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Home My WebLink About05-08-0915056051047 REV-1500 EX (OS-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes Cnunty Code Year File Number Poeox2sosol INHERITANCE TAX RETURN Harrisburg, PA 17126-OS01 RESIDENT DECEDENT ~ ~ ~% ~ ~ ~ ~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Decedent's Last Name Suffix De~_r~fents Firsr Name MI ff~f- rQTZ~L~ ~ r~~ L [.,,, (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) ~ s. 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 TO: Name Daytime Telephone Number Firm Name (If Applicable) REGISTER OF WILLS USE ONLY /f LIME /Z ~ ~~~,1 ~`~S First line of address ..~ ~IlL- sT ~~ C/~ ~t ., Second line of address i"~ c-; ,. City or Post Office State ZIP Code - '..T' t ~~RL ~ s LC- ~' ~ ate _ - ~ ; ~ ~ ... - _,_ Correspondent's a-mail address: ~ ~' - , Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to thd'best of my knoQl9dge aritl'tiefief;~ it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has ab~T'knowledge. S~NATU~RErO~F PERSON RE O SIBLE FOR FILIN RET~ DATE ADDRESS ~ r SIi~ F~E ®RER OTHER SERVE _ ~ y TE/~ ~~ s ADDRESS ~ PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 J ],5056052048 REV-1500 EX Deceden t' s Social Security N umber / ~+ ~-^ Decedent's Name: ` ~~~T~ L: L L ~ L-• r~~ L- ~ ~ / L , / ~ ~ ~/ ~'S- ~ ` 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. ~ l ~~/.._~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ~ ~ ~~..1 9. Funeral Expenses & Administrative Costs (Schedule H) ................. .... 9. f 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ .... 10. ~ ~~v . a 11. Total Deductions (total Lines 9 & 10) ............................... .... 11. ~ / ~G, 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 13j .................... .... 14. TA}: 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 1 5. 16. Amount of Line 14 taxable at lineal rate X .0 ~S ~ 16. ~~ / `, .~ 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' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 15056052048 15056052048 RE'/-1500 EX Page 3 Decedent's Complete Address: File Number STREET ADDRESS CITY c ~ ~ LesG.C STATE ~~ ZI~ ~f Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty (1) , Total Credits (A + B + C) (2) Total Interest/Penalty (D + E ) 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. 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. (3) (~) (5) (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 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 transferretl :.................................................................................... ...... ^ ~C 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. Ditl 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? .................................................................................................................. ...... ^ 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 df;ath 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. §911E~ (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 irnposed 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 irnposed 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 irrposed 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. ~~st ~i1I ttrc~ (~SQ~~ttm~nt I, ETHEL L. HARTZELL, of of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. I. I devise and bequeath all of my estate of every nature and wherever situate in equal shares to such of my children, DONNA H. STRAUSSER and REVENDA ANN ALEXANDER, as survive me by thirty days. II. Should my daughter, DONNA H. ST~tAUSSER, or my daughter, REVENDA ANN ALEXANDER, predecease me or die on or before the thirtieth day following my death, I devise and bequeath the share of such child to her issue per stirpes living on the thirty-first day following my death; and should either of my said adult children leave no such issue living on the thirty- first day following my death, I devise and bequeath the share of such child to my other child or to her issue per stirpes living on the thirty-first day following my death. III. I appoint my grandson, RIRR D. SWEGER, guardian of any property which passes either under this will or otherwise to a minor and with respect to whom I am authorized to appoint a guardian and have not otherwise specifically done so, provided that this appointment of a guardian shall not supersede the right of any fiduciary in its discretion to distribute a share where ~"~ }~ ~, possible to the minor or to another for the minor's benefit. Such guardian shall have the power to use principal as well as income from time to time for the minor's support and education (including college education, both graduate and undergraduate) without regard to his or her parent's ability to provide for such support and education, or to make payment for these purposes, without further responsibility, to the minor or to the minor's parent or to any person taking care of the minor. IV. 