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HomeMy WebLinkAbout02-27-0915056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes Y•' County Code Year File Number PoBOx2sosol INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 ••~ RESIDENT DECEDENT ~I ~~ ~r~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 209-20-8033 December 27, 2008 March 18, 1915 Decedent's Last Name Suffix Goral (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW _':!' 1. Original Return Decedent's First Name MI Ellen, aka Grace S. G _ ___ Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ~:_".. ; 2. Supplemental Return .,_,;~,,, 3. Remainder Return (date of death prior to 12-13-82) .... 4. Limited Estate ~,__., 4a. Future Interest Compromise (date of ~,,,.,, 5. Federal Estate Tax Return Required death after 12-12-82) _.., 6. Decedent Died Testate ! :` ,y 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) t . 9. Litigation Proceeds Received r.::~ :f 10. Spousal Poverty Credit (date of death _ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED, ALL~CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Andrew C. Sheely, Esquire 717-697-7050 Firm Name QfApplicable) _ _ __ _~ Andrew C. Sheely, Attorney at Law 3 REGISTftR~C7F WILLS U~NLY -.~,, ~__ ~ ..:~ - First line of address i --~, # ~ I'rl ~ C7 CX7 ~ l 127 South Market Street `- T ~, 3 ! LL.- ~ ~ rv , ;`,, Second line of address ~ ~ C - © P.O. Box 95 ~ ( ~~ ~ ~ { a . ~ i -t O _ f't-l City or Post Office State ZIP Code 1 _ ATE FILED ~ ~- ? +_' ~ i Mechanicsburg ^PA 17055 r.. Correspondent's a-mail address: andrewc.sheely@verizon.net unaer 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 prepares other than the personal representative is based on all information of which prepares has any knowledge. SIGNAT E OF PERSON ES~P~O~~NSIBLE FOR FILING RETURN 11ATF Aflf)RFSS -------...--- -- -- Blaine eHaven, 50 ~ r e, Mechanicsburg, PA 17055 SIG RE OF P AR R EPRESENTATIVE TF RFCC ------ --g' -------- - Andrew C. Sheely, Esquire, 127 S. Market Street, P.O. Box 95, Mechanicsbur PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051.058 J 15056052059 REV-1500 EX Decedent's Social Security Number Ellen G. Goral, aka Grace S.Go ral ':209-20-8033 Decedent's Name: RECAPITULATION 1. Real estate (Schedule A) ........................................... .. 1. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. 5. Cash, Bank De osits & Miscellaneous Personal Pro ert Schedule E P P Y( ) ...... .. 5. ' 10,026.19 6. Jointly Owned Property (Schedule F) ...:.; Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. ' 10,026.19 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 10,803.40 10. 9 9 ( ) .............. Debts of Decedent, Mort a e Liabilities, & Liens Schedule I 10. i .. 159,040.86 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. ' 169,84426 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 0.00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. 14. 1 ( ) ...................... Net Value Sub'ect to Tax Line 12 minus Line 13 ._ . 14. ', .. .. e v . , 0.00 ~. , , . b _,.. .. ........ ..... __ .. . a _, TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES . _ . 15. Amount of Line 14 taxable at the spousal tax rate, or transfers unc+~~ sec. 9116 (a)(1.2) X .0 15. 16. Amount of Line 14 +~~~ble 0 00' 0 00 . at lineal rate X .015 16 . 17. Amount of Line 14 taxable . _. at sibling rate X ,12 ! 17. 