HomeMy WebLinkAbout09-06-05
REV ~ 1500 EX. ....00,
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FILE NUMBER ()Ll
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SOCIAl. SECURITY NUMBER
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128.080'
----...---..------.-.. -_._~---
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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T~ECEDENT'S NAME (LAST, FIRST.ANDMIDDLE INITIAL-i--
i Potak, Paul Joseph
tDATE"OF DEATH(MM~D5~YEARi- r DATE OF BIRTH (MM-DD~YEARi
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182-18-0086
THlSRETuRNMusr"BE"FILED iNDu~LIC::ATEWITH THE
05/06/2005
06/13/1920
REGJSTER 0'= WI.l.LS
SOCIAL SECURITY NUMBER
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
1. Original Return
0-2. "Supplernental Return
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5. Federal Estate Tax Return Re~uired
8. Total Number of Safe Deposit l30xes
11.Election to tax under Sec. 91113(A) (Attach Sch 0)
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3. Remainder Relurn (date of dealh pripr 1012-13-82)
4a, Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10. Spousal Poverty Credit (date of death between
4. Limited Estate
6. Decedent Died Testate (Attach copy
ofWili)
9. Litigation Proceeds Received
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5521 Carlisle Pike
Mechanicsburg, PA 17050
717/697-1800
1. Real Estate (Schedule A) (1)
None
OFFiCIAl. ust ONLY
2. Stocks and Bonds (Schedule B)
(2)
(3)
(4)
(5)
(6)
(7)
None
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
None
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4. Mortgages & Notes Receivable (Schedule D)
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)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
6,927.73
None
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4,340.00
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20,100.24
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20,310.96
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(8)
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44,751.20
(9)
(10)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
1,007.88
11. Total Deductions (total Lines 9 & 10)
(11 )
7,935.61
12. Net Value of Estate (Line 8 minus Line 11)
(12)
36,815.59
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)
36,815.59
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z 36,815.59 .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
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a.. 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)
1,656.70
1,656.70
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Form REV-150d EX (Rev. 6-00)
Copyright 2000 form software only The Lackner Group, Inc.
Decedent's Complete Address:
STREET ADDRESS
8 Carleton Court
CITY
. STATE PA
Camp Hill
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
6. Prior Payments
C. Discount
Total Credits (A + 6 + C)
3. InteresVPenalty if applicable
D. Interest
E. Penalty
TotallnteresVPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
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. (S)
A. Enter the interest on the tax due. (5A)
6. Enter the total of Line S + SA. This is the BALANCE DUE. (S6)
Make Check Payable to: REGISTER OF WILLS, AGENT
ZIP 17011
(1 )
(2)
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
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?. ........... ............................... ................................................. ..........................
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? ......... .................................... ........................................... ...................... ........
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D ~
D ~
181 0
1,656.70
0.00
0.00
1,656.70
1,656.70
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF lJ'HE RETURN.
8 Carlton Court
Camp Hill, PA 17011
-- -----------
ADDRESS
ADDRESS
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5521 Carlisle Pike
Mechanicsburg, P A 17050
complete. Declaration of
DATE
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. DATE
DATE
1- / - 05
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 usa 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 the surviving spouseiis 0%
[72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemDt 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 c
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116 (a) (1.2)].
'(\A'Pb
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.S~
1.2) [72 P.S. 99116 (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 .5. 9!
