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HomeMy WebLinkAbout03-02-10 15056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po sox zaosol 21 09 00918 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 174-16-0480 07/20/2009 '.08/16/1917 Decedent's Last Name Suffix Decedent's First Name MI HESS ' ' FERN E (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 INAPPROPRIATE OVALS BELOW ~ 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 a,.r. 5. Federal Estate Tax Return Required death after 12-12-82) ~;- 6. Decedent Died Testate ~"„s 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 r ~;,~ 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 TO: Name Daytime Telephone Number LINDA J. OLSEN, ESQUIRE ' ' (717) 232-1851 Firm Name (If Applicable) REGISTER OF WILLS USE ONLY KILLIAN & GEPHART, LLP . ~ o "' First line of address ~ © c~ 1 ~ 1 - 218 PINE STREET ti . tJ A' f 1~~n ~ ] ~ Second line of address rt ~ r ~*'~= ~3 N + r ~ j-j , ~ PO BOX 886 -v City or Post Office _ ~~ State. ZIP Code IL _3 ~.. HARRISBURG PA 17108-0886 ~~ W >~ _~ .: r -, } ..l -~ , .~ " i'"1 °~i r-- - i~Y`t c,~ ~ --rt Correspondent's a-mail address: lolsen@killlangephart.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 P~R$ON,R~SPbNSIBLE FOR FILING RETURN ADDRESS .lsn E_. ss, Executrix, 524 Orrs Bridge Road, Camp Hill, PA 17011-1445 SIGN T F PREPlj~tER C}jHF~~t THAN REPRESENTATIVE Linda ,J. Olsen,~squire, Killian & 15056051058 tart, LLP, 218 Pine Street, PO Box 886, Harri PLEASE USE ORIGINAL FORM ONLY Side 1 h'Hl C - --~ 7DATE .burg, PA 17108-0886 15056051058 l 15056052059 REV-1500 EX Decedent's Social Security Number FERN E HESS 174-16-0480 Decedent's Name: ~~_w..d .. _ ....,. .. ~ _~ _ .., ,... ~_ . _,. "_._ . _ . _ ..".. _" RECAPITULATION 1. Real estate (Schedule A) . ......................................... ... 1. 0.00 2. Stocks and Bonds (Schedule B) .................................... ... 2.I 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00 4. 9 9 ( ) .......................... Mort a es & Notes Receivable Schedule D 4. ... 0.00 5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ..... ... 5. 6,852.20 6. Jointly Owned Property (Schedule F) "Separate Billing Requested .... ... 6. 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property .. (Schedule G) ", Separate Billing Requested..... ... 7. 0.00 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ' 6,852.20 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 10,215.43 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. ' 50.00 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. 10,265.43 12. Net Value of Estate (line 8 minus Line 11) ........................... ... 12. -3,413.23 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. .._.~~..._... -3,413.23 "_.. ...,.w, _.,,. . ~.... ......... .... ..... ., _ ~ ~,,,_~_... TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 00 0 0 00 . (a)(1.2) x .0_ 15. . . 16. Amount of Line 14 taxable 0 00 00 0 . at lineal rate X .0 1s, . 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 -3,413.23 19. TAX DUE ...................................................... ... . .. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT :,,, 15056052059 Side2 15056052059 REV-1500 EX Page 3 Flle Number Decedent's Complete Address: 21 09 00918 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER FERN _ E HESS 174-16-0480 STREET ADDRESS 524 Orrs Bridge Road CITY .STATE ZIP Camp Hill PA 17011-1445 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit ___ B. Prior Payments ___ C. Discount 3. InterestlPenalty if applicable D. Interest E. Penalty 0.00 0.00 0.00 0.00 Total Credits (A + B + C) (2) - Total InterestlPenalty (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. 