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Home My WebLink About05-07-121505611185 REV-1500 EX (02-11)(FI) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of lndivitlual Taxes PO BOX 280601 INHERITANCE TAX RETURN ~! 1 11 1337 Harrisburg, PA 17129-O6a1 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date Of Death MMDDYYYV Date 0( Binh MMDDVVYY 204-01-5947 12052011 01091920 Decedent's Last Name Suffix Decedent's First Name MI SHELLEY HELEN M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Firsl Name: M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (Date of Death Pnor to 12-13-82) ^ ^ ^ 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) ^ 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trusl _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) ^ ^ ^ 9. Litigallon Proceeds Received 10. Spousal Poverty Credit (Date of Death 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT • THIS SECTION MUST ~ COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JOHN R• ZONARICH, ESQ• 717-233-1000 r-:. n ~ REGISTEL3 USE {~NlY x~ '~ ~_~ 7a ~~ -< r i ~ ~7 ~.~7 Firsl Line of Address '4 Z ~ ~ i . _" C J f J ~ _ 17 S • 2ND STREET moo ~ ; Second Line of Address C ~ - : '}~ ~-; -' 6TH FLOOR b --, - T' -c- ~ m U City Or Post Office State ZIP Code DATE FILED ~' HARRISBURG PA 17101 Correspondent'se-maltaddreas: JRZaSKARLATOSZONARICH•COM Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowletlge and belief, it is true, cor omplete. Declaration of preparer other than the personal represenletive is based on all information of which pceparer has arty knoMedge. RUSSELL C• SHELLEY, JR• FF R~ET HUMMELSTOWN, PA 17036 F ER Eq THAN PR ENTATIVE DA -, /1 JOHN R• ZONARICH, ESQ• -o~'J'o1D/ai 7 S•/2ND STIREEB, 6TH FLOOR 1505611185 PA 1710 Side 1 OM464] 3.000 15 0 5 61118 5 J .~ 1505611285 REV-1500 EX (FI) Decedent's Social Secudty Number 204-01-5947 becedent's Name SHELLEY HEL EN M RECAPITULATION t . Real Estate (Schedule A) . . . . . . . .. .. . . .... .... . .... .. 1. 0 , 0 0 2. Stocks and Bontls (Schedule B) . .. 2 0 • 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schetlule C) , 3. 0 , 0 0 4. Mortgages and Notes Receivable (Schedule D) q 0 • 0 0 5. Cash, Hank Deposits and Miscellaneous Personal Property (Schedule E) 5, 177 , 4 2 8 , 0 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested 6. 0 • 0 0 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. 0 • 0 0 8. Total Gross Asset (total Lines 1 through 7) 8. 17 7 , 4 2 a . o 0 9. Funeral Expenses and Administrative Costs (Schetlule H). g. 4 , 252 , 00 10. Debts of Decetlent, Mortgage Liabilities, and Liens (Schedule I) 10. ], 4 0 , 0 0 11. total Deductions (total Lines 9 and 10), 1 t. 4 , 392 • 00 12. Net Value of Estate (Line 8 minus Line 11) 12, 173 , 0 3 6.0 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been matle (Schedule J) , t 3. 10 , 3 8 2.0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) 14. 16 2 , 6 5 4.0 0 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal taz rate, or transfers under Sec. 9116 (a)(t.2) x .o ~ 0 .0 0 15. 0.0 0 16. Amount of Line 14 xable ~ at linealratex.0 4 162,654.00 1s. 7,319.00 17. Amount of Line 14 taxable at sibling rate X .t2 0 •00 17. 0.00 18. Amount of Line 14 taxable at couateral rate x .t 5 0. 0 0 t s. 0. 0 0 19. TAX DUE.. 19. 7,319.00 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505611285 1505611285 OM4848 3.000 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number 21 11 1337 DECEDENTS NAME Y STREET ADDRESS R CITY C P STATE A UP Tax Payments and Credits: 1. Taz Due (Page 2, Line 19) (i) 7 , 319.0 0 2. Credits/Payments A. Prior Payments 7, 0 0 0• l7 ~ B. Discount _ 350 • ~~ Total Credits(A+B) (z) 7,350.00 3. Interest (3) Q•~~ 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) 31 • ~ ~ 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGEPJT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS t. Ditl decedent make a transfer and: Yes No a. retain the use or income of the property transferretl .................. ^ ^X b. retain the right to tlesignate 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 ANC) FILE IT AS PART OF THE RETURN. Far dates of death on or after July 1, 1994, antl 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)J. 