HomeMy WebLinkAbout08-06-091505607121
-'I REV-~I 5OO EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 0 9 D 5 4 2
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
1 9 7 D 3 9 1 4 1 1 1 0 3 2 0 0 8 0 8 1 3 1 9 2 D
Decedent's Last Name Suffix Decedent's First Name MI
A M I G E L S I E E
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
O 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)
0 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
A L L E N E H E N C H 7 1 7 5 6 7 3 1 3 9
Firm Name (If Applicable)
A L L E N H E N C H
First line of address
L A W O F F I C E
2 2 0 M A R K E T
Second line of address
City or Post Office
N E W P O R T
S T R E E T
State ZIP Code
REGISTE~F WILLS US LY
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OAT!{ FILED '
P A 1 7 D 7 4
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Correspondent's a-mail address:
Under penalties of perjury, I dedare that I have examined this return, including accompanying schedules and statements, and to the hest 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.
SIGNATURrE O_F PERS~N RESPONSI~ O~F~ING RETURN^ a , DATE ~ ~~~^~
ADDRESS
4131 6A.ld'N~ DRIVE APT
220 M
THE
PLEASE USE ORIGINAL FORM ONLY
17112
DATE
~~ 3 v c~ 9
74
Side 1
1505607121 1505607121
J~t
~°~°~'~
1505607221
REV-1500 EX Decedent's Social Security Number
Decedent's Name: E L S I E E• A M I G 1 9 7 0 3 9 1 4 1
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.
1 1 4 4 6 ' 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. 1 1 4 4 6. 0 4
9. Funeral Expenses & Administrative Costs (Schedule H) ......... ..... .. 9• 1 D 8 8 8 . 5 6
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ..... ..... .. 10. 1 9 D 1 9 2 . 5 1
11. Total Deductions (total Lines 9 & 10) .................... ..... .. 11. 2 0 1 D 8 1. D 7
12. Net Value of Estate (Line 8 minus Line 11) .................. ..... .. 12• - 1 8 ~ 6 3 5. 0 3
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. - 1 8 9 6 3 5. 0 3
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
D
.
(a)(1.2)x.o _ .
16. Amount of Line 14 taxable
0
0
0
0.
0
0
.
at lineal rate X .0 _ 1 g•
17. Amount of Line 14 taxable
0. D
D
17
0.
D
O
at sibling rate X .12 ,
18. Amount of Line 14 taxable
D D
D
D.
D
0
at collateral rate X .15 1 g.
19. Tax Due ......................................... ..... ..19. 0 . 0 D
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
15D56D7221 1505607221
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 09 0542
DECEDENTS NAME
ELSIE E. AMIG
STREET ADDRESS
1000 WEST SOUTH STREET
CITY STATE ZIP
CARLISLE PA 17013
Tax Payments and Credits:
Tax Due (Page 2 Line 19)
Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. InteresUPenalty if applicable
D. Interest
E. Penalty
(1) 0.00
Total Credits (A + B + C) (2) 0.00
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.
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 QUE.
(4) 0.00
(5} 0.00
(5A)
(5B) 0.00
Make Check Payable to: 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 : .................................................................
i ..... ^ ^
X
ts income; ..........................
b. retain the right to designate who shall use the property transferred or .....
^
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
0
or payable upon death bank account or security at his or her death? ...
intrust for
3. Did decedent own an ......
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-0ne 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 + (8-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERrrANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ELSIE E. AMIG 21 09 0542
Indude the proceeds of litigation and the date the proceeds were received by the estate.
All properly Jointly-owned with fight of survivorship moat be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Account #2621843 with date of death balance of 1158.77. See attached letter from 1,158.77
The Bank of Landisburg dated June 26, 2009.
