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Home My WebLink About07-23-13 J 1505610105 REV-1500 Ex�°'.",�F"�" PA Department of Revenue Pennsylvania OFFICIAL USE ONLY ��a��-� . County Code Year File Number eureau of IndividualTaxes �NHERITANCE TAX RETURN q I I �./ � 1 U PO BOX z8o6oi �. Harrisburg,PA i9128-o6oi RESIDENT DECEDENT p( �� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYV Date of Birth MMDDYYYY 01/28/2013 O5/07/1918 ' DecedenCs Last Name Suffix DecedenCS Firet Name � MI Shoaff Laura R (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffx 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 Retum O 2.Supplemental Return O 3. Remainder Rewrn(Data of�ealh Priorto 12-13-82) O 4. Limited Estate p 4a. Future Interest Compromise(date of O 5. Fetlerel Estate Tax Return Required death aRer 12-12-82) � 6. Decedent Died Testate O 7. Decedent Maintained a Living Tmst _ 8. Total Number of Safe Deposit Boxes (Attach Copy ot Wlll) (Altach Copy of Trust.) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election[o Tax under Sec.9113(A) � Between 1231-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Jane M.Alexander - (717)432-4514 � ..... .... .. . . . . .. . .. . . . .. . .. . ... _. _ . _...._ . . .. . � REGISTER OF WILIS USE ONLV � Firsf Line of Address C \ �_., .. . . ... .. . ....... ;,; O �i 148 S Battimore Street q y _ �� Second Line of Address � v- r � `� � _ � � - G3 = ' � � . � ��L@D` .--� " `�' ...... ... . DATE � 6 City or Post Office � State ZIP Code . .; . � J _ . .. .... . .. . ... _ _ ' � �_ ? Dilisburg PA 17019 :W ;�; ; -,� � `' �' � C'3 � � � correspondent's e-maii address:jmalexander.148@earthlink.net q� �n o Under penalties of perjury,I declare that I have examinetl�his return,induding accompanyin�schedules antl statements,and to Me bes[of my knowledge antl belief, � it is true,correct and mmplete.Dedaration of preparer other than the personal representative is based on all infortnation of which preparer has any knowletlge. SIGNATURE OF_ _ PERSON R�N F R FlLING RETUR�� DATE� / � iP1LC.e� +� � 7,/7'> > . ADDRE55 � 1520 S. Mountain Road Dillsburg, PA 17019 SIGNA REOFPREPARER TH THA EPR SENTATIVE pAT � ADD S 8 . Baltimore Stree Dillsburg, PA 17019 PLEASE USE ORIGINAL FORM ONLY Side 1 � 15�5610105 1505610105 � �� J 1505610205 REV-1500 EX(FI) Decedenfs Social Security Number . . . . .. ... .................... . oecedent's Name: LBUfB R. Sho3ff ': RECAPITULATION . ........... . ._.................... ... .... . .. 1. Real Estate(Schedule A). . .... .. . .. ..... .. ..... .. . .. .. ..... .... ... .. . i. '� . 2. Stocks and Bontls(Schedule B) .. ..... .. . .. .. . . ....... ..... . ... ... .. .. 2, � ! 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .. ... 3. �. � 4. MoAgages antl Notes Receivable(Schedule D).. . ... .... ... .. ....... .. .. . 4, �.. 5. Cash, Bank Deposits and Miscellaneous Personal Property(Scheduie E)... .. . . 5. �I 6,828.73 6. Jointiy Owned Property(Schedule F) O Separate Billing Requested ... .... 6. ' 31,455.30 ; - -----..._,.._ . ..___.__.._.--- _.__._,, 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.. .... .. 7. ��. �35,998.59 '� 9 ) .__.._.__.___....._,...,, 8. ToWI Gross Assets(total Lines 1 throu h 7 .... ... .. . .... . ...... .. ... ... 8. ��. 174,2$2.62 -. 9. Funeral Ezpenses and Administrative Costs(Schetlule H). .. ..... ..... .... .. 9. �- 8,029.36 ' _....___........_.__..-._. 10. Debls of Decedenl, Mortgage Liabilities and Liens(Schedule I)... .. ... .. .. ... 10. � 7479 � . ...._.,,,..'_._.._._,. t1. 7otal Deductions(total�ines 9 and to).. ... .. . ......... .. .. ....... ... .. t1. 8,104.15 , �_..__w�_._.._ ................................._ 12. Net Value of Estate(Line 8 minus Line 11) ...... .. .. ... .. .. ... ....... ... 12. � 166,17$.47 � ;..._._..__.,._..__.._._...,.._...._.__.._...._..._..................._,...; 13. Charitable and Govemmental Bequests/Sec 9713 Tmsfs 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. ��. 166,17$.47 ��, TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABIE RA7ES 15. Amount of Line 14�axable atthe spousaltax rate,or transfers under Sec.9116 ... ...". .. . .............. . . ...... .. .......... ....... .. . ....- , • (a)(12)X.0_ I � 75. � i6. Amount of Line 14 taxable :•__.._......________.......__.__......_....�.._..._....____.._. ._.__._..__.._"'_`_'__._..._._.__._.._._.___ at lineal rate X.0 45 166,178.47 �6.' 7,478.03 17. AmountofLinel4taxable -..._...,.._�____,. . ___ ....__..__._.._.. .... ..._. :__.._..__.._._...___.__... __......_..._._. at sibling rate X.12 '. �7. � - '�,......_'__...__..___.__.,........_.�...___...�_._.._.... ,._._____..._._....._...�,..�..._,..._._...,_...,..___.�_.., 18. Amount of Line 14[axable . � atcollateralrate X.75 �'�. 1g, � . _ ._...._.__".__....._._..__.,_......._._..._.._._ 19. TAX DUE .. ........ ... .. ... ... .. ... ....... ... .. ..... .. ... .. .. ... .. 19. � 7,478.03 ......... ....... .. ........... ..._.... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT � Slde 2 L 1505610205 1505610205 J REV-1500 EX(F1) Page 3 Flle NumGer DecedenYs Complete Address: DECEOENPSNAME Laura R. Shoaff STREETADDRESS 2100 Bent Creek Boulevard cm Mechanicsburg STA� PA ZIP 17050 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 7,478.03 2. Cred'rfs/Payments A.Prior Payments 7,481.25 B.Discount 393.75 Total Credils(A+g) (p) 7,875.00 3. Interest 4. I(Line 2 is greater ihan Line 1 +Line J,enter the difterence. This is the OVERPAYMENT. (3) Fill in oval on Page 2,Line 20 to request a retund. (4) 396.97 5. If Line i +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) � Make check payable to: REGISTER OF WILLS, AGENT. - — - - -- PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 7. Did decedent make a transfer and: Yes No a. retain Ihe use or income of the property transferred.......................................................................................... ❑ � b. retain the right to designale who shall use the property transfened or its income............................................ � � c. retain a reversionary interest.............................................................................................................................. ❑ � d. receive the promise for lile of eAher payments,benefAs or care?...................................................................... ❑ � 2. If death occurted after Dec.12,1982,did decedent irans(er propeAy within one year of death without 2ceiving adequa�e consideration?.............................................................................................................. ❑ � 3. Did decedent own an'in trust fof'or payable-upon�eath bank account or security at his or her death?.............. ❑ � 4. Did decedent ovm 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�AND FILE IT AS PART OF THE RETURN. __ - -- — - For dales of death on or after July 1,1994,and before Jan.1,1995,lhe tax rate imposed on lhe net value of transfers to or for the use of ihe surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of dealh on or after Jan. 1, 1995, lhe tax rate imposed on the net value of transfers to or tor lhe use o�the surviving spouse is 0 percent (72 P.S.§9116(a)(1.1)(ii)J.The statute does not exempt a transfer to a surviving spouse from tax,and the slatutory requirements for disclosure o(assets and filing a lax retum are still applica6le even if ihe 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(rom a deceased child 21 years of age or younger at death to or(or the use of a natural parent,an adop�ive parent or a stepparent of the child is 0 percent[72 P.S.§9N6(a)(1.2)�. . The tax rate imposed on the net value of Uansfers lo or for ihe use of Ihe decedenCs lineal benefiaaries is 4.5 percent,except as noled in�72 P.S.§9176(a)(1)�. . The taz rate imposed on the net value of transfers to or for ihe use of the decedenfs 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 adop6on. __ _, _ _ ,,, ._.._ r_� �,.,.� _, y. . ..�...� .�....�_� ..�,�,_TM�... .o—.......,�._=mm�.s-��....�..�.�.co.-.—.� .v.i.++��rvv�°v. i 4 fi REV-i508 E%�(08-�2) -;,A 'wt r '�' ��" _ . . "� �pennsylvania SCHEiD6lLE E j ,'DEPARTMENLOFR,EVENl1E � CASH�BANK.DGPQSITS�&MISC. � � �.;,:�' mr+eatrANCgTAxnEruRrv , ..y;+�pzERSONQL'PROFERTYs'yf „RESIDENT DECEDENi,,. • , . - . e E57ATE.OF. '� " ` ,.>•+�. , .a ..,,.w,W..�,�,. .�...,p...,.n. ..�« ..P....,.y.... ..w�,... .., .e,.......<...a....�-.....�„ -.,FILEsNUMBER::.w�..,.. ....,.,,, Laura'Rr.Shoaff ^ ' �'42113=0148 ,.,�.: . :� -",� ,�� . , __ Include.the,proceeds,of,litigation,andthedatetheproceeds.were.received.bythe.es[ate.- _- � - - �-. �- , . ..� ,tAll�,pr6per,ty;jofntlypwned;with�,rightof sUrvivorship�must 6e-disclosedson:ScheduleJF �<<o,•..:;.. . . , . .. .._ . _._ _. . ._._... ITEM.; , r �=;�. �.a"ati� t .T:-:. � ; r • r.•VAIUEAT-�DATE � NUMBER- ° � " DESCRIPTION " _ OF DEATH� � � .- ;- �:,,;Refund Forethought Life Insurance' °� %� � ->^ � >, 525.16 2. Refund Express Scnpts � 95.40 3, Refund Uaited Healthcare ,,_ , , 757.91 . yo.�I h^;• '� - q. Refund Bent Creek ROBC Limited'Partnership � 5,398.00 5, Interest on Checking Account #945 10.73 . . t' • . g, CenNC Bank IMerest CD# 3021627=� "'- ` ' � " 41.53 _. _ _. _ _ . . . _ < � . . t_ ie,:;r.. ,. ., .. . . . . . . _. . . ._ ..... .. _ . . . _. . . �. .... Y.... . ' . .6 t .. . `. . .. . . .. ., � , - a ' . . . . i. �dl! . l _ - � . t .a. . s. . i . � i .. . . .ii.. . ' .� � ' � .. . . . . .. .. � ' . `�r . . .. C. . . . : .�.G .. r. . . ' ... . •. � ' . ' ._ ( .i . ' ,i.w . . � . . ' ' � n. . , .> .. . . . . . ... . . �. .. . . _:t . . .. . . . f . . , 1 b t _.`.:.�..__.. , ... . '. . . . : . .. _fi,828:73 � - � � � � � � � �TOTAL�(Also enter on Line 5, RecapitWation)';y . . . If more space is needed..use,additional'sheets of,paper of ihe same srze � ��- -- - � . � � . . �� , � , . + ;r.' . •... . , . _ ,�.. ., , . RF.V-1511 EX+(7ti-09) " � SCHEDULE H ��'`� 7 pennsylvania � oeanarMemroraEVervue FUNERAL EXPENSES AND irvnewrnNCeraxaeruaN ADMINISTRATIVE COSTS RESI�ENT DECEDENT ' ESTATE OF FILE NUMBER Laura R. Shoaff 2113-0148 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A� FUNERALEXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: , 2,013.35 Name(s)of Personal Representative(s) Mae K. Peterson � s[reet nddress 1520 S. Mountain Road city Dillsburg State Pa Z�p 17019 � Year(s)Commission Paid: 2013 z. atcorneyFees: Jane M. Alexander, Esquire 5,552.51 3� Family Exemption: Qf deredent's address is not the same as daimant's,attach explanation.) _ aa�mant None claimed Street Address City State ZIP Aelationship of Claimant to Decedent 4� Probate Fees: 88.50 5. Accountant Fees: 6• Tax Return Preparer Fees: 2012 and 2�13 250.00 � Register of Wills, Short Ce�ificates 25.00 a. Register o(Wills,Cumberland County--Filing Inheritance Tax and Inventory 30.00 9. Oath of NonSubscribing Witness-Maureen Shoaffi 25.00 io. Notary Fees 30.00 >>. Register of Wills,Cumberland County-Filing Release 15.00 TOTAL(Also enter on Line 9, Recapitulation) ; 8,029.36 lf more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) ��pennsylvania SCHEDULE I DEPARTMEMOFREVENUE DEBTS OF DECEDENT, INME0.ITAl/CETA%RENRN MORTGAGE LIABIUTIES & LIENS RESIDEM DKEDEM ESTATE OF FILE NUMBER Laura R. Shoaff 2113-0148 keport debts incurred by the decedent prior to death that remained unpald at the date of death,including unreimhursed medical expenses. ITEM VALUE AT�ATE NUMBER DESCR1P770N OF DEATH 1. Alert Pharmacy 49.79 2. duesf Diagnoslics 25.00 � TOTAL(Also enter on Line 10, Recapitulation) # 74��9 If more space is needed,insert additional sTeets o(the same size. REV-1513 EX+(01-10) �j,�i�pennsylvania SCHEDULE 7 }� �EPAPTM[NTOiREVEN11f ,N„ER„qN�E rn�REnRN BENEFICIARIES AESi�ENT DECEDENT ESTATE OF: FILE NUMBER: Laura R.Shoaff 2113 0148 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECENING PROPERTY Da Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBU7i0N5[Indude ootright spousal distriUU[ions and transfers under Sec 9116(a)(1.2).] 1• Mae K.Peterson 1520 S.Mountain Road,Dillsburg,PA 17019 daughter 1/3residue 2. Richard H.Shoaff PO Box 117 25 W Main St New Kingstown,PA 17072 son t/3residue 3. Everett E.Shoaff 132 Spring Road,Dillsburg,PA 17019 son 1/3residue EN7ER DOLLAR AMOUNTS FOR DISTRIBlI7I0N5 SHOWN ABOVE ON LINES 15 THROUGH t8 OF REV-1500 COVE0.SHEET,AS APPROPRIATE. �I NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: , 1. B. CHARITABLE AND GOVERNMENTAL D15TRIBUi70N5: 1. TOTAL OF PART II —ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ; IF more space is needed, use additional sheets of paper of the same size. . . . . . .. . . . . . _ _ . . . �ttst ��11 �nh (Zesttttr�ent of LAURA A. SHOAFF ' I, Launa R. Shoaff� of the Towns�ip oF Cazcoll, County of York and Commonwealth of Pennsylvania fiecewith publish antl declare this to be sy last Ni11 and Testament. ITEM 1. I direct that all my just debts and funeral expenaes be paitl as soon after my decease as may be wnvenient to the pnnper r administration of my estate. ITEH 2. I give, devise and bequeath my individual esiate unto my husband, Earl E. Shoaff� fon life, or until such time as he may remarry. In the event he nemanry, I tBen direct that he ahall retain one third thereo£ and distriCUte the remaining two thirds unto my children. If he does not resarry, and thene is any of my separate or individual estate remaining at his death, I direct that same ehall be distriDUted unto my children. in equal shanefl per stirpes. ITEH 3. In the event my said husband predeceases me, I give, devise and Dequeath my entire estate remaining aften payment of debts and expenses unto my children, to 6e divided in equal shares per stirpes. ITEM 4. Z nominate, constitute and appoint my tiusband, Eanl E. Shoaff, Executor of this, my last Will and Testament. In the event my eaid husband predeceases me� I then appoint Hae Peterson, my�dau�hten, Executrix in his place and stead. IN WITNESS WHEREOF, I, Laura R. Shoaff, have hereunto subscribed my hand to this, my laet Will and Testament, this � y� day of �-��w{/ , 1992. v ��, df' 05�,�' � � � _ . . . SIGNED, PUBLISHED and DECLARED by the aGOVe named Laura R. Shoaff as and for her last Will and Testament in the presence of us, who, at her request and in her presence and in the presence of each other, nave signed our names as attesting witnesses here2o. '� nesidin at � �� J 8 ��Y/''ri �. f� ��//// ��//�� residing at �V'�/,�, � �"�'� _ p _ ��r� ��. y�--. , TH-�OUGHT� February 13, 2013 LIFE INSURANCE COMPANY Mnke it en.cier for rbose you love� ONE FOREfHOUGHT CEkTER• BATESVILLE,IN 4)006 Mae K. Peterson 1520 S. Mountian Rd. Dillsburg, PA 17019 Re: Forethought Policy/Certificate/Annuity 007614714 _ Insured's Name: Laura R Shoaff Check Reference Number: ECOM420 04404830 — Check Description: Beneficiary Payment ECOM420 B3000 : ,"l ,:i >.