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Home My WebLink About02-16-06 217 . REV-1500 EX (6-00) COMMONWEALTH OF REV-1 500 OFFICIAL USE ONLY PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RETURN DEPT. 280601 FILE NUMBER 21-05-0847 HARRISBURG, PA 17128-0601 RESIDENT DECEDENT - COUNTY CODE YEAR NUMBER DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I- C Norman Adams 174-05-0847 z DATE OF DEATH (MM-DD-YEAR) IDATE OF BIRTH (MM-DD-YEAR) w THIS RETURN MUST BE FILED IN DUPLICATE WITH THE Q W 9/9/2005 9/11/1916 REGISTER OF WILLS 0 w (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Q I!! 0 1. Original Return 0 2. Supplemental Return 03. Remainder Return (date of death prior to 12.13.82) :.: !i III 04. 04a. Future Interest Compromise (date of death after 12-12-82) 05. 0:: :.: 0 11. 0 Limited Estate Federal Estate Tax Return Required w 00 :I: 0::.... 06. 07 0 ll;1Il Decedent Died T eslate (Attach copy of Will) Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Deposit Boxes - < 09. 010. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 011. Election to tax under See, 9113{A) (Attach Sch 0) Litigation Proceeds Received I- :!tHliig&t<<mdi~r:ig@_tgi\mijijWQQijiji$eQ.NPifiiQ'AijP':q_!P'tltiAijtAXlijpQijM~itll;ffl$.HQijijij:M$:mRi&BbtQf z NAME w COMPLETE MAILING ADDRESS Q z Robert M. Frey 5 South Hanover Street ~ FIRM NAME (If Applicable) Carlisle PA 17013 U) w Frey and Tiley ~ ~ TELEPHONE NUMBER 0 0 1(717)243-5838 OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) NONE ;~ 2. Stocks and Bonds (Schedule B) (2) NONE .:_-,-' ) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) NONE ~ "_J 4. Mortgages & Notes Receivable (Schedule 0) (4) NONE -- 5. Cash, Bank Deposits & Miscellaneous Personal Property C;') (Schedule E) (5) 9,861 ........, (6) NONE ~.~ 6. Jointly Owned Property (Schedule F) .0.,_ 'i Z Dseparate Billing Requested " 0 .. j:: -, c( 7. Inter-Vivos Transfer & Miscellaneous Non-Probate Property ,f'"J ....l :J (Schedule G or L) (7) NONE l- ii: c( 8. TOTAL GROSS ASSETS (total Lines 1-7) (8) 9,861 0 w ~ 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 2,067 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 6.428 11. TOTAL DEDUCTIONS (total Lines 9 & 10) (11) 8.495 12. NET VALUE OF ESTATE (Line 8 minus Line 11) (12) 1,366 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) (13) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 1,366 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate ,or transfers under Sec.9116 (a)(1.2) X .0 - (15) Z 0 j:: 16. Amount of Line 14 taxable at lineal rate 1,366 X .O~ (16) 61 ~ :;:) Il.. ~ 17. Amount of Line 14 taxable at sibling rate X .12 (17) 0 0 )( .15 (18) ~ 18. Amount of Line 14 taxable at collateral rate X 19. Tax Due (19) 61 20.0 *1~ijlglij(,~l!rJ,Ii~f.III~11119.fli.lllilf:f:al_l~iIIIT .... ........... . .... '.' ... .... .......................... ..................... .'....,......'..........., .... .. ..........,.. . . ",'::},:::::::*:).::e.~:::$Q.8.l;::xQ:*Jf$WiJ:h'J.;lii'Q.Q~n$.N$.:'P.tl:RltViB.$t;::$.JP.$:"P:$'QHlt"K:MAtff~i#'i ............................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................ . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . , . . . . . . . . . . . . . . ........."........................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......:.;.;.:.:.:.;.:-:.;.:.;.:.:.;-;.;.:......... pt ece ents omDI ete ress: STREET ADDRESS 940 Walnut Bottom Road CITY ~STATE IZIP Carlisle PA 17013 217 C Norman Adams o d C Add Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 61 Total Credits (A + B + C ) (2) 174-05-0847 3. InteresVPenalty if applicable D. Interest E. Penalty TotallnteresVPenalty ( 0 + E ) (3) 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) 5. If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check to: REGISTER OF AGENT 61 61 Did decedent make a transfer and: a. retain the use or income of the property transferred; . PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS 1. Yes D D D D D D D No [KJ [KJ [KJ [KJ o o o IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. b. retain the right to designate who shall use the property transferred or its income; c. retain a reversionary interest; or 2. d. receive the promise for life of either payments, benefits or care? 