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PETITION FOR LETTERS OF ADMINISTRATION
IN TilE ESTATE OF ,~~.~~~.~.~~.,.,~.:"..~~~~.~~~.!....~,~,:,.""",... I)ECI~AHEI).
To ""w'\~X,J;:, .',,)"'\;;l:1r~.. "". ,,,,,,,,,,,,,,..,,........,, """" ..".., ,,,,,,,.. .""""""" '"''
Hegister of IVills fOl' the ('011111,. of ('lImbedaor!. ill till' (',,,nowlllI'ealth of l'elllls,'II'I\I1;a,
The Pc li lioll 0 I' """""',.~ +.G!~ARP",~"", ,\W~p. ~,N".."""."".".,.""""""""""""",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
""""",,,,,,,,,,,,,,,,,,,,,,,,,,,.,,,,.,,,,,,,,,,,,,,, I'espect fllll.l' sholl'el h t hat "",R.,I.9IAR"[)."P',:",WAR"[)~,~"")!:3::"""",,,,,,,
'I fEast Pennsboro t'foll'llshiw (' 1 "I' 1(' t, St,t l' I"~ '1
WRH n reSl( ent 0 ....."......".......""........."............."...."BoJ.ough ,tlllllCI .\lH ,oun).. cl C () l!nns~-
vania. anrl a Citizen of United Slates, alld departed (his life illtestate in the Coullty of ",,'"'''''''''',,'''''''''
",l;;)!!))J? !,:!,r, J,?'.1:19.""""", an d S ta t e 0 f ",' ?,~~~.s. Y.. ~ Y. <l.fl ~,~".,",.,.,"""'"'',.,''''''' '",,'''''''''''''''''','''',''' """"",,,,,,,,,,,
on """"''''',,''''''''''',,'''''''''' the """""".""""""2.~,~J:t,, da,' of ",,!:1?,r.~,t,,""""""""""""""'" A, D" 19~,L".
at the age of ""~J,,,,,,, yeal's,
That the said ",RJ~J!ARP.",r..,,,,,WARP.JW.,,,,,,m.,,,,,, ."."""" deceased, left surviving the following
named widow or husband, heirs and next to kin, 10 lI'it:
Name
Relationship
Residence
Box 371-L-l
Glenmoore PA 19343
........................1.......................................
81~,\1~b,~~t"~,r.A"J,~,1~~,,,,,,,""""
"RJ~J!A~p'",r,..""WARP',J;;N""""",.. ,'"
,,!7-,~Ir. A" ,l-,:,,, ,WAR"I? ~,~""" '"'''' """",'
"",:F.AP:(\';,R"".""."""""""
"'" M9.r.!:I~,R""""""""""""
................................................................
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That those above namerl include all of the next of kin, so far as known,
The said decedent was possessed of pereonal property to the estimute,1 value of $",,),.,5,.,9,Q,O',,,00'......
and of Real Estate, less incumb,'ance. to the eetimated value of $""""....7,0,7,,,,,,,,,,,,,,,, as near ae can be
ascertained.
That the said Real Estate in so far ae ie known is located in ",nliL"""".."""""""""""..""..,,,,,,,..,,
...................................................,..........,............................................""..,....,.................................................................
Therefore, your petitioner(e) ,'espectfully appl,'(ies) 1'01' Letters of Adminietl'ation in the above
named estate,
Dated ",,,,,127d..r.;,,,,,..fj,,,((:;,,........ A, IJ" 1!1,,~.L
(I Signature alld Address
of Petitioner(:..;)
).
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COMMONWEALTH OF' 1'1':NN8),I.I'ANIA I
liS:
COUNTY OF' CUMBlmLANIJ
,",""'''''',','''''''''','''' ",~,I,~,H.AR.-.D.,. .F..:, . ,,\-iAR.-.D. ~.~... .,., """"",.,....,., ..."..".,..",..,. ,.,.. ."", "" ,,' ",,,,,,,,,,,,p.,,,,,, '65 named
in the above awlieatioll heing' dill,\' ",.""""""~,\'!,9.R.N"",."""""",, "ee(>I'llillg' to law, 8"l' t~W the Iact. :itI/I~
forth in the "hove aJlJlliclltioll a,'" tl'lIe to tllll besl or .!-.I..~~.7'.'t;' 1(1I))\>'I~g'J """fI.\ clief. ~(; $ ~~~
Rio /. ,/ . / '~'l" .< --tlJ
swnrn tf'\ I I 'I I t..LJ'-;/. . r // "'/ //-'-// t'.:':1 'TIP')
,,,,,,,,,,,,,,y,,,,tt,,,,,,>f,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, "n( Sll '8crl ,,!( ". . , ,Go'l"r. ,G"""h^'tt."<,, ,""y""",~",';""""N"""",..::O
. HARD P. WARDEN ij~ \0 '. ',;;
before me, . .. '., ",.,. ....... ........ ................ ..... ...........~~:..,j....... .'t::..........'.,:~~
May 29 81 :.,:'_ ".
