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IJETITION I,'on ..nOIlATE and GnANT OF LETTEI~S
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I~I'IIII" IIJ -1'J\UL_W.JORNBY
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To:
"cglslcr of Wills for Ihc
. 1),0""11,\(,". COllllly of _SUMDOIILAND III Ihc
Soeilll S""/lrll)' No. --16:l",:l:l=06:l0__ COlIllIIOIIII'Calih uf I'cnn'ylvallla
Thc pClhlun of Ihc IIl1dcrslgncd rcspcclflllly rcprc.\Cllls Ilnll:
. Itl ternllte
YOllr /ICllllollcr(,). II'ho Is/arc /H ycars 01 ogc or oldcr allllll/'CXCCUIJ.1x
Inlhc la,1 will of Ihc ahovc dcccdclII. dalcd ~ovombe~.
and codlcll(,) dalcd .N/A
Mary R. Fornev. tho primary executrix nllmed in sa~d Will, has renounced
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namcd
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l\lill~' frll'\-IUlI drt:lIIll"llr1l'C\, ~,lI, fCIIlIlll'inlhlll. lleUlh ur C\t...UIUf. el....)
Dcccndcnl wa, domlcllcd UI dculh In CumboJ:land COllllly. Pcnn,ylvanla, wllh
Ius la, I family or principal rc,ldcncc UI .J.5.lLLoC.\UltJQinLfulA!l.. Silver Sorinl1
Townahip
(Ihl \lrl't'I. numhl'r IIlUlll1lllld,'UIiI)')
Decendenl,lhen-Bl )'ear' of ugc, died -Dc.tQ.bor 11
al nn I Y-Bpi.J:it....Hospi.tIlJ..-BaaLPannsbOJ:O-Townahip
Exceplas follows, dccedenl did nOlmurry. was nol dlvorccd und did nol have a child born or adopled
afler execullon of Ihc will offercd for probalc; wa, nOllhe vicllm of a killing and wa, never adjudlcaled
Incompelc,lI: No exceptiens.
lJecendenl nI dcalh own cd properly wllh c'llmUled values u, fallow,:
(/1' domiciled inPa.) All personal properlY
(/1' nOI domiciled In Pa.) Personal properlY In Pcnnsylvanla
(/1' nol domlcllcd In Pa.) Pcrsonal propcrly In Conllly
Value of real eSlale In Penn'ylvanla
sllualed as follows:
, /9 94
S 10,000 00
S-N/II
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S-Non..
WHEREFO"E, pelllloner(s) rcspeclflllly
prescllled herewiJh and Ihc grulll of lellers
Iheron.
reque'I(,) Ihe pro bale of Ihc la'l wiil and codlcll(s)
ToatlUllWltsry
(leMaI11Clllllr)'; udmllll\lflllllll1 c,l.a.; adllllnl'lralloll d.h.n.c.I,n.)
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Freda Acri
354 Locust Point Road
...Maohllni r.oburq,-PJ\. 17n~~
'l(dr -'(r(>\ ') n
OATH OJ,' PERSONAL REPRESENTATIVE
COMMONWEALTH OF I'ENNSYLV ANIA }- I:lS
COUNTY OJ.' C'IIMnRnr.I\Nn
The peliJloner(s) above.namcd swenr(,) or affirm(s) Ihal Ihc S1ulcll1cnls IlIlhe foregoing pellllon arc
lrue and corrccl 10 the besl of Ihe knowlcdge and belicf of peliJloncr(,) nnd IIIl1I as personal represen-
lallve(s) of Ihe ahove deccdCl1I pCliJloncr(s) wiil well and !rilly adminisler Ihe eSlale according 10 law.
Sworn 10 or affirnle<L.J1nd sUb.,cribe d f /;liU!..J,u a C/tv '"
berore me this -16TH day of """"'Jill I\,....i 00'
~ ' '!9..9~,r C- ~
~~~~~,,,., o<I",{ .'if'l( -ct 1;\.,:+"1,/. ~
MARY (}. LEWIS ' Helllsler 7l.. ~I ~
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No. 21 . 94 - 1069
Estate of
PAUL W. FORNBY
I Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW Docember 22 19~, in conslderallon of the pel It Ion on
the reverie side hereor, sallsfaclory proof having been presented before me,
IT IS DECREED thai the Instrument(s) dated November 8. 1973
described therein be admllled to probate ond n1ed or record as the last will of uaul W PlIrA9Y
and Lellerl Testamentary
are hereby granled 10 Freda Acd
FEES
Probate, Letters, Etc. ..,.....,
Short Cerllncales(2 ) . . , , . . , , . .
Renunciation ...... I . . , . . . . . .
JCP
MtR~Il~~~
Msrlin R. MCCeleb (No. 06353)
ATTORNEY (Sup. CI. I.D. No.1
219 Bast Main Street. P.O. Box 230
Mechanicsburl1, Pennsylvania 17055
ADDRESS
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TOTAL _ $ 56.00
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(7171 691-7770
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Mailed letters and order to attorney on 12-22-94.
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This j, III fl'r1il)' 111,1( IIll' il1furln,lIionlH'll' ~i\'l'1l j!ro lCllll'lcly wpu.d frolll ,111 mi~illilllC.'llifh'.IIt, IIllk,lIh dill)' Iilc.'d wilh l11e,15
1.1K.';lllh'~iSlr.H. Thl' 01 i~~ill..1 t'l,t1ilil-,lIt. willl){.' fIlIW,lfllt'd 11llIll' SI,lIl' \'il.d Ilntlltl\ (Will' ltlr pl'I'111.Im'ul Win#-!.
WARNING: 1111 Illegal 10 dupllcalo this copy by photosta\ or photograph.
No.
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COMMONweALTH 0' PINHIVLVtlHlA' DIPARTMINT 0' HULTH . VITAL RICORDI
CERTIFICATE OF DEATH
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Grace Armstron9
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1I.0ctober 14. 1994
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21 - 94 - 1069
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LAS'!, WII~L AND ')'Jo:S'I'AI\1Jo:N'!, OF
PAUL W. Jo'OIlNgy
I, Paul W, )~orney, of JUdge II III , H. D. I, Mechanlcsburg, Cumberland County,
Pennsylvania. declare this to be my Last Will and '!'estament and revoke all Wills
and Codicils pl'evlously made by me,
I'l'EM 1. I direct my Executrix hereinafter named to pay all my just debts.
funeral expenses and other costs of administration of my estate as soon as convenient
following my death.
ITEM 2, All the rest, residue and remainder of my estate, be the same real.
personal or mixed and wheresoever situate, ) give, devise and bequeath to my wife,
Mary E. Forney. providing she survives me.
ITEM 3, In the event my wife, Mary E, Forney, predeccases me, I give, devise
and bequeath all of my estate, be the same real, personal or mixed and wheresoever
situate. to my daughter. Freda (Mrs. Charles) Acrl, 908 S. York Street. Mechanlcs-
burg, Pennsylvania,
ITEM 4, I appoint my wife. Mary E, Forney, as Executrix of my estate provided
she survives me,
ITEM 5, In the event my wife, Mary E, I.'orney, predeceases me or Is unable to
serve as Executrix, I appoint my rJaugh tor. Freda Acrl, as Executrix of my estate,
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~
day of
November, 1973.
.r C-U.-LQ
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The writing contained on this one page was signed and sealed by the
above Paul W. Forney. and by him published and declared as and for his
Last Will and Testament In the presence of us, who have hereunto subscribed
our names as witnesses al his ,'equosl. In his presence,
of each other. the b"t.
and In the presence
day of November. 1073.
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?1 - 94 - 1 069
REGISTER OF WILLS OF COUNT\'
OATH OF SUBSCRIBING WITNESS
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"'., codicil -----
(each) a subscribing witness to Ihe will presellled herewllh, (each) belng-auiY qualified according to
- -
law, depose(s) and so'yes) Ihat --- present and saw
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, sign the same and Ihal~ , signed as a witness at the
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requesl of tesl8l in II- presellce'and (Inlhe pre~ence of each olher) (in the presence of Ihe
. ~........
other subscribing wllness(es)). / -..........
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Sworn 10 er affirmed ~d subscribed before
me this -- day of
./ 19_
(Name)
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(Address)
Reg Isler
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(Name)
(Address)
REGISTER OF WILLS OF CUMBBRLAND COUNTY
OATH OF NON-SUBSCRIBING WITNESS
FRBDA F. ACRI and LBSLIB A MBNRAR
(each). a subscriber hereto, (each) being duly qualified according 10 law, depose(s) and say(s) Ihal
we are familiar with Ihe signature of Paul W. Forney
'. n INdllllk
leStal or of !,tuX.lIlJi:xIlKXlIlI~lllllblNcx'/llilRWWIII(llll>< the will presenled herewith and
MJlII
Ihat ..~ believes the signature on the will Is in the hondwrltlng of
I'HRI~XXXlIliIlVmllll~l#SlIllJIlIIlUCltIl'~I'""IlaIl~lV\IIlll1<ml<ltlIK
"lIlI~H
XX~M'~~~XWK~~J~~~"~ the testator. Paul W. Pornev
10 the besl of Our knowledge and belleI',
/i 1 e-dtv , ~. {i (!.,'vG
Froda F. Acri (Name)
Sworn to or affirmed and subscribed before
me this 16TH day of
19 ,
- IJ -
Reg/sler'
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Un."" Rn"r1.
Mnr-hllnf,..ahllrq,
PA 17055
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Leslie A. MeneafName)
351 Locust Point Road. Mechanicsburl1. PA 17055
(Address)
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21 - 94 - 1069
In Re Ilstate of
RENUNCIATION
PAUL W. FORNBY
deceased,
CUMBERLAND
County, Pennsylvania,
To the Register of Wills of
The undersigned
MARY E. FORNBY. SurYiying Spouse and named Executrix
of
the above decedent, hereby renounee(s) Ihe right to admlnlsler the estale and respectfully ask(s) that Lelters
Testamentary
be Issued to
WITNESS
Freda Acri
mv
hand this IS"H... day of December
, 19.2!....-.
/m"/rAI ;:-~.A~
o (Sianalurt) .r;!
HlIry B. Forney .'
350 Locust Point Road
Mechanicsburl1. PA 17055
(Addr...)
(Slanalurt)
(Addr...)
(Slanalurt)
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(Addr...)
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RegbttJr ot Wills
CERTIFICATION OF NOTICE UNDER RULE 5.61al
'94 DIG 28 All :11
Name of Decedentl
PAUL W. FORNEY
Date of Deathl
October 11, 1994
Clark. 0: '. ~:.,~ ~ourt
C11mbt m,l I'J ('(('J P.^.
will No.
1994-01069
Admin, No.
To the Registerl
I certify that notice of beneficial interest required by
Rule 5.6(a) of the Orphans' Court 'Rules was nerved on' or mailed to
the following beneficiaries of the above-captioned estate on
December 27, 1994 I
Name
Mary E. Forney
Address
354 Locust Point Road. MechanicRhnrq, PII 17n....
Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except No exceptions.
Datel December 27. 1994
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Signature
Name
Marlin R. McCall'!h, F.Rqllirp
Address P.O. Box 230
Mechanicsburq. PA 17055
Telephone (717) 691-7770
Capacity I Personal Representative
X Counsel for personal
representative
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J ~~-1548 EX AFP 112-94*
~ R:OHHOHW[AlT" Of PfNNSYlVANIA
DlPU1'HE:H' OF REvttAJE
IUREAU OF INDIVIDUAL TAXU
DfPT. UUGl
twtRIIIURG, Pi 171U-un
HOTICE or IHHERITAHCE TAX
APPRAIBEnEnT, ALLOMAHCE OA DIBALLOXAHCE
or DEDUCTIOH ..AHD ABBEBBHEIlT or TAX OH
JOIHTLY nELa OR TRUBT ABBETS
DATI! 05-15-95
ESTATE OF FORNEV
W DATE OF DEATH 10-11-94
COUNTY
CUMBERLAND
PAUL
FILE NO, 21 94-1069
S,S/D.C, NO, 162-22-0620
ACN
95104184
MARV E FORNEV
554 LOCUST POINT RD
MECHANICSBURG PA 17055
REMIT PAVMENT TOI
REGISTER OF WILLS
CUMBERLAND CD COURT HOUSE
CARLISLE, PA 17015
Aaount R..1tt.d
CUT ALONO THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ....
R:E;;:i54-i-iiC-AFji-iiif:94)------------------------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE DR DISALLOWANCE OF
DEDUCTIONS. AND ASSESSMENT OF TAX ON JOINTLV HELD DR TRUST ASSETS
DATE 05-15-95
ESTATE OF FORNEV
PAUL
W DATE OF DEATH 10-11-94
COUNTY CUMBERLAND
FILE NO, 21 94-1069
TAX RETURN WAS,
S,S/D.C. NO, 162-22-0620
(X) ACCEPTED AS FILED ( ) CHANGED
JOINT OR TRUST ASSET INFORMATION
95104184
ACN
FINANCIAL INSTITUTION, PNCBANK
ACCOUNT NO.
410079519
TYPE OF ACCOUNT, () SAVINGS ( ) CHECKING ( ) TRUST (~ TIME CERTIFICATE
DATE ESTABLISHED 11-28-86
Account BD18ncD
PDrcDnt TDxDblD
Amount SUbjDCt to TDx
DDbtD Dnd DDduc~onD t~.~-
b1 ". t'" 0::
T8xa . RIIIDun ('/
TDx RDh L X
TDx DUD
,DO
0.500
.00
.00
.00
.05
.00
NOTE, TO INSURE PROPER CREDIT TO
YOUR ACCOUNT. SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS, MAKE CHECK
OR MONEV ORDER PAYABLE TO,
"REGISTER OF WILLS, AGENT,"
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TAX CR,EDXTS: ~
PAVMENT.. RECEIP.T
OAt c;;. [5; NUH'
DISCOUNT (+)
INTEREST (-)
AMOUNT PAID
.
TOTAL TAX CREDIT
BALANCE OF TAX DUE
I NTI!R EST
TOTAL DUE
IF PAID AFTER THIS DATE, SEE AEVEASE FDA CALCULATION OF ADDITIONAL IHTEAEST, .
IF TOTAL DUE IS LESS THAN .:, NO PAVHEHT IS REQUIAEO,
IF TOTAL DUE IS AEFLECTED AS A "CAEDIT" I CAI, YOU HAV BE DUE A REFIJHO.
SEE AEVERSE SIDE OF THIS FOAH FOR IHSTAUCTIONS. I
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DetMh the top portion of thll Notice Met ._It with YOU!" PIYMnt to ttM A..ht.r of NUh prlnttel on the
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.. twca check or IIOMY Dr... p.nbh tal REalSTER Of' WILU, AGO<<.
All p.,..,'s fIIellVMI shliU 'Irlt be IPPllld to MY Int.....t which .IY be due, ..lth MY r...lnder appllld to the tP.
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RU1ItD (tA)1 . nfund 0' . tax erlldSt, which w.. not r....tlld on the to ntum. ..y be request... by cDllPl.UntI !In "AppUcaUon
for Refund 0' P~.ylv."l. Inherlt~. ~ Eltat. T.... (REV-1S.S). Application. .r. eval1lbl. at the OfficI of
the ...I.t... 0' Nl11., MY of the ZS Aavenue Dl.trlot Offlc.. or by CIlllnt the ,pealal Z4-hour Mtwerlng ..~Ic.
nuMMirs for for.' ordtlrlnlll In P.""lylv."Sa l-IU-S6Z-IOS0, outside PennlylvMla WId within lout
HIIrrhbur. ar.. (717)> 7.7-IOM, TOOl (717) nZ-n5Z (....,..ng I....red Dnh'J,
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DUCTJDHlt Any partv' 1n tnbr..t not ..tbf1~ ..Ith the BPPr.s.....,t' .UOWMC' 01" dl"UDMftnC. of IMcIuoUon' 01" ..........t
of tax Uncludlna dbcCU1t 01" Int.n.n .. shown on thl. NoUc. "Y object ..I thin IlIety (60) dly. of r.c.I,t of
thb NoUce bYI
....rUt." prot..t to the PA u.,.rtMnt of RI"WIUII, Board of Appelh, D.pt. ZlUU, H.rrbburlh PA 17121"1021, OR
...1HUng to have tM ..tbr det.rtllned It the -..tit of the HCOlI'\t of the ptr._1 r...n.."t.U"., OR
.......1 to the Drph.....' Court
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AllItlN'
lITRATlY!
CDRRfCTlDHlI FHtulil '1"1"01'" dllCO"lred on thl. .........,t Ihould be Iddn..... In ..rltlng tOI PA o.plrtHnt of R."WIUII,
IUreeu of lndlvldull ',x'" ATTHa po.t A.....eent Rlvl... unit, DEPT. 210601, Harrisburg, PA 17111"0601
~ (717) 717"6101. ... P'" S of the book1.t ~ln.t~tlon. for Inherltsnc. TIX R.turn '01" . R..ldent
~t~ (AtV.1101) for In ..,I.".tlon of ~Inl.tr.tlv.ly correotlbll '1"1"01"'.
