HomeMy WebLinkAbout11-21-06 (2)
REY.~500 EX + (6-00)
.
OFFICIAL USE ONLY
REV.1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
FILE NUMBER
II 06
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
606
NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Eith, Doris E.
DATE OF DEATH (MM-DD-YEAR)
150-05-4473
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DATE OF BIRTH (MM-DD-YEAR)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
04-17 -2006
11-13-1916
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
D
D
D
D
~ 1. Original Return
D 4. Limited Estate
~ 6. Decedent Died Testate (Attach
copy of Will)
D 9. Litigation Proceeds Received
D 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
2. Supplemental Return
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4a. Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10 Spousal PovertY Credit (date of death between
. 12-31-91 and 1-1-95)
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NAME
Jerry A. Weigle, Esquire
FIRM NAME (If applicable)
Weigle & Associates, P.C.
TELEPHONE NUMBER
717/532-7388
COMPLETE MAILING ADDRESS
126 East King Street
Shippensburg, PA 17257
r"-.,)
(1 ) None
(2) 1,238.14
(3) None
(4) None
(5) 38,022.86
(6) None
(7) 35,441.42
(8)
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)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L) D Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
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74,702.42
(9)
(10)
9,105.30
3,465.14
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
(11)
12,570.44
62,131.98
0.00
12. Net Value of Estate (Line 8 minus Line 11)
(12)
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)
(13)
(14)
62,131.98
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, 0.00 x .00 (15)
z or transfers under Sec. 9116(a)(1.2)
0
j:: 16. Amount of Line 14 taxable at lineal rate 13,345.28 x .045 (16)
~
::;)
Q. 17.Amount of Line 14 taxable at sibling rate 0.00 x .12 (17)
:E
0
0 18. Amount of Line 14 taxable at collateral rate 48,786.70 .15 (18)
>< x
~ 19. Tax Due
(19)
0.00
600.54
0.00
7,318.01
7,918.55
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Copyright 2002 form software only The Lackner Group, Inc.
Form REV.1500 EX (Rev. 6-00:
Decedent's Complete Address:
STREET ADDRESS
307 North Fayette Street
CITY Shippensburg
ISTATE PA
I ZIP 17257
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
7,918.55
0.00
Total Credits (A + B + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty (0 + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 1 line 20 to request a refund
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. (5B)
7,918.55
7,918.55
Make Check Payable to: REGISTER OF WILLS, AGENT
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;.................................................................................. 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
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 dedare 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. Oedaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Sam I S. Zem n
DATE
307 North Fayette Street
Shippensburg, PA 17257
J- 5 -(fa
DATE
ADDRESS
ADDRESS
II-IS -0
DATE
126 East King Street
Shippensburg, PA 17257
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. ~9116 (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. ~9116 (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 P.S. ~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. ~9116 (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. ~9116 (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-1503 EX+ (6-98)
,
SCHEDULE B
STOCKS & BONDS
*
C~NWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Eith, Doris E.
FILE NUMBER
21-06-606
ESTATE OF
All property Jolntly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 MetLife - 23 shares, proceeds of sale 1,238.14
TOTAL (Also enter on Line 2, Recapitulation) 1,238.14
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule B (Rev. 6-98)
Rev.15G8 EX+ (6.98)
,
*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Eith, Doris E.
FILE NUMBER
21-06-606
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property Jolntly-owned with the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 Chambers Bridge Residence - refund
VALUE AT DATE
OF DEATH
510.00
2 National Church Residences - refund
13.00
3 New Jersey Natural Gas - refund
3.29
4 Ocean First Checking Account #05008007876
37.467.07
Accrued interest on Item 4 through date of death
29.50
TOTAL (Also enter on Line 5, Recapitulation)
38.022.86
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
Rev-1510 EX+ (6-98)
I
*
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Eith, Doris E.
FILE NUMBER
21-06-606
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM j IUN OF . .._ _." T DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
1 Allianz Life Insurance Annuity #20128500 - 35,441.42 35,441.42
Samuel S. Zeman, beneficiary
TOTAL (Also enter on Line 7, Recapitulation) 35,441.42
(If more space is needed. additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group. Inc.
