HomeMy WebLinkAbout09-25-06
.-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
g~unly Code Year
INHERITANCE TAX RETURN
RESIDENT DECEDENT
File Number
21
06
0658
Date of Birth
189-09-4606
07/16/2006
04/10/1914
Decedent's First Name
Decedent's Last Name
MI
KEIM
JOHN
W
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
~polJsl:}'~~irstf',larne
MI
?pou~e's..Social.?e~urIty.f',IlJrnber
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
te.::l 1. Original Return
c:;::;
2. Supplemental Return
c::::J
c::;
4. Limited Estate
c:;::;
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
F""""""<
O'N_~"....;'
c:::> 4a. Future Interest Compromise (date of
death after 12-12-82)
c:;::; 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
c::::J 10. Spousal Poverty Credit (date of death c:;::; 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 AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIR~JED TO:
Name Daytime Telephd,ie N.umber :So; _._, ;n
H:::::.() . ... ...... .. ........ ,';C C)
(717) 737-3405'-) ~;-.; F")
. ---- - - ~~~--"_:~,~,,.)_ ~,'d-..
.. .5.....:...'.~.~._...;.j:.. ~CJ..-.-~
."REGISTEROFW~lJSE~Y' .. ..
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
{tJ
THOMAS E. FLOWER
Firm Name (If Applicable)
SAlOIS, FLOWER, LINDSAY
, "...."
v
:~_::j C~
, _ - ----n
i >:: c;:"~
:'.~ on
:..J) C.)
'1
First line of address
2109 MARKET STREET
Second line of address
r
(....'1
or Post Office
State
ZIP Code
DATE FILED
CAMP HILL
17011
Correspondent's e-mail address:tflower@sfl-Iaw.com
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.
SIGNAT ~~N~~~ DATE
MA LOUISE McGINN, 13 BENTLEY PLACE, CARLISLE, PA 17013
-~---
-~~._-
SIG~OFPREPAREROTHERT~RHRESENTATIVE __ .. __D~._E //</ /" /_
~-1. CZl- -AAAJ..J-/} .--- --t-/--!--~Je:'
ADD S
SAlOIS, FLOWER & LINDSAY, 2109 MARKET STREET, CAMP HILL, PA 17011
PLEASE USE ORIGINAL FORM ONLY
L
15056051058
Side 1
15056051058
...J
--.J
15056052059
REV-1500 EX
Decedent's Name:
JOHN
W KEIM
RECAPITULATION
1. Real estate (Schedule A). ............................................ 1.
.[)ece<iEl~t'~..~()cial. Sec~~o/..~.~.rT'ber
. 189-09-4606
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
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) CJ Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) CJ Separate Billing Requested.. . . . . .. 7.
8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 8.
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). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11.
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14.
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 .0_
16. Amount of Line 14 taxable
at lineal rate X.O 45 181,744.64
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X. 15
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
L
15056052059
Side 2
15.
5,942.77
144.74
6,087.51
181,744.64
0.00
181,744.64
16.
17.
8,178.51
18.
8,178.51
;) &0 . ~/J fft1A t!
aCt(j.vV ~
O().UU
Nit-PO.
15056052059
-....J
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
JOHN W KEIM
~-
STREET ADDRESS
ONE LONGSDORF WAY
ftt'NMmber .
10658
.,"',....,...,.w."'.w, "'.'woe.....w.....,........
DECEDENT'S SOCIAL SECURITY NUMBER
189-09-4606
CITY
CARLISLE
STATE
PA
I ZIP
17013
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
8,178.51
7,769.65
408.91
Total Credits ( A + B + C ) (2)
8,178.56
3. Interest/Penalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in avalon Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(58)
A. Enter the interest on the tax due.
0.00
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; .......................................................................................... 0 ~
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~
c. retain a reversionary interest; or.......................................................................................................................... 0 [iJ
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [i]
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 [i]
3. Did decedent own an "in trust fo~' 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 ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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. ~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 zero (0) percent
[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 zero (0) percent [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 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 twelve (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-1508 EX+ (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
JOHN W. KEIM
FILE NUMBER
21-06-0658
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.
