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HomeMy WebLinkAbout11-19-07 .....J 150.5604112.5 REV -1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 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 5 File Number 063 7 Date of Birth 210701433 o 5 2 3 2 0 0 5 04251987 Decedent's Last Name Suffix Decedent's First Name POTTER MELISSA MI A (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 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 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 FILL IN APPROPRIATE OVALS BELOW o 1. Original Return o 4. Limited Estate o o 2. Supplemental Return o o 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received [ZJ o o o 8. Total Number of Safe Deposit Boxes S USA N J HARTMAN 71724 9 778 0 Firm Name (If Applicable) State ZiP Code REGISTER OF WILLS US~L Y (") = C --' 'c~O % ',,:0 0 ;.)-0,....., _ ':I'- J -- J>!=n ~:o (()~ ''''0 ) C:5 -11 . '-'"Ie: DAYE~E[) -0 J> \.D DUN CAN & H ART MAN, P C First line of address 1 IRVINE ROW Second line of address City eu Post Office -,:) 3 .r:- ~., ,., .s:- CAR LIS L E P A 17013 Correspondent's e-mail address:susanhartman@planetcable.net Under penalties of pe~ury, 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. De aration of preparer other than the personal representative is based on all infomnation of which preparer has any knowledge. ATUR OF PER R 0 SIBLE FOR FILING RET TE . // a tJ"/ PA 17241 DATE ~~ a.. 1701.3 PLEASE USE ORIGINAL FORM ONLY i Side 1 L 15056041125 150.56041125 ---1 --I 15056042126 REV-1500 EX DecedenfsName: MELISSA A. POTTER 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 N,2!!;Probate Property (Schedule G) U Separate Billing Requested. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7) ........................... 8. 9. 9. Funeral Expenses & Administrative Costs (Schedule H) 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. O. 0 0 TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, 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 15. 16. 17. 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 210701433 O. 0 0 O. 0 0 O. 0 0 D 15056042126 --.J REV-1500 ~ Page 3 Decedent's Complete Address: File Number 21 05 0637 DECEDENrs NAME MELISSA A. POTTER STREET ADDRESS 30 EAST MAIN STREET CITY I STATE I ZIP NEWVILLE PA 17241 Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) Total Credits (A + B + C) (2) 3. InteresVPenalty if applicable D. Interest E. Penalty TotallnteresVPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Une 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) 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 trust for' 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 exemot 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 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-15lO~.. SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MELISSA A. POTTER FILE NUMBER 21 05 0637 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RElATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST VALUE ~F APPLiCABlE) 1. PAYMENT OF