HomeMy WebLinkAbout06-05-15 (2) —I REV-1500 1505610143
EX(Ot-10)
ypx
PA Department of Revenue OFFICIAL USE ONLY
p Pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
Po Box.280601 INHERITANCE TAX RETURN 2 1 15 0 0 1 0 8
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
12 23 2014 01 27 1917
Decedent's Last Name Suffix Decedent's First Name MI
NISSLEY LILLIAN M
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS 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 ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
® 5 Decedent Died Testate ❑ 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of will) (Attach Copy of Trust)
❑ 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 Sch.0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
DENNIS J WARD 717 733 8411
REGISTER OF WILL§;_CASE ONL)M
n crT -`0 t"r1
C C:) _ fT7
First line of address r
114 EAST MAIN STREET
f r:1 cn
Second line of address - 1
SUITE A = M`
DAT72
E FILED �" C,,
City or Post Office State ZIP Code r w r
EPHRATA PA 1 7 5 2 2
Correspondent's e-mail address: dward@dejazzd.COm
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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURNBeverly A. Kreman DATE
old �. aGL�
ADDRESS
2008 Carlisle Road, Camp Hill, PA 17011
SIGNU E OF PR ARE OTH THAN REPRESENTATIVE DATE
bu Dennis J Ward 04/0 V avlS
ADDRESS
114 East Main Street, Ephrata, PA 17522
Side 1
1505610143 1505610143
ADDITIONAL Personal Representatives
Nissley, Lillian M. SS# 12/23/2014
Under penalties of perjury, the undersigned declare that they have examined this return,
including accompanying schedules and statements, and to the best of their knowledge and
belief, it is true, correct and complete.
2 Signature
Name Wayne C. Nissley, Jr.
Address 4196 Jasmine Place
City, State,Zip Mount Joy PA 17552
Date
3 Signature
Name
Address
City,State,Zip
Date
4 Signature
Name
Address:
City,State,Zip
Date
5 Signature
Name
Address:
City,State,Zip
Date
Signature
Name
Address:
City, State,Zip
Date
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: NISSLEY, LILLIAN M.
RECAPITULATION
1. Real Estate(Schedule A).......................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................... 2. 7 0 9 . 9 3
& Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3.
4. Mortgages&Notes Receivable(Schedule D).......................................................... 4.
5• Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 61 , 5 8 4 . 2 1
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 18 . 0 2 9 7 6
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7. 9 0 , 6 6 7 . 0 7
8. Total Gross Assets(total Lines 1-7)....................................................................... g. 1 7 0 9 9 0 9 7
9. Funeral Expenses&Administrative Costs(Schedule H).................... 1 9 4 9 7 1 6
10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule 1)................................ 10. 6 9 6 5 0 2
11. Total Deductions(total Lines 9&10)...........:............................................................ 11. 2 6 4 6 2 1 8
12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 1 4 4 5 2 8 7 9
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. 1 4 4 , 5 2.8 ., 7 9
TAX COMPUTATION-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 .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 1 4 3 , 9 2 8 7 9 16. 6 , 4 76 80
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 6 0 0 0 0 18. 90 0 0
19. Tax Due..................................................................................................................... 19. 6 . 5 6 6 . & 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21 15 - 00108
Decedent's Complete Address:
DECEDENT'S NAME
Nissley, Lillian M.
STREET ADDRESS
Manor Care Health Services
CITY STATE ZIP
1700 Market St., Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 6,566.80
2. Credits/Payments
A. Prior Payments 6,750.00
B. Discount 328.34
Total Credits(A +B) (2) 7,078.34
3. Interest (3) 0.00
4, If Line 2 is greater than Line I+Line 3,enter the difference. This is the OVERPAYMENT. (4) 611.64
Check box on Page 2 Line 20 to request a refund
5. If Line I +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5)
Make Check Payable to: REGISTER OF WILLS, AGENT.
111IN111111111MI
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;................................... H NX
c. retain a reversionary interest;or...................................................................... ........................................... Fx]
d. receive the promise for life of either payments,benefits or care?.............................................................. 1XI
2. If death occurred after December 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?.................................................... ......................_.............___............
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 January 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 21ears 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 172 P.S.§9116(a)(T.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 1.2)[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)1. A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,whether y bloodor adoption.
LAST WILL AND TESTAMENT 0
OF
LILLIAN M.-NISSLEY
I,Lillian M. Nissley, of Camp Hill,Cumberland County, and Commonwealth of
Pennsylvania, being of sound and disposing mind, memory and understanding,'do make, publish and
declare this to be my Last Will and Testament. Any and all Wills and Codicils made by me at any
time prior to this Will are hereby revoked and void.
