HomeMy WebLinkAbout12-02-05
REV-1500 , OFFICIAL USE ONLY
INHERITANCE TAX. RETURN I FILE NUMBER
I 21 05 00304
RESIDENT DECEDENT ! COUN~ODE Y-;;; NUMBER
____~~____L__n~~ _~
I D;~;~S~;,E ~:~I~~ ~~ MI~.LE INITIAL) ---~~----r-~O;I~l_~~U~~~;;BER
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 'I THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
03-24-2005 06-22-1915 I REGISTER OF WILLS
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) -~~---~~~--~t-SOCiALSECURITY NUMBER
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o 3. Remainder Return (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
REV-1600 EX + (6.00)
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COMMONWEALTH OF ~I
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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
. 12-31-91 and 1-1-95)
Copyright 2002 form software only The Lackner Group, Inc.
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~ 1. Original Return
o 4. Limited Estate
~ 6, Decedent Died Testate (Attach
copy of Will)
o 9. Litigation Proceeds Received
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2. Supplemental Return
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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NAME
Jan M. Wiley
FIRM NAME (If appHcable)
Wiley, Lenox, Colgan, & Marzzacco, P.C.
TELEPHONE NUMBER
717-432-9666
COMPLETE MAILING ADDRESS
130 W. Church St
Dillsburg, PA 17019
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(1) None
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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) 0 Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
(2) None
(3) None
Cl
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)
(4) None
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(5) 761,037.29
(6) None
(7) 9,939.58
(8)
(9) 88,241.86
(10) 3,808.17
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770,976.87
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
0.00
(11) 92,050.03
(12) 678,926.84
(13) 0.00
(14) 678,926.84
x .00 (15) 0.00
-----~.--_._~
x .045 (16) 30,551.71
---.------
x .12 (17) 0.00
x .15 (18) 0.00
(19) 30,551.71
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)
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15. Amount of Line 14 taxable at the spousal tax rate.
or transfers under Sec. 9116(a)(1.2)
678,926.84
0.00
0.00
20. [KJ
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
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
Form REV-1500 EX (Rev. 6-00;
Decedent's Complete Address:
STREET ADDRESS
100 Mt. Allen Drive
CITY Mechanicsburg
'--~--T.----.._'----r--
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)
30,551.71
29,659.95
1,527.59
Total Credits (A + B + C)
(2)
31,187.54
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + 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)
(4)
(5)
(SA)
(58)
635.83
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:~~~~s~~~. .~.~.~.I~. ~~~. ~~~. :.~.~.p.~.~. .~~~~~~~~r~~. .~.~ .i~.~..i~~~~~~ .': ....::..: ::::::::: :.':: :::::::.': :.':.' .': 8 ~
d. receive the promise for life of either payments, benefits or care?.............................................................. 0 ~
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?......... [] [Xl
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?...................................................................................................................... iiJ 0
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, il is lrue, correct and
campiete. Dedaration of preparer other than the personal representative is based on all information of which preparer h~S any knowle~_________....__._~____
SIGNATUR OF PERSON RESPON~BLE FOR FILING RETURN ADDRESS DATE
St~_ n.~. Eber.( ----..-......-. ~~c6h~~i~~~~~g~~~ 17055 'V~2.3 I t!) s:-
BIG URE OF PERSON RESP SIBLE OR FILING RETURN ADDRESS D TE ~
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ADDRESS
DATE
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130 W. Church St
DiIIsburg, PA 17019
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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
iving 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. 99116 (a) (1.1) (iill. The statute does 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. ~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.
99116 1.2) [72 P.S. ~9116 (a) (1ll.
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.
llinst lIill ttlt-O- (TI.egmmtnt
OF
KENNETH A. BUSHEY
BE IT REMEMBERED, that I, KENNETH A. BUSHEY, of 153
Logan Road, Dillsburg, Carroll Township, York County,
Dillsburg, York County, Pennsylvania, being of sound mind,
memory and understanding, do make, publish and declare this
as and for my Last Will and Testament, hereby revoking and
making null and void any and all Wills and Testaments and
writings in the nature thereof made by me at any time
heretofore.
