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PETITION FOI{ PlmnA'n: IInd GI{ANT 01<' LETTlmS
N1.,','.,. M _;J.I_-:.g'1'~_~S_
Ilry'"f:f.ewls
Register of Wills fnr the
('nunly of Cumberlllnd in the
Commnnwelllth of Pennsylvnnill
E.l/ale of HELEN A. JON1iS,
Formerll' kl/(lII'/I liS llEUl'N S. CU'MENTS,
. .
Decca,ved.
Social Secur/I)' No, 164.)O..25RO
TIle petilion (lfthe undersigned respectfnlly represents thllt:
Your pctltloner(s), who Is 18 years ofllge or older. Is the executrix nllmed In the last will of the above
decedent. dated July 21. 1994. Rnd codlcll(s) dated NONE.
(iIlate rclevllOl c1rcmmlllOcc!l, e,g, ronuncIAII(lfl, death of CXllCUlor, etc.)
Decedent was domiciled III death In Cumberland County. Pennsylvania. with her lllst family or prlllelplIl
residence at2215 Yale Avenue. Borough nfCamp Hill
(list slfCct. numher nnd l11unlclflullty)
Decedent.lhen 84 years of age, died I'ebnlary 27, 1997. lit Cllmp 11111, Cumberland County.
Pennsylvania.
Except RS follows. decedent did lIotl11811)', was not divorced nnd did not have n child born or ndnplcd
after execution of the will offered for probllte; wns not the victim of n killing and was nevcr adJudicRted
incompetent: NONE
Decedent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $ 25,000.00
(If not domiciled In Pa.) Personal Property In Pennsylvania $
(If not domiciled in Pa.) I'ersonal Property in County $ .
Value of relil estate In Pennsylvania $ 105.000.00
situated as follows: 2215 Yale Avenue. Cum I' 11111
WHEREFOREh petitioner(s) respectfully request(s) Ihe probate of the Inst will aud codlcll(s)
. presented herewlt and the grant of letters testamcntary thcreon,
(testamentill)'; admlnlstratloll l~,I,lt; admInistrAtion d.b.n.o.t.I'I.)
PATRICIA L. COCOS
2215 Yale Avenue
Camp Hill. Pennsylvania 17011
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF' PENNSYLVANIA ) SS
COUNTY OF CUMBERLANIl . .
The pelltioner(s) above-named swear(s) or allirm(s) thRtthe stalcments in the foregoing petition are
tmc and correcl tn the hest or the knowledge and belief or pctitioner(s) and that as personal rcprcsen-
tative(s) oftlle above decedent, pctitioner(s) will wellund truly admlnistcr the cstate according to law.
Sworn to or allirnled and f,ubscribed before me J~;., ~ L'~._
~~~~'.l_;~~~,fW+l ~'tt .
~ C LEWIS I~
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WARNING: 1\ Is 1110[/01 to dupllcolt1 lhls copy by photw,wt 01 pllOtoll'oph.
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COMMO"WIALTH 0' Pfl""SVL\Io\HIA . OIPARTMEHT 0' HEALTH' VITAl. RECORDS
CERTIFICATE OF DEATH
Ol.IAlOlIrI.lIIII
Helen A. Jones
..,
,female
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SOcIAl. ttCU#UT'l' NlJ...."
..164 - 30 - 2580
Wl'IHPl.ACIl~,.,...a
$11I.I or ~or"'llr' C(.l.oI'oIlyl
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teller banki
0lICI'lIIMT'1 WMMQ'iDoM...... C~bWI,..... ~C'odt\
2215 Yale Avenue
, camp lIill, PA 17011
MlU'..w:.~,lMil-~
George Dreisbach
"",....
Diana S. Dllclos
111l).Ul
1f,.__.____..!.y-YM ~ Old
-
....
~1berland _~' ""~~~':::of camp. Hill
1",~ - .......
M01HII""H.A.I4lf'<tt,I.lo.:k",~\ .....-f>e\-
Mary EU ~abeth Freudenberger
WlOfIt,Wfl'I WAA.IHOAooNlU\SnIl. c.yfM. ..l\fJ CodIt
215 Yale Ave., camp Hill, PA 17011
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'*'1OftI""'....O UI;wW'.o.\I.1lMl1 0101,*","
o March 1, 1997 Rolling Green cemetery camp lIill,PA 17011
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. Howard Jones
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ITIlKV. r give and bequeath the oum of Five Hundrlld ($5QO.00) Dollars to the
I AHIlRtcAN CANCIlR SOCIETY, for the use ot the CUMBERLAND COUNTY UNIT.
I I1'1lH VI. I give, devise, and bequeath all the rest, residue, and remainder of my
I
I possossions and ostate of. every nature and wherever situate to those of my issue, per
"tlrpeD, who survive my death by thirty (30) days.
ITKH VII. All of the interests of the benefidaries hereunder shall not be
subject to anticipation or to voluntary or involuntary alienation nor shall they be
sUbjoct to any execution or attachment.
ITIlH VIII. I appoint my daughter, PATRICIA L. COCOS, of Camp Hill, Pennsylvania,
-- executrix of this mY last will. Should my said daughter predecease me or otherwise
'. "'~'- .
C\J (ail to qual ify or cease to serve as executrix of this my last will, I appoint my
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~I daughter, DIANA 8. DUCLOS, of Naples, Florida, executrix of this my last will.
AI n'M IX. In addition to the other powers and authorities granted to my personal
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~ I representatives by Pennsylvania law and by the other terms and provisions of this will,
t) i I hereby give to my personal representatives the following powero and authorities
r-A'. .\lffective without court approval and until actual distribution of all property: to
... 'j..)
~,~ I compL'omise any claim or controversy; to make distribution in cash or in kind, or partly
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' in cash and partly in kind, and in such manner as my peroonal representatives may
I
J determine and at valuations finally to be fi xed by them; to invest in all forms of
property, including any stock or other securities in any corporate fiduciary or its
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succeseor without restriction to investmentn authorized tor Pennsylvania fiduciaries,
2
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C('JMMONweAllHOF, paNNSVLVANIA
OEPARTMENT OPREVENue
BUREAU OF INDIVIOUAL'TAXES
DEPf,260601
HARf~ISBLJRG, PA171<8'OOOI
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
'*
NO. AA 2 4 2 533 f1,Vl1"" lllYOI
REOEIVED FROM:
r
ACN
ASSESSMENT .
