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REV . 1~00 EX + (6-001
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
DA VEY, JOHN R.
21 05
COUNTY CODE YEAl<
SOCIAL SECURITY NUMBER
00855
NUMBER
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
189-09-1894
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
~ Original Return 0 2. Supplemental Return
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>- 0 0 Future Interest Compromise (date of death after
~Scn 4. Limited Estate 4a.
u"'" 12-12-82)
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",00 6. Decedent Died Testate (Attach copy 7. Decedent Maintained a Living Trust (Attach
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a.1O of Will) copy of Trust)
a.
<( 0 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (date of death between
12-31-91 and H-95)
OR/27 /2005
04/01/1915
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
NAME
, >- EDMUND G, MYERS
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~ ~ FIRM NAME (If applicable)
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8 ~ JOHNSON, DUFFIE, STEWART & WEIDNER
TELEPHONE NUMBER
717/761-4540
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)
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)
o 3. Remainder Return (date of death pc,o;:to 12-13-82)---
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o ". Election to tax under Sec. 9113(A) (Attach Sch 0)
COMPLETE MAILING ADDRESS
301 Market St.
Lemoyne, P A 17043-0109
(1 ) None
(2) None
(3) None
(4) None
(5) 12,663,27
(6) None
(7) None L..
nFF-iCiAL JSE Ot\LY
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(8)
12,663.27
(9)
(10)
1 ,3 79.00
1,093 _54
(11 )
2,472.54
(12)
10,190.73
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)
(13)
(14)
10,190.73
15_ Amount of Line 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1 ,2)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
x .00
(15)
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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
1 0, 1 90.73 x .045
(16)
458.58
x .12
(17)
x .15
(18)
(19)
458.58
20. 0
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
128B WEST WILLOW STREET
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 )
458.58
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C)
(2)
0.00
Total Interest/Penalty (0 + E)
4. If line 2 is greater than line 1 + line 3, enter the difference. This is thEOVERPAYMENT.
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 theTAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of line 5 + 5A. This is theBALANCE DUE
(3) 0.00
(4)
(5) 458.58
(5A)
(5B) 458.58
Make Check Payable to: REGISTER OF WILLS, AGENT
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 designation?............................. __............................ __..................................................
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;............................................................................. ~ I
:: ~:~::~ :h~e~;~:i:~~~s:~;e~~es~~~. ~~~I.I. .u.~~. ~~~. :.r~:.~~~~ .t~~~.~.fe.~~~~. .o.r .i.t.~. ~~. ~o.~.e.;..............................~~:: ~:: ~:.' ~:: .........
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?............................. --............................ __............................ __..................... 0
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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.
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
preparer other than the personal repres~_ntati~e !~_ba~ed _9~ all infc:>rmation of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
~{BARA E. D~E~ & ... ...Er f(,,, t~1vr~9J~flIj,~E1'7~rr D
~~ON RESPONSIBLE FOR l~ffff:ftJRN ADDRESS
DATE
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DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
EDMI'ND G. MYERS
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i. .,....,f . '-1 J.
~ .""" ....., 7'~' /V'-
ADDRESS
DATE
301 Market St.
Lemoyne, P A 17043-0109
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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. S9116 (a) (1.1) (ii)]. The statutedoes not exemDta 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 PS 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
DA VEY, JOHN R.
FILE NUMBER
21-05-00855
Include the proceeds of litigation and the date the proceeds were received by the estatEAII property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
1
DESCRIPTION
VALUE AT DATE OF
DEATH
- ----.._-
25.00
Household Goods in apartment - old and worn - junk
2
1966 Monza Coupe -
Appraised value as of April14, 2005
Copy of Appraisal attached.
1,700.00
,
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Citizen's Bank - Checking Account No. 6100770028
Date of death balance
6,873.20
4
Progressive Insurance - Auto Insurance Refund
211.00
5
Gamet Management - Refund - Apartment rent and security deposit
320.07
6
Presbyterian Homes - refund - charges covered by insurance.
