HomeMy WebLinkAbout01-25-08
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15D5bD41147
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 ONLY
File Number
County Code Year
INHERITANCE TAX RETURN
RESIDENT DECEDENT 2 1 0 7
1082
Date of Birth
174205202
03172007
01121924
Decedent's Last Name
Suffix
Decedent's First Name
MI
CSAJKA
LUCY
L
(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
181 1. Original Return 0 2. Supplemental Return 0 3. Remainder Return (date of death
prior to 12-13-82)
0 4. Limited Estate 0 4a. Future Interest Compromise 0 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
181 6. Decedent Died Testate 0 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
0 9. Litigation Proceeds Received 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)
~ORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
ame Daytime Telephone Number
JOHN M. SMITH 7173671370
Firm Name (If Applicable)
GINGRICH, SMITH, KLINGENSMITH
REGISTER:iiFc~LLS USE.PNL Y,
First line of address
222 SOUTH MARKET STREET, SUITE
Second line of address
P.O. BOX 267
City or Post Office
State
.DATE FILED r', ';
ELIZABETHTOWN
PA
ZIP Code
17022
(10;
Correspondent's e-mail address:
Under penalties erjury, I declare that I hav mined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, corr complete. Declaration pr. arer other than the personal representative is based on all information of which preparer has any knowledge.
PER ON RESPO LE FO I G RETURN
Steven M. Csajka
A 17033
John M. Smith
ADDRESS
222 So th Market Street, Suite 201, Elizabethtown, PA 17022
Side 1
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15D5bD4:L:L47
15D5bD41147
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1505bOlf21lf8
REV-1500 EX
Decedent's Name:
CSAJKA, LUCY L.
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)................
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.
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
Decedent's Social Security Number
174205202
5.
7,828.56
7,828.56
956.00
146,780.21
147,736.21
-139,907.65
-139,907.65
15.
16.
17.
18.
19. Tax Due..................................................... ................................................................ 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
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LSOSbOlf2148
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REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 - 07 - 1082
DECEDENT'S NAME
CSAJKA, LUCY L.
STREET ADDRESS
Golden Living Center
770 Poplar Church Road
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
B. Prior Payments
C. Discount
(1 )
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + 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 1 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 + 5A. This is the BALANCE DUE.
(3) 0.00
(4)
(5) 0.00
(5A)
(5B) 0.00
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes
D
D
D
iJ
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? .............. ................ ......... ........................ ................... ........ ................. .... ....... LJ W
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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 income;....................................
c. retain a reversionary interest; or........................ ..........................................................................................
d. receive the promise for life of either payments, benefits or care?..............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?......................................................................................................................
No
W
W
~
W
~
W
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 exemot 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.
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
_I
T FILE NUMBER
121 - 07 - 1082
~-
1-
ESTATE OF CSAJKA, LUCY L.
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 DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 Wachovia Bank Checking Account, closing balance 7,828.56
-
TOTAL (Also enter on Line 5, Recapitulation) 7,828.56
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'LIz T' 51,,;;~'~6 ' :EPLACEMENTOR REFUND OF T\<IS CHECK IF LOST OIl DESTROYED
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SCHEDULE H
RJNERAL EXPENSES &
ADIVIINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 - 07 - 1 082
ESTATE OF CSAJKA, LUCY L.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
A.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Steven M. Csajka
Social Security Number(s) I EIN Number of Personal Representative{s):
201-40-2766
395.00
B.
Street Address
1640 East Caracus Avenue
City Hershey State P A Zip 17033
Year(s) Commission paid 2008
Attorney's Fees Gingrich, Smith, Klingensmith & Dolan -- John M.
2.
450.00
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
Letters T esatmentary
91.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
Filing fee for Pennsylvania inheritance tax return
15.00
TOTAL (Also enter on line 9, Recapitulation)
956.00
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF CSAJKA, LUCY L.
2 Filing fee for final account
Schedule H
FtmraI ExpeIISeS &
Mninistralive Costs continued
I FILE NUMB. ER
21 - 07 - 1082
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5.00
Page 2 of Schedule H
'*
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
liABiliTIES, & LIENS
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I-FILE NUMBER
I 21 - 07 - 1082
I
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF CSAJKA, LUCY L.