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blo
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.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
.------- ----.. ---.-- --- ---
------_._-~.-_._-..-._-_. .----.- ..-- -
ESTATE OF
Potak, Paul Joseph
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONALPROPERTV
. FILE NUMBER
21 - 05 -
--'-'~---"-"-------'--------~--
-----.--~--------_...-._---- .-.---.....---
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
.-- ---_..-----~-_.. ----
I 1996 Plymouth Voyager
2
Misc. personal property
DESCRIPTION
TOTAL (Also enter on Line 5, Recapitulation)
VALUE AT DATE OF
DEATH
---+ .----.------,----.----
2,040.00
2,300.00
4,340.00
ESTATE OF
Patak, Paul Joseph
FILE NUMBER
21 - 05 -
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SCHEDULE F
JOINTLY-OWNED PROPERTY
________ L
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO bECEDENT
A Jeanne G. Potak-Knowlton
8 Carleton Court
Camp Hill, PA 17011
Daughter
JOINTLY OWNED PROPERTY:
..-.-.--------.--~------ .-------------------.--~'---..-.'.--T.-.-. -r+-----.--
LETTER I DATE D~SC~IP:IO~ <?F PROPERTY % OF DATE OF DEATH
ITEM FOR JOINT MADE Incl~d~ n~me C?f ~lnanclallnstltutlon and bank .a?count number DATE OF DEATH DECD'S I . VALUE OF
NUM. BER 1 TENANT I JOINT or ,Slmll.ar Iden.. tlfyln.g numb,. er. Atta.. Ch.d.. e, ed for IOlnt..I,Y-held..real ,VALUE O. F ASSETIINTERESTIDEt;"" EDENT'S INTEREST,
I estate. "
--- -1- 1- - A -12/02/20()3 I Wacl,.o~ia CheCldng-aCocu~t#1()1()080260985-1--- 0~663.481 50% --:------8,831.74
2 I ,05/06/2005 Wachovia Checking Account # 1010084284323 22,536.99 50% 11,268.50
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TOTAL (Also enter on line 6, Recapitulation)
20,100.24
.
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
ITEM
NUMBER
Potak, Paul Joseph
FILE NUMBER
21 - 05 -
This schedul~!!ll!st be ~om~eted_an~ file~ifthe ans\N~r1f allY ~Lqu~stions ~hrOU~:14 on ~ 2 i~~~____~ __
DESCRIPTION OF PROPERTY ---r % OF I
Include the neme of the transferee, their relationship to decedent and the date of transfer I DATE OF DESA T~J DECD'S EXCLUSION I T AXABLE VALUE
_~ __ Atta:h a :py of~he :~ed: rea~:state r ~U~ OF A SE~I' ~~TE~ES~ (IF APPLlCABL:~ j
Wachovia IRA # 257170050229451 6,910.11. 100% I I 6,910.11
Waohovia IRA # 257 J 70050229453 I 5,132.36! 100% I I 5,132.36
I Wachovia Checking account # 1010084284323 made joint 11,268.49 100% 3,000.00/, 8,268.49
within 1 year of DOD
2
3
I
- - -L - -i---
TOTAL (Also enter on line 7, Recapitulation) I
20,310.96
ESTATE OF
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Potak, Paul Joseph
SCHEDU.E H
FUf\ERAL EXPENSES &
ADNIINISlRATIVE COSTS
Debts of decedent must be reported on Schedule I.
ITEM '
NUMBER
A.
B.
FUNERAL EXPENSES:
Hoover Funeral Home
2
Mount Calvary Episcopal Church - Priest
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
DESCRIPTION
I AMOUNT'
---- -----~--I-------~--'------------
1,535.00
100.00
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City State _ Zip
Year(s) Commission paid
Attorney's Fees Ahrens Law Firm, P.c.
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Jeanne Potak-Knowlton
Street Address 8 Carleton Court
City Camp Hill
2.
3.
4.
Relationship of Claimant to Decedent
Probate Fees Register of Wills
5. Accountant's Fees
6. Tax Return Preparer's Fees
1,500.00
3,500.00
State P A
Daughter
17011
Zip
102.00
7.
1
Other Administrative Costs
Estate notice in Cumberland County Law Journal
75.00
2
Estate notice in The Sentinel
100.73
Total of Continuation Schedule(s)
15.00
TOTAL (Also enter on line 9, Recapitulation)
---1-
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6,927.73
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Patak, Paul Joseph
3
PA Inheritance Tax filing fee
Schedule H
FU1eraI Expenses &
Acministrative Costs ccrinued
FILE NUMBER
21 - 05 -
15.00
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-~ - ------ 1~-------------
Page 2 of Sche4ule H
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SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
liABiliTIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Potak, Paul Joseph
Include unreimbursed medical expenses.
