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Home My WebLink About12-29-14 J 1505610105 REV-1500 EX(Oz-11)(FI) � PA Department of Revenue Pennsytvania OFFICIAL USE ONLY Bureau of Individual Taxes ��M1wFMOFqEVENUF County Code Year File Number Po Box 2sosol INHERITANCE TAX RETURN Harrisburu PA i�iz8-o6oi RESIDENT DECEDENT �1 l� � a�� ENTER DECEDENT INFORMATION BELOW - Sociai Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY _ ....._ , _______ � ._.._.___. , _. _..__.._._ _- __ .. ._____.. 171-20-5933 � 12182013 07021928 Name Suffix DecedenYs First Name MI_ _.._ ' F RNEY _ _....... _. __. _.. MR. RAY K _... _.. _... _....._. __. _. _. _......... . pplicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse s First Name ; _ _._. MI _ _.. _...._...... _._..... : _ _..._ .__._... _ ___ _ _.._ . . _. __...� _._... ._...__..._- pouse s ocial Securi Number -- --- ty ' THIS RETURN MUST BE FILED IN DUPLICATE WITH THE _._ _____ .. � REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 1.Original I�eturn � 2.Suppiemental Return O 3. Remainder Return(Date of Death Priorto 12-13-82) O 4. Limited Estate p 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Retum Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Wili) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 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 T0: Name - ----- ------ - - Daytime Telephone Number .... .......... . __.... ___-_ _. ____ _.__._. . . _. _... _.._ ; AVID L FORNEY, EXECUTOR � 202-778-9497 ' REGISTER OF WILLS USE ONLY � First Line of Address E"> � � _..._.. � � � _....... _... _.._.. _.. _.._. _.... ...._.._ K&L GATES, LLP : : Q r~� � _...._ _._..... : ,�, z� t� � c� __.... _...__.... -Q r*� ._ e7 ___..._.__ _. _.. Second Line of Address __.. _.._...._ .� � C7 � ,,,j �7 _., ........ . ......... .. _... ... ...... . .. � � C:�7 . 1601 K STREET NW ' '~ �" N r"t � _...._.............._. .. �� _., LO .:.r C`.� ; _ . _. .... . . ....... .. - r-•. __. _..._ ity or Post Office State ZIP Code ' c'� � oA I�E[�? �-'� ._........._._.. .._....__. .............. . __..rT � � --r .. _....... ............ ... ....... .. w.:�. �.'.'7 .."' __.-- ..�........___.. - ... .� ,. ___,___ _. ... _ WASHINGTON DC ; ;20006 `• ' � � �� ---� _...... _....__ __.. � _. _. , . �� __._..... _._ • � r'_' ...... _: _._.___ _._.� _- - --....__._.. r.,., rr�t , }. Corresponder s e-ma address:RAY.FORNEY.ESTATE GMAIL.COM � � � Under penalties f pery'ury,I clare t I ave examined thi m,induding acc panyin sch ules and statem ts,and to the best of my knowledge and belief, it is true,corcect d mpl .Dec rati n of pr er o er an the personal r resentat e is as d I mation of which preparer has any knowledge. SIGNATURE OF P SO ES S LE FOR ILING TU N DA ADDRESS lz /S' 1601 K STREET NW, WASHINGTON DC 20006 �Z �r � SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610105 15�5610105 J h � 1505610205 REV-1500 EX(FI) DecedenYs Social Security Number _...._... __ ..._. Decedent's Name: RECAPITULATION , _..__..... _... _.. _.... ......_ . 1. Real Estate(Schedule A). .................. ............... ...... ..... 1. ; _._.__.._..,H_.._��._-____.�____.�..._.__.__.._.__�.._; 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. ; ! ..__.__________..__..._�_.v._.._.._ 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. i ^H ...___.__.�._.___�.��_._._.._.____.__ -_; 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6.' 7. Inter-Vivos Transfers 8�Miscellaneous Non-Probate Property - �-�""�-"��-`��-----�--~�-------------- .._ (Schedule G) O Separate Billirg Requested........ 7. �� 8. Total Gross Assets(total�ines 1 through 7).................. ...... ..... 8. ; 9. Funeral Expenses and Administrative Costs(Schedule H)...... ' / •�••......... s. : See Supplemental Attachments ✓ 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............... 10. � i 11. Total Deductions(total Lines 9 and 10)................................. 11. 12. NetValueofEstate(LineBminusLinell) ......................... ..... 