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Home My WebLink About12-29-05 REV-1500 EX + (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT I- Z W C W (.) W C w ~ ~-Ul ()O:~ W ll..() J:OO ,,0: ..J ..... ll.. aJ ll.. <( DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Blauser, Anna I. DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year) OFFICIAL USE ONLY FILE NUMBER 2 1 -0 5 0 9 0 2 COuNTYGOOE ---YEA~ - - NuMBER- - SOCIAL SECURITY NUMBER 1 82- 2 2 - 8 042 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER D 3. Remainder Return (date of death prior 10 12-13-82) D 5. Federal Estate Tax Return Required Q.. 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS Gerald J. Shekletski, Es . 414 Bridge St. FIRM NAME (If Applicable) Stone, Lafaver & Shekletski P.O. Box E TELEPHONE NUMBER 717-774-7435 New Cumberland PA 17070 0.00 X _(15) 0.00 0.00 X -=-- (16) 0.00 0.00 X .12 (17) 0.00 0.00 X .15 (18) 0.00 (19) 0.00 09/22/2005 04/30/1923 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) !Xl 1. Original Return D 4. Limited Estate !Xl 6. Decedent Died Testate (Altach copy of Will) D 9. Litigation Proceeds Received D 2. Supplemental Return D 4a. Future Interest Compromise (dale of dealh after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach copy of Trusl) D 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95) OFFICIAL USE ONLY "I I ! I- Z W C Z o ll.. Ul W 0: 0: o U 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) (1) (2) (3) (4) (5) 8,161.45 \. j ~~ 1,013.41 I; .", ) z o i= ~ ...J :J !:: a.. ~ (.) w a::: 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) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) (7) C>) 9,174.86 (6) 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) (9) (10) (8) 4,378.00 41,553.76 (11) (12) (13) 45,931.76 -36,756.90 12. Net Value of Estate (Line 8 minus Line 11) 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) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o i= ~ I- :J a.. :!: o (.) X ~ I- 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 20. 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < (14) -36,756.90 o d C Ad ece ent's omplete dress: STREET ADDRESS 1700 Market 8t. CITY I STATE I ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 0.00 0.00 Total Credits (A + B + C ) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty 4. T otallnterest/Penalty ( D + E ) 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 (3) 0.00 PLEASE ANSWER THE FOllOWING QUESTIONS BY PlA ~ ~~S ~~ ~\:>\;('V ----- ,:t.'L 1. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred; .................. .................................................... D b. retain the right to designate who shall use the property transferred or its income; ........................................ D c. retain a reversionary interest; or ...................................................................................................... D d. receive the promise for life of either payments, benefits or care? ............................................................. D 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?... ........ ...... ....... .... ...... ............ ................. ........ ........... ... .......... D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ...... ................................ ..................... .......... ........ ................ .......... D (4) (5) 5A) 0.00 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUI= A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: Rf. iB) 0.00 ,TE BLOCKS No !Xl !Xl !Xl !Xl !Xl !Xl !Xl 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 perjury, I declare that 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 personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF RSON RESPON ISLE OR FILING RETURN \ 257 Old Cabin Hollow Road Dillsbur SIGNATURE OF PR _ DATE ~./.~ /- /0) ADDRESS -- ADDRE PA 17070 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) (ill. 