ITEM
NUMBER
1 Hospice of Central Pennsylvania
DESCRIPTION
2
South Central EMS, Inc.
3
Susquehanna Township EMS, Inc.
4
Ceridian COBRA
I FILE NUMBER
i 2] - 05 -
TOTAL (Also enter on Line 10, Recapitulation)
)'
AMOUNT
600.00
62.24
35.00
310.64
1,007.88
T
REV.1513 EJt+ (9'()O)
.
___ __.__._' _.__.__.._..___~__~_.__._._.,_.~.__ __~ _,._______n__.____'..______.____.__ __~.._._.________. ---.,---.--- -----.
I
II SCHEDULEJ
BENEFICIARIES
J______ _ ______
FILE NUMBER
21 - 05 -
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Potak, Paul Joseph
-~~~~E~I-------:A~:~~:::~~S~ OF PERSON(S) RECEIVING PROPERTY
- i. -- -- r~~XABL~-DIS~;1I3U~IONS0nc;u~e~~~i~~;S~0~S~;s~i~utions)
I Jeanne Potak-Knowlton
I 8 Carlton Court
Camp Hill, P A 17011
RELATIONSHIP TO I AMOUNT OR SHARE
I DECEDENT I OF ESTATE
r -~tIruatee(a)--T--- .----- ----
I Daughter IEntire ~esidue
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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
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lB. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART" - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI
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LAST WILL AND TESTAMENT
We, Paul J. and Emma E. Potak, husband and wife, of the
Borough of Northampton, County of Northampton, and
Commonwealth of Pennsylvania, desire to make dispositioQ
of our property, real and personal wheresoever situate,
so that there be no contention concerning any of it aftar
I
the death of either of us, do each mutually in consider~tion
,
of the other making his Will, and of the provisions mad~
herein in each other's behalf, make this as and for our I
Last Will and Testament, hereby revoking all former wil1s
heretofore made by either of us, and we agree that the $ame
,
may not hereafter be changed or varied by either without
the consent in writing of the other.
FIRST: We give, devise and bequeath to the survivor of IUS
all and any real and personal property either owned by ts
jointly or severally for his or her own personal use anC
benefit forever.
SECOND: We appoint our beloved daughter, Jeanne Potak Knowlton
Y~c.~ ~p~Z
l~~-R.(l., H~J:,~, Pennsylvania, as our executrix
I
and waive any requirement of bond or surety as to her a~one.
I
THIRD: The legal debts, administration expenses and fu~eral
I
costs of the first of us to die shall to the extent not!
provided for by his or her separate estate be paid fro~ our
joint property.
., ..
THIRD: The legal debts, administration expenses and
funeral costs of the first of us to die shall to the
extent not provided for by his or her separate estate
be paid from our joint property.
FOURTH: In the event that we meet our death in a commo~
accident or disaster, then we hereby give, devise and
bequ-eath all of our-pro}?lerty "bocur beloved daughter,
Jeanne Potak Knowlton.
FIFTH: That upon the death of the survivor of us, we
give, devise and bequeth all of our remaining property,
real and personal, wheresoever situate, to our beloved
daughter, Jeanne Potak Knowlton.
Dated: October 2, 1980
i
( SEAL)
i
(~EAL)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162E (11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
AHRENS THOMAS J ESQUIRE
5521 CARLISLE PIKE
MECHANICSBURG, PA 17050
-------- fold
ESTATE INFORMATION: SSN: 182-18-0086
FILE NUMBER: 2105-0438
DECEDENT NAME: POTAK PAUL J
DATE OF PAYMENT: 09/06/2005
POSTMARK DATE: 09/06/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 05/06/2005
REMARKS:
CHECK# 1665
SEAL
NO. CD 0051768
,
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $1,656.170
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TOTAL AMOUNT PAID:
$1,656).70
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASB,AJUGH
REGISTER OF WILLS
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