HomeMy WebLinkAbout95-00754
_.ft2.'2~~:;:...~~:>.,:i~
~,
PETITION .'OR GRANT OF LETTERS 0.' AI>MINISTRATION
lis/ale oj Alice lI. Burgard
also known as
No.
To:
c9/- q 5-7 5!:L
Social SecllrllY No,
IJI!('('UJ"tI.
192-32-9262
ReglMer of Wills for Ihe
County of Cumberland In the
Conllllonwellhh of I'ennsylvllnlll
The pellllon of the undersigned respeelfnlly represents Ihlll:
Your pelllloner(s), who Islure 18 yeurs of uge or older, nppl ies__ for ICllers of udmlnlslrntlon
011 Ihc cstnle of
(d.b.n.i Jltnd~nle Ill~: dllranl~ aln~nlla: durante mlnuriullC:)
the nbove decedenl.
Deeendent was domiciled nl denlh In Cumberland Connly, I'cnnsylvanln, wllh
h er Insl family or principal resldcncc III Cumberland County Nursinq liane, Clarem:mt Road,
Carlisle, PA 17013 ClIl' "'.CO. IIl1mll<' .1I~ lI1ulIki""II'1)
Decendenl, then 92 ycnrs of nge, died on Sepj;elnber 19 , 19 9'i ,
at 12:25 AM at Cumberland County Nursing II~-Clarem:mt Rn.olrl, ('..,.HA1". I'll 17013.
Dccendenl al denth owned properlY wllh eSlhllnled vnlues liS folllows:
(If domiciled In Pa.) All personal properly
(I f not domiciled 111 Pa,) Personnl property In I'ennsylvllnlll
(If not domiciled In Pa.) Personnl properlY In COIlIllY
Vnlue of real estate In Pennsylvania
slluated ns follows: Nnn..
S ',nnn nn
S
S
S
Petllloner_ after a proper search hILS- nscerlalned that decedel1lleflno will nnd WIIS survived by
Ihe following spouse (If nny) und heirs:
Name
Relationship
nr:tonn~nn
nrAnnQon
Residence
.250 S, Yox:k Road, DillBburg,
-Joo<lBboro, CliOx:gia
THEREFORE, pelllloner(s) respectfully requesl(s) Ihe 111ll11l of lellers of IIdmlnlSlrnllon In Ihe
upproprlale form 10 Ihe undersigned,
t
"'-
'6 ~
"'f
lij
<>0..
'g'Q
!
Vi
dL~/~/4
Ri"h..ri! M....Lal<..
---2Sn ~ Yn,.k Rn..rl
ni" "\)""g, PA 1701 q
'.
f
i
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLI\ND
H
} 58
"
,'1.", Z,) IH :~jL
The petltloner(s) above.named swear(s) or arnrm(s) that the C".'
stalements In the roregolng petition are true and correct to the best CUI .
or the knowledge and beller or petltloner(s) and thai as personal
representatlve(s) or the above decedent petltloner(s) will well and
truly administer the estate according to law. (-:), II hi..!, J' /
Sworn to or arnrrllcdH and subscribed IJ:.~ _ tJ:."0. ~~
berore!ffi~+~ cbT da?50r Richard M. Lake
,;1
c:./\
i
a
in
No.
21 - 95 - 754
Estate of
ALICE A. BURGARD
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW OCTOBER 11, 19~. In consideration or the petition on
the reverse side hereor. satlsractory ,proor having been presented berore me,
IT IS DECREED that Richard M. Lake
Is/are entitled to Lellers or Administration. and In accord with such finding. Lellers or Administration
are hereby granled to Richard M. Lake
In Ihe estate or
I\lice 1\. Burgard
FEES
Lellers or Administration .,...
Short Certlficates( 2J .' ...' , , . ,
Renunciation "..,...""".,
JCP
I t(' J?71~rt}~ '
R~.hler or Will. (- (/
~J7i)LE~
S 25.00
S 6,nn
S 5.nn
S 5 nn
TOTAL _ S 41.nn
Flied,. ,Ql;TP,B,~~. .1.1..",.. A,D. 19.Jl5-
Paul BradfordAlTORNEY tSup, CI, 1.0, No,) Orr ID No. 71786
7R W. PnnFr..t- Rt-r(...t-, r"r1 i ..1" PI\ 17013
ADDRESS
717-258-8558
I'HONE
Mailed letters and order to Administrator on 10-12-95,
21 . 95 . 754
, ..r
,-'.',',
","
~ I
',"
,j,
'.'1
~
,'"
;"
..
~
c
q
!
21 - 95 - 754
RENUNCIATION
In Re Estate or
ALICE A. BURG1\RD
deceased,
To the Realster or Wills or
Cumber] and
County, Pennsylvania.
The underslaned
Rnnney n. TAke, GrAnnAnn
or
the above decedent, hereby renounec(s) the rlahtto administer the estate and respectrully ask(s) that Lellers
of Administratinn
be Issued to
hand this
WITNESS
Rodney D. Lake
12l! AP-NOLD fLAt.\':
-Jo.n$80(L0 I ~ f\ 30'2..3'-
(Add,ess)
(5Ignalu,e)
(Add,e..)
"~I . J <f'
.- r;-,1 "\ n':
c. '0
co
r:.~
'" (5Ignalu,e)
N
~
<:. "
o ~) ~ .t: (Add,ess)
(UD.: .'2:::1
a: uu
CERTIFICATION OF NOTICE UNDER RULE 5.6/a)
"2:?",rof'''rl
v
Name of Decedent I AI,;,,~ 4.
Date of Deathl 9-/9- 'jr
Will No.
Admin. No. /f9S--CJtJ7S'tf
To the RegisLerr
I certify that notice of beneficial interest required by
Rule 5.6 (a) of the Orphans' Court :Rules was served on or mailed to
the following beneficiaries of the above-captioned estate on
I
Name
~c.'''rl /14. k'-.
Address
:zso
s. Y:...t R./
.
b/'L"..~ ?~ 17419
J
Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except
Datel 1-"Z2 -?t.
s~{?;;/ AI. ~t
Name e:.iu. r/ AI. LtL
Address ZS-O :;5, York 'Rj,
:rA-
f.~ )
r.~
1"1
'A/lrtW]
Telephone(7r71 1",91-1.3~?
Capacity I ~personal Representative
17tJI9
(:.;tIT
.,"-,
~.io
) o.
.. ::J
00
Counsel for personal
representative
NOTICE OF BENEFICIAL INTEREST IN ESTATE
BEFORE THE REGISTER OF WILLS, COUNTY OF ~~, , PENNSYLVANIA
In re Estate of ,4-/, ~l.- A. 8t..1"',Jd.'- , deceased,
No. /.99)- ~f{Of
TOI 72:c.~,-'
25"0 S-
~ 11-, 1 c.. "v
....
IL(. W.
YD'- Ie 72r1.
"FA- /7019
(beneficiary)
(address)
Please take notice of the death of deced~nt and the grant of
letters to the personal representative(s) named below. You may have
a beneficial interest in the estate as follows:
(if additional apace is needed, use back of page)
Name 0 f deceden t A I, ~ -L ,4 . 'Zs- LA ":J d" I
Last known address Lu"./'. ~ N",,..,,;.. J U........u'
J .
of decedent
Date of death
9-19- 9...
L"'.....~ _ CD.
Place of death
!tJur"t; ,\'o
_+J
letters _
/-!O.~
A'~I~I JI'd /'.........
A copy of the will ____ is ~s not attached.
Name(s), addressees) and telephone number(s) of all personal
representatives appointed
Telephone
7/7-t,'JI-13(.j
County of grant of ~iginal
Decedent died ~ testate
intestate.
Name
'le:c.~' M.
t-.L
Address
.4 L,,,~ n
\
o
l
I
I'
II
i,'
,
:.
y
I
t
,
J
!
I~ -
,-
, ~..