2. Irrevocable Burial Fund Account# 700006352 with date of death value of 10252.21 plus 10,287.27
35.06 accrued interest. See attached letter from The Bank of Landisburg, dated 6/26/09
TOTAL (Also enter on line 5, Recapitulation) I ; 11
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+(10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ELSIE E. AMIG 21 09 0542
Debts of decedent must be reported on Schedule L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES;
1. Nickel Funeral Home 8,596.78
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s) Stephanie O' Shura 850.00
Street Address 4131 Fawn Drive, Apt. J
City Harrisburg State PA Zip 17112
Year(s) Commission Paid: 2009
p, Attorney Fees Allen E. Hench 850.00
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. Probate Fees 58.00
5 Accountant's Fees
6. Tax Return Preparer's Fees
7. Estate Notice and Proof of Publication in Cumberland Law Journal 75.00
8. Estate Notice and Proof of Publication in Carlisle Sentinel 208.78
9. Miscellaneous and final probate 250.00
TOTAL (Also enter on line 9, Recapitulation) ~ S , n QQO ~a
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE
DEBTS 0~ DECEDENT,
MORTGAGE LIABILITIES, ~ LIENS
ESTATE OF FILE NUMBER
ELSIE E. AMIG 21 09 0542
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. United Church of Christ Homes Sarah Todd Memorial Home 377.46
2. Dept. of Public Welfare Claim. See attached letter from Pa. Dept. of Public Welfare dated
6/23/09
3. Miscellaneous
TOTAL (Also enter on line 10, Recapitulation) I ;
(If more space is needed, insert additional sheets of the same size)
189,565.05
250.00
190.1
REV-1513 EX + (9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GI cl~ G nnnlr, 21 09 0542
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY 11o Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [indude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Mary Lee R. Crowl Lineal
145 Turkey Hill Road 25% Residuary
Elysburg, PA 17824
2. Josephine I. Ruoss Lineal
1279 Karen Avenue 25% Residuary
Manheim, PA 17545
3. William H. Amig Lineal
1749 Sheaffer Road 25% Residuary
Elizabethtown, PA 17022
4. Terry L. Amig Lineal
1947 Ridge Road 25% Residuary
Elizabethtown, PA 17022
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTfON TO TAXIS NOT BEING MADE
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ;
(If more space is needed, insert additional sheets of the same size)
3G~K~V ~.1J J~.J~.~ ~~~ KJi~GL~1tl~~L~1~L,~~L
~y
HENCH AND CRESSLER
ATTORflTrYS AT LAW
xul 1JIARI~T srREET
NEWPORT PA 17074
TEL (7171567-3139
FAX (7171567-3130
MILLERSTOWN OFFICE
TEL 1717) 5897787
I, ELSIE E. AMIG, of Toboyne Township, Perry
County, Pennsylvania, being of sound mind, memory and
understanding, do hereby make, publish and declare this
to be my Last Will and Testament, hereby revoking any and
all Wills by me heretofore made.
FIRST: I direct payment of the expenses of my last
illness, funeral and burial costs from my residuary
Estate, as an expense of my Estate, as soon after my
death as conveniently may be done. All Federal, State
and other death taxes payable because of my death, with
respect to the property forming my gross .E state for tax
purposes, whether or not passing under this Will,
including-any interest or penalty imposed in connection
with such tax, shall be considered a part of the
administration of my Estate and shall be paid from my
residuary Estate without apportionment or right to
reimbursement.
It is my wish and desire that I be buried in Blain
Cemetery with all arrangements being handled through the
Nickel Funeral Home.
SECOND: I direct that my entire estate, whether
real, personal, or mixed and wheresoever situated, be
sold at public sale, liquidated, and converted to cash,
and the proceeds therefrom and all the rest, residue, and
remainder of my estate, I give and devise, in equal
shares, among the following of my children who survive
me: MARY LEE R. CROWL, JOSEPHINE I. RUOSS, WILLIAM H.
AMIG, VIRGINIA A. KESSLER, and TERRY L. AMIG.
In the event a child fails to survive me, that
child's share shall lapse and I give such share to those
children of mine, above-named, living at the time of my
death.
