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Home My WebLink About03-03-091505607121 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PoBOxzaosol INHERITANCE TAX RETURN 2 1 0 9 0 0 1 1 Hartisbum. PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 6 5 1 2 8 7 6 6 1 2 2 4 2 0 0 8 0 6 1 2 1 9 1 6 Decedent's Last Name Suffx Decedent's First Name MI B L A C K- P L U M M E R A N N A M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 0 1. Odginal Retum ~ 2. Supplemental Return ~ 3. Remainder Return (date of death pdor to 12-13-82) 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 antl 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 Numb R O G E R B I R W I N E S Q U I R E 7 1 7~ 4 9~ 3t~; Firm Name (If Applicable) CA a ~^ `"' REGI ILL33DE ON I:y _, I R W I N & M c K N I G H T P C ' t " ~ t ~~ ~ ? First line of address C'S: 6 0 W E S T P O M F R E T S T R E E T ~,~- - Second line of address ~ y-' w r - r~'~ C ~:~r- G City or Post Office State ZIP Code DATE FILED C A R L I S L E P A 1 7 0 1 3 Correspondent's e-mail address: Under penalties of perjury, I declare Nat I have examined this return, inGuding axompanying schedules and statements, and to the best of my knowledge and belief , it b We, cortect and complete. Dedarallon of preparer other than Ne personal representative Is based on all Information of which preparer has any knowledge. SIG E OF PER ON E ONSI FO ILING R RN jD)ATE ) ) / ADDR S 26 RITNER HIGHWAY CARLISLE PA 17013 SIGNATUR PREPARER OTHER THA~g~~PRESENTATIVE ~{ C -~•--- ~ DATE z 6 U, ADDRE S 60 WEST OMF ET STREET CARLISLE PA 17013 ~_ ~ PLEASE USE ORIGINAL FORM ONLY Side 1 1505607121 1505607121 1505607221 REV-1500 EX Decedent's Social Security Numbe r t7ecedent's Name: ANNA M• BLACK-PLUMMER 1 6 5 1 2 8 7 6 6 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. 7 3 1 6 , 1 6 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous N -Probate Property (Schedule G) ~ Separate Billing Requested ..... .. 7. , 8. Total Gross Assets (total Lines 1-7) ......................... .. 8. 7 3 1 6 , 1 6 9. Funeral Expenses & Atlministrative Costs (Schedule H) .............. .. 9. 6 5 9 8 , 9 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .......... .. 10. 1 5 3 0 3 , 4 0 11. Total Deductions (total Lines 9 & 10) ......................... .. 11. 2 1 9 0 2 , 3 0 12. Net Value of Estate (Line 8 minus Line 11) ....................... .. 12. - 1 4 5 8 6 , 1 4 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. - 1 4 5 8 6 , 1 4 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at fhe spousal tax rate, or transfers under Sec. 9176 (a)(t.2)x.o _ 0. 0 0 ts. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 ~ 0 0 16. 0. D O 17. Amount of Line 14 taxable at sibling rate X .12 ~ 0 ~ 17. ~, ~ ~ 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 0. ~ ~ 19. Tax Due .............................................. .. 19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ ~ p ~~ <Jf~'~ j l~ Side 2 ~~ .L 15O56U7221 1505607221 REV-1500 EX Page 3 Decedent's Complete Address: 20 SOUTH PITT CITY Tax Payments and Credits: 1 Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty 0 00 File Number 21 09 0011 STATE Total Credits (A + 6 +C ) ZIP (1) 0 00 4. If Line 2 is greater than Line 1 +Line 3, enter the difference. This is the OVERPAYMENT.Total Interesf/Penalty (D +E ) Fill in oval on Page 2, 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. (2) 0.00 (3) 0 00 (4) 0 00 (5) 0 00 (SA) B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 0 00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1 Did deced t k en ma e a transfer and: a. retain the use or income of the property transferred; Yes No b. retain the right to designate who shall use the property transferred or its income : ...................... i ... c. reta n 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 " X . Did decedent own an intrust for" or payable upon death bank account or secudty at his or her death? 