Name(s), address(es) and telephone number(s) of all counsel
Name
Address
Telephone
Additional information may be obtained from the undersigned.
Date 1- 2 z- 9t. Signature~,/ 4t. ;.eL
Name '2::d~,..j' /!(, k L
Address z~o 5. ~,., J?./.
D;/i~'''7 ~ /70/9
Telephone 7/7-~9/-1.Y~ 9
Capacity: ~personal Representative
Counsel for personal
representative
-
~
to
t;"_'
1-'';'1
'~'jLt:..
N
c...J
~;.'!
--;
~~J G~
u:
")
P.'
I."
~..5
()O
-\,o~o
\ '~tl..
.,
,,~:fr~'rt\
..,.lll'u.:
.COMMONWfAlfH O' 'fNNSYlYANIA
DEPARTMfNt 0' REVENUE
DEPT. 210601
HAUIS.URD 'A 1712'.060'
IS"-r;t), j
INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
.01 DAnso. DIATH ARII '2/3'''' CHICK Hili
I' A SPOUSAL
POYIITT C"DIT II CLAIMID 0
,ILI NUMBII
)./
COUNIY CODE
RlY.U~ u+ 11P~11
l5
~
e
~
~~~
ala...
.....
...
oC
~l5
!:Ie
OZ
U2
A,
.
~, Original Rolurn
o 4. lImllod Eslalo
.
Ut",
Cd r/';' 1<-
!6-/Z - tJ 'Z- c...,
c.--
QS
07''1
NUMBER
t-f,.,,~,-
YEAR
,{j""~;"'j
/70t'3
o 3, Romalndor Rolurn
l'ar dolo. of doa,h prior 10 12-13,a2}
o 5, Fodoral E.lalo To.
R'lurn Required
_ e. Tolal Number of Safe Deposit Boxes
040,
Supplemental Return
o 6. Docodonl Dlod To.lalo
o 7.
1. Roal E.lalo (Schodulo A) ( I)
2, S'ackl and aond. (Schodulo a) ( 2)
3. Cla.oly Hold Slack/Partno"hlp Inloro.t (Schodulo C) (3)
4, Martgag.. and Nolo. Rocolyablo (Schodulo D) ( 4)
5, Ca.h, aank Dopa.II. & Milcollanoau. Po "anal Praporty( 51
(Scnodulo E)
6, Jalnlly Ownod Praporty (Schodulo F) I 6)
7. Tranofon (Schodulo G) (Schodulo l) ( 7)
g, Talal Gra.. .1...01. (Ialalllno. 1,7)
9. Funeral Expens", Administrative COSh, Milcellaneous I 9}
Expon... (Schodulo H)
10. Dobl., Martgago lIabillllo., lion. (Schodulo I) (10)
11. Talal Dodudlon. (Ia'alllno. 9 & 10)
12, Nol Valuo of E.lalo (IIno a mlnu. IIno 111
13, Charllablo and Gayornmonlal aoquo." (Schodulo J)
\4, Nol Valuo Subod 10 Tax IIno 12 mlnu. IIno 131
15, Amaunl of IIno 14 laxablo 01 6% ralo
llndudo yaluo. from Schodulo K or Schodulo M,)
16, Amount 01 IIno 14 la.ablo 01 15% ralo
(Indudo yaluo. 'ram Schodulo K or Schodulo M,I
17, Prlndpalla. duo (Add to. 'ram IIno 15 and from IIno 16,)
18. Credits Spousal Poverty Credil Prior Payments
+ +
19, If IIno 181. groalor Ihan IIno 17, onlor Iho dlfforonco an IIno 19, Thl. IIlho OVERPAYMENT.
1iI0
20, If IIno 171. g,oalo, Ihan IIno 18, onlo, Iho dlffo,onco an IIno 20, Thl.l. tho TAX DUE.
A. Ent.r the Inlerl.1 on the balance due on Une 20A.
a, Enlo' tho 10101 of lino 20 and 20A an lino 20a, Thl. I. Iho BALANCE DUE.
Mako Chock Payablo tal Rogl.to, of Will., Agont
.. .. SUIlI TO ,\HaWn ALL QUUTlONI ON RIVIIlII IIDI AND TO IIICHICK MATH......", ".' ,,'; - ': :,,,';,
Under penoltle. of perjury, I declor. Ihall hove .xamlned thl. return, Including accomponr1ng .chedule. and .talemenll, and to the be.. of my knowledge and belief,
II I. true, corred and complel.. I declare that 011 r.ol e.tat. hat be.n reported 01 true marllet value. Oeclaratlon of preparer ather than the personal repr..entatlv. II
ba.ed on alllnformollon of which preparer hat any Ilnawledge.
::~t':~Z4i;:l:~~:N 2S-~::~:: ~r-t 7(J. ));//;1..'.1 pA J7~I3' ::~ - U-?7
tit. L
z
o
~
E
~
..
z
o
!i
!;
...
::e
o
u
~
zso j,
Vi 1/.5 ~-u r
/ark
rA
--
1/007.00
( 8)
(11)
(12)
(131
14
(151
K .06.
(16)
K ,15 a
(17)
Discount
Inter..t
(lB)
119)
Check here If you nre 'cquc~llIlg 0 H,.fund of you, overpayment.
(20)
(20.1.)
(20a)
?d,
17~ I 9
o
00,?-
r)
6>
~
00
c
,..".,ci..~ -"::"..>,,,," h:.a",~.G.;.., ",~.~__-.....J....;.~.w-.~~, ..;.;;~.,;.;......~ ::."',,-.,.;...,..~,...,:..~-'-,~;.:.~ o:-:':"~..."~A;':':::,,~..;.:..;.~IL~'
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK (.....) IN THE
APPROPRIATE BLOCKS.
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred, .......................................
b. retain the right to designate who shall use the property transferred or its Income,
~}
:f
"
I!
t
n
f"
, 2.
':
'<
.
,
3.
. . i
c. retain a reversionary nterest or ....................................................................
d. receive the promise for life of either payments, benefits or care? .......................
If death occurred on or before December 12, 1982, did decedent within two years
preceding death transfer property without receiving adequate consideration? If death
occurred after December 12, 1982, did decedent transfer property within one year of
death without receiving adequate consideration? .................................................
Old decedent own an 'in trust for' bank account at his or her death?.....,...............
.:m_ "N9.
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Om
,~) '.-:;
q:.:..
co
-
..
'Cod:
',0-
,00-,
r J ()
:)
co
do
co
N
ffi
u-
rJ
"
..'
,.., ~..
,!
':"li
. D
,-' E
Sa
1'l
(\J ~~
~) {II
\'....n
o Q)
~cr.
a:;
'P'
Pennsylvania Department of Revenue
Bureau of Collections & Taxpayer Services
Harrlshllrll District Office
Lohhy, Strawberry Square
lIarrlshurll, PA 17128-0101
Telephone: 717-783-1405
01/29/97
RICHARD M, LAKE
250 S, YORK ROAD4
D1LLSBURG, PA 17019
RE: ESTATE OF: ALICE A. BURGARD
DATE OF DEATH: 09/19/95
FILE NO.: 2195,0754
Dear RICHARD M. LAKE:
This Is to advise you that the above estate is In a delinquent status. According to our
records, as of this date the estate still is not sellled.
The Inheritance and Estate Tax Act mandates the filing of a tax return and payment of all
outstanding liabilities by a personal representative of the estate or a transferee within nine
months ofthe descendant's death.
The Department's records show that this estate remains open because:
AN INHERITANCE TAX RETURN HAS NOT BEEN FILED.
Accordingly, you are directed to file a return and pay all tax due including Interest within
thirty days from the date ofthis leller, Failure to comply with this directive will result In a
citation filed by this Department with the Orphans' Court Division of the Court of Common
Pleas to show cause for your failure to comply with the law,
111e law provides that any person who willtillly fails 10 file a return required under the
provisions of this Act shall be personally linble Cor n penalty of twenty-five percent oCthe tax
detennined to be due or $1,000, whichever is less. 11lls penalty is In addllion to any olher
liabilities imposed by the Act,
If you have any questions, please conlaet Revenue Investigator THOMAS HOOPER at
the above telephone number.
