The URL can be used to link to this page

Home My WebLink About01-0625 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 *' do- d41- 3 INFORMATION NOTICE AND TAXPAYER RESPONSE FILE NO. ACN DATE 21 - 0\- fo~ 01131560 07-03-2001 REV-1543 EX AFP lD9-DDl ~j EST. OF MARY 0 CLOUSER S.S. NO. 190-26-6863 DATE OF DEATH 04-04-2001 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS [X] CHECKING o TRUST o CERTIF. u, ") BEULAH I BARIC 3 E COUNTRYSIDE DR BOILING SPRINGS PACl1007 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 M & T BANK has provided the Depart.ent with the infor.ation listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this infor.ation is incorrect, please obtain written correction froa the financial institution, attach a copy to this for. and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the C~onwealth of Pennsylvania. Questions .ay be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 1358030 Date 05-27-1997 Established Account Balance Percent Taxable A.ount Subject to Tax Rate Potential Tax Due x 1,338.64 50.000 669.32 .15 100.40 TAXPAYER RESPONSE To insure proper credit to Your account, two (2) copies of this notice .ust acco.pany your pay.ent to the Register of Wills. Make check payable to: "Register of Wills, Agent". Tax x NOTE: If tax pay.ents are .ade within three (3) .onths of the decedent.s date of death, YOU .ay deduct a 5% discount of the tax due. Any inheritance tax due will beco.e delinquent nine (9) eonths after the date of death. PART ill A. [ CHECK ] ONE BLOCK B. ONLY c. [] The above infor.ation and tax due is correct. 1. You .ay choose to re.it paY~nt to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you .ay check box "A" and return this notice to the Register of Wills and an official assess.ent will be issued by the PA Depart.ent of Revenue. [] The above asset has been or will be reported and tax paid with the PennSYlvania Inheritance Tax return to be filed by the decedent's representative. [] The above infor.ation is incorrect and/or debts and deductions were paid by you. You .ust co.plete PART ~ and/or PART ~ below. If yoU indicate a different tax rate, please state your relationship to decedent: PART ~ TAX RETURN - COMPUTA~ION lINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. A.ount Subject to Tax 5. Debts and Deductions 6. A.ount Taxable 7. Tax Rate 8. Tax Due PART @J DATE PAID DEBTS AND DEDUCTIONS CLAIMED OF 1 2 3 4 5 6 7 8 x TAX ON JOINT/TRUST ACCOUNTS x PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on line 5 of Tax Co.putation) Under penalties of perjury, I declare that the facts I have reported above are true, correct and cOBPlete to the best of .y knowledge and belief. I $ TAXPAYER SIGNATURE HOME ( WORK ( TELEPHONE ) ) NUMBER DATE GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. Z. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A _ If the information and cOMputation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. Z. BLOCK B _ If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one COpy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept Z8060l, Harrisburg, PA l7lZ8-060l in the envelope provided. 3. BLOCK C _ If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts Z and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter NOTE: the date the account originally-was established or titled in the manner existing at date of death. For a decedent dying after lZ/lZ/8Z: Accounts which the decedent put in joint names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed $3,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (WW) appears before your first name in the address portion of this notice, the $3,000 exclusion already has been deducted from the account balance as reported by the financial institution. Z. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for jolnt assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY Z (SURVIVORS) = .167 X 100 l6.7Z (TAXABLE FOR EACH SURVIVOR) 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS OR TRUST BENEFICIARIES X 100 PERCENT TAXABLE Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY Z (SURVIVORS) = .50 X 100 50Z (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (line 4) is determined by multiplying the account balance (line Z) by the percent taxable (line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4). 7. Enter the appropriate tax rate (line 7) as determined below. wThe 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 OZ. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% lS% lS% 01/01/9S to 06/30/00 0% 6% lS% lS% 07101/00 to present 0% 4.S%. 