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Home My WebLink About12-02-05 (3)REV-1100 E7C t (0-00) ~i W D v W O COMNONtNEALTH OF PENNSYLVANUI DEPARTMENT OF REVENUE DEPT. 2710801 HARRISBURG, PA 1772&0801 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY RYMBER 21 05 00220 •nnurr rnnc ve.e uuun~e DECEDENr'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Hertzler, Mary Overly SOCIAL SECURITY NUMBER 061-28-3325 ' ` •" """"' """'~""~' ""•' ' ` "~ °'^' ^ ~'^""„"-"""~ THIS RETURN MUST BE FILED IN DUPLICATE YNTH THE 03-06-2005 03-12-1908 REGISTER OF WILLS (IF APPLICABLE) 8URVNING SPOUSE'S NAME (UST, FIRST ANO MIDDLE INITIAL) SOCIAL SECURITY NUMBER a 1. Original Return ~ 2. Supplemental Retum ~ Y m ~ 4. Limited Fatale ~ 4a . Fultn Irilergt CamprwNae (dne d deMh Mar ~, 12-12.82) ~ m Q 8. DDOedent Dlad Testate N~ ~ 7. Decedent Maintained a Living Trust (AtteUl z S d t~ z 5 d 9. LilipetfOn Proceeds RecMved ~ 10. S~loueal POVer1y_Credit (date d deaM txlMean 1 -31-01 end 1-1 NAME Jan M. Wiley FIRM NAME (M appecabb) Wiley, Lenox, Colgan, $ Marzzacco, P.C. TELEPHONE NUMBER 717-432-9666 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Ckxr,ely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages 8 Notes Receivable (Schedule D) 5. Cash, Bank Deposits 6 Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) ^ Separete Billing Requested 7. Inter-Vwaa Transfers 3 Miaceganeous Non-Probate PropeAy (Schedub G or L) Q Separate Bilgng Requested 8. Total Gross Assets (total Lines 1-7) g, Funerel Expenses b Adminiatretive Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedu~ I) 11. Total Deductions (total Lines 9 E 10) 12. Net Valw of Estate (Line 8 minus Line 11) (1) (2) (3) (a) (5) (8) (~ (9> (10) U 9. RamakMer Return (date d deslh prior 1012-1352) 8. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sea 9113(A) (Attach Stll O) 130 W. Church St Dillsburg, PA 17019 (~ c None _ None T m .a "'' ~ ~ ~. None -::? C) -;-, None -; ~`= 7,552.97 None None (8) 7,552.97 13. Charitabb and Govemmerltal Bequestar'Sec 9113 Trusts for which an election to tax has not been made (S121edub J) 14. Nat Value Subject to Tax (Line 12 minus Line 13) (11) 7,552.97 (12) (13) 0.00 (1a) 0.00 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15.Amount of Line 14 taxable at the spousal tax refs, 0,00 x .00 (15) or trensfere under Sec. 9116(a)(1.2) 18.AmouM of Line 14 taxable et lineal rate 17.Amount of Line 14 taxable et sibling rate 18. Amount of Line 14 taxable at colleterel refs 19. Tax Due 20. 0.00 x .045 (16) 0.00 x .12 (17) 0.00 x .15 (18) (19) r-~ o ~ ["'7 ~ ~ 'illt US 1 ~_rr tV ~ l7 _~-, C1~ ~s ___ ~, w '! r-r: cn ~'-~ .~ 7,552.97 0.00 0.00 0.00 0.00 0.00 Copyright 2002 tam sotbl~wro ony The Lackner G-oup, Ins. Form RE1/•1ti00 EX (Rev. 6-00; .,_~ -~ , `' LAST WILL AND TESTAMENT =~ .: `~~-' -.. .. ..~..~ .... : J' :~ .... ~ ..~. ..~ ~: : j MARY... OVERLY HERTZLER ~, - ~._ ~. ,-; . ~~ ... -~ I, MARY OVERLY HERTZLER, of Camp Hill, Cumberland Count, ~~ Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and revoke any Wills and Codicils previously made by me. ITEM I: I direct that all my just debts and funeral expenses, including the cost of a suitable gravemarker and perpetual care for my burial plot, shall be paid from the assets of my estate as soon as practicable after my decease. ITEM II: I express my confidence that my instructions as to my funeral and burial, which I have given to my daughter, GEORGIA ANN HERTZLER BARTHOLOMEW and to my son, PAUL VINCENT HERTZLER II, will be honored. ITEM III: I direct that all inheritance and Estate taxes (including interest and penalties thereon but not including any generation skipping- tax) becoming due by reason of my death, whether such taxes be payable by my Estate or by any recipient of any property, shall be paid by my Executor aut of the property passing under this Will, which is not specifically bequeathed or devised as an expense or cost of administration of my Estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though payable on passing under this Will. In the absolute discretion of=my Executor, my Executor may pay any such taxes immediately or may postpone the payment_of taxes and future or remainder interest until the time possession accrues to beneficiaries. ITEM IV: I make the following charitable bequests: (a) To Guideposts, for use in connection with the publication for the blind, One Hundred ($100.00) Dollars. (b) To Cedar Grove Presbyterian Church, East Earl, Lancaster County, Pennsylgania,-ahe.sum of One Thousand ($1,000.00) Dollars in memory of my parent$~,~: Emma...:. Ranck Overly,.and Hiram Rife Overly. (c) To- the~;;.Cem~;exy>u ~rustees~ o R.aacks United- Methodist .