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Home My WebLink About08-09-12 (2)--~ REV-'~ 5 Ex (o1-10> 1505610143 00 OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes DEPARTMENT OF REVENUE COUntyCode Year File Number Po Box.28oso1 INHERITANCE TAX RETURN Harrisburg, PA 17128-OS01 RESIDENT DECEDENT 2 1 0 9 0 0 7 13 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 198 22 8538 06 15 2009 05 18 1930 Decedent's Last Name Suffix Decedent's First Name KIMMEL MI LOUISE R (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 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 death after 12-12-82) ^ 5. Federal Estate Tax Retum Required ^ g. Decedent Died Testate ~ Decedent Maintained a Living Trust (Attach Copy of Wili) ^ (Attach Copy of Tn,st) 8. Total Number of Safe Deposit Boxes ^ 9. Litigation Proceeds Received ^ 1 p. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) ^ 11.Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATIO OULD BE DI~ECTED TO: Name Daytime Telephon tmJber t;,~ SAMUEL L ANDES 7 17 7 61 x ~~ ~~'~ ~; 1 C r--~. ~. c~ ,~. ,~1 ,,._ _. REGISTER OF C9 USE ONE ' ' ' ' ' ,~ ,.. - ~. ,_.. First line of address C7 C.:: Q ~.. .~, ~ -; ; 525 NORTH 12TH STREET -p-yJ t~ ,`- C ,~. i-- r-fi.t Second line of address v z ~ ~f 3 City or Post Office State DATE FILED ZIP Code LEMOYNE PA 17043 Correspondent's a-mail address: l a w a n d e s@ a o l. c o m 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. SIGNAL' OF PERSON RESPONSIBLE O ILING RETURN ~,-.''' L/ .~,~. DATE ~ J '~---~~~.~• ,~• s~-..c~~~~~., Brian K Peters ADDRESS 1136 State Road, Duncannon, PA 17020 L 1505610143 1505610143 ~~ h<<,~ ~~~ i~vrin ~ stn Street, Lemoyne, PA 17043 Side 1 J 1505610243 REV-1500 EX DecedenYsName: ICIMMEL, LOUISE ROMAINE 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 & Notes Receivable (Schedule D) .......................................................... 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5. 6. 7. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ............. 6. 7. 8. Total Gross Assets (total Lines 1-7)......... .............................................................. 8. 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 11. Total Deductions (total Lines 9 & 10) ...................................................................... 11. 12. 13. Net Value of Estate (Line 8 minus Line 11) ............................................................. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................. 12. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................. 14. Decedent's Social Security Number 198 22 8538 152,520.64 207.93 152,728.57 99,939.41 99,939.41 52,789.16 52,789.16 ~ ~ ~umru iATIaN -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. 16. Amount of Line 14 taxable at lineal rate X .045 5 2 , 7 8 9.16 16. 17. Amount of Line 14 taxable at sibling rate X ,12 17 18. Amount of Line 14 taxable at collateral rate X .15 1 g• 19. Tax Due ...................................................................................... ............................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 2,375.51 2,375.51 1505610243 J REV-1500 EX Page 3 File Number 21 - Og - 0071 3 Decedent's Complete Address: Kimmel, Louise Romaine STREET ADDRESS 1069 Allendale Road, Apt. F CITY Mechanicsburg STATE zIP PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments (1) 2,375.51 A• Prior Payments B. Discount Total Credits (A + B) (2) 0.00 3. Interest (3) 190.19 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2 5 6 5 7 0 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 .............. ^ ^ ............................ ..................... ......................... x ... ..... .................. receive the promise for life of either a benefits or care?...... P yments, ...................................................... 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 fog" 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 AS PART OF THE RETURN. ____T__ ____~-_._ _----__-~.-- .. .. -.~. w`~c3;. - v'a.`.._:, ,. 1 :.: sae . a,..,. -'_ ..,,-.---- ...~ For dates of death on or after Jul 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net~value of transfers to or for the use of the sunnving ~~~ spouse is 3 percent [72 P.S. §91 ~6 (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 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 ya jjs 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) . A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether y bloo~ or adoption. SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERffANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Kimmel, Louise Romaine FILE NUMBER 21 - 09 - 00713 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Proceeds of personal injury/wrongful death action in the matter of Brian Peters, Executor of the 152,020.64 Estate of Louise R. Kimmel vs. Pinnacle Healthcare System, Pinnacle Health Hospitals t/d/b/a Pinnacle Health at Harrisburg Hospital, Katrina B. Cuartero, R.N., and Tara L. Bellamy. Gross recovery including delay damages but before costs and expenses (see Distribution Sheet attached): 2 I Miscellaneous items of furniture, clothing and other personal effects I 500.00 TOTAL (Also enter on Line 5, Recapitulation) I 152,520.64 1 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~~~h~~vr Kimmel, Louise Romaine SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER 21 - 09 - 00713 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANTS} NAME Brian K. Peters A JOINTLY OWNED PROPERTY: ADDRESS 1136 State Road Duncannon, PA 17020 RELATIONSHIP TO DECEDENT Son ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT C~F~SCRIPT.lO~ C~F PRO~'ERTkY Include name o Inanclal Ins I u Ion an ban account numbe or similar identifying number. Attach deed forjointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST A Dec. 2007 Checking Account no 206867-8 with . Commerce Bank (now Metro Bank) 415.85 50% 207.93 i VTAL (Also enter on line 6, Recapitulation) I 207 93 R ,N SCHEDULE H COMMONWEALTH OF PENNSYLVANIA "" `~ DCPENSES INHERITANCE TAX RETURN w ~ A'~ RESIDENT DECEDENT /•y,~V' ESTATE OF Kimmel, Louise Romaine FILE NUMBER 21 - 09 - 00713 Debts of decedent must be reported on Schedule I. ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A• 1 Musselman Funeral Home (funeral expense) 4,629.00 2 Rolling Green Cemetary (headstone) 535.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Brian K. Peters 3,225.00 Street Address 1136 State Road city Duncannon state PA zip 17020 Year(s) Commission paid 2012 2. Attorney's Fees Samuel L. Andes 3,800.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wills 69.00 5. Accountant's Fees 6. ~ Tax Return Preparer's Fees 7. Other Administrative Costs 1 Cumberland Law Journal (advertising) 75.00 TOTAL (Also enter on line 9, Recapitulation) 99,939.41 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Kimmel, Louise Romaine The Sentinel (advertising) Schedule H Funeral E~enses & Adminish~ve Cos~Cs c~ntinulEd FILE NUMBER 21 - 09 - 00713 155.68 Disbursement of funds from personal injury/wrongful death recovery. See Exhibit A I 87,450.73 attached hereto) Page 2 of Schedule H REV-1513 EX+(11-08) ' SCHEDULE J COMMO ERITA CEOTAX RETURNANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Kimmel, Louise Romaine 21 - 09 - 00713 NAME AND ADDRESS OF PERSONS RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER RECEIVING PROPERTY () DECEDENT (Words) (~~~) Do Not List Trustee(s) I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) 1 Stewart Peters 813 Market Street Duncannon, PA 17020 son 1/6th 2 Mark S. Peters 15 Sam Snead Circle Etters, PA 17315 3 Tina L. Peters 828 Bosler Avenue Lemoyne, PA 17043 son daughter 1/6th 1 /6th Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 coverlsheet, as appropriate. III 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 COVER SHEET 0.00 REV-1513 EX+ (9-00) ' SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Kimmel, Louise Romaine NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY FILE NUMBER 21 - 09 - 00713 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT (Words) ($~$) Do Not List Trustee(s) I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) 4 Chris A. Peters 408 Alison Avenue Mechanicsburg, PA 17055 son I 1 /6th 5 Vanessa A. Peters 408 Alison Avenue Mechanicsburg, PA 17055 6 Brian K. Peters 1136 State Road Duncannon, PA 17020 daughter ~ 1/6th son I 1 /6th Page 2 of Schedule J angino-rovner d5O3 1~TORTH FRONT STREET HARRISBURG, PA 17110-1799 RICHARD C. •1NGINO \TEIL J. ROVNER PHONE: (717) 238-6791 FA\: (717) 238-5610 DAVID L. LuTZ 1~'IiCHAEL E. KOSIIC RICFIARD [~-. SADLOCI\ LISr\ 1\'1. 13. ~VOODBURN DARYL E. CIiRISTOPIIER 1~RIS'1'EN V. SINISI w~vw'.angino-rovn er.com E-mail: dchristopher rr angino-i•ovner.com BRIAN PETERS ADMINISTRATOR of the ESTATE of LOUISE KIMMEL v. TARA BELLAMY PINNACLE HEALTH SYSTEM PINNACLE I~[EALTh HO SPITA LS t/ci/b/a PINNACLE HEALTH AT HARRISBU~tG IiOSP1TAL DISTRIB~JTION SHEET TOTAL AMOUNT OF VERDICT PLUS DELAY OF DAMAGES $142,824.00 TOTAL AMOUNT RECOVERED $9,196.64 $152,020.64 DEDUCTIONS: Attorney's Fee (40%) _$60,808.26 Balance $91,212.38 Reimbursement of expenses paid by attorneys to others for records, experts, etc. $24,464.79 Balance $66,747. S9 Reimbursement of liens Medicare $2,146.66 DPW $31.02 Total liens $_ 2,177.68 BALANCE TO CLIENT PLUS ANY INTEREST EARNED WHILE HELD IN BANK ESCROW $64,569.91 FINAL DIVISION: Attorney's Fee $60,808.26 Client's Balance $64,569.91 Reimbursement of Expenses $24 464.79 Reimbursement of Medicare lien $2,146.66 Reimbursement of DPW lien 31.02 This settlement/verdict may be taxable. We recommend that you COllSlllt yolll' aCCOlilltailt or tax attorney for the calculation of your tax liability and any deductions to which you may be entitled. WARRANTY AND NOW, this ~~~.. ~ ~ day of ~,_~;-, ~ 2012, I acknowledge that Ihave apps oved and obtained a copy of this Distribution Sheet. I ful-ther acknowledge that the above balance constidtetesood, total reulibursement for medical expenses, wage losses, pain and suffering and any other losses sustained or claims resulting from our accident. I warrant that if there are any outstanding medical bills, child support al-rearages or claims other than as set forth above, they will be my responsibility; Ifurther warrant that I will pay any outstanding Blue Cross, Blue Shield, Public Assistance; Medicare/Medicaid, medical subrogation liens or any other liens a~~.d expenses not noted above. ~,,,,..---~- { ~ s sue' j f ! '"''~~ j WITI~E ' ~BRIAN~PETERS, ADMINISTRATOR of the ESTATE of LOUISE KIMMEL X00471 Estate of Louise R. Kimmel File No. 21-09-00713 EXHIBIT A Expenses paid from recovery from personal injury/wrongful death action: Attorney's fees paid to Angino &Rovner Reimbursement to Angino &Rovner for exp records duplication, deposition transcripts, Payment of Medicare lien Payment of Department of Public Welfare li TOTAL $60,808.26 pert witness fees, and the like $24,464.79 $ 2,146.66 en 31.02 $87,450.73