HomeMy WebLinkAbout02-26-15 (2) Ex�oz-„� 1505610143
-� REV-1500 ;.;
�' OFFICIAL USE ONLY
PA Department of Revenue pennsylvania Counry Code Year File Number
Bureau of Individual Taxes oEvnRrnneNroFaEVEHUE
Po Box.zaoso� INHERITANCE TAX RETURN 2 1 0 9 0 0 2 0 4
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
02 20 2009
DecedenYs Last Name Suffix DecedenYs First Name MI
CLOUSER DAVID H
(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
� 1. Original Return ❑ 2. Supplemental Return � 3.Remainder Return(Date of Death
Priorto 12-13-82)
� 4. Limited Estate � 4a.Future Interest Compromise � 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
Decedent Died Testate Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
� 6� (Attach Copy of Will) � �' (Attach Copy of Trust)
� 9. Litigation Proceeds Received � 10.Spousal Poverty Credit(Date of Death � ��,Election to tax�nder Sec.9113(A)
between 1231-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
MICHAEL ORESTO PALERMO 717 635 9591 : "..�
C'j `_=' —7
_ �__, _,, R1
REGISTER=�F�LLS USE"ONLY �.:. C'>
E:I3 f*'1 i" C."J
',.1 -;J r'* Q :t7
First Line of Address �--- '
� ..., f��� I
3300 TRINDLE ROAD : I a�
Second Line of Address T' T
, _..; =3 _ ',t
' C'J
DATE FILED �V �""• ;i1
City or Post Office State ZIP Code r� �� r.�
C AM P H I L L P A 1 7 0 1 1 cn "'T"r
CorrespondenYse-maiiadaress: mopCa�palermolawoffices.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.
SIG AT RE OF PERSON RE SI LE FOR FILING RETURN � DATE
Douglas G. Clouser �, Z, )
ADDRESS
1875 Town Hill Road i s, PA 17372
SIG R THA NT TIVE
Michael Oresto Palermo
ADD ESS
Palermo Law Offices
3300 Trindle Road, Camp ill, PA 17011
Side 1
� 1505610143 1505610143 �
�
J 1505610243
REV-1500 EX
DecedenYs Social Security Number
oe�ede�c�s r,ame: C L O U S E R, D A V I D H
RECAPITULATION
1. Real Estate(Schedule A).......................................................................................... 1. 1 S 1 , 0 0 0 . 0 0
2. Stocks and Bonds(Schedule B)............................................................................... 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3.
4. Mortgages&Notes Receivable(Schedule D).......................................................... 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 2 2 , 9 5 5 . 8 0
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested............. 7.
g. Total Gross Assets(total Lines 1 through 7).......................................................... g. 1 7 3 , 9 5 5 . 8 0
9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 2 2 , 2 5 1 . 3 6
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................. 10.
11. Total Deductions(total Lines 9 and 10).................................................................. ��. 2 2 , 2 51 . 3 6
12• Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 1 5 1 , 7 0 4 . 4 4
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. 1 5 1 , 7�4 . 4 4
TAX COMPUTATION-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.00 Q . 0� 15.
16. Amount of Line 14 taxable
at lineal rate X .045 15 6 , 4 5 6 . 4 4 �6. 7 , 0 4 0 . 5 4
17. Amount of Line 14 taxable
at sibling rate X .12 0 . �0 ��•
18. Amount of Line 14 taxable
at collateral rate X .15 0 . �� 18
19. TAXDUE................................................................................................................... 19. 7 , 040 . 54
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
� 1505610243 1505610243 �
REV-1500 EX Page 3 File Number 21 - 09 - 00204
DecedenYs Complete Address:
DECEDENT'S NAME
Clouser, David H
STREET ADDRESS
1204 Mitchell Drive
CITY STATE 'ZIP
PA '� 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 7,040.54
2. Credits/Payments
A. Prior Payments 7,000.00
B. Discount 352.03
Total Credits(A +B) (2) 7,352.03
3. Interest (3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 311.49
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. �5�
Make Check Payable to: REGISTER OF WILLS, AGENT.
