HomeMy WebLinkAbout10-14-14 (2) REV-1500 EX(oz-I1) 1' 1505611101
PA Department of Revenue pennsytvania OFFICIAL USE ONLY
DERRRiMENT OF REVENUE County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN r /
PO BOX PA 1 1'J �(9 3
Harrisburgrg,,PA i28-o6oi RESIDENT DECEDENT 0` 1 0
ENTER DECEDENT INFORMATION BELOW
a V 0 .34;27 / 9 6 :?-
Decedent's Last Name Suffix Decedent's First Name MI
(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
44W 1.Original Return O 2. Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
r//1 O 4. Limited Estate JY)#Ps��/�bp Q 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required
/1/f/ //L/ / "iZ h death after 12-12-82)
6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
N, 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
REGI KC:4F WILLSL!5E OFIL4
r71 _ --t (r) �;O
CD
First Line of Address � D rn
J C7
Second Line of Address r CI
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C'>
n r 7(- tYl
-
DATE FILE f
City or Post Office State ZIP Code o
'Tl
Correspondent's e-mail address: - e�=
Under penalties of perjury,I 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.
- 4TURE OF PERSO RESDSIB R F(W RETURN�x�c ATS
DRE S ' /�-) (liJ�
IGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505611101 1505611101
1505611201
i
REV,1500 EX
. _ Decedent's Social Security Number
• , Decedent's Name:
z RECAPITULATION
1. Real Estate(Schedule A
2. Stocks and Bonds(Schedule B) ... ... . . ...... 2. }❑�_�L [�I.. �n�•I
3.t Closely Held Corporation,Partnership or Sole Proprietorship(Schedule C) . ... . 3. �_921YLj
' 4.. Mortgages and Notes Receivable Schedule D .. . ..... . 4. L , � ��� j• J
� -fir--f'�f-•--� •-`1+---�
5. -Cash, Bank and Miscellaneous Personal Property(Schedule E). ... . . . 5. �3 _,%�,.gj�g3a• j ll'+
6. Jointly Owned Property(Schedule F) O Separate Billing Requested . .. .. . . 6. jj � ,�� D�•�
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property , `' --1 -i
(Schedule G) O Separate Billing.Requested..... ... 7. (_ J0
8. Total Gross Assets(total Lines 1 through 7). ... .:... .. ... .. .. . . . .. . . ... . 8. f I !3 .;pi
pi (i
9. Funeral Expenses and Administrative Costs(Schedule H) ... . 9. L L8j4-5R&�Q, _.J
'10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). . .. .. ... . ..... 10. i_.Ji' 9��1 •T
11. Total Deductions total Lines 9 and 10 . .... .... .. . .. .. . .. . ... .. ... .. . 11. �Ll &a`/ JJ ,I '��
12. Net Value of Estate(Line 8 minus Line 11) . .. ... .. . . . . .. .. .. . . ... .. ... . . . 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for whichIf- ��
A election to tax h'as not been made(Schedule J) . . . ..:�. .�, j....w 13._ -�Q&IF` --''
, y ..`.•�; t (`�(- (�
-14 Net Value Subject to Tax Line 12 minus Line 13 . .. ... .. . .. .. I !I ll - �
TAX CALCULATION-SEE.INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or _
' transfers under Sec.9116 IIII 1``f
(a)(1.2)X.0_ ��L. _ �T '( }x+15. ILJf_ �J` C
•16. Amount of Line 14 taxable -
I � ', l•_ 16. L J!-J'�jUI �fl !, ► •
117.-Amount of Line 14 taxable �'--`a1-11-10[Xr
r - at sibling rate X.12
18. Amount of Line•14 taxableL-
at collateral rate-X f15 +� 41 • � 18. !]U � •
19. TAX DUE ... . .. . . . . . .. . . ....L. a ��'1�� �1
20. FILL IN.THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT rp i
Side 2
S /
1505611201 1505611201 '
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REV-1500tX Page 3 File Number
Decedent's Complete Address:
DE DEN�TZ'SNME
STREETADDR
CITYSTATE ZIP
mcg r� 2aO
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) �---��
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+B) (2)
3. Interest
(3)
4. If tine 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4)
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.
' M
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....................................................................I..................... ❑
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 Dec. 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.
C - _ - -
T
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 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[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-15o8 EX+(u-so)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
EST TE OF: FILE NUMBER:
all-/y -6?9-?
