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Home My WebLink About10-05-06 --.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 Number Date of Death OFFICIAL USE ONLY 9()IJ~tygC>de Year INHERITANCE TAX RETURN _'1 I RESIDENT DECEDENT A.J File Number 206-24-8294 07/05/2006 Decedent's Last Name Suffix ZAZWORSKY (If Applicable) Enter Surviving Spouse's Information Below Last Name ZAZWORSKY CXo a.l~ Date of Birth 09/24/1930 Decedent's First Name MI o First Name MI LAURA A THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS c:::J 4a. Future Interest Compromise (date of death after 12-12-82) c::> 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c::> 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 DIRECTED TO: Namel:l~Y!iITl~Tel~phone Number FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Retum c:::J 2. Supplemental Retum c:::) 4. Limited Estate c:::J 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received c:::) Matthew R. Gover First line of address 2411 N. Front St. Second line of address or Post Office State c::::l 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required c::::l 8. Total Number of Safe Deposit Boxes r--.> : = i(!~!)~~~~~~~~~C) .... ... + r.~ m..______..:....:.:.=::L..m.__...._.3::.:>~..:... REGISTER OF WIi.lJt~E ON~Y: '.'- ~ I ,J.! (Jl . ::.~:.... :0 ..':-:1 f"] 1 '-r', ("") '.:..; c:) ,;c; ::0 ': ;.:.;~ :~} C:J C") ';'1-1 ',1 <:-5 rn CJ 'f"j <:J -- ZIP Code 17110 Correspondent's e-mail address:mattgover@ngplawfirm.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. s"~~::a:~RETURN 'f1rn0(. ADto SS +\" I s ~et . I Ca.\CAf ,-\, \ \, ~ It \ 10\ \ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY L 15056051058 Side 1 15056051058 --.J --.J 15056052059 REV-1500 EX Decedenfs Name: JOHN D ZAZWORSKY RECAPITULATION 1. Real estate (Schedule A). .............. . . . . .. . . .. . .. . . .. . . . . . . . .. . . .. 1. 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) c:::> Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c:::> 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. i 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 .0JL 0.00 16. Amount of Line 14 taxable at lineal rate X.O_ 17. Amount of Line 14 taxable I at sibling rate X .12 . 18. Amount of Line 14 taxable : at collateral rate X. 15 15. 16. 17. 18. 19. TAX DUE... ... ....... ..... . ............ ... . .... .... . .. . ... . .... .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15056052059 Side 2 Decedent's Social ~ecurityNurnber i 206-24-8294 0.00. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00. c:::l 15056052059 -.J REV-fSOO EX Page 3 Decedent's Complete Address: DECEDENTS NAME JOHN 0 ZAZWORSKY STREET ADDRESS 10 Hillside Circle DECEDENT'S SOCIAL SECURITY NUMBER 206-24-8294 CITY Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditsJPayments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 0.00 3. InterestlPenalty if applicable D. Interest E. Penalty Total Credits (A + 8 + C ) (2) 0.00 TotallnterestlPenalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) 0.00 0.00 0.00 0.00 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) 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 [i] d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 ~ 3. Did decedent own an "in trust for" 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. ~9116 (a) (1.1) (ii)). The statute does 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 zero (0) percent [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedenfs 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-l513 EX+ (9-00) '* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF JOHN D. ZAZWORSKY NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Laura A. Zazworsky, 10 Hillside Ct., Camp Hill, PA 17011 1 Estate was opened because title on two vehicles needed to be transferred from Decedent to Spouse. All other assets were held as joint tenants with right of survivorship with the surviving spouse and therefore are not includable for Pennsylvania inheritance tax purposes. RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Spouse FILE NUMBER AMOUNT OR SHARE OF ESTATE Intestate Estate ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET n 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) -- Register of Wills of Cumberland County INVENTORY Estate of John D. Zazworskv Also known as , Deceased Estat~6-00689 Date of Death Jul V 5. 2006 Social Security No. 206-24-8294 T ;:111 r:i'l lL '7.:i'l7.WnrRlqr . Personal Ropraentative(s) of the above Estate, deceased, verify that the items appearing on the following inventOJy include all of the penonal assets wherever situate and all of the real estate in the Conunonwealth oC Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory rqm:scnta its fair value as of the date of the Decedent's death, and that Decedent owned no real estate oUlaide the Commonwealtb of Pennsylvania except that which appears in a memorandum at the end of this invClltOry (pEP 03301). I/We verify that the statemcnla made in this inventory are true and comlCl IIW e understand that talse statements herein made are subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. Name of AttomeY:M; C''h::u:~' ~ F~rlJ:J1l:!nn Personal Representative: T ;m r:i'l A . '7.:i'l7.Wor~~ 1.0. No.: A~AA'- Address: 2411 N. Front St. Harrisburq, PA 17110 Telephone: 717/232-9900 Address: 10 Hillside Ct. Camp Hill, PA 17011 S;gna-'~r~. tJ.tyw-~/ Date: ~Db Description Value 1. 2. 3. 4. 5. 6. 10 Hillside Cir., Camp Hill, PA 17011 Ameriprise Financial Accts. Smi th Barney Accts. M&T Bank Acct. 200f BuiCk park Avenue. 2004 BuiCk Rendevous N/A N/A" N/A N/A N/A N/A l"--.) = c:;) ':;."J c::n rTl a C') (--' C) C.:J '~ 4J -l -:'-0 r"- 0 ~~'F] I rT1 0. 1:::::J .........."'., ~--; -0 C.:.::> -:;--. ' ("I ; i - -n ("-') N In N C) N -;--; NOTE: All property was 'jointy owned by spouse and therefore not subject to Pennsylvania Inheritance tax or probate (Attach Additional Sheets ifnecessary) NOTE: The ~emorandum of real eatale outside the Commonwealth ofPennsylvaoia may, at the election of the pcrsonaI representative, include the value of each Item, but such figwes should not be e:xtended into the total of the Inventory. Total '-0- RW-4 V'