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HomeMy WebLinkAbout06-01-11s J 1505610101 REV-1500 at°'-'°' ~ OFFICIAL USE ONLY PA Department of Revenue pennsylvarda Coun Code Year File Number xwxrxnrox xevexue Bureau of Individual Taxes tY Po Box Z8o5oi INHERITANCE TAX RETURN T~ r'~'~ ~~,~;~~~ Harrtsburg, PA sys28-o60> RESIDENT DECEDENT ~,j~ ~ ~ 1 ~U C.IU P7 ~ ~ ~ ~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Da~~te--of Birth MMDDYYYY 3~ ~y 3S~'l~ ~ Oq,?D/0 119 ~~/9/ Decedent's Last Name Suffix Decedent's First Name MI Col / ~ ® ~ ~ E ~.r-]"m°"(.~ (If Applicable) Enter Surviving Spouse's Information Below Spouse s Last Nama Suffix Spouse's First Name MI Q~IZII~S~ Q ZI~ ® .~~~~~ Tl~-ZIP ^ Spouse s Social Secunty Number ~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~~~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW S. 1. Odginal Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Dfed T®state O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 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) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number A aa D i rl7 97~. 83~5~ REGISTER OF WILLS USFr,~NLY 4 .`~: First line of address ~ OS o Lo o D ~ t Second line of address ~" Under penalties of perjury, I declare that I have examined this return, it it is true, correct and complete. Declaration of preparer other than the S_~p(ATUFj~ OF PERS9CLRESPONSIBCt3 FOR G RETUF'iN accompanying schedules and statements, and to the best of my knowledge and belief, ~I'representative is based on all information of which preparer has any knowledge. ADDRESS`Q C - SIG~RE OF PREPAREC~TH~ E~ENTATIV~ l~ } ~~ ~ ~~// ~/~ ~~// DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 r REV-1500 EX 1505610105 Daced~Ps Pleme: E m m e.1'f' l~'1. C' o f (i/1 s S,2 1. Real Estate (Schedule A) .......................................... ... 1. 2. Stocks and Bonds (Schedule B) .................................... ... 2. 3. Closely Held Corporation. Partnership or Sole-Proprietorship (Sdiedule C) .. ... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................ ... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. 6. Jointly Owned Property (Schedule F) O Separate BBing Requested .... ... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O ~ BiNing Requested..... ... 7. 8. Total Grams Assets (total Lines 1 through 7) .......................... ... 8. 9. Funeral Expenses and Administrative Costs (Sdredule H) ................ ... 9. 10. Debts of Decedent, Mortgage LiabiliEies, and Liens (Schedule I) ........... ... 10. 11. Total Deductbns (total Lines 9 and 10) .............................. ... 11. 12. Nat Value of Estate (Line 8 minus Line 11) ........................... ... 12. 13. Charitable and Govemmentel 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. r . TAX CALCULAT- SEE INSTRUCTIONS Fat APPLICABLE RATES 15. Amount of Lines 94 taxable atJhe sporisei tiax rete, or transfers: uadar Sec. 9116 16. Amount of Line 14 taxable at lineal rate X .0 17. Amount of Line 14 taxable at sibling refs X _12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedents Social Security Numtaer Side 2 L 1505610105 1505610105 O R7=V-1500 EX Page 3 Decedent's Complete Address: Pile Number uEC~rs ~ e ~/1~ ~f /Yl, Co/l~~/s S,Q STREiETADDRESS /I L Q~ ~ ~ QN ~ ,Q // ~+ ! QD d (~ / ~. ~~GC. t~ N~ CITY ~ Q / / S Le STATE ~ ~ ziP/ ~ ~ / Tax Payments and Credits: 1. rex Due {Page 2, L'me 19) 2. Credds/Payments ~ A. Prior Payments B. Discount 3. Interest 4. tr line 2 is greater tlian tine 1 + Line 3, enter the dilfereiwe. fits is the OvERAAYMENT. Fit ~ oval on Papo 2, Lfn. ZO to ngwst a rrrfreld. 