HomeMy WebLinkAbout08-26-15 (2) � 1505614134
EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOx 28060� INHERITANCE TAX RETURN 2 ], 1 5 0 0 6 3
Harrisburq,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYv Date of Birth MMDDYVYY
0 1 0 9 2 D 1 5 0 9 1 8 1 9 3 8
DecedenYs Last Name Suffix DecedenYs First Name MI
K A Y E R R 0 B E R T A
(If Applicable)Enter Surviving Spouse's�nformation Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
Q 1.Original Return � 2. Supplemental Return � 3. Remainder Return(date of death
Prior to 12-13-82)
� 4.Agriculture Exemption � 5. Future Interest Compromise(date of � 6. Federal Estate Tax Return Required
(date of death on or after 7-1-2012) death after 12-12-82)
� 7. Decedent Died Testate � 8. Decedent Maintained a�iving Trust _ 9.Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
� 10. Litigation Proceeds Received � 11. Non-Probate Transferee Return � 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets only)
❑ 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 T0:
Name Daytime Telephone Number
J A C Q U E L I N E A K E L L Y 7 1 7 5 4 1 5 5 5 0
First Line of Address
8 4 5 S I R T H 0 M A S C 0 U R T
Second Line of Address
S U I T E 1 2
City or Post Office State ZIP Code
H A R R I S B U R G P A 1 7 1 0 9
Correspondent's e-mail address: JACKIE@JANBROWNLAW.COM
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REGIS�EjR OF WILLS IIS�ONLY., � '
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REGISTER OF WILLS USE ONLY � :-!^j ,-.�
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ILED MMDDYYYY � t,.� -,i
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PLEASE USE ORIGINAL FORM ONLY
Side 1
(IIIIII IIIII IIIII IIIII IIIII IIII)IIIII IIIII IIIII IIIII'lll IIII
� 1505614134 1505614134 � ��-
�� �
J 1505614234
REV-1500 EX(FI)
DecedenYs Social Security Number
oecedent's Name: R 0 B E R T A • K A Y E R
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. •
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. � • � 0
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. 1 � 2 6 6 4 . � 4
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 1 3 8 9 . � 2
7. Inter-Vivos Transfers&Miscellaneous N n-Probate Property
(Schedule G) � Separate Billing Requested . . . . . . . 7. 1 1 5 6 3 8 . 4 4
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 2 1 9 6 9 2 . 2 �
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9� 1 2 0 6 6 . 6 1
10. Debts of Decedent,Mortgage Liabilities, and Liens(Schedule I) . . . . . . . . . . . . . 10. 5 8 6 3 . � 2
11. Totai Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 1 7 9 2 9 . 6 3
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 2 � 1 � 6 2 . 5 7
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. 2 � 1 7 6 2 . 5 �
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 _ � . � O 15. O . � �
16. Amount of line 14 taxable
at�inea�rate X.045 2 0 1 7 6 2 . 5 7 �6. 9 0 7 9 . 3 2
17. Amount of Line 14 taxable
at sibling rate X.12 � . 0 � 17. � . � �
18. Amount of Line 14 taxable
at collateral rate X.15 � • � � 1 g, � • � 0
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 9 � 7 9 • 3 2
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT QX
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.
SIGNATU OF PERSON RESPON LE FOR FILING RETU � DATE
� � , y �5.
ADDRESS � '
576 SPRING LANE BOILING SPRINGS PA 17007
SIG TURE OF P EPAR OT AN PERSON RESPON I LE FILING THE RETURN � D�ATE _��
A RES
845 SIR THOMAS COURT, SUITE 12 HARRISBURG PA 17109
I IIIIII IIIII'llll�IIII IIIII IIIII II�II II�I'IIIII IIIII�III IIII Side 2
� 1505614234 1505614234 J
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address: 2� 15 0063
DECEDENT'S NAME
ROBERT A. KAYER
------ -- _
_.----- ____
STREET ADDRESS
4837 EAST TRINDLE ROAD
BUILDING 4
---- -- — - -----__ __ —- --- - —_ ___ _- _ __ _ _ __ _ _ _--
CITY STATE ' ZIP
MECHANICSBURG ' PA I 17050
Tax Payments and Credits:
�� Tax Due(Page 2,Line 19) (1) 9,079.32
2. CreditslPayments
A.Prior Payments ___ _ 7,300.00
B.Discount 384.21
___ —.
(See instructions.) Total Credits(A+B) (2) 7,684.21
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) 1,395.11
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 antl: Yes No
a. retain the use or income of the property transferred ...................................................................... ❑ ❑X
b. retain the right to tlesignate who shall use the property transferred or its income ............................... ❑ ❑X
c. retain a reversionary interest ..........................................�......................................................... ❑ �
d. receive the promise for life of either payments,benefits or care. .......................................................
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... � ❑
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... � ❑
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)J.