LIABILITY CLAIM BY HORACE MANN 100,000.00 100,000.00 0 INSURANCE CO TO ADMINISTRATORS OF HORACE MANN 2. PAYMENT OF LIABILITY CLAIM BY PROGRESSIVE 300,000.00 300,000.00 0 INSURANCE CO TO THE ADMINISTRATORS FOR INFORMATIONAL PURPOSES ONLY TOTAL (Also enter on line 7 Recapitulation) $ 0.00 IIf more soace is needed. insert additional sheets of the same size) CLAIM OFFICE ADDRESS: PO BOX 1128 BLUE BEll, PA 19422 ~ Libertx tp Mutual. ~ ~ CHECK REFERENCE CHECK DATE 16993772 12/14/05 CHECIl MIClUNT ,BLOCK IlUIlIEll .$100000.00 006340 CONTACT: LINCH, KEVIN PHONE: 215-641-0400 INSURED NAME:'HUSlER,HESTON CLAIMANT NAME: POTTER,MELISSA PAGE 1 OF ACCIDENT DATE: OS/23/05 aSH: VV0101121401-006340 CLAIM NUMBER: 005945855-0006 POLICY NUMBER: A02-281-533347-804 INSURED OPERATOR: HUSlER,HESTON COVERAGE lIABILITY - BODILY INJURY INVOICE NO DATES OF SERVICE CHARGES PAID ANT ADJUSTMENTS 12/14/05-12/14/05 100000.00 100000.00 PAYMENT TO: DOUGLAS POTTER AND CAROlINE POTTER AS TOTAL CHARGE: TOTAL PAID: TOTAL DEDUCTIBLE: TOTAL WITHHOLDING: CHECK AMOUNT: 100000.00 100000.00 0.00 0.00 100000.00 NOTES FOR FULL AND FINAL SETTLEMENT. PLEASE REFERENCE CLAIM NO AND SEND THIS EOP WITH ALL CORRESPONDENCE ~OFF'CE NO. PA YL4ENT IDENTIFICATION CHECK NUMBER CH"ECK DATE i 0830 CLAIM 005945855-0006 16993772 12/14/05 PAY S 100000. I)') 'PAY TO THE ORDER OF DOUGLAS POTTER AND CAROLINE POTTER AS ADMINSTRATOR OF THE ESTATE OF MELISSA POTTER 310 SAW MILL ROAD NEWVILLE PA 17241 ~7~'~ '/' CALDWELL & KEARNS A PROFESSIONAL CORPORATION .JAMES R. CLIPPINGER CHARLES .J. DEHART. III .JAMES L. GOLDSMITH P. DANIEL ALTLAND .JEFFREY T. McGUIRE' STANLEY .J. A. LASKOWSKI DOUGLAS K. MARSICO BRETT M. WOODBURN RAY .J. MICHALOWSKI 'BOARD CERTIFIED CIVIL TRIAL ADVOCATE ATTORNEYS AT LAW OF COUNSEL RICHARD L. KEARNS CARL G. WASS .JAMES D. CAMPBELL. .JR. 3631 NORTH FRONT STREET HARRISBURG. PENNSYLVANIA 17110-1533 THOMAS D. CALDWELL. .JR. (1928-20011 March 26, 2007 717-232-7661 FAX: 717-232-2766 theflmlOceldwellkeams.com VIA CERTIFIED MAIL Douglas and Caroline Potter 310 Sawmill Road Newville, P A 17241-9580 RE: Estate of Melissa A. Potter v. Weaver Construction Company Our Client: ProgressivelWeaver Construction Company Date of Accident: May 23, 2005 Dear Mr. and Mrs. Potter: I have received your signed Release in this matter. Therefore, I am enclosing the settlement drafts (checks) in this case. If you have any problems or concerns, please let me know. Otherwise, if there is anything I can do for you in the future, please do not hesitate to contact me. JTM/se Encs. cc: Tyeddie Williams, Claim No. 055894472 Progressive 06621-041/115550 , .