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HomeMy WebLinkAbout10-18-111505610101 REV-1500 EX (oiaa) 6f7 OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes "EP.A,rE"T `p`°`"°` County Code Year File Number PO BOX 28ot5oi ~ INHERITANCE TAX RETURN ~, Harrisburg, PAiyiz8-o6oi RESIDENT DECEDENT .,~,~ r~ ~ ~~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 174-20-8179 06/27/2010 11/11!1927 Decedent's Last Name Suffix Decedent's First Name MI COOMBE SHIRLEY M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name 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 ~ t. Original Return O 2. Supplemental Retum O 4. Limited Estate O 4a. Future Interest Compromise (date of death after 12-12-82) Clp 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust (Attach Copy of Will) (P,ttach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-?-95) O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required _._ 8. Total Number of Saie Deport Boxes (~ 11. Election to tax under Sec. 9 i 13(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDEN7IALTAXlNFORMATION SHOULD BE DIRECTED TC: Name Daytime Telephone Number THOMAS E. FLOWER (717) 243-5513 First line cf address FLOWER LAW, LLC Second line of address 1 G W. I~lGH ST. City or Post Office CARLISLE _ _ REGISTER'OFQtOjLLS USE ONLY ` ~..-.; ~~ r ~ ~ ~ r-- - r.=~ _. _ c-Y~ ;5"~' _ ., .::) ~ -; I :1.. - --~ _1 ~~ DATE FILED ~_~ State ZIP Code PA 17013 Correspondent's a-mail address: THOMASEFLOWER GMAIL.COM ADDRESS C. CHRISTINE COOMBE, 1507,CHARLTON AVE, ANN ARBOR, MI 48103 SI TU OF PREPA~tF~t7T~R THAN REPRESENTATIVE nnr~/ 9 /y~" , , THOMAS E. FLOWER, FLOWER LAW, LLC, 10 W. HIGH ST., CARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J -?-I -~- unaer penaicres of per)ury, I tleclare 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 reoresentativa is hacaci nn arr rnfnrm~rr..., .,s,.,ti;,.ti ................... ...... ~-__...~_~-_ 4 � 1505610105 REV-1500 EX DecedenYs Social Security Number oecede�t's rvame: SHIRLEY M. COOMBE 174-20-8179 RECAPITULATION 1. Real Estate(Schedule A). . . ..... . . . . . ... . . .. . ..... .......... . .... . .. . 1. ' 2. Stocks and Bonds(Schedule B) 2. ' 11,234.98; ....... .. ... .. ... .......... . .... . ...... 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. ' 22,032.11 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. ' 0.00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... . .. 7. ' 0.00 8. Total Gross Assets(total Lines 1 through 7). .... ... .......... . ..... ..... 8. I 33,267.09 '; 9. Funeral Expenses and Administrative Costs(Schedule H).......... . .. . .. .. . 9. ', 2,597.11 ' 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) .. ..... ..... .. 10. 189,034.30 11. Total Deductions(total Lines 8 and 10). .. . .... ... . .... . .. ... . . .. . .. .... 11. 191,631.41 ' 12. Net Value of Estate(Line 8 minus Line 11) . . .. ..... . .... ...... ..... ... .. 12.' 0.00 ' 13. Charitable ar�d 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. ' 0.0� TAX CALCULATION-SEE INSTRUCTIONS FOR APPUCABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2}X.0_ 15. ' 0.00 16. Amount of Line 14 taxable at lineal rate X A_ 16. �.�� ]7. Amount of Line 14 taxable at sibling rate X.12 17. 0.00 18. Amount of Line 14 taxable at collateral rate X.15 18. ' 0.00 19. TAX DUE ........ . .. .. . .... .. . ........ ..... . . . .. ..... . .. ..... ..... 