HomeMy WebLinkAbout01-11-11' 1505610140
REV-1500 ~` ~°'-'°'
OFFICUL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
Po Box 28oso1 INHERITANCE TAX RETURN 2 1 1 0 0 8 7 4
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 9 2 3 4 7 4 5 6 0 4 2 7 2 0 1 0 0 4 1 7 1 9 0 6
Decedent's Last Name Suffix Decedent's First Name MI
C R O Z I E R R U T H M
(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 IN APPROPRIATE 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 ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
® 6. Decedent Died Testate ~ 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 ~ 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)
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Name Daytime Telephone Number
G E O R G I A R M A R K E Y 7 1? 2 9 2 6-0 0 2
First line of address
6 0 2 0 P I N E Y
Second line of address
City or Post Office
D O V E R
Corr+a:pondent's e-mail address:
H O L L O W R O A D
State
P A
ZIP Code ~
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Under penalties of perjury, I deGare 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. DeGaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
OF ER ON RESPONSIBLE FOR FILING RETURN DATE
' - ~ to t
ADDRESS
6020 PINEY HOLLO ROAD DOVER PA 17315
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
4 HIGH STREET HANOVER PA 17331
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140
J ~
J
1505610240
REV-1500 EX Decedent's Social Security Number
Decedents Name: RUTH M• CROZIER 1 9 2 3 4 7 4 5 6
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 and Notes Receivable (Schedule D) .......................... 4. •
2 0 9 3 7 ' 6 9
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. •
7. Inter-Vivos Transfers 8~ Miscellaneous N -Probate Property
uested
r
te Billin
Re
~ S
7 0 • 0 0
.......
g
q
a
epa
(Schedule G) .
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 2 0 9 3 7 . 6 9
9.
..................
Funeral Expenses and Administrative Costs (Schedule H) 9. 8 8 7 6 • 7 4
10.
9 9 ( ) .............
Debts of Decedent, Mort a e Liabilities, and Liens Schedule I 10. 1 0 0 7 3• 9 9
11. Total Deductions (total Lines 9 and 10) ............................... 11. 1 8 9 5 0 . 7 3
12. Net Value of Estate (Line 8 minus Line 11) ............................ 12• 1 9 8 6 . 9 6
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. 1 9 8 6. 9 6
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 0 . 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X .045 1 9 8 6. 9 6 1 s.
17. Amount of Line 14 taxable
0 0
0
17
at sibling rate X .12 .
18. Amount of Line 14 taxable
0 0
0
at collateral rate X .15 18.
19. TAX DUE ..................... .......................... ..... .. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240
1505610240
0. 0 0
8 9. 4 1
0. 0 0
0. 0 0
8 9. 4 1
^
J
REV-1500 EX Page 3
Decedent's Complete Address:
Flle Number
21 10 0874
DECEDENTS NAME
RUTH M. CROZIER
STREET ADDRESS
442 WALNUT BOTTOM ROAD
CITY
CARLISLE STATE
PA ZIP
17013-3799
Tax Payments and Credits:
7. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
(1)
89.41
0.00
0.00
89.41
3. Interest
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.
Total Credits (A + B) (2)
(3)
(4)
(5)
Make check payable to: REGISTER OF WILLS, 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 transferred : ................................................................ ...... ^
^
0
b. retain the right to designate who shall use the property transferred or its income; ......................... ...... ^
c, retain a reversionary interest; or .......................................................................................... ......
^ 0
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
^
0
without receiving adequate consideration? ................................................................................
?
"
" .......
^
..
or payable-upon~leath bank account or security at his or her death
intrust for
3. Did decedent own an .......
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
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 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)].
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}]. 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 sti{I 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(x)(1.2)].
• The tax rate imposed on the net value of transfers to 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(x)(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(x)(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.
REV 1508 EX + (6-98)
SCHEDULE E ~+
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MASC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
RUTH M. CROZIER 21 10 0874
Include the proceeds of litigation and the date the proceeds were received by the estate.
AY property )ok~gy-aw~nsd wilfh right of survivorship neat bs dh-cbssd on SdisduN F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Bank of Landisburg, Checking Acct. 609196 4,485.56
2. Capital Blue Cross, refund of health insurance premium 482.68
3. United Church of Christ Homes - Thomwald Homes, refund 7,741.75
4. Nickel Funeral Home -prepaid funeral 8,197.70
3626 Shermans Valley Road, PO Box 910, Loysville, PA 17047
5. Pharmacy -refund 30.00
TOTAL (Also enter on line 5, Recapitulation) ~ ; 20,937.E
(If more space is needed, insert additional sheets of the same size)
REV-1511 t=X+ (10-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NU~ER
RUTH M. CROZIER 21 10 0874
I~scsdsnt's dNdu must ibs rrporbd on 8chsduls L
ITEM
NUMBER DESCRIPTION AMOUNT
q. FUNERAL EXPENSES:
~, Nickel Funeral Home
2. Funeral reception food
B.
