HomeMy WebLinkAbout12-30-14 1505610105
REV-1500 EX(02-11)(FI)
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
Bureau of Individual Taxes OEVNNTI-OENNENOE County Code Year File Number
PO BOX 28o6o1
INHERITANCE TAX RETURN
Harrisburg,PA 17128-o6o1 RESIDENT DECEDENT / a 7 l
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
........................................................................................................................................ ...........................
55011 106/22/2014 02/28/1931
Decedent's Last Name Suffix Decedent's First Name MI
.................................................._........................................................................................................:.....................................................: .....
Griggs j Robert L
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
—.... �— ..................._._.... .......... _......
............................................._.._.................._...._._......................................................................................._.._........_............_........; ..........................................._` :............................................_............_............................................................................................_.................
i............._i
Spouse's Social Security Number
" — THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
OD 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Ronald E. Johnson, Esq (717)243-0123 {
...................................................................................................................................................................................._._. 1
REGISTR OF WILLS �EPNLY
C .0 X M
C> f?'1.
First Line of Address ""D r C>
78 West Pomfret Street y, r-
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....... ....... ....... ...... ...._.._ ......... .... ................... .. .... t r7
Second Line of Address
.......... ......................................................................................................................._................................................................................... - tJ
C 7 "Z7 `r1
City or Post Office State ZIP Code
,,DeXE TED C S
�.; r- rn
Carlisle PA 1..70.1.3.................................._.._............_. (n
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....__..................__....................................................................._........................................................................._.
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Correspondent's e-mail address:rejohnson@pa.net
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.
Sl=PERSON SPO SIBLE FOR FILING RETURN DATE
Ix / Z
ADDRESS
Go 78 st Pomfret Street, rlisle, PA 17013
fS
EROT REPRESENTATIVE DTE
S
West Pomfr EAtreet, Carlisle, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
1505610205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name: Robert L. Griggs
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. 2,951.59
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. 0.00
8. Total Gross Assets(total Lines 1 through 7)............................. 8. 2,951.59
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 4,590.03
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 24,536.24
11. Total Deductions(total Lines 9 and 10)................................. 11. 29,126.27
12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. -26,174.68
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ........................ 13. 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. 0.00
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_ 15.
16. Amount of Line 14 taxable "
at lineal rate X.0_ 16.
17. Amount of Line 14 taxableA
at sibling rate X.12 17.
18. Amount of Line 14 taxable
atcollateral rate X.15 ............................................................................................................................................................... 18.
19. TAX DUE ......................................................... 19. 0.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
L 1505610205 1505610205
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
Robert L. Griggs
STREETADDRESS
700 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 0.00
B.Discount 0.00
Total Credits(A+B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval 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.......................................................................................... ❑ N
b. retain the right to designate who shall use the property transferred or its income............................................ ❑ E
c. retain a reversionary interest.............................................................................................................................. ❑ 0
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ E
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"in 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
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)(i)].
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 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[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[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.
REV-15o8 EX+(o8-i2)
Q7pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Robert L. Griggs 21-14-0711
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. IChecking account no:4745-Wells Fargo Bank (see attached). 2,951.59
i
TOTAL(Also enter on Line 5, Recapitulation) $ 2,951.59
If more space is needed,use additional sheets of paper of the same size.
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REV-1S11 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Robert L. Griggs 21-14-0711
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
_. .. __ .: _._.. ., _._..,:.__..._... .w._..__...._ __.._------.---
1' ',Hoffman Roth Funeral Home&Crematory, Inc. 2,846.53
Si
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t
� 5
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
a
Name(s)of Personal Representative(s) __
Street Address
City State ZIP
Year(s)Commission Paid:
1,200 00
2. Attorney Fees:
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
z:.
4. Probate Fees: 143.50
5. Accountant Fees: _.
6. Tax Return Preparer Fees:
7• Reserve for closing and accounting 400.001;
--- ---------
-
m._. .__ ._..
_.._.._._.....__........k.._ _._..... ._. ___ .. __._
3.