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p $IC1@ 2 � 1505610105 1505610105 J LAST WILL AND TESTAMENT OF SHIRLEY M. COOMBE I, SHIRLEY M. COOMBE of the Borough of Camp Hill, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any will previously made by me. I - I direct the payment of all my just debts and. funeral expenses out of my estate as soon as may be practical after my death. II - I devise and bequeath all of my estate of whatever naturF: and wherever situate unto my husband, William F. Coombe. III - Should my said husband predecease me, then I devise and bequeath all of my estate of whatever nature and wheresoever situate unto my issue per stirpes. IV - I appoint the following executors of my estate in the priority indicated, so that if anyone fails -to qualify or ceases to act, the next shall be substitute executor: my husband, William F. Coombe; my daughter, C. Christine Coombe; my son, Jeffrey L. Coombe; my son, David Michael Coombe; CCNB Bank, N.A., Camp Hill, Pa. None of my personal representatives shall be required to post bond in this or any jurisdiction. . rn' ~~~ ~ Page 1 ARNOLD & SLIKE, ATTORNEYS-AT-LAW, 2109 MARKET STREET, CAMP HILL, PA 17011 IN WITNESS WHEREOF, I~have` hereunto set my hand and seal on this, the ~ day of ~~~%~ 1984. e ~~ C.D`d~'~'f ~j ~ ( SEAL ) irley M. Coombe ;Signed, sealed,. published and declared by SHIRLEY M. COOMBE, Testatrix therein named, on this and one (1) other sheet of paper as and for her Last Will and Testament in our presence, who, in her presence, at her request and in the presence of each other, have hereunto subscribed our names as attesting witnesses. r 1 .' r rft' ! Name Name Camp Hill, Pa. Address Camp Hill, Pa. Address Page 2 ARNOLD & SLIKE, ATTORNEYS-AT-LAW, 2109 MARKET STREET, CAMP HILL, PA )7011 CONIP!IONf~TEALTH OF PENNSYLVANIA) SS. COUNTY OF CUMBERLAND) WE, the undersigned, the testatrix and the witnesses, respectively, whose names are. signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last Will and Testament and that she signed willingly (or willingly directed another to sign for her), and that she executed it as her free will and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix signed the will as witnesses and that to the best of their knowledge the testatrix was at that time eighteen years of age or older, of sound mind,-and under no constraint or undue influence. Subscribed, sworn to and acknowledged before me by the testa ix, and subsc ed and sworn to before me by both witnesses, this /~ day o f ~C%~~a,J 19 8~ otary Public THELMA S. McCAUSLIN, NOTARY- PUBLIC My Commission Expires July 3, 1988 Camp Hill, PA Cumberland County ARNOLD & SLIKE, ATTORNEYS-AT-LAW, 2109 MARKET STREET, CAMP HILL, PA 17011 ~z. Coo-~-n ~6 c.~ statrix ~. 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 August 6, 2010 FLOWER LAW, LLC THOMAS E. FLOWER, ESQUIRE 10 W HIGH ST CARLISLE PA 17013 Re: Shirley Coombe CIS #: 710179092 SSN: ###-##-8179 Date of Death: 06/27/2010 Dear Attorney Flower: Please be advised that the Department of Public Welfare maintains a claim in the amount of $189,034.30 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 $28,835.07, 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 $160,199.23, 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 ~~ 02/2004 ~~ Series Denomination Serial Number ~I-s-s-ue-Da-te-r EE Bond-s $ 50_..