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PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
REV-1500 EX + (6-00)
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Arrigo, Genevieve
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
OFFICIAL USE ONLY
FILE NUMBER
II 05
0801
NUMBER
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
067-14-0085
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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03-13-1922
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4a. Future Interest Compromise (date of death
after 12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy ofTrust)
10 Spousal Pover\}' Credit (date of death between
. 12-31-91 and 1-1-95)
D 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
o 1. Original Return
D 4. Limited Estate
D 6. Decedent Died Testate (Attach
copy of Will)
D 9. Litigation Proceeds Received
2. Supplemental Return
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL)
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NAME COMPLETE MAILING ADDRESS
Diane G Radcliff, Esquire
FIRM NAME (If applicable)
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TELEPHONE NUMBER
(717) 737-0100
3448 Trindle Road
Camp Hill, PA 17011
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)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L) D Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
None
None
None
None
23,427.39
None
None
.....-.-.-.-.-.-.-.-.-.....'.'...'....-.-.~-.-.-.-...-.'.....'.....~.-.-.-.-.-..............~...-.-.-.-.-.-...........,
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: OFFICIA,L USE ONLY i
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(8)
23,427.39
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)
(9)
(10)
5,242.51
3,272.14
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)
(11 )
8,514.65
14,912.74
0.00
(12)
(13)
(14)
14,912.74
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
0.00
671.07
0.00
0.00
671.07
20. IXl
. . .................................>>...<<.......~~~$tlij.1;.iQAij$.WImAAJ.;qQ$$tl9N$.QN~~R~l$.mPi;Aji@ijl$9l'l$QkMAiH#{i...............................
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Copyright 2002 form software only The Lackner Group, Inc.
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 .045 (16)
i= 16. Amount of Line 14 taxable at lineal rate 14,912.74 x
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a.. 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 x
~ 19. Tax Due
(19)
Form REV-1500 EX (Rev. 6-00)
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Decedent's Complete Address:
STREET ADDRESS
1700 Market Street
CITY Camp Hill
I STATE PA
IZIP 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
671.07
665.00
33.55
Total Credits (A + B + C)
(2)
698.55
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)
27.48
(5)
(5A)
(5B)
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 [!]
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.............. D [!]
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 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 of pre parer other than the personal representative is based on all information of which preparer has any knowledge.
ADDRESS DATE
202 Locust Drive
New Cumberland, PA 17070
ADDRESS
DATE
ADDRESS
DATE
3448 Trindle Road
Camp Hill, PA 17011
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) (i1)]. The statute does not exemct 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
Arrigo, Genevieve
FILE NUMBER
21-05-0801
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 Conner Rich Associates
VALUE AT DATE
OF DEATH
10.95
2 PNC Account No. 5004460795
680.61
3 PNC Account No. 5004561668
22,735.83
TOTAL (Also enter on Line 5, Recapitulation)
23.427.39
(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-1151 EX+(12-99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Arrigo, Genevieve
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-05-0801
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 4,551.72
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City State Zip
-
Year(s) Commission paid
2. Attorney's Fees Diane G Radcliff, Esquire
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 93.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 597.79
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 5,242.51
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 REnJRN
RESIDENT DECEDENT
ESTATE OF
Arrigo, Genevieve
FILE NUMBER
21-05-0801
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Adam Dennis - Food and flowers
870.19
2
Barbara Dennis - Funeral Food and payment to Deacon
92.00
3
Smith McCracken Funeral Home
3,589.53
Subtotal
4,551.72
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 RElURN
RESIDENT DECEDENT
ESTATE OF
Arrigo, Genevieve
FILE NUMBER
21-05-0801
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Catherine Alvarez - Reimbursement for death certificates and postage
72.79
2
Register of Wills - Filing fee - Inventory and Inheritance Tax Return
25.00
3
Reserve - Additional expenses/costs
500.00
Subtotal
597.79
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
Arrigo, Genevieve
FILE NUMBER
21-05-0801
ESTATE OF
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1 Burick Azizkhan Internal Medicine
VALUE AT DATE
OF DEATH
300.00
2 Conner Rich Associates
3 Health South - Mechanicsburg
4 Manor Care - Beauty Parlor Bill
5 Philhaven - consultation
6 Q Card Credit Card Balance
7 Quantum Imaging
8 Quest Diagnostics
9 Real Care of California
10 Smith Radiology
10.95
2,207.00
24.00
52.86
55.92
16.22
536.19
35.00
34.00
TOTAL (Also enter on Line 10, Recapitulation)
3,272.14
(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 FILE NUMBER
Arrigo, Genevieve 21-05-0801
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List Trusteelsl
I. TAXABLE DISTRIBUTIONS [include outright srrousal
distributions. and ransfers
under Sec. 9116(a)(1.2)]
Catherine E Alvarez Daughter
202 Locust Drive
New Cumberland, PA 17070
Salvatore Arrigo, Jr. Son
8016 Poulson Street
Citrus Heights, CA 95610
Barbara A Dennis Daughter
3 Perogino Road
Newton,NJ 07860
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)
EFORM 1 004720900
o
. BAN<
Your account was DEBITED for the following reason:
o Check # posted on
IX] Closed account 5004561668
o Branch adjustment (branch name)
o Service charge error
o Other:
encoding error _ posted to incorrect account
Account Number
File ID
AMOUNT $ 22,735.83
5004561668
040
o GENEVIEVE ARRIGO
E 202 LOCUST DR
B NEW CUMBERLAND, PA 17070-3043
1
T
I
PNC Bank, National Association
FOR BANK USE ONLY
Branch #/Dept. #
0000101
Date
09/10/2005
Prepared By (PRINT Name)
KEVIN K RENNE
Authorized By
Customer's Advice of charge
EFORM100472.0900
o
BAN<
Your account was DEBITED for the following reason:
o Check # __ posted on
IX] Closed account 5004460795
o Branch adjustment (branch name)
o Service charge error
o Other:
encoding error _ posted to incorrect account
Account Number
File ID
AMOUNT $ 680.61
5004460795
040
o GENEVIEVE ARRIGO
E 202 LOCUST DR
B NEW CUMBERLAND, PA 17070-3043
I
T
I
PNC Bank, National Association
FOR BANK USE ONLY
Branch #/Dept. # Date
0000101 09/10/2005
Prepared By (PRINT Name) Authorized By
KEVIN K RENNE .
