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Home My WebLink About02-11-1015056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Departrnent of Revenue Bureau of Individual Taxes INHERITANCE TAX RETURN C~wnty Code Year File Number PO BOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 194-26-6303 05/11 /2009 11 /16/1936 Decedent's Last Name Suffix Decedent's First Name MI MARTZ JOSEPH E Ilt Applicable) Entsr Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Soaal Security Number THIS RETURN MUST BE FILED IN DUPLICATE WRH THE REGISTER QF WILLS FILL IN APPROPRIATE OVALS BELOW Cif.? 1. Original Retum ~ 2. Supplemental Retum t~ 3. Remainder Retum (date of death prior to 12-13-82) C:~ 4. Limited Estate C r3 4a. Future Interest Compromise (date of C~ 5. Federal Estate Tax Retum Required death after 12-12-82) ~~ 6. Decedent Died Testate +~ 7. Decedent Maintained a Living Trust _ _ 8. Thal Number of Safe Deposit Boxes (Attach Copy of X11) (Attach Copy of Trust) t~~a 9. Litigation Proceeds Received C~ 10. Spousal Poverty Credit (date of death C~.'~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTI~I MUST f3E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number JODIE L. ROOT (717) 796-2190 Firm Name (If Applicable ) ~, ~.,..- ~ ' REGISTER~LS USE ~ 'I +~? 1 ~ 1`}i .? i ' t~,7 First line of address ~ rn '~- 32 CRESCENT DRIVE , - ~~ ~'~' ~ -"' ~ =` ' F-~~ , ; K Second line of address t:~;> C7 ~~ ~ ' ' } ~ 7 C ~ -I ~ ,;w~- - :..~ "7'i City or Post Office D~TE FILED ~ State ZIP Code ~- - __ _ ~~~~ t . NEW CUMBERLAND PA 17070 Correspondent's e-mail address: Jt'OOt32i~COt11C8St.l1@t under penalties of perjury, I dedare that I have examined this return, inducting accompanying sdiedules and statements, and to the best of my knowledge and belief, it is true, oared an plate. Dedaretbn of preparer other than the personal representative is based on all information of which prepar+er has any Imowledge. SIGNATURE O RS S'PONSIB F FILING TURN DATE 02/10110 ADDRESS 32 CR SCENT DRIVE, NEW CUMBERLAND PA 17070 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE AUUKt55 ~ - PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 15056052059 REV-1500 EX Decedents Social Security Number Decedent's Name: JOSEPH E MARTZ 194-26-6303 RECAPITULATION 1. Real estate (Schedule A) ......................................... .... 1. 0.00 2. Stocks and Bonds (Schedule B) ................................... 2. .... 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00 4. Mort a es 8 Notes Receivable Schedule D 9 9 ( ) ......................... 4. .... 0.00 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .... .... 5. 11,042.58 6. Jointly Owned Property (Schedule F) Separate Billing Requested ... .... 6. 0.00 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested.... .... 7. 0.00 8. Total Gross Assets (total Lines 1-7) ................................ .... 8. 11,042.58 9. Funeral Expenses 8~ Administrative Costs (Schedule H) ................. .... 