HomeMy WebLinkAbout06-27-05
REV-1500 EX (6-00)
OFFICiAl USE ONLY
COMMONWEAL TH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
LL
COUNTY CODE
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YEAR NUMBER
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
SHELLEY CAMERON E.
DATE OF DEATH (MM-DD-YEAR)
SOCIAL SECURITY NUMBER
176-01-7982
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
DATE OF BIRTH (MM-DD-YEAR)
DECEMBER 26 2004 JANUARY 9 1915
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
NOT APPLICABLE
[!] 1 Original Return
D 4. Limited Estate
[!] 6 Decedent Died Testate (Allach copy of Will)
D 9. Litigation Proceeds Received
NOT APPLICABLE
D 2. Supplemental Return D 3. Remainder Return (dale of dealh pnor to 12-13-62)
D 4a. Future Interest Compromise (dale of dealh after 12-12-82) D 5. Federal Estate Tax Return Required
D 7. Decedent Maintained a Living Trust (Attach copy of Trust) L 8. Total Number of Safe Deposit Boxes
D 10. Spousal Poverty Credit (d.le of de"h belween '2-3'-9' .nd '-'-9S) D 11. Election to tax under Sec. 9113(A) (Aflach Sch 0)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
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DANIEL E. BASEHOAR EXECUTOR
FIRM NAME (If Applicable)
TRUST & INVESTMENT CO.
24 N. CEDAR STREET
PO BOX 1000
LITITZ PA 17543-7000
717-625-6231
1. Real Estate (Schedule A)
.00
496,892.11
.00
.00
59,234.05
.00
- OFFICiAl USE ONLY
(1)
2. Stocks and Bonds (Schedule B)
(2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4 Mortgages & Notes Receivable (Schedule D) (4)
5 Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E) (5)
Z 6 Jointly Owned Property (Schedule F)
0 [i] Separate Billing Requested (6)
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:3 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
:J (Schedule G or L)
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ei: 8 Total Gross Assets (total Lines 1-7)
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W 9. Funeral Expenses & Administrative Costs (Schedule H) (9)
0::
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11 Total Deductions (total Lines 9 & 10)
199,851. 91
(8)
13,485.51
309.20
755,978.07
(11)
13,794.71
742,183.36
50,000.00
12 Net Value of Estate (Line 8 minus Line 11)
13 Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J) .
(12)
(13)
14. Net Value Subject to Tax (Line 12 minus Line 13)
692,183.36
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15 Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
.00
.00
577,183.36
115,000.00
x.D _(15)
16. Amount of Line 14 taxable at lineal rate
x.O _(16)
17. Amount of Line 14 taxable at sibling rate
x12 (17)
69,262.00
17,250.00
86,512.00
18 Amount of Line 14 taxable at collateral rate
x 15 (18)
19. Tax Due
(19)
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
2W4645 1000
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedent's Complete Address:
S1REET ADDRESS
325 WESLEY DRIVE
CI1Y I STATE I ZIP
MECHANICSBURG PA 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1 )
86.512.00
.00
79,087.50
4,162.50
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + 8 + C) (2)
83,250.00
Total Interest/Penalty (0 + E) (3)
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 (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5)
3,262.00
A. Enter the interest on the tax due.
(SA)
8. Enter the total of Line 5 + SA. This is the BALANCE DUE.
Make Check to: REGISTER OF
(58)
3,262.00
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred;. . . . . . . . . . . . . . . D
b. retain the right to designate who shall use the property transferred or its income; . D
c. retain a reversionary interest; or . . . . . . . . . . . . . . . . . . . . . . . . D
d. receive the promise for life of either payments, benefits or care? . . . . . . . . . D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . .. D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ~ D
HE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Yes
No
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[K]
[K]
[K]
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ADDRESS
alive is based on all informatIon of which preparer has any knowledge
DATE
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co.
24 N. CEDAR ST.
PO BOX 1000 LITITZ PA 17543
DATE
- Zl - 05
24 N.
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 PS S 9916 (a) (1 1)(i)). "i"--, . ...L/
lN~ 4100. DC) ~I ~
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for t Y < U 9116 (a) (1.1) (ii)]
The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for 1='d 9 lO . <.:.:x::) r II applicable even if
the su rvivtng 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 youn
ora stepparent of the child is 0% [72 P.S. s9116(a)(12)]
!\PD
50.00
an adoptive parent,
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is ,
2 PS s9116(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.E
ind ividual who has at least one parent in common with the decedent, whether by blood or adoption.
2W4646 1000
~', AusT-
ection 9102, as an
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LAST WILL AND TESTAMENT
KNOW ALL MEN BY THESE PRESENTS, that I, CAMERON E. SHELLEY,
currently residing in West Donegal TO'-"TIship, Lancaster County, Pennsylvania, being in
good health and of sound and disposing memory do hereby make, declare and publish
this as my Last Will and Testament, hereby revoking all former Wills and Codicils
heretofore made by me.