DllCOllfT a
If .,y tIX due II p.ld ..Ithln thr.. (5) c.I8nd.r ..,th. .ftll" the dIcldlnt'. duth, . flvl percent (5~)
dlMCQ\t 0' thII tlx plld I. .Uowed.
\t
.1
INTERElTI
Int.r..t II chIIrpd beelmlne with flr.t dey of dell~y, or nll"ll (9J .onth. .... one (1) dey
fro. thII det. of dMth, to the det. c, P'YIIII'lt. T.nl which bIc_ delinquent bI'or. -'-nuIry 1, .'11
bur Int.r..t .t the nt. of .lIe (6):) percent PI" ......... cllcul.tM .t . dilly I"It. of .OODI64.
All tex.. which bIuM dll1,",,*,t on a,. IU.r .IlnU11ry 1, all ..UI bI.,. Int.rut .t . rlt. which ..111 vlry '1"011
cel.ndl,. y..r to eel"''' l;'..,. ..Ith thet r.t. -..ounc~ by the PA Dep.rt~t 0' Revenue. The .,.Uclbl.
Int.r..t r.t.. for 19.2 through 1995 '1""
.'
{,
{;
i
'!-'
~
tilt Int.r..t R.t. D.ll" Int.ra.t Flctor
xur
Intarut Aata
aall" tntara.t Factcr
i'
,
"
1912 ZOX
19n 16X
19M llX
1911 ISX
1916 lOX
..Int.r..t I' oalculltld I'
.100MI
.OO04S1
.000nl
.ODDSI6
.000274
follow.,
1917
19N-I991
1'"
1995-1994
1...
ox
IlX
OX
7X
OX
.000247
. DODln
.000247
.IDn9!
.000247
".
.
J
.
I~T . IALAHCB OF TAX UNPAID X HUKlEI OF DAYI DELINqUENT X DAILY I~T FACTOR
..Any Hotlcl i.sued ..tar the taM bee.... delInquent will r.'lect ~ Int.r..t c.lcul.tlon tD fifteen (15) dly.
t.yond thrI dltl af thrI .....~t. If papent 11 ..... .U.,. the intar..t coaput.Uon dIIt. ahowl on the
Notic., Iddltlonsl Int.r..t lU.t be cllcul.ted.
,,s-s-q
INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
~~.;. 1500 IX.' 17.9'1
I!!
..:5"
blg:~
"''''9
u~...
.
ffi
Iil
ld
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COMMONweALTH O' PfNNSVlVANIA
Df'AIlMfNT O' 1I1YfNUf
D"Y, 10
HAU1SlUIIO,lA ~ ,1.()601
OICIO H 'S NAM! 1\,\ . . '. AND MIDDlI INI IA'I
Forne . Paul W.
lOCI"" lIeUlUlY HUMIU
21
COUNTY CODE
Dlel INI" (OM'll I ADDII .
350 Locust Point Road
Mechanicsburg, Ph 17055
c.... Cumberland
A.MOUNT IlClIVID IUIINUlUCflONI,
DA 10' IIITH
11-22-1912
o 2. Supplemental R,turn
159-24-9515
o Aa. Future Inll'..' Cornpromh.
('0' dol.. of d.o,h alt.r 12.12.82)
elClden. Died r,,'ot, 0 7, OICldenl Maintained a living Trull
(Allach copy a' Will) IAllach copy a' Trull)
ALL.CORRESPONDENCE'AND CONFIDENTIAL TAX.INFORMATION SHOULD BE DIRECTED O.
NAAlI COMmit MAILING AOOUU
Marlin R McCaleb Es uire 219 E. Main Street, 1'.0.
"'''liON' NUM'" Mechanicsburg, Ph 17055
1. A.ol Ella'. ISch.dul. A) (I )
2. Slock. and Bond. (Sch.dul. B) 12 )
3. Clo..ly H.ld S'ock/Palln."hlp In'....t(Sch.dul. C) ( 3 I
~. MollsoS" and Nol.. Roc.lvabl. (Sch.dul. D) I A )
5. Ca.h. Bank a,poIIII & Mlle.llan,oul Penanal Property ( 5 )
(Schedul. EI
6. Jolnlly Own.d Prop.lly (Sch.dul. F)
7. T,an.'", (Sch.dul. G) (Sch.dul. II
8. TOlal Gro.. A..."(lotallln.. 1.71
9, Fun.ral Expln..., Administrative Call', Mlle.lIoneoul
hpI"'" (Schedull H)
1 D. D.b", MollgaS' 1I0bllill.., 1I.n. ISch.dul. I)
II. To'al D.ductlon. (Iolallln.. 9 & 101
12. N.t Vol.. a' E.lal.(lIn. 8 mlnUllln. III
13. Charltabl. and GOVlrnmtntal B.qu.,u (Schedull J)
lA, Nt. Value Sub ed to Tax (lint 12 mlnullIne 13)
15. Spau,al Tro".f." (for dOl'. of d,alh all.r 6.30,9.4)
S.. I""ructlonl for Applicable Plrclntagt 0" Rlv,,,, (IS)
Sid,. (Indude ...olu.. Irom 5ch.dul. K or Sch.dul. M,)
16, Amount of L1n, ,.. taxable 01 6% rolt
(In dud. valUlI from Sch.dul. K or Schedul. M,)
17, Amount of lint 14 laxabl, at 15% roll
(Include valu.. from Sch,dul, K or Sch.dul. M.I
18. Prlnclpalla. d.. (Add la. f,om lIn.. IS, 16 and 17.1
19, C"dit, Spou.al Poverty Credit Prior Payments
1R -;q + +
20. If lIn. 19 Is groa'.. than lIn. 18, .nlo' Ih. dlll.ronco an line 20. Thl. Is Ih. OVERPAYMENT,
iii 0
21. If lint 181, Sflallr thon lint 19, tnl.r th. dlff".ncl on lIn. 21. Thl, I, the TAX DUE.
A. Enl', th. Inl.,.., on .hl balanc. due on lIn. 21A.
B. En'er th. lolal a/lln. 21 and 21A an lIn. 21B. Thl.1I Ih. 8ALANCE DUE.
Mob Chck Payabl. tal R.gl.t.r of Willi, Ag.n'
~ffi
::i'"
"'z
u~
z
~
E
~
ld
..
z
!
..
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u
~
....
9.968.75
(61
(7)
5.011.65
e.:.) K ./
'OR OATIS 0' DIATH AnlR 12/31/91 CHICK HIRI
I' A SPOUSAL
POVIRTY CRIDIT IS CLAIMID
fill NUMIIR
94
YEAR
1069
NUMBER
643.14
o 3. R.malnd.r R.turn
(far dalo. af d.alh p,'o, to 12.13.B21
o 5. federal E.lot. ToJl. R.turn R.qulred
_ 8. Talal Number of Sa'. D'polil BoJl...
~. . ~ <f);;:;;"
DAn 0' OUI"
162-22-0620
II' """CAllI! IUh"lVlNO lP01.lIl" HAM' ILAI" 'II" ANO IIoI'OOtl tNlflAll
E.
Forne , Mary
a 1. O'lglnol R.turn
o A. lIml,.d E.,o'.
Q6.
(91
9.325.61
Box 230
O(j
~ ii,
\rl .,.,:n
'i, . "I
(10)
(16)
643.14
5,01l.65
"
"
(17)
Dlscounl
<.
~.
.'
N
w
"1:)
).> (.8)
" 14,9QO.40
1111
(121
(13)
(1A)
9.325.61
5.654.79
)c, ..oJ_
5.654.79
19.29
300.70
)C ,06_
)C ,15 _
(IB)
319.99
Interllt
38.59
(19)
(20)
Chode here if you arc requesting a refund of your overpayment.
281.40
121)
(21A)
(2IB)
281. 40
,,0,""'::;'-:' ',':c<:i~~".' .BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND TO RECHECK MATH. <; ,',
Und.r p.nahl.. of p.rjury. I d.c1ar. that I hay. 'Aomln.d thl, return, Including accompanying schedule, and 'lat.m.nt.. and to thl bl" of my knowl.dg. and boll.f.
II II tru.. corr.ct and compl'll. I d.clor. lhol all real ..tat. ha. b..n r'por1.cf at true mark.t valu.. Declaration of p"parer oth.r than Ih, p.nonol "pr..entatlv, II
balld on all Information of which prepare' has any knowl.dg..
"0 AfUR! 0' U$ON U ON',. .01IlUNG'IIUUIIN ADOUU OAn I {1 5
,l 354 Locust Point Rd., Mechanicsburg, Ph j ~ - 2 - 1
IONA If O' PIIr:rA I O~II IHA IPIIUfNTATIV! ADDIUS DAIl '
4d. ./?t~ d,t,- P.O. Box 230, Mechanicsbur , Ph 17055 6-LI- J-'j-
Act '48 of 1994 provld.. for tho roductlen of tho tax rat.. Impo..d on tho not valu. of tran.f.,. to or for
tho u.. of tho .pou... Tho rato. a. pro.crlbod by tho "atut. will bOI
. 3% (.03) will b. appllcablo for o.tat.. of docodont. dying on or after 7/1/94 and bofore 1/1/96
. 2% (.02) will b. appllcablo for e.tat.. of docod.nll dying on or after 1/1/96 and b.fare 111/97
. 1% (.01) will b. appllcablo for ..tato. of docodent. dying on or after 1/1/97 and b.for. 1/1/98
. Spou.al tranders occurring an Dr after 1/1/98 will b. .x.mpt from Inherltanc. tax.
PLEASE ANSWER THE FOLLOWING QUESTIONS
BY PLACING A CHECK MARK (....) IN THE APPROPRIATE BLOCKS.
YES NO
1. Old decedent make Q transfer and:
x
o. retain the use or Income of the property transferred, .......................................................
b. retain the right to designate who shall Use the properly transferred or Its Income, ........,......
x
c. retain a reversionary Intoros.; or .......................,..................................,..............,.........
x
X
d, receive the promise for lIIe of either poyments, bonefits or care9...............,............,..........
2. If death occurred on or before Docember 12, 1982, did dace dent within two years preceding
deoth tronsfer properly wllhout receiving adoquate conslderatlon9 If deoth occurred olter
December 12, 1982, did decedent transfor properly within one yeor of deoth without receiving
adequate consideration'... .110'.......,........,.............,............,......... 0.1 III" f.I'..'............,..........
X
3. Old decedent own an 'In trust for' bank account 01 his or her death9............,......,..................
X
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLLrE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
LAST WILL AND TES'I'AMI~NT OF
PAUL W. FOHNIW
I, Paul W. \rorney, of Hldlle 11111, n. D. I, MechanlcBburg, Cumberland County,
Pennsylvania, declare this to be my Lllst WI1111nd 'I'estament and revol(e 1111 Wills
and Codicils previously made by me.
l'rEM 1. I direct my Executrix hereinafter nllmed to pay all my just .lebts,
funeral expenses and other costs of admlnlstrlltlon of my estate as soon as convenient
following my death.
ITEM 2. All the rest, residue and remainder of my estate, be the same real,
personal or mixed and wheresoever sLtuate, IIlLve. devLse and bequeath to my wife,
Mary E. Forney. providing she survLves me.
ITEM 3. In the event my wLCe, Mary E. Forney, predeceases me, I give. devLse
and bequeath all of my estate, be the same real, personal or mLxed and wheresoever
situate, to my daughter, Freda (Mrs. Charles) Acri, 908 S. York Street, Mechanics-
burg, PennsylvanLa.
ITEM 4. 1 appoint my wLfe. Mary E. Forney, as Executrix of my estate provided
she survLves me.
ITEM 5. In the event my wLfe, Mary E. Forney, predeceases me or Ls unable to
serve as ExecutrLx, I appoint my daugh tel', Freda Acri, as Executrix of my estate.
IN WITNESS WHEREOF, I hllve hereunto set my hand and seal thLs ~ day of
November, 1973.
.r C-U-LQ. uJ. )='O"'l.n' 1 J-L-)
(SEAL)
The wrLtlng contaLned on this one pa~e was signed and sealed by the
above Paul W. Forney, and by hLm publLshed and declared as and for hLs
Last Will and Testament In the presence of us, who have hereunto subscribed
our names as witnesses at hLs request, In his presence,
of each other, the ~\~. day of November. 1973.
Uk~..l,Ll9t
and In the presence
~ \\ &dl
.
tL
f"::" /'
\-1?~'''I:'~ ""A'
---..-.. .,--..-------- .- ~. ...-.-..-.. ,-.... .
'.
".
OR Y.l5dJ IX. '....1
.
COMMOHWIAlT~ 0' P1HHIVlYAHIA
INtiUITAH I fA)r .,fUIN
IIUIDl!N DtCID NT
I T TI OP
SCHEDULE B
STOCKS AND BONDS
FILl MBER
Forney, Paul W.
0.0.0.: October II, 1994
21-94-1069
(All prop.rty lolntly-own.d wllh Right of Survlvo..hlp mUlt b. dllclol.d on Sch.dul. P,I
ITEM
NUMBER DESCRIPTION
VALUE AT DATE
OF DEATH
I.
500 shares Pennsylvania Power & Light Co., Common,
HYSE, Cusip 709051 10 6, @ $19.9375.
9,968.75
TorAL AIIO enter on line 2, RICa Itulatlon
'If mort spac. i. nt.d,d, ;nrt" aelditional lit..,. 01 10m. .In.}
S 9,968.75
"
lIV.U09 IX. (1.111
COMMONWI."" O' "NtlU".NI. j SCHEDULE "F"
INHumANel 'AX "'JUaN
UIIOINI OICIOIN' JOINTLY-OWNED PROPERTY
.STATIO. ----- =---. -~~~~o=~==~.ju NUMilU------'--
Forney, Paul W. 0.0.0.1 october 11, 1994 21-94-1069
--
,
.
Jolnllonont(')1
A,
NAM.
l>reda F. Acr i
--- ="::":':Ai~I!!~L=':-~=_-=--= _ RILATIONSHIP TO DEC!DE~r -
354 Locust Point Road Daughter
Mechanicsburg, PA 17055
II,
C.
Jo/ntly.._od ptopo"".
ITIM LmlR DATE
POR TOTAL VALUE DECO'S DOLLAR VALUE OP
NUM.., JOINT MADE DESCRIPTION OP PROPIRTY OP ASSn "'INT. DICEDENT'S INTERIST
TENANT JOINT
" A 8/16/88 Certificate of Deposit No. 5,000.00 50' 2.500.00
0413200107136. The First Dank
and Trust Company of Mechsnic -
burl1, Pennsylvania, (Now PNC
Bank) issued to Paul W. Fornel
and Freda F. Acri.
Interest accrued to D.C.D. 14.42 50' 7.21
2. A 12/26/8~ Certificate of Deposit No. 5,000.00 50' 2.500.00
0413200135624, The First Dank
and Trust Company of Mechanic.-
burl1, Pennsylvania, (Now PNC
Dank) issued to Paul W. Fornel
and Freda F. Acri
Interest accrued to D.O.D. 8.88 50' 4.44
TOTAL (AI.o onlor on lino 6, Rocapltulotlon) S 5.011.65
(II mo,o 'poco I, noodod In ",I additional .hool. 0' .amo "n)
,
PNC Dank, N.A.
. .1:H2 C.lfl(,!t! .'ike
1.'IllI>llill,I'A .7nll
PNClBANK
January 11. 1995
Law Offices of
Marlin R. McCaleb
Frankeberger Place
219 East Main Street
P.O. Box 230
Mechanicsburg, PA 17055
REI Paul W. Forney
Date of Death. October 11, 1994
Social Security No. 162-22-0620
Dear Mr. McCaleb.
As per your request for information on accounts the above
referenced decedent held with us, the information is as follows.
-Certificate of Deposit Account No. 0413200079319 opened 11/28/86
in the name of Paul W. Forney, Mary Forney. Balance at date of
death. $5,000.00. Accrued interest. $ 5.75.
-Certificate of Deposit Account No. 0413200107136 opened 08/16/88
in the name of Paul W. Forney, Freda F. Acri. Balance at date of
death. $5,000.00. Accrued interest. $ 14,42.
-Certificate of Deposi~ Account No, 0413200135624 opened 12/26/89
in the name of Paul W. Forney. Freda F. Acri. Balance at date of
death. $5,000.00. Accrued interest, $ 8.B8.
If I can be of any further assistance, please do not hesitate to
contact me at (717) 730-2321.
Sincerely,
~IJ, ~
Edith TancH
Miscellaneous Services Supervisor
Bank Operations
ETlmky
.' .
. " 1I\/oIJII'h (7.'1]
.
COMMONWfAml 0' PfNNSYLVANIA
INHUITANCf TAX ReTURN
IlfSIOI!NT OI!CfOfNT
SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
PI. a.. PrInt or T .
0.0.0. Octobor 11, 1994
21-94-1069
Forney, Paul W.
~!
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1:
ITEM
NUMBER
A,
B.
4.
C.
"
2.
3.
4,
5.
6.
7.
8.
AMOUNT
DESCRIPTION
"
2.
Funeral Exp.n....
