HomeMy WebLinkAbout04-08-15 r +
pennsytvania 1505614105
DCWTVAErr,Or AVDWZ EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year rile Number _
PO BOX 280601 INHERITANCE TAX RETURN - -'
Harrisburg, PA 17128-0601 RESIDENT DECEDENT ®6
060 V
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
i ; 11132012 03241923
Decedent's Last Name Suffix Decedent's First Name MI
_ ..... _ _...._.._.._...._........._..._......_............._.._._....... _.. _. ..--.........__.._.. _....._.__.._.__..._..._..........._............_.,............._.._.........._.........._._... ..._;
SLAYTON ROSA P
_.....___....__........__..................................._._........._.........___. , _.___...__._.._._.__. ........._._-....._______.._._.......__.................._.__....___-........_........_. _....__...... :..._. .
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
_.-_......_....__.---._....__....__..----......___.....__...--_----._._.-_..__.._.____..........__......_.._-_____._._-.__., r.__...._-_
i
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
C10 1. Original Return O 2. Supplemental Return p 3. Remainder Return(date of death
prior to 12-13-82)
C=) 4.Agriculture Exemption(date of C=:> 5. Future Interest Compromise(date of C=:) 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
Q 7. Decedent Died Testate O 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.) .
O 10. Litigation Proceeds Received O 11. Non-Probate Transferee Return ® 12. Deferral/Election of''pousal 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 TO:
Name Daytime Telephone Number
r._..__...-...._..._....__.._................__..._.._....__.__.....---._.._.._._...................._ -._._._...-------........_._........._..........._....- __..._._...._....__.._., _....._ ._..... ..........._...._......__......_._..
JOHN W SLAYTON (717) 737-4036
_......._..............._........ --.........._._..._-_.......__..........._-_..._.......__-....................._.... _ ..-...._....._...._...._..._.._.._.---............__......__.._....__._....._........ _..__... ..-...._..........._....... -.....__......._...._...._............ ...... .
First Line of Address
r--._......-----...._...._......_..-----._.._.....__.._...... ........--- - -
1807 MICHIGAN AVENUE
__-_......_._........______---.....__....-_________._____.._..._..___._..._..____....._...__.......__..........____.._.._..._._....__...........
Second Line of Address
__----------............__-........—......._.........._...._.__..... .................__._...... _._...........__
i
...............
City or Post Office State ZIP Code
_...... _...._..._...._........__......--....._......_._....._-........._....
.. ._...._.._.._.....-, --..._
LEMOYNE PA 17043
..........._._......_..........__........_.._.._._____......__.__.__------...__.....___.____....___...._._, !...._._..___.....--.--........__..._...._......_.__-_.......... ..................___,
Correspondent's email address:
REGISTER OF WILLS USE ONLY
REGISTER OF WILLS USE ONLY o
M
rT1 n
�DAT>TQ. STQW � CZ)
O
C7 Cj "L7 zi
r> � 3 ZE G)
PLEASE USE ORIGINAL FORM ONLY ='�<. r fes- M
Side 1 Cn �
561 5 1,505614105
1505614205
• REV-1500 EX(FI)
Decedent's Social Security Number
t.-,._.._._....___._.... _..._......__.......__.....___._.____.._..._-...�
Decedent's Name: ROSA F SLAYTON
r
RECAPITULATION
1. Real Estate(Schedule A). . . .. .. . . ... . .. . . .. .. .. . . ... . . .. . . . . . .. . ... . . 1.
2. Stocks and Bonds(Schedule B) . .. . .. . .... .. . .. .. .. .. . . . . . . . . . . . ... . .. 2. i
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .. .. . 3.
i
4. Mortgages and Notes Receivable(Schedule D). . . .. . . . . . . . .. . .. . . .. ... . .. 4. j
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . .. . 5. ;
6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. ... . . 6. 1 j
I_.........._............. ._..._..........____....__.._.____....____...._.___.._.._.__.._..._....__.._,
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested.. ... . . . 7.
8. Total Gross Assets(total Lines 1 through 7). . ... . ... ... .. . .. . .. .. . . .. .. . 8. i 0.00
9. Funeral Expenses and Administrative Costs(Schedule H).. .. . .. . .. . . . . ... . . 9. : 2,815.00
% Debts of Decedent.Mortgage Liabilities and Liens(Schedule 1)... . . . .. . . . . . . . 10.
