HomeMy WebLinkAbout09-17-13 � 1505610105
REV-1500 Ex,��,�,�F�, �,
enns Lvania OFFICIAL USE ONLY
PA Department of Revenue P„,,,,t„Y Counry Code Year File Number
eureau of IndividuatTaxes INHERITANCE TAX RETURN
PO BOX z8o6o1 /? � � � �(
Harrisburg,PA 1�128-0601 RESIDENT DECEDENT /'� I =' � � �'
� ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDOWYY Date of Birth MMDDYYYY
12/04/2012 08/17/1923
Decedent's Last Name Suffx DecedenPs First Name MI
Shaub Georgia A
Qf Applicable) Enter Surviving Spouse's Informatioa Below
Spouse's Last Name Suffix Spouse's First Name MI
N/A
Spouse's Social Sewriy Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original ReNm O 2 Supplemental ReNrn O 3. Remainder ReNm(Date of Death
Prior to 1&13-A2)
O 4. Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Retum Required
death after 12-12-82)
� 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Wilp (Attach Copy o�Trust.)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit(Date of Death O 1 L Election to Tax under Sec.9113(A)
Between 12-31-91 and L1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTE�T0:
Name Daytime Telephone Number
Michael Cherewka, Esquire (71 �F�232-4701 `
_..: �� _ ;
�:REGISTER OF WILLS USE ONCV
First Line of Address � � �- � �. - ..
624 North Front Street
Second Line of Address � �-�" . �
City or Post Off ce Siate ZIP Code "���" DAtE;���Ew� _.;
Warmleysburg PA 17043
Correspondene�s e-maii address: mcherewka@cherewkalaw.com
. Under penalties of perjury,I dedare that 1 have examined this retum,inctuding accompanying schedules and statements,and to the best af my knowletlge and belief,
it is true,c t and complete.D claration of preparer oNer than the personal representative is based on all iniormation af which preparer has any knowledge.
SIGN OF PER N PONSIBLE FOft FILING RETURN D E
L' -- � �'�/,3
nooRess
222 Lowt r Street, Lemoyne, PA 17043
SIGNA �F ppEP / ��THAN REPRESENTATNE Spq;TFy/�
�� �_ V fi!
AD E
624 North Front Street, Wormleysburg, PA 17043
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
� Lsos6lozos
REV-1500 EX(Fq
DecedenPS Social Secunty Number
._ .__ ..._. _..
oa�eae�r:Name: Georgia A. Shaub '
RECAPITULATION
1_ Real Eslate(Schedule A). . .. . ... ... ... ... .. .. ..... .. ... .. .. .. ..... .. . 1. 0.00
z. sro�ks and sonds�sonedu�e e) . ... ._. .. .. .. .... ....... . .. . . .. .. ._ . . z . 29,441.00 �'...
3- Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. .. . 3. 0.�0 '�..
4. Mortgages and Notes Receivable(Schedule D) .. .. ... .. .. ....... ... . .. ... 4. �'��. 0.00 '�..
5. Cash,Bank DeposiGS and Miscellaneous Personai Property(Schedule E).. . . .. . 5. '�. 1,057,�48.00 '..
fi. Jointly Owned Property(Schedule F) O Separate Billing Requested ... ... . & �� 0.00 ���;
.......___. ._._.......... .........__._ ,.__ ��.
7. IntervVivos Transfers&Miscellaneous Non-Probate Property ���
(Schedule G) O Separete Billing Requested_ ... . .. Z �'��, 298,282.00 �'���..
..._._.__.__.__...__...._..
8. Total Gross Assets(total Lines 1 through 7). ... . .. ... ..... .. ... . . .. .. ... 8. ; 1,384,871.62 '
9. Funeral Expenses antl Atlministrtative Costs(Schedule H).. ....... .... .. . ... 9. '��.. 97,129.00 '�..
. _..,_.�__..._.._..a._....._.......__,
10. Debts of Decetlent, Mortgage Liabilities and Liens(Schedule I).... ... ... .. .. . 10. � 51,793.00 �.
_...__ _. ._.__..__ . _
11. Total Deductions(total Lines 9 and 10).... .. ...... .. .. . .. ... .. .... .. .. . 11 '�.. 148,922.00 '��..
..__. ._... .._._. ..����.
12 Net Value of Estate(Line 8 minus Line 11) .. .... .. .. ..... . .. .. .. .. . . . .. . 12. 1,235,949.00 �'
73. Charitable and Governmenhai BequestslSec 9113 Tmsts for which "'" "" -��- - - .....�-...---___.
an election to tax has not been made(Schedule J) ..... .. . .. . .. .. .. . . .. .. . 13. ''��.. 247,190.00 �'��..
. _.,.__._......:
74. Net Value Subject to Tax(Line 12 minus Line 13) .. ... ._.. .... .. ..... .. . 14. � 988,759.00 �
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rete,or
transfersuntlerSec.9116 �-��- �-��� ����� ����� ����� ---- --- �� �..
(a)�t2)X-0 '�, 15. '��.
i6. AmountoF�inel4laxable ������ ����� ����� ���� -����� � ���"� ������� ������� ��.
at lineal rete X.0_ ��, � �g, � ��.
....__.... ..._.. ._.__ .. _____._ __._._. _.___.
17. Amoun}ofLine14taxable . � ��- ������ ��.
at sibling re[e X.12 '�� �7. � '..
_..__._.w _..._.. ._.__......... __.__.. __._... ___..__.____ ,. .,___. _. �
ta. Amount of Line 1a taxable �. ggg�759.00
af.collateral ra}e X.15 '�.. �g. 146,313.85 �.
. .._..._ -'--�.
is. raxoue _ .._ .. . _ ._. . _ .. ._ ._.. .. .. ... .. ._ is. 148,313.85 '
20. FILI IN 7HE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
L 1505610205 150561�2�5 �
REV-1 WO EX(P{) Page 3 Fiie Namber
DecedenYs Complete Address:
DECEDENPS NAME
Georgia A. Shaub
_ ---- _. �,._..
