HomeMy WebLinkAbout10-29-13 (3) i
� 1505610143
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PA Departm�i at Reverwe � 4FFICIAI.USE ONLY
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Pasox2a4sa� tNHERiFANCETAXRETtiRN �1 12 0440
Har�abug.Pn �7i2e-oso� RESIQENT DECEDENT
ENTFA DECEDEXT NIP�tMATiON BECQW . .
Socia!Secuulry N�mber Date at oeath oate oi BiM
as 2s Zoi2 os is i��9
6eced�fYS Las[Name Sutfix �eced�CS First Name MI
CLE6G LORI A
�{b Appltcable)Enter Survivtng Spouss's Mformatfon Balow - -
Spouse's Last tJame . SufRx Spouse's First N2ma MI
Spouse's Socisi Security Number �{�g��RN MUST$E Ftl$D IN DUPLICATE WITH THE
REGISTER OF 1M!!.S
FIIL 1N APPROPRlATE OVAL8.BEI..QW
Q t. qlgtrw Rriwm [� 2.. tiehm . [� 8. Remek+dM rtsam i�au ot o�h � .
, Pdo�t b 12-4382)
' � 4.LFmItedEstste . ❑ 4s`id�af�aRar12-1R�et) ❑ 6. FederdEStaWT�xitaNnRWW�ad
� S' (A�CqaydxnM) ❑ T. y�mmcory�lt�9T� � B. TotaiNumbxMSeMDaPOeR9m�es
❑ a.uuc�nam�ae�r�ee�w«t ❑ �o.�,,,,'"",g�i'�`{�„°"" ❑ ��.�,nromxw�dasec.e��a�a�
t�.�"47
CQRRE$PONDENT-TH18$ECTIDN MUST yE COMPLETED.ALL CORREBPOMDEMCE AND CONfiDEN7UL 7AX NJFORMA7K7N$FIOULD BE DN2EC7E6 TO:
Neme . . ' �3yNIM T918JNIbtf!NtlrtkbN '
J�3 T YING3T E3QUIRE 7I7 B32 5315 �
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RE6��F NflLi�1SE�ItGD
a� -:� --� ct� �
_ . �r.� -�- e-s �,..y ry
Flrstlina�Addr�as rc% = �.._ �,� .�,..� t'��
. .f�— " :;�7 (D ,„7 "—�
48 YORK STREET �..,: <� _' '
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Second Lins of Address ...-, 3 _.� -n '�.
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W� v�Fl u� o
Clty or PoH OHke StaM ZIP Cods , t0
HANt?V'ER PA I7331
cwnsponarn�a a�naq ad�s: Jarrresy�gnyh.cam
ura.rv.�wiwa i inws w.�n. rd rd mm.wnamy do�.oau.nsr,
diebue.ca�actaM�ieM.�M�tlrntl+sry�repro�w w��onM6�i��dwhlehMePrartrsanit�krwM�dpe. ee
VYHl�t D.C
�ooaess
346 Foxi Drpre.Hanowr.PA 1T337
c�a�au�eonsentiw e u�re
�" Jarnes T.Yingst Esquire
44 Yarlc 3baet,Hanaver,PA
SWe1
� 1505614143 1505610Z43 ,,,�,J
�
J 1505610243
ftEV-t500 EX
deceAeni's 5odal Security Number
��'•� Ciegg, Lori A.
RECAPISULATION
. 1. Resi Estate(Scheduie Aj.................................................................._...,............... t.
2. Siadcs and Bonds(Schedule B)..........._........................................................_...... 2.
' 3. Cbsely Neld Cor{wra8on,Partne�ship or Sde-Propr�Orshlp{Sdiecfute C)......... 3. ' : .
4.�bbrtgeges&Notes Receivable{SChedule D}........................................................ 4. . .
5. Cash�BaMC Dapasiis 8 A9isceifaneous Persortai AropertY(Schedule E}............... 5. �1 O$� 63O.45
� 8. Jdntly Owned Properiy{9ctsedule F} ❑ Saparete SiNin9 Recrissted............ �8. .
