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Home My WebLink About12-29-05 REV-1500 EX + (8-00) REV-1500 OFFICIAL USE ONlY '* ~~L~~ '. PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX. RETURN FILE NUMBER DEPT. 280601 HARRISBURG, PA 17128-0001 RESIDENT DECEDENT 2 1 - 0 5 0 1 8 9 COiiN'rvCOiiE -YEAR- - - NuMBER- - DECEDENT'S NAME (LAST, RRST, AND MiDDlE INITIAL) SOCIAL SECURITY NUMBER I- BALOG HELEN 1 8 6-2 6-0 5 0 8 z W DATE OF DEATH (MM-DD-YlllY) DATE OF BIRTH (MM-oo. Y ear) THIS RETURN MUST BE FLED IN DUPLICATE WITH THE C W 12/15/2004 07/16/1910 REGISTER OF WILLS 0 W (IF APPLICABLE) SURVMNG SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER C - - w o 1. Original Return lXl 2. Supplemental Return o 3. Remainder Return (dale of death priorlD 12-13-82) !;c :il: -0 o 4. Limited Estate o 4a. Future Interest Compromise (dale of death after 12-12-$2) o 5. Federal Estate Tax Retum Required (.)It::il: wll.(.) :too lXl 6. Decedent Died Testate (Alla:hcopyofWil) o 7. Decedent Maintained a Living Trust (AIIa:h copy of Trust) Q. 8. Total Number of Safe Deposit Boxes (.)It:...J ~ID c( o 9. Litigation Proceeds Received o 10. Spousal Poverty Credit (dale of death belween 12-31-91 aid 1-1-95) o 11. Election to tax under Sec. 9113(A) (AIIa:h Sell 0) .... THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: z NAME COMPLETE MAILING ADDRESS w 0 William A. Duncan Es uire Duncan & Hartman, P.C. z 0 FIRM NAME (If Applicable) II. 0 w Duncan & Hartman P.C. One Irvine Row It: It: TELEPHONE NUMBER 0 (.) 717-249-7780 Carlisle PA 17013 1. Real Estate (Schedule A) (1) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 17,247.00 _.' , 5. Cash, Bank Deposils & Miscellaneous Personal Properly (5) (Schedule E) Z 0 6. Jointly Owned Property (Schedule F) (6) t= o Separate BHling Requested ~ 7. Inter-Vivos Transfers & Miscellaneous Non..probate Property (7) 0.00 :) I- (Schedule G or L) , ~ -, , ; r',.) 17;247.00 c( 8. Total Gross Assets (total Lines 1-7) (8) .~ '.) 0 13,162.01 w 9. Funeral Expenses & Administrative Costs (Schedule H) (9) a:: 20,734.27 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) (11) 33,896.28 12. Net Value of Estate (Line 8 minus Line 11) (12) -16,649.28 13. Charitable and Governmental BequestslSec 9113 Trusts for which an eleclion to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) -16,649.28 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z 15. Amount of Line 14 taxable at the spousal tax 0 rate, or transfers under Sec. 9116 (a)(1.2) X .000 (15) 0.00 t= c( 16. Amount of Line 14 taxable at nneal rate X .045 (16) 0.00 I- :) Q. 17. Amount of Line 14 taxable at sibling rate X .12 (17) :IE 0 18. Amount of Line 14 taxable at coUateral rate X .15 (18) 0 >< 19. Tax Due (19) 0.00 c( I- D 20. CHECK HERE IF (OU ARE REQUEST'NG A REFUND OF AN OVERPAYf,lENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < REV-1508 EX + (6-98) '* SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER BALOG. HELEN 21 05 0189 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. Cornerstone Federal Credit Union savings account no. 10214-01 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) $ 17,247.00 (If mn'A ~n""" i~ "AAtiAti in~ArI "titiitin",,' ~hAA'" nf thA ~"mA ~i7"\ REV-1511 EX + (12-99) *' SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER BALOG. HELEN 21 05 0189 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. 9,754.40 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Richard A. Hrip 1,207.00 Social Security Number(s)JEIN Number of Personal Representative(s) 205-36-7954 Street Address 6308 Stephens Crossing City Mechanicsburg State P A Zip 17050 Year(s) Commission Paid: 2005 2. Attomey Fees William A. Duncan, Esquire 1,207.00 3. Family Exemption: (If decedenfs address is not the same as daimanfs, attach explanation) Claimant None Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees to date $76.00 176.00 In Reserve: $100.00 5. Accountanfs Fees 6. Tax Return Preparer's Fees 7. Church of God Home, donation 20.00 8. Richard A. Hrip. Reimbursement for expenses for funeral/Estate settlement. 797.61 TOTAL (Also enter on line 9, Recapitulation) $ 13.162.01 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (6-98) *' SCHEDULE. COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER BALOG. HELEN 21 05 0189 Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. The Church of God Home, December payment. 1,019.85 2. Department of Public Welfare, restitution of medical assistance. 