HomeMy WebLinkAbout03-22-13 ..-I REV-1500EX(tl1-10) 1505610143
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County coca rear File Number
Bureau of Individual Taxes 0KPXF MENT O'PENENOE
PO BOX.280601 INHERITANCE TAX RETURN 21 12 01035
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
06 24 2012 12 29 1922
Decedent's Last Name Suffix Decedent's First Name MI
SHIRK LOIS G
(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 OF WILLS
FILL IN APPROPRIATE OVALS BELOW
(� 1. Original Return ❑ 2. Supplemental Return ❑ 3.Remainder Return(dale of death
prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a.Future Interest Cornprmniee ❑ 5. Federal Estate Tax Return Required
(date of death after 1242.62)
8 Decade nt Died Testate ❑ Decadent Maintained a Living TNS[ O_ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Af ll4 (Athion Copy of Trust)
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9. Lit 4on Proceeds Received in.spousal Povedy Credafdete of death ❑ 11,Election to tax under Sec.9113(A)
❑ ❑ aetwean 12-31-91 and .1 95 (Attach Sch.O)
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CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
DEBRA K WALLET 717 737 1300
REGISCHR OF WILL E Of rn
3 a rn C>
First line of address a) c
24 NORTH 32ND STREET C'>
J
rrt JA
T r�
Second line of address
r.'f ATE -'z
'..-r `G FILED e}
City or Post Office State ZIP Coda
CAMP HILL PA 17011 }.� ci r'
Correspondent's e-mail address: Walletdeb @aDLCom
Under penalties of perjury,I 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 otter than the personal representative is based on all information of which preparer has any knowledge.
SIGNATUREOF PERSON RESPONSIBLE FOR FILING ETURN DATE
.[/•emu �, a/ /���, ,.,_„ Ann W. Brooks
—AD RESESS="�
5008 Apache Drive, Mechanicsburg, PA 17050
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
4 Q}ti K,b�wM,x Debra K Wallet 312910 j
ADDRESS
24 North 32nd Street, Camp Hill, PA 17011
Side 1
1505610143 1505610143 J
f ,
J 1505610243
REV-1500 EX Decedent's Social Security Number
Decedent's Name. SHIRK, LOIS G.
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.
867 . 15
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 45 , 121 . 22
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property j
(Schedule G) ❑ Separate Billing Requested............. 7. '
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8. Total Gross Assets(total Lines 1-7)....................................................................... 8. 45 , 988 . 37
9. Funeral Expenses&Administrative Costs(Schedule H) ...... 9. 6 , 557 . 6 9
10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule 1)......................... 10. 28 , 945 . 70
11. Total Deductions(total Lines 9&10)............................................._...................... 11. 35 , 503 . 39
12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 10 , 484 . 98
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)................................................. 13.
10 484 . 98
14. Net Value Subject to Tax(Line 12 minus Line 13)................................_._............ 14. r
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 16 471 . 82
at lineal rate X .045 10 , 484 . 98
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable 18 ',
at collateral rate X .15
19. Tax Due...................... ........................................................................................ 19. 471 . 82
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20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
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Side 2
L 1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21 - 12 - 07035
Decedent's Complete Address:
DECEDENT'S NAME
Shirk, Lois G.
STREETADDRESS
5008 Apache Drive
CITY
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 471.82
2. Credits/Payments
A. Prior Payments 500.00
B. Discount 23.59
Total Credits(A +B) (2) 523.5911
3, Interest (3) 0.01
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4. if line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT. (4) 51.771
Check box on Page 2 Line 20 to request a refund --- -_-----r .
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5)
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Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
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1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;............................... ............. .............................. LJ n
b. retain the right to designate who shall use the property transferred or its income;,......................-...........
c. retain a reversionary interest;or---......................................._._............_.._........._........_....................------- C)LX I
d. receive the promise for[He of either payments,benefits or care?....................................................I.........
2. If death occurred after December 12, 1962, did decedent transfer property within one year of death without _ 1,
receiving adequate consideration?...................................................................................................................... .x
3. Did decedent own an'in trust for' or payable upon death bank account or security at his or her death?....-.-.- E I xI �!
