HomeMy WebLinkAbout97-00667
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10, As a resul~ of thoa(orei11ent,loned podestnan'"!!automoblleaooldent, Mr,Rloll Is
aware Ulat oertalil olalms lire available to' him both' individually, and as administrator of the
',Bstate of tillzel Orabel, Inoludlng both a wrongful deaUl and survlvalllotlon.,
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11, No aotlon has been prought by Mr, Rloe either Individually or on behalf of tho
Bstate of Hazol Orabel oonoernll1li the pedo~trlan'automoblle aooldent, However,Natlonwlde
Mutual Insuranoe Company has offered to oompromlse any and all claims arlsfllg' out of the
automobile acoldent Including both wronglUl death 'and sUrVival olalms. by paying the sum of
$27,531 of which $2,531 has been advance paid. ^ oopyof the propos'ed release Is, attaohed
heroto as Bxhlblt B,
1~, It Is believed and Ulorefore ,averred that Ule Respondents Is satisfied that the
" above.offered settlement Is Just anll reasonable and Is Willing to aocept said offer, for approval
by thls.Honorable CO\lrt In lieu of filing allya,otlons on behalf of Dale Rloe, Individually or the
Bstate of Hazel Orabel, conoernlng this Incident.
13;, The law firm of Peters &:, WasllefskJ docs not represent the Respondent Ih Ulls
matter and has not provided any legal advice regarding th~ matters contained herein, The law
firm of Peters, & Wasllefskl ,represents the Petitioners In this matter and had prepared this
Potltlonln aooord~nce With the terms of the proposed settlement accepted by Dale RIce,
Indlvld\.lally'and as Administrator of the Bstate of Hazel Orabel.
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14, Respondent ,roquests that the sottlement proceedsbo apportioned and paid ps
follows:
a, $17,53110 Dale Rloe pursuant to thewrongfuJ death claim,
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,b, $10,000 to Dale Rice, Administrator of the Estate of Huel Ora\lel,
Deceased, pursuant to the survival action.
1', Ills submitted that the proposed apportionment Is reasonable bocausethe major
Items of damages resulting from this unfortUnate Incident rcvolvearuund emergency, hospital
and l\Ineralllllpensesas well as the 108$, of, the peounlary Val\lll of IIny services, society and
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comfort the decedent may have provIded to Respondent thro\lghout the balance of her lifetime,
Additionally, the Decedent was not working at the time of the acoldent
mentIoned herein, Accordingly, there are no future lost earnings to be claimed In any survIval
aotlon,
1', The only Item of damages to be olalmed b\ any survival action Is pain and
SUffering of the Decedent, which amount Is ,speculative at bost,
,16, There will be, more thansufflcJent sums In the Ejstate to pay aU creditors.
17,' If this Court sees fit to approve this proposed settlemenl,Rnd apportionment of
'proceeds, then It ,Is requested that the' Respondent, Dale Rice, IndividuallY and as Administrator
of the, Estate of Huel Grabel, be authorized to e~ecute II' valid and suffiolent release of al!
olalnia against Petitioners and any and all persons, finns or corporatIons, their heirs,
, '
re~re8!:1ntatlves, assigns and other persorw, finns or corporaUolUl for whose act or failure to act
for Which they may be liable liS a result of the Inoldent referre,d to In this Petition,
WHERBP9RE, Petitioners respectfully request that this Honorable Court enter an
order approving the aforesaid settlement arid apportionment of proceeds and authoflzlng the
Respondent, Dale Rice, to sign a General Release Individually and on behalf of tho Estate of
-4.
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n!l.tt. ~ FIN'''' RELEASll;
PO~ AND IN CONSlDeRA nON of the tOIll! sum of TWenty-lOven Five Hundred
Thltty-one Dol1a~s ($27,'31.00) paid lolhe underslsnlld, reQolpt oC ~hlch II hereby
ao~w.locIiod, and other aood and valuablo conslderallon, tho underslaned 1.1008 l\tI\y releale and
dlaobarao Brian Klfby and Nationwide Mutual [ns\lrance Compllny, their asenlll"servantl, and
employees, their lnsurars, and aU other persons, associations and corporatlonsr whether or"not
AAmcd h~reln, their h~lrl,:el\ecutors, administrators, successorsiasalg1l811nd Insurers, and their
, ,
, respective asents,servants, andomployees frol11 any or all caulolof acllon, claims, demands.
