HomeMy WebLinkAbout80-00194
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
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REV-449 (8'78)
.1.:SIDEN'r UECEDE,H
COUfHY OF __ __________.__
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IMPORT ANT:
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This r~lllrlllll11SIIJl: ctllllpll~ll.tl ill dt'tail 1111I1 fih't1 in dl1Jllll~ale, with 1111 atllldll'd. Wilh the Rt~l!i~tt~f IIf Will!'! of the
Cuullty wlu:rc dcccllclIl rc~idnl; l{C{LIlIl!1i tlue: witllillllillC llI(1llll1~ lIflt'l' dal(~ of dC-Hlh, ulllcss UlI extellsioll is grllnlctl
hy the Sl'crt~lary of RC\lCIIIl\.". <Scctill1\ 70J oj' IIII.' Illhcrltllw,:c >tlltl EsHltc Tux Act '.If 1%1.1
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f\DMIN1STRATUR
Lot" of ___'_ __~~'~Ii;]t.L.4_ND.__ Cuu"'y
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Administrator
Slate of
IN TilE MATTER OF '1'111' ESTA'('I', OF
CtlullIyof
EXCl.lUlur
Dltho ufoln of th" o\.ovo-nom.,d dllc.,Jonl blllng duly sworn, daprJlll
nnd soy
5E. PTl!lHfIJETt.. -G.::!-. If)_7~~J IU'DI~ r"flylng 0 leut willi COI'lY Qf which is herato oftadu,d. }
(MOtlTHI (U/.yl \y~Ar~l....lnle\llnt"
No",. ond odd".. .1 nil""" " } _;[.....'6.. l/11gI1._?1--
oth., Qulhorlud reproseotallYD 10 whom ... t? 'j') n
.11 "".."nod"," .h..ld h, moil,d. ilJ2...[_~LLi1---y-.u.L ~I5J.!..ilt!!_, r'1J .
Thill as sllch~~G1UJ.p.cpoI1Cnl is familiar with the affair:; of said estate and the propel'ty constituting
I EXE(;UTor(-M)Mlt~IST i~ A TOW
the assets thereof and their fair market value.
Thul at the tirllc III' dealh there wns no safe deposit box registered in JcccJcnl's individual/Hillle, or jointly with, or
as OBcnt or deputy of nnutlll~r, or ill decedent's illdivitlualnamc, with right of .1CCCSS by another as agent or deputy, with the
t~XccJ1tion of the following: -
Decedent died
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NAME AND AOOflESS Of riANI< OR OTHER ltlSTlTUTlON
IN WHICH DECEDENT RENH:P A SAFE OEPOSl"r BOX
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THIS SAFE DCPOZIT BOX RENTED
IN NAME Of~ NAMES OF
HELATlONStllf3 Or JOINT
HOl.DEItS TO DECEDENT
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Thnt the contents of sttid safe d~j1()sit box or boxes arc itemized under Schedules
with the exception of the following; fm the !"Casons hereinafter set forth:
of this return,
Thl.lt Schf!JtJ/o A attached herein Ilnd made part hereof sets forth fully and in detail all the rcal property
in the Commonwealth of Pcnnsylvani:l of which decedent died having :in interest {IH.-rein. It ulso sets forth the
mortgage encumLrances upon each fl'lrccl of real property at the dati: of death, giving the amount still due of
death, name of mortgagel.l, tlnte, rute, of inlcre:it, ,U1d book and page of record thcTtlof. It also sell' forth iil tlw
c.olumnli provided thcndofc the assesscd valuation of each of said parcels, the estimuted market vlllue iheftwf
as of date of death of decedent.
