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Home My WebLink About12-01-14 � 150561�14D REV-1500 Ex �°,_,°> OFFICIAL USE ONLY PA Department of Revenue Coun Code Year File Number Bureau of Individual Taxes �Y PO BOx 28oso1 INHERITANCE TAX RETURN �` + Harrisburg, PA 17128-0601 RESIDENT DECEDENT G� � 1 u �� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 9 2 7 2 0 1 4 0 4 0 3 1 9 2 1 DecedenYs Last Name Suffix DecedenYs First Name MI K E E N E R V I V I A N M (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW a 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 Sch.O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Da��time Telephor�`e�lumber �--� �7 C H R I S T A M A P L I N �]r,�7 5� 1 m'�5 5 0 _-� ---- — ' '� �GIS�ER t�F'�IVILL�S NLY ::J r> f"' � t._. �-r� ;'r�1 f`�7 ~ ::�7 e7 First line of address �I." ��' � , `;o �.� '�'J` ._� � � I 8 4 5 S I R T H 0 M A S C 0 U R T �j �� -r, � ,�- � i -�� Second line of address w =`'`� N r-- rn i S U I T E 1 2 �ry �� -� � � ' ' � � � DATE FILED City or Post Office State ZIP Code -- -- ----------- - -__J H A R R I S B U R G P A 1 7 1 0 9 Correspondent's e-mail address: CHRISTA@JANBROWNLAW.COM 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. SIGNATURE OF P 0 RE�SPf�N�SIBLE FOR FILING RETURN DATE ��_ �I��-{'ii��- l� ' Z �—� `� ADDRESS 4029 CAISSONS CT ENOLA PA 17025 SI F PREPARER THER�'HAN.REPR�TATIVE D TE 1 SS 845 SIR THOMAS COURT, SUITE 12 HARRISBURG PA 17109 PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610140 1505610140 J , � 1505610240 REV-1500 EX DecedenYs Social Security Number oecedent'sName: VIVIAN M • KEENER RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �• ' 2. Stocks and Bonds(Schedule B) 2� ' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. • 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . 4. • 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . . . 5. 8 0 1 . 5 5 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 2 8 7 3 . 3 4 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property 5 3 4 8 9 . 6 5 (Schedule G) � Separate Billing Requested . . . . . . . 7. 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. S 7 1 6 4 , 5 4 9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9� 4 7 6 5 . 6 3 10. Debts of Decedent, Mortgage Liabilities, and Liens(Schedule I) . . . . . . . . . . . . . 10. 4 1 4 2 . 3 6 ��. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 8 9 � 7 . 9 9 12. Net Value of Estate(Line 8 minus l.ine 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12• 4 8 2 5 6 . 5 5 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . 13. • 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . 14. 4 8 2 5 6 . 5 5 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 _ � . 0 O 15. O . � � 16. Amount of Line 14 taxable at�inea�rate X .045 4 8 2 5 6 . 5 5 16. 2 1 7 1 . 5 4 17. Amount of Line 14 taxable at sibling rate X.12 � . � � 17. 0 • 0 0 18. Amount of Line 14 taxable at collateral rate X.15 � • � � 18. 0 • � � 19. TAX DUE 2 1 7 1 • 5 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑X Side 2 � 1505610240 1505610240 � REV-1500 EX Page 3 File Number Decedent's Complete Address: o 0 DECEDENT'S NAME VIVIAN M. KEENER — — - -- _ _ _ _ _--- - ____ - -- _ _ __---- STREET ADDRESS 4029 Caissons Court --__ _ _ --- --- __--- --- _ _------- __—� _ _ �I ZIP CITY STATE ; Enola PA 17025 Tax Payments and Credits: �� Tax Due(Page 2,Line 19) (1) 2,171.54 2. Credits/Payments A.Prior Payments e.Discount 108.57 Total Credits(A+g) �2� 108.57 3. Interest (3) 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) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 2,062.97 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Ditl decedent make a transfer and: Yes No a. retain the use or income of the property transferred: ...................................................................... ❑ ❑X b. retain the right to designate who shall use the property transferred or its income; ............................... ❑ X c. retain a reversionary interest;or ................................................................................................ ❑ � d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ ❑X 2. If death occurred after December 12,1982,tlid decedent transfer property within one year of tleath without receiving adequate consideration? ....................................................................................... ❑ � 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her tleath? ......... ❑ X❑ 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 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(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 decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)J.A sibling is defined,unde Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENTDECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: VIVIAN M. KEENER 0 0 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. Capital Blue Cross; refund of premium 660.15 2. RiverSource Life Insurance Company; refund of long term care insurance premium 141.40 TOTAL(Also enter on Line 5,Recapitulation) $ 801.55 If more space is needed, use additional sheets of paper of the same size. REV-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENTOFREVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: VIVIAN M. KEENER 0 0 If an asset was made jointly owned within one year of the decedenYs date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT a,. Nancy L. Puglisse 4029 Caissons Court daughter Enola, PA 17025 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 DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 2008 Metro Bank 50 Plus checking account; 5,746.67 50. 