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Home My WebLink About06-20-0815056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 ~ / Harrisburg, PA 17128-0601 RESIDENT DECEDENT ` G o~4~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Decedent's Last Name Suffix Decedent's First Name MI (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 ,~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Firm Name (If Applicable) ~u~~~ ~ ,D,~9-~! First line of address a~~ 1-,~~sT ~i Second line of address ,..5 ~ l ~~ ~ O,~ City or Post Office ~~~ ~~~ L=CS State ZIP Code ~° } 1 ~'~~ REGIS'€E~2 OF WILLS ~ ONLY ~~ . ~ ~~ ~, <_ i. ~ ~~e_ -' `T, rv _~~ ~, >.. ~~-} ~ ~IE ,t _ _~ rL `~7DATE FILED CYO Correspondent's a-mail address: 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 I:rue, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG~AIJ,IRE OF PERSON RESPONSIBLE FOR FILING RETURN DATE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 J 15056052048 REV-1500 EX Decedent's Social Security~Nuimber Decedent's Name: ~ ~ j~~/ `~~~ 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. ~ ~~~ • `~j 6. Jointly Owned Property (Schedule F) p Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ~ ~~ ~~ 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. 9 ~ 9 ~. 1 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. ~' ~Q l 1 f .Z, 11. Total Deductions (total Lines 9 ~ 10) ................................... 11. /~ ~ ~' ~ Q ~j .~j~~ 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. --~' .--- . 13. Charitable and Governmental Bequests/Sec 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, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. • 18. Amount of Line 14 taxable /~ at collateral rate X .15 ~lJ -• 18• • 19. TAX DUE .................................................... .....19. ----a 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVER PAYMENT p C~ ~~Z ~~~ ~~~ ~ ~~ 15056052048 Side 2 15056052048 J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME STREET ADDRIcSS i CITY ~~~~~ ~ STATE /~~ ,ZIP / ~~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount _- _ Total Credits (A + B + C) (2) 3. Interest/Pe~nalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 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 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT (1) ~- Q ~- - G --- ~- (~ .--_ - a -- ~ --~ 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 :................................................................................... ....... ^ 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? ....................................................................................................... ....... ^ 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ....... ....... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................................................................................................. ....... ^ 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)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. I, ORPHA E. ADAMS, •of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. '3 I. I,direct that my funeral shall be conducted by'the Ewing Brothers Funeral Home of Carlisle, and that I' be buried in similar fashion to~my husband, Luther R. Adams. II. I give and bequeath unto my nieces and nephew, MARTHA GRIFFIE, DIANE PUTT, LINDA WEVODAU.,,BEVEItLY LOHNES and GRANT ADAMS, such articles as they shall amicably agree and select from the contends of my home. III. I give and bequeath the sum of One Thousand ($1,000) Dollars to my half-sister, MRS. LURA JACKSON of Lake Station, Indiana. If she shall predecease me, the said sum shall pass to her surviving children, per capita. IV. I devise and bequeath the residue of my estate of every nature and wherever situate to my niece, MARTHA L. GRIFFIE. V. I make no provisions for any of my other relatives, not for lack•of affection but because of absence of contact. 