HomeMy WebLinkAbout07-11-111505610143
REV-1500 EX (01-10) ]il OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 80X.280601 INHERITANCE TAX RETURN 21 10 12 7 6
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
202 20 2633 10 O1 2010
Decedent's Last Name
DIETER
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Spouse's Social Security Number
Date of Birth
09 30 1928
Suffix Decedent's First Name MI
DORIS C
Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return
4. Limited Estate ~ qa. Future Interest Compromise
(date of death after 12-12-82)
L~
L~ 6 Decedent Died Testate
(Attach Copy of Will) ~ Decedent Maintained a Living Trust
(Attach Copy of Trust)
~~
~ 9. Litigation Proceeds Received ~ 1 p. Spousal Povertyy Credit (date of death
between 12-31 91 and 1-1-95)
~~ 3, Remainder Return (date of death
prior to 12-13-82)
L~ 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
C~ 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
GEORGE F DOUGLAS III ESQ 717 249 6333
._ ,
First line of address
354 ALEXANDER SPRING RO
Second line of address
City or Post Office State ZIP Code
CARLISLE PA
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REGISTER a~.LS USE-ONLY
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Correspondent's a-mail address: gdougldS@SalzmarlnhugheS.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.
SIGNATURE RSO E SIBLE OR FILING RETURN DATE
Patrick L Dieter
ADDRESS
_ 114 Yates Street, Mount Holly Springs, PA 17065-1018
SIGNATUR OF PREPARER OTHER THAN REPR ENTATIVE DATE
~! .n +~-. ~~ _ fi ~ ~~~ ~_ ` t 1. George F Douglas, III Esq. ~ ~ ~.`~ f i ~
ADDRESS
354 Alexander Spring Road, Suite 1, Carlisle, PA
Side 1
1505610143 1505610143
~~
~. a
J
1505610243
REV-1500 EX Decedent's Social Security Number
Decedents Name: D later, Doris C 2 0 2 2 0 2 6 3 3
REC APITULATION
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 8~ Miscellaneous Personal Property (Schedule E) ............... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 2 , 951.44
7. Inter-Vivos Transfers 8 Miscellaneous I~n~; Probate Property
^J Separate Billing Requested............
7.
(Schedule G)
g. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 2 , 951.44
9. Funeral Expenses 8~ Administrative Costs (Schedule H) ... ............ .. 9. 4 , 117.6 6
10.
Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ..............................
10. 162 481.04
~
11. Total Deductions (total Lines 9 8 10) ................................................................... 11. 16 6 , 5 9 8 . 7 0
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. -163 , 64 7 .2 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. -163 , 647.2 6
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 15 0 . 0 0
(a)(1.2) X .00
16. Amount of Line 14 taxable 0 , O O 16. 0 • O O
at lineal rate X .045
17. Amount of Line 14 taxable Q . 0 0 17. O . 0 0
at sibling rate X .12
18. Amount of Line 14 taxable O , O O 18. O - O O
at collateral rate X .15
19 0.00
19. Tax Due ..................................................................................................................
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^
Side 2
1505610243 1505610243 ,~^
REV-1500 EX Page 3
e~___r_~u_ n_ ..~..a.. A.d.~l...c~•
File Number 21-10-1276
vwa.vv^^a v vv...r....... ..~.~.-..--
DECEDENT'S NAME
Dieter, Doris C -_.___
STREET ADDRESS
Forest Park Health Care Center __
700 Walnut Bottom Road _ _
CITY ---r 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.
(1)
Total Credits (A + B) (2)
(3)
(4)
(5)
0.00
0.00
~.~~
` PayableTto ^~REGISTER OF WILLS, AGENT.
Make Check _ _
_, ., _. _ -
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 :.................................. ~~ 0
c. retain a reversionary interest; or ............................................................................................................... x
d. receive the promise for life of either payments, benefits or care? ............................................................ ^ 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without (~
receiving adequate consideration? .................................................................................................................... x
3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death?....... ~_]
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 OF THE RETURN.
r+,:
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
[72 P.S. §9116 (a) (1.1) (ii)J. 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 still 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 (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-1509 EX+ 16-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
Dieter, Doris C
ILE NUMBER
21-10-1276
-f an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Patrick L. Dieter
B.
C.
114 Yates St. Son
Mount Holly Springs, PA 17065
~~~~rr~ v r~~~i~~Cn non~CDTV•
ITEM
NUMBER
LETTER
FOR JOINT
TENANT
DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT
NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR
JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSE % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1 A 2009 JPMorgan Chase Bank, Account No. 4,484.06 50.000% 2,242.03
4211352945
2 A 09/25/2008 Orrstown Bank, Checking Account No. 1,418.82 50.000% 709.41
106004926
TOTAL (Also enter on Line 6, Recapitulation) I 2,951.44
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98)
REV-1151 EX+ (10-06)
COMMNHERITANC,~I,EOT~ RETURLN ANIA
RESIDEN DE EDENT
FUNERAL EXPENSES:
GCTAT~ CIF
FILE NUMBER
21-10-1276
ITEM
NUMBE
A.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
Debts of decedent must be reported on Schedule I.
