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Home My WebLink About11-20-12~ REV 150561D143 1500 Ex (o,_,o, e + - PA Department of Revenue Bureau of Individual Ta Pennsylvania OFFICIAL USE ONLY oevaarM C xes PO 60X 280601 EaroFneverwre ounty Coda rear File Number . Harrisburg, PA 17128-0601 INHERITANCE TAX RETURN 21 12 ENTER DECEDENT INFORMATION BELOW 0274 RESIDENT DECEDENT Social Security Number Date of Death Date of Birth 02 22 2012 08 26 1938 Decedent's Last Name SHIELDS Suffix Decedent's First Name MI SHERLEY 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 QF WILLS FILL INAPPROPRIATE OVALS BELOW X^ 1. Original Retum ~ 2. Supplemental Retum 3. Remainder Retum (date of death 4. Limited Estate ~ prior to 12-13-82) qa Future Interest Compromise (date of death after 12 ~ 5 F 12 d . - e -82) eral Estate Tax Retum Required g. Decedent Died Testate (Attach Copy of wll) ^ ~ Decade t Main ned a Livin Trust (Att~h ~,py ofl~tiat) 9 8 . Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received 1 p, S usal Porerty Credit date of death b~tween 12-31 91 and -t-95) ~ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENT Na me IAL TAX INFORMATION SHOULD BE DIRECTED TO: ~RRY A WEIGLE ESQUIRE Daytime Telephone Number 717 532 7388 REGISTER Q~1i9li.LS USErQNLY ^,x~ First line of address '1' -~'~ °~ - ~ „ 126 EAST KING STREET r~ ~ '' Second line of address ~~ ~ r , ; ~ ~ -. " ' ~ ' - - `~ ~; ,:-- , ; . -~ City or Post Office -r r r ~ ~ SHIPPENSBURG D E FILED State ZIP Code ~' Q ~rj --rz PA 17257 Correspondent's a-mail address: Under penalties of perjury, I deGare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, ft is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. TUR OF PER N SPO IBL FOR FI I~ RETURN DATE ADDRESS IVIIC118e1 ShIeIdS // '-/ /„ ~ / '~ 5 ~~ t, Side 1 15D561D143 15D561D143 J `~ 1505610243 REV-1500 EX Decedent's Name: ShleidS, Shelley A. Decedent's Social Security Number 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 & Notes Receivable (Schedule D) ...................................................... .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............. .. 5. 17 , 0 69.60 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested........... . 6. 7. Inter-Vivos Transfers & Miscellaneous -Probate Property (Schedule G) ~ Separate Billing Requested........... . 7. 80 , 337 .29 8. Total Gross Assets (total Lines 1-7) ................................................................... .. g. 9 7 , 4 0 6. 8 9 9. Funeral Expenses & Administrative Costs (Schedule H) ..................................... .. 9. 13 , 18 8 . 0 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................ .. 10. 12 , 841.68 11. Total Deductions (total Lines 9 8 10) ................................................................. .. 11. 2 6 , 02 9.68 12. Net Value of Estate (Line 8 minus Line 11) ........................................................ .. 12, 71 , 377.21 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, 71 , 3 7 7.21 TAX COMPUTATION -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 .00 15. 16. Amount of Line 14 taxable at lineal rate X .045 71 377.21 ~ 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 . 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 18. 19. Tax Due ................................................... .............................................................. . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 0.00 3,211.97 0.00 0.00 3,211.97 Rev1508 EX+(6-88) .., COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Sh SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER .y A' 21-12-0274 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of Survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION 1 Elmcroft -refund 2 Insurance adjustment for medications -refund 3 Public Opinion -refund at cancellation 4 Various miscellaneous refunds 5 F 8r M Trust Checking Account 5052351 Accrued interest on Item 5 through date of death VALUE AT DATE OF DEATH 246.50 7, 996.48 47.04 30.71 8,748.71 0.16 TOTAL (Also enter on Line 5, Recapitulation) I 17,069.60 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1510 EX+ t6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Shields, Sherle A. 21-12-0274 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S NUMBER THE DATE OF TR~ANSFRER SATTACNTA COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTERESr 1 Prudential AST Preservation Asset Portfolio - 67,206.95 100.000% beneficiary Michael Shields, son 2 Prudential Investment Account 69994 -beneficiary 13,130.34 100.000% Michael Shields, son TOTAL (Also enter on Line 