4. Did decedent own an Individual Retirement Account,annuity,or other non-probate property which L
contains a beneficiary designation. ......... x, 1,
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETU
For dates of death on or after Julyy 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.§919fi
For dates of death on or after January 1, 1995,the tax rate Imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
172 P.S.§91 i6(a)(1.1)(it)]. 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 m5n are still applicable even if the surviving spouse is the only beneficiary. 1
For dates of death on or after July 1,2000: j
•The tax rate imposed on the net value of transfers from a deceased child 21 yaars 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 12)[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 fa)(1.311. A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,wfiether by blood or adoption.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
OOMMONRITMO T gErvrvsYLVaNIa PERSONAL PROPERTY
INHEFIT TH OF
gE510ENT DECEDENT
FILE NUMBER
ESTATE OF Shirk, Lois G. 121 - 12 -01035
Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of
survivorship must be disclosed on schedule F. AT ITEM NUM ER - - ---- .DESCRIPTION - - VALUE D ATHTE OF
1 Cash in possession of Decedent 45.001 1
2 Personal items including personal jewelry and black chest of drawers with Japanese designs 250.001
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3 Pennsylvania Employees Benefit Trust Fund 482.46 i
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4 Asbury Communities, Inc.-resident refund 82.01)
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5 The Fidelity Mutual Distributing Trust 7.69
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TOTAL(Also enter on Line 5,Recapitulation) 887.11.
SCHEDULE F
COMMONWEALTH OF TAX RETURN JOINTLY-OWNED PROPERTY
INHERITANCE TURN
RESIDENT DECEDENT
REEDENT
ESTATE OF FILE NUMBER
Shirk, Lois G. ( 21 - 12-01035
If an asset was made joint within one year of the decedent's date of death,it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
Ann W. Brooks 5008 Apache Drive Daughter
A Mechanicsburg, PA 17055
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JOINTLY OWNED PROPERTY: _ ___ _
LETTER DATE _� SCRIPTI a, OF PR TY %OF DATE of DEATH
ITEM induda name olnanaal maiituleon a bank account numbs DATE OF DEATH DECD'S I vAwe of
NUMBER FOR JOINT JOIN I MADE �r similar identifying number.Attach deed for jointly-held real VALUE OF ASSET INTEREST, DECEDENTS INTEREST
TENANT
JOINT estate.
approx. M&T Bank Checking Account#77977068 2062466 50°/ 10,312.33
2 A approx. M&T Bank Money Market Account 1 66,&87.16 50% 33,443.581
2003 #15004222241892 l
3 A 11/2412009 i PNC Bank Checking Account#5005799627 186.99 50% 93.00
4 A before 20061 Sovereign Bank Checking Account 394-46 ! 50% 197.231,
#231372691
5 A before 20061) Sovereign Bank Savings Account#23310253391 2,150.16 50% 1,075.081
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TOTAL(Also enter on line 6,Recapitulation) T 45,121.2
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SCHEDULE H
FUNERAL-EXPENSES&
CWMON W EALTH OF PENNSYLVANIA ��y����pj�r��/�/ �
INHERITANCE TM RETURN /1L11t�N I rY111YG Kh"J I V
RESIDENT DECEDENT
I FILE NUMBER
ESTATE OF Shirk, Lois G. 21 - 12-01035
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER j FUNERAL EXPENSES: —_
A. 1 i Myers-Harner Funeral Home 3,640.00
2 Blooms(flowers for church) 265.00
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3 1 Camp Hill United Methodist Church(use of facilities and coffee, tea, pastries) 550.00
4 Rock Bass Grill (funeral luncheon) 497.32
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5 Pastor and Organist honorariums 200.00
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B. ADMINISTRATIVE COSTS:
1, Personal Representative's Commissions
Name of Personal Representatives)
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Street Address
city State Zip
Year(s)Commission paid
2. Attorney's Fees Debra K. Wallet, Esq. 750.00
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
State Zip
City
1 Relationship of Claimant to Decedent
4. Probate Fees 15.00
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5. Accountant's Fees
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& Tax Return Preparer's Fees -
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7, Other Administrative Costs
1 Camp Hill United Methodist Church (brass plate for Columbarium) 160.00
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TOTAL(Also enter on line 9, Recapitulation) 6,557.69
Schedde H
Fu>etal F�q>enseS&
COMMONWEALTH OF T PENNSYLVANIA M Costs
INHERITANCE EC RETURN �JJ��1�11111�RjRd
RESIDENT DECEDENT - - - ----
FILE NUMBER
ESTATE OF Shirk, Lois G. 21 - 12 -01035
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2 I Postage, photocopies, etc. 30.0
3 Mileage of Ann W. Brooks, daughter(60 miles x$.555/mile) 33.30
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Page 2 of Schedule H
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SCHEDULE ]
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSVLVAN IA LIABILITIES & LIENS
INHERRANCE TAX RETURN
RESIDENTOECECENT
FILE NUMBER
ESTATE OF Shirk, Lois G. 21 - 12 - 01035
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER Alert Pharmacy Services — _ — -- --- --- __-- ---- 366.401
2 Messiah Village(May and June, 2012 nursing care) 22,534.14]
3 Messiah Village Home Care (May, 2012 one-on-one care) 5,396.48 j
4 State Employees' Retirement System(pension overpayment) 76.781
5 Center for Neurobehavioral Health 421.551
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6 Capital Area Health 20.00
7 Trust Ambulance Services 130.30
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TOTAL(Also enter on Line 10,Recapitulation) 2$,945,
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REV-1613 EX-(11-0$)
SCHED�aULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN I
RESIDENT DECEDENT — _I _—__.