12% lS% CLAIMED DEDUCTIONS - PART 3 DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legallY are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 l/Z" x 11". Proof of payment may be requested by the PA Department of Revenue. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE 8UREAU tl, INDIVIDUAL TAXES t ')E~T. 280601 HARRISBURG. PA 17128-0601 REV-1162 EX( 11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BEULAH I BARIC 3 COUNTRYSIDE DRIVE BOILING SPRINGS, PA 17007 _n__n_ fold ESTATE INFORMATION: SSN: 190-26-6863 FILE NUMBER: 21-2001- 0625 DECEDENT NAME: CLOUSER MARY 0 DATE OF PAYMENT: 07/03/2001 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 04/04/2001 NO. CD 000017 ACN ASSESSMENT CONTROL NUMBER AMOUNT . 01131560 I $213.00 I I I I I - I I I TOTAL AMOUNT PAID: REMARKS: BEULAH I BARIC CHECK#1010 SEAL INITIALS: DO RECEIVED BY: REGISTER OF WILLS *THIS RECEIPT' REPLACED $213.00 MARY C. LEWIS REGISTER OF WILLS CD 000011 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES OE~T}~. .' Hi~JRG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 000011 BEULAH I BARIC 3 COUNTRYSIDE DRIVE BPILlNG SPRINGS, PA 17007 ACN SSESSMENT CONTROL NUMBER AMOUNT _u_.___ fold 01131560 $213.00 ESTATE INFORMATION: FILE NUMBER: DECEDENT NAME: DATE OF PAYMENT: POSTMARK DATE: COUNTY: DATE OF DEATH: TOTAL AMOUNT PAID: $213.00 REMARKS: BEULAH I BARIC CHECK# 1010 SEAL INITIALS: DO RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS REGISTER OF WILLS THIS RECEIPT IS BEING REPLACED WITH NEW RECEIPT CD 000017 PETITION FOR PROBATE and GRANT OF LETTERS Estate of Mary also known as O. Clouse~ No. 21- 01-625 To Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania Social Security No. 190-26-6863 The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older and the exec in the last will of the above decedent, dated June 18, 1980 and codicil(s) dated N/A rix named (state relevenat circumstances, e.g. renunciation, death of executor, etc.) Decedent was domiciled at death in Cumberland her last family or principal residence at Carlisle, Pennsylvania County, Pennsylvania, with 940 Walnut Bottom Rd, S.Middleton Twp. (list street, number and municipality) Decedent, then 95 years of age, died at Manor Care, 940 Walnut Bottom Road, Cumberland County, Carlisle Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: No Exceptions April 4, 2001 Decedent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: $ $ $ $ 4,000.00 WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters testamentary (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) thereon. &d/J ~ Beul~~naric . 3 E. Countryside Dr Carlisle PA 17013 OATH O}' PERSONAL REPRSENTATIVE COMMONWEA TLH OF PENNSYL VANIA COUNTY OF CUMBERLAND The petitioner(s) above-named swear(s) or affirm(s) that the statement in the foregoing peition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me this 15th day of January, 2002 ~.2ey (f~~///</ ""''''./ A2t..! A ~/y . Y . eWls / RegIster 1:.:tf 11:::~~ . ~o. 21-01-625 Estate of Mary o. ClouseR. , Deceased DECREE OF PROBATE A~D GRA~T OF LETTERS AND NOW January 18,2002 in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated_ June 18, 1980 described therein be admitted to probate and filed of record as the last will of Mary O. ClouseR.. and Letters Testamentary are hereby granted to Beulah I. Baris '/:{;r/~Jf:.;J""':KJh) /J.r / \: S-"dl Re ster of V ills Probate, Letters, Etc. Short Certificates( 1 ) Renunciation FEES $ $ $ $ 5. 00 Total $ 30.00 Fi led....... JAHUARY.. .15.... .ZQQ ~ 25.00 Robert G. Frey 46397 ATTORNEY (Sup. Ct. 1.0. No.) 5 South Hanover Street Carlisle, Pennsylvania 17013 ADDRESS (717) 243-5838 ARONE ~ ~~~y JCP po = (t' :j ::;::. 0-< r:: n: ~ :o~ roC) ".~", ,....., ,~ C- :P Z 1'"..., (.... --- V1 :::g N o o ("'I -.... T_J'f)".,""" '_',r.\' This is to certifY that the information here given is correctly copied from an original certificate of death duly filed with Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. me as WARNING: It is illegal to duplicate this copy by photostat or photograph. No. 2:i.-~. ~~~~ Local Registrar Fee for this certificate, $2.00 p 7248082 APi "., 6 2001 Date 21-01-625 /" Hl0S.I43R..,.21I7 COMMONWEALTH OF PENNSYLVANIA' DEPARTMI:N I Ur ","'..III' .....~ "-'- CERTIFICATE OF DEATH A'AlNT '" IANENT ::lt1HlC Y... SEX 2.Female 'fAl'''''Et<<Jt.tU:A SOCIAL SECURITY hVMS[R DAlE OF OEAI'H I~. 0... ....." HAMa Of DECEDENT tF... MOH.. L_. .. AQE{....~ .. 190 - 26 .. A ril 4, 2001 95 e&RIHPLACE1C.tv44" PlACE 0# OI:AtHtCl'4dI U1..,.... .. .....,....dllll.'