__ ~ ~_"'~ i # Bonds Total Price Total Interest Total Value 21 $775.00 YTD Ins $2,784.9b $3,559.96 gip ~ Issue Interest Next Final Serial Number Issue Date Series Denom Price Interest Value Rate Accrual Maturity -94f 11/1994 EE $50 $25.00 $12.98 $37.98 2.43% 0512004 11/2024 21870578$7 12/1979 E 50 37.50 136.94 174.44 4.00% 06/2004 12/2009 2187016790 11/1979 E 50 37.50 136:94 174.44 4.00% 05/2004 11/2009 2186974574 10/1979 E SO 37.50 135.32`-172.82 4.00% 04!2004 10/2009 2185041893 09/1979 E 50 37.50 135.32 172.82 4.00% 0312004 09/2009 .2184998996 08/1979 E 50 37.50 138.78 176.28 4,00% 08/2004 08/2009 2179601482 07/19?9 E 50 37.50 138.78 176.28 4.00% 07/2004 07/2009 2179557958 06/1979 E 50 37.50 138.78 176.28 4.00% 06/2004 06/2009 2179514763 06/1979 E 50 37.50 138.78 176.28 4.40% 06/2004 06/2009 2168532684 05/1979 E 50 37.50 138.36 175.86 4.00% 05/2004 05!2009 2168490776 04/1979 E 50 37.50 136.68 174.18 4.00% 04/2004 04/2009 2167326114 03/1979 E 50 37.50 136.68 174.18 4.00% 03/2004 03/2009 2160560253 02/1979 E 50 37.50 140.16 177.66 4.00% 08/2004 02/2009 2160516971 01/1979 E 50 37.50 140.16 177.66 4.00% 07/2004 01/2009 2152253475 12/1978 E 50 37.50 140.14 177.64 4.00% 06!2004 1212008 2150787291 1111978 E 50 37.50 139.66 177.16 4.00°f° 05,2004 1112008 2147883280 1011978 E 50 37.50 138.00 175.50 4.0-0"~`0 44/2004 101200 2147838805 09/1978 E SO 37,50 138.0€1 175.50 4.(1€x°'4 m3./2fK34 4912t~38 2145691518 O~I97'8 E 50 37.50 141,.52 1 r9t~ 440 0~0 ~2 ,:.143221 07;1978 E 54 37.Sff ~4~.52 ~rb2 ~ 13711E 4~/ 2139811 ~ . , . 2127307474 06/1978 2135408613 05/1978 E 50 37.50 141.02 178.52 4.00% 05/2004 05/2008 2132075022 04/1978 E 50 37.50 150.02 187.52 2.51% 04/2004 04/200$ 2128261056 03/1978 E 50 37.50 150.02 187.52 2.51% 03/2004 03/2008 2123577276 02/1978 E 50 37.50 181.76 219.26 4.00% 08/2004 02/2008 2113168208 01/1978 E 50 37.50 181.76 219.26 4.00% 07/2004 01/2008 2113124181 12/1977 E 50 37.50 181.76 219.26 4.00% 06/2004 12/2007 2113086695 11/1977 E 50 37.50 181.16 218.66 4.00% 05/2004 11/2007 .2113041906 10/1977 E 50 37.50 200.92 238.42 4.00% 04/2004 10/2007_ -4~j~° 09/1977 E 50 37.50 200.92 238.42 4.00% 03/2004 09/2007 ~8~3~ , 0811977 E 50 37.54 205.68 243.1$ 4.00% 0812004 08/2007 .-2090'x`, 07/1977 E 50 37.50 205.68 243.18 4.00% 0712004 07/2007 _ _ _ _ _ _ . , ,,,, „ ,,.,., r cn ~~ 511 205.68 243.18 4.00% 07/2004 07/2007 Savings Bond Calculator ~ Page 1 of 2 3~lV! 02/2004 . , __ ~ ~ Series Denomination Serial Number Issue Date EE Bonds __ ~ 50___. __ _ ~_ f _ _ _ ~ # Bonds ~ Total Price Total Interest Total Value YTD Im 26 $650.00 $1,562.44 $2,212.44 $11.f Issue Interest Neat Final Serial Number Issue Date Series Denom Price In terest Value Rate Accraal Matarity 168481914 04/1984 EE $50 $25.00 $55.24 $80.24 2.50% 04/2004 04/2014 1 b8451094 04/1984 EE 50 25.00 55.24 80.24 2.50% 04/2404 04/2014 164415842 03/1984 EE 50 25.00 55.24 80.24 2.50% 03/2004 03/2014 164384910 03/1984 EE 50 25.00 55.24 80.24 2.50% 03/2004 03/2014 158718677 02/1984 EE 50 25.00 56.24 81.24 . 