Myers Funeral lIome, funeral expense
New Kinl1ston Fire Cempany, funeral dinner
6,130.70
198.91
1,
Admlnl.tratlve Co.lI.
Penonal Repnllentallve Cammllllan.
Social Seeurlly Number of Perianal Rep"..ntallve.
Vear Cammllllan. paid
2,
Allarney Fee.
915.00
3,
Family Exempllan
Claimant Mary B. Forney
Relallan.hlp
Wife
2.000.00
Add".. of Clalmanl at decedent'. death
350 Locust Point Road
St"et Add"..
Mechanicsburg
Stale
PA Zip Code 17055
Clly
Probate Fee.
56.00
MI.e.llan.ou. Exp.n....
Register of Wills, filing Inventory and Appraisement
25.QO
TOTAL IAI.o enter on line 9, Reeapllulallonl
(If more .paee I. n..ded, In..rt additional .h.... of .ame II...)
S
9,325.61
,ft.
_....._c.
"~.IIU EX_ 17-131
COMMONWEALTH OF PENNSVLVANIA
INHERITANr.E TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE "J"
BENEFICIARIES
FILE NUMBER
ITEM
NUMBER
NAME AND ADDRESS OF BENEFICIARY
RELATIONSHIP
AMOUNT OR
SHARE OF ESTATE
1,
A, Taxable Bequltt.:
Mary B. Fornoy
354 Locust Point Rosd
Mochanicsburq, PA 17055
wife
643.14
2.
Freda F. Acri
354 Locust Point Road
Mochanicsburl1, PA 17055
Daul1hter
5.011.65
ITEM
NUMBER
NAME AND ADDRESS OF BENEFICIARY
AMOUNT OR
SHARE OF ESTATE
B, Charitable end Governmentel Bequ8Iu
1,
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS IAlso enlllr on line 13, Recapltuletlonf .
Of more IJNC. II nHdIld I"..rt .ddlllon.l.h.... of ..me .III~
Porno
filE NUMBER
. Paul W. D.O.D.I october II, 1994 21-94-1069
Thl. schedule mu.' be completed and filed If you checked Ih. .pousal poverty credit box on the cover sheet,
. .
SCHEDULE N
SPOUSAL POVERTY CREDIT
AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91
'.- : REY.16.u lit II.Qll "
. . -!jj.
COMMONWEAllH OF PENNSYlANIA
INHERITANCE TAX OIVISION
ESTATE Of
1. Taxabl. Au.'. tolallrom IIn. 9 (coy.r .h..I).................................................................... 1.
14.980.40
2. Insurance Proceeds on liFe of Dec.d.nl.,..,.,.,..""..""""",.,."..,.,.".,..,."",....",....".."",..., 2.
3. Retirement Benefiti",."..""."",."",..".."..,..."...., ....,.,..,..,...,."..,.",.,.".".,......."...,.,""',.. 3.
4. Joint Au." wllh SpOUI. ......................................,.......................................................... 4.
28 052.48
5. PA Lon.ry Winning. ...................................................................................................... 5.
6d.
~-,", ;_.::' ~j
.,.' ..j
.,.).,.'.".:
,;..;yj:.~;t~.',~]
"'''', '!
,'., ~~~,l.:,'.o-_ ~t J
,Ji:,/,':,~... '..-1
,_./l\{,_;'~,;.;;ij
'''{-'-)'':-\.i
.,[!J"."';j'
, ,..~~\;,.,
60. Oth.r Nonlaxabl. Au.lt: Lilt (Anoch sch.dul. If n.c.uary).. 60.
6b.
6c.
6. SUBTOTAL (L1n.. 60, b, c, d)....:...........................................,........................................ 6.
7. Tolal Grall A..." (Add lin.. 1 Ihru 6)..................... ......~................................................ 7.
43,032.88
9. Talal Aclual L1oblliti.. ..................................... ...................... ........... ..... ........... .............. g.
9. N.t Valu. 01 E.lal. (Sublractlln. 9 lrom lin. 7)................................................................ 9.
"'in. 9 is gr.ot.rlhon 5200,000. STOP. Th. .dot. il nal ./igib/. 10 claim lh. cr.dif, "nof, conlinu. fo Porlll,
. . . ..
o
I ..
..PARTJI.,. CALCULATlU.. _. _ _.... ..._.... _____ -- n _'ME -(Attach copias 01 Fedorallndividuollncemo
~:t:;?\';...:. Tax Roturns for decodont and spouse.) . ~,' " . . , .'
- - -
Income: 1. TAX YEAR: 19 93 2. TAX YEAR, 19 92 3. TAX YEAR: 1991
a. Spouse .................,.... 10 20, 30,
b, Decedent ..........,........ lb. 2b 3b,
c, Jolnl".."..",.,.".......... k 4,790.00 2c. 1,982.00 3c.
d. Tax Exempt Income..... d, 2d, 3d,
e, Olher Incomo not 15,542.00 15,103.00
lI.t.d abay. ........... 10, 2., 3.. 14 554.00
1 Total... ... .. 11. 20,332.00 21. 17,085.00 31. 21 709.00
4, Average Joint Exemptlon Income Calculation
40, Add Joint Exemption Income from above:
(11) 20.332.00 + (211 17,OS5.00 + (31) 21,709.00 = 59,126.00
1+ 31
4b. Average Joint Exemption Income ,.,..,..........".,.,..""..."""..,..,.."""...,'"".""".,...",.",..,... = 19,709.00
If lin. 4(b) i. gr.al.r Ihan $40 000 . STOP Th. ."01. I. nol ./igib/. 10 claim 'h. cr.dil /I nol conl;nu. 10 Part 11/
PART. 111._ CALCULATION OF .SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT
'..-"": ESTATES . ..,',' '
1. Insert amount of laxoble transfen to spouse or S100,000, whichever Is len..,.......................
1. 643.14
2. 0.06
3. 38.59
4.
5.
2. Multiply by cr.dit p.rc.ntag. (s.. instructions) ..................................................................
J, This is the amount of the Rosideni Spousal Poverty Credil. Include thl, figuro
In the calculatlon of total credits on line 18 of ,h. cover sheel, ...............,...........,................'
4. for Nonresidents. enter the ratio of the decedent's gross eSlate in PA to the value of the
dec.denl', gross eslole,., ...,." .."""., ",..,.,..",.,.",.,....., ,.., ""." ,..,." " ,...", ...,..'".", ,.., ,...,.,
5, Multiply line 3 by line 4 and enter the Iota I here. This is the omounl of .he Nonresidonl Spousal
Poverty Credit, Include this figure in the calculation of tolol credits on line 18 of the covor sheet,
.' .
',.,
"
, '
~1040
label
(See
Instruclions
on pag.'\.)
Uao the IRS
I.bol.
Olherwlse,
pl.... prlnl
or type.
Presldenlla/
Eleellon Campelgn ~
See 8 011. ,
1
Filing Slalus 2
3
4
Chock only
one box.
Exempllons
(s.. p.g. 12.)
II more than six
dependents,
.00 p.g. 13.
Income
Attach
Copy B 01 you,
Farml W.2.
W-20. 8nd
l099.R h....
If you did not
get a W-2. see
p.go 10.
AU.ch ch.ck or
money order on
top 01 any
Forms W.2,
W.2G.or
1099.A.
AdJuslmenls
10 Income
(5.0 pogo 19.)
L
A
.
.
L
H
.
R
.
U~S~I~dl'~I'd~;iui;;~e~~ fT;;ueR;t~~n ~~91
"1
.1991,endl
t51 oolmonlFlI
1rvtd1l1~1
In191
d If j1lur child didn'lllva with you bulls c1.lmed as your dependenl under a pre.1985 .greement. check hera ~ 0
. Total number 01 exem lions claimed
Slnglo
Married Iillng Joint return (even II only one had Income)
Married fding Hparale return. Enler spouse's social secunly no. above and full name here, ...
H..d of hou..hold (wilh qu.llfylng per. on). (5.0 p.ge 12.) If Ihe qualifying p.raon I. e child but not you, d.p.nd.nt,
enler this child's name hero, ...
5 Quali In widower with de endent child ( ear 6 OUBO died .. 19 . See a
6a (81 Your..I', II your parent (or someone else) can claim you as a dependent on his or her tax
relurn, do nol check box Go, But be sure to check tho bolt on IIno 33b on page 2
FOl'the ., Jan,.Oee, 31, 1091, Of olhe, lall oar
Your 'Irll name and mlllal
(J
Api, no,
00 you want $1 to go to Ihl. fund? . .
If oint relurn dOBS our s OUSB wont $1 10 0 to l~ls fund?
Yo.
Yoa
b
S DU'.
a Dependent.:
III NJmI Ifilll, IMIJI, and Int IlIme)
(3 II Joe t or older,
dependen1'lsoclallecullty
number
4) rpendenl'l
relJIIOnshlplo
ou
7
Be
b
9
10
11
12
13
14
15
1511
17.
18
19
20
21.
22
23
24.
b
25
28
27
28
28
30
31
Weg... a.lerl... lip., otc. IBnBch Form(.) W.2)
T...blolnle,o.t Incomo (.1.0 .nBch Schedule B /I over $400) .
Tn'lIImpllnleresllncom. (see p.ga 16). OON'T Include on line 8. 8b
Olvldond Income (."0 .11.ch Schodu/e B II over S400) .
TaKable refunds 01 stale and local Income taxes, il any, from worksheet on page 16.
Alimony received
Bu.ln... Incomo or (Io.s) IB".ch Schedule C).
C.pil.1 geln or (loss) (B".ch Schedulo 0) . .
C.pllol geln dl'lrlbullon. not r.port.d on line 13 (... p.g. 17).
OIh., golna or (Ioas..) I.".ch Form 4797) . . . . . . . . . . .
TolallRA dl.trlbullon. . ~ '- lab TaK.bl. .mounl (see p.g. 171
Tol.1 pensions and .nnulli.. l.1r!J '_ 17b TaKabl. .mounl (see p.g. 17)
Renls, royallles, partnerships, estates, trusts, etc, (attach Schedule E)
Farm Income or (loss) (attach Schedule F), .
Unemployment compensation (Insurance) (seo pa98 18). , . . , . , . . .
Socl.1 ..curlly bon.IiI.. , 21. I /'Io!J-:S t-{ 1_ 21b Tmble .mounll"e p.ge 181
Olh.r Income (lI.t type .nd emount-se. p.ge19) ..1.(l/1tJ...e.~~..............
Add the amounts shown In the far,- ht column for lines 7 th,ou h 22, This is ur tolJlllncom. ..
Your IRA deduction, from applicablo worksheet on page 20 0121 240
Spou....IRA deducllon. ham .pphc.ble worksheel on p.g. 20 or 21 24b
On..holf of a.lf.omploymont t.. (..0 P090 21) 25
Sell.employed heallh Insuranc. deduWon, ham worksheel on PJg. 22. 28
Keogh retirement pIon and seU-emploved SEP deduction 27
Penally on early withdrawal of savings , 28
Alimony paid, Recipient's SSN .. 29
Add lines 240 lhrou h 29, These are our total ad ultments . . ..
Sublract line 30 from Ilno 23, This IS vour Ddlulted grolllncome. If thIS amount ;s len than
$1r,250 and a child livod With )"ou. see page JS to I,nd out II you can cfn'm the "Eamod Income
Cmd,," on fm" S6 ,.., . '.,.. ..,.....
Cat. No 113200
. 19 OMO No, 1545.0074
Your socl.1 ncurlly number
/bJ. irIJ.: Obd.O
8poun'. 10cl.1 ncurtly numb.r
/.fJ""7 : J.'/i 95'1.S-
For Privacy Act .nd
Paperwork Raductlon
Act Notice, aoo
Inotructlona,
No Nole: ChecAing .Yes - wUl
not chan{1fl )'OUf ta. 01
No reduce r 18fund,
!.':.l_~~..
/',' ~ ~,:
". ,
012.
No, or bO.1I
chuh' on I. _1
.ndlb ~
Ho, 01 vour
children on Ie
who:
. nfldwlth you
. dldn'llIn with
yau dUlla
dlforCl or
IIp.r.llon(11I
p.g.14)
Ho.orother
d,plnd.nl.onlc_
Add numb".
.nl.redon
IInll .bon ...
. ,
, ,.'f'"
;.::~~'~),
.f,,:\'i
\~2.~~J~.
:- :~'~:.
"
. ,
'.
9
10
1
12
3
4
15
18b
7b
18
10
20
21b
22
23
, .
'..,
<'."~I:\:
..' ': :~",
I 00
.!J-
30
31
7)j~
'\
"()tm t040 (109t.
32
33a
Tax
Compu-
tation
If you wonl
Ihe IRS 10
figuro your
tnx, see page
24.
35
38
37
38
39
40
Credits 41
42
~see page 43
5.) 44
45
48
47
48
49
60
51
52
53
Payments ::
58
57
58
59
Other
Taxes
Attech
Forms W-2,
W.2G. end
1099.R 10
front.
80
Refund or 81
82
Amount 83
You Owe 84
Sign
Here
Keep a copy
of this return
for your
records,
Paid
Preparer's
Use Only
Amounl from Iino 31 (adjusted gloss income) , , , ,
Check II: IB"You wora 85 or older. 0 Blind; lB" Spouae wne 65 or older. 0 Blind.
Add tho numbor of boxos chocked abovo nnd entor tho lolnl here, , , ... 330
b II your porcnl (or somoone else) can claim you os 0 dependent, chock hero'" 33b
a It you 010 morrlod filing n soparnle roturn Dnd your spouso Itemlzos doducllons, 0
or you are a dunl.slotus ollon, soo pogo 23 nnd chock horo , . , ... 330
itemized deducllona IIrom Schedule A. line 26). OR
Standard doductlon (shown bolow fOl your filing Slolus). Caution: If you
chechod any bo~ on lino 33a or b, go to pago 23 to find your standard
deduction, If you choched bo~ 33c, your standard deduction Is loro,
o Slnglo-S3.400 0 Heed of houaehold-S5.000
o Married filing lolnlly or Oualifylng wldow(a')-S5.700
o Married filing aeparalely-S2.850
Sublraclllne341,omllne32. . . . . . . . .. . . . . . .
"line 321a S75.060 or lesa. mulllply S2,150 by Ihe tolal number of exempllons claimed on
line 60, If line 32 Is over $76,000, soe poge 24 for the amount to enler , . , , .
Telllblelncome. Sublraclllno 36 /rom IIno 35. (II line 38 I. mo,o Ihen line 35. enler .0-.) .
Enler tax. Chock II I,om e 0 Tax Tobie. bOT.. R.lo Schedulo.. 0 0 Schodul. 0,
or d 0 Form8815(soopage24),IAmount.llany.f,omFo,m(a)8814 . 0 _-1- .)
Addlllon.1 t.... (see p.ge 24). Check II ',om. 0 Form 4970 b 0 Form 4972
Add line. 38 nnd 39. . . . . . . . . . . '. ...... .
PI I 2
34
.'
$05 .
...
,,:....:f'
:,\ ~~!-
.' .
Enler
the
larger
01
your:
38
3
;.r
rJoo
o
....
35
.
38
9
40
o
,. .."
.~~~
" '.:
".
85
Credit for child end dependent care exponses (attach Form 2441)
Credit 'or Ih. alde,ly or the dl..bled I."ach Sc'!edul. R). .
Fo,elgn lax credit (."ach Form" 16) . . . . . . .
Olher c,edlte (se. p.g. 25). Ch.ck II 'rom. 0 Form 3800
b 0 Form 8398 c 0 Form 8801 dO Form (specify) _ 44
Add line. 41 Ihrough 44 . . . . . . . . . . . . . .
Subtract line 45 'rom line 4$0. I' flno 45 Is more than line 40, enter .0-,
Self..mploym.nl t.. (atlach Sch.dul. SE). . . . . .
Allem.llv. minimum I.. (."ech Form 6251) . . . . . . . . . . .
Recepture I..es (see page 26). Check If I,om . 0 Form 4255 b 0 Form 8811 0 0 Form 8828 .
Social .ecurity .nd Medlc.r. la. on lip Income nol reported 10 employer I.,tlch Form 4137)
Tax on .n IRA or . qu.lllled r.llremen' plan (.ttach Form 5329)
Advance eomed Income credit payments from Form W-2 .
Add IIn.. 48 Ih,ou h 52. Thl. I. our lotel t.x. . . . .
Feder.llncome I" wllhheld (II any Is from Fo,m!s) 1099. check. 0,
1991 estlmaled tax paymenls and amount applied from 1990 relum ,
Eamed Incomo credit I./lach Schedulo fie) . . . .
Amount paid with Fo,m 4868 (o.len.lon requesl). . . .
E'cess socl., securily. Medicare. .nd RRTA I" withheld (s.e p.os 211 .
Other p.ymenle (see p.g. 27). Check If Irom 0 0 Fo,m 2439
b 0 Fo,m 4138. . . . . . . . . . . " 69
Add Unos 64 throu h 59, Theso are our toto I a ments , , , . .
If line 60 Is more than line 53, sublract line 53 from line 60, This Is the amo\lnl you OVERPAID.
