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HomeMy WebLinkAbout12-22-11 (2)r ~ 1505610143 REV-'1 ~QD Ex(o~-~a) •~' OFFlCIAL USE ONLY PA Department of Revenue Pennsylvania C~h+code veer File Number Bureau of Ind tdual Taxes "~"°1eB"'OP1e"°"~ Po Box. ~ INHERITANCE TAX RETURN 21 11 0454 Harrisburg, P 1712&0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 196 38 2701 ~~ 03 23 2011 11 16 1953 Decedent's Last Name Suffot Decedent's Fret Name SHOTSBERGER ', JAMES (If Applicable) Er>ber Survivirt~ Sporse's Information Below Spouse's Last Name Buffet Spouse's First Name Spouse's Social Security Numt}er THIS RETURN MUST BE FILED IN DUPLICATE IMITH THE REGISTER OF WILLS FILL 1N APPROPRIATE OVAL BELOW x^ 1. Original Relum ~ 2. Supplemental Retum ^ 4. Limiked Estate ~', ^ ~' t~ death after 72~2~) ^ g. Deced•rd Died Testate I (AaarJr Copy of tMiq ^ 7. D•c•d•Uto~)a LNirg Tnnt (~~ ~~ 9. Litigation Proceeds Reot~ved ^ 10. ~ ~~~r~~d,~~rdeam 3. Remainder Retum {dale of death MI A MI prior to 12-13-82) 5. Federal Estate Tax Retum Required Q 8. 7ota1 Numtttx of Sate Deposit Boxes 11. Election to tax under Sec. 9113(A) {Attach Bch. O} CORRESPONDENT -THIS SECT MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFlDENnAL TAX NdFpRMATION $IIW1t.D BE DIRECTED TO: ~~ Daytime Teleplrorle Number JAMES D (717) 737 8761 ._, First line of address ', ONE WEST STREET second line of address '~, n REGISTER OF WUSE ONLY; -, . ~ ... :-_. C7 ~ > , i.._. i ,~ f.,~, -_~ `- :,~.- - . - :zi l.> DATE FILED ~-, -; ; .rte __. r7 i.~ ~ { ~;. =•r-~ SBIREMANSTOWN, PA 17011 Comesponderrt's e-mail jbogar~bogarlaw.COm Under penedtlea of perjury. l bdiet. drat I gave examined iFris ~. krdutiHrg acoomparrytrg schedules and statertterros, and tD 7 ~~ ~ ~ ledge~ [ IM it h t d tl f ~ b it rs true. correct and compleM. artna ative on a ar o w ~ preparer atlrer than the personal represen ase ~ c S TURF OF H RESr'ONSI FOR FILNG RETURN DAB Jlutin A. Shotsbe er ls~ 1 9 ~ I RESs 288 Slee Hollow R ~ Nit. Lebanon PA 15238 (,2 Z2~ 1 SIGNATlA2E E.PAR REPRESENTATNE DATE James D. Boger ADDRESS One West Main Stree hiremanstown, PA 17011 swe~ 150511]143 1505110143 J r ~ 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: Shot~berger, James A. 196 38 2701 RECAPITULATION 1. Real Estate (Schedule f~,) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Recleivable (Schedule D) ........................................................ 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 192 , 7$7.19 Schedule F) ^ Separate Billing Requested............ y p ~ O ! 6. 7. ~illiscellaneous I~nq Probate Property os Transfers & Inter Viv (Schedule G) LJ Separate Billing Requested............ 7. 8. Total Gross Assets (to~al Lines 1-7) ..................................................................... 8. 192 , 757.19 9. Funeral Expenses & Addninistrative Costs (Schedule H) ....................................... 9. 33 , 743.77 10. Debts of Decedent, Morkgage Liabilities, & Liens (Schedule I) .............................. 10. 2 , 2 9 9.O 0 11. Total Deductions (totall, Lines 9 & 10) ................................................................... 11. 3 6 , O 42.7 7 12. Net Value of Estate (Li e 8 minus Line 11) .......................................................... 12. 15 6 , 714.4 2 13. Charitable and Govern ental Bequests/Sec 9113 Trusts for which an election to tax has n t been made (Schedule J) ............................................... 13. 14. Net Value Subject to Tex (Line 12 minus Line 13) ............................................... 14. 15 6 , 714.42 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxa le at the spousal tax rate, ~r transfers under Sec. 91 ~ 6 15 O . 0 0 16. Amount of Line 14 taxable 15 6 , 714.4 2 1 s. 7 , 0 52.15 at lineal rate X .045 17. Amount of Line 14 taxable O O O 17 0. 0 0 . at sibling rate X .12 . 18. Amount of Line 14 taxable O O O 18 O. O O . at collateral rate X .15 ' . 19. ......................................................................................... Tax Due ......................... 19. 7 , 052.15 20. FILL IN THE OVAL IF l'OU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 1505610',243 I -- -- 1-- 1505610243 REV-1500 EX Page 3 nPr_erlPnt's C~mnlete Address: File Number 21-11-0454 DECEDENT'S NAME Shotsberger, James A~. STREET ADDRESS 3943 Brookridge Drive I I CITY Mechanicsburg STATE PA ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits (A + B) (2) (1) 7,052.15 0.00 3. Interest 4, If Line 2 is greater than Line 1 + ine 3, enter the difference. This is the OVERPAYMENT. Chec box on Page 2 Line 20 to request a refund (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 7,~J2.~ rrJ ~i I Ma a Check Pa able to: REGISTER OF WILLS AGENT. PLEASE ANSWER TH FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent mak a transfer and: Yes No a. retain the us or income of the property transferred :............................................................................... ^ ^x b. retain the rig t to designate who shall use the property transferred or its income :.................................. ^ x c. retain a reve ionary interest; or ............................................................................................................... x d. receive the romise for life of either payments, benefits or care? ............................................................ x 2. If death occurred fter December 12, 1982, did decedent transfer property within one year of death without receiving adequat consideration? .................................................................................................................... ^ 3. Did decedent own n "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x 4. Did decedent own n Individual Retirement Account, annuity, or other non-probate property which ^ ^ contains a benefici ry designation? .................................................................................................................. IF THE ANSWER TO ANY OF THE BOVE 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, 994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 ( ) (1.1) (i)]. For dates of death on or after Janua 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) ('1.1) (ii)]. The sta ute 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 pplicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 000: • The tax rate imposed on the net v lue of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent o the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net v lue of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §911 (a) (1 )]. . The tax rate imposed on the net v lue of transfers to or for the use of the decedent's siblings is 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 FJ(+ (6-98) COMMONwEA,LTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Shotsbergerj, James A. 21-11-0454 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 Estate of Hilda M. hotsberger -James A. Shotsberger was the sole beneficiary of the Estate 186,797.19 of his mother, Hild M. Shotsberger. The net value of Hilda M. Shotsberger's Estate was $186,797.19. (See ttached Pennsylvania Inheritance Tax Return for the Estate of Hilda M. Shotsberger, same being attached at the end of this Return.) 2 1998 Chevrolet Co ette -VIN # 1G1YY23P9N5116882. Value is per attached Edmonds.com 5,960.00 report. Please not this car is in rough condition. It is not inspected. It has mechanical issues and body d mage. The car is not driveable. A private party sale is assumed as the car cannot be driv n to a dealer for trade-in or sale. I'~ TOTAL (Also enter on Line 5, Recapitulation) I 192,757.19 (If more space is needed, additional pages of the same size) Copyright (c) 2002 farm software onlyThe Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) 1998 Chevrolet Corvette Coupe'Base What Your Canis Worth Page 1 of 'Welcome, Ga°SC..53an In ~~-~` k3o¢-«ah ~n 6u¢tiN 11a.U11s:~ln•rwe ur~c..SB}I KAmu dTWI-Knc ., 31Qn_14> (Cars > Che~rtrl >Cnrvette>.,X$9$ C9'v~tte Coune> Prices wlth_DgYbns> Prirns with OCGOns RtAUE `mug ~ ~@i i 1.3;x. I ~CEwsleticr 11M1RIL. SIO'Lb1if fnPN60FmNT fIARIfF~9g01'U°MT SN11180REOCakTEMf 1}I,RICiT SPO1ITOIR eta°SlapEaCONTENT d Cn ? l t Cnr Htstmv Aeneri. !1 l n NraaHaiv Maur Credi. sr c» I o ffr a ~ ~ htB,YYYr£CF: hd~ IY 1au emus ~~SS wmWrcnnys c fAamCneck the H9h[Veh ron¢r i s .it ~ TakE "}12 L17.i:F1aV.T ' .:~ au: aY narirvl Fc~sira'I.'rtn ~/,aaroclwcK ureweeane.. $CG DO('! nit} m Cxs tlsa! a .~ mxpaRi rg rowi cr"ti_ cmruironer ~ N3 ~ ~' 3 r _ True Ma~.Yatue° BE'F^Y£#i G,hR RE`PLACENiEt1T'° i~ .- .:. .4:. r . . ..ar,. ~.tiear~,_~r.~, ~.. kuri~ iH~>a;= ~~ L~bc~°IY~ ~~atu~_ , ~eaaaau: _.. - .- t. 1998 Chevrolet Corvette Coupe -What Your Car is 1Narth ^°'~""`~"~"~ _, --'~ ~ ~' ' t ~ur rc l a 17'055.3 ~ rc' arg~Cn: wr 1~ °!~~ 'iY' cede' Sonro~ . ~~~ 401if H.chx~labwp,'.~_ ` ~ .. ~~ ._._ ..: ~:. _ -~~_.._...___ _._ ......_ 1 . ~^ Truc Market vnlue•~ ` ~- - .: -_., „„ .. ~~,' ~...-.,.. Trade-in. >i,218~' ~ Tips'.8nd,Advic7e'. "-='' _ ~rivah paRg,Sale S?,960 ~. r,~wsrtterea- 57,112 ~ 10Steosis®uvinaatieCSSaE http://w-ww:edmunds.cpmlche^~roletfc~rvette/i 998/tmv-appzaise-zesults.htnl 12/I 7120 I: l _-__._ ,_ -----, REV-11'1 EX+(10-06) COM IMIOHNERIIANCE TF,gP~ RETURNANIA RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Shotsberger,jJames A. 21-11-0454 Debts of decedent must be reported on Schedule I. ITEM ', DESCRIPTION AMOUNT A. FUNERAL EXPENS S: See continuation schedule(s) attached I B. ADMINISTRATIVE OSTS: 1. Personal Representa five's Commissions Name of Personal R presentative(s) 18,355.27 Street Address City State Zio Yearlsl Commissi n paid 2. Attarnev's Fees ~~, Bogar 8~ Hipp Law Offices ~I 10,500.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationship of laimant to Decedent 4. Probate Fees 163.50 5. Accountant's Fees ~ 6. Tax Return Preparer'$ Fees 7. Other Administrative ~osts 4,725.00 See continuation schedule(s) attached ', TOTAL (Also enter on line 9, Recapitulation) 33,743.77 Copyright (c) 2009 form software only,The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued __--- ESTATE OF FILE NUMBER Shotsberget1, James A. 21-11-0454 i i ITEM NUMBER DESCRIPTION AMOUNT 1 Catholic Cemetery ssociation -Cemetery Fees 10,785.00 I 2 Neill Funeral Home -funeral bill 7,570.27 H-A 18,355.27 3 Cumberland Law J urnal -legal advertisement 75.00 4 Journal Publications -legal advertisement 150.00 5 RESERVES: -Cos to conclude administration of Estate, including filing fees for PA 4,500.00 Inheritance Tax Re urn and Inventory, preparation and filing of past due personal income tax returns and payme t of taxes due and preparation and filing of Fiduciary Income Tax Returns '' H-B7 4,725.00 Copyright (c) 2002 form software only~The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1511 FJ(+ (12-08) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWFJ\LTH OF PENNSYLVANIA INHERIL4NCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Shotsbergert, James A. 21-11-0454 Report debts incurred b the decedent prior to death that remained unpaid at the date of death, including unreimbureed medical expenses. ITEM ! VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Citi Financial - loa payoff 2,299.00 TOTAL (Also enter on Line 10, Recapitulation) I 2,299.00 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only ~'he Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV-15113 EX+(17.08) SCHEDULE J COM INOHNE~ITANCE TAX RET~RLVANIA BENEFICIARIES RE,~IDENT DECEDEN ESTATE OF Shotsber er, J mes A. NUMBER NA E AND ADDRESS OF PERSON( )RECEIVING PROPERTY I~ TAXABLE DISTRIB TIONS [include outright spousal ~ distributions, and transfers under Sec. 9116(a)(1.2)1 FILE NUMBER 21-11-0454 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT (Words) ($$$) n~ Nor i iar T~,~~aw~~ Justin A. Shotsb rger 286 Sleepy Hollo Road Mt. Lebanon, PA 15228 Son ~ ~ Total ~ Enter dollar amounts or distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet, as a ro i NON-TAXABLE DIST IBUTIONS: II. A. SPOUSAL DISTRI UTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE ANa GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENT R TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only he Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) _____ _ - - ,~0 150561U143 ..