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, QU~STIONS CONCERNING PROPI:RTY TRANSFERS,
1. Dldde~ede,nl,WlthIl1IWO,'yenrS ofdoath, make anY lrnnsfor of any mutorlalpnrt of his 0, state wlUlbut rO,celvl,n~
valua~le an,d adaquate conslderullon'/ (Answer "Yes" or "No".) NO , ' "
2, Old decadent, ,Within II\Ij years of death, transfer property from hhnself/ herself to hlmself/horsolf and another parly
or parties (Including a spouse) In Joint ownership? (Answer "Yes" or "NO",).J:!Q..... , ,
3, If the;answer 10 One or lwonbove Is "Yes" and the lrnnsfers me claimed to lie nontaxable, plovlde the [ollowlng
Information: ' ' ' '
a. Ago of decadonlntUme of transfer, ' N/A
Ii,C:Opy of death certificate,
Q, Affidavit by theullend,lnll physician Indicating the state o( decedent's health at time of transfer,
d. All other Informallol1 suppolllng nonlaxablllty of transfer,
4. Dlddecedel1t, In his/her lifetime, make aliy transfor olproperty without receiving a valuable or udequale COnsideration
tharefor which Was to lake effect In possession or enjoyment at or aflerhls/her dealtl? (Answer "Yes" or "No",) NO,
Ii, Was there,lll1yposslblllty that the property transferred might relurn to transferor or hls/hor estate, or be subJeot .
, to his/her pqwer of disposition? (Answer "Yes" or "No" ,) NO '
b,What was the transferee's a~o at time of decedent's death? N/A'
6, Old decedent In,hls/her lifetime make any transfer without receiving a valuable and adequate consideration therefor
undor which transferor expressly or Impliedly reserves for hls/hor life or any period which does In fact end before hls/har
death: " "
a, The possession or enjoyment of or the right 10 l~colllo'frol1\ tho property transferred?, (Answer "Yes"or f'Nq" ,), HO
Ii,The rl~ht to designate the persons who shall possessor enjoy the property transferrodor Inoome thern.frol1l?
(Answer "Ves" or "No" ,) no '
~; IHhe answer to live h, above IS"Ves," was tho right reservod in docodent alono( ) or dooodont and OlllQrS ( ),
7, Old decedenUn his/her II fell rI1e make a transfer, the consideration for whloh was transferoe's promise to pay Income
to or for the bonelll or care 0 I transferor? (Answer liVes" or "No".) NO
8, Old decedent, at anytime, transfer property, the bmoficial enjoyment of which wassubjeot to change, beoauseof
a reserved power to alter, amend, or revoke, or which could revort to deoedent under terllls of transfer or by operation of
laW? (AnSWer "Yes" or "No" ,) NO'
9". I the answer tOlll ght above Is "Yes," was the power to alter, amend or revoke the Inleres,t of the beneflolaryreserved
I the deoedent alone ( ) or decedimt and others ( ).
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. eOMMONWM~ rH Of PENNSVWANIA
nUPAIITMENT Of RUVSNUE
rRANSrEH INHURITANOe TA)(
IIEalOENT PEcuonNT
SCHgDUI.E "0"
llENEPIOlAAIES
'*
(lnSltuatIOIl.1 on ROVor8~ SIt/ol
Estate of
OSMn Ji', DIOlt
llBNIiFIOlARles AND APPRIiS$1!8 ReLATIoNSHIP SURVIVED DATE OF
; ," DECEDENT PIRTH
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IN'rERIIST OFQIlNIIFICIARV
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Ilonald L. 010k
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oa~11Uo. Pelll1t~Y :tv/;\n:1~
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Da,unhuer Yoe
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The above beneflolarlal ere living at thll time el<oapt for thafollpwlngl
HO~lrn
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PATIiOF DeATH
;
W!LRUCl;IONS E8RCOMf.kRTING SC~ROU\.E"Ei'
'Sohpdulo 'Ie" must Inoludo all property, 1'001 and por80nol, ownod by tho dqcodont )oln'iIYWlth ,another
party or parties as joint tenants with rluht of survlvorshl!" Both tal1\11blo and Intanolblo P(oportYaro to bll
Inoludod, \..Ist roal esta\o first,
1. D080ri\:l0 011 raollHoPorty as ,\ndlt:alatlln the h18lruU\lon8 for Sohodulo ,. A" ,Doscrll)o 011 parsonol property
aelnqlouted 1.11 tha Instruollons for Sohodulo "ll", Includs Iho name, address U11d rolollon.hlp IU tho
dooodent of ths oo-pwnor (s) ond lho dOlO tl10 jt)lnl ownorshlp was oslobllsl\ocl-