Include unreimbursed medical expenses.
-~ ~-
ITEM DESCRIPTION AMOUNT
NUMBER
1 Pennsylvania Department of Public Welfare, Class 3 claim 28,028.39
2 Pennsylvania Department of Public Welfare, Class 6 claim 118,751.82
~-~ -
TOTAL (Also enter on Line 10, Recapitulation) 146,780.21
.
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
December 18, 2007
GINGRICH SMITH KLINGENSMITH & DOLAN
JOHN M SMITH ESQUIRE
222 SOUTH MARKET ST STE 201
PO BOX 267
ELIZABETHTOWN PA 17022
Re: LUCY CSAJKA
CIS #: 470165903
SSN: 174-20-5202
Date of Death: 03/17/2007
Dear Attorney Smith:
Thank you for your letter of December 11, 2007 concerning the subject
estate.
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $146,780.21 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 $28,028.39, 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 $118,751.82,
is to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise when payment may be
expected. If the estate accounting is complete, please provide a copy of the
informal accounting. Per the information submitted in your letter the
Department will accept $6,897.56 towards its claim. That is the total assets
you reported minus the expenses. If you have any questions please feel free
to call me.
Sincerely,
l~~.~
Carl G. Rinkevich
TPL Program Investigator
717-772-6258
717-772-6553 FAX
Enclosure
REV.1513 EX+ (9-00)
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SCHEDULE J
BENEFICIARIES
_l
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s)
I FILE NUMBER
21 - 07 - 1082
SHARE OF ESTATE I AMOUNT OF ESTATE
(Words) I ($$$)
ESTATE OF
NUMBER
I.
Son
Entire Residue
II.
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I Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
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I NON-TAXABLE DISTRIBUTIONS:
IA. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS
i NOT BEING MADE
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B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
LAST WILL AND TESTAMENT
OF
LUCY L. CSAJKA
I, LUCY L. CSAJKA, of Dauphin County, Pennsylvania, being of
sound and disposing mind, memory and understanding, do hereby
make, publish and declare this to be my Last Will and Testament,
hereby revoking and making void any and all prior Wills,
Codicils, writings thereto, by me at any time heretofore made.
ITEM I. I direct that the payment of my debts and the
expenses of my last illness and funeral shall be paid from my
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: conveniently may be done.
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estate as an administrative expense as soon after my death as
I direct that, if possible, I be interred in the Indiantown
Gap Military Cemetery, Indiantown Gap, Pennsylvania.
Otherwise,
I authorize my Executor to make the decision to purchase a
cemetery plot in a suitable cemetery with a contract for
perpetual care, using therefor, funds from my estate in such
amount as my Executor shall consider necessary and desirable, and 'I
I authorize my Executor to cause title to, or ownership of, such I
plot so purchased to be vested in such person as my Executor
shall designate.
Further, in this connection, I authorize my Executor to
expend funds from my estate in such amount as my Executor shall
consider necessary and desirable for the purchase, erection and
inscription for a suitable marker for my grave.
ITEM II.
I hereby give, devise and bequeath all the rest,
residue and remainder of my estate, realty, personalty and mixed,
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!! wheresoever situate, to my husband, PETER A. CSAJKA, provided
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that he is living on the thirtieth (30th) day after the date of
my death.
ITEM III.
In the event that my husband, PETER A. CSAJKA,
does not survive me by said period of thirty (30) days, then I
specifically give, devise and bequeath all the rest, residue
and remainder of my estate to my son, STEVEN M. CSAJKA, provided
that he is living on the thirtieth (30th) day after the date of
my death.
ITEM IV.
In the event that my son, STEVEN M. CSAJKA, does
not survive me by said period of thirty (30) days, then I
specifically give, devise and bequeath all the rest, residue and
remainder of my estate to my granddaughter, AMY MARIE WILLIAMS.
ITEM V.