K; , _
, �,t%xa"'r�a'�rsrr, ,I � ; M �:'�, , i„�i,��,//.rl,,,, .�,.,,„ :...��i�;, � ':� . .%L�k��r,�l ..��.�Ps,,, ..,�"�r.�'� �����.' .,.r�/� . , e���__...�.�. ..
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:.................................................................................. . x,
b. retain the right to designate who shall use the property transferred or its income:.................................... ' x'
c. retain a reversionary interest;or.................................................................................................................. x
d. receive the promise for life of either payments,benefi are?.............................................................. , x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receivingadequate consideration?....................................................................................................................... x
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?......... I x'.
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
containsa 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.
rm.� �� �... �� ,�� ��✓�,��""' �:_�.s�
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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 is 3 percent[72 P.S.§9116(a)(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 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 ears 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)(�.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)J.
•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 bloo�or adoption.
� ; pennsylvania SCHEDULE A
�. DEPARTMENT OF REVENUE .
INHERITANCE TAX RETURN REAL ESTATE '.
RESIDENT DECEDENT �
FILE NUMBER
ESTATE OF Clouser, David H 2� -09-00204
All real 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 property would be exchanged between a willing buyer and a wilfing 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 surwvorship must be disclosed on
schedule F.
Attach a copy of the settlement sheet if the property has been sold.
Include a copy of the deed showing decedent's interest if owned as tenant in common.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 1204 Mitchell Drive, Mechanicsburg, PA 17050 151,000.00
TOTAL(Also enter on Line 1,Recapitulation) 151,000.00
�y pennsylvania SCHEDULE E
�'� DEPARTMENTOFREVENUE '. CASH BANK DEPOSITS AND MISC. ��
INHERITANCE TAX RETURN '�. �
RES�°E"T°E�E°E"T PERSONAL PROPERTY
FILE NUMBER
ESTATE OF Clouser, David H 2� -os-00204
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 DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 Contents of 1204 Mitchell Drive, Mechanicsburg, PA 17050 22,830.61
2 Member's 1st Escrow Refund 5.19
3 Paul's Stor-All Refund 120.00
TOTAL(Also enter on Line 5, Recapitulation) 22,955.80
REV•1511 EX+(10-09) ,.
� pennsylvania ', n SCHEDULEH '
� DEPARTMENTOFREVENUE � f VNERALpCPENSESAND �.
INHERITANCE TAX RETURN AfUl1p�1@TpATI�/C^f'1CTQ .
RESIDENT DECEDENT �, /yLJ1Y1119h71 IV�111YG liW 1�7 .
'FILE NUMBER
ESTATE OF Clouser, David H 21 -09-00204
DecedenYs debts must be reported on Schedule I.
ITEM ' AMOUNT
NUMBER FUNERAL EXPENSES: DESCRIPTION
A. 1
B. ADMINISTRATIVE COSTS:
�. Personal Representative's Commissions
Name of Personal Representative(s) '
Douglas G. Clouser
Street Address 1875 Town Hill Road '
City York Springs state PA Zip 17372
Year(s)Commission Paid 2014
2. Attorney's Fees Palermo Law Offices, 3300 Trindle Road, Camp Hill, ' 4,500.00
3, Family Exemption: (If decedent's address is not the same as claimanYs,attach explanation)
Claimant Debra A. Houseman 3,500.00
Street Address 1204 MitChell Drive
city Mechanicsburg State PA zip 17050
Relationship of Claimant to Decedent Daughter
4. Probate Fees Filing Fees at Cumberland County Register of Wills 302.00
Court Ordered Appraisal of Estate Real Estate 350.00
Murrel Walters, Robert Knupp&Baric&Shearer Fees 1,472.00
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7, Other Administrative Costs
� Storage Fees at Paul's Stor-All, New Bloomfield, PA 2,289.60
See attached 9,837.76
TOTAL(Also enter on line 9,Recapitulation) ' 22,251.36
' Schedu�H
�' Fur�eral E�es 8�
COMMONWEALTH OF PENNSYLVANIA /��,,�,,�,,�N�+�,�,,��,„�, .
