HomeMy WebLinkAbout03-11-15 (3) � 1505610140
-J REV-1500 EX (01-W) pFFlGIPLU5E0NlY
• PA Dapartment af Revenue Counry COCa Vear FiiaNum�er
BureauollndlvidualTaxes �NHERITANCETA7(RETURN 2 1 1 y y 0 6 4
vOeox28osoi RESIDENTDECEDENT
ne�,�se� ,Pn n+saasoi
ENiER DECEOENT INFORMATION BELOW
SaLidl S¢c�Pity NumbB� oata o(oeatn MMDDYYYY Da�e of Birth MMO�W'��
y 1 0 1 1 2 0 1 4 0 7 1 8 1 9 2 2 M
SUKx �ecetlenfs First Name
DaceCenYs Last Name � E A N M
P 0 E T
(If Appliceble)Enter Surviving Spouse's Information Below MI
SuRx Spouse'sFirstName
Spouse's Last Name
Spousa's Social5ecuriry Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE O�ALS BELOW ❑ 2 Supplemental ReWrn � 3. Remaintle�ReNm(tlate of tlea�h
� 1.OriginalRe�um priorlol&13-82)
� 4a FUWre Interest Compromise(Date of � 5.Federal Estete Tax ReNm Requiretl
� Q Limiled Es�ata death atler12-02-82)
� l.Oecetlent Maintainetl a Living Tmst 0 e.Total Number of Safe�eposit Boxes
Q 6.Decedenl Died Teslate �p�[ac�Copy of Tmst)
(Attach Copy of Will) ��. Election totax un0er Sec.9113(A)
� 9.Litigation Pmceetls Receivetl � 10.Spousal Povery Cretlit(tlate of Oeath � (qttach Sch.0)
belwaen 1231-91 antl 1-1-95)
CORRESPONOENT-TXIS SECTION MUST BE COMPLETED.ALL CORRESPONOENCE AND CONFIOENTIR�L n��o�hooe fJ�fiUbarBE DI9€CTE�TO'.
Name
P E T R I E 7 1�. 7: 5 6� 1;, 9',3 9
C H A R L E S E � ' - - -�_ . �- ' '
�,, REGISTER OF 5 USE ONL'Y �
I � I
Flrsl��neofetldress �. . ' - �
ro �.a i
3 5 2 8 B R I S B A N S T R E E T , , n �
� �„ �
Second line of address �, �
�� DATE FIlEO J
Slate ZIPGotle - --- �— —
City or Posl OKice
H A R R I S B U R G P A 1 7 1 1 1
Correspontlenfa e-mail address: PetrieLaw 2ol.cOfn
Untle�penaNes o�perlury,I Ceclare 0at I�ave exemined�Ms�elurn,IncluEing accompa�ryin9 schetlules anE ste�emenLs.an010 tM1e bes�W my knevAetlBe en0 belle(
it Is Vue,mrtecl antl wmplak.�eGarztlon of prepamr Mher tM1an tlie personal representa0ve Is Oasetl on all inromiation ol w�lc�PrePerer has any knvniedBe.
SIGNATI�E�FPERSONRE�p/g/��/JBLEF9iSF�N�G�iE?S�� �}/��j //��
� � �Q/['�- /// �{ (S
noo HARRISBURG PA 1711L
897 SUNNYHILL LANE onre
SIGNATUREOFPRE RERO ERT��ENTPTNE
nooREss HARRISBURG PA 17111
3528 BRISBAN STREET
PLEASE USE ORIGINAL FORM ONLY
Side 1 �
L 1505610140
Lsos61o140
J 15�5610240
REV-1500 EX DecetlenCs Social Security Number
1
oeceoe�r:Name�. JEAN M � POET
RECAPITULATION
1. Real Estate(Schetlule A) . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . . . . .. . . . . .. . �� �
2. S�ocks antl Bontls(Schetlule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . 2- �
3. Closely Held Caryoration,Partnershlp or Sole-Pmprie�ors�ip(Schetlule C) . . . . . 3. �
4. Mortgages antl Notes Receivable(Schedule D) . . . . . . . . . . . .. . . . . . .. .. . . .. 4. �
$ 7 7 1 . 7 7
5. WSM1, Bank Deposi[s and Miscellaneous Personal Property(Schedule E). . . . . . . 5.
6. Jointly Ownetl Propetly(Schedule F) ❑ Separale Billing Reques[ed . . . . . . . 6. '
P. IntervVivos Transfars&Miscellaneous N¢��PSe a,a erBileo ReQues�etl .. .. . . . ]. '
(ScheduleG) L_1 P 9
8. Total Gross Assets(total Lines 1 thmugh]) . . . . . . . . . ..
_ . . _ _ . . . e. 5 7 7 1 . 7 7
9. Fune�al Expenses antl Atlminis�rative Costs(Schetlule H) . .. . . . . . . . . . . . .. . .
y 8 9 0 . 4 5
10. Debis of Decetlen�,Mortgage Liabili�ies,antl Liens(Schedule I) . . . . . . . . . . .
. . �o. 2 9 9 1 . 1 5
��. TOWI Detluctions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . � - � � � - � �� �� �
�� 3 8 8 1 . 6 0
12. Net Value of Estate(Line B minus Line 11) . . . . . . .. .. . . . . . . . . . .. . . . . . . .
12 y 8 9 0 . 1 7
13. CharitableandGovemmentaleequasis/Sec9113Tmstsforwhich 13
an election to tax has not been matle(Schetlule JJ . . . . . . . . . . . . . . . . . . . . . .
i4. Net Value Subject to Tax(Line 12 minus Line 13) . . .. .