~ " FEB09ZOO71 INRE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY ORPHANS COURT DNISION ESTATE OF MELISSA A. POTTER NO. O~ - l..o 37 ORDER '-upon considera1ionoIlhe within Petition to Settle Wrongful-Death Action, it is-hereby decreed that settlement is approved. Distribution of the proceeds is directed as follows: a) Douglas A. Potter and Caroline A. Potter as Parents of the Late Melissa A. Potter $225,000.00 b) Caroline A. Potter and Douglas A. Potter Administrators of the Estate of Melissa A. Potter, deceased $ 75,000.00 BY THE COURT, ~(L~9(}f)~~ J. t'Vb~h I I Leer Distribution: Caroline and Douglas Potter, 310 Sawmill Road, Newville, P A 17241 Jeffrey T. McGuire, Esquire, 3631 North Front Street, Harrisburg, P A 17110-1533 ~ . Date of Loss 5/23/2005 ce Issued At PA-CPACA-BRN- 56-389 412 Dollars $ ****225,000.00** PAY TWO HUNDRED TWENTY FIVE THOUSAND AND 00/100 ll~~~ B1 SETTLEMENT I ~B 12PCL Payable t;hroughNational City Bank ".: '.' .'- ASHLAND. OHIO 1-877-448-9544 . . . Progressive NQrthern Insurance Company Pay DOUGLAS A.'.JIOTTER AND CAROUNE A: POTIER AS PARENTS'OF 'J'HE. :,_ ':;,' To LATE MELISSA A. POTI'ER . " :: ~,' L 310 SAWMILL RD NEWVILLE PA 17241 of 1 BY T_ tj~I/) AU ORIZED SIGNATURE na~ 50 2~aaOb" 1:0...20 38q 51: ? 70.8 70u- 022S52 1 2-00 1 Oalm # OSS894472 56, 3E 412 PAY SEVENTY FIVE THOUSAND AND 001100 I In Payment Of FULUFINAL HI SETTLEMENT payable tiuough National City Bank ASHLAND. OHIO 1-877-448-9544 ce At PA PA-CPACA-BRN- Dollars $*****75,000.00** 1 g:s 12PCL Pay To Progressive Northern Insurance Company CAROLINE A. .POIIHK AND DOUGLAS A. POTTER ADMINISTRATORS OF THE ESTATE OF MELISSA A. POTTER, DECEASED 310 SAWMILL RD NEWVlLLE PA 17241 ~J . _ I.i {/ i. A. ~A BY -r · tJJ-! ~. V AUT . ZED S IGNAT1JRE ~~5024BaO?~ ~0...~cr3aq5~ 7?0~a?O" R08ERT M. STRICKlER R08ERT A. L.ERMNr PETER D. SOl YMOS CHARLES B. CALKINS PAUL G. LI1'IT MICHAEl B. SCHEIB. TlfOMM> B. SPONAUGlE .AIso Member MD S. 'U.M (T1IXIIlian); also Member CT S. .AIso Member NY and D.C. Bars LAW OFFICES GRIFFITH, 'STRICKLER, LERMAN, SOL YMOS & CALKINS October 24, 2006 (Dictated October 24, 2006) Douglas & Caroline Potter 310 Sawmill Road Newville, P A 17241 RE: Insurer Insured Claim No. DIL Dear Mr. & Mrs. Potter: 110 S. NORTHERN WAY YORK, PENNSYLVANIA 17402-3737 TELEPHONE: (7m 751-76D2 FAX: (717) 751-3783 EMAII.:info8asIsc.mm WEBSITE: lIlI!&mm Am M8Igar8l Gnlb's EMAII.: ao_ ""'" Horaee Mann Insurance Company Caroline Potter 22521B May 23, 2005 ANN tMRGAAET GRAB DAVID E. COOK LORI M. PETERS OF COUNSEL ROBERT H. GRIFFITH MICHAEL P. BIANCHINI I am enclosing herewith an Order of the Court approving settlement of the underinsured motorist matter for Horace Mann Insurance Company's Sloo,ooO.oo policy limit. I am enclosing herewith a copy of that Order for your file as well as Horace Mann's draft in the amount ofSloo,OOO.oo payable to yourselves as administrators of the estate of your daughter Melissa. If I can be of any further assistance in the matter, please do not hesitate to contact me. ;_e!.x.t~lY yours, <. YJZe~ ANN MARGARE jmllpotter-Itr Enclosure 1 r: T ',) 'DOf IJ4Y f-"'CarofuieA:-Potter-~(ri5OUgi"as-A.'-"r'-' In"the COUrt'of'CommonPleas'or--1 ~ Potter, Administrators;of the estate of ~ Cumberland County Pennsylvania i 1 the Estate of MelisSa A. Potter, ~ 1 ~ deceased and Caroline A. Potter and i ~ I Douglas A. Potter, C;lS parents of i i I Melissa A. Potter) deceased i No. 06 _ boe3 Civil Term I I Hmare MMm ~re Can~1 Protinn fm~an~t A~ I ~ Defendanti Ovil Action Law j ........................................