HomeMy WebLinkAbout09-14-05
REV-1500 EX. (lHlO)
COMMONWEALTH Of
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV -1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
BALOG HELEN
DATE OF DEATH (MM-DD-Yea-)
DATE OF BIRTH (MM-DD-Yea-)
11
OFFICIAI. USEONL Y
FILE NUMBER
2 1 -0 5 0 1 8 9
COiiNTYCOiiE -YfAR- - - NUMaER- -
SOCIAL SECURITY NUMBER
1 8 6-2 6-0 508
THIS RETURN MUST BE FLED III DUPlICATE WITH THE
REGISTER OF WILLS
SOQAL SECURITY NUMBER
o 3. Remainder Return (!f;lleofdealh prior III 12-13-82)
o 5. Federal Estate Tax Return Required
.!L 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) IAIIaelI ScI1 0)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAl TAX INFORMATION SHOULD BERECTED TO:
NAME COMPLETE MAILING ADDRESS
William A. Duncan Es uire Duncan & Hartman, P.C.
FIRM NAME (If Applicable)
Duncan & Hartman P.C. One Irvine Row
TELEPHONE NUMBER
717-249-7780 Carlisle PA 17013
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12/15/2004 07/16/1910
(IF APPLICABLE) SURVMNG SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
lXJ 1. Original Return
o 4. Limited Estate
lXJ 6. Decedent Died Testate (Allach copy of WiI)
o 9. Litigation Proceeds Rereived
o 2. Supplemental Return
o 4a. Future Interest Compromise (daleoldealh after 12-12-82)
o 7. Decedent Maintained a Living Trust IAlliI:h copy of Trust)
o 10. Spousal Poverty Credit(daleoldealh~ 12-31-91 atdl-1-95)
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(1)
(2)
(3)
(4)
(5)
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation. Partnership or SoIe-Proprietorship
4. MoI1gages & Notes Rereivable (Schedule 0)
5. Cash, Bank Deposils & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos 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 Liabilities. & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line B rninus Line 11)
13. Charitable and Governmental Beques1SlSec 9113 Trusts for which an eleclion to tax has not been
made (Schedule J)
(6)
(7)
(9)
(10)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPlICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate. or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at "neal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. D
CHECK HERE >= YOJ ARE ~EQUEST\NG A REFUND OF AN OVERPAY',lENT
> > R~ ~IIR~ Tn AN~WFR All OIl~~TlnN~ nN R~VFR~~ ~In~ ANn R~r.W~r.K MATW <. <.
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0.00 ~n
OFFIC!.!,SE ON~: iil I
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17,247.00
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17,247.00
24,141.88
-6,894.88
-6,894.88
0.00
0.00
0.00
Decedent's Complete Address:
STREET ADDRESS The Church of God Home
801 North Hanover Street
CITY C rl" I I STATE PA I ZIP 17013
a Ise
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditsJPayments
A. Spousal PovertyCredn
8. Prior Payments
C. Discount
(1)
0.00
Total Credits (A + 8 + C)
(2)
0.00
3. InterestlPenalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + E ) (3)
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 (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
0.00
0.00
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes Mo
a. retain the use or income of the property transferred; ........................................................................... 0 r&l
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 l&J
c. retain a reversionary interest; or ...................................................................................................... 0 00
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 00
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration?............. ................................................................................. 0 IX!
3. Did decedent own an 'in trust for" or payable upon death bank account or securny at his or her death? ................. 0 IX!
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a benefiCiary designation? ............................................:.......................................................... 0 r&l
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
SIGNATURE
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ADDRESS
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. 99116 (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 survivil
The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets c
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~ne years of age or younger at death to or for'
or a stepparent of the child is 0% [72 P.S. 99116(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 notE
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. 99116(a)(1.3)]. A l
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REV-1508 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BALOG. HELEN
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21 05
Include the proceeds of litigation and the date the proceeds were received by the estate.
AU property jolntly-owned with right of survivorship must be disclosed on Schedule F.
018~
ITEM
NUMBER
1.
DESCRIPTION
Cornerstone Federal Credit Union savings account no. 10214-01
VALUE AT DATE
l OF DEATH
3,693.35
2.
Cornerstone Federal Credit Union checking account no. 10214-07
3,142.51
3.
Young Funeral Home, Ltd. Pre-planned services.
10,411.14
TOTAL (Also enter on line 5, Recapitulation) $
17247.00
IIf mnl'P. "M"" "' nAAriPli in....rt ..rtrtitinn..1 "h_'" nf th" ""mA "i7"\
REV-1511 EX + (12-99)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BALOG. HELEN
ITEM
NUMBER
A.
B.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
21
05
Debts of decedent must be reported on Schedule I.
DESCRIPTION
1.
