HomeMy WebLinkAbout11-20-13 REV-1500 Ex 101-10' 1505610140
OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number
PO BOX 280601 2 1 1 3 0 4 7 7
Hardsbum,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
0 3 2 9 2 0 1 3 1 2 2 2 1 9 3 6
Decedent's Last Name Suffix Decedent's First Name MI
B a s o m Richard L
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
N / A
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
Q 1.Original Return E] 2.Supplemental Retum 3.Remainder Return(date of death
prior to 12-13-82)
4.Limited Estate 4a.Future Interest Compromise(date of 5.Federal Estate Tax Retum Required
death after 12-12-62)
® 6.Decedent Died Testate 7.Decedent Maintained a Living Trust 0 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 TO:
Name Daytime0blephone Nunej- �0 M
Scot t W . M o r r i son , E s q 7137 82=:2 ;0
co
REWSO QF WILI11111,9SE e r I
:Z M CD 0
7C Ca
First line of address
6 Wes t Mai n St r e e t `-
Second line of address - ►
Cn 4C)
P O . B o x 2 3 2
City or Post Office State ZIP Code DATE FILED
New BI oomfi el d PA 17068
Correspondent`s e-mail address: smorrisonlawftentuNink.net
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 arty knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ' � � DATE
ADDRESS
2055 State Route 973W Cogan Station PA 17728
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE D E -
ADDRESS
6 West Main Street New Bloomfield PA 17068
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140
1505610240
REV-1500 EX
Decedents Social Security Number
Decedent's Name: Richard L. Basom
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. 2 7 9 3 7. 6 7
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested ....... S. 8 5 8. 8 5
7. Inter-Vivos Transfers&Miscellaneous N�Probate Property
(Schedule G) Separate Billing Requested ....... 7. •
8. Total Gross Assets(total Lines 1 through 7) ........................... 8. 2 8 7 9 6 . 5 2
9. Funeral Expenses and Administrative Costs(Schedule H) ....... ....... .... 9. 1 1 5 2 8. 3 5
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) ........... .. 10. 1 8 0 8 7. 0 1
11. Total Deductions(total Lines 9 and 10) .............. ........... ..... . 11. 2 9 6 1 5 . 3 6
12. Net Value of Estate(Line 8 minus Line 11) ............ ........ .... .... 12. - 8 1 8. 8 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. - 8 1 8. 8 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_ 15.
16. Amount of Line 14 taxable
at lineal rate X•0„_ 16.
17. Amount of Line 14 taxable
at sibling rate X.12 • 17.
18. Amount of Line 14 taxable
at collateral rate X.15 18.
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 13 0477
DECEDENTS NAME
Richard L. Basom
STREET ADDRESS
1733 McClures Gap Road
CITY STATE ZIP
Carlisle I PA 117015
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2, Credits/Payments
A.Prior Payments
S.Discount
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.
Fill In oval 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; ...................................................................... El b. retain the right to designate who shall use the property transferred or its Income; ............................... ❑
c. retain a reversionary Interest;or ................................................................................................ El d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ EXI
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ 0
3. Did decedent own an'in trust foe 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.
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)(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)(n)].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)].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.
REV-1508 EX+(6.88)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
IN RESID ENE E TAX EDENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Richard L. Basom 21 13 0477
Include the roceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be discioaed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Ameriprise checking account 2,862.67
2. Income tax refund 1,075.00
3. Sate of Volkswagen Passat 24,000.00
TOTAL(Also enter on line 5,Recapitulations S 27 937.67
(If more space is needed,insert additional sheets of the same size)
REV-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY '
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Richard L. Basom 21 13 0477
If an asset was made jointly owned within one year of the decedent's date of death,It must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A.Robert L. Basom 2055 State Route 973W son
Cogan Station, PA 17728
B.
C.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST
1. A. Ameriprise savings account 1,717.69 50. 858.85
i
a
i
TOTAL(Also enter on Line 6,Recapltulatlon) $ 858.85
9 more space is needed,use additional sheets of paper of the ON s(ze.
REV-1511 EX+(10-09)
pennsyfvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
KSID NTDE EOEW URN ADMINISTRATIVE COSTS
RESIDENT DECEDFJJT
ESTATE OF FILE NUMBER
Richard L. Basom 21 13 0477
Decedents debts must be reported on Schedule L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Musselman Funeral Home 8,848.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commisslons:
Name(s)of Personal Representatives) Robet L. Basom 1,439.83
StreetAddrass 2055 State Route 973W
city Conan Station state PA Zip 17728
Years)Commission Paid:
2. Attorney Fees: Scott W. Morrison 750.00
3, Family Exemption:(If decedents address is not the seme as claimants,attach explanation.)
