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HomeMy WebLinkAbout12-21-09 1505607120 ~~~~ ~oo EX (06-05) OFFICIAL USE ONLY PA Department of Revenue county code veer Fee Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box.2soso~ 21 0 9 0 6 0 6 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 196 48 1916 05 31 2009 02 04 1956 Decedent's Last Name Suffot ~ Decedent's First Name MI WEAVER JR. THEODORE S (ff Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Socal Security Number FILL IN APPROPRIATE OVALS BELOW X^ 1. Original Retum 4. Limited Estate B Decedent Died Testate (Attach Copy d Vftl~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Retum ~ 3. Remainder Retum (date of death prior to 12-13-82) qa Future Interest Compromise ~ 5. Federal Estate Tax Retum Required (date of death aRer 12-122) ~ Decedent MamtaMled a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copyroeon~rvTrust) 9. Litigation Proceeds Received ~ 10. betw~een72-311 a~ni_t~-s5jt ~~' ~ 11. Eler~ion to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number EARL RICHARD ETZWEILER (717) 234 5600 Finn Name (ff Applicable) ETZWEILER AND ASSOCIATES First line of address 105 NORTH Second line of address FRONT STREET Cily or Post Office HARRISBIIRG State ZIP Code PA 17101 N REGISTER O,)=aAIILLS USE~ILY ~_ ~ ~, .C ~ ~ ~ ~ -;~rn.. C'7 r. _ - ~ ; r . „ (T7 tV _ i '~ . y.1 _. C~'1 ( . _ ~ --i ,~ _~ ~ ..r~ ~ .) ,.~ ~;t::r IV ~ D LED ,•° N correspondent'se~tiaiiaddress: REtzweiler@Comcast.net Under es of perjury, I dedare that I have examined this return, induding aocomparrying schedules and statements, and to the best of my knowledge and belief, R is true and complete. Dedaration or preparer oti~than the personal represerttabve Is based on all information of which prepar~r has arty knowledge. SIGMA l~i OF 1 E~R N RESDeNS1aLe'Rd2 FILING RETUR DATE _ Theodore S. Weaver Sr. / z f ~$ 43 Parmer Drive, Halifax, PA 17032 SIGN/y'LLI(2E OF PREPARER OTHER THAN REPRESENTATIVE DATE Earl Richard Etzweiler ADDRESS / 105 North Front Street, Harrisburg, PA 17101 Side 1 1505607120 1505607120 J REV-1500 EX osN~: Theodore S. Weaver Jr. Decedent's Social Security Number 196 48 1916 RECaPITULanoN 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 3. Closet' Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. Mortgages ~ Notes Receivable (Schedule D) .......................................................... 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ................ 5. 6. Jointy Owned Properly (Schedule ~ ~ Separate Billing Requested ......:...... 6. 7. Inter-Vroos Transfers 8~ Miscellaneous Non-Probate Properly (Schedule G) ~ Separate Billing Requested ............. 7. 8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 3,750.00 3,750.00 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens {Schedule I) ................................ 10. 11. Total Deductions (total Lines 9 8 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 .00 0 . 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 0 . 0 0 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 . 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 18. 19. Tax Due .................................................................... ................................................. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 15D56D722D 2,606.95 39,122.14 41,729.09 -37,979.09 -37,979.09 0.00 0.00 0.00 0.00 0.00 Side 2 15D56D722D 15D56D722O J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-09-0606 DECEDENTS NAME Theodore S. Weaver Jr. STREET ADDRESS 6405 Glenwood Street, Apt. #8 CITY Mechanicsburg STATE PA ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 0.