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Home My WebLink About11-06-07 --.J 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 ~\ 6~ oa5l Date of Birth 207-34-6648 Decedent's Last Name 03072007 09061912 Suffix Decedent's First Name MI VAUGHN (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix MABEL 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 m 1. Original Return D 2. Supplemental Return D D o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required D 4. Limited Estate D 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 8. Total Number of Safe Deposit Boxes m 6. Decedent Died Testate D (Attach Copy of Will) o 9. Litigation Proceeds Received D D 11. Election to tax under Sec. 9113(A) (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) 717-243-5838 REGISTER OF WILLS USE ONLY FREY AND TILEY First line of address 5 SOUTH HANOVER STREET Second line of address City or Post Office State ZIP Code DATE FILED CARLISLE PA 17013 ""~._; &! ADDRESS 5 SOUTH HANOVER STREET, CARLISLE PENNSYLVANIA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056041114 15056041114 --.J ~ ....J 15056042115 REV-1500 EX Decedent's Social Security Number Decedent's Name: MABEL C. VAUGHN RECAPITULATION 207-34-6648 1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 31000.00 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. NONE 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. NONE 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . 4. NONE 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Schedule F) C]Separate Billing Requested. . . . . . .. 6. NONE 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) DSeparate Billing Requested. . . . . . . . NONE 7. 162553.00 8. Total Gross Assets (total Lines 1-7) . . . . . . . . . . . . . . . . . . . . . . . . . 8. 193553.00 9. Funeral Expenses & Administrative Costs (Schedule H) . . . . . 9. 9388.00 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2428.00 11816.00 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental BequestsfSec 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . .' 13. 181737.00 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 L 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 . 1 5 1000.00 180737.00 15. 0.00 17. 8133.00 0.00 0.00 180737.00 16. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . 19. 8133.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT w Side 2 L 15056042115 15056042115 ....J REV-1500 EX Page 3 207-34-6648 Decedent's Complete Address: File Number 21-07-0257 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUM8ER MABEL C. VAUGHN 207-34-6648 STREET ADDRESS 2309 RITNER HIGHWAY CITY I STATE I. ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) 8133.00 8061.38 424.28 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits ( A + 8 + C) (2) 8485.66 TotallnteresUPenalty ( 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) 0.00 352.66 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) 0.00 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) 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 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 D D D D D 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. c. retain a reversionary interest; or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? . . . . . . . . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? . . 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 o 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. 99116(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 Mabel C. VauQhn 21-07-0257 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 Real Estate, Mountain Land in Lurgan Township and Franklin County (13.706 Acres) VALUE AT DATE OF DEATH 31,000 TOTAL (Also enter on line 1, Recaoitulation) (If more space is needed, insert additional sheets of the same size) $ 31,000 I; 1. FHA Settlement Statement - u. S. Denartment of Housina and Urban Develooment form US HUD - 1 Pane No. 1 2. FmHA 6. File Number 7. Loan Number 8. Mortgage Insurance 3. Conv. Unins. Case Number I( 4. VA K 5. Conv. Ins. C. This form IS furnished to give you a statement of actual settlement costs. Amounts paId to and by the settlement agent are shown. Items marked "(p.D.C.)" were paid outs the closing; they are shown here for informational purposes and are not