HomeMy WebLinkAbout11-13-09--~ REV-7500 155607120
EX (06-05)
PA Department of Revenue OFFICIAL USE ONLY
Bur,.au of +ndividual Taxes ~ counrycole ~,,~, N,.~I F,--
Po Box 28060 .~ INHERITANCE TAX RETURN
Har.isburc PA `7128-0601 ~`' RESIDENT DECEDENT 2 1 0 9 0 0 6 £3 9
ENTER DECEDENT INFORMATION BELOW -
Socal Se,>,rity Number Da ___
te of Death Date of Birth
:L92321465 07042009 03031945
De~e~er? s Last Narn~
Suffix Decedent's First Name
S~CHOCK ~'~'~
BARBARA
I„I
jlf ~kpplicat~lel Enter Surviving Spouse's Info rmation Below
Spet.se's _,,sr Name Suffix Spouse's First Name
'
SCHOt_K c1
SR. DAVID
S ;o~se~s 5~cal Secu~~ty Number E
THIS RETURN MUST BE FILED IN DU
PLICATE WITH THE
REGISTER OF WILLS
FILi_ N APPROPRIATE OVALS BELOW
~~~rai Retarr, ^ 2_ supplemental Return
^ 3- ,Rem au j~. F.e!urn lcate n .:ea ,
^ ~ ~ tea Estate ^ prior .o ? 1:~-c21
qg F~~ture Interest Compromise
(,:ate of death after 1&1L-82) ^ 5. FedE.r .~ Etate Tai: Reurr R ~qu:~e~.J
5 ~ ~ d [ Ged Tcsta~`
r~~.,r oFYcrVUii~~. ^ Cacedent Maintained a Lving Trust
~-
(Attach Copy ofTrust) 8. Tota tw~.;~r ~E~-
~; S
f
C
'
,
a
e
e. ~OS~t E
~_ yes
^ 9 ~''<. ~LOn Proceeds Re:;ewed ^ tp Spousal Poverty Credit (date of death
batween 12-31-91 and 1-~-95) ^ l1.Electo °;c t2x J^oer jec g- ~?,-,;
Name ___
COF;RESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
JOHN W . CARTER , ESQUIRE Daytime Telephone Number
7172495373
Firm Name i1f Applicable)
K Z1 I G H T & ASSOCIATES , P . C , REGISTER C}~{tsVILLS U3E~ONl_Y '
First Isne of aaddress 1
11. ROADWAY DRIVE, SUITE B `°
Second line ~:~f address
City or Post c)ffice
CARLISLE
~.
"T.7
D~'~E FILED L.J
State ZIP Code
PA 17015
Correspondent's a-mail address:
J dE p Halt E s ~f oerury. I d ~iarr that I have examined this return, including accompanying schedules and statements, and to t , Best of my knowledge a~caelie~
if 5 t-ue orre ,= and complete Declaration of preparer other than the personal representative is based on all information of whii,h ,~re;arer has and knowledge.
Si ,N~i-I 7 ~~~PSON RES-'OfJSIB:_~Op}Z FILI RETUR~~
r
~ ~~'"'"° ' ~ ;~-,~~-- David E. Schock, Sr.
~~
150 Bridge Road, Newville, PA 17241
SIGNF,TURE OF P'~F BARER OI HER Tt-rq'N REPRESENTATIVE
.r,.,.....~, ._y..- _~ ., Jj t'~.
r, D'.-R ~sSS
11 Roadway Drive, Suite B, Carlisle, PA 17015
L._. 1505607120
/'F, :..
John W. Carter, Esquire
Side 1
i A'E
~..,. `rte,. ~ ~,. ,,.
1505607120
1505607220
REV-"50'J EX
Decede~it- Scc~al Security N,.rnb~~r
°~rsN~R,~ SCHOCK, BARBARA M
192321465
RECAPITULATION
'. Real Estate (Schedule A) ...............
............... .
__ ....................................
..... 1.
