HomeMy WebLinkAbout09-04-14 (2) _ _ _ ___
J 150561D143
REV-1500 EX�02_,,, ,
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes �P�TMENTOFREVENUE
Po Boxzaosol INHERITANCE TAX RETURN 21 12 151
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
O1 15 2012 10 15 1932
DecedenYs Last Name Suffix DecedenYs First Name MI
BOUDER GAIL L
(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 � 3. Remainder Return(Date of Death
Prior to 12-13-62)
� 4. Limited Estate � 4a.Future interest Compromise � 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
� 6 Decedent Died Testate � � (AttaoheCo a�of Trust a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) PY �
� 9. Litigation Proceeds Received � �� belweenl2 31 51 a dit�(Da�S�f Deatn � 11.Election to tax under Sec.9113(A)
(Attach Schedule O)
r•v
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INF�ATION SHOt7�BE B„�ft ED TO:
Name Daytime e�ne Nur�r � n
�
MARK A MATEYA 717 �1� �5 0� ,;,, �°
� . c�
%� y �--- _ `�
REGISt'�R!?F�1V�LLS USE ONiY�
, _ �. ; , �,.:.� Cs
��,�� c°a � ..� "'g'1
First Line of Address ' "` � �"� � .� �
�? C�,: H
55 W CHURCH AVENUE �,� :�=� � � rn
� � `Q*�
Second Line of Address ` -.,7
DATE FILED
City or Post Office State ZIP Code
CARLISLE PA
Correspondent's e-mail address: mam mateyalaw.com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and ents,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative i as n al ation of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
Jeff Boude ��S
ADDRESS
17 S Hi h Street Newville PA 17241
SIGNATURE OF P EPA R QTHER HAN RE RESENTATIVE DA E
` Mark A. Mateya Z
ADDRESS
55 W. Church Avenue, Carlisle, PA
� Side 1 �
150561D143 1505610143
� 150561D243
REV-1500 EX
DecedenYs Social Security Number
DecedenYsName: BOUC�@�� G1il LOUISe
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1. 9S , 0�� . 0�
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. 19 9, 7 31 . 2�
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 2 , 8 7 8 . 14
7. Inter-Vivos Transfers&Miscellaneous I�aq-Probate Property
(Schedule G) U Separate Billin9 Requested............ 7. 4 61 , 14 9 . 95
8. Total Gross Assets(total Lines 1 through 7)........................................................ g. 758 , 759 . 29
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 1.14 , �31 . 2 4
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 3 , 0 4 5 . 7 7
11. Total Deductions(total Lines 9 and 10)................................................................ ��. 1,17 , �7 7 . O 1
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 641, 682 . 28
�3, 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. 641, 682 . 28
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 . ��
16. Amount of Line 14 taxable 631 , 682 . 28 �6. 28 � 425 . 70
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X.12 � . 0� 17. � . ��
18. Amount of Line 14 taxable
at collateral rate X.15 10 ,0 0 0 . 0 0 18. 1,5 0 0 . 0 0
19. TAXDUE................................................................................................................ 19. 29, 925 . 70
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
� 150561�243 1505610243 �
- . - __ _
REV-1500 EX Page 3 File Number 21-12-151
Decedent's Complete Address:
DECEDENT'S NAME
Bouder, Gail Louise
STREET ADDRESS
2267 Rittner Highway
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 29,925.70
2. Credits/Payments
A. Prior Payments 24,088.86
B. Discount 1,259.63
Total Credits(A +B) (2) 25,348.49
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) 4,rj77.2�
Make Check Pa able 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:.................................. ❑ 0
c. 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 ❑ ❑
receivingadequate consideration?.................................................................................................................... x
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
containsa 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)(i)].
For dates of deaih 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
[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 retum 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 ihe 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 orforthe use of the decedenYs linea{beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
. The iax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)�. A sibling is def ned,
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+(17-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, 8� MISC.
