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NO. 21-80
PETITION FOR LETTERS OF ADMINISTRATION
IN THE ESTAT~; 01' ....g!9.~~!';...!:;.......:;m~.Af.f);;R................... Im($AS~;Il.
To ... klli\t'y....l..\\w.tl?................. ...............................................................................
Register of Wills fOl' the Couuty of CllInberh\lul. ill t he Commonwealth of I'enn,;~'h'anill.
The Peli lion 0 f ...... .9h 19..~. ..~.:.. ..~J.:\~.~%. ~.~!.... ................ .... ............................. ...................... .....................
.......................................................... respect fully showel h that ,.\';.\!gl'lp.~...J;;.,...S.h\\~JJ.e.t"...........................
'd t f Middlesex TowlI,;hip (' I .\ let' St. t of Penn,;yl-
wns n resl en 0 ........................................................."$:II"'4IRRo . .um ,el 1lI11 oun ~, . .\ e .
vllnia. IInd 1\ Citizen of United Stntes. and depnrted thi,; life intestate in the County of ............................
......... .b.IlIi\Q).l?....... .......... and S In t e 0 f ....... ..f..\\IJ.JI.l?yJ.:v.ap;i,a..... .......................... ..... ........... ..... ...... ......... ...... .......
on ....f,;J;'J.Illi-y.................... lhe ...f..9.!,\t'.t.P..................... day of .........J.u.ly............................... A. D.. 19...80...
at the age of .....J.:?.... ~'ears.
That the said .....~!:!f1;.~~~...~......~.~.~~~.~~.~.......................... deceased. left surviving the following
named widow or husband. heirs IInd next to kin. to wit:
Name Relationship Residence
....Cbl9.g...~.,....~J-:\~.~ff\\r;: ............... ......J19.!;b~.t'..................... B.,D......l.....J:ole.w...B.lQomfield,....P A
................................................................ ............................................ ................................................................
................................................................ ............................................ ................................................................
................................................................ ............................................ ................................................................
................................................................ ............................................ ................................................................
................................................................ ............................................ ................................................................
................................................................ ............................................ ................................................................
................................................................ ............................................ ................................................................
................................................................ ............................................ ................................................................
That those above named include all of the next of kin. so far as known.
The snid decedent wns possessed of pel'sonal propel.ty to the eRtimated value of $..J!:?.9.9.....................
and of Real Estate. less incumbrance. to the e,;timated value of $.....N9.11~................... as nellr as can be
ascertained.
That the said Real Estate in so far as is known is located in ............lJ/..A...........................................
........................................................................................................................................................................................
Therefore. your petitioner(s) respectfully apply(ies) for Letters of Administration in lhe above
named estate.
July 22, 1980 ,
Dated .................................................... A. U.. 1.1.........
Signature and Add,'ess
of Petitioner (s)
,,: " ) , /" I /
> (. _~Ct..x- ''j. /, /"1 i ,'L-
........Clil(je..M:....S1i"~~"f'e.i...J.. .''1.La;-11...&..
R.D. 1, New Bloomfield. PA
........................................................................................
........................................................................................
........................................................................................
~~I
COMMONWEALTH OF PENNSYLVANIA I
~ 5S:
COUNTY OF CUMBERLAND I
Chloe M. Sheaffer
........................................................................................................................................................................... named
in the above application being duly ..............~~~.~~..................... according to law. say that the facts set
forth in the nb~';;oa:~lication are true to the. best of ....h(.T-..;_t~:o~\;.e~ an)djb~\ief. r Ii" .) / <l. Lt........................................................... and subscrIbed I .....................'-J<~::-:............. +....""".. l.L..~./~r:. -
before me. t ..................... ...................................................................
......7..4i......~.~.~r...~.~.................... A. D.. 1 !~~...... I .. .................. ....................................................................
......"::!.:)((ur.....(!...:....~~~~~~~.... ..................... ..................................................................