FUNERAL EXPENSES:
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (5) Richard A. Hrip
Social Security Numbef(s)JEIN Number of Personal Representative(s)
Street Address 6308 Stephens Crossing
City Mechanicsburg State PA Zip 17050
Year(s) Commission Paid: 2005
Attorney Fees William A. Duncan, Esquire
Family Exemption: (If decedenfs address is not the same as c1aimanfs, attach explanation)
Claimant None
Street Address
2.
3.
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees to date $76.00
In Reserve: $100.00
5. Aaxluntanfs Fees
6. Tax Return Prepare(s Fees
7.
8.
Church of God Home, donation
Richard A. Hrip. Reimbursement for expenses for funeral/Estate settlement.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
018$
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:
AMOUNT
1,207.00
1,207.00
176.00
20.00
797.61
3407.61
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~EV-15121iX + (6-98)
.
SCHEDULE'
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BALOG. HELEN
FILE NUMBER
21 05
0189
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1. The Church of God Home, December payment.
VALUE AT DATE
OF DEATH
1,019.85
2. Department of Public Welfare, restitution of medical assistance.
19,714.42
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
20.734.27
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
RAI nr.: 1-11=1 1=1\1 21 05 0189
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 [indude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Richard A. Hrip Son One-half Residue
6308 Stephens Crossing (50%)
Mechanicsburg, PA 17050
2. Gregory McGee Grandson One-fCi)urth Residue
1563 New Seneca Turnpike (25%)
Skaneateles, NY 13152
3. William McGee Grandson One-f~urth Residue
1417 Coolwind Court (25% )
Beavercreek, OH 45434
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON 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 TAXIS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
II
LAST WILL AND TESTAMENT OF HELEN BALOG
I, HELEN BALOG, of Butler County, Pennsylvania, being of sound and dis-
posing mind and memory, do make, publish and declare this to be my Last Will
and Testament, hereby revoking and making null and void all Wills and Codicils
by me at any time heretofore made.
I.
First, I direct the payment of all my just debts and funeral expenses as
, soon after my decease as may be convenient.
II.
All my real estate at 109 Duncan Drive, Butler, Pennsylvania, together
with all buildings thereon and all rights and easements apportenant thereto, I
give and devise to my husband, George Balog, if he survives me, for his own use
. during his life,without bond and without liability for impeachment for waste,
provided, however, that my said husband shall keep the buildings on the said
premises adequately insured against loss or damage by fire, shall pay all pre-
miums and all taxes, assessments and mortgage interest, if any, and Shall main-
,
tain and keep the premises in good condition and repair. Upon the de~th of my
said husband, or upon my death, if he does not survive me, I give an~ devise
the said real estate in equal shares to my children, Winifred M. McG~e, now or
formerly of Penn Township, Butler County, Pennsylvania, and Richard A. Hrip, now
or formerly of Carlisle, Pennsylvania, their heirs and assigns forev~r.
III.
All the rest, residue and remainder of my estate of whatever nature and
wherever situate of which I die seized or have the right to dispose of, I give,
devise and bequeath to my children, Winifred M. McGee and Richard A. Hrip, share
and share alike.
IV.
I hereby nominate, constitute and appoint my children, Winifred M. McGee
and Richard A. Hrip, Co-Executors of this my Last Will and Testament" and I
direct that they shall not be required to enter security in any jurisdiction
in which they may act.
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(SEAL)
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IN WITNESS WHEREOFt I have set my hand and seal to this my Last Will and
Testamentt this ;)Jc:t. day of JulYt 1986.
(',~>-~:/'>< ~ /; ~;-' . -;~...'-' ,~) / ,x ;,~, - ,-,
i,'. ~:// J:'L'~''-/ ":i:''')~.F<..t, -, C:-t
Helen Balog/
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(SEAL)
Signedt sealedt published and declared by the said HELEN BALOGt as amd for her
Last Will and Testamentt in the presence of uSt who at her request and in her
presence and in the presence of each other have hereunto subscribed our names as
witnesses.
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Young Funeral Home, Ltd.
;!/ PO Box 1522 127 W.]efferson St.
Butler, PA 16003-1522
(724) 283-3333
Toll Free: 1-800-949-0479
Fax: (724) 287-7511
William F. Young, Jr., Supv.
Robin Young Christy F.o. _ William F. Young III, F.o. -Monica Young Campagna, Mgr.
