HomeMy WebLinkAbout11-16-06
,q-~--T'-'-'-- , --",-
jan M. Wiley
David J. Lenox
Timothy j. Colgan
Christopher J. Marzzacco
THE WILEY GROUP
Attorneys at LaW"
November 15,2006
Wiley, Lenox, Colgan & Marzzacco, P.c.
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, P A 17013
In Re: Estate of Clayton B. Sheaffer, Jr., deceased
File Number 21-06-00754
Dear Register:
David E. Hershey
Bradley A. Winnick
Thomas M. Clark
Enclosed for filing please find an Inventory, the inheritance tax return in duplicate, and the status
report with regard to the above captioned estate. Also enclosed is a check in the amount of
$4,115.66 representing the tax due, and a check in the amount of $30.00 representing the filing
fee.
Please return the recording receipts to my attention in the enclosed envelope.
Thank you for your cooperation.
Sincerely,
~
Dawn Gladfelter/Le
/dg
encl.
(')
~o
,,- ::n
CQ -0
': :;J;P
;:_~ ~~. m
,-. ::n
(:15:::;;<:;
C)O
':) C) 11
cc
; ::IJ
::n-l
):>
......,
=
=
c:ro
Z
C)
...;:::
0"\
-0
:x:
-
..
C)
n
l~' reo,!
C)
C)
(~
r'n
CJ
C,,)
-"\
-q
- C)
,'" ,n
':/) C)
'; j
130 W. Church Street, Suite 100 . Dillsburg, PA 17019 . Phone: (717) 432-9666 · (800) 682-4250 · Fax: (717) 432-0426
Offices in Harrisburg · York · Carbondale
www.wileygrouplaw.com
<<
REV.1SOO EX + (8-00) REV-1500 OFFICIAL USE ONLY
* COMMONWEALTH OF
PENNSYLVANIA FILE NUMBER
DEPARTMENT OF REVENUE INHERITANCE TAX RETURN !1 06 00754
DEPT. 280601
HARRISBURG, PA 17128-0601 RESIDENT DECEDENT COUNlY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
... Sheaffer, Clayton B. Jr. 196-14-3885
z
w DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DO-YEAR) THIS RETURN MUST BE FILED IN DUPUCATE WITH THE
0
W 08-23-2006 06-05-1923 REGISTER OF WILLS
0
w (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST. FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
0
w
lO:~'"
uii!lO:
wA.8
:z:i..
UA.ID
A.
<(
[!J 1. Original Retum
o 4. Limited Estate
[!J 6. Decedent Died Testate (Attach
copy of WilQ
o 9. Litigation Proceeds Received
o
o
o
o
2. Supplemental Retum
4a. Future Interest Compromise (dale of death after
12-12.a2)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10 Spousal PovertY Credit (date of death between
. 12-31-91 and 1-1-(5)
o 3. Remainder Return (dale of death prior to 12-13.a2)
o 5. Federal Estate Tax Return Required
1 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
. , .~..." '\ ;.,~~,.~." ~ _ 'i ..:. ~~ ff.;7(',;;y 'v,':'::'e,' -.:; q"? ''', ":..;~~"" ~w " f~l~.:'~;," 1" .*": .: up:~~~~~~g:r~~
+ '. . ~J, ..,' "lj ". .' ~ ,...t',t :~ .'< J '. ~ ) I ~ <~ A'-..J,YI ",~,,t:ct'.I,, ~,J~ "-'h,~.t"' [~;;-,,,~. ,~.JT!} .''... J,:<J;~~)..,..j;.~J:.~f~0k1:~..t~~~~ "
t-
ill
Q
z
l?
II)
~
o
u
NAME
David J. Lenox
FIRM NAME (If applicable)
The Wiley Group, PC
TELEPHONE NUMBER
717 -432-9666
OFFICIA~SE ONLY
....-- = Xl
'- J c:T' rTl
Co __ C-J
S. :0 ..... (~
c.O .0 c::> TJ
'n --r (") <.: t.:::J
;2-25~ ' (1
, ,- "" :z:: ::0 "" CJ
,~ (J) 7' C")
~'jS)9 -U =8
,',.] 0 r I::ll: c'j
r )C [-'-1
,- ~ r- '
-0 ___ C/) ':-;'r.~
)> ...... .
(8) 122,442.67
(11)
(12)
(13)
(14)
21,336.57
101,106.10
10,000.00
91,106.10
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
z
o
j::
:s
:)
...
0::
c(
o
W
0::
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) 0 Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
COMPLETE MAILING ADDRESS
130 W. Church Street
DiIIsburg, PA 17019
(1) 100,720.85
(2) 13,917.56
(3) None
(4) None
-------
(5) 3,484.23
(6) None
(7) 4,320.03
(9)
(10)
20,846.00
490.57
0.00
3,987.27
120.00
225.00
4,332.27
11. Total Deductions (total Lines 9 & 10)
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)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Copyright 2002 fonn software only The Lackner Group, Inc.
15.Amount of Line 14 taxable at the spousal tax rate, 0.00 x .00 (15)
z or transfers under Sec. 9116(a)(1.2)
0 (16)
i= 16.Amount of Line 14 taxable at lineal rate 88,606.10 x .045
~
:)
D. 17.Amount of Line 14 taxable at sibling rate 1,000.00 x .12 (17)
:liE
0
0 18. Amount of Line 14 taxable at collateral rate 1,500.00 .15 (18)
>< x
~ 19. Tax Due
(19)
Fonn REV-1500 EX (Rev. 6-00;
~
, .
