HomeMy WebLinkAbout08-29-14 (2) � REV-1500 E"�o2-„> 1505610143
`'�' OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENTOFREVENUE
PO BOx.28oso1 INHERITANCE TAX RETURN 21 14 0 5 3 5
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
05 12 2014 03 29 1944
DecedenYs Last Name Suffix DecedenYs First Name MI
SHANK DAVID D
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� t. Original Return ❑ 2. Supplemental Return � 3.Remainder Return(Date of Death
Priorto 12-13-82)
� 4. Limited Estate � 4a.Future Interest Compromise � 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
g Decedent Died Testate � Decedent Maintained a Living Trust � 8. Total Number ot Safe Deposit Boxes
� (Attach Copy of Will) � (Attach Copy of Trust)
� 9. Litigation Proceeds Received � 10.Spousai Poverty Credit(Date of Death � �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
SAMUEL A GATES ESQUIRE 717 �632 4�,$1
� � rn
REGI��F WILL�SE t1�L� _
tTl � C'� � � �
^-•i
First Line of Address 9"--�- z'; �-�,.� � �"'� �
:,. ;w� '
250 YORK STREET `°' C`'- :h �a a
' c7 ��
� � �
Second Line of Address ° � �'' `'� 3 "-�..'� �
c..,�
.,-t h--� r"` �i
�'"""� ATE FILEQ.� f!� �
City or Post Office State ZIP Code ._.» -
HANOVER PA 17331
CorrespondenYs e-mail address:
Under penaities of perjury,I dectare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
�p� ,�,�� Matthew D.Shank �S -a5- 1�
ADDRESS
38 Hair Road, Newville, Pa 17241
SIG OF PREPARER OTH HAN REPRESENTATIVE DATE
Samuel A Gates Esquire S 2z (
ESS
Gates&Gates, P.C.
250 York Street, Hanover, PA 17331
Side 1
� 15�5610143 150561�143 � 1
� 150561�243
REV-1500 EX
DecedenYs Social Security Number
DecedenYs Name: S H A N K� D A V I D D
RECAPITULATION
1. Real Estate(Schedule A).......................................................................................... 1. 1 6 9 , 9 0 0 . U 0
2. Stocks and Bonds(Schedule B)............................................................................... 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3.
4. Mortgages 8�Notes Receivable(Schedule D).......................................................... 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 9 r 7�5 . 8 3
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7. 2 9 2 , 8 0 3 . 5 4
g. Total Gross Assets(total Lines 1 through 7).......................................................... g. 4 7 2 , 4 7 9 . 3 7
9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 5 7 , 9 8 3 . 9 8
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................. 10. 8 6 , 4 9 0 . 3 7
11. Total Deductions(total Lines 9 and 10).................................................................. ��. 1 4 4 , 4 7 4 . 3 5
�2• Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 3 2 S , ��5 . 0 2
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. 3 2 H , ��5 . �2
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.00 15.
16. Amount of Line 14 taxable
at lineal rate x .oa5 2 6 0 , 815 . 0 0 16. 1 1 , 7 3 6 . 6 8
17. Amount of Line 14 taxable
at sibling rate X ,�2 17.
18. Amount of Line 14 taxable
at collateral rate X .15 6 7 , 19 0 . 0 2 18� 10 , 0 7 8 . 5 0
19. TAX DUE................................................................................................................... 19. 2 1 , 8 1 5 . 1 8
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑
Side 2
� 1505610243 1505610243 J
Estate of David D. Shank File: 2114-0535
SS: 205-34-8475
DOB: 3/29/1944
DOD: 5/12/2014
CALCULATION OF TAX
Janet Hoover—Total Gross $94,684.86 1/3 Ameriprise Accounts
2,100.00 Jeep
$96,784.86
Matthew&Jason Shank,
Sons—Tota) Gross $472,497.37
Less Janet Hoover Gross -96,784.86
$375,712.51
Janet Hoover $472,497.37 Total Gross = 96 784.86 Gross
144,474.35 Total Deductions =$29,594.79 Share of Expenses
Matthew&Jason $472,497.37 Tota)Gross =$375,712.51 Gross
Shank,sons 144,474.35 Total Deductions =$114,879.71 Share of Expenses
Janet Hoover Net Amt. $ 96,784.86- $29,594.79 = $67,190.02
Matt&Jason Net Amt. $375,712.51—$ 114,879.71= $260,815.00
REV-1500 EX Page 3 File Number 21 - 14 - 0535
Decedent's Complete Address:
ED NT' NAME
Shank, David D
STREET ADDRESS
40 Hair Road
CITY STATE ZIP
Newville PA 17241
Tax Payments and Credits:
1. Tax Due(Page 2,�ine 19) (1) 21,815.18
2. Credits/Payments
A� Prior Payments
B. Discount
Total Credits(A +B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 2� ,815.�$
Make Check Payable to: REGISTER OF WILLS, AGENT.
y,� � �
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N,.,,. .,�..,„M �„, .,� ,s. '� ,w,.,,.. ,.,F,:�..i ..,,,„ ,. . �,�,7�.`�r,�,' ��`..,r�,.7!,.,,,„'��„<.
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:.................................................................................. � �x
b. retain the right to designate who shall use the property transferred or its income:.................................... � 0
c. retain a reversionary interest;or.................................................................................................................. � x
d. receive the promise for life of either payments,benefits or care?.............................................................. � x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?....................................................................................................................... ❑ ❑X
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?......... � �x
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.
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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 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[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 refurn 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 decedenYs lineal beneficiaries is 4.5 percent,except as noted in
[72 P.S.§9116(a)(1)].
•The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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,w ether�y bloo�or adoption.
� pennsylvania
DEPARTMENTOFREVENUE SCHEDULE A
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Shank, David D 21 - 14-0535
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price
at which property would be exchanged between a willing buyer and a wilfing seller, neither being compelled to buy or sell, both having
reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on
schedule F.
Attach a copy of the settlement sheet if the property has been sold.
Include a copy of the deed showing decedenYs interest if owned as tenant in common.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 40 Hair Road, Newville, PA 17241 169,900.00
TOTAL(Also enter on Line 1, Recapitulation) 169,900.00
�-� pennsylvania SCHEDULE E
� DEPARTMENTOFREVENUE CASH BANK DEPOSITS AND MISC.