1)1 /) ~ .) . ~., ..
""" ",/'/'/Ut'''r..;":,,, ,. .~~~;:~~~'~"" """"""'"'''''''''''''''''''''''''''''''''''''''''',,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,.
Filed: . ""l':iiY"29"~.",~~,~,L""""""""""""",,,,, A !tome,\': P.Mfr.E" ,w..'" " REI:l2:,ULL,J; ,'" ,JJL""""
ATTORNEY AT LA\-]
347 North Potts town Pike
Exton, PA 19341
phone: (215) 363-2612
OATH OF PERSONAL REPRESENT A T1VE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
} 8S:
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,~I9,!'!h.@,,,r,:,,,,WA~,P'E;!':I,,,,,,,,,,'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' petitioner (s)
being duly ""$.!:(Q,B,t;l""",, ,,,,,,....,,,, " """ ,,".. " " " according to law do es""", depose and say that as the
administra tor""..,,,, of the estate of ,,,,.. RI.CHARD",P..""WARDEN..""JR.. " " "'" ,,,...,,,,,, """ """" "," " ".... "'"
........................................................................................................................................................................................
deceased ,,,,,,JUt,,,,,,,,,, will well and truly administer the goods and chattels, rights and credits of said
deceased, according to law, And also will diligently comply with the provisions of the law relating
to Transfer Inheritances,
...."..,....,~~~E!?:",~~..,""'''''''',........ and subscribed
before me,
."..",..""~,~,r.,"~,?....""..""..,,..,,'''' A, D" 19,JU"
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"!;t,K?!C)#.:(.~!t:(r..(:?{/..,"',.."""..",,..,,..,..,....,,'
RICHARD P. WARDEN
............................................................................................
DECREE
Be it remembered that on the "..".....~~,~'''''"..".., day of ''''',...."......'!.~,~,7.......,''''',....,'' A, D" 19..~,L
Letters of Administration in the estate of ,.."",!~J,Q.IM:~.l!.,,,r,:,,,,WA~,P.);:,t;l,',,,,J,B,,.......,,,,...,,"',,..,""'"....,,,,..,,..
.."", "'..',, '''''''' ,..",,,.. ...."" "..""""" ".., ,,,,,,,,,,,,,..,,,,,,, late of ..I,';i,l, ~,t"r.,~T)Xl,~,b,Q ;J;.Q,,, :r.Qw.n~h~,p' '" .."............, "..
Cumberland County, Pennsylvania, deceased, were granted to .."R.~~!:l.(\RP,..!?",."WllJ.l.p.,lm..,........."....".
........................................................................................................................................................................................
Witness my hand and official seal the day and year afore~ai~ y.' )
,..,,,..,..,,,,721z7,,..e.:,,~..,
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF I.WJKJII<<AJOl CHESTER
J
IS:
_.0.___ !n~tlA.RD ~W{\R.!).I~JL_o _. _ _ __..
being duly sworD....... .__ eccerding 10 law, deposes e"d seys thel he.. is the
Administrator _______ of Ihe Estele of RICHARD p, WARDEN. JR,
lete of Ea.sJ:_..l'_e.l}n.sbo.r:Q_'l'o\m_sh~R ..-.....___, Cumberlend Counly, Pe., deceued end thet the
within is en inventory mede by -R,.J:..c..!:!ARJ1J.'...-YAR.UEJL. '__ _'__'_., Ihe said Administrator
of Ihe entire eslato of said decedenl, consisting of all the personal properly and real eslale, excapl real estate outside
the Commonwealth of Pennsylvania, and Ihat the ligures opposite each ilem of Ihe Inventory represent it's fair value
a. of the date of de.odent's dealh,
SWORN TO
and .ubscribed bofore mo,
?dt~;,~
RICHARD P, WARDEN
Box 371-L-l
WANETTA R, HONEYCUTT, Notary Publle
Exton, Chester County, Pa,
My Commission Expires July 51 1982
Glenmoore~ 19343
Addr."
