HomeMy WebLinkAbout08-22-14 1505610105
REV-1500 EX(02-11)(FI)
OFFICIAL USE ONLY
PA Department of Revenue la
PennsylVan County Code Year File Number
Pennsylvania
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO Box 280601 21 -14-0291
Harrisburg.PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
, 03132014 11231914
Decedent's Last Name Suffix Decedent's First Name MI
FETTER MARY H
(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 BOXES BELOW
Q. 1. Original Return Q 2. Supplemental Return Q 3. Remainder Return(Date of Death
Prior to 12-13-82)
Q 4. Limited Estate 0 4a. Future Interest Compromise(date of Q S. Federal Estate Tax Return Required
death after 12-12-82)
0 6. Decedent Died Testate Q 7, Decedent Maintained a Living Trust 0 B. Total Number of Safe Deposit Boxes
(Attach Copy of NAZI) (Attach Copy of Trust.)
Q 9. Litigation Proceeds Received Q 10. Spousal Poverty Credit(Date of Death 0 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1.1-95) (Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
STEPHEN D . TILEY 717-243-5838
REGISTER OF WILLS USE ONLY
C,3 M
First Line of Address C O r,ry n
5 SOUTH HANOVER STREE m = CD o
Second Line of Address %A D r' rr1 m
t� = fTi N isJ
or� CD
DATE FILED? 'O CD 'T1
City or Post Office State ZIP Code
CARLISLE PA 17013 .D rn
C/) C;),
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 then the Personal representative Is based on all Information of which onsomer has any knowledge.
SIG ATUR F PERSON RESPONSIBLE FOR F ING ETU N D TE
.QMa Ce�n,»�Fv ./J� 2,_T E
ADDRESS
934 ALEXANDER SPRING RD CARLISLE PA 17015
SIGN F ERTMf1N REPRESENTATIVE DATE
ADDRESS
5 SOUTH HANOVER STREET, CARLISLE, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
J 1505610205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedents Name: MARY H FETTER
RECAPITULATION
1. Real Estate(Schedule A). . .. .. . .. .. .. . .. . .. . .. . ... . . ... . ... . ... ... 1. - 0 .00
2. Stocks and Bonds(Schedule B).. . .. . .. .. . .. . . .. . .. . .. . . .. . . ... .. .. . 2. 0 .00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).. . 3. 0 • 00
4. Mortgages and Notes Receivable(Schedule D). .. . .... .... ... . . .. . ... .. 4. 0. 00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. ... 5. 4524 .10
6. Jointly Owned Property(Schedule F) =Separate Billing Requested. ... . .. 6. 0. 00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) =Separate Billing Requested.. . .. . . 7. 0 AG
8 Total Gross Assets(total Lines 1 through 7).. . ... . . .. . ... . . . . . .. . .. . . . 8. 4524.10
9. Funeral Expenses and Administrative Costs(Schedule H). .. . ... . . ... ... . . 9. 2254 . 65
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1). .. . . . . . . .. . .10. 385553 . 59
11. Total Deductions(total Lines 9 and 10). ... ... ... . .. . ... . ... . .. . ... . . 11. 387808.24
12. Net Value of Estate(Line 8 minus Line 11). . ... .. . . .. . .... . .. . ... . ... .12. -383284 . 14
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J). .. . . .. . ... ... . .. . . .. ..13. 11.00
14 Net Value Subject to Tax(Line 12 minus Line 13). .. . . .. . ... . . ... . .. . .. 14. -383284 . 14
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 15. 0 .00
16. Amount of Line 14 taxable
at lineal rate X.o 4 5 16. 0 . 00
17. Amount of Line 14
taxable at sibling rate x .12 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate x .15 18. 0. 00
19. TAX DUE. ... .. . .. ... . . .. .. .. .. . . . .. ... ... .. . ... . .. . . ... . .. . ... . . 19. 0 . 00
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT =
Side 2
L 1505610205 1505610205 J
REV-1500 EX(FI) Page a File Number 201-18-0668
Decedent's Complete Address: 21-14-0291
DECEDENTS NAME
MARY H FETTER
STREETADDRESS
442 WALNUT BOTTOM ROAD
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
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 box 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............................................ ❑
c. retain a reversionary interest............................................................................................................................. ❑
d. receive the promise for life of either payments,benefits or care?..................................................................... ❑
2. If death occurred after Dec. 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?........................................................................................................................ ❑
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 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 lax 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 F2 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.
REV-1508 EX-(08-12) SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT TAX REVENUE
RETURN INHERITANCE TAD RET PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Mary H Fetter 21-14-0291
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. M&T Bank
Checking Account No.: 32773145
See Exhibit"A"Attached
Principal 4,524.09
Accrued Interest to DOD 0.01
2. Personal belongings(clothing and personal effects at Thornwald nursing home)
No value. Given to charity. 0.00
3. One(1)Cemetery Lot at Westminister Cemetery, Cumberland County, Pennsylvania
No value. Unable to sell. Cemetery will accept"donation"of lot. 0.00
TOTAL(Also enter on line 5, Recapitulation) $ 4,524.10
If more space is needed,use additional sheets of paper of the same size.
