HomeMy WebLinkAbout06-26-15 REV-1500 Ex(02 ` ' 1505610143
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 15 0342
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
03 07 2015 06 01 1922
Decedent's Last Name Suffix Decedent's First Name MI
BONDRA DOROTHY M
(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
1. Original Return 1-1 2. Supplemental Return E] 3. Remainder Return(Date of Death
Prior to 12-13-82)
4. Limited Estate E] 4a. Future Interest Compromise
(date of death after 12-12-82) 5. Federal Estate Tax Return Required
6 Decedent Died Testate 7. (AttacheGopy of Tn Sd a Living Trust 8, Total Number of Safe Deposit Boxes
(Attach Copy of Will) PY )
g, Litigation Proceeds Received 10.between Pz 31J�a dit(Daf Death 11 Election to tax under Sec.9113(A)
1-1-95) (Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
MICHAEL L BANGS 717 730 7310
REGISTE"F WILLS UWONLY
C crl TT�
First Line of Address + r�
429 SOUTH 18TH STREET I°
Second Line of Address !7 CT) -.J c'a
c
ZJ
`D'ATE FILLED -�
City or Post Office State ZIP Code i a <:>
CAMP HILL PA 17011 i~ art
Correspondent's e-mail address: mikebangS@verizon.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,
it is ue,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
S ATURE OF PERSON R PONSIBL FILING TURN DATE
Barbara M. Bondra .3
ADDRESS
1350 E. Lisburn Road, Mechanicsburg, PA 17055
IGNATURE OF PREPARER OTHER T REPRESENTATIVE DATE
Michael L. Bangs
ADDRESS
429 South 18th Street, Camp Hill, PA 17011
Side 1
1505610143 1505610143 J
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Bondra, Dorothy M.
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&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 115, 735 . 91
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 48 , 825 . 28
7. Inter-Vivos Transfers&Miscellaneousion Probate Property
(Schedule G) u Separate Billing Requested............ 7. 66, 574 . 22
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 231 , 135 . 41
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 6, 964 . 79
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 491 . 26
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 7f 456 . 05
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 223 , 679 . 36
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. 223 , 679 . 36
TAX COMPUTATION-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.00 15. 0 . 00
16. Amount of Line 14 taxable
at lineal rate X .045 223 , 679 . 36 16. 10 , 065 . 57
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................................................................................................................ 19. 10 , 065 . 57
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑X
Side 2
❑ 1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-15-0342
Precedent's Complete Address:
7ECEDENT'S NAME
Bondra, Dorothy M.
i STREET ADDRESS
1 522 Breezewood Court
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 10,065.57
2. Credits/Payments
A. Prior Payments 10,000.00
j.. B. Discount 503.28
Total Credits(A +B) (2) 10,503.28
3. Interest (3)
;4• If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 437.71
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5)
I
i..
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;.................................. El ❑x
c. retain a reversionary interest;or............................................................................................................... ❑ ❑x
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ 0
3. Did decedent own an"in trust for' or payable upon death bank account or security at his or her death?....... ❑ ❑x
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 January 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(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.
Rev-1508 EX+(11-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bondra, Dorothy M. 21-15-0342
Include 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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Exxon Mobile Dividend 783.84
2 M&T Bank-Checking account 16,596.96
3 M&T Bank-Savings account 94,279.11
4 Refund from Delbrook Manor Apartments 100.00
5 Refund of auto insurance 4.00
6 Refund of renters insurance 8.00
7 Sale of automobile-see Bill of Sale 1,700.00
8 US Treasury-2014 income tax refund 2,264.00
TOTAL(Also enter on Line 5, Recapitulation) 115,735.91
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10)
Rev-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bondra, Dorothy M. 21-15-0342
If an asset was made joint within one year of the decedent's date of death,it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Barbara M. Bondra 1350 E. Lisburn Road Daughter
Mechanicsburg, PA 17055
B.
C.
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY oda OF DATE OF DEATH
LETTER DATE VALUE OF
ITEM FOR JOINT MADE (NUMBER OR SNCLUDE EMILARNDENTIFY NG OF FIANCIAL INUMBERTUTIONAATTACH DEEDO OR ND BANK ACCUNTDATE OF DEATH DECD'S DECED NT'S INTEREST
NUMBER VALUE OF ASSE TENANT JOINT JOINTLY-HELD REAL ESTATE. INTEREST
1 A Exxon Mobile Corporation-1136 shares held 97,650.56 50.000% 48,825.28
jointly with decedent's daughter, Barbara
Bondra. Mean value on 3/7/15 was$85.96 per
share.
