HomeMy WebLinkAbout06-06-07
~
15056041114
REV-1500 EX (06-05)
OFFICIAL USE ONLY
County Code Year
File Number
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
dl DI
0124
Date of Birth
191-18-3865
02012007
05091924
Decedent's Last Name
Suffix
Decedent's First Name
MI
MIXELL
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
KATHLEEN
C
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
CiD 1. Original Return
D 4. Limited Estate
DD
D
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
D 2. Supplemental Return D 3. Remainder Retum (date of death
prior to 12-13-82)
D 4a. Future Interest Compromise (date of D 5. Federal Estate Tax Return Required
death after 12-12-82)
D 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Trust)
D 10. Spousal Poverty Credit (date of death D 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
ROBERT M. FREY
Firm Name (If Applicable)
FREY AND TILEY
First line of address
REGIS~
5 SOUTH HANOVER STREET
Second line of address
-n
I =:~
'-.0
City or Post Office
State
ZIP Code
o
DATE FILED '-.0
CARLISLE
PA
17013
RD, NEWVILLE PA 17241/2160 VALLEY ROAD, ENOLA PA 17025
SIGNATURE F PREPARE~EI:i~t,N REPRESENTATIVE
ADDRESS
5 SOUTH HANOVER STREET, CARLISLE, PENNSYLVANIA 17013
PLEASE USE ORIGINAL FORM ONLY
DATE
Side 1
L
15056041114
15056041114
~
.-J
15056042115
REV-1500 EX
Decedent's Name: KATHLEEN C MIXELL
RECAPITULATION
1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . . .
4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . . .
6. Jointly Owned Property (Schedule F) DSeparate Billing Requested. . . . . . . .
I 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) DSeparate Billing Requested. . . . . . . .
8. Total Gross Assets (total Lines 1-7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
191-18-3865
Decedent's Social Security Number
1.
2.
3. NONE
4. NONE
5.
6.
7.
8.
9.
120000.00
278496.00
171661.00
1376.00
15528.00
587061.00
9. Funeral Expenses & Administrative Costs (Schedule H) . . . . . . . . . . . . . . . . . . .
33989.00
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . . . . 10.
11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . .. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . .. 14.
TAX COMPUTATION. SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable at
the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X.O 0
16. Amount of Line 14 taxable
at lineal rate X .0 ~
17. Amount of Line 14
taxable at sibling rate X . 12
18. Amount of Line 14 taxable
at collateral rate X . 15
547943.00 16.
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L
15056042115
15.
17.
18.
15056042115
5129.00
39118.00
547943.00
0.00
547943.00
0.00
24657.00
0.00
0.00
24657.00
D
.-J
REV-1500 EX Page 3 191-18-3865
Decedent's Complete Address:
File Number
21-07-00124
DECEDENTS NAME DECEDENT'S SOCIAL SECURITY NUMBER
KATHLEEN C MIXELL 191-18-3865
STREET ADDRESS
177 CENTERVILLE ROAD
CITY II STATE I. ZIP
NEWVILLE PA 17241
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. CreditS/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
24657.00
3. InteresUPenalty if applicable
D. Interest
E. Penalty
Total Credits ( A + B + C ) (2)
0.00
TotallnteresUPenalty ( 0 + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
FIJI in oval on Page 2, Line 20 to request a refund. (4)
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5)
A. Enter the interest on the tax due.
(SA)
24657.00
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
24657.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D
b. retain the right to designate who shall use the property transferred or its income; . . . . . . . . . . . . . . " D
c. retain a reversionary interest; or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " D
d. receive the promise for life of either payments, benefits or care? . . . . . . . . . . . . . . . . . . . . . . . . . . . " D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? " 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No
o
o
o
o
o
[K]
o D
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for
the use of the surviving spouse is three (3) percent [72 P.S. ~9116 (a) (1.1) (i)).
