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HomeMy WebLinkAbout08-28-09 (2) ! 15056051047 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 280601 2 1 0 9 0 0 2 0 8 Harrisburg, PA 17128-0601 ~~ RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 2 0'3 1 0 7 0 1 7 1 2 1 0 2 0 0 8 0 3 1 3 1 9 2 0 Decedent's Last Name Suffix Decedents First Name MI `W E''R T Z S A R A H M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI W E'R T Z E L M E R H 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) ~ 6. 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 DIRECTifD TO: Name Daytime TelephonerPdytmber ;~ ;x7 ,, _ .. r~ - ~ _ _7 M a r l i n R M c C a l e b 7 1 7 6 9-I`~ 7 2-~ 0 Firm Name (If Applicable) First line of address 2 1 9 E a.s t M a i n S t r e e t Second line of address P O B o x 2 3 0 City or Post Office M e c h a n i c s b u r' g State P'' A ZIP Code 1 7 0 5 5, DATE FILED :-~ 1 7 . ,, .~ ' ~1 ~, - ~ f., i t t _,.` -~1 :.~ u~ REGISTER OF; WILt•$t1JSE OfJCVt ? c:•a ~;;: _~.~ _,--i .. i`J Correspondent's a-mail address: 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. SIGN_A~T SIBLF~ FOF~RILING RETURN DATE ADD'R~SS - " ~ ~ ,i'7~ '- ~- 100~%~ridge .S~tt~et,, New ~nberland, PA 17070 (/ 219 East Ma'n ,- n Box ~n~ Mechanicsburg PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 J REV-1503 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTA SCHEDULE B STOCKS & BONDS FILE NUMBER Sarah M. Wertz SS~~ 203-10-7017 12/10/2008 21-09-0208 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 Merrill Lynch Account No. 872-10388, - value of 88,372.65 securities: $88,187.89; accrued dividends: $184.76. TOTAL (Also enter on line 2, Recapitulation) 88 , 372.65 (It more space is needed, insert additional sheets of the same size) Copyright (c) 1996 farm software only CPSystems, Inc. Form REV-1503 EX (Rev. 1-97) REV -1508 EX t { 1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA (CASH, BANK DEPOSITS, $c MSC. INRESIDENT DECEDEN TN PERSONAL PROPERTY ESTATE OF FILE NUMBER Sarah M. Wertz SS~~ 203-10-7017 12/10/2008 21-09-0208 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. (It more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. t-97) REV-1511 EX i (1-97) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN I ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Sarah M. Wertz SS~~ 203-10-7017 12/10/2008 21-09-0208 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Stone & Murray Funeral Home, - funeral expense. 1,678.05 2 Trinity United Methodist Church, - funeral luncheon. 300.27 B. 1. 2. 3. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: Attorney's Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 4. 5. 6. 7. 1 2 3 Street Address City State Zip Relationship of Claimant to Decedent Probate Fees Register of Wills Accountant's Fees Tax Return Preparer's Fees Other Administrative Costs Cumberland Law Journal - advertising Letters. Register of Wills, - filing Inventory and Appraisement. The Patriot-News, - advertising Letters. TOTAL (Also enter on line 9, Reca (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. 