HomeMy WebLinkAbout08-03-09t
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FAMILY SETTLEMENT AND FINAL RELEASE , --~_` F; ~;,., ..- ~ ~__
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ESTATE OF JUNE M. GRIM ~~~ ~~~ ` ' ~ '
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KNOW ALL MEN BY THESE PRESENTS, that June M. Grim,~'late of N~-th
Middleton Township, Cumberland County, Pennsylvania, deceased, died intestate on
February 14, 2008. A Petition for Letters of Administration were fled in the Office of the
Register of Wills of Cumberland County on April 8, 2008.
WHEREAS, Letters of Administration on the Estate of the said decedent were
duly issued by the Register of Wills of Cumberland County, Pennsylvania, to Marlet E.
Grim and James M. Robinson, hereinafter called personal representatives, and indexed
as File No. 2008-00191;
WHEREAS, the personal representatives have gathered the assets of the Estate
of the said decedent consisting of personal property with the total value of $509,002.14
as set forth in Exhibit "A", which is a copy of the Pennsylvania Inheritance Tax Return
filed and approved by said personal representatives, and which is attached hereto and
made a part hereof, and marked Exhibit "A";
WHEREAS, the debts and deductions, including the payrnent of inheritance tax
in the said Estate, which has now been paid, leave a balance for distribution of
$437,554.99, also as set forth in the statement of said personal representatives, which
is attached hereto and marked Exhibit "B";
WHEREAS, the balance for distribution as shown in the said statement marked
Exhibit "B" has been reduced to cash and has been distributed as herein indicated in
accordance with 20 Pa.C.S. § 2103 (1);
NOW, THEREFORE, the undersigned, being the sole heir under Pennsylvania
law, and being that person entitled to inherit under Pennsylvania law, does hereby
acknowledge that he has this day had and received from the aforesaid personal
representatives, the amounts due him under Pennsylvania law, which amounts he has
received this day or prior to this day; and, he does hereby stipulate that in order to avoid
the expense and time involved in the filing of a formal account and schedule of
distribution, he agrees that no account is necessary and he does hereby agree that he
does consent to distribution being made without the filing of an account and schedule of
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX
PO BOX 280601
HARRISBURG PA 17128-0601 REV-1547 EX AFP (01-09)
DATE 07-06-2009
ESTATE OF GRIM JUNE M
DATE OF DEATH 02-14-2008
FILE NUMBER 21 08-0191
COUNTY CUMBERLAND
JAMES M ROBINSON ACN 101
TURD LAW OFFICES APPEAL DATE: 09-04-2009
28 SOUTH PITT STREET (See reversesi~deunderObjecdons)
CARLISLE PA 17013 Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ _ _ __
----------------------------------------------------------- ------------
REV-1547 EX AFP (O1-09~ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF GRIM JUNE M FILE N0. 21 08-0191 ACN 101 DATE 07-06-2009
TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN N0. O1
1. Real Estate (Schedule A) (1) .00 NOTE: Ta insure proper
2. Stocks and Bonds (Schedule B) C2) ,00 credit to your account,
3. Closely Held Stock/Partnership Interest (Schedule C) (3) .0 0 submit the upper portion
of this form with your
4. Mortgages/Notes Receivable (Schedule D) (4) .00 tax payment.
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) .00
6. Jointly Owned Property (Schedule F) (6) .00
7. Transfers (Schedule G) (7) .00
8. Total Assets (g) .00
APPROVED DEDUCTIONS AND EXEMPTIONS:
9.
Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule
H) C9) .00
10. Debts/Mortgage Liabilities/Liens (Schedule I) (LO) 21.8 36.78
11. Total Deductions
C11)
91 .86.78
12. Net Value of Tax Return (12) 21,836.78-
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J:~ (13) .00
14. Net Value of Estate Sub9ect to Tax C14) 456, 991 .15
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15) .00 X 00 = .00
16. Amount of Line 14 taxable at Lineal/Class A rate C16) 456,991 .15 X 045 = 20,564.60
17. Amount of Line 14 at Sibling rate (17) .00 X 12 _ .00
18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 _ .00
19. Principal Tax Due (lg)= 20,564.60
rex rQCnrTC.
AYM T
DATE RECEIPT
NUMBER SCOU +)
INTEREST/PEN PAID (-)
AMOUNT PAID
05-09-2008 CD009690 1,028.23 20,469.90
11/ [ ~1
TOTAL TAX CREDIT 21,498.13
BALANCE OF TAX DUE 933.53CR
INTEREST AND PEN. .00
TOTAL DUE 933.53CR
^ IF PAID AFTER DATE INDICATED, SEE R~ UE IS LESS THAN S1, NO PAYMENT IS REQUIRED.