.'''\Jtt.... ......., s.... or '0""" elM.'" HOSPItAL: Carlisle,PA .........0 . .. FACIUT'V NAME (llnoI~QNe .....MtClltumtlel' ="",0 .~\ COUNTY OF DLV"H S. White Ie SuRVIVING SPOuSE "'""'..9''''~IWoNJ DE OENT'S U UAL PRtOH KINO Of BU$lHE ~~.~:O"::~::l.:1 ".. Receptionist .... Hospital DECEDENT'S IoWUHQ AOC:IMS8 (So.... CIlyIlo.n, State:.lip Codel DEC€OENT'S ~ ACTUAL ~~~~1~~~A~75~~ Rd. ~E=- '2. "..$~ PA - 'I. FRHEIl'S NAME 'Fir"~. Ld) ... INfClRMAHTS......ECT_ ,,,,. Cumberland 11..0 :.':i..--:=,::'.. MOTHER.SNA~~m..Wfi!S"!e'r ... INfORMAHT'S MAIUHO AOORESS.s.... Ccytfown. S&.M.ltpCpq.. . .... 3 E. Countryside Dr., Bolling Spnngs, Pa 17007 PLACE OF DtSPOSrTtOH. N.,.... 01 c....."Y. CrIfhMofy LION. C Stat.. lIP eoo. Of 0Ihtf~. 2f.~OSpect Hill Cemetery ......EAND.DDRUSOf MCIl,rv Ho Hanover St. UCENSE NUMBER I __1 i George Clouser Beulah Baric ~ , .- ~ , ~ .- 2 < z METHOD Of llIIPOSIT O _liCl c......tonO R._.._S''''O _ OI/lor It.. ...)q ~ DUE 10 lOR AS.c;oNSfOUEHCE Of): IAWo....... '-- ~onMIMddlted\ !l.........,k '......Ty: O&Mf~C\IOndIIlON~tII~.tloA ftOI,iNUliftgftIN ~C6IlM G"WellII'I MAT I l : DUE 10 IORAS.COHSEOUENCE Of): DUE 10 lOR AS. COHSEOUENCE OF), MAE .UlOPsY 'lNOIIIOS MANNER OF DEATH --......E I'RIOR 10 COM"l.E'1lOH OF CAUSE ~ 0 0fJ DltAfH? "_.. - - 0 ,..ndinQ IlwelllQanon 0 ...0 ....... 0 Coutd ftOl be .,.,,1fTlined 0 OArE Of INJURY I....... Crt. -, TIME Of INJUIl., INJURY R WORK' DESCRIBE HOW INJURY OCQIRRED. .... 0 ...0 ."I:DICA1.I!XAMINERICORONEA Oft tM ....1. 0' ..lIIftfftaUon ancUor Inyullgallon. '" my opinion. d.ath occurred It Ihellm.. dal.. and pl.e.. Ind du.lo th. e.u..(.) and ),.~Mner.'I'a'ed............ ............. ......... ................ ..... ......... ... ............. ........ .... ...... REGISTRAR'S StONIoTURE AND NUMB( ~. ~bJ...~~~ I~\I~\IOI ~ 0.:0 ,~n.l:l.... t:lt .... 2.... ",""IEIt rOMo. oNr one) .eUITIFYINQ ","SJOAN cP'f'tywc:wnurtlf'rn9 c:auMoI dNlh ""'*' ~ ghyscllll'lhIt. prClnOlll'QdldNl\and ~ ....231 T.........' .,,,.,......... .lllhaccu"" dw..... eaueael)arwl mettnoI, a. .taIN. .'.................................................. 2'. rt...ACE OF INJURY. AI hom..,.."" JltllC.lacIOIy. omc. bulking. MC,ISPIOfyt .... ."IItOHOUNCIHO ANa aRTIPYJNO 'HYSICIAN (Ph,1CIM bQItl p10n0unr:ww;J dII..1h anCI c~ IOCausa 01 0'.' T...... Mal ctf '"' tno........ d.ath acCW'" a' the dMlt. hl...net pllce. .net due to 1M cauNC'. ancf """"1' II 1"IId... . .. .. . .. .. .. . ... ..... .. ". r')(i Eiii :s~ 0'" ',~.. m n Jt,.." j;' I:~ ~ c..... ~ - VI ::g N o o :::0 :IJa:> (t\ C1 rf~~. Q '~:: CJ ,.... ...t..' 1""" ,....~ ~ -.,., LAST WILL AND TESTAMENT OF MARY O. CLOUSER I, MARY O. CLOUSER, single woman, of 2135 North Fourth Street in the city of Harrisburg in Dauphin County, Pennsylvania. being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament hereby revoking and making void any and all Wills by me at anytime heretofore made. 1. I direct my hereinafter named Executrix to pay all of my just debts and funeral expenses as soon after my death as may be found convenient to do so. 2. All the rest, residue and remainder of my estate, real, personal and mixed. and wheresoever the same may be situate, I give. devise and bequeath to my cousin. Beulah I. Baric, nee Beulah 1. Lay, her heirs and assigns, of R. D. 9. Box 231, Carlisle, Pennsylvania. 3. I hereby nominate, constitut,e and appoint my said cousin, Beulah I. Baric. as Executrix of this my Last Will and Testament and further direct .' that she shall not be required to post any bond to secure the faithful performance of her duties in theCom:rp.onwealth of Pennsylvania or in any other jurisdication. IN WITNESS WHEREOF I have hereunto set my hand and seal to this ~ . i my LastiWill and Testament written on one page this 18th day of June, 1980. ~@,~ Mary 0 Clouser (SEAL) Signed, sealed, puplished. and declared by MARY O. CLOUSER, the Testatrix above named, as and for her Last Will and Testament, in our presence, who, in her presence, at her request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. ~~- ~l ~b~ f3 ~1 Page 1 of 1 Page '_. r' r './-f ,,'I' t r~. ., ,."; .'\ I Z ~-; , r' ' ' REGISTER OF WILLS OF C~TY OATH OF SUBSCRIBING WITNESS/' /,./ /". / codicil (each) a subscribing witness to the will presented herewirJl; (each) being duly qualified according to law, depose(s) and say(s) that ,. present and saw the testat , sign the same and that signed as a witness at the request of testat_ in h presence,.atid (in the presence of each other) (in the presence of the other subscribing witness(es)). Sworn to or affirmed and subscribed before me this day of 19_ (Name) (Address) Register (Name) (Address) REGISTER OF WILLS OF r!iPmlU1~ COUNTY OATH OF NON-SUBSCRIBING WITNESS Ro\'.u-t (;-, ~re CLY\.d -st~ f). I.' ~ (each) a subscriber hereto, (each) eing duly qualified according to law, depose(s) and say(s) that ~(o--!'