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Home My WebLink About10-16-14 1505611185 REV-1500 EX(02-11)(FI) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN 21 14 0420 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 04132014 03271928 Decedent's Last Name Suffix Decedent's First Name M I ROYER J . WILLIAM (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I ROYER XENIA B Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW IF 1. Original Return ❑ 2. Supplemental Return ❑ 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate ❑ 4a. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required death after 12-12-82) 6. 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 ❑ 10. 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 JAMES A . ULSH, ESQUIRE 717-232-5000 REGISTER OF WILLS USE§NLY Q =a rCID j First Line of Address c a 3401 NORTH FRONT STREET Second Line of Address `-? S1 Z PO BOX 5950 City or Post Office State ZIP Code DATE FILED , r' HARRISBURG PA 171100950 Correspondent's e-mail address: J A U L S H a@ M E T T E - C O M 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 person representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DAIE XENIA B . ROYER D 3 ADDRESS 1408 BRANDTON ROAD MECHANI BURG, PA 17055 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DAT METTE, EVANS & WOODSIDE D s ADDRESS 3401 N . FRONT STREET, PO BO 5.950 HARRISBURG, PA 17110-0950 PLEASE USE ORIG NAL FORM ONLY Side 1 1505611185 OM46473.000 1505611185 ' 1505611285 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: R 0 Y E R J . WILLIAM YAM RECAPITULATION 1, Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 . 00 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . 2. 2?2,?28- 63 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C). . . . . 3. 0 - 00 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . 4. 0 - 00 5, Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) . . . . . 5, 79,931 -06 6, Jointly Owned Property(Schedule F) 0 Separate Billing Requested . . . . 6. 0 .00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) � Separate Billing Requested . . . . 7. 3871203 - 14 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . 8. 739-1 862 - 83 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9. 491485-19 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . 10. 25A88 -05 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11, 74 ,573 - 24 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . 12, 665 289 - 59 13, Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J). . . . . . . . . . . . . . . . 13, 248 086 - 45 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . 14. 4171203-14 TAX CALCULATION -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 o D_ 3971203-14 15. 0 .00 16. Amount of Line 14 taxable at lineal rate X.O� 201000 -00 16. 900 .00 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. 900-00 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505611285 1505611285 OM4646 3.000 REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: 21 14 0420 DECEDENTS NAME ROYER J . WILLIAM STREET ADDRESS 1408 BRANDTON ROAD CUMBERLAND COUNTY CITY STATE ZIP MECHANICSBURG PA 1?055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 900 - 00 2. Credits/Payments A. Prior Payments 855 - 00 B. Discount 45 . 0 0 Total Credits(A+B) (2) 900 - 00 3. Interest (3) 0 . 00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) 0 . 00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0 . 00 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 . . . . . . . . . . . . . . . . . . . . . . . . El retain the right to designate who shall use the property transferred or its income . . . . . . . . . . ❑ 0 c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . ❑ 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? ❑ EZ 4. Did decedent own an individual retirement account,annuity, or other non-probate property,which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X❑ ❑ 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. OM4671 2.000 REV-1503 EX+(8-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER J. William Royer 21 14 0420 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Securities held in Merrill Lynch investment Account #872-42747, as follows: 22,000 Par 22,000 Eli Lilly corporate bond Dtd:06/12/1995; Mat:06/01/2025 CUSIP: 532457AMO 28,976.75 Interest accrued to 4/13/2014 566.04 2 10,000 Par 10,000 Texas St Dpt Hsg-Cmty Dtd:11/15/2006; Mat:09/01/2027 CUSIP: 88275FLM9 10,144.05 Interest accrued to 4/13/2014 53.33 3 10,000 Par 10,000 Bedford Cnty PA AMBAC Dtd:08/15/2005; Mat:09/01/2035 CUSIP: 076059CY8 10,114.80 Interest accrued to 4/13/2014 55.56 4 15,000 Par 15,000 PA St Higher Edl Facs Dtd:07/01/2008; Mat:06/15/2021 CUSIP: 70917RRT4 16,138.65 Interest accrued to 4/13/2014 193.33 5 40,000 Par 40,000 PA St First Ser A Dtd:06/07/2007; Mat:11/01/2027 CUSIP: 70914PAV4 44,208.40 Interest accrued to 4/13/2014 844.44 6 20,000 Par 20,000 Phila PA Wtr & Wastewtr Dtd:05/09/2007; Mat:08/01/2024 CUSIP: 717893RV5 21,773.70 Interest accrued to 4/13/2014 175.00 Total from continuation schedules . . . . . . . . . 