9. 4,066.96 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ .... 10. 1,512.66 11. Total Deductions (total Lines 9 & 10) ............................... .... 11. 5,579.62 12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. 5,462.96 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................... .... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .... 14. 5,462.96 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 .o 0.00 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 5,462.96 16, 245.83 17. Amount of Line 14 taxable 0 00 0 00 . at sibling rate X .12 17. . 18. Amount of Line 14 taxable 0 00 0 00 . at collateral rate X .15 18 . 19. TAX DUE ..................................................... .... 19. 245.83 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV 1500 EX Page 3 File Mgt Decedent's Complete Address: a.o...~._...J ~.....~...~ DECEDENTS NAME ...~..._ .__.. ..,.. DECEDENTS SOCIAL SECURITY NUMBER _ JOSEPH E MARTZ 194-26-6303 STREETADDRESS - -- -- 825 MARKET STREET CITY - STATE ~p LEMOYNE PA 17043 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1 j 245.83 2. Credits/Payments A. Spousal Poverty Credit _ __ _ B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total InterestlPenalty (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 Z, Lure 20 to request a refund. (4) 0.00 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 245.83 A. Enter the interest on the tax due. (5A) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 245.83 Make Check Payable fo: REGISTER OF W1LLS, 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 transfemed :.............................................. b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... d. receive the promise for life of either payments, benefi#s or care? ...................................................................... ^ ^ 2. ff death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 3. Did decedent own an "in trust for* or payable upon death bank account or security at his or her death? .............. ^ ^ Q 4. Did decedent own an Individual Retirement Account, annuit)r, or other non-probate property which contains a benefiaary designation? ........................................................................................................................ ^ 0 IF THE ANSWER TO ANY OP 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 (O) 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 benefiaaries is four and one-hal# (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. ~wsa sorts E~oat ° y~ 3 . - ~ :: m 7110 ` . a ~ ~ c ~ ~._ ~_ ~'`~ n ~ ~ ~ ~ ~~ ~ _• . ~ `~ !~- U . N ~D .~ ~ }` ~ A - ~ _ ^, .~ 1 ~ ~ O C _ ~` ~ .t . ~ 1ti.. ~. (~ ~ -.` F ..J •~ ~ C '' ` ~ ~'~ 1~ 2 ._ p .fie •~•t ~, i ' m a - ~. ~: _- ~ ~' n r ~ ~ ~ ~ ^ v ~ ~ ~ `~ v= m ~~ ~ ~. ~ .. ~ _ ~ . ~~'' .