2.73% 08/2004 02!2014 158648951 01/1984 EE 50 25.00 56.24 81.24 2.73% 07/2004 01/2014 158618149 01/1984 EE 50 25.00 56.24 81.24 2.73% 07/2044 01/2014 158662223 12/1983 EE 50 25.00 56.24 81.24 '-2.73% 06/2004 12/2013 152884078 11/1983 EE 50 25.00 56.24 81.24 2.73% 05/2004 11/2013 148588571 11/1983 EE 50 25.00 56.24 81.24 2.73% 05/2004 11!2013 148558049 10/1983 EE 50 25.00 58.80 83.80 2.48% 04/2004 ~ 10/2013 148499142 09/1983 EE 50 25.00 58.80 83.80 2.48% 03/2004 09/2013 1.48467522 09/1983 EE 50 25.00 58.80 83.80 2.48% 03/2004 09/2013 144468357 09/1983 EE 50 25.00 58.80 83.80 2.48% 03/2004 09/2013 144412874 08/1983 EE 50 25.00 59.84 84.84 2.30% 0812004 08/2013 137861160 07/1983 EE 50 25.00 59.84 84.84 2.30% 07/2004 07/2013 137831634 07/1983 EE 50 25.00 59.84 84.84 2.30% 07/2004 07/2013 13778531 06/1983 EE 50 25.00 59.84 84.84 2.30% 06/2004 06/2013 137750160 05/1983 EE 50 25.00 59.84 84.84 2.30% 0512004 05/2013 137719783 05/1983 EE 50 25.00 59.84 84.84 2.30% 05/2004 05/2013 127715305 04/1983 EE 50 25.00 63.46 88.46 2.51°/a 04/2004 04/2013 124980158 04/1983 EE 50 25.00 63.46 88.46 2.51% 04/2004 04/2013 124951336 03/1983 EE 50 25.00 63.46 88.46 2.51% 03/2004 03/2013 124897282 02/1983 EE 50 25.00 73.14 98.14 4.00% 08!2004 02/2013 124868333 02/1983 EE 50 25.00 73.14 98.14 4.00% 08/2004 02/2013 124839706 01/1983 EE 50 25.00 73.14 98.14 4.00% 07/2004 01/2013 Viewing Bonds 1-26 httn://wwws.nublicdebt.treas.~ov/BC/SBCPrice 2/9/2004 Savings Bond Calculator ~ Page 1 of 2 ~ ~ S~ftY1 02/2004 ` . , .-- ~ Series Denomination Serial Number Issue Date - EE Bonds $ 50 _ ~ ~~ _ __ __ # Bonds Total Price Total Interest Total Value YTD Ins 27 $675.00 $2,149.86 $2,824.86 $12.~ Serial Number Issue Date Series Denom Issue Price In terest Value Interest Rate Negt Accrual Final Maturity 114238528 12/1982 EE $50 $25.00 $73.14 $98.14 4.00% 06/2004 12/2012 114207273 12/1982 EE 50 25.00 73.14 98.14 4.00% 06/2004 12/2012 - 114177161 11/1982 EE 50 25.00 73.14 98.14 4.00% 05/2004 11/2012 114123794 10/1982 EE 50 25.00 77.86 102.86 4.00% 04/2004 10/2012 103413757 10/1982 EE 50 25.00 77.86 102.86 4.00% 04/2004 10/2012. 103382775 10/1982 EE 50 25.00 77.$6 102.86 4.00% 04/2004 10/2012 103327409 09/1982 EE 50 25.00 77.86 102.86 4.00% 03/2004 09/2012 103263437 08/1982 EE 50 25.00 79.90 104.90 4.00% 08/2004 08/2012 101265204 08f 1982 EE 50 25.00 79.90 104.90 4.00% 08/2004 08/2012 101213624 07/1982 EE 50 25.00 79.90 104.90 4.00% 07/2004 07/2012 101182673 06/1982 EE 50 25.00 79.90 104.90 4.00% 06/2004 06/2012 97631525 06/1982 EE 50 25.00 79.90 104.90 4.00% 06/2004 0612012 97557387 05/1982 EE 50 25.00 79.90 104.90 4.00% 05/2004 05/2012 97546192 04/19$2 EE 50 25.00 79.90 104.90 4.00% 04/2004 04/2012 91278044 04/1982 EE 50 25A0 79.90 104.90 4.00% 04/2004 04/2012 - 91221352 03/1982 EE 50 25.00 79.90 104.90 4.00% 03!2004 03/2012 91190197 03/1982 EE 50 25.00 79.90 104.90 4.00% 03/2004 03/2012 83606985 02/1982 EE 50 25.00 82.00 107.00 4.00% 08/2004 02/2012 83553104 01/1982 EE 50 25.00 82.00 107.00 4.00% 07/2004 01/2012 83520806 0111982 EE 50 25.00 82.00 107.00 4.00% 07/2004 01/2012 77400173 12/1981 EE 50 25.00 82.00 107.00 4.00% 06/2004 12/2011 77341839 11/1981 EE 50 25.00 82.00 107.00 4.00% 05/2004 11/2011 77309231 11/1981 EE 50 25.00 82.00 107.00 4.00% 05/2004 11/2011 77276931 10/1981 EE 50 25.00 82.00 107.00 4.00% 04/2404 10/2011 77222549 20/1981 EE 50 25.00 82.00 107.00 4.00% 04/2004 10/2011 62241416 09/1981 EE 50 25.00 82.00 107.00 4.00% 03/2004 09/2011 62208257 0911981 EE 50 25.00 82.00 107.00 4.00% 0312004 09/2011 Viewing Bonds 1-27 -ttp:/Iwwws.nublicdebt.treas. ~ovBC/SBCPrice 2/9/2004 Series - Denomination EE Bonds ~ ~° 5Q _ '' " ~~~ # Bonds Total Priee 30 $787.50 Serial Number Issue Date Total Interest Total Value YTD Ins $2,968.36 $3,755.86 $27.