2. Indloote tha to\ol markot Voluopf Iha Jointly Clwnod proporly.
3,lndloate tha porcsnto\10 or Iho deoadent's ,Intorosl,
4. Indloeto tho morkotvellio of Iho decodonl's Inlorosl,
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COMMONWIALTH Oil 'INNSYLVANIA
COUNTY Oil CUMIIRLAND
L
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III
Ootober
_ t:/t ",. ^-.:? ',~~
MilvfsLL J""O. 1;\J:,\ljlhtN iU LOUIIIY
.' MY COM ISSION EXrllRlS UCl.J, 1084
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beln9 duly, .,... ,awr.;>,~'"IL,~':__,. ftodordln9 Id law, dopou. and, "y, that fl/,. "j 1'l_1J1l3 pUl'vl.HulL",__,
..s2_~~~,L.~,____,_,,_,__+___.,:,,~ ,_", o( tho H.hto of ~ OaOEl11 1", Dj,Q.!L~____-~_~~
leltClf _.."l'l9.rlih Mid.(lleaol( /~19Wnl\lhj,n+"'''_'_'h_' Cumberland OClunty, P." d,oulOd .nd th.tth.
within I. an Invontory Ill_do by b...JtU.Hu:'YJ1,Jl.d2;lQIC____-;_uu..c.__, tho, ..Id, aUl'yivil'1e;sp6use
e(tho tn,llro 0, .t, lie of ",'d d.oodonl, oon.l.tln9 of all the penonal proR~rly end r..1 o,t~to, .xoopt rOIl ..tat., oUh\d.
tht COrl)monw~~lth of Ponn.yII'Mle\ ,'nd thai Ih. 119ure. oppo.lt. oaoh Item of the Inl'entory "P""nt It', f.lr y. u.
1\ Clf thed.to of deoodont",de,lh, ' ,
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HERITANCE TAX INFORMA 10
Unlall,f1.d Iiabilltlollncurrocl by tho docodontptlor to hla/hor dooth oro doductlqlo oualnlt hll/hor tail'ablo
IItot.. In addition to dobtllncurrodby tho docodont or altoto, alhot Iloml aro clolmoblo Including tho colt'ol
admlnlltrallon, atlarney 1'01, fiduciary lou, funoral and burial aKllonUI Including tho COlt 01 0 burial lot, tomblton.
or grovo mark.r lind, athor r~lotod burial oxponlU. ' ,
All debtl bolng clalm.d ogoln.' on OIto,taora $ubloct to the approval 01 the Regllter 01 Willi with whom tho
Inhorltonc. TOI:,R.turn II IlIed. Evldoncoto lupport the doceclont's or tho oltoto'lliohllity lor tho d.btl b.lng
clolm.d Ihould bo otlach.d ,10 this Ichedulo.
A lomlly 'x.mptlon moyb. clalm.d byo IpoUse ,010 d.cedent who dledd~mlclled In Pennsylvania. II there II
no Ipoase, or II the IPOUIO hOI lorl.lted hll/horrlghll, thon any child of tho decedent who II a m.mber of the ',ome
household con claim tho 'xemptlan.,In thCl event thero II no luch apoUllar child, the ClMlI11ptlon con b, clall11.dby
o paront or parClnta whoaro memborlol thCl lamo houlohold althCl dClcedent, The lomlly exemption II ollowobl. only
ogolnlt ollets which Pall by a will or by the Ponnlylvonlo Intutate Laws. ' '
NOTEICompenlotlon pold to an estato rClpruentatlvClI nam.ly, on OKlcutoro, administrator, lor services
p~rlorlJ\ed In a,dmln,sterlng an tltate Is reportable lor Pennayl vania Incom. TOM purposu. Thl, taxable Income
Item .hould bo reported on form P A.40.lndl vidual Income Tax Return. '
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INSTRUCTIONS FOR COMPLETING SCtl5QJ.Ll.E "~"
t. ,1.1 thClfo'mlly OKempllon 'Is b.lng clalm.d, Indicate the claimant'. nome, addroll and his/her relatlonlhlp to
the decedent. Entot "fomllyoxemptlon" In the romork. column and tho amoun,t claimed In th' amount coluinn.
2. Alllgn consecutive number,. to each,lIem lI.ted., '
3; Enter tho date on which each d.bt was Incurred ond/or pold.
4. Ent.r th e nomei 01 each payee, , ",
5, Provide a brlo( ewplanatlon In thCl rernarks,column lot each dobt clolmed.
6. Enlorth. OOlO,unl ohlach debt being claimed. ,
7, The lorm,mult be signed by the person who hot aSlumed the rnponslblllty lor poylng the debt II.
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IP ADDITIONAL SPACE IS NECESSARY USE 8Yz" x 11" SHEETS.