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 benef+ciary. For dates of death on or after July 1, 2000: • The tax rate imposetl 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 I72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the tlecetlent's lineal beneficiaries is 4.5 peroe:nt, except as noted in [72 P.S. §9116(a)(1)j. • The tax rate imposed on the net value of transfers to or for the use of the decetlent's siblings is 12 percent [72 P.S. §9116(a)(1.3)J. 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. OM48]1 2.000 REV-1508 EX~ p1-10) Pennsylvania UEPARTh1ENTOF REVENUE INHERITANCE TW(RETURN RESIUENr OECEpENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: HELEN M. SHELLEY 21 11 1337 Include the proceeds of litigation antl the date the proceeds were recaved 6y the estate. All prooerty jointly owned with riaM of survivorship must be tlisclosed on Schetlule F. REM VALUE AT DATE NUMBER rseroionnei OF DEATH 1. MetLife Insurance Co. -Refund of premium for long term care insurance 2,384 2 The Woods at Cedar Run - Refund 3,079 3 Personal Effects 200 4 Merrill Lynch Cash Account No. 872-38070 17,685 5 Merrill Lynch Investment Account No. 872- 56623 153,968 6 Verizon -Refund 2 7 Merrill Lynch -Balance in account 110 TOTAL (Also enter on line 5, Recapitulation) $ ~ 177 , 428 OWasAO 2.000 It Mora space is needed, use atltlhional sheets of paper of the same size. REV-1511 EX+(10-08) pennsylvania SCHEDULE H nEPPRTMEMOF REVENUE FUNERAL EXPENSES AND pJHEPoTPNCE TPX RETURN ADMINISTRATIVE COSTS RESIOENi nECEDENT ESTATE OF 1=1LE NUMBER HELEN M. SHELLEY 31 11 1337 Decedent's debts must be reportetl on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALF~CPENSES: ~ None B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: 3. Family Exemption: (If Decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Retum Preparer Fees: 7. 1 Cumberland Law Journal - Estate Notice 2 Register of Wills - Oath of Office Fee Total from continuation schedules . 2,900 312 135 550 75 20 260 TOTAL (Also enter on Line 9, Recapil swasnc z.ooo If more space is neetled, use additional sheets of paper of the same size. Estate of: HELEN M. 5HELLEY Schedule H Part 7 (Page 2) 21 11 1337 3 The Sentinel - Estate Notice 221 4 SkarlatosZonarich LLC - Costs 9 5 Register of Wills - Filing Fees 30 Total (Carry forward to main schedule) 260 gEV-1512 EX+ (12-08) pennsylvania LEPMTAEN70F REVENUE INHERITPNCE Tp%RErURN SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES 8 LIENS ESTATE OF FILE NUMBER HELEN M. SHELLEY 21 11 1337 Repoli debts incurretl by the decatlent prior t0 death that remained unpaid at the date of death, including unreimbursed metlical expenses. ewasnN 2.000 If more space is needed, insen additional sheets of the same size. REV-1513 EX+(01-10) SCHEDULE J Pennsylvania OEPARTMEMOF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDEM DECEDENT ESTATE OF: FILE NUMBER: vcttcv of ~~ iaoo RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Llst Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [InUUde ouMght spousal tlistnbutions antl transfers under Sec. 9116 (a) (1.2).] 1. Russell C. Shelley, Jr. 8161 Jefferson Street Hummelstown, PA 17036 One Quarter o£ Residue: 43,259 Son 43,259 2 Martha A. Specht 2724 Pennbrook Avenue Apartment 1 Harrisburg, PA 17103 One Quarter of Residue: 43,259 Daughter 43,259 ENTER DOLLARAMOUNfS FOR DISTRIBUTONS SFIOWN ABOVE ON LINES 15 THROUGH 1 a OF REV-7500 COVER SHEET, AS APP ROPRIATE. II NONTAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1~ See Attached 1 TOTAL OF PART It -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. 