0.00 (3) (4) (5) (5A) (56) Make Check Payable fo: REGISTER OF WILLS, AGENT -3,413.23 0.00 0.00 0.00 0.00 0.00 0.00 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 :....................................................................................... ... ^ 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 "in trust fol" or payable upon death bank account or security at his or her death? ........... ... ^ 0 Did decedent own an Individual Retirement Account, annuity, or other non-probate property which 4 . contains a beneficiary designation? .................................................................................................................... .... ^ 0 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 disdosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefdary. Far 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 benefidaries 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 isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. f'r ~ ~.~ t. ~,^' BEFORE THE REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF FERN E. HESS NO 21-2009-0918 DECEASED DECREE OF THE REGISTER OF WILLS AND NOW, this 2"d day of October, 2009, upon consideration of the Petition for Grant of Letters filed by Jane E. Hess, for the above decedent and the instrument offered for probate as the Last Will and Testament which is dated December 7, 1983 and containing certain alterations and interlineations thereon, the Register of Wills having given consideration thereto, has made an official determination regarding those alterations and interlineations and renders the following decision: IT IS DECREED that the instrument be admitted to probate as The Last Will and Testament of Fens E. Hess as originally typewritten. The handwritten modifications to Third (b) (2) are not admitted to probate as they are not initialed or dated by the testator. IT IS FURTHER DECREED that Letters Testamentary are hereby issued to Jane E. Hess. Jane E. Hess shall have all the rights and duties of fiduciaries under the laws of Pennsylvania and shall proceed with the administration of this estate according to law. ~.~~iG~rfL~V~a~~e~ Glenda Farner Strasbaugh, Register o_ Fills n _, , --- o c ' _% _ ~~c7 n _ _..C7L~ ~ - ._~ C', G `n ~. -~. i _ - -. , -~ ~? r - fV , O'~ COPY' LAST WILL AND TESTAMII~T OF FERN E. HESS I, FERN E. HESS, of 2463 Berryhill Street, Harrisburg, Pennsylvania, being of sound mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments, or Writings in the nature thereof, by me at any time heretofore made. FIRST: I desire and direct that all my just debts, funeral expenses and the expenses of the administration of my estate, including all inheritance taxes, be paid by my hereinafter named Executor as quickly and conveniently as may be after my demise. SECOND: I give, devise and bequeath the entire residue of my estate to my beloved daughter, JANE ELIZABETH HESS, or her issue per stirpes. THIRD: In the event my beloved daughter, JANE ELIZABETH HESS, has predeceased me without issue, I desire and direct that the residue of my estate shall be distributed as follows: a) One-fourth (1/4) thereof to the FIRST CHRISTIAN CHURCH of Johnstown, Pennsylvania or the successor congregation thereto. b) Three-fourths (3/4) thereof to my sister, RUTH ENGLISH. In the event that my sister, RUTH ENGLISH, has predeceased me, I desire that her share shall be divided as follows: 1) One-third (1/3) thereof shall descend to the FIRST CHRISTIAN CHURCH of Johnstown, Pennsylvania or the successor congregation thereto. ~~ 2) One-third (1/3) thereof to my b 'aw, ~~ISH, in the event he survives me. In the event he does not survive me, I desire that his share shall descend to TINA RUSSO KEYSER or her issue per stirpes. 