STREETADDRE"5S 6Y
Messiah Village, 10d Mt.Alien Drive
---
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Rayments and CrediEs:
1. Tax Due(Page 2,Line 19) (1) 148,313.$5
2. CreditslPayments �
APsiarPayments --- 181,156.Q4
8 Discount 7,415.69
T TotalCredits(A+8) (2) 188,571.69
3. Inlerest --�
(3}
A. If Line 2 is greatec thsn Line 1+Line 3,anter the difference. 7his is the OVERPAYMENT. ----� ---
Fill in oval pn Page 2,4ine 20 to request a refund. (4) 40,257.$a
5. tf!ine 1 k Line 3 is areater than Line 2,enter a�e difference.This is the FAX DUE (3) 4.40
Make check payable ta. REGISTER t7F WiL.�S,AGENT.
_.. ���:��w �:"��� . ` � ,�.. �aw"�`���i1��t�������.F . .�� �,. �
PLEASE ANSWER THE FQLLOWING QUESTI4NS BY PLACING AN"x"IN THE APPROPft1ATE BLOCKS
1. Did decedent make a transfer and: Yes No
a, retain the use or income of the property[ransferred........................................................._............................... ❑ �
b. retain the nght to desgnate wha shai,use ihe pro�rty Uaasferred or its income..........._._......................._._ ❑ �
c, ratain a reversionary interest......................_.......................................................,__...._,................................_ ❑ �
d. receive the pmmise for life of either payments,benefts ar oare?...................._...............................,,............... � �
i.. If death accurred after Dec.12,1982,did decetlent transfer propeAy within ane year of death
withaut receiving adequate consideratian?._.._............._...................._...,.._..._._._..................................___........ ❑ �
3. Did decetlent own an"in tmst for"pr payable-upan-death benk account or sewrity at his nr her dealh?............_ [� �
4. �id decadent own an individual retirement account,annuity pr other non•probate property,which
' cantains a beneficiary designation? .............._......_.._._..............__............. u �
1F THE ANSWER TO ANY OF THE ABOVE QUE5710NS IS YES,YOU MUST COMPEETE SCHEDULE G ANp FILE IT A5 PART OF THE RETURN,
5� t4���`��jt;'a'�:��5�,`���a� ___'�`S!"�,�r��'..�'�ir��;;�,�t���id����"��r�,_,it'� ;����"��'� � _' . . ��'�`
For dates af death on x after July 1,1994,and before Jan.7,1995,the tax rate im�osed on Lhe net vaiue pf trans{ers to or far the use tif the sunnving spouse
is 3 percent[72 P,S.§9116(a)(9.1)(i)).
For dates of tleath on or after Jan. t, 1995, the tax rate imposed on the net value nf Vansfers ko or for the use of the surviving spouse is 0 percen4
(72 P.S.§9'i&{a}{i.1)(i;j�.The statute doas nct exempf a trensfer ta a surviviny spouse from iax,and fhe sta#uiory requirements ic�r disdosure af assets and
6ling a(ax retum are sti�l applicab(e even iE the surviving spouse is tne onfy beneficiary.
For dates of death on or after July 1,2pp0:
. The tax rafe impas�d on the net value of fransfers from a deceased chitd 21 ysa5 af age or ya��nger at death to or for the use of a natural parent,an
adoptive parent ar a stepparent of the child is 6 percent[72 P.S.§911$(a){1.2j).
. The Cax rate imposed on the net value of transiers to or for fhe usP of the decetlenfs lineal beneficianes is 4.5 percent,except as noted in[72 P,S.§9116(2)(1)�.
• The tax�ate impased on the net vaiue of transfers to ar far the usa o;tna decedenC`s siblings'ss 12 percent[72 p.S.§9418(a}(1.3}�.A sfblietg is defined,
under Sec;ion 9f 02,as an indivi�ual who has st(east ore parerrt in common with t�e decedent,whether by blood or adoption.
REV-1502 EX+ (12-12)
�pennsylvania SCHEDULE A
DEPAqTMEINT�F REVENUE
IN„EarrAN�T,ixR��RN REAL ESTATE
RESIDENTUECEDEM �
ESTATE OF: FILE NUMBER: -
Georgia A. Shaub 2�-12-1296 "
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as che price at which property
would be exchangetl between a wiiling buyer and a wiiling seller,neither 6eing compelled to buy or sell,both having reasonable knowledae of the relevant facts.
_ Real property that is jointty-awned with riqht af survivorship must be disclosed on Schedule F.
�- Attacn a copy of the settlement sheet if the property has been sold.
TeM Indude a copy of the deed showing decedenCS interest if owned as tenant in mmmon. VA W E AT DATE
NUMBER I
DESCRIPIION OF DEATH
1. None
0.00
i
i
I
_ _ TOTAL (Also enter on Line 1, Recapitulation.) 5�� 0.00 �:
If more space is needed, use additional sheets of paper of the same size.
REV-i5o3 EX+L��x) .
�,�jpennsylvania SCNEDULE B
�� OEPARTMENi OF PEVENUE
'""ERn^"�E T�R�'�RN STOCKS & BONDS
RESIDENTDECEDENT . �
ESTATE OF . FILE NUMBER
Georgia A. Shaub 21-12-1296
All property jointly owned with right of survivorship mus[be disclosed on Schedule f.
ifEM
NUMBER DESCRIPTION � � llAWEA7DATE
OF DEATH
Frontier Communications Stock, 110 shares @ 4.69 per share 515.90
2 A T&T Stock,772 shares @$33.49 per share 25 55428
3 Verizon Stock,30 Shares @$43.17 per share 1,295.10
4 LSI Corporation, 1 Share @$6.73 per share 6.73
5 Comcast,48 Shares @$36.86 per share 1 76928
I
i
�— , `
TOTAL (Also enter on Line 2, Recapitulation) s � 29,44129
� If more space is needed,insert additional sheets oi the same size
.