~aes" costs, loss of services, loss ~f, Income, loss of profitS, property damaae, oxpeMes,
oompenSation and other los." of whatsoever kind, oIUOCO\lnt of all known and untcnown lossell
, and damages Illesedly SUSllllned by lh<l undersigned and, inclUding, without IItnlllltlon, ~y clal,ns,
;- , ,
or Joinders, for sole liability, contrlbutlon, indemnity or othe\'Wlse as a result of,arlslnS from, o~
In any way connected with an automobile-pedestrian accident whlch occurrod on July 28,19~1,
on Wost KIna Streot noar the IntCrsectlon of SorieQa Street In Shlppe~b\l1'S, CUD1borWld County I
Pennsylvania, Lotters of Administration ' were arantedto Dale E, Rice on Ausuat 'tt,1997. ,
1 hilrebYllcknowledgo thaI $2,'31 for funeral expenses has been paid 10 me as an
advance paymont asalnst tho wronaful death settletnontp~oceeds, ,Two additional clle!;ks were
prOVided to me as follows:
a, $1',000.00 made payable to bale Rice, Individually,
b. $10,000,00 made payable to Dale Rice, AdtnlnlstnllQr of tho Estate of Hazel
Orabel.
1 hereby declare and represent that In maklnli this release and agreement, It Is
understood and agreed thllt I rely wholly upon my own Judgment, bellet' and knowledge of the
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nature and oxtent of laid damaBol. and that J /lavo not been lnlIuonced 10 any OXlClnl whlllClvor In
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maJdnIJ thIa roloalo by lily reprolencal1ons or ltacomencs regarding laid damage., or regarding any
.othormanorl, mado ~y tho porsons, flnnsor corporations who Iro heroby rolealed, or by any
,poriOn or porions roprolontinll him or Chem,
It Is I\lrthor undorslood and aped that this 14 the complolo release a8l'OOmenl, and
that there are no wrlltenor oral underscandlnari, or agreements, dlrecUy or indirectly cOMecled
,
with thJs release and senlemenlChal are notlncorporaled herein, TbJs asreernent lhall be binding
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upon and .enure 10 t,ho successorl. mlans, heirs. execulors, sdmlnlstrators, and lesal
represencatlves of Che relpectlve parcle.' hereto, Tho conns of thIa release are contraclUal and not
.a mere mica!,
'J understAnd that thJs' settlemonl 1. Che compromise ofa doubll\ll and dllpyted
chdm. and that Ute paYment Is not 10 be cO/lltrued as an admission of liability on Che part of Ute
porsons~ flnm and corpor~tlons hereby released by wholilllablllty Is expressly denied,
It Is I\lrther aareed that J am responsible, for the payment of any lien or charge.
asalnat thll settlement, S~oUld any porson or entity make claim for payment of any liens' or '
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charSes asalnst the pB11les released herein or PelClrs & Waslleflkl, I hereby asrao tolndemnlfy and
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hold harmless said parcles and Peterl arid WasUerlkl from any and all liens, charses, attorneys
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fees, coscs, Interest and oCher sums,
It Is I\lrther underslood and asreed and made part hereof. Utat nolCher I. nor any
. represencatlves, wlll In any way publicize or cause 10 be publicized, In anypewI or .
communications media, Includlns but nbtllrnlted 10. newspapers. masazll)es. jounlals, radio or "
tel~vlslon. the faclS or or the torms and conditions of Chis settlement, All parties to this agrooment
expressly agree to decline comment on any aspect to this setttementto any member of the' news
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F"ETE~S IlcWASII..EFSKI
ATTORNeVI ;..NQ CQVNIKl.O"''',. l-~w
...t NO"TH "'"ONT 8T""T
H~""'",U"O, "'NNOV,W.N'A 11,ItO
,....~HON. (7t7) 111111'7111111
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CO~~~~SVLVANI^
Oep^Rr~nN' OF RBVUNun
OSP UIQeOI
REV-1500
INHERITANCE TAX RETURN
RESI ENT DECEDENT
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2 L 9 7
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00667
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L 7 5 . 0 3 . 3 8 00 0 7/ 2 8/ L 9 9 7 0 6 / ;I. 8 / 1 9 1. 4
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[) 1. Onolnal Ralum
o 4. Llmlled Sltala
[] 6, O~danl Died Tellllo 1""',c;P,~w'l
o HI allon Proceedl R~lvad
8 OT P TB,
[) 2, Supplomental Relum
[) 41, FUlule Inlolall Oomp(QmllO (4," ~oM'lI"a"lldH11
[) 7, OO<;Gdonl Maintained e LlvlllQ T/1Jlll;""'''9,~T'''tl
010, Spou,,1 Pova OledI1i4,"~oM"'lO"'" 11.11,11""",,"
00 D 0 R
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o 3, Romelnder Rllum 14.. ~ oM'" "'" ~ 11.1).111
