HomeMy WebLinkAbout06-25-09J 15056041147
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Cade Year Fite Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
Po Box.2sosol 21 0 9 018 9
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
183 18 8577 02 18 2009 03 20 1913
Decedent's Last Name Suffix Decedent's First Name MI
COCKLIN MIRIAM L
(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
X~ 1. Original Return J
r _'' 4. Limited Estate
g Decedent Died Testate i~
X ~~
-- (Attach Copy of Will) ~-J
MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return ~ ~ 3. Remainder Return (date of death
prior to 12-13-82)
4a. Future Interest Compromise ~-I 5. Federal Estate Tax Return Required
(date of death after 12-12-82) J
~ Decedent Maintained a Living Trust Q 8. Total Number of Safe Deposit Boxes
(Attach Copy of Trust)
9. Litigation Proceeds Received f ~ 10. Spousal Poverty Credit (date of death ~ , 11. Election to tax under Sec. 9113(A)
__, between 12-31-91 and t-1-95) - (Attach SCh. 0)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
WM. D. SCHRACK III 717 432 9733,,
Firm Name (If Applicable)
SCHRACK & LINSENBACH PC
First line of address
124 W. HARRISBURG ST.
Second line of address
PO BOX 310
City or Post Office
DILLSBURG
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ILLS US~.ONLY`~`
REGISTERr`~
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DATE FILED tGt
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PA 17019-0310
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Correspondent'se-mail address: Schracklaw@comcast.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 on all information of which preparer has any knowledge.
'~,~~Q- l~//li%~4:d`CA_ J. Dianne Giancola G /'D -~
14 Westover Avenue Stamford, CT 06902
SIGNATURE 0 EPA R HE AN REPRESENTATIVE DATE
_---- Wm. D. Schrock III ~ /~'~s~
124 W. Harrisburg St., Dillsburg, PA 17019-0310
Side 1
~, 15056041147 15056041147 J
J
REV-1500 EX
Decedent's Name: M I r l a ttl ~.. C. O C k i l tt
Decedent's Social Security Number
183 18 8577
RECAPITULATION
1. Real Estate (Schedule A) ...................................................................................... 1.
2. Stocks and Bonds (Schedule B) .............................~............................_............. 2.
3. Closeiy Neld 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.
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.
5,760.27
5,760.27
9. Funeral Expenses & Administrative Costs (Schedule H) ...................................... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10.
11. Total Deductions (total Lines 9 & 10) ................................................................. 11.
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 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
(a)(1.2) X .00 0 . 0 0 15.
16. Amount of Line 14 taxable
0 Q 0
16.
at lineal rate X .045
17. Amount of Line 14 taxable
17
at sibling rate X .12 0 . 0 0 .
18. Amount of Line 14 taxable
18
at collateral rate X .15 0 . 0 0 .
19. Tax Due ................................. ................................................ 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
15056042148
11,120.27
62,129.60
73,249.87
-67,489.60
-67,489.60
0.00
0.00
0.00
0.00
0.00
Side 2
15056042148 15056042148 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-09-0189
DECEDENT'S NAME
Miriam L. Cocklin
STREET ADDRESS
4 South Baltimore Street
CITY
Dillsburg STATE
PA ZIP
17019
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A, Spousal Poverty Credit
g, Prior Payments
C. Discount
3. InteresUPenalty if applicable
p, Interest
E. Penalty
0.00
Total Credits (A + B + C)
(1) 0.00
(2) 0.00
Total InteresUPenalty {D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is theOVERPAYMENT. (4)
Check box on Page 2 Line 20 to request a refund
g. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is theTAX DUE. (5)
A, Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is theBALANCE DUE (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" tN 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 :................................ ^ ^x
c. retain a reversionary interest; or .............................__.............,...........................................__................ ^ x
d. receive the promise for life of either payments, benefits or care? ........................................................... ^ ^x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ..........................................................................................._..................... ^ 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ^ x^
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .............................._.............................__............................._.................... L^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
` ' ~ Lr:: -
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 statutedoes not exemota 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 for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. A
sibling 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
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
Cocklin, Miriam L. 21-09-0189
Indude the proceeds of litigation and the date the proceeds were received by the estate.
All property Jolntlyowned with the right of survNOrshlp must be disclosed on schedule F.
