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Home My WebLink About02-0192DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 [ / 7- INHERITANCE TAX RETURN RESIDENT DECEDENT 2. Stocks and Bonds (Schedule B) (2) , , 3. Closely Held Corporation.Partnership or Sole-Propdetomhip (3) , , ...~ 4. Mortgages & Notes Receivable (Schedule D) (4) , , i' 5. Cash, Bank Deposits & Miscellaneous Pemonal Property (5) (Schedule E) , ,~ 6. Jointly Owned Properly (Schedule F) (6) ~ 3' 4 ~ 1 3 9 . 0 9 -I 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) ::) (Schedule G or L) , , · ~ 8. Total Gross Assets (total Lines 1-7) (8) 3 4 1 3 9 0 < O 9. Funeral Expenses & Administrative Costs (Schedule H) (9) ~ 5 ~ 9 6 1 · 0 0 n, 10. Debts of Decedent. Mortgage Liabilities, & Liens (Schedule l)(10) , ~ 7 7 1 · 7 8 11. Total Deductions (total Lines 9 &10) (11) , 6 ~ '7 3 2 . '7 8 12. Net Value of Estate (Line S minus Line11) (12) ~ 2 7 , 4 0 6 · 3 1 13. Charitable and Governmental Beques~Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line12 minus Line13) (14) ~ 2 7 , 4 0 6 · 3 1 15. Amount of line 14 taxable at the spousal tax rate , 2 7~ 4 0 6. 3 1 x .0 45 (15) , 1 ,2 3 3 · 2 8 See instructions on reverse side for applicable percentage 16. Amount of line 14 taxable ~ at6% rate , , . x .06 (16) , , 17. Amount of line 14 taxable s; at 15% rote ~ , x .15 (17) O ~ 18. TaxDue (18) ~ 1, 2 3 3. 2 8 19. ~ · > > BE SURE TO ANSWERi,'~QUESTIONS~RE~ERSE SiDE ~AND RECHECK MATH < < Under pefmlti~ of pe~iury, I declare that I have examined ~is return, including accomp~ying schedules ~ statements, and to ~e best of my knowledge ~ belief, it is true, correct and compiate, Declaration of preparer other than the pen',ona~ representative i.bas~l on a~l .fon'nation of v/hich omDarer h. any knowledge. /~~/' '~' DAT~-~'~T~~ SIGI~ATU.RE OF PEI:J~ON FJ~SffON$1B[E FOR FILING RETURN . AODR~ESS ~iG't'NATURE'OF'~'REPt~ER O~g"~rTHAN REPRESENTATIgE' AI~ESS DA THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS [] 3. Remainder Return (~ate o~ea~ pn~to 12-13-82) [] 5. Federal Estate Tax Return Required __ 8. Total Number of Safe Deposit Boxes [] 11. Election to tax under Sec. 9113(A) (Atach Sc~ O) DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) use a blank block to se~ar#a Z S H A F F ER M I L D R E D W III SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH "' 166 -14 -2211 /04 /2001 12 / 22 / LU (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURrP( NUMBER I E~ 1. original Return [] 2. Supplemental Return [] 4. Limited Estate [] 4a. Future Interest Compromise (daa of ~ a~r 12.12.82) [] 6. Decedent Died Testate (Attach co~y of W~) [] 7. Decedent Maintained a Living Trust (Attach copy of Trust) [] 9. Libation Proceeds Received [] 10. Spousal Poverty Credit (date ofd.m ~t~n 12-31-91 aad 1-1-95) ~_ THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE!AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Z ~j NAME COMPLETE MNUNG ADDRESS oZ Mindy S. Goodmanr Attorney at Law 2215 Forest Hills Drive e3°- FIRMNAME (,f~pl~a~) Suite 35 ~' Harrisburg, rv TELEPHONE NUMBER ~'~ T' ' ~ (717)540-8742 1. Real Estate (Schedule A) (1) ~ Decedent's Complete Address: STREET ADDRESS 44:2. ~'ln]~- Rc~f-i-c)m CrTY ISTATE PA I z~P 17013 Carlisle Tax Payments and Credits: 1. Tax Due (Page 1 Line 18) Credits/Payments A. Spousal Poverty Credit B, Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) 4. If line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 19 to request a refund 5. If line 1 + tine 3 is greater than line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make (1) 1,233.28 Total Credits ( A + B + C ) (2) 6 1 . 6 6 (3) (4) (5) 1 , 1 71 . 62 (5^) (SB) 1,1 71.62 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; ............................................................. [] [] b. retain the right to designate who shall use the property transferred.or its income; ................ [] [] c. retain a reversionary interest; or ............................................................................................. [] [] d. receive the promise for life of either payments, benefits or care? ......................................... [] [] 2. If death occurred on or before December 12, 1982, did decedent within two years preceding death transfer property without receiving adequate consideration? If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate cons derat on'~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ...................................................................................................................... [] [] 4. Did decedent own an individual retirement account, annuity, or other non-probate property? .... [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN 72 P.S. §9116 (a) (1,1) (i) provided for the reduction of the tax rate imposed on the net value of transfers to or for the use of the surviving spouse from 6% to 3% for dates of death on or after July 1, 1994 and before January 1, 1995. 72 P.S. §9116 (a) (1.1) (ii) provided for the reduction of the rate imposed on the net value of transfers to or for the use of the surviving spouse from 3% to 0% for dates of death on or after January 1, 1995. 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 JANUARY 1, 1995 - Please answer the following question by placing an "x" in the appropriate space. Did the decedent create a trust or similar arrangement which is solely for the surviving spouse's benefit for his or her entire lifetime? Yes [] No [] If you answered yes to the above question, the tax on the trust or similar arrangement is postponed until the death of the second spouse, at which time it will be fully taxable at the rate(s) applicable to the remainder beneficiary(les). Enter the value of the trust on Schedule J, Part II, in order to remove it from the calculation of the tax due in this estate. You may wish to file Schedule O in order to make the election available under Section 9113. If the election is made, the trust or similar arrangement is taxed in the estate of the first decedent spouse, the portion of the trust or similar arrangement which benefits the surviving spouse is taxed at the zero tax rate, and the remainder is taxed at the rate(s) applicable to the remainder beneficiary(les). If you choose to make the election, you must attach Schedule O to a timely-filed tax return, along with Schedule(s) K and/or M in order to show the apportionment of the trust or similar arrangement between the surviving spouse and the remainder beneficiary(les). COM~IONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mildred Winifred SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER Shaffer If an asset was made joint within one year of the decedent'a data of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A Karl L. Shaffer 6249 Harding Avenue, Harrisburg, PA 17112 Son JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEAT~ ITEM FOR JOIN T MADE Include name of financial instituti(m and ba~k account number o( similar ideflt~/ing number. Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed fo~ joinl~y.held real estate. VALUE OF ASSET INTEREST DECEDENTS INTERE$ ~ A. 9/97 PSECU Savings Account 0166142211-1 $ 2,540.66 50% $ 1,270.. 2. A. 9/97 PSECU CD No. 0166142211-57 $ 6,003.34 50% $ 3,001.~ 3. A. 9/97 PSECU CD No. 0166142211-50 $ 5,002.88 50% $ 2,501.. 4. A. 9/97 PSECU Checking Account 0166142211- $ 6,638.21 50% $ 3,319. 5. A. 9/97 PSECU CD No. 0166142211-51 $20,010.68 50% $10,005. 6. A. 9/97 PSECU CD No. 0166142211-52 $ 5,002.88 50% $ 2,501. 7. A. 9/97 PSECU CD no. 0166142211-56 $20,010.02 50% $10,005. 8. A. 9/97 ~o~m~r~ C~.No. 0542044441 $ 3,069.51 50% $ 1,534. TOTAL(Also enter on line 6, Recapitulation) $ 3 4,1 3 9.0 9 (If more space is needed, insert additional sheets of the same size) COHMONNEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREA~ OF INDIVIDUAL TAXES DEPT. 280601 , HARRISBURG, PA 171Z8-0601 RE¥-XS4$ EX M:P (Il-nS) KARL L SHAFFER 6Iq9 HARDING AVE HaG PA 17112 TNFORHATZON NOTZCE AND ACN TAXPAYER RESPONSE DATE FILE NO. 22 02101909 01-25-2002 EST. OF MILDRED K SHAFFER S.S. NO. 166-1q-2211 DATE OF DEATH 12-0q-2001 COUNTY DAUPHIN TYPE OF ACCOUNT [] SAVINGS [] CHECKING [] TRUST [] CERTIF. REMTT PAYMENT AND FORMS TO: REGISTER OF WILLS DAUPHIN CO COURT HOUSE HARRISBURG, PA 17101 PSECU hms provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that mt the death of the above decedent, you were a Joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain erittan correction from the financial institution, attach a copy to this fora and return it to the above address. This account is taxable in accordance with the inheritance Tax Lams of the Commonwealth of Pennsylvania. Questions may be answered by calling (717) 787-6327. COMPLETE PART I BELOW N N ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 01661q2211-1 Data 09-08-1997 Estibllshed Accoun* Balance 2,5qO. 66 Percent Taxable X 50 · 000 Amount Subject to Tax 1., Z70.55 Tax Rate X . Oq5 Potential Tax Due 57.16 To ln~ure proper credit to your account, two (Z) copies of this notice must accompany your payment to the Register of Hills. Hake check payable to: "Register of Wills; Agent". NOTE: If tax payments arm made wlthin three (3) months of the decedant's date of death, you may deduct m 5Z discount cf the tax due. Any lnhmrttance tax due emil become delinquent nine (9) months after the date of death. PART TAXPAYER RESPONSE A. [] Thm mbove inforletion mhd tmx due is correct. l. You may choose to remit payment to the Register of Nil1/ with two copies of this notice to obtain a discount or avoid interest, or you IIY check box "A" and return this notice to the Register of CHECK -~ Hills and an official assessment will be issued by the PA Department of Revenue. ONE BLOCK s. [] The above asset has been or w111 be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the decedent's representative. C. [] The above information is Incorrect and/or debts and deductions were paid by you. YOU lust complete PART [] and/or PART [] below. PART If you indicate m different tax ra~e) please state your [] relationship to decedent: TAX RETURN - COMPUTATZON OF TAX ON JOZNT/TRUST ACCOUNTS LINE 1. 2. Account Balance 2 $. Percent Taxable $ X q. Amount Subject to Tax q 5. Debts and Deductions 5 - 6. Amount Taxable 6 7. Tax Rata 7 X B. Tax Due 8 PART DATE PAID DEBTS AND DEDUCTIONS CLAZMED PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line $ of Tax Computation) $ Under penalties of perjury, I declare that the fmcts I hmvm reported above ire true, correct and complo'~:e to the best of my knowledge mhd bel:Lef. HOME ( ) WORK ( ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE COHHON~EALTH OF PENNSYLVANIA DEPAR~NENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. lBO601 , HARRISBURG, PA 17128-0601 REV-~S~5 EX &FP KARL L SHAFFER 6Iq9 HARDING AVE HaG PA 17111 ZNFORHATZON NOTICE AND TAXPAYER RESPONSE FZLE NO. 22 ACN 02101916 DATE 01-25-2002 TYPE OF ACCOUNT F. ST. OF MILDRED K SHAFFER [] SAVINOS S.S. NO. 166-1q-2211 [] CHECKING DATE OF DEATH 12-0q-2001 [] TRUST COUNTY DAUPHIN [] CERTZF. REHZT PAYHENT AND FORHS TO: REGTSTER, OF WTLLS DAUPHIN CO COURT HoUsE HARRISBURG· PA 17101 PSECU has provided the Deportment with the in~ormatian listed below ehl~h has been used in calculating tho potentiml tax due. Their records indicate that at the death cf the above decedent, you ware · Joint owner/beneficiary of this account. If you foe1 this information is incorrect, please obtain written correction from the financial institution, attach m copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions amy bm mnsemrod by calling (717) 757-B$ZT. COMPLETE PART 1 BELOW ~ ~ ~ SEE, REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 01661~2211-57 Data 09-08-1997 Established Account Balance 6 · 00:~. ~ Percent Taxable X 5 0.0 0 0 Aeount Subject to Tax 5· 001.67 Tax Rata X · 0~5 Potential Tax Duo 1~5.08 To insure proper credit to your account, two (2) copies of this notice must accompany your payment to the Register of Wills. Hake check payable to: "Register of Wills, Agent". NOTE: If tax payaents are aada within three ($) months of the dacadmnt's dmte of death, you coy deduct a SZ discount of the tax due. Any inheritance tax due will become delinquent nine (9) months mftmr the date of death, PART TAXPAYER RESPONSE A. [] Tho above information and tax due 1s correct. l. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you may check box "A" end return this notice to the Register of CHECK -~ Wills end an official assessment will be issued by the PA Department of Revenue. ONE BLOCK B. [] The above asset has been or will be reported end tax paid with tho Pennsylvania Inheritance Tax return ONLY to be filed by the docsdant's representative. C. [] Tho above information is incorrect and/or debts and deductions were paid by you. YOU mUSt complete PART [] end/or PART [] below. PART Tf you indicate · different tax rate· please state your [] relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Data Established 1 2. Account Balance 2 3. Percent Taxable 3 ~ q. Amount Subject to Tax q 5. Debts end Deductions 5 - 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 PART DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) $ Under penalties of par~lury, Z declare that the facts 1' have reported above ere true, correct and complete to the best of my knowledge and belief. HOME ( ) WORK ( ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE COHHONNEALTH OF PENNSYLVANIA DEPAR~NENT OF REVENUE BUREAU OF INDIVIDUAL TAXES D£PT. ZB0601 · HARRISBURG, PA 1712B-0601 REVo~S EX &FP ZNFORHATZON NOTZCE AND TAXPAYER RESPONSE FZLE NO. 22 ACN 02101911 DATE 01-25-2002 EST. OF HILDRED K SHAFFER S.S. NO. 166-1q-2211 DATE OF DEATH 12-0q-2001 COUNTY · DAUPHIN KARL *L SHAFFER 62q9 HARDING AVE HBG PA 17112 TYPE OF ACCOUNT [] SAVINGS [] CHECKING [] TRUST [] CERTIF. REHTT PAYHENT AND FORNS TO: RESISTER OF WILLS DAUPHIN CO COURT HOUSE HARRISBURG, PA 17101 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decadent, you ware a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach · copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may bm answered'by calling (717) 787-8327. COMPLETE PART 1 BELOW ~ ~ ~ SEE REVERSE SIDE FOR FZLING AND PAYMENT ZNSTRUCTZONS Accoun~ No. 01661~Z211-50 Da*a 09-08-1997 Es/(abllshed Accoun~ Balance 5,002.88 Parcen~ Taxable X 50. 000 Amoun~ Subjec~ ~o Tax 2,501 · Tax Ra~e X · 0~5 Po~en~ial Tax Due To Insure proper credit to your account, two (Z) copies of this notice must accompany your payment to tho Register of Wills. Hake check payable to: "Register of Wills, Agent". NOTE: If tax payments are made within three ($) months of the decadent's date of death, you may deduct a 52 discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the data of death. PART TAXPAYER RESPONSE A. ~ The above information and tax due Js correct. 1. You lay choose to remit payment to ~e Register of g[Zls ~1~ t~o copies of this not[ce to obtain CHECK a d~scount or avoid interest, or you amy check box "A" and ra~rn this notlce to ~e Register of BLOCK B. ~ The above asset has been or ~lll be reported and tax paid ~I~ the Pannsylv~la I~mrttance Tax return ONLY to be fJZed by ~e decedent's repre~ntatJve. C. ~ The above information [s Incorrect and/or debts and deductions ~ere paid by you. You oust coop[eta PART ~ and/or PART ~ PART If you ind/ca~m a dtfferen~ ~ax ra~e~ please s~m~m your rela~ionshlp ~o decedent: TAX RETURN - COHPUTATZON OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Da~a Es~abl/shad 1 2. Accoun~ Belmnce 2. 3. Percen~ Taxable 3 q. Aaoun~ Subjac~ ~o Tax $. Debts and Deductions 6. Aaoun~ Taxable 6 7. Tax Ra~e 7 8. Tax Due PART DATE PAID DEBTS AND DEDUCTZONS CLAIMED PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line $ of Tax Computation) $ Under penalties of perjury, Z declare ~ha~ ~he fac~s ! have raper*ed above ara ~rue, correc~ and complete ~o ~:he bas~ of my knowledge and belief. HOME ( ) WORK ( ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE COMMONHEALTH OF PENNSYLVANZA DEPARTMENT OF REVENUE BUREAU OF INDZVXDUAL TAXES DEPT. Z80601 'HARRISBURG, PA 171ZB-0601 ZNFORHATZON NOTZCE AND TAXPAYER RESPONSE FILE NO. 22 ACN 02101910 DATE 01-25-2002 EST. OF MILDRED K SHAFFER , * S.S. NO. 166-1q-Z211 DATE OF DEAT~ 12-0q-2001 COUNTY DAUPHIN KARL L SHAFFER 62q9 HARDING AVE HBG PA 17112 TYPE OF ACCOUNT [] CHECKZNg E~ TRUST [] CERTTF. REMTT PAYMENT AND FORMS TO: REGISTER OF WILLS DAUPHIN CO COURT HOUSE HARRISBURG, PA 17101 PSECU has provided the Depertaont with the Information listed below which has been used in calculating the potential tax due. Their records indicate that Bt the death of the above decedent, you ware a joint owner/beneficiary of this account, if you feel this information Is incorrect, please obtain written correction from the financial Institution, attach a copy to this fore and return it to the above address. This account Is taxable In accordance with the Inheritance Tax La~s of the Commonwealth of Pennsylvania. Questions may be ans,erad by calling (717) ?BT-85ZT. COMPLETE PART ! BELOW # # N SEE REVERSE SZDE FOR FZLZNG AND PAYMENT. ZNSTRUCTIONS Account No. 01661q2211-~ Date : 09-08-1997 Established Account Balance 6,658.21 Percent Taxable X 50. 000 Amount Sub:iect to Tax :~,$19.11 Tax Rate X · Oq5 Potential Tax Due lq9.~6 To insure proper credit to your account, two CZ) copies of this notice must accompany your payment to the Register of Rills. Hake check payable to: "Register of #111s, Agent". NOTE: If tax payments are made ~lthln three (3) months of the dacmdent's date of death, you ~ay deduct e SZ discount cf the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. PART TAXPAYER RESPONSE ,,,, ..................... .,., ~,..,- ..... ¢I' qi? !" '.' .' '.P~,' ......... .'