HomeMy WebLinkAbout05-05-15 (2) . IIIf..11..lIY IIIIY 11 �
J 1505614134
EX(03-14)(FI)
REV-1500
Bureau of Individual Taxes County Code Year File Number
Po aox 28oso� INHERITANCE TAX RETURN 2 1 1 4 0 9 8 7
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 1 2 9 2 0 1 4 0 4 0 2 1 9 2 2
DecedenYs Last Name Su�x DecedenYs First Name MI
E B E R S O L E D O R O T H Y R
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
a 1.Original Return � 2.Supplemental Return � 3. Remainder Return(date of death
Priorto 12-13-82)
� 4.Agriculture Exemption � 5. Future Interest Compromise(date of � 6. Federal Estate Tax Return Required
(date of death on or after 7-1-2012) death after 12-12-82)
Q 7. Decedent Died Testate � 8. Decedent Maintained a Living Trust 9.Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
� 10. Litigation Proceeds Received � 11. Non-Probate Transferee Return � 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets only)
❑ 13. Business Assets ❑ 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
DAVI D R . GALLOWAY , PLLC 717 697 4700
First Line of Address
WALTERS & GALLOWAY , PLLC
Second Line of Address
54 E . MAI N ST
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City or Post Office State ZIP Code z=' �
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MECHANI CSBURG PA 1 70 55 � � � ,;, c.,
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CorrespondenYs e-mail address: DAVID@WALTERSGALLOWAY.COM � � �'' � �' `"'
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� REGISTEFZ OF WILLS USE,.O�NI�'F�
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REGISTER OF WILLS USE ONLY � ' : � � "Tl
DATE FILED MMDDYYYY . �'i :� t'7
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DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
I I�IIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII \
L 1505614134 1505614134 � �
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� 1505614234
REV-1500 EX(FI)
DecedenYs Social Security Number
DecedenYs Name: DOROTHY R. EBERSOLE
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 2 $ 6 � , 2 2
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. •
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property 1 6 0 2 � rJ 2
(Schedule G) � Separate Billing Requested . . . . . . . 7.
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 3 4 4 6 2 , 7 4
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 4 9 5 4 . 3 0
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule I) . . . . . . . . . . . . . 10. 9 3 � 5 . � �
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. � 4 2 5 9 . 3 1
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . .. . . . . . . . . . . . . . . 12. 2 � 2 � 3 . 4 3
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . 13. 3 4 3 3 . 2 1
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . 14. � 6 7 7 � . 2 2
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 _ � . � O 15. O . 0 �
16. Amount of Line 14 taxable
at�inea�rate X.045 1 6 7 7 0 . 2 2 �6. 7 5 4 . 6 6
17. Amount of Line 14 taxable
at sibling rate X.12 � . � � 17. 0 . � �
18. Amount of Line 14 taxable
at collateral rate X.15 0 • 0 � 1 g. � • � �
19. TAX DUE . . . . ... . . . . ... . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 19. 7 5 4 . 6 6
20. FiLL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Under penalties of peryury,I declare I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has
any knowledge.
SIGNAT F PER ESPO IBLE F ILING R URN DATE �
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ADDRESS
TIMOTHY B. EBERSOLE 1 WILDROSE LN. MECHANICSBURG PA 17050
SIGN P R OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN E ,�
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ADDRESS
DAVID R. GA OWAY 54 E. MAIN ST. MECHANICSBURG PA 17055
I IIIII I'�I IIIII(IIII�IIII IIII)IIIII II�II IIIII IIII)III)(II) Side 2
� 1505614234 1505614234 �
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address: 2� 14 oss7
DECE�ENT'S NAME
DOROTHY R. EBERSOLE
STREET ADDRESS
771 MESSIAH VILLAGE
CITY STATE ZIP
MECHANICSBURG PA 17055
Tax Payments and Credits:
�. Tax Due(Page 2,Line 19) (1) 754.66
2. Credits/Payments
A.Prior Payments
B.Discount
(See instructions.) Total Credits(A+B) (2) 0.00
3. I nterest
(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) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 754.66
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 :::::::::::::::::.:::.::::::::: ❑ ❑X
c. retain a reversionary interest ..........................................�.................... ❑❑ O
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? ......... ❑ 0
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 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 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 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.
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REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
DOROTHY R. EBERSOLE 21 14 0987
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. PNC BANK 12,821.32
CHECKING ACCOUNT(x1129)
2. HARTFORD 64.55
3RD QUARTER ANNUITY PAYMENT
3. EVERENCE FINANCIAL 518.73
4TH QUARTER REFUND
4. 2014 INCOME TAX REFUND 5,954.00
5. BRETHERN IN CHRIST FOUNDATION, INC 13,501.62
THRIFT ACCUMULATION PLAN (TAP)ACCOUNT
TOTAL(Also enter on Line 5,Recapitulation) $ 32 860.22
If more space is needed, use additional sheets of paper of the same size.