FIRST:
I direct that all of my debts not barred by the statute of limitations,
expenses of my last illness, funeral expenses, costs of administration and claims allowed
in the administration of my estate shall be paid by my Executor hereinafter named, from
my estate as soon after my decease as shall be found convenient.
SECOND: To each of the persons listed below who survive me, I specifically
give and devise the following:
1. TEN THOUSAND DOLLARS ($10,000.00) to WILHEMINA COOPER.
2. TEN THOUSAND DOLLARS ($10,000.00) TO FLORENCE JERVIS.
3. TEN THOUSAND DOLLARS ($10,000.00) to VIOLA KRACHANKO.
4. TEN THOUSAND DOLLARS ($10,000.00) to CAROLINE SMITH.
5. TEN THOUSAND DOLLARS ($10,000.00) to MABEL BARROWS.
6. TEN THOUSAND DOLLARS ($10,000.00) to ARLENE HOUCK.
7. FIFTEEN THOUSAND DOLLARS ($15,000.00) to KENNETH
MILLER.
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any existing insurance thereon, in accordance with an unsigned memorandum to be kept
with this my Last Will and Testament. To the extent that such letter fails to dispose of all
of my tangible personal property or if the memorandwn is not in existence at my death,
then I give all such tangible personal property not disposed of to the residuary
beneficiaries.
FIFTH: To my sister ANNA M. SCHRIVER and my sister JANET
BASEHOAR I devise the rest and residue of my estate, both real and personal, wherever
situated and, whenever acquired, in equal shares, share and share alike. In the event that
my sister JANET BASEHOAR should predecease me, her one-half (1/2) share of the rest
and residue of my estate shall go outright in equal shares per capita to her children
DANIEL BASEHOAR, JANE DILLING (WILCOX), SUSAN B. WERT and SALL Y B.
HALL, per stirpes.
SIXTH: I hereby nominate, constitute, and appoint my nephew, DANIEL
BASEHOAR, as Executor of this my Last Will and Testament. In the event that my said
nephew shall predecease me or be unwilling or unable to act as my Executor, then I
nominate, constitute and appoint my sister ANNA M. SCHRIVER without necessity for
posting security regardless of state ofresidence, as Executor of this my Last Will and
Testament. All references to the Executor herein shall be applicable to said substitute
Executor.
SEVENTH: My Executor and Trustees shall have, in addition to the powers and
authority conferred upon them by law, the following additional powers and authority:
1. To sell at public or private sale, exchange, transfer, partition, give options
upon, lease, mortgage, pledge or otherwise dispose of any property, real or personal, at
any time constituting a portion of my estate, and upon such terms and conditions as the
Executor and Trustees shall deem wise.
2. To invest any money at any time in such bonds, stocks, notes, real estate,
mortg,ages, life insurance, annuities or other securities, or such property, real or personal,
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as the Executor or Trustees shall deem wise, without being limited by any statutes or rule
of law regarding investments by the Executor or Trustees.
3. To retain, without incurring any liability, as investments, any property
owned by me at the time of my death, as long as my Executor or Trustees may deem it
wise, and even though such property is not the kind of property an Executor or Trustees
would purchase as an investment; and even though to retain such property might violate
sound diversification principles.
4. To cause any security or other property which may constitute a portion of
my estate to be issued, held or registered in the their own name, or in the name of a
nominee, or in such form that title will pass by delivery.
5. To consent to the reorganization, consolidation, readjustment of the
financial structure, or sale of the assets of any corporation or other organization, the
securities of which constitute a portion afmy estate, and to take any action with reference
to such securities which, in the opinion of the Executor or Trustees is necessary to obtain
the benefit of any such reorganization, consolidation, readjustment or sale; to exercise
any conversion privilege or subscription right given to my Executor or Trustees as owner
of any securities constituting a portion of my estate resulting from any reorganization,
consolidation, readjustment, sale, conversion or subscription.
6. To pay all costs, taxes, charges and expenses in connection with the
administration of my estate, including such compensations to Executor or Trustees which
shall be in accordance with established fees throughout the period of administration of
my estate.
7. To determine what is "income" and what is "principal" hereunder, and
their decision thereon shall be final; and to purchase securities at a premiUm or discount,
and to apply or charge said premium or discount against income or principal as the
Executor or Trustees may determine.
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8. The Executor and Trustees may make payments to or on behalf of any
person who is the beneficiary hereunder but in no event, however, shall payments be
made to any creditor or other such person because of anticipation of payment by the
beneficiary, and any such claim made by way of anticipation by the beneficiary shall be
of no validity or legal effect.
9. To borrow money from any person, firm or corporation, including any
corporation acting as an Executor or Trustees hereWlder, for the purpose of protecting
and preserving or improving my estate hereunder; to execute promissory notes or other
obligations for amounts so borrowed.
10. To employ legal counsel, accountants, brokers, investment advisors,
custodians, managers and other agents and employees and to pay reasonable
compensation out of my estate or any funds held hereunder to which said compensation is
attributable.