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. ep\wil1s\blauser.ann\6-99 LAST WILL AND TESTAMENT OF ANNA I. BLAUSER I, ANNA I. BLAUSER, of Lower Allen Township, cumberland County, pennsylvania, declare this to be my last will and revoke any will previously made by me. ITEM I: I devise and bequeath all of my estate, of every nature and wherever situate, to my husband, WILMER J. BLAUSER, if he survives me. Should my husband, WILMER J. BLAUSER, predecease me, I devise and bequeath all of my estate, of every nature and wherever situate, to my son, GARY E. BLAUSER, if he survives me. Should my son, GARY E. BLAUSER, predecease me, I devise and bequeath all of my estate, of every nature and wherever situate, to my issue, per stirpes. ITEM II: I appoint my husband, WILMER J. BLAUSER, Executor, of this my last will. Should my husband, WILMER J. BLAUSER, fail to qualify or cease to act as Executor, I appoint my son, GARY E. BLAUSER, Executor of this my last will. ITEM III: No fiduciary acting hereunder shall be required to post bond or enter security for the faithful performance of his duties in any jurisdiction. Page 1 of 4 IN WITNESS WHEREOF, I, and seal this I (;, ~ day of ANNA I. BLAUSER, have hereunto set my hand "J, , ,iCJ__- ',6-'..zt. ~ \'. ,/'" , , 1999. /) . ~ . - /,.", '/ (c/bJ-'T <- k /::,. /" ~ e..-. ANNA I. BLAUSER - SIGNED, SEALED, PUBLISHED and DECLARED by ANNA I. BLAUSER, the Testatrix above named, as and for her Last Will and Testament, and in the presence of us, who at her request, in her presence and in the presence of each other, have subscribed our names as witnesses. ~~ - WitnesV Y/y 6/4/Y.fcAv ~k (df , I . Address /7070 ~~~. ~~~Lf1 Witness 7U../-u eu~'-U't.-~, /'4- . Address COMMONWEALTH OF PENNSYLVANIA: SS: COUNTY OF CUMBERLAND I, ANNA I. BLAUSER, the Testatrix whose name is signed to the at- tached or foregoing instrument, having been duly qualified according Page 2 of 4 to law do hereby acknowledge that I signed and executed this instru- ment as my last will; that I signed it willingly and that I signed it as my free and voluntary act for the purposes therein contained. c/-~ ,:/ /' ~ .>' l.~. a d ~::~'-' ~ p-c-- l---- ~ ANNA I. BLAUSER Sworn to or affirmed to and acknowledged before me by ANNA I. BLAUSER, the Testatrix, this /~ ", day of ~ ' 1999. i?--bH1;A~ 1i)k~ Notary Public NOTARIAL SEAL PATRICHIA L YOTER, Notary Public New Cumberland Boro. Cumberland Co. My Commission Expires Nov. 18. 2002 COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF CUMBERLAND we,~~ and < La~tL 'rn. ~ .AL-uYL"'.Y v the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to Law, depose and say that we were present and saw Testatrix sign and execute the instrument as her last will; that Testatrix signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; Page 3 of 4 ~ that each of us in the hearing and sight of the Testatrix signed the will as witnesses; that to the best of our knowledge, the Testatrix was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. ~d~ Witne~-l. ~'m. /cIo~/~~ Witness Sworn to or affirmed to and acknowledged before me by ,.Jj,~ J. ..AA~;ft~ and ,OIt7Vr/LL"1fj. j/dA~ witnesses, this I r.,.JAt day of r ' 1999. P~V~J Notary publi P'A'i1R NOTARIAtLSEA( , - n ICHIA L YOTt:Ff: N ' '~D " , New Cumberl'!lftd R"~ eumal,"--' ,U,/)/,I(: MY CO w, "';It!) mbei'tll1"'C mmlsslon E'xnlIiUS' J.I v :1..., , ',t,I, O. t' nOvo 1a,2OO2 Page 4 of 4 REV-150B EX + (6-9B) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Blauser. Anna I. FILE NUMBER 21 05 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. 0902 ITEM NUMBER 1. DESCRIPTION Citizens Bank checking account #6100770729 VALUE AT DATE OF DEATH 7,467.49 2. HCR Manor Care Refund 693.96 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 8,161.45 Citizens Bank 525 William Penn Place Suite 153-2510 Pittsburgh, PA 15219 November 3,2005 STONE, LAFA VER & SHEKLETSKI 414 BRIDGE STREET POBOX E NEW CUMBERLAND P A 17070 Estate of ANNA I BLAUSER Date of Death: Sep 22, 2005 SSN: 182-22-8042 Dear Sir/Madam: In accordance with your request, the attached information sheet has been provided in the above decedent's name as of his/her date of death. For IL or LC accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 1-888-999-6884 Sincerely, ~~h~ Operations Services '-a( Citizens Bank Account Number 6200377409 Account Title ANNA I BLAUSER OR GARY