REV-1507 EX+(�gg) �
SCHEDULE D
COMMONWEqLTH OF PENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESI�ENT DECEDENT � -
ESTATE OF FILE NUMBER
Georgia A. Shaub 21-12-1296
All property jointty-owned with rigM of survivorship must be disclosetl on Schedule F.
ITEM
NUMBER VAWEA7 DATE
_ �ESCRIPTION OF�FATH
1. None . .. . . ... . .. . . .. .. . . . . . . .
0.00
I
I
I
I
I
_ _ TOTAL(Also enter on line 4, Recapitulation) $ 0.00
(If more space is needed,insert additional sheets of ihe same size)
_ _
REV-i5o8 EX+(u8-a)
�,�jpennsylvania SCHEDULE E
;�11 oeanarMeNroFReveNUe CASH, BANK DEPOSITS & MISC.
I""E"nq"`ET�R�r""" PERSONAL PROPERTY
RESIDEM DECEDENT
ESTATE OF:
FILE NUMBER:
Georgia A. Shaub 21-12-1296
inctude the proceeds of litigation and the date the proceeds were received by the esta[a �
All property jointly owned with right of survivorship must be disclosed on Schedule F.
[TEM
NUMBER DESCRIPTION VALUE AT DATE
Of DEATH
1. � Rowe Pnce Mutual Fund,Account#200317351-0, New Horizons Fund,850.342 shares 30,946.94
Z. T. Rowe Pnce Mutual Fund Account#200311351-0,Price Reserve Fund,63649.25 Shares 63 65021
3. American Centry Mutual Fund,Account#020-000466459,733.427 Shares @$27,76 per share 20 359.93
q. Fronfier Communications,Dividends
2170
g. M 8 T Bank.Checking Account#77204220 4 2�$.�Z
g. BELCO Federal Credit Union,Savings Account#031980 4 048.23
7, Cash on hand
92.69
g. Comcast, Dividends
17.16 '
g. Dividends from Edward Jones Stock Account 22� �� `
�0. Edward Jones, Investment Account#896-12536 452,201.32
��. Edward Jones, InvestmentAcount#896-13972 458 043.45
�2. Edward Jones, Stock Account#896-12985 1 07223
13. Vanguard Explorer Investment, Mutual Fund,Account#9783871829 18 558.65
14. Refund Malpezzi Funeral Home 136.77
15. Haar's Auction,Sale of Personal Fumiture and Fumishings I 74970
�6. Sale of Small Stamp Collection
40.00
17. Sale of Old Coins
875.00
�g. 20?2 Federal Income Tax Refund
1,800.00
1 g. 2012 Pennsylvania State Income TaxRefund 34.00
I
— - �
TOTAL..(Also enter on Line 5, Recapitulation) $ 1,057 148.47�
If more space is needed, use addinonal sheets of paper of the same size.
. . .. .. _. ._ _ -. . _
[ldcli ye:1l eM . . .. . P�Cenrnv-NFac3g -> y� 1�5„¢'^q . . _ . . .. _ _ _ . _ _
., . .�.7�, e. .._ ..
Pebruary 1?, ?0I3 ���American Century
Investmentsm
. i��licl�ael Clizrewka
Attorney at Lasv �
T,7-232-4774 � � -
Re_ Genrgia 9, Shaub
Dera T�fr. Cherewka� .
it has coma to m,y atten[ion that the leiter I faxed to you earlier today co�tuined incouec[
infm-matiun regazding the ne; asszt�alue effective�t the close of businzss oa December 4, ?012.
Please zccep[my siacere npo]a�y, ro[rected informa[io� is provided helow.
- "fhis lz!tzr cor.fi-ms ths'individual Accnun!P20-0G0466459 was rrsistr.red to Gtorgia B. Shach.
At �he close r,f business o�Decembzr 4, 2012. the account held 73,.�2' ;hares at$27.7ti per sharz
for a vaf ua ef$2Q359.93.
�le�se nute[hz shares were not held ir, s 3und tk±e.[pHid ciailv dividznds. 1'herefore.. therz are no
di��idends rhat had 6een zarned but not.paid. .
.4ll.s}iazzs of[he individual accow�t were transferred to an asiste accour,t and reAeemed on
�ccember 25. 2p12. The preceeds were sen!by checi;tn A�chard S. Siirpson Il.
-:f yoc have any questinns or if! mav be nf?urthar assistsnr,e, nlease caC me st ]-8u0—?22�3301.
Bxt48039, weekdays 4om 8 a.m. to 5 p.m. Central tima. �
Sincerei}', -
�_R.Q)�P�(,.Q��.,L�
�Jebbie idiehois
r's[a:r Transfer Consuitant �
Lioaument No. O1Go3964—j5g
Amerir.an Cen[ury investmrnts I P.D.Box 4192:Q rianaas City,MO 64141�6?�0 I amexiceneemnry.com �
.Aniexicae Cen*u:� I,.�zy�ment Servlces„ I!io„ !niai.ual Sunn di�tribu*_or
�::Ol.il T:nerican Centurv p.�prieTary Holdinqs� Snc. Ai1 �iGhts reserved.
