HomeMy WebLinkAbout06-04-14 .
� 1505610140
REV-1500 EX (02-11)(FI)
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
Po Box 2soso� INHERITANCE TAX RETURN 2 1 0 9 1 1 8 9
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 2 0 1 2 0 0 9 1 1 2 1 1 9 2 5
DecedenYs Last Name Suffix DecedenYs First Name MI
H e r r e R u t h e S
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Sociai Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Return � 2.Suppiemental 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)
QX 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.)
o 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 Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
S t e p h e n F . M o o r e , E s q . 7 1 7 2 3 8 7 5 5 5
I� REGIST€1j OF WILLS Uy�NLY—�7
� O "c � �y
First Line of Address ��� � � �,�
c
d 7i --- t`> � ;::7
._� 7
'^-J ;.�. i" � �„v', r'i
P e t e r s & W a s i l e f s k i ,-- _�> r,.,
Second Line ofAddress �- ��; '
...__ , . ,-� �
2 9 3 1 N o r t h F r o n t S t r e e t � �, o ';; � ���' �'
City or Post Office State ZIP Code � `-�D �E FILED���
--1 1""
H a r r i s b u r g P A 1 7 1 1 0 � w �" °
�
CorrespondenYs e-mail address: Sfm a�pWlegal.COm
Under pe Ities of per ry,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and beiief,
it is true,� � ct and e.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SlGNA7' RE E S N �F�NSIBLE FOR FILING RETURN D E
.,r, v �C 2�v'�1 C- vC ��S(l
ADD S
Je e A. Bra , 330 Colt Drive Grantville PA 17028
SIGNATJ OF PR_Eg�R�OT/H�EgyT�RE�NTATIVE D TE
��t� 1"�� L �i
A RESS
Stephen . Moore, Esquire, 2931 N. Front Street Harrisburg PA 17110
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610140 1505610140 �
� 1505610240
REV-1500 EX(FI)
DecedenYs Social Security Number
Decedenrs r,ame: Ruthe S. Herre
RECAPITULATION
1. Real Estate(Schedule A) �• '
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 Misceilaneous Personal Property(Schedule E). . . . . . . 5. 4 � � � � • � �
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(totaf Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 4 � � � � • � �
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9• � 7 9 4 9 . 6 6
10. Debts of Decedent, Mortgage Liabilities, and Liens(Schedule p . . . . . . . . . . . . 10. •
��. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. � 7 9 4 9 . 6 6
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1z• 2 2 � 5 � . 3 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. 2 2 � 5 � . 3 4
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of�ine 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�inea�rate x .oa5 2 2 0 5 0 . 3 4 16. 9 9 2 . 2 7
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. 9 9 2 . 2 7
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 1505610240 1505610240 �
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: 2� 09 1189
DECEDENT'S NAME
Ruthe S. Herre
STREET ADDRESS
101 Deerfield Road
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) gg2.27
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+B) (2)
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) 992.27
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 ...................................................................... ❑ ❑X
b. retain the right to designate who shall use the property transferred or its income ............................... ❑ �
c. retain a reversionary interest ..................................................................................................... ❑ �
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ �
2. If death occurred after December 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ �
3. Did decedent own an"in trust for"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?.................................................................................................. ❑ ❑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�.5 percent,except as noted in[�2 P.s.§s��6(a)(�)].
• 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 atloption.
REV-1508 EX+(OS-12)
pennsylvania SCHEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENTDECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
Ruthe S. Herre 21 09 1189
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. Survival Claim -Jeffrey Bray, Executor of the Estate of Ruthe Herre, Plaintiffs v. 40,000.00
Grandview Corporate Place Associates and Barry Newhart and James A. Yates,
General Partners; Spirit Physician Services, Inc.; Dr. Peter A. Cardinal; Penncrest
Construction Corp.; and Eastern Motor Inns, Inc. Ud/b/a, Grandview Office Group
Court of Common Pleas of Cumberland County-Docket No. 11-5219
Angino & Rovner-Attorneys' Fees -14,000.00
Litigation Expenses -3,949.66
SEE ATTACHED PETITION FOR APPROVAL OF SURVIVAL SETTLEMENT
PURSUANT TO 20 PA. C.S. SECTION 3323 DATED FEBRUARY 26, 2014 AND
COURT ORDER DATED APRIL 9, 2014 APPROVING DISTRIBUTION OF PROCEEDS
ALSO ATTACHED ARE PAGES 1, 2, AND 3 OF ORIGINAL INHERITANCE TAX
RETURN FILED DECEMBER 20, 2010
TOTAL jAlso enter on Line 5,Recapitulation) $ 22 050.34
If more space is needed, use additional sheets of paper of the same size.
