HomeMy WebLinkAbout07-05-121505610140
REV-1500 EX ~°'-'°'
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 2 0 0 8 1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 6 3 2 4 8 4 7 4 1 0 1 5 2 0 1 1 1 2 1 5 1 9 2 9
Decedent's Last Name Suffix Decedent's First Name MI
A L F A N O D O M E N I C A
(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
0 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)
OX 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 SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
D A V I D H S T O N E E S Q U I R E 7 1 7 7 7 4 7~ 4 3 5
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Q~WILLS USE ONLYt ` .}
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First line of address ~ t ' ` ` '
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4 1 4 B R
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Second line of address ~ ~,. _. ~ .
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City Or Post Office State ZIP Code l_____. DATE FILED ~"'
N E W C U M B E RL A N D P A 1 7 0 7 0
Correspondent's a-mail address: D S T O N E a~ S T O N E L A W• N E T
Under penalties of perjury, I declare that I have examined this return, 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.
SIGNATU~~F PERSON RESPONSIBLE FOR FILING RETURN DATE_
/7u.G'~t~. /_.~ ~ `~2~I~r~ ~Y ~~/Jt~i1a/, t(-~ ~-- 17
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
ADDRESS
13 SHOFF CO MECHANICSBURG PA 17055
SIG RER ER N REPRESENTATIVE D~TE
414 BRIDGE ST
NEW CUM
PLEASE USE ORIGINAL FORM ONLY
AND PA 17070
1505610140
Side 1
1505610140
J ~
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: DOMENICA ALFANO 1 6 3 2 4 8 4 7 4
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. 1 3 9 7 4 . 2 5
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ..... .. 7.
8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 1 3 9 7 4 . 2 5
9. Funeral Expenses and Administrative Costs (Schedule H) ........ ........ .. 9• 1 1 4 9 9 . 4 8
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) ... ........ .. 10. 3 5 9 2 5 6 . 5 1
11. Total Deductions (total Lines 9 and 10) ...................... ....... .. 11. 3 7 0 7 5 5. 9 9
12. Net Value of Estate (Line 8 minus Line 11) ................... ....... .. 12. - 3 5 6 7 8 1 . 7 4
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 5 6 7 8 1 . 7 4
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• ~ 0 0 0 15. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate x• 0 4 5 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 0 0 0 18. 0. 0 0
19. TAX DUE ............................................. ....... ..19. 0 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505610240 1505610240 J
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 21 1,2 0081
Tax Payments and Credits:
~. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments -
B. Discount
3. Interest
(1) 0 • 00
Total Credits (A + g) (2) 0 • 0 0
(3) 0 . 0 0
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.
(5)
(4)
0.00
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 : ................................................................ ...... ^
b. retain the right to designate who shall use the property transferred or its income; ......................... ...... ^
c. retain a reversionary interest; or ........................................................................................... ..... ^ 0
d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^ 0
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? .... ..... ^ Q
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 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 to or for the use of the surviving spouse
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,, unde
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX+ (11-10)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE
CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
DOMENICA ALFANO 21 1,2 0081
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• M&T Bank-Checking Acct #60105448 2,438.02
Princ $2,438.01, Int• $•01
2 M&T Bank-Savings Acct #150042],1547441 3,147.58
Princ• $3,147.55, Int• $•03
3 Blue Cross-refund 388.02
4 SecurChoice - Pre-Need and Individual Trust Agrmt 8,000.63
Acct #705013
TOTAL (Also enter on Line 5, Recapitulation) $ 13 , 9 7 4 • 2 5
If more space is needed, insert additional sheets of paper of the same size
REV-1511 EX+ (10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERALEXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
DOMENICA ALFANO 21 12 0081
Decedent's debts must be reported on Schedule [.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1• Keffer Funeral Home-funeral expenses 7,849.63
2• Holiday Inn-luncheon after funeral 1,140.98
3• Keffer Funeral Home-add'1 funeral expenses 457.37
B.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
State ZIP
2. AttomeyFees: David H Stone, Esquire
3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
4•
Street Address
City State
Relationship of Claimant to Decedent
Probate Fees: See # 2 b e l o w
5 , Accountant Fees:
6 • Tax Return PreparerFees:
7•
2
3
4
5
6
Income taxes pd to US Treasury and PA Dept of Rev
Register of Wills, Cumberland County-probate costs
Joanne Alfano-Reimb for prep of income taxes
Register of Wills-filing Inh tax return and Inv
Reserve for filing First and Final Acct
Reserve for closing expenses
1,5DD•00
151.00
105.50
50.00
15.00
130.00
100.00
TOTAL (Also enter on Line 9, Recapitulation) I $ 11 4 9 9 • 4 8
ZIP
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
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
DOMENICA ALFANO 21 12 X081
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• Fox Subacute at Mechanicsburg-debt of decedent 2,046.44
(payment not paid yet)
2 HealthDrive Podiatry Group-debt of decedent (payment 7.81
not paid yet)
3 PA Dept of Public Welfare-claim 357,202.26
Class 3 $130,685.64 and Class 5.1 $226,516.62
(payment not paid yet)
TOTAL (Also enter on Line 10, Recapitulation) S 3 5 9 , 2 5 6 • 51
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF: FILE NUMBER:
DOMENICA ALFANO 21 12 0081
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 PAULA A BOYER Lineal 0.00
13 SHOFF COURT
f1ECHANICSBURG PA 1,7055-
2 JOANNE M ALFANO Lineal 0.00
11803 BRETON COURT #11
REETON VA 20191-
I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET AS APPROPRIATE
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1•
I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
L•
TOTAL OF PART [I -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $
If more space is needed, use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
of
DOMENICA ANN ALFANO, a/k/a
MAMIE ANN ALFANO
X
X 7f
.:::'::..,~:~ :o .., II
X
'C
I, DOMENICA ANN ALFANO, also known as MAMIE ANN ALFANO,
of the City of York, County of York and State of Pennsylvania, do
hereby make my Last Will and Testament and revoke all Wills by me
at any time heretofore made.