^ -'>Di- _ _- '_ - � - ' . � . . . . . '. ��.�y� .. . . - . ' . . . . . .� .� L+��f !1. ��' . . -I� FORE THOUGHT° � � . oare - �� - - var m rHe oaoeR oF , 02/13/2013 Mae K. Peterson nn,our,r � 1520 S. Mountian Rd. "*`**"'"$525.16 Dilisburg, PA 17019 _ I FORETHOUGHT LIFE INSUR.4NCE COMPANY FLIC.WGN 6.3 � BATESVILL DIAN 4 `t*�bank � 5E5IX3 - � 422 � � t. �, vam nne eo oays . ��' S086475��°-:"�:04 2 20 50 38�: � 30ii1673575��' United Healthcare Insurance Co Page 1 of I (877) 620-6192 90-60 PO Box 1459 MN008-W235 Minneapolis MN 55440-1459 CHECK DATE 03-04-2013 CHECK NUMBER 01254790 �� Y �� YO'VG . 4 .: " k J Y .2 .. [ ': � dOUCN�R GROSS AMOUNt .• OISCOUN7 NE f AMOUNt : NUMBER ' • �DATE MUMBER ;, > , . . . ... ..��.. , �. ,.. ..:.. a , , • . .. �. , ::. , ,, : ,. . .:s . ,:'..,. RR1305900022 02-28-13 20026276 757.91 .00 757.91 � THIS CHECK REPRESENTS A REFUND Of UNUSED PREMIUMS. COVERAGE WAS RECENTLY TERMINATE� OUE TO A NOTIFICATION OF DEATH. PLEASE WATCH FOR ADDITIONAI INFORMATION IN YOUR MAIL FOR PAYMENT INFORMATION PHONE : 1-800-809-0453 4ENDOR ID - 800579146 RR1 : 4 1/ENDOR � ,. s. � � ` TOSAL USD 757.91 .00 757.91 SINGLEPAY aemu�miiu aoe� eiiHr» w.i��eeu�maaaw ovon��nu awam..eoo��s»�.eeei xn� . � �� : -� i i i � i �� i � �. ��., � r. -_ � . �.... .... , �: � . . .._. y :''' : �• , ,-._. '�_ ,. � �� ,�1' �. .� , , , . . . , ti'.._ � : � . � ... � ': � . _ . ��A�� .. .r..� . . .. . ... 'KE�'BANK NATONAL ASSOCIATON . . . 36-704 Ilntfed Hea2thcare Insurance ICo� ^` ��Z (877) 620`6192 `" ". " .DATE 03-04-2013 CHECK N0. 01254790 150 ' PO Box 1459 MN008 W235 ;,�.Minneapoiis;MN 55440 1459 y , ; � . �`�}: ,n?�zr ;�x Y��t� , ,,. ,,r.t; ;, ' pp M Y�.�� 91 , ^ .n r`}t � � �. t' v, r� , . F x � . , o r. ,f �;;a�� Pay�'�SEVEN IIUNUREDL��iFTYy§EVEN RND 91�90D DOLLARS.t � �t 5 � , . , t n-� s.� ..�.� :�?.�'. � .�' %. ' : c'. ;. .. - . . . To;The Ortler of . . MRS' EI1RL �E; SHOAFF :. .'. , TO +THE ESTATE OF � � > � , � �"` t/0 MAE K�PETERSON � � ' ' �� f1520 S'MTN <RD�� s ' � ", n 3,- jDILL5q6URGaPA 17019 8804 �.� ; ' ii �' . � . �'�'i.iu��l�i,��"I�'��liu'�IIt�I�I�III��I��II�III111I1II�II - - ..�AVII�ONREDSiGNANRE ' - i i � :i i � �i ii i •i i+•OQO L 2 5�. 790��' �:04 i 207040�: 3509935 i 78 i L��• Caleula��a 'vaitti� rii ivus i�u�,<�. __ , _ -- , -_- . ..�_ - - .- , Calcutaior Results for Redemption Date 01/2013 �,:�� TofaE Price Total Value TotaiInterest - -� $675.00 $3 019 48 �`Ta I��erest $2 344 48 $0 00 Bonds: 1-10 of 10 SerEai # Serdes Denam Essue P9ext Fin�S E�sue TSf�E?C25€ DaYe ticcrda! MaEurity �rice t�€eresf Rate �alue i�4ofe c740845184 EE $100 06/1983 06/2013 06/2013 $50.00 $176.12_ 4.00% $226.12 d58204297 EE $500 04/1983 04/2013 04/2013 $250.00 $880.60 4.00% $1,130.60 L621489935 EE �50 08/1983 02/2013 Q8/2p13 $25.00 $85.84 4.00% $110.84 c740845186 EE $100 12/1983 06/2013 12/2013 $50.00 $171.68 4.00% $221.68 c740845185 EE $100 11/1983 OS/2013 li/2013 $50.00 $171.68 4,00°k $221.68 c740845183 EE $100 06/1983 06/2013 06/2013 $50.00 $176.12 4.00% $226.12. c740845181 EE $1Q0 09/1983 03/2013 09/2013 $50.00 $171.68 4.00% $221.68 c740845182 EE $100 OS/1983 OS/2013 OS/2013 $50.00 $176.12 4.00% $226.12 c740845188 EE $100 02/1984 02/2013 02/2014 $50.00 $167.32 4.00% $217.32 c740845187 EE $100 03/1984 03/2013 03/2014 $50.00 $16732 4.00% $217.32 ToWis for 10 Bonds 675.00 $2 344.45 $3 019.48 . t�otes NI Not Issued NE Not eligibie for payment PS Includes 3 month interest penalty MA Matured and not earnin interest � VY'vll V' � C 1 � �� SE�IE�`�E'`= ; _ ' . _ ��MTEflESi,CE�SjS 9A YERRS _ FROHY69YE�DATE - ; 199: 07 3588' � " '_ = :" 08 x19837 ;� y}� �' _• � . � _ . - Jr. fi . .�l c To LAURA R SHOAFF .FRB PITT £ 1-32 SQRING .ROAD ' dm� �,�,,.42 DI`1LSBUR6 iy PA� 17D19-4352 ' �� ` ` � 1 b}IM9 t AM Ai J�[i��u��uuu��nja�n�tll��i�i1��i��ualil�i�� r OR;=*MAE K=PEfERS6N- ` > , : s RI-=020Z9408& ODl _001 � � - � 0621489935.; ��:. x � ' . -' �,,:.:�. �.�:=L 6 2:t 4 8 q��5 EE:`. .A � .�, � - _ :• ';.� ,` .;v.,�..,,,.r_..,� -. ' `� ; �:QOOfI9000 7� 0 3= � 30 E.2 i 489;93;5��' � httP:��'w�'v�'easurydirect.govBC/SBCPrice 1/29/2013 Calculated Value of Your Paper Savings $ond(s) Page 1 of 1 Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 01/2013 � , � � ?otai Price '�'otal Value 7ota! Ynteresi YTD Interest 1 325.40 5 778.8a $4 453.84 13.24 Bonds: 1-19 of 19 Yssue iVext Fi�al I55ue Tn#er2st �nterest �aiue Note Serial # Series Denant Date Accrua� Potaturity Price Rate D58201806 EE $500 12J1984 06J2p13 12/2014 $250.00 $815.40 4.00% $1,065.40 D58201805 EE $500 12/1984 06/2013 12/2014 $250.00 $815.40 4.00% $1,065.40 c740815283 EE $100 ll/1985 OS/2013 11/2015 $50.00 $154.80 4.00% $204.80 c740815Z70 EE $100 07/1983 07/2D13 07/2013 $50.00 $176.12 4.OD% $226.12 c740835269 EE $100 07/1983 07/2013 07/2013 $50.00 $176.12 4.00% $226.12 c740815277 EE $100 08(1984 02/2013 OS/2014 $50.0� $163.�5 4_0�°fo $213.08 c740815272 EE $100 il/1983 OS/2013 11/2013 $50.00 $171.68 4.00% $221.68 c740815278 EE $100 09(1984 03/2013 09j2014 $50.00 $163.08 4.00% $213.08 c740815279 EE $100 09/1984 03/2013 09/2014 $50.00 $163.OS 4.00% $213.08 c740815281 EE $160 1OJ1984 04/2013 10/2014 $50.00 $163.08 4.00°l0 $213.08 c740815250 EE $100 10/1984 04/2013 10/2014 $50.00 $163.08 4.00% $213.08 c740815274 EE $100 01/1984 07/2013 O1/2014 $50.00 $171.68 4.00% $221.68 c740815273 EE $100 12/1983 06/2013 12/2013 $50.00 $171.68 4.00% $221.68 c740815268 EE $100 12/1982 12/2012 $50.00 $230.32 $280.32 MA c740815282 EE $100 12(1984 06/2013 12/2014 $50.00 $163.08 4.00% $213.08 c740815275 EE $100 02/1984 02/2013 02/2014 $SD.00 $16732 4.00% $217.32 c740815276 EE $10� 04(1984 04f2013 04/2014 $50.00 $167.32 4.00% $217.32 c740815271 EE $100 OS/1983 02/2013 08/2013 $50.00 $171.68 4.00% $221.68 L621476125 EE $56 OS/1983 02j2013 08/2013 $25.Q0 $55.84 4.00°!0 $110.84 Totals for 19 Bonds 1 325.00 4 453.84 5 778.84 Notes NI Not Issued NE Not eligible for payment � PS Indudes 3 month 7nterest penalty YY 1 � � C 1 1 � - ��sa�_f��,� �'� SETi:�ES �� . r}y��p�s� � .INTEAESiCG8E630YE/�NE. i I� F' �n ��Ll . FRCY ISSYG9ATE.'. � 199 07 3588 OSi 1983 ; ,.,, . _ ,.__.. . .. ,.. �.� ti �, - ;.� . "' �' 'c T LAURA R SHOAFF - �RB fIM cc i32 SPRIN6 ROAD �01�1 02•, , - f,_ ��DS-t6SBUR6 - � =` PA �7019-9352 � ' �. - �„ ,T . - , i,..��;,.in,..,..uy.it��r::,�ru,�,r:,ti,�.;tr,,.��ii.,�,i _ QR `R-I�HARD N SHOAFF -- _ RI 020290104 D01 001 - �06214�b123 �isf�� , �, .. -- - ..�.:N� L621416125EE �:OOQ�90007�::03 � 9062i476i25+i• http://www.�easurydirect.gov/�C/SBCPrice 1(2912Q13 t;alculated Value of Your Paper Savings Bond(s) Page I of 1 Calculated Value of Your Paper Savings Bond(s} Calculator Results for Redemption Date 01/2013 �✓ Total Price Tota! Value Total 2nterest YTD Interest 750.00 3 323.68 2 573.68 12.84 Bonds: 1-16 of 16 Issue Next Final Issue -Interest Seriai # Series Denom Date Accrual Maturity Price Interest Rate Value Note C740815258 EE $100 03/1984 03J2013 03/2014 $50.00 $167.32 4.00% $217.32 C740815265 EE $100 07/1984 07/2013 07/2014 $50.00 $167.32 4.00% $217.32 C740815266 EE $100 12/1984 06/2013 12/2014 $50.00 $163.08 4.00°h $213.08 C740815263 EE $100 07/1984 07/2013 07/2014 $50.00 $167.32 4.00% $217.32 C740815264 EE $100 08/1984 02/2013 08/2014 $50.00 $163.08 4.00% $213.08 C74�81526Z EE $100 06/1984 06/2013 06/2014 $50.00 $167.32 4.00% $217.32 C740815261 EE $100 OS/1984 OS/2013 OS/2014 $50.00 $167.32 4.00% $217.32 C740815260 EE $100 OSj1984 OSj2013 OSj2014 $50.00 $167.32 4.00% $217.32 C740815259 EE $100 04/1984 04/2013 04/2014 $50.00 $167.32 4.00°/a $217.32 C740815257 EE $100 01/1984 07/2013 01/2014 $50.00 $171.68 4.00% $221.68 C740815256 EE $100 10/1983 04/2013 10/2013 $50.00 $171.68 4.OQ°/u $221.68 C740815255 EE $100 10/1983 04/2013 10/2013 $50.00 $171.68 4.00% $221.68 C740815254 EE $100 OSf1983 OS/2013 05�2013 $50.00 $176.12 4.00% $226.12 C740815267 EE $100 il/1985 OS/2013 11/2015 $50.00 $154.80 4.00% $204.80 L621476123 EE $50 12/1982 12j2012 $25.00 $115.16 $140.16 MA L621476124 EE $50 12/1982 12/2012 $25.00 $115.16 $140.16 MA Totals for i6 Bonds $750.00 2 573.68 3 323.68 Notes NI Not Issued NE Not eligible for payment PS Includes 3 month interest penalty MA Matured and not eamin interest �` _ ,� p IY V' 1 � � - ii. � � � ��a�� s�R�s EE PS�'�:S�.ICl�� .INTCREIIT CCI��ES i0.YE�N9 �"` iROM 185V6 DATC ` 199 07 3588 " . �12? _ �1982� � ��-,., . . . , _. . . 'if>�'J'� GAT�.... *:` � �,'` T LAURA R SHOAFF ^ ;�RB .PIT7 + � - :. 01-31.-02� �L32 SPRIN6 RD ""'"q""„"' `' DILLSBURG , - . ' PA 17019-9352 e ,,,. L„11L�.III��,��IILL�I�G��,If��l;l��l,l;ill;,�l�l1��1�1 ' OR EVERETT E SHOAF-F `� , -�" RI 020290103 001 001 '- " " '� 'ti " Ob21476124 . , . , , . `�°"„'�°n " � � L b�14 l 612 '+E E -_:.- -. - - -' . . .�:.,..c...H. J�.,.,.�.. • .G.e,.,�.�...., �:000090007�:03 T B0621476.124��' iviemoersist r�u rage i oi � � MEMBERS 1St °FEDERAL CREDIT LJIVION Account Statement LAURA R SHOAFF For Accoun[: 0000212725 1520 SO.MOUNTAIN ROAD DILLSBURG,PA 17019 Reporting Period: 1/Ol/2013 to 1/30/2013 0000 REGULAR SAVIN(:S Joint Owner:MAE K PETERSON � Balance $25.01 0005 MONEY MANAGEMENT Joint Owner:MAE K PETERSON PostDate TransactionDesc 'otion Amount NewBalance 7/11/73 Deposit Check $41.53 $17,130.35 Check Received 41.53 i126/13 Deposit Transfe[From Share 0092 $15,642J4 $32,)73.09 V26/73 Deposit Transfec From Share 0093 $15,64274 g qg,qjs,j �0043 11 MONTH CERT / L>' � B� / � $13,784.55 � 0049 11 MONTH CERT Balante $73,784.55 �,f f 0052 7 MONTH CERT { Balance �� // $5.99129 � ,,� 0053 7 MONTH CERT Ba�l n4g $5.997.29 file://C:\ProgramData\Jack Henry and Associates\Episys For Windows\HTML\HTMLVie... I/30/2013 ,�. BUREqU OF IN�IVIDUAL raxes Penns Ivania lnheritance Tax � '�� ennsYlvania PO B�X 28D601 y � + HARRISBURG PA 17128-o6a1 IIITOfIlIat1011 NOtIC2 - DEPARTMENTOFREVENUE -- -� aev-�sos cr m�ExEC �ee�iz� And Taxpayer Response FILE NO. 6770 ACN 13105936 RECO, D�D p;;�� pF DATE02-06-2013 � _tt Ofi 'tr�13_LS 10i3 FEB 27 p(� � �p TypeofAccoun[ � `L�tate of LAURA R SHOAFF Savings CLERK Ci' DaeofDe th0828-2073 �Tustking MAE K PETERSON ORFNAPlS �Ui1RT COUntyYORK Certifica[e 1520 S MOUNTAIN RD DILLSBURG PA ��o�9-sao4CUA4SERtAPd6 r,�., P,a MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: AccountNo.212725 Date Established 01-04-2002 REGISTER OF WIILS Account Balance $qg,478.97 45 NORTH GEORGE STREET Percent Taxable X 50 YORK PA 1 7 401-1 240 Amount Subject to Tax $24,209.49 � � Tax Rate � X 0.045 Poteniiai Tax Due $ 1,089.43 NOTE": If tax payme�ts are made within three months of the decedenYs date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 7 A �No tax is due. 1 am the spouse of the deceased or i am the parent of a decedent who was 21 years old or younger at date of death. P�oceed to Step 2 on reve�se. Do not check any other boxes and disregard the amount shown above as Potential Tar Due. g `'�The information is The above information is correcf, no deductions are being taken, and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent,child,grandchild, etc.) of the deceased. (Select correct ta�c rate at righ[, and complete Part � 72% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back o/this/orm. E Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both ot the following criteria: A. The decedent was legally responsible for payment,and the estate is insuHicient to pay the deductible items. B. You paid the debts afler the death of the decedent and can furnish proof of payment it requested by the department. (If additional space is required,you may attach 8 1!2"x 11"sheets of paper.) Daie Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction lo the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 7. Enter the date the account was established or titled as it existed at the date o�death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage oi the account that is taxable to you. a. First,determine the percenta9e owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decetlent. ii. Forjoint accounts established more ihan one year prior to the date o(death, the percentage taxable is 100%divided by the totat number of owners including the decedent. (For example:2 owners= 50°/,,3 owners=33.33%, 4 owners =25%,etc.) b. Next,divide the tlecedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amoun[taxable is determined by subtracting the debts and deductions from ihe amouni subject io tax. 7. Enter the appropriate tax rate irom Step 7 based on your relationship to the decedent. If indicatlng a different tax rate, please state OffiCial US8 Oflly 0 qAF your relationship to the decedent: PA Depariment of Revenue 1. Date Established 1 2. Account ealance 2 $ PAD 3. PercentTaxable 3 X �� 4. Amount Subject to Tax 4 $ 2 3 5. Debts and Deductions 5 - ¢ 3 6. Amount Taxable 6 $ 5 7. Tau Rate 7 X 6 8. Tax Due 8 $ � � - i $ 9. Wiih 5°/, Discount(Tax x.95) 9 X St@p 2: Sign and date below. Reiurn TWO completed and signed copies to the Register of Wills lisied on the front ot this form, along with a check for any payment you are making. Checks must be made payable lo"Register of Wills,Agent" Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facis I have reported above are true,correct and comptete to the best of my knowledge and belief. WOrk _ �J�-az./i'' ��iti.l-cw Home 7 I 7 �3Z J"!a � L� 7 �� Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAK!!JG NEEDS ONLY: 1-800-447-3020 �b�fm' BURFAU OF INDIVIDUAI raxES Pennsylvania lnheritance Tax � � �� pennsylvania PO B�X 280601 � DEPARTMENT OF REVENUE HABRISBURG PA R128-0601 Information Notice And Taxpayer Response aEV-�sas ex m�ezec �oe-�z� FILE NO. 2113-0148 ACN 13t08103 ,.