CONTROL
NUMBER
AMOUNT
QgORGE A VAUGHN III
S'T04 TRIND~e: ROAD
CAMP HILL, PA 17011
101
tl!';,f10() 00
FOUl HUlE '
ESTATE INFORMATION:
FILE NUMBER
___.-E1_::1997~03a!S SSN '164~&10:a!Sao
NAME OF DECEDENT (LAST) (FIRST)
hn_J.Q~gs .. HELEN A
OATE of PAYMENT
__.J.? 11 0/ 1997
POSTMARK DATE
_1.2/Q,!jl"97
COUNTY
~.G.UMeJ;RLA~O
OATE OF DEATH
2/27 (J 997
REMARKSPATRICIA L COCOS
C 10 GEORG!1: A VAUGHN.. I I I
SEA~HECK# 2130S
FOtDtlERE ~i
(Mil
~...--....._-
TOTAL AMOUNT PAID
-:S.OOO.oo
CW
OF WILLS
R~OE!VED BY
MARY C. L
Re:GlI Sre::R
IS' j I j) ~
FWILLS4-Aif/V /lJf2f
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS
1'500 f.)( I i1 "~J
CO"MF~.l'IM.lll\ OIP,fMilli~"'"
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OECEO~NT'S NA~t: (tAUT, FIR!!T, AND MIDDLE INITiAL)
.Jone..t....!:Lo10n~. ______.._
~IOCtAL S[CURITY NUMBER OATE OF DEAHl
164.10-2580 02/27/1997
06/1I./19J 2
IlATE OF BIR1H
(IF APPt ;(:ABll:) SURVIVING SPOUSE'S NAMfi (LAST ,FIAST ANP ~IODlE INITIAL)
Jorlt1.~~., L. H<?ward
X 1. Orlginill Relurn
4. Limited Eslal.
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FO'llJ1.rI.SOF Of.ATHAFrEII 'i!l11I91CUECKH~
!f:A~if'(HjSAI [L
l'!l~Ul!r~lltoILI~. _
PILE NUMBSR
(;CIlHlTYCOLJI
21.97.0325
NUI.4DER
tWCfflf,.!'SCOMf'lETE ADORE !is
2215 y" 10 ^vonllo
CalliI' /I J 1.1, l'^ 17011
Cwnbor Illnd
YIIMI
AMOUNT nSCEIVEO (SSE IN~TRUCTIONS'
0.00
05.
o I.
R.mllnd" R.luln
(for dOl.. of d.alh prior to 12-13.821
P.deral Es.ale To> R.lurn R.qul/ld
Total Number of Sa', Deposit 801(.5
3904 Trind1e Road
Calli Hill PA 17011
"
None
None
None
17,069.56
39,766.60
176 ,420 .1,9
(J)
(9)
24,507.:,99
SOCIAL SECURITY NUMBER
195.07-1.833
~plomontal Roturn
D -41. Futuro Inlerest Compromise
(fa, dales of de.th after 12..12..e2)
[}{J G, Duced.nt Died Testate []J 7. D8codenl Maintained a living l'rusl
(Allach copy of willi IAII~:h. copy of Tru5l)
C P Al L CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TOI
R 2 NAMt;' COMPLETE MAILING ADDRESS
R 0 Ge~~q\o A. Vaughn III
~ ~ TELE.PHONE NUM8i;R
T 717 975-9102
1. Roal E5Iate (Sch.dul. A) 1
2, ~Iocks and Oonds (Schedule BI (2)
3. Clos.ly Hold Stock/Partnershlp Inter"l (Schedul. C) (3)
4. M''''~.g.s and Not.s R.c.lvable (Sch.dule D) (4)
5, C.,h. Bank Depaslls & Mlsc.llan.ous P.rsonel Prop.rty (Sch. E) (5)
6. Jointly Own.d Property (Schedul. F) (5)
7. Transfers (Schedul. GI (Sch.~ula L) (7)
8. Total Gro", Ass.ls (Iolal Lines 1-71
9. Funeral EKpenses, Administrative Costs, Miscellaneous
E'pens.s (Srltedule HI
10. Debls. M"rI9ag. LI.bllllllS, Liens (Sch.dul.!)
11. TOlal D.ductlons (tot.1 Lines 9 & lD)
12. N.l Valu. 01 E,'.!. (Line 6 minus Lln. 111
13. Ch.rltabl. end (""v"nmonl.1 B.quasls (Schedul. JI
14. .1-l~1 Valu. SubJecllo Ta, (Line 12 minus Line 13)
15. Spousal Translers (for dat.s of dealh a".r 6-30-941
See Instructions 'or Applicable Percentage on pago 2,
(Includ. values from Schedul. K or Sch.dul. M )
18. Amount of Unit 14 ta)(able 8t e'/. rale
(Include values from Schedule K or Schedule M,)
17. Amount 01 Uno 14 taKable a115% rate
(Includ. valu.s from Sch.dul. K or Sched"l. M.)
15. Principal Ie, due (Add I.. Irom L1n. IS, 16 and 17 I
19, Credits/Sp Poverty Prior Payments Discount
O. 00 + 5 , 000 . 00 +
20, If L1n. 191s great.r than L1n. Ie. enter the differ.nc. on Line 20 This Isth. OVERPAYMENT.
I~ 0 !Check her. If you ar. r.qy..tlng I refund 01 your overpeymenl.!
21. If Line 18 Is gr.alor Ihan Line 19, enter the difference on I.ine 21. This Is lh. TAX DUE.
A. Enter the intef05! on the balance due on Line 21A,
Il. Enter Ih.total of Line 21 and 21A on Une 218. This Is the BALANCE QUE.
MAke Check P.y.bl. 10: Regl,'er 01 Will., Ag.nl
. . BE SURE TO ANSWER ALL QUESTIONS ON PAGE 2 AND TO RECHECK MATH ~ ~
Undo' pen~lIlllS 0(; . :j'Ju/y, fdecfifii'ThiIThlvllllllilmlt'\.;Crillli"'"rllluln,lllcludlng Iccomp.nylng'schlldull!lS and II.lements, and 10 the beal of my k;;owledglllnd EiliiT.lir.rrue,---
correct ilnd compldlu_ I decl/Hlllhat.U re.I"I.11 hili been repolled ill true marl:llt V.IUll, Decllrallon of prep"" olhtf thin the p41rtonalIIp,...nt.lIvllIs bI..a on .lIln'o(INIUonof
which pfllpjrer ha', i"lY knowledge.
.._--
(10)
28,806.31
(11)
(12)
(13)
(14)
(15)
0.00 X
,
(16)
301,942.35X .08'
(17)
o . 00 X .15 '
(IS)
Interost
(19)
(20)
(21)
(211.)
(21Br
SI')NATUAE OF PEHSON AESF'ONSIBlF. FOR FlUNG RETURN
"" I)h. )L'~)
- ld&l-i-e.u. "'\1 ( ~.c....-<
SIQ!,!~URE OF PREPARen..9T~IER THAN REPRESENT AliVE
~/.,/ ,'/
/'//.", .. ....
L< c/ ?-' . ,/;;......-.
C OPY"9hlltll-'Z:::'" only CPSy,'.m..lno.
Patricia L. Cocos
2215 Yale Avenue
i;;;";p'jiii j.,' 'PA--'i7iiii' --. ---... .-. --' - -- --.......
Goorge A. Vaughn, ] Il
3904 Trind1e Road
Camp' iiiii",' -PA" -i7iiii - -...... - - -. -. - -. .. -.. - -....
357,256.65
53 ,311..30
303,942.35
2,000.00
301,942.35
0.00
18,116.54
0.00
18 , 116.54
5,000.00
0.00
J3 ,116_.54
0.00
13,116.54
llATE
~.'!J/';I3
OATE
oP":'J/"1f
For~
If.
1--'2.
------
3.
