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Home My WebLink About09-02-11COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 014930 CONFAIR SUSAN H 2331 MARKET STREET CAMP HILL, PA 1701 1 -------- told ESTATE INFORMATION: FILE NUMBER: DECEDENT NAME: DATE OF PAYMENT: POSTMARK DATE: COUNTY: DATE OF DEATH: SSN: 203-10-8959 2111-0302 SHELLY ELIZABETH R 09/02/2011 08/30/201 1 CUMBERLAND 02/20/2011 REMARKS: ACN ASSESSMENT AMOUNT CONTROL NUMBER REV-1162 EX111-96) 510.96 TOTAL AMOUNT PAID: CHECK#1001 INITIALS: CJ SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS GLENDA EARNER STRASBAUGH REGISTER OF WILD AND CLERK OF ORPHANS' COURT MARJORIE A. WEVODAU FIRST DEPUTY KIRK S. SOHONAGE, ESQ SOLICITOR REGISTER OF VYIL,LS AND CLERK OF THE ORPHAN COUNTY OF CUMBERI,,,4Np S COURT ONE COURTHOUSE SQUARE CARLrsLE, PA 17013 (717) 240-6345 FAX (717)240-7797 INVOICE Bill To: REAGER & ADLER PC 2331 MARKET ST CAMP HILL, PA 17011 Qt3' Fee Description 1 Additional Probate T~ral• ~~ i Dial 1 C nn '.,•.,~ .pi~.VU 15.00 Checks should be made payable to the Register of Wills. Terms: Net 30. Please return one copy of this invoice with your payment. Thank you. InvoiceNo: Invoice Date: 3622 Estate of 92/2011 ELIZABETH R SHELLY Estate No: 21-11-0302 ~; ~-- INVENTORY REGISTER OF WILLS OF cUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS File Number 21 11 0302 Personal Representative(s) of the Estate of ELIZABETH R. SHELLY deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation 1 inventory represents its fair value as of the date of the decedent's death, and that Decedent owned n personal assets wherever situate Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inve p aced opposite each item of said o real estate outside of the ntory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. SUSAN H. CONFAIR Attorney -- (Name) DAVID W. REALER (Address) 2 3 31 MARKET STREET (Supreme Court I.D. No.) 2 0 8 6 8 DATE OF r)Fnru (Telephone) 717-763-138 /20/20 Stocks & Bonds FIGURES MUST BE TOTALED A 17011 ~2~31~8959 Closely-Held Corporation, Partnership or Sole-Proprietorship Mortgages & Notes Receivable Cash, Bank Deposits, ~ Misc. Personal Property PNC BANK, N.A., 600 GRANT STREET, PITTSBURGH, PA 15219 CHECKING ACCOUNT #5140096879 MANOR CARE - NURSING HOME REFUND IRS 8 DEPARTMENT OF REVENUE TAX REFUND (Attach additional sheets as needed) n ~ ~. ~~ .X7 . °~ _ a s r ~ t~ 1 .-iT- _ _ t ~ - l.J - _. I . _ . ~ - -. - ~' ~ (~ ' ~ --,^~ 5,605.98 1,707.12 573.p^ ivV rE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of [he personal repre~SentAap a inclu 7' 886 • 1 p item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S: ~' 3.30/(b)) de the value of each Form RW-09 rev. 10.13.06 CAMP HI 1 LAST RESIDENCE 17~p MARKET STREET CAMP HILL DECEDENT'S SOC. SEC. NO. r .J 1505610140 REV-1500 EX t0,_,o, PA Department of Revenue Bureau of Individual Taxes OFFICIAL USE ONLY PO BOX 2so601 INHERITANCE TAX RETURN County Code Year Harrisbur , PA 17128-0601 File Number ENTER DECEDENT INFORMATION BELOW RESIDENT DECEDENT 2 1 ], 1 0 3 0 2 Social Security Number Date of Death MMDDWW Date of Birth MMDDWW 2 0 3 1 0 8 9 5 9 0 2 2 0 2 0 1 1 0 4 1 9 1 9 2 0 Decedent's Last Name Suffix S H E L L Y Decedent's First Name E L MI (If Applicable) Enter Surviving Spouse's Information Below I Z A B E T H R Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL IN APPROPRIATE OVALS BELOW REGISTER OF WILLS 0 1. Original Return ^ 2. Supplemental Return ^ ^ 3. Remainder Return (date of death 4. Limited Estate ^X 6. Decedent Died Testate ^ ^ 4a. Future Interest Compromise date of death after 12-12-82) ( Pnor to 12-13-82) ^ 5. Federal Estate Tax Return Required (Attach Copy of Will) 9. Litigation Proceeds Recei 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 0 8. Total Number of Safe Deposit Bo ved CORRESPONDENT T ^ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) xes ^ 11. Election to tax under Sec. 9113(A) - HIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE A Name t S ND CONFIDENTIAL TAX INF ORMATION HOULD BE DIRECTED T0 D A V I D W R E A L E R . Daytime Telephone Number 7 1 7 7 6 3 1 3 8 3 r REGI ~ ~ '~ ~R , OF WILLS k1SE ONLYr:~ First line of address ~ ~ ~-• ' 2 3 3 1 M A R K E T S T R E E T ~~ ~ l ~ t :, m I •; Second line of addres =„ r -.