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HomeMy WebLinkAbout06-02-06 REV-1500 EX (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT, 280601 HARRISBURG. PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ~L COUNTY CODE -9~ 0827 ___ YEAR NUMBER ~ Z W C w o w c DECEDENTS NAME (LAST. FIRST, AND MIDDLE INITIAL) Clifford Ma DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 9/8/2005 7/14/1914 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST. AND MIDDLE INITIAL) B SOCIAL SECURllY NUMBER 167-14-7308 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURllY NUMBER ~ [X] 1. Original Retum ::.::S;CI) D u O::::lc:: 4. Limited Estate LLJ a..u :I: 00 r:;;r U O:::~ L.AJ 6. Decedent Died Testate (Attach copy of Will) a..m ~ D 9. Litigation Proceeds Received D 2. Supplemental Retum D 3. Remainder Retum (date of death prior to 12-13-82) D 4a. Future Interest Compromise (date of death after 12-12-82) D 5. Federal Estate Tax Retum Required D 7. Decedent Maintained a Living Trust (Attach copy of Trust) L 8. Total Number of Safe Deposit Boxes D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95-) D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAXINFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS .... Z w o z o [L en w D:: a: o (J Richard C. Snelbaker FIRM NAME (If Applicable) Snelbaker & Brenneman, P.C. TELEPHONE NUMBER 44 West Main Street Mechanicsburg, PA 17055 717-697-8528 1. Real Estate (Schedule A) (1 ) OFFICIAL USE ONLY 2. StOCKS and Bonds (Schedule B) (2) 3. Closely Held Corporation. Partnership or Sole-Proprietorship (3) C) ~; C-~J 0........ . I 1 z o i= :5 ::) ~ a: <C o w 0::: 6. Jointly OllVl1ed Property (Schedule F) (6) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) I f'0 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 0.00 --.... , > 8. Total Gross Assets (total Lines 1-7) (8) 11,309.08 182.13 I ,; :~J- i',) 3~A ' 860.25) --.J ' .i 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent. Mortgage Liabilities, & Liens (Schedule I) (10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for Vvtlich an election to tax has not been made (Schedule J) ( 12) 11,491.21 303,369.04 0.00 11. Total Deductions (total Lines 9 & 10) (11 ) ( 13) 14. Net Value Subject to Tax (Line 12 minus Line 13) ( 14) 303,369.04 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax z rate, or transfers under Sec. 9116 (a){1.2) o !;i 16. Amount of Line 14 taxable at lineal rate I- ;j :e 17. Amount of Line 14 taxable at sibling rate o (,) 18. Amount of Line 14 taxable at collateral rate >< ~ 19. Tax Due 20. ~ x.a ~ (15) x.O ~ (16) x .12 (17) x .15 ( 18) ( 19) 0.00 13,651.61 0.00 0.00 13,651.61 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < 3W4645 1.000 Decedent's Com plete Add ress: STREET ADDRESS 2100 Bent Creek Blvd Silver Spring T CllY Mechanicsbur , Cumberland STATE PA ZIP 17050- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 13,651.61 0.00 11,500.00 575.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) 12,075.00 0.00 0.00 Total Interest/Penalty (0 + E) (3) 0.00 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) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,576.61 A. Enter the interest on the tax due. (SA) 0.00 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58) Make Check to: REGISTEROFWILLS,AGENT 1,576.61 PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred;. . . . . . . . . . . . . . . D b. retain the right to designate who shall use the property transferred or its income;. . D c. retain a reversionary interest; or . . . . . . . . . . . . . . . . . . . . . . . . D d. receive the promise for life of either payments, benefits or care? . . . . . . . .. '.. D 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . .. D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D ~ 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 of preparer other than the personal representative is based on all information of which preparer has any knowledge. Yes No og ~ ~ ~ ~ D SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RElliRN '- /~) '-f~ ~.;>'~?~'- 7~~~~~' ~;:/_ ADDRESS ,; / DATE ~'731/() (p ,(. ",--t...- 106 Skyline Drive, Mechanicsburg, PA 17050 DATE 6/:L/06 Richard C 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. S 9916 (a) (1.1) (i)). F or 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 .5. 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 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. 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. S 9116(1.2) [72 P .S. 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. 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. 3W4646 1.000 I REV-1503 E'X + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS & BONDS FILE NUMBER Mary B. Clifford 21 05 0827 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1.Agere Systems Inc. 6 shares of common stock valued at $10.26 per share 61.56 2 AT&T 204 shares of common stock valued at $19.59 per share 3,996.36 3 Avaya, Inc. 49 shares of common stock valued at $10.10 per share 494.90 4 BellSouth Corp. 2,509 shares of common stock valued at $26.25 per share 65,861.25 5 Lucent Technologies, Inc. 596 shares of common stock valued at $3.15 per share 1,877.40 6 NCR Corp 29 shares of common stock valued at $33.20 per share 962.80 3W46961.000 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 73,254.27 R EV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Mary B. Clifford FI LE NUMBER 21 05 0827 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Commerce Bank checking account #536308034 100,464.34 2 Household goods retained by family members 409.00 3 M&T Bank savings account #015004205864893 45,220.34 4 Orrstown Bank checking account #111000690 93,118.13 5 ROBe Limited Partnership refund on resident care 2,106.17 6 U.S. Treasury refund due on 2005 Final Individual Income Tax 288.00 3W46AD 1.000 TOTAL (Also enter on line 5. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 241,605.98 .REV-1511 EX + (12-99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mary B. Clifford ITEM NUMBER A. B. 3W46AG 1.000 Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: 1. Auer Memorial Home & Cremation Services funeral expense Total from continuation schedules 1 . ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Linda Mary Fortini Social Security Number(s) / EIN Number of Personal Representa Street Address 106 Skyline Drive City Mechanicsburg State PA Zip 17050 Year(s) Commission Paid: 2. Attorney Fees 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 Cumberland Law Journal advertising Executrix notice Total from continuation schedules FILE NUMBER 21 05 0827 TOTAL (Also enter on line 9, Recapitulation) ([f more space is needed, insert additional sheets of the same size) $ AMOUNT 1,479.00 166.51 3,148.00 4,500.00 364.00 75.00 1,576.57 11 309.08 Estate of: Mary B. Clifford Item No. 2 167-14-7308 Schedule H Part 1 (Page 2) Description Amount Ellen Geduldig reimburse for food for funeral luncheon 166.51 Total (Carry forward to main schedule) 166.51 Estate of: Mary B. Clifford 167-14-7308 Schedule H Part 7 (Page 2) 2 Greenawalt & Company, P.C. preparation of Final Individual Income Tax Returns 295.00 3 Linda Fortini reimburse for packing supplies, truck rental and gas for rented truck 132.30 4 Patriot-News advertising Executrix notice 126.27 5 Register of Wills short certificates 8.00 6 Register of Wills filing fee for Inheritance Tax Return 15.00 7 Reserve for additional filing fees, accounting fees and other miscellaneous costs associated with the administration of the Decedent's estate 1,000.00 Total (Carry forward to main schedule) 1,576.57 REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mary B. Clifford SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21 05 0827 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 VALUE AT DATE OF DEATH Alert Pharmacy Services, Inc. prescription services 90.68 2 MaNA America credit card payoff 31.45 3 Pennsylvania Department of Revenue Income Tax due on 2005 Final Individual Income Tax Return 45.00 4 ROBC Limited Partnership beauty shop services at Bent Creek nursing home 15.00 3W46AH 2.000 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 182.13 REV-1513 EX + (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Marv B. Clifford NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] William H. Clifford, III 1544 Giddings Avenue, SE Grand Rapids, MI 49507 1 25% of Residue: 75,842.26 2 Linda Mary Fortini 106 Skyline Drive Mechanicsburg, PA 17050 25% of residue: 75,842.26 3 Victoria Regena Hara 2218 West Hidden Treasure Way Anthem, AZ 85086 25% of Residue: 75,842.26 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) FILE NUMBER 21 05 0827 AMOUNT OR SHARE OF ESTATE Son Daughter Daugher 75,842.26 75,842.26 75,842.26 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE. ON REV-1500 COVER SHEET " NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 8. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 3W46AI 1.000 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) $ 0.00 Estate of: Mary B. Clifford 167-14-7308 Schedule J Part 1 (Page 2) Item No. Description Relation Amount 4 Terry Odhner 14079 North 34th Place Phoenix, AZ 85032 25% of Residue: 75,842.26 Daughter 75,842.26 ....,~, ......--.-~ LAST WILL AND TESTAMENT I, MARY B. CLIFFORD, of the Township of Silver Spring, County of Cumberland, and Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at anytime heretofore made. FIRST. I order and direct that all my just debts and funeral expenses be paid by my Executrix, hereinafter named, as soon as conveniently may be done after my decease. SECOND. I give and bequeath certain items of tangible personal prop~rty unto the persons named as contained on a certain list or schedule which may be found with this, my Last Will and Testament, and which shall be incorporated herein by reference thereto whether prepared contemporaneously herewith or subsequent hereto. THIRD. I give, devise and bequeath all the rest, residue and remainder of my Estate, real, personal and Inixed, whatsoever and wheresoever situated, in equal shares unto such of my children, namely, LINDA MARY FORTINI, TERRY ODHNER, VICTORIA REGENA HARA and WILLIAM H. CLIFFORD, III, as may survive me, share and share alike, absolutely and in fee simple. If any of my said children should predecease me, I order and direct that said residuary estate shall be distributed equally and per capita among the children living at the time of my death without substitution of the issue of any deceased child. LASTL Y. I nominate, constitute and appoint my daughter, namely, LINDA MARY FORTINI, to be the Executrix of this, nlY Last Will and Testament, but if for any reason she should fail to qualify as such Executrix or cease so to serve, then and in that event, I nominate, constitute and appoint my daughter, namely, VICTORIA REGENA HARA, to be the Executrix hereof, each and both to serve without bond or other security as a condition of qualification hereunder. . . LAW OFFICES The preceding instrument, consisting of this and one (1) other typewritten page, each identified by the signature of the Testatrix, was on the date thereof signed, sealed, published and declared by MARY B. CLIFFORD, the Testatrix therein named, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other, have subscribed our names as witnesses hereto. ~~ r.j, .1} ; ( ! <~' II (j CJ /) C (,4:r~ r COMMONWEALTH OF PENNSYLVANIA) SS. COUNTY OF CUMBERLAND ) We, MARY B. CLIFFORD, RICHARD C. SNELBAKER and JANE J. COONEY, the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, 'do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and Testament and that she had signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as a witness and that to the best of his or her knowledge, the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or updue influence. n t \ (, C ~ vii ness j Subscribed, sworn to and acknowledged before me by MARY B. CLIFFORD, the Testatrix, and subscribed and sworn to before. me by RICHARD C. SNELBAKER and JANE J. COONEY, the witnesses, this 22nd day of September, 2003. ~ It . . _ f I _ . . _ ~ptarial ~i.