The URL can be used to link to this page

Home My WebLink About01-02-15 (2) 1505610140 REV-1500 EX (02-11)(FI) OFFICIAL USE ONLY PA Department of Revenue CountyCode Year File Number Bureau of Individual Taxes TAX RETURN PO BOX 280601 INHERITANCE Harrisburg,PA 17128-0601 RESIDENT DECEDENT 2 1 1 3 8 8 3 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 5 1 3 2 0 1 3 0 8 2 4 1 9 1 8 Decedent's Last Name Suffix Decedent's First Name MI G 0 T T S C H A L L M E R R I L L L (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 Q 1.Original Return ❑ 2.Supplemental Return 3. Remainder Return(Date of Death Prior to 12-13-82) F] 4.Limited Estate 4a.Future Interest Compromise(date of 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7.Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) 9.Litigation Proceeds Received 10.Spousal Poverty Credit(Date of Death 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number M U R R E L W A L T E R S I I I E S Q 7 1 7 6 9 7 4 6 5 0 REGISTER OF WILLS USE ONLY N First Line of Address G M 5 4 E M A I N S T R E E T , � �a ' c:> Second Line of Address M r,— 1 1 M [V r-�1 77, City or Post Office State ZIP Code DATE FIL9D M E C H A N I C B U R G P A 1 7 0 5 5 C> ry r M —t r~ o U' Correspondent's e-mail address: murrelp_waltersplallOWay.cOm —,3 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"E OF ERSON SPONS B FOR FILING RETURN DATE ypy�, / .^77 /l ADDRESS MARLA J • HA SEN 18 DEERFIELD RD MECHANICSBURG PA 17050 SIGNAT R OF EP R HER THAN REPRESENTATIVE DATE ADD MU E R • WALT III, 54 E - MAIN ST MECHANICSBURG PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J J 1505610240 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: MERRILL L - GOTTSCHALL 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 and Notes Receivable Schedule D 4, 3 0 0 0 0 . 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . .... . 5. 1 1 1 9 0 . 7 6 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . ... . 6. 4 4 8 0 6 . 1 4 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested . . . .. . . 7. 2 3 9 8 5 2 . 5 1 8. Total Gross Assets(total Lines 1 through 7) .... . . . ... . .. . . . . . . . .. . . .. . 8. 3 2 5 8 4 9 . 4 1 9. Funeral Expenses and Administrative Costs(Schedule H) . . .... .. . . . . .. .... 9. 5 9 8 6 . 0 0 10. Debts of Decedent,Mortgage Liabilities,and Liens Schedule I 10. 1 1 9 7 2 . 2 7 11. Total Deductions(total Lines 9 and 10) . . . . . ... .. . . .. . ... . . . . .. . . . .. .. 11. 1 7 9 5 8 . 2 7 12. Net Value of Estate(Line 8 minus Line 11) . . ... . .. . . . . . .. . . . . . .. . . . . .. 12. 3 0 7 8 9 1 . 1 4 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. 3 0 7 8 9 1 . 1 4 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec. 9116 (a)(1.2)X.0 _ 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate X.045 3 0 7 8 9 1 . 1 4 16. 1 3 8 5 5 . 1 0 17. Amount of Line 14 taxable at sibling rate X.12 0 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE . . . .. .. .. . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . .. . . . . . . .. .. 19. 1 3 8 5 5 . 1 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505610240 1505610240 J REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: 21 13 883 DECEDENT'S NAME MERRILL L. GOTTSCHALL STREET ADDRESS 2100 BENT CREEK ROAD CITY STATE ZIP MECHANICSBURG PA 117050 Tax Payments and Credits: I. Tax Due(Page 2,Line 19) (1) 13,855.10 2. Credits/Payments 11,500.00 A.Prior Payments B.Discount 225.00 Total Credits(A+B) (2) 11,725.00 3. Interest (3) 4. If 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) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 2,130.10 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 b. retain the right to designate who shall use the property transferred or its income ............................... ❑ ❑X c. retain a reversionary interest ..................................................................................................... 11RXd. 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? ....................................................................................... ❑ ❑X 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑X ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. FX] ❑ 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 is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on 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 p2 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)].