5. H tine 1 + line 3 is greater than L'xle 2, enter the difference. this is the TAX DUE. {1) Toth Credits { A+ S) {2) x/ {3) ,~ (a) {5) Make Check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING Ql1ESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decadent make a transfer and: Yes No a. retain the use a income of the properly trar>sferred :............................................................................ .............. ^ .~ b. retain the right to designate who shag use the property transferred a its income : .............................. .............. ^ ~` c. retain a reversionary interest; or ............................................................................................................ .............. ^ d. receive the promise for life of either payments, benefits a care? ................... ..................................... ^ .............. ~' 2. If death ocwned after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideratlon? ..................................... ........................................................... .............. 3. Did decedent own an 'in trust far" a payable~ipon-death bank mount or security at tus or her death? .............. ^ 4. Did decedent own an individual retirement accamt, annuity a other non jxobate fxoperty, which contains a Uenefiaary designation? .......................................................................................................... .............. ^ IF THE ~NSwER roaNY of THe~aBa~E alESTroNS ~ YES, you r~lsT COIt1PL~TE sa~EOULE G ANA FILE R As PaR~ of THE t~TiJt~l. Far 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 ~ after Jan. 1, 1995, the tax rate imposed on the net vakre of transfers to or for the use of the surviving spouse. is 0 percalt [72 P.S: §9116 (a) (1.1) (~)l. The staiu~ does not exenglt a transl~ bo a surviving spouse loan tart, and the statutory requirements for disdosure of assets and fling a tax return. era stiN appitxble eel if the surviving spouse is the only benefrdiary. For dales of deattl On or after July 1,21100: • The tax rate in-posed on the net vakre of transfers from a deceased chid 21 years of age or younger. at-death to a kx the tree of a natural parent, an adoptive parent ar a stepparent of the r~afd ~ ll percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to a fw the use of the decedent's Mteal beneficiaries is 4.5 peralnt, except as rioted in 72 P.S. §9116(1.2) ]72 P.S. §9116(ax1)]. • The tax rate imposed~n the netvai~ of trartslers to or for the u~ ~ the decedent's siblings is 12 percent (72 P.S. §9116(ax1.3)]: A sibling is defined, under Section 9102, as an individual who has at least ate parent in comrrial with the decedent, wtleiher by blood or adopitxr. I1Y.191Q.p~ SCHEDULE E oor~o~«rcwrxoFn~oKviv~ CJ1~i, SAI~lK DEPOSRS, ~ MISC. .rte rax aEruia PERSONAL PROPERTY Include eie poo..er a ~p Nw w we ear ~. paa.a~ ws worm b~ M w~. M ~~ Mrwr.nw ~rw ar r~Ye ~ s~r~r wnt re iew..r.u sdMrr~ f. of oFr~rH ,. ~.. ae. :~rrle.L. it ~!