I. DEBTS AND DEDUCTIONS:
I direct my Executor hereinafter named to pay all of my just debts and expenses of my
last illness and funeral expenses out of my estate.as soon as may be convenient after my decease.
II. TAXES:
I direct that all estate, inheritance and other taxes in the nature thereof,together with
any interest and penalties thereon, becoming payable because of my death with respect to the property
constituting my gross estate for death tax purposes, whether of not such property passes under this
Will small be paid from the principal of my residuary estate, and no person receiving or having a
beneficial interest in any such.property; whether under.this Will or otherwise, shall at any.time be
required to contribute to or refund any part thereof.
III. DISTRIBUTION:
A. I give and bequeath the sum of five hundred dollars.($50q.00) unto my friend,
Susan Snyder,presently of.35 Kreider Ave., Lancaster, .PA 17601; and
B. I give and bequeath the sum of one hundred dollars ($100.00) unto my friend,
Doris Lownsbery,presently of 53 Kreider Ave., Lancaster, RA 17601-,and
C. I give and bequeath my diamond ring, wedding band and all of.my jewelry
unto my daughter,Beverly A. Kreman, presently.of 2008 Carlisle Road,
Camp Hill, PA 17011; and
E. RESIDUE:
I direct my Executor hereinafter named to convert all the rest,residue and
remainder of m estate both real andpersonal, of whatsoever nature and wheresoever
y
situate, into cash,by private.sale or.,public sale, or both,if, as, and when my Executor
deems appropriate under the circumstances then and there existing and I give, devise,
and bequeath all such rest,residue and remainder of my estate so converted into cash
or otherwise, after.payment of all debts and obligations, liabilities, expenses,taxes,
and costs of administration unto my issue in equal shares per stupes:
IV. EXECUTOR:
I nominate, constitute, and appoint my children; Beverly A. Kreman and Wayne C.
Nissley, Jr., or the survivor of them, as Co-Executors of this my Last Will and Testament. I direct that
my Executors shall not be required to file a bond for any purpose whatsoever in connection with the
settlement of my estate: .
IN WITNESS WHEREOF,I have signed this my Last Will and Testament on 1.5 ,2010.
L 1 an M. Nissley
Signed,published and declared by the above named Testatrix,Lillian M. Nissley,as and for
her Last Will and Testament;in the presence'of us, who, at her request,in her presence and in the
presence of each other have subscribed our names as witnesses hereto.
'Q6 0 12, ,
Name V Address
/;70//
is
Name Address
" 2
MEMORANDUM
PA Inheritance Tax Return
Estate of Lillian M. Nissley.
Estate No. 21-15-00108 (Cumberland County, PA)
Date of Death: December 23, 2014 - Date of Birth: January 27, 1917
Social Security No.: - EIN No: 47-6776128
Executors: Beverly A. Kreman and Wayne C. Nissley, Jr.
Re: Schedule—J
Article III. C. of the Decedent's Will dated September 15, 2010 provides as follows:
I give and bequeath my diamond ring, wedding band and all of my jewelry
unto my daughter, Beverly A. Kreman...
The Decedent lived with her daughter, Beverly A. Kreman, for several years prior to
becoming a resident of Manor Care Nursing Home in Camp Hill, PA in October 2014.
Prior to her death while living with her daughter in 2011, the Decedent gifted these items
of jewelry to her daughter. Therefore, none of these items were part of the Decedent's
Estate.
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Nissley, Lillian M. 21 - 15 -00108
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF
NUMBER DEATH
1 MetLife, Inc. 54.61 709.93
I
I
i
I
I
TOTAL(Also enter on line 2, Recapitulation) 709.93
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
coWWNWEALTH OF PENNSYLVANIA PERSONAL PROPERTY
INHERITANCE TAX RETLRN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Nissley, Lillian M. �21 - 15-00108
Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
I Susquehanna Bank-Certificate of Deposit Account No. 10008240383 51,866.48
-Verification attached
2 Susquehanna Bank-Savings Club Account No.420663026 100.01
Verification attached
3 Holy Spirit Hospital-refund 85.58
4 SecurChoice-Prepaid Funeral expense 9,332.22
Verification attached
5 Manor Care Services, LLC- refund 199.92
TOTAL(Also enter on Line 5, Recapitulation) 61,584.21
Susquehanna*,*
April 24,2015 Susquehanna Bancshares,Inc.
