HomeMy WebLinkAbout06-02-111505610143 .
REV-1500 Ex(o,_,o,
PA Department of Revenue OFFICIAL USE ONLY
Pennsylvania County Code Year File Number
Bureau of Individual Taxes oErARTMENT OF REVENUE
Po Box.2soso~ INHERITANCE TAX RETURN 21 11 014 0
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
361 07 0973 O1 19 2011 Ol 27 1923
Decedent's Last Name Suffix Decedent's First Name
MI
HUDSON ROBERT g
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
Id, Mechanicsburg, PA 17055
R OTHER THAN REPRESENTATIVE
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 death after 12-12-82)
^ 5. Federal Estate Tax Return Re wired
q
D g Decedent Died Testate
(Attach Copy of Will)
^ ~ Decedent Maintained a Living Trust
(Attach Copy of Trust) 0
8. Total Number of Safe Deposit Boxes
9. Litigation Proceeds Received ^ 10. Spousal Povertyy Credit (date of death
between 12-31 zJ1 and t-1-95)
^ 11. Election to tax under Sec. 9113 A
( )
(Attach SCh. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND C ONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO
Name :
Daytime Telephone Number
JOHN S DAVIDSON 717 5 5101
REGISTER , ~ US~NLY ~~; ~.
rrri t riEr i
First line of address ~~ N
C? p ~. r~
3 2 0 WEST CHOCOLATE AVE c~ C3 '+"+ ~„ ...r.
Second line of address '""' ~~
PO BOX 4 3 7 ~ t*3 ~;
rM
City or host Office DATE FILED
State ZIP Code
HERSHEY PA 17033
Correspondent's a-mail address: jdavidsonl~yostdavidson.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, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge.
SIGNA R OF PERSON PONSIB F R FILING RETUJ2N DATE
Donna J. Ehrhart .S` - c~~ ._ ~ ~
nnnaGCC
SIGNATURE OF
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
John S. Davidson
DATE
.S.' - Z ~ , Z-~'C.
320 West Chocolate Ave., Hershey, PA 17033
Side 1
1505610143 1505
610143
J
REV-1500 EX
Decedent's Name: HUdSOrI, Robert B.
Decedent's Social Security Number
361 07 0973
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 & Notes Receivable (Schedule D) ........................................................ 4.
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 7 , 7 64.5 9
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers & Miscellaneous I~q Probate Property
(Schedule G) u Separate Billing Requested............ 7.
g. Total Gross Assets (total Lines 1-7) ..................................................................... g. 7 , 7 64.5 9
9. Funeral Expenses & Administrative Costs (Schedule H) ......................... .............. 9.
1,592.50
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ .............. 10. 68 , 958.17
11. Total Deductions (total Lines 9 & 10) ..................................................... .............. 11 7O , 550.67
12. Net Value of Estate (Line 8 minus Line 11) ............................................ .............. 12, - 62 , 7 $ 6 . 0 8
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, - 62 , 7 8 6 . 0 8
TAX COMPUTATION -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 .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 0 . 0 O 16.
17. Amount of Line 14 taxable
at sibling rate X .12 O . O 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 0 . 0 0 18.
19. Tax Due ..................................................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243
1505610243
0.00
0.00
0.00
0.00
0.00
J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-11-0140
DECEDENT'S NAME
Hudson, Robert B.
STREET ADDRESS
Cumberland Crosings Retirement Community
1 Longsdorf Way
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
0.00
3. Interest
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)
(1) 0.00
(2) 0.00
(3)
(4)
(5) ~.~~
Make Check Pa able 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 :............................................................................... ^
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? ............................................................ ^ ^x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of depth 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?....... ^ 0
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)]. A
sibling 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
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hudson, Robert B.
FILE NUMBER
21-11-0140
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.
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
(It more space is needed, additional pages of the same size)
REV-1151 EX+ (10-06)
,.
