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Home My WebLink About04-07-091505607120 ~ REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN 2 1 0 8 0 0 5 8 9 PO 60X.280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 198 32 7987 02 15 2008 07 19 1918 Decedent's Last Name Suffix Decedent's First Name MI GOTTSHALL MADELINE S (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW X^ 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ qa. Future Interest Compromise ~ 5. Federal Estate Tax Return Required (date of death after 12-12-t32) ^ Decadent Died Testate Decedent Maintained a Living Trust ~ 8. Total Number of Safe De osit Boxes X 8. (Attach Copy of Will) ~ ~' (Attach Copy of Trust) p 9. Litigation Proceeds Received ~ 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 TO: Name Daytime Telephone Number ROBERT CLOFINE ESQUIRE 717 747 5995 Firm Name (If Applicable) First line of address 120 PINE GROVE COMMONS Second line of address City or Post Office YORK State ZIP Code REGISTER OF WILLS US~~ILY ~ r_ n ~ r 1 ~ .~ -~ 1 _ l- / ~ °.- 7~r t ~J~ =n J ~. ~';...~-l~ D}K7~i jILED ~, ~ .. PA 17403-5~~~ Correspondent'se-mail address: rob@estateattorney.COm to ,-, f ~ , _~ I_.h ; ` , - ~7 ~ - ~J _--~ _} -~ 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. Linda G. Mulder "~-(,Q - U ESS Ho ckle Drive, Mechanicsbur , PA 17050 S TUR P PARER ER THAN REPRESENTATIVE D TE Robert Clofine Esquire b 120 Ping Grove Commons, York, PA 17403-5151 Side 1 1505607120 1505607120 1505607220 REV-1500 EX Decedent's Social Security Number oe~eaenrs Name: Madeline S. Gottshall 1 9 8 3 2 7 9 8 7 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. 45,598.56 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5. 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 7. 45,598.56 8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 5,324.62 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 44,925.25 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 5 0, 2 4 9 8 7 11. Total Deductions (total Lines 9& 10) ..................................................................... . 11. -4,651.31 12. Net Value of Estate (Line 8 minus Line 11) ............................................................ . 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................. 13. - 4 , 6 5 1 3 1 14. ....................... Net Value Subject to Tax (Line 12 minus Line 13) ......................... . 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 0 0 15. 0 0 0 (a)(1.2) X .00 16. Amount of Line 14 taxable 0 0 0 16 0 0 0 at lineal rate X .045 . 17. Amount of Line 14 taxable 0 0 0 17 0 . 0 0 at sibling rate X .12 . 18. Amount of Line 14 taxable 0 0 0 18. 0 0 0 at collateral rate X .15 19. Tax Due .................................................................................................................... . 19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505607220 1505607220 REV-1500 EX Page 3 nar•_a_dPnt's Complete Address: Fiie Number 21-08-00589 DECEDENT'S NAME Madeline S. Gottshall STREET ADDRESS 72 Greenspring Drive CITY STATE ZIP Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InterestlPenalty if applicable p. Interest E. Penalty 0.00 Total Credits (A + B + C) (1) 0.00 (2) 0.00 Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 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. q. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT (3) (4) (5) 0.00 (5A) (5B) 0 . ~ 0 ~, =~~ ,. . . 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 :.................................................................................. ^ b. retain the right to designate who shall use the property transferred or its income :.................................... ^ ^x c. retain a reversionary interest; or .................................................................................................................. ^ 0 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? ....................................................................................................................... ^ ^x 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? ...................................................................................................................... ^ ^x 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)]. 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-1508 EX+ (8.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Gottshall, Madeline S. 21-08-00589 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Cash distribution from George Gottshall Estate -balance of elective share 14,035.06 2 M 8~ T Bank checking account #0727 673.31 3 Western-Southern Life Assurance Co. Annuity Contract No. W0020539702 -received 30,890.19 as part of the elective share from the George Gottshall Estate TOTAL (Also enter on Line 5, Recapitulation) I 45,598.56 (If more space is needed, additional pages of the same size) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) REV-1161 EX+i12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Gottshall, Madeline S. 21-08-00589 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Linda G. Mulder Social Security Number(s) / EIN Number of Personal Representative(s): Street Address 18 Honeysuckle Drive city Mechanicsburg state PA zip 17050 Year(s) Commission paid 2, Attorney's Fees Robert Clofine Esquire 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 464.00 2,000.00 2,500.00 4. Probate Fees 127.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 233.62 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 5,324.62 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued FILE NUMBER ESTATE OF Gottshall, Madeline S. 21-08-00589 ITEM DESCRIPTION AMOUNT NUMBER Funeral Expenses 1 Bowersox Funeral Home -funeral expenses and luncheon 464.00 H-A Subtotal 464.00 Other Administrative Costs 2 Cumberland Law Journal -estate advertisement 75.00 3 The Sentinel -estate advertisement 158.62 H-67 Subtotal 233.62 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) I Rev-1612 EX+ (6-98) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Gottshall, Madeline S. LE NUMBER 21-08-00589 Include unrelmbursed medical expenses. (If more space is needed, addltlonal pages or me same slze~ Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1613 EX+ (~-00) SCHEDULE J CDMMNHERITANCE~ AXERETURNANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF Gottshall, Madeline S. NAME AND ADDRESS OF NUMBER PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal I. distributions, and transfers under Sec. 9116(a)(1.2)] Ellen G. Ackerson 8 Kingswood Drive Mechanicsburg, PA 17055 David H. Gottshall 1201 Pleasant Dale Avenue Colonial Heights, VA 23834 Linda G. Mulder 18 Honeysuckle Drive Mechanicsburg, PA 17050 FILE NUMBER 21-08-00589 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT (Words) ($$$) Do Not List Trustee(s) Daughter Son Daughter I I Total 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 ~ u.uu Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) r----~ 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 June 16, 2008 ROBERT CLOFINE, ATTORNEY AT LAW 120 PINE GROVE COMMONS YORK PA 17403 Re: MADELINE GOTTSHALL CIS #: 120163856 SSN: 198-32-7987 Date of Death: 02/15/2008 Dear Mr. Clofine: Please be advised that the Department of Public Welfare maintains a claim in the amount of $205,096.59 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 $24,693.57, 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 $180,403.02, 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. I understand she owned a property at 72 Greeaspring Dr., Mechanicsburg, Pa. She was also to have received an estate settlement from Mr. Gottshall so please be sure to include that information also. Sincerely, ,„ a. ~., Susan A. Spracklen Claims Investigation Agent 717-772-6741 717-772-6553 FAX Enclosure ~~ -i.~~-~. c(o c~ ~e~~o~c~ -~~`~~I ~ ~ ~ ~Sv ~~