o 5. Federel Bltale Tex RllUm ReqUired
_ S, Total Number 01 8ele Depolll BOXII
[) 11, EloaIon 10 tax,undor Soo, 9113 A)!""',,,,ol
o 0 ~
2L5 OIlAMBRRIlBU~G TRIJIlT BUIJ,DING
OIIAMBR~flBURG. l'BNNIlYI,VANL\ 1720 L
1. RIel Hltalo ISchedule A) ";.'
(1)
2, SIOCk! and BondllSchedula B) (2) I
3. OlolOly Hold OOrpOlellon,PeMO,.hip 01 SOIe,Propnulorshlp (3)
4. MongegOl & Nolol R~I'/eble ISchedule 01 (4) I
~ 5, Cash, Bank Dopollla & M~lIoneoul Porsonel Proporty 15) 1 0' 0 o 0,0 0
(SChOdule E) ,
Blolnoy Owned Property (Bched"le P) (6) \
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1, Inlel,Vlvol Tlllnllers & M~ClIllanooUI Non,Prob.llo Proporly (71
ISchodulo G or LI
6, Tolll 0,." A"etlllotal Linea I'll (SI 1 o , 0 0 0, 0 0
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8, Puna rei ExponlOl & Adl!\ln~trlUyo 0011a IBelledule H) 18) , 2 4 1 , 0 0
10, Cebla 01 Decedenl, Mortglge Llablllllel, & LlanllBchodule I) 110) , 1 3 5,0 8
II. TOIII ~oduotlonlllotallJnll g & 10) (11) ,3 7 6,0 8
12, Hlmlue ot Sltate (Llno 8mlnuI Llno 11) (12)
13, Ohlntable end Oovemmental BequelWB~ 8113 frUlta lOrWh~h on o~n 10 tax hal not been (13)
~dl (Bchodulo II
14, HII Vllue 8ubjeot to Tal ILlne 12 mlnul Lln113) 114) 9 ,6 2 3, 9 2
16, mounlolllna 14 taxobll
~I altho lpoulel ta~ rale , . , x ,0 (16)
Sit InllNctIonl on IOvarso lido for eppl~bla !lfICllnlego
IS, Amounlof i1ne 14 taxabll X ,00 (10) 9 ,6 2 3 , 9 2
al6%lOle
17, Amounl 01 IIno 1~ Inxoblo X ,15 (17)
a116%lOlo
IS, TIX Due (18) ,5 7 7. 4 ' 4
19,
I ~,,:.r~' com;,... A"'"''
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II PR~IIPURO
nx paymente and Credit"
1, TIlX Due (PlIgel Line 18)
2; QredlltIPaYlMnla
A, SpoII,,1 Poverty Credll
S, PrIor Plyme~la
Q,DlllXlUnl
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I BT^,EpA
I ZIP 17257
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(1)
577,44
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Tolal Credlll (A + S+ C ) (2)
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3, InlareaVPanally If eppllcabla
D,lnlarel\
B, Panally
" TOlellnlarelVPenelly (0 + B) (3)
4, If line 211 greater than line 1 + line 3, anler Ihe difference, Thllll the OVBRPA YMBNT.
., ChICk bOK on PIgl1Llnlle 10 rtqU"t I refund (4)
e, If IInll + line 311 greallr Ihan line 2, enler Ihe dlfferance, Thllll tha TAX DUB, (6)
A, Bnlar thalnlereat on tha tllX due, (6A)
S, Bnter Iha lotll of Line 6+ 6A, ThlaII Iha BALANOB DUB, (6B) 646,49
Make Cheok Pa able to: REGISTER OF WILLS AGeNT ..
69,05
69.05
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64li.49
as 8 SR T II FO L Q 8T 0 8
BYPLAOINQ AN "X"IN THB APPROPRIATB BLooKs
1, Old decedenlmaku tranafer and: Yea No
II relaln 1~' ute or Incom. of the property ,transferred; tlIHj""'''''''t''''''''''I''''''''''''I4+'''''il''n''''n~ I
b, retain the right to dlllgnate who ehell uae the property treneferred or Ita Inoomef ,""""""'"
01 ret., In~ ,reV,llrllOnary Intareat: or""""""",..""""", ''''''',''''''''.'''''''''''''''''.''''''''''''''.,.''''''''."",
d, recelvelhe promlae for life of either psymonta, beneflte or care? ""."""."",,,,.......,,,,..,,,..,..