ITEM 1:
I direct that all my just debts and funeral
expenses be paid as soon after my demise as may be
convenient.
ITEM 2:
In the event that any beneficiary shall
contest this, my Last Will and Testament, I direct that their
share shall immediately lapse.
ITEM 3:
All the rest, residue and remainder. of my
estate, of whatsoever nature and wheresoever situate, whether
it be real, personal or mixed, including property over which
I have a power of appointment, I give, devise and bequeath as
follows:
(A) I give thirty percent (30 %) thereof to my son,
KENNETH R. BUSHEY.
(B) I give forty percent (40%) thereof to STEPHEN R.
EBERLY and GORDON EBERLY, in equal shares, per stirpes.
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~~.t.j~
)ki // 71, die .
~A~
~NNETH A. BUSHEY
(SEAL)
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(C) I give the remaining thirty percent (30%) to KEVIN
BUSHEY, KEITH BUSHEY, KENT BUSHEY, MARGARET EBERLY and
STEPHEN R. EBERLY, JR., in queal shares, per stirpes.
ITEM 4: I direct .my hereinafter named Executor to pay
all inheritance, estate, succession and legacy taxes of
whatsoever nature and kind, to which my estate or the
transfer of any property passing hereunder or otherwise
passing by. reason of my demise, may be subject and to charge
such taxes against my residuary estate, it being my intention
that none of the aforesaid taxes, either federal or .state, on
any property required to be included in my gross estate,
under the provisions of any state or federal law now in force
or hereafter enacted, shall be prorated among the persons
interested in my estate to whom such property is or may be
transferred or to whom any benefit accrues.
ITEM 5: I appoint my grandson, STEPHEN R. EBERLY, as
Executor of this my Last Will and Testament.
Should my
grandson predecease me, fail to qualify, cease to act or
renounce probate, I then appoint my daughter-in-law, MARGARET
L. EBERLY, as Executrix of this my Last Will and Testament.
.ITEM 6:
I direct that my Executor or his successor
shall not be required to give bond for the faithful
performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this 1--/d1 day of
MIl Ad
, 2003.
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cJ(~/f~SEALJ
KENNETH' A. BUSHEY
-2-
COMMONWEALTH OF PENNSYLVANIA
S8
COUNTY OF YORK
We, KENNETH A. BUSHEY, ,JAN M. WILEY, ESQUIRE and
8HERIE A. MINICH, the Testator and the witnesses
respectively, whose names are signed to the attached or
foregoing instrument, being first duly sworn, do hereby
declare to the undersigned authority that the Testator
signed and executed the instrument as his Last Will and
Testament ,and that he had signed willingly (or willingly
directed another to sign for him), and that he executed
it as his free and voluntary act for the purposes therein
expressed, and that each of the witnesses, in the
presence and hearing of the Testator" signed this Last
Will and Testament as witness and that to the best of
their knowledge the Testator was at the time eighteen
(18) years of age or older; of sound mind and under no
constraint or undue influence.
Sworn to and subscribed
before me this ~ day of
.;~ ~;~)
NOTARY PUBLIC
MY COMMISSION EXPIRES:
Notarial Seal ,
G1a......lter Notal"{ Public
S. Dawn "'AO . eounty
DIl\sbU19:~;~May 11. 2005
My Con\ffilSSl(
P ~,""""nIaAsSOCiaUonoINotarieS
t.Aell'bel'. 8..-".-.
Rev-1508 EX+ (6-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BUSHEY, KENNETH A.
