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1505610143
REV-1500 Ex(dz.1,) L
PA Department of Revenue OFFICIAL USE ONLY
P Pennsylvania County Code Year File Number
Bureau of Individual Taxes oer.a*,.E„ror asysaue
PO BOx280601 INHERITANCE TAX RETURN 21 12 0440
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
03 23 2012 08 15 1979
Decedent's Last Name Suffix Decedent's First Name MI
CLEGG LORI 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
1. Original Return ❑x 2. Supplemental Return ❑ 3. RRemaiinder Return(Date of Death
❑ 4. Limited Estate ❑ 4a.Future Interest Compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12-e2)
El 6. Decedent Died Testate 7. Mainljned a Living Trust 8. Total Number of Safe Deposit Btlxes
(Attach Copy of Will) ❑ PAttach Gopy of ruse
❑ 9. Litigation Proceeds Received 10,9fw.a.1 P2 31�i r ndat Da95 f Death ❑ 11.Election to tax under Sec.9113(A)
(Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JAMES T YINGST ESQUIRE 717 632 5315
REGISTER(`ILLS USE�GNLY F- I Q,
DO a r°
First Line of Address , :;1 r r
it
40 YORE( STREET
Second Line of Address
W T
City or Post Offrde DATE FILED —J
Stabs ZIP Code
HANOVER PA 17331
Correspondent's e-mail address: iameslyoD.gnyh.com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowedge and belief,
it is true,correct and complete.Declaration of prepare r other than the persona(representative Is based on all information of which preparer has any knowledge.
SIGNATURE F PERSON SPONSIBLE FOR FILING RETURN DA E
f }E�t William D.Clegg t7Zz ti
345 Foxleigh Drive, Hanover, PA 17331
SI ATURE OF PREPARER OTHER THAN REPRES-NTATIVE DATE
T j� !antes T.Yingst Esquire 17 //z/
RESS
40 York Street, Hanover, PA
Side 1
1505610143 1565610143
J 1505610243
REV-1500 EX
oeceaen•sN�: Clegg, Lori A. Decedent's Social Security Number
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&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5.
32, 718 . 34
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous I�nq Probate Property
(Schedule G) u Separate Billing Requested............
7.
8. Total Gross Assets(total Lines 1 through 7)...............................
8. 32 , 718 . 34
9. Funeral Expenses and Administrative Costs(Schedule H)..................................... s. 30 . 00
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10.
11. Total Deductions(total Lines 9 and 10)................................................................
11. 30 . 00
12. Net Value of Estate(Line 8 minus Line 11)....................................................................................... 12. 32, 688 . 34
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. 32 , 688 . 34
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
atlinealrateX .045 32, 688 . 34 16. 1, 470 . 98
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.
1 , 470 . 98
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑
!_ Side 2
1505610243 1505610243
I
REV-1500 EX Page 3 File Number 21-12-0440
Decedent's Complete Address:
DECEDENTS NAME
Clegg,Lori A.
STREETADDRESS
315 B Rosemont Avenue
CITY STATE ZIP
New Cumberland PA 17070
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 1,470.98
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. (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) 1,470.98
Imo -_ _
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;................................. z
c. retain a reversionary interest;or.................................................._._............._......................................... x
d. receive the promise for life of either payments,benefits or rare?........ ........................................._ H X
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ Fil
3. Did decedent own an`in trust far' 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?........................................................_........................................................ ❑
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 Jury 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
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)(i)),
. 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 fa)(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.
Re,1508 EX+(11-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RE TURN PERSONAL PROPERTY
REWENT DECEDENT
ESTATE OF FILE NUMBER
Clegg, Lori A. 21-12-0440
InClude the proceeds of litigation nod the daze the proceeds were rects"d by 1M muste.
