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Home My WebLink About03-20-15 (2) � � pennsylvania 1505614105 � �NTDF��uE EX(03-14)(FI) REV�i�OO OFFICIAL USE ONLY Bureau of Individual Taxes Counly Code Year File Number Po Box 28o6oi INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT �41j ��3�d��'tf ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 01292013 06121920 DecedenYs Last Name Suffix DecedenYs First Name MI HUMPHREY ESTHER (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI THtS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FIIL IN APPROPRIATE OVALS BELOW � 1.Original Return p 2.Supplemental Return p 3. Remainder Return(date of death prior to 12-13-82) p 4.Agriculture Exemption(date of � 5.Future Interest Compromise(date of p 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) p 7.Decedent Died Testate p 8.Decedent Maintained a Living Trust _ 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) p 10.Litigation Proceeds Received p 11.Non-Probate Transferee Return p 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) O 13.Business Assets O 14.Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ELLA JEAN NICHOLS (717)245-2520 First Line of Address 1208 REDWOOD HILLS CIRC Second Line of Address City or Post Office State ZIP Code CARLISLE PA 17015 CorrespondenYs email address: REGISTER OF WILLS USE ONLY REGISTER OF WILLS USE ONLY DATE�ILEd MMDDYYYY D E FILED STA P_:> e..'^^ I__..� „ �--� c.r1 -.,., .^:3 :-."9 � ` �..,_! i 7 _ ,.� ..., ��::7 _-;� -:�:.�� ,..,� PLEASE USE ORIGINAL FORM ONLY •" � - .� : h� _ . Side 1 � ; 50 14 15056 �� E � i iiiiii oiii iiiii i�iii iiii��iii iii�i��iiiii iiiii iiii iiii _! 14105, , . ,: .� _�-- -;,, �_, `„ cn ..;f �� 1505614205 REV-1500 EX(FI) DecedenYs Social Security Number DecedenYs Name: �� / RECAPITULATION 1. Real Estate(Schedule A). ............................................ 1. 2. Stocks and Bonds(Schedule B) ............... .............. .. . ....... 2. 86,581.00 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. 6. Jointly Owned Property(Schedule F) O Separate Biiling Requested ....... 6. 21,307.25 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets total Lines 1 throu h 7 8. 107,888.25 � 9 ).............. . . ............. 9. Funerai Expenses and Administrative Costs(Schedule H)................ . . . 9. 5,204.00 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I).......... ..... 10. 1,003.00 11. Total Deductions(total Lines 9 and 10)..... . .. ............. .. . . ........ 11. 6,207.�� 12. Net Value of Estate(Line 8 minus Line 11) ..... . . ........ ............... 12. 101,6$1.00 13. Charitable and Govemmental Bequests/Sec.9113 Trusts for which an election to tax has not been made(Schedule J) .......... .............. 13. 14. Net Value Sub'ect to Tax Line 12 minus Line 13 �4. 101,681.00 1 � ) ........................ TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabie at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0_ 15. 16. Amount of Line 14 taxable at lineal rate X.0_ 0.04 �g_ 4,575.64 17. Amount of Line 14 taxable at sibling rate X.12 17- 18. Amount of Line 14 taxable at col�aterai rate X.15 18• 19. TAX DUE ........... . ............... .............................. 19. 4,575.64 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Under penalties of perjury,I declare I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,corcect and complete. Declaration of preparer other than the person responsible for filing the retum is based on all infortnation of which preparer has any knowledge. SIGNATURE O PERS N R NSIBI�L��fi� A E f}� � ✓ �A ADDRESS SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE ADDRESS i iiiiii iiiii iiiii iiii�i�i�iiiii iiiii iiii�iiiii iiiii iiii iiii S,de 2 � � 1 61420 1505614205 REV-1500 EX (FI) Page 3 File Number �x �� ~ O �g"7' Decedent's Complete Address: DECEDENTS NAME ESTHER HUMPHREY _ __ _ __ _ ._- _ _ __ _ _ _ STREETADDRESS _ _ ___ _ --__ 1208 REDWOOD HILLS CIRCLE __ _ _ _ ____ _ ---__ CITY . . � STATE ZIP CARLISLE ' PA ' 17015 Tax Payments and C�edits: 1. Tax Due(Page 2,Line 19) (1) 4,575.64 2. CreditslPayments A.PriorPayments _ _ 1,598.56 B.Discount (See instructions.) Total Credits(A+g) (2) 1,598.56 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) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 2,977.08 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 ............................................ ❑ � c. retain a reversionary interest.............................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ � 3. Did decedent own an"in trust for"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? ........................................................................................................................ � ❑ 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)(ij]. 