2,873.34 Account#0536847643 TOTAL(Also enter on Line 6,Recapitulation) $ 2 873.34 If more space is needed,use additional sheets of paper of the same size. REV-1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER VIVIAN M. KEENER 0 0 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 ITEM INCLUDETHENAMEOFTHETRANSFEREE,THEIRRELATIONSHIPTODECEDENTAND DATEOFDEATH °/oOFDECD�S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. American General Life Insurance Company annuity; 53,489.65 100.00 53,489.65 Policy#SA8541282 Beneficiary: daughter, Nancy L. Puglisse TOTAL (Also enter on Line 7,Recapitulation) $ 53 489.65 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10-09) pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER VIVIAN M. KEENER 0 0 DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers-Harner Funeral Home, Inc.; funeral expenses 509.00 2. Woodlawn Memorial Gardens; gravemarker 2,131.00 3. Chapel Hill UCC; funeral luncheon 280.63 4. Larry Hale, Pastor; clergy fee 100.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Anorney Fees: Jan L. Brown &Associates 1,500.00 3. Family Exemption:(If decedenYs address is not the same as claimanYs,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5 Accountant Fees: 6. Tax Retum Preparer Fees: H&R BIOCk; final income tax return (estimate) 230.00 7, Register of Wills; Inheritance Tax Return filing fee 15.00 TOTAL(Also enter on Line 9,Recapitulation) $ 4 765.63 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT� INHERITANCETAXRETURN MORTGAGE LIABILITIES& LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER VIVIAN M. KEENER 0 0 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. Brockie Pharmatech; outstanding medical bill 313.02 2. Homeland Center; outstanding bill 3,799.00 3. Cumberland County Office of Aging; outstanding medical bill 5.22 4. Bank of America; outstanding bill 12.94 5. Cumberland County Office of Aging; check#1247 wrote pre-death and cleared after death 12.18 TOTAL(Also enter on Line 10,Recapitulation) $ 4 142.36 If more space is needed, insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: VIVIAN M. KEENER 0 0 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. Nancy L. Puglisse Lineal 48,256.55 4029 Caissons Court Enola, PA 17025 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: 1. 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. REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: ____ ____2,06_2_.96 Discount: 108.57 Interest Table _ -- - - � _- __ I ------ � -�- Year Days Delinquent Balance Due � Interest I, �� this time period � this year this period � � - - - - —_ _ __ _ ___- _ _ � Before 1981 --- - _ _ - - --_ - --- _al - --_ -- 1982__ __ _ _-r- - __ _ ;_____ _ _ � _ _ __ _� 1983 __ __ _ _� -- -_ --- --- -- It 1984 _ , � - - -- --_ -- � - __ _ _- , _ _ - — ___ � 1985_ - _ __- -_ _---- __ - 1986 � - - -- - _ _ ___ _-- 1987 _ � _ --- - - _ - � - ---- - � _� 1988 throu�h 1991 -- - -- - _ ___ I _� 1992 - _ _ -- I --- ___ - - -_ li 1993 through 1994_ �I � __ � ___ ._ __ _ _ __ __ - � 4 1995 throu h 1998 �____ _ ; 1999_- � _ ,.--- --_. __ � --- _ _-- i�. ---- _ -- i 2000 -- I � - --- - ' _- �- -- _ __ � _ ' 2001 - _ _ __ � _ _. -- -- i _- __ _ 2002 _------ � _ __ --- _- - -_ - -- -� 2003 --_ _ _ __ _-- - �-_ __ __ --- : r 2004_ _ _ _- � - �, - -- -- __ __ _ _ ___ __ _ 2005 _-�_ -- -- -_ -- --- -- ; --_ - - - - _ _--- - ' 2006 � ' __ _- __ _ __ ___ __ - --- - ; 2007 � __ _ __ - -- __ _ __ -- -- _._ � �� 2008 � � � --- � _- _ __ . __- -- __ 2009 ___ _ _ , _ _ a .__ ___ __ — _ _ ---_ 2010_. — — '— — —-- fi -- -- _ — — __ C 2011 through 2013 � __- , ,_ _ __.. - ---- _ - - -- -- - - _� i-- '_ _ __-- _--- . -- _-- r — —.____ — — I — -- — — _ -- —�I _ __ L — _ ___ ---- — —_ _ — — — — �_ _ ' — — _ — -- �-- — — ___ I _ --- { — — _ ——'� � — — ___-- +-- . , TOTALS __I___ - -- -- I -- ---- --�--- --- Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: _ _ Penalty: ATTACHMENT TO REV-1500 ESTATE OF FILE NUMBER KEENER, VIVIAN M. This is a non-probate estate. The assets listed in the inheritance tax return are all Schedule E, F and G assets. The deductions listed on Schedules H and I should be allowed because the beneficiaryof the Schedule G assets and the surviving joint account owner of the Schedule F assets actually paid the deductible items. See 72 P.S. § 9126. �� . � . .