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HomeMy WebLinkAbout06-07-12'-'~ REV-7 500 Ex,°'-'°' PA Department of Revenue Pennsylvania Bureau of Individual Taxes ^E>•^*^sar Draws^uF PO 60X.280601 INH, Harrisburg, PA 17128-0601 F 1505610143 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Decedent's Last Name Suffix FOREMAN (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW OFFICIAL USE ONLY County COtle Year Fla Number TAX RETURN 21 11 1260 )ECEDENT Date of Birth 10 O1 1925 Decedent's First Name MI LOIS A Spouse's First Name THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS X^ 1. Original Retum ~ 2. Supplemental Retum 4. Limitetl Estate ~ qa Future (merest Compromise (bate of tleeth attar 72-12-82) © g Decetlanl Dietl Testate (Attach Copy of Wilp ~ 7 pece0enl MainfaineG a DvinB Trust (Attach Copy or Trust) e. Litigatlon Proceeds Received ~ 1D. hBM%an P2~11i1 enait~aale3ol aeatn 3. Remaintler Return (date of death priorto 12-13-82) 5. Federal Estate Tax Return Required ~ e. Total Number of Safe Deposit Boxes 11. Election to tax untler Sec. 9113(A) (Attach Sch. O) MI CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TA), INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number BRADLEY L GRIFFIE (717) 243 5551 REGISTER OF SE ONLM'v' ,~ .- First line of address errn-- $ ~' ~ - ~T C`rj 200 NORTH HANOVER ST G'~r •~ ,~,~ c~~ ~, Second line of address L7 L~ =t~ a C'a Y ~ ~~ City or Post Office DATE FILED Gry i~,~ State ZIP Code ~.+j CARLISLE PA 17013 Comesponden['s a-mail address: bgrllfFe@grlfflelElW.COR1 it is true, correct enU complete Declaration of pr parer other than thelpersonalarep2sentaflve a ba d on al n'formatlon~ol whichhpreparerfhasany knowledge,belief, c rxm -mac David L. 200 North Hanover St, Carlisle, PA Side 1 ~.,,~ 1505610143 1505610143 J 1505610243 REV-1500 EX Decedent's Social Security Number °~'~^''s"ame Foreman, Lois A. RE CAPITULATION 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 & Notes Receivable (Schedule D) ...................................................... .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. . 5. 4 , 13 0.02 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous lyoq-Probate Property (Schedule G) LJ Separate Billing Requested............ 7, B. Total Gross Assets (total Lines 1-7) ................................................................. 8 ... . . 4 , 130.02 9. Funeral Expenses & Administrative Costs (Schedule H) .................................... ... 9. 4 , 255.74 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................ .. 10. 524 , 2 69.84 11. Total Deductions (total Lines 9 & 10) ................................................................. .. 11. 528 , 525 , 5$ 12. Net Value of Estate (Line 8 minus Line 11) .................................. 12. -524 395 56 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) ............................................. .. t4. -524_, 395.56 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transters under Sec. 9116 (a)(1.2) X .00 15. O . O 0 16. Amount of Line 14 taxable at lineal rate X .045 0 . OO 16. 0.00 17. Amcunt of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 1 B. Amount of Line 14 taxable at collateral rate X .15 O. O O 18. O. O O 19. Tax Due ................................................................................................................. . 19. 0 . OO 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 I„~ 1505610243 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-11-12(10 DECEDENT'S NAME Foreman, Lois A. STREETADDRESS - 1000 West South Street CITY Carlisle STAi'E ZIP PA 17013 Tax Payments and Credits 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 0.00 (~) Total Credits (A + g) (2) 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the dfference. This is the OVERPAYMENT. Check box 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. Make Check to: OF WILLS, AGE O.DO (3) 0.00 (4) (5) ~.~0 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 :..................... .......................................................... ^ b. retain the right to designate who shall use the property transfered or its income :.................................. c. retain a reversionary interest; or ............................................................................................................... x d. receive the promise for life of either payments, benefits or care? ................. .. ........................................ . ^ 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 "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 uvhich contains a beneficiary designation? ............................................................................._.. n Rev-1608 EX~ (6-eB) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF pENNSYLVANIP INHERITANCE TAX RETURN RESIDENT DECEDENT 21 ESTATE OF Indutle the goceetls or litigation entl the tlele the proceeds were received by the estate. All property Jointly-owned with Me right of survivorship moat De tlfacloaed on aehe~lule F. NUMBER -. _ _,.___ ._ ..____.., ..,...,.~„„o, H~y~~ ~~ uro same szeJ Copyright (c) 2002 form sokware only The Lackner Group, Inc. Form Pq-1500 Schedule E (Rev. G-98) REV4181 EX+)10-OB) SCHEDULE H COM INNO EWEAN OFPRNN VRLN ANIA FUNERAL EXPENSES & REESIDEN~d~EO~b~' ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Foreman, Lois A. 21-11-1260 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: Hoffman-Roth Funeral Home and Crematory, Inc. 1,624.70 B. I ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(sl Commission paid 2. Attorney's Fees Griffie & Associates 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zic __ Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs See continuation schedule(s) attached TOTAL AI 2,250.00 116.50 264.54 ( so enter on line 9, Recapitulation) ~ 4,255.74 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 LE NUMBER 21-11-1260 tltM NUMBER DESCRIPTION AMOUNT Other Admini trativ r-~~te 1 The Sentinel (Advertising) 2 Cumberland Law Journal (Advertising) 189.54 75.00 H-67 264,54 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-7512 E%s (12-081 SCHEDULE 1 DEBTS OF DECEDENT, COMMONV/EALTHOFPENNSYLVANIA MORTGAGE LIABILITIES, & LIENS INHERITANCE Tq%RETURN RESICENL DECEDENT ESTATE OF A. NUMBER Report tlabta fncurretl by ma tlecatlent prior ro tlsaN that ramelnetl unpsitl ae the tlaro M tleeM, Inelutling unreimbunatl mstliul expaneu. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Department of Public Welfare, Estate Recovery Program -Medical Expense Claim (See attached statement) 2 Estate Recovery Program -Medicaid Claim (See attached statement) 77,622.26 506,647.58 TOTAL (Also enter on Line 10, Recapitulation) I 524,269.84 (If more space is neetled atltlitional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Fonn pA-1500 Schedule I (Rev. 12-08) REV-1513 EX* (1108) I SCHEDULE J COMMONWEALTCry OF PE VLyANIA BENEFICIARIES INHER~IITTDEIJTEOTTECED~N~RN ESTATE OF Foreman, Lois A. FILE NUMBER 71 _19 _19Rn NUMBER I• NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a 1.2 RELATIONSHIP TO DECEDENT SHARE OF ESTATE (Words) AMOUNT OF ESTATE ($$$) Eric M. Foreman Grandson One-half interest 138 North Blackberry Lane in the net estate Fayetteville, PA 17222 Jeremy L. Foreman Grandson One-half interest 147 North College Street in the) net estate Carlisle, PA 17013 . Enter dollar amounts for distributions shown above on lines 1 5 throw h 18 on Rev 150 Total 0 cover sheet, as a ro riate. II NON-TAXABLE DISTRIBUTIONS: . 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 (:OVER SHEETI Copyright (c) 2009 form software only The Lackner Group, Inc. Fbrm PA-1500 Schedule J (Rev. 11-OS) ~~~~t 3~i11 ~.n~ C~TP~t~.m.Qnt OF LOIS A. FOREMAN I, LOIS A. FOREMAN, of 207 North Hanover Street, Apartrr-ent 1, Carlisle, ,~ Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void all previous Wills and Codicils heretofore made by me. FIRST I order and direct my Executor hereinafter named to pay all of my just debts, funeral expenses and expenses involved or connected with the administration of my estate as soon after my death as is reasonably possible. However, my Executor need not accelerate and pay those unmatured obligations which, in his, her or its opinion, it might be proper and more advantageous to retain or renew and pay as they become due and payable. If I do not own a burial plot or a grave marker at the time of my death, I authorize my Executor/Executrix, in his, her or its sole discretion, to purchase a burial plot and to erect a suitable grave marker at my grave, and to expend sums from my estate for this purpose. GRIFFIE 8c ASSOCIATES ATTORNEY^~-AT-LAW 200 NORTH HANOVER STREET NORTH MAIN 6TREET CARLISLE. PENNSYLVANIA 17013 CHAMBERSBU RG, PENNSYLVANIA 17207 SECOND I give, devise and bequeath the personal property, together wi1:h all insurance proceeds thereon, to the individuals named pursuant to the sepazate handwritten memorandum attached to this, my Last Will & Testament. THIRD I give, devise and bequeath my entire estate of whatsoever nature and wheresoever situate, together with all insurance proceeds thereon, in equal shares to my grandchildren, ERIC M. FOREMAN and JEREMY L. FOREMAN, who survive me by sixty (60) days, per stirpes. It is further my desire that my ExecutorBxecutrix, after consultation with any heir or heirs of mine who survive me, and in his, her or its own discretion, choose such articles from my tangible personal property (exclusive of cash, stock certificates, bonds, and