HomeMy WebLinkAbout03-04-15 (3) 150SL18403
Pennsylvania
,gl_.2�EX(03-14)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg,PA 17128-0601 RESIDENT DECEDENT 21 14 0968
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
09 19 2014 117 09 1920
Decedent's Last Name Suffix Decedent's First Name MI
KERN EVELYN L
(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
0 1. Original Return 2. Supplemental Return 3. Remainder Return(date of death
S. Future Interest Compromise(date of prior to 12-13-82)
4. Agricultural Exemption(date of S. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
El 7. Decedent Died Testate 8. Decedent Maintained a Living Trust 0 9. Total Number of Safe Deposit Boxes
(Attach copy of will) (Attach copy of trust.)
El 10. Litigation Proceeds Received 11. Non-Probate Transferee Return 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
13, Business Assets F1 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
KEITH R NONEMAKER ESQUIRE 717 632 5315
First Line of Address
40 YORK STREET
Second Line of Address
City or Post Office State ZIP Code
HANOVER PA 17331
rn
Correspondent's email address: C->
REGI "CE
_ Y,---)
Ik Q6WILLS'6SE ONLY
r
REGISTER OF WILLS USE ONLY
DATE FILED MMDDYYYY
`bATE FILED SfAqP 7n,
Side I
1111111 IIIII Ilil(IIIII IIIII IIIA VIII VIII VIII VIII IIII llll ___I 1
1505618403 1505618403
1505618411
REV-1500 EX Decedent's Social Security Number
Decedent's Name: Kern, Evelyn L.
RECAPITULATION
i. Real Estate(Schedule A)......................... ............................................................. 1
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. 441899 - 96
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) [] Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines I through 7)........................................................ 8. 4 4 8 9 9. 9 6
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 2 0 7 4 - 10
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 12-o827 - 03
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 14 -,9111 . 13
12. Net Value of Estate(Line 8 minus Line 11)........................................................ 12. 291998 -83
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. 29 -,998 - 83
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.00 15. 0 . 110
16. Amount of Line 14 taxable
at lineal rate X .045 29,998 - 83 16. 1i349 - 95
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 11 - 00 18. 0 -
19. TAX DUE........................................................................11..................................... 19. 1-,349 - 95
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Under penalties of periury,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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN Jerry C. Kern ? DATE
ADDRESS
575,etrde,r Rd., Newville, PA 17241
SIG AT OF REPARER OTHER THAN REPRESENTATIVE Keith R. Nonemaker Esquire DATE ✓
3(2.1b
ADDA`S?S��
40 York Street, Hanover, PA
111111111111111111111111111111111111111 IN Side 2
1505618411 1505618411
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF FILE NUMBER
Kern, Evelyn L. 21-14-0968
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' ue,correct and complete.Declaration of preparer other than the personal representative is based on all
information of which parer s any know edge.
Signature#2
Name Joshua M.Brady
Address1 7312 South Garnett Rd.
Address2 Apt.234
City,State,Zip Broken Arrow,OK 74012
Date
Signature#3 �,
Name Shawn M.Kern
Addressl 404 North St.
Address2
City,State,Zip Mc Sherrystown,PA 17344
Date ` l 3 IS
REV-1500 EX Page 3 File Number 21-14-0968
Decedent's Complete Address:
DECEDENT'S NAME
Kern, Evelyn L.
STREETADDRESS
410 Big Spring Rd.
CITY STATE ZIP
Newville PA 17241
Tax Payments and Credits:
I. Tax Due(Page 2,Line 19) (1) 1,349.95
Z Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +B) (2) 0.00
3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5, If Line I+Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 1,349.95
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 property transferred;.............................................................................. El F-1
b. retain the right to designate who shall use the property transferred or its income;..........................._.... El Fx�
c. retain a reversionary interest;or................................................................................................................ F1 Fx]
d. receive the promise for life of either payments,benefits or care?............................................................
1:1 nx
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?................................................................................................................... F1 nx
3. 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 a beneficiary designation?.................................................... ............................................................. El 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
1090mm" W,�W M
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
[72P.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 step-parent 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 decedents lineal beneficiaries is 4.5 percent,except as noted in 172 P.S.§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 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.
Rev-1 508 EX+(08-12)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kern, Evelyn L. 21-14-0968
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly.own ad with the right of survivorship,must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
I F&M Trust Checking#3655246 8.569.23
Accrued interest on Item 1 through date of death 0.01
2 F&M Trust Money Mangagement#7159595 32,915.03
Accrued interest on Item 2 through date of death 5.64
3 Presbyterian Homes-refund 3,410.05
TOTAL(Also enter on Line 5,Recapitulation) 44.899.96
(if more space is needed,additional pages of the same size)
Copyright(c)2092 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev.08-12)
REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANTAX
RESIDENT DECE CEDENT RETURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Kern, Evelyn L. 21-14-0968
Decedent's debts must be reported on Schedule 1.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees Guthrie, Nonemaker,Yingst& Hart, LLP 1,500.00
3, Family Exemption: (if decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zin
Relationshio of Claimant to Decedent
4. Probate Fees 170.60
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 403.60
See continuation schedule(s)attached
TOTAL(Also enter on line 9, Recapitulation) 2,074.10
Copyright(c)2013 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.08-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Kern, Evelyn L. 21-14-0968
ITEM
NUMBER DESCRIPTION AMOUNT
Other Administrative Costs
I Cumberland Law Journal-estate notice 75.00
2 The Sentinel-estate notice 328.60
H-B7 403.60
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12-12)
SCHEDULE I
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kern, Evelyn L. 21-14-0968
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 DEKfVi
I Chambersburg Hospital-unreimbursed medical expenses 1.203.68
2 Chambersburg Imaging-unreimbursed medical expenses 2.07
3 Darryl Guistwitte-unreimbursed medical expenses 82.68
4 Darryl Guistwiffe-unreimbursed medical expenses 35.94
5 Emergency Chambersburg Ambulance-unreimbursed medical expenses 100.00
6 F&M Trust Checking#3655245-check cleared post death for September 410.37
7 Friendship Hose Company#1 -unreimbursed medical expenses 100.00
8 Health Network Laboratory-unreimbursed medical expenses 5.78
9 Millennium Pharmacy-unreimbursed medical expenses 102.69
10 Millennium Pharmacy-unreimbursed medical expenses 1.88
11 Mobilex USA-unreimbursed medical expenses 28.66
12 Presbyterian Homes-check cleared post death for September 9,988.90
13 Summit Anesthesiology-unreimbursed medical expenses 27.02
14 Summit Physician Services-unreimbursed medical expenses 737.36
TOTAL(Also enter on Line 10,Recapitulation) 12,827.03
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group,Inc. Form PAA500 Schedule I(Rev. 12-12)
nEV-1513em(01-10)
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kern, Evelyn L. 21-14-0968
NAME AND ADDRESS OF RELATIONSHIPTO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT
Do Not List Trustee(s) - (Words) ($$$)
TAXABLE DISTRIBUTIONS (include outright spousal
distributions,and transfers
I Joshua M. Brady Grandson 25%share of
7312 South Gamett Rd. residue
Apt.234
Broken Arrow,OK 74012
2 Jerry C.Kern Son 50%share of
575 Center Rd. residue
Newville, PA 17241
3 Shawn M.Kern Grandson 25%share of
404 North St. residue
Mc Sherrystown, PA 17344
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
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 11 -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI
Copyright(c)2D1Oform software only The Lackner Group,Inc. Form PA4s0OSchedule JV7ev 01-1N
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