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OFFICIAL USE ONL Y
COMMONWEALTH OF PENNSYLVANIA REV-1500 FILE NUMBER
DEPARTMENT OF REVENUE DEPT. INHERITANCE TAX RETURN
280601 HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 21 2005 0539
COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
.... Thompson, Deborah A. 375-64-7762
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w DATE OF DEATH (MM-DD-YY) DATE OF BIRTH (MM-DD-YV) THIS MUST BE FILED IN DUPLICATE
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W 5/22/2005 9/27/1955 WITH THE REGISTER OF WILLS
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W (IF APPLICABLE) SURVIVING SPOUSE'S NAME SOCIAL SECURITY NUMBER
C I
uJ ){J 1. Original Return 0 2. Supplemental Return 0 3. Remainder Return
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~!:::U) tJ 4. Limited Estate 0 o 5. Fed. Est. Tax Return Req'd
ue::~ 4a. Future interest Compromise
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:cOO tJ 6. Decedent Died Testate 0
ue::....J 7. Decedent had Living Trust 0 8. Total number of SDB's
a..0l -
a.. ~ 9. Lit'g'tion Proceeds Rec'd n 10. Spousal Poverty Credit n 11. Election to tax w/ Sec. 9113(A)
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z NAME: COMPLETE MAILING ADDRESS:
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z Ronald E. Johnson, Esquire
0 Ronald E. Johnson, Esq.
a.. FIRM NAME:
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uJ Andrews & Johnson Andrews & Johnson
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e:: TELEPHONE NUMBER 78 W. Pomfret St.
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u 717 243-0123 Carlisle, PA 17013
1. Real Estate (Schedule A) (1 ) $0.00 OFFICIAL USE ONLY
2. Stocks and Bonds (Schedule B) (2) $0.00 .
.,
3.Closely Held Corporation, Partnership or Sole-Prop. (3)
4. Mortgages & Notes Receivable (Schedule D) (4) $0.00
:2 $2,400.22 -
0 5. Cash, Bank Deposits & Misc. Personal Prop.(Sch.E) (5)
i= 6. Jointly Owned Property (Schedule F) (6) $0.00 ----
:3 D Separate Billing Requested
~ 7. Inter-Vivos Transfers & Misc. Non-Propate Prop. (7) $14,272
.... -
0- 8. Total Gross Assets (total lines 1-7) (8) $16,671.98 ,
<C 9. Funeral Expenses & Administration Costs (Sch H) (9) $13,223.30
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w 10. Debts of Decedent, Mortgage liabilities, & Liens (10) $2,786.76 ( , ,
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11. Total Deductions (total lines 9&10) (11 ) $16,010.06
12. Net Value of Estate (Line 8 minus Line 11) (12) $661.92
13. Charitable and Governmental Bequests/Sec 9113 Trusts
for which an election to tax has not been made (13)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) $661.92
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
z 15. Amnt of Line 14 taxable at the spousal rate,
0
~ or transfers under Sec.9116(a)(1.2) $661.92 x.O_ (15) $0.00
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::l 16. Amount of Line 14 taxable at lineal rate $0 x.045 (16) $0.00
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:E 17. Amount of Line 14 taxable at sibling rate $0 x.12 (17) $0.00
0
u 18. Amount of Line 14 taxable at collateral rate $0 x.15 (18) $0.00
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~ 19. Tax Due (19) $0.00
20 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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Decedent's Complete Address:
STREET ADDRESS
375 Longs Gap Road
CITY
STATE
ZIP
Carlisle
Tax Payments and Credits:
1. Tax Due
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discounts
PA
17013
(1 )
$0.00
Total Credits (A+B+C)
(2)
$0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
4.
TotallnteresUPentalty (D+E)
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
(3)
(4)
$0.00
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.
(5)
(5A)
(5B)
$0.00
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
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:
b. retain the right to designate who shall use the property transerred or its income:
c. retain a reversionary interest: or
d. retain the promise for life of either payments 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 fo~' 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 disignation?
D
D
D
D
D
D
El
El
El
El
El
El
El
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.
DATE
ADDRESS
PA 17013
DATE
ADDRESS
..................................................',.,......'...................................................................-....................................................................................................................................................................................................................................................................................................................................................................................................................................................
For dates of death on or after July 1, 1 994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the sUlViving spouse is 3% [72P.S. Sec. 9116(a)(1.1 )(1)].
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 sUlViving spouse is 0% [72 P.S. Sec. 9116(a)(1.1 )(ii)].
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 deseased 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. Sec. 9116(a)(1.2)].
The tax rale imposed on the nelvalue of transfers to or for the use of the decedenfs lineal beneficiaries is 4.5%, except as noted in 72 P.S. Sec. 9116(1.2) [72 P.S. Sec.9116(a)(1).
