HomeMy WebLinkAbout02-25-11 (2)~ REV-1500 ~` (01-10) . ~ 1505610143
PA Department of Revenue penns~vania OFFICIAL USE ONLY
County Code Year File Number
Bureau of Individual Taxes DEPMTMENT OF REVENUE
Po Box.2sosol INHERITANCE TAX RETURN 21 1 ~ -12 4 4
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
201 16 1024 11 25 2010
Decedent's Last Name
DAVIS
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Date of Birth
03 01 1923
Suffix Decedent's First Name MI
MIRIAM E
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 ^ qa. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
~
® ti Decedent Died Testate
(Attach Copy of Will) ^ ~ Decedent Maintained a Living Trust
(Attach Copy of Trust) 8. Total Number of Safe Deposit Boxes
^ 9. Litigation Proceeds Received ^ t p. Spousal Poverty Cred'R (date of death
between 12-31- 1 and 1-1-95)
^ 11. Election to tax under Sec. 9113(A)
(Attach SCh. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
BRADLEY L GRIFFIE 717 243 5551
First line of address
200 NORTH HANOVER STREE
Second line of address
City or Post Office State ZIP Code
CARLISLE PA 17013
REGISTEFf~/F'~WILLS US~'ONLY _-
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Correspondent'se-mailaddress: bgriffie@griffielaw.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, cortect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
Susan K. Davis
ADDRESS
229 Walnut Street, Carlisle, PA 17013
.I REPARER OTHER THAN REPRESENTATIVE
Bradley L Griffie
200 North Hanover Street, Carlisle, PA 17013
DATE
Side 1
1505610143 1505610143
REV-1500 EX
1505610243
Decedent's Social Security Number
oecedeM~s Nerve: D A V I S, M I R I A M E 2 01 16 10 2 4
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 8~ Notes Receivable (Schedule D) .......................................................... 4.
5• Cash, Bank De osits & Miscellaneous Personal Pro e
P P rtY (Schedule E) ................
5. 7 1 0 3 2 . 4 8
r
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly
(Schedule G) ^ Separate Billing Requested ............. 7, 1 5 , 5 3 3 . 8 0
8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 8 6, 5 6 6. 2 8
9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 7 x 0 9 8 1 1
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 3 7 , 0 5 9.15
11. Total Deductions (total Lines 9 & 10) ...................................................................... 11, 4 4 , 1 rJ 7 . 2 6
12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. 4 2 , 4 0 9 . 0 2
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. 4 2 , 4 0 9 . 0 2
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(ax1.2) X .00 15.
16. Amount of Line 14 taxable
at lineal rate x .045 4 2, 4 0 9. 0 2 16. 1, 9 0 8.41
17. Amount of Line 14 taxable
at sibling rate X ,12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. Tax Due ..................................................................................................................... 19. 1, 9 0 8. 4 1
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
L 1505610243
1505610243
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 - 11 - -1244
D NA
Davis, Miriam E
STREET ADDRESS
4341 Carlisle Road
CITY
Gardners STATE
PA ZIP
17324
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A• Prior Payments
B. Discount
3. Interest
1,812.99
95.42
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 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
Total Credits (A + B)
Make Check Payable to: REGISTER OF WILLS, AGENT.
(1) 1,908.41
(2) 1,908.41
(3) 0.00
(4)
(5) ~.~~
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 .................................................................................................................. ^ ^x
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? ....................................................................................................................... ^ 0
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
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 O F 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
t a transfer to a survivin
The statute does not exem
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ouse from tax
and the stat
72 P
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assets and filing a tax re mare still applicable even if the surviving spouse is the only beneficiary. n
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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)].
• 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 (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)1. A
sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, w ether y blood or adoption.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF ~aVIS, Miriam E 21 - 11 - -1244
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE OF
NUMBER DESCRIPTION DEATH
1 Checking Account No. 9843927444 70,545.48
M&T Bank (See attachment)
2 I Rent Rebate 2010 I 487.00
TOTAL (Also enter on Line 5, Recapitulation) ~ 71,032.48
COMMONWEALTH OF PENNSYLVANIA SCHEDULE G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS ~
RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF Davis, Miriam E
FILE NUMBER
21 - 11 - -1244
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
Include the name of the transferee, their relationship to decedent
and the date of transfer. Attach a copy of the deed for real estate. DATE OF DEATH
VALUE OF ASSET ~~ OF
DECD'S
INTEREST EXCLUSION
(IF APPLICABLE) i TAXABLE VALUE
1 Nationwide Financial Annuity 15,533.80 100% 15,533.80
No. 5993275
(See attachment)
i
I~
i
i
i~
i
~I
i
TOTAL (Also enter on line 7, Recapitulation) 15,533.80
SCHEDULE H
FUMEFtAL EXPENSES 8~
COMMONWEALTH OF PENNSYLVANIA /'-~'~
INHERITANCE TAX RETURN ~~~~/~ ~.-W 1 ~
RESIDENT DECEDENT , , -
FILE NUMBER
ESTATE OF Davis, Miriam E 21 - 11 - -1244
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER FUNERAL EXPENSES:
A. 1 Food/Catering 111.07
B. ADMINISTRATIVE COSTS:
~ , Personal Representative's Commissions
Name of Personal Representative(s)
Susan K. Davis
2.
