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Home My WebLink About08-19-10 (2)h i _J 1505610101 REV-1500 ex(°'_'°' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Coun Code Year File Number Bureau of IndtvfdualTaxes INHERITANCE TAX RETURN PO BOX zi3o6ot ^~ ( r ~ O~ Q Harrisburg, PA 17128-0601 RESIDENT DECEDENT o~ 1 CJ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY O 4. Llmlted Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) O 6. Decedent pied Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Sefe Deposit Boxes (Attach Copy of Wilq (Attach Copy of Trust) ~ 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) 138-42-2128 01252008 03131951 Decedent's Last Name Suffix Decedent's First Name MI ELLIS RHONA W (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI 'ELLIS JOHN Spouse's Social Security Number Z 0 ~ _ , ~~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 36 - 7 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Odginal Retum O 2. Supplemental Retum O 3. Remainder Retum (date of death priorfo 12-13-82) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number VICKY ANN TRIMMER _ 717-620-2440. First line of address PERSUN & HEIM, P.C. Second line of address P.O. BOX 659, 1700 BENT CREEK BLVD. City or Post Office Slate MECHANICSBURG PA REGISTER OF WILLS USE ONLYv 0 ~= fl O ^ ~ ~ ~. `-; 2 C7 } ' C Cry . ',,- t L ' ~~ I~ 7' r.":~ {1 ' O d tJ JC ~ DATE FI :ry ZIP Code 17055-0659 ~- J_ ) _~_, ' r , -~. S_ _? r;, :^~ _i.i i' 7 f" y _> '~ 'm c~~a q •-r, Correspondent's a-mats address: VATRIMMER@PERSUNHEIM. COM Under penalties of pery'ury, 1 declare that I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge end belief, it is We, corred and complete. Dedaretlon of preperer other than the personal representative is basetl on all information of which preparer has eny knowledge. 51GNATUR ERSON ESPONSIBLE FOR FILING RETURN DATA {-~ Y ~/~' / i o Side 1 1505610101 1505610101 ADDRESS " P.O. BOX 659 MECHANICSBURG PA 17055-0659 PLEASE USE ORIGINAL FORM ONLY REV-1500 EX Decedent's Name: RECAPITULATION 150561015 Decedent's Social Security Number 1. Real Estate (Schedule A) ........................................... .. 1. O.OO 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 0 , OO 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. O.OO 4. Mortgages and Notes Receivable (Schedule D) ......................... 4 . . . _ _ ___ -_........_...0.,.00.... 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. _..--___10.00.0..00._. _ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. O.OQ 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8, lOOOO.00 9. Funeral Expenses and Administrative Costs (Schedule H) ............. ...... 9. 3 S OQ. OO 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........ ...... 10. _ ..__0...00. _ _ 11. Total Deductions (total Lines 9 and 10) ........................... ...... 11. ~S C7~. OO 12. Net Value of Estate (Line 8 minus Line 11) ........................ ...... 12. G SOO.OQ aritable and Governmental Bequests/Sec 9113 Trusts for which ,. an election to tax has not been made (Schedule J) .................. ...... 13. - _ O.OO __ 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. ...... 14. • i V0 . ~0 TAX CALCULATION -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 .0 ~ ~ ~OO.OO __ __.... _ __ _..._. _ _ ... _ _ 15. ~, 00 16. Amount of Line 14 taxable _ _ _._._ _._ ~ ._ ._ at lineal rate X .0 ~5 0.00 - 16• 0.00 17. Amount of Line 14 taxable at sibling rate X .12 0 , OO 17. 0 , OO 18. Amount of Line 14 taxable at collateral rate X .15 O , OO 18. 0.00 19. TAX DUE ................................................... ......19J 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 150561015 1505610105 J a REV-1500 EX Page 3 Decedent's Complete Address: Flle Number DECEDENT'S NAME ELLIS RHONA W STREET ADDRESS 518 ALLENVIEW DRIVE CUMBERLAND iMECHANICSBURG STATE ZIP PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments 0.00 B. Discount 0.00 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FIII in oval on Page 2, Llne 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1> n _ nn 0.00 (3) 0 _ on (4) 0.00 (5) 0 . Make check payable to: REGISTER OF WILLS, AGENT. ',.s .'>}L`'~c,.,r4 a r:, P :' r ,?,~..; +. y'-;s".'T X~ aa: s ~yy~..e .... `5'.'a'"y +"~s~,yr'%.' x~~'~' ~`'$~ 'T`..~ ,~~"°~-~y - & y' .. x:. .. r `k x''r"' Vim. y ~'F" ~ "" $ ~:i~i. ,. %'{. r .T.E'tg , J*x. 