2 S!c~Fs and Bonds (Schedule B)
........__ ...................
2.
14,963.55
=. C cseiy Held Corporation, partnership or Sole--Proprietorship (Schedule C)..... .... 3.
+. ~-'~ tgages & Notes Keceivable (Schedule D)._ ..........................__........ .
4.
Cap `i. Bank Depcs~t~ & Miscellaneous Personal Property (Schedule E) ........... .... 5. 7 4 5 4 fi 0 0
6 Jaray Owned Property (Schedule F) ^ Separate Billing Requested......... ... 6
_ Inte -Vivos Transfers & Miscellaneous Non-Probate Property .
(S,bedule G) ^ Separate Billing Requested......... ...
~ 7 7 , 7 3 ~~
00
Total Gross Assets itotal Lines 1-7) ...................
..................... .
..
... $.
167, 237.54
Fr, ~;ral Expenses & Admin strative Costs (Schedule H)
........................
9. 1 5 , 0 4 3 3 0
1;; Dec•; cf Decedent, Mortgage Liabilities, & Liens (Schedule I) ................
10.
3,321.68
Totai Deductions (total Lines 9 & 10)..........__
........................_....................... ..
11.
18, 364.98
~ 2 Net Value of Estate Line 8 minus Line 11) ......
......... ...
_ ..... ...................
13 Cher table and Governmental Bequests/Sec 91 13 Trusts for which
_ 12.
148, 872.56
an ei action to tax has not been made (Schedule J)
......................... .
__...........
. 13.
1~: Net Value Subject to Tax (Line 12 minus Line 13)..
...._ ..................
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLIC
~a.
1.48, 872.56
ABLE RATES
ci Amoi nt of Line 1~1 taxable
at the soousal tax rate, or
tran;;r~n under Sec. c" 16
(a} '_)X.00 154, 706.00 15.
"~6 Amc~nt of Line 14 taxable 0.00
at lineal rate X .0.15 ti3
ii Amcu~itofLine~4;axaole
at sibl ng rate X 1 ~
18 .4mo~u~ ~t of Line "4 taxable
at c~ih~teral rate X 1 ~ 18
1 ~. Tax Die .._ _.
_ ............................... ........._...........___.................... 19.
O.OG
20 FILL. I~, THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
1505607220
Side 2
1505607220
RE` -15)~ _;{ page ,; File Number 21 - 09 - 00689
DE~cedent's Complete Address:
CEDE~,TS NAME
Schock, Barbara M
°TFEE' A ~;~RESS
! 1 ~0 Bridge Road I
1
1
c I-~~~~
Newville STATE ZIP
I'/~ 1 '241 _~
Tax Payments and Credits:
Tax D_~e (Page 1 Line 1 ~~;
2 Creditsi='ayments
i1% 0.00
Spousal Povert~; Credit
~3 Prior Payrnents
C Discount
~~. ! ~~e>~%r'enalty if appiica~le Total Credits (A + B + C) i2'.
~ 0.00
D merest
E -'enaity
Total Interest/Penalty (D + E) (3) 0 . 0 U
4 II Line 2 _. greater than Line ' + amine 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 2 Line 20 to request a refund `~}
~. If Gee 1 ~ Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
~~> 0.00
A E n:er the interest ~~n the tax due.
i5Al
B f n er the total of '_ ne 5 + 5A. This is the BALANCE DUE.
(5B) Q . ~ C1
Make Check Payable to: REG/STER OF W/LLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE E3LOCKS
1 Did decedent make a transfer and:
a. re'ain the use or income of the property transferred :.................................................... Yes No
b reram the right to designate who shall use the property transferred or its income;.......... _ x
c. re(ain a reversionary interest; or._......... x
.............................
.................................................
d. receive the promise for life of either payrnents, benefits or care?......__ ......................_ x
If deati~ occurred after December 12, 1982, did decedent transfer property within one year of c=ra ~ without x
receiving adequate consideration? ...............