3.
4.
Street Address 229 Walnut Street
city Carlisle state PA zip 17013
Year(s) Commission paid 2011
Attorneys Fees Griffie and Associates
Family Exemption: (If decedent's address is not the same as Gaimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 The Sentinel (advertising)
3,500.00
3,000.00
224.50
187.54
TOTAL (Also enter on line 9, Recapitulation) 7,098.11
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Sdied~.ie H
w,,~,Ft~er~ E~er~ses &
/~'1~ 1 ^
FILE NUMBER
ESTATE OF Davis, Miriam E 21 - 11 - -1244
2 Cumberland Law Journal
75.00
Page 2 of Schedule H
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS
INHERRANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF ~aVIS, Miriam E 21 - 11 - -1244
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 Department of Public Welfare 36,226.89
Medicaid Recovery Claim
(see attached statement)
2 Philhaven (medical) 10.00
3 Philhaven (medical) 10.00
4 Gwen Drum 35.00
(Real estate assistance fee)
5 Social Security direct deposit 769.00
(Returned from checking account after date of death)
6 Yellow Breeches Family Practice 8.26
(medical)
TOTAL (Also enter on Line 10, Recapitulation) ~ 37,059.15
REV-1513 EX+ (11-08)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Davis, Miriam E 21 - 11 - -1244
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I~ TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 (a) (1.2)]
1 Susan K. Davis daughter One Third
229 Walnut Street
Carlisle, PA 17013
2 Dennis L. Davis son One Third
228 Main Street
York, PA 17372
3 Michael L. Davis grandson One Third
315 Mumper Lane
Dillsburg, PA 17019
Enter dollar amounts for distributions shown above on lines 1 5 through 18 on Rev 1500 cover sheet, as appropriate.
II 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 LINE 13 OF REV-1500 COVER SHEET I 0.00
WILL OF
MIRIAM E. DAVIS
I, Miriam E. Davis of Cumberland County, Carlisle,
Pennsylvania, declare this to be my last Will and hereby revoke all
prior Wills and Codicils.
I direct that all my just debts, funeral expenses,
gravemarker and administrative expenses shall be paid
from my residuary estate as soon as practicable after my
death.
2. I direct that all inheritance, estate, transfer, succession
and death taxes of any kind whatsoever which may be
payable by reason of my death shall be paid out of my
residuary estate.
3. I direct that my entire estate be distributed as follows:
A. I direct that my entire estate be divided into equal
shares between my son, Dennis L. Davis, my
daughter, Susan K. Davis, and my grandson,
Michael L. Davis.
B. Should any of the above mentioned predecease
me, then their share shall lapse and be divided
into equal shares between the survivors of the
above mentioned.
4. I appoint Susan K. Davis, as Executor of this my last Will.
If Susan K. Davis should predecease me or cease to act
in such capacity, I appoint Dennis L. Davis as alternate.
5. The Executor of this Will shall have the power to
distribute my estate in kind or in cash, or partly in either.
6. I direct that no Executor acting under this Will shall be
required to enter bond in any jurisdiction.
LAW OFFICES OF
'EPHEN J. HOGG
~ S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
IN WITNESS WHER F, I have he eunto set my hand this
%~ S day of , 2009.
~?i .~lit,c,.a~ru,. ~ , '~J C~r~cr~
Miriam E. Davis
I~~
L~
`~
The preceding instrument consisting of this and one other page
was on the day and date hereof signed, published and declared by
Miriam E. Davis as and for her last Will in the presence of us, who at
her request, in her presence and in the presence of each other have
subscribed our names as witnesses hereto.
~~ i~
WITNESS WI NESS
LAW OFFICES OF
fEPHEN J. HOGG
9 S. HANOVER STREET
SUITE 10]
CARLISLE, PA 17013
ACKNOWLEDGMENT
State of Pennsylvania
County of Cumberland
ss
I, Miriam E. Davis, the Testatrix, whose name is signed to the
attached or foregoing instrument, having been duly qualified according
to law, do hereby acknowledge that I signed and executed the
instrument as my last Will; that I signed it willingly and as my free and
voluntary act for the purposes therein expressed.
