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Home My WebLink About01-04-08 --I lSDSbD41147 REV.1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX.280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW SOI:ial Security Number Date of Death OFFICIAL USE ONLY County Code Year File Number '*' INHERITANCE TAX RETURN RESIDENT DECEDENT 2 1 0 7 0423 Date of Birth 195074895 04152007 02221918 Decedent's Last Name Suffix Decedent's First Name MI KOCH JUNE D (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 WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW o 1. Original Return o 4. Limited Estate 9. Litigation Proceeds Received 0 2. Supplemental Return 0 3. Remainder Return (date of death prior to 12-13-82) 0 4a. Futura Interest Compromise 0 5. Federal Estate Tax Return Required (date of death after 12-12-82) 0 7. Decadent Maintainad a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) 0 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) 00 o 6. Decedent Died Testate (Attach Copy of Will) ~ORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: ame Daytime Telephone Number JAMES D. BOGAR 7177378761 Firm Name (If Applicable) BOGAR & HIPP LAW OFFICES REGISTER OF WILLS USE ONLY First line of address City or Post Office SHIREMANSTOWN State PA ZIP Code 17011 ONE WEST MAIN STREET Second line of address Correspondent's e-mail address: Russell A. Koch James D. Bogar hiremanstown, PA 17011 Side 1 L lSDSbD41147 15D5bD41147 --I .-.J 15056042148 REV-1500 EX Decedent's Name: J u n eO. K 0 c h Decedent's Social Security Number 195074895 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) 0 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. 1:4. 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 1"'4taXable 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 15056042148 7,850.63 7,850.63 6,405.93 167,130.78 173,536.71 -165,686.08 -165,686.08 0.00 0.00 0.00 0.00 0.00 o 15056042148 ~ REV-1:500 EX Page 3 Decedent's Complete Address: File Number 21-07 -0423 DECEDENT'S NAME June D. Koch STREET ADDRESS 4048 Seneca Avenue CITY I STATE !ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) 0.00 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + 8 + C) (2) 0.00 Total Interest/Penalty (0 + 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 tequest 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. 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (3) (4) (5) 0.00 (SA) (58) 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: a. retain the use or income of the property transferred;.................................................................................. 0 b. retain the right to designate who shall use the property transferred or its income;.................................... 0 c. retain a reversionary interest; or.................................................................................................................. 0 d. receive the promise for life of either payments, benefits or care?............................................................. 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.................... ................... .................... ........................................................... 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?........ 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?................... .......................................................................... ........................ 0 [!) IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Yes No [!) ~ [!) [!) 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. 99116 (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. 99116 (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. 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) percent, except as noted in 72 P.S. 99116 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 (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) *' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Koch, June D. FILE NUMBER 21-07 -0423 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolnUy-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION 1 Gettysburg Operations, LLC - Refund of funds remaining in Resident's Fund/Petty Cash Fund VALUE AT DATE OF DEATH 28.83 2 M & T Bank - Checking Account No. 5281189 - date of death balance - $6,261.33; accrued interest - $0.14 - Note: Joint Owner, Kenneth D. Koch, died November 24, 2006. 6.261.47 3 Penn Treaty Network - Refund of unearned premium 56.20 4 Penn Treaty Network America - payment from nursing home disability insurance 1.000.00 5 Penn Treaty Network America - payment from nursing home disability insurance 133.32 6 Penn Treaty Network America - payment from nursing home disability insurance 333.30 7 Prudential Financial. Dividend 37.51 TOTAL (Also enter on Line 5, Recapitulation) 7.850.63 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) r! M&TBank 499 Mitchell Road, MiIlsboro, DE 19966 Mail Code DE-MB-12 Phone (888) 502-4349 Fax (302) 934-2955 May 9, 2007 James D Bogar Attorney At Law One West Main Street Shiremanstown, Pennsylvania 17011 Re: Estate of: June D Koch Social Security: 195-07-4895 Date of Death: Aoril15, 2007 Dear Sir or Madam: Per your inquiry dated May 02, 2007, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 52181189 Ownership (Names oj) June D Koch * Kenneth V Koch * Opening Date 08/28/64 Closed 05/02/07 Balance on Date of Death $6,261.33 $ 0.14 Accrued Interest Total $6,261.47 Please be advised, there was no safe deposit box found for the above decedent. * If upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or the name of any possible joint account holder. For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please call the Mechanicsburg Office # 717-255-2031. Sincerely, -~~~r/ Nancy &gett ' Records Management REV-1151 EX+ (12-99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Koch, June D. Debts of decedent must be reported on Schedule I. FILE NUMBER 21-07-0423 ITEM DESCRIPTION AMOUNT NUMBER A FUNERAL EXPENSES: See continuation schedule(s) attached 1,697.22 8. ADMINISTRATIVE COSTS: 'I. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip - Year(s) Commission paid 2.. Attorney's Fees Bogar & Hipp Law Offices 1,947.50 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 106.