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HomeMy WebLinkAbout06-15-12~ REV-7500 Exl°'-'°'; PA Department of Revenue Pennsylvania Bureau of Individual Taxes °V~maa*~eA'r^^~ Po Box.zaosol INH Harrisburg, PA 17128-0601 F ENTER OEGEDENT INFORMATION BELOW Social Security Number Date of Death Decedent's Last Name Suffix SMITH (If Applleable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number 1505610143 OFFICIAL USE ONLY County Code Veer File Number RETURN 21 12 0090 DENT Date of Birth 03 OS 1920 Decedent's First Naame MI JANE E Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Rehm ^ 2. Supplemental Return ^ 3, Remainder Retum (date of death prior to 12-13-82) ^ 4. Limitetl Estate ^ qa_ Future Interest Compromise (date or death soar l2-72-e2) ^ 5. Federal Estate Tax Return Required B Decedent Oietl Testate (Attach COpyM Wi11) ^ 7 Pece~er~t Maintaa~~netl a Living Tmst 8. Total Numbef of Safe De AttBC opy cl Tiust) pO31t BOxea ^ 9. Litigation Proceeds Received ^ 10. s ousel pgven Creditt(date mdeath t t. Election to tax under Sec. 9113 A D~tween 1 -31 ~Ji antl -1 -95) ^ ( ) (Attach SGh. O) CORRESPONDENT - THIS SEGTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numbe(t:,,~ JOEL O SECHRIST ESQ 717 9~ 396 ~ First line of address 568 OLD YORK ROAD Seeond line of address City or Post Offiee ETTERS ZIP Code 17319 N ~' t~ REGISTER ~~ USE ONLY _.. r n~''n ." rs r ~,, , , ~ C7 --rI ~ t OG ' Y m~ _ s ti I v c Q J DATE FILED State PA Correspondents e-mail address: SecnrlsLldWLN9R1011.COM Under penalties of perjury, I tleclare that I have examinetl this return, including accompanying schetlules antl statements, and to the best of my knowledge antl belief, it is true, cortect and complete. D@daration of preparer other than the personal representaave Is based on all information of which preparer has any know) ge. SIGNATURE OF PER ON RESPONSIBLE FORpFILING RETURN DAy t~? %~~~~ ,l,?.P~(~ Mildred Kell ( / ~ ~ Z _. _. _ - ..._.. ..-..-~...,.. -` GATE r Joel O. Sechrist Esq. , ( "[ , ~ PA Side 1 1505610143 ],505610143 J 1505610243 REV-1500 EX Decedent's Social Security Number oacaaam~sName: Smith, Jane E 202 16 9195 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. 9 , 50 9.20 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested........... . 6. 7. Inter-Vivos Transfer9 8 Miscellaneous h{oq-Probate Property (Schedule G) u Separate Billing Requested........... . 7. 8. Total Gross Assets (total Lines 1-7) ................................................................... .. 8. 9 , 5 0 9.2 0 9. Funeral Expenses & Administrative Costs (Schedule H) ...................................... . 9. 9 , 7 0 6.80 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............................. . 10. 3 6 , 0 90.73 11. Total Deductions (total Lines 9 8 10) .................................................................. . 11. 45 , 7 97.53 12. Net Value of Estate(Line 8 minus Line 11) ......................................................... . 12. -3 6 2 8 8 .33 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. -3 6 , 2 8 8 .33 TAX COMPUTATION -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 .00 15. 0.00 i6. Amount of Line 14 taxable 0.00 at lineal rate X .045 16. 0.00 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 wllateral rate X .15 0.00 18. 0.00 19. Tax DUe ................................................................................................................. . 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 150561',0243 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: Flle Number 21-12-0090 DECEDENT'S NAME Smith, Jane E STREET ADDRESS 770 Poplar Church Road CITY Camp Hill STNTE PA ZIP 17011 Tax Payments and Credits: 7. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 0.00 (t) Total Credits (A + B) (2) 0.00 0.00 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Chbok 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. Check to: (3) (4) (5) 0.