.' ." I. [] The above Information and tax due Is correct. ~. You may choose to remit payment to the Register of #Ills with two copies of this notice to obtain CHECK a discount or avoid interest, or you amy check box "A" and return this notice to the Register of BLOCK B. [] The above asset has been or will be reported and tax paid w/th the Pennsylvania Inheritance Tax return ONLY to be filed by the dacedont's representative. C. [] The above information Is incorrect and/or debts end deductions were paid by you. You lust coapleta PART [] and/or PART [] bmloe. PART ]:f you :LndLca~e · dtfferen~ tax rata, please state your relationship to decedent: TAX RETURN - COMPUTATZON OF TAX ON JOZNT/TRUST ACCOUNTS LZNE 1. Date Es*ablLshed 1 2. Accoun* Balance 2 $. Percent Taxable 3 ~ q. Amount SubSect to Tax q $. Debts and Deductions S - 6. Amount Taxable 6 7. Tax Rata 7 ~ 8. Tax Due 8 PART DATE PAID DEBTS AND DEDUCTTONS CLAZME;I PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line $ of TJX CoeduCation) $ Under plnllttll of perjury, T declare that the facts ! have reported above are true, correct and complete ~:o the best of my knowledge and bailer. HOME ( ) NORK ( TAXPAYER S~GNATURE TELEPHONE NUMBER DATE ' COH~ONHEALTH OF PENNSYLVANIA DEPARTNENT OF REVENUE BUREAM OF INDIVIDUAL TAXES DEPT. Z80601 'HARRISBURG, PA 171Z8-0601 RE¥-15¢$ EX AFP (G4)-OG) KARL L SHAFFER 62q9 HARDING AVE HaG PA 17112 ZNFORHATZON NOTZCE AND TAXPAYER RESPONSE FILE NO. 22 ACN 02101912 DATE 01-25-2002 TYPE OF ACCOUNT EST. OF MILDRED K SHAFFER [] SAVZNGS S.S. NO. 166-1q-2211 [] CHECKTNG DATE OF DEATH 12-0~-2001 [] TRUST COUNTY DAUPHIN [] CERTTF. REHIT PAYHENT AND FORHS TO: REGISTER OF WILLS DAUPHIN CO COURT HOUSE HARRISBURG, PA 17101 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were · joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial lnstitut/on, at~ach a copy to this fora end return it to the above address. This account is taxable in accordance with the Z~erJt~ca Tax LaMS of the Coa.onwealth of Pennsylvania. guestJ~s may bi ensuered by calling (717) 787-85Z7. COHPLETE PART ~ BELON . . . SEE REVERSE SZDE FOR FZLZNG AND PAYHENT ZNSTRUCTZONS · coopt ,o. 0~66~Z2~-5~ .~te 09-08-~997 zo insure proper cr.d~t to ~our .ccaunt, Established (Z) capias of ~Js notice must accompany ~our Accoun~ B,~ance 20 ~ O~ O. 68 p.yl~t to ~. R.gJ,t.r of ~ll~s. ~.k. check payable to: "Register of NJ~s, Agent". Percen~ Taxable X 50. 000 NOTE: Zf tax payments are made ,~ln three Amoun~ SubJec~ ~o Tax ~ 0 ~ 005. ~ (5) .on~, of ~e decedent's date of dea~ Tax Ra~e X . 0~5 you may de,ct a 5Z discount of ~e t.x due. Any Jnher~nc. tax due ~li becoee delinquent Po~en~a~ Tax Du~ ~50. ~ nine (9) monks after ~. date of death. ~*~z TAXPAYER RESPONSE CHECK ONE BLOCK ONLY PART TAX L/NE I. []The lbOVe Information and tax due is correct. 1. You Ily choose to remit peylent to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you lay check box "A" and return this notice to the Register of Hills and an official assesseent wilI be issued by the PA Department of Revenue. B. [] The above asset has been or wiIi be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the decedent's representative. C. l-'lThe above lnforeation is incorrect and/or debts end deductions were paid by you. You lUSt complete PART [] and/ar PART [] below. If you indicate · different tax rata, please state your relationship to decedent: RETURN - COMPUTATZON OF TAX ON JOZNT/TRUST ACCOUNTS Z. Data EstabZlshed I 2. Account Balance 2 $. Percent Taxable $ X ~. Amount Subject to Tax q $. Debts and Deductions $. - 6. Amount Taxable 6 7. Tax Rata 7 X 8. Tax Due 8 PART DATE PAID DEBTS AND DEDUCTIONS CLAZMED PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line $ of Tax Computation) $ Under penelt:les of perjury, Z declerl that ~he facts ! have reported mi>ova ara true, correct and complete to the bast of my knowledge mad belief. HOME ( ) WORK ( ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE CONMON~EALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 · HARRISBURG, PA 1712B-0601 REV-~545 EX &cp (Og-II) KARL L SHAFFER 6Iq9 HARDING AVE Hag PA 17112 ZNFORHATZON NOTZCE AND TAXPAYER RESPONSE J FILE NO. 22 ACN 02101913 DATE 01-25-2002 TYPE OF ACCOUNT EST. OF MILDRED K SHAFFER [] SAVINGS S.S. NO. 166-1q-2211 [] CHECKING DATE OF DEATH 12-0q-2001 [] TRUST ,:COUNTY DAUPHIN [] CERTIF. REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS DAUPHIN CO COURT HOUSE HARRISBURG, PA 17101 PSECU has provided the Department aith the information listed below which has been used in calculBting the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If You feel this lnforeetion is incorrect, please obtain written correction floe the financial Institution, attach a copy to this fora and return it to the above address. This account is taxable in accordance with the Inheritance Tax Lacs of the Commonwealth of Pennsylvania. Questions may be answered by calling (717) 757-83Z7. COMPLETE PART ! BELOW ~ ~ # SEE REVERSE SZDE FOR FZLZNG AND PAYMENT INSTRUCTIONS PART Account No. 01661q2211-52 Date 09-08-1997 Es.tablishad Account Balance 5,002.88 Parcan.t Taxable X 50 · 000 Amount Subject 'to Tax 2,501 · 44 Tax Ra.te X · 045 Po.tan.eta1 Tax Due 112.56 To insure proper credit to your account, two (Z) copies of this notice must eccowpany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". NOTE: If tax payments ere Rede within three ($) months of the decedent's date of death, you may deduct e 5Z discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. TAXPAYER RESPONSE CHECK ONE BLOCK ONLY PART TAX LINE A. D The above information and tax due is correct. 1. You lay choose to relit payment to the Register of Mills with two copies of this notice to obtain a discount or avoid interest, or you lay check box ~A~ and return this notice to the Register of Wills end an official assassient will be issued by the PA Department of Revenue· B. [] The above asset has been or will be reported and tax paid with the Pennsylvania Znheritance Tax return to be filed by the deoedent's representative. C. [] The above information is incorrect and/or debts and deductions ~ere paid by you. You oust complete PART ~and/or PART ~below. If you indicate a different tax re.to, please s.tate your relationship to decadent: RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS 1. De.ia Established I 2. Accoun.t Balance 2 3. Percent Taxable 3 ~ q. Amount Subject to Tax q 5. Debts and Deductions 5 - 6. Amoun.t Taxable 6 7. Tax RI.to 7 ~ 8. Tax Due 8 PART DATE PAZD DEBTS AND DEDUCTZONS CLAZNEn PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line ~ of Tax Computation) complete to thl belt of ay knowledge and baiter. HOME C ) WORK ( TAXPAYER SIGNATURE TELEPHONE NUMBER DATE COHNON#~ALTH OF PENNSYLVANIA DEPART#ENT OF REVENUE BUREA~ OF INDIVIDUAL TAXES DEPT. 280601 'HARRISBURG, PA 17128-0601 KARL L SHAFFER 62q9 HARDING AVE HBG PA 17112 REV-I~45 EX &FP (09aDO) ZNFORHATZON NOTICE FILE NO 