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Home My WebLink About01-05-07 REV-1500 E~ + (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT w .... lIl::!1I) () a:lIl: w lL() :z:00 () a:-, ~1II c ..... z w c w o w c DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) !2il1. Original Retum D 4. Limited Estate !2il6. Decedent Died Testate (AllachcopyofWiI) D 9. Litigation Proceeds Received D 2. Supplemental Retum D 4a. Future Interest Compromise (date ofdealh after 12-12-82) D 7. Decedent Maintained a Living Trust (AllachcopyofTrus~ D 10. Spousal Poverty Credit (date of death belween 12-31-91 and 1-1-95) OFFICiAl USE ONLY FILE NUMBER 21 -0 6 0 0 8 8 C'OuNTY"CoiiE -YEAR- - - NuMaER- - SOCIAL SECURITY NUMBER 1 59- 2 4 - 9 225 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER D 3. Remainder Retum (date ofdealh prior1D 12-13-82) D 5. Federal Estate Tax Retum Required !.. 8. Total Number of Safe Deposit Boxes D 11. Election to tax under See. 9113(A) (Allach Sch 0) z o ~ c( ..J ::;) ..... a: c( o W It:: z o ~ ~ ::;) Q. :IE o o S KALEY MIRIAM DATE OF DEATH (MM-DD-Year) D. DATE OF BIRTH (MM-DD-Year) .... Z W C Z o lL II) W a: a: o () TELEPHONE NUMBER 717-697-4650 MECHANICSBURG NAME MURREL R. WALTERS III ESQUIRE FIRM NAME (If Applicable) COMPLETE MAILING ADDRESS 54 EAST MAIN STREET (8) 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT PA 17055 OFFICIAL USE ONLY ,....., = = --.. 90,466.05 (J (';;0 ~:o ""u i~~ :;:;::.;n ',-,. ~ ../.... I c..n X _(15) X _(16) 0.00 83,266.94 X .12 (17) 9,992.03 X .15 (18) (19) 9,992.03 01/11/2006 03/15/1926 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. JoinUy Owned Property (Schedule F) D 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) 13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) (1) (2) (3) (4) (5) (6) (7) (9) (10) 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 See. 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 c.._ ?: ....::... -,\ (j ';~ c= :::0 -j i2 :t> ::: co N W .' {'~') 90,466.05 6,478.20 720.91 (11) (12) (13) 7,199.11 83,266.94 (14) 83,266.94 Decetlent's ComDlete Address: STREET ADDRESS . 324 w. ALLEN STREET CITY I STATE I ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) 9,992.03 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits ( A + 8 + C) (2) Total Interest/Penalty ( D + E) (3) 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 (4) 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) 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) 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 I&J b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 I&J c. retain a reversionary interest; or ...................................................................................................... 0 I&J d. receive the promise for life of either payments, benefits or care? ............................................................. 0 I&J 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?............................................................................................... 0 I&J 3. Did decedent own an .in trust for' or payable upon death bank account or security at his or her death? ................. 0 I&J 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... 0 I&J 0.00 9,992.03 9,992.03 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 perjury, I declll'e that I have examined this retum, includinQ 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. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DA 1. k rJ- 7[-' ADDRESS ADDRESS 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 on 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 exemot 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. ~9116(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.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. ~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-15Q8 EX + (6-98) . ~ SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF KALEY MIRIAM FILE NUMBER D. 21 06 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. 0088 ITEM NUMBER DESCRIPTION 1. SOVEREIGN BANK CHECKING 2. SOVEREIGN BANK SAVINGS 3. SOVEREIGN BANK CERTIFICATE OF DEPOSIT 4. SOVEREIGN BANK CERTIFICATE OF DEPOSIT 5. SOVEREIGN BANK CERTIFICATE OF DEPOSIT 6 COMCAST. REFUND VALUE AT DATE OF DEATH 16,197.14 18,665.48 35,388.30 10,138.39 10,000.00 76.74 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 90,466.05 REV-1511 EX+(12-99) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF KALEY MIRIAM D. SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 06 0088 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOLLINGER FUNERAL HOME & CREMATORY, INC. 2,980.20 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) MABEL K.HOUGH renounced Social Security Number(s)/EIN Number of Personal Representative(s) StreetAddress 2100 BENT CREEK BLVD., APT. 138 City MECHANICSBURG State PA Zip 17050 Year(s) Commission Paid: 2. Attomey Fees MURREL R. WALTERS III 3,300.00 3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees REGISTER OF WILLS 198.00 5. Accountanfs Fees 6. Tax Retum Prepare~s Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 6,478.20 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (6-98) . SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF KALEY MIRIAM D. FILE NUMBER 21 06 0088 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. .IACKSON GASTROENTEROLOGY MEDICAL 2.19 2. WEST SHORE EMS-aLS MEDICAL TRANSPORT 58.72 3. PINNACLE HEALTH HOSPITALS HOSPITAL VISIT 660.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 720.91 ~:''''~HI* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF 1t"111J:V NUMBER I. SCHEDULE J BENEFICIARIES . D FILE NUMBER ?1 OR RELATIONSHIP TO DECEDENT Do Not List Trustee(s) SISTER OORR AMOUNT OR SHARE OF ESTATE 100% 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 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS pnclude outright spousal distributions. and transfers under Sec. 9116 (a) (1.2)] 1. MABEL K. HOUGH 2100 BENT CREEK BLVD., APT. 136 MECHANICSBURG, PA 17050 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART n - 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) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT HOUGH MABEL K 324 W. ALLEN STREET MECHANICSBURG, PA 17055 ______n fold ESTATE INFORMATION: SSN: 159-24-9225 FILE NUMBER: 2106-0088 DECEDENT NAME: KALEY MIRIAM D DA TE OF PAYMENT: 01/05/2007 POSTMARK DATE: 01/05/2007 COUNTY: CUMBERLAND DATE OF DEATH: 01/11/2006 NO. CD 007644 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $9,992.03 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK#106 SEAL INITIALS: CJ RECEIVED BY: REGISTER OF WILLS $9,992.03 GLENDA FARNER STRASBAUGH REGISTER OF WILLS