2, If death occurred on or before Deoe",ber 12, 1982"dld deoedent within two yeara
precadlng death tranafer property wllhout reoelvlng adsquate oonalderatlon? If death ooourred
aftllr Deoember 12, 1P82, did decadent tranafer property within one year of death without
,receiving IIdequate oOn.lderatl~~? ""'''''''''!''III1II''''''''''''Il!''.'''IH''H''''Ht''''/l'~'HHtt''Hlli;n''''i".,,,.. 0 [i)
3, Old ,decedent own an 'In truet for" or paysble upon death benkacoount or eeourlty
4, ~tl:~e~e~:~f~~~~~'I~di~id'~'~'I' ~~'ii;~'~'~'~'i'~'~~~~~l:' ~~~~it~: '~; '~;h~;' ~~~~P~~'b~'i~' ';;;~;;;;;~?:::: B ~
IP THB ANSweR TO ANY OP THS ABove QUeSTION81s ye8,
YOU MUST OOMPLSTe 80HSDULIl Q AND FILII IT AS PART OF THB RSTURN
72,S., g ,18 (al,( ,1 )(1) provided or the reduction of the teXtete Impoeed on the net velue of tranure to or or t e uee of the
lurvlvlng"pouae from 8'10 to 3'10 for detae of death on or after July 1, 1994 end before January 1, 1998,
72 P,S, 09118 (a) (1,1) (II) provided for the reductlcn of the rate Impoeed on the net value of Iranefera to or for the ue,e of Ihe aurvlvln:
epouae from 3'10 to 0'10 for detea of death on or after Janusry 1, 1996, The etatute dcee not exemot a tranef'r to a lurvlvlng apouls
from tax, and the Itatutory raqulrementl for dlloloeure of 8888ts and filing a tax return ere ellllappllceblll eVlln If the aUrYlvlng apouef
la the only benefiolary,
!fOR DATl8 OF DIIATH ON OR AP1'IlR JANUARY 1,1898. Pleaee enewer the following queatlon by plaolng an 'x'ln the
approprtata apaoa,
Did thl dlcedlnt orlalll trult or almllar arl'lngement whloh la lolely for the lurvlvlng Ipoule'l benent fllr hll or h.r entire
IIfetlme? Yel 0 No D
If you anawered Yea to the above queltlon, the tax on the truet or similar errsngement II poatpohed until the death of the aeoond
apoule, at whloh time It will be fully taxable al the rete(l) eppllcable to the remelnder beneflclllry(lel), enter the value of the trust on
Schadule J, Part II, In ordar to remove It from the caloulatlon of the tSX due In thla ellate, You may wllh to file Sohedule 0 In order tC
"'ake the ellotlon available under Seotlon 9113, If the eleotlon 18 made, the truel or Ilmller errangement II taxed In the Istate of Ihe
flrat decedent IpOUle, the portion of the truel or elmller srrMgoment whloh benefite the aurvlvlng epouae Ie taxed et the zero tax rete
and the remainder la taxed al the rate(e) applloeble to the remainder benefiolary(lea), If yoU ohooee to make the eleotlon, you must
a<<ach Sohedule 0 to e tlmely.flIod tax return, along with Sohedule(e) K and/or M In order to show the epportlonment of ths trust or
almller srrengemenl between the surviving epouse and tho remainder beneficlary(lus),
II~"" '''1'''"
ICHIDULI H
PUNIRAL IXPINIIS;.
ADMINISTRATiVe COITI AND
MISCILLANeous eXPINse.
~I.a.. P,ln' or T .
JlAZRL J. GRAUL!
l!!.~97-00667
ITlM
NUMIIR
A. Pllneral, llep.n,,"
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2,
3,
4.
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" ,7,
,8,
DISCRIPTION
AMOUNT
Admlnl.'ta'lv. Ca"ll
,P.ljl1~al R.pr...ntallvl Comml..lonl
SOCllll S.curlty Number 0' P.r.anal R.pr...ntatlvlI
Y.arC;:~mml..lanl pllld
"
Allarn.y F... TDlOTllY B. BPONBRLLBll
200.00
Family exampllon
Cllllmllnt, Relatlonlhlp
Add,... 0' Cllllmant lit dec.dent'l death
Str..t Add,...
City State
Zip Code.
Probot.'Fe.. MARY O.l-EWIS, RRGISTRR orWILLB
,41.00
MI..tll~neou. I"pen...t
.-
TOTAL lAlla .nter on line 9,Rtcapltulallanl $ 241.00
(If ma't .pace I. ntld.d, In.erl additional .h.." of .amt .1..,)
." ,+,~ ... ,.. ......' "'I. '''' .
