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Home My WebLink About10-15-14 , . ' I , ' 1505611185 J REV-1500 EX(02-11)(FI) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po sox 2sosoi INHERITANCE TAX RETURN 21 11 �3 8 4 Harrisbur9,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 071,42010 08121936 DecedenYs Last Name Suffix DecedenYs First Name M I PAPE ANGELICA (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - ' REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW � 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) � 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.) X❑ 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) r�, CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INF�RMATION SH�D BE DIRF�TED TO: Name Daytime�el�one Nurr"f�2r � � BRIDGET M • WHITLEY, ESQ 717r,��0[� �� ' :,Zl t„ �r� ".�i3 '$EGl$T�R`�DF USE`�1�'4 .. _., � ;1 i . . . .... `:.7 , .. ,:. ,. ..._y c"S � � � ':�..�, � �..�.i _.�.! First Line of Address . SKARLATOSZONARICH LLC :W'_� �``� ��= �� r-- Second Line of Address -- N Cn d —�.] 'Ti 17 S 2ND ST SIXTH FL City or Post Office State ZIP Code DATE FILED HARRISBURG PA 171�1 �orrespondent'se-mai�aadress: BMWa�SKARLATOSZONARICH • COf1 Under penalties of perjury, I declare that I have examined this retum,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. SIGNFj, OF PERSON RESPO SIBLE FOR FlLING REfURN DATE /� YrJ- ��. /IJ -/3-l`f I- li]'v�..,-�,a�� ADDRES PHILOMENA BROGAN — 514 9TH STREET NEW �Uf�BERLAND, PA 17070 SIG URE OF PR PARER THE THAN REPRESENTATIVE DATE � �. /D —�'/ RESS BRIDGET M • WHITLE , ESQ • — 17 S• �ND ST . , 6T1-I FL, HBG . , PA 171�1 PLEASE USE ORIGItdAL FORM ONLY Side 1 � 15 0 5 61118 5 onnasa�s.000 15 0 5 61118 5 � � 1505611285 REV-1500 EX(FI) Decedent's Social Security Number oecedent'sName PAPE ANGELICA RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 0 • 0 0 2. Stocks and Bonds(Schedule B). . . . . . . . . . . . . . . . . . . . . . . . . 2. � • �� 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , , , , 3. 0 •�� 4. Mortgages and Notes Receivable(Schedule D) , , , , , , , , , , , , , , , , , q. 0 • �� 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) , , , , , 5. 2 O O,0 0 0 -�� 6. Jointly Owned Property(Schedule F) � Separate Billing Requested , , , , g. 0 • 0 0 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) � Separate Billing Requested . . . . 7. 0 •�� 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . $ 2 O O�0 0 0 -0 0 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . g. 2 5,2 2 0 • �� 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) , , , , , , . . . 10. 2 51,416 • �0 11. Total Deductions(total Lines 9 and 10), , , , , , , , , , , , , , , , , , , , , ��. 2 7 6,6 3 6 • �� 12. Net Value of Estate(Line 8 minus Line 11) , , , , , , , , , , , , , , , , , , , �2, (7 6,6 3 6 • 0�) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J), , , , , , , , , , , , , , , , �3. 0 • 0 Q 14. Net Value Subject to Tax(Line 12 minus Line 13) , , , , , , , , , , , , , , �q. (7 6,6 3 6 • �0) TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable � at the spousal tax rate,or transfers un�er Sec.9116 (a)(1.2)X.0_ � • �� 15. � •�� 16. Amount of Line 14 t xable at lineal rate X.0 4� 0 - 0 0 16. � • 0� 17. Amount of Line 14 taxable at sibling rate X.12 0 • 0 0 17. 