HomeMy WebLinkAbout11-04-13 � 1505610143
REV-1500 EX`°z_,,, �
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes �PARTMENTOFREVENUE
Po Box.2soso� INHERITANCE TAX RETURN 21 �j �Jp
_ Harrisburg, PA 17128-0601 RESIDENT DECEDENT � I� "( 8
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
198 18 5695 05 07 2013 11 18 1925
DecedenYs Last Name Suffix DecedenYs First Name MI
SURFIELD ROBERT L
(If Appticable)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
a1. Originai Return � 2. Supplementai Return � 3. Remainder Return(Date of Death
Priorto 12-13-82)
� 4. Limited Estate � 4a.Future Interesl Compromise � 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
a g Decedent Died Testate � � Deceder]t Maintained a Living Trust � 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Gopy of Trust)
� 9. Litigation Proceeds Received � 1 p.s ousai Povert Credit(Date of Death ��,Election to tax under Sec.9113(A)
b�tween 1231�Jt and 1-1-95) � (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 HUGHES ESQ 717 249 6333
REQi1ST�R OF WI�'S USFE":O,FJ�Y
j �
;:c� �_ _
First Line of Address r i ' c-a c' c'-�r
_:z„ . ,
354 ALEXANDER SPRING RO � =N E°''� �.- M �-=
� �� ; �- ,_;
Second Line of Address r� . "� -� Ci 3 �h
`' : � .�
,� �.., ,
<:�a c:�:`: `. �,�'�
• �,.DATE FIL� �:.::: 8..,..�
City or Post Office State ZIP Code � � ;�
CARLISLE PA 17015 =' � !�
Correspondent�s e-maii address: Jhughes@salzmannhughes.com
Under penalties of erjury,i de that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and beiief,
it is tru a e aration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SI ATURE OF PE ON SP BLE FOR FILING RETURN D E
James D. Hu hes, Petitioner C� y /�
ADDRESS
354 exan Road Suite 1 Carlisie PA 17013
SIGNA RE OF P R OT THAN REPRESENTATIVE ATE �
James D. Hughes Esq. �� y j �
D RESS
354 Alexan r S rin Road, Suite 1, Carlisle, PA
Side 1 �
� 1505610143 1505610143 ,�
� 15�56�D243
REV-1500 EX
DecedenYs Social Security Number
Decedent'sName: SUCfI@ICI, Robert L 198 18 5695
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. MoRgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash, Bank Deposits 8 Miscellaneous Personal Property(Schedule E)............... 5. � , 34 6.23
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous I�q-Probate Property
(Schedu�e G) �J Separate Billing Requested............ 7,
8. Total Gross Assets(total Lines 1 through 7)........................................................ g. 4 , 34 6. 23
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. �. , 2 Q 5 . �j Q
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 27 , �5$. Q$
11. Total Deductions(total Lines 9 and 10)................................................................ 11. ;�$ , Q{3 . $8
12. Net Value of Estate(Line 8 minus Line 11).......................................................... �2, -24 , 617 . 3Jr,
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an eiection to tax has not been made(Schedule J)............................................... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. -2 Q, 6�.7 . 3$
TAX COMPUTATION-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. 0 , Q Q
16. Amount of Line 14 taxable
at lineal rate X .045 a . a� 16. 0 . Q Q
17. Amount of Line 14 taxable
at sibling rate X.12 � . �0 17. Q . Q Q
18. Amount of Line 14 taxable
at collateral rate X.15 � . �� 18. Q . Q Q
19. TAX DUE................................................................................................................ 19. � . �1�
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
L 1505610243 1505610243 �
REV-1500 EX Page 3 File Number 21
Decedent's Complete Address:
DECEDENT'S NAME
surf�e�a, Robert L
STREETADDRESS
210 Big Spring Rd.
CITY STATE ZIP
Newville PA 17241
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 0.00
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +g� (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)
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.�0
Make Check Payable to: REGISTER OF WILLS, AGENT.
,w��;::�
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:............................................................................... ❑ 0
b. retain the right to designate who shall use the property transferred or its income:.................................. ❑ 0
c. retain a reversionary interest; or............................................................................................................... 0
d. receive the promise for life of either payments,benefits or care?............................................................ Ox
2. If death occurred after Dec. 12, 1982, 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?....... ❑ 0
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.
