HomeMy WebLinkAbout05-12-05
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
REV.1500 EX + (6-00)
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FIl.E NUMB!::R
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COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INIT!AL.)
Smith, Agnes K.
DATE OF DEATH {MM-OO.YEAAj
132-16-3326
THIS RETURN MUST BE FILED IN DUPL.ICATE WITH THE
DArE OF BIRTH (MM.OQ- YEAR)
0004
NUMBER
12-10-2004
08-14-1925
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL.)
01.
04
06
09
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1
5. Federal Estate Tax Return Required
Limited Estate
3. Remainder Return (dale of death plior to 12-13-82)
a. Total Number of Safe Deposit Boxes
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o 2. Supplemental Return
O 4a. Future Irllarest Compromise (date of death after
12-12-82)
o 7. Decedent Maintained a Living Trust(Atlach
copy ot Trust)
O 10 Spousal PovertY Credit(date of death between
. 12.31-91 and 1.j.S5)
THIS SECTION MlJST BE COMPLETED: ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAIliNG ADDRESS
James D. Bogar
FIRM NAME {If ~p1icab\e)
Bogar & Hipp Law Offices
Original Return
Decedent Died Testate (Attach
copy of Will)
Litigation Proceeds Received
o 11.Etectlon to tax under Sec. 9113{A){A'itach SCl-.O)
TELEPHONE NUMBER
717-737-8761
One West Main Street
Shiremanstown, PA 17011
None
OFFICIAI.-.lJSE ONLY
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
(1)
(2)
(3)
(4)
(5)
(6)
(7)
58,499.75
39,097.58
None
None
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,
4. Mortgages & Notes Receiveble (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Persona! Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property
(Schedule G or L) 0 Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
28,482.27
1,874.70
97,096.29
None
(8)
(9)
(10)
11. Total Deductions (total Lines 9 & 10)
(11)
12. Net Value of Estate (Line 8 minus Line 11)
(12)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has
not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate, 0.00 x .00 (15)
z or transfers under Sec. 9116(a)(1.2)
0 (16)
>= 16. Amount of Une 14 taxable at lineal rate 164,336.65 x .045
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0- 17. Amount of Line 14 taxable at sibling rate 0.00 x .12 (17)
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0
0 18. Amount of Une 14 taxable at collateral rate 0.00 .15 (18)
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I- 19. Tax Due
(19)
20.0
;~,>il;+\;, ;'\;'~W;jl~~'<\~;4,t>~EI'E:StJRE':td'4N$WER ALL QuEStloNs:~f R'EVE'FlSEi$io$:ANOr~'~qH~~I(;MATH<<'; ':, ;"",
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
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194,693.62
30,356.97
164,336.65
0.00
164,336.65
0.00
7,395.15
0.00
0.00
7,395.15
Copyright 2.002 form software only The Lackner Group, Inc.
Form REV.1500 EX (Rev, 6-00:
Decedent's Complete Address:
STREET ADDRESS
X
CITY Mechanicsburg
ISTATE PA
I ZIP 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
7,395.15
6,583.50
346.50
Totai Credits (A + B + C)
(2)
6,930.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
TotallnteresVPenalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(3)
(4)
(5) 465.15
(SA)
(5B) 465.15
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;...............................~...
c. retain a reversionary interest; or.................. ...... ............................... ..... .................... ...... .........................
d. receive the promise for life of either payments, benefits or care? .............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ........................................... ..................................... ...... ................ ..............
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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? ...................................................................................... ............................. [!J 0
IF THE ANSWER TO ANY OFTHE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjUIY, I declare that I nave examined tnis retum, including accompanying SChedules at'ld stalements, and to the best of my knowledge and belief, it is true. correct
and
COn"IPlete. Declaration of preparer other than the personal representative is based on aU informatiOl'l of which preparer nas any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETURN ADDRESS
Kathleen S. Jordan
OATE
2 Mayflower Avenue
Hull, MA 02045
One West Main Street
Shlremanstown, PA 17011
S/lJi!O<J
DATE
51&105'
DATE
5/&/0!;
SIGNATURE OF PERSON RESPO
Barbara A. Smith
~().~
ADDRESS
101 Oneida Road
Camp Hill, PA 17011
ADDRESS
For dates of death on er July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% {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 transfe
{72 P .5. S9116 {a} {1.1} {Ii}). The statute does not exemot a transfer to a surviving spouse fron
of assets and filing a tax return are still applicable even if the surviving spouse is the only bene
For dates of death on or atter July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty.one years of ~
natural parent, an adoptive parent, or a stepparent of the child \s 0% [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 ben
~91'6 1.2){72P.S.~9116(a)(')].
