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Home My WebLink About04-17-14 REV-1500 Ex(01-10) 1505610143 Zlit PA Department of Revenue OFFICIAL USE ONLY p Pennsylvania county coda Year rile Number Bureau of Individual Taxes of»a,vaan or aavaxae �I PO 60x280601 INHERITANCE TAX RETURN �— 37� Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 12 02 2013 04 05 1929 Decedent's Last Name Suffix Decedent's First Name MI GUNDRUM PAULINE M (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 ® 1. Original Return ❑ 2. Supplemental Return ❑ 3, Remainder Return(date of death prior to 12-1382) ❑ 4. Limited Estate ❑ 41.Future ne're's Comprorrear ❑ 5. Federal Estate Tax Return Required tests of death after 1242-82) g Decedent Died Testate nauseant Maintained a Living Trust 8. Total Number of Safe Deposit Boxes ®. (Attach Copy of Wtll) ❑ (Attach Copy of Trust) tt ❑ 9. Litigation Proceeds Received ❑ 19.between Re a si a atiai95ji death ❑ 11.Electton to tax under See.9113(A) (Attach Sch.0) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOUL�EPE DIRECTED TO: Name Daytime Tet @hone Numb, rn THOMAS N COOPER 717 86" CD573'� uo p OJ In- REGISTER-Ol i U NLW 1T L �I First fine of address C'2 h p 36 WEST MAIN AVE o r Second line of address F—+ C/> f—� DATE FILED City or Post Office State ZIP Code MYERSTOWN PA 17067 Correspondent's e-mail address: 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 ail information of which preparer has any knowledge, SIGNATURE OF ERSON RESPONSI OR FILING RETURN DATE &4 t g �_ Lynn D. Gundrum 4-1 Ib 1IL4— ADDRESS �1j" 47 St. Andrew ay, Etters, PA 17319 SIGNATURE OF A .R OT THAN PRESENTATIVE DATE Thomas N Cooper to Ib ! ! ADDRESS L, 36 West Main Ave, Mye stown, PA 17067 Side 1 L 1505610143 1505610143 J 1505610243 REV-1500 EX Decedent's Social Security Number DecedentaName: GUNDRUM, PAULINE M. RECAPITULATION 1. Real Estate(Schedule A)........................................................................................ 1. 2. Stocks and Bonds(Schedule B)............................................................................. 2. 3, Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3. 4. Mortgages&Notes Receivable(Schedule D)......................................................... 4. 5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 5 , 532 . 45 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested............. 7. g. Total Gross Assets(total Lines 1-7).................................................................... 8. 5 , 532 . 45 2 , 691 . 86 9. Funeral Expenses&Administrative Costs(Schedule H)........................................ 9. 10. Debts of Decedent, Mortgage Liabilities,&liens(Schedule I)................................ 10. 332 , 129 . 10 11. Total Deductions(total Lines 9&10).............:...................................................... 11 334 , 820 . 96 12. Net Value of Estate(Line 8 minus Line 11)............................................................ 12. - 32 9 , 288 . 51 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J)................................................ 13. 14. Net Value Subject to Tax(Line 12 minus Line 13)............-......... - - 14. - 329 , 288 . 51 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 15 (a)(1.2)X .00 16. Amount of Line 14 taxable 16 at lineal rate X .045 17. Amount of Line 14 taxable 17 at sibling rate X .12 18. Amount of Line 14 taxable 18 at collateral rate X .15 19. Tax Due.................................................................................................................. 19. 0 . 00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 0 Side 2 1505610243 1505610243 J REV-1500 EX Page 3 File Number 38 Decedent's Complete Address: DECEDENT'S NAME _ Gundrum, Pauline M. STREET ADDRESS 100 Mt. Alien Drive CITY ^^ -- STATE—- ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1} 0.00 2. Credits/Payments _ A. Prior Payments B. Discount Total Credits(A +B) (2) 0,04 3. Interest (3) 0.44 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 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, (5) 0.00 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;................... ......... ................... x In. retain the right to designate who shall use the property transferred or its income;.._ ...............__.... c. retain a reversionary interest:or....................... ....................................................................................... x d. receive the promise for life of either payments,benefits or care?...____.............._.__...__..................... x 2, If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.......................,.........___............_..........._...................................._............. Cl 11 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?,........ [] o 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 O AND FILE IT AS PART OF THE RETURN. For dates of death on or after Jul yy 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,&§91 i6(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)(tt)(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 1.2)[72 P.S.§9116(a)(1)1. •The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent 172 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,wkether by bloo or adoption. SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERITANOE TAX R@TURN RESIOENi DEOEOENf �FILE NUMBER ESTATE OF Gundrum, Pauline M. I38 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 DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 First National Bank of Fredericksburg, Checking Acct.; Date of Death Balance, $6,432.24, less 5,225.89 outstanding payments of$1,206.45 2 Bankers Life, Premium Refund 306.56 TOTAL(Also enter on Line 5,Recapitulation) 5,532.45 SCHEDULE H "ERAL EXPENSES& WEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COS TS COMMO FILE NUMBER ESTATE OF Gundrum, Pauline M. f 38 Debts of decedent must be reported on Schedule I, ITEM DESCRIPTION AMOUNT NUMBER FUNERAL EXPENSES: A. 1 Grose Funeral Home, Funeral Services 360.86 2 Lantern Lodge, Funeral Luncheon 816.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Lynn D_ Gundrum Michael D. Gundrum 750.00 Street Address 47 St. Andrews Way City Etters State PA Zip 17319 Year(s)Commission paid 2. Attorney's Fees Thomas N. Cooper, Esquire 750.00 3, Family Exemption: (if decedent's address is not the same as claimanfs,attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6, Tax Return Preparer's Fees 7. Other Administrative Costs 1 Register of Wills, Filing fee, inheritance Tax Return 15.00 TOTAL(Also enter on line 9, Recapitulation) 2,691.66 SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH TAX RE6YLVANIA INH LIABILITIES & LIENS E'ANC NCE FPENNRN 1 ftEfiIEYENT CECEC£Nl' ESTATE OF Gundrurn, Pauline IVI. FILE NUMBER 38 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 Messiah Lifeways, Nursing Home Care 1,027.84 2 PA Department of Public Welfare, Medical Assistance 331,101.28 TOTAL(Also enter on Line 10,Recapitulation) 332,12$.10 REV-1513 E%-(11-08) SCHEDULEJ COMMON WEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Gundrum, Pauline M. 38 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Tmstee(s) I TAXABLE DISTRIBUTIONS[include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] 1 Michael D. Gundrum Son 1/2 of Residue 25 Lang Lane Drive Hummelstown, PA 17036 2 Lynn D. Gundrum Son 1/2 of Residue 47 St. Andrews Way Etters, PA 17319 Enter dollar amounts for distributions shown above on lines 15 through 18 on 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 B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 "WILL"OF PAULINE M." GUNDRUM I, PAULINE M. GUNDRUM, Social Security No. of 460 Kutztown Road, Myerstown, Pennsylvania, being of sound mind, memory and understanding, do hereby make my Last Will and Testament, hereby revoking and making void any and all Wills, Codicils or writings of a testamentary nature heretofore made by me. ARTICLE I: I order and direct the payment of all my just debts and funeral expenses as soon as may be conveniently done after my decease . ARTICLE II : I order and direct that all inheritance, estate and succession taxes which become due and payable by reason of my decease shall be paid out of my Estate with the same effect as if aforesaid taxes were expenses of administration, and the personal representative of my Estate shall have no duty or right to obtain reimbursement for the payment of any of said taxes . ARTICLE III: I give, devise and bequeath my entire Estate, both real and personal, wherever situate, unto my beloved husband, EDWARD W. GUNDRUM. ARTICLE IV: In the event, however, that my said husband, EDWARD W. GRUNDRUM, predeceases me, or dies in a common accident or disaster with me, or dies within thirty (30) days of the date of my -1- death, then the residue of my Estate, of whatever nature and wherever situate, shall be distributed as hereinafter set forth. ARTICLE V: Since my spouse and I have already made a gift to our son, MICHAEL D. GUNDRUM, I give and bequeath the sum of TEN THOUSAND DOLLARS, ($10, 000 . 