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Home My WebLink About10-21-14 1505610143 REV-1500 EX(02-11) ~ ' OFFICIAL USE ONLY PA Department of Revenue permsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO BOX.280601 INHERITANCE TAX RETURN 21 13 3.088 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 09 30 2013 03 18 1941 Decedent's Last Name Suffix Decedent's First Name MI SHIPMAN JAYNE A (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 a 1. Original Return ❑ 2. Supplemental Return ❑ 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate ❑ 4a. Future Interest Compromise ❑ 5. Federal Estate Tax Return Required (date of death after 12-12-82) 6 Decedent Died TestateDecedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) ❑ (Attach Copy of Trust) ❑ 9. Litigation Proceeds Received 10.Spousal Povert Credit((Date of Death 11.Election to tax under Sec.9113(A) between 12-31-J1 and T-1-95) (Attach Schedule 0) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number HEATHER D ROYER ESQ (717) 234 2401 REGISTEFR MWILLS ONLY First Line of Address 4431 N FRONT S T 3RD FL I r?� t`' r..3 C-- Second Line of Address c 7 City or Post Office State ZIP Code DATE FILED HARRISBURG PA 17110 w ca Correspondent's e-mail address: hroyer sasllp.com 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. M RE OF PERSON RESPONS LE FOR FILING RETURN DATE Jefferson Jay Shipman !Zn� A RE S 106 W. Main Street Shiremanstown PA 17011 SIGNATURE F P EPARER OtNIEF THAN REPRESENTATIVE DATE Heather D. Royer Esq. ADDRESS 4431 N. Front St., 3rd FI., Harrisburg, PA 17110 1505610143 Side 1 1505610143 J 1p 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: Shipman, Jayne A. RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 278, 000 . 00 2. Stocks and Bonds(Schedule B)............................................................................. 2. 883,396 . 68 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C)......... 3. 4. Mortgages&Notes Receivable(Schedule D)........................................................ 4. 45, 000 . 00 5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 468 , 484 . 86 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 17 , 127 . 29 7. Inter-Vivos Transfers&Miscellaneous fon,-Probate Property (Schedule G) [_] Separate Billing Requested............ 7. 11006, 758 . 84 8, Total Gross Assets (total Lines 1 through 7)........................................................ 8. 2 , 698 , 767 . 67 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 91, 854 . 94 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 40 ,248 . 85 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 132 , 103 . 79 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 2 ,566, 663 . 88 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. 2 ,566, 663 . 88 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. 0 . 00 16. Amount of Line 14 taxable 2 , 566, 663 . 88 16. 115 , 499. 87 at lineal rate X .045 17. Amount of Line 14 taxable at sibling rate X.12 0 . 00 17. 0 . 00 18. Amount of Line 14 taxable at collateral rate X.15 0 . 00 18. 0 . 00 19. TAX DUE................................................................................................................ 19. 115, 499. 87 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑ Side 2 1505610243 1505610243 REV-1500 EX Page 3 File Number 21-13-1088 Decedent's Complete Address: DECEDENT'S NAME Shipman,Jayne A. STREET ADDRESS 106 West Main Street CITY STATE ZIP Shiremanstown PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 115,499.87 2. Credits/Payments A. Prior Payments 110,000.00 B. Discount 5,263.16 Total Credits(A +B) (2) 115,263.16 3. Interest (3) 2.21 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) 23$.92 Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;............................................................................... ❑ ❑ 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?............................................................ ❑ ❑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?..:............................................................................................................... ❑x ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994 and before Jan. 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 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 172 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 172 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 Shipman, Jayne A. 21-13-1088 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 facts. Real property that 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 decedent's interest if owned as tenant in common. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 106 W. Main Street,Shiremanstown, PA 17011 -Value per appraisal 278,000.00 TOTAL(Also enter on Line 1, Recapitulation) 278,000.00 (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 Shipman, Jayne A. 21-13-1088 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM CUSIP VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH 1 Mass Mutual Agency Account-Total value of securities as 691,661.16 of 0913012013 2 Series E Bonds-see attached list 6,150.00 Accrued interest on Item 2 through date of death 32,533.44 3 Series EE Bonds-see attached list 47,800.00 Accrued interest on Item 3 through date of death 105,252.08 TOTAL(Also enter on Line 2, Recapitulation) 883,396.68 (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-1507 EX+(6.96) SCHEDULE D MORTGAGES & NOTES RECEIVABLE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Shipman,Jayne A. 21-13-1088 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 $20000 Shiremanstown United Methodist Church Note 20,000.00 2 $25000 Shiremanstown United Methodist Church Note 25,000.00 TOTAL(Also enter on Line 4, Recapitulation) 45,000.00 (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 D(Rev.6-98) Rev-1506 EX+(11.10) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Shipman, Jayne A. 21-13-1088 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Centric Bank Savings Account-No. 2530689 229,334.14 Accrued interest on Item 1 through date of death 9.42 2 Federated Tax-Free Obligation Fund 18,995.44 3 PNC Checking Account-No.5112130136 50.00 4 Santander Cash Brokerage Account-Acct. No. HD9-224548 35.79 FDIC Insured Bank Deposit Dreyfus Ins Deposit Program C 5 Santander Checking Account-No.0571109853 9,678.66 Accrued interest on Item 5 through date of death 0.05 6 Santander Money Market Account-No.0574179593 11,846.44 Accrued interest on Item 6 through date of death 0.71 7 Wells Fargo CD-XXXXX3012 67,253.95 Accrued interest on Item 7 through date of death 2.76 8 Wells Fargo CD-XXXXXXX2265 84,881.97 Accrued interest on Item 8 through date of death 0.58 9 Wells Fargo Checking Account-XXXXXXX3501 0.62 10 Wells Fargo Savings Account-XXXXXX2004 11,474.45 Total of Continuation Schedule See attached page TOTAL(Also enter on Line 5, Recapitulation) 468,484.86 (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-1508 EX+(1140) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT continued ESTATE OF FILE NUMBER Shipman,Jayne A. 21-13-1088 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Accrued interest on Item 10 through date of death 0.04 11 2001 Volvo V70 Wagon -Value per Edmunds 3,476.00 12 Personal Property& Household Furnishings -Value per appraisal 30,595.00 13 Alert Pharmacy-Refund of overpayment 46.07 14 Highmark-Premium Refund 495.00 15 Milton S. Hershey Medical Center-Refund -overpayment of medical bill 35.00 16 Santander-Refund -Identity Protector Service 15.99 17 United States Tresury-2013 Personal Income Tax Refund 173.00 18 Wells Fargo-Reversed Early W/D Penalty CD#247402053883012 83.78 TOTAL(Also enter on Line 5, Recapitulation) 468,484.86 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 Shipman, Jayne A. 21-13-1088 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 TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT A. Jefferson Jay Shipman 4765 Brian Road Son Mechanicsburg, PA 17050 B. Judson Ross Shipman 922 Lewisberry Road Son Lewisberry, PA 17339 C. Lee Todd Shipman 5212 Oxford Drive Son Mechanicsburg, PA 17055 JOINTLY OWNED PROPERTY: LETTER DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE (NCLUDE NAME OF rIDENTIFY NG BER.ANCIAL INSTITUTION ATTACH DEED IK ACCOUNT FOR DATE OF DEATH DECD NUMBER OR IIMILARS DECE DECEDENT'SINTEREST VALUE OF NUMBER TENANT JOINT VALUE OF ASSE INTEREST JOINTLY-HELD REAL ESTATE. 1 A 8/2004 $10000 Series HH Bond -See attached 10,000.00 50.000% 5,000.00 2 A 8/2004 $10000 Series HH Bond -deferred interest 8,525.00 50.000% 4,262.50 3 B 5/2004 $3500 Series HH Bonds-See attached 3,500.00 50.000% 1,750.00 4 B 5/2004 $3500 Series HH Bonds-See attached 2,967.08 50.000% 1,483.54 5 C 8/2004 $5000 Series HH Bond-See attached 5,000.00 50.000% 2,500.00 6 C 8/2004 $5000 Series HH Bond-deferred interest 4,262.50 50.000% 2,131.25 TOTAL(Also enter on Line 6, Recapitulation) 17,127.29 (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-1510 EX+(08-09) SCHEDULE G pennsylvania INTER-VIVOS TRANSFERS AND DEPARTMENT OF REVENUE INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Shipman,Jayne A. 21-13-1088 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 TRDE NAME ANSFERS ATTACH A COPY