252.00 75.00 30.00 148.17 ~S 2,483.49 Form REV-1511 EX (Rev. 1-97) REV-1512 EX t (1-97) SCHEDULEI COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INRESIDENTDII eoENTR" MORTGAGE LIABILITIES, AND LIENS ESTATE OF FILE NUMBER Sarah M. Wertz SS~~ 203-10-7017 12/10/2008 21-09-0208 Include unreimbursed medical expenses. lit more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97) REV-1513 EX +(9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ----- ESTATE OF FILE NUMBER Sarah M. Wertz SSdk 203-10-7017 12/10/2008 ~1 -(19-()7()R 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(aK1.2)) 1 Elmer H. Wertz Husband Entire Estate 1003 Bridge Street New Clitrtberland, PA 17070 ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON R EV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 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 1500 COVER SHEET S 0.00 tlr more space Is neeaea, Insert addltlonal sheets of the same size) Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1513 EX (Rev. 9-00) LAST WILL AND TESTAMENT DF SARAH MURPHY WERTZ I, SARAH MURPHY WERTZ, of 1003 Bridge Street, New Cumberland, Pennsylvania, do make, publish and declare this. to be my Last Wi11 and Testament, hereby revoking all Wills and Codicils by me at .any time made. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my Estate or by .any recipient of any property, shall be paid by the Executor, from property passing as-part of the rest, residue and remainder of my Estate, as an expense and cost of administration of my Estate. The Executor shall have no duty or obligation to obtain reimbursement for any such tax even though on proceeds of insurance or .other property not passing under. this Willa In the absolute discretion of the Executor, such taxes-may be paid immediately or may be postponed on future or remainder interests until the time possession thereof accrues. to the beneficiaries. ITEM II: 1 direct the Executor to pay expenses of my last illness and funeral. expenses from property passing. .under this Will as an expense and cost of administration of my Estate. ITEM IIIs If my husband, ELMER H. WERTZ, survives me, I give, devise and bequeath to her all my property, real, personal and mixed. .. ~-~/ Page 1 of 5 pages. ~ ~~ c ITEM IV: If my hus-band, Elmer. H. Wertz, does not survive me, all my property, real, personal and mixed, shall be divided into as many shares as required in order. to make the following. disposition, and (a) I give, devise and bequeath one such share i to my son, ROBERT H. WERTZ, or to his issue per .stirpes; I (b) I give, devise and~bequeath.one such share to my son, JAMES M. WERTZ, or: to his issue per .stirpes; (c) I give, devise and ;bequeath one such share to my daughter, SANDRA WERTZ WALLACE, or to her issue per .stirpes; and (d) I give, devise .and bequeath one such share to my son, NED C. WERTZ, or to his issue per .stirpes. ITEM V: In settlement of my Estate, the Executor shall possess, among .others, the following powers: (a) To vary. or to retain investments, when deemed desirable by the Executor, and to invest in bonds, stocks, notes, real estate mortgages or other securities or in other property, real or personal, without being restricted to so-called "legal investments" and without being limited by any .statute or rule of law regarding .investments by fiduciaries; (b) In order to effect a division of the principal of my Estate or for any other purpose, including .any final distribution,. the Executor is authorized to make said divisions or distributions of the personalty and realty, partly or wholly in kind, at a fair value determined at the date of division or distribution, and if it appears. desirable Page 2 of 5 pages. ry _, . __~._ ...._._ .. , .. ,,.U_.__ .. _ .,..... ,..~__ r,~,...,.,..~.r...m....~...,n~..,.,-_.-~.....~._..,.~.,,.,.,,~.~,...,~._,~,.»~~~,.~,,,,,,....,~.,~..~,.,.,,~.,.__.~-..,.~.~.,,,.~,...,.