ESTATE OF FILE NUMBER
Shirk, Lois G.
21 - 12-01035
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE' '
-NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT - (Words) ($$$)
RECEIVING PROPERTY Do Not U9 Tnrema(s)
I. TAXABLE DISTRIBUTIONS(include outright$pousai
distributions and transfers
under Sec.§116(a)(1.2)]
1 ! Ann W. Brooks I Daughter ( All personal jewelry
1 5008 Apache Drive and 40%of
Mechanicsburg, PA 17055 residuary Estate
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2 Robert M. Shirk Son 40%of residuary
27 Airport Road Estate
j Shippensburg, PA 17257
3 Allan Merritt Brooks Grandson Black chest Of
5008 Apache Drive drawers and 20%of
Mechanicsburg, PA 17055 residuary Estate j
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Enter dollar amounts for distributions shown above on lines 15 through 16 on Rev 1500 cover sheet,as appropriate. '
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
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IB.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
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TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.
II
LAST WILL AND TESTAMENT
OF
EMS G. SHIRK
I, LOIS G. SHIRK, of Camp Hill, Cumberland County. Pennsylvania, being of sound
and disposing mind, memory, and understanding, do hereby make, publish, and declare this to
be my Last Will and Testament and hereby revoke all other Wills and Codicils that I have
made, including the Will dated June 20, 2002 and Codicil dated June 10, 2003.
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FIRST: I give and bequeath:
A. All of my personal jewelry to my daughter, ANN W. BROOKS,
jof Mechanicsburg, Pennsylvania, so long as she shall survive me by thirty (30) days;
B. My black chest of drawers with Japanese designs, each scene
containing the initials LGHS, originally given to Lois Grace Helms Shirk and Merritt Beuchler
Shirk in 1950 as a wedding gift, to my grandson, ALLAN MERRITT BROOKS, of
Mechanicsburg, so long as he shall survive me by thirty (30) days.
SECOND: I give, devise, and bequeath twenty (20%) percent of my Estate to my
grandson, ALLAN MERRITT BROOKS, so long as he shall survive me by thirty (30) days. I
direct that this bequest be used for the sole purpose of paying the costs associated with
attending college and obtaining an undergraduate degree.
THIRD: I give, devise, and bequeath all the rest, residue, and remainder of my j
Estate, of whatever nature and wherever situate, in equal shares, to those of my children who
shall survive me by thirty (30) days: my daughter, ANN W. BROOKS; and my son, ROBERT
M. SHIRK, of Shippensburg, Pennsylvania. Should either of my children fail to survive me
by thirty (30) days, but be represented by children then living, these children shall take,per
stirpes, the share to which my child would have been entitled if then Iiving.
FOURTH: If any portion of my Estate shall be payable to a beneficiary who is less
than eighteen (18) years of age, my Executrix may pay such share to the beneficiary's parent
or guardian, as custodian for said minor, who shall deposit such share in the minor's name in a
Uniform Gift to Minors' Act account in a savings institution of the Executrix's choosing,
payable to the minor at majority.
FIFTH: All interests of any beneficiary in the income or principal of this Estate,
while undistributed and in the possession of my Executrix, even though vested and
distributable, shall not be subject to attachment, execution or sequestration for any debt,
contract, obligation or liability of any beneficiary and, furthermore, shall not be subject to
pledge, assignment, conveyance, or anticipation.
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SIXTH: All inheritance, estate, and succession taxes (including interest and any
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penalties thereon) payable by reason of my death shall be paid out of and be charged generally
against the principal of my residuary estate, without apportionment or right of reimbursement
from any person. In the event that a substantial portion, as determined in the sole and absolute
judgment and discretion of my Executrix, of the non-probate assets such as an annuity or
mutual funds are directed to be paid to a beneficiary or beneficiaries, so that the taxes referred
to herein would be paid out of the probate residue passing to the beneficiary or beneficiaries of
this will (whether or not the same as the beneficiary or beneficiaries under the non-probate
assets), my Executrix, in the Executrix's sole and absolute judgment and discretion, shall have
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the right to allocate the full or partial payment of the taxes to the beneficiary or beneficiaries of
the non-probate assets.