~ . . .:.;~, Church of R. D. #1, G. Edgar and Mary:. for the upkeep of the sum of Five Hundred ($500.00) Dol:lars::. (d). To University, 1 r East Mounty~:Vernon'°~P~i'aoe~kx'~a~'~Fe~~~a'?~ 21202 the sum of One Thousand ($1,000.00) Dollars as a gift in memory of Mary Overly Hertzler, Class of 1931•. ITEM V: I give and bequeath all of my household furniture and furnishings, automobiles, books, pictures, jewelry, china, linen, silver, wearing apparel and all other articles of .household or' personal use and adornment, including insurance policies thereon, to my daughter, GEORGIA ANN HERTZLER BARTHOLOMEW and my son, PAUL VINCENT HERTZLER, II, to be divided among them as they shall agree. In the event either my son or daughter shall predecease me then their share shall be divided equally among their issue.survvng at _._ _ my death. ITEM VI: I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, wheresoever situated, to my daughter, GEORGIA ANN HERTZLER BARTHOLOMEW and my son, PAUL VINCENT HERTZLER, II or their issue, per stirpes. ITEM VII: In settlement of my Estate, my .Executor shall possess in addition to and not in"limitation of all powers granted by law or elsewhere herein the following powers: (a) to retain and to invest in all forms of real and personal property, regardless of (i) any limitations imposed by law on investments by executors or trustees, (ii) any principle or law concerning delegation of investment responsibility by executors or trustees, or-(iii) any principle of law concerning investment diversification;.. (b) to compromise claims and to abandon any property which, in my Executor's opinion, is of little or no value; to borrow from, and to sell property to others, and to pledge property as security for repayment of any funds borrowed; (c) to sell at public or private sale, to exchange or to lease for any period of time any real or personal ~,,,,,..,,,.,.c:r.^ . property, and to give options for sales or leases; (d) to join in any merger, reorganization, voting-trust plan or other concerted action of security holders, and to delegate discretionary duties with respect thereto; (e) to use administrative or other expenses of my estate as income tax or estate tax deductions and to value my estate for tax purposes by any optional method permitted by the law in force when I die, without requiring adjustments .between income and principal for any resulting effect on income or estate taxes; (f) to borrow money for the purpose of raising funds to pay taxes or for any purpose deemed by the fiduciary beneficial to my Estate and upon such terms as the fiduciary may determine, and to pledge as security for the repayment of .any such loan or loans any asset of my Estate; and (g) to pay any legacy or to distribute my Estate in cash or in property, or partly in cash and partly in property and to make nonprorata payments or distributions of such cash .property and for those purposes to use and allot any property .not specifically bequeathed, such use and allocation to be conclusive against all parties interested hereunder, so long as the total market value of any beneficiary's share is not affected by such allocation. These authorities shall extend to all real and personal property at any time held by my Executor and shall continue in full force until the actual distribution of all such property. All powers, authorities, and discretion granted by this Will shall be in addition to those granted by law and shall be exercisable without leave of court. ITEM VIII: I nominate, constitute and appoint my daughter, GEORGIA ANN HERTZLER BARTHOLOMEW and my son, PAUL VINCENT HERTZLER II as my Co-Executors under this Will. If either is unable or unwilling to serve, the other shall serve alone. My Executor is specifically relieved from the duty or obligation of filing any bond or other security in any jurisdiction insofar as I am able to do so by law. IN WITNESS WHEREOF, I have hereunto set my hand and seal and caused this my Last Will and Testament, consisting of seven (7) typewritten. pages, including this attestation clause and .the following Acknowledgment r~nd Affida~ to be executed, declared 99 and published this O~~ day of 1996, at ' Pennsylvania. d~ d,,~,~~;e.