The URL can be used to link to this page

Home My WebLink About07-26-07 .-.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 OFFICIAL USE ONLY County Code Year INHERITANCE TAX RETURN RESIDENT DECEDENT File Number 21 06 1008 Date of Birth 204-01-5280 11/01/2006 04/10/1919 Decedent's Last Name Suffix Decedent's First Name MI Short June (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name U' __ ..~ _. ___ _ _ . __... _ . .. MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITHI THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW .., 1. Original Retum <::::) 4. Limited Estate c:::::;; 3. Remainder Hetum (date of death prior to 12-1:3-82) 5. Federal Esta,te Tax Retum Required <:::) 2. Supplemental Retum c:::> c:> C) 4a. Future Interest Compromise (date of death after 12-12-82) <=:) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c:::J 10. Spousal Poverty Credit (date of death c) 11. Election to UIX 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 S,HOULD BE DIRECTED TO: Name Daytime TelephonEI Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes (a> J. Robert Stauffer Firm Name (If Applicable) (717) 766-9673 r-..J C'-'" - --=-.~::,~~:~=~_~:~~O_.~...~.~.~, ",^".~==~~_~~_.~~_~_~_~=~~-=.~=~~,'===-~ REGISJEi}OF WILLUsE ONLY"! . '~~2 ~'l 0" ~ i h First line of address Market Square Building Second line of address City or Post Office Mechanicsburg State ZIP Code <2 (.J' DATE FILE[)\.O , -r\ PA 17055 Correspondent's e-mail address: Under penalties of pe~ury, I declare that I have examined this return, including accompanying il is true, oorrect and oomplete. Declaration of preparer other than the personal represen live' SIGNATURE OF PERSON RESPONSIBLE FOR FILING RET RN 48 W st Allen Street, Mechanicsbur~l, PA 17055 DATE SSI Market Square Building, anicsburg, PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 ....J ~ .-J 15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name: June Short 204-01-5280 RECAPITULATION 1. Real estate (Schedule A). ............................................ 1. 103,534.80 '~.__"';.""'_m_'"'''~''_'__'~'''''_'~'-."'~'"'~__''''='~'--~~_, "","_.,~~.T__~~= ..,,~.~-~.~~~~~==-=~.~,; 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. 3,664.85 6. Jointly Owned Property (Schedule F) C> Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c;:) Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 107,199.65 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 12,877.16 17,701.33 30,578.49 76,621.16 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/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subjectto 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 76,621.16 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 76,621.16 15. 16. 3,447.95 17. 18. 19. TAX DUE..... ... ............. ....................................19. 3,447.95 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L-::t 15056052059 Side 2 15056052059 .-J L REV-1500 EX Page 3 f.ilt N"\!J!!.~!!L . - . Decedent's Complete Address: ! 21 ... 06 ! 1008 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER June I Short 204-01-5280 STREET ADDRESS 709 S. Frederick Street CITY I STATE I ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 3,447.95 Total Credits (A + B + C ) (2) 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) A. Enter the interest on the tax due. 3,447.95 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: YEIS No a. retain the use or income ofthe property transferred;.......................................................................................... [J ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ [J ~ c. retain a reversionary interest; or.......................................................................................................................... [J [iJ d. receive the promise for life of either payments, benefits or care? ...................................................................... [J ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. [J ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. [J ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ [J ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE liT 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. 99116 (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 zero (0) percent [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemot 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 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. 99116(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 four and one-half (4.5) percent, except as noted in 72 P.S. 99116(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. ..... . ... "'''' "'''' "'CIO :! 8, !!;o<:'l 0'" or-- 0 Jrl~ rl . rl' oj 0 ~ ... N ~ rl N ! ~ N rl ~ ... f. .....0 N LO '" ~ ...... CIl <tiN ~ '" ~ 00 'lii -gClO R 00 0 ... '" N NN E-<o 0 rl 0 " '" N N riO Iii ~~ \.... Ln\O -.....' I ....'*'r- c.lPN <if'. CO' t; f"o-r-- ;N~ N~ ... 00 ~ N 00 '" CIO ,..: ~~ rl '" ... i rl :t .....0 is ~~ "'... w i~O I '0 ~ . J .... .. .. :E: .0 ...... W ..... <Ill "-'0 0'" QI.t'I 0'" :J .. .. ~~ 0O'i 0'" 0'" C LO '0 0 00 WO CIOCIO CIOO "'LO !i .... N'" rl rl N '" 88 >'" Nr-IQ C"i..... ~ 0 0 0 0 :J ... 0 ~ 0 "" ft 0 ........ H fl!. :IE ... Po Po - :j- 4( ~go ell'l 00 IDOO ........ Oll'l 0'" ~:OO\ ~ HH ..... Oz LO . o . o . CII ..:I oS CIOCIO CIOll'I m\O (Y) N'" rl Z"'''' 8 "'ffi N 0 ~g 0 0 0 0 (J~ , ID <0 :2 w 0 ::l :2 (J l!l I>l (; II. I>l III 'tl 0 -- H :l: -- Z l>: ..:I " l>: :g ~Ul~ 2~ 2.~ BOle) c: ~~8 a:Q)H 8 (J)r"i- o"-'~ ~~ ~8 ~8 ID~ a: ~ U w ::1 8 S a:w<( (/)>ll. 00:- a:oCl ;2lij~ @(/)ffi J:O:u w_ ...J::EZ >-0<( a:(/)J: a:It)U <(ow lD<o::E ~ ~ " ~ ~ ll. ~ ~...a; a~ 6Hfi i:::J ~..~ a:0 w" IDZ :l~ -0 ~.~ :lz :~ ~d 18 a: ~fZ,""~ >-::)15 ~.;.~ ~::la: -IDA. bila: ~.~..~ It) :8 ..... .... '<t CII o o ill It) 8 o <(tuW gw~ ............. a:. C\J-'___~ 8. ..!;;CJ) 8.....~ <o~98 ....Clla:~ I"-W o~o z W cnofE (/):::(:. 13 wQ.;(/)a: ~<(Ol() <(::E~<( .... zg> <('6 j!:=s...J (/)lD~ (/)-1- w:ll!z ...JC:W o~g Z"iij(/) c:( CIl'W ..Ja:a: w a: U <( ~ o * I .... '" ... '" O'i '" CIO .;!; .... * 8 0 N Q '" 0 r-: 0 (/) oj 0 .~ CII 'i rl CIO rl .... rl '" '" a: -.. c N rl N ! -- ~ ~ I. N N rl ~ 0 -- g ... g ~ Q) ~ ~ 0. .Q Qi 7.19 ~ N LO '" ~ 0 Q) Ci LO M ll'I Qj > 'lii P&1; N ..; I > ~ c: Z 0 ~'" eN ~ @. W == '" rl c> 0\ N N :;) -g iii Iii :;) 1 0 0. 0 (.) E (.) ~ .l!! a: (/) ! 'iJ/I ~- * '" *~: a: (;) :;) -g 1$ 'N M N o. N---~ ~ :;) "0 ~ I '" 1;0- CIO ~ CIl III >- I- 0 rl 0'\ .... la u.. III N M i u.. 0 ~ ll. ! is 0 ~ "0 0 "0 ~ "0 () I "0 <( .<( .... 0: :l:: ~ Qj .~ i ~ Q) (/) 0 (/) @ <tI CIl ... Q) ~ III 0 .~ ~ III 0 ..:J .Q a: (3 ~. i .H a: 0 a:I c: :E: a:I c: W W oe( ~ J oe( a: a i&;JQ Q ~' 0 LlI 0 m a: a. ~ '0; I- ~~ 0,,0'\ (:) 0\ '" '" ~ .~ l!l LO .. 0 0 ;..; C>>:"g:t co o. ~LO Q) ::i a: .... C'ir'l r:c r4 (')J:.t!J ::i a: eN rl 0, N H as as ~ s'" 0 b '" as as 0 I ~ -~ ~ ~ u.. u.. u.. 0 0 ~ ... LIJ C c: Q) 0 Q) li5 E li5 E >- >- LIJ as W as (/) ll. ~. ll. a: :S :S w .~ , w .~ ru CD ru a: Iii 5 a: Iii w E LIJ E w w (/) .a (/) .a . Q) . Q) a: a: tu -w wa:18 Zl-o ::>(/).... ..,~.... olSU ..Ja:~ ow' zfiJ'g Oa:=> ~u..a:I ~;x:~ 5z "'=-0<( a: (/).J: o U J:'OlW (/)~::E :::!: ll. ::E'r(Y) ll.::ECII "f~~ :::!:""'CII c3(/)""- ,.... W CII_ (/)::> Ol_ crl-IX) ::>()a:1t) ~ffi t-?