HomeMy WebLinkAbout04-22-15 1505614134
EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 0 8 0 6 6 6
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 1 0 1 2 0 0 7 0 9 1 2 1 9 3 8
Decedent's Last Name Suffix Decedent's First Name MI
M A Y S D A V I D L
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
M A Y S W A N D A L
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. Remainder Return(date of death
Prior to 12-13-82)
❑ 4.Agriculture Exemption ❑ 5. Future Interest Compromise(date of ❑ 6. Federal Estate Tax Return Required
(date of death on or after 7-1-2012) death after 12-12-82)
❑ 7.Decedent Died Testate ❑ 8. Decedent Maintained a Living Trust 9.Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
❑X 10.Litigation Proceeds Received ❑ 11.Non-Probate Transferee Return ❑ 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets only)
❑ 13. Business Assets ❑ 14.Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
J A C Q U E L I N E A K E L L Y 7 1 7 5 4 1 5 5 5 0
First Line of Address
8 4 5 S I R T H O M A S C T S T E 1 2
Second Line of Address
S U I T E 1 2
City or Post Office State ZIP Code C") 17-11
C_>
H A R R I S B U R G P A 1 7 1 0 9
r-i ra �-1 ri
Correspondent's e-mail address: jackle@janbrown law.COfil
REGIS ER OF wlL16 USE•LaNN,C�,��
J t: C
REGISTER OF WILLS USE ONLY
DATE FILED MMDDYYYY ? ,� , rn
y C:,)
i
DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
I IIIIII VIII VIII VIII VIII VIII VIII VIII VIII VIII IIII IIII
L 1505614134 1505614134 J
1505614234
REV-1500 EX(FI) Decedents Social Security Number
Decedent's Name: D A V I D L • M A Y S
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 and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . .. . . . & 2 2 4 1 6 . 3 1
6. Jointly Owned Property(Schedule F) F-1 Separate Billing Requested . . .. . . 6.
7. Inter-Vivos Transfers&Miscellaneous N Probate Property
(Schedule G) M Separate Billing Requested . . . . . . . 7.
8. Total Gross Assets(total Lines I through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 2 2 4 1 6 . 3 1
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . .. . . . ... . . . . 9. 4 3 0 . 0 0
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .. . 110.
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 4 3 0 . 0 0
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . 12. 2 1 9 8 6 . 3 1
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . 13.
114. Net Value Subject to Tax(Line 12 minus Line 13) ... . . . . . . . ..... . .. . . . . 14. 2 1 9 8 6 • 3 1
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.O _ 2 1 9 8 6 3 1 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate X.0- 0 0 0 16. 0 . 0 0
17. Amount of Line 14 taxable
at sibling rate X.12 0 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 0 0 18. 0 . 0 0
19. TAX DUE ... . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 0 . 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT MR
Under penalties of perjury,I declare 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 person responsible for filing the return is based on all information of which preparer has
an kn9wledge. le2l . 11
SIWURE OFE�RSQ SPO OR LI RN DATE
ADDRESS
17CREEK ROAD NEWVILLE PA 17241
S11 TURE OF PREJARtR OTHE�,,T
WA VEISON RESPONSIBLE FOR FILING THE RETURN DATE
bKESSt/
45 SIR THOMAS CT STE 12 HARRISBURG PA 17109
11111111111111111111111111111111111111111111111111111111 IN Side 2
1505614234 1505614234
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address: 0 0
DECEDENT'S NAME
DAVID L MAYS
STREET ADDRESS
173 CREEK ROAD
CITY STATE
ZIP
INEVVVILLE PA -117241
Tax Payments and Credits:
1• Tax Due(Page 2,Line 19) (1) 0.00
Z Credits/Payments
A.Prior Payments
B.Discount
(See instructions.) Total Credits(A+6 (2) 0.00
3. Interest
(3)
4. If Line 2 is greater than Line I +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 I +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 ....... ....................... ....... ...... ....... 171 MX
b. retain the right to designate who shall use the property transferred or its income ............................... 171 MX
c. retain a reversionary interest ................... ........................................... ..................................... 11 MX
d. receive the promise for life of either payments,benefits or care? ....................................................... 171 MX
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....... .............._..._.... ........ ..................... ....... 171 MX
3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death? ......... EJ FX]
4, Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. 171 IZI
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 step-parent 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 91102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX
RESIDENT DECEDENTRETURN PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
DAVID L. MAYS 0 0
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. Survival action damages pursuant to Court Order dated 10/24/2013. Petition, Order 22,416.31
and Department of Revenue letter dated 10/8/2013 regarding allocation is attached.
TOTAL(Also enter on Line 5,Recapitulation) $ 22,416.31
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHER TANCE TAX RETURN
11ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DAVID L. MAYS 0 0
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2, Attorney Fees: Jan L. Brown &Associates 400.00
3. Family Exemption:(if decedent's address is not the same as claimants,attach explanation)
Claimant
Street Address
City State - ZIP
Relationship of Claimant to Decedent
4. Probate Fees: Register of Wills, Cumberland County 30.00
filing fee Supplemental Inheritance Tax Return and Inventory
5. Accountant Fees:
6, Tax Return Preparer Fees:
7.