() RPb
ie is 0%
jisclosure
,fa
~.14
P.S.
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings j~ is
defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
~~V_48.5 ex+ (1.92)
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SAFE DEPOSIT BOX
INVENTORY
COMMONWEAlTH 0' PENNSYLVANIA
OEPARTMeNT OF REVeNue
INHERITANO TAX DIYISION
DEPT. 280601
H....RRISBURG, PA 17128~601 Please Print or Type
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS
COUNTY CODE FILE NUMBER SOCIAL SECURITY OR DEATH CERTIFICATE NUMBER
DATE OF DEATH
December 10, 2004
(STATE}
PA
DECEDENT'S NAME {LAST, FIRST, MJODlE}
Smith, Agnes K.
ADDRESS OF DECEDENT (STREET) (CITY}
4833 E. Trindle Road Mechanicsbur
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
(NAME)
James D. Bogar, Esquire
(STREET ADDRESS) (CITY)
One West Main Street Shiremanstown
NAME. ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING
C1. (NAME} (RELATIONSHIP)
James D. Bogar, Esquire None
(STREET ADDRESS) (CITY)
One West Main Street Shiremanstown
b. {NAME} (RELATIONSHIP)
Barbara A. Smith Daughter
(STREET ADDRESS) (CITY)
101 Oneida Road Camp Hill.
c. (NAME) (RELATIONSHIP)
Kathleen S. Jordan Dauohter
(STREET ADDRESS) (CITY)
2 Mayflower Avenue Hull
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
(NAME)
M & T Bank
(STREET ADDRESS)
(CITY)
Carlisle
DATE AND TIME OF LAST ENTRY
ll.l~-l \'0'1
TITLE UNDER WHICH BOX S REGISTERED
p.'w<.<;, .~
100 S. Spring Garden Street
I NAME OF PERSON MAKING LAST ENTRY
~~j.,;<",i\..~~
DATE OF CONTRACT TO RENT BOX NUMBER OF BOX
5h \'1.'" ~
NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX
cr. (NAME)
b. (NAME)
~d. c-t'4t.~ 1\ .~ -K..
(STREET ADDRESS)
\ (;) \ "~"t.0, j~d
(STATE)
G........ ~~ p,~
NAME AND TITLE OF EMPLOYE TAKING THE INVENTORY
Wi.t~\. ~~k.:l.. Ju.Jc","L~';'4'~
(STREET ADDRESS)
(CITY)
(ZIP CODE) (CITY}
nOLI
WAS A WILL IN THE BOX? DYES .'ftlNO If yes, cr. Date.n will:
b. Name crnd crddress of persona' representative, if named in the will
(NAME)
(STREET ADDRESS)
(CITY)
c. Name and address of ottorney, if ony
(NAME)
(STREET ADDRESS)
(CITY)
(STATE}
PA
(STATE)
PA
(STATE)
PA
(STATE)
~A
(STATE)
PA
(STATE)
(STATE)
{STATE)
(ZIP CODE)
17055
{ZIP CODE}
17011
(ZIP CODE)
17011
(ZIP CODE)
17011
(ZIP CODE)
02045
(ZIP CODE)
17013
(ZIP CODE)
(ZIP CODE]
(ZIP CODE}
Pege \ ef
SAFE DEPOSIT BOX INVENTORY
INSTRUCTIONS
(1) Cash: Report totol only.
(2) Stacks: List in deteil every common or preferred certificete, werrent or ether rights found in box. Stocks ere
to be designated by name or company, certificate number, date of certificate, name in which stock is registered,
end number of she res end dess of stock.