INHERITANCE TAX RETURN �
RESIDENTDECEDENT PERSONAL PROPERTY
FILE NUMBER
ESTATE OF Shank, David D 21 - 14-0535
Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 Members 1 st Savings xxxx508243-00 22.00
2 2004 Dodge Durango- KBB Value 3,500.00
3 1997 Jeep Grand Cherokee- KBB Value 2,100.00
4 Verizon Refund 12.20
5 Express Scripts Refund 9.62
6 State Farm Refund 22.22
7 Embarq Retirement 2,002.43
8 Tax Pro-rations Credit(see HUD-1) 2,107.36
TOTAL(Also enter on Line 5, Recapitulation) 9,775.83
REV-7510 EX+(OS-09)
���� pennsylvania
DEPARTMENTOFREVENUE SCHEDULE G
INHERITANCETAXRETURN INTER-VIVOS TRANSFERS &
RESIDENTDECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF Shank, David D FILE NUMBER
21 - 14-0535
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF �CLUSION
NUMBER Include the name of the transferee,their relationship to decedent VALUE OF ASSET DECD'S (IF APPLICABLE) TAXABLE VALUE
and the date of transfer. Attach a copy of the deed for real estate. INTEREST
1 Ameriprise One Acct�000c6568 �5,419.88 100% 15,419.88
33.4%transferred to Janet Hoover,fiance
33.3 %transferred to Jason Shank,son
33.3%transferred to Matthew Shank,son
2 RiverSource Life Annuity�000c8005 s,664.57 100% 3,664.57
33.4 %transferred to Janet Hoover,fiance
33.3 %transferred to Jason Shank,son
33.3 %transferred to Matthew Shank, son
3 RiverSource Life Annuity�000c3837 2as,113.43 100% 243,113.43
33.4%tranferred to Janet Hoover, fiance
33.3 %transferred to Jason Shank,son
33.3 %transferred to Matthew Shank,son
4 RiverSource Life Annuity�000c0375 2�,856.71 100% 21,856.71
33.4 %transferred to Janet Hoover,fiance
33.3 %transferred to Jason Shank,son
33.3%transferred to Matthew Shank, son
5 Cornerstone FCU Savings 01 s,634.48 100% 3,634.48
50%Joint ownership with Matthew Shank, son 4/26/14
6 Cornerstone FCU Checking 07 3,926.83 100% 3,926.83
50% Joint ownership with Matthew Shank,son 4/26/14
7 Cornerstone FCU Savings 08 �,187.64 100% 1,187.64
50%Joint ownership with Matthew Shank,son 4/26/14
TOTAL(Also enter on line 7, Recapitulation) 292,803.54
REV-1511 EX+(70-09)
-� pennsylvania ��H
DEPARTMENT OF REVENUE ���
INHERITANCE TAX RETURN wry�pw�pA�p��
RESIDENT DECEDENT ML.Allulrh7 I IV111V C
FILE NUMBER
ESTATE OF Shank, David D
21 - 14-0535
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 Hollinger Funeral Horne &Crematory 10,672.98
2 Eby Granite Works 4,328.00
3 Mt. Holly Church of God - Funeral Meal 200.00
4 Dick Reese- Funeral Service 150.00
5 Mt. Holly Cemetery 750.00
B. ADMINISTRATIVE COSTS:
�, Personal Representative's Commissions
Name of Personal Representative(s)
Matthew D. Shank 8,984.00
Street Address 38 Hair Road
City Newville state Pa zip 17241
Year(s)Commission Paid 2014
2. Attorney's Fees Gates&Gates, P.C. 8,984.00
3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills, Probate Fee 443.56
Register of Wills, Inh. Tax Filing Fee 15.00
Register of Wills, Inventory Fee 15.00
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
$ Cumberland law Journal - Estate Advertising 100.00
See attached 23,341.44
TOTAL(Also enter on line 9, Recapitulation) 57,983.98
Schedule H
Funeral E�ei�ses&
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN Administrativ�e Casis corrtinued
RESIDENT DECEDENT
ESTATE OF Shank, David D FILE NUMBER
21 - 14-0535
9 The Sentinel - Estate Advertising 211.78
�o State Farm 126.39
11 Century Link 203.88
12 BP&A Electric 68.65
13 ADT Security 66.02
14 Superior Landscape 1,166.00
15 PPL Gas 344.00
16 Advanced Septic 1,206.00
�� Cumberland Valley Tree Service 685.00
�a Property Settlement Fees (See HUD-1) 19,263.72
Page 2 of Schedule H
���- pennsylvania SCHEDULE I
DEPARTMENTOFREVENUE DEBTS OF DECEDENT MORTGAGE
INHERITANCE TAX RETURN �
RESIDENTDECEDENT LIABILITIES & LIENS
FILE NUMBER
ESTATE OF Shank, David D 21 - 14-0535
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 PHH Mortgage Services xxxx8613 81,867.69
2 Azizkhan Internai Medicine 13.91
3 Hospitalist of Central PA 74.00
4 Carlisle HMA Physicians 142.43
5 Quantum Imaging 33.23
6 Carlisle Regional Center 65.00
7 Newville Ambulance 100.00
8 Orthopedic Institute of PA 103.37
9 Pinnacle Health 250.63
10 West Shore EMS 986.02
11 Visa xxxx3219 2,854.09
12
TOTAL(Also enter on Line 10, Recapitulation) 86,490.37
REV-1513 EX+(01-10)
��� pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BEN EFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shank, David D
21 - 14-0535
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s?
I� TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
1 Matthew D. Shank Son 50% residue
38 Hair Road
Newville, PA 17241
2 Jason S. Shank Son 50% residue
18588 Path Valley Road
Dry Run, PA 17220
3 Janet L. Hoover Fiance 1997 Jeep 2,100.00
40 Hair Road
Newville, PA 17241
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
II� NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAI DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET O.00
�4 �9:1� 71�33733r9 SANDOE&�SS�C P�uE U5:•'��
F��e �, of 1
��],�TX� �l.P W'�� Ar��ri�ri se�a�
•�----.. —.. . _.:__„w..:.^....----- •
; s�iuem�eu�nt M�aA�na n sHa,n�K �
�. ��i�ne�u: 7357 9672 4 OOt '
Ran�fici�rie�_._.._.._.._ _ .,,..—•- ------.__._.___ ._._. ,.. � -- , s�IPrihiU�is paga
Nabe:Cperd wdwor d�spleyn elt aeeounta wiltt an e+otltip hannifcinry dne;gnakion,etick the AddJUpdate$anoHcinry link to roview e!I al�plhla t+�wVr�tB,
AddliJndale�enefldaN�D
,p�"• . R�•M��'�M - ':� '"i=.i
Y �����+..:'�e ':iW'+d1;�^.'_".�:'y��'a'm',�';..���%L',',(1..:i::rn"�'��� vw•- r"���.
u� Ign9tlon ..Reaues!Soslllnp Correotion
VS R�a Bonua 1 N(2
AV1D D StiNNK RIMARY B�NE�f�IARY
Od0 d93Q Og'15 0375 4 044 ANET L HOOVER FlANCE 33,4o°/a
AS�N 5 SI-1ANK SON 33.3d%
AlTh1EW D SIiPJ�K SL�N 33.30%_
E 8URVIVORS,OR THE�uUI�VIVOR
FtCPQRTIONAT�LY
��u� p*signatlon R_,&s�tf�l.sSB�lina Carrc�tlon
�RIPR�SE ONE ACCT •
AVID D 5h{ANK TOQ PPJMARY BENEFIGIARY
00 OG00 5839 8568 8 133 ANET�HOOVER FIANCE 33.403b
ASQN S S1iANK SON 33.30%
MATTHE�N D SWANif 50N 33,3P"�
D�DS {�,�'�"� ME SURVIVQaS,dRTHE SURVIV�R
PROPOR-ffONAtELY
.:.,:,.,. ,... _. ..... ..,
a�1- ' :d 'RO1�t�V�_':..,��; ..� •. •-�:•:•,:...:: _
- •;;,.:
CGOUmt �3gnBtNon Request Spe111np.Gorr6Ctibn
VS RAVA 4 ADVAM'41 .
AVID�SHANK RIMARY BENFFIC1AFxY
. ono n93i 079i 3E37 2 DOA N�'f L HGqWER FIAlJCE 33.d0%
ASON 5 HANK SON 33,3D°k
�1' �,,Q'�, i I�.�.� ATTHE'hl D SWANK SQN 33.30�
HE SURVI�OR$,OR THE SURVIVOR
PROPORTIONATELY
I�ri= ' :'� b TS7[:�UB41C: WODL'.EhNP...... ...,:.• .. ....,,.,,...,�,,.,:� ..,.•, •..,..
