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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX111-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
OTTO IVO VICTOR III
10 E HIGH STREET
CARLISLE, PA 17013
--------folcl
ESTATE INFORMATION: SSN: 204-03-1599
FILE NUMBER: 2105-0175
DECEDENT NAME: SHUGHART MAYNARD L
DATE OF PAYMENT: 05/11/2005
POSTMARK DATE: 05/11/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 02/12/2005
NO. CD 005312
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,565,55
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$2,565.55
REMARKS: ESTATE CHECK
CHECK# 99
SEAL
INITIALS: RSK
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WilLS
~s.~
RfV_l-"EJl.C5-ll0)
*'
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
fiLE NUMBER
21 05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
00175
NUMBER
COMMONWEALTH OF PENNSYlVANL".
DEPARTMENT OF REVENUE
DEPT. 280601
HAARl$BIJRG, PA 17128-0001
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SHUGHART, MAYNARD L.
!;
..
~
..
"
DATE OF DEATH (MM-D[)'YEAR)
DATE OF BIRTH (MM-DD-YEAR)
02/12/2005
10/29/1918
(IF APPLICABLE} SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL}
)~t'.
-;+ l(/,i&
QFFiCL"'-L US ONl 'f
THIS RETURN MUSt BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
204-01-9198
3. Remainder Return (date of dealh prior to 12-13-82)
SHUGHART, MARTHA R.
rgJ ,. Original Return 0 2. Supplemental Return
..
"lI::;cn 0 4. Limited Estate 0 4a. Future Interest Compromise (date of dealh after
" .", 12-12-82)
....8 rgJ 6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a L.iving Trust {Allach
:J:~-,
"..m of Will} copy of Trust)
~ 0 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (dale of death between
12-31-91 " 1-1-95
'.:-1....'.'. ..
o 5. Federal Estate Tax Return Required
8. iotal Number of Safe Deposit Boxes
o 11.Election to tax under Sec. 9113(A) (Attach Sch 0)
ME
. !; Ivo V. Otto III, Esquire
m..
~ ~ IRM NAME (If applicable)
8~ Martson Deardorff Williams & Otto
ElEPHONE NUMBER
717/243-3341
1. Real Estate (Schedule A)
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g
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t:
~
~
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deduct'"n. (Iotal Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
Ten East High Street
Carlisle, PA 17013
(1) 92,879.25 OF(iCI.v..,~SE ONLY
,
(2) 6,372.30 -')
(3) None
(4) None
(5) 31.40
(6) None
(7) 730.00
(8) 100,012.95
(9) 18,483.81
(10) 1,032.26
(11)
19,516.07
(12)
80,496.88
(13)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
80,496.88
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, 20,484.04 x ,00 (15)
or transfers under Sec. 9116(a)(1.2)
z 60,012.84 .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
~
...
" (17)
.. 17.Amount of Line 14 taxable at sibling rate x .12
'"
0
"
~ 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
0.00
2,700.58
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
2,700.58
20.0
,.~'~..;i..,.,,,.,'*~~~WIi~~!!Il&1~~11Il"<"::::.~.".""'" ..1'!0'.~~:';;' "
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6.QO)
"'~'-
Decedent's Complete Address:
STREET ADDRESS
19 CLIFTON TERRACE
CITY
CARLISLE
[STATE PA
I ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 1 g)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
2,700.58
135.03
Total Credits (A + 8 + C)
(2)
135.03
3. InteresVPenalty if applicable
D. Interest
E. Penally
Total InteresVPenalty (0 + E)
4. If Line 2 is greater than Line 1 + line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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.
A. Enter the interest on the tax due.
S. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(3) 0.00
(4)
(5) 2,565.55
(SA)
(58) 2,565.55
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:
2. 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..................................................................................................... .............
d. receive the promise for life of either payments, benefits or care? ..............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.............................. ............_...........................................................................
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .........
4_ Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?...... ................................................................. ...................................._.........
Yes No
~ I
181 0
o 181
o 181
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
preparer other lhan the personal representative is based on aU information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
MARTHAR.SHUG ART
0\.
DATE
19 Clifton Terrace
Carlisle, PA 17013
ADDRESS
SIGNATURE OF P EPARER OTHER THAN REPRESENTATIVE
Ivo V. Otto III, squ'
ADDRESS
DATE
Ten East Rig!) Street
Carlisle, PA 17013
s-ho/IS
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% (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%
[72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemot 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 twenty-one years of age or younger at death to or for the use of a natural
parent. an adoptive parenL or a stepparent oflhe child is 0% (72 P.S. ~9116 (a) (1.2)J.
The tax rate imposed on the net value of transfers to or for the use otthe decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116
1.2) (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% [72 P .S. ~9116 (a) (1.3)J. 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.
.