- City or Post Office C A M P !J I L L State ZIP Code ~ P A 1 7 0 1 i. Correspondent's a-mail address: SCONFAIRaREAGERADLERPC • COM Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowled it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of wn;~h .,.~.._-__ . SIGNATURE OF PE O~EgpONSIBLE FOR Fu iNr_ orT~ ~~., ge and belief. ADDRESS" 2331 MARKE' THE SIGNATURE PR A R OTH F ADDRESS 2331 MARKET ST EET L 1505610140 REPRESENTATIVE CAMP H I L L CAMP HTII ~~ -t ~, . ; - --~ - ~ ~ ~• G ~~ATE FILED ~~. ~ -~' - •~, •~a~ any Knowledge. DATE d -- 7 i i PA 17011 ~~(e ~ I ~ r~tASE USE ORIGINAL FORM ONLY _ NA 1'701]' Side 1 1505610140 J ~ ~~ _...J 1505610240 REV-1500 EX Decedent's Name: ELIZABETH R • SHELLY Decedent's Social Security Number RECAPITULATION 2 0 3 1 0 8 9 5 9 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 7 8 8 6. 1 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested 7 ... . Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Biiiing Requested .... 6. .... .. . 7. 8. Total Gross Assets (total Lines 1 through 7) ... , , .... .......... ... s. 7 8 8 6, 1 0 9. Funeral Expenses and Administrative Costs (Schedule H) .... . .......... ... s. 3 2 3 7. 0 2 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... . . ~10~ 2 2 6 0. 5 5 11. Total Deductions (total Lines 9 and 10) ....... .................. . . ... 11. 5 4 9 7. 5 7 12. Net Value of Estate (Line 8 minus Line 11) .. . , .... . 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not be 12 2 3 8 8 • 5 3 en made (Schedule J) ... , , . ............. .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .. .................. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15 ..14. 2 3 8 8. 5 3 . Amount of Line 14 taxable at the spousal tax rate or , transfers under Sec. 9116 (a)(1.2)X.0 _ 0 0 0 16. Amount of Line 14 taxable 15. 0 , ~ ~ at lineal rate X .045 2 3 8 8 5 3 17. Amount of Line 14 taxable 16' 1 0 7 . 4 8 at sibling rate X .12 0 ~ 0 0 18. Amount of Line 14 taxable 17. 0 . 0 0 at collateral rate X .15 ~ ~ 0 18 ^. 0 0 19. TAX DUE ..... . .. .......................................... . 19. 1 0 7. 4 8 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610240 1505610240 REV-15p0 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME File Number 21 11 03172 ELIZABETH R. SHELLY STREET ADDRESS 17D0__MARKET STREET CITY -- -- CAMP HILL Tax Payments and Credits: ~ ~ Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 91.6 9 B. Discount 4.83 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. STATE ZIP PA 17D11 (1) 107.48 Total Credits (A + B) (2) 96.52 (3) (4) D . D ^ (5) 1D.96 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIA 1. Did decedent make a transfer and: TE BLOCI($ a. retain the use or income of the property transferred : .................... No .............................................. ^ X b. retain the right to designate who shall use the property transferred or its income; .......,.... ^ c. retain a reversions interest; or ~•~~~~~~~~~•~~••••~ ^ ^X ry ............................................................................................... ^ ^ d. receive the promise for life of either payments, benefits or care? ..................................................... X 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? ......... ^ ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which ^ ^ contains a beneficia desi nation .................. ry 9 ................................................................................ ^ o IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Fur dates of death on or after July i, i 994, and before Jan. i, i 995, the tax rate imposed on-the ..et value of transfers to or for the use of 3 percent [72 P.S. §9116 (a) (1.1) (i)]. the surviving spouse is 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 an filing a tax return are still applicable even if the surviving spouse is the only beneficiary. d 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)(i.3)]. Asibling is defined and Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ' er REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ELIZABETH R. SHELLY FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the state. 11 0 3 0 2 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE ~• PNC BANK, N.A•, 600 GRANT STREET, PITTSBURGH, PA 15219 OF DEATH CHECKING ACCOUNT #5140096879 5,605.98 2• MANOR CARE - NURSING HOME REFUND 1,707.12 3• IRS & DEPARTMENT OF REVENUE TAX REFUND 573.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 7 ~ 8 8 6 • REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ELIZABETH R- SHELLY SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: ~ PARTHEMORE FUNERAL HOME & CREMATION - ADDITIONAL FEES 2• TRINITY UNITED METHODIST CHURCH - CATERING 3• COUPLES FOR CHRIST B FILE NUMBER 21 11 03 AMOUNT 491.52 250.00 50.00 ADMINISTRATIVE COSTS: ~ • Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. AttomeyFees: REALER & ADLER, PC 3. Family Exemption: (If decedent's address is not the same as claimants, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4• Probate Fees: CUMBERLAND REGISTER OF WILLS 5. Accountant Fees: MARK L • WETZEL, CPA - PREPARE 201D TAX RETURNS 11 FROPJT STREET, SUITE 100, SHIREMANSTOWN•~ PA 17011 6. Taz Retum Preparer Fees: ~• LEGAL ADVERTISEMENT - JOURNAL PUBLICATIONS 2,DO0-DO 9o.5a 205.00 150.00 If more space is needed, use additional sheets of paper of the same size. TOTAL (Also enter on Line 9, Recapitulation) I $ 237.02 REV-1512 EX+ (12.08) Pennsylvania SCHEDULE i DEPARTMENT OF REVENUE DEBTS OF DECEDENT INHE , RITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF ELIZABETH R. SHELLY FILE NUMBER Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses ITEM NUMBER . DESCRIPTION VALUE AT DATE ~ DEPARTMENT OF PUBLIC WELFARE LIEN PAYOFF OF DEATH PO BO X8496 1,696.55 HARRISBURG, PA 17105 2• HEARTLAND PHARMACY OF PENNSYLVANIA, LLC - # 7010 SNOWDRIFT ROAD 122264 ALLENTOWN, PA 18106 302.36 3• SUSQUEHANNA INTERNAL MEDICINE 890 POPLAR CHURCH ROAD, SUITE 508 109.76 CAMP HILL, PA 17011 4• PHILHAVEN PO BOX 550 56.88 MT. GRETNA, PA 17064 7• ONHEALTHCARE - #47821 100 W. BIG BEAVER ROAD, SUITE 655 95.00 TROY, MI 48084 TOTAL (Also enter on Line 10 Recapitulation) I $ ii more space Is needed Insert addlUonal sheets of the same size. 2 ~ 2 6 0 5 REV-1513 EX+ (01.1 p1 Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT FSTATe nr. SCHEDULE) BENEFICIARIES ELIZABETH R • SHELLY FILE NUMBER: 21 11 0302 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE I, TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Do Not List Trustee(s) OF ESTATE Sec. 9116 (a) (1.2).] 1• EDWARD Q. SHELLY 304 15TH STREET Lineal NEW CUMBERLAND, PA 17070 2• BRUCE E• SHELLY 739 BOSLER AVENUE Lineal LEMOYNE, PA 17043 1,194.27 1,194.26 -CENTER 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 SECTION 9113 FOR WHICH AN ELECTION '1'0 TAX IS NOT TAKEN: 1. I 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. M ~~ ~# ~ r~ °` ~ . x. 4 `~'.k ~. ' o- - N r-I 1, ,~ .,~ JfF.,' ~ + ~~ + O f. .~ tS~ N N ~ a ro M ~, tr o ~ ~ ~ ~ N O v~ U ~ ~C o a -- ~~ ~ +~ .T 4fff 1-I N N Q ~-1 '~ O r-I F~-~ ~ ~~~ N O ~ ( ~~ ` `:::` _ ~ ~ f.. j i _ t? ~.. ~ C.n C~ ~ i t ~ -.- U a~ ~-~ ~ .,.; ,~°, ~~ ,r..y Q J F- Q Q J W r ^ ~ ~ W z ~ ~ ~ r ~ CJ ~ U c O ~ > ~ Z ~ a w ~ c U ~ ~ ~ ~ > c~ ~ w W Y - ~ Z ~ = Z CL ~ Q ~ O r ~ E ~ ~ ~ m w c~ U ~