Date of Death
28
1981
March
Day
Month
Year
INSTRUCTIONS
J. An invenlory must be filed within Ihreo months after appointment of personal representative,
2, A supplement inventory must be filed wilhin thirly days of discovery of. additional essets.
3, Additional sheets may be altached as to personally or realty
4, See Article IV, Fiduciaries Act of 1949.
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...-.... -- -== -- --
.'tREV.1162 EX
~ COMMONWEALTH OF PENNSYLVANIA
4 NoK 69843 DEPARTMENT OF REVENUE
. . . . OFFICIAL RECEIPT. PENNSYLVANIA INHERITANCE AND ESTATE TAX
If
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II
=
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= Anita L. Warden
~l RECEIVED
IJ FROM
-
....,. _-.. ..JE:::J:: ___ .....
~-~~..~
--
TAX AT 6%
TAXAT1S%
TAXAT_%
ADDRESS 34
ike
ESTATE TAX
,- - {{TA rE~~FORMA riD/;:
DA IE OF DEATH
TOTAL TAX CREDIT
$785.34
-- --- -- --- ---- -
arch 28 1981
FILE NUMBER
21-81-341
DATE OF PAYMENT
November 27. 1981
LESS DISCOUNT
PLUS % INTEREST
(FROM TO_I
NAME OF DECEDENT
ichard P
JE
m
'785.34
Warden
COUNTY
C umber land
---------------
TOTAL AMOUNT PAID
POSTMARK DATE
REMARKS
"PAID ON ACCOUNT"
/
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Ij/SIGNATURE
&
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/J(c..I.fa
/
SEAL
RECEIVED BY
flE:Glsr::n OF \,VILLS
- --- - - - - - -'-'--.--- - - - -.- -- ---.----.
'~~I\(.., ,.,.'~
. " .
, HEV.44<) E')(:(J'~Ol
COMMONWEAL Tti OF PEHto/SYLV;',II"
oEPARrMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIOENT OECEaENT
AFFIDAVIT OF
FIDUCIARY
(lintruc:tlons on Revrrse Side)
.
..,---------
'.---'-.-
ESlate of RICHA~D p, WARDE!L..J~,
Losl AddressJ}21 !I1,}l1ll11~J Avellue
Dolo of Death Narch 28, 1981
Social Secarity No. 182-46-3426
_Sal!)LHill, __PA
17011
Baroaa File No.
((',11 I
{:iT"" q.;)
I ~~ I.> I
Caanty File No.
21-81-341
1. Decodenl di ed:
(xX) Inteslate (without 0 will)
( ) Testate (leaving 0 lost will--capy attached)
2, Is the filing of 0 Federal Esloto, Tox Retarn required for this estate? Yes_ No XX
3, Executor/Executrix 1(XX) Adm;n;stratorlIUI/l\illM;XOO)fJ()l(
Nome RICHARD p, WARDEN
Address
Box 371-L-l
:J 0 T
Glenmoore, PA
ICITVI I:JrA r~1
19343
(ZIPI
4, All correspondence should be muiled to (XXI' Attorney
. ,..
1 ;
) Fiduci ary.
5. If on attorney is represonting tho estate, indicate:
)J&
Nome
DANTE W, ~ENZULLI, JR" ESQUIRE
347 North POttstOIVTI Pike
,00 T
Address
_ Exton,
tCtnl
PL
(S r~. TEl
19341
(liP!
List oli safe doposil boxes registered in the decedent's individual namehor jointly with, or os on agent or deputy
of another, or in decedent's individual name with right of access by onot er os agent or deputy, Include the nome
and address of the bonk or other institution where the sole deposit box is located, the nome (s) in which the box
is registered and the relationship of the joint holders to tho decedent.
._-
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION
IN ....HICH DECEOErH MAINTAIN EO A. SAFE OEi'OSIT BOX
N.I\ME OR HAMES IN WHICH
SAFE DEPOSIT BOX IS REGISTERED
REL~ TIONSHIP OF JOINT
HOLDERS TO DECEDENT
Box 1301
RICHARD p, WARDEN, JR,
Commonwealth National Bank
p, 0, Box 320
------~._-----._----_._----_.- -
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Under pC'llalties of perjUly, i declare that I have examined this return, including accompanying schedules and
'itotcmCt1t5, and to the be5t"f my knowledge and ~clicf it i:; tru2, correct and complete.
