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Home My WebLink About04-14-08 " ,~.t.:. . ,.,.'''''"''.''......-'...,c'.. .JI):~- '\, ... -. 15056051047 j 1 1 OJ ,j I 'j I ! 1 I 1 ! REV-1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes . INHERITANCE TAX RETURN PO BOX 280601 Harrisbu ,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death r::-r;:r:'.'...."y'v-"; ,_c;:'~~ iQUD1.Dl!J.~~~J2~ OFFICIAL USE ONLY County Code Year iji~--l f6fTl "~'~'.' ."""""'" ":,,!,,,,.~,_^~.,.~,.,,.l File Number ~:!"~J-:':";~~~,~,~'~.;: ~ " Date of Birth tLE2I~illThW MI ml l' Suffix I~"..'"" H'~"',,,,,,,,!!_,,,, i ~ rf, ~.JI' ~ & ~-c; J':'<:~'l.t:",w>' ~ ~ ".....1-...J! Spouse's First Name MI [JJlU1JJJIIJ.D THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ; J "'./ \-'FILLINAPPROPRIATE OVALS BELOW " ,"., ,,'- ::"".'" ~.. ,~"," ',.J~~ 1:' ,?r:i9lnal Return '" I,> ", ';',- _....-1 ~ ~', 4"- \(, ': , >'0\ \4. Lin:.it8d Estate <:::) 2. Supplemental Return <:::) ,I <:::) 4a. Future Interest Compromise (date of death after 12-12-82) .. <:::) .r' 6. Decedent Died Testate <:::) 7. Decedent Maintained a Living Trust '.,<7, (Attach Copy of Will) (Attach Copy of Trust) ~,"'. ,."': I .". ~- ,. .. ' -'/<:::):L9. Litigation Proceeds Received <:::) 10. Spousal Poverty Credit (date of death <:::) 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'#"! ..'. '. -....,""rf.7.'"'l~"'-.-'-?'TT1 ~.. .....""mOOt '.' '::-..,~ i':j .' ..fr . A) f::;... It c 0 ~(j'.5 '.Li..,i.,..tLl-W...J ~ REGiSt~ ~ WILLlUJSE O~~ ."~~~ ~ .c.- ::i,--j <:::) 3. Remainder Retum (date of death priort012-13-82)j' "'. 5. Federal Estate Tax Return Required . ! 8. Total Number of Safe Deposit Boxes ~r4?'>"')~~"t" .l..'T'~_r""""~,'.~tl".r;ft ~"'~i'.'.IAIl"t........,It~>"'" ~ "'.1 ~ ~ . ~ g J ~ ~ ~ t J , A :.,..,,~.,...}\..,.,,~ ,.,' s t'. .,},,,,.1..,> J,..).~.J$,,,.,.l,.....'" C~2 C) '_) ''11 c::: . :J:J ;)--1 ):;..0 1"-- 1. ~/) ~;~. .~ . " '-r-.. 1"'-;;"""'y.-"r~r-;<;,;:wl-rLL.''''''n~ ., '" ~ ; ~ ~ ~. I Q j R .";"""..l~l...,L.~..""J\,.J..,,J.......~.-1-! . j State ZIP Code fe]] [!I~ill-'l'J. -0 ,::K N o W . :,~'_~,1'.~{"""">":' ,"!'~~":'~f-'^'_"""'-""'-~' ....-..'~..,.....,'~"":fl"',..,.":...~'<'rJ"~~~~~ I ~~l~}.,.~j~~~.1t~L>.lJ_,J,j DATE FILED ;'1" j ;; i I ,1 '" I ....:..4' Correspondent's' e-mail address: ,'. ,i, 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 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. _,SIGNATURE OF PE ON RESPONSIBLE FILII'JG RETURN ATE. ~.. IfH1- V;? ()j>' -.:::J;CV\n(., ~ Io.s @.. U t. r. 'ton. I'le.. 1- " ., ':~ ..~ 'j . .:~; \.,..."A?~:~E~S>/{,Of'-r1cCio"lclc..:Dr Mec..l-, PeL "> :"~IGNATURE OF PREPARER OTHER THAN REPRESENTATIVE '~~E}:t';~/~-:}l,''}t-; ~." i, 170~ DATE f J .:1 4 ~;'.~ :",';>~';':.,;.~l ADDRESS '0, ":.::!li2':~"~''''.:~. h,:':'~' . ~ ~~.~~ PLEASE USE ORIGINAL FORM ONLY Side 1 j I 'i I .J I L- 15056051047 15056051047 ---I S-j I , j ,i cA r 1 I ',~ , i ! ,J ---I 15056052048 1 ... ~ REV-1500 EX Decedent's Social Security Number, . ~ZI2rn~ Decedent's Name: RECAPITULATION WilliaM 1+. Co l-krya h",' Jr. ; .~";'~~;~',.;~'.:I','.Ii>>'r''-:;,:J_ to " i~~ ;1, 1. Real e~tate (Schedule A). ........................................... . 1. ' c ,,\ :<l ., 2. Stocks and Bonds (Schedule B) ...................................... . 