INHERITANCE TAX RETURN /+�a���'�1p{1Y�VWI.7 WI WI7�
RESIDENT DECEDENT �.
FILE NUMBER
ESTATE OF Clouser, David H 21 -09-00204
2 Mechanicsburg Borough Sewer Fees ' 622.95
3 Property Taxes- Borough of Mechanicsburg , 3,431.81
4 Repairs to Estate Property ' 5,783.00
Page 2 of Schedule H
REV•1513 EX+(O7•10)
� ; pennsylvania ' SCHEDULE J '
�' DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES ..
RESIDENT DECEDENT , �
ESTATE OF FILE NUMBER
Clouser, David H 21 -09-00204
' RELATIONSHIP TO ' SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY DoNot�ist7rustee(s)
I� TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
under Sec.9116(a)(L2)]
1 Douglas Clouser Son one half
2 Debra Houseman Daughter one half
Enter dollar amounts for distributions shown above on lines 15 through 18 on 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
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, O.00
� �
(
1
I
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Price Recommendation
On the basis of viewing your home, my knowledge of the local market, and the recent sale prices of
comparable homes in your area, I wouid recommend that you list your home in the foNowing price range:
AS IS PRICE:
a,as,000 -s,sa,000
Mirifmal Improvements Price:
EE��� -5162,500
Improvements, Replacements for sale:
S164,000 -5168,000
All Prices assume the home �vacank
If you have any questions or would iike more information, please do not hesitate to call or email me.Thanks
again for this opportunity to be of service to you.
PETITION FC�R PROBATE AND GRANT OF LETTER5
REGISTER OF WILLS �F �'-I IMRFRI AND COUNTY, PENNSYLVANIA
a/- o�- o�?��
Estate of ^e�nn u rt�n�icFis FileNumber
also known as
,Deceased Social Security Number
Petitioner(s),who is/are 18 years of age or older,apply(ies)for:
{COMPLETE'A'OR 'B'BELOW.)
❑ A. Probate and Grant of Letters Testamentary and aver that Petitianer(s)is/are the �n_FxFr.[�TnRs named in the
last Will of the Decedent dated ��1712009 and codicil(s}dated NQti � —
b
�4
7":-i ...,
� 17� r,'`-, . .
{State relevant circumstances,e.g.,renunciation,death ofexecutor,etc.) � � i:� ;.'=�
Except as follows,Decedent did not marry,was not divorced,and did not have a child born or adopted after execu. inst�ent(3�aifFet�gd
� ,i_7
for probate,was not ihe victim of a killing and was never adj�dicated an incapacitated person: � _ ; t
�
� 3 .. _,...1
❑ _�_�:..7
B. Grant of Letters of Administration
(I,japplicable,enter:c.r.a.;d.b.n.c.t.a.; pendente lite;durantea6sentie�`,durante rnme�leJ ;r,
�
Petitioner(s)after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse(if any)and heirs:(If
Administration,c.t.a. or d.b.n.c.t.a.,enter date of Will in Section A above and complete list of heirs.)
Name Relationshi Residence
(COMPLETE INALL CASES:) Attacb additional sleeets if necessary.
