HomeMy WebLinkAbout05-31-06_.
rsEV saoocnmi
COMMONWEALTH OF REV -1 J O 0 OFFICIAL USE ONLY
PENNSYLVANIA
EVENUE
DEPARI~PTTB6R INHERITANCE TAX RETURN FILE NUMBER
D 052
5
2
1
HARRISBURG, PA 17128-0601 RESIDENT DECEDENT _ N1
~_ 0
~
M,
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INTIAL) SOCIAL SECl1RI1Y NUMBER
~
Z Sellers, William H. 208-24-4002
W
O DATE OF DEATH (MM-DD•YEAR) DATE OF BIRTH (MM•DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
11/27/05 03/24!26 REGISTER OF WILLS
V
G (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
r ~ 1.OdginalReturn ~ 2. SupplementalRatum ~ 3. RemainderRetum(a.mordaampaa<mrzasaz(
s
5
~ 8 Y ~ 4. Limted Estate ~ 48. FUture Interest COmprOmlSa (dab ardaeth aflx r2.12A2) ~ 5. Federal Estate Tex Retum Required
~ ~ ~ ~ 6. Der~dent Died Testate (nmd, rqy orWlq ~ 7. Decedent Maintained a Livirp Trust (Amd, ~y otTNaq _ 8. Total Number Of Sate Deposit Boxes
9. Litigatbn Proceeds Received ~ 10. Spousal Poverty Credit (am of a.m between r2ar•er and r•r~s) ~ 11. Election to tax under Sec. 9113(A] (nrmm sin of
r
o
NAME
COMPLETEMAILINGADDRESS
~ Andrew C. Sheet , Es uire Andrew C. Shealy, Esquire
y FlRM NAME (xApplrabre) 127 South Market Street
Andrew C. Sheely, Attorney at Law P.O. Box 95
TELEPHONE NUMBER McChaniCStwrg, Pa 17055
(717)697-7050
1. Real Estate (Schedule A) (1) ~ OFFICIAL USE ONLY--~
2. Stocks end Bonds (Schedule B) (2)
c~
r ~ "'' _
3. Closet' Held Corporation, Partnership or Sole-Propdetorship (3)
_^,
~..
`~-~ - " ~ c ~j
i ~ C7
4. Mortgages $ Notes Receivable (Schedule D) (4) - '>~
5. Cash, Bank Deposks $ Miscellaneous Personal PropeAy (5) 19,600.23 -~-' ~ ~ a
' lrJ
Z (Schedule E) ~ - ) C7
Q
Q
6. Jointiy Owned Property (Sctedule F)
~ Separate BIIIing Requested
(6) ..i rl
-
,' m
~ 7. Inteo-Vivos Transfers $ Miscellaneous Non-Probate Properly (7) O - ~ ~~
r
a
Q
V
W
Z
Q
N
a
a
0
U
F
(Stlledale (i of L)
8. Total Gross Assets (total Lines 1.7) (6) 19,600.23
9. Funeral expenses $ Admirpsbative Costs (Schedule H) (9} 808.50
10. Debts of Decedenk Mort~ge Liabilities, $ Liens (Schedule I) (10) 50,697.69
11. Total Deductlons (total Lines 9 $10) (11) 51,506.19
12. Nat Value of Estate (Line 8minus Line 11) (12)
13. Charitable end Governmental BequesLdSec 9113 Trusts for which en election to tax has not been (13) 0.00
made (Schedule J)
14. Nst Value SuhJad to Tax (Line 12 minus Line 13) (14) 0.00
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Litre 14 taxable at Ore spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at kneel rate
17. Anaunt of Line 14 taxable et skrkng rate
18. Amount of Line 14 taxable et colleterel rete
19. Tsx Due
20. ^
x .0 (15)
x .0 (16)
x .12 (17)
x .15 (18)
(19) 0.00
[~r_RdAnt'x Cmm~lete Address:
--------- - - --- - -- --- - - -
STREETADDR
770 Po tar Church Road
clTVCamp Hill STATEPA ZIP 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. CreditslPayments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
Total Credits (A + B + C) (2)
3. Interest/Penalty ifapplicable
D. Interest
E. Penalty
Total InterestlPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Llne 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
o.oo
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) 0.00
Make Check Payable fo: 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 properly transfened :.............................................................................. ............
^
b. retain the right to designate who shall use the property transferred or its income :................................ ............
^ ^x
c. retain a reversionary interest; or .............................................................................................................. ............
^
d. receive the promise for life of either payments, benefits or care? .......................................................... ............
2. If death occurred after December 12, 1982, did decedent transfer properly within one year of death
^
without receiving adequate consideration? .................................................................................................. ............ ^
^ x
^lr
3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? .. ............