......................................................... __
__ .._ _ x
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her ~ ~e~th~
Did decedent own an Individual Retiree gent Account, annuity, or other non-probate property which x
contains a bereficia~y designation? .................
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 date of de2tt on or aster Ju~y 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of±rai~sf~_.rs to or for the ;;se ,,r're
surviving spo s~ is three (3, percent [72 P.S. §9116 (a) (1 1) (i)].
For date of ct~c!h on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use o '},::~ surviving spouse i~ zero
(0) percent [7? F'.S. §9116 (a i (1 1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and `h~- statutory requirer~_nts
Fer dis~lcsure cf assets and fuing 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 imp used on the net ~.~aiue of transfers from a deceased child twenty-one years of age or younger at dea ~ ~ or for the use cf a
natura~~ parent. at adoptive parent. or a stepparent of the child is zero (()) percent [72 P.S. §9116 (a) (1.2)].
The tax ate trio=used on tha net value of transfers to or for the use of the decedent's lineal beneficiaries is four and ~~nc -r a f t4.5t percent
except as note? ~ 72 P.S. §9116 1 2) [72 P.S. §9116 (a) ~ 1)].
The tax rate imposed on th« net value of transfers to or for the use of the decedents siblings is twelve (12) percent ('2~ S X9116 (a l i tti;;j
siblings efin~d under Section 9t02. as an individual who has at least one parent in common with the decedent, whetf e by blood or adc;~t or
-''~ ~a
~.,~ ~ - _ , of P~NN~.~,A~~~ _
E7ax ae7u~r.
_;i-oECeoErn
ESTATE OF SC:fIOCk, Barbara M
Ail property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION
U.S. Savings Bonds
SCHEDULE B
STOCKS & BONDS
FILE NIIMBER
21 - C y )t~689
UNIT v'A~UE V~',l-UEi ~+-~ DATE
OF ~E.~Ti~
33.584 "~1.g~~7.54
TOTAL (Also enter on line 2, Recapitulation)
1ti 9f1 ~;d
;; ;s~
,~.,~~~~~;.::~ ~_ ~oF P~~ ~~,
~w~~-,~. ,~~~Fr~
~- o~~.~~c~,
ESTATE O~ Schock, Barbara M
FILE Nt,+MBER
21 - C9 - 00659
Include the proc2~~cs of litigation and the date the proceeds were received by the estate.All property joint)}~-owned with the right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
2
3
i
4~
5
DESCRIPTION
PSF_:,J
Merr~bers 1st
Orrst~~wn
State Employee's ~etirment
MiscE ll.aneous Personal Property of Decedent
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
~.'~ DE.;TFi'
X3.1 30.00
16.00
1.5(x.00
TOTAL (Also enter on Line 5, Recapitulationf
7~ 546 +~0
~~.
~4
C~^~unorrNE~.~T-~ c~E PENNS~'~~ara,-.
Nr RTi ~~<_'AX RETURN
~~ ~~~~ ~ ~ECE~ENr
ESTATE OF ~~;hock, Barbara M
INTER-VIVOSD RANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
~ 1 - 09 - 00689
This schedule must be completed and filed if the answer to any of questions 1 through 4 pan page 2 is yes.
ITEP/1 ~~_s~~Rl~noN ~E RRORERTv
~UMBtP In ~~ ar;e ?`toe transferee, their relaGOnshiU to decedent DATE OF DEATH ~ OF -
~~In~
an .he 13~, f'n;cy(e,. Attach a co VALUE OE ASSET DECDS ~' '- - ~ UE
py of the deed `~r real estate. , pc~ C.A~3 = T,G}; L,f3' ~1/A-
INTEREST -
1 Defr~rred Compensation PA State IRA 55,102.00 100% ~.
2 Me~r.bers 1st IRA
22,628.00 100%
:_'~' ii~~ 0i)
----------~ TOTAL (Also enter on line 7, Recapitulation} 77,730.00
SCHEDULE H
v~ ~ ~ yoi
`~ FUNERAL DCPENSES &
__~;r `~T
,~ ~ ~ ' ~ ADMINISTRATNE COSTS
ESTATE O~ Schock, Barbara k~
Dek>ts of decedent must be reported on Schedule I.
