HomeMy WebLinkAbout11-07-13 � 15056�Z�8�
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pe11t75yfiYAfl1A OFF2C[AL U5�ONLY
PA Departrr�ent af Revenus �Fw.,,_,.�.,_�>�` Caunty Caie Y�ar File Numd�r
Buraauatlndivieuat=a7ces [�}.���(7AI�tGE TAX RETURN
PO 80X 2$Q607 � /��/ ')
r+�m�,�,aA y7�ss�sal RESiCfEhiT CIEGEDENT � I �C.. C✓ /�Jti
ENTER 13ECEDENT iNFOFtR9AT10N BELOVY
Soci�i 5ecuriiy Numt�er L3ate of�eath Mtv1DDYl'YY Date oi Birth NtMt3E7YYYY
093-4Q-233], 06D32�12 7,�2"�1949
Decede�t's Lasi hlame S�x Dec�dent`s Frs1 Name Ml
SN�PPARD RO�IALD J
{Ii Appiieabta}Entar Surviving�pouse's Information 8oicw
S�use's Last t�lame Suffix Spause`s First Name �vtl
Spouse's Sraclal Security Number
THIS RETURN 1VIUST BE FILED IN[3t1PL.tCATE WITH THE
REGISTER C)F 1NILLS
fIE.L IN APPRC1PRfATE 80XES BH�.OW
Q 1.Orqinai f2eium Q Z.Supp6ementa6 Reium (� 3.Remaindstr Retum{fSate of�esih
Prior to 12-f 3-$2}
� 4.LimSted Esiala [� 4u.Future Inieres3 Campromise(date ot [� 5.FedoraE Esiate Tax Rofum Requirod
sieaih aRer 1?-12-82)
(� 6.6QCede�t Died Testate Q 7.ber:edeni Mafntained a Living Trust CI B.Totaf Number oC 5afo Deposi#Bozns
(Ariadw Copy oi WiUj (Adach Copy aC Trust)
Q 9,lRi��tian Proceeds Received Q 10.Spousal Pa+resrty Crecttl(�ala of Death Q 1 t.Eleclioa ta 7�c und�t S�c,81 S3{A)
Belvfean 12-35-91 and i-1-95} (Ad�h Sahedul�a Q)
C�2Rf5P8MQENT-TH�SECTiONMUSTBECOMi+t£tEQ,ALLCtSRRESPOMDENCEkl+DCONFi0EN71AL7.UCINFORMAT1QNSt10U6QBE0[RECTEDTff: �_,��
Name bayUme�lephnrre Num'�ei �7 f'�1
R46ERT G. FREY 7y724��38 � �
.�:. � c�
v
i �R6►F wi� sF o�µ-r�
� � �,*t --J � �
3> N � � c�
First Une af Address ;� � � _� -�
�.y � "ci '
S S. HAN{fVER ST. n Q `�r► � '� c�
Secorxi Line oi Rddtess � � � � �
;> O
Cify ar Pas!Office 5tate ZIP Code Da7E Fl��D
CARLISLE PA ��013
eonaspondont`se-mai�addrass: RFREYn�FREYTILEY.Ct}M
Under penaM6�s of pe�jury.[dsdaro that I have exami�ad this eetum,irtcludirtg�cartspanyin�schedulas artd siatemenis,and ta the E�esi cN rny ktu�wlodge and bmliaf,
�i is trup,correct nnrt ceampble.Declaration of prnparer other than the�rsnna!representative is bascxf on aA infomsatton ot vfiich prepar�e has attp knw.indge.