Decedent's Complete Address:
STREET ADDRESS
23 S. St. John's Road
CITY Camp Hili
ISTATE PA
IZIP 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
4,332.27
216.61
Total Credits (A + B + C)
(2)
216.61
3. InteresVPenalty if applicable
D. Interest
E. Penalty
TotallnteresVPenalty (0 + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
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. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
4,115.66
4,115.66
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;.................................................................................. ~ ~
~: ~::::~ ~h~:::i~~:~s:~::s~;.~~~.I~.~~~.~~~.~~~:.:~.~~~~~~~.~.~.~.~.~~~:~~:::::::::::::::::::::::::::::::::::: ~
d. receive the promise for life of either payments, benefrts or care?............................................................. [!J
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?...................................................................................................................... [!J 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe<jwy, I declare that I have examined this return, including accompanying schedules and statements, and to tha best of my kn<M1edge and belief, ft Is true, COITllCI and
COl\'1ll8l8. DecIaralion of preparer other than the personal representative Is based on an information or which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETURN ADDRESS
James B. Sheaffer
o
o
[!J
[!J
274 N. Cherry Point Road
Okatie, SC 29909
DATE
I r/trl'
111/y~v
IC/ty~;
ADDRESS
25 S. Sl Johns Road
Camp Hill, PA 17011
ADDRESS
130 W. Church Street
Dlllsburg, PA 17019
For dates of d ath 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 exemDt 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 parent, or a stepparent ofthe child is 0% [72 P .5. ~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%, 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)]. 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.
..
LAST WILL AND TESTAMENT
OF
CLA YTON B. SHEAFFER, JR.
BE IT REMEMBERED, that I, CLAYTON B. SHEAFfER, JR., of 23 S. St. John's
Road, Camp Hill, Cumberland County, _Pennsylvania, being of.sound mind, memory and
understanding, do make, publish and declare this as and for my Last Will-and Testament, hereby
revoking and making null and void any and all Wills and Testaments and writings in the nature
thereof made by me at any time heretofore.
ITEM 1: I direct that all my just debts and funeral expenses be paid as soon after my
demise as may be convenient.
ITEM 2: I specifically devise my residence at 23 S. S1. .Tohn's Road, Camp Hill,
Pennsylvania to my sons, James-B. Sheaffer and Daniel L. Sheaffer, Sr. In the event Daniel L.
Sheaffer, Sr. should predecease me, his share of the residence shall be devised to his wife, Janet
M. Sheaffer and, in the event James B. Sheaffer shall predecease me, his share of the residence
shall be devised to Daniel L. Sheaffer, Sr.
ITEM 3: I specifically bequeath Fluffy the cat and all his belongings to Barbara
Sheaffer.
I bequeath the following amounts to the named persons and organizations:
$5,000.00 to Calvary United Methodist Church
located in Dillsburg, Pennsylvania. in memory of
my wife, Mary E. Sheaffer;
1
RECORDED OFFICE OF
REGISTER OF WILLS
2006 AUa 24 PM 1:00
CLERK OF
ORPHAN'S COURT
CUMBERLAND CO., P A
~
$5,000.00 to God's Missionary Church located in
Camp Hill, Pennsylvania., in my memory and in
memory of my wife, Mary E. Sheaffer;
$500.00 to Tammy Emeigh;
$.1,000.00 to Carl Sheaffer and Shirley Sheaffer,
or the survivor of them, in thanks for all the good
things they made for my family;.
$1,000.00 to Sam Swab and Mary Swab, or the
survivor of memo
Any specific bequest which fails for the prior death or dissolution of the named
beneficiary shall lapse and be added to my residual estate.
ITEM 4: All the rest, residue and remainder of my estate, of whatsoever nature and
wheresoever situate, whether it be real, personal or mixed, including property over which I have
a power of appointment, I give, devise and bequeath in equ81 shares unto my sons, James B.
Sheaffer and Daniel L. Sheaffer, Sr.
In the event Daniel L. Sheaffer, Sr. should predecease me his share of the residual estate
shall be distributed to his wife, Janet M. Sheaffer and, in the event James B. Sheaffer sh8.II
predecease me his share of the residual estate shall be distributed to Daniel L. Sheaffer, Sr.
ITEM 5: I direct my hereinafter named Executors to pay all inheritance, estate,
succession and legacy taxes of whatsoever nature and kind, to which my estate or the transfer of
any property passing hereunder or otherwise passing by reason of my demise, may be subject and
to charge such taxes against my residuary estate, it being my intention that none of the aforesaid
taxes, either federal or state, on any property required to be included in my gross estate, under the
2
provisions of any state or federal law now in force or hereafter enacted, shall be prorated among
the persons interested in my estate to whom such property is or may be transferred or to whom
any benefit accrues.
ITEM 6: I appoint my sons, James B. Sheaffer and Daniel L. Sheaffer, Sr., as Co-
Executors of this my Last Will and Testament. Should either of the named co-executors
predecease me, fail to qualify, cease to act, or renounce probate, then the remaining co-exeClltor
may serve alo.ne withollt necessitating a replacement for the failed "appointn'lent.
ITEM 7: I direct that my Executors or their successor shall not be required to give bond
for the faithful performance of their duties in any jurisdiction. .