That Sdll!clu.lu B ilttached herelo und inl!de part hereof sets forth fully and ill dCluil uti pcrsonal prol,crty
whercsovcr situat~d owned by thedcGcdcllt ill the time of dc.llh; all moneys left by the decedent Ilt the limc of
death, wlwtl~cr in decedcnt's immediate j1ossession, standing to decedent's crcdil in banks of deposit, sllvings
banks, trust companies, or other irH.;titutioIlS, whethcr individually, or in trust for any ot.her person or persons
giving also sCllUratcly the accrued iuh:rcsl Ihercon, if any, down to the last interest day prior to decedent's
death in thc CUSL' of savings banks,' and HJ the dale of decedclI"s death in all olher cascs; all bonds, postal
savings, treasury certificates or notes and other evidence of indebtedness of the United Statcs to lhe de~
cedent;- all ubligations, whether by ~tatulc ur a~rcclllenl they .Ire desiglHt led as lax frec, of the Unitcd States,
or any state, or political subdivisi(Jn tht-reuf. 01 or any foreign cnUl11ry. which lIre owned at Ihe timc tlf death;
all wcaring appluel, jewelry, silverwure, pictures, books, wurks of art, household furnilufe, horses, c:uriages,
automlibilcs, boals, and allY ;lnd all other pcrsonal chattds of whatsoever kind or nature, len Ly decedent,
togethcr with tile fuirly estimated lLlarl\ct value thereof; all bonds ami lHongagcs held by decedent amI of all
claims due and (,wing dect.:tlclll at the timc uf dcath, and all promissory note:~ or other instnlments in writing
for the pnymcfll of money of which dl'CCJl'tlt died possessed, of whatsocver nature, with intcrest thereon, if
any. J.tivjnl~ tlu.: faCt .value and c~..limi1tt:d fair malkct valut~ Ihereof, ;lIld if such estimalcd fair murket vl.Ilue be
less than Ihe iacc Vldul', il sets forth briefly the reasons for such depreciation us 10 each item; al1 moneys
payable 10 the estate from life iUl-Jurancc policies carried by decedent; all annuity and cudowlTlcnt contracls
the procel~ds of which were payaLlc upon the death of the decedenl,: all :\nd the corporate slocks and dividcnds
dl1t~ Iht~rcon and unpaid liS of the dilh: 'of death, bonds and accrued iUlc'resl thcrcoil to the dalc of dccedcnt's
dCBth and other in\'cstmcllt securities owned by thc deccdent al lhe time of death, with the market vRlu'c thcrc~
of at such time.
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In the ellsc of secllrlt.1C!1 of c\O!'iC Uf f'oml}y eo!'pCr1ltjons, f,lle vHllWS I'H{lorterl 11ft) I1S fat'- llll
possible suhslflnl.lnlcct by f'in'tIlr.l'1! Rt./ltC'IlJlmts or tho corpnrrlt.Jotls, shnwlng; the ~ISSP.t.~ nnd lIabilities
tln,'rllll" liS of' the ,\1\1.(> 01' IlrHltil. 'rlH~ !.If:hl~(ha1e nlso snt.~J fort.h t.he tlltHPS.t (If' decedent. fJ.L t.he time or
deflt.h 111 fUl~' cO-I"lrl.nersltlp or IJlIstneS'5.. IUllt 1n ~mpport, of' till! vl\l'll~ of' <jlh~h Inl.crnsL thCt'o Is nnncxeil to
slltd SChottlll/!, f'lnlllwl1l1 gt..1l'~mnllt.s .;hnwlng I.llen5'iDlS find Il!lllll1tlllS 01' snl<l CO-IJ.'lrlrwrshlp 01" oUSlne"'l6.
A ('opy 01' till' cn-pllrt,'ll~rshlp n~rl?(!ml~nt., (I r ofnl, n 5ln leml"!nt H(, ttlng for th r,he flIll11rr~ or t.he Ilgrl~emcnt.)
t()gotlt(~r wlth 11 stlltf'mrmt St!I,t11l14 forth t.he I:tlllrllct.er or t,lI", lJltsil\f~ss, Its locaUun, and such other {'acts
pert/tilling to thn hw;lllflSS liS I1Il1y!ln pertlnf"!l1t to f\ f'ntr Ilwl .lust, npprldslll 01' t.lw tlfHHldent's 1nt.erl!st
tlll!I'HIII mllsl 1.c s\llimltted. It SItOUIII nlsn Sl't, fort.h In Itemized form, together with tht:! fnLr market vnlue
ttWI"JOf', /ltJy utllel' propert.y OWlIf!c1 or lJI1<jllenl.tHld hy tlw tlCCI~dellt Ilt ttle tlrne of dfHltll.