~ Serial Number Issue Date Series Denom Issue Price Interest Value Interest Rate Nezt Accrual I+Ynal Maturity 62147897 08/1981 EE $50 $25.00 $84.14 $109.14 4.40% 0$/2004 08/2011 62115360 07/1981 EE 50 25.00 84.14 109.14 4.00% 07/2004 07/2011 62083738 0711981 EE 50 25.00 84.14 109.14 4.00% 07/2004 07/2011 57556351 06/1981 EE 50 25.00 84.14 109.14 4.00% 06/2004 06!2011 57521514 05119$1 EE 50 25.00 84.14 109.14 4.00% 0512004 OS<2011 5748$676 05/1981 EE 50 25.00 84.14 109.14 4.00% 08/2004 05/2011 57431960 04/1981 EE 50 25.00 89.00 114.00 4.00% 04/2004 04/2011 57399377 04/1981 EE 50 25.00 89.00 114.00 4.00% 04/2004 0412011 47756906 03/1981 EE 50 25.00 89.00 114.00 4.00% 03/2004. 03/2011 47698033 02/1981 EE 50 25.00 .91.28 116.28 4.00% 08/2004 02/2011 4766IIOb 02/1981 EE 50 25.00 91.28 126.28 4.00% 08/2004 02/2011 42389146 01/1981 EE 50 25.00 91.28 116.28 4.00% 07/2004 OI/2011 42331150 12/19$0 EE 50 25.00 91.28 116.28 4.00% 06/2004 12/2410 42294328 12119$0 EE 50 25.00 91.28 116.28 4.00% 06/2004 12/2010 28592304 11!1980 EE 50 25.00 91.28 116.28 4.00% 05/2004 11/2010 28521979 1011980 EE 50 25.00 101.88 126.88 4.00% 04/2004 10/2010 28483742 10/1980 EE 50 25.00 101.88 126.88 4.00% 04/2004 10/2010 28447971 10/1980 EE 50 25.00 101.88 126.88 4.00% 04/2004 10!2010 28381542 09/1980 EE 50 25.00 101.88 126.88 4.00% 03/2004 09/2010 28343311 08/1980 EE 50 25.00 104.40 129.40 4.00% 08/2004 08/2010 26721324 0$!1980 EE 50 25.00 104.40 129.40 4.04% 08/2004 08/2010 26658762 07/1980 EE 50 25.00 104.40 129.40 4.00% 07/2004 07/2010 25556505 06/1980 EE 50 25.00 104.40 129.40 4.00% 06/2004 06/2010 25515092 06/1980 EE 50 25.00 104.40 129.40 4.00% 06/2004 06/2010 25444254 05/1980 EE 50 25.00 104.40 129.40 4.00% 05/2004 05/2010 2403906$ 05/1980 EE 50 25.00 104.40 129.40 4.00% 0512004 05/2010 239923668 0411980 EE 50 25.00 103.12 128.12 4.00% 04/2004 04/2010 2200179922 03/1980 E 50 37.50 133.52 171.02 4.00% 03/2004 03!2010 ttn://wwws.nublicdebt.treac. ~nv/RC:/SRC:Price 2/9/2004 avings Boyd Calculator ~ a bb/ ~ ~ ~ 6 Page 2 of 2 s 2200143474 02/1980 E 50 37.50 136.94 174.44 4.00% 0812004 02/2010 ~~+••~•+ ••.n~~ n+ ~+ non- ~ cn ~7 cn 1 Z~ Qd 17d d4 4.(1(1%, (17/2004 O1 /2010 From:PENN WASTE INC. 717 801 4684 09/01/2011 14:54 #060 P.002/002 ~-~~~~~ Penn Waste, Inc. ~~~~ P O Box ,3©b6 York, PA 174Q2 0001711OC~6 - 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Pennvvastecom Phorte (717) 767-4456 1 Fax {717) 767-4785 Nnv-30-30 RS 17919 0 ~: ESCAPE OFrVIrILLIAM F GOOMBE ;: ~ ', C/Cl ATTORrtEY THOMAS FLOWERS iQ W HYGH'.5C • r ;91.50 CARLISLE, PA 17413 ~ .. • ~ • _ (D001) WILLIAM' F COOMBE 1 . 2117 MAYFR~D ~tJ, CAMP F[ZLL PA' 1 Serv ?l001'Cnrbside Trash & ReCydinO 32Q0 30 -Nov'' Curbside Trash & Recyding 1;00 $45:75 OlJan11-31Mer11 is ' ti , i PAl(MEKi I5 DUE'UPOPI RECEIPT. For your aonVe~Eenoe, Y4u.may pay online h~~1~ure.bllLtrusLCOm/,p'Bnnw~~/~?4pl,Qn.@t~nsePalmv,php '", .' ,~ rr ~ it i it ~ ~~ ~ 591.50. Pen+~.Waste, Inc. 0001711066 P O Sono 3066 ~ r lrork, PA 17402 ~ Nc7v-30-10. ,~ '~ , ' kvww,penrtv+~astE+cann RS 17919 ' Phone (7~7) 7f7=4458.. '' ~ Fax (7~7) 767=d2~ From: PENN WASTE INC. 717 801 4684 09/01/2011 14:53 #060 P.001/002 penrr Waste, Inc. ~ ~ Box 3(366 YOHc, PA 17403. WVI-Mfl'. (>e1MWdS~e.tOm Phone (}`itj 767-aa56 fax {71T} 7b7-4285 ESTATE OF WILLIAM F COOMBE C/O ATTORNEY THOMAS FLOWERS': ~~~~~ l0 W HIGH ST ~' ~J CA ItLISLE, PA 1701 ~~ ~ r•1 ~!!!.., . . ~~ t)d01765002 _ 1 - Feb-28-11 RS 17919 0 g91.5a {OOdl) WILLIAM F CAOM6E 2117 MAYERED iN, CAMP HILL'PA Serv #p01 Curbside Trash & F~ecydin~ 32.04 2$ -Feb Curbside Trash 8~ Recyd'my L00 #45.f5 dlAprii-30Jun11 i PAYMElrFT IS DUE i1pOPf RECEIPT. For your conven[enoe, .you may pay online: of ' '//secur~i~il , ./Pe~n.MKastelobPJonetln-~ ..: .php , .