(3) Obligations of U. S. Government: Number of items, dete of issue, fece velue, names in which registered
end type of ownership, I.e., iointly held, peyeble on death, etc.
(4) Bonds: Designate by neme, emount, seriel number, or other designation. (Beerer Bonds)
(51 Bank and Savings and Loan Passbooks: Stete neme of depositor, number ef book, last date eppearing in
book, neme of benk and brench, end be Ie nee.
(6) Jewelry, Coins, Stamps, Manuscripts, etc: List end describe es fully es possible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List end describe es
fully es possible.
IS) All other contents.
ITEM
NO.
ITEM DESCRIPTION
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....
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PRINT
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PRINT TITLE CHECK A. PRQPRIATE sOX;
M~r~' .~,,-,tQ< e:S~9~ o Executo;\trix) OAdministrator(trix)
, ,- '. ~..4--1A.J :JUt.t., Estate Representative 0 Joint owner of safe deposit box
NOTI: At1ach additional 81f2" x 11" .sheet (5) if necessary or use duplicates of this page of form.
Rev-1503 EX+ (H8)
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SCHEDULE B
STOCKS & BONDS
COMMONWeALTH OF PeNNSYLVANIA
INHERITANCE TAX ReTURN
RESIDENT DECEDENT
FILE NUMBER
21-05-0004
ESTATE OF
Smith, Agnes K.
All property jointly-owned wIth right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 G E Mutual Fund - S & S Program Mutual Fund, 45.44 33.117.58
Account No. 097-2000686234
2 162.5 shares of GE Stock - Value as of date of death 36.80 5.980.00
TOTAL (Also enter on Line 2, Recapitulation) 39.097.58
(If more space is needed, additional pages of the.same size)
Copyright (c) 2002 form software only The Leckner Group, Inc.
Form PA-1500 Schedule B (Rev. 6-98)
Rev-1S08 EX+ (6-98)
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
AESIDENTOECEOENT
ESTATE OF
Smith, Agnes K.
FILE NUMBER
21-05-0004
IncllJde the proceeds of litigation and the date the proceeds were received by the estate.
All property jolntly-owned with the right ollurvlvorshlp must be dr.dOlled on schedule F.
ITEM
NUMBER DESCRIPTION
1 Com cast Financial Agency - Refund
VALUE AT DATE
OF DEATH
50.40
2 Cornerstone Federal Credit Union Account No. 2153-01 - Savings Account No.
2153-01, date of death value $3,470.02
3.470.02
3 Cornerstone Federal Credit Union Account No. 2153-09
1.090.58
4 Country Meadows Associates - Refund
4.473.78
5 M& T Bank, Certificate of Deposit Account No. 031003910368628 - Date of death
balance $7,507.40, accrued interest $43.89
7.551.29
6 M& T Bank, Checking Account No. 2679025227 - Date of death balance -$3,099.89,
accrued interest $0.04
-3.099.85
7 M&T Bank, Checking Account No. 9836501677 - Date of death balance $10,790.33,
accrued Interest $0.60
10.790.93
8 M& T Bank, Savings Account No. 015004200827151 - Date of death balance
$68,141.15, accrued interest $42.95
68.184.10
9 Pinnacle Health System - Refund
5.00
10 Union Central Life Insurance Co. - Monthly Annuity Payment
1.976.26
11 Western Southern Life Assurance Co. - Monthly Annuity Payment
1.043.78
12 Personal Property - Value as per attached appraisal
1.560.00
TOTAL (Also enter on Line 5, Recapitulation)
97.096.29
(If more space is needed, additional pages of the.same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule E (Rev. 6-98)
It
CORNERSTONE
Federal Credit Union
P.O. Box 1181. 5 East Gate Drive. Carlisle. PA 17013
Telephone (717) 249-1661 FAX (717) 249-8208
www.comerstonefcu.org
Member founded - Service based
James Bogar
One West Main St
Shiremanstown, P A 17011
RE: The Estate of Agnes K. Smith
Mr. Bogar:
At the time of her death, Agnes K. Smith was the sole owner of account 2153
which included both a savings and a second savings account. The primary savings
account was opened on September 4, 1987 and the second savings account was opened
on July 6, 1988. As of January 4,2005 the account was closed by Kathleen Jordan and
Barbara Smith. The balances of the account as of December 10, 2004 were as follows:
Account Number
Type
DOD Balance
Bal as of close date 1/04/05
2153-01
Savings
$3470.02
$3479.15
2153-09
Savings
$1090.58
$1093.33
If you require any further information, please call me at 717-249-1661 ext 240.