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-1507 EX+(04-13) pennsylvania SCHEDULE D DEPARTMENT OF REVENUE MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER MERRILL L. GOTTSCHALL 21 13 883 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. B-31 LLC 30,000.00 NOTE TOTAL(Also enter on Line 4,Recapitulation $ 30 000.00 (If more space is needed,insert additional sheets of the same size) REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: MERRILL L. GOTTSCHALL 21 13 883 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. BRIDGES AT BENT CREEK 5,125.00 REFUND 2. DEPARTMENT OF THE TREASURY 411.00 2013 INCOME TAX REFUND 3. DIAKON LUTHERAN SOCIAL MINISTERIES 3,611.00 REFUND-RESIDENTIAL CARE 4. BANKERS LIFE&CASUALTY 2,043.76 REFUND-LONG TERM CARE INSURANCE TOTAL(Also enter on Line 5,Recapitulation) $ 11 190.76 If more space is needed, use additional sheets of paper of the same size. REV-1509 EX+(01-10) pennsylvania SCHEDULE DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MERRILL L. GOTTSCHALL 21 13 883 If an asset was made jointly owned within one year of the decedents date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. MARLA J. HANSEN 18 DEERFIELD ROAD DAUGHTER MECHANICSBURG, PA 17055 B. CHERYL A. KRCHNAR 6409 DUBLIN ROAD DAUGHTER HARRISBURG, PA 17111 C. JOINTLY•OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 7/5/2012 METRO BANK 41,245.94 100. 41,245.94 CHECKING 2. A. &B. BANK OF AMERICA 10,691.29 33.3 3,560.20 CHECKING TOTAL(Also enter on Line 6,Recapitulation) $ 44,806.14 If more space is needed,use additional sheets of paper of the same size. REV-1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER MERRILL L. GOTTSCHALL 21 13 883 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IFAPPLICABLE) VALUE 1. GENWORTH 30,000.00100.00 30,000.00 ANNUITY MARLA J. HANSEN - DAUGHTER-50% CHERYL A. KRCHNAR - DAUGHTER-50% 2. SCHWAB 209,852.51 100.00 209,852.51 MARLA J. HANSEN - DAUGHTER-50% CHERYL A. KRCHNAR - DAUGHTER-50% TOTAL (Also enter on Line 7,Recapitulation) $ 239 852.51 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER MERRILL L. GOTTSCHALL 21 13 883 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MUSSELMAN FUNERAL HOME, LEMOYNE, PA 2,431.00 2. ST. STEPHENS LUTHERAN CHURCH-FUNERAL 100.00 3. GARY CARNS- DOVES-RELEASED AT SERVICE 140.00 4. CAITLIN GLASS, MINISTER- HONORARIUM 200.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 1• Name(s)of Personal Representative(s) MARLA J. HANSEN Street Address 18 DEERFIELD ROAD City MECHANICSBURG State PA Zip 17050 Year(s)Commission Paid: (RENOUNCED) 2. Attorney Fees: MURREL R. WALTERS, III 3,100.00 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: CUMBERLAND COUNTY REGISTER OF WILLS 15.00 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9,Recapitulation) $ 5,986.00 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & MENS RESIDENT DECEDENT ESTATE OF FILE NUMBER MERRILL L. GOTTSCHALL 21 13 883 Report debts incurred by the 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. DIAKON LUTHERAN SOCIAL MINISTRIES 4,724.00 RESIDENTIAL CARE 2. HOME INSTEAD SENIOR CARE 219.50 RESIDENTIAL CARE 3. WEST SHORE EMS 355.14 AMBULANCE 4. ROBERT H. HANSEN 287.12 MILEAGE- DOCTOR APPOINTMENTS 5. ALERT PHARMACY 39.20 MEDICAL 6. DR. HARDISTY 14.54 MEDICAL 7. BRIDGES AT BENT CREEK 5,935.00 RESIDENTIAL CARE 8. PENNSYLVANIA DEPARTMENT OF REVENUE 139.00 2013 PERSONAL INCOME TAX 9. OMNI CARE PHARMACY 169.77 MEDICAL 10. BANK OF AMERICA 89.00 VISA TOTAL(Also enter on Line 10,Recapitulation) $ 11,972.27 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MERRILL L. GOTTSCHALL 21 13 883 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under 1. See.9116(a)(1.2).] 1. MARLA J. HANSEN Lineal 18 DEERFIELD ROAD MECHANICSBURG, PA 17050 2. CHERYL A. KRCHNAR Lineal 6409 DUBLIN ROAD HARRISBURG, PA 17111 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. 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 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, $ If more space is needed,use additional sheets of paper of the same size.