11. To carry on any business owned or controlled by me at my death for
whatever period oftime they shall think proper, and they shall have the power to do any
and all things they deem necessary or appropriate, including the power to close out,
liquidate or sell the business at such time and upon such terms as they shall deem best.
12. To do all other acts in their judgment necessary or desirable for the proper
and advantageous management, investment and distribution of my estate.
EIGHTH: I direct that all transfer and inheritance taxes, state or federal, on
property passing under this Will shall be paid out of my residuary estate and that my
Executor pay, or provide for payment of such taxes at such time, or times, and in such
manner as my Executor deems best. Transfer or inheritance taxes, state or federal,
payable as a result of my death and assessed with regard to property passing outside my
probate estate shall be chargeable against the persons receiving such property.
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NINTH: Should any part, clause, provision and/or condition of this Will be
held void, invalid and/or inoperative then I direct that such invalidity shall not effect any
other clause, provision, and/or condition hereof, but the remainder of the Will shall be
effective as though such void clause, provision and/or condition had not been contained
herein.
IN WITNESS WHEREOF, I, CAMERON E. SHELLEY, the Testator to this,
my Last Will and Testament, typewritten on six sheets of paper which I have identified at
the bottom of each page by my signature, hereunto set my hand and seal the 17 ~
day of J..A./VvI_L
2004.
COpy
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CAMERON E. SHELLEY
The preceding instrument consisting of this and five other typewritten pages, each
identified by the signature of the Testator, CAMERON E. SHELLEY, this day and date
thereof signed, published and declared by CAMERON E. SHELLEY, the Testator
therein named, as and for his Last Will, in the presence of us who, at his request, in his
presence, and in the presence of each other have subscribed our names as witnesses.
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
S5
I CAMERON E. SHELLEY, Testator, whose name is signed to the attached or
foregoi~ instrument, having been duly qualified ~ccording ~o law? do, h~reby acknowled~e thatJ
signed and executed the instrument as my Last Wl~l; that I sIgned It wllImgly; and that I signed It
as my free and voluntary act for the purposes therem expressed.
~t:~
CAMERON E. SHELLEY -
Sworn or affirmed to an
Testator, the /1ltiJ day 0
nowledged before me by CAMERON E. SHELLEY,
2004.
~J;'" ,'I- R,J~
Notary Public ')
NOTARIAL SEAL
Roberta L. Radcliff. Notary Public
WormleySburg Boroug/l, County 01 Cumberland
My CommisSion Expires Jan. 20, 200S
(SEAL)
COMMONWEAL TH OF PENNSYLVANIA
: S5
COUNTY OF CUMBERLAND
We}:)vIIJNlf;3 ~ ~fKK~) and DAvIT) 1I/fA>>C4.rr
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 Testator sign and
execute the instrument as his Last Will; that he signed willingly and that he executed it as his free
and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of
the Testator signed the Will as witnesses; and that to the best of our knowledge the Testator was
at that time eighteen or more years of age, of sound mind and under no constraint Or undue
influence.
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~orn oNffi7!;d to and subscribed to before me by ~A;,.J I.
and I/). 4() (,L f FF witnesses' ay of
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(SEAL)
7
NOTARIAL SEAl
Roberta L. Radcliff, Notary Public
Wormleysburu BorougtJ, CountY 01 Cumberland
My Commission Expires Jan. 20, 2005
1-
REV-1503 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE B
STOCKS & BONDS
FILE NUMBER
CAMERON E. SHELLEY
21-2005-0027
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1_ ASSETS HELD BY SUSQUEHANNA TRUST & INVESTMENT CO. UNDER AGENCY
AGREEMENT DATED 7/17/2003; SEE ATTACHED LETTER DETAILING STOCKS
AND BONDS HELD AS OF DATE OF DEATH
496,892.11
2W4696 4.000
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
496 892.11
***
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* *
Susquehanna
, f /';, \ !.l \1 ,: ~:' " (,-,';- F:i (: .';'
January 5, 2005
*ir..*
Wendy L. Basehoar, Sr. Vice President
Susquehanna Trust & Investment Company
PO Box 1000
Lititz P A 17543-7000
Dear Wendy:
This letter will certify that at the time of Cameron E. Shelley's death on December 26,
2004, that Susquehanna Trust & Investment Company held the assets shown on the
attached sheets under and Agency Agreement dated July 17, 2003.
All assets shown on the attached have been valued using Internal Revenue Service
standards. In summary, we held the following:
Assets Shown on the Attached Valuation Sheets:
Cash/Cash Equivalents:
$472,317.52
24,574.59
TOTAL VALUE OF ASSETS HELD AS OF DECEMBER 26, 2004:
$496.892.11
Should you need any further information concerning Mr. Shelley's agency account, please
do not hesitate to contact me.
