HomeMy WebLinkAbout05-02-06
REV-1500 EX + (6-00)
'*
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
REV -1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
FILE NUMBER
21 -050637
COUNlYCOi5E --vEAA- - - NUMBER- -
DECEDENTS NAME (LAST. FIRST, AND MIDDLE INITIAL)
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POTTER MELISSA ANNE
DATE OF DEATH (MM-DD-Year)
DATE OF BIRTH (MM-DD-Year)
SOCIAL SECURITY NUMBER
2 1 0 - 7 0 - 1 433
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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OS/23/2005 04/25/1987
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
D 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
00 1. Original Return
D 4. Limited Estate
D 6. Decedent Died Testate (Attach copy ofWilij
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (dateofdeathafler12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
SUSAN J. HARTMAN ONE IRVINE ROW
FIRM NAME (If Applicable)
DUNCAN & HARTMAN P.C.
TELEPHONE NUMBER
717-249-7780 CARLISLE PA 17013
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1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash. Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities. & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
OFFICIAL USE ONLY
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491.01
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780.62
(8)
7,640.80
14. Net Value Subject to Tax (Line 12 minus Line 13)
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 _ (15)
X _ (16)
X .12 (17)
X .15 (18)
(19)
16. Amount of Line 14 taxable at lineal rate
(11)
(12)
(13)
7,640.80
-6,860.18
17. Amount of Line 14 taxable at sibling rate
(14)
-6,860.18
18. Amount of Line 14 taxable at collateral rate
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19. Tax Due
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedent's Complete Address:
STREET AD[\qESS
30 EAST MAIN STREET
CITY I STATE I ZIP
NEWVILLE PA 17241
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
Total Credits ( A + 8 + C) (2)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + 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)
S. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (S)
A. Enter the interest on the tax due. (SA)
8. Enter the total of Line S + 5A. This is the BALANCE DUE. (S8)
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; ........................................................:.................. D 00
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 00
c. retain a reversionary interest; or ...................................................................................................... 0 00
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 00
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?............................... .......... ... .................................................. 0 00
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 00
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................................. ... .. .... ................. ........................... D 00
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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. ~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. ~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 retum 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. ~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%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(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. ~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-1508 EX + (6-98)
..*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
POTTER MELISSA ANNE
FILE NUMBER
21 05
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
0637
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
DESCRIPTION
Adams County National Bank Acct. # 2187280
L575268473 EE Bond - 04/1999
L586363574 EE Bond - 03/2000
L591722696 EE Bond - 03/2001
L622074184 EE Bond - 03/2002
L599247251 EE Bond - 04/2003
VALUE AT DATE
OF DEATH
144.03
32.04
30.74
28.92
27.50
26.38
TOTAL (Also enter on line 5, Recapitulation) $
(If more soace is needed. insert additional sheets of the same size)
289.61
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PATJ~I01" UOND
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Date
5-12
5-19
5-26
5-31
Account No.
Page 1
6-05-05
2187280
Enclosure Debits 1
801 T
MELISSA A POTTER
30 EAST MAIN STREET
NEWVILLE PA 17241
********************
NEED INSURANCE?
Look to Adams County National Bank's new affiliate,
Russell Insurance Group, for all your insurance needs.
Auto - Home - Boat - Motorcycle - Property - Life and Health
Call Toll-Free 1.800.289.4097 For Your Quote.