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 0.00 Total Credits (A + B + C) (2) 0.0 0 3. interest/Penalty if applicable p. Interest E. Penally Total Interest/Penally (D + E) (3) 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) 0.0 0 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) Q , Q Q Make Check Payable to: REG-STER 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. n:tain the use or income of the property transferred :.................................................................................. x b. retain the right to designate who shall use the property transferred or its income :......................:............. x _ c. retain a reversionary interest; or .................................................................................................................. x d. receive the promise for life of either payments, benefits or care? .............................................................. x 2. If death occurred after December 12, 1982, did decedent transfer property wfthin one year of death wfthout receiving adequate consideration? ....................................................................................................................... ^ 3. Did decedent own an "in trust for or payable upon death bank acxount or security at his or her death?......... ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate properly 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 Juy 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surv'ving 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) (i~]. 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 ff the surv'ving spouse is the only benefiaary. 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 p2 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. Rev-1606 D(r (&iNl) SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY Kni of rve+srwANrA WF~tIrANCE TAX REILRN I~SIDENT DECEDENT ESTATE OF FILE NUMBER Weaver, Theodore S. Jr. 21-09-0606 IncNide the proceeds a r6iya~wn and the eats the proceeds were received ~r the estate. All Properly Jolydly-owned wHh the rfyM or survivorsldp mud be dfecloesd on scMduh F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Bob Reed, purchase of 15' 9" Coleman stenos 200.00 2 RTR -Route 22 Storage, refund of portion of storage fee 25.00 3 Dennis Webster, purchase of 1991 Ford T-bird in poor condition 275.00 4 Donald Hale, purchase of 10 yr. motor outboard 150.00 5 Robert Bowman, purchase of washer and dryer 50.00 6 Service Supply Corp., purchase of scaffolding and concrete ties, etc. 1.750.00 7 Tim Miller, purchase of 1995 Ford tuck 500.00 8 Tim Miller, purchase of miscellaneous tools, supplies, etc. 800.00 TOTAL (Also enter on Line 5, Recapitulation) I 3,750.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software ony The Lackner Group, Inc. Forrn PA-1500 Schedule E (Rev. 6-98) REV-1161 p(+ (129) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~ INRESDENTDECEDENTR" ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Weaver, Theodore S. Jr. 21-09-0606 Debts of decedent must be reported on Schedule 1. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Theodore S. Weaver Sr. Social Security Number(s) / EIN Number of Personal Representative(s): Street Address 43 Parmer Drive City Halifax State PA Zip 17032 Year(s) Commission paid 2, Attorney's Fees Earl Richard Etzweiler 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 900.00 900.00 4. Probate Fees 81.00 5. Accountant's Fees 6. Tax Return Preparers Fees 7. Other Administrative Costs 725.95 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 2,606.95 Copyright (c) 2002 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Weaver, Theodore S. Jr. 21-09-0606 ITEM NUMBER DESCRIPTION AMOUNT Other Administrative Costs 1 Dauphin County Reporter, advertise Letters of Administration 75.00 2 Etzweiler 8 Associates, postage, photocopies, etc. 50.00 3 Paxton Herald, advertise Letters of Administration 48.00 4 Register of Wills of Dauphin County, Executor take Oath 20.00 5 Theodore S. Weaver, Sr., mileage incurred to settle estate 532.95 H-67 subtotal 725.95 Copyright (c) 2002 form software ony The Lackner Group, Inc. Form PA-1600 Schedule H (Rev. 6-98) Rev-1612 p(+ (6-88) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS COFe AONINFALT}1 of PEr-wsnv~r6n MgWTANCE TAX RETURN RE6DENT DECEDFNi ESTATE OF FILE NUMBER Weaver, Theodore S. Jr. 21-09-0606 Include unnimburssd medlpl axpeneea. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Associated Cardiologist, outstanding medical bill 2,300.00 2 Camp Hill Emergency Systems, outstanding medical bill 890.00 3 CTI Networks, outstanding internet~ bill 16.00 4 Direct TV -final satellite bill 85.01 5 Dirtywork Enterprise, clean out apartment 100.00 6 Dirtywork Enterprise, clean out apartment 300.00 7 Dirtywork Enterprise, clean out apartment - pd. 7127/09 185.00 8 Holy Spirit Hospital, 1st outstanding hospital bill 17.350.85 9 Holy Spirit Hospital, 2nd outstanding hospital bill 13.339.70 10 Mid Penn Bank Checking Account#9012147 -negative balance 498.43 11 PPL Electric Utilities -past due bill when Decedent died 481.90 12 Quantums Imaging, outstanding medical bill 36.50 13 Quest Diagnostics, outstanding medical bill 42.85 14 South Central EMS, outstanding ambulance bill 1,160.85 15 Spirit Physicians Services, outstanding medical bill 815.00 16 T-Mobile, outstanding cell phone bill 186.01 17 The Battery Warehouse, two batteries for vehicles 121.88 Total of Continuation Schedule See attached page TOTAL (Also enter on Line 10, Recapitulation) 39,122.14 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-11500 Schedule I (Rev. 6-98) Rw-1b72 p(+ (~) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS CoNMONwEn~TM of PENNSnvANw continued INHHtRANCE TAX RETURN RESDENi DECEDENT ESTATE OF (FILE NUMBER Weaver, Theodore S. Jr. 21-09-0606 Copyright (c) 2002 form software ony The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-~s~s or+ (cool SCHEDULE J COMMO A"iA ~RA ~ XE C BENEFICIARIES RETURN N E A E RESIDENT DECEDENT ESTATE OF FILE NUMBER Weaver, Theodore S. Jr. 21-09-06 06 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) 0o Na ua T I TAXABLE DISTRIBUTIONS [nclude outright spousal f ~ distributions, and trans ers under Sec. 9116(a)(1.2)] Melissa A. Smith Daughter 33 Sylvia Drive Depew, NY 14043 Total Enter dollar amounts fordistributions shown above on lines 1 5 through 18, as appropn ate, on Rev 1500 cove r 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 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1600 Schedule J (Rev. 6-98) PO Box 67015 Harrisburg, PA 17106-7015 RETURN SERVICE REQUESTED 07/31/09 ENU323/OD1 201703704 000155010007 ~'II~II~II~~I~111~~'fl~~ll'Ill~l~~ll~l~ll~if~l~~lll~~~lllll~l~~l~ Theodore Weaver 43 Parmer Dr Halifax, PA 17032-9671 ASSOCIATED CARDIOLOGIST 856 CENTURY DRIVE MECHANICSBURG PA 17055, ACCT#: ENQ323 DUE DATE: 08/10/09 AMOUNT DUE: $2,300.00 AMOUNT PAID: SEND TO: ASSOCIATED CARDIOLOGIST C/O Business Office Solutions PO Box 67015 Harrisburg, PA 17106-7015 ~~u~~~n~~u~~~~~nn~~n~~n~~~nun~~~~~~n~~~~~ ENTER ADDRESS OR INSURANCE CHANGES ON BACK AND CHECK HERE - ***PLEASE DETACH AND RETURN IN THE ENCLOSED ENVELOPE WITH YOUR PAYMENT*** STATEMENT OF ACCOUNT * Below is a listing of all accounts included in the amount due: ASSOCIATED CARDIOIAGIST 261415 04/15/09 52,300.00 PLEASE PAY THIS AMOUNT: $2,300.00 THIS BALANCE IS DUE BY 08/10/09. ANY QUESTIONS PLEASE CALL 1-800-360-2998 EXT 6728. TO USE MASTERCARD, VISA OR DISCOVER SEE BACK OF THIS NOTICE. ACCOUNT MONTTORING CONDUCTED BY BUSINESS OFFICE SOLUTIONS. ***PLEASE RETAIN THIS PORTION FOR YOUR RECORDS*** THE "PLEASE PAY THIS AMOUNT" REPRESENTS THE BALANCE WE ESTIMATE YOU OWE. ANY BALANCE UNPAID BY YOUR INSURANCE WILL BE DUE FROM YOU...THANK YOU ID #: ENQ323 Calls to or from Business Office Solutions maybe monitored or recorded for quality assurance. HBCS 242 NORTHGATE DR1VE, SUITE L110 ~~~ SALISBURY, MD 2L801 Temp-Return ServicewwRequested ° ~IIII~~II~II~~~IINI <P;l~~~ix6~~#~> OCT 2-I 2009 Date of Service: Ol/05/09 Original Creditor: HOLY SPIRIT HOSPITAL Patent Name: Theodore s Weever Patient Responsibilit}~: ~~'~3'~.~D.``.I#~>~ Account Number: 33656208 ~saas-ion, THEODOR S WEAVER 8'~,~ 43 PARMER DR HALIFAX, PA 17032-9671 M ~n 4 a Dear Theodor S Weaver: N ~ Your account has been assigned to us for collection. In order to avoid fiiriher collection activity. please send payment in full or contact our office at: 1-8110-323-1023. Unless tiou notify this office within 30 days after receiving this notice that you dispute the validity of this debt or anY portion thereof, this office will assume the debt. is valid. If you norifv this office in writing within 3U da}'s from receiving this notice, this office will: obtain verification of the debt or obtain a copy oi' a