7. Inter-Vhros 7rar�sfers 8 F#sceilanerws Proba#e Pro erty .
{scr,�dwe G� � secerote s�nmc RBa�eea............ �.
s. 'raar cross nsaae:ttaat ur�es�n,roi,gn�.................................:........:...........:. a. 14 9,83Q.45
9. Funerai�xpenses and Admintsvative Costs ischedu�e ti).................................... 9. 16 J 375.58
�o. o�rrs a�dent.Mort�ase�ianmaes ana uens(sched�,ia q............................ �o. 7 ,07 6.73
n. Taw osa�ct;a�s{mta�unes s and in}........................................................_...... ». 23,452.31
12. Nat Vsiw af EstMa(Line 8 minua Une i i�:...............:....................._........_......._ 12. 8 6�178. I4
13. Ch�ritabie and C�dvenxlieilhal BequestslSeC 8113 Tntsts for whir.h
an eiectlon lo tax has rat be�n mada(SCheduls J}.............................................. 13.
14. Nat Valua Su4Ject W Tmc{Ltna f2 minus Une 13�........»............._...................... 14. 8 B i 17 f,!. 1$
TAX COMPIl1'AT10N-SEE INSTRUCTIONS FOR APPLICABl.E RATES
15. Amount of Line 14 fa�able
ffi M�e sppusal tax rdte.ar .
transfeia uMer Sec.9116 ' � '
(axt 2}X.06 . 15. O .00
18. AmouM of Line 74 faxaMe 8 6 178 .14 16. 3�$7 8.02
at tlneai rate X .045 �
t�. Amamt of Une t4 fa�ble
atsibNrgraeex.�2 0 . 00 �7. 0. QQ
16. AmountOf W�e 74 Fa%able
atcdleleralratsX.75 4,OQ is. 0.00
19. TAX DUE.......................................»..„....,.........................................._..................19. � $�$T8.02
20. Flll IN THE OVAL IF YOU ARE REGUESTIN6 A REF!!ND Ol°AN 4VERPAYMENT. �
Stda 2
� 3SD561U243 150563D243 �
REV-1500 EX Pege 3 Ftle Number 21-12-44A0
DecedenPs Comptete Address:
DECEDENTS NAME
Clegg,6ari A.
BTREETADDRESS
31b B Rosemom Avenue
CITY STATE Z1P
New Cumberland PA '17070
Tau Paymenks and Credits:
�. Tax Due(Fage 2.Lirre te} (1) 3,87$_02.
' 2. credifsJPayments . � . . .
A Prior Paymenb3 ' , �
B. Diswunt 0.00
, . TWat Credlts{A +8y (2} i1.8Q
3. Intmest � . (3) .
4. U Line 2 Is graeter'tl�l.lne t+Lkur 3.eMer @re"�ence. St�s fs the OVERPAYMENT. (4)
Cfrock box on Pa�2.Una 2Q ta nqusst a rohm�!
5. H Line 1 +Llne 3 Ls�t�fhart Line 2.enter tlre dlRerence. This Is U�e TAX DUE. {5} $�$7$.�'Z
Make Ghecic Pavabie to: RE+�ISTER OF WIU.S.AGENT.
PLFABE AHSWER 7HE FOILOMViNG QllESTiON3 BY PLACiNG AN"X"iN THE APPROPRIATE 9LOCKS
7. iNd decedent meke a transfer and: Yq No
a. re�M Mre use ar incane oi Cie WoPartY traroferred:.......................................„................„........._.........
b. retain Me rigl�t b deslgnaM xArn shaN use Ihe ProPeKY transfetred a`ita irxwme:..................»......_......
a rataln a reversicrary�Meresk or_................_..................._............_....................._........................._......
d. rmceWe tlre p�omixe ku IHa of Ntl�er paymeMB,6enelNs or c�e?....................................................:.......