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'CO . NBYWANIA
DePARTMeNT OF ReveNUE
DIIPT, 160601
REV.1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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2 1 9 7
'0667
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1 7 5 .03 .3 8 0 0 0 7/, 2 8/ 1 9 9 7 0 6 / 28
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9 1 4
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F
REGISTER OF WILLS
o 3, Remainder RelUmI4",d.III,...b II'IHII
o 5, Pederel Eelale T.! Relum Rli<Iulred
_ B. Tolal Number of 8"e Depot" 8011I
011. EieQ1Jon 10iAli under8eo, 9113(A) (J<Io<hk'Oi
I
TNe
o 2, 8upp~lMnlal Relum
o 4., PuluII Inlell" Compromlae l.d.III1 ....1l,Il,UI
o 7, DocedenlMalnlalnod. LMng TIUII """'~rdl"'ll
010,8 talpove CredII14Il1d4111._Il,II,II0r41>,,1I1
215 OIUU{BER8BURG TRU8T BUILDING
OllAMBIlR8BURG.PIlNN8YLVANIA 17201
63-3939
1, Rill EllalO (80hedulO AI (1)
2, 81oe'" end 8ondllSehOdule SI (I)
3, CIOII11 Held Corpor.tIOn,Pnrtnerehlp or SOIe,Propnetorehlp 131
4, Mong.gll to NOIII Reee~.ble (8ehedu~ D) 141
5, Cllh, 8.nk Depotll8 & Mllcelllneoul Pereon'l Property lei
~ ISehedu~ EI . ,
6, JolnUy OiInod Property (Sehedu~ PI 16)
7, Inler.vlvol Tr.nllere & Mllcefl.neoul Non,Prob.to Property (7)
ISeI1edu~ G or LI
6, Tolll GrOll AlII\llIolal Llnll1-71
9, Puner.1 E!plllIIe & Admln18InlUv. OOlla (Sehedule HI 191
10, D'bla?' O.eedenl, Mono.ge Llebfllllel, & LlOne (6ehedulO II (10)
11, Tolll D.duotJoneltolal LlnllU 101
.,/\, '
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1 0, 0 0 0 ,0 0
x ,0
(81
, 2 4 1,0 0
, 1 3 5,0 8
(11)
\12)
(13)
(14)
(15)
,06 118)
,11 (171
(IBI
10,000.00
,376,08
~
12, N.t V.lu. Oneill. (Line S mlnulLln.,11
13, ChentablO .nd Gov.mmental8equtllll8eo 9113 TlUlta for wh~h.n eieQ1Jon 10 tax hll nOI betn
rt;Ide (SChedU~ J)
14, N.I V.lu. 8ubJtct to Tex (Lln.l1 mlnu. Lln.13)
Ie, Amount 01 lint 1 taxeb
.llhtlpoUII, iAli reI. I ,
S..lnll1\lCllonl on rev.ree .lde lor oppllcable pereentago
16, Amount of line 14l8x.ble
.16% rile "
17, Amounl of lint 14lax.blO
.1 18%lIle
9,623,92
x
9,623,92
"
x
IB, T.x Du.
19,
,577,44
>> R 8 0 VBR 8 ElA D 0 0 T
/'del pon"llel penu"I, I lit< "' ~141 hlV' uemned ~Il relvm, utl", ~J!I!q l<liedulel or4 l_~, "" b N bell d my or4ll1l~ ,1111""', ""'reel
~"r~"'IeIIm: rm"1In"'ro:"oIof1~h 1If....~ '" en, k""'"td<>t
81GN TU E Of' ERSO U PONSI LE OR FILING RETU N AOORE8S 19461 8WRIlTWATRR ROAD
DALIl Il. RICE DRY RUN. PRNNSYI.VANlA 17220
SIONATURE OF PRE PARER OTHER THAN REPRESENTATiVe AOORESO 215 CIIAHBRR8BURO TRUST BUILDING
TIHOmy 8. SPONBIlI,LER CIIAMBIlRBBURG, PRNN8YI,VANlA 17201
<<
wnplOlI OIolllllOll of ",.p"., 01/10.
DATE
DATE
Decedentl, Com lete Addre..:
so I
17257
TIX Plyment. Ind credltll
1, Tax Due (Page 1 Une 18)
2, Credlts/Peymonls
A, SpoII,,1 Pove~y Credit
S, P~OI Psymonls
C, OlsQQunl
(1)
577.44
3, InterOlVPenllty If epplloable
0, Inlorost 69 . 05
e, Penllty ., _
, TolellnlerOlVPonllty ( 0 . B) (3).
