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HomeMy WebLinkAbout12-20-07 .. -I 15056041125 REV -1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 17128-0001 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year 2 1 0 6 File Number o 4 0 4 Date of Birth 166485433 o 5 0 2 2 0 0 6 03071948 Decedent's Last Name Stephens Suffix Decedent's First Name Car r i e MI M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix 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 00 1. Original Return D 4. Limited Estate D 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 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 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received D D D D 8. Total Number of Safe Deposit Boxes 2. Supplemental Return D D 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required J u d i t h Firm Name (If Applicable) T . W a 1 z W a 1 z & W a 1 7. , Attorneys r-..,) (:;-1 REGISTER OF_~S USE OItY - -5-) c=~ . (, ~.''r1 n; N => ':::0 ,.~ ("~) (-) c~Q ;~') ,'"' :::7 First line of address 341 Mar k e t Street Second line of address -u ~....,", City or Post Office State ZIP Code DATE FILED (...) Newport P A 17074 Correspondent's e-mail address: Under penalties of pe~ury, 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. SIGN RE PERSON R~ SIBLE FOR FILING TURN ATE /{)7 Side 1 L 15056041125 15056041125 -I J~ \ --I 15056042126 REV-1500 EX OecedenrsName: Carrie M. Stephens 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) 0 Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) 0 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 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 _ 15. 16. Amount of Line 14 taxable at lineal rate X.O 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. Tax Due ................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056042126 Decedent's Social Security Number 166485433 5006.28 5006.28 7511.81 1004.00 8515.81 -3509.53 -3509.53 o 15[]56[]4212b --.J REV-150<1EX Page 3 Decedent's Complete Address: DECEDENTS NAME Carrie M. Stephens STREET ADDRESS 2 West Penn street File Number 21 06 0404 CITY Carlisle I STATE PA I ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. CrednslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InterestlPenalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) TotallnterestlPenalty ( D + E) (3) 4. If Une 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 Une 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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (SA) (5B) . ". '.' 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; ...................................................................... 0 00 b. retain the right to designate who shall use the property transferred or its income; ............................... 0 00 c. retain a reversionary interest; or ................................................................................................ 0 00 d. receive the promise for life of either payments, benefits or care? ....................................................... 0 00 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... 0 00 3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ......... 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. 0 00 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 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 decedenfs 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. REV-150~ EX + (6-98) '* SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Carrie M. Stephens 21 06 0404 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 lolntlv-owned with riaht of survlvorshlD must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH None TOTAL (Also enter on line 1, Recapitulation) $ (If more space Is needed, insert addltlonal sheets of the same size) REV-1503 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Carrie M. Stephens FILE NUMBER 21 06 0404 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1504 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSEL Y.HELD CORPORATION, PARTNERSHIP OR SOLE.PROPRIETORSHIP ESTATE OF Carrie M. Stephens FILE NUMBER 21 06 0404 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 TOT At (Also enter on line 3, Recapitulation) $ (If more space is needed, Insert additional sheets of the same size) REV-1505 EX + (6-98) '* . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF Carrie M. Stephens FILE NUMBER 21 06 0404 1. Name of Corporation Address City 2. Federal Employer 1.0. Number 3. Type of Business State Zip Code State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year Product/Service 4. Common Preferred $ $ Provide all rights and restrictions pertaining to each dass of stock. 