139,484.58 TOTAL (Also enter on Line 2,Recapitulation) $ 272,728.63 2w4696 2.000 If more space is needed, insert additional sheets of the same size Estate of: J. William Royer 21 14 0420 Schedule B (Page 2) Item Value at Date No. Description of Death 7 10,000 Par 10,000 Unv Pittsbrgh Cmwlth Hgh Ed Dtd:03/31/2009; Mat:09/15/2031 CUSIP: 91335VHP4 11,150.20 Interest accrued to 4/13/2014 36.11 8 10,000 Par 10,000 Montgomery Cnty PA Dtd:05/15/2009; Mat:12/01/2032 CUSIP: 613579593 10,510.80 Interest accrued to 4/13/2014 157.99 9 5,000 Par 5,000 PA St Higher EFA Dtd:11/01/2005; Mat:11/01/2033 CUSIP: 70917N8U1 5,242.15 Interest accrued to 4/13/2014 111.11 10 10,000 Par 10,000 Central Dauphin PA Sch Dtd:10/01/2006; Mat:02/01/2030 CUSIP: 153300QH4 10,293.65 Interest accrued to 4/13/2014 87.50 11 200 Shares Allete, Inc. CUSIP: 018522300 10,224.00 200 shares of common stock at $51.12 per share 12 100 Shares JP Morgan Chase & Co. CUSIP: 46625HI00 5,524.25 100 shares of common stock at $55.2425 per share Dividend accrued on 4/13/2014 38.00 13 156 Shares Johnson & Johnson CUSIP: 478160104 15,085.20 156 shares of common stock at $96.70 per share 14 28 Shares Kraft Foods Group, Inc. CUSIP: 50076QI06 1,566.29 28 shares of commoon stock at $55.93875 per share Dividend accrued on 4/13/2014 14.70 Total (Carry forward to main schedule) 70,041.95 Estate of: J. William Royer 21 14 0420 Schedule B (Page 3) Item Value at Date No. Description of Death 15 85 Shares Mondelez International CUSIP: 609207105 2,929.10 85 shares of common stock at $34.46 per share Dividend accrued on 4/13/2014 11.90 16 60 Shares Medtronic, Inc. CUSIP: 585055106 3,498.30 60 shares of common stock at $58.305 per share Dividend accrued on 4/13/2014 16.80 17 100 Shares Novartis ADR CUSIP: 66987V109 8,329.50 100 shares of common stock at $83.295 per share 18 80 Shares PNC Fincl Services Group CUSIP: 693475105 6,537.60 80 shares of common stock at $81.72 per share 19 100 Shares Procter & Gamble Co. CUSIP: 742718109 8,096.90 100 shares of common stock at $80.969 per share 20 120 Shares Pub Svc Enterprise Grp CUSIP: 744573106 4,662.00 120 shares of common stock at $38.85 per share 21 121 Shares Royal Dutch Shell PLC CUSIP: 780259206 8,912.56 121 shares of common stock at $73.6575 per share 22 100 Shares Virg El Pwr $5 Pfd Dtd:05/25/1944; Mat:12/31/2049 CUSIP: 927804609 10,735.00 100 shares of preferred stock at $107.35 per share 23 217 Shares Enterprise Prdts Prtn LP CUSIP: 293792107 15,712.97 217 shares at $72.41 per share Total (Carry forward to main schedule) 69,442.63 REV-1508 EX-(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RESIDENT DECEDENT TURN PERSONAL PROPERTY ESTATE OF: FILE NUMBER: J. William Royer 21 14 0420 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. 2005 Mercury Grand Marquis, 138,000 miles - sale proceeds 4,300.00 2 Final income distribution as the beneficiary of Residuary Trust A (credit trust) under the Last Will and Testament of Annette H. Royer dated March 18, 1997 424.55 3 Genworth Insurance - long term care insurance payments received after death 4,498.25 4 Money market funds held in Merrill Lynch Account #872- 42747 40.59 5 PNC Bank Checking Account #5140054185 70,639.13 Interest accrued to 4/13/2014 0.11 6 Transunion Privacy Litigation Settlement - class action proceeds 25.80 7 Verizon Wireless - refund 2.63 TOTAL(Also enter on line 5,Recapitulation) $ 79,931.06 2W46AD 2.000 If more space is needed,use additional sheets of paper of the same size. REV-1510 EX+(08-09) SCHEDULE G pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER J. William Royer 21 14 0420 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. DESCRIPTION OF PROPERTY EXCLUSION TAXABLE ITEM INCLL.DETFENWEOFTHE TRANSFEREE,THEIR RELATIONSHIP TOOECEDENTAND DATE OF DEATH %OFDECD'S NUMBE THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IFAPPLICABLE VALUE 1. IRA, Merrill Lynch Account #872-8699 387,203.14 100.0000 0.00 387,203.14 Beneficiary is decedent's spouse; see attached for itemization of assets and valuation TOTAL(Also enter on line 7,Recapitulation)$ 387,203.14 If more space is needed,use additional sheets of paper of the same size. 9W46AF 2.000 REV-1511 EX-(08-13) SCHEDULE H pennsylvania DEPARTMENTOF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER J. William Royer 21 14 0420 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Myers-Harner Funeral Home Funeral services 9,998.00 Total from continuation schedules . . . . . . . . . 