Sincerely:
~;~~rLLr
JeI'\Perry
,) \
Enclosures: Statement copies on interest activity on account 2153.
MEMBER SAYINGS ACCOUNTS FEDERALLY INSURED To $100,000 By THE NAllONAL CREDIT UNION ADMINISTRATION
CORNERSTONE FEDERAL C.U.
P.O BOX 1181
CARLISLE PA 17013
(717) 249-1661
IZ-Member Inquiry Date Printed: 01/11/2005
Member: 2153 - AGNES K SMITH
SSN: 132-16-3326
Date Range: 10/01/2004 - 01/11/2005 Transaction History
Share Record: 01 - REGULAR SHARE ACCOUNT ;:nU1nS3
Tran Post Transaction Chk Post Ending
No. Date Description No. Srce Amount Fee Balance
2 10/01/04 DIVIDEND 30 8.72 .00 3470.02
3 01/01/05 DIVIDEND 30 8.75 .00 3478.77
4 01/04/05 DIVIDEND 1 .38 .00 3479.15
5 01/04/05 TRANSFER IN 1 1093.45 .00 4572.60
CLOSE 09 AND TRANSFER TO 01
6 01/04/05 CLOSE ACCOUNT 15348 1 -4572.60 .00 .00
End
CORNERSTONE FEDERAL C.U.
P.O BOX ll8l
CARLISLE PA l70l3
(71. 7) 249-1.66l
IZ-Member Inquiry Date Printed: Ol/ll/2005
Member: 2153 - AGNES K SMITH
SSN: l32-l6-3326
Date Range: lO/Ol/2004 - Ol/ll/2005
Transaction History
Share Record: 09 - SPECIAL SAVINGS l
Tran Post Transaction Chk Post Ending
No. Date Description No. Srce Amount Fee Balance
2 lO/Ol/04 DIVIDEND 30 2.74 .00 l090.58
3 Ol/Ol/05 DIVIDEND 30 2.75 .00 l093.33
4 Ol/04/05 DIVIDEND l .l2 .00 l093.45
5 Ol/04/05 CLOSE ACCOUNT l -l093.45 .00 .00
CLOSE ACCOUNT AND TRANSFER TO Ol
End
,
"
fmM&I'Bank
499 Mitchell Road, MiII,boro, DE 19966 Mail Code DE-MB-12
Phone (888) 5024349
Fax (302) 934-2955
January 14,2005
James D. Bogar
Attorney At Law
One West Main Street
Shiremanstown, Pennsylvania 17011
Re: Estate of' Allnes K. Smith
Social Security: 132-16-3326
Date of Death: December 10,2004
Dear Sir or Madam:
Per your inquiry dated Janwny 04, 2005, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
1.
Type of Account
Checking Account
Account Number
2679025227
Ownership (Names of)
Agnes K Smith
Kathleen Jordan,Barbara A Smith, POA's
Dorothy Smith, William P Smith, POA's
Opening Date
9/1/75 Closed 1/4/05
Balance on Date of Death
-$3,099.89 (negative balance)
Accrued Interest
$
0.04
Total
-'3,099.85
2.
Type of Account
Checking Account
Account Number
9836501677
Ownership (Names of)
Agnes K Smith
Kathleen Jordan,Barbara A Smith, POA 's
Dorothy Smith, William P Smith, POA's
Opening Date
10/19/04 Closed 1/4/05
Balance on Date of Death
$10,790.33
Accrued Interest
$
0.60
Total
"$Tifi90~93"""'-""'"'' .......................................................
3.