~ ~ Z ~~ `uj ~, ~ ,~ _ n ~.! r.. ~ ~~ .W ~'~_ `~~, ;- m ) ~ • , ~ ' ` ~ W ~ ' f • ... REV-1511 EX+ (10-09) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT 2. ~ NICHE PURCHASE - PATRICIA A. MARTZ ESTATE OF FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' STONE-MURRAY FUNERAL HOME B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address CREMATION 1,800.00 DEATH CERTIFICATES 36.00 CLERGY 125.00 TAX 60.00 INTERMENT RIGHTS W/NICHE PLATE 720.00 INTERMENT ~ RECORDING FEE 385.00 SERVICE CHARGE EXPENSE 302.90 City Year(s) Commission Paid: Z• Attorney Fees: 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant 4. 5. 6. ~. $. 9. 10. 11. Street Address Gty State Relationship of Claimant to Decedent SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS State ZIP ZIP Probate Fees: Accountant Fees: Tax Retum Preparer Fees: NICHE TRANSFER FEES -ROLLING GREEN CEMETARY HOME DEPOT -GLOVES & MASKS TO CLEAN APARTMENT TIGER TRASH - DUMPSTER TO CLEAN APARTMENT PP ~ L - 6/09 - 7/09 - PP&L - TO CLEAN APARTMENT USPS -ADDRESS FORWARDING FOR MAIL 76.00 0.00 0.00 120.00 9.82 395.00 36.24 1.00 TOTAL (Also enter on Line 9, Recapitulation) ($ 4,066.96 If more space is needed, use additional sheets of paper of the same size. THE Ht7ME DEPC)T 4120 6000 CARLISLE PIKE, MECH PA 17055 STORE MANAGER CHET KEf=LEY (7171795-9602 4120 00057 86033 06/13/09 SALE 14 SCOT57 11:59 AM suss . ~~~'. 641817002094 NTOXMASKS SA> 202.46 4.92 662909291158 10CT GLOVE <A> ' 046677104580 100W4PK <A> 3.47 SUBTOTAL 0`87 SALES TAX 9.26 TOTAL 0.56 ,~(XXXXXX;{X5074 VISA ~9 ~ 82 AUTH CODE 020041/1573934 9.82 TA f ~ • 4120 57 86 33 0t1/ 3/2009 30 3 RETURN POLICY DEFINITIONS POLICY ID DAYS POLICY EXPIRES ON A 1 90 09/11/2009 THE HOME DEPOT RESERVES THE RIGHT t0 LIMIT / DENY RETURNS. PLEASE SEE THE RETURN POLICY SIGN IN STORES FOR DETAILS. GUARANTEED LAW ~ICE5 LOOK FOR THOUSAN[y; pF LOWER PRICES ST4RENIDE ~c:r~cx~r~r~c~rx~cx~r~r~rrc~c~r~rrc~c~rx:~c~c~ ,~~r~r~c~cx - k~~k~~ ENTER FUR ~+ CHA,~, -ro ~=N ~ ~~ , ootE HOME DEPaT GIFZ CAPD !~ '> Share Your Opinion With Us! Complet the brief survey about your store visl and enter for a chance to win at: www.homedepot.:am/opinion +PARTIG=PE EN UNA . UPORTUNIDAD DE GANAR UNA TARJETA DE REGALC7 DE T HD DE $~ , UOt~ t iComparta Su Opir~ibn! Complete la breve encuesta sobre su visits a la tienda y tenga la oportunidad de ganar en: www.homedepot.comlopinion T R A S H Return Top Portion with Payment To: Tiger Trash P.O. Box 2444 York, PA 17405-2444 28393 Jodie Root 32 Crescent Dr BNew Cumberland, PA 17070 Date Invoice Paae 6/29/09 101783 1 Total Invoice o . 00 PPL Electric Utilities Electric Service Fur: JOE IViARTZ 825 MARKET ST, 1ST FL RIGHT LEbiOYNE PA 170}3 Final Bill Questions about this bill? Please contact us b A 24 at i-8oa3a2~-s~`~s (1-800-DIAL-PPL) ., or write to: Customer Service 827 Hausman R~. Allentown, PA 18104-9392 www.pplelectric.cum Electric Use This graph shows your electnc use over the last 13 months. Tti~pes of 11-~eter Readings: Actual - Adj usted Estimated Costumer Q ~~, ~ ~ ~ ~~' - ~~ .. :--~ .; . ~, Summary Page KWH -Average Per Day :~ Yc~~?Bit1,~ECOUtu~Gsr~t~F 29470-80008 ~:; =~_ ~:: >rT~;vy: ~ ca calliii ~'o~:v~ritiii ~ ~_' :_:: '::?:;: Balance as of Aug 3, 2009 $29.53 Char es: Tota~PL ELECTRIC UTILITIES Charges $6.71 Total Charges $36.24 .::~~:. ..