.,m`-:: � . .
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 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 stiil 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(a)(1)).
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs sibiings is 12 percent[72 P.S.§9116(a)(1.3)]. A
sibling is defined under Section 9102, as an individuai who has at least one parent in common with the decedent,whether by blood or adoption.
Rev-1508 EX+(71_10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE pERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Surfield, Robert L 21
Include the proceeds of litigation and the date the proceeds were received by the estate.
Ali property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Cash on hand 5.14
2 Adams Electric Co-op-payout of patronage account 503.11
3 F&M checking account,$3459586 3,189.60
4 Refund-Presbyterian Homes refund check 486.37
5 Refund -refund of petty cash from Presbyterian Homes 162.01
TOTAL(Also enter on Line 5. Recapitulation) 4,346.23
(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)
REV-1511 EX+�10-09)
pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Surfield, Robert L 21
DecedenYs debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 740.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
James D. Hughes
Street Address 354 Alexander Spring Road, Suite 1
cicy Cariisle State PA zio 17013
Year(s)Commission Paid 500.00
2. ,attornev's Fees Salzmann Hughes, P.C. 500.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach expianation)
Claimant
Street Address
City State Zio
Relationship of Claimant to Decedent
4. Probate Fees
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. OtherAdministrative Costs 65.50
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 1,205.50
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Surfield, Robert L 21
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex e�
1 Engraving Service-headstone engraving 140.00
H-A 140.00
Other Administrative Costs
2 Certified mail costs 7.00
3 Cumberland County Orphan's Court-filing fee for small estate petition 43.50
4 Cumberland County Register of Wills -filing fee to file inheritance tax return 15.00
H-B7 65.50
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1572 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN NiORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Surfield, Robert L 21
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 Penna. Department of Public Welfare-DPW will receive a pro-rata share($858.15) 25,475.50
2 Pinnacle Health Medical Services -Pro-rata share for In-patient care medical services;dates 2.58
of services 4/18/13 and 4/25/13
3 Salzmann Hughes, P.C. -outstanding invoice for Power of attorney services rendered, pre- 2,280.00
death,from 4/30/13 through 5/7/13 regarding decedent's medical care
TOTAL(Also enter on Line 10,Recapitulation) 27,758.08
(If more space is needed,additional pages of the same size)
Cnnvrinhf/rl 9!1llA fr.rm enffiu�re nnhi The I ar4ner f:rnnn Inc Form PA-150f1 Sr.heriula I fRav 19_f1Rl
RE�/-1513 EXr(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT OECEDENT
ESTATE OF FILE NUMBER
Surfield, Robert L 21
RELATIONSHIP TO
NUMBER NAME AND ADDRESS OF DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
PERSON(Sl RECEIVING PROPERTY i (Words) ($$�)
�, TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
1 Joseph C Bowen Friend Residue as per
Item Three of � �
Will.
Total
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
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
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev. 01-10)
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Pennsylvania, being of sound mind, disposing memory and fuil leg�l t��e, do hcreby �nak�, '
publish and declare this to be n1y Last Will and Testament, hereby revoking all Wills and
Codiciis heretofore made by me.
ONE. I direct my Executor or Executrix, as �e case may be, to pay all of my
debts, funeral and administrative expenses as soon as convenient after my decease. Furthermore,
I direct that all state, ixaheritance, succession and other death taxes imposed or payable by reason
of my death and interest and penalties thereon with respect to all property composing of my
�
gross estate for death tax purposes, whether or not such property passes under this Will, shall be •
paid by the Executor or Executrix of my estate. Further, to the extent that sufficient assets exist 4
in my estate, any and a11 inheritance or other estate taxes, whether to non-charitable or charitable �
beneficiaries, shall be paid by my Executor or Executrix from the residuary of my estate. �
TWO. My Executor or Executrix may, at his or her discretion, compromise
claims, borrow money, retain property for such length of time as he or she may deem proper;
lease and sell property for such prices, on such terms, at public or private sales, as he or she may �
deem proper; and invest estate property and income without restriction to legal investments
unless otherwise pzovided hereunder. I authorize and empawer my Executor or Executrix to sell
any realty and/or personalty owned by me at my death and not specifically devised or
bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/vr
biils of sale therefor, in fee simple, as I couid do if living. My Executor or Executrix is
authorized and empowered to engage in any business in which I may be engaged at my death, for
such period af time after my death as seems expedient to said Executor or Executrix.