Customer's Advice of Charge
c
ARRlGOG
V oucher No.
99,500
HERITAGE MEDICAL GROUP
GENEVIEVE ARRIGO
Check Date:9/22/2005
Check No. 88350
Discount Taken Amount Paid
Invoice No.
Date
Invoice Amount
CONNER RICH 6/28/0: 9/13/2005
Cust No. PATIENT REFUND
$10.95
Deltfi.x q I~ oC:;
$10.95
'"
$0.00
$0.00
88350
$10.95
$10.95
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Series
I EE Bonds
Denomination
Serial Number
Issue Date
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$ 1200-_::1
Results
# Bonds Total Price Total Interest Total Value YTD In
65 $5,225.00 $2,601.46 $7,826.46 $173.
Issue Interest Next Final
Serial Number Issue Date Series Denom Price Interest Value Rate Accrual Maturit~
r130509453ee 02/1996 EE $200 $100.00 $45.44 $145.44 3.23% 02/2006 02/202(
r 130509451 ee 02/1996 EE 200 100.00 45.44 145.44 3.23% 02/2006 02/202(
rl30509452ec 02/1996 EE 200 100.00 45.44 145.44 3.23% 02/2006 02/202(
rl2371332gee 05/1995 EE 200 100.00 49.28 149.28 3.23% 11/2005 OS/202:
rl25110807ee 07/1995 EE 200 100.00 49.28 149.28 3.23% 01/2006 07/202:
rl ]8058742ee ] 1/1994 EE 200 100.00 58.32 158.32 3.]0% ] 1/2005 ] 1/202"
rl1805874] ee ] 1/] 994 EE 200 100.00 58.32 ] 58.32 3.10% 11/2005 11/202"
r117140782ee 1 1/1 994 EE 200 100.00 58.32 158.32 3.10% 11/2005 11/202"
r112746041ee 07/1994 EE 200 100.00 62.00 162.00 3.28% 01/2006 07/202"
rl ] 2746042ee 07/1994 EE 200 100.00 62.00 162.00 3.28% 01/2006 07/202"
rl12746043ee 07/1994 EE 200 100.00 62.00 ]62.00 3.28% 01/2006 07/202"
rl25110808ee 07/1995 EE 200 I 00.00 49.28 149.28 3.23% 01/2006 07/202:
r12511080gee 07/1995 EE 200 100.00 49.28 ] 49.28 3.23% 01/2006 07/202:
r1251108]Oee 07/]995 EE 200 100.00 49.28 ]49.28 3.23% 01/2006 07/202:
r1251108] lee 07/1995 EE 200 100.00 49.28 149.28 3.23% 01/2006 07/202:
r 123 713 3 3 I ee 05/1995 EE 200 ] 00.00 49.28 149.28 3.23% I ] /2005 OS/202:
rl23 713330ee 05/1995 EE 200 ] 00.00 49.28 149.28 3.23% ] 1/2005 OS/202:
rl23713328ee 05/1995 EE 200 100.00 49.28 149.28 3.23% 11/2005 OS/202:
rl12746040ee 07/1994 EE 200 100.00 62.00 162.00 3.28% 01/2006 07/202"
r11714078]ee ] 1/1994 EE 200 100.00 58.32 ] 58.32 3.10% 11/2005 ] 1/202"
rl17140783ee 11/1994 EE 200 ] 00.00 58.32 158.32 3.10% 11/2005 1 ] /202"
rl]7140785ee 11/1994 EE 200 100.00 58.32 158.32 3.]0% 11/2005 11/202L
rl17140784ee 1 ] /1994 EE 200 100.00 58.32 158.32 3.10% 11/2005 11/202L
rl17010013ee 1 0/1 994 EE 200 100.00 59.60 159.60 2.97% 10/2005 10/202L
rl17010014ee 10/1 994 EE 200 100.00 59.60 159.60 2.97% 10/2005 1 0/202L
rl17010015ee 10/1 994 EE 200 100.00 59.60 159.60 2.97% 10/2005 10/202L
rl17010016ee 10/1994 EE 200 100.00 59.60 159.60 2.97% 10/2005 10/202L
rl1274603gee 07/1994 EE 200 100.00 62.00 162.00 3.28% 01/2006 07/202"