TOTAL(Also enter on Line 6, Recapitulation) 48,825.28
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule F(Rev.01-10)
Rev-1510 EX+(08.09)
SCHEDULE G
pennsylvania INTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bondra, Dorothy M. 21-15-0342
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.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THE DA E OF TROANSFERSATfACH THEIR CO Y OF THE RELATIONSHIP TO
FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 American General Life Insurance Company-Annuity 66,574.22 66,574.22
Contract VP222443; decedent's daughter Barbara
Bondra is the beneficiary of this annuity.
TOTAL(Also enter on Line 7, Recapitulation) 66,574.22
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule G(Rev.08-09)
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITACE TAX
RESIDENT'DEC ENT RETURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Bondra, Dorothy M. 21-15-0342
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 1,388.99
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State ZiD
Year(s)Commission Paid
2. Attornev's Fees Michael L. Bangs 5,000.00
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State ZiD
Relationshio of Claimant to Decedent
4. Probate Fees 315.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 260.30
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 6,964.79
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Bondra, Dorothy M. 21-15-0342
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Neill Funeral Home, Inc. 1,388.99
H-A 1,388.99
Other Administrative Costs
2 Cumberland Law Journal -estate advertisement 75.00
3 The Patriot News-estate advertisement 185.30
H-B7 260.30
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bondra, Dorothy M. 21-15-0342
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 Apria Healthcare 14.09
2 L. B.Smith Ford-vehicle state inspection 106.42
3 Michael Langen-per capita taxes 9.80
4 PA Department of Revenue-2014 income tax due 103.00
5 PP&L-final bill 236.75
6 Verizon 21.20
TOTAL(Also enter on Line 10, Recapitulation) 491.26
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bondra, Dorothy M. 21-15-0342
RELATIONSHIP TO
NUMBER NAME AND ADDRESS OF DECEDENDo Not List T SHARE OF ESTATE AMOUNT OF ESTATE
PERSONS)RECEIVING PROPERTY (Words) ($$$)
TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Barbara M. Bondra Daughter Entire
1350 E. Lisburn Road
Mechanicsburg, PA 17055
Thomas Bondra FSC Son
6001 Ammendale Road
Beltsville, MD 20705
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
r'
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev. 01-10)
American General Life Insurance Company
The United States Life Insurance Company in the City of New York
April 23, 2015
BANGS LAW OFFICE, LLC
ATTN: MICHAEL BANGS
429 SOUTH 18TH STREET
CAMP HILL PA 17011
Re: Annuity Contract VP222443
Deceased Dorothy Bondra
Dear Mr. Bangs:
Thank you for your recent inquiry regarding the above referenced annuity contract. We would
like to take this opportunity to respond to your request.
According to our records the primary beneficiary for this policy is Barbara Bondra. The
accumulated value of this contract as of 03-07-2015, the date of death, is $66,574.22.
Mr. Bangs, we appreciate the opportunity to assist you. Should you have any questions, please
contact our Client Care Center at 1-800-424-4990.
Sincerely,
Jennifer Contreras
Annuity Claims Department
Annuity Service Center- P.O. Box 871 •Amarillo, TX 79105-0871
Administrator for Renaissance Life& Health Insurance Company of America • Administrator for John Alden Life Insurance Company
M M&T Bank
499 Mitchell Road,Millsboro.DE 19966 Records Management
Phone 888-5024349
Fax(302)934-2955
April 13,2015
Bangs Law Office. LLC
429 South 18'h Street
Camp Hill, PA 170111
Re: Estate of Dorothy M Bondra
Social Security:
Date of Death: March 7, 2015
Dear Sir or Madam:
Per your inquiry on April 1,2015, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
I Type of Account Checking
Account Number 16475305
Ownership(Names ofi Dorothj,A4 Bondra
Opening Dale 0812811964
Balance on Date of Death $ 16,59696
Accrued Interest $ .01
Total $ 16,596.97
2. Type of Account Savings
Account Number 15004205323617
Ownership(Names ofi Dorothy M Bon&o
Opening Date 0711012003
Balance on Date of Death S 94,279.11
Accrued Interest S 1.78
Total $ 94-280.89
For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds,
please call the West Shore Plaza Branch at 717-731-1730.
This letter does not include any accounts in which the deceased may have been listed as Power of.Attorney,Custodian of uniform Transfers,
Representative Payee,or Trustee under a Written Agreement.