Clock, Grandfather, colonial, cherry, 75"
Rocking chair, black, gold stencil, splat back
Wall Clock, Sligh, finial, side columns
Sofa, rolled arms, ::s cushion, striped upholstery
Table, drop leaf, walnut, HH 16", 15" leaues
Deep Frames, walnut, II HI 3", 2 @ 60.80
Chair, occasional, walnut finish, beige
Small pictures, assorted
Umbrella Stand, brass, 20", lion's head
Wall Shelf, knickknack, narrow drawer down
Chair, desk, t~pestry, single splatback
Mirror, wall, gilded, scroll frame, 25H35"
Fire Place Set, 6 piece, brass/glass insert
Planter, Majolica Like, I 8H 12"
Tea Set, 6 pieces, Reed and Barton, SIP
Bowls, I - 8", I - 18", SIP
Lustres, crystal, 8 prisms, 13", 2 @ 55.00
Music BOHes, angel figurines, 6", 2 @ 18.00
Jardenier, 2 handles, lIiolets/gold, 18" 12"
Hauersham, oriental, black and gold, 37"76" 13"
Plates, IMl Austria, 12",2 @ 11.00
Plates, decoratlue, 6 @ 6.08
Decanters, LenoH, Atlantis, 11 @ 45.00
Bowls, glass, 2 cut, 3 press,
Uase, orange/green, glided, 2 handles, 7H8"
Knick-Knacks, glass, B @ 4.80
Dishes, napples, glass, 20 @ 4.00
Bowls, Leno", cream/gold, U", 2 - 1 0"
Trays, 1 Germany, 3 @ 15.80
BOllll, iridescent pink, 7"
Bowl, LenON - 9", Hong Kong - 7"
Pitcher, milk, ironstone, 7"
Bowl, pedestal C' 2 Candlesticks, clear glass
Cream and Sugar, swirl pattern
Knick-Knacks, 6 @ 3.90
Wade Figures, 2 @ 3.00
.4.
(.5.
"'6.
'-1.
B.
<-9.
10.
I-f'l.
12.
l13.
14.
15.
16.
/..-1"1.
118.
'--19.
'-20.
21.
22.
',;.4 ~ 23
" .
v24.
25.
26.
27.
28.
29.
38.
31.
'32;
33.
34.
35.
36.
'i1
.~
rr l~.?!.. ..,. ..::::.::... .."_ _.:: _..::-:_ .'__""_"_'__"__
~x.~
\.
675.00
145.00
90.90
365.00
275.00
120.00
65.00
25.00
30.00
45.00
65.89
70.80
225.98
40.00
166.00
28.00
118.80
20.88
85.08
575.00
22.08
36.00
495.00
128.08
38.00
32.80
80.00
120.00
45.09
35.08
55.0B
25.00
44.00
15.00
18.09
6.08
,......".'~. ",_'_""".,..". .._,...._......,......... ._>-...._. .... .~..~..._....._h"_~....,_.,. .,,_...,.~,..... _._...
Wash Stand, walnut, brown marble top, 30H311" 360.00
Cabinet, curio, 4 door, pecan, 36H72" 140.00
~ ~ f"1 ' 39. Paperweights, glass, 17 @ 10.00 178.00
40. Knick-Knacks, 17 @ 3.00 51.00
.41; Figurine, Hummel, "Goose Girl", 4 1/2",47/3/0 160.60
42. !nkwell, glass, Sterling SlIuel' Top 18.00
43. Statue, carued wood, 91/2" 25.00
\44. Chest-on,.Chest,4 drawers down, 2 ouer I 260.00
45. Chairs, needlepoint, spindle back, 2 @ 80,00 160.60
(46. Rings, 14K/diamond, wedding band - 14K 1660.00
1-47. Ring, onYH, 4 diamond chips, 14K 80.00
48. Necklace, sterling 24.00
-49. Class Ring, high school, 10K 18.00
56. Jewelry, costume, 14 bOHes @ 5.00 70.00
\ 51. Necklace, onYH/pearls 60.60
"52. Cupboard, corner, cherry, recent 575.06
I 53. Pitchers &0 Uases, pressed, cut, 14 @ 15.68 210.00
to tI<"'~54. Pitcher, glass, Oewey/l'1anila, 1898 Comm. 45.00
55. Dishes, cut glass, 2 @ 45.00 90.00
56. Bowls, clear, green, fluted, '1 @ 12.011 84.00
l.-57. Hen on Nest, 6", green, Iridescent, new 15,00
58. BOil/Is l} Knapples, clear glass, 8 @ 7.00 56.00
1---59. Basket, bride's, glass, etched 18.00
60. Pitchers &0 Tumblel's, clear, glass, 9 @ 8.90 72.00
t:J. ;~~t' J 61. Pitchers, water, clear glass, 10", 3 @ 24.00 72.00
. ,
\-62. Bowl, cut glass, ruby/clear, <1 112H II" 125.00
,,63. Baskets, ruby/clear glass, 3" l} 6" 70.00
rli4. Salts, set of 8 32.00
65. China Set, ,Johnson Brothers, 16 place settings,
125 pieces, "Heritage Hall" 750.00
1.-66. HlItch, cherry, 59H76"20" 775.06
\.-67. Table, oual drop leaf, w/4 chairs l} tea cart,
matched, Hepplewhite 225.00
68. Nose Spray, amber glass 10.00
69. Pie Cupboard, Pine, 2 drawers up, 2 doors down 325.60
70. Compote, blue, 8" 18.00
\,11
.e~.~
I","~...
r~.." U ._.u..... ,,,,,,_,,,,,,,--,. ...-........ "...- ~'._"~.'..,A '...........,-~..._..-..~.._.........-- - ----...
" .
\
~_:,~.,.~,.."......-;'*" 1"'- _ ~y f.'
t-II.
72.
'-73.
'74.
1--15.
\.?6.
n.
78.
79.
80.
81.
82.
83.
84.
85.
l.86.
87.
8B.
89.
90.
91.
'-92.
93.
94.
95.
96.
97.
98.
99.
100.
vnJI.
102.
vt03.
104.
~l~':'l
r;-:...O..:... .
..._, ...._.,..~. ._......_............ "..._........"......, M',,,,,,,,,, ...._......
