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REV.1500 EX + (6-00)
OFFICIAL USE ONLY
REV.1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
*
FILE NUMBER
II 05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
0802
NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Gillam, Janet Irene
DATE OF DEATH (MM-DD-YEAR)
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193-30-0383
DATE OF BIRTH (MM-DD-YEAR)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
08-25-2005
03-29-1908
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
o 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach
copy of Will)
o 9. Litigation Proceeds Received
o
o
o
o
o 3. Remainder Return (date of death prior to 12-13-B2)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
2. Supplemental Return
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4a. Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10 Spousal Pove~ Credit (date of death between
. 12-31-91 and 1-1-95)
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NAME
Gary L. James, Esq.
FIRM NAME (If applicable)
James, Smith, Dietterick & Connelly, LLP
TELEPHONE NUMBER
717/533-3280
COMPLETE MAILING ADDRESS
134 Sipe Avenue
Hummelstown, PA 17036
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
(1 ) None
(2) None
(3) None
(4) None
(5) 7,119.88
(6) 27,335.93
(7) 183,472.17
(9) 5,736.66
(10) 5,528.53
OFFICIA~=pSE ON~Y
~.-'--; -\
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) 0 Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
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(8)
217,927.98
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
(11 )
11,265.19
206,662.79
0.00
12. Net Value of Estate (Line 8 minus Line 11)
(12)
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)
206,662.79
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate, 0.00 X .00 (15)
or transfers under Sec. 9116(a)(1.2)
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0 (16)
i= 16.Amount of Line 14 taxable at lineal rate 206,662.79 x .045
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Q. 17.Amount of Line 14 taxable at sibling rate 0.00 x .12 (17)
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0
(,) 18. Amount of Line 14 taxable at collateral rate 0.00 .15 (18)
>< x
~ 19. Tax Due
(19)
0.00
9,299.83
0.00
0.00
9,299.83
Copyright 2002 form software only The Lackner Group. Inc.
Form REV-1500 EX (Rev. 6-00;
Decedent's Complete Address:
STREET ADDRESS
403 Allegheny Drive
CITY Mechanicsburg
ISTATE PA
IZIP 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
9,299.83
8,834.84
464.99
9,299.83
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C)
(2)
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is theOVERPA YMENT.
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 theTAX DUE
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is theBALANCE DUE
(3)
(4)
(5) 0.00
(5A)
(5B) 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;............................................................................. [!] D
b. retain the right to designate who shall use the property transferred or its income;................................ [!] D
c. retain a reversionary interest; or............................................................................................................ [!] D
d. receive the promise for life of either payments, benefits or care?........................................................... [!] D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?................................................................................................................
D
D
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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?............................................................................................................... [!] D
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 pe~ury, I declare that I have examined this retum, 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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE
Na cy D. Lemmons 35 West Maple Avenue
Shiremanstown, PA 17011
ADDRESS
134 Sipe Avenue
Hummelstown, PA 17036
\,~ 1. :2-",=-)-
DATE
ADDRESS
For dates of t --en or. er 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"To"[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 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. 99116 (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.
99116 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.S. 99116 (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.
Rev-1508 EX+ (6-98)
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Gillam, Janet Irene
FILE NUMBER
21-05-0802
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 DESCRIPTION
1 PNC Bank Checking Account No. 5140217159 - valued per letter dated 9/6/05
VALUE AT DATE
OF DEATH
7,119.88
TOTAL (Also enter on Line 5, Recapitulation)
7,119.88
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
Rev-1509 EX+ (6-98)
*'
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Gillam, Janet Irene
FILE NUMBER
21-05-0802
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
A. Joyce M. Gillam
ADDRESS
RELATIONSHIP TO DECEDENT
Apt 101, 2514 Tunlaw Rd NW
Washington, DC 20007
Daughter
B. Nancy D. Lemmons
35 West Maple Avenue
Camp Hill, PA 17011
Daughter
C.
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY %OF DATE OF DEATH
LETTER DATE
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSET INTEREST DECEDENT'S INTEREST
JOINTLY-HELD REAL ESTATE.
1 A.S 6/21/1996 BlackRock Account No. 0009536152- 82.007.80 33.333% 27.335.93
valued per letter dated 10/7/05
TOTAL (Also enter on Line 6, Recapitulation) 27.335.93
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule F (Rev. 6-98)
Rev.1510 EX+ (6-98)
*'
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Gillam, Janet Irene
FILE NUMBER
21-05-0802
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
1 Protective Life & Annuity Company Contract No. 91.255.46 100.000 0.00 91.255.46
G70015575 - owner is the Janet M. Gilliam Living
Trust dated 3/15/1994; beneficiary is Trust -
valued per Protective
2 Protective Life & Annuity Company Contract No. 91.262.91 100.000 0.00 91.262.91
G70015576 - owner is the Janet M. Gilliam Living
Trust dated 3/15/1994; beneficiary is Trust -
valued per Protective
3 Auer Memorial Home & Cremation - prepaid 953.80 100.000 0.00 953.80
funeral account
TOTAL (Also enter on Line 7, Recapitulation) 183.472.17
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 ScheduleG (Rev. 6-98)
REV-1151 EX+ (12-99)
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Gillam, Janet Irene
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-05-0802
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
See continuation schedule(s) attached
3,037.66
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City
Year(s) Commission paid
State Zip
2.
