HomeMy WebLinkAbout09-12-11 ,5056],01,05
.~ REV- ~ 5 O O EX (02-11) (FI) ~;
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania -
DEPANiNENTOFPEVENUE County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN ~ ` I ~ "'
PO BOX 280601 /.-r /` ~ 1
Harrisburg, PA 1~1z8-o6o1 RESIDENT DECEDENT (,J (tl `-1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
175-40-7132 09/27/2010 08/23/1949
Decedent's Last Name Suffix Decedent's First Name MI
__ ___ __
__
SHELLENBERGER BARRY L
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
SHELLENBERGER ' LYNNE
Spouse's Social Security Number
- - - - ---- THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
166-46-282s REGISTER OF WILLS
..............................
__ -
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death
O 4. Limited Estate
O 6. Decedent Died Testate
(Attach Copy of Will)
O 9. Litigation Proceeds Received
O 4a. Future Interest Compromise (date of
death after 12-12-82)
O 7. Decedent Maintained a Living Trust
(Attach Copy of Trust.)
O 10. Spousal Poverty Credit (Date of Death
Between 12-31-91 and 1-1-95)
Prior to 12-13-82)
O 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
O 11. Election to Tax under Sec. 9113(A)
(Attach Schedule O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
LYNNE SHELLENBERGER 69'7-2248
First Line of Address
108 N LOCUST LANE
Second Line of Address
City or Post Office State ZIP Code
MECHANICSBURG PA 17050
Correspondent's a-mail address:
REGISTER OF WILLS USE ONLY
_~Q _. ..
- ~
I.1 "~ ~
~;~~ .~
~~, .
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_._
DATE ~f~F~..~
:.~ _, ~_~
Under penalties of perjury, I declare that I ve examined this return, including accompanying schedules and statement;;, and to the best of my knowledge and belief,
it is true, correct and complete. Declaraf of preparer other than the personal representative is based on all informati~~n of which preparer has any knowledge.
(GNAT OFD ~ OIL RESPON LE R f IL}t9G RET N ~i/~ /~,~p~.7~j
LOCUST LANE MECHANICSBURG PA 17050
~E OF PREPARER OT~FiER REPRESENTATIVE
DATE
/J /r
r
AD
430 N ENOLA DRI ENOLA PA 17025
PLEASE USE ORIGINAL FORM ONLY
1505610105
Side 1
1505610105 J
~~ ~~
~• :~
J
REV-1500 EX (FI)
Decedent's Name:
1505610205
Decedent's Social Security Number
175-40-7132
--_
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. 12,906.17
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. 4,140.51
8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 17,046.68
9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 9,218.50
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .............. . 10.
11. Total Deductions (total Lines 9 and 10) .................. . ............. . 11. 9,218.50
12. Net Value of Estate (Line 8 minus Line 11) ............................. . 12. 7, 828.18
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. 7,828.18
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
18....
trans ers under ec. 9 _ _ 7
828 __
'
,
.
(a)(1.2) X ,0_ 15.
0.00
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 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
11pr_pripnt'~ C~mnlete Address:
File Numt~er
DECEDENT'S NAME
BARRY L SHELLENBERGER
STREET ADDRESS
108 N LOCUST LANE
CITY
MECHANICSBURG STATE
PA ZIP
17050
Tax Payments and Credits:
1.
2.
Tax Due (Page 2, Line 19)
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.
Total Credits (A ~• B) (2)
(3)
(4)
(5)
o. o0
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 right 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 occurred 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" 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, which
contains a beneficiary 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 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 aercent, 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 percE;nt [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 t,y blood or adoption.
REV-isiz Ex+ clo-a9~
~ pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
BARRY L SHELLENBERGER 2010-01064
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A, FUNERAL EXPENSES:
1' SULLIVAN FUNERAL HOME 4,745.00
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
368.00
2. Attorney Fees:
3. Family Exemption; (If decedent's address is not the same as claimant's, attach explanation.) 3,500.00
Claimant LYNNE SHELLENBERGER
Street Address 108 N LOCUSL LANE
city MECHANICSBURG State PA ZIP 17050
Relationship of Claimant to Decedent WIFE
4. Probate Fees: 81.50
5. Accountant Fees: 250.00
6. Tax Return Preparer Fees; 250.00
~~ DEATH CERTIFICATES 24.00
State Z] P
TOTAL (Also enter on Line 9, Recapitulation) I $ 9,218.50
If more space is needed, use additional sheets of paper of the same size.