22 AND ' TAXPAYER RESPONSE ACM 02101915 DATE 01-25-2002 TYPE OF ACCOUNT EST. OF MILDRED K SHAFFER [SAVZNOS S.S. NO. 166-1q-2211 []CHECKING DATE OF DEATH 1Z-0q-Z001 []TRUST COUNTY DAUPHIN []CERTZF. REHZT PAYHENT AND FORHS TO: REGISTER OF WILLS DAUPHIN CO COURT HOUSE HARRISBURG· PA 17101 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a Joint owner/beneficiary of this account. If you feel this information Is incorrect, please obtain written correction from the financial Institution, attach a copy to this form and return it to the above address. This account is taxable in accordance eith the Inheritance Tax Laws of the Commonwealth of Pennsylvania. guastions lay be answered by calling (717) 787-85Z7. COMPLETE PART I BELOW ~ ~ ~ SEE REVERSE SIDE FOR FILING AND. PAYMENT INSTRUCTIONS Account No. 01661q2211-56 Date 09-08-1997 To insure proper credit to your account, two Established (Z) copies of this notice suet accoapany your Account Balance 20 · 010. 02 payl~t to the Register of Mills. Hake check payable to: "Register of #ills, Agent". Percent Taxable X 50 . 000 NOTE: If tax payments ara aada within three Amount Sub~lect to Tax 10· 005.01 ($) months of the decedent's date of death, Tax Rate X .0~5 you amy deduct a 5g d~scount of ~e tax ~y ~nhart~nca ~x due ~11 become delinquent Po~en{/al Tax Due ~50. Z~ nine (9) monks after ~a data of death. PART TAXPAYER RESPONSE A. [] The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK ONE BLOCK ONLY PART TAX LINE a discount ar lvoid interest, or You lay check box "A" and return this notice to the Register of Will/ and an official assessment will be issued by the PA Department of Revenue. B. [] The above asset has bean or will bm reported and tax paid with the Pennsylvania Inheritance Tax return to ba filed by the dacadant's representative. C. []The above information is incorrect and/or debts and deductions ware paid by you. You oust complete PART [] and/or PART []below. relationship to decedent: RETURN - CONPUTATZON OF TAX ON JOINT/TRUST ACCOUNTS 1. Date Established I 2. Account Balance 2 3. Percent Taxable $ ~ q. Amount SubSect to Tix ¢ 5. Debts end Deductions ~ - 6. A~ount Taxable 6 7. Tax Rate 7 ~ 8. Tax Due 8 PART DATE PAID DEBTS AND DEDUCTIONS CLAZMEn PAYEE DESCRTPTION AMOUNT PAID TOTAL (Enter on Line $ of Tax Computation) $ Under penlltie$ of perjury, Z dlclerm the(: the facts Z have reported lbove ere true· correct end complete to the best of 1¥ knowledge lnd belief. HOME ( WORK ( TAXPAYER SIGNATURE TELEPHONE NUMBER DATE ~age: 1 Document Name: untitled CKREST CK REQUEST STATEMENT ( LST ACCOUNT NUMBER 0542044441 TITLE MILDRED K SHAFFER BANK 0184 ) PREVIOUS STATEMENT BALANCE PLUS DEPOSITS AND CREDITS LESS CHECKS AND DEBITS CURRENT STATEMENT BALANCE 3,069.51 709.57 1,171.68 2,607.40 DATE LAST STATEMENT 12/09/01 STATEMENT PROCESS CYCLE 012 DATE SERIAL TC 12/13 421 95 12/13 424 95 12/13 12/14 422 93 12/14 426 93 12/14 12/17 423 95 12/17 12/19 427 95 12/19 Ol/O2 14 01/02 14 Ol/O2 AMOUNT DESCRIPTION p~ITEM SEQUENCE NBR 50 00 PRIORITY 5 CHECK/~U~~2-- 213-202-201-041300 ~89 46 PRIORITY 5 CHECK 213-202-201-001380 2330 05 ENDING-BALANCE ~~21 100 00 PRIORITY 3 CHECK--~m~ 4-203-201-084280 174 90 PRIORITY 3 CHECK --~ 214-203-200-092390 2~5 15 ENDING-BALANCE j 00 PRIORITY 5 CHECK~ 217-202-202-036260 19f2 15 ENDING-BALANCE / .32 PRIORITY 5 CHECK~ 219-201-200-038870 l%97~NDING-BALANCE /~8.80 A~-PAR KNIT MILLS I-PN PMTS/BG 006-006-020-112645 ~30~_77 ~C-US TREASURY 312 -CIVIL SERV 006 006-020-110707 25Tr7.40 ENDING-BALANCE Date: 1/5/2002 Time: 08:56:27 AM COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mildred Winifred Shaffer SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A B 5. 6, 7. FUNERAL EXPENSES: DESCRIPTION James L. Schwartz (Funeral Home) John Punako (clearing, maintenance Taylor's Memorials (engraving) After Service Luncheon of plot) ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address C~y Stare Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedents address is not the same as claimant's, attach explanation) Claimant Zip Sffeet Address Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Retum Preparer's Fees State Zip TOTAL (Also enter on line 9, Recapitulation) (if more space is needed, insert additional sheets of the same size) AMOUNT 4,676.00 75.00 60.00 150.00 0.00 750.00 250.00 5,961 .00 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RE SIDENT DECEDENT ESTATE OF Mildred Winifred SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES~& LIENS Shaffer FILE NUMBER Include unreimbursed medical expenses. ~TEM NUMBER DESCRIPTION Outstanding nursing home bill (United Shurch Outstanding medication bill (PharMerica) of Chri TOTAL (Also enter on line 10, Recapitulatior s~) AMOUNT $ 689.46 82.32 771 -78 (if more space is needed, inser~ additional sheets of the same size) WILL I, MILDREDK. SHAFFER, of the Borough of Mifflinburg, Union County, Pennsylvania, declare this to be my last will and revoke all wills and codicils pre- viously made by me. FIRST: I direct that all of my just debts, including the expenses of my last illness and funeral expenses shall be paid out of my estate as soon as practicable after my death. SECOND: personal, ed, I give, and if he does not survive me, follows. All the rest, residue and remainder of my estate, both real and of every nature and wherever situate, of which I may die seized or possess devise and bequeath :o my husband, Ralph E. Shaffer, if he survives me, then my said residuary estate is to be disposed of as a. I give and bequeath unto my grandchild, Michael E. Shaffer, if he shall survive me, the sum of ten thousand ($10, 000.00) dollars; unto my grandchild, Beth Ann Shaffer, if she shall survive me, the sum of ten thousa . . and unto my grandchild Brent W e~'a~"~- ~, ,. ...... nd ($10. 000.00) dollars; rthousand (.