An property jolnfly4 med with the right of survlvonship must be disclosed on seneoulo F.,
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Estate of Lori Ann Clegg v. Ronald and Josephine Ressler et al.-survival claim benefit 32,018.34
check dated June 27,2014
2 2009 Honda Accord-recovery sale price 700.00
TOTAL(Also enter on Line 5,Recapitulation) 32,718.34
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10)
REV-0SH Fx.Ita-09)
pennsyivania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
MHERMANCE TAX RESIDENT DECEDENT ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Clegg, Lori A. 21-12-0440
Decedent's debts must be reported on Schedule I.
ITEM
NUMBF DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorneys Fees '
3. Family Exemption: (If decedent's address Is not the some as claimant's,attach explanation)
Claimant
Street Address
City State Zio
RetationshiD of Claimant to Decedent
4. Probate Fees 30.00
5. Accountant's Fees
S. Tax Return Preparer's Fees
7. Other Administrative Costs
TOTAL(Also enter on line 8,Recapitulation) 30.00
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA•1500 Schedule H(Rev. 10-09)
REV-1513 E%•(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERRANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Clegg, Lori A. 21-12-0440
NUMBER NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
PERSON(S1 RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List Tmstegial I• TAXABLE DISTRIBUTIONS (include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
1 Sharon L.Clegg Mother One-half residue
345 Foxleigh Drive
Hanover, PA 17331
2 William D.Clegg Father One-half residue
345 Foxleigh Drive
Hanover, PA 17331
Total
Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 1500 cover sheet as a ro 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
l
TOTAL OF PART II -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-1500 Schedule J(Rev.01-10)
JUi/15/2014/TUE 01 :51 PM ' Martz & Gailey, LLP PAX N0. 717 852 8268
P. 002
I
t
WILLIAM D. CLEGG Administrator of the : IN THE ORPRANS- COURT OF
Estate of LORI A. CLEGG
: CUMBERLAND COUNTY,
: PENNSYLVANIA
NO, 21-12-0440
ORDER
� AND NOW,this
the Petition, it is hereby Ordere eland De reed as follows:upon presentation and consideration of
Petitioner may execute the Release in favor Of Progressive Insurance Company
and disburse proceeds as sat forth below:
A. Wrongful Death Action- $ 50,000 (50 %)
$ 32,018.34 William and Sharon Clegg 00
4
$ 1,315.00 Martz& Gailey(50% costs) UJJ j
I ,
$ 16,666.66 Martz&Gailey(50%fee) CSR
B. Survival Action- $ 50,000 (50%) a l i� a is
00
$ 32,018.34 Willi v r
am Clegg, Administrator UI'
' $ 1,315.00 ~r '
Martz&Oailey(50% costs) a c
� n
` I $ 16,666.66 Martz& Gailey(50% fee)
o u� to C
I � _ z
L C �
C3 CC u) Qe 4 BY'
w 1- J d I
O N a U d W
ww o { J'
Thomas A. Placey
t ti U Common Pleas Judge
WILLIAM CLEGG, ADMINISTRATOR OF THE ESTATE OF LORI CLEGG v.
RONALD AND JOSEPHINE RESSLER, et al.
CLOSING STATEMENT
Amount of Settlement $100,000.00
DISBURSEMENTS:
Attorney's fee:
1/3 of$100,000.00 $ 33,333.32
COSTS:
Patriot-St. Denis Towing $ 1,600.00
Clerk of the Orphans' Court 30.00
ARCCA 1,000.00
TOTAL COSTS $ 2,630.00
TOTAL DISBURSEMENTS $ 35,963.32
CHECKS PAYABLE:
William and Sharon Clegg $V20 34
William Clegg, Administrator of the Estate of Lori Clegg 34
Martz& Gailey, LLP (costs) 00
Guthrie Nonemaker Yingst & Hart 16,666.66
Martz& Gailey, LLP (fee) 16,666.66
$100,000.00
By:
Herman'A. Gailey, III, Esquire
The above-captioned matter has been settled to my complete satisfaction and all
disbursements made with complete approval. I agree that a minimum of ten (101
business days will be allowed for clearan e of the settlement draft.
Approval this a7 441 day of , 2014.
41A
WILLIAM CLEGG
a
S ARON CLEGG