18. Amount of dine 14 taxable at collateral rate X .15 18. 0.00 19. TAX DUE ...................................................... ...19.' _ _ _. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~Q a ~ 15056052059 Side 2 15056052059 REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Ellen G. Goral, aka Grace S. GOral DECEDENT'S SOCIAL SECURITY NUMBER 209-20-8033 STREET ADDRESS 801 North Hanover Street CITY STATE ZIP Carlisle ~ PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 0.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable D. Interest __ E. Penalty Total InterestlPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. - Fill in oval on Page 2, 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) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 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 :.......................................................................................... ^ 0 b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ ^x c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. ^ ^X 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN 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 three (3) percent [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 zero (0) percent [72 P.S. §9116 (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 zero (0) percent [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 four and one-half (4.5) percent, 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 twelve (12) percent (72 P.S. §9116(a)(1.3)]. Asibling 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-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDVLE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY TART ESTATE OF „~ Ellen G. Goral, aka Grace S. Goral 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 NUMBER DESCRIPTION 1. PNC Bank Irrevocable Burial Reserve -Account #31900260234 2. I PNC Bank Irrevocable Burial Reserve -Account #31500260583 3. ~ PNC Bank Checking Account #5080520673 4. ~ Decedent was a long term resident of the Church of God Home and owned no personal property. FILE NUMBER 09- VALUE AT DATE OF DEATH TOTAL (Also enter on line 5, Recapitulation) $ _ (If more space is needed, insert additional sheets of the same size) i - Return to tap ~f page..: $ 5,008.44 $ 1,162.90 $ 3, 854.85 0.00 10,026.19 . ~zb. 4. 2009 3,05PM PNC BANK 412-705-2747 ~~ G ~~ t.~i~o ~H~ w~-rr February 4, 2009 Andrew Shealy Attorney at Law RE: E Grace Croral SSN: 209-20-$033 DOD: 12-27-2008 Dear Mr. Shealy: No. 7784 P. 1 In response to yowr :request for Date of Death (DOD) balances for the customer noted above, our records show the following: Certificate of Deposit Account # 31400260234 Established; 04-13-2005 E GRACE GQRAJ. SHAFFER FUNERAL HOME IRREV BURIAL RESERVE DOD balance: $ 5,000.00 + 8.44 accrued interest Account # 31500260583 E GRACE CORAL SHAFFER FUNERAL HQME IRREV BURIAL RESERVE DOD balance: $ 1,159,11 + 3.79 accrued interest CLeching Account Account # 5080520673 E GRACE CORAL DOD balance: $ 3,854.85 non interes# beaaxzzg Established; 04-29-2005 Established: 02-23-1996 Page 1 of 2 REV-1511 EX+ (72-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ellen G. Goral, aka Grace S. Goral ITEM (UMBER A. FUNERAL EXPENSES: t' Schaeffer Funeral Home 2. Funeral Luncheon Reimbursement 3. Burial clothing (dress) B. 1 2. 3. 4 5. 6. 