FOR CALCULATION OF ADDITIONAL INTEREST. DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
~ REV-1500 15056041147
EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX.280601 2:1 0 8 0 0 1 9 1
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
02142008 040.31923
Decedent's Last Name Suffix Decedent's First Name MI
GRIM JUNE M
(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~ WIL'LS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ® 2. Supplemental Return ^ 3. Remainder Retum (date of death
prior to 12-13-82)
4. Limited Estate ^ qa. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
^ (date of death after 12-12-82)
8 Decedent Died Testate ^ 7_ Decedent Maintained a Living Trust Q 8. Total Number of Safe Deposit Boxes
^ (Attach Copy of Will) (Attach Copy of Trust)
9. Liti ation Proceeds Received 1 D. Spousal Poverty Credit (date of death ^ 11. Election to tax under Sec. 9113(A)
^ 9 ^ 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
JAMES M ROBINSON 7172459688
Firm Name (If Applicable)
TURO LAW OFFICES
First line of address
28 SOUTH PITT STREET
Second line of address
City or Post Office
CARLISLE
State ZIP Code
PA 17013
Correspondent'se-mail address: JrObInSOn QetUrOlaW.COm
rJ
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 f reparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU F P ON RESP NS FO ING RETURN DATE
'~j~/ ,.~.~ Marlet E. Grim ~C~
ADDRESS
4533 Darcelle Drive, Union City, CA 94587
SIGNA RE OF PREPARER OT E AN RESENTATIVE ATE
James M Robinson ~ ~~ I / ~
A R SS
2 South t, Carlisle, PA 17013
Side 1
15056041147 15056041147
ADDITIONAL Personal Representatives
Grim, June Marie SS# 193-18-7017 2/14/2008
Under penalties of perjury, the undersigned declare that they have e;~amined this return,
including accompanying schedules and statements, and to the best of their knowledge and
belief, it is true, correct and complete.
2 Signature 1
Name es M. binson
Address 28 South P t Street
city, state, zip Carlisle PA 17013
Date
3 Signature
Name
Address
City, State, Zip
Date
4 Signature
Name
Address:
City, State, Zip
Date
5 Signature
Name
Address:
City, State, Zip
Date
6 Signature
Name
Address:
City, State, Zip
Date
15056042148
REV-1500 EX
Decedent's Social Security Number
~ecedenYs Name: GRIM , JUNE MAR 1 E
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.
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. 0 0 0
9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9.
2 1 , 8 3 6 . 7 8
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10.
2 1, 8 3 6. 7 8
11. Total Deductions (total Lines 9 8 10) ..................................................................... . 11.
12. Net Value of Estate (Line 8 minus Line 11) ............................................................ . 12. - 2 1 , 8 3 6 . 7 8
13, Charitable and Governmental BequestsJSec 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. - 2 1 , 8 3 6 . 7 8
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 15.
16. Amount of Line 14 taxable
8 3 6. 7 8
- 2 1 16 - 9 $ 2 6 6
,
at lineal rate X .045
17. Amount of Line 14 taxable
17
at sibling rate X .12 .
18. Amount of Line 14 taxable
18
at collateral rate X .15 .
19. Tax Due ................................................................................................................... .. 19. - 9 8 2. 6 6
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
15056042148 15056042148
REV-1500 EX Page 3 File Number 21 - 08 - 00191
Decedent's Complete Address:
DECEDENT'S NAME
Grim, June Marie
-------_
- ------- --
STREET ADDRESS
1000 Claremont Drive
CITY ~ STATE --^ZIP - - - -
Carlisle PA I 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. InteresVPenalty if applicable
p. Interest
E. Penalty
-49.13
Total Credits (A + E3 + C)
Total InteresVPenalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box 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.
q- Enter the interest on the tax due.
g- Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
(1) -982.66
(2) -49.13
(3) 0.00
(a> 933.53
(5)
(5A)
(5B) ~ .
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 :.................................................................................. ^ ~x^
b. retain the right to designate who shall use the property transferred or its income :.................................... ^ C',
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 ~ 1
receiving adequate consideration? ....................................................................................................................... ^
3. Did decedent own an "in trust for" or payable upon death bank account or security rat his or her death?......... ^ ^x
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 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 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)]. 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.