~....._ - to partition any real estate,. the Executor is authorized to make, join in and consummate partitions of lands, voluntarily or involuntarily, including giving of mutual deeds, recog- nizances, or other obligations, with as complete powers as an individual owner in fee simple; F (c) To sell, either .at Rublic or private sale and upon such .terms- and conditions as the Executor. deems advantageous. to my Estate, any or all real or personal estate or interest therein. owned by my Estate severally or in con- junction with .other persons or acquired after my death by the Executor, and to consummate said sale or sales by sufficient deeds or other instruments. to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers. to see to application of the purchase money or to make inquiry .into the. validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in performing any power. conferred upon the Executor in this paragraph or elsewhere in my Will; (d) To mortgage real estate .and to make leases of real estate; (e) To borrow money from any part, including. the Executor, in order to pay indebtedness of mine or of my Estate,. expenses of administration or inheritance, legacy, Page 3 of 5 pages. -, _ ..~ . estate .and other taxes, and ~o assign and pledge assets of my Estate therefor; (f) To pay all costs,aaxes, expenses and charges in connection with the administration of my Estate; (g) To vote .any shares~of stock, which form a part of my Estate, and otherwise to exercise all powers incident to the ownership of such stock; (h) In the. discretion of the Executor, to unite with .other owners of similar property in carrying out any plans for the reorganization of .any corporation or company the securities of which form a part of my Estate; and (i) To do all :other acts, deemed. necessary or desirable, for the proper and advantageous management, investment .and distribution of my Estate. ITEM VI: Any person who 'shall have. died at the same time as Testatrix, or in a dommon disaster with her, or under such circumstances. that it is difficult or impossible to determine who died first, shall be .deemed to have predeceased her. -ITEM VII: If, at any time, any minor shall be entitled to receive any funds hereunder, FULTON BANK '(a bank with its principal office in Lancaster, Pennsylvania, and. with an office in Harrisburg, Pennsylvania) or its successors, shall act as Guardians Page 4 of 5 pages. cif the .funds payable to such minor .and shall have full authority to use such funds in any manner it shall deem advisable for the best interest of such minor. ITEM VIII: I hereby nominate,. constitute and appoint my husband, ELMER H. WERTZ, to be the Executor. In the .event of my husband's death or inability or refusal to serve, I nominate, constitute and appoint ROBERT H WERTZ to be the Executor,-.and in the event of his. death or inability or refusal to serve, I nominate, constitute and appoint, JAMES M. WERTZ, to be the Executor. The Executor shall not be required to give any bond or bonds. IN WITNESS WHEREOF, I have set my hand and seal to this my Last Will and Testament, consisting of this and the preceding four (4) pages, at the end of each page of which I have also set my hand for greater security and better identification this / 7 day of ~ G~~ , 1975. Page 5 of 5 pages . ~ ~ ~~ ( SEAL ) Sarah u h Wert We, the undersigned, hereby. .certify that the foregoing Will was signed, sealed, published and declared by the above-named Testatrix as and for her Last Will and Testament, in the presence of us, who, at her request .and in her presence .and in the presence of each other, have hereunto set our hands and s-eats. the. day and year above written, and we certify that, at the time of the. execution thereof,. the Testatrix was of sound .and disposing mind and memory. (SEAL) Residing at: 3 ~5~ ,. ~, ~~ , ~~ . c (SEAL ) Residing at: ~ O ~ „~.. ~;. (SEAL) Residing .at: ~ ~~^ ~cs-c~ G"~Q~-.