~_8 REV-1500 Ex`°'_'°' OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE Po Box.2sosol INHERITANCE TAX RETURN 21 10 0559 Harrisburg, PA ,17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMA ION BELOW Social Security (Number Date of Death Date of Birth 196 14 3221 05 11 2010 12 15 1922 Decedent's Last: Name Suffix Decedent's First Name MI SHOTSBERGER II HILDA M (If Applicable) Enter Surviving ~pouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI I~ Souse's Social Securit Numbe(- p y THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER O F WILLS FILL IN APPROPRIATE OVALS (BELOW 1. Original) Retum I~ ~ 2. Supplemental Retum ~ 3. Remainder Return (date of death priorto 12-13-82) 4. Limited Estate ', ~ 4a. Future Interest Compromise death after 12-12-82) (date of ~ 5. Federal Estate Tax Retum Required g Decadent Died Testate (Attach Copy of Will) ~ rr~~ T• (AtlsaatleGOMalof ~rnuest a Living Trust PY ) 0 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Receiv~d ~ 10. beiweeni2 3i~Cand~t~dat~es~f death ~ 11, Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT -THIS SECTIO MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number JAMES D BOGAR I''~, 717 7 3 7 ~,8,~7 61 I ~ rn REGISTER OF E ON~. ~j ~ First line of address ONE WEST MAINISTREET Second line of address ', City or Post Office SHIREMANSTOWN Correspondent's a-mail Under penalties of perjury, I declare t at I have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct apd complete. Decla lion of preparer other than the personal representative Is based on all information of which preparer has any knowledge. I ATURE OF PE O ftESPONSI LE FOR FILING REI UKN UH 1 C rC,~ _ Marv E. Shotsbertaer ~~~/-~-e %/ 3943 Brookrid a Drive echanicsbur PA 17050 SIG U E OF PREQA R OTHER THA REPRESENTATIVE - DATE ~G_W_ Its///J James D. Bogor -~ (Z I + ! ~ . v One West Main Street, ~5hiremanstown, PA Side 1 State ZIP Code PA ~3" ~ t-"~ I-? C/? -- 1..._. ~ c_ ~:_ ~: , Q ©O -r~i _ , - ~`~ C'? ~p -! ~ D- th? ~ .~ DATE FILED ~`' 1505610143 15056117143 150561243 REV-1500 EX Decedent's Social Security Number DecedenPsName: Shotsberger, Hilda M. 196 14 3221 RECAPITULATION 138,587.40 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Sche ~ule B) ............................................................................. 2. 3. Closely Held Corporation Partnership orSole-Proprietorship (Schedule C)......... 3. 4. Mortgayes & Notes Rece ivable (Schedule D) ........................................................ 4. 5• n~ Cash, Bank Deposits & iscellaneous Personal Property (Schedule E) ............... 5. 124,751.54 6. Jointly Owned Property ( ~ chedule F) ^ Separate Billing Requested............ 6. 244.55 7. Inter-Vivos Transfers & IV h d l G scellaneous -Probate Property ~ Se arate Billin Re uested 7 e u e (Sc ) I p g q ............ . g. Total Gross Assets (tota l Lines 1-7) ..................................................................... g, 2 63 , 583.4 9 36,879.74 9. Funeral Expenses & Adm inistrative Costs (Schedule H) ....................................... 9. 30 , 848.53 10. Debts of Decedent, Mort~ age Liabilities, & Liens (Schedule I) .............................. 10. 11. Total Deductions total L ( ines 9 & 10 ................... ) ................................................ 11. 67 , 728 ' 27 12. Net Value of Estate (Lin 8 minus Line 11) .......................................................... 12, 195, 855.22 13. Charitable and Governm ntal BequestslSec 9113 Trusts for which an election to tax has not een made (Schedule J) ............................................... 13. 14. Net Value Subject to Ta (Line 12 minus Line 13) ...............................:............... 14, 195 , 855.22 TAX COMPUTATION - SEE I STRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabl at the spousal tax rate, or transfers under Sec. 911 (a)(1.2) :K .00 15. 16. Amount of Line 14 taxabl 195 855 .22 16. at lineal rate X .045 , 17. Amount of Line 14 taxabl at sibling rate X .12 0 . 0 0 17. 18. Amount of Line 14 taxabl at collateral rate X .15 0 . 0 0 18. 19. Tax Duey .......................... I~'i ...................................................................................... . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 15056102Li3 1505610243 0.00 8,813.48 0.00 0.00 8,813.48 ry t ~ s REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-10-0559 DECEDENT'S NAME Shotsberger, Hilda M. STREET ADDRES~~ 2910 Morningside Drivle CITY Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2', Line 19) 2. Credits/Payments A. Prior Payments B. Discount 9,534.00 440.67 3. Interest 4. If Line 2 is greater than Line 1 + Lie 3, enter the difference. This is the OVERPAYMENT. Check ox 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. Total Credits (A + B) (1) 8,813.48 (2} 9,974.67 (3) (4) 1,161.19 (5) Mak Check Pa able to: REGISTER OF WILLS AGENT. PLEASE ANSWER THE OLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did'. decedent make transfer and: Yes No a. retain the use r income of the property transferred :............................................................................... ^ ^x b. retain the right to designate who shall use the property transferred or its income :.................................. x c. retain a revers ovary interest; or ............................................................................................................... x d. receive the pr mise for life of either payments, benefits or care? ............................................................ x 2. If death occurred aft r December 12, 1982, did decedent transfer property within one year of death without receiving adequate onsideration? .................................................................................................................... ^ 3. Did decedent own a "intrust for" or payable upon death bank account or security at his or her death?....... ^ ^x 4. Did decedent own a Individual Retirement Account, annuity, or other non-probate property which contains a beneficia designation? ................................................................................................................... ^ IF THE ANSWER TO ANY OF THE A OVE 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, 19 4 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 0 percent [72 P.S. §9116 (a) (1.1!) (ii)]. The statut 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 ap licable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 20 0: • The tax rate imposesd on the net valu of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent oft e child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate impose>.d on the net valu of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 () (1)]. . The tax rate imposed on the net valu of transfers to or for the use of the decedent's siblings is 12 percent [7L 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-1502 E~X+ (11.08) ' SCHEDULE A REAL ESTATE COMMONW E4LTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENTDECEDENT ESTATE OF ', FILE NUMBER Shotsber a ~, Hilda M. 21-10-0559 All real property owned solely or a ~ exchanged between a willin a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Rea property which Is jointly-owned with nght of survivorship must be disclosed on schedule F. Attach a copy of the settlement sheet if the property has been sold Include a copy of the deed showing decedent's interest if owned as tenant in common. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Real Estate -All th t certain piece or parcel of land being known and numbered as 2910 138,587.40 Morningside Drive, Camp Hill, Pennsylvania. The property was acquired by Henry Shotsberger and H Ida Shotsberger, his wife, by Deed dated November 30, 1978 and recorded Decembe 1, 1978 in the Cumberland County Recorder of Deed Office in Deed Book "E", Vol. 28, Page 61. A copy of said Deed is attached hereto and incorporated herein. The said Henry Shotsb rger died August 9, 1997, whereupon full and complete title to the within described real esta a became vested solely in Hilda Shotsberger, the Decedent herein. The total assessed val a of this real estate is as follows: County Assessed Value $109,990.00 x Common Level Rat I ~' I I I I ~~ I I ii ~I I II I II I I ~~ on 1.26 = $138,587.40. TOTAL (Also enter on Line 1, Recapitulation) 138,587.40 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only it he Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-.13) Henry Ha II, Inc., Indiana, Pa. P,C~QRDe`u-Or FILE ftF 7RE RECORDER OE GiitUJ ~~ CUl~1fERLd!iD GOL'N?'( FENNsYLa'dh'Is ~QEC ~ ~ Ol f~~'7~ ~ ~ ~, o in the year f % ~ MADE THE ~ y f o f our Lord one thousand ntine hundred seventy -eight I: 19 7 8 ) BETYVEEN THELMA G. GRAHAM, by her Attorneys-in-Fact, Irene G. Critchley and Thelma G. Rathfon, 'duly con~;tituted and acting by virtue of a Power of Attorney dated May 9, 1978, party of the first part, Grantor , and HENRY SHOTSBERGER and HILDA SHOTSBERGER, his wife, parties of the second part, as tenants by t:he entireties, Grantees WITNESSETH, that in consideration of Forty-one Thousand Five Hundred------ ($41,500.00)-------------------------------------------------Dollars, in h¢nd paid, the receipt whereof tis hereby acknowledged, the said grantor does hereby grant and convey to the said grantees,their heirs and assigns, ALL That certain lot or piece of land situated in Lower Allen Township, Cumberland County, Pennsylvania, bounded and described as follows: BEGINNING at an iron pin, said pin being one thousand ninety- five (1095) feet from the northeast corner of Thirty-second Street and Morningside Drive; thence eastwardly along the northern side of Morningside Drive sixty (60) feet to .an iron pin; thence northwardly along the line of property of Paul L. Cressman, Jr. and Thelma M. Cressman, his wife, and others, one hundred fifty (150) feet'to an iron pin; thence westwardly along the line of property of the Pennsylvania Railroad, sixty (60) .feet to an iron pin; thence south- wardly along the line of property of Paul L. Cressman, Jr. and Thelma M. Cressman, his wife, and others, one hundred fifty (150) feet to an iron pin, the place of Beginning. BEING the same premises which Paul L. Cressman, Jr. and Thelma M. Cressman, his wife, .Earl N. Stauffer and Hazel C. Stauffer, his wife, and Lawrence F. McVitty and Claire C. McVitty, his wife, by deed dated April 7,' 1954, recorded in the Cumberland County Recorder's Office in Deed Book S, Vol. 15, Page 73, granted and conveyed unto William H. Graham and Thelma. G. Graham, his wife. The said William H. Graham having died the 22nd day of April 1968, title remains vested in Thelma G. Graham as surviving tenant by the entireties. HAVING THEREON ERECTED a one story brick dwelling house known as 2910 Morningside Drive, Camp Hill. iownzhi of0 .:.......... ..... Cumb. Co., Pa. f~% Real Estata Transfer Tax ~ C Date r. A:. +. .... i_,_ ~2rimb. o. Dist. Col. Agt/Z J -w J~-• . _. School Dist. Cumb. Co., Pa. Real Ezt-7a+e Transfer Tax .y ~ .~~/~ Amt ~C1 ~'~/. Y Date ~ /~/.~ ~ j ,~mb. Co. Dist. Col. Agiz. C~OU~ ~rt~E ~~~ And the said grantor hereby covenants and agrees that the property hereby conveyed. 2oill warrant generally "' COMMONWEALTH OF PENNSYLVAhJ;H DEP.:RTnAENT OF REVENUE _ REALTY ~g pp a _ T~2AhSFER DfCI-'TO f# W 1 ~' ~ ~ _ "'' TAX IN WITNESS WHEREOF, said grantor has hereunto set her hand and seal da d ear fast above written. the y an y ~ e i/ r ---------- ----------. smei. - ,$~xp~, ¢~pg(p~t sxcD ~PLitrYTPa [It f.F~Y ~rpgpIrtE ~ -- -----'"- ah am Thelma G _ G ~ t ~~ ~l ~_- ~~- -_____~ ~ L~~ ~ w chl Irene G. Cri ___ Attorney in Fac ~~ /~I / ~~ , ? ///J 7 BV !(/llflXiW_A: ~S' ~f~.'7 ----- F = ^ ~'~ - .._..•.-. SEIAL -- ---._---__--------------- _._ h on ..__ Thelma G. R a t Attorney-rvin-Fact State Of Pennsylvania ss. County of Cumberland y f , T978 ,before me, On this, the 3 ate`' ~ ° the undersigned o~lcer, personally appeared Irene G. Critchley and Thelma G. Rathfon; Attorneys-in-Fact for Thelma G. Graham known to me (or satisfactorily proven) to be the persons whose names are subs ~b~ed to_,t3?~J' executed same fix urithin instrument, and acknowledged that they ~{~td,~ned, as the act of their principal for the purposes therein contai *ef,,»;:',~;.,-ti,~ IN WITNESS WHEREOF, I hereunto set my hand and o,~eial seal. .;~~';~~,~;.