HomeMy WebLinkAbout06-04-121 1505610143
J REV-1500 Ex`°'-'°''
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania c°vmy code veer Fila Number
Bureau of Individual Taxes "E""^"°"'°'"~'"A°E
Po Box.zsosol INHERITANCE TAX RETURN 21 12 0135
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
Decedent's Last Name
STONE
(If Applicable) Enter Surviving Spouse's Information Below
Suffix Decedent's First Name
FLORENCE
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Securty Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Retum
^ 4. Limited Estate
I~ g Decedent Died Testele
' (Aflech Copy of With
^ 9. Litigation Proceetls Received
^ 2. Supplemental Retum
^ qa FuWra Interest Compromise
(tlale M tleath atler t2-12A2)
^ ~' (AttectlheC°py of~i~soa Living Trust
^ 1 D Spousal Poverty Cretlitt(date of death
tureen 72-31.9'1 and t-1-95)
^ 3. Remainder Retum (date of death
MI
E
MI
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD 9E DIRECTED TO:
Name Daytime Telephorte'Number
BRADLEY L GRIFFIE 717 243 15'~~51 ~,'
RE(i1STER OF
First line of address
200 N HANOVER STREET
Second line of address
City or Post Office
CARLISLE
Correspondent's a-mail address:
State ZIP Code
PA 17013
schedules and statements.
is based on all information
Christine S Crout f/kla/ Grlffie
Side 1
1505610143
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prior to 12-13-62)
5. 1=ederal Estate Tax Retum Required
8. Total Number of Safe Deposit Boxes
^ 11.1=lecuon to tax under Sec. 9113(A)
iAnach Sch. O)
1505610143
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1505610243
REV-1500 EX
Decadent's Social Security Number
Dacetlenrs Neme: Stone, Florence E
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 8 Notes Receivable (Schedule D) ...................................................... .. 4.
5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) .............. . 5. 8 r 551 • 07
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers 8 Miscellaneous Ikon,-Probate Property
(Schedule G) a Separate Billing Requested............ 7.
g. Total Gross Assets (total Lines 1-7) ................................................................... .. 8. 8 , 551.07
9. Funeral Expenses 8 Administrative Costs (Schedule H) ...................................... . 9. 5 , 330.04
10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............................. . 10. 2 94 , 151.21
11. Total Deductions (total Lines 9 8 10) .................................................................. . 11. 2 99 , 4 81.25
12. Net Value of Estate (Line 8 minus Line 11) ......................................................... . 12. -2 90 , 930.18
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. -2 90 , 93 0.18
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 15 0 . 0 0
(a)(1.2) X .00 .
16. Amount of Line l4 taxable 0.00 i6. 0.00
at lineal rate X .045
17. Amount of Line 14 taxable
0
0 0
17
0. 0 0
.
at sibling rate X .12 .
18. Amount of Line 14 taxable
0.00
18
0 • 00
at collateral rate X .15 .
19. Tax Due ................................................................................................................ .. 19. 0.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-12-0135
Decedent's Complete Address:
DECEDENT'S NAME
Stone, Florence E
STREET ADDRESS
1000 Claremont Road
CITY
Carlisle STATE ZIP
PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 0.00
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits (A. + g) (2) 0.00
3. Interest
(3)
q. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2 Line 20 to request a refund
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferretl :............................................................................... ^ ^x
b. retain the right to designate who shall use the property transferred or its income :.................................. ^ ^x
c. retain a reversionary interest; or ............................................................................................................... ^ ^x
d. receive the promise for life of either payments, benefits or care? ............................................................ ^ ^x
2. If death occuned after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? .................................................................................................................... ^ ^x
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? .................................................................................................................. x
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT ASPART 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the usf> 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 [7:! P.S. §9116 (a) (1.3)]. A
sibling is delined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
WILL OF
FLORENCE STONE
I, FLORENCE STONE, of 139 South Pitt Street. Carlisle,
Cumberland County, Pennsylvania, declare this to be my last Will
and 'Hereby revoke all prior wills and codicils.
1. I direct that all my just debts, funeral. expenses, grave-
marker and administrative expenses shall be paid from my residuary
estate as soon as practicable after my death.
2. I direct that all inheritance, estate, transfer, success-
ion and death taxes of any kind whatsoever which may be payable by
reason of my death shall be paid out of my residuary estate.
3. I direct that my entire estate be distributed as follows:
A. I leave my entire estate of whatever nature and wherever
situate to my niece, Christine Susan Griffie, should she
survive me.
