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REV.1500 EX + (6-00)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
I FILE NUMBER
II
05
0641
_.
I DECEDENrS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Sheetz, Glen A.
~_._--'~-~----'-----,-,--
; DATE OF DEATH (MM-DD-YEAR)
COUNTY CODE Y.fO~_~~!:l~R.
-----..-
SOCIAL SECURITY NUMBER
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166-70-5651
DATE OF BIRTH (MM-DD-YEAR)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
06-30-2005
05-02-1974
REGISTER OF WILLS
I (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
...".' 1. Onginal Return
....J 2. Supplemental Return
,----!
3. Remainder Return (date of dealh pnor to 12-13-82)
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~ 4a. Future Interest Compromise (date of death after
~ 12-12-82)
~I 6. Decedent Died Testate (Attach 7. Decedent Maintained a Living Trust (Attach
copy of Will) copy of Trust)
9 Litigation Proceeds Received 10 Spousal Poverty Credit (date of death between
, . . 12-31-91 and 1-1-~5)
ITHIS SECTION MiisT..BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
, NAME COMPLETE MAILING ADDRESS
I Patricia R. Brown, Esq.
I FIRM NAME (If applicable)
I SALZMANN HUGHES PC
,
8. Total Number of Safe Deposit Boxes
4. Limited Estate
5. Federal Estate Tax Return Required
11. Election to tax under Sec. 9113(A) (Attach Sch 0)
I TELEPHONE NUMBER
354 Alexander Spring Road, Suite 1
Carlisle, PA 17013
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
4. Mortgages & Notes Receivable (Schedule D) (4) None
5, Cash, Bank Deposits & Miscellaneous Personal Property (5) 2,943.17
(Schedule E)
z 6. Jointly Owned Property (Schedule F) (6) None
0 D Separate Billing Requested
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< 7, Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) None
...J
::l (Schedule G or L) [J Separate Billing Requested
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a: 8. Total Gross Assets (total Lines 1-7)
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() 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 4,019.00
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10, Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 1,051.84
i 11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
OFFICIAL USE ONLY
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(8)
2,943.17
(11 )
5,070.84
(12)
insolvent
13. Charitable and Governmental Bequests/See 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)
0.00
(14)
0.00
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate, 0.00 x .00 (15)
or transfers under See, 9116(a)(1.2)
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0 .045 (16)
i= 16,Amount of Line 14 taxable at lineal rate 0.00 x
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0- 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 x .15 (18)
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I- 19. Tax Due (19)
0.00
0.00
0.00
0.00
0.00
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
>> BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH <<
Copyright 2002 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev, 6-00:
Decedent's Complete Address:
STREET ADDRESS
213 Gheary Avenue, Apt. A
CITY New Cumberland
I STATE PA
I ZIP 17070
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1 )
0.00
0.00
Total Credits (A + 8 + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + 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.
8. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(3)
(4)
(5) 0.00
(SA)
(58) 0.00
A. Enter the interest on the tax due.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes
o
D
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3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... D ii::j'
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which ..
contains a beneficiary designation?...................................................................................................................... D L;i?l
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 pe~ury, 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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Donald ft..-Sheetz
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred;..................................................................................
b. retain the right to designate who shall use the property transferred or its income;....................................
c. retain a reversionary interest; or..................................................................................................................
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?.................................................................................................................... ..
No
i
DATE
SIGNATUR
132 East Liberty Avenue
Carlisle, PA 17013
3
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DATE
ADDRESS
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
Patricia R. Brown, Esq.
ADDRESS
'5// Ij. /V6.
DATE
354 Alexander Spring Road, Suite 1
Carlisle, PA 17013
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) (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 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)
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Sheetz, Glen A.
FILE NUMBER
21-05-0641
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jolntly-owned with the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 Cash on hand
VALUE AT DATE
OF DEATH
16.00
2 US Treasury, income tax refund
2.036.00
3 Members 1st Federal Credit Union - savings account
105.00
4 Members 1st Federal Credit Union - checking account
136.17
5 Personal property sold
650.00
TOTAL (Also enter on Line 5, Recapitulation)
2.943.17
(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)
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Sheetz, Glen A.
FILE NUMBER
21-05-0641
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION
NUMBER AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 3,165.00
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 SALZMANN HUGHES PC 750.00
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 44.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 60.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 4,019.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
Rev-1502 EX+ (6-98)
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SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Sheetz, Glen A.
FILE NUMBER
21-05-0641
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Ronald L. Smith Funeral Home
3,165.00
Subtotal
3.165.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
Rev-1502 EX+ (6-98)
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SCHEDULE H-B7
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIOENT DECEDENT
ESTATE OF
Sheetz, Glen A.
FILE NUMBER
21-05-0641
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Wagner's Tax Service - tax preparation fee
60.00
Subtotal
60.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
Rev-1512 EX+ (6-98)
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SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Sheetz, Glen A.
FILE NUMBER
21-05-0641
Include unrelmbursed medical expenses.
ITEM
NUMBER
1 American Water Co.
2 Comcast Cable
3 Pinnacle Health Hospitals
4 PP&L
5 UGI
6 Verizon Wireless
DESCRIPTION
VALUE AT DATE
OF DEATH
39.25
229.73
11.46
585.01
11.22
175.17
TOTAL (Also enter on Line 10, Recapitulation)
1,051.84
(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
NUMBER
Sheetz, Glen A.
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116(a)(1.2)]
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s)
FILE NUMBER
21-05-0641
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
I.
1
Donald A. Sheetz
132 East Liberty Avenue
Carlisle, PA 17013
father
1/2 remainder
2
Mary Weibley
17 South Elmer Avenue
Halifax, PA 17032
mother
1/2 remainder
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)
SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
t'-Jame of Joint Owner
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
Estate of: GLEN A. SHEETZ
Date of Death: 06/30/2005
Social Security Number: 166-70-5651
,., lK
MEMBERS 1st
FEDERAL CREDIT UNION
238646 -00
12/12/2003
$105.00
$.00
$105.00
None
238646 -11
11/19/2004
$136.17
$.00
$136.17
None
;Q; ~RS 1STJ7DE~ L CREDIT UNION
~~ u/O~z:
nise A. Wolfe .
Insurance Services S pervisor
August 31,2005
5000 Louise Drive . Po. Box 40 . Mechanicsburg, Pennsylvania 17055 . (717) 697-1161 . wv.'w.memberslst.org