HomeMy WebLinkAbout01-31-11~ Y
1505610140
REV-1500 ~` ~°'-'°'
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year Fife Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ 1 I ( a ~ ~`1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW
1 8 1 3 2 2 6 2 1 0 9 2 3 2 0 1 0 1 2 0 7 1 9 3 6
Decedent's Last Name Suffix Decedent's First Name MI
S H U G H A R T N E V I N C
(if Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
S H U G H A R T D O N N A K
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required
death after 12-12-82)
^ 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death ^ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
GORRE5PC7NDENT - 1 NI5 5tG11UN MU51 13t GUMt'Lt l tU. ALL GUKKtSF'VNUtNGt ANU tiVNtiUtN I IAL 1 A~ INtUKMAI WN JtiWLU Ct UIKtI.I tU 1 V:
Name Daytime Teiephonre Number
R O G E R B I R W I N 7 1 7 2~-~1~.~ 2~° 5 ~,-
First line of address
6 0 W E S T P O M F R E T S T R E E T
Second line of address
City or Post Office
C A R L I S L E
State
P A
DATE FILED
ZlP Code ~
1 7 0 1 3
Correspondent's e-mail address:
1
~.
~.:.~~~
_~~
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it i e, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SI Rl AFi P S ESPOIVjSIj3~~E ;OR FhLIJVG E ~R~ ' sDA~~ , ~ r
1012 BAISH ROAD V MECHANICSBURG_ PA .17055
SIGNATUR P EPARER OTHER THAN PRESENTATIVE ATE
Il
ADDRES
60 WEST P~6MF ET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 J
~~
J
1505610240
REV-1500 EX Decedent's Social Security Number
DecedenrsName: NEVIN C• SHUGHART 1 8 1 3 2 2 6 2 1
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1. •
2. Stocks and Bonds (Schedule B) ...................................... 2. •
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. •
4. Mortgages and Notes Receivable (Schedule D) .......................... 4. •
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 1 0 8 0 0 . 0 0
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. •
7. Inter-Vivos Transfers & Miscellaneous N -Probate Property
h
l
S
d
G
~
1 2 9
4
6 5
3
7
(
c
e
u
e
)
Separate Billing Requested ....... 7. ,
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 1 4 0 2 6 5. 3 7
9. Funeral Expenses and Administrative Costs (Schedule H) ............ .... .. 9• 1 4 3 7 0 . 0 1
10. Debts of Decedent, Mort a e Liabilities, and Liens Schedule I
9 9 ( ) ........... 10.
.. 5 9 4 . 5 2
11. Total Deductions (total Lines 9 and 10) ......................... .... .. 11. 1 4 9 6 4 . 5 3
12. Net Value of Estate (Line 8 minus Line 11) ...................... .... .. 12. 1 2 5 3 0 0 . 8 4
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................ .... .. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .. 14. 1 2 5 3 0 0 . 8 4
TAX CALCULATION -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 0. 0 0 15. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate X .045 1 2 5 3 0 0. 8 4 16. 5 6 3 8. 5 4
17. Amount of Line 14 taxable
at sibling rate X .12 0. 0 0 17. 0. 0 0
18. Amount of Line 14 taxable
at collateral rate X .15 0. 0 0 18. 0. 0 0
19. TAX DUE ................................................ .... ..19. 5 6 3 8. 5 4
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505610240 1505610240 J
1
REV-1500 EX Page 3
D~cedelnt's Complete Address:
File Number
0 0
DECEDENTS NAME
NEVIN C. SHUGHART
STREET ADDRESS
1012 BAISH ROAD
CITY
MECHANICSBURG STATE
PA ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) _ 5_,638.54
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits (A + B) (2) 0.00
3. Interest
(3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 5,638.54
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred : ................................................................. ..... ^
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 after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................................................................................. ...... ^
3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? ... ...... ^ 0
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ............................................................................................ ...... 0 ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1,1994, and before Jan. 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan.1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements fior 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 21 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 0 percent [72 P.S. §9116(x)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(x)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(x)(1.3)}. A sibling is defined, undE
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
IN RESIrDENT D EDENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
NEVIN C. SHUGHART 0 0
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 1998 FORD EXPLORER 2,525.00
2. 12000 CHEVROLET SILVERADO 1500 ~ 8,275.00
TOTAL (Also enter on line 5, Recapitulation) ~ $ 101800.00
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX+ (08-09)
~pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF
FILE NUMBER
NEVIN C. SHUGHART 0 0
This schedule must be completed and filed ff the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
°lo OF DECD'S
INTEREST
EXCLUSION
pF APPUCAe~E~
TAXABLE
VALUE
1. OHIO NATIONAL FINANCIAL SERV{CES 123,520.17 100.00 123,520.17
CONTRACT #S1807445
BENEFICIARIES: CHILDREN OF DECEDENT
2. OHIO NATIONAL FINANCIAL SERVICES 5,945.20 1'00.00 5,945.20
CONTRACT #E5501488
10 PAYMENTS REMAINING $594.52 X 10 = $5,945.20
BENEFICIARIES: CHILDREN OF DECEDENT
TOTAL (Also enter on Line 7, Recapitulation) ~ $ 129,465.37
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
' ` pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
NEVIN C. SHUGHART 0 0
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. NEVIN MYERS FUNERAL HOME 8,261.51