Form PA-1500 Schedule G (Rev. 6-98)
REV-~151 EX+ (12-99)
..
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Eith, Doris E.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-06-606
ESTATE OF
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
See continuation schedule(s) attached
1,635.80
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
B.
Samuel S. Zeman
Social Security Number{s) I EIN Number of Personal Representative{s):
Street Address 307 North Fayette Street
City Shippensburg State
Year(s) Commission paid
PA
Zip 17257
3,500.00
2.
Attorney's Fees
Weigle & Associates, P .C.
3,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
Register of Wills, Cumberland County
178.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Other Administrative Costs
See continuation schedule(s) attached
291.50
TOTAL (Also enter on line 9, Recapitulation)
9,105.30
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
ReY.~502 EX+ (6-9S)
*'
SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Eith, Doris E.
FILE NUMBER
21-06-606
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Express Mailing to Leber Funeral Home - reimbursement made to Samuel S. Zeman
18.80
2
Leber Funeral Home
1.617.00
Subtotal
1.635.80
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
Rev-1502 EX+ (6-98)
.
*
SCHEDULE H.B7
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Eith, Doris E.
FILE NUMBER
21-06-606
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Cumberland Law Journal - advertising Letters Testamentary
75.00
2
Linda K. Klein - notary fees
15.00
3
News Chronicle - advertising Letters Testamentary
92.75
4
Register of Wills, Cumberland County - filing PA Inheritance Tax Return
15.00
5
Register of Wills, Cumberland County - filing Family Settlement Agreement
75.00
6
Weigle & Associates, P .C. - reimbursement for postage, xerox copies, and long
distance telephone calls
18.75
Subtotal
291.50
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
Rev-1512 EX+ (6.98)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Eith, Doris E.
FILE NUMBER
21-06-606
Include unrelmbursed medica' expenses.
ITEM
NUMBER DESCRIPTION
1 Comcast Cable
VALUE AT DATE
OF DEATH
28.20
2 Cordia Communications
58.84
3 Cordia Communications
0.88
4 Eloise Eith - reimbursement for payment to Merry Maids for cleaning
231.48
5 James E. Rotolo, M.D.
11.81
6 Jersey Central Power & Light
7.94
7 Menno Haven Penn Hall
3.023.58
8 New Jersey Natural Gas
34.85
9 Ocean County Family Care
67.56
TOTAL (Also enter on Line 10, Recapitulation)
3,465.14
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
REV~513 EX+ (9..00) *
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Eith, Doris E. 21-06-606
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List Trustsets)
I. TAXABLE DISTRIBUTIONS [include outright sp,ousal
aistributions, and ransfers
under Sec. 9116(a)(1.2)]
1 Samuel S. Zeman Friend Allianz Annuity 35,441.42
307 North Fayette Street
Shippensburg, PA 17257
2 Eloise and Kenneth Eith Niece 9/18 of residue 13,345.28
288 Vermont Drive
Brick, NJ 08723
3 Richard and Catherine Eith Stepchild 6/18 of residue 8,896.87
16209 SE 178th Street
Renton,VVA 98058
4 VValter and Mary Eith Stepchild 1/18 of residue 1,482.80
25011 129th Place SE
Kent, VVA 98031
5 Linda and Henry Heimink Stepchild 2/18 of residue 2,965.61
18507 East Kansas Place
Aurora, CO 80017
Total 62,131.98
Enter dollar amounts for distributions shown above on lines 5 through 18, as appropnate, 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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 6-98)
../ote: Your Sale Proceeds Check is Attached
OMS NO. 1545-0715
.
.<OKER'S Name, Address, ZIP Code, 2006 Proceeds From Broker and Barter Exchange Transactions
Federalldentificalion Number and Form 1099-8 Instructions for Recipient
Telephone Number: Brokers and barter exchanges must report proceeds from transactions to
Substitute COpy B FOR RECIPIENT you and to the Internal Revenue Service. This form is used to report
Mellon Investor Services -.IMPORTANT TAX INFORMATION..... these proceeds.
