HomeMy WebLinkAbout04-09-14 (2) J 1505610140
REV-1500 Ex "7e'
OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 4 0 1 1' 0
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY
0 1 1 2 2 0 1 4 0 8 0 2 1 9 2 3
Decedent's Last Name Suffix Decedent's First Name MI
Z A B L 0 C K Y F R A N C E S A
(If Applicable)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
0 1.Original Return 2.Supplemental Return ❑ 3. Remainder Return(date of death
prior to 12-13-82)
4.Limited Estate 4a.Future Interest Compromise(date of ❑ 5.Federal Estate Tax Return Required
death after 12-12-82)
❑X 6.Decedent Died Testate 7.Decedent Maintained a Living Trust _ 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9.Litigation Proceeds Received E] 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 Daytime Telephone NumpP5
D O U G L A S G - M I L L E R 7 1 •� 2 4 9s2 TTf3
3: °
RE ER70 WILL E On4Y,;O
S GS —A a)'
n r+T m
First line of address D N 70 CD A
Z >c O O
I R W I N & M C K N I G H T , P C m o o 'E ! :
Second line of address O 1-� r— m
Y
6 0 W E S T P 0 M F R E T S T R E E T -0 s (n CDP
City or Post Office State ZIP Code DATE FILEOC
C A R L I S L E P A 1 7 0 1 3
Correspondent's e-mail address:
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 any knowledge.
SIGN R F PFtRSCARPPONSlBI_5 FOR FILING RETURN DATE
A DRE l�
32-IKSHBURG DRIVE MECHANICSBURG PA 17050
SIGNA RE O REP R OT R THAN REPRESENTATIVE DA
ADD SS
60 WE T POMFRET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140
V"
J 1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: FRANCES A • ZABLOCKY
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 1
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . .. .. . . . . . . . . . . . . . . .. . . . . . . . 2.
1 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. 8 3 4 3 , 6 2
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested .. . . . . . 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested .. . . . . . 7.
8. Total Gross Assets(total Lines 1 through 7) .. . . . . . . . . . . .. . . . . . . . . . . . . . 8. 8 3 4 3 , 6 2
9. Funeral Expenses and Administrative Costs(Schedule H) . .. .. . . . . . . . . . . . . . 9. 1 9 1 8 . 5 0
10. Debts of Decedent,Mortgage Liabilities,and Liens Schedule I 10. 1 0 8 7 7 1 . 8 4
11. Total Deductions(total Lines 9 and 10) .. . . . . . . . . . . . . . . .. . . . . .. . . . . . . . 11. 1 1 0 6 9 0 . 3 4
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . .. . . . . . . . . . . . . . 12. - 1 0 2 3 4 6 . 7 2
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. - 1 0 2 3 4 6 . 7 2
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 _ 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate X.0_ 0 . 0 0 16. 0 . 0 0
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 0 0 18. 0 . 0 0
19. TAX DUE . . . . . . . . . . . . . . . .. . . . . . . .. . . . . .. .. . .. . . . . . . . . . . . . . . . . . . 19. 0 . 0 0
20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
L 1505610240 1505610240
REV-1500 Ex Page 3 Fire Number
Decedent's Complete Address: 21 14 0110
DECEDENT'S NAME
FRANCES A. ZABLOCKY
STREET ADDRESS
1000 WEST SOUTH STREET
CITY STATE ZIP
CARLISLE PA 17013
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+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; ...................................................................... ❑ ❑
b. retain the right to designate who shall use the property transferred or its income; ............................... ❑❑ IZI
c. retain a reversionary interest;or ...................................................... El
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ ❑X
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate considerat ion? ....................................................................................... ❑ ❑JC
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ ❑JC
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. ❑ ❑X
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)(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)(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,undei
Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
FRANCES A.ZABLOCKY 21 14 0110
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
1. F&M TRUST 8,343.62
CHECKING ACCOUNT#3359352
TOTAL(Also enter on Line 5,Recapitulation) $ $343.62
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+(10-00)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN
RESIDENT DECEDENT ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
FRANCES A. ZABLOCKY 21 14 0110
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1. FUNERAL LUNCHEON 700.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representafive(s) BETTY Z. EBERSOLE 400.00
Street Address 32 ASHBURG DRIVE
City MECHANICSBURG State PA ZIP 17050
Year(s)Commission Paid:
2, Attorney Fees: IRWIN & McKNIGHT, P.C. 600.00
3, Family Exemption:(If decedents address is not the same as claimants,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: REGISTER OF WILLS 143.50
6 Accountant Fees:
6. Tax Return Preparer Fees:
7. CUMBERLAND LAW JOURNAL- ESTATE NOTICE 75.00
TOTAL(Also enter on Line 9,Recapitulation) $ 1,918.50
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES Sr LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
FRANCES A. ZABLOCKY 21 14 0110
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. SARAH A. TODD MEMORIAL HOME - NURSING 1,127.95
OUTSTANDING CHECK CLEARED AFTER DATE OF DEATH
2. SARAH A. TODD MEMORIAL HOME - NURSING 73.15
3. DPW CLAIM 107,570.74
CIS#: 370333664
TOTAL(Also enter on Line 10,Recapitulation) $ 108 771.84
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
FRANCES A. ZABLOCKY 21 14 0110
RELATIONSHIP TO DECEDENT AMOUNTORSHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS (Include ouMghtspousal distributions and transfers under
Sec.9116(a)(1.2).]