ITEM
NUMBER
DESCRIPTION
MEMBERS 1ST F.C.U., ACCOUNTS NUMBERED 214304:
1. CHECKING ACCOUNT, 24,743.39 PLUS 2.83 ACCRUED INTEREST
2. SAVINGS ACCOUNT #214304-00
3. CERTIFICATE OF DEPOSIT #214304-40,113,507.88, PLUS 232.30 ACC. INT.
4. CERTIFICATE OF DEPOSIT #214304-46, 15,123.75, PLUS 20.51 ACCRUED INTEREST
5. CERTIFICATE OF DEPOSIT #214304-47,30,499.67 PLUS 62.55 ACCRUED INTEREST
6. US SAVINGS BONDS, SEE ATTACHED LIST WITH VALUES
7. TRESSLER LUTHERAN, REFUND OF RESIDENT PAYMENT
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
VALUE AT DATE
OF DEATH
24,746.22
25.39
113,740.18
15,144.26
30,562.22
1,928.90
1,684.98
187,832.15
REV-1511 EX+ 112-99>W
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
JOHN W. KEIM
FILE NUMBER
21-06-0658
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
HOFFMAN-ROTH FUNERAL HOME, BALANCE DUE AFTER PREPAYMENT
407.70
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Year(s) Commission Paid:
2.
Attorney Fees
5,000.00
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
294.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
8.
PUBLISH EXECUTOR'S NOTICE, SENTINEL
EXECUTOR'S NOTICE, CUMBo LAW JOURNAL
166.07
75.00
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
5,942.77
REV-1512 EX+ (12-03)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
JOHN W. KEIM
FILE NUMBER
21-06-0658
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
5.
WEST SHORE EMS 89.16
MASLAND ASSOCIATES 17.64
ANDORRA RADIOLOGY 9.64
CONTINUING CARE RX 10.00
LOCAL PER CAPITA TAX 9.80
GOODWILL FIRE & RESCUE 8.50
2.
3.
4.
6.
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
144.74
RE~1513 "'.1"""1 '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
JOHN W. KEIM
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 91.16 (a) (1.2)]
1. MARY LOUISE McGINN, 13 BENTLEY PL., CARLISLE, PA 17013
2. JOHN W. KEIM, JR., 27 GREGORY ST., GOLDEN BEACH,
QUEENSLAND 4551, AUSTRALIA
3.
BRETT J. KEIM, 237 MIDDLE ROAD, NEWVILLE, PA 17241
4.
WALTER J. KEIM, JR., 204 DOWNING PL, MECHANICSBURG, PA
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
DAUGHTER
SON
GRANDSON
GRANDSON
FILE NUMBER
21-06-0658
AMOUNT OR SHARE
OF ESTATE
.45
.35
.10
.10
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, 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 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)
LAST WILL AND TESTAMENT
OF
JOHN W. KEIM
I, JOHN W. KEIM, of 214 Todd Circle, Carlisle, Cumberland County,
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 any and all former Wills, Codicils, or writings in the nature thereof, by me at
any time heretofore made.
FIRST: I hereby order and direct my Executrix or Executor,
hereinafter named, to pay all my just debts, funeral expenses, testamentary expenses
and all Inheritance, Estate, Transfer and Succession Taxes, as soon as may be
conveniently done after my death, out of my residuary estate.
SECOND: I give, devise and bequeath all the rest, residue and
remainder of my estate t9 my wife, HELEN W. KEIM, provided she survives me by a
period of thirty (30) days.
