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HomeMy WebLinkAbout02-22-12` 1505610140 J REV-1500 ~` ~°'-'°' OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po Box 280601 INHERITANCE TAX RETURN 2 1 1 1 1 1 9 7 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 7 9 1 0 3 8 7 9 1 0 3 0 2 0 1 1 0 1 3 1 1 9 1 3 Decedent's Last Name Suffix Decedent's First Name MI F A I L O R A N N A E (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 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^X 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 ~ 5. Federal Estate Tax Return Required death after 12-12-82) Q 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS StG 1IVn MUS I lit GVmYLt 1 tu. ALL VVrcrctarvnutnut nnu wnr~u~n i w~ i w~ mruReu+i gun anw~u o~ u~n~~ i w ~ u: Name Daytime Telephone Number R O G E R B- I R W I N E S Q U I R E 7 1 7 2 4 9 2 3 5 3 First line of address I R W I N & Second line of address 6 D W E S T City or Post Office C A R L I S L E M c K N I G H T P - C- P O M F R E T REGISTER QF.~IYILLS USE OMt~ '"' ~ ~-,7 -gyp 1 7'i -l~(;~ > r-- -~> ~ N r m ~T ~ ~ h~ _ ~ _~~~ .._<. --, a •~ -~ - -_ ..f -- GJ S T R E E T State ZIP Code L P A 1 7 0 1 3 ...a 1-- Ti i~' t r-C-e f";~ ~. ~ ~ <-~~ .. r!~ _`i ~-; ., _>:• ~--: _..~ Q Correspondent's e-mail address: Under penalties of perjury, I deGare that 1 have examined this return, inGuding 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. OF PERSQN RESPON~LE FOR FILING RETURN ~+_~ ~ DATE 1490 LONGS GAP ROADD CARLSILE PA 17013 SIGNATURE OF REPARER OTHER TIN REPRESENTATIVE DATE 3 ~,c~~ z L y i t_ ADDRES 60 WEST P FRET STREET __ CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610140 1505610140 J 1505610240 REV-1500 EX Decedents Social Security Num ber decedent's Name: ANNA E• F A I L O R 1 7 9 1 0 3 8 7 9 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 and Notes Receivable (Schedule D) ........................ .. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 5 4 7 4 . 6 1 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property (Schedule G) ~ S r t Billi R t d 7 epa a e ng eques ..... e .. . 8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 5 4 7 4 . 6 1 9. Funeral Expenses and Administrative Costs (Schedule H) ................ .. 9• 3 5 4 0. 9 6 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... .. 10. 9 9 8 5 1. 0 2 11. Total Deductions (total Lines 9 and 10) ............................. .. 11. 1 0 3 3 9 1. 9 8 12. Net Value of Estate (Line 8 minus Line 11) .......................... .. 12. - 9 7 9 1 7 . 3 7 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. - 9 7 9 1 ? . 3 ? TAX CALCULATION -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.o _ 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X •045 0. 0 0 16. 0. 0 0 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 D. 0 D 18. 0. 0 D 19. TAX DUE .................................................... ..19. 0 • 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 a 1505610240 1505610240 J REV-1500 EX.Page 3 Decedent's Complete Address: File Number 21 11 1197 DECEDENT'S NAME ANNA E. FAILOR STREET ADDRESS 1000 CLAREMONT ROAD __ CITY CARLISLE STATE PA ZIP 17013 Tax Payments and Credits: ~. Tax Due (Page 2, Line 19) 2. Credits/Payments 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. 