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nEV."GO (0.78)
APPLICATION FOR CH^RITAB~E EXEMPTION
FROM PENNSY~VANIA TRANSFER INHERITANCE TAX
{t.c' of Ml1Y ?:fl, 1956, P.L. 1757, and Act of June IS, 1961,
P.L. 373, (IS amended)
COMM()NWr:.l~LTH OF PI::NI~S'(LVJ\N'^
OEPf\WrMENT OF rH:VENUE
nUH[^U OF FIELD OPCflJ\TION::'
Application is hereby filed for the approval
of on exemption from Pennsylvania Tron!der
Inheritance Tax on the transfer of the propcrty
dC5cribcd below:
1. Bureau File iI___d!~J.:()::.d 3c! ____.___..__._______
2. Date 01 Death _... ,1/2/80._.________
/1),';- 1 Jr:;y{)
3. Date of Approval _L._~"'-"__c_0-,_LZu-
4. Nome of Decedt'nt
Fdn~ " Hazen
5. The Commonwealth's appraised value of the property for which 0/1 exemption is claimed is $ 8 re '~~..oJ{~J
(Note: Where the property is otht'r than a spt"cified amount of cosh, the exemption cannot be a~~r~~d 1Q~~the\~c\1M5~.o1
IIH~ property hos beon established by appraisal by the Commonwealth, except in those Coses where tht' amount of the gift
or bequest represent!> 0 stated fractional or pcrcentage portion of the entire estc;te or the entire residue. In those cascs
enter .'5uch fractional or percentage amount obove).
6. Check the manncr in which the transfer was effected and submit a copy of the document authorizing thc transfer, unless
such material has bcen previously filed.
WILL 0.;
DEED 0;
TRUST INDENTURE 0;
SURVIVORSHIP 0;
OTHER 0;
(If other, explain)
7. Correct Busincss Nome and Address of Charitable Organization receiving property:
NAME _Ameri can Bib le_SQCj.e.ttiegacy....D.ep.atlmen.L(l/8J:e.sidllE.)
ADDRESS 1865 ~roadway , New York, ~:,;'^' Yljrk 10023
CXl See listing on reverse side for odditional choritable organizotions covered.
8. I certify that the information contained herein is, to the best of my knowledge and belief, true and correct.
The Com~cn~:ea1th Nat.ional 9ank, Trustee in possession (If assets
(' ;J 0
Signature 01 Applicant ...!l.Y_z:;/7't1?'7 f1 R7 E~tat~ Tax ~:dn;.;f'r
Address of Applicant 10 South Market Square, Harri~~.nnsylvania 1710R
Official Title
Dotc
This form must be completed in triplicate and all three copies delivered to the Register of Wills for the County in which the
decedent resided, or in which letters were issued tor a non-resident. decedent's estate. If the decedent was a non-resident of
Pennsylvania and letters were not issued by a Pennsylvania Register of Wills, deliver all three copics to the Director, Bureau
of Field Operations, Penna. Department of Revenue, P.O. Box 2970, Harrisburg, Pa. 17105.
Do not writc below this line. For Official Usc Only
APPROVED: For the Se~retary 01 Revenuo REFERRED to Bureau Headquarters
Approved 0
For Secretary of Rovenuo,
~
Denied* 0
(Initials of Register of Wills)
(Authorized Signature)
/lJ (County)
_LZ.C'!;t . v?, /tJJ{}
(Date 01 Approval)
(County)
(Title)
(Date of Roferral)
(Date of Action)
" See reverse side for reasons
MUST BE FI~ED IN TRIP~ICATE
REV'''5~ (1-S01
, SCHEDULE "F"
COMMONWEA~TH OF PENNSV~VAN1A
OEPARTMENTOF REVENUE STATEMEfH OF DEBTS
TRANSFER INHERITANCE TAX , iJ AI)I,p DEDUCTIONS
RESIDENTDECEOENT ::;:t)/~'.!!!..'cz;;.(!"f-i,_.<.;:j,., L9.&J. _ ._"
Estate of Edna J. Hazen Date of Death January 2, 1980
WHEN CLAIMING THE FAMILY EXEMPTION, COMPLETE THE FOLLOWING:
~
,; I' ',\ . .'
File No",;) /-,?() ',,)3 [)
Claimant
None
Relationship to Decedent
Claimant's Address
ITEM DATE NAME OF PAYEE REMARKS AMOUNT
NO.
r Jan. 7 M.F. Rocke Stora e Co. Statement 40.48
2 10 Cowley Associates Professional Services 15.00
3 28 Bethany Village Statement 56.75
4 Feb. 8 Cowley Associates Professional Services 15.00
5 19 M ers Funeral Home Funeral 691.12
6 21 Dixon's Pharmacy Statement 15.30
7 21 Bethany Village Statement 1.35
8 March 2 Bethany Village Statement 33.00
9 5 Bethan Villa e Statement 25.35
10 11 M.F. Rockey Storage Co, Storage 50.96
11 12 Rev, PaulO. Schroeder Funeral Expense 25,00
12 12 Rev. Orville V. Warner Funeral Ex ense 25.00
13 12 Or. Kendrick Khan Funeral Expense 25.00
14 13 M.F. Rocke Stora e Co, Statement 80.96
15 13 M.F. Rockey Storage Co. Storage 25.48
16 April 2 Springfield Monument Co. Monument Lettering 35.00
17 14 Internal Revenue Service 1979 I ncome Tax 110.00
18 14 Penns lvania De artment of Reven e 1979 Income Tax 37,00
19
20
21
Reserves
The Commonwealth National Bank
The Commonwealth National Bank
Beckl ey and Madden Attorney's Fee
6,508.00
565.00
3,905.00
TOTAL THIS PAGE Continued
I hereby certify that to the best of my knowledge and belief the foregoing is a jost and true statement of debts, funeral
ilxpenses and expenses of administration submitted to the estate as deductions for Inheritance Tax purposes.