Filed: ........g:~.ty.......~.~.~....~.~~Q............................ Allol"lley:
(ovel"l
Rr:.V.44g I:X" (3.801
COMMONWEAL TH OF PENNSYL VANIk
DEPARTMENT OF REVENUE
TRANSFER INNERITANCE TAX
RESIDENT DECEDENT
*'
AFFIDAVIT OF
FIDUCIARY
(Instructions on Reverse Sido)
Estote of _JUGIiN.E E. SHEAFFER
Lost Address _BoJL10L_
_ New Kings_town, PA 17072
Do te of Deo th
July 4. 1980
186-14-2394
Social Security No.
Bureau File No.
ICITYI
ISTA TEl
('ZIP)
;:( /- k b -if? y'
Co un ty FiI e No.
1. Decedent died:
(X) Intestate (without a will)
( ) Testate (leaving 0 lost will--capy attached)
2. Is the filing or 0 Federal Estate Tax Return required for this estate? Yes_ No X
3. ) Executor/Executrix ( X) Administroior/ Administratrix
Nome Chloe M. Sheaffer
Address Paradise Park, Lot 87
New Bloomfield, PA 17068
(CITY)
(ZIPI
(STATEI
4. All correspondence should be moiled to ( X) Attorney
) Fiduciary.
5. If on attorney is representing the estate, indicate:
Name J. Michael Eakin
Address Market Square Building
Mechanicsburg, PA 17055
(CITY)
(STATE)
(ZIP)
List 011 safe deposit boxes registered in the decedent's individual nome, or jointly with, or os on agent or deputy
of another, or in decedent's individual nome with right of access by another os agent or deputy. Include the nome
and address of the bank or other institution where the safe deposit box is located, the nome (s) in which the box
is registered and the relationship of the joint holders to the decedent.
NAME ANa AOORESS OF BANK OR OTHER INSTITUTION
IN WNICH DECEDENT MAiNTAINED A SAFE DEPOSIT BOX
NAME OR NAMES IN WHICH
SAFE DEPOSIT BOX IS REGISTEREO
RELA TIONSHIP OF JOINT
HOLDERS TO DECEOENT
NONE
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and
statements, and to the best of my knowledge and belief it is true, correct and complete,
(tjJ.;,J-- )1/, jh~ I~ loft f(!
SIGNATURE OF FIDUCIARY OATE
INSTRUCTIONS FOR COMPLETING SCHEDULE "A"
Schedule "A" should include a detoiled description af all real properly located in Pennsylvania
and held solely by the decedent or held jointly with another individucl (s) as tenants in common. List the
decedent's percentage of ownership and the estimated market value af the decedent's interest. (Property held
as joint tenants with the right of survivorship or tenants by entireties should be reported on Schedule "E".)
All real estate located in Pennsylvania should be described by lat and black number, street
. address, number of ccres and general description of land and buildings. Also, include the book and page
number in which the deed is recorded and the exact title as indicated on the deed. If the properly has been
sold, attach 0 copy of the settlement sheet, If the property is subject to a mortgage encumbrance, include
the name of the mortgagee, date, rate of interest and the outstonding balance on the date of death and
attach a statement from the mortgagor verifying the outstanding balance.
Prapt'rty taxes and interest on mortgages as of the date of death, assessments and other
encumbrances should be listed on Schedule "F". Do not deduct them on Schedule "A".
It ~~E~ TR~:~~
Date March 16. 1981
J. Michael Eakin Esq.
Market Square'Building
MechanicsburE, Pa. 170~~
Re: Estate of. En!:e"!! E.. Sh!!affer
Date of Death July 4. 1980
Dear Mr. ERkin
In answer to your request concerning accounts owned, either separately or jointly, by
the above referenced decedent and the balance in each account -as of the date of
death, we have checked our records and are submitting the following infonnation in
duplicate. We suggest that you me one of these letters attached to the Pennsylvania Inven-
tory forms (Reel to substantiate the balance you report
Note that we have shown the correct registration for each account. Also, interest accrued to
the date of death, if any, is listed as a separate figure.