5. Was the decedent employed by the Corporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Yes 0 No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ....................................... 0 Yes 0 No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ............... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock in this company 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 Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers ancllor sales. 9. Was there a written shareholders agreement in effect at the time ofthe decedenrs death? . . . . . . . . . . . . 0 Yes 0 No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ................................................. 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedenrs death? ....................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, induding dates and amounts received. 12. Did the corporation have an interestin other corporations or partnerships? . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No If yes, report the necessary information on a separate sheet, induding 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 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. Ust of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. Ust 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 decedent's stock. (If more space is needed, insert additional sheets of the same size) REV-1506 EX + (9-00) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF Carrie M. Stephens FILE NUMBER 21 06 0404 1. Name of Partnership Address Date Business Commenced Business Reporting Year City State Zip Code 2. Federal Employer 1.0. Number 3. Type of Business 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 Percentagetransferredlsold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreementin effect atthe time of the decedenfs death? . . . . . . . 0 Yes 0 No If yes, provide a copy of the agreement. 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 retums (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/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedenfs partnership interest. REV-1507 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Carrie M. Stephens ITEM NUMBER 1. SCHEDULE D MORTGAGES & NOTES RECEIVABLE FILE NUMBER 21 06 0404 All property jolntly-owned with the right of survivorship must be disclosed on Schedule F. DESCRIPTION TOTAL (Also enteron line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH REV-1!:i08 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Carrie M. Stephens FILE NUMBER 21 06 0404 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. DESCRIPTION PPL Refund Embarq Telephone Refund Refund from Housing Authority of the County of Cumberland Commonwealth of Pennsylvania 2006 Refund Checking Account #9838899103 with M&T Bank Date of Death Balance Savings Account #0150042000944559 with M& T Bank Date of Death Balance Arrears paid to decedent for Cumberland County Spousal Support Order VALUE AT DATE OF DEATH 61.61 3.43 132.66 298.08 109.57 368.46 4,032.47 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 5 006.28 m1 M&rBank 499 Mitchdl Road. Millsboro. DE 19966 Mail Code DE-MB-12 Phone (888) 502-4349 Fa;~ (302) 934-2955 July 12.2006 Walz & Walz Attorneys At Law 341 Market Street Newport, Pennsylvania 17074 Re: Estate of: CarrieM Stephens Social Security: 166-48-5433 Date of Death: Mav 02. 2006 Dear Sir or Madam: Per YOllr inquiry dated June 27, 2006, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: I. 7).pe qf A ccoun/ Checking Account Account Number 9838899103 Ownership (Names qf) Carrie M Stephens. Donald E Bergan ... Opening Dale 04/21/06 Balance on Date of Death $109.57 A ccrued Interest $ 0.00 Total $109.57 2. Type of Account Savings Account A ccmmt Number 015004200944559 Ownership (Names oj) Carrie M Stephens. Donald E Bergan ... Opening Date 09//2/94 Balance on Date of Death $368.43 Accrued Interest $ 0.03 Total $368.46 Pkase be advised. there was no safe deposit box found fortiieabo~edeceaent:HHH* For "further account information, regarding ownership, closures and/or reimbursement of funds, etc., please call the High Street Carlisle Office # 717- 240-4536. Sincerely, ~~ Nancy Clagett Records Management PPL Electric Utilities Corp. Two North Ninth Street Allentown PA 18101 ate 06/07/2006 r'- ! No. 0010846160 62-4 311 I ****Sixty-One and 61/100 US Dollars**** Iir~ ..'" . CARRIE M STEPHENS-ESTATE C/O RICHARD BROWN 38 S 2ND ST APT C NEWPORT PA 17074 VOtD ...;..- -If ~ -............... ..- r tl L 11"00 .08 ~ b I. bOIl" 1:0 ~ * *000 ~ 71: 2 III 9 5 2 8 0 2 II" '.' . THE BACK OF-THIS ElOCUMENiT CONiTAINS:ANt ARTIFICliAIL WAJrERM'ARK - HOlEl! All[ AN; AN'GlETO VIEW' '-. ;.';. - .,-,.. .. 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"c \ ..;. . ..' . : _'~ . . ~' ' ~ '",1 n".~1i 1,~i;~~II:~Jtrt;l~lrltl"l,l,., ~',ill ,r,,_I~I~ ,1.1,,1 :.: . ~.: 11.00 ~ ~ 7 9 ~ 8 7 ~ II. I: 0... * 2 0 ~ 8 2"": ~ bOO ~ ~ 2 a ~ ~ II. 1~~~I~!lO'GiTiffi.