~ ~• •~ • • •~ •• • ~ • • x+45.75 ~ i~ ~ ~ ~~ -, ~ ~ $91.50 0001965Q02 ~ Per1n Waster Inc. i * t~ O Bane 8066 - ~ ~ Fet~2$-11 ~' York, PA X17402 ~ ~ ~ Vvww.pennwaste.com RS 27919 ohotre {TI7) 7b7-4456 ;, ~ ,d. ,, f~c (717 767-4285 J 150561D1D1 -- ~ ~jil Z ~ l _._ REV-1500 Ext°~ ~°'~ ~ "'!! l ~ enns lvania PA Department of Revenue P Y OFFICIAL USE ONLY Bureau of Individual Taxes ~` ""T"`"T°`"`"`"°` INHERITANCE TAX RETURN Coun Code Year tY File Number PO BOX z8o6oi Harrisburg, PA i~iz8-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 174-20-8179 06/27/2010 11 /11 /1927 Decedent's Last Name __ __ Suffix Decedent's First Name MI COOMBE __ _. _ SHIRLEY , M (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 ~ 1. Original Return I nla Kt I urcn Mus I tit FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Retum 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) ~ fi. Decedent Died Testate O ?. Decedent Maintained a Living Trust _._ 8. Total ~.^;umber of Sate Deposit Boxes !Attach C'o~~~ of Willi :Attach Copy of Truati ~~ ~ - _, 3 ;-. First line cf address FLOWER LAW, LLC Second line of address 10 W. HIGH ST. City or Post Office CARLISLE State ZIP Code PA 17013 Correspondent's a-mail address: THOMASEFLOWERCc.~GMAIL.COM UATE FILEU Under penalties of perjury, I declare that 1 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 OF PERSON RESPONSIBLE FOR FILING RETURN DATE AUDRE55 C. CHRISTINE COOMBE, 1507,CHARLTON AVE, ANN ARBOR, MI 48103 SI TU OF PREP R THAN REPRESENTATIVE DAT 9 y~, ~ THOMAS E. FLOWER, FLOWER LAW, LLC, 10 W. HIGH ST., CARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 REV-1500 EX Decedent's Name: SHIRLEY M. COOMBE RECAPITULATION 15D5610105 Decedent's Social Security Number 174-20-8179 1. Real Estate (Schedule A) .......................................... ... 1. 2. Stocks and Bonds (Schedule B) .................................... ... 2. '` 11,234.98 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. '. 0.00 4. Mortgages and Notes Receivable (Schedule D) ........................ ... 4. i 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. ' 22,032.11 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 0.00 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. ' 33,267.09 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 2,597.11 10 rJebts of ~~eredert, Mortgage Liabilities, an~i Liens ,Schedule li . . _ ?n 1 R, Zn 9,C34.,,•~• ~. w~ r., en ;~: ace : - -,•, . ~. . , '4 +~et Vaiue Subject to Tax ;Line +2 rnmtas ure ' ` ~•? ~ Q~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPI_IGABLE RATES ____ `~~ -_~~~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0._ 16. 0.00 17. Amount of Line 14 taxable at sibling rate X .12 17. ' 0.00 18. Amount of Line 14 taxable - at collateral rate X .15 1g. ` 0.00 19. TAX DUE ....................................................... .. 19. 0.00` 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 15D5610105 1505610105 J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME SHIRLEY M. COOMBE STREETADDRESS 100 MT ALLEN DR MECHANICSBURG STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments _ B. Discount 3. Interest 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. File Number (1) Total Credits (A + B) (2) (3) (4) (5) >!;r'] ~ttc `~'SUr^9t ~1~°J~~'~!