FILE NUMBER
21-05-00304
ESTATE OF
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 Citizens Bank Account Number 6100705145:
VALUE AT DATE
OF DEATH
98,852.95
2 Citizens Bank Account Number 6140708311:
25,030.45
3 Misc. Refunds/Deposits:
1,290.44
4 PNC Bank CD#21001013891:
10,013.24
5 PNC Investments:
435,951.55
6 Sovereign Bank Account #0571143202:
8,762.13
7 Sovereign Bank Account #1685167742:
10,163.46
8 Sovereign Bank Account Number 0575293048:
15,714.88
9 Sovereign Bank Account Number 1685167742:
10,163.46
10 Sovereign Bank Account Number 1685374256:
20,095.99
11 Sovereign Bank Account Number 1685374264:
10,048.00
12 Sovereign Bank Account Number 1685387001:
20.009.83
13 Transamerica Life and annuity Co, Annuity Number 26142040:
94,940.91
TOTAL (Also enter on Line 5, Recapitulation)
761,037.29
(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)
"TRANsAMERICA
I. L'". . A N DAN N U , T Y
,j
TransamericaLife fusurance and
Annuity Company
Home Office:
Charlotte, North Carolina
Administrative Office:
4333 Edgewood Road NE
PO Box 3183
Cedar Rapids, Iowa 52406-3183
April 21, 2005
Estate of Kenneth Bushey
c/o Jan M Wiley Esq
130 W Church St Suite 100
Dillsburg PA 17019
RE: Annuity Number{s) 26142040
Dear Estate of Kenneth Bushey:
We have received notification, Kenneth A Bushey, annuitant of the
above listed non-qualified tax deferred annuity is deceased. Our
office wishes to extend sincere condolences for your loss.
Our records indicate the following annuity information:
Annuitant:
Owner:
Primary Beneficiary:
Annuity Policy Date:
Full Value as of 4/21/2Q05:
Taxable Portion:
Full Value as of 3/24/2005:
Kenneth A Bushey
Kenneth A Bushey
Estate of Kenneth A Bushey
April 19, 2001
$95,262.62
$15,263.24
$94,940.91
The attached document reflects the options available to the primary
beneficiary listed above.
The full value as of the date of death is for tax purposes only and is
not a guaranteed death benefit amount.
Operations performed on an automatic basis when applicable have been
terminated, such as; Systematic Payouts or Automatic Billing.
The attached document contains general tax information based on
Transamerica Life Insurance and Annuity Company's interpretation and
should not be relied upon for your personal tax planning. If you have
questions concerning the direct tax consequences when selecting an
option, you may wish to consult a tax advisor.
Mel11befoftl1e~EGO~.Grou}J
Any additional questions regarding this annuity can be directed to the
Annuity Service Center at 1-800-553-5957. A Transamerica Life
Insurance and Annuity Company representative will gladly assist you
with any questions you may have regarding this annuity and help you
meet your financial goals.
Sincerely,
$~tf;:til
Ansara C. Kula
Transamerica Life Insurance and Annuity Company
FMG Claims
Enclosure(s) :
Annuity Claimants Statement
Death Option Packet
Postage Paid Return Envelope
Death Option Packet
26142040
please submit. the following documents upon selection of an option,
defined below:
. Certified copy of the death certificate
. Original annuity policy
. Annuity Claimant's Statement
. Letters of Testamentary
The Claimant Information section on the Annuity Claimant's Statement
needs to be completed in the name of the estate. Please include the
estate's tax identification number and signature(s)of the executor(s)
Since the beneficiary is an estate, the Annuity Claimant.'s Statement
needs to be completed in the name of the estate, with the estate's tax
identification number and the signature of all executors. please do
not complete in the name of the executors.
As primary beneficiary of this annuity, the estate will have the
following options available for death claim processing:
Delay the Lump Sum Payment up to 5 years from date of death
As the executor, you will be responsible for notifying the company to
remove any remaining funds prior to December 31st of the fifth year
following the death.
Lump Sum Payment
The annuity funds will be disbursed to the estate in a lump sum
paYment.
please note, regardless of which option is chosen, the taxable amount
will be reported on a Form l099-R the January following the
distribution.
In certain circumstances, if the only beneficiary of the estate is the
spouse of the deceased, they may be allowed to continue the annuity in
their name as sole owner.
Court Ordered Processing / MA 1 MB3 02-10
P.O. Box 841005
Boston, MA 02284
April 22, 2005
The Wiley Group
Attention: Jan M. Wiley
130 W. Church St., Suite 100
Dillsburg, P A 17019
RE: Estate of Kenneth A. Bushey
Date of Death: 3/24/05
Dear Ms Wiley:
Per your request, enclosed please fmd the account information as of the date of death for
the above-named decedent. For your information, accrued interest is not included in the
date of death balance.
