HomeMy WebLinkAbout10-12-05
REV1S00EX'I'~'1 '* i REV -1500
COMMONWEALTH OF PENNSYLVANIA I INHERITANCE TAX RETURN IFllENUMBER rrCi'
DEPARTMENT OF REVENUE I 2 I>
DEPT. 280601 I. RESIDENT DECEDENT I 1 05
HARRISBURG. PA 17128-0601 . -----1 COUNTY CODE YEAR NUMBER
DECED-E~T.S~:-~E (lAST,FIRST,~~D MiD~~-;-~) -==C======---==---i=- SOCIALSEClJRITY NUMBER---=-C:::-c~---
JACOBS, JANET S. i 162-22-0293
+--------------------,--- ---.---.---+------------.---.------- -.-
DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) I THIS RETURN MUST BE FilED IN DUPLICATE WITH THE
04/12/2005 I 06/24/1928 I REGISTER OF WILLS
~(IF APpLiCABLE) SURVIVING SPo"USE'S NAME ( lAST. FIRST AND MIDDLE INITIAl}------i- SOCIAL SECURITY NUMBER
I
-------------------- ------------------._L________.___ ____
o 2. Supplemental Return 0 3. Remainder Return (date of death prior to 12-13-82)
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4. Limited Estate 0
6. Decedent Died Testate (Attach copy 0
ofWIiI)
9. Litigation Proceeds Received 0
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
o 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
1 Origin'll Return
---'THIS SECTION MUST BE C
NAME
Hillary A. Dean, Esquire
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FIRM NAME (If applicable)
Martson Deardorff Williams & Otto
TELEPHONE NUMBER
717/243-3341
-----~---~_._---
---------_..~.__.-._--~-
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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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)
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)
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FIDSNTIAL TAx INFORMATION SHOULD BE DIRECTED TO:
COMPLETE MAILING ADDRESS
1 0 East High Street
Carlisle, P A 170 13 ~'..'
._,
(1 ) None '>FC;)\
(2) None
(3) None
(4) None
(5) 6,562.65
(6) None
(7) None
(8)
(9) 10,464.20
(10) 160,651.55
(11 )
Co,
6,562.65
171,115.75
(12)
insolvent
---------------.-.-
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 minus Line 13)
(13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1.2)
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16. Amount of Line 14 taxable at lineal rate
17.Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
--------,_.~
x .00
(15)
x .045
(16)
x .12
(17)
x .15
(18)
(19)
20. 0
._--,--,------~--~~-----
>> BE $URE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH <<
lpyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
121 Walnut Bottom Road
CITY
I STATE PA
i
I ZIP 17257
Shippensburg
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1 )
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + 8 + C)
(2) 0.00
4.
Total Interest/Penalty (0 + E)
If Line 2 is greater than Line 1 + Line 3, enter the difference. This is theOVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is theTAX DUE.
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + 5A. This is theBALANCE DUE
(3)
(4)
0.00
5.
(5)
(5A)
(58)
0.00
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 ~
~.' ~::::~ :h~e~;~:i~~:~s;~~~::;~~. .~.h~ll. ~.~.~. .t.~.~. ~~~~.~_~:. .~~~~~.~~.~~~~ .o.~ .i.t~. ~~~.~.~.;..............................~_. ...... ...... ........ ...-.-.....0 B ~
d. receive the promise for life of either payments, benefits or care?........................................................... 101
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 ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?............................................................................................................... ii1 M
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 penalties of perjury, 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
pre)O"",r other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
C~ie L. Jacobs f\
'( ~ I' I
23 Medford Drive
Mebane, NC 27302
DATE
ADDRESS
/lJ /-tf#$~
16/12-Jtu-
DATE
(
ADDRESS
10 East High Street
Carlisle, P A 17013
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. 39116 (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. 39116 (a) (1.1) (ii)]. The statutedoes not exempt 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. 39116 (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. 39116
1.2) [72 P.S. 39116 (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. 39116 (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.
-
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEAlTli OF PENNSYLVANIA PERSONAL PROPERTY i
rN~~~;6~~~ED~~E~~~~RN I I
- ---~------- ~ ------- -----------__L_____
-----_.~.._.~----~~_._--_._------~'---_._-_.._.~~-I------.---.-.------- --
ESTATE OF I FilE NUMBER
JACOBS, JANET S. I
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
DESCRIPTION
Many Insurance Company annuity # SN152838: Beneficiary, estate
-_._-~~---~-------------
VALUE AT DATE OF
DEATH
6,562.65
-----_._---._--~_._---_._-----~---- -
TOTAL (Also enter on line 5, Recapitulation)
---'~~-~--_._---._-
6,562.65
-
.
