HomeMy WebLinkAbout09-04-07
...J
15056041147
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes~. .,' ".
PO BOX.280601 ~
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
OFFICIAL USE ONL
County Code Year
File Number
INHERITANCE TAX RETURN
RESIDENT DECEDENT 2 1 07
0519
Date of Birth
178164511
09182003
12031921
Decedent's Last Name
SuffIX
Decedent's First Name
MI
PE I FE R
JR.
JOHN
F
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Suffix
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE
REGISTER OF WILLS
10 Spousal Poverty Credit (date of death
. between 12-31.91 and t-1-95)
o
5, Federal Estate
FILL IN APPROPRIATE OVALS BELOW
[!] 1. Original Return
9. Litigation Proceeds Received
o
o
o
o
4a. Future Interest Compromise
(date of death after 12-12-82)
o
o
2, Supplemental Return
o
[!]
o
4. Limited Estate
6. Decedent Died Testate
(Attach Copy of Will)
7 Decedent Maintained a Living Trust
. (Attach Copy of Trust)
~ORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION
ame Daytime Telephon
MICHAEL L. BANGS 71773073
,...~.,
Firm Name (If Applicable)
First line of address
(;;;:)
LS USE eNL Y
(.~
::,
-0
I
429 SOUTH 18TH STREET
Second line of address
City or Post Office
CAMP HILL
State
PA
ZIP Code
17011
Correspondent's e-mail address:
Under penalties of ~rjury.1 declare that I have examined this return, including accompanying schedules and statements, and to the best f my knowledge and belief,
it is t ,correct and complete. Declaration of preparer other than the personal representative is based on all information of which prepar r has any knowledge.
OF PER9~N RES NSIB E OR F ING RETURN
Patricia A. Haslam
vT' DATE 7
o - g-{)
013
Michael L. Bangs
429 South 18th Street, C mp Hill, PA 17011
Side 1
L
:L5[]56[]4:L:L47
:L5[]5604:L:L 7
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15[]5b[]42148
REV-1500 EX
Decedent's Name: John F. Peifer Jr.
Decedent's Socic I Security Number
178164 )11
RECAPITULATION
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 D)............................................................ 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E).................... 5.
6. Jointly Owned Property (Schedule F) 0 Separate Billing Requested.............. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) D Separate Billing Requested.............. 7.
8. Total Gross Assets (total Lines 1-7)........................................................................ 8.
9. Funeral Expenses & Administrative Costs (Schedule H)............................................ 9.
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 ).............................................................. 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 Line 13)................................................... 14.
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, of
transfers under Sec. 9116
(a)(1.2) X ~
16. Amount of Line 14 taxable
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
0.00
15.
0.00
16.
0.00
17.
0.00
18.
19. Tax Due........................................... ............ ................... ................... ....... ................. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
L
:L5056042:L48
5,884.69
5,884.69
12,294.48
74,603.80
36,898.28
-31,013.59
- 31,013.59
0.00
0.00
0.00
0.00
0.00
D
15[]5b0421l8
-1
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
John F. Peifer Jr.
STREET ADDRESS
Green Ridge Village
File Number 21 - 07 - 051 9
Newville
I STATE
PA
\ZIP
17241
CITY
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
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C)
(2
0.00
0.00
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 2 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.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(3 0.00
(4
(5 0.00
(5Jl )
(5E) 0.00
Make Check Payable to: REGISTER OF WILLS, AGENT
__:=~ xx"'..~_......... ".......v
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPR ATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;..................................................................................... D D
b. retain the right to designate who shall use the property transferred or its income;........................................ 0 D
c. retain a reversionary interest; or........ ................ ........ ................ ............ ............. ......... ............ ...................... D 0
d. receive the promise for life of either payments, benefits or care?.................................................................. 0 [J
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death withou
receiving adequate consideration?................. ..... .......................... ................ ............. ........ ....................... ............. 0 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.............. D 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?................................................................................................................. ...... 0 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS ~ART OF THE RETURN.
~;;Hl~ -:.:. -':'~~-..l. - I ~ _~';t/1+Rl1,; t~"'lt ~.,~d~.:; '": f '"d+J4!~j- Jl~I..-l:~ .{~l:j+:lt.:;~. t: ~fi;f1 '1 ~'~ :Utl~"l~:. ~ ~i:;1 ?'!l d~~':\d: t . +<. "i:f!*~.t. ,i 1:>1~: I ,~J t,\f f . r I, \ ~Et l:F .t+l~ t..w. r . : '" t
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 th use of the
surviving spouse is three (3) percent [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 sp use is zero
(0) percent [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory re uirements
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 u e of a
natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [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 four and one-half (4.5) pe cent,
except as noted in 72 P.S. ~9116 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 twelve (12) percent [72 P .S. 99116 ( ) (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 r adoption.
