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HomeMy WebLinkAbout08-25-14 J d 1505610143 REV-1500 EX(d2-11, ' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania CauMy code Year Fire Number Bureau of individual Taxes oeeJ° ei PO BOX.280601 INHERITANCE TAX RETURN 21 13 1312 Harrisburg,PA 17126.0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 11 26 2013 08 02 1920 Decedent's Last Name Suffix Decedent's First Name MI SHEDLOSKY DDS EDMOND F (if Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI r Spouse's Social Security Number THIS RETURN MUST BE FLED IN OUPLiCATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW fxl 1. Original Return 2. Supplemental Return 3. Remafider Return(Date of Death Prior to 1243-82) 4. Limited Estate 48,Future Interest Compromise S. Federal Estate Tax Return Required (date or death after 12-12.82) ® 6, Decadent Died Testate � 7. Do Melt��rced o LK"Trust 8. Total Number of Sate Oaposif Boxes (Attach Copy of Will) (Altech rust) 9. Litigation PfarREdS Received 10,S P red't D dl Death 11.Election to tax under See.9113(A) ti9 t�n t 1a�t<•17 (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIREC,ER T0: Name Daytime Telephone NuLaer M CRAIG S BOYD ESQ 610 858 3164: ' c C) C:' BD -p C72 rn a REGISTER OF WILLS(UUS&NEY C11 C7 > First Line of Address b n o 381 6TH AVENUE S CC) r fir r Second Line of Address � v � � Cf> y C ) City or Post Office DATE FILED State 21P Code NAPLES FL 34102 Correspondent's e-mail address: craigsboyd(Mgmail.com Under penalties of per)ury.I declare that I have examined this return,including9 wl accompanying schedules and statements,and to the best or my knowledge and belief, it is true,correct and complete.D;eeeclyaaradon of preparer other than the person3i representative is based on all information of which preparer has any knoedge. IG SNATU F PER N RE0.�t FILING REjyM DATE /SC cw Mark Shedlosky L/ ADDRESS 312 West Main Street4 Shiremanstown PA 17011-6332 SIGNATURE PR R 4TH REP SENTATIVE TE Craig S. Boyd Esq. Is ne ADDRESS 7 East Philadelphia Avenue, Naples, FL 34102 Side 1 1505610143 1505610143 PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Shedlosky, Edmond F. DDS 21 .13-1312 Under penalties of perjury,1 declare 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#2 � Name J ie Shedlosky Panes Addressl 316 North 26th Street Addressl City, State,Zip Camp Hill,PA 17011 Date §1104.Appointments and incompatible offices,PA STS Pa.C.S.A.§1104 Purdon's Pennsylvania Statutes and Consolidated Statutes Title 8 Pa.C.S.A.Boroughs and Incorporated Towns Part I.Boroughs(Refs&Annos) Chapter u.Powers,Duties and Rights of Appointed Officers and Employees Subehapter A.General Provisions 8 Pa.C.S.A.§1104 Formerly cited as PA ST 53 P.S.§46104 §1104.Appointments and incompatible offices Effective:June 17,2014 Currentness (a) General rule.--Unless there is incompatibility in fact, an elective or appointive officer of the borough shall be eligible to serve on any board, commission, bureau or other agency created by or for the borough or any borough office created or authorized by statute and may accept appointments under the statute. (b)Prohibition.-- (1)Except as set forth in paragraph(2),no elected borough official of a borough with a population of 3,000 or more may serve as an employee of that borough. (2)Paragraph (1)shall not apply to a borough official serving as an employee of that borough prior to the certification of the 2010 official census or a subsequent latest official census which indicates an increase in the population of that borough to 3,000 or more. (c) Multiple offices.--If there is no.incompatibility in fact and subject to subsection (a) as to compensation, appointees of council may hold two or more appointive borough offices,but no mayor or member of council may serve as borough manager, secretary or treasurer. (d)Magisterial district judges.--No person holding the office of magisterial district judge may at the same time hold any elected or appointed borough office. (e)Secretary and treasurer:-The offices of secretary and treasurer may be held by the same person if authorized by ordinance. (f)Police officers and firefighters.-- (1)No police officer or firefighter may hold an elective office of the borough that employs the police officer or firefighter. WeSllawNexr 02014 Thomson Reuters. No claim to original U.S. Government Works. 1 §1104.Appointments and incompatible offices, PA ST 8 Pa.C.S.A.