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OATil OF PlmSONAL REPHESENTATIVE
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COl :'iT\' OF ~~.!~an ______ J ,.
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No. 21-96-630
Estate of Richard G. Koont7.,i1/k/a Dick Koontz
. I>eccuscd
DECREE m' PHOIIATE AND GRANT 01: LETTERS
AND NOW August 15, Il}~. in <onsideralion of the pClilion on
Ihe reverse side hereof. sutisfaclllry proof huving been presellled bcfore me,
IT IS DECREED Ihutthe instrumcnl(s) dated November ~ 1985
described thercin bc admilled to probulc and filcd of record as Ihe last will of
Richard G. Koontz,a/k/a Dick Koontz
and Lellers Testamentary
arc hereby gral1lcd to Sydney E. Marichak and Mary Jo Weishaupt
n, ' / '-..), /
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RcgiMcr of Will~ ' t\~lt, ~:I-
Mary c. Lewis .("
FEES
x-Pages
JCP
S 235.00
S 18.00
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S 12.00
TOTAL S 5.00
l~\lffiJ,!i1;, ~~,.,m,6.""", ,;!7.Q,QO..
ATIn~NE\' (Sup, CI, 1.1>. No,)
Probate, Lellers, EIC, ,.""",
Short Cerlifieates(6 ) , . , . , , , . , .
Renunciation "."""""..,
ADDRESS
Filed
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Mailed Letters and Order to Executrix Sydney E. Marichak on 8-16-96.
21-96-630
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LAST WILL AND TESTAMENT
I, Richard G. Koontz, of 132 North Earl Street, Shippensburg,
Pennsylvaia, being of sound and disposing mind, memory and under-
standing, do hereby declare this to be my Will, hereby revoking any
and all former Wills and Codicils thereto by me at any time hereto-
fore made.
FIRST: I direct that all my just debts and funeral expenses,
including all expenses of my last illness, shall be paid from my
estate as soon as practicable after my decease, as a part of the
expense of the administration of my estate.
SECOND: I give, devise and bequeath the residue of my estate
of every nature and wherever situate to my wife, Mary E. Koontz,
providing she shall survive me by thirty (30) days.
THIRD: Should my wife, Mary E. Koontz, predecease me or die
on or before the thirtieth (30th) day following my death, I give,
devise and bequeath the residue of my estate of every nature and
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wherever situate to my children, namely, S,dney E. Marichak and
Mary Jo Weishaupt, in equal shares, provided that the share of any
child who predeceases me or dies on or before the thirtieth (30th)
day following my death shall be distributed to her issue, per
stirpes, living on the thirty-first (31st) day following my death
and in default of any such then living issue, such share shall be
added to the share or shares for my other child.
FOURTH:
I have previously loaned my daughter, Mary Jo
Weishaupt and her husband, Walter J. Weishaupt, the sum of Eight
Page One of a Five Page Will
Thousand Seven Hundred Fifty ($8,750.00) Dollars. It is my desire
that any amount outstanding on this debt be deducted from Mary Jo
Weishaupt's share of my estate.
FIFTH: In the event that anyone entitled to a share of my
estate should be under the age of eighteen (18) years at the time
for distribution to him or her, I constitute and appoint sydney E.
Marichak, Guardian of any property which passes either under this
Will or otherwise to said minor. In the event the said sydney E.
Marichak is unable to act as Guardian, I appoint Mary Jo Weishaupt
in her stead. said sydney E. Marichak, as Guardian, aforesaid,
shall, in her sole discretion and without Order of Court, use
principal as well as income from time to time as may appear to be
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necessary for the minor's welfare, comfort, medical care,
recreation, support and education, without responsibility to the
minor or to any person taking care of the minor; and the remaining
balance in the hands of said Sydney E. Marichak, as Guardian, shall
be distributed to said minor when he or she attains the age of
eighteen (18) years. If such minor dies prior to attaining the age
of years, said Guardian is authorized in her discretion to pay part
or all of his or her funeral expenses and the remaining balance in
the hands of said Sydney E. Marichak, as Guardian, shall be
distributed to his or her personal representative. In the event
the funds held by the Guardian for any minor become, in the opinion
of the Guardian, too small for proper and efficient administration,
the Guardian, in her sole discretion, may deposit such funds in a
savings account in the name of the minor.
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Page TWO of a Five Page Will
1
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SIXTH: Any fiduciary under this Will shall have the following
powers in addition to those vested in them by law and by other
provisions of my Will applicable to all property, whether principal
or income, including property held for minors, exercisable without
Court approval, and effective until actual distribution of all
property:
A. To retain any and all of the assets of my estate,
real or personal, without regard to any principle of diversifica-
tion of risk.
B. To invest in all forms of property, including stock,
corrunon trust funds and mortgage investment funds without restric-
tion to investments authorized for Pennsylvania fiduciaries, as
they deem proper, without regard to any principle of diversifica-
tion of risk.
C. To sell at public or private sale, to exchange or to
lease, for any period of time, any real or personal property, and
to give options for sales, exchanges or leases, for such prices and
upon such terms or conditions as they deem proper.
D. To allocate receipts and expenses to principal or
income or partly to each as they from time to time think proper.
E. To compromise any claim or controversy.
F. To distribute in cash or in kind or partly each.
G. To hold property in their names without designation
of any fiduciary capacity or in the name of a nominee or
unregistered.
Page Three of a Five Page Will
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SEVENTH: I direct that all taxes that may be assessed in
consequence of my death, of whatever nature and by whatever
jUrisdiction imposed, shall be paid from my residuary estate as a
part of the expense of the administration of my estate.
EIGHTH: I appoint my wife, Nary E. Koontz, Executrix of this,
my Will. Should my said wife, predecease me, fail to qualify or
cease to act as Executrix, I appoint my daughters, SYdney E.
Marichak and Mary Jo Weishaupt, CO-Executrices of this, my Will.
NINTH: No bond shall be required of any fiduciary hereunder
in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to
this, my Last Will and Testament, consiSting of five typewritten
pages, the first three of which bear my signature in the margin for
the purpose of identification, this IS-.d- day of ,,(/,,1Ie;"1bt'~
1985.
-Gl,J.--t~7i- t
(SEAL)
Signed, sealed, Published and declared by the above named
Testator, Richard G. Koontz as and for his Last Will and Testament
in our presence, who in his presence, at his request and in the
presence of each other have hereunto set our hands as attesting
witnesses.
Page Four of a Five Page Will
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CERTIFICATION OF IID'rICI; \JNDr.~I,-B.tJl!t:_ ~ , 6 W.
Decedent :J;c A(lrd wi. Kt1tJn l-c,
Name of C/,
Date of Death: f/'/9C,
/11" - oa Go -~6 f'f/ }( 11'(, (': <:' '- ~ (')
Will No. AcJm1n, No,
To the Register:
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 tile above-captioned estate on
ail 6, /.:? I / tj t'/(;o :
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Naml1
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Address
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Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except
Date: 7 JtA, /.3 , 111t.
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Sign ture
Name-"st/d;rtN f I) l/'l rld.'t'U("
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Address /7 / li/o/c./(' (]I:
/) led} I 1.1 tt /76 S;,:}
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Telephone(
Capacity: r---- Personal Representative
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Counsel for personal
representative
NOTleF: OF IJF:I'I,,~~ICIAI. IN1'EHES1' IN ES.T~1'E__
BEFORE TilE REGI STF:R Of' WI LI.S, COUN'I'Y m' (!I.lJ,TJ.bc.r.!ttrd PENNSYLVANIA
In re Estate of R;c/Jf1.CCL ,~. J..<{I{If) 1'2-, deceased,
No. of
TO:2hA~ ~(\ LlliJ5.hl!.I.I.,p-t_~~L, m4r.t.t/IA.~eneficiary)
1L~.L.1lVe., /7 7YJ~1 J't'/ n~_ (address)
rS h ~ A 11:<. 57 7rJe(j~ r'1'I J7fib-6-'
Ple4s~~ke notice 01 the death of decedent dnd the grant of
letters to the personal representative(s) named below. You may have
a beneficial interest in the estate as follows:
'~~'/l:;_/!~9.J~.AAJ~/J- 9-- ~1/.{.h1&,- ~ Jr~~//_.A~~_
(if additional spac~s needed, use back of page)
Name of decedent ffic h/J ni A-, ';-<;M T2-
Last known address /,3:1. -..n., f:~ / ~7
of decedent '7---1-Ll /7 d.5 7
Date of death
Place of death (> /Yl)/J .ht'-r:S to\,rc.
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County of grant of origin.l letters
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(\'l..rYI bCr/t:4-vJ
Decedent died V test.at,~
A copy of the will ~ is
intestate,
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is not attact,ed,
Name(s), address(es) and telephone number(s) of all personal
representatives appointed
Name
~ty\f1 /' ICJlI:\..~
r1\(lI'~ ~ LUet> J1IUlf1
Address Telephone
v _ L^ I ~ 717-
I l-LnC:l/J I);" n 91.Jl:L4-t-'Ft 7lt.- ,:>'~/i 3
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LAST WILL AND TESTAMENT
I, Richard G. Koontz, of 132 North Earl Street, Shippensburg,
Pennsylvaia, being of sound and disposing mind, memory and under-
standing, do hereby declare this to be my Will, hereby revoking any
and all former Wills and Codicils thereto by me at any time hereto-
fore made.
FIRST: I direct that all my just debts and funeral expenses,
including all expenses of my last illness, shall be paid from my
estate as soon as practicable after my decease, as a part of the
expense of the administration of my estate.
.
SECOND: I give, devise and bequeath the residue of my estate
of every nature and wherever situate to my wife, Mary E. Koontz,
providing she shall survive me by thirty (30) days.
THIRD: Should my wife, Mary E. Koontz, predecease me or die
on or before the thirtieth (30th) day following my death, I give,
devise and bequeath the residue of my estate of every nature and
~ J" ~( /1/ /s'j 'i'~-
wherever situate to my children, namely, S,dney E. M,arichak and
Mary Jo Weishaupt, in equal shares, provided that the share of any
child who predeceases me or dies on or before the thirtieth (30th)
day following my death shall be distributed to her issue, per
stirpes, living on the thirty-first (31st) day following my death
and in default of any such then living issue, such share shall be
added to the share or shares for my other child.
FOURTH:
I have previously loaned my daughter, Mary Jo
Weishaupt and her husband, Walter J. Weishaupt, the sum of Eight
Page One of a Five Page Will
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Thousand Seven Hundred Fifty ($8,750.00) Dollars. It is my desire
that any amount outstanding on this debt be deducted from Mary Jo
Weishaupt's share of my estate.
FIFTH: In the event that anyone entitled to a share of my
estate should be under the age of eighteen (18) years at the time
for distribution to him or her, I constitute and appoint Sydney E.
Marichak, Guardian of any property which passes either under this
Will or otherwise to said minor. In the event the said Sydney E.
Marichak is unable to act as Guardian, I appoint Mary Jo Weishaupt
in her stead. Said Sydney E. Marichak, as Guardian, aforesaid,
.
shall, in her sole discretion and without Order of Court, use
principal as well as income from time to time as may appear to be
necessary for the minor's welfare, comfort, medical care,
recreation, support and education, without responsibility to the
minor or to any person taking care of the minor: and the remaining
balance in the hands of said Sydney E. Marichak, as Guardian, shall
be distributed to said minor when he or she attains the age of
eighteen (18) years. If such minor dies prior to attaining the age
of years, said Guardian is authorized in her discretion to pay part
or all of his or her funeral expenses and the remaining balance in
the hands of said sydney E. Marichak, as Guardian, shall be
distributed to his or her personal representative. In the event
the funds held by the Guardian for any minor become, in the opinion
of the Guardian, too small for proper and efficient administration,
the Guardian, in her sole discretion, may deposit such funds in a
savings account in the name of the minor.
Page TWo of a Five Page Will
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SIXTH: Any fiduciary under this Will shall have the following
powers in addition to those vested in them by law and by other
provisions of my Will applicable to all property, whether principal
or income, including property held for minors, exercisable without
Court approval, and effective until actual distribution of all
property:
A. To retain any and all of the assets of my estate,
real or personal, without regard to any principle of diversifica-
tion of risk.
. B. To invest in all forms of property, including stock,
common trust funds and mortgage investment funds without restric-
tion to investments authorized for Pennsylvania fiduciaries, as
they deem proper, without regard to any principle of diversifica-
tion of risk.