included in the totals. O. Name and Address of Borrower: E. Name and Address of Seller: PAUL W. BRENIZE DORIS M. BRENIZE 4438 MAC LAYS MILL ROAD SHIPPENSBURG, PA 17257 GEORGEJ.VAUGHN,EXECUTOR HAROLD L. VAUGHN, EXECUTOR ESTATE OF MABEL C. VAUGHN I H. Buyer's Settlement Agent: ,TIN 25-1730538 Frey & Tiley Law Office 5 South Hanover St. Carlisle, PA 17013 TIN G. Property Location 2 TRACTS OF MOUNTAIN LAND LURGAN TOWNSHIP FRANKLIN COUNTY PARCEL NO. 13G73 I. Settlement Date: October 1, 2007 Place of Settlement: 5 South Hanover Street Carlisle, PA 17013 I F. Name and Address of Lender N/A J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 100 Gross Amount Due From Borrower 400 Gross Amount Due To Seller 101 Contract sales price 31,000.00 401 Contract Sales price 31,000.00 102 Personal property 402 Personal property 103 Settlement charges from (line 1400) 851.50 403 104 404 105 405 Adjustments for items paid by seller in advance: Adjustments for items paid by seller in advance: 106 City/town taxes 10/1/07 to 12/31/07 0.00 406 City/town taxes 10/1/07 to 12/31/07 0.00 107 County taxes 407 County taxes 1 DB Assessments 408 Assessments 109 409 110 School taxes 10/1/07 to 6/30/08 23.54 410 School taxes 10/1/07 to 6/30/08 23.54 111 411 112 412 120 Gross Amount Due From Borrower 31,875.04 420 Gross Amount Due to Seller 31,023.54 ---------- ----~----- ---------- ----~----- 200 Amounts Paid By Or In Behalf Of Borrower 500 Reductions In Amount Due To Seller 201 Deposit or earnest money 1,000.00 501 Excess deposit (see instructions) 1,000.00 202 Principal amount of new loan(s)**'" 502 Settlement charges to seller (line 1400) 310.00 203 EXisting loan(s) taken subject to 503 Existing loan(s) taken subject to 204 504 Payoff of first mortgage loan 205 505 Payoff of second mortgage loan 206 506 207 507 208 508 209 509 Adjustments for items upaid by seller Adjustments for items upaid by seller 210 City/town taxes 1/1/07 to 10/1/07 510 City/town taxes 1/1/07 to 10/1/07 211 County taxes 511 County taxes 212 Assessments 512 Assessments 213 513 214 School taxes 7/1/07 to 10/1/07 514 School taxes 7/1/07 to 10/1/07 215 515 216 516 217 517 218 518 219 519 220 Total Paid By/For Borrower 1,000.00 520 Total Reductions to Amt Due Seller 1,310.00 ---------- ---------- ---------- ---------- 300 Cash At Settlement From/To Borrower: I 600 Cash At Settlement To/From Seller: I 301 Gross amount due from borrower (line 120) 31,875.04 601 Gross amount to seller from (line 420) 31,023.54 302 Less amounts paid by/for borrower (from line 220) ( 1.000.00) 602 Less reductions in amount due seiter (from line 520): (1.310.00) 303 Cash (Xl From ( ) To Borrower 30,875.04 603 Cash ( ) From (X) To Seller 29,713.54 ---------- ---------- ------ ---------- 31,000.00 0.00 IHUD-1 700 Total Sales/Broker's Comm. based on price: Division of Commission (line 700) as follows: 701 to 702 to 703 704 Commission paid at Settlement 705 800 Items Payable In Connection With Loan: (Mortgage Amt: O.OO) Total charges, Lines 801 through L. SETTLEMENT CHARGES @ % = 0.00 .000 % to .000 % to 801 Loan Origination Fee 802 Loan Discount 803 Appraisal Fee 804 Credit Report 80S Lender's Inspection Fee 806 Mortgage Insurance Application Fee 807 Assumption Fee 808 809 810 811 900 Items Required By Lender To Be Paid In Advance: 901 Interest From 1-0ct-07 to @ 0.000 to to to to to per day ~ 902 Mortgage Insurance Premium for 903 Hazard Insurance Premium for 904 905 1000 Reserves Deposited With Lender: 1 months to years to years to Toal Reserves, Lines1001 thorugh 1008: mos. @ per month mos. @ per month mos. @ per month mos. @ per month mos. @ per month mos. @ per month mos. @ per month 1001 Hazard insurance 1002 Mortgage insurance 1003 City property taxes 1004 County property taxes 1005 Annual assessments 1006 1007 School taxes 1008 Aggregate Settlement Adjustment 1100 Title Charges: 1101 Settlement or closing fee 1 un Abstract or title search 1103 Title examination 1104 Title insurance binder 1105 Document preparation 1106 Notary fees 1107 Attorney's fees (includes above items numbers: 1108 Title Insurance to to to to to to to ZULLINGER-DAVISjFREY & TILEY to ) FREY & TILEY (COMMONWEALTH LAND TITLE INS. CO.) ) (includes above items numbers: 1109 Lender's Coverage $ 1110 Owners Coverage $ 1111 CLOSING SERVICE LETTER TO COMMONWEALTH