%SCRIPT.ION C�F PRO�ERTY %OF DATE OF DEATH
ITEM Include name o Inanclal Instltu F an bank account numberDATE OF DEATH VALUE of
NUMBER FOR JOINT MADE or similar identifying number.Attach deed for jointly-held real'VALUE OF ASSET DECKS
TENANT JOINT estate. I INTERES DECEDENT'S INTEREST
1 A Checking Account--used to pay expenses for I 6,000.00 50% 3,000.00
i property owned by decedent
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TOTAL(Also enter on line 6, Recapitulation) 3,000.00
REV-1511 EX+(10-09)
-A; pennsylvania SCHEDULER
DEPARTMENT OF REVENUE I FUNERAL EXPENSES
DXPENSESANND
INHERITANCE TAX URN
RESIDENT DECENT FDMIN1cpT1VE COSTS
ESTATE OF Owens, Raymond F FILE NUMBER
_
21 - 13 - 1053
Decedent's debts must be reported-on Schedule I.
ITEM —
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 1 Cremation Society of PA 195.00
2 Funeral Luncheon 200.00
B. ADMINISTRATIVE COSTS:
�. Personal Representative's Commissions
Name of Personal Representative(s)
i
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees Nora F. Blair, Esquire 2,000.00
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 Cumberland County Register of Wills 208.50
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5. Accountant's Fees
6. + Tax Return Preparer's Fees
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7. Other Administrative Costs
Lower Allen Township (curb replacement) 195.00
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See attached 13,945.12
TOTAL(Also enter on line 9, Recapitulation) i 16,743.62
Schedule H
Funeral Eensee&
T
INHERITANCE TAX RETURN tive
COMMONWEALTH PENNSYLVANIA AdministraCosts continued
RESIDENT DECEDENT
ESTATE OF Owens, Raymond F FILE NUMBER
21 - 13- 1053
2 Real Estate Taxes---$21,635.24 taxes since decedent's death. Estate is responsible 10,817.62
for one-half of those taxes. Funds from joint account used to pay some of these
expenses but funds were depleted before all were paid.
3 Administrator's expenses 269.00
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4 Erie Homeowners Insurance--amount shown is one-half of the premiums paid since 2,604.50
date of death.
5 Repair& Maintenance 254.00
Page 2 of Schedule H
pennsylvania SCHEDULE 1
DEPARTMENT OFDEBTS OF DECEDENT
INHERITANCE TAXAXRETURN
, MORTGAGE
RESIDENT DECEDENT LIABILITIES & LIENS
FILE NUMBER
ESTATE OF Owens, Raymond F 21 - 13 - 1053
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Dr. Owens. Funds from joint account with ex-wife were used to pay these medical expenses. 39.71
2 Magnetic Imaging 107.44
3 Internists of Central PA 113.97
4 Holy Spirit Hospital 1,022.97
5 Drs. Andrew and Patel 97.33
6 Mid Penn Urology 511.33
7 K.K. Surgical Group 263.28
8 West Shore Anesthesia 51.30
9 Moffit Pease Lim Associates 16.62
10 West Shore Pathology 43.21
11 Orthopedic Surgical Center PA 30.87
12 West Shore Emergency Medical 73.76
TOTAL(Also enter on Line 10, Recapitulation) 2,371.79
REV-1513 EX+(01-10)
Pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Owens, Raymond F
21 - 13- 1053
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I, TAXABLE DISTRIBUTIONS(include outright spousal
distributions, and transfers
under Sec.9116(a)(1.2)]
1 Robert Owens Son One-third of your
2901 Society Hill Drive, Apt 102 father's interest in
Camp Hill, PA 17011 the real estate
located at 5223
Windsor Road,
Mechanicsburg, PA i
l 17055 after payment
of all expenses. The
distribution of this j
will need to be
determined.
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
REV-1513 EX+(01-10)
pennsylvania
DEPARTMENT OF REVENUE SCHEDULE J
INHERITANCE TAX RETURN BENEFICIARIES continued
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Owens, Raymond F
21 - 13 - 1053
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I� TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
2 Lisa Owens Daughter One-third of your
1 A Old Depot Road father's interest in
New Cumberland, PA 17070 the real estate
located at 5223
Windsor Road,
Mechanicsburg, PA
17055 after payment
of all expenses. The
distribution of this
will need to be
determined.
3 Karen L. Owens Daughter One-third of your
500 Geneva Drive, Apt A6 father's interest in
Mechanicsburg, PA 17055 the real estate
located at 5223
Windsor Road,
Mechanicsburg, PA
17055 after payment
of all expenses. The
distribution of this
will need to be
determined.
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Page 2 of Schedule J