~ ;`,,' ~l'~'6~T~~ rl'"' n.°' 1^r°nl-r 0.00 0.00 0.00 0.00 0.00 ;ia to rye+~± .a `~ rlr I~ 1,: k .;'-fig, 1Srt'r~( ;_ ... _ _. _ _.. '<: ~, retain the right to designate vrho shall use one ~~rcperty fray (erred or its inccmr _ _ _.___ __ ' iX ;. retain a reversiona interest; or ...................................................................._........_..... _ ..........._ ......... ry _f Lx~' d. receive the promise for life of either payments, benefits or care?._ ................:..._:... ......_ _. __...:............ ^ Lx-1, 2. If death occurred after Dec. 12, 1982, did decedent transfer property within me year of. death without receiving adequate consideration? .....................................................:.. x 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? .............. ^ z^ 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 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 Jan. 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)]. 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)]. Asibling 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-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER SHIRELY M. COOMBE 21-10-0668 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (li-1o) Pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Shirley M. Coombe 21-10-0668 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 on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PNC BANK CHECKING ACCOUNT 22,032.11 NOTE: DECEDENT EXPECTS AONE-THIRD (1/3) SHARE OF HER PREDECEASED HUSBAND'S ESTATE (WILLIAM F. COOMBE, FILE N0. 21-10-0298) WHICH HAS NOT YET BEEN SETTLED DUE TO DIFFICULTIES & DELAYS IN SELLING MR. COOMBE'S RESIDENCE, VALUED AT 173,000 ON SCH. A OF HIS ESTATE'S INHERITANCE TAX RETURN. THE EXECUTRIX OF SHIRLEY COOMBE'S ESTATE INTENDS TO FILE A SUPPLEMENTAL RETURN TO DECLARE THE DISTRIBUTION FROM MR. COOMBE'S ESTATE WHEN RECEIVED. THE SHIRLEY COOMBE ESTATE WILL STILL BE INSOLVENT AFTER RECEIPT OF SUCH DISTRIBUTION. TOTAL (Also enter on Line 5, Recapitulation) $ I 22,032.11 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (SO-09) ~~i Pennsylvania ~.. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Shirley M. Coombe 21-10-0668 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A• FUNERAL EXPENSES: 1. B. 1 TRINITY EVANGELICAL LUTHERAN CHURCH MEMORIAL DINNER 2 FUNERAL HOME HAIRDRESSER 3 FUNERAL HOME FLOWERS a OBITUARY 5 ORGANIST s MESSIAH VILLAGE ~ ESTATE NOTICE ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP 166.15 45.00 185.00 297.00 100.00 42.00 168.96 0.00 Year(s) Commission Paid: 2. Attorney Fees: 1,327.50 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) 0.00 Claimant Street Address City State Relationship of Claimant to Decedent 4. 5. 6. ~. Probate Fees: Accountant Fees: Tax Return Preparer Fees: ZIP TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. 