HomeMy WebLinkAbout11-24-14 1505610105
REV_1500 EX(02-11)(FI)T
PA Department of Revenue pennsytvania OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 28o6oi INHERITANCE TAX RETURN
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
.
.. .............
04/01/2014 06/07/1926
Decedent's Last Name Suffix Decedent's First Name
Ml
.................. Beverly
DeVore
(If Applicable)Enter Surviving Spouse's information Below
Spouse's Last Name[ Suffix Spouse's First Name.1 MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
CW 1.Original Return C=:) 2.Supplemental Return C=:) 3. Remainder Return(Date of Death
Prior to 12-13-82)
C=:) 4.Limited Estate C=) 4a.Future Interest Compromise(date of C=:) 5. Federal Estate Tax Return Required
death after 12-12-82)
OND 6.Decedent Died Testate C=:) 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received C=) 10.Spousal Poverty Credit(Date of Death C=) 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule 0)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Heather L. Zielonis E(71 7):76:8�-O��-A�7 �
rn
O REGISTEER,"91' LLS USE C)
r-1 .73
:z
First Line of Address
rp 771
,6 Ash Drive
Second Line of Address
_Tl
co t w M
r Post Office IbAiif.
City or State— ZIP Code FILED
iMechanicsburg ................. -TI
I PA 17050
.............
.................................
Correspondent's e-mail address:heather@intergraprint.us
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.
SIGNATURJE)OF PERSON RESPON IBLg FOR FILING RETURN DATE
11/16/2014
ADDRESS
6 Ash Dyfye, Mechanicsburg, PA 17050
HA EPRESENT E DATE
ADDRESS .11 11/16/2014
&I-Ongwood Drive, Mechanicsbrg, PA 17050
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
1505610205
REV-1500 EX(FI) Decedent's Social Security Number
Decedent's Name:
RECAPITULATION
1. Real Estate(Schedule A). ............................................ 1.
2. Stocks and Bonds(Schedule B) ....................................... 2. 200,339.72
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3.
4. Mortgages and Notes Receivable(Schedule D)........................... 4.
I
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 22,121.62
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property C
(Schedule G) O Separate Billing Requested........ 7. i 0.00
8. Total Gross Assets(total Lines 1 through 7)............................. 8. 222,461.34
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9, i 40,741.18
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 84,613.06
11. Total Deductions(total Lines 9 and 10)................................. 11. 125,354.24
1i
12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. i 97,107.10
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ........................ 13. I 0.00
i
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. 97,107.10
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.0_ 15. 0.00
16. Amount of Line 14 taxable -�
at lineal rate X.0 45 97,107.10 16.' 4,369.82
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 I 18.
19. TAX DUE................ .......................................... 19.( 4,369.82
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
L 1505610205 1505610205
nsV-mo sx(FyPage x File Number
Decedent's Complete Address:
DECEDENT'S NAME
DeVore, Beverly L.
6 Ash Drive
CITY STATE ZIP
Mechanicsbsurg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2.Line 19) (1) 436982
2. Credits/Payments
A.Prior Paymonts O.00
B.Discount 0.00
Total Credits(A+B) (2) 0.00
3. Interest
(3) 0.00
4. 0Line 2isgreater than Line 1 +Line 3.enter the difference. This isthe OVERPAYMENT
Fill|noval onPage 2'Line 3Vmrequest urefund. (4)
5. If Line I+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 4.368.82
Make check payable to: REGISTER OFWILLS,AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X° UNTHE APPROPRIATE BLOCKS
1. Did decedent make atransfer and: 0m No
u. retain the use orincome of thopmpodyhanefemad------------------------------ El N
kretain the right todesignate who shall use the property transferred orits income ............................................ 0 1111111
c. retain areversionary interest------------------------------------------ [] 0
d. receive the promise for life ofeither payments,benefits mcare?...................................................................... [] 0
l If death occurred after Dec.12.1982,did decedent transfer property within one year of death
wkhomteceivingodeouotemnxidomUon?------------------------------------' ID 0
8. Did decedent own an"in trust foe'or payable-upon-death bank account or security at his or her death?..............
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains obeneficiary designation? ........................................................................................................................
��
|FTHE ANSWER TOANY OPTHE ABOVE QUESTIONS|S YES,YOU MUST COMPLETE SCHEDULE G AND FILE|TASPART OFTHE RETURN.
For dates ofdeath onorafter July 1.1094.and before Jan.1. 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
ix3percent[72PS.§0118(o)(1.1)(i)].
For dates of death on or after Jun. 1. 1995, the tax rate imposed on the net wduo of transfers to or for the use of the surviving is O percent
[72PS.§9116(a)(1.1)(ii)).The statute does not exempt a transfer to a surviving spousehnmtax.andthostatuhorymquimmonbfordiuo|ouunuofauuetsand
filing a tax return are oU||opp|ioub|o 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 o,astepparent m[the child ioOpercent[72PS.§8116(a)(1.2)].
w The tax rate imposed on the net value oftransfers to or for the use of the decedent's linealbeneficiaries is4.5percent,except msnoted in[72PS.§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 P.S.§0i16(a)(1.3)].Asibling iudefined,
under Section 9102.as an individual who has atleast one parent in common with the decedent,whether by blood or adoption.