7 SCNEDt~LE N FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reported on Schedule I. DESCRIPTION $9,577.00 900.12 76.28 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Blaine DeHaVen Social Security Number(s)IEIN Number of Personal Representative(s) Street Address 508 Miller Avenue city Mechanicsburg state PA Year(s) Commission Paid: Attorney Fees Andrew C. Sheely, Esquire Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees zip 17055 _ Zip 25o.oa TOTAL (Also enter on line 9, Recapitulation) I $ 10,803.40 (If more space is needed, insert additional sheets of the same size) 01-05-2009 12:31 PRGEl TELEPHONE (61 D1 377.1020 FAX 1810) 37T-7P106 ~" •"' ~~ SCHAEFFER FUNERAL HOME CORFV A. SCHAEFFER, F.D. THIRD AND ALUM STREETS LEHIGHTDN. PENNSYLVANIA 1$236 Itf %~ STATEMENT OF FUNERAL GODS AND SERVICES SELECTED (~hXrI+CX am Ollly fOr QInXtl 'tttatta Illat yntl xelecl 1n' Ihal aR rtayuiral. If svr are nx(uinal by law nr by x ulytutcry nr cnlutelory W tun any ilctne. Wu will explain Ihe: rcaumE ilt writing bclnw. If you Xrlutltnll a funcn,l Qlxt Inay trgulrc t.'„drxhrno~, Xuch aX X lixiurn) with vir>tain~;, you luny have N lacy fi,r ombahnlr,~t Yuu du nal lour In lay fnr c,nlwlmixR you did nut ul,prove if ynu xr erlexl arfztnSurrrnlx xuch as a diraa ~~rcmalMn nr utrmaiiattl but'lol. If cllurgcd fnr rnthxhnirrlr, we w/ill caplnin why t+clnw. For the Xcrvicn ul't ~P~ r' C C , 'rL: + _, _- DxW of Dctlth ~ ~uv~ ~? 1W ~ .._ Dulc of Burud ~'!~M ~ db _ ~. A. PROFB8810NAL 8~lVIC13S1 SBLEL"f'FD: lu G. SPHCIAL CHAROB9: Non•da:liwNlllc Scrvilxx ul' Ttutcrnl Diralur xlxl Stuff„$ ~~_ Transfer of Rcmvhtx to rultoml Haltn.•....•. .- _•••••• S~ rrl :................................................... S L'mhnlmi w Other Prnpamdon ol'tiw &tdy ,~ ................. ... ... S,~yr~'.•,, B. PACIWT[BS AND RHLAT6D STAFF CFiARG}IS: SltahcrufRln,veiny.....,,,...,,......,......,, ..... _.... _ $ Uw of Facilillce alal Stuff SCrvICCA for Vio-w(n!: ,..,,,,. $W hllncral xl Ftwtility ur fkhur k.e>vrtirm R. Stull' SavicrX SJoD `~ Mcmnrittl Sorvicc nl 1"tlcilily nr Onc~r L,u:atinn nett SUQ Suroiccx.. ~ ...................................... $ Gravtuitla Nqui,tncnl +nrd SWff5crvicrx ........... .......5~~ RcfriRcfation u~ Unanbxhutld RcmainX ................. ••. S_. I°urwnrdinK ul' Retnainx 'fv: Rex:erivinF of RpnxinX I'mm: tl'rowr.l Ilm,d TOTAL SPHCIAL CHAROBS ..............................5 O C. AUTOMlYI7V8 I1QU[PMENT: (laud 5crv' Mi]cR) FI. SCHAHPPOt PLANS: Fmtcml Cnlsh ............. .:... ~cc 251. S ,! S'~" Ale packxgu4 funornl YcrvictlX which xro pnrw~l ItlXX Qiatt Ihcir adal L.imoue)note) ............................................... ~ S ..f individlwl curni,uncnis 1'nmt our ~nnrral prior lint. Olltrr AutomoUvo Pyuipotcrn ........................... .. $ D. MERCHANDISE 9EI.EC'fHD: rv ~'W 3 Ctsxhct ........................................... .............. (Dttacriplitml P'fih t ate. ...........:-.. , .......... ial onUril fl O v __ DfJ~'x' $ { ........... uv ulcr ~ ~- ~ ` Bttrinl $ S f:rmnation Urn .........................,..................... _ (IksacripQonf •- AcknowlodRcrtt~uniX ............ ....................... ~ A)lL Rclt(alX:r Blink ...................... ....._................... T~ E. ADDTI'IONAL Pl'tillviS: i? Miicagc btrylrad Zi milt: nrdiun ~)Sl,~hnilo.....,,,.... $ I (~.~ 1,uul, CtcrRy or pmnily Sateen ........................... . AdJilionnl l.iumUaila: (Allar3 Hnun,) ......... .......... $ Notary 4crviuv Pcc ........................................... S _ S Fxx Mcehhtc ...................................._.........., S 1111IF,uuranttr ........................ ............................ Mclnorial Fuhll;ra/l'mycr Can1x .......................... , S~J(,,_ Cnu!il'ix (Inlctivo ExtcrivrT ............................... . ...... Caao Ai 'I' f S S . ................... ... .......... w nnn r Tmunta/Infcelivtm Diacalw (:aXn .. ..................... -_. S Shiva Candle ..................................._............. Tianlvtrnry Grave Maltcr.,• ............................... S_ S N1L_ TOTAL tt48RCHANDlBE SEL,BCI'ED ................. S H~_ud F. CASK ADVANCESI Cpnclary Cltar~,tvl ......................._..., ...........,, Ncwapr~tcr NWUV;X .........................................., Tclr)thftnc and Ttllcgralnx .................................. Au qru .............................__......................, . ~~eMua Oft' Srto~mn 5-,,.~.Otltcr 5...~..; .... (~pn~rtil"tnlf Coptea ................... Oitt o - uwrt kwtctal Ditr:cloy ............................ Florwr-r (InI;LPA Satca Tnx)...... _ ....................... Wn charge you lur our xtirviocs Ht nhhliumk: _ 51~`.~`o $ $- - S- - s~~ S $ _~~. $ $ -- 3~ _ $- - f i Trnditiotut! 9rrvicc with VixiGtlion ( ) Trxditiutlal 5croice without VixitaUplt ( 1't'fxdiliunul Sltip-In with Viuiultion ( )'l'radilianxl Sltil~h, wrtlunll ViwW[ittn ( )'I'redir(nnul GmvCXidr with ViXiwtion ( 1'I'n,ditiomd Grnvcxidu wilhOUt Vixilulioa I ) Ship•Irt (4raw:xidr with Vixilutiurt ( ) Ship•In Gntvcxldc wiLlunlt ViviWLiun ( ) Inttnuhxlr Burial ( ) Trtditinnnl Crentotian Sr,vicc with Visitation ( ) Tneslitionnl Cruaution Service without. Vixitatlon ( ) Tmditiunul Mcnvmxl Srroitt with ViSilnlien ( ) Tnldililnla) Mumnrwl SCrvltx: wtilhout Vlsilatibrt f ) C:mnmlion, 1'riwelr Vicwinr, Grnviceirlc Sn,v'icc ( ) Crumatinn with PrivaR: Family Vitnviag { 1 l:ronwlion wish Gmvcxi+lr Srtvice I ) Dipu'1 (7n:maficnt TIYl'AL SP.RVICFdl SHL,ECTHD ...........................5 ~Sq~•''t' Tlln punhxXrr huX I+aYivai a fTG Dlrchlaure/Dlsclaimnr Pone. 'I he initinlx in the M,x kr the left aro of Qtr pctetm whn nxuivul the aMrvc ntutlionod fnmt. It' any htw, cutnclcry, ur emrnntnry fcyuircmcnla hour rcquiral Qte purehoac of any of the i1cmX lixtal, the law rlr raquuirolru:nt h cxplainaf hcluw~ _~~.v„eir-„t fZ~rj~'ilt u5 d~ t:. .. 'J~ew.l~.4 - _ _ RuuXtut for Entlrehrxng;_ t7AMt1 ,y,!n~C~ za'77~Jw! TOTAL S&IIVICES, MERCHANDISE, areti CASK ADVANCES ......................................................................... ..S • S~ Un Pail at ur prior to arrnnfK:mcnlX, <.r idhcr Cll•Ji1x ...................................................................................... S f3Af.ANCE DUE ................................................ ...................................................................... the balance con Ihla IuwuunL 11tia ra x club ltunaacnon: Tltr umll:rxiFncd jnimly xuJ luavrrally xgnx tll pay SCflA6PPER FUNBitAL HOME ~.~~• .......5 , tRtltae Ilu n>i,NrmXi,ltl ur ul:lrcd value ,+1' such adtiirinnnl survict:a, itullrnxlX, vrxl raXh aQvanuX ter Ina ' ht: hlrnishcll by SCHABFMI®t FUNIDWI. tlOlt~B. $lleh pxylnnnl Rlellll BC 111adC WIQIUI lltlrty dayN Inns dldc of the funeral anlvicca. A 1XIe lX.~nnlty el 1 112 9'e per mnnlh (187X per year) will be xaXtlsXixl nn the unpaid tatla»cr fnr maWrials and Xr[vieca. DiSCL.AIMfiR l]P WAARANTSHS BCNABFFBR f?C]N~tAL HOMH MAffEB NO WARRAN'PifsS OR RHPRL?