�.:
G�qy� IgRAM4i1 Reauest Speiltnp.Correcllan
N SE(iIMME[]qUAL
AVIb Q SHANK RIMARY BENEFICIARY
Op p93�on�1 5sd0 S d0a ANFf L HOdVEFi F�ANC��AO°k
{f SON 33.3Q90
���: 3�JGt�: S� A7TNEW D 3FWNK 5ON 33.30°10
B SURVIVpR$,OR THE SURVIVOR
ROPOft'ilONA7El.Y
NOtes:
• InFormation for Annuivea hetd in a�counts on i1+e Ame+iprrso Brokeiage Ptatform is not
irlClvtlGti.�4r�30r1Eficiary IRfotmefion raferto 1he Account ProfilB p��5 D�tNd CP+'rta�.
FOR INTERNAL US£UNI,v.Nor FoR usE wl'Ri CLIENT3 UNLE6s D1$CL08UR�IS PRaviDEU-
Vlaw Corpwata Er1tI1Me ond IMfN1AEnt pitu�J4uur��Vvobaua RWOU and Ytapulolbm,PMa�Y&SCC1�rip1 C6MOf Md/�M�1 F.-�+��Frnud,
Qppy�{p�Q 2Q16�013 AmMprlao Flnandd,liro.hll�Iphtl M36NStl.USEM W I111S DR6lipM6 W IM P��tl by Iha tertn�af lhe J\merlpiisa Flndf�tldl WEbsflB Ru168 ME R6Q�IIFIIPR��
, _
�����.� 1� �,���`� _ ,����i��'��:. �
��ac�a�
Group; Hausehafd 0389 2191 2 OQ1 Clients: MR pAVID D SHANK
Group Staius: Achiever Circle
�nroliment Date: 031231�007
�randfathered_ Nr� �
Amewipris�Account T�'F.�1h $�80,3A�4.�d
,ACTIV� J�►�C��{'�iTS��WITH POSITlONS I SIJB�ACCaUNTS
ON�Flr�ancial Account �
AMERlFRISE ONE ACCT ' ' '
DAVIa D SHANK TOD � ' . �
Q000 0000�838 6�P8 8133 ,
Tr�nsf�rred from:ooao ooao sss� oaaa a a�� . pou � ib,&'UQ� 2�? ���: ; �,�,::,,�
C�ISH VALUE($): 322.9� ACGOUNT VALUE($)_15,742,85 tas af Q5/19�014} ,
MARGIN V}�UE($): 0.+�0
SECURlTIES VALUE�$}: 15,419.SE �
:r., srP•. —�-P� ..y -:.r -,:4': - '•�?s:,� ;G.,,-,�ti:•;,y:• .,r. ;:•)!: ,;,�.;:"'.'.^.^.':°�^y�• ,•.,-:i,z
.,,,. .,. „i ,-., •.;:•• ,.t •,,or••....,..,. .�„-.�.. ........-ti,:
:,.s;.. ,...��•:,.. �.. ....�.
....,. � y • ,ax��... ...�..1:. .�.'_,. . .a. ... ., � .'. �..�.� •• , I�:
OPPEN EQ 1NCM C OCEI�f 573.4430b �6.89 Q5f49/2d14 '�6,4'f9.88
--.�....�..�.,_� � ---.�__...._......._...._...��..,.,._wW....�,..�..,.�y..,..,..y...�....
Rt�v�r�aurca I,pfe Annuliy
RVS Rata Bonus 7 MQ
i]AViR Q SHANK •. , �Oip , , � � .,,
0000 Q930 0825 0375 4 004 '
CONTRA�7 DAl`�: o���ai2aos ACCQU�ITVALUE(�):21,a��.�� �asato5r�srzo�a.7
tQ'iAl.PURCHASE PAYM�NTS{$): 2�,000.00 , �—
Na alloc�tlon irrformatton found for thfs ascounk
Ta#al Value of Non�lualifled Accounts:$37,599.�6
MR DAYI�D SHANK-Indlvlduai IRA
RtverSaurce L(fe Annulty
RVS RAV�k 4 A�,DVAi+tT Q
bAVib D SHaNK Q�1Q�' aA.'�3, 1'1`�.�F.� • .� `
D000 4�3'I 1�791 3837 2 04�3
C�NTRAGT RATE: D3/12l2007 ' ACCOUNT 1/ALUE($):242,7�14.44{�s of o5�t8t24��}
Tc�TAI,PURCHA�E PAYM�NT�($}_3�3,908.36
... .._..__ r�.��� ux a
rr',�+,v,�a�,��-♦--,� i .'.r.� �v ��Q BtICfl> �t �a • •+, � � Vr���
` ��i� `.� � ,���'P,����' a�a��m�`�h�'���,..�?„_,.��r ry� '.1�:4ii�:i'.�J F ■•����,`ci? '�i�'�,����i�d,r�;J'�y:„`1''`<�'�
_ �l;l���lvu_n\iD��A,{.. ._�4Ntl.: ir�m_Y��M��l._�
A/O' —
I il
FIXEI]ACCOUNT 80.00 4.8� b.QOp O.OQO 1't,223,65
BLACKROCK Gl8 ALOC V.1. a.ao �f0.30 27,�73.445 4_1?5 25,OA5.44
FD CL3
COl.VP BALANGEl7�UND 0.0� 90_4� �6�5b9.700 7.�29 �5,326.$�
CL3
C6L VP CASH 4b.�0 Q.00 Q.000 0.(lQ0 O,QO
MANA�EMEN'T�D CL3 .
COL VP�M�l��lNG• 0.0� �.20 7,826.19� 1.612 92,692�13
MARKET�q CL3
COL VP HICH YI�LD BOND 0_Q� 6.30 8,3$5_24� 9.824 15�296.4�
FD CL3
EATON UAN��VT FLTNG �}.p0 8.24 '11,831.085 1.297 �i5,080.52
FtT INCOM�
.IANUS,45p Sa G�BL AA 0.00 10.4�1 21,043.270 1.201 25,271.43
PR�'MD SS
I�PPENHEfM�Ft GIOB}�L 0.00 a.23 7,9&5.282 1.589 ��,$85.�43
�urr�v�s� �
iVY�UNDS VIP ASSEi" 0.�0 2Q.02 42,204,�20 �1.�t52 �iS.6�6.54
STRATEGY
LAZARD RET GLBL bYN Q.00 10_49 ,�2,35�.227 1.13� �5,�76.84
MLT F'RT SS
FT1lIPT FRN4CLN 1NC VIP p Op '10.s6 23,2Z4.293 1.135 2�,357.20
FUNd CL2
Subtat�l for MR DAY�p p�HANK-individual 1RA:�?,42,7A4��d
MR DA'V1D Cl SHANK�403(b)TSA P►,hllc School Empt�ayaes
R1�rerSource�if�An�ulty
MOD�E S�"t"1`k.�pAENT OR
tiaviops�araK ��Ll° �`ta��f-�? , ,
017DU 0531 0471 5800 5 004 �
CQNTRAGI`I�ATE: �$l15/1976 �ccaun�r�a�,u�(��:N�T AVAILABLE
TOTAL PUFtCHASE PAYMENTS($}: 9,{155,OQ
No allocaUon Inf�rl�fa�tl4n faund for thi�ac�ount
,. .. ��...,.�.._._.. ...... ,...... ...... .................._......_..... , ,.,_.... , .,,...._...