{JJi'\1(i;G1I1(O(otUIl"'.LI!'!HiI;.&=tl~A.=D)!j(Ojilf1l[C4;1=h'lll(or:...UH:t=t.IfOOll.....,JI::ol::l.-.~:lI:I~'IIAiln;;:r.-:MI[otl:t<JI~~th'!JI1=O}:::uto1:;IOJ=::~~~~I~',~==~=-~.l1DI:z:J:{ol:;tA:CfOlIY,j~I3:'1lt=''':1i:i=-~U.:-fll~.ai:;J:t..'~flU!:I=-..''':3lJ17~M::-..~~ r HOUSING AUTHORITY OF THE . 5 0 7 9 i COUNTY OF CUMBERLAND 1ft : PUBLIC SENIOR HOUSING - TWO WEST PENN t:::3 M&I'Bank 114 N, HANOVER ST,. SUITE 104 -...--- CARLISLE. PA 17013-2445 (717) 249-1315 NUMBER 60-295/313 *** One Hundred Thirty Two Dollars And Sixty Six Cents *** PAY TO THE ORDER OF DATE AMOUNT 6/21/06 $ 132.66 Carrie Stephens C/O Richard James Brown 38 South 2nd St., Apt. C Newport, PA 17074 VOID AFTER 90 DAYS CL.O.-~ .r;..t..- ~.::1f;;: ~ti'l,~'l~"'_.;;.""',.,_;l!l-li';,V~"'El::mt~ll<tt'[.I~'h"..,'q"'-..OI.'".ll~!;:..,lI~I....~F;I:..,:i~~ft'~.,i=t'"I~:~U~~t~~,~~:~,::~~=1.'~~;~0i:'10)~~ -""".P",Mi':~"_'-?~'7'J 11"00000050 ? 911. 1:0 ~ ~ ~O 29551: 2 b 7 50 bOb 5 711. 1,,;'/. 1i~;;g (1)- ~ g r~ 0 ~ t' 0 <c ~ ~ ffi C') ~''';. fj' ~ 0:: ....'" ~ > ~ i~ W J;; zU) 0:: . a.:: -" 'f; ...... ~: W ex) :J:V _ a.C') U) ~ ~"'~>~,~~ 0 iI ~ Ii ( :;)~,-~iI)"'l1.,"i='i;_'~~ U Cl <C N U -= i g ;t;~~~~ . ..5<.'-(~~" ~~'~"&lOlnlll~I~III~lnrfr' * 5 2 0 0 0 0 0 0 2 9 8 0 8 * -- 0(') ..;) 00 () ~ . ~ ~"~ G. q \'; --- NJ ("I ~ () YJ ~ ~)c- G- -=-C) :::r- ~, .. l llP :I:l! .... U)8 ~~ ff3- ' c.ll <C~ ~!ll ~ ()~ ~ O~ - ~ ~ ~~D . u go ~ ::l .l! .5 ~ (J III ... IT 0 r1"l U1 IT ['- CC d 0 0 a: ['- 0 .. ru IT ~ ~ ... IT B ... c.ll ~ ~ ... I"- ~ c.ll .., .... ~C< 0 .. z~ ~ - ~i2~ c.ll z .. - U1 .. ot;~ J ~~ U1 ... . j:: ::) w ru ... '< J:~ ! ~; []"" 0 I i~~~ ~ i5!s 0 ... '" -~~, - ... '\ 0 r1"l "'~<D ru adO '" 0 !:j~~~ 0 .. U1 - c( ;.J J:::. w ;:O:;t:::t ~ .. ~ _(']a. ... A1NO SNOI!:IlfSNlflllllSOd30 l:l0:l 03Sn 39 O! ... . 13>101.1 llSOd30 ... . CC .. r1"l J 0 0 ~ ! ! i i I . I I I I a;- ~,-.. ~- (...." '" '- ~ " <.:J """- ..... ! .::- ~ --';.: I ~:I ..:.- o f ~I ""- LU t:( o ~J \...r' '- <;. -<:... ~ ~...;, ~ Z <C a: I- c..Z -Q ~~ t=-=a:: -0 mI WI- o~ a::\.l w ~\J ::> z w w >- o ~ ("\1 ::; w c;- o~ o v .. ~~ \S o o o <( rf) ::r-- '- ~ C <6 t; 2!-J ::J-4O ". gc..... t:- ' ~::! 5 Cll en ::J w en c CJ Z ~ z a:: S2ti;~ a::ow 000 -:2- ~ ,:, ~' " w ~"., ;) , ....... ~g' 0'- 3:~...: ~1ii ~ '-!II Cl $~i3 e ~ f! a. 0 !II , , , ca...-C\.I .s: >- >. 0lQ.Q. '1:00 000 cj~,' ~ ,~ @(j' Ul r{'; " , UJ~ t;: ~ G ~ .... ~ co o o ~ .... ~ o 0 a. ~~ --- ! i I I ! i I I I I I I I I I ! I I ! i I I I a;- 'l $-.:' '" <C ...... ~.. ~ -'. .- \ . z Oy i='1 0..,; <~ urv z> <C~ Dii I- c..Z -Q ~~ t=-=a:: -0 .a3I WI- ,"O=> ", <{ CJ Z ~ z a:: -~I!! Sl"'z a::ow 000 LU t:( o '" '.,. -...... ~i ..... ~~ z ", a: !l;. W~ ::E' <( ~..... '" w ::E.~ ~_ g.., 00'-..;,,1 A,. ~. t.... (;) J " ; W 2 ~ 'Q C'" - 50 <t' ~ ~- ~a c-- 0.... Ii: If....... 0: Cll 1;5 ::J w en c .,~~ :,.3: l: ...: Ol~ Q. .~&l 2l lJlal:;: 8'; g '- i ~ a. 0 !II , , , a;..-C\l .S :>O~ 0lQ.Q. 'C 0 0 000 cj~.,. z J g \ J (f)" v UJ~ t;: , <'il ~. (r- ...J ,......... ::J ..., ~ .... o ~ co o o ~ .... ~ o 0 a. ~~ REV-1~09 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Carrie M. Stephens SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER 21 06 0404 If an asset was made Joint within one year of the decedenfs date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A. B c JOINTL Y.OWNED PROPERTY: ADDRESS RELATIONSHIP TO DECEDENT lETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANClAlINSTlTUTION 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 DECEDENTS INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-Hi10 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Carrie M. Stephens FILE NUMBER 21 06 0404 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 ITEM INClUOE THE NAIotE OF THE TRANSFEREE. THEIR RaATIONSHIP TO 0EC8lENT ANO DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE CATE OF TRANSFER ATTACH A COPY OF THE OEEO FOR REAL ESTATE. VALUE OF ASSET INTEREST ~F APPUCAll.E) VALUE 1. TOTAL (Also enter on line 7 Recapitulation) $ (If more space is needed. insert additional sheets of the same size) REV-1;" EX' ('. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Carrie M. Stephens SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 06 0404 Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. David M. Myers Funeral Home 6,469.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Seeurity Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Yea~s) Commission Paid: 2. AtlomeyFees Walz & Walz, Attorneys at Law, P.C. 750.00 3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 59.00 5. Accountanfs Fees 6. Tax Return Prepare!'s Fees 7. Cumberland Law Journal 75.00 8. Carlisle Sentinal 158.81 TOTAL (Also enter on line 9, Recapitulation) $ 7511.81 (If more space is needed, insert additional sheets of the same size) <'~<<\\'~>>>:..'