~~ PLEASE ANSWER THIE FOLLOWING QUESTIONS BY PLACING AN "X" IN T'HE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :........................................................................... ^ .... b. retain the fight to designate who shall use the property transferred or its inceme :.................................. ^ x c. retain a reversionary interest: or ............................................................................................................... d. receive the promise for life of either payments, benefits or care? ............................................................ g z 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 "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x Rev-1808 EX+ (8-98) SCHEDULE E CASH, BANK DEPOSITS, 8r MISC. PERSONAL PROPERTY COMMONWEALTHOF PENNSYLVANIA INHERITANCE TAX RETURN RESIOENTOECEOENf ESTATE OF Inclutle the proceeds of litigation antl the tlate the proceeds were received by the estate. All property jolntlyavmatl with the dghl or survivonhlp must be dlaclosstl on achetlula F. NUMBER (lf more space is needed, additional pages o/the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) REV-7757 Ex~ (10-OtlI qpx y~y COMA R ID~~ECE~RN ANIA SCHEDULE H FUNERAL EXPENSES & ESTATE OF FILE NUMBER Smith, Jane E 21-12-0080 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: Clyde W. Kraft Funeral Home 9,106.30 B. ADMINISTRATIVE COSTS: 1. Personal Represefttative's Commissions Name of Personal!Representative(s) Street Address City State Zio _ Year(sl Commission paid 2. Attorney s Fees Joel O. Sechrist Esq. 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address Ciry State Zio __ Relationship ~f Claimant to Decedent 4. Probate Fees See continuation schedule(s) attached 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 500.00 100.50 TOTAL (Also enter on line 9, Recapitulation) 9,706.80 Copyright (c) 2009 form software Drily The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) T_ _. __ _. SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Smith, Jahe E 21-12-0090 ITEM NUMBER DESCRIPTION AMOUNT Probate Fees 1 Register of Will9 fee to file inheritance tax return 2 Register of Wily probate fee H-B4 15.00 85.50 100.50 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev4512 E%+ (12-0BQ SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OFPENNSYIVANq INHERITANCE Tq%RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Smith, Jane E 21-12-0090 Repotl tlebh Incurnstl by tM decedent prior to death ihal remained unpaitl at Ma tlale or death, Indutlirrp unmlmbursed metlical szoeneee. (If more space is needed, adtligonal pages of the same size) Copyright (c) 2009 form software ohly The Lackner Group, Inc. Form PA-7500 Schedule I (Rev. 12-09) REV-151]EX. 111-0N) _ ~ SCHEDULE J COMM-Q(~y~F,ALT,t~D PENN,~S`(hYANIA IiGXERpEE~1~r`^ BENEFICIARIES ESTATE OF FILE NUMBER Smith, Jane E 27-72-0090 NUMBER AME AND ADDRESS OF ~ RELATIONSHIP TO DECEDENT SHI\RE OF ESTATE AMOUNT OF ESTATE pERS N(S) RECEIVING PROPERTY (Worts) ($$$) I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a 1.2 Mildred Kell Sister-in-Law entire estate 506 Bowman ,Avenue Lewisberry, PIA 77339 Total Enter dollar amou is for distributions shown above on lines 1 5 throw h 18 on Rev 150 0 cover sheet as a r o riate. II NON-TAXABLE D STRIBUTIONS: . q. SPOUSAL DIS RIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO "!AX IS NOT TAKEN B. CHARITABLE A,ND GOVERNMENTAL DISTRIBUTIONS TOTA L OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-t500 COVER SHEET Copyright (c) 2009 form software orhly The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) SST I~ 1~~ T ®~ ~ ~ ~o S1VI~'~ I, JANE E. SMITH, of the Borough of Cohunbia, in t:he County of Lancaster, and Commonwealth of Pennsylvania, hereby revoke all wills and codicIls, as well as all other instruments of a testamentary nature, heretofore made by me and do hereby make, publihh azzd declare this to be mylast will and testament. FIRST: I direct that my executor, hereinafter named, pay my just debts and reasonable fjaneral expenses as soon as convenient after my death. SECOIND: All the rest residue and remainder of my estate, both real and personal, of {whatsoever kind and wherever situated of which I die seized or possessed or of which '~Z shall be entitled to dispose at the time of my death, I give, devise and bequeath, absolutely and forever, to my brother, WILLIAM