1
2.
3.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
Year(s) Commission Paid: _.
State i ZIP
Attorney Fees:
Family Exemption: (If decedent's address is not the same as daimant's, attach explanation.)
r _taimant
4.
5.
6.
7.
8.
9.
10.
11.
Street Address
c;~y State _ ZIP
Relationship of Claimant to Decedent
Probate Fees: Register of Wills (letters, inventory, inh. tax return)
Acxountant Fees:
Tax Return Preparer Fees: Scott A. Ruth, Attorney at Law
Cumberland Law Joumat (advertising of letters testamentary)
Perry County Times (advertising of letters testamentary)
Carlisle Sentinel (advertising of letters testamentary)
Vital Records, death certificates
Postage/Delivery
106.50
120.00
75.00
50.00
187.54
20.00
20.00
TOTAL (Also enter on Line 9, Recapitula~on) f g 876.74
8,197.70
100.00
If more space ~ needed, use additional sheets of paper of the same size.
REV 1510 EX+ (08-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NOH-PROBATE PROPERTY
ESTATE OF FILE NUMBER
RUTH M. CROZIER 21 10 0874
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page titrBe of the REV-7 500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, TF~IR RELATIONSHIP TO DECEDENTAND
TFE DATE OF TRANSFER• ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
tIF APPUr,Ae~E1
TAXABLE
VALUE
1. Prudential Life Insurance 4,852.97 100.00 4,852.97 0.00
Policy No. M05884541
Beneficiary:
2. Prudential Life Insurance 2,780.24 100.00 2,789.24 0.00
Policy No. M53366984
Beneficiary
TOTAL (Also enter on Line 7, Recapitulation) ~ s 0.00
ff more space is needed, use additional sheets of paper of the same size.
REV 1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
RUTH M. CROZIER 21 10 0874
Report debris incurr+ad by the decedent prior bo death that remained unpaid at the dabs of death, induding unroimbursed medical eo~penses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. George Branseum, MD 39.75
2. Commonwealth of Pennsylvania, Department of Public Welfare, Estate Recover Program, 10,034.24
CIS # 360242806
TOTAL (Also enter on Line 10, Recapitulation) ~ S
If more space is needed, insert additional sheets of the same size.
0,073.99
REV-1513 EX+(01-10)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEF{CIARIES
ESTATE OF: - - - FILE NUMBER:
RUTH M. CROZIER 21 10 0874
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do I~t Lbt Tn~e(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS [lndude ouuttnngght spousal dlstributbns and transfers under
'
Sec. 91
i6 (a) (1.2).)
1. George Glenn Crozier Lineal
5360 Waggoners Gap Road 1/4 interest
Landisburg PA 17040
2. Robert S.Crozier lineal
1735 Landisburg Road 1/4 interest
Landisburg, PA 17040
3. Paul R. Crozier Lineal
537 Pine Hi{I Road 1/4 interest
Landisburg, PA 17040
4. Georgia R. Markey Lineal
6020 Piney Hollow Road 1 /4 interest
Dover, PA 17315
II.
1.
1.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
NON-TAXABLE DISTRIBUTIONS:
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 UNE 13 OF REV-1500 COVER SHEET. i
If more space is needed, use additional sheets of paper of the same size.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF•PROGRAM INTEGRITY
DMSION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
August 25, 2010
PAUL CROZIER
537 PINE HILL RD
LANDISBURG PA 17040-9740
Re: Ruth Crozier
CIS #: 360242806
SSN: ###-##-7456
Date of Death: 04/27/2010
Dear Mr. Crozier:
Please be advised that the Department of Public Welfare is attempting to
recover the monetary value of any and alb. eligible assets in the subject
estate. Although the amount in the estate may be considerably less than that
which is owed to the Department, our claim is against the estate, no one
else. Your responsibilities, as the primary next of
kin/administrator/executor, is to advise the Department of any assets in the
estate and to insure that the remaining money, after all funeral and
administrative costs are deducted, is sent to the Department.
The Department of Public Welfare maintains a claim in the .amount of
$10,034.24 against the above-mentioned estate. This claim is for restitution
of medical assistance granted on behalf of the decedent for which the Probate
Estate is now responsible to reimburse the Department according to Act 49, 62
P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June
30, 1995. Enclosed is the Department's itemized statement of claim.