\:\' :,'~<<<"~<:<<:<<<>\; \,>CQ ,,\\'c..'\\\ \\~',\\'6 "'\'" \\co, \\,a 6 \ "" "'I' . \\T-' '. \ '01-1" " 111~0\ .,,\\\",'-r:2.\\," \ ..,\ ,\ --'-'.' .' \ \\ \ '\'.,\ -'. , ,\>~,>:\.\\\ . \ . , =:\,\,S, ,\llIIl:t', \', \ \\"'\' \,' '\,,:;,J' \\ '\',.\ ,\ :~~l~~s~ \~ZQ.;, ' \\ \: "" ::)j::.\ \\ ,\z,u.a:. '\' \ :,a:.~~, ,\<'<' "O_~"""" I;:V# '" ", - "'," \', '.- ,'\' '<'4e'a:.z:\,\, \\,.~...'.\\\.. ::!f~~~\~~' \..., ZI-O>' ," '~,!!:!CIl~':<' ;> .oJ I- ... ',\ \clcSOW~, , '>';'l'<~iC\,\ ,,'.J ~ ~ &, ,> ',." \~S~~":\' \ ':,~,~:\~::~\~nmwoCNY1W<O g~ cr- .\\\\," . " ( '" , RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17G13 Receipt Date: Receipt Time: Receipt No.: 5/09/2006 10:45:29 1044308 STEPHENS CARRIE M Estate File No. : Paid By Remarks: 2006-00404 WALZ & WALZ MG ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS ADM SHORT CERTIFICATE JCPFEE AUTOMATION FEE Check# 8553 Total Received......... 20.00 24.00 10.00 5.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN $59.00 $59.00 WALZ & WALZ,ATTORNEYS AT LAW, P. C. IOL TA CUENT TRUST FUND 341 MARKET STREET NEWPORT. PA 17074 PH. (717) 567-6993 1737 ffilDLo g I b~YDI~~EC 1~I\ord'\o.v-J ~ ~yra-2 ~ I ~).e.^,~~~. ~ _ 00_ ~;:;;NAnONALBANK. .Q".. ....,......' --dAf.--V......... /J ..... FOR . .'. .,~~~ 1:0 ~. ~01125gl:... 2?O?50.u .~?~? .. :., .... > .. '../ ..... 60-925/313 BRANCH 3 DATE 'I $lE)~ fD ....,'~ 'IItutW, OOUARS , D.,..._ . "ek. ,I...." CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, P A 17013 July 28, 2006 Cwnberland Law Journal is published every Friday by the Cwnberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cwnberland County and the legal newspaper for publication of legal notices. TO: Judith T. Walz, ESQUIRE Carrie M. Stephens, ESTATE RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cwnberland Law Journal. Advertisement inserted on the following dates: July 14, July 21,July 28, 2006 Advertising Cost Second Proof Request 75.00 $ 0.00 $ 0.00 $ 0.00 ------------- $ 75.00 Proof of Publication Payment received Total Amount Due Payment received by WALZ & WALZ, ATTORNEYS AT LAW, P.C. Judith T. Walz, Esquire Shaubut C. Walz, III, Esquire 341 Market Street Newport, PA 17074 Tel. 717-567-6993 Fax 717-567-6994 Friday, i\ugust 04, 2006 Carlisle Sentinal i\ttn: Jolene P.O. Box 130 Carlisle, Pennsylvania 17013 Dear Jolene: Enclosed please find the check in the amount of $158.81 for the Carrie M. Stephens Estate ad that you requested. If you have any questions or concerns, please do not hesitate to contact our office. Thank you. Sincerely, rotl~~ TanaAZang 0- Legal i\ssistant . Enclosure ..AI ~ ATTORNEYS AT LAW. P. C. WAlZ& W~ ST FUND ~ IOLTACUENTeJrMwPORT,PA 17074 L OLP 341 MARKETSTR . DATE PH. (717) 567-6993 _ 81 ~ . ~- P -J $15g-~ \~~~~t~~;M/A)nd-~ ~S~~- Cl 1736 80.,925/313 BRANCH 3 ~ FlnlIo""'~ . THE FIRST NATIONAL BANK II. O,_AT FOR 1:0 ~ . ~Oq 2 Sq-: ...2707501) 1 REV-t512 EX + (12-03) . SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Carrie M. Stephens FILE NUMBER 21 06 0404 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, Including unrelmbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Carlisle Reginal Medical Center 21.00 2. Blue Mountain Anesthesia Assoc. 3.00 3. Lee & Cathy Morrison, cleaned out and disposed of trash in the appartment decedent resided in. 900.00 4. Oustanding check (difference between date of death balance in Acct #9838899103 at M & T Bank of $109.57 and liquidation payment on 7/11/07 of $29.57 80.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheels of the same size) 1.004.00 ..-;. . / '. .,/ ;'CARusLE h\ J" REGIONAL 45 Sprint Drive "--_."?' ME Die ^ LeE N T E R Carlisle. PA 17013 ADDRESS SERVICE REQUESTED I PATIENT ACCOUNT STA~EMENT ' 0078.52 8.58HI1A 000343l - IF PAYING BY CREDIT CARD, FILL OUT BELOW AND SEE REVERSE SIDE CHECK CARD USING FOR PAYMENT . ~ASTERCARD . ~SCOVER IZ ~SA '~~ ~ERICAN EXPRESS ACCOUNT NO. STATEMENT DATE . BALANCE DUE 9336067 09/1112006 $21.00 STEPHENS, CARRIE M 38 S 2ND ST APT C ~ NEWPORT go. PA 17074 CARLISLE REGIONAL MEDICAL CENTER 246 PARKER ST. P.O. 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(!) 1ll:J til-a.. c.~ w co IllM U <~~ ~z Q. ,.. ~c"'lIl: ~~ :irn!- -g~ Q. ~ ..rt1 t- ~:;) ,LU WC~ "'- <( O' ZG'~ . ,.. z ~5i 1-,.. :;) CII :0 :::J Cf1 NO a:~a.. (/) lIl: enN 0 X lIl: -t ~:><~ 1llJ: OJE w 0 LUIll z: 0 11.1 .. ~~LLJ -0- a:en:l: ~Q) c:l cco -...... CD CD :0 coLU "'- ....I....IL co a:co 11.1 z: -<lIOW J:'" a: ,. c:'Qc:'Q COo 00; <( coc co 5: :3 0 ~ .1\ ~~ Ill_ OI"tZ I CIIC11~ ~- ~ L U _LL co .. -oJ ~ LL ill C,) .................................. :0 0 cooco co co co co co co co co co co co co coco 0 ,. c:'Q~O 056 I- ""'IllIll"'~I"4I"4I"4I"4I"4I"4I"4I"4""" z .1\ 0 COI"4NNNCOrtlrtlrtlrtlrtlrtlrtlrtlCOCOCO LU Z ~~~~~Illllllllllllllllllllllllll""" (J) 00000000000000000 ." , ""'."l"''',* SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Carrie M. Stephens NUMBER I. 1. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) None - Insolvent Estate FILE NUMBER 21 06 0404 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET ll. 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 IT - 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) R,EV-15" EX' '12~. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on Rev.1500 Cover Sheet ESTATE OF FILE NUMBER Carrie M. Stephens 21 06 0404 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 retum. o Will 0 Intervivos Deed of Trust 0 Other o Ufe or DTerm of Years o Ufe or DTerm of Years o Ufe or DTerm of Years o Ufe or DTerm of Years o Ufe or DTerm of Years 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 2. Actuarial factor per appropriate table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interest table rate - 031/2% 06% 010% OVariable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ o Ufe or 0 Term of Years o Ute or o Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which annuity is payable .......................................... $ 2. Check appropriate block below and enter corresponding (number) .. . . . . . . . . . . . . . . . . . . . . . . . . . Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12) o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( ) 3. Amount of payout per period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 4. Aggregate annual payment. Line 2 multiplied by Une 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Annuity Factor (see instructions) Interest table rate - 03 1/2% 06% 010% 0 Variable Rate % 6. Adjustment Factor (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Value of annuity -If using 3 1/2%, 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 retum. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Unes 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-1644 EX + (3..04) '* INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT INHERITANCE TAX RETURN RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER 21 06 0404 I. ESTATE OF SteDhens ,Carrie M. (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 Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. n. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on (Date) 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 .............................. $ 2. Stocks and Bonds . . . . . . . . . . . . . . . . . . . . . . . . . $ 3. Closely Held Stock/Partnership. . . . . . . . . . . . . . . $ 4. Mortgages and Notes. . . . . . . . . . . . . . . . . . . . . . . $ 5. Cash/Misc. Personal Property. . . . . . . . . . . . . . . . $ 6. Total from Schedule L-1 ................................................... .$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . $ 2. Unpaid Bequests . . . . . . . . . . . . . . . . . . . . . . . . . . $ 3. Value of Un includable Assets . . . . . . . . . . . . . . . . $ 4. Total from Schedule L-2 .................................................... $ E. Total Value of trust assets (Line C-6 minus Line 0-4). . . . . . . .. .. . . . .. ... . . . .. ... . . . . . . $ F. Remainder factor (see Table I or Table II in Instruction Booklet) . . . . . . . . . . . . . . . . . . . . . . . . G. Taxable Remainder value (Line E x Line F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ (Also enter on Line 7, Recapitulation) m. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed C. Corpus consumed .......................................................... .$ D. Remainder factor (see Table I or Table II in Instruction Booklet) . . . . . . . . . . . . . . . . . . . . . . . . E. Taxable value of corpus consumed (Line C x Line D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ (Also enter on Line 7, Recapitulation) Rev-1645 EX + (3-84) INHERITANCE TAX SCHEDULE L-l COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN 21 06 0404 RESIDENT DECEDENT -ASSETS- FILE NUMBER I. Estate of Steohens Carrie M. (Last Name) (First Name) (Middle Initiaij II. Item No. Description Value A. Real Estate (please describe) Total value of real estate $ (include on Sedion II, Line C-' on Schedule L) B. Stocks and Bonds (please list) Total value of stocks and bonds $ (include on Sedion II, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-' 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 Ll III. TOTAL (Also enter on Sedion II, Line C-6 on Schedule L) $ (If more space is needed, attach additional 81fz x 11 sheets.) REV-16.o16 EX + (3.8.01) INHERITANCE TAX . SCHEDULE l-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT elECTION INHERITANCE TAX RETURN -CREDITS- FILE NUMBER. 21 06 0404 RESIDENT DECEDENT I. Estate of Steohens Carrie M. (Last Name) (First Name) (Middle Initial) II. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) Total unpaid liabilities $ (include on Sedion II, Line 0-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) Total unpaid bequests $ (include on Sedion II, Line 0-2 on Schedule L) C. Value of assets reported on Schedule L-1 (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 Sedion II, Line 0-3 on Schedule L) III. TOTAL (Also enter on Sedion II, Line 0-4 on Schedule L) $ (If more space is needed, attach additional 81h x 11 sheets.) _-,..m,. SCHEDULE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT (Check Box 4a on Rev.1500 Cover Sheet) ESTATE OF FILE NUMBER Carrie M. Stephens 21 06 0404 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 o Trust D 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 decedenfs death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. o Unlimited right of withdrawal D Limited right of withdrawal m. 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%, 0 3%, 0 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%, 0 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) . . . . . . . . . . . . . . . . . . . . . $ (If more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99) (I) . '* . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION (AVAILABLE FOR DATES OF DEATH 01101192 to 12131194) ESTATE OF FILE NUMBER Carrie M. Ste hens 21 06 0404 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet SCHEDULE N SPOUSAL POVERTY CREDIT PART I - CALCULATION OF GROSS ESTATE 1. Taxable Assets total from line 8 (cover sheet) ...................................................................................... 1. 5 006.28 2. Insurance Proceeds on Life of Decedent .............................................................................................. 2. 3. Retirement Benefits ... ....... ... ....... .................. ...... ........ ..... ........ ........... ........... ......................................... 3. 4. Joint Assets with Spouse ...................................................................................................................... 4. 5. PA Lottery Winnings ....... .......... ... ...... ...... ...... ...... ....... ...... .................... ......................... ........................ 5. 6d. 6a. Other Nontaxable Assets: List (Attach schedule if necessary) .. 6a. 6b. 6c. 6. SUBTOTAL (Lines 6a, b, c, d) .............................................................................................................. 6. 7. Total Gross Assets (Add lines 1 thru 6) ............................................................................................... 7. 5 006.28 8. Total Actual Liabilities ... ....... ...... ... ....... ...... ....... ...... ......... ...... .......... ........... .............. ......... ........ ....... ..... 9. Net Value of Estate (Subtract line 8 from line 7) ................................................................................... If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part n. 8. 9. 5,006.28 PARTIr - 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 2a. 3a. 2b. 3b. 2c. 3c. 2d. 3d. 2e. 3e. 2f. 3f. a. Spouse ............................. 1a. b. Decedent ......................... 1b. c. Joint ................................. 1c. d. Tax Exempt Income ......... 1d. e. Other Income not listed above ..................... 1e. f. Total................................. If. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1f) + (2f) + (3f) = (+3) 4b. Average Joint Exemption Income ............................................................................................................... = If line 4(b) is greater then $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part OJ. PART III - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT ESTATES 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................................... 1. 2. Multiply by credit percentage (see instructions) .................................................................................... 2. 3. 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. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ..... .... ...... ..... ............. .... ..... ..... ..... ......... ........... ........ ................................ ........ 4. 5. 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. REV-1649 EX + (6-98) '* SCHEDULE 0 ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Carrie M. Stephens 21 06 0404 Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the 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.l. 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 sim- ilar 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 traction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule O. 