0 •0❑ 18. Amount of Line 14 taxable at collateral rate X.15 � • �� 18. � • �� 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 0 • 0� 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 � 1505611285 150567,1285 � OM4648 3.000 REV-1500 EX(FI) Page 3 File Number DecedenYs Complete Address: 21 11 �3 8 4 DECEDENT'S NAME PAPE ANGELICA STREET ADORESS CUMBERLAND CITY STATE ZIP NEW CUMBERLAND PA 17070 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) � • �0 2. Credits/Payments A. Prior Payments � • �� B. Discount �• 0 0 Total Credits(A+g) (2) �•�� 3. Interest (3) 0 •�� 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) �•�� 5. if Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) �•�� 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 . . . . . . . . . . ❑ ❑X 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ L^J 3. Did decedent own an"in trust for"or payabie-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 beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ 0 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)]. Fw 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 chiid 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 decedenYs Iineai 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 decedenYs sibiings 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. OM4671 2.000 REV-1511 EX+(10.09) SCHEDULE H pennsylvania �PARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENTDECEDENT ESTATE OF FILE NUMBER Angelica Pa�e 21 11 0384 DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: � Joseph A. Moran Funeral Home 9,985 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 5,000 Name(s)of Personal Representative(s) Philomena Brogran Street Address 514 9th St City New Cumberland State PA ZIP 17070 Year(s)Commission Paid: Payment Pending 2. Attorney Fees: 8,000 3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach e�lanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 53 5. Accountant Fees: 6. Tax Return Preparer Fees: 1,550 7. 1 William J. Mansfield - Estate Advertising 282 Total from continuation schedules . . . . . . . . . 350 TOTAL(Also enter on Line 9,Recapitulation) $ 25 220 swas,n�z.000 If more space is needed,use additional sheets of paper of the same size. ,REV-1512EX+(�p_12) SCHEDULE I pennsyivania DEPARTMENTOF REVENUE DEBTS OF DECEDENT, INHERITANCETAXRETURN MORTGAGE LIABILITIES& LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Angelica Pane 21 11 0384 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH �• Wilkes & McHugh, P.A. - Counsel Fees 68,373 2 Wilkes & McHugh, P.A. - Costs 40,011 3 Wilkes & McHugh, P.A. - Medicare Lien Escrow 23,221 4 Department of Public Welfare Third Party Liability lien 23 5 Department of Public Welfare Medical Assistance Estate Recovery claim 119,788 TOTAL(Also enter on Line 10,Recapitulation) $ 251 416 zwasaH 2.00o If more space is needed, insert additional sheets of the same size. (Page 1 of 3) (Page 1 of 90) . � , � . ,;�,�;;+}"-,.,z-..� �;�,./�'7.j2_'�.-y;".,�'�av:%�Y':{'d. _ __ __ . j PHII.OMENA BROGAN,Administratrix of the : COURT OF COMMON PLEAS Estate of ANGELTCA PAPE, deceased : MONTGOMERY.COUNTY Plaintiff, : NO.: 11-08451 vs. ; NORTHERN HEALTH FACILITIES,INC. : ELECTROMCALLY FILED d/b/a MOUNTAIN CITY NURSING AND . REHABILITATION CENTER, et al.. : 'lll ��`�,��'I II` Defendants. . Y I 2�ii i-ox:+�i-c�i i9 s»iz�>>�+�i.i�<�n-� n 991Qq29 o Ord`'r O � � � Rcpt�Z218J116 Fre:SO.OQ � \•tark L.a�}'-\IontCo Prothonotan• II � ORDER av� N AND NOW,this�day of , 2014, on considerati'on'of the N • � N outstanding Petition to Approve Partial Settlement and Distribution of the Petitioner/Plaintiff, � � Philomena Brogan, Administratrix of the Estate of Angelica Pape, deceased, the proposed partial 0 a �, settlement in the above-captioned lawsuit by gross payment on behalf of the Settling Defendants w .. eGwynedd Square Nursing Center a/k/a Gwynedd Square Center for Nursing and Convalescent � .. a Care and Morris Kaplan in the sum of$200.000.00 is hereby APPROVED. Settling Defendants � oshall forward all settlement drafts or checks to Wilkes & McHugh, P.A. for proper distribution _ __ ____ _--=—_ _ _ _--- -__ __ _ __- v _ - -_ __ _ _ _ �' within twenty(20)calendar days from the date of this Order, The case will continue against tfie 6 qremaining non-settling Defendants. 