~: a 'r~t><s ~o~oun~. ~o: IraXe~: khan: ~-~ ;~A : ~I~I~i ......::..... :::. . :.: ~.2. Accowit Balance $36.24 ~F# ~o~~ v~wJo9 48 40 32 24 16 8 0 Page I Meter Reading Information Meter #63104843 Aug 1 Actual 21818 Jul 9 Actual 2 l 815 23 Da s KWH Billed _ ~ 3 Average -Aug 2008 2009 Tee erature ~ 77F 73F KW Per Day S 0 Yearly CTse: Total Averagge Use A~ionthly Sep 2007 -Aug 2008 4713 39~ Sep 2008 -Aug 2009 4717 393 ASONDJFMAMJJA 2008 Months 2009 Other important information on back ~ ------------------------------------------------------------------- REV-1512 EX+ (12-08) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES 8F LIENS ESTATE OF FILE NUMBER JOSEPH E. MARTZ Report debts incurred by ffie decedent prior to death that remained unpaid at the date of death, inciuding unreimbursed medical expenses, ITEM NUMBER VALUE AT DATE DESCRIPTION _ OF DEATH i• SHIRLEY PREY -GARAGE RENTAL FOR MAY 70.00 2. ELIZABETH STONER -APARTMENT RENT FOR MAY 250.00 3. HOLY SPIRIT HOSPITAL - UNPAID UNREIMBURSED MEDICAL 1,041.95 4. ASSOCIATED CARDIOLOGIST -UNPAID UNREIMBURSED MEDICAL 71.93 5. BRIAN PEEPER, D.P.M. -UNPAID UNREIMBURSED MEDICAL 14.18 6. WEST SHORE EMS -UNPAID UNREIMBURSED MEDICAL 64.60 TOTAL (Also enter on Line 10, Recapitulation) I $ 1,512.66 If more space is needed, insert additional sheets of the same size. S~1/`~~U r'~~1.~ ~~G~rC~p~ IL~.V~.~,~~ avid 1 ~ ~! r Z,ab~e`E-~ S`~e ~~e. r ~ /~P~1- +2Q~a~~ d v v~o~ PAUI V1n`Q.~`~- ~~ S~j r y ~~v~ ~ - S L ~~f 1c~ok o.~nd a~1.so ~u~lled `~-~t,.,es~e P'~°P~~ ~j Cv v~'~i rvv~ ~~e o~ ~/V~o v~~ S . ~~~~ LY SPITAL The Spirit of Caring For Account I~ormation, Please CaII 800-997^8573 Transaction Date Description PREVIOUS BALANCE 11/17/08 NACL .9% 250ML 11/17/08 NACL .9% 250ML 11/17/08 NACL 0.45% 1000 11/17/08 NACL 0.45% 1000 11/18/08 NACL .9% 250ML 11/18/08 NACL 0.45% 1000 11/30/08 MED C/A HOSP-IP M90 MEDICARE I/P 12/03/08 TRAV/METRA IP PYMT M90 MEDICARE I/P 12/03/08 TRAVLERS MEDI C/A IP M90 MEDICARE I/P 12/17/08 MEDI PYMT-HOSP IP M90 MEDICARE I/P 12/17/08 MEDI C/A HOSP-IP M90 MEDICARE I/P 12/17/08 MED C/A HOSP-IP M90 MEDICARE I/P 01/19/09 MEDI LATE CHRG ADJ I M90 MEDICARE I/P 01/30/09 TRAV/METRA IP PYMT M90 MEDICARE I/P 01/30/09 TRAVLERS MEDI C/A IP M90 MEDICARE I/P 05/21/09 MEDI LATE CHRG ADJ I M90 MEDICARE I/P Estimated Insurance Due: .00 Total Patient (}edits: Account Amount 25,418.20 79.70 79.70 82.50 82.50 79.70 82.50 -16,747.11 .00 -49.68 -7,647.09 -16,648.11 16,747.11 -247.50 -6.53 -24.84 -239.10 ~1~~~°9 9/ ~~~~ M90 MEDICARE i/P .