HomeMy WebLinkAbout04-28-15 (2) pennsylvania 1505614105
'i7 OEPAR MENTOFREVENUE EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT f I
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth _ MMDDYYYY
7 07282014 05311945
Decedent's Last Name Suffix Decedent's First Name MI
Hair FBOnnie ILI
(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
C D 1. Original Return p 2. Supplemental Return p 3. Remainder Return(date of death
prior to 12-13-82)
C=) 4.Agriculture Exemption(date of O 5. Future Interest Compromise(date of p 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
C=:) 7. Decedent Died Testate p 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
CM 10. Litigation Proceeds Received p 11. Non-Probate Transferee Return O 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
O 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:
Name Daytime Telephone Number
Mark F. Bayley, Esquire (717)241-2446
First Line of Address
17 West South Street
Second Line of Address
City or Post Office State ZIP Code
Carlisle PA 17013
Correspondent's email address: markbayley@bayleymangan.com
m
REGIST ,R QFJWILLS U911PONV(--
REGISTER OF WILLS USE ONLY m
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PLEASE USE ORIGINAL FORM ONLY
Side 1
iiiii qljlil�liiiii ilii iiiiiiiiiiiliiilii15 641 5 1505614105
1505614205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name: Bonnie L. Hair
RECAPITULATION
1. Real Estate(Schedule A). . ....... .. .... .... ............... .. ...... ... 1.
2. Stocks and Bonds(Schedule B) .. . .. .. ...... .. .. ............. .... . ... . 2. 625.39
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. 60,335.68
6. Jointly Owned Property(Schedule F) O Separate Billing Requested . ...... 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested....... . 7.
8. Total Gross Assets(total Lines 1 through 7).. . ... .. ........ .. .. ... .. .. .. 8. 60,961.07
9. Funeral Expenses and Administrative Costs(Schedule H).. ...... ... .. . .. .. . 9. 15,505.99
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)... ... .. ... . ... 10. 292.40
11. Total Deductions(total Lines 9 and 10)... ........ ..... ..... .. ..... .. ... 11. 15,798.39
12. Net Value of Estate(Line 8 minus Line 11) . .. .. ..... ..... .... ... ... .. . . . 12. 45,162.68
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. 45,162.68
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 45 45,162.68 16, 2,032.32
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 18.
19. TAX DUE . .. ..... .. ........... .. . .... .. .. ........ ........... .. . ... 19. 2,032.32
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.
SIGNATU IBLE FOR FILING RETURN DATE
AC7 syu�a�c ��. , C_e.r l�S�� f i ✓'I 1 -7OI �3
$IG�N URE PREPAIRER OTHER HAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE
ApD ZSSt�. 5�� -, sk'• �r�:Sle �/�- 1 761
Side 2
1 6 4 1505614205
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Bonnie L. Hair
STREET ADDRESS
33 West Willow Street
CITY STATE 717013
Carlisle PA
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 2,032.32
2. Credits/Payments
A.Prior Payments
B.Discount
(See instructions.) Total Credits(A+B) (2)
3. interest
(3)
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)
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 2,032.32
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 ............................................ ❑ 0
c. retain a reversionary interest .............................................................................................................................. ❑ 0
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ N
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?.............. ❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? .......................................................................... El ■
..............................................
