HomeMy WebLinkAbout04-18-05
REV.1500 EX (6.00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
t0flPU
REV-1500
w
....
:.:::!(f)
0"''''
wo.o
",00
0"'-'
0. III
0.
"
INHERITANCE TAX RETURN
RESIDENT DECEDENT
~
Z
W
C
W
(.)
W
C
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
FR(1}J-rZ /"I/t.e& /2ITe. (,<J.
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
01 - ~ ~ - ,9. 0 cJ :;; 0'1 - 30- I 909
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
OFFICIAL USE ONLY
FILE NUMBER
d-L~ 05 0 'i~1_
COUNTY CODE
YEAR
NUMBER
~ 1. Original Return
D 4. Limited Estate
D 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date aldeath after 12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy oITrust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
SOCIAL SECURITY NUMBER
i 7'/
01.,09
- ,;tD
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3, Remainder Return (date 01 death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
....
Z
W
o
Z
o
0.
U>
W
'"
'"
o
o
. e../
FIRM NAME (If Applicable)
FRIl.)72.-
COMPLETE MAILING ADDRESS " n U
foi.f fJ1jJ& Tl2ee. ,..,,,-) e.
;JeM)() dIe I PI1 17::J.Lf/
OFFICIAL USE ONLY
,,'j
c_~'
..~.._-~_.~._~-----#.._~-}
.-.)
r--(j
(8)
-,.. (,)
;<).. 1 6-ye. 4::7
I,
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5) 17& t,. S- 3
(6) 'ill~$;.OO
(7) 9? &67. 7'1
(9) 9,). os.-.OO
(10) '/9:1.00
,';. 1--")
1'-0
(11)
(12)
(13)
9" 9? 00
/ 01. 90/. J< 7
3, Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
z
o
!;;:
...J
::::l
~
ii:
<I:
(.)
w
0::
5 Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8, Total Gross Assets (total Lines 1-7)
(14)
/~ 901. J.7
9 Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
z
o
!;;:
I-'
::::l
II..
:E
o
(.)
X
~
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
,.0_(15)
, .0 if!: (16)
S Ro. sta
(19)
Sflo .s-I::,
16. Amount of line 14 taxable at lineal rate
I~ ,/01. '")..7
'0
17. Amount of Line 14 taxable at sibling rate
, .12 (17)
18. Amount of Line 14 taxable at collateral rate
, .15 (18)
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS~ 0/' (JIAJt!- TRee D;q J ve
CITY
ZIP,?:). W
&.JUt/Ie
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
5'';0..51,
:19.03
Total Credits (A + B + C) (2)
J,9. 03
3. InteresVPenalty if applicable
D. Interest
E. Penalty
TotallnteresVPenalty ( 0 + E I (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
A. Enter the interest on the tax due.
(5)
(5A)
55/.53
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) ~~ 5 I . 52>
Make Check Payable to: REGISTER OF WILLS, AGENT
ml_llIT 1l1U1II11 1Il1.~__.JIIIlI_ 11111 .l__.~__...u I IllIlmlll _ HI 1,__
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; ...... . 0 ~
C. retain a reversionary interest; or.... . ............... D [KJ
d. receive the promise for life of either payments, benefits or care? ................. .............. ... 0 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .................. ........ ~ D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ..... 0 ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ..... .. ................... ... 0 []I
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined this retum, 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 r senlati . based on all information of which preparerhas any knowledge.
S
DATE
If 2Cu!;
ADDRESS
c,1.f PIilJ& T!ee.e- DRive , rJfA...tJudte l Pi7 17a..'It
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE I
DATE
ADDRESS
"'.. -
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. 99116 (al (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% [72 P.S. 99116 (al (1.1) (ii)).
The statute does not exemot 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 twenty-one 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% [72 P.S. 99116(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%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(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+ (6-98)
. ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
FILE NUMBER
All teal 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 properly 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.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV"~'~""'97I.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1504 EX+ (1~97) .
..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF
FILE NUMBER
Schedule C-1 or C-2 (including all supporting information) must be attached tor each closely-tlelcl corporation/partnership interest 01 the decedent, o\ller tllan a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM NUMBER
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV'"",:'"971 '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIOENT DECEDENT
SCHEDULE C-1
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
ESTATE OF
FILE NUMBER
1. Name of Corporation
Address
City
2. Federal Employer 1.0. Number
3. Type of Business
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
Zip Code
State
Product/Service
4.
TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common $
Preferred $
Provide all rights and restrictions pertaining to each class of stock.
5. Was the decedent employed by the Corporation? D Yes D No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? D Yes D No
If yes, provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? D Yes D No
if yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years ~the date of death was prior to 12-31-82?
DYes D No if yes, D Transfer D Sale Number of Shares
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
Consideration $
Date
9. Was there a written shareholders agreement in effect at the time of the decedent's death?
If yes, provide a copy of the agreement.
D Yes
D No
10. Was the decedent's stock sold? DYes
If yes, provide a copy of the agreement of sale, etc.
11. Was the corporation dissolved or liquidated affer the decedent's death? DYes D No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
D No
12. Did the corporation have an interest in other corporations or partnerships? DYes D No
If yes, report the necessary information on a separate sheet, including a Schedule C-l or C-2 for each interest.
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete copies of financial statements or Federal Corporate Income Tax retums (Form 1120) for the year of death and 4 preceding years.
C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market valuels. If real estate appraisals have been
secured, attach copies.
D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent.
E. List of officers, their salaries, bonuses and any other benefits received from the corporation.
F. Statement of dividends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
REV-1506 EX+,19-0.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
ESTATE OF
FILE NUMBER
1. Name of Partnership
Date Business Commenced
Address
Business Reporting Year
City
State
Zip Code
2. Federal Employer 1.0. Number
3. Type 01 Business
Product/Service
4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $
5.
A.
B.
C.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted to the decedent?
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
DYes 0 No
9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-82?
DYes 0 No
If yes, 0 Transfer 0 Sale
Percentage transferred/sold
Consideration $
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
10. Was there a written partnership agreement \n effect at the time of the decedent's death?
If yes, provide a copy of the agreement.
Date
DYes 0 No
11. Was the decedent's partnership interest sold? ......
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedent's death? ................. 0 Yes 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
DYes ONo
13. Was the decedent related to any of the partners?
If yes, explain
14, Did the partnership have an interest in other corporations or partnerships? .. . . .. 0 Yes 0 No
If yes, report the necessary information on a separate sheet, including a Schedule C~ 1 or C~2 for each interest.
............. DYes ONo
THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedent's partnership interest.
B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/so If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
REV-.'507 EX+ (1-97) .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
,.
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
'~'''''~''.7) '*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
1fI1J-((9/1e,Z, Te- (J..J. FR1I1J7-z-
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
NUMBER
1.
DESCRIPTION
FoRe-rlwvc;I,T fllCep.4lb FtJlJe-/?'4i..-
VALUE AT DATE
OF DEATH
? 7~".S- .3
TOTAL (Also enter on line 5, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
$ ?7(PiGD
REV""",,,,,,,.71.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
;f)Ut;v-e-/G,rTe- W. rr?4rtJ7z...
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. R /f!/ef.1/f61 FtZfltJ72-
~'f PINf/ TRe-e. (Jf.lIVe,
VQMJvllle)f1R /7';l'lr
50.)
B.
c.
JOINTLY.OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of flnancial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deedforjoinlly-held real estate. VAlUE OF ASSET INTEREST DECEDENT'S INTEREST
1- A. %~7 ~ICAJe-a ST()/Je FeIJQtZ'1<..- cl/2e.i)/ r 9730.0/ SD:b 'IK/iJ~-,OD
UJJIOttJ
/H.<..--; .,'f 60;1..3 .
TOTAL (Also enter on line 6, Recapitulation) $ '1!1~ {;,OO
(If more space is needed, insert additional sheets of the same size)
'''''''",''''''''''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
(fl /H!.7 tI-u2./ r e-
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON.PROBATE PROPERTY
t,<J rl?lt..u Tz.
FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDETHENAMEOFTHETRAN$FEREE, IHEIRRELATIONSHIPTODECEDENTANOTHE DATEOFTAANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
ATTACH A COPV OF THE DEED FOR REAL ESTATE. If APPliCABLE'
NUMBER VALUE OF ASSET INTEREST
1, f!. (lJ I cJ) ft e-/ FRrJwT z. ScJ.-..J iqfj33 '/7 ~-V )10 9 fj(;(r7Y
I - Iii . os'
/-J."O~
TOTAL (Also enteron line 7, Recapitulation) $ If 7 ~tJ. 7'1
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99) .
. ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
;f/Mft/e~t Tr::--
FILE NUMBER
ITEM
NUMBER DESCRIPTION AMOUNT
A FUNERAL EXPENSES: ~ ?J,S;t0
1. E vJ I tJ9" I?nl?O Iil'M2 50 FtJNef2rtI /+pM'" ,:1/1-1 G 1/;j,~()D
e /I1'Ztt 5 f-e (11 e /11 0 f2r /] t. 6'e,(?// l C ... , :z.1lP ISD.Du
PIU;,rOR S<JfoJ tEflh'.~ /JS--'o<)
/?tch.,.r& rr<t rr ~O.l)O
t:ftI2'- lIefA..-eMAt!;
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commiss(Q(ls
Name of Personal Representative{s)
Social Security Number(s)/EIN Number of Personal Representative(s}
Street Address
City State _ Zip
Year(s) Commission Paid:
2. Attorney Fees
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's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9. Recapitulation) $ 9~f).s.OD
W Pt<I1,<J[z..
Debts of decedent must be fepofted on Schedule l.
(If more space is needed, insert additional sheets of the same size)
""""'~'I''''~.
~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
FilE NUMBER
jJ7 /H27 lJ t. /Zt r e.- IJJ . P ((IT tV T z.-
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
DESCRIPTION
;#fJe-.r FRIUJr-z...,eNll lfliu-, atJ,"O fU<t~.
~~ w.1.V e-d~ ~ a ~
AMOUNT
'-19 ~ .00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space IS needed, Insert additional sheets of the same size)
'If 2. ,00
REV-1513 EX+ ~9-00~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
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)]
1-
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1-
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
,.
TOTAL OF PART" - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
RfV15"EX'[1~n.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on Rev.1500 Cover Sheet
FILE NUMBER
ESTATE OF
This schedule is to be used for all single life, joint or, successive life estate and tenn certain calculations, For dates of death
prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5 -1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Will 0 Intervivos Deed of Trust 0 Other
LIFE'ES'tATE'INTEREsT.CAl.CI.Il.ATIOH
NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS
LIFE TENANHS) DATE OF BIRTH DATE OF DEATH PAYABLE
o Life or 0 Term 01 Years _
o Lile or 0 Term of Years _
o Lile or 0 Term 01 Years _
o Lileor 0 Term of Years _
1. Value of fund from which life estate is payable
2. Actuarial factor per appropriate table
Interest table rate - 03 1/2% 0 6% 0 10% 0 Variable Rate
3. Value of life estate (Line 1 multiplied by Line 2)
ANNUI'I'YlNTEREStC~Ul..AiJ10N
$
%
$
NAME(S) OF NEAREST AGE AT TERM OF YEARS
ANNUITANHS) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE
o LileorD Term of Years _
o LileorD Term 01 Years _
o Lile or 0 Term 01 Years _
o Lileor 0 Term of Years _
1. Value of fund from which annuity is payable
2. Check appropriate block below and enter corresponding (number)
Frequency of payout- 0 Weekly (52) 0 Bi-weekly (26)
o Quarterly (4) 0 Semi-annually (2) 0 Annually (1)
3. Amount of payout per period
4. Aggregate annual payment, Line 2 multiplied by Line 3
5. Annuity Factor (see instructions)
Interest table rate 031/2% 06% 010% 0 Variable Rate
6. Adjustment Factor (see instructions)
7. Value of annuity -If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period,
calculation is : Line 4 x Line 5 x Line 6
If using variable rate and period payout is at beginning of period, calculation is :
(Line 4 x Line 5 x Line 6) + Line 3 $
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on
Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on
Lines 13, 15, 16 and 17.