Please feel free to contact me if I can be of any further assistance.
Very truly yours,
tid~ Ot
'"
Laurie DiGiando nico
GAG Team Leader
(617) 533-1789
Enclosures
Sovereign Bank
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
Kenneth A. Bushey
195-07-4906
March 24, 2005
Account #: 0571143202 Type:
In the name of: Kenneth A. Bushey
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info:
Money Market Savings
Open date: 5/5/2003
$8,762.13
2/28/2005
$2.59
$3.21
Account #: 0575293048 Type:
In the name of: Kenneth A. Bushey
Date of Death Balance:
Int.(YTD) from 1/112005 to
Accrued interest to date of death:
Other Info:
CD
Open date: 9/20/2001
$15,714.88
2/28/2005
$17.11
$40.31
Account #: 1685167742 Type:
In the name of: Kenneth A. Bushey
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info:
CD
Open date:
2/5/1988
$10,163.46
2/28/2005
$14.47
$34.17
Account #: 1685374256 Type:
In the name of: Kenneth A. Bushey
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info:
CD
Open date: 10/18/1993
$20,095.99
2/28/2005
$27.94
$65.94
Account #: 1685374264 Type:
In the name of: Kenneth A. Bushey
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info:
CD
Open date: 10/18/1993
$10,048.00
2/28/2005
$13.97
$32.97
Page 1 of 2
Sovereign Bank
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
Kenneth A. Bushey
195-07-4906
March 24, 2005
Account #: 1685387001 Type:
In the name of: Kenneth A. Bushey
Date of Death Balance:
Int.(YTD) from . 1/1/2005 to
Accrued interest to date of death:
Other Info:
CD
Open date: 10/28/1996
$20,009.83
2/28/2005
$33.16
$78.27
Page 2 of2
+: CITIZENS BANK
525 William Penn Place
Suite 153-2510
Pittsburgh, P A 15219
May 5, 2005
THE WILEY GROUP
130 W. CHURCH STREET SUITE 100
DllLSBURG, PA 17019
Estate of KENNETH A BUSHEY
Date of Death: Mar 24, 2005
SSN: 195-07-4906
Dear SirfMadam:
In accordance with your request, the attached information sheet has been provided in the above decedent's
name as of his/her date of death.
For n... or LC accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please
call 1-888-999-6884.
Sincerely,
0gA~~
cLC~Walker. .' .
Operations Services
.~CITIZENS BANK
Account Number 6140708311
Account Title KENNETH A BUSHEY
Date Opened 11/1/1996
Account Type Time Deposits
Principal Balance as of DaD $25000.00
Interest from Last Posting to DaD $30.45
Account Balance as of DOD $25030.45
YTD Interest to DOD $152.26
.~CITIZENS BANK
Account Number 6100705145
Account Title KENNETH A BUSHEY
Date Opened 10/6/1982
Account Type Checking
Principal Balance as of DOD $98849.59
Interest from Last Posting to DOD $3.36
Account Balance as of DOD $98852.95
YTD Interest to DOD $.00
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22.29000
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lot: OlJl~!2005 co O)!2~/200~
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: 0300l/200S '
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o PNC13AN<
August 2, 2005
Jan M. Wiley, Esquire
130 W. Church Street, Suite 100
Dillsburg, PA 17019
RE: Estate of Kenneth A. Bushey, deceased
SSN: 195-07-4906
000: 3/24/2005
Dear Attorney Wiley:
In response to your request for Date of Death balances for the customer noted above, our
records show the following:
Certificate of Deposit
Account #21001013891
Established 02/10/1994
KENNETH A BUSHEY
DOD balance: $10,000.00 + $13.24 accrued interest
The decedent maintained Investment Account (INV #13533240). For further information,
you may call the Brokerage Department at 1-800-762-6111.
Please note that this office only provides date of death balances for deposit accounts
(lRAs, CDs, Checking and Savings accounts). We do not process any financial
traWl8ctions or provide statements. If you need assistance with any of these items,
please call1-888-PNC-BANK (1-888-762-2265) or stop by yoor local PNC Bank branch
office.