5 10 382 9WOBAI 2.OW If more space is needed, use additional sheets of paper of the same size. Estate of: HELEN M. SHELLEY Schedule J Part 1 (Page 2) Item No. Description 3 Tracy Acker 804 Wertzville Road Enola, PA 17025 118 of Residue to Tracy Acker 804 Wertzville Road Eno1a, PA 17025: 19,034 4 Christine Acker 307 Hickory Hill Road Harrisburg, PA 17109 118 of Residue to Christine Acker 307 Hickory Hill Road Harrisburg, PA 17109: 19,034 5 Chad Shelley 4240 Storeys Court Apartment C Harrisburg, PA 17109 118 of Residue to Chad Shelley 4240 Storeys Court Apartment C Harrisburg, PA 17109: 19,034 6 Brian Shelley 546 Terrace Avenue Mt. Joy, PA 17552 118 of Residue to Brian Shelley 546 Terrace Avenue Mt. Joy, PA 17552: 19,034 Relation Granddaughter Granddaughter Grandson Grandson 21 11 1337 Amount 19,034 19,034 19,034 19,034 Estate of: HELEN M. SHELLEY Schedule J Part 28 (Page 1) Item No. Description 1 Harris Street United Methodist Church 1605 Susquehanna Street Harrisburg, PA 17101 21 11 1337 Amount 6~ of Residue: 10,382 10,382 ~~tt~~ ttt ~~~ ~E~~tme~t~t OF HELEN M. SHELLEY I, HELEN M. SHELLEY, of the Borough of Camp Hill, Cumberland County, Pennsylvania, declare this my Last Will and revoke any Will previously made by me. ARTICLE I. 1 give and bequeath my automobiles, household and personal effects and other tangible property of like nature (not including cash or securities), together with any existing insurance thereon, unto my children, RUSSELL C. SHELLEY, JR., of Humme{stown, Pennsylvania and MARTHA A. SPECHT, of Mifflintown, Pennsylvania, to be divided between them in as nearly i equal shares as is practical. Should either of my children not be living on the thirty-first (3151) day following my death, I direct that said deceased child's share shall be divided among his or her issue, per stirpes. ARTICLE II. I devise and bequeath all the rest, residue and remainder of my estate, of whatever nature and wherever situate, to the following individuals or entities: A. Six (6%) percent of said rest, residue and remainder to HARRIS STREET UNITED METHODIST CHURCH, Harrisburg, Pennsylvania. B. Eleven (11%) percent of said rest, residue and remainder to my granddaughter, TRACY ACKER, of Susquehanna Township, Pennsylvania, should she survive me by thirty (30) days. Should my granddaughter, TRACY ACKER, predecease me or fail to survive me by thirty (30) days, I devise and bequeath the same in accordance with the provisions of Article II, § G. C. Eleven (11%) percent of said rest, residue and remainder to my granddaughter, CHRISTINE ACKER, of Susquehanna Township, Pennsylvania, should she survive me by thirty (30) days. Should my granddaughter, CHRISTINE ACKER, predecease me or fail to survive me by thirty (30) days, I devise and bequeath the same in accordance with the provisions of Article II, § G. D. Eleven (11°10) percent of said rest, residue and remainder to my grandson, CHAD SHELLEY, of Swatara Township, Pennsylvania, should he survive me by thirty (30) days. Should my grandson, CHAD SHELLEY, predecease me or fail to survive me by thirty (30) days, I devises and bequeath the same in accordance with the provisions of Article II, § F. E. Eleven (11%) percent of said rest, residue and remainder to my grandson, BRIAN SHELLEY, of Swatara Township, Pennsylvania, should he survive me by thirty (30) days. Should my grandson, BRIAN SHELLEY, predecease me or fail to survive me by thirty (30) days, I devise and bequeath the same in accordance with the provisions of Article ll, § F. F. Twenty-five (25%) percent of said rest, residue and remainder to my son, RUSSELL C. SHELLEY, JR. Should my son, RUSSELL C. SHELLEY, predecease me or fail to survive me by thirty (30) days, I devise and bequeath the Same unto his issue, per strpes. G. Twenty-five (25%) percent of said rest, residue and remainder to my daughter, MARTHA A. SPECHT. Should my daughter, MARTHA A. SPECHT, predecease me or fail to survive me by thirty (30) days, I devise and bequeath the same unto her issue, per stirpes. `.. ARTICLE III. I direct that all estate, inheritance, transfer and other taxes of a similar nature payable by reason of my death, together with any interest and penalties thereon, and imposed with respect to property, whether or not disposed of by this Will, shall be paid out of the residue of my Estate. I further direct that any and all such taxes shall be paid from and deducted from my