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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT 280601
HARRISBURG. PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
00937
NUMBER
Future Interest Compromise (date of death after
12-12-82)
Decedent Maintained a Living Trust (Attach
copy of Trust)
Spousal Poverty Credit (date of death between
12-31-91 and 1-1-95)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONflDENnAL TAX INFORMA nON SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
Dale F Shughart, Jr. Esquire
DECE:DENTS NAME: (LAST, FIRST, AND MIDDLE INITIAL)
Hicks. Mary A
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DATE OF DEATH (MM-DD-YEAR)
DATE: OF BIRTH (MM-DD-YE:AR)
10; 18/2005
02/23/1912
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST FIRST AND MIDDLE INITIAL)
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o 2. Supplemental Return
o 4a,
o 7.
o 10,
1. Original Return
4, Limited Estate
6, Decedent Died Testate (Attach copy
of Will)
9. Litigation Proceeds Received
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FIRM NAME (If applicable)
TELEPHONE NUMBER
717241-4311
Real Estate (Schedule A)
2 Stocks and Bonds (Schedule B)
3 Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5 Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6, Jointly Owned Property (Schedule F)
o Separate Billing Requested
7, Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8, Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10, Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11, Total Deductions (total Lines 9 & 10)
12, Net Value of Estate (Line 8 minus Line 11)
175-20-4950
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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3. Remainder Return (date of death pnor to 12-13-82)
5, Federal Estate Tax Return Required
8, Total Number of Safe Deposit Boxes
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11, Election to tax under Sec. 9113(A) (Attach Sch 0)
10 West High Street
Carlisle, P A 17013
(1) None
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(2) None
(3) None
(4) None
(5) 7,854.86
(6) None
(7) None
(8)
7,854.86
(9)
(10)
3,482.53
23,661.91
(11 )
27.144.44
(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, x .00 (15)
or transfers under See, 9116(a)(1_2)
z x .045 (16)
0 16, Amount of Line 14 taxable at lineal rate
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"- 17. Amount of Line 14 taxable at sibling rate x .12
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x 18. Amount of Line 14 taxable at collateral rate (18)
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19. Tax Due (19)
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 <<
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
I SI KlTI AIlIlRESS 211 SiKh Lane
(IT,( Carlisle
STAlE PA'17013 71P 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
Total Credits (A + B + C)
(2)
0,00
3. Interest/Penalty if applicable
D. Interest
E Penalty
B. Enter the total of Line S + SA. This is the BALANCE DUE.
(3) 0.00
(4)
(S) 0.00
(SA)
(SB) 0.00
Total Interest/Penalty (0 + 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
S If Line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
Make Check
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:
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?.......... ................................................... ..................... .........................
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?....................................... ..................... ...................... ...................................
Yes No
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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 1$ based on all Information of which preparer has any knowledge
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
~.e ~e \1. j~cks. ,J... .'J ~
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GNATURE OF PE~N ~~L OR FILING RETURN
DATE
211 Birch Lane
Carlisle, P A 17013
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bATE
ADDRESS
SIGNA TURE OF
ADDRESS
DATE
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10 West High Street
Carlisle, P A. 17013
For dates of death on or 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. 16 (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. S9116 (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. S9116 (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.S%, except as noted in 72 P.S. S9116
1.2) [72 P.S. S9116 (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. S9116 (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.
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hicks, Mary A
FILE NUMBER
21 - 05 - 00937
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorshilp must be disclosed on schedule F.
ITEM
NUMBER
1 Clothing and personal effects.
DESCRIPTION
VALUE AT DATE OF
DEATH
0.00
2
M & T Bank checking account #2676014018
Principal 5,879.18
Interest -0-
5,879.18
3
Sun Life Financial, refund
253.12
4
American General, final pension payment
50.00
5
HighMark Blue Shield, refund
325.34
6
. NeighborCare Pharmacy, refund
1,347.22
TOTAL (Also enter on Line 5, Recapitulation)
7,854.86
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COrliiMONWEAL TH OF PENNSYLVANIA
INHEf-=lITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
RJNERAL EXPENSES &
ADIVIINSTRAllVE COSTS
ESTATE OF
FILE NUMBER
21-05-00937
Hicks, Mary A
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
St. Stephens Lutheran Church, Honorarium for Pastor and use of Church.
B.
ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Leslie M. Hicks, Jr.
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address 211 Birch Lane
City Carlisle
Year(s) Commission paid 2006
State P A
Zip 17013
2.
Attorney's Fees
Dale F. Shughart, Jr. (estimated)
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
4.