C. To sell at public or private sale, to exchange or to
lease, for any period of time, any real or personal property, and
to give options for sales, exchanges or leases, for such prices and
upon such terms or conditions as they deem proper.
D. To allocate receipts and expenses to principal or
income or partly to each as they from time to time think proper.
E. To compromise any claim or controversy.
F. To distribute in cash or in kind or partly each.
G. To hold property in their names without designation
of any fiduciary capacity or in the name of a nominee or
unregistered.
Page Three of a Five Page Will
'.
SEVENTlI: I direct that all taxes that may be assessed in
consequence of my death, of whatever nature and by whateVer
jurisdiction imposed, shall be paid from my residuary estate as a
part of the expense of the administration of my estate.
EIGHTH: I appoint my wife, Mary E. Koontz, Executrix of this,
my will. Should my said wife, predecease me, fail to qualify or
cease to act as Executrix, I appoint my daughters, sydney E.
Marichak and Mary Jo weishaupt, co_Executrices of this, my Will.
NINTH: No bond shall be required of any fiduciary hereunder
in any 3urisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to
this, my J;.ast Will and Testament, consisting of five typewritten
pages, the first three of which bear my signature in the margin for
the purpose of identification, this /5'.JI.. day of ffi lIt!mht'r,
1985.
~IJ~-/h'1? t
(SEAL)
Signed, sealed, published and declared by the above named
Testator, Richard G. Koontz as and for his Last Will and Testament
in our presence, who in his presence, at his request and in the
presence of each other have hereunto set our hands as attesting
witnesses.
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Page Four of a Five Page Will
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We, Richard G. Koontz'd l Q, \<.."-\'\'IL.',...~ and Cia, \ .J)~,
~v-,~ , the Testator and the witnesses, respectively,
whose names are signed to the attached or foregoing instrument,
being first duly sworn, do hereby declare to the undersigned
authority, that the Testator signed and executed the instrument as
his Last Will and that he had signed willingly (or directed another
to sign for him), and that he executed it as his free and voluntary
act for the purposes therein expressed, and that each of the
witnesses, in the presence and hearing of the Testator signed the
Will as witnesses and to the best of their knowledge, the Testator
was at that time eighteen (18) years of age or older, of sound mind
and under no constraint or undue influence.
/JJ j._ b -V J-
Tes1~tor ~
Subscribed, sworn to and acknowledged
before me by Richard G. Koontz, the
Testator, and subscribed and sworn to
before me by ~~~':~L"'ti_
and C\a I . (~, ,
witnesses, ih~ 11l(~ ay 0 ovember,
1985.
C\"u..,s ~.~\..." \\-
NOTARY PUB Ie
My eommlulon .,pires lollY 25. 198'
ChambershOra, Frln~lIn Co.. PA
Page Five of a Five Page will
20. If line 19 is gr.ot.r than line 18, enter the difference on line 20. This Js the OVERPAYMENT.
aD
21. If Line 18 II greoler than line 19, .nttr the differencI on line 21. This i. the TAX DUE.
A. Enler the Inll,ISt on the balance due on line 21 A.
B, En'" the 10101 01 Une 21 ond 21A on line 21B, Thi. ;.,he BALANCE DUE,
Make Chick Payable to: bgl.t., of Will., Aglnt
:;:;::'-c"";-;"-,>,,.-..,~ >', BE SURE TO'ANSWER ALL QUESTIONS ON REVERSE SIDE AND TO RECHECK MATH ~~' ",'",
Under penalti., of perjury. I declar. thai I have uomined Ihis relurn, including accompanying schedules and slol.menh, and 10 the best of my knowledge and belief,
it IIttu., corred and complell, I declar. that all real .,tol, hOI been reported at Irue mathl value. Declaration of prepare' other Ihon the penonal r.presentotive is
bosed on 011 information 01 which prepare' hOI any ~now'edge.
SIGN UIIE Of PUSON ON.SIIU fOR fILING RETURN ADDIlESS DAtE 1
. J,' , '/7~~;: u.. /? /1C.5S 'I/:J..C'/11
SIGtA TUllE Of PII 'AllER OTHEIl THAN REPRUENT:'TIVl DATE
R[V.ISOO u.. 17.9"1
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Pi:; .') i q(,-C (, 5c
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
(, ,
~-'
'OR DATlS 0' DIATH Ann 12/31191 CHICK It___
If A SPOUSAL
POVIRTY caron 15 CLAIMID 0
flU NUMB.R
C:,-,
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COUNTY CODE YEAR ':.' NUMBER
, -
OtCIOWI $COMmIE ADOIlUS - JL ,orA-liE e-r
13 ~ 7;OA..' Tit /::rlA .....
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COIIIlI CtL /r-"t'l
AMOUt" IlfcmtD ISU INS1RUC1l0NSj
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Supplemental Return
03,
OS,
Remainder Return
(/0' do'e, 0/ d.olh prior 10 12,13,82)
Federal Ellale Tax Return Required
o A. limited Ellale 0 040. Fulure Inter"l Compromile
Ifor do... 0/ deolh ohe, t2.12.821
o 6. Decedent Died T"tale 0 7. Decedenl Moinlained a li't'ing Trult
(Alloch copy 0/ Will) (Alloch copy 0/ Tru"l
;~. ORRESPONDeNCE:AND,CONFIDENT1AL'TAX'INFORMAnON,SHOULD BE DIRECTED TOf,"- ",'!',::.-;, :':, ',;,;~'(:;',~~ :",:,
NAME j r:- COMPlETE MAIliNG ADDRUS ~ R
S an c::, \ 17 mFttUo;e I-' '
mIP"ONENUM" 3 -/> m echo 1'/1- 17056"""
7 tt" - Y7 3 '/
L 8. Tolal Number of Safe Depolit BaK"
~.l
(1)
(21
(3)
(41_--=-__
(5)_'-13 /';'7~' I'
z
.,
5
::>
t:
:c
lil
a:
1. Reol E.lole (Schedule A)
2. Slock. ond 80nd. (Schedule BI
3, Clo.ely H.ld slock/Portnenhip In'ere" ISchedule C)
A. Mortgagt1 and Notes Receivable (Schedule 0)
5. Calh, Bonk D,polill & Miscellaneous Personal Property
(Schedule E)
6, Joinlly Owned Prop.rty (Schedule F)
7, Tronden ISchedule G)lschedule II
B. Tolal Gran Auah (10101 Lines \-7)
9. Fun.ral Expenlel, Administralive COlli, Miscellaneous
Expen.e, (Schedule HI
10. Debts, Mortgage liabilities_ lien I (Schedule I)
11, Tolol Deduction. ('0101 line. 9 & 10)
12. Net Value of Eslal. (line 8 minulline II)
13. Charitable and Governmental Bequelts (Schedule J)
104. Ne' Value Subject to Tax (line 12 minus line 13)
15, Spou.ol Tron.fe" (for dole. 01 deolh ohe, 6.30-94)
See Inltrudions for Ar,plicable Percentage on Revene
Side. (Include values rom Schedule K or Schedule M.)
16. Amount of line 1.4 laJllabl. at 6% role
(Include values from Schedule K or Schedule M.l
17. Amount of line 1.4 taKable at 15% role
(Include yolue, from Schedule K or Schedule M,)
18. Principal tax due (Add lox from lines 15, 16 and 17.)
19. C,edill Spousal Poverty Credit Prior Poyments
+
+
(19)
(20)
-
-
(6)
(7)
1-;( 15, g'tj, &9
- /,/
-
Y( .
(8). / ,3.5) '7'16. /1
1101
(111--iLl,'?::... 'l~1. 109
-(121 / P. () 0'9~.";~
(13) -
(141 l;;j I . Z'1~, ~;<
(151
(16)
(17)
x._=
/~J 71 f, '-Id.
, ..I
x ,06 ;;it '1; 3 I ~. '11
x .15 =
z
.,
8
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(18)
Discounl
Inler81t
Chuck here if you are requesting a rdul'Id of your overpayment.
(21)
(21AI
(21BI
., I
7lf,;ZW{j;J ltj?.t~~,/JI-
'II;;, 'flf7
RICHARD G. KOONTZ
ITEM I DESCRIPTION
NUMBER
A. Funeral Expenl":
1. Fogelsanger-Bricker Funeral Home, Inc. -
Funeral Services
NOTE: See attached receipt from Funeral Home (attached)
UYlJll (It 1'111
ESTATE OF
B.
4,
C.
1.
2,
3,
4,
5,
6,
7,
8,
9.
. ... -. ..........'.......
~ .:"v
~",',;;/.'.t\
- ~r.oi':ho
COMMONW[AlTH Of PfNN5'1'~VANIA
INHUIlANCf lol. RETUIIN
RESIDENT O[C(O[NJ
SCHEDULE H
FUNERAL' EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
. ,l_Pleal__"-r'-n~r Ty,"_, , _ ,
FILE NUMBER
1996-00630 / il c~.'('" ,-,(. ~(l
AMOUNT
$6,477.00
. Admlnlltrative Caltl:
1.
Personal Representativo Commissions
Social Security Number 01 Personal Representative:
Vear Commissions paid
2,
Allorney Fees -Consultation with Attorney on 8112/96 $125.00
125.00
3,
Family Exemption
Claimant
Address of Claimant at decedent's death
Street Address
City
Zip Code
Relationship
State
Probate Fees at Carlisle PA on August 13, 1996 Cost $270.00
270.00
Mlleellaneaul Expenlel:
Register of Wills of Cumberland County - letters
Testamentary, Short Certificates, etc.
Mother's Death Certificates for proof of her death (no on hand)
News Chronicle Newspaper - legal Advertising-Notice of Death
Hale Real Estate - Real Estate Appraisal Fee
Carl Thompson - Tax Preparation for 1995 overdue taxes
McNeils lock Shop (replacement of locks on house) 8/26/96
Real Estate Taxes Paid 8/26/96
Tritt's Plumbing (repair leak under kitchen sink
Erie Ins. Grou (homeowners)CONTINUED - SEE ATTACHED SHEET OF PA ER 297.00
TOTAL (Also enter on line 9, Recapitulation) S 1..3 :<: \ , t,l\
(If mare Ipaee II needed, Inlert addltlanallheets of lame 1111.)
25.00
25.00
68.74
75.00
100.00
96.72
789.49 - .
44.76
Page 2 of FOnD H
Richard G. Koontz
1996-00630
10. Stamps plus correspondence materials 25.00
11. Trash & Sewer and Recycling
Boro of Shbg. 426.42
12. Baker & Russel (Heating Oil) 921.91
13. GPU Electric (Electricity) 256.65
14. PFG Gas Co. (Gas) 132.66
15. United of PA (Phone Service) 382.97
16. Additional Administrative Services BOO.OO
17. 2/18/96 IRS 1995 Tax return plus penalty
(Note Item 15 indicates $100.00 paid for
late tax return preparation). 262.01
18. Medical Bills 268.84
19. Real Estate Taxes Paid to Elva J. Goodhart 360.46
Tax Collector
20. Haintenance of vehicle before selling 200.00
21. Credit Card Dept Mellon Bank 57.67
22. Lawn Service 111.30
23. Snow Removal 40.00
24. Internal Revenue Service - Paid as a result of
audit of past taxes paperwork attached 757.08
25. Internal Revenue Service 1995
Penalty plus interest 262.01
26. IRS 1996 Tax Return - This does not include
the 10S we paid on the IRA Money 191.00
27. Estate Account Maintenance Fee
Sept. 96 through may 97 32.00
TOTAL $13.881.69
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28221-011-09628-7 9705 CPr 14
~<iii:I Department ollhe Treasury
~&IJII;,ternal Revenue Service
PHILADELPHIA, PA 19255
Dale of this nolice: FEB, 10, 1997
Taxpayer IndenlJly'ng Number 193-12-7775
Form: 1040 Tax Period: DEC, 31. 1995
For ass is lance you may
call us at:
1..,.111..,.,1,11,.,',1.1.1111"..1,1111,1",1,11,1,11.",1111,'
RICHARD G KOONTZ DECD
SYDNEY MARICHAK EXEC
132 N EARL ST
SHIPPENSaURG PA 17257-1206324
1-800-829-8815
CALLER ID. 420;23
REQUEST FOR TAX PAYMENT
ACCORDING TO OUR RECORDS, YOU OWE $262,01 ON YOUR INCOME TAX. PLEASE
PAY THE FULL AMOUNT BY MAR. 3. 1997. IF YOU'VE ALREADY PAID YOUR TAX IN FULL OR
ARRANGED FOR AN INSTALLMENT AGREEMENT, PLEASE DISREGARD THIS NOTICE.