SIGN~TURE OF ATTORNEY/FIDUCIARY
OFFICIAL USE ONLY
DATE
DEBTS AND DEDUCTIONS ARE ALLOWED INTHESUMOF S 'a .'n"c.;- ,').; AT
,. .
IE?I
PERCENT.
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,
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DATE
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,
NOI1V'VIIHO:lNI XV'130NV'1IH3HNI WH3N3El
.
QUESTIONS CONCERNING PROPERTY TRANSFERS
1. Did decedent, within two years of death, make any transfer of any material part of his estate without receiving
valuable and adequate consideration? (Answer "Yes" or "No".) No
2. Oid decedent, within two years of death, transfer property from himselfl herself to himself/herself and another party
or parties (including a spouse) in joint ownership? (Answer "Yes" or "No".) ..JI..Q....
3. If the answer to one or two above is "Yes" and the traosfers are claimed to be nontaxable, provide the following
information:
a. Age of decedent at time of transfer.
b. Copy of death certificate,
c. Affidavit by the attending physician indicating the state of decedent's health at time of transfer.
d, All other information supporting nontaxability of transfer.
4. Did decedent, in his/her lifetime, make any transfer of property without receiving a valuable or adequate consideration
therefor which was to take effect in possession or enjoyment at or after his/her death? (Answer "Yes" or "No".) No
a. Was there any possibility that the property transferred might return to transferor or his/her estate or be subject
to his/her power of disposition? (Answer "Yes" or "No".) N/A
b. What was the transferee's age at time of decedent's death? N/A
5. Did decedent in his/her lifetime mal<e any transfer without receiving a valuable and adequate consideration therefor
under which transferor expressly or impliedly reserves for his/her life or any period which does in fact end before his/her
death:
a. The possession or enjoyment of or the right to income from the property transferred? (Answer "Yes" or "No" ,) ~
b. The right to designate the persons who shall possess or enjoy the property transferred or income therefrom?
(Answer "Yes" or "No".) Yes
6. If the answer to five b. alx>ve is "Yes," state whether the right was reserved in decedent alone or others. Alone
7. Did decedent in his/her lifetime make a transfer, the consideration for which was transferee's promise to pay income
to or for the benefit or care of transferor? (Answer "Yes" or "No".) No
8. Did decedent, at any time, transfer property, the bmeficial enjoyment of which was subject to change, because of
a reserved power to alter, amend, or revoke, or which could revert to decedent under terms of transfer or by operation of
taw? (Answer "Yes" or "No",) No
9. If the answer to eight above is "Yes," was the power to alter, amend or revoke the interest of the beneficiary reserved
in the decedent alone or the decedent and others? (Answer "Yes" or "No".) N/A
,"':'.....1-;...'"
;_7'.~'f'" ,.t
Second Amendment To Agreement of Tru:'lt to be signed by its (Vice) Pre-
sidant, itG sa.l to ba .ffixad and to be cttastad by it. (Assistant)
Seerat'I)'. all by ordar of its Board of Diractor. nnd .11 of the fore-
80ing on the day ~nd y~nr first above writt~n.
HITm:ss:
7jj ~"J;' '/c'r(f,~-
ATr~ST:
TIm CO!'E'lmn'IEALTll llATIOHAL BAil!(
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/~;^13S1stnnt) Secretary
~EAL). ,
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/j/k-" ,/. #' /'. /~ . .
By: l?/" 't'.(.,'l'::~ ..4 /7r.~ ..i4';(:;...~.::/
~ice) President (trusta.)
... ~-""""""'''';'''~,.i.,
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-5-
(SEAL~
REV-453 EX+ (3.aO)
COMMONWEA~ TH OF PENNSY~VAN1A
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEOENT
SCHEDULE "0"
BENEFICIARIES
*'
(Instructions 011 Rel'erSfl Sic/D)
Estate of
Edna J, Hazen
BENEFICIARIES AND ADDRESSES RELATIONSHIP SURVIVED DATE OF INTEREST OF BENEFICIARY
DECEDENT BIRTH
Eva Bouraeois Friend vp< 2/03/20 $5.000 & 1/8 ~p<irl"p
R.R. #1 Box 53A
Thomaston, Maine 04861
Helen Gleason Fri end Yes 2/15/97 ~5 000 ,
Star Route I
- i
Meadville, Pennsylvania 16335 i
!
,
American Bible Society Charitv 1/8 \"pcirt"p i
Legacy Department ,
i
1865 Broadway ,
,
,
New York, New York 10023
,
!
