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Home My WebLink About09-19-0815056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year file Number Poeoxzsosol INHERITANCE TAX RETURN Hanisburg, PA 17128-0601 ~ RESIDENT DECEDENT 21 06 0052 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 105-44-7841 ' 10/16/2004 12/12/1953 Decedent's Last Name Suffix Decedent's First Name MI BROTHERS Jr. ', Clark W (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI n/a 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 2. Supplemental Return 3. Remainder Return (date of death prior to t2-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) _ 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) •: 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death ::: 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 TO: Name Daytime Telephone Number Daryl Christopher (717) 238-6791 Flrm Name (If AppllCable) REGISTER OF WILLS USE ONLY Angino & Rovner, P.C. ~ ~ ,--- ~ , _, - -, First line of address , , f 4503 North Front Street T' ~<? ~ ~ ' ` ~ -= n-; ._ it Second tine of address ., '° '' ° - r ' ~ t,p ,; ' `I __, ~ ? ...~ Brothers Estate ~'~ = ~ -c~ ~- ~ City or Post Office ~i~u. D:_. ~ ED State ZIP Code _ _ - ~ ~ _ r __ - ~ ~ ~ _ ,. Harrisburg PA 17110-1799 ~' Iv -- -~ _~'~ --T-~ cv 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 true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI TURE OF PERSONftESPpNSIBLE FOR FI TURN DATE ADDRESS - - __ -_ _ __ _ _ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS __ _ __ PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Decedent's Social Security Number Clark W BROTHERS 105-44-7841 Decedent's Name 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. 72,625.52 6. Jointly Owned Property (Schedule F) : "' Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) :Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. ' 72,625.52 9. Funeral Expenses 8 Administrative Costs (Schedule H) ................... .. 9. 4,989.19 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) .............. .. 10. 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. ', 4,989.19 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ', 13. Charitable and.Govemmental BequestslSec 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. 67,636.33 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 0 0.00 15. ' 0.00 16. Amount of Line 14 taxable at lineal rate X .045 67,636.33 16. 3,043.63 17. Amount of Line 14 taxable at sibling rate X .12 17, 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ....................................................... ..19. 3,043.63 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 File Number _ Decedent's Complete Address: 21 06 0052 DECEDENTS NAME DECEDENT'S SOCIAL SECURITY NUMBER Clark W BROTHERS 105-44-7841 STREET ADDRESS Seven West Locust Street CITY STATE ZIP Enola PA 17025 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 3,043.63 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount --- Total Credits (A+ B + C) (2) 0.00 3. InteresUPenalty if applicable D. Interest _ _ __ _ _ E. Penalty Total InterestlPenalty (D + E) (3) 0.00 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) 3,043.63 A. Enter the interest on the tax due. (5A) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 3,043.63 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 :.......................................................................................... ^ ^x 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 "in trust 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? ........................................................................................................................ ^ ^x 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. REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDVLE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER BROTHERS Clark William Jr. 21-06-0052 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. (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCNEDVLE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER BROTHERS Clark William Jr. 21-06-0052 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~' Standard Funeral Expenses 4,935.19 Lombardo Funeral Home 102 Linwood Avenue Buffalo, NY 14209 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) .Street Address City .State Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Retum Preparer's Fees ~. Inheritance Tax Filing Fee Zip Zip 39.00 15.00 TOTAL (Also enter on line 9, Recapitulation) $ 4,989.19 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-0O) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BROTHERS