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COM NHERITANCE TAX RETURNAN~ LIABILITIES, & LIENS
RESIDENT DECEDENT
i
ESTATE OF Grim, June MarieFILE NUMBER
2' 1 -08-00191
Include unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 Patient Accounts Billing Office -Acct. No. 10003233HAR 21.836.78
TOTAL (Also enter on Line 10, Recapitulation) ~ 21,836.78
Aug 20 08 03:11 p
PATIENT ACCOUNTS
BILLING OFFICE
1?515 Research Blvd, Bldg 2, Suite i00, Austin, TX 78759
P.O. Box :,035+Jd Austin, TX 78720-3500
FOR II~QUIRIE3 PLEASE CALL
LOCAL: 5 ] 2-7] 9-7580
TOLL FREE:1-304-88a-2456
August 16, 2008
June Grim
4533 Darcelle Dr
Union City, CA 94587-4719
Responsible Party: June Grim
p.2
~~
ACCOUNT IDENTIFICATION
Re: Triumph Healthcare Harrisburg
Reference Number :17336018 - 353
Account Number : 10003233HAR~
Patient Name :June Grim
Date of Service : 11-30-07
Balance Due : $21.836.78
This is our final attempt to reach an agreement for payment of the above referenced account. Any further
may= result in your account being placed with a collection agency.
Please remit payment today in the accompanying envelope. To pay by credit card you may complete the
detachable coupon or contact a representative at one of the telephone numbers listed above.
If you have already made payment arrangements and/or paid your account in fill, please disregard this not
Thank you.
Personal checks that you send us for payment maybe processed electronically. This means that checks ger
clear faster, banks no longer return checks and bank statements are valid proof of payment.
-------------------------------------------------------------Detach and Return----------------
P.O. Box 203600
Austin, TX 7$720.3600
Return Service Requested
~~~~,4 ~~
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PERSONAL & CONFIDENTIAL
June Grim
4533 Darcelle Dr
Union City, CA 94587-4719
IhLuhi6l~Ish~IJnJ~lei16~~I~nI1L6udhull~llnil
Reference Number :17336018-353
Account Number : 10003233HAR
Balance Due : $21,835.78
Amount Enclosed: $
^ Visa !] M;'C
Credit Card #:
Exp. Date: ,_.J !
Cardholder:
3 or 4 digit security code:
Signature:
353
Patient Accounts Billing Office
P.O. Box 2035(10
Austin, TX 78'720-350(1
n..~u~~l~l~„r„1.llumulluhl~n,~~u~~~n~~~u~~~l:.l,r
C20 000~55P 1 9-03 000'ID1 228 067200 Z-CRE
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
BUREAU OF INDIVIDUAL TAXES AppRAISEMENT, ALLOWANCE OR DISALLOWANCE:
INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX
PO BOX 260601
HARRISBURG PA 17128-0601 REV-1547 EX AFP (06-05)
DATE 07-28-2008
ESTATE OF GRIM JUNE M
DATE OF DEATH 02-14-2008
FILE NUMBER .?1 08-0191
COUNTY IUMBERLAND
JAMES M ROBINSON ACN LO1
TURD LAW OFCS APPEAL HATE: 09-26-2008
28 S P ITT ST (See reverse side under Objections)
CARLISLE PA 17013 Amount Remittecl~- -~
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER 01= WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, I'A 17013
CUT ALONG THIS LINE _ ~ R_ETA_IN LOWER POR_TION_ FOR YOUR RECORDS ~-- _ _______________
REV-1547 EX AFP (03-05~ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF GRIM JUNE M FILE N0. 21 08-0191 /RCN 101 DATE 07-28-2008
TAX RETURN WAS: C X) ACCEPTED AS FILED C ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1) .00 NOTE: To insure proper
2. Stocks and Bonds (Schedule B) C2) ,00 credit to your account,
3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 submit the upper portior
of this form with your
4. Mortgages/Notes Receivable (Schedule D) (4) .00 tax payment.
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 509,002.14
6. Jointly Owned Property (Schedule F) (6) .00
7. Transfers (Schedule G) (7) .00
8. Total Assets (g) 509,002.14
APPROVED DEDUCTIONS AND EXEMPTIONS:
2;t, 995.53
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) C10) 2.178.68
11. Total Deductions (11) 30. 74. 1
12. Net Value of Tax Return C12) 478,827.93
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) .00
14. Net Value of Estate Subject to Tax (14) 478,827.93
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (Lg) .00 X 00 __ .00
16. Amount of Line 14 taxable at Lineal/Class A rate (16) 478,827.93 X 045 _ 21,547.26
17. Amount of Line 14 at Sibling rate (17) . DO X 12 _ . 00
18. Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 15 __ .00
19. Principal Tax Due (19)= 21,547.26
TAY f DCTTTC.