45.00
72.BO
90.BO
111.00
Elephants, assorted sizes, 5 @ 9.00
figurines, luory, 1/2 - 6", 3 @ 24.00
Table, coffec, cherry
Flatware, serulce for 0, 31 pieces
Bedroom Suite, cherry, Incl bed, triple dresser,
chest-.on-chest, green mirror 425.08
Clocl<, shelf, Seth Thomas, 11 H 16", triple column,
marbleized base 160.00
Cups/Saucers Set, 15 @ 6.00 90.00
Mug, nandle, 6", Bennington 35.00
Plates, dinner, 4 @ 3.00 12,00
Luncheon Plates .- 12, Cups - 10, glass 88.00
Saucers, 5 @ 2.00 10.00
Candelabra, siluer plate 15.00
Coasters, glass, sterling trim, 3 @ 5.00 15.00
Egg Plate, clear glass 1 ~.OO
Goblets, 'Water, etched, 6 @ 7.00 42.00
Goblets, blue, Pfalzr;raft, 16 @ 4.00 64.00
Stemware, Candlewlcl<, 9 @ 15.00 135.00
Plates, fluted, blue, green, mill<, Carniual, 6 72.00
Knicl<-Knacl<s, 2 bOHes 40.00
Bowls, pressed, clear glass, 3 @ 7.00 21.00
Platter, clear glass, 15" 22.00
Cream &0 Sugar Set 5, 2, 1 Nippon 18.00
Trays, slluer plate, 3 @ 8.00 24.00
Shot Glasses, 13 @ 2.00 26.00
Salts, 46 @ 2.00 92.00
Glasses, pressed, 1 @ 3.00 21.BO
Bowls, f1Oluered, 2 @ 15.00 30.BO
Bowl, wood, 15" B.OO
Glasses, water, 17 @ 2.00 34.00
Bowls, gl~ss, ornate, 3 @ 20.BO 6B.80
Bowl, cut glass, 9H4" 65.0B
Bowl, pressed, gold edged, 9" 25.BO
Pitcher, water, pressed glass, 9" 15.00
China Set, Harmony House, "Fleur", 42 pieces 126.00
.-J'~
".- ,..... " ~: .~~.....-~,., ':" H,/ -, ':J' .::' ..~~~~::.:...:.:~-....~:~:~~~.._.::...::=-o-:_.......... :::'~'-"::--""':--:_ ~ib
t~ ._'_.....,~.&J1Ill'.. _ 'qlf ~ .
, .
...-..
-----..--
"
H"_'__
105. Trays, bowls, slluer plate 44.00
106. Plates, 7, incl commemoratlue, Majolica 61.00
107. Lazy Susan, Japan 24.00
108. Plates, commemoratlue, Royal Cupenhagen,
1966-1972, 6 @ 15.00 90.00
, 109. Plates, Mother's Day, Royal Copenhagen,
.'
1972-1975,4 @ 15.00 60.00
110. Glasses, set of 0, parfait 16.00
111. Glasses, pressed, 16 @ 3.00 48.00
v112. Plates, seruing, 3 Inc I lenoH 70.00
, 113. Cream &< Sugar, cut glass, 4" 45.00
114. Goblets, Candlewlt!<, ruby Co clear, 34 @ 12.09 408.00
.,
J.I1 11/I(1115. Cruets, pressed, 11 Inc 1 Candlewick 165.00
1,-116. Bowl, f1u~ed, cut 1, 4H12" 45.00
117. Glasses, Ice cream, 8 @ 3.00 24.00
118. Knick-Knacks, 13 @ 2.00 26.00
b.'; I!'f" 'f 119. Bells, glass, metal, 23 @ 7.00 161.00
120. Paperweigilts, cobalt, 8ell System, 2 - 2" &< 3" 55.00
121. Set, fruit salad, '1 pieces 18.80
-I. III/(itI22. Seruing Sets, bOHed, 8 @ 10.80 80.00
123. Glasses, water, set, Durand, 6 12.00
1124. Bowl &< Candelabra Sets, glass, swirl, 2 @ 30.00 60.00
125. Trays, pressed glass, 3 footed,S @ 4.00 20.00
126. Glassware, bOil, incl compote, cups, pitcher 35.00
12"'. Pie plate, Autumn Leaf, Halls, 10" 18.00
128. China, dinner, clear glass, 75 pieces @ 2.00 150.00
129. Tray, glass, fruit, grapes, 14" 20.00
13D. Pitcher, milk, Bennington, 6" 35.00
APPRA I SAL TOTHL
14,459.00
..,
;:'
,~..,.I'/"I. oJ-lJ -"..'~'(..t
~~~-l"-~,.r<> ~';'pl
ii', .
.., t" ..
r;:'
..
,,'". ' .~ .....
['J_.t.. il..""._"....___._""....__""~_~_"W________,,_ - .... 'w.
'-.......-.-...-.__..............--...._....,.,...,.........._. .._.,...._~_..~..........~.~..._ ...;::....,..:..=::-::==....-.'-..::::::-- -:'"7:=......-......-J~U
EXPENSE CHARGE TABLE
ANNUITANT HELEN A. JONES
POLICY NUMBSR NP3-881712
THIS TABLE IS TO BE: USED WITH THE GUARANTEED CASH SURRENDER SECTION OF THIS
POLICY (SEE PAGE 9) .
DURING
POLrCY
YEAR
EXPENSE
CHARGE
PERCENT
1
2
3
6
4
2
THE EXPENSE CHARGE WILL B8 DETERMINED AS OF THE DATE .oF WITHDRAWAL. WE WILL
MULTI PLY THE AMOUNT OF' THE ACCUMULATION VAl.UE OF YOUR POLICY (SEE PAGE 7) TO
BE WITHDRAWN BY THE APPLICABLE EXPENSE CHARGE PE~CENT.
GUARANTEED CASH SURRENDER AMOUNT TABLE
THIS TABLE SHOWS 'l'HE MINIMUM AMOUNT YOU WH,L RECEIVE IF YOU SURRENDER YOUR
POLICY, ASSUMING THAT YOU PAID $1,000 AS A SINGLE PREMIUM AND MAKE NO PRIOR
WITHDRAWLS.
END OF GUARANTEED END OF GUARANTEED
POLICY YEAR AMOUNT POLICY YEAR AMOUNT
1 $ 973 11 $ 1,460
2 $ . 1,028 12 $ 1,511
3 $ 1,109 13 $ 1,564
4 $ 1,148 14 $ 1,619
5 $ 1,188 15 $ 1,675
6 $ 1,229 1.6 $ 1,734
7 $ 1,272 17 $ 1,795
8 $ 1,317 18 $ 1,857
9 $ 1,363 19 $ 1,923
10 $ 1,411 20 $ 1,990
THE GUARANTEED AMOUNT DEN1'H BENEFIT AND PAID-UP ANNUITY WILL NEVER BE LESS
THAN THE MINIMUM VALUES REQUIRED BY LAW,
ADDITIONAL INTEREST
. At uur dlscretlun, ilddltion.lllllleTestll1ay be declilred .mllually on illl Payment
Options, This Interest willll'ngll1l'n till' I",riod und,,, Option 2, ilmllncreilse the
Installment amounts under 01'1101," 3 ,1n<1 4,
_.~~~_~____.____"_""..L_~~..._ "._,.._.,_. _._.._."...__._.._____.____~____u.._,.__
OIYJ'(ON 3 TABLE
MINIMUM MONTlIl:r INSTAI.I.MENT PAYMENT PEH $1.000 APPLIED
~~............... --..............-.r. m._ _.' -------------,---------- --~-.'-....l.-.w---- --.----l-~-
Nun,t",. i M,fnlhl~ Nurnl....' I """I\lhl; i'hlllll"'f I "'''fll\,1I Nu",I..., I M"nlhh NlInlllllf j ,"",.ntlllv
u(Y..r,-!<<~~ _~'0.t:.~!.:._~1.'~11l" nl -~~~~"~!~,__l_!:.,!_~~~~_'_.L.~.!..~~~~!.~_t-,~~:~~~~~I _ III Yu~~.....
