HomeMy WebLinkAbout02-19-10J 1505607121
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA pepartment of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN 2 1 0 6 0 8 1 7
PO BOx 2806ot RESIDENT DECEDENT
Harrisbu , PA 17128-0601
ENTER DECEDENT INFORMATION BELODate of Death Date of Birth
Social Security Number
1 9 4 6 0 8 9 0 4 0 8 0 5 2 0 0 5 1 1 2 8 1 9 7 3 MI
Decedent's Last Name Suffix Decedent's First Name
J U L I A A
L A I D A C K E R
(If Applicable) Enter Surviving Spouse's Information Below Suffix Spouse's First Name MI
Spouse's Last Name L
LAI DACKER JASON
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW ^ 3. Remainder Return (date of death
1. Original Return ^ 2. Supplemental Return prior to 12-13-82)
tate
d E
i ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required
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te
4. Lim death after 12-12-82)
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T ^ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
^ a
e
es
6. Decedent Died
(Attach Copy of Will)
Received
d
^ (Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
nder Sec. 9113(A)
^ 11 ~
haO
^ s
9. Litigation Procee between 12-31-91 and 1-1-95) )
Attach Sc
BE DIRECTED T0:
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIA
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ep
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COR RESPONDENT - D
ber
ne Num
ho
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l
Name
D O N I S H t R A
K I
S ZAGURSKI E
7 1 7 4 3 6 8 0 4 4
Firm Name (If Applicable)
J O H N S T O N &
First line of address
ZAGURSKI E P C
1 1 7 MAI N STREET
Second line of address
P O. BOX 0
City or Post Office
M I F F L I N
State ZIP Code
REGISTER OF WILLS USE ONLY
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Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including aa:ompanying schedules and statements, and to the hest of my knowledge and belief,
k is true, correct and complete. Dedaretion of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGN URE OF PERSgN RESPONSIB OR FILING RETURN DATE ~,
7 ~ ~~
132,fd~R~E'S ROAD
cir on r [)F JilYtF~ARER OTHER THAN REPRESENTATIVE
117 IN STREET, P.O. BOX 0
1505607121
PINE GROVE PA 17963
~' ~/!~
MIFFLIN PA 17058
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505607121
J
1505607221
REV-1500 EX Decedent's Social Security Number
1 9 4 6 0 8 9 0 4
Decedent's Name: JULIA A. LAIDACKER
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'
9 7 2 7
5.2 1
5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ....... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ...... .
6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
^ Separate Billing Requested .......
7. ,
(Schedule G) 9 7 2 7 5, 2 1
.••.•..•.••.,
8. Total Gross Assets (total Lines 1-7) • • • • a.
5 9 5
5, 0 0
9. Funeral Expenses & Administrative Costs (Schedule H) • • • • • • 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule 1) ............ 10.
5 9 5 5.0 0
11. Total Deductions (total Lines 9 & 10) ....... • • • • • • • • • • • • • • • • • • .. 11'
•....•.•.,.,.12. 9 1 3 2 0, 2 1
12. Net Value of Estate (Line 8 minus Line 11) • •
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 6 7 2 7 5 , 2 1
' t tax has not been made (Schedule J) • • • • • • • •
an election o
24045,
0
0
14. Net Value Subject to Tax (Line 12 minus Line 13) ............ .... ..14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APP LICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
Q~ Q
0
15.
Q'
Q
Q
(a)(1.2) X •0
16. Amount of Line 14 taxable 2 4 0 4 5. 0 0 1s. 1 0 8 2. 0 3
at lineal rate X .045
17. Amount of Line 14 taxable 0 0 0 17. Q • Q Q
at sibling rate X .12
Q
Q
Q
18. Amount of Line 14 taxable 0 . 0 0 18. •
at collateral rate X .15
1 s.
19. Tax Due ................................................
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
1505607221
Side 2
1 0 8 2.0 3
1505607221
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENTS NAME
JULIA A. LAIDACKER
STREET ADDRESS
6408 GLENWOOD STREET
CITY
MECHANICSBURG
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
File Number
21 06 0817
STATE
PA
Total Credits (A + B + C )
ZIP
17050
l1) 1.082.03
(2) 0.00
3. InteresUPenalty if applicable
D. Interest
E. Penalty Total Interest/Penalty (D +E )
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 DUE.
(5A)
(5B) 1,082.03
Make Check Payab/e to: REG/STER Of W/LLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes No
1. Did decedent make a transfer and: X
a. retain the use or income of the property transferred : ...................................................................... ^
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, benefits or care? ....................................................... ^ ^
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^
3. Did decedent own an "intrust for' or payable upon death bank account or security at his or her death? ......... ^ 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
X
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)]. 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.
