HomeMy WebLinkAbout97-00270
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e"M~m"~~~'\'I!: '.l\!WiJlr~ANIA
HARAISR~R~,~~~t~tl-060 1
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLG
,
-/' Ii"
WfllUd r:i 01 UlAl1I AnEIl III )1/lJl CH~CK H~RE
IF A ~irOU~i^1 0
J'9.l'lJIIll'tiUl!illfL'ILIlU'- __ ________
FILE NUMBER
REV. 1500 EX ; (1.i4)
U(CUltiNT'!j NAMj; (I.A!iT, rm!'.T, ANO MIDDLE INITIAL) m:CLUI.N"~, CUMf'Lt Tl'. A()(Jflt~!}
Mo!!.t.z.!!r..Li!!:.!~~"...B... ____.____ _._ _______ 620 A Stilt" StnJUt
ilOCIAL !1l!CUAITV NUMtll!=tO'''E ()f [)EAn~ lOME m 811H11 I.UI1l0Y"ll I PA t 70/,]
181- 3? -/,982 12/20/] 996 02/07/19/,0
_____ ______~ _0_____ COllllly Cumburlutld
IIF APPlleA",").UAVIVINO S'OU'E" NAME ILART,FlAST AN" MIDPllINITIAl) ~-"r.IA~ !lEeUmr;;;UW;EA -JA-';OUNT "EeEIVEOI'EE ,N',"UCTlON',
0,00
B---- ----. ----.--.-------r--r- -------..
2. SupplorMntal Holum L-J 3. Remaindor Return
40, Fulu,elnleresl CompromISe (lor dal.. 01 d.alh pnor 1012-13.62)
(lor dates 01 death aller 12 12-82) 05. Fedoral E~lal8 Tal( Helum Required
[]] 6, Decedenl Died Te'lale [] 7, Docedenl Malnlalned a Living Trusl 0 8, Tol.1 Number 01 Safe Oepo.it Boxe.
(Atlach cop~f Will) (Allach a copy 01 Trusll _
C P ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO,
o 0
R N
R D
E E
S ~
20, If Line 191. grealer Ihan Line 18, onler Ihe dltlerence on L1n. 20. This i, Ihe OVERPAYMENT,
[f] 0 ~tICk horo If you ore reque.tlng a refund of your oveiP.oymont.]
21, II Line 181s gr.ater tha" Line 19, .ntor the dltlerenc. on Line 21 Thl.ls the TAX DUE,
A. Enter the Interest on the balance due on Uno 21A.
8, Enter the tolal 01 L1n. 21 and 21A on L1'\e 21B. Thi. is the BALANCE DUE,
Make th.ck Po able to: Register of Wills, Agent
. . 8E SURE TO ANSWER ALL QUESTIONS ClN PAGE 2 AND TO RECHECK MATH .. ..
ana8f penalties 01 JlIlrlury, I decl'f6 ihi'iTlliYIIII~dmln!td thl,', IntU/n.lncludlng accol1lpanyll'l9 schedules and slatemenls, and to tho best of my krwwledge.nd bellef, Ills true,
cotrecllnd complete, I declarelhalllll roal nlale hu been IlIported dllrue mol/ko! v.lue. Decldrilllon 01 pr6palBI other than the petsonallllp,eselltallvo Is bUild on IlIlnformllllon of
which plllpafltl hIS .ny knowllldge
CAB
U P L
C ~ g
K 0 K
P 5
2197.0270
r.Olmrv CODE
YEAR
Nl!MUUI
o
E
C
~
E
~
K 1. Original Return
4, L1mil.d Eslale
COMPLETE MAILING ADDRESS
R
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A
P
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A
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N
NAME
Gear" A. Vaughn III
fEI.EPHONE NUMBER
717 975-9102
1, Real E,tate Schedule A 1
2, Stocks and Bonds (Schedule BI (2)
3, Clo,ely Held Slock/Portnershlp Inlere.1 (Schedule C) (3)
4, Monga9os and Noles Receivable (Schedule 01 (4)
5, Cash, Bank Deposits IJ. Miscellaneous Personal Properly (Sch. E) (5)
6, Jointly Owned Property (Schedul. F) (6)
7, Transfe" (Sch.dule G) (SChedule LI (7)
8, Total Gross Asse" (total Line. 1-7)
9. Funeral Expenses. AdmlnlslraUve Costs, Miscellaneous
Expen... (Schedule H)
10, Debts, Moogage Liabilities, Liens (Schedule II
11, Total Ceducllons (total Line. 9 & 101
12, Net Volu. of Eslate (Line 8 mi,u. Line 11)
13, Charllabl. and Governmenlal B.ques" (Schedule J)
14, Nel V.lue Subect to Tax (Llns12 minus line 13)
15, Spousal Tran.le" (fo, dale. 01 dealh after 6-30-94)
See Instructions lor Applicable Percentage on page 2.