ITEM 8: My Personal Representatives shall have the following powers in addition to
those vested in them by Law and by other provisions oftrus, my Last Will and Testament,
exercisable without court approval, and effective until distribution of all property:
1. To retain any or all of the assets of my estat~, real or personal,
without restriction to investments authorized for Pennsylvania
fiduciaries, as they from time to time may deem proper, without
regard to any principal of diversification or risk.
2. To invest in all forms of property without restriction to investments
authorized for Pennsylvania fiduciaries, as they from time to time
may deem proper, without regard to any principal of diversification
or risk.
3. 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 they from time to time may deem proper.
4. To allocate receipts and expenses to principal or income or partly to
each as they from time to time may deem proper.
5. To borrow money from persons or institutions, themselves included, and
3
to mortgage or pledge any or all real or personal property as they in their
sole discretion shall choose, without regard to the dispositive provisions of
this instrument.
6. To compromise any claim or controversy asserted by or against my
estate or trust estate.
7. To make distribution in cash or in kind or partly in cash and partly in kind,
and in such manner as they may determine, and at valuations finally to be
fixed by them.
IN WITNESS WHEREOF, I have hereunto set my hand.and seal this 31st day of
October, 2005.
o~
/
I
/
t
, ~~
~{~~.' ~. ,V
4
COMMONWEALTH OF PENNSYLVANIA
. .
.
: SS
COUNTY OF YORK
We, Clayton B. Sheaffer, Jr., David J. Lenox, Esquire and Julie A. Rudy, the Testator
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 Testator signed
and executed the instrument as his Last Will and Testament and that he had signed willingly (or
. willingly directed another to sign for him), and that he executed it as his free and voluntary act
for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of
the Testator, signed this Last Will and Testament as witness and that to the best of their
knowledge the Testator was at the time eight"1,8) years of age or older, of sound mind and
. . .under no constraint or undue influence.
. .
C
Sworn to and subscribed
.sf:
before me this .31 day of
o chJW ,2005.
~:::;:llwA'J .d&. dfdLO
NOTARY PUBLIC
MY COMMISSION EXPIRES:
COMMONWEALTH OF PENNSYlVANIA
Nf::i;:;.~; St:-..t5
s, '~"(; (;,~,d~.;", ;\!:~ty Public
Uli'$'_llll"p 51;'10. \'.~.s; Ultnty.
MyColl'tn~ Exj:lites May 17, 2009
Member. Pennsylvania Asaoclatlof! of Notaries
COMMONWEALTH OF PENNSYLVANIA
NoIariaI Seal
S. Dawn Gladfelter, NotaIy Public
0II.1sburg Boro, York ColJ1ty
My Commission Expires May 17. 2009
Member, Pennsylvania Association of Notaries
.s
REV-485 EX + (3-04) ~_
( · 'WJ}'
COMMONWEAlTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG. PA 17128-0601
SAFE DEPOSIT BOX
INVENTORY
Please Print or Type
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCiAl INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS
COUNTY CODE FILE NUMBER
&-(57:;-
'6
Ko
(7l./l
(CITY)
ca VIA
-~co
(STATE) (ZIP CODE)
P/7 / cJl/
elL 511 eo {'-fer I ,5'1'
, (CITY)
5 - S..f. ~ k Vi "5 K () ac2 La ~ ;Lt. il
NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT TH BOX OPENING
a. (NAM~7 a ~ e s: 5 ~ e C( ,/\1 er (RElATIO~~
'-J /5. T!
(STREET NAME) ~ ~ /J (CITY)
:2 7</ ..0. C~ef(' t-b .',--t'-cX a. l
b. (NAME) ,. '\ ~ (RELATIONSHIP)
I5c>cPe0-'1 /Z1. u..o, e '1 );SU/7 "-
(STREET NAME) . . '- l.EITY)
g-41 TCCA/"Z? (.'-' Chvrc?' <?d v/ (/~ ~d
c. (NAME) _ f'-r (RELATIONSHIP)
'-./ e l"""t .I e ;SP.A k. .
(STREET NAME) D (CITY)
S-C>06 LOv:<;. e: Y. r-,W ~a.-'l'(: ~
. NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
jSTATEl
/
(ZIP CODE)
70 II
(STATE)
C.
(NAME) ./1 ~ (
v v' e.-- ..:> el' .s;
I~+- Fe u
~/'
a. (NAME) . 1/ C'
5' a /J'1l.lf:. / ' ,:)t-<Jet..{ J, .
(STREET ADDRESS) / ~
-; 9' Ic~ r? .> 'f'I ~ VI".
(CITY~ ~ ~J ( ( ~ATE)
. NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY
b tt v: cP -3, Le/l o)c
~~AM~ ~
a'So '?o ~. D.q..-'l'c el L . 5l~C{ Ii (> r. ~ r .
(STREET ADDRESS)
-d ~ 5'. 51.vc>h...,
e:~ N.II
t2/)a/
~TATE)
I~
WAS A WILL IN THE BOX? 0 YES
NO
'fyes,
b. Name and address of personal presentative, If named in the will
(NAME)
(STREET NAME)
(CITY)
(STATE)
(ZIP CODE)
c. Name and address of attorney, if any
(NAME)
(STREET NAME)
(CITY)
(STATE)
(ZIP CODE)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
ITEM
NO.
