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Home My WebLink About05-02-14 (2) J 150561014Q REV-1 500 Ex PA Department of Revenue ,�rFl¢;I°l use nlat.Y Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number PO BOX 280601 2 1 Q 9 Q 7 4 4 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 2 1 1 2 0 0 8 0 1 1 5 1 9 3 9 Decedent's Last Name Suffix Decedent's First Name MI S H A F F E R M A T T H E W D (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI S H A F F E R R 0 W E N A J Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW FXJ 1,Original Return ❑ 2.Supplemental Return 3.Remainder Return(Date of Death Prior to 12-13-82) 4.Limited Estate ❑ 4a.Future Interest Compromise(date of 5.Federal Estate Tax Return Required death after 12-12-82) 6, Decedent Died Testate 7, Decedent Maintained a Living Trust 0 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) 9.Litigation Proceeds Received 10,Spousal Poverty Credit(Date of Death E] ,1.Election to Tax under Sec.9113(A) Between 12.31-91 and 1.1-95) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number J 0 H N C - Z E P P I I I 7 1 7 .5 2 8 8 9 0',,0 N Rf TTERR OF WILLSNSE OtlWYF Co First Line of Address M - n --c CO P - 0 - B 0 X 2 0 4 _ ra Second Line of Address City or Post Office State ZIP Code �iiATIE FILtz r C>Tj a Y 0 R K S P R I N G S P A 1 7 3 7 2 Correspondent's e-mail address: Under penalties of perjury,l declare that I have examined this return,including accompanying schedules and statements,and to the beat of my knowledge and belief, It is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS ATURE F PR AR R THAN REPRESENTATIVE DATE ADDRESS A.0 .) BOX 204 YORK SPRINGS PA 17372 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 1 1505610240 REV-1500 EX(FI) Decedeffs Social Security Number Decadeffs Name: MATTHEW D. SHAFFER RECAPITULATION 1. Real Estate(Schedule A) ............ ........ ... . .... . ..... . .. . .. . . . 1 2. Stocks and Bonds(Schedule B) ..... ............. .... . . ..... ... ... . .. 2. 1 Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. ... 3. ' 4. Mortgages and Notes Receivable(Schedule D) ...... .... ..... .... ....... 4. ' 5, Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)..... . . 5. 4 9 6 2 . 0 0 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers&Miscellaneous No -Probate Property (Schedule G) Separate Billing Requested . .... .. 7. 8, Total Gross Assets(total Lines 1 through 7) . ..... . . .. ,.,., 8. 1 9 7 5 0 , 0 5 9. Funeral Expenses and Administrative Costs(Schedule H) .. . .............. . 9. ' 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) ............ . 10. 11, Total Deductions(total Lines 9 and 10) ....... ......... ............. .. 11. 12, Net Value of Estate(Line 8 minus Line 11) .................. .......... 12. 1 9 7 5 0 . 0 5 13. Charitable and Governmental Bequests/Sec 9113 Trusts 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. 1 9 7 5 0 . 0 5 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0 _ 1 9 7 5 0 . 0 5 15. 0 . 0 0 18. Amount of tine 14 taxable at lineal rate X.0 0 . 0 0 16. 0 • 0 0 17, Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17, 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18, 0 . 0 0 19. TAX DUE ........_..................... ....................... 19. 0 . 0 0 20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505610240 1505610240 REV-1500 Ex(FI) Page 3 File Number D'ecedent's Complete Address: 21 09 0744 DECEDENTS NAME MATTHEW D. SHAFFER STREETADDRESS 64 Schoolhouse Road C" STATE ZIP Gardners PA 17324 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments B.Discount 3. Interest Total Credits(A+8) (2) 0.00 4. If Line 2 is greater than Line 1+Une 3,enter the difference.This is the OVERPAYMENT. (3) Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Une 1 +Une 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN 'X' IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred ...................................................................... ❑ IXI b. retain the right to designate who shall use the property transferred or its income ............................... ❑ c. retain a reversionary interest ..................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ 3. Did decedent own an'in trust for or payable-upon-death bank account or security at his or her death? ......... ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in p2 P.S.§9116(a)(1)). • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1503 EX+(8-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER MATTHEW D. SHAFFER 21 09 0744 All property Jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 317 Shares of PNC Stock value at date of death $46.65 a share 14,788.05 held at Stifel, Camp Hill, PA TOTAL(Also enter on tine 2,Recapitulation) $ 14 788.05 If more space is needed,insert additional sheets of the same size REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE RESIDENT DECE ENTTURN PERSONAL PROPERTY ESTATE OF: FILE NUMBER: MATTHEW D. SHAFFER 21 09 0744 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Cash held in non joint account at Stifel, Camp Hill, PA 4,962.00 TOTAL(Also enter on Line 5,Recapitulation) $ 4,962.00 If more space is needed, use additional sheets of paper of the same size. REV-9514 EX+(08.13) . pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER MATTHEW D. SHAFFER 21 09 0744 Decedents debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Michelle N.L. Shaffer 0.00 Street Address 66 Schoolhouse Road city Gardners state Pa zip 17324 Years)Commission Paid: 2, AttomeyFees: John C. Zepp, III 0.00 3, Family Exemption:(if decedents address Is not the same as claimants,attach explanation.) Claimant StmetAddress CRY State ZIP Relationship of Claimant to Decedent 4. probate Fees: Cumberland County Register of Wills 99.00 5 Accountant Fees: B. Tax Return Proparer Fees: 7. TOTAL(Also enter on Line 9,Recapitulation) $ 99.00 If more space Is needed,use additional sheets of paper of the same size. REV-151t EX-(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MATTHEW D. SHAFFER 21 09 0744 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not ListTrustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS pnclude out r�"ght spousal distributions and transfers under Sec.9116 1. Rowena J. Shaffer Spousal 100.00 64 Schoolhouse Road Gardners, PA 17324 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE, II. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 3. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: t. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0.00 If more space is needed,use additional sheets of paper of the same size.