Very truly yours,
/lJJ!jj))
Stephen E. Wenzel
Vice President
SEW/csk
Mailing Address:
24 North Cedar Street
PO Box 1000
Lititz PA 17543-7000
717-625-6231
Est2te Val~ot~on
Date 0 Dea 2 I" ,~ 20
/ L tJ
'v'al'J3t c,n 0 e: 2/26 i.O
Prcces ""g te : 20 ~
Estate of: C;.J~E:<ON E. i-~ELLEY
Report Type: Date 0 Death
N~~ber of Securit es: 22
tIle 10: S:iE:"LEY, CAt; ECN S.
Shares
or Par
Sec'..:r: tv
OescLptio:1
H:gh/I'.sk
LCI-.'i'B:.ci
I~ean and/or D1V and Int
Adjustments Accrua~s
Securit~,1
Value
:i 25000 B;;OOKHi'.VE::; Pi'. G.O. BCS iil3529BK6)
Flnancial Ti~es IGteractive Date
OTC: 12/15/2001 Mat: 02/15/2005 3.2%
:2/23/2004 :00.19000 Mkt
12/27/2004 100.18200 Mkt
I:1t: 08/15/2004 to 12/26/2004
100.186000
25,046.50
291 . 11
21
5000 CA?ITAL PROJS FIN ACTH FLA SOL REV 80S i1~0426AG21
Financial Times Interactive Data
OTO: iO/0:/1999 Mat: 10/01/2019 8%
12/23/2004 98.79000 Mkt
12/27/2004 98.79000 Mkt
Int: 10/01/2004 to 12/26/2004
98.790000
4,939.50
94 .44
31 15000 O.RLYNTON SCH JI S'? P.I\ G.O. BOS (143110EEO)
FlnanClal T:rnes Interactive Oata
DTD: 05/0:12001 Ma t. 10/0112007 4%
12/23/2004 102.86100 Mkt
12/27/200; 1 J2. 80500 Mkt
102.833000 15,424.95
Int: 10/01120.04 to 12/2612004 141. 67
4) 2032.62 Fi\"'.NKLIN n.x FREE TR i354723850)
CA T/r INCM .n.
Mutual ?:J~d ias quoted by NJ;S CAQ i
12/23/2004 11.99000 Mkt
11.990000 24,]71.11
51 15000 GHSATER ORL.n.:\OO !l.V I.n. T ION Jl.JTH REV BDS i3922"4PZ3)
Financial Tirr,es InteractIve Data
D'2"'D: 06/01i'999 t~at : 10/0112028 5.125%
J.2/23/2004 101.91200 Mkt
12/27/2004 101. !l000 Hkt
101. 811 000 15,271.65
Ir~: :0/01/2004 to 12/26/2004 181.51
61 20000 NEW BPIGriTJN PA Jl.REA SCH OIST G.J. REF i642683FF81
FinanCIal Ti:T;es Interactlve Data
OTO: 04/01/20C1 1.1at: 08/15/2001 4%
12/2312004 104.58900 Mkt
12/27 12004 104.50600 M.{t
104.547500 20,909.50
Int: 08/15/2004 to :2/26/2004 291.11
7 ) ~500D NJRTHERN YORK CNTY PA SCH OIST G.J. 8DS (666095EZ3)
tl:la:lcial Times Interactl ve Oata
0:0: 04/01/2001 Mat: 11/15/2007 4 .05 %
12/23/2004 102.47100 Mkt
'2/27/2004 102.~2500 Mkt
102.448000 15,367.20
Int: 11/15/2004 to 1212 6/2004 69.19
B)
1550 NUVEEN PREM INCOME MUN FD i67062T100)
COM
:\ew York Stock Excharge
12/2312004
12/27/2004
13.67000
13.67000
13.61000 H/L
13.59000 H/L
D1V: 0.08 Ex: 12/13/2004 Rec: 12/1512004 Pay: 12130/2004
13.635000
21,134.25
124 . DO
9 )
1870 NUVEEN MUN MKT OPPORTUNITY rD i67062W103)
CJM
New York Stock Exchange
12/23/2004 13.95000
12/27/2004 13.98000
13.86000 H/L
13.89000 H/L
D1V: 0.079 Ex: 12/13/2004 Rec: 12/15/2004 Pay: 12130/2004
13.920000
26,030.40
147.73
Page 1
To:s report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. If you have questlons,
please contact EVP Systems at (818) 313-6300 or www.evpsys.com. iRevlsion 7.0.4)
te c: Debt
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Sr:6 re s
Securit),
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or ?a r
Hlqr./Ask
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833 O??ENHEI~ER MU~TI-SECTOR INCOM (683933105)
Sri BEN INT
~ew York StecK Excrange
12/i'3/200y
a.9200C
8.80000
8.80000 H/L
8.7200e; H/L
l2/27/2004
] II 20000 OXfORD P,'l. i\.RE:A SCH CIST RE, 80S (691789E\;7)
FinancIal Times InteractIve Data
DTD: 12/15/2001 Mat: 02/15/2005 3.2%
12/23/2004 100.17600 Mkt
12/27/2004 100.17200 Mkt