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. V. I appoint my daughters, DONNA H. STRAUSSER and REVENDA ANN ALEXANDER, co-executrices, or the survivor of them, executrix, of this my last will. VII. I direct that my executrices and guardian shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand this ~~/day of~~~„~,~„, 1991. ETHEL L. HARTZ L The preceding instrument, consisting of this and two other typewritten pages identified by the signature of the testatrix, ETHEL L. HARTZELL, was on the day and date thereof signed, published and declared by ETHEL L. HARTZELL, 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 subsc ed our names as witnesses hereto. ~ ` ~. v' mil/ ~j.t r,t ~wti l o ~ ~ -a'~u~.-.. ( ,ilia ~~ c~' J o ~~ /~~s~~ Y REV-1508E%~ (1-971 SCHEDULE E COMINONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & M~$C. INHERITANCE TAX RETURN PERSONAL PROPERTY DCCInFNT nFCFf1FNT ESTATE OF l ~~/ 1 ~~ !~- ~ ~ / ~ ~`~L.. ~ ~ • ,~~ ....? •/ ~ _ ~~ G a Include the proceeds of litigation 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 ,. /,~ ~-r--,bra-.~« ~ ~~ ~ 2.3y~og Zy ~~z~.~ ~~'~" u N D ~S' , r~=~~/mss' ~J~j ~''8-~/T' v~~. ~G ~ ~j 49t/ liL~j'/ ~ ~~ ~ ~~~s~ P :~ /~~ ~/• ~ SG/~G ~-- G""~L GYM ~ ~ ~ ~. ~-~ia~mL~vf S~ ~s'T`~'"~,11 TOTAL (Also enter on line 5, Recapitulation) I $ ~~ ~~~ - / (If more space is needed, insert additional sheets of the same size) I~ M&T { ar~lcr:7~=~ .. , 00 0 06128M NM 017 23440 ETHEL L HARTZELL 1059 MAIN ST EXTD . FELTON PA 17322-7955 CARLISLE NEST nrrniiAlT CIIMMADV BEGINNING BALANCE DEPOSITS.& OTHER ADDITIONS CHECKS PAID -0THER SUBTRACTIONS CURRENT INTEREST PD ENDING BALANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 7,454.49 1 65.77 1 250.00 0 0.00 0.00 7,270.26 ACrf111NT Af TTVTTV POSTING DATE TRANSACTION DESCRIPTION DEPOSITS,INTERE T 8 OTHER ADDITIONS CHECKS S OTHER SUBTRACTIONS DAILY BALANCE 11-10-07 BEGINNING BALANCE 57,454.49 11-13-07 CHECK NUMBER 5697 250.00 7,204.49 11-30-07 PA TREASURY DEPT ANNUITANT 65.77 7,270.26 ENDING BALANCE 57,270.26 CHECKS<PAID SUMMARY 5697 :L1-13-07 250.00 .r P ~, ~ooen ~ero~ `, c~ k~ REV-1511 EX+ (10-06) ~. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE N FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) ~O/V/V/~i ~, ~~'72,f,2-~Gr~SS'G 2 __ Street Address ~l/'~~~j' /~~-l/Y .-~7"''. f ~Xp7~~ City y/=G-L~ N State r~_ Zip l ~.32- Z- Year(s) Commission Paid: ~ CO 9 2. Attorney Fees /~~~~~ ~ ' /~~N~L3LS' 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant I(/GVt/L: Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees ~~-CJS'T~/L pL Gt/~ ~~S 5. Accountant's Fees ~~~ ~./9~Q. C~'i~S~ 6. Tax Return Preparers Fees ~~. Ga ~ /O. a0 ~.3, ao ,2~s,~G may, s~ 3~ a a TOTAL (Also enter on line 9, Recapitulation) $ /j ~~ ~i / V (If more space is needed, insert additional sheets of the same size) REV-1512 E:X+ (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBSER DESCRIPTION OF DEATH t. ~li 6 !(e sG~G ~a ~ ~~/pL4y L E S ~ `.~; ~-~ ~ / /~ ~Pr' ~~ TOTAL (Also enter on line 10, Recapitulation) $ ~,o~ ~ ~~ (If more space is needed, insert additional sheets of the same size) R 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 April 14, 2009 HUMER & DANIELS LAW OFFICES IaILLIAM S DANIELS ESQUIRE FARMERS TRUST BLDG STE 205 ONE W HIGH ST CARLISLE PA 17013 e Re: ETHEL HARTZELL CIS #: 800188108 SSN: 174-05-3116 Date of Death: 11/17/2007 Dear Attorney Daniels: Please be advised that the Department of Public Welfare maintains a claim in the amount of $31,266.03 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 $21,971.73, 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 $9,294.30, is to be entered as a priority Class 5.1 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, r-~ Elizabeth D. James TPL Program Investigator 717-772-6397 717-772-6553 FAX Enclosure i COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY. UNIT PO BOX 6486 HARRISBURG PA 17105-8486 April 7, 2009 STATEMENT OF CLAIM SUMMARY NAME Estate of HARTZELL, ETHEL ID 800 188 408 CLASS 3 CLASS 5.1 TOTAL MEDICAL .00 .00 .00 INPATIENT 00 .00 .00 OUTPATIENT g 176.33 31,101.73 LONG TERM CARE 21,925.40 ~ 164.30 46.33 117 97 DRUG 971.73 21 9,294.30 31,266.03 REIMBURSEMENT TO DPW , COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 REV-1513 EX+ (9-00) SCFIEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE t7F//~~ ~~~ ~ ~ ' ~~~~~ ~ , FILE NUMB~R- O ~ / / /~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBEFI NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. SSG' /~-7~ G'/~C-!~ /~GS'~/~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: 11. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 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) ROSTER OF BENEFICIARIES SCHEDULE "J" Five Names and Addresses 1. Donna H. Strausser 1059 Main St. Extended Felton, PA 17322 Relationship Daughter 2. Jonathan Alexander 1842 Beech Grv. Charlottesville, VA 22911 3, Kristen Keiffer 560 N. Pine St., #3 Middletown, PA 17057 4. Keith Sweger 10040 S W 214`" St. Miami, FL 33189 Grandson Granddaughter Grandson Share 1/2 1/8 1/8 1/8 5. Kirk Sweger Grandson 1 /8 12A First Montgomery Dr. Mt. Holly, NJ 08060