$10, 000.00)dollars, ;r°~l]"t~'~h~~ ~r~;a~lr s..urvi, ve me, the sum of ten me. Provided, however, that 'f ,,,, ~,~ ~:., ....... it omy one of them shall survive a descendant or descendants surviving me, such descenda - - - g[ · 1 a,q ~,~ ~,~u granc~cnudren shall predecease me leavin in equal shares, net stir,~es ,,_,~ ...... nt or descendants shall take predeceased me ~ould ha~e' ~2~u ~l~'~-P~¢~r _ca_pi~,. t,t?.pa.rt which .the grandchild who ta,,,.u ,~ ~u~zu grandchild nad survived me b. All the rest, residue and remainder of my said residuary estate, I give, devise, and bequeath unto my son, Karl L. Shaffer, in fee simple. THIRD: I nominate, constitute and appoint my husband, Ralph E. Shaffer, Executor of this my last Will and Testament. In the event that my husband, Ralph E. Shaffer, shall predecease me or shall fail to qualify, die, resign or cease to act for any reason as Executor, I appoint my son, Karl L. Shaffer, Executor, in place of my said husband. FOURTH. I direct that, a. Whenever the term "Executors" is used in rhi.~ u, iI] r'~c~' ~r~ ~l~m ~,l~ ..... , _ FIFTH: Should any part of my estate vest in al~solute ownership in any minor. I authorize my Executors, in their discretion, in each such case. to hold, administer. invest and reinvest such part for such minor's benefit during his or her minority, and to apply so much of the net income and such part of the principal of said share as said Executors, in their discretion, shall deem necessary to such minor's proper care, maintenance, support and education, or, in the discretion of said Executors to make such payments to the legal guardian of such minor or to the person with whom such minor may reside, or directly to such minor, or otherwise, as my Executors may, from time to time, deem expedient, and to accumulate, for the benefit of such minor. any income not so applied or paid; but this authority shall be construed as a power onlyand shall not operate to suspend the absolute ownership of such share, or of such accumulations of income, if any, of such minor, or to prevent the absolute vesting thereof in such minor. ii SIXTH: I authorize my Executors, for the payment of debts, or for any pur- pose of administration or distribution, to sell any or all of my real estate and person- ?.~ al property at public or private sale, and to execute deeds of conveyances therefor .~/without liability on the part of the purchasers to see to the application of the purchase i' money. IN WITNESS WHEREOF, I, the said MildredK. Shaffer, have to this my last Will and Testament, set my hand and seal this ::l-O ~ day of ~r--.~.~.~.c~_.~__ __, One Thousand Nine Hundred Eighty-four (1984). SIGNED, SEALED, PUBLISHED AND DECLARED by Mildred K. Shaffer, the Testatrix, as and for her last Will and Testament, in the presence of us, upon at her request, in her presence, and in the presence of each other, scribed our names as witnesses hereto. who there- have sub- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 000880 GOODMAN MINDY S ESQUIRE 2215 FOREST HILLS DR SUITE 35 HARRISBURG, PA 17112 ........ fold ESTATE INFORMATION: SSN: 166-14-2211 :ILE NUMBER: 2102-01 92 DECEDENT NAME: SHAFFER MILDRED W DATE OF PAYMENT: 02/21/2002 POSTMARK DATE: 02/20/2002 COUNTY: CUMBERLAND DATE OF DEATH: 1 2/04/2001 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $1,171.62 TOTAL AMOUNT PAID' $1,171.62 REMARKS: KARLLSHAFFER C/O MINDY S GOODMAN ESQUIRE SEAL CHECK# 431 INITIALS: CW RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS REGISTER OF WILLS /~--~/--~ COMMON"EALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERTTANCE TAX DIVISION DEPT. 280601 NOTICE OF INHERITANCE TAX HARRISBURG, PA 17128-0&01 APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX HINDY S GOODMAN ATTY ST 35 2215 FOREST HILLS DR REV-1547 EX AFP C01-02) !-~:~ ~. DATE 04-08-2002 i'":. ESTATE OF SHAFFER MILDRED W DATE OF DEATH 12-04-2001 FILE NUMBER 21 02-0192 '02 APR 12 ?] :5~OUNTY CUMBERLAND ACN 101 Amount Remitted HBG MAKE CHECK PAYABLE AND REMIT PAYMENT TO; REGISTER OF HILLS CUMBERLAND CO COURT HOUSE CARLTSLE, PA 17015 CUT ALONG THIS LINE ~-- RETATN LONER PORTTON FOR YOUR RECORDS *~ REV-1547 EX AFP C01-02) NOTTCE OF TNHERTTANCE TAX APPRAISEMENT, ALLONANCE OR DTSALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SHAFFER NILDRED N FILE NO. 21 02-0192 ACH 101 DATE 04-08-2002 TAX RETURN WAS: C X) ACCEPTED AS FILED C } CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRATSED VALUE OF RETURN BASED ON: ORIGINAL RETURN [. Real Estate (Schedule A} 2. Stocks and Bonds (Schedule B~ (2) $. Closely Held Stock/PartnershiP Interest (Schedule C} ~. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposlts/Mlsc. Personal Property (Schedule E} 6. Jointly O~ned Property (Schedule F} 7. Transfers (Schedule G} ¢7) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTTOHS: 9. Funeral Expenses/Adm. Costs/N/sc. Expenses (Schedule H) C9} lO. Debts/Nortgage Liabilities/Liens (Schedule I) C10} 11. Total Deductions 12. Net Value of Tax Return .00 .00 .00 .00 .00 159.09 .00 C8) 771.78 NOTE: To insure proper credit to your account, submit the upper portion of this form ~ith your tax payment. 54, I~9.09 5~961.00 C11) &.7~2.78 27,406.51 .00 Charitable/Governmental Bequests; Non-elected 91~$ Trusts (Schedule J) Net Value of Estate Sub3ect to Tax C1~) 27,406.51 If an assessment ~as issued previously, 11nes 14, 15 end/or 16, 17, 18 and 19 .00 1,255.28 15. 1~. NOTE: reflect figures that Include the total of ALL returns assessed to date· ASSESSMENT OF TAX: .00 x O0 = 15. Amount of Line 1~ at Spousal rate C15} 16. Amount of Line 14 taxable at Lineal/Class A rate Cl6) 27,406.$1X 045 = 17. Amount of Line 14 at Sibling rate {17) .00 x 12 = · O0 X 15 = 18. Amount of Line l~ taxable at Collateral/Class B rate (18) C19)= DISCOUNT C+) INTEREST/PEN PAID C-) 61.66 AMOUNT PAID 1,171.62 .00 .00 TOTAL TAX CREDTT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 1,235.28 19. Principal Tax Due TAX CREDTTS: DATE NUMBER 02-20-2002 CD000880 1,255.28 .00 .00 .00 C IF TOTAL DUE IS LESS THAN 91, NO PAYMENT IS REQUIRED. IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR}, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.