HomeMy WebLinkAbout08-09-05
RfV.11OD EX + (6-00)
'W COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
OECEOENl'S NAME (lAST, ARST, ANO MlOOlE INITIAl)
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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Charlotte K Li selt
OATE OF DEATH (MM-IJD.Year)
DATE OF BIRTH (MM.DIl-Y~1
OfFICIAl VSE ONlY
FILE NUMBER \ \ , ^
-b.v~ - -9-",.5 .a ..::r ~~
SOCIAL SECURITY NUMBER
1 6 5-2 2-7 3 7 6
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOClAL SECURITY NUMBER
D 3. Remainder Return (daleofdealhpriork/12-13-32)
o 5. Federal ESlate Tax Retum Required
_ B. Totel NumberofSefe Deposit Boxes
o 11. ElecliDnlotaxunderSec, 9113jA)_Sd>0)
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02/25/2005 10/07/1917
OF APPUCABLE) SURVMNG SPOUSE'S NAME (lAST, FIRST, AND MI/JDLE INITIAL)
PA 17110
OFFICIAL USE ONLY
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/Xl 1. Original Retum
o 4. Umi1ed Estate
o B.DecedentDiedTesIate __"WIll
o 9.li1i9ation Proceeds Raceived
o 2. Supplemenlal Retum
o 4a.FuturelnterestCornpromiseCdaeofdealhafter12.12-82j
o 7. Decedent Maintained a living Trust (Attacl'lcopy oITrusl)
o 10. Spousal Poverty Credit (dalll otdeath be(ween 12.31-91 .,d '.I.95}
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NAME
Marielle F. Hazen Es uire
FIRM NAME (W Applicabla)
Law Office of Marielle F. Hazen
TELEPHONE NUMBER
717-540-4332
COMPLETE MAILING ADDRESS
2000 Ling/estown Road
Suite 202
Harrisbur
1'"<')
150.005.87
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnarship or BoIe-Proprielolship
4. Mor1gages & Notes Receivable (Schedule D)
5. Cash, Bank Deposils & Miscellaneous Personal Proparty
(Schedule E)
6. JoInIly Owned Property (Schedule F)
o Separate Billing Raquested
7, Inter-V_ Transfers & Miscelleneous Non-Probate Property
(Schedule G or L)
8. Total GrolS Ao_ (lolalllnes 1.7)
9. Funeral Expenses & Admlnistrat1va Cosis (Schedule H)
10. Dobis of Deceden~ MorfgagallabUI1ies. & Liens (Scheduie I)
It Total Deductions (loIaJ Uoes 9 & 10)
12. Net Value 0' Eslale (line B minus line 11)
13. Chari1abfe and Govemmenlal BequestaiSec 9113 Trusls for which an election lo tax has not been
modo (Schedufa J)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(B)
161,108.40
2.300.47
9.326.92
(11)
(12)
(13)
11.627.39
149,481.01
(9)
(10)
14. NetValueSubjectloTax (LIoa12 minus lina 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of line 14laxabfe allhe spousal lax
rate, orllansfels umlar See. 9116 (a)(1.2)
0.00 X
_(15)
X .045 (16)
(14)
149,481.01
16. Amount of Line 14laxable at lineal rate
149,481.01
0.00
0.00
X .15
(17)
(18)
(19)
0.00
6,726.65
0.00
0.00
6.726.65
X .12
17. Amount of L1na 14 taxable at ~b1ing rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND QF AN OVERPAvr.1ENT
o eel
, ec ent's ComDlete Address:
STREETAOORESS
801 North Hanover Street
CITY . I STATE I ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Une19)
2. CreditslPayments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
6.726.65
6 000.00
31578
Total Credits (A +8 +C)
(2)
6.315.78
3. InterestlPenalty n applicable
D. Interest
E.Penalty
TotallnteresllPenalty ( D + E)
4. ff Una 2 is 9reater than Una 1 + Une 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Une 20 to request a refund (4)
If Una 1 + Una 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
8. Enler the total of Une 5 + 5A. This is the BALANCE DUE. (58)
Make Check Payable 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
a. retain the use or income of the property transferred; ........................................................................... 0
b. retain the righl to designate who shall use the property transferred or its income; ........................................ 0
c. retain a reversionary interest; or ...................................................................................................... 0
d. receive the promise for Ine of either payments, benefits or care? ............................................................. 0
2. n 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 trustfo~ or payable upon death bank account or security at his or her death? ................. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... IXI
(3)
0.00
5.
0.00
410.87
410.87
No
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IXI
IXI
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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.
!he best of my knowledge and belief, ~ ~ lJue. ""'"" and compIe\e.
Under ~ ofpoljlly,l declare lhaIt haYeexarined this IlIlum, incI . '!"""'I""~ng schedules and ._Is.
~of__II18I!he""""'a1....__~basedOllall ofwhich as
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
OATE
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ADDRESS
ADDRESS 2000 l:inglestown Road, uite 202
Harrisbul'!l
PA 17110
IT ...~~.Illlm. - .
