HomeMy WebLinkAbout01-0094
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REV-1500
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FilE NUMBER <<{
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COUNTY CODE YEAR
OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
OEPT 280601
HARRISBURG, PA 17128-0601
INHERITANCE TAX RETURN
RESIDENT DECEDENT
NUMBER
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C
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C
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
R-e ec.(. -
DATE OF DEATH (MM- D-YEAR) DATE OF BIRTH (MM-DD-YEAR)
~()", '\- ?..oob IC\ 23
(IF APPLICABLE) SURVIVING SPOUSE'S AME (LAST, FIRST, AND MIDD E INITIAL)
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THIS RETURN MUST BE FilED IN DUPLICATE WITH THE
REGISTER OF WillS
SOCIAL SECURITY NUMBER
1/'\ 0-
SOCIAL SECURITY NUMBER
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1. Original Return
D 4. Limited Estate
D 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after 12-12-82)
D 7. Decedent Maintained a Living Trust {Attach copy of Trust)
D 10. Spousal Poverty Credit (date of death betwesn 12-31-91 and 1-1-95)
D 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Alt.3cl1 Sch 0)
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COMPLETE MAILING ADDRESS
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TELEPHONE NUMB
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate BiUing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or l)
8. Total Gross Assets (total Lines 1-7)
OFFICIAL USE ONLY
~
"'C4U1....
(1)
(2)
(3)
(4)
(5)
"'0"'-0
V'\ 6\\.\....D
\)0'\"1,00
(6)
no (V..
(7)
no", e....
(9)
(10)
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(8) \0'\'\.60
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9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total lines 9 & 10)
(11)
(12)
(13)
\r\ 6 'i\...L.
\)Oqq,Co
Y\olf\e
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x.O_ (15)
x.o~ (16) Jtq ,,\-,c,
x .12 (17)
-
x .15 (18)
(19) ~q.'-\-5
16. Amount of Line 14 taxable at lineal rate
I) 0<\ Clio Dc)
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET DDRESS
STATE
Q\\
ZIP
\10\
CITY
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
l.\C\ . '\-5
Total Credits (A + B + C ) (2)
-
3. InteresUPenally if applicable
D. Interest
E. Penally
TotallnteresUPenally ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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)
-
A. Enter the interest on the tax due.
(5A)
~
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
L\'{ . '\-5
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;..... . .................. ................... .................................. D G'"
b. retain the right to designate who shall use the property transferred or its income;.. .................... .... D G'
~'. :::~v: ;~:e;~~::;f~~t~;:~~ :~;~~rpay~~~;~:~~~~fi~~;~;~?:::::::::::': B ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .......... ................ ..................... ....................... .................... ....... 0 W
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? ................. .................... .................. ................ 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,
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 complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESP.Q..NSIBLE F
~ 'to
ADDRESS
~G RETURN
DATE
q, So \l'<'lCLV\'&
SIGNATURE OF PREPARER OTHER T
\..a.w~..
REPRESENTATIVE
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DATE
ADDRESS
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. ~9116 (al (1.1) (ill.
For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% 172 P.S. ~9116 (a) (1.11 (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutoI)' 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 twenty-one 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% [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%, except as noted in 72 P.S. ~9116(1.21 [72 P.S. ~9116(a)(111.
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.31]. 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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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
~-e\n~
~. VWD,",
FILE NUMBER
Iflclude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1..
DESCRIPTION
~~ ~~~'j\: 0030q-'\15b-0:;-
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"\0"'-- m
VALUE AT DATE
OF DEATH
11
\) 0'1'1,00
TOTAL (Also enter on line 5, Recapitulation) $ \ ) 0 C\, q, DO
(If more space is needed, insert additional sheets of the same size)
WARNING: IT IS IllEGAL TO ALTER THIS COpy OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
COMMONWEALTH OF PENNSYLV AflJlA
DEPARTMENT OF HEALTH VITAL RECORDS
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
CERT" NO, T 4 713 6 8 3
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ate of Issue of ThiS Certification
Name of Decedent
sex~ Sociai Security No ---/.--!J.LL-a - ~~--- Date of Death V;-tr'. ..-~ :J-bt:)t/
LaJ32~S- Birthplace LJ+~./ - .IO.-____~__________
'.' - &' ~~cM~ (!~~b'"
Race.~_nn_Occupat'on ~~~ Armed Forces? -(Yes or NO)~ ---
Mantal Status ~~_ ~~~~n~e~~sdt1s..t.Wak~h~ . -1Z~7"-13 _
f\JlFl,i'~r <31r8ct .. ~l:'y- \_~.( I (l'v\r, ~)Lir;::.
~:%~~~~t~~~~u_u~ Fu:~al Direc~or. ~ t JzLn /J-----
Funerai Establishmen.txS/~ ~. t;;/.A<4'1L'.A.LLP-4.J~~.J~:F3' _ ~.&- I .. -- ~-_._-
Interval Between
Onset and Death
21-01-94
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'-~~)
Ld :~~
Date of Bi rth
.J:~~?YL\I~ni E
Part I:
Irnrnedlate Cause
(a) -.Cl ..d~-J2 ----------.----.--
--------------~----
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---L-_______.____.._..._ ..' ...c...._.._.____ __u_
Part II-
(d) . ____.______u_______._____
Other Significant Conditions
Manner of Death
Describe how injury occurred:
Natural
.x
HOtTlIClcle
o
Suicide
Pending Investigation
Could not be Determined
[J
Accident
Name and Title of certfier__~ 3~ ~ t4'A1'~~.J-----~D_Q-Coro-ner:_f.jfE
Address ...n......____ ~. ~..,.&. (jH-kJ,.J~ ---------
T his 1St 0 C e r t if Y t hat ttl e I n for mat ion her e g i v e n i S cor r e c 11 y cop i e d fro man 0 rig i n a Ice r t i fie ate
of death duly flied with me as Local Registrar'. Ttle original certificate will be forwarded to the
State Vllill Re ords Of'ice for permanent filln~-4
k_H4) L'. h '7 ~hl.3
5' Mic _ R,".~:~R;Q/u.J_Jhh4.'lci;; ,'", fL
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REY-1547 EX AFP <12-00)
KAREN E KROH
850 MANDY LN
CAMP HILL
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
03-19-2001
KROH
11-04-2000
21 01-0094
CUMBERLAND
101
REBECCA
E
Allount Remitted
PAL~7011
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
RE-Y=is'4j-Ei--AFP--fi"2:ooj--NOY-iCE-OF-i-tiHEifiTAifCE-YAX-APPRAisi:ifENT~--A[i-ciwAirCE-oi-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF KROH REBECCA E FILE NO. 21 01-0094 ACN 101 DATE 03-19-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
1,099.00
.00
.00
(8)
NOTE: To insure proper
credit to your account,
subllit the upper portio,
of this forll with your
tax payment.
1,099.00
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
.00
.00
(11)
(12)
(13)
(14)
00
1,099.00
.00
1,099.00
NOTE:
I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ~
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate
16. Allount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rate
18. Allount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
1,099.00 X 045 =
.00 X 12 =
.00 X 15 =
(19)=
.00
49.45
.00
.00
49.45
(15)
(16)
(17)
(18)
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
01-19-2001 AA477915 2.47 49.45
TOTAL TAX CREDIT 51.92
BALANCE OF TAX DUE 2.47CR
INTEREST AND PEN. .00
TOTAL DUE 2.47CR
· IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
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