480 Washington Blvd. This is important tax Information and is being
Jersey Cily, NJ 07310 furnished to the Internal Revenue Service. If 1a. Date of Sale 1 b. CUSIP Number
you are required to file a re/urn, a negligence 08114/2006 59156R10
22-3367522 penalty or other sanction may be imposed on 2. Stocks, Bonds, etc. 4. FEOERAL INCOME TAX WITHHELD
you if this income is taxable and the IRS
Telephone: 1-800-649-3593 determines that it has not. been reported. $1,238.14 $0.00
TO WHOM PAID REPORTED [iJ Gross Proceeds
TO IRS 0 Gross Proceeds less commission and
options premiums
7. Description
DORIS E EITH METLlFE, INC.
175 CHAMBERS BRIDGE RD APT 125 InlieStor 10 w Recipient's ldentirication Number on File
BRICK NJ 08n3-3501 806485905096 150054473
Box 1a. - Shows the trade date ofthe transaction. For aggre9"ate reporting, no entry will
be present
Box 1b. - For broker transactions, may show the CUSIP (Committee on Uniform Security
identifICation Procedures) number of the item reported.
Box 2. - Shows the proceeds from transactions Involving stocks, bonds, other debt
obligations, commodities, or forward contracts. Losses on forward contracts are shown
in parentheses. This box does not include proceeds from regulated futures contracts.
Report this amount on Schedule 0 (Form 1040), Capital Gains and Losses.
Box 4. - Shows backup withholding. Generally, a paver must backup withhold at
a 28% rate if you did not furnish your taxpayer identification number to the payer.
See Form W-9, Request for Taxpayer IdentiflC8tion Number and CertifICation, for
information on backup withholding. Include this amount on your Income tax
return as tax withheld.
Box 7. - Shows a brief description of the item or service for which the proceeds or
bartering income is being reported. For regulated futures contracts and forward
contracts, -RFC- or other appropriate description may be shown.
~:~k~)imJJ):!:)M:)t~j@j):IM)~!!it~wwii)iM~~~~)~)i)i)~~!~!~~~!~)Wmftt1~W@~ll~m~~~fftJ)~~)~j~~~~f~)Mif~lf1if@~rI1@I~fil~~[~fi$~~~)~~~Jlttfi.tw.~~r@ffimf[w~iii~!W~!wlmrt'ffl@)
For inquiries about your account, contact Mellon Investor Services, MetLife's Transfer Agent:
Telephone: 1-800-649-3593 U.S. Mail:
E-Mail: metlife@melloninvestor.com MetLife
Internet: www.melloninvestor.com/isd c/o Mellon Investor Services
PO Box 444 7
South Hackensack, NJ 07606-2047
YOUR ACCOUNT HAS BEEN CLOSED. THE ATTACHED CHECK REPRESENTS THE FULL VALUE OF YOUR ACCOUNT.
/I IMPORTANT TAX RETURN DOCUMENT ATTACHED II
--------~---------------------------------------------~---------------------._----------------------------------------------------.--
METLIFE, INC.
INVESTOR 10
806485905096
SHARES SOLD
CUSIP
001 92859156R10
OPENING TRUSf INTERESf BALANCE
23.??oo
ACCOUNT KEY
EITH----DORIEOOOO
23.??oo
TAX WITHHELD
NET PROCEEDS
$0.00
$1,238.14
TRANSACTION DATE
08114/2006
CHECK NUMBER
239454
PRICE PER SHARE ($)
53.8322000
CLOSING TRUSf INTERESf BALANCE
SHARES SOLD
CHECK AMOUNT
$1,238.14
00.??oo
Metlif.
PLEASE DETACH BELOW
:1.'I=-'1:1:r'..I:IIII"tI'h"I::iI~..:""''':I'1~n'It1:''1~:.::I:r'"..J:t=-.:J:a:,.ttl:..I=-.:n.."",'I.IItI'h'''::iIn.II.ln.,"..~.'.M.4:'ih;:llt\'.(.4.';;I:IU.f:lt.:l.II,..~w;.1~~~re1i1.I..Mm
60-160
--433-
PO BOX4410
SOUTH HACKENSACK. NJ 07606-2010
100686C 01 AT 0.308 "AUTO T3 2616308723-3501 254 DOMOOOOO101
11I11.1..1.1.111..1.1..11...11..1.1.1111..1111111.1.1.1..11111
PAY TO THE
ORDER OF:
DORIS E EITH
175 CHAMBERS BRIDGE RD APT 125
aRICK NJ 08723-3501
UI 0 0 2 l q L. 5 L.III I: 0 L. II 0 ~ b 0 ~ I:
CHECK DATE
08/17/2006
CHECK NUMBER
239454
PAYABLE AT MELLON BANK N.A. PITTSBURGH, PA.
