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Home My WebLink About12-15-09 REV-1500 EX(06-05) 15056051058 OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number INHERITANCE TAX RETURN _..--..... PO BOX 280601 21 08 0193 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 02/12/2008 04/05/1958 1 Decedent's Last Name Suffix Decedent's First Name MI [Campbell Campbell Quinten (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name _ _ MI _.,. _ ...... _.....__...._.—.._ _.. ...- ._........ 1.Campbell Debra Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW CeD 1.Original Return C ) 2.Supplemental Return C) 3. Remainder Return(date of death prior to 12-13-82) 4.Limited Estate C ) 4a. Future Interest Compromise(date of C� 5. Federal Estate Tax Return Required death after 12-12-82) C D ' 6. Decedent Died Testate C 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) C:D 9.Litigation Proceeds Received 1 10.Spousal Poverty Credit(date of death C= 11. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number I Andrew H Shaw, Esquire _ ........ . .. . -..__ _ .._. .._ ._.. --.._ .__. __ .-- -. . Firm Name(If Applicable) REGISTER O�WILLS USE 41kY Law Office of Andrew H c_0 .._ _. .. ---..........— C7)First line of address z) t i 1200 S. Spring Garden St. --- l.. Second line of address .. `7 C`7 Suite 11 s ry -_ City or Post Office State ZIP Code _ DAiLED Carlisle PA 17013 --REGISTER OF WILL/CLERK OF ORPHANS'CRT --_...---..........----........ PLEASE NOTE: DUE TO AN ELECTRONIC Correspondent's e-mail address: aShawlaw@COmCaSt.net MALFUNCTION WITH TIMECLOCK-THE Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statem: CLOCK DATE ON.THIS DOCUMENT IS 12 it is true,correct and complete.Declaration of preparer other than the personal representative is based on all inforr, HOURS BEHIND THE ACTUAL TIME. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS 427 N. Pitt Street, Carlisle, PA 17013 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 200 S. Spring Garden St., Suite 11, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 V' 15056052059 REV-1500 EX Decedent's Social Security Number _-.,.... ............. Decedent's Name: Quinten D Campbell RECAPITULATION 1. Real estate(Schedule A). ..................... ....................... 1. 11,138.601 1 2. Stocks and Bonds(Schedule B) .................................... ... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .... . 3. 0.001 4. Mortgages&Notes Receivable Schedule D 4. 0.00 5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E) ........ 5. 50.00 6. Jointly Owned Property(Schedule F) C= Separate Billing Requested ....... 6. 0.00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) C3 Separate Billing Requested........ 7. 0.00 E 8. Total Gross Assets(total Lines 1-7).................................... 8. 11,188.60 9. Funeral Expenses&Administrative Costs(Schedule H) ............ ....... 9. 293.00 10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule 1)................ 10. 0.00 11. Total Deductions(total Lines 9& 10)................................... 11. 293.001 12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. 10,895.60 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .............. ....... ... 13. 0.001 14. Net Value Subject to Tax(Line 12 minus Line 13) ....... ........... ...... 14. 10,895.60 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.0 0 10,895.60 15. 0.00 ' 16. Amount of Line 14 taxable at lineal rate X.0 45 0.00 16. 0.00 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 18. 0.00 19. TAX DUE ......................................................... 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 08 0193 --� DECEDENT'S NAME DECEDENTS SOCIAL SECURITY NUMBER Quinten D Campbell STREETADDRESS 427 N. Pitt Street CIN STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2 Line 19) (1) 0.00 2. Credits/Payments 0.00 A.Spousal Poverty Credit B.Prior Payments 0.00 C.Discount 0.00 Total Credits(A+B+C) (2) 0.00 3. Interest/Penalty if applicable D.Interest 0.00 E.Penalty 0.00 Total Interest/Penalty(D+E) (3) 0.00 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) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 A.Enter the interest on the tax due. (5A) 0.00 B.Enter the total of Line 5+5A.This is the BALANCE DUE. (5B) 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;.......................................................................................... ❑ b. retain the right to designate who shall use the property transferred or its income;............................................ ❑ 10 c. retain a reversionary interest;or.......................................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2. If death occurred after December 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ 10 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? ........................................................................................................................ ❑ ❑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. For dates of death on or after July 1, 1994 and before January 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three(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 zero (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 of after July 1,2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one 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 zero(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 four and one-half(4.5) percent, except as noted in 72 P.S.§9116(1.2)[72 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 twelve(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-1502 EX+(8-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Quinten D. Campbell 21-08-0193 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 willing 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 survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 429 N. Pitt Street,Carlisle,PA 17013 11,138.60 TOTAL(Also enter on line 1,Recapitulation) $ 11,138.60 (If more space is needed,insert additional sheets of the same size) REV-1508 EX+(8-98) ,I* SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Quinten D. Campbell 21-08-0193 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. Personal effects 50.00 TOTAL(Also enter on line 5, Recapitulation) $ 50.00 (If more space is needed,insert additional sheets of the same size) REV-1511 EX+(12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Quinten D. Campbell 21-08-0193 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 0.00 Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) _ Street Address City State Zip Year(s)Commission Paid: 2. Attorney Fees 250.00 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation) 0.00 Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 43.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 7. TOTAL(Also enter on line 9, Recapitulation) $ 293.00 (If more space is needed,insert additional sheets of the same size) REV-1513 EX+(9.00) ab SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Quinten D. Campbell 21-08-0193 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 Debra R.Campbell spouse 10,895.60 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18,AS APPROPRIATE,ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ONLINE 13 OF REV-1500 COVER SHEET $ 0.00 (If more space is needed,insert additional sheets of the same size) ^ r