Include the proceeds litigation and the date the proceeds were received by the estate. a`,ZCV41_ GD p2;9,3All property jointly owned with right of survivorship must be disclosed on Schedule F. ;
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
TOTAL(Also enter on Line 5, Recapitulation) $ 9 93✓ /
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
` pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Decedent's debts must be reported on Schedule I. _
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. MLk5Selin q Ir, tA rNk ro,,)
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP v
Relationship of Claimant to Decedent
4. Probate fees:
5. Accountant Fees:
6. Tax Return Preparer Fees: �--
7 �V
TOTAL(Also enter on Line 9, Recapitulation) $ 99 5�
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTAT OF ( � C&"� a+ FILE NUMB
J
Report debts incurred by the decedent or to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
�. W 54 5,�a o, EMS
H-s-Cs �y (Z-/->r
3-., MSH me %, 4 i5)o,3\S C-7 r
13, l q LJ_92
TOTAL(Also enter on Line 10, Recapitulation) $
If more space is needed,insert additional sheets of the same size.
t
a
WILL
I, BETH A. SHAMBAUGH, of Cumberland County, Pemisylvania, make this will,
hereby revoking all my former wills and codicils.
ARTICLE ONE
BEQUEST OF TANGIBLE PERSONAL PROPERTY
§1.1 I bequeath all my tangible personal property, exclusive of any such
property used in a trade or business, in accordance with the terms of a signed and dated
memorandum I may prepare. If no such memorandum is located or received by the executor
within 60 days after being appointed as such, after conducting a reasonable search for such
memorandum, the executor shall be held harmless for distributing such property as hereinafter
provided.
§1.2 1 bequeath any such property not disposed of by such a memorandum
to my companion, BRENDA K. BUFFINGTON, if she survives me. If my said companion
does not survive me, I bequeath such property to my brother, CHARLES U. SHAMBAUGH, if
he survives me.
§1.3 I direct that the expenses of storing, packing, shipping, insuring and
delivering any such property to the beneficiary entitled thereto shall be paid by the executor as
an administrative expense of my estate. In addition, to the extent practicable in the executor's
sole discretion, I bequeath any policies of insurance on such property to the beneficiary entitled
to such property.
r
ARTICLE TWO
DISPOSITION OF RESIDUE
§2.1 I devise and bequeath all the residue of my estate to my companion,
BRENDA K. BUFFINGTON, if she survives me. If my said companion does not survive me, I
devise and bequeath said residue to my brother, CHARLES U. SHAMBAUGH, if he survives
me, or, if he also does not survive me, to his issue who survive me, per stirpes.
ARTICLE THREE
APPOINTMENT OF FIDUCIARIES
§3.1 I appoint my companion, BRENDA K. BUFFINGTON, executor of
this will. If my said companion is unable or unwilling to act or continue as executor, for any
reason whatsoever, I appoint my brother, CHARLES U. SHAMBAUGH, successor executor.
ARTICLE FOUR
DISTRIBUTION TO CUSTODIAN
§4.1 Except as otherwise may be provided in this will, if any beneficiary
entitled to receive a mandatory distribution of property from my estate is under 25 years of age,
the fiduciary then serving shall distribute such property to a custodian for such beneficiary,
whether then serving or selected and appointed by such fiduciary(including such fiduciary),
under the Pennsylvania Unifonn Transfers to Minors Act until such beneficiary attains the age
of 25 years, and such custodian's receipt therefor shall be a complete release of such fiduciary.
ARTICLE FNE
POWERS OF FIDUCIARIES
§5.1 No fiduciary under this will shall be required to give bond or other
security for the faithful performance of the fiduciary's duties.
§5.2 Any such fiduciary shall have the following powers, in addition to
those given by law:
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§5.3 To invest in, accept and retain any real or personal property,
including stock of a corporate fiduciary or its holding company, without
restriction to legal investments;
§5.4 To sell, exchange, partition or lease for any period of time any real or
personal property and to give options therefor for cash or credit, with or without
security;
§5.5 To borrow money from any person including any fiduciary acting
hereunder, and to mortgage or pledge any real or personal property;
§5.6 To hold shares of stock or other securities in nominee registration
fonn, including that of a clearing corporation or depository, or in book entry
form or unregistered or in such other form as will pass by delivery;
§5.7 To engage in litigation and compromise, arbitrate or abandon claims;
§5.8 To make distributions in cash, or in kind at current values, or partly
in each, allocating specific assets to particular distributees on a non-pro rata
basis, and for such purposes to make reasonable determinations of current
values;
§5.9 To make elections, decisions, concessions and settlements in
connection with all income, estate, inheritance, gift or other tax returns and the
payment of such taxes, without obligation to adjust the distributive share of
income or principal of any person affected thereby;
§5.10 To allocate, in the executor's sole and absolute discretion, any
portion of my exemption under Section 2631(a) of the Internal Revenue Code to
any property as to which I am the transferor, including any property transferred
by me during my lifetime as to which I did not make an allocation prior to my
death; and
§5.11 To disclaim any interest I may have in any estate if my executor
deems such disclaimer to be in the best interests of my estate and the
beneficiaries thereof.
