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REV-1500 EX (6-001
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SHOPE, JEANETTA
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
04-30-1998 05-30-1921
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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[il1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attacl1 copy of Trust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
OFFICIAL. USE ONLY
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FILE NUMBER
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COUNTY CODE YEAR
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NUMBER
SOCIAL SECURiTY NUMBER
195 50
9753
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCiAL SECURITY NUMBER
o 3. Remainder Return (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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NAME'
Kenneth J. Suter, Assistant Counsel
FI~~~i'tflilfA~Ii""J1~partment of Public Welfare
TELEPHONE NUMBER
(717) 787-1619
COMPLETE MAILING ADDRESS
Commonwealth of Pennsylvania
Department of Public Welfare
Office of Legal Counsel
3rd Fl West, Health & Welfare Building
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)
5. Cash, Bank Deposits & 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 8 minus Line 11)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
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14. Net Value Subject to Tax (Line 12 minus Line 13)
(1)
(2)
(3)
(4)
(5)
$2.863.98
(6)
(7)
(9)
(10)
4,512.80
98.723.88
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 lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
OFFICIAL USE ONLY
(8)
/, 8fi'L 98
(11)
(12)
(13)
103~236.68
100,172.70--
(14)
- 0 -
x.O_ (15)
x.O_ (16)
x .12 (17)
x .15 (18)
(19) - o -
Decedent's Complete Address:
STREET ADDRESS
Jeanetta M. Sho e
Star Route 112
STATE
CITY
Shi
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
- 0 -
Total Credits ( A + B + C ) (2)
3. Interest/Penalty 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.
(SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) - 0 -
Make Check Payable to: REGISTER OF WILLS, AGENT
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PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
6. retain a reversionary interest; or.......................................................................................................................... 0
d. receive the promise for life of either payments, benefits or care? ........,............................................................. 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
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? ........................................................................................................................ 0
No
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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.
Under penalties of pe~ury, I declare that I have examined this retum, including accompanying schedules and statements. and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of pre parer other than the personal representative is based on all information of which preparer has any knowledge.
DATE
Ol
Office of Legal
17105-2675
DATE
ADDRESS C Department of Public Welfare,
3rd Floor West, Health and Welfare Building, Harrisburg, PA
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
Counsel
ADDRESS
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 surviving spouse is 0% [72 P.S. 99116 (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 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. 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 noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)].
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 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-1506 EX. (1-97)
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Shope, Jeanetta M.
FILE NUMBER
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
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
$2,863.98
Conserved Social Security Benefits
TOTAL (Also enter on line 5, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
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$ 2,863.98
REV-1511EX+ (1-97)
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Shope, Jeanetta M.
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
1.
B.
1.
2.
3.
4.
5.
6.
7.
8.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
Fogelsanger-Bricker Funeral Home, Inc.
$4,471.80
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Numbe~s) I EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Yea~s) Commission Paid:
Attomey Fees
Family Exemption: (If decedenfs address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
Probate Fees
Accountanfs Fees
Tax Retum Preparer's Fees
Cumberland County Register of Wills
$15.00
$26.00
Cumberland County Clerk of Orphans Court
TOTAL (Also enteron line 9, Recapitulation) $4,512.80
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX. (1-97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Shope, Jeanetta M.
FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1.
Commonwealth of Pennsylvania - Medicaid Estate Recovery
$98,723.88
TOTAL (Also enter on line 10, Recapitulation) $ 98,723.88
(If more space is needed, insert additional sheets of the same size)
'.- .0'71-12-nl
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03:15 PM FROM 7175328471
TO 717 717 772 0717
POI
.Fogeblunger-Ilricker Funeral Honle. Inc.
Norma,n H. llricker, F.D.
112 West King Street
P.O. Box .Vt(i
Shiflpen.<;{)ur!!. p(!!"l.';ylvQ,nia 172.57
Phnne 717-/5.12-22/1
To: Neoma Minium
Pennsylvania Department of P~blic Welfa~e
(717) 787-1619 fax (717).772-0717
from: Fogclsanger-Bricker Funeral Hom@, Inc:.
112 W. King srreet, ShippcnSburg, PA
Re: Copy of Funeral Bill for Jeanetta M. Shope
If you have any questions, please call 717 532-2211.
~ArSMi{j MI MBm AI" INVIT/lTION
q..y~_ NA (I( WA.f. SEU7'CTE{) MOnTlClANS
07-12-01 03: 15 PM FROM 717 532 8471 TO 717 717 772 0717 P02
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
8UREAU OF FINANCLAL OPEAATIONS
ESTATE RECOVERV PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-5486
July 05, 2001
SOUTH MOUNTAIN RESTORATION CENTER
VELVA M MORRIS GUARDIAN OFFICER
10058 S MOUNTAIN RD
SOUTH MOUNTAIN PA 17261
Re: JEANETTA SHOPE
CIS #: 7501.17231
Co/Rec: 21/0078233
Date of Birth: 9/24/1927
SSN: 195-50-9753
Dear Ms. Morris:
Please be advised that the Department of public Welfare maintains a
claim in the amount of $98,123.88 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, 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 $17,695.95, 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 $81,027.93, 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. Xf the estate contaiDs
rea1 estate. please provide copies of the deed, the latest tax assessment,
and a current app~ai8al, if available.
Sincerely,
~a.:Jrd
Debra A. Wiest
TPL Program Investigator
717-772-6713
717-772-6553 FAX
Enclosure
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GUARDIAN OFFI~Fj