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REV-1500 EX (02-11)(FI) 1505610140
OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 4 0 0 5 4
ENTER DECEDENT INFORMATION BELOW
1 2 2 5 2 0 1 3 0 1 1 1 1 9 7 1
Decedent's Last Name Suffix Decedent's First Name MI
S Y B E R T D A V I D A
(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 F] 3. Remainder Return(Date of Death
Prior to 12-13-82)
F] 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 F1 10.Spousal Poverty Credit(Date of Death 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 TO:
Name Daytime Telephone Number
W I L L I A M A D U N C A N 7 1 �7 2 4 9� 7 7 0
sit
REGIS.,:R OF WILt.1�3USE 0LP
First Line of Address
1 I R V I N E R O W
Second Line of Address
►—� r- M
•- I t—
City or Post Office State ZIP Code DATE FILED
N
C A R L I S L E P A 1 7 0 1 3
Correspondent's e-mail address: bill@duncanhartmanlaw.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 tr , rrect and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGA U OF PER 7"PON IBL OR FILING RE N DATE
Ji - /S-
ADDRESS
46 QUARRY HILL ROAD, NEWVILLE, PA 17 241
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610140 1505610140
0`✓
1505610240
REV-1500 EX(FI)
RECAPITULATION
1. 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. 3 8 2 5 • 0 3
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6.
7. Inter-Vivos Transfers&Miscellaneous N n-Probate Property
(Schedule G) Separate Billing Requested . . . . . . . 7.
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . .. . . . . . . . . . . . . . . 8. 3 8 2 5 . 0 3
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9• 1 2 7 6 7 . 1 8
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . . . . 10. 9 6 0 3 • 4 9
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 2 3 7 0 • 6 7
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. - 1 8 5 4 5 . 6 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 8 5 4 5 . 6 4
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 1 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate x.045 - 1 8 5 4 5 . 6 4 16. - 8 3 4 . 5 5
17. Amount of Line 14 taxable
at sibling rate X.12 0 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 0 0 18. 0 . 0 0
i.
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. - 8 3 4 . 5 5
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
1505610240 1505610240
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: 21 14 0054
DECEDENT'S NAME
DAVID A. SYBERT
STREET ADDRESS t
65 BIG SPRING AVE. APT. 4
CITY STATE ZIP
N EVVVI LLE PA 17241
Tax Payments and Credits:
I. Tax Due(Page 2,Line 19) (1) -834.55
2. Credits/Payments
A.Prior Payments
B.Discount
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.
Fill in oval on Page 2,Line 20 to request a refund. (4) 834.55
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
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. ...................................................................... ❑ X❑
b. retain the right to designate who shall use the property transferred or its income ............................... ❑ 191
c. retain a reversionary interest ..................................................................................................... El0
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ 171
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... 171 171
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ X❑
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 surviving 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 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 p2 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-1508 EX+(08-12)
pennsylvanial, SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
DAVID A. SYBERT 21 14 0054
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. LIBERTY LIFE ASSURANCE CO. OF BOSTON CHECK 138.06
2. LIBERTY LIFE ASSURANCE CO. OF BOSTON CHECK 171.52
3. STATE OF MINNESOTA REFUND 3.16
4. CREDIT CARD REFUND 86.29
5. U.S. TREASURY- INCOME TAX REFUND 3,317.00
6. COMMONWEALTH OF PA REFUND 109.00
TOTAL(Also enter on Line 5,Recapitulation) $ 3,825.03
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE RR
FUNERAL EXPENSES
AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DAVID A. SYBERT 21 14 0054
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. HOFFMAN ROTH FUNERAL HOME 11,348.68
2. FUNERAL LUNCHEON 150.00
3. BURIAL PLOT. 500.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees: DUNCAN & HARTMAN, PC 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: REGISTER OF WILLS 203.50
5 Accountant Fees: `
f
6. Tax Return Prepares Fees:
7. ADDITIONAL FIDUCIARY FEES-REGISTER OF WILLS-PET.TO SETTLE SM. EST. 65.00
i
TOTAL(Also enter on Line 9,Recapitulation) $ 12 767.18
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania` SCHEDULE
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES& LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DAVID A. SYBERT 21 14 0054
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. PPL BILLING 576.77
2. NATIONAL RECOVERY AGENCY- HERSHEY MEDICAL CENTER BILL 3,000.00
3. MS HERSHEY MEDICAL CENTER 441.00
4. SADLER HEALTH CENTER CORP MEDICAL 42.00
5. BANK FEE 7.00
6. SOUTH MOUNTAIN STORAGE 87.47
7. SOUTH MOUNTAIN STORAGE 35.99
8. SOUTH MOUNTAIN STORAGE 397.46
9. WATER &SEWER BILLING - PAID LANDLORD 160.26
10. LVNV FUNDING LLC C/O SIMM ASSOCIATES, INC. -GENERAL ELECTRIC 3,890.54
[SEE ATTACHED]
11. ELITE ENTERPRISE SERVICES LLC CO SIMM ASSOCIATES, INC. -CASH NET 965.00
[SEE ATTACHED]
.I
TOTAL(Also enter on Line 10,Recapitulation) $ 9,603.49
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:
DAVID A. SYBERT 21 14 0054
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. DAVID F. SYBERT ; Lineal
46 QUARRY HILL ROAD 1/4 SHARE
NEWVILLE, PA 17241
2. THERESA L. SYBERT Lineal
46 QUARRY HILL ROAD 1/4 SHARE
NEWVILLE, PA 17241
3. CHRISTINE M. SHEETS Sibling
44 QUARRY HILL ROAD 1/4 SHARE
NEWVILLE, PA 17241
4. COREY A. SYBERT Lineal
517 BROADWAY AVE, NORTH#10 1/4 SHARE
ST. HILAIRE, MN 56754
%
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:
t
i
{
f
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.