Sincerely,
Tomara Williams
Records Management
BILL OF SALE
qI, BARBARA M. BONDRA, Executrix of the Estate of Dorothy Bondra, do hereby sell a
I �� [ FG R lD E•5 L 69-F , Vehicle Identification Number(VIN)
j F6 VIP L3FFA W,-�l-i69 to
for the sum of
j E E & k Q RL—I> bOL L.r9 r�J ($ N CC)_ Dollars.
/' 11
Date: } / c ti��� , /C-
BARBARA M. BONDRA -
WILL
OF
DOROTHY M. BONDRA
I, DOROTHY M. BONDRA, of the Borough of Camp Hill, Cumberland County,
Pennsylvania, declare this to be my last will and revoke any will previously made by me.
ITEM I. I direct that all my just debts and funeral expenses, including my gravemarker
and all expenses of my last illness, and any and all taxes and assessments imposed by any
governmental body as a result of my death, whether on property passing under this will or
otherwise, shall be paid from my residuary estate as soon as practicable after my decease as a
part of the expense of the administration of my estate.
1
ITEM II. I give and bequeath all of my household goods, automobiles,jewelry, and all
other articles of household and personal use, equipment and ornament, together with all
insurance thereon and relating thereto, to my daughter, BARBARA M. BONDRA, of
Mechanicsburg, Pennsylvania, provided she survives my deathh by thirty (30) days.
ITEM M. I give, devise, and bequeath all the rest, residue, and remainder of my
possessions and estate of every nature and wherever situate to my daughter, BARBARA M.
u
BONDRA, of Mechanicsburg, Pennsylvania, provided she survives my death by thirty (30) days.
�\ ITEM IV. I appoint my daughter, BARBARA M. BONDRA, executrix of this my last
will.
ITEM V. In addition to the other powers and authorities granted to my personal
representatives by Pennsylvania law and by the other terms and provisions of this will, I hereby
1
give to my personAl representatives the following powers and authorities effective without court
approval and until actual distribution of all property: to compromise any claim or controversy; to
make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as
my personal representatives may determine and at valuations finally to be fixed by them; to
invest in all forms of property, including any stock or other securities in any corporate fiduciary
or its successor without restriction to investments authorized for Pennsylvania fiduciaries, as my
personal representatives deem proper, without regard to any principle of risk or diversification; to
retain any or all assets of my estate, real or personal, without regard to any principle of risk or
diversification; to sell at public or private sale, to exchange, or to lease for any period of time,
any real or personal property and to give options for sales, exchanges, or leases, for such prices
and upon such terms or conditions as my personal representatives deem proper; and to allocate
receipts and expenses to principal or income or partly to each as my personal representatives
deem proper in their sole discretion.
ITEM VI. I direct that my personal representatives and fiduciaries shall not be required
to give bond for the faithful performance of their duties in any jurisdiction_
IN WITNESS WHEREOF, I have hereunto set my hand this day
of � 1998.
DOROTHY M. BONDAA
2
The preceding instrument, consisting of this and TWO other typewritteh pages, each
identified by the signature of the testatrix was on the date thereof signed, published, and declared
by DOROTHY M. BONDRA, the testatrix therein named, as and for her last will, in the presence
of us,who at her request, in her presence,and in the presence of each other, have subscribed our
names as witnesses hereto.
COMMONWEALTH OF PENNSYLVANIA )
( SS:
COUNTY OF CUMBERLAND }
The undersigned, being the testatrix whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, does hereby acknowledge that I signed and
executed the foregoing instrument as my last will,that I signed it willingly; and that I signed it as my
free and voluntary act for the purposes therein expressed.
Sworn or affffmed to and acknowledged
bef a by thewestattax
n �above
thi day of ' iLL� 1999
-Notary Public _
tcwK A 6,1Twpwp., CU} �7 Pubtk
.. +'
My CoarmiWon Expiry May
Co., PA
COMMONWEALTH OF 10 1 )
( SS:
COUNTY OF CUMBERLAND }
WE, ,c l�.L t ,�/` �—�---and LYNN Eh 4,FN CF6D 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;that she signed it willingly and that she executed it as her free and voluntary act for the purposes
therein wed;that each of us in the hearing and sight of the testatrix signed the will as witnesses;
and that to the best of our knowledge,the testatrix was at that time 18 or more years of age,of sound
mind,and under no constraint or undue iluence.
f V1
J
Sworn or affirmed to and
4nowledge be me this
y ofI rh�
Votary Public
t SEAL
WMY 5. CH"00. Nwary Pik 4
Lowrt A1611 Twp., Cuenbe&nd Ca, pA
A'C4nw*m$on May 10, 1999