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Home My WebLink About09-10-07 c, ~" ~ 15056041125 REV-1500 EX (06-05) PA Department of Revenue '* ~~~~~~~~~~uaITaxes INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year 2 1 0 7 File Number o 2 9 5 Date of Birth 203058475 030 4 2 007 o 2 0 5 1 9 2 1 Decedent's Last Name W 0 1 t z Suffix Decedent's First Name Mar y MI E (If Applicable) Enter Surviving Spouse's Infonnation Below Spouse's Last Name Suffix 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 OVALS BELOW 00 1. Original Return D 4. Limited Estate 00 6. Decedent Died Testate (Attach Copy of Will) o 9. Litigation Proceeds Received D 2. Supplemental Return D 4a. Future Interest Compromise (date of death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach Copy of Trust) D 10. Spousal Poverty Credit (date of death 0 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number D D o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes H . Ant h 0 n y Adams 717 532 327 0 4 9 W est Ora n g e S t r e e t o Firm Name (If Applicable) First line of address State ZIP Code C? (::> ~~\ --n 5:5 'l) --l DKrE FILED -":' Second line of address Sui t e 3 City or Post Office f"v , "1 o .::- S hip pen s bur 9 P A 1 7 2 5 7 Correspondent's e-mail address: Nt A Under penalties of perjury, I declare that 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. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG :ru 0 O~FILI G UR OAT Carlisle 17015 Orange Street, Suite 3 Shippensburg PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056041125 15056041125 ---I 6N\ ., ---I 15056042126 REV-1500 EX Decedenfs Name: Ma ryE. W 01 t z 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) D 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 I or transfers under Sec. 9116 (a)(1.2) X.O _ 16. Amount of Line 14 taxable at lineal rate X .0 17. Amount of line 14 taxable at sibling rate X. 12 18. Amount of Line 14 taxable at collateral rate X. 15 o . 0 0 15. o . 0 0 16. o . 0 0 17. o . 0 0 18. 19. Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056042126 Decedent's Social Security Number 203058475 10140.09 1 0 1 4 O. 0 9 1 6 2 1. 0 0 3 9 0 3 4 . 4 4 4 0 6 5 5. 4 4 - 3 0 5 1 5. 3 5 - 3 0 5 1 5.3 5 O. 0 0 O. 0 0 O. 0 0 O. 0 0 O. 0 0 D 15056042126 -..J REV-1500 EX Page 3 Dece~nt's Complete Address: File Number 21 07 0295 DECEDENTS NAME Mary E. Woltz -----_._-,_._- . STREET ADDRESS 700 Walnut Bottom Road h _.___. _ .-----,--- CITY I STATE I ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 Total Credits (A + 8 + C) (2) 0.00 3. InteresUPenalty if applicable D. Interest E. Penalty 0.00 0.00 0.00 T ota! Interest/Penalty ( D + E ) (3) 4. If Une 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill In oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Une 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) B. Enter the total of Une 5 + 5A. This is the BALANCE DUE. (5A) (58) A. Enter the interest on the tax due. 0.00 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 00 b. retain the right to designate who shall use the property transferred or its income; ............................... 0 00 c. retain a reversionary interest; or ....... ............ ................................................................... .......... 0 00 d. receive the promise for life of either payments, benefits or care? ....................................................... 0 00 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... 0 00 3. Did decedent own an "in trustfor- or payable upon death bank account or security at his or her death? ......... 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. 0 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS 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) (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 zero (0) percent [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 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 lineal beneficiaries is four and one-half (4.5) percent, 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 twelve (12) percent [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-1508 EX + (6-98) 'W SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mary E. Woltz FILE NUMBER 21 07 0295 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. DESCRIPTION ITEM NUMBER 1. Checking Account at M&T Bank Account # 97584126 VALUE AT DATE OF DEATH 10,140.09 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 10,140.09 REV-1511 EX + (12-99) * >. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mary E. Woltz SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Debts of decedent must be reported on Schedule I. FILE NUMBER 21 07 0295 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) JoAnn T. Woltz 493.00 Social Security Numbe~s)/EIN Number of Personal Representative(s) Street Address 51 Summerfield Drive City Carlisle State P A Zip 17015 Yea~s) Commission Paid: 2007 2. Attorney Fees H. Anthony Adams 1,000.00 3. Family Exemption: (If decedenfs address is not the same as daimanfs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wills of Cumberland County 98.00 5. Accountanfs Fees 6. Tax Return Prepare(s Fees 30.00 7. TOTAL (Also enter on line 9, Recapitulation) $ 1 621.00 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) " ' * SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mary E. Woltz FILE NUMBER 21 07 0295 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, Including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION 1. Commonwealth of Pennsylvania Department of Public Welfare VALUE AT DATE OF DEATH 39,034.44 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 39.034.44 ~_15~~'1. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MEW Itz SCHEDULE J BENEFICIARIES FILE NUMBER arv 0 21 07 0295 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright s~usal distributions, and transfers under Sec. 9116 {a} {1. }] 1. Michael E. Woltz Lineal 8579 Harscrable Road 25% Westfield, NY 14787 2. Michelle W. Woltz Lineal 649 Manor Drive 25% Harsham, PA 19044 3. Shamus B. Woltz Lineal 25% Niceville, FL 32578 4. JoAnn T. Woltz Lineal 51 Summerfield Drive 25% Carlisle, PA 17015 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET n. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - 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 PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARlY LlABILllY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 June 25, 2007 H A ADAMS STE 2 49 W ORANGE ST SHIPPENSBURG PA 17257 Re: MARY WOLTZ CIS #: 870181192 SSN: 203-05-8475 Date of Death: 03/04/2007 Dear Attorney Adams: Please be advised that the Department of Public Welfare maintains a claim in the amount of $39,034.44 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $19,389.20, was incurred 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 $19,645.24, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when paYment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, ,..c:e J I..l: It 1k.l';~ /"'~JC.1 V Snober V. Ketty Claims Investigation Agent 717-772-6608 717-772-6553 FAX Enclosure --- f~ (" /1/"- """, \~....4 C .. /. itfj 1 S'Z.? \ \) P II \'2: () 4 :;y" , ,;.. '~ r-,', (0(-,\1 \./ C;\l"- OO....u-...' I>"~ ('f"" \l~,T "r \I!-'; \4 ~:~ U,)\ i t",\ C\ \~,W --"I, ',f' :~(' P[\ \)1..' " .,., <;\ f:S ':::~ 1 /C;) /~(/ , .L \/( =----/ n .:::) s:: s~q --? - - ~ - = - - ..:;:::. =- - - - - _ to- ~ ~ i~ ~