1 : $84.11' (,: W>1' 1\ : $4.(1'1 111: $1>70 21 : $,.511
2 : 43.0, 'I: I.U8 12 : H.46 17: 11.47 22 : 5.39
I I I I I
3 : 29.19 H: 11.'10 13 : 7.94 1H: 0.20 23 : 5,24
4 : 2227 9: 111.7, 14 : 7A9 19: ,.'17 24 : 5.09
I I I I I
5 : lH.12 JO : 9H'1 I, : 7.\0 20: 575 25 : 4.%
I I .....,.,..... "",..~.___~__ _..___._1___.__ ~_ I
_._.__u~___n_~__~__
OrynON 4IABL
"-y'lINIMUM MONTHLY 1~..?_~~~Ltv1Yt--J'f'.l~AY
MALE
- -.-.--.- -_.--
N"
G\I~fdnIH\1 CIl'fdlltl'l'dl\'IWd 11\\t.IIWl'J\l {;u
All" I'ni\ld lIl'iun 211y,',II\ ,--~~~ ~~-
50 $4,79 $4.71 $4.5U $4.54 50
51 U7 4.79 4.55 4.01 51
52 4,97 4.87 4.61 4.I1H 52
53 5.06 4.96 .l.67 4.76 ,r:;,1
54 5.17 5.05 4.73 4.H3 54
55 5.27 5,14 4.79 4.92 55
56 5,39 5.24 U5 5.00 56
57 551 5.34 4.91 5.09 57
58 5,63 5,45 4.97 5.19 5H
59 5.77 5.56 5.0.1 5.29 59
60 5,91 5.118 5,10 5.39 60
61 6.06 5.60 5.16 5.50 61
62 6,22 5,93 5,21 5.62 62
63 6,39 11.07 5.27 5,74 63
64 6.58 11,21 5.33 5.87 64
I
65 6.77 6.35 5.38 11.ot 65
66 6.99 6.50 5.43 6.111 66
67 7.21 11.66 5.48 6.31 67
68 7,46 6,83 5.52 11.47 118
69 7.72 7.00 5.511 6.115 119
70 8.00 7,17 5.60 6.83 70
71 8.31 7.35 5.63 7.03 71
72 8.64 7.53 5,66 7.23 72
73 8,99 7.71 5.118 7.45 73
74 9,37 7.89 5.70 7.69 74
75 9.79 8,07 5.72 7.94 75
76 10.23 8.25 5.'13 8.21 76
77 10.72 8,43 5.74 8.49 77
'/8 11.25 8.60 5.74 8.HO 7H 1
79 11,82 8.77 5.75 9.13 79 1
80. 12.44 8.93 5.75 9.48 eo
E
MENT PER $1,000 APPLIED
~~---..-
___ FEMc'.':.!'._.
N"
Jldl1l.'fd
I\'ll{ll'
$U5
4.43
4.50
4.58
4.66
7.04
7.32
7.61
7,93
8.28
8.66
9.08
9.53
0.03
0.57
11.16
.Age nearest birthday on the dale of thl' first payment,
Value. for other ages wm ~ fmnished upon reque",!'
11
\401.1
4.75
4.85
4.94
5.05
5.111
5,27
5.40
5.53
5.117
5,82
Cilllrlllt"dl\>rl"J 1!HIIUm...nl
IOY"M1 W~"lr~ flflund
-~---
$433 $4.23 $4.24
439 4.29 4.29
4.411 01.34 4.311
4.54 4.40 4.42
4.62 4,46 4.49
4.70 4,53 4.57
4,78 4.59 4.64
4.87 4,66 4.72
4.97 4.73 4.81
5.07 4.80 4.90
5.17 4.87 4,99
5.28 4,94 5,09
5.40 5.01 5.20
5,52 5.08 5.31
5.66 5,15 5.43
5.80 5.22 5,55
5,95 5.28 5,69
6.10 5.35 5.83
6.27 5.40 5.99
6.45 5.46 6.15
6.63 5,51 6.32
6.82 5,55 6,51
7.02 5.59 6.71
7.22 5.02 6.92
'/.43 5,65 7,15
7,64 5.68 7,39
7.85 5.69 7.115
8,05 5.71 7,92
8.26 5.72 8.21
8.45 5.73 8.52
8.64 5.74 8.85
5.98
6.16
6.36
6.57
6.80
LIBERTY LIFE ASSURANCI' COMPANY OF BOSTON
AMENDATORY
AGREEMENT
PAA.8SS1
PURPOSE OF AGREEM ENT
This Agreement is meant 10 qualify this policy as an annully under the Internal Revenue
Code ~72(s). Any ambiguity ill this Agreement will he resolved In favor of the meaning
which maintains the trealml'llt of the policy as an annully.
MODIFICATION OF P(lLlCY
This policy is chanf.\ed as foil, 'ws. Each chanp,e supersedes any polley provision which
may be inconsistent wllh it.
MODIFICATION OF T11 E DETERMINATION OF MONTHLY ANNUITY
PROVISION
The first sentence of thl9 provision Is hrreby deleted and is replaced by this new
sentence:
We will pay lhe Monthly Annuity lothe Annuitant beginning on the Maturity Date
shown on page 3, If you ,,"d the Annullant are living on the Maturity Date.
n,e last sentence of this pro\ Islon is hereby deleted and is replaced by this new sentence:
However, If the Monthly Annuity Is less than $50, the Accumulation Value will be
paid In one sum in lieu "j any olhel'benefit.
MODIFICATION OF Tl IE DEATH BENEFIT PROVISION
this paragraph Is hereby del,'led and is replaced by these new paragraphs:
Before the Maturity Dal,', we will p,'y a Death Benefit upon receipt of proof,
satisfactory to us, of th., earlier of: your death; or the death of the Annuitant. The
Death Benefit becomes !,'yable on the earlier of these two dates. The Death Benefit
will be paid to the Beneficiary if living on that date of death. If no Beneficiary Is then
living, the Death BeneW will be paid to you. Thl' fl.'ath Benefit will be equallO the
Accumulation Value Oil Ihat date of death.
The Death Benefit must be distribuled withill 5 years after the date II becom s
payable, However, If the Beneficiary is an illdlvlJual, payments may be made under
an Option. Payments under the Option must be payable: for the life of the
Beneficiary or for a ternlnot longer than the life expectancy of the Beneficiary; and
must start withill \ year "fter the date the Death Benefit becomes payable.
MODIFICATION OF CASH SURRENDER PROVISION
The first sentence of this prcl'!ision is hereby deleted and Is replaced by Ihls new
sentence:
You may withdraw all or p,ut of the Accumulation Value of your polley (see page 7),
by writ/ell "'quest, at any lime 011 or before the Maturity Date and before the Death
Benefit is payable.
MODIFICATION OF OWNER PROVISION
The language of this provisi<'n is hereby deleted and Is replaced by the following
paragraph:
The Owner is as named ill the application on the Date of Issue, Unless othel'wise
provided, all ownership lights terminate at the earlier of: 1) the date a Death Benefit
becomes payable under Ihe policy; and 2) the d"te of the Annuitant's death after Ihe
Maturity Date. You may <hange the Owner from time to time until ownership rights
terminate. At the death of th,' Owner, the executors or administrators of his or her
estate will be the Owner, unless otherwise provided. The ownership rights of a
corporation. partnership or fiduciary will belong to its successor or assigns.