~~~ ~- ~~
Miriam E. Davis
Sworn to or affirm d aD.d acknowle d before m Miriam E.
Davis the Testatrix, this ~- day of ,
2009. /
81@1E11 J. MOON NOTARVRlBIlC
CAgJYI! 110RO. pN~IpEfHM1D CO.. M
""°°""~°"°'"°'""E""'`°"°`"'~"°°B Not rV Public/Alto
AFFIDAVIT
LAW OFFICES OF
CEPHEN J. HOGG
9 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
State of Pennsylvania
County of Cumberland
ss
We, lv,r bLE /~ 13LI~~~J and ,~.--Js~ ~ erC~, the
witnesses whose names are signed to the attache or foregoing
instrument, being duly qualified according to law, do depose and say
that we were present and saw the Testatrix sign and execute the
instrument as her last Will; that the Testatrix signed willingly and
executed it as her free and voluntary act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of
the Testatrix signed the Will as a witness; and that to the best of our
knowledge the Testatrix was at that time 18 or more years of age, of
sound mind and under no constr ~nt r. undue infl ence.
`l/~. -
this
?S~°rn to or affi
_~-~ day of
to before me by witnesses,
~, 2009.
Notary Public/Atto
SCHEDULE
«E~~
0 MBTBank
December 30, 2010
Griffie & Associates
Attorneys and Counselors at Law
200 North Hanover Street
Carlisle, PA 17013
499 Mitchell Street, Millsboro, DE 19966
RE: Estate of Miriam Davis
Date of Death: November 25, 2010
Social Security Number; 201-16-1024
Dear Mr. Griffie:
In response to your request, please be advised that at the time of death, the above-
named decedent had on deposit with this bank the following accounts.
1. Account Type ........................... Checl~ng Account
Account Number ....................... 9843927444
Oumership (Names off .............. Miriam Davis
Opening Date ...........................06/29/07
Balance on Date of Death.........$70,544.95
Accnied Interest $ 0.53
Total .......................................$70,545.48
The above named decedent did not have a safe deposit box.
* If upon reviewing the information above, you believe there are additional accounts not
referenced, please provide us with an account number and/or the name of any possible
joint account holder. For any additional information on the above accounts, including
ownership and any changes, closures and/or reimbursement of funds, please contact
our Mount Holly Springs Branch at 631 Holly Pike, Cumberland, PA 17065 or # 717-
486-3038.
Sincerely,
Charlene Warrington, Adj ent Services
1-888-502-4349
SCHEDULE
«G~~
On ?'our Side®
January 24, 2011
The Estate of Miriam E Davis
CIO Bradley L Griffie
200 N Hanover St
Carlisle, PA 17013
It was good to hear from you.
Dear Mr Griffie:
Nationwide Financial
Income Products Service Center
P.O. Box 182290
Columbus, OH 43218-2290
Thank you for your recent request for more information about the annuity contract of Miriam E
Davis for contract # 5993275. We wanted to get back to you as soon as possible.
Here is the answer to your question.
The value on this annuity at the time of the annuitant's death (date of death value) is
$15,533.80. This amount represents an estimate of the value of all future remaining payments.
Please keep in mind.
This value reflects our interpretation of the valuation required for federal estate taxes as defined
in Section 20.2031-8 of the Internal Revenue Code. In providing this estimation, we do not
recommend use of this value for any other purpose.
We're here if you need us.
tf you have any further questions about this account, please contact us at 1-800-634-5222,
Monday through Friday between 8:00 a.m. and 5:00 p.m. Eastern time.
Best regards,
Income Products Service Center
MF
Annuities and life insurance products are underwritten by Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance
Company, Columbus, Ohio. The general distributor for variable annuity contracts and variable life insurance policies is Nationwide
Irnestment Services Corporation. In MI Only: Nationwide Investment Svcs. Corporation.
Nationwide, Nationwide Financial, the Nationwide framemark end On Your Side are federally registered service marks of Nationwide
Mutual Insurance Company.
IAM-0278A0
SCHEDULE
«I~~
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
January 13, 2011
GRIFFIE & ASSOCIATES
BRADLEY L GRIFFIE ESQUIRE
200 NORTH HANOVER ST
CARLISLE PA 17013
Re: Miriam Davis
CIS #: 500251990
SSN: ###-##-1024
Date of Death: 11/25/2010
Dear Attorney Griffie:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $36,226.89 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, 1999, 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 $27,745.31, 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 $8,481.58, is
to be entered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and 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,
~~
Marie A. Trayer
Claims Investigation Agent
717-772-6723
717-772-6553 FAX
Enclosure