all other tangible evidences of intangible personal property) as he, she or it believes will be useful to such heir or heirs or desirable for him or her or them to have, either from a sentimental point of view or otherwise, and to deliver such articles to such heir or heirs or among such heirs in equal or unequal shazes as determined by the further exercise of his, her or its discretion, provided no other heir objects to the distribution. All tangible personal property not so distributed is to be sold, either publicly or privately, by my Executor/Executrix, adding the proceeds of such sale or sales to my residuary estate and to be disposed of in equal shares among my surviving heirs after payment of my estate debts, taking into account the tangible personal property otherwise provided to them. FOURTH Any devise or distribution under this Last Will and Testament which is payable to any beneficiary who may be under 21 years of age or, in the judgment of my GRIFFIE & ASSOCIATES Attorneys At Law 200 N. Hanover Street 2 38 N. Main Street Carlisle, PA 17013 Chambersburg, PA 17201 Executor/Executrix, mentally disabled, shall be held in a separate: trust by my Executor/Executrix as trustee until such beneficiary reaches 21 years of age or during such period of disability. During the term of any trust created pursuant to this Paragraph, the Trustee is authorized to expend and apply so much of the net income and principal of each such trust as the Trustee shall consider advisable for the health, maintenance, support, and education (including college education, undergraduate and graduate) of each such beneficiary until he or she attains 21 years of age, or until al] such amounts are paid out of trust. I direct that no Trustee shall be required to give or post bond for the faithful performance of the Trustee's duties in this or any other jurisdiction. FIFTH I grant my ExecutorBxecutrix the following powers in addition to and not in limitation of such powers as my ExecutorBxecutrix shall hold by law: (a) To retain all property received including the stock of any corporate fiduciary acting hereunder, provided such property remains productive. 2 (b) To join in any corporation, partnership, recapitalization, merger, reorganization or voting trust plan; to delegate authority with respect thereto; to deposit investments under agreements and pay assessments; and generally to exercise all rights of investors, including but not limited to, the voting of shares. (c) To manage, operate, repair, improve, mortgage or lease on any terms any real estate held or owned by my estate. (d) To operate any business that I may own at my death. 200 N. Hanover Street Carlisle, PA 17013 GffiFFIE & ASSOCIATES Attorneys At Law 3 38 N. Main Street Chambersburg, PA 17201 (e) To invest any funds of my estate in any stocks, bonds, notes or other securities or property, real or personal, without regard to the principle of diversification or any other statute or general rule of law in his, her or its absolute discretion, it being my intention to give my ExecutorBxecutrix the broadest investment powers possible, providing such investments do not unnecessarily prevent the prompt settlement of my estate. (fj To sell or otherwise dispose of any property, real or personal, tangible or intangible, at any time forming a part of my estate in any manner and on such terms and conditions as my ExecutorBxecutrix shall 'see fit in his, her or its absolute discretion. (g) To borrow money for the payment of taxes or for any other proper purposes in the administration of my estate, and to mortgage or pledge estate assets as security. (h) To compromise claims without court approval including, but not limited to, any controversies with the United States of America or the Commonwealth of Pennsylvania concerning estate and inheritance taxes on any interests that may pass under this my Last Will and Testament. (i) To distribute in cash or in kind upon any division or distribution of my estate. (j) To undertake any and all acts deemed necessary and proper by my ExecutorBxecutrix for the proper, advantageous and prompt management of the settlement of my estate. (k) In general, to exercise all powers in the management of my estate which any individual could exercise in the management of similar property owned in his GRIFFIE & ASSOCIATES Attorneys At Law 200 N. Hanover Street 4 38 N. Main Street Carlisle, PA 17013 Chnmbersburg, PA 17201 own right, upon such terms and conditions as to him, her or it may seem best and to execute and deliver all instruments and to do all acts which he, she or it deems necessary or proper to carry out the purposes of this, imy Last Will and Testament. SIXTH I specifically have not provided foi any distribution herein to my sons, DAVID