ITEM
NUMBEF3 FUNERAL EXPENSES: DESCRIPTION
A. 1 Professional Service
2 Cas~et
3 Buri< l Vault
~ Obituaries in Local Newspapers
5 Open and Close Gravesite
FILE NUMBER
2 " - 09 - 00689
APv10UNT
B. ADMINISTRATIVE COSTS:
1 Per,cnal Representab,e~s Commissions
Soca~ Security ,'Vumb~x<s} / EIN Number of Personal Representative(s): ~-
Stree Address -
Cit~.
State Zip
Yeart;j Commission paid --
~. attorn,;y~s Fees Knight & Associates, P.C. --John W. Carter, Esquire
,, =am;!} Exemption: i If decedents address is not -he same as claimants, attach explanation)
C a mant David E. Schock, Sr.
Street Address 150 Bridge Road --
~ty Newville State PA Zip 17241
-aatiooship of Cta rnant to Decedent SpOUSe _
a ~roba(; F=ees Letters of Administration -
5~ >~ccoi,r_anfs gees
o. Tax Ream Preparers Fees
Other 4lministrative Costs
l_ega~ ~'u~lication of Jeath Notice -Cumberland Law Journal
c~5 ( 0
~.1 E~0 C'C,
~~<S.Cu
362.E
49;i.0'J
1,~-J0 OG
3,00 00
3_.00
`.;x.00
TOTAL (Also enter on line 9, Recapitulation)
15,O~f3.30
~2~~
:~~r ~~on, ~a~rH of PEVr ~ _tawa
NHE 'f-' A~dCE TAX RE _Rh
R~;i 7E~JT DECEDE~i`
ESTATE OF Smock. Barbara M
Sdiedule H
~~y~Fu~~,e~,r{~al,,,Exper~s &
"'~'~~W.71l QYVC~~
2 Legal Publication of Death Notice -Carlisle Sentinel
FILE NUMBER
21 - 0~ ~ 0)0689
1 f6 :~;0
Page ~' cf Schedule H
g~,~~
'J~. ~'
Ev~:~ .
. ~r .-~,Eti'r,
ESTATE OF Schock, Barbara M
Include urireimbursed medical expenses.
`EM
^JU`/1BER
7
L
3
FILE NUMBER
21 - C9 ~ 00689
DESCRIPTION
DecE dent's outstanding medical bills at death, after reimbursement from Insurance
Deoedent's cell phone bill at death
Decedent's taxable share of real estate at death jointly owned with her spouse
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
~~MO~,+wT
~I.i)~10.OC
E 7.18
.~, c.;,0
TOTAL (Also enter on Line 10, Recapitulation)
3.3?1 ~R
IOMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
UREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTAiE RECOVERY PROGRAM
PO BOX 8485
HARRISBURG. PA 1105-8486
~iCC '.b.'r l4~ 'J O~ly
- - s _ .. . , , _. . ~. 1~ ~'
;F_'' _.~. ~ ~~.
R~=: '~R3ARA M SCriOCK
~~iJ:-9?_-32-1456
__ _~__ _ t~_.
s- ~_ ~- , ~~=r letter da=ed :,epte~~ r 1~, 2009, the sera°~- _ - _
.A:' ~ _
- ~ ,~ n7) , Estate RP~~ woe;-y pr a~„ has r~~
_~ ~~ewed
c _ ._a _ ,_ ._~`_ng the apo~ r~~l-~r ,i- ~~, I
_.c,i ~idual .
-_ -- terrr.Lned t.".~, ~h_ ~ inr, ~ ~-idua- did not recE~ _-
-~ _ - _ he q~es _icnE _~ >/e ~ _c,d.