~.Nt.c~; Z C~ C ~i 4! U C N ~ Q (~ ~ Q ~ O a 0~ W ~+ N W ~ ~ j ~ ~ . U U 0. 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G ~ T i '4 w ~ G lC N ~ ~ .J t6 '~ l4 y 7 ~p ~ y O _ w.. ^ ~i y m 4~ ~ p m y 3 ,~'- m m p r ~p G~ ~ ~ w m p U 'd m ~ ~ ~ p O ~ •~ ~~ N p U Q Cl ~ ~ U) ~ ~: 4 ' ~ ~ • u, ~ w 43chedule g • 1 FORM 1' ~~hoice~TM - r~ ~ ~ ~_ (a pre-arranged funeral program administered and endorsed `~ 1 by the Pennsylvania Funeral Directors Association) PART I Pre-Need and Individual Trust Agreement ("Thy Agreem/ent") ~ _ T-hi-s Agreement is made this ~•~ r ~ ~'~ by and between Funeral Home ___ --~1 `~~~= `~,~~'~'~f _ __ ~ 'L- l~~~r''~'~`' ~~ ,~~ AME ; t ~,,, ~ 1~~ Address . ~ ] ,~ JL/~'J / M f~~ . BUSINESS ADDRESS ~~ and the Purchaser S ~-~ Z A - ~'~ ~~~ ~~ (M) (hereinafter "You") ~ ~, N E ~ D/ B s CIAL SECURITY # ` ADDR S ~/' for the Benefit of (if Beneficiary 's is different from the Purchaser) NAME D/O/B SOCIAL SECURITY # ADDRESS (M) (F) ANNUAL FINANCE Amount Financed Total of Payments Total Sale Price PERCENTAGE CHARGE The amount of credit The amount You will have The total cost of RATE The dollar amount the Provided to You or on paid after You have made purchase on edit, The cost of Your Credit credit will cost You. Your behalf. All payments as scheduled. including ur do n L~ /~'~ Payment f $ -~~V ~~--~--~- . as a yearly rate. It not paid in full, Your Payment Schedule will be: No. of Amount of When Payments Are Due payments payments $ Monthly beginning _ Mo. Da Year See reverse side for any additional information about Nonpayment and default. Itemization of Amount Financed Cash Price Total Downpayment (a) Cash - $ (b) Death Benefit of Paid Up Life Insurance Policy Assigned: $ Unpaid Balance of Cash Price & Amount Financed = $ You hereby agree to buy and Funeral Home hereby agrees to sell the funeral goods ("Merchandise"), funeral services ("Services") and cash advance items for 3rd parry charges ("Cash Advances") which are described in itemized list attached as Exhibit A for a Total Sale Price of $ __ ___ . (see paragraph 5 on the reverse side for price details) After payment of the Total Sale Price and all other payments required to be made, the Funeral Home will render, upon the death of the Beneficiary, all the Merchandise, Services and Cash Advances described on attached Exhibit A. This Agreement is subject to the terms and con- ditions shown above and on the reverse side of this page, which you have read and accepted. PNC ga~ak National 4ssoi~i~tjon `~,,~~~~~,, BANK AUTFfORIZED PERSON License Number of Funeral Director ~""~--?~~~,~ SUBJECT TO TERMS AND CONDITIONS ON REVERSE SIDE: You acknowledge receipt of a completed copy hereof. You, the buyer, may cancel this transaction at any time prior to midnight of the third business day after the day of this transaction. See the attached Notice of Cancellation form for an explanation of this right. PART II The Trustee hereby accepts the Trust herein created for the Beneficiary under the Master Pre-Need Trust Agreement with the Funeral Home. DATE You ereby elect that this Agreement shall be: Irrevocable upon payment in full of the Total Safe Price Revocable by You at Your option at all times u d the Funeral Home agree that Services and Merchandise shown on Exhibit A are: Guaranteed by the Funeral