SEVENTH: In addition to all rights and powers conferred by law, I authorize and
empower my Executrix and her successors, in her absolute discretion and without necessity of
obtaining court approval:
A. To buy investments at a premium or discount.
B. To hold property unregistered or in the name of a nominee.
C. To give proxies, both ministerial and discretionary.
D. To compromise claims.
E. To join any merger, consolidation, reorganization, voting trust
V plan, or any other concerted action of security holders and to delegate discretionary duties with
respect thereto.
J F. To lend to, and buy from, my estate.
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G. To borrow and to pledge real and personal property as security therefor.
H. To sell at public or private sale for cash or credit or partly for each, to
exchange, or to lease for any period of time, any real or personal property, and to give options
for sales, exchanges, or leases.
I. To exercise any option permitted by law which she believes to be
advantageous from the viewpoint of overall tax reductions, including, without limitation of the
foregoing, power and authority to claim administration or other expenses either as income tax
deductions or inheritance or estate tax deductions, without regard to whether they were paid
from principal or income and without requiring adjustments between principal and income for
any resulting effect on income or estate taxes, and a deduction of such expenses for income tax
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purposes shall be given effect in computing the respective shares of all persons interested in
MY estate set forth herein, even though the effect is to increase the share of one beneficiary or
class of beneficiaries hereunder at the expense of another; and to make such adjustments, if
any, between beneficiaries with respect thereto as she shall deem appropriate in view of the
nature of the transaction and the amounts involved.
J. To distribute in cash or in kind or partly in each.
K. To employ agents, legal counsel, brokers, and assistants, and to pay their
fees and expenses as she may deem necessary or advisable to carry out the provisions of this
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Will or any Trust.
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V1 The powers granted hereunder shall be exercisable with respect to all real and personal
property, including, but not limited to, income and principal held for minors or disabled
0 beneficiaries at any time, until the actual distribution of all property. All powers, authorities
and discretion granted here shall be in addition to those granted by law and shall be exercisable
without leave of court. However, nothing herein shall be interpreted or construed to
encourage, authorize, empower, or permit the Executrix to act or cause anyone to act in a
manner contrary to or inconsistent with accepted standards of portfolio diversification and risk
management.
SEVENTH: I nominate, constitute, and appoint my daughter, ANN W. BROOKS, as
Executrix of this, my Last Will and Testament. In the event of the renunciation, death,
resignation, or inability of my daughter to act for whatever reason in this capacity, then I
nominate, constitute, and appoint my son, ROBERT M. SHIRK, as Executor of this, my Last
Will and Testament.
I direct that no representative named above shall be required to post security for the
faithful performance of his/her duties in any jurisdiction insofar as I am able by law to relieve
him/her of such obligation. Any of my representatives shall be entitled to reasonable
compensation for the performance of the duties set forth here.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 11�day of
("IAA 2009, on this, the fifth of five typewritten pages. I have also signed the
left-hand margin of the first four of these pages for purposes of identification only
LOIS G. SHIRK
SIGNED, PUBLISHED, and DECLARED by the Testatrix, LOIS G. SHIRK, as 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 as witnesses.
n +lsi9 $rtr�1�(sJ �.2rlL
Yhc 4C+,v t.cs 6w" q
ACKNOWLEDGMENT
Commonwealth of Pennsylvania
County of Cumberland
I, LOIS G. SHIRK, Testatrix, whose name is signed to the attached 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; and that I signed it as my
free and voluntary act for the purposes therein expressed.
LOIS G. SHIRK
Sworn or affirmed to and subscribed before me by LOIS G. SHIRK, the Testatrix, this
I I day of fR�I 12009.
Notary Pu is
CAMMONWEALTH OF PENNSYLVANtA
Mary M.Loper.Notary PubNo
Memberr,pe�nosywsnla AssoGation of Notaries ''
AFFIDAVIT
Commonwealth of Pennsylvania
County of Cumberland
We, Debra K. Wallet and Ay
.In L Mr-&j � � the witnesses whose names are
signed to the attached instrument, being duly qualified according to law, depose and say that
we were present and saw the Testatrix, LOIS G. SHIRK, sign and execute the instrument as
her Last Will and Testament; 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 that time 18 years of age
or older, of sound mind, and under no constraint or undue influence.
Sworn or affirmed to and subscribed to before me by
it br-P- and
�n L . fit witnesses, this 1
Aa I day of > �
2009.
Notary Publi
COMMONWEALTH OF PENNSYLVANIA
Nolan Seal
Mary M.Loper,Nay Public
Camp Hit Born.Ctxnbarlard CatntN
MWY C9rrardt>slort E> Oct 27,2011
Member,PonnsyHanla Association of NOtarlee