Very truly )'ours~ ,
li,'- J? _ /1
'.:.,,,'r,,.I, ..tt"'r" )Q......"'.r....h~
ii I
Shirley Baughman
District Adrninistmtor
-;
\;,.'-::'.' .' , ~ ,
j,:' " "'" ," .
, ". ~ ' , :' ::'i .. " , ,
":"" ' ""..... .;..: :',' \" , '
". . "",<' '~:;,,:,;:,;', "'. ,.', "p' "",', ..,.,:.. '.- ':" ."'i,:J ;.:'.';
, "', .. ,'; i" '.., .,.'.,.' ,:', ':;",;:':,:';' ;. . :,,:". ' ,:;:.. ..
" "', ",.'; ',.';" Z,:' ,~;<;" ',' :j"." ',,' 'X
:.. ,,:;:", ", . ':,,' ;' ;,'," ".;"" .. "',' .
;C:..~;,'..:" y:;, ,;"; ,';. '; f",:,: :'>':
;' ';" .,' . ' ;:r~~!:'~~~~ ~,:=tl; "';"~f; ,', ''''.'
.;' ,,', .'," ". :, '... '
. ',' ~~
""~
.,',
c'
.c
:.~r ~;,'
. :,1'~'i'"
. . .' .~,: ; ;f~~i;;i
.' ~"<:'~'~::.""'~~!':i';! ';" .
~;:;. -;:'~I;;\'
'~,,':{ ','
, .' ,"\::;"':.: ,:: ;.: .
:, :;, i.'",..:C> ;'."
,.' :";,, " '.',,',:1:::" :. ~ . '\"
': ::'.. ;" '1-", 'u )::',.: .. ", ','
" ''-: '".'< :c,..., .',..,.<,:'.':....,:. ,"'''':." '.,'. ....,:'" ,": c ,:.
.. '" .,'~': ", '. i, (,,:;;. ". ,,:,. '",','
'. ,~:;..,:,.:,:'.", "/"''''';','', ':' ,:", J> :""""'oC':','
" : :;, ;......: ::<'.',,; ,. .",';',"'., ',,":" c., ;,,'.'; ::' ',',,;';V<, ,,<:'." ','
."'"",." .' ,'". :;)<,:'~.'".::,"(':,:.";i;" "
, " " " ..,. ' "':',':, ' "";'>." :,:\.,,:\. ''',:'' .' ",'
,,', ' "', : ," "oO "';"~;~""" ,,',.'
",:
:\ ::: :
:,
" "
,
.,.,'
",:
;i:.
~,' "
,:
,~ ;
I: . , ' , ."." :,':: u.: u ,'< " '.' " " ,.,', ':...
" " ~;/ '.' :~;;!i';:;;:'""'1!\ . . .!. i'e .'; ";L'" '" .' iZ:""".. Ji....
".' .. ~~?::*;j$0~1~/1" .:" ,i,. .'}~m::..; ...
.,,'."'. , , ';,,~. '':. "~,I "'!!i'~ :>~""'~:~"'j":"""::""': "..',C,.-:,,;:,"':'::/;:;: ~" ,'.'::,
,o,::! ,'" ,'. "",..:" n .': ',!:~~ ';is,' ,..:,." ':":'<:'u".":~.i:::>'
L. ""'''' '".,." ' ",:,'>,'.'
,
~I~:3t~Ui{~~}~fi;i~i~~~~~l~1t~~f{~~~I~~;~;~~~::I~;']~1 ~ ~~.
-:~;:!!~'f.~-~~:i;:>:~:~:~~11~'t~: J v -'.<(;~~
REY.IS02 Ih 112.Uj
~ SCHEDULE A
COMMONWIAUN 0' PlNNmVANIA REAL ESTATE
mHfllTANCI TAX RnURN
ESTATE OF II~ID'N' DI~'DI-"l =,~,=,~=~,=-" ,=,~_.._,=~=". ,.. -, =-.~.--_._- - ---FiLf';jUMBEjCo===="'O"'"'--'''~O''
(Proportv lolnllv-ownod with Righi 01 Survlvorahlp;"u.ti.o dl.;i~~~-.i on "S;h;d~I~-ilAlir;~I;.,;;;;h;~ld bo ;;porlod at lair markot'valuo
whIch I. dollnod a. tho prleo at whIch proportv would bo OMehangod botwoon a willing buvor and a wIlling .ollor, nolthor bolng eompollod
to bu or .on, both having roo.onablo knowlod~~!..!J1.!!olov_anllact., _..,.. ...________......___'____
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
_._~..._._._~--~_.__.._.._"--_.-.-.._--_._-"~ ~-_._._._._+~_.
1,
" ;
TOTAL IAlta onlor on IIno I, Rocap'lIul~~~J
{II mar. space 1a "..ded, ins.rt add.Wono' sh..ts 01 sam. size.}
S
-..,- -----_._~_._-
.h,j
a!Y.U03 u. 14.161
,
~~
COMMONWfALT~ 0' PINNlYlYANIA.
. INHUITAN f TAX IIInUAN
AUIDfN DreEDENT
ISTATI OP
SCHEDULE B
STOCKS AND BONDS
FILE NUMBER
(All proportv lolntlv-ownod with RighI of Survlvonhlp mu.1 bo dller.,od un Schodulo F.I
ITEM
NUMBER DESCRIPTION
I.
VALUE AT DATE
OF DEATH
"
TOTAL Also enter on line 2, Reco Ilulollon
(II more 'pac. ;. n..d.d, ins.rt additional .h.." of .am. lill.}
s
..\l1~11l.IJ.tJl \r:x'.lI_
~.
COw.oNW,AllH O. "NNSYlVANIA
- INH.lnANel 'AX .nulN
..SlDINT Dle.DINT
ISlATI OP
SCHEDULE C
CLOSELY HELD STOCK,
PARTNERSHIP AND PROPRIETORSHIP
Plea.e Print or l' e
FILE NUMBER
ITEM
NUMBER
DESCRIPTION
VALUE AT
DATE OF DEATH
1.
TOTAL AI.a enler on line 3, Reea i1ulatlan S
(I' mo,. 'pace I. n..d,d, in.ert additional ,h,1I of .ome ,ize,'
" 9.
,.
I'
,
~<
10,
11.
12,
"..,
IIY.I6OJUtIUJI
_~..,a..Q
~
SCHEDULE C-l
CLOSELY HELD CORPORATE STOCK
INFORMATION REPORT
. COMMONWEALTH Of 'ENNSYLVANIA
INHERITANCE TAX RUURN
RESIDENT DECEDENT
Pleo.. T . or Print
ESTATE OF
FILE NUMBER
. ,
The (ollowing informotion must be submitted with this schedule: '
A. Detall.d description showing the method of computation utilized In the valuation of the dlcld,nl', Slack.
8. Comple'. copl.. of flnanclal.latemenll or campl.,. copl.. of the Fed,ral Tax Returns (Federal Form 1120) for ,hI year of d.ath and.c
prlcedlng yean.
C. Statement of dividends paid each y.ar. lht tho.. declared and unpaid.
D. lilt nom.. of offlcen, lalorl.., bonuses and any other ben.nll recllved from Corporation.
E. If the Compony owned real.'Iol., lubmlt a Il,t .howlng ,he completl addr.n/es and estimated fair Markot Value/s. If Real Estate Appraisals
have been secured, please attach copies.
f. list prlnclpolllod;holden at dot. of dealh, number of ,hares held, and relallonshlp fo decedent.
G. Any other In'ormollon relative to the valuation of the decedflnl's Inlerell.
1. Nom. of Corporallon
Street Addre..
State of Inc.
Dot. of Inc.