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-)
AMOUNT PAID
05-09-2008 CD009690 1,077.36 20,469.90
TOTAL TAX CREDIT 21,547.26
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL I)UE .00
~ IF PAID AFTER DATE INDICATED, SEE REVERSE C IF TOTAL DUE IS LESS THAN 81, NO PAYMENT IS REpUIRED.
FDR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE: OF THIS FORM FOR INSTRUCTIONS.)
15056041147
R~V-1500 EX (Oti-05) OFIFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO 60X.280601 ;) 1 0 $ 0 G 191
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
193187017 02142008 04031923
Decedent's Last Name Suffix Decedent's First Ns~me MI
GRIM JUNE M
(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 ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
^ 6 Decedent Died Testate ^ ~ Decedent Maintained a Living Trust Q 8. Total Number of Safe De osit Boxes
(Attach Copy of Will) (Attach Copy of Trust) p
^ 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 TO:
Name Daytime Telephone Number
JAMES M ROBINSON 7'172459688
Firm Name (If Applicable)
TURO LAW OFFICES
First line of address
28 SOUTH PITT STREET
Second line of address
City or Post Office State ZIP Code
CARLISLE PA 17013
Correspondent's a-mail address: j r O b i II S O Il @ t 11 T O l a W C O m
REGISTER OF WILLS USE ONLY
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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. Declar ion of preparer other than the personal representative Is based on all information of which preparer has any knowledge.
SIGNATUR OF PERSO RE NSI OR FILING RETURN DATE
Marlet E. Grim ~fi/ ,Qty Zaa~
ADDR SS
4533 Darcelte Drive, Union City, CA 94587
SIGNAI)URE OF PREPARER OTHE HAN I+r~P~ESENTATIVE ...r.-
James MRobinson -~ ~~~~~;~,
'2,8 South Pitt street, Carlisle, PA 17013
Side 1
15056041147 15056041147
ADDITIONAL Personal Representatives
grim, .ions liliarie ~S# 183-18-7017 2114/2008
Under penalties of perjury, the undersigned declare that they have examined this return,
including accompanying schedules and statements, and to the best of their knowledge and
belief, it is true, correct and complete.
2 Signature i ~~
Name Janes M. R inson
Address 28 South Pit Street
city, state, zip Carlisle
Date ~~ ~ ~11~
Signature
Name
Address
City, State, Zip
Date
4 Signature
Name
Address:
City, State, Zip
Date
5 Signature
Name
Address:
City, State, Zip
Date
6 Signature
Name
Address:
'L-c:~
PA 17013
-c.:;>
City, State, Zip
Date
15056042148
REV-1500 EX
Decedent's Social Security Number
oe~eaenrs Name: GRIM , JUNE MARIE 19 318 7 017
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. 5 0 9 , 0 0 2 1 4
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 0 9, 0 0 2 1 4
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... .. 9. 2 7, 9 9 5 5 3
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................. ... 10. 2 , 1 7 8 6 8
11. Total Deductions (total Lines 9 & 10) ................................................................... ... 11. 3 0 , 1 7 4 . 2 1
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... ... 12. 4 7 8 , 8 2 7 9 3
13. Charitable and Governmental BequestslSec 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. 4 7 8 , 8 2 7 9 3
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, of
transfers under Sec. 9116
(a)(1.2) X .00 15.
16. Amount of Line 14 taxable
at lineal rate x .045 4 7 8, 8 2 7. 9 3 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.
21,547.26
21,547.26
Side 2
15056042148 15056042148
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 - 08 - 00191
DECEDENT'S NAME
Grim, June Marie
STREET ADDRESS
1000 Claremont Drive
CITY
Carlisle STATE ZIP
PA i 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
p. Interest
E. Penalty
1,077.36
Total Credits (A + B + C)
(1) 21,547.26
Total InterestlPenalty (Cr + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box 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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILL.', AGENT
(2) 1,077.36
(3) 0.00
(4)
(5) 20,469.90
(5A)
(56) 20,469.90
_K; r.
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 :.................................... ^
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 I~
receiving adequate consideration? ....................................................................................................................... ^ x^
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? .................................................. . .............................................................. ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDIILE 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 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 beneficiarie:o 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.
