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~~ Pennsylvania INHERITANCE TAX RETURN
_.- . -_ _
-
~Et~~T T ~~ ~~:EN~~E NONRESIDENT DECEDENT FILE NUMBER
- 11 0710
PO BOX z8o6oi _ _
z ~
HARRISBURG, PA i~iz8-o6oi COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
~ JR
JOSEPH PETER SHAMANSKY 191-46-3000
Z .
,
W DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
W 11 /12/2010 02/16/1957
V (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
W
w ~ 1. Original Return ^ 2. Supplemental Retum ^ 3. Remainder Return (dateotdeath priorto tz-t3-azi
Y z Y ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date or death arter 12-tz-ezl ^ 5. Federal Estate Tax Return Required
~ ~ ~ ^ 6. Decedent Died Testate (Attach copy or wiul ^ 7. Decedent Maintained a Living Trust (Attach copy otTmst) ~ 8. Total Number of Safe Deposit Boxes
am
a
a ^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date or death between t2-at-st and t-t-ssl 11. Election to tax under Sec. 9113(A) (Attach srh of
~ THIS. SECTION MUST BE GO~PLETED. ALL CORRESPONDENCE ANO` CONFIDENTIAL TAX INFOf2MATiON SHOULD BE DIRECTED`TO:
w NAME COMPLETE MAILING ADDRESS
o ANTHONY T. MCBETH 407 NORTH FRONT STREET, FIRST FLOOR
y FIRM NAME u(Apprcab~e) CAMERON MANSION
HARRISBURG, PA 17101
p TELEPHONE NUMBER
(717) 238-3686
METHOD REFER TO METHOD OF COMPUTATION IN THE NONRESIDENT DECEDENT INSTRUCTION BOOKLET (REV-1736)
Check One: ^ Flat Rate ^ Proportionate (Complete Worksheet on Reverse Side)
._- -
1. Real Estate (Schedule A) (1)
!`l -1'3
2. Stocks and Bonds (Schedule B) (2) - `~ -
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) I' ;-~
(Schedule C) ~
i
4. Mortgages 8 Notes Receivable (Schedule D) (4) ~' ~.. -
5. Cash, Bank Deposits 8 Miscellaneous Personal Property (5) 4,295.00 ' ~` _ -
Z (Schedule E) _ _
t.
~ ~ .. ;.
~ 6. Jointly Owned Property (Schedule F) ls) ~~ -a ~ ~ ~,'~
1~ ~ , ,
J ^ Separate Billing Requested 42,937.00
~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
~ (Schedule G or L)
~ 47,232.00
Q 8. Total Gross Assets (total Lines 1-7) (8)
U 5,075.00
W 9. Funeral Expenses & Administrative Costs (Schedule H) (9)
~ 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 R 10) (11) 5,075.00
12. Net Value of Estate (Line 8 minus Line 11) (12) 42,157.00
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
(14) 42,157.00
14. Net Value Subject to Tax (Line 12 minus Line 13)
W SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
iY Z
W ~ 15. Amount of Line 14 taxable at the spousal tax x .0 _ (15)
H
= rate, or transfers under Sec. 2116 (a)(1.2)
U ~ 42,157.00 x .a 45 (1s) 1,897.00
W = 16. Amoun[ of Line 14 taxable at lineal rate
= Q. x .12 (17)
U ~ 17. Amount of Line 14 taxable at sibling rate
U OU 18. Amount of Line 14 taxable at collateral rate x .15 (18)
(1 y) 1,897.00
X 19. Tax Due -Make check payable to Commonwealth of PA
Q~ 20.^ • • • • •
> > BE SURE TO ANSWER ALL QUESTIONS ON REtiIERSE SIDE AND RECHECK MATH c <
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P,E~'-1737-4 EX - ,6-08)
Pennsylvania
INHERITANCE TAX RETURN
NONRESIDENT DECEDENT
SCHEDULE E, PART 1
MISCELLANEOUS
PERSONAL PROPERTY
ESTATE OF
SHAMANSKY, JOSEPH P.
FILE NUMBER
21-11-0710
Part 1 must include all tangible personal property having its situs in Pennsylvania. Examples of tangible personal property are
jewelry, furniture, paintings, etc. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
Complete Part 2 on reverse side ONLY when the proportionate method of tax computation is elected.
(If more space is needed, use additional sneers or paper or ine same si~e~
REV-1737-6 EX + (6-08)
pennsylvania
UEPA RTM F..NT O~ REVEPJUE
INHERITANCE TAX RETURN
NONRESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS & Use Schedule G, Part 2, ONLY for
proportionate method of tax computation.
MISC. NON-PROBATE PROPERTY
ESTATE OF
SHAMANSKY,JOSEPH P.
FILE NUMBER
21-11-0710
Part 1 must include all transfers of real estate and tangible personal property located in Pennsylvania.
