HomeMy WebLinkAbout08-20-15 pennsylvania 1505614105
DL9A11TMFNT OFNEVFMIE EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO Box 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 t 12 ( 1 7 -7
ENTER DECEDENT INFORMATION BELOW
10292012 08301936
Decedent's Last Name Suffix Decedent's First Name MI
Chubb Clarence LL
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
I - . I :�= F1
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
OD 1.Original Return O 2. Supplemental Return O 3. Remainder Return(date of death
prior to 12-13-82)
O 4.Agriculture Exemption(date of O 5. Future Interest Compromise(date of O 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
C D 7. Decedent Died Testate O 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
O 10. Litigation Proceeds Received O 11. Non-Probate Transferee Return O 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
O 13. Business Assets 14.Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Brian K. Zellner, Esquire (717) 774-1357
First Line of Address
2608 N. 3rd Street
Second Line of Address
City or Post Office State ZIP Code _
Harrisburg PA 17110
Correspondent's email address: bzellner@hynumpc.Com
REGISTER OF WILLS USE ONLY
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L REGISTER OF WILLS USE ONLY cin
DATE FILED MMDDYYYY M rn
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DAT,E;FILEDSTAMP O O
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PLEASE USE ORIGINAL FORM ONLY .:.* W Cn O
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Side 1
50�iiiii
614105 1505614105
.J 1505614205
REV-1500 EX(FI)
RECAPITULATION
1
1. Real Estate(Schedule A). ............................................ 1. 100,000.00
2. Stocks and Bonds(Schedule B) ....................................... 2. 0.00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.001
4. Mortgages and Notes Receivable(Schedule Dk............ ............... 4. 30,000.00 1
5. Cash,Bank Daposits and Miscellaneous Personal Property(Schedule E)....... 5. 1,724.00
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. ; 0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. 0.00
�i
8. Total Gross Assets(total Lines 1 through 7)............................. 8.! � 131,724.00-
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 12,750.001
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10.1 147,394.251
11. Total Deductions(total Lines 9 and 10)................................. 11. 160,144.25
12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. { -28,420.25
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which ��
an election to tax has not been made(Schedule J) ........................ 13.± 0.00 !
14. Net Value Subject to Tax(Line 12 minus Line 13) ............ ............ 14. i -28,420.25
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_ { # 15.r� 0.00
16. Amount of Line 14 taxable i .� j
at lineal rate X.0_ i 1 16. 0.00
17. Amount of Line 14 taxable
m__
at sibling rate X.12 17. 0.00 1
18. Amount of Line 14 taxable I
at collateral rate X.15 ! 18. 0.00 i
19. TAX DUE ... ..................................................... 19. 0.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Under penalties of perjury,I declare 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 person responsible for filing the return is based on all information of which preparer has
any knowledge.
SIGU OF PERS_9N RESPONSIBLE FOR FILING RETURN DATE
ADDREW
63) OT X ne,,, cj,,,,b »J` ��4- 7o 2,a
SIG URE F P PARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE
8l� IS`
A ESS
26081v. 3-d Si- 4+ :5
Side 2 J
1505614205
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Clarence Lamar Chubb
STREET ADDRESS
4601 Chestnut Avenue
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1)
2. Credits/Payments
A.Prior Payments
B.Discount
(See instructions.) Total Credits(A+B) (2)
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)
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5)
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 .......................................................................................... ❑ ■
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ N
c. retain a reversionary interest .............................................................................................................................. ❑ N
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 0
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?.............. ❑ 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 step-parent 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-1502 EX+ (02-15)
i pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Clarence Lamar Chubb 2012-01177
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1' 4601 Chestnut Avenue, Camp Hill,PA 17011 100,000.00
TOTAL(Also enter on Line 1, Recapitulation.) $ 100,000.00
If more space is needed, use additional sheets of paper of the same size.