SAFE DEPOSIT BOX INVENTORY Page
INSTRUCTIONS
of
-',
The Department is authorized under federal law , 42 U.S.C. ~ 405(c), to use the decedent's Social Security number in
administering this state tax law. The Department uses Social Security numbers to establish a decedent's identity and
ensure proper credit for tax payments.
Cash: Report total only.
Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be
designated by name of company, certificate number, date of certificate, name in which stock is registered, and
number of shares and class of stock.
Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and
type of ownership, Le., jointly held, payable on death, etc.
Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds)
Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book,
name of bank and branch, and balance.
Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible.
Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully
as possible.
All other contents.
ITEM DESCRIPTION
.L
PRINT TITLE
1116/~ t' !;r ~'$ 4!c
~/2S/()t.
o Executor(trix) 0 Administralor(lrix)
stale Representative iii Joint owner of safe deposit box
NOTE: Attach additional 8'12" x 11" sheet(s) if necessary or use duplicates of this page of form.
, ,
Rev-1102 EX+ (....)
*'
SCHEDULE A
REAL ESTATE
COMolONWEALlH OF PENNSYLVANIA
INHERITANCE TAX RET\JRN
RESIlENT DECeDENT
Sheaffer, Clayton B. Jr.
FILE NUMBER
21-06-00754
ESTATE OF
All nal property owned 8OIe1y or as a t1Inant In common IIIUlIt be nportecl at fair market value. Fair market value Is defined as the price et which property woUd be
exchanged beIw8en a wIing buyar and a wiling aelIer, naIther being compelled to buy or sen, both having reasonable knowledge al the ~ facts.
Real property which Is jolnlly-own8cl with right of survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 Sale of property situate at 23 S. St. Johns Rd., Camp Hill, PA:
VALUE AT DATE
OF DEATH
100,000.00
2 Tax proration due estate from sale of property:
720.85
TOTAL (Also enter on LIne 1, RecapItulation)
100,720.85
(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 A (Rev. 6-98)
A. Settlement Statement
U.S. Department of Housing
and Urban Development
~
,r
OMB Approval No. 2502-0265
B. T of Loan
1.0 FHA 2.0 FmHA 3.0 Conv. Unlns. G.F1Ie_
4. 0 VA 5. 0 ConY. Ins.
7.Loon_
8. Mor1pge~ Case_
C. Note: ThIs form Is furnished to give you a statement of actual setIlement costs. Amounts paid to and by the seUfement agent are
shown. Items maOOld "(p.o.c.)" were paid outside closing; they are sI10wn here lor Informational purposes and not
Included In the totals
O.llImoond__"_ E._ond_.,_ F.___.oIL...-
CHARLes L MILLI!R. .JR. .JAMES a. SHl!AfFeR INTeGRITY BANK
DANieL L SHI!AfFI!R
45 SOUTH weST AVENUE CO-EXECUTORS OF ESTATE OF 3345 MARKET STREET
SHIRI!MANSTOWN PA "17011 CLA YTOM 8. SHEAFFER CAMP HILL PA 17011
G. Pnlporty '--tGn H._Agent
TAX PARCEL NO. 13-24-0799-097 MURREL R. WAL T1!RS III, ESQUIRE
23 S. ST. JOHNS ROAD _oi_ l. 511_ 0tl\0
CAMP HILL PA 17011 54 EAST MAIN STREET 11/612008
MECHANICSBURG PA 17055 DlIburHrrW1I o.le
I.ol: IlIock: 11/612008
J. Summery of llotTower's Tnmsactlon
100. Gross Amount Due From Borr_
K. Summary of S.I...... Transaction
400 Gross Amount Oua To Sall.r
101. Conlracl sales """" 1 00,000.00 401. ConIIlIcI sales nllee 100,000.00
102. Penronal- 402. Personal nmnNfv
103. S.t1lemllntch8taes 10 bomlwerlllne 14001 2,834.00 403.
104. 404.
105. 405.
Adlustm.nta for _. Deld bv ..1I.r In advanc. _Ids for t....... oald bv setler In advanc.
106. CltvIlllwl1taxe. to 406. CItvItDwn taxes to
107. CountY taxes tt/lll2OO6 10 12/31/2l106 64.10 407. Countv taxes 111612006 to 12/3112006 64.10
106. Assessments 10 406. A............ms 10
109. SCHOOL 11/ll12OO6 to 6I3O/2lI07 807 A3 409. SCHOOL 111612006 10 6130/2007 607.43
110. SEWER 11/ll12OO6 10 12/3112006 49.32 410. SEWER 111612006 to 12/3112006 49.32
111. 10 411. to
112. Ie 412. to
113. Ie 413. Ie
114. 10 414. 10
115. 10 415. 10
120. Gross Amount ou. From 8cIrT_ 103,554.85 420. Gross Amount Due To SalI.r 100,720.85
200. Amounts P.1d Bv Or In 88M1f Of Borrower 500. Reductions In Amount 0.. To Saller
201. DeDOsltoreameslmanev 10 000.00 501. Excess dtltloaIl 1...lnstruCllansl
202. PrtncIDaI amount of new Ioanl.1 80,000.00 502. SattlemenIdw'lHts to sallerlllna 1400) 2,090.75
203. ExI.Uno Ioan'sl Iaken ._ 10 503. Eldattnoloanlsl Iakan sublect to
204. 504. PIlYllll of IIrst ........a"" Io8n
205. 505. P- of second mollml<le loan
206. 506.
207. 507.
208. 508.
209. 509.