Complete Part 2 ONLY when the proportionate method of tax computation is elected.
Include in the description of property the date the transfer was made and the name and relationship of the transferee. This schedule
must be completed and filed if the answer to questions 1 through 4 on the reverse side of the REV-1737 cover sheet is yes.
ITEM DESCRIPTION OF PROPERTY
Include the name of the transferee, the relationship to Decedent and the date of transfer.
DATE OF DEATH
% OF DECD'S
EXCLUSION
NUMBER Attach a copy of the deed for real estate. VALUE OF ASSET INTEREST (IF APPLICABLE) TAXABLE VALUE
~ PENNSYLVANIA STATE EMPLOYEE RETIREMENT ACCT 42,937.00 100 42,937.00
PART 1 TOTAL $ $ $ 42,937.00
•
ITEM DESCRIPTION OF PROPERTY
Include the name of the transferee, the relationship to Decedent and the date of transfer.
DATE OF DEATH
% OF DECD'S
EXCLUSION
NUMBER Attach a copy of the deed for real estate. VALUE OF ASSET INTEREST (IF APPLICABLE) TAXABLE VALUE
1.
0.0
PART S TOTAL $ $ $
TOTAL (Also enter on Line 7, Recapitulation.) $ 42,937.0
(If more space is needed, use additional sheets of paper of the same size)
REV-1737-6 EX + (E-08)
REVERSE
i~ pennsylvania
~3 ,,_PAR7PnFi`dTv=REVENUE
INHERITANCE TAX RETURN
NDNRESIDENTDECEDENT
SCI~IEDULE H
FUNERAL EXPENSES & Use Schedule H ONLY for proportionate
method of tax computation.
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
SHAMANSKY, JOSEPH P. 21-11-0710
Debts of decedent must be reported on Schedule I.
ITEM NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~ KRAMER FUNERAL HOME, ALEXANDRIA, LA 71301 2,721.00
B. ADMINISTRATIVE COSTS:
1' Personal Representative's Commission(s)
Name(s) of Personal Representative(s)
(Submit requested information for additional personal representative's on additional sheets)
Social Security Number(s) or EIN Number(s) of Personal Representative(s)
Street Address(es)
City(ies) State(s) ZIP(s)
Year(s) Commission Paid
2. Attorney Fees
3. Probate Fees
4. Accountant's Fees
5. Tax Return Preparer's Fees
6. Miscellaneous Expenses
ADVERTISING
BANK CHARGE
FEE FOR TRANSFERRING TRUCK TITLE
TOTAL (Also enter on Line 9, Recapitulation.) ~ $
(If more space is needed, use additional sheets of paper of the same size)
1,889.00
172.00
254.00
16.00
23.00
5,075.00
REV-1737-7 EX t (6-08)
REVERSE
pennsytvania SCHEDULE J
~.- . "~ kr EM1,~E BENEFICIARIES
INHERITANCE TAX RETURN
NONRESIDENT DECEDENT
ESTATE OF FILE NUMBER
SHAMANSKY, JOSEPH P. 21-11-0710
When flat rate method is elected, list the beneficiaries of the Pennsylvania property.
When proportionate method is elected, list all beneficiaries.
RELATIONSHIP TO
ITEM DECEDENT AMOUNT OR SNARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under Sec. 2116 (a)(1.2)]
1.
JEREMY L. SHAMANSKY, 764 ERFORD RD, CAMP HILL, PA 17011 SON 109
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON REV-1737 COVER SHEET OR THE PROPORTIONATE METHOD WORKSHEET ON THE REVERSE SIDE
OF REV-1737 COVER SHEET, AS APPROPRIATE. ___
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II
(Enter total non-taxable distributions on Line 13 of REV-1737 cover sheet.) $0.00
(If more space is needed, use additional sheets of paper of the same size)
REV-1737-t EX + (6-OS)
-~ i ' pennsylvania NONRESIDENT DECEDENT
'~ "F`'~"' ~''~"' "~ ~E"~"~` AFFIDAVIT OF DOMICILE
PO BOX z8o6oi
HARRISBURG, PA i9iz8-o6oi
This affidavit must be completed and sworn to by a person having personal knowledge of these
facts, preferably by a surviving spouse or member of the decedent's family.
Name of Decedent Date of Death
JOSEPH PETER SHAMANSKY, JR. 11/12/2010
legal Address at Time of Death:
Street Address CitylBorough State ZIP Code
8321 HIGHWAY 488 ELMER LA 71424
__ -- _ --
The following information is submitted in support of the statement that the above individual was
not domiciled in the Commonwealth of Pennsylvania at the date of death.