(Include value, Irom Schedule K or Schedule M.I
16, Amount of Line 14 taxable al8% ral8
(Include value, from Schedule K or Schedule M.I
17, Amount of L1na 14 laxabla at 15% rate
(Include value, from Schedule K or Schedule M.I
1.. Principal tax due (Add ta, Irom Line 15, 16 and 17)
19,Credlt'/Sp Poverty Prior Paymenls Discount
7 , 1 2,S-'-.QQ
7?,00
(11) 7,200.00
(1~) (3,203.11)
(13)
(14) (3 203,11)
0.00 X , D.OO
0.00 X .06 ' 0.00
0,00 X .15 ' 0,00
(1.) 0,00
Interost
390/, Tr Indle Road
Cam HIll PA 17011
one
None
None
Non-;;
3,996,89
None
-0.
(8)
....l., 996.89
(9)
(10)
(15)
(18)
T
A
X
C
o
M
C
f
N
(17)
(19)
(20)
0,00
0,00
.
.
(21)
(21A)
( 218)
0,00
0,00
0,00-
.7:;ASO; RE':;.:;LE ~~;'Na HETUAN
Samuel E. Fasick
620 State Stroet
L~moyi1'o;' pli" i"ioi.'j......-.. -. -" ---- -- --... -...-
$'\ /Cf -"y..
DATE
-'~ -/-"
(1/' /, r?
DATE
i:.SIONATU~~ O~~A'AOTHEA THAN AE""'NTATlV'
/(0/ -> -' "......c4t.-
. (,,( \'
,--- pyrlUhl (e) 1 9~ form loltwa,. only CPSy.l.ms, Inc.
3904 Trind1e Road
i;~inp' iiiii',: 'PA" 'i70ii" --..- -... .---.. -'
FOIm 1500 (A...., 7-94)
.,.
BANKERS LIFE COMPANY
Dea Moina., Iowa
f Herein call.d The Rankol1 UI.I
Certlfieo that the Partlclp.nt I. entitled to moothly ~nnuity collllllencln~ on hia Annuity Commencement D.tt.
in accordance with the Group Annuity Conlnct,
Certlficotc No, A-....8._.__._..__._ Date of this C.rtific.tc..._..._!Ll!1Il'J'J.J....)996 u,__
POrt1clpOIlL_ uo._e _ Q!.!I_c.!,__R_,.. ~tunt.~ur . Date of nirthFc~r...uar~..2.!...1940_
Group Allnuity Conlract No, GA 52605 .. Contra<'thulder.T~US.'.I~IlEs...g.l"._S.~~~E~~~D CIIEVROLET
E~IPLOYEEH I PROFIT SHARING PLAN
Bmpl;y~=:~==.-~~~~-t H~~~g~:~t;~f~ ~-I~{~'~ i-OYlicfjT""l,.fof~:Shiirlni>, .1'1 lill
Name 01 PI.n.._._...____.___._____..... _. ...__._._..___..__......,._._ U._____
Annuity Initial Annual Rate Amount Applied to
Purch..e Date of Intereat' Purcha.. Annuity
(I) ~mbo.~..!.?80 ___,~3.:50r~_ .._ _ k__.7.!!!~~___
(2) ___._____..__ ___..__.______.u ___.._____.__
(3) __._...______..__ __._.____
Beneficl.ry..._.1i. amuc 1 _~_I::!iaJ~hi:.~.~:>_~!.....~.!~_~v_~.!...,:, .~I~~ w 1 a ".. _~~_~~~~.!!.:
rOO Annuity M.turity D.te,
Annuity Commencement Dote I.