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 decedenfs survivinQ spouse under a Section 9113 (A) trust or similar arranQement. Description Value Part A Total $ Part B: Enter the descriotion and value of all interests included in Part A for which the Section 9113 (A) election to tax is beina made. Description Value Part B T atal $ (If more space is needed, insert additional sheets of the same size) REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: Discount: Interest Table Year Days Delinquent Balance Due Interest this time period this year this period Before 1981 1982 1983 1984 1985 1986 1987 1988 throuah 1991 1992 1993 throuah 1994 1995 throuah 1998 1999 2000 2001 2002 2003 2004 2005 2006 TOTALS Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: Penalty: LIMITED POWER OF ATTORNEY TO HANDLE ALL ~TTERS REGARDING THE ADMINISTRATION OF THE ESTATE OF CARRIE M. S~PHENS PRINCIPAL: j( fC l+-A- ~ ~ ;::r~ ~~ 16ro UJ"Y) AGENT: . ..Tu 't\ I "'l- 1-+ r-. W ""- ~ !, Richard James Brown, of38 S. 2nd Street, Newport, Pennsylvania, do hereby appoint JudithT. Walz, Attorney at Law, and President ofWalz and Walz, Attorneys at Law, P.C., 341 Market Street, Newport, Pennsylvania 17074, as my attorney-in-fact (hereinafter referred to as "my agent") with full power of substitution, for me and in my name, to handle all transactions for me without limitation, as completely as I might do if personally present, including but not limited to exercising the followingpowers. This power shall not be affected by my becoming disabled or incapacitated after my signing this document. All acts done by my agent pursuant to this power during any period of my disability or incapacity shall have the same effect and inure to the benefit of and bind me and my successors in interest as if! had full capacity and were not disabled. This power of attorney shall encompass the administration of the estate of Carrie M. Stephens as my substitute Administrator. My agent shall have full authority to make decisions and enter into contracts with regard to this estate. My agent's powers shall include but not be limited to the fOllOwing: . 1. To have the full power, right and authority to do, perform and to cause to be done and performed all such acts, deeds, matters and things in connection with the administration of the Estate of Carrie M. Stephens as my agent, in her sole discretion, shall deem reasonable, necessary and proper, as :fu11y, effectually and absolutely as ifmy agent were the Administrator thereof. 2. To apply for all insurarice proceeds which I may have the right to receive as a result of being the beneficiary of policies owned by Carrie M. Stephens, late of Cumberland County, Pennsylvania and naming me as beneficiary. All proceeds received therefrom shall be made payable to Walz & Walz, Attorneys at Law, P.C., agent for Richard James Brown and delivered to Walz & Walz, Attorneys at Law, P.C. at 341 Market Street, Newport, PA 17074. Insurance proceeds shall be used for payment of all legal fees and costs the funeral bill for Carrie M. Stephens, both of which are approved. 3. To sign, execute, deliver, acknowledge and make declarations in any document or documents that may be necessary, desirable, convenient or proper in order to exercise any of . the powers described; to enter into contracts; and to pay reasonable compensation or costs in the exercise of any such powers. 4. For the purposes of inducing ~y Insurance Company, bank, broker, custodian, insurer, lender, transfer agent, taxing authority, governmental agency, or other party to act in accordance with the powers granted in this document, I hereby represent, warrant and agree that: A. The powers conferred on my agent by this document may be exercised by my agent alone and my agent's signature or act under the authority granted in this document may be accepted by third parties as fully authorized by me and with the same force and effect as if I were personally present, competent, and acting on my own behalf. B. No person who acts in reliance upon any representation my agent may make regarding the scope of authority granted under this document shall incur any liability to me, my estate, my heirs, successors or assigns for permitting my agent to exercise any such power, nor shall any person who deals with my agent be responsible to detennine or insure the proper application of funds or property. C. My agent shall have the right to seek court orders mandating appropriate acts if a third party refuses to comply with actions taken by my agent which are authorized by this document, or enjoining acts by third parties which my agent has not authorized. In addition, my agent may bring legal action against any third party who fails to comply with actions I have authorized my agent to take and demand damages, including punitive damages, on my behalf for such noncompliance. 