IF YOU HAVEN'T PAID, MAIL YOUR CHECK OR MONEY ORDER AND TEAR-OFF STUB
FROM THE LAST PAGE OF THIS NOTICE. MAKE YOUR CHECK PAYABLE TO INTERNAL REVENUE
SERVICE AND WRITE YOUR SOCIAL SECURITY NUMBER ON IT. IF YOU CAN'T PAY IN FULL,
PLEASE CALL US TO DISCUSS PAYMENT.
TAX STATEMENT
PAYMENTS AND CREDITS
TAX WITHHELD
ESTIMATED TAX PAYMENTS
OTHER CREDITS
OTHER PAYMENTS
TOTAL PAYMENTS 8 CREDITS
$.00
.00
.00
757.08-
$757.08-
TAX
TOTAL TAX ON RETURN
LESS.
TOTAL PAYMENTS 8 CREDITS
OVERPAID TAX
PENALTY
INTEREST
AMOUNT YOU OWE
SUBTRACT PAYMENTS WE HAVE NOT I1lCLUDED ABOVE $
PAY THIS AMOUNT (USE TEAR-OFF ON LAST PAGEl $
$757.08
757.08-
.00
204,41
57.60
$262.01
PAGE 1
. Boo18Z7 .
PHILADELPHIA SERVICE CENTER
193-12-7775
CP, 14
TAX PERIOD, DEC. 31. 1995
EXPLANATION OF PENALTy'AND INTEREST CHARGES
M $170.34 FILING AND PAYING LATE
WE CHARGED A 5% COMBINED PENALTY OF 4 1/2% FOR FILING LATE AND 1/2% FOR PAYING
LATE BECAUSE, ACCORDING TO OUR RECORDS. YOU FILED YOUR RETURN LATE AND DIDN'T
PAY YOUR TAX BY THE DUE DATE OF YOUR RETURN. THE COMBINED PENALTY IS 5% OF
YOUR UNPAID TAX FOR EACH MONTH OR PART OF A MONTH YOUR RETURN IS LATE, BUT NOT
FOR MORE THAN 5 MONTHS, WHICH WOULD TOTAL 25% (22 1/2% LATE FILING AND 2 1/2%
LATE PAYING).
IN ADDITION TO THE 22 1/2% LATE FILING PENALTY FOR THE FIRST 5 MONTHS YOUR
RETURN IS LATE, WE CONTINUE TO CHARGE THE 1/2% LATE PAYING PENALTY FOR EACH
MONTH OR PART OF A MONTH FOR AS LONG AS YOUR TAX IS UNPAID, BUT NOT FOR MORE
THAN 25%. THEREFORE, THE MAXIMUM PENALTY WE CAN CHARGE IS 47 1/2% (22 1/2%
LATE FILING PLUS 25% LATE PAYING).
IF YOU DIDN'T FILE YOUR RETURN WITHIN 60 DAYS OF THE DUE DATE, THE MINIMUM
PENALTY IS $100 OR 100% OF THE BALANCE OF TAX DUE ON YOUR TAX RETURN. WHICHEVER
IS SMALLER. IF YOU THINK WE SHOULD REMOVE OR REDUCE THIS PENALTY, SEE "REMOVAL
OF PENALTY."
M
$34.07 PAYING LATE
WE CHARGED A PENALTY BECAUSE, ACCORDING TO OUR RECORDS, YOU DIDN'T PAY YOUR TAX
ON TIME. INITIALLY, THE PENALTY IS 1/2% OF THE UNPAID TAX FOR EACH MONTH OR
PART OF A MONTH YOU DIDN'T PAY YOUR TAX.
IF WE ISSUE A NOTICE OF INTENT TO LEVY AND YOU DON'T PAY THE BALANCE DUE WITHIN
10 DAYS FROM THE DATE OF THE NOTICE, THE PENALTY INCREASES TO 1% A MONTH.
THE PENALTY CAN'T BE MORE THAN 25% OF THE TAX PAID LATE. IF YOU THINK WE SHOULD
REMOVE OR REDUCE THIS PENALTY, SEE "REMOVAL OF PENALTY."
THE INTEREST RATES ON UNDERPAYMENT AND OVERPAYMENT OF TAXES ARE AS FOLLOWS,
PERIODS PERCENTAGE RATES
UtWERPAYMENT
JANUARY 1, 1987, THROUGH SEPTEMBER 30,1987.....,.......,. 9
OCTOBER 1, 1987, THROUGH DECEMBER 31, 1987..,............. 10
JANUARY 1, 1988, THROUGH MARCH 31, 1988....,.,.......,.... 11
APRIL 1, 1988, THROUGH SEPTEMBER 30, 1988,................ 10
OCTOBER 1, 1988, THROUGH MARCH 31,1989.........,......... 11
APRIL 1, 1989, THROUGH SEPTEMBER 30,1989..,.............. 12
OCTOBER 1, 1989, THROUGH MARCH 31, 1991..........,........ 11
APRIL I, 1991, THROUGH DECEMBER 31, 1991..,.....,......... 10
JANUARY I, 1992, THROUGH MARCH 31,1992.........,......... 9
APRIL 1, 1992 THROUGH SEPTEMBER 30, 1992.............,.... 8
OCTOBER 1, 1992 THROUGH JUNE 30, 1994..,.,......,......... 7
JULY 1,1994 THROUGH SEPTEMBER 3D, 1994...,...."......". 8
OCTOBER I, 1994 THROUGH MARCH 31, 1995.....,.......,...... 9
APRIL 1, 1995 THROUGH JUNE 3D, 1995,.,...............,.... 10
JULY 1, 1995 THROUGH MARCH 31, 1996.............,......,.. 9
APRIL 1, 1996 THROUGH JUNE 30,1996........,.............. 8
BEGINNING JULY 1, 1996.....,......,....................... 9
OVERPAYMENT
8
9
10
9
10
11
10
9
8
7
6
7
8
9
8
7
8
BEGINNING JANUARY 1, 1987, THE INTEREST RATE WE PAY ON YOUR OVERPAYMENT OF TAXES IS
ONE PERCENT LESS THAN THE RATE OF INTEREST WE CHARGE ON YOUR UNDERPAYMENT OF TAXES.
THE LAW REQUIRES US TO REDETERMINE THESE INTEREST RATES QUARTERLY.
WE COMPOUND INTEREST DAILY EXCEPT ON ESTIMATED TAXES FOR INDIVIDUALS OR CORPORATIONS.
WE CHARGE A SPECIAL INTEREST RATE OF 120 PERCENT OF THE UNDERPAYMENT RATE IF,
- THE RETURN, NOT INCLUDING EXTENSIONS, IS DUE BEFORE JANUARY 1, 1990,
- THE UNDERPAYMENT IS MORE THAN $1,000, AND
- THE UNDERPAYMENT CAME FROM A TAX-MOTIVATED TRANSACTION.
WE CHARGE INTEREST ON PENALTIES FOR LATE FILING, OVER OR UNDERSTATING VALUATIONS,
AND SUBSTANTIALLY UNDERSTATING THE TAX YOU OWE. ALSO, WE CHARGE INTEREST ON FRAUD
AND NEGLIGENCE PENALTIES IF THE TAX RETURNS, INCLUDING EXTENSIONS, ARE DUE AFTER
DECEMBER 31, 1988.
PAGE 2
, B0018Z7 ,
PHILADELPHIA SERVICE CENTER
193-12-7775
CP, 14
TAX PERIOD, DEC, 31, 1995
WE WILL CONTINUE TO CHARGE INTEREST UNTIL VOU PAV TltE AMOUNT VOU OWE IN FULL.
If
$57,60 INTEREST
WE CHARGED INTEREST BECAUSE, ACCORDING TO OUR RECORDS, VOU DIDN'T PAV VOUR TAX ON
TIME, WE FIGURE INTEREST FROM THE DUE DATE OF VOUR RETURN (REGARDLESS OF
EXTENSIONS) TO THE DATE WE RECEIVE VOUR FULL PAVMENT OR TltE DATE OF THIS NOTICE.
If ADDITIONAL INTEREST CltARGES
PLEASE PAV THE AMDUNT VOU OWE WITHIN 10 DAVS FROM THE DATE OF THIS NOTICE, IF WE
DON'T RECEIVE VOUR PAVMENT BV THEN, WE WILL CONTINUE TO CHARGE INTEREST UNTIL
VOU PAV VOUR TAX IN FULL. I
WE WILL ALSO CHARGE A PENAL TV FOR PAVING LATE. THE PENALTV IS 1/2~ FOR EACH MONTH
OR PART OF A MONTH VOUR TAX REMAINS UNPAID FROM THE DUE DATE OF VOUR RETURN, BUT
MAV NOT BE MORE THAN 25~ OF THE TAX VOU PAID LATE. IF VOU THINK WE SHOULD REMOVE
OR REDUCE THIS PENALTV, SEE "REMOVAL OF PENALTY."
INTeREST rAID
BEGINNItlG WITH TAX VEAR 1991, VOU CAN NO LONGER DEDUCT INTEREST VOU PAID TO THE
INTERNAL REVENUE SERVICE AS AN ITEMIZED DEDUCTION Otl VOUR FORM 1040, SCHEDULE A.
INTEREST REDUCED
IF WE REDUCE INTEREST THAT VOU PREVIOUSLY REPORTED AS A DEDUCTION ON VOUR TAX
RETURN, YOU MUST REPORT THIS REDUCTION OF INTEREST AS INCOME ON YOUR TAX RETURN
FOR THE YEAR WE REDUCE IT.
INTEREST REMOVED - ERRONEOUS REFUND
THE LAW REQUIRES US TO REMOVE INTEREST UP TO THE DATE WE REQUEST VOU TO REPAY
THE ERRONEOUS REFUND WHEN.
- YOU DIDN'T CAUSE THE ERRONEOUS REFUND IN ANY WAY, AND
- THE REFUND DOESN'T EXCEED $50,000.
IRS MAY REMOVE OR REDUCE INTEREST ON OTHER ERRONEOUS REFUNDS BASED ON THE
FACTS AND CIRCUMSTANCES INVOLVED IN EACH CASE.
NETTED INTEREST
EFFECTIVE JANUARY 1, 1987, THE CURRENT INTEREST RATE WE PAY WHEN VOU OVERPAY YOUR
TAX IS 17. LESS THAN THE RATE OF INTEREST WE CHARGE WHEN YOU UNDERPAV VOUR TAX.
HOWEVER, IF WE REFUND AN OVERPAVMENT TO VOU WITH INTEREST AND WE HAVE TO INCREASE
YOUR TAX AT A LATER DATE, WE GIVE SPECIAL CONSIDERATION TO THE INTEREST ON THESE
ACCOUNTS.
ON THE TAX INCREASE AFTER THE REFUND, WE'LL CHARGE THE LOWER REFUND RATE OF
INTEREST ON THE TAX INSTEAD OF THE HIGHER UNDERPAVMENT RATE OF INTEREST, WE'LL
CHARGE THE LOWER INTEREST RATE ON THE NEW TAX (UP TO THE AMOUNT OF THE REFUND)
FOR THE SAME PERIOD OF TIME WE PAID INTEREST ON THE OVERPAYMENT.
REMOVAL OF PENALTIES - REASONABLE CAUSE
THE LAW LETS US REMOVE OR REDUCE THE PENALTIES WE EXPLAIN IN THIS NOTICE IF YOU
HAVE AN ACCEPTABLE REASON. IF VOU BELIEVE VOU HAVE AN ACCEPTABLE REASON, YOU MAY
SEND US A SIGNED STATEMENT EXPLAINING VOUR REASON. WE WILL REVIEW IT AND LET VOU
KNOW IF WE ACCEPT YOUR EXPLANATION AS REASOIlA3LE CAUSE TO REMOVE OR REDUCE VOUR
PENALTY, THIS PROCEDURE DOESN'T APPLY TO INTEREST AND, IN SOME CASES, WE MAY ASK
YOU TO PAY THE TAX IN FULL BEFORE WE REDUCE OR REMOVE THE PENALTY FOR PAYItlG LATE.
