HomeMy WebLinkAbout01-0534
RfV-15(lO!'X(6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT 280601
HARRISBURG, PA 17128-0601
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REV-1500
OFFICIAL USE ONLY U
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FILE NUMBER
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
NUMBER
Q5~Y
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COUNTY CODE
YEAR
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DECEDENT'S NAME (LAST FIRST, AND MIDDLE INITIAL)
QIOrk Wi\llQIY\ E-
DATE OF DEATH (MM-DD-YEAR)
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SOCIAL SECURITY NUMBER
\ql -L\2 -1iLJO
DATE OF BIRTH (MM-DD-YEAR)
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(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST FIRST AND MIDDLE INITIAL)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
A
~ 1. Original Return
o 4. Limited Estate
o o. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interesl Compromise (date of death after 12-12..a2)
o 7. Decedent Maintained a Living Trust (il.ttacl\tOP';' otTrusl)
o 10. Spousal Poverty Credit (date 01 death between 12.31-91 aM 1-1-95)
o 3. Remainder Return (date of dealh prior 10 12-13-82)
o 5. Federal Estate Tax Return Required
8. To181 Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113{A) jAttachSth OJ
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NAMWrrl d
FIRM NAME (II Applicable)
COMPLETE MAILING ADDRESS D '
IDLP Carnbl'-idse.. \1Ut:..
\-\ex'5h~ I 'PA \10':)3
TELEPHONE NUMflfR e,{}
l'i\l-) 533-10.8
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
O-CD
O-CD
O,CD
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OFFICIAL USE ONLY
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
o. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
(8)
5Lo\~.50
0,00
(11)
(12)
(131
O. C:()
(6)
OeD
(7)
D.CD
i-\q~l. loO
(9)
(10)
9. FIJC\8ral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule \)
11. Total Deductions (tolal LInes 9 & 10)
12. Net Value of Estate (line 8 minus Une 11)
5lo11,50
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election \0 tax has not been
made (Schedule J)
14. Net Value Subject to Tax {Line 12 minus line 13)
(14)
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SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x.O_ (15)
x .045 (16)
x .12 (17)
x .15 (18)
(19)
0_00
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o no
0_00
0.00
16. Amount of Une 14\axab!e at lineal rate
<.\"'<;50.0'/
17. Amount of line 14 taxable at sibling rate
18. Amount of line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS de
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CITY
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STATE
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditsJPayments
A. Spousal Poverty Credit
6. Prior Payments
C. Discount
(1)
0.0::.:;
Total Credits ( A + 6 + C ) (2)
3. InleresUPenalty if applicable
D. Interesl
E. Penalty
Total InteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enler the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
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5. If Line 1 + Line 3 is greater than Line 2, enler the difference. This is the TAX DUE.
0.00
A. Enler the inlerest on the tax due.
(5)
(5A)
(56)
6. Enler the total of Line 5 + 5A. This is the BALANCE DUE.
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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 Iransfer and: Ves
a. retain the use or income of the property transferred;................................ .........u....'m.. ....... 0
b. retain the right 10 designate who shall use the property transferred or ils income; ..................................... ...... 0
c. retain a reversionary interest; or......"....."................................ ........................................ ... ........................ 0
d. receive Ihe promise forlile of either payments, benefits or care? .................................. ................................... 0
2. If dealh occurred after December 12, 1982, did dacedent transfer property within one year of dealh
without receiving adequate consideration? ...... ...................... ........................................................ .... 0
3. Did decedent own an "in Irust for" or payable upon dealh bank account or security at his Of her dealh? . 0
4. Did decedent own an Indiyidual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ..... .................................. "................... 0 E:Y
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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Under penalties of De~llry, I declare that I have examined this return, including accompanying schedllles and statements, and to the best of my knowledge and befief, il is true, correct
and complete
Declaration of preparer other than the personai representative is based on aU information of which preparer has any knowledge.
OR FILING RETURN DATE
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DATE
ADDRESS
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For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on tile net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. 99116 (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 Ihe surviving spouse is 0% 172 P.S. 99116 (a) [1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are stH! applicable even if
the surviving spouse is the only beneficial)'.
For dales of death on or after Juiy 1,2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natura! parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. 99116(a}(1.2)J.
The tax rate imposed on the net value of lransfers 10 or for Ihe use of the decedent's Iineai beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)1.