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory
requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for
the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half
(4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. A sibling
is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
217
REV-1502 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF FILE NUMBER
Kathleen C Mixell 21-07-00124
All real property owned solely or as a tenant In common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which Is jolntly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
Real Estate, 177 Centerville Road, West Pennsboro Twp, Cumberland County
VALUE AT DATE
OF DEATH
120,000
TOTAL (Also enter on line 1 RecaDitulation)
(If more space is needed, insert additional sheets of the same size)
$
120 000
DESCRIPTION OF REAL ESTATE IN THE
ESTATE OF KATHLEEN C. MIXELL
ALL THAT CERTAIN tract of land situate in West Pennsboro Township,
Cumberland County, Pennsylvania, bounded and described as follows:
BEGINNING at a point in the gutter on the eastern side of Pennsylvania
State Highway Route 233, at corner of lands of Paul A. Mixell and Gloria J.
Mixell, his wife, described in Cumberland County Deed Book "I," Volume 21,
Page 763, which has themailingaddressofI75CentervilleRoad.Newville.PA
17241; thence from said point at the place of beginning along line of said land
known as 175 Centerville Road, North 58 degrees 50 minutes East a distance of
200.00 feet to a point in line oflands now or formerly of Donald T. McCullough;
thence along line of said land now or formerly of Donald T. McCullough, South
28 degrees 37 minutes East a distance of 75 feet to an iron pin; thence still along
line of said land now or formerly of Donald T. McCullough, South 58 degrees 50
minutes West a distance of 200.00 feet to a point in the gutter on the eastern side
of said Pennsylvania State Highway Route 233; thence along said Pennsylvania
State Highway Route 233, North 28 degrees 37 minutes West a distance of 75 feet
to an iron pin at the Place of BEGINNING.
THERE IS EXCEPTED from the above described tract of land a portion
of it which was granted and conveyed to Commonwealth of Pennsylvania,
Department of Transportation, by instrument dated June 17,1983 and recorded
September 27, 1983, in the hereinafter named Recorder's Office, in Deed Book
"J," Volume 30, Page 1011.
THE TRACT of land herein conveyed has erected thereon a dwelling
house which has themailingaddressofl77CentervilleRoad.Newville.PAI7241.
THE WITHIN conveyed property is a portion of the tract of land which
Donald T. McCullough and Helen G. McCullough, husband and wife, by deed
dated July 3,1962 and recorded July 19, 1962, in the Office of the Recorder of
Deeds, in and for Cumberland County, at Carlisle, Pennsylvania, in Deed Book
"0," Volume 20, Page 960, granted and conveyed to Sylvester A. Mixell and
Kathleen C. Mixell, husband and wife.
THE SAID Sylvester A. Mixell having died on January 10, 2005, title to
the same remained vested by operation of law solely in his surviving spouse,
Kathleen C. Mixell.
217
REV-1503 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
Kathleen C Mixell
FILE NUMBER
21-07-00124
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
Orrstown Bank, Account #50001367007, Investment Holdings as of Date of Death
Accrued I nterest as of Date of Death
VALUE AT DATE
OF DEATH
276,588
1,908
TOTAL (Also enter on line 2 Recaoitulation)l$
(If more space is needed, insert additional sheets of the same size)
278 496
APR~05-2007 THU 01:06 PM
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FAX No. 2412004
p. 002
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'.INVESTMENT HOLDINGS AS OF 2J1107 (000)
~'~..;.' , ;,':, ;. . .Doti:-PmCEt'~~CC~~EO 'NTEREST ,: ..i' "~f .
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111XtJPf2 FHL8 6% 111111t5 30.000.0000 C,:, ,~.71UO :;. ~ I' ,.' 9t..~';.^ 837Q.00
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217
REV-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Kathleen C Mixell
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21-07-00124
Include the proceeds of litigation and the date the proceeds were received by the estate.