Ir.c: 08/15/2C04 ~o 12/26/2004
12) 15000 PENNSYLVANIA ST UNIV REF 80S (709235LPB)
Flnarc:al Ti~es Interactive Data
DTD: 05/01/2002 Mat: 08/15/2006 3.2%
l2/23/2004 101.50800 Mkt
12/27/2004 101.45800 Mkt
Int: 08/15/2004 to 12/26/2004
13\ 15000 PINE-RICHLM.IJ SCH CIST FA G.O. REF (7227;OLFLi
Financial Tl~es Interactive Data
DTD: 03/1512001 "Iat: 09/e'I12007 4%
12/23/2C04 104.33400 ~k~
12/27/2004 104.25100 Mkt
Int: C9/01/2004 to 12/26/20C4
14) 10000 PUL.;SKI CNTY ILL FI!, COR? DETE FIRST mG (745432AC8)
Financial Times !nteractlve Dcta
DTD: 08/01/1997 Ma~: 08/01/20l8 7.5%
12/23/2004 99.56900 Mkt
12/27/2004 99.23500 Mkt
Int: 08/01/2004 to 12/26/2004
1 c',
5420 P\.JTNA1~ MANAGED MUN INCO~1 TR (7468231031
COM
New York S:ock Exchange
12/23/2004 1.160ae
12,27/2004 .15000
7.11000 H/L
7.11000 H/L
01\': 0.0492 Ex: ,2/21/20'04 Rec: 12/23/2004 Pay: 01/03/2005
16 I
1970 PUTNs~ ~UN OP?ORTUNITIES TR [74(922103)
SH B% INT
New YOc~ S~oc~ Excha~qe
12/23/2004 12.24'000
12/27/2004 12.18000
12.15000 H/L
12.11000 H/L
Div: 0.0754 Ex: 12/21/2004 Rec: 12/23/20C4 Pay: 01/0312005
17)
5000 SANTA ROSA BAY BRJG AUTH FLA R RE:V BDS (802576AA6)
Financial Tl~es Interactive Data
OTD: 10/15/1996 Mat: 07/01/2028 6.25%
12/23/2004 89.05700 Mkt
12/27/2004 88.95500 Mkt
Int: 07/01/2004 to 12/26/2004
18) 15000 SLIPPERY ROCK PA AREA SCH DIST G.O. BDS i831493,LO)
Fi~ancial Times Interactive Data
DTD: 03/l5/2001 Mat: 10/0112007 4%
12/23/2004 102.40200 Mkt
,2/27/2004 102.39700 Mkt
Int: 10/01/2004 to 12/26/2004
Page 2
Estate of: C~ERON E. HELLE
Report TYPE: Dale 0 Deat
Nu~ber of Securl~ es:
Fl1e 10: SHELLE:, C~, RON E.
Mean ar.d/or Div and I~t
Adjustments Accruals
Securitv
'/a~ l...:e
7,332.73
20,034.80
15,222.45
15,643.88
9,940.20
38,658.15
23,974.90
4,45'0.30
15,359.93
ThIS report was pcoduced with EstateVa1, a product of Estate ValuatIons & PrIcing Systems, Inc. If you have questIons,
please co~tac: EVP Syste~s at (8181 313-6300 or www.evpsys.com. [ReVISIon 7.0.4)
8.810000
100.174000
232.89
101.483000
174.67
104.292500
191.67
99.402000
302.08
7.132500
266.66
12.170000
148.54
89.006000
151 a'
102.399500
141. 67
Jate 0 D>2:a h :
\; a 1 L:a t cr; D te :
?roces In~ a :e :
6/ 004
61 0(: ~
31 005
~t.a:es
Of Par
SeC'Jflty
Desc~:.ptiC:1
Higr./Ask
191
1500C
H B~DG AUTH FA CC~ RSV RSt a :857320838)
mes InteractIve Da:a
OCl Mat: 07/l~/2007 4.1%
STATS PUB S
Financial T
OTD: 041151
~2/2J/20C4
12/27/2GO~
Int: 07/15/2004 to 12/26/2004
2C)
40000 J~~T~O STATSS TRSAS ~TS (9128288,6)
Government/Agency (Dealer QuotatIons)
OTO: 08/15/2003 Hat: 08 15/2006 2.375%
,2/23/2004
12/27/2004
99.15625
99.09375
Int: 08/15/2004 to 12/26/2004
21)
40000 UNITSO STATSS TREAS NTS (912828aU3)
Government/Agency (Dealer QuotatIons)
DTD: 12/31/2003 Hat: 12/31/2005 1.875%
12/23/2GO~ 99.18750
12/27/2004 99.15625
:nt: 06/30/2004 to 12/26/2004
22)
3612 VAN KA!~PEN TR INVT GRADE ~1UNS (9209291061
COH
New York Stock Sxcr.ange
12/23/2004 1~.99000
12/27/2004 14.99000
LOv..'/Bid
lC4. 41200 ~1kt
104.33300 i'1kt
99.09375 Ala
99.03125 Ala
99.12500 Jl./8
99.09375 1'./8
Di'J: 0.0825 Ex: 12/;312004 Ree: 121l5/200~ Pay: 12/3112004
14.92000 H/L
14.92000 UL
Tetal Value:
Total Accrual:
Total: $472,317.52
Page 3
Es:a~e cf: C~~~?ON E. SHELLEY
Report T~'pe: Date of Death
Number of Securities: 22
Flle :C: SHELL::Y, Cr~JjEFO:J s.