Ad"-enta for _. unottld bv ..ller AdIustm.nta for ltema uoD8ld bv .ell.r
210. CI~taxes to 510. CIIvIIown taxes 10
211. Counlv taxes to 511. CountYtaxe. Ie
212. Assessmen1S 10 512. Assessments to
213. 10 513. 10
214. to 514. to
215. 10 515. to
216. 10 516. to
217. 10 517. to
218. Ie 518. to
219. 10 519. Ie
220. Total Paid BylFor Borrower 90,000.00 520. Total Reduction Amount 0... Saller 2,090.75
300. Cash At S.lIlement FromfTo Borrower
800 Cash At SatIlam.nt ToIFrom Seller
301. Gro.. AmolA'1I due from bonower INne 1201 103,554.85 801. Gross IIITIOlllII due to saller lllna 420) 100,720.85
302. Less amount....... IwIrnr bonower IUne 220\ 90.000.00 802. Les. reducUons In amL due saller (line 5201 2,090.75
303. Cash !XI From o ToBorro_ 13,554.85 803. C.h 1:&1 To o From Seller 98,630.10
SUBSTITUTE FORM 1099 SELLER STATEMENT
The InlormaUon contalned In Blocks E. G. H. and I and online 401 {or,lIne 403 and _lis Impoo1ant llaX Infamallon and I. being furnished to Iha Inlemal Revenue
Setvtce. 1f)OU IIl8 required to ale. relum, . negligence penelty or _ uncUol1 will be Imposed on )OU If this Item Is required to be reported and Iha IRS delerm/nes
lhal R has not -. reported. It thls real astaltlla )OUI" pr1ncIpal residence. ale Form 2119, Sale or Exchange of Pl1I1cIpaI ResIdence, for aoy gain, wItII )OUr Income Ia.
retum; lor _ transacUons, comp!etelha applicable parts of Form 4797, Form 6232 and/or SchaduIa 0, Form 10401. You are required to provide Iha SeUlemant Agent
(named above) wlth your ccxract blxpayer ldenUllcaUon number. 1f)OU do not provide Iha SeUlttm8f1l Agent w11h your correct wepayer ldanUflcaUon number. )OU may be
subjecllo clYN or afmlnal penalties Imposed by law. llllder penalUes Of peljury, I certify Ihat Iha number shcMn on this slalement Is my correct taxparer identification number.
(So/let's Slgnaluntl
L Settlement Charaes
700. Tala! Sa'~'oker's Commission baaed on Dl'lce $ 100,000.00 G .,.- 0.00 Paid Rom Paid From
Division of Commission (lne 7001 as follows: 8omlwer's Seller's
701. $ 10 Funds AI Funds AI
Selllemenl Selllement
702.. $ 10
703. Corrvnlsoton oald at SelIIament
704.
8QO. Items Pavable In ContwctIon WI1h loan
801. Loan OrtalnaUon Fee 80,000.00 %
802. Loan DIscount 80.000.00 %
803. ADDralsal Fee ID
804. Credit Reoort lo
805. Lande(s InsORCtlon Fee
806. Marlaa"" Insurance AnaIIr.a1IDn Fee ID
807. Assumallon Fee
808. DOCUMENT FEE INTI!GRITY BANK 300.00
809. COMMITMENT FEE INTEGRITY BANK 400.00
810. FLOOD SEARCH FEE INTEGRITY BANK 15.00
8".
812..
813.
900. Items Raoul,ed Bv Lenda' To Be Paid In Advance Exdude last day In cales - lne 901
901. Interestfmm 10 lilS Idav
902. Marlaaae Insurance Premium !of monlhs to
903. Hazatd Insurance PremIum !of veers ID
904. VIl8rs ID
905.
monlh
monIh
month
month
monIh
month
month
1100. TIlle CharaeII
1101. SellIementordootnolee ID
1102. Abstract or lIlIe search ID
1103. TIlle examlnatlon ID
1104. TIlle Insurance binder 10
1105. Documenl Drepera1lon 10 DAVID ... LENOX. ESQ. IP.O.C.)
1108. No\aIv fees 10 CASH 15.00
1107. AlIDmeV's lees 10
lInc1udes above Items numbers: 1
1108. TItle Insurance ID MURREL R. WALTERS III, ESQUIRE 923.00
/Includes above Items numbers: 1101.1104,1008 PENN ATTORNEYS nTLE INS. CO. I
1109. Landefs "'"""""a S 80,000.00 Endrs. 100, 300 & 8.1
1110. Qwne(s cova""'" S 100.000.00
1111.
1112.
1113. CLOSING PROTECTION LETTER 35.00
54.50 ; Releases
93.00
1 000.00
a $
$
1,000.00
23.00
1300. AddltJonal Sallfament CharQeS
1301. Survev to
1302. Pest InsoectJon to
1303.
1304. SEWERlTRASH .10/1/06-12/31/08 LOWER ALLEN TOWNSHIP 90.75
1305.
1306. HARDY'S AUCTION 1.000.00
1307.
1308. FEDERAL EXPRESS RETURN MTG PKG TO INTEGRITY BANK 30.00
1400. Total Sa_Charges lente,on 1__ 103, secUon J-and 502, SecIIon K) 2.834.00 2.090.75
CERTIFICATlON
I have carefUly __ the HUD-l SeQlement SlaI8IlIent and lD \he best of my knowledge and belief. K Is a true and accurate slaternanl of all receipts and dlsbUrsamenls
on my account or by me In lhls lraneacllon. I further certify..lhall;':' received a copy of tIie HUD-~ ~ ~ Bonower
.JAMES B. S I!AFFER CHARLES L MILLER, .fRo }
~ h
FFE
1 S Stal8ment which I have prepared Is a true and accurate lICCClUIl Df \he funds which were received and have been or witt
1he _ of thls transacllon. ;f/A
. v~j ~
f...-.. SelIlementAgent ' CJ b Dale
MURR . WAL RS III, ESQUIRE
WARNING: K Is a clime Ie knowingly maka false sta_1S \0 the united SlaleS on thIS or any DIher similar form. Pena/1fes upon convlctlon can IncIuds a flne and
Imprlsoom&nL For detal1s sse: T1Ile 18 U.S. Cods Section 1001 and SeclIon 1010.
Seller
Bonower
U.I. GCMII8IEIIT PIIInIG DfftCE: fill t.M4-245
Rev-1M3 EX+ (S-II,
.
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INtERITANCE TAX RETURN
RE8IDeNT DECEDENT
Sheaffer, Clayton B. Jr.
FILE NUMBER
21-06-00754
ESTATE OF
All property /OInt1y-ownecl wlth right of sulVlvorshlp must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 Manulife Finaicial Corporation: 32.98 13.917.56
TOTAL (Also enter on Line 2, RecapItulation) 13.917.56
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Fonn PA-1500 Schedule B (Rev. 6-98)
Mellon Investor Services
P.O. Box 3333
South Hackensack, NJ 07606
October 7, 2006
. Mellon
TIIE WILEY GROUP
ATIN DAVID J LENOX
130 W CHURCH STREET SUITE 100
DILLSBURGPA 17019
rompany I MANULIFE
ame FINANCIAL -/
CORPORATION
Account ISHEAFFER-CLAY -!QOO I
Key
Control ./' 1200610030004299 --- I
Number
Telephone 1800-249-7702 I
Number
RE: ESTATE OF CLAYTON SHEAFFER JR j
Dear Mr. Lenox:
Thank you for your inquiry regarding the re-registration of shares.
Our records indicate this account held 422 shares as on August 23, 2006. The closing price of stock on same date
was $32.98 per share.
This letter contains instructions for transferring shares from an account when the owner(s) is deceased and the
estate has been probated. If you cannot locate the stock certificate(s), or if the estate has not been probated,
please call the toll-free nurober shown above to obtain further,information ~d requirements.
. .........
50 Shares or Less More than 50 un to 250 Shares More than 250 Shares
Submit items 1 through 3 Submit items 1, 2, 3 and 4 Submit items 1 through 5
or
Submit items 1, 2, 3 and 5
Required Items
1. Cmnpleted Transfer of Stock OWnership form signed by the Executor or Authorized Representative.
2. The original st€?ck certificates (if applicable).
3. Iriheritance Tax Waiver (if applicable). If the deceased owner resided in one of the follo~g states, please
obtain an Inheritance Tax Waiver from the state's Tax Department Office. AL, cr, IN, MT, NC, NJ, NY,
OH, OK, RI, SD, TN and Puerto Rico.
4. A certified copy, with original signature and s€fal affixed, ofthe Certificate of Appointxnent.ofExecutor(s)
dated With one year of the transfer. " , ' , . " '" .:. ,', ,
5. Medallion Signature Guarantee on Stock Ownership form.
,
Note: All submitted documents will be kept as part of the permanent record of transfer and will NOT be returned.
Please be sure you keep a copy for your records.
Sendth,ereqllired items to: . " ,
'First ClasslRecistered/Certified Mail.
Mellon Investor Services' ',. ",
POBox3310
'South Hl:\ckensackNJ 07606
Ovemight/Exnress Mail (onlv)
Mellon mvestot'SerVices '. ,- " ,
480 Washington Blvd., 27th Floor
, Jersey City, NJ 07310 "
Visit In~estor ServiceDirect@ atwww.melloninvestor.comlisdto sign up for Mlink, a secure server enabling you to
view information or perform various transactions on your account.
Sincerely,
Mellon Investor Services
. .
Rev-1508 EX+ (8.88)
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
NERlTANCE TAX RETURN
RESIDENT DECEDENT
Sheaffer, Clayton B. Jr.
FILE NUMBER
21-06-00754
ESTATE OF
Include the proceeds ollitigalion and the date the procaeds _ I8C8iv8d by the estate.
All property Jolnlly-ownecl with the right of aurvlvonohlp must be dlacloaad on ac:hecIule F.
ITEM
NUMBER DESCRIPTION
1 Insurance refunds:
VALUE AT DATE
OF DEATH
415.72
2 Members 1st FeU Savings:
2,429.01
3 Personal property sale proceeds:
639.50
TOTAL (Also enter on LIne 5, RecapItulation)
3,484.23
(If more space is needed. additional pages of the same size)
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Fonn PA-1500 Schedule E (Rev. 6-98)
ReY-1'110 EX+ (IJaI
*'
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMllNWEALTH Of' PENN8Y\.VANIA
INHERITANCE TAX RE1\JRN
RE81DeNT DECEDENT
Sheaffer, Clayton B. Jr.
FILE NUMBER
21-06-00754
ESTATE OF
ThIs sdleduIe must be compIeled end filed lithe __to Bny otqueslions 1lhrough 4 on the reverse side of the REV-1500 COVER SHEET Is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH 'Mo OF DECO'S EXCLUSION TAXABLE
NUMBER INCLUOE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COpy OF THE DEED FOR REAL ESTATE.
