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REV a 1500 EX +....(8-001
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COMMONWEALTI-i OF PENNSYlVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENTS NAME (LAST. FIRST, AND MIDDLE INmAL)
Green, Rozella M
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
OFFICIAL USE ONLY
FILE NUMBER
21 0<6
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
182-22-5583
00iJ75
NUMBER
THIS RETURN MUST BE FILED IN DUPLICATE 1I\IITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
181 1. Original Return 0 2. Supplemental Return
I!! 0 0 4a. Future Interest Compromise (date of death
~=!Ul 4. Limited Estate
uO:lIl:: after 12-12-82)
wlLU 0 0
:cOO 6. Decedent Died Testate (Attach CXlIlY 7. Decedent Maintained a Living Trust (Attach
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lLlll afWill) CXlIlY of Trust)
lL 0
c( 0 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death between
01/09/2005
02/29/1912
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
o 3. Remainder Retum (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11.Election to tax under Sec. 9113(A) (Attach Sch 0)
THIS SECTIONMU$1l.~.b,~AUZ.'
ME
rn!i Stephen O. Fugett
~ ~ IRM NAME (If applicable)
8 2 Patrick / Fugett Associates
ELEPHONE NUMBER
717/737-2390
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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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) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line B minus Line 11)
COMPLETE MAILING ADDRESS
240 South 18th Street
Camp Hill, PA 17011
(1 ) None
(2) None
(3) None
(4) None
(5) 568.48
(6) None
(7) None
(9)
6,764.00
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)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1.2)
16, Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
x .00
x .045
x .12
x .15
OFFICIAL USE ONLY
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(12)
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Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
104 Novem ber Drive
Apartment 1
CITY
I STATE PA
I ZIP 17011-5030
Camp Hill
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 (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
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.
8. Enter the total of Line 5 + 5A. This is the BALANCE 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 "XU IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the ~se or inc~me of the property transferred;..........................:.......................................................... Fl ~
~: ~:::~ ~;:~~~:n~:I~~::;;~r ~~~I.I..~~~.~~~.~~~~~.~~~~~~~~~.~~~~.~~~~~;.................................................................................. 0 ~
d. receive the promise for life of either payments, benefits or care?............................................................... 0 rgJ
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.
Under penalties of pe~ury, I declare that I halle 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 representatille is based on all infonnation of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE
Georl)' J. Green, Jr. 145 Lenker Drive
Harrisburg, PA 17112
ADDRESS
ADDRESS
240 South 18th Street
Camp Hill, PA 17011
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. 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 exemDt 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 .5. 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 12% [72 P.S. 99116 (a) (1.3)J. 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 Green, Rozella M
FILE NUMBER
21 - 05 -
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE
NUMBER OF DEATH
1 checking account 400.00
2 personal property 168.48
TOTAL (Also enter on Line 5, Recapitulation) 568.48
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SCHEDULEH
FUNERAL EXPENSES &
~ISTRATIVE COSTS
COMMONWEALlH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Green, Rozella M
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21 - 05 -
ITEM DESCRIPTION AMOUNT
NUMBER FUNERAL EXPENSES:
A. 1 Please see attached, itemized list from Hetrick Funeral Home, Inc. 6,614.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City State Zip
-
Year(s) Commission paid
2. Attorney's Fees
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
5. Accountant's Fees
6. Tax Return Preparer's Fees 150.00
7. Other Administrative Costs
1
TOTAL (Also enter on line 9, Recapitulation)
6,764.00
,
Invoice
Hetrick Funeral Home, Inc.
3125 Walnut Street
Harrisburg PAl 71 09
Date
9/18/2006
Invoice #
687
Bill To
George Green, Jr.
104 November DR., Apt. 1
Camp Hill, PA 17011
Due Date
9/18/2006
Terms Customer:Job
Rozella Green
Quantity Description Rate Amount
Traditional Services 2,850.00 2,850.00
Opening and Closing of Grave 1,065.00 1,065.00
Cemetery Equipment 150.00 150.00
12 Death Certificates 2.00 24.00
Coleman Casket 1,495.00 1,495.00
Guardian Vault 950.00 950.00
Obituary in Patriot News 80.00 80.00
Total $6,614.00
Payments/Credits $0.00
Balance Due $6,614.00
(1) REV 9/86 . -- . .' ectl CO ied from an original certificate of death dulr filed with me as
~his is to certify that the informa~l?n here'11~enf IS cO~ed ~ th~ State Vital Records Office for permanent fIlmg.