Tlll~ Schedule C fltlnclwd hereto IInd llullle 1111l't hCl'pol' sets f'nrt,h II t.rlle IInswer t.o ench inquiry
contlllncd therein l1I\li in tllP case ol'tl'nnsl'm's nf}lroJlcrt.~', renl or Jlf~rsonfll, wlthtn two years of decedent's
rlcnl.ll, In l~ont.elllpllltl()n of llec(!elcnt's flent.h, or lnt.ended to t.!1ke effect 1n possession or enjoymrmt lit or
uf'tel' t\fmth, slllft sclwdlllf~ set.s forth t.IH~ natllrf~ Illld VI\llw of such property, 1.0 whom trnnst'erl'erl, t.he
r(~lllt1ol1shJp of t.he t.rllnsferecs to the de(~cllt~nt., thl! Ilroport,lonut.e SIlIlI'C receIved hy cHeh tl'(ln5t'~rfJe and
IlIl other fllClS of' Il pert,lnen!. llal.ure l'e~llrrlt.lJ~ slIlfl l.rllnst'ers. In t,he cnst! of I.rllnsl'ers l.ntendec1 to
tnkt' l!t'f'ect in possession 01' en.loywmt. at or uCtCI' elel\t.h, t.here is nlso attncllnfl to tile Hchcrl1l1e a cony
of'. the (lfJed,trust n~reemeTlt. or othor instrument crcnting the trllSt.. Ther'~ 15 cilso Ret forth 111 said
schcelule Il list of 0]1 property, relll Itnd personal, w1t.h Jt.s vlllue, y,hleh 1111~SfJS nt (Iccedent's rlellth by
virtue of' the exercise by decedent, either ind1vldulllly, 01' Jointly wi th nnQl;hClr, or nny flower 01' llppoinf,-
ment vested In decedent., either individunlly or .1oinUy, hytlle will, deed, or other instrument of" another,
with n eopy of U:e instrumcmt. creatln~ such power nttnehed to the schedule.
Thllt Schedule 0 nttachef! twreto and mllde pllrt hereof' sets forth the nameS nnd addresses of nll
persons bcnef'lclnlly int.erested ll1 this estntc ut. th(~ time of' decedent's neath, the nature of t.heir res-
pect1.ve interests, their relu.t1onship, if tiny, to the ({('cedent, together wtth the llges Ilt the time of
decedent.'s death of all minors, llnnuttltnts and benef'icl11rius for life under decedent's Will. It also
contains a stlltement showing which of the heneficillrl,cs nllmed in the decedent's will, if tinY, died prior
t.o decedent, the rtlttes of their denth, their issue, tUHI the r(~11ltion5hifl of stich issue to the beneficiary.
Thllt S.:/Iedule E IlUnched hereto nnd mn(le 1\ pnrt her~of sets forth all property, real and lJcr-
sonlll, owned by the decedent Jointly with Illlotlwl' 01' others, including intnnJ;tble, st.nnd~ng in the nElme
of the decedent and others, plus the dat.e and plllCe of record of' instrullIents effecting the 'vestit.ure of
relll estu,te nnd the date of acquisition of personnlty, plus the name, address and relationship, if any,
of co-o\mers to the decedent.
That Scftedvle F nUnched hereto LInd mude Ii pnrt hereof sets forth fully and in d.etail all liebts
,and deductions cluimed for and on behalf of this decertcnt's cstute, including funerd expenses paid;
fnmnyexemption, where appl ienlJle; costs of Ildmlnh;l.rat.1oTl of' this estate; counsel fees Rnd f\ldiclary's
commissions paid or to be }uddj cost expended for burinl tl'usts, tombstones or gl'avemnrker.s, and reli-
glous sel'vices, in consequence of t.he denth of the decerlentj debts and.cluims owing nnrl unpa1rl nt time of
death; taxes accrued chargeable 1'01' })crlorl prior to decedent's death (except those a.llowed under Section
651 of the Inheritunce and Estllte 'I.'ox Act); together wit.h Ii statement. of collnternl pledger! for ob11gn-.
tions, if any. It is agreed thut the f'iducinry will present pl'OOi' 01' sIdd clllimed obligations upon re-
qnest, that if the amount actulLlly p(11d in settlement ot'uny fce, commission or debt is less than the
estimnted amount cl/timing "nIt III lowed, that the Slllne will he reported to the Register of Wills, and that
the umount of tnx nssesscd COOl he !'cussessed in nccordnnce t.herevt'j th.