~ familiar with the signature of :;0<>...,.., (3.. Fr7 codicil will tc"lal_ vf (one of the subscribing witnesses to) the presented herewith and codicil believes the signature on the will is in the handwriting of that -.!I' -e ~c.. "" , 3 o~~____, ~. r: ~ 1 to the best of ~)' __ knowledge and belief. .~ \ ct' A_ ~ Sworn to or affirmed and subscribed before ~,_ me this 15th day of (Name) \ JANUARY Wx~2 S- 5., v~ H~V\cv~.sr. C ~ /, '5/e. e fJ- 170 ( .3 >>y(}j/:/2!f///~d/iU4"L4 "'~h -(?t;1d~' ~ RegIster I .~ p?'V ./ ~ (Name) S- S6V~ ~"-"'ove..r <S.i. L....r f,'5/e fA- n 0/3 ) I (Address) 217 REV-1!lOO EX (S-QO) J w ... :.:::!!:<Il ull::':: wCl.U :r:OO Ull:...J !l:lll 0:( COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT I (0 - 241 - :3 e.., OFFICIAL USE ONLY FilE NUMBER 2 1- 010625 COUNTY CODE YEAR NUMBER DECEDENT'S NAl'v1E (LAST, FIRST, AND MIDDLE INITIAL) Clouser, Ma O. DATE OF DEATH (MM-DD-YEAR) SOCIAL SECURITY NUMBER 190-26-6863 DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPUCATE WITH THE I- Z W C w o w c 4/4/2001 8/26/1905 REGISTER OF WILLS SOCIAL SECURITY NUMBER I- Z W C Z ~ rn w a: a: o o [8] 1. Original Return o 4. Limited Estate [8] 6. Decedent Died Testate (Attach copy of Will) o 9. Li~galion Proceeds Received ;',THIS,SEqtiON' ~i:JSTi BE ,COMPLETEq[/ NAME Robert M. Fre FIRM NAME (If Applicable) o 2. Supplemental Return 04a. Future Interest Compromise (date of death after 12-12-82) o 7. Decedent Maintained a Living Trust (Attach copy of Trust) 010. Spo"'" Pov8fly Crodn (date of death between 12-31-91 and 1-1-95) o 3. Remeinder ReItm (dale of death prior to 12-13-82) o 5. Federal Estate Tax Return Required _ 8., Total Number of Safe Deposit Boxes 011. Election to tax under Sec. 9113(A) (Attach Sch 0) 717243-5838 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) COMPLETE MAILING ADDRESS 5 South Hanover Street Carlisle PA 17013 (1) NONE (2) NONE (3) NONE (4) NONE ......... ''''''. ;;-J :-.,'~ ';I; j i"} ..",," .. OFFICIAL USE ONLY :n~ ~J C") ::::-.:: 0 "'N" , -'"" :;\ c.~. '1 (G !~:L 2 3. Closely Held Corporation, Partnership or Sole-Proprietorship "Tl m CD 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfer & Miscellaneous Non-Probate Property (Schedule G or L) z o 1= c:C -I :) l- ii: c:C frl a: 8. TOTAL GROSS ASSETS (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 1,812 (5) (6) NONE 3,272 \;..) +'-..) \....,J ~, (7) NONE (8) 3,272 11. TOTAL DEDUCTIONS (total Lines 9 & 10) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 10) NONE (11) (12) 1,812 1 ,460 o 1,460 12. NET VALUE OF ESTATE (Line 8 minus Line 11) 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate ,or transfers under..Sec.9116 (aX1.2) x .0 (15) 0 Z 0 1= 16. Amount of Line 14 taxable at lineal rate x .0 (16) 0 c:C I- :) a.. 17. Amount of Line 14 taxable at sibling rate x .12 0 ~ (17) 0 0 >< 18. Amount of Line 14 taxable at collateral rate 1 ,460 x .15 (18) 219 c:C I- 19. Tax Due (19) 219 Dece ents ample e ress: STREET ADDRESS 940 Walnut 90IIlmmm AimJjj CITY I STATE IZIP Carlisle PA 17013 217 Clouser, Mary O. d C I t Add Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 190-26-6863 219 213 11 Total Credits ( A + B + C ) (2) 224 3. InteresVPenalty if applicable D. Interest E. Penalty 4. TotallnteresVPenalty ( D + E ) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (3) o 5. (4) If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) Make Check Pa able to: REGISTER OF WILLS, AGENT 5 o o 1. Did decedent make a transfer and: PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS a. retain the use or income of the property transferred; Yes o o o o o o o No [8] [8] [8] [8] [8] [8] [8] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. b. retain the right to designate who shall use the property transferred or its income: . . . . . . . . . . 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? . . . . . . . . . . . . . . . . . . . . . . . . . Under penalties of pe~ury, I dac/ara that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is trua, and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledoe. SIGNATURE OF PERSON R>>PONSIB~E FOR FILING RETURN ~j,~ ADDRESS lATE "( {/OZ 5 South Hanover Street, Carlisle PA 17013 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of Iransfers 10 orfor the use of the surviving spouse is 3% [72 P.S. Section 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 0% [72 P,S, Sac/ion 9116 (a)(1, 1 HiI)]. 