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Home My WebLink About08-24-0915056051058 ,/ 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 Harrisburg, PA 17128-osol 21 09 0480 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 206-32-0294 05/18/2009 01 /28!1941 Decedent's Last Name Suffix Decedent's First Name MI MOOD THOMAS E (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 (date of 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Wilt) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousa{ 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 Lisa Marie Coyne r.. s (717) 737-041}4 ~ ' t ~: _. .1' , ~- Firm Name (If Applicable) • I _ , REGISTER f3~ LS USE t,RjQ[Y Coyne & Coyne P.C. ~ ~ j ~.._ , .I ; , N i , First line of address l 3901 Market St. ~ 1 ~ ' ` ~` ~ ~ ~ ~.. Second line of address ~~:_- -- - ~J t~,) _.~ .. ~~J -. ,. t> ~ City or Post Office DATE FILED ~ State ZIP Code Camp Hill Correspondent's a-mail address: lisa@coyneandcoyne.com PA .17011-4227 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. SIG TURE PERSO RES ONSI LE FOR FILING RETURN DATE A SS Zoe A. Buhosky 3431 Wilson ve., Orefield, PA 18069 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 i SCHEDULE E CASH, BANK DEPOSITS, & MISC. ~ COMMONWEALTH OF PENNSYLVANIA ~ PERSONAL PROPERTY ~ INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MOOD, THOMAS E FILE NUMBER 21 - 09 - 0480 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 DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 National Penn Bank 12,200.49 Savings Account 2 ~ Golden Living Resident Account 758.68 TOTAL (Also enter on Line 5, Recapitulation) 12,959.17 y~ ~~rlo~ ,~ BANKING I INSU~ VESTMENTS IiRUST June 1, 2009 Lisa Marie Coyne Coyne & Coyne Attorneys at Law 3901 Market Street Camp Hill, PA 17011 Re: Estate of Thomas E. Mood Dear Ms. Coyne: Listed below is the information you requested concerning the account(s) held by the above-name decedent with our bank. The balances were taken as of the date of death, May 18, 2009. # 620993720 Savings Account: Thomas Mood Opened: November 28, 2008 Balance $12,199.13 + $1.36 Accrued Interest Closing Date: May 26, 2009 If you have any further questions, please contact me at 610-369-6358. Sincerely, DIANE L. MASON Assistant Vice President DLM: slk 1.800.822.3321 I www.nationalpenn.com I Philadelphia & Reading Avenues I P.O. Box 547 I Boyertown, PA 19512 Member FDIC l Equal Opportunity Lender Name.• MOOD, THOMAS Account Type: Non-Transferring Account #: 641200828 Tax ID: 206-32-0294 Allowance: $ 0.00 Current Balance: $ 758.66 Res ID: 99985 Date Opened.• 07/07/08 Statement Date: 06/10/09 Status: Active Acct Restraints: No Restraints Status Reason: Open Acct Date Description Debit Crsdit Rejsct Balance Batch Record Saq Accouat Credited DisburaiaQ Check 01/01/09 OPENING BALANCE 38.62 01/02/09 US TRSRY 303SOC SEC 425.00 463.62 20102 0 01/02/09 CARE COST AUTO WDL 380.00 83.62 20102 0 2000036920178 O1J02I09 INTEREST PAID 0.01 83.63 40102 0 01105/09 RESIDNT ADVANCE CASH 45.00 38.63 8B167P 010209W2 1 2000042935076 2328 02/02/09 INTEREST PAID 0.00 38.63 40202 0 02/03/09 US TRSRY 303SOC SEC 425.00 463.63 20203 0 02/03/09 CARE COST AUTO WDL 380.00 83.63 20203 0 2000036920178 02104109 RESIDNT ADVANCE CASH 45.00 38.63 SC270P 020309W2 1 2000042935076 2345 03102/09 INTEREST PAID 0.00 38.63 40302 0 03/03!09 US TRSRY 303SOC SEC 