1. EDWARD CHARLES CASE, JR. Collateral
12930 CLARKSVILLE PIKE REMAINDER
CLARKSVILLE, MD 21029
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
OF
FRANCESA. ZABLOCKY
I,FRANCES A. ZABLOCKY, of Franklin County, Pennsylvania, do make,publish and
declare this to be my Last Will and Testament,hereby revoking all Wills and Codicils which I have
previously made.
ITEM I
I direct my Personal Representative pay all my just debts and all funeral expenses as soon
as practicable following my death. I authorize and direct my Personal Representative to pay my
funeral expenses without the necessity of an order of court and without regard to any applicable
statutory limitation.
ITEM II
My Personal Representative, without any apportionment,shall pay from my residuary
estate all inheritance, estate, succession and other transfer taxes occasioned by my death,together
with the reasonable expenses of determining the same and any interest or penalties thereon not
caused by negligent delay, all probate and on-probate property included in my gross estate or
taxable by reason of my death, whether payable by my estate or by therecipient of any such
property.
ITEM III
I give, devise and bequeath that all the rest,residue and remainder of my estate,both real
property,wherever situate,owned by me at the time of my death and tangible personal property
shall be liquidated.
After all my personal property and estate is liquidated,and all bills are paid,any remaining
monies are to be put in an interest bearing trust account for Edward Charles Case,Jr., son of
Edward Charles and Patricia Kathleen Case.
The trust account cannot be touched until Edward Charles Case Jr. reaches the age of
twenty-five (25)years.
ITEM IV
I constitute and appoint Betty Jane Harris to be my Personal Representative of this, my
Page 1 of 3
Last Will and Testament. If Betty Jane Harris shall fail for any reason to continue or qualify as
Personal Representative hereunder, I constitute and appoint Colleen Kennedy Rettig,Esquire to
serve as my Alternate Personal Representative. All of my Personal Representatives shall serve
without bond,and are authorized to execute on my behalf of my estate any tax return which may
be filed.
My Personal Representative shall be entitled to exercise all of the powers conferred upon
personal representatives by Pennsylvania law, and in addition thereto, shall have the specific
power to invest,reinvest,sell,mortgage or otherwise dispose of all or part of my estate,without the
necessity of obtaining prior or subsequent court approval.
ITEM V
This will cannot be contested.
IN WITNESS WHEREOF, I have hereunto signed my name this Oday of
Jo.nucuri j 2008.
FRANCES A.ZABLgCKY�
The foregoing instrument was signed,published and declared by FRANCES A.
ZABLOCKY,to be her Last Will and Testament,in the presence of both of us,who,at her request,
in her presence and in the presence of each other,have hereunto subscribed our names as witnesses
thereto.
of M i.IneS�o(Oe Pa
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Name
Page 2 of 3
AFFIDAVIT
STATE OF PENNSYLVANIA
ss
COUNTY OF FRANKLIN
WE, the undersigned, the Testator and witnesses, respectively,whose names are signed to
the attached and foregoing instrument,being first duly sworn,do hereby declare to the undersigned
authority that the Testator signed the instrument as her Last Will and Testament and that she signed
voluntarily and that each of the witnesses in the presence of the Testator at her request, and in the
presence of each other, signed the Will as witnesses and that to the best of their knowledge, the
Testator was at least eighteen(18)years of age, of sound mind,and under no constraint or undue
influence.
FRANCES A. ZABL66KY
Witness
WW i6ess
Sworn to and subscribed before me by the Testator, FRANCES A. ZABLOCKY, and
subscribed and sworn to before me by W and MrIG S. of ley ,witnesses,
this , j S-M day of Jani�RYT_. 200
ARY PUBLIC I
Page 3 of 3 AIWARMENM
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February 18, 2014
Irwin&McKnight, P.C.
C/O Douglas G. Miller
60 West Pomfret St.
Carlisle, PA 17013
RE: The Estate Of Frances A Zablocky
Dear Mr. Miller:
In reference to your letter dated February 12`h for the above name, Frances A.Zablocky. Ms.
Zablocky had one deposit account with F&M Trust. The following are answers to your questions:
1. The registered owner of the checking account was tilted:
Frances A Zablocky
32 Ashburg Dr
Mechanicsburg, PA 17050
2. The account was opened on November 04, 1998
3. There was no change of ownership or registration of the account within the last year.
4. There were no accounts open or closed within one year prior to the date of death.
5. The accrued interest to the date of for the Calendar year(2014)was$0.19
6. The date of death balance(principal plus accrued interest) is$8,343.62
If there is any additional information, please do not hesitate to contact me.
Sincerely,
David R.Winters
214A Westminster Dr.
