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ITEM PERSONAL PROPERTY _ LIst all tangible and intangible personal property owned individually bv Estimated Department Valuation
NO. the decedent at the time ot death. Market Valuo 10fflci.1 U,. Only 1
--
Q1e $500 U.S. series "R" Bond,
paid on death to John CSisak 500.00
\ Total 500.00 r/rlJ, ~ 411
- t'", ~:
ITEM JOINTLY.OWNED PROPERTV- Ust all reai and p"rsonal property owned bV the decedent with Euimoted Department Valuation
NO. with another party or parties 85 joint tenants with right of survivorship. Include name. address and Market Value (Official Use Onlv~
r1I1ationship to the decedent of the joint ownedd and the date the lolnt ownership was croated.
Savings account #01-7-08031, Dauphin o=posit Bank &
TrusL Cb., opened prior to 1965 joint with John CSisak, 2,123.97
decedent I s son. Date of death: $4,247.93
Savings aocount #30-0010033-3, ():)ln1'Ol~lth National
Bank, opened 2/3/76 joint with John CSisak, decedent'S 2,876.65
son. Date of death: $5,753.29
'IWO $1,000 U.S. Series "R" Bonds, joint with John
CSisak, decedent's son. Bonds kept in safe deposit
OOlt jointly held by the co-tenants. $2,000.00 1,000.00
\ Total 6,000.62 ,. tH-C. (".2 L1A
-
ITEM TRANSfERS _ Ust all ree' end personal propertY tfensterred within twO veers of death. Estimated Depertment VeluDtion
NO. Market Value (Of~icia' Use Onlv)
N
0
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E I Totsl .,,/}t1,
- 0 - -~ ~.
un 1'1..11 d8l>01lt box.. rl1lln.,ed in ,h. dec.d.nt', n.m.. or joln,ly with. D' .. .n .g.nt or depu,y 01 .noth.r. or In dee.d.nt', Indl,ldu.1 n."" with right 01
1CC01' II egont a' depu,y, Include the n."" Ind edd,... at Ih. b.nk or oth.. in..I,u,lon "".re Ih. ,"f. d.po,I' box I,l"'at.d. the n.m.ld in which ,,,. box i,
''ti1tered .nd the f,'ationshlp of theloint holdeflto the decendent.
Name and Add,.s of Bank or Other Institution
In Which Oecedent Maintained I Sate Deposit Box
Name or Names In Which
Safe Deposit Sox Is Reginered
Relationship of Joint
Ho!d.rs to Decedent
~N
~33 North 21st Street
camp Hill, PA 17011
NOTE: You moy .,pedll" Ihl p'OCI..lng at ,hi, ,.IU," by filing ,,;,h It Ind II I PI" uf the re'u,", 1'11'" Irom finln..,1 inllitu,iont or mongego hold.".
wlily'ng 10 I""",n.. on d8l>O\it or owned by the dec....nt II at Ih. d'" 01 d.ath, Suc" 1.11." mull be ,Igned by I ..,pon,ibl. alii.... 01 the finlnciol
;ntlitul1on 0< """Igolll holder ond ,ndlc"" cl.lrly lmounll 01 princiP"lnd in'....1 in ,h. decedent"lCCoUn'1! tho d". 01 dOlth Ind thllY.,. at 1CC0un'.
KCOUnl nurrber..,d the .uct n,me Of ".mII I" "","ich the ilCcou~t i~ f1!~;,tf'ltld.
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BENEFICIARIES
.~
BENEFICIARIES AND ADDRESSES
(State full names and addrones of all who hU\lo an mterest
either \lested. contingent or other interest)
RELATIONSHIP
TO DECEDENT
SURVIVED
DECEDENT
STATE YES
ORNO
AGE OF LIFE
TENANTS OR
ANNUITANTS
AT DEATH OF
DECEDENT
INTEREST OF
BENEFICIARY
IN ESTATE
~
..--...-.----.. --.
John esisak
430 North 21st Street
CamP Hill, PA 17011
.._------ ~--_...
$91'L------
Y'es _____ _QLlY;Je
tire resid~_.
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INFORMATION
PLACE FOR FlUNG _ The retum i. to be filed in dupli<IIe wilh the Regi"o, 01 W,II. ot 'he county wherein tho decedent ,..ided.
TIME FOR FILING _ The retum i. duo mne month. all.. Ihe decedent'. dollh. unle.. en ....nllon lor 1,1'09 h.. baan applied for Ind granted by thl SoclO18fV
01 Revenue within the nine-month p811od.
FAILURETO FILE RETURN _ Soction 791 01 tha 1961 Slaluto provod.. Ih.t ". any petlOn wt10 w.ulul'. fail. to lIIe a ..tumor othe,,"portIOClUired of him
. .hall be petlon.lI. liable... to a penolty of 25", of tho t.. ultimatolv found to be duo or $1.000 wl\,chOVO' i. tho I..... to be ..covered by"'.