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_ _
ANGINO&R�VNER,P.C.
David L.Lutz, Esquire
Attorney]D#� : =�9�6
4503 North Front Street
Narrisburg. PA 17110-170S
(717)238-6791
FAX(717)238-5610
Attorneys for Plaintiffs
F,-mail:dlu[za,angino-rovner.com
JEFFREY BRAY. EXECUTOR OF THE : IN THE COURT OF COMMON PLEAS
ESTATE OF RUTHE HERRE, : CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff :
v. : CIVIL ACTION—LAW
: NO. 11-5219
GRAl�TDVIEW CORPORATE PLACE :
ASSOCIATES AND BARRY NEWHART :
AND JAMES A. YATES, GENERAL :
PARTNERS; SPIRIT PHYSICIAN :
SERVICES, INC.; DR. PETER A. :
CARDINAL; PENNCREST .
CONSTRUCTION CORP; AND :
EASTERN MOTOR INNS, INC. t/d/b/a; :
GRAI�TDVIEW OFFICE GRGUP, :
Defendant : JURY TRIAL DEMANDED
ORDER
AND NOW, this ���. day of , 2014, upon consideration of the
Petit:on for ,�pproval of the Survival S°ttlement Pursuant to 20 Pa.C.S. §3323, it is hereby
;ays9�
ORDERED and DECREED that the Petition is �ranted. Jeffi�ey A. Bray, ExecLitor of the Estate
is hereby authorized to execute the Release. The settlement tunds shall distributed as follo�vs:
Estate of Ruthe E. Herre $22,0�0.34
Angino & Rovner, P.C.
35% attorney's fee $14,000.00
Expenses _ _ $ 3,949.66 _ _.
TOTAL ANTOUNT OF SETTLEM�NT �40,000.00
BY THE COURT:
��r����� ���"�
-�
>` J.
DISTRIBLITION:
Hugh P. 0'Neill, III, Esquire Thomas M. Chairs, Esquire
Peter J. Spe.aker, Esquire Dickie, McCamey & Chilcote, P.C.
Thomas, Tilomas & Hafer Plaza 21, Suite 302
305 Nortr.Front Street 425 North 21st Street
P.O. Box 999 Camp Hill, PA 17011
Harrisburg, PA 17108 Attoiney for Spirit Physician
Attorneys for Defendants Services, Inc. and Peter A. Cardinal
Gra�dview Coiporate Place Assocs.,
Barry Newhart and James A. Yates
Gregory Cassimatis, Esquire
Cinncirulati Insurance
4999 Louise Drive
Suite 103
Mechanicsburg, PA 17055
(717) 791-0400
Atiorney for Defendant Eastern Motor Inns;
Inc. t/d/b/a Grandview Off ce Group
Thomas B. Sponaugle, Esquire
Griftith, Strickler, Lerman, Solymos & Calkins
1 i 0 South Northern Way
York, PA 17402-3737
(71%) 757-7602 __.
Attorney for Defendant Penncrest Const. Corp.
TRUE COP�( Ff�fJM RECORD
In�'esfimony whereof, I here unto se#my hand
and th .se of said Co rt at riisle, Pa.
This Y�f--1���-- 20�
� Prothon ary
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ANGINQ&ROVNER,P.C.
