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OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV.1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
p674
NUMB~R
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FILE NUMBER
II 06
~9UNTLCODE_ YEAfL
SOCIAL SECURITY NUMBER
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DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL)
Grenoble, John J.
-----.. . ------... -..----
DATE OF DEATH (MM-DD-YEAR)
208-24-2308
DATE OF BIRTH (MM-DD-YEAR)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
02-25-2006
03-13-1933
REGISTER OF WILLS
-- - ---
----- --
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
X 1. Original Return
2. Supplemental Return
3. Remainder Return (date of death prior to 12-13-82)
4. Limited Estate
4a. Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
LJ 1 O. rn~-~~I (date of death between
I i 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
X 6. Decedent Died Testate (Attach
copy of Will)
_ _J 9. Litigation Proceeds Received
11 Election to tax under Sec. 9113(A) (Attach Sch 0)
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FIRM NAME (If applicable)
Said is, Flower & Lindsay
TELEPHONE NUMBER
(717)?43-6222
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
26 West High Street
Carlisle, PA 17013
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
, Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L) , __! Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
None
None
(5)
(6)
(7)
29,421.00
None
None
\,c
(8)
29,421.00
(9)
(10)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
(11 )
12. Net Value of Estate (Line 8 minus Line 11)
(12)
2!),421.00
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has
not been made (Schedule J)
! 14. Net Value Subject to Tax (Line 12 minus Line 13)
(13)
None
(14)
2!~,421.00
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate, 29,421.00 x .00 (15) 0.00
z or transfers under Sec. 9116(a)(1.2)
0
~ 16.Amount of Line 14 taxable at lineal rate 0.00 x .045 (16) 0.00
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a.. 17. Amount of Line 14 taxable at sibling rate 0.00 x .12 (17) 0.00
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0
u 18. Amount of Line 14 taxable at collateral rate 0.00 (18)
~ x .15 0.00
19. Tax Due (19) 0.00
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Copyright 2002 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00:
Decedent's Complete Address:
STREET ADDRESS
270 Frost Road
CITY
STATE P A
~
ZIP
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
0.00
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C)
(2)
0.00
Total Interest/Penalty (0 + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5) 0.00
(5A)
(5B) 0.00
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property lransferred;.................................................................................. ! i x
b. retain the right to designate who shall use the property transferred or its income;.................................... x
c. retain a reversionary interest; or................................................................................................................. x:
d. receive the promise for life of either payments, benefits or care?............................................................... ix'
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?............ ............. ................... .............. .................................. .......................... x
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.........
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?..................................................................................................................... x,
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury. I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief.t is true, correct and
complete. Declaration off'reparer ottler than thef'"rson~1 rel"eserllativeis bas"d onaU infoImation of.....hichpreparer hasany.knowledge,.
SiGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
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x
DATE
270 Frost Road
Gardners, PA 17324
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, DATE
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SIGNATURE OF PREPARER OTHER THA EPRESENTATIVE
George F. Douglas III
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ADDRESS
DATE
26 West High Street
Carlisle, PA 17013
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a
natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S.
991161.2)[72P.S.99116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116 (a) (1.3)]. A sibling is
defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Rev-1508 EX+ (6-98)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Grenoble, John J.
FILE NUMBER
21-06-0674
Include the proceeds of liligallon and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 Lincoln Financial Group - Long term health care policy payment due to the estate _
(company would not payout benefit without estate being probated)
VALUE AT DATE
OF DEATH
29,421.00
TOTAL (Also enter on Line 5, Recapitulation)
29.421.00
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
REV.1513 EX+ (9-00)
SCHEDULE ..
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Grenoble, John J.
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116(a)(1.2)]
FILE NUMBER
21-06-0674
I.
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s)
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
1
Isabelle M. Grenoble
270 Frost Road
Gardners, PA 17324
Spouse
entire estate
Total
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
Copyright (c) 2002 form software only The Lackner Group, Inc.
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
Form PA-1500 Schedule J (Rev. 6-98)
FieldNet
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Account Lookup
TodaY'$ date Is June 22, ~OU6
Close llVndQW +
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St;larCh'Qr jliew CQntr<J.;;t / Polity
Informatfon Shown 18 liS of 06/16{2006 and COuld differ hased on litH lasl promllJm paymAnt rHC9hffJd, the
policy status, and any policy changlls which may have occurrod today.
