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Home My WebLink About04-13-06 /'- 21-05-0986 -.J 15056051058 REV.1500 EX (06-05) PA Department of Revenue . Bureau of Individual Taxes . PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year INHERITANCE TAX RETURN RESIDENT DECEDENT File r~umbe( ~\ - ~S - ~~~(~ Date of Birth J:Xp 12-26-04 160-20-9785 10-19-00 8-29-26 Decedent's Last Name Suffix Decedent's First Name MI Cooper Francis R (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Cooper Joanne K Spouse's Social Security Number 159-22-8760 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW X 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 4. limited Estate 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTiON MUST BE COMPlETED. ALL CORRESPONDENCE AHD CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes Michael s. Travis Firm Name (If Applicable) 717-731-9502 REGISTER OF WiLLS USE .oNLY First line of address 3904 Trindle Road Second line of address City or Post Office Camp Hill State PA ZIP Code 1 7011 O,~.H~ '-..~. Correspondent's a-mail address: Under penalties of perjury, I declare lhall have examined this relum, including accompanying schedulas and statements, and 10 the best of my knowledge and belief, · is true. correct and com_ Dedamtion of r>>epater other than the _I "'_ is based on all infonnation of which "'-ref has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETURN Laurie J. Weller, Administratrix ADDRESS .108 May DRive SIGNATURE OF: ~c~ -<-.-U.NA ( ClJo i./i-I --- Camp Hilh PA 1 7\J11 ER THAN REPRESENTATIVE OAf / <..t /:J () ,., I ( '---------_._--~-------------------- --------------.--------- // JA~E/. -Z/~~-~- Camp Hill, PA 17011 PLEASE USE ORIGINAL FORM ONLY L 15056051058 Side 1 15056051058 ....J ~ -.J 15056052059 REV-1500 EX Decedent's Name: Francis R. Cooper RECAPITULATION 160-20-9785 Decedent's Social Security Number 1. Real estate (Schedule A). " . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 2. $56,000.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . " 3. 4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . . . . . 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . 5. 6. Jointly Owned Property (Schedule F) Separate Billing Requested 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested.. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . , , . . . . . . . . .. 8. $56,000.00 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . " 9. $ 6, 730.31 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . , . . . 10. 11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. $ 6, 730. 31 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. $49,269.69 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 0 14. Net Value SUbJect to Tax (Line 12 minus Line 13) ........................14. $49,269.69 TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0JL 16. Amount of Line 14 taxable at lineal rate X.o.4.5 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of line 14 taxable at collateral rate X .15 30,000 $19,269.60 15. 0.00 867.14 16. 17. 18. 19. TAX OUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 867.14 20. Fill IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15056052059 Side 2 15056052059 --I REV-1500 EX Page 3 Decedent's Complete Address: 21 -05-0986 DECE ENTS NAME DECEDENTS SOCIAL SECURITY NUMBER _F1;~ci~____~___Q2<:>~________ _ ____ _____________ ____ ________ 1@=~g:::n?~ STREET ADDRESS --.J.1_L_~yJ!!li ~~ _ ____________________________________ _______________________________ ___ ___ ___.____ _._______._______ ______ File Number CITY Camp Hill STATE PA ZJp Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditS/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount 17011 (1 ) $867.14 3. InteresUPenalty if applicable D. Interest E. Penalty $357.14 Total Credits ( A + B + C ) (2) 4. TotallnteresUPenalty ( 0 + E ) If Line 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT, Fill in oval on Page 2, Line 20 to request a refund. $357.14 5. If Line 1 + line 3 is greater than Line 2, enter the difference. This ;s the TAX DUE. (3) (4) (5) (SA) $357.14 ~357.14 A. Enter the interest on the tax due. 8. Enter the total of Line 5 t 5A. This is the BALANCE DUE. (58) $1 ,224.28 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 a. retain the use or income of the property transferred;.......................................................................................... 0 b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 c. retain a reversionary interest; or................... ..........................................................,............................................ 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ...... ..... ....................... ........ ..........,...... .................. .......... .... ................... 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............ ......................... ................................. ................... ..... ......"...,...........,.. 0 No ~ Ga !Xl IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDUlE G AND FILE IT AS PART OF THE RETURN, ~ /Xl ~ 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 three (3) percent [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 zero (0) percent [72 P,S_ ~9116 (a) (1.1) (ii)]_ The statute does not exemot 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 vafue 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 ;s zero (0) percent (72 P.S. 99116(a)(1.2)1. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4_5) percent, 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 twefve (12) percent (72 p. 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, REV.1503 EX+ (6.~J8) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANI..e. IHHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Francis R. Oooper FILE NUMBER 21-05-0986 ITEM NUMBER 1. All property jointly-owned with right of survivorship must be disclosed on Schedule F. DESCRIPTION VALUE AT DATE OF DEATH 16 Shares Bank of Lilly $ 56,000.00 TOTAL (Also enter on line 2, Recapitulation) $ 56,000.00 (If more space is needed, insert additional sheets of the same size)