MODIFICATION OF BENEFICIARY PROVISION
The language of this provision is hen.by deleted and is replaced by the following paragraphs:
The Benefldary Is a5 named in the application un the Date of Issue, You may change the
Beneficiary from lime tullme until ownership rights terminate.
The Interest of any Ilcnefldary who dies aller un amount becomes payable to that
Benllflciary will belong 10 the ex,'cutors or administrators of that Beneficiary's estate.
MODIFICATION OF CHANCH OF OWNERSHIP OR BENEFICIARY
PROVISION
The first sentence of this provision Is hereby deleted and Is replaced by this new sentence:
Any change In Owner or Beneficiary must be made by writ/en request.
MODIFICATION OF PAYMENT PROVISION
The language of this provision is hereby deleted and is replaced by these new paragraphs:
The proceeds of this policy will b,. subject to the Interest of an assignee, to whom payment
will be made In one sum. If you ,md the Annuitant arc alive on the Maturity Date, we
will pay any remaining I"oceeds 10 the Annuitant; and to the Beneficiary after the
Annuitant's death. If there Is no Beneficiary alive at the Annuitant's death, any
remaining proceeds will be paid 10 you.
Unless otherwise provided, payment will be made in equal shares to those beneficiaries
entitled to receive the proceeds.
lithe Owner dies on or aller the MatUlity Date and before the enlire proceeds have been
distributed to the Annuitant, any remaining proceeds must bc distributed at least as
quickly as under the method 01 distribution in effect on the Owner's date of death.
However, If Option I was In effe, l. distribution of the remaining proceeds must be made
within 5 years allm the Owner's date of death.
MODIFICATION OF PROOF BEFORE PAYMENT PROVISION
The first sentence of this provision is hereby oeleled and is replaced by this new senlence:
Payment to the Beneficiary will be made only If we receive proof, satisfactory to us, of
either the Owner's or the Annuitant's death.
MODIFICATION OF PAYMENT OF PROCEEDS OPTIONS PROVISION
The languagt~ of this provision is hen by deleted and is replaced by this new paragraph:
The proceeds may be applied under one of the following Options, subject to any
restrictions set out in this policy. An Option must be selected by writlrn request. You may
select an Option on or before th.. Maturity Dale and before the Death Benefit becomes
payable. II you have not selected an Option, the Beneflciary may choose one.
PAA.8551
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
ANNUITY APPLlCAflON
PART I
I, Annuitanl (fiul. middle Inill,l. I,,,):
---".~ a~J9-~~-------
2, Bi"h Dale: .1. In,u"n,'. A~e: . 4. S.,:
MOC"DUYU~ <is\ ____~~'~:Ie__
S. Nume nfOwner (if /in ndwr Owner i~ dcsignlllcd,lhc Annullu"l will
he Iht. Owner):
--
6. (a) Owner', Sac; 'I Sc<:unly ur T., Idcnllftc.liun Numbur:
(b) Annuh.nl', Sud,l Securily Numher:
L~--=-?P-=--d~t) ....
1. PremiU"a~r~.~~\.t"f\ecl. diy, ,I,lc. lip cudc):
C f\~-1\H]Ll-c . L1Sll.-
8. Plan ofannuily: ~ ,"' .
$\~ .~_...- ~
9, If Ihi, i, a I<,..lble remiu", Annuily Ihuw:
(a) Frequency of Premium Reminder
DAD s 0 Q 0 M 0 PAC
(b) Anticipated am Inl of each Prcmilllll payment
v'
$
(c) ^l1luunl uf I'irsl Premium 10 he c\eluded from W.lver of
PTem;u", B,neftl ealeulallon $=:
(Depoall Premium less mod.1 prcmium),
-
__'~__'____'_____' _NL...g.4.Q5_5_ .
10 Addlilunalllenelit\ (Comple" flAIIT IA):
rJ W,lycr uf Premium
n OlhOl'
ii-:-ii y" )l. 'Nu
l2."iJ~NO
Iii ^nnuilllnl'~ he..llh slII.'h 11"- lu WIUTYl1t" rea"
t'Iondhle t.ll,peClllliOfI ~)f life'.'
I, Ihi. Annuity Inlended 10 replllCe m chllnge,
In whole or In purl. any ..1"ln8 life In.ur-
IInce. includinglJ.S (loyernmenl Life IflOur.
1tncc. nr Annull~ in Ihis or IUlother l'lH'npwny?
If "yes," ~i\ll~ l'llll1l1any, plUllllllU amount:
13. N'llIe (11,,1. middle initial. '"I) nf
~w:tif\ltn'hiPCQ(S;IS'~ twt~S\~
._~t' ~~.-:..j)~~j)~~S\i
14. $_~JlQ.~~_ h" been p,ld in ",'''ange
for Ihe RCCClpl beorlng Ihe ,ullle number" lhia Appllealion.
15 Olher InSlrucllon"
16, Home Offiee Eodur>cmcnl:
Part I 03 Insurance age is 82
17. I declllle thal.1I stalemelll' and .n,we," in all PIIl1' of Ihll Applieuli('n are !ruc nnd eomplele 1(1 the heS! of my knowledge and bell.f.
'.gree Ihal they will forlll Ih. b"l, for. and bu u purl of. ony Annuliy con!r,,1 issued by Ihe Company. I ulao llgll'C Ihal:
(.) Nu Sitl.:s Reprcs.enlalivc or Medii:al Examine, ha~ the uUlhorilY III (I)deterrnine insurubilil)': (2) waive any ri~hts or requlrenumh uf
Ihc COlllpany; or (3) make 0' mud,fy any Annuliy eun!ruel. No Informalion acquired by any ,uch person will bind the Company unle"
II has been 001 OUI in wrillng In a Pa" of Ihi. Applle>llon.
(b) Noehan8e a, '''a8e. .mounl. beucftti. cl",llIcallon. or ploo of Anoully will take effeClunlesa agrced In In writing by lhe Applleanl.
HoweYllr. acceplllnce of any polICY 'ssued 00 Ihc hasi. of Ihl, -'I'pll"l,on will be orolille.lion by Ih. Appileanl of any olh..
corn:ctlons, modHicatiorls, ur adllitions madr. hy the Company in (Juestion * 16llhovc,
Ie) Any 1'.Ylllenl .uhmluud wllh .hls Applleallun will be upplled 10 pay Ih. ftrsl premium of Ih. polley upplled for. If no ""liey i, I..ucd.
Ih. Cumpany'. only lIabllily will he 10 refund Ihe paymenl.
Daledll_____.__ 0-. . ~bill.__n on
~"".",'''' ~
l~) P-A
/
PlA.1l0J AI
J
1881712
3L~-_-
.",
r
t1 &"""", ,f ^,",,""' "...".., ''''<0' .
~,M~ fA' ') -. J_.___.__
y----r-~-\;~
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON
~NIJITY APPLICATION
\RT 1
" Annuli ani (11"1, millllle inililll, Illsl):
-~ 'i~re:,,)9~"'t- - --- -
'. Dirlh Dale: J. Jnsurllnee Age: 4 Sex:
~~uay [-Year' SdMll1':
~ __~ __ 82______._._-.-:_~~._
Name of Ow neT (if noolher Owner is llesignllled .Ihe Aonuilllnl will
be Ihe Owner):
~~---_._--------
(ll) Owoer's Sacllll Security or li,x Illentificallon Number:
(b) Aonuilafll'~OClal Seeurily Number:
_._JJL~~.:.~~~JJd_..______
I~m'"m 'J3j:;'YAlk:' ~i". ""'. ",,""~l,
__ rAMP }11Ll} LLl..DJ.l
Planof~-',
~I\~f.t.~xlble premll~~d~~ls[~~
(a) pr~~~ of Premium Reml ler
o A [] Q 0 M 0 PAC
(b) Anticipaled am I of ea Premium paymenl
N2 ...94065.......