�y 1 8 9 0 . 1 7
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amoun[of Line 14[axable
at Ihe spausal tax rate,or
transfersuntlerSec.9176 � . � 0 15. � • � 0
(a)(�?)x'�-
16. Amount of Line 141axable � , O 0 16. � . Q 0
at lineal rate x ��_
1]. Amoun[of Line 14 taxable � . 0 p 17. � • � �
ats2lingrete X 1]
ie. nmo�oioru�eia�a.acia y 8 9 0 . 1 7 ie. 2 B 3 . 5 3
atcollateralrate X.15
19. TAXDUE . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .
�y 2 8 3 . 5 3
20. FILL IN THE OVAL IF VOI/ARE REOUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
L 1505610240 150561�240 J
File Number
REV4500E% Paga3 21 14 �Q(�'Q
DecedenYs Complete Address:
OECEDENTSNAME
JEAN M. POET _ . . . _ . . — _ . — - . __ — _ _ —__ ._. — — . — .—
siaeernooaess � � _ __
10 HOUSE AVENUE __ _ . . - -- � ��
-- _. —— __ . —. . — — _ . . . _.. —._ _ . — ._ � gTATE .__ — _ _ ZIP_. . . _ -.
ciTv pq 17011
CAMP HILL
Tax Payments and Credits: ��� 283.53
t Tax�ue(Page 2,Line 19)
2. CreditslPaymenis
A.Prior Paymenls
B.Discoun� To�alCredlls(A.8) (2) 0.00
3. Interest (3)
4. If Llne 21s grealer Ihan Llne 1 +�Ine 3,enier the tllfference.This Is�he OVERPAYMENT. (4� 0.00
Fill in oval on Page 2.Line 1010 requeat a refuntl.
6. If IJne 1 �L1ne 3 is grealer Ihan Llne 2,en�er Ihe dlHerence,Thls Is Ihe TAX DUE.
�5� 283.53
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes No
i. Dltldecedentmakeatransferand�. O
a. retaintheuseorinmmeoi�hepmpedy�2ns�erred�. ....... ........ X
...... ....._.
b. retainlherighttodesignalewhoshallusethepropedY��ansiertedoritsincome ���� ... ❑ ❑
X
c. retain a reversionary interesC or ........ ................ ...... ....-.. ...- � X
d, receivelhepromiseforlifeo�eitherDayments,beneflsorcare� ....... ........ ............
2. If dea�h ocwrred after December 12,1982,ditl decedenl trensfer Dropetly within one year of death ❑ O
ualemnsideration? .....-..... ............... ........ ❑ O
._......_.,
3. Diddecedentlownao'inimstfor'orpayable-upon-0eathbankaccountorsecurityalhisorherdeatM ......
4. �iddece0entownanindividualreliremeniaccowt,annuiryorothernon-pmhatepmperty,which O ❑
coniainsabeneticiarydesignalion7.._._,. """""�""""""""" X
......_,.._. .........._...
IF THE ANSWER TO ANV OF THE ABOVE�UESTIONS 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.i, 1995,the tax rate imposetl on the net value of Vansfers to or for�he use of the surviving spouse i�.
a percen�(�z P.s,gs�i s�a�(�.�)(�)1.
For dates of dealh on or after Jan.1,1995,the tax rate imposed on Ihe net value of[ransfers to or for the use of the surviving spouse is 0 percent
�72 p.5.§9116(a)(1,1)(ii)].The staWte does not exempt a transfer�o a survivinq spouse hom lax,and�he slatutory requirements for disclosure of assels and
fling a�ax reWm are still applicable even if Ihe surviving spouse is lhe only beneficiary.
For dates of death on or a%er July 1,2000�.
• The tax rate imposetl on the net value of Uansfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adopGve parenl or a stepparent of the child is 0 percent[/2 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers lo or for lhe use of the decetlenYs lineal benefciaries is 4.5 percent,except as noted in
�2 Ps,§siis(�.z)p2 P.s.§st�sle)(t)b
• The tax rate imposed on ihe net value of Uansfers to or for Ne use of the decedenPs siblings is 12 percent[/2 P.S.§9116(a)(1.3)).A sibling is defined,unde
Section 9102,as an individual who has al least one parent in common with the decedent,whether by blood or adoption.
