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Home My WebLink About06-22-07 (2) ~ 15056051047 REV-1500 EX (06-05) 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 OFFICIAL USE ONLY INHERITANCE TAX RETURN RESIDENT DECEDENT Date of Birth Decedent's Last Name Suffix MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW .. 1. Original Return c::> 4. Limited Estate c::> 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c::> 2. Supplemental Return c::> c::> c::> 4a. Future Interest Compromise (date of death after 12-12-82) c::> 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c::> 10. Spousal Poverty Credit (date of death c::> 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 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes - Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. PO SIBLE FOR FILING RETURN ../AA- ADDRESS J) 350 1J6h Ie v-' mt'f/ 126Jqd Ai:!. W O'f--Co....J SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE fli /73.5<:9 DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 --.J ~~ ---I 15056052048 REV-1500 EX Decedent's Name: RECAPITULATION 1. Real estate (Schedule A). .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages &'Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Schedule F) c:::> Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c:::> Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 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 Subjectto 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 .0_ 16. Amount of Line 14 taxable at lineal rate X.O_ 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE.. .,. . . . .. . ., . .. .. . ., . ., . . . . . . .. . . . . . . .. .. . . . . . . . . . .. . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT iV ~" \ ~~ ~vf cr: L..- 15056052048 Side 2 Decedent's Social Security Number 15. 16. 17. 18. c:::> 15056052048 ....J REV-1 !jOO EX Page 3 , Decedent's Complete Address: DECEDENT'H~~' ~~~~~e tlf U( ~____~__ STREET ADDRESt ~2() ~~_~ Hlnfh It m~~~~__~ ~ _~~~~ i. ~~~ ___~_.___~ ~_____~ CITY G- I-A r11 J'l m File Number 2aa7- CO oz... ~~TSTATp fj-~ -----TzIP-~~--------.. il 7 tJ Z 7 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) #5/,5 r Total Credits (A + 8 + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty ------- .. ~--~-~-~ Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (58) A. Enter the interest on the tax due. if j (,5 r f Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No 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 18I 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................... ........................................................................ ... ... .... ..... .... D 1&1 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 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 exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-15q2 ~X+ (6-9W COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER /Jele.AI ('(J RenOO J.()(J7-o0ifOZ. 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 jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH JJoAe TOTAL (Also enter on line 1, Recapitulation) $ 0 (If more space is needed, insert additional sheets of the same size) REV.1\i03 EX. (1.97) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF HeletJ m ReAlize I FILE NUMBER 2(Ja7-oo~ All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH ;1)DNf- TOTAL (Also enter on line 2, Recapitulation) $ " IIf mnrl> '.m::l~I> i!': nAMed. insert additional sheets of the same size) -'~..'''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C ClOSEl Y.HElD CORPORATION, PARTNERSHIP or SOlE.PROPRIETORSHIP ESTATE OF Me I~n m. {(en tze I FILE NUMBER ..J. () 0 7 -CJd q () z., Schedule C.1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH ;1J 0 tV f:- TOTAL (Also enter on line 3, Recapitulation) $ 0 (If more space is needed, insert additional sheets of the same size) REv-1505EX + (1-87)' SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF H~ Ip AI m ffent z.e I FILE NUMBER cloo7-oolfoZ- 1 , Name of Corporation Address City 2. Federal Employer I.D, Number 3. Type of Business Zip Code State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year State Product/Service 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? D Yes D No If yes, Position Annual Salary $ Time Devoted to Business 6, Was the Corporation indebted to the decedent? D Yes D No If yes, provide amount of indebtedness $ 7, Was there life insurance payable to the corporation upon the death of the decedent? DYes D No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes D No If yes, D Transfer D Sale Number of Shares Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. Consideration $ Date D Yes D No 10. Was the decedent's stock sold? DYes D No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? DYes D No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? D Yes D No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax retums (Form 1120) for the year of death and 4 preceding years. C, If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s, If real estate appraisals have been secured, attach copies. D, List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedenfs stock. REV-1S06 EX+ (9-00) SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF fie Ie () rn Renfzel FILE NUMBER 2. ()(J 7- (j(J <t (J z. 1 . Name of Partnership Address Date Business Commenced Business Reporting Year City 2. Federal Employer I.D. Number 3. Type of Business State Zip Code Product/Service 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ 5. A. B. c. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. 0 Yes 0 No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold Consideration $ Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? . . . . .. 0 Yes 0 No If yes, provide a copy of the agreement. Date 11. Was the decedent's partnership interest sold? ....................................... 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... 0 Yes 0 No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/so If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. . REV-150? EX+ (1-97) SCHEDULE D MORTGAGES & NOTES RECEIVABLE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF fleJeAl , FILE NUMBER m R en -J 1e I c:2 ()() 7- 00 'f 0 Z. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. AJOAlf TOTAL (Also enter on line 4, Recapitulation) $ 0 (If more space is needed, insert additional sheets of the same size) REV.l508 EX + (1-97) , SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF lie/ell IYl RenfzeJ FILE NUMBER .2 oa7-CJ(J 'faZ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. p~ (3 A n k -C hec I< 111c.. P/ll~ BAnk- Cer-+ I~IC ~te DESCRIPTION .Jf .5/-fi'O()(J 'o~l( a ~ .D~ ~S (1' -=Ft 31706Z bill> I Cf VALUE AT DATE OF DEATH 3c)3~. ?7 :3/57.97 po Bd'i 53523" f. tis burG-A. fit }5..2 53-523d TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) $ f>.39b.9'q , Rtv-1509 EX + (1-97) '* SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ).Jelen YYl /foni ze I FILE NUMBER .:l CJ(j 7 ~ao q 0 z. 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. /Uo.A/~ B. c. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY '10 OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. .AJ d Jf} e. TOTAL (Also enter on line 6, Recapitulation) $0 (If more space is needed, insert additional sheets of the same size) ~"'"..,," '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTAneOt n ~ 11= m f(en-fte / SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBA TE PROPERTY FILE NUMBER ~ oo7-0ogaz. 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. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ATTACH A COPY OF THE DEED FOR REAL ESTATE. NUMBER VALUE OF ASSET INTEREST IIF APPLICABLE \ 1. )JoAl<2... TOTAL (Also enter on line 7, Recapitulation) $0 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF J-k Ie n m If~frfze/ SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Debts of decedent must be reported on Schedule I. FILE NUMBER :1 aa 7- 0 cJ V tJ z.. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _Zip Year(s) Commission Paid: 2. Attorney Fees 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ C> (If more space is needed, insert additional sheets of the same size) , REV-1512 E:+ (12-03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTAT~ OkF. tie r1 m tlenftel FILE NUMBER .:2ao7-cJavoz- Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH AfA,1 Ren t- P,nnn-cle Aer+lth-- CDnf/nUI(1G- CAfle. ~,II"e. ~ees ,C(.,(mb.er-Inh J Carnbe..../nnd C~()5Slnc;:. ffL Erec-t ~ Ie ~d.\I, +le s SaO.aO ,;2:loq.S? 3 8'.,? i (1" 103 d (J 4 tJO.dd 3.J.57 'Ve firz 0111 101,52-- TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 33g-d,~~ . REV-1513 EX+ (9-00) -. . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF J/ek# m fen fze I NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. C~A\o- (<.onize/, 1/5 C,1t-I,.. (!!f<.deJ)Ay-+onR 81?1\Ch, C I 32/Z.~ 2. 1711- (lid 4 R~ niZe I. Zfrl K' :Ytnf~ ~I p,1 ~+ 51l1iLIIAe.. c,tf"~ ~4'o 6 3 Ron 1'<1111,)836 Dove DrJ,'/Or-K (M' 17400- I{ JIm kin 1 I () 5 5ff.mc- J.IMJe ,mfJ!'K: ks (! 6yne re , 5 C', 2 9q&1 5 D~dc.. k,rrt 11 l66 &lSCIIJ fJ J. f-It'U:J C heSAA>Rk If ~ J.33~<i i> 'S,hll/ kJni J 6L'ffhe Wood lSd., 7 5i1r<fi cn5mmk""- ..11'( 5Lewlsber-J.4j ~d fY18:= h IJ n t:. 5 jN" R. v fA f76 55 2J VQnnf5~S"5f1.A1 lieS5, 356k'6hler flJl/1 f2J .A)f?w O'/.Co....J ff}- /1350 FILE NUMBER J OCJ7-(j(J t{ 02- RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE S+e f'C.~A-nd cnl Id /JJi.. O/J- IJ~ II " I ~(YJ- II I ..vhwu- SfefC:f.An.Je}.., I~ ( AQ/J..- II I ~G/I.L II I ~Q/J- .:? ll06.6Cl 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ , (If more space is needed, insert additional sheets of the same size) .REV.1514.EX+ (12.0. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on REV.1500 Cover Sheet ESTATE J9F I fie Ie 11 (YJ This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. o Will 0 Intervivos Deed of Trust 0 Other tJen tz.e I FILE NUMBER ~ (JO 7 - OCJ 1.(02. D Life or D Term of Years D Life or D Term of Years D Life or D Term of Years D Life or D Term of Years D Life or D Term of Years 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Actuarial factor per appropriate table ................................................. Interest table rate - D 3 1/2% D 6% D 10% D Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ D Life or D Term of Years D Life or D Term of Years D Life or D Term of Years D Life or D Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and enter corresponding (number) .......................... Frequency of payout - D Weekly (52) D Bi-weekly (26) D Monthly (12) D Quarterly (4) D Semi-annually (2) D Annually (1) D Other ( ) 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ................................... 5. Annuity Factor (see instructions) Interest table rate - D 3 1/2% D 6% D 10% D Variable Rate % 6. Adjustment Factor (see instructions) .................................................. 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-l6.4.4 EX+ (3-8.4) INHERITANCE TAX * SCHEDULE "L" "". " .- COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT OR INVASION INHERITANCE TAX RETURN ;loa 7-0(]<{~ RESIDENT DECEDENT OF TRUST PRINCIPAL FilE NUMBER I. Estate of t<en f-ze I /If? /{>n/ yY1 (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Sedion 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. Remainder Prepayment: A. Election to prepay filed with the Register of Wills on (Date) (attach copy of election) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L- 1 1. Real Estate S 2. Stocks and Bonds S 3. Closely Held Stock/Partnership S 4. Mortgages and Notes S . 5. Cash/Misc. Personal Property S 6. Total from Schedule L-l S D. Credits: Complete Schedule L-2 1. Unpaid Liabilities S 2. Unpaid Bequests S 3. Value of Unincludable Assets S 4. Total from Schedule L-2 S E. Total value of trust assets (Line C-6 minus Line D-4) S :-:.,... F. Remainder factor (see Table I or Table II in Instruction Booklet) G. Taxable Remainder value (Line E x Line F) S (Also enter on Line 7, Recapitulation) III. Invasion of Corpus: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Dete of Birth Age on date Term of yeers income or Annuitent(s) corpus consumed or annuity is peyeble e. Corpus consumed S D. Remainder factor (see Teble I or Teble II in Instruction Booklet) S E. Taxeble velue of corpus consumed (Line C x line D) S (Also enter on line 7, Recapitulation) 2- P.EV;~6A5 EX+ (70* INHERITANCE TAX SCHEDULE L-l COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN J.. 60 7-M4o z.. RESIDENT DECEDENT -ASSETS- FILE NUMBER I. Estate of Ken+~e-I tJ~ I~ y fY7 (Last Name) (First Name) (Middle Initial) II. Item No. Description Value A. Real Estate (please describe) Total value of real estate $ (include on Sedion II, Line C-1 on Schedule L) ;~ B. Stocks and Bonds (please list) Total value of stocks and bonds $ (include on Section II, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) Total value of Closely Held/Partnership $ (include on Sedion II, Line C-3 on Schedule L) D. Mortgages and Notes (please list) Total value of Mortgages and Notes $ (include on Sedion II, Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property $ (include on Sedion II, Line C-5 on Schedule L) III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ 0 (If more space is needed, attach additional 8Y2 x 11 sheets.) REV-1646 EX+ (3-84) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-2 REMAINDER PREPAYMENT ELECTION -CREDITS- FilE NUMBER I. Estate of RQntzel (Last Name) -IJ~ Ie A/ (First Name) II. Item No. Description A. Unpaid liabilities Claimed against Original Estate, and payable from assets reported on Schedule l- 1 (please list) Total unpaid liabilities $ (include on Section II, line 0-1 on Schedule l) B. Unpaid Bequests payable from assets reported on Schedule l-l (please list) Total unpaid bequests $ (include on Section II, line 0-2 on Schedule l) C. Value of assets reported on Schedule l-l (other than unpaid bequests listed under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: Total unincludable assets $ (include on Section II, line 0-3 on Schedule l) III. TOTAL (Also enter on Section II, line 0-4 on Schedule l) (If more space is needed, attach additional 8Y2 x 11 sheets.) 2 ()() 7 -()(}t{ 0 ?- m (Middle Initial) Amount $ o REV-16~7 EX+ (9-0* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet ESTATE OF He leAl WI IfRrrtze I FILE NUMBER zoa7-ad f.{6t:- This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. o Will 0 Trust 0 Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. 