7,161.79 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 13,580.00 Name(s)of Personal Representative(s)XENIA B. ROYER Street Address 1408 BRANDTON ROAD City MECHANICSBURG State PA ZIP 17055 Year(s)Commission Paid:2 014 2. Attorney Fees: 13,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) 3,500.00 Claimant XENIA B. ROYER Street Address 1408 BRANDTON ROAD City MECHANICSBURG State PA ZIP 17055 Relationship of Claimant to Decedent SURVIVING SPOUSE 4. Probate Fees: 498.50 5. Accountant Fees: 1,350.00 6. Tax Return Preparer Fees: 7. 1 Cumberland Law Journal Estate Notice 75.00 2 The Patriot News Estate Notice 246.90 Total from continuation schedules . . . . . . . . . 75.00 TOTAL(Also enter on Line 9,Recapitulation) $ 49,485.19 3W46AG 2.000 If more space is needed, use additional sheets of paper of the same size. Estate of: J. William Royer 21 14 0420 Schedule H Part 1 (Page 2) Item No. Description Amount 2 Blooms by Vickery Casket flowers 166.37 3 CHPC Presbyterian Women Memorial luncheon 518.23 4 Family dinners for private burial and memorial service 1,421.45 5 Gingrich Memorial Headstone 2,515.00 6 Honorariums for pastor, organist and custodian for memorial service 525.00 7 Miscellaneous funeral expenses Photos and backboard for memorial service; postage 295.74 8 Rolling Green Cemetery 1,720.00 Total (Carry forward to main schedule) 7,161.79 Estate of: J. William Royer 21 14 0420 Schedule H Part 7 (Page 2) 3 Pete Markley Removal of handicap ramp at residence 75.00 Total (Carry forward to main schedule) 75.00 REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENTOF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER J. William Royer 21 14 0420 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• American Home Medical Wheelchair rental 1.39 2 American Home Patient Oxygen 53.44 3 Barry Wagner Barber bill 50.00 4 Camp Hill Presbyterian Church Balance on 2014 pledge 5,700.00 5 Capital Area Health Association Medical services 92.70 6 Chase Card Services 205.69 7 Checks written prior to death which had not cleared the decedent's checking account at'death 1,070.23 8 Jumper's Shoe Service Shoe repair bill 165.00 9 Messiah Lifeways Nursing home services 17,649.60 10 Tracy Wiechman Griswald caregiver 100.00 TOTAL(Also enter on Line 10,Recapitulation) $ 25,088.05 2w46AH 2.000 If more space is needed, insert additional sheets of the same size. REV-1513 EX+(01-10) SCHEDULE J pennsylvania DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: J. William Royer 21 14 0420 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).) 1. Xenia B. Royer 1408 Brandton Road Mechanicsburg, PA 17055 Specific monetary bequest 10,000.00 IRA, Merrill Lynch Account #872-8699 Inventory Value: 387,203.14 Surviving Spouse 397,203.14 2 Suzanne M. Royer 218 Margate Road Lutherville, MD 21093 General Bequests: 10,000.00 Daughter 10,000.00 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. See Attached 1 B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1 1. See Attached TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 248,086.45 9W46Ai 2.000 If more space is needed,use additional sheets of paper of the same size. Estate of: J. William Royer 21 14 0420 Schedule J Part 1 (Page 2) Item No. Description Relation Amount 3 Lynne A. Royer 2 Hillcrest Drive Orinda, CA 94563 General Bequests: 10,000.00 Daughter 10,000.00 F , Estate of: J. William Royer 21 14 0420 Schedule J Part 2B (Page 1) Item No. Description Amount 1 Lehigh University 27 Memorial Drive West Office of Advancement, ATTN: L. Wiedorn Bethlehem, PA 18015-3086 Specific monetary bequest 10,000.00 10,000.00 2 Camp Hill Presbyterian Church 101 N. 23rd Street Camp Hill, PA 17011 Specific monetary bequest 5,000.00 5,000.00 3 Presbyterian Senior Living One Trinity Drive East, Suite 201 Dillsburg, PA 17019 Specific monetary bequest 5,000.00 5,000.00 REV-1649 EX+(01-14) pennsylvania SCHEDULE O DEPARTMENT OF REVENUE DEFERRAUELECTION OF INHERITANCE TAX RETURN SPOUSAL TRUSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER J William Royer 21 14 0420 X❑ PART A-DEFERRING STATEMENT For all trust assets reportable for Pennsylvania inheritance tax purposes for which a deferral of tax is chosen,the personal representative responsible for filing the return and the trustee(s) of the trust in question hereby acknowledge the department's Statement of Policy set forth at 61 Pa. Code § 94.3 concerning any potential termination of the trust under 20 Pa.C.S.§ 7710.1 that occurs after the return was filed. ❑ PART B - ELECTION TO TAX AMOUNTS Complete this section only if making the election to tax the sole use tax. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust.This election applies to the Trust(marital, residual A, B, bypass, unified credit,etc.). Enter the description and value of all interests for which the election is made. DESCRIPTION VALUE Total 0.00 If more space is needed, insert additional sheets of the same size. 3W46E2 3.000