Depart~nt ot Revenue as deblS of hlo.e amount ate focoverable bvlaw,"
DEDUCTIONS _ Un"'"f,ad Iiabilil.o' incuro.d bv tho decodont proot'O h" ho' death "0 doducliblo ag"n" h,,'ho' ta..blo .""0 In addit,on to debts incun-ed
b. the decodenl 0' ."..e. olho, ,10m' alo cla,mablo ,"cluding tho coat of aom.m".."on. aI\O"'" ,..., I.duc'or. f.... ,,,,,,,..I and burial .,pen'"
including the co.1 of a bUflollot, tombi\Ol\8 or g'8\1e ml!ilr"'81, and other r~ated bU~lal e-.penfot'5
FAMILY EXEMPTION _ A lam.lv o,omplion ",av be cleimod b, . apou,. 01 a docodenl who d,ed dom,c<lod ,n Ponn.~..n,a " thero i. no .pou... or ,f "'a
.pouao haa lorio,ted I""hor IIghll, ,hon an. child of ,he dOledonl who ia a mem"," of tho ..mehou..hoIO can claim tho .,.rnpt,on In ",...ont tMIO"
no' auch apou'o 0' child, the ..omption can be cI..med bV a p"onl 0' p"enl' who a'. mombotl of Iho ..me h.u..hold .. the doc.don' The fomily
uemption 1$ allowable only again,' afoiet5 which pi" bv II Will or bv the hnm.vl~anI8 Inle'ill,e lIWl.
FIDUCIARY COMMISSION _ Compon..',on p..d.O an"'ot. ,.p,o..ntat,... "amelv. an.,ecutO! 0IOdm,""t'"01. fOllen',co. por1ormed In adm""....'ng on
,""0 " ,oportahle for ~.nn.ylvan;a Income T" pu",oao. Th" la..ble ,"come ,'om ,hould be ,opo,.ed on fo"" PA.4D. Indi.lduallncomt fa, Return
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--'-- ~.
ITEM Date Namtl 01 Payee Natufll 01 Dubt Amount
NO. ---
- ---
,,4 L. DI\Uey
Hale Inc. Funeral oxpcmo5 paid -~._._._._--------'---- ~L392.05
-- ._-
lTcbn eaillak Family exemption (wilt not be allowlld unlun decode", died
residing with II plnonl, spouso or childron,) 2,000.00
-
AdminiSlrotion Ellponsei
, ,
, Wilt Counsel Fees 200.00
- -
Fiduciarv COInmiS5ion
(Other Oabu and Claimsl
D. McInxoi, M.D. Bill 75.00
Dairiea , Inc Bill 1.33
RIr,Jiatar ot: w:I.l.ls File inbar1t.ance tax retuxn 5.00
~ ot: WUla File d.ebtlI and &lduct.1.oM 5.00
i_Total 4,678.38 Aid
---
DEBTS AND DEDUCTIONS
Under penaltie5 of perjury. I decl,f8 lhllt I have examined this return. and to the hest of my knowledge and belief. it is true, corteet and complete.
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I do hereby ceJtilv that I have BPprsiuld the a\oseU contained h(!lmo lfl conlollllitv WIth Pr.nmylvania law.
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~ Apjlll15el CI Dale
In the l'vcP,llhal IInV IUIUIC inlerMl in thi. t~lale i, ~Iamle"ed in pm~c~~lon 01 ClljOVlTllmt to follaleral hell. 01 the deceth>nt aUll! the e...pltolltlOn f)t any
t."t.to tOf life or fOl Vean, the Corn",on~allh heluhv cklHenlv f(~~f!'l"'" ttlll lighl10 ijppral5e and anl'55 uaruler lHhelll..nCl~ lakc,..t thlllawlul t'nll.1H'lal
ralt! un anv 5I.II,;h lutult! intlllll\ot.
.._.._------~--_._----
___._______ _..__"..___._.n._.n..___
Debu Ind deductIon" Ire allowed 10 Ihe 51..1111 01 $
--..-----
at _____ % 1... Idle
----.--..-----~e.~o1 Will,
(Jill!':
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BENEFICIARIES
....
