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Home My WebLink About07-22-15 (3) REV-1500 EX (01-10) 1505610140 OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 4 1 0 7 1 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 1 0 5 2 0 1 4 0 8 2 2 1 9 2 0 Decedent's Last Name Suffix Decedent's First Name MI K 0 L L E R G E R A L D I N E H (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 RX 1.Original Return 2. Supplemental Return 3. Remainder Return(date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise(date of 5. Federal Estate Tax Return Required death after 12-12-82) ❑X 6. Decedent Died Testate R 7. Decedent Maintained a Living Trust 0 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 C H A R L E S E P E T R I E 7 1 7 5 6 1,01 9 -% 9 rJ - - M REGJ§TQ OF WILLS�JdSE OM Y6 M C') �- p iJ r"' N J til First line of address h rT'I 3 5 2 8 B R I S B A N S T R E E T 4� ::D -T-t Second line of address O .. I— M -i Qi City or Post Office State ZIP Code _ ____ DATE FILO H A R R I S B U R G P A 1 7 1 1 1 Correspondent's e-mail address: PetrleLaW AOL.COm 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. SIGQATURE OF P RSON RE O /FOR FILI G ETURN DATE 7/21/2015 ADDRESS 78 LITTLE RUW ROAD CAMP HILL PA 17011 SIGNATURE OF.PFjEP ER O ER THA EP ENTATIVE DATE l 7/21/2015 ADDRESS 3528 BRISBAN STREET HARRISBURG PA 17111 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J 1505610240 REV-1500 EX Decedent's Social Security Number DecedenYSName: GERALDINE H - KOLLER 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. 4 0 6 0 9 7 . 3 2 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested . . . . . . . 7. 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 4 0 6 0 9 7 . 3 2 9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 3 0 5 2 0 . 5 0 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . . . . 10. 2 0 6 6 • 5 0 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 3 2 5 8 7 0 0 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 3 7 3 5 1 0 . 3 2 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. 3 7 3 5 1 0 . 3 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 _ 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate X .0_ 0 . 0 0 16. 0 . 0 0 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 4 0 6 0 9 7 . 3 2 18. 6 0 9 1 4 . 6 0 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 6 0 9 1 4 . 6 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505610240 1505610240 J REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 14 1071 DECEDENT'S NAME GERALDINE H. KOLLER STREET ADDRESS 1700 MARKET STREET CITY STATE ZIP CAMP HILL PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) {1) 60 914.60 2. Credits/Payments A.Prior Payments 57 000.00 B,Discount 2,999.91 Total Credits(A+B) (2) 59 999.91 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) 914.69 Make check payable to: REGISTER OF WILDS, 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; ...................................................................... ❑ n b. retain the right to designate who shall use the property transferred or its income; .............................I. ❑ n c. retain a reversionary interest;or ................................................................................................ ❑ 0 d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ 0 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ X❑ 3. Did decedent own an"intrust for"or payable-upon-death bank account or security at his or her death? ❑ n 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?............ ....... ....... ......... ..............__..... ....... ........._........... ❑ 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 stepparent of the child is 0 percent[72 P.S.§9116(x)(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(x)(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+(6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF FILE NUMBER GERALDINE H. KOLLER 21 14 1071 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. ACCOUNT AT FULTON BANK 63,809.69 2. FULTON FINANCIAL ADVISORS ACCOUNT 342,287.63 TOTAL(Also enter on line 5,Recapitulation) $ 406,097.32 (If more space is needed,insert additional sheets of the same size) REV-1511 EX+(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER GERALDINE H. KOLLER 21 14 1071 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1 Personal Representative Commissions: Name(s)of Personal Representative(s) SANDRA KAUFFMAN 15,000.00 Street Address 78 LITTLE RUN ROAD City CAMP HILL state PA.-ZIP 17011 Year(s)Commission Paid: 2015 2. Attorney Fees: CHARLES E. PETRIE 15,000.00 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: 520.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9,Recapitulation) $ 30,520.50 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 GERALDINE H. KOLLER 21 14 1071 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. MANOR CARE FINAL COSTS 1,115.97 2. FUNDS RETURNED TO PSERS 950.53 TOTAL(Also enter on Line 10,Recapitulation) $ 2,066.50 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: GERALDINE H. KOLLER 21 14 1071 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. RICHARD AND SANDRA KAUFFMAN Collateral 406,097.32 78 LITTLE RUN ROAD CAMP HILL, PA 17011 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. []. 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 11 -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. LAST WILL AND TESTAMENT 1, GERALDINE H. KOLLER, of 20 North 12th Street, Apartment 112, Lemoyne, County of Cumberland, Pennsylvania, do hereby make, publish, and declare this to be my LAST WILL AND TESTAMENT, revoking any and all prior wills and codicils, in manner following, that is to say, FIRST, that I direct that my Personal Representative shall pay all of my just debts and funeral expenses as soon as this shall be practicable. SECOND, that I give, devise, and bequeath all of my property, real, personal, and mixed, to my husband, ROBERT W. KOLLER. THIRD, that if my husband has predeceased me, or has failed to survive me for a period of at least ninety (90) days, or if our deaths should occur in such a manner that it cannot be determined which of us has predeceased the other, then I give, devise, and bequeath all of my property, real, personal, and mixed, to SANDRA J. KAUFFMAN. If Sandra has predeceased me, or has failed to survive me for a period of at least ninety (90) days, then I give, devise, and bequeath all of my property, real, personal, and mixed to RICHARD KAUFFMAN. FOURTH, that I hereby direct that no share of my estate shall pass to my son, DONALD KOLLER, of West Palm Beach, Florida. FIFTH, that I hereby appoint SANDRA J. KAUFFMAN as the Executrix of my Estate. I direct that my Personal Representative shall not be required to post bond in this or in any other jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 26ffi day of June, 2009. GERALDINE H. KOLLER WITNESS WITNESS ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN 1, GERALDINE H. KOLLER, testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me by GERALDINE H. KOLLER, the testatrix, this 26ffi day of June, 2009. :.' V GERALDINE H. KOLLER COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL KELLY P.ROBERTS, Commission AFFIDAVIT WE, CHARLES E. PETRIE and ROBERT W. KOLLER, 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 testatrix sign and execute the instrument as her Last Will and Testament; that GERALDINE H. KOLLER signed willingly and that she 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 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 influence. Sworn or affirmed to and subscribed before me by CHARLES E. PETRIE and ROBERT W. KOLLER, witnesses, this 26th day of June, 2009. WITNESS WITNESS TAR ZRZYV,,PUBLIC COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL KELLY P.ROBERTS,Notary Public Pa)dang Boro..Dauphin County COmn'100011 Expires January 27.2013