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HomeMy WebLinkAbout09-21-09 (2)J REV-1500 1505607120 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO 60X.280601 21 0 9 0 015 3 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 191184269 12242008 08111925 Decedent's Last Name Suffix Decedent's First Name MI ZULLINGER DOROTHY 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 Retum ^ 3. Remainder Retum (date of death prior to 12-13-82) ^ 4. Limited Estate ^ qa, Future Interest Compromise ^ 5. Federal Estate Tax Retum Required (date of death after 12-12-82) ^ g Decedent Died Testate ^ ~• gttsach Copy of Trust)a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) ( ^ 9. Litigation Proceeds Received ^ 10~ be~nveenP2-31`ty9Craerdit;datge5jf death ^ 11.Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: fVame Daytime Telephone Number HAMILTON C DAVIS 717532513 a r_ o Firm Name (If Applicable) . E : ;'. ZULLINGER DAVIS, PC REGISTEROL~USE~LY ? ~' First line of address '='' c~ ~ --- 20 EAST BURD STREET, SUITE 6 ~©~,~, ~ '' =' Second line of address -~~-i , 'n .~- - DATE FILED ~'"~ City or Post Office State ZIP Code SHIPPENSBURG PA 17257 Correspondent'se-mail address: HCD@hamiltondavislaw.com 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. SIGNATURE OF S RESPO R FILING RETURN DATE • ROY S. ZULLINGER, JR. _ /, a ADDRES 444 WHI MER ROAD, SHIPPENSBURG, PA 17257 SIGNATU OF PREPA R OTHER THAN R RESENTATIVE DATE Hamilton C Davis ~ ADDRESS 20 East Burd Street, Suite 6, Shippensburg, PA 17257 Side 1 1505607120 1505607120 1505607220 REV-1500 EX Decedent's Social Security Number DecedenYsName: ZULLINGER, DOROTHY M. 191184269 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. 5. 6. 7. 8. Mortgages & Notes Receivable (Schedule D) .......................................................... Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ............. Total Gross Assets (total Lines 1-7) ....................................................................... 4. 5. 6. 7, 8. 4 4 , 3 3 8 . 7 6 4 , 3 3 $ . 7 6 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 1 , 5 9 6 . 2 5 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 4 2 , 0 6 4 . 0 2 11. Total Deductions (total Lines 9 & 10) ...................................................................... 11. 4 3 , 6 6 0 . 2 7 12. Net Value of Estate (Line S minus Line 11) ............................................................. 12. 6 7 8 . 4 9 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. 6 7 $ 4 9 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 at lineal rate X .045 6 7 8. 4 9 16. 3 0 . 5 3 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 1 t3. 19. Tax Due ..................................................................................................................... 19. 3 O . 5 3 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505607220 1505607220 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 09 - 00153 ZULLINGER, DOROTHY M. STREET ADDRESS SHIPPENSBURG HEALTH CARE CENTER 121 WALNUT BOTTOM ROAD CITY STATE ZIP SHIPPENSBURG PA 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 30.53 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Total Credits (A + B + C) InteresUPenalty if applicable (2) 0.0 0 p, Interest E. Penalty 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. (4) 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. (5) 30.53 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 3 D . rJ 3 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 :.................................................................................. ^ O b. retain the right to designate who shall use the property transferred or its income :.................................... c. retain a reversionary interest; or .................................................................................................................. ^ x^ 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^ 