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. ASSOCIATED CARDIOLOGISTS, P.C. 856 CENTURY DRIVE MECHANICSBURG, PA 17055 STATEMENT DATE: 09/03/20.09 ACCOUNT#: 260219 PAY THIS AMOUNT: 71.93 :~ SHOW AMOUNT FORWARDING AND ADDRESS CORRECTION REQUESTED PAID HERE $ FOR BILLING INQUIRIES, PHONE (717) 591-7122 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - J - - - - ADDRESSEE: JOSEPH MARTZ 825 MARKET ST 1ST RE LEMOYNE, PA 17043 DATE OF PROCEDURE _ _ _ SERVICE CODE. _ _ __PROCEDURE DESCRIPTION 11/18/08 99253 -------------------- HOSP CONSMOD SEVER55 11/18/08 9330726 ECH02D INTERPRETATION 11/18/08 9332026 DOPPLER ECHO-INTERPRET 11/18/08 .9332526 DOPPLER COLOR FLOW INT 11/19/08 99232 SUBSHOSPMOD COMPLEX25 11/20/08 99232 SUBSHOSPMOD COMPLEX25 11/21/08 99232 SUBSHOSPMOD COMPLEX25 DIAGNOSIS CHARGE CREDIT BALANCE 790.5 185.OQ 163.83 21.17 427.31 105.00 95.83 9.17 427.31 50.00 46.23 3.77 427.31 10.00 9.26 .74 790.5 125.00 112.64 12.36 790.5 125.00 112.64 12.36 790.5 125.00 112.64 12.36 ---------------------------------------------------------------------------------------- Patient Aging: Current 30 Days 60 Days 90 Days 120 Days ________ ________ ________ ________ _________t- .00 .00 71.93 .00 .00 TOTAL ACCOUNT BALANCE: 71.93 l~lU ~` q 1 INSURANCE PENDING: .00 PLEASE PAY THIS AMOUNT : 71.93 `~ (~ - - -- - - ~~,t*~***~*-,~*~~~*~~x~r~*~~~x~x~~ S'~1~TEMENT M~SSAGE **~t~c~~c~r*~t-~~~~~~~t~~x~t~~~*~F~F'~~ ACCOUNT#: 260219 MAKE CHECKS PAYABLE TO: ASSOCIATED CARDIOLOGISTS, P.C. 856 CENTURY DRIVE MECHANICSBURG, PA 17055 STATEMENT DATE: 09/03/2009 ALL BILLING QUESTIONS CAN BE MADE BETWEEN THE HOURS OF 8:30AM AND 4:OOPM. FOR BILLING QUESTIONS CALL: (717) 591-7122 FOR TOLL FREE CALL: 800-845-1742 C. Brian Peffer, D.P.M. 890 PoplarChurch Rd Ste 301 Camp Hill, PA 17011 (717)763-4693 JOSEPH E. MARTZ 825 MARKET STREET 1ST RE LEMOYNE, PA 17043 Statement Date Chart Number Page 08/04/2009 MARJO005 ~ LMake Checks Payable To: ~ C. Brian Peffer, D.P.M. 890 PoplarChurch Rd Ste 301 Camp Hill, PA 17011 (717)763-4693 Previous Balance: 0.00 Patient: JOSEPH E. MARTZ Chart Number: MARJO005 Case: CONSULT/ MEDICARE RR Date of Last Payment: 2/6/2009 Paid by Applied to Dates Procedure Charge Primary Deductible 11 /21 /08 99252 80.00 -56.72 Amount: -56.72 Paid By Guarantor Adjustments Remai -9.10 / 14. ~~~~~ 9~~'{~0~ Amount Due 14.18 WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUITE 211 ~ ` CAMP HILL, PA 17011 Phone #: (S00) 367-0512 Federal Tax ID: 23-2463002 ~~~]~' ~~Q PATIENT NAME: JOSEPH MARTZ PATIENT NUMBER: 77088 NMCI INSURANCE: PALMETTO GBA CALL NUMBER: 31167138 NONE A194266303 DATE OF CALL: 11/17/2008 TIME OF CALL: 07;23 PM CALLER: 31167136 FROM: 825 MARKET ST JOSEPH MARTZ TO: HOLY SPIRIT HOSPITAL 825 MARKET ST LEMOYNE, PA 17043 REASON(S) WEAKNESS -MUSCLE ~'~, FOR 1 ~ ` TRANSPORT ' ~ INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT BLS EMERGENCY BASE RATE A0429 1.0 785 47 BLS MILEAGE A0425 2.0 . 13.08 785.47 26 16 INF CONTROL GLOVES (PR) A0382 2.0 3 83 . . 7.66 Total Charges 819.29 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Medicare Assignment Adjustment 08/28/2009 Medicare Part B Payment 118889273 08/28/2009 496.31 258.38 Ttriai Crecllt~ 754.09 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~--~ $64,60 RETURNED CHECK FEE - $31.00