ITEM I: I direct the payment out of my estate of my
debts and the expenses of my illness and funeral.
ITEM II: I give, devise and bequeath my entire estate,
real and personal, to my husband, James L. Alfano, provided he
survives me for a period of thirty (30) days after my death.
ITEM III: Should my husband predecease me, or in the
event of his death within the period of thirty (30) days after my
death, then in either event I give, devise and bequeath my entire
estate, real and personal, to my daughters, Joanne M. Alf ano and
Paula A. Alfano, share and share alike.
ITEM IV: I nominate, constitute and appoint my husband,
James L. Alfano, Executor of this my Last Will and Testament, and
I direct that he shall not be required to enter security in any
jurisdiction in which he may act. I direct that my Executor shall
have full power to sell all or any of my real estate at public or
private sale, for such prices and upon such terms as he may deem
best, and to grant and convey good and sufficient title without
liability on the part of the purchasers to see to the application
of the purchase money. In case of vacancy in said office, I
appoint Joanne M. Alf ano and Paula A. Alfano succeeding Executrices
with all the powers, authority and discretion of the first named.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
to this, my Last Will and Testament, this
Q~ day of
~~'~ , 1973.
?~ ~ ~~~
Domenica Ann A ano, a a(SEAL)
Mamie Ann Alf ano
Signed, Sealed, published and
Declared by Domenica Ann Alf ano,
also known as Mamie Ann Alfano,
the above named Testatrix, 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, all
being present at the same time,
have hereunto subscribed our names
as witnesses:
Address
,~
' -_ Address
- ~~'~m' ~ ( n n ,.,..n , Address
~YLNTl .YD COtlLM
M&T~ank
499 Mitchell Road, Millsboro, DE 19966 Adjustment Services
Phone 888-502-4349
F ax (302) 934-2955
February 7, 2012
Stone LaFaver and Shekletski
POBoxE
New Cumberland, PA 17070
Re: Estate of Domenica Alfano
Social Security: 163-24-8474
Date of Death: October 15, 2011
Dear Sir or Madam:
Per your inquiry on January 25, 2012 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 of)
Opening Date
Balance on Date of Deat{t
Accrued Interest
Total
2. Type of Account
Account Nttmber
Ownership (Names of)
Opening Date
Balance on Date of Death
Accrued Interest
Total
Savings Account
15004211547441
Domenica A Alfano
Joanne Marie Alfano (POA)
Paula Ann Boyer (POA)
0927/04
$3,147. SS
$ .03
$3,14758....
Checking Account
60105448
Domenica A Alfano
Joanne Marie Alfano (POA)
Paula Ann Boyer (POA)
08/31/68
$2, 438.01
$ .0/
$2,438.02
~• Pennsylvania
'• •
DEPARTMENT OF PUBLIC WELFARE
April 23, 2012
STONE LAFAVER & SHEKLETSKI
DAVID H STONE ESQUIRE
414 BRIDGE ST
NEW CUMBERLAND PA 17070
Re: Domenica Alfano
CIS # : 780238551
SSN: ###-##-8474
Date of Death: 10/15/2011
Dear Mr Stone:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of $357,202.26 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 $130,685.64, 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 $226,516.62, 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,
~.:~~.~y
Marianne Meckley
TPL Program Investigator
717-772-6246
717-772-6553 FAX
Enclosure
Bureau of Program Integrity ~ Division of Third Party Liability ~ Recovery Section
PO Box 8486 i Harrisburg, Pennsylvania 17105-8486
COMMONWEALTH Of PENNSYLVANIA
`-----,-_.~ BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX 8486
HARRISBURG, PA 17105-8486
April 5, 2012
STATEMENT OF CLAIM SUMMARY
NAME Estate of ALFANO, DOMENICA
ID 780 238 551
MEDICAL CLASS 3 CLASS 6 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT 18,569.71 .00 18,569.71
LONG TERM CARE 111,982.99 226,313.88 338,296.87
DRUG 132.94 202.74 335.68
REIMBURSEMENT TO DPW 130,685.64 226,516.62 357,202.26
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113
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