HomeMy WebLinkAbout04-18-13 .j REV-1500 6X(02-11) 1505610143
PA Department of Revenue OFFICIAL USE ONLY
p pennsytvania covey cone veer File Number
Bureau of individual Taxes °a"NiMF1i0F"°"°"W
PO BOX.280601 INHERITANCE TAX RETURN 21 13 0083
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
01 05 2013 02 09 1923
Decedents Last Name Suffix Decedent's First Name MI
WRIGHTSTONE FRANCES E
(if Applicable)Enter Surviving Spouse's Information Below j
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE PILED 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)
El 4. Limited Estate 4a.Future Interest Compromise 5, Federal Estate Tax Return Required
(date or death after 2-12-82)
® a Decadent Died Testate T Dace�erplt Maintxxmer a Living Trust _� 8, Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Arta Gopy of Tm8)
9. Litigation Proceeds Received El to.=S 12 3i-Ta� tltDet�e m Oeain 1 i.Election to tax under Sao.9113(A)
(Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JAMES D BOGAR (717) 737 8761
RE00TAR OF WILLS UgGWLY
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First Line of Address rn °J
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ONE WEST MAIN STREET sy Zc 1='t co
Second Line of Address c VM,
y.^DATE PMED I= �
City or Post Office State ZAP Code ..
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SHIREMANSTOWN BA 17011 vi
Correspondent's e-mail address: ibogar @bogariaw.aom
Under penalties of perjury,I declare that I have examined this return,including accompanyind 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.
S R OF PERSON^SPONStBLE FOR FLING RETURN DATE
James D. Bo gar
ADDRElIS
One West Main Street Shiremanstown PA 17011
SIGN E OF PREP ER ER THAN REPRESENTATIVE DATE
James D.Bogar t{(ls�lt
ADDVSS
One West Main Stree , Shiremanstown, PA 17011
Side 1
L 1505610143 1505610143
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J 1505610243
REV-1500 EX
Decedent's Social Security Number
Dec wt's Name. Wrightstone, Frances E.
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. I.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 7 , 140 . 68
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6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested......... 6.
7, Inter-Vivos Transfers&Miscellaneous Non,-Probate Property I
(Schedule G) u Separate Billing Requested............ 7,
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8. Total Gross Assets(total Lines 1 through 7).,....... .......... ......... ........... 8. 7, 140 . 68
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9, Funeral Expenses and Administrative Costs(Schedule H)................ ................... 9. 2 , 710 . 22
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 15, 658 . 60
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 18 ,368 . 82
12. Net Value of Estate(Line 8 minus Line 11)_....._................................................. 12. -11,228 . 14
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. -11,228 . 14
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 15 0 . 00
(a)(1.2)X.00
16. Amount of Line 14 taxable 0 .00 1s. 0 . 00
at lineal rate X _045
IT Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable 0 . 00
at collateral rate X.15 0 . 00 18,
19. TAX DUE............... ........ ............. ................._................... 19. 0. 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
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Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21-13-0063
Decedent's Complete Address:
DECEDENT'S NAME
Wrightstone, Frances E.
STREETADDRESS
4637 E.Trindle Road
CITY � STATE ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2, CreddsiPayments
A. Prior Payments
B. Discount 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. (4)
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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. (5) 0.00
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Make Check Pa able 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;......... ................... x
b. retain the right to designate who shall use the property transferred or its income:.,,............ ...........
a retain a reversionary interest;or-.,.......................................................... ...... ....._................. x
d. receive the promise for life of either payments,benefits or care?..... ..................................................... x
1 if death occurred after Dec. 12, 1962, 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
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?.................................................................................................................. ❑ 51
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 is 3 percent[72 P.S.§9116(a)(1.1)(1)].
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 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)(12)].
• 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(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 by blood or adoption.
Rey-15D8 EX.(11-10)
SCHEDULE E
Pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT TAX REVENUE
RET URN RN PERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Wrightstoner Frances E. 21-13-0083
Include the proceeds of litigation and the date the proceeds were received by the estate
Alt prop"jo fly-amted whit the right of survivorship neret be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
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1 Cedar Haven-balance of funds in trust account 416.05
2 Citizen's Bank-Checking Account No.6100716732;principal balance at date of death 6,724.63
$6,724.57;accrued interest$0.06
3 Personal Property-The decedent had no personal property of any value,as she had been in 0.00
nursing home facilities for approximately five years at the time of her death.
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TOTAL(Also enter on Line S.Recapitulation) 7.140.68
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10)
Citizens a n k One Citizens Drive
ROP 112
Riverside, R102915
February 8,2013
James D Bogar
One West Main St
Shiremanstown PA 17011
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Estate of FRANCES E WRIGHTSTONE
Date of Death: Jan 05, 2013
SSN: 204-03-4735
Dear Sir/Madam:
In accordance with your request,the attached information sheet has been provided in the above decedent's
name as of his/her date of death. As per your request,none of the decedent's accounts seemed to be"roll-
over" accounts. As for the titles of accounts when they were opened,account ending in 3634 has always
been titled as such. For account ending in 6732,the account was converted from Mellon Bank on 2002 as
a joint account but became individually titled as shown on the attached worksheet on May 18,2006. For j
all other inquiries, please call 1-877-579-2667.