FOREMAN and RICHARD FOREMAN, not for want of affection, but because I have provided for them as I desire during my lifetime. SEVENTH I nominate, constitute and appoint my son, DAVID L. FOREMAN, as Executor of this my Last Wil] and Testament. In the event my son is deceased, unable or unwilling to serve or shall cease to serve for any reason whatsoever, then I nominate, constitute and appoint my brother, WII,LIAM L. HOFFMAN, as Executor of this my Last Will and Testament. I direct that my Executor shall not be required to give or post bond for the faithful performance of his, her or its duties in this or any other jurisdiction. EIGHTH I hereby declare it to be my expressed desire that my Executor/Executrix employ the law firm of Griffie & Associates, of Cazlisle, Pennsylvania, for legal advice and assistance regazding this my last Will and Testament, they having considerable knowledge of my affairs, views and wishes respecting any matters that may arise at the probate of this instrument, the administration of my estate, and the execution of the powers herein mentioned. GRIFFIE & ASSOCIATES Attorneys AC Law 200 N. Hanover Street Carlisle, PA 17013 5 38 N. Main Street Chambersburg, PA 17201 IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will and Testament this 3~ day of SP~-~cMb et" , 1999. WI ~ LOIS A. FOREMAN 00 N. Hanover Street Carlisle, PA 17013 GRIFFIE & ASSOCIATES Attorneys At Law 6 38 N. Maiu Street Chambersburg, PA 17201 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVAI~TIA: SS. COUNTY OF CUMBERLAND I, LOIS A. FOREMAN, 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 and Testament; that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. -~ Gum ~ I ~" CI22~'yy(,et~-(~ LOIS A. FOREMAN Sworn or affirmed and acknowledged before me by LOIS A. FOREMAN the Testatrix this ~~ day of ~ 1999. ,~ Notarial Seal Robin J. Goshom, Notary Public Carlisle Boro, Cumberland County My Commission Expires Apr. 17, 20(13 200 N. Hanover Street Carlisle, PA 17013 GRIFFIE & ASSOCIATES Attorneys At Law 7 38 N. Main Street Chambersburg, PA 17201 AFFIDAVTI' COMMONWEALTH OF PENNSYLVANIA: SS. COUNTY OF CUMBERLAND //// ~ WE, e,co~ ~ . Gf,`'~-~ and /~h n.rr .~ . ~ 5 ol^n~ the witnesses whose names are attached to the foregoing document, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the instrument as her Last Will and Testament; that she signed willingly and that she 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 ithe Last Will and Testament as witnesses and that to the best of our laiowledge the Testatrix was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affir//med and subscribed before me by Inc mr~~,~- and ~ ;n~ of -~ L~~ 5 ~ Y'tti- this ~ ~ day of - , 1999. Notary Public Notarial Seal Robin J. Goshorn, Notary Public Carlisle Boro, Cumbedand County My Commission Expires Apr. 17, 2003 200 N. Hanover Street Carlisle, PA 17013 GRIFFIE & ASSOCIATES Attorneys At Law 8 38 N. Main Street Chambersburg, PA 17201 a~ 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Phone 888-502-4349 F ax (302) 934-2955 December 8, 2U1 I Griffie and Associates 200 North Hanover Street Carlisle, PA 17013 Re: Estate of Lois A Foreman Social Securitv 201-16-5773 Date of Death October 16, 2011 Dear Sir or Madam: Per your inquiry on December 2, 2011, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Account Number Ownership (Names ofl Opening Date Balance on Date of Death Accrued Interest Total Checking Account 3740898030 Lois A Foreman David L Foreman (POA) Eric M Foreman (POA) 0820/99 $2,973.19 $ .00 ------------ $2,973.19 For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please tall the nigh Street Carlisle Olrirx at N717-2J0-053G. W e were unable to locale any sate deposit box for the above-mentioned decedent This letter does not include any accounts m which the decena~d may have been listed as Power of Attorney, Custodian of Uniform Transfers, Itepresentafive Payee, ar Trustee under a Written Agreement Sincerely, Tammy Spencer Adjustment Services pennsylvania DEPARTMENT OF PUBLIC WELFARE February 6, 2012 GRIFFIE & ASSOCIATES BRADLEY L GRIFFIE ESQUIRE 200 N HANOVER ST CARLISLE PA 17013 Re: Lois Foreman CIS #:530159783 SSN: ###-##-5773 Date of Death: 10/16/2011 Dear Attorney Griffie Please be advised that the Department of Public Welfare maintains a claim in the amount of $524,269.84 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 517.622.26, 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 5506.647.58, 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, -...~6~1TIW.S~. Enclosure Angela S. Bonner Claims Investigation Agent 717-705-9701 717-772-6553 FAX Bureau of Program Integrity i Division of Third Party Llablllty Recovery Section PO eox 8486 I Harrisburg, Pennsylvania 17105-8486