Michael E. Kosik,Esquire
Attorney ID# : 35513
4503 North Front Street
Harrisburo,PA 17110-1708
(717)238-6791
FAX(7l7)2;8-5610
Atto�:neys for Plaintiff(s)
E-maiL mkosikVangino-rovner.com
JEFFREY BRAY, EXECUTOR OF THE : IN THE COURT OF COMMON PLEAS
ESTATE OF RUTHE HERRE, : CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff :
�• : CIVIL ACTION—LAW
: NO. 11-5219
GRANDVIEU' CORPORATE PLACE :
ASSOGIATES AND BARRY NEWHART :
AND JAMES A. YATES, GENERAL :
PARTNERS; SPIRIT PHYSICIAN :
SERVICES, INC.; DR. PETER A. :
CARDP�TAL; PENNCREST :
CONSTRUCTION CORP; AND :
EASTERN MOTOR INNS, INC. t/dlb;a, :
GRANDVIEW OFFICE GR.OUP, :
Defendant : JURY TRIAL DEMANDED
PETITION FOR ApIPROVAL OF SUR�'IVAL SETTLEMENT'
PURS�TANT TO 20 PA. C.S. �3323
AND NOW, comes Petitioner Jeifrey Bray, Executor of the Estate of Ruthe Herre,
Deceased, seeking Court Approval of the settlement of the survival claim on behalf of the
beneficiaries of the Estate, respectfully representing the following:
546243
1. Petitioner Jeffrey. Bray, is the son of the Decedent who has been appointed the
Executor of the Estate of Ruthe Herre by virtue of Letters Testamentary granted to hiin by the
Register of Wills of Cuinberland County; Pennsylvania, on 23`d day of December 20G9. See
Certificate of Grant of Letters Testamentary attached hereto as Exhibit A.
2. Petitioner's Decedent's claim arises out of an incident on July 10, 2009 when
Petitioner's Decedent was walking through a main entrance/exit hallway at 205 Grandview
Avcnue, Enola, Cumberlar�d Caunty, Penr,sylvania.
3. Petitioner's Decedent's was injured as she )eaving the Beltone Hearing aid office
located on the second floor of the building and she was walking up the hallway when she was
struck by a door leading from a conference room in the offices of Defendant Spirit Physician
Services, Inc. through which Defendant Dr. Peter A. Cardinal was exiting.
4. Defendant Peter A. Cardinal has sought a Stipulation seeking to discontinue the
actior_against him and which may be pending v��ith the Court.
5. Defendant Grandview Place Associates and Defendant Barry Newhart and
Defendant James Yates were general partners in Grandview who owned the building from the
time it was built around l 990 through the time it was sold on October 10, 2008.
6. Defendant Pennerest Construction Corp. is a Pennsylvania corporation which was
the original contractor for the building as well as the contractor responsible for reconstruction
and remodeling of the office suite before it was subsequently rented to Defendant Spirit
Physician Services, Inc.
7. Defendant Eastern Motor Inns, Inc. t/d/b/a Grandview Office Group was the
owner of the property at the time of Petitioner's Decedent's accideut and had been the owner of
the building since October 10, 2008.
546243
8. The case had previously been the subject of a Motion for Judgment on the
Pleadings filed by Defendants Grandview Corporate Place Associates, Bar:y Newhart and James
Yates �vhich was denied by the Court on March 11, 2013.
9. As a result of the incident on July 10, 2009, Petitioner's Decedent's sustained a
broken left hip for which she required treatment and hospitalization.
10. On December 1, 2009, Petitioner's Decedent Ruthe Herre, who was 83 years old,
died unreiated io �he injuries sustained ir�th� 3uly 2GU9 incident.
1?. Petitioner, Teffrey Bray, Executor of the Estate of Ruth Herre instituted suit
against the various Detendants on June 24,.2011 in Cumberland County seeking to recover for
personal injuries sustained by the Petition�,r's Decedent.
12. Petitioner's Decedent Ruthe Herre was not employed at the time of the accident
and had retired before the date of accident and, therefore, there was no claim for lost eaining or
earning capacity.