9ENEFICIARIES AND ADDRESSES
(Stille lutl n.l"105 and addllmes 01 nU who havo on Interust
ClthOIIlCUtld. contingent or othol 11l11!rllUI
RELATIONSHIP
TO DECEDENT
-:::<:,,,-,---
SURVIVED AGE OF LIFE
DECEDENT TENANTS OR
STATE YES ANNUITANTS
OR NO AT DEATH OF
DECEDENT
INTEREST OF
BENEFICIARY
IN ESTATE
.----.-----.------
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INFORMATION
PLACE FOR FlUNG _ "he ,etu'I' is to be filed in dupltcBte With the Register of Will. of the county wherein the decedent resided,
,
TaME FOR FILlNO _ Thfl retum it due nine month. after the decedent's death, unless an ,slllension tor filing has been 8pplied for and granted by the Secretlry
of Revenue Within the nine-month period
fAILURE TO FILE RETURN _ Section 791 of the 1961 Statute provides 'hat ., .. any person whO wiMully fails to file a Ulturn or other report required of him
"hall be pet1ionally h6ble "to a penalty of 25"" of the tak ultimately found to btI due or $1,000 whichever is thele"er to be recovered bv the
Department ot Revenue" debts of li"'e amount 8rtJ recoverable by IlIw"
DEDUCTIONS _ Un""."ed h.b,ht,e. .ncuned bv .he decedent pOlO' '0 h.._he, de.lh a'e deduc',ble aga,n" h.. hOf ta,able e"al. In .dd,tior.'o deb" incuned
by the decedent Of estate, t;ther 11ems ate claimable incl'ldll'lg the cost of administration, altorney tees, fiduciary fees, funeral and burial ellpenses
enc:luding the co,t ot 8 burial lot, tombstone 01 grave m81~et, and other filiated bunal ekpen,es
fAMILY EXEMPllON _ A lamtly ell-emption may be dalmfld bv a 5opouloe 01 a decedent who dIed domiCiled in Pennsylvania If there is no sPOU'Ul, or if the
,pou,e heo 'o"e,'.d ti.. 'he' flgh", .h,," anv ch,ld 0' the d.,.d""t who " a m.mb.' ollh. ,ame OOu,ehold can claim tho .'emp'ion In Ihe e,en' 'h"e II
not such 'POuse ot c;hlId. thtlllllemptlon c.n be cl84med by tl pllrent 01 palenti who are members of the nme hou5ehold 15 the decedent. The family
ellemption " allowablt!! only .gal''',' ."e's which pasfI hI' II will 01 bV the Pennsv'var,la Intestate taw'
flDUCIARV COMMISSION _ Compenutlon paId to an ~"'a'e ft1ple"ent8tlve. rUlmt!ly, an ellecutol or administrator, for ,ervices performed in administering an
",t.te 1\ rftPonltJie fOt Pennsylvanll Inc;ome 1 all purpofoe5 nit' likable Income Itam $hOuld be ref)orted on Form PA-40, Individual Income Tilt Retum,
ITEM PERSONAL PROPERTY _ List all tangible and intangible personsl property owned Individually by Estimated Department Valuation
NO. thedltCedent at the time 01 death. Market Value IOlfieisl Use Only I
- .
Qle $500 U.S. ser'...es "H" Bond, 500.00
paid en death to Jolln QlislIk
I Tolal 500.00 ~tI'd . "T) .4.B
ITEM JOINTLY.OWNED PROPERTY- Li5t all real and Pflrsonal property ownerj by the decedent with Elilimated Department Valuation
NO. with another party or partics as joint tenanu with right of survivorship. Include name,oddress and Market Value IOfficial Usa Onlyl
relationship to the decedent of the joint ownerlliland the date the joint ownerlihip wes croated.
savin9s aoccunt .01-7-06031, 0Il.~ ~it BanK ,
'1'mIt OJ., ~ prior to 1965 joint with Jolln CIIisl1k, 2,123.97
~t'. 1ICXl. 0Ilte of cleathl $4,247.93
IlaV1n9a IICCOImt .30-0010033-3, ~.,,"JIe'.l.th Naticnal
BaIlK, openIl12/3/16 joint with Jolln CaisaIt, ~'. 2,676.65
1Cln. 0Il.te of deathl $5,753.29
'l\io $1,000 U.S. Series "H" BcIIda, joint with Jchn
C.l"'''', ~t'. 1lCXl. BoI1d8 kept in safe d8p0Bit 1,000.00
boX jointly held l7;{ the co-tenant8. $2,000.00
I Total 6,000.62 1(,', ~. G,,? All
ITEM TRANSFERS _ List all real and personal property transferred within twO vears of death. Elitimated Department Valuation
NO. Market Value (Of~icial Use Onlv~
N
0
N
E
I Total - 0 - _.~. " A~
un.n ufe deposit bOKes reoistered in the dec~dent's name, or jointly with, or as an agent or deputY of another, or in decedent's individual name with right of
ecc:ess iii aoent or deputy. Include the name and itddreu of the bank or other institution where the fo81e depoliit box is located, the name(sl in which the bOK i.
rtgi"lred and the r.lationJhip of the joint holders to tht decendent.
