HomeMy WebLinkAbout09-28-15 (2) ��`' pennsylvania 1505618403
� DEPARTMENTOFREVEN�X(03-14J
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes CounryCode Year File Number
Po Box 2soso� INHERITANCE TAX RETURN
Harrisburq,PA 17128-0601 RESIDENT DECEDENT 21 15 0 0 3 2 5
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYW Date of Birth MMDDYWY
07 17 2�14 04 14 1965
Decedent's Last Name Suffix DecedenYs First Name M�
GOETZ REBECCA J
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
GOETZ JOSEPH W
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Retum � 2. Supplemental Retum � 3. Remainder Return(date of death
prior to 12-13-82)
� 4. Agricultural Exemption(date of � 5. Future Interest Compromise(date of � 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
� 7. Decedent Died Testate � 8. Decedent Maintained a Living 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 ❑X 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
DAVID J LENOX 717 271 7175
First Line of Address
8 TRISTAN DRIVE SUITE 3
Second Line of Address
City or Post Office State ZIP Code
DILLSBURG PA 17019
CorrespondenYs email address: �aw(c�davidjlenox.comcastbiz.net �-'� �--,
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REGI_Y,Ef�Si1F WILLS,II�E ONI:�C�-
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REGISTER OF WILLS USE ONLY �"' �� �
DATE FILED MMDDYYYY ':,. ~- �� :
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DATE FILED ST F' ' f`�'t
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Side 1
� I I��I�I II��I�IIII��I�I�III�����I II��I i�lll�I�II��I��IIII I�'I 1505618403 �
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J 1505618411
REV-1500 EX
DecedenYs Social Security Number
DecedenYs Name: Goetz, Rebecca Jean
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2. 9,8 5 4 - 0 7
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.
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. 9,8 5 4 • 0?
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 5,419 • 4 0
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10.
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 5,419 • 4 0
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 4 ,4 3 4 - 6 7
13. Charitable and Governmental BequestslSec 9113 Trusts for which
an election to tax has not been made(Schedule J)............................................... 13.
14. Net Value Subject to Ta�c(Line 12 minus Line 13)............................................... 14. 4,4 3 4 • 6 7
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.o0 4 , 4 3 4 • 6 7 15. 0 - 0 0
16. Amount of Line 14 taxable
at lineal rate X .045 0 •0 0 �6• 0 -0 0
17. Amount of Line 14 taxable
at sibling rate X.12 ❑ -0 0 17• 0 -0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 -0 0 �8• 0 - �0
19. TAX DUE................................................................................................................ 19. 0 .�0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Un 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 i tru ,correct and compiete. claration of preparer other than the person responsible for filing the return is based on all information of which preparer has
an kno ledge.
SIG AT RE F PERSO RE NSIBLE FOR FILING RETURN �oseph W. Goetr ^AT
`�� Z
ADD E _
11 3 a dpiper Ct., Mechanicsburg, PA 17050
SI R F P PA OT THAN REP SENTATIVE David J. Lenox TE
? s^ � 3""
ADDRESS
8 Tristan Drive;Suite 3, Dillsburg, PA
� �I��I�I II��I�IIII��I�I�III��I��I II'II I�III�I��I II��I(I�I I��I Side 2 1505618 411 �
REV-1500 EX Page 3 File Number 21-15-00325
Decedent's Complete Address:
DECEDENT'S NAME
Goetz, Rebecca Jean
STREET ADDRESS
1133 Sandpiper Ct
CITY STATE ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
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) Q.QQ
Make Check Pa�rable to REGISTER OF WILLS AGENT.