$
o Monthly (12)
o Other ( )
$
%
$
(II more space is needed, insert additional sheets of the same size)
R~V.1644 EX-t (3-84) INHERITANCE TAX
~tJ-
SCHEDULE "L"
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT OR INVASION
INHERITANCE TAX RETURN
RESIDENT DECEDENT OF TRUST PRINCIPAL FilE NUMBER
I. Estate of
(last Name) (First Name) (Middle Initial)
This schedule is appropriate only for estates of decedents dying on or before December 12, 1982.
This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions
of Section 714 of the Inheritance and Estate Tax Act of 1961 or 10 report Ihe invasion of Irusl principal.
II. Remainder Prepayment:
A. Electian to prepay filed wilh Ihe Regisler of Wills on (Date)
(allach copy of election)
B. Name(s) of Life Tenanl(s) Dale of Birth Age on dole Term of years income
or Annuilanl(s) of election or annuity is payable
e. Assets: Complele Schedule L-l
1. Real Estale S
2. Slocks and Bonds S
3. Closely Held Slock/Partnership S
4. Mortgages and Noles S
5. Cash/Misc. Personal Properly S
6. T 0101 from Schedule L-l S
D. Credits: Complete Schedule L-2
1. Unpaid Liabililies S
2. Unpaid Bequesls S
3. Value of Unincludable Assels S
4. T 0101 from Schedule L-2 S
E. Tolal value of Irusl assels (Line C-6 minus Line D-4) S
~J:'
F. Remainder factor (see Table I or Table II in Inslruction Booklet)
G. Taxable Remainder value (Line E x Line F) S
(Also enter on Line 7, Recapilulation)
III. Invasion of Corpus:
A. Invasion of corpus
(Month. Doy. Year)
B. Name(s) of Life T enanl(s) Dale of Birlh Age on dale Term of years income
ar Annuitant(s) corpus consumed or annuity is payable
e. Corpus consumed S
D. Remainder factor (see Table I or Table II in Instruction Booklet) S
E. Taxable value af corpus cansumed (Line C x Line D) S
(Also enler on Line 7, Recapitulation)
REV-1645 EX+ (7.85) INHERITANCE TAX
. .,*-
SCHEDULE L-l
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT -ASSETS- FILE NUMBER
I. Estate of
(Last Name) (First Name) (Middle Initial)
II. Item No. Description Value
A. Real Estate (please describe)
Total value 01 real estate S
(include on Section II, Line C-1 on Schedule L)
B. Stocks and Bonds (please list)
Total value 01 stocks and bonds S
(include on Section II, Line C-2 on Schedule L)
C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2)
(please list)
Total value 01 Closely Held/Partnership S
(include on Section II, Line C-3 on Schedule L)
D. Mortgages and Notes (please list)
Total value 01 Mortgages and Notes S
(include on Section II, Line C.4 on Schedule L)
E. Cash and Miscellaneous Personal Property (please list)
Total value 01 Cash/Misc. Pers. Property S
(include on Section II, Line C-5 on Schedule L)
III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) S
(II more space is needed, attach additional ay, x 11 sheets.)
R~V.1646 EXt (3.B.4) INHERITANCE TAX
* SCHEDULE L-2
COMMONWEALTH Of PENNSYlVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN -CREDITS- fiLE NUMBER
RESIDENT DECEDENT
I. Estate of
(last Name) (First Name) (Middle Initial)
II. Item No. Description Amount
A. Unpaid Liabilities Claimed against Original Estate, and payable fram assets
reported on Schedule L- 1 (please list)
Total unpaid liabilities S
(include on Section II, Line 0-1 on Schedule L)
B. Unpaid Bequests payable from assets reported on Schedule L-l (please list)
Total unpaid bequests S
(include on Section II, Line 0-2 on Schedule l)
C. Value of assets reported on Schedule L-l (other than unpaid bequests listed under
I1BI/ above) that are not included for tax purposes or that do not form a part
of the trust.
Computation as follows:
Total unincludable assets S
(include on Section II, Line 0-3 on Schedule L)
III. TOTAL (Also enter on Section II, Line 0-4 on Schedule L) S
(If more space is needed, attach additional 8% x 11 sheets.)
REV-164? EX~ 19-OO*,
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE M
FUTURE INTEREST COMPROMISE
Check Box 4a on Rev-1500 Cover Sheet
ESTATE OF
FILE NUMBER
This Schedule is appropriate only for estates of decedents dying after December 12, 1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in
possession and enjoyment cannot be established with certainty.