Very truly yours,
Farmers Trust Compan;y
~~ .
Olive Bolinger r
Supervisor
Bookkeeping Department
Balance in account # 5-75283 $1,846.76
.REV....I\..OI SCHEDULE "C"
COMMONWEAL TN OF PENNSYLVANIA TRANSFERS
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
ESTATE OF _ F.1lr.F,NF. F. SHFA FFFR
.
INSTRUCTIONS:
1. Answer the questions on reverse side.
2. If the answer to any of the questions on the reverse side is "Yes," provide a description of the property transferred per
Schedules "A," "B," or "E," its estimated market value at date of death, dates of transfer, to whom transferred and
relationship of transferees to decedent. Attach a copy of any trust deed or instrument relating to the transferred property.
ITEM
NO.
DESCRIPTION
ESTIMATED
MARKET VALUE
DEPT, VALUATION
(OFFICIAL USE ONL YI I
NONE
TOTAL THIS PAGE
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 "Ves" or "No".)
2. Did decedent, within two years of death, traosfer property from himself! herself to himself/herself and another party
or parties (including a spouse) in joint ownership? (Answer "Ves" or "No".) -
3. If the answer to one or two above is "Ves" and the transfers ale 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 "Ves" or "No".)
a. Was there any possibility that the property traosferred might return to transferor or his/her estate or be subject
to his/her power of disposition? (Answer "Ves" or "No".)
b. What was the transferee's age at time of decedent's death?
5. Did decedent in his/her lifetime make 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 "Ves" or "No".)
b. The right to designate the persons who shall possess or enjoy the property transferred or income therefrom?
(Answer "Ves" or "No".)
6. If the answer to five b. above is "Ves," state whether the right was reserved in decedent alone or others.
7. Did decedeot in his/her lifetime make a transfer, the consideration for which was transferee's promise to pay income
to or for the beoefit or care of transferor? (Answer "Ves" or "No".)
8. Did decedeot, at aoy lime, transfer property, the b61eficial 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
law? (Answer liVes" or "No".)
9. If the answer to eight above is "Ves," was the power to alter, amend or revoke the interest of the beneficiary reserved
in the decedent alooe or the decedent and others? (Answer "Ves" or "No".)
RE'l~S':;' EX+ (3.80)
. COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIOENT DECEOENT
Estate of
EUGENE E. SHEAFFER
ITEM
NO.
DESCRIPTION
NONE
-=-'7
tt.'
C
SCHEDULE "E"
JOINTLY OWNED PROPERTY
(lnstrucrions on Reverse Sldel
TOTAL
MARKET
VALUE
PE
\
~
TOTAL THIS PAGE
VALUE OF
DECEDENT'S
INTEREST
*
DEPARTMENT
VALUATION
(Offlciel Use Onlyl
INSTRUCTIONS FOR COMPLETING SCHEDULE "E"
Schedule "E" must include all property, real end personal, owned by the decedent jointly with another
party or perties as joint tenants with right of survivorship. Both tangible and intangible property are to be
included. List real estate first.
1. Describe all real property as indicated in the instructions for Schedule "A". Describe all personal property
as indicated in the instructions for Schedule "B". Include the name, address and relationship to the
decedent of the co.owner (sl and the date the joint ownership was established.