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 suroiving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the suroiving 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 decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. . 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 blood or adoption. REV-i5o3 EX+(&u) '-'-� pennsylvania SCHEDULE B � DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER ESTHER HUMPHREY �� ✓� 'O/g� All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1' RYDEX ETF TR SP500 EQUAL 2,841.00 2 GREAT PLAINS ENERGY INC 21,830.00 3 KIMBERLY CLARK CORP 12,986.00 4 VERIZON COMMUNICATIONS 9,024.00 5 GENERAL MOTORS SMART NOTES 4,989.00 g GENERAL MOTORS SMART NOTES 19,911.00 7 GENERAL MOTORS SMART NOTES 15,000.00 TOTAL(Also enter on Irne 2, Recapitulation) $ 86,581.00 If more space is needed,insert additional sheets of the same size REV-15o9 EX+{o1-10) � pennsylvania SCNEpuLE F DEPARTMENTOFREVENUE )OINTLY-OWNED PROPERTY INHERtTANCE TAX RETURN RESIDENT OKEDEN7 ESTATE OF: FILE NUMBER: �S��er� �f �� 0�3 -0 �'� If an asset became joiMiy owned with' one year of th decedeM's data of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(Sj RDDRESS RELATIONSHIP TO DECEDENT p.ELLA JEAN NICHOLS 1208 REDWOOD HILLS CIRCLE DAUGHTER CARLISLE,PA 17015 B•LISA HATHCOX 1208 REDWOOD HILLS CIRCLE GRANDDAUGHTER CARIISLE.PA 17015 C. ]OINTLY OWNED PROPERTY: LFffER ppTE DE5CRIFftON OF PROPERTY %oF onTe oF oEant ITEM FOR]OINT MADE INCLUDE NAME OF FtNANQAI 1N5fIfUTION NID BANK ACCOUNi NtR�IBER OR SIMIIAR DA7E OF DEATH DECEDENT'S VALUE OP NUMBER TENANT )OINi IDENiIFY[NG NUM882.ATTAQi DEED FOIi 70INRY HELD REAL ESTA'fE• �A111F OF 0.5SET INTEREST �ECE�ENT"'INTERE'`'� 1• A• JOINT CHECKING ACCOUNT AT MEMBERS FIRST 3,445.74 1/3 1,148.58 2 JOINT SAVINGS ACCOUNT AT MEMBERS FIRST 2,089.88 1!3 696.62 3 JOINT CERTIFICATE OF DEPOSIT AT MEMBERS FIRST 19,462.05 1/2 19,462.05 TOTAL(Also enter on Line 6,Recapitulation) $ 21.307.25 If more space is needed,use additlonai sheets of paper of the same size. REV-1510 EX+(OS-09) � pennsylvania SCHEDULE G DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX REfURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE Of FILE NUMBER ESTHER HUMPHREY � D/� � ✓/ � G�/ This schedule must be compieted and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE 7RANSFEREE,IHEIR RELATIONSHIP TO DKEDENf AND DATE Of DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER 'fHE DAlE OF TRANSFER.ATfACH A COPY OF THE DEED FOR REAL ESfAlE. VALUE OF ASSET INTEREST (IF APPL[fABLE) VALUE 1 IRA-MEMBERS FIRST- DONATED TO ANNE HUMPMREY SCHOLARSHIP AT ITHACA COLLEGE. 3,473.43 0 3,473.43 0.00 TOTAL(Also enter on Line 7, Recapitulation) � 0.00 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+ (08-13) � pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND 1NHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ��f � �l �1� �i r� �'- z0�.�o� Y Decedent's debts st be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' HOFFMAN ROTH-CARLISLE 1,351.53 MEMORIAL SERVICE-CBKS SERVICE/MUSIC/FLOWERS 1,439.00 MEMORIAL SERVICE-PERRY, NY SERVICE/MUSIC FLOWERS/FOOD 796.00 FUNERAL LUNCH-CBKS 1,025.00 CEMETARY-BURIAL AND TOMBSTONE REVISION 243.00 CASKET FOR ASHES 350.00 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: 3. Family Exemption: (If decedent's address is not the same as ciaimant's,attach explanation.) Claimant Street Address__ City--.__— _ State _ZIP Relationship of Ciaimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ 5,204.00 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+ (12-12) � pennsylvania SCHEDULE I DEPARTMENTOFREVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ESTHER HUMPHREY �d� � � � �� 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• CARLISLE HOSPITAL 403.84 AMBULANCE COMPANY 140.11 HOSPITALISTS 108.74 DOCTOR BILLS 107.16 US INCOME TAX 114.77 ESTATE FEES 128.50 TOTAL(Also enter on Line 10, Recapitulation) $ 1,003.12 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) ;:�� pennsytvania SCHEDULE � DEPARTMENT OFREVENUE 1NHERITANCE TIU(RETURN BENEFICIARIES RESIDEMi DECEDENT ESTATE OF: FILE NUMBER: ESTHER HUMPHREY � a�3 "J � � RELATIONSHIPTO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Indude outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. ELLA JEAN NICHOLS DAUGHTER 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAI DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CNARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additionai sheets of paper of the same size.