Decedent was domiciled at deaih in r��mharland Coun4y,Pennsylvania,with his/her last principal residence at 1204
�itchell Drne Mechanicsbura PA �T050 Mechanicsbura Borouah _
(Lis1 street address,towu/crty,tawnship.county,state,zip codeJ
� � �r�n1��d9 at u„�.,c.,,��.u,,,�ital
Decedent,then years of age,died on----•-
Camo Hill PA '���-
Decedent at death owned property with estimated values as follows: 10.0OO.OQ
(Ifdomiciled in PA) All personal property $
(If not domiciled in PA) Personal property in Pennsylvania $
([f not domiciled in PA) Personal property in County �
Value of real estate in Pennsylvania $ 151.000.00
12U4 Mitchell Drive,Mechanicsburg,PA
situated as follows:
Where{ore,Petitioner(s)respectfully request(s)the probate ofthe last Will and Codicil(s)presented with this Petition and the grant of Letters in the appropriate form to
the undersigned:
Signature Typed or printed name and residence
� � Douglas G.Clouser
� i , Debra A.Houseman
� 7 G ,��
Page 1 of 2
Farm RW-01 rev. I0.13.06
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA ,
: SS
COUNTY OF riiMgFR!oND _ •
The Petitioner(s)above-named swear(s)or affirm(s)that the statements in the foregoing Petition aze true and correct to the best of
the knowledge and be[ief of Petitioner(s}and that,as personal representative(s)of the Decedent,Petitioner{s)will well a�d truly
administer the estate according to law.
Sworn to or affirmed and subscribed �
Signature ojPersonal Representative u S G.CI S �
before me tE�e �day of �
l.v�U� Q.iu� + ' � .
Signafure of Persorra(Representative Debra A.House 9n
r+�
0
For the Register Signature of Personal Representative `a �
� � A'', .
� ; . ;- ,
� � �7 <`.;';a,��
1 t;'"- ��Y7
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Q��- Q�-U�� r,�- n� .,� �.;,�_.7
File Number. Q�'T' s _ ��-�
=�� r:;
c==? s--. -
Estate of DAVID H GLOIlSER �e�ceased � •' `:.;
l�y-�� -�SoS�� `°
Social Sec ' Numbex: Date of Deaike: �l2�� 4 8
AND NOV�. Q���_��_,2009 ,in consideration of the foregoing Perition,satisfactory proof
having been presented before me,IT IS DECREED that Letters TpQ+�`men arv
are hereby ganted to �liSi��i,� "'""'��""'�"�~"e Ho�¢eman
in the above estate
and that the instrument(s)dated
described in the Petition be admitted to probate and filed of recor s the last Will( Codicil(s) f ecede _.
� �
EEES /,�, ~ - ;,
�/� U" �rster Will � � ,f �
Letters ............................. $ �' ! i .. -
� � � ,
Short Certificate(s} ......••••.. $ � Attomey Signature: ���
;.
Renunciation(s)�•F•,J• ••••••••• $ � ' �
� + .... $ Attorney Name: tN„rrAl R=W�iterc.III —_-
•••• � � Supreme Court I.D.No.: �4849
.... $ �
$ AddTeSs: 5d Fa4t Main Str�et
•'•• $ Marhanir.ah����,pA 17055
.... $ - -- —
.... $
..•. $ 7i 7.Fi97-QFJ,5�0
.... $
�a� Telephone: - -- •
TOTAL ............................. $ .
Form RW-02 rev.10.13.06 Page 2 of 2
LAST WILL AND TESTAMENT
� oN�
BE IT REMEMBERED TI�AT
I, DAVID H. CLOUSER, a resident of Cumberland County, Pennsylvania,
being of sound mind, memory and understanding, do make, publish and
declare this to be my LAST WILL AND TESTAMENT, hereby revoking any and
all Wills and Codicils previously made by me.
I
I declare that I am not married, my beloved wife having pr ecease�me,
O _�
and that I have two children, DOUGLAS G. CLOUSER �B� A:�; �;;
� � w `'''';':i
HOUSEMAN. "'
��� c?=?
� � _ -'_�
II - <:? -�`'
� cn . ,'.'�
' ,
I direct that all my just debts and funeral expenses shall be paid fro3� my
residuary estate as soon as practicable after my decease.