THIRD: In the event that my wife, HELEN W. KEIM, fails to survive
me by thirty (30) days, I give, devise and bequeath all the rest, residue and remainder of
my estate as follows:
A. Forty-five (45%) percent of my estate to my daughter, MARY
LOUISE McGINN;
B. Thirty-five (35%) percent of my estate to my son, JOHN W.
KEIM, JR.;
C. Ten (10%) percent of my estate to my grandson, BRETT J.
KEIM; and
D. Ten (10%) percent of my estate to my grandson, WALTER J.
KEIM, JR.
LASTL Y:
I nominate, constitute and appoint my daughter, MARY
LOUISE McGINN, to be the Executrix of this my Last Will and Testament. In the event
that my said daughter, MARY LOUISE McGINN, shall be unable to serve as Executrix for
any reason, I appoint my granddaughter, KRISTIN L. MAHOONEY, as Executrix. No
Executrix shall be required to file bond in this or any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
~5t' day of ~~ ,2004.
,/'1 0
r~~ ~
0:;/ Jo~ . W~
SIGNED, SEALED, PUBLISHED and
DECLARED in the presence of:
.J!tb~ ~ A~~/
2
COMMONWEALTH OF PENNSYLVANIA
ss
COUNTY OF CUMBERLAND
We, James D~ Flower, Jr., Esq. and Dawn L. Flower ,
the witnesses whose names are signed to the attached or foregoing instrument, being
duly qualified according to law, do depose and say that we were present and saw
Testator sign and execute the instrument as his Last Will; that he signed willingly and that
he executed it as his free and voluntary act for the purposes therein expressed; that each
of us in the hearing and sight of the Testator signed the Will as witnesses; and that to the
best of our knowledge the Testator was at that time 18 or more years of age, of sound
mind and under no constraint or undue influence.
Sworn or affirmed to and subscribed to before me by James D. Flower, Jr., Esq.
and
Dawn L. Flower
this
25th
day of
August
2004.
~;~l),1kmtJ
l ' Witness
4mvf~~)
Witness
NOTARIAL SEAL '
R~NEE L MURRAY, Notary Pubfir. !
Carflsle ~, Cum~ Coul1t!t.!.~ ,
My Commlsston Expires D8c. i ~, ~105 f
. .,.~'_._.~-_.
4
COMMONWEALTH OF PENNSYLVANIA
ss
COUNTY OF CUMBERLAND
I, JOHN W. KEIM, Testator, whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instrument as my Last Will; that I signed it
willingly; and that I signed it as my free and voluntary act for the purposes therein
expressed.
Sworn or affirmed to and acknowledged before me, by JOHN W. KEIM, the
Testator, this ?t;th day of Anqll!=:t I 2004.
p~~
John W. Keirn, Testator
~L,~
NOTARIAL SEAL
R~NEE L MURRAY, Notary Public
Carl.sle Boro, Cumberland County, PA
My CommISSion Expires Dec. 13, 2005
3
9
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CERTIFICATES OF DEPOSIT:
Account Number/Suffix
Date. Certificate. Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CERTIFICATES OF DEPOSIT:
Account Number/Suffix
Date Certificate Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
Estate of: JOHN W.KEIM
Qateof Death: 07/16/2006
Social Security Number: 189-09-4606
fvl~
MEMBERS 1st
FEDERAL CREDIT UNION
214304 -00
02/16/2002
$25.39
$.00
$25.39
None
214304 -11
02/16/2002
$24,743.39
$2.83
$24,746.22
None
214304 -40
03/08/2002
$113,507.88
$232.30
$113,740.18
None
214304 -46
04/01/2006
$15,123.75
$20.51
$15,144.26
None
214304 -47
04/01/2006
$30,499.67
$62.55
$30,562.22
None
/
~B:RS 1aEL CREDIT UNION
~WOlfe ~
Insurance Services Su~lvisor.
September 15, 2006
5000 Louise Drive · P.O. Box 40 · Mechanicsburg, Pennsylvania 17055 · (717) 697-1161 · www:members1st.org
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