HomeMy WebLinkAbout06-24-05
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FilE NUMBER
21 05
.COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
00362
NUMBER
COIJoMOtIWE.AL TH Of PENN5'1LVANIA
DEPARTMENT OF REVENUE
DEPT,280601
HARRISBURG. PA 17128-0601
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
O'HARA, MARGARET H.
~~~~~~;A~~;MDD.YEARl r;;~~;~'~~Hl(~M'DD'YEARl ----
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after
12-'\2-82)
o 7. Decedent Maintained a Living Trust (Attach
copy 01 Trust)
o 10. Spousal Poverty Credit (date of death between
12-31-91 and 1-1-95\
THIS SECTION MUST BE COMPLETED. ALll1CORRE!;POl'lOENCE AND CONF.lDENiI1ALTAx lNFORMATION SI-IPULD\BE DIRECTE[lhTb:
AME COMPLETE MAILING ADDRESS
Carl C. Risch, Esquire
181
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181 6.
09.
1. Original Return
4. Limited Estate
Decedent Died Testate (Attach copy
of Will)
Litigation Proceeds Received
IRM NAME (If applicable)
Martson Deardorff Williams & Otto
ELEPHONE NUMBER
717/243-3341
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole.Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash. Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter~VivQs Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1~7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent. Mortgage Liabillties, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
174-05-0547
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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1
3. Remainder Return (dale 01 death prior to 12-13-82)
5. Federal Estate Tax Return Required
8 Total Number of Safe Deposit Boxes
o 11 ,Election to tax under$ec. 9113(A) (Attach Sch 0)
Ten East High Street
Carlisle, PA 17013
(1)
(2)
(3)
(4)
CfF',C\;:"',
None
None
None
None
(5) 5,874.56
(6) None
(7) None ('''~
(B) 5,874.56
(9) 4,098.91
(10) 22,403.85
(11)
26,502.76
(12)
insolvent
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate.
or transfers under Sec. 9116(a)(1.2)
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o 16.Amount of Line 14 taxable at lineal rate
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~ 17. Amount of Line 14 taxable at sibling rate
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g 18. Amount of Line 14 taxable at collateral rate
19. Tax Due
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
20. 0
>>BE SURE lClI\Nll,WEBl:t.ESTlONS ON RI;,V.~A"R15'RecHEcK M~ ,,~~t:
Form REV-1500 EX (Rev. 6-00)
Copyright 2000 form software only The Lackner Group, Inc.
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Decedent's Complete Address:
STREET ADDRESS
442 Walnut Bottom Road
I STATE PA
I ZIP 17013
CITY
Carlisle
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2, Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + B + C)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + SA. This \s the BALANCE DUE.
Make Check
to: REGISTER OF WILLS, AGENT
(1)
(2)
0.00
(3) 0.00
(4)
(5) 0.00
(SA)
(5B) 0.00
1. Did decedent make a transfer and:
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; or............... .....................................
d. receive the promise for life of either payments, benefits or care? .... ...........................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?. .................................... ............................,...............
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes No
~ I
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? ................................ . ..................................... ....................
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
preparer other than the persOl1al representative is based on all information of which pre parer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Doris H.,,~ss. .." / ~ /
-^JI ~ ",. IV.( <1"'/
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
P.O. Box 224
Boiling Springs, P A 17007
ADDRESS
DATE
t Q3/05~
DATE
ADDRESS
DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENT ATNE
Cad C.~,h J\
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Ten East High Street
Carlisle, PA 17013
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For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)l.
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%
[72 P.S. 99116 (a) (1.1) (ii)). The statute does not exemat a transfer to a sl..ll'l\\'\ng 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 twenty.one years 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% [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%. except as noted in 72 P .S. ~9116
1.2) [72 P.S. ~9116 {a}{1}J.
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% (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.
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF' PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
O'HARA, MARGARET H.
I FILE NUMBER
21 - 05 - 00362
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
1 M&T Bank, Checking #1135457 3,129.12
2 U.S. Treasury, V A benefits for Oct-Dec, 2004 1,498.00
3 U.S. Treasury, V A benefits for Jan-Mar, 2005 90.00
4 Aetna, prescription coverage 1,157.44
TOTAL (Also enter on Line 5, Recapitulation) 5,874.56
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SCHEDULEH
FUNERAL EXPENSES &
ADI\IIINISTRATlVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I FILE NUMBER
21 - 05 - 00362
ESTATE OF
O'HARA, MARGARET H.
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
1 Hoffman-Roth Funeral Home 352.20
B. ADMINISTRATIVE COSTS: 300.00
1. Personal Representative's Commissions
Doris H. Hess
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address P.O. Box 224
City Boiling Springs State PA lip 17007
-
Year(s) Commission paid
2. Attorney's Fees Martson Deardorff Williams & Olto (estimated) 2,500.00
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 85.00
5. Accountant's Fees
6. Tax Return Preparer's Fees 2004 INCOME TAX RETURNS 35.00
7. Other Administrative Costs
1 P A Dept. of Revenue, 2004 income tax 443.00
2 Certified mail 4.42
Total of Continuation Schedule(s) 379.29
TOTAL (Also enter on line 9, Recapitulation) 4,098.91
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Schedule H
Funeral Expenses &
Administrative Cos1s continued
ESTATE OF
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
O'HARA, MARGARET H.
I FILE NUMBER
21 - 05 - 00362
75.00
3
Cumberland Law Journal, advertise grant of letters
4
The Sentinel, advertise grant of letters
5
Register of Wills, filing fee, inheritance tax return
6
Register of Wills, additional probate fee
7
Reserved for filing Account
Page 2 of Schedule H
144.29
15.00
15.00
130.00
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SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSVLVANIA
INHE~lrANCE TAX RETURN
RE$IDENTDECEDENT
I FILE NUMBER
21 - 05 - 00362
ESTATE OF
O'HARA, MARGARET H.
