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Home My WebLink About02-16-07 --.J 15056051058 REV.1500 EX (06-05) PA Department of Revenue . Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number a\ Ot O\s~ Date of Birth 181-14-0999 1 0/06/2006 01/25/1923 Decedent's Last Name Suffix Decedent's First Name MI Shock Richard G (If Applicable) Enter Surviving Spouse's Infonnation 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 Retum 2. Supplemental Retum 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes Cynthia A. Shaul Firm Name (If Applicable) (717) 766-1478 REGISTER,O{ WILLS USE ~y ( ~." -..... First line of address r-_ . , ",--j 544 Appalachian Avenue C", Second line of address City or Post Office Mechanicsburg State ZIP Code DAT~~ILED C) PA 17055 (,) 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 all information of which preparer has any knowledge. SIGNAT[{ OF PERSON RES<<SI~FILlNG RETURN D~T~ . / . 'ADDRES.~11..1Jv ~.---- -..~ -.--~-..~. ....2ljJ.~ La:L...___ __ 0tllYlJ (/6 tlbrw-e.- _~__' ..---...-.----- SIGN~&>>~~THEUAryRJU4IVE~-.~-..--- .. ~JtJ. '7 _ ADDRESS..~ . /1. .. . . 0M1\.i.. l-14 ~I/"'L PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 --.J L 15056051058 ~ -I 15056052059 REV-1500 EX Decedent's Name: Richard G Shock 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 Properly (Schedule E) . . . . . . .. 5. 6. Jointly Owned Properly (Schedule F) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (Schedule G) Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10)...................................11. 12. Net Value of Estate (Line 8 minus Line 11) . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . 12. 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. TAX COMPUTATION. 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_ 16. Amount of Line 14 taxable at lineal rate X.O 45 76,205.61 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 19. TAX DUE. . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 L Decedent's Social Security Number 181-14-0999 14,166.17 1,815.25 68,477.69 84,459.11 7,333.50 920.00 8,253.50 76,205.61 76,205.61 3,429.25 17. 18. 3,429.25 15056052059 ---I REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Richard G Shock _.._-~----"~ .~~ ...."_...~~---- STREET ADDRESS Claremont Nursing and Rehabilitation Center ~------~-- ---------- File Number DECEDENT'S SOCIAL SECURITY NUMBER 181-14-0999 1000 Claremont Drive _.~._-_.- CITY Carlisle I STATE ~A i ZIP i I 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 3,429.25 Total Credits ( A + 8 + C ) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty -------- .. Total Interest/Penalty ( D + E ) (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) 3,429.25 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SA) (58) A. Enter the interest on the tax due. 3,429.25 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;.......................................................................................... 0 ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~ c. retain a reversionary interest; or.......................................................................................................................... 0 [i] d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [i] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ~ 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. ~9116 (a) (1.1) (ill. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. ~9116 (a) (1.1) (iill. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedenrs lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(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 EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Richard G. Shock -181-14-0999 FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All properly jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Susquehanna Valley FCU - Account No. 14828 7,612.17 2. Pre-paid funeral expense - Check # 507 - Malpezzi Funeral Home 6,554.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 14,166.17 ,- ,~ r-', ,- .._; -.- . i"\ _. 