�� DATE 02-19-2013 REGISTcR OF �'a'#�LS Type of Account t�13 FEB 2� P� � 5$ Estate of LAURA R SHOAFF Savings SSN X Checking CLERK Di` Date of Death Ot-28-2013 r�usc 152DKSPMOUNTAIN RD ORPHANS' GOURT CountyCUMBERLliND Certificate DILLSBURG PA 17019-B��BERLAP�Q CO., F!a FUITON BANK NA provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No.3619 Remit Payment and Forms to: Date Established 06-18-2007 REGISTER OF WILLS Account Balance $20,344.62 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Ta� $ 1 p,772.37 Tax Rate X 0.045 Potential Tax Due $457J5 NOTE`: If ta�c payments are made within three months of the decedent's date of death, deduct a 5 percen[discount on the tax With 5% Discount(Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. f am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on�everse. Do not check any other boxes and disregard the amount shown above as Potential Tar Due. g ��The information is The above information is correct, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent, child,grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropnate on the back of this/orm. E Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax iorm Retum filed by the es[ate representative. REV-1500. Proceed to Step 2 on reve�se. Do not check any otherboxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficien[to pay the deductible items. B. You paid[he debts after the death of the decedent and can furnish proof of payment if requested by the department. (If addi[ional space is required, you may attach 8 1/2"x 11"sheets of paper.) DaTe Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the da[e of death. 2. Enter the[otal balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First, determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. Forjoint accounts established more than one year prior to the date of death,the percentage[axable is 700%divided by the total number of owners including the decedent. (For example:2 owners= 50%, 3 owners=33.33%,4 owners =25%,etc.) b. Next, divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 7 based on your relationship to the decedent. If indicating a different tax rate, please state Officiai Use Only �nnF your relationsnip ro the decedent: PA Department of RevenUe 1. Date Established i �� b - 2. Account Balance 2 $ PAD � � - - � �� - 3. Percent Taxable 3 X �� `" � � " " ' � ' � �in � r 4. Amount Subject to Tax 4 $ � " � � � �� 5. Debts and Deductions 5 ' �� n �� _� � 6. Amount Taxable 6 $ 6 � 7. Tax Rate 7 X .. �. � �� 7. E 8. TaxDue 8 $------�- 8�e. .. __ , .. . .. , �� . 9. With 5% Discount (Tax x .95) 9 X - _ - - - - g" � St@p 2: Sign and date below. Return TWO completed and signed copies[o the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent" Do not send payment directly to the Department of Reven�e. Under penalty of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. Work y�y� , �- �;-�,.J Home 7 �7 ��z-SUbi L��,��zo�3 Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 REV-t510 EY.+•,'6E-09) � 2°¢ SCHEDULE G r�i�; pennsylvania �y� oEPnarn�emraFae�ENUE INTER—VIVOS TRANSFERS AND iNHea�TnNCeraxaeTURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Laura R. Shoaff 2113 0148 This schedule must be mmpleted and filed if the answer to any of questions 1 through 4 on page three of the REV-I500 is yes. ITEM DESCRIPTION OF PROPERTY �rvauoernexamEOVlxEmnNS.earE,lHE�aaEUnorvswarooECEOervrnxo DATEOFDEATH ;oOFDECD'S EXCWSION TAXFBLE NUhiBER 1HEOarearmaxs.e:. anncxnccProFrxEOEEOrosaeaiESrnrE, VALUEOFASSET INTEREST ��rnvauc+a�l VALUE 1 Members 1st 11 month certificate Share ID 0043 Mae Peterson and Richard Shoaff 06/02/11 13,793.73 100 13,793J3 z Members tst 11 month cedificate Share ID 0049 13,793.73 100 i3,793.73 Mae Peterson and Everett E.Shoaff children O6/02/N 3 Members 1st 7 month certifcate Share ID 0054 g,gg�,q3 100 8,981.43 Mae K.Peterson and Everett E.Shoaff children 04/06/11 4 Members tst 7 month certifcate Share ID 0094 g,gg�.qp 100 8,981.42 Richard H.Shoaff and Mae K.Peterson children 04/O6/11 5 Members 1st 7 month certifcate Share ID 0096 12,047.18 100 12,047.18 Mae K.Peterson and Everett E.Shoaff children 04/12/11 6 Members ist 7 month cedifcate Share ID 0095 12,047.18 100 12,047.18 Richard H.Shoaff and Mae K. Peterson children 04/12/11 � Members 1st 19 month certi�icate Share ID 0086 6,895.07 100 6,895.07 Richard H.Shoaff and Mae K. Peterson children 12/13/10 g Members 1st �9 month cedificate Share ID 0085 6,895.07 100 6,895.07 Mae K.Peterson and Evered E.Shoaff children 12/13/10 9 Centric Bank N.A. 60 month certificate No: 3021627 10,032.75 100 10,03215 Mae Peterson,Richard Shoaff, Everett Shoaff children 08/OS/08 �p Bankers Life and Casualty Company Annuity Policy#7583422 30,543.73 100 30,543.73 Mae K Peterson, Richard H.Shoaff,Everett E.Shoaff children 04/OS/87 �� Members 1st 7 month certificate Share ID 0052 5,993.95 100 5,993.95 Mae K.Peterson and Everett E.Shoaff children 08/04/11 �Z Members 1st 7 month certifcate Share ID 0053 5,993.95 100 5,993.95 Mae K.Peterson and Richard H.Shoaff children 08/04/11 TOTAL(Also enter on Line 7, Recapitulation) $ 135,998.59 If more spare is needetl,use additional sheets of paper of the same size. BUREAU OF tNO�vm�,� TaXES Penns Ivania lnheritance Tax ��' pennsylvania Po HOX 28a6o1 y �� DEPARTMENTOFREVENUE HABRISBURG PA 17128•0601 Information Notice p¢vasa3 Ex uoc¢xec �aeaz� And Taxpayer Response FILE NO.6770 ACN 13105939 G E O F DATE 02-06-2013 REGiSTER OF '�dILLS Type of Account %013 FEB 27 P� � 59 Estate of LAURA R SHOAFF Savings SSN Checking CLERK O.r- Date of Death Ot-28-2073 x r��st 1520KSPMOUNTAIN RD pRpHANS� �l1�RT CountyYORK Certificate DILLSBURG PA 17019-88�p��BERLAPdD GO., pA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No.212725 Remit Payment and Forms to: � Date Established 06-02-2011 REGISTER OF WILLS Account Balance $ 13,793.73 45 NORTH GEORGE STREET . YORK PA 17401-1240 Percent Taxable X 50 � Amount Subject to Tax $6,896.87 Tax Rate X 0.045 � Potential Tax Due $310.36 NOTE': If tax payments are made within three months of the decedenYs date of death, deduct a 5 percent discount on the tax With 5% Discount(Tax x 0.95) $(see NOTE") due. Any inheritance tax due will become delinquent nine months after the date of death. PART St@p 1 : Please check the appropriate boxes below. 1 A �No tax is due. 1 am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any oiher boxes and disregard the amount shown above as Potentia/Tax Due. g �The intormation is The above information is correct, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any othe�6oxes. C �The tax rate is incorrect. � 4.5% I am a lineal beneticiary (parent,child,grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � �z�o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. !isted. Comp/ete Part 2 and part 3 as appropriate on the back o1 this lorm. E �Asse±will be reported on The above-identified asset has been or will be reported and tax paid with[he PA Inheritance Tax inheritance tax form Retum filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following c�iteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (!f additional space is required, you may attach 8 1/2"x 17"sheets ot paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 ,or y g ( ) ( ) percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter[he total balance ot the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in Irust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 700%divided by the total number of owners including the decedenL (For example:2 owners=50%, 3 owners=33.33%, 4 owners =25%,etc.) b. Next,divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax raie from Step 7 based on your relationship to the decedent_ If indicating a different tax rate,please state +�-� � �"c=�(jf,��g'� �jS2 flllly ��AAF� `�� your relationship to the decedent: �° �crt � � ^y-�-° �-'�?� �� PA 13epartinerrt of Fievenve��,�� ,� t. Date Established t ��,��,�� s �,�s��,�,� �� _ � �,£$ 2. Account Balance 2 $ ,�,'��»� ��«��.�„��,, . 3, PerceMTaxable 3 X � � x �n � ,� ��.��. � r , 4. AmounT Subject to Tax 4 $ � a*,�,�,�.� * ��„ � - .��, � 5. Debts and Deductions 5 - ��`� x��,P �. � � ��r 6. Amount Taxable 6 $ �� ,��, � � � � 7. Tax Rate 7 x �� L°s-.', t�:��a`��.�'i�"� "�'��:�3�,��'n�'��i� 8. Tax Due 8 $ 8 .. �'� ��,�� 9. With 5% Discount(Tax x .95) 9 X `'�� ,� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, alo�g with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent" Do not send payment directly to the Department of Revenue. Under penalty of pery'ury, I declare that the facts I have reported above are true, correc[and complete to the best of my knowledge and belief. Work �r'�-e- `7�: `7C c-�"i�-Cr� Ho m e `y! 7 �.'�Z ��C� / 1�-7��4 13 Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 a�R�� oF INOIVIDUAL T0.XE5 .� pennsylvania Po eoX zaoso� Pennsylvania fnheritance Tax HARRISBURG Pn 17128�0601 Information Notice DEPARTMENTOFflEVENUE Alld TaXPHyP•f RP.$P�fl$@ xEV-isun cx no�cxEC�oe-�z> FILE NO.6770 ACN 13105938 �. r DATE 02-06-2013 RE61SiE€� OF h}3LLS �t7 Type of Account ;Ul3 FEB 2 7 P� Eslete��URA R SHOAFF Savings SSN Checking CLERK GBateotoeathot-28-2013 x Trust RICHARD H SHOAFF YORK Certificate ro sox ii� ORPHAtdS' C �J`� NEW KINGSTOWN PA 17072-0117 CUA96ERLdPlD GO., PA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No. 212725 Remit Payment and Forms to: Date Established 06-02-2011 REGISTER OF WILLS Account Balance $13,793.73 45 NORTH GEORGE STREET YORK PA 17401-1240 Percen[Taxable X 50 Amount Subject to Tax $6,896.87 Tax Rate X 0.045 Potentiat Tax Due $310.36 NOTE': If tax paymenis are made withi�three mon[hs of[he decedent's date of death, deduct a 5 percent discount on the tax With 5%Discount (Tax x 0.95) $(see NOTE') due. Any inheritance tax due wi{I become delinquent nine months after the date of death. PART St@p 1: Please check the appropriate boxes below. 1 A �No tax is due. 1 am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. P�oceed to Step 2 on reverse. Do not check any other boxes and dis�egard the amount shown above as Potential Tax Due. g � The information is The above information is correct, no deductions are being taken, and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent, child, grandchild, etc.)of the deceased. (Select correct tax rate at right, and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15%a All other relationships (including none). p �Ghanges or deductio�s The i�formation above is incorrect andlor debts and deductions were paid. listed. Comple[e Part 2 and part 3 as appropriate on the back ol this�orm. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Re[um filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any othe�boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (tt additional space is required, you may attach 8 U2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), olease obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it exis[ed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First, determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners= 50%, 3 owners=33.33%,4 owners = 25%, etc J b. Next, divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amoun[subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to Ihe decedent. If indicating a different tax rate, please state $�'�"�� 1�t#ic�al Use yQr�lyx�kl�F,�y�"'`� � °w��.t� your relationship to the decedent �� ' � � n �PA��epartmentof F�euenue�� ,' � 1. Date Established 1 '� �? �- '� ,�� `� � '��.�+, �'`�� `�� PAD „ �a�: �� -�. x ��s��aam 2. AccountBalance 2 $ ,� ��+ ° '� ��'�'� ,� ;:� �,�;�.�;,�-�4 � 3. Percent Taxable 3 X �� ' ; ,�'� �� .��a;.'� �Y„�i'��,�' , -�s: 4. Amount Subject io Tax 4 $ $ . �:- "*`�" ��a�ia" � `�`,�� '''-;;� 5. Debts and Deductions 5 - 4"' "'�� '� � s;�,t��.::*,� 6. AmountTaxable 6 $ � ' �� ,. � 7. Ta� Rate � X 7°�, � ��-��'��u ��'��t��`�� 8. Tau Due S $ i I._ �„ v.a'�`�t " '�.�'''a�e��cn� �� t�&�''s��!`"�a 9. With 5% Discount(Tax x .95) 9 X - St@p 2: Sign and date below. Re[urn TWO completed and signed copies to the Register of Wills listed on the front of this form; along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. / Work �� S/ku%/ Home�/ �)—�%��'�i �Zl�y// � Taxpayer Signature � Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 BUREAU oF iN07VIDUAL TAxes Penns Ivania lnheritance Tax -` � enns lvania PO BOX 280601 y ., ��-�� P y HaRRISBURG PA 17128-0601 IllfOfflllt1011 NOIIC2 � DEPARTMENTOFREVENUE Af1C� TdXpaye( R@$POfI$@ . . . � xev-�sas ex m.exec <aeazo RECORDED Ot=F!