LAND TITLE INSURANCE CO. Endorsements: 1112 1113 OVERNIGHT DELIVERY FEES TO FREY & TILEY 1200 Government Recording and Transfer Charges: 1201 Recording fees: Deed $41.50 1202 City/county/stamp Deed $310.00 1203 State tax/stamps: Deed $310.00 1204 Mtg pages.: Releases $ Deed Pages: 0 Mortgage ??? Mortgage $ Mortgage $ 1205 1300 Additional Settlement Charges: 1301 Survey to 1302 Pest inspection to 1303 Current Taxes due from Borrower/Seller to 1304 1305 1306 1307 1400 Total Settlement Charges (enter onlines 103, Section J and 502, Section K) Paid From Borrower's Funds at Settlement 0.00 0.00 0.00 500.00 41.50 310.00 851.50 Page No. 2 Paid From 700 Seller's Funds at 701 Settlement 702 703 704 705 800 801 802 803 804 805 806 807 808 809 810 811 , 900 901 902 903 904 90S 1000 1001 1002 1003 1004 1005 1006 1007 1008 1100 1101 1102 1103 1104 1105 1106 P.O.C. 1107 1108 1109 1110 1111 1112 1113 1200 1201 1202 310.00 1203 1204 1205 1300 1301 1302 1303 1304 1305 1306 1307 310.00 1400 IHUD-l I CERTIFICATION I direct and authorize the Company to make dIstributions indicated for my account on the attached HUD-l Settlement Statement, approving the tax prorations Indicated therein, and understand that prorations were based on figures for the preceding year, or estimates for the current year, and in the event of any change for the current year, all necessary adjestments must be made between Seller and Borrower direct; likewise any DEFICIT in delinquent taxes will be reimbursed to Attorney/Title by Seller. I have carefully reviewed the HUD-l Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction. I further certify that I have received a copy of the HUD.l Settlement Statement. /lJ /1). ~~ PAUL W. BRENIZE - ~~. 7)1. ~~L DORIS M. BRENIZE ~~~~~ GEORGE J. VAUG, CUTO~ . HAROLD L. VAUGHN, EXECUTOR To the best of my knowledge, the HUD.1 Settlement Statement which I have prepared is a true and accurate account of the funds which were received and have been or will be disbursed by the undersigned as part of the settlement of this transaction. October 1, 2007 Date Settlement Agent WARNING; It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include fine and imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010. INFORMATION REPORTING ON REAL ESTATE TRANSACTIONS THIS HUD SETIlEMENT STATEMENT CONTAINS IMPORTANT TAX INFORMATION (BOXES E, G, H, I, M AND LINE 401) AND IS BEING FURNISHED TO THE INTERNAL REVENUE SERVICE. IF YOU ARE REQUIRED TO FILE A RETURN, A NEGLIGENCE PENALTY OR OTHER SANCTION WIll BE IMPOSED ON YOU IF THIS ITEM IS REQUIRED TO BE REPORTED AND THE INTERNAL REVENUE SERVICE DETERMINES THAT IT HAS NOT BEEN REPORTED. Solicitation of TIN Seller is required by law to provide the Attorney/Company with his/her correct taxpayer identification number. If correct taxpayer identification number is not provided, he/she may be subject to civil or criminal penalties imposed by law. Certification of TIN Under penalties of perjury, I certify that the taxpayer identification number shown in this statement is my correct taxpayer identification number. Seller Seller TAX PRO-RATION ADDENDUM Date of Pro-Ration: Borrower Seller I SCHOOL REAL ESTATE TAX Owes: October 1, 2007 from July 1, 2007 to June 30, 2008 School Real Estate Tax- Face P.O.c. School Real Estate Tax- Per Day $0.08500 ASSESSMENT: COUNTY & MUNICIPAL TAX Owes: from January 1,2007 to December 31, 2007 Co. & Munic. Real Estate Tax- Face $0.61 P.O.C. Parcel No.: Co. 8< Munic. Real Estate Tax- Per Day $0,61080 See Settlement Sheet Li nes Yes 106 & 406, 110 & 410, School taxes P.Q.C. or charged to Seller: D 210 & 510, 214 & 514, School taxes P.Q.C. or charged to Borrower and 1303 for Co. & Munic. P.O.c. or charged to Seller: Results of this Addendum, Co. & Munic. P.D.C. or charged to Borrower 217 REV-150B EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mabel C. VauQhn Include the proceeds of litigation and the date the proceeds were received by the estate. All propertY 'ointlv-owned with right of survivorship must be disclosed on Schedule F. FILE NUMBER 21-07-0257 ITEM NUMBER DESCRIPTION M&T Bank, Checking Account #2679042941 2 M&T Bank, Savings Account #015004212115916 3 M& T Bank. CID#031 003911155222 4 (2) Grave Sites in Cumberland Valley Memorial Gardens 5 Refund, Church of God VALUE AT DATE OF DEATH $2,336.00 $150,468.00 $2.021 $400.00 $7,328.