Indicate below the type of instrument which created the future interest and attach a copy to the tax return.
D Will D Trust D Other
I. Beneficiaries
NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within
9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse
exercises such withdrawal right.
D Unlimited right of withdrawal D Limited right of withdrawal
IlL Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amount of Future Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..$
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(also include as part of total shown on Line 13 of Cover Sheet) .. .. ..$
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One 06%, 03%, 00%......................$
(also include as part of total shown on Line 15 of Cover Sheet)
4. Value of Line 1 taxable at lineal rate
Check One 06%, 04.5% .. .. . .. . .. . .. . . .. . .. . . . .. . .$
(also include as part of total shown on Line 16 of Cover Sheet)
5. Value of Line 1 taxable at sibling rate (12%)
(also Include as part of fotal shown on Line 17 of Cover Sheet) .. . . . .$
6. Value of Line 1 taxable at collateral rate (15%)
(also include as part of total shown on Line 18 of Cover Sheet) .. .. ..$
7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) .................. .. ..$
(If more space is needed, insert additional sheets of the same size)
"V.1648 ,x (1:921 ..
COMMONWEALTH OF PENNSYlANIA
INHERITANCE TAX DIVISION
ESTATE OF
SCHEDULE N
SPOUSAL POVERTY CREDIT
AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91
I FILE NUMBER
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet.
PART I - CALCULATION OF GROSS ESTATE
1. Taxable Assets total from line 8 (cover sheet) .................................................................... 1.
2. Insurance Proceeds on Life of Decedent ............................................................................ 2.
3. Retirement Benefits..................................................... .......................... .... ...................... 3.
4. Joint Assets with Spouse ................................................................... .............................. 4.
5. PA Lottery Winnings ...................................................................................................... 5.
6b.
60. Other Nontaxable Assets: List (Attach schedule if necessary).. 60.
6<-
6d.
6.
SUBTOTAL (Lines 60, b, c, d)............................
............................ 6.
7. Total Gross Assets (Add lines 1 thru 6).................................................... ........................ 7.
8. Total Actual Liabilities...... ............................. ..... ..... .................... ................................... 8.
9. Net Value of Estate ISubtractline 8 from line 7)................................................................ 9.
If line 9;s greater than $200,000 - STOP. The estafe;s not eligible to claim the credit. If not, continue to Port II.
PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income
Tax Returns for decedent and spouse.)
Income: L TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19
a. Spouse..................... . 10. 20. 30.
b. Decedent................... lb. 2b. 3b.
c. Joint............... .......... k 2c. 3<-
d. Tax Exempt Income..... ld. 2d. 3d.
e. Other Income not
listed above ........... 1e. 2e. 3e.
I. Totol.......................... II. 2f. 3f.
4. Average Joint Exemption Income Calculation
40. Add Joint Exemption Income from above:
(H)
+ (21)
+ (31)
=
(+ 3)
Ab. Average Joint Exemption Income ..................................................................................... =
If fine 4(b) is greater than $40,000 - STOP. The estate is not eligible to cfaim the credit. If not, continue to Port fll.
PART III - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT
ESTATES
1. Insert amount of taxable transfers to spouse or $100,000, whichever is less.......................... 1.
2. Multiply by credit percentage (see instructions) ................ ................................................. 2.
3. This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet. ............................. .............. 3.
4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate............................................................................................. A.
5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. 5.
REV.1649 EX + (1-97)
'.
SCHEDULE 0
ELECTION UNDER SEC. 9113(A)
SPOUSAL DISTRIBUTIONS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Do not complete this schedule unless the estate Is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act.
If the election applies to more than one trust or similar arrangement, a separate form must be filed for each lrust.
This election applies to Ihe Trust (marital, residual A, B, By-pass, Unified Credit, elc.).
If a trust or similar arrangement meets the requirements of Section 9113(A), and:
a. The trust or similar arrangement is listed on Schedule 0, and
b. The value of Ihe trust or similar arrangement Is entered in whole or in part as an asset on Schedule 0,
then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be inctuded in the election to have such trust or
similar property treated as a taxable transfer in this estate. If less than the entire value of Ihe trust or similar property is included as a taxable transfer on Schedule 0, the
personal representative shall be considered to have made the election only as 10 a fraction of the trust or similar arrangement. The numerator of this fraction is equal to
the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's
survivin souse under a Section 9113 A trust or similar arran ement.