4 D ^ ^ ... . id 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 p2 P.S. §9116 (a) (1.1) (i)j. 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 [/2 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 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 (O) 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 far the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)j. 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 SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER ANNA M. BLACK-PLUMMER 21 09 0011 Include the proceeds of litlgation and the date the proceeds were received by the estate. ITEM VALUE AT DATE NUMBER DESCRIPTION nG nGCTu CREDIT UNION - 2. (MEMBERS 1ST FEDERAL CREDIT UNION -SAVINGS ACCOUNT 6,612.36 703.80 TOTAL (Also enter on line 5, Recapitulation) I $ (If more space H needed, insert additional sheets of the same size) REV-1511 FCC+(10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ANNA M. BLACK-PLUMMER 21 09 0011 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. EWING BROTHERS FUNERAL HOME 1,139.90 B. ~ ADMINISTRATIVE COSTS: 1. I Personal Representative's Commissions Name of Personal Represenfadve (s) Street Address ZtiS/ KI I NCR HIGHWAY City CARLISLE State PA Zip Year(s) Commission Paid: 2, AttomeyFees IRWIN & McKNIGHT 3. Family Exemption: (If decedents address is not the same as claimant's, attach explanation) Claimant SHIRLEY A. BLACK sveet Address 120 SOUTH PITT STREET City CARLISLE State PA Zip 17013 Relationship of Claimant to Decedent DAUGHTER 4. Probate Fees REGISTER OF WILLS 5. I AccountanCs Fees 6. I Tax Retum Preparefs Fees PATRICIA A. ROSENDALE, CPA 7. ~ REGISTER OF WILLS -FILING FEE TOTAL (Also enter on line 9, Recapitulation) I $ 750.00 750.00 3, 500.00 79.00 350.00 30.00 (It more space is needed, insert additional sheets of the same size) REV-1512 EX + (t 2-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE/ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ANNA M. BLACK-PLUMMER 21 09 0011 Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH OF PUBLIC WELFARE -CIS #850194739 15, 303.40 TOTAL (Also enter on line 10, Recapitulation) I $ more space is needed, insen additional sheets of the same size) REV4513 EX + (9-011) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ANNA M. BLACK-PLUMMFR NUMBER c i ua uu l I NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS pnclude outdght sppoousal distdbutions, and transfers under Sec. 9116 (a) (12)] 1. JOEL L. BLACK Lineal 2657 RITNER HIGHWAY 1/3 REMAINDER CARLISLE, PA 17013 2. RAYMOND S. BLACK Lineal 139 E. SOUTH STREET 1/3 REMAINDER CARLISLE, PA 17013 3. SHIRLEY A. BLACK Lineal 120 S. PITT STREET 1l3 REMAINDER CARLISLE, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 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 $ (~~ niuie space is neeaea, mser[ aoainonai sneers of the same size) s WILL OF ANNA MAE BLACK PLUMMER I, Anna Mae Black Plummer, of Carlisle, Cumberland County, Pennsylvania, declare this to be my last Will and hereby revoke all prior Wills and Codicils. 1. I direct that all my just debts, funeral expenses, gravemarker and administrative expenses shall be paid from my residuary estate as soon as practicable after my death. 