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Home My WebLink About04-22-15 (2) J1505611185 REV-1500 EX(02-11)(FI) OFFICIAI USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN 21 13 0115 PO BOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMODYYYY Date of Bi�th MMDDYYYY 22�- 01,1,3201,3 01,117,953 DecedenYs Last Name Suffix DecedenYs First Name M I (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I ROCK JEANNINE M Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 179-44-89],8 REGISTER OF VIIILLS FILL IN APPROPRIATE BOXES BELOW � 1. Original Return � 2. Supplemental Return � 3. Remainder Return(Date of Death Priorto 12-13-82) ❑ 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 fl_ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) ❑ 9. Litigation Proceeds Received ❑ 10. Spousal Poverty Credit(Date of Death � ��' Attach S�edute Oer Sec.9113(A) Between 12-31-91 and 1-1-95) ( ) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JOHN D • SHERIDAN, ESQ • 717-540-9170 REGISTER OF WIUL�USE ONLY C `r' � r'yl �� n First Line of Address '�' � � �� , � 2.:.7 .. r.._ N SUITE 201 � ' = -,, �7 r"� .�_.. rv , ��f Second Line of Address � `'; , .. , c,":� 2080 LINGLESTOWN ROAD m� =� � � State ZIP Code DATE FILED = " City or Post Office = � � r � HARRISBURG PA 1711Q ,� � cr' �' � c.� �orrespondent'se-mai�address: SSHERIDANa�SSBC—LAW - 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 true,correct and compte4e. Dedaration of ptep8rejr other than the personal representative is based on all mtormation of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOf2�F f G RETtUE�2N � � OATE" ffJ r`" 1 { � � �J�� \ ��f ��f� } f I �T �_v � ' �( f� �, ADDRESS ; ` 57,2 HALYARD WAY -r r EN4LA, PA 17025 SIG TURE�y�'}'�EPARER._- EF� HAN REP �NTATIVE DATE � - _.-� ; f;l ls� t«�, ____ �;7�� ¢� ! A,�b ES ._.,'. . ,20 0 LINGLESTOWN RD - � SUITE 201, HARRISBURG , PA 1,71,1,0 � PLEASE USE ORiGINAL FORM Oi�LY � Side 1 � 7,50567,7,7,85 ],5C1561,7,185 � � OM4647 3.000 \V/� \\ ..�»v.n i.i r ,irc.'n... o Estate of 220-58-5977 Executors (Page 1) Name JEANNINE ROCK Address 512 HALYARD WAY ENOLA, PA 17025- Tax ID 179-44-8918 �m,,,,,, , .��,..,.. , ` 1505611285 J REV-1500 EX(FI) DecedenYs Social Security Number DecedenYs Name: RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . � 0 • �� 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . 2 � , �� 3. Closely Held Corporation,Partnership or Soie-Proprietorship(Schedule C), , , , , 3. � • �� 4. Mortgages and Notes Receivable(Schedule D) , , , , , , , , , , , , , , , , , q. � • �� 5. Cash, Bank Deposits a�d Miscellaneous Personal Property(Schedule E) , , , , , 5. 5],5,8 6 7 • �� 6. Jointiy Owned Property(Schedule F) � Separate Billing Requested , , . , g. O . O O 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) � Separate Billing Requested . . . . 7. � • �� 8. Total Gross Assets(total Lines 1 through 7) , , , , , , , , , , , , , , , , , , g 5],5,8 6 7 • �0 9. Funerai Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . g. ],7,0�� • �� 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) , , , , , , , , , �p, �16,5 4 9 • 0� 1 1. Total Deductions(total Lines 9 and 10), , , , , , , , , , , , , , , , , , , , , ��. 6 3 , 5 4 9 • �� 12. Net Value of Estate(Line 8 minus Line 11) , , , , , , , , , , , , , , , , , , , �Z. 4 S 2,318 • �� 13. Charitable and Governmentai Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J), , , , , , , , , , , , , , , , �3. � • �� 14. Net Value Subjecf to Tax(Line 12 minus Line 13) , , , , , , , , , , , , , �q. 4 S 2 ,�18 • �� TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabie at the spousal tax rate,or transfers un�er Sec.9116 (a)(�.2)x.o— 226 , 7,59 • 00 �5. � • 0� 16. Amount of Line 14 t xable at�inea�ratex.o4� 226 , 1,59 • 00 �s. 1� � 177 • 00 17. Amount of Line 14 taxable at sibling rate X.12 0 • a a 17. � • �� 18. Amount of Line 14 taxable at couateral rate x.�s � , �� g O • 0 0 19. TAXDUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. �� 177 • �� 20. FILL IPJ THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMEPJT � �I(�G' 2 �,5�56?,��8� 1�5Q5I�7,1,235 � OM4648 3.000 ��arr.u_r.