Subtotai far MR Dq,il)p[�$HANit-403(b)T3A Pubiic�choot Employ�as:�O.QO
total Yaiue�f Quatifl�d Accounts:�242,'7A�4.�4�4
r
Braksr�d tttnar�nr,e � .. . . . .. .
CLNY1'RM 7�M 325
DAVid D SFiANK
oaoo oo��asss 7s7o a o�Q
PURCHA��DATE: 05N41Z0�2
� p n p�
BUREAU OF INDIVIDUAL TAXES 4 ;°�� �`�'�••�������"`
Pennsylvania lnheritance Tax ` ''
PO BOX 280601 �, DEPARTMENT OFREVENUE
HARRISBURG PA 17128-0601 Information Notice �
'""-"-"'"'--' REV-1543B E%DocEXEt (U8-12>
And Taxpayer Response FILE NO.2114-0535
ACN 14504562
DATE 07-10-2014
Type of Account
Estate of DAVID D SHANK Security
SSN 205-34-8475 X SEC Acct
Date of Death 05-12-2014 Stock
JASON S SHANK County CUMBERLAND Bonds
18588 PATH VALLEY RD
DRY RUN PA 17220-9730
AMERIPRISE 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.7913837
Date Established REGISTER OF WILLS
Account Balance $243,114.43 1 COURTHOUSE S�UARE
CARLISLE PA 17013
Percent Taxable X 33.333
Amount Subject to Tax $81,037.33
Tax Rate X 0.045
Potential Tax Due $3,646.68 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 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
sho!�n. above as Potenfial T�n!�e.
g �The�nf�rmation is The aUave irforma.ior:is correct, no dc�uct�cns are bEir�y taken,and paymer�t 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% 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 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.
BUREAII OF INDIVIDUAL TAXES Pennsylvania lnheritance Tax `��.�,'" '� peni1S�f�V�!'�lc'�
PO BOX 280601 DEPARTMENT OFREVENUE
HARRISBURG PA 17128-0601 Information Notice
--'"—"'"-"-- REV-15438 EX DocEXEC (08-12)
And Taxpayer Response FILE NO.2114-0535
ACN 14504563
DATE 07-10-2014
Type of Account
Estate of DAVID D SHANK Security
SSN 205-34-8475 X SEC Acct
Date of Death 05-12-2014 Stock
MATTHEW D SHANK County CUMBERLAND Bonds
38 HAIR RD
NEWVILLE PA 17241-9503
AMERIPRISE 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.7913837
Date Established REGISTER OF WILLS
Account Balance $243,114.43 1 COURTHOUSE S�UARE
Percent Taxable X 33.333 CARLISLE PA 17013
Amount Subject to Tax $81,037.33
Tax Rate X 0.045
Potential Tax Due $3,646.68 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 Step 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 other boxes and disregard the amount
sho!��n abo��e as?oten!ia!Tax�ue.
g �The informat��n �s The a�cve infG�mati�r is�orrect, ro deductions arz beir-y tak�n,and payment wiil 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 � 12qa 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 Fart 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.
01;05/04 1�:17 PM Paoe 3
t��
bUR@AU OF INDIVIDUA� 7J1XES }�c��':'-'
Po eox zeosoi Pennsyivania lnheritanceTax �"' � °�:�� pennsylvania
HARR75BURG Pq z�ize-scoz Information Notice �
�� �° DEPARTMEN7QFREVENUE
And Taxpayer Response ��� - ' ""�1iG3`"°°"'F�`°°.�_,
FI�E NO.217 4-0535
ACN 14504561
DATE 07•10-2014
7ype ot Account
Estate ot DAV10 0 SHANK Secunly
SSN 205-34-8475 X SEC Acct
Date of Death OS-i2-20i4 Stock
JAMET L HOOVER CountyCUMBERLAND
635 N HANOVER 37 Bends
CARLISLE PA 17013-1934
AMERIPRISE 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.
Accounl No.7913837 Remit Payment and Forms to:
Oate Established REGISTER OF WIL�S
Account Balance $243,174.43 7 COURTHOUSE SQUARE
Percent Taxable X 33.333 CaRLISLE PA 17D73
Amounl Subject to Tax �81,�37_33
Tzx Rate X 0.150
Po:ential Tax Due $12,155.60 N07E': tf 2ax payments are made within three monihs o}the
With 5%Discount 7ax x 0.95 decedent's date of death,deduct a 5 percent discount on the tax
{ ) $(see NOTE'} due_ Any inheritance tax due will become delinqueni nine r�onths
atter the date of death.
PART St@ 1 : Please check ihe a p
� P ppro riate boxes betow.
� �Nfl tax is due. `I am the sp4use of the deceased or I am the parent of a decedent who was
2'1 years old or vounger at date c#dea,h.
Proceed to Step 2 on reverse. Do not check any ofherboxes and disregarcY the amount
shown aboue as Potenfial T�,x Due.
o �7he;rfa,-mation is The above informaEion is correct,no deductions are being taker,and pay„�ent wi�l be sent
correct. �1ith my response.
Proceed tv Siep 2 on reverse. Do not check any other boxes.
� �The tax rate is incorrect, � 4.5% 1 am a lineal beneficiary(parent,child,grandchild,e:c.)of the deceased.
(Selecl correct tax rate at
richt,and complete Part � �po�, �am a sibling of the deceased.
3 on reverse.)
� 15% All other relationships(including none�.
p �Changes or deductions 7he information above is incorrect and;or debis and deductions were paid.
listed. Complefe Part 2 and part 3 as appropriate on the back of fhis form.
� �Asset will be reported on Tha above-identified assst has been or will be reported and tax paid with the PA Inher;tance Tax
inheri►ance tax form Fietum filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do nol check any other boxes.
Please sign and date the back of the form when fir�ished.
;,-�
" ` pennsylvania
B�R�� oF INDIVIDUAL TAXES Pennsylvania lnheritance Tax i�'
Po BoX 280601 ` DEPARTMENT OFREVENUE
HARRISBURG PA ���28-060� Information Notice ��.1.1�
REV-1543B EX DocE%EC f08-121
And Taxpayer Response
FILE NO.2114-0535
ACN 14504559
DATE 07-10-2014
Type of Account
Estate of DAVID D SHANK Security
SSN 205-34-8475 X SEC Acct
Date of Death 05-12-2014 Stock
JASON S SHANK County CUMBERLAND Bonds
18588 PATH VALLEY RD
DRY RUN PA 17220-9730
AMERIPRISE provided the department with the information below indicating that at the death of the
above-named decedeni you were a joint owner or beneficiary of the account identified.
Remit Payment and Forms to:
Account No.58386568
Date Established REGISTER OF WILLS
Account Balance $15,800.20 1 COURTHOUSE SQUARE
Percent Taxable X 33.333 CARLISLE PA 17013
Amount Subject to Tax $5,266.68
Tax Rate X 0.045 NOTE*: If tax payments are made within three months of the
Potential Tax Due $237.00 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 ofher boxes and disregard the amount
shown above as Potential T�Due.
g n The irformation is The abcv��n`r„m&tion is Cor�eCt, no ueductions are b�ing taken,and paymeni vrill be sent
U 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% 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 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.