13. PPtitioner's Decedent's Ruthe Herre incuned medical bills directly related to the
medical treatment resulting from the incident �vhich were paid by Advantra HMO for which no
right of subrogation has been asserted, anc! therefore, no claiin for medical expenses was pursued ..
as part of this setilement.
14. Petitioner through counsel confirmed that Ivledicare is not asserting a lien for
payment of any medical bills. See letter from CMS/MSPRC dated January 13, 2012 attached as
Exhibit B.
15. Petitioner, Jeffrey Bray, on behalf of the Estate, has agreed to resolve the personal
injury claim which arose prior to his mother.'s death with the various Defenda�its for an amount
of$40;000.00.
�4Ci243
16. I�TO claim for wrongful death damages pursuant to 42 Pa.C.S.A. �8301 is possible,
and therefore, the total settlement is being allocated to the Survival Action pursuant to 42
Pa.C.S.A. §830'L, and therefore no approval or allocation was necessary from the Pennsylvania
Department of Revenue.
17. The beneficiaries of the Estate are the Petitioner, Jeffrey Bray, 330 Colt Drive,
Grantville, PA 17028 who is Decedent's son, as well as his brother, John Bray, 12 Little
Swatara C�urch Road, Richiaiid, PA 17087.
18. There are no outstanding debts of the Estate.
19. P:ior to her death, Petitioner's Decedent retained the la�v firm of Angino �
�ovner, P.C. t� prosecute tnis action and recover against the Defendants and entered into a
contingency fee agreement with said attorneys providing fees for the professional services and a
percentage oi any amount recovered plus expenses.
20. Your Petitioner has agreed, subject to approval of Your Honorable Court, to pay
Angino & Rovner the sum of $14,000.00 for the work it has performed on Petitioners' claim
which amounts to a fee of 35°/o.
21. Angino & Rovner, P.C. has incurred expenses of $3,949.66 in obtaining medical
records; expert review, and deposition costs.
22. Plaintiff is represented by Michael E. Kosik, Esquire of Angino & Rovner, P.C.,
4503 North Front Street, Harrisburg, PA 17110, (71?) 238-6791.
23. Defendant Grandview Corporate Place Associates, Barry Newhart and James A.
Yates are represented by Hugh P. 0'Neill, III, Esquire, Thomas, Thomas & Hafer, PO Box 999,
Harrisburg, PA 17108, (717)237-7100.
546243
24. Defendant Eastern Motor Inns, Ii.c. t/d/b/a Grandview Office Group is
represented by Gregory Cassimatis,.Esquire, Cincinnati Insurance, 4999 Louis Drive, Suite 103,
Mechanic�burg, PA 17055, (717) 791-0400.
25. Defendant Penncrest Construction Corporation is represented by Thomas B.
Sponaugle, Esquire, Griffith, Strickler, Lerman, Solymos & Calkins, 110 .South Northern Way,
York, PA 17402-3737, (717) 757-7602.
26. Defendant Spirit Physician Sei-vices, Inc. and Dr. Peter A. Cardinal are
represente.d by Thomas 1V1. Chairs, Esquire, Dickie, McCamey & Chilc�te, P.C., Plaza 2.1, Suite
30"Z, 42� rlortl�.21St Street, Camp Hill, PA 1701 l, (717) ?31-4800.
27. All Defendarits are participating in the settleinent and therefore concur with the
filir�g of this Petition.
28. Judge Christylee L. Peck has previously ruled on this case by Order dated March
11, 2013. �
WHEREFORE, Petitioner prays your Honorable Court to enter an order approving said
coinpromise settlement, directing the distribution of the proceeds thereof in accordance with the
averment of this Petition, and authorizing your Petitioner, upon payiilent of the aforesaid sums
and payment of the record costs by the Defendant, to mark the action settled and discontinued
and to execute anci deliver to the Defendant sufficient release discharging it, its heirs,�ancl assigns
and any and all other persons, associates or corporations from any claim, demand, right of cause
�46243
of action arising from or as a result of the injuries and ultimate death suffered by Ruthe E. Herre,
Decedent.
AN O V. ER, P.C.
