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Home My WebLink About10-05-06 REV .1500 EX + c....) *' REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 COUNTY CODE COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG. PA 17128-Oe01 OFFiCiAL USE ONLY -l 06 ~~1- YEAR NUMBER DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER LOCKWOOD, Florence M. 200-24-6204 I- Z DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH w Q w 01/09/2006 11/14/1929 REGISTER OF WILLS 0 w Q (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ~ 1. Original Return 0 2. Supplemental Return 0 3. Remainder Return (date of death prior to 12-13-82) w I- 0 Limited Estate 0 4a. Future Interest Compromise (date of death after 0 5. Federal Estate Tax Return Required "'~~ 4. 12-12-82) frlll.g :z:li!... 0"'11I II. 0( o 6. Decedent Died Testate (Attach copy of Will) o 9. Litigation Proceeds Received THE 7. Decedent Maintained a Living Trust (Attach copy of Trust) 10. Spousal Poverty Credit (date of death between o 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (Attach Sch 0) <hI- l:!ffi IlI:Q OZ o~ AME Hillary A. Dean, Esquire IRM NAME (If applicable) Martson Deardorff Williams & Otto ELEPHONE NUMBER 717/243-3341 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship Z o 1= :5 ::> l- ii: 0( o W Ill: 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) COMPLETE MAILING ADDRESS 10 East High Street Carlisle, PA 17013 (1 ) None (2) None (3) None (4) None (5) None (6) None (7) 7,505.49 (9) 1,671.00 (10) 20,044.02 OFFjC!A, , USE ONl..'f ......., e:.:) c:> c,,,", C::l ("-) -l I CJl ,:::~3 t~S .: i".) '-__7 1--7-j C] =) -:-1 ., (') IT! -) -... ,.._'~ ,~._) il ( .. -II CJ =-i -~> Ul (8) 7,505.49 (11 ) 21,715.02 (12) insolvent 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Copyright 2000 form software only The Lackner Group. Inc. 15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec. 9116(a)(1.2) Z .045 (16) 0 , 16. Amount of Line 14 taxable at lineal rate x 1= ~ ::> (17) II. 17.Amount of Line 14 taxable at sibling rate x .12 :E 0 0 ~ 18. Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 1000 Claremont Road CITY Carlisle I STATE PA I ZIP 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 + 8 + C) (2) 0.00 3. Interest/Penalty If applicable D. Interest E. Penalty Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is thEOVERPAYMENT. 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 theTAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is theBALANCE DUE (3) 0.00 (4) (5) 0.00 (5A) (58) 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;............................................................................. ~ ~ ~: ~:::~ ~~e~~~i~~:~:~~;=s~~~. ~~~~I. .~.~~. ~~~.:.~~:.~~. .~~.~.~~~~~.~. .~~ .I.~. ~~.~.~~~.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'~~::::::::::: ~~..... 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?............................ .................................................................................... 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?................................................................................................................ ~ . 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 pena~ies 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 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 111 Faith Circle DATE A bur H. Lockw od Carlisle, P A 17013 ADDRESS /o/-V/CJ(, DATE .--- , .. fl(P ADDRESS 10 East High Street Carlisle, 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. S9116 (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 statutedoes not exemot 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 .5. 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 4.5%, except as noted in 72 P.S. ~9116 1.2) [72 P .5. 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 .5. 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. . SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT LOCKWOOD, Florence M. ESTATE OF ITEM NUMBER This schedule must be com leted and filed If the answer to an DESCRIPTION OF PROPERTY % OF Indude the name of the transferee. their relationship to decedent and the date of transfer. ~:L~E ~ ~~~T:T DECO'S EXCLUSION TAXABLE VALUE Attach a copy of the deed for real estate. F I NTEREST (IF APPLICABLE) M&T Bank checking account #23499907, made joint with Arthur H. Lockwood, son, 6/2005 10,505.49 100% 3,000.00 7,505.49 TOTAL (Also enter on line 7, Recapitulation) ! 7,505.49 . SCtEDULEH RJNERAL EXPENSES & ADNNSTRATlVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT - ---.-_.._------- ESTATE OF LOCKWOOD, Florence M. FILE NUMBER 21 - 06 - Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT FUNERAL EXPENSES: Auer Memorial Home & Cremation Services, Inc., Harrisburg, PA, balance due 156.00 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Social Security Number(s) I EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid Attomey's Fees Martson Deardorff Williams & Otto (estimated) 2. 1,500.00 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 Retum Preparer's Fees 7. 1 Other Administrative Costs Register of Wills, filing fee, Inheritance Tax return 15.00 TOTAL (Also enter on line 9, Recapitulation) 1,671.00 *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF LOCKWOOD, Florence M. I FILE NUMBER 21 - 06 - Include unrelmbursed medical expenses. ITEM NUMBER 1 DESCRIPTION 2 PharMerica, account payable Claremont Nursing and Rebilitation Center, account payable ~--~---~----- TOTAL (Also enter on Line 10, Recapitulation) AMOUNT 19,182.00 862.02 20,044.02 . , r" . . " i\Ol1t J\llt;S//_ ~ Q,'. to- ~ CSr; ,,~ -~ l , ,oJ '-" -,-.. ~ 1 (,.j~J() f~;'~;-.'-"~i(~; ,. 0::- :;>",:j ~ Cl'';i;:'' PA 178 I, ,;,;';5 \7:7) 2432031 f;;x (717) HO-1952 1\.ehabilitation Center January 31, 2006 Mr. Art Lockwood 111 Faith Circle Carlisle, Pa. 17013 RE: FLORENCE LOCKWOOD - OUR RESIDENT ACCOUNT #4613 Dear Mr. Lockwood: The Claremont Nursing and Rehabilitation Center has received notification from the County Assistance Office that Medical Assistance for Mrs. Lockwood was approved for the period of July 21,2005 through September 30,2005. Mrs. Lockwood became ineligible for Medical Assistance effective October 1,2005 due to excess resources from the sale of her home. Please find enclosed the Private Pay and Medicare Coinsurance bills due Claremont Nursing and Rehabilitation for the months of October through December, 2005. The following is a summary of the Private Pay Bills due: October 1-8, 2005 Medicare Co-insurance October 9-30, 2005 Private Pay November 2005 Private Pay December 2005 Private Pay TOTAL $912.00 $5,175.00 $6,750.00 $6.975.00 $19,812.00 Please direct prompt payment to our Business Office at the above address. Should you have any questions, please feel free to contact Denise Lehman at (717) 240-1908. Sincerely, ~ll~~t?r Business Office Manager DD/dl Ene: Private Pay BIlls Medical Assistance Notice C>\~ :JJ/u ~ I _:1 Sf. IT ice ngcl/c.lj {!/ ( 'w II/Jf '-/(/1/(( ("Otl II tu