o the dote one month .fter Annuity Maturity Date,
Nom'" Income Fonnl 0 Option I 0 Option .
o Option 3, __.._____._ to__._..._
ortnult.nt (__ __._
lOX date of birth
[ Cert.ln or I'Ixed Period i. _.1ll._ years,
Pa)"TlCnta to beneficiary IXI to be continued,
o to be commuted,
Normal Retirement Date J~J1Jl.~I!"e~.!-.l\.l\!!.!..t~_ Mat .!!E.!ll...Q!.t~-.-J!!!!ch I, 2005)
Amount of
Mnnthly Annultye
971.42**
$-.--.--.--
llcntzcr, Ginter
_.j,
(Name)
, contingent
.
(] Option 2
o Opt/on 5
1
The Group Annuity Contr~ct between the Contracthnlder and The Bankers Life i. the nnly cnntroct ~nd all righ18
and benefits are fixed and determined soldy by ~"d In accordance with iu rrovialons, Amendments to and change.
in rhe Group Contract affecting the b<nefits ~nd panicipatinn privileges 0 the Participants may be made hy the
Contracthnlder and The Dankers Life which shall be binding and conclusive nn ear.h Particlp~nt and beneficiary,
A cnpy of the Group Contract is held by the eontracthold.r and may be inapected at any reasonable time upon
request, This Cenificate merely .ummariles some of the provisions of the Group Contract principally ~ffecting the
Participant and doe. not in any WilY constitute a contract,
IMPORTANT
If Annulry Purchase Date precede. Annuity Maturitr Date, a. soon a. Annulry Marurlty Dare It determined, IOnd
this Certificate to The Ballke.. tHe for completion 0 the Retirement Endorsement, page .,
Thlt Certificate i. non-tran.ferahle, ,
. Not applicable wh<re Annuity Purcha.e Dale c<,indd". with AnnuJty Maturity Date (,ee Retirement Endnrsement.
page 4). Where Annuity Purchase Date prcad.. Annuity Marurity Date, the amount of monthly annulty mown
on duo palle lJ pavable if AlUlIIJty Maturity Dllte coincide. with Nom,al Retirement Date and if paid in accordance
with the Nonnat'lncome Form.
-11,~ ~
CttAlnMAN AND
CHIEF E)((CUTIIJE OfFICER
**
Thla Certificate superaed.. all certlficat.. preYlously l..u.d to the Participant under the Group Contract. S.e palle
. for notadoOl by The Bankert Ufe.
Group Annulty Ceetlficote-GIA Keep tW. C.rti6cate
G' CA 13126
THE BANKERS LIFE ~
I"HIIII" llrl OOI,u'''N'f Oil "'OINIIII, IOWA 1010'
304.'1
..
Item. No.. 1 Ihmu.:h .. below have .ppUratlon only where Annuity Purdliue Dale I'rc('c.'4Jclt Anlluity Milturity O.lIr..
NO. \, DUJlJN/1'lONS, No"n.l 1l,.tlr'lIlrn'. I),,,. I, the Parliripal\t'. I\orlllill rctir"l\wnl dalf' I\nder Ihe Plan, U
reported to The Ili\llb'rll I.i(e hy thr Conlr;\cthold,'r, If nil norlllal ri'lln'llH'nt ,laic jPo !lPN'lfil'd lIIider the Plan. it is
the first day o( tilt: l\Ionth roinciding with or flext (ollnwln~ thl' Partidpantlll t1~~h birthday. Normal Retirement Dille
I. .hown on the (ace o( thl. certlficale,
Annuity Malurily Dale Is the Partlclpant's No""," R,'lirel1\Cl\t nalc, cxrept .s fo\lowa:
(a) early Retl..m.nt, Annuity Maturity Dalt' lIlay bt. any datI' I\n or .fter both tbe Partldp'lOt's terllllnalioll o(
r.mploymcnt and hili blest ^nnulty Purchase Diue under the Clrouf Contractf Rnd prior to hili Normal Retfr~l11cnt
1)"le, a. request,'d hy the Participant in wrlliu~ to The !lanke" ,ife,
(b) Lale Reelrem.nt, If the Participant's earliest Annuity Pur.'ha," Date under the Omop (".,ontnct ocw" nn nr
after the dal< 5 ye.rs frior tn Normal Rellrelllent Date and If the Participant COllllollrs aellvely at wurk for the
Employer .(ter Norma Retirement n.te, Anility Matllrily Date ""'Y he any date whirh follow. Norm.1 Relire'
ment Date, aod whkh I, on or after hi. lateet Annllity Pllr,h",,, Date lindeI' the Omllp Conlrucl, and which
Is not )altr than the first day of the "''''lIh coill.-idin~ with or 1I('xt followln~ the earlier of (i) termln.tlnn of
elllplor.ment or (ii) the date 5 year. after Norm.1 Relirement D,te .s requested hy the Contractholdel' and the
Partie pant in writing 10 The Dankers Life,
NO, 2. RA 1'8 OP INTIlRBST. Inlere.t I, compounded onnu.lly from Purch... Date.