REVA511 EX+(0 8-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TM RESIDENT DECEDENT URN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Mary H Fetter 21-14-0291
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman-Roth Funeral Home 416.15
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 750.00
Name(s)of Personal Representative(s) Darlene L. Cornman&Grant Hockenberry
StreelAddress See Schedule"J"
city State ZIP
Year(s)Commission Paid: 2014
2. Attomey Fees: 750.00
3. Family Exemption:(If decedent's address Is not the same as dalmant's,attach explanation.)
Claimant
Street Address ,
City State ZIP
Relationship of Claimant to Decedent -
4. Probate Fees: 106.50
5. Accountant Fees: Incl. in Atty fees -
6. Tax Return Preparer Fees: Incl, in Atty fees
7. Westminster Cemetery- Engrave date of death on gravemarker 210.00
8. Register of Wills-Reserve for Filing Fee for Agreement&Release 20.00
TOTAL(Also enter on Line 9, Recapitulation) $ 2,254.65
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
INHERITANCE TAX RETURN DEBTS OF DECEDENT,
RESIDENT DECEDENT MORTGAGE LIABILITIES $LIENS
ESTATE OF FILE NUMBER
Mary H Fetter 21.14-0291
Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,Including unrelmbursed medical expenses.
ITEM
VALUE AT DATE
NUMBER
DESCRIPTION OF DEATH
1.
Pennsylvania Department of Public Welfare
Estate Recovery Program
See Exhibit"B" 385,553.59
TOTAL(Also enter on Line 10,Recapitulation) $ 385,553.59
If more space Is needed,Insert additional sheets of the same size.
REV-1513 EX.(01-10)
pennsy OF SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Mary H Fetter
21-14-0291
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[include outrightspousal distributions and transfers under
Sec.9116(a)(1.2).]
Darlene L. Cornman
1 934 Alexander Spring Road niece 100%
Carlisle, PA 17015
Grant Hockenberry
2. 513 Sand Bank Road Brother None-Contingent Beneficial
Mount Holly Springs, PA 17065
ENTER DOLLARAMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,ASAPPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AN D GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET.
0.00
If more space is needed,use additional sheets of paper of the same size.
ACCOUNT HO ACCriMT TYPE STAIE11EfIT PERIOD::: PAGE
32773145 MAT CLASSIC CHECKING W/INTEREST MAR.09-APR.08,2014 1 OF 1
00 0 04319H MM 017 -
pper�.. 000004549 FIDS1549DO1704081404 02 001000 13371
Ell E
ara s MARY H FETT
442 WALNUT BOTTOM RD
CARLISLE PA 17013-3742
INTEREST EARNED FOR STATEMENT PERIOD 0.03 HIGH STREET-CARLISLE--
INTEREST PAID.YEAR TO DATE _ 0.13 -
ACCOUNT SUMMARY
BEGINNING.- -":� . : REPOS ,.i'B � :.�:].
.. :._::-BALA17CE :.. :LTIIER..ADDI IONS --?:= :=iiEaTS.!'AIL - S #RACtIOtFS.;:: . :INTfREST PL ; w_A�.]wr :
N0. I AMOUNT ND. AMOUNT I N0. I AMOUNT
4,524.09 1 11 28.14 1 ol 0.00 1 21 31052.23. 0.04 1,500.04
ACCOUNT ACTIVITY
:::P,DSTIlIB - .
DATE ;YBAl75AEYIfIi�1iLE5CiEIPYfON ;: 6.:9THER ADOi7F>`YONS .- .S ;=1sAlANeE-
03-08-14 BEGINNING BALANCE - 04,524.09 ,
03-31-14 In Branch Transfer/Withdrawal - 3,024.09 1,500.00
-04-01-14 MASSMUTUAL--PENS3GN-CK------- ._____ _ _ •28:14' -.__._ _.._ --_..11528:14 ._
04-08-14 INTEREST PAYMENT 0.04
04-06-14 MASS MUTUAL RECLAIM 28.14 1,500.04
ENDING BALANCE 51,500.04
ANNUAL PERCENTAGE YIELD EARNED = 0.00 2
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LENDER 2014 MIT BANK-MEMBER FDIC. NMLSB 381076
Pennsylvania
DEPARTMENT OF PUBLIC WELFARE
April 18, 2014
FREY & TILEY LAW OFFICES
STEPHEN D TILEY ESQUIRE
5 SOUTH HANOVER ST
CARLISLE PA 17013
Re: Mary Fetter
CIS #: 890189002
SSN: ###-##-0668
Date of Death: 03/13/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney Tiley:
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$385.553.59 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 $32,278.25, 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 $353.275.34 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 flied 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 Uablllty I Recovery Section
PO BOX 8486 1 Harrisburg, Pennsylvania 17105-8486