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Home My WebLink About03-31-11I 155610140 REV-1500 EX (01-10) OFFICIAL USE ONLII PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po Box 28oso1 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 0 D 5 2 9 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 8 6 2 8 6 4 9 1 D 6 0 6 2 0 0 9 0 1 1 6 1 9 3 7 Decedent's Last Name Suffix Decedent's First Name MI S H E L L E N B E R G E R P H Y L L I S A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW a 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) 0 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust D 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 tai: under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) GUKKtJYU1VUtIV 1 - t rna at~i wh mua~ CC t,~mr~~ i cu, HLL IiVKRCJrV1VUC1Yl.C HIYU IiVIYr1UCIY 1 INL Iran IIYrVR1Y1Ml IVIY ~Jr7VVLV DC LlIRCI+I Cu I V. ~.r Name Daytime Telephvt~e Number ~- .. ~ ::~ ~~ M U R R E L W A L T E R S I I I E S Q- 7 1 7 6~. ~7 7 4 6 5 ~~ ' ~-~ REGISTE~S USE~„QJ~1LY _ x ~...~~ t ~~.'N First line of address ~ -- ~ ':---~ 5 4 E A S T M A I N S T R E E T ~, ~ c~ Second line of address ~r`"~ `~ C_ City or Post Office M E C H A N I C S B U R G Correspondent's a-mail address: State ZIP Code ~ DATE. FILED P A 1 7 0 5 5 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 is true, correct and com lete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN e. RE OF PE ~/ OyS)B; E F~~~ G RETURN D~E XDpRESS ~ DENNIS R- H L DER R, BOX B94 LEWISBERRY PA 17B39 SIGNATURE OF PR O, k°i H REPRESENTATIVE I~,~,-E ,.~ r ADDRESS ' 1 MURREL WALT44RS III ESQ 54 E MAIN ST MECHANICSBURG PA 17D55 PLEASE USE ORIGINAL FORM ONLY Side 1 15D561D14D 15D561D1,4D J ~~~~- J 1,50561,0240 REV-1500 EX Decedent's Social Security Number Decedent's Name: PHYLLIS A• SHELLENBERGER 1, 8 6 c! 5 6 4 9 1, RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. • 2. Stocks and Bonds (Schedule 6) ...................................... 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. 9 ~ 8 8 • 0 6 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 9 0 8 8 . 0 6 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9• 1 I 5 8 . 4 5 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1} ............. 10. 7 9 2 9 . 6 1, 11. Total Deductions (total Lines 9 and 10) ............................... 11. 9 0 8 B . 0 6 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 0 . 0 0 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. 0 . 0 0 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 15. • 16. Amount of Line 14 taxable at lineal rate X .0 16. • 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 1 g. 19. TAX DUE ...................................................... 19. • 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1,50561,0240 1,5056],0240 J Decedent's Complete Address: 21 10 0529 DECEDENT'S NAME PHYLLIS A. SHELLENBERGER _,_ STREET ADDRESS 940 WALNUT BOTTOM ROAD _ _, CITY CARLISLE STATE PA ZIP 17013 Tax Payments and Credits: ~. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B, Discount 3. Interest 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. 5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (3) (4) (5) 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 : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or .............................................. ............................... ................... ^ Q d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ Q 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? ......... ^ XO 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ............................................................ ... ................................... ^ ^X 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 is 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 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 beneficiaries is 4,5 percent, except as noted in 72 P.S. §9116(1.2) [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. Total Credits (A + B) (2) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER PHYLLIS A. SHELLENBERGER 21 10 0529 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. PENN MUTUAL COMPANY 5,694.28 LIFE INSURANCE 2. f MANOR CARE NURSING HOME I I REFUND 3,393.78 TOTAL (Also enter on line 5, Recapitulation) I $__ 9.088.06 (If more space is needed, insert additional sheets of the same size) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER PHYLLIS A. SHELLENBERGER 21 10 0529 Decedent's debts must be reported on Schedule [. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS; 1. Personal Representative Commissions: Name(s) of Personal Representative(s) DENNIS R. SHELLENBERGER 315.95 Street Address P.O. BOX 394 City LEWISBERRY State PA- ZIP 17339 Year(s) Commission Paid: 2, Attorney Fees: MURREL R. WALTERS, III, ESQ. 750.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZfP Relationship of Claimant to Decedent 4. Probate Fees: CUMBERLAND COUNTY 92.50 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL (Also enter on Line 9, Recapitulation) I $___ _ 1,158.45 If more space is needed, use additional sheets of paper of the same size. RCV-IJ IL C/~T 11L-VOJ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER PHYLLIS A. SHELLENBERGER 21 10 0529 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimburse~d medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PENNSYLVANIA DEPARTMENT OF WELFARE 7,929.61 MEDICAID BENEFITS TOTAL (Also enter on Line 10, Recapitulation) N $ 7,929,61 If more space is needed, insert additional sheets of the same size.