:�.neri�_sn C?ntury Bxo'serage. Tnc. , Kembes SIpC . . �
0 M�TBank
499 Mitchell Road,Millsborq DE 19966 Adjustrnent Services
Phone 688-502-4349
F ax (302)934-2955 �
� February I5,2013
Law Offices Of
Michael Cherewka
624 North Front Street
Wormleysburg, PA 17043
Re: Estate of Georaia A. Shaub
Social Securitu: 190-16-3922
Date of Death: December 04, 2012
Deaz Sir or Madam:
Per your inquiry on January 09,2013,please be advised that at the time of death,the above-named decedent had
on deposit with this bank the fol]owing:
1. TypeofAccount CheckingAccouM
AccountNumber 77204720
Ownership(Names o,� Georgia Ann Shaub
RichardS. Simpson, III(POA)
Opening Date 08/28/1964
Balance on Date ojDeath $4,Z78.69
Aceruerl7nterevt $ .03
Total �- -------
--..__.--------------------------
$4,278.72
For any addifional informafion on[he above accounts,including ownership and any changes,closures and/or reimbnrsemen(uf(unds,
�� please call the Union Deposi[a[7fl*230•3541.
We were miable to loca[e aoy safe deposit boz for the above-menHOned deredent.
This le[ter.does no[include any accounis in which the deceased may have been Hsted as Power of Aaorney,Custodian of liniCorm Transfers,
Represenfstive Payee,or Trus[ee under a W ritteu AgreemenL �
Sincerely,
Valarie Meroer
Adjustrnent Services
_ _
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REV-i5og EX+loa-io)
� pennsylvania SCHEDULE �
oEpAqrME�r�FpE�E�UE JOINTLY-OWNED PROPERTY
MHERITnNCE 7A%Rf.tURN
RFSIOENT DECEbENT
ESTATE OP: FIEE NUNBER:
Georgia A. Shaub . 21-12-1296
If an asset bacame joinGy owned wfthin one year of the dacedenYs datc of death�it must be reported on Schedule G.
SURVNING 76INT TENANT(5}NAME{5) ADDRESS RElATIONSHIP 70 DKEDENT
A. None .. .. -- . .— . - .. -� . - . . . �
B. � . . . �� . .
C.
i
_.. �_._
70IHTLY OWNE6 PROpERTY:
LETIER DAtE DESCRIP110N OF PROPEftTY �u oe oATE OF DEATH �
❑EM F00.]QIN� MAOE INCLUQE NAME OF 9NAN(3Al INS'fIIU770N ANO&4NK ACCOUNT NIIMBE0.OR SIMIW3 DAiE OF�EAiH �ECEOENT'S VAWE Of
NUMBER TENqM )07M IpENlIFlTNG NUMSER.ATTAG4 pEEO FORJOINTLY HELD REAI ESTATE. VAFt1E OF ASSEf INfERESF OECEDfM51NTFRE5f
� A �w,e o.oa
I
1_____ _ _
, T4TAE(Also enter on Line 6, Recapitulation} 5 Q.GO
If more space is needetl,use additional sheets of paper of the same size.
REV-I510 EX+(08-09)
� pennsylvania SCHEDULE G
oEOnarMeNraFRE�eNUe INTER-VIVOS TRANSFERS AND
rNHerurANCernxaeruan MISC. NON-PROBATE PROPERTY
RESIDENT DECED[M
ESTATE OF FILE NUMBER
Georgia A. Shaub 21-12-1296
_ �his schedule must be mmpleted and filed if the answer to any of questions 1 through 4 on page thr=e of the REV-1500 is yes.
DESCRIPTION OF PROPERiY
�M �rvnu�ErnEwaMEOrniEmansreaeE,TM[�apeunaxsn�arooFCEOemnxo �ATEOFDEATH °kOFDECD'S EXCLUSION TAXABLE
NUMBER ixcoarormnxsFEU. anuxncowarlHEOeEOroaaen�ESrn1E, VALUEOFASSET INTEREST pFnwucnai� VALUE
1. BELCO Federal Credit Union,IRA Account#031980 7,p77,�g 100 O.oO 7,077.18
Z MetLife PNC annuity,Contract#A2064951
49,355J0'� 100 0.00 49,35570
� New York Life Insurance,Annuity,Account#N3 200 033 qg,368.69� 100 0.00 . 49,388.69
4 New York Life Insurance,Annuity,Account#NP 460 334 1g2,q6029 100 O.OD 192,46029
ti.
6.
I
TOTAL(Also enter on Line 7, Recapitulation) g 298,251.86
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�'�� DEC 1=DENT i�.'iSTATE INFORNIf I!ON(On Date of Death)
,,�
� � I fle�rn� ,� .i �n.i � . ,.ie �ac::oi.intvra; helc �J'f'��:�ft, i A b_�hqU
t"�- -- � -�--_. _ . —
, __.._ . __ _ _. . ----------------�--- -----_.
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� � F�.cu -��, a in;� 31 � �i� ,�J ''� q�J i9S OF 1 f3u �:; , Ol�ai�6`I
_i,_� -- -- —=`:'. _. ,
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�
�: �;};?" Certi�.5:, -e�s: Balance F�r,crued G'����idends C i�cate Number YTD Dividends
r ___ra�.._---- -------- — _.
.�5,1_ _. . . . .
,1;�_, . . _. . _ __
�� V�arre�;: i� �nhi.h Safe Deposit Box v✓as helcl: �'\�
r I -- -
ji�.. . .. . . .. . . . . _
�. � ', ` �ate ;I : I ox wa: i�tia ly rented: j /_',,.
-----��--------
� 5 3ran��.t ; ,i�irms: <�:w.�ic�i the box is located: _��I_ ���
a,. -
� 7 i.can li 'n--iaticn Balan::e A cru=d Interest Per Diem Int '
Y
A. Unse.cured Loa�s: �_
.� �� L1 1 Classic Vie�,a Card � — -- — .
�,� , --� ���..:� — -- — .
�.,��-"="�, -- �--��--� — -- — ��.
� ' B. Ser.ured Loans:
�� : , _}.�.
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�� � i i
`�' -- - — -
:.�.'��'�-� ... I✓�o,tnage Loarn::�: '., $ $
'.'��, $�.�.._.� $ $
��'�' 8 I�i=cel�r`uus: --_�1�.�8_ ._------------ -- —
-�&" -- -- - ._.- --- -------- — - --- —
,,�,
s
� _���� ��i?'s,�=��$'iE��; � � '
:A1 .