Totol Number of Shoreholdora
Clly
Stole
Zip Code
Foderol'. D, Number
(Some A. Foderol Form 1120)
3, Type of Bu.ln...
2,
Buslne.. Reporting Veor
10
Product
4,
STOCK
TOTAL' SHARES
OUTSTANDING
PAR VALUE
. SHARES OWNED
BV DECEDENT
TYPE
Common
Preferred
Provld. all right. and r..trlctlons pertaining to each clan of stocle.
S, Wo. decedenl employed by Ihe Corporotlon' 0 Ve. 0 No
If yes, Position Annual Salary S Time Devoted to buline..
6, Wo. Ihe Corporollon Indebled 10 Ihe decedenl' 0 Ve. 0 No
If yes, provide amount of lndebtednen S
7. Was there life Inaurance payable 10 the corporation upon death of decedenl' 0 Vea 0 No
If yea, Coah Surrender Value: S Net Proceeda Payable: S
Owner of Policy
B. Old th. decedent soli or transfer slack of thla company within one year prior to death If the dote of dealh waa on or aft.r 12/13/82 or wllhln
Iwo yeors If Ihe dole of deolh wo. prior 10 12/13/82' 0 Ve, 0 No
If YOl: 0 Tronsfer OSale I of SharOl Transfere. or Purchaser
Considerallon S Dot.
Attach a separate sheet for oddltlonaltransfen and/or salOl.
Did the corporallon have an Inlerest In other corporation. or partnerships' D Ve. D No
If YOl, report the necenary Information on a separate sheet, Including Schedule "C.l" or "C.2" for each InterOlt.
Was there a written shareholder', agre.mentln eHect at the time of Ihe decedent's death' DvOI
If yes, provide a copy of Ihe agreement.
Was the decedent's stock sold' 0 Ves 0 No
If YOl, provide a copy of the agreement of sale, etc.
Was the corporation dlnolved or liquidated after the decedent's dealh' 0 Ves 0 No
If yes, provide a breakdown of liquidation distributions, etc. Attach a separale sh..r.
o No
..._~,.._....
IItV.'15MU.I"21
,;~
COMMONWEALTH Of PfNNSnVANIA
INH!RITANCE tAX RETURN
RUIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INTEREST REPORT
PI.a.. T . or P,lnl
FILE NUMBER
ESTATE OF
The following i~formation must be submitted with this schedule:
A. Delalled de.crlptlan .hawlng the melhad of campulatlan utilized in the valuation of the decedenl'.lnlere.t,
B, Complete caple. of IInanclal .Iatement. or complete caple. of the Federal Tax Relurn. (Farm 1065) far the year of death and
4 preceding years, Including a balance .heel far the year of death.
C, If Ihe Company awned Real E.tate, furnl.h a 1I'I.hawlng Ihe camplele addrellle. and e.tlmaled Fair Markel Valuel., If Real
E.late Appraisal. have been .ecured, plea.e attach caple.,
0, Any alher Information relative 10 Ihe valuation of Ihe decedenl'. Inlere.t,
Addrell
Federal I. D. Number
IA. per Farm 10651
Dale Bu.lnell Commenced
1. Name of Partnership
Bu.lnell Activity
2, Decedent was a DGeneral DUmlted partner. If decedenl was a limited partner, provide Inltlallnve'lment S
3.
PARTNIR'S NAMES
'" OF INCOMI '" OF OWNIRSHIP
SALARY
BALANCE OF
CAPITAL ACCOUNT
A,
B,
C,
0,
4, E.tlmated Value of decedenl'. Inlere.l: S
5. Wa'lhe partnership Indebled 10 Ihe decedenl' DYOI DNa
If ye., provide amount of Indeblednell S
6. Wa'lhere life In.urance payable 10 Ihe parlnershlp upon Ihe death of Ihe decedent' DYe. DNa
If ye., Ca.h Surrender Value: S Nel proceed. payable, S
Owner of Polley:
7, Was Ihere a written partnership agreement In effect allhe time of Ihe decedent'. death' DYe. DNa
If ye., attach copy of agreemenl,
8, Old Ihe partnership have an Inlere'lln any ather parlnershlp. or corporation.' DYe. DNa
If ye., report the necellary Infarmallan an a .eparale .heel, Including Schedule "C. 1 " or "C.2" far each Intere.I,
9. Old Ihe decedent'.lntere.t In Ihe parlnershlp change In Ihe year before dealh If Ihe date of dealh was an or afler 12113182
or If dealh occurred prior 1012113182 In Ihela'llwa year" DYe. DNa
If ye., explain:
10, Was Ihe decedent related to any of Ihe ather parlners' DYe. DNa
If ye., explain:
11. Was the parlnershlp dlllalved or IIquldaled after decedenl'. dealh' DYe. DNa
If ye., report alllhe relaled Information, Including caple. of the Sale. Agreemenl andlar Settlemenl Sheet.
12, Wa'lhe decedent'. partnership Inlere.1 .ald' DYe. DNa
If ye., provide a copy of Ihe agreemnl of .ale, elc.
II)t.U01IU v....
'*'
CllMMONWIAITN O. P1NNSYlYANIA
INN......NC. tAX.nu'N
....DlNT DICIDINT
ISTATI 0'
SCHEDULE D
MORTGAGES AND NOTES
RECEIVABLE
Ploo.o Prlnl or l 0
PILI NUMBER
IAll-"'t IoM,I, _..4 wlltl tho ...h. ., SvrvI_1p mu,' ... 41,,10..4 .. kh.4ulo .,)
ITIM
NUMBER
DESCRIPTION
VALUE AT
DATI 0' DEATH
s
I" maIO 'pac. II n..d.d, In,.rt oddiliono' ,,,..,, 0/ .om. ""'1
ITEM
NUMBER
DESCRIPTION
VALUE AT
DATE OF DEATH
U\LtIOtu. (f.etl
,.
SCHEDULE E
CASH, BANK DEPOSITS AND
MISCELLANEOUS
PERSONAL PROPERTY
eOMMONW'AL'" o. "HHSYLYAH'A
INHllnANe. TAX .nulN
IIIIDINT DICIDIHT
F
FILE
Plea.. Print or ~ e
MBER
(All p,ept"Y loln,ly.ownod with 1M Right 0' Survivorship mu.t b. dl.clo..d on Schedule FI
TOTAL AlIa enter an line 5, Reea lIulallan S
IAltoeh additional 8"'. )C 11'" ,h..11 If more .pac. I, n..ded.)
~'..._t..;;;. .i>..,..';M_<~,," .....,..s,"',;,.. '","~;"" 'v>, :?n.'"'J,'..':"'; r-".-' "_.,
UYISOfU+llJ.J11
.
COMMONWEAUH OF PENNSYlVANIA.
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
I FILE NUMBER
Jolnllonanll.),
NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
B.
C.
Jalnlly-ownod proporty.
ITEM LmER DATE DOLLAR VALUE OP
FOR TOTAL V ALU E DECD'S
NUMBE' JOINT MADE DESCRIPTION OF PROPERTY OF ASSET '!bINT. DECEDENT'S INTER 1ST
TENANT JOINT
1.
TOTAL (AI.a onte' an line 6, Recapltulatlan) S
(If mot. space is n..ded insert addilional sh..,s 01 some size)
IEY.Uta EX+ (2.'7)
'*
SCHEDULE G
TRANSFERS
PLEASE PRINT OR TYPE
COMMONWI'AlTH 0' 'INNSYLYANIA
INHIIITAHC. TAX lnulN
IIIIOINT DlC.DlNT
ESTATE OF
FILE NUMBER
THIS SCHEDULI MUST BI COMPLlTED AND FILED IFTHI ANSWER TO ANY OF THE QUESTIONS ON THI REVERSE SIDI OFTHI COVER SHEET IS YES.
