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HomeMy WebLinkAbout07-06-15 pennsytvania 1505614105 DECARTMENTOF REVENUE 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 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 10302014 03051929 Decedent's Last Name Suffix Decedent's First Name MI Ebersole Mary 1 (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=:) 1.Original Return M 2.Supplemental Return p 3. Remainder Return(date of death prior to 12-13-82) C=) 4.Agriculture Exemption(date of p 5. Future Interest Compromise(date of © 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) C1 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.) C=:) 10. Litigation Proceeds Received Q 11.Non-Probate Transferee Return p 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) C1 13. Business Assets O 14. Spouse is Sale Beneficiary (No trust involved) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ......... Vicky Ann Trimmer (717) 724-9821 First Line of Address ......... Daley Zucker Meilton Second Line of Address ............ _.._...... 635 N 12th Street City or Post Office State ZIP Code sv _. _..... PA ;17043 n :;0rn Lemoyne ...... ..... ................. Correspondent's email address: vtrimmer@dzmmlaw.com r_ cf7 r7-- -i rri TER OF VMS 6,6 6NILY I C:> }. REGISTER OF WILLS USE ONLY DATE FILED MMDDYYYY -r1 DATE FILED STAMP PLEASE USE ORIGINAL FORM ONLY Side 1 1 056141 1505614105 1505614205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Mary J. Ebersole € r 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. l 4. Mortgages and Notes Receivable(Schedule D) .. .......... ............ ... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 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. 23,792.00 9. Funeral Expenses and Administrative Costs(Schedule H).................. . 9. 4 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)......... . ..... 10. 143,988,00 11. Total Deductions(total Lines 9 and 10). . . . .. . . . .. . . .. . ... .. .. . . .... .. . . 11. 203,324.00 12. Net Value of Estate(Line 8 minus Line 11) . .. .. .. .. ..... . .... . .. . . ... .. . 12. 474.00 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. 474.00 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_ i 15. 16. Amount of Line 14 taxable at lineal rate X.0 45 474.00 `:. 16. . 21.33 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 ................. 2j.33 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT i 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 know dge. SIGN ;M!7 SPONSIBLE FOR FILING RETURN DA 2gK ADD SS N CX SIGNATURE 9F PEPAR R OTHER HAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE fd �+ ADDRESS � 1111111 VIII VIII 11111111111 I VIII VIII VIII 111111111 llll Side 2 1 0564205 1505614205 REV-1 50C EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME Ebersole Mary J STREETADDRESS 1 Longdorf Way Cumberland County CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 21.33 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 I +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 21.33 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 ....................................... ................................................. ❑ 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?.... .......__........... ........... ....... ❑ E 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? ....................................................................................................................... ❑ 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 JanA,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent F2 P.S.§9116(a)(1.1)(1)]. 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 F2 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-1512 EX+(02-15) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Ebersole Mary J 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 PA Dept of Public Welfare-Estate Recovery Lien 143,998.91 TOTAL(Also enter on Line 10, Recapitulation) $ 143,998.91 If more space is needed,insert additional sheets of the same size. �►� pennsyLvania DEPARTMENT OF PUBLIC WELFARE February 24, 2015 PERSUN & HEIM P C VICKY ANN TRIMMER ESQUIRE P O BOX 659 MECHANICSBURG PA 17055-0659 Re: Mary Ebersole CIS #: 410514241 SSN: ###-##- Date of Death: 10/30/2014 ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Trimmer: 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 $143,988.91 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. A portion of this medical expense, namely .00, 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 $143,988.91, 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 pennsylvania DEPARTMENT OF PUBLIC WELFARE Your Responsibility to Provide Information to the Department Please acknowledge receipt of this letter and advise whether the Department's claim is admitted and when payment may be expected. When the estate accounting is complete, please provide a copy. The Department audits all estate recovery claims and therefore we require documentation to substantiate