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HomeMy WebLinkAbout03-07-12 1505610105 ~ REV-1500~xtoz_~~,t~l. enns lvania OFFICIAL USE ONLY PA Department of Revenue p Y County Code Year File Number D[P1NfNfNi pf RLVLNUL Bureau of Individual Taxes INHERITANCE TAX RETURN ,! PO BOX z8o6o1 ~ ~ j ~ f,? T Harrisburg, PA 17128-o6os RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 162-22-6115 10/22/2011 ' 09/19!1928 Decedent's Last Name Suffix Decedent's First Name MI ;Sheriff Ada _ ~ _ , (ff 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 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return t= 3. Remainder Retum (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) Cib 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of y'Jill) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9713(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SNOULD 8E DIRECTED T0: Name Daytime Telephone Number Ronald E. Johnson, Esq ; (717 243-01~ REGISTER' ILLS US LY - Vf c: _ ' ,-~ First Line of Address ::` ~ Uj ~ v I z ,E.-p~,~, , 78 West Pomfret Street ~O-~rt 'a ; ` ~-, ' ~ ` Second Line of Address r ~ ~ ~- ~~ ~y+ _ __. , ~ .._ ~~ _ . _.... __ __. _._ DATE FILED` C.. Clry or Post Office State ZIP Code ' Carlisle PA 17013 Correspondent's a-man address: rejohnson@pa.net Under penalties of pery'ury, I declare that 1 have examined this Tatum, 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 PF,J;2SON RE$PQ~1SIt~E FOg FILING RETURN DATE c/o 78 Vyest Pomfret Street fYarlisle, PA 17013 U gj Pf3i2PyRiER r)Q N REPRESENTATIVE 78 West Pomf,~Street, Carlisle, PA 17013 FORM ONLY 150561Q1D5 Side 1 DATE 155610105 J 150561205 ' REV-1500 EX (FI) Decedent's Name: Ad8 i. $h2rlff RECAPITULATION Decedent's Soc(al Secudty Number ... 162-22-6115 1. Real Estate (Schedule A) ........................................... .. 1. _ _... _ 0.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2.' 0.00 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. 3,889.87 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. ._ 3,889.87 i transfers under Sec. 9116 - - : - - - (a)(1.2) X .0~. 15. 0.00 16. Amount of Line 14 taxable _` ".' ~ w° _ _ _._ __ . '. at lineal rate X .0 ! 16. ' 0.00 17. Amount of Lina 14 taxable - at sibling~rate X .12 17. 0.00 18. Amount of Line 14 taxable - at collateral rate X .15 1 g, ' _. .. _ ___ 0.00 19. TAX DUE ......................................................... 19.i 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable. at the spousal tax rate, or 9. Funeral Expenses and Administrative Costs (Schedule H) ......... .......... 9. 4,150.22 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ..... .......... 10. 46,766.90 11. Total Deductions (total Lines 9 and 10) ....................... .......... 11. 50,917.12 ' 12. Net Value of Estate (Line 8 minus Line 11) .................... .......... 12. ._ -47,Q27.2~a ', 13. Charitable and Governmental BequestslSec 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. -47,027.25 S Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENTS NAME Ada I Sheriff STREET ADDRESS 801 N Hanover Street CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments 0.00 B. Discount 0.00 3. Interest d. 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. (t) 0.00 Total Credits (A + B) (2) 0.00 (3) 0.00 (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS t. 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 ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occulted after Dec. 12, 1982, did decedent transfer property within one year ofdeath - without receiving adequate consideration? .............................................................................................................. ^ ~ ' 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 JS 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 io 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)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 childis 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{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. LAST WILL AND TESTAMENT OF ADA I. SHERIFF I, ADA I. SHERIFF,, of 812 North Pitt Street, Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last will and Testament,'hereby .revoking all other Wills and Codicils heretofore-made by me. FIRST I direct the payment of my just debts and expenses of my last illness and funeral from my estate as soon after my-death as conveniently may be done. I further direct that all death taxes shall be paid from my residuary estate and that they shall be included as an administrative expense. SECOND All the rest, residue and remainder of my estate, I give, devise and .''.:~ty..'.ewtY'. .: n e.