HomeMy WebLinkAbout08-06-06
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OFFICIAL USE ONLY
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
~ 1. Original Return 0 2. Supplemental Return
o 4. Limited Estate 0
~ 6. Decedent Died Testate (Attach ~
copy of Will)
O 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (date of death between 0 11.Election to tax under Sec. 9113(A) (Attach Sch O}
12.31.91 and 1.1.95)
TliI$,SEC'I'ION,l\ftUST'~EC()M"li~,.AtI...CORRESPONDENCE'AN1)C1)Nt=n;)t;N"I1"1..'J!~I~~.()RI\IATION'S"'l1)tlUIil,''''E'1)llteCTl!1)'rro:'... ,.
NAME COMPLETE MAILING ADDRESS
Gary L. James, Esq.
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Cover, Clyde R. Jr.
DATE OF DEATH (MM.DD.YEAR)
DATE OF BIRTH (MM-D[)"YEAR)
04-10-2006
05-25-1922
FILE NUMBER
ll. 06
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
~ER
184-12-3022
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o
o
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3. Remainder Retum (date of death prior to 12-13-82)
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST. FIRST AND MIDDLE INITIAL)
Cover, Helen P.
5. Federal Estate Tax Return Required
4a. Future Interest Compromise (date of death after
12.12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
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FIRM NAME (If applicable)
James, Smith, Dietterick & Connelly, LLP
TELEPHONE NUMBER
717/533-3280
8. Total Number of Safe Deposit Boxes
(1 )
(2)
(3)
(4)
(5)
(6)
(7)
None
None
None
None
None
179,890.82
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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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) 0 Separate Billing Requested
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)
(8)
179,890.82
12. Net Value of Estate (Line 8 minus Line 11)
(9)
(10)
13,071.11
2,767.34
(11)
(12)
(13)
15,838.45
164,052.37
None
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)
(14)
164,052.37
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPI..ICABLE RATES
0.00
3,691.18
0.00
0.00
3,691.18
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 <<
15. Amount of Line 14 taxable at the spousal tax rate, 82,026.19 x .00 (15)
or transfers under Sec. 9116(a)(1.2)
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0 82,026.18 .045 (16)
~ 16. Amount of Line 14 taxable at lineal rate x
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tI. 17. Amount of Line 14 taxable at sibling rate 0.00 x .12 (17)
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0
u 18. Amount of Line 14 taxable at collateral rate 0.00 x .15 (18)
S
19. Tax Due (19)
Copyright 2002 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00:
-
Decedent's Complete Address:
STREET ADDRESS
3424 Bedford Street
CITY Camp Hill
\STATE PA
-\ZIP 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
3,691.18
0.00
Total Credits (A + B + C)
(2)
0.00
3. InterestlPenalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty (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.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5)
(5A)
(5B)
3,691.18
3,691.18
Make Check Payable to: REGISTER OF WILLS, AGENT
1. Did decedent make a transfer and: Yes
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?...................................................................................................................... ~ 0
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 retum. 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
Helen P. Cover
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
No
o
o
o
o
o
o
~
~
~ J I--t/r./
LE R FILING RETURN
3424 Bedford Drive
Camp Hill, PA 17011
'(-s
DATE
l~~b
DATE
ADDRESS
1. S. 2<;,.;;><:-
DATE
REPRESENTATIVE
ADDRESS
134 Sipe Avenue
Hummelstown, PA 17036
For dates of death on or after July 1, 1994 and before January 1, 1995. the tax rate imposed on the net value of
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.
991161.2)[72P.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.
.
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
Rev.1MO EX+ (6-98)
COMMONWEAl. TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21-06-
ESTATE OF
Cover, Clyde R. Jr.
This schedule must be completed and filed ~ the enswerto any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM .....~v '" ...., " ~, :1 Y DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COpy OF THE DEED FOR REAL ESTATE.
1 Equity Services IRA No. DFJ-928372 - beneficiary 41,256.62 100.000 0.00 41,256.62
is the Clyde R. Cover Living Trust dated
10/26/01; valued per letter dated 7/11/06
2 LSW Annuity Policy No. 458150X - beneficiary is 9,084.38 100.000 0.00 9,084.38
the Clyde R. Cover Living Trust dated 10/26/01;
valued per letter dated 7/11/06
'"' 3 Midland National IRA No. 8000012138- 106,349.95 100.000 0.00 106,349.95
beneficiary is the Clyde R. Cover Living Trust
dated 10/26/01; valued per letter dated 7/11/06
4 Sentinel Variable Annuity Policy No. NL9005825 - 19,741.18 100.000 0.00 19,741.18
beneficiary is the Clyde R. Cover Living Trust
dated 10/26/01; valued per letter dated 7/11/06
5 Cash gifts to Justin Barnes for college savings 300.00 100.000 300.00 0.00
plan - great-grandson
6 Cash gifts to Olivia Cover for college savings 600.00 100.000 600.00 0.00
plan - great-granddaughter
7 Cash gifts to Zachary Barnes for college savings 300.00 100.000 300.00 0.00
plan - great-grandson
8 PNC Checking Account No. 5070089648 - titled in 3,458.12 100.000 0.00 3,458.12
the Clyde R. Cover Living Trust dated 10/26/01;
valued per letter dated 5/25/06
9 PNC Checking Account No. 5070089648, accrued 0.57 100.000 0.00 0.57
interest - titled in the Clyde R. Cover Living Trust
dated 10/26/01; valued per letter dated 5/25/06
TOTAL (Also enter on Line 7, Recapitulation) 179,890.82
."