26 North Cedar Street
P.Q. Box 1000
Lititz,PA 17543-7000
Tel 1.800.311.3182
DENNIS J WARD Fax 717.625.4478
114 EAST MAIN STREET
SUITE A
EPHRATA PA 17522
RE: Lillian M Nissley Estate
DOD: December 23, 2014
SS#:
Tracking# 415841
To Whom It May Concern:
In response to your letter of April 22, 2015,we have prepared the attached list of accounts.
® There is no safe deposit box in the name of the decedent.
❑ There is a safe deposit box#000 in the name of the decedent located at the branch name.
If I can be of further assistance, please feel free to call.
Dawn M Berrier
Susquehanna Bank
Deposit Research Department Lead
1-800-311-3182
DMBljran
Lillian M Nissley
DOD: December 23,2014
ACCOUNT DATE
TYPE/ OPENED/ INTEREST ACCRUED ACCOUNT YTD
ACCOUNT TITLE NUMBER MATURITY RATE INTEREST BALANCE* INTEREST
Lillian M Nissley Checking 11/12/80 .100% $.54 $22,010.04 $5.77 as O��•S�
Ste° Beverly Ann Kreman 420663006
('� � Lillian M Nissley Savings 3/6/04 .050% $.11 $8,942.08 $2.20 $�1`f�•f�
.Y�GC• Beverly Ann Kreman 420663020
Lillian M Nissley CD 6/23/10 .350% $.49 $51,865.99 $166.27 ,f g�(i,•��
5A.. �' 10008240383 6/23/15
Lillian M Nissley CD 11/23/10 .150% $.02 $5,106.71 $7.02 $/lib.-73
t•
Beverly Ann Kreman 10008760315 11/23/15
Lillian M Nissley Club 11/16/92 .100% $.01 $100.00 $.29 U0,01
• �° 420663026
* Account balance does not include accrued interest.
KEARNEY A, DE FUNERAL HOME, INC
KEARNEY A. SNYDER FUNERAL HOME,INC. Branch Office:
141 East Orange Street RICHARD A.SHEETZ FUNERAL HOME
Lancaster,PA 17602 2024 Marietta Avenue
Phone(717)394-4097 Lancaster,PA 17603
Fax(717)394-0292 Phone(717)397-6329
Randy L. Stoltzfus, Supervisor
January 9, 2015
Mrs. Beverly Kreman
2008 Carlisle Rd.
Camp Hill, PA 17011
Dear Mrs. Kreman:
Per your request we are sending you a copy of your mother, Lillian Nissley's, funeral expenses.
She did indeed have funds set aside to help with these costs and that check will be arriving next week
from SecurChoice in the amount of$9,332.22. As you will see from the enclosed invoice the total
costs came to $10,615.05. So the balance due will be $1,282.83 to cover expenses that were not
included in the Trust amount.
If you have any questions, as always, feel free to contact our funeral home.
Sincerely,
J remy R. DeBord
uneral Director
www.KaSnyderFuneralhome.com
i
WIM SCHEDULEF
COMMONWEALTH RITANC TAX RETURN
JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Nissley, Lillian M. 21 - 15 -00108
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
Beverly Ann Kreman 2008 Carlisle Road Daughter
A Camp Hill, PA 17011
JOINTLY OWNED PROPERTY:
LETTER DATE EfSGRIPT.I C�F PROdPERT�I' %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name o Inanclal Ins I u Ion an ban account numbe DATE OF DEATH DEGD'S VALUE OF
NUMBER TENANT JOINT or similar identifying number.Attach deed for jointly-held real VALUE OF ASSET estate. INTEREST DECEDENTSINTEREST
1 A 11/12/1980 Susquehanna Bank Checking Acct. No. 22,010.58 50% 11,005.29
420663006
-Verification attached
2 A 03/06/2004 Susquehanna Bank Savings Acct. No. 8,942.19 50% 4,471.10
420663020
-Verification attached
3 A 11/23/2010 Susquehanna Bank CD No. 10008760315 5,106.73 50% 2,553.37
-Verification attached
TOTAL(Also enter on line 6, Recapitulation) 18,029.76
Lillian M Nissley
DOD: December 23 2014
SSN:
ACCOUNT DATE
TYPE/ OPENED/ INTEREST ACCRUED ACCOUNT YTD
ACCOUNT TITLE NUMBER MATURITY RATE INTEREST BALANCE* INTEREST
Lillian M Nissley Checking 11/12/80 .100% $.54 $22,010.04 $5.77 as -)a
Beverly Ann Kreman 420663006
Lillian M Nissley Savings 3/6/04 .050% $.11 $8,942.08 $2.26 grit),
Beverly Ann Kreman 420663020
Lillian M Nissley CD 6/23/10 .350% $.49 $51,865.99 $166.27 A
10008240383 6/23/15
Lillian M Nissley CD 11/23/10 ISO% $.02 $5,106.71 $7.02
Beverly Ann Kreman 10008760315 11/23/15
Lillian M Nissley Club 11/16/92 .100% $.01 $100.00 $..29 IOU,
420663026'
Account balance does not include accrued interest.
