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HomeMy WebLinkAbout01-05-15 pennsytvania 1505614105 DE-EK W AF.VEWE EX(03.14)(FI) REV-1500 OFFICIAL USE ONLY County Code Year File Number Bureau of Individual Taxes 1-- 1................................ .............. PO,BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT a,lI I Lj ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 105312014 :02021935 ............-............. ............ ............. ..........-....................... Decedent's Last Name Suffix Decedent's First N MI . ............ I Stasyszyn Carl (if Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ........... .......... ............ ................ .......... .......... .................. ............ ............ .............. 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.Agriculture Exemption(date of C=:> 5.Future Interest Compromise(date of 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) c@D 7. Decedent Died Testate CM 8. Decedent Maintained a Living Trust 1 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) C=D 10. Litigation Proceeds Received C=:) 11.Non-Probate Transferee Return C=:) 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) C=:) 13. Business Assets C=:) 14.Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT- THIS SECTION MUST BE COMPLETED,ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED M: Name Daytime Telephone Number 'Law Office of John C Oszu S�W fC7- (717)243-7437 ............................. ....... ---—------­----- First Line of Address ..................... ......... .......... 104 S Hanover St .............-------...... ___W....__._.,..,... _..._..-- ...­­__,­,,,__­ ........... Second Line of Address ........................ .... .......... City or Post Office State ZIP Code .......... ............... Carlisle PA 17013 --------- C=w Correspondent's email address: Johno@carlislepalaw.comM rTi REGISTER­QF,#II0§USC�NLY U0 M rTj REGISTER OF WILLS USE ONLY 4-ATT,EFILIE,.,- D r1i DAjj FILED STAMP-C Cn PLEASE USE ORIGINAL FORM ONLY Side 1 111111111111111111111 P11 11111 qu 1111111111111111111111 15 561 10 1505614105 1505614205 REV-1500 EX(FI) Decedent's Social Security Number ......................... ................. Decedent's Name: RECAPITULATION 1. Real Estate(Schedule A). ............................................ I 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. 15,308.08 & Jointly Owned Property(Schedule F) C=) Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) C=> Separate Billing Requested........ 7. ryMN�ry 8. Total Gross Assets(total Lines I through 7).. ............... ............ 8. 15,308.08 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 12,102.41 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)... ........... 10. 18,664.23 11. Total Deductions(total Lines 9 and 10). .............................. .. 11. 1 30,766.64 12. Net Value of Estate(Line 8 minus Line 11) ......................... 2. -15,458.56 13. Charitable and Governmental Bequests/Sec.9113 Trusts for which an election to tax has not been made(Schedule J) ........................ 13. 14. Not Value Subject to Tax(Line 12 minus Line 13) . ......... ............ 14. 0.00 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under See.9116 (a)(1.2)X.0 15.1 16. Amount of Line 14 taxable at lineal rate X.0 16. 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. 1 19. TAX DUE ...................................... ............... .... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C:) Under penalties of perjury,I declare 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 responsible for filing the return is based on all information of which preparer has any knowledge. _S6GW,ATURE OF PERS ES�NSIBLE FOR FILING RETURN DA U _ A -I A61111ESS 522fi Cobblestone Dr., Mechanicsburg, PA 17055 SIGN,1,U F P THER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DAT TDDRE-16 104 Hanover St., Carlisle, PA 17013 1111111111111111111111111111111111111111111 Side 2 150 614205 1505614205 nsWmmsx (F; Page o File Number Decedent's Complete Address: DECEDENT'S NAME Carl Stasyszyn STREETADDRESS 1517 Shirley Ave. CITY STATE Zil Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2.Line 1Q) (1) 0.00 2. Credits/Payments A.Prior Payments B.Discount (See instructions.) Total Credits(A+B) C2) 3. Interest (3) 4. |fLine 2isgreater than Line 1 +Line 3.enter the difference. This iothe OVERPAYMENT. Fill inoval onPage 2,Line 20torequest arefund. (4) 5. If Line I +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) Make check payable to: REGISTER nFVUU WILLS, 8T (�[�AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN °X' IN THE APPROPRIATE BLOCKS 1. Did decedent make utransfer and: Yes No a. retain the use mincome ofthe pmportyVanofen*d—____—__—_------_---.. F-1 �U� � kretain the right todesignate who shall use the property transferred mits inoomo --------------.. f-1 0 c retain oreversionary interest ------------__—..