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Home My WebLink About12-14-05 REV-I500 FX (6-00) OFFICIAl USE ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ~L COUNlY CODE -..9~ 0331 _ _ _ YEAR NUMBER I- Z W o w u w o DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) Adams Elizabeth DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 3/13/2005 1/14/1904 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) M SOCIAL SECURITY NUMBER 193-24-1729 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER W I- :.: :$(/) UO:::': Wo.U zOO UO::...J o.lll 0. < [Xl 1 Original Relum D 4. Limiled Estale [Xl 6. Decedent Died Testale (Mach copy of Will) D 9. Litigation Proceeds Received D 2. Supplemental Relum D 3. Remainder Relum (date of death prior!o 12-13-82) D 4a. Future Interest Compromise (date of death after 12-12-82) D 5. Federal Eslale Tax Return Required D 7. Decedent Maintained a Living Trust (Attach copy oITrust) L 8. Tolal Number of Safe Deposit Boxes D 10. Spousal Poverty Credil (dale or death between t2-31-91 and 1-1-951 D 11. Election to tax under Sec. 9113(A){AltachSchO) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS I- Z ILl o Z o 0- m ILl ~ a:: o () Richard C. Snelbaker FIRM NAME (If Applicable) Snelbaker & Brenneman, P.C. TELEPHONE NUMBER 44 West Main Street Mechanisburg, PA 17055 717-697-8528 0.00 2,691.00 0.00 OFFICIAL USE ONloY ---I 1. Real Estate (Schedule A) (1) 2 Stocks and Bonds (Schedule B) (2) : -' I ,~) ).-~ -or .-~ ') 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Noles Receivable (Schedule D) (4) 5. Cash, Bank Deposils & Miscellaneous Personal Property (Schedule E) (5) Z 6. Joinlly Owned Property (Schedule F) (6) 0 D Separale Billing Requesled I- ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probale Property (7) ::::> (Schedule G or L) l- ii: 8. Total Gross Assets (total Lines 1-7) ~ U W 9. Funeral Expenses & Administrative Costs (Schedule H) (9) e::: 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) I: (--;, 0.00 4,738.24 1,044.24 ~-, 0.00 ..;- (8) 2,462.27 54,094.19 8,473.48 (13) 56,556.46 (48,082.98) 0.00 (11) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) (12) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) (48,082.98) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amounl of Line 14 taxable at the spousal lax rate, or lransfers under Sec. 9116 (a)(1.2) 0.00 x .0 ~(15) 0.00 x.o 45 (16) 0.00 x .12 (17) 0.00 x .15 (18) (19) 0.00 0.00 0.00 z o j:: < I- ::J 0.. :!; o U X < I- 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 laxable at sibling rale 18. Amount of Line 14 taxable at collateral rale 0.00 0.00 19_ Tax Due 20. ~ CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT :>:> BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < 3W4645 1.000 Decedent's Complete Address: SiREET ADDRESS Claremont Nursing and Rehab Center Cumberland County. Middlesex Township CIIY I STATE I ZIP Carlisle PA ~7013- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 0.00 0.00 0.00 3. Interest/Penalty if applicable D. Interest E, Penalty Total Credits (A + B + C) (2) 0.00 0.00 0.00 TotallnterestlPenalty (D + E) (3) 0.00 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 (4) 0.00 5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check to: REGISTER OF 0.00 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;. . . . . . . . . . . . . . . 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 preparer other than the personal representative is based on all information of which preparer has any knowledge. OF PE;8S0N RESPONSIBLE FOR FILING RE RN DATE Yes No ~ ~ ~ USJ ~ og ADDRESS / -- r~ 303 Shepherds town Rd., Mechanicsburg, PA 17055 DAT . ~ !DS-- 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. S 9916 (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. S 9116 (a) (1.1) (il)J 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 vaiue 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. S 9116(a)(1.2)J. 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 PS. S 9116(1.2) [72 P .8. S 9116(a)(1 )J. 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. S 9116(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. 3W4646 1.000 REV-1503 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS & BONDS FILE NUMBER Elizabeth M. Adams 21 05 0331 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. Prudential Financial 46 shares of common stock, valued at $58.50 per share VALUE AT DATE OF DEATH 2,691.00 3W4696 1.000 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 2,691.00 R EV-150~ EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Elizabeth M. Adams FILE NUMBER 21 05 0331 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 VALUE AT DATE OF DEATH 1 PNC Bank, N.A. Interest accrued to 3/13/2005 Savings account #5030011109 4,737.27 0.97 3W46AD 1000 TOTAL (Also enter on line 5, Recaoitulationl $ (If more space is needed, insert additional sheets of the same size) 4,738.24 REV-1509 Ex + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Elizabeth M. Adams SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER 21 05 0331 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 ADDRESS RELA TlONSHIP TO DECEDENT A. Adams, John J 525 7th Street, New Cumberland, PA 17070 Son B. c. JOINTLY-OWNED PROPERTY: LEnm DATE DESCRIPTlON OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINA.NCIAL INSTITUTION AI'V BJoJ.I< ACCOLNT DATE OF DEATH DECD'S VALUE OF N...MBER OR SIMILAR IDENTIFYING MJMBER. ATTACH DEED FOR NUMBER TENANT JOINT ..K)INTL Y -I-ELD REAL EST ATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 1 A 3/1/1999 PNC Bank, N.A. 2,088.47 50.0000 1,044.24 checking account #5000632297 TOT AL (Also enter on line 6, Recaoitulationl $ 1,044.24 ,W46AE 1.000 {If more space is needed, insert additional sheets of the same size} REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Elizabeth M. Adams FILE NUMBER 21 05 0331 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. James R. Gingrich Memorials inscription on cemetery marker 100.00 B. 1. ADMINISTRATIVE COSTS Personal Representative's Commissions 370.00 Name of Personal Representative(s) Gilbert M. Becker Social Security Number(s) I EIN Number of Personal Representative(s) 204-03-5562 Street Address 303 Shepherds town Road City Mechanicsburg State PA Zip 17055 Year(s) Commission Paid: 2. Attorney Fees Snelbaker & Brenneman, P.C. 1,200.00 3. Family Exemption: (If decedent's address is not the same as daimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 72.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 Cumberland Law Journal advertising Executor's notice 75.00 2 Patriot-News advertising Executor's notice 126.27 Total from continuation schedules 519.00 3W46AG 1.000 TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) $ 2,462.27 Estate of: Elizabeth M. Adams 193-24-1729 Schedule H Part 7 (Page 2) 3 Register of Wills filing fee for Inheritance Tax Return 15.00 4 Register of Wills short certificate 4.00 5 Reserve for filing fees, accounting fees and other miscellaneous costs associated with the administration of Decedent's estate 500.00 Total (Carry forward to main schedule) 519.00 REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Elizabeth M. Adams SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21 05 0331 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH Commonwealth of Pennsylvania Department of Public Welfare Class 3 claim for restitution of medical assistance provided within last six months of decedent's life in the amount of $21,004.04 and Class 6 claim for remaining balance in the amount of $33,090.15 54,094.19 3W46AH 2.000 TOTAL (Also enter on line 10. Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 54,094.19 REV-1p1;>"EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Elizabeth M. Adams SCHEDULE J BENEFICIARIES FILE NUMBER 21 05 0331 1 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] John J. Adams 525 7th Street New Cumberland, PA 17070 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE NUMBER I PNC Bank, N.A. Inventory Value: 1,044.24 Son 1,044.24 2 Tanya Mowery 1520 Fisher Road Mechanicsburg, PA 17055 Granddaughter 0.00 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 3W46AI 1.000 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) $ 0.00