(a) during the fi,'.'year period commencing on Annuity PurchOle Date, at the "'te shown on the faC'/; o( (hi.
certificate,
(b) during each of the next three five'ye.... period., .t the rate (nr the immedl.tely preceding fivc'year period,
reduced by 0,5%,
(c) during the five'year period after the fourth ftve'year period, at the rate for Ihe immedi.tely preoeding nve'ycar
period, reduced hy ,25%,
NO, J. DBATH BIJNflJlJTS. If the Pilrllclpant', death occurs prior to Annuity Maturity Date, n,e Bankers LiCe,
upon receipt of due proof of death. will pay to Ihe hencficiary the greater o( (i) or (il) below,
(i) The amount applied 10 purch.se annuity,
(il) 96% o( .uch amount with intere.t OIl the rate described in No, 2,
NO.4. CASH SURRIlNDER, At any time prior to Annuity M.turlty Date, a Participant whose termination of
employmelll I... occurred may malIC written request to The !lankers Life to surrender all amoul1to of annuity which
have been purchascd for him under the Group Contract, Upon rereipt of such request The Bankers Life willl'ay to
the Participant a ,ingle sum cash payment in lieu of any and all otber benefits to which rhe P.rticipant, beneficiary
oc contingent annuitanl mighl become eligible under the Group Contract, The amount of 'Ingle surn c..h payment
It the grearer of (i) or (il) below,
(i) The amount applied to purchase annuity,
(il) ^ pew:ntage of such amount with interest at the rate described in No, 2, Such percentage is determined
below.
NUlJlber of Years between
Annuity Purchll$O Date and
Date of Surrender
Leas than 5
5 but I... than 6
6 but Ie.. than 7
7 but Ie.. than 8
8 bul Ie.. than 9 .
9 or more
Percentage
91%
92%
9)%
94%
95%
96%
Q' CA 13126
(2)
34."
,~
NO. " OPTIONS, If Annuity M.tllrily Date haa nut yet 'k:curreJ, the "Mtlcipant may file a written reqnut with
n,e Banke.. life at ita Horn.. Office on a form fumiahed hy The nanke" Life fur one of the nptiuna ..t out btlow in
lieu of the Non"al Income Porm, Soch a reqntdl will collBlilole an e1rctlon of aud, opliun unlil and unle.. further
written req\lul i5 maJe hy the Partidpant in like 1Ili\1H1U on or prior to AnnUity Maturity Date that the election be
changed, Annuitl' payable uoder ony option will be equivalent in value to the annuity flayahle under any other option,
Opdoa I - Llf. Annlllly, Annuity payahle fur life of the I'artleip.n!.
Opdon 2 - Certain and Ufo Annulry. Annuity payable for 5, 10 or 15 yea.. certain (whichever ia appllcahle)
and a. Ion.: thuuflcr u the PiUtidpant ia livin..:. Should lh~dth of the PartJcipant OCl'Ur prior to the end of the
certain perlou, any pa.ymenta (ur the bal"ncr (If Ruch period will he cnnt,inued II duc to hJ. bcne(tduy or commuted
and the v;lluc paid in one lurn to W. beneficia.ry.