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 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. SCHEDULE E CASH, BANK DEPOpSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA i PERSONAL PROPERTY INHERITANCE TAX RETURN v7 /1 fl I RESIDENT DECEDENT FILE NUMBER ESTATE OF ZULLINGER, DOROTHY M. 21 - 09 - 00153 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 ORRSTOWN BANK CHECKING ACCOUNT NO. 311669 36,369.77 2 ACCRUED INTEREST ON NUMBER 1 2 gg 3 SHIPPENSBURG HEALTH CARE CENTER REFUND 7,966.00 TOTAL (Also enter on Line 5, Recapitulation) 44,338.76 i H COMMONWEALTH OF PENNSYLVANIA ~~ INHERITANCE TAX RETURN eM~\OG~'7'fl ATI~/L f'-~1~-TG- RESIDENT DECEDENT gyn. x~~h7 ~ IW ~ ~YG N1J~7 ~ ~7 FILE NUMBER ESTATE OF ZULLINGER, DOROTHY M. 21 - 09 - 00153 Debts of decedent must be reported on Schedule L ITEM NUMBER ~ FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 ;PRE-PAID B. I ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): ~ Street Address City State Zip Year(s) Commission paid 2. Attorney's Fees HAMILTON C. DAVIS, ESQUIRE 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 CUMBERLAND COUNTY LEGAL JOURNAL -LEGAL ADVERTISING TOTAL (Also enter on line 9, Recapitulation) 1,400.00 75.00 1,596.25 Schedule H Funeral E~enses ~ COMMONWEALTH OF PENNSYLVANIA /,~1n~~1~.,~ ^~,,,,~ ~n~ INHERITANCE TAX RETURN F~M.N ~ ~ YYG VW RESIDENT DECEDENT ESTATE OF ZULLINGER, DOROTHY M. THE NEWS CHRONICLE -LEGAL ADVERTISING FILE NUMtStK 21 - 09 - 00153 121.25 Page 2 of Schedule H SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF ZULLINGER, DOROTHY M. 21 - 09 - 00153 Include unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE CLAIM 35,475.02 2 I OUTSTANDING CHECK ISSUED TO SHIPPENSBURG HEALTH CARE CENTER PRIOR TO I 6,589.00 DATE OF DEATH I TOTAL (Also enter on Line 10, Recapitulation) I 42,064.02 REV-1513 EX+ (8-00) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ZULLINGER, DOROTHY M. 21 -09-00153 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee(s) I TAXABLE DISTRIBUTIONS [include outright spousal . distributions, and transfers under Sec. 9116 (a) (1.2)] 1 ROY S. ZULLINGER, JR. i Son RESIDUE 678.49 444 WHITMER ROAD I SHIPPENSBURG, PA 17257 Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropriate, on Rev 1500 cover 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-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 RUG 27 2009 2:35Ph! HP LRSER.?ET 3200 C~P;RST~T B A Tradition of Excellence August 27, 2009 To; Zullinger -Davis 20 East Burd Street Suite b Shippensburg Pa ]7257 From: Txaci Yohe Orrstown Bank Customer Service Center 1?O BOX 250 Shigpensburg, Pa 17257 Re: Estate of Dorothy M Zullinger Date of death December 24, 2008 IT 1S HERF.RBY CERTIFIED THAT THE ABOVE NAMED DECEDENT, aN THE ABOVE DATE, HAD THE F©L.I;DWINO ACCO LINTS WITH DRRST~WN BANK: CHECIffNG ACCOUNT Account Title of Account Data opened Principal Accrued Interest 3l 1669 Dorothy M Zullinger 6/01/73 36, 369.77 2.99 SAYINGS ACCOUNT Account # Title of Account Date opened rind al Accrued Interest CERTIFICATE DF DEPOSIT Account # Title of Account Date Opened Principal Accrued Interest P.O. Box 25d • Shippensburg, PA 17257 • 717,530.3530. 717.532.4143 fax A~i~ ~ y f u~9 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION pF THIRD PARTY LIABILITY ESTATE REOOVERY PROGRAM PO BOX 8486 HARRISBURG, PA M17105-8486 April 13, 2009 HAMILTON C. DAVIS PO BOX 40 SHIPPENSBURG PA 17257 Re: DOROTHY ZUI,LINGER CIS #~: 560186707 55N: 191-18-4269 Date of Death: 12/24/2008 Dear Mr. Davis: Please be advised that the Department of Puhlic Welfare maintains a claim in the amount of $35,475.02 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 $.OD, 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 $35,475.02, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate corxtains real estate, please grovide copies of the deed, the latest taar~ assessment, and a current appraisal, i.f available. Sincerely, ~.,~,., Susan A. Spracklen Claims Investigation Agent 717-772-6741 717-772-6553 FAX Enclosure I COMMONWEALTH OF PENNSYI-VANW DEPARTMENT OF PUBLIC WELFARE BUREAU OF fiNANC1AL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8488 . HARRISBURG PA 17105-8488 April 10, 2009 STATEMENT OF CLAIM SUMMARY 'NAME ~. Estate ofi ZULLINGER, DOROTHY •~1-1D,:, __ 55018b 707 ~- 111E[31CAL pgt}~ g~MENT 70 b i~ 35,475.D2 ~ 35,475.02 .OD OF Pi=R1N5YLv1±Nl~`` er ': - ,~OMlwb1J1~~L~ _ ' ' D1tRA~?