10. A..lllliliOII."II1t'IIl'IiIS (ColIIl'lell' I'AJr~ IA):
[ I l'Iaiverofl'rcmium 11/4
r] Olhe.. _.. _.n _". ...._...__.___.....____._______..
_h - "V" --- ,,----- -- - - ----.-- ------.------
II I'J Yes {1 Nil Is ^Ul1uitulllls Ill'lllih lillch liS In wlIrrulll H rcu
,onllhle expe('llIIion of life?
--~;~-i:i-.,:;_pi:'N:;-.I;lhIS Anll~~~lnlelllled 10 Teplao. or ~hllnge'-
in whole or in pari, llny exisllng life in,ur.
IInee. including U.S. Governmenl Life In,ur.
anee, or Annuily In Ihi, or anolher company'!
If "ye,," give company, pl.nanll amount:
D. Name (firsl, mllldle inilial. lasl) of
Beneficiary anll relalionship 10 Annultllnl:
Patricia L. Cocos and Diana S. Duclos
(daughters) "qually if living. otherwise; to
survivor if any. otherwise I to the Estate of
last surviving payee. .
14. $_S:J~Q.()(l_ O!? has bcen paid In exchange
fOT Ihe Reeelpl bellring the same number as Ihis Application.
15. Olher Inmuctions:
$456.98 will be paid on February 27. 1994 and
every month thereafter through
January 27. 2004.
These payments are guarantead.
$456.98 will be paid on February 27. 2004 ano
every mont.~ thcreaHer for the lifetime of the
Annuitant. Payment will be made only aa long
thc Annuitant is then living.
J declare Ihat all slalemems and answeTS In 1111 Paris of lhis Appllclltionllrc Il1le lInd eomplele 10 Ihe hest of my knowledge and belief.
I ISTeelhallhey will form the basis for. and be a pari of, lIny Annully conlnlel issuell by the Company. 1.1,0 agree 111111:
(I) No Sales RepTesentalive or Medical Examiner has Ihe .lllhorily 10: (I) delermine insur.bllity; (2) waive any rights or requlremems of
the Company; or (3) m.ke or llIodify any AnnullY conlraet. No infoTmaliol1 acquirell by lIny such person will bind Ihe Company unless
II has been sel OUI in writing Ilia Pari of this Application.
(h) No change as 10 age, amounl, benefits, classificalion, or plan of Annuily will lake eff<lel unless agreed to In writing by Ihe Applicam.
Ilowever, scceplance of any policy issued on lhe basis of this Applicalion will be a rallllcalion by Ihe Applicant of any other
COllections, modificulhms, or uddilinns mullc by the Company in QucMion (116 uhove.
(c) Any payment submilled wilh Ihis Application will he applied 10 pay Ihe lllSl premium oflhe policy applied fOT. Ifno policy is issued,
Ihe Company's only Iiabilily will he 10 refuod the payment.
.."'~ l",,~,"
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Register of Wills of
CUMBERLAND
County, Pennsylvania
INVENTORY
E,tal. of Helen A. Jonas
No. 1997.325
alllO known as
Dal. of D.alh 02/27 /1997
,O.c....d Social Sacurlty No. 164 - 30 - 2580
Patricia L. Cocos-c-__. _
Personal Representatlve(s) of the above Estate, deceased, verify thai the Items appBarlng In tho following Inventory lnch,lde all ollhe
personal assets wherever situate and all of the real estate In the Commonwealth of Pennsylvania of said Docedent, that the valuation
placed (\pposito Ell:lch itlBtrl of said Inventory represants Its fair value as 01 the dale of the Decedent's death. and thai Decedent owned
no real estate outside of the Commonwealth of Pennsylvania OKcept that which appears In a memorandum at the end of this
Imenlory, I /We verify thill the statements made in this Inventory are true and correct. l!We understand that false ~lalem9nts herein
are made subject to the penalties of 18 Pa. C.S. Seclion 4904 relating to unsworn falsIfication to authorities.
Personiii! Roprflsentiltlve
Name of Gaorge A. Va\\ghn III
Atlorn.y:
1.0, No.: 25650
Add,." : 3904 Trindle Road
Camp Hill , PA 17011
,.I.phone: 717/975-9102
Slgnat",.:
,/J~ .)O./')
f-I,,'t t\.. C:_.!',,~
Patricia L. Cocos
SlgnaM.:
Add...s: 2215 Yale Avenue
Camp Hi 11 , PA 17011
T.lephone: 717 /763 -4712
-xp.3 j<J2!
Dat.d:
Description
Val".
(')0
(-: ii.
, . , ~:~l
.'
(See oontJnuEltion page(s) ElttaclMd)
-"~I
III
cn
~,\
c:J
f.ji
. .
'''''-J
\!",
(Attach addlllonal.h.at. If n.c....ry)
Total:
141,069.56
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvanin may, al the eleclion of the personal representative,
lnclud$ the valuo ot each itern. bul such ligures shmlld not be ext&nded into the total of tho Inventory.
Prepared by Ihe Permsyl"'1nll Bar Assl.lclllt!on
Copyright (c) 19\16 form SOIlWiHll only CPSystems, Inc
Form"RW~7 (199<l)
-""
..
COMMONWEALTH OF PENNSVLVANIA
DEPARTMENT OF REVENUE
RUR~AU Of INDIVIDUAL TAXES
INHERITANCE fAN DIVISION
OCPT. 210601
IlARRlsaUAG, PA 11128-0601
NOTICE Of INHERITANCE TAN
APPRAISEMENT. AllOWANCE ON DISALLOWANCE
Of DEDUCTIONS AND ASSESSHENT Df TAX
DATI:
ISTA'tI! OF
DA TI OF DEATH
FILE NUMBER
COUNTV
ACN
05-25-98
JON[S
02-27-97
21 97-0325
CUMRERLANO
101
CA;;ouniR~.ltt.~_ _J
MAKE CHICK PAVABLE AND REMIT PAYMENT TOI
REGISTER OF WILLS
CUMRERLANO CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR VOUR REcallDS ....
R 'Eli: iii47" iii" AiiP'- {il9"=97Y"Niif i lii --OF"i:"NHEiii;: AileE - YA'x - 'A"ppiiA"i SEHEN'r-; -A L Lo'wANcE"oli--"" - - -" -"""". -.