Opdon J --loint life IrntaUm.nt Refund Annuity, Annllily payable for life of the Participant and upon hi. death
'12. % or al (whichever i. al,plkahle) of .uch annuity will be continued to the contingent annuiunt fOf life of
contingent anl\lIltolnt. If,..t llC death of both the Pa.rtidpanl and the ccmlinl:lcnt annu/tallt the aum of the pay-
ments made i~ less than thr amount applied to purd\asc slIch allnuity. with Interest to ^nnuity Matw1ty Date at
t.he rate descrihed in No, 2, monthly pa.yment." will continue to till' Particl/1ant1a beneficiary until the IU," of the
payments equals tlaJJ ilmount. The monthly payments to the beneficiary wi I be the same ,unounta ill would hive
been payahle to the Participant, if living (,lS would have been payahle to the contingent annuitant, if living, if the
Participant pn:Jeceallcu the contingent annuitant), The Participant may not change his contingent annuitant on or
after Annuity Maturity Date,
Option 4 - Singl. Life In..allm.nt Ilcfruul Annuily, Annuity payable fur life of the I'articipant, and if at the death
of the Participant the sum of the payments made i. Ie.. than the amuunt applied to purch.se .uch annuity, with
interest to Annuity Maturity Date at the rate described in No, 2, monthly payment> will continue to the Participant'l
btneflciary until the .um of the payments equals said amount,
Option 5 - Fixed p.riod Annuity. Annuity payable for a fixed period of complete years '(not lesa than 5 nor more
than IS), Should death of the Participant occur prior to the end of the f,xed period, any paymenta for the balance of
such period will be continued as due to his beneficiary or commuted and the value paid in one sum to hi. beneficiary,
Od.tr Optiolll pel'mitted under the Plan may be arranged by written agreement between the Contractholder and
The Bankers Life,
NO.6. CHANGE OF BENEFICIARY. The Participant may change his beneficiary by executing and filing a
written deaignation to that elfect with The Bankers Life but such designation will not be effective until received by
The Bonkers Life, The designation, when received, will be elfective .. of the date it waa executed; but any pay menta
made by The Bankers Life prior to receipt of such designation will fully diac.harge The Bankers Life to the extent
of ouch paymentD, The nan.." Life reserves the right to require the Participant'. certificate for endor..ment of
any such chonge of btneflciary,
NO.7. MISSTATEMENTS. If the age or sex of the Participant or contingent iL/Illuiunt is lound to have been
miaauted
(a) the amount of annuity payable by The Dan.c" Life will be that provided by the amount appUed to purchase
of such annuity. dr.lCrrnined .. of the date of purchase estahlished by the m;.,Uted infOl'lllation and on the
b..io 01 the correct age and sex,
(bl any overpayments by The Danke.. Life resulting from any misstatement. will be deducted frolll amouota there.
.fter payable to the Participant, his contingent annultont or his beneliclary,
(c) any "nJerpayment by The Danke" Life resulting from any misstatement will be paid in full With the oexr
payment due the Pan,cipant, hia contingent annuiuot or his beneliciary,
NO. S, OWNERSHIP. Notwith.tandlng any previous provi.ion. of this eenifl,atc to the contrary, the Contract-
holder, if the Contractholder is truSlee unJer the Plan, (and not the Participant, beneficiary or contingent annuitant)
is the sole owner DC all payments, rights, (Jptions, and privileges heretofore granted or made payable under this
contract to or on behalf uf <lny Participant while he ill actively at work (01' the Employer. The C<mtracuwluer is thw
entJdeu, wit-hoUI the cun6Cnt Of parth.:ipatlun of 5\11.:h Paflkipant, bcndlclary or conti.ngent annuitant, to exercise all
IUch rights, options, a.nd privile~e8 anJ to receive aU such pay menU.
"Trustee under the 1'1,\1\" mean. a person or persons or flnn de.i~naled a.s troalee under tne Plan with dutiea
and rupo06ibilit,u .. ..t forth in an agreemenl of trust hy and between the Ilmploycr ond such person or persona
or firm,
OPeI\ 13126
(3)
u."
/7:/{.Y/O
lURE AU OF INDIVIDUAL TANES
INHfRITAHCE YAk nlvIslOH
[)[PT. '.'0601
IlANJlJSRURO, Ii. 11111-0'01
COMMONWEALTH OF PENNSYLVANIA
D!PARTMENY OF REVENUE
NOTICE OF INHERITANCE TAN
APPRAI$EMENT, ALLONANCE OR DISAI.LONANCE
OF DEDUCTIONS ANO ASSESSMENT Of TAN
DATI!
