HomeMy WebLinkAbout12-13-06
ReV-1500 EX 16-00)
OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1!500
INHERITANCE TAx RETURN FILENUMBER
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RESIDENT DECEDENT COUNTYCOOE YEAR
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DECEDENrS NAME (LAST. FIRST, AND MIDDLE INITIAL)
BURKETT Jane 1'.
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DO-YEAR)
Se tember 16 2006 October 10 1 18
(IF APPliCABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAl)
X/A
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~ 1. Original Return
D 4: limited Estate
D 6. Decedent Died Testate (Atlach copy of Will)
o 9. litigation Proceeds Received
D 2. Supplemental Return
o 4a. Future Interest Compromise (dale of death aller 12-12-82)
o 7. Decedent Maint~jned a living Trust (At1acIIllOfl)'ofTl\IIt)
D 10. Spousal Poverty Credit (dele of death beIween 12.31.91 end 1.1.95)
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SOCIAL SECURITY NUMBER
194 24
2208
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WillS
SOCIAl SECURITY NUMBER
D 3, Remainder Return (dele of death prior to 12.13-82)
o 5. Federal Estate Tax Return Required
-2. 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (.A.lfachSch 0)
NAME
J. Robert Staurrer, Attorney
COMPLETE MAILING ADDRESS
Market Square Bldg.
Mechanicsburg, PA 17055
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FIRM NAME (If AppIk:able)
TELEPHONE NUMBER 66 . 6
717-7 -9 73
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation. Partnership or SoIe-Proprietorship
4. Mortgages & Notes Receivable (Schedule 0)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-VlVOs Transfers & Miscellaneous Non-Probat$ 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)
13, Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
(1)
(2)
(3)
(4)
(5)
0.00
0.00
0.00
0.00
0.00
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(6)
73,471.25
(8)
625.00
2,<<;61.88
(11)
(12)
(13)
(7)
(9)
(10)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
o 0
. _ x .0 ~ (15)
69~ aS4.Jt.. ~!~.J!2 (16)
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)( .12 (17)
o x .15 (18)
(19)
16. Amount of Line 14 taxable at Hneal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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0.00
73,471.25
.3,586.88
.6' ,864.37
0.00
(14)
6',1384.37
0.00
~.1!W..79
~.1h4.79
Decedent's Complete Address:
STREET ADDRESS Messiah Vi 1la e
100 Ht. Allen Drive
Hechanicsburg, PA
CITY
17055
STATE
FA
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditsJPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
3,14.4.79
0.00
0.00
'57.2'
Total Credits ( A + B + C )
(2)
157.23
3.
InteresUPenalty if applicable
D. Interest
E. Penalty
0.00
0.00
(3)
(4)
(5)
(5A)
0.00
0.00
2.987..56
0.00
2J,87.56
4.
TotallnteresUPenalty ( D + E )
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. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.......................................................................................... D
b. retain the right to designate who shall use the property transferred or its income; ............................................ D
O. retain a reversionary interest; or.......................................................................................................................... D
d. receive the promise for life of either payments, benefits or care? ...................................................................... D
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 tiust 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? ........................................................................................................................ D
Under penalties of pe~ury, I declare thai 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.
Declarat' p r other I rsonal presentative is based on an information of ich preparer has any knowledge.
E
_ DATE .
J f,. OWN'E' I ~ ~/./-tJ(
Lyman Ave., Womelsdor~, PA 19567
I
PA 17055
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. ~9116 (a) (1.1) (i)).
For dates of death on or after January 1, 1995, the tax rate imposed 1)0 the net value of transfers to or for the use of the surviving spouse is' 0% [72 P.S. ~9116 (a) (1.1) (ii))
The statute does not exempt a transfer to a surviving spour.e 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 deceas07d 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. ~9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's Oneal beneficiaries is 4.5%. 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 decedent's siblings is 12% [72 P.S. i9116(a)(1.3)). A sibling is defined, under Section 9102, as ar
individual who has at least one parent in common with the decedent, whe~ by blood or adoption;
N:V.tSllt EX +Ct.f7)
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SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
REI NT NT
ESTATE OF
JA}m F. BURIU~TT
FILE NUMBER
If In ISset WlS made joint within one yelr of the decedent's dlte of death, It must bt reported on Schedule G.
SURVMNG JOINT TENANT(S) NAME
.
i AOORESS
RELATIONSHIP TO DECEDENT
A. Carole Spahr
17 South Road
Mechanicsburg, PA 17050
B. Sue Ellen Hahn
612 Lyman Ave.nue
Womelsdorf, 1A 19567
c.
Daughter
Daughter
JOINTLY -OWNED PROPERTY:
OOE DE~~~~mftm
MADE Include name of lInanclallnslitutlon and bri eccount number ex .....ldenllfylng number. AltKh
JOINT deed for Jointly-held real estate.
LETTER
ITEM FOR JOINT
NUMBER TENANT
1. A.
2. A.
3. A.
4. A.
5. A..
6. A..
7. A.
8. B.
9. B.
'-.0. B.
Regular SaTing. Acoount No. 203!~64-
00 With Uembers 1st federal Credit
union.
Checking Apcount No. 203464-11 with
Members 1st 7ederal Credit Union~
~oney Management Account )To. 203464
05 with Meaberst 1st 'ederal Credit
Union.
8/31 Certificate of Deposit io. 203464-4
-005. with Members 1st Federal Credit
Union.
