HomeMy WebLinkAbout08-04-15 apennsytvania 1505614105
, DE9ARTMEM OF REVENUE EX(03-14)(FI)
REV`1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year. File Number
INHERITANCE TAX RETURN
PO BOX 280601 RESIDENT DECEDENT
Harrisburg, PA 17128-0601 ENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
Y ;08042015
Decedent's Last Name Suffix Decedent's First Name MI
Hosfelt i Betty ; M
(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
(ND 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 C=:> 5.Future Interest Compromise(date of cm 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
C=:) 7.Decedent Died Testate O 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=D 11.Non-Probate Transferee Return C=:) 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
C=D 13. Business Assets C=:) 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
Paul D. Daggs, Esquire 1(717) 884-4963
First Line of Address
130 W. Church Street
Second Line of Address
iSuite 100
_J
City or Post Office State ZIP Code
Dillsburg PA :17019 VTI C')
Correspondent's email address: paul@daggslaw.com
C-) (TI rn
r—
REGISTER 0rA(VILLS@§E ONE?
REGISTER OF WILLS USE ONLY
DATE FILED MMDDYYYY
CP
DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
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1505614105
1505614205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name: ;,
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. ! 4,976.00
(`- 'i
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. 4,976.00
9. Funeral Expenses and Administrative Costs(Schedule H)... . ... .... ..... . .. 9. ; 1,385.00
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I). . .. ........ ... 10. 79,774.00
11, Total Deductions(total Lines 9 and 10).. .. ... .. ...... .... ........ ...... 11. i 81,159.00 ,
12. Net Value of Estate(Line 8 minus Line 11) ......... . .. ............. .. . .. 12. ` -76,183.00
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. -76,183.00
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfersunder Sec.9116 _.._r. ..._...._...__.. ._..... .-....___._.._._..._._.__._...____.. ____.-...-----..._._.._..-_-_......____...�__.--_..._.___._.
(a)(1.2)X.0_ 15.
16. Amount of Line 14 taxable
at lineal rate X.0_ ! 16. .
17. Amount of Line 14 taxable
at sibling rate X.12 ; 17. :
18. Amount of Line 14 taxable
at collateral rate X.15 18.
i
19. TAX DUE . .... ........ ... . ... .. ...... ...... ........ . ........ ... . .. 19.1 0.00r
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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
K.A. ��a., t_ �,y. 08/01/2015
ADDRESS fl
707 Doubling Gap Road, Nemille, PA 17241
SIGNATUFQF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE
(�/ ; w 08/01/2015
ADDRESS
130 W. Church Street, Suite 100, Dillsburg, PA 17019
1111111111111111I1I1I11111111 Ilil�lbll111(11111111111111 Side 2
5056 4 5 1505614205 J
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Betty M. Hosfelt
STREET ADDRESS
725 Doubling Gap Road
CITY STATE 717241
Newville PA
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
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) 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.......................................................................................... ❑ E
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ ❑
c. retain a reversionary interest .............................................................................................................................. ❑ ❑
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 0
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ N
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ 0
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 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-1508 EX+ (02-15)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Betty M. Hosfelt 2015-00512
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. F&M Trust Acct No.0005083680 4,976.00
TOTAL(Also enter on Line 5, Recapitulation) $ 4,976.00
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
Betty M. Hosfelt 2015-00512
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' pre-paid
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:
1,000.00
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: 135.00
5. Accountant Fees:
6. Tax Return Preparer Fees:
7. Publication expenses,filing fees,postage,copies,parking 250.00
TOTAL(Also enter on Line 9, Recapitulation) $ 1,385.00
If more space is needed,use additional sheets of paper of the same size,
REV-1512 EX+ (02-15)
b7pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Betty M. Hosfelt 2015-00512
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 DPW Medical Assistance claim 79,774.00
TOTAL(Also enter on Line 10, Recapitulation) $ 79,774.00
If more space is needed,insert additional sheets of the same size.
R E C 0 R D E,--' C E 0i=
tR E L S
2015 7 P n "1 22 LAST WILL AND TESTAMENT
I, BETTY M. HOSFELT, of Lower Mifflin Township, Cumberland
ORPH'I'sN"
Cotnty,' Pennsylvania, declare this to be my last Will and
CUM
Testament and revoke any Will previously made by me.
