HomeMy WebLinkAbout97-0562
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n,. II ( COMMONWEALTH OF PENNSYLVANIA
ljJY"" DEPARTMENT OF REVENUE
DEPT 280601
HARRISBURG PA 17128-0601
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OFFICIAL USE ONLY
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
c how s k
DATE OF BIRTH
SOCIAL SECURITY NUI>4B~R
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DATE OF DEA.r~."
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1 Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6 Jointly Owned Property (Schedule F)
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8 Total Gross Assets (total Lines 1-7)
(IF APPLlCABlEj SURVIVING SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INITIAL)
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
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00 1. Original Return 0 2. Supplemental Return 0 3 Remainder Return (date of de.ltl pnor to 12-13-82)
o 4. Limited Estate 0 4a. Future Interest Compromise (date of dealtl affer 12-12-82) 0 5 Federal Estate Tax Return ReqUired
!Xl 6. Decedent Died Testate (Mach copy of Will) 0 7. Decedent Maintained a Living Trust (Mach copy ofTrust) .Q.. 8. Total Number of Safe DepOSit Boxes
o 9. litigation Proceeds Received 0 10 Spousal Poverty Credit (date of death between 12-31-91 and 1-1.95) 0 11 Election to tax under Sec. 9113(A) (Attach Soh o)
TtiiSSEtttiOi\fMust:ae:OOMPWEbiAtLtiORRE:S:6NDEiiiCitAN:tttoNRDENTtAt/tAJfiNFORMAti6tifSfiOOlDBEDfREC:'l$OtO;<<
NAME COMPLETE MAILING ADDRESS
Richard C. Snelbaker Es uire
FIRM NAME (If Appicable)
Snelbaker Brenneman & S are P.C. 44 West Main Street
TELEPHONE NUMBER
717-697 -8528 Mechanicsbu P A 17055
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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)
14 Net Value Subject to Tax (Line 12 minus Line 13)
15 Amount of line 14 taxable
at the spousal tax rate
See instructions on
16 Amount of line 14 taxable
at 6% rate
17. Amount of line 14 taxable
at 15% rate
9 Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11 Total Deductions (total Lines 9 & 10)
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18 Tax Due
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OFFICIAL USE ONLY
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PA 17055
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE B
STOCKS & BONDS
ESTATE OF
Dmochowski Helen J
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
FILE NUMBER
21 97
0562
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
7,256.25
International Diary Queen, Inc.
300 shares common stock @ $24.1875
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
7 256.25
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
Dmochowski Helen J
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
FILE NUMBER
21 97
0562
ITEM
NUMBER
1.
DESCRIPTION
Mortgage/Bond Note, agreement dated 5/13/1994 with Cheryl M. Dmochowski-Zeigler,
balance owing at date of death
VALUE AT DATE
OF DEATH
331,032.28
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
331 032.28
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Dmochowski. Helen J
FILE NUMBER
21 97
0562
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
Dauphin Deposit Bank and Trust Company, checking account #28691253
VALUE AT DATE
OF DEATH
4,390.39
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
4 390.39
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER.VlVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
ESTATE OF
Dmochowski Helen J
0562
FILE NUMBER
21 97
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.
DESCRIPTION OF PROPERTY '10 OF
ITEM INCLUDE THe NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO OECEOENT ANO THE OATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
NUMBER ATTACH A COPY OF THE OEED FOR REAL ESTATE. VALUE OF ASSET INTEREST
QF APPLICABLE)
1. Travelers Insurance Companies, IRA Annuity Contract 38,613.73 100. 38,613.73
#028874-8033050.
TOTAL (Also enter on line 7, Recapitulation) $ 38613.73
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(If more space IS needed, Insert additional sheets of the same sIZe)
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COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIOENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
ESTATE OF
Dmochowski Helen J
21
97
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
1
2
3
B.
1.
2.
3.
4.
5.
6.
7.
8
9
DESCRIPTION
FUNERAL EXPENSES:
Myers Funeral Home, funeral services
Diocease of Harrisburg, cemetary plot
Cheryl Dmochowski-Zeigler, reimbursement for funeral expenses
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Year(s) Commission Paid
Attorney Fees Snelbaker, Brenneman & Spare, P.C., Richard C. Snelbaker
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
Probate Fees Register of Wills, Cumberland County
Accountant's Fees
T ax Return Preparer's Fees
Register of Wills, filing fee, this return
Cumberland Law Journal, advertising Executrices notice
The Patriot-News, advertising Executrices notice
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
0562
AMOUNT
8,259.00
610.00
615.25
5,000.00
255.00
15.00
60.00
214.18
15.028.43
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
Dmochowski Helen J.
FILE NUMBER
21
97
0562
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
176,409.74
1.
Dauphin Deposit Bank and Trust Company, commercial loan #0100101234479002
2
Internist of Central PA, medical services
3.16
3
PA Department of Revenue, 1996 taxes
336.00
4
PA Department of Revenue, interest on extension filed for 1996 taxes
77.07
5
DQ Moe, Inc., health insurance premium
2,153.10
6
Messiah Village, resident billing
5,098.69
7
Pinnacle Health Services, medical services
40.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
184 117.76
REV-1513 EX + (1-97)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
. Hp.lp.n ,I ?1 Cl7 056?