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 0%[72 P.S. Section 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 4.5%, except as noted in 72 P.S, Section 9116(1.2) [72 P,S. Section 9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings Is 12% [72 P.S, Section 9116(e)(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. AT. REV-1508 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Estate of Mary O. Clouser SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Include the pRlceeds 01 Iitlgetion and the data tha pC'CIC88de were receivad by tha ..tata. ALL PROPERTY JOINTL y-oWNED WITH THE RIGHT OF SURVIVORSHIP MUST BE DISCLOSED ON SCHEDULE F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH M & T Bank, Checking Account 1,339 2. Refund, Manor Care Nursing Home 587 3. Refund, Manor Care Nursing Home, Patient Private Acct 1,134 4. Refund, Blue Cross and Blue Shield unused premium 212 5. TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 3,272 11 M&rBank July 9, 2001 Re: Mary 0 Clouser Acct # 1358030 To Whom It May Concern, Mary 0 Clouser had the above referenced checking account with us at M & T Bank. It was opened on May 27, 1997. The account is titled Mary O. Clouser, Beulah I Baric as Power of Attorney. The balance in the checking account as of April 4, 2001 was $1,338.64. If you have any questions please give me a call at 717-240-4512. Sincerely, '/lidtd1ffff(l1/- Kandy L. Coyle () Asst. Branch Manager Manufacturers and Traders Trust Company · One West High Street, Carlisle, PA 17013 · (717) 240-4536 . Fax: (717) 240-4518 AT REV-1511 EX + (1-97)(1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mary O. Clouser SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reDorted on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Carlisle Memorial Service 95 2. Hoffman Roth, balance due in excess of prepaid funeral services 98 3. Burial Clothing 71 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Beulah I. Baric Social Security Number(s) I EIN Number of Personal Representative(s) Street Address 3 E. Countryside Drive City Boiling Springs State P A Zip 17007 Year(s) Commission Paid: 2002 750 2. Attorney Fees 750 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 0 4. Probate Fees 33 5. Accountant's Fees 0 6. Tax Return Preparer's Fees 0 7. Filing Fee 15 TOTAL (Also enter on line 9 Recaoitulationl $ 1 812 (If more space is needed, insert additional sheets of the same size) 217 REV-1513 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF M 0 CI SCHEDULE J BENEFICIARIES FILE NUMBER ary ouser RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee/s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Beulah I. Baric 3 Countryside Drive Boiling Springs PA 17007 Cousin 100% 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 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) LAST WILL AND TESTAMENT OF MARY O. CLOUSER I, MARY O. CLOUSER, single woman. of 2135 North Fourth Street in the city of Harrisburg in Dauphin County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament hereby revoking and making void any and all Wills by me at anytime heretofore made. 1. I direct my hereinafter named Executrix to pay all of my just debts and funeral expenses as soon after my death as may be found convenient to do so. 2. All the rest. residue and remainder of my estate, real. personal and mixed, and wheresoever the same may be situate. I give. devise and bequeath to my cousin, Beulah I. Baric, nee Beulah I. Lay, her heirs and assigns, of R. D. 9, Box 231, Carlisle, Pennsylvania. 3. I hereby nominate, constitute and appoint my said cousin, Beulah I. Baric. as Executrix of this my Last Will and Testament and further direct that she shall not be required to post any bond to secure the faithful performance of her duties in the Commonwealth of Pennsylvania or in any other jurisdication. IN WITNESS WHEREOF I have hereunto set my hand and seal to this my Last Will and Testament written on one page this 18th day of June, 1980. ~ (J), ~ Mary 0 Clouser (SEAL) Signed, sealed, pul:>lished, and declared by MARY O. CLOUSER, the Testatrix above named, as and for her Last Will and Testament. in our presence, who, in her presence, at her request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. Page 1 of 1 Page ~h.._ ""'1 ---ff'~ l3. ~1 '\ /6-,52~/-0 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX f COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE II"'.