Claknant
Street Address
Clly State ZIP
Relationship of Clalmant to Decedent
4. Probate Fees: Glenda Farrier Strasbaugh 183.50
5 Accountant Fees:
6. Tax Return Prepansr Fees:
7. The Sentinel-estate advertising 232.02
8. Cumberland Law Journal-estate advertising 75.00
TOTAL(Also enter on Line 9,Recapitulation) ; 11 528.35
If more space Is needed,use additional sheets of paper of the same size.
REV-1592 EX+(12-08)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES,&LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Richard L. Basom 21 13 0477
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. Payoff Line of Credit 322.50
2. Volkswagen credit-payoff loan 17,389.88
3. State Farm-insurance 320.63
4. Holy Spirit Hospital-medical account 54.00
i
i
1
i
I
1
TOTAL(Also enter on Line 10,Recapitulation) i 18,087.01
If mom space Is needed,insert addillonal sheets of the same size.
N
LAST WILL ANC TESTAMENT
u•.
OF
RICHARD L, BASOM
/ N4!
RICHARD L. BASOM, of Camp Hill Cumberland County, Pennsylvania, being
.: of sound and disposing mind, memory and ur derstanding, do hereby make, publish and
h.
k; declare this as and for my Last Will and Tesl?ment, hereby revoking all other Wills and
Codicils heretofore made by me.
FIRST
u I direct the payment of my just debts e nd expenses of my last illness and funeral
t
a
from my estate as soon after my death as r,onveniently may be done. If there be no
e.
- cemetery lot available for my interment m rued by me at the time of my death, I
authorize my personal representative to purchase such cemetery lot with a contract for
r,
{ perpetual care, using therefor funds from my ?state in such amount as he shall consider
` necessary and desirable, and I authorize my personal representative to cause title to or
ti•: ownership of such lot so purchased to be vested in such person as my personal
representative shall designate,
' Further, I authorize my personal reprs sentative to expend funds from my estate,
h in such amount as my personal representati m shall consider necessary and desirable
for the purchase, erection and inscription of a suitable marker for my grave.
SAID'IS SECOND
SHIM, FLOWER
& LINDSAY
A7TORNEY&AT-LAW I give, devise and bequeath all the re st, residue and remainder of my estate to
2109 Market Street
Camp Rift, PA my son, ROBERT L. BASOM, IN TRUST, N -VERTHELESS, upon the following terms
and conditions:
}
c:.
A. The purpose of this trust is to a ssist with the Costs of my grandchildren's
P
education;
V
B. My Trustee shall invest the fund s comprising this trust in an ordinary bank
savings account or certificate(s) of deposit, sc that the funds will be readily available as
needed, because it is not my intention that the funds be invested for income or growth;
C. My Trustee shall apply, from tin, e to time, so much of the income and/or
principal of this trust as he shall deem approl mate, in his sole and absolute discretion,
for the education of my grandchildren, whetho, r to pay for college, trade or professional
school or any associated expenses, including i books, room and board, miscellaneous
fees, etc.:
D. The payments to be made from this trust need not be equal in amount,
and my Trustee may pay more for the benefit. of one or more of my said grandchildren
than for another or others, in his sole and absc lute discretion;
E. My Trustee's decisions with rest iect to applying the funds hereunder for
my grandchildren's education shall not be rev ewable by any court, and no beneficiary
shall have the right to compel payment from this trust, and my Trustee shall not be
required to account to any court or other-tribuni il for his administration of this trust;
F. My Trustee shall have the power :o terminate this trust simply by spending
the last dollar for the education of my grandi:hildren, or any of them, without further
SAIDIS
HUFF, MOWER formalities, and he shall be answerable to nc one for the wisdom or propriety of his
& LINDSAY
ArrORNCV5•A*1.AW decisions, in administering this trust.
2109 Markel Sireet
Camp Hill,PA
qy 2
THIRD
I direct that any and -all inheritance, estate, ai id transfer taxes imposed upon my estate
passing under this Will or otherwise shall be paid out of the principal of my residuary
estate.