Type of Account
Savings Account
Account Number
015004200827151
Ownership (Names oj)
Agnes K Smith
Kathleen Jordan,Barbara A Smith, POA's
Dorothy Smith, William P Smith, POA's
Opening Date
12/6/95 Closed 1/4/05
Balance on Date of Death
$68,141.15
$ 42.95
Accrued Interest
Total
$68,184.10
4.
Type of Account
Certificate of Deposit
Account Number
031003910368628
Ownership (Names oj)
Agnes K Smith
Kathleen Jordan,Barbara A Smith, POA 's
Dorothy Smith, William P Smith, POA's
Opening Date
8/12/99 Closed 1/4/05
Balance on Dote of Death
$7,507.40
Accrued Interest
$ 43.89
Total
$7,551.29
Please be advised, there was no safe deposit box found for the above decedent
For further account information, regarding ownership, closures andlor reimbursement of funds, etc., please call the
Stonehedge Office # 717-240-4524.
Sincerely,
'~o17~cV
Nancy Clagett
Records Management
m1M&TBank
2679025227
M&T SELECT WITH I r-TEREST
N)V, 20 -DEC. 17 I 2004
1 OF 1
00 3 04345M M 021
AG NlS K SMITH
RM 508
4833 E TRI IDL RD
MECHAKICSBURG PA 17050
I t-TEREST PAID YEAR TO DATE
194.43
5TO ~EDGE
BEGtNN:l'G
81\LA N::E:
0.04
802.74
00.
1
AMJU "1 ro.
3 625.00 3
AMOU 1-1
4 370.63
t':OSTIl'G
TE
ACTIVITY
OE:P:0s::P'S/~-rrEiRES~: ;:9HECKS").. OTHER
T -. 'IT TRA
11-20-04 BEGINI\Il'G BALAl'CE
11-30-04 CHECK WMBER 7488
12 -09 -04 CHECK WMBER 7490
12-09-04 IN5UFFICIEl-T FUID5 FEE-CHECK NJMBER 7490
12 -13 -04 TELLER TRA l'iSFER CREDIT
12-13-04 CHECK NJMBER 7492
12-14 -04 PREPAID LEGAL PAYMEJ:\T
12-17-04 It-TEREST E'AYME!\T
100.00
3,770.63
32.00
sa02.74
702.74
3,099.89-
3,625.00
500.00
16.00
25.11
9.11
9.15
0.04
E!>Dr I'G 81\L1\ KE
$.15
c'E{ECKS:<PAro SU~R~:
7488 11-30-04
100.00
7490* 12 -09 -04
3,770.63
7492* 12-13-04
500.00
ANNJAL PERCE"TAGE YIELD EARKED'" 0.10 !II
Il-PRESSED BY THE SERVICE YOU RECEIVED AT M&T? IF YOU'D LIKE TO WMI ~ATE AN M&T
BAN< EI'-PLOYEE FOR EXCEPTIOt-AL CUSTOMER SERVICE, PLEASE COMPLETE OUR M&T SERVICE
EXCELLE N:E FORM AT WWW.~A~TBAI-K.COM!EXCELLE N:E. WE APPRECIATE YOUR FEEDBACK!
M&T'S WEBSITE IS A POWERFUL RESOURCE THAT CA N HELP YOU MAKE I N:ORMED FI I-A N:IAL
DECISIOt-S. YOU CANACCESS YOUR ACCOUI-TS, USE PLANN:l'G TOOLS, OPEN AN ACCOUi'T,
OR FI N) YOUR r;EAREST M&T BM N:H OR ATM. VISIT WWW.MA!.DTBA I-K. COM TODAY!
JmnesD.BogM,Attomey
1 West Main St.
Shiremanstown, P A
William G. Rowe Appraiser
211 N. Old Stone House Rd.
Carlisle, PA 17013
Re: Estate of Agnes Smith
Personal Property Appraisal
Harrisburg Storage
165 Lmnont St.
New Cumberland, P A
Cherry Hutch
Lift Chair
2 Pc. Rattan table & chair
Sofa
Secretary
T.V.