City
Relationship of Claimant to Decedent
Probate Fees Register of Wills, paid 60; owe 15
State
Zip
5. Accountant's Fees
6
Tax Return Preparer's Fees Mentzer & Company
7
1
Other Administrative Costs
Cumberland Law Journal. advertise Letters
2
The Sentinel. advertise Letters
Total of Continuation Schedule(s)
TOTAL (Also enter on line 9, Recapitulation)
150.00
500.00
2,000.00
75.00
90.00
75.00
137.03
455.50
3,482.53
SchedLE H
Fu1eraI Expenses &
AcminislralNe CosIs continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hicks. Mary A
FILE NUMBER
21 - 05 - 00937
3
M & T Bank, checks
12.50
4
Register of Wills, filing Inheritance Tax Return and Inventory
30.00
5
Register of Wills, two Short Certificates
R.OO
6
Leslie M. Hicks, reimburse out of pocket expenses for gas, postage, photocopies and long
distance.
50.00
7
Postmaster, certified mail
5.00
R
Register of Wills. reserve for account.
350.00
Page 2 of Schedule H
ESTATE OF
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SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
!NHERITANCE TAX RETURN
RESIDENT DECEDENT
Hicks, Mary A
Include unrleimbursed medical expenses.
ITEM
NUMBER
I
DESCRIPTION
Department of Public Welfare, Medical Assistance Recovery
FILE NUMBER
21 - 05 - 00937
TOTAL (Also enter on Line 10, Recapitulation)
AMOUNT
23,661.91
23,661.91
FILE NUMBER
21 - 05 - 00937
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s)
REV-1513 EX+ (9-00)
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SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hicks. Mary A
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Cheryl Lynn Hicks
30 North 36th Street
Harrisburg, P A 17109
Granddaughter
2
Leslie M. Hicks. .Ir.
211 Birch Lane
Carlisle. P A 17013
Son
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
AMOUNT OR SHARE
OF ESTATE
-0- Tangible propel1y
disposed of during
lifetime.
10000 residue
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
Moxham Lutheran Church
5]2 Park Avenue. Johnstown. PA 15902
0.00
TOTAL OF PART" - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
~M&fBank
499 Mitchell Street, Millsboro, DE 19966
March 27, 2006
Dale F. Shughart, Jr.
Attomey At Law
35 East High Street
Suite 203
Carlisle, PA 17013
RE: Estate of Mary A. Hicks
Date of Death: October 18, 2005
Social Security No.: 175-20-4950
Dear Mr. Shughart:
In response to your request, please be advised that at the time of death, the above-
named decedent had on deposit with this bank the following accounts.
1. Account Type......................... ..Checking Account
Account Number.............. ...... ...26760140 18
Ownership (Names oj)............. ..Mary A. Hicks
Opening Date.... . .. . .. . .., .. . .. '" '" . . 09 / 12/91
Balance on Date of Death........ ..$5,879.18
Accrued Interest
$
0.00
Total..................................... ..$5,879.18
The above named decedent did not have a safe deposit box.
For any additional information on the above accounts, including ownership,
statements and closures please contact our Carlisle Pike branch at 717-795-1710.
Sincerely,
()LtM11JJ !JA1JZvr
Charlene Warrington, Records Management
1-888-502-4349
LAST WILL AND TESTAMENT
I, MARY A. HICKS, of Lorain Borough, Cambria County,
Pennsylvania, being of sound mind, memory and understanding, do
make, publish and declare this as and for my Last Will and
Testament, hereby revoking all former Wills by me at any time
heretofore made.
FIRST: It is my will that all my just debts and funeral
expenses be first fully paid as soon as may be after my decease.
SECOND: All the rest, residue and remainder of my estate,
real and personal, I give, devise and bequeath unto my beloved
husband, Leslie M. Hicks, and I appoint him Executor hereof, ~
provided, however, that if he predeceases me, or dies within sixty.
(60) days of my death, then I give, devise and bequeath the rest
of my estate as follows:
I give and bequeath the sum of Five Hundred ($500.00) Dollars
unto the Moxham Lutheran church of Johnstown, Pennsylvania.
I give and bequeath my books, my electric organ and all of my
stock in the Penn Traffic Company unto my granddaughter, Cheryl
Lynn Hicks.
All the rest of my estate, I give, devise and bequeath unto
my son, Leslie M. Hicks, Jr., and I appoint him Executor hereof.
If my son predeceases me, I give, devise and bequeath the rest of
my estate unto my granddaughter, Cheryl Lynn Hicks and any other
grandchildren I may have, share and share alike, and I appoint my
granddaughter, Cheryl Lynn Hicks, Executrix hereof. If my grand-
daughter, in such event, is a minor or unable to so serve, I
appoint the United States National Bank in Johnstown Executor
hereof.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this!
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-3/ - - day of August, 1971.
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(SEAL)
signed, sealed, published and declared by the above named
'Testatrix, MARY A. HICKS, as and for her Last Will and Testament,
in the presence of us who at her request and in her presence and
in the presence of each other, have hereunto subscribed our nameE
as witnesses thereto.
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