2. Indicate the total market value of the jointly owned property.
3. Indicate the percentage of the decedent's interest.
4. Indicate the market value of the decedent's interest.
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FII" Number
INHERITANCE TAX SUMMARY SHEET
(BUREAU USE ONLY)
21-80-0498
ILl Original
o Supplemental
o Remainder
REY."'" EX+ (HOI
Estate Name
EURene E. Sheaffer
Date af Death
July 4. 1980
Social Security Number
186-'34-2394
REPORT OF INHERITANCE TAX APPRAISER
I, tho undorslgnod duly appalntod Inherltanco Tax Appraiser In and lor tho County 01 Cumberland
Ponnsylvanla, do respoctfully roport that Illavo appralsod tho roo I and porsanal praporty as reportod In tho farogalng
rotum at tho valuos lOt forth oppasito oach It om In tho last column ta tho right In Schodulos "A", "B", "C", and "E"
(", . ",-i:' ,,)
"fl/'..../..' J'" ~/d'f
INHERITANCE TAX APPRAISER
Datod:
May". ]Q81
ADJUSTMENTS REMAINDER APPRAISEMENT CODE
IHVEHTORY VALUE AS APPRAISED CODE (HARRISBURG USE ONLY)
Roal Proporty (Schodulo A) S None 00+ 112+
Perlonal Property (Schedule B) la+
Jolnt.Hold Proporty (Schodulo E) 2Jl+
Transf.r. (Schedule C) 30+
TOT AL GROSS ASSETS
L.I. D.bt. and Deduction. 40- 93-
(SCHEDULE F)
CLEAR VALUE OF ESTATE
o Lifo Estate ~ FACTOR PRINCIPLE VALUE CODE
o Annuity
FOR USE OF REGISTER ONLY
TalC on $
TalC on $
~
COMPUTATION OF TAX
5
5
5
6%
15%
T ax on $
5-
Tax on $
5
Tax on $
Exemptions
Tolal Estate
TOT Al. TAX
INTEREST FROM
BALANCE
TO
5
5
5
LeIS Credits
DATE OF PAYMENT
AMOUNT PAID
TAX CREDIT
5
5
INTEREST FROM
BALANCE DUE
COMMONWEAl.TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
INHERITANCE TAX
APPRAISEMENT
~
, t~ii'~~
;~~~~
\.,:,:.'~~.",..t.
REV-4D7 EX+ 17-eO)
[iJORIGINAL
o SUPPLEMENTAL
File No. .2.1-~O-O_~9B
Estate of Eugene E. Sheaffer
County
C\.lIIIbIDB,nQ,
Date of Death
July 4. lqBO
In the ovont that any futuro Interost In this cs:lato Is transferred In possession or enjoyment to collateral heir. of the decedent after tho
oxplratlon of any estate for life or for years, tho Commonwealth hereby expressly fucrVlll the right to appraise and auoss tronsfer
Inherltanco tax.I at the lawful collateral rate on any such futuro Interest.
PROPERTY NOT INCLUDED IN RETURN BUT APPRAISED BY THE COMMONWEALTH
ASSET SUMMARY
DEPARTMENT'S
APPRAISED VALUE
Totol Real Property - SCH. "A" , . . , .. S
Total Personol Property - SCH. "B", , . . S
Total Jointly Owned Property - SCH. "E" $
Total Transfers - SCH. "C". . .'. . . .. $
None
14.406.?q
Unreported S
Unreported S
Unreported S
Unreported S
$ None
$ 14.406.?q
$ Nnn,:.
$ N,..nA
$ 14,~.79
Nnne
Nnne
o LIFE ESTATE
DANNUITY
TOTAL GROSS ASSETS
DREMAINDER
TOTAL VALUE
$
I do hereby certify that the above appraisement is made in confannity with Pennsylvania low and has been filed this
day with the Register of Wills.
I:;" ')., ,,~) I /B
.>;'1'/'o't/a .Iff tt' ;',/ "," / 05 21 1
APPRAISER DATE
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REV0455 EW+ 13.MOI
COMMONWEALTH OF PENNSVLVANIA
DEPAIlTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDEr~T
SCHEDULE "F"
STATEMENT OF DEBTS
AND DEDUCTIONS
-
--
- -----
.-
.-.
-
0;il1.iL'~
5=c:?~ -?I
AMOUNT
...........--
Estate of EUGENE E. SHEAFFER Date of Death 7-4-80_File No. ;;? 1- X' 0 ~ V9'.r1
WHEN CLAIMING THE FAMILY EXEMPTION, COMPLETE THE FOLI.OWING: I
Claimant Chloe H Sheaffer
Relationship to Decedent Mother / Adminis tratrix
Claimant's Address Paradise Park. Lot 87. Ne,,' Bloomfj(>]cJ PA 17068
ITEM
NO.