Mean a:1d/cr Jiv and Int
Adjus~me~ts Accruals
SeC'Jrit'y'
\/al '~e
15,655.88
39,637.50
39,656.25
5~,017."6
$468,085.49
ThiS report was produced w,tr. EstateVal, a product of Sstate Valuations & PriCIng Systems, Inc. If you have questions,
please contact EVP Systems at (8181 313-6300 or www.evpsys.com. (RevisIon 7.0.4)
104.372500
27 5.04
99.093750
343.34
99.1"0625
364 . 81
1".955000
297.99
$4,232.03
. REV-1508 EX. (6-98)
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
CAMERON E. SHELLEY
FILE NUMBER
21-2005-0027
I nclude 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 DESCRIPTION
VALUE AT DATE
OF DEATH
1. CASH IN DECEDENT'S WALLET AT DEATH
6.00
2. SUSQUEHANNA BANK PA; BALANCE IN CHECKING ACCOUNT NO. 0156141301
AS OF DATE OF DEATH
INTEREST ACCRUED TO DATE OF DEATH
10,283.87
.48
3. PATRIOT NEWS, SUBSCRIPTION REFUND
22.48
4. BETHANY VILLAGE RETIREMENT CENTER:
REFUND OF DECEMBER 2004 ROOM CHARGES
REFUND DUE ON APARTMENT PURCHASE AGREEMENT
1,079.23
46,155.00
5. STATE FARM, REFUND OF PREPAID PREMIUM ON RENTERS' POLICY NO.
38LC59674
22.50
6. STATE EMPLOYEES RETIREMENT SYSTEM, PRO RATA BENFITS FOR DEC 2004
834.49
7. INTERNAL REVENUE SERVICE, FORM 1040; REFUND OF PERSONAL INCOME
TAXES; TAX YEAR END: 12/31/2004
644.00
8. PA DEPARTMENT OF REVENUE, FORM PA40; REFUND OF PERSONAL INCOME
TAXES; TAX YEAR END: 12/31/2004
186.00
2W46AD 3 000
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
59 234.05
January 13,2005
Susquehanna Trust & Investment Co.
POBox 1000
Lititz P A 17543
RE: Cameron E Shelley Estate
SS# 176-01-7982
ODD: December 26, 2004
Your File #:
To Whom It May Concern:
5usquehann~
Susquehanna Bank PA
24 North Cedar Street
P.O. Box 1000
Lititz, PA 17543-7000
Toll free 800.311.3182
In response to your letter of January 4,2005 here is the above customer account information as of
December 26, 2004.
. Account Title:
Account #1
Cameron E Shelley
Bethany Village
Retirement Center
. Account #//Type
Checking
#156141301
. Date Opened/Maturity Date: 05/08/03
. Interest Rate: .10%
. Account Balance*: $10,283.87
. Accrued Interest: $0.48
. YTD Interest: $21.51
* Account balance does not include accrued interest.
There is no safe deposit box in the name of this decedent.
If I can be of further assistance, please feel free to call.
S~l1cerely, ?/r/ /
, /__',., /f;..- ,>
, ' ". 't "
~~0"{/t 7?/{ Jy ~_.{4---
;i l' anet M. Peters
" Support Services Supervisor
1-717 -625-6295
Account #2
. REV-1510 EX + (6-98)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
CAMERON E. SHELLEY
FILE NUMBER
21-2005-0027
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERlY
I TE M It'oCUDE Tt-E N<ME OF Tt-E TRANSFEREE. THEIR RELA TIONSHIP TO DECEDENT AND
NUMBER Tt-E DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE
1. AMERICAN SKANDIA ANNUITY NO.
000218294; ANNUITY PROCEEDS
PAYABLE AT DEATH TO DECEDENT'S
SISTERS (JANET S. BASEHOAR AND
ANNA M. SCHRIVER)
2. TRANSAMERICA ANNUITY NO. 7853091
ANNUITY PROCEEDS PAYABLE AT DEAT
TO DECEDENT'S SISTERS (JANET S
BASEHOAR AND ANNA M. SCHRIVER)
DATE OF DEATH
VALUE OF ASSET
% OF DECO'S
INTEREST
132,664.92 100%
73,186.99 100%
TOTAL (Also enter on line 7, Recapitulation) $
2W46AF 3000
(If more space is needed, insert additional sheets of the same size)
EXCLUSION
IF APPLICABLE)
3,000.00
3,000.00
TAXABLE
VALUE
129,664.92
70,186.99
199 851.91
America)l
Skandia
John Reavy
Senior Customer Service Associate
American Skandia Life Assurance Company
A Prudential Financial company
Annuity Sef\llces
POBox 7960
Philadelphia, PA 19101
(800) 752-6342
wwwamericanskandia.prudential.com
A Prudenrwl FlI1ol1cwl Cnmp(l!1)'
SUSQUEHANNA TRUST & INVESTMENT COMP
ATTN:WENDYLBASEHOAR
24 NORTH CEDAR STREET
PO BOX 1000
LlTITZ PA 17543
Client: Cameron E. Shelley
Contract Number: 0002] 8294
February 4, 2005
Dear Ms. Basehoar:
Thank you for your recent inquiry concerning Mr. She]ley's above referenced annuity contract.