DESCRIPTION VALUE
Part A Total $
PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made.
DESCRIPTION VALUE
Part B Total $
(If more space is needed, insert additional sheels of the same size)
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013-
(717)243-2421
February 4,2005
R. Michael Frantz
64 Pine Tree Drive
Newville, PA ] 7241
The Funeral Service for Marguerite W. Frantz
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
TIlE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SER VICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELEcrED WHEN MAKING THE FUNERAL ARRANGEMENTS.
1. PRon:SSIONAL SERVICES
S~rvi('cs of Func:ral Director/Staff. . . . . . .
Fl!NERAL HOME SERVICE CHARGES
SELECTED MERCHANDISE:
Solid Oak Casket. . . . . . . . . . . , . . . . . . . . . .
#5 American OBC, . . . . . . . . . . . . . . . . . . . . .
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THA T YOU HA VE SELECTED . . . . . . . . . . . . .
Cash Advances
Opening Grave, . . . . . . . .
Certitied Copies of the Death Certificate.
Hairdresso:r. . . . .
Rock Charg~ ......
60+ Red Ros~s Plus Ta.\. . . .
TOT AL CASH ADV ANCES AND SPECIAL CHARGES.
Total
Total Cost
. . . . . . . . . . . . . . . . . . . .
SUB-TOTAL
INITIAL PA YMENT I DISCOUNT I CREDITS
$3580.00
$3580.00
$3375.00
$1175.00
$8130.00
$300.00
$30.00
$35.00
$45.00
$185.50
$595.50
$8725.50
$8725.50
0.00
(
ql.t~~ I
~ 6rr \.0">
z..l
$8725.50 ~ 12 ;.-r Af~
~ ?r:~s:I - /"Nep "'7 /
The \lI1ruid halancc o\'cr 45 days is subjected to a IOU % service charge per month. 12.0000 % pel annum. - /"': _"\
&CA,<JU'( S~"~{,,<>J..J
,0 LdAl,<J"'/ ~/~ /6/e7J.:n-;-<-T.'
.:::;L ,%//'./ .;()O T r-"-"7'
/) /J 3'0: CXJ
27<"/112 ('pr0 ;':"A~
/-~//d. ,~,,,-,,--
/."d .fa240'
TOTAL AMOUNT DUE
ss-- (/"
"i J.,f, S-O
;T 0< S-o. fO
tJ lIe~fl7 oAJ G r.Av e.
Of/"'''''''''
0/ Rod:: (h.~ 0"; :
~A.." iZa..,lffpL,
Member of National Funeral Directors Association
,;zoo
-
Q :rOo S-O
00
~,4&""'('"
"7)/.<."-.
CORNERSTONE FEDERAL
P.O BOX 1181
CARLISLE PA 17013
(717) 249-1661
C.U.
IZ-Member Inquiry
Member: 6023 - MARGUERITE W FRANTZ
Joint: FRANTZ, R MICHAEL
SSN: 174-20-0609
Share Information
Record
Type/Digit
(O)wnership
Accr Divs
Lock/Warn
Userl/2/3/4
S/L. Donor
prl Dist/Meth
Opened
Closed
Last Tran
Last F/M
NR Sts/Lim
Draft Counters
Total Credits
Total Debits
Total Drafts
NSF Drafts
OlD Transfers
Reg-D W/Ds
Withdrawals
Date printed: 04/14/2005
Eff Date: 04/14/2005
07-SHARE DRAFT ACCOUNT
Draft/O
Joint - If Defined
.00
/ / /
N
.OO/N
11/13/1997
03/04/2005
03/04/2005
05/05/1999
0/ 0
M-T-D
o
o
o
o
o
o
o
Balance Information
Current Balance
(Check Holds)
(Minimum Bal)
(Loan Pledge)
(Fixed Hold)
(S/L Hold)
Available Balance
Y-T-D Life
o 0
o 0
o
0.00
.00
.00
.00
.00
.00
(Closed)
r
~. ~S>r~~c~~CJn~~
~ M4mb<1r founded- StIrv/a based.