§1104 (2)No police officer or firefighter who is employed by a regional department,council of government or other cooperative venture may hold an elective office of any municipality that participates in the regional department,council of government or other cooperative venture. (3)No police officer or firefighter may hold an elective office of the borough in which the police officer or firefighter resides if the department employing the police officer or firefighter is providing police or fire protection service to that borough by contract. (g)Majority vote required.-.All appointments to be made by the council shall be made by a majority of the members of council unless a different vote is required by statute. (h) Construction..-Nothing contained in this section shall be construed to affect the eligibility of a borough official to hold any other public office or receive compensation. Credits 2014,April 18,P.L.432,No.37,§ 1,effective in 60 days[June 17,20141. Editors'Notes BOROUGH CODE COMMENTS Borough Code 2012: Incorporates a provision of Act 104 of 2011,with a clarifying amendment added in Senate Appropriations Committee on April 2,2012,that provides that a borough official employed by a borough with a population of less than 3,000 may continue to be employed by that borough after its certification of any decennial census,beginning with the 2010 census,which shows its population has increased to 3,000 or more.Now provides that no person holding the office of magisterial district judge may at the same time hold any elected or appointed borough office (previously, the prohibition was only against holding the office of borough treasurer).However,see 42 Pa.C.S. 4 3302,prohibiting a magisterial district judge from holding any elected or appointed public office in the Commonwealth. Thus, no substantive change in law is made since other law prohibited a magisterial district judge from holding other elected or appointed office. Adds a new subsection (f) that states a police officer or firefighter may not hold an elective office in the borough that employs the police officer or firefighter and that the police officer or firefighter employed by a regional department,council of government or other cooperative venture may not hold an elective office in a municipality that participates in that venture, thus integrating operative provisions of HB 1288,PN 3913 (2010).A section is added to the end of the bill thatprovides the addition of 1104(f)shall apply to officials elected or appointed to fill a vacancy in an elected office after the effective date of the section.Editorial amendments.Subdivided for clarity. Borough Code 1966: Derived from 1927,May 4,P.L.519,art.Xi,§ 1104,added 1943,May 27,P.L.674, §2,as amended 1947,. July 10, P.L. 1621, § 34; 1953,July 2,P.L.320,§ 1. "Mayor"substituted for"burgess." W sill vNeXt`O 2014 Thomson Reuters. No claim to original U.S.Government Works. 2 § 1104.Appointments and incompatible offices, PAST 8 Pa.C.S.A.§ 1104 All references to appointments by the "burgess with the approval of council' or by "the corporate authorities" or by"the burgess and council'were deleted,because the Borough Code of 1966 has no provisions for appointments otherwise than by the council. Any borough,rather than boroughs with less than 2500 population only, may combine the offices of secretary and treasurer,with one individual appointed to the two offices. The prohibition against a justice of the peace holding the office of treasurer was inserted to conform to the Act of 1963,August 1,P.L.436,§ 1. Notes of Decisions(1) 8 Pa.C.S.A. § 1104,PA ST 8 Pa.C.S.A. § 1104 Current through 2014 Regular Session Acts 1 to 130 End of Document ©2014 Thomson Reuters.No claim to original U.S.Government Works. 3 Vvves,aNNexf©2014 Thomson Reuters. No claim to original U.S. Government Works. J 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name. Shedlosky, Edmond F. DDS RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 408 , 000 . 00 2. Stocks and Bonds(Schedule B)............................................................................. 2. 17 , 130 . 36 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3. 4. Mortgages&Notes Receivable(Schedule D)........................................................ 4. 4 5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 689. 00 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 118 ,512 . 99 7. Inter-Vivos Transfers&Miscellaneous NtProbate Property (Schedule G) a Separate Billing Requested............ 7. 252 , 152 . 72 g. Total Gross Asses (total Lines 1 through 7)................................................... 8. 800 , 485 . 07 9. Funeral Expenses and Administrative Costs(Schedule H)........... 9. 18 , 729 . 