~ H(~'CC: 03-11-2002 CLOUSER 04-04-2001 21 01-0625 CUMBERLAND 101 Allount Rellitted Hee DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN '02 MAR 18 P 2 :1 7 ROBERT G FREY 5 S HANOVER ST CARLISLE PA l7tla~'1183 CumL(.; *' IEV-1541 EX iFP [01-021 MARY o MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV=is4j-i3c-AFP-COY:02Y-NoYici--OF-YNHiifiTANci-YA"X-A-PPRAisiMENT~--Ai:.l-owANci-oR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF CLOUSER MARY 0 FILE NO. 21 01-0625 ACN 101 DATE 03-11-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: IS. Allount of Line 14 at Spousal rate (IS) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. AlIOunt of Line 14 at Sibling rate (17) 18. A.ount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due DITS: RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Hortgages/Notes Receivable (Schedule D) S. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 3,272.00 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) 10. Debts/Hortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) 1,812.00 .00 (11) (12) (13) (14) NOTE: .00 X .00 X .00 X 1,460.00 X DATE NUHBER + INTEREST/PEN PAID (-) AHOUNT PAID INTEREST IS CHARGED THROUGH 03-26-2002 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax payment. 3,272.00 1.812 00 1,460.00 .00 1,460.00 00 = 045 = 12 = 15 = .00 .00 .00 219.00 219.00 (19)= .00 219.00 2.91 221.91 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) RESERVATION: Estates of decedents dying on or before DeceMber 12, 1982 -- if any future interest in the estate is transferred in possession or enjOYMent to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Co.-onwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. PURPOSE OF NOTICE: To fulfill the requireBants of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of 2000. (72 P.S. Section 9140), PAYMENT: Detach the top portion of this Notice and subBit with your paYBent to the Register of Wills printed on the reverse side. --Make check or Boney order payable to: REGISTER OF KILLS, AGENT REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, Bay be requested by coapleting an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office of the Register of Wills, any of the 23 Revenue District Offices, or by calling the special 24-hour answering service for forBs ordering: 1-800-362-2050; services for taxpayers with special hearing and I or speaking needs: 1-800-447-3020 (TT only). OBJECTIONS: Any party in interest not satisfied with the appraiseBent, allowance, or disallowance of deductions, or assessBent of tax (including discount or interest) as shown on this Notice Bust object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, DR --election to have the Batter deterMined at audit of the account of the personal representative, DR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS: Factual errors discovered on this asseSSBent should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post AssessBent Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of adMinistratively correctable errors. DISCOUNT: If any tax due is paid within three (3) calendar Bonths after the decedent's death, a five percent (51.) discount of the tax paid is allowed. PENALTY: The 151. tax aBnesty non-participation penalty is coaputed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first dey after the end of the tax aBnesty period. This non-perticipation penalty is appealable in the saae aanner and in the the seBe tiMe period as you would appeal the tax and interest that has been assessed as indicated on this notice. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) Bonths and one (1) day frOB the date of death, to the date of paYBent. Taxes which becaMe delinquent before January 1, 1982 bear interest at the rate of six (61.) percent per annua calculated at a daily rate of .000164. All taxes which becaMe delinquent on and after January 1, 1982 will bear interest at a rate which will vary frOB calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are: Year Intarest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor 1982 201. .000548 1992 91. .000247 1983 161. .000438 1993-1994 n .000192 1984 111. .000301 1995-1998 91. .000247 1985 131. .000356 1999 n .000192 1986 101. .000274 2000 81. .000219 1987 91. .000247 2001 91. .000247 1988-1991 111. .000301 2002 61. .000164 