~ ~~; ,;; ., ,^. r .:~,.. •.~ ~„ s- ' ~~~'~~ NQTARY P .. ' ~ , .21 1981 : ?.f~+;;~~_^ 7 ~Qenite9 ~-. J-...... - ~ .~ - • ~mayn~, Pa. Cumberland CaatiS~'itle'~Af ~ (~~'~* w ~ State of ~ ss County of day of , 19 ,before me, On this, the the undersigned o$ceer, personally appeared subscribed to the known to me (or satisfactorily proven) to be the person executednsame for the purposes therein within instrument, and acknowledged that contained. IN WITNESS WHEREOF, I hereunto set my hand and o~eial seal. ~~ --•-----------•---------•------------- s$an Title of Officer. do hereby certify that the precise residence and~ost of.~ce, address <i'`~ o f the within named grantee is ~7-~ / a ~icfY?~--"-- ~ ~' ~ ~~ 17~~/ - _ j Attorney for •`--'- EOtiri `,G''~ FAEE ,36G - --------------------- 1 -- : •`-~------ •ua~~?.~nz ariogro a~rop a~~ ` o p2ros a2~g ~o proa puv puv~ fiat .capon uaaz~ --- - aBgd `--•- -- - ------- •1od ~~~ ~ - .. Moog paaQ ui `ft~uno~ ppvs a~{~ ~o aa~a s,.cap.cooa~ aug up ~67 'Q 'T~ - o,, L :,~~,~ ----•---------------- ~o fcrop~.~: -------------- szz~~ uo Q~Q?I0~'~27 •ss ~~ 5'IA7~6'd7dSt~It~L~d .d0 H ti~~ilt~l 11i0~ ~z xn~~' o ~ ~ ~ ~ ~ ~ ~ moN ~ xx a~nc~ " '^ ~ ~ ~ N r ~ ~x ~ ~ ~~i I ]. ~ a '-~ Z ;7w , ~~ o ~ ` ~ n, ~ w N oy as wwz ~n ;* m ~+ mo .v -' Z C tV „ Rev-1508 E4X+ (6-98) ' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMON WEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OFFILE NUMBER Shotsberger,; Hilda M. 21-10-0559 Include the proceeds of litigation and the date the proceeds were received by the estate. Wells Fargo Advisors, LLC Three Lemoyne Drive Lemoyne, PA 17043 August 19, 2010 JamES D. Bogar Attorney At Law ' One'West Main Stre t Shiremanstown, PA 7011 RE: Estate of Hilda ~. Shotsberger Dear James, Tel 717-761-7344 Fax 717-975-8426 800-468-8685 ~ ni~~r ,~_ ~iD x' „~ ;,x , ~ ~ . i ~~~,Y 1 '~~ ~~ We are responding t your letter requesting information for the estate of Hilda M. Shotsberger. Ms. Shotsberger had on account with us. That account was solely owned. The value of the account on the date of death, May 11, 20 0, was $124,251.54. Please see the attached spreadsheetfor a breakdown by individual security. ~, As discussed earlier,) Russell has retired, so please feel free to contact me directly vrith any more questions. Sincerely, Michael C. McGoi Financial Advisor r, CRPC~ Member FINRA/SIPC C ~ Cn ~ O ~ m -~ m ~ m ~ m ~ -i ~ D ~ O ~ m ~ m ~ z -D z -p ?~ -p m O C Z O Z Q ~ ~ ~ r p r O r z ~ ~ ~ QJ - - ~ ~ D m z m r D m D O D m D c n ~ n ~ D O D ~ D ~ D o n ~ _Z ~ D T ~ ~ ~ r- c' r m m T D -~ -n m y~ ~ , ~ z ~ cn ~ ~ z D r~ m ~ m ~ oo m -D O - ~ c C~ ~ O ~ r c~ = Z D .D ~i -n Z ~ D m O ~ ~ ~ ~ r ~ m ~ C~ cn O ~ cn O D Z D Z -~ ~ z ~ .n v m ~ Cn O ~ O D r- m cn c~ c~ O D -< O r- ~ r! - 0 r 0 r m Cn rn- ~ c~ O m D n Z -i W~ cn ~ O ~ m rn ~ -n Z ii r .~~ z D a rn = m p n = --~ p ~ D '< D r m Z ~ _{ z r- O .O ~ ~ n O D Cn z C!) ~ ~ ' O c m ~ w p ~ m r = - -n -{ ~ D D n O O O D ~? y m C) ~ iT! zt G~ ~ ~ - z C7 m -I m 'O -1 ~ - Ln W C) O m ~ ~ D Z ,~ D r ~ ~ D ~ D ~ '~ ~ n rn ~ = ~ v W m O c ~ ~ D ~ "D r O i m n ~ m r D r- cmi~ cmi~ ~ ~ ~ D D O ~ rn ~ -~ = D D ~ ~ ~ ~ ~ m p C~ c~ ~ ~ 2 Z ~ r O %~ rn ~ c -I -I -i -~ -1 -I Cn (n ~ ~ 'D '0 ~ 'U O Z Z ~ ~ r O r r ~ ~ W - D -I ~ rn r ~ D D D D --~ C~ r n m D ~ -- D D ~ fA C < z~ ~ Z C_ T. --O ,Dn Y ,m~ ~ ~ m ~ ~ m ~ c -~r~ ~ z ~ ~ ~ m ~ o ~ ~ -~ ~ z o N W O O ~. :A N C~ N ~. 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N 00 ~ -T ~ ~I ~I ~ V 0o ~ CJi O -~ ~ .A fT7 Oo -~ O O ~1 ~1 cD O 00 .A V CTS c~ CD ~ -~ fW O .A W c0 N ~ O (~ tD W W W 0 0 0 W -A N (Ji -~ J~ O W O -~ N N .A 00 -~ O O O N N O O W (D V 0o N W W W -~ W 00 O O U1 O CC> W -~ O CJi U't ffl U'i O ~. O N A N Cfl O ~ O 00 N O O O O Ut 00 CJ~ 00 ~ -V.I ~ j OVD ~ N C~Jt ON O COJ~ N ~ W O O ~ W W I J .Rev-1509 EK+ (6-98) ' SCHED~JLE F COMMONWEAL'THOFPENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITMICE TAX RETURN RESIDEIVTDECEDENT ESTATE OF FILE NUMBER :5hotsber er,'Hilda M. 21-10-0559 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. James A. Shlotzberger 3443 Broodridge Drive Son !i Mechanicsburg, PA 17050 B. C. JOINTLY OWNED PROPERTY: DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S VALUE OF DECEDENTS INTEREST NUMBER FOR JOHN MADE NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSE INTEREST TENANT JOINT JOINTLY-HELD REAL ESTATE. 1 A Sovereign Bank -The is a joint account with 489.10 50.000% 244.55 James A. Shotsberger -date of death balance is $489.09; accrued interest $0.01. TOTAL (Also enter on Line 6, Recapitulation) 244.55 (If more space is needed, additional pages of the same size) Copyright (c) 2002 forrn software only he Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-9t".) .=S~overeign° ~ Santander Court Ordered Processing\ Decedents - MA1-MB3-02-]0 - P. O. Box~41005 -Boston, MA 02284 June 9, 2010 Jarnes D. Bog r Attorney at La One West Mai Street Shiremanstow , PA 17D11 RE: Estate of ilda M. Shotsberger Date of D ath: 05/11/10 Dear James D~ Bogar: _ _ __ _ _ _ __ Per your requ st, enclosed please find the account information as of the date of death for the above- arced decedent -For y~arTnforrrratiorr, accrued--inter-esst-i~ocr~ine~ed +n-- the date of de th balance. Please feel fre~ to contact me if I can be of any further assistance. Very truly your, ~~~ ~'~.'.(` ~` tic-~r~C~ 1~1~y2.t..C -~ Laurie DiGian omen'co Team Manage 617-533-1789', Sovereign Bank ESTATE OF Hilda M. Shotsberger SOCIAL SECURITY ~#: 196-14-3221 DATE OF DEATH: I May 11, 2010 Account #: 1 O51 C In the name of: Hilda Date of Death Ba] Int.(Y'TD) from _ Accrued interest ~ Other Info: fed to 4304 Type: Checking Open date: 11/30/1998 4. Shotsberger or Tames A. Shotsberger nce: $489.09 1/1/2010 to 4/6/2010 $0.61 date of death: withheld $.16 $0.01 Type: Checking Open date: 6/24/2008 Account #: 0461143690 In the name of: Hilda M. Shot Date of Death Ba ante: Int.