Home upon timely payment of the Total Sale Price Not Guaranteed by the Funeral Home ou nd the Funeral Home agree that Cash Advances shown on Exhibit A are: Guaranteed by the Funeral Home upon timely payment of the Total Sale Price Not Guaranteed by the Funeral Horne CLUSION WARRANTIES: THE FUNERAL HOME IS NOT PROVIDING TO YOU ANY WARRANTY OF MERCHANTABILITY OR WARRANTY OF FITNESS FOR A PARTICULAR PURPOSE FOR THE MERCHANDISE. The only warranties You are receiving for the Merchandise are the express written warranties, if any, which are provided by the manufacturers of the Merchandise sold to You under this Agreement. Only the manufacturer shall have any liability to You under such warranties. You and the Funeral Home have signed this Agreement on the day and year written above and intend to be legally bound. By signing this Agreemen the Funeral Home, as agent for the Purchaser, hereby agrees to establish an individual trust with the Trustee under the Master Pre-Nee ust Agreement (the "Master Trust") between the Funeral Home and the Trustee (the "Trust"). ~~_ ~ 'I ! '~ "~f Signature of Licensed Funeral r ignature of Purchaser White Copy - PFDA Yellow Copy -Funeral Home Pink Copy -Purchaser PFT 501-07-03 Schedtil~e E . 2 ~~ ~~ 6 1 ~- 0 r i^ r w W 0 W i^ r w O r ui ~ !~~ h ~pp L ae~oi~a-ee ~~OD m~~ ~m c°D O ~ ~ o ~ ~ ~ r arn~ X ~ . ~ ~ ~ ~. ~ ~ ~ ~ ` O 1-' .n O O H; D -+' N` ~. Q (J1 N O CO ~,. at x- x~ c~ ~- ; ~ ~ °~ ~ ~ '~` o ~ '~ w Z n ~ '~' ~ ~~ ~ z -~"' ~ ~ a O S '~ N ~F N ~ 0 m ~ x- ~~ 2 Z o x- ~F D ~Cl? m '~ x~ ~- ~' h-' Ca' c rn~ x~- ~.~ N ~!- -J i x- ~ , O ~ ~; Security Fealureelncluded. ~ D ells on back . ^vVVV^~\' ` V 0 ' Schedule E.2 z~~ £ o O H N R~ ~~ a~~ ~r J O f--~ O O ~ 'T] C1 r{ ~ ~ R7 o ~ ~ ~. a w lrt f•'h n rt (D 1-h (t 0 rt, n lp N N O 0 >E >f N m N 0 x~c ~~~ ~ ~- ~- ~ ~ ~,~o ~~~D ~° 8 ~~ ~~ N ~, ~~ m H t7 Balance Forward 4,8'15.00 11/26/08 PAYMENT RECEIVED -THANK YOU!!! 4,875.00 0.00 11/01/08 *** Assisted Living *** WATCHMATE MONITORING AL 40.00 1.00 40.00 40.00 11/01-11/30 11/04/08 #184 BARBER/BEAUTY SHOP ~ 14.00 1.00 14.00 54.00 SHAMPOO/SET 11/18/08 BARBER/BEAUTY SHOP 14.00 1.00 14.00 68.00 SHAMPOO/SET 11/30/08 SRC - JUNIATA 11/01-11/30 153.00 30.00 4,590.00 4,658.00 11/30/08 MISC. MED SUPPLY - AL 14.00 3.00 42.00 4;700.00 3 PKG. PULL-UPS 11/6,18, 25 ~l ~~ ~ y ~ RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 50711 4,700.00 0.00 0.00 0.00 0.00 $4,700.00 RESIDENT NAME SARAH M. WERTZ F«r„PS-o, A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! Schedule I.3 . . esslah v~ ~~A~~ 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 ELMER H WERTZ 900 COCKLIN STREET MECHANICSBURG, PA 17055 -, I ~ ~ . ~_ .-~ ,.~. Form PB-01 QUESTIONS? CALL: 71 697-4666 RESIDENT # ' " U tT STMT. DATE 50711 459 12/31/2008 RESI~NT S SARAH M. WERTZ TOTAL AMOUNT DUE $1,365.89 DATE DUE 01/31/2009 DATE DESCRIPTION RATE ~ ~ CHARGES CREDITS BALANCE Balance Forward 4,700.00 12/31/08 PAYMENT RECEIVED -THANK YOU!!! 4,700.00 0.00 *** Assisted Living %** 12/01/08 WATCHMATE MONITORING AL 1.29 9.00 11.61 11.61 12/09-12/09 #184 , 12/02/08 BARBER/BEAUTY SHOP 14.00 1.00 14.00 25.61 SHAMPOO/SET 12/08/08 SRC - JUNIATA 153.00 8.00 1,224.00 1,249.61 12/09/08 SRC - JUNIATA 116.28 1.00 116.28 1,365.89 ..- f ~ ~ ~0 ~ 6 ~ RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 50711 1,365.89 0.00 0.00 0.00 4.00 ~ $1,365.89 RESIDENT NAME SARAH M. WERTZ FormPB-O7 N/A A 1 % finance charge may be assessed on accounts for which payment has not been received by tie due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! Schedule I.4