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HomeMy WebLinkAbout09-06-07 (3) 2- / -Ol-O~L~ REV-1731-1 EX + (9-00) .. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 This affidavit must be completed and sworn to by a person having per.9ltill:khcNde~ of=ttrWie facts, preferably by a surviving spouse or member of the decedent's family. Name of Decedent (,Dale.~ peath DORA J. SHUMATE Co. '-' 04l.2Q12007-; Legal Address at Time of Death: Street Address NONRESIDENT DECEDENT AFFIDAVIT OF DOMICILE VA Zip Code 24312 RFD #1 Cily/Borough AUSTINVILLE State The following information is submitted in support of the statement that the above individual was not domiciled in the Commonwealth of Pennsylvania at the date of death. 1. Names and addresses of the decedent's surviving spouse and members of his/her immediate family: Name and relationship to decedent THOMAS K. SHUMATE - SON Street Address 406 SPRING HOUSE ROAD Name and relationship 10 decedent SUSANNE M. SHUMATE - DAUGHTER-IN-LAW SlreetAddress 406 SPRING HOUSE ROAD Name and relationship to decedent City/Borough CAMP HILL State PA Zip Code 17011 City/Borough CAMP HILL State PA Zip Code 17011 City/Borough State Zip Code Street Address 2. Did the decedent ever live in Pennsylvania? If yes, during what periods? o Yes Ja No 3. Did the decedent spend time in Pennsylvania during the fIVe years preceding death? 1/ Yes If yes, during what periods and at what address? THE ONLY TIME SPENT IN PA WAS DURING THE LAST TWO WEEKS OF DECEDENT'S LIFE, AND SHE STAYED 0 IN CAMP HILL, I MOVED HER TO PA SO THAT I COULD OVERSEE HER CARE. MY RESPONSIBILITIES HERE IN 0 PA WOULDN'T PERMIT ME TO ADEQUATELY OVERSEE HER CARE, HAD SHE REMAINED IN VA. o No 4. What was the nature of decedent's places of residence during the five years immediately preceding death? Indicate whether decedent resided in a house or apartment and whether it was rented or owned by the decedent, and/or whether decedent resided in a hotel or the home of relatives or friends, SEE ATTACHED STATEMENT. 5. Was the decedent employed during the five years preceding death? If yes, list the name and address of employer(s). o Yes II No 6. Did the decedent leave a will? 1/ Yes 0 No If yes, state the court which admitted the will 10 probate, the date admitted, and attach a copy, including all codicils, and a certificate of issuance of letters testamentary. CARROLL COUNTY, VIRGINIA, ADMITTED ON MAY 1, 2007 7. If the decedent did not leavea will, hasan administrator of his estate been appointed? 0 Yes 0 No If yes, state the court which appointed the administrator, the date of appointment, and attach a certificate of the issuance of letters of administration. N/A 8. At any time during the last fIVe years did the decedent execute a will, a codicil, trust indenture, deed, mortgage, lease or any other document in which the decedent was described as a resident of Pennsylvania? 0 Yes II No If yes, describe such document. v NONalSIDINT DICIDINT AFFIDAVIT OF DOMICILI (continued) 9. Had the decedent paid a tax on income or on intangible property to any state, county, or municipality during the last five years? If yes, where and when was it paid? ,a Yes 0 No Page 2 DECEDENT PAID VA STATE AND PERSONAL PROPERTY TAXES, AND ALSO PAID All COUNTY AND REAL ESTATE TAXES ASSESSED BY THE APPROPRIATE VA COUNTY, IN EACH OF THE PAST FIVE YEARS. a 10. To what regional office of the Internal Revenue Service did the decedent forward his Federal Income Tax returns during the last fIVe years preceding death? 2001 - MEMPHIS, TN 2002 - MEMPHIS, TN 2003 - MEMPHIS, TN 2004 - SAN FRANCISCO, CAD 2005-ATLANTA,GAD 2006 - A TLANT A, GA 11. At the time of death, did the decedent own, individually or jointly, any interest in real property, including lease-holds or tangible personal property located in Pennsylvania? 0 Yes JrJ No If yes, describe the property in detail. 12. In what business activities was the decedent engaged during the last five years preceding death? Indicate whether decedent was employed or otherwise engaged in business, and state the names and the addresses of the persons, firms or corporations with which the decedent had such business affiliations. ( Except for employer listed in #5 ) OPERATION OF FARM IN AUSTINVillE, VA 13. What is the estimated gross value of the decedenfs estate, wheresoever situated, exclusive of real property and tangible property located outside of Pennsylvania? $450,000 14. At the time of death, did the decedent own or operate an automobile? If yes, in which slate was it reQistered? VIRGINIA ,a Yes o No Yes 0 No 15. At the time of death, was the decedent a member of a church or any other organization ? ~ If yes, provide the name and address of the church or any other organization. TRINITY UNITED METHODIST CHURCH, AUSTINVillE, VA 16. State the purpose or reason the decedent owned real property in Pennsylvania. N/A 17. Include any other information you wish to submit in support of the contention that the individual was not domiciled in Pennsylvania at the time of death. If more space is needed, insert additional sheets of same size. I OPENED THE CITIZENS BANK ACCOUNT, #6218189094, STRICTLY TO MORE EFFICIENTLY MANAGE HER D FINANCIAL AFFAIRS DURING HER IllNESS. Name of person completing affidavit Relationship to decedent THOMAS K. SHUMATE Street Address c.{6G 5~tr-lr~ l4u.>e.rAd., SON PA Zip Code 17011 City ~~ If/f/ Slate Under penalties of perjury, I declare that based on my personal knowledge of the decedent, the information provided on this form is true, correct and complete. Signature of person completing affidavit Date ~/.;( ~oC-7 ESTATE OF DORA J. SHUMATE Form REV-1737-1 EX SSN 226-10-1432 QUESTION #4. DECEDENT LIVED IN BRISTOL, VA, AT THE HOME OF RELATIVES. THIS RESIDENCE WAS THE HOME OF DECEDENT'S SISTER, AND DECEDENT MOVED THERE TO ASSIST WITH HER SISTER'S MEDICAL CARE. UPON THE DEATH OF HER SISTER, THE RESIDENCE PASSED TO DECEDENrS NEPHEW, BUT SHE WAS PERMITTED TO REMAIN AT THE RESIDENCE. DURING THIS PERIOD, DECEDENrS PERSONAL PROPERTY WAS LOCATED AT THE HOUSE SHE OWNED IN AUSTINVILLE, VA AND IN A MOBILE HOME WHICH WAS ALSO OWNED BY THE DECEDENT, BUT SITUATED ON LAND WHICH WAS RENTED BY DECEDENT AND LOCATED IN GALAX, VA.