COMMONWEALTH OF PENNSYLVANIA SCHEDULE G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS &
RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF Nissley, Lillian M. FILE NUMBER
21 - 15-00108
This schedule must be completed and filed if the answer to any of questions I through 4 on page 2 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % EXCLUSION 1 TAXABLE VALUE
Include the name of the transferee,their relationship to decedent VALUE OF ASSET DECD'S
NUMBER t II
and the date of transfer. Attach a copy of the deed for real estate, INTEREST (IF APPLICABLE)
1 American National Insurance Company Annuity 90,667.07 100% 90,667.07
Contract No. 1494658-Verification attached
I
90,667.07
TOTAL(Also enter on line 7, Recapitulation)
all
AMERICAN
AMERICAN NATIONAL INSURANCE COMPANY
LIFE INSURANCE&ANNUITY CLAIMS DEPARTMENT ,
PO BOX 10466 SPRINGFIELD,MO 65808-0466 TEL: (800)615-7372 FAX:(281)538-6757
February 17, 2015
Dennis Ward
114 E Main St Ste A
Ephrata, PA 17522
RE: C918542 LILLIAN NISSLEY 14949658
Dear Mr. Ward:
Thank you for your letter
Per your request, the date of death value of the above listed policy is $90,667.07. The final value will be
calculated as of the date we receive the certified death certificate.
According to our records the beneficiaries are Wayne Nissley and Beverly Kreman, equal shares.
Upon receipt of the claim forms,this will have our prompt and courteous attention.
If you have any questions,please contact us at 800-615-7372.
Sincerely,
TRICIA NELON/lr
//iiim+ �aaaH�
NATIONAL
AMERICAN NATIONAL INSURANCE COMPANY
SHARON L.ZAJACK,SR.CLAIMS SPECIALIST,LIFE INSURANCE AND ANNUITY CLAIMS DEPARTMENT
P O BOX 10466 SPRINGFIELD MO 65808-0466 BUS: 1-800-615-7372 FAX: (281)538-6757 EMAIL: SHARON.ZAJACK@ANICO.COM
January 13, 2015
BEVERLY KREMAN
2008 CARLISLE RD
CAMP HILL, PA 17011
RE: Claim C918542 - LILLIAN M.NISSLEY - Policy: 14949658
Dear Ms. Kreman:
Please accept our sincere sympathy.
Our records indicate that you are a beneficiary of this non-qualified contract.
The methods of settlement are outlined in the enclosed brochure. The enclosed Request for Payment of Annuity
Benefits form should be fully completed and returned with a certified death certificate (which becomes a
permanent part of our file and will not be returned). Please refer to the claim requirements on page three of the
Request for Payment of Annuity Benefits form for additional requirements to avoid delays in claim processing.
If you wish to defer payment at this time,please send a simple statement to that effect. Otherwise, we will be
required to contact you on a regular basis in order to stay compliant with state regulations.
If you have any questions,please contact us at 800-615-7372. Please refer to claim C918542 in all
communications.
Sincerely,
abli
SHARY ZAJACK/DH
AMERICAN
ATION N
AMERICAN NATIONAL INSURANCE COMPANY
SHARON L.ZAJACK,SR.CLAIMS SPECIALIST, LIFE INSURANCE AND ANNUITY CLAIMS DEPARTMENT
P O BOX 10466 SPRINGFIELD MO 65808-0466 BUS: 1-800-615-7372 FAX: (281)538-6757 EMAIL: SHARON.ZAJACK@ANICO.COM
January 13, 2015
WAYNE NISSLEY
4196 JASMINE PL
MOUNT JOY, PA 17552
RE: Claim C918542 - LILLIAN M. NISSLEY - Policy: 14949658
Dear Mr. Nissley:
Please accept our sincere sympathy.