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)(11)(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(x)(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-1503 EX+(02-15)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE 4 p}�
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bonne L. Hair 21-14-748
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1' Walmart stock(7.833 shares) 625.39
TOTAL(Also enter on Line 2, Recapitulation) $ 625.39
If more space is needed,insert additional sheets of the same size
REV-1508 EX+(08-12)
pennsytvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
Bonnie Lou Hair 21-14-748
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. Blue Advantage Health(refund) 236.36
2. State Farm(auto insurance refund) 103.32
3. M&T(cash account(s)) 2,169.74
4. State Farm(refund) 26.46
5. Comcast(refund) 48.29
6. Loss of income insurance proceeds(State Farm) 385.25
7. Funeral expense insurance proceeds(State Farm) 2,500.00
8. Survivor action proceeds(State Farm/Erie)(See attached petition for approval of settlement,Order of 54,153.95
Court of 3-18-15,and Settlement Distribution Summary)
9. U.S,Treasury(federal income tax refund) 584.00
10. Walmart(employment proceeds) 128.31
TOTAL(Also enter on line 5, Recapitulation) $ 60,335.68
If more space is needed,use additional sheets of paper of the same size,
REV-1511 EX+(02-15)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bonnie L. Hair 21-14-748
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman-Roth 15,245.49
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 0.00
Name(s)of Personal Representative(s) Brian Hair
Street Address 67 Meade Drive
City Carlisle state PA ZIP 17013
Year(s)Commission Paid:
0.00
2. Attorney Fees:
0.00
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: 160.50
5. Accountant Fees: 100.00
6. Tax Return Preparer Fees: 0.00
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 15,505.99
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(02-15)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bonnie L. Hair 21-14-748
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman-Roth 15,245.49
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 0.00
Name(s)of Personal Representative(s) Brian Hair
Street Address 67 Meade Drive
city Carlisle State PA zip 17013
Year(s)Commission Paid:
0.00
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) 0.00
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 160.50
5. Accountant Fees: 100.00
6. Tax Return Preparer Fees: 0.00
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 15,505.99
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(02-15)
10 pennsytvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Bonnie L. Hair 21-14-748
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. Orrstown Bank I Delux(checks) 26.90
2. The Sentinel(advertising) 77.26
3. PPL(electric) 8899
4. Cumberland Law Journal(advertising) 75.00
5. PA Dept.of Revenue(state taxes) 13.00
6. Cumberland County Tax Bureau(local taxes) 11.25
TOTAL(Also enter on Line 10, Recapitulation) $ 292.40
If more space is needed,insert additional sheets of the same size.
In re: Bonnie L. Hair : IN THE COURT OF COMMON PLEAS
OF-CUMBERLAND COUNTY
ORDER OF COURT
AND NOW, this day of — ,2015,upon
Petition for Approval of Settlement Regarding Wrongful Death Claim Pursuant to
Pa.R.C.P. 2206 by the Administrator of the Estate of Bonnie L. Hair, docketed in the
Cumberland County Register of Wills Office at 21-14-748, it is directed as follows:
1. The Administrator of said Estate is approved and granted leave to settle
bodily injury claims associated with the automobile accident that occurred on July 10,
2014, involving tortfeasor Santos Zamudio,with Erie Insurance in the amount of
$50,000.
2. The Administrator of said Estate is approved and granted leave to settle
ti
first party underinsured bodily injury claims associated with the same accident with State
Farm in the amount of$100,000.
3. Attorney Mark F. Bayley's contingency fee of 25%of the gross settlement
proceeds as well as reimbursement for advanced costs of approximately$4,500 are
approved.
co
3 : :i
4. For state inheritance tax purposes, 50%of the net settlement proceeds
distributable to the Estate and Ms. Hair's only child shall be deemed wrongful death
proceeds and 50%shall be deemed survival proceeds.
BY
Thea Placey J.
CoMmon Peas Judge
CC. Mark F. Bayley, Esquire
PA Department of Revenue, Inheritance Tax Division, Bureau of Individual
Taxes, PO Box 280601, Harrisburg, PA 17128
TRUE COPY FROM RECORD
In Testimony whereof, t here.unto set my hand
and the�e of said urt.at Ca isle, pa,
This Y of
20 is_
Prothon ry
�/` /Z
r
Mark F.Bayley,Esquire
17 West South Street
Carlisle,PA 17013
(717)241-2446
Supreme Court I.D.#87663
'rrxP;tra,
In re: Bonnie L. Hair IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY
NO. ao
PETITION FOR APPROVAL OF SETTLEMENT REGARDING WRONGFUL
DEATH CLAIM PURSUANT TO PA.R.C.P.2206
AND NOW, comes Brian Hair,Administrator of the Estate of Bonnie L. Hair,by
and through his attorney, Mark F. Bayley, and avers as follows:
1. No judge has previous involvement with the within matter.
2. The Petitioner is Brian Hair who resides at 67 Meade Drive, Carlisle, PA
17013.
3. Petitioner was appointed as Administrator of the Estate of Bonnie L. Hair
on August 12, 2014.
4. Said Estate is docketed in the Cumberland County Register of Wills
Office at 21-14-748.
S. The Petitioner is Bonnie L. Hair's only child and is legally the sole heir
and/or beneficiary of the Estate and any applicable wrongful death proceeds involved
with this matter;he is 41 years old.
6. Bonnie L. Hair died intestate on July 28, 2014 as a result of complications
caused by an automobile accident that occurred on July 10, 2014; she was never married.
