HomeMy WebLinkAbout04-19-111505610101
REV-1500 ex(°1.1°'
PA Department of Revenue pennsytvan9a ~
Bureau of Individual Taxes o,.,~..,F~.o. INHERITANCE TAX RETURN
PO BOX 280601
Harrisburg, PA 1128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth
181-42-7670 01 /03/2010 ' 11 /06/1950
Decedent's Last Name Suffix Decedent's First
RUSSELL LESTER
(If Applicable) Enter Surviving Spouse's Information Beldw
Spouse's Last Name Suffix Spouse's First N
N/A
Spouse's Social Security Number
71HIS RETURN MUST BE FILED IN D PLICATE WITH THE
REGISTER OF ILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return O
O 4. Limited Estate O 4a. Future Interest Compromise (date of O
death After 12-12-82)
O 6. Decedent Died Testate O 7. Deced~nt Maintained a Living Trust _
(Attach Copy of Will) (Attach) Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O
between 12-31-91 and 1-1-95)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CO RESPONDENCE AND CONFIDENTIAL TAX
Name
Andrew H. Shaw
USE ONLY
~iCode Year File Number
I ` ~ ~~
MMDDYYYY
MI
E
MI
3. Remainder Return (date of death
prior to 12-13-82)
:.. Federal Estate Tax Return Required
fl. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
)RMATION SHOULD BE DIRECTED T0:
Mime Telephone Number
17) 243-7135
REGISTER OF~LLS USE ONLY:
-_
~~
First line of address - -
200 S. Spring Garden St y=
c:Y
-
~ j t
'"
~
Second line of address ~
~
-- ~
~ -
C=) ~ - .
Suite 11 - _~
~
~
~
City or Post Office State ZIP Code Da~FILED
,
.
_
Carlisle PA 17013
Correspondent's e-mail address: andreW aShawlaw'COm
Under penalties of perjury, I declare that I have examined this return, in luding accompanying schedules and statem nts, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the ersonal representative is based on all info ation of which preparer has any knowledge.
SIGNAT F PE PONSI E FOR -LING RETURN DATE
04/19/11
ADDRESS
11 School House o ewville, PA 17241
SIGNA~E OF P A R THAN REPRESENTATIVE DATE
ADdRESS ~
200 S. Spring Garden Street, Suite 11, Carlisle, I~A 17013
ORIGINAL FORM ONLY
Side 1
1505610101
1505610101
: ~ ;'fi't
i C--:
~ ~i
J
~`~
1505610105
REV-1500 EX
Decedent's Name: Lester E. Russell
Decedent's Social Security Number
181-42-7670
RECAPITULATION
1. Real Estate (Schedule A) ........................................... .. 1. 0.00
2. Stocks and Bonds (Schedule B) ..................................... .. 2. 0.00
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 0.00
4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 5,000.00
6. Jointly Owned Property (Schedule F) O Separatle Billing Requested ..... .. 6. 0.00
7. Inter-Vivos Transfers & Miscellaneous Non-Probate 11'roperty
(Schedule G) O Separate Billing Requested...... .. 7. 0.00
8. Total Gross Assets (total Lines 1 through 7) ............................ .. 8. 5,000.00
9. Funeral Expenses and Administrative Costs (Schedule H) ............. ...... 9. 4,442.42
10. Debts of Decedent, Mortgage Liabilities, and Liens ($chedule I) ........ ...... 10. 137,823.41
11. Total Deductions (total Lines 9 and 10) ........................... ...... 11. 142,265.83
12. Net Value of Estate (Line 8 minus Line 11) ........................ ...... 12. -137,265.83
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. -137,265.83
TAX CALCULATION -SEE INSTRUCTIONS FOR
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0 0
16. Amount of Line 14 taxable
at lineal rate X .0 0
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
RATES
0.00 15.
0.00 1s.
0.00 17.
0.00 18.
19. TAX DUE .........................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 1505610105 1505610105
0.00
0.00
0.00
0.00
0.00
O
REV-1500 EX Page 3
Decedent's Complete Address:
r
III
File Numbe~
i
DECEDENTS NAME
Lester E. Russell
STREET ADDRESS
15 School House Road
CITY
Nevwille STATE
P ZIP
17241
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
3. Interest
.00
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)
Make check payable ~o: REGISTER OF WILLS, ~
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN
1. Did decedent make a transfer and:
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 Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ......................................................................................
3. Did decedent own an "in trust for' or payable-upon-dedth bank account or security at his or her c
4. Did decedent own an individual retirement account, anhuity or other non-probate property, which
contains a beneficiary designation? .............................
(3)
(4)
(5)
ENT.