-.-.-....-........-.........-......--.-...--...--.-.............-.---.-.........-----.-..-.--...-----.....-..." Order of Court AND NOW, this 13th day of October, 2006, in consideration if the attached petition, the proposed Underinsurance settlement of $100,000.00 for the death of Melissa A. Potter, is approved, and the following distribution is directed: Douglas A. Potter and Caroline A. Potter as parents of the late Melissa A. Potter $75,000.00 Caroline A. Potter and Douglas A. Potter, Administrators of the Estate of Melissa A. Potter, deceased $25,000.00 ~",..... ~~, .. 1.'P.l~~~A~~,I'';~~~Y.d,I~~~;h!M~.Pl F1~ HORACE MANN INSURANCE COMPANY (HMI) Payable at MID IIIIIIOU NalioD.11la.Dk D 322E.c..-"~LCl701 217-747~ .Horace Mann 4000582431 , - Educated Financial Solutions DATE 70-933 711 217~1e0.2500 Ex1.4540 8/3012006 loss Dale 05232005 ~I Policy # 20463120 Region 60 Claim Number 225218 r PAY TO THE ORDER OF: DOUGLAS A. POTTER and CAROLINE A POTTER as Administrators of the Estate of MELISSA A. POTTER MAIL TO: GRIFFITH. STRICKLER, LERMAN. SOL YMOS & 110 SOUTH NORTHERN WAY YORK. PA 17402 ~ VOID AFTER 90 DAYS -................... _ ,,-_StO.OOD.lID -D~t!. ~ 11-1.000 SB ~a. i I.... -:01 I. I.Oq i iBI: 001-0 1 ~... OET~___= 8/3012006 4000582431 1 000.00 CI8im Number 225218 ~ L.- Date 05232005 ~ Poley. 20463120 RegIon 60 l'nSiM"8d: POTTER, CAROUIE A I Ched< Issued By. Da...d~ Reason: DIM Claim Settlement ~ CJ-~~~~:~ f .r~'"~"S"T'" ,;~~:J;:~~~~~iI~~i.."A..JAd1,~~,,~~.~..~...:.1t.:r-_~n,'_;;;.'...._t.-~.-,_. .-----.. u"'li.'t~""'1!! ~..lI. J<l III rll V"'~t . HORACE MANN INSURANCE COMPANY (HMI) " " "I' Horace Mann Payable at 91..\.tji;) 0 1111-. Nan....lIlaloJc , l: .Il!:.~ 3ZlE.~.8pl(naIiIM.LfIZ701 ,:- Educated Financial Solutions 217-747-6643 I 217-7811-2500 Elct. 4540 4000580802 DATE 70-933 711 8/28/2006 Claim Number 225218 loss Dale 05232005 I~ Policy # 20463120 Region 60 PAY TO THE ORDER OF: DOUGLAS A. POTTER and CAROLINE A POTTER as Administrators of the Estate of MELISSA A. POTTER MAIL TO: GRIFFITH. STRICKLER. LERMAN. SOL YMOS & 110 SOUTH NORTHERN WAY YORK. PA 17402 ~ $99.000.00 VOIO AfTER 90 DAYS ~C _...........-11_.-_$10._00 b~f!.~ "-"ODD 5808020- -:0 I' I.I.Oq ~ ~81: 001'-0 I' 20- .,.,""'......."""""'" ~ Claim Number 225218 ~ loss Dale 05232005 ~ PolIcy " 20463120 RegIon 60 I~~~A I Check tssuecI9y. D8Vid~ Keason: DIM Claim Settlement ~ 0- ~~~~::ci~~ ~"~"'''. 'w COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ''l SCHEDULE J BENEFICIARIES FILE NUMBER 1. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS pndude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Caroline A. Potter 310 Sawmill Road Newville, PA 17241 Douglas A. Potter 310 Sawmill Road Newville, PA 17241 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do NotUstTrustee(s) OF ESTATE NUMBER I. mother 50% 2. father 50% ENTER DOUAR 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 TAX IS NOT BEING MADE 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)