~-J MARY OV RLY HE ZLER _._ __ ___ ..,,,~.~r......_._.~..-- ,.,~.._,t .,...- ACKNOWLEDGMENT .COMMONWEALTH OF PENNSYLVANIA? SS: COUNTY OF ? I, MARY OVERLY. HERTZLER, the Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly and that -I signed it as my free and voluntary act for the purposes therein expressed. MARY O RLY HE TZLERe Sworn or affirmed to and acknowledged before a by MARY E OVERLY HERTZLER, the Testatrix this day of , 1996. My Commission Expires: µOTAR1A[ SEAL KATRR`iA K, ydA$$, Notanf i%u6lic Comp FGI! Bono. Cumberland Cc., PA My tommissian 6~res Sept. t9, 1`}P8 AFFIDAVIT COUNTY OF ~!~(/./t'l,~{1 ~"/ tPi'e witnesses, whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw MARY OVERLY HERTZLER sign and execute the instrument as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge, the Testatrix was at the time twenty-one (21) or more years of age, of sound mind and influence. Residing at ~Q ~~ /~'`~`~- ~ --~-r- 1996. No~a~ry Public ~ " " ( SEAL ) ~~.---•-------~~ pEc7~ARtA! SEAL KATRINA K. NJASS, tdo3ary Qub:iC Camp !5q Baro, Cumbaelan~ ro., PA Nry Commission 8x{~ires $ept. 79, tS'98 and acknowledged of a me by 7 and the witnesses, this day of ttw-tsoe ok. te-sel cc~ano~atH of vErsavwnwk CofERtTANCE TAX RE7URN- RE81nEM OEIX~ENr SCHEDULE E CASH, BANK DEPOSITS, 8k MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Hertzler, Mary Overly _ 21-05-00220 mr~,e. n,e proceeds or oupeuon.na nro aa~e ub proceed. were reoNvea ey me eska~e. ~ proPMtY JolntlYowned wah tlt• rlpM of wnrlvoreMp mrrt be diadosed on uhaduN F ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Citizens Bank Account Number 6140692889: 5.16 2 MS<T Bank Account Number 29933315: 3,797.66 3 M8rT Bank Account Number 98128221: 3,750.15 TOTAL (Also enter on Line 5, Recapitulation) I 7,552.97 (If more space is needed, additional papas of the same size) Copyright (c) 2002 form sofiwaro ony The Lackner Group, Inc. Fonn PA-1500 Schedule E (Rev. &98) p~ June 6, 2005 The Wiley Group Attorneys at Law Wiley, Lenox, Colgan 85 Marzzacco, P.C. 130W. Church Street, Suite 100 Dillsburg, PA 17019 499 Mitchell Street, Millsboro, DE 19966 RE: Estate of Mary O. Hertzler Date of Death; March 6, 2005 Social Security Number: 061-28-3325 Deaz Ms. Gladfeiter: In response to your request, please be advised that at the time of death, the above- named decedent had on deposit with this bank the following accounts. 1. Aco~unt TtJpe...: ......................: Checlang Account Account 1Vivielier `'.:::; :::':::::.:..:.: 299333 T5 Ownership (Names~ofl.:.:::::.::::: Mary O: Hertiler . Opening Date.........:.:.::.::.:..::...05/05/97 (account closed 03/08/05) Balance on Date of Death.......:.$3,797.66 Aocxued fiterest $ 0 00 Total ......................................$3,797.66 2. Aoaount 7t~pe ........................... Checking Account Account Number ...................... 98128221 Oumership (Names off ............:: Mary O. Hertzler Opening Date:::••••:..:.::.:...::.:.::.05/08/97 (account closed 03/08/05) Ba?diue oii Du"te of Death::.:.:::.$3,750.15 .. . . Accrueid Interest ... ...... $ .;; : -0.00 _; :., 7btaC ......................................$3,750.15 • Page 2 The above named decedent did not have a safe deposit box. June 6, 2005 For any additional information on this account please contact our Hampden branch at 717-255-2293. Sincere~ly~, ~ /~ Chazlene Warrington, Records Management 1-888-502-4349 Ci~iz+~r~~ ~~n~C,, July 8, 2005 S. DAWN GLADFELTER 130 W. CHURCH STREET SUITE 100 DII.LSBURG PA 17019 Estate of MARY OVERLY HERT7.i.RR Date of Death: Mar 06, 2005 SSN: 061-28-3325 Deaz Sir/Madam: 525 William Penn Place Suite 153-2618 Pittsburgh, PA 15219 In accordance with your request, the attached information sheet has been provided in the above decedent's name as of his/her date of death. For IL, or LC accounts, contact our Loan Department at 1-800-708-6680. For all otherinquiries, please call 1-888-999-6884 Sincerely, ~~~5 amela wis Operations Services ~~t#z~t~ B~rtk. Account Number 6140692989 Account Title MARY O HERTZLER Date O ened 12/2/1994 Account T e Time De osits Princi al Balance as of DOD $5.09 Interest from Last Postin to DOD $ .07 Account Balance as of DOD $5.16 YTD Interest to DOD $4.95 REV-~~s~ Ex« tax-so> COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES ~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Hertzler, Mary Overly 21-05-00220 vents or aeceaent must de reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. ~ FUNERAL EXPENSES: See continuation schedule(s) attached 451.