COM INO EWRR TAN E~TF,qJPP~ RET RN ANIA
RESIDEN~ DECEDEN~
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Hudson, Robert B. 21-11-0140
Debts of decedent must be reported on Schedule I.
ITEM
N MBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Donna J. Ehrhart
Street Address 904 Eppley Road
city Mechanicsburg state PA zip 17055
Year(sl Commission paid
2. Attorney's Fees YOSt & Davidson
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zia _
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
750.00
750.00
92.50
TOTAL (Also enter on line 9, Recapitulation) I 1,592.50
Copyright (c) 2009 form software only The Lackner Group, Inc. Form SPA-1500 Schedule H (Rev. 10-06)
Rev-1512 EX+ (12-08)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FIDE NUMBER
Hudson, Robert B. 21-11-0140
Report debts incurred by the decedent prior to death that remained unpaid at the date of dParh inrlu,~inn ~~.,re;...ti...eea .....a:.._~ _..______
~n more space Is neeaea, aatlltlonal pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form'PA-1500 Schedule I (Rev. 12-08)
T - --
REV-1513 EX+ (11-08)
,.
COMMONWEALT OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDEN DECEDENT
ESTATE OF
FILE NUMBER
"""~""~ ^~"C' ~ °• 21-11-0 140
NUMBER NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO
DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
Tr (Wordsl) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 a 1.2
1 Donna Jean Ehrhart Daughter 1/4 of residlue
904 Eppley Road
Mechanicsburg, PA 17055
2 Barbara Ann Floyd Daughter 1/4 of residue
71 Oliver Road
Enola, PA 17025
3 Robert B. Hudson Jr. Son 1/4 of residue
23195 Red Hawk Drive
Lebanon, MO 65536
4 Deborah Suzanne Wegert Daughter 1/4 of residue
6034 Sherwin Court
Harrisburg, PA 17112
Total
Enter dollar amounts for distributions shown above on lines 1 5 throu h 18 on Rev 150 0 cover sheet, as a r o riate.
II NON-TAXABLE DISTRIBUTIONS:
. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FO R WHICH AN ELECTION TO TAX IS NQT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COV~R SHEET
Copyright (c) 2009 form software only The Lackner Group, Inc. Form ~A-1500 Schedule J (Rev. 11-08)
SCHEDULE J
BENEFICIARIES
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
April 11, 2011
DONNA J EHRHART
904 EPPLEY RD
MECHANICSBURG PA 17055
Re: Robert Hudson
CIS #: 490217615
SSN: ###-##-0973
Date of Death: 01/19/20];1
Dear Ms. Ehrhart:
Please be advised that the Department of Public Welfare is attempting to
recover the monetary value of any and all 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
$68,917.17 against the above-mentioned estate. This claim is for restitution
of medical assistance granted on behalf of the decedent for whicch 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 $23,166.85, was ~.ncurred
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 45,750.32, 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 died, the
latest tax assessment and a current appraisal, if available,.
Sincerely,
Judy E. Deaven
Claims Investigation Agent
717-214-1284
717-705-8150 FAX
Enclosure
Please complete the enclosed Asset Itemization Form and return it in the
c:.._
:~ ~,~ . ;
:;ti ~. ,~ ~ LAST WILL AND TESTAMENT
~-- _~- =s c~~~
~.~~
i-. ,_ - ~ ~r~ ~ `~; _.- ROBERT B. HUDSON
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=: } ~~OBERT B. HUDSON, having my legal residence at 159 Sunrise Drive, Lower
Swatara Township, Dauphin County, Commonwealth of Pennsylvania here~y declare this to be
my Last Will and Testament, revoking all other Wills and Codicils heretofore made by me.
ITEM ONE: I direct that the expenses of my last illness anc~ funeral be paid from
my estate as soon as practicable after my death.
ITEM TWO: I give my tangible personal property to my I, wife, VIRGINIA H.
HUDSON, if she survives me for a period of thirty (30) days. If she doe not so survive me, I
give to my children who survive us both so much of said property as they ~Imay each select, any
unselected items shall be sold and the proceeds distributed as part of the rest] of my estate.