IN U.S. DOLLARS
I PA V***********-**$1,238.14 I
~~
AUT /ZED SIGNATURE
o ~ ."'0 ~O 1111
..4)CEAN
FIRST
JUl 2 () T -
July 20, 2006
Weigle & Associates, P. C.
Attorneys at Law
126 East King St.
Shippensburg, PA17257-1397
Re: Estate of Doris E. Eith
To Whom It May Concern:
Our records indicate that at the time of Doris E. Eith' s death on April 17, 2006, she was
named on one account held at Ocean First Bank.
Checking account # 05008007876, held individually, in the name of Doris E. Eith, with a
0.0.0. balance of $37,467.07
The account was opened on June 19, 1991. The current balance of the account is
$37,488.87. A total of $21.80 in interest has accrued to the account since Doris's
passing.
We have received the Non-Resident Decedent Affidavit of Domicile, as well as the
closing withdrawal slip signed by Mr. Samuel S. Zeman. However, we require further
documentation before we can close the account, and issue an official check for the
balance of the account.
In order to close the above account we require the following documentation: an original
copy of the Death Certificate, an original copy of the Surrogate's Certificate, a copy of
the Executor's ID, such as a valid driver's license or a valid U.S. Passport. The original
Death Certificate can be returned to you, should you require; however we must witness
an original copy.
Should you have any questions regarding this letter, or require further information, please
contact the Berkeley Branch at (888)-623-2633 ext. 4500.
Sincerely,
r; J ~.
~/~
Andrew Toensmann
Customer Service Representative
Berkeley Branch
OceanFirst Bank · 730 Jamaica Boulevard · Toms River, NJ 08757 · 1 (888) OCEAN33 tel · www.oceanfirst.com
Allianz Life Insurance Company of North America
PO Box 59060
Minneapolis, MN 55459-0060
800/950-1962
Allianz @
May 18,2006
SAMUEL ZEMEN
307 N FA YETIE ST
SHIPPENSBURG, PA 17257
Re: DORIS E EITH, deceased
Policy Number: 6769447
Taxable Amount: $5,441.42
Dear SAMUEL ZEMEN:
Please accept our sincere sympathies and thank you for providing the necessary information to
process your claim.
The net benefit of $35,441.42 has been deposited in a Guaranteed Benefit Account established in
your name with Sta'te Street Bank.
Your Guaranteed Benefit Account is currently earning interest at a rate of 2.50%. You will be
able to access your benefit simply by using your Guaranteed Benefit Account checks. You will
be receiving your checks and a complete packet of information regarding your Guaranteed
Benefit Account from State Street Bank. .
You will be receiving a 1099-R early next year indicating your gross distribution amount and the
taxable amount of $5,441.42.
Information regarding death claim payments is being supplied to the state pursuant to
requirements of the New Jersey Division of Taxation. It is the position of the Division of
Taxation that a beneficiary or beneficiaries may be personally liable for any and all"inheritance
and/or estate taxes until paid. .
Should you have any questions, please do not hesitate to contact your agent or call the Claims
area at (800) 950-1962. Thank you.
Sincerely,
John Witcpalek
Claims Examiner
C: MICHAEL J BONACCOLTA #5122
3509
. ALLlANZ LIFE
. Insurance Services #960
P.O. Box 570
Rockland, MA 02370-0570
Allianz (@
SAMUELZEMEN
307 N FAYETTE ST
SHIPPENSBURG
Page 1
PA 17257-1105
1...111'111111.1.1.1.1...111.1111.111111..1.1.1111.1'111.1..11
20128500
PRIMARY
ACCOUNT NUMBER
5/31/2006
STATEMENT
CLOSING DATE
TAX 10 NO:
BALANCE
LAST STATElvJENT
0.00
NO. I
2 I
CREDITS
TOTAL AMOUNT
35,460.84
NO.
