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Home My WebLink About08-13-18 -J REV-1500 Ex cot-„> 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 2 1 15 00398 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 01 13 2015 09 18 1924 Decedent's Last Name Suffix Decedent's First Name MI CLEMENTS THEODORE E (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 ❑ 2. Supplemental Return ❑ 3.Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate ❑ 4a, Future Interest Compromise ❑ 5. Federal Estate Tax Return Required (date of death after 12-12-82) g Decedent Died TestateE]❑ 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.betousalween P2v3 9Crredditi DatteS)f Death ❑ 11.Election to taxu under Sec.9113(A) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ROBERT P KLINE 717 770 2540 REGIST&OF WILLS iE OOMY �.� O First Line of Address I1 -T- 714 cn . ~ + 1 714 BRIDGE STREET Mc.� c�n � Second Line of Address -- PO BOX 461 -� DATE FILE City or Post Office State ZIP Code F_ NEW CUMBERLAND PA 17070 co U' Ti Correspondent's e-mail address: rkline@klinelawoffice.com Under penalties of perjury,I declare thatI h ve examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correc, and complete.Decl ti f preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE O/PERS N RES NSI E 0 FILING RETURN DATE Theodore E. Clements , t,`j j ADDRESS 10 Ash Drive, Mechanicsburg, PA 17050 S ATUR F PRE OTHER THAN REPRESENTATIVE DATE �2HRobert P Kline c j ADDRESS Kline Law Office 714 Bridge Street, New Cumberland, PA 17070 Side 1 1505610143 1505610143 J 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: CLEMENTS, THEODORE EDGAR 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. 5 , 150 . 54 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 9 , 747 . 53 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested............. 7. 40 , 270 . 46 8. Total Gross Assets(total Lines 1 through 7).......................................................... 8. 55 , 168 . 53 9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 13 , 960 . 40 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................. 10. 4 , 110 0 9 11. Total Deductions(total Lines 9 and 10)..................................................................11. 18 , 070 . 49 12• Net Value of Estate(Line 8 minus Line 11).............................................................12. 37 , 098 0 4 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. 37 , 098 0 4 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. 16. Amount of Line 14 taxable 16. 1 , 669 . 41 at lineal rate X .045 37 098 . 0 4 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE.................................................................................................................19. 1 , 669 . 41 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑ Side 2 1505610243 1505610243 J REV-1500 EX Page 3 File Number 21 - 15 - 00398 Decedent's Complete Address: DECEDENT'S NAME Clements, Theodore Edgar STREET ADDRESS 2907 Westbury Court, Apt. 707 CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2, Line 19) (1) 1,669.41 2. Credits/Payments A. Prior Payments 1,55.0.00 B. Discount 81.58 Total Credits(A +B) (2) 1;631.58 3. Interest (3) 0.00- 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 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) 3 7.8 3 Make Check Payable to: 'REGISTER OF WILLS, AGENT. .,. __ .,..I ..r.,y. :a .<J.9ri •'777, F. ...._.`,. ..z,�, ��: '� .�, _.�?.',� .. .m.,wxh,.x.�.,...te. ...�. .�7�...>r�,.4.. ,.��;..,.. ..._. . ..�. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No I 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;....................................❑ z c. retain a 'reversionary interest;or...............................................................................................................❑ d. receive the promise.for life of either payments, benefits or care?.............................................................. ❑x 2. If death occurred after Dec. 14 1982, did decedent transfer property within one year of death without receiving adequate consideration?.....................................................................................................................❑ ❑x 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 containsa 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 RETUR 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 ret m 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)l. •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 bloocr or adoption. ^ ^ -A pennsylvania SCHEDULE E DEPARTMENT OF REVENUE INHERITANCE TAX RETURN LC7ASH, BANK DEPOSITS AND MISC. RESIDENT DECEDENT PERSONAL PROPERTY FILE NUMBER ESTATE OF Clements, Theodore Edgar FILE NUMBER Include the proceeds of litigation and the date the proceeds were received bythe estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F.ITEM VALUE AT DATE OF NUMBER DESCRIPTION DEATH 1 2002 Honda Civic 4,800.00 2 Capital Blue refund 335.24 3 Transamerica Premier Life refund 5.35 4 AMA Insurance refund 9.95 TOTAL(Also enter on Line 5, Recapitulation) 5,150.54 REV-1509 EX+(01-10) 1, pennsylvania DEPARTMENT OF REVENUE SCHEDULE F INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Clements, Theodore Edgar 21 - 15-00398 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 Pennie A. Bohl 500 Park Avenue Daughter A New Cumberland, PA 17070 JOINTLY OWNED PROPERTY: LETTER DATE L FfSCRIPTl0�1 gF PROd%RTY %OF DATE OF DEATH ITEM FOR JOINT MADE Include name o Inanclal ins Itu Ion an bank account numb rDATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT or similar identifying number.Attach deed for jointly-held real VALUE OF ASSET estate. INTEREST DECEDENT'S INTEREST 1 A M&T Bank 19,495.05 50% 9,747.53 TOTAL(Also enter on line 6, Recapitulation) 9,747.53 REVA 510 EX+(08-09) PennsY Ivania ti DEPARTMENT OF REVENUE SCHEDULE G . INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS & RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY ESTATE OF Clements, Theodore Edgar FILE NUMBER 21 - 15-00398 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF EXCLUSION TAXABLE VALUE Include the name of the transferee,their relationship to decedent VALUE OF ASSET DECD'S IF APPLICABLE NUMBER and the date of transfer. Attach a copy of the deed for real estate. INTEREST ( ) 1 AIG Annuity#VP222445 40,270.46 100% 40,270.46 TOTAL(Also enter on line 7, Recapitulation) 40,270.46 REV-1511 EX+(10.09) -A pennsylvania SCHEDULEH DEPARTMENT OF REVENUE FUNERALE)FENSESAND INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF Clements, Theodore Edgar FILE NUMBER 21 - 15 -00398 Decedent's debts must be reported on Schedule 1. ITEM NUMBER -f EMNUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 Musselman Funeral Home 8,735.00 2 Rolling Green Cemetery 2,331.00 3 Patriot News 356.70 B. ADMINISTRATIVE COSTS: 1 Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(s)Commission Paid 2. Attorney's Fees Kline Law Office 1,500.00 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 Register of Wills 15.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7, Other Administrative Costs Clean Machine 200.00 See attached 822.70 TOTAL(Also enter on line 9, Recapitulation) 13,960.40 • pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, MORTGAGE INHERITANCE TAX RETURN RESIDENT DECEDENT LIABILITIES & LIENS FILE NUMBER ESTATE OF Clements, Theodore Edgar 21 - 15 -00398 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 AARP Chase#4408-0410-1324-4391 633.19 2 Bank of America#4313-0728-5818-8132 2,959.11 3 AAA Financial Services#5490-9960-2403-9732 281.26 4 AT&T Consumer 18.44 5 Verizon 31.92 6 PPL Electric 130.84 7 Sears 55.33 TOTAL(Also enter on Line 10, Recapitulation) 4,110.09 REV-1513 EX+(01.10) �A. Pennsylvania SCHEDULE DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF Clements, Theodore Edgar FILE NUMBER 21 - 15-00398 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List-Trustee(s) TAXABLE DISTRIBUTIONS[include outright spousal distributions,and transfers under Sec.9116(a)(1,2)] 1 Theodore E. Clements Son one-half 10 Ash Drive Mechanicsburg, PA 17050 2 Pennie A. Bohl Daughter one-half 500 Park Avenue New Cumberland, PA 17070 Enter dollar arnounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate, NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHE T 0.00