III
I direct that all taxes that may be assessed in consequence of my death, of
v�hate�er nature and by v��ha.tever jurisdicdon imposed, shall be paid from my
residuary estate as a part of the expense of the administration of my estate.
IV
I give, devise and bequeath all my property, whether real or personal,
wherever situate, including any property over which I may have a power of
appointment, to my children, DOUGLAS G. CLOUSER and DEBRA A.
HOUSEMAN, in equal shares, per capita.
V .
My daughter, DEBRA A. HOUSEMAN, currently resides with me at my
residence. If Debra should continue to reside there at my death, then I give her
the opportunity to continue to reside there with the condition that she
immediately after my death start paying alI utilities. After the passage of three (3)
months after my death, she may continue to reside there if she pays not only the
vtilities but also taxes and insurance, as well as making a monthly payment of
THREE HUNDRED DOLLARS ($300.00) to my son, DOUGLAS G. CIAUSER.
�
I nominate, constitute and appoint my son, DOUGLAS G. CIAUSER, and
my daughter, DEBRA A. HOUSEMAN, as Co-Executors of this LAST WILL, to
serve without bond.
IN WITNESS WHEREOF, I, DAVID H. CLOUSER, have set my hand to this
�
LAST WILL this ��7 day of �--�� , 2009.
�A,������
DAVID H. CLOUSER
Signed, sealed, published and declared by the above-named DAVID H.
CLOUSER, as and for his Last Will a.nd Testament, in the presence of us,who, at
his request a.nd in his presence, and in the presence of each other,have hereunto
subscribed our names as witnesses.
r i .
.
�� A
i��� �4'C'� � � ...
�. L
,�; �r f?c-;��;L
�-
ACKNOWLEDC�rEMENT
COMMONWEALTH OF PENNSYLVANIA .
ss.
COUNTY OF CUMBERLAND •
I, DAViD H. CLOUSER, Testator, whose name is signed to the attached or
foregoing instrument, having been duly qualifled according to law, do hereby
acknowledge that I signed and executed the instrument as my LAST WILL; that I
signed it as my free and voluntary act for the purposes therein expressed.
���L �,,�-.-�� � _
� DAVID H. CLOUSER
Sworn or affirmed to and acknowledged before me by DAVID H. CLOUSER,
Testator, this /�`�`� day of �F ��T�<«� , 2009.
,
�S�C.r�'" � � 1 . ,�v�ri��
Notary Public
Nor�auu seu.
DIANE M SMITH
Notory tubllc
MECHM�CSBURG BORO.CUM�tUWD CNiY
My Commla�ion Expin�Jun 22,20f4
AFFIDAVIT
COMMO!�WEA.LTH OF E'ENNSYLVANIA .
ss.
COUN'1 Y OF CUMBERLAND •
/ and��/It'f�� ��. '7i 'C'%'���
We, �l l:��'2cy r�. c;1�C�tr"F./C�l�y ' y
the witnesses whose names are signed�O the attached or foregoing instrument,
being duly qual�ed according to law, do depose and say that we were present
and saw Testator sign and execute the instrument as his LAST WILL, that DAVID
H. CIAUSER signed willingly and that he executed it as his free and voluntary
act for the purposes therein expressed; that each of us in the hearing and sight of
the Testator signed the Will as witnesses; and that to the best of our knowledge,
the Testator was at the time 18 years of age or mor�of sound mind and�under
no constraint or undue influence.
, (/ ,�/C .
/ � .. �
.- ,
� `� 7
l.f l.Z.�� / (.... L�,
8worn or affirmed to and acknowledged bef`ore me
this ��y7-day of r,��>i-��cc�-.�.�,, , 2009.
;-�
i . ,,, -�
«�Lci�-` � . ��?r�u��
Notary Public
�—
NOIARIAL SEAL
DIANE M 3MITM
Nofory ►ub11c
MECHAMCSBURG BORO�CUMBERIMJDCMY
My Comm���lon fxpir�s Jun 22.2012