�� OF FILEN0. 6770 ACN 13105939 � - y;.r!! LS DATE 02-06-2013 ZUi3 fE8 27 P� � �9 TypeofAccount CLERK QF Estate of LAURA R SHOAFF Savings SSN Checking ORPHANS' GOURT DateofDeath01-28-2013 x Tr�st 1520KSPMOUNTAIN RD CU�P9BERLAtdD Gfl., PQ CountyYORK CertifiCate DILLSBURG PA 17019-8804 MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.212725 Date Established 06-02-2011 REGISTER OF WILLS Account Balance $ 13,793.73 45 NORTH GEORGE STREET Percent Taxable X 50 YORK PA 17401-1240 Amount Subject to Tax $6,896.87 Tax Rate X 0.045 Potential Tax Due $310.36 NOTE': If tax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5%Discount (Tax x 0.95) $ (see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART $t@p 1 : Please check the appropriate boxes below. 1 /+ �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Taz Due. g �The information is The above information is correci, no deductions are being taken, and payment wili be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent, child,grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � 12°/a I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back ol this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. P�oceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions musl meel both of the following criteria: A. The decedent was legally responsible for payment,and Ihe estate is insufficient to pay the deductible items. B. You paid the debts after the death o(Ihe deceden[and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 71"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculalion $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), please obtain a written correction irom the financial institution and attach it to this form. t. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter ihe percentage of the account that is laxable to you. a. First, determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners= 50%, 3 owners=33.33%, 4 owners = 25%, etc.) b. Next, divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. � Enter the total ot any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deduclions from the amount subject lo tax. 7. Enter the appropriate ta�c rate from Step 1 based on your rela[ionship to the decedent. If indicating a different tax rate, please state Official Use Only �AAF your relationship to the decedent: PA Departmeni of Revenue 1. Date Established 1 2. Account Balance 2 $ �A� I 3. Percent Taxable 3 X 1 "I 2 4. Amount Subject to Tax 4 $ 3 ! 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 $ `� ' 7. Tax Rate 7 X 6 i 8. Tax Due 8 $ 7 � 8 i 9. With 5% Discount (Tax x .95) 9 X ____� ___ _ __�_ Ste}� 2: Sign and date below. Return lW0 completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent° Do not send payment directly to the Department of Revenue. Under penalty o(perjury, I declare lhat the facts I have reported above are true, correct and complete to the best of my knowledge and belie(. Work 7'��. `� ��',�-Z�Z�r�w Home y17 ¢.3� ��Q� I 1� 7�ZG/.3 Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 BIIREAU OF INDIVIDIIAL TAXES Penns Ivania lnheritance Tax � ^■lennsVlvania PO BOX 2806�1 Y 'X • �� r J HnRRISBURG PA 1�128-Obol �flf�ffll$tI0f1 NOtlC2 �� DEPARTMENTOPREVENUE And Taxpayer Response "°,s""°°""` ,°° "' FILE NO.6770 ACN 13105940 � DATE 02-06-2013 � F OF RE6�STER OF 4911!_lS Type of Account ��13 FEB 27 P� � �tate of LAURA R SHOAFF Savings � N Checking Date of Death 01-28-2013 X Trust EVERETT E SHOAFF CLERK OF CountyYORK Certific8te 132 SPRING RD ORPNAPlS� COUR7 DILLSBURG PA 17019-9352 CUA98ERLAMD CO., PA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. AccountNO. 212725 RemitPaymentand Formsto: Date Established 06-02-2011 REGISTER OF WILLS Account Balance $ 13,793.73 45 NORTH GEORGE STREET Percent Taxable X 50 YORK PA 17401-1240 Amount Subject to Tax $6,896.87 Tax Rate X 0.045 Potential Tax Due $310.36 NOTE": If tax payments are made within three months of the decedenYs date of death, deduct a 5 percent discount on the tax With 5°/Discount (Tax x 0.95) $ (see NOTE`) due. Any inheritance tax due will become delinquent nine months after the date of death. PART St@ 1 : Please check the a p � () ppro riate boxes below. A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard ihe amount shown above as Potential Tar Due. g �The information is The above information is correc[, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild, etc.)of the deceased. (Select correct tax rate at right, and complete Part � �p�a I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete PaR 2 and part 3 as appropriate on the back o1 this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax torm Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), please obtairt a weitten correction from the financial institution and attach it to ihis form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners= 50%, 3 owners=33.33%,4 owners =25°/, etc.) b. Next, divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate,please state e ��,�w.� �Q�Ci31 �52�It1y []AAF��,..�;��?:�,�,�� our relationshi to the decedent: � �$ "�"" r�° �� v P ,��. ��PA;�epari'ir�ent oY Revenue ,� 1. Da[e Established 1 � �#,�yr�,�.� `�'� ,y�, ,,, , �,*��*_�,��``� � u�� P�1D-. 2. Account Balance 2 $ �� vs�.. =w �, �.�", u� '��'# � �.�v��'�I =! 12F; '�`- 3. Percent Taxable 3 X � �;��1� �, � ��' 4. Amount Sub'ect to Tax 4 $ ?�'* � � T��"` ' 1 � �3�f .��T�*'�a�as�'�+'� ��s��;� 5. Debts and Deductions 5 - 4 `� ��.��"'�; , �� ° 5 �`'��,�_�,�d.�i� ,=��`a� �� 6. Amount Taxable 6 $ � � 6 ��' '�s" '�' 7. Tax Rate � X � :�" � .. �..��n�--+�*�� ,::�'��:�u 8. Tax Due 8 $ ��";� "" '� 9 With 5% Discount(Tax x .95) 9 X �.�''�]�w;�.«� 'T s "�'s'w�' a�,s.w. -�i�- -- Step 2: Sign and date below. Retum TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent" Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. Work (,��GC7W � C�G�/// Home �1�—y��'" -r'1��7 ot "t�"a��3 Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 e�a�� OF INDIVIDIIAL TAXES Penns Ivania lnheritance Tax - � " PennS�/�Val11d PO BO% 280601 Y � DEPARTMENTOFREVENUE HARRISBURG Pp 1]128-0601 Information Notice ,E,-„�>Ex m�exeo �oe-�z� And Taxpayer Response FILE NO.6770 ACN 13105945 ' � O F DATE 02-06-2013 REGISTER OF �ILLS ��3 �EB 27 Q� .�i o TypeofAccount �State of LAURA R SHOAFF Savings SSN Checking MAE K PETERSON CLERK 4� CountyYORKa1-28-2013 X T�USt 1520 S MOUNTAIN RD ORPNANS� C��R� Certificat2 DILLSBURG PA 17019-8804 CU:MBERLAND CO., PA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: AccountNo.212725 Date Established 04-06-2011 REGISTER OF WILLS Account Balance $g,gg�,q3 45 NORTH GEORGE STREET � Percent Taxable X 50 YORK PA 17401-1240 Amount Subject to Tax $4,490.72 Tax Rate X 0.045 NOTE': If tax payments are made within three months of the Potential Tax Due $202.08 decedenYs date of death, deduct a 5 percent discount on the tax With 5%Discount (Tax x 0.95) $ (see NOTE`) due. Any inheritance tax due will become delinquent nine months after the date of death. PART $t@p 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or 1 am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potentia/Tax Due. g �The information is The above information is correct, no deductions are being[aken, and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent, child, grandchild,etc.) of the deceased. (Select correct tax rate at right, and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as appropriate on the back of this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. � REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts aRer the death o(the decedent and can furnish proof of payment if requested by the department. (If addilional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Descrip[ion Amount Paid Total Enter on Line 5 oi Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. En[er the date the account was established or titled as it existed at the date of death. 2. Enter the total balance ot the account including any interest accrued at Ihe date of death. 3. Enter the percentage of the account that is taxable to you. a. Firsl,determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by[he deceden[. ii. For joint accounts es[ablished more than one year prior to lhe date of death, the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%,,3 owners= 33.33%, 4 owners =25%,etc.) b. Next, divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the lotal of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracling the debts and deductions from the amount subject to[ax. 7. Enter the appropriate tax rate from Step 7 based on your relationship to the decedent. If indicating a difterent tax rate,please state OffIC181 USB Only ❑AAF your relationsnip to the decedent: PA Department of Revenue 1. Date Established 1 2. Account Balance 2 $ PAD � 3. Percent Taxable 3 X � 4. Amount Subject to Tax 4 $ 2 3 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 $ 5 7. Ta�c Rate 7 X 6 � 8. Tax Due 8 $ � g 1 9. With 5% Discount(Tax x .95) 9 X ? Step 2: Sign and date below. Return lW0 completed and signed copies lo the Register ot Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable lo"Register of Wills,Agent" Do not send payment directly to the Department of Revenue. Under penalty of perjury, 1 declare that the tacts I have reported above are true,correct and complete to Ihe best of my knowledge and belief. WOrk �su `�! °��z�Z�vS�r�. Home `7/ 7 �.3L e5:v6 / .9Z��Z-°1.'> � Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 euR�,u oF INDIVIDUAL TAXES Pennsylvania lnheritance Tax ��' pennsylvania PD BOX 200601 �� DEPARTMENTOFREVENUE HARRiSBURG PA 17128-0601 Information Notice x[v-�s<s cx m�e�EC �oe-ix� And Taxpayer Response FILE NO. 6770 ACN 13105946 RE ORD�D OFfICE OF DATE02-06-2013 RE6ISTE� OF ��iLLS ��13 FEB 2� P� � �q TypeofAccount �stalSof LAURA R SHOAFF Savings SSN Checking GLERK QF DateofDeath01-28-2013 x T�ust EVERETT E SHOAFF ORPHANS� Cd��ntyYORK CertifiC2t2 132 SPRING RD DILLSBURG PA 17019-9352 C�UR4BERLAMD CO.. �A MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.272725 Date Estabiished 04-06-2011 REGISTER OF WILLS Account Balance $8,987.43 45 NORTH GEORGE STREET Percent Taxable X 50 YORK PA 17401-1240 Amount Subject to Tax $4,490J2 Tax Rate X 0.045 Potential Tax Due $202.08 NOTE': If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount(Tax x 0.95) $ (see NOTE`) due. Any inheritance tax due will become delinquent nine months after the date of death. PART St@p 1 : Please check the appropriate boxes below. 1 /+ �No tax is due. i am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potentia/Tax Due. g �The information is The above information is correct, no deductions are being taken, and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any othe�boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent, child, grandchild, etc.)of the deceased. (Select correct tax rate at right,and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as app�opriate on�he back ol this lorm. E�Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criterie: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof oi payment if requested by the department. (If additional space is required, you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 ,or Y 9 ( ) ( ) percent taxable(Line 3), please obtain a written correction from Ihe financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death, the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners =33.33%, 4 owners =25%,etc.) b. Next, divide the decedenYs percentage owned by the number oi surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting [he debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicatin a different tax rate, lease state � _ �� ' � � 9 P �Official Use OnI " your relationship to the decedent: 4� � � � � � y=�� '�-� � � �PA Department of Revenue�`'�"�,�� 1. Date Established 1 '�� ,� -�c��g �,; � �� ,� �`f� ,1��'��`'��rei`�'"�%�'`:�an��'�'�``��`kr"�`t��. "aF�:' 9kx 2. Account Balance 2 $ �A � � ��'�s+t��#w�a}�+��'s�ks:�'.�` .'a'�°�Z'�Frm+,��, . 3. Percent Taxable 3 X ' - , 2 „�""�`��'*�`�� °`r� n_ , � � ��r 4. Amount SubJect to Tax 4 $ � � � �s 3� '�'��t�^�,�$� �"�" �"�� a�"�� 5. Debts and Deductions 5 - 4,, ; ,�,�,�, �,r�� m�t;r ;; � 6. AmountTaxable 6 $ J� � �`��" �� ' 7. Tax Rate 7 X � :.+:�-A��'�`�'��n��°`�"�� v ``'�,�...$�.n��..m.� �� ,'��i�'�,�� : . . �S�'��"��x '�u�� 8. T� Due 8 $ � 9. With 5% Discount(Tax x .95) 9 X � �� ' � �� ..— ...,r,.—. � St@p 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. WOrk �`'�_z��.,�� Home 7/7' Y}�` ��d7 c? -9-, o/3 Taxpayer Signature �� Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 a�R�� oF INOIYIDUAL r�ES Pennsylvania lnheritance Tax ' � `� pennsylvania Po BoX 2B06o1 � � DEPARTMENT OF REVENUE HARRISBIIRG PA 1]128-0601 Information Notice "" ' ' REV�I543 EM UecEl(E[ t16-lt) And Taxpayer Response FILE NO.6770 ACN 13105948 D p F�� O F DATE 02-06-2013 REGtS7�CR OF ; P� ,, 59 Type of Account tU13 FEB 27 � Estate of LAURA R SHOAFF Savings SSN Checking CLERK �r DateofDeath01-28-2013 X Trust POCBOXD117SHOAFF ORPHpp�S' COURT COUntyYORK CBrtifiCate NEW KINGSTOWN PA vo�z-e�},,�BERLAN� ��•� PA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.212725 Date Established 04-06-2011 REGISTER OF WILLS Account Balance $g,gg�,qp 45 NORTH GEORGE STREET Percent Taxable X 50 � - . YORK PA 17401-1240 -- Amount Subject to Tax $4,490.71 Tax Rate X 0.045 Potential Ta�c Due $202.08 NOTE': If tax payments are made within three months of the decedenYs date of death, deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $ (see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART $tep 1 : Please check the appropriate boxes below. 