4, II line 21s groeter then line 1 + line 3, onlorthe difference. This II Ihe OVIIRPAVMINT,
Check box on Pia' 1 Lln'11 to I1CIUllt.l1furiif (4)
8, If line 1 + line 311 groelorthen line 2, el1ler Ihe difference, This II Iho TAX PUI, ,(8)
, A, Bnlorthe Inloreel on Ihe lax due, (SA)
S, Bnlerlhololel 01 Uno 8. SA, This II Ihe IiIALANOI DUll. (8B) 646.49
.ke.Oheok P. .ble to: RBGISTBROF WILLS AGeNT
Totel Credlll (A' B +OJ (2)
69.05
646.49
'pI. 8 0 <J l:\ 18T 0
IiIV PLAOINa AN "X"IN THI! APPROPRIATUI.t)OK8
1. Old decedent meku treneler end: .' Yee No
Ii ret.ln the ule or Income 6fth~ property tran.ferredl "'""'''''II'UI''''IIIIlI"IlIlHIIlIlIIIlH'IIIIlIl'''''' ~ I
:: ~,::::~, ~h,~e~:~~I~~:~:~~,e, ~~Irr~~, ~~~~~ ,~,~,~, ~,~"~.:.~~.~,~,~.,t,~;,~~.~~,~~;,~.~:,~~.;,,I,~,~~,~,~:,:: ::::::::::::: ',I "
d, ricelve the promlll forme of either peymenle, benefite or OIre? """"",,,,,,,,,.,,,,,,,,,,,,,,,,,.,,. ,
2, If deeth oO<lurred on or before Deoember 12,1982, did deoedent within two yee"
preOldlng deeth trentfer property without reoelvlng adequeta oonelderetlon? If deeth ooourred
after Deoember 12, 1982, did decedent tranlfer propertywlthln one yeer of deeth Without
receiving adequete,oonllderaUon?;."", ,Ht" f".,.t" Iltt' I""" ,'" '"'''''' ",.." t I' It'" '" '"'' ,I..", qt'"""".""" 0 [iJ
3, Old'deOldent own en 'In trult for' or payable upon deeth bank aocount or oeo~rllY .
4, ~\~'I;e~e~:~~~~~~~' i~di~i~;~'~'i ~~'il~~'~~'~'i ~'~~~~~l:' ~~~~iiy: '~; '~;h~;' ~~~:r;r~'b~\'~"~';~~~;;Y?:::: B ~
72 ., , Be (,) I)provdedfort .,edu lono the tex rete Impo'ed on the natvaueCl tren..ra to or or the uae of tho
,ulVlvlng apoulefrom 8% to 3% for dete, of deeth on or efter July 1, 1994 end bafore Jenunry 1, 1996,
72 P.S, 19118 (I) (1,1 )(11) provided for the reduQllon of the rate Impolod on the net valuo of tranlfera to or for the Ule of the aurvlvlr
,pOUle from 30/. to 0% for datee of daeth on or after Jenuary 1, 1996, The ,telute doee nol eHemal a tllnefer to a IUlVlvlngapouBe
from tlHi,and the ItltUtOry requirement. for dllololure 01 a..ele and ftllng e tax retum ere atlll eppllOlble even If the eurvll'lng 'POUI
la the only benaftolary,
POR DATl8 01' OI!ATH ON OR APTER JANUARV1, 1986, Pleale anewar the follOWing que.1I0n by pleolng an 'x' In the
approprlete Ipaoe,
Old tha dIal dint oreall a trult or 11m liar arrlnglment whlohll eallly for thl lurvlvlnll Ipoule'a beneflt for hla or her antlr
1I'llIme? Y.. 0 No []C ,
If you anawered yeo to the ebove queetlon, the teH on the truol or almllar arrengement 18 poetPoned until thedeeth of ths IIcond
'POUII, at whloh time It will be fully texable at the rete(e) eppllcebleto the remainder banenolary(lel). Snter the value of the trult on
Bohedule J, Partll,ln order to ramove It from the illlloUlatlon ofthl tex due In thle ..tate, You mey wleh to nle Sohedule 0 In order t,
mlkl the ellotlon avalleble under Seollon 9113, If the eleotlon Ie mede, the, truet or Ilmll" arrangement Ie taxed In the eltet, of the
firat decedlnt Ipou.e, the portion of the tru.t or Ilmllar arrengement Whloh beneflllth.eulVlvlng Ipouee Ie taxed et the zero lax rat,
and the remainder II texed at the rete(e) appllOlbleto theremelnder beneftolary(lea), If you ohoole tomek. the eleollon, you mUll
a<<loh Sohedule 0 to a tlmaly.flIed taX return, along wllh Sohedule(l) K end/or M In ordlr to ehow the apportionment of the trUlt or
Ilmller arrengement between thi IUlVlvlng IpoUle end the retTlelnder benenolary(I..),
't-;f'-,
I \i;
m,II11 I" 1',111
lll'ANIA
SCHIDULI H
PUNIRALIXPINSlS'
,ADMINISTRATIVI COSn'AND
MISCILLANIOUS IXPINSlS
Plte..' Print or T .. .
QAZKL J. OMBLB
U-97-00667
N~T~~IR
A, punlllllllCp.na'"
'1.
DIICRIPTION
AMOUNT
,.
Ii
8, Admlnlatrllllv. Coat..
1, Perlqnal R.pr'l.nlallv. CQmml"IQnl
SQclal SiJcurlty !'lumber af P.rlanal Repr"'nlatlvlI
Year Cammllllonl paid
2, '
AJtarnaY F'QI TIHOTllY, II. SPONSIlLLRR
200.00
~, pall1l1y ex.mptlon
Claimant R.latlonlhlp
Acldr... of Claimant at d.c.dent'l death
Str.et Acldr...