Amounl 01 IIn. 81 10 b. REFUNDED TO YOU. . . .. ......
Amounlelllne 6110 be APPLlEO TO YOUR 1992 ESTIMATED TAX ~ 83
" line 53 I, mo,. Ihan line 60. subt,aCI line 60 'rom line 53. Thl. I. Iho AMOUNT YOU OWE.
Attach check or money order for full amount payable to ~Internal Revenue Service," Wrile your
name, address, social security number, day1imo phone number, and "1991 Form 1040" on It. ,
Esllmated tax enoll soe 0 028, Also Includo on lino 64. 65
".;..,.
4
42
43
45
48
47
48
49
60
51
52
53
.
o
.
C:>
54
55
58
57
58
\','"
:r:~~:~:
'"... ,..,
.
Under penallies 01 perlury. I doclare thai I havo e.amlnod Ihls rolum and accompanying schedules and statements, and 10 the besl 01 my knowledoe and
belief, they are t,ue, correel, and completo, Doelaralion 01 preparelf (Olhe, than la.payer) is basod on alllofo'malion 01 vohlch prepa,er has any knowledge.
~ Your sIgnAture Oalo Your OCCUp,11ion
~ Spouse', signature (II jOint 'clurn, BOTH must !Oign)
Dalo
Spouse's OCCUp,1t'on
(i1f
Dale
,~. .l/ p"r'-
Schedules AID (Form 10401 1991
Namt(s) shown on Fom' 1040. 100 not .nler name and 1OCI4I1OCUlllV number it shown on othor aldo I
:> u
U",
...,
OMS Uo. 1545.00,", Page 2
Your 10tl.1 ..curtty numb.r
6 i ~(,rJO
"
',....:h~.. I
;' ',' ,:,1
. ...,..'
~ .,'..::,.;, -:' :
Part I
Interest
Income
\S.e
p.oes 15
end 43.)
Nole: II you
received a Form
HHlo.INT. Form
1090.0ID. Dr
substitute
slalement, from
8 brokerage firm.
IIsllhellrm'B
name 8S the
payor and enter
the lotallnteresl
shown on that
form,
Part II
Dlvldand
Income
(See
pBg.S 16
snd 43.)
Note: II you
received a Form
109o.DIV. or
subslllute
statement, from
8 brokerage
IIrm.lIstlhe
firm's name os
Ihe pey.r end
enter the lolal
dividends
shown on thai
form,
Part III
Foreign
Accounts
and
Foralgn
Trusta
(See
pege 43.)
Schedule B-Interest and Dividend Income
All.ehmont DB
Sequence No.
II you received more then $400 In talable Inlerest Incoma, or you ore claiming tho eleluBlon ollnlerestlrom
eerie. EE U.S. eevlng. bond.l..ued after 1009 (Bae page 431, you muet completa Port I. LI.t ALL Inler..t racelved
In Part I. II you received more than $400 In tDkable Inleresl Income. you mu.t 01.0 complete Part III. II you received,
a. a nominee, Intereel that aolually belong. to snother pereon, or you received or paid accrued Intereet on .ecurllle.
transferred between Intorolt 0 ment dotal, laD ngo 43.
Inlereatlncome Amount
1 Inlereat Income. (Llat name 01 payer-If any Inlereal Income la from
seiler-financed mortgages, see Inatrucllona and IIslthls Intereat firs!.) ~ ........
FI1flJ11ta{j... .-rAv.~T...............................................................
. f1 f($.r::.(j~}).(~.. i-: :{J~v.~....................................................
......,...".....".".....,.............,....,.....,...........,.......",.................
....,.............,......,................,......."....."..,...."...........,............
1
.................,..,..,...,.......,..........,......,..........,.............".....,.~....
..........,.................,.............,............."....,..............,..............
.....,..............,.~....,............,............."..,.................,......,........
'.'
.......,................,.....,.........."..........,.....,......"..",....".............
;',,:.;".
~' ~ ;:., ":,
.~'. ~ :.:;,...:
. ,'.
..................................~.................,..."......,...........,.............,.
.................~.....,...........,..................."...........,.........,......,...,..
.....,.........................,.....,....:..........................,......................
2 Add the amounts on line 1 . . . . . . . . . . . , . . . . . ,
3 Enler the elcludable savings bond Intereat, If any, from Form 0015, line 14.
Attach Form 8815 to Form 1040 . . . . . . . . . . . . . . .. 3
4 Subtraetllna 3 from line 2. Enler the resull here and on Form 1040 line 8a. ~ 4
II you received more tlian $400 In gross dividend. and/or olher dlstrlbullon. on .toek, you mu.t complate Pert.
II and III. II you received, a. a nominee, dividend. that actually belong to anothar person, see peg. 43.
Dividend Income Amount
5 Dividend Income. (L1at name of payer-Include on this line capllal geln
dlstrlbullons, nonla.able dlatrlbutlons, etc.) ~ ......................................
.~ !l:J4M. r.y. ./:I.!(? ff. ...,:(rY.~~~C................................................
.r:J..:t-..~...............................................................................
2
........,.........................,...,........,.."................,.,....,.......,...,..,.
................,.,.....,............,.....,..,.."...,'".,.......,............~.......,...
.....,....,....,......,.....,..................,................~....",......,....,......,.
5
......,....".,...,....."..."....,.....,.,..,."..,..,,...",....,...,..,."....,.....,...
..,.....,.,........,...,..........,..........,.,...,..............,.",....,.......,........
"....,.......".........,....".....,........,..,....,............,......,..,......."..,.,
. '.
;~ ;",: '.:
"
.......,........,.....,...............,......,.....,.......,.,....,......,.,....,...........
.,............,....",.......,.....,."...."....,................,.....,....,.......,......
................,.......................,......,...,.,....,.......,................,......,.
.,......................,.....,..,......,.....,...............,.....",...........,...,.,...
6 Add the amounts on line 5 . . . . . . . . . .
7 Capllal geln dlatrlbutlons. Enler here and on Schedule 0'. 7
6 Nonla,able dislribullons. (Sss the Ins\. for Form 1040, line 9.). 8
9 Add lines 7 and 8 . . . . . . . . . . . .. ......
10 Sublractllne 9 from line 6. Enlar Ihe resull here and on Form 1040, line 9 . ~ 10 106-
'/f you rocslvsd capital gain dlslributlons bul do not need Schedule D 10 report any other gains or losses,
sss the Inslructlons lor Form 1040, lines 13 and 14.
II you received moro then $400 01 Interest or dividends, DR II you hed a forel9n account or were a
grantor 01, or a transleror to, s lorelgn trust, you mu.t answer both question. In Part III.
11s At any time during 1991, did you have an Inlerealln Dr a slgnalure or olher aulhorlly over a financial
account In a lorelgn counlry (such as a bank accounl, .ecurilles accounl. or olher financial
accounl)? (See page 43 for e.ceplions and f,ling requiremenls lor Form TO F 90.22.1.)
b ""Ves," enler the name of the lorelgn country ~ .......................................................
12 Were you the grantor of. or tmnsleror 10. a foreign trustlhal elisted during 1991, whelher or not
ou have an baneficlalInterealIn It? II ..Ve.... au ma have 10 liIe Form 3520. 3520-A. or 926 .
For Paperwork Reduction Act Nollce, Beo Form 1040 Inatructlons. Schedule 0 (Form 1040) 1991
~1040
Filing Status
ISee pege 10,)
Check only
one box.
Exempllons
ISee page 11.)
If more than she
dependenls.
.ee page 12.
'.
tncome
Al1lIch
Copy B 01 your
Forma W.2.
Wa2Q. end
1099-A her..
II you did nol
get a W.2. soe
p.ge 9.
Allach check or
money order on
top 01 .ny
Form. W-2.
W.2G,or
1099.A.
Adjustments
to Income
ISo. pogo 1 B.)
.".',
. ,...
v: ~ -;:!
A usted
Gross Income
Oep"""'.'" 01 the Tf.,uury-lI,t.",ull1o"."ue 6.""u:.
U,S, Individual Income Tax Return n1
1]@92
illS u.. ani, 00 r.ol wllte 01' Ilapl. In ,hi. .pan
, 10!l2, omMO .19 OMD No. 1545.0014
Your 10cl.1 ..curttv numb.'
/6D? !r?;?! ~6dO
SPOUI'" locl.l..curlty number
M""7 ;~'I; 'Lf'^~-
For Prlvacv Act and
Paporwork Roducllon
Act Notlco, .00 P.O. 4.
fOt the .,.110I' Jan, '-Ooc, 31, 1992, Of other tal '1'111' begInning
YOI.II 11111 naml and Initial LAS' name
fJl9 U J..
II. toml "Iu'n, ,pouse', 'If.t naml and .MIIII
L
.
o
I
L
II
I
n
I
rrJt< YJL
lint nilml
"PI. no,
c' · <;
00 you want SIlo go 10 lhls lund? .. .
If a oint relurn does our a Duse want $1 to 0 to 'his fund?
Nol.: ChedJng "Ves. WIll
no' chlngo )'OUr ,.. or
,educe , refund.
5lngl.
Married filing JoInt return (even II only ono hod Incomo)
Married Ming separal' relurn. Enlel spouse', social security no, abo....e and lull name here, ~
Head 01 household (wilh quslilylng per.on).(So. page' 1.) If lho quelilying pe,.on Is II child but nol your dop.nd.nl.
enler this child'. name hero, ~
Quail In widower wllh de endent child ( oar souse dlod" 19 . See a e 11.
88 (E Yourself. II your parent (or someone elae) can claim you as a dependent on hiS 01' her tM
return. do not check boll 60. But be sure to check the ball on Iina 33b on page :1
b Souse..
o Depend.nts:
(1) N.m. (lirst.lnlllJl, .nd IlSl n.mll
5
II ""
Ilundtr
"'
(3)1 'Q' 1oroder.
dependent'llocl.1 seculit)'
numb r
4 ependen!"
rel1tlon'hlpto
au
II) No, 0 mon~1
livtdln)'OUr
h<lm ~l
Label
(See
InstructlOt\s
on page 10 I
U.. Ihe IRS
I.bel.
OlhoMi.e.
please prInt
or Iyp..
Prllldlnllll
Ellcllon Clmpllun It.
See a 8 10, ,
1
2
3
4
d \I you, cliild dldn'lllYl wilh you bull. claimed as your deplndenl under a p,e'1985 ag,eemenl. check he,e ~ 0
. Tolal number 01 exem tlons claimed
7
Ba
b
9
10
11
12
13
14
15
16.
17.
lB
19
20
21.
22
23
2411
b
25
26
27
2B
29
30
31
W.ges. .elarl... Ups. ole. AUach Form(.) W.2
T.uble Inl.,..t Incomo. Attach Schodulo B II ovor $400
Tu.mmpllnlerelllncoml (sel pagl151, OON'T Includl on Iinl6a Bb
~ividend Incom.. Attach Schodul. B \I over $400
Taxable refunds. credits, or offsets olllato and local Income taxes frem worksheet on page 16
Alimony received
Business Income or (loss). Attach Schedule C or C.EZ .
Capil.1 geln or (Io,s). Att.ch Schodul. 0 .
Capital gaIn dlslributlons not repor1ed on line 13 (see pago 15)
Other gelns or Vosse.). Allach Form 4797 _ ...... - . . . - .
Tol.IIRA dlstribullon.. lJ.!!.J LJ b Taxsble .mounl (.eo pago 15)
TOlal penllon. and annullies l.1!!J I~ b Taxable amounl (... page 16)
Rents, rovaltlos, partnershIps, eslales, trusts. ote, Attach Schedule E
Farm Income or (loss), Attach Schedule F ,
Unemployment compensation (see page 17) ., ..,....,..
Social .ecurlty bonelll. I 21. I I I b Taxableamounl (.e. p.g. 171
Other Income,llsllype and amount-see pago 18 .., '........ .............,.,........
Add the amounts in the far, ht column fo' lines 7 throu h 22. This Is our total Income . ~
Your IRA deduction from applicable wOtksheet on pdge 19 or 20 248
Spau,,'. IRA deducllon lrom applicable work.heelon pagl19 0' 20 24b
Ono.hall 01 .olf..mploymonll.. (.0. page 20) 25
Self.employod health Insurance doductlon (soe pago 20) 28
Keogh reUrement plan ond self. employed SEP deducllon 27
Penally on esrlv withdrawal 01 savings . 28
Alimony paid. Recipienl'. SSN ~ 29
Add lines 240 throu h 29, Theso aro our total ad uslments . ~
Sublract line 30 from line 23, This Is you, .dJu.ted gro.. Income. If 'his amount Is less 'han
$22,310 .nd a child lived wilh you. see p'fJe EIC.' to find 001 if you can cldim the .ElJm~
Incom. Cmdl'. on Ime 56 . ~
Cat, No, 113209
No.olbolll
ch.chdonll _-'1
.ndl' lA
No. 01 your
chlldrln onlc
who:
. Ilvsd wllh you
. dldn" IIvI wllh
you dUI to
dlvon:1 Dr
..,aratlon ("I
p.g.ll)
No, 01 other
d.p.nd.nllonlc_
Addnumb:11'I
Intlred on
IInnlbovl ...
12
13
4
15
16b
b
lB
19
20
21b
22
23
30
31
7
Form 1040 (109'1
feD 689
FOIm '0401'9911
Tax
Compu-
tation
IS.. page
22,)
II you wanl
Ih. IAS 10
ngur. your
tax, Ite page
23. 39
40
41
42
43
44
Credits
(S.. page
23.)
Other
Taxes
Payments
Att.ch
Forms W..2.
W-2G .nd
1099.R on
tho front.
60
Refund or 61
Amount 62
You Owe 63
AII.ch check or 64
money order on
top of Form(.)
W.2/elc.. on
the ront.
Sign
Here
K..p II copy
of this relum
for your
records.
Paid
Preparer's
Use Only
fEO 690
d
35 - 0 -
36 bao
0
38 0
9
40
Und.r pen.IUes of perjury, I declare thai I ha~. e..mlned Ihis rei urn and .ccompanying schedules and II.temenls, and 1_0 the besl of my knowIedal and
belief, 'hlY ate true, cOH.cl, and complelO. Oetlarahon of pteparer (olher lhan tlllPilVeI) Is based on alllnfOl'm.tion 01 which preparer Miait)' knOwledge,
~ Your .Igna'ur. Oa'. Yo'" DCcup.lI0n
~ Spouse'. sIgnature, II . joint relvln, BOTH must Ilgn.
32 Amount hom Uno 31 (adJustod gross Income) ".', .
33. Ch.ck II: ri!I Vou woro 65 or oldor. 0 Blind: ~ Spou.. wa. 65 or old.r. 0 Blind.
Add tho numbor of bo~os checkod abovD nnd enler 'he tolal hore , , ... 338
b II your po rent (or someono olso) enn claim you os a dependent, check hOlD , ... 33b
a II you ure murrled liling separatoly Bnd your spouse Itemizes deductions or you
are a dual'atBtus ollon, aBO pago 22 and chock herB. , , . . . , ,... 330
\ n.mlzed deduction. Irom Sch.dulo A. line 26. on 1
34 Enler Standord d.ldUCtlon shown below lor your fIling atatus, But If you checked
Ithe any box on IIn8 338 or b, go to page 22 to find your standard deduction.
arg.r If you checked box 33c, your alandard deduction Is zero,
of
your: . Slngll.-S3,600 . H.ad 01 hou..hold-S5.250
. Marrl.d IlIlng lolnlly or Ouallfylng wldow(or)-$6.000
. Marrl.d II1lng .oparat.ly-S3.000
Subtract IIn. 34 Irom IIno 32 . . . . . . . . .
IIl1no 32 I. S78.950 or I.... multiply S2.300 by Iho tol.1 numbor of ...mpllon. clolmod on
line 6e, If line 32 Is over $78,g50, aeo the worksheet on page 23 lor tho amount to ontor .
Tauble Income. Subtract line 36 from IIno 35. IIlIno 36 la more than line 35, enter .0. ,
Enlerlax. Chock Iflrom a IEl Tax Tabl.. b 0 Tax Aalo Schedul.s. c 0 Sch.dule D,
or d 0 Form 86'5 (.00 p.ge 23). Amounl,lI any. from Form(.) 6614 ~ · I
Addlllonal texo. (soo pego 231. Chock Illrom . 0 Form 4970 b 0 Form 4972 .
Add IIno. 3S ond 39. . . . . . . . . .
Credil for child IIOd d.pondonl cere expon.a.. AII.ch Fonn 2441 41
Crodlt for Ihe .Ide~y or the dl.obled. Atlech Schedule A ., 42
Forolgn tex crodlt. Atlech Form 11'6 . . . . . .. 43
Oth.r crodlt. (.00 page 24). Chock II from a 0 Form 3600
b 0 Form 6396 0 0 Form 6601 d 0 Form (speclly)_ 44
Addlln.s41 through 44 . . . . . . . . . .. .
Subtract line 45 'rom line 40. II Une 45 Is more than line 40, enter ..0. ,
Soll.omploymont tex. Attach Schodul. SE. A1.0. .eo IIno 25. . . .