(Y'TD) from AccrLYed interest o date of death: Other Info: Closed 7/2/08 $100.00 Closed prior to n/a n/a III! Page 1 of 1 REV-1151 EX+ (10-06) I CDM IN~ ERITANTCE TAX R~TURN~IA RESIDENT DECED NT SCHEDUL@ a1 FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Shotsberger, Hiilda M. _ 21-10-0559 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENS ~I S: See continuati I on schedule(s) attached 9,325.96 B. I ADMINISTRATIVE C STS: 1. Personal Representati e's Commissions Narne of Personal Rep esentative(s) Street Address City State Zip Yearlsl Commissio raid 2, Attomev's Fees i i I Bogar & Hipp Law Offices 21,000.00 3, ~ Family Exemption: (If ecedent's address is not the same as claimant's, attach explanation) Claimant Street Address City _, State Zio Relationshio of CI imant to Decedent 4. Probate Fees ~'I 417.50 5. Accountant's Fees ~!i ~i 6. Tax F2eturn Preparer's ~ees 7. Other AdministrativeC sts 6,136.28 See continuati n schedule(s) attached ~~ TOTAL (Also enter on line 9, Recapitulation) 36,879.74 Copyright (c) 2009 form software only ii he Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-08) ___._ ' SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF I FILE NUMBER Shotsberger,' Hilda M. 21-10-0559 ITEM ' AMOUNT NUMBER DESCRIPTION 1 Neill Funeral Home - funeral .bill 9,325.96 ~I H-A 9,325.96 Othe i ve Costs 2 Ameriscape -Lawn maintenance 60.00 3 Bonnie K. Miller, Tr asurer-.Tax certification fee 10.00 4 Bonnie K. Miller, Tr asurer - County/Township Taxes 645.73 5 Bonnie K. Miller, Tr ~asurer-School Taxes 1,195.91 6 Cumberland Law Jo urnal -Legal Advertising 75.00 7 Journal Publication -Legal Advertising 150.00 8 Lower Allen Towns hip -Sewer and Trash bill 600.20 9 PA American Water -Utility bill 256.65 10 PPL •• Utility bill ', 388.69 11 R.T. nunn - Homeo~ I rner's insurance payment 609.10 12 RESERVES: -Cos to conclude administration of Estate including filing fees for PA 2,000.00 Inheritance Tax Ret rn and Inventory, preparation and filing of final Personal Income Tax Returns and Fiduci ry Income Tax Returns 13 Sovereign Bank - fe ~ for date of death valuation letter 20.00 Copyright (c) 2002 farm software only ~T'he Lackner Group, Inc. ill - - - Form PA-1500 Schedule H (Rev. 6-9~•j SCWE®llLE FI FUNERAL E)CPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Shotsber er,l Hilda M. 21-10-0559 ~, NUM ER I DESCRIPTION AMOUNT 14 Welis~ Fargo - 2010 Annual Fee 125.00 Copyright (c) 2002 form software only~,The Lackner Group, Inc. II H-B7 6,136.28 Form PA-1500 Schedule H (Rev. 6-9") SCH EDULE H B.2. EXPLANATION OF ATTORNEY'S FEES ESTATE OF ~~, FILE NUMBER Sho sberger, Hilda M. 21-10-0559 I DESCRIPTION The attor this Estate arE incurred. The i extraordinary E passing of JamE the originally al of Hilda M. Shot additional effor of Mary E. Shot due to the fac became divorcE encountered wi are continuing damaged as a i Key's fees generated with respect to the administration of in access of attorney's fees which would normally be icreased number of hours is due to, among other things, Fforts required as a result of the last illness and untimely s A. Shotsberger on March 23, 2011. Mr. Shotsberger was pointed Executor pursuant to the Last Will and Testament ~berger. As a result of Mr. Shotsberger's untimely passing, s were required with respect to securing the appointment ~berger as Executrix. This matter was further complicated that James A. Shotsberger and Mary E. Shotsberger d on October 19, 2010. In addition, difficulties have been :h respectto disposition of the real estate, which difficulties nd ongoing. The home located on the real estate became esult of storms occurring in the Spring of 2011. Addition I efforts have been required as a result of the failure of the Decedent, Hild M. Shotsberger, to file final Personal Income Returns, as well as previou ly filed Personal Income Tax Returns that were improperly prepared. The e efforts are expected to be continuing and ongoing until same are resol ed. Finally, a ditional efforts were required as to a review of the records of the Decede t with respect to determining the existence of additional assets, and, m~re importantly, the existence of debts and expenses. The agre d upon hourly rate for professional services rendered with respect to conc usion of the administration this Estate is $210.00 per hour, all by agreem nt with Mary E. Shotsberger, Executrix. A copy of the engagement le ter, same being dated April 11, 2011, and further, being acknowledged eing acknowledged by Mary E. Shotsberger, Executrix, on April 11, 2011,. is attached hereto and made a part hereof. JAMES D. BOGAR ATTORNEY AT LAW ONE WEST MAIN STREET SHIREMANSTOWN, PENNSYLVANIA 17011 www. bogarandhipplaw. com e-mail mail@bogarlaw.com JAMES D. BOGAR JENNIFER B. HIPP* I~ LAUREN E. BOGAR 'Also admitted to New Jerse~v Bar ii April 11, 2011 TELEPHONE (717j 737-8761 FACSIMILE (717) 737-2086 Direct a-mail jbogarQbogarlaw.com Mary E. Shots erger 3943 Brookrid e Drive Mechanicsburg,, PA 17050 I, RE: The Estate of Hilda M. Shotsberger Dear Mary: ', ]~7e are w iting to confirm our recent conversations conce:riling th Estate of Hilda M. SYiotsberger (hereinafter the "Estate") Y u asked that we provide representation for the Estate. We a cept and appreciate your confidence. 1~s we ex lained, the administration of the Estate will involve many hings. Initially, all assets must be identified and valued as of the date of Hilda's death. Efforts are being made to make i~hese determinations. 