Did decedent own an Individual Retirement Account, annuity, or other non-probate propery which
4
.
contains a beneficiary designationl ............................................................................................................ ............ ^ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
oedxatian or x aher then the mat r reeenutlw a bawd on aN inbr
SiG REEF PERSOlt7RES S6LEFOR FILING RETURN
Michael L. Seifried, Executor, 300 West Main Street, Shiremanstown, PA 17011
SIG E OF PjtEPJM~R OT N RE SENTATIVE
Andrew C. Shealy, Esquire, 1~'`/ S. Market Street, P.O. Box 95, Mechanicsburg, PA 17055
for dates of death on or after July 1,1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. §9116 (a) (1.1) (i)j.
For dales 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°h [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 beneficary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of Vansfers from a deceased chile! twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of he child is 0% [72 P.S. §9116(a)(1.2)j.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2} [72 P.S. §9116(a)(1)].
Tha tax rate impos~l on the net value of Vansfers to or for the use of the decedent's siblings is 12°~ (72 P.S. §9116(a)(1.3)j. Asibling is defined, under Section 9102, as an
individual who has at least orte parent in common with the decedent, whether try blood or adop8on.
REV-1508 EX+ (&9a)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCI'I~t~~LL E
CASH, BANK DEPOSITS, 8 MISC.
PERSONAL PROPERTY
ESTATE OF WILLIAM H. SELLERS 21-05-
Include the proceeds of litigation end the date the proceeds were received by the estate.
All propsAy jointlyowned with right of survivorship must be disdosed on Schedule F.
(If more space is needed, insert addNional sheets of the same size)
REV-1511 EX+ (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF WILLIAM H. SELLERS
FILE NUMBER 21- 0 5 -10 5 2
Debts of decedent must be reported on Schedule L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
e. ADMINISTRATIVE COSTS:
1. Personal RepresenteNve's Commissions
MICHAEL L. SEIFRIED, EYECUTOR $ 0.00
Name of Personal Representative(s)
Social Security Number(s~EIN Number of Personal Representative(s) - -
300 WEST MAIN STREET
Street Address
City SHIREMANeTOWN State PA Zip 17011
Yeer(a) Commission Paid:
2. AltorneyFees ANDREW C. 88EELY, ESQUIRE, PER AQREEMENT $ 687.50
3. Family Exemptlon: (It decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
Gty state zip
Relationship of Geimant to Decedent
4. Probate Fees CUMBERLAND COUNTY R66ISTER OF WILLS-PROBATE FEES $ 106.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
FILING FEES FOR INRERITANCE TA% RETURNS 15.00
TOTAL (Also enter on line 9, Recap~ulation) ; 808.50
SCNEpYLE M
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
(It more space is needed, insert addNional sheets of the same size)
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Sgware
Carlisle, PA 17613
SELLERS WILLIAM H
Estate File No.: 2005-01052
Paid By Remarks: SHEELY ANDREW C
CMM
Receipt Distribution
Receipt Date: 12/05/2005
Receipt Time: 10:25:53
Receipt No.: 1042674
Fee/Tax Description Payment Amount Payee Name
WILL 15.00 CUMBERLAND COUNTY GENERAL FUN
PETITION LTRS TEST 60.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 16.00 CUMBERLAND COUNTY GENERAL FUN
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN
JCP FEE
--- 10.00
- BUREAU OF RECEIPTS & CNTR M.D
Check# 2764 ------------
$106.00
Total Received......... $106.00
REV-1512 EX+ (6&8)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
scN~ou~E i
DEBTS OF DECEDENT,
MC-RTGAGE LIABILITIES, ~ LIENS
ESTATE OF FILE NUMBER
WILLIAM H. SELLERS 21-05-1052
Include unreimburesd medical sxpsnsas.
(If' more space is needed, insert additional stu>als of the same size)
R
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
December 15, 2005
ANDREW C SHEELY ESQUIRE
127 S MARKET ST
P O BOX 95
MECHANICSBURG PA 17055
Re: WILLIAM SELLERS
CIS #: 720172056
SSN: 208-24-4002
Date of Death: 11/22/2005
Dear Mr. Sheely:
Please be advised that the Department of Public Welfare maintains a
claim~in the amount of $49,757.73 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 $29,298.59, 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 $20,459.14, is
to be entered as a priority Class 6 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 curreat appraisal, if available.
Sincerely,
~~~~~6
ole L. Lipscomb
TPL Program Investigator
717-772-6606
717-772-6553 FAX
Enclosure
cc: Michael L. Seifried
~~
Claim Against Dec~emt's Estate
Bstate Of: williem 3ellas Cast #717-240-6345
The tmdatsignod hereby presents fmc fitiag agaiASt tba above estate this gtatcmcm of
claim and alleges: .
Bovesly Enterprites/Wett Shore Health & Rehab Center
P.O. Box 180970 Fort 3auth, AR. 72918
The basis of claim is: Sa Attached
The amount of tha claim is 5803.56
Undor penalties ofppjpey, Y dae]are thsL Y have and the $oxagomg, said the Sws aAe~ed are true m the base
of my lmawkd,~e and be11e1:
,SY,gxad on: ~ ~4Q6
t Sandra Htuuett
r.Swsar Hitt ~ateaasnr tc e~Drr~ect ~.