(1)
0.00
0.00
0.00
0.00
0.00
E APPROPRIATE BLOCKS
Yes No
.................... ^ X^
.................... ^ X^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, IYOU 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 t an:sfers 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 ion the net value of transfers to or r 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 tatutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the ohly 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
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §91~16(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal I
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 bf the decedent's siblings is 12 percer
Section 9102, as an individual who has at least one parent in common with the decedent, whether by bloo~
0.00
death to or for the use of a natural parent, an
^ x^
is 4.5 percent, except as noted in
[7;? P.S. §9116(a)(1.3)]. Asibling is defined, under
or adoption.
~ __ __
REV-1508 EX+ (6-98) ~,
SCHEDULE E
CASH
BANK DEPOSITS & MISC.
COMMONWEALTH OF PENNSYLVANIA ,
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lester E. Russell 21-10-0209
Include 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 o Schedule F.
ITEM VALUE AT DATE
NUMBER DE' CRIPTION OF DEATH
1. Ford Ranger pick up truck 5,000.00
TOTAL (Also enter on line 5, Recapitulation) S 5,000.00
(If more space is needed, insert additional sheets of the same size)
T_
REV-1511 EX+ (10-09)
~ pennsylvania SCHEDULE H I,I
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lester E. Russell 21-10-0209
Decedent's debts must be reported on Schedule I.
ITEM AMOUNT
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
1' Egger Funeral Home, Inc. 3,345.00
B.
1
2.
3.
4.
5.
b.
7.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
State
Attorney Fees:
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
C+ty State
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
Estate Advertising
0.00
750.00
95.50
251.92
TOTAL (Also enter on Lin 9, Recapitulation)~~ 4,442.42
If more space is needed, use additional sheets of paper of the same si e.
~~l' / Ci~~~, JZG.
G~ti~~
15 Big Spring Avenue
NEWVILLE, PENNSYLVANIA 17241 ~
F. CHARLES EDGER, Supervisor 717-776-3414 FRANK C. EDGER, Funeral Director
January 21, 2010
Funeral Bill for Lester E. Russell
Date of Service January 6, 2010
Professional Services $2,050.00
6 Death Certificates $6.00 a piece $36.00
Valley Times Star Obituary $35.00
Sentinel Obituary $89.00
Urn $220.00
Cemetery Opening $915.00
Total $3,345.00
REV-1512 EX+ (12-OS)
>, pennsylvania
~ SCHEDULE I
DEPARTMENT OF REVENUE
~ DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lester E. Russell 21-10-0209
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, in l udtng unreimbursed medical expenses,
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1~ Department of Public Welfare, Estate Recovery 79,675.93
2. Green Ridge Village 42,527.62
3. Discover Bank 11,615.78
4. Bank of America 2,793.22
5. Ford Motor Credit 1,210.86
TOTAL (Also enter on Line 10, capitulation) $ 137,823.41
If more space is needed, insert additional sheets of the same size.
'K ,
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 9, 2010
ANDREW H SHAW ATTORNEY AT LAW
ANDREW H SHAW
200 S SPRING GARDEN STREET
SUITE 11
CARLISLE PA 17013
Re: Lester Russel_
CIS #: 800176009
SSN: ###-##-7670
Date of Death: O1;
Dear Attorney Andrew H. Shaw::
Please be advised that the Department of Public Weli
claim in the amount of $79,675.93 against the above-mentJ
claim is for restitution of medical assistance granted or
decedent for which the Probate Estate is now responsible
Department according to Act 49, 62 P.S. 1412, effective ~
amended by Act 20-95, effective June 30, 1995. Enclosed
itemized statement of claim.
'0:3/2010
a:~e maintains a
oned estate. This
behalf of the
to reimburse the
uc~ust 15, 1994, as
i:~ the Department's
A portion of this medical expense, namely $17,187.1 was incurred
during the last six months of the decedent's life; there ore, it is a Class
claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, rarely $62,488.82,
to be entered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advisE
Commonwealth's claim is admitted and when payment may be
estate accounting is complete, please provide a copy. Ii
real estate, please provide copies of the deed, the late:
and a current appraisal, if available. Please complete
Decedent's Assets Itemization Form and return to the Depa
include proof of funeral bill, proof of burial account, F
care account, copies of original life insurance policy fc
beneficiaries, proof of any and all stocks and bonds, dot
statements and copies of original signature cards or pro<
institution showing ownership of any and all bank account
these documents to the address above no later than .. P]
enclosed Decedent's Assets Itemization Form and return t<
Please include proof of funeral bill, proof of burial acc
personal care account, copies of original life insurance
beneficiaries, proof of any and all stocks and bonds, dot
statements and copies of original signature cards or proc
institution showing ownership of any and all bank account
these documents to the address above no later than March
3
is
whether the
e~:pected. If the
t:he estate contains
t tax assessment,
the enclosed
rt:ment. Please
roof of personal
rms naming
e of death bank
f from banking
s. Please forward
ease complete the
t:he Department.
oulnt, proof of
policy forms naming
e of death bank
f from banking
s. Please forward
5, 2010.