OF THE E THEIR DEEHIPD FOR REAL EST ESTATE, VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1 Jackson Nat'l Life Policy 1012692435-Fixed Index 37,836.31 100.000% 37,836.31 Annuity-IRA 2 Jackson Nat'l Life Policy 1012692443-Fixed Index 25,565.07 100.000% 25,565.07 Annuity 3 Mass Mutual IRA-Account#71-001955 671,068.37 100.000% 671,068.37 See attached detailed investment breakdown 4 Mid Penn Bank IRA-Account No. 1285380000 77,834.65 100.000% 77,834.65 Beneficiaries -Jefferson Shipman 34%; Lee Todd Shipman 33%; Judson Shipman 33% 5 Mid Penn Bank IRA-accrued interest 594.96 100.000% 594.96 6 Santander IRA-Acct No. HD9-224662 22.17 100.000% 22.17 Beneficiaries-Jefferson Shipman, Lee Todd Shipman and Judson Shipman,equally 7 Jefferson Shipman-2013 gift 14,000.00 100.000% 3,000.00 11,000.00 8 Judson Shipman -2013 gift 14,000.00 100.000% 3,000.00 11,000.00 9 Lee Shipman -2013 gift 14,000.00 100.000% 3,000.00 11,000.00 10 Mid Penn Checking Account-No. 18009027 154,699.31 100.000% 154,699.31 ITF Jefferson J.Shipman and Lee Todd.Shipman 11 Series I Bond-POD Jefferson Shipman 5,000.00 100.000% 5,000.00 See attached 12 Series I Bond -Accrued Interest 1,138.00 100.000% 1,138.00 TOTAL(Also enter on Line 7, Recapitulation) 1,006,758.84 (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 TAX RESIDENT DEC ENTTURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Shipman,Jayne A. 21-13-1088 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached 7,163.38 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Jefferson Jay Shipman Street Address 106 W. Main Street City Shiremanstown State PA zio 17011 Year(s)Commission Paid 2014 40,000.00 2. Attorney's Fees Smigel, Anderson & Sacks, LLP 25,000.00 3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) Claimant Street Address City State ZiD Relationship of Claimant to Decedent 4. Probate Fees 1,233.50 See continuation schedule(s) attached 5. Accountant's Fees 6. Tax Return Preparer's Fees 3,210.00 See continuation schedule(s) attached 7. Other Administrative Costs 15,248.06 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 91,854.94 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 Shipman, Jayne A. 21-13-1088 ITEM NUMBER DESCRIPTION AMOUNT Funeral Ex ep nses 1 Judson Shipman -Reimburse Funeral Luncheon-Country Cupboard 456.55 2 Mifflenburg Cemetery Co. -Burial Plot 1,200.00 3 Parthemore Funeral Home-Creamation 3,320.83 4 Pastor Swanger 500.00 5 Touchstone Memorials-Gravemarker 1,686.00 H-A 7,163.38 Probate Fees 6 Register of Wills -Probate Fee 1,218.50 7 Register of Wills -Filing Fee-Petition to Purchase Real Estate 15.00 H-B4 1,233.50 Tax Return Preparer Fees 8 MMSA-2013 RMD/Savings Bond advice 685.00 9 MMSA-2013 Final Personal Income Tax Returns 1,025.00 10 MMSA-Fiduciary Income Tax Preparation 1,500.00 1-11-136 3,210.00 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 Shipman,Jayne A. 21-13-1088 ITEM NUMBER DESCRIPTION AMOUNT Other Administrative Costs 11 Advanced Disposal -Trash bill 42.21 12 Advanced Disposal -Trash bill 42.21 13 Advanced Disposal -Trash bill 42.31 14 Beth A. Monighan,Tax Collector-2014-15 School Taxes 3,949.92 15 Bonnie Mehaffie-Title Search 35.00 16 Comcast -Cable bill 171.55 17 Comcast -Cable Bill 171.58 18 Comcast -Final bill 644.80 19 Cordier Auctions&Appraisals-Personal Property Appraisal 2,137.50 20 Cumberland Law Journal -Legal advertisement 75.00 21 D.A. Potts Appraisal Service-Appraisal -residence 375.00 22 Judy C. Prowell-2014 Co/Twp Real Estate Taxes 1,325.26 23 Lower Allen Township-Sewer bill 65.00 24 Lower Allen Township-Sewer bill 70.00 25 Lower Allen Township-Sewer bill 70.00 26 Mass Mutual Agency Account-Fiduciary Fees 2,684.83 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 Shipman,Jayne A. 21-13-1088 ITEM NUMBER DESCRIPTION AMOUNT 27 Mass Mutual Agency Account-Fiduciary Fees 912.90 28 Pennsylvania American Water-Water bill 98.48 29 Pennsylvania American Water-Water bill 31.75 30 Pennsylvania American Water-Water bill 32.01 31 Pennsylvania American Water-Water bill 36.26 32 Pennsylvania American Water-Water bill 33.53 33 Pennsylvania American Water-Water bill 32.51 34 Pennsylvania American Water-Water bill 46.81 35 Pennsylvania American Water-Water bill 33.79 36 PP&L-Electric bill 206.16 37 PP&L-Electric Bill 43.51 38 PP&L-Electric bill 81.90 39 PP&L-Electric bill 66.54 40 PP&L-Electric bill 92.99 41 PP&L-Electric bill 106.66 42 PP&L-Electric bill 62.38 43 PP&L-Electric bill 46.51 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 Shipman, Jayne A. 21-13-1088 ITEM NUMBER DESCRIPTION AMOUNT 44 PP&L-Electric Bill 19.55 45 Santander-Date of Death Balance Fee 20.00 46 The