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HomeMy WebLinkAbout10-02-14 1505610101 REV-1500 Ex(°'-lo) OFFICIAL USE ONLY PA Department of Revenue Pennsylvania OE-M-0FNEVENVE County Code Year File Number Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN L VHarrisburg,PA 17128-06oi RESIDENT DECEDENT �^ Wj 0 � ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Lei.. r/12 I �U® �b�� Decedent's Last Name Suffix Decedent's First Name MI i0j, (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI 01 Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE �Ulll�'�I❑ REGISTER OF WILLS FILL N APPROPRIATE OVALS BELOW 1.Original Return p 2.Supplemental Return Q 3. Remainder Return(date of death ., prior to 12-13-82) Q 4. Limited Estate p 4a. Future Interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12-82) CM 6. Decedent Died Testate p 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Q 9. Litigation Proceeds Received Q 10.Spousal Poverty Credit(date of death Q 11. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.O) - CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 7-_- _:�T-rr, L-4 R 6IS R OF W116 US_N� First line of address r M rri Second line of address c, *t Z3 711 City or Post Office State ZIP Code DATE IRbIED Cn o ` I h14 L �DCIDCIFI ,112E 11DD1�1 Correspondent's e-mail address: If©SQA K/mus LVq+v ell✓403'PN. ce 1-t. Under penalties of perjury,I declare that I have examined this return,including acconipanying 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 URE OF PE SON RESPONSIBLE FOR FILING RETURN 17 D TE A D iS re) CJ ( Q SIGNiNTURE OF PRE RTHER THAN REPRESENTATIVE DATE ris D S PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610101 1505610101 vi 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. Real Estate(Schedule A). ....... .... .................... ............. 1. JLJL 1JW J •L�D 2. Stocks and Bonds(Schedule B) ..................... .................. 2. :Ja��_IiJidfl;� 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. ... 3. ��� �%�•�VG/J; "... .� 4. Mortgages and Notes Receivable Schedule D �J0D0' 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 6. Jointly Owned Property Y(Schedule F) OSeparate Billing Requested ....... 6. (�JJU�L___1 J- Q: �•������ 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 8. Total Gross Assets(total Lines 1 through 7). ..... ..... ..... ............. 8. 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 1 11_01� ' j2. � 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule I) ......... ..... 10. Ll ,u111-1 11. Total Deductions total Lines 9 and 10 .. ...........•. 12. Net 11 13. Chartable and Governmental Be Bequests/Sec 9113 Trusts for which 12 1 � 1 -- � .� ( ) ... ..... q an election to tax has not been made(Schedule J) .. . .... ..... ......... ... 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) . ... .. .................. 14. J JI JI ,Z�� �l • TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 - _ I { I .I 15. �J (a)(1.2)X.0L �Jl�J�JJ�J 16. Amount of Line 14 taxable at lineal rate X.0q.5rJUi � � � �.(La 16 17. Amount of Line 14 taxable --i at sibling rate X.12 �L]I � JJ 17 18. Amount of Line 14 taxable a at collateral rate X.15 4` 18 19. TAX DUE ... ... ................. .... .......... ..... ......... ..... . 19. JJ� 20. FILL IN THE OVAL 1F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 L 1505610105 1505610105 REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NA t,I M�C STREET ADDRESS s3v 41 eL 4A CITY STATE ZIP � A, c- /,4 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) L1 6 C) 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 3. Interest 4. If Line 2 is greater than Line 1 +Line 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) 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;............................................ ❑ ja c. retain a reversionary interest;or.......................................................................................................................... ❑ a d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ _- a 2. If death occurred after Dec. 12,1982,did decedent transfer property within one year of death without receiving adequate consideration?..............................................................................................................0 El3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ tQ- 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)(()]. 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(1.2)[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-1502 EX+ (11-08) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER All real property owned solely or as a tenant in common must be reported at fair market value.Fair 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 that 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. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. TOTAL(Also enter on Line 1, Recapitulation.) $ If more space is needed, insert additional sheets of the same size. REV-1503 EX+(6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL(Also enter on line 2, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1507 EX+(1-97) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 4, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1508 EX-(1-97) y SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF FILE NUMBER 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 d J c- 2lie,•'`�J TOTAL(Also enter on line 5,Recapitulation) $ •� -C, (If more space is needed,insert additional sheets of the same size) REV-1509 EX-(1-97) 4& SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 A. B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number.Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed forjointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL,(Also enter on line 6,Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1510 EX+ (08-09) T_- SCHEDULE C ® {i pennSytvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER This schedule must be completed and filed if the answer t0 any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OFTRANSFER, ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. AT. TOTAL(Also enter on Line 7, Recapitulation) $ 35��• ')'7 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+ (10-09) 4- b-i pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. 1. FUNERAL EXPENSES: LL1 VAS cLvl. - A g S 4'v V Vt (40', C-/ B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Attorney Fees: 3 O Cl 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: 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-08) ® pennsylvania SCHEDULE .I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER 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. TOTAL(Also enter on Line 10, Recapitulation) $ If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) r J ® ]pennsylvania SCHEDULE , DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: 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).] 2 4 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 TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: i. TOTAL OF PART II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. Performance Checking Statement PNC Bank Primary account number:51-4011-5523 Page 1 of 2 For the period 11/16/2013 to 12/16/2013 Number of enclosures:0 C3 For 24-hour banking,and transaction or DIMKO V ANGELOFF interest rate information,sign on to ROBERT W STAUB PNC Bank Online Banking at pnc.com. 353 RAYMOND RD a For customer service call 1-888-PNC-BANK ENOLA PA 17025-2145 Monday-Friday: 7 AM-10 PM ET Saturday&Sunday: 8 AM-5 PM ET Para servicio en espanol,'1-866-HOLA-PNC Moving? Please contact us at 1-888-PNC-BANK ® Write to:Customer Service PO Box 609 Pittsburgh PA 15230-9738 Visit us at PNC.com TDD terminal:1-800-531-1648 For hearing impaired clients only Performance Checking Dimko V Angeloff Interest Checking Account Summary Robert W Staub Account number: 51-4011-5523 Overdraft Protection has not been established for this account. Please contact us if you would like to set up this service. Overdraft Coverage -Your account is currently Opted-Out. You or your joint owner may revoke your opt-in or opt-out choice at any time. To learn more about PNC Overdraft Solutions visit us online at pnc.com/overdraftsolutions. Call 1-877-588-3605,visit any branch,or Sign on to PNC Online Banking,and select the"Overdraft Solutions"link under the Account Services section to manage both your Overdraft Coverage and Overdraft Protection settings. Balance Summary Beginning Deposits and Checks and other Ending balance other additions deductions balance - 21,870.28 874.92 2,501.57 20,243.63 Average monthly Charges balance and fees 21,093.01 .00 Transaction Summary Checks paid/ Check Card POS Check Card/Bankcard withdrawals signed transactions POS PIN transactions 5 0 0 Total ATM PNC Bank Other Bank transactions ATM transactions ATM transactions 0 0 0 Interest Summary As of 12/16,a total of $1.26 in interest was Annual Percentage Number of days Average collected Interest Paid paid this year. Yield Earned(APYE) in interest period balance for APYE this period 0.01 % 31 21,093.01 .18 FROM Sullivan Funeral Home PHONE NO. : 17177322I62 SEP. 04 2014 01: 10PM Pi SULLIVkN FUNERAL HOME & CREMATION SERVICES, I I Monday,November 18,20 13 Robert Staub 311 College Hill Rd. Enola,PA 17025 Dear Robert, Thank you for placing your tnist in our.,�ervices.We hope that we have:met your cxpectutions and made this difficult time a little easier. Below are the charges that your family has incurred.Plca,e make paymot,within 30 days of the above date. DIMKO V. jkN-,(-.