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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 260601
HARRISBURG. PA 17126-0601
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NUMBER
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SMITH, 1. JEFFREY
182-40-9446
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
11/23/2004
OS/28/1947
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL)
2. Supplemental Return
D 3 Remainder Return (dale of death prior to 12-13-82)
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THIS SECTION MUST BE COMPtETEO. ALL."
AME
Hillary A. Dean, Esquire
IRM NAME (If applicable)
Martson Deardorff Williams & Otto
4a. Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trusl)
10. Spousal Poverty Credit (dale of death between
12-31-91 and 1-1-95
'ilfONDENCE AND cd
5 Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11.Eleclion 10 tax under Sec. 9113(A) (AttachSch 0)
TIAL TAX INFORMATION Sk(1)Ull BE DIRECTED TO:
COMPLETE MAILING ADDRESS
ElEPHONE NUMBER
717/243-3341
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
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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)
6. 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)
9. Funeral Expenses & Administrative Costs (Schedule H)
9,039.10
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10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
(11)
12. Net Value of Estate (Line B minus Line 11)
(12)
9,039.10
13. Charitable and Governmental Bequests/See 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)
9,039.10
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, 9,039.10 x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
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~ 17.Amount of Line 14 taxable at sibling rate x .12 (17)
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~ 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
0.00
0.00
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
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lilECHECK MAT~"'M \
Copyright 2000 form software only The Lackner Group. Inc.
Form REV-1500 EX (Rev. 6-00)
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Decedent's Complete Address:
STREET ADDRESS
291 Smith Road
CITY
Shippensburg
I STATE PA
I ZIP 17257
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
0.00
Total Credits (A + B + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty (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 + 5A. This is the BALANCE DUE.
(3) 0.00
(4)
(5) 0.00
(SA)
(58) 0.00
Make Check Payable to: REGISTER OF WILLS, AGENT
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? ....... .................................... .......... .................................... ........ ..................
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 Ufe 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?................. .......................................... ............................................. D
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
preparer other than the personal representative is based on all information of which pre parer has any knowledge
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Susan D. Smith
DATE
291 Smith Road
Shippensburg, PA 17257
Oir03 -OS-
ADDRESS
DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
Hilla ~. Dean, Esquire
ADDRESS
DATE
10 East High Street
Carlisle, PA 17013
(J(P -03-or
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 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%
[72 P.S. ~9116 (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 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 twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116 (a) (1.2)].
The tax rate imposed on the net value oftransfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116
1.2) [72 P.S. ~9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [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.
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SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
I FILE NUMBER
21 - 05 - OSOI
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price
at which property would be exchanged between a willing buyer and a wimng seller, neither being compelled to buy or sell, both having
reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on
schedule F.
SMITH, J. JEFFREY
ITEM
NUMBER
1
DESCRIPTION
VALUE AT DATE OF
DEATH
9,039.10
Undivided one-third interest in mountain land containing 4.45 acres situate in Penn Township,
Cumberland County, being Parcel No. 31-12-0328-061. See Deed dated February 27, 1974, recorded in
Cumberland County, PA, Deed Book "N", Volume 25, Page 99 (copy attached). Value is one-third of
2004 assessed value of 24430 x common level ratio of 1.11 ~ 27117.30.
TOTAL (Also enter on Line 1, Recapitulation)
9,039.10
REV-1513 EX+ (9-00)
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SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SMITH, J. JEFFREY
I FILE NUMBER
21 - 05 - 050 I
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE
nn Nn"
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1 Susan D. Smith Spouse Entire residue
291 Smith Road
Shippensburg, P A 17257
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
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LANDIS a: BLACK
:AFlLISLE.p"NNSYLVAN[A
LAST WILL AND TESTAMENT
OF
J. JEFFREY SMITIl
I, J. JEFFREY SMITIl, of Penn Township, Cumber land County, Pennsyl-
vania, declare this to be my Last Will and Testament and revoke any will or
codicil previously made by me.
ITEM I: I direct that all my just debts, funeral expenses and
administra~xpenses including my grave marker shall be paid fyom the assets
of my estate, as soon as practicable after my decease.
ITEM II: I devise and bequeath the residue of my estate, of every
nature and wherever situate, to my wife, Susan D. Smith, providing she shall
survive me by thirty (30) days.
ITEM III: Should my wife, Susan D. Smith, predecease me or die on
or before the thIrtieth day following my death, I devise and bequeath the resi-
due of my estate, of every nature and wherever situate, to my issue, per
stirpes, living on the thirty-first day fOllowing my death.
ITEM IV: I direct that all taxes that may be assessed in conse-
quence of my death, of whatever nature and by whatever jurisdiction imposed,
shall be paid from my residuary estate as a part of the expense of the adminis-
tration of my estate.
ITEM V: Should my wife, Susan D. Smith, predecease me, I appoint
Richard Decker and Betty Decker, his wife, of York Springs, Pennsylvania, or
the survivor of them, guardians of the persons of my minor children.
ITEM VI: I nominate and appoint the First National Bank of
Shippensburg, Pennsylvania, Trustee of the share of any beneficiary who may be
a minor. The income andlor principal of said trust l'lIBy be accumulated or
expended for the maintenance, education and support of such beneficiary as my
trustee in its discretion may detennine; and my trustee, in the expenditure of
income and/or principal for such purposes, may, in its discretion, apply the
same directly without the intervention of a guardian or pay the same to any
person having the care or control of said beneficiary or with whom the benefi-
ciary resides, without duty on the part of the trustee to supervise or inquire
into application of the funds by any person to whom any payment is made. The
balance of such income and/or principal shall be paid to such beneficiary upon
reaching majoTity, or to such beneficiary's estate in the event of death prior
thereto.
ITEM VII: I appoint my wife, Susan D. Smith 1 ExecutTix of this my
Last Will and Testament. Should my wife, Susan D. Smith, fail to qualify or
cease to act as Executrix, I appoint the First National Bank of Shippensburg,
Pennsylvania, Executor of this my Last Will and Testament.
I.....w OFFICES
LANDIS a: BLACK
C4"LISI...E. f'ENNsyI...V4NJA
ITEM VIII: I direct that my Executrix, guardian or trustee, or their
successors, shall not be required to give bond for the faithful performance of
their duties in any jurisdiction.
IN WITNESS WHEREOF, I have heretlllto set my hands this /1fJ!- day of
February, 1977.
The preceding instrument, consisting of two (2) typewritten pages,
the first of which bears my signature in the margin thereof for the purpose
of identification, was on the day and date thereof signed, published and
declared by J. Jeffrey Smith, the Testator therein named, as and for his Last
Will and Testament, in the presence of us, who, at his request, in his presence,
and in the presence of each other, have subscribed our nameS as witnesses
thereto.
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