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
HELEN A FILE NO. 21 97-0325 ACN 101
GEORGE A VAUGHN
3904 TRINDLE RD
CAMP HILL
III
PA 17011
ESTATE OF JONES
TAX RETURN WAS I (X J ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST . SEE REVERSE
APPRAISED VALUE OF RETURN BASED ONI ORIGINAL RETURN
1. Rill E.t.t. (Schldul. A)
2. stock. and Bonda (Schedull B)
:5, Clo'lly Held Stock/Plrtnerlhlp Inte.,.e.t (Schedule C)
4. Mortglgl./Notle Rlceivable (Schldull 0)
S, C..h/Bank Dlpo.it./Hi.c. P.r.on.l Proparty (Sch.dull E)
6. Jointly Own.d ProPlrty (Schldull F)
7. Tran.fera (Schedull G)
8. TDt.1 A.~.t.
( ) CHANGED
11)
(Z)
(3)
(4)
IIi!
(6)
(71
124.000.00
.00
.00
.00
11.069.56
39.766.60
176.420.49
(5)
APPROVED DEDUCTIONS AND EXEMPTIONS I
9. Fun5rll ExpI".../Ad~. COlts/Hi.e. f.Kpln... (Schldull H)
10. O.bt./Hortg.g. Llobllltl../LI.n. (Soh.dul. II
11. Total O.ducUona
12. Net V.1ue of T.x Rlturn
1S. Ch.r-1tablI/GolJlrNtlnt.l Bequl.t.J Non-Illctld 9115 Trust. (Schedull J)
14. Net ValuI of Eat.t. Subjlct to Tlx
24,507.99
28.806.31
1111
I1Z)
1131.
1141
(9)_
(101
*,
(
tn.IJ4111'" C"-"I
HELEN
A
DATE
05-25-98
NOTE I To in.\lrl "roplr
crldit to your .ccount,
.ubMit thl upp~r portio
of thh forR with your
tax P'YMnt.
357,256.65
~:L~14 ~o
303,942.35
2,000.00
301,942.35
11 an a..e.sment was i.sued previously, line. 14. 15 and/or 1'. 17 and 11 will
reflect figure. that include the total D1 ill r.lIturna BlOSllt.lilld to datil.
ASSESSH!NT OF TAXI
IS. Aao\JIlt of Linl 1', .t Spou..l rite US)
16. AMount of Line 14 tl~.bl. .t Linl.l/CI... A rat. (16)
17, A~ount of Line 14 t.~abll .t Coll.tlrll/CI... Brit. (17)
la. PrincipII TlX Dul
NOTE I
TAX CREDITS I
PAYHENT
DATE
12-09-97
02"20-98
RECEIPT
NUNSER
AA242533
AA269780
DISCDUNT (.)
INTEREST/PEN PAID (-I
.00
.00
BALANCE OF UNPAID INTEREST/PENALTV AS OF 02-21-98
. If PAID AfTER DATE INDICATED, SEE REVERSE
fDR CALCUL~TION OF ADDITIONAL INTEREST.
.00 X .00,
301.942.35 X .06,
/J1)8, X .15,
;'1' (~L
IT
AMOUNT PAID
5, 00.00 c
13iU6.54
~.. ,
12 ( ,.
TOTAL TAX CREDIT
---- .
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DllE
.00
18.U6.54
~ .00
;J .1l6.54
r.'.,
~
VI C
...
18,116.54
.00
290.20
290.20
If TOTAL DUE IS LESS THAN .1. ND PAYHENT IS REQUIRED.
If TDTAL DUE IS REFlECTED AS A "CREDIT" (CRI. VDU HAV SE DUE
A REfUND. SEE REVERSE SIDE Of THIS fDRH EOR INSTRUCTIONS. I
PA'ttE1ff1
OItaoh the tOfl portion of this 'HqUoe IIf'Id aubAlt wUh your Pa~t ... paYlltda to tM ,... Met .tetra..'
",rioted on tho nYlr.. IIH,
If RF.SIDEltT DEcnElIT 1IIIk. ..- or ..... order .....,1. tOI REGISTER OF ,WILLS, AGENT.
If NOH-RESIDl!1IT DEct!1lf.1IT 1IIIk. ohook or ...... order p.yobl. toi COHItOIlIfEALTHDF PENNSYLIIAIIIA.
RfFUND (CRU A refi.RI of a tax credit, which N4l1 not r~lted CHI the hx Return, HY be requ..ted by cOIIplatJng Iifl
"APPJJcet!on for Rduncl of PeM.yJ,vanla lntMrltanoeltttd Estat. hx"(REY~l!n). AppUcatJon. ara 1tY.J1~J.t lit
the Off101 of tht Reg,.tar of Will., ~y of tht Z3 Ravenue District Offiae. or frOll the DepartMent'. I.-hour
,"lWIrlng service ~rft for for.. orderingl In Penn.ylvanta 1-800-562-2050, outllde P8nnlylvanla
end within 1001I1 H<<irrhburg ares (717) 787-8094, TDDI (711) 772-2252 U...rlng l"Palred only),
REPLY TO,1 b.Uonl rqardlng errorl oont.Jned on this not1c:e .hould be IKkIr...4Kt tOI PA IH.partHnt of Revent.Hl, IurlllU
of Individual T.)Ce., AlTNl Po,t A..e....nt Revl.w Unit, Dept. 280601, H.rrl.bUrg, PA 17128-0601, phone
(717) 781-6505.
D],9COlIO'I
tf ~y tax due Is paid within thr8e (!)oaland.r aonthl ftfter tt~ die_dent', death, II five par~ant (5X) dleoount
of t~ tax paid Ie allowed.
PENALTY:
The 15% tax .-ne.ty non-participation penalty II OOIPuted on the tot.l of the tax and Interelt ......ed, end not
paid before JlOUary 18, 1996, the flr.t day ~ft'r the and of the tlX .."..ty period.
INTEREST a
Inter..t is charged beginning with fJr.t day of dllif~CY, or nJne (,) .unth. end one (1) day fru. the date of
death, to the date of aa~t. Ta)C.. which be~... delinquent blfor. Jenuary I, 1982 bear Interelt at th. rat. of
.ix (6~) ptrcant per annUl oaloulat.d at a dalJy rate of .000164. All ta)Ces whioh beo.-e d.llnquent on end aftar
JanuarY I, 1982 will bear lnt.re.t at a tate wh'oh will vary fr08 nalandar yoar to oalendar year "Uh that rate
annouflC*I by the PA o.part..nt of RevMlU8. The eppllgltble int.r..t rate. for nil thrOUl1h 1998 arlltl
YHr Jnter..t Rate Daily Inter'lt Faotor Ve.r Inhr..t Rah DaUy Int.r"t Footor
1912 20~ .000541 1987 9% .01'10247
1983 16~ .000458 1988~1t91 m .0OOSOl
1984 IlX .000301 1992 9l .000Zft7
1985 IS:< .0003&6 1993~11)94 7% .000192
1986 lOX .000274 1995.19'8 9l .000247
-~Int.r..t il OIlcul.tld I' followll
INTEREST . BALANCE or TAX UNPAID X HU"BER OF DAYS DELINQUENT X DAILY JNTBRE8T "ACTOR
nAny Notice hlued aftar the till beeOlMs cialJnquent wHl reflect 10 intire.t oalculntlon to fineen US) days
beyond tM date of the .....lAInt, If pay..nt is .... aft.r the int.rut COIIpUt.Uon dllt.. Ihown on the
Notioe, addItional lnt.re.t .ult be caloulated.
,'L..",,',;,',