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NU"BER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax beCOMes delinquent will reflect an interest calculation to fifteen (IS) days beyond the date of the assessBent. If paYBent is Bade after the interest cOMputation date shown on the Notice, additional interest Bust be calculated. /6-;)~ /-~ 'v BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT '* REV-16Dl EX AFP 101-121 .02 ~PR-1 1'10 '02 ~\\\ < DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 03-18-2002 CLOUSER 04-04-2001 21 01-0625 CUMBERLAND 101 MARY o Rf;C:':> ROBERT G FREY 5 S HANOVER ST CARLISLE Amount Rellitted PA 1 to 1:3 G\.HntJ . MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 NOTE: To insure proper credit to your account. submit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REY=i6"ifj-E3f-AFP--foY:02y------...--iNirERITANCE-YAX--STAfEMENY-OF'-Accouiif--...--------------------- ESTATE OF CLOUSER MARY 0 FILE NO. 21 01-0625 ACN 101 DATE 03-18-2002 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE. APPLICATION OF ALL PAYMENTS. THE CURRENT BALANCE. AND. IF APPLICABLE. A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 03-11-2002 PR I NCI PAL TAX DUE: ........................................................................................................................................................................................................................... 219.00 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 07-03-2001 CDooOO17 10.95 213.00 03-18-2002 REFUND .00 4.95- TOTAL TAX CREDIT 219.00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 . IF PAID AFTER THIS DATE. SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1. NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) PAYMENT: Detach the top portion of this Notice and submit with your payment made payable to the name and address printed on the reverse side. If RESIDENT DECEDENT make check or money order payable to: REGISTER OF WILLS, AGENT. If NON-RESIDENT DECEDENT eake check or eoney order payable to: COMMONWEALTH OF PENNSYLVANIA. REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by coepleting an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office of the Register of Wills, any of the Z3 Revenue District Offices or froe the Department's Z4-hour answering service for fores ordering: 1-800-36Z-Z050; services for taxpayers with special hearing and I or speaking needs: 1-800-447-30Z0 (TT only). REPLY TO: Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assesseent Review Unit, Dept. Z80601, Harrisburg, PA 171Z8-0601, phone (717) 787-6505. DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5%) discount of the tax paid is allowed. PENALTY: The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax aenesty period. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January I, 198Z bear interest at the rate of six (6%) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January I, 198Z will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOOZ are: Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor 198Z ZO% .000548 199Z 9% .000Z47 1983 16% .000438 1993-1994 n .00019Z 1984 11% .000301 1995-1998 9% .000Z47 1985 13% .000356 1999 n .00019Z 1986 10% .000Z74 ZOOO 8% .000Z19 1987 9% .000Z47 ZOOI 9% .000Z47 1988-1991 11% .000301 ZOOZ 6% .000164 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NU"BER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payeent is made after the interest computation date shown on the Notice, additional interest must be calculated. CYv STATUS REPORT UNDER RULE 6.12 Name of Decedent: MARY O. CLOUSER Date of Death: April 4, 2001 Will No. Admin. No. 21-01-0625 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate if complete: Yes ( ) No (X ) 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: When the PA Dept of Public Welfare sends us a statement showing they are satisfied with this estate. 3. If the answer to No.1 is Yes, state the following: (a) Did the personal representative file a final account with the Court? Yes ( ) No ( ). (b) The separate Orphans' Court no. (if any) for the personal representative's account is: (c) Did the personal representative state an account informally to the parties in interest? Yes ( ) No ( ) (d) Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: April 24, 2002 ~6,.C7> Signature ( Robert M. Frey Name (Please type or print) 5 South Hanover Street Address "'WU~) .,~, (717) 243-5838 Telephone No. 9): ll'i t1Z ckJ\! ZOo Capacity: ( ) Personal Representative ()() Counsel for personal representative '. / t., - ~--<-/ / - --..2 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG, PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' IEV-1607 EX AF' <01-02) ROBERT G FREY 5 S HANOVER ST CARLISLE '07 L j";'.' 