A1tomatlvo mInimum tex. An.ch Form 6251 . . . . .. .....
Aoc.plur. taxo. (seo page 25). Chock Iflrom a 0 Fonn 4255 b 0 Form B611 c OFonn 8B2B
Social .ocurity IInd M.dlcore lex on lip Incomo nol ropo~ed 10 omployor. Allech Fonn 4137
Tax on quallllod roliremenl plan.. Including IRA.. Attoch Form 5329
Advance earned Income credit payments Irom Form W.2 ,
Add line. 46 throu h 52. This Is our 101011.. . . . . .
Federal Income lax withheld. II anI Is Irom Form(.) '099. check ~ 0
1992 estimated tax payments and amount applied Itom 199t retum.
Eamed Incom. cr.dlt. Attach Schodul. EIC . . . . .
Amount paid with Form 4S68 (oxlen.lon roquosl). . . .
bCIII ..rlal murily. M,dlca... IIId RRTA tax withheld (see p.ge 26) .
Olh.r Pllym.nl. (s.e page 26). Check II from a OFo,," 2439
b 0 Form 4'36 . . . . . . . . . . . . ., 69
Add lines 54 Ihrou h 59. These Bro our total 8 ments . . , .
Jllin.60 15 more than line 53, subtract line 53lrom line 60. This Is the amount you OVERPAID,
Amount ollln. 6' you wanl AEFUNDED TO YOU. . . . . . . . . .
Am.unl 01 line 61 Y.u Willi APPLIED TO YOUR 'In ESTIMATED TAX ~ 83
IIl1n. 53 I. more than IIn. 60. subl,act IIn. 60 from line 53. Thl. I. the AMOUNT YOU OWE.
Attach check or money order for full amount payable to .Intemal Revenue Service." Write your
name, address, social security number. daytime phone number, and "'1992 Form 1040"' on It
85 Estimated lax analt see B e 27 , Also Include on line 64 85
35
38
37
38
~
45
46
47
48
49
50
51
52
53
45
48
47
45
49
50
111
52
53
64
115
56
67
50
59
~
~
64
55
56
67
50
D.le
Spouse', occupation
Pao. 2
c:;
o
o
o
~ I,',.
Dale
../ e~f
:j- .;;' 1":.'-
. .'
OM. No. \$4$-007. Page 2
Your loc:l.llNCurtty number
16UlI~0l1 0
Schedule B-Interest and Dividend Income ==~o. 08
If you h.d ov.r $400 In I...bl. Inl.r..1 Incom. OR .r. cl.lmlng Ih. .xc1u.lon 01 Int.r..1 'rom
..rl.. EE U.S. ..vlng. bond. I..u.d .<<.r lOaD, you mu.t compl.l. Ihl. p.~. U.I ALL Inl.r..1 you rec.lved. If you h.d
ov.r $400 In t..obl. Inl.r..llncom., you mu.1 .Iso compl.l. Po~ III. If you rec.lv.d, .. . nomln.., Inl.r..llh.t .c1u.11y
b.lonD' to onolhor f..lIlon, or you r.c.lv.d or p.ld .ccru.d Int.r..1 on s.curlll.. Ir.n.'.".d b.tw..n Inl.r..t p.ym.nl
d.I.., ... .. B. ,
Inlorosllncomo Amount
1 W.t noma 01 pay.r-If any Intoro,' Incomo I. from .ollor.fln.nc.d mo~gag..,
.ee page B.1 and 11.1 Ihl. Inlerest flrsl ~............................................
6 Add tho amount. on line 5. , . . . . . . . .
7 C.pltuJ gsln dlstrlbullons. Enter h.re .nd on Sch.dul. 0' .
6 Nonlaxobl. dl.lrlbullons. (See Ihe Inst. 'or Fonn 1040, IIn. D.)
9 Add IIn.. 7 end 8 . . . . . . . . . . . . .
10 Subtrsct line 9 from line e. Ent.r the result here .nd on Form 1040, line 9 . ~ 10
'If you received ceplfal gain distributions but do not need Schedula D to report any other gains or losses,
see ths InstlUctlon. lor Form 1040, IInas 13 and 14.
Part III If you h.d ov.r $400 of Inleresl or dividend. OR had a 'orelgn .ccount or were. gr.nlor of, or. tr.nsf.ror
Foreign to, s foreign lrusl, you must complele Ihls pe~.
~~~ountll 110 Alony lime durlng 1092, did you have an Inlerest In or a slgnslure or olher authority over a flnanclel
account In a foreign counlry, such as a bank account, securllles account, or olher flnanclsl
~i:n sccounl? See page B.2 for .xc.pllons and filing requlrem.nls for Form TO F 00.22.1 , . . ,
b If .V..,. enl.r Ih. nsme of Ih. foreign counlry ~ .......................................................
(S.. 12 W.r. you Ih. granlor of, or transf.ror to, a 'orulgn tru.' th.t .xl.ted during 1992, wh.ther or not
p.g. B.2.) au hav. an ban.nclallnlere.t In II? If 'V.." au m. have to file Form 3520. 3520.A, or 92e .
Far Paperwar1< RoducUo" Act NaUce,... Farm 1040 In.trucllana. Schodule B (Farm 104011~2
Part I
Intereat
Income
(S.o
p.g..'4
.nd B.l.)
NaIll II you
received a Form
10DD.INT, Fonn
1099.010, or
.ub.tllul.
statement tlom
. brokerage flrm,
II.t Ih. firm'.
name II tho
p.y.r snd enl.r
Ih. 101.llnt.,..,
.hown on th.1
form.
Part II
Dlvld.nd
Income
(s..
p.g.. 15
end B.l.)
Nate: If you
roc.lvod a Fonn
1099.01V or
aub.tltuI.
statement from
. brok.r.g.
finn, 11.1 tho
firm', name as
Ihe p.y.r .nd
enter the tolal
dlvld.nd.
shown on that
form.
~.. .,
",:,'.
'::,', ,,'
....
...........................................,...............,..".............'..............
.f.i:'/(~ 1I1<<1:!.S.. ..T.f.{HST.:.............. .......... ....... ...... ............... ...........
1
...................................~........................................................
............................................................................................
...................................... ...."....".........................................
2 Add tho amounla on IIno 1 . , . , , , , , , , , , . , . . .. 2
3' Excludablo Inlers.1 on s.ri.. EE U.S....vlng. bond.lssuod after 1989 from Form
8815, line 14. You MUST attach Form 8815 to Form 1040 . . . , , " 3
4 Subtract IIn. 3 from IIno 2. Ent.r Iho r.sull h.re and on Form 1040 IIn. e. ~ 4
II you h.d over $400 In graso dlvld.nd. and/or oth.r dlslrlbutlan. on slack, you must compl.lo Ihls part end Part III, If
you roc.lvod, .s 0 namln.., dlvld.nds th., aclu.11y b.long 10 .nolhar p.rson, SOl p.g. B-1.
Dlvld.nd Incom. Amounl
5 U.I nome 01 paysr-lnclud. on Ihla IIn. c.pll.1 g.ln dl.trlbulion., nonl..abl.
distributions, otc. ~ ....................................................................
...}1'IJ....L::.............................................................................
.. C.r. .'r...................................................................................
.. tM 13.9.11 f.l;.... I:I!. (0 /:I... .T.N.c."'tl1~7............................................
...........................................,........................,.............,.........
5
............................................................................................
.......................,.............,.....,................................................
.......................,....................,...............................................
........................,.................,....,.......................,...........'........
............................................................................................
........................................................................................~...
I
6
fEO 692
.,. ,
'.
.' ,
.
'SCHEDULE E
(Ferm 1040)
OMO No, '~"S'OO"
Supplemental Income and Loss
(From ronlol reol e.lale, royalUee, pertner.hlpe, e.lalee, Iru.I., REMIC., elc.)
~ A<<ach to Fonn 1040 or Form 1041.
~ Saalnatrucllona for Schadulll E IFonn 1040).
~@92
:,1":,
:' ,
AII.c.hment 1
StQL.tInc.e No. 3
Your loclal security numb.r
i~!O
Income or Lo.s From Renlol Roa Estolo and Royalllo. Note' Roperl Income ond o'ponso. Irom the ronlol 01 person.I
proporlyon Schedule C or C.EZ, Ropo" I.rm ronlollncomo or lo.s Irom Form 4835 on page 2, line 30.
D.p"'~"ID'lhrlT"..uty
1"1.'nal"h.I'IUe~. en
Namel') shown on return A
cJt- oJ- mil
1 Show the kind and locallon 01 each renlol rest e.lole property, 2 For each ronlol raal oslalo Yes No
A '~~.i'~~':,~~~';:';:""'Pi''{'''''''' ........................... property 1I.lad on Iina 1, did you X
or your family usa il for per.onal A
B purposas lor more than the
.....,.......",.,..........,.,............,..,..,.,..,..,.....,.,.....,..,..,., grealer a. 14 days or 10% of Ihe
lolal days renled at fair renlal B
C ..........""".,..,...............,...,........."",...,.....,............,.. valua during tho tax yaar? (See
page E.l.) C
Income: Properties Tolol.
A B C (Add column. A, B. and C,I
3 Renl. received. , . 3 lIOn 3 I
4 Rovellles received 4 4
Expensee:
5 Advertising . 5
6 Auto and trevel (see page E.2) 6
7 Cleaning and malnlenance, , 7
6 Commissions . , 8
9 Insurance . . 9
10 Legal ond olher professional fees 10
11 Managemenl fees. . 11
12 Mortgage Interesl paid to banks,
elc. (see page E-2) 12 12
13 Olher Interesl . , 13
14 Repairs 14
15 Supplies . . 15
18 Taxes . . . . 16 /Io/'"
17 Ulllllles 17
18 Olher (list) ~........................
....................,..................
......................~.........,..,... 18
............"...,............,....,... ~
19 Add lines 5 through 18 . 19 IJI'l(;., 19
20 Depreclallon e.pense or deplellon
(see psge E.2). . . . . . . 20 20
21 Totale.penses. Add lines 19 and 20 21 1106
22 Income or (loss) from renlal roal
eslale or royally properties.
Sublraclllne 21 from line 3 (renls)
or line 4 (royallles). lf Ihe resullls (ro)
a (loss), see page E-2 to find oul 22
If you musl file Form 8198. . .
23 Deduclible rental real oslale loss.
CauUon: Your rental real sstale
loss on line 22 may be limited. Soo
page E-3 to find out if you must 23 b )( )
fila Form 8582. . . . . . .
24 Income. Add poslllve amounls shown on Iino 22. Do nollnclude any losses. 24
25 Losses. Add royally losses from line 22 and renlal real eslale lossos from line 23. Enter the lotal. "
losses here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .' 25 ( )
26 Total rental real estate and royally income or (loss). Combine lines 24 and 25. Enler Ihe resuil here.
lf Parts II. III, IV, and line 39 on page 2 do not apply to you. also enter this amount on Form 1040. (Go)
line 16. Olherwlse. Include Ihls amount in Ihe tolal on line ~O on paae 2 . . . . . . . . . 26
For Paperwork Reduction Act Notice, leI Form 1040 InstructIon.,
Cal.No t'3.t4L
Schodule E IForm 1D40) 1992
rED 699
"
."
F
0,
I
m
1040
Label
(S..
Inllrucllon.
on p.g. 12.)
U..lho IRS
I....'.
Otherwlsl,
pl.... pMnl
or typ..
Pruld.ntlll
EI.otlon comr.lgn
(S.. p.g. 12.
1
2
3
4
Filing Stalu.
(S.. p.g. 12.)
Ch.ck only
one box,
Ex.mptlon.
(S.. p.g. 13.)
II mora th.n IIx
dependentl,
... pllg. 14.
Income
Allach
Copy Bofyour
Form. W-2,
W-2G. and
lll1l9-R h.r..
II you did no!
get a W-2, 1.1
p.g. 10.
II you .re
.".chlng .
chIck or money
orde,. put tt on
top 01 .ny
Form. W-2.
W-2G. or
l099--R.
AdJu.lm.nl.
to Incomo
(S.. p.g. 20.)
AdJu'l.d
Gro.. Income
0200 TlnK.y
Oepartment of the Treasury - Inllrnal Revenue ServlcI
U.S. Individual Income Tax Return
1993
illS Uu Onlv _ Do nol w,Il1 or Itapl,ln Ihl, ,pIC'.
01010 No. 154&..0014
Forlha .., Jan. , _ D.e, 31 1013 or othilia. .., b. Inn!
'1I1131ndln
..0
L
A
B
E
L
YOUI loclal..cu,IIV numbll
162-22-0620
H
E
R
E
PAUL FORNEY
MARY FORNEY
350 LOCUST POINT RD,
MECHANICSBURG, PA 17055
Spall..'. loclal"CUllly numb"
159-24-9515
For 1'I1..cy Acl.nd
P.p.rwork R.ductlon
Act NaUee ... .. 4.
V.. No Nol.: Chic kIng .v..'
X will nol chang. )'OUI
1&11 01 "dun your
X ,.Iund,
II
IIa
.. Doyouw.nlS3logoIOlhl.lund? .............
, Ue oint return, dOli ur IOU'. want 53 to Q to thl, fund?
Slngl.
X MarM.d filing lolnt relurn (.v.n It only on. had Incom.)
...."I.d 'Ulng ..p.rala ,.Iuln, Enl., ,pou..'. lotllllucu,llv no, abovI and lull ".m. hili, ...
Haad 01 hou..hold (wllh qulllfylng p.roon). IS.. P'._ 131 IIlh. qualifying p.roon la . child but nol your d.p.nd.nl,
.nlll thl. child'. no.me hll.. ~
Oulll n wldow.r wllh de .ndanl child .." ou.. dl.d ~ 19 . Se. a . 13.
Yours,If.1I your parent (or lomeone Ille) can claim you a. a dependent on his or hlr tax }NO' or bou.
chac:hd on e.
return. do not chick box Be, But be lur. to check the box on IInl 33b on page 2 and lib
X S DUll ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dependent.: cf',t PI II IgI I 01 old." (41 a.pand.nt', m1!1~I~~.I~~d No, of VOUI
t Ham. fl"t,lnlllal.andIUlnam. und., .oc:I::=:=,~~n~'~mb.r 1t1.1I0~~hIP10 Invou,homa :Wh~~'.nonlSll
2...
b
o
. llwld wllh you
. dldn" lIy, wUh
~fv~1f. Jr
~:G:'rl\on (...
aapandln'l on lie
nolanllltd ,bov.
d II VOUfChlld dldn'llIve wllh Vou bull.clalmed.1 )'OUI dlp,ndlnl und.r I prt.1;I' la,..menl, chick ha,. ...
. Total number of Ixem tlona claimed , , . . , . . . . . . . , . . . . .
7 Wllg.., .II.M.., tip., .10. AII.ch Form(.) W-2 ............
IIa r..abl.lnlll.lllncom. (so. p.g. 16). A".ch Sch.dul. B II over $400
b r.......mpllntarell (.e. p.ga 17). DON'T Includ. on IIn. 6.. .. 6b
9 DI.ldend Incom.. ^""ch Schadul. B II over $400 ............
10 Taxable refunds, credit,. or offsell of state and local Income taxal (sea page 17)
11 Alimony received, , , . . , , , . . . , . . , , . , , ,
12 Bualn...lncom. or ~o..). Mach Schadul. C or C-EZ ....
13 C.pllll gain or ~o..). ^".ch Schadul. 0 ...........
14 Capilli glln dlllMbutlon. nolreport.d on IIna 13 (se. page 17)
16 OIher glln. or Qo....).Ad.ch Form 4797 ......... ..... .... ....
lllaTotll IRA dlllMbutlon. .. . . . ~ I b Taxllblellmounl (so. p.g.18
17. Totll p.nalon. .nd .nnuIU.. . . ~ b Tax.bla lImount (ao. page 16
18 Rental real Iltatl, royalUes, partnershIp., S corporatIons, trust., elo, ^UBch Schedule E
10 F.rm Incom. Dr ~o..), M.ch Sch.dul. F . . . . . . . . . . . . .
20 Un.mploym.nt comp.n..tlon (ao. page 191 . . . . . . . . . . . . .
21.Sodalllcurity benefits, , . , . ~ I b Taxable amount (lea paga19
22 Other Income, Usttype and amount- soe pago20 , , . . , . , , , . . . , . . . . ,
Add numb."
~~~~':goD\I~'" 2
7
IIa 2 604.
I!IIIIIIIII'
9 ~ 191.
10
11
12
13
14
111
16b
17b
16 995.
19
20
21b
------------------------------------------------.
4 790.
23 Add the amountaln the far ri hI column 'or Unes 7 Ihrou h 22. ThIll. our total Income ...
24aYour IRA d.duction (..a pllge 20) ...... 2411
bSpou....IRA d.duotlon (... page 20) .......... 24b
26 On.-hlll ol..lI-employm.nll.. (.e. Pllg. 21) . . . . . . 25
26 S,"-.mploy.d h.allh In,uI.nc. d.duc\lon (... page 22) . 26
27 K.ogh retiremenl pl.n and .ell-.mploy.d SEP deducllon . 27
2S P.nalty on ..My wllhdrowlli oh.vlng. .......... 28
29 Alimony paid. Recipient'. SSN ~ 29
------------------------------------------------.