2. If daath accured aRer Qec. 12, 19&2, dk decedent transfer property wNhin wre y�r of death w�tt'�oet
rrx�lvk�g adeQuete annBM9tatbn?..................................._......................,........................................................❑ �
3. DM decedent own an Yn 4trat to�' or PaYabie upon desth baMc accourd or searity at his ar her deaih?....... ❑ [�
4. Did�ent own an indvMuai retlrem�t�cbw.rn4 annuity,a oUier nor►probate property wHch
cbnteMsa beneRdery dasignatlon?.................................................................................................................. ❑ �
iF SF�ANSWER t0 ANY OF TNE XBOVE CUE3Ti0NS 1.S YES,YW MUST COMPLETB sCF1EDULE 6 AND F�E IT A$PAR7 OF T!�RET1lRN.
Far datea of death m or after July 1,1984 and betore,lan..t.1985.fhe La�c refe Imposed on�ra�t v�ro a trarmtera�or for the use af ihe�rvhdng
sp«,sa�e 3 percene�2 as.§e��e(a}{i.��p��.
Par s�tea�desm on or afRer Jarxay t.ta95,�a trx ratia Nnpased ai C�e r�et w,�e�trarefiers m or br me use m u,e wrvWiny apa,se le o vercent
t72 a.s.y91 te(e){t.t?{Y)]. nw W Wto aaes na ez�r,pe a transrx b a sutrn+ino spousa fram k�x,ana tl,a sqwFwy requVements tw disctosure or
asse4s and fldrg a cax retum are stlN a�ppXcahle avan N tlie su�vl�AnO sS�ouse is tlm aMy benetidary.
For dates of deatlr on or�.kdy 1,2006:
.'it�ta�t re�s.knPOCed an tho net vdue of traislers irom a detxaaed drlW 21 Y�rs of age or younger at deetl�k+a'for tlie t�e of a nehual perent,mE
acbpdve peroM,a a stappnrsiK ct tlie d�id b 0 percant(12 P.S.§St 18(s}(1.2p.
�. s'ftfe ta�t ra4e knposad on Me net vaiva of traosters 60 or fa'tha t�se W tAe tlecedenPs Rneal benefldaries is 4.b pemen4 excePt as noted In
� [72 P.$.§Qt t8(a)(iH. . � . . .
� .Ttro ta�c tate YnPOead at tlie ns#volue W trarisFens id a�r ihs wa of ihe decedenPs eiM4gs b 12 perc�nt(72 P.S.89716(a?(l.3 A -
smbnp ta detMad wder 3mction 9tQ2���fndNWuet wM tms st i�st wie psrent in commm wRih tlx decedarN.wi�fher by�'M adoptlqn.
Rm)E68EX�(N-16}
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, � MiSC,
�PARTMENT OF'REVENUE
,N„E,�,,�.,��T�cR��RN PERSONAL PROPERTY
������
ESTATE OF FILE NUMBER
Cfegg. Lari A. 21-12-04A0
IndUdatlMF o111tlgBtlonMltltlledabthsPlowelMwEfsrM�iiveAlylMe&�Bte.
All propaq Jolntly�Md Mth tM rlgM M wrvhaaA'q mwt psrtlhebasd on acl+sOUN f.
ITEM . � VAEUE AT QATE .