Michael E. Kosik
I.D. No. 36513
4503 N. Front Street
Harrisburg, PA 17110
(717) 238-6791
Attorney for Petitioner
546243
VERIFICATION
I, JEFFREY BRAY, EXECUTOR OF THE ESTATE OF RUTHE HERRE, do swear and
affinn that the facts set forth in the foregoing PETITION are true and correct to the best of my
knowledge, information and belief. I understand that this verification is made subject to the
penalties of the Rules of Civil Procedure relating to unsworn falsification to authorities.
__
+ `r` Av `.�"
�;�� 11� 1 �
JEF��'�'`B I�, EX CUTOR OF THE
ESTATE OF RUTHE HERRE
;
Dated: `'�'`�,�t�
546243
� 15056�7121
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of individual Taxes County Code Year File Number
POBOX280601 INHERITANCE TAX RETURN
Hamsburg,PA t7128-OSOt RESIDENT DECEDENT 2 1 0 9 1 1 8 9
ENTER DECEDENT INFORMATION BELOW
Sociai Security Number Date of Death Date of Birth
1 8 � 2 0 1 2 1 4 1 2 � 1 2 0 0 9 1, 1 2 1 1 9 2 5
DecedenYs Last Name Su�x DecedenYs First Name MI
H e r r e R u t h e S
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Sociai Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
O 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)
QX 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 � 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 SNOULD BE DIRECTED T0:
Name Daytime Telephone Number
S t e p h e n F • M o o r e , E s q • 7 1 7 2 3 8 7 5 5 5
Firm Name(If Applicable) _,
� REGISTER OF WILLS USE ONLY
P e t e r s & W a s i 1 e f s k i ', '=' '
First line of address �I �p ��' �7�
�� G7 r,r�C7
2 9 3 1 N o r t h F r o n t S t r e e t ' =�' �' '�- ��
��� � ,�'-; -=,
Second line of address � ��� �''� a- .`�_'''
I C70� �: 'j —ri
Ciry or Post Office State ZIP Code ��gILED _ _ a__ �--�
�� � f_T7
H a r r i s b u r g P A 1 7 1 1 0 D � `"�
�
Correspon nP e-maii addr s:sfm(a�pwlegal.com
Under pen Ges of p rjury,I dec at I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is Uue, rred an p ete. clar ion ot preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGN URE E N ES L R FILING RE,ZURGe�r n � ' l I��j'i9 /I O
E�C (?f' 'ioC�-
AO
Jeff e - Bra , 330 Colt Drive Grantville PA 17028
SIGNAT F PR RER OTHER THAN REPRESENTATIVE ATE
� � �
ADD ESS
S • F . M ore , Esq • 2931, N •Front Street Harrisburq PA 17110
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 15�5607121 1505607121 �
� 1505607221
REV-1500 EX
DecedenYs Social Security Number
DecedenYs Name: RUthe S. He��e 1 8 0 2 0 1 2 1 4
RECAPITULATION
1. Real estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1•
1 8 0 0 0 0 , 0 0
2. Stocks and Bonds(Schedule B) $ 9 3 3 6 . 9 6
. .. . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. .. . 3. •
4. Mortgages&Notes Receivable(Schedule D) . . .. . . . . . . . . . . . . . . . . . . . . 4. •
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E) . . . .. . . 5. 4 � $ � 4 • 6 8
6. Jointiy 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 1-7) . . .. . . . . . . . . . . . . . . .. . . . . . . . 8. 3 � 0 � 4 1 � 6 4
9. Funeral Expenses 8�Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . 9. 2 4 5 1 � � 2 7
10. Debts of Decedent,Mort a e Liabilities,&Liens Schedule I 10. 9 1 8 3 $ , 7 4
9 9 ( ) . . . . . . . . . . . .