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 designation? DATE Feb. 14J 2006 ADDRESS 5 South Hanover Street, Carlisle, Pennsylvania 17013 DATE Feb. 14 2006 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 PS Section 9116 (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. Section 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 lhe 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. Section 9116(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%, excepl as noted in 72 P.S. Section 9116(1.2) [72 P.S. Section 9116(a)(1)]. The tax rate imposed on the net value of transfers to or for Ihe use oflhe decedenl's siblings is 12% [72 P.S. Section 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. 217 REV-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF C Norman Adams FILE NUMBER 21-05-0847 Include the proceeds of litigation and the date the proceeds were received by the estate. All prooertv iointlv-owned with riaht of survivorshiD must be disclosed on Schedule F. ITEM NUMBER 1 2 3 4 DESCRIPTION Citizens Bank, Checking AccountNo. 6100727742 Refund, Comcast, Utilities:Cable Refund, Michael J. Camlinde and Associates, Medical Refund, United American Insurance Company, Insurance Premium VALUE AT DATE OF DEATH 9,568 50 70 173 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 9,861 -- 81976824 united american=;,'=su~ce company 3700 SOUTH STONEBRIDGE DRIVE . POST OFFICE BOX 8080 . MCKINNEY, TEXAS 75070 Date 02108/2006 Estate of C Norman Adams 23 Circle Dr Carlisle PA 17013 Policy 574282805 Check No 359524 --_.--~~.....-.......~ ...-.....--. "--__...___-c;;..._.~'__<_ _ '---'-'--~~""""--;'-'-'-<.~~"'__,"",",_--W' Dear Sir or Madam: We are concerned to learn of the death of our Insured. Attached is the refund of monies paid beyond the date of death for policy number 574282805. Sincerely, Ann Braswell, Vice President Policy Service Detach This Portion At Dotted Line Before DepOSiting Check 62DU UNITE.D AMERICAN lNSURANCECOMPAN'{ . .' . .., . . Post Office Box8080 - McKinney, TexasI5070-8Q80 DAT~: 02J0812OQ6 51-44 'f'f9c . Policy: 514282806 . .- -'_". '.. C_"'. ",' '-', ", "'0' '000" ...~. ..' . ...... ..~.i..;..;.... . ......... ..... ...... ,..... ....... . .. ".".. - ),.',-.., "'~ ,-. .. ." ,." . , --' :"-~' -:: (. Pay To The Order Of: Voidtf NOtPresentedWdt'l~1i.~ ...... Estate olC Nonnan Adams 23 Circle Dr Carlisle PA 17013 1~~jo'---- .. ~ Authorized Signature ft_ h'~ ""- I' a'H. -. '.,11' o-~. :~:E ('itizens Bank" Account Number 6100727742 Account Title C NORMAN ADAMS Date Opened 6/6/1966 Account Type Checking Principal Balance as of DaD $9568.41 Interest from Last Posting to DaD $.00 Account Balance as of DaD $9568.41 YTD Interest to DaD $7.19 MICHAEL J. CAMLlNDE & ASSOC INC. 01-01 2231 NORTH BOULEVARD WEST DAVENPORT, FL33837 BankofAmerica, ~ ACH FlIT0630000~7 ~. U44::J4U 63-41630 FL 1635 10/18/2005 ~ i i a PAY TO THE ORDER OF ADAMS, CHARLES NORMAN , $51.05 ***Fifty One Dollars and 05 Cents*** DOLLARS I , , ! j i IEl G. ~-.--~) f ~( ., ... __--;f/~~' . . k\ ,,-:;.-:.. //~'_I 'j .tT~i'r' ( ) r.1.~M._CJ.___.______.__________.____________.._____________ AUTHORIZEO SIGNATURE ADAMS, CHARLES NORMAN C/O RENELE L BROWN 23 CIRCLE DRIVE CARLISLE, PA 17013 I.!" ------~ /1"0'"',",5100"" 1:01; ~0000L, 71: 00 :\L,L,bb 5(; 5qL,lI" r MICHAEL J. CAMlINDE & ASSOC INC. 044540 $51.05 10/18/2005 crm.9310149*1 REFUND DUE TO OVERPAYMENT CLIENT: CENTRAL PENN MEDICAL DOCTOR: CRIM MD, LAURA ADAMS, CHARLES NORMAN C/O RENELE L BROWN 23 CIRCLE DRIVE CARLISLE, PA 17013 PATIENT: crm.9310149 ADAMS, CHARLES NORMAN MICHAEL J. CAMLlNDE & ASSOC INC. 01-01 2231 NORTH BOULEVARD WEST DAVENPORT, FL 33837 BankofAmerica. ~ ACH FlIT06JOO0047 ~. 044542 63-4/630 FL 1635 10/lS/2005. j i j a I ! DOLLARS I .. t i IEl PAY TO THE ORDER OF ADAMS, CHARLES N 1$18.90 ***Eighteen Dollars and 90 Cents*** ADAMS, CHARLES N C/O RENELE L BROWN 23 CIRCLE DRIVE CARLISLE, PA 17013 MEMO .---.----.---------------- ilia L, L, 51. 2/1" ':0[; ~OOOO'"' 7': 00:1 L, L, b b 5 b 5 q 1.11" r ., MICHAEL J. CAMlINDE & ASSOC INC. 044542 $18.90 10/lS/2005 crm.9310341*1 REFUND DUE TO OVERPAYMENT CLIENT: CENTRAL PENN MEDICAL DOCTOR: CRIM MD, LAURA ADAMS, CHARLES N C/O RENELE L BROWN 23 CIRCLE DRIVE CARLISLE, PA 17013 PATIENT: crm.9310341 ADAMS, CHARLES N 217 REV-1511 EX+(12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER 21-05-0847 C Norman Adams ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Ewing Brothers Funeral Home, Funeral Services 464 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attomey Fees 1,500 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 84 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. Register ofWil/s, (1) Short Certificate 4 8. Register of Wills, Filing Fee for Pennsylvania Tax Return 15 TOTAL (Also enter on line 9 Recaoitulation) $ 2067 Debts of decedent must be reported on Schedule I. (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) 217 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF C Norman Adams SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-05-0847 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 HCR-Manor Care Nursing Home, Medical VALUE AT DATE OF DEATH 5,168 2. NeighborCare Pharmacy Services, Medical 1,260 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 6,428 217 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER C Norman Adams 21-05-0847 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Stephen C. Adams Son 50% of residue of estate 816 Golden Eagle Drive Conway, South Carolina 29527 2 Renelle L. Brown Step-Daughter 50% of residue of estate 23 Circle Drive Carlisle, Pennsylvania 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 $ (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF C. NORMAN ADAMS I, C. NORMAN ADAMS, widower, of 36 East High Street in the Borough of Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void any and all Wills by me at any time heretofore made. 1 . I direct my hereinafter named Executors to pay all of my just debts and funeral expenses as soon after my death as may be found convenient to do so. I direct that my funeral services be conducted by Ewing Brothers Funeral Home, 630 South Hanover Street, Carlisle, Pennsylvania, and that my body be interred beside that of my wife, Hazel A. Adams, on my burial lot located in the Traditional Section of Westminister Cemetery near the Borough of Carlisle in North Middleton Township, Cumberland County, Pennsylvania, which lot is located beside the lot on which the bodies of my parents, George W. Adams and Hazel J. Adams, are interred. 2. I direct that all inheritance, transfer, succession, estate and death taxes which may be payable on account of my death, including interest and penalties thereon, shall be paid from the residue of my estate regardless of whether the assets upon which such taxes are based are included in my probate estate. 3. All of the rest, residue and remainder of my estate, real, personal and mixed, and wheresoever the same may be situate, I give, devise and bequeath as follows: One-half (1/2) to my son Stephen C. Adams, his heirs and assigns, provided he shall survive me by a period of ninety (90) days, but should he fail to survive me then to such of his issue that shall survive me by a period of ninety (90) days, per stirpes; and the other one-half (112) to my step-daughter, Renelle L. Brown, her heirs and assigns, provided she shall survive me by a period of ninety (90) days but should she fail to so survive me then to such of her issue as shall survive me by a period of ninety (90) days, their heirs and assigns, per stirpes. 4. I hereby nominate, constitute and appoint my said son, Stephen C. Adams, and my said step-daughter, Renelle L. Brown, or either of them as co-Executors of this my Last Will and Testament and I further direct that neither of them shall be required to post any bond to secure the faithful performance of his or her duties in the Commonwealth of Pennsylvania or in any other jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament written on one (I) page, this 28th day of August, 1998. C.~a??~~ C. Norman Adams (SEAL) Signed, sealed, published, and declared by C. NORMAN ADAMS, the Testator above named, as an~ for his Last Will and Testament, in our presence, who, in his presence, at his re9uest, and III the presence of each other, have hereunto subscribed our names as attesting WItnesses. ~h7..~1 ~~ COMMONWEALTH OF PENNSYl VANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT FREY ROBERT M 5 S HANOVER STREET CARLISLE, PA 17013 u______ fold ESTATE INFORMATION: SSN: 174-05-1641 FILE NUMBER: 2105-0847 DECEDENT NAME: ADAMS C NORMAN DATE OF PAYMENT: 02/16/2006 POSTMARK DATE: 02/16/2006 COUNTY: CUMBERLAND DATE OF DEATH: 09/09/2005 NO. CD 006335 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 , $ 5 9.00 I I I I I I I I TOTAL AMOUNT PAID: $59.00 REMARKS: ROBERT M FREY CHECK# 0995 SEAL INITIALS: RSK RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIOUAL TAXES DEPT. 2B0601 HARRISBURG, PA 1712B-0601 REV-1162 EX(11-96) PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT RECEIVED FROM: FREY ROBERT M 5 S HANOVER STREET CARLISLE, PA 17013 -------- fold ESTATE INFORMATION: SSN: 174-05-1641 FILE NUMBER: 2105-0847 DECEDENT NAME: ADAMS C NORMAN DATE OF PAYMENT: 02/16/2006 POSTMARK DATE: 02/16/2006 COUNTY: CUMBERLAND DATE OF DEATH: 09/09/2005 NO. CD 006336 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $2.00 , I I I I I I I TOTAL AMOUNT PAID: $2.00 REMARKS: ROBERT M FREY SEAL INITIALS: RSK RECEIVED BY: REGISTER OF WILLS -. GLENDA FARNER STRASBAUGH REGISTER OF WILLS