�il � r � 's
- - . �?/2� - __,�� ;_.7?��22E5 � - 'tiI�'i='^E��' ^CLTY °� °AGc '-�1/2^ .
Meri�f e Investurs U SA ln�urana Company �£n m�.Z�c���.r�-���x�.
P.��. 3cx 2t35 'vri176
Dcs AA_ine�, '�.A 503G8-Ga95 •
�Illetl�fe���tf�������
ESTAiE UF GESHAUB
28Z LOW7HER 5T
LEMOYNE, PA 77p43
I
DaTe: � 05-17-2013 Customer Service: 'f-800•343-849E Check No: 067482257
Concract No: A2084957
Claim Proceeds �
I
Gross Payment 49,355J0 i
Federal Withholding 3,871.14 '
52ate �thholding 594.22 �
Net Payment 44,890,34 '
,�
��� (
`s � �
� + • � . . .. , . .
h a--,ti ,a" '� R�§. •vx i �.� r
. �' ��i,����`�5�� "� �4�, �5'""�,�r � ti���T�'�+,�`°� "�,?��^�y'°�'r�
,
MrtLih'� �11� ' -{ u � .pmY �9 ` R wz� y `x 3 � 'f`x?' ��:#� �'� �;� ��( %�a�" �
P.O. Bo" 5 . � .w� � -. 'S��1F "Ee:'r?� Pa�' v� ra� �. el,S • 1�F ".$' .5,�t_
�Des fJOinp, IA 50306-0296 � � .�� frµ� > war� y, � ecPi'��umba� �
� ,�� � � y1 �� y, p xx4 sT�, �R51 r ., v. 069 482257 �
Forty Four Thousand Eight Hundr���.�"'���`fp�, 'pylers . R:l�,����;�;�F;°�.��' yg �'
P'�Y to the Ordlr of:, '�5.� :.x� l�B.ri^�� , ' ' �L ��`y�,+'a.`: ���3 � 4.':E21, . f°om Wb ot I�w i .
'�"�- 05-17-2013 i
�� �F� �ryLL,,���,, � � d� y�<�`.rp' ��'� f'yW� . � aT� �;��.y•; � aXw 4mount �I
������ ��� :�S� 4� �����f ..�•�� xj�art� � �i �'' �.+sss#44,890.34I .
JPMO Ch nk ,A'.'"'wu,',�� .282 S • `�'F� ��'"'�� "���� � �'2:tr'� '�
EOto 7e�be1 Road � �� �EMOYNE, PA 17043 � � �
Syracuae, NY 13208 . �� � ' . -. . .' .
� . � - . .� . . . . . ' � 0.UTNan¢{pfIONATUeE �
�'R� .)]�.V ¢T�}, ��til� . .. ,7:' AUh�? �� A � � �F. wFr .
������''`�� ��,-��• 5 ���• �:ozi � w ��r$����'� 7a��� '���rr�, � k� t ��,
''x �'�u'u �e:A �r'm .& � m6F � u . �,l�a' � 'fa.- s A y��" t ?,, �� y,' � .
..�5' �sw.xa! �,:>,�sx`��• 9aa. ,a�+t� C�' e . .e,�4" u .+� �a..: �a� �'f.
�> 2°/2�13 11:33 71i774c2Eo � WIED��AN UOUTY P�� PAfiE 04/04
/;
� T4e ComWiuRY You Le�p� . Nen�YoTRLih In.�urance aud Anndd Carpor�tlon
A Ddaware Corpora6ae)
O.Box L30339
Daila,7X 733 13-05 3 9
l•8D0-695-73ld
wxw.newyorld�Je.eom
May 22, 2fl13
E6TATE OF GEORGTA ANN SHAUB
RICHARD S SIIvIPSON II
282 LOWTHER STREET
, LEIe�01'-NE PA 17043
Annnitant(s}: Georgia Ann Shaub
Policy(s): N3 200 033 and NP 400 334
Claim�: 359017
Dear Richard S. Sunpscn II:
We aze pleased to reply to youz zequest for tax informatian on the above anttuity(s). Ylease be ad�rised
that Form 7J 2 is only used in the filing of Estate Tax foz Life Tnsurance Coniracts. However,the
following iu£uzznarion should be of assietance to you:
Annuity Policy Number: N3 200 033
Issus Date ofAnnuity: Ju1y 15, 1992
Valaess o£Date oflleath, $49,388.69
Se�ieficiary(s): Estate of Georgia Ann S}saub
Azwuity Policy Number: Np 460 334
Iseue Date of Azmulty: May 30, 1985
Va1ue as of Date of T7eath: �192,46029
Bencficiary(s}: Estate of Georgia Ann Shaub
We hope this information will bc helpful to you. Tf you l�ave an}•quesuons,please contect us at the toll-
ftee numbez ahove. Any one of our represcntatives will be trappy to assist you.
S��IY�
�I��
Rebecca Bernal
Cnstomer Service Representative
REV-1511 EX+ (.0-09J
'��;; pennsylvania SCHEDULE H
���P4A�ME���FaE�E��E FUNERAL EXPENSES AND
�r�HERnANCET^xRET�RN ADMINISTRATIVE COSTS
kESIDENT DKEDENt
ESTATE OF PILE NUMBER �
Georgia A. Shaub 21-12-1296
Decedent's debtr must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: . .. .
I Malpezzi Funeral 11,979.00
z Romberger Memorials 90.00 1
�
1
B, ADMIMSTRATIVE COSTS: �
1. i �eaonal Representative Commissions: 40,784.36 ���.