ITEM DESCRIPTION OF PROPERTY TOTAL VALUE DECD, DOLLAR VALUE
EXCLUSION ,~ OF DECEDENT'S
NUMBER Include nome 01 tlte Iran.,-,..., 1MII' ,.lotionsIJp to o.c.dent, dole 0' 'ron,'et. OF ASSET INTEREST
TOTAL lAlla enl.t on line 7. R.cooltulollon) S
(II mote 'p~ It rtHd.d, In.ert odditionol .11..,. oI.omlt slu.}
U\tlSlllhl'.II'
SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
PI.... Prlnt or T
-!~
COMMONWEAUH 0' 'ENNSYlVANIA
INHUITANCE TAX UTUAN
.UIDENT DEceDENT
ITEM
NUMBER
A. Fun.ral Exp.n....
DESCRIPTION
AMOUNT
1007, 00
1.
B.
Admlnl.tratlv. Co.".
Personal R.pre.enlotlve Comml..lon.
Social Security Number of Personal R.pre.entatlve,
Year Comml..lon. paid
1.
2,
Allorney Fee.
3.
Family Exemption
Clalmanl
Addre.. of Claimant at deced.nt'. death
Street Addre..
Relatlon.hlp
City
4. Probate Fee.
C. MI.c.llan.ou. Exp.n....
1.
2.
3.
4,
5.
6.
7.
8,
State Zip Code
TOTAL (AI.o enlor on IIn. 9, R.capltulatlon)
(If mar. .pac. I. n..d.d, In..rt additional....... of 10m. .In.)
On
s
.ry.l~"ll. (7..11
~~
CQMMOHWrAUH Of HHHInw.HtA
IHHllllANCIW"'UlN
IUIDIHI DICIDINI
ISTATI OF
ITIM
NUMBIR
I,
1.i;lii~~ij~~~~"~f<~lit;lt. -'>~\;~,p_"r ,:
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE L1ABLlTIES AND LIENS
PI.a.. Print or T .
I FILl NUMBER
DESCRIPTION
AMOUNT
, ,IS ".','
,':.; '.-J",',~',
... --,-,.
. - ---'--,
TOTAL (Allo Inti' on I/nl 10, Rocopllulotlon) $
I" molW IpOCI " n..dld, Inll" odditlonollh.." 0' 'oml oIzl,)
;~'-_', :':;"1 .::-,ti:;;!':(::~~_;}~l"i"-'-~! '
'IV-ISUlIt .,1'1
.
COMMQNWtAI1H 0' PlNN."VANIA
INNlllTANCl'AX InUIN
IllIotN' OICIOI"'
SCHEDULE J
BENEFICIARIES
J
ESTATE Of
Fill NUMBER
ITIM
NUMBER
NAME AND ADDRESS OF BENEFICIARY
RELATIONSHIP
AMOUNT OR
SHARE Of ESTATE
A, TaKabl. B.qutllll
I,
ITEM
NUMBER
NAME AND ADDRESS OF BENEFICIARY
AMOUNT OR
SHARE OF ESTATE
B. Charitable and Governmental Blque.1I1
1.
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (AI.a .nler on IIn. 13, R.capltulallan) S
(If more 'pace I, needed, Inlert additional ,heet' of lame Ibtl)
l.v-UI411'11911
~~' ,Q
f'i< '
-.
COMMONWEAlTH 0' PENNSYlVANIA
INHfRlTANCf TAX RETURN
RUIDENT DECIDfNT
SCHEDULE K
LIFE ESTATE/ANNUITY/
TERM CERTAIN
ESTATE OF I FILE NUMBER
Thl. .ch.dul. hlo b. u..d lor oll.lngl. III., lolnl or .ucc...lv. III. ..101.. and I.rm cerlaln calculallan.. Far dol.. of d.alh alt.r
12,31.61 and b.for. 5.1.89, actuarial lacta" lor .ln91.1i1. calculallan. can b. lound In R.v.nu. 8aakl.IIREV,15018), For dol..
of d.alh an or alt.r 5.1,89 actuarial factan can b. lound In IRS Publica lion I 1<157 Actuarial Valu.., Alpha Volum..
Th. In.lrum.nt cr.allng Ih. IIf. Inl.r..II. at (Ploa.. attach a copy of In'Irumont)
o Will 0 Inl.rvlvo. C..d of Tru'l 0 Oth.r
LIFE ESTATE INTEREST CALCULATION '
Namol'l 01 Lifo Tonanll.1
Pr...nt Ag.
(Noaroat Blrthdayl
T.rm of Y.an Llf. E.tat. I. Payabl.
Dolo of Birth
o life or 0 Term of Years
o life or 0 Term of Years
o lIf. or 0 T.rm of Voan
o lIfo or 0 Term of V.an
1. Valu. of Fund from which LIf. E.lal.(.)I. payabl.t......................................................... S
2, ~~:~~::ai:~:~~I~.~ [)p~~~al. da~~ ...D'.iii%...[j'v~;i~'b'I~.R~';~"......"'......,........'"%
3. Valu. of L1f. E.lal. (L1no 1 x L1no 2)..,..............................,.............,.......................... S
ANNUITY INTEREST CALCULATION '
Namo(.) 01 Annullanl(.)
Pr...nt Ag.
(Noaroat Blrthdayl
T.rm of Y.ar. Annultv I. Payabl.
Dolo of Birth
o lIf. or 0 Torm 01 V.an
o lIf. or 0 Torm of Voon
o lIl. or 0 Term of Voon
o lIf. or 0 Torm of V.an
1. Value of Fund Irom which annully I. ~yablo ..............,........,..,...................................... S
2, Frequency of pa,}'out ' 0 Wookly 0 81.wookly 0 Monlhly
o Quart.rly 0 S.ml,Annually 0 Annually 0 Olhor
3. Amaunl of payaul por p.rlad.......................................................................................
<I, Annual paymonl .."...,.,.....",..,..,.""..,.....,.,."""",..,.,...""",..""...,......".."".,.."""".,..
5, Annully Faclar 1.00 In.lructlon.)
Inlore.1 Table ralo - 0 311,% 06% 0 10% 0 Variable Role %
6, Adlu.lmonl Factor (.0. In'lructlan.) ............................,......................,..,........................
7. Valuo of Annullr.' If u.lng 311,%, 6%, 10% or If variable role and period payaull. 01 ond
of porlad, calcu allan II: L1no 4 x L1no 5 x L1no 6........................................................
If uling varlablo ralo and porlad payoul h 01 boglnnlng of r.erlod, calculallon II:
(L1no 4 x L1no 5 x L1no 61 + L no 3.
NOTEt Tho valu.. of Ih. fund. which creal. Ih. abovo fuluro Inlore.l. mu.t bo roporlod a. parI of Iho E.lale All.". Line 1 Ihraugh
line 7, Tho Re.uhlng Lifo/Annully Inlor.'II.).hould be roporled allho approprlalo lax ral. on L1no. 13, 15 and 16 a. roqulrod,
.
flh'.U~'" lX+ P.ul
..
COMMONWEALTH Of PENNSYlVANIA
INHERITANCE' AX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE "L"
REMAINDER PREPAYMENT OR INVASION
OF TRUST PRINCIPAL
i
, '
I
!
I'
I
i
i
I
I
FilE NUMBER
II.
(la,' Nam.) (Finl Nam.) (Mlddl, 1"llial)
Thl. .chedule I. appropriate only for e.tal.. of decedent. dying on Dr before Oecember 12, 1982.
Thl. "hedula I. 10 ba u.od lor all remainder return. when an elecllon to prepay ha. baen /lIed under Iha pravlllon.
01 SectIon 714 of the Inheritance and E.tate To.. Act of 1961 or to raport thalnva.lan 01 tru.I prIncIpal,
Remainder Prepaymenll
A, Elactlon to prapay /lIed wllh Iha Rag"ter of Will. an
(attach copy 01 election)
B, Namel') of LIla Tenanl(') Oale 01 Blrlh
or Annullant(.)