Sentinel -Legal Advertisement 147.06 47 UGI-Gas Bill 161.40 48 UGI -Gas bill 41.18 49 UGI -Gas Bill 230.38 50 UGI -Gas Bill 227.53 51 UGI -Gas Bill 225.14 52 UGI -Gas Bill 180.85 53 UGI-Final Gas Bill 103.11 54 Zeplin Security Group, Inc. -Tech support invoice 25.00 1-1-137 15,248.06 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 OF REVENUE INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Shipman, Jayne A. 21-13-1088 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Alert Pharmacy 67.91 2 Messiah Lifeways-Room and Board 3,440.00 3 Messiah Lifeways-Transport 381.94 4 Pennsylvania Department of Revenue-2013 Personal Income Tax Due 359.00 5 United States Treasury-2013 estimated quarterly payment 36,000.00 TOTAL(Also enter on Line 10, Recapitulation) 40,248.85 (If more space is needed,additional pages of the same size) Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08) REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Shipman,Jayne A. 21-13-1088 NAME AND ADDRESS OF RELATIONSHIP TOSHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S)RECEIVING PROPERTY DECEDENTt List Do s (Words) ($$$) ITAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.9116(a)(1.2)] Jefferson Jay Shipman Son One-Third 106 W. Main Street Shiremanstown, PA 17011 Judson Ross Shipman Son One-Third 922 Lewisberry Road Lewisberry, PA 17339 Lee Todd Shipman Son One-Third 530 Criswell Drive Boiling Springs, PA 17007 Total Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate. 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) f . REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA ...... .. No. 2013- 01088 PA No. 21- 13- 1088 Estate Of: JAYNEA SHIPMAN (First,Middle,Last) Late Of: SHIREMANSTOWN BOROUGH CUMBERLAND COUNTY Deceased C) Social Security No: WHEREAS, on the 11th day of October 2013 an instrument dated April 18th 2012 was admitted to probate as the last will of JA YNE A SHIPMAN (First,Middle,Last) late of SHIREMANSTOWN BOROUGH, CUMBERLAND County, 4 who died on the 30th day of September 2013 an WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA FARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: JEFFERSON JA Y SHIPMAN who has duly qualified as EXECUTOR(RIX) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURTHOUSE, CARLISLE, PENNSYL VA NIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 11th day of October 2013. au L)AQj R g suer of WVAS ti Deputy **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) Last Will and Testament OF JAYNE A. SHIPMAN I, JAYNE A. SHIPMAN, of the Borough of Shiremwnstov.., Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby.revoking and making void any and all Wills or Codicils at any time heretofore made by me. ARTICLE I DEBTS I direct the payment of all my legal debts, and the expenses of my last illness and funeral from my Estate as soon after my'death as conveniently may be done. ARTICLE II TANGIBLE PERSONAL PROPERTY I give and bequeath my motor vehicle(s), household goods and personal effects and other tangible personalty of 'like nature (not including cash or securities), together with any existing insurance thereon, unto those of my children who survive me, to be divided among them with due regard for their personal preferences in as nearly equal shares as is practical. If there be disagreement as to the disposition of any item or items described in this Article ; I direct that suO �, item or items shall be disposed of as part of the residue of my Estate under Article III': U) ARTICLE III REST,RESIDUE AND REMAINDER I give, devise and bequeath all the rest, residue, and remainder of my Estate, of whatsoever nature and wheresoever situate, in equal shares unto my children, JEFFERSON JAY SHIPMAN, LEE TODD SHIPMAN and JUDSON ROSS SHIPMAN. Should any of my children. predecease me, I give and bequeath such deceased child's share unto his then-living issue, per stirpes. ARTICLE IV DISTRIBUTION TO BENEFICIARIES UNDER THE AGE OF TWENTY-FIVE (25)/INCAPACITATED BENEFICIARIES Whenever my Personal Representative is directed to distribute property to or for the benefit of any beneficiary who is under (a) twenty-five years of age, or (b) a legal disability or otherwise suffers from an illness or mental or physical disability that would make distribution directly to such beneficiary inappropriate (as determined in my Personal Representative's sole discretion exercised in good faith), my Personal Representative may distribute such property to the person who has custody of such beneficiary, may apply such property for the benefit of such beneficiary, may distribute such property to a custodian for such beneficiary, whether then serving or selected and appointed by my Personal Representative (including my Personal Representative), under any applicable Uniform Transfers.to Minors Act — or Uniform Gifts to Minors Act, or may distribute such properly directly to such beneficiary without liability on the part of my Personal Representative to see to the application of such property. This provision shall not in any way operate to suspend such beneficiary's absolute ownership of such property or to prevent the absolute vesting thereof in such beneficiary. 