2. TOMBSTONE 140.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2. Attorney Fees: IRWIN & McKNIGHT, P.C.
3, Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant CHERYL .L. SHUGHART
Street Address 1012 BAl S H ROAD
City MECHANICSBURG state PA Zlp 17055
Relationship of Claimant to Decedent DAUGHTER
4. Probate Fees: REGISTER OF WILLS
5 Accountant Fees:
6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA
7. I REGISTER OF WILLS -FILING FEE
2,000.00
3,500.00
88.50
350.00
30.00
TOTAL (Also enter on Line 9, Recapitulation) I $ 14,370.01
!f more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
FILE NUMBER
NEVIN C. SHUGHART 0 0
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
OHIO NATIONAL FINANCIAL SERVICES -REIMBURSEMENT OF PAYMENT ~ 594.52
TOTAL (Also enter on Line 10, Recapitulation) I $ 594.52
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
` Pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BEWEF~^I A ~'C~
INHERITANCE TAX RETURN G Gf ~r !1 G
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
NEVIN C. SHUGHART 0 0
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 [Indude outtsn'g ht spousal distributions and transfers under
Sec. 91't6 (a) (1.2).)
1. CHERYL L. SHUGHART Lineal 25,060.16
1012 BAISH ROAD ~ 115TH REMAINDER
MECHANICSBURG, PA 17055
2. NEVIN E. SHUGHART Lineal 25,060.17
102 MILL ROAD 1/5TH REMAINDER
DILLSBURG PA 17019
3. JEFFREY SHUGHART Lineal 25,060.17
78 HORSEKILLER ROAD 115TH REMA[NDER
SHIPPENSBURG PA 17257
4. ELAINE SHEAFFER Lineal 25,060.17
148 SIMMONS ROAD 1/5TH REMAINDER
MECHANICSBURG PA 17055
5. BETH A. BEAR Lineal 25,060.17
401 1ST STREET ~ 1/5TH REMAINDER
CARLISLE PA 17013
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON L1NES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size.
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One Financial Way
Cincinnati, Ohio 45242
"~"' Ohio National
®Financial Services
Post Office Box 237
Cincinnati, Ohio 452oi-0237
Telephone: Si3.794.6ioo
www ohionational.com
December 6, 2010
ROGER IRWIN, ATTORNEY
WEST POMFRET PROFESSIONAL BLDG
60 WEST POMFRET ST
CARLISLE PA 17013
~tECEIYED
ID~C 0 9 2010
Contract: S 1807445, E5501488
Annuitant: NEVIN C SHUGHART, DECEASED
Dear Mr. Irwin,
~R'WiN & ~fcKN~GH~
i~W OFFICES
Thank you for submitting the authorization to release information to your firm. Nevin Shughart
held the above-referenced annuity contracts with our company. The information you requested is
as follows:
S1807445
Owner: Nevin Shughart
Anniversary Date: 07/28/2006
Date of Death Value: $123,520.17
Cost Basis: $53,765.21
We have not received claim forms for this contract. The beneficiaries are Cheryl Shughart, Nevin
E. Shughart, Jeffrey Shughart, Elaine Sheaffer, and Beth Bear.
E5501488
Owner: Nevin Shughart
Annuitized: 08/01/2006
10 monthly payments of $594.52 remain, each to~be divided equally between the beneficiaries
We have received claim forms and reimbursement of the October payment for this contract.
I have included the forms required to complete the claim on contract S 1807445. Each beneficiary
will need to complete a form. If you have any questions, please contact us at 800-366-6654, or
directly at 513-794-6433, or by email at kzielinski@ohionational.com.
Sincerely,
~~ ~~~
Karen Zielinski
Annuity Claims
cc: Jack Snavely II 18384-121158
~~ \y ~~~^
C ~~'
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The Ohio National Life Insurance Company
Ohio National Life Assurance Corporation
~`~N - Ohio National
financial Services
November 23, 2009
NEVIN SHUGHART
1012 HAISH RD
MECHANICSHURG PA 17055
Dear Customer:
The Ohio~National Life Insurance Company
P.O. Box 237
Cincinnati, OH 45201-237
Overnight Pack~agges
One Financial Tay
Cincinnati, OH 45242
Toll Free: 800-366-6654
www.ohionational.com
This is a conf rmation of your most recent scheduled payment from Ohio National Financial
Services. Below is the detailed information in support of this payment.
Reference no: 09112300053
Payment Information:
Total Benefit $594.52
Total Deductions $0.00
Payment Amount $594.52
Contracts included in this Checlc/EFT:
# ID: Owner: Due date:
1) 03FPNILC E5501488 Shughart Nevin 12101/2009
Please call our Customer Service Center at 800-366-6654 if you have any questions concerning
the above information.
Sincerely,
Annuity Administration
..
**T~IIS IS NOT A BILL**