Clark William Jr. 21-06-0052 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE t TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 • Clark William Brothers, III Son 72,625.52 660 Front Street Enola, PA 17025 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I ~ 72,625.52 (If more space is needed, insert additional sheets of the same size) BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION Po Box 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE WEB ADDRESS www.state.Da.us August 14, 2008 Daryl E. Christopher 4503 N. Front St. Harrisburg, PA 17110 Re: Estate of Clark Brothers, Jr. File Number: 2106-0052 Court Number: CCP Perry County No. 2006-158 Dear Mr. Christopher: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the decedent died as a result of a construction accident. Decedent is survived by his adult son. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the net proceeds of this action, $108,938.27 to the wrongful death claim and $72,625.52 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa. C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death/survival action. Since ely, ~~~~~~~ Holly A. McClintock Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes PHONE: 717-787-1794 FAx' 717-783-3467 EMAIL: hmcclintocC~state.oa.us ~NGI~Tb & ROVNER, P.C. 4503 NORTH FRON'1 HARRISBURG, PA 1 717/2386791 FAX 7 17/23 856 10 wW W.ANGINO-ROVNER.COM EMAIL: DCHRISTOPHER@ANGINO-ROVNER.COM RICHARD C. ANGINO MICHAEL E. KOSUC NEIL J. ROVNER RICHARD A. SADLOCK JOSEPH M. MELILLO LISA M. B. WOODBURN DAVID L. LUTZ DARYL E. CHRISTOPHER CLARK WILLIAM BROTHERS, III, Personal Representative of the- Estate of Clark William Brothers, Jr., Deceased, v. PETER BOLOGNA DISTRIBUTION SHEET TOTAL AMOUNT OF SETTLEMENT $285,000.00 DEDUCTIONS: Attorney's Fee (35%) $ 99,750.00 Balance $185,250.00 Reimbursement of expenses paid by attorneys to others for records, experts, etc. $ 3,686.21 Balance $181,563.79 Escrow for future expenses $ 8,000.00 Balance $173,563.79 Less payment for Inheritance Tax & Filing Fee ($3043.63+$15.00) $ 3,058.63 BALANCE TO CLIENT PLUS ANY INTEREST EARNED WHILE HELD IN BANK ESCROW $170,505.16 DIVISION OF DISTRIBUTION Wrongful Death $108,938.27 less escrow $ 8,000.00 $100,938.27 Survival Action $ 72,625.52 less [nh Tax & Filing Fee $ 3,058.63 $ 69,566.89 FINAL DIVISION: Attorney's Fee $ 99,750.00 Client's Balance $]70,505.16 Reimbursement of Expenses $ 3,686.21 Escrow $ 8,000.00 Register of Wills, Cumberland County $ 15.00 Register of Wills, Agent $ 3,043.63 This settlement/verdict may be taxable. We recommend that you consult your accountant or tax attorney for the calculation of your tax liability and any deductions to which you may be entitled. 391824 his iti tit certify that the 1;]l'Ol'117:1U011 here hivl;r i+: a:n'rcctl)• t•lii~i~,:cl Il•~~In un ltrijZtt)at CcrttfiCa(c ltl cic;tt'h duly fill:cl with (11C a~ Local kl;risu•~r. "I'hc nril~inai ccrlific;tlc. will hr 'trw:n•lllai I~) 1!I~. Sl.:ur '~%i(al l~ccln•~I, UI•licr. far llcrnt:mcnl tiling,. WARNING: I: is illegal to duplica~tc tEil4: copy by photostat or photograph. .~ I~uc. fl,r this c~ltiliC:uta, ;~~.0(1 •,~~~•;;,:•-. :.. f ,.,~~,: ~.. '•%~. .~ cal kl:(:istC:u• ;f~ 1 Hood Trtuma ~fM ~ rsw ~ W~~OIO~•flw , P 10585541 NCI. .,. Clark Wllllam Oro1hOr9. Jr. t~w..w.ti Oclobor 74, 2004 1raU iN-~rr~tr^ V• • 4,t,. . ~ ~ vurno N..r p „r,,,r ~ as 16, 200/ ^~ t0: ~ rrawN rr. ~~~- "•"~+~ ~ ~^/rr.AraIICWIlIIruUbrti • ^nMOrN~Nt.rw+~YKwr,r~wr.wwr 7r Nr1~1I~/~,~~, ~r1~Iwrw~~Al~ly ~lr+~~, ~~rr~t+r~w~s.rur..Ai ~, 'rrOMOI~MO~ttrl~~Il~~rNt~Mr1Yw(r•I ~MpY.r.~Ir11 Arr.rr,q~••/•~.~rww..rrwr~r, w,rr/~M~ Iw~•PlMrrrn~~•NM~......... ^ ................ '~0!y1LlQAll~ltJNq _ IW1r t~ riwrr~(.~ I~rrw•lYr^ t ow.w.~u ,. Potty J. 6orbe/ 1271 Stxtllt :IItA 9tr~el • I.IfI]I J u~gl.~.•11n. iAl COMMONWEA(, H OF PENN$YLWa,NIA • OEPARTMC•NT OF HCA~TH • VITAL RECORDS -~lNIMINt CERTIFICATE OF DEATH IN ~tt~,u, (Coronet lM.-GtINQ cruet ..~....~.J. __ •r•r•a•.~.r11M Lombardo Funeral Lorne 102 Linwood Areere S851Via8an Fsfb Hlvd. 1614 M~iie Street 3060 Abbott RoRd Amherst, N.Y.142?+6 Snyder NY 14228 Qre6srd Hark, TIY 14127 B~Aa~~ ~ g3?-7100 839-1133 823-48t2 FUNERAL STATEMENT Funeral Expenses For: Clark William Brothers Jr. SUMMARY OF EXPEN Total of Funeral Home Charges $2599'00 Buffalo News $137.44 Lakeside Cemetery $965.00 Clergy $200.00 Death Certificate $10.00 Airlines $318.75 National Mortuary Shi $705.00 Total Balance Due $4935.19 if there are any questions or concerns that remain unanswered, please call me. Sincerely, Rose Dibble Office Manager -...T,. ~~ llnifed We Siand