1 /+ �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above information is correct, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent, child,grandchild,etc.) oi the deceased. (Select correct tax rate at right, and complete Part � �2=�o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropnate on the back of this lorm. E �Asset will be reported on The above-identified asset has been or will be reported and ta�c paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any otherboxes. Please sign and date the back of the form when finished. PART Debts and Deductions z Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proot of payment if requested by the department. (If additional space is required, you may attach 81/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 ,or Y 9 ( ) ( ) percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners= 50%, 3 owners =33.33%, 4 owners =25%, etc.) b. Next,divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4: The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate, please state O�CI�� l3S£O�ly Q AAF. your relationship to the decedent: ,. ,'. � � �}�-�g�g�{jjEX1#Of�18VBRUS ., � � 1. Date Established 1 ,. 2. Account Balance 2 $ ��+D � � > r 3. PercentTaxable 3 X n�'4 �� ' � � �� 'G :: \ .R�' $ � � , ��' , 4. Amount Subject to Tax 4 $ ,- ` 5. Debts and Deduc[ions 5 - � y� � �� 4 d " 2��, ~~-��'�� i 6. Amount Taxable 6 $ 5� 7. Tax Rate 7 X (�"�t c : � ��.'t a�a�: ��^�ar.�' " � � + : 3 �4" � :�4A%v'am,��-a�`�� Y' �� 1 r+�}i�' h a�, i„� 8. Tau Due 8 $ $ , , , . ' ac'xR q�g -. .. ._ ` " 9. With 5% Discount (Tax x .95) 9 X ,�,,,a,,..,k.....;�_...,.,,��,a,..x�d..,,.,„a,.�_.,:..:,'` ..��:' ..:i StBp 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. a Work �Li `�=t%Y/�i,l/ Home 7J��L� —�4�J� �Z�c?j�l� Taxpayer Signature � Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 BuR�au oF iNOiviouai TAXES Pennsylvania lnheritance Tax = � �� PennS�/�V81118 Po eaX 28D601 DEPARTMENT OFflEVENUE HARRISBURG PA 1�128-0601 Information Notice acv-�sas cx o«evec �ae-�z� And Taxpayer Response FILE NO. 6770 ACN 13105947 DATE 02-06-2013 , iv RE6tSTER pf k��,LS Type of Account �C13 FE8 27 P(1 ? Sg Estate of LAURA R SHOAFF Savings � SSN Checking CLERK Ot Date of Death 01-28-2013 x T�USt MAE K PETERSON CountyYORK Certificate 152D S MOUNTAZN RD ORPNANS� COURT DILLSBURG PA 17019e��ERLA�� CQ,� ('�Q MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: AccountNo.212725 Date Established 0406-2011 REGISTER OF WILLS Account Balance $g,gg�,qp 45 NORTH GEORGE STREET YORK PA 17401-1240 Percent Taxable X 50 Amount Subject to Tax $4,490.71 Tax Rate X 0.045 Potential Tax Due $202.08 NOTE`: If tax payments are made within three months of the decedenYs date of death, deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months after the date ot death. PART St@p 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potentia/Tar Due. g �The information is The above information is correct, no deductions are being taken, and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The tax rate is incorreci. � 4.5% I am a lineal beneficiary(parent,child, grandchild, etc.) of the deceased. (Select correct tax rate at right,and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as appropriate on the back of this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insu�cient to pay the deductible items. B. You paid the debls after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calcuiation $ PART Tax Calculation 3 If ou are makin a corcection to the establishment date Line t account balance Line 2 , or Y 9 ( ) ( ) percent taxable(Line 3), Flea�e obtain a written correction from the tinancial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the dale of death. 2. Enter the total balance o(the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners= 50%,,3 owners=33.33%,a owners =25%,etc.) b. Next, divide the decedenYs percentage owned by the number of surviving owners or beneticiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total o�any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracling the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate irom Step 1 based on your relationship to the decedent. If indicating a diflerent tax rate, please state � OfflCldl U52 O�ly �AAF � your relationship to the decedent: PA Department of Revenue 1. Date Established t 2. Account Balance 2 $ pAD � 3. PercentTaxabie 3 X � � 2 4. Amount Subject to Tax 4 $ 3 i 5. Debts and Deductions 5 - 4 I 6. Amount Taxable 6 $ 5 � 7. Tax Rate 7 X 6 8. Tau Due 8 $ 7 — _ i 8 9. With 5% Discount (Tax x .95) 9 X , _ � St@FD 2: Sign and date below. Return 7W0 completed and signed copies to the Register of Wills listed on the front of this torm, along with a check for any payment you are making. Checks must be made payable to"Regisler of Wills,AgenL" Do not send payment directly to the Department of Revenue. Under penalty of pery'ury, I declare that the facts I have reported above are true,correct and complete to the best oF my knowledge and beliet. WOrk �11a.L `�: ��-v Home `�/ y 43Z S�b I z��L-�73 � Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 a�R�� oF INOIVIUUAL TAxES � pennsylvania Po BoX �ea6a1 Pennsylvania lnheritance Tax HA2RISBURG Pa 1�128-0601 information Notice DEPARTMENTOf REVENUE And Taxpayer Response R`�„""�""",�' ��, FILE NO. 6770 ACN 13105955 RE C 0��E DATE 02-06-2013 REGISTER OF �4'ILLS Type of Account ��13 FEB 27 P� � 5�..�tate of LAURA R SHOAFF Savings SSN Checking G LE R K G F Date of Death 01-28-2013 x T�usc MAE K PETERSON ORPNANS' COURT CountyYORK Certificate 1520 S MOUNTAIN RD DILLSBURG PA i�oiv-sso4CUP46ERLAtdD CO.. PA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.212725 Date Established 04-'12-2011 REGISTER OF WILLS Account Balance $12,047.18 45 NORTH GEORGE STREET Percent Taxable X 50 YORK PA 17401-1240 Amount Subject to Tax $6,023.59 Tax Rate X 0.045 Potential Tax Due $271.06 NOTE': If tax payments are made within three months of the decedenYs date of death, deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $(see NOTE") due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potentia/Tax Due. g �The information is The above information is correct, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorreci. � 4.5% 1 am a tineal beneficiary (parent, child, grandchild, etc.)of the deceased. (Select correct tax rate at right, and complete Part � �p�, I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as appropriate on the back of this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet bolh of the(ollowing criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of ihe decedent and can furnish proot of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 0(Tax Calculation $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 ,or Y 9 ( ) ( ) percent taxable(Line 3), please obtain a written correction irom the financial institution and attach it to this form. 1. Enter the dale the account was established or[itled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "in trusl for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death, the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%,3 owners=33.33%, 4 owners = 25%, etc.) b. Next,divide the decedent's percentage owned by the number o(surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by ihe percent taxable. 5. Enter the lotal of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions irom the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate,please state � �� - —�� - -"--�" i your relationship to the decedent: OffiCi31 USB On1y ❑AAF PA Department of Revenue � 1. Date Established 1 2. Account Balance 2 $ PAD . 3. Percent Taxable 3 X � 2 4. Amount Subject to Tax 4 $ 3 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 $ 5 - 7. Tax Rate 7 X 6. . 8. Tax Due 8 $ � 8 � 9. With 5% Discount (Tax x .95) 9 x St@p 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent:' Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. WOrk �J1aA `7c' `�`'��sm✓ Home yly l��Z 5a6/ �7��73 Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 eua�,u oF INOIVIDOAL TAXES Penns Ivania lnheritance Tax :'� pennsylvania PO BO% 280601 Y HARRISBURG Pn 1�128-0601 Information Notice DEPARTMENTOF REVENUE And Taxpayer Response wEV-ua3 ex m�esec �ae-iz� FILE NO.6770 ACN 13105956 ��C� O� DATE 02-06-2013 REGIST�R OF �'�1LL � Type of Account :u13 FEB 27 P� � �9tate of LAURA R SHOAFF Savings SSN Checking EVERETT E SHOAFF CLERK �� CountfYORK01-28-2013 X Certficate 132 SPRING RD ORPHANS' COURT Y DILLSBURG PA 17019-9352 ��BERLAND C0.> PA MEMBERS isT Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: AccountNo.212725 Date Established 04-72-2011 REGISTER OF WILLS Account Balance $ 12,047.18 45 NORTH GEORGE STREET . YORK PA 17401-1240 Percent Taxable X 50 Amount Subject to Tax $6,023.59 Tax Rate X 0.045 � Potential Tax Due NOTE': If tax payments are made within three months of the $271.06 decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is -ihe above information is correct, no deductions are being taken,and payment will be sent ��correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent, child,grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � �pqa I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back ol this lorm. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following c�iteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach S 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter ihe total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death, the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners= 50%, 3 owners= 33.33%, 4 owners = 25/a, etc.) b. Next, divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. En[er the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a difterent tax rate, please state [Q{#j�jg(�]S2�111y �AAF your relationship to the decedent: � x }�,J��g�3ft�.(71�tit 4f ReVSflue -- �� 7. Date Established 1 �" � ` � �= ��';�`�.� � � 2. AccountBalance 2 $ P�� i 3. Percent Taxable 3 X ��h ' � _ "" � �� s � � � ' 4. Amount Subject to Tax 4 $ � � y � 5. Debts and Deductions 5 - z}� _�� , ,� �j.��m« � �y;- � , :� „ , 6. Amount Taxable 6 $ � 7. T� Rate 7 X �� , �' � �., �� "�*�rk9 x .,�, � �- , a s- �' -� ,a.� ` � 8. TaxDue 8 $ �" « �_ � $ ' ` - i 9. With 5% Discount(Tax x .95) 9 X � :�� Step 2: Sign and date below. Return TWO completed and signed copies to[he Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent." Do not send payment directly to the Department of Revenue. Under penalty of pery'ury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. ��/ Work ,��:�/ Home 7/7'S�3oZ��C�17 � Taxpayer Signature Telephone Number Datea,. „aQ/3 IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 6UREAU OF INOIVIOUAL TAXES .+ � ,� pennsylvania Po eox 280601 Pennsyivania lnheritance Tax HARRISBURG PA 17128-0601 Information Notice DEPARTMENTOF REVENUE And Taxpayer Response "� 154"�"""` "" '_' FILE NO. 6770 ACN 13105954 R E C 0 R D DATE 02-06-2013 REGIS7ER OF �Pd1LL5 Type of Account ?�13 FEB 27 P(� 3 59 Estate of LAURA R SHOAFF Savings SSN Checking C LE R K 0 F' Date of Death 01-28-2013 x rrusc RICHARD H SHOAFF ORPHANS� �d�R� CountyYORK Certificate PO BOX 117 NEW KINGSTOWN PA i�o��ggRLAND CO., PA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.212725 Date Established 04-12-2011 REGISTER OF WILLS Account Balance $ 12,047.18 45 NORTH GEORGE STREET . YORK PA 17401-1240 Percent Taxable � � �X 50 � � Amount Subject to Tax $6,023.59 Tax Ra[e X 0.045 Potential Tax Due NOTE': If tax payments are made within three months of the $2��.os decedenYs date of death, deduct a 5 percent discount on the tax With 5% Discount(Tax x 0.95) $ (see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART $tep 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above information is correct, no deductions are being taken, and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrecL � 4.5% I am a lineal beneficiary (parent, child, grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � �p�o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back o/this lorm. E �Asset will be reported on The above-identified asset has been or will be reported and ta�c paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of ihe foilowing criteria: - A. The decedent was legally responsible for payment,and Ihe esta[e is insu�cient to pay the deductible i[ems. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 81/2"x 11"shee[s of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), please obtain a w�itt¢n correction trom the tinancial institution and attach it to this form. 1. Enter the da[e the account was established or titled as it existed al lhe date of death. 2. Enter the total balance of Ihe account including any interest accrued at the date oi death. 3. Enter the percentage ot the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners=33.33°/,,4 owners =25%, etc.) b. Next,divide the decedent's percentage owned by ihe number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debls and deductions from the amount subject to tax. 7. Enter the appropriate tax rate(rom Slep 7 based on your relationship to the decedent. fl indicating a different tax rale,please state Official Use Only p,anF your relationship to the decedent: PA DBpartment of R2vertue � 1. Date Established 1 2. Account Balance 2 $ PAD . 