ESTATE OF
JACOBS, JANET S.
----.._--~._--~--._- -----------.-------
--.-. -------._---_. -_..._------~- ---'~_._-_.-
SCHEDULE H I
FUNERAL EXPENSES & I
_.L\DMI~'STRAT1VE COSTS ---_J__
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
'----, ._--~-_._----_.__.--._---------------_._-------_. ----
I FILE NUMBER
2 I - 05 -
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
-----~--,--~-- --~_._.._-----------------.-
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
F ogelsanger - Bricker Funeral Home, Inc., Shippensburg, P A
7,120.00
2 Sandra 1. Jacobs, travel expenses to plan and attend funeral
481.68
3 Connie L. Jacobs, travel expenses to plan and attend funeral
354.18
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Connie L. Jacobs
Social Security Number(s) I EIN Number of Personal Representative(s):
164-46-4870
Street Address 23 Medford Drive
City Mebane State NC
Year(s) Commission paid 2006
Attorney's Fees Martson DeardorffWiUiams & Otto
325.00
Zip 27302
2.
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
2,000.00
City
Relationship of Claimant to Decedent
State
Zip
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Cumberland County Orphans' Court, filing fee, Small Estate Petition
30.00
2
Connie L. Jacobs, reimbursement of travel expenses for estate administration
138.34
Total of Continuation Schedule(s)
15.00
-_.._-----_._--~-._-----------------._---- --
TOTAL (Also enter on line 9, Recapitulation)
10,464.20
-
.
Schedule H
Funeral Expenses &
Actninistrative Cos1s continued
--,-
-- -- -------~
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
-----------------------/ALENUMBER-.-------
i
i 21-05-
ESTATE OF
JACOBS, JANET S.
3
Cumberland County Register of Wills, filing fee, inheritance tax
- -------"- --.------..-.-.-- .-----.--______ .._u.__ _ ___'_ ______ ___.______,.____
15.00
-.------------- ----------------.-
---------- ---~._------~----._._-_._-
i
--..--_____-------1________..________
Page 2 of Schedule H
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
I
I
~ ---~------ -- -~- -- --___~L_ _~___ __ __ ~__ ~___~__~~ ___
~--"--_._----------------I------'-"--'- -__._____
. FILE NUMBER
21 - 05 -
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
------------- .~._---_._-- ----------..--
-- --- ------- --- --.---.--- --------
ESTATE OF
JACOBS, JANET S.
--- '-.--- - ----..--- -- ..---- --"- . "--- --- ------------- -- - -- -- ---.. --.._- ----0. __ ~_.. u_.
Include unreimbursed medical expenses.
ITEM
NUMBER
I
DESCRIPTION
PA Department of Public Welfare claim # 550153134 for medical assistance
._---------~--~-~-
AMOUNT
.~--_._-~-
160,651.55
TOTAL (Also enter on Line 10, Recapitulation)
160,651.55
REV.1513 EX+ (9-00)
.
SCHEDULE J
BENEFICIARIES
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RES-'QE~T[)~C!:.DJ=~~___ _-1__ __ .
--..--.-----------.--- _.~--- '--------
--- --.-..----------~--_______L_._____.._.____.____ __.______
----.---------.---.------- -----.-.-- ._-_.!--------~----_.._-
FILE NUMBER
21 - 05 -
ESTATE OF
JACOBS, JANET S.
I
NUMBER I
I
--._-- '-- ------------..-..------------ --.._~--- ---"---.- ----------------...------------------------------ --.-
_ ~ RELATIONSHIP TOI AMOUNT OR S.H ARE
DECEDENT r OF ESTATE
Do Noll islIrustee.~----L_______._
I ;
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
,
-- --- ------ "'--,--- ---
I.
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Connie L. Jacobs
23 Medford Dr.
Mebane, NC 27302
Daughter
Estate insolvent
2 I Sandra 1. Jacobs
300 Vuemont Place NE, Apt. F-302
Renton, W A 98056
Daughter
Estate insolvent
I
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover she~t
,
II. !NON-TAXABLE DISTRIBUTIONS:
IA. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
I
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEEj
-------.-._-_.__.._----._-._---.._-.~--_.__._._-----~------------._-