5. Questions pertaining to the va1idity~ construction and powers created under this instrument shall be determined in accordance with the laws of the Commonwealth of Pennsylvania. 6. Reproductions of this executed original shall be deemed to be original counterparts of this power of attorney and shall have the same power, force and effect as the original. Specimen signature of my agent: ~~ In witness whereot; Thereby c"'1itY~ the g~ ~. e of my agent and have signed this power of attorney this ~1JilY of" ' 20..Q&. ~~f JP~<f~ PRINCIPAL'S GNATURE COMJ.\tIONWEALTH OF PENNSYLVANIA COUNTYOF f~, Onthe c2/l~Tdayof witness, a Notary Public, in and for the onwealth of Pennsylvania, personally appeared the above-named PRINCIPAL, and in due form oflaw acknowledged the foregoing Power of Attorney to be hislher act and deed and desired the same to be recorded as such. Witness my hand and N otaria Seal the day and year aforesaid. :88.: 20tL& before me, the subscribing o ary Public My Commission ExpIres: (SEAL) NOTARIAL SEAL Tana A. Zang, Notary Public Newport Boro., Perry County My commission expires December 16, 2009 LIMITED PO\-VER OF ATTORNEY TO HANDLE ALL MATTERS REGARDING THE ADMINISTRATION OF THE ESTATE OF CARRIE M. STEPHENS, PRINCIPAL: ~~~l.jR R D JA-rr,'l"~ ~r{){A_rYJ . AGENT: ..j ud l' '1-A f'; WI"'} l- '7-: NOTICE TO PRINCIPAL THE PURPOSE OF TInS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE THE ADMINISTRATION OF THE ESTATE OF CARRIE M. STEPHENS, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR AFPROV AL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE, EVEN AFTER YOU BECOMEINCAP ACITATED, UNLESS YOU EXPRESSLY LIl\.1IT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEP MATE FROM YOUR AGENT'S FUNDS; ALL FUNDS SHALL BE RETAINED IN THE IOLTA ACCOUNT PRIOR TO DISTRIBUTION. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POwER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA. CONS. STAT. ANN. CH. 56. IF THERE IS ANYTInNG ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HA VB READ OR HAD EXPLAINED TO l\1E THIS NOTICE AND I UNDERSTAND ITS CONTENTS. Date: c;,/;J./!M . fP~~t3~ . PRINCIPAL dl LJl\.fiTED PO'VER OF ATTORNEY TO HANDLE ALL MATTERS REGARDING THE ADlVllNISTRATION QF THE ESTATE OF CARRIE M. STEPHENS PRINCIPAL: roo{ l eN ~Rb .:::rf} me.s./6 ro wn. AGENT: Iud .'}!l J;. LA )J1..1-~ NOTICE TO AGENT I, JUDITH T. WALZ, Attorney at Law, and President ofWalz and Walz, Attorneys at Law, P.C., 341 Market Street, Newport, PA 17074, HA VB READ THE DURABLE POWER OF ATTORNEY AND AM THE PERSON IDENTIFIED AS THE AGENT FOR THE PRINCIPAL. I HEREBY ACKNOWLEDGE THAT IN THE ABSENCE OF AN EXPRESS PROVISION TO THE CONTRARY IN THE POWER OF ATTORNEY OR IN TITLE 20 OF THE PENNSYLVANIA CONSOLIDATED STATUTES WHEN I ACT AS AGENT: I OWE A DUTY TO EXERCISE THE POWERS FOR THE BENEFIT OF THE PRINCIPAL. I OWE A DUTY TO KEEP THE ASSETS OF THE PRINCIP AL SEPARATE FROM MY ASSETS IN THE ATTORNEY lOLTA ACCOUNT. I OWE A DUTY TO EXERCISE REASONABLE CAUTION AND PRUDENCE. I OWE A DUTY TO KEEP A FULL AND ACCURATE RECORD OF ALL ACTIONS, RECEIPTS AND DISBURSEl\1ENTS ON BEHALF OF THE PRINCIPAL. I AGREE TO USE FUNDS RECEIVED FROM INSURANCE PAYABLE TO THE PRINCIPAL AS BENEFICIARY FOR THE FOLLOWING PURPOSES, IN THE FOLLOWING PRIORITY: 1. FOR THE FUNERAL BILL OF CARRIE M. STEPHENS. 2. FOR LEGAL FEES AND COSTS RENDERED IN THE ADMINISTRATION OF THE ESTATE OF CARRIE M. STEPHENS. 3. TO THE CHARITIES: a. NEWPORT SENIOR CENTER IF THEY QUALIFY AS A CHARITY; b. NEWPORT FIRE CO. IN THE NAl\1E - POSSIBLY IN THE l\1EMORY OF ME AND/OR A MEMBER OF MY FAMILY. Date: q b./ ) ({) ~. I I C0Ml\10NWEALTH OF PENN8YL VANIA 17 :88.: COUNTY OF I......~ : On the :J./>r dayoY ~ ,2oak before me, the subscnbing witness, a Notary Public, in and for the C. onwealth of Pennsylvania, personally appeared the above-named AGENT, and in due form oflaw acknowledged acceptance of the foregoing Power of Attorney to be her act and deed and desired the same to be recorded as such. Witness my hand and Notarial Seal the day and year aforesaid. Notary Public My Commission Expires: (SEAL) NOTARIAL SEAL Tana A. Zang, Notary Public Newport Boro., Perry County My commission expires December 16, 2OQ~ r- I I I I I i L.LJ CJ a: a: I'- f- a.. 0 (/) ..... f- 00f-1'- .z 0...-0:000::) a: 01'--0 '0..0..- :IE: (/) 3: Ua: . L.LJ L.LJ :::l :z Cl (', Cl C)~J , _'<I' "-10.1 (!) -I'. "J"- ~ -E:I7 ~ C") Cl 1'. q ~~ "'3: ~~ ~~ ~.., :)~ c:> c::> c::> c::> !: I ',_ .....__., 1,,~') /,.1 c.:::i :: CL. - I-;.i;:_ (~lt C:, i l .i~. C.'~ C" C"<") C:) f .~_J (~ " t ,. ~,~ I:'- Q) 00 "-' CO ::l CO o I ~ 8 o ~ U c'd ~ Q) '-~ o~~>. u.- g. '" ~~Cl'ja ~ '- 1:: Q) _ 0 ;:l ~ l-c l-c 0 ~ Q)Eu~ ,..c "-' "-' ~.~ ~ ~ u~Ou tt @. ~ .~ ~ ~ - ~ '-':: '1 ~ ~ r ~1&~~ ~r'-'t: '-!:i ~ ~"~ ~ ~ ~~.