judgment: and mail you a copy of such judgment or verification. [f you request this office in writing «~itlun 30 days after recewing this notice, this oft`ice will provide you with the name and address of the original creditor, if different from the current creditor. This communication is from a debt collector. Sincerely, Collection Division 1-8(>0-323- l U23 Hours: Monday-Thursda}~ 8:OOam-9:OOpm. Frida}~ B:OOam-S:OOpm F.ST. Payments received will be applied to the oldest account. To lkwe your payment applied to a specific account, please call the toll free number listed above. Hospital Billing & Collection Service, Ltd. is a debt collector that is attempting to collect a debt and any information obtained will be used for that purpose. _ _ If Payment Has Already Been Ntade Please Disregard This Letter , ~ Bo-ones-sass-~o» PLEASE RETURN THIS PORTION WITH YOUR PAYMENT Re: HOLY SPIRIT HOSPITAL Patient Name: Theodore s Weaver Account Number: 33656208 .......................... Patient Responsibility: ~.,*~< ~; a N A 05301 51 OOOOOOOODD000000000 006766940 8 D17350B5 0 Payment Amount $ HBCS PO BOX 83172 WOBURN MA 01813-3172 Ill~tttt~lllt~itt~tilttlltttllt~t~llit~tlt~ltllt~tittll,~l~l,I 1 of 1 I~ ' COMPUTEE~ CREDIT, ING. CLAIM DEPT 082515. 640 West Fourth Street . Post Office Box 5238. Winston-Salem, NC . 27113-5238 .336-761-1538 September 08, 2009 148 SH510 36834 0543107894 Theodore S Weaver Jr For: Weaver Jr, Theodore S 6405 Glenwood St Apt 8 Mechanicsburg, PA 17050-1979 u~~~~n~~~~un~~~~~~nnn~~~~~n~n~~~~~u~~n~~n~n~~~~ Holy Spirit Hospital Attention: Patient Financial Services Telephone: (717) 763-2138 ACA INiBANAiIONAL 'Ibt Mwciari°n °f C.aedit and Colkcdon PmE~amb Acct. No. 34371633 A Date of Service: 04-15-09 AMOUNT DUE $13,339,70'-: Dear Theodore S Weaver Jr: You have failed to resolve your financial obligation to Holy Spirit Hospital. Your overdue balance remains unpaid, despite our previous attempt to collect it from you. This is a serious matter and we expect payment. Computer Credit, Inc. is a debt collector and a member of ACA International, the Association of Credit and Collection Professionals. Unless you dispute the validity of the amount owed, you must satisfy your debt of $13,339.70. This is an attempt to collect a debt and any information obtained will be used for that purpose. Your cooperation is anticipated. C. Jordan Director of Operations To learn more about why you received this letter, you may contact CCI ~www.infocxnatiancci.com login-code: 0543107894 WMP Return this portion with your payment ~ .- • ~ ^® ^® ^ CARD NUMBER EXP DATE SECURITY CODE AMOUNT SIGNATURE PRINT CARDHOLDER'S NAME LL BILLING ZIP CODE Computer Credit, Inc. 1610 z"id` ""` CCI KEY: 0543107894 PATIENT I~fAMI , Weaver:J r, The©dor8 5 AMOUNT.DIJE ' $13,339'~Q You may make check payable to: Holy Spirit Hospital P.O. Box 822183 Philadelphia, PA 19182-2183 ~n~~~~~~un~~~~u~nl~~~n~~~n~~~~n~n~~~~~n~n~~~n~u~~ __ . - South Central EMS, Inc. Gp 8065 Allentown Blvd. [[ HARRISBURG, PA 17112 (888)463-3488 Federal Tax ID: 23-7096198 Patient Name: THEODORE WEAVER Patient Number: 17836 Call Number. 0902212 Date Of Call: 04/13/2009 Caller: 911 or Equivalent From Location: 310 FEESER RD To Location:HOLY SPIRIT HOSPITAL THEODORE WEAVER Membership Status Not a Member 6405 GLENWOOD ST, APT 8 Reason(s) 518.82 MECHANICSBURG, PA 17050 For 782.5 Transport 401.9 780.8 DESCRIPTION OF CHARGES HCPC QUANTITY UNIT PRICE AMOUNT Advanced Life Support 1 Emerg. A0427 1.0 850.00 850.00 Cardiac Monitor 20224 1.0 120.00 120.00 Ground Mileage A0425 12.0 10.00 120.00 Oxygen Administration A0422 1.0 70.00 70.00 Total Charges 1160.00 Total Credits 0.00 PLEASE PAY THIS AMOUNT => 51160.00 Credit card payments may be online at www.ambcoach.com "DETACH ALONG ABOVE LINE AND RETURN STUB WITH YOUR PAYMENT" Patient Name: WEAVER, THEODORE Patient Number: 17836 Call Number: 0902212 Current Date: 07/13/2009 Amount Due: 51160.00 Amount Enclosed $ This account is now OVER 50 DAYS PAST DUEI! Payment must be received WITHIN 15 DAYS, or we will have no choice but to refer this account for further COLLECTION ACTIVITYI South Central EMS, Inc. 8065 Allentown Blvd. HARRISBURG, PA 17112