Our records indicate that you are a beneficiary of this non-qualified contract.
The methods of settlement are outlined in the enclosed brochure. The enclosed Request for Payment of Annuity
Benefits form should be fully completed and returned with a certified death certificate (which becomes a
permanent part of our file and will not be returned). Please refer to the claim requirements on page three of the
Request for Payment of Annuity Benefits form for additional requirements to avoid delays in claim processing.
If you wish to defer payment at this time,please send a simple statement to that effect. Otherwise, we will be
required to contact you on a regular basis in order to stay compliant with state regulations.
If you have any questions,please contact us at 800-615-7372. Please refer to claim C918542 in all
communications.
Sincerely, pp
A 1Ln, Q�4QrG�r
SHARY ZAJACK/DH
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES&
INHERITANCE TAX RETURN
RESIDENT DECEDENT ADMINISTRATIVE
COSTS
ESTATE OF Nissley, Lillian M. FILE NUMBER21 - 15 -00108
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION i AMOUNT
A. 1 Kearney A. Snyder Funeral Home, Inc. - Funeral Services (Sch. E. Item 4. shows 10,615.05
prepaid amount) -Verification attached
2 St. Peter's Church - Funeral luncheon 131.69
-Verification attached
B. I ADMINISTRATIVE COSTS:
1. I Personal Representative's Commissions
Name of Personal Representatives)
i
I
Street Address
City State Zip
i Year(s)Commission paid
2. Attorney's Fees Dennis J. Ward, Atty. PA Sup. Ct. ID# 15987 7,500.00
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 Cumberland County Register of Wills 320.50
5. Accountant's Fees
6. Tax Return Preparer's Fees Included in No. 2. above
I
7. Other Administrative Costs
1 The Sentinel- Estate Notice 179.92
I
I �
TOTAL(Also enter on line 9, Recapitulation) 19,497.16
Schedule H
COMMONWEALTH OF PENNSYLVANIA Funeral
INHERITANCE TAX RETURN AdrTinis' a Costs continued
RESIDENT DECEDENT
ESTATE OF Nissley, Lillian M. FILE NUMBER
21 - 15-00108
2 Cumberland Law Journal - Estate Notice 75.00
3 Postage and Delivery Charges 50.00
4 Photocopies and Fax Service 50.00
5 Travel Expense-Gas, tolls, parking (Lancaster Co./Cumberland Co.) 75.00
6 Reserve for additional Probate fees and filing Final Account 500.00
i
I
i
Page 2 of Schedule H
Kearney A. Snyder Funeral Home, Inc.
141 E. Orange Street
Lancaster,PA 17602
(717)394-4097
January 9,2015 u
Beverly(Howard)Kreman \, o
2008 Carlisle Rd.
Camp Hill,PA 17011
The Funeral Service for Lillian M.Nissley
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES,FACILITIES,AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
Professional Service
Funeral Director&Staff 5,195.00
Total Professional Service """""""""""""""""- ; p"""
Merchandise
Casket:Aries Copper 1,895.00
Outer Container:Guardian 1,395.00
Burial Clothing:Ethel Maid Pink 135.00
Memorial Folders 50.00
Total Merchandise Selected """"""""""""---""-3;475-M"""
AT THE TIME FUNERAL ARRANGEMENTS WERE MADE,WE ADVANCED CERTAIN PAYMENTS TO
OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES.
Cash Advances
Cemetery Charges 700.00
Lancaster Newspaper 330.05
Certificates 10 @$6 each 60.00
Clergy Honorarium 200.00
Flowers 220.00
Cemetery Equipment 210.00
Organist 150.00
Sexton 75.00
--------------------------------
Total Cash Advances 1,945.05
Total Sales Tax 0.00
Total Contract 10,615.05
TOTAL AMOUNT DUE 10,615.05
?3U,a 2
The unpaid balance over 30 days is subjected to a 1.5%service charge per month,or 18%per annum.
/27 Y3 3Ak- DUr-
tO
ST. I[Y
ERS
EVANGELICAL LUTHERAN CHURCH
January 9, 2015
Beverly Kreman
2008 Carlisle Road
Camp Hill, PA 17011
Dear Beverly,
Below is the total amount due for the funeral luncheon for your mother, Lillian Nissley.
Total 313 1,469
May God bless you and your family during this difficult time.