2. ~ c: 'i! .'~ " ~ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 3. P - -:.. , , --r'" ~..1' '. ?_ . '';',' ;; :'. : I . ; . . " : r};.' , /,t,} g~ ' 4... Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . , . . . . . . . . . . . . . . . . . . 4. ' , 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. II ~J.J;J, 7 , lpO , 1'f'ri'1J~ ,..., ':' i ~ 1. r ~ If.;'" ~ I 6. Jointly Owned Property (Schedul~ F) .c:::) ,Separate Billing Requested ...... . 6. fl ~ 7. Inter-Vivos Transfers &'Mi~cellaneous Non-Probate Property ,f~"iiil ~, ' ~ ,~. (Schedule G) c:::) Separate Billing Requested. . . . . . . . 7. In ' ,', ,:;7 (0 ~ ~.. ft. ,; " f~I.,{.t:.'" 'l:~ "J~~i'\ r;;'.i' .;:~ -,'.! '.'i\~: ~. -: lI/'" " cA~3 8. Total Gross Asse~s (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. ~ ,J.,. ,.l:L, ~ 7 ltO .. ' I ~. ~. . D'~'!U;.'~~11~:l'~.?~.- ~'\ '. " , f ~ .. . .....- III j; I". I.) 'II- IR ,9: Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . , . . . . . . . . 9.~1 ~ ...o,I,..!,'~"J~}Jr~~'1 :-:"~" : ,., ..',,;.: ~ 10. ~ 1 " , 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . ., . . . . . L l~ ., W ~ '.1 (f..'~e ,! ~l ~ ." I'" .'~ ,'.'. , ',' ~ ' '.. ., F;~F '-: J 11. Total Deductions (total Lines 9 & 10). . . . . , . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 11. g i I, 9 "r 7 f f./ -, '\ .,~ 1 n:rr""~";" : ,', 'I ' , .. . .' 'J 12 H' ... "'.)L i~' ' " f-' !~ 12. Net Val~~,; o~, Esta~e (L!ne 8, minus Line 11) .. .. . .. . .. . .. .. . .. . . . .. . .. .. .. 7' $ 13. ,Charitable and Governmental Bequests/See 9113 Trusts for which .....,: an election,to tax has not been made (Schedule J) 13. . . , ..00. 0...0.......00..... ~~~~~';l'i. t<.,#< I '- 14~~Net Value Subject to Tax (Line 12 minus Line 13) ~ 1 ,~ ~J .. 0...... a. a o. a 0.......0 14. ~,. 4 .1..^~.,~~~/. r ..,.-., "_..,,~' ;(1 " :,..~> TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Une 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable ",' at lineal rate X .0_ 17. Amount of line 14 taxable , at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 18. I"l--n"'''r'''''~''''''''r''-'r ~r ""~'f"""\~" j ~ ~ .. j ~ ~ ~ ~ ; ~ .l ~ ; ~ .'IIl""A:r.., '-''''1r ......<<':......, ....,. (.. ,~Jot', f<o:', ,-" ,.,.,,' " l' . ':J:' " li t f ~ " ~ ' .., i ~ .: , ~ ' ,,' ~ ~: I. I ~ / .' ~ ~.",L,~.,.;;:,:~.....,,;~~~;;~,~t,.ft'. "J ';,'~;fK'i}~"';T% 'v t ,~. ~ ~,' )', ~: I 1$ . ~" .\...i..,.......l), ,,,,i,~ ..'"..:.~_",,,....k~ l'<-~-f fr"''''tk:,It''''''''''~;.i;<.: ""<.~'''-'' 1,,{'11<: ,~,"'~' ,;;-}"-~;:}j;t., (.,. ;!t""''';'\!;.,:,; ~!~l~..';"~:'. L~L~~~~~~~(\~~iLl~ ,J)~~~ r~~,.,~"^ :~LA\Nl. .,,_<~i ~""'.;i;' ~~- ~ " 15. '1 I; ~,,~,. 16 ~ ~ . !..,~ Y,<i~~ Ii ~ 17.l.t 19.. TAX DUE,......................................................... 19, ol '-'to ,<' ,.~'..~'~:'-~~l""'''7<''''' .,..;' ~'Lt;i'-..J~"ftS,'i~~to.;\V."~.' \..:"~ ~ .j ':.' .,....._f?~i~.;;..;.,,~r';t~ ;/:':;; l'-."{ f,.~ _'~",' ~ I,,',";; , .' . .. '. \ ~,. . . ;'~ .". 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ ' " '''',vC) , , .. ..~. _ ,., ".'