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Home My WebLink About05-15-14 ( 1505610140 —I REV-1500 EX (02-11)(FI) OFFICIAL USE ONLY Department of Revenue Bu reau of Individual Taxes County Code Year File Number Bu Po sox zaasol INHERITANCE TAX RETURN 2 1 1 4 0 2 4 3 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date Of Death MMDDYYYY Date of Birth MMDDYYYY 0 7 1 5 2 0 1 3 0 3 2 0 1 9 2 4 Decedent's Last Name Suffix Decedent's First Name MI D I C K E N B E T T Y (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 Q 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) 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 El 11.Election to Tax under Sec.9113(A) Between 12-31-91 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 H U 8 E R T X - G I L R O Y E S Q 7 1 7 2 4 3 3 3,4 1 Ic,> C.`• __ __ l REGISTERS USE O .,y �L7 T' C 1 A lira First Line of Address --T,- Cn 1 0 E A S T H I G H S T R E E Tc'> ZD Second Line of Address City or Post Office State ZIP Code ---..DATE FILED C:> — w. C A R L I S L E P A 1 7 0 1 3 Correspondent's e-mail address: 11GILROY(a)a,MARTSONLAW,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 true and complete.Declaration of parer other than the personal representative is based on all information of which preparer has any knowledge. SIQ&ATUR ERSO B R Fll_!%a RETURN DATE _Vgettz.4 ADDRESS + - 5388 ER AP ROAD LANDISBURG PA 17040 S DATE S EAST HIGHT STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 \ 1505610240 REV-1500 EX(Fl) Decedent's Social Security Number Decedent's Name: BETTY DICKEN 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 2 8 3 , 6 8 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested 6. 7. Inter-Vivos Transfers&Miscellaneous N n-Probate Property (Schedule G) t Separate Billing Requested . . . . . . . 7, 8. Total Gross Assets(total Lines 1 through 7) 8. 2 2 8 3 . 6 8 9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . 9. 5 0 9 3 . 5 0 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . . . . 10. 2 2 1 1 3 1 . 0 8 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 11. 2 2 6 2 2 4 . 5 8 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 12 - 2 2 3 9 4 Q . 9 Q an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 14 - 2 2 3 9 4 0 . 9 0 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. 16. Amount of Line 14 taxable 0 . 0 0 at lineal rate X .0- 11 . 0 0 17. Amount of Line 14 taxable 16' 0 . 0 Q at sibling rate X.12 0 . 0 0 17, 18. Amount of Line 14 taxable 0 . 0 0 at collateral rate X.15 0 . 0 0 18 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610240 1505610240 REV-1500 EX(F!) Page 3 File Number Decedent's Complete Address: 21 14 0243 DECEDENTS NAME BETTY DICKEN STREETADDRESS ii- 1000 Claremont Drive CITY —,.._.— ---- ----- —._..._--- STATE , zip �i---- Carlisle PA ; 17013 Tax Payments and Credits: I. Tax Due(Page 2,Line 19) {t) 0.00 2. Credits/Payments A.Prior Payments B.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 ........................................................................ ❑ IZI b. retain the right to designate who shall use the property transferred or its income ❑ FRI c, retain a reversionary interest ..................................................................................................... ❑ 0 d. receive the promise for life of either payments,benefits or care? ..._.................................................. ❑ 2. If death occurred after December 12,198Z did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... 171 n 3. Did decedent own an'intrust for'or payable-upon-death bank account or security at his or her death? ....... ,. ❑ n 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)(11)(1)]. 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 172 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 fling 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 172 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 f72 P.S.g9116(a)(1)I • The tax rate imposed on the net value of transfers to or for the use of the decedents 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-(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE INHERITANCE TAX RETURN CASH, BANK DEPOSITS & MISC. RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: BETTY DICKEN FILE NUMBER: 21 14 0243 Include the proceeds of litigation and the date the proceeds were received by the estate. ITEM All property jointly owned with right of survivorship must be disclosed on Schedule F. NUMBER DESCRIPTION VALUE AT DATE 1. Santander Bank ckecking#2474068198 OF DEATH ($2,283.60+$.08 interest) 2,283.68 See attached 2 Pruco Life Insurance Company Policy#R5248159,beneficiary:Estate 0.00 Procee ds: $5,540.79. See attached TOTAL(Also enter on Line 5,Recapitulation) $ 2,283.68 If more space is needed, use additional sheets of paper of the same size. REV-1591 U+(08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER BETTY DICKEN 21 14 0243 Decedents debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: 1. Boyer Funeral Home,New Bloomfield,PA 2,575,00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Thomas H.Hager,111 390.00 Sheet Address 5388 Waggoners Gap Road City Landisburg State PA Zip 17040 Years)Commission Paid: 2014 2, Attorney Fees: Martson Law Offices(estimated) 2,000.00 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,Cumberland County 88.50 51 Accountant Fees: $. Tau Return Preparer Fees: 7. Petition filing fee 20.00 8, Santander Bank,fee to obtain date of death value 20.00 TOTAL(Also enter on Line 9,Recapitulation) $ 5,093.50 If mom 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& LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER BETTY DICKEN 21 14 0243 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. PA Department of Public Welfare,CIS#150207683 221,131.0$ See attached TOTAL(Also enter on Line 10,Recapitulation) $ 221 131.0$ If more space is needed,insert additional sheets of the same size. Santander ESTATE OF Betty J Dicken SOCIAL SECURITY#: DATE OF DEATH: July 15, 2013 Account#: 2474068198 Type: Money Market Open date: 1/11/2008 In the name of: Betty J Dicken (Thomas H Hager POA) Date of Death Balance: $2,283.60 Int.(YTD) from 1/1/2013 to 7/9/2013 $6.34 Accrued interest to date of death: $0.08 Other Info: Page 1 of 1 Form / 1 L (Rev.May 2000) Life Insurance Statement OMB No. 1545-0022 Deaanment of the Treasury Internal Revenua S.mm Decedent—Insured (To be filed by the executor with Form 706,United States Estate(and Generation-Skipping Transfer)Tax Return,or Form 706-NA,United States Estate(and Generation-Skipping Transfer)Tax Return,Estate of nonresident not a citizen of the United States.) 1 Decedent's first name and middle initial 2 Decedent's last name 3 Decedent's social security number 4 Date of death Betty J I Dicken (ifknown) 07/15/2013 5 Name and address of insurance company Pruco Life Insurance Company,PO Box 13902. Philadel hia. PA 19176 6 Type of policy 7 Policy number Pruvider R5248159 8 Owner's name. If decedent is not owner, 9 Date issued 10 Assignor's name.Attach copy of 11 Date assigned attach copy of application. assignment. 03/19/1993 12 Value of the policy at the 13 Amount of premium(see instructions) 14 Name of beneficiaries time of assignment Thomas H Hager III Admin Of The Estate $430 . 96 Pf Betty Dicken 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 15 $ 5, 000.0 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . 16 $ 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . 17 $ 540.79 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . T8 $ 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . 19 $ 20 Interest on indebtedness (line 19) accrued to date of death. . . . . . . . . . . . . 20 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 21 $ 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 22,$ 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . 23 $ 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . 24 $ 5, 540.79 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . 25 $ 26 Policy provisions concerning deferred payments or installments. Note: If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of the insurance policy. / 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . 27 $ 28 Date of birth,sex,and name of any person the duration of whose life may measure the number of payments. 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . 29 $ 30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits. 31 Were there any transfers of the policy within the three years prior to the death of the decedent? . . . ❑ Yes ❑ No 32 Date of assignment or transfer: Month Day Year 33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? . . . . ❑ Yes ❑ No 34 Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by him/her at the date of death? . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No 35 Names of companies with which decedent canted other policies and amount of such policies if this information is disclosed by your records. The undersigned officer of the above-named insurance company(or appropriate Federal agency or retirement system official)hereby certifies that this statement sets forth true and correct information. Signature ► Gj -- Tine ► Secretary Data of Certmwnon ►03/2 5/14 Cat.No.10170V Form 712 (Rev.52000) • pennsylvania DEPARTMENT OF PUBLIC WELFARE April 9, 2014 MARTSON DEARDORFF WILLIAMS OTTO GILROY & FALLER HUBERT X GILROY ESQUIRE 10E HIGH ST CARLISLE PA 17013 Re: Betty Dicken CIS #: 150207683 SSN: ###-##- Date of Death: 07/15/2013 r ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Gilroy: 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$221.131.08 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 $30.416.68, 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 $190.714.40, 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 l Recovery Section PO Box 8486 1 Harrisburg,Pennsylvania 17145-8486