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Home My WebLink About01-22-131505611180 REV-1500 EX (02-11) (FI) pennsylvania OFFICIAL USE ONLY PA Department of Revenue DEPARTMENT oR REVENUE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ~ PO BOX 280601 ~~ ~~ `~ ~ ~ ~f __ Harrisburg, PA 17128-0601 RESIDENT DECEDENT (, / ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name 11,1,1201,2 01091902 Suffix Decedent's First Name SHOFFNER (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number FILL IN APPROPRIATE BOXES BELOW 1. Original Return 0 2. Supplemental Return MI A MI 3. Remainder Return (Date of Death Prior to 12-13-82) 0 4. Limited Estate 0 4a. Future Interest Compromise (date of 0 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate (Attach Copy of Will) 0 7. Decedent Maintained a Living Trust 0 8 Total Number of Safe Deposit Boxes (Attach Copy of Trust) 9. Litigation 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 BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIR~TED T0: ' Name 'a Da time Tel ~ y e~one Numbers ~;,~~ HERBERT C SHOFFNER ~~ ~ I.:a ~ j..y ,P (71?) 3~.~ 19 `~:^ ~"~ ~~ , . First Line of Address 84? HECK HILL RD Second Line of Address City or Post Office State ZIP Code LEWISBERRY PA 17339 Correspondent's a-mail address: H E R B S H O F F a~ E P I X. N E T Under penalties of perjury, t declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowled e SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE 847 HECK HILL RD LEWISBERRY PA 17339 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY L 1505611180 SHIRLEY Spouse's First Name THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS Side 1 1505611180 J h~ J 150561,1,280 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: SHIRLEY A SHOFFNER RECAPITULATION 1. Real Estate (Schedule A) ......................................... 1. NON E 2. Stocks and Bonds (Schedule B) ......................... . .......... 2. N 0 N E 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... 3. NON E 4. Mortgages and Notes Receivable (Schedule D) ............ ........... 4. NON E 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) .. .. 5. ], 7 3 8 , O O 6. Jointly Owned Property (Schedule F) Separate Billing Requested .... ... 6. 9 21, 7 2 2 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested .... ... 7. NON E 8. Total Gross Assets (total Lines 1 through 7) 8 1, 0 9 5 5 2 2 9 Funeral Expenses and Administrative Costs (Schedule H) .............. .. 9. 1, O 2 6 2 . O O 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .......... .. 10. 1, O 1, 7 , O 0 11. Total Deductions (total Lines 9 and 10) ........................... .. 11. 1,12 7 9 . O O 12. Net Value of Estate (Line 8 minus Line 11) ......................... .. 12. - 3 2 3. 7 8 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................... .. 13. O , O O 14. Net Value Subject to Tax (Line 12 minus Line 13) 14 3 2 3 7 8 TAX CALCULATION -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 .0 O 15. O O O 16. Amount of Line 14 taxable . at lineal rate x .0 4 5 9 21, 7. 2 2 16. 41, 4. 7 7 17. Amount of Line 14 taxable at sibling rate X . 1, 2 17. 0 0 0 18. Amount of Line 14 taxable . at collateral rate X . 1, 5 18. 0 . 0 0 19. TAX DUE ...................................................... .19. 41,4.77 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPA YMENT ~ Side 2 L 1505611280 1505611280 J REV-1500 EX (FI) Page 3 File Number 208-24-2076 Decedent's Complete Address: DECEDENT'S NAME SHIRLEY A SHOFFNER STREET ADDRESS 25 W LISBURN RD CITY MECHANICSBURG Tax Payments and Credits: 1 Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3 Interest 18.66 STATE PA Total Credits (A + B ) 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. 5 If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. ZIP 17055 (1) 414.77 (2) 18 66 (3) (4) 0 00 (5) 396.11 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 ........................ ...... .......................... ....................................................... 0 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? ............ . . ..................................................... . .. .................................. 0 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 percent, 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 percent [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (11-10) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: SHIRLEY A SHOFFNER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivnrshin m~~c* ho ,a;~,.~„~,.,~ ,... ~..w_~..~_ .- FILE NUMBER: n more space Is neeaea, use additional sheets of paper of the same size. REV-1509 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ~a~Hit vr: FILE NUMBER: SHIRLEY A SHOFFNER If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME{S) ADDRESS RFI ~TI(IAICUID Tn n~rcn~nir A HERBERT C SHOFFNER 847 HECK HILL RD LEWISBERRY, PA 17339 B C SON JOINT LY OWNE D PROPE RTY: LETTER DATE DESCRIPTION OF PROPERTY ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH % OF DECEDENT' DATE OF DEATH S V NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE of ASSET INTEREST ALUE OF DECEDENT'S INTEREST M & T BANK CHECKING ACCOUNT #1921444 1. A. 4/18/05 11,536.54 50.00% 5,768.27 2 M & T BANK SAVINGS ACCOUNT #21000001231365 . A 4/18/05 6,897.89 50.00% 3,448.95 0.00 0.00 0.00 0.00 0.00 0.00 0.00 O.OU 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL (Also enter on Line 6, Recapitulation) I $ 9,217 22 If more space Is needed, use additional sheets of paper of the same size. REV-1511 EX + (10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER SHIRLEY A SHOFFNER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. BEAVER URICH FUNERAL HOME (Cremation Services) 5,479 2. Identification Viewing Meal for Family 215 3. Post-Funeral Meal 483 4. Organist for Memorial Service 75 5. Clergy for Memorial Service 100 B 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Don P. Shoffner Street Address 25 W. Lisburn Rd. city Mechanicsburg state PA zIP 17055 Relationship of Claimant to Decedent SOn 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. Disposal of Personal Effects Dumpster Rental U-Haul Truck Rental TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. 3,500 350 60 10,262 REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER SHIRLEY A SHOFFNER Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH 1. Past Due Rent 475 2. Outstanding Medical Bills MSH Physicians Group 35 Hershey Medical Center 90 Heritage Medical Lab 25 Tristan Associates 75 Medco Health Solutions (Medicare Part D premium) 60 Quest Diagnostics 11 Holy Spirit Hospital (Services on Date of Death, Net of Insurance Reimbursement) 55 West Shore EMS (Services on Date of Death, Net of Insurance Reimbursement) 150 Camp Hill Emergency Physicians (Services on Date of Death, Net of Insurance Reimbursement) 16 Pinnacle Health Lab 25 TOTAL (Also enter on Line 10, Recapitulation) I $ 1,017 If more space is needed, insert additional sheets of the same size.