. Messiah College Charity 1/8 residue ,
,
Grantham, Pennsylvania ,
17027 i
,
i
I
The Student Aid Fund of The Charit..Y- 1/R rpsidllp i
,
Central Pennsylvania Conference, I
i
United Methodist Church r
. i
,
Harrisburo, Pennsylvania 17109 I
- \
liP, rF'sidllF' ,
Board of Missions. Methodist Charitv ,
!
Church i
i
475 Riverside Drive I
I
New York, New York 10027 I
,
,
, j
,
2/09/21 $5.000 & 1/8 r"c:id"" I
Dorothy Schnidt Friend Yes !
i
44 Morgan Circle i
;
!
Swarthnore. PennsYlvania 19081 I
!
The above beneficiarip.s are living at this time except for the following:
DATE OF DEATH
NAME
REV-4~3 EX"- (3.80)
COMMOr;WEA~ TH OF PENNSV~VANIA
OEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEOENT
SCHEOULE "0"
BENEFICIARIES
'*
(Instructions on Rev""e Sidel
EstBte of
Edna J. Hazen
BENEFICIARIES AND ADDRESSES RELATIONSHIP SURVIVED DATE OF INTEREST OF BENEFICIARY
DECF.DENT BIRTH
Lucile J. Baker Friend Yes I en"' , IA ~"dn""
c/o Robert E. Laubscher
644 Hillcrest
Vista, California 92083
Clifford C. Leonard Friend Yes 5/5/94 1/8 residue
95 Oranneville Road
Greenville, Pennsylvania 16125
Enna Rochin Friend NO
.
Methodist Home for the Aned Inc. Do~<nn"
Bethany Village Retirement Center ($610.94)
325 Wessley Drive
Mechanicsburg, Pennsylvania 17055
.
~ -
.
.
-
-
.
The above benBficiariAS Bre living at this time except for the following:
NAME
DATE OF DEATH
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COIo'MONWEA~ TH OF PEHHSY~VANIA
DEPARTMENT OF REVENUE
BUREAU OF FIE~D OPERATIONS
INHERITANCE TAX SECTION
OFFICIAL NOTICE OF DETERMINATION
AND ASSESSMENT OF PENNSYLVANIA
ESTATE TAX
;!-.J}-Z
DATE: _
ESTATE OF:
FILE NO:
COUNTY OF:
DATE OF DEATH:
n-l-X'O
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,..2/-'j'tJ-,2:30 ,
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TO:
-----------------------------------------------------------------------------------------~
A, DETERMINATION:
1. Taxable estate based upon:
The United States Estate Tax Return (Form 706)
Tho communication from the Federal Government
confirming the acceptance of or changes to the
Federal Estate Tax Return
2. Amount 01 credit for State death taxes (as veri lied)
3. Pennsylvania inheritance tax assessed
(excluding any discount and/or interest)
4. Normal inheritance tax paid to other States or
Territories 01 the United Stotes (excluding
any discount and/or interest)
5. Total inheritance tax credits (line item 3 plus line item 4)
6. Total liability lor Pennsylvania estate tax (line item 2
minus line item 5)
NOTE: Complete line items 7 and 8 ONLY when detennination
is based on Federol Closing Letter
7.
Amount of Pennsylvania estate tax assessed on determination
dated
Addition (reduction) to Pennsylvania estate tax (line item 6
minus line item 7)
8.
/ (J I, "$ -~.
$ l'l) 1,1
$ /[/,1 It/ ~
$ I) ,) .... /Z.
$ - I) ~
1./1) b / 2-
$ v
$ ..' 1/
$
I' d
.-:/.1.J- j,
Determination prepared b~:'- ,C I/-'tf;.,-, .,-.
Date: /,;, - /~- 5((; ,y
os
/t;.J.J/'- ,~"v._.y--
(,
..--- --- ----- - -------.----------------------- ----------------------------- -.---------------
B. ASSESSMENT:
1. Pennsylvania Estate Tax reflected on:
line item A (6)
line item A (8)
2. Less credits:
DATE OF PAYMENT
INTEREST
(S I
IS )
(S I
AMOUNT PAID
------
3. Balance of Pennsylvania estate tax due
interest is due at the rate of six (6) percent per annum from
Assessment preparod by:
Dote:
$
CREDIT
=
=
=
$
to the date 01 payment.
AGENT FOR THE COMMONWEAL. TH
SEE REVERSE SIDE FOR INSTRUCTIONS
'-.
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COMMmn"EALl'H OF PENNSYVIANIA
COUNTY OF DAUPHIN
':;5:
On this, the '.l:\ ,I., day or C'. ..~..._\- . 1966, before me, the
'..
undersigned aUicer, personally a.ppeared EIJNA J. HA.ZEN. known to me (or
sEltislactorily proven) to be the person who~c name is subscribed to the within
instrwnent. and acknowledged that she executed the same for the purposes theroin
contained.