11. Total Deductions(total Lines 9 and 10). ..... . .. . ... . . . .. ... . ... .... . . . . 11. J
12. Net Value of Estate(Line 8 minus Line 11) ... .. .. ... . .. .. . . . .. . . .. . . .. . . 12. i -2,815.00
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which
an election to tax has not been made(Schedule J) .... ... . . .. ... . . . .. . .. . . 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) ... . .... . .. . . .. ... . . .. . . 14. 0.00
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 _._... _....._.__..._..._.__....._._._._... ........ -.--------------. ...._.......- ........._.........._......_...................._..._............... .
.............-................._............ _.._.
I
(a)(1.2)X.0_ i 15.
16. Amount of Line 14 taxable
at lineal rate X.0_. 16.
17. Amount of Line 14 taxable 4
at sibling rate X.12 17. i
18. Amount of Line 14 taxable i
at collateral rate X .15 18.
19. TAX DUE . .. . . .. .... .. ... .. . ... ... ... ........ .. . ... . . .. . . .. ... . ... 19. 1
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 return,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.
SIGNATE OF PERSq N� RE SP LING RETURN DATE
ADQ5FAS
SkV OF PR PARE THAN PERON E�ONSIBLE FOR FILING THE RETURN 9ATC /
f�Q AD E S J�6vi� / &WIS`r t .6i 7D
1111 ligilli1ii 1111�i�ii iiiii ii i«�i Side 2
0 2 5 1505614205
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
ROSA F SLAYTON
STREETADDRESS - --
807 MICHIGAN AVENUE
CITY I STATE ZIP
LEMOYNE PA 17043
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1)
2. Credits/Payments
A.Prior Payments
B.Discount
(See instructions.) Total Credits(A+B) (2)_ L4'(p
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)
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?...................................................................... 0 ❑
2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ E
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? ........................................................................................................................ 0 ❑
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 parert, 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 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 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.
{
t REV-1511 EX+ (08.13)
11apennsyLVania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAxRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF _ FILE NUMBER
ROSA F SLAYTON
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
i' WRENN YEATTS FUNERAL HOME 2,815.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions
Name(s)of Personal Representative(s)..._....__.._.._._....__ .___._-....__.......
_._...._.__._._._... .... ..._.. ._..a....._ ._....._._......_.. .
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City..__...__._....._..,_.___ ___...__......._..._.__..,_...___...__...__.._.__.__..__.._State... ..-._....ZIP•... .._ ..... ._. ._.
Relationship of Claimant to Decedent
4. Probate Fees:
5. Accountant Fees:
6. Tax Return Preparer Fees:
7,
TOTAL (Also enter on Line 9, Recapitulation) $ 2,815.00
If more space is needed,use additional sheets of paper of the same size.
. .
WREN....J�����r� ! EAT 8 S
F"rera/ Homes
Crematim-,Services
Septemberl0,201
Mc�W.Slayton
BD7Michigan Avenue
Lemoyne, PA 17043
Re: Rosa Slayton
Dear].VV.,
| have updated the arrangements for Rosa and have added funds for alocal gathering,transportation
and lodging expenses,flowers for the casket and additional amounts-for the cemetery and the
_ .
newspaper. The additional funds are$ 2Q1E0Oand acheck can bemade to Homesteaders Life
Company for that amount. | have enclosed papers for you tosign and return tornewith the check. |will
mail you back your copies after they are processed.
I feel these additional amounts should cover any and all expenses for Rosa's funeral.
Thank you,
Ke|sterVVhitt
_
. '
`
r*REELOc+�/oxeruSERVE/o�
North Main Chapel 0 703 North'Mwn Street r Danvi."ile,Virginia 24540 (431-4) 793-5511
Westover Chapel 9 5858 Riverside Drive 6 Danvilie, Virginria 24541. t, (434) 793-17514
Yaoo*ym/ue Memorial Chapel ° w7, Main Street " zaoc*yvui,,North Carolina z/37* ° (336)694-1000
ww"^wmso-'euuo.Co,z
ENROLLMENT FOR HOMESTEADERS LIFE COMPANY
GROUP INSURANCE TO P.D.BOX 1756/DES MOINES,IOWA 50306/800-477-3633
PROPOSED INSURED (Please Prim
5I-,A 1111MA) I?OSA* It- Zq 7293
Last First Initial Sex Birthdate(M/DPO, Age SS}
S No.
sol MI&441&4,.i pj 170 q3 717-737-qO3�
Residence-No.and Street Gity or Town State Zip Phone No.