1 Members 1st FCU IRA: 4,320.03 4,320.03
TOTAL (Also enter on Line 7, Recapitulation) 4,320.03
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Fonn PA.1500 Schedule G (Rev. 6-98)
.:$t.
:MEMBERS1~t:
~8,1E({~i.~rr;Orr.~l~ :
\.'l>
Rossmoyne
5000 Louise Drive
Mechanicsburg PA 17055
Inquiries Call:
717-795-5100
Acct XXXXXXX456
Eff: 09/06/06
Tlr: 0539
ESTATE OF CLAYTO
Date: 09/06/06
Time: 3:51pm
Deposit to CHECKING 11
Prev Ba1:
Mount:
New Bal:
Seq:
Chk hId rls 09/15/06
due to New Account
1,377.32
205.00
1,582.32
*555280
205.00
Check Received
~ n...LltIJtl
::P'''S. ~1,.M\l
Authorized by
10 Source:
o Drv Lie
o SigCard
o Known
o Other
~ j...",c
!((."..V"\
ESTATE OF CLAYTON B SHEAFFER
:1\(EMBERS.lst:
f~~i.~ lll),(f.QriI~:
RosslI1oyne
5000 Louise Drive
Mechanicsburg PA 17055
Inquiries Call:
Acct KXXXXXX280
Eff: 09/21/06
Tlr: 0797
.:st:
717-795-5100
SHEAFFER,CLAYTON
Date: 09/21/06
Time: 3:46pm
Deposit to CHECKING 11
Prev Bal:
Amount:
New Bal:
Seq:
959.09
56.50
1,015.59
*555227
Check Received
Authorized by
ID Source:
o Drv LL10
o SigCard ()..
o Known
o Other
..01
CLAYTON B SHEAFFER
8J;<'~~
R~c'-t 1vt~
~
~:$t:
MEMBERS1~:
flfl)'E.({~l. ~ l:lpn:. .OOlOfC: :
Rossmoyne
5000 Louise Drive
Mechanicsburg PA 17055
Inquiries Call:
717-795-5100
Acct XXXXXXX260
Eff: 09/15/06
Tlr: 0797
SHEAFFER,CLAYTON
Date: 09/15/06
Time: 12:50pn:
Deposit to CHECKING 11
Prev Bal:
Amount:
New BaI:
Seq:
804.87
154.22
959.09
i635396
Check Received
~ :r::h~. ~ft.tVLd
Authorized by
10 Source:
o Drv Lie
o SigCard
n Known
o Other
CLAYTON B SHEAFFER
REGULAR SAVINGS ACCOUNT:
Account Number/ Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
IRA SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Beneficiary
Estate of: CLAYTON B. SHEAFFER, JR.
Date of Death: August 23, 2006
Social Security Number: 196-14-3885
~lm
MEMBERS 1st
FEDERAL CREDIT UNION
194280 -00
06/09/2000
$2,427.32
$1.69
$2,429.01
None
194280 -11
06/09/2000
$.00
$.00
$.00
None
194280 -10
06/09/2000
$4,319.56
$.47
$4.320.03
Mary E. Sheaffer (deceased)
~ 7gCREDlTUNION
Denise A. Wolfe ~
Insurance Services SU~isor
September 28. 2006
5000 Louise Drive . P.o. Box 40 . Mechanicsburg, Pennsylvania 17055 · (717) 697-1161 . www.members1st.org
b-Smre ryCG0
DefJOSTr f72rT1/Il
~J<J[;. :St:
:MEMBERS.l~.
(-B';1U~I.~IDPl:f"Ql\I~ :
RossMoyne
5000 Louise Drive
Mechanicsburg PA 17055
Inquiries Call:
717-795-5100
Acct XXXXXXX456
Eff: 10/06/06
Tlr: 0797
ESTATE OF CLAYTO
Date: 10/06/06
Time: 9:18am
Deposit to CHECKING 11
Prev Bal:
Amount:
New Bal:
Seq:
8,794.04
639.50
9,433.54
1642422
Check Received
Check Received
Check Received
Check Received
Check Received
Check Received
Check Received
Check Received
Check Received
Check Received
58.50
12.00
38.00
22.00
27.00
36.50
24.50
155.00
234.00
32.00
Authorized by
ID Source:
o Drv Lic
o SigCard
o Known
o Other
ESTATE OF CLAYTON B SHEAFFER
RJ:It.It1S1 EX+ (ft.99)
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEAlT1-l OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Sheaffer, Clayton B. Jr.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-06-00754
ESTATE OF
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 12,454.00
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
2. Attorney's Fees The Wiley Group, PC 3,597.75
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
4. Probate Fees Daniell. Sheaffer, Sr. (reimbursement for probate cost) 260.00
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7. Other Administrative Costs 4,534.25
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 20,846.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
Rev-film EX+ (I-te)
*'
SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMClNWEALni OF PENN8Y!.V_
INHERITANCE TAX RETURN
RElllDENT DECEDENT
ESTATE OF
Sheaffer, Clayton B. Jr.