REV-15o8 EX+ (si-io)
~ ennsylvania SCHEDULE E
p CASH, BANK DEPOSITS & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
BARRY L SHELLENBERGER 2010-01064
Include the proceeds of litigation and the date the proceeds were received try 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. M & T BANK 3,906.17
2 1982 CORVETTE 9, 000.00
TOTAL (Also enter on Line 5, Recapitulation) $ I 12,906.17
If more space is needed, use additional sheets of paper of the same size.
REV- .S:L 0 EX~t (OS-09)
`; pennsylvarna
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
BARRY L SHELLENBERGER 2010-01064
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY DATE OF DEATH_ % OF DECD'S EXCLUSION TAXABLE
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FDR REAL ESTATE, VALUE OF ASSES INTEREST (IF APPLICABLE) VALUE
~. LYNNE SHELLENBERGER - WIFE -IRA - 2010 4,140.51 100 4,140.51
TOTAL (Also enter on Line 7, RecaE-itulation) $ I 4,140.51
If more space is needed, use additional sheets of paper of the same size.
~~~ l'bl~~1l ~3~l~1lt~
ACCOUNT N0. ACCOUNT TYPE
9837296467 M8T CLASSIC CHECKING W/
- .i. _.. . ~ . ...u.d-` .,. ..:2 , r . ~. ..,,. ... ~;;.. ...A,aii..,>.« r< ..... . _„ ._ u.1_1.+~.:. ~~'~u-iiua.t`.:..~.tf». to~.:+'d
STATEMENT PERIDD PAGE
INTEREST OCT.16-NOV.16,2010 1 OF 1
00 0 06121M NM 017
17688
BARRY L SHELLENBER6ER
108 N LOCUST LN
MECHANICSBUR6 PA 17050-1658
INTEREST PAID YEAR TO DATE 0.54
Af'f`f111NT CIIMMARV
SUMMERDALE PLAZA
BEGINNING
'BALANCE DEPOSITS~8
DTHER ADDITIDNS
-CHECKS PAID -OTHER
SUBTRACTIONS CURRENT
INTEREST PD ENDING
BALANCE
N0. AMOUNT N0. AMOUNT N0. AMOUNT
3,906.16 0 0.00 0 0.00 1 3,906.17 0.01 O.OD
Af'f'f111NT Af'TTVTTV
POSTING.
-DATE
TRANSACTION DESCRIPTION DEPOSITS,IMTEREST
8 OTHER ADCIITIONS CHECKS & OTHER
SUBTRACTIONS DAILY
BALANCE
1D-16-10 BEGINNING BALANCE 53,906.16
10-26-10 INTEREST PAYMENT 0.01
10-26-10 CLOSEOUT 3,906.17 0.00
ENDING BALANCE 50.00
ANNUAL PERCENTAGE YIELD EARNED = 0.00
BEGINNING JANUARY 27,2011, THE EXTENDED OVERDRAFT FEE WILL BE RE]:NSTATED FOR M8T CHECKING ACCOUNTS. IF
YOUR ACCOUNT IS OVERDRAWN, WE WILL CHARGE YOU S10 FOR EVERY 5 BUSINESS DAYS FOR UP TO 40 BUSINESS DAYS
UNTIL YOU PAY US ALL AMOUNTS OWED. YOU WILL NOT BE CHARGED IF THE OVERDRAFT ZS SOLELY ATTRIBUTABLE TO
ATM AND EVERYDAY DEBIT CARD TRANSACTIONS AND YOU HAVE NOT ELECTED TO PERMZT US TO AUTHORIZE AND PAY
THESE TRANSACTIONS WHEN YOU DO NOT HAVE SUFFICIENT AVAILABLE FUNDS IN YOUR ACCOUNT. REMEMBER, YOU CAN
MAKE OR CHANGE THIS ELECTION AT ANY TIME.
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STATEMENT OF
FUNEI:AL GOODS AND SERVICES SELECTED
No. ~ ~ ~'3 J:?
DECEASED ~}A~.~"'^; C' ~~t[.~-~~~Y
DATE OF DEATH y ~'- J ?'~
PLACE OF DEATH t-/4a+6
DATE OF STATEMENT ~ ~ ~~ t I J
A. CHARGE FOR SERVICES SELECTED
1. Professional Services:
Basic Services of Funeral Director & Staff ..... ~~, ~t''/~
g ...........................
Embalmin ~~
Other preparation of body ................. .