30 Add II nil 248 through 20, These are your total adJultment., , , , , . . , . . . . ..
31 SUbtl.~ IIn\~ltOm IIn. 23hJhl, I. YOUH.dIU.I.d g,o..lru:ol'\" "thle ernounl
rs Ie" an: 050 ana a c ildllvettwlt v"u. Jee page EIG- 0 flndout If you
can cI mine .rned Income Credl'- on ine 66 ",..,."".,." ,.." ..
FOI P.p.'....o'lI A.duellon Ael Nollte, ... up.r.'.lnIIIIlCUon.
30
31
orm
~AUL & MARY FORNEY
Form 1040 1993
32
33a
Tax
Compu-
tallon
(S.. p.g.
23.)
If you w.nt
tho IAS 10
figuro you,
tax,I'1
p.g. 24.
,
Credlta
(S.. p.g.
25.)
Other
Taxea
paymenta
AU.ch
Form. W-2,
W-2G, and
I099-A on
tho fronl.
60
61
Refund or 62
Amount 63
You Owe
SIgn
Here
K..p . copy
of thl, 'elurn
for your
record.,
PaId
Prep6rer's
Use Only
TenKev
162-22-0620
b
Amountfrom IIn. 31 (.djullod oro..lncomo) ... . . . . . . . . . . . . . . . . . .
Check It:DVou we,e 85 or oldor. DOllnd;Dspou,., was 65 or older, DBlInd'Q
Add the number of bO.1I checked above Bnd enlllr thelotaJ hel. , . , . .. ... 3341
If your p.ront (or .omoon. 01.0) clln c1.lm you .. . dop.ndonl. chock hor.. ~ 33b
If you are married filing nparately and your spouI.ltemlz.. deduction. or
you are a duaJ"ltatul allen, aell paoe 24 and check he,. . , . I . , . . . ... 330 0
{u.mllOd doductlon. from Schodulo A,lIn. 26, OR }
Enler Stand.rd doductlon .hown bolow for your filing .t.lu.. But If you chockod
the ant' bale on Ifne 33a or b, go to page 24 to find your standard deduction.
large' If you checked box 330, your standard deduction II zero,
01 0 Slnglo - $3,700 0 H..d of houlOhold - $5.450
your: 0 MII,ri.d filing JolnUy or Qualllylng wldow(or) _ $6.200
o Mllrri.d filing ..pllr.I.ly - $3.100
Subtr.ct IIn. 34 from IIn. 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If Iln. 321. $61,350 or I.... multiply $2.350 by th.lotlll numb.r o'o..mptlon. c1ll1m.d on
Ilnl el. II line 321, over S81 ,350, see the worksheet on page 25 for the amount to enler .
Taxlbl.lncome, Subtr8C1l1ne 38 'rom line 35. If line 38 Is more than line 35, Inter -0-. .
Tax, Check If from aOO T... Table, bD Tn R.leSch.dul.., 0 D Sch.dul.0 TnWoIIl-
Ihlll, ord D FOlme0151...pagla5I, AmountfromForm(l) &814 ~ e
Additional tax.. (..0 p.g. 26). Chock II !rom .0 Form 4970 bO Form 4972. . . .
Addllno.38l1nd39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ~
Cr.dlllor child IInd dop.ndont c.r. .'p.n.... AII.ch Fonn 2441 41
Cr.dlt lor tho old.riy or tho dl..bl.d. AII.ch Sch.dulo A . . . . 42
For.lgntaxcrodll.AllllchForml116 ........... .... 43
OIh.r crodlt. (... ~ 26). Ch.ck IIlrom .0 Form 3600
bO Form6396oU Form 6601 dO Form (.poclfy) 44
Add IIno. 41 through 44 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtr.ct IIn. 451rom IIno 40. IIl1n. 45 I. moro th.n IIno 40. onl.r -0- .. . . . . . . . .. ~
S,"-.mploym.nt tax. Au.ch Sch.dulo SE. AI.o, ..olin. 25 . . . . . . . . . . . . . . . .
AlI.rn.UvomlnlmumtllX.AII.chForm8251 ........................
Recapturetaxe8 (,.. pag. all). Check If from a D Form 4255 bD Formll"1 cD Form8112a
Soclal..curity IInd M'dlc... tax on tip Incom. not ..port.d to .mploy.r. AU.ch Form 4137
Tax on qusllflod ,.Ur.m.nt pl.n..lncludlng IRA.. II roqulr.d. III1.ch Form 6329
Advance earned Income credit payments 'rom Form W-2
Add IIn.. 48throu h 52. Thl. I. our lotal tax
32
l:jj;I'"
,111:'I'IIi
+'1'
11'1'1;'11'
1l'I,lll'illi",
"III'
l'illl'I'
!h1"I'
ill:!,r:I!I:
'h",.
I,;LI!,I,
34
l'l'llli'lll'
!IWI!
36
Pa e2
4 790.
o
34
36
36
37
38
39
40
41
42
43
44
46
48
47
48
49
50
61
62
63
54
66
66
lS7
I58a
66b
59
........ ~
54
F.dlrallncome In withheld. If anv II hom FOlm(,) 10g0, chlcll ...
1993 1,lImalld In p.ym.nt. and amounlapplled Irom 1C1g211lurn
earned Income credIt Attach Schedule EIC . , , . . ,
Amount paid with Form 4666 (o"'.n.lon r.quo.l) . . . .
Eleen loclarucurlty, Mldlcarl, and nATA lilt wllhhlld (III page 21)
D.f.rral 01.ddltional1993Iax... AUllch Form S641 . . . . . . . .
OIh.r p.ym.nt. ('.0 p.o. 2S). Ch.ck IIlrom 8 0 Form 2439
bO Form 4138 ...... . . . . . . . . . . . . . . . . . , ,
Add IInel 64 throu h 69, These are our total . menta , . , , ,
If lIne eo II mor. thanlln. 53, ,ublrlcllln. 53 rrom tin. SO, Thllllthl .mounl you OVERPAID
Amount ollln. 81 you wllnt REFUNDED TO YOU
Amount olllno 61 you w.nt APPLIED TO YOUR 1994
ESTIMATED TAX ..................... ~ 63
If IIno 531. more than IIn. 60. .ublr.ct Iln. 60 Irom IIn. 63. Thl.l.tho AMOUNT YOU OWE.
For details on how to pay, IncludIng what to write on your payment, aee page 29 ",..
Estimated tax enal see a e 29 , Also Include on line 64 65
6 200.
-1 410.
38
37
4 700.
0,
154
55
55
67
588
55b
~
~
~
38
39
40
:111'1111
111,111
1;llillll
46
46
47
48
49
60
51
52
63
,llilli'llll'
,"111'1111111
'l,ill'II'
',I" !
i '11'1 11,,'1.
11"111<
'l'I,II',il',',
; .'111
il,.il,I"'.',.I.
"1"1"1
'111'ii
'!I'il'lllll
JI,!]dll:
60
61
62
o.
69
6S
0,
o.
o.
o.
Undll penalUu of perlutv, I deer." that I nlY. ...mln.d Ihll raturn.nd accompanying IChldul.. and .tltemlnh, and 10 Ih. bll' of mv .nowlldg. and
~lle'llh'V 11..ru., cOlfeel, and compllle, O.cl.,aUon 01 prep."r lolh.' lh.n I..p.~.t) II bu.d onaUlnform.Uon Dr which prep'"' ha'anv knowlldge.
You, ,llInalure Dlt. Your occupaUon
RETIRED
~ Bpou"'1,Ign.lure.If alolnl r.turn, BOTH mUIIII;n. Oala ;:~~;:; ~c~;;llon '
~ 'Ai Oal.
Preps",'1 (t-J .-c-13t n..- Chlcllll
II ".Iura _--" _ I '1 J I, o.J "U~emplo 'Id
Flrm'l nama (01 VOUI.
U ..lr.lmploYld) and ~
add"" ,.
---------------------------------
-------------------------------------
For Paplrwork Rlductlon Act Nollce, II. "p.,.,.ln,lruclionl
"'-V t
.'
'.
Schoduloo A&B
Ham'lll.hown on FOlm '040,
PAUL & MARY FORNEY
OMD No. 1645-0074 _.'~
YoulSoclal8lCUIII~ humb"
162-22-0620
Part I
Interest 1
Income
(Soo
pog.. 16
ond B-1.)
Nolo: If you
IIcolvod a Form
l099-INT, Form
1099-01D, Dr
.ubll1ltuto
.tlt.m.nt from
a brok.rage firm,
1111 tho flrm'o
name a. the
payer and enter
Iho tolollnteroll
.hown on thot
form.
2
3
4
Part II
DivIdend
Income 6
(Soo
pog.. 17
and B-1.)
Noto: If you
recalved a Form
t 099-DIV Dr
.ubl1ituto
atatem.nt from
a brokerage
flrm.1I111ho
firm's name .a
tho payer and
onter tho 10101
dlvldond.
shown on that
form.
Part III
FQrelgn
Accounts
and
Trusts
(Soo
pago B-2.)
0200 T.nK.y
Schedule B - Interest and DivIdend Income
Allachm.nl
S.qu.nc. No, 08
Not.: II you had over $400 In lalllbl.lnterllt Incom., ou mUlt a110 com lete Part III.
lnlerllt Incom.
U.t name of payer, If any Intefllt Income II from a ..lIer-fln.nced mortgage and Ihe
buy.r Uled thl property a. a personal ".Idence,'" paO' B-1 Bnd lilt lhle
Int.r..t firat, Alia ehow that buyer'e eoefll secuflty number and addr... ...
FARMERS TRUST CO
?=~~~=~======================================:=:
Amount
692.
1 912.
-------------------------------------------------
------------------------------------------------.
-------------------------------------------------
1
-------------------------------------------------
-------------------------------------------------
-------------------------------------------------
-------------------------------------------------
-------------------------------------------------
-------------------------------------------------
-------------------------------------------------
-------------------------------------------------
Add tho amounts on Iino1 .,...".........",.......,..
Excludablolnloroll on ..ri.. EE U.S. ..vlng. bond.llluod after 19B9 from Form
8816,lIno 14. Vou MUST a<<ach Form BB15 10 Form 1040 .............
Subtroct IIno 3 f,om IIno 2. Enter tho r..ull h.ro IInd on Form 1040.lIno Ba . . . . .
Note: If u had over $400 In rO'1 dIvidendi and/or other dlatrtbutlone on atock.
Dlvld.nd Incomo
UII namo 0' pllyer. Includo groll dlvld.nda andlol othor dlllributlon. on otock
h.,.. Any c.pllol goln dlotributionl and nont..ablo dl.tribuUon. will bo d.duct.d
on IIn.. 7 and 8 ...
LIBERTY HIGH-I-N-C-O-ME----------------------------.
?y=~~===========================================:
2
2 604.
3
~ 4
u must com lete Part III.
2 604.
Amount
208.
983.
-------------------------------------------------
-------------------------------------------------
II
-------------------------------------------------
-------------------------------------------------
-------------------------------------------------
------------------------------------------------.
-------------------------------------------------
------------------------------------------------.
----..--------------------------------------------
-------------------------------------------------
6 Add tho amount. on IIno 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
7 Capllol goln dlltrlbution.. Entor h.,. and on Schodulo C.. . . .. 7 1111111!1!i!1
8 Nontaxable distributions. (See thelns1. for Form 1040, line 9,) . ., 8 illl:lii!!:
9 Addlln..70nd8 ......................... e
10 Subtroct IIn. 9 from IIno 6. Enter ther..ull hi" IInd on Form 1040.lIn. 9 ~ 10 1 191.
. 11 you r.c.lvod capllol oaln dl'lrlbuUonl but do not n.od Schodulo D to IIpOri ..ililll'll'iiilll'i'iHI'!iII'III!illil'II"I"'Ihllli/ ;'II"!IIII!III
an other alna or 10lses, aee th.lnstruct!onl for form 1040, IIn8113 and 14, idijL[,!1i1ii [liil!ll11:lil!lilt li,I:::i1i!liH<:\ii:il !III
If you had over $400 of Interest or dividendi OR had a foreign account or wore a grantor a', or a Iflnstetor
to. a fotel n lrult, au must com lete this art,
11. At any time during 1993, did you have an Intereslln or a a1gnature Dr other authority over a finandal
account In a foreign country, such 8S a bank account, securities account, or other financial
account? See page B-2 for exceptions and fHing requirements for Form TD F 90-22,1 .", , , , , , . . . . . ,
b II.VeI,. enler lhe name of the foreign country ~
12 Were you the grantor of, or transferor to, a rorelg~ t'~slih;t ;xist~d du~ng 19931~h;jh~;-o~;:;-ot - - - - - - - - -.
au have an beneficlollnlerest In II? If .Ves,. au ma hove to file Form 3520, 3520-A, or 926 "".."...
1,191.
For r.p.'....ollt n.dutUan Act Hallet. ,.. up.III.lnlllucllonl
" '
. "
, ,
Supplemental Income and Loss
(From finial r.al ..lal., royoll.., portn.rohlp., 1993
S corporaUonl,l.tatll,lrUIII, REMIC" ate,) AII.ehmenl 13
g~:,~~"j::~.D~ul:;:,'~:~U'V .. Attach to form 1040 or Form 1041. ...seeln.tr Jolla"_ rar Schedul. E Form 1040 . S.qIMMe ND,
Nom.(.) .~own on fllurn Vour .oclal ...urlty numbor
PAUL & MARY FORNEY 162-22-0620
Part I iil'IW Incoma or LOBI From Ranlal Raal Ellala anel Royaltlol Not.: A.pM Incom. IInd ..p.n... from your bulln... of r.nUng
OMB No. 1645-0074
SCHEDULE E
(Form 1040)
o."onol OIOO.rtv on Sch.dul. 0 or O-EZ I... .... E-Il. A.non f.rm r.ntollncom. or lOll from Form 4lI3B on 0.0. 2.lIn. 30.
1 Shaw the kind .nd 10c.Uon of ..ch r.nlal r..l..l.l. .ro.orty' 2 For oach rental real ..'.te V.. Na
A ARM LAND AND BARN prop.rIy lI.t.d on IIn. " did you
~ECHANICSBUR-G--PJ\---------------------- or your I.mlly uu It for p."onol A X
a purpose. for mor.than the
.-------------------------------------- gr"l.r 0114 d.y. or 10'1(, of the
total d.y. r.nl.d .1 folr r.ntal a
0 --------------------------------------- .alu. during Ih. tex y..r? (S..
p.g. E-l.) C
Incomo: ProaerUe. Tolal.
A B 0 IAddcolumntA.O,andO,1
3 Rentl received .. . .. . .. . . . 3 2.200. 3 2.200,
4 Roveltl.. r.c.I..d .. . .. . . . 4 4
Exponlol: : II ~ I:! I! I
I Ad..rtillng . . . . .,. . .. . . . B III!!!!!I!,
B Auto and tr...1 (... p'O. E-2) . . . . B :IIIII!II
7 Ol..nlng .nd malnt.n.nc. . .. . . . 7 111"1'
8 Oomml.llon. ..",.... . . . B 1!:i!II! i!
Iml" 1'1
8 Insurance "....., . .. . . . 0 ,11!:;li II
10 L.gal and olh.r prol..lI.nll f... . . . 10 IIII!II'II!
IIVII,
11 Management fen ......, . . . 11 :!'Iili;l,
12 Mong.g.lnl.r.at pold 10 b.nk..
.10. (... p.g. E-2) . . .. . . . 12 12
13 Oth.r Inl.,..l . . .. . .. . . . 13 IIIII1111I
14 R.palr. .. . . . ., . .. . . . 14
lB Suppll.. ., . . . .. . .. . . . lB
lB lUll .. . . . .. . .. . . . 16 1 205. III:III!IIII
17 UUllti.. . .. . . . .., , .. . . . 17 1,111'11'1
II Oth.r Olat)~ ------------.. I:'!III
11.1 ;
-------------------- :1111,':li'
16 ",\\"1,'
-------------------- I;,'I;'!II'
II'illl'l'"
-------------------. ; i:lj!!II'
IhJ:i:i!
10 Add IIn.. 51hrough 16 . . . .. . . . 18 1 205. 10 L205.
20 Oepreclatlon I.pen.. or depletion
(... p.g. E-2) . ,.".'., . . 20 I
21 Tolol ..p.n.... Add IIn.. 18 IInd 20 . . 21 1.205,
22 Incom. or 0011) from r.ntol r.1I
.at.l. or royalty prop.rtill.
Subtraet IIn. 21 from IIn. 3 (I.nl.)
or IIn. 4 (royolU..). IIlh. I.'U~ I.
. 0011), ... pJg. E-2 to find out
If you muat fiI. Form 8186 . . . . . . 22 995.
23 Oeductlble rental real astale 10sl.
CauUon: Your rental ,eal estateloas
on IIn. 22 may b. 1Im1I.d. S.. p.g. E-3
to find out It you mUlt file Form 8582 , . 23 O. O. O.