$RNTATIONS GUNC13RFfINC TNB PRODUCT51 SOLD HfIREfN. THB ONLY WARfitANTfES, EKPRg89ED OR DNPLIItD. GRANTED fN t'UNNHCTION WtTll THE PR(.)DUCTS SOLD WITH PUNHRAL SI~VICB, ARE THli H:XPRFBSED WRl7TBN WARRAM'fIIS, 1F ANY. EXTENDED BY THf3 MANUFAC7'URIDlB T1116R130F. THB SCHAEFFER PUN&RAL HOME HERJ3N~r EXPRESSLY D18CLA1MS Ai.l. WARRANTIES, EXPRHSSED OR aKPL18D, RHLATING TO ALL SUCH PRADUCTS, INCLUDING, BU1' NtYI' L[M1TED TA, THB IMPLIRD WARRANI'IB4 OF MHRCHANTABILyf'Y AND Pf['IYP.SS FUR A PARTICULAR PURPOSE, l1Wr, IhC~Untk-nyig~noid, acktmwlalge that the forc~ning Xuemnlcul has I,crn rrud to mclus mul 1/wc Ix:n:by auknnwhxl~e m)6ilx of compl,tle:d copy. (RucbXw:r) iAtldrc«s) _. (AILlreXXl f.-- SL'FIAEFFfsR FU ~ ~` usre ..f~~~T cif _ ~1~i~ _ J 4lpnnnm. of fund mvXA REV-1512 EX+ (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT] INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE t7F FII F NIIMRFR Ellen G. Goral, aka Grace S. Goral Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. Pennsylvania Department of Welfare Class 3 claim $19,145.62 2. Pennsylvania Department of Welfare Class 6 claim 137,846.60 3. Reversal of Black Lung Payment paid after date of death from decedent's PNC account (Schedule E) 599.00 4. Reversal of Social Security Payment paid after date of death from decedent's PNC account (Schedule E) 769.00 5. Reversal of PPG Retirement Payment paid after date of death from decedent's PNC account (Schedule E) 95.85 6. Reversal of Railroad Retirement Payment paid after date of death from decedent's PNC acct. (Schedule E) 584.79 TOTAL (Also enter on line 10, Recapitulation) a I 159,040.86 (If more space is needed, insert additional sheets of the same size) GONMAONWEALTh10f PENNSYLVANIA DEPARTMENT OF PUBLIG WEI.FARF. BUREAU OF FINANGIA! DPERATIONS DIVISION OF ThIIRD PARTY LIA8161TY ESTATE RECOVERY PROGRAM PO BDX 8A86 4iARRISSURC3, PA 17105.548E January 12, 2009 ANDREW C SHEFl1Y ESQUTRE 12.7 SOUTH MAh:<ET ST P 0 BOX 95 MECHANZCSBURC' PA 17055 Re: ELLEN GORAL CTS #: 040173893 SSN: 209-20-8033 Date of Death: 12/27/2008 Dear Attorney Shealy: Please b~ advised that the Department of Public Welfare maintains a claim in the :amount of $156,992.22 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for ~~~Ihich 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 Ac~_ 20-95, effective June 30, 1995. Enclosed is the Department's it~emi~ed stag-went of claim. A portion, of this medical expense, namely $19,145.62, was incurred during the la~~t 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. ~:.S.A. 3392(3). The balance of the claim, namely 413?,846.6Q, is to be entered as a priority Class 6 claim against the estate. Please a.:knowledge receipt of this letter and advise whether the Commonwealth'::. Claim is admitted and when payment may be expected. Tf the estate accoun-ing is complete, please provide a copy. If the estate ooataina real estate, please provide copies of the deed, the latest tax assessor®nt, and a aurr®at appraisal, if available. Sincerely, '' .,G Terri M. Smith Claims Investigation Agent 717-772.-6961 717-7'72-6553 fiAX Enclosure REV-1513 EX+ (9-00) SCNEDIJLE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ellen G. Goral, aka Grace S. Goral 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. Leonard Blaine DeHaven, 508 Miller Avenue, Mechanicsburg, PA 17055 Son Rest,Residue of Estate 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 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)