A portion of this medical expense, namely $10,034.24, was incurred
during the last six months of the decedent's life; therefore, it is a~Class 3
claim pursuant to Section 3392 of the Decedents; Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim; namely $.00, is to be
entered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of .this letter and advise when payment may be
expected. If the estate accounting is complete, please provide a copy.. If .
the estate contains real estate, please provide copies of the deed, the
latest tax assessment and a current appraisal, if available.
Sincerely,
Susan A. Spracklen
~. ~~ Claims Investigation Agent
717-772-6741
717-772-6553 FAX
Enclosure` .:..... ~. ~ ~.~ .. - r. . ,; .. _ .
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LAST WILL AND TESTAMENT ~;., ~' rn N '~~ ~ =~ i
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RUTH M . C~ROZ IER-vv, ~ r_ .> ~._..>
w ~-~ ;
04
I, RUTH M. .~~.,~~1: ~• f of R. D. #1, Landisburg, Spring Township,
Perry County, Pennsylvania, being of sound and disposing mind, memory,
and understanding, do hereby make, publish, and declare this my Last
Will and Testament, hereby expressly revoking all other writings in
nature testamentary by me at any time heretofore made.
FIRST: I direct that all my debts and funeral expenses be paid
as soon after my decease as may be practicable.
SECOND: I hereby give, bequeath and devise all the.-rest and
residue of my estate and property, real, personal and mixed, of what-
soever nature and wheresoever situated, of which I may die seized or
possessed or to which I may be entitled or of which I may have the
right to dispose at the time of my death, absolutely and in fee simple
to my husband, George A. Crozier, if he is living at the time of my
death.
THIRD: In the event that my husband is not living at the time of
my death, or in the event that he and I shall die simultaneously, then
I give, bequeath and devise all my property to my children, G. Glenn
Crozier, Robert S. Crozier, Paul R. Crozier and Georgia R. Markey, in
equal shares..
FOURTH: T hereby appoint my husband, George A. Crozier, as Executor
of this, my Last. Will and Testament, but in the event that he is unable
~~~~ t ~ ~. ~ ~~ f~-~. c` ~ (SEAL )
RU H M. CROZIER
PAGE ONE OF TWO
or unwilling to serve, I then appoint my four children G.. Glenn Crozier,
Robert S. Crozier, Paul R. Crozier and Georgia R. Markey, as Executors
of this, my Last Will and .Testament, .and I direct that they shall not be
required to give bond or other security. in any jurisdiction wherein pro-
ceedings may be held in connection with my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 12th
~r-"~
``--_ t~%/_ G[ ~l ~l~ ~ i` ~~, _~ ~ r (SEAL)
RUTH M. CROZIER J
PAGE TWO OF TWO
day of June, 1981.
WI NE S:
RIITH M CROZIER
C/O PAIIL R CROZIER
537 PINE HILL ROAD
LANDISBIIRG PA 17040-9740
Pg 1 of 1
0
" Effective March 1, 2010, if we decide to place a hold on a check you
deposit, the funds will generally be available on the second day after the
day of the deposit."
MEMBER FDIC
04/15/2010 Beginning Balance .~ ~~~egular DDA 4,485.56
1 Deposits/Other,. Credits :~ ~~~ + 1, 472.00
1 Checks/Other ~~~,ebi~s~. ~ . 1, 472.00
,_.
05/16/2010 Ending Balance 32~ Da
________________ ~-~ ys~~n.Statement Period 4 485.56
-------------~-. -- - -~----~--}---------------------------- r -------
05/03/2010 --_---=--_--- D~pos~'~~/Ot;~r -~~its'~=------=---------=-=-=-------- --
ACH Deposit ~ 1,472.00-
IIS TREAS IIRY 3 0 3 .:,:=.~ ~SOC ;'S;EC .. ~ . , . ,
.:... .
.....
_~__ ::
. :~:~~$~
05/03/2010 Force Pay Debit ~~~ 4th~ef bed _________________________________
..: ~ . 1, 472.00
--------------------------
~ I Total For I Total I
This Period ( Year-to-Date (
I----------------------------------
I Total_Overdraft_Fees ----~--------------00---~-------------------I
. 0 I
I_-_ ------------------ __________ __
--------------------------
I Total_Return-Item_Fees I 00 ( - I
------ ----------------------------------------------------~~---i
-------------------~--~-------- Daily Ending Balance __
---------------------------
04 15 4,485.56 05/03 4,485.56
May 16, 2010