Folding Bookcase
Bookcase
Armoire
Sock chest
CMd Table
Metal rack
Night Stand
Books
Misc. House WMes
Total
April 3, 2005
$450.00
125.00
115.00
125.00
215.00
85.00
45.00
125.00
185.00
20.00
10.00
10.00
25.00
5.00
20.00
$1560.00
~~ ~~
William G. Rowe
Rev-1510 EX+ (6-98)
.
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALT1i OF PENNSYLVANIA
INHERIT...v.lCE TAX RETlJRN
RESIDENT OECEDENT
Smith, Agnes K.
FILE NUMBER
21-05-0004
ESTATE OF
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECO'S TAXABLE
EXCLUSION
NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COpy OF THE DEED FOR REAL ESTATE.
1 Union Central Insurance and Investments - 38.013.10 38.013.10
Annuity Contract No. A64002220S
2 Western-Southern Life Assurance Company - 20.486.65 20.486.65
Annuity Contract No. W0020539249
TOTAL (Also enter on Line 7, Recapitulation) 58.499.75
(If more space is needed, additional pages of the.same size)
Copyright (c) 2002 form software only The Lackner Group, Inc,
Form PA-1500 Schedule G (Rev. 6-98)
rAN 12 2el05 15:03 FR UNION CENTRAL
",.....
513 595 2127 TO 917177372086
,.-..,
Facsi.~ile
Transmission
P.01/01
TII. Uol.. C..tnJ
Life JMurance Company
Cincinollli Obio
(m) '9' 2200
www.unioneemnJ.com
lalUraaee ad lIl'veltbleatt
TO: Bonnie FAX: 717-737-2086
FROM: Becky V onderbaar FAX: 513-595-2127
DATE: Januat)' 12, 2005 TIME: 2:44 PM
PAGES:
(l1ldllllillc 1
lel4 ,heet)
RE: A64002220S
Agnes K. Smith
COMMENTS:
The value of Policy A64002220S as of the dale of death of the owner, 12-10-04, is $38,013.10.
Confidentiality Notice
The p48eS comprising lhis facsimilo lI'lIDsmlSsion contains collfidcnliaJ inf01'll1ltt!0n from The Union CcnlrII Life In.unnce
Company. This information is inlellded sOlely for U50 by rhc Individual or entity named above.. the recipient h=f. If you are
notllle lnwulod recipien~ b. awere that auy diacloaure. copying, distribution or use of the conlClllS oftllis traIlsmission is Slrictly
prohibited. If you bov. rcocived this traIlsmis$ion in mor, pica. notifY '" immediately by calling (800) 82j.15S1 so wo may
arranv;c to retrieve this tnnsmiu:ian at no eoJt to you.
s....mcsprvdu"''-d iIllOudlCilriUoo_lIle..
...bJidWy 0(1111 Uoioa CaOlIIlJl'o """"""'CcmpanY.
1876 Way"", Road. c;.ci...~. Obiomco. (lI3) 59l-26OO.
** TOTAL PAGE.01 **
(II
Western-Southern Ufe~
01/21/2005
JAMES D BOGAR
ATTORNEY AT LAW
ONE WEST MAIN STREET
SHIREMANSTOWN PA 17011
Subject: Annuity Contract W0020539249 - AGNES K SMITH
Western-Southern Life Assurance Company
Dear Mr. Bogar:
Thank you for contacting the Western-Southern life Assurance Company about the
annuity contract of Agnes K. Smith.
We received your coorespondence dated January 12, 2005 requesting additional
information for the purpose of preparing the Pennsylvania Inheritance Tax Return.
. hope the following information is helpful:
. Contract(s) Owned - W0020539249
. Approximate Value of Annuity as of 12/10/2004 - $20,486.65
. Investment Basis of Annuity as of 12/10/2004 - $19,049.20
. Investment Date - 02/08/2001
. Owner Named - Agnes K Smith
. The initial funds were rolled over to us from M&T Securities on 02/08/2001.
If you have questions, please call your sales representative or our Annuity Operations
Department at 1-800-926-1702. A representative will be happy to assist you.