FILE NUMBER
21-06-00754
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Daniel L. Sheaffer, Sr. (reimbursement of funeral expenses):
4.000.00
2
Gingrich Memorials (grave marker, stone, engraving):
2.008.00
3
Myers Funeral Home (balance of funeral goods and services):
6.446.00
Subtotal
12.454.00
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Form PA.1500 Schedule H-A (Rev. 6-98)
Rev-f&o2 EX+ (8118)
'*
SCHEDULE H.87
OTHER
ADMINISTRATIVE COSTS
continued
~lHOF l'eNNS'I\.VANA
NiERlTANCe TAX RETURN
RESIDENT DECEDeNT
Sheaffer, Clayton B. Jr.
IFILE NUMBER
21-06-00754
ESTATE OF
ITEM
NUMBER DESCRIPTION AMOUNT
1 Cumberland Law Journal (estate advertising): 75.00
2 Jenny Middlekauff (nursing care for Mr. Sheaffer before death): 2.000.00
3 Members 1st FeU (estate checks): 9.95
4 Real Estate closing - Seller's costs: 2.090.75
5 Register of Wills (filing fee): 30.00
6 Sonia Freeman (cleaning house): 100.00
7 The Sentinel (estate advertising): 202.37
8 UPS Overnight Packages: 26.18
Subtotal
4.534.25
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Fonn PA.1500 Schedule H-B7 (Rev. 6-98)
Rev.1's12 EX+ (e-fa)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
~1HOFPeNNSVlV_
INHERITANCE TAX RETURN
RESIIleNT DEceDENT
ESTATE OF
Sheaffer, Clayton B. Jr.
FILE NUMBER
21-06-00754
Includ. unrelmburslld mlldlca' .xpen....
ITEM
NUMBER DESCRIPTION
1 Hershey Medical Center:
VALUE AT DATE
OF DEATH
57.75
2 Metro Medical SErvices:
3 Nationwide:
4 Nationwide:
5 PA American Water Co.:
6 PP&L:
7 Spirit Physician Services:
43.90
54.67
58.67
41.92
223.66
10.00
TOTAL (Also enter on Line 10, Recapitulation)
490.57
(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 I (Rev. 6-98)
RE'I1-1S1~ EX+ (too,
'*
SCHEDULE ..
COMMONWEAlTH OF PENNSYlVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Sheaffer, Clayton B. Jr. 21-06-00754
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not Ullt TRlateefsl
I. TAXABLE DISTRIBUTIONS [include outright sfrousal
Clistributions, and ransfers
under Sec. 9116(a)(1.2)]
1 Shirley Sheaffer Sister-in-Law 500.00
PA
2 Tammy Ebaugh Friend 500.00
644 Fickes School Road
York Springs, PA 17372
3 Carl Sheaffer Brother 500.00
41 Oneida Road
Camp Hill, PA 17011
4 Daniel L. Sheaffer Son Fifty percent of
25 S. St. John's Road residuary
Camp Hill, PA 17011 estate
5 James B. Sheaffer, Sr. Son Fifty percent of
274 N. Cherry Point Road residuary
Okatie, SC 29909 estate
See continuation schedule attached Continuation 1,000.00
Total 2,500.00
Enter dollar amounts for distnbutions shown above on lines 5 through 18, as appropnate. on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
See continuation schedule(s) attached 10,000.00
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 10,000.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 6-98)
~ J ~
SCHEDULE ~
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
Clayton B. Sheaffer Jr. 196-14-3885 08/23/2006
Item Name and Address of Person(s) Share of Estate Amount of Estate
Number Receiving Property Relationship (Words) ~$$$)
6 Mary Swab
PA
Friend
500.00
7 Sam Swab
PA
Friend
500.00
Total 1,000.00
1
~ ... ~
Rev-1H2 EX+ (6-18)
*'
SCHEDULE .1-118
CHARITABLE AND GOVERNMENTAL
DISTRIBUTIONS
continued
COUMONlIIlEALlH OF Pl!NNSVLVAMA
INIERITANCE TAX RET\JRN
_DECEDENT
Sheaffer, Clayton B. Jr.
FILE NUMBER
21-06-00754
ESTATE OF
ITEM
NUMBER
1
DESCRIPTION
Calvary United Methodist Church, Oillsburg, PA:
AMOUNT
5,000.00
2
God's Missionary Church, Camp Hill, PA:
5,000.00
Subtotal
10,000.00
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Fonn PA-1500 Schedule J-IIB (Rev. 6-98)
I
'J" ":l '"
~~o~-
0',00
'" ('\J ,,-
00 ....
Ii"' Li"
l'O .....
CD
0.. :>
o
z
. (k
+:
. +:
LLl
o
o
()
101.I 0 e:
'" tf) 2
;!:Oo
\I'l -It
o "^-c
C. .,'w
~ O~
:::I .. :E
o If"l '"
N~N
~..... ~
.....,.... N
(-
)
I
~
{jI)
:s
~
.:I
t:
:s
~ ~
u ;
C&
=OOtrl
{jI) :s ~..
~~{jI)=
~U:s~
~'Cj<
't;~t:~
... 't: :s ..
~~~~
-;; ,Qa U .~
.. ~ 't:
tf:s==
~uou
~
~ 0
0 0
~ c.: .l!!
. '3 0"1
~! x 0 V) ...
0 u . R
c:: u (j)'"
... (!) ~
~~ --I N ~~
N
& . .... V) ,
>-~ ..c.~
~E ~~ I: ::;)
~.~ ~ ~ ::;)-0
..c...!!!
U7:
~ .0
00 ~
~ "0 0
~ U M
~