1 VI. I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. VII. I appoint FARMERS TRUST COMPANY of Carlisle, Pennsylvania, or its successor in business, Executor of this my last will and testament. VIII. I direct that my executor shall not be required to give bond for the faithful performance of its duties in any jurisdiction. • IN WITNESS WHEREOF, I have hereunto set my hand .this ~~ ~O day of l~'Z-~-L y 1993. • • • • ORPHA E. ADAMS . , The preceding instYument, consisting of this and one other typewritten page identified by the signature of the testatrix, ORPHA E. ADAMS, was on the day and date thereof signed, published and declared by ORPHA E. ADAMS, the testatrix therein named, as and for her•last will, in the presence of us, who, at her . request, in her presence, and in the presence of each other have subscribed our n s as witnesses hereto. .• -tr~-s~ c.c~._ Q ~-~ ~,~~-s, ~~ ~ ~-3 zy ,a ~- . ~ i .~,~, ~.. a S X03 ~ ~~.~ ~ ~ ~ ~, ~ ~ ~~~~ ;; - ,.~ . . i ,.. ~I~ ~JI~~J ~J~`, ~: ~ z REKf50! IX • (1i7( COMIAON4VEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF~ ~~ S~ ~~~ / f`j ~ FILE~~ / _O ~~~ Indude the proceeds of I'diga6on 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ~~~~ ~du~~~ ~ ~~~ .. ~~3,0~ z , I ~ d~j o~ 7-13/fo/K ~ ~. ~ mac- ~jo~v r- ~/ ~ /~~S'/~/G ~ Rc-~~~ ~ ~ ~ ~~~ ~~G~/ /, ~ 2~. o z ' TOTAL (Also enter on line 5, Recapitulation) I S ~~ ~~ Z, (If more space is needed, insert additional sheets of the same size) Ewing Brothers Funeral Home, Inc. 630 South Hanover Street Carlisle, PA 17013- (717)243-2421 April 22, 2006 Martha L. Griffie 550 Bernheisel Bridge Rd. Carlisle, PA 17013 The Funeral Service for Orpha E. Adams We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in,regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Services of Funeral Director/Staff , $3695.00 , FUNERAL HOME SERVICE CHARGES $3695.00 SELECTED MERCHANDISE: Diplomat 18G steel Gask. Cask, $2495.00 #5 Regular OBC Sealed , $995.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $7185.00 Cash Advances Opening Grave, , $750.00 Clergy/Mass Offering, $75.00 Certified Copies of the Death Certificate , $24.00 Flowers , $159.00 Sentinel C1bit $93.20 Dress w/Underclothing $135.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES . $1236.20 Total Total Cost $8421.20 SUB-TOTAL $8421.20 INITIAL PAYMENT /DISCOUNT (CREDITS 9792.13 ' TO"CAL AMOUN"C DUE $-1370.93 The unpaid balance over 4S days is subjected to a 1.00 % service charge per month - 12.0000 % per annum. ~~~~ ~rP~<~ ~ ~ ~G - dY ~~d ~ 9 ~ i y/j~l db ~,.~~,M-~ ti~ ~~ ~ ~~ ~~ ~~~,~~ _~ ~~a~, 0'02 ~~-- ~ ~o ,s-~~ o~ ~x~°~r ~~~~~ 5 °' 36 N~ ~ ~ ~'~' ~ ~ ~ .gyp W tiM .Y g ~ 6'- o ° N m ~. ~* ~. _~ ~, * N ~ ~ c.L1 ~, ~ ' k ~ ~ ~ ~ # J ,~ 5 * ~ .a. ~' L{~ at 9F +~!- N ~ 9t ~ ~ ' i4 iF ,Yr Xr ~ ~ • ~ ik ~ O ~ `'' ~ d ~.. ,~ rf1 V ~ N .. z ~ :+ O ,~ ~ G '~ Q~ ~ N ~ Q ~' ~ c.0 " i 0. ~ ~$+` ~7` Z ~ W Z~~~= a '?. ° ~~ N~ ~ ~' ~ ~ o r x Z `~ ~- ~ ~o ~ o ~ w ~ a ~ . ~~ a ~ . o.o REV-1511 EX+ (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE CASTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: _ ~. S ~iINL= 2/~ ~- .Z, G~/.zG/sue ~~ ~o~~~ L S'C%2-vigil /~O. ~0 e. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions ~1 / - Name of Personal Representative(s) _ ~ /~~ T~~i-~ L , ~/'~//CjC/C Street Address ~~~~ ~~ ~____~~~ City ~~?G~~'CC- State ~~Zip ~~~_~ Year(s) Commission Paid: _ __________ _____! 