24 Income. Add pOsltlv8 amounts shown on line 22. Do not Include any 101'81 , .. . .. . . . . . 24 995.
2B Lall.., Add royalty 101se. flom line 22 and rental real estate losses from 110123. Enler the total
10.... he,. ",.", , .. . .......'" , .'"",...,. . ",.". , 25 O.
28 Total rental real Il1al. and royalty Income Dr pon). ComblneUnes 24 and 25. Enter the relult here.
If Partlll, III, IV, and line 39 on page 2 do not apply to you, also enter thl. amount on Form 1040,
line 18. Otherwise. Include this amount In the tolal on Une 40 on Cloa 2 ,.. , .. . ".,. , ",., . 2G 995.
hnK.V
FOfPlp.''l'Work ".d~lIon Act Nolin, ... ..p.rlt.l"allucllo"1
Form 1040 Sch.dul. E (1993)
': '
Passive Activity Loss LImitations
OMII No. 1&4&-100B
Form 8582
1993
"" See .ep.rlte In.ttuGtlonl.
~ Altach 10 Form 1040 or Form 1041.
:~Ia~~::n~o. 88
Ida"t1I~lnD numbal
162-22-0620
O.pallm.nl 01 lh. TIU.UIV
Inla.n" na"nu. S.''fIU
NalM('. ,ho""non ..Ium
PAUL & MARY FORNEY
1,' pal1ll!111I1 1"3 pe..l.e AcU.lly La..
. CauUan: See thelnltructJonl for Work.heet. 1 and 2 on a e 7 before com lotin rart I.
Rontal Ro" E.lale AcU.IU.. With AcUvo Plrtlclp.llon (For Iho d.finlUon of IIct1'0 pllr1lclpaUon
.00 AcU.o PertlclpeUon In 0 Ronlal R.el E.lal. Acll.lly In Iholn.lructlon',1
1 I ActI.IU.. wllh nollncomo (from Work.hooll, column (0)) .
Ie
b Actlvltl.. w~h nolloll (from Work.hooll, column (b))
lb
o Prlor YOlr unallowad 10.... (Irom Work.h.ol I, column (c)) .
10
d Comblno IIn.. 10. lb. ond 10
All Othor Pe..l.o AoU.IU.o
......,.... .
,........,.,....."...,... .
2 0 Actlvltln w~h nollncom. (Irom Work.hooI2. column (a))
2e
b ActI.ltln wllh nollo.a (from Work.h..12, column (b))
2b
a Prlor y.er unallow.d 10.... (from Work.hoot 2, column (c))
20
d Comblnolln.. 2e, 2b, and 20 ...........................
2d
3 Combln.lln.. ld and 2d.II Ih. ...uh I. nollncom. or zoro, ..olh. In.lructlon. for IIno 3. IIlhl.
line and lint 1d are 10...., go 10 line 4, Otherwl.e, enter -0- on Une 9and go 10 line 10 . . . , .
1!!l1'ai1ll1i11, Spocl.1 Allowanc. lor R.nlal Rnl E.lal. With AcUv. Pertlclp.Uon
Noll: Enter all numbers In Part 11 al Dsltlve amounll. See Instruction. on a ,,7 fDr e)lam les.
3
995.
4
4
,:tlill:li!iil
l'I":i'il,
1:'lllli:~lr
:::W1'1
8 [1111,'11:
........ "1"["
III' 'i i! I: I~ 1[' 'I: Ii; ,1:,:; ":"!: i!: 1:1 II i i 'I! I ill! i 'I'll Ii I! I i:: i ':[1111[1 i Iii: 11'1" Ii: :
III Ilil[II,.II,1 iihlli,jllllll:II"II' :II'!III'
ill;!II:'
Subtract line 8 from lIn" 5 .....,.,.,."..,."..,....., 7 :1.1:1111:
Multiply IIn. 7 by 50% (,5). Do not .nlor more Ihan $25.000. It morrl.d filing IOparlll.ly. .00
Instructions ,.....,.,..
Enter 1he ImlUer of thelDIS on line 1d Dr Ihelols on line 3 .,.."...,..
,..,...... .
5
Enter $150,000. If married filing suparatel)', see Ihelnstruct!onl . .
5
8
Enler modIfied adjusted gross Income, but nolless than zero (seo
Instruction.) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Naill: If IIn. 8 I. equal to or gre.lor Ih.n IIn. 5. .klp IIn.. 7 IInd O.
ont.r -0- on IIn. 9, and then go 10 Iln. 10 Oth.rwl.o. go 10 IIno 7.
7
8
II
9
Enter Ih" .maller of I1no 4 or line 8
9
o.
I'! part' 11I'1 Tolal La.... Allow.d
10
Add Ihe Income. If any, on IIn8l18 and 28 and enter thelDtnl
10
""...,.".."".,..,'" ,
11 Total 10 lies allowed from all p...lv" Ictlvltles for 1993. Add IIno. Q and to. SeD th"
Instructions to find out how to report the 101l8S on your IIlI( relurn. ".,.",.,.,.".""... 11
o .
TanK.V
For r.pllwollr R.ducllon Act Nolin. ...lnallucllon.
Form 11582 (1993)
'I ;,
ALTERNATIVE MINIMUM TAX
Passive Activity Loss Limitations
OMU No. 1541l-1000
Form 8582
1993
alp,'lmlnl of Ihl TI..IUIV
Inllfnal Revenue ','vln
Namt(ll'hoWnon liMn
PAUL & MARY FORNEY
I ' Part' 1,,11'1 1"3 Pa..I.. AolI.lly La..
I, 1 " Caution: S.. thllnltructlonl for Work.heet. , and 2 on a 17 befall com letln Part l.
R.ntal R..I E."". AoU.III.. Wllh AolI.a Parllolpallon (For Ih. denn'Uon of .011.. p.r1Iclp.llon
... Aotl.. Partlolpatlon In a R.n"'l R..I E."'l' Aollylly In Ih. In.truc1lon.,)
.. See lepsrl'l In.tructlonl.
~ Attach to Form 1040 or Form 1041.
~~I'~~::"~o. 88
Idlnllr~tngnumb"
162-22-0620
o Prlor ye.r unallow.d 10.... (from Worksh..II, column (el) .
10
li'liII'!!1
::!I,l::'I::
~!!:I! [I ! I!
',lii-!!IIIl;
1",'111
995 '11',1
. 1)"111
li:II[I::1
1'111111:
lil'I'a,'I'I:I:,
:'1",,11
!llllld!
dlil;1
1 a Ao1IylU.. with net Income (from Work.heell, column (.11
I.
b Ao1IylU.. with n.t 10.. (from Work.heel,. column (bl)
Ib
d Combine IIn.. 1a, 1 b, and 10
All Oth.r pa..ly. AcU.IU..
,....,...."...,...,....".,.,.......".. .
2 a Ao1Iyltl.. with nellneome (from Work.heel2, column (.11
2a
b Ao1I.IU.. wOh n.t 10.. (from Workoh..12. column (bl)
2b
o Prlor y..r unallow.d 10.... (flam Work.h..12, column (el) .
20
d Combln. itn.. 2.. 2b. IInd 20
.."".."....,.,.,.......... .
2d
3 Comb/n.lln.. ld and 2d. If tho r..ulll. n.llncom. or zoro, ...lh.lnllruo1lon,'or IIn. 3. If Ihl.
IIn. .nd IIn. Id .r.lo..... go 10 IIn. 4. OIh.rwl.., .nt.r -a- on lin. 9 .nd go 10 IIn. 10 . . . . . .
I'IP rtl:l!illl Sp.elal Allowane.lor R.n"'l R..I E."'l. With AoUy. Participation
:I, .. Note: Enter all numberlln Part II al olltJve amounts. S.elnstructlons on . 17 for exam les,
3
995.
4
Ent.r Ih..mall.r olth.lo.. on IIn. Id orth. 10" on Iln. 3 ...............
....... ,
4
',"",',11\"1','"
:I'\:!II:II'I
11;11"1
,,1.1'1"1"'1'
1'1111'
,11111
lill!lllll:i
'.,'II"lllilllll\'1
111.1111'1,'
Iii ! ~
1111'11.11,
8
Enter $150,000, II married filing separately, see the Instructlona "
..."., .
5
o
Enter modified adjusted groas Income, but not lesl than IIfO (see
Inllructlon.) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Not.: IIl1n. 81. .qual to or gr..t.r Ih.n IIn. 8, .klp IIn.. 7 .nd B.
.nt.r -a- on IIn. 9. .nd Ih.n go to line 10 OIh.rwl.., go 10 IIn. 7.
6
lil:iill!'[illjil[!ill!:II@'llli,lllillli'[!:lil!II!1i
1,;1..11 ,,111,1.11;<1 li!;!,!:;.II,I'::11
7
o
Subtr.ct IIn. 0 from IIn. 8 ...............,........,... 7
MulUply IIn. 7 by 60% (,6). Do nol.nter more Ih.n $26.000. If m.rrl.d filing ..p.r.t.ly, ...
Instructions ,..,..."..
6
9 Enter the .mlll.,r of line 4 or line 8
1:1 Part! III: I To"'l La.... Allow.d
9
o.
10
Add the Income, " any, on Ilnlla 1 Band 28 and enter the total
,..,..,.,."".,....,..., .
10
11
Total 10.... allow.d Irom all pa..I.. Ictl.IIf,,'or 11l93. Add IIn.. 9 .nd 10. S'.lhll
Instructlonl to find out how to re art the 10lses on our lax retuln. ,."."",.
,."....", .
11
o .
T."I(.~
FOI raplIlItOl1l. n.ducUon ,A,I Nolin, ..llnllluellonl
Form 11!162 (11l93)
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
i.
J
III
.___.FR!;;ilA ACRL_ ____._
-----_._._._,-.~ ---------,...-- ---
--- -.-.------..
b.lng duly _S.WC.l:l1.-______ .ccordlnl1lo I.w, d.po... .nd "Y' Ih.1 she -J.s.-tha..ExecutJ:ix__
---------.-- ---- 01 Ih. E...,. 01 ~UL W. FO!lliEY
1.1. 01 -.Silver. Spring. Township ____ ___, Cumberl.nd County, P.., d.c....d end thot tho
within Is.n Inv.nlory m.d. by __heL..__._._..___ "__ _.___, tho ..ld-Exec.ut.r.ix
01 tho .ntlre ..1.1. 01 ..Id dec.d.nl, con.""ng 01 .lIlh. perianal prop.rty and raal ....I., ..c.pl real estal. outsld.
tho Commonweallh 01 Penn.ylvanla, and thot Ihe flguro. oppo.lte .ach Item 01 Ih. Invenlory repre.enl It'. lair value
a. 01 Ihe del. 01 decedenl'. dealh.
Sworn
- and .ub.crlb.d belor. mo,
.~de0 a~
Eucutor . AJmlnht"for
Freda Acri
_3.5.4J.Q...G.W>.L~t Road
'TII~b/~',
_Notar pu~
[ rIot,,!,,! tl~~1
:\1;-,1110 n. M:ir;,1j~b, Not:i:Y Publl:J
H,:;.l :Ullc~btJrD 1:1010. Cuml.ld~r:\nd County
l/iCOlllmir.!Jon fl.plfos Occ, 14, 1998
i.::o.~iUiF,,"",As::oc!i.OOoIOINoL>1os
Oal. 01 Oeoth 11
Day
19 95
MechftnJ..QIilJm.r.g., PenlJ.Sy~ania-Llo.5.5__
Add,,,.
Ogtober
Month
l'l'l.t
V."
INSTRUCTIONS
.1, An Inv.nlnry must be flied withIn Ihree monlh. alt.r appolnlmenl 01 p.rsonal repr..enlallve,
2. A luppl.m.nl Invenlory mu.1 be fII.d within Ihlrty day. 01 dl.cov.ry 01 additional ....ts,
3, ' Addlllon.1 .h.ets mey b. a"ach.d .. 10 p.rsonalty or roally
4, 5.. Artlclo IV, Flduclarle. Acl 011949.
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Inventory of the real and personal estate of
1
PAUL W. FORNEY
deceased
~
I.
PERSONAL PROPERTY:
1. 500 Shares Pennsylvania Power & Light Co., Common, NYSE,
Cusip 709051 10 6, @ $ 19.9375.
$9,96875
~
1
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~
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REAL PROPERTY:
None
None
TOTAL ESTATE $ 9,96 75
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DC.":i.~~.'i1Ar.i!'._IO..I...22.'. O. 5~:g.....".~p.,""MO......~.W...EA..LTH.. O.F. PEN.N.. SV. ~VA. NIA. .
!l'1'..,."'.'-'.,.,...."... ",. h ,"" . '.,DIPARTMINTO. .IVINUI . .... .'
ri~,j;t;..$4'r;~~'!'::cf:!O';ICIAl RICEIPT. PENNSYLVANIA INllERITANCI AND ESTATE TAX.
ACN
RECEIVED FROM, ~ ASSESSMENT P:'
II CONTROL Ii:I
NUMBER
..,','" .....-......,
...... .....,.. ','
.,..
AMOUNT
MC CALEB MARLIN R
e19 E MAIN STREET
101
-19. 'JO
MECHANICSBURG, PA 17030
'CHDH,.,
ESTATE INFORMATION,
J!:II filE M R
~ el-1994-1069
EJ NAME OF DECE~NT
II DATE OF PAYMENT
m POSTMAR DA E
COUNTY
SSN 16e-ee-06eO
(FlRSTI Mil
CUMBERL NO
DATE OF DEATH
REGISTER OF WILLS
.19.70
'- Z
REMARKS
SEAL
FREDA F ACRI
C/O MARLIN R MCCALEB ESQ.
CHECK" 1130
MARY C. LEWI
REGISTER OF WILLS
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!.;~;"i"I..';I. '.OFFICIALRECEIPTe PENNSYLVANiA INHERITANCE AND ESTATE TAX
;:,;,'<.
".:
RECEIVED FROM,
D
ACN
ASSESSMENT I!'
CONTROL iii
NUMBER
AMOUNT
MC CALEB MARLIN R
e19 E MAIN STREET
101
.eSl .40
.
i'"
MECHANICSBURG PA 1700~
;',IOlD Hili
..
. ~
ESTATE INFORMAIION,
m FilE MBER
U el-199 -1069
EJ NAME OF DECEDENr (LASTI
II DAlE OF ~ V
g POSTMAR
COUNTY
SSN 16e- e-06eo
(FIRST) (Mil
'o(DH"r~
t
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REGISTER OF WILLS
('\ . ,'1
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RECEIVED BY J/I/I) , '.' 1;4'''/''
'j' $ "'1."0 .. _
. ..' ( i'-' ,.,
. ~C.I ,. I'{ !f.-II,.. ('f i
MARY C. LEWIS
REGISTER OF WILLS
'iSI 40
61<
I
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,
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r
I
DATE OF D
FREDA F ACRI
m TOTAL AMOUNT PAID
REMARKS
SEAL
CHECl<lI l1e6
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REV~lS47 EX AFP (12-94*
COti1DNWEALTH Of' PENNSYLVANIA
1r~'PAR'"EHT OF REVENUE
~'UREAU OF INDIVIDUAL TAXES
~ DEPT. 180611
HARRISIURO, PA 17121-0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE DR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
ACN 101
DATE 09-25-95
ST TE OF FILE NO.
DATE OF DEATH 10-11-94 COUNTY CUMBERLAND
NOTE. TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUB"IT THE UPPER PORTION OF THIS FOR" WITH YOUR TAX
PAYHENT TO THE REOISTER OF WILLS. HAKE CHECK PAYABLE TO "REOISTER OF WILLS, AGENT"
REMIT PAVMENT TO:
MARLIN R MCC~LEB E5Q
219 E MAIN 5T
PO BOX 230
MECHANICS BURG PA 17055
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
AMount R.nltt.d
/9,' 70
CUT AI.OHI; THIS LfNE ~ RETAIN LOWER PORTION FOR YOUR RECORDS .....
".n..:-,~.~:r-~"'" roo:' ::.-.-.:-:::r-;';.........;'';~..-...:;,~'l:.':,'1~';o-.''~..;.:,':.::';:;.~....~~,-..:,.';.-.:',::~~':":~.- .... .......-- -_...._.._..---~...~,~.~-=~==~:-.!'.!',....--':...
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.\llEV-1547 EX AFP 112"94*
....... COttOMAUtl OF Pf","YlIJAHIA
DE.PARrHEHr Of REYEHUE
, IURfAU OF INDIVIDUAL TAXES
PEPf. Zl06G1
H1RAlSBLRO, PA 111l'~D601
!!J-5-q
NOTICE eF INNERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
ACN 101
DATE 09-25-95
FILE NO.