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)
1. Karen J Sipe Daughter 50% of residue
225 Cold Springs Road
Gettysburg, PA 17325
2 Cheryl Dmochowski-Zeigler Daughter 50% of residue
184 Gold Lane
Grantville, PA 17028
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, 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. NONE 0.00
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1. NONE 0.00
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEE I $ 0.00
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(If more space IS needed, Insert additional sheets of the same sIZe)
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LAW OFFICES
SNELBAKER.
McCALEB Be ELICKER
LAST WILL AND TESTAMENT
I, HELEN J. DMOCHOWSKI, of the Township of Hampden, County of Cumberland
and Commonwealth of Pennsylvania, being of sound and disposing mind, memory and
understanding, do make, publish and declare this as and for my Last Will and
Testament, hereby revoking and making void all former wills and codicils by me
at any time heretofore made.
FIRST. I order and direct that all my just debts and funeral expenses be
paid by my Executor or Executrices, as the case may be, hereinafter named, as
soon as conveniently may be done after my decease.
SECOND. I give, devise and bequeath all the rest, residue and remainder
of my Estate, real, personal and mixed, whatsoever and wheresoever situated,
unto my husband, LUCIAN F. DMOCHOWSKI, absolutely and in fee simple, if he
survives me by as many as sixty (60) days.
THIRD. If my husband, LUCIAN J. DMOCHOWSKI, does not survive me by as
1
many as sixty (60) days, then and in that event, I give, devise and bequeath
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all the rest, residue and remainder of my Estate, real, personal and mixed,
whatsoever and wheresoever situated, in equal shares unto my two daughters,
namely, KAREN J. SIPE and CHERYL M. DMOCHOWSKI, share and share alike, abso1utel
and in fee simple.
If either of my said daughters should predecease me and leave issue to
survive me, I order and direct that the share of such deceased daughter shall
be distributed unto her issue per stirpes by representation and not per capita,
subject, however to the provisions of Item Fourth hereinbelow.
If either of my said daughters should predecease me without leaving issue
to survive me, then and only in that event, I order and direct that the share
or such deceased daughter shall be distributed unto my remaining living daughter
or if neither daughter survies me, then to the issue of either daughter.
FOURTH. I order and direct that the distributive share of any beneficiary
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under the age of twenty-two (22) years at said time of distribution shall be
delivered and paid over to DAUPHIN DEPOSIT BANK AND TRUST CO}WANY of Harrisburg,
Pennsylvania, my testamentary trustee, IN TRUST, NEVERTHELESS, to hold, manage,
invest and reinvest for the use and benefit of each such beneficiary (in sepa-
rate trusts), said Trustee to have discretionary power and authority to use and
apply from time to time such amounts of both principal and income as sald
Trustee shall deem necessary and proper for the beneficiary's support, care and
education (including post - high school education of either academic or voca-
tional disciplines); and upon the respective beneficiary's attainment of age
twenty-two (22) years, larder and direct said Trustee to terminate the trust
and pay over to the beneficiary the then remaining net balance of said trust,
if any, absolutely.
LASTLY. I nominate, constitute and appoint my husband, LUCIAN F. DMOCHOWS
to be the Executor of this, my Last Will and Testament, but if for any reason
he should fail to qualify as such Executor or cease so to serve, then and in
that event, I nominate, constitute and appoint my daughters, KAREN J. SIPE and
CHERYL M. DMOCHOWSKI (or either of them in the event that one should fail to
qualify or cease so to serve), to be the Executrices hereof, each and all to
serve without bond or other security as a condition of qualification hereunder.
IN WITNESS WHEREOF, I, HELEN J. DMOCHOWSKI, have hereunto set my hand and
seal to this, my Last Will and Testament which consists of two (2) typewritten
pages to each of which I have affixed my signature this o<~~~ day of
O-./~~ .1/
A.D., One Thousand Nine Hundred Eighty-One (1981).
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LAW OFFICES
SNELBAKER.
McCALEB 6< ELICKER
The preceding instrument, consisting of this and one (1) other typewritten
page, each identified by the signature of the Testatrix, was on the date thereof
signed, sealed, published and declared by HELEN J. DMOCHOWSKI, the Testatrix
therein named, as and for her Last Will and T~S... t, in the presence of us,
ho, at her request, in her presence, and in, e pr enc . each other, have
subscribed our names as witnesses hereto. . - . _ ~
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COMMONWEALTH OF PENNSYLVANIA)
SS.
COUNTY
OF
CUMBERLAND)
We, HELEN J. DMOCHOWSKI, RICHARD D. SNELBAKER and JANET M. FORRY
the Testatrix and the witnesses, respectively, whose names are signed to the
attached or foregoing instrument, being first duly sworn, do hereby declare to
the undersigned authority that the Testatrix signed and executed the instrument
as her Last Will and Testament and that she had signed willingly, and that she
executed it as her free and voluntary act for the purposes therein expressed,
and that each of the witnesses, in the presence and hearing of the Testatrix,
signed the Will as witness and that to the best of his or her knowledge the
Testatrix was at that time eighteen years of age or older, of sound mind and
under no constraint or undue influence.
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Wltness
Subscribed, sworn to and acknowledged before my by HELEN J. DMOCHOWSKI, the
Testatrix, and subscribed and sworn to before me by RICHARD C. SNELBAKER
and JANET M. FORRY witnesses, this 27-;1, day of ~c../
1981.
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Notary Pllblic
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LAW OFFICES
SNELSAKER.
McCALEB a. ELICKER