Attorney's Fees
James, Smith, Dietterick & Connelly, LLP
2,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
69.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Other Administrative Costs
See continuation schedule(s) attached
130.00
TOTAL (Also enter on line 9, Recapitulation)
5,736.66
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
Rev-1502 EX+ (6-98)
.
SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Gillam, Janet Irene
FILE NUMBER
21-05-0802
ITEM
NUMBER DESCRIPTION AMOUNT
1 Auer Memorial Home & Cremation - coroner fee 25.00
2 Auer Memorial Home & Cremation - obituary notices 382.00
3 Auer Memorial Home & Cremation - funeral bill 953.80
4 David H. Binkley - honorarium - organist 100.00
5 Delta Airlines - travel expenses for family to attend funeral 856.58
6 Mechanicsburg Presbyterian - funeral luncheon 250.00
7 Michaels - supply for picture display 7.40
8 Pastor Mrytle McCall - honorarium 100.00
9 Pastor Rick Sweeney - honorarium 100.00
10 Royer's Flowers - flowers for funeral services 262.88
Subtotal
3.037.66
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
Rev-1502 EX+ (6-98)
*'
SCHEDULE H-B7
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Gillam, Janet Irene
FILE NUMBER
21-05-0802
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
James, Smith, Dietterick & Connelly, LLP - reservation for estate administration
closing costs
100.00
2
Register of Wills, Cumberland County - filing fee for Inventory and PA Inheritance
Tax Return
30.00
Subtotal
130.00
Copyright (c) 2002 form software only The Lackner Group. Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
Rev-1512 EX+ (6-98)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Gillam, Janet Irene
FILE NUMBER
21-05-0802
Include un reimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1 Alert Pharmacy Services, Inc. - unreimbursed prescription drug charges
VALUE AT DATE
OF DEATH
244.95
2 Messiah Village - unreimbursed nursing home care
5.145.15
3 WSEMS-Chambersburg ALS/BLS - unreimbursed ambulance service
138.43
TOTAL (Also enter on Line 10, Recapitulation)
5,528.53
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
REV-1513 EX+ (9-00)
*'
SCHEDULE .J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Gillam, Janet Irene
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
tlistributions, and transfers
under Sec. 9116(a)(1.2)]
FILE NUMBER
21-05-0802
I.
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(sl
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
1
Joyce M. Gillam
Apt. 101,2514 Tunlaw Road NW
Washington, DC 20007
Nancy D. Lemmons
35 West Maple Avenue
Shiremanstown, PA 17011
Daughter
Annuity
Contract No.
G70015576 &
1/? nf ~".c::itill'"
Annuity
Contract No.
70015575 & 1/2
1 03,335.12
2
Daughter
1 03,327.67
nf ~".c::itill'"
Total 206,662.79
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
Copyright (c) 2002 form software only The Lackner Group. Inc.
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
Form PA-1500 ScheduleJ (Rev. 6-98)
Register of Wills, Cumberland County, Pennsylvania
INVENTORY
Estate of Janet Irene Gillam
, Deceased
No. 2005-802
Date of Death 08/25/2005
Social Security No. 193-30-0383
also known as
Nancy D. Lemmons
The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory
include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania
of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of
the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except
that which appears in a memorandum at the end of this Inventory. l!We verify that the statements made in this Inventory
are true and correct. l!We understand that false statements herein are made subject to the penalties of 18 Pa. C. S.
Section 4904 relating to unsworn falsification to authorities.
Gary L. James, Esq.
I Adth.
Attorney:
Signature:
J.D. No.: 27752
Signature:
James, Smith, Dietterick & Connelly,
Firm: LLP
Signature:
Address: 134 Sipe Avenue
Hummelstown, PA 17036
Telephone: 717/533-3280
Address: 35 West Maple Avenue
Shiremanstown, PA 17011
Telephone: 717 -761-1242
Dated:
II JdOl/oS
Personal Property
Cash...............................................................................................
Pe rso nal Property... ...................... .......... ............ .... ..... .................
Stocks/Listed.................................................................................
Stocks/C losely Held......................................................................
Bonds.............................................................................................
Partnerships and Sole Proprietorships .....................................
Mortgages and Notes Receivable...............................................
A II Oth e r Property.............................................. ...........................
7,119.88
,:
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Total Personal Property.........................................
7,119.88
Total Rea I Property................................................
Total Personal and Real Property.........................
7,119.881
Total Out-of-State Real Property..........................
Register of Wills, Cumberland County, Pennsylvania
INVENTORY
Estate of Janet Irene Gillam
also known as
, Deceased
No.
Date of Death
Social Security No.
21-05-0802
08/25/2005
193-30-0383
Cash
PNC Bank Checking Account No. 5140217159 - valued per letter dated 9/6/05
7,119.88
Total Cash
7.119.88
(Attach additional sheets if necessary)
Total Personal Property and Real Estate
7,119.88