http://wwwS. publicdebt. treas.gov/BC /SBCPrice
8/26/2005
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Sa,,'il~g~~ Bond Calculator Page 2 of3
c69011829gee 09/1999 EE 100 50.00 13.24 63.24 3.25% 09/2005 09/202(
c696271115ee 11/1999 EE 100 50.00 12.52 62.52 3.42% 09/2005 11/202(
c69128624gee 1 0/1999 EE 100 50.00 13.08 63.08 3.25% 09/2005 10/202(
c688783135ec 08/1999 EE 100 50.00 13.40 63.40 3.42% 09/2005 08/202(
t$.,
c687763~0Iee 071\ 999 EE 100 50.00 13.56 63.56 3.42% 09/2005 07/202(
c682905916ee 06/1 999 EE 100 50.00 13.76 63.76 3.42% 09/2005 06/202(
c699139900ec 02/2000 EE 100 50.00 12.00 62.00 3.42% 09/2005 02/203(
c679610063ce 05/1999 EE 100 50.00 13.92 63.92 3.42% 09/2005 OS/202(
c678763020ee 04/1 999 EE 100 50.00 14.40 64.40 3.25% 09/2005 04/202(
c671993881ee 03/1999 EE 100 50.00 14.60 64.60 3.25% 09/2005 03/202(
c671343726ee 02/1999 EE 100 50.00 14.76 64.76 3.42% 09/2005 02/202(
c6986 7 ()()()3ec OJ/2000 EE 100 50.00 12.16 62.16 3.42% 09/2005 01/203(
c462833220ee 02/ 1994 EE 100 50.00 32.68 82.68 3.22% 02/2006 02/202"
c504160761ec 12/1 994 EE 100 50.00 29.16 79.16 3.10% 12/2005 12/202L
c473360174ee 07/1994 EE 100 50.00 31.00 81.00 3.28% 01/2006 07/202L
c473360173ee 07/1994 EE 100 50.00 31.00 81.00 3.28% 01/2006 07/202"
c469708244ee 04/1994 EE 100 50.00 3 1 .44 8 1 .44 3.10% 10/2005 04/202"
C516614467EE 05/1995 EE 100 50.00 24.64 74.64 3.23% I1/:Z005 OS/202:
C541051572EE 10/1995 EE 100 50.00 23.52 73.52 3.cl7% 10/2005 10/202:
C515067950EE 04/1995 EE 100 50.00 27.96 77.96 3.03% 10/2005 04/202:
C509023266EE 02/1995 EE 100 50.00 29.16 79.16 3.10% 02/2006 02/202:
C514474287EE 03/1995 EE 100 50.00 27.96 77.96 3.03% 09/2005 03/202:
C662725483EE 12/1998 EE 100 50.00 15.12 65.12 3.42% 09/2005 12/202~
C652383917EE 07/1998 EE 100 50.00 16.68 66.68 3.42% 09/2005 07 /202~
045845701 EE 07/1995 EE 500 250.00 123.20 373.20 3.23% 01/2006 07/202:
045845700EE 0711995 EE 500 250.00 123.20 373.20 3.23% 01 /2006 07/202:
D45845702EE 07/1995 EE 500 250.00 123.20 373.20 3.23% 01/2006 07/202:
045845703 EE 0711995 EE 500 250.00 123.20 373.20 3.23% 01/2006 07/202:
L565829080EE 04/1998 EE 50 25.00 8.98 33.98 3.25% 09/2005 04/202~
L570740335EE 11/1998 EE 50 25.00 7.66 32.66 3.42% 09/2005 II /202~
L569436744EE 09/1998 EE 50 25.00 8.14 33.14 3.25% 09/2005 09/202~
L525624860EE 01/1995 EE 50 25.00 14.58 39.58 3. I 001<) 01/2006 01/202:
L566034367EE 05/1998 EE 50 25.00 8.52 33.52 3.42% 09/2005 OS/202~
L566278016EE 06/1998 EE 50 25.00 8.42 33.42 3.42% 09/2005 06/202~
L566559399EE 07/1998 EE 50 25.00 8.34 33.34 3.42% 09/2005 07 /202~
1509701973ee 04/ I 993 EE 50 25.00 17.76 42.76 3.03% 10/2005 04/202:
1570355168ee 1011998 EE 50 25.00 8.06 33.06 3.25% 09/2005 I 0/202~
8/26/2005