In addition to powers given to him by law, my
Executor and his successor shall have the following powers,
applicable to all property held by them, effective without court
Order and until actual distribution:
(a)
To retain any property received by them, including the
stock of any corporate fiduciary acting hereunder;
(b)
To sell real estate for any purpose, publicly or
privately, for such prices and on such terms as they deem proper
without liability on the purchasers to see to application of the
purchase moneys;
(c)
To compromise controversies;
(d)
To distribute in cash or kind or both at such
valuations as they may fix.
ITEM VI.
All taxes, interest and penalties thereon payable
by reason of my death with respect to property comprising my
'y./~'1 0>" c , y" /1 .
f&y~CS~KA (':-~-1eP/
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(SEAL)
Page 2 of 6 Pages.
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gross taxable estate, whether or not passing under this Will,
shall be paid from the principal of my residuary estate.
ITEM VII. I nominate, constitute and appoint my husband,
PETER A. CSAJKA, Executor of this my Last Will and Testament.
Should my husband, PETER A. CSAJKA, predecease me or, for any
reason fail to qualify as such Executor or, having qualified,
fail to serve as such Executor, I nominate, constitute and
appoint my son, STEVEN M. CSAJKA, as his alternate Executor.
Should my son, STEVEN M. CSAJKA, presecease me or, for any reason
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I serve as such Executor, I nominate, constitute and appoint my
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fail to qualify as such Executor or, having qualified, fail to
granddaughter, AMY MARIE WILLIAMS, as his alternate Executrix.
No fiduciary acting hereunder shall be required to post bond or
enter security in any jurisdiction.
IN WITNESS WHEREOF, I have set my hand and seal to this my
Last Will and Testament, consisting of this and two (2) other
pages at the end of which I have also set my hand and affixed my
<;? iL\.
seal for greater security and better identification this
() (+r~j{-'R
day of
/ A.D. 1996.
;f M-U! ,Yo C~/.../ (SEAL)
LUCY L~;tSAJKA ( .
Page 3 of 6 Pages.
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We, the undersigned, hereby certify that the foregoing Will I
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was signed, sealed, published and declared by the above-named i
Testatrix as and for her Last Will and Testament, in the presence I
of us who, at her request and in her presence, and in the presencJ
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of each other, have hereunto set our hands and seals the day and i
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year above written, and certify that at the time of execution \
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thereof, said Testatrix was of sound and disposing mind, memory
and understanding.
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Page 4 of 6 Pages.
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA)
) 55:
COUNTY OF DAUPHIN )
I, LUCY L. CSAJKA, Testatrix, whose name is signed to
the attached or foregoing instrument, having been duly qualified
according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will; that I signed it
willingly; and that I signed it as my free and voluntary act
for the purposes therein expressed.
Sworn or affirmed to and acknowledged before me by
LUCY L. CSAJKA, the Testatrix, this ?~~ day of
('1- \ .' .P.
L/\. O\{)<.Q ~
, 1996.
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LUCY L.( CSAJKA
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C '(}~.hA -'
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NOTARY PUBLIC
ri r-d?S
NOTARIAL SEAL
V1CKl L PETERS. Notary Publtc
Deny T wp. Dauphin County
Mv COmmission Expires "'011114,1997
Page 5 of 6 Pages.
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA)
) 55:
COUNTY OF DAUPHIN )
willingly and that LUCY L. CSAJKA executed it as her free and
i
We, R. ERIC PIERCE and A~f/N('--^-tV\' A-~trp()L \
the witnesses whose names are signed to the attached or foregoing I
instrument, being duly qualified according to law, do depose and [
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voluntary act for the purposes therein expressed; that each of us i
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was at that time eighteen (18) or more years of age, of sound mind
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say that we were present and saw Testatrix sign and execute the
instrument as her Last Willi that LUCY L. CSAJKA signed
in the hearing and sight of the Testatrix signed the Will as
witnesses; and that to the best of our knowledge, the Testatrix
and under no constraint or undue influence.
Sworn or affirmed to and subscribed to before
PIERCE and /~(eJ/Ni(^- ~/(. A1A..K(lt1Ll-witnesses, this
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(, C*.O~'JI{; K>, ' 1996.
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C (:k c ,./'7\ <
NOTARY PUBLIC
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