B. Should my niece predecease me, I then leave my estate of
whatever nature and wherever situate to her daughter,
Alison Rebecca Griffie.
LAW OFFICES OF
'EPHEN J. HOGG
1 E. LOUTHER STREET
CARLISLE, PA 17013
4. I appoint my niece, Christine Susan Griffie, as Executrix
of this my last Will. If she should predecease me or cease to act in
such capacity, I name Farmers Trust Company to so serve.
5. The Executrix of this Will shall have thE= power to dis-
tribute my estate in kind or in cash, or partly in either.
6. I direct that no Executrix acting under i;his Will shall be
required to enter bond in any jurisdiction.
N WITNESS WHEREOF, I have hereunto set my h<~nd this °7/.~~day
of ( , , ,~. ,c , 1992.
.~ ~ L
i
tFL RENCE STONE
~~.
~Sir~n .
The preceding instrument consisting of this and one other
page was on the day and date hereof signed, published and declared
by FLORENCE STONE, as and for her last Will 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.
~ O
/_ ~ ~jiL / ~ I , 1,%LVl/C"ai l_
LAW OFFICES OF
'EPHEN J. NOGG
1 E LOUTHER STREET
CARLISLE, PA 17013
ACKNOWLEDGEMENT
Commonwealth of Pennsylvania
County of Cumberland
ss
I, FLORENCE STONE, the testatrix whose name is signed to the
attached or foregoing instrument, having been duly qualified accord-
ing to law, do hereby acknowledge that I signed and executed the in-
strument as my last Will; that I signed it willingly and as my free
and voluntary act for the purposes therein expressed.
~~~
~ C
FLORENCE STONE
Sworn to or affirmed and acknowledged efore me by FLORENCE
STONE, the testatrix, this ~/~ day of ~ ~ i ,,,~~ , 1992.
___. _.... .1 Y
__.
~,
Notary
_... _
AFFTnAVTT
LAW OFFICES OF
CEPHEN J. NOGG
11 E LOUTHER STREET
CARLISLE, PA 17013
Commonwealth of Pennsylvania
County of Cumberland
ss
we, 574~1~/ L ,~urs~ and ~~G(SCii; /7~/, ~Qn/~/' ,
the witnesses whos names are signed to the attached or foregoing in-
strument, being duly qualified according to law, do depose and say
that we were present and saw the testatrix sign and execute the in-
strument as her last Will; that the testatrix signed willingly and
executed it as her free and voluntary act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of
the testatrix signed the Will as a witness; and that to the best of
our knowledge the testatrix was at that time 18 or more years of age,
of///sounp%d,/mi//n//d and,~und`er n~o constraint or undue influence.
Sworn to or aff' med and subscribed to before me by witnesses,
this ~/,~~ day of ~. , ~
Rev-1608 E%+ (6-981
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF VENNSVLVANbI
INHEPITANCE TA%0.ETUPN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Stone Florence E 21-12-0135
Inclutle the proceetls of litigation antl the date the pmceetla were recaivetl Dy the eetete.
All property jolntlyawned with tha fight of survivorship moat be tllacloaetl on sehetlule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 M&T Bank -Checking Account #1119052 338.24
(See attached statement)
2 M&T Bank -Savings Account #15004200895926 5,430.09
(See attached statement)
3 Refund from Claremont Nursing & Rehabilitation Center - (Personal Care Account) 1.471.09
4 Refund from overpayment of funeral expense from Forethought (Prepaid Funeral Reserve) 1,311.65
TOTAL (Also enter on Line 5, Recapitulation) I 8,551.07
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
REV-1151 E%+Ite-O6)
COM INONtytEALN~O ~F~151RN ANIA
RE ID DE ED N
SCHEDULE H
FUNERAL EXPENSES 8r
ESTATE OF FILE NUMBER
Stone.Florence E 21-12-0135
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
All I~ARFl7
~A,~~FUNERAL EXPENSES:
See continuation schedule(s) attached
941.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Christine S Crout f/k!a/
Street Address 207 Meals Drive
City Carlisle State PA Zio 17015
Year(sl Commission paid 2012 1,500.00
2. Anornev's Fees Griffie & Associates 2,000.00
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zio
Relationshio of Claimant to Decedent
4. Probate Fees 124.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 764.54
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulatian) 5,330.04
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Stene.Florence E 21-12-0135
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Paid in full by Forethought Life Policy
2 Memorial Stone to Gingrich Memorials
941.00
H-A 941.00
Other Administrative Costs
3 Advertising to Cumberland Law Journal
4 Advertising to the Sentinel
5 Reserves
75.00
189.54
500.00
H-B7 764.54
Copyright (c) 2002 form software only The Lackner Group, Inc. 1=orm PA-1500 Schedule H (Rev. 6-98)
Rev-0513 EXH t12-0a)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEFLTH OFPENNSTLVhNIR
INHERRpNCE TN(REfURN
RESIOENr DECEDENT
ESTATE OF FILE NUMBER
Stone, Florence E _ 21-12-0135
Report tlebh incumtl by the tleeatlenl prior to tleelh that remained unpaid at the tlate of death, inelutling unrolmburoed medical eapenaes.