Sincerely, �� 10
Cj
Sandy Shattuck
Parish Secretary
I�
10 Delp Road, Lancaster PA 17601
Phone:717-569-9211 -Fax: 717-581.1049
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS
INHERITANCE TAX RETURN f
RESIDENT DECEDENT
ESTATE OF Nissley, Lillian M. FILE NUMBER21 - 15 -00108
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Manor Care Services, LLC - Nursing Home balance due 6,886.00
-Verification attached
2 Suburban Geriatrics- Medical services balance due 73.02
3 Stephen S. Snoke, MD- Medical services balance due 6.00
TOTAL(Also enter on Line 10, Recapitulation) 6,965.02
100� 7 ad ,
A Monthly Statement
• • - • IFTIMI 57. - Please note that the website address for paying
Statement Date 12/31/2014 your bill online has changed. The new address
Account Number 000583-4595 is located below for your convenience. The new
site will be available as of October 1, 2014.
Inpatient Amount Due $6886.00
Outpatient Amount Due $0.00
If you are interested in receiving your monthly
Total Amount Due $6886.00 statement electronically via email, please speak to
the business office at your facility for more
information.
Balance Due Upon Receipt
If you would liko ko pay your bill onlino,: ,r.o:4
www.patientnotebook.com/MCHSCampHil[SNF
�:Questions
Questions?
,Coverage • • Please.call 717-737-8551 to reach the business
office during our regular business hours
Please confirm that the information is correct for:
Mail Check Payable and Remit'To:
Patient Name LILLIAN NISSLEY HCR MANOR CARE SERVICES, LLC
Medical Record No. 000583-4595 FACILITY 0583
A/R Representative LILLIAN NISSLEY PO BOX 637602
Primary Payer: PRIVATE PAY CINCINNATI OH 45263-7602
Secondary Payer: HEARTLAND HOSPICE SERVICE
Insurance information and payment activity
on individual accounts are included in the
attached detail.
Payments by check will be converted into electronic fund transfers.Funds may be debited from your account as soon as the same day payment is receive
--------------------------m
CAMP HILL
1700 MARKET STREET Patient Name Medical Record Statement Date
CAMP HILL PA 17011-4817 LILLIAN NISSLEY 000583-4595 12/31/2014
RETURN SERVICE REQUESTED Amount Due Amount I Am Paying
$6886.00
stmt ID#:715131816 MAKE CHECK PAYABLE AND REMIT TO
11111'1111111111'11111'11111111'1'1'111"1"1111111 fill 11i1 Ill 111 91194-14493 HCR MANOR CARE SERVICES, LLC
w LILLIAN NISSLEY FACILITY 0583
2008 CARLISLE RD PO BOX 637602
CAMP HILL PA 17011-5912 CINCINNATI OH 45263-7602
IIIll�ll�llllllllllllll�lllllllllllll�llfill 1lll1l
I I�IIIIII III VIII VIII VIII VIII IIII VIII VIII VIII IIII IIII 91194.28985 -4538756
UL.LIAN M NISSLEr ii/so 4251
2006 CAHUSLE RD 6p-l7Bl3
CAMP HILL,PA 17011 `� 04
717-761-5905 —1— Date
3`
Pay to the
Order sof ✓ L� � � $
Susquehanna Bank
www.susqu&ovvLrml
For, ( Y,
C031309123i: 04 206630 060 1, 251
REV-1513 EX+(11-08)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Nissley, Lillian M.
21 -, 15-00108
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) i DECEDENT ; (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
ITAXABLE DISTRIBUTIONS[include outright spousal —
distributions, and transfers
I under Sec.9116(a)(1.2)]
1 I Beverly A. Kreman Daughter 1/2 Residue
2008 Carlisle Road
f Camp Hill, PA 17011 j
_
i
2 Susan Snyder Friend ( 500.00
39 Kreider Ave.
Lancaster, PA 17601
i
3 Doris Lownsbery ; Friend i 100.00
53 Kreider Ave.
Lancaster, PA 17601
I
I
I C
Enter dollar amounts for distributions shown above an lines 15 through 18 on Rev 1504 cover sheet,as appropriate. I
IIS NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
i
i
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
i
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHE T 0.00
REV^613sw(9-00)
SCHEDULEJ
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN BENEFICIARIES continued
RESIDENT DECEDENT
ESTATE OF Nissley, Lillian M. FILE NUMBER
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
4 Wayne C. Nissley, Jr. Son 1/2 of Residue
4196 Jasmine Place
Mount Joy, PA 17552
-
Page 2ofSchedule J
/