BUREAU OF INDIVIDUAL TAXES t-;'� };� p�nnsylv�r�ia
Pennsylvania lnheritance Tax ,
PO BDX 280601 � DEPARTMENT OFREVENUE
HARRISBURG PA 17128-0601 Information Notice � :
-���"-�°��-�- ftEY-1543B EX UocEXEL (OB-12)
And Taxpayer Response
FILE NO.2114-0535
ACN 14504560
DATE 07-10-2014
Type of Account
Estate of DAVID D SHANK Security
SSN 205-34-8475 X SEC Acct
Date of Death 05-12-2014 Stock
MATTHEW D SHANK County CUMBERLAND Bonds
38 HAIR RD
NEWVILLE PA 17241-9503
AMERIPRISE 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.58386568
Date Established REGISTER OF WILLS
Account Balance $ 15,800.20 y COURTHOUSE S�UARE
Percent Taxable X 33.333 CARLISLE PA 17013
Amount Subject to Tax $5,266.68
Tax Rate X 0.045
Potential Tax Due $237.00 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) $(see NOTE*) due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART Step 1 : Please check the appropriate boxes below.
1
A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do nof check any other boxes and disregard fhe amount
s"cwn above as Pcts^fia; ,Tax Due.
g �The information is The above infermation is cor;ect, no ueduct�ons are beirg taken,anu payment will be sent
correct. with my response.
Proceed to Step 2 on reverse. Do not check any other boxes.
� �The tax rate is incorrect. � 4.5% I am a lineal beneficiary (parent,child,grandchild,etc.) of the deceased.
(Select correct tax rate at
right,and complete Part � 12% I am a sibling of the deceased.
3 on reverse.)
� 15% All other relationships(including none).
p ❑Changes or deductions The information above is incorrect and/or debts and deductions were paid.
listed. Comp/ete Part 2 and part 3 as appropriate.on the back of this form.
E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please sign and date the back of the form when finished.
01;05/04 i�:19 PM Page 12
`7�+—$��_
BUREAII �F INDIVIDUAL TAXES 1'r,�� �� pennsytvania
Penns Ivania lnheritance Tax ,;
PO 0a% 2BU6p1 Y DEPARTMENY OF nEVENUe
H4RR]S911R6 PA 17126-U601 Inform�tion Notice ���I �EV-jyc�6 cc�n.��[c ior•ie:
And Taxpayer Response
FILE NO_21140535
ACN 74504585
DA7E 07-1�-2014
Type of Account
Estate of�AVID D SHANK 5ecurity
SSN 2�5-34-8475 X SEC Acct
Date of Death 05-12-2014 Siock
JANET L HOOVER County CUM6EF1[AND Bonds
635 N HANOVER ST
CARLISLE PA 17013-193G
AHERI PRTSE 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 icfentified.
Account No.7158005 Remit Payment and Forms to:
Date Established REG{STER OF WILLS
kccount Balance $3,664.57 1 COl1FlTHOUSE SQUARE
CARLISLE PA 17813
Percent Taxable X 33.333
F�mou:�t 5ubject to Tax $ 1,227.51
Tax Rata X 0.150
Po�entiaf Tax bue $18323 NOTE': If tax payments are made w�ithin three monihs oi the
detedent's date oi death,deduct a 5 percent discount on[he tzx
�Nith 5%Discount(Tax x 0.95) $(see NOTE') due. Any fnheritancetax due will become delinquent nine mor.ths
after the date ot death.
PART Step 1: Please check the appropriate boxes below.
1
� �No tax is due. I am tf�e spouse of the deceased or I am the parent of a decedent who was
21 years ol�+ or�our+ger at date of tfea�h,
Proceed to Step 2 on reverse. Do noi check any ofher boxes and disregard the amoLnt
shown a6ove as PotertiaJ Tax Due.
g �The informafion is 7he above information is corr�ct,no ded�ctions are being telcen,and p�ynen,vril!b�sertt
correct. with my response.
Proceed to S�eA 2 on reverse. Do not check any oiher boxes.
� �The tax rate is incorrect. � � 4.5% i am a lineaf beneficiary(parent,child,grandchild,etc.}of the deceased.
(Select correct tax rate at
rioht,and compiete Pact � 7 2% I am a sibling of the d2ceased.
3 cn reverse.)
� 15% All other relationships(including none).
p �Changes or deductions The information above is incorrect and(or debts and deductions were paid.
listed_ Complefe Part 2 and part 3 as appropriafe on fhe back o1 fhis form.
E �Asset wiil be reported on 7he above-identified asset has been or will be reported and tax paid with the PA Inheritan�e Tax
inheritance tax form Return i�led by the estate representative.
REU•1500. Proceed to Step 2 on reverse. Do nof check any other boxes.
Please sign and date the back of the form when finished.
� p�nrtsylvania
BUREAU oF INDIVIDUAI TAXES Penn Information Noticee Tax ��
Po BoX 280601 y ` � DEPARTMENT OFREVENUE
HARRISBURG PA 17128-0601 �^`
REV-1543B Ek DocEXEL (DB-12)
And Taxpayer Response FILE NO.2114-0535
ACN 14504566
DATE 07-10-2014
Type of Account
Estate of DAVID D SHANK Security
SSN 205-34-8475 X SEC Acct
Date of Death 05-12-2014 Stock
MATTHEW D SHANK County CUMBERLAND Bonds
38 HAIR RD
NEWVILLE PA 17241-9503
AMERIPRISE 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.7158005
Date Established REGISTER OF WILLS
Account Balance $3,664.57 1 COURTHOUSE SOUARE
Percent Taxable X 33.333 CARLISLE PA 17013
Amount Subject to Tax $ 1,221.51
Tax Rate X 0.045
Potential Tax Due $54.97 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.
� U The irf�r;naticn is The above informat�on is correct, r�o 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 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.
BUREAU oF INDIVIDUAL TAXES Pennsyivania lnheritance Tax �::,`� ��� {�@�������nla
Po Box 2e06o1 DEPARTMENT OF REVENUE
HARRISBURG PA 17128-D601 Information Notice .
—"'��"���-'"" REV-1543B EX DocEXEt <OB-12)
And Taxpayer Response
FILE NO.2114-0535
ACN 14504565
DATE 07-10-2014
Type of Account
Estate of DAVID D SHANK Security
SSN 205-34-8475 X SEC Acct
Date of Death 05-12-2014 Stock
JASON S SHANK County CUMBERLAND Bonds
18588 PATH VALLEY RD
DRY RUN PA 17220-9730
AMERIPRISE 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.7158005
Date Established REGISTER OF WILLS
Account Balance $3,664.57 1 COURTHOUSE S(�UARE
CARLISLE PA 17013
Percent Taxable X 33.333
Amount Subject to Tax $1,221.51
Tax Rate X 0.045
Potential Tax Due $54.97 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 Poten.tia!Tar.Due.
g �The informa±ien is The above;nfcrmatior; is ccrract, r�u��duct�ons di2 Gzifly taken,and payrnent wiii be seni
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 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.
*
RF'�'�ENEC�
, JUiv 0 5 2014
CORNERSTONE sA�
P.O.Box I 181,5 Eastgate Drive,Carlisle,PA 17015
� F e d e r a I C r e d i t U n i o n Te�ephone (717) 249-I 66 I FAX (717) 249-8208
Member founded— Service based www.cornerstonefcu.coop
June 3, 2014
Gates & Gates Attorneys
250 York Street
Hanover PA 17331
RE: The Estate of David D Shank
Dear Samuel:
At the time of his death, David D Shank had a joint owned account with Matthew D Shank.