18 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)..... 1........................ 10. r 040 . 54 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 19, 769 . 7 2 12. Net Value of Estate(Line 8 minus Line 11)........................................................ 780.. 12. r 715 . 35 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. 780 ,715 . 35 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 15 0 . 00 (a)(1.2)X.00 16. Amount of Line 14 taxable 780 , 715 . 35 16. 35 , 132 . 19 at lineal rate X .045 17. Amount of Line 14 taxable 0 . 00 17. 0 . 00 at sibling rate X.12 18. Amount of Line 14 taxable 0 . 00 18. 0 . 00 at collateral rate X.15 19. TAX DUE................................................................................................................ 19. 35 , 132 . 19 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 1505610243 1505610243 REV-1500 EX Page 3 File Number 21-13-1312 Decedent's Complete Address: DECEDENT'S NAME Shedlosky, Edmond F. DDS STREETADDRESS 2500 Market Street CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: I. Tax Due(Page 2, Line 19) ' (1) 35,132.19 2. Credits/Payments A. Prior Payments 35,000.00 B. Discount 1,756.61 Total Credits(A +13) (2) 36,756.61 3. Interest (3) 4. If Line 2 is greater than Line I +Line 3,enter the difference. This is the OVERPAYMENT. (4) 1,624.42 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) Make Check Payable to: REGISTER OF WILLS, AGENT. 11,11 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;-........................................_..._-..................—....... ❑ b, retain the right to designate who shall use the property transferred or its income;...........................-..... ❑ c. retain a reversionary interest:or..................._....................................................._................................... ❑ x d. receive the promise for life of either payments,benefits or care?.................................-......................... ❑ 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. Far dates ofdeath 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 o`,death on or after January 1,1995,the tax rate imposed on the net value of transfers to crier 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'ax 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[72 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-1502 EX.(01-10) SCHEDULE A pennsylvania REAL ESTATE DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Shedlosky, Edmond F. DDS 21-13-1312 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 willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant fad.. Real property that is jointly-owned with night 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 decedent's Interest If owned as tenant in common. ITEM VALUE AT DATE, NUMBER DESCRIPTION OF DEATH 1 Real Estate-situate 2500 Market Street,Camp Hill, Cumberland County, Pennsylvania; I/N/0 205,000.00 Edmond F.Shedlosky&Eleanor R. Shedlosky; More fully described in a Deed recorded in Cumberland County Deed Book: 20073 Page: 7225;Value per appraisal 2 Real Estate-situate 2506 Market Street;Camp Hill, Cumberland County, Pennsylvania; I/N/O 203,000.00 Edmond F.Shedlosky&Eleanor R. Shedlosky; More fully described in a Deed recorded in Cumberland County Deed Book: 20073 Page: 7226;Value per appraisal TOTAL(Also enter on Line 1, Recapitulation) 408,000.00 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule A(Rev.01-10) Rev-'1503 EX+(6-98) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Shedlosky, Edmond F DDS 21-13-1312 All property jointlyovmed with right of survivorship must be disclosed on Schedule F. VALUE AT DATE ITEM CUSIP NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH 1 5915611108 296 shares of Metlife Inc-Com; I/N/O Edmond F.Shedlosky; 52.72 15,605.12 Account#C0049619537 2 744320102 17 shares of Prudential Financial Inc-Com; I/N/O Edmond 89.72 1,525.24 F.Shedlosky;Account#C0031168074; TOTAL(Also enter on Line 2, Recapitulation) 17,130.36 (If more space is needed,additional pages of the same size) Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B(Rev.6-98) Rev-1508 EX+(11-10( SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Shedlosky, Edmond F. DDS 21-13-1312 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 I VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 -Automobile-2002 Toyota Camry; IIN/O Edmond F. Shedlosky; Mileage: 106,000; Fair - 4,689.00 condition; Value per Kelley Blue Book TOTAL(Also enter on Line 5, Recapitulation) 4,689.00 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10) Rev-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Shedlosky, Edmond F. DDS 21-13-1312 If an asset was made joint within one year of the decedent's date of death,it must be reported on schedule G. SURVIVING JOINT TENANTS)NAME ADDRESS RELATIONSHIP TO DECEDENT A. Mark Shedlosky 312 Main St. Son Shiremanstown, PA 17011 B. Robert Panas 8 Chestnut St Grandson Wilkensburg;PA 15221 C. Julie Panas 318 N. 26th St. Daughter Camp Hill, PA 17011 JOINTLY OWNED PROPERTY: DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S DECEDENT'S INTEREST NUMBER FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER.ATTACH DEED FOR VALUE OF ASSE INTEREST TENANT JOINT JOINTLY-HELD REAL ESTATE. 