�7A7URE C�(�P�E�RSON RES(P'�ONS�tBL�-E FQR FiLING f�E'fURN DATE
l.t.l i�.rilY���1i _,�i" �'(Pl ��•CSFS"l 3
ADORE5S
.7�-1 � '�c�ec�.� � N c�
SIGNATU�OI�PR ARER OTHER TCiAt�T f2EPt2ESENTATIVE RATE
�G
a�iJRESs
5 S{�E1TH HAt�t�VER STREET� CARLISLE, PA 17C1�3
PLEASE llSE tiR1GINAL FQFtM ONLY
5ide 1
� 7,5C1563�11,8C1 1�50�€�11180 �
� �s�s��1�e�
REl!-15{30 EX{FE) Decedent's Social Security Number
oec+�dent'aNamu: R�(}tJA�I} J $HEPPAI�D (793-�iD-c�331
RECAPITULA77C3N
�. �eae�sta�e�sct�sauie�>................ .. ... ............ .. ...... �. N 4 td E
2. StockS and Hor�ds(Schedufe B}... .. ... ....... ....... .. ..... ....... 2 (�{}(�j�
3. Closely Ne{d Cotporation,Partnership ar Sole-Proprietorstiip{Schedule C}... 3. N t�N E
4. Mo�g3ges atld No#es ReCBiYabl�(SCh�dule D)........................ 4. ��N E
5. Cash.Bank C3e�sits and 1�lis�celiar�ecus Personat Propesty{Scheduie E).... 5. �'��E
&. Jointiy Owned Property{Schedule F} (�Separate Si3ling Req�sted., ..... &. N�}N�
7. ir�er-Vrvos�rans#ers�k4Eisceliar�eous htfln-Prohate Propsrty
{scr,e��0e�} �Separate 8ilting Req�sted.. .. ... 7. b1�3339.�]Q
8. Total Gross 1�sseLS(total�ines 1 thraucth�. 8. 6�,333 9.�Q
9. Fune€at Expenses and Admfnistrative Casks(8chedU3e H).. .............. 9. ��I��
i0. CYebts of Dea�denl,tvtortgage Uabilities and�i�ns(Scheduls 1}..... . . ... .. 10. N 4 N E
i 1. Total E}eductfons{total Lines 9 end i 0)... .. ..... .. ... ......... ..... 11. � .C)0
12. Not Vniuo af�stato{tine 8 minus lrne 11}.. ... .. .......... .. ........ 9�. I���339.�Q
13. Charitabie and Gavemmerttal BequesislSec 91'f 3 Trusts ior which
an eleotian ta tax has not been made(Schedule J}... .. ..... ..... .. .....i 3. �.��
1a. Not Valuo Subisct to Tax Line 12 minus Line 1�}......................14. �Z���9.�7 CI
YAX GAE.GULATiON-SEE INSTRUGTI�NS FOR APPLICASLE RRTES
15.Arttaunf of t,ine 14 faxai�le at
the spousaf tax rate,or
tr�rl5f�r5 under S�C.9116
{a}(1.2)X.0 � 15. 0.Cl CI
18.ArnouM oi Line 14 taxable
�c��n���ratex.fl 45 6�,��39.OD �s. �76Q[]. 26
17.Amourh ot{.tne 14
tasr3hle at siblii�rate X ###I 17. D.Q D
#c.Amcur�ot L'a�:� 14 t��hl3
at ca��atera!rate x #### t 8. D.D 0
�s.TA,xou�.. ..... . ....... ... .. ..... .. . .. . .... .. .. ........ .... .. �s. �76DtJ.�'6
�f?. Fll.L!N TH�BCfX IF YOt1 Rf2E REQtJES7tN6 A 32EFUND QF AN t3VERPAYMENT 0
"3i$@ 2
�,,,,, �,SClS6],1�280 15C�5b1ti�8� �
REV-15t?0 E.X(Fi} Paga 3 File Number 093-40-2331
�ecedent's Camplete Address: 21-12-13742
QECEDENT'S NAME
RONALC7�!SHEPPARO
sT���T�aa�t�ss
8�1 OAK FLAT RC?AD
CITY 5TA7� ZiP
NEWVIl.LE PA 172d1
Tax Paymer�ts and Credi#s.
1, Ta�c oue(wage 2,Line,$) t�) 27600.28
2 CreditslPayrrFar�ts
A.Prior Payments
8.D+scauM
Tatat Credits(A+�) {2) �.00
3. interest
(3)
4. !f Line 2 is greater ihan Une i +Line 3,enter the difference,This Is the OVERPAYM�NT.