Since 1 ,
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Decedent Accoun ocessing
REF#: 578250
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Citizens Bark
A
Accouunt Number 6100716732
A' ccount Title Frances E Wrightston
Date Opened 6/6/1966
Account Type Checking
Principal Balance as of DOD _ $6724.57
Interest from Last Posting to DOD $ .06
Account Balance as of DOD $6724.63
Yl TD Interest to DOD $ .00
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let Citizens Bank .
Account Number
Account Title 6254223634
Date 101 pened Frances E Wrightston
Account T e V 3!1612011 `
Princi at Balance as of DOD — Savings
Interest from Postin to DOD — $ OQ — -- _
Account Balance as of DOD $ '00
YTD Interest to DOD
$ AQ — I
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REV-1611 EX.110A9)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
RESIDENT ED RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Wrightstone, Frances E. 21-13-0083
Decedent's debts must be reported on Schedule L
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
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See continuation schedule(s)attached 52D.16
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B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
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Street Address
City State Zip
Year(s)Commission Paid j
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2. Attornev's Fees Boger& Hipp Law Offices 1,995A0
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3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
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Street Address
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City State ZiD
RelationshiD of Claimant to Decedent
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4. Probate Fees 133.50
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5. Accountant's Fees li
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6. Tax Return Preparer's Fees
7. Other Administrative Costs 61.56
See continuation schedule(s)attached
TOTAL(Also enter on line 9,Recapitulation) 2,710.22
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10.09)
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SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Wrightstona Frances E. 21-13-0083
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Maipezzi Funeral Home-funeral bill 520.16
H-A 520.16
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Other Administrative Costs
2 Advanced Podiatry Services, LLC -medical bill 36.70
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3 Fredericksburg Community Health Center-medical bill 24.86
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H-B7 61.56
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Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1600 Schedule H(Rev.6-98)
Rev-1512 EX-(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Wri htstone Frances E. 21-13-0083
Report debts Incurred by the decedent prior to death that remained unpaid at the data of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Pennsylvania Department of Public Welfare-claim for restitution of medical assistance per 15,658.60
attached letter
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TOTAL(Also enter on Line 10,Recapitulation) 15,658.60 1
(H more space i8 neetled,additional pages of the same size)
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Copyright(c)2008 form software only The Lackner Group, Inc. Farm PA-1500 Schedule I(Rev. 12.08)
pennsylvania
❑EPART ME NT OF PUBLIC WELFARE
February 12, 2013
JAMES D BOGAR ATTORNEY AT LAW
ONE W MAIN ST
SHIREMANSTOWN PA 17011
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Re: Frances Wrightstone
CIS #: 560328392
SSN: ###-##-4735
Date of Death: 01/05/2013
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Dear JAMES D BOGAR:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of $15,658,60 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 $15,658.60, 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.00, 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.
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Sincerely,
Marianne Meckley
TPL Program Investigator
717-772-6246
717-772-6553 FAX
Enclosure
Bureau of Program Integrity i Division of Third Party Liability i Recovery Section
RD Box 8486 h Harrisburg, Pennsylvania 17105-8486
COMMONWEALTP OF PENNSYLVANIA
BUREAU OR PROGRAM INTEGRITY
DIVISION OF THIRD PART\'LIABILITY
RECOVERY SECTION
PO BOX 8486
HARRISBURG,PA 1713c We
February 1, 2013
STATEMENT OF CLAIM SUMMARY
NAME Estate of WRIGHTSTONE, FRANCES
ID 560 328 392
MEDICAL CLASS 3 CLASS 5.1 TOTAL
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INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 15,658.60 .00 15,658.60
DRUG .00 .00 .00
REIMBURSEMENT TO DPW 15,658.60 .00 15,658.60
COMMONWEALTH OF PENNSYLVANIA:
DEPARTMENT OF PUBLIC WELFARE
- EIN- 23-6003113
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Page 1 of 2
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 1,2013
STATEMENT OF CLAIM
NAME WRIGHTSTONE,FRANCES
ID 560 328 392
LEBANON CO COMMRS
590 S 5TH AVE
LEBANON PA 17042
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUALCHARGES AMOUNT APPROVED
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10/14112 - 10/31112 01/24/13 55130244110860001 55130244110860001 3,549.60 3,549.60
DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2 : 29410 DSM DEMENTIA IN COND CLAS
PROC CODE : 000000
11/01/12 - 11130/12 01/24113 55130244110730001 55130244110730001 5,916.00 5,680.00 I,
DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE li
DIAGNOSIS 2: 29410 DSM DEMENTIA IN COND CLAS
PROC CODE : 000000
12101112 - 12/31/12 01/24/13 55130244113540001 55130244113540001 6,113.20 5,877.20
DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2 : 29410 DSM DEMENTIA IN COND CLAS !!
PROC CODE : 000000
01/01/13 - 01105113 00 100 100 00000000000000001 551.80 551.80
DIAGNOSIS I : ESTIM !!