-r.iu�-'lr�� € REV-1500 EX(FI) Page 3 File Number DecedenYs Complete Address: 2 y 13 O 1,1,5 DECEDENTS NAME STREET ADDRESS M R AND C�Ty STATE ZIP ENOL.A PA 1,7 25- Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) �,� ,17 7 • �� 2. Credits/Payments A. Prior Payments � • �� B. Discount Q • 0� Total Credits(A+g) (2) � • �� 3. Interest (3) � • �� 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in box 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) 1� ,17 7 • �� Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IP1 THE APPROPRIA7E 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 properry transferred or its income . . . . . . . . . . ❑ ❑X 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � a 3. Did decedent own an"in trust for"or payabie-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)(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)j. 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(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)j. A sibling is defined, under Section 9102, as an individual who has at leasi one parent in common with the decedent,whether by blood or adoption. 0 M 4671 2.000 REV-1508 EXf(08-12) pennsylvania SCHEDULE E �EPARTMENTOFREVENUE CASH, BANK DEPOSITS 8� MISC. INHERITANCETAXRETVRN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: STEVEN E ROCK ESTATE 21 13 0115 Include the proceeds of litigation and the date the proceeds were received by the estate. All ro ert 'ointl owned with ri ht of survivorshi must be discfosed on Schedute F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Z`MG HEALTH LONG TERM INCENTIVE PROGF2AM PAYMENT 2011-2013 CYCLE (AMOUNT NOT AVAILABLE AT DEATH; PAID 3/2014) 349,800 2 TMG HEALTH LONG TERM INCENTIVE PROGR.i1M PAYMENT 2012-2014 CYCLE (AMOUNT NOT AVAILABLE AT DEATH; PAID 3/2015) 166,067 FOTAL(A�so enter on line 5, Recapitulation) � 515,867 2wasaD 2.00o If more space is needed,use additional sheets oi paper of the sam�size. _,<mwi,.r v..r-r.�or-ir� � pennsylvania SCHEDULE H DEPARIMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER STEVEN E ROCK ESTATE 21 13 0115 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: � None 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: 17,000 3. Family Exemption:(If decedent's address is not the same as claimanYs,attach explanation.) Claimant Street Address ��ty State PA ZiP Relationship of Claimant to Decedent 4. Probate Fees: S. Accountanf Fees: 6. Tax Return Preparer Fees: 7. None TOTAL(Also enter on Line 9, Recapitulation) $ 17,000 9W46AG 2.000 li more spaca is needed, use additional sheets of oaper of ihe same size. ____ REV-1512EX+(12-12) SCHEDULE ! pennsylvania DEPARTMENTOF REVENUE DEBTS OF DECEDENT, - INHERITANCETAXRETURN MORTGAGE LIABILITIES 8� LlENS RESIDEM DECEDENT ESTATE OF FILE NUMBER STEVEN E ROCK ESTATE 21 13 0115 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,inctuding unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH �� SALLIE MAE STUDENT LOANS 46,549 TOTAL(Also enter on Line 10,Recapitulation) � �6,54� zwasnr+z.000 If rnore�pace is needed, insert additional sheets of the sarne size. REV-1513EX+(01-10) SCHEDULE J pennsylvania DEPARTMENTOF REVENUE BENEFIC{ARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: STEVEN E ROCK ESTATE 21 13 0115 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERN Do Not�ist Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] �. JEANNINE M. ROCK 512 HALYARD WAY ENOLA, PA 17025 One Half of Residue to JEANNINE M. ROCK 512 HALYARD WAY ENOLA, PA 17025: 226,159 Surviving Spouse 226,159 2 RACHAEL M. ROCK TRUST UNDER WILL C/O KENNETH ROCK, TRUSTEE RR2 BOX 108-H KEYSER, WV 26726 16. 666667 of Residue: 75,386 Daughter 75,386 I Ef�fTER DOLLAR AMOUNTS FOR DISTRIBUl10NS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. �� NON-TAXABLE DISTRIBUTIONS A.SPOUSAL DISTRIBUIIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS' 1. 70TAL OF PART II-ENTEP.TOTAL P�lON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV_1500 COVER SHEET. $ � If more space is needed, use additional sheeis of paper oi ihe same size. 9W46AI 2.D00 .��ryllllli�lq�.r��..��,P.in.,�, k Estate of: STEVEN E ROCK ESTATE 21 13 0115 Schedule J Part 1 (Page 2) Item No. Description Relation Amount 3 R.ANDALL S. ROCK 1611 SPRING KNOLL LANE HARRISBURG, PA 17110 16.666667 of Residue: 75,386 Son 75,386 4 MELISSA A. REAGAN 115 LENTZ DRIVE HARRISBURG, PA 17112 16. 666667 of Residue: 75,386 Daughter 75,386