.. _ g
__o~ai~i t~ ~r i-:?nra.Gtycn you provided, t_~:
-- - ~ardm wi~~ nc se«=K ~rY recovery from t2i_s _ _
M=decal f~ssi. ~an~_° and ! ad an appli~at~or _.-,,s
. ,_ ~~ ~ ~f death, p easF, aavr~e us and provides ~ - -~
_- c ~+ ~y aft_e~t a rF cover}' by ,a_r Depart~ren`. ~ -=-
~..
_ questio~_s )~
,~!s~ fee L free to ~ontact nr .
S inc _ _ al's,
'~ rry1 ~}
--~
'~aro! e ~_. Procope
~eco~: er ~ ;;ecti-_>;~ C~`anaa
PSEC~k
.r~Ti': ~~~~. CARTER
i ~ 'RC~~'~.DWAY Dk StP'~ $
November 10, ?009
Account ~ 0192~X?:,~XX
VI<A FP.~~ 717.249.047
:'-e `~ il~~wintr is nc~ sta~u; o~ g ~ggp~4 ~ SCHOCK's a
ccoun t with PSECU as of the date ~i~ ~ ~;~.
Joint C ~1+.~~'~ Name NONE
Date o rb ~i~~atL 07.04?009
I)atc c~ i 3irth 3.03.194
Shari
S t) ~ Description Open dote Balance
Regular Sham;
05
21
1991 Accrue} ~)YVtdend
~' ~
titone ~h
~ andlez .
.
as.a1
I99I
S ~ J.>>3
~t
S0.(,
~~ ~ 7
lC[oney I~tark~;; .
11
16
2000 0.00
,
0.00
.
. ~
9,1a~.6~ 0,79
Loan Description O en Date
p
~, i'v VISA
0?
i1
I998 Balance Accrued Interest
.
. $ 0.00 X0.00
t ~ ,~~.. . 'lid ~'a~`l:c;i .I ~;:. ; dliu i}` 2009 tl1l~ LLyi ~[.~ .i~1iC; UI ~Cdill Wd5 .bb'-~.v~~. ~y ~ d0 ilOt ~laVt ~ ..c !1C~'JSl: CJ-i;_;.
ter >ur i~~ >rnbe:g_
Tf'~'-'u l:a~'e any question;; please CaI1234-848c in Harl-isbu:a or om- toll-free number, (800) 237~~'1;' ~~. _~t ;ue 1na3~u
pn,mpt, d?'.t~r b and then ~;anension 2227.
S'z~~ are;,.-.
%i' 'I ' /~
"~i:ac:e f~_~rfa
>1~~~.ber C,>x y;
..c~ Repre~~~~:ativa
_7.:~c~ 5~,pport 7Jv~
ivt in A ~'~ernsylve~ni~ ;~~,e trrtoJlvy~, ~,rcc;si L.,a,a~;
o tidre<s_ i ~,redit Un on P~oc~, Harrisburg, PA 1 71 7 ii 2990 • , ' ~ ?,;
Mo(Iing Address: FO. Box bi013, Fi~rnsburc~, PA 171Co_7i713 . ~~ ~ ~~~ ._- ~~ ~`~"' ~ ~ ~~~
~L~' ~ ~=~' ~ `~6 ~~~
This agdi~ ~~fd~ ,; :ede~olly i~s~rcd b h. 'J g59C1.~.C0l1'!
y ; '' O1r~n0 ~ e~ ~ _. -r.i(+.olr'O ~'1 ` _.~_. ~_. . r. ~. ..r.. o.
:.1
{
F
~
~~~1~~~~~~ ~~[•
i LllFR.Ii. i:I2Fr~1 i L~nt.).V
REGU(_-AR SAVINGS ACCOUNT:
acco~, t Number~Suffix
171796-00
?ate ;~~count Estab~ish ~d
'rinc:c 13alance at Date cf Death 10!31/1997
~~accn,aa interest ±o Da±e of Death 522,2G8.90
ota! ~ ircipal arn1 Accrued Interest to Date of Death S 91
522
X9
81
"Jam= cf Joir.t Ovwne- ,
.