BLAUSER Date Opened 1/13/2004 Account Type Checking Principal Balance as of DOD $1960.76 Interest from Last Posting to DOD $ .00 Account Balance as of DOD $1960.76 YTD Interest to DOD $22.85 It Citizens Bank Account Number 6203204459 Account Title ANNA I BLAUSER OR GARY BLAUSER Date Opened 1/13/2004 Account Type Checking Principal Balance as of DOD $66.06 Interest from Last Posting to DOD $.00 Account Balance as of DOD $66.06 YTD Interest to DOD $.00 Citizens Bank Account Number 6100770729 Account Title ANNA I BLAUSER OR WILMER J BLAUSER Date Opened 10/12/1984 Account Type Checking Principal Balance as of DOD $7467.49 Interest from Last Posting to DOD $ .00 Account Balance as of DOD $7467.49 YTD Interest to DOD $ .00 REV-1509 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Blauser. Anna I. FILE NUMBER 21 05 0902 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Gary E. Blauser E. Blauser 257 Cabin Hollow Road Dillsburg, PA 17019 Son B c JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY '10 OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTSINTERES 1. A. 01-2004 Citizens Bank checking account #6200377409 1,960.76 50. 980.38 2 A 01-2004 Citizens Bank checking account #6203204459 66.06 50. 33.03 TOTAL (Also enter on line 6, Recapitulation) $ 1,013.41 T (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Blauser. Anna I. FILE NUMBER 21 05 0902 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ParthemDre Funeral Home and Cremation Services, Inc. 3,165.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees Gerald J. Shekletski, Esq. 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 Letters Testamentary 83.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. East Pennsboro Ambulance Service 100.00 8. Filing Fees - Inventory $15.00 + Inheritance Tax Return $15.00 30.00 TOTAL (Also enter on line 9, Recapitulation) $ 4,378.00 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (6-98) SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Blauser Anna I. FILE NUMBER 21 05 0902 Include unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION Commonwealth of Pennsylvania, Department of Public Welfare VALUE AT DATE OF DEATH 41,553.76 TOTAL (Also enter on line 10, Recapitulation) $ 41,553.76 (If more space is needed, insert additional sheets of the same size) . 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 December 6, 2005 STONE LA FAVER & SHEKLETSKI GERALD J SHEKLETSKI ESQUIRE 414 BRIDGE ST POBOX E NEW CUMBERLAND PA 17070 Re: ANNA BLAUSER CIS #: 370174816 SSN: 182-22-8042 Date of Death: 09/22/2005 Dear Mr. Shekletski: Please be advised that the Department of Public Welfare maintains a claim in the amount of $41,553.76 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 $24,889.82, was incurred during the last six months of the decedent's lifei 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 $16,663.94, 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, :S~[.~ Sharon E. Smith TPL Program Investigator 717-772-6397 717-772-6553 FAX Enclosure 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. Gary E. Blauser Lineal 257 Old Cabin Hollow Road Dillsburg, PA 17019 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 DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ '''-n'' e, .". COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Blauser Anna I SCHEDULE J BENEFICIARIES (If more space is needed, insert additional sheets of the same size) FILE NUMBER 21 05 0902 IN THE OFFICE OF THE REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA INVENTORY Estate of Anna I. Blauser No.21 05 0902 also known as , Deceased Date of Death 9/22/2005 Social Security No. 182228042 Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Name of Attorney: Gerald J. Shekletski, Esq. 1.0. No.: 40486 Personal Representative: ~~h~ Gary E. Blauser, Executor Address: 414 BridQe S1. New Cumberland Dated PA 17070 Telephone: 717-774-7435 Description Value PERSONAL PROPERTY 1. Citizens Bank checking account #6100770729 7,467.49 2. HCR Manor Care Refund 693.96 REAL ESTATE NONE " Total (Attach Additional Sheets if necessary) 8,161 .45 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. RW-4 0~