THREE. I give, devise and bequeath all of my estate of whatever nature and
wherever situate to JOSEPH C. BOWEN,per stirpes,which provides that the child or children of
any deceased beneficiary sha1l take the share their parent would have taken if living.
FOUR. I hereby nominate and appoint JOSEPH C. BOWEN to be the Executor of
this my Last Will and Testament. In the event for whatever reason he is unable to serve as the
Executor of my estate, then in that event i hereby appoint JAMES D. HUGHES to be the
substitute Executor of this my Last Will and Testament, whereby the said substitute personal
representatives shall have the same powers as are given to the original Executor hereunder.
'� FIVE. No•person(s) shall benefit hereunder unless such beneficiary shall survive
me by sixty(60) days.
SIX. No Executor acting hereunder shatl be required to post bond or enter
security in this or any other jurisdiction.
SEVEN. No beneficiary may assign, anticipate or pledge its interest in any income
or principal held or distributable hereunder, and no beneficiazy's creditars may levy, attach or
othexwise reach any such interest.
EIGHT. It is hereby my intent to specifically exclude my son, Robert L. Surfield
Jr., from any inheritance whatsoever under this my Last Will and Testatnen�.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this �day of Ju1y,
2005.
�• '
(SEAL}
R4BERT Z. SURFIEL
2
Signed, sea.ted, published and declared by the above-named person as and for a Last Will
and Testament, in our presence, who at said person's request, in said person's presence and in the
presence of each other have hereunto set our names as subscribing vc+itnesses.
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ACKNOWLEDGMENT AND AFFIDAVIT
WE, R4BERT L. SURFIELD, RONDA L. WICKARD and KAMELA S.
� CORNMAN, the testator and witnesses respectively, whose names are signed to the foregoing
insirument, being first duly sworn, do hereby declare to the undersigned authority that the
testator signed and executed the instrument as his Last WiII, and that he had signed willingly,
and that he executed it as his free and voluntary act for the purpose herein expressed, and that
each of the witnesses, in the presence and hearing of the testator, signed the Will as a witness a.nd
that to the best of their knowledge the testatar was, at that time, eighteen years of age or older, of
sound mind and under no constraint or undue influence.�
� �• ....�.-Y.�/'
RO ER L.SU �EL
.����- , �.,�,���c.,�
R ND`r�'L. WICKA i
, f
. . . ; � ��
KA LA S. CORNMAN
CUMMONWEALTH OF PENNSYLVANIA .
. SS:
COUNTY UF CUMBERLAND .
Subscribed, sworn to and acknowledged before me by ROBERT L. SURFIELD, the
testator herein, and subscribed and sworn ;�efore me by RO A L. WICKARD and
KAMELA S. CORNMAN,witnesses, this �('� day of July, 005. '�
� ° �
CUMMONWEAi,TH OF PENNSYLVAI�IIA � ,
�Jotarial Seal
racqueline l.Drawbau�h, Natary Public �
sos�m araa���,TWn.,c����v o ary Public
My Commissiort�xpiregAug.14,2'�Q7
+Aember,Pertnsylvania Associadon of Notarias
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f ,�. r>si�.. �+� _.t'. - .. , ..
)une 25, 2013
SALZMANN HUGHES
JAMES HUGHES
79 ST PAUL DRIVE
CHAMBERSBURG PA 17201
Re: Robert Surfield
CIS #: 760191187
SSN: ###-##-5695
Date of Death: 05/07/2013
�;
ESTATE RECOVERY STATEMENT OF CLASM
Dear Mr. Hughes: �
Under State and Federal law, the Department of Public Welfare (the Department) is
required to recover medical assistance {MA) reimbursement from the probate estates of
deceased individuals who were over age 55 when such assistance was received. 42 U.S.C.
g1396p(b)(i). 62 P.S. § 1412. This letter sets forth the amount af the Department's claim
against the estate of the above referenced individual and explains the obligations of
executors, administrafiors, and persons receiving estate property.