C. KELL, provided that if he shall predecease me or fail to survive me by thirty (30) days, then to my sister-in-law, N MILDRED IC~LL. z ~ ~, x ~'~~e ~ ~' 3t s b c'? -~ +v ~ , o acs r__ I THIRD: All federal, state and other death taxes payable because of my death on property forming my gross estate for tax purposes whether or not it passes under tlus will, shall be paid out of the principal of my general estate just as if they were my debts, and none of those taxes shall be charged against any beneficiary or any outside fund. Anyi death taxes on future interests may be paid whenever my executor may think best. FOURTH: I appoint my brother, WILLIAM C. KELL, to be the Executor of my will. In the event', he predeceases me or shall be iulable or unwi11i1g to serve, then I appoint my sister-fin-law, MILDRED ICELL, to serve as substitute Executrix of this my will. I direct that pry Executor and substitute Executrix shall not be required to serve with band, surety ~r security. I authorize any personal fiduciary representative named herein to exercise the following powers, in addition to fllose given by law, to be exercised in their sole discretion: to retai$r any real and personal property which may at any time form part of my estate as long als they may deem advisable; to repair, alter, improve or lease, for any period of time, an~ real or personal property and to give options for leases; to sell at public or private dale, for cash or credit, with or without security; to exchange or to 2 partition any real or personal property and to give options for' sales or exchanges; to compromise claims without Court approval; and to make dishibiitron in kind. IN WTTN~SS WHEREOF I, JANE E. SMITH, the Testatrix:, have to this my will, written on ~ sheets of paper, set my hand and seal this /.3 day of r 2000. Q (SEAL) JANE E. SMITH Signed, sewed, published and declared by the said, JANE E. SMITH, as az1d for her last will and!itestament, in the presence of us, who, at hear request and in her presence, and ui t~e presence of each other, have subscribed our naznes as witrlesses thereto. A c ~ ~'~ / 3 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF LANCASTER I, JANE E. SMITH, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed it ~, willingly az1d that I signed it as my free and voluntary act for the purpose therein expressed. JAT~TE E. SMITH Svyorn or affirmed to and acknowledged before me, by JANE E. SMITH, the Testatrix, this /3,~ day of i %~'~-~-~- 2000. ~1, _-. Notary '. A.t^t'1uA V N( Notarial Seal Yvonne M.Yohe; Notary;Pubiic ~~ Columbia Boro, Lanbaster County COMMCNWEALTH OF PENNSYLVANIA My Commission Expires Oct: 29, 21703 '~ Mme, FenlsASSOCIatlonof Notarlsa COUNTYY OF LANCASTER Yale, DAVID T. MOUNTZ and EMILIE A. GOCHNAUER, whose names are signed t~ the attached or foregoing instriunent, being duly qualified according to law, do depc}se and say that we were present az1d saw 1`estatrix sign and execute the ulstrum~nt as her Last Will; that JANE E. SMITH sifined willingly as her free and voluntary act for the purpose 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 that time 18 or more years of age, of sound mind az1d under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by DAVID T. MOUNTZ and EMILIE A. GOCHNAUER, this ~ day of '~~.~, 2000. Yvonne M.Yohe! Notary Publtc V ', ~~~ Columbia 9oro, Lencastar County Notary Pub~l'c My Commisalon Expires Oct. 23, 2003 MemDBr, penngyNpnlaASSOC~tlonotNofarles RESIDENT FUND MANAGEMENT SERVICE STATEMENT GGNSC CAMP HILL WEST SHORE LP GLC - WEST SHORE #00285 770 POPLAR CHURCH.. ROAD CAMP HILL, PA 17011 ACCOUNT NUMBER: 641202430 FACILITY RESIDENT IDENT: 42186 JANE SMITH c/o GEORGE KELL FOR JANE SMITH 368 CAMERON RD ETTERS PA 17319 QUARTERLY STATEMENT FOR THE PERIOD 10/01/2011 THRU 12/30/2011 REF BATCH&SEQ TR $NSACTION DESCRIPTION DEBITS CREDITS DATE BALANCE BE INNING BALANCE 10/01/2011 62.50 B-21003 U TRSRY 303XXSOC SE 1043.00 10/03/2011 1105.50 B-21003 C COST AUTO WDL 996.00 10/03/2011 107.50 'B-41003 I REST PATD 0.00 10/03/2011 107.50 D-10071:1D1 10 P RSONAL CHECK 2457.29 10/12/2011 2564.79 W-10121:1 W2 8 B AUTY SHOP 09/2011 36.00 10/13/2011 2528.79 B-41101 I TEREST PAID 0.07 11/01/2011 2528.86 B-21103 U TRSRY 303XXSOC SE 1043.00 11/03/2011 3571.86 B-21103 C COST AUTO WDL 99B.00 11/03/2011 2573.86 D-11011:LD1 5 S ATE/CNTY/CITY CK 289.37 11/03/2011 2863.23 W-11161.1 W1 6 B AUTY SHOP 10/2011 16.00 11/17/2011 2847.23 B-21130 P TREASURY DEPT ANN 289.37 11/30/2011 3136.60 B-21130 C COST AUTO WDL 244.37 11/30/2011 2892.23 B-41201 I TEREST PAZD 0.10 12/01/2011 2892.33 W-120817.W2 6 B AUTICIAN 11/2011 65.50 12/09/2011 2826.63 BALANCE 12/30/2011 2826.83 SUMMARY: 8 CR~DIT(S) TOTALING .............5122.20 6 DE IT(S) TOTALING .............2357.87 YEF~R-TO-DATE INTEREST PAID........0.17 A {~~pY~{p~{/~q ~pap~ aq~ f.