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J 1505610105
REV-1500°``°""`~'
enn varda OFFICIAL USE ONLY
PA Department of Revenue P ~ County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX z8o6ot g
HaMSburg, PA i~tz8-o6oi RESIDENT DECEDENT ~ ~ O g d ~ I
ENTER DECEDENT INFORMATION BELOW
Sodal Severity Number Date of Death MMDDYYYY Date of Birth MMDDYYW
10/29/2008 ~Z' O 3 f / 9 Y'7
Decedent's Last Name Suffix Decedent's First Name MI
SHOMPER Lee Ann
(If Applicable) EMar Survhring Spouse's Information Below
Spouse's Last Name
_ Suffix Spouse's First Name MI
SHOMPER 'Donnie N
Spouse's Soaal Severity Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
_2 by - 5y-__$ ? 55 , REGISTER OF WILLS
FlLL IN APPROPRIATE OVALS BELOW
(~ 1. Original Return O 2. Supplemental Realm O 3. Remainder Return (Date of Death
Prior to 12-13-82)
O 4. Limned Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
C70 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT - THIS SECTION MUST eE COMPLETED. ALL CORRESPONDENCE AND CONflDENTIAL TAX INFORMATION SHOULD BE.DIRECTED Ttf:
Hama Daytlme Telephone Number
Donnie N. Shomper (717)~~-
_ y~ z - is ~/ y ~
REGISTER OF 11WLLS USE ONLY
First Line of Address
860 Walnut Street
Second Llne of Address
Apt A5
City or Post Office
State ZIP Code _
Lemoyne PA 17043 ~T+ ~ ~
Correspondent'a e-mail address:
Under penalties of perjury, I declare That 1 have examined this return, including accompanying schedules and statameras, and to the best of my knowledge and belief,
it is true, correct end complete. Declaretion of preparer other than the personal represemative is based on all information oT which preperer hea any knowledge.
SIGNAT RE OF PERSON RESPON51pyLE FOR FILING RETURN DATE
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
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1505610205
REV-1500 EX (FI) Decedent's Social Security Number
_. _ __ _.
t7ecedent's Name: '
RECAPITULATION
1. Real Estate (Schedule A) ............................................ .
2. Stocks and Bonds (Schedule B) .......................................
3. Closely Held Cor{wrafion, Partnership or Sole-Proprtetorship (Schedule C) .... .
4. Mortgages and Notes Receivable (Schedule D) ...........................
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)...... .
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ...... .
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Rroperty
(Schedule G) O Separate Billing Requested....... .
8. Total Gross Assets (total Lines 1 through 7) ............................. 8.
31,800.00
9. Funeral Expenses and AdminisVative Costs (Schedule H) ................... 9.
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10.
11. Total Deductions (total Lines 9 and 10) ................................. 11.
12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. ', 31,800.00
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
_
..._ ~ _.
an electlon to tax has not been made (Schedule J) .................... .... 13.
_ _
..
14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .... 14. ! 31,800.00
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Llne 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 _
(a)(1.2) x .0 0 31,800.00 15. 0.00
16. Amount of Line 14 taxable
at lineal rate X .0 _ i6.
17. Amount of Line 141axable
at sibling rate X .12 ' 17.
_ _ __ __. .......,_ ___ _........
18. Amount of Line 14 taxable __ . .. W W ___ __~
at collateral rate X .15 ', 18.
19. TAX DUE ..................................................... .... 19. 0.00 ',
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610205 J
REV-1500 EX (FI) Page 3 Flle Number
Decedent's Complete Address:
DECEDENTS NAME
SHOMPER Lee Ann
STREETADDRE93
860 Walnut Street
_-- - _ _..----- - - STATE _ _~.----- ZIP ------...
Lemoyne PA 17043
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 0.00
2. CreditslPayments
A. Prior Payments _ _
B. Discount
3. Interest - -- Total Credits (A + B) (2)
(3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Filt 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) 0.00
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 dght to designate who shall use the property transferred or its income ................................. ........... ^
c. retain a reversionary interest ................................................................................................................... ........... ^
d. receive the promise for life of either payments, benefits or care? ........................................................... ........... ^
2. If death occurted after Dec. 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................................................................................................... ........... ^
3. Did decedent own an °in trust for" orpayable-upon-death bank account or security at his or her death? ... ........... ^
4. Did decedent own an individual retirement account, annuity or other non-probate propert
whkh
y,
contains a benefirtiary d~ignatbn? ............................................................................................................. ........... ^
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~ ath o § raft `r j fly ; (), 94, and before Jan. 1, 1995, the taz rate imposed on the net value of transfers to or for the use of the surviving spouse
Is 3 rcent 2 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 for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 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(a){1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefidaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(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(a)(1.3)]. Asibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1513 EX+ (OS-30)
~ pennsylvania
DEVARTMENT OF REVENUE
INHERITANCE TAX RENRN
RESIDENT DECEDENT
SCHEDULE ]
BENEFICIARIES
ESTATE Of:
FILE NUN9ER:
RELATIONSHIP TO DECEDENT AMOUNT OR SNARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not List Truatete(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal dlsMbutlons and transfers under
Sec. 9116 (a) (1.2).]
1. Donnie N. Shomper
860 Walnut Sfreet Lemoyne, PA 17043
Spouse
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER BECKON 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
31,800.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEEL I$
If more space is needed, use additional sheets of paper of the same size.
REV-s.5o8 EX+ (ii-IO)
` SCNlpULE E
pennsytvania
~~ DEPARTMENT OF REVENUE CASHr BANK DEPOSITS ~ MISC.
INNERIfANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
SHOMPER Lee Ann 21-08-1197
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned wish right of survivorship must lx d'ulciosed on Schedule F.
If more space is needed, use additional sheets of paper of the same size.
This is Go certify that this is a true copy of the rewtd which is on file in the Pennsylvania Department of Health, in accordance with
the Vital Statistics Law of 1953, as amended.
WARNING: It Is Illegal to duplicate this copy by photostat or photograph.
5622729
No.
Linda A. Caniglia
State Registrar
JUN 0 2 2010
Date
atos.tw ~ nmaa COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDfi 104729
~ CORONER'S CERTIFICATE OF DEATH
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