Copyright (c) 2009 form software only The Lackner Group, Inc. form PA-1500 Schedule I (Rev. 12-OB)
(If more space is neetled, atlditional pages of the same size)
1JIP\
SCHEDULE J
qqpXp
COMINO{NWtEALTCHCOE
EDN~N~RLN ANIA
D BENEFICIARIES
G
RE I
ESTATE OF FILE NUMBER
Stone,Florence E 21-12-0135
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (W'ords) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
• distnbutions, and transfers
under Sec. 9116 a 1.2
1 Christine S Griffie Niece One hundred
207 Meals Drive percent:
Carlisle, PA 17015
Total
Enter dollar amounts for distributions shown above on lines 1 5 throw h 18 on Rev 150 0 cover sYleet, as a r o riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
1~8TBa~k
499 Mitchell RoaQ Millsboro, DE 19966 Adjustment Services
Phone 888-502-434)
Faz (302)934-2955
February 17, 2012
Griffie and Associates
200 North Hanover Street
Carlisle, PA 17013
Re: Estate ofFlorenee E Stone
Social Security: 174-20-8584
Date of Death January 20 2012
Dear Sir or Madam:
Per your inquiry on February 2, 2012, please be advised that at the time of death, the above-named decedent had
on deposit with this bank the following:
1. Type ofAccount Checking Account
Account Number 1119052
Ownership (Names of) Florence E Stone
Opening Date 0821/91
Balance oit Date of Death $338.24
Accrued Interest $ .00
Total $338.24
2. Type of Account Savings Account
Account Number 15004200895926
Ownership (Natues af) Florence E Stone
Opening Date 09/10/91
Balance on Date of Death $5,430.06
Accrued /merest $' .03
Tota! $5,430.09
~~ pennsylvania
DEPARTMENT OF PUBLIC WELFARE
1
April 4, 2012 '
GRIFFIE & ASSOCIATES
BRADLEY L GRIFFIE ESQUIRE
200 N HANOVER ST
CARLISLE PA 17013
Re: Florence Stone
CIS #: 260190379
SSN: ###-##-8584
Date of Death: 01/20/2012
Dear Bradley L. Griffie, Esquire:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of 5294,151.21 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 529,308.16, 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). Thee balance of the
claim, namely 5264.843.05, 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.. PNease complete
the enclosed Decedent's Assets Itemization Form and return to the Department.
Please include proof of funeral bill, proof of burial account, proof of personal care
account, copies of original life insurance policy forms naming beneficiaries, proof
of any and all stocks and bonds, date of death bank statements and copies of
original signature cards or proof from banking institution showing ownership of
any and all bank accounts. Please forward these documents to the address above
no later than May 10, 2012.
Sincerely,
Kari\n L. Tyler VT
Claims Investigation Agent
717-772-6614
Bureau of Program Integrity i Division of Third Par[y Liability Recovery Section
PO Box 8486 Harrisburg, Pennsylvania 17105-8466
~~~ ' pennsyl~cania
DEPARTMENT OF PUBLIC WELFARE
717-772-6553 FAX
Enclosure
Bureau of Program Integrity ~ Divlslon of Third Party Llabllity ~ Recovery Section
PO Box 8486 ~ Harrisburg, Pennsylvania 17105-8486
COMMONWEALTH OF PENNSYLVANIA
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX 8466
HARRISBURG. PA 1]105-8486
March 6, 2012
STATEMENT OF CLAIM SUMMARY
NAME Estate of STONE, FLORENCE
ID 260 190 379
MEDICAL CLASS 3 CLASS 6 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 29,297.72 264,419.35 293,717.07
DRUG 10.44 423.70 434.14
REIMBURSEMENT TO DPW 29,308.16 264,843.05 294,151.21
i COMMONWEALTH OFPENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
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