Name(s)of Personal Representative(s) Richard S. Simpson, 11 � � � � � �
street nddress 426 South Third Street
ciN Lemoyne scate PA ZIP 17043
Year(s)Commission Paid: 2012
41,534.36
z. Attorney Fees � -
0.00
3. Familq Exemption: (If decedent's address is not the same as claimant's,attach explanation.) . . . . �..
Claimant
�
Street Address �
I
�� Citv _State__ ZiP _
� Relationship of Claimant to Decedent _ ______
I . . . . ... ..
4. i Pro6ate Pees: 801.50 �.
5. Accountant Fees � 774.00 ��
6. 7ax Retum Preparer Fees: 400.00 �
� Vita-Check, Department of Sta6stics,Death Certifcates 82.00
s. Legal Advertising-Cumbedand taw Journal 75.00 '
9. Legal Advertising-Senfinel 182.50 '
i o. Smart Move Makers, Removal of Fumiture hom Messiah Viilage to Haar's Auction 366.00 �'
't Postage,Ovemight Delivery Service and Mileage 60.00 ;
TOTAL(Also enter on Line 9, Recapitulation) $ 9�,�28.�Z .�
If more space is needed, use additional sheets of paper of the same size.
��AN�
vJ
��i550C�`�?
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREE�
CARLISLE, PA 17013
Tele: (7'17)2493166 Faz:(7'I�.249-2663
March 8, 2013
Cumberland Law Journal is published every Friday by the Cumberland Couniy
Bar Association and is desig�ated by the Court of Common Pleas as the official legal
publication for Cumberland County and the legal newspaper for publiGation of legal
notices.
TO: Michael Cherewka, Esquire
RE: Georgia A. Shaub Estate
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on fhe foilowing dates:
February 22, March 1, and March 8, 2013
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 0 .00
Total Amount Due $ 75.D0
Payment received by
r�,� /�.„ . AD NUMBER PAGE N0.
l lle �`en{��rel . MICHAEL CHEREWKA �
''� � 624 NORTH FRONT STREET 418256 1 of 1
www.cvmberlink-�om
WORMLEYSBURG, PA t7043 � BILL DATE SALESPERSON
� 717-232-4701
� o2r2s/13 wolfc
CPRILfE SFiIPPHJSEURC, PERR1'�Q1MY � � —
� START�DATE � STOP DA7E �
02/11/13 02l25/13
- AD NLJMBER AD�ESCRIPTION CLA55 � LWES ,.
E 418256 � � NOTICE NOTICE !S HEREBY GIVEN THAT .1Q PUBUC NOTICES 3D ` 2 cols
- Pubfication Insertions Rate Net Amount I 6ross Amount �
3THESENTINEL-LEGAL � 3 LGL $759.30 �
-OTAL AD CHARGE . $159.30
3 MOBILe SfTE MOB2 $2.(70 �
3 PROOF OF PUBLICATIOPI O1PRF $ZO0
� �
I .
i
II
L I
Purchase order Est. G.A. Shaub PAY THIS AMOUNT i $168.30 $201.96`
i
� . � I 'AFTER 03l22l73
1--- —
� THE SENTINEL
Thank you for advertising with The Senfinel! Deadfine for c!o LEE NEWSPAPERS
in-col�mn legal ads is 4:00 p.m. hvo business days prior to PO BOX 540
date of ir.serEion. For quesfions, call (717) 240-7130. WATERLOO IA 50704-054A
Retum fhis portion with your payment �ega�
� Check# � ❑Credit Card Ad Number 418256
THE SENTiNEL
c/o LEE NEWSPAPERS � � � C� � � � Billino Date 02l25lt3
PO BOX 540 -
WATERLOOIA 50704-054� Acct#: I I AmountDuc $ 168.30
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Amount , $
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t3� MICHAF_L CHERFWKA r./o LEE�NEWSPAPERS �
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WORMLEYSBURG, PA 17043 . . CWCINNATI OH 45274-2546 ..
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VitalChek Orcler• Receipt
. . .': Print� .
Purchase Dat�e: Wednesday, January 16, 2013
Payment Metho�d: Visa XXXX XXXX XXXX 5941
Agency: Pennsylvania Vital Records
Ship to: Michaei Cherewka
624 North Front Street
Lemoyne, PA 17043
Shipping Method: UPS Air
Estimated Processing Time: 10 - 15 business days
Order Number. 32650051 Pin: 809433
Item Record Ordered Qty Price Extra Copies Total -
1 Death: Betty J Rivers 6 $9.00 $45.00 $54.00
Agency Expedite Fee: $0.00
Processing: $10.00
Shipping: $18.00
Tax: $0.00
Total: $82.00
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https://www.citalchek..eom/receipt.aspx 1!3 6/2Q 13
REV-;SI2 EX+(12-12) �
j� pennsytvania SCHEDULE I
��� oEaaarn�rvroFaevENUE DEBTS OF DECEDENT,
NHEUT""cET^x RET�R" MORTGAGE LIABILITIES & LIENS
Hesroenr oECeoer�r
ESTATE OF FILE NUMBER
Georgia A. Shaub 21-12-1296
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses,
]TEM VALUE AT DATE
NUMBER . DESCRIPTION OF DE4TH
1 Messiah Lifeways, Invoice for Room&Board for November,2012 9 321.00
2 �Alert Phamiacy 82.06
3 Messiah Lifeways, balance due up to date of death 1,814.36
4. Alert Pharmacy 35.02 '
5. Federal Income Tax,Withholding 39,946.67
6. PA Personal Income Tax,Withholding 59422
I
i
I
— ---- �
TOTAL(Also enter on Line 10, Recapitulation) $ � 51,793.33:
If more space is needed, inser[additional sheets of the same size.
RE4-151?EX+(0140)
� 'pennsytvania SCHEDULE 7
mHERRAN�E Tr�R�n,RN BENEFICIARIES
RESIDEM DECE�ENT
ESTATE OF: FILE NUMBER:
Georgia A. Shaub 21-12-1296
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTV Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUIlONS[Include outnght spousal distributions and transfers under
Sec 9116(a)(11).]