7, Recapitulation) (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. ~ioN TAXABLE ,ABLE) VALUE 0.00 67,206.95 0.00 ~ 13,130.34 I 80,337.29 Form PA-1500 Schedule G (Rev. 6-98) ' - SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Shields, Sherley A. 21-12-0274 ITEM NUMBER DESCRIPTION AMOUNT 1 Funeral Ex en nses Carl McKee -funeral service 100.00 2 Greencastle Bronze 8~ Granite -monument engraving 195.00 3 Kelso-Cornelius Funeral Home 7,385.00 4 Kelso-Cornelius Funeral Home 1,113.00 5 Ken Reid -funeral service 100.00 6 Open Door Church -funeral service 300.00 H-A 9,193.00 7 Attorney Fees Weigle & Associates, P.C. 981.25 8 Weigle & Associates, P.C. 2,437.50 H-B2 3,418.75 T;, ~; 9 Other Administrative Costs Cumberland Law Journal -advertising Letters Testamentary 75.00 10 Linda K. Klein -notary fee 20.00 1'' 11 News Chronicle -advertising Letters Testamentary 104.75 i' 12 Register of Wills, Cumberland County -filing PA Inheritance Tax Return 15.00 'I t 7 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) ~~ SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Shields, Sherley A. 21-12-0274 ITEM NUMBER DESCRIPTION AMOUNT 13 Register of Wills, Cumberland County -filing Family Settlement Agreement 75.00 14 Weigle 8~ Associates, P.C. -reimbursement for postage, xerox copies, and long distance 25.00 telephone calls H-B7 314.75 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+(12-08) SCHEDULE 1 DEBTS OF DECEDENT , MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Shields, Sherle A. FILE NUMBER 21-12-0274 ITEM Report debts incurred by the deeedsnt prior to death that romained unpaid at the date of death, including unroimbursed medical expansee. NUMBER DESCRIPTION VALUE AT DATE 1 Alpha Diagnostic LLC OF DEATH 156.58 2 Care First Pharmacy 7,418.12 3 Chambersburg Imaging Associates 8.08 4 F & M Trust Checking Account 5052351 -check written prior to date of d th ea , clearing after date of death 183.00 5 Fayetteville Volunteer Ambulance 183.00 ti Shippensburg EMS 574.05 7 Summit Anesthesiology 38.27 8 Summit Cancer & Hematology 228.32 9 Trust Ambulance Company 2,884.00 10 USPS 9.64 11 West Shore EMS 1,158.62 TOTAL (Also enter on Line 10, Recapitulation) 12 841.68 (If more space is needed, additional pages of the same size) ~ Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV-1513 EX+ (11-081 COM N~N IED NNT DEC DEN~YLN ANIA SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER JIIICW,, ~nene h. ~ 21-12-0 274 NUMBER NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE PERSON(S) RECEIVING PROPERTY (Words) ($$$) I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a 1.2 1 Michael Shields Son 100% 71,377.21 1984 Clinton Avenue Chambersburg, PA 17201 Total 71,377.21 Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 150 0 cover sheet, as a r o riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) LAST WILL AND TESTAMENT I, Sherley A. Shields, presently residing at 1575 Palm Spring Drive, Chambersburg, Franklin County, Pennsylvania 17201, being of sound mind, memory and disposition, do hereby make, publish and declare this my Last Will and Testament, hereby revoking and making void all wills by me at any time heretofore made. FIRST. I order and direct the payment of all my legally enforceable debts and funeral expenses as soon as may be convenient after my decease. SECOND. I give, devise and bequeath all my estate, real, personal and mixed, whatsoever and wheresoever situate, to my beloved husband, Harry G. Shields, provided that he survive me by a period of sixty (60) days. ' THIRD. In the event my said husband, Harry G. Shields, should predecease me or is not living on the 60~' day following my death, I then give, devise and bequeath my said estate to my son, Michael Shields, on a per stirpes distribution~basis. FOURTH. I nominate, constitute and appoint my husband, Harry G. Shields, to be the Executor of this my Last Will and Testament. In the event that he be unable to fulfill the duties of Executor, I then nominate, constitute and appoint my son, Michael Shields, to be the Executor of this my Last Will and Testament. In the event that he be unable to fulfill the duties of Executor, I then nominate, constitute and appoint my granddaughter, Stephanie Shields, to be the Executrix of this my Last Will and Testament. _ FIFTH. I direct that my personal representative(s) shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I, Sherley A. Shields, have hereunto set my hand and seal to this my Last Will and Testament, written on one (1) page, this day of C~J ~ r _, 2004. ~~3'~~ r WEIGLE & ASSOCIATES, P. C. -ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 This instrument was by the Testatrix, on the date hereof, signed, published and declared by her to be her Last Will and Testament, in our presence, who at her request and in the presence of each other, we believing her to be of sound and disposing mind and memory, have hereunto subscribed our names as witnesses. COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBEfZI,AND I, Sherley A. Shields, the person 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; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me by Sherley A. Shi lds, the Testatrix, this >~ day of ~ , 2004. ~~ ~y WEIGLE & ASSOCIATES, P.C. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPEN56URG, PA 17257-1397 k /la. .. COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND iNDA ' and j- jl_ )~,~,,,,~ ,the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Sherley A. Shields, the Testatrix, sign and execute the instrument as her Last Will; 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 the time eighteen (18~ or more years of age and of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed before me and L i~v~A )C. ~~LE ~~ ~h - wi esses, this ~ day of u ~ , 2004. ~cu t _ Imlay h+bMc MV CommM~bn E>~Zpp WEIGLE & ASSOCIATES, P. C. -ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 MaFCh ~a, 201 Z Weigle & Associates, P.C,. Attorney's-at-Law 126 East King St Shippensburg, PA 17257-1397 RE: Sherley A. Shields To Whom It May Concern: In reference to the above customer, our records show the enclosed information to be accurate as of the date of decedents death. If I may be of any further assistance, please contact me. Sincerely, ~~ti~ ~~ Brenda Mahn Deposlt.Operations Clerk 717-261-3668 717-2646116. 888-264-6116. P.O. Box 6010 Chambersburg, PA 17201-6010 `~ FINA.NCTAL'SO4U"TION-S.. FROM P,.EO?LE YDU KNOW .,. N D J W_ N = O N N ai d r ~ ~~ ~ ~ Te w ~ LL N {L ci $ m ~ Z ~ o o ~ w U N C O .~ 7 i0 .t7. W d D a; O a m r w a n W c ' o m ~ _v c O 6 ~ 1 Q c ~ ~. y 0 u ,~ a ~ m u .- c o w m m~ w «~ O p r ~~a _~ 9 m V V Q w d V C d0 W W O W d d m . ., 8~ y ? H (~ lJJ O U Q O U a m O o Z r~i ~ o v v Q F C y u L U Prudential Mazch 26, 2012 ESTATE OF SHERLEY A SHIELDS , 1984 CLINTON AVE CHAMBERSBURG PA 17201-4209 Reference Number: Account: Registration: Dear Sir/Madam: 6809283218/2569994 0'087-X~~XXX4407 SHERLEY A SHIELDS This letter is in regard to a recent inquiry As of the close of business on February 22, 2012, the above referenced account was valued at $13,130.34. This value is based on a balance of 2,374.384 shares at the Net Asset Value (NAV) price of $5.53 per shaze. As changing market conditions may cause the NAV price to fluctuate on a daily basis, the account value is subject to change. If'you have questions or need further assistance, please contact the Prudential Mutual Fund Service Center at (800) 225-1852 Monday through Friday between 8:00 a.m. and 6:00 p.m. Eastern time. For account information that is available 24 hours a day, 7 days a week, you may access your account online at www.prudentialfunds.com. Sincerely, Jo-Anne Morse Shazeholder Services Specialist III Prudential 1 nvestments Prudential Mutual Fund Services LLC P O Box 9655 Providence, RI 02940 (800)225-1852 Prudential Sherley A Shields 1575 Palm Spring Dr Lot 114 Chambersburg, PA 17202 Prudential Annuities A Business of Prudential Financial, Inc. P.O. Box 7960 Philadelphia, PA 19176 (888) 778-2888 Contract Number: E0392234 May 7, 2012 Dear Ms. Shields: Thank you for your recent inquiry concerning the value of your Strategic Partners III Rpll & Step. As of February 22, 2012, the Contract Fund Value was: Investment Option Value AST Preservation Asset Allocation Portf $67,206.95 Total Contract Fund Value $67,206.95 Your satisfaction is important to us. If you have questions, please contact your financial professional or our Annuities Service Center at (888) 778-2888. Representatives are available to assist you Monday through Thursday between 8 a.m. and 7 p.m., and Friday between 8 a.m. and 6 p.m. Eastern time. Thank you for choosing to do business with Prudential Annuities. Sincerely, Annuities Service Center Annuities are issued by The Prudential Insurance Company of America and Pruco Life Insurance Company (in New York, by Pruco Life Insurance Company of New Jersey), all located in Newark, NJ, or by Prudential Annuities Life Assurance Corporation, Shelton, CT. Annuities are distributed by Prudential Annuities Distributors, Inc., Shelton, CT. All are Prudential Financial, Inc. companies and each is solely responsible for its own fmancial condition and contractual obligations. CFECCContVa1042012