TOTAL(Also enter on Line 9,Recapitulation) $ 430.00
If more space is needed,use additional sheets of paper of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
DAVID L. MAYS 0 0
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under
Sec.9116(a)(1.2)]
1. Wanda Lou Mays Spousal 21,98631
173 Creek Road
Newville, PA 17241
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
l
LOCKS LAW FIRM
BY: JERRY A. LINDHEIM,ESQUIRE Attorneys for Plaintiff
IDENTIFICATION NO. 53099
601 WALNUT STREET-Suite 720 East
PHILADELPHIA,PA 19106
(215)893-0100
WANDA MAYS,individually,and as COURT OF COMMON PLEAS
Executrix of the Estate of David Mays,deceased CUMBERLAND COUNTY
Plaintiff
VS.
NO. 09-6667
Manor Care,Inc., et al. 1;
Defendants =� '
ORDER
AND NOW,this 0?�ay of ��,� 2013,upon consideration of
the outstanding Petition for Approval of Settlement of Wrongful Death and Survival Actions,the
proposed settlement with Dow Brophy, M.D. and Manor Care of Carlisle, PA, LLC,et al., having
a gross value of$800,000.00,is hereby approved,to be distributed and allocated as follows:
TO: LOCKS LAW FIRM—fee $320,000.00
LOCKS LAW FIRM-reimburse costs 28 228.00
Medicare Lien $3,445.80 ,
The balance of$448,326.20 is hereby allocated 95%to the Wrongful Death action and 5%
to the Survival action,distributable as follows:
f
Wrongful Death Action:
TO: Wanda Mays, spouse $425,909.89
Survival Action:
TO: Wanda Mays,Executrix, who shall not be
entitled to receive said proceeds until application
has been made to the Register of Wills of
Cumberland County to determine the need, if any,
for additional bond. $22,416.31
Wanda Mays, Executrix, is ORDERED and DIRECTED to file a copy of this Order with
the Register of Wills of Cumberland County pursuant to 20 Pa. C.S.A. §3323(b)(3) within thirty
(30)days.
BY THE COURT
J.
} r pennsyLvania
t DEPARTMENT OF REVENUE
October 8,2013
Jerry Lindheim,Esquire
Locks Law Firm
601 Walnut Street,Suite 720
Philadelphia,PA 19106
Re: Estate of David Mays
File Number 2108-0666
Court of Common Pleas Cumberland County
Dear Mr.Lindheim,
The Department of Revenue received the Petition for Approval of Settlement Claim to be filed on
behalf of the above-referenced Estate in regard to a wrongful death and survival action. It was forwarded
to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the
actions.
Pursuant to the Petition,the 69 year old decedent died as a result of injuries received in a fall.
The sole heir to decedent's estate is his spouse. Therefore,any proceeds paid to settle the survival action
would pass to decedent's spouse and would be subject to a zero percent inheritance tax rate. 72 P.S.
§9116(a)(1.1)(ii). Accordingly,regardless of the allocation of the subject proceeds,there would be no
inheritance tax consequences.
Please be advised that based upon these facts and for inheritance tax purposes only,this
Department has no objection to the proposed allocation of the gross proceeds of this action,$760,000.00
to the wrongful death claim and$40,000.00 to the survival claim. Proceeds of a survival action are an
asset included in the decedent's estate and,although subject to the imposition of a zero percent
inheritance tax rate in this instance,they must be reported on decedent's Pennsylvania inheritance tax
.return. 42 Pa.C.S.A. § 8302; 72 P.S. §9106,9107. Costs and fees must be deducted in the same
percentages as the proceeds are allocated. In re Estate of Merryman,669 A.2d 1059(Pa.Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this matter. As
the Department has no objections to the Petition,an attorney from the Department of Revenue will not be
attending the hearing regarding it. Please contact me if you or the Court has any questions or requires
anything additional from this Bureau.
Sin ely,
annon E.Baker
Trust Valuation Specialist
Inheritance Tax Division
Bureau of Individual Taxes ( PO Box 280601 J Harrisburg, PA 17128 1717.783.5824 1 shabaker@pa.gov
i
I
LOCKS LAW FIRM
BY: JERRY A.LINDHEIM,ESQUIRE Attorneys for Plaintiff
IDENTIFICATION NO.53099
601 WALNUT STREET-Suite 720 East
PHILADELPHIA,PA 19106
(215)893-0100
WANDA MAYS,individually,and as COURT OF COMMON PLEAS
Executrix of the Estate of David Mays,deceased : CUMBERLAND COUNTY
Plaintiff
VS.
NO. 09-6667
Manor Care,Inc.,et al.
Defendants
PETITION FOR COURT APPROVAL OF SETTLEMENT OF AN ESTATE'S
ACTION UNDER THE WRONGFUL DEATH AND SURVIVAL ACTS
Petitioner, Wanda Mays, Executrix of the Estate of David Mays, deceased, by and
through her attorneys,LOCKS LAW FIRM,hereby petitions the Court as follows: .