PAGE 3
';'. ":"'l~
'.' .
o CORRECTED
PAYER'S namo. SUOlll addrllus. CIIV. 5Iah!. .,nd ZIP codo
;1LLL':N JAN" Nt.
l~ ~ ~"~~Er S~VA~L
n~~RlS~uR~ ~A l71J~-~u7f
PAYER'S Foderal identlhcnl10n
numbor
RECIPIENrs idDnlilicallDn
numbor
~~-~b5~3ub ~~~-~~-17oL
. RECIPIEUfS namo, s1reel addlass (1l'ICtuding apt. 00-1, ary. slato and ZIP code
1;) T ~t= l\.lCUAl\~\ .; :~Oulii7.
In i1 0:1<1\1. liT
SHIPP~I.S"U;l.li VA 1"1<.:;7,
Account number (optional)
OOZ5b:;~17111
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Retirement Claim No.
CS F1760106W
,
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:5 to ,0.100.17
21 T axablo amount
1.:,ij06.~7
2b Taxablo amount r-71
nol dotormlOod L.i.J
3 Cnpltal Oalf\ (Includod
in bOx 20)
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5
7
9.
lD
locall"" wllhliDId
,
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...... --
2263,00
Oiltnbutlon COde
4.DEATH.BENEFIT
.PAID TO SURVIVOR ANNUITANT PRIOR TO DEATH
To separate, cut on the dotted line
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dilltnbuuon [i]
4 Fodorol incomo lme
wllhhold
O.JI.'
Not unrealized
approclalion ,n
omployor'S socuntios
Othor.
Stalo/P~yer's slate no.
14 Nome of locnli1y
19~t,)
Copy 2
Fllo Ihls copy
with your s1010,
city, or locol
Incomo lox
rolurn, whDn
required.
o
local dlstnbutlOn
OcpartmOnt of tho Treasury. Intemal Revenue SOMcO
Stale 1
.-
tate Income lax WIthheld
tate 2 tate Income tax WlUlnel(l
NONE
NONE
Nole
CarDfully road the enclosed
Information
,~_. ,
'-, l,...
("..
'-..:"
P:~O ~~~:~~~::TE~~g~~~NAGEMENT STATEMENT OF SURVIVOR ANNUITY PAID
P,O. BOX 961 Copy 2. To befllDd wllI1annultanl'. atatD or 1996
WASHINGTON,DC 20044-0961 52-6083699 local tal relurn
SuMVOt'I Sodal SeaJnIy No. ". Federal Income Tax wunneld Gross annuity amount
193.12.m5 NONE
Healtn Insurance Premiums
1194,60 PAID
TO .. RICHARD G KOONTZ
132 N EARL ST
SHIPPENSBURG PA 17257-1206
~
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-
'.. V
1040A (PI U.S. Individual Income Tax Return 1996
Label ISM a. 15.) U.. the IRS label. O1htHWlSlJ. IPRse ont In ALL CAPrTAL lETTERS.
Irul Lnl ",m.
Presldentl lection Ca algn Fund (SOO pago 15,)
Do you want $3 to go to this fund? . , . . , . . , , ,
II a 'oint return, does our spouse want $3 to 0 to this lund?
1 iQ"!)ingle
2 0 Married liling joint return (even if only one had income)
3 0 Married filing separate return. Enter spouse's social security number
above and lull name here, ~
4 0 Head 01 household (with qualifying person), (See page 16,) If the qualifying person is a child
but not your dependent, enter this child's name here, ~
o Qualifying widow(er) with dependent child (year spouse died ~ 19 ), (See page 16,)
Yourself. If your parent (or someone else) can claim you as a depondent on his or her tax retum. do n~t }
check box 6a,
bDSpouse " '
C Oapendonls. II more than six dependents, see page 17, (2) Dependenl's social (3) Dependent's (41 No. 01
secunly nwnber, II born in ,roIalionship months
ived in your
Dee, 1996, see page 18, to you 00me in 1996
''":
....
FOOl1
Depar1menl 01 tho Treasury-Internal Revenuo Service
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IRS Use Onlv-Do nol wflle Of staple In thiS space.
OMO No. 1545.0085
~
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'"II. USlnamlt
For Privacy Act and
Paporwork
Reduction Act
Nollca, see page g.
Vea No
V
Note: Chocking .Yos. will
not chango your tax or
reduce our relund,
- -
5
60
No. at bo..,
checked on
11n.. 61 end 6b
o
1 Fint name
lAslnamo
No. 0' your
children on
1In_ ec who: ffi
. Itveet with
you
. did not UV.
wtth you dUB
to_
ri aepanUon r:r:1
ISH POllo 1811:::c.J
"-'<len1s , r=El
on ec not
.,tered .bon
d Total number 01 exemptions claimed . , . , , , , . , , . , . , , . , , .
7 Wages, salaries, tips, etc. This should be shown in box 1 of your W-2 lorm(s), Attach
Form(s) W.2.
8a Taxable interest income, II over $400. attach Schedule 1.
b Tax-exem t interest. DO NOT include on line 8a.
9
Add numbers
em_In 'rr.l
box" above L.JLJ
, , ~
7$~
8a$~
6b$
Dividends, If over $400, attach Schedule 1.
9 $EEEQEEEJ
10b$rml810~G:J
11b$~
12 $EEEEEEEI
13b~EEElEE3:J
~ 14 ,$~
10b
10a
Total IRA distributions,
11a Total pensions
and annuities,
10a$
11a$
11b
-,
~
;;;;;;
=
~
;;;;;;
=
;;;;;;
~
~
-
;;;;;;
=
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=
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~
14
Unemployment compensation:
Social security ~ 13b Taxable amount
benefits, 13a$~ (see page 22),
Add lines 7 through 13b (far right column), This is your total income.
Your IRA deduction (see a e 22), 15a$
b Souse's IRA deduction see a e 22 , 15b$
Add lines 15a and 15b, These are your total adjustments.
Subtract line 15c Irom line 14, This is your adjusted gross income.
II under $28,495 (under $9,500 il a child did not live with you), see the instructions
lor line 29c on page 29, ~
Attach Copy B 01 W-2 and 1099-R ~ere, Ca1.No,12602S
12
13a
15a
15c$
~
c
16
16$~
1996 Form 1040A page 1
1996 Form 1040A paga 2
17$~
.... ....,
'17 Enter the amollnt from lino 16,
18a ChoCk { ~ou woro 65 or oldor 0 Blind } Entor numb or of
if: 0 Spou.a was 65 or older 0 Blind boxes chackod ~ 180 I
b II you are married filing separately and your spouso itemizes deductions,
see pogo 26 and check here , . . , , , , . . , , " , , , , , . 18b 0
19 Enter the standard deduction for your filing stalus, But see page 26 if you checked
any box on line 180 or b OR someone can claim you as a dependent, . ,: "',
. Single-4,OOO . Married filing jointly or Qualifying widow(er)-6,700
. Head of household-5,900 . Married filing separately-3,350
20 , Subtract line 19 from line 17, II line 19 is more than line 17, enter 0,
21 Multiply $2,550 by the total number of exemptions claimed on line 6d,
22 Subtract line 21 from line 20.11 line 21 is more than line 20, enter 0, This is your taxable income.
If you want the IRS to figure your tax, .ee page 26.' ~ 22
-',
I . ,'"
" .
19
20
21
o
$~
23$~
23 Find the tax on ttie amount on line 22 see a e 26 ,
24a Credit for child and de endent care ex enses, Attach Schedule 2,
b Credit for the elderl or the disabled, Attach Schedule 3,
c Add lines 24a and 24b, These are your total credits.
25 Subtract line 24c from line 23, II line 24c is more than line 23, enter 0,
26 Advance earned income credit payments from Form(s) W-2.
27 Household employment taxes. Attach Schedule H, '
28 Add lines 25, 26, and 27, This is our total tax.
29a Total Federal Income tax withheld from Forms W-2 and 1099. 29a $
b 1996 estimated tax a ments and amount a lied from 1995 return, 29b$
c Earned Income credit Attach Schedule ElC if au have a ali in child, 29c $
Nontaxable earned Income: amount. $ and e .
d Add lines 29a, 29b, and 29c (do not include nontaxable earned income), These are your .
total payments. ' ' . 29d$
30 II Iin~ 29d is more than line 28, subtract line 28 from line 29d, This is the amount you overpaid, 30 $
31a Amount of line 30 you want refunded to you. If you want it sent directly to your bank 31a$
account, see page 35 and fill In 31 b, C, and d,
b Routing ~
number L...Ll.J...J... c Type: 0 Checking 0 Savings
d Account
number
24a$
24b$
24c$
25 $
26 $
27 $
.28 $
32
$
-
~
.-
==
~
.-
==
.-
~
==
==
-
==
-
==
.-
.-
=
.-
~
33$~
34
Sign
here
Keep a copy 01
this return far
your records.
Paid
preparer's
use only
Undor penallles 01 perjury. I dect<lt9 lhat I have examined thiS relum and tlccompanying schedules and statements, and 10 the
best of my knowledge and beliol. they are true. correct, and accurately list 311 amounts and sources 01 income 1 receIVed dunng
the lax year. Declaration of preparer (olher lhan tho la.lpaycr) 15 based on all mformation of which the preparer has any knowledge.
~ Your 5ulnature Dale Your occupation
~
pause's Slgnalure. II jOlnl relurn, 80TH mu5l sIgn,
Dille
Spouse's occupntJon
Preparer's ~
Slgnalure ,
00110
prp rpr''1 'SN
Firm's nnme lor yours ~
I' sell.employedl and
address
Check II
self-employed 0
EIN
ZIP
codo
'us GovtImmltf1IP1lnI1090"oe. 1'}91. 417.6ni&OO10
@ Pnrtl~ on I"Krcl~ P'IH'
1996 Form 1040A page 2
....i
rotm
Depar1menl ollh. T,o,uuty-lnlorn..IIl......nuu Sm\'tce
1040A (PI U.S. Individual Income Tax Return
1996
IR~ Uso Only-Do nol .....'110 Of 51.1010 In lhls spaco.
Label t5ett Iltl "'5) U.e the Ins label, O1h..rwl'ln. >1M51' pMI tn ALL CAPITAL LETTERS.
L .RiCIlard (;
A It.. fOol1l "'lum. lPOU'." "'I n..rNt
o
E
L
H
E
n
E
trl,l
In,1 I..nl"4rl1.
AJJlro
Presldentl lectlon Ca algn Fund (Seo pogo 15,)
Do you want $3 to go to this fund? , , . . . . , ,
If a joint return, does your spouse want $3 to 0 to this fund?
1 ~ingle
2 0 Married filing joint return (even if only one had income)
3 0 Married filing separate return, Enter spouse's social security number
above and full name here. ~
4 0 Head of household (with qualifying person), (See page 16,) If the qualifying person is a child
but not your dependent, enter this child's namo here, ~
5 0 Qualifying widow(er) with dependent child (year spouse died ~ 19 ), (See page 16,)
6a &"" Yoursetf. If your parent (or someono olsc) can claim you as 0 dependent on his or her tax return, do n~t }
check box 6a,
b 0 Spou.. ' ,
C O.pendents.1I mom than six depend.n's, see page 17, (2) Depeodcnt's soci31 (3) Dependent's (4) No, of
secunty number. If born in .raationship ~l~~
Dee, 1996, see page 18. to you home WI 1996
Yos No
V
1 First name
Last name
d Total number of exemptions claimed, , , , , , , , , , , , , , , . , , ,
7 Wages, salaries, tips, etc, This should be shown in box 1 of your W-2 form(s), Attach
Form(s) W-2,
Ba Taxable interest income, If over $400, attach Schedule 1.
b Tax-exem t interest. DO NOT include on line Ba, Bb$
9
Dividends, If over $400, attach Schedule 1,
10a$~
11a$~
10b Taxable amount
(see page 20),
11 b Taxable amount
(see page 20),
10a
Total IRA distributions,
11 a Total pensions
and annuities,
=,
~
=
=
~
=
=
=
~
~
-
=
=
=
=
=
~
=
=
12 Unemployment compensation,
13a Social security ~ 13b Taxable amount
benefits, 13a$~ (see page 22),
14 Add lines 7 through 13b (far right column), This is your total income. ~
15a Your IRA deduction see a e 22), 15a $
b Souse's IRA deduction see a e 22 , 15b$
c Add lines 15a and 15b, These are your total adjustments.