�ii!in 6ox on Page 2,t.ine 20 ta noqumst a roiund. {4) 0.0�
5. If Line S +l.ir�e 3 3s qreafer#han Line 2,ersfer tt�dtffer�r�e.T'his is the?AX aUE, {5} 2�8tI0.26
Make check payable ta: REGIST'ER t�F WILLS, AGENT
� � � �-
�--:� �'������, ��r ,�...� %�a '� ������ •.:��' ,�� � ;��_.� �
PL�ASE ANSWER THE FOLLOW(tVG QUESTIONS BY PLACING AN"X"IN 7NE AF'RR�PRIATE BL4CKS
1. Did decedent make a transfer and: Yes No
a. retain the sFSe or incame af the properiy iransferred.................................................................................... ❑ Q
b. retain ttae rtght ta designate who shall use the property transferred nr its ie�came�.......................................... Q �
c. retairt a rever�ionary ir�erest.............................�......._................................,.........._......................,......,......,... ❑ �
�. rcce�e tn���am��io:r�re or eitr,e�aaymerns,t�r�fits or care?........................................_.......,..............,,. Q Q
2. Ifi death occurred atier Dec.12, 1982,d+d decedent transter property wiEt�n one year of death
withaut receivins�adeqt�te cansiderat{on?.........................................................................................................• ❑ �
9, pid dec+edent own an°in trus2 fat"or payabie-upan-death trank accourtt ot s�curity at hia or her death?............ (� [�
4. Did decedent owrr an individua!retirement account,armuity or other rsan-prabafe property,which
contain�a beneficiary des�gnatlon?.................................................................................................................... IX� ❑
(F TME ANBYtIER TG AFIY OF THE ABOVE QUE5110NS IS YES,YOU MUST COMPLETE SCHEDl3l.E G AND FILE IT A3 PAR7 OF THE RE�EIRN.
„ �, � ti�;�.� �,n,;,..� �� � x.�.F �n� �
,,a,, ,..a� r, � , ;, 2
...,.....� )
� ' n <..'.:;.� l - '�°:f, . , 9C�k_ ..0
, m,kF..,z . :�% ....
For dates o/death ar�or after Juiy 1,19�4,ar�befare Jan.1,t935,t�tax rate impased on ttse net value af fransfers tp or tar the�rs�oi the ssmiving
s�ause is 3 percent(72 P.S.§9i 16(a){1.1}(i)J•
Far dates efi death on or aRer dan.1,1�95,ihe tax rate irt�posed on the t'm�t vait�o!tra�fers to or for tt�use nf the stttviv�ng spouse�s Q percent
j72 P.S.§8916{aj(1.4}{iij].The statute dcses not e�mpt a tcartsfer ta a surviv�ng spause trom tax,and th�sfa#ulary reqcaremer�ts foc disctosure of
assets and fiiting a tayc retum are stil!applicable eve�if the survivir�spouse is ihe on{y ben�ficiary.
For dates af death an ar ari�r July 1,20Q0;
* The tax rate impased on the net vats�of transiers tram a deceased child 21 years af age or younger at death to or!or the use of a�at�ual parer�,an
adoptive parent or a�tepparent of tl�chifd is D percent j72 P.S.§9316{a}{1.2}].
* Tire iaY rate i►�aseci on ihe ne#value ot transfers to or for the use nf i�e�eedent's fineai tzenefiaaries is 4.5 p�c�nt,except as nrsted in(72�'.S.§9116(a}(1)].
• The tax rate impased on the net value af trdnsters ta or ftu the use af the decederst's sibtings is 12 percent[l2 P.S.§9116(a)('i.3}).A sibling is
defined,under Section 9102,as an individual wh�has at least ane parer�in common with the decedent,v�#lEtit��6y bSoad vr`adopEiOn.
���.,��n�X����, SCHEDU�,E G
p���sy������ INTER-VfVOS TRANSFERS &
DEPARFlv1ENT Ot REJENU�
INHERl7ANCETA7CRE7'tJRM {��gC. NON-PRE)BATE PR{�PERTY
REStpENT nECE6ENT
E57ATE C}F FItE NUCIABER
Ronaid J She�Par�+ 21-12-0742
Th�s schadulo must be compleied artd tiled ii thu answar to any nt qussiians 1 ihrough 4 an page three of tha REV-i5t��yes.