ITEM I. I direct my hereinafter named Executor to pay
all my just debts and funeral expenses as soon after my death
as may be convenient.
ITEM II. I devise and bequeath my entire estate, of every
nature and wherever situate, to my husband, RAYMOND J. HOSFELT,
providing he shall survive me by thirty days.
ITEM III. Should my husband predecease me or die on or before
the thirtieth day following my death, I specifically bequeath
the following items of personal property:
A. To KAY D. HOSFELT, my china closet and salt and
pepper shakers;
B. To JAY D. HOSFELT, my grandfathers clock.
ITEM IV. Should my husband predecease me or fail to survive
me by thirty days, I devise and bequeath all the rest, residue
and remainder of my estate, of every kind and nature and wherever
situated, equally and jointly to my children, KAY D. HOSFELT
and JAY D. HOSFELT, or per stirpes to the issue of any deceased
child.
ITEM V. I direct that all estate, inheritance, transfer
or other succession or death taxes which shall become payable
upon or with respect to any property or any interest in property
which is included as part of my gross estate for the determination
of any such taxes shall be paid by my executor out of that portion
of my property which would otherwise be disposed of under
Item II or Item IV. hereof, in the same manner as an expense of
administration, and shall not be prorated or charged against
any other property so included as part of my gross estate.
I
ITEM VI. I name my husband, RAYMOND J. HOSFELT, if he shall
survive me, Executor of my will. In the event, however, that
my said husband shall predecease me or shall fail to qualify, or,
after qualifying, shall fail or cease to act as executor, then
I name Kay D. Hosfelt and Jay D. Hosfelt as substitute executors.
I direct that any fiduciary hereunder be excused from filing
bond.
IPJ WITNESS WHEREOF, I have hereunto set my hand and seal
this / day of March, 1978.
Bdtty M. dsfelt
Signed, sealed, published and declared
by the above-named Testatrix, as and for
her last will and testament, in the
presence of us, who, at her request and
in her presence and in the presence of
each other, have hereunto subscribed our
names as witnesses thereto.
-2-
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF CUMBERLAND SS: ,
I, BETTY M. HOSFELT , whose name is signed to the attached
or foregoing instrument, having been duly qualified according
to law, do hereby acknowledge .that I signed and executed the
instrument as my last will; that I signed it willingly; and that
I signed it as my free and voluntary act for the purposes therein
expressed.
Wil. 7 J"t')
Betty OSteitl
Sworn to and subscribed
before me this \✓ day
f �`�F�'s c ► 19 7 8. \
LAVANA L. SRECHBTL, NOTARY PUBLIC
NotarItOUTHAMPTON TC:% NSH:P, PRA NXLIN CO.
MY. 4;OMMISSION EXPIRES AUG.10,1981.
t.
COMMONWEALTH OF PENNSYLVANIA )
SS: ,
COUNTY OF CUMBERLAND )
W' , and
4, - i the witnesses
whos names are signed to the attached or foregoing instrument,
being duly qualified according to law, do deposes and say that we
were present and saw testatrix sign and execute the instrument as
her last will, and that she signed willingly and that she executed
it as her free and voluntary act for the purposes therein contained;
that each of us in the hearing and sight of the testatrixsigned
the will as witnesses; and that to the best of our knowledge
testatrix was at that time 18 or more years of age, of sound mind
and under no constraint or undue nfluence.
Sworn to and subscribed
before me this '��' day
:1978.
➢..AVFltL1 L.r{3Lr!'{.7'61_, td7TAR,(PtJ•9t_IC .
notary SOtJTH„t,9RT0t4
'F %
4V)Nsb , FRANK-1-IN CO.