Listed below is the information you have requested in your letter dated May 28, 2014:
1) The type of each account:
Savings 01, Checking 07, S�vings OS
2) Date of death balance including accrued interest:
Savings 01-$3634.48
Checking 07-$3926.83
S.avings 08$1187.64
3) Ownership was a single account prior to April 26, 2014
4)Account was opened:
Savings-0110/7/1981
Checking-0710/7/1981
Savings-08- 10/09/2009
If you require any further information, please call me at 717-249-1661, ext 251.
Sincerely:
� ' ) v
�.�./ '
�
Cindy Willhide
Financial Seroice Representative
MEMBER SAVINGS ACCOUNTS FEDERALLY INSURED TO $250,000 BY THE NATIONAL CREDIT UNION ADMINISTRATION
� St
�
MEMBERS 1S�
FEDHRAL CREDIT iJNION
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 508243-00
Date Account Established 05/28/2013
Principal Balance at Date of Death $22.00
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $22.00
Name of Joint Owner None
MEMBERS 1ST FEDERAL CREDIT UNION
��,¢�.da_=2-.i(�
Tessa L Klugh
Lending Insurance Support Specialist
July 1, 2014
Estate of: DAVID D SHANK
Date of Death: 05/19/2014
Social Security Number: 205-34-8475
5000 Louise Drive • P.O.Box 40 • Mechanicsburg,Pennsylvania 17055 • (800) 283-2328 • wwwmemberslst.org
OMB Approvai No.2502-0265
�, �,����a A. Settlement Statement (HUD-1)
-�
.- . ..
1.�FHA 2.�RHS 3.Q Conv.Unins. 6.File Number: 7.Loan Number: 8.Mortgage Insurance Case Number:
14-1576EX 0256754813
4.Q VA 5. XQ Conv.Ins.
C.Note:This form is furnished to give you a statement of actuai settlement costs.Amounts paid to and by the settlement ageMS are shown.Items marked
"(p.o.c)"were paid outside the ciosing;they are shown here for informational purposes and are not included in the totals.
D.Name&Address of Borrower: E.Name&Address of Seller: F.Name&Address of Lender:
lester D.Singer,Sharon�Singer Estate of David D.Shank Members 1st Federal Credit Union
r� SfS 8-//-/y PO Box40,Mechanicsburg,PA 17055
G.Property Location: H.Settlement Agent: I.Settlement Date:08/1'V2014
40 Hair Rd. Capital Area Abstractors,LLP Disbursement Date:08/1 Y2014
Newville,PA 17241 500 N.Progress Ave.,Harrisburg,PA 17109
Penn Township
Phone:717-920-9179 Fax:717-909-3045
Place of Settlement: TitleExpress
500 N.Progress Ave.,Harcisburg,PA 17109 Printed 08/1'V2014 at 12:46 pm
by DB
:. . � .
100. Gross Amount Due from Borrower 400. Gross Amount Due to Selier
101. Contract sales price 169,900.00 401. ConUact sales price 169,900.00
102. Personal ro e 402. Personal ro e
103. Sett�ement charges to borrower(line 1400) 6,861.26 403.
104. 404.
105. 405.
Ad'ustments for items aid b seller in advance Ad'ustments for items aid b seller in advance
106. City/town taxes to 406. Cityltavn taxes to
107. County taxes 08I1112014 to 12I31I2014 179.35 407. County taxes 0811112014 to 12131/2014 179.35
108. School taxes 08/11I2014 to O6I30/2015 1,902.10 408. School taxes 0811112014 to 0613012015 1,902.10
109. 3rd quarter refuse 08It 1I2014 to 09/3012014 25.91 409. 3rd quaRer refuse 08111I2014 to 09/30/2014 25.91
110. 410.
111. 411.
��2• 412.
120. Gross Amount Due from Borrower 178,868.62 420. Gross Amount Due to Seller 172,007.36
200. Amounts Paid b or in Behalf of Borrower 500. Reductions In Amount Due to Seller
201. Deposit or eamest money 1,000.00 501. Excess deposit(see instructions)
202. Principal amount of new loan(s) 161,405.00 502. Settlement charges to seller(line 1400) 14,166.72
203. ExisGn loa s taken sub"ect to 503. Existin loa s taken sub'ect to
204. Credit for Appraisal 425.00 504. payoff of first mortgage loan#7116088613 to PHH 30,540.50
Mort a e
205. 505. Payoff of second mortgage loan
206. 5p6.
207. 507.
208. SellerAssist 5,097.00 508. SellerAssist 5,097.00
209. 509.
Ad'ustments for items un aid b seller Ad'ustrnents for items unpaid b seller
210. City/town taxes to 510. Cityltown taxes to
211. County taxes to 511. County taxes to
212. School taxes to 512. School taxes to
2�3• 513. Escrow for Inheritance Tax Payment 28,215.00
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
22�• Total Paid b Ifor Borrower 167,927.00 520. Total Reduction Amount Due Seller 78,019.22
300. Cash at Settlement fromfto Borrower 600. Cash at Settlement tolfrom Selier
301. Gross amount due from borrower(Iine 120) 178,868.62 gp�. Gross amount due to seller(line 420) 172,007.36
302. �ess amounts paid bylfor borrower(line 220) 167,927.00 602. Less reduc6ons in amount due seller(iine 520) 7g,p�g,22
303. Cash X❑ From ❑ To Borcower 10,941.62 603. Cash Q Ta � From Seller 93,988.14
mis ra�,umess u asdan a w�ny�ana oMa m�wia��me�.rio cmneemteniv�•=.,�.a;a°mi.a�m�.e a m.�iory 4Me ia dws��B•a�o o�ie.iM'9`�"�m'r�w �.��«m yo�.,,�..q„„ �,,,a.
