HomeMy WebLinkAbout81-00326
:.l26
No, 21-81
PETITION FOR PROBATEdF WILL "NO Le1'TERS TESTAMENTARY
In Iho ~olalo 01 ~~J\l1ZUlILL.JJhoPwlL1L
,~.,,"m~,,___'ri~_.1 deoeaeod,
To Roglolat 01 Wille fot tl10 Oounly 01 Oumborlancl, In tl10 Oommonwoalth bl Pennsylvania, '
. and Codicil
Petltlonor(s) Ya/(aro) tho oxoollt ,r.j,~l;lfJ.,...,. namqd In tho Lasl Will and tootamont pL'_______
^n~ula 1.. Shopwel1 -n 2/1 1971
_'_m~~~m._.~~__.m~.""~-"'U_"-~""~~""" c1ated "fI I!L"'.........=--......""
Deoedent wase oltlllln 01 the United Btates and a roeldont 01 ..uNJil.W.\!.i1L.L
TP/NN~lpAaotollgI1L OL,unbarlandCounty, Oommonwealth 01 Ponnoylvanla.
Deoedent died, on 'ri..u~Ol.l(.!~L_.n__"...m. tllo_J:}'Ul~" day of..._J:lE2'-...'..-..-~. A.D. 19~, In,\he
County of _~cumbBr.1alld._~-'-H,u,-~-,"_._.,ul State of l.'e.nl1a~.l\t1.lU h~tho 'ago of '76 years,
Deoedent has (~tnP,., been married and ~rta/(ha8 not) had 9hlldren born to M!v (her) slnoe the ex.
eoutlon 01 the above de,sor,lbed WilL , Untlotl.mnCed
Deoedent was possessed 01 personal property 10 the valuo of .~,,_..-.......:....-_.
and ,of real estate 10 the value of ~_m Ur1.5':.'.I.l:;~n~~,~:::~_"~_""___ri
--,
as near as oan be asoertalned; said teal aslata situated !IS follOWB-. 36 NDl1Jh High Street I
Nowvit1e, Penna,
+...-...~..............__~...~.._,...j.~_';__~"'"_______'~~-"""-'-"~---<-~-_."'-_.~'__T-+
Thet\llore, your petltlooer(s) respeotfully apply(lee) for the ptobate of the said Last Will and Tes\a.
meo\, and for Letters Testamentary theroo,
Dated ~..___) ~~!<-;-__7:._?< .___1....19 8 ~_.___---cuu__
Na~~l~eat'~t~o~~~~lss u~A ~f~~fn ii~~ :~:tgi~~ ~ 7BOX
-.... -~~.-~_._---_. '
l.L4
'.-;lit~tta?-1Jawt ~q"'lfJtN~IT..,t.l-gtrl c" ,
_JilOl.\'!'ygJ~:,- Pa, ,1.72(+1
OOMMONWgALTH OF pgNNSYLVANIA )
~ S8 -
COUNTY OF.OUMBgRLAND I
._.~c_,_.,...__,. AuaMa YmSt; iD.liUl!lct.At.hfl...M.gY._J)f,!y.tg!l.~._~__._ .
,
named In above' ap~lIoallon, being duly -c,,~~p.:r..Q.~-- aooordlng to law say(s) that tha
. ~talemonl~ epl forth In thl~ petlllon ara true to tho best oL.tl18 ir ," know!edgeandballaf,
Swor!' and sUbsorlbed boforo"
me'", ?t(<.t.'j 'j..V 1981.
";0) , / ,. "._~~~.~_."., '''"" '" 1
v/J1?Uyj" ,(d · ., . t~-
f(~ c)I ~eglBter
__. __.._,~ _....,. ~ ...._..__~__"'~_~~-'-~.,.....c_,...--.,
-.-------------~,---~....~-_.~....."'--~,,..--.-.-,.-~~~++---+...~.-.;.......,,.-
- ',.1. " ' j'/' '
,{...~cJ(c:(.'C,'Z'I( ('a';..'Y...'L~:J.~
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\~~o
Fllml:;.,a)! 26
I 1981
/-', ,,In'' .'.
'" U!_;(.;e<<.:.->n.rtt.~a;ri'-..~,,-__._----
Allorney Henry L. St'uart C1lP
~
0'\1'11 0.' Illm!l()NAI, IU:I'RI':"mN'l'ATIVI~
COMMONWl1AI..Tl1 OF I'BNNHYLVANIA 5S1
COUNTY OF CUMIIBRLANI)
noforo mo, Iho Royls\ol' fpr tho f'rohlllo III Wills ulld ytlllulny Ill' Lol1ol's of AdlTlllllslrllllonIn IlIld fot tho COllntyof
CUllthorland, Ilorsllillllly ollmo__j"l/1 May ~H 11(' and l\l'h!! May Dl1ytrm
I.....
..
who, bolnll dllly....JllqDrn
, do
_doposo IInd sny thnlns IIKecl u t d,() (~H
An"1l1n l,,-1lhopwe]]
deoellSed
of tho Inst WlIIand Tostnmonl of
they
wlll'wollnnd tl'\lly ndmlnlslor lho yoods nlid o!lnllols, tlyhts und ol'odltsof slIld decensed ucoordlnll to laW, And
.8\</01:1\
und subsorlbed bofore me,
also will dlllllenily oomply with Ihe provlslonsllf the IIIw rollltlng to Trunsfor Inherltnnoes,
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Dc II remombored Ihllt on the
26thdlly,or
Itnz111a L.
O.:CREE
May
recorded Ihe Insl WlIllIlld Tcstnl11enl of
Fihopwell.
,A,O,,19..1ll-, there Wils probftted .l\nd
Inte of
N"wv~llQ .
Testamentary
Decenscd, Lollol'S wcro grunled to A dl1
Wltlless illY hllnqnlld clfflellll senllho dnY IInd yont IIfor08nld,
.685
,
, CllmberlnndCOllnlY, Pennsylvllnla,
May Sti.l1O n~ Atllt\, MaY Da?'t:on
2,9;~4< c? Jf1~~
( "t/ ',.' . Register
IIttV.! noo E)i'" 10.611
, nUf'RIIU Of RKAMINATION
nRNNRVLVANIA oBPAnTMbNTOF RbVBNUB
n.o, SOK B327
HIIRRIBPUllll, nil 11100
~. r
no~on"1 NaOlo llall, rlrl}.l.and Mlddlu Inltlall OonodulIl'l Addroll
h().O l.ll L\\ tln~,.o...........L' 'O\oN, \-I (ll<~ &u-l-
DEOEASEO Bnnlal sooui\"i'VlIiImiiar1- . 0010 or Oootli ..I p
"___'_ _LilS:..Q..C\:-*!5~___ D~=J \.~ I I N~v (Jl!J~~ ,"~4 (
CUEOK " Orlolnol Roturn [i] 2, SUllplohlOntol Roturn 0 3, Romolndor Roturn 0
APPRo,
PRIATE 4, LIfo Eltato I ,I 0, rodoral ellolo Tox 0 '
AOlurn Roqulrod,
SLOCKS 6, Oooodonldlod tollato rv1 7, OooOdonl malntalnod IIIYlng 0 S, Number of IOfo dopollt 0
.____ (Attaoh QOPV of WIlli bQj troll (Allooh OOIIY 01 IrIlld . bOXBllnYentorlod
All onrnilpondonoo ond oO,lfldontlaltoxlnlormollon Ihould bo dlroolod tol
:~::i;T :!~~ L. ~~~L ._]~~4~~t~,~~
1/ ....Q.:;itl .._(/
INHERITANOIl TAX RIlTURN
RESIDIlNT DIlOIlDIlNT
Plio Numllor
~\.'6'I~~BL_
ZIII
Aooep1tulatlon
CALCU,
lATION
1, Rool ElIoto (60110dulo A)
2, Slockl and SOlidI (SchudUlo S)
3, OIOlolV Held StocklPertnmhlp Intoroll (Schodulo 0)
'4" MortOIOBl ond Notol (Sc!ledulo 0)
6, Co,h & Milcollonooul Porloool Proporty (Sobodulo E)
61 Jolntlv Ownod Proportv (Sohodulo FI '
'7, nonlfon (Schodulo al
B, Tolararoll AllOll (totol IInol \071 '
B, 'Fuoorol ~XPO",OI AdmlnlltrotlyO OoltllMllcollonoool
ExpoOlOl (Sohodlllo HI '
10, OobtllMortgeg"ILlonl (Sohodlllo II
11, TotolOoduotlonl hOlelll0Q19 & 101
12, NOI Valuo of ElIete Wno B mlnulllne ,t II
13, oharltablo BoquoltG (Schodule J)
14. Not ValllOlubJact 10 lax IIIno 12 mlnllllll\o 13),
( '1_\1.4.9.o..o~~-
UI' " ' _
( 3)
( 4)
161~':5I~itl$t\'i$
I 61:":'--9,t)~O .00
( 71 '
( BI _/.olD1 Y.t1]J <a
, nECAPIT.
ULATION
AND
'"TAX,
( 01
(lQ)
ml-~~'n\6:~it
(131
(14) EI,D 150. QA.
CDmputatlon ofT',H '
'16, Amounl of IIno 14 Imblo at 0% rala
(lnoluda v.hlal from Schodulo K)
lB,' Amount cfllno"14 Imblo at 16% rate
(lncludo value, from Sohedulo KI
17, Principal ta,H duo (odd tox from IIno 1,6 plul tax !fom IIno 16)
lB, Total.PrloY ~aVmOntll
(a) Amount Paid
(b) Plul DIloollnt
, (cl Mlnllllnlorall
10, ' Balanco DIIIl Ulna 17mlnlllllno lBI
Mako Chock Pavable tOI Roglltor of WillI, Agenl
· .. P~BASB REOHBOK MATH · · ·
(16)
(lB) .!ilr-D !)D .~
X,OO.
x.16.-3/~ S']. Lt.~
1171 f I lD 5'liD ,.;1..
(lB)
"
. (101
"
-U~~r 1I01;altlol of norJllry, Idoolaro tblt I hoyO oxamlnodthll roturn~lncllldln~-acodmponVlng lchodlllal and ,Ilotomontl, ond'ta tho bUll of my kl1owlodgo
and bollol, It lltruo, orrant, undcOmlllo\D. Doclarallon of proparer othor thon tho pononal,roprolOnlallYo II bOlod 011 olllnlnrmatlon of whloh proparor hal
any knowlodgo, " '"
TATlvslSI
'Aopne~8
OATe
BIONI\'l'uriiiof. PRUPARSA OTHan THAN RsnnssaNTIITlva~
'''"---.
,
WitfiYJ..v.N:Ul\.ltlliJillll~JAX GEN.gRAL INFORMATIO~
1. SO S spa S aLE FOR RETU N
Soctlon 701 of tho Inhorltonco And Estotn Tax Aotol 1961 provl<!ns that the lollowlngpersoris sholl proparo and fila
a rolurn: " ' ( ,,', , " ' ";'I,{ " . ' ,',
n, Tho porsonnl,ropteaontstlve of tho oslote 01 tho lIo,6edent 08 to proporty of t1.1o,,<ieoodont udmlnlslored'by him
and such additional property which Is or may bo subject to Inherltanoe :fax of which hebhe shdll, have or
acqulro knowlodgo: ' . .' " \1,;
b,Tho transloroootpr,opo!\y upon thotrnnslor 01 whlohlnhorltonce Tnx Is or mny bo Imposed by the 1961Statulo,
Includlngatrustooof'proporly transforrod In trusl, provldod that no soparoto roturn neod be mode by.lhe Ironsferee
" 01 property Included In lho return of,n porsonol rOlllosontntlvo, , "
2, PLACE FOR FILING
Tho return 'Is to be fllod ,ll1l1upll rlntowllh the Roglslor of, Wills of tho cqunly wherein tho decedent resided,
3, TIME FOR FILI~g
Tho return Is duo nlnol"qtl~IS pflorll)odecedont's deolh, unloss an extonslon lor IIllng hns beon applied for and
gran tod by tho Socretory'olRbvehil,ewjthln tho nlno-l1Ionlh porlod, ' ,;" i '.',' ,
4, EA!J:.\illlUo FILE RETURN " ' " ; , ',," ''.
.! .. ~ ' ,
Section 791 onho 19618101u1o provldosthat I', "any person Who wllllully lolls to 1I10'orelurn or other report
requlrod of him, I ,sholl bb personallY liable.' , ,10 a'penolty 01 25%01 {he iax;uIHmolelyfOunft:lo1be'(Jue or $1,000 ..
whichever Is 1110 losser to bo rocovered by the Departmont of Rovenue os dobts 01 like amounl are recoverable by
low,.": , .,
1"
5, JAX RATES
,
Inheritance tax Is payablont 1I)!l rate of,6% on tronsf.ors 10 lineal descendon\~, ~uQh as lather.1110ther, husband, wife,
son, daURhler, Rrandchlldren, Rrandparent; son.ln.lawend douwllor.ln.law and at thb ram of 15%a~ to all olhars, ,
6,~ 1,,;'.""'\"
Tho lox assessed qh Ihetransfar bf~r~perIY reportod In 1I1O'return Is due 9 monlhs after the 'd~Q~aaht's deoll1, Inlerest
at tho rale 01 6% per annum accrues theroafter until peymentlsmedo, All pnYlIlentsreoolved are flrsl applied to any
Interest whlchmaybo due with any remalnqer applied to the tax, !FTAX IS PAID Wll'HIN 3 MONTHS AFTER THE
DECEDENT'S D~ATH, A,PISCOUNT Of' 5% OF THE TAX PAYMENT IS ALLOWED, " '
All chocks shOllJd be made payable 10 tile Reglstor 01 Wills 01 tl1acounly wl1ereln Iho.decedonl resldeci'andate
recelvod subject to the final determination 01 tile Department 01 Revenue,
7, FAILURE TO PAY
The tox.as Imposod; togother with miylntorost thoreon, oro a lion upon real proporty, whlch'Uen .remains In effootunUI
tho lo~os and Into.ro~1 hovebeonpalllln,JulI.;..TM taxo~m,nyb~ sued for aR~ln~\MY r~l\1 proportyln"tn~qecMen.t!:~
eslate,or ogalnsLany,property belOt1RlilR to 0 transferee liable for tho lax, ,,,.,,
8, FILlN GO F: FALSE RETURN
, AnYllerson who wlllfullYil1a~es a false return or repottrequlred 01 hl111 shail,lt1acc'ordance with Secllon,793 of the
1961810tuto; be guilty of a nilsdeineanorond, 00 convlctlonthoreol, shilll bl! sentonced to pay a line not eXceeding
$1,000 or undergollnprlsonmCflt not exceodlnR one year or both, '
tmll: COnUlOIlSatlon paid to an oslo Ie rOllrosonlotlvo;lwn\ely, on oxoculor or mhnlnlstrnlor, for services perlonl1ed
I,ll arlinlnlsterlng on eslntelsrollortable for Pennsylvania Incoll1e Tax purpo~os, This taxable InCollle,JtelO'shouldbe
lepotled on lorm P A'40.lndlvlduallncolllo TnxRoturn,
,
'fill'
QUESTIONS CONCERNING PRO~ERTY TMNSFERS
,~' ,~~~~~Icee~~~tia~J~I~~1~:lr~~I~r~tl~~oiIIlIA~:'Ga:~ran~J~~P~~ofiN~~I~r "w~rlal parI 01 hl~ ostllta wUhal,'1 rocol~lnR
2" Old decedenl, within two yoars'of doath, tronsfor properly from hlmsolf! horsolf 10 hlnl,sol(/he'rsolfancfanolher'parlY
or parties (Inoludlng a spouse) In joint ownership? (Answer IiYils" or IiNoli.).!~ '
3, If the answar to one or two above Is "Yos" and Ihe transfers are clalmod to bo nontaxablo, provide thofollowlnR
Information: .
a, Age of dooedent at time of transfer, ~..~
b. Copy of death cortlfloate, , " ' ,
0, AffidaVit by the attending physician Indloatlnn tho state ofdecedent's,hoalthnttlme of transfer,
d, All othe; Information slipportlnA nontaxablllty of tronsfor, ' ,
4, Old deoedent, In his/her Ilfotlmo, mako any transfor of proportywltholll rocelvlng a valuablo or ntleCiuate conslderatl&'!
thorofor which wes 10 take ortllctln possession or on/oymont at or afler his/her death? (Answer IiYes" or "No'!..)" 0
a, Was there any Posslbllltv thetlho property transferred llilglit rolUIn 10 lmnsfarar or hls/hor ostale or be subject
to his/her powor of disposition? (Answer "Yes" or IiNa",) ~~~ .
, ......
b,What was thetronsferee's age at lime of decodent's death? ' ", I'
6. DI.ddecedent In hls/herllfellnlo make any transfor wlll10ut receiving a valuable and adequate consideration Iherefor.;
under Wlllch transleror expressly or Impliedly reservos lor his/her life or nny porlod which does In fact end, before hls/het
death: . . ,. . , '
0, Tha posseRslon or onjaymolltof'or tho right to IncarnefronHhe Ilroporty transferred? (Ans\Vor "Yos" or "No" i) No
ib, The rlgnlto deSignate the persons who ,shall possess arenloy the propertytranslerred Ot Income therofrom?
(Answer lIYes" or lINo",) No. "
6. ',If theonswor 10 flvo b, above I~ I,fYes," wns tho rlghl 'reserved In,docQdenl nlono (.) or decedent and oihers ( ).
7, Old deOedqhtln his/her l!follrne mako a trens/er, the consideration lor which was.!rensfotoo's promise to pay Income i
to or fer ,tho bonefll'or core 01 tronsforor? (Answor "Yos" or lINo".) bin ,,'
8. ,Old deceden.!, ot any tlmo, {ransler properly, Ihe, baleflclal enJoymont 01 Which Was sublectta change/becellsoof
,. 0 reserved power to alter, amentf, 'or revoke, or which cotlld reverllo decedont under terms a/transler or by operation 01
law? (Answer "Yes" or "No".) "ijo '. .
,
9, ,If theonswer to olght ebovels lIY~s," was tho power to alter, amend or revoke thelntoresl aflhe benoflclary'reseryed
In the decedentolane ( ) ordecedontandolhors ( ), '
SCHEPULll "Ii"
JOINTLV OWNeD pnOPEATV
fWV'4d4 Ul<' 13'011
COMMONweAL TH OP peNIHYL VANIA
DQPARTMSNT OF ReveNUQ
TRANSFeR INHeRITANCQ TA)( ,
RUIDeNT PscSDeNT
IImtrllOrlcJl/8 (1/1 RIIVllrllI Slcll')
Sstato 0 f
~nllul11 L , SlJ.gpwe 11
~ .......-.-~-,..~.~
n.:':t=g:~:;..;;..;;,~,""~':.,,,'i. _
-_c:,.;,,-';-;:;~~:C:~~';'.-.,;.';;'Z.~~'~I.......~;~=.;or,;......--'_."'- .:_.,','i__"--- - -
ITaM
NO.
DBSCRIPTION
_~. '_'_::;::<~_~_~''''''''''' =~=, ~_,~_.~"..~,,:...",,-,~ ~- . ~.,o;'~~'J. 1-i""-~="4',~r
Sedee H Bonds
1. Deoedent or Mrs. Oors B. Hanc ck
1000 Ml1407846H issued Apr 19 0
1000'M40522594H issued Dee 19 5
, (May 1971)
1000 Ml1698227H issued Oot 19 1
2" Decedent or Benjamin J . Barkl w
1000 M40522iSSH issued Jul ~9 2
1000 M40S22!17H issued ,Jul 19 2
1000 M11694194H1ssued Aug 19 1
3. Decedent ,or Ada M. (May) St1n ,
1000 M11407844H issued Apr 119 0 '
1000 M40S22589H issued Jul 19 2
1000 Ml~451470H issued Jul19 2
1000 M16451471H issued Jul 19 2
1000 M1645t472H issued Oct 19 1
1000 M164S3843H issued Jan 19 6
1000 M40522590H issued Jul 19 2
1000 M11698223H issued Oct 19 1
4. Decedent or Ruth Shively
1000 ~40522592H issuedNOv 196
1000 M40522592H issued Nov 19 7
1000 Mll697478H issuetlOct 19, 1
5. , Deceden t or Il'reqa J,ohnson '
1000 M11698226H issued Oct 19 1
TotAL
MARK eT
'VALue
mOIN! VALUeOF
D' DllceDeNT'S
DWHIRIHI' INTeReST
1000 50 500.00
"
1000 50 500.00
1000 50 500,00
1000 50 500.00
1000 50 500.00 ,
1000 50' 500.00
1000 50 500.00
1000 50 500.00
1000 SO 500.00
1000 50 500.00 i
1000 SO 500.00
1000 50 500,00
1000 50 500.00
1000 50 ,500,00
1000 50 500.00
1000 50 500.00
1000 50 5,00.00 '
1000 50 500.00
..-------...-,.......-._--...~........-- ,..
....;1
TOTAL .
9,000.00
lI'addltlonol .poco I. nDcouary, uso B~" x 1.1"5hoots,
DePARTMIlNT
, V~LUATlON
IOfPICIA~.vSB ONL YI
...._"" -~..
Ii
"0
..'
QgHERAL l.Iil:!!B.lTANCE TAX INflORMATIOli
Un,allilled Ilabllllle', Inourrod by tho docodontprlor to hla/hor doatll aro doduotlblClagalnat hla/n.rlaxablo
..toto. In addition 'to dobt. Inourred by the docodont or oatato, othor Iton1l ato claimable Inclulllng tho coat 01
admlnl.trallon! attorney looa, Ilduclary 1001, lunoral clnd burial oxpensoa Including tho coat 01 a burial lot, tClmbltono
or gro~o morkor and oth.r relatod:butlal oxpon"a. 0
All dobta,bolng clalmod ogolnat an utato <<to lublodt to tho approval 01 tho Rogllter ol\'lllla with whom tho'
Inhotltance Tax Roturn II III ,d., Evldonco .to support tho docodont's or tho ostotO'1 liability lor tho dobtl b,lng ,
claimed should be attaohed to thll schodule.