"-_,"'l-~'. ."_'4
IN WITNESS WHEREOF. I have herc\l.'lto set my hand and octic!al
DeaL
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COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21-80-0230
ESTATE OF EDNA J. HAZEN, DECEASED
LATE OF THE BOROUGH OF MECHANICSBURG, PENNSYLVANIA
FIRST AND FINAL ACCOUNT OF
THE COMMONWEALTH NATIONAL BANK
TRUSTEE UNDER AGREEMENT DATED AUGUST 29, 1966
AMENDED FEBRUARY 9, 1970 AND MAY 31, 1975
ACCOUNT STATED TO OCTOBER 31, 1980
SUMMARY AND INDEX
PRINCIPAL PAGES
Receipts 3-6 $193,879,20
Net Loss on Conversions 6-10 4,392.7B
Adjusted Balance $189.486.42
Less Disbursements 10-13 26,222.85
Balance Before Distributions $163,263.57
Distributions to Beneficiaries 13 8,500.00
Investments 13-18
Capital Changes 18-22
Principal Balance Remaining $154,763.57
INCOME
Receipts 23-25 $164,058.22
Less Disbursements 26-28 153,156.65
Balance Before Distributions $ 10,901. 57
Distributions to Beneficiaries 28 9,905.97
Income Balance Remaining $ 995.60
Combined Balance Remaining $155,759.17
L..;tl~
.- 12U.
, C.'i"
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t'. .'
COMPOSITION OF NET BALANCES
Market Value Account
PRINCIPAL 10/31/80 Value
Cash and amounts temporarily invested in
Commonwealth National Bank Common Fund A-2 $154,763.57 $154,763.57
TOTAL PRINCIPAL $154,763.57 $154,763.57
INCOME
Cash 995,60 995.60
TOTAL INCOME 995.60 995.60
TOTAL COMBINED PRINCIPAL AND INCOME $155,759.17 $155,759,17
""Clo S3 ,',.GE 121
2
Principal Receipts (continued)
2/11/75 Edna J. Hazen -
$1,000 Messiah College Annuity,
Board of Trustees and Associ ates 1. 00
$1,000 Messiah College Annuity,
Board of Trustees and Associates 1.00
$1,000 Moody Bible Institute of
Chicago Gift Annuity Agreement #23584 1.00
$1,000 Messiah College Gift Annuity 1.00
$1,000 American Bible Society Gift
Annuity Agreement #46311 1.00
$1,000 Fidelity Mutual Annuity
Agreement #390964 1.00
$1,000 Moody Bible Institute of
Chi cago Gift Annui ty Agreement #24991 1. 00
$1,000 Messiah College Gift Annuity 1.00
State Capital Savings and Loan
Account #8-2879
17,517.49
2/25/75 Received from Edna J. Hazen - addition to Trust
Mutua 1 Life Annuity #1039 $ 1. 00
Mutua 1 Life Retirement Contract #66884 1. 00
Mutual Life Annuity #1038 1.00
Equitable Life Assurance, Annuity
#141646.34 1. 00
Equitable Life Assurance, Annuity
#14135377 1. 00
Equitable Life Assurance, Annuity
#11710445 1. 00
Equitable Life Assurance, Retirement
Annuity #4554006 1. 00
l.....i, ~d I,',~E 1~J
4
36,218.81
., ,,'
Pri nci pa 1 Receipts (continued)
Equitable Life Assurance, Contract
#294155 1.00
Equitable Life Assurance, Life
Annuity #294154 1. 00
Equitable Life Assurance, Contract
#245340 1. 00
5/21/78 Received from Edna J. Hazen - Moody Bible Institute
of Chicago Gift Annuity Agreement #25517
7/8/75 James H. Groner - sale of automobile
11/18/75 Received from Edna J. Hazen - $1,000 Messiah
College Gift Annuity
6/14/76 Received from Edna J. Hazen - Messiah College
Gift Annuity dated June 10, 1976
1/26/77 Received from Edna J. Hazen - Moody 8ible
Institute Annuity Agreement #26018
4/19/77 Received from Edna J. Hazen - balance of checking
account 142-452192-8
11/7/77 Muriel Hann - refund of symphony concert tickets
8/1/79 Commonwealth of Pennsylvania - retirement benefits
2/22/80 Adjustments to establish date of death values
6,296 units Commonwealth National
Bank Common Fund C
$ 9,420.20
1,668 units Commonwealth National
Bank Common Fund G
(1,075.40)
3,366 units Commonwealth National
Bank Common Fund B
(2,781. 06)
320 shares American Telephone and
Telegraph Company, common
100 shares General Motors, common
760.00
(2,191. 95)
, . . 1'.1':1:'
l,.,..H ~u 11I~t ,:;.
5
10.00
1,000.00
1,500.00
1. 00
1.00
1.00
1,388.56
4.25
528.80
Conversions Into Cash (continued)
3/10/80 6,296 units Commonwealth National Bank
Common Fund C
Proceeds $58,977. 15
Account Value 57 ,233.11 1,744.04
3/10/80 1,668 units Commonwealth National Bank
Common Fund G
Account Value $15,518.07
Proceeds 14,294.93 1,223.14
3/12/80 300 shares American Telephone and
Telegraph Company, common
Account Value $15,683.75
Proceeds 13,936.91 1,746.84
3/12/80 100 shares General Motors Corp.,
common
Account Value $4,975.00
Proceeds 4,896.28 78.72
3/12/80 226 shares Pennsylvania Power and
Light Company, common
Account Value $4,507.71
Proceeds 3,580.51 927.20
3/14/80 20 shares American Telephone and
Telegraph Company, common
Account Value $1,036.25
Proceeds 919,78 116.47
$ 7,358.09 $ 11,750.87
NET LOSS AS SIIOWN ON SUr1MARY PAGE 4,392.78
$ 11,750.87 $ 11,750.87
CONVERSIONS INTO CASH NO GAIN/LOSS
3/8/67 John H. and Thelma L. Kline Mortgage
11/13/69 .841 shares National Investors Corporation
11/26/69 .549 shares Wellington Fund
$ 3,600.00
7.31
6.84
2/6/70
$5,000 Commonwealth National Bank Savings
Certificate #11-146 at 5%
5,000.00
L......"