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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:.....................:............ ❑ ❑z
c. retain a reversionary interest;or.........................................................�-----................................................ ❑ �
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?.................................................................................................................... ❑ �
3. Did decedent own an"in trust fo�' 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 ❑ ❑
contains a beneficiary designation?.................................................................................................................. X
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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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 retum 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 decedenYs 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 decedenYs 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-1503 EX+(OS-12)
SCHEDULE.B
pennsylvania STOCKS & BONDS
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Goetz, Rebecca Jean 21-15-00325
All propertyjointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 Express Scripts Holding Company(ESRX) 9,854.07
TOTAL(Also enter on Line 2, Recapitulation) 9,854.07
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule B(Rev.08-12)
REV-1571 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN
RESIDENTDECEDENT ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Goetr, Rebecca Jean 21-15-00325
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
N MBER
q. FUNERAL EXPENSES:
See continuation schedule(s)attached 3,778.90
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid
2. Attorney's Fees David J. Lenox 1,500.00
3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zio
Relationshi�of Claimant to Decedent
4. Probate Fees
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 140.50
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 5,419.40
Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.08-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Goetz, Rebecca Jean 21-15-00325
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex ep nses
1 Parthemore Funeral Home 3,778.90
H-A 3,778.90
Other Administrative Costs
2 Probate costs 140.50
H-B7 140.50
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN B E N E FI C IARI ES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Goetz, Rebecca Jean 21-15-00325
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$)
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
1 Joseph W.Goetz Spouse 100%of estate 4,434.67
7733 Sandpiper Ct.
Mechanicsburg, PA 17050
Totai 4,434.67
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro 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 sofiware only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
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PARTHEMORE Funer � & Cremation Services, Inc.
� �,�
Mr Joseph W.Goe � 7/18/2014
1133 Sandpiper Co rt �
Mechanicsburg,PA l��
For The Services of Rebecca Jean Goetz
1303 Bridge Street
P.O. Box 431
New Cumberland, PA 17070 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way
we can. Please feel free to contact us if you have any questions in regard to this statement. The following
PN:(717) 774-7721 is an itemized statement of the services,facilities,automotive equipment and merchandise that you selected
FX:(717)774-5546 when making the funeral arrangements.
www.parthemore.com
Terms Due Date Account#
Net 3J 3,'.7/2014 6917.3
_"." °,""'",��"' `..',.�.� .�.".""`"``,""..._ Description Amount
0.00
Direct Cremation 2,645.00
Gilbert W.Parthemore Memorial Service 630.00
Founder 50 Wildflower Memorial Folders 0.00
Gilbert J.Parthemore
Superviser Total Services and Merchandise 3,275.00
Stephen K.Parthemore 0.00
President;CF5P Death Notice,Harrisburg Patriot 239.40
15 Certified Copies of Death Certificate 90.00
Bruce R.Parthemore Clergy Honorarium 150.00
Pre-Need Coordinator,CPC Glass Vase of Black-Eyed Susan Flowers 60.00
Cumberland County Coroner Fee,Cremation Autharization 30.00
.."` ➢ " '�„` �.' '` � } ��` Total Cash Advances 569.40
Immediate Pay Discount-Thank you! -65.50
Professional Memberships: ���
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Directors Association i l� <
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,� , ,; �; � ,: �, � �.-
Order��j�rh� �
Goldcn Rule
TO�� $3,778.90
Payments/Credits -$3,��s.90
-Ee Balance Due $o.00
----, __
David J. Lenox
Attorney At Law
8 Tristan Drive, Suite 3, Dillsburg, PA 17019
717-271-7175 (phone)
717-271-7178 (fax)
Septembex 25,2015
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle,PA 17013
In Re: Estate of Rebecca Jean Goetz, deceased
File Number: 21-15-00325
Dear Register:
Enclosed for filing,please find an Inventory, the Inheritance Tax Return in duplicate,and the Status
report with regard to the above captioned estate.
I have enclosed an extra page 1 of the 1500. Please stamp with the time and date when Yeceived and
Yeturn to my attention. I am enclosing a self-addressed, stamped envelope foY youx use.
Thank you fox yout cooperation.
Sincexely,
David J. Len x,Esquire
DJL/saw
Encl.
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Sheryl A. Wasbers, Office Adm.: Ext. 102,Sheryl@davidjlenox.comcastbiz.net
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