The tax rate Imposed on the net value of Iransfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(a)(1.3)]. A sibiing is defined, under Section 9102, as ar
individual who has at least one parent In common with the decedent, whether by blood or adoption,
REV.1508EX~ (1-97)
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
V-h\\\Orf\ E.. C\OyL
FILE NUMBER
2\-0\- OOs.-oLJ
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
NUMBER
1.
'?..
3.
VALUE AT DATE
OF DEATH
DESCRIPTION
T ruStQy' ~e.:t\ VU'0 e..-n\- 'Sa\) \ c..c:.. '3
H(le. U0(. ~CXY\<,-<S .L\O\ l\L..)
No. \Q\-U.'2-1140
;c\Q4o.85
{:u l +0" \>::a.,,\!..
:nV\ no. ~c.c.cun I;-
No. \~1()-81q\q
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NQrlO1l IN\de... In-suvCHIU. 'Rek.tnd
45.5Y
k. Cab\e.. ~e.KAnd
\ce,. CD
1. \Jex\ t.OI\ 1\e.-fl..u'id
\5.00
8. \Q,S\."
LNo
Ch(A/ro\d CD \Jo\lex- t...u1omo'o\ \e...
t>-\c.)
'tfX). CO
TOTAL (Also enter on line 5, Recapitulation) $ l\C\'iRJ. LDO
Ilf more space is needed, insert additional sheefs of the same size)
- -;, Tlustar Retirement Services
TRUSfAY"o" P-.O. Box 14540
UZ Des Moines. IA 50306-3540 J
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- - PATRICIA A. SHENK \ ~
106 CAMBRIDGE DR. ,JI .
HERSHEY, PA 17033 .
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Social
Member
Planholder Name
Pl an 10
Security Number:
Check Date:
Check Number:
Benef it :
Beneficiary:
WILLIAM CLARK
FINE LINE HOMES 401(K) R
(3)00645
191-42-7740
OS/24/01
T 00005145
Death
PATRICIA A. SHENK
Beneficiary's SSN: 197-40-5990
OTH1114 TRSOM
If you have questions about this distribution
Please call: 1-800-654-1156
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Amount of Distribution
$2,940.85 Amount of Distribution
$2,940.85
Taxable Amount
$2,940.85 Check Amount
$2,940.85
The attached check is a distribution from a qualified plan under 401 (a) of the Internal Revenue Code.
This distribution is a death benefit from the above account. Any taxes withheld are based on the Taxable Amount shown
above.
We'll report this payment to the IRS and send you an IRS Form 1099-R next January. Please inform us of any change in
address or incorrect data before December 31 so there won't be a delay in receiving your IRS Form 1099.R.
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WILLIAM E CLARK
209 4TH ST 1ST FL
NEW CUMBERLAND PA 17070-2118
~~~TATEMENT OF ACCOUNTS
People dedIcated to your success.;'
1370-87919 X
STATEMENT PERIOD
FROM THROUGH
4-01-01 6-30-01 0
PAGE ." .;[..<>F."
.
o ENCT:,QS!lRES
029.40903370
0221810139.0
01721205210
01721205'260
332.05
133.47
4..65
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STATEMENT SAVINGS
PREVIOUS DEPOSITS/ WITHDRAWALS/
STATEMENT BALANCE CREDITS 2 DEBITS 2
93~.69 465.52 1,204.65
ACCOUNT: 1370-87919
INTEREST
PAID
1.40
INTEREST PAID THIS YEAR
ACCOUNT/INTEREST INFORMATION
2..80
.
DATE ACTIVITY DESCRIPTION REFERENCE
04-01 BEGINNING BALANCE
,04-30 DEPOSIT
;05-11 WTHDRWL
05-29 DEPOSIT
0,5-29 WTHDRWI.
06-29 INTEREST CREDIT
06-30 ENDING BALANCE
DEPOSITS/ WITHDRAWALS/
CREDITS DEBITS
1,200.00
1.40
***
ANNUALPERGENTAGE YIELD EARNED DISCLOSURE FROM
ANNUAL PERCENTAGE YIELD EARNED
AVERAGE DAILY COLLECTED BALANCE
INTEREST EARNED
4-01-01 THROUGH
.73%
770.14
1.40
"THE RIGHT RATES.. . SUPERIOR SERVICE. THAT'S WHAT YOU'LL FIND
AT FUr.TON. MORTGAGE cOMPANY A DIVISIoN OF FULTON BANI<'. .