(3) 0.00
(4) 0.00
(5) 1,082.03
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
JULIA A. LAIDACKER 21 06 0817
Include the proceeds of litigation and the date the proceeds were received by the estate.
All properly jointly-owned wdh right of survivorship must be disclosed on Schedule F.
VALUE AT DATE
ITEM DESCRIPTION OF DEATH
NUMBER
~, WRONGFUL DEATH SETTLEMENT SURVIVAL ACTION NO. 2006-CV-5780-MM 97,275.21
(SEE ATTACHED ORDER)
TOTAL (Also enter on line 5, Recapitulation) I S 97
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE N
ESTATE OF
JULIA A. LAIDACKER 21 06 0817
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A, FUNERAL EXPENSES:
~. Rolling Green Cemtery
B.
2.
3.
DESCRIPTION
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Street Address
City State ZIP
Year(s) Commission Paid:
AttomeyFees DONIS H. ZAGURSKIE, ESQUIRE i
Family Exemption: (If decedents address is not the same as claimants, attach explanation)
Claimant
SVeet Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5 AccountanCs Fees
g, Tax Retum Preparers Fees
7
CUMBERLAND COUNTY REGISTER & RECORDER'S OFFICE (SHORT CERT.)
TOTAL (Also enter on line 9, Recapitulation) 13
(If more space is needed, insert additional sheets of the same size)
AMOUNT
4,451.00
1,500.00
4.00
5
REV-1511 EX + (10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
JULIA A. LAIDACKER 21 06 0817
Debts of decedent must be reported on Schedule I.
ITEM AMOUNT
NUMBER DESCRIPTION
A. FUNERAL EXPENSES: 4,451.00
1, Rolling Green Cemtery
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Street Address
Chy State Zip
Year(s) Commission Paid:
2 AttomeyFees DONIS H. ZAGURSKIE, ESQUIRE 1,500.00
3, Family Exemption: (If decedents address is not the same as claimants, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5 Acxountant's Fees
6. Tax Retum Preparers fees
7. CUMBERLAND COUNTY REGISTER & RECORDER'S OFFICE (SHORT CERT.) 4.00
TOTAL (Also enter on line 9, Recapitulation) I E 5,955.
(If more space is needed, insert additional sheets of the same size)
.~,
t
Adrninistratur ~ ICI THE COURT (~F C0~11~IG:~ PLEr'.S
of the Es~ate of D.~L'PH1N COL'~'TY, PE~ti"SYL~'.~~L~
JULIE :~. LAID:~CI;ER, Deceasec?
Plaintil'
~' CIVIL ACTION' - b1EDIC.~L
. PROFESSlON.~L LIABILITY' ACTION
LAUREN B. BOW'~'~L~~f, PA-C,
COLONIAL PART; FAMILY ~~0. 2006-CV_5780-ItiI~tiI
PRACTICE, and HERITAGE •
MEDICAL GROUP, LLp, ~ PETITION FOR APPROVAL OF
WRONGFUL DEATH AND SURVIVAL
Defendants :ACTIONS
. O-R
AND NOtiV, this ~~r~~
----._ day o f ~.~, r ~. , , ~'
f '~~~~~ ~ , 2009, pursuant
to Pa.
R.C.P. 2206(b) and Dauphin County Rule of Court 2206, and upon
consideration of the Petition for Approval of Wrongful Death and Survival
Actions, it is hereby- ORDERED that the gross settlement in the
amount of
$~~0,000 is approved and shall be distributed as follo~c~s:
Wrongful Death Action:
Survival Action:
Total Gross Settlement
~.
.~= -
:,,
r~ ~~
;:~ •~;
$385,000.00 ~ -' '~J
• _ _=, rim.
$165,000.00 - +^ ~~~ l-~r,;
~~ : _' -c
$550,000.00 ~ -' _~, ' ~'
"'~ CJ ' ^
~D
BY THE COURT:
~~~~~
J.
0
~ 209 State Street
Harrisburg, Pennsylvania 17101
717.232.6300
FAX 717.232.6467
^ ^ . www.schmidtkramer.com
N J U R Y LAWYER S
December 8, 2009
VIA CERTIFIED MAIL
Donald Zagurskie, Esquire
Johnson, Zagurskie 8~ Mummah
117 Main Street
PO Box 0
Mifflin, PA 17058
Re: Estate of Julie Laidacker v. Bowman, et al.
Dear Don:
Enclosed you will find a check in the amount of $97,275.21 representing the
Estate's share of the wrongful, death settlement in the above-captioned matter.
It is my understanding that you will complete administration of the estate and
the distribution to the beneficiaries, Jason Laidacker and Jack Hall. Thank
you.
Very truly yours,
..r
;~
scxlVliDT KRAMER PC
Charles E. Schmidt, Jr.
Attorney at Law
CES/jg
Enclosure