-EL0FF,1SR. PROfESSIONA-L SERVICES Package Fwi=l Offering $6485.00 $inc Embalming $inc Dressing,Casketing,and Cosmetology $inc Total Funeral Service SclLct.W TOTAL IIROFESSJONAL SERVICES $6,495.00 Use of Facilities&-Staff for Visitation $inc Use of Facilities&Stag-for CeremonyatVuacralklorne $inc Transfer of Rcmains to Funeral 110me $inc Hcarse Funeral Coach $inc Flower Vehicle $inc PI*ower[Lead Car S inc Service J Utility.Vehicle $inc OTHER MERCHANDISE SELECTED Casket:: Coliunbia Treemont 20ga, $1,350-00 Acknowledgement Card-, 25 $inc -Register Book Military $inc MemorialTolders Military t inc CASH ADVANCES TOTAL OTHER MEr!— RC51AN1XSSELECTED $1,350.00 Certified Copies of Death Certificate $inc Cumberland County Honor Citiard $ 1.00.00 CASH ADVANCE TOTAL $100.00 TOTAL OF SERVICES $7,935.00 BALANCE DjT.E $7—,935.00 If there-,are any questions or Concerns that remain Llnanswered,please call me, Sincerely, Mario A.Billow Funeral'Director. OMB Approval No.2502-0265 A. Uhl mmint Stamment (HUDA) J!, FX�FHA 2.❑RHS 3.❑Conv.Unins. 6.File Number: 17.Loan Number: 8.Mortgage Insurance Case Number: P,365 14711222 446-2142389-703 ❑VA 5.[]Conv,ins, Note:This form is furnished to give you a statement of actual settlement costs.Amounts paid to and by the settlement agents are shown.Items marked "(p.o.c)"were paid outside the closing;they are shown here for Informational purposes and are not included in the totals. Name&Address of Borrower. E.Name&Address of Seller: F.Name&Address of Lender: as S.Myers Robert Staub,Nancy Staub Pacific Union Financial,LLC 351'.-abacker'Road,Columbia,PA 17512 311 College Hill Road,Enoia,PA 17025 1603 LBJ Freeway,Suite 630,Farmers Branch TX 75234 s.Property Location: H.Settlement Agent I.Settlement Date:0812812014 .53 Raymond Road I st Advantage Settlement Services Inc. Disbursement Date:0812812014 :nota,PA 17025 6375 Mercury Drive,Suite 102,IN)Iechanicsburg,PA 17050 last Pennsboro Township 717-591-7755 Place of Settlement: TitleExpress 6375 Mercury Drive,Suite 102,Mechanicsburg,PA 17050 Printed 08128/2014 at I t51 am by VW 100. Gross Amount Due from Borrower 400. Gross Amount Due to Seller 101. Contract sales price 125,000.00 401. Contract sales price 125,000.001 102. Personal voce"t 402. Personal property 103. Se','.Iementcharges toborro,,-ae (line 1400) 6,587.19 403. 104. 404. 105. 405. Adjustments for items paid by seller in advance -Adjustments for items paid by seller in advance 106. City/town taxes to 406. City/town taxes to 107. County taxes 08012014 to 12/31/2014 160A6 407. County taxes 08128/2014 to 1213112014 160,461 108. School Taxes 08/28/2014 to 06/30/2015 1,296.82 408. School Taxes 0812812014'o o 06,130015 1,296.821 109. 3rd Qtr Sewer 08128/2014 to 0913012014 33.82 409. 3rd Qtr Sewer 0812812014 m 0913012014 33.82 110, to r 410, to - 411. ,12. 412. 120. Gross Amount Due from Borrower 133,078.29 420. Gross Amount Due to Seller 126,491.10 200. Amounts Paid by or in Behalf of Borrower 500. Reductions In Amount Due to Seller 201. Deposit or eamest,money 1,000.00 501, Excess deposit(see instructions) 202. Principal amount of new loan(s) 122,735.00 502. Settlement charges to seller(line 1400) 111,758.29 203. Existino loan(s)taken subject to 503. Existing loan(s)taken subject to 204. 504, Payoff of first mortgage loan to Citilvlortgage,Inc. 211,406.75 205, 505. Payoff of second mortgage loan 206, 506. 2071. 507. 208. Tax Service Fee Credit 69.00 508. Tax Service Fee Credit 69.00 209. Seller Credit 5,899.29 509. Seller Credit 5,899.291 Adjustments for items unpaid by seller Adjustments for items unpaid by seller 210. City/town taxes to 510. City/town taxes to 211. County taxes to 5111. County taxes to 212. School Taxes to 512. School Taxes to 213. 513, 214. 514. 2115, 515, 216. 516. 217. 517. 218. 5"8. 219, 519, 220. Total Paid by/for Borrower 129,70129 520. Total Reduction Amount Due Seller 39,133331 300. Cash at Settlement fromito Borrower 600, Cash at Settlement tolfrom Seller 301. Gr-os amount due from borrower(line 120) 133,078.29 601, Gross amount due to seller(line 420) 126,49100 302 Less amounts paid by/for borrower(line 220) 129,703.29 602, Less reductions in amount due seller(line 520) 39,1133.33 303. Cash ❑d From E] To Borrower 3,375.00 603. Cash To ❑ From Seller 87,357.77 -7 _ffly Wid=B­rW Tu ct:vcvMgrs in:a:ma6Y,.EDttty the"3 Previous editions are obsolete HUD-1