SCHEDULE A
REAL ESTATE
COMMONWEAlTH OF PENNS'I1..VAN~
..,HERITANCE TAX RETURN
RESIDENT DECEDENT
I FILE NUMBER
21 - 05 - 00175
All re.al property owned solely or as a tenant in c~",mon must be r"ported at fair mark'!t value. Fair market value is defined as the price
at whIch property would be exchanged between a willing buyer and a wllfing 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.
ESTATE OF
SHUGHART, MAYNARD L.
ITEM
NUMBER
I
DESCRIPTION
VALUE AT DATE OF
DEATH
92,879.25
Undivided one-half interest in real estate at 19 Clifton Terrace, Carlisle, Cumberland County, known as
Parcel No. 40-23-0602-172, more particularly described in Deed dated August 27, 1992, to Maynard L.
Shughart and Martha R. Shughart, as recorded in Cumberland County Deed Book "W", Volume 35, Page
674. See also Agreement dated September 14, 1992, between decedent and his wife (copy attached).
Value is assessed value for Cumberland County (167,350) x common level ratio of 1.11 x 50%.
TOTAL (Also enter on Line 1, Recapitulation)
92,879.25
.
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF SHUGHART, MAYNARD L.
I FILE NUMBER
21 - 05 - 00175
All property Jolntly--owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF
NUMBER DEATH
1 110 shares Prudential Financial 57.93 6,372.30
TOTAL (Also enter on line 2, Recapitulation) 6,372.30
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH Of PENNSYLVANIA
~HERITANCETAXRETURN
~ENT DECEDENT
ESTATE OF
SHUGHART, MAYNARD L.
I FILE NUMBER
21 - 05 - 00175
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
NUMBER
I
DESCRIPTION
VALUE AT DATE OF
DEATH
31.40
Masland Associates, refund of overpayment
2 Note: Shop and related equipment and antique car were sold prior to death
TOTAL (Also enter on Line 5, Recapitulation)
31.40
*'
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SHUGHART, MAYNARD L.
FILE NUMBER
21 - 05 - 00175
This schedule must be completed and i ed i the answer to anv of ouestions 1 through 4 on Daile 2 is ""s.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF
NUMBER Include the name of the transferee, lheir relationship 10 decedent and the date of transfer. VALUE OF ASSET DECD'S EXCLUSION TAXABLE VALUE
Attach a copy of the deed for real estate. INTEREST (IF APPLICABLE)
I M&T Checking Account registered to decedent transferred 3,730.0( 100% 3,000.00 730.00
to joint account of decedent and wife shortly prior to death
TOTAL (Also enter on line 7, Recapitulation) 730.00
f I f
.
SCHEDULEH
FUNERAL EXPENSES &
ADMINISlRA11VE COSTS
COMMONWEAL lH OF PENNSYlVANIA
tlHERrTANCE TAX RETURN
RESIDENT DeCEDENT
ESTATE OF
SHUGHART, MAYNARD L.
I FILE NUMBER
21 - 05 - 00175
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
I Hoffinan-Roth Funeral Home, Carlisle, P A 8,225.45
2 Grace United Methodist Church, Carlisle, funeral luncheon 240.00
3 Minister 50.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City State - Zip
Year(s) Commission paid 2005
2. Attorney's Fees MartsonDeardorffWiIliams & Otto (estimated) 5,750.00
3. Family Exemption: (If decedenfs address is not the same as claimant's, attach explanation) 3,500.00
Claimant Martha R. Shughart
Street Address 19 Clifton Terrace
City CARLISLE State PA Zip 17013
Relationship of Claimant to Decedent Spouse
4. Probate Fees Cumberland County Register of Wills 192.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
I Certified Mail 9.07
2 Postage - Notice to heirs 8.00
Total of Continuation Schedule{s) 509.29
TOTAL (Also enter on line 9, Recapitulation) 18,483.81
.
Schedde H
Fl.I1eI'lII Expenses &
Mninislralive Cosfs oontinJed
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SHUGHART, MAYNARD L.
I FILE NUMBER
21 - 05 - 00175
3
Cumberland Law Journal, Advertisiog Letters Testamentary
75.00
4
The Sentinel, Advertisiog Letters Testamentary
144.29
5
Register of Wills, filing fee, inheritance tax return
15.00
6
Register of Wills, additional probate fee
75.00
7
Reserved for filiog Account, miscellaneous expenses
200.00
Page 2 of Schedule H
*'
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMOHWEA!. TH OF PENNSYlVANIA
~HERrrANCETAXRETURN
RESIDENT DECEDENT
ESTATE OF
SHUGHART, MAYNARD L.
I FILE NUMBER
21 - 05 - 00175
Include unreimbursed medical expenses.