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REV-1510 EX+(08-09)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DOROTHY R. EBERSOLE 21 14 0987
This schedule must be completed 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 TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD�S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATfACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IFAPPLICABLE) VALUE
1. THE HARTFORD 1,602.52 100.00 1,602.52
VARIABLE ANNUITY
BENEFICIARIES-CHILDREN
TOTAL (Also enter on Line 7,Recapitulation) $ 1 602.52
If more space is needed,use additional sheets of paper of the same size.
II11�.IlIIIY 11414AI 1
REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DOROTHY R. EBERSOLE 21 14 0987
DecedenYs debts must be reported on Schedule[.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. FLOWERS 340.00
3. MAUVE GOWN - FUNERAL CLOTHING 165.00
4. MEAL 488.80
5. BUSE FUNERAL HOME- PRE-PAID 0.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)ofPersonalRepresentative(s) TIMOTHY 6. EBERSOLE 1,700.00
StreetAddress 1 WILDROSE LANE
City MECHANICSBURG State PA ZIP 17050
Year(s)Commission Paid: 2015
2. Attomey Fees: WALTERS&GALLOWAY, PLLC 2,000.00
3, Family Exemption:(If decedenYs address is not the same as claimanYs,attach explanation.) 0.00
Claimant None
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. ProbateFees: REGISTER OF WILLS, CUMBERLAND COUNTY 175.50
5 Accountant Fees:
6. Tax Retum Preparer Fees:
7. FEDERAL EXPRESS- DISTRIBUTION TO BENEFICIARIES 80.00
8. REGISTER OF WILLS, CUMBERLAND COUNTY-Short Certificate 5.00
TOTAL(Also enter on Line 9,Recapitulation) $ 4 954.30
If more space is needed,use additional sheets of paper of the same size.
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REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT�
INHERITANCETAXRETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DOROTHY R. EBERSOLE 21 14 0987
Repo�t 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. MESSIAH VILLAGE 9,273.82
NURSING HOME
2. ALERT PHARMACY 31.19
PRESCRIPTION DRUGS
TOTAL(Also enter on Line 10,Recapitulation) $ g 305.01
If more space is needed, insert additional sheets of the same size.
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REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
DOROTHY R. EBERSOLE 21 14 0987
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).j
1. SARA ANN GOODEN Lineal 25.00
65 POPLAR LN.
ELIZABETHTOWN, PA 17022
2. TIMOTHY B. EBERSOLE Lineal 25.00
1 WILDROSE LN.
MECHANICSBURG, PA 17050
3. A. RICHARD EBERSOLE Lineal 25.00
231 REXMONT RD.
LEBANON, PA 17042
4. P. KARL EBERSOLE Lineal 25.00
902 CHURCH ST.
LANUISVILLE, PA 17538
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:
1. BRETHERN IN CHRIST FOUNDATION 3,433.21
PO BOX 290
GRANTHAM, PA 17027
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 3 433.21
If more space is needed,use additional sheets of paper of the same size.
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Jack Wi![IEbersole.Dor
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LAST WILL AND TESTAMENT C � � `' ►T�
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I, DOROTHY R. EBERSOLE, of Cleona, County of Lebanon nd ;�; _','
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Commonwealth of Pennsylvania, realizing the uncertainty of fichis;,, �
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life, but with confidence in God and trust in his Son, my Lord and
�
Savior, Jesus Christ, who died for my sins upon the cross and rose
again to redeem and give me eternal life, bei.ng of�Ysound and
disposing mind and memory, do hereby make, publish and declare this
as and for my Last Will and Testament, hereby revoking all other
Wills and Codicils heretofore made by me.
FIRST: (a) I direct my funeral and
last sickness expenses� and my just debts to be paid as soon as
possible after the probate of this my Will. After the payment of
my debts and said expenses, I give, devise and bequeath my property
and estate as hereinafter provided.
(b) For informational purposes,
at the time I execute this Will, I have four children: SARA ANN
GOODEN, of Elizabethtown, Pennsylvania, TIMOTHY B. EBERSOLE, of
Mechanicsburg, Pennsylvania, A. RICHARD EBERSOLE, of Rexmont,
Pennsylvania, and P. KARL EBERSOLE, of Mount Joy, Pennsylvania.
SECOND: All the rest, residue and
remainder of my property and estate, real, personal or mixed,
wheresoever situate and of whatsoever the same may consist, I give,
devise and bequeath to my descendants who survive me, in equal
shares, per stirpes.
THIRD: If a share of my residuary
estate is distributed to a beneficiary who is under the age of
r
twenty-one (21) years, said beneficiary's share shall b� held IN
TRUST to be administered and distributed as follows:
(a) The Trustee shall divide the Trust Fund into
separate Trusts for each beneficiary under the age of
twenty-one (21) years.