ARTICLE SIX
PROVISION FOR TAXES
§6.1 All estate taxes, inheritance taxes, transfer taxes and other taxes of a
similar nature payable by reason of my death to any government or subdivision thereof upon or
with respect to any(a)property passing under the terms of this will subject to any such tax and
(b) trust includible in my estate for federal estate tax purposes that is a charitable remainder
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Y
trust within the meaning of Section 664 of the Internal Revenue Code, and any penalties
thereon, shall be paid by the executor out of the principal of that portion of my estate disposed
of by ARTICLE TWO of this will, and all interest with respect to any such taxes shall be paid
by the executor out of the income or principal or partly out of the income and partly out of the
principal of such portion of my estate, in the absolute discretion of the executor, without
reimbursement from or apportionment among the beneficiaries, recipients or owners of such
property for any such taxes,penalties or interest; provided, however, that no such taxes,
penalties or interest shall be charged against any property of such portion of my estate that
otherwise passes to charity and for which my estate would be entitled to a charitable deduction
for federal estate tax purposes. As to any other property, the transferee thereof or any fiduciary
holding legal title to such property, as the case may be, shall bear liability for all such taxes,
penalties and interest thereon. hi accordance therewith, I direct the executor to exercise all
rights of reimbursement granted under Sections 2206, 2207, 2207A and 2207B of the Internal
Revenue Code (to the full extent permitted therein) and under state law as to any property
subject thereto.
ARTICLE SEVEN
MISCELLANEOUS PROVISIONS
§7.1 Any terns used in the singular or plural, or in the masculine, feminine
or neuter form, shall be singular or plural, or masculine, feminine or neuter as a proper reading
of this will may require.
§7.2 As used in this will, the term "Internal Revenue Code" shall mean the
hlternal Revenue Code of 1986, as amended from time to time, or the corresponding provision
of subsequent law.
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t
§7.3 An individual fiduciary shall be entitled to receive reasonable
compensation for such fiduciary's services hereunder.
§7.4 A corporate fiduciary shall be entitled to receive compensation for its
services hereunder in accordance with its schedule in effect when the services are perfonned,
but not in excess of such compensation as would be approved by a court of competent
jurisdiction.
§7.5 Every successor or additional fiduciary shall have all rights, powers,
privileges and duties, whether discretionary or otherwise, herein given to the original fiduciaries
and shall be subject to the same reservations, limitations, terms and conditions.
§7.6 In case of the merger or consolidation of a corporate fiduciary, the
resultant company shall become such fiduciary's successor without notice to any party.
IN WITNESS WHEREOF I have hereunto set my hand and seal this 4fH day of
, Zoos.
LIT- 0'( �- ilb-, (SEAL)
BETH A. SHAMBA
Signed, sealed, published and declared by the above-named BETH A. SHAMBAUGH
as and for her last will, in the presence of us and each of us, who, at her request and in her
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4
and in her presence and in the presence of each other, have hereunto subscribed our names as
wi lesses thereto the day and year last above written.
esiding at
residing at M (61)r, dt-, ;zYetk_.
g
residin at
4e
Lj
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COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF
I, BETH A. SHAMBAUGH, the testator, whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby acknowledge that
I signed and executed the instrument as my Last Will; and that I signed it willingly and as my
free and voluntary act for the purposes therein expressed.
le�"—
a ,'J-�ai'-�
BETH A. SHAMBA G
Sworn to or affirmed and aclmowledged before me by BETH A. SHAMBAUGH, the
testator, this 4r/i day of /2)1;y , 2005.
(SEAL)
Not4ey Publi
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL S_A
JACLYN W.ADKINS, Notary Public
Upper Allen Twp. Cumberland Co.
My Commission Expires Dec.6,2008
-7-
i
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF Cur�18 Q���o
We, r' , CLo 1&11 1&u.) PLOO P( and
6,111 CLu-g'J , the witnesses whose names are signed to the attached or
foregoing instrument, being duly qualified according to law, do depose and say that we were
present and saw the testator sign and execute the instrument as her Last Will; that the testator
signed willingly and executed it as her free and voluntary act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of the testator signed the will
as a witness; and that to the best of our knowledge the testator was at the time 18 or more years
of age, of sound mind and under no constraint or undue influence.
mess
Wit ess
Sl
Witness
Sworn to or affirmed and subscribed to before me by L iLe-z-✓
and C%mic y �S �'/��✓�� , witnesses, this
I Il day of /2'I Y , 2005.
(SEAL) w
Not Publi
COAMMONWEALYH OF PENNSYLVANIA
N RIAL SEAL
JACLYN K ADKINS, Notary Public
Upper Allen Twp. Cumberland Co.
My Commission Expires Dec.6,2008
-8-
x
MEMORANDUM
In accordance with ARTICLE ONE of my will dated , 2005,
and any codicil thereto, I, BETH A. SHAMBAUGH, bequeath the items of tangible personal
property herein specified that I still own at the time of my death to the following beneficiaries
who survive me:
(1) To
(2) To
(3) To
(4) To
(5) To
Date:
BETH A. SHAMBAUGH
z
RECORDED Of"'`<GE
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