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Home My WebLink About10-23-06 -I 15056051047 REV-1500 EX (06-05) PA Department of Revenue .,. Bureau of Indvidual Taxes PO BOX 280601 Hani8btI'9, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 1?'J.67'80SfOI Z0'WO,," Deoedenfs Last Name Suffix Iff e-. C.I-If I AI (If Applicable) Enter Surviving Spou.... Information Below Spouse's Last Name SUffIx OFFICIAL USE ONLY County Code Year IN~~~::': DT:E~~RN '. 11 ()Y(,. File Number 11 ~ Date of Birth IZD7/9 I 7 Decedent's First Name (fE1O)f-:z; I uE MI D Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVAI.S BELOW ~ 1. Original Return c::;) c::;) 3. Remainder Return (date of death prior to 12-13-82) c::;) 4&. Future Interest Compromise (date of c::;) 5. Federal Estate Tax Retum Required death after 12-12-82) c::;) 7. Decedent Maintained a UvIng 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 SECl10N MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ~() I3ERTvJ iY/fJg JIf./fT-r/8 IYZ--l,~'f5Sj~ Fum Name (If Applicable) ~W LIJYLJ~ Ilrr:O';eUeY First line of address t?-9'f IZ'I/$T /l!/JIW5ri3Ec7 Second line of address 2. Supplemental Return c::;) 4. Umlted Estate c::;) 6. Decedent Died Testate (Attach Copy of Will) c::;) 9. Utlgation Proceeds Received 8. Total Number of Safe Deposit Boxes REGISTEI!l>>F WIllS US@!NLY 0'" C) f- I', :..u ::., c:::> (J -f N W ~ ..)..1 ,,"1 ie.fle') '.:, , C) ~-~ ~ [7) jd!im ,..\, r?.J (-~~ --n . -:, (.=") c-- in ;~-, < ~-~=:) "'=::.." J i -u ~ l~7;'l;#d 5"/,<!.;WtJ- State ZIP Code ~;J/~ ~73' ~7 =lMT~ FILED .. Side 1 L 15056051047 15056051047 --.J -I 1505605204& REV-1500 EX Decedenfs Name: /Ill'- d 4h1 (] ercJd:/1 ~ J) RECAPITULAnON . 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 0) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . " 5. 6. Jointly Owned Property (Schedule F) <:::) Separate Billing Requestad . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c::;) Separate BiDing Requestad.... . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . .. .. . . . . . . . .. . . . . . . . . . . . . . . . . . .. 8. Decedenfs SoCial Security Number /9 r\ 07",SJ;>'~Y 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. . 10. Debts of Decedent, Mortgage Liabillties, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10). .... .... . .................... .. ... 11. 12. Net Value of Estate (Une 8 minus Une 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 Une 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION. SeE INSTRUCTIONS FOR APPUCABLE RATES 15. Amount of Una 14 taxable at the spousal tax rate, or transfers under See. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at Uneal rate X.O_ 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 REQUES'nNG A REFUND OF AN OVERPAYMENT Side 2 L 15056052048 PI-? I L/ '-,YO 2,.7D~~? /Z870~72 3 I '58-50 . 0.00 15. o. 0- Q. 0- 0.00 16. 17. 18. C) 1505605204& .-.J REV-1500 EX Page 3 Decedent's Complete Address: De S E File Number STREET - Tax Payments and Credits: 1. Tax Due (Page 2 line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) o Total Credits ( A + B + C ) (2) o 3. InterestlPenalty if applicable D.lnterest E. Penalty TotaJlnterestIPenaIty ( 0 + E ) (3) 4. If line 2 is greater than Line 1 + Une 3, en. the difference. This is the OVERPAYMENT. FIll in oveI on Page 2, Une 20 to request. refund. (4) 5. If line 1 + Une 3 is gl'88ter than line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of line 5 + 5A. This is the BALANCE DUE. (58) (J n o o [) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. ~d :u: :; ~= ::property transferred; .......................................................................................... D lr :: ::~ :e::a~::..~~~~.~~.~~.~.~~.~.~.~.~::.~~.:::::::::::::::::::::::::::::::::::::::::::: B I d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 2f' 2. If death occurred after December 12. 1982. did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 .if 3. Did decedent own an -in trust for" or payable upon death bank account or security at his or her death? .............. 0 J)l 4. Did decedent own an Individual Retirement Accoun~ annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 ...8l IF THE ANSWER TO ANY OF THE ABOVE auESnoNS 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) Q)). For dates of death on or after January i. 