PROC CODE : W0305 CASE MIX III
PROVIDER SUBTOTAL LEBANON CO COMMRS 16,130.60 15,658.60
03 100004862 0009
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Page 2 of 2
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REV-1513 EX.(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Wri htstone, Frances E. 21-13-0083
NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER
PERSON(S)RECEIVING PROPERTY (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal Do Not List Timsteelali
distributions,and transfers
under Sec.9116(a)(1.2)]
Hope E. DeFrayne Friend Ten percent of
15 N.Stoner Avenue rest, residue and
Shiremanstown, PA 17011 remainder
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Anne M. Hubbard Friend Forty-percent of
PO Box 350 rest, residue and
133 Twin Creek Drive remainder
Jonestown, PA 17038
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Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet as appr o nate.
NON-TAXABLE DISTRIBUTIONS,
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
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B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1 Messiah College 0.00
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TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE 0.00
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev. 01-10) '�
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LAST WILL AND TESTAMENT
of
FRANCES E. WRIGHTSTONE
I, FRANCES E. WRIGHTSTONE, of Shiremanstown, Cumberland
County, Pennsylvania, make, publish and declare this as and for
my Last Will and Testament, hereby revoking all other Wills and
Codicils heretofore made by me.
FIRST: I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
including any property over which I hold power of appointment and
together with any insurance policies thereon, as follows:
(A) Ten (10%) percent thereof to my friend, HOPE E.
DeFRAYNE, of 15 North Stoner Avenue, Shiremanstown, Pennsylvania,
provided, however, that should she predecease me, then to her
issue per stirpes by representation.
(B) Forty (40%) percent thereof to my friend, ANNE M.
HUBBARD, of 394 East Front Street, Lewisberry, Pennsylvania,
provided, however, that should she predecease me, then to her
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`t, husband, JAMES F. HUBBARD, of 394 East Front Street, Lewisberry,
Pennsylvania.
(C) Fifty (50%) percent thereof to MESSIAH COLLEGE, of
Grantham, Pennsylvania, to be used to establish a scholarship
fund, in my name, for needy students, the establishment and
administration thereof to be in the sole and complete discretion
of MESSIAH COLLEGE.
SECOND: In addition to all powers granted to them by
law and by other provisions of this Will, I give the fiduciaries
acting hereunder the following powers, applicable to all proper-
ty, exercisable without court approval and effective until actual
distribution of all property:
(A) To sell at public or private sale, or to lease,
for any period of time, any real or personal property and to give
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options for sales, exchanges or leases, for such prices and upon
such terms (including credit, with or without security) or
conditions as are deemed proper. This includes the power to give
legally sufficient instruments for transfer of the property and
to receive the proceeds of any disposition of it.
(B) To partition, subdivide, or improve real estate
and to enter into agreements concerning the partition, subdivi-
sion, improvement, zoning or management of real estate and to
impose or extinguish restrictions on real estate .
(C) To compromise any claim or controversy and to
abandon any property which is of little or no value.
(D) To invest in all forms of property, including
stocks, common trust funds and mortgage investment funds, without
restriction to investments authorized for Pennsylvania fiduci-
aries, as are deemed proper, without regard to any principle of
diversification, risk or productivity.
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments.
(F) To exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, gift and estate or inheritance tax
laws.
(G) To make distributions to my herein named benefici-
aries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in order
{ to pay debts, taxes, or estate or trust administration expenses,
to protect or improve any property held under my will, and for
investment purposes.
(I) To select a mode of payment under any qualified
retirement plan (pension plan, profit sharing plan, employee
stock ownership plan, or any other type of qualified plan) to the
extent the plan or the law permits them to do so, and to exercise
any other rights which they may have under the plan, in whatever
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manner they consider advisable.
THIRD: I direct that all inheritance, estate, trans-
fer, succession and death taxes, of any kind whatsoever, which
may be payable by reason of my death, whether or not with respect
to property passing under this Will, shall be paid out of the
principal of my residuary estate.
FOURTH: All interests hereunder, whether principal or
income, which are undistributed and in the possession of the
fiduciaries acting hereunder, even though vested or distribut-
able, shall not be subject to attachment, execution or sequestra-
tion for any debt, contract, obligation or liability of any
beneficiary, and furthermore, shall not be subject to pledge,
assignment, conveyance or anticipation.
FIFTH: I nominate and appoint JAMES D. BOGAR, Execu-
tor, of this, my Last Will and Testament. In the event of the
death, resignation or inability to serve for any reason whatso-
ever of the said JAMES D. BOGAR, I nominate and appoint ANNE M.
HUBBARD, Executrix of this, my Last Will and Testament. I direct
that my Executor or Executrix, as the case may be, and their
successors, shall not be required to post security or a bond for
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the performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal to this, my Last Will and Testament, this :3rd' day of
2000.
ssyy y,�f N_.�E.
t7Y, Wt . f/1L 27 Lcxcc (SEAL)
FRANCES E. WRIG STONE ,
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Signed, sealed, published and declared by the above-
named Testatrix as and for her Last Will and Testament in our
presence, who, at her request, in her presence and in the
presence of each other, have hereunto subscribed our names as
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attesting witnesses.
Address
Address 4
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