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Home My WebLink About01-03-121505610105 REV-1500 ex caz_~~, tFt, PA Department of Revenue Pennsylvania OFFICIAL USE ONLY DFieaiNFHi DF FEaFnVE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX z8o6oa, Z. ( (( B sZ Harrisburg, PA 1'7128-06oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 203-10-8798 04/02/2011 05/25/1923 Decedent's Last Name Suffix Decedent's First Name MI ', GOUSE WILLIAM L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82} C~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number THOMAS E. FLOWER (717) 243-5513 First Line of Address FLOWER LAW, LLC Second Line of Address 10 W. HIGH ST. City or Post Office CARLISLE Correspondent's a-mail address: TOmCcDFIOWer-L2W.COm State ZIP Code PA 17013 REGISTER OF WILLS USE ONLY n .. -;-7 _T_ C ~ -= ~'r~ ; f -'? C.. ~ _;.~ DAT~'FtLED ~ - __y , 3) ~~ .~'> r.. 4,I ~~ C. "r t 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. SIG TURE OF PERSON RESPONSIBLE FOR FILING RE~TUR~ D TE ADDRESS 381 Criswell Drive, Boiling Springs, PA 17007 A E OF PR~PA~F~RgT R THAN REPRESENTATIVE hnT~ ADDRESS FLOWER LAW, LLC, 10 WEST HIGH ST., CARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 1505610205 REV-1500 EX (FI) Decedent's Name: WILLIAM L. GOUSE Decedent's Social Security Number 203-10-8798 RE CAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 60,000.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 8,864.42 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 68,864.42 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 13,695.24 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 800.30 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 14,495.54 12. Net Value of Estate (Line 8 minus Line 11) ........................... .. . 12. 54,368.88 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J} ..................... ... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 54,368.88 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable - - - at lineal rate X .0 _ 16 17. Amount of Line 14 taxable at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 54,368.88 18 8,155.33 19. TAX DUE ....................................................... .. 19. 8,155.33 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L, 1505610205 1505610205 J REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: WILLIAM L. GOUSE STREET ADDRESS 381 CRISWELL DRIVE MONORE TOWNSHIP CITY BOILING SPRINGS STATE ZIP PA 17007 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount (1) Total Credits (A + B) (2) 3. Interest (3) 4. !f 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) 155.33 0.00 0.00 0.00 8,155.33 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 .......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" 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 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 an or after Jan. 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 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 21 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 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 4.5 percent, except as noted in [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 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at feast one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (11-U8j Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER WILLIAM L. GOUSE 21-11-0528 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1' DWELLING HOUSE ON 3.2 ACRES, TAX PARCEL ID #22-30-2664-017, 381 CRISWELL DR., MONROE TOWNSHIP, CUMBERLAND COUNTY, PA and 2. UNIMPROVED LAND, 1.88 ACRES, CRISWELL DR,TAX PARCEL ID #22-30-2664-018, IN FLOOD ZONE & CONTIGUOUS TO PARCEL DESCRIBED AT ITEM NUMBER 1. 80TH PARCELS HAVE BEEN LISTED FOR SALE AS A SINGLE PROPERTY AND THE HIGHEST OFFER SO FAR HAS BEEN $60,000. UPON SALE, A SUPPLEMENTAL RETURN WILL BE FILED, IF NECESSARY TO DECLARE ADDITIONAL VALUE RECEIVED TOTAL (Also enter on Line 1, Recapitulation.) ~ $ If more space is needed, insert additional sheets of the same size. 60,000.00 60,000.00 REV-1508 EX+ (11-i0) ~ SCHEDULE E J ,, Pennsylvania ~i DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE 7AX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: WILLIAM L. GOUSE 21-11-0528 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. REFUND, CHRISTIAN COMPANION SENIOR CARE 388.00 2. REFUND, HIGHMARK HEALTH INS PREMIUM 351.96 3, ORRSTOWN BANK, FUNDS ON DEPOSIT 5,027.71 4. ERIE INSURANCE GROUP, RETURN OF UNUSED PREMIUM 111.00 5, NET PROCEEDS AUCTION OF HOUSEHOLD FURNISHINGS AND PERSONAL EFFECTS 2 985 75 TOTAL {Also enter on Line 5, Recapitulation) $ ( 8,864.42 If more space is needed, use additional sheets of paper of the same size. REV-151L EX+ (1U-U9) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER WILLIAM L. GOUSE 21-11-0528 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I' EWING BROTHERS FUNERAL HOME, PROFESSIONAL SERVICES 1,665.00 z. AUTOMOTIVE TRANSPORT SERVICES 525.00 3. REFRIGERATION AND CREMATION CHARGES 465.00 a. OBITS, HONORARIA & MISCELLANEOUS FUNERAL COSTS, LESS $100 VA FUNERAL CREDIT 961.48 B. ADMINISTRATIVE COSTS: I. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City _ State .ZIP Year(s) Commission Paid: _ ___ __ 6,150.00 2. Attorney Fees: 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 4. probate Fees: 353.50 5. Accountant Fees: 6. lax Return Preparer Fees: ~• PUBLISH ESTATE NOTICES, LAW JOURNAL ($75), PATRIOT NEWS ($144.17) 219.17 8. SCHOOL DISTRICT REAL ESTATE TAXES 2,465.72 s. BRETT LECHTHALER, REAL ESTATE APPRAISAL 300.00 ~o. METED, ELECTRIC BILL 41.03 ~~. PENN WASTE, TRASH HAULING 47.85 12. CARLISLE PROPANE, HEATING FUEL 501.49 TOTAL (Also enter on Line 9, Recapitulation) $ 13,695.24 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-U&j ~ Pennsylvania SCHEDULE I ~~ DEPARTMENT DF REVENUE DEBTS OF DECEDENT, INHER[TANCETAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT E5TATE OF FILE NUMBER WILLLIAM L. GOUSE 21-11-0528 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsytvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: FILE NUMBER: WILLIAM L. GOUSE 21-11-0528 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).j 1~ LISA M. MINNICH, 381 CRISWELL DR., BOILING SPRGS., PA 17007 NIECE 100% 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. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ If more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT I, WILLIAM L. GOUSE, of the Township of Monroe, County of Cumberland, Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former Wills, Codicils and Trusts by me at anytime heretofore made. FIRST. I order and direct that all my just debts, funeral expenses and expenses in ~ connection with administration of my Estate be paid by my personal representative or !representatives, hereinafter named, as soon as conveniently may be done after my decease. I further authorize my personal representative to expend funds from my Estate in such amounts as my personal representative shall consider appropriate, for the disposition and memorial of my remains. SECOND. I give, devise and bequeath all of my real estate with improvements 'ski thereon erected unto my niece, LISA M. MINNICH, if she survives me. THIRD. For the purposes of this my Last Will and Testament, a person shall not 31 be deemed to have survived me unless he or she shall have survived me by more than ninety (90) days. FOURTH. All the rest, residue and remainder of my Estate, real, personal and WAYNE F. SHADE Attorney at Jaw 53 West Pomfret Street Carlisle, Pennsylvania 17013 mixed, whatsoever and wheresoever situate, I give, devise and bequeath unto my nieces, LISA M. MINNICH and AMY L. MINNICH, in equal shares. FIFTH. If my niece, LISA M. MINNICH, should fail to survive me, I give, devise and bequeath my entire estate unto my niece, AMY L. MINNICH. If my niece, ~ AMYL. MINNICH, should fail to survive me, I give, devise and bequeath my entire ~ estate unto my niece, LISA M. MINNICH. SIXTH. If both of my nieces should fail to survive me, I give, devise and bequeath my entire estate unto my brothers, HARRY V. GOUSE and FRANK M. ~ GOUSE, in equal shares. If either of them should fail to survive me, I give, devise and bequeath my entire estate unto the one of them who shall survive me. SEVENTH. I order and direct that any estate, inheritance or similar tax due as a W AYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle, Pennsylvania 17013 ~ result of my death with respect to any property passing as a result of my death, shall be paid from the residue of my Estate before its division into shares and prior to distribution as an expense of administration and that no part of the taxes should be prorated or ~ ~~ apportioned among the persons or beneficiaries receiving the taxable property. It is my express intention that all inheritance taxes imposed as a result of my death be paid from f the residue of my Estate whether or not the property passes under my Last Will and Testament. My personal representative shall have full power and authority to pay, compromise or settle any such taxes at anytime whether with respect to present or future interests. -2- EIGHTH. Any and all decisions, determinations or actions made or taken :by a ~~ personal representative hereunder, if made in good faith, shall be final and conclusive on II all persons who are or may become interested in my Estate. No fiduciary acting under this my Last Will and Testament shall be liable for any error in judgment or for any !I depreciation or reduction in value of any Estate assets at anytime, in the absence of l willful default. LASTLY. I nominate, constitute and appoint my niece, LISA M. MINNICH, to be the Executrix of this my Last Will and Testament, but if, for any reason, she should fail to qualify as such Executrix or decline or cease so to serve, I nominate, constitute and appoint my niece, AMYL. MINNICH, to be the Executrix hereof, each to serve without bond. IN WITNESS WHEREOF, I, WILLIAM L. GOUSE, have hereunto set my hand and seal to this my Last Will and Testament which consists of five (5) typewritten pages to each of which I have affixed my signature, this 2nd day of July , A.D. Two Thousand Nine (20Q9). ~i'-~-~ I.... ~~ ~ w , (SEAL) William L. Gouse WAYNE F. SHADE Attorney at law 53 West Pomfret Street Carlisle, Pennsylvania 17013 -3- The preceding instrument, consisting of this and four (4} other typewritten pages, each identified by the signature of the Testator, was on the date thereof signed, sealed, ~ published and declared by WILLIAM L. GOUSE, the Testator therein named, as his Last Will and Testament, and we, at his request, in the presence of each other, have subscribed our names as witnesses hereto. Acknowledgment ' COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF CUMBERLAND ) I, WILLIAM L. GOUSE, the person whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by WILLIAM L. GOUSE, this 2nd day of JL1Y , 2009. William L. Gouse WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle, Pennsylvania 17013 i ~%- .~, ~. Notary P lic ~trro~~s,>'r+~riv~- -4- NOTARIAL 5EA1. CONNIE J. TRITT, N.ohry PubNc CaMlitle 9oau., C.an~uion C~~ Ocipbrt~5, 2012 V i Affidavit ..~ ~~'~ WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle, Pennsylvania 17013 COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF CUMBERLAND ) We, Wayne F. Shade and Helen H. Shade ,the witnesses whose names are signed hereto, being duly qualified according to law, do depose and say that the preceding instrument was, on the date thereof signed, sealed, published and declared as his Last Will and Testament, by WILLIAM L. GOUSE, the Testator therein named, willingly and as his free and voluntary act for the purposes therein expressed; and that, to the best of our knowledge, the Testator was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and subscribed to before me by Wayne F. Shade and Helen H. Shade ,witnesses, this 2nd day of July , 2009. ~~ Notary P lic cari~w of nv~uw- NOTARIAL SEAL CONNIE J. TRITi', Noiry Public . Cumb~Arid faun o~ob.rs, ~O~x -5-