Date _c n-Ownershi0 Established None
CHECKING ACCOUNT
%-~ccoar° NumbeNSuffix
Date nc~ount Establishec 171796-11
F = Balance at Date of Death 02/25/2005
r~-,: Interest :0 rata o` Death 54,394.77
Tota~ >'~ papal anc Acc-~..ad 'nterest to Uate of Death
' S.X
54
394
82
err c
'oint Owner ,
.
Ca e '~ '~' Ownersh p Established None
Primary Qwr~e~: David Schock
14799-00
06/11 /1973
54,228.50
$.17
S4,228.67
Barbara Schoc-
05/28/1985
14799-11
05/28/1985
59,533.20
5.12
59,533.;;2
Barbara Schcci
05/28/1985
IPlVESTiViNT SAVINGS ACCOUNT
~~co~r~'; Number/Su`f~x
Date r-o~nt Establisne~; 171796-05
^cica Bala~~ce at Date of Death 09/29/2008
A.crua; !nterest to Date if Dea'
h 523 697.68
.
i ~,'.al ;=c iapai and Accr ed !nterest to Date of Death 51 17
523
698
85
Iv 3me ~;~ Joiot Owner ,
.
Non=
IRA CF_RT!FICATE:
Accou~ VumberiSuf'iK 17179b'-15
r- F =~~~nt Establis^ec ~7/11/2n07
P .ac ,! 3alance a` Date c,` Ceath 522
623
07
Accrued Merest to Date c` Deat~ ,
.
55
41
Tcta~ Pr rciaal and .accrc~~ed L:terest to Date of Death
^
` .
S22
628
48
i~rne ,
3ereficiary ,
.
David Schock
CERTI~=IC:ATE OE DE?OSIT
Ac-cur' t.u nberiS~ff~x --
DaL Ac~_unt Established
Prr-cipa'~ 3alance at Date of Death
Accrue- S iterest to Date o' Death
Taal P~~~r.:ipal and Accru-=_~ !r,*erest to Date of Death
V=. ~,e c _ ~~^t Owner
Day: Jc ~' C rmership Esta'c,isned
CE~TIFiCATE OF DEPOSia:
oun "~~rnbeNSuffi<
Data Accc srt EstabLs~~~G
~rir,:ioa~ ~~a!ance at Da e ct Death
'.r;' n;ec 'merest to Date of Death
-otal Pr~~c pal and Aocruec !n`.erest to Date of Death
tJar~e o- -! >irt Ownei
171796-40
11 /07/2000
512,878.95
51.84
512,880.79
Davic Schock
11/07/2000
171796-41
01/16,'2008
S10,641.52
S 1.73
510,643.25
None
d
MEMBERS 1sT FEDER L C ~~ W!T UN;C'i
.--, !1
Danielle A.`~line
Insurance Services Specialist
November 5, 2009
f~:str;te ot~: 13,a1?13.A12:4 SCHOCK
Dafe of Ueath: July 4, 2009
5oriai Seder ty Nurnoer 192-32-1465
~ti,lr,~re ~~~. :r i.-.t~t~ fl-- 4 -
q~~ ,~
_. ._ r, r, _ _~ .. ~ _.- ..-.. f-..