ITEM THREE: All the residue of my estate I give to my ~i, wife, VIRGINIA H.
HUDSON, if she survives me for a period of thirty (30) days. If she doesll not so survive me, I
give said residue in equal shares to my children, DONNA JEAN EHR~HART, DEBORAH
SUZANNE WEGERT, BARBARA ANN FLOYD and ROBERT B. HUDSON, JR.
In the event that a named child is not living at the time of my death, said child's share
shall be paid to his or her then living issue per stirpes, or, if he or she has none, shall be added
equally to the shares of the other named children then living, or, if deceased; to the issue of such
deceased child, per stirpes.
ITEM FOUR: I direct that such assets of my estate as may be distributable to
any beneficiary who has not attained the age of twenty-one (21) years as of the date for
distribution be paid to a custodian for said beneficiary under the provisions of the Pennsylvania
Uniform Transfers to Minors Act. I hereby authorize my Executor to s¢lect and appoint any
person or trust company including the Executor as custodian to receive paynq~ent of such gift.
ITEM FIVE: All estate, inheritance, succession and other de~th taxes, imposed or
payable by reason of my death, and interest and penalties thereon, with r~spect to all property
comprising my gross estate for death tax purposes, whether or not such property passes under this
Will, shall be paid out of the principal of my general estate, as if such taxes were administration
expenses, without apportionment or right of reimbursement. I authorize my~ legal representatives
to pay all such taxes at such time or times as may be deemed advisable.
ITEM SIX: I appoint my wife, VIRGINIA H. HUDSON, Executrix of this Will and
direct that she be permitted to serve without bond and without any intervention of any court
except as required by law. I authorize my Executrix to sell, encumber, mortgage, invest,
distribute in kind, or retain any items of personally property of my estate in' such manner as she
shall deem proper, limited only by her own discretion. If for any reason my Executrix appointed
under this Will should fail to serve in that capacity, I appoint my daugh~er, DONNA JEAN
EHRHART, my Executrix with the same powers and privileges set forth abo~e.
IN WITNESS WHEREOF, I have at Hershey, Pennsylvania, ~I,this .,~~~ day of
~' ~ , 1998, set my hand and seal to this, my Last Will and Test~mment consisting of
three (3) pages, including the acknowledgment.
,. ~--~': (SEAL)
ROBERT B. HUDSON
SIGNED, sealed, published and declazed by ROBERT B. HUDSON, the above named
Testator, as and for his Last Will and Testament, in the presence of us, who, ~t his request, in his
presence and in the presence of each other, have hereunto subscribed our names as witnesses.
Lesidence ~r~ ~.~t ~/~~~ ~~,~ , .~~~---~
a
~:
Residence I ~ f
7
ACKNOWLEDGMENT
_ ~-- U r
We, ROBERT B. HUDSON, •~~~ ~•~,~.. ~ • ~~,~. ~k;~.and D ~ '~V ! ` 6 ~ the
Testator and the witnesses, respectively, whose names are signed to the attached or foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authori~ that the Testator
signed and executed the instrument as his Last Will and that he had signed willingly (or willingly
directed another to sign for him), and that he executed it as his free and voluntary act for the
purposes therein expressed, and that each of the witnesses, in the presence end hearing of the
Testator, signed the Will as witnesses and that to the best of their knowledge the Testator was at
that time eighteen years of age or older, of sound mind and under no cdnstraint or undue
influence.
Subscribed, sworn to and acknowledged before me by ROBERT B.. HUDSON, the
Testator ,and subscribed and sworn to before me by .1Lit rr, ,~ !J~''~%/I ~: ~.~ and
- ~
i ' o G ,witnesses, this,3~day of - ,~~~,G , 199f~.
Ce~cz. I~~. .~
NOTARY PUB IC
hOTA~t.~.t. S~~.
~~ T~ pain .,ah,~ ~~,
~;';; +Ccxa~is~o~ t~ Ja+9l 19, 2~Ai
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