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 2,655.21 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 6,405.93 Copyright (e) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1502 EX+ (6.9S) SCHEDULE H.A FUNERAL EXPENSES continued CCMMON~LTHCFPENNSYLVAN~ INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Koch, June D. FILE NUMBER 21-07-0423 ITEM NUMBER DESCRIPTION AMOUNT 1 Flowers on Locust 212.00 2 Malpezzi Funeral Home - balance due on account of funeral bill 331.43 3 Romberger Memorials - headstone 950.00 4 St. John's Lutheran Church - funeral luncheon 203.79 Subtotal 1.697.22 Copyright (e) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-98) Rev-1502 EX+ (S-9S) SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued COMMONWEAlTH OF PENNSYl. VANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Koch, June D. FILE NUMBER 21 ~07 ~0423 ITEM NUMBER DESCRIPTION AMOUNT 1 International Paper Pension Trust - Return of final pension payment 513.96 2 Register of Wills - Short Certificate 4.00 3 RESERVES: - Costs to conclude administration of Estate, including miscellaneous filing fees and expenses 500.00 4 Shepherd's Choice - Final nursing home bill 1.637.25 Subtotal 2.655.21 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B7 (Rev. 6-98) Rev-1512 EJ(+ (6-98) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Koch, June D. FILE NUMBER 21-07 -0423 ESTATE OF Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION 1 Department of Public Welfare - Claim for restitution of medical assistance per attached letter. (Complete copy of claim not attached.) VALUE AT DATE OF DEATH 167.130.78 TOTAL (Also enter on Line 10, Recapitulation) 167,130.78 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule I (Rev. 6-98) *' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG. PA 17105.8486 June 1, 2007 JAMES D BOGAR ATTORNEY AT LAW ONE WEST MAIN ST SHIREMANSTOWN PA 17011 Re: JUNE KOCH CIS #: 720162307 SSN: 195-07-4895 Date of Death: 4/15/2007 Dear Attorney Bogar: Please be advised that the Department of Public Welfare maintains a claim in the amount of $167,130.78 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 $22,157.33, was incurred during the last six months of the decedent's lifei 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 $144,973.45, 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, (bqk /) I.' 1'1"/ ...J.. L~!~LZ/2... Angela D. Carter Claims Investigation Agent 717-772-6612 717-772-6553 FAX Enclosure REV-1513 EX+ (9-00) SCHEDULE .J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NUMBER Koch, June D. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] RELATIONSHIP TO DECEDENT Do NotUst Trustee(s) FILE NUMBER 21-07-0423 SHARE OF ESTATE AMOUNT OF ESTATE (Words) ($$$) I. See attached schedule Total Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet ll. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) SCHEDULE .. BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: June D. Koch 195-07 -4895 04/15/2007 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 1 Edward L. Koch Son 25% of rest, residue 2541 Spring Road and remainder Carlisle, PA 17013 2 Russell A. Koch Son 25% of rest, residue 25 Courtland Road and remainder Camp Hill, PA 17011 3 Stephen H. Koch Son 25% of rest, residue 4048 Seneca Avenue and remainder Camp Hill, PA 17011 4 Lois A. Lane Daughter 25% of rest, residue 8919 Village Grove Drive and remainder Fort Wayne, IN 46804 Total 1 ':'''- >J .\\ \~. ~ '\ --~~ ~ 'J' ,'::- ." \---~'" " 11Lasl Jlill a1tb QJ~Blctttt~1tt OF JUNE D. KOCH I, JUNE D. KOCH, of Lower Allen Township, Cumberland County, pennsylvania, make, publish and declare this as and for my Last will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. FIRST: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, unto my husband, KENNETH V. KOCH, provided he survives me by sixty (60) days. SECOND: Should my husband, Kenneth V. Koch, predecease me or die on or before the sixty-first (61st) day following my death, I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, in equal shares, to my children, STEPHEN H. KOCH, RUSSELL A. KOCH, EDWARD L. KOCH, and LOIS A. LANE, provided that should any of my children predecease me, I give and bequeath such child's share unto his or her issue per stirpes by representation, and if there be a failure of same, then I give and bequeath such deceased child's share to my sur- viving children as provided herein. THIRD: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all property, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or condi- tions as are deemed proper. This includes the power to give \." \~ \~ ~ ~ \J ,"- '~ '" \>:\ C>,;., legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivision, improvement, zoning or management of real estate and to impose or extinguish restrictions on real estate. (C) To compromise any claim ~r controversy and to abandon any property which is of little or no value. (D) To invest in all forms of property, including stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privilege given by the Federal and other tax laws, including, but not necessarily being limited to', personal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named benefici- aries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever manner they consider advisable. FOURTH: I direct that all inheritance, estate, transfer, succession and death taxes, of any kind whatsoever, 2 which may be payable by reason of my death, whether or not with respect to property passing under this Will, shall be paid out of the principal of my residuary estate. FIFTH: All interests hereunder, whether principal or income, which are undistributed and in the possession of the fiduciaries acting hereunder, even though vested or distributable, shall not be subject to attachment, execution or sequestration for any debt, contract, obligation or liability of any beneficiary, and furthermore, shall not be subject to pledge, assignment, conveyance or anticipation. SIXTH: I nominate and appoint my husband, KENNETH V. KOCH, Executor of this, my Last Will and Testament. In the event of the death, resignation or inability to serve for any reason whatsoever of the said Kenneth V. Koch, I nominate and appoint LOIS A. LANE, Executrix of this, my Last will and Testament. I direct that my Executor or Executrix, as the case may be, and their successors, shall not be required to post security or a bond for the performance of their duties in an~' jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this let day of (?/!y/.-,;;'l:: / 1990. /'l /) A/ ;J '. ,I /?hll /~/ t 17' 4',- "J///r/ /1/" ,-,-t70u June 0'./ Koch (SEAL) I~/ Signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. Address 'l , ___iftu,,-,-<, J b0Y!-iJZc (J L~A'.hT2 cY.lgM/L6{~ Address 3