HomeMy WebLinkAbout04-14-08
REV-1500 EX + (~)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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OFFICIAL USE ONLY
FILE NUMBER
2 1 - 0 8 G <....\ t q
"'"CoUNTYCOoE --YEA~ - - NU'MBER- -
DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL)
SHANK
DATE OF DEATH (MM-DD. Year)
DONALD M.
DATE OF BIRTH (MM-DD-Year)
SOCIAL SECURITY NUMBER
2 04- 0 1 - 3 6 2 4
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date of death prior to 12-13.82)
D 5iFederal Estate Tax Retum Required
_ 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113{A) (Attach Sch 0)
THIS. SECTtCJN.MuStBE.cbMpL.E"f'EO:AIdt.'CORRESPONDENCEANDCONFI.DENl1ALTAXINFORMATIONSHOOLD Be. DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
MARCUS A. McKNIGHT III 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353 CARLISLE PA 17013
0.00 X _(15) 0.00
0.00 X .045 (16) 0.00
0.00 X .12 (17) 0.00
0.00 X .15 (18) 0.00
(19) 0.00
01/22/2008 10/02/1922
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
lli] 1. Original Return
o 4. Limited Estate'
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 48'. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Allach copy ofTrust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
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(8)
1 ,463.02
300,543.76
(11)
(12)
(13)
(14)
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20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON ReVERSE SIDE AND RECHECK MATH < <
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1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
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)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a){1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
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IAL USE ONLY
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16,215.97
302,006.78
-285,790.81
-285,790.81
Jecedent's Complete Address:
STREET ADDRESS
CITY
I STATE
I ZIP
ax Payments and Credits:
Tax Due (Page 1 Line 19)
Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1 )
0.00
0.00
Total Credits (A + B + C)
(2)
0.00
Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + E)
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
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(3)
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + SA. This is the BALANCE DUE.
Make Check
(4)
{5}
(SA)
(58)
AGENT
0.00
0.00
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
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
0.00
No
IZl
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IZl
IZl
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THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
'er 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.
laration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
~~RE?F PERSON R'1SPONSIBLE FOR FILING RETURN DATE
_\l A 0~AM,J "'1~ J"-O~
'R S 16 JASON AVENUE
DENVER PA
IATURE OF PREPARER OTHE
lESS
tes 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 3%
;. S9116 {a} (1.1) (i)].
es 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 0% [72 P.S. 9.9116 (~) (1.1) (H)]..
Itute 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
living spouse is the only beneficiary.
'~a~~ f~~~~~~ ~~ ~~:rn~~I~a~~:~W~ansfers from a deceased child twenty-one years of age or younger at death to or for the use o~ a \'\a\ula\ ?ale1\t, an ado?t\\Ie parent,
parent of the child is 0% [72 P.S. S9116(a)(1.2}j. . 1',9'\'\6\'\.2) \12.? .s. fS9'\'\Q\a)\'\)\.
~ ~ol ce~\. as l\o\.ed In 11 '? .s. ~ Cl'2. san
,\\. ~ ~ ~ ,~~~ ~~~ ~\1\(!~ ~d~ ~:::~:~ ?~~~:""a\\\~\\ ~ ,"""'l ,. Q<<'''''' un'" - 9\ .'
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REV-1508 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
SHANK
FILE NUMBER
DONALD M. 21 08
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.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
1,668.15
M&T BANK - CHECKING ACCOUNT
2.
THE ESTATE OF PAULINE L. SHANK
14,547.82
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
16215.97
REV-1511 EX + (12-99)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SHANK
DONALD
Debts of decedent must be reported on Schedule I.
M.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
21
08
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. AUER MEMORIAL HOME AND CREMATION 138.02
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)IEIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees IRWIN & McKNIGHT 1,200.00
3. Family Exemption: (If decedent's address is not the same as claimanfs, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees PATRICIA A. ROSENDALE, CPA 95.00
7. REGISTER OF WillS, FILING FEE 30.00
TOTAL (Also enter on line 9, Recapitulation) $ 1 463.02
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (6-98)
.
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SHANK
DONALD
M.