( ll. w " ~ .~ Ii: iii frl olt ....~ ~o lll- (I)!:: -0 F~ OJ: ~(.) 3:05 a:.j:j: Q;o U:u. ~ 8 ill U) 8 It) It) o .... .... lI;IZ; z. iii8 It,'w <('e) (1)'<( We) ~Ht ....0 !!::::!: ~, ~ ,. ~..~ ll. o f3 o tu -w wa:1t) Z'I- It) ::)(n~ ..,~.... olS~,<c ::E ll. :~'r~ Il. ::E "" ..,. <(...., :~~~ ;;5 (/) ....- ,r- W'~C\I (n::>of ll: I- IX) :::l Ucr It) ......w......o i= O:E CII ~ ..~ ~ ~ ~ ~ g REV-1002 EX+ (6-9_ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF June I. Short FILE NUMBER 21-06-1008 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 which is Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 709 S. Frederick Street, Mechanicsburg, Pennsylvania Assessed Value $90,820.00 Common level Ratio 1.14 TOTAL (Also enter on line 1, Recapitulation) (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH 103,534.80 103,534.80 ~gUlar Checking Account Statement ~c Bank (3~ PNCBANK For the period 10/24/2006 to 11/21/2006 Primary account number: ~,0-7002-6444 Page 1 of 3 Number of enclosures: 0 JUNE I SHORT DECD 709 S FREDERICK ST MECHANICSBURG PA 17055-6407 a. For 24-hour banking, and transaction or interest rate informatk>n, sign on to 'It PNC Bank Online Banking at pnc.com. For customer service call1-888-PNC-BANK between the hours of ,6 AM and Midnight ET. Para servicio en espar'iol, 1-866-HOLA-PNC Moving? Please contact us at 1-888-PNC-BANK 81 Write to: Customer Se,rvice PO Box 609 Pittsburgh PA 15230-9738 Q Visit us at pnc.com 'I-TDD~~'~~~~~8~~-~;;1~~8 .For hearing impaired clients only rn double Visa Extras points when you use your enrolled PNC Bank Visa Check Card for qualifying purchases on I"andomly ected Mystery Bonus Days between Oct 1 and Dec 31, 2006. Visit any branch or www.pnc.comlextras for prol~ram details. Igular Checking Account Summary :ount number: 50-7002-6444 June I Short Deed Beginning balance 5,100.25 Deposits and other additions 1,892.34 Checks and other deductions 6,959.25 End i ng balance 33.34 Please see the Activity Detail section for additional information. llance Summary Average monthly balance Charges and fees 1,993.49 .00 :tlvity Detail tposits and Other Additions Amou nt Descrl ptlon '02 705.00 Tel 0400004102 0006 Transfer From XXXXXX5729 '02 140.00 Tel 04000041020007 Transfer From XXXXXX8284 ID3~I,Oi4.00'--Di;ect Deposit - Soc Se-c-----~---- ---..- US Treasury 303 XXXXX5280A 115 33.34 Reverse ACH Debit Effective 11-14-06 There were 4 Depos:its and Other Additions totaling $1,892.34. ;--_,,"'-:'..-'lIii.~~~~:.-___...,.,_. -___.__..'--..___,.....,._,..-__.-._" ~.. ~.". leeks and Substitute Checks ck Date Iber Amount paid ,5 2,224.40 10/25 ,6 80.00 10/31 ,7 91.31 11/03 Reference number Check number Amount 64.70 2,850.00 Date paid 11/06 11/07 Reference number 026426194 025642262 024471422 026083970 024748179 5358 5359 ap in check sequence There were 5 check~; listed totaling $5,310.41. There was 1 Bankin,g Machine Withdrawal totaling $20.00. nking/Check Card Withdrawals and Purchases Amount Description '30 20.00 ATM Withdrawal Main & Market Sts FORM953R-1005 ltegular. Checking Account Statement :..r"":-" j, ~ For 24-hollr information, sign on to PNC Bank Online Banking on pnc.com. Account number: 50-7002-6444 - continued tnline and Electronic Banking Deductions ate Amount Description VlO 1,014.00 Direct Payment - Reversal US Treasury 303 XXXXX5280A V14 33.34 Direct Payment - Ins Prem Monumental Life Mm1732065 For the period 10/24/2006 to 11/21/2006 JUNE I SHORT DECD Primary account number: 50-7002-6444 Page 2 of 3 There were 2 Online or Electronic Banking Deductions totaling $1.047.34. There were 2 Oth,sr Deductions totaling $581.50. tther Deductions 1/15 1/15 Amount Description .00 Outstanding Item Close 581.50 Debit Memo Reference No 027512308 ate taily Balance Detail ate Balance Date Balance Date Balance Date Balance 0/24 5,100.25 10/31 2,775,85 11/06 4,478.84 11/14 581.50 0/25 2,875.85 11/02 3,620.85 11/07 1,628.84 11/15 33.34 0/30 2,855.85 11/03 4,543.51 11/10 614.84 aviitgs Account Statement ~c Bank e~ PNCBANK For the period 10/01/2008 to 12/31/2008 Primary account number: !iO-3000-8284 Page 1 of 2 Number of enclosures: 0 JUNE I SHORT DECD 709 5 FREDERICK 5T MECHANICSBURG PA 17055-6407 lQl For 24-hour banking, and transaction or .b3 interest rate information, sign on to '!l" PNC Bank Online Banking at pnc.com. For customer service call1-888-PNC-BANK between the hours of 6 AM and Midnight ET. Para servicio en espallol, 1-866-HOLA-PNC MovinU" Please contact lIS at 1-888-PNC-BANK I2!SI Write to: Customer SElrvice PO Box 609 Pittsburgh PA 15230-!1738 C Visit us at pnc.com .b3 Iil TDD terminal: 1-800-~~1-164~-..- For hearing impaired client.. only ~PORTANT ACCOUNT INFORMATION nendment to the Consumer Schedule of Service Charges and Fees e infol1nation stated below amends ce11ain infol1l1ation in our Consumer Schedule of Service Charges and Fees. All other infonnation in : Schedule continues to apply to your account. Please review the following infonnation and retain it with your records Teclive Febrl1al1' 2, 2007 .her Aecol1nt Charges and Senices nsufficientJUnavailable Funds Fee $31 - $36 per item based on the number of insufficienUunavailable items during the current and previous eleven service charge cycles: 1 -- 3 items $31 4 -- 6 items $34 7 or more $36 ~ontinuous Overdraft Fee , $6 assessed each day your account remains ovemrawn for a period.greater than 4 consecutive cnlendar days, up to a maximum of$30. 111is charge is in addition to any insufficient/unavailable fhnds fees assessed. tel"naf.ional Seniees ntemotional Checks , $40 per check June I Short Decd livings Account Summary count number: 50-3000-8284 .Iance Summary Beginning balance 147.85 Deposits and other additions .05 Checks and other deductions 147.90 Endi ng balance .00 As of 12/31, a total of $.47 in interest was paid this year. terest Summary Annual Percentage Yield Earned (APYE) 0.00% Number of days I n I nterest peri od Average collected balance for APYE Interest Paid thl s period o .00 .00 FORM953R.'005 Savings 'Account Statement 0/31 Amount Description .05 Inter:s.t..~a.yme~:~_ For the period 10/01/2006 to 12/31/2006 JUNE I SHORT DECO Primary account number: 50-3000-8284 Page 2 of 2 There was 1 Deposit or Other Addition totaling $.05. - ~ For 24-hour information, sign on to PNC Bank Online Banking on pnc.com. Account number: 50-3000-8284 - continued leposits and Other Additions late 1/02 1/15 1/15 Amount 140.00 .00 7.90 Description Tel 04000041020007 Transfer To XXXXXX6444 Outstanding Item Close Debit Memo Reference No 027512306 There were 3 Other Deductions totaling ~.147.90;. )ther Deductions late )aily Balance Detail .ate 0/01 Balance 147.85 Date 10/31 Balance 147.90 -- Date llL2!. Balance 7.90 Date 11/15 Balance .00 Date: 06-01-2007 ..-~:::::::::-~ www.haat~s.com Settlement Se 11 et~: 223 ---- Item HAAR'S AUCTION GERORGE ARNSBAUGH 223 SILVER SPRINGS RD MECH PA 17050 De sct"' i pt i on 717--/+32-8246 Pt~ ice Qt ~,I f0 Page: ~ ..::, ----------------------------------------------.