20 !")").) 1 It K _, _) 'L. DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04-01-2002 CLOUSER 04-04-2001 21 01-0625 CUMBERLAND 101 MARY o A.ount R_i tted PA HJ)l~ Ct,I'f MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, sub.it the upper portion of this for. with your tax pay.ent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV=i60-j-e.x--iFP--COY:02Y------...-iNHiiiTANC'E-YAX-ST'AfEMENY-CrF'-ACCouiif--...------------------ --- ESTATE OF CLOUSER MARY 0 FILE NO. 21 01-0625 ACN 101 DATE 04-01-2002 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 03-11-2002 P R I NC I PAL TAX DU E : .............-.........................................................................................................................-.................................-.......-...-............................... 219.00 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 07-03-2001 CDOOOO17 10.95 213.00 03-18-2002 REFUND .00 4.95- TOTAL TAX CREDIT 219.00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 II IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J PAYMENT: Detach the tDP pDrtiDn Df this NDtice and submit with YDUr pay.ent .ade payable tD the name and address printed Dn the reverse side. If RESIDENT DECEDENT Bake check Dr BDney Drder payable tD: REGISTER OF WILLS, AGENT. If NON-RESIDENT DECEDENT .ake check Dr .Dney Drder payable tD: C0l1l10NWEAL TH OF PENNSYLVANIA. REFUND (CR): A refund Df a tax credit, which was nDt requested Dn the Tax Return, .ay be requested by cD.pleting an "ApplicatiDn for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office of the Register of Wills, any of the 23 Revenue District Offices or fro. the Depart.ent's 24-hour answering service for for.s ordering: 1-800-362-2050; services for taxpayers with special hearing and / or speaking needs: 1-800-447-3020 (TT only). REPLY TO: Questions regarding errors cDntained on this notice should be addressed to: PA Depart.ent of Revenue, Bureau of Individual Taxes, ATTN: Post AssesSBent Review Unit, Dept. 280601, Harrisburg, PA 17128-0601, phone (717) 787-6505. DISCOUNT: If any tax due is paid within three (3) calendar .onths after the decedent's death, a five percent (570) discount of the tax paid is allowed. PENALTY: The 1570 tax a.nesty non-participation penalty is co.puted on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax a.nesty period. INTEREST: Interest is charged beginning with first day Df delinquency, or nine (9) Bonths and one (1) day from the date of death, to the date of pay.ent. Taxes which beca.e delinquent before January 1, 1982 bear interest at the rate of six (670) percent per annu. calculated at a daily rate of .000164. All taxes which beca.e delinquent on and after January 1, 1982 will bear interest at a rate which will vary fro. calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are: Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor 1982 2070 .000548 1992 970 .000247 1983 1670 .000438 1993-1994 77- .000192 1984 1170 .000301 1995-1998 970 .000247 1985 1370 .000356 1999 770 .000192 1986 1070 .000274 2000 870 .000219 1987 970 .000247 2001 970 .000247 1988-1991 1170 .000301 2002 670 .000164 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUKBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (IS) days beyond the date of the assess.ent. If paYBent is .ade after the interest computation date shown on the Notice, additional interest must be calculated. (}. ~ STATUS REPORT UNDER RULE 6.12 Name of Decedent: MARY O. CLOUSER Date of Death: April 4, 2001 Will No. Admin. No. 21-01-0625 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate if complete: Yes (X) No ( ) 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is Yes, state the following: (a) Did the personal representative file a final account with the Court? Yes ( ) No (X ). (b) The separate Orphans' Court no. (if any) for the personal representative's account is: (c) Did the personal representative state an account informally to the parties in interest? Yes (X ) No ( ) (d) Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. r~"\ ~-~,-r-, Signature I Robert M. Frey Name (Please type or print) 5 South Hanover Street Address Date: May 24, 2002 ';'-J ''-^"'''''. "" r'-J (717) 243-5838 Telephone No. p Capacity: ( ) Personal Representative -.:; c ( X) Counsel for personal representative