FOURTH
In addition to the powers confers;d by law, I authorize any personal
representative acting under this instrument, in his absolute discretion:
A. To retain in the form receive i, or to sell either at public or private sale
any real or personal property;
B. To Exercise any options tC subscribe for stocks, bonds, or other
tea'
investments;
C. To join in any plan of le[se, mortgage, consolidation, exchange,
reorganization or foreclosure of any cc rporation in which my estate or any trust
may hold stocks, bonds or other securit es;
D. To sell, transfer, convey, m)rtgage, pledge, lease or exchange any
property, real or personal, which at an,, time may form part of my estate, for the
payment of debts or taxes, or for any pi Irpose of administration or distribution, for
such prices and upon such terms as my personal representative, in his sole
SAIDIS discretion, may deem wise, and to exe%ute and deliver deeds of conveyance or
HUFF, FLOWER
& LINDSAY transfer thereof;
A7TORN US•AT•LA W
2109 Markel Streei E. To make settlements and cor 1promises on such terms as my personal
Camp Hill,PA
representative in his sole discretion in lay deem wise without the necessity of
obtaining any court approval thereof;
3
r:,
F. To make distribution hereuno ler either in cash or kind, as my personal
representative in his discretion may de)m wise.
?kr.
FIFTH
I do hereby nominate, constitute and aF point my son, ROBERT L. BASOM,to act
as Executor of this my Last Will and Testamer t.
SIXTH
I direct that no personal representat ve, guardian, trustee or other fiduciary
appointed under thiss instrument shall be required to give bond for the faithful
performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I, RICHARC L. BASOM, have hereunto set my hand
and seal to this my Last Will and Testament, consisting of four (4) typewritten pages,
the first three (3) of Which bear my signature in the margin for identification, this
day of , 2004.
RICHARD L. BASOM
Signed, sealed, published and decla:-ed by the above-named RICHARD L.
BASOM, Testator, as and for his Last Will ar d Testament in the presence of us, who
have hereunto subscribed our names at hl s request as witnesses thereto, in the
presence of said Testator and of each other.
SAIDIS
HUFF, FLOWER
LINDSAX ►• r f � l ADDRESS
1109 Market Su'CCl /�J
Camp Hill, PA
i
ADDRESS
4
rr
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF CUMBERLAND
r/-� / -
We, RICHARD L. BASOM, �aou ,�iacl and r'JVL!/ �l �!►i�rrCf' , the
Testator and witnesses, respectively whose lames are signed to the foregoing or
attached instrument, being first duly sworn, do hereby declare to the undersigned
authority that the Testator signed and execul ad the instrument as his Last Will and
Testament and that he signed willingly and thi It he executed as his free and voluntary
act for the purposes therein expressed, and the it each of the witnesses, in the presence
and hearing of the Testator signed the Will a;; witnesses and that to the best of their
knowledge the Testator was at the time eights yen (18) or more years of age, of sound
mind and under no constraint or undue influent e.
RIC. ARD L. BASOM
I ne �-
V ness
Subscribed, sworn to and acknowledges I before me by RICHARD L. BASOM, the
Testator, and ub:icribed to .and swo n or affirmed to before, me by
7. 1L.. and -witnesses, this day of
4'
>? � F PENNSYLVANI Notary Public
Notarial Seal
Sallie Alle►louse, Notary Public
Camp Hill BOro. Cumheriand County
[MY Commission Ex flirt!, Mar. 29, 2008
SAIDIS
HUFF, FLOWER
& LINDSAY
ATTgaNr)'S-AT-LA W
2100 Markel Street
CemR Hill, PA
5
Pennsylvania
DEPARTMENT OF PUBLIC WELFARE
May 1, 2013
SCOTT W MORRISON ESQUIRE
6W MAIN ST
PO BOX 232
NEW BLOOMFIELD PA 17068
Re: Richard Basom
SSN: ###-##-5501
Dear Attorney Morrison:
Pursuant to your letter dated April 26, 2013, the Department's, Estate Recovery
Program, has reviewed the information you provided regarding the above-referenced
individual.
It has been determined that this individual did not receive any type of assistance
during the questioned period.
Therefore, according to the information you provided, the Department's Estate
Recovery Program will not seek any recovery from this estate. If your client applied for
Medical Assistance and had an application and/or hearing pending at the time of death,
please advise us and provide any additional information that may affect a recovery by our
Department.
Thank you for your cooperation in this matter. If you have any questions, please
contact me.
Sincerely
� - Y
Vince A. Porter
Recovery Section Manager
(717)772-6604
Bureau of Program Integrity Division of Third Party Liability Recovery Section
PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486
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