16 Subtract line 15c from line 14, This is your adjusted gross income.
If under $28,495 (under $9,500 if a child did not live with you), see the instructions
for line 29c on page 29, ~
Attach Copy B of W-2 and 1 099-R .here, Cat. No, 12602S
OMU No. 1545.0085
~
[jj]jjTIjJ
-
For Privacy Act and
Paperwork
Reduction Act
Notice, see poge 9,
Note: Checking .Yes. will
nor change your tilX or
reduco our refund.
No. o. bo..,
checked on
lines Sa and 6b
o
No. o' your
children on
11n_ 6c who: ffI
. Uved wtth
you
. did not IN.
wtth you due
to divorce
or IIp8f1ltion ~
(SM page 18) L.:I:.J
Oepend..,..
on 6c nol rn
entered above ~
Add numbers'lJI]
entered In
. . .. boxes above
;a:fn1mj
9 $EEE:QEEEI
10b$I73l810~ I::EJ
11b$~
12 $ EEI.:.]EE[]
13b$~
14$~
15c$ ~
16$~
1996 Form 1040A page 1
1996 Form I O~OA ' paqo 2
",'
'17
18a
Ehlor Iho a~.lInt from lino 16,
Check { ~ou woro 65 or older 0 Blind } Entor numbor 01
": 0 Spouso was 65 or older 0 Blind boxos chocked ..
b II you are married filing soparalely and your spouso ilomizes deductions,
see a 0 26 and check hero , , , , , , . , , , , " , , , , , ~ 18b 0
Enter Iho standard deduction for your filing status, But see page 26 if you checked
any box on line 18a or b OR someone can claim you as a depondent, .
· Singl0-4,ooO . Married filing joinlly or Qualifying Widow(er)-6,700
· Head of household-5,900 . Married filing separalelY-3,350
Subtract line 19 from line 17, II line 19 is more Ihan line 17, enter 0,
Multi I $2.550 b the total number of ex em tions claimed on line 6d, 21
Subtract line 21 from line 20,11 line 21 is mOte lhan line 20, enler 0, This is your taxable income,
II ou want the IRS 10 Ii ure our tax, see a e 26. ~ 22
17 $
18a [2]
.'
19
.'
20
21
22
19
20
$~
23$~
23 Find the tax on lhe amount on line 22 see
24a Credit for child and de endenl cate ex enses, Attach Schedule 2,
b Credit for the elderl or the disabled, Attach Schedule 3,
c Add lines 24a and 24b, These are your total credits.
25 Subtract line 24c from line 23, II line 24c is mote than line 23, enter O.
26 Advance earned income credit payments from Form(s) W-2,
27 Household em 10 ment taxes, Attach Schedule H.
28 Add lines 25, 26. and 27, This is our total tax.
29a Total Federal income tax withheld from Forms W-2 and 1099, 29a $
b 1996 estimated lax a menls and amount a lied from 1995 return, 29b$
c Earned Income credit Attach Schedule 8e if au have a quali in child, 29c $
Nonlaxable earned income: amount ~ $ and e ~
d Add lines 29a, 29b, and 29c (do not include nontaxable earned income), These are your .
total a ments. . ~ 29d$
30 If Iin~ 29d is more than line 28, subtract line 28 from line 29d, This is the amount yOU overpaid. 30 $
31 a Amount of line 30 you want refunded to you. II you want it sent directly to your bank 31 a $
account, see page 35 and fill in 31 b, c, and d,
b Routln9 n-rTrT-rr-r-,
number ~ c Type: 0 Checkln9 0 Savln9s
d Account
number
24a$
24b$
o
24c$
25 $
26 $
27 $
~ 28 $
32
;;33
~
--
-
-
-
--
~
--
~
~
-
--
~
-
-
-
=
;;
--
-
==
--
~
33$~
34
Sign
here
Under penall'6S 01 perJury, r declate that I have exammed IhlS return and accompanying SChedules and statements. and 10 the
be" 01 my knoWledge and be"el, they are lrue, correct, andaccu,,,ely ,,,' aJlamounts and SOOrca, 01 Income' rece~ed durrng
lhe 1l1J( year. Dectarallon or prepllter (other than the ta:cpayerllS based on 4/1 mformahon 0' Which Ihe preptlter has any knowledge.
~ Your sIgnature Date Your OCCupatIon
~
Keep a copy of
this return for
your records,
Paid
pre parer's
use only
Spouse's SIgnature. IljOlnl retum, BOTH must sl9n.
Spouso.s occupation
Dafo
Prepllter's L
Slgnalure ,
00110
Pr~ "rer'S N
Check II
self.employed 0
EIN
ZIP
COOe
Firm', name lor yours ~
I' sell-employed) and
oadress
'US Go....,nmttll PFlI'II.nqOHIC8 lGG1. 0411.617160010
@ PrinrN on t'KycJed ~".,
1996 Form 1040A page 2
'.-1
..
-'-'I"~ -~.-..~.-".,.... ,......, .......,... <_.. ..--...,.,.............:T'-...(::.::'r..f,.~.,....~:.'r-.-..;...f ':'.~.~'f\'.:..., '. .....t(..."..f',.~....
,Schedule 1,; Deportment ollhe Trouu~emaI Ae~ ~eM<~ ::',:,,;j':": '''.'':, ;~.",~.', " ' ''';.'~ :'.,> ,.."..';\ :~;:.r:"
(Forl)11040Aj, :, ,.Interest.and Dlvid.end In~ome ". >\' :~~;:~:~.-i;:;..".l.:;; ,c.',:";,,:;,,, :'" ,,' ',:,-;,'!!':t:, '
.. .,',' ".~. for Form 1040A Filers .".IPJ ." .,.' "',:"1996 ",,;\"".,. " ' ',' 'OI.lBNO,l~
Natnelsllhown on Form 1040A: Af11 MO If1l1141lsl wt Your IO~ ..cumy numb<<
R.trJy.,fY'I 6. . '!<.conTz 1/1913./2tlllll1.,1
Part Ilnte~st Income: (See 'pag~'s-19' ~nd 56,( ,,"{' ~.,; :';.'.:':;/::': ::;i:; ~:"~, ~'o:, ":. . ' , . >>';:.< :.,:.
~ .". ,_. ...... -' . ',,' ..~ ,~ .n:.,."......' l-'i.;'.:.:.. . '. . "
Note: If you received e Form 1099-1NT, Form 1099-0ID, or substitute statement from e brokerage firm,:/
':, "',enter the firms name end thetoteJ Interest shown on'~het (orm:'::}",.- .': :i:,.
1 . Ust name of payer, If any interest Is from a seller-financed mO,rtgage an.~ the buyer . """. '..... '".. '
.. " used the property as a personal residence, see page SO'and list this interest first. i\Jso, ." , ,~,,;;,,.:;,,
,- . show that buyer's social secu~ty number and addressa.,'''-.i:. .'h;' :'.f, ;\~ ,~,,~';.:"r!;;""..2: ......:~., .. ' ',". Amount~ ' ~:~.~. "
11.elbn Bal"l/\ C~/w lV\terec:;t ',1.$ ". G I-~
:~~~~ ~k ~o~f:c~~rket~..: :~ 2 ~I~~
':<$
" t.
,
_'i,.~,$
~. ....
...$
. '''~''''
~:':'$
':.;;';.0:..
"""$
I......
~_..:\:.
'..~.$
~:1;\
.. " ,;~ $
'. .. ~.J)'
: " ':"" ....,.".-",., .:,.,:;;~.~,'>,:~,.,_".,~..,:.~/'..:~..f,{:~
..2 Add the amounts'on line 1.:;' ~\.:~ ,. ;,',,,:,":',~},;.',-".;>~..~~~3-.,,;.;,!,'",.::,:!'...,-;.,;,:;;f'",,:\,,_;::2..$ :? 6" .-
,':3 . Excludable Interest on seHes EE U,S, savings bondsissuedafter1989.fromForln881S;line14;--;'.tW~" ,~,. 'iiii.T"" ..
.~ ';;,-,'~~~...You' ~uiSt'attach t:"oiTrl'88'15tc) FOrm ',04OA ;:,~~,,:-,~~;~':.->~,'!>:~~t.."i.~~~:::f":'b'::;~\:':>':.:~~';~"ff~";.I'"i~it.-;i:;i~".~ - - I ~ . ~
:S'4~SUbtiai:t'ilnti 3-frtim'ii~e:i;Eilt~j-'tiie-ii1~ult iiem~a--ori'Fbr01~'1640A.:iiiia'8a~,;~;'&S:~:i9( $ ~~ 1 -: :-
. ~;.. J',':' .....j. ..'~. . -.~..~ ..:"..t...... ..~. '~-i..:.;......"'-::-,....._.'..............l....,.:"l.;.,....:.:1',~'~~~;.:- "~';~.i~.i'..,;:~f.-.."ir:~..oo;.....,..::.-. ..-~; \............:1 ~..:.'.. :t'$;"* "'';;~=,~.
~.,. '. . .." .; ,". ~.;.,.;.. ,!.' .--:..~:\ :.; .,.......r~. :',~ :f~~:, .oIl.:~:/I:._\ :::J ~f:,;;~V...~f:/..~:....;.;t ~,i~~~3~~~.:~'~7~~~~~f~~....;;t' .~:;.~~'~~.;:~:~,;;" .~..:.~{~~.j\~~ .~.~:~:'::\~~~ ~t~~:~f:
.oP.art 1I,',y,Divldend Income, ,:(5ee pages 20,and,50.\,i:;;~.};::.;',"k/f~~';;~;;::.l:7..'\'r{;,~~)',~;'7,:\:,:~.:"" :.;/:.l.,-...~],.:.L:.,::.
I "r' -. .."'~: .,." ". .:....- ... .. .. ..... to: - .,.' :. . '.- '. ._...,~..,:.::-,,;1.~.. _','",,":,,"'. "..;....._.... ....~.-.!""..;_..V...:....I.....';:". ". ,..,).P'..."'\..~.; ...~ I'," :-1.1 .....1.
-.' '," ':'. '; :\..., Note: If you received aForm'1Q99-DlVor subSt/(Ute.Stiltemen(froma:tirokerifgefirm"enter the fiiin's~?':,,'
~.. .~~. .\' . "..::-"~ " ': .-.~...' . .. ,..' .'d' th' t tal" 'd- 'd d sh.... ....... th' t fe" , :~, ';~';''''':';;:''"' ':.. .....,.;:t. '.-:' ..' ....~': :;'.':,': -.~:... .'i"', ...'t":{:~--:f 1~:'...~. ".
.- - ,.":.. . .... ',......name an e 0 IVI en s own on a. rm...,.~, .,.,~""l' ',..'\. ... ~"'.,o ...,...~;:.,,,.'.. '..t.... ..41..;':"_',:.. "~ t:-.... ,\!,.:..;. "
,-,.. .'.. '.,' '. -'" . .. -:. . - -:-......,. - - .', :." .' . .., . . .. '" . . ';" .~. '.. ~ . ~ .':'- ""'-' .... - .":.\:..,:":"...'..... '- '....j.. ..;- . .'.- ... .. ~ '" ~:.'..'. ';: ." :...'~' ~.~ -.::.. ~'.';. '. '.
'5 '. Ust name of payer .... ._. ~l':'~"':"'" ..' " ~ .. ..:~ "':'.:~. ":"7-~.'.:"1)\f;:::\'~ '~~'..!.;.-~:'.(.'::" ./: -:": .f..,:....;..:..., ~ ~ ~ ,.,: .>~/:.;~Amount :::':',::,.:;- -...
" :'5 $
......
('i,;;~
:;'1<<$
.~.
':"~i.' .
,', $
:::$
,., $
'~ "..
$
- ~", $
.,,$
'$
':'\".
':"$
, '$
$
..
,~ sOIIIIJJ
1990 Schedulo 1 (Form..lll4OAj .
,
.
;
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'.
6 Add the amounts on line 5, Enter the total here and on Form 1040A. line 9. " ,
For I'1Iporwork Reductfon Act Notice, _ Form 1D4OA InstnJctfons, "_' CaL No. 12606K "
. _ @ Pml'wdon~,.".
.US.GPO; '000401.&02
PENN:. ~'" ~~~,!~,!~~~~.~..~~,,~!T.URN 2 ~..""..
Commonweallhol, sylvania I 996 PAOOPnr1~T\(rnIOrROYonult C. "A.40 IOf).l}61
RoylOW aJllhc preprlnlod InlormallOn on your labul ,Hld placo II Hl 1110 name and adtlross aroa.