Sincerely,
rcx uateiiime huu-ir-cuiu~iut~ iu:uy
08/17/2010 14:18 7177762349
RESIDENT STATEMENT FROM
GREEN RIDGE VILLAGE
SWAIM HEALTH CENTER
210 BIG SPRING ROAD
NEWVILLE, PA 17241.9486
717-776-8258
rirrrbc~uy
BUSINESS OFFICE G6'V
r. uuc
PAGE 02
Statement Data Due Date ACCOUNT NUMBER
02128/Z010 Upon Receipt 814~48GRV
• ~ e ~ ~ ~ $ 2,827,62
AMOUNT PAID ~
Please make check payable to GREEN RIDGE VILLAGE
LESTER E RUSSELL Remit To:
c/o AMY RUSSELL GREEN RIDGE V LLAGE
i 1 SCHOOLHOUSE RD PO BOX 34309
NEWVILLE, PA 17241 NEWARK NJ 07 69-4308
Please detach and return this portion with dour remittance to the address above.
Comments
_. .
..
if you have any questions regarding your statement, please ~contacf~the •t3usiness Office~at (77 7j77 -x256. • I
tf you have received new insurance cards, please bring a copy to the. Business, Office. Thank you! ,j
_ . ,.
•I ..
Balance Forward $42,527.62
TOTAL BALANCE DUE:
S4Z, 527.62
FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
SWAIM HEALTH CENTER LESTER E RUSSELL ~ 61448GRV ~~
COMMONWEALTH OF PENNSYLVANIA
OF
NOTICE OF CL4IM
In Re: The Estate of:
LESTER E RUSSELL
Deceased
COURT
BERLAND
ORPHAN
OF COMMON PLEAS
COUNTY
~' COURT DIVISION
Court File No: 21 20IJ0-0209
TO: THE CLERK OF THE ORPHANS' COURT DIVISION: Not cep of claim by
creditor, Pursuant to Section 3532(b)(2) of the Probate, Estate ,and Fiduciaries
Code, 20 PA.C.S.A. §3532(b)(2).
1}
2)
3)
4)
5}
6)
7)
8)
Claimant's name: creditors} listed on attached claim derail
Claimant's address: C/0 DCM SERVICES LLC, 4150 OLSC~N MEMORIAL HWY #200
MINNEAPOLIS MN 55422
Creditor listed below is the owner and holder of a claim i~ t:he amount of
$ 11,615.78
The facts upon which this claim is based is an account fo credit evidenced by
the attached Affidavit of Account Stated.
See attached claim detail for claim basis and/ors pporting Affidavit
statement
Dececaeni:'s address:
Date of Death: l/3/2010
That the claim arose prior to the death of the decedent oh or about
That the claim is secured by.
On behalf of the claimant, I do solemnly declare and affirm and
perjury that they Information and representations made herein
to the best of my knowledge, information an belief
Dated: ~ I
laimant
Written notice of claim was given to Personal Representative anc
as stated below:
ANDREW H SHAW
Name
200 S SPRING GARDEN ST
Address
CARLISLE, PA 17013
r 1:he penalties of
ire true and correct
': 4w #C6 ~4 viy
/ar his/her counsel
City/State/Zip ~ ~~ ~D
Date notice mailed
STATE OF PA
PROBATE COURT
CUMBERLAND
COUNTY
STATEMENT AND PROOF
OF CLAIM FILE NO: 21-10-
0209
Estate of Lester E Russell
Andrew H Shaw
200 S Spring Garden St
Carlisle, PA 17013
Phillips & Cohen Associates, LLC, on behalf of Bank of America
DS-014-02-03, 1000 Samoset Drive, Wilmington Delaware 19884
rated at Estate Unit,
, submit the following
claim against the estate for the sum set forth.
DESCRIPTION _
VALUE
Bank of America - 4313042999440189
AMOUNT DUE $2,793.22
File# MD8351344
There is now due on the claim, above all legal set-offs, the sum of $2,793.22
Notice to interested persons: This is a claim by a personal repre
will be allowed unless notice of an objection by an interested pe
mailed to the personal representative not later than
I declare that this claim has been examined by me and that its
of my information, knowledge, and belief.
,f,~-
Authorized signature
Elizabeth A. Hansen
Name
Phillips & Cohen Associates, Ltd.
c/o Bank of America
DES-014-02-03
Estate Department
1000 Samoset Drive
Wilmington, DE 19884
Telephone: 888-221-4299
~tive. This claim
i.s delivered or
are true to the best