Rev-150S EX+ (6-9S)
~
~
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETIJRN
RESIDENT DECEDENT
Peifer, John F. Jr.
FilE NUM ~ER
21-07 -O~ 19
ESTATE OF
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
NUMBER DESCRIPTION
1 Citizens Bank - Account 610071-684-8
VALUE AT DATE
OF DEATH
5.884.69
TOTAL (Also enter on Line 5, Recapitulation)
5.884.69
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-150[) Schedule E (Rev. 6-98)
REV-1151 EX+(12-99)
'*
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUME ER
21-07 -05 9
Peifer, John F. Jr.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
See continuation schedule(s) attached
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
1.
Patricia A. Haslam
Social Security Number(s) / ErN Number of Personal Representative(s}:
Street Address 482 Wheatfield Drive
City Carlisle State PA
Zip 17013
Year(s) Commission paid
2.
Attorney's Fees
Michael L. Bangs
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Other Administrative Costs
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation)
AMOUNT
7,009.78
2,500.00
2,500.00
83.00
201.70
12,294.48
Copyright (c) 2002 form software only The Lackner Group. Inc.
Form PA-150[) Schedule H (Rev. 6-98)
Rev-1502 EX+ (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Peifer, John F. Jr.
SCHEDULE H-A
FUNERAL EXPENSES
continued
IFILE NUM 3ER
21-07 -Of 19
ITEM
NUMBER DESCRIPTION
1 Cocklin Funeral Home, Inc.
Subtotal
AMOUNT
7,009.78
7.009.78
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 ;chedule H-A (Rev. 6-98)
Rev-1502 EX+ (6-98)
. SCHEDULE H-B7
OTHER
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA continued
INHERITANCE TAX REllJRN
RESIDENT DECEDENT
ESTATE OF IFILE NUM El ER
Peifer, John F. Jr. 21-07 -O! 1 9
ITEM
NUMBER DESCRIPTION AMOUNT
1 Cumberland Law Journal - estate advertising 75.00
2 The Sentinel - estate advertising 126.70
Subtotal 201.70
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 S c edule H-B7 (Rev. 6-98)
Rev-1512 EX+ (6-98)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEAllll OF PENNSYLVANIA
IPoIiERITANCE TAX RE11JRN
RESIDENT DECEDENT
Peifer, John F. Jr.
IFILE NUME ER
21-07 -05 9
ESTATE OF
Include unrelmbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 PA Department of Public Welfare - Claim for restitution of medical assistance grante( 74,603.80
on behalf of the decedent (see letter of June 6, 2007 attached).
TOTAL (Also enter on Line 10, Recapitulation)
74,603.80
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Sch ldule I (Rev. 6-98)
REV.1513 EX+ (9..00)
*'
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Peifer, John F. Jr.
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
tfistributions, and transfers
under Sec. 9116(a)(1.2))
RELATIONSHIP TO
DECEDENT
Do Not List Trustee{sl
I.
Patricia A. Haslam
4.2. Wheatfield Drive
Carlisle, PA 17015
Niece
Scott M. Stoner
1017 Dogwood Lane
Enola, PA 17025
Nephew
Stephen J. Stoner
1604 Airport Drive
Mechanicsburg, PA 17055
Nephew
FILE NU~ BER
21 ~07 -O!i 19
SHARE OF ESTATE MOUNT OF ESTATE
(Words) ($$$)
One-third of
Residue
One-third of
Residue
One-third of
Residue
Total
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
Copyright (c) 2002 form software only The Lackner Group, Inc.
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Form PA-1500 )chedule J (Rev. 6-98)
0.00
UI-,' GoJ' t::..1!-,vJ 1 .1. ,,-+. ..J'-'
"IU . D~_:J"4 Lr'''-=-I~_)
~
~'t Citizens Bank"w,
71.1;
Account Number 6100716848
Account Title JOHN F PEIFER
Date Opened 6/611966
Account Type Checking
Principal Balance as of DOD $5884.69
Interest from Last Posting to DOD
Account Balance as ofDOD $5884.69
YID lnterest to DOD
.'
..
. -,
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-6466
June 6, 2007
BANGS LAW OFFICE
MICHAEL L BANGS ESQUIRE
429 S 18TH ST
CAMP HILL PA 17011
Re: JOHN PEIFER
CIS #: 630153342
SSN: 178-16-4511
Date of Death: 09/18/2003
Dear Attorney Bangs:
Please be advised that the Department of Public Welfare maint
claim in the amount of $74,603.80 against the above-mentioned esta
claim is for restitution of medical assistance granted on behalf 0
decedent for which the Probate Estate is now responsible to reimbu
Department according to Act 49, 62 P.S. 1412, effective August 15,
amended by Act 20-95, effective June 30, 1995. Enclosed is the De
itemized statement of claim.