Mako .1"Y ntcr.UJly conochOn\ 10 your 'Jlll'l .11111 ctun;k "1(! SSNlNAMElADOnESS Ching_ bOI bolow
If you do nol hnve a proprlnted labal. ontor allln'ormatlon - plaasa print.
voun SOCIAL SECURITY ~UMB(R SPCUSE S ~OCtAl SECUlHf't' ~jU'.'OER, 111(1" d 1"11\9 \ep,lI.:a~elf
-.J,:lUfl..JJ:Jl}i .~ _J
=k'oo~t';:~'Po""'c"'iiJ"nQ lot
Home..t3~ N Eqr~
C"IOI s'(17Roensbu r'f}.
o SSN/NAME1AO~RESS CHANOE
II ANY 01 the aCo~e IMlormallon IS dlllell!nl horn your 1995 PA la_ reluln check thl, BOI II your addlenchclnged. also pro-
vide 1M n.1me and IIp Code ellfle Clly. lownsh.p, be/ough 01 municipality ....here you h~cd on 12:31;96
I I I I II "~AO All I"'STRUC~,C"S ef~CR~ CCIJPlET,NG -CUll PA lJ
Nlm. Zip Cod. I~
la Gross Compensation hom W.2forms and other wage statemenlS .. . . .1.1 0 1.1 AUlch your W.2larml to thl
1b Unrclmbursed Employee Buslncss Expenses ham PA Schedule UE .1b lb river.. Itdl of your ,.Iurn.
le Nel PA Ta.able Compensation. Subtract Ilno lb from hne la . . .1e lc
2 PA Taxable Inlere51 (Complele and allaeh PA Schedule A ,lover 51,000) , ' , ,2 2
3 PA Ta.able DiVidends (Complete .1nd allach PA Schedule B it over 51.000) . . .3 - 3
4 Netlneome or (loss) horn the OperatIon 01 a Busmess, ProfeSSion or Farm. . , .4 4
5 Net Gain or (loss] from the Sale. Exchangc or Disposlhon 01 Property . .5 5
5.1 Amount 01 Gain Excluded from PA Schedule PA.19. ........................ .5.1 5.1 Do not ,dd or deductlln. Sa
6 Net Income or ILossllrom Rents. Royalllcs. Palents and Copynghts . . . . . . . . . .6 6
7 ESlale and TlUstlneome ' , , , ... ' . ' .... .. ...., . .. . .. .7 Cl 7
8 Gambling and lOllory Wlnnmgs . . . , ..... . .. . . . .. . .8 - C> 8
9 TOTAL PA TAXABLE INCOME Add hnes Ie, 2. 3, 4, 5, 6, 7 and 8, Do no' ,ubUlet . 110"1 reponed 9 9
on on. or marl linn Irom Ih. profll.lncom. or glln on tny olh.r Income linl. Not can 'pou..' offllll each oth.r', Incom. tnd llonnllvln lion the 11m. Ilnl.
10 PA TAX LIABILITY Mull,ply line 9 by 2,8~. (0,0281, ..,........ ........,..,.... ..10 26
11 Tolal PA Tax W,lhheld from W,2 10lms, ele. .",...", . , ' , .. ' , . , .. ' , .. . .. , ' , .. ' , , , , , .. ' . , ,II 0
12a Cred,llrom 1995 PA Tax Return 1- C -t===:J 12e Paymenlw,lh 1998 Exlension.." ,.."" ,.,..'
12b 1996 Esllmated Payments - C J;;] 12d Nonresident Tax Withheld from PASChedules NRK.l
12e Tolal ESllmaled Payments and Cred,ls Add hnes 12a, 12b, 12c and 12d ' , .., , , . ' . .. ' , , ' , , ' , , , .. , ,
13a Household Members flam PA Schedule Sp, Pan II. line 4 ,13a 0 13a
13b Your Elig,b,loly Income from PA Schedule Sp, Pa~ Ill. lone 2 . ,'" ,13b - 0
13c Your TOlallncome Irom PA Schedule SP Pa~ III, hne I . " , , ,13c 0
13d Ta. ForgIVeness CredIt from PA Schedule SP, Pan Ill, line 7 .,.....,... .13d
14 Tolal Credit for Taxes Paid to Other Stales or Countries from PA Schedule(s) G . . . , . ., . . .14
15 Employmenllncenllve Payments Credlllrom PA Schedule \'II. .,.""..... .15
16 TOTAL PAYMENTS ANO CREDITS Addl,"e. 11. 12e,13d, 14 and 15 ,16
17 PA TAX OUE Lone 10 IS more Ihan hne 16 ............"........,.. ,17 - 17
Make check payable 10 PA OEPT, OF REVENUE, USE YOUR PAN.
18 OVERPAYMENT Lone 16,s male Ihan hne 10 ' .18 0 ---l..- 18 Check all your calculations
IMPORTANT: The lotal 01 hnes 19a through 19d must equal line 1 e. Please do not call about your rolund unlll 8 woeks aller lilin
19.1 Amount 01 line 18 you want as a Refund Check malted 10 you . .19a 19a
19b Amount 01 line 18 you want Credited 10 your 1997 ESllmated Ta. Account .19b 19b
19c Amount of line 18 you wanl to Donale to the WIld Resource ConservatIon Fund 19c 19c
19d Amount of line 18 you want to Donate to Ihe US OlympIC Commlllee. PA DiVISIon .19d 19d
SIGH YOUft IItT\111lt. Unci" ptlUftltS otlltflUl'r, II...." NIII9 fOIIllI,1 ~KlJrt ltl.ll lfftl II'" II,,","" tM rttum, 1I'du~1lI,'U 'tCOlnlllllflll' Kfltdllln 'lid It.I!lmrnts. 'illS 10 UIt lln1 01 my 1011I1 bettd, II is'''''. C<<TtC1'1lCI tomplttl.
EJ
SI,l!e
ZiP Code
17 2 t;7
o fiSCAL YUH nLEn
Frnm I '0
TYPE FILUt IChl(1I Onl't 0"11
slY'" MD JO
S"V'j!fl 'hrr;{'tj ~hffl~
F,h"qSepm:e1f F~"'9JO."lry
II chUCklOq bot ~ bccausc tho l.uP.1yot 1$ do,
(c.ued r.nlnr 1M 0,11(' 01 Death I '
RESIDENCY STATUSIChlCIl Onl't aMI
R [l;y' NR 0 P 0
Re\lIJenl r4onre\oCel'll P.1r':'ye.1rfeSlIJenl
Enler thO lime you were J PA resldenl
Irom I I /90 10 I 196
HALl, OF 5CH~~~L~~~~ifVl
SCHOOL ~~
FO
FlOal
eA
2. I
8'00
OPTION FOR A 1197 BOOKLET
o Check II you will nol need a '997 PA Tax Booklel
PLEASE DO NOT USE CENTS. ROUND 10 WHOLE. DOllARS
12e
You must file by
13b Apr1115,1997.
13c File early, II you con,
_ 13d
_ 14
o 15
_ 0 16
See instructions for
HOW TO PAY
VourSIIilM,ufl
Dolle
O.l,l,",,,T.I.p"OI",,Num~'
Spout.. Sililnlluf. {If IlhnIilIOlnU"
C..!e
BE SURE YOU
(AND YOUR SPOUSE) SIGN
P,t'P"f'" O. COfT'P.Jny tU"," 0'''''1 llltn 1.\lpJ.."\\ b..,e() on 03,1 ,,,IO"".ll,cn 01 ....",ch !.." p"'rllt'. /'1,n 1"'1" ."c""lld~1l 'DOUDLE CHECK ALL "'ATH' ATTACH ALL SCHEOULES AND FORMS.
I D." I ~.."'''. ":'"'' """'"
NEXT YEAR. you Will also t:c atJlo fa make a donaliOn 01 all or pan 01 your ovcfpavmenlto the ORGAN DONOR AWARENESS TRUST FUND.
'-
.'
........ ':' ...",'
.... ;. '.:. .,......',~~~ ':' i,
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OMD No, 1545-0074 ~. 2
Your loc11l security nwnber
I "3: 2: S"
Attachment
Sequence No. 08
" ';,,:
Schedules A&D (Form t(40) 1996
Name(sl !hewn on F 10"0,00 not M110f...na
. '.' :~'"''''''
Part I
,Interest
Income
(See pogo B.1.)
Note: If you
received a Form
1099.INT, Form
1099-010, or
substitute
statement from
o brokOfago firm.
list the finn's
name as the
poyer and ontOf
Iho lolallntorosl
shown on thaI
form,
Part II
Dividend
Income
(Se<i pogo B-1.)
;i'
....
Note: If you
recoived a Fonn
1099-01Vor '
substituto
statement from
a brokerago
finn, list the
finn's name as
tho payer and
onler the tolal
dividends
shown on that
fonn, ' '
Part III
Foreign
Accounts
and
Trusts
Schedule B-Interest and Dividenllncome
',.
, Nole:" ou had ove, $400 in taxable interest income, ou must oJso CDm 'ete Port lit,
'1 ,'Ust name of payer, If any Interostls lrom a seller-financed mortgage' and the
buyer used the property as a personal residence, see page B.l and list this
Inter st first. Als ,show th buyer;s social security number and addross ~
. .~. '..
Amounl
,
" ,
.... . . - ;... ;'"
...................................:'......~..u....................................................
, ,
.........................................................-....-....................-...........
..............................................................................................
...... .........................~ ...:.......... ..... .... ....~ .....~ .... ......... ....... ..~.: .~~ .....:~..;.~.. ::. .... .
1
.,':.
............................................................................................
.......... ,.......... .I.'~ ;.:............. ~...~... .t~.::~~;::.:...~..~.;.:........... :..~.:.:.' .'.............
. , '
.............................~.................................................:.....................
. .. ,', .,
............. ~ .........-... .... ............... ....~..... "-... ........:. ........ ~.. .~....~........t~ .'-::7~.".: .::
......................................................................................................................
. . '. . . .' ~ :.! . , ..' ~ _.; .. :;.~.f 1 ..... '.1 .... ::: .:
..,.......................................................................................................................
2 Add the amounts on line 1 '." : .. '; ..,. .. '. ':;,: . ;',;,.,:::',':':.:; 2
.. -' ., ,. .. ... . ..,...,.....
3 Excludable Interest on series EE U,S, s8vlngs'txinds Issued 811er1989 trOm Form .",:,,:.,'"
BB15,IIne 14, Vou MUST attach Form 8815 io Form 1040 .:, -:,/:,:.~';.~,";;,:-,' '., 3 ,,,"-': 0- '
4 Subtract line 3 from line 2, Enter the result tiere orid'oil' Form 1040 firie 8a ~ . 4" "
Note: If ou hod over $400 in ross dividends andlor otherdlsttfbutfons on stock.' must oJso com lete Port lit,
5 Ust name '0, payer. Inclu~e gross ~lv.ld~ndS ll!1di.os~iti'~(~IStribuil~i,;;Ji:9:,~6ck, . _~ount
, here, Any capital gain distributions and nor)loxable i:IIstrlbutlons will b800ducled ' '."';' . ".;'
'~~.~~~:~:~_~.~~~.~.:::::::~:::~:r::::::::;:::~~~:~~~Z~:':~~:~]:\fr~~~i:::: :" " ' '
......... .~....... -. ---...... -... - ,.................. ........ ----. -. -.-..-..---.... -.....
. " :....'.. ;.. ~.. '.,'- . . '
.................................................................:.~......:............-.~..................
...:":1'."","
-
-
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5
. . . ...
..............................................................-.......................................
, "
... .......~......... :....... ......... ~.........:.. :........ ........ .... ........ ........ .;....-:...........
. '.,
..................................................................................................
, .
6 Add the amounts on line 5 , . '.' .' , :,., '. , .-
7 Capital gain distributions, Enter here and on Schedule 0' . 7
8 Nontaxable distributions, (See the Inst. for Form 1040, line 9,)' 6
9 Add lines 7 and 8 . , '. . . .'. . , . . '..' .' .. . . . .
1'0 Subtract line 9 lrom line 6, Enter therosult hero and on Form,l040, line 9 . ~ 10
'If 'you do not need Schedule 0 10 report any other gains or lOsses, .see the :,
Instructions for Form 1040, line 13, ., . ;,
,Vou must complete this port if you (a) had over $400 0' Interest or dividends; (b) had a lorelgn account; or
(c) received a distribution lrom, or were a grantor of, or a transferor to, a foreign trust. " ,~,.,
6
"
'..-. '.-
o
11a At any time during 1996, did you have an Intereslln or a sl9nature or other authority over a financial
account In a foreign country, such as a bank' account, securities account, or either financial
account? See page B-1 lor exceptions and filing roquirements for Form TO F 90-22, i " , . ,
b If "Ves," enter the name 01 the lorolgn country ~ ___....................._...._......-.._................