REV-1503 EX+(02-15)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Clarence Lamar Chubb 2012-01177
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1' None
0.00
TOTAL(Also enter on Line 2, Recapitulation) $ 0.00
If more space is needed, insert additional sheets of the same size
I I
REV-15o4 EX+(g-iz)
SCHEDULE C
pennsylvania CLOSELY-HELD CORPORATION
DEPARTMENT OFREVENUE i
INHERITANCE TAX RETURN PARTNERSHIP OR
RESIDENT DECEDENT SOLE-PROPRIETORSHIP
ESTATE OF FILE NUMBER
Clarence Lamar Chubb 2012-01177
Schedule C-1 or C-2(including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent,
other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM NUMBER VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. None 0.00
TOTAL (Also enter on line 3, Recapitulation) $ 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1507 EX+ (02-15)
-j-r7--Qjs Pennsylvania SCHEDULE D
DEPARTMENT OF REVENUE MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Clarence Lamar Chubb 2012-01177
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Decedent loan money to James Pool and Kristen Kay Pool. No writtten documentation. I 30,000.00
I _
TOTAL(Also enter on Line 4, Recapitulation) $ 30,000.00
(If more space is needed,insert additional sheets of the same size.)
REV-1508 EX+(02-15)
r pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Clarence Lamar Chubb 2012-01177
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- furniture of the Decedent 500.00
2. Decedent's automobile 1,000.00
3. Bank account of the Decedent 224.00
TOTAL(Also enter on tine 5, Recapitulation) $ 1,724.00
If more space is needed, use additional sheets of paper of the same size.
REV-1509 EX+(02-15)
j pennsylvania SCHEDULE F
DEPARTMENT REVENUE JOINTLY OWNED PROPERTY
INHERITANCE TAXAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Clarence Lamar Chubb 2012-01177
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. None
B.
C.
JOINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. None.
TOTAL(Also enter on Line 6, Recapitulation) $ 0.00
If more space is needed, use additional sheets of paper of the same size,
REV-1510 EX+ (02-15)
Z7pennsylvania SCHEDULE G
, DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Clarence Lamar Chubb 2012-01177
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.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. None. 0.00
TOTAL(Also enter on Line 7, Recapitulation) $ 0.00
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+ (02-15)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Clarence Lamar Chubb 2012 -0117
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. funeral,grave opening,engraving headstone 10,750.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees: 2,000.00
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:
5. Accountant Fees:
6. Tax Return Preparer Fees:
7.
TOTAL (Also enter on Line 9, Recapitulation) $ 12,750.00
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (02-15)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Clarence Lamar Chubb 2012-01177
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• Mortgage on 4601 Chestnut Avenue, Camp Hill, PA-Countrywide Home Loans 124,241.26
2. Lowe's 450.62
3. Capitol One Bank,USA, NA 4,874.12
4. Hartzell Rupp Opthalmology 105.68
5. West Shore EMS-ALS 1,468.99
6 Chase Bank USA, NA 6,209.17
7. Pennsylvania American Water 117.39
8. Hampden Township 325.61
9. American Express 6,875.85
10. Citi Visa 2,725.56
TOTAL(Also enter on Line 10, Recapitulation) $ 147,394.25
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (02-15)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Clarence Lamar Chubb 2012-01177
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under
Sec. 9116(a)(1.2).)
1. Kelly Lynn Hoon, New Cumberland, PA daughter 100%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1 None 0
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
None 0
TOTAL OF PART II — 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 of
1, Clarence Lamar Chubb
whose address is 4601 Chestnut Avenue, Camp Hill, PA 1:7011
declare that this is,my Last'Will and Testament and I revoke all previous wills.
I am not currently married.
I have four child(ren)living, whose vital information is,as follows:
Name Addrtw Date of Birth
Lee Ann Trayer Marysville, PA 6-20-60
Kelly Lynn Hoon New Cumberland, PA 3-29-62
Clarence Lamar Chubb Etters, PA 1-20-63
Kristen Kay Pool Mechanicsburg, PA 3-22-68
1 have gratidchild(ren)living, whose vital.information.is:as follows.,
Nawe Adtb Date of Jill
Page '
of pages Testator's initial
I make the following specific gifts:
To my son, Clarence Lamar Chubb I leave all my tools
To my daughter, Lee Trager, I leave the blue kitchen table
To my daughter, Kristen Kay Pool, I leave the wall clock in the living room
To my daughter, Kelly Lynn Hoon I:leave the remainder of my real and personal
property.