��. Total Deductions(total Lines 9 8 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. � 1 6 3 5 0 , 0 1
12.Net Value of Estate(Line 8 minus Line 11) . .. . . . . . . . . . . . . . . . .. ... . . 12• � 9 3 7 9 � , 6 3
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. � 9 3 7 9 � , 6 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 0 _ � . � O 15. O . � �
16. Amount of Line 14 taxable 1 8 7 5 4 1 . 6 4 8 4 3 9 . 3 7
at lineal rate X .045 �g,
17. Amount of Line 14 taxable
at sibling rate X.12 � • � � 17. � • � �
18. Amount of Line 14 taxable 6 2 5 0 . 0 0 9 3 7 . 5 0
at collateral rate X.15 18.
19.Tax Due . . .. . . . . . .. . . . . . . . .. ... .. . . . . . . . . . . .. . . .. . . . . . . . 19. 9 3 7 6 . 8 7
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑X
Side 2
� 1505607221 1505607221 J
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 2� os 1189
DECEDENT'S NAME
Ruthe S. Herre
STREETADDRESS -
101 Deerfield Road
��n STATE � ZIP
Camp Hill PA � 17011
Tax Payments and Credits:
1� Tax Due(Page 2 Line 19) (1) 9,376.87
2. Credits/Payments
A.Spousal Poverty Credit
B.Prior Payments 10,849.38
C.Discount
?c,al Credits(A+g+�) (2) 10.849.38
3. InteresUPenalty if applicable
D.Interest
E.Penalty
Total InteresUPenalty(D+E) (3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT.
Fill in ovai on Page 2,Line 20 to request a refund. (4) 1,472.51
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
A.Enter the interest on the tax due. (5A)
B.Enter the total of Line 5+5A.This is the BALANCE DUE. (56) 0.00
Make Check Payabie 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; ............................... ❑ OX
c. retain a reversionary interest:or ................................................................................................ ❑ X❑
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ �
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ �
3. Did decedent own an"in trust for'or payable upon death bank account or security at his or her death? ......... ❑ �X
4, Did decedent own an Individual Retirement Account,annuity,or other non-probate property which
contains a beneflciary 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 afler July 1,1994 and before January 1,1995,ihe tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three(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 zero(0)percent
[72 P.S.§9116(a)(1.1)(ii)J.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 twenty-one 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 zero(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 decedenCs lineal beneficiaries is four and one-half(4.5)percent,except as noted in
72 P.S.§9116(1.2)p2 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 twelve(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.
� �. a,�..�.��.�.� .�..�� �� �� _ ,�, �.� �� ��� ��.,�„�.�,� ..
HOLSWORTH, SANDER AND ASSOCIATES, P. C.
ATTORNEYS AT LAW
5801 BROWNSVILLE ROAD
PITTSBURGH,PA 15236
CHARLES L.HOLSWORTH PHONE:(412)653-2556
JAMES M.SANDER FAX:(412)653-2558 �
CURTISJ.GALLATIN e-mail:llblswoKh.larv��aorQ �
oFCOUNSEC: June 2, 2014 � o � ,~,��, rn
MALVIN G.SANDER � � C Ga a
rn �' c� z ��� �
Cumberland County Register of Wiils � �� r°, � ��+ �
1 Courthouse Square, Room 102 � `y= _ �f �
,., �
Carlisle, PA 17013 � G `�; � .��� �
.J C":. .'�-
. � N t=� Rj
In Re: Estate of Patricia A. Grohol � � � � °
File Number: 21-13-01258
To Whom It May Concern:
Please find enclosed several items for filing.
1. The original Inheritance Tax Return, one copy and a coversheet.
A check is also enclosed for payment of inheritance tax.
2. The Inventory and a copy.
3. Satisfaction and Release of Claim, one copy and a coversheet. A
check is also enclosed for filing
Please file and stamp the coversheets as filed and return them together with the
receipt to our office in the enclosed, stamped envelope. If you have any questions,
please do not hesitate to contact our office by telephone or at our email address.
Sincerely,
Li-.a�� L. l,�.��;���
��Charles L. Holsworth
CLH:tIj
Enclosures: Inheritance Tax Return & 1 copy
Inventory
Satisfaction and Release of Claim
Checks for$1,378.12 & $10.00
Coversheets