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Home My WebLink About01-31-13J 1505611180 REV-1500 ~ lpz-„> (Fi> pennaylvanie OFFIC44L USE ONLY PA Department of Revenue cePMTNERrOFRFVENIIE County Code Year File Number BuresuatlndividualTaxes INHERITANCE TAX RETURN PO BOX 280801 Hartisbum, PA 17128-0801 RESIDENT DECEDENT 2t-1 t-0~s5 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 199-07-9813 D6162011 01151920 Decedent's Last Name Suffix Decedent's First Name MI TRIMMER DOROTHY M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number TH{3 RETURN MUST BE FILED iN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Retum [] 2. Supplemental Retum 0 3. Remainder Retum (Date of Death Prior to 12-13-82) 4. Limited Estate Q 4a. Future Interest Compromise (date of 0 5. Federal Estate Tax Retum Required death aRar12-12-82) 8. Decedent Died Testate 0 7. Decedent Mairnained a Living Trust D 8. Total Number of Sara Deposit Saxes (Attach Copy of WXt) (Attach Copy of Trust) [~ 9. Lidgadon Proceeds Received Q 10. Spousal Paveny Credit (Date of Death [~ 11. Elacdon to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule 0) CORRESPONDENT- TNp SECTIWI MUST BE COMPLETED. ALL CORRESPONDENCE AND CONfl~NTU1L TAX INFORMATION SNOUID BE DNIECTED TO: Name Daytime Tebphone Number STEPHEN D. TILEY r.,; 717-~3-583$° ._, ~ First Line of Address 5 SOUTH HANOVER STREE Second Line of Address City Or POSt Office CARLISLE CorrsspondsnYs a-rrrafl addrss:: State ZIP Code PA 17013 Gp,TER OF WLLLS US 'U ~ ~ ~ ` C - A• f ' `-i Q - ' n ~ r rl .~~ N I Cr t r~ w~~ _~,.i ' ~ ,...- _.T7 .W;J C . ~~7 S .. ..... = ~ ..~ -- V r1 l'~; l ~'" DA -FILED U) ~ Under penaldes or perjury, I dadare that I have examined this return, including aocomparrying schedules and statements, and to the best of my knowledge and belief, R is true, correct and COrtIp1eM. DeGaration of DBOafer other than the personal representative is based On all information Of which preparer has env knowledge. SIGr~E O P,gSON PONSIBLE FOR FILING RETURN DATE ~l~G~ I -3/-J3 AUL R. TRIMMER_ 437 PEAKVIEW ROAD_ YORK SPRINGS_ PA STEPHEN D. TILEY, 5 SOUTH HANOVER STREET, CARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15D5611180 1505611180 J J 1505611280 REV-1500.EX (FI) Decedents Social Security Number DecedenrsName: DOROTHY M TRIMMER 199-07-9813 RECAPITULATION 1. Real Estate (schedule A) ......................................... 1. N 0 N E 2. Stocks and Bonds (Schedule B) ... , ................................ 2. N 0 N E 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... 3. N 0 N E 4. Mortgages and Notes Receivable (Schedule D) ........................ 4. N 0 N E 5. Caah, Bank Deposits and Miscellaneous Personal Property (Schedule E) .... 5. 8 8 7 0 . 0 0 8. Jointly Owned Property (Schedule F) OSeparate Billing Requested ...... . 6. N 0 N E 7. Inter-Vroos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested ...... . 7. NON E B. Total Gross Assets (total Lines 1 through 7) 6 8870 00 9. Funeral Expenses and Administrative Costs (Schedule H) ................ 9. 32 $ $ , Q 0 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ 10. 2 714 5 . 0 0 11. Total Deductions (total Lines 9 and 10) ............................. 11. 3 0 4 0 3 . 0 0 12. Nat Value of Estate (Line 8 minus Line 11) ........................ ... 12. - 215 3 3.0 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................. .... 13. 0 . 0 0 14. Net Value Subleet to Tax (Line 12 minus Line 13) 1a 215 33 00 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 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 4 5 16. 0. 0 0 17. Amount of Line 14 taxable at sibling rate X # # tl 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X # # p 18. 0 . 0 0 19. TAX DUE .................................................... ... 19. 0 . 0 0 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505611280 .1505611280 J REV-1500 EX (FI) Page 3 File Number 199-07-9813 Decedent's Complete Address: 21-11-0795 DECEDENTS NAME DOROTHY M TRIMMER STREET ADDRESS 514 CHERRY STREET CITY CARLISLE STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2; Line 19) 2. Credits/Payments A. Prior Payments 8. Discount (1) 0.00 Total Credits (A + B) (2} 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FIII In box on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. {5) 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 inwme ........................................ .. ^ c. retain a reversionary interest ....................................................................................................................... ... ^ d. receive the promise for life of either payments, benefits or care? ......:......................................................... .. ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without roceiving adequate consideration? ....................................................................................................... ... ^ 3. Dld 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? .................................................................................................................. .. ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN REV-tsoalx+c"''°' SCHEDULE E pennsylvania CASH, BANK DEPOSITS, 8~ MISC. ~IH RT~~E°~ nRN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Dorothy M. Trimmer __ _ _, _ _ _ 21-11-0795 Include the proceeds of litigation and the date the proceeds were received by the estate If more space is needed, use additional sheets of paper of the same size. REV-t511 EX+(10.09) pennsylvania DEPARTMENT OF REVENUE INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS Dorothy M. Trimmer- 21-11-0795 DecedaM'a debts moat be reported on Schedule L A. I FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal RepreaeMatlva(s) Paul R. Trimmer streetAddreas 437 Peakview Road city York Springs state PA zIP 17372 veer(s) Commission Paid: 2013 2. 3. 4. 5. 6. 7. Attorney Fees: Frey 8 Tiley Family F~cemption: (If decedent's address is not the same as Gaimant's, attach explanation J Claimant Street Address City Sate Relationship of Claimant to Decedent Probate Fees: Axountant Fees: Frey & Tiley Tax Return Preparer Fees: Frey & Tiley Register of Wills -Filing Fee for Small Estate Petition 8. Register of Wills -Filing fee for Inheritance Tax Return TOTAL (Also enter on Line 9; Re If more space is needed, use additional sheets of paper of the same size. ZIP Included Included 689 2,500 54 15 REV-1512 EX+(12-08) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN RESIDENT DECEDENT MORTGAGE LIABILITIES 8 LIENS ESTATE OF FILE NUMBER Dorothy M. Trimmer 21-11-0795 Report debts incurred by the decedent prior to death that remained unpaid at the date of loth, including unrelmbuned madkal expenses. REV-1513 EX+ (01.10) Pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Doroth M. Trimmer 2-11-0795 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME ANp ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not List Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS pndude outripM spousal dlsVitluBOns and transran under Sec. 9118 (a) (1.2).] 1 ~ Paul R. Trimmer, 437 Peakview Road, York Springs, PA 17372 Son 100 Percent ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUG H 18 OF REV-1500 COVER SH EET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTKNS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 8. CHARRABLE AND GOVERNMENTAL DISTRIBUTIONS: L TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-7500 COVER SHEET. ; 0.00 it more space is neeaec, use ac0itionai sneers or paper o(me same size. -~1 sV1.$~l' ~3~~~c ACCOUNT N0. ACCOUNT TYPE 730912 M&T SELECT KITH INTEREST .STATEMENT PERIOD PAGE JUN.04-.1UL.01,2011 1 OF 2 00 0 04319N NM I17 13659 DOROTHY M TRIMMER 437 PEAK VIEW RD YORK SPRINGS PA 1737 2 INTEREST EARNED FOR STATEMENT PERIOD 0.05 INTEREST PAID YEAR TO DATE 0.42 ArrnnuT c+nuuwnv HIGH STREET-CARLISLE _ > : ,, _.. BA E OTHE . ' IT ':: i CHECK3:'PA ` : YRACTtdlts ER t PD ..' .::BA `ANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 8,025.61 6 .42 , .60 0 0.60 0.05 7,879.48 AI.I.UUn1 ALI1V1iY _:... _ * is 06-04-11 BEGINNING BALANCE i8, 025.61 Ob-16-11 CHECK NUMBER 6899 1,507.60 6,518.01 06-..^.7-11 DEPOSIT 52.65 6,570.66 OZ-pl-11 US TREASURY 312 XKCIV SERV 1,308.77 07-U1-11 INTEREST PAYMENT 0.05 7,879.48 ENDING BALANCE 17,879.48 ~HECKSPAID SU1k1ARY ~i899 06-16-11 1,507.60. ANNUAL PERCENTAGE YIELD EARNED = 0.00 MANT TO TAKE ADVANTAGE OF LON MORTGAGE RATES? RAISE THE GREEN FLAG. MITH TODAY'S LON RATES, NON•S THE TIME TO CONSIDER A MORTGAGE NITH MiT. MHETHER YOU•RE LOOKING TO PURCNASE A HOMES RENOVATE OR REFINANCE-NE HAVE OPTIONS THAT ARE RIGHT FOR YOU. TO LEARN MORE, CALL 1-800-557-0535. FOR CUSTOMER SERVICE WESTIONS, PLEASE CALL 1-800-724-2440. «~~ ..- ... _. .. ... __ g . , .: ~. :~ ~~ V Forest Park Health Center 700 Walnut Bottom Road Carlisle, PA 17013 (888)880-7090 STATEMENT Resident: Trimmer, Dorothy (23175) Location: - Statement Date: 7/1/2011 ALL TRANSACTIONS PROCESSED AFTER Jun 30, 2011 WILL APPEAR ON YOUR NEXT STATEMENT Paul Trimmer 437 Peak View Road York Springs, PA 17372 Amount Due $0.00 PLEASE DETACH AND RETURN WITH YOUR PAYMENT Amount Enclosed $ Forest Park Health Center Resident: Trimmer, Dorothy (23175) 700 Walnut Bottom Road Location: - Carlisle, PA 17013 Statement Date: 7/1/2011 (888)880-7090 ffective Date Description Units Unit Amount Amount BALANCE FORWARD $1,607.60 6/1612011 Payment -#6899 ($30.00) 6/16/2011 Payment ($1,477.60) BALANCE DUE $0.00 PLEASE CALL WITH ANY QUESTIONS: 888-880-7090 TRACI EXT. 872 '.8" Pennsylvania DEPARTMENT OF PUBLIC WELFARE April 5, 2012 FREY & TILEY STEPHEN D TILEY ESQUIRE FIVE SOUTH HANOVER ST CARLISLE PA 17013 Re: Dorothy Trimmer CIS #: 150269051 SSN; ###-##-9813 Date of Death: 06/15/2011 Dear Attorney Tiley: Please be advised that the Department of Public Welfare maintains a claim in the amount of 325.636.60 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 $25.636.60, 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 S.OO, 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, /J/~ Patricia Nace TPL Program Investigator 717-772-6617 717-772-6553 FAX Enclosure b~lT "fii" Bureau of Program Integrity i Division of Third Party Liability i Recovery section PO Box 8486 y HaMsburg, Pennsylvania 17105-8486