..6 j"Gr 1~,
8
Conversions Into Cash No Gain/Loss (continued)
4/22/70 $1,000 United States Treasury 8ills due
April 22, 1970 996.30
4/30/70 $5,000 United States Treasury Bills due
April 30, 1970 4,951. 92
11/6/72 1,500 units Commonwealth National Bank
Common Fund A-I 10,500.00
4/26/73 3,500 units Commonwealth National Bank
Common Fund A-l 3,500.00
4/3/75 State Capital Savings and Loan PassDook
Account #8-2879 17,517.49
5/1/75 6,600 with Commonwealth National Bank
Common Fund A-I 6,600.00
5/12/75 1,000 units Commonwealth National Bank
Common Fund A-I 1,000.00
5/21/75 16,564.61 units Commonwealth National Bank
Common Fund A-l 16,564.61
10/28/75 1,000 units Commonwealth National Bank
Common Fund A-1 1,000.00
12/8/75 285.60 units Commonwealth National Bank
Common Fund A-1 285.60
6/29/76 7,500 units Commonwealth National Bank
Common Fund A-1 7,500.00
7/12/76 963,26 units Commonwealth National Bank
Common Fund A-1 963.26
9/28/76 1,000 units Commonwealth National Bank
Common Fund A-1 1,000.00
8/23/77 1,500 units Commonwealth National Bank
Common Fund 'A-l 1,500.00
"
11/1/77 2,000 units Commonwealth National Bank
Common Fund A-I 2,000.00
t....,..h
~ci iuGE 1~3
9
Conversions Into Cash No Gain/Loss (continued)
2/19/80 1,000 units Commonwealth National Bank
Common Fund A-I
3/31/80 12,400 units Commonwealth National Bank
Common Fund A-I
7/9/80 2,000 units Commonwealth National Bank
Common Fund A-I
9/30/80 500 units Commonwealth National Bank
Common Fund A-I
10/8/80 37,447.73 units Commonwealth National Bank
Common Fund A-I
PRINCIPAL DISBURSEMENTS
9/8/66
Commonwealth National Bank - registered
mail and insurance charges
9/8/66
American Telephone and Telegrapn Company -
transfer tax
9/8/66
First National City Bank - transfer tax on 100
shares Hershey Chocolate Corporation
Bankers Trust Company - transfer tax on 100
shares Allied Stores Corporation
Commonwealth National 8ank - registered mail and
insurance charges
9/8/66
5/2/69
10/2/69
Chase Manhattan 8ank - stock transfer handling
charge
2/4170
Commonwealth National Bank - registered mail
insurance charge
1/10/80 -
2/8/80
2/19/80
Cowley Associates - professional services
Myers Funeral Home - funeral expenses for Edna
J. Hazen
4...,..."
" 1'"".':l
uU fi\uE r.~
10
1,000.00
12,400.00
2,000,00
500.00
37,447.73
$ 1. 43
B.OO
2.50
2.50
.30
1.50
1.50
30.00
691.12
','
Principal Disbursements (continued)
2/21/80 Dixon's Pharmacy - ethical drugs
2/21/80 Bethany Village Retirement Center - professional
service
15.30
59.70
242.88
3/11/80 M. F. Rockey Storage Company - storage and insurance
3/12/80 Reverand Paul D. Schroeder - officiating at funeral
services for Edna J, Hazen
25,00
3/12/80 Reverand Orville V. Warner - officiating at funeral
service for Edna J. Hazen
25.00
3/12/80 Or. Kendrick Khan - officiating at funeral service
for Edna J. Hazen
25.00
3/31/80 Cumberland County Register of Wills - inheritance tax 12,397.50
4/2/80
Springfield Monument Company - inscription of
Edna J. Hazen monument
35.00
4/16/80 Termination of the following annuities on the
death of Edna J. Hazen:
Fidelity Mutual Annuity #390964
$
1.00
Equitable Life Assurance #245340 1.00
Equitable Life Assurance #294154 1.00
Equitable Life Assurance #294155 1.00
Equitable,Life Assurance #4554006 1.00
Equitable Life Assurance #11710445 1.00
Equitable Life Assurance #14135377 1.00
Equitable Life Assurance #14164634 1.00
Mutual Life Retirement Contract #66884 1.00
Mutual Life Annuity #1039 1,00
Mutual Life Annuity #1038 1.00
L..,'\,.l\
., 13. u.