r��se�ti�r�ar�oF�RO��R�
ITEM �+c�.ute-�s�e+tsc�aF'tt<s rntt<sf�r.�.rt+E�c R�.,+t�on:w�p ro cec�:�*rr�uuo DA't�OF D�TH °,6 OF QECO'S EJtCI�US!(3N T�JCr'#$LE
hiUMBER m€ar.rEarrw�ks�€��rrna��.caaro�n�eo�€aRORxexcesr,��e VAI.UE{)FASSET' INTEREST `*„`Q`,��''`2°' VALUE
�. State Emplayees R�tirement Systerx� 613,339 10�.4fl°�a 0' 6�3,339
0
Q
0
0
a
0
4
t}
�
0
0
0
0
0
C�
0
Q
U
a
�
0
0
v
0
�
�
0
a
a
a
0
0
�
a
�
0
0
0
0
0
0
�
�
�
0
TOTAL Also enter an Line 7 Reca itulation S 613 339
If more space is needed,use additiona!sheets of paper of the same size.
. _
REV-1513 EX�{o�-�ay
pennsylvania SCNEDULE J
c�ARrah�Nr G�REV�rSUE
�rar��aTnr,���,vic e�ru�xrr BENEFIC(A�IES
RES€DENT pECQSENt'
ESTATE OF; FILE NUMBER:
Ronald J She aed 21-12-OT42
RFIATiti�FiSi4PTODE�BEt� AMCI�3NTORSHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECENING PROPERTY do Not L.Ist Trustce(s) OF ESTATE
1 TAXABIE DISTRIBLlTICWS[include outright spouSal eiisl�ibuiions and traresfarss und�r
Sec.9t15(u}(1.2}.�
Ryar�Sheppard
1.80 C3ak Ftat Road,Nerwitle,PA i7241 son 112 csf retirernent
Danielle Palmer
2' 3�5 Edward J. Roy Qrive,Apt.204 Manchester, NFi 03104 daughter 1t2 of refirement
ENTER OOILAR{tE�?UNTS FOit DlSTRIBUTit�NS SHpWN A80VE ON LINES 15 THROUGt{t8 QF REV•1SQD COV£R 9HEET,AS AFPRC7PRlATE.
11 t,MOt3-TAXABLE€}157RIBi111ONS
A SPOUSAL CNS7Ri8LiT10�JS UNDER SPCTICNJ 91 f 3 FOR 4YHICH Aht E4.ECT1C7N TCS 1'AX IS NOT tAKEN:
1.
8. CHAWTABl.E RND GOVERNMENTAL DISTRIBUTtt7A4S:
1.
TQTAL QF PART II—EN7'ER TptAl NflN•TAXABLE pISTR18UTiUNS 4N ttNE 13 C7F REV-1500 CQVER 5HEET. S 0.04
li more space is na�ded,use additiona9 shn�sts oF paper of ths same stze.
COMMONWEALTH OF PENNSYLVANIA
STATE EMPLOYEES' RETIREMENT SYSTEM g
30 NORTH THIRD STREET,SUITE 150 �
HARRISBURG,PA 17101-1716
1-800-633-5461
www.sers.state.pa.us
March 19, 2013
RYAN SHEPPARD
37 S YORK RD
DILLSBURG PA 17019
Re: Ronald J Sheppard
SS: 093-40-2331
Dear Mr. Sheppard:
This is in regard to the death benefit payable to you, from the account of Ronald J Sheppard. This
account has a Guaranteed Present Value that is still payable.
In order to proceed with the final settlement of this account, the enclosed forms must be completed,
notarized, and returned to this system at the address shown above as soon as possible. Please note:
the Retirement Code does not provide for the payment of interest on the principal sum of a death
benefit.
The following information is being provided:
Balance of Guaranteed Present Value Payable to you: $306,669.29
Taxable Portion: $306,669.29
Non Taxable Portion: $0.00
If you have any questions or need assistance, please contact the field office nearest you at
1-800-633-5461.
Sincerely, .
��. r�����.