3850 HARTZDALE DRIVE CAMP HILL, PA 17011-7809 LOCAL: (717) 737-4152 TOLL FREE: (800) 948-1454 FAX: (717) 737-0589 Member#: Social Security *: Statement Date: Page#.:: [>jail Code: IVeb Code: 14828 X-XXXX 'j 0/31/2006 nn~HH luHI;~Hjg:u,lslHi3JuHHni~n~ ~ CltNTHIA SHAUL REP PIWEEFOR SHOCK, CYNTHIA A SHAUL - 544 APPALACHIAN AVE MECHANICSBURG, PA 17055 YTD TAXABLE DIV: $.00 YTD TAXABLE INT: $.00 YTD FINANCE eHG: $.00 OVERDRAFT FEES THIS PERIOD: $.00 OVERDRAT FEES YTD: $.00 RETURNED ITEM FEES THIS PERIOD: $.00 RETURNED ITEM FEES YTD: $.00 iRAN POST TRANSACTION ~ATE DATE DESCRIPTION T~V~,N At10UNT FEE AMOUNT FINANCE LOAN CHARGE PRINCIPAL BALANCE 10/01 Type: 00 = REGULAR SHARES - 00 10/31 ----------------------------~- ----~~~-~-- --~----- ------~-- -----~~--- ~~=~----~-= PREVIOUS BALANCE NElli BALANCE ,5,,00 .5 ~ 00 10/01 10/03 '10/05 10/16 Hl/17 'J 0/19 l!)/.::n Yvos: 40 - SHARE DRAFT = 40 10/03 US TREASURY 303 10/05 AARP HEALTH CARE PRENIUM 10/16 Item#- 1005 10/17 Item#- 100~ 10/19 Item#- 1006 943.00 170.75- , VoJuc:. PREVIOUS BALANCE ---.,...., r ~,--,/ &839.92 7782.92 . 76'12.'17 7576.17 71.193 .56 7LJ09.85 7&j09 ~ 85 36.00- 82.61- 83.71- NE~i BAU,NCE I'cem:!* Amount Cleared Items This PeriOd NOTE: An ** indicates a Skip in se~uence. Item~ ,Il.mourrt Itelii~ Amount Item# Amount ----~--- ~--------~- --~~--~- ~-=~~--~-~~ --~-~~-- ----------- ~------- --~~-~~---- 1004 82.61 1005 36.00 1006 83.71 Summary Description Count Debits Credits Share Draft Items 3 ATM Transactions 0 EFT Transactions 2 Electronic Checks 0 Voice Transactions a Other Withdrawals a Other DepDsits 0 202.32 .00 170.75 .00 .00 .00 .00 .00 943.00 .00 .00 .00 Balance FOl"'1;16H'''d: Net Change: Net'J Balanc,:!;. 6?839.92 569.93 'y409~85 Remember to use your SVFCU Platinum Visa with ScoreCard Rewards for all of your holiday purchases. Earn prizes for you while shopping for others! ('{;.00515 REV-1509 EX+ (6-98) SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Richard G. Shock - 181-14-0999 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. FILE NUMBER SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Cynthia A. Shaul 544 Appalachian Avenue Mechanicsburg, PA 17055 Daughter B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUOE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF OEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 08/01/03 Susquehanna Valley FeU - Account No. 12070 1,815.25 100 1,81525 TOTAL (Also enter on line 6, Recapitulation) $ 1,815.25 (If more space is needed, insert additional sheets of the same size) E: F - I *-e.JV'\ ~ - '- 3850 HARTZDALE DRIVE CAMP HILL, PA 170'1-7809 LOCAL: (717) 737-4152 TOLL FREE: (800) 948-14SLf FAX: (717) 737-0589 l'lemberiif. : Social Security #: Statement Date: Page~: r<lail Code: Web Code: 12070 1{-XXXX '10/3'1/2006 1 ~n~~nftn nnn!!lni! ilLdl ~HH3 i H Lni~~n Inid RICk~IARD G. SHOCK CYNITHIA SHAUL 544 APPALACHIAN AVENUE MECHANICSBURG, FA 17055 YTn TAXABLE DIV: ~;. 24- YTD TAXABLE INT: $.00 YTn FINANCE CHG: $ .00 OVERDRAFT FEES THIS PERIOD: $. a OVERDRAT FEES YTD: $.00 RETURNED ITEM FEES THIS PERIOD: $.00 RETURNED ITEM FEES YTD: $.00 POST TRANSACTION DATE DATE DESCRIPTION TRAM AMOUNT FEE A~!OUN.r FINANCE LOAN CHARGE PRINCIPAL BAi..ANCE -~-~~-----~--------------~-~-- ---~----~~- -~-~---- --------- ---------- ---~~-----~ 0/01 Type: 00 - REGULAR SHARES - 00 ()/31 PREVIOUS Bi.\Uj,t~CE NE\1 BALANCE 5.00 iL 013 10/D1 Type: 40 - SHARE DRAFT - 40 0/25 10/25 Item#- 588 10/26 10/26 Iteml- 590 10/~31 289.50- '100.00- ~!;OUS BALA~~~~~.~~ . ~ ~ !\~""'ryV I" ", ? 14,,5. , 5 of' ctccc5 NEW BALANCE 1425 < 75 Item~ Amount Cleared Items This PeriOd NOTE: An ** indicates a skip in sequence. Item~ Amount Xtem# Amount ItsmlJi: Amalln"!: -----~-~ --~-~-----~ -------- ----------~ -~---~-~ -~--------~ -~~--=-- ~------~--- 588 289.50 1f{}Y{ 590 100.00 Description Debits Credits Share Draft Items 2 ATM Transactions 0 EFT Transactions 0 Electronic Checks 0 Voice Transactions 0 Other Withdrawals 0 Other Deposits 0 389.50 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 Balance FortlJal'd: Net Change~ NstlJ Balance: 1,815.25 389.50.,. 