uU "I;~E
11
Pri nci pa 1 Disbursements (continued)
$1,000 Moody Bible Institute of
Chicago #25517 1,000.00
$1,000 Messiah College Gift Annuity 1. 00
$1,000 Messiah College Gift Annuity 1. 00
$1,000 Moody Bible Institute of
Chicago #26018 1.00
$1,000 Moody Bible Institute of
Chicago #24991 1. 00
$1,000 Moody Bible Institute of
Chicago #23584 1. 00
$1,000 American Bible Society Gift
Annuity #46311 1. 00
$1,000 Messiah College Annuity 1.00
$1,000 Messiah College Annuity 1. 00
$1,000 Messiah College Gift Annuity 1. 00
$1,000 Messiah College Gift Annuity 1. 00 1,021. 00
4/17/80 Edna J. Hazen Estate #19002-01-3
$110.00 Federal Income Tax and
$ 37.00 State Income Tax 147.00
9/29/80 Cumberland County Register of Wills - Pennsylvania
Inheritance Tax 406.62
10/6/80 Cumberland County Register of Wills - filing
costs for Debts and Deductions and Pennsylvania
Inheritance Tax Return 6.00
Reserves:
Commonwealth National Bank - termination fee
6,508.00
Commonwealth National Bank - preparation of
final Life Returns and Death Tax Returns
565.00
1,.,.....H
~J i,,:;E 1:)1
12
Pri nci pa 1 Investments (continued)
11/22/72 2,072 units Commonwealth National Bank
Common Fund B 20,692,25
4/13/73 3,500 units Commonwealth National Bank
Common Fund A-1 3,500.00
5/7/73 385 units Commonwealth National Bank
Common Fund B 3,791.59
10/5/73 65 units Commonwealth National Bank
Common Fund B 629,32
10/5/73 223 units Commonwealth National Bank
Common Fund C 1,994.04
11/20/73 535 units Commonwealth National Bank
Common Fund C 4,774.61
2/7/74 178 units Commonwealth National Bank
Common Fund C 1,422.10
4/5/74 175 units Commonwealth National Bank
Common Fund B 1,674,89
6/28/74 1,300 units Commonwealth National Bank
Common Fund A-1 1,300.00
9/1B/74 1,500 units Commonwealth National Bank
Common Fund A-1 1,500.00
12/4/74 1,500 units Commonwealth National Bank
Common Fund A-1 1,500.00
3/10/75 2,300 units Commonwealth National Bank
Common Fund A-1 2,300.00
4/4/75 17,517 units Commonwealth National Bank
Common Fund A-1 17,517.00
5/6/75 6,600 units Commonwealth National Bank
Common Fund A-1 6,600.00
5/9/75 1,668 units Commonwealth National Bank
Common Fund G 16,593.47
.........1'
, . ,"
.....0 IIIi.Jt
15
1;)4
,
Principal Investments (continued)
7/9/75 1,939,67 units Commonwealth National Bank
Common Fund A-I 1,939.67
8/14/75 2,500 units Commonwealth National Bank
Common Fund A-I 2,500.00
9/23/75 1,200 units Commonwealth National Bank
Common Fund A-I 1,200.00
10/22/75 1,500 units Commonwealth National Bank
Common Fund A-I 1,500.00
3/16/76 3,415.97 units Commonwealth National Bank
Common Fund A-I 3,415.97
5/6/76 1,100 units Commonwealth National Bank
Common Fund A-1 1,100.00
6/18/76 500 units Commonwealth National Bank
Common Fund A-I 500.00
7/8/76 1,000 units Commonwealth National Bank
Common Fund 1;-1 1,000.00
7/19/76 1,000 units Commonwealth National Bank
Common Fund A-I 1,000.00
8/4/76 600 units Commonwealth National 8ank
Common Fund A-1 600.00
9/9/76 1,000 units Commonwealth National Bank
Common Fund A-I 1,000.00
10/12/76 1,400 units Commonwealth National Bank
Common Fund A-I 1,400.00
12/17/76 1,500 units Commonwealth National Bank
Common Fund A-1 1,500.00
3/9/77 1,400 units Commonwealth National Bank
Common Fund A-1 1,400.00
5/5/77 2,988.56 units Commonwealth National Bank
,. Common Fund A-I 2,988.56
I...,J..II
, ~"i:
uU 111~1.