----------------------------------- Total ww~..,. haat~s .co m Light-table-sewing machine Treadle sewing machine Night stand Fan Don k e y--c.:n~t Li.bt~at~y table Chair-pottie-heater Reft~i gel'~at Ot- 2 ch a i t~ s Stand Fan Light s Dt~esset~ Paper cut t et~ Gt~een dresset~ Ca5e-coolet~ Heat et"'-smoket" Sewing cabinet Tt"'..mk Fl'''ame-pict Ut~e File cabinet Headboard Lawn chait~s Cha i t..s Card table-chairs Sectional bookcase Sectional bookcase Chest of dt'awet~s T abl e-chait..s Gt~een bool{case Empi t"e chest Wat'drobe Commission at 40.0001- HAAR'S AUCTION Items: 124 Amount: 280.80 Less adjustments: Net due to seller: ~ (.5 /-~7 717-432-8246 ~~ :1 :1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0. c:500 17.00 2.00 0.7500 10.00 15.00 0.2500 25.00 0.7500 6.00 1. 00 0.2500 12.00 3.00 12.00 1. 00 5.00 35.00 5.00 0.2500 1. 50 0.2500 2.00 0.2500 8.00 230.00 1. 00 5.00 0.5000 50.00 45.00 20.00 \ 702.00 -280.80 421. 20 Ji'1~9':\- ~ . 7y/, I'> REV-1508 EX+ (6-98) '*' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF June I. Short FILE NUMBER 21-06-1008 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 NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. PNC Bank, N.A., Checking Account No. 5070026444 2,775.85 147.90 2. PNC Bank, N.A., Savings Account No. 5030008284 3. Haar's Auction, Net proceeds from sale 741.10 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 3,664.85 REV-1S11 EX+ (12-99>* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Myers Funeral Home 37 West Main Street, Mechanicsburg, PA 17055 1 60.40 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 1,500.00 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Lester W. Erb, Inc., fuel oil 8. PP&L, electric 9. Borough of Mechanicsburg, sewer and refuse 10. United Water 11. Holy Spirit Hospital, medical bill 12. Register of Wills - Filing Fee inheritance tax 252.00 TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) 459.78 112.32 224.32 59.97 93.37 15.00 $ 12,877.16 *' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 6486 HARRISBURG. PA 17105-8486 January 12, 2007 J ROBERT STAUFFER J ROBERT STAUFFER ESQ 1 WEST MAIN STREET MARKET SQUARE BUILDING MECHANICSBURG PA 17055 Re: JUNE SHORT CIS #: 960183316 SSN: 204-01-5280 Date of Death: 11/01/2006 Dear Mr. Stauffer: Please be advised that the Department of Public Welfare maintains a claim in the amount of $17,701.33 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $17,701.33, was incurr'ed 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 Fiducia.ries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $.00, is to be entered as a priority Class 6 claim against the estate. ---- Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assesElment, and a current appraisal, if available. Sincerely, " 'r",u.'-.x::::r,~bn d 1'-- Jessica L. Strawbridge TPL Program Investigator 717-772-6238 717-772 -6553 FAX Enclosure REV-15t2 EX+ (12-03) '* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF June I. Short FILE NUMBER :21-06-1008 Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unrelmbursed medical expensas. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Commonwealth of Pennsylvania Department of Public Welfare, Claim for Medical Assistance 17,701.33 ; TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) . 17,701.33 . REV.15~3 EX+ (9-00) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF June I. Short fILE NUMBER 21-06-1008 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)] 1. Sandra Amsbuagh 223 Silver Spring Rd., Mechanicsburg, PA 17050 Daughter one half of estate 2. Treva Short 48 West Allen Street, Mechanicsburg, P A 17055 Daughter on half of estate I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET U NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size)