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. S9116 (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. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's Uneat beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. S9116(1.2) [72 P.S. S9116(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. i9116(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-,508 ex. I"") .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF MOain, CeraJ.rl:ire D. 8/k./8 Jerald:i1E D. M:Cla.:im s.s. !'b. 199-07-8JS4 Include the proceeds ct litigation and the dae the proceeds were ~ by the estate. All property Jointly.ownecl with right of survivorship must be discIoHd on Schedule F. FILE w.ER ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH l. 2. 3. 4. 5. 6. 7. ~t Life S:m'es, ~t ~ ~t Life dividm dECk AN!J) refurl IN:: lBK accant 51-Lill3-9751 AllState refurl IRS refurl Life Ins. of lfIErica 1,047.38 27.00 213. :0 4,171.31 32.00 lIJ7.oo 3,814.03 TOTAL (Also enter on line 5, Recapitulation) $ 9,712.22 Of more space is needed. insert ~ditional sheets r:J the same size) REv.1511 EX- (12.... COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUBER M:Cl.a:in, ~ D. 8/k/a Jeral..d:irE D. M:Cl.a:in 8.8. fu. 199-07-8J54 Debts of decedent must be reportIId on Schedule L ITEM NUMBER A. B. 1. 2. DESCRIPTION 1. 2. 3. 4. 5. FUNERAL EXPENSES: Cmmticn fee Urn fiB:lstae <hve op:ning Attorrey's fees to a:iert W. ~, Jr. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of P8lSOllal Representative(s) Jares M:ftm1d Social Security Number(s)IEIN Number of Personal Representative(s) Street Address R.R. L Ibx 333 S:oo:cn State ~Zip 16678 City Year(s) Commission Paid: 2!r6 Attorney Fees 3. Family Exemption: (If decedenrs address is not the same as c1almant's, attach explanation) Claimant 4. 5. Street Address City State _Zip Relationship of Claimant to Decedent Probate Fees -Smll estate ~ fees ani costs Accountant's Fees 6. Tax Return Preparer's Fees 7. 8. 9. 10. ll. 12. 13. 14. Cert:i.fia:l ~ fees for ~ 'Tr:cMU. ~ $432.00/'ll.ln1nl<e fees $ll.SO/U-h:Jul $l36.84 lBl::nrarrl nm1s Storage fees $SOO/F\El for lHEu1 $B3.m Ebst:age $39.28 ThJ.ej;hJre tall calls $ISO.OO Jdn H:n:Dck, return of arn.ri.ty dECk :isaB:i after chlth M1tml of l!Ierican, return of dECk :isaB:i after death U.8. Lep:1rtm:nt of Trmsury, return of a:ri.al security dEck :isar:rl after <H~ AMOUNT 1,525.00 498.00 974.00 SO. 00 1<X>.00 1,758.00 1,axJ.00 ro.oo 125.00 25.00 500.34 7.1:>.00 585.00 189.28 216.66 86.12 1,554.00 TOTAL (Also enter on line 9, Recapitulation) $ lO,l46.llJ (If more space is needed, insert additional sheets of the same size) ""51''''._ . COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES AND LIENS Please Print or Type FILE NUMBER ESTATE OF M:Cla:in, Cerald:ire D. a/k/a Jeral.d:i.re D. M:Clain S.S. rh. 199-07-8)54 ITEM NUMBER DESCRIPTION AMOUNT 1. 2. 3. l fu\er1y Eht:erpr.ises, ~ lnIE care lbly ~t HEpital, lnspital bill t:UDJv& cmnt a:n:mt f:fJ]JJJJ22f.t8~m4 476.00 912.00 1,336.32 TOTAL (Also enter on line 10, Recapitulation) (If more space is needed, insert additional sheets of some s;ze.) $ 2,72f.t..32 REV-1513 EX. (~) *' SCHEDULE J BENEFICIARIES COMMONWEAlTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF M:a.a:in, ~ D. a/kla.kalrl:irE D. M:a.a:in S.S. N:>. 199-07-0054 RELATIONSHIP TO DECEDENT Do Not Uat Trustet(s) NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) &e atta::brl Cl'.k.---:l,lIr;",;..J+I......., ~j~.ml AMOUNT OR SHARE OF eSTATE N/ A In9:llVEnt ENTER DOLlAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE. ON REY-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 \he same size) " . Beneficiaries Marilyn Godwin 10653 Parliament Place Jacksonville, FL 32257 Karen Tarleton 1712 Manschester Court North Jacksonville, FL 32259 John Thompson 1961 Frosty Hollow Road Roaring Spring, PA 16673 Vivian Reed 921 Main Street Saxton, PA 16678 James R. McDonald R.R. I, Box 333 Saxton, PA 16678 Jerry L. Thompson Broad Street Broad Top City, PA 16678 Gerald R. Thompson 411 3 Street New Cumberland, PA 17070 Timothy S. Thompson 1209 Indian Peg Road Mechanicsburg, PA 17055 Robert Grandville Address Unknown Robert Diaz Address Unknown Kenneth Diaz Address Unknown Jay Thompson Address Unknown Ronald Thompson Address Unknown