HomeMy WebLinkAbout04-08-15 (2) t� Y
1505610140
REV-1500. EX (01-10)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 4 1 0 2 5
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 0 1 8 1 0 2 4 0 1 1 0 1 9 4 9
Decedent's Last Name Suffix Decedent's First Name MI
K E L L E Y J A M E S R
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
❑X 1.Original Return ❑ 2.Supplemental Return 3. Remainder Return(date of death
prior to 12-13-82)
F] 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 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 11. Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
J OS E P H C M I C H E T T I J R . 5 7 0 7 9 7 8 6 5 1
REGISTEROF WILLS US,LY
First line of address
� 0<
9 2 1 MARKET STREET -' Aw '
M
Second line of address Cn ;;a Gb 4
a c�55 CDr�
City or Post Office State ZIP Code l)A�E11 ED
TREVORTON PA 17881 ~
C7isjjr
Correspondent's e-mail address: MICHETTI!PTD.NET
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,
f is tr , orrect and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
ASIGNATURE
P S N RES O IBL ILING RETURN DATE
4/6/2015
TE VA EY RO D DORNSIFE PA 17823
PR ARER HEkTHAN PRESENTATIVE DATE
4/6/2015
ADDRESS
921 MAR ET STREET TREVORTON PA 17881
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140
A
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: JAMES R. KELLEY
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 2 0 4 • 4 1
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested . . . . . . . 7. 5 8 4 8 8 . 6 6
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 9 0 6 9 3 . 0 7
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 1 0 1 7 3 • 0 7
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . . . . 10. 1 3 2 2 8 . 0 0
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 3 4 0 1 . 0 7
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 6 7 2 9 2 . 0 0
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. 6 7 2 9 2 . 0 0
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 _ 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate X .045 6 7 2 9 2 . 0 0 16. 3 0 2 8 . 1 4
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 0 0 18. 0 . 0 0
19. TAX DUE . 19. 3 0 2 8 • 1 4
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
L1505610240 1505610240
REV-1500 EX Page 3 File Number
Decedent's IComplete Address: 21 14 1025
DECEDENT'S NAME
JAMES R. KELLEY
STREET ADDRESS
99 SALEM CHURCH ROAD APT. D
CITY STATE ZIP
'MECHANICSBURG I PA 117050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 3,028.14
2. Credits/Payments
A.Prior Payments 2,500.00
B.Discount 131.58
Total Credits(A+B) (2) 2,631.58
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) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 396.56
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; ...................................................................... E] 0
b. retain the right to designate who shall use the property transferred or its income; ...............................
❑ 191
c. retain a reversionary interest;or ................................................................................................ El ❑X
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑
IR
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... El 0
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
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 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(1.2)[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,unde
Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1508 EX+(6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE
RESIOENT D EDENT"
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
JAMES R. KELLEY 21 14 1025
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. M &T Bank Checking Account 16,704.41
No. 9839270049
2. 2006 Chevrolet Truck as sold privately 15,000.00
VIN#2GCEK13Z561305622
3. Personal Property of the Decedent 500.00
TOTAL(Also enter on line 5,Recapitulation) $ 32 204.41
(If more space is needed,insert additional sheets of the same size)
REV-1510 EX+(08-09)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
JAMES R. KELLEY 21 14 1025
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.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. American Funds, Plan ID BRK50441, Ritner Steel 248.94 100.00 248.94.
Deferred Compensation Plan, daughters, Jaimi L. Spickler
and Amber N. Reber, beneficiaries
2. Nationwide Life and Annuity Insurance Company, Contract, 58,239.72 100.00 58,239.72
No. 01-5939143, daughters, Jaimi L. Spickler and Amber N.
Reber, beneficiaries
TOTAL (Also enter on Line 7,Recapitulation) $ 58 488.66
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
penn ' ivania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
JAMES R. KELLEY 21 14 1025
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
- A. FUNERAL EXPENSES:
1. Cocklin Funeral Home-funeral expenses 41476.00
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: 4,530.00
3, Family Exemption:(If decedents address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 180.50
5 Accountant Fees:
6. Tax Return Preparer fees:
7. The Sentinel -advertising grant of letters 251.26
8. Cumberland Law Journal -advertising grant of letters 75.00
9. Verizon Wireless-telephone billing due 204.42
10. Southwest Credit-account due 127.43
11. PPL Electric Utilities -electric service due 128.46
12. Reserve for administration 200.00
TOTAL(Also enter on Line 9,Recapitulation) $ 10 173.07
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-08)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE DEBTS.OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES,& LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
JAMES R. KELLEY 21 14 1025
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. Social Security Administration 13,018.20
re-payment of benefits
2. Centers for Medicare and Medicaid Services- Medicare Part B coverage due 209.80
TOTAL(Also enter on Line 10,Recapitulation) $ 13 228.00
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
JAMES R. KELLEY 21 14 1025
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. JAIMI L. SPICKLER Lineal 33,646.00
252 Feaster Valley Road
Dornsife, PA 17823
2. AMBER N. REBER Lineal 33,646.00
1301 B Summer Hill Road
Auburn, PA 17922
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 ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.