~ ~a.. ys ~ CG~re.marx~ /~rcrs'i n~ ,{~ryx.t7 ~~s~r1.cL C3ct,A~. GtL~.act!!y' / l ~Y 6 7 3 ~ Gocu-,~.. o-,~' Cu~n~3erG~c~,C c%4 /~. ~ / oo. oa y ~o03 ~e~f4- ~ a 7 i °~ i g ~,, -7/r7f,-~t~ ,03 - ~ ~ :.. I ~ 4 I' • r. ~, Y C ~.(.a~.-dog .~e,vl--b- ~,CR /~fF~ ~~.~.~~~.~.} 1:/~, tea, ~a {If moos 1p.oe is ~..de~, inldltadd)iarl si~ele dws same di0S) HEV45,1 EX+(10.06) CQ1MIOfiYYElIL1'M Of AENli819 Y~M~A ~~ a swEtor,~ TAx NETUFaa aQ~~ COSTS RETL10i<If1' O[CECEhCT EsrA~ aF ~/'~'I /~'l ~. ~. ~Dlli/!.S J`~iQ.. nLE e~ !/ © -- d 9 l ~ naAaa or ataoedwlt w.~a e. ~w~+ se sahsArs t ...... A FUNERAL EKES: Gfu.~.~~ _ ~ ~ a a, a o Dd P~ S~ - {~a.~~~tl ~ ~0 o D ~ -~T~a I'i ~/fl..~aaC°~anr~ ~e,~~ n ! S ~., vo e. ~-~: 1. Paraontl Fla~aeaeYslirey Camiaaisl~a -m..~~(, lcla.r, eta. J: Gz~od u1i,U -_-- ___. c~ ~,,i- _. _ .. ___ ~e-~-~ - 2. Atlalne~r Fear 3. Fa1e9y E~oampUelr ~ dao101afe e00naa a sot eis asps sa dsilwl's, sMscil apMiikdq Cldmini 34ss1Addisas ~ BiMa Lp _._. P of psimant 6e DaoadaM 4. Pro6sM Feat 5. Aammsrs9 Foss e. ~ wwm wapsura Faea ., TQTAt (Also ever on 6ne 8, Reoapitulefor-) I E a ! (~ 7 / O (Y mole apses (a aseda0. itrall sdalfo~IS1 atsar of e^ eelna a(~ ~i•isiz oc+ cu-ee~ SCHEDULE I v~nia °E DEBTS OF DECEDENT, nuc aerww I~RTGA6'E tIABIIITIES ~ LIENS a~oee orc~na esr~re of G`~/J7/77 E. ?'~/~ /~~ ~Dlls /IS ~/e. ~ /~ - Q ~ /f Ra«r +.~w aKVwr ~ n.. Noiwat r~ w a.a a~ac ron~.rue....w ,~ ~ aM. w aetlr. ~... ~.r~...r ~.,...... - -r ~^~( +~•~ wwwA~ w~Ni N Y~{ iYYR Mfg co~wroawmun~ of ~xaxvA~a~ D~wrMarr OF PIIlLIC WBFAgE awrAUOF ~eoawa rne<rarr oive~o~r of rwm ~wmr wearrv EbTATE m9eoyaCr PAOfilbWi Poeauswe WUi~mIRG, PA t7106MB6 Auqust 4, 2010 iiANETA GOODFiIN 508 COLONY RD CAMP HILL PA 17011 Re: EmmeCt Collins CIS #: 190206088 SSN: ###-##-3592 Date of Death: 05!09/2010 Dear Ma. Goodwin: Please be advised that the Department of Public flelfare is attempting to recover the monetary value of any and all eligible assets in the subject estate. Although the amount is tho astata *aY be ooass~~~~~y las than that which is owed to t2w Dapartaant, our claia is against the ostata, no oar alp. 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 coney, after all funeral and administrative costs are deducted, is sent to the Department. The Department of Public welfare maintains a claia in the amount of ~a8d,./s9.31 against the above-mentioned estate. this claim is for restitution of medical assistance granted vn behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 99, 62 P.S. 1412, effective Auqust 15, 1994, as amended by Act 20-95, effective Jane 30, 1995. Enclosed is the Department's itemised statement of claim. A portion of this aedical expense, namely ;27,iBT.67, xas incurred daring 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 Biduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the clefs, namely $57,301,61, 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 tho astab aooonu~ting is Qowpiete, phase prevyd• a ~4, ~ the estate ooataine s+aal Oatat:, please pravida c~opis+s of the deed, tfia !stoat tax assasssettt cad a cursmnt apQraiarl, ii available, Sincerely, ~~ ~• ~ Karen H. Peterson Claims investigation Agent 717-772-6615 717-772-6553 FAX Enclosure rn 00 00 0 0 0 0 0 0 0 00 ~ ~ ~ m r~ ~ ~ ~~~ t~ ~ ~ ~ D ~ L" s ~ ~ ~ ~ ~ ~! ~~~~~~~~i~~~~~~~ 6 ~~ ! ~ ~ ~ 8 2i ~ ~ m° m D 0 3m m 0 ~I N 1 ,~,. ~' ~ ,; _ `;~~su~+-~ ann~24 arc off, ~~o c~ ~~- o r 0 _o ~~ W