10-11-94 COUNTY CUHBERLAND
NOTE. TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBHIT TNE UPPER PDRTION OF TN IS FORH WITH YOUR TAX
PAVHEHT TO THE REOISTER OF WILLS. HAXE CHECK PAVABLE TO "REOISTER OF WILLS, AOENT"
REMIT PAYMENT TO:
HARLIN R HCCALEB ESQ
219 E HAIN ST
PO BOX 230
HECHANICSBURG PA 17055
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17013
AMount H..Ht.d
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS .....
iiEii=is4i-Ex-"AFP--fiif:94riiiiYicE--oii"i"NHEifif;,;icE"i:Ax-A-ppiiA-isEifEiiT~--Ai:.rOWANCE"ijR---"----"m_----
DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX
PAUL W FILE NO. 21 94-1069 ACN 101
TAX RETURN WAS, C I ACCEPTED AS FILED I XI CNANGED SEE
ESTATE OF FORNEY
DATE
ATTACHED
09-25"95
NOTICE
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R..l Eat.t. (Schedule Al (1)
2. stock. and Bond. (Schedula DJ (2)
5. Clo..ly Held stock/Partner.hip Int.r..t CSc~l. C) (3)
4. "ortaag../Not.. Receivabla (Schedule OJ (~)
5. Caah/Bank Dapodta/Hilo. P.rlonal Property eSchedul. E) (5)
6. Jointly Owned Property (Schedul. FJ (6)
7. Tran.fara ISchadula QJ (7)
8. Tot.l A...t.
.00
9,968.75
.00
.00
.00
5.011.65
.00
CDI
14.980,40
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Fun.ral Expan.../Ad.. COlt./Hl.c. Exp.n... (Sch.dul. H)
10. D.bt./Hortgag. Llabil1tl../Ll.n. ISch.dul. I)
11. Tot.l D.duotiona
12. N.t V.lu. of T.M R.turn
13. Charitabl./Dov.rn..nt.l a.qu..t. (Sch.dule J)
14. N.t Value of E.t.t. Subjeot to T.x
191
1101
9,325.61
.00
1111
1121
I1S)
1l~1
r,
,j
:1
q .3.:"; 1;1
5,654.79
.00
5,654,79
,f/
,
,
,
/
I
,
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I
NOTE:
If an sssasDment was issued previoUSly, lines
reflect figures that include the total af ALL
ASSESSHENT OFrAX:
15. A.ount of Lin. 14 .t Spou..l rat.
16. A~t of Lin. 14 taxable at Lin.al/Cla.. A r.t.
17. A.ount of Lin. 14 t.xabl. at Col1at.ral/CI... 8 rat.
18. Prlncip.l rax Du.
14. 15 and,or 16, 17 and 18 will
returns assessed te date.
U51
U61
U1I
643.14 X ,03.
5,011.65 X ,06.
.00 X .15.
uel
19.29
300.70
.00
319.99
r
I
,
I
TAX CREDITS:
PAVHEHT
DATE
10-11-94
06-23-95
RECEIPT
HUHDER
SPOUSAL
AA047916
DISCOUNT C.I
INTEREST C-I
.00
.00
AHOUHT PAID
19.29
281.40
INTEREST IS CHARGED FROM 07-12-95 TO 10-03-95
AT THE RATES APPLICABLE AS OUTLINED ON THE
REVERSE SIDE OF THIS FORH
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST
TOTAL DUE
300,69
19,30
,40
19,70
.
. IF PAID AFTER OATE INOICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN .1. NO PAVHEHT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICAI. YOU HAV BE DUE
A REFUND. SEE REVERSE SIDE OF TNIS FORH FOR INSTRUCTIONS,I
.
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RESERVATION. Est.t.. af decedent, dwlne on or ~for. o.c~r 11, 19.' .. l' en>> future 1n'.r..t In the I.,.t. I. tren.f.rred
In pa.....ton or -nJo~t to Cl... I (coll,'.r.l) ~flol.rt.. of t~ decadent .,t.r the I.plrallon of env I.t.t. 'or
11'. or 'or y..r., the C~.lth hlr~V IkPr...ly r...rv.. tn. right to ~r.I.. Iftd ...... t,-nl'.r Inherlt~. ,....
at ttM I.rut Ch.. . (eatht.rat) nt_ on MY wch future In'.nlt.
I'\.IlPClU "
NOTlCEr To fulfill the requlr..-nt. of S.allon 2140 of the Jnherlt~. end Eat,t, 'ax Act, Aot ZI of .991. 72 P.S.
IHUon 1140.
PAYltENTI o.tach the top portion of thl, HatlCt Md IUbIIlt wlth your PIWMnt to the Reallt.t 0' Will. prlntMl on the nv.r.. ,Ide.
...... cMck or .....y anNr p."., tal REGISTER OF HILLS.. AaEHT
AU p'~ts nCllved thall flnt be 1IPP1I1d to MY Int.r..t WItch ..y tM ..... with MY r_lnder .,lIed to tM tax.
RUUKD ItR). , r.,&rId of . tax arMl!t, Wilch .... not ,...-..ted on ttM Tme Rdurn, ..r b. r""",.ted by cOIIPleUna M -AppllcaUon
for A.fund of P~.Ylvanl. Inheritance end [.tata Tax- lREV~ISIS). application. ar. avallabl. at the Offlc.
of thai A....t.r of Will., WlY of tn. ZJ Revenue Dlltrlct Offlc.., or by cellint thai .peal.l Z4~hour
MlWrlnt ..rvlca OUIIben for 'or.. order inti In Pann.w1vWlIII l-100~S'2~ZD50, outalde Pann.ylYMla III'Id
within local Harrisburg ar.. (717) 7.7~I094, TDD' (717) 77Z-2152 (Hearint 1.,.lred Onlr).
OUCTlDNSI Any p.rty In Int.r..t not .athfled with tM ...r.I....,t, .llowanc. or dl..lIovanc. of deduotlon., or ........,t
of tax (Inoludlna dl.count or Int.r..t) .. .hown on thl. Hatlc. lU.t objeot within .Ixty (60) dart 0' rac.lpt of
thh Hatlc. bra
"~"riUM protnt to tha PA Dep.rt""t of .evanua, loard of Appe.h, D~t. ZlUZl, Harrhburll, PA 17ua~I0Z1, OR
....lecltlon to MY' ttM ..U.r d.t".lned .t IlUdIt of the account of thai panonal rapr..ant.tlv., OR
.......1 to the Orphane' Court.
ADMIN
JllllATlYt:
CDRRECTIOHII
INTEREST I
flGtual .rror. dl.covared on thl. ......eant .hauld be addr...ed In wrltlna tal PA Dep.rt..,t of R.venue,
Bur.au of Indlyl~l Tax.., ATTNI Po.t ......eent ..vl... Unit, Dept. 210601, ttarrl,bUrl, P' 171Z'-0'Dl
Phone (717) 7'7~6SD5. ... p... S of the booklat -In.tructlon. 'or Jnherltanc. Tax ..turn 'or I ..,Idant
Decadent- IRfV~.5D.) 'or an .xpl~tlon 0' ~lnl.tratlv.1Y correot.bll .rror..
If any to due II p.ld within thr.. IS) cllendar Mnth. .ft.r thai dac.....t.. cN.th, . flv. parcant IIX) dl,cCllrlt of
the tax p.ld J, .IJowed.
Int.r..t I. charged beGinnlna with flrat d.V of cs.lInquency, or nine (9) .wtth. ~ OM III day 'rOIl tha dat. 0'
..th, to the d.t. 0' PI~t. Tan. which bac..a delinquent bafon J....ry I, 1912 baar Int.rnt It the rat. of
,Ix (6X) percant per ....... cllcul.ted .t . dllb nt. of .DGOI"". All t.n. which ttac... delinquent on Met .ft.r
J~ry ., .,IZ ..Ill b.lr Int.r..t .t . r.t. which will Vlry 'rOIl calendar y..r to c.I~'r r..r ..Ith that r.t.
announced by tha PA Dep.rt..,t of R.venue. ~ appllcabla Int.ra.t r.t.. 'or 1"2 through 1'9S .r'l
DJSCOUNTI
~ Int.rnt R.t. D.lly Jnt.,...t factor ~ Jnt.,..t R.t. DIUr Int.r..t factor
1912 'OX .DDD541 1917 OX .GlDZ47
1911 I~ .ooooa 1'.....". .IX .GODSOl
.... IIX .Donal .". .X .DDU47
nl5 UX .DDDS56 I"J~lf94 n .ODn9Z
.... lOX .DDDZ74 .". 'X . DooZ47
-"Intarnt I. c.lcul.ted .. followll
lllTEllEllT . IALAlfCE OF TAX UNPAID X HUllIER of DAYI DELI"qllEllT X DAILY lllTEllEllT FACTOR
"~Any Notlc. I,eued .ft.r the t.x bacoaa. dlllnquant will r.'llOt an Intlrllt c.lcul.tlon to flft"" (15) dart
berand the dIIt. of tha .....lNnt. If p,pant II aIMM aft., the Int.,..1t ~t.tlon data Ihown on the
Notlc., additional Intar..t IIlJlt be CII1cuhtad.
, ,
'..;",J
..v.W'll........
.
INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH Of PENNSYLVANIA
DEPARTMENT Of REVENUE
IURIAU OP INDIVIDUAL TAXIS
DEPT. 210601
HARRISBURO, PA 17121-0601
DECEDENT'. NAME
5CHSDULI
ITIM
NO,
H
fiLE NUMBER
A
eXPLANATION OF CHANOes
_.l1Ildu..Sectlon_2116 .._inhoritance..Ux. upen.tbo ..tranafer ..of._ proparty-paal1ng.- ---
to or for tho uao of a huaband or wlfe shall be at the rate of J percent
_.Ior_,eatate. _ of...docedoDtB.dy lng..oD. or..af tor .July-l, ..1994, . aAd _lMIfore-.___.____
January 1,1996.
.~-----_-....-----..~ ...-~----.-,--------------_.__..-----------
----------------------_.-...~------_._----_.._--_......_-----
----------...-...-.-------...-------..------
or'
~--------------------_.._-,..------~~----,--------""'------_..----
_..___...__'._...___ ~,_'_"_~"n""_~_.__"~ ._.. ~ .. ._____.~._.. _...~._._____~_.._._._____._ _...____...._.._.__........
.__.-.._-~,,_._-.... -" .-... --_.-.._~_...<..._._.~.. _._,----_.~... -'------_..._..........._--_..:-...._-_..~..._~ -.------
TAX EXAMINER,
~hpf 1 n Mngnnnn11
PAGE
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RI!V-1607 I!X AFP 112-941*
CottttOHWUL TN 01' POttSVLVAHIA
DEPARTttEHT or RfVENUE
IURUU DP' INDIVIDUAL TAlCfl
DEPT. 2.1601
HARRIIBURG. PA 17111-06'1
ACN 101
INHERITANCE TAX
STATEMENT OF ACCOUNT
DATI! 11-06-95
o FORNEY PAUL W FILl! NO. 21 9Q-l069
DATI! OF DEATH 10-11-9Q COUNTY CUMBERLAND
HOTE. To INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBNIT THE UPPER PORTION OF THIS FORH WITH YOUR TAX
PAYNENT TO THE ADDRESS SHOWN. NAKE CHECK PAYABLE AND RENIT PAYNENT TO. "
MARLIN R MCCALEB ESQ
219 E MAIN ST
PO BOX 230
MECHANICS BURG PA 17055
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
AllOUIIt R..Uted
CUT ALONG THIS LINI! ~ RI!TAIN LOIII!R PORTION FOR YOUR FILI!S .....
iiitii=i6'ii'f-iX"Aiip--m-=94y------..ii-iNifiRiTANCir-;:Aif-i'i'jiiiHEri;:-'iiF-A'i:ciiilifi--iii.---------------------
I!STATI! OF FORNEY PAUL W FILl! NO. 21 9"'-1069 ACN 101
TNIS STATENENT IS PROVIDED TO ADVISE OF TNE CURRENT STATUS OF THE STATED ACN IN THE NANED
ESTATE. SHOWN BELOW IS A SUHKARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYNENTS,
THE CURRENT BALANCE, AND, IF APPLICABLE. A PROJECTED INTEREST FIGURE.
DATI! 11-06-95
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT. 09-18-95
PRINCIPAL TAX DUEl. 319.99
PAYMENTS (TAX CREDITS).
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST (- )
10-11-9'" SPDUSAL .00 19,29
06-23-95 AAO...7916 ,00 281. ...0
10-0"'-95 AA082205 ,...1- 19,70
TOTAL TAX CRI!DIT
BALANCI! OF TAX DUI!
INTI!RI!ST
TOTAL DUI!
319,98
.01
,00
,01
. IF PAID AFTER THIS DATE, SEE REVERSE
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
I IF TOTAL OUE IS LESS THAN '1,
NO PAYNENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREOlr" ICRI,
YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORlt FOR INSTRUCTIONS, I
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PA'tItEKT.
a.tech the tOP portion of thh Notice ... .,.It with 1QUt p.,..nt ... peYlble to U. ..- WId ..scir."
prlntM on the raven. ,1M.
If RESIDENT DlCEDOfT ...... cheCk or 1MIM1 or.r p.yIlbl1 tOI REGISTER OP' WILLS, AGENT.
If NDM-RES1DOfT DEtEDEHT ... cMok or 110M. order pa~l' tal cotttONWEALTH OF PENNSYLVANIA.
All p.penta received ...n M .,..1IM flnt to MY intar..' which ..y be due with MY r.-l,.r ."Uad to the tax.
REFUND (CA)I . r.'1oN of . taM credit, which .,.1 not reque,.tad on the Tme Return, ..y be reque,ated by cOIIPldlnl 8ft
"",UC8t1on for A~ftn:I of P......1VM.. Inherltencl .nd E...ta r.... (REV-UIS), Appllutlonl .t. 1IVl111bll .t
the officI of the R..ht,r 0' WUlI, MY of the U Alv"" DlItt'ot afflcII or fr. the __rt-'t'l Z4"hoUr
.,,~rlng ..~Ic. ~r. for for.. ar~rlntl In P..,lvlv.nl, 1-100-56Z-1150, outside pennlYlvenll
end within local Harrlsbur. .t.' (117) 717-1094, fDae (717) 771-Zt5Z (~rlna 1.,.lr. only).
AEPL't TOI Questlonl r...rdlna .rron cont.l,*, on thll notlc. shoUld eM Mldr..'" tal PA DeII,rUMt of Revtlll'lUll. Bur'"
of tndlvl~1 Tax'" ATTNa PDlt A.......nt R.vl.. Unit, DePt. Zla6'1, Hlrrlaburg, PA 171ZI-0611, phDnI
(717) 7.7-6501.
DISCDtlfTI If 111)' tlM due II paid within \hr.. (3) ca'endar 1lDn\h. a,hr tM Me..,t" death, . flv. IMrc.,t (U) dhcount
D' the tlM p.ld I, .Uowd,
INTEREST' Inl....t Ie .....god ",Innlno .lIh lI"t .... of doU........., o. nIno '" _tn. end .... Ul .... I... tho dot. of
..th, tD the dIIt. D' p.~t. T.... which He.- .1I"..,.t befDr' JlI1UIr)' 1, .9IZ bMr Int.....t at the rata D'
.Ix ('X) ,.reent per ...... c.lculated It a dally r.t. D' .000164. AU tax.. which tMc.- dllI~t an and att.r
J....rY 1, 191Z ..111 belr Int.n.t at . ,.at. which will vary frDII calendar y..,. to ca'"'' V_r with \hit rat.
announced by the PI Depart...,t af R.v....... TM 1IPP1IcMtI. Int.,..1t r.t.. fDr 1912 through 1995 .r'l
y... Int.,..,t alh DaUy Int.r..t fllOtC,. y... Int.r..t Rat. u.Uy Int.r..t Facta,.
1911 lOX .aOOMI 1917 'X .OOlt47
I..S lAX .aI14S1 .911-1991 UX .aOUal
1914 IU tOOUOl 1"2 'X .000147
1911 1>X .OOOSH 1995-1994 n .DOn9Z
1914 lOX .a00174 1"5 OX .OOOZ47
"'Int.r..t I' calcul.tad .. 'Dllow'l
I!ITEREIIT . BALAIlCB OF TAll UNPAID X HUKBEA OF DAYS DELIHQUEKT X DAILY INTEREBT FACTOR
._any Matlc. I'~ aft.r tn. tIM beeoae. ~llnquent will r.,lllOt ~ Int.r..t calcul.tlon to 'If teen (11) dav.
blvand the data af \hi ..........t. If p.~t II .1Ide Ift.r the Int.r..t co-..tltlan data IhaWn on tha
Notice, additional lnt.r..t au.t bI calculated.
STATUS REPORT UNDER RULE 6.12
Name of Decedent: ;?t tU.. tv. H/2,.,;ey
Date of Death: 6' d;/u- /it; /Pf~
.
Will No. .:;/_ y~.. I'tJ~.f Admin, No,
pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes )( No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3, If the answer to No, 1 is Yes, state the following:
a. Did the personal reJ(resentative file a final
account with the Court? Yes No .
b, The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in inteJ:est? Yes No k
d. Copies of receipts. releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
du~/? t!d!.~
Signat:.ure
&a.,.1i':' ,(. titd/fJ6
Name (Please type or print)
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Address ' .
(-;1'/7) ~f?/... 77r()
Tel. No.
Date:
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Capacity: personal Representative
~counsel for personal
representative
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