1. Names and addresses of the decedent's surviving spouse and members of hislher immediate family:
Name and Relationship to Decedent
JEREMY L. SHAMANSKY -SON
Street Address CitylBorough State ZIP Code
764 ERFORD ROAD CAMP HILL PA 17110
Name and Relationship to Decedent
Street Address City/Borough State ZIP Code
Name and Relationship to Decedent
Street Address City/Borough State ZIP Code
2. Did the decedent ever five in Pennsylvania? ~ Yes ^ No
If yes, during what periods?
FROM HIS BIRTH IN 1957 UNTIL 1998
3. Did the decedent spend time in Pennsylvania during the five years preceding death ? ^ Yes S1 No
If yes, during what periods and at what address(es)?
OCCASIONAL BRIEF VISITS ONLY
4. What was the nature of decedent's place(s) of residence during the five years immediately preceding death?
Indicate whether decedent resided in a house or apartment and whether it was rented or owned by the decedent, andlor whether decedent resided in a
hotel or the home of relatives or friends.
HE LIVED IN A HOUSE AT THE ABOVE ADDRESS WITH HIS GIRLFRIEND, JUDY CROSS
5. Was the decedent employed during the five years preceding death? R[ Yes ^ No
If yes. list the name(s) and address(es) of employer(s).
HE WAS NOT EMPLOYED WHILE LIVING IN LOUISIANA; HE HAD RETIRED FROM HIS JOB AS A PRISON GUARD
IN 1996
6. Did the decedent leave a will? ^ Yes No
if yes, state the court that admitted the will to probate and the date admitted, and attach a copy (including all codicils) and a certifiicate of issuance of
letters testamentary.
7. If the decedent did not leave a will, has an administrator of the estate been appointed? R[ Yes ^ No
If yes, state the court that appointed the administrator and the date of appointment, and attach a certificate of the issuance of letters of administration.
CUMBERLAND COUNTY ORPHANS COURT/REGISTER OF WILLS, SEPTEMBER 1, 2011 COPY OF CERTIFICATE
ATTACHED
8. At any time during the last five years did the decedent execute a will, codicil, trust indenture, deed, mortgage, lease or any other document in which
the decedent was described as a resident of Pennsylvania? ^ Yes SI No
If yes. describe such document.
NONRESIDENT DECEDENT AFFIDAVIT OF DOMICILE (continued) Page 2
9. Did the decedent pay a tax on income or on intangible property to any state, county or municipality during the last five years?
If yes, where and when was it paid? ~ Yes ^ No
LOUISANA STATE INCOME TAX
10. To what regional office of the Internal Revenue Service did the decedent forward his federal income tax returns during the last five years
preceding death?
I DO NOT KNOW, BUT I WOULD PRESUME HIS INCOME TAX RETUNS WERE SUBMITTED TO THE AUSTIN,
TEXAS REGIONAL OFFICE OF THE IRS
11. At the time of death, did the decedent own, individually or jointly, any interest in real propel ,including lease-holds, or tangible personal property
located in Pennsylvania? Yes ^ No
If yes, describe the property in detail
BANK ACCOUNT (CITIZENS) 1994 CHEVY BLAZER (WITH DECEDENT IN LOUISANA BUT STILL TITLED BY
PENNSYLVANIA) AND A PENNSYLVANIA STATE EMPLOYEE RETIREMENT ACCOUNT
12. In what business activities was the decedent engaged during the last five years preceding death?
Indicate whether decedent was employed or otherwise engaged in the business, and state the names and the addresses of the persons, firms or corpora-
tionswith which the decedent had such business affiliations (Except for employer listed in #5).
NONE OTHER THAN HIS EMPLOYMENT DESCRIBED ABOVE
13. What is the estimated gross value of the decedent's estate, exclusive of real property and tangible property located outside of Pennsylvania?
$47,232.00 MORE OR LESS
- -
14. At the time of death, did the decedent own or operate an automobile? R[ Yes ^ No
If yes, in which state was it registered?
PENNSYLVANIA
15. At the time of death, was the decedent a member of a church or any other organization ? ^ Yes Sl No
If yes.. provide the name and address of the church or any other organization.
16. State the purpose or reason the decedent owned real property in Pennsylvania.
HE DID NOT OWN REAL PROPERTY IN PENNSYLVANIA AT THE TIME OF HIS DEATH
17. Include any other information you wish to submit in support of the contention that the individual was not domiciled in Pennsylvania at the time
of death. If more space is needed, use additional sheets of paper of same size.
HIS DEATH CERTIFICATE, ISSUED IN LOUISANA, DESCRIBES HIM AS A RESIDENT OF RAPIDES PARISH,
LOUISANA
Name of Person Completing Affidavit Relationship to Decedent
JEREMY L. SHAMANSKY SON
Street Address City State ZIP Code
764 ERFORD ROAD CAMP HILL PA 17011
Under pena ies of pe ury, declare that based on my personal knowledge of the decedent,
he infor atio provided on this form is true, correct and complete.
ianature f Person Completi Affidavit Date
11 /25/2011