.r" Side 2 L --.J 15056052048 15056052048 REV-1500 EX Page;) Decedent's Complete Address: DECEDENTS-NAME File Humber cJC() 7 - OD~ U:J 0 STREET ADDRESS WdlllM-\ 3D7 1+. Co I +e np,b, II " S.J-~e- r Jr. ~1o~rl""1'.6 STATE {J~ ZIP I)() 70 Tax Payments :and Credits: . " .' ~".;,~, .'.:.; -\4 ,..' ..... i . . 1:/(1ax Due (P,age2 Line 19)" . 2.,,' CredilsIPayments'::~;:: j }~ A. SpousaIP,oYertycr8dit "<J'~ B. ~ ~ts' C. Discount~t<<, : . . ~',:.:: ;~::. ...,,;~/ .;~J:' I~ :-~?'~~l~,::'.> --". 1, ';'. (1) -0- Total Credits (A + B + C ) (2) -0- 3. ' ,lnterestJPenaIty, if applicable . D.lnterest~.>, ;' .. E. Penalty., 'X " . '''\, . .' . . TotallnteresUPenalty ( 0 + E ) 4. If Line 2 is greaterlhan Una 1+ Una 3, enter the difference. This is the OVERPAYMENT. FiIIln oval on Page 2, Une 20 to request a refund. . (3) -0'- (4) --'0 - (5) -(J- (5A) -c,)- (58) - 0 .--.- 5. If Una 1 + Una 3 is greater than Una 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. " "~"';.<c ". -, " ....-. B. Enter th8tota1 of Una 5 + SA. This is the BALANCE DUE. i. ........:~.:iI'1"':;--\ Make Check Payable to: REGISTER OF WILLS, AGENT . I'..'. <".- <iIf.<f. 't~:1':'~" t~ ~''l'-. .:: . JoIl-" J" .' '" , ;' . PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No ~y " a. retain the use or income of the property transferred;.......................................................................................... 0 l25J b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~ 'c.:: retain a reversionary interest; or...............................................................................;;......................................... 0 ~ . d.; receive the promise for lite of either payments. benefits or care? ................."................................................... 0 ~ .If death occurred after December 12, 1982, did decedent transfer property within one year of death ..' ::::without receiving adequate consideration? .............................................................................................................. 0 t&I :t'3~;,;Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 t8 . 4~' . :=e:=:~I~:~:n:a~;~ti~:::~~.~:~~~:.~~~~~~:.~~.~.t.~.~~.~~~~:.~~~~~~.:.~~~.:..:~~~~...................... 0 ~ .~ . "~' <(' .....~~ 1. ~...~"' : ~.... ..".I:'~,!;'~: ".Jp.\~.~~~""4i:-*t; 'F:t.:..~' , " .' . '.. .~~ 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) pe~nt [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 deattion or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. 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. SCHEDULE A REAL ES1A1E ~E'I.1502 E)(.+ t6.98* COMMONWEALTH OF PENNS'iLVANIA INHERITANCE T~ RE1URN RESIOENi OECEOENi ESTATE Of ITEM NUMBER 1. f\LE NUMBER ;)007 ,. ()O~ v 0 DESCRIPTION jUo~ I 1OTAl. ('\sO .",er 01\ \\n8 '. Aecapi\Ula~on) $ - 0 --- (II ""'...... " _. """. .ddlt""" -, d \he - ,,.,j REV-1503 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Wtl/, AM If. Co I krya.h" , 5r. All property jolntly-owned with right of survivorship must be disclosed on SChedule F. FILE NUMBER ~07 - OOlDfto ITEM NUMBER 1. DESCRIPTION }Jane.- TOTAL (Also enter on line 2, Recapitulation) $ (II more space is needed, insert additional sheets of the same size) () ----.;. ;,.'IE Of FIlE llIlll8Ell \...JI II ,CV^ 1+. to \4 "hI' .:Jr. dOO,- DOt.t.D ..... 0.1 "C~ ~...........,.,.,..-l ""'''' """"" "'............. ~........ "'... ---- -... a............... .__"'............ ,..,..-.."'......."'.....__. ,'V',., na.< . :i..~AUJE ,.10A~;\..,' NUMBER QESCRlI'lIOll ,,,,,,'OI'.oel(11I ,0~r"" 1. ,.,~* ~-mCf PENNS'i'LVfoWo. INHERItANCE t t-.X REtURN RESIDENt DECEDENt SCHEDULE C ClOSElY.HElD CORpOAA 'f\ON, pARflIERSIIIP or SOLE.PI\OPRlEtORSII1P None- 101"'- (AlSO _ '" "'" 3. ReC8I""""",l $ - 0- \" _ space \s ,eede<l. insert """""'" ".,... "''''' ""'" ...,1 REV-150S EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF City 2. Federal Employer 1.0. Number 3. Type of Business State_ Zip Code FILE NUMBER ~() 7 - ODl.J(,O State on Incorporation Date of Incorporation Total Number of Shareholders lJd/,bw\. 1+. Co III ry~~" I 3,-_ 1. Name of Corporation Address .~'." . -.. . Business Reporting Year Product/SelVice -Cl-' 4. ;,;STOCK,..(.k v~i1~;~~ti~~'\~ ~. . TOTAL NUMBER OF SHARES OUTSTANDING ", PAR VALUE ;;"',1 NUMBER OF SHARES ~i.OWNED BY;THE'DECEDE Common ~--~ Preferred Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation1 ................................. 0 Yes 0 No If yes, Position Annual Salary $ lime 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 an 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? o Yes 0 No If yes, 0 Transfer 0 Sale Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedenfs death? ....0 Yes 0 No If yes, provide a copy of the agreement. Number of Shares Consideration $ Date 10. Was the decedenfs 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 decedent's death? .................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. 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 stock. B. Complete copies of financial statements or Federal Corporate Income Tax retums (Form 1120) for the year of death and 4 preceding years. " '...... > .,'_ ,," ,,'.i, ~.,' .. -::~,', . - '," ~'..".'".; _.* C: If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate apprtliS8Jshave::;' been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. 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+ (9000. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF LJII)l~ J1-. Co l-kryah", 3r- FILE NUMBER dOO 7 -oo~(p6.. . Date Business Commenced Business Reporting Year 1 . Name of Partnership Address State Zip Code City 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? 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 . . . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ; DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? . . . . .. 0 Yes 0 No If yes, provide a copy of the agreement. 11. Was the decedenfs 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 atter 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 decedenfs 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+ (1-97) r. _~:~9.. ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ITEM NUMBER FILE NUMBER (&ill, lAM ~ - Co, k:ya hI" Jr: ,;;)00 7 - OO~(PO All property Jointly-owned with right of survivorship must be disclosed on Schedule F. ", '~/"}';~<':,":"", VALUE DESCRIPTION ' A',,' OF ESTATE OF ,i 1, fJ O(\L. TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-l518 EX. (1"7) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEAl. TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right of survivorshIp must be dllcloaed on Schedule F. ITEM VALUE AT DATE.': NUMBER DESCRIPTION j OF DEATH .,c. ,,' 1. f1 +-T Gll.Ak ~((Jr dDO I !1, 1-$lA. ~i.s ~'l f1 0,,-4(7) Sfo r-J- dOO!: ~L.u-ki /1cr6ro/c/~ P<.rU.I\/t' CJoihi"S- I L ~;1u.~ TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) ~.\~ * cOMM~~ Of PENNS"1LV~NI~ INHERl1~NCE 1/I.X RE1URN Rt;SloEN1 oECEOEN1 TATE Of W d\,~ SUR-JI'JINGJOIN1 1E~tS) ~ME A. B. f'J Q (\Q c. SCHEDULE f JO\tlil. '{-OWNEO PROPERt'l ~. Co l-k eJ\A ! :Jr- f\\.E NUMBER dOD' - 00 lit.. 0 ........_..... joIOl_... 'P"..... --"...... -.' -......... on........ G. foJ)ORESS tJI/Y ot;tE Of w1H VtJ,.uEOf ~1 JO\NiL'f .oWNED PROPERi'f: ""'" "" ",_'\ONOf-" ... """", .... --.--......-.....--............. ....... """" "'" .... "to'>'!""'''- 1. A. f\J)i1' lot AL.(AIsO _ on 1il\6 6. ...............l $ - cI- (' _ space is """,,",. ",sert _~.- of \h6.........l ".".M" .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Lv" II ~ l+. Co l-krYAhn, ::J"'r. FILE NUMBER d()() 7 - OD ~ !.JJ 0 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. ITEM NUMBER 1. DESCRIPTION OF PROPERTY INCLUDE THE NAIIE Of THe TlIAHSfEAfE, THEIR RElATIONSHIP TO OECEOENT 00 THE DAlE Of 1lWlSFER. ATTACH ACCP'f Of THE oeEO FOR REAl. ESTATE. DATE OF DEATH VALUE OF AS ET %OF DECO'S EXCLUSION' ;' TAXABLE VAlUE INTEREST,',,,,,,,\-,, -0- /VO(\e- .1 ;' TOTAL (Also enteron line 7. Recapitulation) $ - () - (If more space is needed, insert additional sheets of the same size) iEV-'5" EX+l'O-Q6) ~ COMMON'HE^LTH Of PENNS'fL""NI" INHEf\ITANCE TAt.. f\ETUf\N f\ESIOENT Oe.CEOe.Ni seMIDULI M fUNERAl EXPENSES & AOM\N\SlAAlNE COS'TS f\LE NUMBER C;Joo7 _oD(,,(oZ> 2. t.\tOrne't fees 3, f""" E-""" t' _" "",",' " "'" "" -" .._r,,''''''' ",..,-1 Claimant Street t-ddre5S ---------- CI\'f State __Zip ---- ES,,~"E Of W i\ h "'" \+' Co \4<. IIh/\ ::r r. _ ot........ _ .. ,....... on......... t DESCRIPTION ITEM NUMBER t.. .fUNERAL EXPENSES: 1. H)....~..... ~\ C-eJ"~ ~y.r(\seJ ~~~("\~ t\,Me- a. 'I. f>.OMINISiAA'T\VE COS'TS: ' pefSOnal Representative'S commiSsions _",..-..__'1 ~.."o.,.~~~1.l S....- .J!tof~r~,<h~rO-""'" CI\'f e.C y...,)~""" _rotl.~,,".~ State.2a--ZIP ~ Relationship 01 Claimant to Decedent 4. Probate feeS 5. t.CCOIlntan~s fees 6. la'$. Return Preparer's fees 7_ ',' ."J:i\lij"".. tot~L lA"" em" on uno S. Recap\\llla\lOO) $ If 1./ ';" t' - ,P'" ",_, """ """",," ,-" "" "me ""') REV-1512 EX. (12'()3) .. COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ITEM NUMBER 1. Wdl,ltN1 1+. (DI-kr'fahA1 Jr. Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unrelmbursed m.dlcal.xpen....".;, VAlUE AT DATE ;~,,},:" . .., 'OF DEATHZ;i"4K'?~~jj~( FILE NUMBER C)(f) 7 - aJiI c., 0 ESTATE OF DESCRIPTION CI t; h I\~nct e\. ( ~. H-S 6C- ~e.- fz:ti I CredIt ,J ,"' TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00. COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF .' W ell. ~ J.J-. Co 1* e,J'1\ Jr. FILE NUMBER dO{)? - OD(,(,O RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not L1stTrustee(s) OF ESTATE NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ChCLd Co Jk~ahl1 '-I/)5" !k~ I fX,!< TIn V(.. )Jew Ctc.MbL!!r\Md.) PCL /!DiD 60f) 1. ;...j ';.