1. Petitioner is Wanda Mays, who was granted Certificate of Grant of Letters
Testamentary on the Estate of David Mays, deceased by the Register of Wills in the County of
Cumberland, in the Commonwealth of Pennsylvania on June 20, 2008,No. 21-08-0666. .A true
and correct copy of the Short Certificate is attached hereto as Exhibit A.
2. Petitioner, Wanda Mays, is the wife and widow of the decedent, David Mays.
Wanda Mays,is the sole beneficiary of the Estate of David Mays.
3. This action was commenced against,inter alfa,Dow E.Brophy,M.D.,(hereinafter
referred to as "Dr. Brophy") and several Manor Care entities as the result of medical negligence
leading to the November 1, 2007 death of Mr. Mays associated with a fall and resulting subdural
hematoma. A true and correct copy of the Complaint against Dr. Brophy and Manor Care of
Carlisle,PA,LLC,et al.,P.C.is attached hereto as Exhibit B.
4. At the time of his death,David Mays was 69 years old. He was retired,disabled,
and survived by his wife and three children.
5. The within litigation was contentious and involved the taking of the depositions of
Dr. Brophy and Mrs. Mays. In addition, several medical experts were retained to review and
provide opinions in this matter as to the acceptable standards of care and as to the issue of
causation. These experts include individuals in the field of Emergency Medicine,
Neurosurgery,nursing,and Family Practice.
6. Subject to the approval of the Court, the parties have entered into a global
settlement agreement made on behalf of Dr. Brophy and Manor Care of Carlisle, POA, LLC, et
al. for the payment of cash with a present net value of eight hundred thousand dollars
($800,000.00). A true and correct copy of the Release and Settlement Agreement is attached
hereto as Exhibit C. This settlement is as to all claims, as all other defendants will be dismissed
from the action.
10. The total legal expenses of this litigation total$26,753.52.
11. Counsel was retained on the basis of a contingency agreement providing for
counsel to receive forty percent (40%) of any recovery or settlement. See attached Contingency
Fee Agreement at Exhibit D. Counsel requests attorney's fees in the amount of$320,000.
12. The net proceeds of the settlement,after deduction of legal costs and counsel fees is
$453,246.48.
13. There is a Conditional Payment Medicare lien in the amount of$5,852.52 asserted
against the recovery in this matter. See a Conditional Payment Medicare letter attached at Exhibit
E. The net proceeds of the settlement,after deduction of the Medicare lien is$447,393.96.
14. By this Petition,Wanda Mays,in her role as Executrix of the Estate of David Mays,
deceased, seeks authority and approval to enter into the proposed settlement with Dr.Brophy and
the Manor Care entities in the amount of$800,000.00.
15. Pursuant to applicable Pennsylvania law, all settlements that arise out of the
Wrongful Death and/or Survival Act must be approved by the Court. See, 20 Pa. C.S.A.
§3323(a).
16. It has always been the policy of the Commonwealth to favor Wrongful Death
allocations over Survival Actions because Wrongful Death damage would normally be determined
by a jury before any damages under the Survival Act would be calculated. See, Krause v. B&O
Railroad, 33 D&C 3d 458, 5 Fid. 2d 106 (1983); In Re: Winder Estate, 36 Som. Leg. J. 337
(1979).
17. Petitioner requests allocation of the net proceeds of the settlement as follows:
A. Wrongful Death Action: 95%
B. Survival Action: 5%
18. Pursuant to the Wrongful Death Act, 42 Pa. C.S.A. §8301, the sole pecuniary
beneficiary of the Wrongful Death claim is the Petitioner, decedent's wife, Wanda Mays.
Petitioner requests this Court to approve this settlement as proposed so that the net proceeds of the
settlement be distributed under the Wrongful Death and Survival Acts as set forth below:
A. Wrongful Death Action: $425,024.26
B. Survival Action: $22,369.70
19. The aforesaid allocation has been submitted for approval to the Commonwealth of
Pennsylvania, Department of Revenue. By letter dated October 8, 2013, the Department has
indicated its approval of the above allocation and that it will not be attending any Hearing for the
approval and allocation of the proceeds in this matter. A true and correct copy of the October 8,
2013 letter from the Commonwealth of Pennsylvania,Department of Revenue is attached hereto
as Exhibit F.
20. Counsel is of the professional opinion that the total settlement reached in this
matter in the amount of$800,000.00 is reasonable in view of the dispute associated with whether
any treatment could have extended the life of the decedent. See Affidavit of Jerry A. Lindheim,
Esquire which is attached hereto as Exhibit G.
WHEREFORE, Plaintiff, Wanda Mays, as Executrix to the Estate of David Mays,
deceased, respectfully request that this Honorable Court approve the proposed settlement and
distribution set forth herein.
Respectfully submitted,
LOCKS LAW FIRM
BY: Al Jerry Lindheim
JERRY A.LINDHEIM,ESQUIRE
Attorneys for Plaintiff
Dated: