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No, 21..81 ~~~t8
PETITION flOR PROBATE OF WILL AND LETTERS TESTAMENTARY
In the Estate of
J,) 1tu....._R '
e~AO,K.
, deoeaaed,
To R~glst!lr at Wills for theOaunly of Oumberland, In tho OQmmonwo!llth of Ponnsylvanla,
Petltlo\lor(8lls,(ate) the eX(lout a JI. named In Ihe Last Will and TOBtamonl af......:J r\ 1\ III
fl., , 0 ~I\ A k ," " " , dated . (,1 (.II'I/;;"r./, ' L~U 1
Oeoedent was,8 oltlzen af the United BtateB and a resldent'af !\J HJ, (1"~,, 1,,,,,10. V\t(
, leWf\shlp(Baraugh), Oumberland Oallnty, Oommonwealth af Pennsylvania,
Deoedent'dledon,-.Jvr,,(ocO ,'" the 511. dllyaf mil v _A,D,1\l..LL,lnthe ,
Oa~nty of&n:t.L'I.r I,..,,{ , " ,Bta~ Of.1.fI' " M the lIge af J..i:. years,
Deoedent ~~~l been '11arrled and hllal:{flAe.."t'I'6,1J had ohlldren barn tohlm (he~ slna!lthe e~'
;~~~~~n~'~~: ~~~~:s~~~O~n~r~I~I~1 property ta the value af :/I'I!Jll, ,.,
arid af real eslate ta the value af~"rJL' ~ltl'l 000
as near as 011I\ be aaoertalned: oald realestale situated asfallaws', ~ I' P;' I'flr
2 r II; II'!' fl) P l \!.!l.('
Therefor , your petltlaner!8)';reopoatfully applv(lea) for the probale af the Bald Last
ment and far Letters Testamentary theron. '
Dlted7?Ltlt 7) 19 JI 1
OOMMONW~ALTH ,OF PENNSYLVANIA l
OOUNTY OF OUMBERLAND ~ ss
(.JM, I ",' f<., , (f1; lit,..
, i / ' " '/'): "Y;;~F~_ /1
,/ / . ,".i" "-',
Name and address ,/ ( lu. ./1 ' /,- (?/,.-~'
a,f Petltlaner(s) '(l I /J (1'1 ' II
--L{lU a. ' II, uf.f'
t~ ~ !I" (Jrir,- Sf
p;, (./ Ljp roll.
Te II t1J
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me, '~1, 1,'1t 198.L
.... C. ,-) "
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Flied: Yr\/L.t7, Iff!" '
:.;(1.,f1-,;J9'8" /1.,;,;47....3
'named,'ln,abave apPIIOatlOn,' be,l~g dU,ly.ElLl..'C1fh " '_,' \loo.ooaarradlng ta 11Iwsay(s) lha\,the
statemMtllset forth In this pelltlan are true ta the bestaf-1l.l.L_ knowledge and belief.
",)l'Mf'" '" . and subsoribed befare )
y..j' /) ~i.-/x" '/-/
./ [(:",",,/.> ,.7.......1:'1' //"-', , '
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lr~b'
Attarney
rPfl7
I<d/'ttr', A",tJuh. ti"sJ,
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1.1I1R~lf tid()~'C.;', j}/i. 17//J I
21-81
f.lt, U.-I
,...,,1U
OATH OF NON.SUBSCRIBING WITNESS
OOMMQNWEALTH OF PENNSVLVANIA,} 881
OOUNTV OF OUMBERI.ANP
This, the ___O'.,..i.f~,.u-
'~jJ:ij1'Y__nm......_' ----,_.. n
nm'___....._,_~..__,_.._.._._.___'_. day of
A,D, 19JL, before me, Register forthe
,.