2. I direct that all inheritance, estate, transfer, succession and death taxes of any kind whatsoever which may be payable by reason of my death shall be paid out of my residuary estate. 3. I direct that my entire estate be distributed as follows: A. I leave to my daughter, Shirley Ann Black, all my personal items including, but not limited to, my diamonds and jewelry, as welt as any automobile I may own at my death. B. I leave to my daughter, Shirley Ann Black, a life estate in my residence at 120 South Pitt Street, Carlisle, Pennsylvania, for gnd during the term of ~P~~ -~ her natural life or for so Ion as she wishes to /~ ~J ~ ~ reside there as her personal residence. She shall ,~ j ,y~ have the right to any rents or profits of the first S t floor rental unit of said property. The condition of,~.( ~~ this life estate is that Shirley Ann Black shall '' X1,,11 maintain this home as her personal residence, pay ~., all real estate taxes, homeowner's insurance premiums, municipal assessments and maintenance on said property as long as she resides therein. In the event she vacates said property, fails to fulfill the above conditions, or in the event of her death, the remainder interest in said property shall become a part of my residuary estate. LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 77013 C. I devise and bequeath the rest, residue and remainder of my estate, including the above real ,p ,7 .. ~ ;~`~ ~~ ~~ estate to my children, Richard E. Black, Raymond S. Black, Joel L. Black and Shirley A. Black share and share alike. Should any of my children predecease me, their share shall lapse and go into the residuary share. D. Should my daughter, Shirley Ann Black predecease me, any share of my residuary estate to which she would have been otherwise entitled, shall go to my grandson, Steven E. Lowry. 4. I appoint Joel L. Black as Executor of this my last Will. Should Joel L. Black predecease me or cease to act in such capacity, I appoint Shirley Ann Black as my alternate. 5. The Executor of this Will shall have the power to distribute my estate in kind or in cash, or partly in either. I direct that no Executor acting under this Will shall be required to enter bond in any jurisdiction. UW OFFICES OF s~~tv J. xoc~ 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 IN WITNE,~S WHEREOF, I have hereunto set my hand this ~ day of 'r ~~ 2004. .•. Anna Mae Black Plummer The preceding instrument consisting of this and two other pages was on the day and date hereof signed, published and declared by Anna Mae Black Plummer, 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 names as witnesses hereto. a,~ . ~C.t~+~X W TNESS ~~~~~ W NESS LAW OFFICES OF s~rxEN J. xocG 79 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 ACKNOWLEDGMENT State of Pennsylvania LAW OFFICES OF sx~t~ty J. xoc>G 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 County of Cumberland ss I, Anna Mae Black Plummer, the 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 as my free and voluntary act for the purposes therein expressed. Anna Mae Black Plummer Sworn to or affirmed and acknowlefiged befor~%Ime by Anna Mae Black Plummer, the testatrix, this ~ day of _~~~'~GGGGZi 2004. i -``~~ NoTARULREAL STEPHEN J. F1066, NOTARY PUBLIC '' / CARLISLE BORO, CUMBERLAND CO., PA --r~`- iRYDDMMroex,NEXPIRE9 SEPTEMBER b,2o0b Notary Pu AFFIDAVIT State of Pennsylvania ss County of Cumberland We, o and /,,(~. ~ ~~ ~~ ,the witnesses whose names are sig d to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the testatrix sign and execute the instrument as her last Will; that the testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testatrix signed the Will as a