3,534.00
TOTAL (Also enter on Line 5, Recapitulation)
12,663.27
CORY AIR RANCH INCORPORATED
1079 BON-OX ROAD
GETTYSBURG, P A 17325
717-624-2805
April 14,2005
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John Davey
9 RicWand Lane # 1 08
Camp Hill, P A 17011
Vehicle Appraisal For: 1966 Monza Coupe
~: I07376VV115587
Color: Maroon Red
Options: Custom wheels with Bowtie Caps, Modified V8 Engine
Additional Features: None
Structural Condition: Exterior and superstructure are composed of steel and appear to be in excellent
condition. No major repair and no rust damage visible. .
EnginelTransmission: Completely rebuilt engine. Compression is 100%. No oil leaks or unusual sounds
when driving or idling. Transmission shifts properly and consistently. No leaks or noticeable damage.
Bright metal/Paintwork: Bright metal is in new condition. No dents on bumpers or stainless steel trim.
All brightwork appears to be original. Paint is professionally done.
Interior: Paintwork on interior panels appear to be original and in excellent condition. Carpet appears to
be an exact reproduction. All gauges function properly. Vehicle equipped with speedometer, odometer,
fuel gauge, and temp-press warning light, two speed windshield wipers with correct switch. Headlight
switch is correct and original. All interior trim and ornamentation is correct original and in excellent
condition. Additional features listed above. .
VViring: All wiring harnesses appear to be original with no modification. No cracked or deteriorated
wiring is apparent. Heater/de-fogger has three speeds and functions properly and appears to be original.
Tires: Radial, Black sidewall, P195/70R14 series, nominal wear.
Glass: All glass is free of scratches and chips.
Overall condition of vehicle is excellent. This vehicle would be classified as a number two car. This
vehicle is a good performer and should give many years of dependable service if maintained properly.
Total of vehicle is $1700.00
All data is accurate to the best of my ability~A" A. date ~{!/<:I r<; 'f
Corvair Ranch Inc. has been around since 1986. We specialize in restoration of 1960-69 Corvaris, Chevelles, Chevy II,
and Full Size Chevrolet. Do not hesitate to contact us with your questions or needs.
SCHEDULE H
FUNERAL EXPENSES &
ADMINlSTRAllVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
DAVEY, JOHN R.
FILE NUMBER
21 - 05 - 00855
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
Funeral Expenses - Prepaid
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
1.
Social Security Number(s) / EIN Number of Personal Representative(s):
2.
Street Address
City
Year(s) Commission paid
Attorney's Fees JOHNSON, DUFFIE, STEWART & WEIDNER n
State
Zip
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.
I
Other Administrative Costs
Register of Wills - file Inventory and Inheritance Tax Return
2
Verl Williams - Hauling away and disposing of apartment contents - junk
TOTAL (Also enter on line 9, Recapitulation)
0.00
1,000.00
99.00
30.00
250.00
1,379.00
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
DA VEY, JOHN R.
FILE NUMBER
21 - 05 - 00855
Include unreimbursed medical expenses.
ITEM
NUMBER
I
DESCRIPTION
AMOUNT
Checks that cleared after death - Citizen's Bank Account No. 6100770028
Check No. 1053 - Carlisle Meals on Wheels - $103.50; Check No.1 060 - Barbara Davey _ Expense
reimbursement - $139.00; Check No. 1061 - Garnet Management - Apartment rent _ $585.00.
827.50
2 Sprint - decedent's account - final charges 26.46
, Concast Cable - decedent's account - final charges 3.19
-)
4 PP&L - decedent's account - final charges 51.03
5 TeleCom USA - decedent's Account - final charges 23.03
6 Hartzell Eye Mds. - decedent's account balance 72.35
7 Cumberland-Goodwill Fire/Rescue - balance not covered by insurance. 51.98
8 Lifeline - balance not covered by insurance. 38.00
TOTAL (Also enter on Line 10, Recapitulation)
1,093.54
REV"'513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
DA VEY, JOHN R.
FILE NUMBER
21 - 05 - 00855
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s)
AMOUNT OR SHARE
OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Barbara E. Davey
12 S. 19th Street, Apt. D
Camp Hill, PA 17011
Daughter
Residue
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheEjt
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 SHEE