I. Estate of
(DOlo)
Age on dale
of election
Tarm 01 yean Income
or annully " payable
C, A"el.. Complete Schadule L,l
1. Real E.tate S
2, Stock. and Bond. S
3. Clo.ely Hald Stack/Parlna"hlp S
4. Mortgage. and Nate. S
5, Ca.h/MI.c. Penanal Property S
6. Talallram Schadule L.! S
0, Credll.. Complete Schadule L.2
1. UnpaId L1obllllle.
2. UnpaId Beque.t.
3, Value 01 Unlncludable A"el.
4, Tatallram Schedule L.2
E, Total value of Iru.t a"et. (Line C,6 mlnu. Line 0,4)
F. RemaInder lactar (.ee Table I or Table II In In.tructlan Booklet)
G. Taxable RemaInder value (Line E .. Line F)
AI.o enter an LIne 7, Reca Itulation
S
S
S
s
s
s
III.
Inva.lan of Carpus:
A, Inva.lon 01 corpu.
(Month, Day, Voor)
B, Name!.) of Lllo Tonont(.) 001001 BIrth
or Annullant('l
Ago an dole
corpus consumed
Torm of yean Income
or annully 11 payable
s
C, Corpus can.umed
O. Romolndor factor ('00 Table I or Tablo II In In.tructlan Booklet)
E. Taxoblo value of corpus con.umed (Line C x LIne 0)
(AI.a entor an LIne 7, Recapllulollon)
s
...__;>,.....>.... ....,."-ff'",,...'._;,.~.~...p ""." .' "-'('j'.C ...;-~".' ~.', ,,"'.
.,.",
UY.I645 EX + (7.151 INHERITANCE TAX
..
SCHEDULE L-l
COMMONWEALTH Of PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT -ASSETS- FILE NUMBER
I. Eltat. of
ILaU Name) (flul Name) IMlddl. 10lUall
II. It.m No. D.scrlptlon Valu.
A, Real E.lale (ploa.e de.crlbe)
Talal value 01 real e.late S
i1~c1ude an Section II, lIno C.l an Schedule LI
B. Stack. and Band. (plea.e lI.t)
Talal value 01 .Iack. and band. S
Ilnclude an Section II, line C.2 an schodule LI
C. Cla.ely Held Stack/Partnership (atlach schedulo C.l and/or C.2)
(plea.ell.t)
Talal value 01 Clo.ely Hold/Parlnorshlp S
Ilnclude an secllon II, lIno C,3 an schodulo Ll
D. Mortgage. and Nole. (ploa.e 11.1)
T 0101 value 01 Mort~a~.. and Nale. S
ilnclude on Section I, Ino C.4 an schodule Ll
E, Ca.h and MI.cellanoou. Personal Property (ploa.e 11.1)
T al~1 value 01 Ca.h/MI.c. Pers, Prat,orty 5
ilnclude an Section II, lIno C-S an chedule LI
III. TOTAL (AI.a enler on Section II, lIno C.6 an Schedule Ll S
(II mare 'pace I. needed, atlach additional ay, x 11 .heol.,)
"V'.I."!X. "'''*
COMMONWEALTH Of PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE L.2
REMAINDER PREPAYMENT ELECTION
.CREDITS.
FILE NUMBER
I. E.tate of
r II. Item No.
A.
Lo,' Nom.
flntNam.
Mlddl.lnltlal
Amount
Oe.crl lion
Unpaid lIobllltl.. Claimed agaln'l OrigInal E.lale, and payable from a..e"
reported an Schedule L.l Iplea.e 11111
Tolol unpaid lIabllltle.
Include an Section II, LIne 0.1 an Schedule L
B. Unpaid Be que... payable from a..el. reported an Sch.dule L.l Iplea.e 11.1)
s
Talal unpaId beque'I'
Includ. on S.ctlon II. line 0.2 an Schedule L
C. Valu. of a..el. repart.d an Sch.dule L.l (olher Ihan unpaId beque'I.II'led und.r
"B" aba.e)lhal are not Includ.d for lax purpo.e. or that do nolfarm a part
of the tru'l.
Compulallon a. fallowlI
s
T alai unlncludable a...'.
Include on Section II, line 0.3 an Schedule L
s
III.
TOTAL AI.a ent.r on Secllan II. line 0.4 an Schedule L
III more .paco I. needed, allach additional 8Y, x 11 .hee'..)
s
,!.t
)
'r..
...
..
.
~\
"
~.
\Ii.
~~i'
~
i:
UV.l&47U+ (Il.'bl
. ~:..\t..~
... .!'U;
COMMONWEALTH Of PENNSYlVANIA
. INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE M
FUTURE INTEREST COMPROMISE FILE NUMBER
I. Eltate of
Ilal' Nam.) (Flrl' Nom'l (Mlddl, !~I~___
Thll Ichedule II opproprlate onlv for Eltat.. of deceden" dVlnll alter Oecomber 12, 1982.
Thl. .chedule I. 10 b. u.ed for all fulure Inlere." where tho ral. of lax which will b. applicable when tho fulure
Inlero.t ve.l. In po.....lon and enloym.nt cannol be e'labll.hod with cerlalnly.
II. Ben.flclarl..
NAME
OF
BENEFICIARV
SEX
RELATIONSHIP ~ Mal.
F Female
DATE OF BIRTH
AGE ON DATE
OF DECEDENT'S DEATH
1.
2.
3.
4.
5.
III. Explanallon of Compromlle Offe..
'.
I V . Summary of Compromlle Offe..
I. Valu. a' Fulure Inlore.l:. . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . .5._.
2. Amounl 01 L1no 1 Exempt 'rom Tax.,.,........................."... .5....__..__ ..0.........
(01.0 enl.r an L1no 13 Recopltulallon)
3. Amounl a' LIne 1 T axabl. 01 6% Ralo , . . . . . . . . . . . . . , . . . . . . . . , , . . . . . . . , s.u ........-, ..u_ . ............u ..
4. A~~~nf~r'i.I~~ \I~~~~bl~a~t ~~,:~I~II~O~~.....,................,...... ,5..__..... ____...
(01.0 enter on L1n. 16. Tax Com pula lIon)
(II moro 'poco I. nood.d. alloch addillonal 8 y, x II" .h..Is)
A[Vlb48 n 11'''11
,,~:J~:9n
....~~~
COMMONWEALTH Of PENN~Y1ANIA
. "-'HERJIANCf.l.AX D!VI~ION (AVAILABLE FOR DECEDENTS DYING AFTER 12/31191) .. _ ........
.~STA.T~_~f__________._..__,_ ....._.._..... ..._____________________JfILE ~_UMBER
Thi' "hodulo mUll bo complolod and filod if you chockod the spousal poverty credit box on tho cover sheet.
. .
SCHEDULE N
SPOUSAL POVERTY CREDIT
I. Taxable Aneh total from lino 8 (covor shoot).................................................."................ 1.
2. Insuranco Proceods on Ufe of Decedent ............................................................................ 2.
3. Retiremont Bonofits........... ................................... .... ........ .......... ............ .............. ...... ..... 3.
4. Joint Asseh wirh Spouse........................"....................................................................... 4.
5. PA LoII.ry Winning, ......................................................................................,............... 5,
60. Olh.r Nonloxobl. AII.h' Lill (Alloch sch.dul. if n.c.nory).. 60.
6b.
6c.
6d.
6. SUBTOTAL (Lin., 60, b, c, dl,............,.........................................,..,....,................,........ 6.
7. Tolol Grall Allol' (Add lino. Ilhru 6)...............,..,..........,...............,..,....,...................,... 7,
g. Tolol Acluol Liobillll.. .............,. ................".......".......... ..................... ........,.,..,. ...'......., g.
9. Nol Voluo of Eslol. (Sublrocllin. B from lin. 71........,...................,..............,...........,........ 9.
IIl'n.9'sgr.ol.r,h $200000 STOP Th .1101 ;Inol tg'bl tad 'mlh ".d" Ifn , cont'nu. to Par'"
PART 11- CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income
Tax ReturnS far docedont and spa~se.)