CHECKS AND DEBITS
NO. I TOTAL AMOutlT
2 I 35,460.84
20128500
BALANCE
THIS STATEMENT
0.00
GUARANTEED BENEFIT ACCOUNT
ACCOUNT TRANSACTIONS
DATE. . . . . . . . . . . AMOUNT. . . . . . . . . . . . .BALANCE. . . DESCRIPTION
05/18 35,441.42 35,441.42 DEPOSIT-CASH
154301875
CK# 501
CREDIT-INTEREST
DEBIT-ZERO BAL CLOSE
OS/26
05/31
05/31
35,441. 42-
19.42
19.'42-
0.00
19.42
0.00
RATE HISTORY
DATE. . . . . . . . . . . . RATE
05/18 2.500%
DATE. . . . . . . . . . . . RATE
DATE. . . . . . . . . . . . RATE
****** CURRENT INTEREST RATE
****** INTEREST CREDITED YEAR-TO-DATE
2.500% ******
19.42 ******
SHOULD YOUR ADDRESS CHANGE, PLEASE NOTIFY OUR OFFICE.
PLEASE BE ADVISED THAT IN THE EVENT OF YOUR DEATH THE
ACCOUNT BALANCE WILL BE PAID TO YOUR ESTATE. THANK YOU.
********** END OF STATEMENT **********
NOTICE: See reverse side for reconciliation of this statement and important information. 960-2
...JlI10E: NJ OF INDIVIDUAL TAXES
'NH~RITt '~CE TAX DIVISION
DEF'T. 280601
HARRISj3URG, PA 17128-0601
COMMONWEALTH OF PENN:iYLVANIA
DEPARTMENT OF REVENUE
Rf:(:EIVE{) JAN
JERRY A WEIGLE ESQUIRE
WEIGLE & ASSOCIATES
126 E KING STREET
SHIPPENSBURG PA 17257
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
~T~ OF DEATH
o Ff.1UIt.-t-..!O.
COUNTY
ACN
REV.1547 EX (12-87) PC
01-02.2003
MOHNS LOIS M
11.24.2001
2801-0687
Franklin
101
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
Register of Wills
Franklin County Courthouse
157 Lincoln Way E.
Chambersburg, PA 17201
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
- -REV:1547 Ein06-97fpC - -- n_ - -. -. -- -Notie-E-cfF -INifE RfiANCif TAX Ap.PRAis-EMENt: - "U:'OWANCE- OR- - - - - -.. - - - - - - - - - -- - - - - - - -. - - - --
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
MOHNS LOIS M FILE NO. 2801.Q687 ACN 101 DATE 01.Q2-2003
TAX RETURN WAS: ( 0 ) ACCEPTED AS FILED ( 181 ) CHANGED SEE ATTACHED
RESERVATION CONCERNING FUTURE INTEREST. SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closelv Held Stock/Partnership Interest (Schedule C)
4. MortoaoeslNotes Receivable (Schedule D)
5. Cash/Bank DepOSits! Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 44,979.18
10. Debts/Mortoaoe LiabilitieslLiens (Schedule I) (10) 2.794.05
11. Total Deductions (11) 47.773.23
12. Net Value of Tax Return (12) 231.380.01
13. Charitable/Governmental Beauests: Non-elected 9113 Trusts (Schedule J) (13) 20.231.12
14. Net Value of Estate Subiect to Tax (14) 211.148.89
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16,17 and 18 will reflect figures
that InclUde the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 taxable at Siblino rate
18. Amount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
ESTATE OF
(1 )
(2)
(3)
(4)
(5)
(6)
(7)
0.00
121.693.00
0.00
0.00
157.460.24
0.00
0.00
(8)
NOTE: To Insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
279.153:24
62.787.28
148.361.61
X.OO
X.045
X.12
X .15
(19)
7.534.48
22.254.25
29.788.73
(15)
(16)
(17)
(18)
PAYMENT RECEIPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID (.) AMOUNT PAID
02-19-02 FNOO0830 1,489.44 30,000.00
TOTAL TAX CREDIT 31,489.44
BALANCE OF TAX DUE 1,700.71 CR
. INTEREST 0.00
TOTAL DUE 1,700.71 CR
*
IF PAZD APTER DATE ZHDZCATBD, SBE REVERSE
FOR CALCULATZON OF ADDITZONAL IH'1'ERBST.