Carlisle, PA 17013
(717)-243-2513
dave.winters@f-mtrust.com
717-264-6116 888-264-6116 P.O.Box 6010 Chambersburg,PA 17201-6010
FINANCIAL SOLUTIONS ... FROM PEOPLE YOU KNOW
Betty Z. Ebersole
32 Ashburg Drive
Mechanicsburg,PA 17050
February 18,2014
Estimated cost of memorial service for Frances A. Zablocky to be held in
Swoyersville PA at the convenience of the family:
Approximate attendance: 20
Cost of room and meal: 20 x $30=$600
Gratuity for minister 100
Total estimated cost $700
STATEMENT
Sarah A Todd Memorial Home /► �� Statement Date: 01/13/2014
1000 West South Street /
Carlisle, PA 17013-2798 Due Date: 01/25/2014
Telephone: (717) 245-2187 jX /
� Amount Enclosed $ 1, 1 J-7, `�J
Amount Due: $ 1,127.95
Account#: 102370
RE: Frances A Zablocky
Betty Ebersole
32 Ashburg Drive
Mechanicsburg, PA 17050
KUMBalance B/F 1,097.95 1,097.95
12/16/13 EBERSOLE, BE TY
12/31/13 Cable Television 1 34.65 34.65 1,097.95 34.65
01/01/14 MEDICARE -1 104.90 -104.90 -70.25
01/01/14 RESIDENT INCOME 1,198.20 1,127.95
Current 31-60 Days 61-90 Days Over 90 Days Amount Due
1,127.95 .00 .00 .00
NOTE: *****PAYMENT IS DUE UPON RECEIPT*****BUT NO LATER
THE 25TH OF THE MONTH***** Please remit the AMOUNT DUE
your statement.Include the ACCT# from the statement on the MEMO Statement Date: 01/13/2014
of your check.Payments after 1/9114 do not reflect on statement. Due Date: 01/25/2014
NOTE:**LATE PAYMENTS ARE SUBJECT TO A 1.25%LATE CHARGE PER
MONTH **A$10.00 FEE WILL BE CHARGED far RETURNED CHECKS
Frances A Zablocky-Account#: 102370
Sarah A Todd Memorial Home
1000 West South Street
Carlisle, PA 17013-2798
Telephone: (717)245-2187
Print View Page 1 of 1
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STATEMENT
Sarah A Todd Memorial Home Statement Date: 02/12/2014
1000 West South Street
Carlisle, P 7013-2798 Due Date: 02/25/2014
Teleph e: (717)245-2187
Amount Enclosed $
Amount Due: $ 73.15
Account#: 102370
RE: Frances A Zablocky
Betty Ebersole
32 Ashburg Drive
Mechanicsburg, PA 17050
BaWnce B/F 1,127.95 1,127.95
01/16/14 EBERSOLE,BETTY 1,127.95 .00
01/01/14 RESIOENTINCOME 19.00 19.00
01/07/14 Guest Meals-Supper SNF 1 6.13 6150 25.50
01/08/14 ue Meals-Supper SNF 1 6.13 6,50 32.00
01109/14 est Meals-Supper SNF 1 6.13 6.50 38.50
01/11/14 Cable Television 1 34.65 34.65 73.15
Current 33-60 Gays 61-90 Days Over 90 pays Amount Due
54.15 19.00 .00 .00 _
NOTE: *****PAYMENT IS DUE UPON RECEIPT*****BUT NO LATER
THE 25TH OF THE MONTH***** Please remit the AMOUNT DUE
your statement.Include the ACCT# from the statement on the MEMO Statement Date: 02/12/2014
of your check.Payments after 2/11/14 do not reflect on statement. Due Date: 02/2512014
NOTE:**LATE PAYMENTS ARE SUBIECT TO A 1.25%LATE CHARGE PER
MONTH **A$10.00 FEE WILL BE CHARGED for RETURNED CHECKS
Frances A Zablocky -Account#: 102370
Sarah A Todd Memorial Home
1000 West South Street
Carlisle, PA 17013-2798
Telephone: (717)245-2187
!` Pennsylvania
} DEPARTMENT OF PUBLIC WELFARE
February 26, 2014
RECEIVED
IRWIN & MCKNIGHT PC
DOUGLAS G MILLER ESQ MAR 0 4 20114
W POMFRET PROFESSIONAL BLDG
60 W POMFRET ST RM&NICKNIGHI
CARLISLE PA 17013-3222 LAWOFPICES
Re: Frances Zablocky
CIS #: 370333664
SSN: ###-##-
Date of Death: 01/12/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Atty Miller:
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.
§1396p(b)(1). 62 P.S. § 1412. This letter sets forth the amount of the Department's claim
against the estate of the above referenced individual and explains the obligations of
executors, administrators, 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 of Claim Amount
The Department maintains a claim in the amount of $107,570.74 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 medical expense, namely $33,373.64, 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 $74,197.10, is to be entered as a priority Class 5.1 claim against the estate.
You should refer to Section 3392 for a more complete explanation of the priority rules.
If a lawsuit is filed for injuries sustained by the decedent prior to death, then the
Department may also have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separately.
Bureau of Program Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486