All Drooertv lolntlv-owned with rlaht of survivorshiD must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION
1 2005 Toyota Cambry Automobile
2 Miscellaneous Household Goods
3 ACNB, C/O #2990043
4 ACNB, SuperNOW Acct #221-481
5 Orrstown Bank, Checking Acct #401374
6 Orrstown Bank, C/D#4000001071
7 M&T Bank, C/O #031003914691710
8 Refund, Capital Blue Cross
9 Refund, Comcast Cable Communications
10 Refund, Embarq
11 Refund, MetLife Automobile & Home Policy #37A 740 361816-0
VALUE AT DATE
OF DEATH
15,000
10,000
4,869
23,672
30,415
84,012
2,987
405
49
4
248
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
171,661
March 20, 2007
Frey & Tiley
Attn: Robert M Frey
5 South Hanover Street
Carlisle P A 17013
Re: Estate of Kathleen C Mixe11
Dear Mr. Frey:
The following information is being provided as per your request:
Acct. Type Account No. Account Accrued Ownership Date Opened
Principal Interest
on to
D.O.D. 0.0.0.
Passbook 96-5213-2 $446.53 $0.15 Jt wi Tyler 12/31/02
Savings MixeD
Passbook 96-5532-8 $2,301.64 $0.96 Jt wi Randall 12/31/02
Savings Scott Belgard
Certificate of 2990043 $4,709.35 $159.63 Jt wi Sylvester 2/26/98
Deposit MixeD
Super NOW 221-481 $23,671.82 $0.32 Individual 2/16/88
Account
Individual 4550919-2 $15,481.81 $46.67 Individual 2/10/05
Retirement
Account
~
ADAMS
COUNIY
NATIONAL BANK.
~~
Inquiries concerningACNB Corporation stock information should be directed to the Registrar and Transfer
Company at 1-800-368-5948. If you need any additional infOrmation, please contact me at (717)339~5122..
PO Box 3129, GETTYSBURG, PA 173251 PHONE 717.334.31611 TOll.REE 1.888.334.ACNB (2262) I www.acnb.com
11 M&fBank
499 Mitchell Road, MiIIsboro, DE 19966 Mail Code DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
March 16, 2007
Frey & Tilley
Attorneys At Law
5 South Hanover Street
Carlisle, Pennsylvania 17013
Re.: Estate of' Kathleen Mixell
Social Security: 191-18-3865
Date of Death: February 1.2007
Dear Sir or Madam:
Per your inquiry dated March 13, 2007, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
1.
Type of Account
Certificate of Deposit
Account Number
031003914691710
Ownership (Names of)
Kathleen Mixell *
Sylvester A Mixell *
Opening Date
01/02/98 Closed 02/08/07
Total
$2,977.03
$ 9.60
-"Ii986. (ff--------------------------------------------------------
Balance on Date of Death
Accrued Interest
Plea'le be advised, there was no safe deposit box fOlmd for the above decedent.
* For further account information, regarding ownership, closures and/or reimbursement of funds, etc., please call
the Colonial Park Office # 717-255-2233.
Sincerely,
~....-./ ..
~7/
=z
Records Management
ORRSTOWNBANK
A Tradition of Excellence .
March 13,2007
77 East King Street
P.O. Box 250
Shippensburg, PA 17257
To: Frey & Tiley
5 South Hanover Street
Carlisle, Pa 17013
From: Traci Shaffer
Orrstown Bank
Customer Service Center
PO BOX 250
Shippensburg, Pa 17257
Re: Estate of Kathleen C. Mixell
Date of death February 1,2007
11' IS HERERBY CERTIFIED THAT THE ABOVE NAMED DECEDENT, ON THE
ABOVE DATE, HAD THE FOLLOWING ACCOUNTS WITH ORRSTOWN BANK
CHECKING ACCOUNT
Account # Title of Account
401374 Kathleen C Mixell
, Date opened Principle Accrued Interest
09/06/94 30411.65 3.74
SA VINGS ACCOUNT
Account # Title of Account
Date opened Principle Accrued Interest
CERTIFICATE OF DEPOSIT
Account # Title of Account
40000010701 Kathleen C Mixell
Date Opened Principle Accrued Interest
05/30/06 84000.00** 11.85
**Funds transferred from Members 1st
217
REV-1509 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
Kathleen C Mixell
FILE NUMBER
21-07-00124
If an asset was made Joint within one year of the decedent's date of death, It must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Tyler Mixell
B. Randall Scott Belgard
C.