(IF TOTAL DUB ZS LESS '1'HAH $1, NO PAYMBN'l' ZS RBQUZRBD.
IF 'l'O'1'AL DUB ZS RBFLBC'l'BD AS A CREDIT (CR) ~ YOU MAY BB DOE
A REFUND. SBE REVERSB SZDB OF 'l'HIS FORK FOR INSTRUCTIONS.)
INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAl TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME
FILE NUMBER
REVIEWED BY
ACN
2801-0687
101
LOIS M MOHNS
J. Paul Dibert
SCHEDULE ITEM
NO.
EXPLANATION OF CHANGES
H
B-1
The deduction for personal representative commissions has been reduced from
$ 20,075.00 to $ 15,000.00. No information was submitte1:l with the return to indicate a
demand for extraordinary services. The Department bases its ruling on the assets filed for
inheritance tax purposes, reasonableness, research and complexity of the estate.
The calculation of the Pennsylvania inheritance tax is adjusted for the following
reasons.
The estate chose to tax the net estate to the surviving sister, Doris E Eith, age 83. The
trust established under Paragraph SECOND of the decedent's Will established a trust for
the benefit of the decedent's sister for her lifetime with a remainder passing to Samuel S
Zeman, age 60, a friend of the decedent or if Mr. Zeman predeceases Ms. Eith, to the
Salvation Army of Chambersburg, PAr a tax exempt organization. Mr. Zeman, the
trustee, has the sole discretion to distribute trust income and principle for the benefit of
Ms. Eith. The use Is limited to Ms. Elth's health, support and maintenance taking Into
account her other available assets and sources of Income.
As the trust is totally discretionary and the estate failed to request a future interest
compromise, the Department is required to tax the trust at the highest tax rate based on
the most logical distribution of the trust Income and principle during the lifetime of Ms.
Elth and upon her death to either Mr. Zeman or the Salvation Army.
Based on the facts known and the ages of the distributes, the Department taxes the trust
as a life estate of income only for the benefit of Ms. Eith with a portion of the remainder
passing to Mr. Zeman based on a 88% probability that he will survive Ms. Eith and a
portion of the remainder pas$lng to the Salvation Army based on a 12% probability that
fl.r. Zeman will predecease Ms. Eith. The tax calculation is as follows:
Net Estate
Life Factor, age 83, 5.0% IRS Table
Life Estate for MS. Eith @ 12%
Remainder interest at death of Ms. Eith $ 168,592.73
Probability the Mr. Zeman will survive Ms. Eith )( .88
Mr. Zeman's share of remainder @ 15%
Salvation Army's share of remainder-tax exempt
$ 231,380.01
)( .27136
$231,380.01
-62.787.28
168,592.73
-148.361.61
$ 20,231.12
ORIGINAL
Page 1
FACTORS FOR A LIFE OR LIVES
Interest Rate: 5.0 %
Age: 83
Payment Frequency: Annual
Life Estate Factor: 0.27136
Remainder Factor: 0.72864
Annuity Factor: 5.4272
Adjustment Factor: 1.0000
Adjusted Annuity: 5.4272
PROBABILITY X WILL SURVIVE Y
Age X:
Age Y:
Probability:
60
83
0.88023
"'.
, ..
JJll ~~p ~DtV of ~ob, ~mn
DORIS E. EITH
I, DORIS E. EITH, residing at 175 Chambersbridge Road, Apt. #125, in the Township of
Brick, County of Ocean and State of New Jersey, being of sound and disposing mind, memory
and understanding do hereby make, publish and declare this to be my Last Will and Testament
in manner and form following, that is to say:
FIRST:
do hereby cancel, annul and revoke any and all former Wills and
Codicils made by me.