3. PercentTaxable 3 x 1 2 4. Amount Subject to Tax 4 $ 3 � 5. Debts and Deductions 5 - 4 � 6. Amount Taxable 6 $ 5 j 7. Tax Rate 7 x 6 8. Ta�c Due 8 $ 7 . . 8 � 9. With 5% Discount(Tax x .95) 9 x — _ �____`� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the iront oi this form, along with a check for any payment you are making. Checks must be made payable to"Regisler of Wills,Agent" Do not send payment directly to the Department of Revenue. Under penalty oi pery'ury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and beliet. WOrk ' Home 7/ '-� ' -��F2 (3L o7 / Taxpayer Signature Telephone Number ate IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 BoR�,u oF �NO��o�,� Tnxes Pennsylvania lnheritance Tax � ' pennsytvania PO BOX 280601 DEPARTMENT OFpEVENUE HARRISBURG PA 1�328-0601 Information Notice And Taxpayer Response °E� ��°°Ex vo�exec uean FILE NO.6770 ACN 13105953 �E O R�} �-,� DATE 02-06-2013 �cisr�� oF �arrtits� Zf113 FEB 27 TrPe or n��o��t P� ,�i E�$�e of LAURA R SHOAFF Savings SS 199-07-3588 Checking CLERK 0'r Date of Death 01-28-2013 x rrUSc MAE K PETERSON ORPNANS� COURT ountyYORK Certificate 1520 S MOUNTAIN RD DILLSBURG PA 17019-8804 GU:A96ERLAND CO.,. pQ MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-�amed decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: AccountNo.212725 Date Established 04-12-2011 REGISTER OF WILLS Account Balance $12,047.18 45 NORTH GEORGE STREET Percent Taxable X 50 ' � � ' YORK PA 17401-1240 Amount Subject to Tax $6,023.59 Tax Rate X 0.045 Potential Tax Due $p7�,pg NOTE': If tax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax Wi[h 5%Discount (Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above information is correct, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild, etc.) of the deceased. (Select correct tax rate at right,and complete Part � �p% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as approp�iate on the back ol this form. E �Asset will be reported on The above-identitied asset has been or will be reported and tax paid with the PA Inheritance Tax nheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insutticient to pay Ihe deductible items. B. You paid the debts aher the death of the decedent and can turnish proof of payment if requested by the department. (If additional space is required,you may attach 8 7/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 ,or Y 9 ( ) ( ) percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage oi the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounis that are held"in trust for"another or others were 100%owned by lhe decedent. ii. For joint accounts established more than one year prior to the date of death,ihe percentage[axable is 7 00%divided by the total number of owners including the decedent. (For example:2 owners=50%,3 owners=33.33%, 4 owners =25%,etc.) b. Next,divide[he decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting ihe debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate irom Step 7 based on your relationship to the decedent. If indicating a different tax rate, please state OffiCial Use Only ❑AAF your relationship to the decedent: PA DepBrtment of RevenuB � 1. Date Established 1 � 2. Account Balance z $ �?AD 3. PercentTaxable 3 x 1 , 4. Amount Subject to Tax 4 $ 3 � 5. Debts and Deductions 5 - q 6. Amount Taxable 6 $ 5 7. Tax Rate 7 X 6 , S. Tax Due 8 $ � ' 9. With 5% Discount(Tax x .95) 9 X �8 � StCp 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front oi this torm, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agenl" Do not send payment directly to the Department of Revenue. Under penatty of perjury, I declare that the facts I have reported above are true,conect and complete to the besl of my knowledge and belief. WOrk �)� '7�• �H.S-m,i Home '7/'7 ¢31 SaG � L�7�Ld ! ', Taxpayer Signature Teiephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 BOREAU OF INDIYIOVAL Tnxes Penns Ivania lnheritance Tax ' �� " ^yennSY lvania PO BOX 280601 Y ' � • + NABRISBURG PA 1]I2B-0601 IflfOfllldtlOfl NOtIC@ - DEFAFTMENTOFREVENUE And Taxpayer Response "� „"`X°°""` `°'„' FILE NO.6770 �� ACN 13105952 DATE 02-06-2013 � RE6ISTER OF 4'9iLLS Type of Account 7013 FEB 27 ��N� X Trust RICHARD H SHOAFF CLERK 6buntyYORK Certificate PO BOX 117 NEW KINGSTOWN PA 17072-0117 ORPHAtdS� COURT C"UMBERLARD C9., PA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: AccountNo.212725 Date Esiablished 12-13-2010 REGISTER OF WILLS Account Balance $6,895.07 45 NORTH GEORGE STREET PercentTaxable X 50 YORK PA 17401-1240 Amount Subjeci to Tax $3,447.54 Tax Rate X 0.045 Potential Tax Due $155.14 NOTE`: If tax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5%Discount (Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tar Due. g �The information is The above information is correct, no deductions are being taken,and payment will be sent b�'correct. with my response. Proceed to Step 2 on reve�se. Do not check any oiher 6oxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child, grandchild, etc.) of the deceased. (Seteci correct tax rate at right, and complete Part � �p�a I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as appropriate on the back ol this form. E (�Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax v'inheritance tax form Return fited by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid[he debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 81/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), please obtain a wr.tten correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First, determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death, the percentage taxable is 100%divided by the total number of owners including the decedent. (For example: 2 owners=50%, 3 owners=33.33%, 4 owners =25%,etc.) b. Next,divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate,please state s ` ` Offj��gj 1JSe;QqJ�+ �ppF�,, ��, �. 't �2, your relationship to the decedent: ,' � � "'� � , ,� a PA t�epartrroent ofi Revenue 1. Date Established 1 �'�� " ,�� ,�� 2. Account Balance 2 $ p��'�; �� '_ '� _ 3. Percent Taxable 3 X �;; �� °� a � '"$'-� Y �tw� �� $ � �+c ��.} � ntk� TA .. '"' �'+'»K�k$�`� 4. Amount Subject to Tax 4 $ � "�� — - 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ �? �� ,. ..k � _ 7. Tax Rate 7 X � � a� � :�f , ,�, �`� ��r��;a,{�:�a��.,P�°��`�+��'��3��'��;�=� � S. Tau Due 6 $ � ��s �+�y��.�a-�� 9. With 5% Discount(Tax x .95) 9 x � .,; . .. . ..; . �. .. .;,.�..<:.... . ... .:. . ..::.�, .:.-..... _- Step 2: Sign and date below. Re[urn TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent" Do not send payment directly to the Department of Revenue. � Under penalty of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. WOfk / � Home )I �—�v � �2 UL OJ � Taxpayer Signature Telephone Number ate IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 BUREAU OF INOIVIDUAL rnXES Penns ivania lnheritance Tax -�- � � DennSV lvania PD BOX 280601 Y • + HARRISBURG PA 17128-0601 IllfOffT7HtIOlI NOtIC2 ' DEPARTMENTOFREVENUE And Taxpayer Response "� """°°""` `°° '�, FILE NO.6770 ACN 13105951 p E p 0�F i C E 0 P DATE 02-06-2013 RE6ISTER OF �l1LLS 2013 FEB 27 �� y �� Type of Account Estate of LAURA R SHOAFF Savings SSN Checking CLERK 4F Date of Death 01-28-2013 x rr�s� MAE K PETERSON t YORK Certificate 1520 S MOUNTAIN RD ORPHANS� CG �Y DILLSBURG PA 17019-8804 G�t�I�M�BERLANb CQ., P�t MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.212725 Date Established 12-13-2010 REGISTER OF WILLS , Account Balance $6,895.07 45 NORTH GEORGE STREET PercentTaxable X50 YORK PA 17401-1240 Amount Subject to Tax $3,447.54 Tax Rate X 0.045 Potential Tax Due $ 155.14 NOTE': If tax payments are made within three months of the decedenYs date of death, deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tar Due. g �The information is The above information is correct, no deductions are being taken, and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child, grandchild,etc.) of the deceased. (Select correct tax rate at righ[,and complete Part � 1 p�o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as appropriate on the back ol this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-7 500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required, you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First, determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For join[accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners= 33.33%, 4 owners =25%, etc.) b. Next,divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject lo tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship ro the decedent. If indicating a different tax rate,please state �'at��,��C)�Ci31 �752 011Iy�i�AF� '��„ ' your relationship to the decedent: �� t*��, # '' '� h.� � � v „_ � � ,�,P, De�arimen#of Aeaeraue ,�� 1. Date Established 1 ��?,'t�� ,�ri�,��'��`° s: ��' � a 2. Account Balance 2 $ p�� .��+� .,. -��r,�� ' �� 3. PercentTaxable 3 "' "�� u� � � �' °� � ' X � � ,: � �;_.,; �•�'�_� ' ' . 4. Amount Subject to Tax 4 $ �� . ��.��r��`� �'�� 5. DebtsandDeductions 5 - 4 ��'� :� '� 2��" ° 6. Amount Taxable 6 $ �, ` �� X � � ..s� 7. Tax Rate 7 � � : ° �� ,� S. Tax Due 8 $ �+ �w � 8 ��a� : ;��t;��- �� 9. With 5% Discount (Tax x .95) 9 X �' "� �� .aaa:,w.x _ °° ,� cJtep 2: Sign and date below. Return TWO completed and signed copies to the Register of Wilis listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent" Do not send payment directty to the Departmeni of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work `/�-az-`�C�'. '�z�tr�-cri Home -7/ 7 -tI �Z -� o�l L�?�z-v 1.3 Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 BI/REAU OF IND7VIOUAL TAXES Penns Ivania lnheritance Tax �� f� ^■/ennS�/lvania PO BOX 280601 y �� f J HARRISBURG PA v126-o6a1 IllfOffTla(IOfI NOtICO � OEPARTMENTOFREVENUE And Taxpayer Response "`" „"`"o.�eacc �oe-�x� FILE N0.6770 � � � � �� ACN 13105951 DATE 02-06-2013 RECORDED OFFi� REGISTEft OF 4�l��S TypeofAccount st f LAURA R SHOAFF Savings ��13 FEB 27 ?(rl '�sr�� Checking Date of Death 01-28-2013 X Trust MAE K PETERSON - GLERK C� COUntyYORK Certificat2 1520 S MOUNTAIN RD DILLSBURG PA 17019-8804 ORPHAtdS� COU�T GUMBERLAMD CO., Pl� MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. AccountNo. 212725 Remit Payment and Forms to: Date Established 12-13-2010 REGISTER OF WILLS Account Balance $6,595.07 45 NORTH GEORGE STREET . Percent Taxable X 50 YORK PA 17401-1240 Amount Subject to Tax $3,447.54 Tax Rate X 0.045 Potential T� Due $ 155.14 NOTE': If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax With 5%Discount (Tax x 0.95) $ (see NOTE') due. Any inheritance tax due will become delinquent nine monihs after the date of death. PART St@p 1 : Please check the appropriate boxes below. 1 . /+ �No tax is due. 1 am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potentia/Tax Due_ g �The information is The above information is correct, no deductions are being taken,and payment will be sent correc[. with my response. P�oceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent, child, grandchild, etc.) of[he deceased. (Select correct tax rate at right,and complete Part � �2% I am a sibling of the deceased. 3 on reverse.) � 75% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back o/this lorm. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Retum filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets ot paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), pleace obtain a writte�correction from the financial institution and attach it to this torm. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the to[al balance of the account including any interest accrued at the date of dea[h. 3. Enter the percentage of the account that is taxable to you. a. First,determine Ihe percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage tauable is 100%divided by the total number of owners including the decedent. (FOr example:2 owners=50%, 3 owners=33.33%, 4 owners =25%a, etc.) b. Next, divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate, please state t�" �" fliflC�a1 l)SB(3�Iyr�,4AF�� ,�� j your relationship to the decedent: 4.��;„� � � ,p/��gpg��pgl3t Of�381%eTIUB�`�i' ��'_ 1. DateEstablished 1 � �,��''�° ��, =.�'y',��s��'�� 2. Account Balance 2 $ ��"� � � �� w"� " �'� �a� �`,�.?=� � ''a�,wz*�- ,�, b� � _ ,� n�.a., . 3. PercentTaxable 3 x , ��"' a� �� ,�'�� ;;�5'��r�` , _'.'�,k � <.� ,� °.' � ' �*:: 4. Amount Subject to Tax 4 $ �, �° �? ��,�� =� . P � �� 5. Debts and Deductions 5 - 4 ` '� ' '` `'` ` ' ° � � . �` '� �7� � 6. AmountTaxable 6 $ � �<�; �'��y�� *;�� 7. Tax Rate 7 X ��, ` u { �, y��' , � :[��i�� r��k��u�� ` _. 8. T� Due 8 $ $" � "a,��'..: � � �`�,� 9. Wlth 5%Discount(Tax x .95) 9 X �� .µ��'.:� ..-•..._ ,-. . ':'--'..�... .-_,' ..�: . St@p 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent" Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. Work �7',fir.� `t�.'��e%c�-./ Home `71 7 - '� �L — o7LY(C I Z�� Z�7 '� Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 � B�R�,� oF INOIVIOUAL TAxes Penns ivania lnheritance Tax � � `.