1,425.75 Remember to use your SVFCU Platinum Visa with ScoreCard Rewards for all of your holiday purchases. Earn prizes for you while shopping for others! 6~t]OD:,5b REV-1510 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Richard G. Shock-181-14-0999 FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE "TRANSFEREE, THEIR RElATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPUCABlE) VALUE 1. Knights of Columbus Retirement Annuity - Account No. 0102448358 68,477.69 100 68,477.69 TOTAL (Also enter on line 7 Recapitulation) $ 68,477.69 (If more space is needed, insert additional sheets of the same size) KNIGHTS OF COLUMBUS SUPREME OFFICE 1 COLUMBUS PLAZA NEW HAVEN, CT 06510 CHECK NUMBER: CHECK DATE: 0006287337 Oct 2-1,2006 02448358 $68,477,69 POLICY NUMBER: CHECK AMOUI~T: RICHARD G SHOCK 544 APPALACHJAN AVE MECHANICS8URG PA 17055-5506 Policy Surrender Analysis For Policy [\lumber: 02448358 Policy Surrender Value - As Of 10/22/06 ADDIT!ONS TO POLICY SURRENDER VALUE Cash Value Of Paid-Up Additional Insurance Dividends On Deposit - Including Interest Dividend For Current Policy Anniversary Half - Maturity Deposit - Including Interest Premiums Paid Beyond Surrender As Of Date $68,477.69 0.00 0.00 0.00 0.00 0.00 DEDUCTIONS FROM POLlCY SURRENDER VALUE Policy Loan - Including Interest Federal Withholding Tax State 'Withholding Tax Annuity Surrender Charge 0.00 0.00 0.00 0.00 In compliance with your recent election, Federal Income Tax has not been withheld from the surrender proceeds of your insurance policy. Although Federal Income Tax has not been withheld, you are liable for payment of tax on the taxable portion of these proceeds. If you have any questions concerning this matter, we encourage you to contact your tax consultant or the Internal Revenue Service EX. 7 TOTAL SURRENDER PROCEEDS PAYABLE $68,477.69 ~ office nearest you. Taxable amount of this distribution that we are required to report to the I.R.S.: $314.49 va) IJ e_ // _J REV-1511 EX+ (12-99>w COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Richard G. Shock - 181-14-0999 FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Pre-paid funeral expense - Check # 507 - Malpezzi Funeral Home Funeral expense - final adjustment - Check # 588 - Malpezzi Funeral Home Fee for religious service - Check # 589 - Fr. Richard Waldron, Pastor Funeral luncheon - Check # 590 - Saint Elizabeth Ann Seton Parish Alter server gratis - (2 alter servers @ $20.00 each = $40.00 - paid in cash) 6,554.00 289.50 50.00 100.00 40.00 2. 3. 4. 5. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City . State Zip Year(s) Commission Paid: 2. Attorney Fees (See. I+e.m ~os. 1?-"Z below) 3. Famiiy 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 8. Attorney Fees - Check # 591 - Said is, Flower & Lindsey Attorney Fees - Check # 592 - Saidis, Flower & Lindsey 220.00 80.00 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 7,333.50 REV-1512 EX+ (12-03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Richard G. Shock - 181-14-0999 FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Claremont Nursing and Rehabilitation - Check # 1008 920.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 920.00 .:,.- ,:","';. ;~' p. c~! \ I .:JC-ll eo G ! I;> .. _.._.__.~--...". I - ~~~: N2.~"~._.Doc..uw\e..n.f~:h9IL COMMONWEALTH OF PENNSYlVANIA DEPARTMENT OF REVENUE BURE.AU OF INDIVIDUAL TAXES DEPT 230601 HARRISBURG, PA 17128-0601 REV-1162 EX(ll-96) RECEIVED FROM: PENNSYLV ANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SHAUL CYNTHIA A 544 APPALACHIAN AVENUE MECHANICSBURG, PA 17055 ESTATE INFORMATION: SSN: 181-14-0999 FILE NUMBER: 2107-0152 DECEDENT NAME: SHOCK RICHARD G DA TE OF PA YMENT: 02/16/2007 POSTMARK DATE: 02/1 6/2007 COUNTY: CUMBERLAND DA TE OF DEATH: 10/06/2006 NO. CD 007812 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $3,429.25 I I I I I I I I TOTAL AMOUNT PAID: REMARI<S: SHAUL CHYNTHIA CHECI<# 594 SEAL INITIALS: AJW RECEIVED BY: REGISTER OF WILLS $3,429.25 GLENDA FARNER STRASBAUGH REGISTER OF WillS