Sincerely,
~mlL 1JJJ1h
Rachelle Wells
1-800-762-1775
P7-PFSC-04-F
500 first AVe.
Piusburgh PA ]$2]9
Member FDIC
-r,-,"'T"^I n ri-1
Rev.1510 EX+ (8-98)
*'
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BUSHEY, KENNETH A.
FILE NUMBER
21-05-00304
ESTATE OF
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 DECO'S TAXABLE
EXCLUSION
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 Conseco Services, Annuity No. 01A114068 9.939.58 9,939.58
(Kenneth R. Bushey, beneficiary):
TOTAL (Also enter on Line 7, Recapitulation) 9,939.58
(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 G (Rev. 6-98)
CONSECO SERVICES, L.L.C.
P.O. BOX 1982
CARMEL IN 46082-1982
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CONSECO..
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September 2, 2005
Mr. Kenneth Ray Bushey
519 North Lewisburg Road
Mechanicsburg, PA 17055-6019
Re: Annuitant/Owner - Kenneth A. Bushey, deceased
Policy No. 01A114068
Dear Mr. Bushey:
We have completed a review ofthe recent claim for benefits under the above policy and
are pleased to advise that we will be issuing a check in the amount of$9,939.58. This
represents the full value of this policy's benefit and will require the personal endorsement
of the payee.
Death benefits for this check were calculated as follows:
Face Value
Total Death Benefits
$9.939.58
$9,939.58
No portion of this death benefit is taxable.
Very truly yours,
!Nancy CPatricia 9rl.ay
Nancy Patricia May
Claims Examiner
Annuity Claims Department
cc: Dawn Gladfelter I The Wiley Group
REV-1151 EX+ (12-99)
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BUSHEY, KENNETH A.
FILE NUMBER
21-05-00304
ESTATE OF
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
See continuation schedule(s) attached
10,494.86
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
B.
Stephen R. Eberly
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address 2176 Merrimac Ave.
City Mechanicsburg State
Year(s) Commission paid 2005
See continuation schedule(s) attached
PA
Zip 17055
38,500.00
2.
Attorney's Fees
See continuation schedule(s) attached
38,500.00
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
614.00
See continuation schedule(s) attached
5. Accountant's Fees
6.
Tax Return Preparer's Fees
133.00
See continuation schedule(s) attached
7.
Other Administrative Costs
See continuation schedule(s) attached
0.00
TOTAL (Also enter on line 9, Recapitulation)
88,241.86
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
RESIOENT DECEDENT
BUSHEY, KENNETH A.
FILE NUMBER
21-05-00304
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Cocklin Funeral Home:
10.268.43
2
Steve Eberly (after funeral dinner):
226.43
Subtotal
10.494.86
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
Rev-1602 EX+ (6-98)
.
SCHEDULE H.B1
PERSONAL REPRESENTATIVE'S
COMMISSIONS
continued
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BUSHEY, KENNETH A.
FILE NUMBER
21-05-00304
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Stephen R. Eberly (Executor fee):
38.500.00
Subtotal
38.500.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B1 (Rev. 6-98)
ReY-1502 EX+ (6-98)
.
SCHEDULE H-82
ATTORNEY'S FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BUSHEY, KENNETH A.
FILE NUMBER
21-05-00304
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
The Wiley Group:
38.500.00
Subtotal
38.500.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B2 (Rev. 6-98)
Rev-1502 EX+ (6-98)
SCHEDULE H.B4
PROBATE FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BUSHEY, KENNETH A.
FILE NUMBER
21-05-00304
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Register of Wills (probate):
614.00
Subtotal
614.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule H-B4 (Rev. 6-98)
Rev-1502 EX+ (6-98)
*'
SCHEDULE H-B6
TAX RETURN
PREPARER'S FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BUSHEY, KENNETH A.
FILE NUMBER
21-05-00304
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
A to Z Tax Service:
133.00
Subtotal
133.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B6 (Rev. 6-98)
Rev-1512 EX+ (6-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BUSHEY, KENNETH A.