NuMeER DESCR1PTidN pp pEp7�{
1 Estate of Lorl Ann Clegg v.Geico Insurance Company-survival clalm beneflt check dated 88,339.42
4ctaber 8,2013
2 I.A Fitness Internatlanat-flnal paychecR 175.91
3 M3'E Bank Aecount#T494-bank tse retund 37.d0
4 Patlent First-retund �.24
5 Dominlon Entsrprises•check on hand 45.33
8 Metro 9ank Checking Account#2833768618 457.89
7 BanKof Amerlta-reiund 109.99
8 Gelca Gsnerellnsurance-auto cl�im 8,876.83
9 C�lco QeaeraF In+eurance-deducUbFs refund 500.00
10 Vanguard 1RA Account#68U58898752-paYabk W estate 3.282.2$
TOTAL lAlso enter oo Une 5.Rscapit�latlonS 149.83Q.48
� tMmorespaceb`roaee.s�anaipagesdu»s�ne�) � . �
Copyrl�rt(c}2010 fwm soNv2re aUy The Ladcnet GroEp,U�c. Fam PA-t500 Sct�dule E{Rev.tt-10}
�
REV•151i E%*(10-04)
pennsylvania SCHEDULE H
��M#�� FUNEi2AL EXPENBES AND
ItVMER17ANCE TAX RETURN
RE310EMOECEDEN! ADMlNIS7RATIVE GOSTS
ESTATE OF FILE NUlABER
Clegg, Lori A 22-12-8d48
decede�rYa debts must ba reported on Schadule!.
1TEM DESCRIPTION AMOUNT �
p, FUNERAI EXPENSES:
See conNnuation schedule(s)attached 1s,7o9.oq
B. AAliINNI$TRATlYE CO3T3:
1. Persanai Re�sresentaUve's Cammisstor�s
Nsms o(Persorra�Representadve(s}
Sb�eet Address'
City StBte � Zln_
Year(e)Commission Paid
Z Rttame�sPaes � . � .
3. FamGyy Exemption: (if decedeM's address is nat the same as daimanPs.attach�pianatlon)
t�aimant
Sttea4Addre3s -
City Stete Zio
Ralatlonshto of Claimant to Decedent
4. Probata Feas 34$.50
5. AawuntaM's Feea
&. T�Retum PreparePa Fees
7. Otlrer Administrative Cas� 31i.8$
Sae continoffifon sahedute(s}attached
TOTAi.{Also snter w�Ilne 8,Recapitukatlon) 18,375.58
Copyright(c}2409 fam software adp SYre Lackner C3rcwp,inc. � Form PM75U0 ScMetlula H{Rev.10-09)
(
�
SCHEDULE H
FUNERAL EXPENSES AND AD�AAINiSTRATNE COSTS
continued
ESTATE dF FlLE NUMBER
CIegB, Lari A 21-12-4440
ITEM
NUkNBEF2 " � DESCfttPTtON ' � AM4UNf .
Funeral EYpenses
1 Ali Satnts Episcopai Church-funeral service 350.OQ
2 Organlst-funeral service 180.p8
3 Reat Haven CemeterY-brcnze piaque 1.d12.00
4 Reat Haven Cemetery-memorial l.914.06
5 Reverend Douglas Smith-lurrera!servfcg 200.00
8 Wetzei Funsrei Home-funeral service i1.732,00
H-A 75.708.40
tkher AdminiatraNve Caats
7 Cumberland Law Joumai-estate notice 75.00
$ Malro Bank Check(ng Accowtt#28337888/8-l�nk ctua►ges p�t death 31.88 .
9 The SaWnai-es#ate�atics 210.T8
H-B� 377.Q8
Copyrtght(c)2002 torm aofM�are oMY Thb Wckn�Cx4uP.lnc. Fartn PA-1306 Sdieduie H(Rev,&98)
- . � �. . � ' � -_ _�... �
Ravd5t2 EXa(i2-08}
SCHEDULE i
pennsytvania pEBTS OF DECEDENT,
DEPARTMEM OF REVENUE
�N„�n,,�7,�R�, MORTGAGE LIABtL1TtES AND LiENS
RE5IDENT DECEDEM
ESTA7E OF FILE NUMBER
Clegg, Lorl A 21-12-6440
Rppqt aWM mampd EyMw a�e�Elmt P�1a arM tlwt nmsMM unp�W MtM ah ot MNh,InckMlnp unrNmbunW m,dcel�xpw��.