REV-1503 EX+(6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF DeVore, Beverly Lou 21 - 14-00385
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF
NUMBER DEATH
1 Janey Montgomery Scott 200,339.72
TOTAL(Also enter on line 2, Recapitulation) 200,339.72
Pennsylvania SCHEDULE E
DEPARTMENT OFCASH BANK DEPOSITS AND MISC.
INHERITANCE TAXAXRETURN
�
RESIDENT DECEDENT PERSONAL PROPERTY
FILE NUMBER
ESTATE OF DeVore, Beverly Lou 21 - 14 -00385
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 OF
NUMBER DESCRIPTION DEATH
1 Members First Federal Credit Union 20,863.80
Checking Account
2 1991 Dodge Spirit ES 995.00
3 ADT Dividend 6.40
4 MedNVestVaco Corporation Dividend 29.75
5 Tyco Electronics- Pension 220.91
6 Tyco Electronics- Dividend 5.76
TOTAL(Also enter on Line 5, Recapitulation) 22,121.62
REV-1510 EX+(08.09)
pennsylvania
DEPARTMENT OF REVENUE SCHEDULE G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS &
RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF DeVore, Beverly Lou FILE NUMBER
21 - 14 -00385
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF EXCLUSION
NUMBER Include the name of the transferee,their relationship to decedent VALUE OF ASSET DECD'S TAXABLE VALUE
and the date of transfer. Attach a copy of the deed for real estate. INTEREST (IF APPLICABLE)
1 IRA Janey Montgomery Scott 25,396.49 0% 0.00
TOTAL(Also enter on line 7, Recapitulation) 0.00
REV-1511 EX+(10.09)
pen nsylva n is SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL
/'/�AANND
INHERITANCE TAX RETURN ADMINISTRATIVE COS 1 J
RESIDENT DECEDENT
ESTATE OF DeVore, Beverly Lou FILE NUMBER21 - 14 -00385
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 Myers Buhring Funeral Home and Crematory 19,999.00
Mechanicsburg, PA
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Heather L. Zelonis Patricia D. Sheaffer 20,000.00
Street Address 6 Ash Drive
City Mechanicsburg State PA zip 17050
Year(s)Commission Paid 2014
2. Attorney's 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 Register of Wills Cumberland County 508.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
Cumberland Law Journal - Estate Advertisement 75.00
Carlisle, PA
See attached 158.68
TOTAL(Also enter on line 9, Recapitulation) 40,741.18
Schedule H
COMMONWEALTH OF PENNSYLVANIA Funeral ENenses&
INHERITANCE TAX RETURN Administratinie Costs continued
RESIDENT DECEDENT
ESTATE OF DeVore, Beverly Lou FILE NUMBER
21 - 14 -00385
2 The Sentinel- Estate Advertisement 158.68
Page 2 of Schedule H
REV-1512 EX+(12-12)
Pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DeVore, Beverly Lou 21 14 385
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
US Postal Service 49.00
F2. SilverScript Insurance 67.60
F3 Capital Blue Cross 660.15
CVS Pharmacy 260.85
uu�.0
5. : WalMart-various medical supplies. 108.74
6. Holy Spirit Hospital 66,258.90
7. Life Care,Wilson Lane,Mechanicsburg,PA 4,500.00
8. US Department of Treasury-Federal Income Tax,2013 688.00
F-91 I Pennsylvania Department of Revenue-State Tax,2013 438.00
10. Carly A.Pownell-Assistant Care 3,600.00
F1 Pennsylvania Department of Transportation-Title Transfer and Registration 136.00
i�.wwwwewwwiw•wwwwwn
12. West Shore EMS .- 987.11
13. Monie Harshman-reimbursement for food-fellowhip following funeral 91.21
14. US Postal Service - 12.85
15. Patricia Shaeffer-Reimbursement-expenses F750-00
�
16. 'L-Heather Zielonis-Carpet Cleaning;Decedent's bedroom/sitting room 300.00
17. Heather Zielonis-Reimbursement,Duncan DeVore Travel and Hotel Expenses 681.90
Elevator Ready;Inc.Purchase and installsion of elevator for personal use of decedant in Zielonis home 3,445.00
19. Charles Inners,M.D. 38.5-41-
F
20. G.Angotti-Administrative/Secretarial Services 750.00
21. Walters&Galloway-Consultation re Probate Estate_75.00
F221 William H.DeVore,Jr.-travel and hotel expense 225 00
23 Members First Federal Credit Union-VISA Credit Card 38.00
24. GEICO Auto Insurance-1991 Dodge ES 360.00
25. The Butcher Shop,Chambersburg,PA -Fellowship following viewing 91.21
TOTAL(Also enter on Line 10,Recapitulation) $ 84,613.06 -
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(01-10)
7
pennsylvania SCHEDULE J
rr DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
DeVore, Beverly Lou 21 14 385
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).]
I. HeatherL Zielonis 6Ash Drive,Mechanicsburg,PA 17050 �Daughther 1/4 of residue,
�_. _ __�... '__.g_ ��
2. Patricia D.Sheaffer,8 Longwood Drive Mechanicsburg,PA 17050 Dau hter 1/4 of residue
Duncan K DeVore 946VHenning Road,Perkiomenville^PA 18074 ( Son .. 1/4 of residue
L3.�
4. [WHarn H DeV14ore,Jr., 14067 Mountain Green Rd,Willow HiII,PA 17172 Son of residue
F_ _ f
1
� ll
+, 10 of residue
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:
i. N/A
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
NIA
E
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0.0OJ
If more space is needed,use additional sheets of paper of the same size.