FILE NUMBER
21 08
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
VALUE AT DATE
OF DEATH
1. DEPARTMENT OF PUBLIC WELFARE CLAIM - SEE ATTACHED
298,609.46
2. CLAREMONT NURSING AND REHABILITATION CENTER
1,934.30
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
300,543.76
~V-""8<.'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FilE NUMBER
""II, ".1. ~,..,.. A' Ii M. 21 nA
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not list Trustee(s) OF ESTATE
1. T A>~ABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. CHRISTAL A. BURNS Lineal
16 JASON AVENUE 1/3 REMAINDER
DENVER, PA 17517
2 MICHAEL A. SHANK Lineal
1/3 REMAINDER
MIAMI, FL
3. DONALD SHANK Lineal
1/3 REMAINDER
DENVER, PA 17517
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
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)
I!M&rBank
499 Mitchell Road, Millsboro. DE 19966 Mail Code DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
February 5. 2008
Law Offices
Irwin & McKnight
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013-3222
RECEIVED
FEB 0 7 2008
IRWIN & McKNIGHT
LAW OFFICES
Re: Estate of' Donald M Shank
Social Security: 204-01-3624
Date of Death: Januarv 22, 2008
Dear Sir or Madam:
Per your inquiry dated January 31, 2008, 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
A ccount Number 9835621054
Ownership (Names oj) Donald M Shank *
Opening Date 12/20/04 Closed 0//30/08
Balance on Date of Death $/,668./4
Accrued Interest $ 0.01
Total $1,668.15
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 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
High Street Carlisle Office # 717-240-4536.
Sincerely, . ?
r:zy07/
Nancy Clagett
Records Management
OF PENNSYLVANIA, A PRIVATE LAW FIRM
elderlawpa.com
February 7, 2008
Irwin & McKnight
Marcus A. McKnight, III, Esquire
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
RECEIVED
!FEB 0 8 2008
Re: Estate of Donald M. Shank
IRWIN & McKNIGHT
tAW OFFICES
Dear Attorney McKnight:
Enclosed herewith please find a check representing the 1/3 election taken by Donald
M. Shank. The check is for $ 14,547.82 and includes an additional $1,087.87. We
anticipated a large medical bill which in the end, was only a third of the amount. Also, the
estate received a refund from the Carlisle Regional Medical Center.
It is my understanding that your office will be taking the entire responsibility of
compliance with the insolvency rules of ~3392 and Estate Recovery.
Sincerely,
~/tL.( 1"~~/LIn
David R. Morrison, Esquire
DRM/cmm
cc: Christal Burns
c: \ work\ wp07\Shank. est
David R. Morrison & Associates. 600A Eden Road. Lancaster, PA 17601 . 717-560-1500
-
-
AVER MEMORIAL HOME AND CREMATIC
4100 Jonestown Road. Harrisburg, PA 17109. 1-800-720-8221 . Fax 717-541-(
AUER "E"RL HO"E I CR"TN SRV
4199 JONESTOWN ROAD
HARRISBURG. PA 17199
(711) S45 - 4001
MerChant 10: 095170&0
. 1-23-2008
Phone Order
XXXXXXXXXXXX9179
VISA EntrY: Manu
Total: $ 138.\J.
91126/98 14:49:
InvU: 999991 Appr Code: 9265
Apprvd: Online Batch<<: 0901
AVS Code: EXAC HATCH V
CVV2 Code: "ATCH "
Mrs. Christal A. Burns
16 Jason Avenue
Denver, PA 17517
Customer COpy
THANk YOU!
---'-O.ll.L.a..aAl ~ I
Donald M. Shank - Deceased
SPECIAL CHARGES
X Direct Cremation Sl,295.00
Forwarding Remains
Receiving Remains
Immediate Burial
Nationwide Guarantee Program
Worldwide Travel Protection
TOTAL SPECIAL CHARGES
S1,295.'
