HomeMy WebLinkAbout05-12-091505607121
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 2sasol 2 1 0 9 D 1 8 6
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
2 0 8 2 4 2 7 2 2 0 2 0 5 2 0 0 9 0 7 0 7 1 9 1 6
Decedent's Last Name Suffix Decedent's First Name MI
O B E R M A N E L V I E M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
MI
D 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
^X 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 T0:
Name Daytime Telephone Number
J A N L B R O W N 7 1 7 5 4 1 5 5 5 0
Firm Name (If Applicable) _ -
REGISTER OF WILLS USE 6t~LY
J A N L B R O W N & A S S O C `'- ~~ -
~
First line of address _ -p ~~
~ --
~' r-~ ~..4 I "~
8 4 5 S I R T H O M A S C T S T E 1 2 ~~
' ~' ` -" ~'
i
,
rv _
Second line of address
_ ~ -?.l
- ---- 4:
- ..r -:
DATEF~LED
City or Post Office State ZIP Code - = -"
<i
H A R R I S B U R G P A 1 7 1 0 9
Correspondent's a-mail address: BRENDAJLB@VERIZON.NET
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 all information of which preparer has any knowledge.
SI NATURE OF PERSON R PONSIBLE FOR FILING RETURN ~ DATE
ADDRESS //
105 E ALLEN ST APT 201 MECHANICSBURG PA 17055
SIGNATURE C~}EPAI~Eft OZHER THAN REPRESENTATIVE DATE
~` ~f` l/ Yl~..~. 5/8/2009
845~v~R~'fHOMAS CT STE 12 HARRISBURG PA 17109
PLEASE USE ORIGINAL FORM ONLY
1505607121
Side 1
1505607121
J ~~,
-D
1505607221
REV-1500 EX Decedent's Social Security Number
Decedent's Name: ELVIE M• OBERMAN 2 0 8 2 4 2 7 2 2
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.
8 9 1 2 . 9 7
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5.
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. 8 9 1 2. 9 7
-_
9
3 3 6 2 .
8
7
..........
9. Funeral Expenses & Administrative Costs (Schedule H) ... .
...
5 5 5 0 1 0
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ...... ... ... 10. .
11. Total Deductions (total Lines 9 & 10) ..................... ... ... 11. 8 9 1 2 . 9 7
12. Net Value of Estate (Line 8 minus Line 11) .................. .... ... 12• 0 • 0 0
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ........... .... ... 13.
0 0 0
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
0 0
0
15
0.
0
0
(a)(1.2) x.o _ .
16. Amount of Line 14 taxable
0 0
0
0.
0
0
at lineal rate X .045 16,
17. Amount of Line 14 taxable
0 ' 0
0
17 0 • 0 0
at sibling rate X .12 .
18. Amount of Line 14 taxable 0 0 0 0• 0 0
at collateral rate X .15 1 g•
0 . 0 0
19. Tax Due ......................
................... ... ....19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505607221 1505607221 J
REV-1500 EX Page 3
npr_priPnt's Cemnlete Address:
File Number
21 09 0186
DECEDENT'S NAME
ELVIE M. OBERMAN
__
STREET ADDRESS
1700 Market Street - - - - -
__
CITY ' STATE i ZIP
Camp Hill ~ PA 17011
Tax Payments and Credits: (1) o.oo
1. Tax Due (Page 2 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + g + C) (2) 0.00
3. InterestlPenalty if applicable
D. I nterest
E. Penalty
Total Interest/Penalty (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) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 0.00
Make Check Payable fo: 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 : ................................................................. .....
b. retain the right to designate who shall use the property transferred or its income; ......................... ......
^
^X
c. retain a reversionary interest; or .......................................................................................... ......
^ 0
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? .................................................................................
? ......
^ ^X
...
3, Did decedent own an "intrust for" or payable upon death bank account or security at his or her death ......
Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
4
.
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 childtwenty-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)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ELVIE M. OBERMAN 21 09 0186
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.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. PNC Bank Checking 51-4004-7399 5,269.16
2 Monumental Life; cash surrender check 746.60
3 Monumental Life; cash surrender check 1,866.60
4 Capital BlueCross; refund 161.62
5 HCR ManorCare; private pay portion patient refund 829.68
6 RxAmerica; credit refund 39.31
TOTAL (Also enter on line 5, Recapitulation) I $ 8, 912.97
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RFSIr1FNT f)FCFnFNT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
ELVIE M. OBERMAN 21 09 0186
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Burial clothing; Boscov's 92.97
2 Funeral luncheon; American Legion Post 26 623.90
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s) Shirley L Stewart & Joyce I Lucas
Street Address 105 E Allen St Apt 201 & 27 E Locust St
City Mechanicsburg State PA zip 17055
Year(s) Commission Paid: 2009
450.00
2 Attorney Fees Jan L Brown & Associates 2,000.00
3, Family Exemption: (If decedents address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills, Cumberland County 117.00
5 Accountants Fees
6. Tax Return Preparers Fees for tax years 2008 and 2009 75.00
7. PNC Bank; bank fees 4.00
TOTAL (Also enter on line 9, Recapitulation) I $ 3,362.87
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (12-03)
SCHEDULE 1
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ELVIE M. OBERMAN 21 09 0186
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
NUMBER DESCRIPTION OF DEATH
1. Department of Public Welfare; Estate Recovery Program 5,550.10
Restitution of medical assistance; CIS # 860235049
Class 3 Claim of $13,535.04
Amount available for payment to DPW = $5,550.10
TOTAL (Also enter on line 10, Recapitulation) I $ 5.550.10
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (g-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ELVIE M. OBERMAN 21 09 0186
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER 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. Shirley L Stewart, daughter Lineal 0.00
105 E Allen St, Apt 201, Mechanicsburg, PA 17055
2 Joyce I Lucas, daughter Lineal 0.00
27 E Locust St, Mechanicsburg, PA 17055
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
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
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)
~~~ ~L ~~~ t~11 ~ ~ 11 ~ ~ 11 ~~ 1 ~ 1l
OF
ELVIE M. OBERMAN
I, ELVIE M. OBERMAN, presently of Enola, Cumberland County, Pennsylvania,
being of sound mind and disposing memory, realizing the uncertainty of this life, do hereby
make, publish and declare this to be my Last Will and Testament, revoking any and,.~.ll
c.'~
--
previous Wills and Codicils, and hereby will and dispose of all the property whi~ I ovvr~~,t
r-, ;.~ _
my death in the following manner: .-"'~' ~ _
-- ~ ~-; --
_ ~. - ,
_ -.:.1
-;~ --i --
Y- CJl
I. U1
As Co-Executrices (herein referred to as "Executor") of this my Will I name and
nominate my daughters, SHIRLEY L. STEWART and JOYCE I. LUCAS.
