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HomeMy WebLinkAbout10-29-08 15056041114 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 290801 O~~ Harrisburc PA 1~12e-oeol RESIDENT DECEDENT ,~ / )~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 180-26-7102 08312008 08061922 Decedent's Last Name Suffix' Decedent's First Name MI BURGER VICTORIA L (If Applicable) Enter Surviving Spouse'a Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number © 1. Ongmal Retum 0 2. Supplemental Retum 0 3. Remainder Retum (date of death 4. Limited Estate 4a. future Interest Com romise (date of P Prior to 12-13-92) ~ 5. Federal Estate Tax Retum Required death after 12-12-82) © 9. Decedent Died Testate (Attach Copy of Will) ~ 7. Decedent Maintained a Living Trust 0 9. Total Number of Safe Depos@ Boxes (Attach Copy of Trust) Q 9. Litigation Proceeds Received ~ 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. O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX IN Name FORMATION SHOULD BE DIRECTED TO: Daytime Telephone Number ROBERT G. FREY 717-243 ~ 8 Finn Name (If Applicable) - ~ ~' - - , REGISTER G LLS US LY f FREY & TILEY ~=~ -I ,_ , ._ ~; First tine of address --. rr, N - i ~` -` 5 SOUTH HANOVER STREET -~ _ -- `-~~`~~ `~ ''~~-'' Second line of address `~ ..: ` -~ _; - -- ~ ~;~ --r W - - i a i ~.' ~ '~ ~._. City or Post Office State ZIP Code DATE FILED CARLISLE PA 17013 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Correspondent's a-mail address: RFREY@ FREYT ILEY . COM nder penalties o perjury, I declare that I have examined this return, indudmg accompanying s u es and statements, and to a best o my knowl a an beh , it b true, correct end complete. Dedaretlon of preparer other than the personal representative is based on all information of which preparer has anv knowladae. ADDRESS 1690 SIGNATUF ADDRESS 5 SOUTH HANOVER STREET DATE 20/29/08 ARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 15056041114 RS GAP ROAD, CARLISLE, PA 17013 DATE 10/29/08 15056041114 ~,~, 15056D42115 REV-1500 EX Decedent's Social Security Number Decedent's Name: VICTORIA L BURGER 180-26-7102 RECAPITULATION 1. Real estate (Schedule A) ........................................... 1. NONE 2. Stocks and Bonds (Schedule B) ...................................... 2. NONE 3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C) ..... 3. NONE 4. Mortgages i3< Notes Receivable (Schedule D) ............................ 4. NONE 5. Cash, Bank Deposits i~ Miscellaneous Personal Property (Schedule E) ........ 5. 6 5 2 2 . 0 0 6. Jointly Owned Property (Schedule F) OSeparate Billing Requested ........ 6. NONE 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested ........ 7 NONE 8. Total Gross Assets (total Lines 1-7) .................................. 8. 6 5 2 2 . 0 0 9. Funeral Expenses & Administrative Costs (Schedule H) .................... 9. 3 2 8 5 9 . 0 0 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............... 10. 3 8131.0 0 11. Total Deductions (total Lines 9 & 10) ................................. 11. 7 0 9 9 0 . 0 0 12. Net Value of Estate (Line 8 minus Line 11) ............................. 12. - 6 4 4 6 8 . 0 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ....................... 1g, 0 . 0 0 14. Net Value Subiect to Tax (Line 12 minus Line 13) 14 6 4 4 6 8 0 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 1 g, Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .0 4 5 18. 0.0 0 17. Amount of Line 14 taxable at sibling rate X • 12 17. 0 0 0 18. Amount of Line 14 taxable . at collateral rate X . 15 1 e. 0.0 0 19. TAX DUE .......................................................19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ Side 2 15056D42115 15D56D42115 ,~„~ REV-1500 EX Page 3 180-26-7102 Decedent's Complete Address: Flla Number 21-08-927 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER ICTORIA L BURGER 180-26-7102 STREET ADDRESS - ROAD .CITY Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) Total InterestlPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FIII In oval on Page 2, Llne 20 to request a refund. (q) 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. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (gg) (1) (5) Make Check Payable to: REGISTER OF WILLS, AGENT 1 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOC~~~= 1. Did decedent make a transfer and`. Yes No a. retain the use or income of the property transferred : ....................................... ~ a b. retain the right to designate who shall use the property transferred or its income : ................ c. retain a reversionary interest; or ...................................................... ~ ^X 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" ar payable upon death bank account or security at his or her death? .. ~ QX 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 RE'~'?RN. 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, theaax rate imposed on the net value of transfers to or for the use of the surviving spou~w is= zero (0) percent [72 P.S. §9116 (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.s#ilLapplicable.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,.whetherb)rblood-or.adaption. STATE I ZIP z~~ REV-1508 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER VICTORIA L BURGER 21-08-927 Include the proceeds of litigation and the date the proceeds were received by the estates ~~~.. wavc ~~ ~ ~ccucu, n i~oi i auaiilOnal SrIeeLS OT [r1G' S8rT1@ SIZ2} REV-1511 EX + (10-08) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER VICTORIA L BURGER 21-08-927 Debts of decedent must be re orted on Schedule I. IT 11A A• FUNERAL EXPENSES: 1. Hoffman Roth 43 B• ADMINISTRATIVE COSTS: 1 • Personal Representative's Commissions Name of Personal Representative(s) Lofs Wickard street Address 1690 Waggoners Gap Road city Carlisle state PA zip 17013 Year(s) Commission Paid: 2008 2. 3. 4. 5. 6. 7. Attorney Fees Family Exemption: (fl decedent's address is not the same as GaimanYs, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparel's Fees Pa. Dept. of Welfare: Medical expenses within the last 6 months TOTAL (Also enter on fine 9 R~ (If more space is needed, insert additional sheets of the same size) Zip S 1,500 1,500 109 29, 707 REV-1512 EX+(12-03) SCHEDULEI COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, 8 LIENS ESTATE OF VICTORIA L BURGER FILE NUMBER 21-08-927 Repoli debts Incurred by the decadent prior m daprti Wtii~ti ro~,~i„ea ,,.....~a __ _~.~_ ~_._ _. ,_ _. .. z1~ REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER acrc NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS [inGude outright spousal disVlbutions, and transfers under Sec. 9118 (a) (1.2)] 1 Lois Wickard 2 Sherry Sutherland 3 Doris Sanno RELATIONSHIP TO DECEDENT Do Not List Trustaaf:l niece AMOUNT OR SHARE OF ESTATE lapsed ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 AS APPROPRIATE ONIREV 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 1 Newburg Church of the Brethren 2 American Cancer Society 3 Heart Association 4. Arthritis Association 5. Animal Protection Institute of America lapseed TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET I (if more space is needed, Insert additional sheets of the same size) s 217 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE) BENEFICIARIES 9ER NAME AND ADDRESS OF PERSON S) RECENING PROPERTY ~Do Not Llat TDrustae(s) T I. TAXABLE DISTRIBUTIONS (InGude outright spousal distributions, and transfers under Sec. 9118 (a) (1.2)j FILE NUMBER AMOUNT OR SHARE OF ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 AS APPROPRIATE ONIREV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE Cystic Fibrosis Foundation B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 6 United Methodist Church of Mt. Holly Springs 7 Humane Society of the United States 8 In Defense of Animals 9. International Fund for Animal Welfare TOTAL OF PART 11-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) lapsed lapsed lapsed 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 September 17, 2008 FREY & TILEY ROBERT G FREY ESQUIRE 5 SOUTH HANOVER STREET CARLISLE PA 17013 Dear Attorney Frey: Re: VICTORIA BURGER CIS #: 140154096 SSN: 180-26-7102 Date of Death: 08/31/2008 Please be advised that the Department of Public Welfare maintains a claim in the amount of $67,838.26 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 $29,707.14, 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 $38,131.12, 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 assessmeat, and a current appraisal, if available.. Sincerely, Enclosure ~: ~Q~.~ Judy E. Deaven Claims Investigation Agent 717-214-1284 717-~~,=,:,~ FAX