12 Ourlng 1996, did you receive a distribution from, or wero you the grantor of, or transferor to, a
forei n trust? If "Ves," see a e B-2 lor other lorms ou ma have to file ."",
For Poperworlc Reduction Acl Nollce, 50. Fonn 1040 InstructJone, @ "'nrod on _ PO"" Sch.dule B (Fonn 1040) 1996
'usOPO"gge.",01.502
(S..
page B-1.)
SHORT CERTIFICATE
I
I
I
i STATE OF PENNSYLVANIA
1
i COUNTY OF CUMBERLAND
I, MARY C. LEWIS
Register for the probate of Wills and Granting
I
Letters of Administration &c. in and for said
county of CUMBERLAND do hereby certify that on
the 15th day of Auqust A.D.,
one thousand nine hundred and ninety six.
Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
, late of SHIPPENSBURG BOROUGH
estate of KOONTZ RICHARD G
\W\~'l', r .Ll'l~'.L'1 J:4lJ.UUL~)
alkla KOONTZ DICK
in said county, deceased, to
MARY JO WEISHAUPT
lW\~'~' r.L~~'t, M.LUU~~J
SYDNEY E MARICHAK
\LA~'~I rl~~~1 M.LUU~~J
and
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand
of said office at CARLISLE, PENNSYLVANIA, this 15th day
A.D., one thousand nine hundred and ninety six.
File No. 1996-00630
, PA File No. 2196-0630
Date of Death 08/01/1996
S.S. t 193-12-7775
and affixed
of August
the seal
cmM(j (', 'f.'~ fwJ ;{O'/! Al,df' Regl,'"
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
"\/.IJOtU.(I_11)
~
SCHEDULE E
CASH, BANK' DEPOSITS AND
MISCELLANEOUS
PERSONAL PROPERTY
I Ploa.o Prlol or Ty 0
FILE NUMBER I
1996-00630 / lit' '.:llq~- ~('3,'
ESTATE OF
COMMONwrAUH o. peNNSYLVANIA
INH""ANC' rAX .nu'N
".ID.N! D.e.D.Nl
RICHARD G KOONU
IAU p'.p.rty 1.,.t1y.ow..d wllh ,h. R"hl .f Surv/....hlp mUll b. dlu/.,.d .. Schodul. '1
ITEM
NUMBER
DESCRIPTION
VALUE AT
DATE OF DEATH
NOTE: PLEASE SEE ATTACHED ,INFORHATlDN
(Attach additional Sl\- )( II- .hee'. if mort .poce it needed.)
s'I.3 ;J.?O'/I
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, ';r:'~~~~~:", 25711101;~~~f' <-'i\:~- u.;c.-~ "
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ashier's Check', . @ Mellon Ban~
, ~rllon Bank, N,A,
: >hlladrlphla. PA
nale
34'310
DECEMBER 20, 1996
6133367 9
, , Amount '
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<:. '-'I ~ .;.,1 ',.,'.~.' ..,
roth.~o~T. OF RICHARD G. KOONTZ - SYDNEY E NARICHAK& ~!ARY JO WEISljAUPT, $***,f13,806.17***
l.U- :EXECOTORS**if
I Remill.r IRA
M.mo 355-100482/418676
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~ ERIE INSURANCE GROUP
ERIE.
NOT VAllO UNl!SS PRfSENTEDWlTIlIN 60 CAYS OF CATE
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CATE
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11 14 96
Pay 10 the
ordor of
THE ESTATE OF RICHARD G KOONTZ,
132 NORTH EARL ST
SHIPPENSBURG PA 17257-1206
$34.00 I
CODe
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Exactly *****34 Dollars and 00 cents
AGENT
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POUCY NUMBER
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RICHARD G KOONTZ
132'N EARL ST
SHIPPENSBURG PA 17257
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Acct 43226772B9 I Personal Banking ~ SMART Bonus Pg 1 or ~
KOONTRG.02 org 0442 Ragion 0275l-checking with Inte~~t posted 07/1
_____________Amounts------------- ____________Account Information-------------
Ledger 2,311.11 00 limit Not Avail
close 0 Return and charge
No Close 1 Unc funds Not Perm
Notices S payment cd 0
cycle cd 018
Mail Regular
Safekeep checks No
SC waiver 0
Last trans 07/16/96
Principal
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Accrued int CTD
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Fed tax whld YTD
Fed tax exempt code
10.06
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Last stmt
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03/29/80
07/09/96
410.00
Monthly
06/26/96
2,133.11
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opened
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Last stmt
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08/13/84
09/28/95
600.00
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06/26/96
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Acct 4100703430 f personal Banking '\ Pg 1 of J
KOONTRG.02 org 0441 Region 0275~oney Market Accoun~ posted 07/1'
_____________Amounts------------- ____________Account lnformation-------------
Ledger 8,578.59 00 limit Not Avail
Close 0 Return and charge
No Close 1 Unc funds Not Perm
Payment cd 0
Cycle cd 018
Mail Regular
Safekeep checks Yes
SC waiver 0
Last trans 06/26/96
Secondary
F6=Toggle
~ .
We, Richard G. Koontz, ~l,Q,R"-\"dt.,.~~"" and Ch\"...V~,
~,~ ~~ , the Testator and the witnesses, respectively,
whose names are signed to the attached or foregoing instrument,
being first duly sworn, do hereby declare to the undersigned
authority, that the Testator signed and executed the instrument as
his Last Will and that he had signed willingly (or directed another
to sign for him), and that he executed it as his free and voluntary
act for the purposes therein expressed, and that each of the
witnesses, in the presence and hearing of the Testator signed the
Will as witnesses and to the best of their knowledge, the Testator
was at that time eighteen (18) years of age or older, of sound mind
and under no constraint or undue influence.
(0" 1.- b -z/. .J
Tes~~tor ~
tness ",
( I v. " \\
~ -..-J.'
W tness
Subscribed, sworn to and acknowledged
before me by Richard G. Koontz, the
Testator, and subscribed and sworn to
before me by ~~~'~~kN"~
and 0a 1 . ,.". ( , ,
wi tnesses, ih~ I~ ~ ay 0 ovember,
1985.
C't:1! ..oS ~ .(~Sl..." ~'-"
NOTARY PUB Ie
My eommlulon 8Illlres MIV 25. 198"
C~.mbe"""rR, Franklin Co" P^
Page Five of a Five Page will
SEVENTH: I direct that all taxes that may be assessed in
consequence of my death, of whatever nature and by whatever
jurisdiction imposed, shall be paid from my residuary estate as a
part of the expense of the administration of my estate.
EIGHTH: I appoint my wife, Mary E. Koontz, Executrix of this,
my Will. Should my said wife, predecease me, fail to qualify or
cease to act as Executrix, I appoint my daughters, Sydney E.
Marichak and Mary Jo Weishaupt, Co-Executrices of this, my Will.
NINTH: No bond shall be required of any fiduciary hereunder
in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to
this, my Last Will and Testament, consisting of five typewritten
pages, the first three of which bear my signature in the margin for
the purpose of identification, this 1S".it- day of Akvemhl!r;
1985.
-b?-J. . ,l~ 7(-{
(SEAL)
Signed, sealed, published and declared by the above named
Testator, Richard G. Koontz as and for his Last Will and Testament
in our presence, who in his presence, at his request and in the
presence of each other have hereunto set our hands as attesting
witnesses.
I,
/j-n" /fp/"LtA-V1 1/,1./ ~~j<f1-'4.
Address
.5')\/ qj i-:fh({t'--f/J_lI.5f OJUlWO,MUL~J{ tc~,
A dress ' , '
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. .
Page Four of a Five Page Will
SIXTH: Any fiduciary under this Will shall have the following
powers in addition to those vested in them by law and by other
provisions of my Will applicable to all property, whether principal
or income, including property held for minors, exercisable without
Court approval, and effective until actual distribution of all
property:
A. To retain any and all of the assets of my estate,
real or personal, without regard to any principle of diversifica-
tion of risk.
{
~
r'JS
B. To invest in all forms of property, including stock,
common trust funds and mortgage investment funds wi thout restric-
tion to investments authorized for Pennsylvania fiduCiaries, as
they deem proper, without regard to any principle of diversifica-
tion of risk.
C. To sell at public or private sale, to exchange or to
lease, for any period of time, any real or personal property, and
to give options for sales, exchanges or leases, for such prices and
upon such terms or conditions as they deem proper.
D. To allocate receipts and expenses to principal or
income or partly to each as they from time to time think proper.
E. To compromise any claim or controversy.
F. To distribute in cash or in kind or partly each.
G. To hold property in their names without designation
of any fiduciary capacity or in the name of a nominee or
unregistered.
Page Three of a Five Page Will
1
t'
~
<$
" .
Thousand Seven Hundred Fifty ($8,750.00) Dollars. It is my desire
that any amount outstanding on this debt be deducted from Mary Jo
Weishaupt's share of my estate.
FIFTH: In the event that anyone entitled to a share of my
estate should be under the age of eighteen (18) years at the time
for distribution to him or her, I constitute and appoint Sydney E.
Marichak, Guardian of any property which passes either under this
will or otherwise to said minor. In the event the said Sydney E.
Marichak is unable to act as Guardian, I appoint Mary Jo Weishaupt
in her stead. Said Sydney E. Marichak, as Guardian, aforesaid,
shall, in her sole discretion and without Order of Court, use
principal as well as income from time to time as may appear to be
necessary for the minor's welfare, comfort, medical care,
recreation, support and education, without responsibility to the
minor or to any person taking care of the minor; and the remaining
balance in the hands of said Sydney E. Marichak, as Guardian, shall
be distributed to said minor when he or she attains the age of
eighteen (18) years. If such minor dies prior to attaining the age
of years, said Guardian is authorized in her discretion to pay part
or all of his or her funeral expenses and the remaining balance in
the hands of said Sydney E. Marichak, as Guardian, shall be
distributed to his or her personal representative.
In the event
the funds held by the Guardian for any minor become, in the opinion
of the Guardian, too small for proper and efficient administration,
the Guardian, in her sole discretion, may deposit such funds in a
savings account in the name of the minor.
Page Two of a Five Page Will
X
I'
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~
LAST WILL AND TESTAMENT
I, Richard G. Koontz, of 132 North Earl Street, Shippensburg,
Pennsylvaia, being of sound and disposing mind, memory and under-
standing, do hereby declare this to be my Will, hereby revoking any
and all former Wills and Codicils thereto by me at any time hereto-
fore made.
FIRST: I direct that all my just debts and funeral expenses,
including all expenses of my last illness, shall be paid from my
estate as soon as practicable after my decease, as a part of the
expense of the administration of my estate.
SECOND: I give, devise and bequeath the residue of my estate
of every nature and wherever situate to my wife, Mary E. Koontz,
providing she shall survive me by thirty (30) days.
THIRD: Should my wife, Mary E. Koontz, predecease me or die
on or before the thirtieth (30th) day following my death, I give,
devise and bequeath the residue of my estate of every nature and
~J...,( 11/1~'ly~-
wherever situate to my children, namely, sydney E. Marichak and
Mary Jo Weishaupt, in equal shares, provided that the share of any
child who predeceases me or dies on or before the thirtieth (30th)
day fOllowing my death shall be distributed to her issue, per
stirpes, living on the thirty-first (31st) day fOllowing my death
and in default of any such then living issue, such share shall be
added to the share or shares for my other child.
FOURTH:
I have previously loaned my daughter, Mary Jo
Weishaupt and her husband, Walter J. Weishaupt, the sum of Eight
Page One of a Five Page Will
J [, I.
1--\
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NOTICE Of BE,tiEflCIAI. INTEREST IN ESTAT~
BEfORE THE REGISTER Of WIU,S, COUNTY Of (1lrn~L(~ PENNSYLVANIA
In re Estate of Ric)Ja....r..d::5, KO{lI) 7"2...., deceased,
No.
of
TOI/TtA.9 -:S" WPIS~
116 Lt1 pAVe."
cS h :t:: -A- I 1.<. 57
. PIe se take notice 01 the death of deced~nt
letters to the personal representative(s) named
a beneficial interest in the estate as follows:
'1}f:<J!jp9::lh9.J~.M.L~ ~ ~I~L~ L~ f'
q ,-<;~, rnilf1iJat!>eneficiarYl
/'7 '7Y1~l/1tr f);r, (address)
.