Richard A. Hrip
6308 Stephens Crossings
Mechanicsburg, P A 17050
December 22, 2004
Services for Helen Hrip Balog who died on December 15, 2004
TRANSPORT A TION
Extra transportation
MERCHANDISE
16 ga. Casket & Services (6735-350)
Monticello vault
Dress
CASH ADVANCES
Grave opening Rose Hill Cemetery
Stone lettering
Father Dennis Bogda
Local news release
Cantor
10 copies of certificate
Flowers & tax
Donation for funeral dinner
Deacon of the Church
TOTAL CHARGES
Payments
December 17,2004 National City Trust
$ 10,411.14
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HAouMT - IJ..- J 7 ~
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$ 250.00
$ 6,385.00
$ 845.00
$ 100.00
$
$
$ 1,185.00
$ 105.00
$ 100.00
$ 110.00
$ 50.00
$ 20.00
$ 254.40
$ 300.00
$ 50.00
9,754.40
10,411.14
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CORNERSTONE
P.O. Box 1181. 5 East Gate Drive. Carlisle. PA 170 I 3
Telephone (717) 249-1661 FAX (717) 249-8208
www.comerstonefcu.org
Federal Credit Union
Member founded - Service based
February 10, 2005
Duncan & Hartman, P.c.
One Irvine Row
Carlisle, PAl 7013
RE: Helen Balog
Mr. Duncan:
Please find the following information regarding the account of Helen Balog. The
account was opened December 1,2003 in the names of Helen Balog with Richard Hripias
Representative Payee.
Account #
Type of Acct. DOD Balance
Interest Rate
Current Balance
10214-01
Savings $3693.35
1.00%
$4058.96
10214-07
Checking $3142.51
0.25%
$2124.61
The 1099' s were sent out at the beginning of January so it would have been
mailed to the address on the account which is:
6308 Stephens Crossing
Mechanicsburg, P A 17050
Please contact me if you require any further information on this account or if you
have any questions.
Sincerely;
"------\t~
Jen ~r
MEMBER SAVINGS ACCOUNTS FEDERALLY INSURED To $100,000 By THE NATIONAL CREDIT UNION ADMINISTRATION
December 27,2004
6308 Stephens Crossing
Mechanicsburg, P A 17050
Ms. Sue Keener
The Church of God Home, Inc.
801 N. Hanover Street
Carlisle, PAl 70 13
Dear Sue:
Enclosed is a check of$I,019.85 for the December and fmal payment of my mother,
Helen Balog. Also enclosed is a $20.00 donation to the Church of God Home, Inc. in
memory of my mom. I hope to send to you additional contributions in the near future in,
memory of mom. Thank you for all of your assistance and help while mom lived at the
Church of God Home.
Sincerely,
~LlQ,#~
Richard A. Hrip
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
April 27, 2005
DUNCAN & HARTMAN P C
WILLIAM A DUNCAN ESQ
ONE IRVINE ROW
CARLISLE PA 17013
Re: HELEN BALOG
CIS #: 270169006
SSN: 186-26-0508
Date of Death: 12/15/2004
Dear Attorney:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $19,714.42 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.S. 1412, effective August 15, 1994, ~S
amended by Act 20-95, effective June 30, 1995. Enclosed is the Departmen~'s
itemized statement of claim.
A portion of this medical expense, namely $~9,714.42, 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 $.00, is td 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 cont~ins
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
,
~
iD~~. h."~,
Brian M. Holler
Claims Investigation Agent
717-772-6607
717-705-8150 FAX
Enclosure
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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
April 26, 2005
STATEMENT OF CLAIM SUMMARY
Estate of BALOG, HELEN
270 169 006
INPATIENT
OUTPATIENT
LONG TERM CARE
DRUG
.00
.00
15,611.13
4,103.29
.00
.00
.00
.00
.00
.00
15,611.13
4,103.29
19,714.42
.00
19,714.42
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May 24, 2005
6308 Steph~IlS Crossing
Mechauicsburg, P A 17050
Mr. Wi1Ham A Duncan
Duncan & Hartman, P.C.
llrvine Row
Carlisle, PA 17013
Dear Bill:
The following is a stunmary of the expenses incwred by me associated with the fimeral of my
mother, Helen Balog, and miscellaneous expenses associat.ed with the Estate settlement of my
n:J,other.
Expenses Incwred
Reason fOf Expenses
Comments
$176.04
Lodging during the funeral
for IllY wife, Sue, and I
(12/18/04-12/2004)
See receipt
$180.67
Lodging during the funeral
for my sons, Max & Andrew
(J 2/18/04-12/2004)
See receiJJt
$185_90
Mileage to and from my home in
Mechanicsburg, P A to 1he Y (lung
Funeral Home in Butler, P A
(434 miles) plus 25 additional miles
driving within Butler
(459 miles X $.405 per mile = $185.90)
$.405 per mile is
the current IRS
allowable ex'pense
$200_00
Meals and miscellaneous expenses
for family during the funeral ill
Butler, PA(12/18/04-12/20/04)
Estimate
$3_00
Payment for mother's 2004
Pennsylvania State Income Ta..x
See copy of 2004 Tax
Form
$52.00
Required copies of death
certificates for my stepfather,
George Balog
See receipt
797.61
Total Expenses
~a,~
Richard A- Hrip