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Home My WebLink About08-16-1015056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN 21 06 0700 Po sox zsosol RESIDENT DECEDENT Hanisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Date of Birth Social Security Number Date of Death 164-30-2995 05/0712005 10/18/1937 Suffix Decedent's First Name MI Decedent's Last Name R Sr. Carl Gelbaugh (If Applicable) Enter Surviving Spouse's Information Be low Suffix Spouse's First Name M~ Spouse's Last Name _ Dana Shultz spouse's social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 180-50-7233 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Remainder Return (date of death ° - 3 .-~ 1. Original Return _ 2. Supplemental Return . '"~~ prior to 12-13-82) Future Interest Compromise (date of 4a 5. Federal Estate Tax Return Required . ,. . 4. Limited Estate ` °' death after 12-12-82) Decedent Maintained a Living Trust ~:';~% 7 _ ._ 8. Total Number of Safe Deposit Boxes . ".-; 6. Decedent Died Testate (Attach Copy of Will) (Attach Copy of Trust) nder Sec. 9113(A) 11 ~~~ a ~~ 9. Litigation Proceeds Received '~ ~ 10. be~eenl2-31 91 and 1~1tg5)f death ~" . (Attach Sch ff) E DIRECTED T0: THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIALDAX 10on H F CORRESPONDENT - Numbe e Telep tim Name (717) 238-2000 Gregory M. Feather Firm Name (If Applicable) _ _ REGISTER OF WILLS USE ONLY r~ Handler, Henning & Rosenb«t~ ~ LL P c~ First line of address 0 Z]~' - ~ `y "" 1300 Linglestown Road ~ n G -- Second line of address _ ~-!? ;~ ~~~c1 '~ DATE FI~~~ _*.'1 ~ State ZIP Code City or Post Office _ ~. _ „CJ --~ 17110 PA z~ ~ _ _ Harrisburg i~ c Correspondent's a-mail address: feather@hhrlaW.COm accompanying schedules a cludin i nd statements, and to the best of my knowledge and belief, g n any knowledge. Under penalties of perjury, I deGare that I have examined this return, ct and complete. DeGaration of preparer other than the personal representative is based on all information of which prepare it is true, corre SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE 07/06/10 ADDRESS 15 H ~ n Roa ings, PA 17007 DATE SIGNATU F P R AN RE ENTATIVE 07/06/10 i VF ~ ~. `~ r'i l C-~ N.uvrcc u 130 Lin estown Road, Harrisburg, PPLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J J 15056052059 REV-1500 EX Decedent's Social Security Number Carl R Gelbaugh 164-30-2995 _.~ _ ~. _.e ._ _..e _~.__. Decedent's Name: ~~ RECAPITULATION 1. Real estate (Schedule A) . ............................................ 1. 2. Stocks and Bonds (Schedule B) ...................................... 2. . • 3. Closely Held Corporation, Partnership or Sole-Propnetorship (Schedule C) .... 3. . 4. Mortgages & Notes Receivable (Schedule D) ............................ . 4. 35,970.56 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 ~ Separate Billing Requested....... . 7. (Schedule G) -.b 8 35,970.56 8. Total Gross Assets (total Lines 1-7 ......... • • _...._„ ___ __~.._ . _ _.__ . .. 9. Funeral Expenses & Administrative Costs (Schedule H) ................... 9. . . 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. 35,970.56 12 • • ........ 12. Net Value of Estate (Line 8 minus Line 11) ................. . .. . 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 an election to tax has not been made (Schedule J) ...................... . .. 14 35,970.56 14. Net Value Subject to Tax (Line 12 minus Line 13) ... ... _. .~_~w. ,.~ ..~ . _ _ _ _ _ .~ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or 1 00 0 transfers under Sec. 91 6 35 970.56 . 15. , (a)(1.2) X .0 ~ 16. Amount of Line 14 taxable 16. at lineal rate X .0 - 17. Amount of Line 14 taxable 17 at sibling rate X .12 18. Amount of Line 14 taxable 18 at collateral rate X .15 0.00 ....... ...19. 19. TAX DUE ............................................... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 06 0700 DECEDENT'S SOCIAL SECURITY NUMBER DECEDENT'S NAME 164-30-2995 Carl R Gelbaugh STREET ADDRESS 211 Woods Drive clTv Mechanicsburg Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount ZIP 17050 o.oo 0.00 0.00 0.00 0.00 0.00 0.00 STATE PA (1) Total Credits (A + B + C) (2) 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Fill in oval 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. (5) (5A) A. Enter the interest on the tax due. (5B) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes No 1. Did decedent make a transfer and: 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 : ............................................ ^ 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? .............................................................................................................. ^ 3. Did decedent own an "intrust fcr" or payable upon death bank account or security at his or her death? .............. ^ 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 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 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+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RFGinENT DECEDENT SCNED~ILE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 2106-0700 ESTATE OF Ciera M. Grant Include the proceeds of litigation and the date the proceeds were received by the estate. _ ~.~ _._~. _. _........,..~ti~., m~~af ho diedesed on Schedule F. REV-1513 EX+ (11-OB) ~i` Pennsylvania !!i~'~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ciera M. Grant SCHEDULE 7 BENEFICIARIES NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. ~ Dana Shultz RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Spouse h1Lt ryUMpCK 2208-1099 AMOUNT OR SHARE OF ESTATE 35970.56 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE, II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. 35970.56 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. C c' o G .-- ~CV ~ CV 5 O~ Q z ~~ O ~ U E~4~ ~~~ @ ~_ a ~ v ~ N ~'~i4 ~ N p Q T U zs a~ :~ -~ ., ~,; r`y. j c: ~' U U ~ ~ ° o ~' i'~ M .. ~ _ y ~._ ~ - ~ U ~." ~ = o 'q ~ .~: a, ~ ~;; . Cox _ °' ~ ~ c cn °? ~ U T ; a~ ~ ,.c ai o ..._ G =. c N C _7 O n 2 O+ j Q ~ O J Q J N ` ~ a ,r~~ W v Q ~ p ~ C C > d '~ OI w ~ r'Y NCO ~~ " O Cd _ J D Q ~ ~--1 i„ t~~ •:-t ~~} !') 1':~ s1f .=..p ~~i .r.~ andlar~ aannim rg,ua ATTORNEYS AT LAW August 6, 2010 Register of Wills Dauphin County Dauphin County Courthouse 101 Market St., Room 103 P.O. Box 1295 Harrisburg, PA 17108-1295 Re: Estate of Carl Gelbaugh, Date of Death: File No.: Administratrix-Estate: Vioxx Litigation Dear Sir or Madam: Sr., deceased 5/07/2005 21 06-0700 Dana Shultz Gregory M. Feather Feather cz hhrlaw.com In connection with the above-referenced matter, enclosed are an original and two copies of the Inheritance Tax Return-Resident Decedent, with regard to litigation proceeds. Please file and docket the same and return atime-stamped copy to our office in the enclosed courtesy envelope. Should you have any questions or require anything else regarding this, please do not hesitate to contact me. VE,-,. +.-~ ~Li vni arc H~ B~ GMF/vff/enclosure cc: Dana Shultz 15 Hamilton Rd. Boiling Springs, PA 17007 Handler, Henning 8~ Rosenberg, LLP 1300 Linglestown Road, Harrisburg, PA 17110 Phone: 717-238-2000 "` Fax 717-233-3029 www.hhrlaw.com ~~~ /C~!~ Sandra C. Snyder ~Daupkin County Court .7fouse loom 103 1~gister of Zth'lrs ancC 101 Market Street ::~: C(zrkof Orpkans' Court i t 7farris6urg, RYA 17101-2080 7eG 717-780-6500 somas ~ Gacki, Esquire ~'ax; 717-780-6474 SoCcitor MEMO To: Marjorie A. Wevodau From: Pat Petrun Date: August 9, 2010 Re: Rev 1500 Margie- We received this in error at our office. Would you please process in Cumberland. I thank you in advance. 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