-mel./1. PA )7(J5~
./ ~
and the grant of
below. You may have
Jrt.L'L.I_~~ j ~
(if additional spac~~s needed, use back of page)
Nameot deceaent meh/) rei f;. ;-<;MI:z.-
Last known address /3.:J.. /I, f:~ / ~7
of decedeo' ;;'/~7i!~ 1" rr /70167
Date of death 1-;
Place of death {l MJ77 .btGrs tUI.rC,
{
County of grant of origin,l letters
, ~rr
'(lJU'YJ btrlo.-M
Decedent died testat~
A copy of the will ~ is
intestate.
is not attac~ed.
Name(s), address(es) and telephone number(s) of all personal
representatives appointed
Name
Address Telephone
J 717-
/7 Ih':vJ ()fO n r, 1mI'd Ph 7lt.'~:"~"i?
I _ I." 717-61""-
11_Q..~Aj, Ave, ,-cJ/,t I f'H 4.!lL!'
{:t~~ ~~
\
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Name(s), addressees) and telephone number(s) of all counsel
Name
'7L.rrvt-
Additional information may
Date /}Jt-lA., I. ~ ;Q1t,.
./
___"W,~._;.p, .
.
.
"-... ,,~~..~.....~--,._-
Address
Telephone
be obtained from the undersigned.
Signature ~,d"'l;~ J7:.~~
Name ~,dJl v- ~ l!. /7?/l rl/" )u((,,,,c:
Address ) 7 7n/1..h/i r c> ~
//J .p ( ), .r' )I}- /7 A5S
,
Telephone 7/, - 7/../.. - 3 ?tf ~
Capacity: L~rsonal Representative
Counsel for personal
repreSentative
rJ //tJ 'J
BUREAU Of INDIVIDUAL TAKES
INIIIRIUHCI lAM DivISION
DUll. :'lIObOI
tlAIINISftURC, PA 1110'11 obOI
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
~~~
NOIIcr Dr INltrRIIANCr TAK
APPRAlsrNINT. ALLOWANcr OR OISALLOWANcr
or DEDUCTIONS AND ASSESSNLNT or IAK
II.jh'lI u, Inti,
SYDNEY E MARICHAK
17 MANOR DR
MECHANICSBURG PA 17055
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
07-28-97
KOONTZ
08-01,96
21 96-0630
CUMBERLAND
101
RICHARD
G
r"~c=~~~~~~~~.!~~~i}~d - - ,1
I
MAKE CHECK PAYABLE AND REMIT PAYMENT ro:
REGISTER OF WILLS
CUM8ERLAND CO COURT HOUSE
CARLISLE. PA 17013
CUT ALONG TMIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV :i5'4'7 " EX"AFj>""fo3: 97"j - Noi'"icEuoi' - "iNti Eiii i' AN"CE -r AX - APiiiiA'i sEMENi'";" AL.i."OWAN-cE"oli"" _m_m_ - -" - --
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF KOONTZ RICHARD G FILE NO. 21 96,0630 ACN 101 DATE 07"28"97
TAK RETURN WAS: I X I ACCEPTED AS fILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R..l Est.t. (Schedule AI el)
2. Stocks and Bonds (Schedul. BJ (2J
3. Closely Hald stock/Partnership Interast (Schedul. CI (3)
4. Hartg.gas/Not.. Racelvable <<Schedule 01 (41
S. C.sh/Bank Deposits/Hilc. Parsonal Property (Schedule E) 151
6. Jointly Owned Property (Schedule f) (6)
7. Transfars ISchedule GI (7)
8. Total A...t.
CHANGED
NOTE: To insure proper
credit to your account,
subnlt the upper portion
of this forn with you~
talC pay.ent.
92.500,00
,00
,00
.00
43.280,11
,00
.00
(BI
135.780.11
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expen.e./Adn. Costs/Hisc. Expense. (Schedule H) (9)
10. Oebt./Ho~tgage Liabi1ities/Lians (Schedule II (10)
11. Total Oeduction.
12. Net Value of Tax Return
15. Charitable/Governnental Seque.t. CSchedule J)
14. Net V.1ue of E.t.t. Subject to Tax
13,881.69
,00
(111
U21
U31
U41
13,88T 6'l
121.898,42
,00
121.898.42
will
If an assessment was issued previously, lines 14, 15 and,or 16, 17 and 18
reflect figures that include the total of ~ returns assessed to date.
ASSESSMENT OF TAX:
15. A.aunt of Line 14
16. Allount of Lin. 14
17. Aaount of Line 14
18. Principal TalC Due
NOTE:
at Spou..l rat.
taxable at Lin.al/Cla.. A rat.
tax.bl. .t Collat.raI/CI... B rate
USI
U61
U71
.00 X .00=
121.898,42 K ,06=
.00 X ,15=
UBI
.00
7.313,91
.00
7.313,91
TAX CREDITS:
PAYNENT
DATE
04"30"97
DISCOUNT (+1
INTEREST'PEN PAID (-I
,00
RECEIPT
NUNBER
AA211244
ANOUNT PAID
7.313.91
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
7,313.91
.00
,00
.00
. IF PAID AfTER DATE INDICATED, SEE REVERSE
FOR CALCULATION Of ADDITIONAL INTEREST.
If TOTAL DUE IS LESS THAN S1. NO PAYNENT IS REQUIRED.
If TOTAL DUE IS REflECTED AS A "CREDIT" (CRI. YOU NAY BE DUE
A REFUND, SEE REVERSE SIDE Of THIS fORN FOR INSTRUCTIDNS.I
'_jCJ
RESERVAtlONI E.t.t.. of a.c.a.nt. aylng on or bafora O.c.~.r 12, 1982 -- If any future Intara.t In the ..t.ta I. tr.n.farraa
In po.....lon or anjoy..nt to CI... B (coll.t.r.l) ben.flclarl.. of the a.caa.nt ftft.r the a.plratlon of any ..tata for
Ilf. or for vaar.. tha Co"on~.alth h.r.by ..pr...ly r...r~.. tha right to .ppral.. and ...... tran.f.r Inh.rlt.nca T....
.t the l.wful CI... B Icollat.r.l) rat. on any .uch future Int.r..t.
PURPOSE Of'
NOTICEI
To fulfill the requlr..ant. of Section 2140 of the Inh.rltanca ana E.t.t. Ta. Act, Act 21 of 1995. (72 P.S.
S.ctlon 9140>>.
PAYMENT:
O.tach tha top portion of thl. Notlc. and .ubalt with vour Ply..nt to the Aagl.t.r of Will. printed on the r.~er.. .Ia..
"Hak. check or .oney order pay.ble to: REGISTER OF MILLS, AGENT
REFUND ICA):
A r.fund of . taM credit. ~hlch wa. not requ..tad on the T.. Raturn, .ay bl reque.taa by co.platlng an "Appllc.tlon
lor Aalund 01 P.nn.yl~anl. Inheritance .na Est.tl r.." (REV-IlIl,. Appllc.tlon. ara av.llabl. at tha Offlc.
of the R.gI.ter 01 Will., any of the Z3 Revlnu. DI.trlct Office., or by c.lllng tha special 24-hour
an.werlng .arvlc. nu.ber. for for.. ordering: In Pann'ylv.nl. 1-800-362-Z050, aut.la. Pann.ylv.nl. and
within loca. H.rrlsburg .re. (711) 181-8094, TOOa (111) 172-22S2 (Heartng 1~.lred Only).
OBJECTIONS I
AnV Party In Int.r..t not ..tlsfled with the appral.eaant. .llowanc. or dl..llowanc. of deduction., or .......ent
01 taM (InclUding dl.count or Inter..t) .. shown on thl. Hotlce aust object within sl.ty (60) a.ys of r.C.lpt 01
thlt Notlc. bYI
AO"IN
ISTRATIVE
CORRECTIONS:
--~rltt.n prot..t to the PA nepart.ant of Aav.nu., Board of App..I., D.pt. Z81021. Harrl.burg, PA
--.l.ctlon to have the ..ttar a.t.r.lnad .t audit 01 tha .ccount of the person.l r.pres.nt.tlv.,
--app..1 to the Orphan.' Court.
171U-IOZl,
OR
OR
Factu.l .rror. dl.cov.r.d on thl. ........nt .hould b. .ddr....d In writing tal PA D.part..nt 01 Rev.nu..
Bur.au 0' Indlvldu.l T...., ATTH: Po.t A".ss..nt R.vl.w unit, D.Pt. 280601. Harrl.burD. PA 11128-0601
Phone (111) 181-6505. S.a P.g. 5 of the booklet "In.tructlon. for Inherltanc. la. R.turn for. Re.laent
D.c.dent" (REY-ISOI) for an ..plan.tJon 0' ad.lnl.tratlv.ly corr.ctabl. .rror..
DISCOUNT:
If ~y ta. due I. paid within thr.. (3) c.l.nd.r aonth. .fter the d.cedent.. d.ath, . Ilva p.rcant (S~) dl.count 01
the t.x pala I. allow.d.
PENALTY:
lhl lS~ t.. aana.ty non-p.rtlclpatlon p~lty I. coaputed on the tot.l of the t.. and Intar..t .......d, and not
Plld b.for. Janu.ry 18, 1996, the flr.t d.y .fter the end of the ta. aan..ty p.rlod. Thl. non-p.rtlclp.tlon
panalty I. appa.labl. In the .... aannar and In the tha .... tl.. p.rlod a. YOU would appe.l the t.. and Int.r..t
t~t ha. b.an ......ad a. Indlcat.d on thl. notlc..
J"JERESII
Intera.t I. ch.rg.d b.glnnlng with flr.t day of d.llnqu.ncy, or nln. (9) .onth. .nd ona (1) d.y fro. the d.t. of
death, to the aat. of pay.ant. T.... which bec... a.llnquent b.for. January 1, 1982 b.lr Inter..t .t the r.ta a'
.1. (6~) parc.nt p.r annu. calcul.t.d at . d.lly rata of .000164. All t.... which b.c... d.llnquent on and aftar
Januery I, 1982 will b..r Int.r..t .t . rat. which will v.ry fro. c.lend.r ye.r to c.l.ndar y.ar with that rat.
announc.d by the PA Oep.rt..nt of R.v.nu.. The appllc.bl. Jnter..t rat.. for 1982 through 1997 .r.1
!!!! Inh,.ut Rat. D.Uy Int.rest feetor !!!r Inter..t Ret. Dally Int.,...t fflctar
1'8l lU .000S48 1987 'X .000241
19U 16:< .000458 1988-1991 11" .000301
198ft IIX .000301 1992 'X .0002ft7
1985 13% .000356 1993-1994 7% .tlOO192
1986 1'% .000274 J995-1997 'X .00021t1
uInhr..t It c.Jcul.t.d o. loUowt:
INTEREST . BALANCE OF TAX UNPAID X NU"BER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Hotlce 1.lued .ftar the tax bacoa.. d.llnqu.nt will r.fl.ct an Int.r..t c.lcul.tlon to fllt.an (15) day.
beyond thl d.t. 0' the .......ant. If pay.ant I. .ad. .ftar the Int.r.lt Coaputatlon d.ta shown on the
Notlc., addltlon.l Int.rut ault b. c.lculat.d.
,
~'
./
STATUS REPORT UNDER RU1,E 6,12
Name of Decedent:~\(tr(l
Date of Death: 1- 1- q L,
Ale.
w:R'\ No. l'fYf (;-(J (i & 2t!
C~ l~lII117_-
fh (-i Ie
.\<:Imi". No. :211/".-/ C (" 3d
pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of th~ above-captioned estate:
1. State whether administration of the estate is complete:
Yes y, 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 representative 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 interest? Yes '~ No
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.
Date:
/(1 rtlqg
,
~ \l' '
, ~(LUL~ ( ;1l()JtLrkJ;
S1.g ature
~ cln E'\-~ f \ \\ \c'\..rl c.~ ruZ
Nam (Plea type or print)
\ '1 yy\{)....n D (' 0 ( . fYIsfl7) PfIr
Address \'11150
Onl 7 (,I., - 3't?-~
Te I. No,
"
~:.: :>
,,,,-
_v
,----
Capacity: ,/ Personal Representative
~
Counsel for personal
representative
(HAH: rmfl AM))