0 Unlimited right of withdrawal 0 Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ..... .$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One o 6%, o 3%, o 0%......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One o 6%, o 4.5% .......................... .$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) .. . . ..$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ..... .$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ..................... .$ C> (If more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99) SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION ESTATE OF !Yl enftel FILE NUMBER :L. 007- ()() ~ Z- This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. PART I - CALCULATION OF GROSS ESTATE 1. Taxable Assets total from line 8 (cover sheet) ............................................ 1. 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joint Assets with Spouse ............................................................ 4. 5. PA Lottery Winnings ............................................................... 5. 6b. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilities .............................................................. 8. 9. Net Value of Estate (Subtract line 8 from line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9. If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part II. PART fI - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income Tax Return for decedent and spouse.) Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse .......... . 1a. 2a. 3a. b. Decedent ......... . 1b. 2b. 3b. c. Joint ............ . 1c. 2c. 3c. d. Tax Exempt Income . . 1d. 2d. 3d. e Other Income not listed above . . . . . . . . 1e. 2e. 3e. f. Total ............ . 1f. 2f. 3f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) + (3f) (+3) 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................... 1. 2. 3. Multiply by credit percentage (see instructions) ........................................... 2. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. ............................... 3. 5. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................. 4. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. . . . . .. 5. 4. REV-16A9 EX + (1-97) SCHEDULE 0 ELECTION UNDER SEC. 9113(A) SPOUSAL DISTRIBUTIONS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATEfi/ ~ FILE NUMBER e en ~ Renf2e / :l6(j7-CJeJ ifoz.. Do not complete t IS schedule unless the estate IS makmg the election to tax assets under Section 9113(A) ofthe Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b, The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0, The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's survivin souse under a Section 9113 A trust or similar arran ement. DESCRIPTION VALUE Part A Total $ 0 PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made. DESCRIPTION VALUE Part B Total $ (If more space is needed, insert additional sheets of the same size) 6 fiffi:mTcr ~. (;R~IIr1Ii1J( Pit 1702t..Ol(1 between the hours of 6 Para servicio en espai'lol, 1-866~HOl,A.~eN:c: Mc:wviftg'P P\ease contact us at '~S8'8-PNC-BAWK 12!!'J Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 Q-Ylf!~ fJsat~_qe-!J!cc .. I TDE>termina': 1-800-531-1648 For hearing impaired clients only 'elation.hip Overview tank DePOSIt AccountS escri plion W:rest Checking :e.tificate(s) Of Deposit 'oW. Deposits Account Number 51-8000-0384 Total of 1 Deposit Balance 3,232.97 3,157.97 6,390.94 tenters. Are your valuables covered? If a fIre or other unexpected event occurs, yom'landlord's insurance isn't likely to cover replacement ~X()urperSQJla.Jproperty,. Rentersinsura11.<le can llelp you protect yourself. For more infonnation and a tree no obligatiotl quote visit .tlc:eoI11.linsuranee. Product not available in FL, NC and NJ. nePNC Visa@ Gift Card is the perfect gift for everyone on your list. So, let them do the shopping. Stop in any branch today or visit nc.coI11.1giftcards. You getthe gift of convenient, one.stop shopping and they get what they want. lfiiiifty.-se 1II.a nte....'.Ch.c;ldng Account Summary lCC9unt number: 51-8000-0384 Heten M Rentzel .........h.....ry .33 Checks and other deductions 1,698.37 Ending balance 3,232.97 Please see the Activity Detail section for additional information. . Begi~ balance 4,931.0] f)e~its81ld other additions Average monthly balance 4,087.09 Charges ;anli (~s .00 r,aniJactiOn Summary Chl;!C.ks pailil Cl1eck Card. POS withdrawals signed transactions Chl;!Ck Card/ElankC<lrd POS PIN transactioo$ 6 0 o fola' AfM PNC Bank transactions ATM transactions Other Bank ATM transactions o 0 o Annual Percentage Yield Earned (APYE) Number of days in interest period Average collected balance for APYE Interest Paid this period As of 04106, a total of $1.68 in interest was paid this year. nt.r..t Summary REGISTER