TllIlt the tot.uls of tJll! npPl'op1'i&..tl.! c\})unUls in Schedules "A", flU", "G", "E", fillel "F" as directed therein,
h(\vc heen Clll'riE'flf'orwnrd nnd llroperl~' registered in the Summllry.
Subscribed and sworn to before me this .................................
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DERLM1~\COUj , PCIl!-;!" 1,1y Co.,w\i~~ion Expiros
tor.~.........~............_..
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D(LL~;:;~~~.~~~~>.!1(!I'.. .......... ............
(City or Town and St4te)
";,~ n~..:- M0:1J"'1 l., J,~.'l. 17n,
SOTE: Before signing nfj'tdnvit llIilke sure nll hllUlk Sll1wes ill the Ilt'fldnv1t flnll schedules nnnexed nre
f'111etl ill with detlltls or the worrt "None", nlllt In el1se the Ils:.-;c>ls fT!clwle I'ure fillll unl1sterl securities,
'H~I~lIrl t.1I'S of close or. ffilntly cnrporntiotls or 1m Interest. in any co-pllrt.nersh111 or huslness, that the
r)nt.u 1l1l11 st.A.tcrnellts requirecl under the pnrlq;l'lIplJ IllJoVI~ rC)Ilt1.ng to Schedule "0" fire attached. Also make
cl~rlnln Om!. column #1 in t.he "Slln.nnl'Y" hl1.s been pruperly cnmpleted fiS 1l110Vc-dlreclcd.
.
He CoO::!" 14.131
COMMMEALTH OF PENNSYLVANIA
-DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
.TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "At'
REAL PROPERTY
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Real property in Pennsylvania, with statement of mortgage encumbrances upon each parcel at death of dece.
dent. Property held by the decedent as tenant in cammon with another or ather, should be identified
as to quantum of interest and the estimated value should be that a! the decedent's interest only. (Piuperty
held as joint tenants with right of surviarship or tenancy by entireties should be reported on Schedule "E.")
Tho real property loc:otod In the Commol'lweolth of Pennsylvonla should be (1) (2) (3\
dOllcrlbed by lot and block number, Itrcot and street numbor, together with DEPARTMENT
o general description of the property, with 0 reference to tho record of tho ASSESSED VALUE VALUA TlaN
conveyanco by which the decedent took title; If a form ,tate numbor of o. FOR YEAR OF ESTIMA TED CAUTION
crol; also ,'atemont of mortgage encumbrancu upon coch parcel at death
of decedent. Toxes, assessments, accrued Interest on mortgages, o'e.,ora DECEDENT'S MARKET VALUE (Do not wrll.
to be lI.ted on Schedule tiFt! and must not be deducted from this schodlJle. DEA TH In thll lpace)
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Insert this total opposite "real property". Schedule" A" in the X X X X X
"As Reported" column an the last page of this return.
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RE\;'.4~31a.i8)
CO~t\lONWEALTIl OF PENNSYLVANIA
TRANSFER INIlERITANCE TAX
RESIDENT DECEDENT
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INTI'I(EST OF
BENI~F1Clt\RY
IN ES'LITE
nENEI'ICIAHIES '\I\'D ADDRI....l;)SES
(Statc full nl.mcs ,lnd addrl~sscs of all who
haVCt1l1 intcrest, vestcd, ~onlin~cnt or other-
wise, iu eS['I/cJ
Ri..:LATIONSIIIP
(If sten-d,li!dr('n or
illqdtill1at.., cl1jldr(~1l
are iU'Inlvt!d. S('l
forth this fact,)
SUR"I\' E!l
DECEDENT
STATE Y'"
OJ{ NO
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OF
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Deponent further says thet all the above-named bencficioril!s arc living at thio;; time- except below:
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Real PWllcrly
Personal PWllcrly
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