Include unreimbursed medical expenses.
ITEM
NUMBER
I
DESCRIPTION
AMOUNT
Belvedere Medical Center, account payable (Class 3 claim)
66.06
2
Pharmerica, account payable (Class 3 claim)
705.39
3
Phil Haven, account payable (Class 3 claim)
50.50
4
Pennsylvania Department of Public Welfare (Class 3 claim)
14,557.77
5
United Church of Christ Homes (Thomwald Home), account payable (part Class 3 and part Class 6 claim)
7,002.50
6
Darlene Moyer, 2005 personal tax (Class 6 claim)
10.00
7
PA Dept. of Revenue, 2004 estimated tax penalty (Class 6 claim)
11.63
TOTAL (Also enter on Line 10, Recapitulation)
22,403.85
. REY.1513 EX+ (9-00)
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SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
O'HARA, MARGARET H.
I FILE NUMBER
21 - OS - 00362
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DE~,::DENT OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
I Not applicable
Enter dollar amounts for distributions shown above Dn lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8485
HARRISBURG, PA 17105-8486
May 9, 2005
MARTSON DEARDORFF WILLIAMS & OTTO
CARL C RISCH ESQUIRE
10 EAST HIGH ST
CARLISLE PA 17013
Re: MARGARET OHARA
CIS #: 490169838
SSN: 174-05-0547
Date of Death: 4/2/2005
Dear Attorney Risch:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $14,557.77 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.B. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely $14,557.77, was incurred
during the last six months of the decedentls 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 $.00, is to be
entered as a priority class 6 claim against the estate. ----
please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. If the estate contains
real estate. please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
sincerely,
patricia Nace
Claims Investigation Agent
717-772-6616
717-705-8150 FAX
Enclosure
set-! ..L
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
May 6, 2005
STATEMENT OF CLAIM SUMMARY
Eslate of OHARA, MARGARET
490 169 838
INPATIENT
OUTPATIENT
LONG TERM CARE
DRUG
.00
.00
.00
.00
.00
.00
.00
.00
14,557.77
.00
14,557.77
.00
14,557.77
.00
14,557.77
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
May 6, 2005
STATEMENT OF CLAIM SUMMARY
Estate of OHARA, MARGAlRET
490 169 838
INPATIENT
OUTPATIENT
LONG TERM CARE
DRUG
.00
.00
.00
.00
.00
.00
.00
.00
14,557.77
.00
14,557.77
.00
14,557.77
.00
14,557.77
THORNWALD HOME
442 WALNUT BOTTOM RD
ARLlSLE
17013
PA
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLlCWELFARE
May 6, 2005
STATEMENT OF CLAIM
. .
NAME OHARA, MARGARET
ID 490169838
11101104 - 11130/04 04125/05 55051084217310001 4,281.90 2,619.60
DIAGNOSIS 1: 2979 PARANOID STATE NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
12/01104 - 12/31/04 04/25105 55051084217300001 4,424.63 2,764.37
DIAGNOSIS 1: 2979 PARANOID STATE NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
01/01/05 - 01/31/05 05/02/05 55051144640980001 4,424.63 3,214.97
DIAGNOSIS 1: 2979 PARANOID STATE NOS
DIAGNOSIS 2: 0
PROC eODE : 000000
02/01105 - 02128/05 05/02/05 55051144640970001 3,996.44 2,733.86
DIAGNOSIS 1: 2979 PARANOID STATE NOS
DIAGNOSIS 2: 0
PRoe CODE: 000000
03101/05 - 03/31/05 00/00/00 00000000000000001 3,224.97 3,224.97
DIAGNOSIS 1: ESTIM
PRoe CODE: W0305 CASE MIX
THORNWALD HOME 20,352.57 14,557.77
03 100755529 0006
LAST WILL AND TESTAMENT OF MARGARET H. O'HARA
I, MARGARET H. O'HARA, of Carlisle, Cumberland County, Pennsylvania,
make, publish and declare this to be my Last Will and Testament, hereby
revoking any and all former Wills by me at any time heretofore made.
1. I direct the payment of m1 just debts and funeral expenses as
soon after my death as will be convenient to my E~ecutor, hereinafter named.
2. give, devise and bequeath all my prope~ty, whether real,
personal or mixed, and wheresoever situate at the time of my death unto
my husband, Christian B. O'Hara.
3. Should my husband fail to survive me then I direct my Executor,
hereinafter named, to sell all my property, either at public or private
sale, and for the best price or pri~es that can be obtained for the same,
and the proceeds thereof distributed, share and share alike, unto my
brothers and sisters. Should any of my brothers or sisters fail to
survive me then the share to which that brother or sister would have been
entitled shall be distributed to his or her children, share and share
alike.
4. I nominate, constitute and appoint my husband, Christian B. O'Hara,
to be the Executor of this, my Last Will and Testament. If my said husband
shall fail to survive me, or shall for any other reason be unable or
unwilling to fulfill the obligations of this trust, then I name Farmers
Trust Company, of Carlisle, Pennsylvania, tp be the Executor of my Will.
IN WITNESS WHEREOF, I have hereunto set my ha.nd a!ld seal this 31st
day of May, A.D. 1967.
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(SEAL)
Signed, sealed, pUblished and declared by the above named Testat~ix
as and foT. her Last Will and Testament, in the presence of us, who, in her
presence, at her request and in the presence of each other have hereunto
subscribed our names as witnesses.
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