`` pennsylvania PO BO% 280601 ' Y ." DEPARTMENT OFREVENUE HARRISBURG PA 1]128-0601 Information Notice q¢vasae sx oe.e�ec ioeaa And Taxpayer Response FILE NO.6770 ACN 13105950 DATE 02-06-2013 RE61STEit OF i�1LLS Type of Account I013 f EB 2 7 P(� 4 �tate of LAURA R SHOAFF Savings N Checking CLERK OF Date of Death 01-28-2013 x Trust EVERETT E SHOAFF CountyYORK Certificate 132 SPRING RD ORPNANS' COURT DILLSBURG PA i�oi9-9as2GUM8ERLAMD CO., PQ MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.212725 Date Established 12-�3-2010 REGISTER OF WILLS Account Balance $6,895.07 45 NORTH GEORGE STREET • YORK PA 17401-1240 Percent Taxable X 50 Amount Subject to Tax $3,447.54 Tax Rate X 0.045 NOTE': If tax payments are made within three months of the Potential Tax Due $ 155.14 decedent's date of death,deduct a 5 percent discount on the tax With 5% Discount (Tax x 0.95) $ (see NOTE') due. Any inheri[ance tax due will become delinquent nine months after the date of death. PART $t@p 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other 6oxes and disregard the amount shown above as Potential Tax Due. g i��The information is The above information is correct, no deductions are being taken,and payment will be sent '�`�'correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent,child, grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � �p�/ I am a sibling of[he deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes o�deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this lorm. E ��,Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return tiled by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible tor payment,and the estate is insufficient to pay the deductible items. B. You paid the debts afler the death of the decedent and can furnish proo(of payment if requested by the depaAment. (If additional space is required,you may attach 81/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Tolal Enter on Line 5 of Tax Ca�culation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued al the date of death. 3. Enter the percentage of the account that is taxable to you. a. Firsl,determine the percentage owned by the decedent. i. Accounts that are held"in trusl for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date o(deaih, the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners=33.33%, 4 owners =25%,etc.) b. Next, divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter ihe total of any debts and deductions claimed from PaR 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter ihe appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate, please state Official Use Only ❑AnF —' your relationship to the decedent PA Dep8rtm@nt Of R@v8nU0 7. Date Established 1 I 2. Account Balance 2 $ PAD � 3. Percent Taxable 3 x � ! 2 4. Amount Subject to Tax 4 $ 3 � 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 $ 5 7. Tax Rate 7 X 6 _ , , 7 . � 8. Tax Due 8 $ $ � 9. With 5% Discouni(Tax z .95) 9 X __-_ � —_.t St@�3 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,AgenL" Do not send payment directly to the Department of Revenue. Under penalty ot perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work Home 7�7- y3�- 9B� Taxpayer Signaiure Telephone Number Datea_rJ 3 IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 BUftEAU OF INOIYIDUAL rpXES Penns Ivania lnheritance Tax ': ��-;� PennS�/LVa1118 - Po eox zaoso� y HARRIS6URG PA 1�128-0601 Information Notice OEPAFTMENTOFREVENUE And Taxpayer Response aE° ��°Ex oe�czcc �oe-iz� FILE N0.6770 ACN 13107270 DATE 02-74-2013 RECORDED QFFICE OF REGISTER OF �`aiE.LS TypeofAccount Estate of LAURA R SHOAFF Savings 10i3 FEB 27 P� � �N Checking ate of Death 01-28-2013 X Trust MAE K PETERSON CountyYORK Certificate 1520 S MOUNTAIN RD CLERK OF DILLSBURG PA 17019-8804 ORPHANS' COURT CU�ABERLAND GO., PA. CEN7RIC BANK provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No.3021627 Remit Payment and Forms to: Date Estabiished 0&05-2008 REGISTER OF WILLS Account Balance $ 10,032.75 45 NORTH GEORGE STREET YORK PA 17401-1240 Percent Taxable X 33.333 Amount Subject to Tax $3,344.02 Tax Rate X 0.150 Potential Tax Due $501.60 NOTE': If tax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5%Discount (Tax x 0.95) $ (see NOTE") due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. a I�The inf�rmatinn is ThP above information is correct, no deductinnc 2re heinc�taken,and paym?nt will bP sen? correct. with my response. � Proceed to Step 2 on reverse. Do not check any other boxes. � The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent, child, grandchild, etc.)o�the deceased. (Select correct tax rate at right, and complete Part � �p� I am a sibling of the deceased. 3 on reverse.) . � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as appropriate on the back of this lorm. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax `�'Inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 ,or Y 9 ( ) ( ) percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First, determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners =50%, 3 owners=33.33%,4 owners = 25%, etc.) b. Next, divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from[he amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate, please state flffacial Use Only'p nAF � '�"' your relationship to the decedent: �' , � *•*--� �� 1. Date Es[ablished 1 � ' P�'��e��RSV'2tlU6�i��'� : 2. Account Balance 2 $ PA�.� �� . 3. PercentTaxable 3 X '1� � y,°; �� _ „ ,;. ,:. +� 2 '�"`� .. : �:'�;_,.. , -., ��' ,. .��r �, 4. Amount Subject to Tax 4 $ �" ��° �, � _ y , 5. Debts and Deductions 5 - �� 6. Amount Taxable 6 $ � u � � ��q� �'� ��i.. �� , a -.- '�? 9A�' ��1'��'� .� 7. Tax Rate 7 X S ��?�5ra�d� �� .i��.�i;�� 8. Tax Due 8 $ -� �-� � �� 9. With 5% Discount Tax x .95 9 $ � � �� '.�� ( ) X �_s.�.a�:u�iris�.,��;y a�.-r�c. � - St@p 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payabie to"Register of Wills,Agent." Do not send payment directly lo the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work �7�J:��rt�-N/crrJ Home 71� �3z So (� I ,Z�IS, z o I Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 BUftEAU OF IND7VIDUAL TAxES Pennsylvania lnheritance Tax -� � = PennS�/LVd1118 PO BOX 280601 � NaRRISBURG PA 17126-0 6 01 IllfOf1118t1O11 NOtIC@ � DEPARTMENTOFREVENUE ' ---- ---� vevasae ex m.exec �oeaa And Taxpayer Response FILE NO.6770 ACN 13107272 I C E O� DATE 02-14-2013 RE6ISTER UF :�I�LS ;?013 FE8 27 P�l 3 58 TypeofAccount Estate of LAURA R SHOAFF Savings . SSN Checking RICHARD H SHOAFP CLERK OF CountyYORK01-28-2013 X Certficate Po aox ii� ORPhANS' GOURT NEW KINGSTOWN PA i�o��,pg�RLAtdd CO., PA CENTRIC BANK provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: AccountNo.3021627 Date Established 0&05-2008 REGISTER OF WILLS . Account Balance $ 10,032.15 45 NORTH GEORGE STREET YORK PA 17401-1240 Percent Taxable X 33.333 Amount Subject to Tax $3,344.02 Tax Rate X 0.150 Potential Tax Due $501.60 NOTE*: If lax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5%,Discount (Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART St@p 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 27 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potentia/Tax Due. g �The information is The above information is correct, no deductior.s are beir.g taken, 2nd paymer.t will be sent carrect. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. �"�The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent,child,grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � �z% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as app�opriate on the back of this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax nheritance[ax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART 2 Debts and Deductions Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient lo pay the deductible items. B. You paid lhe debts after ihe death of the decedent and can furnish proof of payment if requested by the depaRment. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Caiculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 , or Y 9 ( ) ( ) percent taxable(Line 3), please obtain a written correction trom the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of[he account that is taxable to you. a. First,determine ihe percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the tolal number of owners including the decedent. (For example:2 owners=50%,3 owners=33.33%,4 owners =25%,etc.) b. Next,divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from PaR 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a ditterent tax rate,please state OffiCial Use Only �AAF �� your relationship to the decedent: PA Department of Revenue I 1. Date Established 1 i 2. Account Balance 2 $ PAD 3. Percent Taxable 3 X � 4. Amount Subject to Tax 4 $ Z 3 5. Debts and Deductions 5 - 4 6. Amount Taxable 6 $ 5 7. Tax Rate 7 X s � 8. Tax Dua g $ � 8 9. With 5%Discount(Tax x .95) 9 x � �� St@p 2: Sign and date below. Return TWO completed and signed copies to ihe Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wilis, Agent." Do not send payment directly to the Department of Revenue. Under penalty of pery'ury, I declare ihat[he facts I have reported above are true,correct and complete to ihe best of my knowledge and belief. / � WOrk Home ( 6 7 f3 _2 � Taxpayer Signature Telephone Number D te IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 BURFAU OF INDIVIDUAL TaXES Pennsylvania lnheritance Tax � �� pennsylvania PO BOX 280601 + pEPARTMENT OFREVENUE HARRISBURG PA 1�128-0601 Information Notice � AIIC� T3Xp3y0f R2$4JOIl$B ... xEV-�son Ex oo�eKec �oe-�x� FILE NO.6770 ACN 13107271 RECQRDE OFFICE OF� onTEO2-ia-2ois EGISTER 0� t�ILLS Type of Account 1013 Fi8 2� P� � Sg Estate of LAURA R SHOAFF Savings SSN Checking CLERK 0� Date of Death 01-28-2013 x TrUSt EVERETT E SHOAFF ORPHANS' COURT CountyYORK Certificate DILLSBURGGPAD17019-��BERLAND CO., PA CENTRIC BANK provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: AccauntNo. 3021627 Date Established 08-OS-2008 REGISTER OF WILLS . Account Balance $ 70,032.15 45 NORTH GEORGE STREET _ YORK PA 1 7401-1 240 Percent Taxable X 33.333 Amount Subject to Tax $3,344.02 Tau Rate X 0.150 Potential Tax Due $501.60 NOTE': If tax payments are made within three months of the decedent's date of death,deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $ (see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART St@p 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The ahove information is corrert, no deductions are being taken,and payment wil! be sen? correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent,child,grandchild,etc.) of the deceased. (Select correct tax rate at right, and compie[e Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Retum filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PA�T Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach S 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If ou are makin a correction to the establishment date Line 1 account balance Line 2 , or Y 9 ( ) ( ) percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this torm. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage ot the account that is taxable to you. a. First, determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 700%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners =33.33%, 4 owners = 25%, etc.) b. Next, divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate,please state ` : � Q��J (JSg��r �pqF�x ; ,��„ your relationship to the decedenC ' �, „� a�� F' �A�Departm�nt of Revenus�� 1. Date Established 1 � � � �� t ; 2. Account Balance 2 $ P�� : � " �' � ��"`'�"��"� `�'� "`��,-�++ �� '`�' ��, 3. Percent Taxable 3 X ��Y �� $��.��.��„�� 4. AmountSubjecttoTax 4 $ � �q �� ,r � -�--� �� '' � �� :�� 5. Debts and Deduc[ions 5 - t} �. �.,�.� ,��,� .�:��Ft ,� 6. AmountTaxable 6 $ 5�� `'�� '�"�� "��.�� 7. Tax Rate 7 X � � �� '�'� ��` � � °. TflX Du2 E $ � '�� ' i � :��',t�`��bt'�i'w�� "„��"� � 8 . �€� ��,��` °"�?�'�"s`� 9. With 5% Discount(Tax x .95) 9 X - - St@p 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty ot perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. � Work ��<� �Zt�OiG�-�-'� Home +�/�7 '�.7� �'S�LI`7 .�2 /�/ ,?�i 3 , axpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 . _ c;L.ativi�wuivuNisncanvrurrx� - �� P.O.Box 1937 Carmel.IN 46082-1937 (800)6213724 February 20, 2013 For local Service, contact: Mae K Peterson Hranch Sales Office 1051 1520 S Mountain Rd 1215 MANOR DR- STE 300 Dillsburg PA 17019 MECHANICSBURG, PA 17055 Phone: (717) 791-2100 Agent: NONE Insured: Laura Shoaff __ . _ _, ..Contrac_t_ Number: . 7583422 Dear Mae K Peterson We again wish to extend our deepest sympathy to you and your family for your recent loss. Your claim on the- above mentioned contract has been approved and processed. The benefits have been calculated as follows: � - �Death Benefit $30, 543.731�_ Your Share -- ��0,181 .25 Taxable Amount $ 6, 341 ,25 f_---� Eederal Tax Withholding $ 634.13 State Tax Withholding " $ 634.12 Final Benefit Amount $ 8,913.00 A Form 1099-R will be mailed at the end of this tax year for the taxable amount . We realize that the period following such a loss is a difficult time for individuals and families and we are committed to providing you with the best possible service. If you have any questions regarding your claim, please contacC �tir office a� the number above.