265.50 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,597.11 REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER SHIRLEY M. COOMBE 21-10-0668 Report debts incurted by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (If more space is needed, insert additional sheets of the same size) Free Checking Account Statement ' PNCBANK YVC Bank For the period 07/2312010 to 0812®/2010 Primary account number: 50-0663-7283 Page 1 of 2 Number of enclosures 0 022670 SHIRLEY M COOMBE DECD ~+ - 1507 CHARLTON ST ANN ARBOR MI 48103-4167 For 24hour banking, and transaction or interest rate information, sign on to PNC Bank Online Banking at pnc.com. "a For customer service call 1-888-PNC-BANK Monday - Friday: 7 AM - 10 PM ET Saturday & Sunday: 8 AM - 5 PM ET Para servicio en espariol, 1-866-HOLA-PNC Morins't Please contact us at 1-888-PNC-BANK ® Write to: Customer Service PO Box 609 V isit us at pnacom ® TDDterminal:1-800-531-1648 Eor htarin~ iniNaired clients oril~~ Free Cheel0ng Account S~unntary Shirley M Coombe Decd Account number: 50-0663-7283 Overdraft Protection Provided By: Coit~aat PNC to sstaibWh O+irerdraift Protoottron Balance Summary Beginning Deposits and Checks and other Ending balance other additions deductions balance ??,032.11 1„'t35_(}t} .UU ?5,317.11 Average monthly Charges balance and fees 2>,874.0(} .00 ActiYlty ~tal~ Deposits and Otfier Additions There was 1 Deposit or Other Addition Cate Amount Description totaling $1.2$5.00. (iY:'(}`? 1,285.(}t} llirect Deposit - Civil Sere 118 "['t easut-~° 31 ~ F 329E>759 M1M1' CSF Daily Balance Detail Date ante ~ Date Balance t}7."_'3 2°_,03_'.I1 ! 08j'0,~ >3,3171I Is a Roth IRA Conversion Right for You? Go to pnc.com/rothconversion to use anew online tool from PNC that can help you find out. :z ', 11 C PN DM LT01-J O 674125-N 40-N N N N N N-001-038614 BUREAU OF COLLECTIONS & TAXPAYER SERVICES PO BOX 28104! HARRISBURG PA 17128-1041 THOMAS E FLOWER 10 W HIGH ST CARLISLE PA 17013-2922 Date: Estate of: SHIRLEY SSN: Date of Death: File Number: 07/01/2011 M COOMBE REV-834 FO AFP (07-OS) 174-20-8179 06-27-2010 2110-0668 Department records indicate you are responsible for the settlement of the above estate or that you represent the responsible party. The estate is in delinquent status, as the inheritance tax return has not yet been filed. The Inheritance and Estate Tax Act mandates the filing of a tax return and payment of all outstanding liabilities by a personal representative or a transferee of an estate within nine months of a decedent's death. If this estate was opened for the purpose of filing a lawsuit, please provide the court term and docket number of the proceeding in writing to this office. The Department may postpone further action regarding the estate pending the completion of the lawsuit. If there is any other reason that a return has not been filed, please contact the office listed below. Under Act 40 of 2005, additional collection costs, including but not limited to fees of up to 39 percent of the amount due and attorney fees incurred in securing payment, maybe imposed on any liability not paid prior to referral to a collection agency or contract counsel. To avoid further action, a return must be filed within 15 days of the date of this letter. If the return has been filed recently, please disregard this notice. Direct any questions regarding this estate to: Harrisburg Call Center (717) 783-3000 TDD# 1-800-447-3020 (service for taxpayers with special hearing and/or speaking needs) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE Inheritance Tax Non-Filer Delinquency Notification RETURNS SHOULD BE FILED AND PAYMENTS MADE AT THE REGISTER OF WILLS LISTED BELOW: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 t