ESTATE OF
DA TE OF DBA TH
FILE NUMBER
COUNTY
AtN
11-2',"97
MENTZER
12,.20-96
II 97-0270
CUMBERLAND
101
C~~un~ R;~I:~ ]
MAKE CHECK PAYABLE AND REMIT PAYMENT TOI
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS .....
REV: is'4j"E'iC""Fji"r OF97Y"iloYicE" "O'F" i:"N'HEiii TAH"eE "T"A'x"iippiiiiisi!"i.fiil'r;" Ai:. rOWAtic'E" oli-"." .,". "_.. - - -...
DISALLOWANCE OF DEDUCTIONS AND ASSESSM!Nl' OF TAX
GRACE R FILE NO. 21 97-0270 ACN 101
GEORGE ^ VAUGHN
3904 TRINDlE RD
CAMP HIL L
III
PA 17011
ESTATE OF MENTZER
TAN RETURN WAS, (X) ACCEPTED AS flLED
RESERVATION CONCERNING FUTURE INTEREST " SEE REVERSE
AiiiiiiAISE,D VALUE OF RETURN BASED ONI ORIGINAL RETURN
1. R..l ~~t.t. (Schedule A)
2. stock. end Bondi (Sch.dul. B)
5. Cl01111y Held stock/Partner.hip Int.rut (Schedulo C)
4. Hodg8pll/Notlll" Raeeivable (Schedule 0)
S. C..h/Bank o.poIH:.ll1hc, Perlon.l Propedy (Schadul. E)
6. Jointly Owned Property [Schedule Fl
7, Tranlf.,.1 (Schedule Q)
8. 1'ot.1 Au.h
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. fun.ral Expensen/Adm. COlt,/Misc. Expans.. (Schedul. H)
10, o.bto/Hode.v. 1I.bllltl../1I.no ISchodul. Il
11. Total o.duClUona
12. Net V.1u. of T.x R.turn
IS. Ch.ritabla/Gov.rn...nbl Bequ..t.; Non~.l.ct.d 911S Trult.
14. ~.t V.1U11 of e.t.t. S~lbj.ct to T.lC:
NOTE:
If an assessment was iSRued previously, lines
reflect figures that include the total of ill
ASSESSMENT OF TAXI
15. AMOunt of U,n. 14 .t Spa\l..l r.t. US)
16. AMount of line 14 't.xabh .t Lin..lICh.. A r.t. (16)
17. Atlouni: of Lin. 14 t.xable .t Coll.hrellCI... B r.t.. (17)
la. Princlp.l rex Due
TAX CREDITS I
PAYMENT
DATE
RECEIPT
NUMBER
DISCOUNT (+1
INTEREST/PEN PAID 1-)
I ) CHANGED
(1)
(21
(3)-
(~)
(5)_
(61
(7)
,00
,00
,00
,00
3.996,89
......!l.Q..
,00
(8)
(>
*
(9)
(10).
7,128,00
72,00
1111
(12)
(13)
1141
In-IU1IM." Ift,HI
GRACE
R
(Schodulo J)
DATE
11-24-9"
NOTEI To iraur. prop.r
cr.d! t to your acoount I
$ubllit the Uppflr portion
of thh for.. with your
tax paYMent.
3,996,89
7.:>00.00
3,203,11"
,00
3,203,11"
14, IS and/or 16, 17 and 18 will
returns assessed to date.
.00 N ,00. ,00
,00 N .06. .00
,00 N ,15._ .00
(18)_ .00
TOTAL TAX CREDn ri=
BALANCE OF TAX DUE .
INTERES(~ND~~N~
TOTAL DUE ===
AMOUNT PAID
.00
.00
.00
.00
. IF PAID AfTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN 01, NO PAYMENT IS REQUIRED,
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YOU HAY BE DUE
A REFUND, SEE REVERSE SIDE Of THis FORM fOR INSTRUCTIONS.)