.~.,Jrl) /-:7 ) /J
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. . It'll . . 1__ __.______ ""_
SIG~ATURI: 0:;- FIDUCIARY
Mechanicsburg, PA
17055
/Cl_-<'J - q
DATE
)
.'
4~""~lIl.l; H t!.t.'1'
COMMONWEAL TH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIOENT OECEOENT
SCHEDULE "B"
PERSONAL PROPERTY
~,,~:
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(Instructions 011 HIJVI.'fSl! Sidf!)
Estate of RICHARD p, HARDEN, JR,
ITEM UNIT ESTIMATED DEPARTMENT
NO, DESCRIPTION VALUE MARKET VALUATION
VALUE {OFFICIAL USE ONI, vi
1. Death benefits due from Aetna Insurance
Company under auto insurance policy no,
57 SXl1298070PCH (see attached letter) $15,000,00
2, 1966 MG (destroyed in auto accident whicl
caused death of decedent - no insurance
and no salvage value)
3, Commonwealth National Bank
10 South Market Street
Harrisburg, PA 17108
Checking Account #141-108178-7 125,60
4, Passbook Account #1/1-0012649-4 68.55
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TOT AL
$15,194. ~ /.r. /1;l.Ir
- j-~Ad
, II additional space is necessary, use B' ," x 11" sheets,
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" ,)
2, Did decedent, within t'M) years of death, transfer property from himself/ herself to himself/herself and another party
or parties (including a spouse) in joint ownership? (Answer "Yes" or "No",) -
3, If the answer to one or t'M) above is "Yes" and the transfers are claimed to be nontaxable, provide the following
information:
a, Age of decedent at time of transfer.
b, Copy of death certi ficate.
c, Affidavit by the attending physician indicating the state of decedent's health at time of transfer,
d, All other information supporting nontaxabiiity of transfer.
4, Did decedent, in his/her lifetime, make any transfer of properly without receiving a valuable or adequate consideration
therefor which was \0 take effect in possession or enjoyment at or after his/her death? (Answer "Yes" or "No",)
a, Was there any possibitity 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" ,)
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 impiiedly 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 enioy the property transferred or income therefrom?
(Answer "Yes" or "No" ,)
6, If the answer to five b, above is "Yes," was the right reserved in decedent alone ( ) or decedenl and others ( ),
7, Did decedent in his/her lifetime make a transfer, the consideration for which was transferee's promise 10 pay income
to or for the benefit or care of transferor? (Answer "Yes" or "No",)
8, Did decedent, at any time, transfer property, the bfl1eficial enjoyment of which was subiect 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 "Yes" or "No" ,)
9, If the answer to eight above is "Yes," was the power to aller, amend or revoke the interest of the beneficiary reserved
in the decedent alone ( ) or decedent and others ( ),
QUESTIONS CONCERNING PROPERTY TRANSFERS
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INSTRUCTIONS FOR COMPLETING SCHEDULE "E"
Schedule "E" must include all property, real and personal, owned by the decedent jointly with another
party or parties 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[s] 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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Page 2
SAFE DEPOSIT OOX MENTORY
structions: 1 CASH: Report total only. 2 STOCK: List in detail evez-y cOll1lllon or
preferred certificate, warrant or other righte found in box. Stocke are to
be designated by name of company, certificate number, date of certificate,
name in which stock ie registered, number 'of shares and class of stock.
(3) OBLIGATIONS of U.S. GOVERNMENT: Number of pieces, dates of issue, face
value, namell in which registered. (4) OONDS: Designate by name, amount,
lIerial number, or otherwise. (5) SAVlNGS BANK or PASS OOOKS: State name
of depositor, number 01: book, bet date appearing in book, name of bank and
branch, and bal,ance. (6) JEWELRY, COlNS, STAMPS, MANUSCRIPTS, ETC.: List
and describe as .ful.ly ae possible. (7) List Deedll, Mortgages, Current
InllUrance Policiee or other evidences of indebtednees. (8) All other contento.
Checks to Checking account II 141-108178-7 123 checks and cover
BOMC Statement of earnings in envelope
Loan papers to Blazer Consumer Dis. Co. 10-17-79
BOMC job description
Blue Cross Papers and Explanation of Blue Shield Benefits
Loan papers commercial credit 5-9-79
Avco Loan papers 2-7-80
Silo Audio World Receipt
3 Mechanicsburg sport letters
Birth certificate 9-24-57 Seid1e Memora1 Hospital
Meehanicburg Senior High Diploma
2 detention stubs (school)
Student I/O card Mechanicburg, Senior lIigh
Penna. Game Commission card
Blue Cross and Blue Shield I/O cards Misce1aneous pictures and ornament
Aetna personal auto app1ieation
CNB PIN number
Aetna premium notice 9/29/79
Aetna letter
Aetna letter
Aetna Auto ins, Policy
Aetna auto premimu notice 1/26/80
Social Security Card from HEW
Letter from Probation offiee 5/27/80
Title to 1976 Ford sdn.
