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Home My WebLink About08-17-15 REV-1500 EX(02-11) Iff 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 14 1183 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 12 01 2014 04 22 1926 Decedent's Last Name Suffix Decedent's First Name MI ANTOSZKOW MILDRED 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 X❑ 1, Original Return ❑ 2. Supplemental Return ❑ 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate1:1 (date of death fter 12-12-82) 4a Future InterestaCompromise ❑ 5. Federal Estate Tax ReturnRequired a 6 Decedent Died Testate (Attach Copy of will) 7. Decedent MaintTrust)aLiving Trust g, Total Number of Safe Deposit Boxes ❑ ❑ 9, Litigation Proceeds Received ❑ 10.boenP2 art%Cre ditiDatte f Death ❑ 11.Election totax under Sec.9113(A)ee (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number DIANE G RADCLIFF (717) 73729100 70. c� rn REGISTEf10F WILfE_USE�8 cn C-3 U) c� First Line of Address !'fi r t— I-- I'I rT1 3448 TRINDLE ROAD r ? ry Second Line of Address :3 City or Post Office State ZIP Code YY DATE FILEp_. v7 _ CAMP HILL PA 17011 Correspondent's e-mail address: dianeradcliff@_)comcast.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 true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE N RESPONSIBLE FOR FILI IG RETURN DATE RONALD E ALRIDGE 1 ADDRESS 3044 Telegraph Road, Elkton, MD 21921 URE OF PREPARER OTH�R®[J EPRES NTATIVE DATE Diane G Radcliff A 34 rindle Road, Camp Hill, PA Side 1 1505610143 1505610143 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: ANTOSZKOW, MILDRED 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. 359, 377 . 93 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) LJ Separate Billing Requested............ 7, 8. Total Gross Assets (total Lines 1 through 7)........................................................ 8. 3591377 . 93 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 2 , 882 . 27 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 21648 84 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 5,531 11 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 353 , 846 . 82 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. 353 , 846 . 82 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal.tax rate,or transfers under Sec.9116 15 0 . 00 (a)(1.2)X.00 16. Amount rate X .045 �Line 14 taxable at lineal rate 353 84 6 . 82 16. 15 , 923 . 11 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. 15, 923 . 11 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑ Side 2 L 1505610243 1505610243 J REV-1500 EX Page 3 File Number 21 14- it V,5 Decedent's Complete Address: DECEDENT'S NAME ANTOSZKOW, MILDRED M STREETADDRESS 2100 Bent Creek Boulevard CITY STATE ZIP Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 15,923.11 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits(A +B) (2) 0.00 3. Interest (3) 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) 15,923.11 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;.................................. 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?.................................................................................................................... ❑ n 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ Q 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. 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 ANTOSZKOW, MILDRED M 21 14 119S 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 Aberdeen Proving Ground Federal Credit Union 8,000.00 2 Fulton Bank-Account No.5623 145,699.72 3 Fulton Bank-Certificate of Deposit No. 3280328065 10,006.90 4 Fulton Bank-Certificate of Deposit No.375752 30,025.67 5 Wells Fargo-Money Market Account No.49419829 149,400.28 6 Wells Fargo-Checking Account No.626083905 5,408.74 7 Wells Fargo-Certificate of Deposit No.247402804007826 10,000.00 8 Ambulance Service -Refunds for service from 7-15-14-11-24-14 436.20 9 Donegal Insurance-Refund-Automobile Insurance 80.00 10 Highmark-Refund 221.42 11 The Bridges at Bent Creek-Refund-Assisted Living/Nursing Care(ROBC Limited 99.00 Partnership) TOTAL(Also enter on Line 5, Recapitulation) 359,377.93 (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-1511 EX+(10.09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RESIDENT DEC ENTTURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ANTOSZKOW, MILDRED M 21 t 11 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT UMBER A. FUNERAL EXPENSES: 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 Diane G Radcliff 1,168.75 3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) Claimant Street Address City State ZiD Relationship of Claimant to Decedent 4. Probate Fees 480.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1,233.02 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 2,882.27 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 ANTOSZKOW, MILDRED M 21 ITEM NUMBER DESCRIPTION AMOUNT Other Administrative Costs 1 Estate Advertisement 233.02 2 Reserve for additional tax and attorney's fees 1,000.00 H-B7 1,233.02 Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98) Rev-1512 EX+(12-08) 4 SCHEDULE I pennsylvania DEBTS OF DECEDENT, DEPARTMENT OF REVENUE INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ANTOSZKOW, MILDRED M 21 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 I Alert Pharmacy Service, Inc. 939.72 2 Colonial Park Care Center 1,498.82 3 Community Life Team-Transport-11/23/14-11!24/14 186.40 4 Consumer Cellular 23.90 TOTAL(Also enter on Line 10, Recapitulation) 2,648.84 (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 ANTOSZKOW, MILDRED M 21 T3 NAME AND ADDRESS OF RELATIONSHIP TOSHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT 0 Not List Tru too(O (Words) ($$$) I� TAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.91 16a 1.2 1 Ronald E Alridge �yY-" .GCJ 50%of residuary 3044 Telegraph Road estate Elkton, MD 21921 2 Matthew Dunbar Nephew Specific Bequest 5306 Kensington Lane of$5,000 Charleston,WV 25313 3 Samuel Dunbar Nephew Specific Bequest 5306 Kensington Lane of$5,000 Charleston,WV 25313 4 Christopher Meadows Nephew Specific Bequest 3433 Pluto Road of$5,000 Shady Spring,WV 25918 5 David Meadows Nephew Specific Bequest 3433 Pluto Road of$5,000 Shady Spring,WV 25918 See continuation schedule attached Continuation Total Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet as appro riate. NON-TAXABLE DISTRIBUTIONS: II. . A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev.01-10) SCHEDULE J BENEFICIARIES (Part I,Taxable Distributions) ESTATE OF: MILDRED M ANTOSZKOW 12/01/2014 233-42-0576 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 6 Michael Meadows Nephew Specific Bequest of 3433 Pluto Road $5,000 Shady Spring,WV 25918 7 Edith Marie Ranieri 50%of residuary estate 3044 Telegraph Road Elkton,MD 21921 Total 1