DESCRIPTION AMOUNT
See continuation schedule(s) attached
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Yearlsl Commission raid
2. Attorney's Fees Salzmann Hughes, P.C.
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Caaimant
Street Address
City State Zia
Relationship of Claimant to Decedent
1,950.00
1,800.00
4. ~ Probate Fees I 86.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 281.16
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 4,117.66
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Dieter, Doris C 21-10-1276
ITEM AMOUNT
NUMBER DESCRIPTION
Funeral Exgenses
1 Neptune Society -funeral services 1,950.00
H-A 1,950.00
Other Administrative Costs
2 Register of Wills -filing fees 15.00
3 Salzmann Hughes, P.C. -reimbursement for payment to Cumberland Law Journal for legal 75.00
advertising
4 Salzmann Hughes, P.C. -reimbursement for payment to The Sentinel for legal advertising 191.16
H-B7 281.16
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1512 EX+ (12-OS}
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Dieter, Doris C 21-10-1276
Rannrt debts incurred by the decedent arior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
(If more space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08)
REV-1513 EX+ (11-OS)
SCHEDULE J
COMMNHERITANCE~FgP RETURNANIA BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
flintar rlnric C_ 21-10-1276
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
o Not Li Trustee
I TAXABLE DISTRIBUTIONS [include outright spousal
• distributions, and transfers
under Sec. 9116 a 1.2
1 Patrick L Dieter Son
114 Yates Street
Mount Holly Springs, PA 17065-1018
2 Max A Buford Son
2861 N. Starlight Dr.
Prescott Valley, AZ 86314
Total
Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 15 00 cover sheet, as a r o riate.
NON-TAXABLE DISTRIBUTIONS:
II. 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
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
J ~MorganChase ~ j
January 5, 2011
Salzman Hughes P.C.
Attorney at Law
354 Alexander Spring Rd., Suite 1
Carlisle, PA 17015
JPMorgan Chase Bank, N.A.
Customer Fulfillment-Deceased Processing
Mail Code: TX3-7814
P.O. Box 659516
San Antonio, TX 78265
RE: Doris C. Dieter
Social Security Number: XXX-XX-2633
Date of Death: 10/1/10
Dear Sir or tiladarli:
Please find listed below the information requested in your letter dated
12/6/ 10
VERIFICATION OF FUNDS
JPMorgan Chase Bank, N.A., a federally insured financial institution, duly incorporated and qualified to act as such under the laws of
the United States of America, by and through the undersigned officer, hereby certifies (as of even date herewith) as to the following
accoun
ts.
Account Number
Ownership of Account
Principal
Accrued
Balance as of Interest as of
D.O.D. D.O.D.
XXXXX2945 Doris C. Dieter /Primary Joint OR $ 4,484.06 $ 0.00
Checkin Patrick L. Dieter / Seconda Joint
Safe Deposit Box: Yes X No
Box Number Banking Center _
Description of loans if any: None
Should you have any questions in reference to deposit accounts, please contact us at 866-893-0745, or fax inquires to 1-866-406-3463.
If you have questions on any other account types, please contact appropriate line of business.
organ Chase Bank, N.A.
/~ --
Annette Mahan
"This letter is written as a matter of business courtesy, without prejudice, and is intended for the confidential use of the addressee only. No consideration has been paid or received for the issuance of this
letter. The sources and contents of this letter are not to be divulged and no responsibility is to attach to this bank or any of its officers, employees or agents by the issuance or contents of the letter which
is provided in good faith and in reliance upon the assurances of confidentiality provided to this bank. Information and expressions of opinion of any type contained herein are obtained from the records of
this bank or other sources deemed reliable, without independent investigation, but such information and expressions are subject to change without notice and no representation or warranty as to the
accuracy of such information or the reliability of the sources is made or implied or vouched for in any way. This letter is not to be reproduced, used in any advertisement or in any way whatsoever except
as represented to this bank. This bank does not undertake to notify of any changes in the information contained in this letter. Any reliance is at the sole risk of the addressee."
Telephone Number
rma
Cook, Florence AM.docx
JAN-04-2011(TUE) 13;00
TC~~'I~~
BA-~3K
A Tradit~an ~f Ex~elterece
Date 12/31 /2010
To: Salzmann Hughes, P.C.
- George F. Dou~Ias, III,, Esq.
From: Traci Yohc
Urrstown Bank
PG BOX 250
Shippcnsburg, Pa 17257
Rc: Estate of Doris C ~l~eiter
Date of death 101112010
!T 1S HEREBY CERT7FIF1.7 THAW Tl~' ABOYE NAMED DECEDENT, ~N ?'HE
A,~OYL~' DATE, IfAD THE FQLLOWINC ACCQUNTS WTI'H QRRST'Qy3rNBANK:
CI~ECKING ACCD~IVI"
Account # Ttle_af Account
106004926 Doris C Dictcr
Patrick L Dieter
SA YI~VCS AC'C'(~II11r7'
Account # Title of Account
Date opened Princi al Accrued Interest
09/25/05 1,418.82 0.00
Date opened Pr~_ nCipat Accrued Interest
P. 001/007
CERTIFICATE OF DEPOSIT
Accou~~ ## Title of Account Datc_Opcncd Prime Accrued ~rnter~t
P.O. ~c 250 * Slupp~nsbuxg, PA 17257 • 717.530.3530 • 7'17.532.4143 fax
~~
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 11, 2011
SALZMANN HUGHES & FISHMAN PC
GEORGE F DOUGLAS, ESQUIRE
354 ALEXANDER SPRING ROAD
SUITE 1
CARLISLE PA 17015
Re: Doris Dieter
CIS #: 230209949
SSN: ###-##-2633
Date of Death: 10/01/2010
Dear Attorney Douglas:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $162,481.04 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 $32,918.87, 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 $129,562.17,
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,
4 A ~ /
Elvetta E. Knox
Claims Investigation Ager.t
717-772-6613
717-772-6553 FLAX
Enclosure