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bouder, Gail Louise 21-12-151
Include the proceeds of litigation and the date the proceeds were received by the estate.
All propeRy jointly-owned with the right of sunivorship must be disclosed on schedule F. . .. ..
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 CenturyLink-Refund on overpayment for telephone service-Check No. 0003952738 13.74
2 Comcast-Refund on Cable TV Account 09547-38593101 85.74
3 Encompass-Refund on auto insurance premium -Policy No. 281387776 175.00
4 Encompass Home&Auto Ins. -Refund on Homeowners Insurance-Check No. 0071291939 35.00
5 Highmark-Refund on Medical Insurance Premium 423.07
6 R.J. Marzella Esquire&Associates-Survivor's proceeds from wrongful death action against 190,000.00
Forest Park Health Center
7 SEI Private Trust-Retirement distribution from Carlisle Corporation Tire 8�Wheel 199.86
8 The Sentinel-Refund of Newspaper Subscription 48.79
9 Miscellaneous Personal Property-Appraised by William Rowe, Rowe's Auction Service-See 8,750.00
attached appraisal
TOTAL(Also enter on Line 5, Recapitulation) 199,731.20
(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-1511 EX+(10-09) gCHEDULE H
pennsylvania
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bouder, Gail Louise 21-12-151
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
q, FUNERAL EXPENSES:
See continuation schedule(s) attached 9,820.30
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid
2. Attorney's Fees Mateya Law Firm 18,500.00
3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zio
Relationshi�of Claimant to Decedent
4. Probate Fees 335.50
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 85,375.44
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 114,031.24
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Bouder, Gail Louise 21-12-151
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex e�
1 Ewing Brothers Funeral Home-Funeral 7,994.30
2 Westminster Cemetery-Purchase of grave plot 1,826.00
H-A 9,820.30
Other Administrative Costs
3 Citizens Bank-Bank fee for checkbook for estate account 29.00
4 Cumberland County Law Journal-Legal Advertisement of estate 75.00
5 Cumberland County Prothonotary-Filing fee for Wrongful Death Action 207.50
6 Cumberland County Sheriff-Fees for service of pleadings on Defendant in wrongful death 125.00
action
7 Douglas Bowerman,M.D.-Medical Expert Report for wrongful death action 1,000.00
8 Douglas Bowerman,M.D. -Medical Expert Report for wrongful death action 350.00
9 Encompass Home 8�Auto Insurance-Insurance premium on residence-Policy No. 75.38
281387776
10 Enjoli Neely-Misc.expense for wrongful death action 16.40
11 Jeff Bouder-Reimbursement for expenses relating to civil action 444.72
12 Jeffrey L Bouder Ins Agency-Reimburse for Homeowners Insurance 146.00
13 Marzella&Associates-Fees for Expert Medical Report 3,000.00
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Bouder, Gail Louise 21-12-151
ITEM
NUMBER DESCRIPTION AMOUNT
14 R.J. Marzella 8�Associates-Out of Pocket expenses for wrongful death action 2,575.15
15 R.J. Marzella&Associates-Legal Fees in pursuit of civil action for wrongful death 76,000.00
16 R.J. Marzella Esq&Associates-Miscellaneous copies and postage for wrongful death 876.25
action
17 Rowe's Auction Service-Auctioneer's commission on sale of personal/household property 233.64
18 The Sentinel -Legal Advertisement for Estate 221.40
H-67 85,375.44
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
_ _ _
Rev-1512 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bouder, Gail Louise 21-12-151