425.00 463.63 20303 0 03/03/09 CARE COST AUTO WDL 380.00 83.63 20303 0 2000036920178 03f04l09 RESIDNT ADVANCE CASH 45.00 38.63 8B371P 030309W1 3 2000042935076 2358 04101(09 INTEREST PAID 0.00 38.63 40401 0 04/03109 US TRSRY 303SOC SEC 425.00 463.63 20403 0 04/03/09 CARE COST AUTO WDL 380.00 83.63 20403 0 2000036920178 05/01/09 US TRSRY 303SOC SEC 425.00 508.63 20501 0 05/01/09 INTEREST PAZD 0.00 508.63 40501 0 05/07/09 US TRSRY 303SSA ERP 250.00 758.63 20507 0 06/01/09 INTEREST PAID 0.03 758.66 40601 0 06/03/09 US TRSRY 303SOC SEC 425.00 r 58.66 20603 0 7 ~ ~,~ ~, Sa ~- ~O~L~IL' ~ ~Vl~il CC. h ~ ~ u^ Page: 1 ' SCHEDULE H FUNERAL EXPENSES & COMMONWEALTH OF PENNSYLVANIA ' ADIYIINI~ I IW~ VW 1 ~7 INHERITANCE TAX RETURN RESIDENT DECEDENT __ -__. _. ____ _-. -.. - .___ - J~_..-._ ESTATE OF MOOD, THOMAS E Debts of decedent must be reported on Schedule 1. ITEM DESCRIPTION NUMBER __ __ __ A, 'FUNERAL EXPENSES: 1. Myers-Hamer Funeral Home 2. Reception 3. Honorarium FILE NUMBER ~ 21 - 09 - 0480 AMOUNT 5,620.00 200.00 100.00 B. 'ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions ~ ZOE BUHOSKY Social Security Number(s) / EIN Number of Personal Representative(s): I Street Address 3431 Wilson Ave. City Orefield State PA Zip 18069 Year(s) Commission paid 2009 2. ', Attorney's Fees Coyne & Coyne, P.C. 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 Cumbelrand County Register of Wills 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 ~'i Filing Fee--- Inheritance Tax Return 2 Postage 800.00 1,500.00 48.00 15.00 150.00 Total of Continuation Schedule(s) 26,162.95 TOTAL (Also enter on line 9, Recapitulation) 34,595.95 j ~i H Sch ~ d e C ' ., ~ .~ ... Fw~'al - l _- - _ COMMONWEALTH OF PENNSYLVANIA A INHERITANCE TAX RETURN f'~ 1 '~n~~~ C~~ ~~ RESIDENT DECEDENT ESTATE OF FILE NUMBER MOOD, THOMAS E 21 - 09 - 0480 3 ' Legal Advertisement-- Law Journal 75.00 4 Legal Advertisement-- Patriot News 123.38 5 Mileage for Administrator @, $.55/mile 165.00 6 Class 3 Claim-- DPW 25,674.57 7 Reserves 100.00 8 Toll Calls for Administrator I 25.00 Page 2 of Schedule H I SCHEDULEI DEBTS OF DECEDENT, MORTGAGE I' COMMONWEALTH OF PENNSYLVANIA ~ LIABILITIES, & LIENS INHERITANCE TAX RETURN RESIDENT DECEDENT ~, __ _._.__._ __ __ 1 _-.- ___.._ ESTATE OF '! FILE NUMBER MOOD, THOMAS E ~ 21 - 09 - 0480 Include unreimbursed medical expenses. ITEM NUMBER 1 Class 5.1 Claim--- DPW DESCRIPTION AMOUNT 310,585.44 TOTAL (Also enter on Line 10, Recapitulation) ~ 310,585.44 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 June 5, 2009 COYNE & COYNE PC LISA MARIE COYNE ESQUIRE 3901 MARKET S CAMP HILL PA 17011-4227 Re: THOMAS MOOD CIS #: 850160462 SSN: 206-32-0294 Date of Death: 05/18/2009 Dear Attorney Coyne: Please be advised that the Department of Public Welfare maintains a claim in the amount of $336,260.01 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 $25,674.57, 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 $310,585.44,-~'Z, 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, Elizabeth M. Wilson TPL Program Investigator 717-214-1868 717-772-6553 FAX Enclosure REV•1513 EX+ (g•D0) I pSCHEDULEJ COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT __. _. ESTATE OF MOOD, THOMAS E NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY __ I~ TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 Zoe A. Buhosky 2 Wilberta A. Mood FILE NUMBER 21 - 09 - 0480 RELATIONSHIP TO AMOUNT OR SHARE I DECEDENT OF ESTATE -.. Do.NQtLisf__Tmstae(s~. _ -~. _- - _ _ __... _ Sister 1/2 of Residual Sister 1/2 of Residual ,Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT ~I BEING MADE ''B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS ADMINISTRATION No . 