Sincerely,
J YATES
Annuity Administrator
Annuity Operations Department
Member, Western & Southern Financial Groupilt
Annuity Operations Group. PO Box 2918. Cincinnati, Ohio. 45201-2918
Phone (800) 926-1702. Fax (513) 629-1799
REV-1151 EX+(12-99)
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Smith, Agnes K.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-05-0004
ESTATE OF
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 8,871.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Kathleen S. Jordan Barbara A. Smith
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address 2 Mayflower Avenue
City Hull Stale MA Zip 02045
-
Year(s) Commission paid 8,520.00
2. Attorney's Fees Bogar & Hipp Law Offices 8,520.00
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 314.00
5. Accountanfs Fees
6. Tax Retum Preparer's Fees
7. Other Administrative Costs 2,257.27
TOTAL (Also enter on line 9, Recapitulation) 28,482.27
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Scheduie H (Rev. 6-98)
Rev-1502 EX+(5-98)
.
SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX REnJRN
RESIOeNTOECEDENT
Smith, Agnes K.
FILE NUMBER
21-05-0004
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Myers-Harner Funeral Home. Funeral Bill
7.821.00
2
SI. Patrick's Cemetery - Grave Opening
1.050.00
Subtotal
8.871.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
Rev-1502 EX+ (6-98)
.
SCHEDULE H.B7
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALn-l OF PENNSYLVANIA
INHERITANce TAX RETVRN
ReSIOENTOeCEDENT
ESTATE OF
Smith, Agnes K.
FILE NUMBER
21-05-0004
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Comcast. Final Bill
50.40
2
Comcast - Final Bill
50.40
3
Harrisburg Storage Company - Personal Property Storage
994.86
4
Linden Hall Antiques - Personal Property Appraisal
65.00
5
RESERVES: - Costs to conclude administration of Estate including filing fee for Pa.
Inheritance Tax Return, Inventory and First & Final Account; preparation of
Personal and Fiduciary Income Tax Returns
850.00
6
Space Mart Self Storage - Personal Property Storage
165.36
7
United Parcel Service - Next Day Air to Co-Executor (4)
81.25
Subtotal
2.257.27
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B? (Rev. 6-98)
R.v-1512 EX+ (6-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Smith, Agnes K.
FILE NUMBER
21-05-0004
ESTATE OF
Include unrelmbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1 Capital One - Credit Card - Final Bill
VALUE AT DATE
OF DEATH
1.359.00
2 Internal Revenue Service. 2004 Personal Income Tax
439.00
3 J C Penney - Credit Card - Final Bill
31.80
4 MSHMC Physicians Group. Medical Bill
44.90
TOTAL (Also enter on Line 10, Recapitulation)
1,874.70
(If more space is needed, additional pages of the_same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule I (Rev. 6-98)
REV 1513 EX (9-00)
*'
+
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DEceDENT
ESTATE OF FILE NUMBER
Smith, Agnes K. 21-05-0004
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not UstTruatee(a)
I. TAXABLE DISTRIBUTIONS [include outright sfrousal
C1istributions, and ransfers
under Sec. 9116(.)(1.2)]
1 Kathleen S. Jordan Daughter
2 Mayflower Avenue
Hull, MA 02045
2 Barbara A. Smith Daughter
101 Oneida Road
Camp Hill, PA 17011
3 Dorothy P Smith Daughter
3223 Mulberry Drive
Clearwater, FL 33761
4 William P. Smith, Jr. Son
140 Hunter Lake Drive, Unit "F"
Oldsmar, FL 34677
Total
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule J (Rev. 6-98)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BOGAR JAMES D
1 W MAIN STREET
SHIREMANSTOWN, PA 17011
____uu lold
ESTATE INFORMATION: SSN: 132-16-3326
FILE NUMBER: 2105-0004
DECEDENT NAME: SMITH AGNES K
DATE OF PAYMENT: 05/12/2005
POSTMARK DATE: 05/1 2/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 12/10/2004
NO. CD 005316
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $465.15
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
CHECK# 110
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
$465.15
GLENDA FARNER STRASBAUGH
REGISTER OF WillS