1. Christine Kuklinca Niece 367,694.69
697 Chalfonte Place,NE,Warren,OH 44484
2. Paul K. Rivers Nephew 367,694.69
100 CresNiew Drive,Butler, PA 16001-3506
3. Mary A.Thomsley Friend 105,055.62
Colgate Drive,Camp Hill, PA 17011
840,445.00
ENTER DOLLAR AMOUNTS FOR DISTRIBUT[ONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REVd5�0 COVER SHEEf,AS APPROPRIATE.
I� NON-TAXABLEI DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SEQION 9113 FOR WH1CH AN ELEQION TO TAX[5 NOT TAKEN;
1.
kl. CHARITABLE AND GOVERNMENTAL DISTRIBUTfONS',
1.
Trinity Presbyterian Church in America,6098 Locust Lane, Harrisburg,PA 17109 123,595.00
2. Bethesda Mission,2101 North Front Street,Building 1,Suite 301, Harrisburg,PA 17110 123,595.00
�
TOTAL OF PART II- ENTER TOTAL NONdAXABLE DISTRIBUTIONS ON LINE 13 OP REVd500 COVER SHEET. $ 247,190.00
If more space is needed,use additional sheets of paper of the same size.
LAST WILL AND �'ESTf4MENT
K1VC7'�! ALL MFN BY THESE PRESEI'TTS, that T, GE012GIAA.3HAUB, alk/a
GEO.RGIA B.SHAUB cunently residitzg in Mechanicsburg, Cnmberland CounTy,
Commonwealkh of Pennsylvania, being in good health and of sound and disposinb memory do
hereby make, dec3are and pvblish this as my Last Will and Testasnenf, hereby revokiag a2I
formez Wills and Codicils heretofore made by ma.
FIR�T: T duect that all of my debts not baxred by the statute of limitations,
expenses of rny Iast illness, funexal expenses, costs of adxpuristraLion and claims allawed in the
administratio�a of m_y estate shall be paid by my �.xecutor hereinafte-r named, from tny estate as
saan after my decease as shaII be found converuent.
SECt7N13: I bequeath my aufo�abiles, household and personal effects and other
tangible persr>nalty of like nature (not including cash or securities), together with any existing
insur�iace thereon, as are set fo�t2r in�separate Memoraudusn,which I shall place witl�my Wil],to
the persons th'rein designated. Any property and other personal effects not othenvise specifically
�isted in such separate memorandum shall be said by me Executor, 3aereinafte;r named, and the
proceeds adde d to ihe residue of my estate.
THI32D: 1 give, devise and bequeath the rest, residue and remasnder�f my estate,
v�hetY:er real, personal or m'vted, and of any nature whatsoever and wherever situate, as follows:
A. Seventy ('70%)percent to rny sister, BETTY J. RIVERS of 100 Crestview
I7rive, $utler,Pennsytvataia provided that�l�e survives me. In the eveni
that my sister predeceases, i give, devise and bequeafh her share to her
issue, per stirQes, who survive me.
B. Ten(IO%j percent thereof ta fhe TRIIVI'Z'X FRESBY'I'ERIAi'�f CIILIRCH
IN AMEI2ICA, currently located ak 6098 Lacust Lane, Hanisburg,
Danphin Connty, Pennsylvania, ta be uivid�d such that Seventy-five
{75 i:�}perce�±thereaf will go to the bnilding fund and Twanty-five {25°l0;
percent thereof te the missions fund; and
C. Ten{2f1%}percent thereof to the BEi'CHESADA MISSION of Harrisbura,
Pennsylvania.
i�`' �-' � !L� �
�=�??z��� i
D. Ten{IO%}percent thereof to my dear friend, MARY A.THURNSLEY, of
Camp Hill, Pennsylvania.
FOUR7'FI: I hereby nominata, constitute, and appoint RICHARD S,
SIMPSON, Il, as Executor of tliis my I.ast Will and Tes'tament. Tn the event that RICIIARD S,
SIMPSON, TI shaIl pradecease me, ar be anwiiSing ar unable ta <ret as my Executar, as afaresaid,
then [ nominate, constiiute and appoint Michael Cherewka without necessity for patiting security
regardless of staie of residence,,as Executor af this,my Last Will and Testamenf. A11 referencas
to the> Execut+�r herein shall be applicable to said substitute Executor.
FIFI'H: My Executor shall have, in addition to the powers and authority conferred
upan Him by(aw, the following additional pawers aad autharity:
l. To sell at pablic or private sale, exchange, transfer, partifion, give options
upon, lease, n�ortgage,pledge, qr otherwise dispose of any property, real or personal, at any time
constituting a portian of my estate, and upon such terms and conditions as the Executor shall
deem wise.
2. To invast any money at any time in such bands, sfocks,notes, real estate,
mortgages, life insurance, annuities or other securities, or snch property, real or personal, as the
Executor shall deem wise, without being limited by any statutes ar rule af law regarding
investments by the Executor.
3. To retain, withont incurring any liability, as investments, any property
awned by me at t3ze tisne of my death, as 2ong as my F�cacutor may deem it wise, and even
though such property is not the kind of property an Executor would purchase as an invesiment;
and even thaugh to retain such property mi�t violafe sound diversification principtes.
4. To cause any security ar other praperty which may constiiute a portion of
my estate to be issued, held ox xegistered in the Executor's own narue, or in the nasne of a
nominee,or in such form that title will pass by delivery.
��������� �.�(;'""� 2
5. To con�sent to the reorganization, consolidation, readjustmei�t of the
financial structure, or sale of the assets �f any c�arporatic�n or athez organization; the securities af
which constiTute a portion of my estate, and to take any acYion with referenc✓e Yo sucli securities
which, in the opinion of the Exc cutar is necessaxy ta abtain tfie b�nefie af any such
reorganization, cons�lidation, raadjusYment or sale; to exercise anq conversion privilege or
subscription a•ight given to my Executor as owner of any securities constltuting a partion of my
estate resultii�ig from any reorganization, consolidation, readjustment, sale, conversion or
subscriptioo.