Name and Addrllis of Bank or Other Institution
In Which Decedent Maintained a Safe Deposit Bail!
Name Of Names In Which
Safe Deposit BOK Ii Registered
Relationship 01 Joint
Holde,. to Decedent
.-:.-..... ~,,1th Nadmal Bank.
Haty OIiaak or John c.t-,lt
san
U3 Nci:th 2lat Street
C&p I:lill, PA 17011
NOTE: You NV eKpedite theproclluing 01 ,his return by filing with it and 81 a part of the tuturn, hHtt-11i from 'tnlnc,e' institutions or mortg. hold,,.,
ctrtifying to .mount, on deposit Of owned hy the decedent" of ,he datft of death. Such leulls must be II9J'ed bv. ,esponslble QUitet of the fin,nel,l
imtitution or mDf'lgagt holder and indicate cleltlv ,mounn of princlpIIl and intef~t In the decedent's account It the dale of deeth and the tVpe of ICcount,
IC'COUnt nu~ end thl I..ltt R.m. or n.mes in ......ich the Keount is m~i'lcrod.
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INHERITANCE TAX SUMMARY SHEET
(BUREAU USE ONLY)
REY-4U EX" tHO)
File Humber
21-Bl-051j3
Mary csisak
Estate Home
February 15, 19B1
Dote 01 Death
Social Securi ty Humber
197-05-3716
REPORT OF INHERITAHCE TAX APPRAISER
@ Original
o Supplemental
o Remainder
I, tho und,,"lgn.d duly .pp.lnt.d Inh.rlt.nc. T.. Appr.ller In .nd l.r tho C.unty.f (', mh~''''
P.nnlylv.nl., d. ,.Ip.ctfully rep.rt th.t I b.v. .ppr.l..d tho ...1 .nd p....n.1 property .. rop.rt.J In t · .reg.lng
..tvm.t tho v.lu.. I.t forth .pp.I'" ..ch It om In th.I..t c.lumn tho right In Sch.dul.. "A", "8", "C", .nd "E"
O.t.d: October 2. 1991
(HA:~~~t~~E~li oNLY) rREMA\ND~R APPRAISEMENT CODE
INVENTORY
VALUE AS APPRAISED CODE
s NNB 00+
500 00 10+
6,000 62 21J+
NONE 30+
6..5.0
40-
R.ol PropOIty (Schedule Al
Personal Property (Sch.dul. B)
Jolnl.Held Property (Schedul. E)
Tron,f." (Sch.dul. C)
TOTAL GROSS ASSETS
L.u D.bt. and D.ductlons
(SCHEDULE f)
CLEAR VALUE Of ESTATE
o Life E.talO
o Annuity
RATE
FACTOR
PRINCIPLE
FOR USE OF REGISTER ONLY
To.. on $
Tall: on $
T all: on S
~
6%
lS%
Tax on$
TOM on S
e.emptlonl
Total e.tate
TDT.u. TAX
INTEREST FROM
BALANCE
TO
Leu C,edlt.
DATE OF PAYMENT
AMOUNT PAID
5
INTEREST FROM
12+
93-
VALUE
CODE
-
COMPUTATION OF TAX
5
S
S
5-
5
$
5
$
TAX CREDIT
5
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1~,.EV:IIOIEX '" '. ' ,
. I::',;' I';: ,,',' . COMMONWEALTH OF PENNSYLVANIA
: 4 NOH' 69770' DEPARTMENT OF REVENUE
I .' . OFFICIAL RECEIPT' PENNSYLVANIA INHERITANCE AND' ESTATE TAX
; \I .,
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II
=
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~ GaBer F. Fabiankovit~
U ~~g~VED Cbristo her M. Cicconi
. \DDRESS P.O. Box 889
-
TAX AT 6%
TAX AT 15%
TAXAT_%
ESTATETAX
Harrisbur
Pa. 17108
109.33
TOTAL TAX CREDIT
'--ESTATErnFoRMATIoN:---------- ---------------
DAlE OF DEATH Februar 15 1981
FilE NUMBER
21-81-543
lESS DISCOUNT
PLUS % INTEREST
IFROM __ TO_I
DATE OF PAYMENT
October 21 1981
Ma cs1&ak
m
m
TOTAL AMOUNT PAID
109.33
NAME OF DECEDENT
COUNTY
CUmberland
----------------
---------------------------
POSTMARK DATE
REMARKS'
PAID IN FULL
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RECEIVED RV
REGISTEH or- WilLS