SECOND:
I order and direct my Co-Executors, hereinafter named, to pay all of my
just debts, funeral and testamentary expenses out of the residuary of my estate as soon after
my death as conveniently can be done.
THIRD:
I do hereby give, devise and bequeath all of the rest, residue and
remainder of my estate, real and personal, of whatsoever kind and wheresoever situate, to be
divided as follows:
A. One-half to my niece, ELOISE EITH, and her husband, KENNETH EITH,
or the survivor of them. In the event that both Eloise Eith and Kenneth Eith shall have
predeceased me, this bequest shall lapse and be divided among the remaining residuary
beneficiaries, proportionate to the ratio which each surviving beneficiary's bequest bears to the
bequests of the remaining surviving beneficiaries.
B. The remaining one-half of my estate shall be divided as follows:
1) Two-thirds of such remaining one-half of my estate shall be
distributed to my step-son, RICHARD EITH, and his wife, CATHERINE EITH, or the survivor of
them. In the event that both Richard Eith and Catherine Eith shall have predeceased me, then
this bequest shall lapse and be divided among the remaining residuary beneficiaries,
.
proportionate to the ratio which each surviving beneficiary's bequest bears to the bequests of
the remaining surviving beneficiaries.
2) One-third of such remaining one-half of my estate shall be divided
as follows:
-".
(a) Two-thirds to my step-daughter, LINDA HEIMINK, and her
husband, HENRY HEIMINK, or the survivor of them. In the event that both Linda Heimink and
Henry Heimink shall have predeceased me, this bequest shall lapse and be divided among the
remaining residuary beneficiaries, proportionate to the ratio which each surviving beneficiary's
bequest bears to the bequests of the remaining surviving beneficiaries.
(b) One-third to my step-son, -WALTER EITH, and his wife,
MARY EITH, or the survivor of them. In the event that both Walter Eith and Mary Eith shall
have predeceased me, then this bequest shall lapse and be divided among the remaining
residuary beneficiaries, proportionate to the ratio which each surviving beneficiary's bequest
bears to the bequests of the remaining surviving beneficiaries.
FOURTH:
I do hereby nominate, constitute and appoint my niece, ELOISE EITH,
and SAMUEL ZEMAN, or the survivor of them, as Co-Executors of this my Last Will and
Testament.
FIFTH:
I direct that no bond shall be required of my Co-Executors in the State of
New Jersey or in any other jurisdiction.
IN WITNESS, WHEREOF, I, DORIS E. EITH, the Testatrix, sign my name to this
instrument this cJtR.J4, day of NiOCJtMlJir, 2002, and being duly sworn, do hereby
declare to the undersigned authority that I sign and execute this instrument as my Last Will and
that I sign it willingly (or willingly direct another to sign for me), that I execute it as my free and
voluntary act for the purposes therein expressed, and that I am eighteen (18) years of age or
older, of sound mind and under no constraint or undue influence.
l) J~J::
~ ~ ~-.fo-..A--M.-/ L.s.
DORIS E. EITH
We, the undersigned witnesses, sign our names to this instrument, and being duly
sworn, do hereby declare to the undersigned authority that the Testatrix signs and executes this
instrument as her Last Will and that she signs it willingly (or willingly directs another to sign for
2
-~~
~
her), and that each of us, in the presence and hearing of the Testatrix, hereby signs this Will as
witness to the Testatrix's signing, and that to the best of our knowledge the Testatrix is eighteen
(18) years of age or older, of sound mind, and under no constraint or undue influence.
itJg
,
residing at'~~ K:I'-'?f IV 'T t
k ~~-'
(J
residing at ~~ 8-
THE STATE OF NEW JERSEY
COUNTY OF OCEAN
Subscribed, sworn to and acknowledged before me by the aforenamed Testatrix and
subscribed and sworn to before me by the aforenamed Witnesses, this ~ ~ day of
~
,2002.
~~~
ANNE MARIE MOZER
NOTARY PUBUC OF NEW JERSEY
My Commission Expi.res Oct. 26, 2003
winword\pardes\wills\deeith
3