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HomeMy WebLinkAbout03-26-07 I : EV-1soO EX (6-00) OFFICIAL use ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ~L COUNlY CODe ~L 0429 ___ YEAR NUMBER I- Z W C W (.) W C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Vick Seth DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 5/3/2005 8/6/1985 OF APPLICABLE) SURVMNG SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) not appli.cable D 1. Original Retum D 4. Limited Estate D 6. Decedent Died Testate (Attach copy of \Mil) [XJ 9. Litigation Proceeds Received A SOC~LSECURITYNUMBER 165-66-5914 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WillS SOC~SECURITYNUMBER UJ r ~ ~(/) o~~ UJ 0..0 :J:~ o o..aJ 0.. c( [i] 2. Supplemental Retum D 3. Remainder Retum (dale of death prior to 12-13-82) D 4a. Future Interest Compromise (date of death after 12-12-82) D 5. Federal Estate Tax Retum Required D 7. Decedent Maintained a Living Trust (Attach copy of TNst) L 8. Total Number of Safe Deposit Boxes D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) COMPLETE MAILING ADDRESS 820 Homestead Road ..... NAME z w c Paul L Feldman Es ire z 0 FIRM NAME (If Applicable) 0.. en w Feldman & Feldman, LLP a:: a:: 0 TELEPHONE NUMBER 0 215-887-5300 1. Real Estate (Schedule A) (1 ) 2. Stocks and Bonds (Schedule B) (2) Jenkintown PA 19046 4. Mortgages & Notes Reeeivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . (5) OFFICIAL USE O~ ~ (";::;", 1...... C:J So -.l ",.,:n .n~3~o .:''',>r- ..::.:" in ': (~{) :~ ::;'~~ :;Cl N OJ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) z o i= ~ :;:) I- 0: <( o w n:: 6. J~ OVofled Property (Schedule F) U Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) (6) f",,) $0.00 N r- 8. Total Gross Assets (total Lines 1-7) (8) $129,625.62 9. Funeral Expenses & Administrative Costs (Schedule H) (9) $765.00 $2,410.00 10. Debts of Decedent. Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) (11 ) 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) (12) (13) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLlCABL.E RATES (14) $126,450.62 15. Amount of Line 14 taxable at the spousal tax $126,450.62 ~ (15) z rate, or transfers under Sec. 9116 (a){1.2) x .0 0 j:: 16. Amount of Line 14 taxable at lineal rate $0.00 x .0 . 45 (16) c( r ::>> $0.00 0.. 17. Amount of Line 14 taxable at sibling rate x .12 (17) ::r!J: 0 $0.00 0 18. Amount of Line 14 taxable at collateral rate x.15 (18) >< c( 19. Tax Due r (19) $0.00 $0.00 $0.00 $0.00 $0.00 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~1.. 3W4645 1.000 Decedents Complete Address: S1REET ADDRESS 641 Lindsev Road Cumberland ellY I STATE TZlP Carlisle PA 17013- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) $0.00 $0.00 $0.00 $0.00 Total Credits (A + B + C) (2) $0.00 3. Interest/Penalty if applicable D. Interest E. Penalty $0.00 $0.00 Total Interest/Penalty (D + E) (3) $0.00 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) $0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) $0.00 A. Enter the interest on the tax due. (SA) $0.00 B. Enter the total of Line 5 + SA. This is the BALANCE DUE. Make Check Pa able to: REGISTER OF WILLS, AGENT (5B) $0.00 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes D D D D without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . .. D 3. Did decedent own an "in trust 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 [j 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 declare that I have examined this return. induding accompanying schedules and statements, and to the best of my knowledge and belief. it is true, correct and complete. Dedaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNA lURE OF PERSON RESPONSIBLE FOR FlUNG RElURN 1. Did decedent make a transfer and: a. retain the use or income of the property transferred;. . . . . . . . . . . . . . . b. retain the right to designate who shall use the property transferred or its in~me; . c. retain a reversionary interest; or . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefrts or care? . . . . . . . . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death No [}g ~ og og og [SI DATE n Ho Ilo1Ilck Jenldntown, PA 1 (215) 887.5300 .,. ? 820 Homestead Road Jenkintown PA 19046 - 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.~ 9916 (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 exempt 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 chUd twenty-one years of age or younger at death to or for the use of a natural parent, an adoptiw 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 benefidaries 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. 3W4646 1.000 . REV-1508 EX + (~98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX REl1JRN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Seth A. Vick FILE NUMBER 21 05 0429 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1 American Outfitters Refund 2 Litigation Proceeds 3 United States Treasury Refund 4 PA Department of Revenue Refund 5 Progressive Refund 6 Capita~ Tax Collection Bureau Refund 7 Capital Tax Collection Bureau Rafund 8 Insurance premium Reimbursement VALUE AT DATE OF DEATH $35.45 $128,663.56 $801.00 $4.54 $33.00 $4.38 $1.69 $82.00 3W46AD 1.000 TOTAL (Also enter on line 5. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) $129,625.62 ~EV-1511 EX + (12-~ COMMONWEALTH OF PENNSYLVANIA INt-ERlTANCE TAX RETURN RESlDENf DECEDENf STATE OF Seth A. Vick SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 05 0429 Debts of decedent must be reported on Schedule I. B ITEM NUMBER DESCRIPTION AMOUNT FUNERAL EXPENSES: 1. None ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) I EIN Number of Personal Representative(s) - - Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees $750.00 3. Family Exemption: (If decedent's address is not the same as claimant's. attach eJq)lanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees $15.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. None TOTAL (Also enter on line 9. Recapitulation) $ $765.00 ~ A 3W46AG 1.000 (If more space is needed. insert additional sheets of the same size) ;EV.1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INl-ERlTANCE TAX RETURN RESIDENT DECEDENT ESTATE OF S_eth A. Vick SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21 05 0429 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, Including unreimbursed medical expenses. ITEM NlJJIBER 1. DESCRIPTION VALUE AT DATE OF DEATH $2,410.00 ~lton S Hershey Medical Center 3W46AH 2.000 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) $2,410.00 ,EV-1513 EX+ (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEOENf STATe OF Seth A Vick NUMBER I 1 NAME AND ADDRESS OF PERSON{S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [indude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) Angela S. Vick 641 Lindsey Road Carlisle, PA 17015 One Half of Residue: $63,225.31 2 Lonnie Vick 641 Lindsey Road Carlisle, PA 17015 One Half of Residue: $63,225.31 RELATIONSHIP TO DECEDENT Do Not List Trustee{s) FILE NUMBER 21 05 0429 AMOUNT OR SHARE OF ESTATE Mother Father $63,225.31 $63,225.31 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 3W46A11.000 TOTAL OF PART" - 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) $ $0.00 H: ()_,,_S()~ REV i f()~ This is to ~ertify that t~e .informa~i?n here. given is correctly copied from an original certificate of death duly filed with me as LQcal RegIstrar. The ongmal certIfIcate wIll be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 No. ~-~. ~t.u..~~ Local Registrar p 11331468 WAY 5 2005 Date H1OS.144 Flow. 1/91 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (Coroner) DATE OF DERll (NonIh, DBy, ~ May 3, 2005 ~(Cllyond ~ or Foreign CounIry) ~D .... ~ ~ ~ PA NoD MIlT': 0lIw___~",-,1Iul nat...ulllng ~11lII.~_~"'Pl\RT I. Vs i ~ ~ 1 '~AHDc:llnlFY*GPHYllICWC ~boltl pronouncing_8I1d-ulylng"'_oI~ lb..._"'''''.........__..__._._........__.._---<.,____........................ . 'IIEIlICAL iI!XAIII'IIRICO 0.."'''- ",--..son Uldfar ~.In my opinion, ... _...-I at ...IIIM................ ..... 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I II" .,,,1, II ,-: . .. -. I 1111 IIJ 11111 . I I .. II I I I !II III . III I l1li111' E ' ..' I ..' III. '.. _II BI, II", ... .. lilli" ... -'" III" ...., .' ..'