Probate of Willa and Granting Letters of Admlnlslratlon In and for the county of
Cumberland, I~ the Commonweallh of penna~lvanla, personally oame.....Pa 1I/~, lie
j.1~~__.:.cC.oJL!1L.-QX\~.,.--G./1J-~_._J",,-...[{l~..i../JJ:t::....-..---,---~ ,who being duly
_5.1.1:ul.r..b~.--O',....,. according to law deposed and say that they are well aqqualnled with
, J'" e C
t.he handwriting of _.,_...I.LI:I[,Ln...-'.~-_-_'I..U:\..l!....--iS...~--O'_-_u----~-'---~'
, whose name Is ,attached as_uI~.d~,-{~, r_"~___"'T..'~__nn______~ tO,an Instrument of writing
purported to be _fL__-.DJj:c..bllf!:.II,.LuLl\L_-!'L'-,'lR~T......1wf.L the Last Will and Testament of
____IQ._lj.l\L___'.R~,___..c.._L.fll_!,_.~_,._",..~.._~~.__"--.-.--,..------~-
. 'I ' 0
late .'Of _..iUc..Io.I.L.--.CJ.LI'l1,-hs.,dr&.rI.L~u.i.c\-!uQJj,!;.dll""LC"uL'a.ld-r.J~1'L5'ij I \J~l1i~deoeased
and that the said algne\lbre Is true and genuine, and that the said
_____.,._~....~...._._n----.----- Is now ~eoeased or abeent .-'
,...;._ Sl!,!.9.LO______~~u and Bubscrlbed' before me,
this ._...______j_,....---~1_1.1-~_-.-n..'----- day of
11'IAY f /
_"._,.n_ ........__' ..,....___."n'--.. ... _O" __~_ ....,..A, D, 19..____
, ... -,,^ "j),'
--,--=:'rril(C1/.1--C..!~~WJ-;W-"-"---'-"'--""':-
, . Ragla\er
,,\lA/AA "l"~ '\IV I)'
per,._"_:;c~J:{4.u.~r ..2":6Idt~f/~~~er.._-.m..'
(' ., ,,) "",.J, ''/'
\....:.'-;:'JJJ) ;//"J.&..,.J.. (11,)),(".,...) -
(!/' /) (/;"l) /,//
AU,.(_I.!e.f // (,/c.ccf'{..?
f" ~~ ~J
OATil (U' 1'lo:HHONAI, IH:I'Rmlt:NTA'rIVR
COMMONWl!ALTII OF PENNSYLVANIA ~~I
COUNTY 011 CUMIIBRLANI>
1I0foro mo, tho Rogl~lol' fur Iho Pruhlllo of Willi IIl1d grunlhlg of Loltors uf Admlnlstrnllcnlnlll1d I' Of tho County of
Cumborlnnd, pOl'6lllllllly Cllmo~l.C' I R, 1l1.J,W' __
who, belna dilly .~ 4'" " ~\ , dll L' J dOlllliO IInd sllY thllllli r: 1-.." ~. \' ,I " v-
ol' tho'last WUlnnd TOSIIIIllOIII,IlL~, I" ~.I fZ, (LJ..J1 fI K. _dooellsod
~I f" will woll a/ld tfllly IIdmlnlilor Iho Ilolldslllld ohllltols, rights IInd oredlts of said deoea8ed acoordlng te law. And
IIlsc will dlllgonlly oomply wllh 1110 pl'ovlsloll8 of tho lawrolallng,l~ Trans for Inhefl~~noe8:.'~nnd 8ubsorlbed before me.
,,', "IYI LI (J;-i--:-::-:^'O" 19.LL /(~:--(//:i,~::t;;'.1j,
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.~{) , '0*7\~" (t~~ <, \ "
Register
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llIlCREE
110 It ro'mombored thnl on tho
7th dny of
"1ay
,^,0..19~, thero was probnted IInd
Inte of
I Cumberlalld Caunly, Pdnnsylvnl1ll1,
Paul R. Miller
reoorded the Inil will and Te~lamont of
John R, Olark
New Oumberland
OecoIl8ed.' loeltm Testamentary .wero grunled 10
Wlln08! Illy hand IInd offlolnl sonllho dllY lIndyollr, nrOrei(lld,
f;:no
.....' \,,~ /\,) \
V Y 0';l~1 '-:, ,d"\L\W-,tt
(r.fh.(.,I~Y\.o ~Vf\
RECAPJTULA TION
Apprulaud YuluoorpUl"Ronul proJlarty ",',',,,It'lIlt'''''lll,'"io..''''''tQ''llIj'otHltlOqqllll''''"l1 . 11I"1t,11~rJI9111
AppralHed Yl\lu,u of flint onuuo 111111"11 HIII'II"""."'li"" IHIIIIIIIl,HHlllIlIlIIIIII""l1'''llitl''ll . ~,~,\,1An't9IQ'it
Total apprutsnd vnlull "HIlII,' 111'1, 111.1 II .,.,1111; !'IIIIHII' II' 1111~111',1 I"'" "'I ,'....... t "1'1 1111111' III . )1?;\n,~~"l1~H'
AFFIDAVIT OF PERSONAL REPRESENTM'tVE
Counlyof ~I1llI' aal ,
,,9aw.I\.. ..M1l1e.v.. !llIil' II f i j I" I" II'" j ,. It I. 1'1 t . ,. 1"1' 1'1' ,. .., II, II 1,111" ,,I,' 'I IIII t f I; 11.t'11 j II" I'll II t 1111. 1ft II" 'I IIIIII
g~QCUI or
Mnll.odfdmt
or the gAln to ;qr.IH~III1~T,Olllfl:c.1t;."QLJ\RKIlII' IIlililllll'Iilllliu"!lltltitltlll!IIHllil lilli'll" "'
<locouRCHI, 6'ulllf{ duIY'"jjllllS.W.~,'U1.t\",jj,jjlj"I';llHII1l1I'''1I11111l1IltlHIII B9cofcHru:t to 1"wl'dopose 's'nd,aay tHat tho
Hem a appearing III Iho Illye!\(ory Ino111<10 nil III Iho pom>nAI,ansQla wherever nHuale and, all 01, t~e
ronl oatnlc',ln the COnlll\ollWOnllh or Pcnh8ylvanlli or 8ald dQt1utlonl\ Ihal'the yalllatlon placed appatlte
ondll\QIt1 a(aald Inyontory I'Cpl'OnOf!lM Ila (ah' VAlUe a,~ o( IhQ datQ a( ,Ihe dceedenl'n dealh I and that
decode,lIt oWl\Qrl ilo ronl Q81nto ollt81dQ thQ COl11l11ot\\vcnlth o( pel1nsylvanlA Q~cepl Ihal whloh appeara
111 n 1I10ll1nrlll1dllm nllhQ Ql1d n( the 1l1\'Ql1lory, /) " ,," 'I,
<1111l!llllIlillll!IUii,'IIIII"'"1l11 and fluhRcrJhed ~ ~"';'I,~J; d ,~~'. / /.
1 r 'I II dIP I"~ ""'I'J '1"(.~ ,:;"",,1..,"':" ,:',2'tofu .~.l"",,,,,,,,,,,,,,H,,
lC' ore' mcj 1I'jI','I..(I(HlIfI"..II"'''"!1I11. ay 0 au. WI;J art .ooutor. A.1UUIblIl .
"ltl!tlll~lltltlll'I'1l iliA, 0;, 19~~,
, ~r"
11111 .1. I". HI" "fu "'''''1''1'''"11
6 - /' r; . oE,' ~ , '
INSTRUCTIONS
,,,62.16,,J?1',ICI3,.o.nIMD.,,,F,m;,,t,,Ws;mt.h.. ",T~XAa,,7.pl18 '
An~i.aa
j, An Invllntory mU81 bd ntQd Within IhrQ8 monlha altar appolntmont of porsonal rOpr8lantatlva,
a, A otlPlllQntonlallnvonlnl'Y muol ho nlod wlWn thlrty,4II1'0 of dlsoovary of additional ..seI8,
8" A~dlllo\1al ohoolo moy tio nltnOh8d qs 10 potoonallY or r8Rlty,
., SoeArllnlB IV, I"ld\10101'!8. Acl 01 lUB,
p; ~: '~ i l!l J I~
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KNOW AU.. MUN llYTlIl!SI! 1'1UlSllN'I'S' Thill I, - .J~pAi>( ,A~,,,_(.:r(UI./;.'J.:..._.-.
of tho C1ly/:!'u'..n....r.wM\i'(~!:,dl/y,/k1',4....,.( ., ClIllnly lIf. ..'-''t/.'''/,1~:~'!/"'N;'''(,
IIlId Sllllcof f"ftALR".i:L--.,--- ._,..."".--" hchllfof RlIlllld IInd t!IKpmlng mind IIl1d,lIlclllury, dOlllllkc,
, publlfih IInd duclllrc Ihu fOIl\Jwlng III hc my \.AST \\III..L AND Tj1STAMENT, 11lIr,'hy 'lovlIklllg 1111 WIIIRby 010
1IlllllY limo horotuforc 1I\lIdo,
FIIlS'I': I dlrccl my l~x\lo\lll>r/I!,xoolllrlx, hcrolllllftor nllmud, III pllynll lilY fllnorl\1 oXPCnKOR, IIdl11ll1lKtrllllon
llXpOOKos 01 my, ,oKtllloo'llIclmllllg IlIhorllllllco IInd KIIOOUKKllIn IIIXUR, sllllu lIr [udorlll; whloh mllY he oOOIlSIOIlOd hy tho
PllsslIgo 01 or suocosslon 10 III1Y IlIlurosl III I11Y osllll\! ulldor Iho 10rlnK lIf Ih,ln IIIKlrllnlonl, IInd 1111 my jusl dobIS,
oKcoPUllg morlgngo 1I010K 1I00ufod hy morlgllgoR uroll relll,oR\lIIQ, '
STicaNDI All tho rOKI, 10KI\h10 nnd rOlllllllldor o[ my OKIIIIO, hlllh 1'0111 IInd porRlIlIlIl, of Whlllsouvor klnd,or
chllfllctor, IIl1d whoroROovor RIlUlllod, shllll ho ',Uvldo,! Inlo, ,,--.. f:., ".C,\lllll P"rlR, IInd I give, dovlKo lint! hU,\\IOlllh
0';0 slIch pllrt to enoh of Iho fOIlPWhlg.,.....f:{Ji"- ..w..peI'ROnR, III 'ho hlR/hol'R IIhsllllllc1y IInd lnlovcr;
The ~hllro Jlllny pmoo IIhovo nlllllud who nhllllllol RUI'vlve 1110 Rhnll ho dlvldod IImonlllhe olhor hOl\OOclllrlos IIl1mcd
IIbovo, In 0,\11111 KhUl'OR,
':l
,'I'f1I,81J:l herohy Ilppnhll__..l,;;z.w.,(H_.R"....t.V./~;;:d'i:;I.',,~-H......._-.nR RXOOIIIOl'lExoc\IIrlK of Ihlsmy
LAST WILLANP TES't'AMEN'I' und 1 dll'ccl thlll Bueh IwrRoll Rhllll ~orvo wlllwl\t hom\.
IN WITNESS WHmWOF, 1 hllvc hCI'Ollll\o licl my hllnd Ilnd BCIIIIII.w_.;;/e.H!-,-__1ilh{L.:dc:!?'~A/-(7L_,
this di1:,v .,.dIlY ol~__.__;-__,~__.__,..,~..,19___-",
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(sign hOl'il)n_j_tr.:hn--....L!l.--~--<-,~d, ,'..___~_,.~I"S,
(
Slgl\o(l, RCl\lo~l, pllbll~hcd ;iIld doclnrodto hc hlR/her LAS1~ WII"L ANI) TESTAMENT by tho within I\lImod
1'ostotor,ll\ iho rroNonoo oIUB, who 11\ hls/hol' pl'UROIIOO nud nl hl~/hilr ruquilsl, lIud III 'tho prcRcnee of oneh othor,
hllVo herounto sUbscrlbud ollr 1I1\IllCR IIIl wIIIlOR,CR:
(2)
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Clly Sin Ie
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INPORMA TION
Thla dooum.nl' la Ih. NoIIC. requlr.d IC b. glv.n under S.cllon 709 of th. Illh.rll.nc. .nd SII.I. T.. Acl
of 1981 172 P,S. uollon 2486), ,',
If th. ta. II p.ld wllhln Ihrtl (31 month I Ifler Ihe dec.d.nl'l delth, . dlloount of 611 of Ih. I.. p.ld II .1I0w.d,
Inherll.no. Ta. beoomu d.llnquanl nine (9) monlhl .fI.r Ille d.o.dent'l dtlllh, Inlereat la ohargedtl Ih.
ral. of al.(6), parc.nl p.r Innum on Ihe .mounl of unp.ld I... (SSE EXAMPLE BELOWI
EXAMPLE: If. b.l.no. of I.. due of .2,000,00 la In . d.llnqu.nl IIlluI from 3-3-80, .nd p.ym.nl II m.d.
on 6-23-80, Ihllnlereatll o.loul.l.d II Indlo'l.d b.low: ' ' ,
,
"
Intereal from 3-30-eO 10 6- 23-80
Reaulll In:
2 Monlhl . ,010
20 Cl'YI . .:L...Cl.O.3.3.e.
R.I. of. Int.rut . .'lIT331l
B.I.nol of la. due
Rite of Inter81t
, INTEREST
.2,000.00
. ,01331\
. 28,70
STeP 3
Add th. Inler.1I
10 the b.I.noe of
II. du.,
BII.no. of II. dUI $2,000,00
PIUI Intereal 10
:.....QAt. of P.vm.ol (+) . 26.70
'I'OTAL I.. .na
Inl.reat to 0.1.
of P.ym.nt $2,026,10
STlP 1
, Cet.rmlne the r.le of
, Inler.al from Ih. I.bl. b.low.
STBP 2
Mulllply Ihe b.llno. of
I.. duo by Ihe r.l. of
Intereal,
----.-----------------------------------------------------------------
1 monlh .0011 4 month. .020 7 montha ,,0311 10 monthl ,0110
2 monthl .010 6 monlll. ,0211 8 month I ,040 11 monthl ,01111
3 month I .0111 8 monlhl ,030 9 monlhl ,046 12 mOnlhl ,080
1 day ,00017 1" daYI ,001S8 2 1 dlya ,003112
2 d'YI .00034 1 2 d'YI ,00203 22 d.ya ,00389 '
3 d'YI ,000111 13 d'YI .00220 23 dlYI ,00388
4 dlYI ,0008B 1 4 d'YI ,00237 24 dlYI .00403
II daya ,00086 111 dlY' .00260 26 dlYI ,00420
6 daYI ,00101 18 day I ,00267 26 daya ' ,00437
7 d.ya ,00118 1 7 d'YI .00284 27 dlya ,004114
8 d.ya .00136 18 d'YI ,00301 28 daYI .00471
9 d.ya ,001112 19 daYI ,00318 29 daYI ,.00488
10 dlVl ' ,,00189 ' 20 dlYI ,00336 30 daYI ,001100
------------~-----------------------~--------------------------------
Any parly In Int.real, Including, Ih. Commonweallh and Ihe 'perlon.1 repr.untallve, nOI utllfl.d wllh th.
appr.lum.nt and au.umenl mlV obj.CI wllhln 11.ly (801 daYI afl.r r,o'IPI of Ihll NoIIO. II provld.d by
8.01l0nl 001 of Ih. Inh.rll.nc. and Ea'lle re. Ao' of 1961 (12 P,8, UC, 2486 - 1001).
MAl<I CHBCK CR MONBV OROBR PAYABLB TOI "RIQ1STell OP W1LLS, AQINT"
,. ..... . F
DETACH THE TOP PORTION OP THIS PORM ANO SUBMIT WITH YOUR PAYMENT TO THE REOISTEROP WILLS POR
THE COUNTY SHOWN ON THE REVERSE, SEE THE INHERITANCE TAX INSTRUCTION !lOOK POR ADDRESS,
j ,. .
!tUV.lfiOO [:)( I (0.81) ,
PURnAU OP eXAMINATION
P~NN9V~VANIA PSPARTMSNT ap ReveNue
P,O, pax 8321
UARRlBPURe, PA 1710e
.
Oooodonl'l Nomo (to t, Flnl, and "lUldlo 111111011
DBCEASBD -.CJ,(lc.\{~ J1_,-__~-,-
SoololSoourltyNumhor Dolo 01 Ooolh .
___ Ji5..:.&!e.ll~.,.;.- 5.: 05 ~ ~ \ _
CHBCK " 0,101001 Roturn II 2, SUPlllornootol Ilolurn 0
APPRO,
PRIATE
BlocKS
____0
II ~ ,24'( - ~,)
INHeRITANOB TAX RBTURN
RBSIOBNT DeoeOENT
Plio Numbor ~\,' 'lll- D~:t~
. Oooolloot'l Alldroll
4'~ ~I'~+\'\ &. '
t\,Lt uJ (ILL ~ bu 'ci.rH~ , ,P A
1'1-0 '1-0
3, Romolndor Iloturn 0
4, llfo Bltoto D '6, Fodorol Blllto ToM 0
Roluro Roqulrod,
0, Oooollont dlod tOltOlo 7, Oooodont mollllolnod ollvlog 0 U, Nllmbor of IOfo dopoalt 0" .
IAttooh oop of Willi truit IMooh oopy 01 trultl ' , bOMollovontorlod
All ccrrolpolldonco ood oOnfldonllol toM loformilloo Ihould ho dlrootodlo:
CORRE,
SPONDENT Nom\.J _","",\
~ QIJ::)
Tolophone No, .
=
1.
2.
3,
4,
6,
REOAPIT, 0,
UlATION 7,
0,
AND O.
TAX 10,
11.
12,
CAlCU, U.
lATION 14.
f.\. Ii) LL~~\ i:. I
'we.t.+
. 1\ I
Stoto
21
ROcopltulollon
Rool 611010 ISohedulo AI ' ,
Stookl 0011 BondI (Schedule B)
OIololy Hold Btock/Ponnorlhlp lotoroll (Schodulo 01
Mortgogol 0011 Notol (Schodulo 01
COlh & Mlloo)\onuoul POrlonolPropur\V ISchodulo E)
Jointly Owood ProportV (Scho~ule FI
Traolloll (Schodulo 01 .
rutol Groll Alletahotol IInol 1-71
Fuuum!. EMpOOIOI Admlnlltrotlvo COlta/Mlloolloneoul
EMponlol (Sehodulo HI
Oollta/Mongogol/llool (Sohodule II
lotol Doduotlonl hotolllnolO & 101
Net Voluo 01 Ellolo (1100 B mlnulllne 111
'Chorltoblo BoquoltalOchodulo JI
Not Value Iubloot to 10M (1100,12 mlmnllno 131 ,
(11 \ 2l';JtDO,OlJ
( 2)
I 31
( 41
161 lPt.t.~~
(6)__
( 71
( SI-19~-
( 01
(101
(111 \~\1 "&15.!5~
(121 ?'o'.~l
(13)
\141 .~[}'"1. U, I
Computatloo of TOM
M,OO-
\~,L\lD
(161~J
16, Amounl of IIno 14 tmblo ot 0% toto
lIncludo voluol from Sohodulo'X)
18, Amount of IIno 14 10Koblo 0116% ralo
lIoelude voluol from SChodula XI
17, i'rlnclpal taM duo (add 10M from 110010 plul ta~ from IIno 10)
18, Tolali'rlor paymoo,,1
,(01 AmollOt Pold ,
(bl PIUIOllcouot
(el Mlnullnleioll
19, Rolooco DUO lIlne 17 I1110ullloo 10)
Moke Chook Payoblo tOl, Roglnor of WillI, Agont
I I I PLEASBRECHBCK MATH II I
(101
M,10-
(111
\~A~
(10).
(18)
- - .......--
Uodorpouolllol ofpurlul'{, I d6ol~ro thaI I I!ovooxomlnod thll rrturn,lncludlng oecomllonylng IOhodulCI and Itatomen", ood to tho bOil or ,ny knowlodgo
and bollol, It I,IUUO, oorroc lid complolo. Oaololollon of "tuporer othor than tho pOlloool ruprolonlollvo llholod 011 allloformollon of which proparor hOI
anVknowloduo:
ADDRUSS
OATS
SIGNATURD OF pnErAREn OTHER THAN AEPRSSENTATIVS
AODRESS
DATE
"
QUESTIONS CONCERNINO PROPERTV TRANSF~Rj
L Old docodel1t, wllhlnlwo, yomsaf doalh, make allY trallstor of allY molarlalpmt af his osloto wllhout rooalvlOR
voluabla ondadonllotu consideration? (Answor "Vos" or IINa',I,) NO , .
2, Old dacodont, wl(llln,tlVOYoors ofclllolh, trollsfor proporly from I1lmselrlll'orself lolllmsolrlharsolf and onolher parly
or portlos (lncllldlnRo spause) In/oint oWllorshlp? (AIl~wor "V os" ar "Na",) ,..1lI.O-' .
3. If Iho lUJSWor 10 Olle or two ooovo,ls IIVOS" olld Iho trOllsfors mo clalmod to bo rlllntaxablol pravl~,o lho followlnR
Information: '
a, Ago of ~ocodont al Ilrn,e of transfor,
b, Copy of doath certlflcale, , , '
c, Artldavlt bylheallfindlng physlclon Indicating Iho slato of docodalll's health 01 tlmo of trallsfor. '
d, All olhor Infor/natlon supporllng nontaxabllllyoflransfor,
4, ,OlddO,oOc,lont,lnhIS,/horllfellm,e,makfi any transto,r ofproporly without r,o celvlng a valllablo or adequata consideration
therefor l'Ihlchwas 10 tOkeeffoctln,possesslon or onjoymont at oraHor hls/hor death? (Answor "Vas" or "No!!,)', NO
a. wo Wore any posslbl/lly'lhol Ihe proporty lransfarrodmlght rolurn to transferor orhls/hor ,eslale or be subjecl
to ,his/her powor of dlspODIlIo!l? (Answor uVes" or "No",) . ,
b, Whatwas tholransforoo1s aRO 01 tlmo ofclocodent's death?
6, Old deoedont In hls/hor IIfollrl1e mal<e any transfer wllhout receiving a valuoble and adaqunle consideration therefor
IInder wlHch Ironsforor expressly or ImpliedlY rosorves (or hls/hor Ilfo or any period which doos In foci end before his/her
death:
, ,a, The possossloll or, onjoyment of or the rlRhlto Income from the proporty transferrod? (Answer liVes" or IINo" ,) NO
b, TharlghllodeslRnate tHe persons who shall pos$pss or onJoy Iho proporty transferrod or Incomo therefrom?
(Answer "Vos"ofIlNo",), NO .
6, Hthe ans~er to five b, orovels "Ves," slato wholh'er the rlRhl was reserved In deoedelll alono or others;
7, O'lddocodent Ihhls/hor lifetime moko ,i1 tranSfor, tlfe consideration for wlilch was lransleree's promise 10 pay Income
to or for Iho benetll or oore of,transferor? (Answer "Yes" or "No",)' 'Nn
8, Old decadent, atony time, ,transfer proporly, Ihe bmeflclalenjoymenl of which was subJocllo ohange, bocause of
a reservOd power 10 altor, omend,or. revoko, or which could revert 10 deoedent IInderterms of transfer or byoporallon of
law? (Answer ,I.yes" or "No" ,) . Nn
9, I,f Iho answer toeiRhl a~ove Is I.yas," was the power 10 aller, OInend,orrovOkothe Intorest of the 'bonetlclllly reserved
In the decodent, alonoor the dooodent and othors? (Answor "Ves" or "No",) ,
j,)
"
"
"UV,41~ I:X. 13.1101
OOMMaNW8A~TH ap P8NNSV~VANIA
DBPARTM8NT ap R8V8NU8
TRAN8P8R INH8RITAN08,TAX
R881DBNT DBCBDINT
SOHEDULE "0"
B&NeFIOIARleS
*'
(/II,truer/Oll' all Rover,s S/dul
estate af
JOI.IN I~. CtlARK
BeNBFIOIA.RI~S ANDADDReSSBS '.' ReLATIONSHIP SUIWIVSD , DATE OF INTERP.8T OF BEf)lEFICIARV
. D&OeDENT BIRTH
II Puul R. Mlltal' s~oP-8Q1L_.~ YOR , ~l:- 25%
- 6216 Pl'loo Dl'lva -
lI'Ol'l Worth 'l'oxns 76118 --
" , ,
, "
, YOR' 2511.
2 Paulette .Teun' Collin.. 8t,ent,uulll1lOI' 8-9-
" ,
'24 Stillwell Dt'lva (g~~d a V N.1....Q.Q ,
Dalevl1le, Aldbamu 31> 32 2 Hox 702
APO, N.V; 09039 , ,
I .. 25%
3. Bat'I'V Deun MilloI' sten-son Yea , . .12~B~4B
Not'thwoocl Munot'. Lot 32
'RD 1/1 Yn,'le J'lnvan Pn: 1737 ) - - ,-
,
--, .._---..~_.... ......-..-. ---;------.-.......-.._.- -,-~---~.....---..-. -_..------ --.-----------..
4. Kuthleen Marie Clal'k daullhto!;... Yea 10- 30~55 25%
261~m N ,AI''' Ave -
Harrllilbul'a. Pat 1'(109 ,
" ,.- -----...-
- -
, ,
, "
! --
,
- - --...,-.--.----..-.----. ..........- ..,.. --- --- 0--
, ,
,
_.-- .. , - ......._--.,.._---..,...-.~------......~- ...._..._--..-.~- ---.,-- ..-_.._--....- -~.,~~"'._-_._.-'_.._..._---~-
"
- - ,
. .
,
, -
:': ,
,-, - - ~-
, . , ,
. ~
, ,
.,
.- .