Although the amount in the estate may be considerably less than that which
is owed to the Department, our claim is against the estate, no one else.
Statement af Claim Amount
The Department maintains a claim in the amount of�,449,817.18 against the
above-mentioned estate. This claim is for repayment of MA granted on behalf of the
decedent. Enclosed is the Department's itemized statement of claim.
A portion of this medicaf expense, namely �25, 75.50, was incurred during the last
six manths of the decedent's life; therefore, it is a Class 3 clairn pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Cade, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely �424,341.68, is to be entered as a priarity Class 5.1 claim against the
estate. You should refer to Section 3392 for a more comptete expfanation of the priority
ru les.
If a lawsuit is filed for injuries sustained by the decedent prior to death, then the .
Department may a(so have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separately.
eureau of Program Integrity J pivision of Third Party Liability � Recovery Section
PO Box 8486 ( Harrisburg, Pennsylvania 17105-8486
4� 1 � 'y ��
'o `�+'nd�,�is.�t=„k�,��"s 4t� £'�'+„ � qu� �s ""` ".+� ,s. �n . : . zf4 h� .���aw f? �� ,�� �i*;��''` _.
{�c,y t s ?::f� s r�� �k�v s�;.��j is 'f'n�w� ,r :,�. k�S+�ii��...t< <T.�� k �.,,'i�'h �'h;�`.x-�r `�'�' u` `7'.���ry�v c _�'.S� 1,..� `5€' ��'�''�5,k,y��,},"f-i"'� „'.'�`�a n.
Your Responsibility to Provide Information to the Department
Please acknowfedge receipt of this letter and advise whether the Department's claim
is admitted and when payment may be expected. When the esfiate accounting is complete,
piease provide a copy.
The Department audits all estate recovery claims and therefore we require
documentation to substantiate al( deductions fram the gross estate. The regulations
governing how the Department computes its estate recovery claim are found in 55 Pa. Code
Chapter 258. These regulations are readily available on the Internet, in addition to being
carried in most local law libraries. =�
In order to document computation of the amount due the Department, the foliowing
items should be submitted to the address below:
1. For real estate:
a. Copy of the deed
b. Copy of the latest tax assessment
� c. Copy of a current appraisal, if avai(able
2. Copy of the funeral bif!
3. Copy of the statement of the burial accaunt if one existed
4. Copy of the statement of the personal care account balance at date of death, if the
decedent was in a nursing home
5. Copies of original and updated life insurance policy forms naming beneficiaries
6. Copies of any and all stocks and bonds
7. Copies of bank statements showing balances on the date of death
8. Copies of signature cards or other proof of when accounts were made joint
9. A list of any gifts or other transfers for (ess than fair market value made by the
decedent (persona[ly or under a power of attorney)
Your Responsibilities to the Department
Under State law, executors or administrators may be personally liable to pay the
Department's estate recovery claim if they transfer estate property without the
Department's claim being paid. Persons who receive that property without paying valuable
and adequate consideration to the estate may also be personal(y liable. The responsibilities
of the primary next of kin/administrator/executor, is to advise the Department of any assets
in the esfiate and to ensure that the remaining money, after alE funeral and administrative
costs are deducted, is sent to the Department. Accordingfy, you must ensure the •
DepartmenYs claim is satisfied before making distribution of asseks to heirs.
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 848b � Harrisburg,Pennsylvania 17105-8486 '
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adminlstering the e�tat�. If y�u m���s��n+� �i�±�+l�i�►�'� r�rt+��1��;��D��#+cttin[���t'#t� y�u �t�t��
act p�udently and m�ke purchases as li the m�r��y vVer��omlr�� put o�'yaur own packet.
The Department's approva! is required if you eXp�ct the legaf fees fa exceed more than the
g�ea� oi 6% of the estate assets or $1,000. Contingent fees for estate administration wfll
generaily not be approved. If you do not obtain approval, the Department may consider the
excessive fees to be a transfer for less than valuable and adequate consfderation.
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Sincerely,
Katie J. East
TPL Program Investigator
717-772-6713
717-772-6553 FAX
Enciosure
Bureau of Program Tntegrity( Division of Third Party Uability � Recovery Section
PO Box 8486 J Harrisburg, Pennsylvania 17105-8486 -