P.o. BOX 1181
CARLISLE. PA 17013
717.:249.1861
STATEMENT OF ACCOUNT
NOTICE
see ENCLOSED FORM FOR IMPORTANT
INFORMATION REGARDING YOUR RIGHTS TO
DISPUTE BILLING ERRORS
NOTICE
see ENCLOSED FORM FOR IMPORTANT
INFORMATION IN CASE OF ERRORS OR
QUESTIONS ABOUT YOJA ELECTRONIC
TRANSFERS IDENTIFIED WITH LETTERS "EFT"
000677
MARGUERITE W FRANTZ
R MICHAEL FRANTZ
64 PINE TREE DRIVE
NEWVILLE PA 17241
MEMBER
NUMBER
STATEMENT
DATE
6023
01 01 2005 - 01 31 2005
OWNERSHIP OF SHARE. DEPOSIT AND CEATIRCATE ACCOUNTS SHOWN ON THIS STATEMENT IS NOT TRANSFERABLE EXCEPT 00 THE BOOKS OF THE CAEDIT UNION.
. Trans~ctioo Date:.
Transaction Description
Transaction
Amount
Principal Payments
New Loans
and Credits
FINANCE
CHARGE
BALANCE
'SHARE Ol.;REGULAR SHARE ACCOUNT
01-01 Previous Balance
12-31e DIVIDEND 49.11
Annual Percentage Yield earned from 10/01/2004 - 12/31/2004
on an average daily balance of $ 19484.36 was 1.00%
01-26 TRANSFER OUT -19433.47
From: 6023-01 To: 70263-01
01-31 New Balance
Year-to-Date Dividends this account 49.11
19484.36
19533.47
100.00
100.00
01-01
12-31e
SHARE 07..SHARE DRAFT ACCOUNT
Previous Balance
DIVIDEND
Annual Percentage Yield earned from
on an average daily balance of $
DEPOSIT
US TREASURY.303-S0C SEC
DRAFT # 313 0011063530
TRANSFER OUT
From: 6023-07 To:
DRAFT # 315
DRAFT # 314
DRAFT # 316
New Balance
Year-to-Date Dividends this account
6.38
10/01/2004 -
10121.18 was
858.00 EFT
12/31/2004
.25%
9489.69
9496.07
01-03
01-03
01-10
01-10
01':'19
01-26
01-31
263-07
0013016412
0011143158
0011082578
-33.58
-500.00
10354.07
10320.49
9820.49
9805.69
9755.69
9630.01
9630.01
-14.80
-50.00
-125.68
. Draft#
313
Amount
33.58
Draft#
314
Amount
50.00
Draft#
315
Amount
14.80
6.38
Draft#
316
Amount
125.68
Total Dividends Earned This. Year $
.Total Finance Charges Paid Th,R Year $
55.49
.00
- - - - - - - - - - - - - - - - - - - - - -
Nothing fancy...just good personal service. At Cornerstone we stick to the
basics...Personal attention. Low interest rates. Low/no fees. High dividend
rates. Friendly service. We have a full array of loan and deposit products and
our loan process is fast and convenient. No matter what type of loan you are
looking for, we make it simple. You can apply for almost all of our loans over
the telephone and, in most cases, have same day approval. You can also apply
online with our convenient Internet application. Call or go online today and
have your loan.before you know it! .
Do you have outstanding credit card balances on high rate cards? ~f so, you need
to take advantage of our 1% cash back balance transfer rebate. We will give you
1% cash back, up to $75 when you transfer your balances to a CFCU Visa card.
Call for more details but hurry, this great deal expires on February 28, 2005.
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL" AXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
FRANTZ R MICHAEL
64 PINETREE DRIVE
NEWVillE, PA 17241
~____n_ laid
ESTATE INFORMATION: SSN: 174-20-0609
FILE NUMBER: 2105-0361
DECEDENT NAME: FRANTZ MARGUERITE W
DATE OF PAYMENT: 04/18/2005
POSTMARK DATE: 04/1 8/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 01/28/2005
NO. CD 005221
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $551.53
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$551.53
REMARKS:
CHECK# 3990
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WillS