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 162,553 I!M&fBank 499 Mitchell Road, MiIlsboro, DE 19966 Mail Code DE-MB-12 Phone (888) 502-4349 Fax (302) 934-2955 May 11,2007 Frey & Tiley Attorneys At Law 5 South Hanover Street Carlisle, Pennsylvania 17013-3385 Re: Estate of: Mabel C Vaughn Social Security: 207-34-6648 Date of Death: March 7. 2007 Dear Sir or Madam: Per your inquiry dated May 10,2007, 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 Checking Account Account Number 2679042941 Ownership (Names oj) Mabel C Vaughn * Opening Date 09/01/67 Balance on Date of Death $2,335.66 Accrued Interest $ 0.00 Total $2,335.66 2. Type of Account Savings Account Account Number 015004212115916 Ownership (Names oj) Mabel C Vaughn * Opening Date 11/08/06 Balance on Date of Death $149,912.97 Accrued Interest $ 555.46 Total $150,468.43 3 Type of Account Certificate of Deposit Account Number 031003911155222 Ownership (Names oj) Mabel C Vaughn * Opening Date 10/14/89 Closed 03/27/07 Balance on Date of Death $2,010.00 Accmed Interest $ 10.82 Total ......._~m_.._..__....... $2,020.82 Please be advised, there was no safe deposit box fOlmd for the above decedent. * If upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or the name of any possible joint account holder. For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please call the High Street Carlisle Office # 717-240-4536. Sincerely, ~~/C:7<<~ Nancy Clagett Records Management 217 REV-1511 EX+(12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Mabel C. VauQhn FILE NUMBER 21-07-0257 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Fogelsanger Bricker Funeral Home, Funeral Services 233 2. Edna Worthington, Funeral Reception 100 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 8,742 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 294 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Register of Wills, Filing Fee Pennsylvania Inheritance Tax Return 15 8. Register of Wills, (1) Short Certificate 4 TOTAL (Also enter on line 9 Recaoitulation) $ 9388 Debts of decedent must be reported on Schedule I. (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12--03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mabel C. VauQhn SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-07-0257 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH -24 310 43 5 209 1,136 32 -24 106 73 186 19 327 3 -94 121 1. Refund, Barbara J. Wiser, TIC, School Taxes(10/1/07 to 6/30108) 2. Realty Transfer Tax on the sale of the real estate 3. Barbara J. Wiser, TIC Real Estate Taxes on Mountain Land 4. Deborah L. Piper, Tax Collector 5. Pennsylania Department of Revenue, 2006 Income Taxes 6. Carlisle Regional Medical Center, Medical 7. Lancaster HMA Phys Management Center, Medical 8. Refund, Philhaven, Medical 9. Cumberland Goodwill Fire & Rescue, Medical 10. West Shore EMS, Medical 11. Guistwite Family Practice, Medical 12. Kinetic Imaging, Inc., Medical 13. Continuing Care RX, Medical 14. Masland Associates 15. Refund, Insurance from Fire Company 16. Church of God Home, Nursing Company TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, Insert additional sheets of the same size) 2,428 217 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Mabel C. Vauahn 21-07-0257 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)J 1 George J. Vaughan, 10 Royal Drive, Carlisle PA 17015 Son 1/8 residue of the estate 2 Harold L.Vaughan,6119 Stephens Crossing, Mechanicsbug PA17050 Son 1/8 residue of the estate 3 Mildred L. Welsh, 2319 Ritner Highway, Carlisle PA 17015 Daughter 1/8 residue of the estate 4 Janet K. Smith, 1963 Fay Loop Avenue, Carlisle PA 17015 Daughter 1/8 residue of the estate 5. Emma J. Wigfield, 705 Palmwood Street, Delta OH 47515 Daughter 1/8 residue of the estate 6. Mary E. Arnold, Shady Lane, Carlisle PA 17013 Daughter 1/8 residue of the estate 7. Anna M. Farner, N. College Street, Carlisle PA 17013 Daughter 1/8 residue of the estate 8. Evelyn V. Frick, 21 Royal Drive, Carlisle PA 17015 Daughter 1/8 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 1 Ridge Church of the Brethren, 105 Ridge Road, Shippensburg PA 17257 1,000 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0 (If more space is needed, insert additional sheets of the same size)