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-7500 Schedule E (Rev. 6-98)
REV-1151 EX+ ('12-991
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INRESDEN7EDECEDENTRN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Cocklin, Miriam L. 21-09-0189
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A- FUNERAL EXPENSES:
Cocklin Funeral Home
9,141.12
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
J. Dianne Giancola
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address 14 Westover Avenue
city Stamford state CT zip 06902
Year(s) Commission paid 2009
2, ~ Attorney's Fees Wm. D. Schrack III
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. I Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
500.00
950.00
77.00
7. Other Administrative Costs 452.15
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 11,120.27
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev, 6-98)
Rev-1502 EX+(6.98)
SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Cocklin, Miriam L. 21-09-0189
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-'1500 Schedule H-A (Rev. 6-98)
Rev-1502 EX+(6.98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE 7AX RETURN
RESIDENT DECEDENT
SCHEDULE H-B7
OTHER
ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Cocklin, Miriam L. 21-09-0189
ITEM
NUMBER DESCRIPTION AMOUNT
1 Executrix's expense for family dinner with decedent's handicap son before funeral 104.96
2 ~ Executrix's hotel expense incurred in trip from Stamford, CT to Dillsburg to arrange I 58.85
for and attend to duties regarding funeral, estate probate, banking duties, etc.
3 Executrix's travel expenses incurred in trip from Stamford, CT to Dillsburg to 264.00
arrange for and attend to duties regarding funeral, estate probate, banking duties,
etc. (480 miles @ .55 per mile}
4 ~ Federal Express -shipping fee of burial clothing to funeral home ~ 24.34
Subtotal I 452.15
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B7 (Rev. 8-98)
Rev-1512 EX+ 18.98}
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Cocklin, Miriam L. 21-09-0189
Include unrelmbursed medical expenses.
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98)
SCHEDULE J
ANIA
COMM
O
TA BENEFICIARIES
TAX RETURN
NCE
NHERI
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Cocklin, Miriam L. 21-09-0189
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT
Do Not List Trustee(s) (Words) ($$$)
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116(a)(1.2)]
Robert A. Cocklin Son residuary
1 W. Penn Street -Apt. 517 estate
Carlisle, PA 17013
J. Dianne Giancola Niece $1,000.00
14 Westover Avenue
Stamford, CT 06902
Total
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropr iate, on Rev 1500 cove r 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-TAXABLt UI51 KI13U I IVNJ ulv LIIVt -IS vr• rcty--lave ~..vv~rc oncc i I ~..+.. _
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98)
A: W il113\Cocklin. Mir(amd)
±~~~~ tll ~rt~ ~e~~~ztte~#
OF
MIRIAM L. COCKLIN
BE IT REMEMBERED, that I, MIRIAM L. COCKLIN, of 4 South Baltimore Street,
Dillsburg, York County, Pennsylvania, being of sound mind, memory and understanding, do make,
publish and declare this as and for my Last WiII and Testament, hereby revoking and making null and
void any and all Wills and Testaments and writings in the nature thereof by me at any tune heretofore
made.
ITEM 1: I direct that my hereinafter named Executors pay all my just debts, my funeral
expenses, and the expenses of the administration of my estate. With this direction, I authorize and
empower my Executors to expend for my funeral expenses and interment such amounts as they may
consider necessary and proper, without regard to any limit that may be prescribed by a court of law.
ITEM 2: I direct my Executors to pay all inheritance, estate, succession, and Legacy taxes
of whatsoever nature and kind, to which my estate, or the transfer of any property passing hereunder
or otherwise passing by reason of my demise, may be subject, and to charge such taxes against my
residuary estate, it being my intention that none of the aforesaid taxes, either federal or state, on any
property required to be included in my gross estate, under the provisions of any state or federal law
now in force or hereafter enacted, shall be prorated among the persons interested in my estate to
whom such property is or may be transferred or to whom any benefit accrues.
ITEM 3: I give and bequeath the sum of One Thousand Dollars (51,000.00) to my niece,
J. DIANE GIANCOLA, absolutely.
ITEM 4: All the rest, residue and remainder of my estate, of whatsoever nature and
wheresoever situate, whether it be real, personal or mixed, including property over which I have a
power of appointment, I give, devise and bequeath unto my son, ROBERT A. COCKLIN.