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medicai expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Century Link-Telephone service at residence 42.64
2 Medicare Lien 1,689.04
3 Pinker&Associates-Medical bill -Account No. 270740 25.00
4 PP&L Electric-Electric service at residence 65.92
5 PP8�L Electric-Electric service at residence 86.49
6 PP&L Electric-Electric service at residence 37.97
7 PP8�L Electric-Electric service at residence 41.29
8 PPL-Electric service at residence 57.42
9 Select Medical Corporation-Medical serivices 1,000.00
TOTAL(Also enter on Line 10, Recapitulation) 3,045.77
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
_ _ _ _ . _
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bouder, Gail Louise 21-12-151
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
ce
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
See attached schedule
Total 641,682.30
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev. 01-10)
SCHEDULE J
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
Gail Louise Bouder 01/15/2012 204-26-8407
Item Name and Address of Person(s) Share of Estate Amount of Estate
Number Receiving Property Relationship (Words) ($$$)
1 Brenda Anderson None Ten Thousand Dollars
21 Mel Ron Court
17015
2 Jack S Bouder Child 159,701.04
198 York Road
Carlisle, PA 17013
3 Jeff Bouder Child 159,701.04
17 S High Street
Newville, PA 17241
4 Paul Bouder Child 159,701.04
2264 Ritner Highway
Carlisle, PA 17013
5 Paula K Bouder Daughter-in-Law 50%of M8�T Bank 2,878.14
pq Account
6 Ronald L Bouder Child 159,701.04
621 Whiskey Spring Road
Boiling Springs, PA 17007
Total 641.682.30
1
DISTRIBUTION SHEET
TOTAL AMOUNT OF SETTLEMENT $ 190,000.00
DEDUCTIONS:
Attorney's Fee (40%) $ (76,000.00) �'
Balance $ 114,000.00
Retainer $ 3,000.00
Reimbursement of monies paid by attorney
to others for records and out-of-pocket
expenditures: $ (l, 698.90) �
(see financial report attached)
Copies and Postage � (876.25) `�
Medicare Lien $ (1,689.04)
BALANCE DUE TO CLIENT $ 112, 310.96
REFUND OF RETAINER& INTEREST � 444.72
TOTAL AMOUNT $ 112,755.68
WARRANTY
��
AND NOW, this �.� day of ���J�, 2014, I, Jeffrey Bouder, Executor
of the Estate of Gail Bouder acknowledge receipt of the sum of$ 112,755.68 and that I
have read, understood, approved and obtained a copy of this Distribution Sheet. I further
acknowledge that the above balance constitutes our reirnbursement for all medical
expenses, wage losses, funeral expenditures, pain and suffering and any other losses
sustained or claims resulting from the injuries that were sustained January 10, 2012. I
warrant that if there axe any outstanding medical bills or claims other than as set forth
above they will be my responsibility. I further warrant that I will pay any outstanding
medical subrogation liens or any other liens and expenses not noted above.
l� -ZGa�`� ��� ���'
� ` =-
Dated J rey tor o` f� the
� Estate of Gail Bouder
��� R.J.MARZELLA,ESWIIRE AND ASSOCIATE3,P.C.
07ro���� Account QuickRepoR
�mwew.
All Tranaaetlons
Ty e Deta N�m Name Memo SpIR AmouM 8alance
CIIeM Prapaids
CWM'S
BouASr,Est Ga0 � �/
Check 09/12/2013 20929 Douglas Bowerman,M.D. Bank(M&n Cheekin9-FTC 1,000.00 `'
Check 12/17/2013 27197 CumbeAantl CouMy Prothonotary Bank(Mdn Checking-FTC 103J5✓/
Check 12/17l2013 21198 Cumberland CouMy ProthorMary Bank(M8n C�ecking-FTC 103.75✓/
Check Ot/0612014 21286 Cumberland County Sheritt 8ank(M&n Checking-FTC 125.00�/
Check OZ/28I2014 21315 Enjoli Neely Benk(M&n Checking•F'fC 16.40✓/
Chack 05I19/2014 21499 Douglas Bowe�man,M.D. 8ank(M&n Checking-FTC 350.00��
Tdal Boutler,Est Gail 1,898.90
Total CWM'S 1.698.90
TMaI Clierd Prepaids 7,898.90
TOTAL 7,896.90
Papa 1 of t