JOINTLY -OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 12.31.02 ACNB, Passbook Savings, Acct #96-5231-2 447 50.00% 224
2. B. 12.31.02 ACNB, Passbook Savings, Acct #96-5532-8 2,303 50.00% 1,152
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
TOTAL (Also enter on line 6 Recaoitulation) S 1376
(If more space is needed, insert additional sheets of the same size)
March 20, 2007
Frey & Tiley
Attn: Robert M Frey
5 South Hanover Street
Carlisle P A 17013
Re: Estate of Kathleen C Mixell
Dear Mr. Frey:
The following information is being provided as per your request:
Acct. Type Account No. Account Accrued Ownership Date Opened
Principal Interest
on to
D.O.D. D.O.D.
Passbook 96-5213-2 $446.53 $0.15 It wi Tyler 12/31/02
Savings Mixell
Passbook 96-5532-8 $2,301.64 $0.96 It wi Randall 12/31/02
Savings Scott Belgard
Certificate of 2990043 $4,709.35 $159.63 It wi Sylvester 2/26/98
Deposit Mixell
Super NOW 221-481 $23,671.82 $0.32 Individual 2/16/88
Account
Individual 4550919-2 $15,481.81 $46.67 Individual 2/10105
Retirement
Account
/"-.....
ADAMS
COUNIY
NATIONAL BANK
ffZ~
Inquiries concerning.ACNB Corporation stock information should be directed to the Registrar and Transfer
Company at 1-800-368-5948. If you need any additional information, please contact me at (717)339-5122.
~-
."'1
, ~ ~ A .
PO Box 3129, GETTYSBURG, PA 173251 PHONE 717.334.31611 TOllFREE 1.888.334.ACNB (2262) I www.acnb.com
217
REV-1510 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
Kathleen C Mixell
FILE NUMBER
21-07-00124
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPUCABlE) VALUE
1. ACNB, IRA Account 4550019-2 15,528 100.00% 15,528
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
TOTAL (Also enter on line 7 Recaoitulation) $ 15 528
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
(If more space is needed, insert additional sheets of the same size)
March 20, 2007
FreY & Tiley
.Attn: Robert M Frey
5 South Hanover Street
Carlisle P A 17013
Re: Estate ofKatbleen C Mixell
DeaiMr. Frey:
The following infonnation is being provided as per your request:
Acct. Type Account No. Account Accroed Ownership Date Opened
Principal Interest
on to
D.O.D. D.OD.
Passbook 96-5213-2 $446.53 $0.15 . It wI Tyler 12/31/02
Savings MixeI1
Passbook 96-5532-8. $2,301.64 $0.96 It wI Randall .12131102
Savings Scott Belgard
Certificate of 2990043 $4,709.35 $159.63 It wI Sylvester 2/26/98
Deposit Mixe11
Super NOW 221-481 $23,671.82 $0.32 Individual 2/16/88
Account
Individual 4550919-2 $15,481.81 $46.67 Individual 2/10/05
Retirement
Account
/"-......
ADAMS
COUNIY
NATIONAL BANK
~~
Inquiries concemingACNB Co1p()ration stock information should be directed. to the Registrar and Transfer
Company at 1-8~-368~5948. .Ifyou need any additional inf<mnatiOD, please co~ me at (717)339';5122..