For dates of death on or after July 1, 1994 and before January 1. 1995, the lax rate Imposed on the net value of transfers to or for the use of the survlving 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 oflransfers 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 retum are still applicable even n
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 of transfers 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 l).
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 Secfion 9102, as an
individual who has at Ieasl one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX. (8-98)
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Charlotte K Liosett
FILE NUMBER
21 05
100Ud81h8 pIOCIlOds of litigation and the date Ih8 proceeds were received by Ih8 estate.
All property jolnUy-owned with right ohurvlvorshlp must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
5,271.53
Church of God
Nursing Home Refund
TOTAL (Also enteron line 5, Recapitulation) $
(If more space is needed, Insert additional sheels of Ih8 same size)
5 271.53
REV-1509,EX + (8-.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
Charlotte K LiDsett
FILE NUMBER
21 05
If an lull was made joint within one year of the decedents date of death, it must be reported on Schedule G.
SURVMNG JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Robert J. Lipsett
2901 Butler Street
Harrisburg, PA 17103
Son
B William J. Lipsett
590 Kalla Drive
Harrisburg, PA 17109
Son
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JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FDRJOINT MADE INCLUDE NAME OF ANANOAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECQS VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTL Y.HELD REAL ESTATE, VALUE OF ASSET INTEREST DECEDENrSINTEREST
1. A. Citizens Bank Account 17,493.01 33.3333 5,831.00
Chk#610067-728
TOTAL (Also enter on line 6, Recapitulation) $ 5831.00
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(If more space Is needed. insert additional sheels of the same SIze)
REV-1Sl0 EX + (6-98)
..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Charlotte K LiDsett
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
FILE NUMBER
21 05
This schedule must be completed and filed W the answer 10 any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDe TtE lWIEOFTHE TMHIFEREE, TlEIRRELATION8HIPTOOECEOENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER llEMTEOFTRAN8FEFl ATTACHACOf1'(OFTtlEOEEOFORREALESTAl'E VALUE OF ASSET INTEREST VALUE
,,"".....,
1. Transamerica Annuity No. 27304514 92,438.50 100. 92,438.50
William Lipsett, Robert Lipsett & Jeanne Bell - Beneficiaries
2. Monumental Life Annuity No. 0100N222183 57,567.37 100. 57,567.37
William Lipsett, Robert Lipsett & Jeanne Bell - Beneficiaries
TOTAL (Also enter on line 7 Recapitulation) $ 150 005.87
(If ITIO!O space is needed, Insert additional.hee1s of the same size)
REV-1511 EX + (12-99)
*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Charlotte K LiDsett
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
Debts of _nl musl be reported on Schedule I.
FILE NUMBER
21 05
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Cantone's - Funeral Reception 432.64
2. Pearlers - Funeral Flowers 262.83
8. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of _I Represen1ative (s)
SodaI SeaJrily Number(s)IEIN Number of Personal Representative(s)
Sbeel Address
City State Zip
Yee~s) Commission Paid:
2. Attorney Fees Marielle F. Hazen 1,500.00
3. Family Exemption: (If decedenfs address is not the same as claimanfs. attach explanation)
Claimant
Sbeel Address
City State lip
RelationShip of Claimant to Decedent
4. ProbateFees Register of Wills - Filing Fee for Tax Return 25.00
5. Accountanfs Fees
6. Tax Retum Prepare(s Fees
7. Citizens Bank - Bank Fees 80.00
TOTAL (Also enter on line 9, Recapitulation) $ 2 300.47
(If..,re space is needed, insert additional sheels of the same size)
.REV-1512-EX + (6-98)
*'
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMO~THOFPENNSYlVAN~
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
21 05
Charlotte K ljDsett
Include unrelmbursed medical expenses.
VALUE AT OATE
OF OEA TH
ITEM
NUMBER DESCRIPTION
1. Church of God Home
2. Church of God Home
Nursing Home Care - Citizens Chk#1334 Cleared on 2/28/2005
3. DFAS
Pension Reclaimed
4. Social Security
February & March Benefits Reclaimed
5. Philhaven
Medical Bill
6. Continuing Care RX Inc.
Medical Bill
7. Bluecross
Pension Reclaimed
8. Dr. Gustuits
Medical Bill
98.27
5,359.62
366.00
2,362.00
24.97
171.33
786.65
158.08
TOTAL (Also enteron line 10, Recapitulation) $
(K more space is needed. Insert addlllonal sheels of the same size)
9326.92
REV_'513EX+I"
COMMONWEALTH OF PENNSYLVANIA
INHERrrANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
?1 n<:;
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
1. TAXABLE DISTRIBUTIONS [mdude ~ht s~usal d~tribulions. and !Jansfe", under
Sec.9116(a (1. ))
1. Robert Lipsett Lineal
2901 Butler Street, Harrisburg, PA 17103 33.3%
2. William Lipsett Lineal
590 Kalla Drive, Harrisburg, PA 17109 33.3%
3. Jeanne Bell Lineal
52 Warrington Drive, Rochester, NY 14618 33.3%
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 TAXIS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
REV-1500 Discount, Interest and Penalty Worksheet
Discount Calculation
Total Amount Paid within three calendar months of the decedent's date of death: .