'lONG TERM CARE - Ul TRACARE SINGI.E
Policy Information
Policy Number
Product Typo.
Sefl~s'
Issuod by'
~tatus
Insured(s)'
lnsurod(s) Sex:
Date(s) of Birth:
Owner:
14401146
UltraCare SIngle
1999
MM1
CI~lm Pain
JOHN J GRE'NOBLE-
M
03/13/19:l3
.JOHN .J GRENOflll
Promfum Informallon
Single Premium. $1 g, 140.11'1
I
$;/<;j421()(j
ServicIng AgHnt lnformation
ServiCing RORERl .J
^~]er1t
A.slont ID.
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:),~!viclnQ
AI] eil cy
ANI"AN
Ban9fit Information
Monthly A/motit (per
Insured):
DBath Benefit.
$1,22;-' il8
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1)1 ^NGAN~tJf'INSVCS.c()rv
03i
Policy Dates
ISSue Date:
Paid to Date:
AdditIOnal A(Jflnt Inform<ltion
AllUl In: 11;-,'Q;>
12103/2002
N/A
'Additional Information
RIder/OptIon Information
Convalescent Care
Extension of Ben6fJt
.
AddrHl'i15 Information
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AddmS8 2:
City.
StatB, Zip.
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LAST WILL AND TESTAMENT
t John J. Grenoble, of Gardners, Pennsylvania, being of sound and
disposing mind, memory and understanding, declare the following to be my last
will and testament, hereby revoking any and all wills heretofore made by me.
Item 1. I direct my executor hereinafter named to pay all my debts
and funeral expenses.
Item II. I give, devise and bequeath all my property, both real and
personal to my wife, Isabelle M. Grenoble, providing she survives me by thirty
days.
Item III. My wife, Isabelle, and I are the grantors of a joint
revocable trust agreement dated March 19, 2004, with Manufacturers and
Traders Trust Company in Carlisle, Pennsylvania, as the Trustee. The said joint
revocable trust agreement shall be known as the "John and Isabelle Memorial
Trust Fund." In the event my wife does not survive me, or dies in a common
disaster with me, I hereby exercise the power of appointment referred to in
Article I of the aforesaid trust and direct the Trustee to hold the assets of the
aforesaid trust in further trust and continue the trust in perpetuity subject to the
following terms and distribute the income from the aforesaid trust as follows:
A. One -half to Mt. Zion Evangelical Lutheran Church, 4200
Carlisle Rd., Gardners, P A,
B. One-half to Lutheran Theological Seminary, 61 Seminary
Ridge, Gettysburg, P A.
C. If either the Mt. Zion Evangelical Lutheran Church or the
Lutheran Theological Seminary ceases to exist then the
bequest for that organization shall pass to the Synod Church
Council, Harrisburg, Pennsylvania. Upon the death of the
second spouse, the assets of the revocable trust shall go into
trust for the benefit of these two organizations. The trust is
perpetual, and the income only shall be distributed to the
beneficiaries quarterly, and Manufacturers and Traders Trust
Company shall serve as the Trustee.
Said trust shall be subject to the following provisions:
(1). In the event that the foregoing charitable organizations are
not organizations described in Sections 170 ( c ) and 2055 (a) of the
Code of 1986, as amended (hereinafter referred to as the "Code"),
at the time when any principal or income of the trust is to be
distributed to it, then the Trustee shall distribute such principal or
income to such one or more organizations described in Sections
170(c) and 2055(a) as the Trustee shall select in its sole discretion.
(2). The Trustee shall make distributions at such time and in such
manner as not to subject the trust to tax under Section 4942 of the
Code.
(3). The Trustee shall not engage in any act of self-dealing, as
defined in Section 4941(d) of the Code, and shall not make any
taxable expenditures, as defined in Section 4945(d) of the Code.
The Trustee shall not make any investments that jeopardize the
charitable purpose of the trust, within the meaning of Section 4944
of the Code and the regulations there under, or retain any excess
business holdings, within the meaning of Section 4943 ( c ) of the
Code.
(4). The operation of the trust shall be governed by the laws of
the Commonwealth of Pennsylvania. The Trustee, however, is
prohibited from exercising any power or discretion granted under
said laws that would be inconsistent with the qualification of the
trust as an exempt organization described in Section 501 ( c ) (3) of
the Code and the corresponding regulations.
(5). The Trustee, however, shall have the power, acting alone, to
amend the trust in any manner required for the sole purpose of
ensuring that the trust qualifies and continues to qualify as an
exempt organization described in Section 501 ( c ) (3) of the Code
and the corresponding regulations.