ITEM
NUMBER
I Chapel Pointe, balance on account
DESCRIPTION
AMOUNT
554.30
2
AAA Financial Services, credit card account
96.15
3
Lancaster HMA Phys Mgmt Cent Pen, account payable
109.84
4
Millennium Phannacy Systems, Inc., acconnt payable
271.97
TOTAL (Also enter on Line 10, Recapitulation)
1,032.26
. REV-1513 EX+ (9-00)
.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DEceDeNT
ESTATE OF
SHUGHART, MAYNARD L.
I FILE NUMBER
21 - 05 - 00175
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
I Martha R. Shughart Spouse 20,484.04
19 Clifton Terrace, Carlisle, PA 17013
(Present Value of Life Estate)
2 Jay L. Shughart Son 7,787.32
185 Lost Hollow Road, Dillsburg, PA 17019
(1/8 Remainder Value of Life Estate)
3 Parker W. Shughart Son 7,787.32
1623 Trindle Road, Carlisle, PA 17013
(1/8 Remainder Value of Life Estate)
4 Nancy C. Hoff Daughter 7,787.32
317 Co!. Thos. Heyward Road, Bluffton, SC 29910 (1/8 Remainder Value
of Life Estate)
See Continuation Schedule{s) attached
Enter dollar amounts for distributions shown above on lines 15 through 18. as appropriate. on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
.
SCHEDULE J
BENEFICIARIES continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SHUGHART, MAYNARD L.
I FILE NUMBER
21 - 05 - 00175
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT
Do Not List Trustee{sl OF ESTATE
I. AXABLE DISTRIBUTIONS [include outright spousal distributions. and transfers under
Sec. 9116(0)(1.2)]
5 Judy L. Line Daughter 7,787.32
]6]9 Trindle Road, Carlisle, PA 17013
(1/8 Remainder Value of Life Estate)
6 Virginia M. Wessels Daughter 7,787.32
811 Route 15N, Dillsburg PA 17019
(1/8 Remainder Value of Life Estate)
7 Robert C. Shughart Son 7,787.32
1621 Toodle Road, Carlisle, PA 17013
(1/8 Remainder Value of Life Estate)
8 Dixie G. Fenicle Daughter 7,787.32
106 Fairway Drive, Carlisle, P A 17013
(118 Remainder Value of Life Estate)
9 David B. Shughart Son 5,501.60
24 Mill Street, Mt. Holly Springs, P A 17065
(1/8 Remainder Value of Life Estate)
Page 2 of Schedule J
REV.1514.EX.... (9-o0)
*'
SCIfillJLE K
UFE ESTAlE,ANNUfTY
& TERM CERTAN
(Check Box 4 on Rev-1500 Coller Sheet)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SHUGHART, MAYNARD L.
I FILE NUMBER
21 - 05 - 00175
This schedule is to be used for all single ute, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89.
actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found
in IRS Publication 1457, Actuarial Values. Alpha Volume for dates of death on or after 5-1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Intervivos Deed of Trnst
NEAREST AGE AT
LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE
Martha R. Shughart 08/2011921 83 181 Life or o Term of Years
o Life or o Term of Years
o Life or o Term of Years
o Life or o Term of Years
NAME(S) OF
,R;>'~
, _ _ _ _ _ ;w',;/>,:<;,~~t~i0_frr;;~
TERM OF YEARS LIFE ESTATE IS
/+t~q;.,:;
1. Value of fund from which life estate is payable
$
80,496.88
2. Actuarial factor per appropriate table IRS 87520 Rate of 4.6%
Interest table rate. 03 1/2% 06% 0 10% 181 Variable Rate 4.6%
3. Value of life estate (Line 1 multiplied by Line 2)
.25447
$
20,484.04
NAME(S) OF NEAREST AGE AT
ANNUITANTS DATE OF BIRTH DATE OF DEATH PAYABLE
o Life or o Term of Years
o Life or o Term of Years
o Life or o Term of Years
o Life or o Term of Years
TERM OF YEARS ANNUITY IS
1. Value of fund from which annuity is payable
$
2. Check appropriate block below and enter corresponding (number)
Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26)
o Semi-annually (2) 0 Annually (1)
3. Amount of payout per period
4. Aggregate annual payment. Line 2 multiplied by Line 3
o Monthly (12) 0 Quarterly (4)
o Other
0.00
5. Annuity Factor (see instructions)
Interest table rate - 03 1/2% 06% 010% 0 Variable Rate
6. Adjustment Factor (see instructions)
7. Value ofannuity - If using 3 1/2%,6%. 10% or if variable rate and period payout is at end of period,
calculation is: Line 4 x Line 5 x Line 6
If using variable rate and period payout is at beginning of period, calculation is:
(Line 4 x Line 5 x Line 6) + Line 3
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of
this tax retum. The resulting life or annuity interest{s) should be reported at the appropriate tax rate on Lines 13. 15, 16, 17 and 18.