8/31 Certificate of Deposit Ho. 203464-4
005. with. Members 1st JPedera1 Credit
Union. I
9/8/ Certificate of Deposit )To.1 203464-4
005. with Members 1st rederal Credit
i _. I
. non.. . I
9/8/. Certificate of Deposi t )fo.1 203464-4
20q5. with Members 1st 7ederal C~edit
nion. . I
8/,31 Certiticate of Deposit :Mo.! 20.3464-4
200S.with Members 1st Federal Credit
nion.
Certificate ot Deposit )lo. 203464~'
with Members 1st Federal Credit .
nion.
Certi~icate or Deposit >>0. 203~64-~
itk Members 1st 7ederal Credit
nion.
8/31
'005.
9/8/
00,$ .
DATE~DEATH
VAlUE OF ASSET
7,1...82.75
6,069.61
6,418.,7
33,518.89
20,041.01
31,271.15
lO,~J7.~O
.,_ . '0_- .
33,5.76.8'
20,041.01
31,271.15
%OF DATE OF DEATH
DECD'S VAlUE ~
INTEREST DECEDENT'S INTERESl
5~
5~
5~
3,741.3[
~,0.34.el
.3,209.28
6,Q50.'4
3,lW..5..87
1.1,192.96
6;'680.34
10,42).72
TOTAL,(Also enter on One 6, Recapitulation) $Carried :Forwaro
(If more space Is needed, Insert additional sheets of the same size)
REI/oI'llUX -/'''7)
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SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYlVANIA
INHERIT ANeE TAX RETURN
NT T
ESTATEOF
FILE NUMBER
JAVE .,.. BURKETT
If an Hut WI' made joint within one year of the decedent'. date of death, It must be rwported On 8chedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
Carole Spahr
17 South Road
11echanicsburg, FA 17050
Daughter
B.
Sue Ellen Uahn
612 Lyman Avenue
Womelsdorf, PA 19567
Daughter
c.
JOINTLY -OWNED PROPERTY:
LETTER DATE DESCRFTION OF PROPERTY %OF DATE OF DEAlH
ITEM FOR JOINT MADE Include name of finlllClallnstitullon and bank ICCOUI1t number or ... kIenllryIng number. AIIIch DATE OF DEATH DEro'S VAlUE OF
tMABER TENANT JOINT deed for JoInIr.fleld real estele. VALUE OF ASSET INTEREST DECEDeNT'8INTRS
~ A.
11. B. 9/8/ Certifioate of Deposit no. 20.3464-47
2005. with.. Jlembers 1st Federal Credit
Union. .. . 10,337.60 33-~ ~ 3,445.6
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I TOTAL, (Also enter on Hne 6, Recapitulation) $ 7 3,-"1i.!~
i
.-
If more s ace Is needed. Insert additional 8heetJ of the same size
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REV-'Sll EX+ ('2-".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
J A t;TE J". BURKETT
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
){alpezzi J'uneral Home, balance due on .funeral
expenses.
$
125.00
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
!
I
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Social Security Number(s)/EIN Number of Personal Represenfutive(s)
Street Address. !
I
Name of Personal Representative(s) i
0.00
City
State _ Zip
Year(s) Commission Paid: .
2.
Attorney Fees J. Robert Stauffer, Esq., attorney tee.
500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
0.00
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
4.
Probate Fees
0.00
0.00
0.00
5.
Accountant's Fees
6.
Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed. insert addi~ional sheets of the same size)
I
625.00
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.:~::., ..r CuMllOf/Wr,^, ",or ''(t"'~YI VIIII'II
;'J.'~....",;~ji(;..~"~' ./;.;1''''' ''''I\I'.:F '^~ m: IlNtfI
""~:.'\" . ":.... . ntSJ~'" ~'JI III
r--...~~.t":!':l. t"'~.'" .~':-:---~.
'!.ES1^lE Or:' .
-). .,. .
; JAJ'E J'. BURKETT
SCHEDULE I
VEDTS OF JJECEUENT
,
MOHlGAGE LIAUILlllES & l.IENS
....... ;--~-~. -. .. ~~., ... -- .~. .' ~~~.. .. --....------.
filE ,mMBER
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---
Include "III eltllh", !Il!d medlcnl eXI'e"!!",,,
-~___.____ .......__~....__~._._...._~_...._._____._....._ ......._ - _, ... ~. _"0 ___ .__ __..._. 1..-.............._......_...._._._....__.___......._.______..
IIEM
NUMUr: H liE Sf.;! W ' "'-',,
------.- -'--"'-'-' .___.."._c._._...___._ .-.....--.. .. - -'.....-.---......--..t-...... ..---.--.-..-..---..---
1. Heritage IQedical, ..medical servioes. $
2. Susquehanna Surgeons, balance que.
). Uessiah Village, final bill to~ room, board and care.
4. Jeff Marks, D.P.M., balance due.
S. Philbaven, cons~ltat1on. I
.'
,.
,
!
,
t.
AMOUIIT
101.98
27.1<9
2,80).20
23.51.
27.50
T01Al (Also enter on One to, Recapitulation) $ 2, ,61. Be
(If ,m;es\Jat.; Is IlCecifiJ.lii;e.laJdlllo"al sheets of lhe same sIze)
REV-1513 EX. 19-00*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
JAXE 11". BURKETT
NUMBER
I
NAME AND ADDRESS OFPERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (8) (1.2)] i
Carole Spahr
17 South. Road
Heomanicsburg, PA 17050
2. Sue Ellen.-Rahn
612 L:J1'lan Avenue
W0l11s1sdor.f'; PA 1'567
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
1.
Daughter $ 41,726.36
Daugltter
31,142.89
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
1.
1
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
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)