HomeMy WebLinkAbout06-27-14 (2) 1505610143
REV-'1500 Ex(�-11> ,.�
PA Department of Revenue - OFFICIAL USE ONLY
p Pennsylvania County Code Year File Number
Bureau of Individual Taxes MPARrIeEM Of asOENYE
PO BOX.280601 INHERITANCE TAX RETURN t ! 1
Harrisburg.PA 17128-0801 RESIDENT DECEDENT 21 f' 14 tot
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
10 02 2013 08 14 1912
Decedent's Last Name Suffix Decedent's First Name MI
HILLEGAS LOTTIE
(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
1. Original Return 2. Supplemental Return L] 3, Remainder Return(Date of Death
Prior to 12-13-52)
4. Limited Estate 41.Future m ereet Compranise `� 5. Federal Estate Tax Return Required
(date of death after 1242-E2)
f� g, Decadent Died Testate I" Decede t Main Netl a Living Trust 0 e, Total Number of Safe Deposit Boxes
l (Atlatli COPY Of VJIIp I_J (Attach RGopy o�aimsl) p0
I 9. Litigation Proceeds Received 10.SG usal Pov Crwft Data&Death t t.Election t0 tax under Sea 91 i3 A
i-1 n2°N,aen 12-31 and -1-95) u (Attach Schedule O) ( )
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
SUSAN E LEDERER 717 652 7323
r.�
/ter o
+" REGISTETWF_kMLLS U4 ON N, F T
First Line of Address rT1 --�fv
r—
5011 LOCUST LANE --�—.- 71 M r i
Second Line of Address 4 `0
CD O
City or Post Office FILED r o t---
State ZIP Code
HARRISBURG PA 17109 ca �'1
Correspondent's e-mail address: Susa idDledererlaw.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,correct and complete.Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
Ona"6Lt. TD Shirley M.Westhafer (A .�5 f I
ADDRESS
6604-A Carlisle Pike, Mechanicsburg, PA 17050
S NATURE OF PREPARER OTHER THAN REPRESENTATIVE DAT
A _ � Susan E. Lederer SI}�{
ADDRESS
5011 Locust Lane, Harrisburg, PA 17109
Side 1
1505610143 1505610143
J 1505610243
REV-1500 EX
Decedent's Social Security Number
Decetlent'sNama' j�jjjegdS, Lottie
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&Notes Receivable(Schedule D)........................................................ 4.
5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 8 , 007 . 22
6. Jointly Owned Property(Schedule F) 11 Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) U Separate Billing Requested.... 7. 9, 371 . 65
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 17 ,378 . 87
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 10 , 386 . 65
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)............................ 10. 6, 434 . 46
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 16, 821 . 11
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12, 557 . 76
13. Charitable and Governmental Bequests/Sec 9113 Trusts forwhich
an election to tax has not been made(Schedule J)............................................... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 557 . 76
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 . 00
16. Amount of Line 14 taxable
at lineal rate X .045 557 . 76 16. 25 . 10
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................................................................................................................ 19. 25 . 10
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-14
Decedent's Complete Address:
DECEDENTS NAME
Hillegas, Lottie
STREETADDRESS
1000 Claremont Road
CITY STATE ZIP
Carlisle PA 17413
Tax Payments and Credits:
t. Tax Due(Page 2,Line 19) (t} 25.10
2. Credfts/Payments
A. Prior Payments
B. Discount OM
Total Credits(A +B) (2) 0.00
1 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) 25.10
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;.................................. x�
a 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, did decedent transfer property within one year of death without
receiving adequate consideration?................ ........................................................................................... ❑ 0
3. Did decedent own an 1n 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 t��t
contains a beneficiary designation?................ ....... ...-... .... ... .... ........ .......... ................... k_zJ ❑
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)(1)).
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
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
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 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[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 individual who has at least one parent in common with the decedent,whether by blood or adoption.
RcvA508 Ex,(1140f
SCHEDULE E
pennsyivania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hilfegas, Lottie 21-14
Indudp the proceeds of Illigation end the dote fho proceeds WeM tnCCIVpG 1sy the 85f820.