0.00 Total Credits (A + g) (2) 0.00 (3) (4) 0.00 (5) 0.00 Make check payable 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 : ................................................................. ..... ^ X^ . b. retain the right to designate who shall use the property transferred or its income; ^ ::: :::::::::::::::::::::: 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 property within one year of death without receiving adequate consideration? .................................................................................. ..... ^ ^X 3. Did decedent own an "intrust for" or payable-upon~ieath bank account or security at his or her death? .... ..... ^ X^ 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 F1LE 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-1508 EXt (11-10) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS, 8~ MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: ANNA E. FAILOR 21 11 1197 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. MEMBERS 1ST FEDERAL CREDIT UNION 4,386.61 SAVINGS ACCOUNT #275074-00 2. MEMBERS 1ST FEDERAL CREDIT UNION 1,088.00 CHECKING ACCOUNT #275074-11 TOTAL (Also enter on Line 5, Recapitulation) I $ 5,474.61 If more space is needed, insert additional sheets of paper of the same size REV-1511 EX.t (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ANNA E. FAILOR 21 11 1197 Decedents debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. EWING BROTHERS FUNERAL HOME, INC. 288.96 2. CUMBERLAND MEMORIAL GARDENS 1,261.50 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) GLORIA M. ADAMS 750.00 Street Address 1490 LONGS GAP ROAD City CARLISLE State PA Zlp 17013 Year(s) Commission Paid: 2. Attorney Fees: IRWIN 8~ McKNIGHT, P.C. 750.00 3, Family Exemption: (If decedents address is not the same as claimanPs, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: REGISTER OF WILLS 85.50 5 Arx;ountant Fees: 6. Tax Return PreparerFees: PATRICIA A. ROSENDALE, CPA 375.00 7. REGISTER OF WILLS -FILING FEE 30.00 TOTAL (Also enter on Line 9, Recapitulation} I ~ , ~,,,, „~ If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RE5IDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER ANNA E. FAILOR 21 11 1197 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. DPW CLAIM -CIS #: 240149958 99,851.02 TOTAL (Also enter on Line 10, Recapitulation) I 3 gg,$51 If more space is needed, insert additional sheets of the same size. REV-1513 EXt (,01-10) • pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ANNA E. FAILOR 21 11 1197 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustees) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. GLORIA M. ADAMS Lineal 1490 LONGS GAP ROAD CARLISLE, PA 17013 2. BARBARA A. SANGREE Lineal 421 WARMSIDE DRIVE LAS VEGAS, NV 89145 3. ROBERT FAILOR, DECEASED Lineal ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S If more space is needed, use additional sheets of paper of the same size. ~~~t iU ~~ c~ P~~~m~~t I, ANNA E. FAILOR, of Silver Springs Township, Cumberland County, Pennsylvania, declare this instrument to be my last will and testament, hereby expressly revoking all wills and codicils heretofore made by me. 1. I direct my executrix to pay all of my debts, funeral , n :~:. and administrative expenses as soon as may be done conve~,'1~tly -- fT_j "-ri after my decease. ^_~~ ~- "~~ Z'' _ "i .....: J `_,, ,-~ •- ~ ~' t -- 2. I authorize and empower my executrix to sell any=~,ea~~y =- owned by me at my death and not specifically dev~d or ~.. ~, , bequeathed herein, at either public or private sale, and to give good and sufficient deeds therefor, in fee simple, as I could do if living. 3. I give, devise and bequeath all the rest, residue and remainder of my estate, of every nature and wherever situate to my three children, share and share alike, the child or children of any deceased child taking the share their parent would have taken if living. 4. I nominate and appoint Gloria M. Adams to be the executrix of this my last will and testament; she is to serve as such without bond. 5. I hereby suggest that my personal representative retain the services of Irwin, Irwin & McKnight as attorneys in the -,.-, ~-, ~,. r - .'1 _~ i~ --;-, ~.-~ -.. settlement of my estate. IN~~WITNESS WHEREOF, I have hereunto set my hand and seal this ~o+"day of April , 1988. { ,, . ~~"~l.l...._..' .. ,~ ,-_ ._ .