6.000.00
---- --
Discount:
315.78
Interest Table
Year Days Delinquent Balance Due Interest
this time period this year this period .---.-
Before 1981 .-. ~_..._-----
1982 ___._____u_
1983
1984
1985
1986
1987 -------.-
1988 throuah 1991 --.-.- ---
1992
1993 throunh 1994
1995 throunh 1998 - .--
1999 __'0' - -...------------ .--
2000 ---- ----.--. -----~ _._____ __ ..______._ __.n_.__
2001 -----.-..----...
2002 .-
2003
2004
-
.-- -.---..-.--.-
-- ,---- -- ...----- ~._,-------.-._-_.__...__._----
TOTALS ._._--------_._--~-~--
Penalty Calculation
If the decedenfs date of death was on or before March 31, 1993, insert the applicable amount:
Total Balance Due on January 17, 1996:
Penalty:
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
LIPSETT ROBERT J
2901 BUTLER STREET
HARRISBURG, PA 17103
____un fold
ESTATE INFORMATION: SSN: 165-22-7376
FILE NUMBER: 2105-0416
DECEDENT NAME: LIPSETT CHARLOTTE K
DATE OF PAYMENT: 05/06/2005
POSTMARK DATE: 05/04/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 02/25/2005
f
NO.'C~005296
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ACN
ASSESSMENT
CONTROL
NUMBER
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AMOUNf"
1 01 I $6,000.00
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TOTAL AMOUNT PAID:
REMARKS: R J LIPSETT
CHECK#1347
SEAL
INITIALS: VZ
RECEIVED BY:
TAXPAYER
$6,000.00
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
Cumberland County Register of Wills
INVENTORY
Estate of Charlotte K. Lipsett
No. 21
05
0416
also known as
, Deceased
Date of Death 2/25/2005
Social Security No. 165227376
Personal Representative(s) of the above Estate, deceased, verify that the nems appearing in the following inventory include all of the
personal assets wherever snuate and all of the real estate in the Commonweallh of Pennsylvania of said Decedent, that the valuation
placed opposite each nem of said inventory represents no fair value as of the date of the Decedent's death, and that Decedent owned no
real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. IM/e
verify that the statements made in this inventory are true and correct. IM/e understand that false statements herein made are subject to the
penalties of 18 Pa. e.s. Section 4904 relating to unsworn falsification to authorities.
Personal Representative:
Name of
Attorney: Marlelle F. Hazen, ESQuire
I.D. No.: 68003
Address: 2000 LinQlestown Road, Suite 202
Harrisbura
Telephone: 717-540-4332
Robert J. Lipsett
Dated
PA 17110
Description
Value
Church of God
Nursing Home Refund
5,271.53
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Total
(Attach Additional Sheets if necessary)
5,271.53
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative,
Include the value of each item, but such figures should not be extended into the total of the Inventory.
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The Law Office of
MAmEuE F. HAzEN
Certified Elder Law Attorney"
An Eslale Planning and Elder Law Firm
2000 Linglestown Road
Suite 202
Harrisburg. PA 17110
m.: (717) 5404332
FAX: (717) 540-4313
www.hazenelderlaw.com
Madelle F. Hazen, JD, CErA'
Jeta C. Combs, ParalegaI
Jessica A. Holland, Paralegal
Calherlne M. Semon, ParalegaI
KIm M. Smith, Office Admlnlstrator
August 8, 2005
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Re: Estate of Charlotte K. Lipsett
Social Security No.: 165-22-7376
PA File No.: 21-05-0416
To: The Register of Wills:
Enclosed for filing please find the original and one copy of the above-referenced
Inheritance Tax Return and Inventory, along with a copy of the first page of the
Inheritance Tax Return. We also enclose an Estate Information Sheet for your files.
Please date stamp the first page of the return and a copy of the Inventory and return them
to my office in the enclosed self-addressed envelope.
Also enclosed are checks, one for the inheritance tax in the amount of $410.87
and one in the amount of $30.00 for the filing fees.
If you have any questions or need anything additional, please do not hesitate to
contact our office.
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*Certified Elder Law Attorney by the National Elder Law Foundation as authonzed by the Pennsylvania Supreme Court
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAl TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HAZEN MARIELLE F
2000 L1NGELSTOWN ROAD
SUITE 202
HARRISBURG, PA 17110
nnn__ fOld
ESTATE INFORMATION: SSN: 165-22-7376
FILE NUMBER: 2105-0416
DECEDENT NAME: LIPSETT CHARLOTTE K
DATE OF PAYMENT: 08/09/2005
POSTMARK DATE: 08/08/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 02/25/2005
NO. CD 005668
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $410.87
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TOTAL AMOUNT PAID:
REMARKS: MARIELLE HAZEN, ESQ
CHECK# 1352
SEAL
INITIALS: RSK
RECEIVED BY:
REGISTER OF WILLS
$410.87
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
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