17. Undersigned counsel has advanced expenses of approximately$4,500 to
date which are agreed to be reimbursed to undersigned counsel out of settlement
proceeds.
18. Medicare has not reported any liens regarding this matter to date.
19. Petitioner is not currently aware of any potential third party liens and does
not believe that any exist.
20. After subtraction of attorney fees and reimbursement of attorney costs, it
appears that there will be net settlement funds of approximately$108,000.
21. For state inheritance tax purposes, staff of the Department of Revenue's
Inheritance Tax Division has agreed to apportion 50%of net settlement proceeds
distributable to the Estate and Ms. Hair's only child as wrongful death proceeds and 50%
as survival proceeds. See letter attached as "Exhibit A."
WHEREFORE, the Petitioner requests that the Court approve the proposed
settlement, payment of attorney fees and reimbursement for costs advanced by attorney,
and for state inheritance tax purposes to order that 50% of the net settlement funds be
deemed wrongful death proceeds and 50%be deemed survival proceeds.
Respectfully submitted,
BAYLEY & M GAN
Mark F. Bayley, Esquire
17 West South Street
Carlisle, PA 17013
(717) 241-2446
Supreme Court I.D.#87663
In re: Bonnie L. Hair IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY
NO.
VERIFICATION
I verify that the statements made in the foregoing document are true and correct. I
understand that false statements herein are made subject to the penalties of 18 Pa. Cons.
Stat. § 4904 relating to unsworn falsification to authorities.
Brian Hair
'
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DEPARTMENT OFREVENUE
March 2. 2U15
Mark F. Blayley, Esquire
Bayley&Mangan
17 West South Street
Carlisle, PA 17013
Re: Estate ofBonnie Hair
File Number 2114-O748
Court mfCommon Pleas Cumberland County
Dear Mr. Bayley:
The Department ofRevenue has received your correspondence. Attached was the petition to
approve ocompromise settlement hzbe filed mnbehalf ofthe above-referenced estate inregard hoa
wrongful death and survival action. |twas sent hmthis office for the Commonwealth's approval ofthe
allocation hothe proceeds paid tosettle the actions.
According to the Petition, the 69 year old decedent died as a result of a motor vehicle accident.
Decedent issurvived byher adult child.
The petition also states that the decedent experienced substantial pain and suffering for 18 days
period,from the time mfthe original accident until her date ofdeath. Pain and suffering are aspects of the
claim that are to be considered under the survival action portion of the settlement, Kiser v. Schulte, 048
A.2d1 (PA 1994)
Please beadvised that based upon these facts and case law,the Department disagrees to the
proposed allocation of a 75/25 split between wrongful death and survival action. However,for inheritance
tax purpose only, this Department would not object 0wthe allocation ofthe net proceeds ofthis action,
$54,000.00 to the wrongful death claim and $54,000.00 to the survival claim. This imequal tma58/5O
split. Proceeds of a survival action are an asset included in the decedent's estate and are subject tothe
imposition ofPennsylvania inheritance tax. 42Pa.C.S.A.§8302. 72P.8.$9106. 9107.
1 trust that this letter is a sufficient representation of the Department's position on this matter.
Please contact me ifyou mrthe Court has any questions or requires an,,ohing additional from this Bureau.
1S nnon E. Baker
rustuation Specialist
Inheritance Tax Division
Bureau orIndividual Taxes | MO Box28U6O1 \ Hanisburg, KA17128 ( 717J83.5824 \ shabaksr@pa.gov
Estate of Bonnie L. Hair
Settlement Distribution Summary
Gross settlement proceeds:
State Farm(Underinsured bodily injury recovery) $100,000.00
Erie(First party bodily injury recovery) $50,000.00
$150,000.00
Minus attorney fees-25% $37,500.00
$112,500.00
Minus expenses advanced by attorney*: $4,192.10
$108,095.39
Net settlement proceeds available for distribution: $108,307.90
Distribution to Brian Hair: $54,153.95
(wrongful death recovery)
$54,153.95
Distribution to the Estate of Bonnie L.Hair: $54,153.95
(survival recovery)
0
*
FPA(autopsy): $3,500.00
Prothonotary(filing fee re:petition to approve settlement): $115.75
StarMed(record reproduction): $79.40
Cumberland County Coroner's Office(record reproduction): $85.00
North Middleton Police Dept.(record reproduction): $15.00
Archangel Investigations,LLC(private investigator): $396.95
Total: $4,192.10