Documentation of purchase of 76 Ford
BOMC job description
Loan papers Blazer Consumer Disc. Co. 8/4180
Loan papers HFC 2/11/81
Sears Battery Warranty store 2624
Loan papers HFC 2/11/81 (paid)
Loan papers HFC 3/25/81
Loan papers Blazer consumer Dise, (paid) 8/4/80
And now this --l!.- day of March
certifT under penalty of perjuz-y that the
to the bost of m.r knowledge and belief.
, 19~, I hel"eby
above record is correct and complete
~~~~?~/-.
, ~ Sigriature (
Alan McConnell, Personal Loan Adm.
Print Name a.rxI Title
NOTE: UIIO eeparate aheets if necessary.
REV-4U EX+ (s-aO)
INHERITANCE TAX SUMMARY SHEET
(BUREAU USE ONLY)
Flte Humber
21-81-0341
ITI Ori ginal
o Supplemenlal
o Remainder
Estate Home
Richard P. Warden, Jr,
Date of Death
March 28, 19B1
Social Security Number
182-46-3426
REPORT OF INHERITANCE TAX APPRAISER
I, Ihe undersigned duly appainled Inharitance Tax Appral.er in and for the County 01 Cumberlar.d
Pennsylvania, do re.pectfully report thai I nave appraised the reol and personal praperly a. roported in the oregoing
retum at the values set forth opposite each item in the last column to the rl.sht in 5ch utes llAu, "B", "C", and liE"
Doled: December 16, 1981 1'.()--'
ADJUSTMENTS REMAINDER APPRAISEMENT CODE
INVENTORY VALUE AS APPRAISED CODE (HARRISBURG USE ONLY)
Real Preperty (Schedule A) $ None 00+ 92+
POrlonal Property (SChCldul. B) 15,194 15 to+
Jolnt.Held Property (Schedulo E) None 20+
Transfers (Schedule C) None 30+
TOT AL GROSS ASSETS 15 194 15
Leu D.bts and Oeductlon. 40- 93-
(SCHEDULE F)
CLEAR VALUE OF ESTATE
o Lile Estale RATE FACTOR PRINCIPLE VALUE CODE
o Annuily
FOR USE OF REGISTER ONLY
Tax on $
CODE
COMPUTATION OF TAX
$
$
$
$
$
6%
T ax on $
15%
Tax on $
Tax on $
Tax on $
ExemptlC:lnS
Total Estate
TDTAl. TAX
INTEREST FROM
BALANCE
TO
$
$
$
Leu Credits
DATE OF PAYMENT
AMOUNT PAID
DISCOUNT
INTEREST
TAX CREDIT
$
+ $
$
=
$
+
=
BALANCE
TO
$
REY..4Il7 EXt (7"80)
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENlIF
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
~~ t
..~).i;'
r '(!Ii
",(,,;'Ii~~.
1~IIiERITANCE TAX
APPRAISEMENT
QORIGINAl.
o SUPPLEMENT AL
Estate af
Richar~..!.:...~"Ede.!:_!.._J::~___________ _____ Fi leNa. ___.___~1-8_1__::93':.1.
Caun ty
Cumberland
Date af Death _..
March 28, 1981
In the event that any fulure Interc~t In Ihis estotc 15 transforred In posses!'iion or enjoyment tu .::olloleral heirs of the decedent after the
expiration of any ostate for life or for Yf:nrs, Ih'3 Commonwoalth hereby expressly rosctlws the right to opproise and 055055 transfer
Inheritance taxes at the lawful collateral cain on any such futuro Inler~5t.
- -_.
PROPERTY NOT INCLUDED IN RETURN BUT APPRAISED BY THE COMMONWEALTH
ASSET SUMMARY
DEPARTMENT'S
APPRAISED VALUE I
Total Real Property - SCH, "A". . . . .. $
Total Personal Property - SCH. "B". . . , $
Total Jointly Owned Property - SCH. "E" $
Total Transfers - SCH. "C". . ,', . . " $
None
..1.41 94. 15
None
Unreported $
Unreported $
Unreported $
Unreported $
$ -1lonp
$ 15,194.15
$ None
$ None
$
None
o LIFE ESTATE
TOT AL GROSS ASSETS
DREMAINDER
15,194.15
DANNUITY
TOTAL VALUE
$
I da hereby certify that the above appraisemellt is made in confat~ with Pennsylvania law and has been filed this
day with the Register af Wills. ~~7 A:. _
~4rJ/.-l!:..t(ltl.,1.,v('~ December 16,1981
- I . APP~~S~~---- DATE
.