^1L:r'ti ,^,are~, chase anr~ ~1-~a.rc a l i kP t;n M T sons; wAYNE B. SHERIFF, JR., DENNIS R. SHERIFF, and LARRY L. SHERIFF. THIRD Should any of my sons predecease me having issue surviving him, his share shall be equally divided among his issue. Should any of my sons die without issue surviving him, his share shall be divided among my surviving sons. FovRTH I do hereby nominate, constitute and appoint my granddaughter, MELANIE SHERIFF REIFSTECK, to act as Executrix of this my Last Will and Testament. IN WITNESS WHEREOF, I, ADA I. SHERIFF, have hereunto set my hand and seal to this my Last Will and Testament, consisting of 3 typewritten pages, the first page of which bear my signature in the margin for identification, this ~S(S~" day of ~ ~ , . 20? 0. ". -- ADA I. SHERIFF Signed, sealed, published and declared by the above-named ADA I. SHERIFF, Testatrix, as and for her Last Will and Testament in the presence of us, who have hereunto subscribed our names at her request as itnesses thereto, in the esence of said Testatrix and of each other. - AnDR~ss a b ~~ . ~ ; r. . ~ ~ ~ hl~~~ 1~ l ~~ ~3 An~~~ss 2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND . We, ADA I. SHERIFF, ~ ^ s ~ ,. ~~. ~~ ~ii~ ~ and %Cz~ii_.~Q L LCJL~e~.e_, the Testatrix and witnesses, respectively w se names dare signed to the foregoing or attached 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 and that executed as her free 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 the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. Subscribed, sworn to and acknowledged before me by ADA I. SHERIFF, the Testatrix, an subscribed to and sworn or affirmed to before me by .l . ~~ 1 T'. and _~~ ~.:(~~ , witnesses, this a d y of ~ 2010. Notary Public s~ BARBARA E. STEEL, Notary Pn513c Carlisle Bo% Cumberland County, PA My Commission Expires June 7, 2011 3 ~~.~ f~ ADA I~: SHERIFF • REV-i5o8 EX+ {u-io) ~r ` ~' pennsytvania DEPARTMENT OF REVENUE • INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Ada I. Sheriff 21-11-1344 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 nn Schedule F u more space is needed, use atltlitional sheets of paper of the same size.. Sovereign Bank ESTATE OF Ada I. Sheriff SOCIAL SECURITY #: 162-22-6115 DATE OF DEATH: October 22, 2011 Account #: 2891029321 Type: Checking Open date: 2/1211986 In the name of: Ada I Sheriff (Melanie C Reifsteck, FOA) Date of Death Balance: $3,632.19 Int.(YTD) from 1/112011 to 10!13/2011 $0.40 Accrued interest to date of death: $0.01 Other Info: Page 1 of 1 ' REV-511 EX+ (10-09) • ~ i ~~~ pennsylvania ~' DEPARTMENT DF REVENUE • INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Ada I Sheriff 21-11-1344 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Hoffman-Roth Funeral Home 2,012.98 2 George's Flowers -funeral flowers 110.24 s Carlisle Memorial -headstone 910.50 B. 1. 2, 3, a. 5. 6. 7. a s ADMINISTRATIVE COSTS: Personal Representative Commissions; Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: Attorney Fees: Family Exemption; (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: Sovereign Bank -bank fee Reserve for closing Register of Wills -filing fee ZIP 750.00 81.50 20.00 250.00 15.00 ,TOTAL (Also enter on Line 9, Recapitulation) $ 4,150.22 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-OB} '~-~ ~~ pennsylvania ~'- } DEPARTMENT OF REVENUE INRERITANLE TA% RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Ada I. Sheriff 21-11-1344 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, intluding unreimbursed medical expenses, [f more space is needed, insert additiona4 sheets of the same size. ~~ Pennsylvania DEPARTMENT OF PUBLIC WELFARE February 11, 2012 ANDREWS & JOHNSON ' RONALD E JOHNSON ESQUIRE 78 WEST POMFRET STREET CARLISLE PA 17013-3216 Re: Ada Sheriff CIS #:027968659 SSN: ###-##-6115 Date of Death: 10/22/2011 Dear Attorney Johnson: Please be advised that the Department of Public Welfare maintains a claim in the amount of 546,766.0 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 527.745.34, was incurred during the last six months of the decedent's fife; 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 519,021.56, 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, ~~~~~]~J/ ~ ~h~l~'~II~/ Eivetta E. Knox Claims Investigation Agent 717-772-6613 717-772-6553 FAX Enclosure Bureau of Program Integrity I Divls(on of Third Party Liability I Recovery Section PO Box 8486 i Harrisburg, Pennsylvania 17105-8486 ' REV-~5i3 EX+ (O1-10} ~ pennsylvania SCHEDULE 7 ~~., DEPARTMENT OF REVENUE • INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Ada I. Sheriff 21-11-1344 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec, 9116 (a) (1,2).) 1• Wayne B. Sheriff, PO Box 231, Fort McCoy, FL 32134 son 113 2 Dennis R. Sheriff, 812 N Pitt Street, Carlisle, PA 17013 son 1/3 3 Larry L. Sheriff, 1882 Ester Drive, Carlisle, PA 17013 son 113 II ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX 15 NOT TAKEN; 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, I~ If more apace is needed, use additional sheets of paper of the same size.