2. Attorney Fees., ~~/~~~ !C ~~ /y~CL!. s ~/; 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) ~~ ~ ~ W Claimant w ~/ ~!~ ~ ___ __ ___ Street Address City State Zip _ Relationship of Claimant to Decedent / / , L 4. Probate Fees /-~~G~~S~`C~~ ~'L vv ~ L- L s ~J ~ ~O 5. Accountant's Fees r 6. Tax Return Preparer's Fees ~'. ~~~'~ Vim- ~ / ~ ~, o~ ' TOTAL (Also enter on line 9, Recapitulation) I $ 9~ ~~-~ ` (If more space is needed, insert additional sheets of the same size) ~. ~3 ~J tl) r-. , ~ = Q N al ~ '" ~.. m~~~ a ~~U ~~~ ~~o ~ r Q m~ •~ ~ N r ... ~ ~ ~ Q ~ ~' ~ ~ ~m~ z ~ ~ ~ o ~~~ ~ ~.~ ~~~ ~ N~ ~. ~ ac ~ ~ ~. ~ m m RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: Cumberland County - Register Of Wills Receipt Time: One Courthouse S uare Receipt No.: Carlisle, PA 1713 ADAMS ORPHA E Estate File No.: Paid By Remarks: 2006-00444 MGIFFIE MARTHA Fee,/Tax Description PET LTRS ADM OTHER WILL RENUNCIATION JCP FEE AUTOMATION FEE Check# 9696 Total Received......... 5/23/2006 11:01:34 1044460 Receipt Distribution ----- -------- -------- --- Payment Amount' Payee Name 20.00 CUMBERLAND COUNTY GENERAL FUN 15.00 CUMBERLAND COUNTY GENERAL FUN 5.00 CUMBERLAND COUNTY GENERAL FUN 10.00 BUREAU OF RECEIPTS & CNTR M.D 5.00 CUMBERLAND COUNTY GENERAL FUN ---------------- 55.00 55.00 REV-1512 EX+, (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIJLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & L1ENS ESTATE OF ~~~,/~~~~~~ O~'~, r.,~~ ~' - ~`~~FILE N~B~ ~~ Report debts incurred by the decederrt~prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ~2 ~Z ~~ (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 PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 August 8, 2006 HUMER & DANIELS LAW OFFICES WILLIAM S DANIELS ESQUIRE FARMERS TRUST BLDG STE 205 ONE W HIGH ST CARLISLE PA 17013 Dear Attorney Daniels: Re: ORPHA ADAMS CIS #: 540134047 SSN:, 311-48-5086 Date of Death: 02/17/2006 Please be advised that the Department of Public Welfare maintains a claim in the amount of $440,114.24 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 medi xpense, namely $27,427.92, was incurr d during the last six month of t decedent's life; therefore, it is a Class 3 - claim pursuant to SeQtion 3392 the Decedents, Estates', and Fiducia ies Code, 20 Pa. C.S.A. 3392(3 Th a nce of the claim, namely $412,68 , is to be entered as a priority lass laim against the estate. Please acknowledge receip is 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, ~• Angela S. Bonner Claims Investigation Agent 717-705-9701 717-705-8150 FAX Enclosure REV 1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES E5TATE OF _, FILE NUMBER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY - - RELATIONSHIP TO DECEDENT Do Not Llst Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) 1. ENTER DOLLAR AMQUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS ARPROPRIATE, ON REV-1500 COVER SHEET lI 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 NQN-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) ADDRESSES OF BENEFICTARJF.S OR PHA E. ADAMS ESTATE ,: ,,,, . ~; ~ Mat~,~,: c~~ ::,~. - ~ tii ~~' ~ ~~ ,~ ~2csr Road~ 550 Berheisel-Bridge ` ' ~~~ rs' ~ T~'" ~ ~ Carlisle, PA ~ 17013 .. .. ~ ~ gdmuustratnx ' :y Beverly~J. Lohnes ~ • ~ ~,'.. /1//~ GL' ~/~~-~^3' !n''~'~s 562 Magaro Rd. ` Eaola,'PA 17025 4 i :, 1 .. Linda J: W evodau • ~ /f/l ~ G-~ ~~''~S ' . 559 Magaro Road ~ • - • Enola; PA .17025. Gaant R Adams " _ ~ ~~~~ ~~ G. ~. ^ / ~= "''1 560 Magaro Road Enola, PA 17025 ' . Diane L. Putt . • Valley Road ~/~ CC ~~ rS . / ~~`-S Enola, PA 17025 Roger Jackson ~' ~~~~~ ~ ~ ~ o a p . ~ Ave. 3501 E. 34 Lake Station, IN 46405 ~ ~ ;• •