~e 9 ~[ (~ y6 • Nr R Yfl L.~\s ae~~LY W~I~ ~J V Exhibit to Schedule E The Resident Fund Management Servfe~ is a service of Netlonal Detacare Corporatlon end Wechovie Benk. Ali eocounts are held at Weohovie Benk, en FDIC insured finanoial institution. This tetement was prepared by ~Netionel Detecere using transaotions provided by the facility. If you have any questions regarding your account, please contact ffie busine~s office et the facility. i ~- T W C O ? mpjo~ If ~ O"om p x Al y ~ -1 ° m m ~ c~zT A. Oy ~ O -„ OD ~ m o ~ ~~m."0 ~' ? = m # f ~ o m ` -~ _ o v m a s oem z v z ~ A em ~ Q ~ ws C /1 v ~ . , x k ~ m D 4 ~ m m m mZ -ip ? O my°o~ zcmmm ~ ,~ O Zy Z « C D O m = `° ~ ~m m n ~ ymnw~ Q c > >o~ ° m n ~ ~, z H<m ~ ~ i v ~A ~ _ ~ OA(] mc> ~~ y ~ ~ o i°z°ti N m N zy°cx -~ -~ ~N ~n ~~ f ~ ~ ADOtAnA N ~ /~ / < 0~ '(~ /~ •~ •I 3 j m T i Q m Z y ~ ~ ~ ~ m~~ m °°~~o ~ ~~°~~ omzr + oDi~ rt °o z ~ D Z O Z 1T1 O ~ D ~ r m < o T ° m ~ ~ bq ~ ~ ~ N ~ rt y ~ ~ C d ~ A N O '' "' () n ~ Z .~~. °~ S m ~ m D r m S 0 g Exhibit to Schedule E i pennsylvania DEPARTMENT OF PUBLIC WELFARE April 4, 2012 JOEL O SECHRIST ESQUIRE JOEL O SECHRIST ESQ 568 OLD YORK RD ETTERS PA 17319' Re: Jane Smith CIS #: 420311892 SSN: ###-##-9195 Date of Death: 12/01/2011 Dear Joel O Sechri~t, Esquire: Please be a vised that the Department of Public Welfare maintains a claim in the amount of 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 rei burse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, s amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's item zed statement of claim. A portion o this medical expense, namely 530,531.54, was incurred during the last six months of the ecedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Es tes, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely .1 , is to be entered as a priority Class 5.1 claim against the estate. Please acknowledg receipt of this letter and advise whether the Commonwealth's claim is admitted and whe 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 as essment, and a current appraisal, if available.. Please complete the enclosed De edent's Assets Itemization Form and return to the Department. Please include p oof of funeral bill, proof of burial account, proof of personal care account, copies f original life insurance policy forms naming beneficiaries, proof of any and all st cks and bonds, date of death bank statements and copies of original signatur 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 Ma 10, 2012. Exhibit t© Schedule I Sincerely, Karin L. Tyler Q Claims Investigation Agent 717-772-6614 717-772-6553 FAX Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Boz 8486 I Harrisburg, Pennsylvania 17105-8486 Joel O. Sechrist, Esquire Attorney at Law 568 Old York Road Etters PA 17319 717 938-3396 Facsimile 717 938-9613 June 14, 2012 Register of Wills ', 1 Courthouse Squ~re Carlisle, PA 1701 Re: Estate of Jane E. Smith #21-12-0090 6 N C ~ ~~ ~ S: - r* ~ ~~ ._ U; _ GJl v~.:~ p Off-;. ~ ~ c~r~, ~"; T . .. ~ .: - 9 N - -y 0 n v De Register of VfJills: Enclosed a~e two copies of the inheritance tax return and the $1 `i.00 filing fee in regazd to the above estate. lease send the receipt to me at the above address. ~ 4 ~~ ~ ~O~F {. w ~ f ~~~ mu': ~ a ,`s v~~~ ~w~ ..wi'~ N ~ 1 j~~~'~ lisa~ s r; d¢I, lam, C7 G7 ~ ~ ~ M •-- u,~ ~J CJ ,+: N ~ F.-. 2 - N r-I L 1 fd ~ ~ w - - _ ;~Cl ~ tr '- .__ ~,'~ ~ ~.. y,U 3 m -c~ ~ ~ m a ~ w _~~ ~ _ > o ~ ;_ ,_~ ,~, ~ ~ ai `~ ~ ~ O~ v w rn ~ ., + l v ~ ~ O ~ u m v a ~ U ~, -- ^" cd M a ~ ~ N ~ ',- 'r .~ NbF:. 0 ~ O ^j ~~v~i W