ITEM� ' . � YALUE AT DRTE
Nt1MBEF2 � . DESCi2lPTtON OF DEATH �
1 Cumberiand Counry Tax Bureau•2012 local tax due 21.35
2 M&7 Bank Checking Accodnt#98577D3202-retumed check fee 20.Qq
3 MercantFie AdjustmeM Bureau-aollecNon for UGi UttliHes 140.51
4 PA Department of Revenue-24�t ineome tax past tk�e 384.87
5 PA Department of Ravenue-2Q72 state income tax due d1.00
6 U.3.Treasury-2012 federal income tax due 6,489.Qp
TO7AL tAlsp eMer on Line 10,RecapllWatlon) 7,078.73
(N mare qsxa�is needed,addinand papu athe aeme slze) . � .
Copyright{c}2048 frnm softv�re aMy The tadcner GrouP,ina � Form PM150U SchedUe I(Rev.12-08}
REV.1513 EXat41-10}
pennsytvania SCH�DULE J
DEPARTMENT OFREVENUE p p c
INXERITANCETAXRETUftN QE���IG�itIGS
RESIDEN7 pECEpEN7
ESTATE OF FILE NUMBER
CI ,LoN A. 21-12-0440
R�,noNSt�ia Ta
NUMBER NAMf AND A6DRESS QF SHARE QF ESTATE OUNT OF ESTATE '
PERSONf51RECEIVINGPROPERTY DECEpENT ��� ��$�
I, 7AXABLE DIBTRIBUTIdNS jinclutle outright spousal
tlistributions.�.!hensfe[s
underSec.911 a 12
7 $haron L.CIe99 Mother One-half residua
345 Foxleigh Ddve
Nanaver,PA i733t
2 Wlllfam D.Glegg Father One-fralf residue
S45 Foxleigh Drive
Hanover,PA l7331 .
Total
�qr . amau�s 1a"�ebibatldw shown abave on IMes 15 18 on Rev 1 0 cover shee a
NON-TAXABI.E DISTRIBUTIONS:
�• A.SPOUSAL DlSTRi@UTfON3 ttNDER SECTipN 9133 FOR Wt#K;H AM ELECTION TQ TAX iS Np77qy(EN .
B.GHARITABLE ANOOOVERNMEN7AL DISTRIBUTION3
TOT � . P ��. � -EkfERTOTALNpN-TAXABLEbISTRIBIJT'16N30Nt,.INE130FREY-15QOCOVERSHE � `
� Copyr�rt{o}2410 fam sdtwewre ortg�The Lacknar£iroup,I�c. � � Fam PA�160@ SchedWe J{Rev.Ot-14}
-
. _ ._
WILLIAM CLEGG,ADMINISTRATOR OF THE ESTATE OF LORI CLEGG v.
GEICO INSURANCE COMPANY
CLOSING STATEMENT
Amount of Settlement $300,000.00
DISBURSEMENTS:
Attorney's fee:
1/3 of$300,000.00 $100,000.00
COSTS:
Northwest Regional Police Department $ 120.80
Wetzel Funeral Home 20:00
Hanover Medical Group 65.60
LancasterCounty Coroner 100.00
Lancastcr County Prothonotary 157.25
Laacaster County Sheriff 145.00
Chebkmate Investigative Services 1,000.00
Chsrles Tuer Investigations 192.50
Patriot–St. Denis Towing 1.520.00
TOTAL COSTS $ 3,321.15
TOTAL DISBURSEMENTS 5103,321.15
CHECKS PAYABLE:
William and Sharon Clegg $ 98,339.43
William Clegg,Adminis�ator of the Estate of Lori Clegg 98,339.42
Maztz&Gailey, LLP(costs) 3,321.15
Martz& Gailey, LLP (fee) 100.000.00
5300,000.00
By. .
Herman A.Gailey, ,Esquire �
The above-captioned matter has been settled to my complete satisfaction and all
disbursements made with complete approval. I agree thst a mioimam of tea (101
basiva�d�ve will be allowed for clearance of the settlement draft.
Approval flus $'� day of Or ��,(�i _2013.
'VI�ILLIAM CLEGG
! �
SHARON CLEGG �—