Kelly Lynn Hoon will distribute any additional personal items according to my wishes.
Page,:) of .. .... pagges Testator's initials
....
....... ... ................. ........ ................... ................
i
2
E
I give all the rest of my property,whether real.or personal, wherever located.,
to Kelly Lynn Hoon
my Daughter
or if not surviving; to
my
All beneficiaries named in this will must survive me by thirty(30) days to receive any gift
under this will. If any beneficiary and I should die simultaneously, I shall be conclusively
presumed to have survived that beneficiary for purposes of this will.
I appoint Kelly Lynn Noon
my Daughter
of New Cumberland, PA
as Executor, to serve without bond. If:not surviving or otherwise unable to serve.,
I appoint
my
of
as Alternate Executor, also to serve without bond. ;In addition to any powers, authority, and
discretion granted by law,I grant such Executor or Alternate Executor any and all. pourers to
perform any acts,in.his or her sole discretion and without court approval,for the management
and distribution of my estate, including independent administration of my estate.
[THE RESTOF THIS PAGE IS LEFT INTENTIONALLY FLANK]
i
Page ,y of pages Testator's initials
I publish and sign thisLast Will and Testament; consisting of typewritten
Pages, on 6:4 3- t and declare that I do so freely, for the
purposes expressed, under no constraint or undue influence,:and that I am of sound mind
.and of legal age.
% rf? .r
cr r— y
Signature of Testator _ Printed Name of Testator
We,the undersigned,being first'swom on.oath and under penalty ofper}ury, state that:
On in the presence of of us,the above-named
Testator published and signed this Last Will and Testament anti-thein at Testator's request,
and i.n.Testator's presence, and in each other's presence, we all signed below as witnesses,
and we declare that,tee the fest of our knowledge;the Testator signed this.instrument.freely,
under no constraint or undue.in-fluence, anis is of sound mind and legal age.
:Signature of Witness Signature of witness
Printed N"oMfitness - Printed Name of Witness
a 4
<
address of Witness .Address cif Witness
_............................_._....._---
Signature of Witness
Printed Name of Witness
Address of Witness
i
I
Pcr
ofd pages 6., r Testator s initials'
Pa. "i
'Of _
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.............._......... ......_.................... .... ............... ..__. .... .......... ...... .w..._...... ........ . .. ....... ... ....
Notary Acknowledgment
State of
County of
On the
testator,
and the witnesses,personally came before me and,
being duly swd6idid state that they are the persons described in the above document and that
they signed the above:document in my presence as a free and voluntary act for the purposes
stated.
i.
COMMONWEALTP OF PENNSYLVANIA
Notary Public, In and for the County of NotarW S" -------
State of
MY Wnmisslon EVMS Jan.25,2011
P'OM�Ova -
A.
of Notmies
Tyly commission.expires: Notary Sea]
Pagepages Testator's initials
........... ................................. ..................................................... 1-11,11111,............;.............-..................................
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2605 N.3rd Street
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Cun b6lan l C Ala tY COurth°use
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1 C°ulth2use Sq
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C
HYNUM LAW
2608 NORTH 3RD STREET
HARRISBURG, PA 17110
PHONE [7171774-1357
FAX 17171774-0788
August 18, 2015
Cumberland County Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Suite 102
Carlisle, PA 17103
Re: Estate of Clarence L. Chubb
21-12-1177
Dear Sir/Madam:
Enclosed please find an original and one (1) copy of the Inheritance Tax Return in
the above-referenced matter. Kindly return a time-stamped copy in the enclosed
envelope.
If you have any questions or concerns, please contact our office. Thank you for
your time and attention to this matter.
Very truly yours,
Brian K. Pellner, Esquire
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