�
MY CO'ml"'3L:(F.I Er,r;Ii;E3 AUr, 10,1981
FRM20 South Miin Street
poBox wm
o oLSm cxvm»cm»"rg.pAnzn1
Last statement: October 20. 2O14 Page 1of1
This statement: November 2D.2O14 0005083680
Total days instatement period: 31 (0)
^
`^` `^``~AUTo'^8CH5-D|G|T172sr Direct
8950.59004V0,381 4169 71777O-2240
F& MTrust
BETTY HDSFELT 51 South High G1
725DOUBLING GAP RD
NevvviUe PA 17241
NsvvvLLsPA 17241-9794 '
Senior Checking,
Account number 0005083880 Beginning balance $4.976�02
Low balance S4.976�02 Total additions 21
Average balance $4.076D2 Total subtractions O�OO
Avg collected balance $4.976 Ending balance 84.876,23
Interest paid year to date $229
CREDITS
Date Description Additions
DAILY BALANCES
Date Amount Date Amount Date Amount
1.9-20 4,976.02 11-20 4,976.23
INTEREST INFORMATION
Annual percentage yield earned 0,05Y6
Interest-bearing days 31
Average balance for APY 84.97602
Interest earned $021
OVERDRAFT/RETURN)T[M FEES
Total for Total
this period year-to-date
Total Overdraft Fees $0.00 $000
Total Returned Item Fees $0.00 1 $0.00
Thank you for banking with F&/mTrust
pg7N
20 South Main Street
TR T PBox 6010
rsbu
�t Chh ambersburg,PA 17201
Last statement: December 20, 2013 Page 1 of 2
This statement: January 20, 2014 0005083680
Total days in statement period: 31 (1)
Direct inquiries to:
717 776-2240
*"AUTO"SCH 5-DIGIT 17257
836 1.0960 AV 0.360 41 65 F & M Trust
IIIIIIII.IIIII,IIII.-IIIIIII-IIIII"'--'IIII'll-llrl 51 South High St
BETTY M HOSFELT Newvllle, PA 17241
725 DOUBLING GAP RD
NEWVILLE PA 17241-9794
Senior Checking
Account number 0005083680 Beginning balance $5,073.94
Enclosures 1 Total additions .22
Low balance $4,973.94 Total subtractions 100.00
Average balance $4,983.62 Ending balance $4,974.16
Avg collected balance $4,983
Interest paid year to date $0.22
CHECKS
NIumber Da te Amount Numb D^to ;mount.
3045 12.24 100.00
CREDITS
Date Description Additions
01-20 ' Interest Credit 0.22
DAILY BALANCES
Date Amount Date Amount Date Amount
12-20 5,073.94 12-24 4,973.94 01-20 4,974.16
INTEREST INFORMATION
Annual percentage yield earned 0.05%
Interest-bearing days 31
Average balance for APY $4,983.62
Interest earned $0.22
pg7W
20 South Main Street
—MUST
6010
Ch Box rsbu
Chambersburg,PA 17201
BETTY M HOSFELT Page 2 of 2
January 20, 2014 0005083680
OVERDRAFT/RETURN ITEM FEES
Total for Total prior
this period year-to-date
Total Overdraft Fees $0.00 $30.00
Total Returned Item Fees $0.00 $0.00
Thank you for banking with F & M Trust
15 Big Spring Avenue
NEWVILLE, PENNSYLVANIA 17241
F. CHARLES EGGER, Supervisor 717-776-3414 FRANK C. EGGER, Funeral Director
February 21, 2014
Funeral Bill for Betty M. Hosfelt
Date of service December 16, 2013
Professional Services $4,375.00
Burial vault ' $1,045.00
Aurora Olive Tone Casket $1,650.00
Cemetery Opening $600.00
Sentinel Obituary $153.18
Valley Times Star obituary $50.00
Public Opinion Obituary $177.40
Death Certificates $6.00 a piece $18.00
Total $8,068.58
Payment by Homesteaders Life Company $8,064.93
Funeral Bill Paid In Full
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DEPARTMENT OF PUBLIC WELFARE
July 28, 2014
KAYKIN7LER
7O7DOUBLING GAP RD
NEVVVILLEPA 17241
Re: 8ettyHnsfe|L
CIS #: 550317034
SSN: ###-##'7221
Date ofDeath: 12/12/2013
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Kay K|nzler:
Under State and Federal law, the Department ofPublic Welfare /the Department) is
required to recover medical assistance (MA) reimbursement from the probate estates of
deceased individuals who were overage 55 when such assistance was received. 42 U.S.C.
61396p(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 inthe 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 $79,773.57 against the
above-mentioned estate. This claim is for repayment of MA granted on behalf ofthe
decedent. Enclosed is the Department's itemized statement of claim.
Aportion ofthis medical expense, namely , was incurred during the last
six months of the decedent's life; therefore, it is o 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
dairn. namely , is to be entered as priority Class S.1 claim against the estate.
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 mtenritv | Division orThird Party Liability | Recovery Section
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