19,714.42 TOTAL (Also enter on line 10, Recapitulation) $ 20,734.27 (If more space is needed, insert additional sheets of the same size) R"'.""" <'_ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BALOG HEI EN 21 05 01RO 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. Richard A. Hrip Son One-half Residue 6308 Stephens Crossing (50% ) Mechanicsburg, PA 17050 2. Gregory McGee Grandson One-fourth Residue 1563 New Seneca Turnpike (25%) Skaneateles, NY 13152 3. William McGee Grandson One-fourth 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 TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DI$TRIBUTIONS 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) 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 death of my said husband, or upon my death, if he does not survive me, I give and devise the said real estate in equal shares to my children, Winifred M. McGee, now or formerly of Penn Township, Butler County, Pennsylvania, and Richard A. Hrip, now or formerly of Carlisle, Pennsylvania, their heirs and assigns forever. 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, I 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. - '. f/.':<:// ./.li"~( ("LI' (SEAL) 'H~(e~'-Balog" ./ 'd/.' Young Funeral Home, Ltd. :t/ PO Box 1522 127 W. Jefferson 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 FD. _ William F. Young III, F.D. -Monica Young Campagna, Mgr. Richard A. Hrip December 22, 2004 6308 Stephens Crossings Mechanicsburg, P A 17050 Services for Helen Hrip Balog who died on December 15, 2004 TRANSPORT A TION Extra transportation $ 250.00 MERCHANDISE 16 ga. Casket & Services (6735-350) $ 6,385.00 Monticello vault $ 845.00 Dress $ 100.00 CASH ADVANCES Grave opening Rose Hill Cemetery $ 1,185.00 Stone lettering $ 105.00 Father Dennis Bogda $ 100.00 . Local news release $ 110.00 Cantor $ 50.00 10 copies of certificate $ 20.00 Flowers & tax $ 254.40 Donation for funeral dinner $ 300.00 Deacon ofthe Church $ 50.00 TOTAL CHARGES $ 9,754.40 Payments $ 10,411.14 December 17,2004 National City Trust $ 10,411.14 p~o~ CHE~;~ I - . f>JJaOU ~ O/>.iE ~ \N\i\/>.LS ~ Ii fD5(P.7,f ~~. ~ CORNERSTONE p.o. Box 1181, 5 East Gate Drive, Carlisle, PA 17013 Federal Credit U n ion Telephone (717) 249-1661 FAX (717) 249-8208 Member founded - Service based www.comerstonefcu.org February 10, 2005 Duncan & Hartman, P.C. One Irvine Row Carlisle, PA 17013 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 Hrip as 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; "-..' J en p,erry \ i MEMBER SAVINGS ACCOUNTS FEDERALLY INSURED To $100,000 By THE NATIONAL CREDIT UNION ADMINISTRATION December 27,2004 6308 Stephens Crossing Mechanicsburg, P A 17050 Ms. Sue Keener The Church of God Home, Inc. 801 N. Hanover Street Carlisle, PA 17013 Dear Sue: Enclosed is a check of$I,019.85 for the December and [mal 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, ~kla~~ Richard A. Hrip *' 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 $1.9,714.42 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 IS, 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 $19,714.42, 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 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, ,. ~ it)~~ lk.)J-u-f!t, Brian M. Holler Claims Investigation Agent 717-772-6607 717-705-8150 FAX Enclosure * f. ~" ! -"4.:- ( 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 .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 15,611.13 .00 15,611.13 DRUG 4,103.29 .00 4,103.29 19,714.42 .00 19,714.42 U~.~q rftA '~'~JO~JO~ ..~~U \" i .t\..t'.t'...'"\.L t"C.:J L.gj 1.J1l..J~ l)~) ':'0 i)~) May 24, 2005 630& Stephens Crossing Mechanicsburg, P A 17050 lVIr. William A Duncan DUllcan & Hartman, PoCo Ilrvine Row Carlisle, PA ] 7013 Dear Bill: The following is a SLUl1mary of the expenses incurred by me associated with the fimeral of my mother, Helen Balog, and miscellaneous expenses associated with the Estate settlement of my mother. Expenses Incurred Reason for Expenses Comments $176.04 Lodging during the funeral See receipt for my wife, Sue, and I (12/18/04-12/2004) $ 180.67 Lodging during the funeral See receipt tor my sons, Max & Andrew (] 2/1 8/04-12/2004) $IBS_90 Mileage to and from my home in $.405 per III ile is Mechanicsburg, P A to the Y (lung the current IRS Funeral Home in Butler, P A allowable expense (434 mile,{) plus 25 additional miles driving within Butler (459 miles X $.405 per mile = $185.90) $200_00 Meals and miscellaneous expenses Estimate for f.'unily during the funlO'ral in Butler, PA (12/18/04-12/20/04) $3_00 Payment for mother's 2004 See copy of 2004 Tax. Pennsylvania State Income Ta."'( Form $52.00 Required copies of death See receipt certificates for my stepfather, George Balog 797.61 Totalli:x!,enses r0relY, ~4J. a,#~ Richard A_ Hrip