The tax rate imposed on the net value of transfers to or for the use of the decedenfs siblings is 12% [72 P.S. Sec.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.
SCHEDULE E
CASH, BANK DEPOSITS AND
MISCELLANIOUS PERSONAL PROPERTY
ESTATE OF
FILE NUMBER
Deborah A. Thompson
Include the proceeds oflitigation and the date the proceeds were received by the estate
All property jointly-owned with Right of Survivorship must be disclosed on Schedule F
DESCRIPTION
21-05-0539
ITEM
NUMBER
VALUE AT DATE
OF DEATH
1
Checking acct no: 1691032069-Sovereign Bank
$2,400.22
2
3
4
5
6
7
TOTAL (also on line 5, Recapitulation)
$2,400.22
SCHEDULE G
TRANSFERS
ESTATE OF
FILE NUMBER
ITEM DESCRIPTION OF PROPERTY TOTAL VALUE DECD.% EXCLUSION TAXABLE
INCLUDE TIlE NAME OF TIlE TRANSFEREE. TllElRRELATIONSIDP TO DECEDENT ANI
NUMBER TIlE DATE OF TRANSFER. ATTACH A COPY OF TIlE DEED FOR REAL ESTATE. OF ASSET INT (if applicable) VALUE
1 General Motors 401 K - Fidelity
Investments payable upon
death to Mark Thompson, her
husband $14,271.76
Deborah A. Thompson
This schedule to be completed and med if the answer of the question on the reverse of the cover is yes.
21-05-0539
TOTAL (also on line 7, Recapitulation)
$14,271.76
SCHEDULE H
FUNERAL EXPENSES, ADMINISTRATIVE
COSTS AND MISCELLANEOUS EXPENSES
ESTATE OF
FILE NUMBER
B.
ITEM DESCRIPTION AMOUNT
NUMBER
Funeral Expenses:
1 Ronan Funeral Home $7,650.30
2 Wagners Gap Community Cemetary - cemetary lot $440.00
3 Minnich & Sons - gave opening $550.00
Administrative Costs:
1 Personal Representive Commissions
Name of Personal Representative(s)
Social Security Number of Personal Representative:
Street Address:
City: State: Zip:
Year(s) commissions paid:
2 Attorney fees to Andrews & Johnson $750.00
3 Family Exemption $3,500.00
Claimant Mark Thompson
Street: 375 Longs Gap Road
City: Carlisle. P A 17013
Relationship of Claimant to Decedent: Husband
4 Probate Fees to Register of Wills $68.00
5 Accountant Fees
6 Tax Return Preparer's Fees
7 Register of Wills - P A Inheritance Tax Return - filing fee $15.00
8 Reserve for closing and accounting $250.00
9
10
11
12
13
14
15
16
17
18
19
TOTAL (also on line 9, Recapitulation) $13,223.30
Deborah A. Thompson
Debts of decedent must be reported on Schedule I.
21-05-0539
A.
SCHEDULE I
DEBTS OF DECEDENT
MORTGAGE LIABILITIES AND LIENS
ESTATE OF
FILE NUMBER
Deborah A. Thompson 21-05-0539
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM DESCRIPTION VALUE AT DATE
NUMBER OF DEATH
1 Carlisle Digestive Disease - medical bill $37.22
2 Hillside Gastroenterology - medical bill $30.00
3 Bronstein & Jefferies - medical bill $108.70
4 Lancaster HMA Phys. Mgmt - medical bill $102.28
5 Carlisle Regional Medical Center - medical bill $237.76
6 Drs. Currie & Hecht - medical bill $364.00
7 Moffit Heart & Vascular Group - medical bill $17.90
8 MSHMC Physicians Group - medical bill $316.40
9 Andorra Radiology - medical bill $15.20
10 Dr. Guistwite- medical bill $139.65
11 Cumberland Goodwill Fire & Rescue - medical bill $268.84
12 West Shore EMS - medical bill $10.02
13 Critical Care Systems - medical bill $28.00
14 Omega Medical Lab - medical bill $11.70
15 Dr. Cluck DDS - medical bill $887.00
16 Prescriptitions $212.09
TOTAL (also online 10, Recapitulation)
$2,786.76
SCHEDULEJ
BENEFICIARIES
ESTATE OF FILE NUMBER
De or ompson 21-05-0539
ITEM NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR SHARE
NUMBER Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRlBunoNS {include outright spousal distributions. aud trausfers under Sec. 9116(0)(1.2)]
1 Mark Thompson husband 100%
375 Longs Gap Road, Carlisle, PA 17013
2
3
4
II NON-TAXABLE DIS1RIBUTIONS:
A SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. Charitable and Govemmental Bequests:
b ah A Th
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (also enter on line 13, Recapitulation)
$0