~E~r~~ PUBL(C W ~LFARE ~'• ~f~ ':~~3 60031:13 ,. :. ,_ 'CQMMpN1NEALTH OF PENNSYL`JP.NIA ;, , " QEPARTP~IENT OF PUBi1C WELFARE April 10, 2009 STATEMENT OF CLAIM _;; - 3g '.fiIAME`: 2:ULLINGER, DOROTHY ~D 560 186 707 SHIPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM RD 3HIPPENSBURG PA 17257 011D1I07 - 01!31!07 DIAGNOSIS 1 : 4389 DIAGNOSIS 2 : 25DD0 PROC CODE : OODDOD 03101107 - 03/31107 DIAGNOSIS 1 : 4389 DIAGNOSIS 2 : 25000 PROC CODE : 000000 44101107 - 04130!07 DIAGNOSIS 1 : 4389 DIAGNOSIS 2 : 254D0 PROC CODE : ODOD00 D5101107 - D5I31107 DIAGNOSIS 1 : 4389 pIAGNOSIS 2 : 2500D PROC CODE : OODD00 46101!07 - 06130!07 DIAGNOSIS 1 : 4389 DIAGNOSIS 2 : 25000 PROC CODE : 000000 D71D1107 - 07131107 DIAGNOSIS 1 : 4389 DIAGNOSIS 2 : 25000 PROC CODE : 000000 0$!01!07 - 08!31!07 DIAGNOSIS 1 : 4389 D1AGN051S 2 : 25080 PROC CODE : 000400 D9101107 - 09130107 DIAGNOSIS 1 : 4389 DIAGNOSIS 2 : 25000 PROC CODE : 000000 11/05/07 90073044D3D050001 90473044030050001 Ui+ISPECIFIED LATE EFFECTS DIABETES MELLITUS WITHO 11105!07 90673044030870001 90673044030070DD1 UNSPECIFIED LATE EFFECTS DIABETES MELLITUS WITHO 0911D/07 20072474083750001 20472474083750001 UNSPECIFIED LATE EFFECTS DIABETES MELLITUS WITHO 091101D7 2D072474083734001 2007247408373DOD1 UNSPEC-FIED LATE EFFECTS DIABETES MELLITUS WlTHO 09110!07 20072474083710D01 2007247408371D001 UNSPECIFIED LATE EFFECTS DIABETES MELLITUS W[THO 10122107 55072894495060D01 5507289449506DOD1 UNSPECIFIED LATE EFFECTS DIABETES MELLITUS WITHO 10122!07 55D72894495460001 550728944954600D1 UNSPECIFIED LATE EFFECTS DIABETES MELLITUS WITHO 10!22107 55072894496140001 55072894496140001 UNSPECIFIED LATE EFFECTS DIABETES MELLITUS WITHO 1ARGES, .AMOUNTQPPROVED 5,716.09 4,496.89 5,716.09 4,457.89 5,478.3D 5,660.91 5,478.30 5,fifi0.91 5,660.91 5,478.30 4,220.10 4,402.71 4,220.10 4,059.27 4,059.27 3,887.90 ,. - `GOMMpNWf~ALTH OF PENNSYLVANIA . pEPp~RTN~ENT S~~,f'UBLIC WELFARE' April 10, 2009 STATEMENT OF CLAIM NAME} ~ ZULLINGER, DORO7HY D;i;:; 58D 186 707 SHIPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM RD HIPPENSBURG PA 17257 ;. . ,_ _ .: DATE,OF SEf2UICE PAYM!?NT DACE= ,. O.RIGINAL:,CRiJ ; j AA~US7E,D CRN ,= USUALCf~iARGES AMOUNTIIPPRO~!~Q: 10/01/07 - 10131/07 11!14/07 27073194024310001 27073194024310001 2,898.16 1,644.96 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 ; 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 'Pgd~l/!(t•~fj~ll~`TG7'!`~Lk~ ` SHIPPENSBURG HEALTH CARE CTR 47,747.97 35,449.09 ~~,t y f r ' ~ .; , 03 001550908 OD02 F ~ } ..~ ~} - ~ - ' COMMONWE,~,LTH OF PENNSYLVANIA . . , I' -DE;PARTfJiENT OF:P..IfBLIC WEEFARL MILLENNIUM PHARMACY SYSTl=M5 tNC 2250 MILLENIUM WAY STE 300 NOLA PA 17025 April 10, 2009 STATEMENT OF CLAIM :.;_;; ;NAME;:; ZULLINGER, DOROTHY i~';~'.=;, 560186 70T DATE I'JF SEIdVIGE ~ .~-< <. PAY1+!IEI~T MATE :- 'OI21G1t3HL CRN ' ~ r ..; ADJU`~TED 1CRN, ~ U5lJAL C{~f~RGES ~±AMOUNT RPPRQII~ 08!20107 - OS12DJ07 12110!07 25073205468460001 2507320548$460001 81.97 77.18 DIAGNOSIS 1 : 0 NDC CODE : OD0027510D1 HUMALOG 100 UNITSIML VIAL - DIABETIC THERAPY 091D6107 - 09106!07 10!01107 260724954D9D700D1 2507249540907D001 4.59 4.16 DIAGNOSIS 1 : 0 NDC CODE : 516724032D1 WARFARIN SODIUM 5 MG TABLET - ANTICOAGULANTS 09/07107 - 09/07/07 10!01167 250725D5621D50D01 25072505621050001 5.14 4.59 DIAGNOSIS 1 : 0 NDC CODE : 51672402701 WARFARIN SODIUM 1 MG TABLET - ANTIGOAGULANTS RROVIDER=SI~B TOTial. y, MILLENNUM PHARMACY SYSTEMS INC 92.70 25.93 - - ~ ' 24 001887261 0002 ~: ~, .N _~. ~ ,-;-