- - Sincerely, Annuity Claims Department BLC0311 9EJ �� BLQPB . _ _ BUREAU OF INDIVIDUAL TAXES y �� pennsylvania ro Box zao6o� Penns Ivania lnheritance Tax � � ,;� HARRISBURG Pq 1�128-U601 Iflf01'fl'18CIOil NOtIC@ OEPARTMENTOF REVENUE And Taxpayer Response "°""' "°°""` `°° ", FILE NO. 6770 ACN 13105941 EC4R�� OF:=IGE OF DATE02-06-2013 ftEGISTE�t OF !?ILIS 1013 FEB 27 Pf� ? �9 TYPe of Account st�4e o AURA R SHOAFF Savings SSN Checking CLERK �ate of Death 01-28-2013 x Trusc MAE K PETERSON � }y YORK Certificate 1520 S MOUNTAIN RD ORPHANS� C�tYRi DILLSBURG PA 17019-8804 CUMBERLAND CO., PA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No.212725 Remit Payment and Forms to: Date Established 08-04-2011 REGISTER OF WILLS Account Balance $5,993.95 45 NORTH GEORGE STREET Percent Taxable X Sp YORK PA 17401-1240 Amount Subject to Tax $2,9g6.98 Tax Rate X 0.045 Potential Tax Due $ 134.86 NOTE': If tax paymeMS are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $ (see NOTE`) due. Any inheritance tax due will become delinquent nine months after the date of death. PART Ste 1 : Please check the a � P ppropriate boxes below. A �No tax is due. 1 am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g�The information is The above information is correct, no deductions are being taken,and paymen[will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent,child,grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � �2% I am a sibling of the deceased. 3 on reverse.) � 15% All o[her relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and paR 3 as appropriate on the back of this/orm. E f�/ Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax �'='inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deduc[ible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required, you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account[hat is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners =50%, 3 owners=33.33%, 4 owners =25%, etc.) b. Next, divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amoun[subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. �:. � If indicating a different tax rate, please state �e�i� ��i)#fICI81 US2 Oilly �AAF,� ,x,"� your relationship to the decedent: * '� �. .PJ� D@PHft(1'12�tt O#.R8V217UB��: � ��, 1. DateEstablished 1 �' `� t�4*, ��,��;� �+��s��,�,�„� __ . 2. Account Balance 2 $ ' " '` . _ PAD �$ X P , �+� � z ,:� � . ��'��°<� 3. Percent Taxable 3 `� � :i � � 4. Amount Subject to Tax 4 $ �� ,.r� � �,�'�.�m�'� ��s,� ,.�. 5. Debts and Deductions 5 ' 9; ��' " ` � " ` $:� ; �' � �� s�� 6. Amount Taxable 6 $ �. � `�"�`"'j� '�'� ' �,��°�� -+��,,,.�� . ,'�iEr {�sr'�,�� -a . s.. �,i. 7. Tar Rate � X �:. :.. � ��-�v..�,�c rfr.�a�ab'�,.a�� +s: ,��°.'� 8. Tax Due 8 $ « �' i'� "�" "' "� „ ".� $� ' " ,°3_� � ��'��.$:��¢5`� , _ �"�,��;.�..*�-�-� 9. With 5% Discount(Tax x .95) 9 X 4` :' � , : . _,,.: ,, , St@p 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent" Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work �r1tLe `� `� f1.�c/a2w Home 7�7 - �� L- ��'-to ! 1.�7 �ZoI , Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 � BUREAU oF INOIVIOUAL r�ES Pennsylvania lnheritance Tax �� `�' pennsylvania PO BOX 2806U1 HARRISBURG PA 1]I28-0601 If1TOffTIatIO11 NOtICB ' DEPARTMENT OF REVENUE And Taxpayer Response "`"'°"`"°°"`E"°° "' FILE NO. 6770 ACN 13105942 DATE 02-06-2013 REGlS7ER OFrk�)LLS Type of Account �u13 FEB 27 p(� 3 59 Esrate of uauRa R sHOAFF sa�;,,gs SSN Checking CL�RK flF CountyYORK�� 282013 X Trust EVERETT E SHOAFF Certificate 132 SPRING RD ORaHA�S� GOURT DILLSBURG PA 17019-9 �MBERLAND C�7., pq MEMBERS i sr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No.212725 Remit Payment and Forms to: Date Established OS-04-2011 REGISTER OF WILLS Account Balance $5,993.95 45 NORTH GEORGE STREET Percent Taxable X 50 VORK PA 17401-1240 Amount Subject to Tax $2,ggg.gg Tax Rate X 0.045 Potential Tax Due $ 134.86 NOTE': If tax payments are made within ihree months of the With 5% Discount Tax x 0.95 decedenYs date of death,deduct a 5 percent discount on the tax ( ) $(see NOTE") due. Any inheritance tax due will become delinquent nine months after the date of death. PART St@p 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above informa[ion is correci, no deductions are being taken,and paymant will be sen: correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent,child,grandchild,etc.)of the deceased. (Select correct tax rate at right, and complete Part � �p�, 1 am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this lorm. E I X I Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax S�inheri[ance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1) account balance(Line 2),or percent taxable(Line 3), please obtain a written correction irom the financial insiitution and attach it to this form. 1. Enter[he date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to Ihe date of death, the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners=33.33%, 4 owners =25%, etc.) b. Next, divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step i based on your relationship to the decedent. If indicating a different tax rate, please state a �f#lCIa1 U58 Oflly,Q AAF �° your relationship to the decedent: � P}#pgpg�jj7teni Of R2v2ftL8 �' 1. Date Established 1 � � ��`��'�5.��,�� ' g � ��k ��n� � � � 2. Account Balance 2 $ �� , qg�,.'+` �` '� " °�a -a i� p '"j-T�"'�"'_°��,'rt* �v' �.'t �. .�` � �;� a�`$'w.��3�!. `�� . . a'_��'.:,�m,4 �. 3. Percent Taxable 3 x 2��,�a� t , r ��';� 4. Amount Subject to Tax 4 $ � '� � .�� ' s�a' ° ` `+'�'�"' � "'� ' ��CZ��#�.7?R�' �n -v �5?.' �'�'� '�"�% z 5. Debts and Deductions 5 - $�e; �.� � �fi�, ° £F ��rn,��, , # 6. AmountTaxable 6 $ �''�""� � � ° :_� � �'' � r��;rex��.��,"+�r a�.�5�'�`s� � �Y�ti '�c '�r ��i fi t 7. Tax Rate 7 x � , i��;��.��i s«� s r�+� r;,� s: 3. Tax DU° 8 $ u °``'a '"`�,�, �-,�„'�„xs :;��" "� �'�,:`_"-i�i� �'.�,1,5? $ �t .W. '�#i.�:;" _ h 9. With 5% Discount(Tax x .95) 9 X �� ''"" �� '��-�-'�--`` � St2p 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent" Do not send payment directly to the Department of Revenue. Under penalty oi perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. �. � Work ��L•.e•�•C-I� ��I��h�-l/�J Home 7/7- Y31- �'1&0'/" n2 - %- a o/3 Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 � ^ BURFAU UF INDIVIDUAL TnxES Penns Ivania lnheritanceTax ':� ��' ■lennsVlvania PO BOX 280601 y ,;� r J HARRISBURG PA 17128-0601 II�fOflll$Y1011 NOtIC@ ' DEPARTMENTOFREVENUE eEV-�s�3 Ev oe�cecc <oe-�z� And Taxpayer Response FILE NO. 6770 RECORDE[? �;r�=�� F DATE02-06-2013 r� r :: [ 10i3 FEB 27 �(� ; 5q Type of Account Estate of1AURA R SHOAFF Savings . c�Ep� ��SN199- �Checking ORFHAtd$• � ateofDeath01-28-2013 x Trusc MAE K PETERSON t�D�r�yYORK Certificate 1520 S MOUNTAIN RD CU"A96ERLAMO CO., P DILLSBUR6 PA 17019-8804 �] MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account No.212725 Remit Payment and Forms to: Date Established 08-04-2011 REGISTER OF WILLS Accoun[Balance $5,993.95 45 NORTH GEORGE STREET Percent Taxable X 50 YORK PA 17401-1240 � Amount Subject to Tax $2,996.98 Tax Rate X 0.045 Potential Tax Due $ �3q.gg NOTE': If tax payments are made within three months of the decedenPs da[e of dea[h, deduct a 5 percent discount on the tax With 5%Discount (Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine mon[hs after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or 1 am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on�eve�se. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The informa[ion is The above information is correct, no deduc[bns are being taken, and payinent will be sent correct. with my response. P�oceed to Step 2 on�everse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child, grandchild, etc.) of the deceased. (Select correct[ax rete at righ[, and complete Part � �2�e I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as appropriate on the back of this lorm. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Retum filed by the estate representative. REV-7 500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay[he deductible items. B. You paid Ihe debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required, you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. t. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners=33.33%, 4 owners =25%, etc.) b. Next,divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax ra[e from Step 1 based on your relationship to the decedent. If indicating a different tax rate, please state ,� �k h �? OffIC18) USB�illy �AAF � " �, a '� your relationship to the decedent: � �� `` °` �'�� `�`� PA�epa+tinento# Revenue� 7. Date Established 1 � � ' �� '� "� � - � �-'�� :> ��i,�,`'��c a�wb �e..� 2. Account Balance 2 $ �� "" �' �-3�%�'��'�F��w��,�e. „ ��.,; 3. Percent Taxable 3 X �� ' �-*�„�z � ,� � 4. Amount Subject to Tax 4 $ �. _ ��+��` �� K��+��.`�� :`� ��8 ��: �: � sr�� T 5. Debts and Deductions 5 - 4:� �q� �' ,� � _ . w,$�� v� � , Fv; : �2 ��`.WwU,�� }��NN�-_ H 6. Amount Taxable 6 $ k� ? ��k�� a��,}��`��-�'��'�� 7. Tax Rate 7 X �� x ��_�� `�� d4 ':��--".-'�.�"�` .:�a� 8. Tax Due 8 $ $ �'!� �, � �. �� = � ��`� � � o. , 9. With 5% Discount(Tax x .95) 9 X �'>- �^"+^� "+�' "" ...� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any paymen[you are making. Checks must be made payable to"Register of Wills,Agent" Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work yh�' � `� '°��+�Z,�c�t�.. Home —1 I 7 4-3 2 ci!t 61 ��7 �T f 3 Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 BUREAU OF INDIVIOUAL Taxes Penns Ivania lnheritance Tax �`� pennsylvania PO BOX 280601 y � Y HARRISBUkG PA 1�128-U6a1 If1fOYfTlatlOfl NOYICe ' DEPNRTMENT OF REVENUE And Taxpayer Response aE°�s°=`a oa�evec �ae-�a FILE NO.6770 ACN 13105944 _ �� DATE 02-06-2013 REGISTEf� UF �JILI_S Type of Account �?013 FEB 27 Pfl � S9 Es[ate of LAURA R SHOAFF Savings SSN Checking RICHARD H SHDAFF CLERK O�' CountyYORK01-28-2013 X Certficate Po sox ii� ORPNANS' CCllRi NEW KINGSTOWN PA 1707z��ERLAN6 CO.. PA MEMBERS isr Fcu provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No. 212725 Date Es[ablished OS-04-2011 REGISTER OF WILLS Account Balance $5,993.95 45 NORTH GEORGE STREET Percent Taxable X 50 YORK PA 17401-1240 Amount Subject to Tax $2,996.98 Tax Rate X 0.045 Potential Tax Due $ 134.86 NOTE`: If tax payments are made within three months of the decedent's date of death,deduct a 5 percent discount on the tax With 5% Discount(Tax x 0.95) $ (see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART St2p 1 : Please check the appropriate boxes below. 7 A �No tax is due. I am the spouse of the deceased or 1 am the parent of a decedent who was 21 years old or younger at date of death. P�oceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tar Due. g �The information is 7he above information is correct, no deductions are being taken,and payment will be sent correct. with my response. P�oceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent, child, grandchild, etc.) of the deceased. (Select correct tax rate at right, and complete Part � �2% I am a sibling of the deceased. ' 3 on reverse.) � 15% All other rela[ionships (including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete PaR 2 and part 3 as appropriate on the back of this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the es[ate represen[ative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PAR7 Debts and Deductions 2 Allowable de6ts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required, you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correCtion from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total halance of the account including any interest accrued at the date of tleath. 3. Enter the percentage of the account that is taxable to you. a. First,de[ermine the percentage owned by the decedent. i. Accounts that are heid"in trust for"another or o[hers were 700%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death, the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners=33.33%, 4 owners =25%,etc.) b. Next, divide the deceden['s percentage owned by the number of surviving owners or beneticiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate, pfease stafe �in°'° � �°OfflGidi USB 011ly [,3 qAF�� } � �� your relationship to the decedenY. �� ,_ �PA Dsp�rtrnenio#F�evenue=�� :r� 1. Date Established t �, t�a�. ��"`�"� � �r �,. ��, �� 2. Account Balance 2 $ P�� ;� �� '��"� U�''�a �� 3. Percent Taxable 3 X '� ° " 2 `� _ �"�� 4. Amount Subject to Tax 4 $ �x fa� �s�<� j, � � �� ; ��§��a�� ,� "� ��,'��": 5. Debts and Deductions 5 - ��: >�k a�i��= � �°� a :, � �5 �-.. d�".�U`�i?-�as�r,°��avs W�1P,��.}a��,��!�'�.`�"'��"`t'�z� 6. Amount Taxable 6 $ �; �pAg.�, �. f �.��4'�4e �'�� +'}hvy... ��k �s�S a. 7. Tax Rate 7 X �+ N �f� ;�,;_ , ��,,„ h ,�,�� t�,� �� 8. Tax Due 8 $ $, a ,z.��,�s;`±'�+`t�t� � ' t�"t' .. „�' 9. With 5% Discount(Tax x .95) 9 X '� - _ �-:;s,,,as,�a-�ac� - St2p 2: Sign and date below. Return 7W0 completed and signed copies to the Register of Wills listed on Ihe front of this form, along with a check for any payment you are making. Checks must be made payable to"Regis[er of Wilis,Agent" Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare[hat the fac[s I have reported above are true,correct and complete to the best of my knowledge and belief. � J ' , / Work �--Q.�/( �`� �� Home '7J 7� E 9�-�¢23 6z�c�'>�/3 Taxpayer Signature Telephone Number Dat� IF YOU NEED FURTHER ASSISTANCE, CONTACT YORK COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVtSION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 ,�-° .�ones Accounting Services 106 S Baltimore St Dillsburg, PA 17019 717-432-3746 February 7, 2013 � CONFIDENTIAL LAIJRA SHOAFF 132 SPRiNG ROAD DILLSBURG, PA 17019 717-432-5589 For professional services rendered in connection with the preparation of your 2012 individual tax return: Form 1040 (Individual Income Tax Retum)....................................................$ 125.00 Amount due $ 125.00 � - � ,. . Jat� d�a O�i �i Jheck# IO,� ,nitial --��