%�Ilemenl pracess Wniu b e RESPA mvaraE Ireneexiiun M��Inlwm�tlm Eurinp�Ir
See attached addendum for additional information
Previous editions are obsolete Page 1 of 4 HUD-1
700. TotalRealEstateBrokerFees 9,888.18 Paid From Paid From
Division of commission line 700 as follows: B01't'Ow21''S S2118t''S
701• $q;gq4.09 to Century2lABetterWay Funds at Funds at
702. $4,gq4.09 to ExitRealtyCapitalArea S2ttl2m2nt S2tt12mEnt
703. Commission paid at settlement 9,888.18
704. hansacGon fee to Exit Realty Capital Area 150.00
800. Items Pa able in Connection with Loan
801. Our origination cha�ge (Includes Origination Point 0.000%or$0.00) $595.00 (from GFE#1)
802. Your credit or charge(points)for the specific interest rate chosen $ (from GFE#2)
803. Your adjusted origination charges (from GFE A) 595.00
804. Appraisal fee to Members tst Federal Credit Union (�m GFE#3) 425.00
805. Credit re rl to from GFE#3
806. Tax service to from GFE#3
807. Flood certification to from GFE#3
808. to
900. Items Re uired b Lender to be Paid in Advance
901. Daily interest charges from from 0811112014 to 09/01I2014 @$18.2410/day (from GfE#10) 383.06
902. MoRgage insurance premium for months to (from GFE#3)
903. Homeowner's insurance for ears to State Fartn Insurance Com anies (from GFE#11) 705.00
904. months to fmm GFE#11
1000.Reserves De osited with Lender
1001.Initiai deposit for your escrow account (from GFE#9) 906.20
1002.Homeowners insurance 2 months $ 58.751monlh $117.50
1003.Mortgage insurance months $ 72.63/month $
1004.Property taxes months $ O.00lmonth $
1005.County taxes 7 months $ 38.151month $267.05
1006.School taxes 3 mpnths $ 205.171month $615.51
1007.Aggregate Adjustment $-93.86
1100.Title Cha es
1101.Title services and lenders title insurance $ from GFE#4 1,645.00 120.00
1102.Setllement or closing fee to $
1103.Owners title insurance-First American Title Insurance Company $ from GFE#5 165.00
1104. Lendefs title insurance-Firsi American TiUe Insurance Company $1,435.00
1105.Lenders title policy limit$161,405.00 Lender's Policy
1106.Owners title policy limit$169,900.00 Owners Policy
1107.AgenYs portion of the total title insurance premium $1,296.25
to Ca ital Area Abstractors,LLP
1108. Undenvriter's portion of the total tiUe insurance premium $303.75
to First American Title Insurance Com an
1109. to $
1200.Govemment Recordin and Transfer Char es
1201. Govemment recording charges $ (from GFE#7) 188.00
�z02•Deed$77.00 Mort a e$111.00 Release$
1203.Transfertaxes $ (fromGFE#8) 1,699.00
1204.City/County taxlstamps Deed$1,699.00 MoR a e$
1205.State Tax/stamps Deed$1,699.00 Mort a e$ 1,699.00
1206. Deed$ Mort a e$
1207. $
1300.Additional Settlement Char es
1301.Required services that you can shop for (from GFE#6)
t302.Survey to $
1303.SepGc Inspection to ECO-Tech $275.00 P.O.C.B'
1304.2014/2015 School taxes to Mable G.SNtt 2,412.80
1305.3rd quarter refuse to South Ham ton Cumbe�land Trash 46.74
��i � • � 6,861.26 14,166.72
'Paid outside of closing by(B)orrower,(S)eller,(L�nder,(I)nvestor,Bro(K)er."Credit by lender shown on page 1."'Credit by seller shown on page 1.
See attached addendum for additional information
Previous editions are obsolete Page 2 of 4 HUD-1
Com arison of Good Faith Estimate GFE and HU0.1 Cha es Good Paith Estimate HUD-1
Cha es That Cannot Increase HUD-1 Line Number
Our origination charge # 801 595.00 595.00
Your credit or charge(points)for the specific interest rate chosen p 802 0.00 0.00
Your adjusted origination charges # 803 595.00 595.00
Transfertaxes # 1203 1,699.00 1,699.00
Char es That in ToWi Cannot lncrease More Than 10% Good Faith Estimate HUD�1
Govemment recording charges # 1201 266.50 188.00
Appraisalfee #804 425.00 425.00
#
#
#
#
#
#
691.50 613.00
� $ -78.50 or -11.3521°/a
Char es That Can Chan e Good faith Estimate HUD-1
Inilial deposit for your esaow account # 1001 78572 90620
Daily interest charges from #901 1824101da 394.67 383.06
Homeowner's insurance # 903 720.00 705.00
Title services and lenders title insurance # �101 1,808.75 1,645.00
Owners title insurance-First American TiUe lnsurance Company # 1103 42.46 165.00
#
#
Loan Terms
Your iniGal toan amount is $161,405.00
Your loan term is 30.years
Your initial interest rate is 4.1250%
Your initial monthly amount owed for principal,interest,and any moRgage $854.88 includes
insurance is QX Principal
X❑Interest
XQ Modgage Insurance
Can your interest rate rise? ❑X No. ❑Yes,it can rise to a maximum of %. The first change
will be on 1 I and can change again every years after I l . Every
change date,your interest rate can increase or decrease by %. Over the life of
the loan,your interesl rate is guaranteed to never be lower than %or higher
than %.
Even if you make payments on time,can your loan balance rise? ❑X No. ❑Yes,it can rise to a maximum of$ .
Even if you make payments on 6me,can your monthly amount owed for XQ No. ❑Yes,the first increase can be on I I and the monthly
principal,interest,and mortgage insurance rise? amount owed can rise to$ .
The maximum it can ever rise to is$
Does your loan have a prepayment penalty.� ❑X No. ❑Yes,your maximum prepayment penalty is$ .
Does your loan have a balloon payment? X❑No. ❑Yes,you have a balloon payment of$ due in
years on / I .
Total monthly amount owed including escrow account payments ❑You do not have a monthly escrow payment for items,such as property taxes
and homeowners insurance. You must pay these items direcily yourself.
XQ You have an additional monthly escrow payment of$302.07
that results in a total initiai monthly amount owed of$1,156.95. This inGudes
principal,interest,any mortgage insurance and any items checked below:
Q Property taxes QX Homeowner's insurance
�Flood insurance ❑X School taxes
❑ ❑
Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form,please contact your lender.
See attached addendum for additional information
Previous editions are obsolete Page 3 of 4 HUD-1
HUD CERTIFICATION OF BUYER AND SELLER
I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief,it is a true and accurate statement of all receipts and
disbursements made on my account or by me in this transaction.I further certi(y that I have received a copy of the HUo-1 Settlement Statement.
ster D.Singer
�������
Sharon .Singer
F
�c� � � �o�
Estate of David D.Shank
The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction I have caused or will cause the funds to be
disbursed in accordance with this statement.
, ������
SETfI MENT AGENT DATE
WARNING:IT IS A CRIME TO KNOW INGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM.PENALTIES UPON
CONVICTION CAN INCLUOE A FINE AND IMPRISONMENT.FOR DETAILS SEE TITLE 18:U.S.CODE SECTION 1001 AND SECTION 1010.
See attached addendum for additional information
Previous editions are obsolete Page 4 of 4 HUD-1
Last Will
and
Testament
of
�����1 �o ���.��
I,David D.Shank,of 40 Hair Road,Newville,Cumberland County,Pennsylvania,
being of sound and disposing mind,do make,publish and declare this as and for my Last
Will and Testament,hereby revoking any and all Wills by me at any time heretofore made.
FIRST:I do direct that all my just debts,including funeral expenses,be paid by my
hereinafter named Executor as soon after my decease as may conveniently be done. All
inheritance,estate,transfer,succession and death taxes of any kind whatsoever,which may
be payable Uy reason of my death,whether or not with respect to property passing under
this will, shall be paid out of my residuary estate.
SECOND : I specifically give, devise and bequeath my real property situated at
8016 Mire Pond Two, Chincoteague, Va. unto my sons, Jason S. Shank and Matthew D.
Shank. If a son(s) should predecease me,his share shall lapse. In the event my sons can
not agree on whether to retain the property as co-tenants or to sell the property and divide
the sale proceeds equally, the son desiring to retain the property shall be entitled to buy-
out the other sori s interest in the property. In 2013 the buy-out value shall be Twenty
�,w,_...,_* _:.
Page 1 of 6 David D. Shank
Thousand Dollars($20,000.00)and shall increase by Three percent(3%)arulually. The buy
out price set forth herein shall control and the assessed value,appraised value,fair market
value or any other valuation of the property shall not be relevant except to the
determination of any inheritance tax. The son opting to retain the property and buy-out
the other shall have one-hundred(180)days from receipt of written notice by the other that
, , , , , < <.._ • �,. �.__. ,��..,..,.'. • �t. �; �„
ri2 QeS1TeS I115 111i�TeST iC� i[7e�Gu�tl�-t'Su� w CXeiCiSc SuCii uuy-vut� GUICl VJ1JC� u�2 v�,«Gi� w
buy-out is forfeited and the property shall be sold.