You wrote in to notify us of Mr. Shelley's death, along with a request for claim forms and values.
Because December 26, 2004 was not a business day, I am not able to provide you with the value of
the annuity as of that date. For the last business day prior to this date, December 23, 2004, the
contract fund value was $132,664.92. The Post Tefra Cost Basis amount for the contract was
$50,000.00 while the remainder is considered earnings.
We have presented this information based on our understanding of tax law. The beneficiaries may
wish to consult with their tax adviser if they have any tax questions. Because each situation is
unique, neither American Skandia nor its representatives can provide tax advice.
Our records indicate that the primary beneficiaries are Janet S. Basehoar (Sister) and Anna M.
Schriver (Sister) in equal shares. I have enclosed 2 death benefit claim packages for your
convenIence.
If you have any questions, please call American Skandia Customer Service at (800) 752-6342. We
are available Monday through Friday between 8:00 a.m. and 8:00 p.m. Eastern Time. Accurate
records help us serve you better. When making a change, please consider the need for changes to
all of your American Skandia products. Thank you for choosing American Skandia for your
insurance and financial services.
SJZ ~
.lohn Reavy
Senior Customer Service Associate
Registered Representative
Enclosures
American SKandla MarKeting. Inc, and Ameflcan Sl<andla life Assurance Corporation are Prudential Fmanclal compames
American Skandla Life Assurance Corporation IS solely responsible for ItS ftnanclal condlllon and contractual obligations
Registered Representat<ve
American Skandla Marketing, Inc
A Prudential Financial company
One Corporate Drive
Shelton, CT 06484-0883
,
l~T~~~~RI~^
Transamerica Occidental Life
Insurance Company
4333 Edgewood Road NE
PO Box 3183
Cedar Rapids, Iowa 52406-3183
January 11, 2005
Anna M Schriver
C/O Wendy L Basehoar
24 North Cedar St
Lititz PA 17543-7000
RE: Annuity Number 7853091
Dear Anna M Schriver:
We have received notification, Cameron E Shelley, annuitant of the
above listed non-qualified tax deferred annuity is deceased. Our
office wishes to extend sincere condolences for your loss.
Our records indicate the following annuity policy information:
Annuity Policy Date:
Full Value as of 12/26/2004
Cameron E Shelley
Cameron E Shelley
Anna M Schriver
Janet S Basehoar
February 26, 2001
$73,186.99
Annuitant:
Owner:
Primary Beneficiary(ies)
The attached document reflects the options available to the primary
beneficiary{ies) listed above.
A variable annuity provides for a fluctuating return and benefit, in
response to its underlying investments, regardless of the option
chosen. The death benefit amount will be defined, according to the
provisions of the contract, upon receipt of the requested documents
associated to the death option you choose. It is important to note; a
variable annuity will continue to be subject to the variable market
until all of the annuity funds are disbursed.
The full value as of the date of death is for tax purposes only and is
not a guaranteed death benefit amount.
Operations performed on an automatic basis have been terminated, such
as: Dollar Cost Averaging, Rebalance and/or Systematic Payout, when
applicable.
Member of the _eGON. Group
The attached document contains general tax information based on
Transamerica Occidental Life Insurance Company's interpretation and
should not be relied upon for your personal tax planning. If you have
questions concerning the direct tax consequences when selecting an
option, you may wish to consult a tax advisor.
Any additional questions regarding this annuity can be directed to the
Annuity Service Center at 1-800-525-6205. A Transamerica Occidental
Life Insurance Company representative also will gladly assist you with
any questions you may have regarding this annuity and help you meet
your financial goals.
Sincerely,
~~~
Kerry J. Strait
Transamerica Occidental Life Insurance Company
Claims
Enclosure(s)
Annuity Claimants Statement
Postage Paid Return Envelope
Death Option Packet
cc: Wayne Edward Dewey
REV-1511 EX + 112-99)
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMIN ISTRA TIVE COSTS
ESTATE OF
CAMERON E. SHELLEY
ITEM
NUMBER
A.
1-
2
3
4
5
6
7
8
9
10
B.
1.
2.
Debts of decedent must be reported on Schedule I.