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Georgia Ann Social Security Number(s) / EIN Number of Personal Representative(s): street Addroas 6017 William Drive city Mechanicsburg state PA Z;p 17050 Year(s) Commission paid 2005 1,500.00 2. Attorneys Fees Wlley, Lenox, Colgan, dk Maraacco, P.C. 1,500.00 3. Famiy Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wills: 88.00 5. Accountant's Fees 6. Tax Return Proparor's Fees Hartman 8a ScheuchenZwler: 170.00 7. Other Administretive Costs 3,843.97 See continuation schedule(s) attached TOTAL (Also enter on Ilne 8, Recapitulation) 7,552.97 Copyright (c) 2002 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule H (Rev. 6-98) rtv-~eoz EX+ lassl SCHEDULE H-A FUNERAL EXPENSES continued co~e~oNwenuN w vErwsnva~ gN1ERITANCE TA%RETURN REBOENr [IECEOENr ESTATE OF FILE NUMBER Hertzler, Mary Overly 21-05-00220 Copyright (c) 2002 form software only The Lackner Group, Ine. Form PA-1500 Schedule H-A (Rev. 6-98) R~r-7602 Elr* 16-sel caew~ONwFru.n~ of veNN6r~v~Nw INNERRAHGE TA7(REiURN RE667Blr OECEOENT SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Herizler, Mary Overly 21-05-00220 ITEM NUMBER DESCRIPTION AMOUNT 1 Checkbook reconciliation: 0.67 2 Department of Welfare (claim): 3,166.51 3 M8rT Bank (bank fee): 32.00 4 Paul Dalbey, DPM: 17.48 5 Pharmerica: 5.00 6 Philhaven: 50.50 7 Register of Wilis (filing fee): 30.00 8 Thomwald Nufsing Home: 535.20 9 Three Springs Family Practice: 6.61 Subtotal I 3,843.87 Copyright (c) 2002 form software only The Lackner Group, Inc. Fonn PA-1600 Schedule H-67 (Rev. 6-98) COMMONWEALTH OF PENNSYLVANU DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCWL OPERATIONS DNISION OF THIRD PARTY LU101LITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 June 7, 2005 THE WILEY GROUP DAVID J LENOX ESQUIRE ATTORNEYS AT LAW 130 W CHURCH STREET SUITE 100 DILLSBURG PA 17019 Re: MARY HERTZLER CIS #: 310169585 SSN: 061-28-3325 Date of Death: 03/06/2005 Dear Mr. Lenox: Please be advised that the Department of Public Welfare maintains a claim in the amount of $20,766.80 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~17,212.96, 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 $3,553.84, 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 dead, the latest tax assessment, and a current appraisal, if available. Sincerel ~~j~~~~ VL(/ Nicole L. Lipscomb TPL Program Investigator 717-772-6606 717-772-6553 FAX Enclosure Jan M. Wiley bavid E. Hershey David J. Lenox Bradley A. Winnick Timothy J. Colgan Thomas M. Clark Christopher J. Marzzacco ~ Ari D. Weitzman THE WILEY GROUP Attorneys at Law Wiley, Lenox, Colgan &Marzzacco, P.C. December 1, 2005 Nicole L. Lipscomb TPL Program Investigator Commonwealth of Pennsylvania Department of Public Welfare Estate Recovery Program PO Box 8486 Harrisburg, PA 17105-8486 IN RE: ESTATE OF MARY HERTZLER SSN: 061-283325 Date of Death: 03/06/2005 Dear Ms. Lipscomb: As you are aware, this office represents the above captioned estate. I have prepared. the Inheritance Tax Return and met with the Executrix today to explain the estate to her. As you will see on the enclosed copy of the Inheritance Tax Return, this estate had very limited assets.. After paying he costs of administration, the balance of the estate account is $3,166,51.. I am enclosing a check, payable to the Department of Public .Welfare in that amount. Please confirm in writing your receipt and acceptance of this check as a full and complete settlement of the claim .against the above estate. Thank you for your cooperation. Should you have any questions, please contact. me. _ __ ___Siacerely JAN M. WILEY, ESQUIRE JMW/sdg encl. 130 W. Church Street, Suite 100 • Diflsburg, PA 17019 • Phone: (717) 432-9666 t (800) 682-4250.• Fax; (71 )2-0426 'Offices in Harrisburg • York • Carbondale www.wileygrouplaw.com „~