RESERVATION I
_OF
MOTlCEI
PAYMENT I
REfLWD (CR) I
DIJECTlDNfh
..o..1N
ISlRATlVE
CORRECTlO$I
DISCDlMl I
PENAL TV 1
INTERl:Sll
""I"
(!.J
1:1
:'\
(ie,
E.t.t_. of dtoadtnt. dylnt on or blfofl Dea.-ber 12, 1912 .~ If tnyfutur. int.r..t In the ..tat. la ,rln,'.rred
in po.~..lon or tnjov-ent taCI... . (eollatlr.l) bln-fleilrl.. of thl ~edent .ft.r the INplr.tion ef any ..t.t. for
l1f. or for VI.r., tht Co.-onwellth hlrlbv INpr.,.ly r...rv.. tn. right to appr.l.. and ...... trlO'f.r rnhlrlt~. T.N"
at the l.wful Cl... I (coll.t.r,l> r.t. on anv lueh future tnt.r..t.
To fulftll thl raqutr...nto af Slotlon 2140 of thl Inhtrltano. and E.tlt~ Tax Aot, Aot 21 of 1995. (72 P.S.
$.vUon 9140).
Dlt~h t~ top portion of thl, Notto~ end lubelt with your PIV.~t to thl Ratl.t.r af Willi prlnt.d on thl r.ver.. .ide.
--H.h chick or ~v order pllyabl. tOI REGISTER OF MILLS, AOENT
A r.fund of . t.x oredit, which we. net r.que.tad on th. T.x R.turn, ..v b. raque.t.d by ooaplatinl an "Applioltlon
for R.fund of PlImly1vanl. Inh'rHlnu and [.tet. raIC" (REY~1313)' ApPlloetlon. art IveUabl. at tM Of flu
of Uw R..I.tar of NUll, MY of the 23 R.v.nue Ohtrtot OfficII, or bv olllllnl thtl .p~l.l 24-hour
an'Wlrlng 'lrvlc. nuebar. for for.. orderlnDI In Plnn.ylvnnla 1~&OO~:S62-2050, outsldl P'M'Y1vanla and
within looal H.rrl.burg ~rea (717) 781~8094, TOpt (717) 772~2252 (HI.rlng Iap.Jr~ Only).
Any p.rty In Int.r..t not .,tl,flad with tha .ppr.I....nt, allow.nca or di.allowanca of ~Otlonl, or ......-.nt
of hIC (Including dhcooot or Intar..t) .. .hown on thl. Hatlc. au.t obj.ct withIn ,hcty (60) d.y. of l'aclipt of
thlt NoUce O:lYl
hwr1tten proto.t to the PA V.pa"t..nt of Ravonu., !oard of Appoah, Dopt. 281021, Harrhburg, PA 17\28-1021, 01
--elltOtlon to hevo the I..tt.,. dIIter.lned at .udlt of the account of the p'''lonal rapr..~tlltlve, OR
~-app.al to tha Orphan.' Court.
FMtual erro,., dhc:ovlred on thh au.ngnt .hould b. tlddr....d In writing '(01 PA Depart.."t of RIVWIUI,
lurt..., of Individual TaICU, ATTNI po.t A.......nt R.vl.w Unit. Oapt. 280601, Hal'rhbur'g, PA I?UI-060t
Phone (711) 7a7~6S05. Sa. pege 5 of thl booklat "In.truotlon. for InherJtance T.x Return for a R..ldant
Decadent" (REY~1501) for an IICplanatlon uf adalnl.tr.tlvlly oorr'otabl. .rror..
If any tax due II pllid ~jthln throe (3) calandar a~th. aft.,. the d.oadent', d.ath, . flw. percent (5~) dl.oount of
thl talC p.ld 11 .Ilowed.
Th. 15~ t.IC .an..ty non~p.rtlclpaUon p.nalty It co_put.d on th, tot.1 of the tax .nd Int"..t ......teI, and not
paid blfor. J,muary ta, 1996. the flr.t day aft.,. the .nd of the ttllIC ..nllth parlod. 'Jhhnon-partloIPltlon
penalty i. ~pa.labl. In thl ...1 .ann.r a~ In 1h. tha .... tll. p.rlod .. ~ou would ~a1 thl talC and Intar.,t
thet ha. bean ......Id .. Indlcat.d on thl. not Ie..
