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Home My WebLink About05-25-1015056071120 --~ 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 BOX.280601 ~ ` 4~ C Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 f ~e ~~~ /~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 207 44 7076 Ol 05 2010 05 12 1951 Decedent's Last Name Suffix Decedent's First Name MI WEAVER VIRGINIA L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI WEAVER FRANK E Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW X 1. Original Return ~ 2. Supplemental Return ~ 3. p o io d2rlReBt~)n (date of death I~ qa Future Interest Compromise ^ 5. Federal Estate Tax Return Required r__ J 4. Limited Estate LJ (date of death after 12-12-62) ' g Decedent Died Testate ~ Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes ~~_ _- (Attach Copy of Will) ^ (Attach Copy of Trust) ~ ' 9. Liti ation Proceeds Received 1p. Spousal Povert Credit (date of death ! 11. Election to tax under Sec. 9113(A) g ^ between 12-31 ~1 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 JERRY A. WEIGLE ESQUIRE 717 532 7388 Firm Name (If Applicable) WEIGLE & ASSOCIATES, P.C. First line of address 126 EAST KING STREET Second line of address City or Post Office SHIPPENSBURG State ZIP Code PA 17257 REGISTER ~rWjILLS US~DNLY ~; ~ :.~. _..~ - r~~ ... _ ~ -'. ~..r ~ - -~ -n -ti, nJ D~E FILED ~J :~ l _' r-; --_' Correspondent's a-mail address: Undtrueecorrect andecompletde.cDeclaration of preparer odther thatn the persolnalaep~esentative s based on d mfo mation~ f wh~hhpreparerfhas any know edge belief, SIGN RE OF PERS R 0 SIB~E FOR FILING RETURN DATE -,~ ~ . //l Frank E. Weaver 3 Ritner Hi hwa Newville PA 7e S NATU E OF REPA ROT HAN REPRE NT TI 1 A RE 126 East King Street, Shippensburg, P 15056071120 rry A. Weigle Esquire Side 1 _Z DATE ``~ 15056071120 ~ ^~-- 4 15056072120 REV-1500 EX oeoeder,r5 Name. Virginia L. Weaver REC APITULATION 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. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7 Inter-Vivos Transfers & Miscellaneous coq Probate Property . (Schedule G) a Separate Billing Requested............ 7. g. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 9 Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 10 Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 11 Total Deductions (total Lines 9 & 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 ~ ~~ 15. • (a)(1.2) X .00 16. Amount of Line 14 taxable ~ ~ ~ 16. • at lineal rate X .045 17. Amount of Line 14 taxable 1 ~ at sibling rate X .12 0 0 0 18. Amount of Line 14 taxable 18 at collateral rate X .15 0 • 00 19 . Tax Due ................................................................................................................. . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Decedent's Social Security Number 207 44 7076 7,781.00 94,723.29 102,504.29 -102,504.29 -102,504.29 0.00 0.00 0.00 0.00 0.00 Side 2 15056072120 15056072120 J REV-1500 EX Page 3 nnrnrlnn4'c Cmm~lPtP Address: File Number 21 DECEDENT'S NAME Virginia L. Weaver _ _ STREET ADDRESS 3150 Ritner Highway CITY Newville Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable 0.00 STATE I ZIP PA (1) Total Credits (A + B + C) p 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. Check box on Page 2 Line 20 to request a refund 5. If Line ' + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A, Enter the interest on the tax due. g. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to ~ REGISTER OF WILLS, AGENT (2) 17241 0.00 0.00 (3) (4) (5) 0.00 (5A) (5B) ~.~~ 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 :................................................................._ ._....... _ J ~l x i b. retain the right to designate who shall use the property transferred or its income;........_............ _.......... J j x c. retain a reversionary interest; or ................................................................................................. ...._..... __:'- i 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 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 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. REV-1151 EX+(10-06) ;; , SCHEDULE H FUNERAL EXPENSES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF I FILE NUMBER Weaver, Virginia L. 21 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER q. FUNERAL EXPENSES: See continuation schedule(s) attached B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) 7,616.00 Street Address City State Zip Yearlsl Commission Daid 2. Attorney's Fees Weigle & Associates, P.C. 150.00 3_ Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zir, Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 15.00 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 7,781.00 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Weaver, Virginia L. _ 21 NUMBER DESCRIPTION AMOUNT Funeral Ex ep nses 1 Fogelsanger-Bricker Funeral Home 7,616.00 H-A 7,616.00 Other Administrative Costs 2 Register of Wills, Cumberland County -filing Insolvent PA Inheritance Tax Return 15.00 H_B7 15.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+ (12-08 ) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Weaver, Virginia L. 21 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, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV-1513 EX+111-OS) 't, COMMO ERITANTCECT~ERETURNANIA RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Weaver, Vir inia L. 21 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NAME AND ADDRESS OF DECEDENT NUMBER PERSON(S)RECEIVINGPROPERTY Do Not List Trustees (Words) ($$$) TAXABLE DISTRIBUTIONS [include outright spousal I. distributions, and transfers under Sec. 9116(a)(1.2)] Not relevant as estate is insol Total ~ Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 1500 cover sheet, as a ro r NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETi Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) O o 0 0 0 0 0 0 o ~ ~ ~ I ~ o I .o N c'"1 ~ ~ ~ ~ ~ !` (/} !` t!} ~I ~ ~ ~I N c(1 d' Q W U ca ... u O ~ t6 ~ l~ O O `d 0 0 0 0 cd E-+ r'`' m m o aroi 3 •~ ~ o o H u~ c~ n o H ° ~ m N S ~ ~ M o M t` F . o W S W ri rn ~' E Q ~ a ~ ~ ~ U ~ •~ ro •~ .•••i o ~+ ~ a •~ ~+ x ~ G4 •~ N ~ (A o O N ro h •~ ~ ~ v ~ M z ~ ~ ~ C o n o d' -~ •_ a ' E ~ z o t~ N _ ~ 7 a m ~ ~ w ] ~ a> [i7 O' c N x N [ o ^ ~ W 1.1 ~ • l to ~ 4.. ~ C%] ?~ CG r ~ ~ •~ ~ a ~ •~I a ,o ~ ~ o ~ -~ ° ~ ~ = a ~ ~ ~ w c o z w ~° as ww ¢ ~ ~ ~ i ~- -I a i z ~~ o Q b C '.. N ~ ~ .~ C ~ ~ O L is U y w H ~ ~ ~ ~ b p •fl C O ~ _ ~ U •_ C m ~ O c d a~ c > _ °~ x •- ~ ~ o ~ U •~ ~ U Q ~ ~ ¢( O ~ ~ T h ~ ~ U ~ 3 .° Q r~ ~ Q ~ U 1= N ~i ~ !` ~ ~ ~ ,`~ S-I U ~' r~ •~+ cn a ~+ r- oa o ~ .. I ~ r`') U~ N S-I •rl M N .'~ ~I N :S I fn~ ~ ~ ~~ 3 0~ X .Ll N ~YU~ h.+ C ~ O W M ro mr~ Can ~ ~ ~ ~ 3 Gl, -- a~ O R~ r 0~ N •r1 •- O ~- ,C I~ W ~- w cn -- P- ----_ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG. PA 17105-8486 February 1, 2010 WJIGLE & ASSOCIATES JyRRY A WEIGLE ESQUIRE 12 6 EAST KING~SATR1~257 S ;-i I PPENSBURG Re: Virginia Weaver CIS #: 330167483 SSN: ###-##-7076 Date of Death: O1 /C5 /2010 Dear Attorney Weigle: Please be advised that the Department of Public Welfare maim a ins a c 1 aim in the amount of $94,723.29 against the above-mentioned esta ~ e• This claim is for restitution of medFStatesissnowcregponsiblentoereimbu r Sehtre decedent for which the Probate 1994, as Department according to Act 49, 62 P.S. 1412, effective August 15, artment's amended by Act 20-95, effective June 30, 1995. Enclosed i_s the De p itemized. statement of claim. A portion of this medical expense, namely $17,470.01, was inc u raedClass 3 during the last six months of the decedent's life; therefore, it i c iaries claim pursuant to Section 3392 of the Decedents, Estates, and Fidu 253 28, is Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $77 . t o be entered as a priority Class 5.1 claim against the e:>tate. Please acknowledge receipt of this letter and advise whether ~ he If the Commonwealth's claim is admitted and when payment may be expected. ~e contains estate accounting is complete, please provide a copy. If the esta ssment r_aal estate, please provide copies of the deed, the latest tax ass ~ ' and a current appraisal , if available . Sincerely, r'~ ~. ~~f Elizabeth D. James TPL Program Invest:igatcr 717-772-5397 717-772-6553 FAX enclosure