• 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 tlecedent'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+(08-12)
pennsylvania SCHEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS 8� MISC.
INHERITANCE TAX RETURN
RESIDENTDECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
ROBERT A. KAYER 21 15 0063
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. M&T Bank savings account; Account#15004229590771 64,178.01
2. NY City Employees' Retirement System; final pension payment 633.25
3. Country Meadows; refund 3,701.19
4. NY City Employees' Retirement System; death benefit paid to estate 32,100.12
5. PA Treasury; unclaimed property 9.30
5. U.S. Treasury; 2014 income tax refund 1,729.05
6. Carlisle Regional Medical Center; refund 313.82
TOTAL(Aiso enter on Line 5,Recapitulation) $ 102 664.74
If more space is needed, use additional sheets of paper of the same size.
REV-1509 EX+(Ot-10)
pennsylvania SCHEDULE F
DEPARTMENTOFREVENUE �OINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ROBERT A. KAYER 21 15 0063
If an asset was made jointly owned within one year of the decedenYs date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A.Jeffrey A. Kayer 5 Cypress Hollow Road son
Enola, PA 17025
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 VA�UE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 8/14/02 M&T Bank checking account; Account#950984509 2,778.04 50. 1,389.02
TOTAL(Also enter on Line 6,Recapitulation) $ 1 389.02
If more space is needed,use additional sheets of paper of the same size.
REV-1510 EX+(08-09)
pennsylvania SCHEDULE G
DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ROBERT A. KAYER 21 15 0063
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 OECEDENT AND DATE OF DEATH %OF DECD�S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATfACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IFAPPLICABLE) VALUE
1. M&T Bank checking account; Account#950217588 6,706.36 100.00 6,706.36
TOD to daughter, Kristine M. Amtower
2. Edward Jones account; Account#270-18501-1-3 99,932.08 100.00 99,932.08
Beneficiaries are 3 children: Kristine M. Amtower,
James J. Kayer and Jeffrey A. Kayer
3. Gift to daughter, Kristine M. Amtower, in January 2015 6,000.00 100.00 3,000.00 3,000.00
4. Gift to son, James J. Kayer, in January 2015 6,000.00 100.00 3,000.00 3,000.00
5. Gift to son, Jeffrey A. Kayer, in January 2015 6,000.00 100.00 3,000.00 3,000.00
TOTAL (Also enter on Line 7,Recapitulation) $ 115 638.44
If more space is needed,use additionai sheets of paper of the same size.
REV-1511 EX+(OS-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ROBERT A. KAYER 21 15 0063
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman-Roth Funeral Home&Crematory, Inc. 501.71
2. Baughman Memoriais; gravemarker 495.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2, anomey Fees: Jan L. Brown &Associates 9,750.00
3, family Exemption:(If decedenYs address is not the same as claimanYs,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: R2glStef Of WIIIS 360.50
5 AccountantFees: Michael A Kunisky, CPA 300.00
6. Tax Retum Preparer Fees: ParkS& Company 305.00
7. Hoffman-Roth Funeral Home and Crematory, Inc.; death certificates 18.00
8. Register of Wills; Exemplified record copy 40.00
9. Register of Wills; additional short certificates 15.00
10. Cumberland Law Journal; legal advertising 75.00
11. The Sentinel; legal advertising �79.92
12. Register of Wills; FSA filing fee 20.00
13. USPS; certified mailing fee 6.48
TOTAL(Also enter on Line 9,Recapitulation) $ 12 066.61
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT�
INHERITANCETAXRETURN MORTGAGE LIABILITIES& LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ROBERT A. KAYER 21 15 0063
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medicai expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Pulmonary and Critical Care M; outstanding medicai bills 42.66
2. Diamond Pharmacy; outstanding medical bill 69.37
3. Care Plus Oxygen of Lemoyne; outstanding medical bill 2.64
4. Country Meadows at Home; outstanding medical bill 104.50
5. American Express; outstanding bill 42.44
6. M&T; check#0055 cleared after death 4,275.11
7. Pulmonary And Critical Care; outstanding medical bill 17.69
8. Hampden Township EMS; outstanding medical bill 72.9�
9. Cariisle Regional Medical Center; outstanding medical bills 563.16
10. Medoptions of Pennsylvania; outstanding medical bill 672.54
TOTAL(Also enter on Line 10,Recapitulation) S 5 863.02
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:
ROBERT A. KAYER 21 15 0063
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. Kristine M. Amtower Lineal 67,254.19
576 Spring Lane
Boiling Springs, PA 17007
2. James J. Kayer Lineal 67,254.19
3212 Andrea Avenue
Harrisburg, PA 17109
3. Jeffrey A. Kayer Lineal 67,254.19
5 Cypress Hollow Road
Enola, PA 17025
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
jI. 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 II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
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