APPLICANVOWN ER(if Other than Proposed insured)
5 LA)IYVAI 5-t),VAI JAI 1117 IF,7 far
Last First Initial Address
Z e,^*,vn oe /W 41.E seA/
City V state Zip SS No. Relationship to Insured
BENEFICIARY :rO,#A/ W- Si4f YIU^I d^/
(AI'8r payment any assignments,
ts,remaining proceeds are to be paid Relationship to Insured
to the insured unless beneficiary is specified above.)
R 13 SINGLE PAYMENT PLAN For issue ages 0-80,if the insured does not sign the enrollment form,
E 13 Certificate Face Amt $ the initial face amount of the certificate will be equal,to 1.005 times
0 E3 Rider Premium $ 7—SIS-00 the premium paid.
U
E 13 MULTIPLE PAYMENT PLAN(The proposed insured must sign the it the following questions are both answered 'no,' we may issue a
S enrollment form to qualify for the Multiple Payment plan.) certificate providing an immediate death benefit equal to the fare
Years amount.
T
Premium Face Amt. $ OPTIONAL HEALTH HISTORY(Multiple Payment Plans)
E' Payable 1. Is the insured now bedridden, or currently admitted to or been
Premium $ advised to enter a hospital, nursing home, hospice program, or
any extended care facility,, or been diagnosed as having or been
The death benefit payable during the first six months will be the sum of treated for AIDS or ARC?
the premium paid plus 5%. Death benefits payable after the first six 0 YES El NO
E months are as follows: 2. Within the past five years has the insured been diagnosed or
treated for any of the following ailments?
N Years Premium Payable Heart Disease Live,"Disease Alcohol Abuse
E Less than 5 years 6 Months-1 Year = 50%of Face Amt. Circulatory Disease Kidney Disease Drug Abuse
F Year 2 = Face Amt. Stroke Anemia Nervous Disorder
5 years or greater 6 Months-1 Year = 35%of Face Amt Lung Disease Cancer
Year 2 = 70%of Face Amt, Diabetes El YES El NO
T Year 3 = Face Amt.
S If death by accident during the limited period,the face amount is payable.
Payment Method E3 Monthly 13 Annually 13 Semiannually 0 Quarterly 171 Multiple 131ii-(List other policies for PAC or Ma)
13 Direct Bill 13 Preauthorl7ed Collection(PAC-See Reverse)
Dividends 13 Purchase Additional Insurance 0 Accumulate at Interest 0 Paid in Cash 12 Reduce Premium
Replacement-Will the proposed certificate replace any existing life insurance or annuityn
cc tracts?
13 yes No (if'Yes,'corriplete replacement papem)
DECLARATIONS—To the best of my knowledge and belief, all, statements and answers on this enrollment form are
complete and true. It is agreed that no insurance shall take effect until the premium has been paid and a certificate has
been issued while the insured is living. I certify, if I am applying for insurance on behalf of the insured, that I have an
Insurable interest in the sed Insured's life, and have full authority to use his/her funds as premiums on the insurance
�Paid with this enrollment form.
applied for. I have.
Signed at h ,L, 7 Date rt -`7-
ity, state
of ApplicantfOkwr(if bd&than Proposed Insured) -Signature of Proposed insured
Agent'sStatement: By my signature I certify that, to the best of my knowledge, all information contained in this
enrollmon fcprn is4rrect,was recorded accurately, and confirm this enrollment form was signed in my presence.