''','
, A lamlly "cemptlon may bo alolmod by a .pouso of a dllcodo'nt who died domlcllod In Pennaylvanlo. If thoro la
no apouse, or II tho apouu haa lorloltod hla/hor rlghta, thon any child 01 tho docodont who la 0 membor 01 tho aomo
houaohold can claim the exemption. In tho ovorU thoro la noauch .paulO or child, tho oMlIIT1ptlon oon bo clolmod by
a poront or paronta wh,o a,rlj'mombers 01 tho aame houaohold oa, thodocodont. T~o lomlly oxomptlon la allowable only
aqalnat aneta whloh 'pan by a will or by tho Pennaylvonla Intostato Law.. '
NOTEIComponadtlon paid to an o.tato ropruontollvo/ namoly', an oxocutor or admlnlltratot, lor uorvlou
porfarmed In admln,laterlng on,..tote I. reportablo for Ponnaylvon,lo Income Tax purpoau. Thll taxoblo Inoome
Itom ahould bo reportod on lotm PA.4D.lndlvlauollncomo Tax Roturn. ' . .
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INSTRIICTION~ FnR rnMPI FTlt-Ir. ~rHFnlit F"FIi
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,aENERAL.I~HeRITANCE TAX INFORMATION
Unsallafl,d IIabllltlos Inourred by tho docodonl prior 10 hls/hor dqath ora doductlblo agalnsl'hls/her hlxablo
estate. In addlllon 10 debla Incurred by iho'docodontor Dltatv, athor Ifoma aroclalmablolnalucflnglhe ooal of
admlnlstrallon, atlornClY foea, flduolary foos, funoral and burial oxponaoa Includlng,tho cost 0,10 hurl,allotllombstono
or gravel markor,and olhot rolated burial oXPQnaos.
All debta being ,clalmodogalnal an utalo aro aublocl to tho approval 61 Iho Ruglslor 01 Willa with whom 11\0
Inhorltanco Tax Roturn la fllod, Evldonao ,10 support tho doaodont's or the ostato's liability lor Iho dehlabolng
ololmed should bo'attached la Ihls schodulo. .
,A fomlly 'exoniptlon mar be clolmod by a sp,ouu 01 a'docodonl who cfled dOlnlalled \n Ponnsylvanla. II Ihoro Is
no spouso, or If Iho apllUU has lorfoltod hla/hor rights, thon any child 01 tho dococfonl who Is a mombor al Iho same
houuhold can claim Iho exemption. In tho ovent th% Is nO sU,ch spouso or chlld,'lheoXllmptlonoan bo olalrlled by
a paront or Paronls who aro members 0,' tho samohoulohald as Iho deaodont. ThQ lamllr oxomptlon Is allowabloonly
against ass,ts which pan by a wl.ll,or by tho Ponnsylvanla Intostato laws. ' .
NOrIS' Componaatlanpald la ~n estate roprosontatlvol ~amoly, an ox~cutot at admlnlslralor, fot utvlces
porformod In admlnlstorlngan !,tato Is roportablo I,or Ponnsylvanla Income Tax purpous. This taxable Income
Item should bo roported On /qrIllPA.40.lndlvlduallncomo TalC Roturn.
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" ,1, If Ih,/amlly ex.mptlan Is being clalmod, Indlc',ate, tho clalmant~s namo, addrouandhls/hor r.latlon.hlp to
" the, decodenl.Enler "family exemption" In Ihe remarks column and tho amount ololmodlnlho amounlcolumn.
'~" Asslgnconuoutlve numbors,lo each Item IIslod. , '
3. 'Enter Ihe dOlo lln ,whl,ch oach d,ebl wos Incutlll,dand/or paid. '
4. Ent.ttho namosQI oaoh payoo, ' ,
5. Pto~ldu brlofexplanallon In Iho remarks colu,mn lot ooch debt,clalmed.
6. Enter the amount 01 each dobl being claimed. " , ,
7. The form must bo Signed by Iho person who has assu,mod the responsibility lor Paying Ihe dobls.
.,INSTRUctIONSFOR COMPI.J:T!NG5C~"
IF ADDITIONAL. SPACE IS NECESSARY US!: BW' x 11" SHEETS.