DATE
NAME OF PA VEE
REMARKS
M ers-Hall
Chloe Sheaffer
PP&L
Bell Tele hone
UGI
Farmers' Trust Co.
James Sheaffer
Wm Schultz Acct.
Eakin & Eakin
Eakin & Eakin
Funeral Ex enses
Reimburse Has ital exnense
Final lirrht bill
Final telephone bill
Final as bill
Loan on Camara
Re air of Camara
Prep. of 1980 artnershi ret.
Attorne I s fees
Reimburse for letters of
administration short cert.
2360.00
2
2 .1
33.66
6.01
2139.53
514.10
45.00
600.00
TOTAL THIS PAGE
I hereby certify that to the best of my knowledge and belief the foregoing is a just and true statement 01 debts, funeral
expenses and expenses of administration submitted to the est t as edu ~s f r Inheritance Tax purposes.
J::::: I ~ ).~ ~ )
SIGNAT Rr- (F TOPNEY/Flr;?"f:I'" [;lV- DAT~
OFFICIAL USE ONLY
DEBTS AND DEDUCTIONS ARE ALLOWED IN THE SUM OF S 6-C; '13 /j'1 AT
~
PERCENT.
DATE
,
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COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "a"
PERSONAL PROPERTY
'$:
,~~~'
._~Z.
;....'i.J.~-~.t.
.....,.:1~~..
(Instructions 011 Rflvcrsc Side)
Estate of EUGENE E. SHEAFFER
ITEM
NO.
DESCRIPTION
UNIT
VALUE
ESTIMATED
MARKET
VALUE
DEPARTMENT
VALUA liON
(OFFICIAL USE ONL Yl
1.
Bank deposit made prior to date of
death (7/14/80), but credited on first
business day after date of death
(7/7/80). This amount therefore is not
included in amount approved in bank
account shown on original Schedule "B"
(See Item No.4, $1846.76).
$ 242.15
TOTAL
242.15
'f-:t.. IS-
~
If additianal space is necessary, use 8\," x 11" sheets.
EAKIN & EAKIN
ATTORNEYS AT I.AW
MARKET SQUARE BUILDING
MECHANIC5BURC3, PA. 17055
..CHN .... EAKIN
... MICHAII. I[AItIN
nLlPHQNf. .,....:11'11
May 27, 1981
Gloria Rkchard
Chief Appraiser
Penna. Department of Revenue
Re: Eugene E. Sheaffer
.
Dear Ms. Rfchard:
Attached are amended Schedules "B" and "F" in the above
estate. The original Schedule "B", Item 4, was a bank account
in the amount of ~150l.l0, which was the amount in the account
when closed by the Administratrix. The bank later confirmed
a balance as of the date of death of ~1846.76, which figure
was used in arriving at the approved appraisement of the estate
dated May 21, 1981, the total being ~14,406.79.
The amended schedules reflect a deposit into the account
by the deceased prior to his death, but not credited until
July 7th, 1980, the first business day after his death. Listed
on the amended Schedule "F" are 7 checks written by the decedent
prior to his death which were not paid by the bank until after
his death.
These amendments should act to reduce the total taxable
estate to the amount originally claimed, $14,070.13. If there
are any questions about the situation, please feel free to con-
tact me.
Very truly yours,
~\~LOJJ)~~jL,--
J. Michael Eakin
JME:amb
REV.5U FO iNIOl
~~
..~~'
NOTICE OF FILING OF APPRAISEMENT
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
J. Michael Eakin, Esquire
Market Square Building
Mechanicsburg, FA 17055
RE: Estote of
County of
File No.