~~ ':"1 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. ;u/ (1- B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. ;Jfr TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ - (,J- (If more space is needed, Insert additional sheets 01 the same size) REV.1514 EX+ (12-03) '* 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 This schedule is to be used for all single life, joint or suc ssive life estate and term certain calculations. For dates of death prior to 5-1-89 actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. . Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99 and in Aleph Volume for dates of death from 5-1-99 and thereafter. . Indicate the type of instrument which created the future interest below and attach a copy to the tax return. o Will 0 Intervivos Deed of Trust 0 Other :Yr. FILE NUMBER OJOO )-Ci) illo 0 ~,:':;(..~!~~~~~~);~;~~;~~~(S):1"t,~'~ ;;~';;;A:i$::r:":,~' '1;1::: o Life or 0 Term' of v81riS,$ o life or 0 Term 'of' Years:; o life or 0 Term of YearS ' o Life or 0 Term of YearS 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Actuarial factor per appropriate table ................................................. Interest table rate - 031/2% 06% 0 10% 0 Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ ;~;~~4f~; o Life or"O ferm;br~~~;f;'~~ .~ - ,', :>'. ;:~:: ;-'.:','; o life or 0 Term of Yea~;~" ',' ",'; ;,~:,. .;,:::.' o Life or 0 Term of YearS'~;: ., .;V.',1!{~>'~; 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) . .[] 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 Line 3 ................................... 5. Annuity Factor (see instructions) Interest table rate - 0 3 1/2% 06% 010% 0 Variable Rate % 6. Adjustment Factor (see instructions) .................................................. 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and periOd payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period, calculation is: (L.lne 4 x Line 5 x Line 6) + Line 3 ..................................................$ ,. r .:~i;' . :'~t '. f7~ .~ ;, .';'.,.,-.....:,. ,..~~~-~ :"~:~~}7\~ .'.".... .,',,-'.' >~. ;:~';../:)~! ':. ;'.:,:".\~ (",:-;..:,~j: ',.'< NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through ,16. (If more space is needed, insert additional sheets of the same size) April 8, 2008 Cumberland County Register of Wills One Courthouse Square Carlisle, PA 17013 RE: Estate of William H. Colteryahn, Jr. File #2007-00660 To Whom It May Concern: ~ -'c;o , ::D ~:g .L..- -,"; --- ([) ;;<.;. ,. :,-~; C-"J ) -~=) -:::r~1 )c:::: '~ -CJ )>~ Enclosed are two copies of the Inheritance Tax Return for the Estate of William H. Colteryahn, Jr. I inadvertently mailed the original to the Pa. Department of Revenue, Inheritance Tax Division. r-:l = c:;::::) ~:lI.'" I received a call today from Chan Williams (of the Inheritance Tax Division) who said he has it but he informed me that I needed to first file two copies with you. He then said you are to send it to him for final processing. I'm sorry for the oversight on my part. Please let me know if you have any questions or if you need any additional information. Enclosures Very truly yours, 1< ~~- C~17 t~ Jeanne Jacobs, Executrix 1608 McCormick Drive Mechanicsburg, P A 17055 717-790-9522 "'l"'-1.aI ~ ?O - ... -0 :3t r:-? o w