Skbscribed and sworn to ba, fona A,s ~~ ~:.
l.. Nc~F~-ry Public ' Q
P.O. box 790970 _ -
Focc Smid., .~R 72918-097'0
479.?A~.~000 ~ B7'7.E23.BS75 ..
www 6er.rlyrares.com
REV-1613 EX. )tA7)
CC~IMCNWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE)
BENEFICIARIES
WILLIAMS H. SELLERS
nuMSert 21-05-1052
NUMBER
NAME AND ADDRESS OF PER50N(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT
Do Not List Trustee(s) AMOUNT OR SHARE
OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outrtght spousal distributions)
L
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIAT E, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
ST. JOHN'S LUTHERAN CHURCH 100% of Rest,
44 WEST MAIN STREET Residue &
SHIREMANSTOWN, PA 17011 Remainder of estate
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET S
~n 11 nna aNaw ra 1lovuw, n1i5Cll GUNUUf1~Sf1@B6 W DIB lBlrle SIZ9i
LAST WILL AND TESTAMENT
~F
WILLIAM H. SELLERS
I, ~'VILLIAM I-I. SELLERS, of l Ob9 Allendale Road, Apt. ll,
Mechanicsburg, (Upper Allen Township) Cumberland County,
Pennsylvania, ::n.ake, publish and declare this as and for my Last Will and
Testament, hereby revoking all other Wills and Codicils heretofore made
by me.
E~~T: I direct that all inheritance, estate, txansfer, succession
and death taxes, as well as my just cJebts and funeral expenses, of any kind
whatsoever, wY~ich may be payable by reason of my death, shall be paid
out of the prin~~ipal of my estate as the same can conveniently be done.
~1~C~1~: 1 give, devise and bequeath all the rest.., residue
and remainder of my estate of whatever nature and wherever situate,
including any Iroperty over which C hold power of appointment and
together with any insurance policies thereon, to ST. JOHN'S
LUTHERAN 1:HURCH, 44 West Main Street, Shiremanstown, Penn-
sylvania.
THIR~.I : In addition to all powers granted to them ley law and
by other provisions of this Will, 1 give the fiduciaries acting her-~~under the
following powers, applicable to all property, exercisable without court
approval and ei~fective until actual distribution of all property:
(A} To sell at public or private sale, or to lease, faz- any period
of time, any real or personal property and to give options for s~iles,
exchanges or 1°ases, for such prices and upon such terms (including credit,
with or without security) or conditions as are deemed proper. 'Chis
includes the p~~wer to give legally sufficient instruments for tra-tsfer of the
property and to receive the proceeds of any disposition.
(B j To partition, subdivide, or improve real estate and to
enter into agreements concerning tl~e partition, subdivision, improvement,
zoning or management of real estate and to impose or extinguish restric-
tions an real estate.
(C;i To compromise any claim or controversy and to abandon
any property which is of little or no value.
(D} To invest in all forms of property, including stocks,
common trust funds and mortgage investment funds, without rt~striction t.o
investments authorized far Pennsylvania fiduciaries, as are der>7ned
proper, without regard to any principle of diversification, risk or pro-
ductivity.
(E) To exercise any option, right or privilege granted in
insurance policies or in other investments.
(F) To exercise any election or privilege given by the Federal
and other tax laws, including, but not necessarily being limited to, per-
sonal income, ,lift and estate or inheritance tax laws.
(G;i To make distributions to my herein named beneficiaries
2
xn cash or in kind or partly in each,
{H) To borrow money from themselves or others in order to
pay debts, taxes, or estate or trust administration expenses, to protect or
improve any property held under my will, and for investment purposes.
{I} To select a mode of payment. under any qualified retire-
ment plan (pension plan, profit sharing plan, employee stock o~mership
plan, or any other type of qualified plan) to the extent the plan or the law.
EQr,Z$~~: I nominate and appoint my friend, MI(HAEL
L. SEIFRIED, of 300 West. Main Street, (Borough of Shiremanstown),
Shiremanstowr-, Pennsylvania, execrator, of this, my Last Will and Testa-
meat. In the e~rent of the death, resignation or inability to serge for any
reason whatsoEVer of MICHAEL L. SEIFRIED, I nominate and appoint,.
ST JOHN'S LUTHERAN CHURCH, or its successor, Executor, of this,
my Last Will and Testament. I direct that my Executor and their succes-
sors, shall not be required to post. security or a bond for the performance
of their duties in any jurisdiction.
IN WITNESS WI~ERL-OF, I have hereunto set my hand and
seal to this, my Last Will and Testament, this 4 day of June, 1999.
~,~~~'~~~ ~-; ~/.--~~.~.~-. (SEAL)
WILLIAM ~I. SELLERS
3
..
Sigled, sealed, published and declared by the above-named
Testator as anct for his Last Wi11 and 'Testament in our presence, vho, at
his request, in JZis presence and in the presence of each other, have here-
unto subscribed our names as attesting witnesses.
//2 n/. '~t~ ~` cSb~{ i" f~s~ ~?/ ~d r ~v it _ ~y~~-^~ ~ ~~
Address Name
_,
,~ ~ ~r
Address Name
4