********************
218 728 0
CAREFREE CHECKING
Previous Balance
+Deposits/Credits
-Checks/Debits
-Service Charge
+Interest Paid
Current Balance
Days in Statement
5-08-05
3
9
166.55
167.91
334.46
.00
.00
.00
Period
28
Tracer
28
28
29
15
- -DESCRIPTIVE TRANSACTIONS-
Description
SAYLOR'S ~~KET PAYROLL
PAYROLL
SAYLORS MKT PAYROLL
CLOSING TRANSACTION
Amount
54.73
57.21
55.97
144.03-
- - - - *
* - - - - - - - - - - -EFT ACTIVITY- - - - - - - - - - - - - - - *
Date Tracer Description Amount
5-09 9 STAR POINT OF SALE PURCHASE 22.22-
SAYLOR'S
NEWVILLE PA
5-11 7 STAR POINT OF SALE PURCHASE 13.17-
0263 SHEETZ
CARLISLE PA
5-11 7 STAR POINT OF SALE PURCHASE 25.84-
Wal-Mart Super
CARLISLE PA
5-16 13 STAR POINT OF SALE PURCHASE 25.03-
SAYLOR'S
NEWVILLE PA
5-16 13 STAR POINT OF SALE PURCHASE 22.96-
SAYLOR'S
NEWVILLE PA
5-23 9 ATM WITHDRAWAL 42.00-
---------- ---._._-~------ - - ------
REV-1509 EX + (6.98)
.-
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
POTTER MELISSA ANNE
FILE NUMBER
21 05
0637
If an asset was made joint within one year of the decedenfs date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. CAROLINE A. POTTER
310 Sawmill Road
Newville, PA 17241
MOTHER
B DOUGLAS A. POTTER
310 Sawmill Road
Newville, PA 17241
FATHER
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JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DE CD'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST
1. A. 05/1999 F & M Trust Company Acet. # 08-05977 353.42 50. 176.71
2. B. 04/1989 L390563197 EE Bond 59.56 50. 29.78
3. B. 05/1990 L457156178 EE Bond 57.24 50. 28.62
4. B. 04/1991 L477480202 EE Bond 55.02 50. 27.51
5. B. 04/1992 L480879328 EE Bond 52.88 50. 26.44
6. B. 04/1993 L505450856 EE Bond 42.76 50. 21.38
7. B. 04/1994 L523482037 EE Bond 40.72 50. 20.36
8. B. 03/1995 L536389353 EE Bond 38.98 50. 19.49
9. B. 04/1996 L546316227 EE Bond 35.82 50. 17.91
10. B. 03/1997 L556608366 EE Bond 34.20 50. 17.10
TOTAL (Also enter on line 6, Recapitulation) $ 491.01
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
POTTER, MELISSA ANNE
Decedent's Name
Page 2
21 05 0637
File Number
Schedule F-2 - Jointly-Owned Property
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTSINTERES
11. B. 04/1998 L567785857 EE Bond 33.80 50. 16.90
12. B. 04/1999 L575268472 EE Bond 32.04 50. 16.02
13. B. 04/1999 L575268473 EE Bond 32.04 50. 16.02
14. B. 03/2000 L586363574 EE Bond 30.74 50. 15.37
15. B. 03/2001 L591722696 EE Bond 28.92 50. 14.46
16. B. 03/2002 L622074184 EE Bond 27.50 50. 13.75
17. B. 04/2003 L599247231 EE Bond 26.38 50. 13.19
SUBTOTAL SCHEDULE F-2 105.71
GRAND TOTAL SCHEDULE F-2 $ 491.01
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. HAlL TO: '.. . .
MELISSA 'PtlTTER
'$1 O$AWHI l LRD
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Value As Of
Page 1 of2
1i11.?ll)/~
Savinc
Help
CALCUJ
106/2005
Update
Bond Info
Series
Denomination
Serial Number
lEE Bonds
~
$150
3
Results
Total Value
$860.36
# Bonds
21
Total Price
$525.00
Total Interest
$335.36
Issue Interest
Serial Number Issue Date Series Denom Price Interest Value Rate
L390554223 04/1989 EE $50 $25.00 $34.56 $59.56 4.00%
L390554229 05/1989 EE 50 25.00 34.56 59.56 4.00%
L333662170 04/1988 EE 50 25.00 36.96 61.96 4.00%
L611734129 03/2005 EE 50 25.00 0.00 25.00 3.25%
'r; L603481424 03/2004 EE 50 25.00 0.68 25.68 3.25%
L390563197 04/1989 EE 50 25.00 34.56 59.56 4.00%
L457156178 05/1990 EE 50 25.00 32.24 57.24 4.00%
L477480202 04/1991 EE 50 25.00 30.02 55.02 4.00%
L480879328 04/1992 EE 50 25.00 27.88 52.88 4.00%
L505450856 04/1993 EE 50 25.00 17.76 42.76 3.03%
L523482037 04/1994 EE 50 25.00 15.72 40.72 3.10%
L536389353 03/1995 EE 50 25.00 13.98 38.98 3.03%
L546316227 04/1996 EE 50 25.00 10.82 35.82 3.07%
L556608366 03/1997 EE 50 25.00 9.20 34.20 3.07%
L567785857 04/1998 EE 50 25.00 8.80 33.80 3.25%
L575268472 04/1999 EE 50 25.00 7.04 32.04 3.25%
. --
L575268473 04/1999 EE 50 25.00 7.04 32.04 3.25%
L586363574 03/2000 EE 50 25.00 5.74 30.74 3.25%
L591722696 03/2001 EE 50 25.00 3.92 28.92 3.25%
L622074184 03/2002 EE 50 25.00 2.50 27.50 3.25%
L599247231 04/2003 EE 50 25.00 1.38 26.38 3.25%
View 10 I Viewing Bonds 1-21
Issue Date
ITD In1
$14.:
Next Final
Accrual Maturity
10/2005 04/2019
11/2005 OS/2019
10/2005 04/2018
07/2005 03/2035
07/2005 03/2034
10/2005 04/2019
11/2005 OS/2020
10/2005 04/2021
10/2005 04/2022
10/2005 04/2023
10/2005 04/2024
09/2005 03/2025
10/2005 04/2026
09/2005 03/2027
07/2005 04/2028
07/2005 04/2029
07/2005 04/2029
07/2005 03/2030
07/2005 03/2031
07/2005 03/2032
07/2005 04/2033
Le end
Note Description
NI Not Issued
NE Not Eligible for Payment
P5 Includes 3-month interest penalty
MA Matured and Not Earning Interest
http://wwws. publicdebt. treas.govIBC/SBCPrice
4/13/2006
REV-1510 EX + (6-98)
.W
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
POTTER.MEUSSAANNE
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
21 05
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
0637
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST VALUE
(IF APPlICABlE)
1. Payment of liability claim by Liberty Mutual Insurance Co. to 100,000.00 100,000.00 0.00
the Executors
TOTAL (Also enter on line 7 Recapitulation) $ 0.00
IJ~_____ _.____ ~_ ____-'__1 ~___...J. _-lI...I~.L~_._ _. _.___...._ _~A.I..._ -_.~~- _!-_\
CLAIM OFFICE ADDRESS:
PO BOX 1128
BLUE BELL, PA 19422
~ Libertx
\p Mutual.