H
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GENERAL INHERITANCE TAX INFORMATION
Unsatislied liabilities incurred by the decedent prior to his/her death are deductible ageinst his/her taxable
estate. In addition to debts incurred by the decedent or estate, other items are claimable including the cost of
ad,ninistration, attorney lees, fiduciary fees, funeral and burial expenses including the cost of a burial lot, tombstone
or grave marker and other related burial expenses,
All debts being claimed against an estate are subject to the approval 01 the Register 01 Wills with whom the
Inheritance Tax Return is liled. 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 il the spouse has lorleited his/her rights, then any child 01 the decedent who is a member 01 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 01 the same household as the decedent, The lamily exemption is allowable only
against assets which pass by a will or by the Pennsylvania Intestate Laws,
NOTE: Compensation paid to an estate representative; namely, an executor or administrator, lor services
performed in administering an estate is reportable lor Pennsylvania Income To, purposes. This taxable income
item should be reported on form PA.40.lndividuallncome Tax Return.
r '" " () > t'1 > ~
z >- 0 0 0 '" " $
Cl () C " -l Z s:
t'1 t'1 ;>:: Z ;;:J >- p
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INSTRUCTIONS FOR COMPLETING SCHEDULE "F"
1. If the lamily exemption is being claimed, indicate the claimant's nome, address and his/her relationship to
the decedent, Enter "Iamily e,emption" in the remarks column and the amount claimed in the amount column,
2. Assi gn consecuti vc numbers to each item Ii sled.
3. Enter the dote on which each debt was incurred and/or paid,
4, Enter the names of each payee.
5. Provide 0 briel e,plonotion in the remarks column for each debt claimed.
6. Enter the amount of each debt being claimed,
7. The form must be signed by the person who has assumed the responsibility lor paying the debts,
IF ADDITIONAL SPACE IS NECESSARY USE B'','' , 11" SHEETS,
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF EXAMINATION
OFFICIAL NO'1"ICE OF
INHERITANCE TAX
ASSESSMENT
'*'
COUNTY FILE NO:
'.,f
:..: <'/ /
DATE
/
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ESTATE
"
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FILE NO,
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COUNTY
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,
OATE OF OEATH
.'>
~
.~/ /. ,:;";
"
Appraised Value of Estate:
Real Estate
$
Personal Property
+ //,-' //.'!
,
" .
--
Jointly Held Property/Transfers
+
~.._.------
Total Gross Estate
$ ,'~'
./ '/ .~/ /1,
-
Clear Value of Estate
, , ) . It./ I
I
$ :., I ?c.f / ;/
Total Approved Deductions
Less: Approved Charitable Exemptions
...~__...u.____,_
Clear Value of Estate Subject to Tax
6
,.'
'.
f"q
.-:..
::' /
Amount Taxable @ 6% Rate
$ ./:;< II \"'i
~
,.. r'.
/
tax due
$
,,/' ./ ".J- ::{ t:l
I
Amount Taxable @ 15% Rate
tax due
TOTAL PENNSYLVANIA INHERITANCE TAX DUE
$
," .,/;"";:~ 17
I ( .... ...... ,
. ... .... .... "" ... A five percent discount totaling $
will be granted if the Inheritance Tax is paid by
Less Credits:
DATE OF PAYMENT
AMOUNT PAID
DISCOUNT
INTEREST
TAX CREDIT
l;.. '/ 'r I
$ ,-1'
I'
~.,.
+ S
$
=
$
"'./.
,
+
=
+
=
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
is
BALANCE OF PENNSYLVANIA INHERITANCE TAX DUE
$
,.....,
. I
./;1 :f ,0".
,I".. /,' ~"
'f..' .
">,t. 1/,iL/!...ifAF-'f...- ..
. !.'. " I /
Assessed by: ,,' .'" I . '. / ' ,
. . Agentforth. Commonw..lIh -; .
Sp.e Informal Ion on Re\lorso Side i.1 ,.
,/ j-
'I // L~_~~' ( \'.
I I
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