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REV-1500 EX + (9-81) INSOLVENT
BUREAU OF EXAMINATION INHERITANCE TAX RETURN
PENNSYLVANIA DEPARTMENT OF REVENUE RESIDENT DECEDENT
P.O. BOX 8327 f File Number 21-78-432
HARRISBURG, PA 17105 It; - IFf} - I f /1-1.3 - I
,
Decedent's Name (Last, First, and Middle Initial) Decedent's Address
Hisiaszek, Helen Rock1edge Dr. , S. Hid. Twp.
DECEASED Social Security Number I Date of Death Carlisle, Pa. 17013
115-01-4524 7/16/78
CHECK 1. Origi nal Return Q 2. Supplemental Return D 3. Remainder Return 0
APPRO-
PRIATE 4. Life Estate D 5. Federal Estate Tax 0
BLOCKS Return Required.
6. Decedent died testate D 1. Decedent maintained a living 0 8. Number of safe deposit 0
(Attach copy of Will) trust (Attach copy of trust) boxes inventoried
All correspondence and confidential tax information should be directed to:
CORRE-
SPONDENT Na~ F. Douglas, Jr. Address 27 w. Hiqh St.
eorge Carlisle, Pa. 17013
Telephone No. 717 243-1790
City State Zip
Recapitulation
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) ( 2)
3. Closely Held Stock/Partnership Interest (Schedule C) ( 3)
4. Mortgages and Notes (Schedule D) ( 4)
5. Cash & Miscellaneous Personal Property (Schedule E) ( 5) 1,500.00
RECAPIT- 6. Jointly Owned Property (Schedule F) ( 6)
ULATION 1. Transfers (Schedule G) ( 1)
8. Total Gross Assets (total lines 1-7) ( 8) 1,500.00
AND 9. Funeral Expenses Administrative Costs/Miscellaneous
Expenses (Schedule H) ( 9) 5,212.45
TAX 10. Debts/Mortgages/Liens (Schedule I) (10)
11. Total Deductions hotallines 9 & 10) (11) 5,212.45
12. Net Value of Estate (line 8 minus line 11) (12) 0
CALCU- 13. Charitable Bequests (Schedule J) (13)
LATION 14. Net Value subject to tax (Une 12 minut line 13) (14)
Computation of Tax
15. Amount of line 14 taxable at 6% rate (15) x.06= 0
(include values from Schedule K)
16. Amount of line 14 taxable at 15% rate (16) x.15= 0
(include values from Schedule K)
11. Principal tax due (add tax from line 15 plus tax from line 16) (11) 0
18. Total Prior payments:
(a) Amount Paid
(b) Plus Discount
(c) Minus Interest (18)
19. Balance Due Wne 11 minus line 18) (19)
Make Check Payable to: Register of Wills, Agent
* * * PLEASE RECHECK MATH * * *
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and beli . 1$. true, correct, and complete eclaration of preparer other than the personal representative is based on all information of which preparer has
any owledg~.
.a -.2-J> 3
DATE
01.)111
THAN REPRESENTATIVE
~ - /7-71
DATE
REV-l508 EX+ (9-81)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE "E"
CASH AND MISCELLANEOUS
PERSONAL PROPERTY
Helen Hisiaszek
FILE NUMBER
21-78-432
(All property Jolntly-owned with the Right of Survivorship must be disclosed on Schedule "F")
ITEM
NUMBER
DESCRIPTION
VALUE AT
DATE OF DEATH
1.
Cash award.ed1'to Survival Action as adresul,tfof
the automobl e aCCldent causlng the eath 0
Helen Misiaszek on July 16, 1978
in Cox, et al v. Misiaszek, No. 2549 Civil 1980
Cumberland County
$1,500.00
TOTAL (Also enter on line 5, Recapitulation)
$
1,500.00
(If more space Is needed Insart additional sheets of I8me size)
\
REV-1S11 EX+ (9-81)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE "H"
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
Helen Hisiaszek
FILE NUMBER
21-78-432
ITEM
NUMBER
DESCRIPTION
AMOUNT
1.
A. Funeral Expenses:
Raiano Headowbrook Funeral Home
St. Mary's Perpetual Care
Hampden Monument Co.
Caske-t Spray
Reilly's Restaurant, lunch for funeral guest3
B. Administrative Costs:
1. Personal Representative Commissions
2. Attorney Fees
C. Miscellaneous Expenses:
1.
Sentinel, ad costs
Cumberland Law Jou~:-na.;_
$3,765.00
250.00
802.50
100.00
282.95
6.00
6.00
TOTAL (Also enter on line 9, Recapitulation)
$
$5,212.45
(If more space Is needed insert additional sheets of same size)