3) One-third (1/3) thereof to TINA RUSSO KEYSER, or ern E. Hess Page One of Two Pages. her issue per stirpes. In the event that TINA RUSSO KEYSER dies without issue, I desire that her share shall descend to the FIRST CHRISTIAN QI[JRCH of Johnstown, Pennsylvania or the successor congregation thereto. FOURTH: I name, constitute and appoint my daughter, JANE ELIZABETH HESS, to be the Executrix of mY estate. In the event that my daughter, JANE ELIZABETH HESS, has predeceased me or is for any reason unable to so act, I name, constitute and appoint my sister, RUTH ENGLIGH to be the Executrix of my estate. In the event that my sister, RUTH ENGLISH has predeceased me or is for any reason unable to so act, I name, constitute and appoint to be the Exeuctor of my estate the Paster of the First Christian Church of Johnstown, Pennsylvania. IN WITNESS WHEREOF, I, FERN E. HESS, have hereunto set my hand and seal to this, my Last Will and Testament, this '7 ~L day of o~.c.Y vY~(t.e~.v 1983. ~11x ~ ~ /~-~--d , (SEAL) ern ess Signed, sealed, published and declared by the above named FERN E. HESS, as and for her Last Will and Testament, in the presence of us, who at her request, in her presence and in the presence of each other, have hereto subscribed our names as witnesses. WITNESS: Address: 7` WITNESS: ~ ~J Address • / ~~ ~(~.~,~ ~ -~CL~, ( ~~U-uhZ,~ ~Gc,~. ~5 G/ ~~_ r Page Two of Two Pages. REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER FERN E. HESS 21 09 0918 Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) Account Number 6100678946 Account Title FERN E HESS Date Opened 8/5/1983 Account Type Checking Principal Balance as of DOD $6852.20 Interest from Last Posting to DOD $ .00 Account Balance as of DOD $6852.20 YTD Interest to DOD $ .00 REV-1E.l EX+ ~1Q-09 pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AN D INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER FERN E. HESS 21 09-0918 Decedent's debts must be reported on Schedule I, ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: -' 1' Hoffman-Roth Funeral Home & Crematory, Inc. 9,886.43 B. I z. 3. 4. 5, 6. 7. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address _ City __ State Year(s) Commission Paid: Attorney Fees: KILLIAN & GEPHlART. LLP Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City ___ _ _ State Relationship of Claimant to Decedent Probate Fees: REGISTER OF WILLS Accountant Fees: Tax Return Preparer Fees: ZIP ZIP 250.00 79.00 TOTAL (Also enter on Line 9, Recapitulation) I $ 10,215.43 If more space is needed, use additional sheets of paper of the same size. +~ +i ..J ~I ~' r~ ~~~ ~ ~~ ;'' ; FUNERAL HOME cS~ CREMATORY, INC. Jane Elizabeth Hess 524 Orrs Bridge Road Camp Hill, PA 17011 219 Norfh Hanover Street Carlisle, Pennsylvania 17013 717.243.451 1 toll free 1.866.451.4511 fax 717.243.3723 v,~ww.hoffmanroth.ccm info~hoffmanroth.com August 19, 2009 Statement of Funeral Expenses for: Fern E. Hess Date of Death: July 20, 2009 Account Id: 15679-163 PACKAGE: Traditional Funeral Service TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,350.00 Sub Total: $ 4,350.00 MERCHANDISE: Casket: Sterling $ 2,300.00 Outer Container: Monticello $ 1,320.00 -Sub Total: $ 3,620.00 AUTOMOTIVE EQUIPMENT: Mileage To Johnstown 170-25X 2.50 $ 362.50 Sub TotaL• $ 362.50 TOTAL FUNERAL HOME CHARGES: $ 8,332.50 CASH ADVANCES: Grandview Cemetery $ 725.00 5 Certified Death Certificates