ITEM 5: I nominate, constitute and appoint my niece, J. DIANE GIANCOLA and my son,
ROBERT A. COCKLIN as Executors of this my Last Will and Testament.
I'T'EM ~: I direct that my hereinbefore named Executors shall not be required to give bond
for the faithful performance of their duties in this or any jurisdiction.
,.-- _
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ day of
~} c~ C/ 5 ~' , 1999.
N>IRIAM L. COCKLIN
The preceding instrument, consisting of this and one (1) other typewritten page, was on the
day and date thereof signed, sealed, published, and declared by the Testator herein named, as and for
her Last Will and Testament, 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.
' OF
2
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF YORK
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We L. COCKLIN, ~ c.~C ~ and
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.~.,~~~;~Z~ ... ~2~,1'72~~, the Testator and the witnesses, respectively, whose names are
signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testator signed and executed the instrument as her Last Will and
Testament, and that she signed willingly, and that she executed it as her free and voluntary act for the
purposes therein expressed, and that each of the witnesses, in the presence and hearing of the 'Testator
signed the Will as witnesses, and that to the best of their knowledge, the Testator was at the time
eighteen (18) years of age or older, of sound mind, and under no constraint or undue influence.
L. COCKLIN
Cam.. ~
SWORN TO AND SUBSCRIBED
BEFORE ME TffiS Z~~ DAY
~~~~C , 1999.
l
Notarial Seal
Janet S. Gore, Notary Public
Dillsburgg Boro, York County
My Commissjon Expires Oct. 25, 2002
ember, nrtsy-vania Association o o apes
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Circle Gold
Account Statement
1-800-773-7373 ~ uP 4
Cail Citizens' PhoneBank anytime for account infonnatian,
current rates and answers [o your questions.
Beginniny January Z8, 2009
through February 25, 2009
US259 BR319 4 1
Contents
MIRIAM l COCKLIN
14 W E S T O V E R A V E Summary Page 1
STAMFORD CT 06902 Checking Page 2
Check Images Page 4
Circle Gold Summary
Account Account Number Balance Balance MIRIAM L COCKLIN
Last Statement This Statement Circle Gold Checking w/Interest
DEPOSIT BALANCE 610074-558-9
Checking
Circle Gold Checking w/Interest 610074-558-9 3,756.51 2,542.19
Circle Gold Money Market 621043-564-9 3,215.53 3,218.08
Monthly combined balance to waive monthly fee is
Your monthly combined balance this statement period is
~, Total Deposit Balance
5,760.27
20,000.00 ~ Total Relationship Balance
6,675.98 5,760.27
i~
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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 9, 2009
SCHRACK & LINSENBACH P C
PO BOX 310
DILLSBURG PA 17019-0310
Re: MIRIAM COCKLIN
CIS #: 510192193
SSN: 183-18-8577
Date of Death: 02/18/2009
Dear Attorney:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $85,166.70 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 $23,037.10, 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 $62,129.60, 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, if available.
Sincerely,
(,t.,
Terri M. Smith
Claims Investigation Agent
717-772-6961
717-772-6553 FAX
Enclosure
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SCHRACK ~e, LINSENBACH
LAW OFFICES
124 W. HARRISBURG ST.
P.O. BOX 310
DILLSBURG, PA 17019-0310
PHONE (717) 432-9733
FAX (717) 432-1053
June 17, 2009
Register of Wills
Cumberland County Court House
One Courthouse Square
Carlisle, PA 17013
Re: The Estate of Miriam L. Cocklin
D/D: February 18, 2009
File #: 21-09-0189
Dear Register:
Attorneys
WM. D. SCHRACK III
BRIAN C. LINSENBACH
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You will find enclosed herewith the original and one copy of "Inheritance Tax Return -
Resident Decedent", Form REV-1500, submitted on behalf of the Executor of the above-noted
Estate. Also enclosed is Estate check # 104, in the amount of $15.00, to cover the filing fee, along
with a third signature page stamped "COPY", which I ask that you time stamp and return to me
in the envelope provided.
Please include the Official Revenue Receipt when returning the time stamped "face
page". Thank you for your attention to this request.
Sincerely,
. D. Schrack III
SCHRACK &LINSENBACH
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