THIRD :
A. I direct my Executor to sell my real property situated at 40 Hair Road,
Newville, Pennsylvania.
B. Until the property is sold, my fiancee,Janet L. Hoover may continue to
reside therein. My estate shall pay all mortgage payments, taxes, insurance and utilities
(except telephone and cable/satellite) on the property, without contribution or
reimbursement from my fiancee, pending the sale of the property.
C. Any life insurance proceeds payable to my estate shall be used by my
Executor to apply toward the mortgage payments and/or satisfaction and/or reduction
of the mortgage.
D. I direct my Executor to utilize the net sale proceeds, after payment of all
debts of my estate; pursuant to paragraph FIRST above, to purchase a residence for my
fiancee's use. My fiancee, Janet shall control all decisions regarding the purchase of the
residence, conditioned upon i) the new property being located in Cumberland, Coun ,
r �/� ,�'tc'�v�E.t�.
� �
Page 2 of 6 David D. Shank
Pennsylvania and ii) the property not being suUject to a mortgage. Title to the property
shall be sori s names, Matthew D. Shanlc and Jason S. Shank, as Tenants In Common,
subject to a life estate unto my fiancee,Janet L.Hoover.
E. The life estate shall terminate upon any one of the following
circumstances;
,{ � a..,,1�...
. l. 1Vly 11alLCCC j UCdlll� Ql . .
ii. Her remarriage or co-habitation. Co-habitation shall be defined as
my life tenant residing with and/or staying overnight at any place with another person of
the opposite sex for a cumulative total of thirty(30)days or more within any sixty(60)day
period; or
iii. Her admission to a nursing home, assisted living facility,
rehabilitation facility,hospital or otherwise institutionalized for a period of One Hundred
Eighty (180) days within a one (1) year period, or
iv. Her failure to occupy the property as her principal place of
residence for a period of One Hundred-Twenty (120) consecutive days, or
v. Her delinquency of more than ninety (90) consecutive days of
payment of any utility provided by a municipality or municipal authority,property taxes
and assessments;or
vi. Her failure to maintain the property and its fixtures in a good and
habitable condition commensurate with the condition of the properties in the surrounding
community or neighborhood. Her financial obligation shall be limited to repairs a d
�
Page 3 of 6 David D. Shank
maintenance expenses costing less than$1,000.00 per repair/maintenance item.
F. Any excess proceeds from the sale of my home, not needed for the
purchase of a new residence for Janet, shall be distributed in accordance with paragraph
SEVENTH below.
SIXTH: I specifically give, devise and bequeath unto my fiancee,Janet L.Hoover
! f Y 1 / \ T Y P � �_ : .1 _. __L_._'.�_ � •
her cnoice ot one or my venicie�sJ i own ai tne tirne ai�ny uear��anu dny �u,.�«sru��gs i��l�y
home at 40 Hair Road,Newville,except my mother's china cabinet and its contents and my
mother's writing desk.
SEVENTH:I do give,devise and bequeath the rest and remainder of my estate unto
my children, Matthew D. Shank and Jason S. Shank,per stirpes.
EIGHTH: I do nominate, constitute and appoint as Executor of this my Last Will
and Testament, my son, Matthew D. Shank. In the event the said Matthew D. Shank is
unable or unwilling to serve as the Executor of this my Last Will and Testament, I do
nominate,constitute and appoint my son,Jason S.Shank,as the Alternate Executor of this
my Last Will and Testament. No fiduciary shall be required to enter bond or furnish
sureties in any jurisdiction.
--� �
�� �
Page 4 of 6 David D. Shank
IN WITNESS WHEREOF, I, David D. Shank, Testator, have to this my Last Will
and Testament,contained on this page and the foregoing pages,set my hand and seal,this
� �'�"' day of F��e���N , 2013.
/
� (SEAL)
David D. Sha
The foregoing instrument,contained on this and the preceding pages,was by him
signed, sealed, published and declared as and for his Last Will and Testament, in the
presence of us,who, in his presence and in the presence of each other, and at his request,
have hereunto subscribed our names as witnesses.
a J
� � of 1��-�nc�,�L,�?c�
. �
(.�r�+-�- of �-- �i..c-i;�Cf� � f}��.
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y�TE' �tr - , ���<° � �'� 1 ;� �and
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��`--�-; ��ti-�-- t11e Testator and Witnesses, respectively, whose names
are signed to the attached or foregoing instrument, being first duly sworn, do hereby
declare to the undersigned authority that the Testator signed and executed the instrument
as his Last Will and Testament and that he had signed willingly and that he executed it as
his free and voluntary act for the purposes therein expressed,andthat each of the witness-
es,in the presence and hearing of the Testator,signed the Will as witnesses and that to the
best of his/her knowledge,the Testator was at the time eighteen(18)years of age or older,
Page 5 of 6
of sound mind and under no constraint of undue influence.
;
,
.
,
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TESTATOR
� �
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WITNESS
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J.i �
'�a�.'�.1 (,�;�
T�TTT�jF��
SUBSCRIBED, sworn to and acknowledged before me by David D. Shank, the
�
Testator, and subscribed and sworn to before me by'��arG--c,� �� and
� ' `f�'► j`
��'`���; �,u�'�- Witnesses,this�day of r ����- �Z" ` 2013.
i , _� � .I
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�� � 1
OTARY PUBLIC
MY COMMISSION EXPIRES:
E:!'7fM�11E7�f�ilF:v�L��1£..-'e�#��t____ ,�f��'lLVAP,�
Nctariai Seal
Carol M.gweitzer,�Jotary Ai�biic
Nanc�ver Bcsro,Yark Cvunty
My Con7mi�lr�t;���g p�.11,2�J15
MEhfB�R,PFMFlSYLN,�ldIA r�55QC7A`ildW OF NQTARIES
Page 6 of 6
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GATES&GATESa
TRIAL ATTORNEYS
Samuel A.Gates,Esq. Gregory L.Hollinger,Esq.
Kevin G.Robinson,Esq. Rachel L.Gates,Esq.
♦ ♦ ♦
Samuel K.Gates,Esq.(retired)
rv
«!�}
August 27,2014 Q �
io � � � �
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CD
� �j � ^AC�!
Cumberland County Register of Wills �, � � � � �
One Courthouse Square �--, c� -°r� � �
Carlisle,PA 17013 � � f,,, � �
„� "
C� .�. :
RE: Estate of David D. Shank � N �
SSN: �c�c-�-8475
Dear Sir/Madam:
Please be advised that this firm represents Matthew D. Shank, Executor of the Estate of
David D. Shank,who died on May 12,2014.
Enclosed please find three copies of the inheritance taac return to be filed, along with a
check in the amount of$21,815.18 for the inheritance ta�c owed.
Also enclosed is the inventory to be filed for the estate.
Please return one copy each of the clocked in copies of the inheritance tax return and the
inventory for our file in the SASE. Thank you.
Best Regards;
�ates c��i�tes P.c.
�i.
Samuel A. Gates,Esq.
SAG/clv
Enclosures
♦ 250 York Street, Hanover, Pa. 17331 ♦ (717) 632-4971 ♦ fax (717) 632-2243 ♦