Eu~ene E. Sheaffer
Cumberland
;>1-80-0498
Dear Mr. Eakin:
You are hereby notified thot the SI1pp1ementa1
appraisement in the estate of Eu!,:ene E. Sheaffer
has been !iled in the office of the Register of Wills of Cumberland
County on June 18 , 19 81. Said appraisement reflects the following valuations:
Real Estate
Personal Praperty
Jaintly Owned
Transfers
Total
Nnnp.
242.15
Nnnp.
None
5242.15
As to such tax that is paid within three months from date of death, a five (5%) percent
discount is allowable. As to ony tax that remains unpaid after nine (9) manths (fifteen months
when death occurred from December 22, 1965 to June 16, 1971, inclusive; and twelve months when
death occurred prior ta December 22, 1965) from date of death, interest at the rate of six (6%) percent
per annum is charged.
Any party in interest who is aggrieved by this notice may object thereto within sixty days
after receipt of said notice as provided by Section 1001 of the Inheritance and Estate ~-x Act 0'
1961,72 P.S. 2485-1001, P.L. 373.
Date
June 18. 1981
PIN!,') #1 "JloJri )
Si gned
Title
Chipf Appl"l=liF:er
NOTE: This is not a bill.
COM\\ONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
INHERITANCE TAX
APPRAISEMENT
.~.
~~
,~~
,,~.~>.'
REV..." EXt (710.
DORIGINAL
Q SUPPLEMENTAL
Estate of Eugene E. ~ffer
File No. :>1-80-0498
County Cumherland
Dote of Death .Tu1y 4, 191\0
In the oven' that any future In'orelt In this estate Is transferred In possession or enjoyment to collatefal heirs of the decodent after tho
uplratlon of any ..tato for IIf. or for yoar., tho Commonwealth hereby oxpreu'y rOIll'Y.I the right fa appraise and auolC transfer
Inheritance tOXOI at tho lawful C'ollateral rote on any such futuro Inter..t.
PROPERTY NOT INCLUDED IN RETURN BUT APPRAISED BY THE COMMONWEALTH
ASSET SUMMARY
DEPARTMENT'S
APPRAISED VALUE
Total Real Property - SCH. "A" . . . . .. $
Total Personal Property - SCH. "B". . . . $
Total Jointly Owned Properly - SCH. "E" $
Total Transfers - SCH. "C". . .'. . . .. $
Nnn~
Unreported $
Unreported $
Unreported $
Unreported $
$ Nnnp
$ :>4:>.15
$ Nnnp-
$ Nnnp
$ 242.15
?u? 1 5
None
Nnne
DLlFE ESTATE
DANNUITY
TOT AL GROSS ASSETS
DREMAINDER
TOTAL VALUE
$
I do hereby certify that the above appraisement Is made in conformity with Pennsylvania law and has been filed this
day with the Register of Wills.
/tJ!/',o Jf /11 J if/'"A4 J(.J ) 06/18/81
APPRAISER !lATE
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REV0455 EX" (3.80)
COMMONWEALTH OF PENNSVLVANIA
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
~~~~t~
STATEMENT OF DEBTS
AND DEDUCTIONS
Estate of EUGENE E. SHEAFFER Date of Death 7-4-80
WHEN CLAIMING THE FAMILY EXEMPTION, COMPLETE THE FOLLOWING:
File No. 21-80-498
Claimant
Relationship to Decedent
Claimant's Address at time of Decedent's Death
17EM DATE NAME OF PAYEE REMARKS AMOUNT
NO.
1. Checks written on bank account
(See Item No, 4 !'; "j, I> rlll 1 I> "R")
_ltnd passed ~rior to date of
death paid by bank from said
account after date of death,
as follows:
litH Readers Di~est S 6.93
Iit10 Bell Telenhone 25.88
7/1 Geor~e Smiley 60.00
J..jl John Dau~hton 230.00
J..j? Earl Stanton (sic) 80.00
.J.j1 r.""lh 150.00
7/3 Cash 35.00
TOTAL I S _587 III
I hereby certify that to the best of my knowledge and belief the foregoing is a just and true statement of debts, funeral
expenses and expenses of administration submitted to the e9f as d ducti n or Inheritance Tax purposes.