Income:
I. TAX YEAR, 19
2. TAX YEAR, 19
3. TAX YEAR, 19
a. Spouse...................... 10.
b. O.c.d.nl...............,... lb.
20.
30.
2b,
,11>,
c. Joint.......................... 15'1
-~~
3c.
d. Tax Exompl Incomo.....
e. Othor Incomo not
lilt.d obov. ..,........
w. _._________.___..__... __'____ .2d
"--------------- '~<!"
_Le... __._.__,_._~~___. .-..__.____1.~~ _.___._.__
-___~.!t.
f. TOlol.................~= If~ '__
4. Avorago Joint Exomptlon Income Calculation
40. Add Jolnl Exomption Incomo from above:
_21.
31.
(If)
--- + 121) ._____.____. + (31)
=
(+ 3)
4b. Average Joinl Exemption Income ..................................................................................... =
If lino 4(b) ;1 gr.oter Ihon 540.000 . STOP. Th. .110'. il not .ligibl. to claim th. croclil. 1/ nol, conlinue 10 Port /II.
. . .. '" .
1. Insert amount of loxable tranlfers to spouso or S100,000, whichever is Iou.......................... l.
2.
3.
Multiply by crodlt percentage (soo Instructions) .................................................................. 2.
This Is Iho amounl of the Resident Spousal Poverty Credil. 'ncludo Ihis figure
in tho calculation of totol credits on line 1 B of Iho cover shool. ..............................."....".....
For Nonrosldents, enler Ihe ralio of Iho decodont's gran oslole in PA to Ihe voluo of the
docedont's gross oslolo. ......................... ......................... ...... ... ........ .............. ...... .........
Multiply line 3 by line 4 and enlor Ihe 10101 horo. This is Iho amount of Ihe Nonresident Spousal
Povorly Credit. Include Ihis figuro in Iho calculation of tolal c.redits on Iino 1 B of tho cover shool.
4.
.3. __......______
5.
_4, .....__......_......________.
s.
I
I
I
I
I
I
IS -c;O-3
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVIIION
DfPT. ra060l
HARRISaURG, PA 17121.0601
COMMONWEALTH DF PENNSVLVANIA
DEPARTMENT OF REVENUE
~*
NOTICE DF INIIERITANCE TAX
APPRAISEHENT. ALLDWANCE OR DISALLOWANCE
OF DEDUCTIONS AHD ASSESSHENT OF TAX
In.uu"," I....,'
RICHARO M LAKE
250 S YORK RD
DILLSBURG
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
05-26-97
BURGARD
09-19-95
21 95-0754
CUMBERLAND
101
A.aunt R..lttad
ALICE
PA 17019
MAKE CHECK PAVABLE AND REMIT PAVMENT TDI
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ... RETAIN LOWER PDRTION FDR VDUR RECDRDS ~
REV:i5W-ix-"Fji-rOY:97T"NoYicE""eijO-YriHiiiiTANci-YAin-pjiRA'isiHiN'i'-;-Ai.i."OWANci-oii-----------------
DISALLOWANCE OF DEDUCTIDNS AND ASSESSMENT DF TAX
ESTATE OF BURGARD ALICE A FILE NO. 21 95-0754 ACN 101 DATE 05-26-97
TAX RETURN WAS I (X I ACCEPTED AS FILED
RESERVATION CDNCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE DF RETURN BASED DNI ORIGINAL RETURN
1. H..l Eat.t. (Schedule A)
2. Stock. ond Bond. (Schedul. Bl
5, Clo..ly Hold stock/Pert~rohlp Int.r..t (Schedule CI
4. Kortgag..lNot.. Receivabl. (Schedule DJ
S. CaahJBank o.pollta'Hlac. Par.onal Prop.rt~ (Schedul. EJ
6. Jointly Owned Property ISchodul. FI
7. fran.far. (Schedule OJ
I. Total A...t.
I CHANCED
III
121
151
141
151
(61
171
.00
.00
.00
.00
.00
.00
.00
(BI
NOTEI To tn.ur. proper
cradit to your account,
.ubIIlt the upp.r portion
of thla fare with your
tax pay.ent.
APPROVED DEDUCTIONS AND EXEMPTIONS I
9. FU'Mral E)(p..,.../AdII. COlh/Hlaa. Expen... (Schedule H) (9) 4,007.00
10. D.bt./Hortaog. Llabiliti../Li.n. ISch.dul. II 1101 .00
11. Tot.l Deduction. 1111
12. Hat Value of Tax R.turn (12)
15. Ch.rltabl./CoY.r~t.l aaqua.t. (Schedule J) (131
14, N.t Velue of E.t.t. Subj.at to Tex 1141
NOTEI If an asssssmsnt was 1ssusd prsv10usly, l1nss 14, 15 and/or 16, 17 and 18
reflsct f1gurss that 1ncluds ths total of Abb rs~urns assssssd to dats.
ASSESSMENT OF TAXI
15. Aaount of Line 14 .t $pou..l ~.t. (IS)
16. Aaount of Line 14 taMable .t LJn..l/Cl... A ~.t. 116)
17. A.aunt of Lin. 14 taxable .t Coll.terel/Cl... 8 r.t. (171
18. Prlnclp.l Tax Due
4.007 DO
4,007.00-
.00
4,007.00-
wl1l
,00
.00
.00
.00
.00 X,OO.
.00 X ,06.
,00 X .15.
IlBI
TAX CREDITS I
PAYHENT
DATE
DISCOUNT 1+1
INTEREST/PEN PAID I-I
RECEIPT
NUHBER
AHOUNT PAID
TDTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
.00
.00
.00
.00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATIDN DF ADDITIONAL IHTEREST,
1 IF TDTAL DUE IS LESS THAN .1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI. YDU KAY BE DUE
A REFUND. SEE REVERSE SIDE DF THIS FORK FDR INSTRUCTIDNS.I
",-
A
.00
"t3 01
-
'.~
M
0-
'"
I
"
tl
\~<(
"\(J_
"
~
'.
.~. ,
1,)
C'II'
(1)0:
0:
\]\
-,
-; t:
ci=i
GO
RUOIYATlDNI EUat.. 0' ......ts dyl", on 0,. bII'or. o.c....,. 11, I'll ... If an. futura In.aru. In the aUala .. .nn,'arr..
In po.....lon 0,. anJo~t to Cl... . (ooll,'.r.l) bene'lcl.rl.. 0' the deoedant ,'t.r the explr"1on 0' an. ..tlt. '0,.
II'. 0,. for wear., the ~Ith ~rlbY ..,r...l. r...,.v.. the rlDht to appr.l.. and ...... tran.',,, Inher1t~ T....
at the lawful Cl... . (ooll.t.rll) rat. on any ~ fulur. 1nt.r"I.
-,.
NOTlCEI To fulf111 the requlr--.nt. of SeQtlon 2140 of the Inhlr1tenc. and E.I.I. f.. Act, Aot 21 0' 1"5. (72 P.I.
..tlon '140>.
PAYtDf, DttltCh the top porUon of thh NoUc. MIl ..11 .,lth your P'VMnt 10 the R..ht.r 0' Willa print.. on the raYllr.. ....
.......... chedc or IIOMV O,.der pe_h tOI REGISTER OF MILLS, AaEHT
RU\IrQI (au, A r.,und of . t.. or.Ut, Wilch .... not ,......Ied on the fa. R.turn, "V be r.qu..ted bV C___l.U,.. M IIApplluUon
'or R.'und 0' Pann.Vlv.nl. Inhe,.ltanc. MIl E.I.t. f..~ (REV-15l5). Appllcellon. .r. .v.11~1. .t the Offlce
of the R..l.t.,. of WI11., any of the 25 R.venue Dl.lr101 Of'lc.., 0,. bV c.lllng the ~l.l 24-hou,.
en...,.l", ..rvlc. nuebe,.. for fo~. 0,..,.1,..1 In Penn'vlvanl, l.IOD-562-20S0, out.lde Penntylvenl. MIl
.,1th1n local "-,.r1abur. .r.. (717) 7.7.1094, fDD' (717) 712"2252 (",-,.Ing lap.lrld Dnlv).