~'r ~~ (SEAL) A PJ ILOR Signed, sealed, published and declared by Anna E. Failor, the testatrix above named, as and for her last will and testament, in the presence of us, who at her request, in her presence and in the presence of each other have subscribed our names as witnesses hereto. ACKNOWLEDGEMENT AND AFFIDAVIT WE, ANNA E. FAILOR, SHARON L. SCHWALM and KATHLEEN M. KENNEY, the testatrix and 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 that she. had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in their presence and hearing of the testatrix, signed the Wi11 as a witness 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. i; ; :: ~ c _; ~ ~' ANN FAILOR SH RON L. SCH KATHLEEN Pt. KE~iiFEY COMMONWEALTH OF PENNSYLVANIA: ss. COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by ANNA E. FAILOR, the testatrix, and subscribed and sworn to before me by SHARON L. SCHWALM and KATHLEEN M. KENNEY, witnesses, this ~8~ day of April, 1988. C::R~ i~i_ c:~•.:~, f~17 ;,}j,a"iJJ `7 ?Y'r'~".;:$ ':icf. ~.5, 1^~~: .. .._s. ,. r., .. .,.. _. , _. ,. i .~ti~.c ~~. i~(1 ~.... ... MEMBERS 1St FEDERAL CREDIT UNION SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner CHECKING ACCOUNT: 27507400 11 /18/2005 $4,385.65 $.96 $4, 386.61 None Account Number/Suffix 27507411 Date Account Established 11/18/2005 Principal Balance at Date of Death $1,088.00 Accrued Interest to Date of Death $0.00 Total Principal and Accrued Interest $1,088.00 Name of Joint Owner None VISA ACCOUNT: Account Number/Suffix 4672090000220095 Date Account Established 06/29/1989 Principal Balance at Date of Death $0.00 Joint Cardholder None N~t~:~1~lf~l~ ~~~~ ~ r L~~ll RWif~a ~ ivri(idlCaH Ab`U" OFF;CEc MEMBERS 1ST FEDERAL CREDIT UNION LeiG~h~Knne Stallin g gs Lending Insurance Support Specialist December 1, 2011 Estate of: Anna E. Failor Date of Death: 10/30/2011 Social Security Number: 179-10-3879 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org Ewing Brothers Funeral Home, Inc. G~ 630 South Hanover Street Carlisle, PA 17013- (717)243-2421 November 9, 2011 Gloria M. Adams 1490 Longs Gap Rd. Carlisle, PA 17013 The Funeral Service for Anna E. Failor We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES One Day event all inclusive , _ $4795.00 FUNERAL HOME SERVICE CHARGES $4795.00 SELECTED MERCHANDISE: 20G Silver Hammertone Gask. Casket, $1050.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $5845.00 Cash Advances Clergy/Mass Offering, $100.00 Certified Copies of the Death Certificate , $12.00 Flowers. $159.00 The Sentinel Obit with Photo $148.69 Light Lavender Dress, $125.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES . $544.69 Total Total Cost , $6389.69 SUB-TOTAL $6389.69 _~, tl [~,~ IMTIAL PAYMENT /DISCOUNT /CREDITS 6030.00 ~ ~ `"" - ~ TOTAL AMOUNT DUE .~'~T The unpaid balance over 30 days is subjected to a 1.50 % service charge per month - 18.0000 % per annum. .~ ~Pi~ ~ ,~v = ~lo~ Jim-~,. (~~ ,~ `- ~/ O ©- `~ - t~-C~i~ ~ocz.~..T~To ~~¢CPn~o/ pennsylvana DEPARTMENT OF PUBLIC WELFARE December 7, 2011 IRWIN & MCKNIGHT PC ROGER B IRWIN ESQUIRE WEST POMFRET PROFESSIONAL BUILDING 60 WEST POMFRET STREET CARLISLE PA 17013-3222 Re: Anna Failor CIS #: 240149958 SSN: ###-##-3879 Date of Death: 10/30/2011 Dear Mr Irwin: ~~ ~~EC ~ ~ Zn~O ?~tWIN & ivlcKNIGH~ NVII OFFICES Please be advised that the Department of Public Welfare maintains a claim in the amount of $99,851.02 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 $31.570.20, 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 $68.280.82, 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, Marianne Meckley TPL Program Investigator 717-772-6246 717-772-6553 FAX Enclosure Bureau of Program Integrity i Division of Third Party Liability I Recovery Section PO Box 8486 I Harrisburg,. Pennsylvania 17105-8486