REV-1508 E%+(e-90)
SCNEDULE E
coMnnoNweairHOFaehesrivnNw CASH, BANK DEPOSITS� & MISC.
iNneRirnNcelnur+eluRr+ pERSONAL PROPERTY
aEsioENT oEceoEH1 FILE NUMBER
ESTATEOF 21 14 1064
JEAN M. POET
Indude�he DroceeOs af IiMgatbn and�he tlate Ne procee0s were receivetl by Ne estate
pllpropertyloinity�ovmaEwRM1riBh�o(aurvivorshipmustbeEisclosedon5chetlukF. VAWEAT�ATE
ITEM DESCRIPTION OF�EATH
NUMBER 1,896.82
�. REFUND FROM GOLDEN LIVING
14.95
Z. REVERSE MONTHLV SERVICE CHARGE
2,73020
3, 53 SHARES OF PRUDENTIAL STOCK
1,130.00
q, REFUND FROM VFW
TOTAL(Also enter on Iine 5,Recapitulalion) S 5 77t77
(H more space is neeEeO,inseM1 addAional shcets of Ne same size)
RFV451t E%+(�0-OB)
pennsylvania SCHEDULE H
oea�a�erv`o�aEveuue FUNERALEXPENSESAND
iHNERi,nxcE*nxr�ruw� ADMINISTRATIVE COSTS
r+�smErvr oECEo[H* FILE NUMBER
ESTATEOF z� �4 �p�4
JEAN M. POET
oacedenfs tlebts muat ba repone0 an Schetluk�.
ITEM DESCRIPTION AMOUNT
NUMBER
q. FUNERALEXPENSES'.
1.
g ADMINISTRPTIVECOS75'.
�. Personal RepresenWtive Canmissions�
Name�s�ot Persanai aepresenta�ive(s)
SVeetAdOress
gy�e ZIP
CAy
VeeQs)CommissianPeitl: �--
750.00
2 AnomeyFces: CHARLES E. PETRIE
3 Family�emption'.(If decedenYs aedress is notlhe same as claimenYs,attach explanation.)
Claimenl
$heetNdtlress
Syre ZIP
City
Relatlomhip o�Claiman�Io�ewtlent
135.50
Q. PmbalaFees',
5. AaounbniPees:
6. TazReNmPreparerFees:
4.95
�. M 8 T SAFE DEPOSIT FEE
TOTAL(Also enter on Line 9,Recapilula�ion) S 890.45
If more space is neetled,use atlGitional sheets of papar ot Ihe same size.
aE�,"�Ex",��a, SCHEDULE I
pennsylvania
oeana.MeHroraeveHue DEBTSOFDECEDENT,
wHEairnNcerAxReruRN MORTGAGE LIABILITIES,8 LIENS
aEsioENroECEOEnr
FILE NUMBER
ESTATE OF
21 14 1064
JEAN M. POET
Report debts incurred by the decedent prior to tleath that remained unpaitl at the date of death,inclutling unreimbuned medical ezpenses.
VALUE AT�ATE
TEM �ESCRIPTION OF OEATH
NUMBER
803.60
�, EAST PENNSBORO AMBULANCE SERVICE
294.70
2. OMNICARE
46 22
3, VERIZON
1,086.63
q, HOLY SPIRIT EMS
760.00
5, GOLDEN LIVING
TOTAL(Also enler on Line 10,RecapiWlation) S p gg�.15
II mo2 space is neetle4 insert atldltional shee6 of the same size.
RER15H EX�(01-10�
pennsylvania SCHEDULE J
oeanarmenr oF aevEHue BENEFICIARIES
INHERIiANCEiA%PEID0.N
RESI�EM DWE�ENT
FILE NUMBER:
ESTATE OF:
JEAN M. POET 21 14 1064
RELATIONSHIPTODECEOENT AMOUNTORSHARE
NUMBER NAME AND ADDRESS OF PERSON(5)RECEIVING PROPERTY Uo Not LiatTruslee(s) OF ESTATE
I TAXABLE�ISTRIBUTIONS pndu8ec�9�196(aj(�usa'I'tlisvibuiionsandvans�ersuntler
1, JEAN M. BARRETT Collateral 630.06
897 SUNNY HILL LANE
HARRISBURG, PA 17111 630.06
2. KAREN ANN HOLIENBUSH Collateral
314 E. DERRY ROAD
HERSHEY, PA 17033 Collateral 630.05
3. WILLIAM E. TODD
3910 WALNUT STREET
HARRISBURG, PA 17109
ENTER DOLLAR AMOUMS FOR DISTRIBUTIONS SHOWN ABOVE ON LINE515 THROUGH 18 OF REV-0500 GOVER SHEET,AS APPROPRIATE.
Q, NON-TAXABLE�ISTRIBUTIONS'.
A.SPOUSAL DISTRIBUTIONS UNOER SEGTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN'.
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTALOFPARTII-EMERTOTALNON-TAXABLEDISTRIBUTIONSONLINE130FREV-i50000VERSHEET. S
I(more sDace is needed,use addi�ional sheets of paper of Ne same size.