~
~
CHECK REFERENCE CHECK DATE
16993772 12/14/05
CHECK AMOUNT . BLOCK NUMBER
.$100000.00 006340
CONTACT: .LINCH,KEVIN
PHONE: 215-641-0400
INSURED NAME: HUSLER,HESTON
CLAIMANT NAME: POTTER,MElISSA
PAGE
1 OF
ACCIDENT DATE: OS/23/05
OSH: VV0101121401-006340
CLAIM NUMBER: 005945855-0006
POLICY NUMBER: A02-281-533347-S04
INSURED OPERATOR: HUSlER,HESTON
COVERAGE
LIABILITY - BODILY INJURY
INVOICE NO DATES OF SERVICE
CHARGES PAID AMT
ADJUSTMENTS
12/14/05-12/14/05 100000.00 100000~00
PAYMENT TO: DOUGLAS POTTER AND CAROLINE POTTER AS
TOTAL CHARGE:
TOTAL PAID:
TOTAL DEDUCTIBLE:
TOTAL WITHHOLDING:
CHECK AMOUNT:
100000.00
100000.00
0.00
0.00
100000.00
NOTES
FOR FULL AND FINAL SETTLEMENT.
PLEASE REFERENCE CLAIM NO AND SEND THIS EOP WITH ALL CORRESPONDENCE
CAREFULLY DETACH CHECK BEFORE DEPOSITING -RETAIN STATEMENT FOR YOUR RECORDS
'!,i;J!~E-,(JJ~~.~~_1:Hgt'rr~CITY 9.F-,HI~ MULTI.~9NE S~CL!R1T.j D9c_~~r;~,"[ , ' , . 9_HE~K ~A_C~GRQYHQ ~~;,A_Cf1~~~_~_9.Q~Q!L~811Ql}A~.I=Y..ff!QM.,I9.P JQJ;~QIT9.~~.
' ~", .. '. ~ .' . ~ ~" ..., -'" ''', ;" ""'~,. ,,' .. o2.:-21",3~11,' "~. - . ;'HTI;P.'A~!}pp.ofEcnox PATf"tSSP77Ti '53
O<J6340 '. ", . , , . / "', , ", .' , '
BLUE BELL, PA \.~ - 'Liberiv- .:- CITIBAN~ DE, ,ONE'PENNS~WAY .',
PO BOX 1128 ~ - fA" 71' - NEW CAS~U:, DE 19720 '
BlUE BEll, PA 19422 Mutucu.. ~~
* PAY *ONE*HUNDRED*THOUSAND*DOLLARS*NO* CENTS*
PA YMENT IDENT/FICA nON
CHECK NUMBER
CHECK DATE
CLAIM 005945855-0006
16993772
12/14/05
PAY
$ 100000.00
PAY TO THE
ORDER OF
DOUGLAS POTTER AND CAROLINE POTTER AS
ADMINSTRATOR OF THE ESTATE OF MELISSA
POTTER
310 SAW MILL ROAD
NEWVILLE PA 17241
REV~513 EX + (_
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
FILE NUMBER
7
AMOUNT OR SHARE
OF ESTATE
NUMBER
I.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
1.
Caroline A. Potter
310 Sawmill Road
Newville, PA 17241
Douglas A. Potter
310 Sawmill Road
Newville, PA 17241
mother
50%>
2.
father
50010
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
n. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - 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)