at $ 6.00 each $ 30.00 Newspaper Notice -Patriot $ 201.92 Clergy $ 200.00 Flowers $ 159.00 Newspaper Notice -Johnstown Tribune $ 138.01 Mauseleum Rental $ 100.00 Sub Total: $ 1,553.93 Total Funeral Expense: $ 9,886.43 Total Payments Made: $ 9,886.43 Payments made: Jane Hess Check 0991 Aug 18, 2009 6,000.00 Jane Hess Check 2085 Aug 18, 2009 3,886.43 Total Balance Due: $ 0.00 Please return this portion with your Remittance Fern E. Hess Amount Enclosed S E R V I N G OUR COMMUNITY S I N C E 1 9 0 7 REV-151.2 EX+ (;2-08) j~',i`~ Pennsylvania SCHEDULE I ~ DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER FERN E. HESS 21 09 0918 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. PENNSTATE ' ' 1st Statement ~ Milton S. Hershey Pa e 1 of 2 ® Medical Center ~ This bill represents the portion remaining after your PO Box 643291 Pittsburgh, PA 15264-3291 insurance company has processed your claim. Please send your payment for the full amount due. If you have any questions concerning how your insurance company processed your claim, please call them. FERN HESS tvoo~os 524 ORRS BRIDGE RD CAMP HILL PA 17011-1445 I~~~III~~~III~~~~~~II~~~II~~~II~I~~I~I~~I~I~I~~~I~I~I~,III~~~I Patient Name HESS FERN E AMOUNT DATE DESCRIPTION Statement Date 09/29/09 06/29/09 BLS NON-EMERGENCY TRANSPT 871.00 06/29/09 Service Date(s) 06/29/09 BLS MILEAGE, PER MILE 270.00 Type of Service OUTPATIENT pg/O i/09 BLUE SHIELD PAYMENT HOSP -84.40 Account Number 13192290 08/01/09 BLUE SHIELD CONT ADJ HOSP -185.60 New Charges/Adj $ 1;141.00 09/05/09 BLUE SHIELD PAYMENT HOSP -247.28 New Payments/Adj $ -1,116.00 09/05/09 BLUE SHIELD CONT ADJ HOSP -598.72 Account Balance $ 25.00 TOTAL 25.00 Amount Pending Insurance $ 0.00 Amount You Owe $ 25.00 i ' This new statement has been specially designed Far billing questions or insurance changes: with you in mind. Let us know what other Para preguntas acerca de su factura o cambios de seguro contamos con resentantes disponibles pars asistir a la comunidad hispana. re improvements we should make. p Phone: (717) 531-5069 or (800) 254-2619 Available Hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 prn Please a-mail your ideas to: Thursday & Friday 8:00 am to 4:30 pm Statementideas~a hmc.psu.edu Written Correspondence: or write to us at: Penn State Milton S. Hershey Medical Center Penn State Milton S. Hershey Medical Center Patient Financial Services Department Statement Ideas, PO Box 854, MC A410 PO Box 854, MC A410 Hershey, PA 17033 Hershey, PA 17033-0854 Please Note: Your physicians will bill separately for their professional services. HeRSHEVST-~ HAMPDEN TOWNSHIP ~~ULANCE 230 SOUTH SPORTING HILL ROAD MECHANICSBURG, PA 17050 (717) 761-5343 TAX # 23-6050136 BILL TO: FERN HESS 524 ORR'S BRIDGE ROAD CAMP HILL, PA 17011 INVOICE #: 0901054 DATE: 07/24/2009 PATIENT: FERN HESS ACCOUNT #: FEM102339180CONTROL #: 0901054 DATE OF SERVICE: 06/07/2009 PATIENT PICKED UP: 524 ORR'S BRIDGE ROAD CAMP HILL, PA 170 PATIENT TAKEN TO: UNIVERSITY HOSPITAL - HERSHEY DESCRIPTION UNIT COST--QTY. AMOUNT DUE- 2009 BLS BASE RATE A0429 550.00 1.0 550.00 2009 MILEAGE A0425 15.00 18.0 270.00 U~ (,~ t ,~ ~ ~~ ~~~ 3~J ' 1~,~ ~.~'~ ,~`~L 'v Comments: FIRST NOTICE - PLEASE SEND PAYMENT SUBTOTAL 820.00 IN 30 DAYS. THIS INVOICE IS YOUR RESPONSIBILITY. AMOUNT 00 795 PLEASE WRITE THE INVOICE NUMBER ON YOUR CHECK . PAID THANK YOU 25.00 THANK YOU. TOTAL ,~. .::. ~,„u ;: ,. ,~, i~ CMS ~~ ra. ~`~ ~ `~ i` ~ .; .. l .~ N N to V ~+ N L .. yA '~ ~,n-~ ~r ,;, : f, . ~~- ~~ .~ i~ ~ 0 BAR -~ P~4 I ~ 39; V~-1+.~ f~~ ~J1i ..:?HAWS CC .. -n ~ .:. ~~.ANa c -:. ~~:: _. 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