Sincerely,
.-
PO Box 3129, GETTYSIlURG,PA 173251 PHONE 717.334.31611 TOIJ.FlEE 1.888.3J.f.ACNB (2262) I www.acnb.com
217
REV-1511 EX + (12-99)
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Kathleen C Mixell
FILE NUMBER
21-07-00124
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Ewing Brothers Funeral Home, Funeral Service 11 ,303
2. Funeral Luncheon 575
3. Funeral Flowers 148
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees 21 ,450
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 448
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Filing Fee, PA Inheritance Tax Return 15
8. Register of Wills, Additional Probate Fee 50
TOTAL lAlso enter on line 9 Recapitulation) $ 33 989
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
T
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
Kathleen C Mixell 21-07-00124
Report debts Incurred by the decedent prtor to death which remained unpaid as of the date of death, Including unrelmbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
5,129
217
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENt DECEDENT
ESTATE OF
Kathleen C Mixell
SCHEDULE J
BENEFICIARIES
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1 Paul A. Mixell, Jr, 312 Birch Lane, Hummelstown PA 17036 Grandson 1/12% residue of the estate
2 Kathy Frederick, 171 Centerville Road, Newville PA 17241 Granddaughter 1/12% residue of the estate
3 Anthony Wayne Mixell, 1276 Kline Place, Rahway NJ 07065 Grandson 1/12% residue of the estate
4 Tyler A. Mixell, 506 S. Fayette Street, Shippensburg PA 17257 Great-Grandson 1/12% residue of the estate
5. Paul A. Mixell, 175 Centerville Rd. Newville PA 17241 Son 4/12% residue of the estate
6. Wayne M. Mixell, 2160 Valley Road, Enola PA 17025 Son 4/12% residue of the estate
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0
FILE NUMBER
21-07-00124
(If more space is needed. insert additional sheets of the same size)
LAST WILL AND TESTAMENT
OF .
KATHLEEN C. MIXELL
I, KATHLEEN C. MIXELL, of West Pennsboro Township (mailing address: 177
Centerville Road, Newville, pA 17241), Cumberland County, Pennsylvania, being of sound and
disposing mind, memory, and understnnding, do hereby make, publish, and declare this as and for
my Last Will and Testament, hereby revoking and making void any and all Wills by me at any time.
heretofore made.
1. I direct my hereinafter named Executor or Executors to pay all of my just debts and
funeral expenses as soon after my death as may be found convenient to do so. I direct that my
body be cremated and that my funeral services be conducted by Ewing Brothers Funeral Home, 630 .
South Hanover Street, Carlisle, Pennsylvania, and that my ashes be delivered to my Executor or
Execlltors for disposition .in whatever manner is deemed appropriate by my Executor or Executors.
2. I direct that all inheritance, transfer, estate, succession, and death taxes which may be
payable on account of my death, including interest and penalties thereon, shalI be paid from the
residue of my estate regardless of whether the assets upon which such taxes are based are included
i 11 my probate estate.
3. All the rest, residue, and remainder of my estate, real, personal, or mixed, and.
wheresoever the same may be situate, I give, devise, and bequeath to my husband, SYLVESTER A.
MlXELL, his heirs and assigns, to the exclusion of my children, born and unborn.
4. Should my said husband, Sylvester A. Mixell fail to survive me, I give and bequeath
all lawn care equipment and tools including tractors and mowers to my son, PAUL A. MIXELL, but
should he predecease me then the same shalIlapse and b~ included in the residue of my estate.
5. If at the time of my death I am the owner of the mobile home park located at 75
Bonnybrook Road in South Middleton Township, Cumberland County, Pennsylvania, I give, devise,
and bequeath the same. including all mobile homes and equipment located at said park which are
owned by me, in equal shares to my two sons, PAUL A. MIXELL and WAYNE MELVIN
MIXELL, their heirs and assigns, provided each of them shall survive me by a period of ninety (90)
days, but should either of them fail to so survive me then the share such deceased son would have
received shall pass to such of his legitimate issue as shall survive me by a period of ninety (90)
days, their heirs and assigns, per stirpes.