City
Stale
Zip Code ,
4,
Probate Fe.. MARY' O. LIlWIS, RIlGISTIlR or WILLS
41.00
Mlle.llan.oue IICp.n....
1,
2;
3,
4, "
6;
6,
,.
.. 7,
8,
TOTAL (Alia .nt.r on IIn. 9! Recapltulatlonl $ 241.00
(If more .pae. I. need.d, Inlert additional .hee" of .am. .11.,)
I
II!
g
,,,,,,"","'''~ ~',
~:VLVANIA
DEPAAlt.ltlNl Of' REVBNue
DE T.l1Oe01
REV.1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
"U ."'.1Il00ll
G
1 7 5. 0 3 . 3 8 0 0'
I
[] 1. O~lnal Ralum
o Ulmlted Sllo!la
[J 0, ~anl Died Tello!le IAao:~"'rolWlI
o 9, L allon Proceedl Received
63~3939
1, R8oI1 SIIo!Io! (Bd1edule Al
" 2, SIOCl<I end IlOndl (Bd1edule BI
~
~
3, CIoteIY Hald COlJlOrtlUon,Partnallhlp or SOIe.Proprielolthlp
4, Mol1Oa,9e1 & NOlol Receivable (Schodule 01
5, Calh, Bank Dapoll1l & Mll<:ello!nooul Peltonal Proflll!1y
(Schedule S) ,
S, JOlnUy OIIned proflll!1y (Ildledule F)
7 Inlo,.vivOl Trtlnlloll & M~llo!n~uI NOn,Probale Propa!1y
(Schl<lule 0 or L)
S, Total Oroll Amla (Iolal Llnell-7)
9, Funortll Elpanlll & Admlnietrallve COlts (Bd1edulG H)
(U)
10, Debts of DececlanL Mo~.ge LIe~lItlel, & LIeI1l (/ldladule I) (10)
", TotlIDlductJonl(toIaIL~9& 10)
t'I;:!,;'
i,'",'J
'pP>lNliillif"""""" "",
2 1 9 7
", ,;4'.-'" i'.".."r., ~
,
10667
I
o 6 / 1. 8 / 1 9 1, 4
'Hit RBTURN MUir 81 Flun tH DUPLfOA'. WITH nil
RBGISTBR OF WILLS
o 7/2 8/ 1 9 9 7
. .
215 OlUU(BRRBBURG TRUST BUILDING
CIUU(BRRBBURG. PF.NNSYLVANlA 17201.
(1)
(2)
(3)
(4)
(5)
(0)
(7)
. j ~ "
f'~ n'
'(I,',
,,",
l
"
1 0, 0 0 0 ,0 0
(0)
I 2 4 1 ,0 0
t 1 3 5,0 8
(11)
(12)
(13)
(14)
(16)
,06 (16)
,15 (171
(16)
12, HIl Valua 01 ellala (Lln, 0 mlnUl Line 11)
13, Chartlable and qoyammanlal BlqUUl\llSoo0113 Trults /IlI,wtllch an alac:Uon to ,lax hll nol bean
madl (Bd1Idule J)
14, HIl Valua 8ubjtot \0 ,Ta. (Lk1t 12 mlnul Llno 13)
10, mount 0 line 1 laxa
lithe lpOutlllax ra18 I t X ,0
See Inllrllc1lona 00 I1Yel1ll~e for Ippllcable pan:entaga
10, Amount of IIna 141aIabla", '
116%rtlla " X
17, Amount of Hne l4lalable
al 10% 1118 X
16, Tax DUa
19,
DALE R. RICE
SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE
TIHOTlIY R. RPONRR!.l.RR
" "
.
10,000,00
,3 7 11.0 8
9 j 6 2 3, 9 2.