} RESERVATION= PURPOSE OF NOTICE= PAYMENT= REFUND CCR)= OBJECTIONS= ADMIN- ISTRATIVE CORRECTIONS= DISCOUNT= PENALTY= INTEREST= Estates of decedents dying on or before December [2, 1982 -- if any future interest in the estate is transferred in possession or enSoyment to Class B Ccollateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B CcoIlatera[) rate on any such future interest. To fulfill the requirements of Section 21~0 of the Inheritance and Estate Tax Act, Act 23 of 2000. C72 P.S. Section 91~0). Detach the top portion of this Notice and submit with your Payment to the Register of Hills Printed on the reverse side. --Hake check or money order payabIe to= REGISTER OF HILLS) AGENT A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an 'APplication for Refund of Pennsylvania Inheritance and Estate Tax" (REV-I3IS). Applications are available at the Office of the Register of Mills, any of the 2S Revenue District Offices, or by calling the special 24-hour answering service for forms ordering= 1-800-362-2050; services for taxpayers with special hearing and / or speaking needs: 1~800-447-S020 (TT Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment of tax Cincluding discount or interest) as shown on this Notice must object within sixty C&O) days of receipt of this Notice by= --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN= Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-&505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent'* CREV-1501) for an explanation of administratively correctable errors. If any tax due is paid within three CS) calendar months after the decedent's death, a five percent C5%) discount of the tax paid is allo~ed. The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and tn the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became deIinquent before January 1, 1982 bear interest at the rate of six C&%) percent per annum calculated at a daily rate of .00016~. All taxes which became delinquent on and after January 1, 1982 wil! bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are= Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor 1982 20% .000548 1992 1983 16X .000438 1993-1994 7~ 1984 11% .000301 1995~1998 9~ 1985 13~ .OO035& 1999 198& 10X .00027~ 2000 8% 1987 9% .000247 2001 1988-1991 11% .O00$0l 2002 --Interest is calculated as follows= INTEREST = BALANCE OF TAX UNPAID .0002q7 .000192 .000247 .000192 .000219 .0002q7 .O001&~ X NUNBER OF DAYS DELXNI;~UENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will refZect an interest caZculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIV[DUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD REV-1162 EX(11-96) OO2O16 DUPLICATE KARL L SHAFFER 6249 HARDING AVENUE HARRISBURG, PA 17112 ........ fold ESTATE INFORMATION: SSN: 166-14-221 1 FILE NUMBER: 2102-01 92 DECEDENT NAME: SHAFFER MILDRED W DATE OF PAYMENT: 01/06/2003 POSTMARK DATE: 01/03/2003 COUNTY: CUM BERLAN D DATE OF DEATH: 12/04/2001 ACN ASSESSMENT CONTROL NUMBER AMOUNT 02101914 $229.69 TOTAL AMOUNT PAID' $229.69 REMARKS: KARLLSHAFFER SEAL CHECK# 203 INITIALS' CW RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXES TNHERZTANCE TAX DTVTSTON DEPT. 280601 HARRISBURG, PA 17128-0601 KARL L SHAFFER 6Zq9 HARDING AVE PA 17112 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT. ALLONANCE OR DISALLONANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 12-:50-2002 ESTATE OF SHAFFER DATE OF DEATH 12-0q-2001 FILE NUMBER 21 02-0192 ~:~ ".:~ : COUNTY CUMBERLAND SSN/DC 166-1~-221 ACN 0210191~ Amoun'l: Rem J.~:~:ed REV-16q8 EX AFP (01-05) MILDRED W HAKE CHECK PAYABLE AND RENZT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 1701:5 CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS REV-1548 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRA/SENENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON dOINTLY HELD OR TRUST ASSETS DATE 12-$0-2002 ESTATE OF SHAFFER MILDRED W DATE OF DEATH 1Z-OR-ZOO1 COUNTY CUMBERLAND FILE NO. 21 02-0192 S.S/D.C. NO. 166-1q-2211 ACN 0210191q TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED FINANCIAL INSTITUTION: PSECU dOINT OR TRUST ASSET INFORMATION ACCOUNT HO. 01661~2211-5~ TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (~ TINE CERTIFICATE DATE ESTABLISHED 09-08-1997 Account Balance Percent Taxable X 0.500 Amount Subject to Tax 5,002.57 Debts and DeductAons - .00 Taxable Amount 5,002.57 Tax Rate X .~5 Tax Due 225.12 10,005.1:5 NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE TO: ""REGISTER OF WILLS, AGENT." TAX CRED'rTS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) INTEREST IS CHARGED THROUGH 01-07-200:5 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. ZF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) .00 225.12 q.57 229.69 PURPOSE OF NOTICE: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act Z$ of ZOO0. (TI P.S. Section 9140). PAYMENT: REFUND (CR}: OBJECTIONS: ADMIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side. -- Make check or money order payable to: REGISTER OF HILLS, AGENT. A refund of a tax credit, ahich Nas not requested on the tax return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1315). Applications are available at the Office of the Register of Hills, any of the Z$ Revenue District Offices or by calling the special g4-hour answering service for forms ordering: 1-800-36Z-ZO50; services for taxpayers with special hearing and or speaking needs: 1-800-447-$0Z0 (TT only). Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions or assessment of tax (including discount or interest) as shown on this Notice may object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021~ Harrisburg, PA 171Z8-10Z1, OR --electing to have the matter determined at the audit of the account of the personal representative, OR --appeal to the Orphans' Court Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, DEPT. Z80601, Harrisburg, PA 17128-0601 Phone (717) 787-650S. See page S of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-15013 for an explanation of administratively correctable errors. If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (SI) discount of the tax paid is allowed. The 151 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same tiaa period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became deIinquent before January 1, 1982 bear interest at the rate of six (6Z) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on or after January 1, 1981 will bear interest at a rate which mill vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through Z003 are: Interest Daily Znterest Daily Interest Daily Year Rate Factor Yea.