HomeMy WebLinkAbout01-26-06
REV-1500 EX (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
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COUNTY CODE YEAR NUMBER
DECE~. .T,'S,.NAM. E (L.A..Sr FIRST, AND MIDDLE '..NITIAL).
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DATE OF DEATH (MM-DD-yr) I DATE OF BIRTH (MM-DD-YEAR)
d. - f- d). 00 :;- / - 3) - ~ I
- __ _____ - __._u___ ____._____ -------.--- --~-----
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
I SOCIAL SECURITY NUMBER
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
g;. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Allach copy of Wall
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (dale of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy afTNsl)
o 10. Spousal Poverty Credit (dale af dealh between 12-31-91 and 1-1-95)
SOCIAL SECURITY NUMBER
o 3. Remainder Return (dale afdeath prior 10 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 Scl10}
THIS ECTION MUST Be COMPLETED. ALL CORRESPONDENCE ANDCONFIDENTtALIAXINFORMATION8HOlJLOBeOIRECTEO//TO:
:::ENAME ~el1J./btZ g _W~~~~ COM~ MA~GADt::~/ow Jt
TELEPHONE -NUM'ER 7/7 -dV~-: i 5YS:- c aJ." s~ fi fi no /-3 ,
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1. Real Estate (Schedule A)
2 Stocks and Bonds (Schedule B)
3. Closely Heid Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule 0)
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/See 9113 Trusts for Which an election to tax has not been
made (Schedule J)
(9) J b~7 79
(10) t g; YJli/ q /
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)
xO (15) "-U--
x .0 (16)
x .12 (17)
x .15 (18)
(19)
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 < <
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Decedent's Complete Address:
STREET ADDRESS ~ -?.. __ ~_ _~~J /LIJ_"'d ~__ __ __ _____
__~S ~__I!/i../J_.D/3__
-.--- ------- ------------- - ------ -------
CITY
-----r STATE'- -----lZIP
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
6
3. Interest/Penalty if applicable
D. Interest
E Penalty
Total Credits ( A + B + C ) (2)
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)
B. Enter the total of Line 5 + 5A This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
D
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.......................................................................................... 0 Gr'
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 Gr
c. retain a reversionary interest; or.......................................................................................................................... 0 I:r
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 Gr'
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 G(
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 Gr
4. ~~~t~~nc:~e~~~;i:i:~ I~~~~dn~:o~~ti~~~~~t.~~~~~.~.~,..~.~~~.i.~:. ~~. .o~.~.~.~ .~~~~~r~~~~~. :.~o:..~.~~. .~~~~~....................... 0 ~
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 scheduies and statements, and to the best of my knowledge and belief, it is true, correct and complete.
Declarati of pre parer other than the personal representative is based on all information of which prepare, has any knowledge.
DATE
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
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 PS. ~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 exemot 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 PS. !)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. 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.
Estate of Dorothy M. Warner:
Balance in the Sovereign Bank checking account of Dorothy M. Warner at the time
of her death on February 8, 2005 was $4,063.56. This amount was transferred into
an Estate Account on February 28, 2005:
Administrative Fees:
$25.35
$326.41
$84.00
$137.03
$75.00
$3,415.77
Debts:
$8,484.91
Funeral was pre-paid.
Check Book Fee
Sarah Todd Nursing Home
(Final Payment)
Dorothy Mae Warner (Daughter & Executrix of the Estate)
(Reimbursement for payment made to Register of Wills)
The Sentinel
(Notice of death)
Cumberland Law Journal
(Notice of death)
Balance in Estate Account
Priority Class 6 Claim against the Estate from the Department of
Public Welfare
t Sovereign Bank
STATEMENT OF ACCOUNTS
.
1-877-SQV-BANK (1-877-768-2265) www.soverelgnbank.com
TOTALLY FREE CHECKINC
ESTATE OF DOROTHY M WARNER
Account # 2891099923
Balances
Deposits/Credits
+ $4,063.56
Average Daily Balance
$3,561.73
Account Activity
Date Description
02-25 Beginning Balance
Additions
Subtractions
Balance
$0.00
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03-08 CHECK BOOK FEE
03-21 Ending Balance
$4,038.21
$4,038.21
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page 3 of3
2891099923
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WaFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 1710~86
May 27, 2005
DOROTHY MAE WARNER
53 E WILLOW ST
CARLISLE PA 17013
Re: DOROTHY WARNER
CIS #: 550169087
SSN: 181-32-3083
Date of Death: 2/8/2005
Dear Ms Warner:
please be advised that the Department of Public Welfare is attempting to
recover the monetary value of any and all eligible assets in the subject
estate. Although the amount in the estate may be considerably less than that
which is owed to the Department, our claim is against the estate, no one
else. Your responsibilities, as the primary next of
kin/administrator/executor, is to advise the Department of any assets in the
estate and to insure that the remaining money, after all funeral and
administrative costs are deducted, is sent to the Department.
The Department of Public Welfare maintains a claim in the amount of
$3~,677.25 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 $23,192.34, 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 $8,484.9~, is
to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise 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,
~d#LL-
Michael J. Macaluso
Claims Investigation Agent
717-772-6611
717-705-8150 FAX
Enclosure