DIJECTlDNI. Anw p'rty 1n lnt.,...t not .aU.,1ee1 .,Uh the appr.hlNt'll, .Uowanc. 0,. dh.UDWnCl. of deO.MIUon., or ..........t
of tn Unoludl,.. dhOCU1t or lntara.U .a IhcMIn on thh NoUc. .,.t obJlGt 1lI11h1n .bly (AG) dI)'I of r~.lpt 0'
thh NotlOl bVI
--.,,.ltlan prola.t to the PA o.,a,.t-.nl of Ravenue, Board of Appeal., Dlpt. 211021, Har,.labu"l, PA 17121-1021, OR
--,lIGUon 10 hey, the ..U., .b,..dnecl at audit of thtI ~CU'l1 of tM perlOMI rlpr...,I.UYII, OR
--.....1 to the Orphan.' Court.
AllIIN
IITRATJVE
CDRRECTlOHII
FlGtual .rror. dl.cov.red on thl. .....-..nl .hould b. Iddr...1d In IlIrltlng tOI PA Deparl.ent of R.venu.,
Iura., 0' Individual Tax.., ATTN. Po.t A.....Mnt R."I... lklll, D.t. 210601, H.rrhburg, PA 17121-0601
Phone (717) 7.7-6505. Sea P... 5 of I~ booklat ftln.truotlon. for lnhlrlt~. T.~ Raturn for. R..ldlnt
Dec~t~ (REV-lI01, '0,. ~ .kpl~llon af ~lnl'lratl"alw correat~la .rror..
o lIteUn' I
If InV tax due I. p.ld wIthin thr.. (5) c'lendar ~th. a'l.r I~ ~ldanlt. de.th, . fl~a parcant (IX) dl.count of
the t.x paid I. .llow.d.
~ 15X tax .-ne.tv non.p.rtlolp.tlon ~llv 1. coaputld on 1M tol.l 0' the t.x and lnl.r..t ......ed, and not
p.ld before Januarv II, 1996, I~ f1r.1 dew a't.r the and 0' IhI I.. .-na.t. period. Thl. non-p.rtlalpat1on
penal ly h ....Iabl. In tM .... alf'll'Mlr W"Id In 1M IhI .... U.. ptIr lod II YOU lllOUld .,.al lhe lax IInd Int.,...t
IhIt htt. bean .....Ied II lndlc.teel on thh noUu.
POtALTY,
1H1Df:ITI
Intar..t It cNrDad betl,....l", IlIlth fir" dav of dallnquencV, or nine C,) IIOnlh. and one ell day fr~ tM d.t. of
..th, 10 IhI dal. of pa)'MJl'll. fax.. whlch bite... dallnquanl befor. J..u.ry 1, I'" baar 1nt.r.'1 .t thl nt. of
.1M (0) percanl par ~ c.lcullted at . dalh rat. 0' .000164. AU talll, Whlch bee... delinquent on W"Id .ft.r
Januarv 1, 1'" .,111 bear Int.r..t at . rala which 1lI111 v.rw froe cal~r y..r to calandlr y.ar 1lI1th that r.l.
announced by IhI PA Gaparttenl of R.vanu.. ThI appllcabl. Int.r..t rat.. 'or 19'2 thrOUGh 1"7 .ral
,
, l!!!: lnta,," R..I. P.lly Inl.r'.1 Factor !!!r lnt.r..t R.I. Dally Inl.r"l Faclor
,
~
19" .n .DOO54' 1917 OX .ooaru
1'15 10 .000451 1'''.1''1 IIX .aaasu
I... IU .DOasOl I'" OX .00atU
I'll IU .000556 1"5-19fll 'X ,0001"
I... In .0D027" 1995.1991 OX .00atU
--Int.r..t 1. calCUlated ,. 'allOM"
IHTERElT . IALANCE DF TAX UNPAID X HUHIER DF DAYS DELIHQUENT X DAILY INTEREST FACTDA
.-Anv Hotlc. l..uad .ft.,. the tex bee.... dallnquenl 1lI111 r.fleat In Inl.r..t calcul.llon 10 flfleen (IS) day.
beyond the dal. 0' IhI .....~t. If P'weanl I. aade ,'t.r IhI Inl.r..1 caaput.tlon dal. ahown on the
Holle., addlllonal Int.r"1 lU.t be c.lcul.led.
--.
JRD/June 30, 1992/17858
REGISTER OF WILLS
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
NOTICE PURSUANT TO RULE 6,12
PENNSYLVANIA SUPREME COURT ORPHANS' COUllT RULES
To: Penonal Representative
Counsel: PAUL BRADFORD ORR, ESQ.,
RE: Fatate of ALICe; A. BURGARD ,DccCllSed, Late of
MIDDI,t;St;X 'I'W I'
Fatate No.: 21-95-0754
Date orI}ecedent's Death: 9.19.95
Pul'5uant to Rule 6.12, the above named personal repTcsemative or the above named attorney, if
applicable, within two (2) years of the decedent's death, and annually thereafter until administration is
completed, Is required to file with the Register of Wills a Status Report as required by Rule 6.12, in
substantially the prescribed form, showing the date by which the personal representative, or attorney, as
applicable, reasonably believes administration will be completed, The pU'llose of this Notice is 10 advise
you that unless the requisite Status Report is filed with the Register of Wills or Clerk of the Orphlll15'
Court, as appropriate, within ten (10) calendar days afTer the date of this Notice that the Reglsler of Wills
Is required 10 notify the O'llhans' Court Division, Court of Common Pleas of such delinquency and to
request that said Court conduct a hearing to determine whether sanctions should be imposed upon the
delinquent personal representative and the delinquent personal Tepresentalive's counsel, if any,
Accordingly, If the requisite Status Report is not filed by 11 -10 , 19~J you are hereby
advised that a request will be submitted to the Court in accoTdance with Rule 6. 12.
V rvv1 11 ltlJ4.,
Date:
10-21-97
Distribution to Estate File
STATUS REPORT UNDER RULE 6,12
Name of Decedentl
f)l./e,6,
-
Deathl 'l'.::J1-~~
2./~ 9.\~07r(.1
II. B/J/<6tlRD
Date of
Will No.
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 estatel
1, Stat~whether administration of the estate is complete I
Yes.....6... No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete I
J, If the answer to No.1 is Yes, state the followingl
a, Did the personal .~esentative
account with the Court? Yes NO~,
b, The separate Orphans' Court No,
the personal representative's account is:
file a final
(if any) for
c, Did the personal representative s~e an
account informally to the parties in interest? Yes~ No
d. Copies of receipts releases, joinders and
approvals of formal or informal acc~~be~d with the
Cerk of the Orphans' Court and may ~& ~ d ~ is report,
I Datel~ ^ l\' :\vJoV' signature' -^^..
\\ ID c(l k -to 11tYr"1I-\r) PAVL B. oRR
~ V Ve)\ v..e. S ~ j) . f Name (Please type or print) J
;:;--- ~ I( v\v A<,o aj fhl~ t? I,IJ ~f"J- 5'-1- W0.t PA
vl~~ ~VPXI ~ }~)/""'I'lo\J) -1'1! + wlo Address Z[ cP ,?fS-Y nOJ']
v-.tA5 Ueft I'(f'lSo V~1\1 Tel. No.
{d: j.AlA ~ Y ~evJcw~- Capacity: Personal Representative
~~ ASS ~ J....i5 Icounsel for personal
VII" representative
(MAH: rmf I AMJ ) R9Vl.>~e. RJv""",, (f)
~ fPivlV1 ev fj~~