(b) With respect to such separate trusts, the
Trustee shall, from time to time, pay or apply so much of
the current and accumulated income from each such Trust
and so much of the principal thereof to or for the
support, maintenance, health and education of the
beneficiary for whom such Trust shall have been set
apart, as the Trustee shall see fit, always taking into
account all other sources of income, property and support
available to him for the purposes aforesaid, and shall
accumulate and hold or invest the unused balance, if any,
ir.. � .rv� . �
of the income. When such beneficiary shall attain the
age of twenty-one (21) years, the entire remaining
balance of said Trust, and the accumulated and unpaid
income thereon, shall be paid and transferred to such
beneficiary, discharged of all Trusts.
FOURTH: I hereby authorize and empower
my Executors and Trustee to lease, mortgage, pledge, sell or convey
any and all of my estate, real, per�onal and mixed, using their
discretion as to the manner, time and terms thereof, and to convey
�
the same by proper deeds or other instruments, and nd' person
dealing with my said Executors and Trustee shall be responsible for '
the application of any proceeds or purchase monies. I further !
authorize my Executors and Trustee to manage my estate and property �
and to invest and reinvest the principal thereof at their
discretion in such form of investment as may commend itself to the
�
best judgment of my said Executors and Trustee.
rIFTH: I direcz that ail taxes that may
be assessed in consequence of my death, of whatever nature and by
whatever jurisdiction imposed, shall be paid from my residuary
estate as a part of the expense of the administration of my estate.
SIXTH: I nominate, constitute and
appoint my children, SARA ANN GOODEN, of Elizabethtown,
3
Pennsylvania, TIMOTHY B. EBERSOLE, of Mechanicsburg, Pennsylvania,
A. RICHARD EBERSOLE, of Rexmont, Pennsylvania, and P. KARL
EBERSOLE, of Mount Joy, Pennsylvania, to be the Executors of this
my Last Will and Testament.
SEVENTH: I appoint LEBANON VALLEY
NATIONAL BANK, as Trustee of any Trust created under this my Will.
EIGHTH: � direct that no Executor or
Trustee shall be required to give any bond, and rthat if,
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notwithstanding this direction, any bond is required by any law,
statute or rule of court, no surety shall be required thereon.
IN WITNESS WHEREOF, I have hereunto set my harid and seal this
��
p� S day of �N � � � A.D. � 1996 .
�
- •lJ�.�s�l%K�1�-'K il •P '
DOROTHY R. EBERSOLE
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SIGNED, SEALED, PUBLISHED and DECLARED by DOROTHY R. EBERSOLE
Testatrix above named, as and for her Last Will and Testament, and
we, at her request, in her presence, and in the presence of each
other, have subscribed our names as attesting witnesses thereof.
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Address G�.rn i� �,� /70y2
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A C K N 0 W L E D G M E N T
COMMONWEALTH OF PENNSYLVANIA .
. SS .
COUNTY OF LEBANON
I, DOROTHY R. EBERSOLE, Testatrix, whose name is signed to the
attached or foregoing instrument; having been duly qualified
according to law, do hereby acknowledge that I sigried a�d executed
the instrument as my Last Will and Testament; that Irsigned it '
willingly; and that I signed it as my free and voluntary act for
the purposes therein expressed.
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Sworn or affirmed to and
acknowledged before me by '
DODOTHY R. EBLRSGi,E, the Testatr�r., thi5
a R r,f day o f ��.�� , A.D. , 19 9 6 .
NO'�RY BL C
NOTARIAL SEAL
MRRY C.GARRETT,NOiARY PUBLIC
MOP,iH CORNWALL TWP.,LEBAiVON CO.,PA
�iY CON:MI�SION EXPIRES MARCH 2,1998
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A F F I D A V I T
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF LEBANON • SS .
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We, _ 70�i., T, �� ��,. Ti" and�C�.i'Y1.l C � �0`4--� ,
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and
say that we were present and saw the Testatrix sign and execute the
instrument as her Last Will and Testament; that DOR4THY R. EBERSOLE
signed willingly and that DOROTHY R. EBERSOLE executed �it as her
free and voluntary act for the purposes therein expressed; that
each of us in the hearing and sight of the Testatrix signed said
Last Will and Testament as witnesses; and that to the best of our
knowledge the Testatrix was at that time eighteen (18) or more
years of age, of sound mind and under no constraint or undue
influence. ,
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Sworn and affirmed to and
acknowledged before me by
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Witnesses, this ��.� day
of �v,�/i' , A.D. , 1996 .
V .�i1.� �• Q`7.Gt.t�S D f-t
01�ARY � BLIC
�� NG?ARIAL SEAL
I MARY C.fARR4TT,NOTARY P��R���
� NORiH CORMt4ALL i4�lP.,LcBAiJON!,'0 pq, � '
, t,�Y COt�It:SlSSIOFJ E%PiRES ASARCH 2 1998 �
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