all deductions from the gross estate. The regulations governing how the Department computes its estate recovery claim are found in 55 Pa. Code Chapter 258. These regulations are readily available on the Internet, in addition to being carried in most local law libraries. In order to accurately compute the amount due the Department, the following items should be submitted to the address below: 1. For real estate: a. Copy of the deed b. Copy of the latest tax assessment c. Copy of a current appraisal, if available 2. Copy of the funeral bill 3. Copy of the statement of the burial account if one existed 4. Copy of the statement of the personal care account balance at date of death, if the decedent was in a nursing home 5. Copies of original and updated life insurance policy forms naming beneficiaries 6. Copies of any and all stocks and bonds 7. Copies of bank statements showing balances on the date of death 8. Copies of signature cards or other proof of when accounts were made joint 9. A list of any gifts or other transfers for less than fair market value made by the decedent (personally or under a power of attorney) Your Responsibilities to the Department Under State law, executors or administrators may be personally liable to pay the Department's estate recovery claim if they transfer estate property without the Department's claim being paid. Persons who receive that property without paying valuable and adequate consideration to the estate may also be personally liable. The responsibilities of the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to ensure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. Accordingly, you must ensure the Department's claim is satisfied before making distribution of assets to heirs. Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 ` ` ~ ' . �=~~ ~ ������m������� ' o--'---�' --'-- osp^nrmcwrop ,onucws*^ns Insolvent Estates and the Fiduciary Responsibility to Creditors If there are not enough estate assets to pay the claims of all creditors in full, then the executor or administrator has a duty 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 of your own pocket. The Department's approval is required if you expect the legal fees to exceed more than the greater of 696 of the estate assets or $1,000. Contingent fees for estate administration will generally not beapproved. Ifyou donot obtain approval, the Department may consider the excessive fees to be a transfer for less than valuable and adequate consideration. Sincerely, &,�a govo� Desiree D. Havasi Claims Investigation Agent 717-772-6961 ' 717-772-6553 FAX Enclosure Bureau sProgram Integrity | Division of rmm Party Liability | Recovery Section COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105-8486 February 23,2015 ' STATEMENT OF CLAIM SUMMARY NAME Estate of EBERSOLE,MARY ID 410 514 241 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00- .00 OUTPATIENT .00 58.78 58.78 LONG TERM CARE .00 143,831.02 143,831.02 DRUG 00 99.11 99.11 REIMBURSEMENT TO DPW .00 143,988.91 143,988.91 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN- 23-6003113 Page 1 of 14 REV-1513 EX+(02-15) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Ebersole Mary J 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• Robert G.Ebersole Son 474 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: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS; i. TOTAL OF PART H—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. Iladeis injustice Partners in Rmiukiov- June 30, 2015 • Office of the Register of Wills Cumberland County Courthouse, One Courthouse Square Carlisle, PA 17013 Re: Estate of Mary Jane Ebersole File No. 21-15-0194 PATRICIA CAREY ZUCKER Dear Gentleperson: SANDRA L. MEILTON STEVEN P. MINER Please find enclosed for filing an original and two (2) copies of a Supplemental QUINTINA M. LAUDERMILCH Inheritance Tax Return in the above-referenced Estate. Please return the date- VICKY ANN TRIMMER stamped copies to me in the enclosed self-addressed, stamped envelope. SUSAN E. GOOD Thank you for your assistance with this filing. Should you have any questions, PATRICIA A.PATTON please do not hesitate to contact me. OFFICE ADMINISTRATOR Very truly yours, DALEY ZUCKER MEILTON & MINER, LLC ry Courtney M urina C= rn Paralegal ;:0 J> r M r_ M CD lcmj ;U Enclosures (D C)ni -In <D C> DALEY ZUCKER MEILTON & MINER, LLC 635 N. 12TH STREET, SUITE 101, LEMOYNE, PA 17043 - 717-724-9821 - 717-724-9826 FAX - DZMMLAVV.COM it 1 f 11.1. ffl 1111:1f1 � 111 ISI f� I Illi 1 � �P-SES Posr� Daley,S—�_ illiton&fimft 1AX i RECORDED OFFICE OF cif!1►iO..a1 i?�M.LYS z '�mw PITNEY BOWES W.7s moyn--eifA{ 13�043R REGISTER OF WILLS 02 1P ��2.08� Lail' 1862342 JUN 30 2015 815 J"L_ 6 Pi 3 1u 1,111 MAO ED FROM ZIPCODE 17043 J L CLERK OF 1 .e_I. rt-- CUMBERLAND C.-O., PA QN �-41CIE- U1 1 Ch Cs U u C> U cu U- OCL_ d. O C SLol�cr- CD JQ man•Uj Uj Q- 635 N. 12TH STREET, SU ITE101dei- - _ LEMOYNE. PA., 1-7043Uj ' y N Office of the Register of Wills - Cumberland County Courthouse One Courthouse.Square Carlisle, PA- 17013