..
- -
. I.
-
The 8bQve beneflcllrles Ire IIvlno at this-time exoept for the followlngl
,
NAME
DATeop DeATH
\
,I
\
, ,
,
ii'
I
I
I
,
I
I
I
I
" \,
,
1
lliURUCTIONS FOR OOMPI.ET~G 80HE\)UI.E "E"
. SohodulolE" mllst Inolude all'!lrOpOrW, .roal und \leraonal, ownod hy tlia deoodentlQlntlywlth onather,
\l,orty ar \loftles oa Ipllll tenants with floht of survivorship, Botl1,\onolblo ondlntonglblo proPllrty ore tobo' .
Inoludod, ~Ist real oatettl 11m, .
1", 'Qosorlbe 011 rool prqporly 8R Indloetoc! In tho'll1struotlons for Sohedulo "A," Ooaorlbeoll personolpraporty
aslndlooted In tl10 Instruotlona for SohedLlle"a'," ,Inolude the nome, address ond'felatlonshlp ta tho
deoadonl of\haoQ~ownorI81 und the date theloln\ ownership w,Qsostabllshed, '
2. Indloete the to(ol market valuQof'the jointly owned property,
3. I'ndloete the peroentage af tho deoec,lont's Intorost.
4, Indloete the !narket valuo oltha deos(tent's Interest,
!:: :0 ,~ 8 6 ~ e; ~
z ~ z z
~ ~ t:;l I
~ ~ p !5
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!5 p Vl
Z 0 Vl $
p ....,
l:l
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,."
QENERAL INHERITANCE TAX IHFORMATION
Unlatllflod Ilabllltlollncurred by the decedent prlar to his/her death ara deductlbla against his/her taxahle
estate. In addition to debtl Incurred by the decedent or eltate, ather Items aro clallnabl,~ Including Ihe COlt 01
admlnlltratlon,attorney fee" Ilduclary feel, luneral and burial oxpenaOI Including tho COlt of (I burial lot, tomb,stone
or grave markor and ather,relatod buriol eXpenlOI.
All debh being clalilled agalnlt an oltato alo aubloct.to tho approval of .tho Register of Willi with whom the
Inhorltanqe Tax Roturn 1lllIod. Evldenco to support the decodent's or tho natato's, liability lor the dobtl being
clelmod should be ettachod to thll Ichodule.
A family oxemptlon may bo claimed by 0 IpaulO 01 a docadent who dlod domiciled In Pennlylvanla. ,If there 15
no IpOUle, or II the IpOUIO haslor/olted hla/hor rights, then any child 01 tho decedont who II a member 01 the sarno
houlehold can claim theexemptlen. In the avent thore II no luch spouse or child, the eXllmpllen can be,clalmod by
a parent or perentl whe arememberl 01 tbe lame heulahold as the decedent. The lamlly exemption la allowoble only
agalnlt anetl whlcb pau bY' e will or by the Pennsylvanlalntoatate Laws~ '
NOTEI Componsatlon paid to an estate reprOlentutlve/ homely, an"executor or ad'lllnlstrator, lor servlcOl
per/ormed Inadmlnlsterlngqn ntatels reportable for Pennsylvania Income Tax purposos. Thlltaxable Incol\1e
Itel\1 Ihould be reported on 16rm PA.40.lndlvlduallncome Tax Return.
~ ~ ~ 8 ~ ~ z i ~ ~
~ ~ t:I
Z ~ ;;j p ,
p Z
P , 0
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(") Zit '-I
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11<'" r' Q.
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INSTRUCTIONS FOR COMPLETING SCl:lEDU~"
1., Utho lamlly exemption II being claimed, Indicate the clalmant1s name, ,address and his/her r~latlonshlp to
tho decodent. Enter "family exemption" In thoromarks calumn and the amaunt claimed In the amount column.
2. ~ulgnconsecutl...e numbers to each Item listed.
3. Enlor the date, on which each 'debt was Incurred and/or paid.
4. Enter the namu of each payee. '
S.P'rovlde b briel explanqtlon ,In the fen'arks ,column lor each debt claimed.
6. Enter the amount of each debt being claimed. "
7. Tho lorm must boslgned by the porson who has euumod the responsibility lor paying tho debts,
IF ADDITIONAL SPACE IS ~ECESSARY USE BW' x 11" SHEETS,