HomeMy WebLinkAbout06-23-05
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REV.1500 EX (6-00)
REV-1500
.. COMMONWEALTH OF
, PENNSYLVANIA
. ' -- .. DEPARTMENT OF REVENUE
. DEPl 280601
HARRISBURG, PA 17128-0601
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 05
0339
COUNTY CODE YEAR
NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
CLARK, CLARISSA B.
SOCIAL SECURITY NUMBER
508-07-6693
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DATE OF BIRTH (MM-DD-YEAR)
01/26/1917
DATE OF DEATH (MM-DD-YEAR)
04/03/2005
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
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~ 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Mach copy of Will)
o 9 Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise Idate of death after 12-12-82}
o 7. Decedent Maintained a Living Trust (AttachcopyofTrust)
o 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95)
o 3. Remainder Return (date 01 death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Mach Sch 01
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THIS SECTION MUST BE COMPI..ETED. AI..I..>CPRRESPONDENCEANDCONFIDENTIAL TAX INFORMATION SHOULOSE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
James D. F1o\ill'er,Jr., Esquire_____ 26 West High Street
FIR~ ~AME III Applicable) . Carlisle PA 17013
Saldls, Shuff, Flower & Lindsay ,
-..------- - ----.------
TELEPHONE NUMBER
(717) 243-6222
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
(1)
(2)
(3)
(4)
(5)
570,410.86
155,077 .80
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5. Cash, Bank Deposits & Miscellaneous Personal 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)
(6)
(7)
725,488.16
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
(9)
(10)
(8)
5,644.76
1,334.56
(11)
(12)
(13)
6,978.32
718,508.84
0.00
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
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 rninus Line 13)
(14)
718,508.84
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)
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718,508.84 X.o 45 (16)
32,332.89
16. Amount of Line 14 taxable at lineal rate
x12 (17)
17. Amount of Line 14 taxable at sibling rate
x .15 (18)
18 Amount of Line 14 taxable at collateral rate
19. Tax Due
(19)
32,332.89
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedent's Complete Address:
STREET ADDRESS
2A T Ocl(:LQr~I~
CITY Carlisle
-- ----rSTATE-..--
I PA
I ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
32,332.89
30,631.21
1,701.68
Total Credits ( A + 8 + C ) (2)
32,332.89
3. Interest/Penalty if applicable
D. Interest
E. Penalty
4.
Total Interest/Penalty ( D + E )
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
(3)
(4)
(5)
(5A)
(58)
0.00
0.00
0.00
0.00
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 + 5A. This is the BALANCE DUE.
0.00
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;.......................................................................................... 0 [K]
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 [K]
c. retain a reversionary interest; or.......................................................................................................................... 0 [KJ
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [KJ
2. If death occurred after December 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? .............. 0 [K]
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 [K]
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under pena~ies of pe~ury, I declare that 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 personal representative is based on all information of which preparer has any knowledge.
SIGN~TURE OF, P~RS~ONSI~)E !O'F~~NG RETURN
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Cornelia C. Middleton, Executrix, 300 West Willow Street, Carlisle, PA 17013
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DATE _
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For dates of death on or after 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 PS. 99116 (a) (1.1) (i)J.
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of trar
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory reql
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 twenty-one years of
or a stepparent of the child is 0% [72 P.S. 99116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal bene
The tax rate imposed on the net value of transfers to or for the use of the decedent's sibling
individual who has at least one parent in common with the decedent, whether by blood or adoptil
is 0% [72 PS. 99116 (a) (11) (ii)].
~x return are still applicable even if
i\B?n
natural parent, an adoptive parent,
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16(1.2) [72 P.S. 99116(a)(1)].
efined, under Section 9102, as an
REV-1503 EXT (6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clarissa B. Clark
FILE NUMBER
21-05-0339
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
Smith Barney Account No. 431-20597-1-2-025, Stocks
Smith Barney Account No. 431-20597-1-2-025, Preferreds
VALUE AT DATE
OF DEATH
161,887.21
2.
12,940.00
3.
Smith Barney Account No. 431-1-2-025, Closed End Fund
70,859.22
4.
Smith Barney Account No. 431-20595-1-4-025, Mutual Funds
294,576.65
5.
Smith Barney Account No. 431-20595-1-4-025, Unit Trusts
30,147.78
See attached statement for Items 1 through 5
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
570,410.86
REV-1508 EX+ (6-98)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clarissa B. Clark
FILE NUMBER
21-05-0339
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
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1. Checking Account #1169102046763, Wachovia. See attached letter
28,335.15
2. IRS, federal tax refund
347.00
3. The Patriot-News, refund
49.35
4. Miscellaneous personal property
5. Reed & Barton Francis I, Sterling Silver Flatware, 5 piece service for 8. See attached statement
2,000.00
1,344.00
6. Todd Home, refund
1,210.75
7. Smith Barney Account No. 431-20597-1-2-025, Cash Account
1,154.68
8. Smith Barney Account No. 431-20597-1-2-025, Money Market Account
102,408.81
9. Smith Barney Account No. 431-20595-1-4-025, Bank Deposits
14,917.00
10. Smith Barney Account No. 431-20595-1-4-025, Fixed Income
525.81
See attached statement for items 7 through 10
11. United Church of Christ Homes, refund of Sarah Todd Home
1,210.75
12. Roland Electric Piano. See attached statement from St. John's Episcopal Church
1,574.00
TOTAL (Also enter on line 5, Recapitulation) $
155,077.30
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clarissa B. Clark
FILE NUMBER
21-05-0339
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Auer Memorial Home & Cremation Services, Inc., funeral
The Butcher, Baker & Sandwich Maker, Inc., funeral buffet
Carlisle Barracks State Store, wine for funeral buffet
Charles Farris, funeral music
Truman Bullard, funeral music
Clergy Discresionary Fund
1,638.00
351.38
80.35
150.00
50.00
100.00
2.
3.
4.
5.
6.
B. ADMINISTRATIVE COSTS:
1 . Personal Representative's Commissions
2.
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
Stale
Zip
Year(s) Commission Paid:
Attorney Fees
2,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
4.
Street Address
City
State
Zip
Relationship of Claimant to Decedent
5. Accountant's Fees
Probate Fees
598.00
7.
6. Tax Return Preparer's Fees
B.
9.
10.
Cumberland Law Journal, Advertising Estate Notice
The Sentinel, Advertising Estate Notice
75.00
137.03
450.00
15.00
Zeigler's Movers, move furniture
Register of Wills, fee to file Inheritance Tax Return
5,644.76
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (12-03)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clarissa B. Clark
FILE NUMBER
21-05-0339
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
Pennsylvania Department of Revenue, quarterly income tax payment 131.00
2. Kevin B. Benton, C.P.A., Preparation of tax return for 2004 285.00
3. Pennsylvania Department of Revenue, 2004 income tax 270.00
4. MBNA America, credit card account 631.88
5. Sprint, telephone bill of 04/25/05 16.68
TOTAL (Also enter on line 10, Recapitulation) $
1,334.56
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clarissa B. Clark
FILE NUMBER
21-05-0339
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. Cornelia C. Milddleton, 300 West Willow Street, Carlisle, PA 17013 Daughter 718,508.84
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
1.
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00
(If more space is needed, insert additional sheets of the same size)