0 � IT IS FURTHER ORDERED and DECREED that the settlement proceeds from this � � ; partial seftlement be allocated and distributed as follows: � u A TO: Wilkes& McHugh, P.A.-fee* $ 68,372.79* 0° *Plus 50%of any negotiated savings after final .. � satisfaction of the Mcdicare lien,not to cxcccd the . ; Fee Contract rate of 40%of the settlement-($80,000.00) 0 ,.. � 0 N � d h � U ' This order/judgment was docketed and sent on 08/07/2014 pursuant to Pa. R. C. P. 236. i � (Page 2 of 3) . . :s'�-,L.�S�i' -� �i�-f 33,=� m•.Cm.,a.'--3 ":�.'��'.Y_. . _ _ __ _ _ _ _ ___ _ . _ __ _ _ . _ __ . ! . TO: Wilkes& McHugh, P.A. —reimburse costs $40;010.54 'T'O: Wilkes& McHugh, P.A. —Escrow Account Maximum Estimated Medicare lieri $23,221.07 TO: PA Department of Public Welfare—Final Medicare lien $22.80 , TO: SkarlatosZonarich LLC—Escrow:Account Maximum Medicaid Estate claim� $68,372.80** **Though it is understood that$1,19;788.18 is the maximum Medicaid Estate Claim, it is equally understood that there is not money available to escrow the maximum amount of the Medicaid Estate Claim;theiefore,escrow of the lesser amount of$68,372.80 is not only permitted, but required under the circumstances�of this case. There being no eligible wrongful death beneficiaries,the balance of$0.00** (**plus any negotiated savings after satisfaction of the above Medicare Lieri) is hereby allocated in its entirety to the survival action, distiibutable as follows: Survival action: TO: Philomena Bro�gan, Administratrix, who shall not be entitled to receive said proceeds prior to making application � to the Register of Wi11s of Cumb�erland Countyro det�rtnine- - -- _ the need for.posting additional bond. $0.00** Philomena Brogan, Administratrix, is ORDERED arid DIRECTED to file a copy of this Order with the Register of Wills of Cumberland County within thirty days pursuant to 20 Pa. C.S.A. §3323(b)(3). B THE CO T: . '• _. J. (Page 3 of 3) � , ; �4 _._ .— — - — � � 1 � ..=`_�"+'G�'s� � -,.'Y+i''�.�:,�..y'K`�,:? „�.�+d;:_�� .� .iri?,r,�y.r::�.... � � Copies of O�r mailed ; August � , 2014,to: 1 John B. Zonarich, Esqie � � Ruben J. Krisztal, Esquire 4 Gerald J. Dugan, Esquire David M. McGeady, Esquire ` � William J. Mundy, Esquire ; ; By � � ; ; � !_ __ ---- _ � , '� µ �,�, 17 South Second Street,6`� Floor ��r��,.�� ,�,� Harrisburg,PA17101-2039 S�und Ad�-ice.Str�artes�I)ecisions. 717.233.1000 Voice 717.233.6740 Fax www.s ka rl a to szo n a ric h.co m October 13, 2014 r•-.� �� Office of Register of Wills � � �-i `�' 1 Courthouse Square � �' � `="' `�' � � -;,, :�� Carlisle, PA 17013 �'' ='_ '' '- { '~� =�' f--� �;.. , ; � 'I C!'i _ �,:':3 RE: Estate of Angelica Pape ` � _� �' No. 21-11-0384 , 7 =�. � `' . � c=� � rv :_ r,ro To whom it may concern: � � � � � _ o0 Enclosed for filing are the originals and one copy of the Inheritance Tax Return and Inventory for the above-referenced estate. Please time-stamp the additional signature pages and return to me in the envelope provided.. Also enclosed is a check in the amount of $270.00 representing the filing fee in the amount of $30.00 and additional probate in the amount of $240.00. If you have any questions or concerns regarding this filing, please give me a call. Thank you. Sincerely, �" � 4�_ Sharon K. Shaffer Sr. Estate Administrator sh aron(a�s karlato szo nari ch.c om Enclosures ;sooios�z.�� A Member of LawPactT"'-An International Association of Independent Law Firms ��:: .N.. . v . .. . . _...... . �.*�; . . . . . ... _ . . . . . � Do � � Q �� N � � O- W � � �"I O O � n � n � - N n O (D = � � � (Q = ,.,, (n � � (n• = n `'_� � ,�_. � 2 � � = c _� <=� � � � O �' -n = :'� -,- i`^ —1 [!) .� � � n = °^ x. . . � „� t� O � � � _ : c.rt � � � �j � � _ ~ . � �; W � fD _ 'T7 'r7 "Y7 W � � _ ,� � � -rr O �p � �v �"" �' 0 - � � � Q - N �� m� -f, - Op '►1 (� ' _ ; = 30383 T O�AtCi� � -nIO�O�A � N��Cp � �� A�vimlo . � v.S}�IZ�P��7:.7 �h�.h ZZ9VS99000SZ90