2. Facilities, Equipment & Staff:
Use of Facilities & Staff for Viewing /Visitation ...
Use of Facilities & Statt for Funeral Ceremony .. .
Use~fFaci~ities&Staffforivlemonal5ervicer... -~-----'"---- -~~-~ ~~
Use of Equipment & Staff for Graveside Service ...
Use of Equipment & Staff for Church Service... .
3. Transportation:
Transfer of Remains to Funeral Home ........ ~
Hearse . ...............................
Limousine ...........................
Sedan .... ...........................
Service /Utility Vehicle ................... .
4. Other Services /Facilities /Equipment:
~or•~+t" ~~i+~~sr"t~t!
TOTAL OF SERVICES SELECTED . ... . ................$
f~ltilli~
CHARGE FOR MERCHANDISE SELECTED
B
.
Casket (or other receptacle) ........ ....................... .
NamelNo. ~`"~"sf"~r f ~'rvja`r
Material
Color
Outer Burial Container ..................................... .
NamelNo.
Material
Acknowledgement Cards ....................................
~ L
Register Book ............................................. ~
Memory Folders /Prayer Cards ................................
Clothing ..............................................
Cremation Urn .................................... K.~ .
TOTAL OF MERCHANDISE SELECTED ....................$
C. SPECIAL CHARGES
Forwarding remains to: ~ Receiving remains from:
Immediate Burial ........................................ .
Direct Cremation .......................................... ~J`
Other .................................... .............
TOTAL OF SPECIAL CHARGES .. .......................$
~~o~ "'-
TOTAL FUNERAL HOME CHARGES ....................... $
'This total does not include Cash Advances)
Charges are only for those items that you selected or that are
required. ll we are required bylaw or by a cemetery crr crematory
to use any items, we will explain the reasons in writing below.
It you selected a funeral that may require embalmins~, such as a
luneral with viewing, you may have to pay for emb~3lming. You
do not have to pay for embalming you did not approve it you
selected arrangements such as a direct cremation o~ immediate
burial. It we charged for embalming, we will explain why below. i
CASH ADVANCES
Certified Copies of Death Certificate ~ i
,i.C~ ~ $ (`° -- each $_i.,r.~
f
Clergy ,f ca `~'
Musician =
Paid Newspaper Notice _
Cemetery _ _
~:-
Other ~.+~~i~.-~stf... iw~cc'+':. _,r-'
TOTAL CASH ADVANCES $ __
We charge you for our services in obtaining: (specify cash advance items).
SUMMARY ~
Total Funeral Home Charges ................. $ ~_~~
"-`Local'SalesTax(If~applicable) ...... "........ $ __~
State Sales Tax (if applicable) ................. $ _!
Total Cash Advances ....................... $ ~
GRAND TOTAL $ ^~"~-
Less Credits and Payments
$
$
Total Credits ........................$
BALANCE DUE' - $ ~~~'~ a0
Billing To
DISCLOSURES
Reason tore balm ng ~~ ~'~ N~2sip
~~ i~~
If any law, cemetery or crematory requirements have requ~ied the
purchase of any items listed, the law or requirement is explained below.
ACKNOWLEDGEMENT AND AGREEMENT
I hereby acknowledge that I have the legal right to arre~nge the final
services for the deceased, and I authorize this funeral establishment
to perform services, furnish goods, and incur outside charges specified
on this Statement. I acknowledge that I have received the General
Price List and the Casket Price List and the Cuter Burial
Container Price List.
~.Teagts~y4+a my ent:
lye Y•~---~-_'
Full payment is due no later than ~ ~ ~~
If any pa .ment is not paid when due, an unanticipated LATEt~C,HARGE
of ~'~ % per month (ANNUAL PERCENTAGE RATE ~ ~4 9b)
on the unpaid balance will be due. I agree to pay the Balance Due
listed on this Statement, plus any Late Charge. to the event I default in
payment to this funeral establishment, I agree to pad- reasonable
attorney's fees and court costs in addition to any late Charge
applicable. I understand and agree that I am assuming personal
liability for the charges set forth in this Statement and that this is in
addition to the liability imposed by law upon the estate of the
deceased. By my signature below, I hereby agree to all of the above
and acknowledge receipt of a co of this S)ateme t. .,
~ ed f ~ ~ ~~' ~ ~~ ~ Dated
~'Soclal Security Number L'~
x
Signed Dated
ACCEPTANCE This funeral establishment agrees to provide all services,
~,.merchandisg and cash advances indicated on this Statement.
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