1 B 06/11/2012 Integrity Bank-50+Account#201055853; 12.39 0.500% 6.20 I/NIO Edmond F. Shedlosky& Robert Panas; 2 B 0611112012 Integrity Bank-Savings Account#401007671; 10,290.92 0.500% 5,145.46 I/N/O Edmond F.Shedlosky&Robert Panas; Established: 06/11/2012 3 A 04106/2005 Metro Bank-Savings Account#626513683; 71,830.87 0.500% 35,915.44 IIN/O Edmond F.Shedlosky&Mark E. Shedlosky; Established: 04/0612005 4 A 03/31/2005 Metro Bank-Checking Account#536961295; 4,049.41 0.500% 2,024.71 I/N/O Edmond F. Shedlosky&Mark E. Shedlosky; Established: 03/3112005 5 A,C 03/2412010 Wells Fargo-Investment Account#4311 226,263.54 33.333% 75,421.18 -9776; I/N/O Edmond F. Shedlosky,Julie R. Shedlosky&Mark E.Shedlosky;p Opened: 03/24/010 TOTAL(Also enter on Line 6, Recapitulation) 118,512.99 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule F(Rev.01-10) Rev-1610 EX.(0849) SCHEDULE G pennsylvania INTER-VIVOS TRANSFERS AND DEPARTMENT TAX REVENUE RETURN INHERITANCE TAX RET MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Shedlosky, Edmond F DDS 21-13-1312 This schedule must be completed and filed If the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD's EXCLUSION TAXABLE NUMBER THE DATE OF TROANSERSATTACH THEIR COPY OF THE DEED FFOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE) VALUE 1 Wells Fargo-IRA Account#7631-8685; I/N10 Edmond 242,231.31 100.000% 242.231.31 F. Shedlosky; Established:0511111994; Beneficiaries: Julie R.Shedlosky&Mark E. Shedlosky 2 r Wells Fargo-American Dental Association IRA Plan r 9,921.41 100.000% 9,921.41 #DD1111111111; I1NlO Edmond F. Shedlosky; Beneficiaries: Julie R.Shedlosky&Mark E. Shedlosky TOTAL(Also enter on Line 7, Recapitulation) 252,152.72 (If more space is needed,additional pages of the same size) Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule G(Rev. 08-09) REV-1511 EX+(10.09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE S; ENTD ED RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Shedlosky, Edmond F DDS 21-13-1312 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached 9,090.71 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(s)Commission Paid 2. Attorney's Fees 3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) Claimant Street Address City State Zio RelationshiD of Claimant to Decedent 4. Probate Fees 793.02 See continuation schedule(s) attached 5. Accountant's Fees 6, Tax Return Preparer's Fees 500.00 7. Other Administrative Costs 8,345.45 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 18,729.18 Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Shedlosky, Edmond F. DDS 21-13-1312 ITEM NUM ER DESCRIPTION - AMOUNT Euneral Expenses 1 Church of the Good Shepherd-Funeral luncheon& honorarium to Priest 200.00 2 Gate of Heaven-Open grave and other fees 3,060.00 3 Parthmore Funeral Services-Funeral 5,830.71 H-A 9,090.71 _Probate Fees 4 Cumberland County Law Journal-Fee to advertise estate notice 75.00 5 Patriot News-Fee to advertise estate notice 109'52 6 Register of Wills-Probate fee to open estate 608.50 H-B4 793.02 Other Administrative Costs 7 Borough of Camp Hill-Sewer service provided for decedent's properties;Service dates: 587.25 11126113.01116/14 8 Borough of Camp Hill-Sewer service provided for decedent's properties;Service dates: 550.50 01/16/14-05108114 9 Erie Insurance Group-Homeowner's insurance premium for decedent's properties; 806.00 10 Erie insurance Group-Homeowner's insurance premium for decedent's properties; 796.00 11 PAWC-Water expense for decedent's properties;Service dates: 11/26113-12/27113 439.81 Copyright(c)2002 form software only The Lackner Group,Inc. Form PAA500 Schedule H(Rev.6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Shediosky, Edmond F.DDS 21-13-1312 ITEM NUMBER DESCRIPTION AMOUNT 12 PAWC-Water expense for decedent's properties; Service dates: 12/27/13-01116/14 69.36 13 PAWC-Water expense for decedent's properties;Service dates:02121114-04103114 164.76 14 PAWC-Water