THIRD: In addition to all powers granted by law, I
give my Executrix, hereunder, the following powers, which
may be exercised without leave of court: to retain and. to
invest in .all forms of real and personal property; to
compromise claims and to abandon any property which is of
little or no value, if deemed appropriate to my Executrix;
to sell at public or private sale, to exchange, or to
lease for any period of time, any real or personal
property, or interest therein, and to give option for
sales or leases, and to give a good deed of conveyance
or bill of sale for the transfer thereof; to allocate-any
property received or charge incurred to principal or
income or partly to each, without being obliged to apply
the usual rules of Trust accounting; to distribute in cash
or in kind (according to the fair market value prevailing
at the time of distribution) or partly in each.
FOURTH: I nominate, constitute and appoint
STEPHANIE O'SHURA as Executrix of my Last Will and
Testament and my Estate. In the event STEPHANIE O'SHURA
is unable or unwilling to serve, I nominate, constitute
and appoint MARY LEE R. CROWL as Executrix of my Last Will
and Testament and my Estate.
FIFTH: I direct that no Executrix acting under this
Will shall be required to enter bond for the faithful
performance of duties, in any jurisdiction.
IN WITNESS WHEREOF, I, the said ELSIE E. AMIG, have
hereunto set my h nd and seal, to this my Last Will and
Testament, thisf~ day of December,. 1999.
(SEAL)
E S E E . AMTG
HEfJCfi AND GRESSLER
ATTORNEYS AT LAW
224 MARiO=T STREET
NEWPORT PA 17074
TEL (717) 5673139
FAX 017) 567.3130
MILLERSTOWN OFFICE
TEL ~1n 5ss•77a7
The writing contained in this and the preceding
sheet was signed and sealed by the above named, ELSIE E.
AMIG, and by her published and declared as and for her the
Last Will and Testa ent, in the presence of us, who have
here to subscrib our ames as witnesses at her request,
in , er pnc~.
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Th
e ~Cirl~O~ LCi[1~15~ti1' ESTABLISHED 1903
~
P.O. BOX 179 LANDISBURG, PA 17040
Bank records indicate the following account '~'~ JUN 2 G 2009.
balances on November 3, 2008 for: ~tl~ E,
Rw, F: f
Elsie E. Amig SS# 197-03-9141 ~~ ~-
1750 Stoney Creek Road
Dauphin, PA 17018
Acct Sole Jt. Acct. Account Type Balance Interest Accrued
Opened Ownership With Number Bearing Interest
4/1/1985 Yes 2621843 DDA $1,158.77 No $0.00
10/5/1995 Yes Irrevocable Burial Fund 700006352 CD $10,252.21 Yes $35.06
Respectfully,
Community Offi Manager
~,~~~
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DNISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-6486
June 23, 2009
ALLEN E HENCH
ALLEN E HENCH ESQ
LAW OFFICES
224 MARKET ST
NEWPORT PA 17074
f~~~ SUN 2 ~ 2009 ;,,
!~ ~ ~~
Re: ELSIE AMIG
CIS #: 001037415
SSN: 197-03-9141
Date of Death: 11/03/2008
Dear Attorney Allen E Hench:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $189,565.05 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 $28,107.23, 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 $161,457.82,
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,
i~.c~-J
Karin L. Tyler
Claims Investigation Agent
717-772-6614
717-772-6553 FAX
Enclosure
ALLEN E. HENCH
LAW OFFICI=S
220 MARKET STREET
(CORNER OF MARKET AND SECOND & ONE=HALF' STREET)
NEWPORT PENNSYLVANIA 'I 7074
c~ i ~ ss~-3 i 39
Fax HuMaER (717) 567-3130
Email: attorneY~a7~pa.net
August 5, 2009
Cumberland County Register of Wills
1 Courthouse Square
Room 102
Carlisle, PA 17013
Re: Estate of Elsie E. Amig
File Number: 21-09-0542
Dear Register:
I enclose two (2) original Rev-1500 Pennsylvania Inheritance Tax Returns for
filing in the above referenced Estate. I also enclose a check in the amount of $15.00 for
the filing fee.
I also enclose an additional copy and ask that you please time stamp this and
return to me in the self-addressed stamped envelope provided.
If you need anything further, please let me know.
Thank you.
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Sincerely, .-,
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Enclosure
cc: Stephanie O' Shura
7-30-09W
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