NOTICE OF CLAIM
(Filed Pursuant to 20 Pa.C.S. § 3532)
COURT OF COMMON PLEAS OF
Cumberland COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF David Sybert , DECEASED
No.21-14-0054
To the Clerk of the Orphans' Court Division:
Enter the claim of LVNV Funding LLC C/O Simm Associates, Inc. in the
(Claimant)
amount of$$3,890.54 , against the above entitled Estate.
The Decedent, who resided at 46 Quarry HIII Rd
(Street Address)
Newville, PA 172419403 , died on 10/25/2013 Written notice of
(Date of Death)
said claim was given to David F Sybert C/O William Duncan
(Personal Represen ative o his/her counsel)
at 1 Irvine Rd Carlisle PA 17013
on 09/30/2014 (Address) y
(Date)
L in L / kimm Associates, Inc.
(CI .ant)
800 Pencad . r r.
(Street Address)
Newark, DE 19702
(City,State,Zip)
(Claimant's Counsel) (Supreme Court I.D.No)
(Address)
(Telephone)
Form OC-07 rev. 10.13.06 i
STATEMENT OF CLAIM
STATE OF: PENNSYLVANIA COUNTY OF: CUMBERLAND
ESTATE OF: David Sybert Estate#: 21-14-0054
This claim is being filed on behalf of LVNV Funding LLC, 55 BEATTIE PLACE Suite
110 Greenville, SC 29601.
The nature of the claim is for the General Electric Capital Corporation/LVNV
Funding LLC account#6032201404116496, established on 05/24/2006 and said balance
has accrued since that date. The balance due on the account is$536.49 AND Sears
National Bank/LVNV Funding LLC account#0362099853081, established on
10/01/1994 and said balance has accrued since that date. The total balance due is
$3,890.54.
The balance has accrued since the accounts inception and said balance represents
an accumulation of charges as posted to the account number described above.
I declare or affirm that I have read this ocu< ent a I'know or believe its
representations are true and complete.
:s u
AwnWY011 , Ag t
SIMM Associat s
800 Pencader Dn
Newark, Delaware 19702
STATE OF DELAWARE,NEW CASTLE COUNTY,
SUBSCRIBED AND SWORN TO before me this 9/30/2014.
To me known and known to me to be the same person described in and who executed the
foregoing instrument and she duly acknowl ed to me that she executed the same.
11 AMP,
Notary Public: Danielle M. Gibbs
Expiration Date: August 19, 2015
NOTICE OF CLAIM
(Filed Pursuant to 20 Pa.C.S. § 3532)
COURT OF COMMON PLEAS OF
Cumberland COUNTY,PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF David Sybert ,DECEASED
No.21-14-0054
To the Clerk of the Orphans' Court Division:
Enter the claim of ELITE ENTERPRISE SERVICES LLC C/O Simm Associates, Inc.in the
(Claimant)
amount of$ 965.00 , against the above entitled Estate.
The Decedent, who resided at 44 CUMBERLAND AVE.
(Street Address)
SHI PPENSBURG, PA 17257 ,died on 10/25/2013 Written notice of
(Date of Death
said claim was given to David E Sybert C/O William Duncan Esg
(Personal Representatry o his/her coon
at 1 Irvine Rd , Carlisle PA 17013
(Address)
on 09/30/2014
(Date)
ELI C/O Simm Associates,Inc.
e
4
(Cla Can[) t
80TO Pencad Dr,
(Street Address)
Newark DE 19702
(City,State,Zip)
(Claimant's Counsel) (Supreme Court I.D.No.)
(Address)
(Telephone)
Form OC-07 rev. 10.13.06
STATEMENT OF CLAIM
STATE OF: PENNSYLVANIA COUNTY OF: CUMBERLAND
ESTATE OF: David Sybert Estate#: 21-14-0054
This claim is being filed on behalf of ELITE ENTERPRISE SERVICES LLC, 56
HEYWOOD STREET WORCESTER, MA 01604.
The nature of the claim is for the CashNet account# 1243351. This account was
established on 02/22/2008 and said balance has accrued since that date. The balance due
on the account is $965.00.
The balance has accrued since the accounts inception and said balance represents
an accumulation of charges as posted to the account number described above.
I declare or affirm that I have read thi do ument -J know or believe-its
representations are true and complete.
F
ofi�
n, Ag t
IMM s s otes
800 Pencader je
Newark, Delaware 19702
STATE OF DELAWARE,NEW CASTLE COUNTY,
SUBSCRIBED AND SWORN TO before me this 9/30/2014.
To me known and known to me to be the same person described in and who executed the
foregoing instrument and she duly acknowledged to me that she executed the same.
Notary Public: Danielle M. Gibbs
Expiration Date: August 19, 2015