expense for decedent's properties;Service dates;04/03/14-05106/14 167.88 15 PAWC -Water expense for decedent's properties;Service dates:05106114-06/03/14 148.22 16 PAWC-Water expense for decedent's properties;Service dates:06/03114-07102/14 59.97 17 PAWC-Water expense for decedent's properties;Service dates: 07/02114-07130114 129.97 18 Penn Waste-Trash removal services provided to decedent's properties;Service dates: 104.65 11/26113-12/27/13 19 Penn Waste-Trash removal services provided to decedent's properties;Service dates: 124.65 12127113.03124114 20 Penn Waste-Trash removal services provided to decedent's properties;Service dates: 124.65 03124114-05130/14 21 PP&L-Electric service provided to decedents properties;Service dates: 11126113-12127113 174.44 22 PPBL-Electric service provided to decedent's,properties;Service dates: 12/28/13-01/16/14 167.35 23 PPBL-Electric service provided to decedent's properties;Service dates:01/16114-02121114 150.99 24 PP&L-Electric service provided to decedent's properties; Service dates: 02/21/14-03124114 36.72 25 PP&L-Electric service provided to decedent's properties;Service dates:03124114-04121114 34.17 26 PP&L-Electric service provided to decedent's properties;Service dates:04121114-06/26114 145.55 Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Shedlosk , Edmond F. DDS 21-134312 ITEM NUM ER DESCRIPTION AMOUNT 27 PPBL-Electric service provided to decedent's properties;Service dates: 06/26114-07130114 142.34 28 UGI-Gas service provided to decedent's properties;Service dates: 11126113-12/27113 487.24 29 UGI -Gas service provided to decedent's properties;Service dates: 12127113-01/16114 696.31 30 UGI-Gas service provided to decedent's properties; Service dates:01116114-02121/14 352.24 31 UGI -Gas service provided to decedent's properties; Service dates:03124/14-02121/14 695.81 32 UGI-Gas service provided to decedent's properties; Service dates: 03/24/14.04121114 589.46 33 UGI -Gas service provided to decedent's properties; Service dates: 04/21/14-05123114 111.29 34 UGI-Gas service provided to decedent's properties; Service dates: 05123114-06124114 115.21 35 UGI -Gas service provided to decedent's properties; Service dates: 06/24114-07/30114 29.99 36 Verizon -Telephone services provided to decedent's properties; Service dates: 01/13/14 142.67 H-137 8,345.45 Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 6-98) Rev-1512 EX+(12.08) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTMENT TAX REVENUE RETURN INHERITANCE TAX RET MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT FILE NUMBER ESTATE OF 21-13-1312 Shedlosky, Edmond F DDS Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,including unrelmbursed medical expenses. VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER 1 Elder's Choice-Medical bill for services rendered to decedent; Service dates: 10/22/13 840.00 -11/19/13 2 Elder's Choice-Medical bill for services rendered to decedent; Service dates: 11/20/13 180.00 A1126/13 3 Hershey Kidney Specialists -Co-pay due for services rendered to decedent 20.54 TOTAL(Also enter on Line 10, Recapitulation) 1,040.54 (If more space is needed,additional pages of the same size) Form PA-1500 Schedule I(Rev. 12-08) Copyright(c)2008 form software only The Lackner Group, Inc. REV-0$13 EX*(01.10) pennsyivania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Shedlosk , Edmond F. DDS 21-13-1312 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$) TAXABLE DISTRIBUTIONS [include outright spousal 1. distributions,and transfers under Sec.9116 a 1.2 1 John Panas Grandson 116 share of 318 North 26th Street residue Camp Hill, PA 17011 1 2 Julie Shedlosky Panas daughter 50%of real 318 North 26th Street estate& Camp Hill, PA 17011 personal property 3 Mark Panes Grandson 116 share of 318 North 26th Street residue Camp Hill, PA 17011 4 Matthew Panas Grandson 116 share of 8 Chestnut Street residue Wilkinsburg, PA 15221 5 Robert Panas Grandson 116 share of 530 25th Avenue residue San Francisco,CA 94121 See continuation schedule attached Continuation Total Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as apDropr iate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART ii-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J (Rev.01-10) SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Edmond F.Shedlosky DDS 1112612013 203-05-6485 Item Name and Address of Persons) Share of Estate Amount of Estate Number Receiving Property Relationship {Words) ($$$) 6 Mark Shedlosky Son 113 of residue&50%of 312 West Main Street real estate and Shiremanstown,PA 17011-6332 personal property 1