(6). Nothing herein shall be construed to restrict the Trustee
from investing the trust assets in a manner that could result in the
annual realization of a reasonable amount of income or gain from
the sale or disposition of the trust assets.
Item IV. In the event that my wife does not so survive me, or dies
in a common disaster with me, I make the following specific bequest:
A. The sum of $2,500.00 to the Kiwanis International
Foundation, 3636 Woodview Trace, Indianapolis, Indiana 46268--
3196.
Item V. In the event that my wife does not so survive me, or dies
in a common disaster with me, I give, devise and bequeath, all the rest, residue
and remainder of my estate as follows:
A. Twenty Five per cent (25%) of my estate to my two
grandchildren: April Marie Broomhead and Steve Broomhead of 21
Columbus Ave., Belle Vernon, P A 15012. If one of them is
deceased, then their share shall go to my remaining living
grandchild.
D. Seventy Five per cent (75%) of my estate to be divided among
my 13 nieces and nephews as follows. If any of my nieces or
nephews shall be deceased, their share shall go to my remaining
living nieces and nephews.
Jacob Charles Sheely, III
818 Merdith Dr.
Media, P A 19063
David William Sheely
411 West Simpson St.
Mechanicsburg, P A 17055
Laura Ellen Sheely
265 Skyline View
Carlisle, P A 17013
Mary Beth Bergey
2840 Louisiana Ave.
Baltimore, Md 21227
Loline Marie Himmelreich
4832 Smith St.
Harrisburg, P A 17109
Charles William Reider
2629 South 3rd Street
Steelton, P A 17113
Pamela Ann Reider
2153 S. 3rd Street
Steelton, P A 17113
Linda Carol Biesecker
691 Winebary Circle
Lewisberry, P A 17339
Loline Elizabeth Saras
312 Trexler Ave.
Kutztown,P A 17530
John William Judge
6205 Patricia Court
Fredericksburg, VA 22407
Elaine Mae Macedonia
314 Loch Lomond
Madison, AL 35758
Ann Louise Masood
13 Georges Place
Fredonia, New York 14063-2122
Marian Leslie Steele
15 Freshfields
Comberbach
Northwich
Cheshire CW96QE
England
Item VI. I nominate, constitute and appoint my wife, Isabelle M.
Grenoble, as my executrix. If she should be unable to serve, I appoint my
attorney, George F. Douglas, III, Esquire, as substitute executor, and I direct that
either of them may serve without bond.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
./'
1'-/ If1 day of
,2004.
(SEAL)
Signed, sealed, published and declared by the above-named testator, as and for
his last will and testament, who at his request, in his presence, in our presence,
and in the presence of each other, have hereunto subscribed our names as
attesting witnesses: 0
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COMMONWEALTH OF PENNSYLVANIA)
COUNTYOFCUMrnERLAND
I, John J. Grenoble, whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instrument as my last will, that I
signed it willingly, and that I signed it as my free and voluntary act for the
purposes therein expressed.
~2t~~
Johh-1. Gre ble
Sworn to and subscribed before me
this I (prti day of
(1'\ OJ.4/
,
, 2004.
NOTARtAlSEAL
KathyL. Mummert, Notary .Public
Borough of Carlisle, Cumberland Co., PA .
My.CommissionExph'es Aug.11, 2007
..
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF CUMBERLAND )
We, ttQJ~"J4,:.:J, ~'\~,9)C}.(r- f/~~ and Ar)"\(mdr.l Dl, ,Y-nJUf\ , the
J / . c. -
witnesses whose names are signed to the attached or foregoing instrument,
being duly qualified according to law, do depose and say that we were present
and saw testator sign and execute the instrument as his last will, and that he
signed willingly and that he executed it as his free and voluntary act for the
purposes therein contained, that each of us in the hearing and sight of the
testator signed the will as witnesses; and that to the best of our knowledge, the
testator was at that time 18 or more years of age, of sound mind and under no
constraint or undue influence.
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Sworn to and subscribed before me
this t ''oj: "'1) of
(t
\<},t1,.
jf
, 2004.
l(t,LtYVLf()rli/;.j
Notary
NOTARIAL seAL
Kathy t. Mummert, Notary ,Public
Borough of Carlisle, Cumberland Co., PAl_
My Commission Expires Aug. 11, 2007