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Home My WebLink About04-30-15 pennsytvania 1505614105 EX(03-14)(FT) REV-1500 OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number INHERITANCE TAX RETURN POBOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MIVIDDYYYY Date of Birth MMDDYYYY .............................................. ................. ..................... .. .. ...... ................................................ k-2 .............. .......... Decedent's Last Name Suffix Decedent's First N.me Ml VVidra 'Doris (if Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ..................... ........ ....... .. ............................... ..................................................................... ...... .................. ................ ........... ......... ........................ .............. THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW cW 1. Original Return C=) 2.Supplemental Return C=:) 3. Remainder Return(date of death prior to 12-13-82) C=:) 4,Agriculture Exemption(date of O 5. Future Interest Compromise(date of C=:) 6, Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) C=:) 7. Decedent Died Testate C=:) 8. Decedent Maintained a Living Trust 0 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) C=) 10, Litigation Proceeds Received C=:) 11, Non-Probate Transferee Return C=D 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) C=:) 13. Business Assets O 14.Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NameDaytime Telephone Number .............. ........... 'Shaun E. O'Toole 695-0389 ................................ ____..............- . ........ ................................. ................... .......... .............. ................................................ First Line of Address 1220 Pine Street ........... .................. ............... Second Line of Address City or Post Office State ZIP Code ........................................................ ..........I............... ........................ ....... Harrisburg PA 17101 ........... Correspondent's email address: REGISTER OF WILLS U§kPNLY REGISTER OF WILLS USE ONLY rn n 7..DATE FILED MMODY YY Y - c> _0 G C:3 __j DATE FILED STAMP-n r— rn PLEASE USE ORIGINAL FORM ONLY Side 1 11111111111111 IN 1505614105 1505614105 1505614205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Doris R. Widra RECAPITULATION 1. Real Estate(Schedule A). ... . . .. . .. .. .. . .. ..... ... . . .. ... .. . .. ... .. .. 1. 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). . .. ... 5. j 17,661.71 i 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. .. .. . 6. j 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property 1 (Schedule G) O Separate Billing Requested.. .. . .. . 7. 8. Total Gross Assets total Lines 1 through 7 8. } 17,661.71 9. Funeral Expenses and Administrative Costs(Schedule H). . .... . ... .. .. . .. . 9. 4,105.00 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). ... .. ... .. .. .. 10. 1 153,193.06 s 11. Total Deductions(total Lines 9 and 10).. .. .. . . . . .. ... ... .. .. . ... . ..... . 11. ? 157,298.06 f 12. Net Value of Estate(Line 8 minus Line 11) . . . .. .. .. .... .. . . .. . . . . .. . .... 12. ; -139,636.35 13. 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. 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 ......... i (a)(1.2)X 15. 0.00 16. Amount of Line 14 taxable at lineal rate X.0_ 16. 1 0.00 17. Amount of Line 14 taxable at sibling rate X.12 17.1 0.00 18. Amount of Line 14 taxable at collateral rate X.15 i 18. j 0.00 19. TAX DUE .. ... .. .. .. . . . . .. . ..... .. . . . . ... .... ... .. .. ... .. . .... ... . 19. 0.00 ; ........ . ._............ _.._._. .. ............ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O 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 any knowledge. SIGNAT F PE `ON IBLF OR FILING RETURN DAIE ` N (j. oil 24 /16' A RESS 220 Pine Street, Harrisburg, Pennsylvania 17101 SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE ADDRESS Side 2 1505614205 1505614205 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME Doris R.Widra ................... ............. ........................................... STREETADDRESS 210 Big String Road .............................. ......... ........... .................... CITY STATE ZIP Newville PA Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) 0.00 2. Credits/Payments A.Prior Payments ................................................ ............. .............. B.Discount (See instructions.) Total Credits(A+B) (2) 0.00 3. Interest (3) 0.00 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.......................................................................................... ❑ 0 b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ ■ c. retain a reversionary interest ....._................................................................................._.................................. ❑ N 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?.............. ❑ N 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 03 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 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-i5o8 EX+(o8-i2) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Doris R.Widra 21-14-0493 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 Checking Acct.#9852877324 15,735.54 2. Carlisle Corporation-Amount due from deceased husband's retirement fund 1,926.17 TOTAL(Also enter on Line 5, Recapitulation) $ 17,661.71 If more space is needed,use additional sheets of paper of the same size. MM&TBank . . ACCOUNT NO ACCOUNT TYPE:': .$TATEMEN$ PFiRTPD kAGE 9852877324 M&T CLASSIC C14ECKING WfINTEREST DEC.02-JAN.01,2014 1 OF 1 00 0 04344M NM 017 29091 DORIS R WIDRA 109 BEETEM HOLLOW RD NEWVILLE PA 17241-9539 INTEREST EARNED FOR STATEMENT PERIOD 0.13 SPRING GARDEN INTEREST PAID YEAR TO DATE 0.14 ACCOUNT SUMMARY aEG NNING Z3...... TS & {3TFiER Ltk?i? NF &NI32NG;:> .. .t7THER:>ADnITIbNS ;CFiECKSs?PAID. SU@TRACTIONS :>:.. . II3T'E12�ST<.pD '.. :.:; BAIAt3CE NO. AMOUNT NO. AMOUNT NO. AMOUNT 7,675.44 21 8,941.70 1 315.00 1 0 1 0.00 0.14 16,302.28 ACCOUNT ACTIVITY POSTING DUPS,TS. INTEREST CFiPCK� & PTH�R AAIIa�I :: :; `.. {)TFfER-.AT7L1ITIt}p2S'. .. 12-02-13 BEGINNING BALANCE $7,675.44 12-02-13 DEPOSIT 8,060.10 15,735.54 12-03-13 SSA TREAS 310 XXSOC SEC 881.60 16,617.14 12-04-13 CHECK NUMBER 0259 315.00 16,302.14 01-01-14 INTEREST PAYMENT 0.14 16,302.28 ENDING BALANCE $16,302.28 C;t3ECtS::;LAT�7.SJh7MhRY 259 12-04-13 315.00 ANNUAL PERCENTAGE YIELD EARNED = 0.00 ❑CORRECTED(if checked) OMB No.1545-011 2011 PAYER'S name,street address,city,state,and ZIP code 1 Gross distribution 2b Taxable amount Form 1099-1 RETIRENMENT SERVICES $ 1926.17 not determined ❑ Distribution: CARLISLE CORP EMPLOYEES RET PLAN 2a Taxable amount Total From Pensions Annuities 733 AlARQUI 1"TE AVE,N9306-042 $ 1926.17 distribution ❑ Retirement o MINNEAPOLIS.NIN 55479 3 Capital gain(included in 4 Federal income tax Profit-Sharin( box 2a) withheld Plans,IRAs PAYER'S federal identification number RECIPIENT'S identification number $ $ 192.62 Insurance 41-6257133 Na'\_,X1-9430 5 Empfoyee contributions 6 Net unrealized Contracts,etc /Designated Roth contributions appreciation This information is bein- RECIPIENT'S name,street address(including apt.no.),city,state,and ZIP code or insurance premiums in employee's securities furnished to the Interna $ $ Revenue Servic- ESTATE OF DORIS WIDRA 7 Distribution [NSENSIMPLE1$ Other COPY C code(s) C/O SHAUN O'TOOLE 7 Is % For Recipient's 220 PINE STREET a Your percentage of total b Total employee Records IIARRISBURG,PA 17101 distribution contributions $ 2 State tax withheld 13 State/Payer's state no. $ 59.13 PA 18550756 14 State distribution 10 Amount allocable to IRR within 5 years11 1st year of desig.Roth contrib. $ ---1926.17 1926 17_--__ 15 Local tax withheld 16 Name of locality $ Account number(see instructions "Tracking# $ 17 Local distribution 25664800 _ 65000008255524T1 $-----------------------------------------$ —-- ----------------- FORM 1099-R Department of the Treasury-Internal Revenue Service $ REV-1511 EXE (02-15), pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris R. Widra 21-14-0493 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 ZI" Year(s)Commission Paid: 2. Attorney Fees: 4,000.00 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 4. Probate Fees: 105.00 5. Accountant Fees: 6. Tax Return PreparerFees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ 4,105.00 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+ (02-15) V1'0-,T pennsylvania SCHEDULE I t DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris R.VVidra 21-14-0493 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. Presbyterian Homes,Inc.,d/b/a Green Ridge Village-nusing home care 8,084.82 2. PA Department of Welfare-Estate Recovery Amount(Medicaid) 145,108.24 TOTAL(Also enter on Line 10, Re-apitulation) $ 153,193.06 If more space is needed,insert additional sheets of the same size. COURT OF COMMON PLEAS CUMBERLAND COUNTY,PENNSYLVANIA ORPHANS' COURT DIVISION In Re: Estate of DORIS R. WIDRA, No. Deceased, NOTICE OF CLAIM FILED PURSUANT TO 20 Pa. C.S. §3532 OF THE PROBATE, ESTATES AND FIDUCIARIES CODE To the Clerk of Orphans' Court: Enter the claim Presbyterian Homes, Inc. d/b/a Green Ridge Village (Green Ridge Village) in the amount of $8,084,82. The sum of $8,084.82 is a priority claim under 20 Pa.C.S.A. § 3392(3) for the value of nursing care and services rendered to the Decedent within six (6) months of death. The Decedent, who resided at Green Ridge Village, located at 210 Big Spring Road, Newville, PA 17241, died on December 2, 2013. Written notice of said claim was given to Shaun O'Toole, Esquire, Administrator of the Estate of Doris Widra, at 220 Pine Street, Harrisburg,PA 17101. Respectfully submitted, Dated: By: Nicole M. Weigel Attorney I.D.Number 206827 Presbyterian Senior Living One 'trinity Drive East, Suite 201 Dillsburg, PA 17019 17) 502-8976—Phone (717) 502-8842—Fax nweigel@presbyieria,nseniorliviniz.org Counsel far Claimant - ' ~ �"~� . ��u�� n~ ^�^^�� ~^^~� osr^orwsw` orPUBLIC ws�rARe � May 19, 3014 ` VlCKlVVALLDCK 109BEETEM HOLLOW RD NEVVV{LLEPA 17341 Re: DorisVVidna CIS #: 540281820 SSN: ###-##-9OgS Date ofDeath: 12/02/2013 ESTATE RECOVERY s'rATEMENT OF CLAIM Dear � 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. G1396p(b)(1). 62 P'S. § 1412. This letter sets forth the amount of the Department's da|rn 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. Statementof Claim Amount The Department maintains a dnino in the amount uf $150,044.52 against the above-mentioned estate. This c|uirn is for repayment of M/\ granted on behalf o[the decedent Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $4"936.28, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 c|oirn pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3302(3). The balance of the claim, namely is to be entered as priority Class 5.1 claim against the cataLe. You should refer to Section 3392 for a more complete explanation of the priority rules. If 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 orProgram integrity| Division v/Third Party Liability | Recovery Section poBox o4oa /Harrisburg,Pennsylvania /r1os'owun , . IN pennsyLvania DEPARTMENT OF pouuc wsLp^ne Insolvent Estates and the Fiduciary Responsibility WmCreditors If there are not enough estate assets to pay the claims nfall creditors in full, then the executor or administrator has a duh/ to act in the best interest of creditors when administering the estate. If you must spend the estate's money to administer it, you must act prudently and make purchases as if the money were corning out ofyour own pocket. The Department's approval is required if you expect the legal fees to exceed more than the greater ofG96 of the estate assets or $1,000. Contingent fees forestate administration will generally not beapproved. l[you dnnot obtain approval, the Department may consider the excessive fees to be a transfer for less than valuable and adequate consideration. Sincerely, MadaoneMeck|ey TPLProgram Investigator - 717-772-6246 �� { 717-772-6553 FAX Enclosure ' Bureau of Program Integrity Division of Third Party Liability | Recovery Section