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. REV. 1500 EX + (6..o0)
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
00857
NUMBER
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
....
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
McLain, Clifford James
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
09/06/2005
09/08/1923
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL)
156-14-4203
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
~ 1. Original Return 0 2. Supplemental Return
w
.... 0 Limited Estate 0 Future Interest Compromise (date of death after
~~~ 4. 4a.
12-12-82)
w"-U ~ 0
:x:OO 6. Decedent Died Testate (Attach copy 7. Decedent Maintained a Living Trust (Attach
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,,-Ill 01 Will) copy 01 Trust)
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..: 0 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (date 01 death between
12-31-91 and 1-1-95
o 3. Remainder Return (date 01 death prior to 12-13-82)
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)
THIS SECTION MUST BE COMPLETED. AlL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
AME COMPLETE MAILING ADDRESS
!z Christopher E. Rice, Esquire
~ IRM NAME (II applicable)
~ Martson Deardorff Williams & Otto
"-
ELEPHONE NUMBER
717/243-3341
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3, Closely Held Corporation, Partnership or Sole-Proprietorship
4, Mortgages & Notes Receivable (Schedule D)
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5
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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)
Ten East High Street
Carlisle, P A 17013
(1 ) None
(2) None 1"~
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(3) None .:-......
(4) None )
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(5) 49,926.53 eX1
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(6) None -~, .-,
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(7) None ['0 1"['1
(8) c::::> 49,926.53
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(9) 6,593.99
(10) 3,012.30
(11 )
9,606.29
(12)
40,320.24
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)
40,320.24
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 .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
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"- 17. Amount of Line 14 taxable at sibling rate x .12 (17)
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0
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~ 18. Amount of Line 14 taxable at collateral rate 40,320.24 x .15 (18) 6,048.04
....
19. Tax Due (19) 6,048.04
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
>> BE SURE TO ANSWER Al&:QUESTIONSON REVERSE SIDEANl) RECHECK MATH <<
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
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Decedent's Complete Address:
STREET ADDRESS
16 Clay Road
CITY
Carlisle
STATE PA
ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
6,048.04
302.40
Total Credits (A + B + C)
(2)
302.40
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty (D + 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) 0.00
(4)
(5) 5,745.64
(5A)
(5B) 5,745.64
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:
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 desig nation?....................................................... ...............................................................
Yes No
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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.
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
Carolyn R. Henry 140 Belvedere Street
Carlisle,PA 17013
DATE
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
7
ADDRESS
DATE
l~l5" /OS
ADDRESS
DATE
~
Ten East High Street
Carlisle, PA 17013
/ d.-/S /0-5
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. 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 spouse is 0%
[72 P.S. 99116 (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 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.
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McLain, Clifford James
I FILE NUMBER
21 - 05 - 00857
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
1
DESCRIPTION
VALUE AT DATE OF
DEATH
46,942.31
Citizens Bank, Money Market Acct. No. 610073-248-7
2
Citizens Bank, Checking Acct. No. 610073-513-3
1,142.22
3
1997 Chevrolet Cavalier, 2-door coupe, fair condition
1,700.00
4
Personal property, appraised value
142.00
TOTAL (Also enter on Line 5, Recapitulation)
49,926.53
ESTATE OF
ITEM
NUMBER
A.
B.
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SCHEDULE H
FUNERAL EXPENSES &
ADIVIINIS1RATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
McLain, Clifford James
I FILE NUMBER
21 - 05 - 00857
Debts of decedent must be reported on Schedule I.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
Hoffman-Roth Funeral Home, Carlisle, P A
2
St. John's Church, collumbarium
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City
Year(s) Commission paid
State _ Zip
2.
Attorney's Fees
Martson Deardorff Williams & Otto (estimated)
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.
Register of Wills, Cumberland County
Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Cumberland Law Journal, advertising Letters Testamentary
2
The Sentinel, advertising Letters Testamentary
Total of Continuation Schedule(s)
TOTAL (Also enter on line 9, Recapitulation)
2,169.70
500.00
3,250.00
136.00
75.00
144.29
319.00
6,593.99
.
Schedule H
Funeral Expenses &
Mninistrative Cos1s continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McLain, Clifford James
I FILE NUMBER
21 - 05 - 00857
3
Register of Wills, filing fee, inheritance tax return
15.00
4
Register of Wills, short certificate
4.00
5
State Farm Insurance, vehicle insurance pending disposition
200.00
6
Reserved for additional probate, filing fees
100.00
Page 2 of Schedule H
ESTATE OF
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SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
McLain, Clifford James
I FILE NUMBER
21 - 05 - 00857
Include unreimbursed medical expenses.
ITEM
NUMBER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
DESCRIPTION
AMOUNT
Citizens Bank, checking 610073-513-3, outstanding check on date of death
9.73
Martson Deardorff Williams & Otto, account payable for estate planning
400.00
81. John's Episcopal Church, Carlisle, PA, balance due on pledge
780.00
Cumberland Valley Nephrology Asso., account payable
34.24
Belvedere Medical Corporation, account payable
45.72
Carlisle Regional Medical Center, account payable, June admission
936.46
Masland & Associates, account payable
253.03
Lancaster HMA Physicians Management, account payable
30.61
Pinker & Associates, account payable
25.17
Walnut Bottom Radiology, account payable
33.01
Watershed Urology, account payable
144.49
Cumberland Pathology Asso., account payable
107.47
Blue Mountain Anesthesia Asso., account payable
16.05
Central Penn Management Group, account payable
16.05
Andora Radiology, account payable
45.96
Central Penn Medical Group, ER, account payable
29.60
18 Note: The above medical bills are not reimbursable by insurance
Bronstein Jeffries, P.A., account payable
104.71
TOTAL (Also enter on Line 10, Recapitulation)
3,012.30
.REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McLain, Clifford James
I FILE NUMBER
21 - 05 - 00857
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE
n. .._
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1 Carolyn R. Henry Niece Entire residue
140 Belvedere Street, Carlisle, PA 17013
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
F: IFILESIDA T AFILE\Estate Planningl 117 56. I. will
11756.1/8/8/05/clm
LAST WILL AND TESTAMENT
JRIGINAL RETAINED BY'
IAW OFFICES
c::://;1mhol2 :Dw'l.do-r,ff <'Wd'llam;,.
A PROFESSIONAL CORflORAlIOI'J
TEN EAST HIGH STREET
<"ARUSLE. PA 17013
'"'171 2.43.3341
I, CLIFFORD JAMES McLAIN, of West Pennsboro Township, Cumberland County,
Pennsylvania, being of sound and disposing mind and memory, do hereby make, publish and declare
this to be my Last Will and Testament, hereby revoking any and all former Wills or Codicils made
by me.
1.
I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and
all death taxes (whether such taxes may be payable by my estate or by any recipient of any property)
shall be paid from my residuary estate as soon as practicable after my decease and as part of the
administration of my estate. My Executrix shall have no duty or obligation to obtain reimbursement
for any such tax so paid, even though on proceeds of insurance or other property not passing under
this Will.
2.
I give, devise and bequeath all of my estate, both real and personal property, unto my niece,
CAROLYN R. HENRY, absolutely.
3.
I nominate, constitute and appoint CAROLYN R. HENRY as Executrix of my estate.
4.
I direct that my Executrix shall not be required to file a bond to secure the faithful
performance of her duties in any jurisdiction.
5.
I authorize and empower my Executrix, in her sole and absolute discretion, to purchase or
otherwise acquire and retain any investments of which I die seized or any real or personal property
of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of or grant options in
regard to any or all property of any kind forming a part of my estate for such terms and such prices
as she may deem advisable; to borrow money for any purposes connected with the protection and
preservation of my estate; to mortgage or pledge any real or'personal property forming a part of my
, }
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[Initials]
Page 1 of 3 Pages
estate or to join in or secure the partition of same; to compromise any claims or demands of my
estate against others or of others against my estate; to make distribution in kind and to cause any
share to be composed of cash, property or undivided fractional shares in property different in kind
from any other share; to employ agents, attorneys and proxies and to delegate to them such power
as my Executrix considers desirable and to pay reasonable compensation for such services as may
be rendered by such agents, attorneys and proxies; and to execute and deliver such instruments as
may be necessary to carry out any ofthese powers. In addition, I direct that my Executrix shall have
the power to conduct an inventory of any safe deposit box necessary to the administration of my
estate.
IN WITNESS WHEREOF I have hereunto set my hand and seal this
;ft1/l.i :s...-t. ,,~xLtS-
:;,r:) /J(ctay of
L~;,;...... (SEAL)
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testator, as and
for his Last Will and Testament, in the presence of us, who at his request, have hereunto subscribed
our names as witnesses thereto, in the presence of the said Testator and of each other.
U~ 5 }It
Page 2 of 3 Pages
COMMONWEALTH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERLAND )
We, Clifford James McLain, ChristopherE. Rice, Esquire, and JI \/l'Jfi'lflln. i.Ii:! I.dr,., .'"." ~
the Testator and witnesses, respectively, whose names are signed to the 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 that the Testator has signed willingly, and that the Testator
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 the Will as a witness and that to the
best of his /her knowledge the Testator was at that time eighteen years of age or older, of sound mind
and under no constraint or undue influence.
(J
1 (l!.-L.',,,--
&.~ S. fL-
Witness
~ ~f!l]V~ ~
Wltnes -
Subscribed, sworn to and acknowledged before me by Clifford James McLain, the Testator,
and subscribed and sworn to before me by Christopher E. Rice, Esquire and
~f""L"l. {1!ol1 12 '*". I~ .;J. , the witnesses, this d. 3"<~y of Iho"sr, ",).0&'::'-.
/! '\...
N~P~bt~,j-(:~\,,.c.. lLL(je/Ujj
NOTARIAL SEAL
CORRINE L. MYERS, NOTARY PUBLIC
CARLISLE BORa, COUNTY OF CUMBERLAND
MY COMMISSION EXPIRES MAY 27,2007
Page 3 of 3 Pages