6. Tu pay a11 casts, tases, chaxges and expenses in connection with ihe
administration of my estate, mcluding such compensations to Executor which shall be in
accordance with established fees throughaut ihe period of administrauon of my estate.
7. Ta deiermine what is"income", and what is"princzpal"hereunder, and
my Executor's decision thereon shall be fmal; and to purchase securities at a premium or
disconni, and to apgty or charge said premium or discount against income ar principal as the
Execntor maq determine.
8. The Executor may make payments to or on behalf a£any person who is
the beneficiary hereunder buT in no event, howevar, shall payments be mac�e to any creditor or
other such persan becaase of anticipation of payment by the bene�ciary, and any sueh c3aun
made by way of anticipation by the beneficiary shall be of no validity or legal effect.
9, To bonow money fiom any person, fum or corporation, including any
corporation acting as an Esecutor hereunder, far the gurpase of pr�tecting and preserving ar
impraving my estate hereunder; to execute promissory notes or other obligations for amounts so
8anowed.
10. 'To emptoy legal counsel, accauntants,brokers, investment advisors,
custodians, managers and other agents and emplvyees and to pay reasonable compensation out of
my estate ar any fuads held hereander To which said compensation is attributabte_
�X✓���� � ��.��- 3
11. To carry on any business owned or controlled by me at my death for
wbatever period of time my Executor shall think proper, and my F,xecutor shall have the power
to do any anc all things my Executor deems necessary or appropriate, including the power to
close out, liquidate or sell the business at such time and upon such terms as my Executor shall
deem best.
12. To do all other acts in my Executor's judgment necessary or desuable for
the proper and advantageous management, investment and distribution of my estate.
SIXTH: I direct that all transfer and inheritance taares, state or federal, assessed
because of my death, whether the funds, property or insurance proceeds to which sucb taxes are
attributable pass under this Will or not, shall be paid out of my residuary estate; that my Executor
pay, or provide for payment of all such taxes at such time, or times, and in such manner as my
Executor deems best.
IN WTTNESS WHEREOF, I, GEORGIAA. SHAUB, a/k/a GEORGIA B. SHAUB, the
Testator to this, my Last Will and Testament, typewritten on five sheets of paper which I have
identified at the bottom of each page by my signature, hereunto set my hand and seal the
" 2008.
��'y day of Q
�
;� ,�,:.� ,C. , �� �.-�
GEORGIA . SHAUB, a/k/a Georgia B. Shaub
The preceding instrument consisting of this and four other rypewritten pages,each identified by the
signature of the Testator, GEORGIA A. SHAUB, a/k/a GEORGIA B. SHAUB, this day and date thereof
signed, published and declazed by GEORGIA A. SHAUB, a/k/a GEORGIA B. SHAUB, the Testator
therein named, as and for her Iast WIlI,in the presence of us who, at her request,in her presence, and in
the presence of.each other have subscribed our names as witnesses.
� Q� `-� 1� �--�--� - /` ��
4
�
COMMONWEALTH OF PEN�TSYLVANIA:
: ss
CC}UN'I`Y d�CLTMBERLAND .
I, GEi�RG�A A. SI-Iz�UB, a/k1a GEORGIA B. SF�AUB, T'estator whose name is si�aed to
the atfached or foregoiug instrument, having bean.duly qualified according to law, do hereby
acknowledge tbat I signed and executed the instrument as my Last Will; tbat I signed it willingly;
and that I szgned it as my free and voluntary aci far the purgases therein expressed.
GEOR����.`SHAUB�/lc/a�B. SHAUB
Sworn or af€irmed to and acknawiedged before me by GEORGIA A. SHAiJB, a1k1a
GEOP.GIA F. SHAUB, Testator, the__ zg'� _ day of �_7,"'__' 2008.
l��;Gt�f ��tdjlG�-
{SEAL) ccrviMOr��ozaiY± a�i b�k�s�r�.�r.�,n,ia
,ao���:�i s��
M+c;�ae!Chet�ewka,Notary Pub6s
Womisys6urg C,cro,C�umbedand Gounty
My Commis��cn E•:phes P.pr.27,2009
Me�nb=C F'=rn....t,�;'ni:�n^s=ci3tiGn Of Nctanes
COMMONWEALTH (JF PE]"TN3YLVANIA:
: ss
COUNTY OF CL�MBERI.AND .
We ��F��t~rz�r•, c �scz� and �j��.� �c�c��. ,
the wituesses whose names ara signed to the attached or foregoing instrument, being duly
qualified accc>rding to law, do depose and say tLat we were present and saw Testator sign and
execute th�instrumeut as her Iast Will;that she signeci willingly and that she executed it as her
frea and voluntary act for tfie purposes therein expressed; that each of us in the hearing and sight
of the Testatar signed the Will as witnesses; and that to the best pf our knowledge khe Testator
was at that iime aightean or mare years af age, of saund mind and under no constraint or undue
inflnence. -.
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,
Swom or affumed to and subscribed to before me bp !atlaroH �}ti rc�e.K and
�lie�.qptk witnesses, this Z8�'' day of ��� , 2008.
(SEAI.) �l�� C�2CU,�rs.._-.-
N , ,�iublic�ri-,oF aerarvs��v4TU�a
Not�rial Sed
Michael Gherewka Natary Pu�ic
Vtamteysburg 8r,m,Cum6erfandCowriy
` 5 My Commi=sicn c�.xcires Apr.27,2(�9 �
! M=mbGr.P„nnc-yr��_n;;y y�,oaiztit�n of Noiarie9
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