A portion of this medical expense, namely $19,087.75, was inc rred
during the last six months of the decedent's life; therefore, it is a Class 3
claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $55,516.05, is
to be entered as a priority f~_ass_2.~ claim against the estate.
Please acknowledge receipt of this letter in writing, providin
information previously omitted that is required, according to Title
Code S 258.4; particularly written documentation or tbe gross value of the
decedent's estate. Advise whether the Commonwealth's claim is admitted and
when payment may be expected. If the estate contains real estate, lease
provide the full address of the property, including the zip code, c pies of
the deed and the latest tax assessment, as well as a current apprai aI, if
available. When the estate accounting and inheritance tax forms ar
complete, please provide copies.
Sincerely,
(d0-9 &~
Kelly J. Snider
TPL program Investigat.or
717-214-1861
71 7 - 7 72 - 6553 FAt'C
Enclosure
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WILL
OF
JOHN F. PEIFER
I, JOHN F. PEIFER, of Cumberland County, Pennsylvania, declare this to be my last
will and revoke any will previously made by me.
ITEM I. I direct that all my just debts and funeral expenses, including my
and all expenses of my last illness, and any and all taxes and assessments imposed
governmental body as a result of my death, whether on property passing under this 'll or
otherwise, shall be paid from my residuary estate as soon as practicable after my de ease as a
part of the expense of the administration of my estate.
ITEM II. I give and bequeath all of my household goods, automobiles, jew lry, and all
other articles of household and personal use, equipment and ornament, together wi all
insurance thereon and relating thereto, in equal shares, to PATRICIA A. HASLAM, SCOTT M.
STONER, and STEPHEN J. STONER, or to those of their issue, per stirpes, as surv ve my death
by thirty (30) days.
ITEM III. I give, devise, and bequeath all the rest, residue, and remainder 0 my
possessions and estate of every nature and wherever ~ituate~ in equal shares, to PAT ...JCIA A.
HASLAM, SCOTT M. STONER, and STEPHEN J. STONER, or to those of their is ue, per
stirpes, as survive my death by thirty (30) days.
ITEM IV. I appoint my daughter, PATRICIA A. HASLAM, executrix ofth s my last
will.
1
r
ITEM V. In addition to the other powers and authorities granted to my pers nal
representatives by Pennsylvania law and by the other terms and provisions of this 11, I hereby
give to my personal representatives the following powers and authorities effective . thout court
approval and until actual distribution of all property: to compromise any claim or c ntroversy; to
make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as
my personal representatives may determine and at valuations finally to be fixed by t em; to
invest in all forms of property, including any stock or other securities in any corpor te fiduciary
or its successor without restriction to investments authorized for Pennsylvania fiduc aries, as my
personal representatives deem proper, without regard to any principle of risk or dive sification; to
retain any or all assets of my estate, real or personal, without regard to any principle of risk or
diversification; to sell at public or private sale, to exchange, or to lease for any perio of time,
any real or personal property and to give options for sales, exchanges, or leases, for uch prices
and upon such terms or conditions as my personal representatives deem proper; and 0 allocate
receipts and expenses to principal or income or partly to each as my personal repres ntatives
deem proper in their sole discretion.
ITEM VI. I direct that my personal represen~tives and fiduciaries shall not be required
to give bond for the faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand this
day of
lJo iJ ( <('
, 1997.
2
,"
The preceding instrument, consisting of this and TWO other typewritten pa
identified by the signature of the testator was on the date thereof signed, published,
by JOHN F. PEIFER, the testator therein named, as and for his last will, in the pres nce of us,
who at his request, in his presence, and in the presence of each other, have subscrib d our names
as witnesses hereto.
/. - (g-9 7
3
. .
'" .
COMMONWEAL TH OF PENNSYLVANIA )
( SS:
COUNTY OF CUMBERLAND )
The undersigned, being the testator whose name is signed to the attached or foreg ing
instrument, having been duly qualified according to law, does hereby acknowledge that Is gned and
executed the foregoing instrument as my last will, that I signed it willingly; and that I sign d it as my
free and voluntary act for the purposes therein expressed.
COMMONWEALTH OF PENNSYLVANIA )
( SS:
COUNTY OF CUMBERLAND )
WE, (\~ARv( ~ J ~ To~ and M l C ~L L . 6.AJjb$ , the witn sses whose
names are signed to the attached or foregoing instrument, being duly qualified according t law, do
depose and say that we were present and saw the testator sign and execute the instrument s his last will;
that he signed it willingly and that he executed it as his free and voluntary act for the purp ses therein
expressed; that each of us in the hearing and sight of the testator signed the will as witness s; and that to
the best of our knowledge, the testator was at that time 18 or more years of age, of sound ind, and
under no constraint or undue influence.
4