3 Security Option
Agent's Signature Agent Number Prod.Code Mkt.Code LJ Advantage Option
GP-201-VA Copies:White-Homp-Opadpm!white-HnrnP.-,tP.;v1Pm*Pink-Prnvli.r-rl—nm,-n�4— o—non
PRENEED FUNERAL AGREEMENT AND ASSIGNMENT
EXHIBIT 1 — STATEMENT OF FUNERAL MERCHANDISE AND FUNERAL SERVICES
NOTE: THIS AGREEMENT IS TO BE FUNDED BY THE ASSIGNMENT OF INSURANCE BENEFITS
FOR THE BENEFIT OF R0-54 - Slay ftyl
(Funeral Recipientlinsdred) ddress if diffnt than below', (Phone)
ti
IN AGREEMENT WITH AND ASSIGNMENT TO Wree?- ro
4;1errj_ Alwe- 56?93-dcsa
(Funeral Provider Name) I (Funeral Director#)
GUARANTEED PROFESSIONAL SERVICES GUARANTEED MERCHANDISE
Services of Funeral Director and Staff $ Casket $
Embalming (See Agreement and Below*) $ Manufacturer
Other Preparation $ Product Code
Visitation—Days at$-------/Day $ Product Number
Funeral Ceremony/Memorial Service $
Other Use of Facilities and Staff (Specify) Exterior Description
$ Interior Description
Transfer of Remains to Funeral Home $ Outer Burial Container $
If beyond a—mile radius, which is our service area, Product Name
there will be a charge of$_per mile one way.
Product Number
Family Car(s)_at$_each $
Limousine—Hearse $ Manufacturer
Cremation $ Constructed of
Forwarding/Receiving Remains $ Other Guaranteed Merchandise (Specify)
Other Services/Facilities/Equipment (Specify) $
TOTAL GUARANTEED SERVICES Is TOTAL GUARANTEED MERCHANDISE $
NON-GUARANTEED CASH ADVANCES
Death Certificates—at Escort 1 1 $
Flowers SLA9JVF—T+ r0- $ 315ZO Grave Opening and Closing 14CReAse 5 $ 500-00
Music Memorial CardsiBook $
Honorariums MjtAJS7rX_ $ ?=(l0.6 0 Clothing (Specify) $
Obituaries 1A)C"A5e-1 $ '306.0D Monument/Marker $
Hairdresser Engraving
Shipping Container $ Sales Tax Estimate $
Other(Specify) AWEL—LO 96(AJ Other (Specify) L41CAL G-4,T4S9jaJ6 15400100
We charge you for our services in obtaining:
TOTAL NON-GUARANTEED CASH ADVANCES 21 0 IS-0 D
ADJUSTMENT F$
TOTAL GUARANTEED AND NON-GUARANTEED FUNERAL PRICE x.13 t
OD
*REQUIRED PURCHASES—Charges are only for those items that you selec!ed or that are required. 114, we are required by law.
or by a cemetery or crematory to use any items,we will explain the reasons in writing below.
Ikhl1VbCA`B1'Lrr'Y—By kWWng,he're'( you irrevocably assign ownership of the rde insurance funding this contact to the
namAkieral'home to quardy for Medicaid or other public assistance.SEE REVERSE FOR TERMS,OF IRREVOCABILITY.
EXHIBIT I ABOVE AND THE PRENEED FUNERAL AGREEMENT AND ASSIGNMENT ON THE REVERSE SIDE SHALL
CONSTITUTE THE TERMS AND CONDITIONS OF THIS AGREEMENT.
AGREE E AND,ASSIGN 8 AGREEMENT ANaACCEPTANCE BY.
.5
i re of Purchaser) (Date) (Si atur of Pr9V1 r' Auft, resenWtve) (A ent's License
c-A 1'6.,i;A1 N I
(7dress) (Phone) (Fup9q Provider'?Address)
10M X-1 F 6__ _�/o N
'0 /1404 11 / 21 51f
el po' -7
joty,State), (zip) State,Zip) (Phone)
HOME SALES ONLY: You,the Buyer, may cancel this transaction at any time prior to the third business day after the date of
this transaction. See the attached Notice of Cancellation form for an explanation of this right.
REV-1513 EX+ (01-10)
pennsytvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ROSA F SLAYTON
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. JOHN W SLAYTON 807 MICHIGAN AVE LEMOYNE PA 17043 SON 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. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ONLINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
u
;`
4
hti
IL
ia ~ag
.'1 V 'IX
Q �o
A
U
r
C �
O
co
N
�f00 Q
O
R'S•v�.
C'�O