~sT®w~a~
B~~
A Tradition of Excellence
Fasr F; rid; St; rt
D~_rte: vovesnber ~, 2009 ~.~. ~~_,a::~.,.,
~~~~: ~: Kni ~ht ~ Associates
1 Road«~ay Drive
Suite E
Carlisle: Pa 17015
:~ r:>~n: Traci ~"c,he
Orrstol~-n Bank
PO BC:k 250
Shippensburg, Pa 17257
Re' Estate <~f Barbara M Schack
Date of death July 4, 2009
IT .IS HEREBY ~ ER1'IFIED THA "T THE X480 ~~ NAMED DECEDENT, D:~~ 7 :~E
frIsOVE D.:~TE, ~r~ 77fE ~'~ILf~i~~JG ACCOU:,~'TS YT~ITH ORRSTO~~~ ~.=':~,',';:
.?._~unt ~ 3 itle of Account
~_=~ ~ 1~'GS.4CCOl~il'T
A,.;=;;cunt ~ 'I~itle of Account
Date opened Principal Accrued lner~at
Date opened Principal Accrued In _erest
_C ~~.~~ 7~N1 C-~ TF, ; ) ~ DF. PnSI'~'
;~.ccount .7 ".title of~Account Date Opened Princit~al Accrued ''~t;~-~st
40GO01201 ~ B~~rbara M Schack 08!07108 2,760.66 £,. ~~ 1
~ ~
State Employees' Retirement System
so r~ ~~~n Tn, + ~, ~,- s, ,~ ~ ~
rig-mist ii ~~, Perri /'/dC 7 ?0' 7 '1E
www.s s.state pa.us
Te'ephrne 1-~-
ax_ 7'~ 7-
~ ~~
August 4. 2009
D,~.VIC ~~~.HOCK
,,'~ _~ gF~ GG~ R
Member SS^~ i~:~;~:- x;
Beneficiary ~~;~ =i ;<k;x,- ,
`' ~~i~~'~' "~ ~ ~ ~~~-~ ~ ~,~ X152.11 will be mailed to ycu within two weeks. Fedor ~,i ~.,,~, ~~ ~ ,,i~~_~ it ..,_
~~'~' =~ ~ i - ~e withheld for federal tax purposes lfyou have elect~~ci t:;
rortion of X0.00 will be transferred to your qualified plar~~.
7 r ~ = 1~ - ~~ ` ~ ~~=r~s_^~ting your designated share of i 00.00~~~ in the final set~~~er" ~ ;- r
,f t?,=~F3-Air, ~:^ ~r,F'~~>i, ,~'
!~, will be mailed to you with r-~ t~°~o weeks.
f ., ~ ,
~ ~~ '- ~ ~~ /~ ~ , _%~-OVe Was a rTlember Of till ~ctf"el?l8iii System v2fGf~ J~,~~~
~~,. .
~~,ank .t ~,~~ ~ r _~ ~~ lnat date were taxed as part of their gross income at treat ri~, ~ ~l~ ~F
[~,;~ ~ ~~ ~~' ~ r~i ~r~~ld on that portion of their contributions. The difference oet~~,._- - ~~ _ ,,,,r, ,~,,
Y '~ ~ , r~r -,-~ i~_r share of the deceased mer~~ber's non-taxable contnb~tic~
t~ ~ CIE ~ ~r e ,r_ y r~c Mme tax purposes.
-~ r ~ ~,- ~;= ~ _:~ reported to the i~terral R-~ r,u Ssrvice. of a ' 09~g ~~ ,
~- t"~ trli ~i /~~~ ~~/ I receive one prior to January 31 of next year, with the r~ec~
''f~~ ~ ~~c ' '~r r ,~r ~~,~ this payment. Uncer current la~r~ there are nc Pennsylv~~nia ~ , _r_,~;
~x~ ~ c' 3 ~y ,~_-~~,t, raid from this sysiem.
i ~ ~ I tr=. ~ -n t ,_, ~ ~~.'9R form that you ~eceive should be kept in a safe place a; ~.~, i~ ; E,e ! ~1,..
'~~"' ~~ ~ ~' ~~ - ire : your Federal Inccme Tax Retur~~. This is the only no+i~ - ,~; . ,
sincerely,
~ ~
Debra G. Murph;, Director
Benefi! Determination Division
III III IIII III IIII~ III IIlII IlilO IIII III III !II II11 ill