,...._ ...: .._m.:_y..._.. _.....,.._,....,.,..�------
TOTAL(Also enter on Line 9, Recapitulation) $, 4,590.03 y; .
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 DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Robert L. Griggs 21-14-0711
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
1 ;Capital One account no:0260 473.02
Capital One account no:9218 - 559.06
r 3.1 ;Capital One account no:5025 747.99
( ; (see attached for 1-3 above)
F4. PA Dept of Public Welfare-statement of claim(see attached) 22 7
F
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El
F-1
F-1
F-1
F-]El
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F-1
E
TOTAL(Also enter on Line 10, Recapitulation) $24,536.24
If more space is needed,insert additional sheets of the same size.
Claim Detail
CL602939
IN RE THE ESTATE OF: ROBERT L GRIGGS
CASE NUMBER: 2014-00711
PF REFERENCE NO: CL602939
Claim detail is as follows:
************0260
Capital One
$473.02
UNSECURED.
THE DECEDENT PURCHASED GOODS AND/OR SERVICES IN THE AMOUNT OF $473.02,
EVIDENCED BY ACCOUNT NUMBER************0260.
************9218
Capital One
$559.06
UNSECURED.
THE DECEDENT PURCHASED GOODS AND/OR SERVICES IN THE AMOUNT OF $559.06,
EVIDENCED BY ACCOUNT NUMBER ************9218.
************5025
Capital One
$747.99
UNSECURED.
THE DECEDENT PURCHASED GOODS AND/OR SERVICES IN THE AMOUNT OF $747.99,
EVIDENCED BY ACCOUNT NUMBER************5025.
Claim Balance: $ 1,780.07
CAPITAL ONE REFERS TO EITHER CAPITAL ONE N.A. OR CAPITAL ONE BANK USA,
N.A.
Claus DGeils CAPONS 820121227
pennsyl.yania
DEPARTMENT OF PUBLIC WELFARE
August 13, 2014
ANDREWS &JOHNSON
RONALD E JOHNSON ESQUIRE
78 WEST POMFRET STREET
CARLISLE PA 17013-3216
Re: Robert Griggs
CIS #: 400858011
SSN: ###-##-
Date of Death: 06/22/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney Johnson:
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$22,756.17 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.
T A portion of this medical expense, namely $14,843.73, 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 $7,912.44, 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 filed 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 Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
REV-1513 EX+(01-10)
pennsyLvania . SCHEDULE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Robert L. Griggs 21-14-0711
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 outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
1• Debra L.Frey,7 Whispering Pines Lane,Carlisle,PA 17015 'daughter 25%
2. :Gregory W.Griggs,3625 Vista Ocean#9,Oceanside,CA 92057 <son 25%
3. Kathy A.Griggs, 10 Tunbridge Lane,Carlisle,PA 17013 daughter 25%
4 Sharon Lee Griggs, 1414 Bradley Drive G-214 Carlisle PA 17013 daughter 25%
... _....... . ..__........................ .....
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.. _,,.,_.,.....�_.............. ,.,.�.........
............ -J�..,....�...,,....,,......... .::
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
,
�r
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
.........._............................................_...._.._.,....__.........._.................__.......__........_......................._._.........---....-.......,.............._...__....__.............................
....._.. ,.:,......:.,::.....,........_.,...........,......_....:................
�... .......... ,. ,,....,..,.,...,,..,. ..............,.,. .._....,._,. ,...,,.,.,..._,..........,,...,,..... ,.. .,.,,.,.,..,,,.,,....,...,_...,,...... r_...
..,,..,...,..
.......... ,.,...._..,........,....,.,.,.,.,,.,..,,..,...,,,,.. .,.,,.,........,..,,....,,,.,.,..,.,,..,,,...,...,.....,...,.,,.�... y..,.+r .....,...a ..........
_ ... _
2
,
,
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET.
..............:........�..,:.-.,,,.. .cars:
If more space is needed,use additional sheets of paper of the same size.