Residuary Estate prier to the calculation of the shares of the residuary beneficiaries, so that each residuary beneficiary, charitable or not, shall bear a portion of the burden of such taxes. ARTICLE IV. I appoint my son, RUSSELL C. SHELLEY, JR., of Hummelstown, Pennsylvania, Executor of this my Last Will. Should my son, RUSSELL C. SHELLEY', JR., fail to qualify or cease to act as Executor, I appoint my daughter, MARTHA A. SPECHT, of Mifflintown, Pennsylvania, Executrix of this my Last Will. ARTICLE V. I direct that my Executor or successors shall not be required to give bond for the faithful performance of his or her duties in this or any other jurisdiction. IN WITNESS :R~!-IEREOF, !have hereunto set my hand and seal this. ~ day of ~1-~C«z~:~~E~; 1998. /~~~ ~~. JCL SEAL) Signed, sealed, published and declared by the above-named l"estatrix as and for her Last Will and Testament in the presence of us, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names al s witnesses. l ('hu~f~nc ~~4A~r~ u . ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss: HELEN M. SHELLEY, Testatrix, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; grid that I signed it as my free and voluntary act for the purposes therein expressed. /Ft/u~L(J ~Yl~ _+~ HELEN M. SIiELLE Sworn to or affirmed to and acknowledged before me, by HELEN M. SHELLEY, the Testatrix, this c~ ~'a day of -c~ .,._o _ . ,_.^. , 1998. NJTARfAL SEAL DIANNE LENIG, ?~lotary Pubilc I Lemoyne 8omugh Cumherlard Co. My Commission Es:pirs Dec. 21, 200? AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUN"fY OF CUMBERLAND ss: We, d a„; ~{ ~-~,,. ~, and I'h rU ~_, the witnesses whose names are signed to the fioregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the foregoing instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge, the Testatrix was at least 18 years of age, of sound mind and under no constraint or undue influence. I_I ~'° Sworn to or affirmed to and subscribed to before me by ~ , and ~ ~~ti,-an~itnesses, this a '~dday of ~'1~s~~.,->.~..., , 1998. n_~` '., NOTAi~IAL SEAL DIAPJNE LENIG, Notary Public Lemoyne Borough Cumberland Co. My Commission Expires Tasc. 21, 2001 >>sszs ~ ~, _._. r -~ , ; -`; ~.. A-- MetLifelnsuranreCompalryoffonnedicut CHECK NO. ~~ 4400017830 119 P O BOX 40006 LYNCBBURG VA 24506 DATE OF CHECK 018 'P~II8111D 8I0$T ~ SI0$T! lIYS 111D 7B/100 DDLL~B PAY TO THE ORDER OF FiET•RIS M gBgT.T.Wy VOID AFTER 120 DAYS 829 LI~9BURN RD APT 20'4 C CHECKAMOURIT ' CAMP F{'ZLL PA 17011 C ~S'1 ~ 885.7$ • 1~ _ ~ +~ n, NA. '. :ONNECi1CUf '~ II'4 4000 1 78 3C)li' ~:Oii900445~: 70 240u' MetLife Insurance Company of Connecicut LONG TERM CARE INSURANCE DIVISION P.O.Box 4f1(X17 LYNCHBURG VA 245(16-9939 '• 0000000844 00000000001002005B31N5:00 • I,.,IIL.dIL..,,.11...1111..,.IL.dL..IL,.Ii..,ll.,,ll...l THE ESTATE OF HELEN SHELLY 824 LISBURN RD. APT 204 CAMP HILL PA 17011 Page 1 of 2 Ago"4484 Claimant: HELEN M SHELLEY Claims: (600) 876-4582 Payment for Dec 1 2011 through Dec 5 2011: $498.60 Section A - Policy Details Daily Max: $101.00 Elimination Period: 100 Days Elimination Period Met: Oct 24 2011 Lifetime Max: Unlimited Benefits Paid to Date: $4,226.52 Remaining Balance as of Dec 7 2011: Unlimited Section B - Summary Total Amount Billed: $623.25 - Total Exclusions and Plan Limits: $124.65* = Total Paid: $498.60 * See Explanation of Benefits Paid section for details ~~ •~« ~^~^^~ Please detach before negotiating check Metlife Itsurance Company of Connecticut LONG TERM CARE INSURANCE DIVISION P.O.eax 40007 LYNCHBURG VA 24506-9939 r. ~,,, ~~,.~. r.r;,..f», CHECK NO. ` 5y 9460357435.. 119 DATE OP CHECK 12/08/11 PAY EXACTLY ""' FOUR HUNDRED NINETY EIGHT DOLLARS AND 60 CENTS 9•g4603574i35u• ~:0 1 1900 44 5i: 0000068595u^ PAY TO THE ORDER OF THE ESTATE OF HELEN SHELLY VOID AFTER 180 DAYS ~ ~ 824 LISBURN RD. ..APT 204 CHECKAMOUNT CAMP HILL PA 17011 $498.60 .. iaeow sMnO so pJl[ n1aN Ni~naee ry y 3 ~ L d a o~ 4 +~r~ S $Q ~' ~ ¢ 'h ~ D °D ~ ~ o O Q V N ~ t N N r (f} m N N O YQ Z~ M ~~ ~_ 7 ZN ~ ~ °~ as 1O O zx ~ m ~ O x l LL O ~. 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