12 13. Charitable and Governmentai 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. ; 104,339.74 ; ' 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 : 16. Amount of Line 14 taxable �� ""' �----------- __., at�ineal rate X.0 45 104,339.74 : �g ; 17. Amount of Line 14 taxable ��' ��-- ------•------------------ i at sibling rate X.12 �� ` 18. Amount of Line 14 taxable � i ---.-_�..m..... at collateral rate X.15 ' ' � _................................................................................................................................................_......................': 18. : ; �__...�______�___�... ._ 19. TAX DUE .......................... .............................. . 19.: 4,695.29 ': __...... _ _.......__ __.; 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT � Side 2 L 1505610205 1505610205 J REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Ray K. forney STREETADDRESS 1801 Warren Street cirv New Cumberland ':, STATE ZiP j PA 17070 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 4,695.29 2. Credits/Payments A.Prior Payments 4,247.79 B.Discount _ 110.00 3. Interest Total Credits(A+g� �2� 4,357.79 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. �3� Fili 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) 337.50 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 prope�ty transferred.......................................................................................... � � b. retain the right to designate who shall use the property transferred or its income ............................................ � � I 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 accounf or security at his or her death?.............. ❑ � 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 suroiving 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 disciosure 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 decedenYs 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 decedenYs 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. ESTATE pF RA.Y K. FORNEY Social Security No.: 171-20-5933 Date of Death: December 18, 2013 Cumberland County Probate File: 2014-00005 Pa. File: 21-14-00005 SUPPLEMENTAL INHERITANCE TAX RETURN (FORM REV-1500) SUPPORTING ATTACHMENT LINE 14. Net Value Subject to Tax (as filed) $96,839.74 Adjustment to Schedule H (see below) 7,500.00 Line 14. Net Value Subject to Tax $104,339.74 � Explanation of chan�e: By letter dated August 8, 2014, the Executor filed the Inheritance Tax Return for the Estate of Ray K. Forney in which a proposed Personal Representative Commissions of$7,500.00 was claimed. On December 15, 2014, the Executor waived the entire amount of the Personal Representative Commissions of$7,500.00. This is the only change to the return. Accordingly,the net value of the estate subject to tax increased by $7,500.00. REV-1511 EX+ (OS-13} '�� pennsylvania SCHEDULE H S DEPARTMENT OF REVENUE - FUNERAL EXPENSES AND INHERITANCETAXRETURN ADMINIST��l1TIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Ray K Forney Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A• FUNERALEXPENSES: 1' Snyder Funeral Home — funeral expenses Schedule H-1 3, 041.00 B. ADMINISTRATIVE COSTS: O.oO 1. Personal Representative Commissions: _f , Name(s)of Personal Representative(s) David L. Fornev StreetAddress 1600 K Street City washinqton State DC ZIP 20006 r2/�5.�� Year(s)Commission Paid: 2015 Z• Attorney Fees: 1,012.50 � 3• Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address i I City State ZIP � Relationship of Claimant to Decedent 4• Probate Fees: 363.50 5• Accountant Fees: 6• Tax Return Preparer Fees: 390.00 �• See additional expenses attached at Schedule H-2 32, 141.10 t�!/3 �� 3 G q��/o TOTAL(Also enter on Line 9, Recapitulation) $ If more space is needed,use additional sheets of paper of the same size. _:,. � �,� �.��. . _ _, '� O au m � w a Q! O cs � _ � .� ... �. �oiz � T a - w •� z S7"� � \ � �� - '� o � .� � ' � � � � � ' , . f�1 �F � �i� �O � t;i ��.. �s-5 4�:� � ,� v `.».e'r�23.�t�o"�C�`� �.- �, ��fl t ^y 1}4� �t��ii`,J" �J�i$4 .:J �`'� �;- :}��tiJ � . � �� }t�� 4�^ �T ZI W� 6Z �� w- , �.e�� SC� .�i�"�,�r�� ::!JtJ� P�� i ��i��,� ��fl�3� � y,, _ . �� _ T-,--:""- _ .^-