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Home My WebLink About12-23-13 � 15�5610101 REV-1500 Ex`°l l°, �` OFFICIAL USE ONLY PA Department of Revenue Pennsylvania ;:>.,.,,;<„,,.„,: County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 28o6oi / Harrisburg,PA 1�128-o6oi RESIDENT DECEDENT �'� �d ��0 ENTER DECEDENT INFORMATION BELOW Sociai Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 174-20-8179 ' 04/09/2012 11/11/1927 DecedenYs Last Name Suffix DecedenYs First Name MI COOMBE SHIRLEY M (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI S�ouse's 5ocial Security Number THIS RETURN MUST�E FiLcD fN uU�LiCATE Wi i H THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW p 1.Original Return � 2. Suppiemental Return p 3. Remainder Return(date of death prior to 12-13-82) p 4.Limited Estate O 4a. Future Interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12-82} � 6.Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of 5afe Deposit Boxes (Attach Copy of Wiil) (Attach Copy of Trust) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 17. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Rttach Sch.O) CORRESPONDENT— THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INfORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ,THOMAS E. FLOWER (717�43-5513 ;''; � �.,.� =� r-�t _��-3..._------,-------�.. 17EGISTER OF WILLS US�_,�t�,Y �;;:,° � ,� � ;."d7 -,,�� ...) C.'`) €.,,. ' �.� �...y C.7 First line of address ��i "� � � �`� �`r .. �_�� C�J C.s FLOWER LAW, LLC 4 ` , c.; r�'° _ ,, . _,,, _ � Second line of address �.? � � � ..,� � , _., �..3 _:._: t -' i:? 10 W. HIGH STREET . � � r�,, �.� �''� City or Post Office State ZIP Code `' DATE Fu.ED �r'� a , � CARLISLE PA 17013 CorrespondenYs e-maii address: TOM@FLOWER-LAW.COM 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 uue,correct and complete.Dectaration of preparer other than the personai representative is based on all information of which preparer has any knowledge. SIGN14TUR� F PERSON RESPON�LE FOR FILING RETURN DATE G' �z��t 3 ADDRESS �- C. CHRISTINE COOMBE, 1507 CHARLTON AVE,ANN ARBOR, MI 48103 SI AT E F P R HER THAN REPRESENTATIVE D�ITE v � 11/11/13 ADDRESS FLOWER LAW, LLC; 10 W. HIGH STREET, CARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 � 15056101�1 ],5�5610107, J � 1505610105 REV-1500 EX Decedent's Social Security Number oecedent•s Name: SHIRLEY M. COOMBE 174-20-8179 RECAPITULATION 1. Real Estate(Schedule A). .. .. . .. . ... . . . . . .. . .. . . . . . . .. . . .. . . . .. . .. . . . 1. 2. Stocksand Bonds(Schedule B) .. . . . . . .. . . . . . . .. . . . . . . . . . . . .. . .. . . . . . . 2. 3. Closety Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. .. . 3. 4. Mortgages and Notes Receivabie(Schedule D)... .. ..... ..... .. . .. . .. . .. . 4. ' 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . .. . .. 5. 53,950.30 6. Jointly Owned Property(Schedule F) O Separate Biliing Requested .. . . .. . 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.. . .. . . . 7. 8. Total Gross Assets(total Lines 1 through 7)... . .. .. . . . ... .. . . .. . .. .. . .. . 8. 53,950.30 9. Funeral Expenses and Administrative Costs(Schedule H). .. . . . . . . . . . . ... . . . 9. ' 7,394.24 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) . . .. . . . . . . . . . . 10. 45,556.06 11. Total Deductions(total Lines 9 and 10). . . .. . .. . . . . . . . .. . .. . . . .. . . . . .. . . 11. 53,950.30 12. Net Value of Estate(Line 8 minus Line 11) . .. . .. .. . .. . . . .. . . . . . .. . . . .. . . 12. 0.00 13. Charitable and Govemmentai Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ... . . . ... . . . .. . . . .... . . . 13. 0.00 14. Net Value Subject to Tax(Line 12 minus Line 13} ...... ... .. . ... .. . .. ... . 14. 0.00 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_ 15. 16. Amount of Line 14 taxabie at lineal rate X.0_ 16. 17. Amount of Line 14 taxable at sibling rate X.12 �7. 18. Amount of Line 14 taxable at coilateral rate X.15 �g, 19. TAX DUE . .. .. ... .. . .. .. . . . . . .. ... .. . . . . . . . .. . . . .. . . . . . . . . . . .. ... . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN dVERPAYMENT p Side 2 L 1505610105 150567,�1,05 J REV-1500 EX Page 3 File Number r,, Decedent's Complete Address: �' � ��'� d�`� DECEDENT'S NAME SHIRLEY M. COOMBE __ __ _ _ STREETADDRESS 100 MT ALLEN DRIVE CITY _ STATE ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19} (1) 0.00 2. Credits/Payments -- -- A.Prior Payments - —_ .___ B.Discount Total Credits(A+B) i2? 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) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5} 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 income:............................................ ❑ x❑ c. retain a reversionary interest;or.......................................................................................................................... ❑ x❑ d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ x❑ 2. If death occurred after Dec.12, 1982,tlid decedent transfer property within one year of tleath without receiving adequate consideration?.............................................................................................................. ❑ 0 3. Oid decedent own an"in trust for"or payable-upon-tleath 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 TQ ANY OF THE RBOVE QUESTIONS IS YES,YOU MJST COMPLETE SCHEJ!!LE C ANQ�ILE!T AS PART QF 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) (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 tleceased 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)j. . 