6. Should my said husband Sylvester A. Mixell fail to survive me. then in such event, all
the rest, residue and remainder of my estate, real personal and mixed, and wheresoever the same
may be situate, I give. devise and bequeath as follows:
(a) 5% to my grandson, PAUL A. MIXELL, JR., his heirs and assigns.
provided he shall survive me by a period of ninety (9Q) days, but should he fail to
so survive me then to such of his legitimate issue as shall survive me by a period
of ninety (9Q) days, their heirs and assigns, per stirpes, and if there be no such
issue the same shall lapse and be added proportionately among the other legatees
set forth in subparagraphs below.
(b) 5% to my granddaughter KATHY FREDERICK, nee MIXELL, her
heirs and assigns, provided she shall survive me by a period of ninety (90) days.
but should but should she fail to so survive me then to such of her legitimate
issue as shall survive me by a period of ninety (90) days, their heirs and assigns,
per stirpes, and if there be no such issue the same shall lapse and be added
proportionately among the other legatees set forth in subparagraphs above and
below.
(c) 5% to my grandson, ANTHONY WAYNE MIXELL, his heirs and
assigns, provided he shall survive me by a period of ninety (90) days, but should
he fail to so survive me then to sue:1 uf his ItgililllullO issue as shall survive me by
a period of ninety (90) days. their heirs and assigns, per stirpes, and if there be no
such issue the same shall lapse and be added proportionately among the other
legatees set forth in subparagraphs above and below.
(d) 5% to my great-grandson TYLER A. MlXELL, his heirs and assigns,
provided he shall survive me by a period of ninety (90) days, but should he fail to
so survive me then to such of his legitimate issue as shall survive me by a period
of ninety (90) days, their heirs and assigns, per stirpes. and if there be no such
issue the same shalIlapse and be added proportionately among the other legatees
Page I of 2 pages
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set forth in subparagraphs above and below.
(e) 20% to my son, PAUL A. MlXELL, his heirs and assigns, provided
he shall survive me by a period of ninety (90) days, but should he fail to so
survive me then to such of his legitimate issue as shall survive me by a period of
ninety (90) days, their heirs and assigns, per stirpes, and if there be no such issue
the same shall lapse and be added proportionately among the other legatees set
forth in-subparagraphs above and below.
(f) 20% to my son, WAYNE MELVIN MIXELL, his heirs and assigns,
provided he shall survive me by a period of ninety (90) days, but should he fail to
so survive me then to such of his legitimate issue as shall survive me by a period
of ninety (90) days, their hefrs and assigns, per stirpes, and if there be no such
issue the same shall lapse and be added proportionately among the other legatees
set forth in subparagraphs above.
7. The meaning of "legitimate Issue" as used in this Last Will and Testament shall
be limited to a child or children born to a female descendent of Testator regardless of whether the
mother is married to the father of such child or children, and shall be limited to a child or children
born to a male descendent of Testator where the father of such child or children is married to the
mother either before or after the birth of the child or children. In any case the meaning of child or
children or legitimate issue as used above shall not include any adopted child or children.
. 8. I hereby nominate, constitute, and appoint my husband, SYLVESTER A.
MIXaL, as Executor of this my Last Will and Testament, but should he predecease me or fail to
qualify, or cease serving as such, then in such event I nominate, constitute, and appoint my two sons,
PAUL A. MIXELL and WAYNE MELVIN MIXELL, as alternate or successor Executors and I
further direct that none of them shall be required to post any bond to secure the faithful
performance of his duties in the Commonwealth of Pennsylvania or in any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and
Testament written on 2 pages, this 10th day of June, 2003.
~ ClCkiU4t_ ~ 1M ~t, L/J (SEAL)
KATHLEEN C. MIXELL
Signed, sealed, published and declared, by KATHLEEN C. MIXELL, the Testatrix above
named, as and for her Last Will and Testament, in our presence, who, in her presence, at her request,
and in the presence of each other, have hereunto subscribed our names as attesting witnesses.
~~hf_ "hi
4 rJ. cL~
Page 2 of 2 pages