II.
I direct that my legally enforceable debts and the expenses of my last illness and
funeral shall be paid by my Executor as soon after my decease as maybe convenient.
III.
All of my automobiles, household and personal effects and other tangible personalty
of like nature, together with insurance thereon, I give to my daughters, SHIRLEY L.
STEWART and JOYCE I. LUCAS.
D. In di~~iding into separate shares or in distributing the same, to divide or
distribute in cash, in kind, or party in cash and partly in kind, as Executor thinks fit.
For purposes of division or distribution, to value the estate and any part thereof,
reasonably and in good faith, and such valuation shall be conclusive upon all parties.
To whatever extent division or distribution is made in kind, my Executor shall, so far
as Executor finds practicable, allocate to the respective beneficiaries approximately
proportionate amounts of each kind of security or other property in the estate.
E. To use his discretion to elect the most propitious settlement option with
regard to any qualified employee benefit plans available to me at my death so long
as such election shall be in accordance with the Plan's Administrative Committee or
Administrator as the case may be.
F. To borrow money without liability on the part of the lenders to see to the
application thereof, and to mortgage or pledge any real or personal property.
VII.
I direct that no bond or other security be required of my said Executor in any
jurisdiction in which she or they may act.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
day of , 1999.
SEAL)
LVIE M. OBERMAN
-3-
CONII~IONWEALTH OF PENNSYLVANIA
.,~ SS.
COUNTY OF / ~ 6[_ L~ Y~~~ r' p
_ _ ,,.i `
~Ve, E VIE M. OBERMAN, the testatrix, and ~~ ;~'r; .; ~,. r--l. } h ,,, (~ ~ ,
and , thew-itnesses,
whose n• mes are signed t the attached or foregoing instrument, beingfirst duly sworn, do
hereby declare to the undersigned authority that the testatrix signed and executed 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 his or
her knowledge the testatrix was at that time eighteen (18) years of age or older, of sound
mind and under no constraint or undue influence.
LVIE M. OBERMAN w
~ ~~ ~" ,,
~.~~~~
WITNESS
W'ITNE
~._._.._
TNESS
Subscribed, sworn to and acknowledged before me by ELVIE M. OBERMAN,
the testatrix, and subscribed and sworn to before me by ~ ;- z ,, ~., ~ . ~,~ ,~ ~ ~ -L ,
(C_ t and ~/C'-~ i-c ~ ~.- ~~~~~~ ~ ~ ~~ ,witnesses,this %:`~'"'`~~
day o~ :i c, ~. , 1999. '
(SEAL)
Not lic
Notarial Seal
RoxAndra M. Rosario, Notary Public
Susquehanna Twp., Dauphin County
My Commission Expires Feb. 24, 2003
Member, Pennsylvania AssoCiatlon of Notaries
tssaaa _t - 5 -
ATTACHMENT TO REV-1500
ESTATE OF
ELVIE M. OBERMAN
FILE NUMBER
21 09 0186
Legal fees reflected on Schedule H were incurred in connection with the decedent. Fees
covered preparation and filing of the Inheritance Tax Return as well as work involved with
probate and estate administration (including Department of Public Welfare estate recovery).
The attorney's fees are reasonable in amount considering the legal time required and
expense involved in these matters.
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
March 27, 2009 ~~~ ll 1 1009
JAN L BROWN & ASSOCIATES
JAN L BROWN ESQ
845 SIR THOMAS COURT
STE 12
HARRISBURG PA 17109
Re: ELVIE OBERMAN
CIS #: 860235049
SSN: 208-24-2722
Date of Death.: 02/05/2009
Dear Attorney Brown:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $13,535.04 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 $13,535.04, 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 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,
~:_ Q~
Judy E. Deaven
Claims Investigation Agent
717-214-1284
717 - T.b~ - ~3 FAX
7~5- ~*f 5 C~
Enclosure
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 25, 2009
JAN L BROWN & ASSOCIATES
JAN L BROWN ESQ
845 SIR THOMAS COURT
STE 12
HARRISBURG PA 17109
Re: ELVIE OBERMAN
CIS #: 860235049
SSN: 208-24-2722
Date of Death: 02/05/2009
Dear Attorney Brown:
This letter is to advise you that according to the information you
provided to our office regarding the assets of the above-referenced estate,
the Department of Public Welfare will accept the balance, namely $5,550.10
remaining in the estate for payment of our existing claim.
Please have the check made payable to the Department of Public Welfare
and forwarded to my attention at the above address.
Your cooperation in resolving this matter is appreciated.
Sincerely,
Judy E. Deaven
Claims Investigation Agent
717-214-1284
717 - ~?-'rE - 6#sEti FAX