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 individuai who has at least one parent in common with the decedent,whether by blood or adoption. REV-15o8 EX+(ii-io) �� M pennsytvania SCHEDULE E '� DEPARTMENT OP REVENUE CASH, BANK DEPOSITS & MISC. [NHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: SHIRLEY M. COOMBE 21-10-0668 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH �. DISTRIBUTION FROM WILLIAM F.COOMBE ESTATE(1/3 SHARE OF RESIDUE)PAID FROM SETTLEMENT FUNDS UPON SALE OF REAL PROPERTY BY WILLIAM F.COOMBE ESTATE, RECEIVED NOVEMBER 8,2013. 53,950.30 TOTAL (Also enter on Line 5, Recapitulation) $ 53,950.30 If more space is needed, use additional sheets of paper of the same size. RE!1-I5L1 E:(+(I(i-09j �" pennsylvania SCHEDULE H DEPARTMENT OF R[VENUE FUNERAL EXPENSES AND �� SNHERITANCETAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER SHIRLEY M. COOMBE 21-10-0668 Decedent's debts must be reported on Schedule I, ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: • L B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 4,360.87 Name(s)af Personal Representative(s} C. CHRISTINE COOMBE Street Address_1507 CHARLTON AVE City ANN ARBOR _ _ __ State__MI Zip 48103 Year(s)Commission Paid: 2013 2• Attorney Fees: 3,033.37 3• Family Exemption: (If decetlenYs address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5• Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ 7,394.24 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-U8j ��,'I�`N pennsylvania SCHEDULE I �;; DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCETAXRETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER SHIRLEY M. COOMBE 21-10-0668 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• TOTAL DPW MA CLAIM:$189,034.30.PORTION ALLOCABLE TO THIS RETURN:$45,556.06 45,556.06 TOTAL(Also enter on Line 10, Recapitulation) $ 45,556.06 If more space is needed,insert additional sheets of the same size. < COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRIN DNISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG,PA 17105-8486 August 6, 2010 FLOWER LAW, LLC THOMAS E. FLOWER, ESQUIRE 10 W HIGH ST CARLISLE PA 17013 Re: Shirley Coombe CIS #: 710179092 SSN: ###-##-8179 Date of Death: 06/27/2010 Dear Attorney Flower: Please be advised that the Department of Public Welfare maintains a claim in the amount of $189,034.30 against the above-mentioned estate. This claim is for restitution of inedical 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 3U, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $28,835.07, 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 $160,199.23, 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, �'�� ' �� .�..� � Marie A. Trayer Claims Investigation Agent 717-772-6723 717-772-6553 FAX Enclosure II . LAST WILL AND TESTAD4ENT OF SHIRLEY M. COOMBE I, SHIRLEY M. COOMBE of the Borough of Camp Hill, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any will previously made by me. I - I direct the payment of all my just debts and funeral expenses out of my estate as soon as may be practical after my death. II - I devise and bequeath all of my estate ot whatever ' natur.e and wherever situate unto my husband, William F. Coombe. III - Should my said husband predecease me, then I devise ' and bequeath _all of my estate of whatever nature and wheresoever situate unto my issue per stirpes. ' � IV - I appoint the following executors of my estate in the � priority indicated, so that if anyone fails -to qualify or ceases to act, the next shall be substitute execut�r: my husband, Willi.am F. Coombe; my daughter, C. Christine Coombe; my son, Jeffrey L. Coombe; � my son, David Michael Coombe; CCNB Bank, N.A. , Camp Hill, Pa. None ; of my personal representatives shall be required to post bond in this i or any jurisdiction. . rn� ��+0 P/. . Page 1 i'' ARNOLD & SLIKE,ATTORNEYS-AT-LAW,2109 MARKET S7REET,CAMP HILL,PA 1701 I IN W�NESS WHEREOF, I have hereunto set my hand and seal on this, the / day o� �t� 1984. � � ,. rna ��'''I� P/ �S EAL) irley M. Coombe - ;Signed, sealed,. published and declared by SHIRI,EY M. COOMBE, Testatrix ther-ein named, on this and one (1) other �sheet of paper as and for her Last Will and Testament in our presence; who, in her presence, at her request and in the presence of each other, have hereunto subscribed our names as attesting witnesses. ; f' /�� '�� Cam Hill, Pa. ��•� Name Address ,`ri {� ^ Cam Hil1, Pa. Name Address Page 2 ARNOLD&SLIKE,p'['�'ORNEYS-A'f•LAW,2109 MARKET SCREET,CAMP HILL,PA 17011 , COPilMONin1EALTH OF PENNSYLVANIA) , . SS, COUNTY OF CUMBERLAND) WE, the undersigned, the testatrix and the witnesses, respectively, whose names are. signed to the foregoing instrument, bei�g first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last "viTill and TeGtament and that she signed willingly (or willingly directed another to sign for her) , and that she executed it as her free will . and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing af the testatrix s�gried the will as witnesses and that to the best of their� knowledge the testatrix was at that time eighteen years of age or older, of sound mind, and under no constraint . or undue inf.luence. , �2• C��m�6 e. statrix �..-�. � , (�litness .�-- ° Witness Subscribed, sworn to and acknowledged before me by the testat�ix, and subsc ed and sworn to before me by both witnesses, � this � day o f �C;%,�� , 19 8� . / � � otary Public � THfLMA S. MoCAUSLIN, N.dTARY PUBLIC My Commisslon Expires luty 3, 1988 Camp Hill, Pq Cumberland County ARNOLD & SLIKE,A7TORNEYS-AT-LAW,2109 MARKET STREET,CAMP H1LL,PA 17011