~ocal Registrar. The original certificate wII e orwar
. . by photostat or photograph.
Foc for ili:~::~:::I::S:legal to dupllcme thIs copy ~?j~fJ
No.
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, Date
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11074013
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
SiATE FILE NUMBER
Ht051.J Rev. 2187
elf RINT
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iIJ."EHT
,CfINK
NAME OF OECEOENT (Fnl. MiOdle. lul)
1.
AGE (lpt Birlhday)
SEX
SOCIAL SECURITY NUMBER
1. 182- 22 - 5583
BIRTHPLACE (CIIy IIUl
Slale 01 F'nill" COunuy)
in
5.
. . CO\JHlY OF DEATH
92 Yrs.
Ib.
OECEDeHrS USUAl OCCUPATION
(~...=:~"::':~
1tL Clerk l1b. Dept of Transpor
DECEOEKrS MAILING ADDRESS (SlIMt CiIyfT-.. Slala. ZIp Code) OECEDENTS
104 november Drive, Apt 1 ~~ENCE
Camp Hill, PA 17011 ~~.
Ie. Camp..aill
\oJhite
KIND OF BUSINESS llHOUSTRY
MAAlTAL STATUS. Manied.
"- MMled. Widowed.
ON_ (Specify)
1.. Widowed
SURVIIIING SPOUSE
H''''''. tIW.m.... nIlINI)
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1..
FATHER'S NAME (FnI, Middle.lul)
n.
INFORMANl'S NAME (Type/Prinl)
211L George J. Green, Jr.
METHOD OF DISPOSITION
IluriaI e9 CnIm8llon ~aI tam Slate 0
oa.. (Specify)
17b. COunty
17d.~ ~':i:=:':::oI
Camp Hill
Qlylbo< ,
Frank Hoch
MOTHER'S NAME (FilII, Middle. Maid." S,,",ame)
1.. Ella Mae Bowers
INF~l'.s M#JlING AOORES.SJSI1eet. CilylTown, Stele. Zip Codal.
20b. 14:J LenKer KG., Harrisbur t'A 17111
LOCATION. CilyfTown. Shll.. Zip Cod.
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: on_ and death
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I any. INding 10 IrnmediaIe
. . ....... En!<< UNDERL YlHG
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tWllIinQ en ""'" ) LAST d.
WAS AN AUTOPSY WERE AUTOPSY FI1<<lINGS
PERFORMED? AVAlLAlll.E PRIOR TO
COMPLeTION OF CAUSE
OF DEATH?
DUI!
DUE (OR...."
OF),
MANNER OF OEATH DATE OF INJURV
iM <_".00.> V-I
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_ 0 Could nol be d.termlned 0 30.. 3Gb. II. JR.
PLACE OF INJURY. AI_. ,...... _~ 1ecIofy, oIIicll
2IL 2Ib. 2.. ~.... 1_) lot.
CERTIFIER (Check only QII8) SIGNATURE AND TITLE OF CERTJ
l~IGoI~~~~~.n::::~.....,"=<:r".=r.f''=:'':~~.~~.~.~.~.~~~................. ~ 31b.
"PROltOUMCING AMI) CERTIfYING I'HYSICIAH (Phyoicien _ pnl<lOUfICing ""'" ond C8f1lIylng 10 ....... 01 dellll) \.ICENSE NUMBER _ €'
To Ihe bell 01 my _.. _III oc.......... 11th. 11_. dol.....d pl_. _ due to th. caUI..(I) end mll1_.1 .blled...................... 0 31... 111 I) pi d r:. , lId. .;7';t., ;[ ~ r
"MEDICAL EXAMlHERlCORONER =~:r~~~~ OF ~:~. ~~~Pl~ED~~~S~ ~~O:tJf
On the beal. 01__ endIor In....tlgetlon. In my opinion, d..th occurnd OIl the II""-I!.te, _ pllce, ond _ 10 the ceu18I(.) - '.. 7 M ~~..L /}t/ <
31"- II .lIled................................................................................ ........................................................................ 0 32. - :.... i" 1'., {)v If
REGlSTRAR'S SIGNATURE AND NUMBER OATE FILED (Monlll. 0.'1'. Ya.,) .
TIME OF INJURY
INJURV AT WORK? DESCRIBE HOW INJURV OCCURRED.
VII 0 No
VII 0
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