All pmperty)olnityo mlwim the right olsurvivorship must be Elaclosod on echetlula F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Checking Account No.1007011072786,held at Wells Fargo Bank,titled to Lottie Hilfegas 7,469.52
2 Check from Capital Blue Cross(refund of health insurance premium) 437.70
3 Miscellaneous personal property 100.00
TOTAL(Also enter on Line 5.Recapitulation) 8.007.22
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Fonn PA-1500 Schedule E(Rev. 11.10)
Rev-1510 E%+(08-09)
CHEDULE G
pPennsylvania SINTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCE 7A%RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF
Hilleclas, Lottie FILE NUMBER
21-14
This schedule must be completed and filed If the answer to any of Questions t
through 4 on page dlree of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY
NUMBER THELI T E O F T R O A F N S F E R.S A T f A C(1 A C O P Y o f THE DEIED FOR REAL ESTATE. VALUE OF AS$ET % DECO'S (IF APPLICABLE
INTEREST EXCLUSION TAXABLE
1 Jeffrey A. Naugle Funeral and Cremation Services ) VALUE
(prepaid funeral contract) 9,371.65 100.000% 9,371.65
TOTAL(Also enter on Line 7, Recapitulation)
is 9,371.65
Copyright(c)2009 form software only The(Lackner Group,Inc.n additional pages of the same size)
Form PA-1500 Schedule G(Rev.08-09)
REV-1511 Ex+(19419)
Pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX
RESIDENT DEC ENTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Hiliegas, Lottie 21-14
Decedent's debts must be reported on Schedule 1.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
Jeffrey A. Naugle Funeral and Cremation Service
9,371.65
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid Waived
2, Attorney's Fees Law Offices of Susan E. Lederer(estimate) 1,000.00
3. Family Exemption: (If decedent's 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's Fees
6. Tax Return Preparefs Fees
7. other Administrative Costs Cumberland County Register of Wills(filing fee) 15.00
TOTAL(Also enter on line 9, Recapitulation) 10,386.65
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09)
Rev-1612 EX+112,oej
pennsylvania SCHEDULE 1
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF
Hille as, Lottie FILE NUMBER
21-14
ITEM Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbun dmedical expermtm.
NUMBER
DESCRIPTION VALUE AT DATE
1 Claremont Nursing Rehab Center OF DEATH
9 (patient care)
2 Alert Pharmacy ervices; Inc. 6,259.83
Y (prescription bill)
174.63
TOTAL(Also enter on Line 10, Recapitulation) 6,434.46
Copyright(c)2008 form software only The(if Lackner Group, Inceq adtlitional pages of the same size)
Form PA-1500 Schedule I(Rev. 12-08)
REV-1613 EX.(01 40(
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hille as, Lottie 21-14
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$)
I TAXABLE DISTRIBUTIONS (include outright spousal
distributions,and transfers
under Sec.91 16 a 1.2
Shirley A.Westhafer Daughter 100%of 557.76
6604-A Carlisle Pike residuary estate
Mechanicsburg, PA 17050
Total 557.76
Enter dollar amounts for distributions shown above on lines 15 through 16 on Rev 1500 cover sheet,as aODrov riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART It-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 4 500 Schedule J(Rev.01-10)
-et
Wells Fargo"' Essential Checking
Account number:1 00701 1 07 2 786 r September 7,2013-October 4,2013 a Page i of 3 +F _
F.ODCKTDTttFi 015:05 Questions?
Utlllil' 'ulstIII I'lllR'!"it'111'lllli111'11Ilrr'r'rm!lilr
LOTTiE HiLLEGAS Available by phone 24 boors a day,7 days a work:
6604A CARLISLE PIKE 1-800-T4-WELLS (1-500-869-3557)
MECHANICSBURG PA 17050-1706 7T 9 1-800.877-4833
Fn espatiol. 1-877-727-2932
M 1-800-288-2288(6 am to 7 pm PT,M-F)
Online:wellsfargo.com
Write: Weiss Fargo Bank,N.A.(345)
P.Q.Box 6995
Portland,OR 97228.6995 �n
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You and Wells Fargo Account options
Thank you for being a loyal Wells Fargo customer.We value your trust in our A check mark in the box indicates you have these
company and took forward to continuing to serve you with your financial needs, convenient services with your0«aunt. Go to z
wellsfarga•com or call the number above ifynu have i
questions or it you would like to add new services. z l
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Online Bill Pay Auto"l4ansfedPayment e
Online Statements Overdraft Protection z
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My Spending Report Overdraft Service I A
You could go to Super Cowl XLVtii in NY7N1,courtesy of Visa!