---------------------- U� �[�� �� d mm�mthe pmm�ohx0�oyeKho puymon�bunoh�moam?--------.------------ Fl�� U��� l Ifdeath occurred after Dec.12,1982,did decedent transfer property within one year ufdeath without receiving adequate consideration?—................... ........... .................................................... — ............ �[�� �U� � l Did decedent own om"in trust for'or bank account msecurity athis mher death?.............. El 0 4. Did decedent own an individual retirement account,annuity or other non-probate property,which [� U� contains ebeneficiary designation? ---..-------..----..-----------------.~.----.. IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES.YOU MUST COMPLETE SCHEDULE G AND FILE ITASPART OF THE RETURN. For dates ofdeath onurafter 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 io3percent[72PS.§9118(g)(11)8U. For dates of death on or after Jun. 1, 1995. the bm rate imposed on the net wdVo of transfers to mfor the use of the surviving spouse N U percent [72PS.K911S(o)(1.1)UU>.The statute does not exempt utransfer b a survivingspouse from tax,and the statutory requirements for disclosure of assets aoU filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates ofdeath nnorafter July 1.2OOO: w 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 urostep-parent mfthe child\uUpercent F2RS.QH1iO(o)U.2\l. w 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,exceptmsnoted in F2PG.§9116(a)U\l * The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percentPS. §9118(m)U.3)].Asibling indefined, under Section 9102,as an individual who has at least one parent in common With the decedent,whether by blood or adoption. REV-15o8 EX+(o8-12) Pennsylvania SCHEDULE E. DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. r r . INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Carl J. Stasyszyn 21-14-0618 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 7 • VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 'Citizens Bank Checking Account XXX708 4 ~ 1,096 48 1 21 Wal-Mart paycheck ' 624.74 3 COBRA insurance refund , 21.07 4. Humana auto insurance refund 12.601, 5 4The Sentinel-newspaper cancellation refund' - .. _ 13.30 6 2008 Nissan Quest 3.5 SE � 12,935.82 F ,7 Misc household item sold at auction ... 1 �_-,^ ,442.28 8 State Farm payment plan refund y 32.34 ` 9 Woodforest National Bank Acct 1332345576 5.00 10 lWal-Mart Employee Incentive Bonus Check _ 124.45 dT� '- -aS.�"6.:'.•C'lii+" -r'.SIN-�.+e� .:.JC>'+._-��..m�......a f. r _. 308.08� TOTAL(Also enter on Line 5, Recapitulation) $ ', 15, 8 8 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+ (08-13) U--r,1-1 j7pennsytvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Carl Stasyszyn 21-14-0618 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: Ewing Brothers Funeral Home,Carlisle,PA 10,221.22 B. ADMINISTRATIVE COSTS: L Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 1 Attorney Fees: 1,500.00 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: 183.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. The Sentinel-advertising 116.20 8 Cumberland County Law Journal 75.00 9 USPS-registered letter for safe deposit box entry 6.49 TOTAL(Also enter on Line 9, Recapitulation) 12,102.41 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, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Carl Stasyszyn 21-14-0618 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. Quest Diagnostics 16.74 2 Allied Interstate-medical expense 1,371.93 3 JL Hardesty-medical expense 64.07 4 Central Penn Management Group-medical expense 222.64 5 Three Springs Family Practice-medical expense 170.93 . 6 Carlisle Medical Group,LLC-medical expense 111.32 7 DISH Network 107.05 8 PPL 409.89 9 Quantum Imaging and Therapeutic Assoc-medical expense 59.78 10 Verizon Wireless 69.89 11 Carlisle Physician Services 172.16 12 Citizens Sank-overdraft fees 362.60 13 Cohick&Associates-tax prep fees 1,404.00 14 Pinnacle Health Carodivascular Inst.-medical expense 63.26 15 2008 Nissan Quest 3.5 SE-auto loan due 12,935.82 16 Deluxe Check 24.25 17 Capital One Auto Payment 928.38 18 State Farm Auto Insurance 169.52 TOTAL(Also enter on Line 10, Recapitulation) $ 18,664.23 If more space is needed,insert additional sheets of the same size.