PROFESSIONAL SERVICES
Services of Funeral Director & Staff
Embalming
Other Preparation of the Body
Facilities & Staff for Viewing ($200/hour)
Facilities & Staff for Funeral Service
Facilities & Statf for Memorial Service
Staft & Equipment tor Viewing ($200/hour)
Arrange/Deliver Ashes To National Cemetery
Staff & Equipment tor Memorial Service
Private Family Viewing/Witnessing Cremation
Witnessing the Cremation
Packaging And Forwarding Cremated Remains
Personal Delivery of Cremated Remains
X Scattering of Cremated Remains in Arizona S195.00
Medical Documents/Courier Fee
TOTAL PROFESSIONAL SERVICES
S 195. (
AUTOMOTIVE EQUIPMENT
Removal Vehicle
Casket Coach
Flower Car
Lead Car/Clergy Car
Service Vehicle
Family Car
TOTAL AUTOMOTIVE EQUIPMENT
Sf{). (
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MERCHANDISE
Register Book
Memorial Folder
Thank You Cards #
Remembrance Package
Casket
Cardboard Container
Cremation Container
Urn Burial Vault
Veterans Flag Case
Grave/Memorial Marker
TOTAL MERCHANDISE
$ (b. I
CASH ADVANCED ITEMS
Grave Opening
Cemetery Equipment
Vault Service Charge
Newspapers
X Patriot News
Clergy
Church/Organist/Soloist
Flowers
Crematory Charge
X County Coroner Cremation Approval Fee
X 10 Certified Copies of Death Certificate
$113.02
$25.00
$60.00
TOTAL CASH ADVANCED ITEMS
$198.
SUMMARY OF CHARGES
Special Charges
Professional Services
Automotive Equipment
Merchandise
Cash Advanced Items
SUB TOTAL
$1,295.00
$195.00
$0.00
$0.00
$198.02
$1,688.02
CREDITS
-$710.00
TOTAL
$978.02
AMOUNT PAID
1-26-2008
-$978.02
BALANCE DUE
$0.00
THIS STATEMENT MAY NOT REFLECT ALL NEWSPAPER CHARGES
ont J'fur8 .
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1000 Claremont Road
Carlisle, PA 17013-8805
main (717) 243-2031
fax (717) 240-1952
rJ(ehabilitation Center
January 29,2008
Ms. Christal Burns
16 Jason Ave.
Denver,Pa.17517
RE: DONALD SHANK
Dear Ms. Burns:
Please accept the following as a Final Statement for Mr. Shank from Claremont Nursing
and Rehabilitation Center.
The final balance due Claremont for Mr. Shank's bill is $1,934.30. The fo!lowing is an
accounting of the resident income due:
December 2007
January 2008
Balance Due
$951.52
$982.78
$1.934.30
Should you have any questions, please feel free to call Denise Lehman in our billing
office at (717) 240-1908.
(J:iJ,
Denise Lehman
Billing Analyst
J/1 serl/ice agency oj Cumberland County
Statement
CLAREMONT NURSING & REHAB CTR
1000 CLAREMONT ROAD
CARLISLE, PA 17013
Telephone: (717) 243-2031
Statement Date: 03/20/2008
Donald Shank
Christal Burns
16 Jason Avenue
Denver, PA 17517
Due Date: 04/01/20Q8
_..... R~,_Donald._M~ ~~~nk_~~_.
Account Nr: 4167
--------------------------------
Date Description --~~;;----;~~~-----;h~~~~~---;~;;~~~~----~~l~~~~
Quant
--------------------------------------------------------------------------------
BALANCE FORWARD
1,826.30
1,826.30
YOUR ACCOUNT IS OVERDUE
PLEASE PAY IMMEDIA TEL Y
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. ,,~~.,., ,:,.,
Payment is due by the loth of each month.
please send payments to the Attention of the Business office
Include the Resident's number in the Memo Section of the check
For questions please contact Denise Lehman at 717.240.1908
Thank you
1121"d
1:>1:>81211:>81:> ) '[) T
.
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
RECEIVED
February 8, 2008
IRWIN MCKNIGHT & HUGHES
MARCUS A MCKNIGHT III ESQUIRE
WEST POMFRET PROF BLDG
60 WEST POMFRET ST
CARLISLE PA 17013-3222
FEB 1 2 2008
IRWIN & McKNIGH r
LAW OFFICES
Re: DONALD SHANK
CIS #: 410269761
SSN: 204-01-3624
Date of Death: 01/22/2008
Dear Attorney McKnight:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $298,609.46 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 $17,847.76, 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 $280,761.70,
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,
Elizabeth D. James
TPL Program Investigator
717-772-6397
717-772-6553 FAX
Enclosure