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 trensferred :.......................................................................................... ^ 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 care1 ...................................................................... ^ 2. If death occurred after Dec. 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 secudty at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER~ TjO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. .~'EC'tl'e ^gT=s°^Y5}A i f e Vii: 'e.n T~ ~~f{WX '. ~"Y a,. .. .. ~~d.~.~`.d ~i.#.~uU' n •. ~' l~.L.. Ni .+. F. nx For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)J. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent (72 P.S. §9116 (a) (1.1) (ii)J. 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 21 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 0 percent [72 P.S. §9116(a)(1.2)J. The tax rate imposed on the net value of transfers fo or for the use of the decedent's lineal beneficiaries is 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 12 percent [72 P.S. §9116(a)(1.3)J. 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. Total Credits (A+ B) (2) FEV•150e EX+(698) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, Sr MISC. INHERITANCE TAX RETURN RESIDENiDECEDENT PERSONAL PROPERTY ESTATE OF FILE NUMBER Rhona W. Ellis Include the proceeds of litigation and the dale the proceeds were recshred by the estate. All properly jofntlyowned with the right of survlvorahip moat ba disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 CNA Settlement - $80,000 allocated to wrongful death, $10,000 allocated to survival action 10,000 TOTAL (Also enter on line 5 Recapitulation) $ ~ 10 000 3waenD t.oo0 (If more apace is needed, insert additional sheets of the same size) REV-1511 EX+(10.08) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8 INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENTDECEDENi ESTATE OF FILE NUMBER ono qP. Ellis Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~, None B. ADMINISTRATIVE COSTS: t. Personal Representative's Commissions Neme of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 3 , 500 Claimant John S. Ellis Street Address 518 Allenview Drive City MechanicaburQ State PA Zip 17055 Relationship of Claimant to Decedent SURVIVING SPOUSE 4. Probate Fees 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. None TOTAL (Also enter on line 9 Recapkulation) ~ $ 3 500 7W46AG 1.000 (If more space is needed, insert additional sheets of the same size) REV-1513EX~(11-08) SCHEDULE J ' pennsylvania DEPPR7MENTOf REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT Rhona W. Ellis FILE NUMBER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS (inGude outright spousal distributions, and transfers under Sec. 2116 (a) (1.2).] 1. John Ellis PO Box 26 Georgetown, NID 21930 0~ of Residue: 6,500 Surviving Spouse 6 500 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPR OPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTIONTO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS , 1. OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 awaenl z.ooo It more space is neetletl, insert additional sheets of the same ..---~ .rutu~ ~. t;LL1J, 11141Vldually and aS Administrator of the ESTATE OF RHONA W. ELLIS, and ESTATE OF RHONA W. •ELLIS - vs. Plaintiffs, IN THE COURT OF COMMON PLEAS CHESTER COUNTY NO. 08-09262 HERR FOODS, INC. ~~ and =..) ~_J JOHN HERR, ~. ; -;~:_,. • -- r' - Defendants. '-- '.': ~" ` c~ ~__ ~ -.~ ORDER AND DEC F.F ~ ~" ~~~ - i=: y :, AND NOW, this I'.r day of ~,`c~y- , 2010, upon consideration of the Petiti~m to • Settle Wrongfu} Death and Survival~Actio4 •l'tled~on- - 2010, it is hereby ORDERED and DECREED that the petition is GRANTED. The Court authorizes Petitioner, John S. Ellis, Administrator of the Estate of Rhona W. EIlis, deceased, to enter itrto a"settlement with Herr Foods, Inc., John Herr, a/k/a Jay Hen, and' CNA Insurance Company in the gross sum of $90,000.00. IT IS HEREBY ORDERED AND DECREED that both wrongful death and survival claims asserted by John S. Ellis, individually and as Administrator of the Estate of Rhona W. Ellis and Estate of Rhona W. Ellis, are settled. Respondents shall forward all settlement drafts or checks payable to Petitioner as pro se plaintiff for proper distribution. IT IS FURTHER ORDERED AND DECREED that the settlement proceeds are allocated as follows: 1. Wrongful Death $ 80,000.00 2. Survival Claim $ 10,000.00 TOTAL $ 90,000.00