2009- 00480 PA No . 2 7 - 09- 0480 Estate Of : THOMAS E MOOD (First, Midd/e, Last! Late Of : EAST PENNSBORO TOWNSHIP CUMBERLAND COUNTY Deceased Social Security Na : 206-32-0294 WHEREAS, THOMAS E MDOD /First, Midd/e, Lastl late of EAST PENNSBORO TOWNSHIP CUMBERLAND COUNTY died on the 18th day of May 2009 and, WHEREAS, the grant of Letters of Administration is required for the administration of the estate. THEREFORE, I, GLENDA EARNER STRASBAUGH , Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, have this day granted Letters of Administration to: ZOE A BUHOSKY who has duly qualified as ADMINISTRATOR(RIX) of the estate of the above named decedent and has agreed to administer the estate according to law, all of which fu11y appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 22nd day of May 2009. **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) ~~ ~ ~~ ~s i~ -~~ ~~ . ~~ ~ ,~1~~3 C OYNE & C OYNE A PROFESSIONAL CORPORATION ATTORNEYS AT LAW Henry F. Coyne Lisa Marie Coyne Jaime L. High 3901 Market Street Camp Hill, Pennsylvania 17011-4227 717-737-0464 Fax: 717-737-5161 August 21, 2009 Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Dear Madam: Re: Estate of ?'homas E. Mood, Deceased No. 21-09-0480 We represent the Estate of the Late Thomas E. Mood. Enclosed please find an original and two (2) copies of the Inheritance Tax Return for this insolvent estate. Kindly docket the original "clock-in" the copies and return to this office the yellow "clocked-in" copy with the enclosed stamped envelope. Also enclosed is estate check no. 106 in the amount of $15.00 which represents the filing fee for the Inheritance Tax Return. Kindly issue a receipt for payment of this filing fee. Thank you for your assistance. If you have any questions, please contact me. Very truly yours, COYNE & COYNE, P.C. ~z ~~ c-~ ~~ c~. ~ ..~ ~"-"- ;=. c; c-~ Li Marie Coyne ~ t ~, ~, ;;: LMCJamd `--' ~ ' ~~ c~ - -~ _~ Enclosure " % ~-,-~ ~ -i Cc: Zoe A. Buhosky, Administrator -'' ~ O ~. ,. ~: - usa nr~~ uass ~h ~~ us•~ ~~~uT «ASs ~ ~~ ~- C7 ' ' N c_ . c. F-- t - ~` ; p-' ~~ CJ J _7 ~; t~ ~l..cl t ~ ~; t~3 L ~ i '~ . 1 ~. . L: r~ N A-+ Q ~ W ^~ ,., o z ~~ ~. J~ L: N .~ O ~ U y ~ M ~ ~ ~ O h 3 `~ ~ r' 0 o ~ ~ a ~ ~ ~- o ~.flU.~ on ~ ~ .~ c1,000 ~~ t i : ~' ~~~ ~ ~'. '~~ j''.'t~ ~=~ ~ ~; f~ .~ ~ A~ i 4, ~ ~ ~4Y. ~ '~~ 1;' ~~ ', ~~' ~ ~ ;~a~. t }1 E~'~ 4 ~a ~ ~' ~~; ~ ~~ i <~ e~ ~ ~ ~ ~ ~ .~ °~ ,. tt t .~~~ i Sr' F ~ 1 ~,. ~. _ L.. J 15056052059 REV-1500 EX THOMAS E MOOD Decedent's Name: 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. £~. Total Gross Assets (total Lines 1-7) .................................... 8. 9, Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. Decedent's Social Security Number 206-32-0294 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 .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 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..TAXDUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 12,959.17 12,959.17 34,595.95 310,585.44 345,181.39 0.00 0.00 0.00 15056052059 Side 2 15056052059