1~j
16
PrinC'ipal Investments (continued)
6/7/77 1,000 units Commonwealth National Bank
Common Fund A-1 1,000.00
7/6/77 1,500 units Commonwealth National Bank
Common Fund A-1 1,500.00
8/4/77 1,500 units Commonwealth National Bank
Common Fund A-1 1,500.00
3/2/78 3,000 units Commonwealth National Bank
Common Fund A-I 3,000.00
3/9/78 2,000 units Commonwealth National Bank
Common Fund A-I 2,000.00
4/14/78 2,500 units Commonwealth National Bank
Common Fund A-I 2,500.00
8/3/78 3,000 units Commonwealth National Bank
Common Fund A-I 3,000.00
10/16/78 2,000 units Commonwealth National Bank
Common Fund A-1 2,000.00
10/26/78 1,000 units Commonwealth National 8ank
Common Fund A-1 1,000.00
4/6/79 4,000 units Commonwealth National Bank
Common Fund A-I 4,000.00
5/7/79 2,500 units Commonwealth National Bank
Common Fund A-I 2,500.00
9/14/79 3,500 units Commonwealth National Bank
Common Fund A-I 3,500.00
10/29/79 2,500 units Commonwealth National 8ank
Common Fund A-I 2,500.00
2/8/79 8,000 units Commonwealth National Bank
Common Fund A-I 8,000.00
3/12/80 23,343 units Commonwealth National Bank
Common Fund A-2 23,343.00
L..,..II
1'1,:":
~6 1.,Gt ~v
17
Principal Investments (continued)
3/28/80 97,000 units Commonwealth National Bank
Common Fund A-2
5/23/80 4,000 units Commonwealth National Bank
Common Fund A-2
6/9/80 4,000 units Commonwealth National Bank
Common Fund A-2
10/9/80 37,539 units Commonwealth National Bank
Common Fund A-2
97,000.00
4,000.00
4,000.00
37,539.00
CAPITAL CHANGES
Pennsylvania Power and Liqht Company, common
8/31/66 215 shares Received from Settlor to $ 6,396.25
establish trust
ill shares 6,396.25
4/28/67 Purchased 5 warrents .78
215 shares 6,397.03
4/28/67 11 shares Executing 215 warrents at 330.00
20 war rents per 1 share at
$30.00 a share
226 shares 6,727.03
10/6/70 Sold 226 Rights @ $14.12
226 shares 6,727.03
2/22/80 Adjustment to establish
date of death value (2,502.95)
226 shares 4,224.08
3/12/80 . 226 shares Sold 4,224.08
-0- _-0-
American Telephone and Telegraph. common
8/31/66 320 shares Received from Settlor to $ 15,960.00
establish Trust
5/20/70 Sold 320 Rights @ $134.00
320 shares 15,960.00
7/23/71 Sold 320 Rights @$83.11
320 shares 15,960.00
2/20/80 Adjustment to establish
date of death value 620.00
320 shares 16,580.00
1..."..1\
..,0 'nCt 131
18
Capital Changes (continued)
3/12/80 300 shares Sold 15,543.75
20 shares 1,036,25
3/14/80 .1.Q. shares Sold 1,036.25
-0- -0-
Diversified Legal Common Fund
8/9/67 25 units Purchased $ 349.17
5/8/68 25 units Sold 349.17
-:0- -0-
5/6/69 242 units Purchased 3,798.37
11/6/69 3B units Purchased 561. 46
280 units 4,359.83
2/5/70 776 units Purchased 10,220.78
1056 uni ts 14,580.61
5/6/70 512 units Purchased 6,420.14
1568 uni ts 21,000.75
8/11/70 69 units Purchased 834.75
1637 uni ts 21,835.50
11/11/70 81 units Purchased 1,016.86
ITI8 units 22,852.36
2/9/71 67 units Purchased 964.77
1785 uni ts 23,817.13
5/6/71 66 units Purchased 998.32
I85I units 24,815.45
8/12/71 67 uni ts Purchased 968.30
me units 25,783.75
11/15/71 935 units Purchased 13,724.27
2853 units 39,508.02
2/7 /72 2853 units Exchanged for 434 units 39,508.02
Commonwealth National Bank
Common Fund Band 4238 units
Commonwealth National Bank
Common Fund C
-0- -0-
Equity Fund
9/6/67 103 units Purchased $ 1,030.00
12/6/67 103 uni ts Purchased 1,097.85
206 units 2,127.85
3/5/68 95 units Purchased 985.72
301 units 3,113.57
9/9/68 255 un; ts Purchased 2,857.88
556 units 5,971.45
...".."
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~...6 I..~E \..lL.J
19
Capital Changes (continued)
12/9/68 9 units Purchased 110.54
565 units 6,081. 99
3/5/69 50 units Purchased 541. 38
615 units 6,623.37
6/3/69 293 units Purchased 3,375.45
908 units 9,998.82
9/4/69 47 units Purchased 522.32
955 units 10,521. 14
12/3/69 448 units Purchased 5,050.02
I403 units 15,571.16
6/4/70 22 units Purchased 178.98
1425 units 15,750.14
12/14/71 77 units Purchased 872.41
1502 units 16,622.55
2/7/72 1502 units Exchanged for 2032 units 16,622.55
Commonwealth National Bank
Common Fund C
:0:- -0-
Genera 1 Motors, common
8/31/66 90 shares Received from Settlor to $ 6,333.75
establish Trust
90 shares 6,333.75
6/13/6B 10 shares Purchased 833.20
'j]Q shares 7,166.95
2/22/80 Adjustment to establish
date of death value (2,185.70)
100 shares 4,981. 25
3/12/80 100 shares Sold 4,981.25
-0- . -0-
Commonwealth National Bank Common Fund B
2/7/72 434 units Received in exchange for $ 4,320.76
2853 units Diversified Legal
Common Fund
5/9/72 116 units Purchased 1,155.90
550 units 5,476.66
6/14/72 119 units Purchased 1,193.83
669 units 6,670.49
11/22/72 2072 units Purchased 20,692.25
2741 units 27,362.74
5/7/73 385 units Purchased 3 ,791. 59
3126 units 31,154.33
i..."..1\
,,(; I ;.~t 1:'>9
20
"
Capital Changes (continued)
10/5/73 65 uni ts Purchased 629,32
3191 units 31,783.65
4/5/74 175 units pUI'chased 1,674.89
3366 units 33,458.54
6/27/74 Segregation of Franklin New York (654.16)
Corporation Notes to 3366 units
Commonwealth National Bank
Common Fund B-1
3366 units 32,804,38
2/22/80 Adjustment to establish
date of death value (2,856.06)
3366 units 29,948.32
3/7 /80 3366 units Sold 29,948.32
-0- -0-
-
Commonwealth National Bank Common Fund B-1
6/27/74 3366 uni ts Segregation of Franklin New $ 654.16
York Corporation Notes From
Commonwealth National Bank
Common Fund B
3366 units 654.16
1/28/77 3366 units Removal due to worthless value
of Franklin New York
Corporation Notes 654.16
-0- -0-
-
Commonwealth National Bank Common Fund~
2/7 /72 4238 units Received in exchange for 2853 $ 35,187.26
units Diversified Legal Common
Fund
2/7/72 2032 units Received in exchange for 1502 16,622.55
6270 units units Equity Fund
51,809.81
9/15/72 910 uni ts Sold 7,519.45
5360 units 44,290.36
9/29/72 Segregation of certain assets (4,668.20)
to 5360 units Commonwealth
National Bank Common Fund C-1
5360 units 39,622.16
10/5/73 223 units Purchased 1,994.04
5583 units 41,616.20
11/20/73 535 units Purchased 4,774.61
6118 uni ts 46,390.81
....,....