~I
AT
(,Yl'
% TAX RATE
OFFICIAL USE ONLY
DEBTS AND DEDUCTIONS ARE ALLOWED IN THE SUM OF $ 5,'1' '7 8'1
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DATE
GENERAL INHERITANCE TAX INFORMATION
Unsatisfied liabilities incurred by the decedent prior to his/her deoth ore deductible ogoinst his/her toxoble
estote. In addition to debts incurred by the decedent or estote, other items are c1aimoble including the cost of
odministration, attorney fees, fiduciary fees, funerol ond burial expenses including the cost of a burial lot, tombstone
or grave marker and other related burial expenses.
All debts being claimed agoinst an estate are subject to the approval of the Register of Wills with whom the
Inheritance Tax Return is filed. Evidence ,to support the decedent's or the estate's liability for the debts being
claimed should be attached to this schedule.
A family exemption may be claimed by a spouse of a decedent who died domiciled in Pennsylvania. If there is
no spouse, or if the spouse has forfeited his/her rights, then any child of the decedent who is a member of the same
household can claim the exemption. In the event there is no such spouse or child, the exemption can be claimed by
a parent or parents who are members of the same household as the decedent. The family exemption is allowable only
against assets which pass by a will or by the Pennsylvonia Intestate laws.
NOTE: Compensation paid to an estate representative; namely, an executor or administrator, for services
performed in administering an estate is reportable far Pennsylvonia Income Tax purposes. This taxable income
item should be reported an form PA.40.lndividuallncame Tax Return.
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INSTRUCTIONS FOR COMPLETING SCHEDULE "F"
1. If the family exemption is being claimed, indicate the claimant's name, address and his/her relationship to
the decedent. Enter "family exemption" in the remarks column and the amount claimed in the amount column.
2. Assign consecutive numbers to each item listed.
3, Enter the date on which eoch debt was incurred and/or paid.
4, Enter the names of each payee.
5. Provide a brief explonation in the remarks column far each debt claimed.
6. Enter the amount of each debt being c1oimed.
7. The form must be signed by the person who has assumed the responsibility for paying the debts.
IF ADDITIONAL SPACE IS NECESSARY USE BYz" x 11" SHEETS.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF EXAMINATION
OFFICIAL NOTICE OF
'--/.- INHERITANCE TAX
C., , , AjSESSMENT
trvv1 t..,-., / ,
COUNTY FILE NO: cQ I - Y (j - II l1Y:'
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Appraised Value of Estate:
Real Estate
Personal Property
'~ 'I
" . . , +
\,:, ' """ ,] ( ;
Jointly Held PropenylTransfers
Total Gross Estate
Total Approved Deductions
,
"'J . ~ II'
,,' .A,""'~'..,
'. .tlt I'" ....;
'"
Clear Value of Estate
Less: Approved Charitable Exemptions
Clear Value of Estate Subject to Tax
Amount Taxable @ 6% Rate
$ ,r !) (, '? t.- t/
Amount Taxable @ 15% Rate
DATE
ESTATE
f',
),
FILE NO,
COUNTY
DATE OF DEATH
$
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$
talC due
tax due
TOTAL PENNSYLVANIA INHERITANCE TAX DUE
.. * * .. .. '" A five percent discount totaling $
will be granted if the Inheritance Tax is paid by
Less Credits:
DATE OF PAYMENT
AMOUNT PAID
DISCOUNT
.;:?-~'j'~'1
$ l/ ';<1./. Of,
$
+
+
+
Interest accrues at the rate of six (6) percent per annum
on the unpaid balance of Inheritance Tax from
to date of payment. Interest due if paid by
INTEREST
TAX CREDIT
$ fLc[t)..., 01-,
- $
=
=
=
BALANCE OF PENNSYLVANIA INHERITANCE TAX DUE $
is
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