Int"..t II ohargld beginning with flrlt day of rj"llnqu.noYI or nln. (91 1I0nth. .nd one (1) dell fro. the ct.t. of
dlath, to thilt dl'lta of pay...nt. TaICU which baCilli. dal.lnquant bafor. January I, 19'2 b..t Int"rut at the r.t. of
.h (6~) perolnt plr .nnue cllculahd at II dally r.tl of ,00016<\. All talC.. which bac..e d1IUnquent on and after
Januar~ I, 198Z will boar Int.r..t at 8 rat. which will vary fro. c,lender v.ftr to c.lendar y'ar with that rftte
~unced by the PA O.part.*"t of R.venue, The applloabll Int.ragt rat.. for 1982 through 1997 ar~l
'!!!! Intlr..t Rat. Dally Intl'lrut F80tor !!!r Int.r..t ~at. Oally Intere.t Fa1i2!:
19&2 20% .OOOS4& 1987 'X ,0002ft7
1965 16% .0004U 19&a~1991 Ill: .000301
1914 11% .000101 1991 'X ,000247
1985 13:( .000156 199:\"1994 7% .000192
19a6 10% .000274 1995-1991 OX ,000247
-- Int.r..t II oalculat.d .. follo"'.l
INTEREST' BALANCE OF TAX UNPAID X NUNBER DF DAYS DELINQUENT X .DAILY INTEREST FACTOR
--An~ NoUoa l..ued .fhr thll talC b.oo... cfQJlnquant will r.flt/at an J"tar"t oaloulat1on to flft"" (IS) day.
blvond the d.ta of the ........nt. If p.y..nt I' aftd. .ftar the Intar,'t co~ut.tlon d.ta lhown on the
Notice. .ddltlonal int.r..t MU.t ba ca1culatad.
-.
RegIster ot Wl/ls ot
CUMJl1\RLANIJ
County, Pennsylvania
INVENTORY
Eltalo 01 Graoe R. Mentze~
No.~_-0270
.110 known al
Calo 0' Duolh 12/20/1996
,O.co.,ed Social S.curl\y No. _)81- 32 -4982
-
Samuel E, Fasl~ _
Personal Repr.senlative(s) ollhe above Estate, deceasod, verity lhallhe Items appearing In Ihe 'ollowlng Inventory Inclllde all of the
personal Isseis wherever situate and .III! of tha real flsta!. In the Ccunmonweatth at PennsVlvanla of said De-cedent, that the valuatlcm
plac~d opposIte each Ilem of said Inventory represents ils fair value as of the dale of the Docedent's death, and thai Decedont owned
no real .statl outside of the Commonwealth of Ponnsyh/anla except thai which appears in a rY'Ktmorandum .III the end of this
Inventory. I /We verify that tho slalemElnts mado In this Inventory are Irue and correct. IflNe ~md6rstand thallalse statements herelrl
are made subject 10 tht pena~los of 18 Pa, C.S. Section 4904 rolallng to unsworn falsification to authorities.
Porsonal Representallve
No"", of George A. Vaughn III
AUorney:
1.0. No,: 25650
Address: 3904 Trlndle Road
Camp Hill, PA 17011
Telaphone: 717/975-9102
Slgnatur.:
"'. , . /
L n / (. t;1'_/'
Samuel E. Faslok
Signature:
Address: 620 State Street
Lemoyne, PA 17043
Telephone: 717 /737 - 9093
Datod: ,y' /'/0/1?
De'crlpllon Valuo
(See conti~uat1on page(s) attaohed)
C::" i i
"(~' f',d Ell
{D,
(Auach oddhlonal ,h.e" II neoosury)
TOIOI,
3,140,89
NOTE, Thu Memorandum 0' real e,tale outside the Commonwealth of Penn'ylvanla may, atlhe election 01 Ihe person. I reprasenlotlve,
Include the value 01 each Itom, but such Ilgu,.. should not be e"ended Inlo the total of Ih. Inventory.
pr.fNIr.d by the P.nM)'h'lnlll ear Assoclallon
Copyrlghl(c) 1m formlol1wlreonlyCPSyalflmll, Inc. Fo'm.RW~7 (1992)