witness; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of so ind and under no constraint or ndue influence. Sworn to or affi and subscribed to efore me by witnesses, this ~ day of 20 ~ A ~/ -G G- NOTA~AL~ Notary Public/At n STEPHEN J. H000. NOTARY Pi18Lli CARLISLE BORO, CUMBERLAND CC.. Da MY COMMNiSXNd EXPIRES SEPTE;BER 8, 2005 TaxDB Result Details •Detailed Results for Parce104-21-0320-169. in the 2004 Tax Assessment Database DistrictNo 04 Parcel ID 04-21-03 20-169. MapSuffix , HouseNo 120 Direction S Street PITT STREET Owned BLACK, SHIltLEY ANN C/O PropType R PropDesc LivArea 1510 CurLandVal 18000 CurImpVal 74260 CurTotVa1 92260 CurPrefVal Acreage .03 CIGrnStat TaxEx 1 SaleAmt 1 SaleMo Ol SaleDa 03 SaleCe 20 $aleYr OS DeedBlcPage 00266-04864 YearBlt 1910 HF_File_Date 10/21/2004 HF_Approval_Status A http://taxdb.ccpa.net/details.asp?id=04-21-0320-169.&dbselect=l Page 1 of 1 1/5/2009 St MEMBERS 1'~ ® ~~~` '' ` °'' rsnaxntceson• uMON iRWIIV & MCPHWGH PANS QFFfCES SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Interest Earned 01/01/2008 - 11/30/2008 Name of Joint Owner CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Interest Earned 01/01/2008 - 11/30/2008 Name of Joint Owner SAFE DEPOSIT BOX: Estate of: ANNA MAE BLACK PLUMMER Date of Death: 12/24/2008 Social Security Number: 165-12-8766 223895-00 11/07/2002 $8,612.36 $4.17 $6,616.53 $95.10 None 223895-11 11/07/2002 $703.80 $.00 $703.80 $.00 None Yes BERS 1sT FEDERAL C~g~DIT UNION Danielle A. Kline Insurance Services Specialist February 19, 2009 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 www.memberslst.org 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 February 2, 2009 I RWIN & MCKNIGHT ROGER B IRWIN ESQUIRE WEST POMFRET PROFESSIONAL BUILDING 60 WEST POMFRET STREET CARLISLE PA 17013 ~g4'~il'r ~~l',~,.]~`~61 Iy,9 rb~ Ps ~; ~ t'P Il;tyc. ~L7 'l/~ ~} a UU JI fRWlfvs fvlcf(iUIGHt _AV11 OfPoCE Re: ANNA PLUMMER CIS #: 850199739 SSN: 165-12-8766 Date of Death: 12/24/2008 Dear Attorney Irwin: Please be advised that the Department of Public Welfare maintains a claim in the amount of $15,303.40 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 99, 62 P.S. 1912, 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 $15,303.40, 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 $.00, 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, i£ available. Sincerely, r ~, Elizabeth M. Wilson TPL Program Investigator 717-214-1868 717-772-6553 FAX Enclosure I COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BO% 8466 HARRISBURG PA 11105-8466 January 30, 2009 STATEMENT OF CLAIM SUMMARY ~~ `_: Estate of PLUMMER, ANNA IPt' ~~" ~ ~- 860 194 739 January 30, 2009 STATEMENT OF CLAIM NAML~:' PLUMMER,ANNA ~Q,,, ,';; c' 850 194 739 JORCARE HEALTH SEI WALNUT BOTTOM RD PA 17075 09101108 - 09130108 DIAGNOSIS 1 : 8058 DIAGNOSIS 2 : 80700 PROC CODE : 000000 10101108 - 10131108 DIAGNOSIS 1 : 6056 DIAGNOSIS 2 : 60700 PROC CODE : 000000 77101108 - 11/30/08 DIAGNOSIS 1 : 8058 DIAGNOSIS 2 : 80700 PROC CODE : 000000 12101108 - 12124108 DIAGNOSIS 1 : 8058 DIAGNOSIS 2 : 80700 PROC CODE : 000000 11117108 20082974022020001 VERTEBRAL FX NOS-CLOSED FRACTURE RIB NOS-CLOSED 12101108 20083134042660001 VERTEBRAL FX NOS-CLOSED FRACTURE RIB NOS-CLOSED 12129/08 20083384253570001 VERTEBRAL FX NOS-CLOSED FRACTURE RIB NOS-CLOSED 01126109 20090014042790001 VERTEBRAL FX NOS-CLOSED FRACTURE RIB NOS-CLOSED 20082974022020001 20083134042660001 20083384253570001 20090014042790001 4,958.10 5,123.37 4,978.20 3,816.62 4,073.89 4,239.25 4,073.89 2,916.37 PROUIq~ft Si.tB TOTAL MANORCARE HEALTH SERVICES-CARLISLE 18,876.29 15,303.40 '. 03 102063521 0001