Learn more by visiting wellsfargo.comffootball
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No purchase or obligation necessary to enter or win. m
Activity summary Acconitnumber: 1007011072786
Beginning balance on 9l7 $8,546.52 LOTITE HILLEGAS
DepositsiAddiuons 25630 Pennsylvania account terms and conditions apply
Wthdrawai•Jsubtractioos - 1,335.30 rot Direct Deposit and Automatic Payments use
Ending balance an 1014 $7,467.52 Routing Number(RTN):031000503
Overdraft protection
This account is not currently covered by Overdraft Protection, if you would like more information regarding Overdraft Protection and eligibility requirements
please call the number listed tin your statement or visit your wells Fargo store.
Account number:1007011072786 ■ September 7,2013-October 4,2013 n Page 2 of 3 M
Transaction history
Check Deposits/ t'Vithdrerwors! Ending doily
Date Number Vescpown A d �n�n.S S u b fol7f,_e� 5- (60A
?,eFe.37
9119 3056 Check 673.15 7,213.22
iinatwi!iated Life Pension 130924 - - --- - -- -i2bJo. . . . . . . . . .. . . .
National Reuiem Pe.Mica I 3D924 xxxxXB6 i-9 Larne Hillegoss 6: 7i4160.52
...
-monthly lfheck Retu',nA,una,ge,5,tort Fee", ,- ," " 11.._...1".11
Ending balopce9n 1014 7,467.52
Totals $256.30 $1,33530
The Ending Daily Balance does not reflect any pending withdrawals orholds on deposited funds thatmoy have been outstanding an youraccounr when your
tromactionspoved. If you had insufficient available funds when 0 transaction posted,fees mayhove been assessed
Suronaaryof checks written(checks listed are also displayed in fine preceding Transoction history)
Number Date Ammar Number Elate Amount
3055 911i 6fi0.t5 3056 9179 673.15
IMPORTANT ACCOUNT INFORMATION
Revised Agreement forOnfine Banking
We've updated our Online Access Agreement,
lo see what has changed,please visit wellsfargo.com/onlineupdates.
wells Cargo Liepositect item uctaits I-a-14C I ul
01 Wells Fargo Online''
Deposited Item Details
Deposit#665773792 to Crown Classic XXXXXXXXX8439
Deposit
Date Description Amount Status
02/03/14 DEPOSIT MADE IN BRANCHISTORE#665773792 $437.70 Posted
02103714
Deposit Item(I of 1)
Item# Bank Account# Check# Amount
I MANUFACTURERS&TRADERS TR CO XXXX0303 103104 $437,70
Note:The account number,signature,and endorsement may be removed from the image(s)for security reasons.To
obtain a full copy of the image,please send us a secure email or call us at 1-800-956-4442,24 hours, 7 days a week.
CZ912N lr%WMNU03�
It.apital BLue W trot 103104,
28�JAN-2014 103104
To*"@ eat* pAkDtals P15 . _ ,A, t ;� e4 IN
littps:Himage.NN,cllsf,ir�io.coi-n/im,,ii,,em,,in/display.do?sessionld=6ab86557crif9dbaEC)d9ca75... 5/11/2014
*4:::x-- Caaa&Jeffrey A.
Funeral and Cremation service j
...where Memories are Shared
www.ianauglefcs.com info @janaugiefcs.com
Payment Summary
Effective: June 20, 2014
l
Mrs. Charlotte (Lottie) Hillegas I
f Contract Number: 13155 Contract Date: 09/25/2012
Coritracf:Deta!!s
Contract Total Less Discounts Additional Additional 1 Original Balance i
Purchases Discounts{
$9,371.65 -$0.001 $0.00 -$0.00; $9,371.85'
Payment;:Dlscount and Adjustment Details
Date Pay MethodtCheck No ITYpe Applied To Received From Amount:
10/8113 Check 40641767 Payment Contract Homesteaders life Co. $2,623.23;
;tiolw3 Check#0641766 Payment Contract Homesteaders Life Co. j $9,146.32
j 1021/13 Check#23854 Payment Contract Reimbursement For $
7,876.38
II i Overpayment
10!21/13 Check#23854 Payment Contract Reimbursement For Post $-521.52
{ Funeral Gathering
Total $9,371.85{
Current Balance Due _
Original Batancs Less Payment 8 Adjustments Refunds Plus Late Fees Amount Due;
- $9,371.65 $9371.66! +$0.0o +$0.001 $0!
Buyer Information:
I
135 W. PUMPING STATION ROAD QUAKERTOWN, PA 18951
1215) 536-3343 FAX(215) 536-2250