~r Rate Factor Year Rate Factor 198Z ZOg .000548 1987 9Z .000247 1999 7Z .00019Z 1983 16X .00043B 1988-199X 11Z .000301 ZOO0 8Z .000219 1984 llZ ,000301 1992 9Z .000Z47 ZOO1 9Z .000Z47 1985 1SZ .000356 1993-1994 7Z .00019Z ZOOZ 6Z .000164 1986 102 .000274 1995-1998 9Z .000247 ZOO3 5Z .0001~7 --Interest is calculated as follows: /NTEREST = BALANCE OF TAX UNPAZD X NUNBER OF DAYS DELZNQUENT X DALLY TNTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (1S) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. INHERI1ANCL T4X DIVISION DEPT. Z80601 HARRISBURG, PA 171ZB-0601 KARL L SHAFFER 62q9 HARDING AVE HBG CUT ALONG THIS LINE ~ PA 17112 u~ iMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISE~IENT. ALLORANCE OR DISALLO#ANCE OF DEDUCTIONS, AND ASSESSHENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 12-:50-2002 ESTATE OF SHAFFER MILDRED 9ATE OF DEATH 12-0q-2001 FILE NUMBER 21 02-0192 COUNTY CUH~ERLAND SSN/DC 166-1q-2211 ACM OZlO191q HAKE CHECK PA~ASLE AND REHZT PAYHENT TO= RE~[STER OF MILLS CUHSERLAND CO COURT HOUSE CARLISLE, PA 17015 RETAIN LOWER PORTION FOR YOUR RECORDS NOTICE OF {NMERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS~AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 12-50-2002 ESTATE OF SHAFFE~'~ !~:! MILDRED W DATE OF DEATH 12-0q-2001 COUNTY CUMBERLAND FILE NO. 21 02-0192 S.S/D.C. NO. 166-1q-2211 ACN 0210191q TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: PSECU ACCOUNT NO. 01661q2211-Sq TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (~ TIME CERTIFICATE DATE ESTABLISHED 09-08-1997 Accoun~ Balance Percen~ Taxable ~ 0.500 Amoun~ Subjoc~ ~o Tax 5,002.57 .00 Debts and Deductions - Taxable Amoun~ 5,00Z.57 Tax Ra~e ~ .~5 Tax Due ZZ5.12 10,005.1:5 NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE-ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE TO: "RESISTER OF WILLS, AGENT." TAX CRED'rTS: PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) tBTOTAL TAX CREDIT ALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE INTEREST IS CHARGED THROUGH 01-07-2005 .00 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM IF PAID AFTER THIS DATE~ SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( ZF TOTAL DUE IS LESS THAN $1, NO PAYHENT ZS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR)~ YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. ) 225.1Z q.57 229.69 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DI'VISTON DEPT. HARR'TSBURG, PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE ZNHER-rTANCE TAX STATEMENT OF ACCOUNT REV-I~07 EX AFP (01-03) KARL L SHAFFER 6Iq9 HARDTNG AVE HBG PA 17112 DATE 01-Z1-Z00$ ESTATE OF SNAFFER DATE OF DEATH 1Z-0q-Z001 FILE NUMBER 21 0Z-0192 COUNTY CUMBERLAND ACN 0Z10191q M/LDRED W t Amoun~ Rmni'l:'ked MAKE CHECK PAYABLE AND REM'rT PAYMENT TO: REG/STER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 NOTE: To insure proper cradi~ ~o your account, subet~ ~he upper portion of ~his fora w1~h your ~ex payeen~. ONG THIS LINE P RETAZN-~Y-E'-~-r-C)-~-O-~--F'O---'R-'---Y--~-R-':R-~'~JI~T ~ ~._A_~ .............. ~:_.;~ ...... -G~-'~'~ ZTANCE TAX STATEMENT uP ~ ~-~N ~EV-1607 EX AFP (01-uaz ....... R MILDRED W F'rLE NO. 21 0Z-019Z ACN 0210191q DATE 01-ZI-Z00$ ESTATE OF SHAFFER THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN TN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, APROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 12-$0-2002 PR/NC/PAL TAX DUE: ........................................................................................................................................................................................................................... 225.1Z pAYMENTS PAYMENT DATE 01-05-2005 (TAX CREDITS): RECEIPT NUMBER CD00Z016 INDISCOUNT (+) TEREST/PEN PA/D (-) q.qS- IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" {CR), YOU MAY BE DUE A REFUND. SEE REVERSE S/DE OF THIS FORM FOR INSTRUCTIONS. AMOUNT PAID 229.69 TOTAL TAX CREDIT aALANCE OF TAX DUE i INTEREST AND PEN. TOTAL DUE ZZ5.Zq .1ZCR .00 .1ZCR PAYMENT: Detach the top portion of this Notica and submit with your Payment made payable to the name and address Printed on the reverse side. -- If RESIDENT DECEDENT make check or money order payable to: REGISTER OF NTLLS, AGENT. -- If NON-RESIDENT DECEDENT make check or money order Payable to: CONNONNEALTH OF PENNSYLVANIA. REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may bm requested by compZating an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-/SIS). Applications are available at the Office of the Register of Hills, any of the Z3 Revenue District Offices or from the Department,s gq-hour answering service for forms ordering: 1-800-36g-ZOSO; services for taxpayers with special hearing end / or speaking needs: 1-BO0-q4?-3gZO (TT only). REPLY TO: Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. gB0601, Harrisburg, PA 17lgB-OBO1, phone (717) 787-6505. DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (SI) discount of the tax paid is allowed. PENALTY: The 15Z tax amnesty non-participation penalty is computed an the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. INTEREST: Interest ]s charged beginning eith first day of delinquency, or nine (93 months and one (l) day from the date of death, to the date of Payment. Taxes which became delinquent before January l, 19ag bear interest at the rate of six (6Z) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January l, 198g will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 198g through gO03 are: Interest Daily Interest Daily Interest Daily __Rate Factor Year Rate Factor Year Rate Factor 198g gOZ .000548 1987 9Z .000247 1999 7Z .O0019g 1983 16Z .000438 1988-1991 llg .000301 go00 8g .O00ZX9 1984 ZIg .OOO$Ol 1992 9Z .000247 gOO1 9Z .000947 1985 Z~Z .000556 1993-1994 72 .OOOlgZ Zoog 62 .000164 1986 log .000Z74 1995-1998 9Z .000247 gO03 5Z .O00137 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY TNTEREST FACTOR --Any Notice isSued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If Payment is made after the interest computation date shown on the Notice, additional interest must be calculated.