!l,623,92
7 7. 4 4
ptIIlIII/OiI'oI
DATB
DATB
MAKI CHICK PAVAI~I ANP RIHIT PAVMINT Tal
RRGISTER ~F WILLS
CUMSERLANDCO COURT HOUSR
CARLISLE, FA' 170111
CUT A~OHD THII ~I!lll ....' RITAIN ~CWIR PORTION liaR VCUR R~CORPI ~
_W:IIW'.11I'"~W-fD1f:n,)"-ilflVia'-1I'.-YtiA'lfffllli, ol-YA'~.'A'lS,~~'A"filJ<<il".., ~t1.ll'''~,WI.'llll'------------ -- ---
, "PZ8Aj;~OIlANCI OllPliiUCTloNI ANP All IIHlh all TAlC
ISTATI all, GRAnR HAZEL J IIX~I NO. i!1 97-0667 ACN 101 DATI 1O~28..i999
,
TAN "BTUMfWAal C X) ACCIPTlD AaflUID (') CHAHGBD
8 0 0 C X D " I 'X T RIIT - II II
APIIRAXIIDALUI Oil RITURN IAIID aNI DRIGINA~ RETURN
1, "..lB.t.t. (lQhIdul. A) ,
I, .t~. '"~ I~. CIo~l. II '
I, Cla..l~Hlld .taak/P.rt~r.hAp Int.r..t caah'dUl. 0)
~. Hart...../HQt.. "toeAvlbl. (lah.dUl. DI
J, C.II1/I~ IIIfIa.H./Hha, P.r.an.l Prap.rt~ ,caah<ld~l. B)
6. .loAntl~' 0lmId PrOHrty cSah<ldUl. FI
'1, Trlln.f.r. ISahldul. 8)
I. "tat.i' AII.h
APPROVllhDIDUO'UONI AND IXIMP,1\IONIII I ,
9, Funar.l B~fIlIn.../A"', Caeh/Hha, B~Plln... (lah<ldUl. HI, I"
10, IIIbh/HQrt.... ~AIbUHA../Lbll\l CSahldUlI Ii UOI 1~8, 08
I:
11, Tat.l lIIM'Uanl C 11 I
Iii Hit V"lUl af T.~ R.t~rn (111
11, ChlrHlbl./Oav.r,...,t.l S'q\II.hINan~.l.atH 9111 Tr~.t. Clat\.d~h 'JI C1l1
l~, Hit V.lUl af Blt.t.l~j'at taT'M Cl~)
. ,
HOT. I ~~!~~.U:~~~t t~:~ i~:~~glt~;i~~~~~, a~~~~~ , ~:~u~~. .~~~:~.~~ I t~ 7 d:~=.l$W~U
ASI.IIHINT all TAXI ' ' : ' , ,
11, AIlaunt afLAIl4l l~ .t SpOIl,'l r.t. ,(11) ,00 K ,00. . ,,00
~6i AItount af LAIl4l l~ t,Mlbl. .t ,LAIl4l.lICl.1I A r.t. (6) 9,625, 92 N ,06. 877'. '\4
11, ~t,af LAll4ll~ t.Mlbl. .tCall.t.r.l/Cl... Ir.t. (11) ,OO',K .18.' ,00
lS, ~rAnoApIl T.~ IIUI Ilal 877 ,44
,TAlC CRIDnl,
~AYHBHT
" DATB
/!l-IC/h-./l'
IURBAU OF INDIVIDUAL TAKBI
'*'RITAIlC:~ TAxDlvmDll
DI!l'T 110601
,~I..UHo. PA 111"'001\
COHMONWIALTH all PINN8VLVANIA
DIPARTMINT OF RIVINUI
NDTICB OF INHBRITANCB TAX
APFRAISPHBHT, ALI.DWANCB OR DIBALLDWANCB
OF DBDUCTIONS AND AIBBaaNBNT OF TAN
ili
DATI'
ISTATI OF
DATI all DIATH
IIXLI NUHIIR
OOUNTV
AON
10-25-1999
GRABLE
07-28-1997
21, 97-0667
CUMBERLAND
101
AlMluni ' "1fIlttotd
"
TIMOTHV. S SPONSELLER
US CHAMBEIlSBGTRST BLD
CHAMBBIlSBIJRtJ, LI'A 17201
CL'!
UI
ClI
CI)
C~)
(B)
C61
m
.00
.00
,00
.00
lO,OOD.DO
,-DO
iDO
ee)
241,00
RIDUP'
HUHlB"
allcaIlHT HI
lNTE"Bn/PBNPAID Co)
AIIOUHT PAID
TOTAL TAX ORIDXT
BALNCI,OP TAX DUI
XNTIRI8T AND PIN.
TOTAL DUI
l!.,.
..
"VtlUl'.'" Cf1."1
.HAZEL
J
I'
HOTII Ta Anlur. prapor
arHit ,to ~aur ...aaunt,
lulNlH t~ Upper portion
af thAi ~ar. with ~a~r
t.x P.~.."t,
"
10,000,00
!l76 - nA
eJ,6211,92
.00
'9.6211,92
890,42
12,98CR
.00
12,98CR
" IF PAID AFTB~ DATB INDICATBD, BBE RBVBRBB
FOR CALCULATION OF ADDITIONAL INTERBST,
IF TOTAL DUB II LBSI THAN .1, NO PAYNBNT II RBquIRED.
IF TOTAL DUB IB RBFLECTED AS A "CREDIT" ICRI, YDU HAY BE DUE
A RBFUND, lEE RBVERSE SlOB OF THIS FDRH FOR INSTRUCTIONS, I
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