'Phe exter#.t of our representation will include, but not necessarily b~ limited to, the following: the determination and valuation of ssets, the determination and payment of any and all lawful expens s; the filing of all required inheritance tax returns, incl ding the Pennsylvania inheritance .tax return and related filin requirements; preparation of accounting, be it a court accounting or an informal or family accounting; any and all misce:Llaneous correspondence and telephone calls; disposition of assets if req fired or requested; and various other miscellaneous matters that ill present themselves during the course of admin:istratio of the Estate. We advis d that our fee for legal services to be provided with :respect o the administration of the Estate will be based on the total nu er of hours that we expend to conclude the administratio of the Estate. Our hourly rate is $210.00 per hour. This will include professional services rendered by Jennifer B. Hipp, Esquire, Lauren E. Bogar, Esquire and me. Mary E. Shotsberger April 11, 2011 Page 2 Although we a~'e unable to provide you with an estimate at this time as to the number of hours we will be required to expend regarding the''administration of this Estate, we cari assure you that 'we will v~ork diligently and quickly. As to payment of fees, we as:k that tv~o-thirds (2/3) of the fee be paid at the time that the Pennsylvania Inheritance Tax Return is filed, with the balan~~e beingldue at the time of preparation of= the accounting of the Estate or~lthe conclusion of the Estate. As you a~e aware, we have accumulated a substantial amount of time to date concerning the administration of this Estate. That time will~~ also be included. Should tl~e need arise for the rendering of extraordinary services, we ill reserve the right to make additional charges for sE=rvices t,'hat are so rendered. This would include, but not necessarily b~ limited to, litigation that may arise during the course of the administration of the Estate. As we explained, it is not normal~~,that extraordinary matters are encountered. We will :receive your authority to proceed in these areas. It might also be neces ary for me to advance or expend costs on behalf of the E:~tate. T~e will keep track of these costs and expenses so advanr_ed . ' 64e ask that you countersign a copy of this letter and return same t:o me in the enclosed self-addressed, stamped envelope. We will endeavor to keep. you apprised of all developments in the course of the administration of the Estate. Please feel free to contact me (directly at any time if you have any questions. V y truly yours, AMES D. 0 AR JDB/bbl DATE : ~ e`~'-~n'K"J ~~~~~~~~~ j Mary E. Shotsbe e .. Rev1512 EX+(12-OS) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDEPJT DECEDENT SCHE®ULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, St LIENS ESTATE OF FILE NUMBER )Shotsberger, Hilda M. 21-10-0559 Report debts incurred by a decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM ' VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Golden Living Cent~ r Claim -See attached claim. 4,753.54 2 IRS - 2005 Personal Income Tax payment 440.00 3 IRS - 2006 Personal I Income Tax payment 1,501.00 4 IRS - 2007 Personal Income Tax payment 1,766.00 5 Pennsylvania.Depar ~ment of Public Welfare -Claim for restitution of medical assistance per 22,387.99 attached letter TOTAL (Also enter on Line 10, Recapitulation) I 30,848.53 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only l~he Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-0?) ~, I ivi nc~ Cairn Against Decedent's Estate ESTATE O~: Hilda Shotsberger Case# 21-10-0559 'The undersigned) hereby presents for filing against the above estate this statement of claim and alleges: ~I Golden Livingcenter- WEST SHORE PITTSBURGH LLC PO BOX 180970 Fort Smith, AR. 72918-0970 The basis of claim is: SEE ATTACHED: The amount of the claim is $4753.54 NOTE- If ther is insurance pending on this account and the insurance fails to pay then amount will become due pr~vately 'Under penalties f perjury, I declare that I have read the foregoing, and the facts alleged are true to the best of my knowledge and belief. Signed ON: September 29, 2010 ~-~'` i~~ n Tankersley, ollections Manage I SWEAR THI$ STATEMENT IS CORRECT ;Subscribed and s~uvorn to before me _ Notary Publ' My Commission Expires / P.o. Box 180970 Fort Smith, AR 72918 Phone: 479-201-2000 Toll -Free: 877- 82 3 - 8 375 www.goldenliving.corn COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 June 10, 2010 JAMES D BOGAR AT~i'ORNEY AT LAW ONE WEST MAIN ST SHIREMF~NSTOWN PA 17011 Re: Hilda Shotsberger CIS #: 740246820 SSN: ###-##-3221 Date of Death: 05/11/2010 Dear Attorney: Please be ad claim in the amou claim is for rest decedent for whit Department accord amended. by Act 20 itemized statemen ised that the Department of Public Welfare maintains a t of $22,387.99 against the above-mentioned estate. This tution of medical assistance granted on behalf of the the Probate Estate is now responsible to reimburse the ng to Act 49, 62 P.S. 1412, effective August 15, 1994, as 95, effective June 30, 1995. Enclosed is the Department's of claim. A portion ofIthis medical expense, namely $22,387.99, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant toll Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S. 3392(31- The balance.of the claim; namely $.00, is to be entered as a prio ity Class 5.1 claim against the estate. Please ackno ledge receipt of this letter and advise whether the Commonwealth's cl im is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, plea a provide copies of the deed, the latest tax assessment, and a current app aisal, if available. Sincerely, Patricia Nace Claims Investigation Agent 717-772-6616 717-772-6553 FAX Enclosure r. COMMONWF~4LTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 June 9, 2010 STATEMENT OF CLAIM SUMMARY -- I NAME Estate of SHOTSBERGER, HILDA ~ ~ 740 246 820 --- k ~ ~CLAS~ 3 `. ~ ~ CL4S~ 51 ~ ~ TOTAL .' NIEDI~P,L ~ INPATI~NT .00 .00 .00 OUTP TIENT .00 .00 .00 LONG ERM CARE 22,387.99 .00 22,387.99 00 .00 .00 DRUG . ~~~ ~ W 22,387.99 .00 22,387.99 ~~ COMGAONWEALTH OF PENNSI'L~AN14 DEPARTfv1ENT OF PU6LIC. WELFARE EIN - ~3-600S113 II --- COfAflnONVG'EALTH`OPPEf~1ht5YLV,aMi~ bLPARTP~4ENl OF PIJF~I:IC ~"JELEAFtE- L-~ -- __. --------- June 9, 2010 STATEMENT OF CLAIM NAME SHOTSBERGER,HILDA ID 740 246 820 GOLDEN LIVINGCENTER-W EST SHORE 770 POPLAR CHURCH RD CAMP HILL PA 17011 ~ _ ~PAYMEN3~ DAM`E' 'ORIGINAL'CRN DA~TE'OF SERVICE. _ ADJUSTED'CRi~ USUAL-CHARGES 'AIa10LJ _ pJTAPPRCIVED _ 12102/09 - 12131!09 05!25110 27101454020140001 27101454020140001 2,829.45 1,373.49 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : OOOODO 01!01110 - 01!31/10 05/25/110 271014540201.70001 27101454020170001 6,747.15 5,291.19 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 URIN TRACT INFECTION N05 PROC CODE : 000000 02/01110 - 02/28/110 05/25/110 27101454020180001 