2 ARTICLE V POWERS OF FIDUCIARIES My fiduciaries shall have the following powers in addition to those vested by law and by other provisions of my Will applicable to all property, whether principal or income, including property held for minors, exercisable without court approval and effective until actual distribution of all property: A. To make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as my fiduciaries deem appropriate. B. To retain any or all of the assets of my estate,real or personal, without restriction to investments authorized for Pennsylvania fiduciaries, as my fiduciaries deem proper, without regard to any principle of diversification or risk. C. To invest in all forms of property without restriction to investments authorized for Pennsylvania fiduciaries, as my fiduciaries deem proper, without regard to any principle of diversification or risk. D. To sell at public or private sale, to exchange, or to lease for any period of time any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms or conditions as deemed proper. E. To allocate receipts and expenses to principal or income or partly to each as from time to time considered appropriate. 3 F. To compromise any claim or controversy. G. To make such elections, decisions, concessions and settlements in connection with all income, estate, inheritance, gift, generation skipping or other tax refunds and the payment of such taxes as my fiduciaries shall deem appropriate, without obligation to adjust the distributive share of any person thereby affected. ARTICLE VI TAXES I direct that all estate, inheritance, transfer and other taxes of similar nature payable by reason of my death, together with any interest or penalties thereon, and imposed with respect to any property, whether or not disposed of by this Will, shall be paid out of the residue of my Estate. ARTICLE VII CUSTODIAN OF ESTATES If, at any time any individual under the age of twenty-five (25) shall be entitled to receive any assets by reason of my death other than those passing to such individual under the terms of this Will, whether payable by operation of law or by contract, I appoint my Personal Representative as Custodian under the Pennsylvania Uniform Transfers to Minors Act to hold such assets for the benefit of such individual to the age of twenty-five (25)years. 4 ARTICLE VIII APPOINTMENT OF PERSONAL REPRESENTATIVE I name, constitute and appoint my son, JEFFERSON JAY SHIPMAN, Executor of this my Last Will and Testament. Should my son, JEFFERSON JAY SHIPMAN, fail to qualify or cease to so act, I name, constitute and appoint my son, JUDSON ROSS SHIPMAN, alternate Executor to complete the administration of my Estate. I direct that no fiduciary appointed herein shall be required to post bond for the faithful administration of the duties required in any jurisdiction. I authorize my Executor or Successor to act as ancillary administrator of my Estate in any state without the necessity of posting bond or of selecting an ancillary administrator for such purposes. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament,this— (� day of ,2012. (SEAL) JAYNE A. SHIPMAN Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us,.who at her request, in her presence and in the presence of each other,have hereunto subscribed our names as witnesses. —An :487536 5 e AFFIDAVIT AND ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND We,JAYNE A. SHIPMAN,�Q 1-0� 4WO44 and ad b• V v I , the Testatrix and the 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 Testatrix signed and executed the instrument as her Last Will and that she had signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness and that to the best of his/her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. A E A. SHIPMAN i Witness Witness Subscribed, sworn to and acknowledged before me by JAYNnnE A. SHIPMAN, Testatrix, and and and witnesses,this day of ' 2012. 4lJ Notary Plul5lic CGMIidONMEALTH OF Pi 4NVL%JAN1A NoWiN Seal Dana L.Wieseman,notary Public Lemoyne®aro,Cumberland County Poly Commission Expires Jan.15,21113 Member,Panclay viola Moci3tion of(votaries