. . .' I I, .. ' - ...... II II .... . .. III '... III ." I III , .", .." I ..-' , .,: << .. -- .. I I III III I II1II I'll I ) GENERAL REIJEASE For and in consideration of the sum of Three Hundred Thousand Dollars ($300,000.00), the sufficiency of which is hereby acknowledged, LONNIE L. VICK and ANGELA S. VICK, CO-ADMINISTRATORS OF THE ESTATE OF SETH VICK, DECEASED, and any successors, heirs, personal representatives, aS8igl1ees~ executors, attorneys, agents, servants, elnp)oyees, and any and all other related persons, entities, associatiollS or corporations and their predecessors, successors and assigns, whether herein referred to or not of LONNIE L. VICK and ANGELA S. VICK, CO-ADMINISTRATORS OF THE ESTATE OF SETH VICK., DECEA...~ED, (hereinafter collectively "Releasors"), hereby remise, release and forever discharge UNITED PARCEL SERVICE, INC. (nul'S"), and each of their successors, heirs, personal representatives) assignees, executors, attorneys, agents, servants, employees, affiliates, parents. subsidiaries, directors, officers, insurers, and any and all other related persons, entities, associations or corporations and their predecessors, successors and assigns, whether herein referred to or not, (hereinafter collectively IfReleaseestt), of and from any and all manner of actions and causes of action, suits, debts, dues, accounts, controversies, bonds, covenants, contracts, agreements, judgments, claims, demands, reckonings, promises and matters or things, whatsoever in kind and nature, in law or equity, known or unknown. foreseen and unforeseen, which the Releasors and all others claiming by or through them in any way might have claimed or could claim against Releasees relating to an incident that occurred on May 3, 2005, in Carlisle, Pennsylvania ("the incidentr,), including especially~ but not limited to, all claims and demands that any of the Releasees are alone liable, jointly and severally liable, or liable by way of contribution or indemnity to Releasors, for personal injury, pain and suffering, loss of earnings and/or earnings capacity, for wrongful death, loss of parental consortium, loss of filial consortium, damages, punitive damages, property damage, attorneys' fees and costs, medical bills both past and future or expenses and any other damages or losses of any kind or nature, known or unknown, some or all of which claims were raised or could have been raised in the lawsuit captioned LONNIE L. VICK and ANGELA S. VrCK, CO-ADMINISTRATORS OF TIlE ESTATE OF SETH VICK, DECEASED, PlaintifJ.~ v. UNITED PARCEL SERVICE, INC., Defendants. pending in the United States District Court for the Middle District of Pennsylvania, Case No. 1:CV-05-1510 ("the lawsuit"), liability for which is expressly denied by those released herein, which the Releasors ever had, now have, nlay or will have, or which their executors, administrators, successors, assigns, or any of them, ever had, now have, mayor will have against the Releasees, for or by reason of any cause, matter or thing whatsoever. Releasors bereby declare and represent that it is understood and agreed that this settlement is the compromise of a disputed claim, and that this settlelnent is not to be construed as an admission of liability on the part of Releasees, by whom liability is expressly denied. No promise or inducement which is not herein expressed has been made to Releasors. and in executing this release, Releasors do not rely upon any statement or representations made by any person, firm or corporation hereby released, or any agent, physician, doctor or any person representing them or any of them, concerning the nature, extent or duration of such danlagcs or losses or the legal liability therefore. It is further understood that the Releasors and:their attorneys, Kline & Specter, P.C., will indemnify, defend and save harmless Releasees and any of their agents, servants or employees from any losses, damages, claims, third~party claims, expenses and liens of any kind, including, but not limited to, claims made by third parties arising out of the incident~ statutory and conlmon 2 law liens, medicalliens, hospital liens, govermnent liens or attorney liens, filed by or owing to any person, tirol, company, organization, state, and/or federal agencies or entities or corporations having a claim against the Releasors by reason of the incident mentioned above should any claim, demand or suit be and/or have been made. Concurrent with the execution of this Agreement, counsel for plaintiffs will deliver to counsel for UPS, an executed Stipulation of Dismissal With Prejudice of this matter. Within ten (10) days thereafter, counsel for UPS shall deliver to counsel for plaintiffs settlenlent drafl(s) in the anlount of Three Hundred Thousand Dollars ($300,000.00) in the form of a check in good funds and made payable to, LONNIE L. VICK and ANGELA S. VICK, CO- ADMINISTRATORS OF THE ESTATE OF SETH VICK, DECEASED and their attorneys KLINE & SPECTERJ P.C. At that time, the Stipulation of Dismissal shall be filed with the United States District Court for the Middle District of Pennsylvania. This Settlement Agreement and Release shall be binding "upon Plaintiffs (Releasors) and their heirs, personal representatives, successors, and assigns. Plaintiffs (Releasors) intend that this General Release shall be complete and shall not be subject to any claim of mistake of fact, and that it expresses a FULL AND COMPLETE SETTLEMENT OF LIABILITY CLAIMED AND DENIED, and that this General Release and Confidentiality Agreement is intended to avoid any further litigation relating to the incident, and is to be final and complete. Plaintiffs (Releasors) acknowledge and represent that they have reviewed and understand the terms of this General Release as written in the English language and as reviewed with them by their counsel. Plaintiffs (Releasors) acknowledge and represent that there is no agreement or reservation which is not clearly expressed herein, and that the 3 execution hereof is made with the full knowledge that this General Release covers all possible claims. All of the tenns of this Agreement, specifically including the amount ofcollsideration paid by Releasees, are confidential and shall not be di~c1osed by the Releasees, the Releasors., or thdr respective attorneys, to any person or entity except as required by law. The Court retains jurisdiction over this case to enforce this Agreement. IN WITNESS WHEREOF, Plaintiffs (Releasors) having read this General Release and understanding its nleanmg and effect, have hereWlto set their hand and seal this _ day of ~ 2006. ~--fr!14 (~~ L. VICK ~~ ~~ ;-' NESS. ~gu~ WI ESS DAVID J. CAPUTO KLINE & SPECTER, p.e. A'ITORNEY FOR PLAINTIFFS Dated MICHAEL J. O~NEILL 0.. DANIEL ANSA DLA PIPER US LLP ATTORNEY FOR DEFENDANT UNITED PARCEL SERVICE, INC. Dated 4 , .~ 'I1Ie gross settlenlent procecds arc $300,000.00, This represent'i paYlnent of S300tOOO.OO by Liberty Mutual Insurance COlnpany on behalf of United Parcel Service as set forth in the General Release, attached as Exhibit ':A." The total legal fee on the settlerl1ent is $100,000.00, representing one-third or 33 1/30/0 of the gross settlement, as set f011h in the Contingent Fee Agreement attached as Exhibit "ll." The costs in the atnount of $71,208.10 \vill be paid out of the scUlcnlcnt proceeds after deducting the aUon1ey's fee~ $71,208.10 in costs will be paid to Kline & Specter, P.C. (see Exhibit ~';C')) and $\28.34 in costs will be paid to Steven Banko, Esquire, (see Exhibit "ry'). To the extent any olher additional medical bills or other bills) liens or subrogation interests and/or legal expenses which are known or becOln~ known, I.onnie and Angela Vick recognize that these cJainls or hills are their ohligation are not the obligation of their legal counsel. The entire terms of the distribution have heen fully explained to tht: satisfaction of r .onnie Vick and Angela Vick. '111is Recapitulation has been read carefully before it was signed. The clients acknowledge that Kline & Specter, P.C. has not provided tax, estate or finan.cial advice. DATE: LO~~lE L. VTCK DATE: ANGEl.A S. VICK Sworn to and Subscribed before me this day of 1 2006. .-..- -.-.-.