OF WILLS CUMBERLAND County, Pennsylvania CERTIFICATE OF GRANT OF LETTERS No. 2007-00402 PA No. 21-07-0402 Es ta te Of: HELEN M RENTZEL (First, Middle, Last) Late Of: UPPER ALLEN TOWNSHIP CUMBERLAND COUNTY Deceased Social Securi ty No: 162-07-0732 WHEREAS, on the 25th day of April 2007 instruments dated: July 28th 1999 August 19th 2003 were admi t ted to probate as the last will and codicil of HELEN M RENTZEL (Fi,st, Middle, Lastl la te of UPPER ALLEN TOWNSHIP, CUMBERLAND County, who died on the 22nd day of March 2007 and" WHEREAS, a true copy of the will &codicil as probated is annexed hereto. THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of wills in and for CUMBERLAND County, in the Commonweal th of pennsyl vania, hereby certify that I have this day granted Letters TESTAMENTARY to: DENNIS G HESS who has duly qualified as EXECUTOR(RIX) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 25th day of April 2007. ~~S4(1~y\QA~~ eglsttu of ills ~ ~Jl~ eputy ~ ~ ~ ~ LAST WILL AND TEST AMENT OF HELEN M. RENTZEL I, Helen M. Rentzel, of the Township of Upper Allen, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, declare this to be my last will and testament, hereby revoking all wills and codicils previously made by me. ITEM I: I direct that all expenses of my last illness, my funeral, and my gravemarker shall be paid from my residuary estate as soon as practicable after my decease as a part of the cost of the administration of my estate. ITEM II: I bequeath the sum of One Thousand Dollars ($1,000.00) to Dennis Hess and Sue Hess, husband and wife, or to the survivor of them. ITEM ill: I direct that the remainder of my estate be liquidated, and that- it then be distributed in equal shares to the following: A. one share to David A. Rentzet; B. one share to Craig Rentzet; C. one share to Sarah Ensminger; D. one share to James Kint; E. one share to Douglas Kint; 10f3 F. one share to Ronald Kint; G. one share to John Kint; and H. one share to Jackie Kint. Should any of the named beneficiaries predecease me, then I bequeath such share to the other named surviving beneficiaries equally. ITEM IV: I appoint Dennis Hess and Sue Hess, husband and wife, or the survivor of them as co-executors of this my last will and testament. ITEM V: I direct that my co-executors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. ITEM VI: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shaU be paid from my residuary estate as a part of the expense of the administration of my estate. IN WITNESS WHEREOF, I have hereunto set my hand this ,.j (f-.day of ~~.~. t7 , 1999. ( I , /. L't Of~ y:n. ~-;[-:y-L--- Helen M. Rentzel 20f3 The preceding instrument, consisting of this and two (2) other typewritten pages, identified by the signature of the testatrix, was on the date thereof signed, published and declared by Helen M Rentzel, the testatrix therein named, as and for her last will and testament, in the presence of us, who at her request, in her presence and in the ce of each other, have subscribed our names as witnesses her o. Witness 7 ,-1112}{)", 3 of3 II COMMONWEALTH OF PENNSYLVANIA ss: COUNTY OF ADAMS We, Helen M. Rentzel, __]JilLion.. V)aiJ l S> and W~ T .W( , the Testatrix and the witnesses, respectively, whose names are signed to the attached foregoing instrument, being first duly sworn, do hereby declare tq the undersigned authority that the Testatrix signed and executed the foregoing instrument as her last will and testament and that she had signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the will as witness and that to the best of their knowledge the Testatrix was at that time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. WIL, JldhAJ Witness / Notary Public My commission es: Notacial Seal Michele D. Barbagallo. Notary Public Gettysburg Boro, Adams County My Commission Expires May 7, 2001 J 40f3 CODICIL TO THE LAST WILL AND TEST AMENT OF HELEN M. RENTZEL I, Helen M. Rentzel, of the Township of Upper Allen, Cumberland County, Pennsylvania, declare this to be the sole codicil to my last will and testament dated July 28, 1999. ITEM A: I revoke Item II of my last will and testament dated July 28, 1999, in place thereof! ;:'-"',', add the following: C) :;;0 -..:-0 --' r~...1 ITEM II: I bequeath the sum of Two Thousand Dollars:'. ::::<: '_..' (.r: ($2,000.00) to Dennis Hess and Sue Hess, husbaitCB 1.0 and wife, or to the survivor of them. ITEM B: In all other respects I hereby ratifjr, confirm, and republish my last will and testament dated July 28, 1999, as and for my last will and teStament. IN WITNESS WHEREOF, I have hereunto set my hand and seal this lqzt, day of O(l~~;~ 1> )--2003. 1 (r~ )- y .- ~/ ..~~ Helen M. Rentzel The preceding instrument, consisting of this and one (1) other typewritten page, identified by the signature of the Testatrix, was on the date thereof signed, published and