. WlIETHERYOU,'RE. . BllYING YOUR E[RST HOME OR . YOUR F'OUR'l'H HOME
EULTON MORTGAGE cOMPANY . liAS. TlIEEXPERIENCEAND.RESOURCES.T.6
GET yoUTO;SETTLEl1ENTFAS'I',EFFICIENTLY AND WITHABSOLUTELl(
NO SURPRISES. . FOR MORE' INFORlfATlON 'OR TO SClIEDULEAN'"
APPOINTMENT TO MEE'I' WITH US, CALL 717~295~9034,;
OR 1~800-220-9034." . . ,
.
,DIRECT
IN'QUIRIES TO:
FULTON !lANI<
PO BOX 488'7
LANCASTER,PA 17604-4887
11~1~1~~ml ~~ ~~ I~I ~II
MP1597
WILLI AK E CLARK
C/O PATRICIA SHENK
106 CAKBRIOGE OR
HERSHEY
PA 17033-2169
WILLIAK E CLARK
C/O PATRICIA SHENK
106 CAKBRIOGE OR
HERSHEY
PA 17033-2169
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re POliCY Number: 58370 247752
~ Refund Amount: $ *****45.54
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Check Number: 58026531
Check Issued: 06-28-2001
This refund was issued for the following reason(s):
CANCELLATION CREDIT REFUND.
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Agent Name:
Agent Phone Number:
Agent Number:
If you have any questions, please contact your Nationwide representative.
R ERWIN
717-533-5579
0007249
Detach Stub Before Cashing And Keep For Your Record
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REV-1511 EX+ (12-99) .
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
f1/,/ J4/77
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FILE NUMBER
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ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: ,p
1. Tre...h ~ ~I..OSt:X Funex-o\ \\om e.- l
. 5573.50
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) \No. \ \! e.d
Social Security Number(s)lElN Number of Personal Representatlve(s)
Street Address
City State _ Zip
Year(s) Commission Paid:
2. Attorney Fees tJ\p..
3. Family Exemption: (If decedent's address is not the same as claimant's, aUach explanation)
Claimant N\l\
Street Address
City State _ Zip
Relationship of Claimant to Decedent
4. Probate Fees d Ccu (\"'/
Cu ffibalOX"\ L-\I.-\.ao
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ 5LP 11 ,!so
Debts of decedent must be reported on Schedule I.
(II more space is needed, insert additional sheets of the same size)
Stephen R. Hall, Supervisor
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II4~esd~it~~;Stteet 0.;~~lKQwn, ~~"~7036
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Statement of Services and Merchandise
May 16,2001
Mrs. Patricia A. Shenk
106 Cambridge Drive
Hersa~y, PA 17033
Services for: William E. Clark
Date of Death: April 26, 200 I
Services of Funeral Director and Staff for a Standard Service
Embalming, Other care of Deceased, Use of Facilities for Visitation,
Use of Facilities for Service or Use of Equipment for a Church
Service, General Use of Facilities, Transfer of Deceased to Funeral
Home, Hearse, Family Car, Flower Car, Acknowledgment Cards,
Register Book, Memorial Folders or Prayer Cards, and Casket
(18 Ga. Blue Steel Ext. Blue Crepe Int.) $5275.00
Subtotal Services and Merchandise
$5275.00
Cash Advances
Flowers...................................................................... .
Clergy Honorarium.......... ........... .................... ................
Certified Copies (5 @ $2 ea.).................................. ...c........
$ 238.50
$ 50.00
$ lO.OO
Subtotal Cash Advances
Total Due
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$ 298.50
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
NUMBER
I.
II.
1/\1I\lI01"<\ \=:ny\ c..\OYK..
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1. ~O\\'1~lJ+h Oav-\(
lo.~ Vcex.xw-\d?r V-,cod
B\lo\-\SbL\(31?A nCJ~~
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!;.\\\O~'DU(Sl?~ \102\..\
FILE NUMBER
R.,\ -0\ -oob:5L\
RELATiONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trusteels) OF ESTATE
dQu9,Vltex
50'10
so\')
5010
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
WI;\-
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
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TOTAL OF PART n. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert addnlonal sheets of the same size)