FILE NUMBER
21-05-00304
ESTATE OF
Include unrelmbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1 Alert Pharmacy:
VALUE AT DATE
OF DEATH
12.58
2 Bank Fee (checks):
9.95
3 Messiah Village (last illness):
3.739.64
4 PA Dept. of Revenue (2004 taxes):
46.00
TOTAL (Also enter on Line 10, Recapitulation)
3,808.17
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
REV-1513 EX" (9.(lO)
*'
SCHEDULE ~
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
BUSHEY, KENNETH A. 21-05-00304
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not Ust Trustee(s)
I. TAXABLE DISTRIBUTIONS [include outright Sfrousal
distributions, and ransfers
under Sec. 9116(a)(1.2)]
1 Keith Bushey Grandson six percent
211 Bishop Road
Mechanicsburg, PA 17055
2 Kenneth R. Bushey Son Thirty percent
519 North Lewisberry Rd. Ext.
Mechanicsburg, PA 17055
3 Kent Bushey Grandson six percent
126 Manor Drive
Di/lsburg, PA 17019
4 Kevin Bushey Grandson six percent
12 Audubon Park
Di/lsburg, PA 17019
5 Gordon E. Eberly Grandson twenty percent
30 Lee Ann Court
Enola, PA 17025
See continuation schedule attached Continuation
Total
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 6-98)
SCHEDULE ..
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
KENNETH A. BUSHEY 195-07-4906 03/24/2005
Item Name and Address of Person(s) Share of Estate Amount of Estate
Number Receiving Property Relationship (Words) ($$$)
6 Margaret Eberly Granddaughter six percent 0.00
2176 Merrimac Avenue
Mechanicsburg, PA 17055
7 Stephen R. Eberly Grandson twenty percent 0.00
2176 Merrimac Avenue
Mechanicsburg, PA 17055
8 Stephen R. Eberly, Jr. Grandson six percent 0.00
2176 Merriman Avenue
Mechanicsburg, PA 17055
Total
1
Register of Wills of
Cumberland
INVENTORY
Estate of KENNETH A. BUSHEY
also known as
. Deceased
County, Pennsylvania
No. 21-05-0304
Date of Death 03/24/2005
Social Security No. 195-07-4906
Stephen R. Eberly
- --, ----- --- ---- ..----.---.-.-- -- --
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.
Attorney:
Personal Representative /
,
Jan M. Wiley
06298
Signature:
1.0. No.:
Signature:
Firm:
Wiley, Lenox, Colgan, & Marzzacco,
nPA~.
Signature:
Address: 130 W. Church St
_[)iIISEu_r9!F'A 17019
Telephone: 717 -432-9666
Address: 2176 Merrimac Ave.
Mechanicsburg, PA 17055
Telephone: 717-697-5031
Dated:
II-~d ~-o'5"
Personal Property
Cash...............................................................................................
M iscella neous Property................................................................
StOcks/Listed................................................................................ .
Stocks/Closely Held......................................................................
Bonds.............................................................................................
Partnerships and Sole Proprietorships .....................................
Mortgages and Notes Receivable...............................................
Total Personal Property.........................................
Total Real Property................................. ...............
Total Personal and Real Property.........................
Total Out-ot-State Real Property..........................
v"-
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761,037.29,
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761,037.29
761,037.29/
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In the Court of Common Pleas of
Cumberland
County, Pennsylvania
IN RE:
ORPHANS' COURT DIVISION
Estate of
KENNETH A. BUSHEY
NO. 21-05-00304
Status Report Under Rule 6.12
Name of Decedent: KENNETH A. BUSHEY
Date of Death: 3/24/2005
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with
respect to completion of the administration of the above-captioned estate:
1.
State whether administration of the estate is complete:
Yes X No
,")
2.
If the answer is No, state when the personal representative reasonably believes that the
administration will be complete.
3.
If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes No X
b. The separate Orphans' Court No. (if any) for the personal representative's account is:
c. Did the personal representative state an account informally to the parties in interest:
Yes X No
d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may
be filed with the Clerk of Orphans' Court and may be attached to this report.
Date:
/I /~"$ los-
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Jan M. Wiley
130 W. Church St.
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Telephone: 717-432-9666
Capacity:
Personal Representative
X Counsel for Personal Representative
~~.