Debra G. Murphy, Director
Benefits Determination Division
Enclosures
BEN55 I I�'I'I'lll'(II"IIII"I'll'llll II"��II��(II'I(I"I II"I�II'I II�I I'll
�c„ �:. www.sers.state.pa,us � r• f '
p r� '� �� z,'� ���!,����;
"` Te18Ks13^nE`}.8C10^��v3•5451 '--:: r
..�,�,..,��,. �,,. :,��.,--
Fax.7t?-?8'-8860
Apri15, 2413
DANI:ELLE PALMER
24 RANGE FiD
�EER�'I�LQ NH 03437
Member SSN: �CJCX-K?�-2331
Qsar Benefieir�ry: Beneficiary SSNlE3N: XXX-XX-740$
A ct�eck in the amaur�t o#�245,335.�3 wi11 be ma=.Ied to you vvi�hic� two w�e#cs. #f yo� have el�c:ed to
rollvuer your#inal se�tlement paymen�,,tt�e amount listed �aelovu will be transferrect ia your qualified
plan wifhin two weeks.This �Sayment represer�ts your desigrsaied share ofi 5U.04°!o in tY�e fina(
settlemant of the accQUni o# R4M1IA�.�J �HEP'PARD.
Breakdown of Pa�ments.
__.. ... _. ___ �
Nan-Ta�c�ble: �J.Oi�
----................................................................ ...�--.._.... __....____....... ---- ._--- ;.-..... .... - --.....--........................................._.............._..._.:.
Ta�abls: .�306;669.29
- -- - -- -------- --- -- - -................_..... ................_.......................................;..................................... - -. . __ .
Grass Amount: ' �30fi;669.29
.... ..... ..... ... ..... .. _ _ _ . _ . . _ ...
Federal V�IsthhoEci�ng Tax: �6� 333 8�
................ ......... , .,..... ,. ....... ..... - .
Nort-Taxab#e Cantributions tfl i'RA Rt�l(ov�r: ' �0.00
_ _ _ _ _ :
Non-Taxabl� Contribu#ions t� Roth tRA Raiiovsr: _ $� fl�
. ...... . .. . ....- -..... .._..... ..:.- ---- .... ...,.........--- - ... . ........... .-- -----,_ _..... _........... -_
Taxable �ontributiar�s#o IRA Roliov�r. ��.�1a
_....... _ .._- - .. _.: . - ..... __._. _ _.... _,
Taxable Contributions to Rt�th IRA Ral3over: , _ $0 Ofl
...._ ......... ........ ...... .. . ......... . ....__ .......... ............. ................ - -- ____
To#a1 Deduction Ar�ount. , �51,333.86 ',
......................_.................................................._.__...................._..........................:.................. ............._ _ _
Net Arnount P$id ta You: �245.335.43
.,.,.., . ... ...... .__ . _ _. ... __. ...... _. _...... .... ........ ....
1� the in�'rviduat Iisted �bove vvas a mernber of ttz�Retirement systern befu€e,Jar�uary'�, 1�82, t�eir
c�ntributior�s pr�or to #hat date v��ece t�xed as part of the;:r gross income at that t'tr��. ThereiQre, no
taxes are being withheld on t~at porti�n af their contrib�f"sons. Th� di#ference between i�e amoun�of
�nur��yrnent�nr� yo;sr shar�af i�ae deceas�d mernber�s :�on-taxab#2 c�ntrib�iie�s, :f a�^t>r, is _ _
taxable for fiederal inc�rne tax purpvses.
This payment wili be �epor#eci io€he Iniernal F?evenue Service. You�ri(1'r�ceiv?a 1���R fcrm pri�r
to Janu�ry 31 of next year a(ong wit� necessary#ax inft�rmatian rRgardinr t�►is pa��meni. Und�r
curreni law the�e are no Pennsylvania Gtate or iocal taxes or� any ber:efits �aid�rc�m this�yst�m.
This letter and the 1 C�99R�form that you receive sh�u(d be kept in a sa#e �lac�, �5 yo�w��i �a�d t��
informatic�n when filing your Federa( Inco�e Tax Return. This is the�n�y notiee you wifl receiv�.
Sincerefy,
��� � �
Debra G. Mur�hy, Ditector
Ben�fit D�termination Div��:on
E��.��F�i: �l�l�fl tl��!illll Il�(�!I�lI t���!II11���I��llf ll l�Ifl�:ll ll II[tl�III 111