DESCRIPTION
FUNERAJ... EXPENSES:
PARTHEMORE FUNERAL HOME, FUNERAL EXPENSES
DEATH NOTICE, YORK PA NEWSPAPERS
DEATH NOTICE, HARRISBURG PA NEWSPAPERS
CERTIFIED COPIES OF DEATH CERTIFICATES
TENT AND CEMETERY EQUIPMENT
CLERGY HONORARIUM
FLOWERS, CASKEt SPRAY
PADDLETOWN CEMETERY, GRAVE OPENING
GRANITWERKS MEMORIALS, MEMORIAL STONE COSTS
BETHANY VILLAGE RETIREMENT CENTER, POST FUNERAL MEAL
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Year(s) Commission Paid:
Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State
Zip
Relationship of Claimant to Decedent
Probate Fees
REGISTER OF WILLS OF CUMBERLAND COUNTY
5. Accountant's Fees
4.
6_
7.
2W46AG 3 000
Tax Return Preparer's Fees
FILE NUMBER
21-2005-0027
SUSQUEHANNA TRUST & INVESTMENT CO. I SERVICES RE ADMINISTRATION
SUSQUEHANNA TRUST & INVESTMENT CO., FED EX CHARGES
SUSQUEHANNA TRUST & INVESTMENT CO., VALUATION OF SECURITIES
TOTAL (Also enter on line 9. Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
AMOUNT
8,198.00
126.25
185.28
24.00
100.00
250.00
140.00
550.00
281. 80
233.00
80.00
20.00
464.00
250.00
2,500.00
43.58
39.60
13 485.51
. REV-1512 EX + (6-98)
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
CAMERON E SHELLEY
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
FILE NUMBER
21-2005-0027
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
2.
DESCRIPTION
ALERT PHARMACY SERVICES INC., PHARMACY BILL DUE AT DEATH
DOUGLAS QUINN, REIMBURSEMENT FOR MEAL PURCHASED BY DECEDENT FOR
NURSING HOME STAFF FOR CHRISTMAS
QUANTUM IMAGING & THERAPEUTIC, MEDICAL BILL DUE AT DEATH; DATE OF
SERVICE: 4/01/2004
VALUE AT DATE
OF DEATH
98.20
198.78
12.22
2W46AH 3000
3.
TOTAL (Also enter on line 10. Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
309.20
REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
CAMERON E. SHELLEY
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers
under Sec. 9116 (a) (1.2)J
SEE ATTACHED FOR LISTING OF ALL BENEFICIARIES
FILE NUMBER
21-2005-0027
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
AMOUNT OR SHARE
OF ESTATE
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
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
Church of God, Etters PA 17319
2W46AI 2 000
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
(If more space IS needed, Insert additional sheets of the same size)
50,000.00
$
50 000.00
CAMERON E. SHELLEY BENEFICIARIES
SECTION 1 - TAXABLE DISTRIBUTIONS
Name Address RELATIONSHIP Interest
Wilhemina Cooper 1581 Mt. Cobb Road, Lake Ariel PA 18436 Friend 10,000.00
Florence Jervis RR #1, Factoryville PA 18419 Friend 10,000.00
Caroline Smith 221 Bardwell Road, Factoryville PA 18419 Friend 10,000.00
Mabel Barrows 673 Piketown Rd, Harrisburg, PA 17112 Friend 10,000.00
Arlene Houck (Mrs. John H.) 7600 Linglestown Road, Harrisburg PA 17112 Friend 10,000.00
Kenneth Miller 4827 N. Capistrano Loop, Beverly Hills FL Friend 15,000.00
34465-4517
Robert Miller clo Speciality Cakes, 5246 Simpson Ferry Friend 5,000.00
Road, Mechanicsburg PA 17055
Douglas Quinn 791 Ridge Road, Lewisberry PA 17339 Friend 20,000.00
Donald and Janice Duzenbery 4680 Tahiti Drive, Bonita Springs FL 34134 Friend 25,000.00
Anna M. Schriver 325 Wesley Drive, Mechanicsburg PA 17055 Sister 1/2 Residue
Janet Basehoar 239 Hershey Drive, Manheim PA 17545 Sister 1/2 Residue
SECTION 2 - NON-TAXABLE DISTRIBUTIONS
Name Address RELATIONSHIP Interest
Church of God, Goldsboro PA Goldsboro Church of God, Etters PA 17319 Charity $50,000 In Trust
Glenda Farner Strasbaugh
Register of Wills
and
Clerk of Orphans' Court
Marjorie A. Wevodau
First Deputy
KirkS.Sohonage. Esq
Solicitor
Register of Wills and Clerk of the Orphans' Court
County of Cumberland
One Courthouse Square
Carlisle, PA 17013
(717) 240-6345
FAX (717)240-7797
INVOICE
Bill To:
InvoiceN 0:
Invoice Date:
Estate of:
Estate No:
424
6/28/2005
CAMERON E. SHELLEY
21-05-0027
DANIEL BASEHOAR
24 N. CEDAR ST
P.O. BOX 1000
LITITZ, PA 175437000
JA
Qty
1
Fee Description
Additional Probate
Fee
Total
50.00
$50.00
Total:
$50.00
Checks should be made payable to the Register of Wills. Terms: Net 30.
Please return one copy of this invoice with your payment. Thank you.