27101454020180001 6,094.20 4,638.24 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 599D URIN TRACT INFECTION NOS PROC CODE : 000000 03/01/10 - 03/31/10 05/25/10 27101454020200001 27101454020200001 6,747.15 5,291.19 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 04101110 - 04/30/10 05125(10 27101454020210001 27101454020210001 6,529.50 5,073.54 DIAGNOSIS 1 : 29011 S1~NILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 UR~fAI TRACT INFECTION i;IOS PROC CODE : 000000 05/01!10 - 05/11/10 05/25/10 27101454020230001 2710145402023000'1 2,176.50 720.34 DIAGNOSIS 1 : 290(1 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 599(1 URIN TRACT INFECTION NOS PROC CODE : 000(100 PP,OUIDEF.".SUB TvTAL GOLDEN LIVINGCENTER-WEST SHORE 31,123.95 22,387.99 _ `-' 03 101553152 0001 ..REV-1513•X+ (11-08) ~~ COM IN~ ERITAN HE~ AX RETURNANIA RESIDENT DECEDENT SCHEDULE .D BENEFICIARIES ESTATE OF Shotsberger, Hilda M. NAMEIAND ADDRESS OF NUMBER PERSONlSp RECEIVING PROPERTY TAXF~BLE DISTRIBUTIONS [include outright spousal I. ! .distributions, and transfers under Sec. 9116 a 1.2 1 James A. Shatsb rger Deceased - 3/23/1 Subsequent to th death of Hilda M. Shotsber FILE NUMBER 21-10-0559 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT (Words) ($~~)_ Son Rest, residue and remainder of Estate I Total I Enter dollar amounts f r distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet, as a ro I NON-TAXABLE DIST IBUTIONS: II. A. SPOUSAL DISTRI UTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CIHARITABLE ANC GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENT R TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software onlyiThe Lackner Group, Inc. Forrn PA-1500 Schedule J (Rev. 11-08; .', ~ ,, LAST WILL AND TESTAMENT OF HILDA M. SHOTSBERGER I, H LDA M. SHOTSBERGER, of Lower Allen Township, Cumberland Cou ty, Pennsylvania, make, publish and declare this as and. for my ast Will and Testament, hereby revoking all other Wills and Codi ils heretofore made by me. FIRS I devise and bequeath all the rest, residue and remainder of m~r estate of whatever nature and wherever situate, including any ~roperty over which I~hold power of appointment and together with ~ny insurance policies thereon, to my son, JAME5 A. SHOTSBERGER. ~ SECO D: Should my son, JAMES A. SHOTSBERGER, prede- cease me, then~~I devise and bequeath all the rest, residue and remainder of m~ estate of whatever nature and wherever situate, including any roperty over which I hold power of appointment and together with ny insurance policies thereon, to his wife, MARY E. SHOTSBERGER THIR In addition to all powers granted to them by ,law and by oth r provisions of this Will, I give the fiduciaries acting hereund r the following powers, applicable to all proper- ty, exercisabl without court approval and effective until actual distribution o all property: (A) To sell at public or private sale, or to lease, for any periodlof time, any real or personal property and to give options for sa es, exchanges or leases, for such prices and upon such terms (in luding credit, with or without security) or conditions as ~re deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the'Iproceeds of any disposition of it. (B) '~,To partition, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivi- sion, improvement, zoning or management of real estate and to ill III imposes or extinguish restrictions on real estate. (C) To compromise any claim or controversy and to abandon any property which is of little or no value. (D) ~To invest in all forms of property, including stocks, common~'Itrust funds and mortgage investment funds, without restriction tol'~,investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversificatioh, risk or productivity. (E) ', To exercise any option, right or privilege granted in in:aurance policies or in other investments. (F) ', To exercise any election or privilege given by the Federal and ot~er tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named benefici- aries in cash pr in kind or partly in each. (H) !To borrow money from themselves or others in order to pay debts, axes, ar estate or trust administration expenses, o protect or ~mprove any property held under my will, and for investment pur~oses. (I) I~,To select a mode of payment under any qualified retirement play (pensi.on plan, profit sharing plan, employee stock ownershi~ plan, or any other type of qualified plan) to the extent: the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever manner they consider advisable. .~ FOUR H: 1 direct that all inheritance, estate, trans- fer, :auccessio~n and death taxes, of any kind whatsoever, which may be payable!,by reason of my death, whether or not with respect to property pa~sing under this Will, shall be paid out of the principal of m~y residuary estate. FIFT All interests hereunder, whether principal or incomE~, which ire undistributed and in the possession of the fiduciaries acting hereunder, even though vested or distribut- 2 . -. ~. able, shall not be subject to attachment, execution or sequestra- tion for any debt, contract, obligation or liability of any beneficiary, nd furthermore, shall not be subject to pledge, assignment, c nveyance or anticipation. SIR H: I nominate and appoint JAMES A. SHOTSBERGER, Executor of this, my Last Will and Testament. In the event of the death, resignation or inability to serve for any reason whatsoever ofthe said JAMES A. SHOTSBERGER, I nominate and appoint MARY ~. SHOTSBERGER, Executrix of this, my Last Will and Testament. I direct that my Executor or Executrix, as the case may b~e, and their successors, shall not be required to post security or all bond for the performance of their duties in any jurisdiction.', IN ~lITNESS WHEREOF, I have hereunto-set my hand and seal to this,ll~my Last Will and Testament, this q~ ~ day of ra-v i~~~2nG,d~+ey' ( SEAL) HILDA M. SHOTSBERGER d Sig~ed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament in our presence, who!„ at her request, in her presence and in the presence of e~ch other, ha~.re hereunto subscribed our names as ` attesting wit~esses. ~ ~~ ~. Address ', '' ~ ':~~` ~~ Address 3