(If more space IS needed. addItional pages of the same size)
Copyright (c) 2002 tonn software only The Lackner Group, Inc.
Form PA-1500 ScheduleG (Rev. 6-98)
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REV-1151 EX+ (12-99)
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21-06-
ESTATE OF
Cover, Clyde R. Jr.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
See continuation schedule(s) attached
5,199.11
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
B.
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City
Year(s) Commission paid
State Zip
2.
Attorney's Fees
James, Smith, Dietterick & Connelly, LLP
7,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
372.00
7.
Other Administrative Costs
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation)
13,071.11
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
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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
Cover, Clyde R. Jr.
FILE NUMBER
21-06-
ITEM
NUMBER
DESCRIPTION
Neill Funeral Home, Inc. - funeral services
AMOUNT
4,892.00
1
2
Old Country Buffet - funeral reception
307.11
Subtotal
5,199.11
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
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Rev-1002 EX+ (6-98)
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SCHEDULE H-87
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Cover, Clyde R. Jr.
FILE NUMBER
21-06-
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
James, Smith, Dietterick & Connelly, LLP - reservation for trust administration
closing costs
150.00
2
Register of Wills, Cumberland County - filing fee for Return
15.00
3
Register of Wills, Cumberland County - reservation for accounting fee
180.00
4
Vital Records - additional death certificates
27.00
Subtotal
372.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
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Rev-1512 EX+ (6-98)
.
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Cover, Clyde R. Jr.
FILE NUMBER
21-06-
Include unrelmbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1 Critical Care Curative - unreimbursed medical bill
VALUE AT DATE
OF DEATH
384.87
2 Harrisburg Pharmacy - unreimbursed prescription bill
18.50
3 Johns Hopkins - unreimbursed medical bill
957.88
4 Mid-Florida Urological Associates - unreimbursed medical bill
124.00
5 Prescriptions - unreimbursed medication bill
567.80
6 WellSpan Health - unreimbursed medical bill
625.13
7 West Shore Ambulance - unrelmbursed ambulance bill
89.16
TOTAL (Also enter on Line 10, Recapitulation)
2,767.34
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500Schedule I (Rev. 6-98)
-
-
REV-1513 EX+ (9-00)
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SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
NUMBER
Cover, Clyde R. Jr.
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
. U\;:i I KIIjU IIUN::> l!nctude outngnt spousal
distributions. and transfers
under Sec. 9116(a)(1.2)]
FILE NUMBER
21-06-
ESTATE OF
RFI -ru
DECEDENT
Do Not List Trustee(s)
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
I.
See attached schedule
Total 164,052.37
Enter dollar amounts for distributions shown above on lines 5 through 18. as appropnate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 6-98)
-
SCHEDULE J
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
Clyde R. Cover Jr. 184-12-3022 04/10/2006
Item Name and Address of Person(s) Share of Estate Amount of Estate
Number Receiving Property Relationship (Words) ($$$)
1 Justin Barnes Great-grandson Cash gift to college
PA savings plan
2 Zachary Barnes Great-grandson Cash gift to college
PA savings plan
3 Olivia Cover Great-granddaughter Cash gift to college
PA savings plan
4 Corey L. Barnes Grandson 1/10 of residue 16,405.24
897 Edmund Avenue
York, PA 17404
5 Timothy R. Barnes Grandson 1/10 of residue 16,405.23
PA
6 Melissa C. Brown Daughter 1/10 of residue 16,405.24
1609 Thompson Lane
Mechanlcsburg, PA 17055
7 Brian R. Cover Grandson 1/10 of residue 16,405.23
2606 Northfleld Drive
East Petersburg, PA 17520
8 C. Robert Cover Son 1/10 of residue 16,405.24
140 Shenks Ferry Road
Conestoga, PA 17516
9 Helen P. Cover Spouse 1/2 of residue 82,026.19
3424 Bedford Drive
Camp Hill, PA 17011
Total 164,052.37
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