, 't'
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21
hLl
Capital Chanqes (continued)
2/7/74 178 units
6296 units
Adjustment to establish
date of death value
1,422.10
47,812.91
9,508.18
Purchased
62% units
3/10/80 6296 units
--=D-'
Sold
57,321,09
57 , 321. 09
-0-
Commonwealth National Bank Common Fund C-1
11/20/73 5360 units
--::0-
Segregation of certain assets $ 4,668.20
from Commonwealth National Bank
Common Fund C
Sold 4,668.20
-0-
9/29/72 5360 units
Commonwealth National Bank, Common Fund G
5/9/75 1668 units Purchased $ 16,593.47
2/20/80 Adjustment to establish
date of death value (1,087.15)
1668 units 15,506.32
3/10/80 1668 units Sold 15,506.32
--::0- -0-
National Investors Corporation
10/15/69 1441. 841 shares Addition to Trust by $ 11,534.73
Settlor
1441. 841 shares 11,534.73
11/13/69 .841 shares Sold 7,31
1441 shares 11,527.42
2/19/70 52.812 shares Purchased 403.48
1493.812 shares 11,930.90 .
2/19/71 39.676 shares Purchased 298.76
1533.488 shares 12,229.66
11/4/71 1533.488 shares Sold 12,229.66
-0- -0-
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HE"V.463 (6.16)
COIIMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
INHElllTANCE TAX SECTION
OFFICIAL NOTICE OF DETERMINATION
AND ASSESSMENT OF PENNSYLVANIA
ESTATE TAX
//-33~ .z
L
DATE: .,.p -..<Co ~,PI
ESTATE OF: ~-"//VA V. )/~.:z"-#
FILE NO: ~/ - 5'tJ.:< 3<'
COUNTY OF: fI "-",, 6r~ /A""";
DATE OF DEATH: 1-"<. pC'
TO:
---. - - - -- --- - --... - - -- - - -- -- - - -- --- --- -- - -- ----- ------- - - -- --- - --- --- - -- - -- -- --- -- - -- --- - --.
I.. DETERMINATION:
1. Taxable estate based upon:
4 The United Stoles Eslole Tax Return (Form 706)
~ The communication from the Federal Government
confirming the acceptance of or changes to the
Federal Eslole Tax Relurn
2. Amounl 01 credillor Slole deolh loxes (os verilied)
3. Pennsylvania inheritance tax assessed
(excluding any discount and/or interest)
4. Hormal inheritance tax paid to other States or
Territories ollhe Uniled Sloles (excluding
any di scount and/or interest)
5. Total inheritance tox credits (line item 3 plus line item 4)
6. Total liability for Pennsylvania estate tax (line item 2
minus line item 5)
NOT E: Complele line ilems 7 and 8 ONL Y when delerminolion
is based on Federal Closing Letter
7.
Amount of Pennsylvania estate tax assessed on determination
doled /() - S' . S'~
Addilion (reduclionl 10 Pennsylvania eslole lox (line item 6
minus line item 7)
8.
Determination prepared by:
Dale:
$ /(J1/9RJ.J'
$ ,.d-
S 1.1. J/S'I,t,.2
s -0.
$ / 311.''/, ~.2
$ .- CO -
$
$
jJa.~~ ~.c/
,,;J-:U:.J'/
.0.
.C)-
----------------------------------------~-------------------------------------------------.
B. ASSESSMENT:
1. Pennsylvania Estate Tax reflected on:
line item A (6)
line ilem A (8)
2. Less credits:
DATE OF PAYMENT
AMOUNT PAID INTEREST
(5 I
(S I
- (5 1
3. Balance of Pennsylvania estate tax due
Interest is due at the rate of six (6) percent pcr annum from
Assessment prepared by:
Dote:
$
CREDIT
=
=
$
10 Ihe dote of poymenl.
AGENT FOR THE COMMONWEAl. TH
SEE REVERSE SIDE FOR INSTRUCTIONS