00) , unto my son, LYNN D. GRUNDRUM. ARTICLE VI : All the rest, residue and remainder of my Estate, shall be divided into two (2) equal shares and distributed as follows : (A) I give and bequeath one (1) share thereof unto my son, MICHAEL D. GUNDRUM. In the event he does not survive me, his share shall be divided equally among his surviving issue, per stirpes . (B) I give and bequeath one (1) share thereof unto my son, LYNN D. GRUNDRUM. In the event he does not survive me, his share shall be divided equally among his surviving issue, per stirpes . ARTICLE VII : I hereby nominate, constitute and appoint my husband, EDWARD W. GRUNDRUM to be the Executor of this, my Last Will . In the event he is unable to act, or ceases to act as Executor for any reason, then it is my desire that my sons, MICHAEL D. GUNDRUM and LYNN D. GUNDRUM, be appointed as Co-Executors to serve in his place and stead. -2- ARTICLE VIII: No bond or surety shall be required of my Executor, or alternate Co-Executors in any jurisdiction. IN WITNESS WHEREOF, I, PAULINE M. GUNDRUM, the Testatrix, have to this, my Last Will, set my hand and seal this 11 -41 day of 2001 . 1111 . J (SEAL) PAULINE M. GUNDRUM WITNESSES: p -3- COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF LEBANON ) WE, PAULINE M. GUNDRUM, Testatrix, and two (2) witnesses, whose names are signed to the foregoing instrument, being duly affirmed according to law, do hereby declare to the undersigned authority that the Testatrix signed and executed the within instrument as and for her Last Will, and that she signed willingly, and that she executed it as her free and voluntary act for the purposes herein contained, and each of the witnesses in the presence and hearing of the Testatrix signed the Will as witnesses, and that to the best of their knowledge the Testatrix was at the time eighteen (18) years of age or older, of sound mind, and under no constraint or undue influence. (SEAL) PAULINE M. GUNDRUM �sl o� C � (SEAL) WITNESS n L s J..uel.�.o (SEAL) WITNESS Affirmed and subscribed to before me this d'�h day of w 2001 . -4- Ills pennsylvania _* DEPARTMENT OF PUBLIC WELFARE December 30, 2013 STEINER SANDOE & COOPER THOMAS N COOPER ESQUIRE 36 W MAIN AVE MYERSTOWN PA 17067 Re: Pauline Gundrum CIS #: 350199901 SSN: ###-##- Date of Death: 12/02/2013 ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Cooper: Under State and Federal law, the Department of Public Welfare (the Department) is required to recover medical assistance (MA) reimbursement from the probate estates of deceased individuals who were over age 55 when such assistance was received. 42 U.S.C. §1396p(b)(1). 62 P.S. § 1412. This letter sets forth the amount of the Department's claim against the estate of the above referenced individual and explains the obligations of executors, administrators, and persons receiving estate property. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Statement of Claim Amount The Department maintains a claim in the amount of $331,101.26 against the above-mentioned estate. This claim is for repayment of MA granted on behalf of the decedent. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $29,463.76, 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 $301,637.50, is to be entered as a priority Class 5.1 claim against the estate. You should refer to Section 3392 for a more complete explanation of the priority rules. If a lawsuit is filed for injuries sustained by the decedent prior to death, then the Department may also have a lien against the personal injury action. A statement of claim for that injury-related lien must be requested separately. Bureau of Program Integrity I Division of Third Party Liability I Recovery Section RD Box 8486 1 Harrisburg,Pennsylvania 17105-8486 STEINER, SANDOE & COOPER Attorneys at Law KENNETH C.SANDOE 36 West Main Avenue THOMAS N.COOPER Myerstown, PA 17067 WILLIAM H.STURM,JR. Telephone:(717)866-5737 FAX:(717)866.7162 Of Counsel:HENRY J.STEINER April 16 , 2014 Lisa M. Grayson, Register of Wills Cumberland County Courthouse 1 Courthouse Square, Suite 102 Carlisle, PA 17013 Re: Estate of Pauline M. Gundrum Dear Ms . Grayson: Enclosed for filing with your office are the original and one copy of the Inheritance Tax Return for the above-named decedent, together with a check in the sum of $15 . 00 representing your filing fee. Should you have any questions or require additional information, please feel free to contact me . Very truly yours, STEINER, SANDOE & \COOPER J,1 lLl� /LLUo� o rrn v c =D rn C7 Tina Zellers , Secretary m = � M M rn rn tz ° Encl . o 0 ^ -� F . r M RI n r-. to o t-+ 'n RECEIPT FOR PAYMENT ------------------- ------------------- LISA M. GRAYSON, ESQ. Receipt Date : 4/21/2014 Cumberland County - Register Of Wills Receipt Time : 09 : 39 : 19 One Courthouse Square Receipt No. : 1077719 Carlisle, PA 17Q13 GUNDRUM PAULINE M Estate File No. : 2014-00377 Paid By Remarks : STEINER SANDOE & COOPER DB1 ---------- -------------- Receipt Distribution ---------- -------------- Fee/Tax Description Payment Amount Payee Name INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 46324 $15 . 00 Total Received. . . . . . . . . $15 . 00 ƒ�qm w . §§ �-e ;)x .� � U) U) _cts U m � ! 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