~I SCHEDULE E ~
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH OF PENNSYLVANIA i PERSONAL PROPERTY
INHERRANCE TAX RETURN
RESIDENT DECEDENT ~
FILE NUMBER
ESTATE OF Grim, June Marie 21 - 08 - 00191
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 I VALUE AT DATE OF
NUMBER DESCRIPTION
DEATH
1 Smith Barney Acct. No. 504-44261 507,025.64
2 ~ Charles Schwab Acct. No. 1383-9007 ~ 2.39
3 ~ F & M Trust Irrevocable Burial Fund #02-11483 ~ 1,974.11
TOTAL (Also enter on Line 5, Recapitulation) ~ 509,002.14
SCHF(~l N F H I
y'
FUNERAL EXPEfVVSES &
COMMONWEALTH OF PENNSYLVANIA I
INHERITANCE TAX RETURN I Ar1A AlA lIC~T~AT'1~/C /'N'1G"TY~
RESIDENT DECEDENT ! /'1LJ1~~~~\K7 ~ fY1 ~ NYC \.ilJ~7 ~ ~7
- --- ---FILE NUMBER --- - - -
ESTATE OF Grim, June Marie 21 - 08 - 00191
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION ~~: AMOUNT .
A. 1
', Austin H. Eberly Funeral Home, Inc.
B. ~ ADMINISTRATIVE COSTS:
1. i Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
I
Street Address
I
City State Zip
i Year(s) Commission paid
2. ~ Attorney's Fees Turo Law Offices
i
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
I, Relationship of Claimant to Decedent
a. I Probate Fees Register of Wills
Cumberland Law Journal
The Sentinel -Legal
5. ! Accountant's Fees
6. , Tax Return Preparer's Fees
7. ; Other Administrative Costs
1 Family Travel Expenses to Funeral -Airfare, Lodging, Rental Car
9,021.70
15,270.07
511.00
75.00
166.60
2.951.16
TOTAL (Also enter on line 9, Recapitulation) 27,995.53
~ SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COM NHERWIT~ANCEDTAX RETURNANIA LIABILITIES, 8 LIENS
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Grim, June Marie 21 - 08 - 00191
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Philip D. Carey, MD 27.02
2 Carlisle HMA Physician Management 12.37
3 Cummings Associates, P. C. 135.00
4 Carlisle Ear Nose & Throat Associates 90.21
5 Blue Mountain Anesthesia Associates 16.60
6 Harrisburg Gastroenterology, Ltd. 10.51
7 West Shore EMS -Carlisle 84.68
8 Special Event Emergency Medical Services, Inc. 768.55
9 Special Event EMS (Dillsburg) 490.34
10 Nephrology Associates of Central PA 297.88
11 Joseph P. Cardinale, D.O. 245.54
TOTAL (Also enter on Line 10, Recapitulation) I 2,178.68
REV-1513 EX+ (9-00)
~I
'' ; SCHE®ULE J
COMMONWEALTH OF PENNSYLVANIA i BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF i F(LE NUMBER
Grim, June Marie
__ 21 -08-00191
RELATIONSHIP TO SHARE OF ESTATE ~ AMOUNT OF ESTATE
NAME AND ADDRESS OF PERSONS I I (Words) ~ ($$$)
NUMBER i, O DECEDENT
RECEIVING PROPERTY oo Not List Trustee(s) i ~
I, ';'TAXABLE DISTRIBUTIONS [include outright spousal I it
distributions, and transfers
under Sec. 9116 (a) (1.2)j ~
1 Marlet E. Grim 'Son ~ E:ntire Estate 478,827.93
4533 Darcefle Drive
. Union City, CA 94587 ~ ~ j
I
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. INON-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-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-15(10 COVER SHEET ~ O.OO
EXHIBIT "B"
GROSS ESTATE NET OF TAX
LIABILITIES
A. Austin H. Eberly Funeral Home, Inc.
B. Turo Law Offices
C. Register of Witls
D. Cumberland Law Journal
E. The Sentinel -Legal
F. Family Travel Expenses
G. Patient Accounts Billing Office
H. Philip D. Carey, MD
I. Carlisle HMA Physician Management
J. Cummings Associates, P.C.
K. Blue Mountain Anesthesia Assoc.
L. Harrisburg Gastroenterology, Ltd.
M. West Shore EMS -Carlisle
N. Special Event Emergency Medical Services, Inc.
O. Special Event EMS (Dillsburg)
P. Nephrology Associates of Central PA
T. Joseph P. Cardinale, D.O.
TOTAL LIABILITIES
AMOUNT REMAINING TO BE DISTRIBUTED
DISTRIBUTIONS:
Marlet E. Grim
$ 489,465.77
$ 9,021.70
15,270.07
511.00
75.00
166.60
2,951.16
21,836.78
27.02
12.37
135.00
16.60
10.51
84.68
768.55
490.34
297.86
245.54
$ 51,910.78
$ 437,554.99
$ 437,554.99
TOTAL DISTRIBUTIONS $ 437,554.99