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Home My WebLink About04-22-08 .-J 15056051047 REV.1500 EX (06-05) PA Department of Rewnue * Bureau of Individual Taxes PO BOX 280601 , _ Harri.c;burfk~A_!?.1?_~1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death County Code Year INHERITANCE TAX RETURN RESIDENT DECEDENT .1' C,q ~" V Date of Birth I t::.7 3~ 2 3d oCf ;)'(i i C( Decedent's First Name 3 Decedent's Last Name Oil L 'J.. ~:~- C ~ Suffix It I~ ALL e I, C cJ E.. (If Applicable) Enter Surviving Spouse's Information Below Spouse's last Name Suffix r(:-NN Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Rle Number ott~ ~ Ml 1--: MI "..,.. 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 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 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 CONRDENTlAl TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 4. limited Estate 8. Total Number of Safe Deposit Boxes 6. Decedent Died Testate (Attach Copy of Will) 9. litigation Proceeds Received ]/.\ N fYI SLOA./ 7 I f 7 l; (, ~'( ) ,.J-... Firm Name (If Applicable) First line of address Q >'55 "'0 -:c c; --\_-~r- _.;' fT, ~ Z:..- ,~~ ~22 ..--', {- 7 tV (; /'ZT ,0.{ V I C v_ D.<.... Second line of address City or Post Office ljei t:.'-':':" {~ A A' I C ~~ b Ll. ri. !i /---\ (,'-5 c'" :iJ "CI~'1 )> State ZIP Code ! 7 (.' t~ C iJ 1\ ~ G t:..:::~ ,;r;,.. .'U ::,~J r'0 I'.:J ""D --1.--. ~;> en Correspondent's e-mail address: L- (' t) h (.., 'I 5' L 'oj 5 {j j".' <.:: IZ. . '2,' ,v , ME." .--.".,-<-- ---_... -,."..""--.--, ---~~"- .--.. .-.-. ,"-"".'-.- --'~-~"'-'---'-"'-'---~'-~'~.--'~'-- "---,'-"' Under penalties of peljury, I declare thai 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. DecIll~~~.of.p_rtl~f9~ other than the personal representative is based on all infonnation of which preparer has any knowledge, SIGNATVRE OF PERSON, ~ESPqNSIBLE FOR FILING RETURN DATE "~ 'It ,\!.~'- i --/'7--;-" ADDRE4t~L I" , 'I,J.\....\;(;."l-- ~, v {, -/ tJt',^Lr/-r(..-,c::~;... ,"~,2- lVlc<.-/-t-/'JA..<s b..:.".J 1'.:\, {/<..,,-c SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 -.J --.J 15056052048 REV-1500 EX Decedent's Social Security Number Decedent's Name: I t.. 7 .3 (. I .) 3<:;, 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. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. ,.. l' I /.J ( I . c; / '-' . (. C- t.f c; 3 j ('- CF . "", IJ . (" 'i C; .:=> .::1 ':i ,',) I f' t." I -5 I t . . "" f c (, I .3 . I ,;J 6. Jointly Owned Property (Schedule F) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested.. . . . . .. 7. 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 APPUCABLE RATES 15. Amount of Line 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 .O~ I C f. / 3 .-) 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. :;. 16. '1 I t . (. ,! 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. "1 I I .(~ .x 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056052048 15056052048 --.J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME T c /--1 Av' IJ 1-f~1 /~()/ e "'< ~"'-_~ sTREET ADDRESS' ---. ~ 2-- !- Z:.._.~I E~ 5 / ~ 1-1. _c.:- I tis!" IE- ... File Number /) _.!< / Lf 2.J:. 4;, CITY i}1 C C- H/'-1 "'-' ,c..':- t~ l/iV> STATE ZIP 1.:14 i 7 c.l.:r:s- Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount i.f77 ~ L- (1) ( ~I.P~ -)~~-= 3.~~~ "1 Total Credits ( A + B + C ) (2) 5" 3.07 3. I nterestlPenalty if applicable D. Interest E. Penalty 4. ------..----.-- TotallnterestlPenalty ( D + E ) If Line 2 is greater than Line 1 + Une 3. enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (3) (4) (5) (5A) (5B) r..f;)., l.f. ,.rJ 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. L-f) '--f . S:.s - 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;.......................................................................................... 0 181 b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 :gr c. retain a reversionary interest; or.......................................................................................................................... 0 ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death 3. ~:~~e:;~;:~~~:~:~;~:~::~~.~~~.d~~fu.~~~.~;;;;~~~~;.~ri~.~~.~;~.~~.~~;.d~~~~;:::::::::::::: 8 ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 fl 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. 99116 (a) (1.1) (i)J. 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. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and filing a tax retum 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. 99116(a)(1.2)J. The tax rate imposed on the net value of transfers to or for the use of the decedenrs lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)J. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(a)(1.3)J. 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. REY-f511 EX+ (1()-()6)* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAl EXPENSES & ADMINISTRA1lVE COSTS ESTATE OF SO N".v FILE NUMBER /-hv'2<J.}e IZ. od e.- Debts of decedent must be reported on Schedule L ITEM NUMBER A. 1. DESCRIPTION FUNERAL EXPENSES: ;Z, /}<}/ne.e r/7/VIJ -.I.:{ d e i!L AMOUNT ?; '-IQ3.;;2 <t .-- B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State _Zip 2. Attorney Fees 3. Family Exemption: (If decedenfs address is not the same as claimant's. attach explanation) Claimant SlreetAddress City State _Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accounlanfs Fees 6. Tax Retum Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ ?;4 9 3 . :J Y (If more space is needed, insert additional sheets of the same size) REV-'IS09 EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 5''', H IJ AI. '-/Ai{(1!e ilL, de.:.- If an asset WlS made joint within one year of the decedent's date of death, it must be reported on Schedule G. SCHEDULE F JOINTly-oWNED PROPERTY SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. ,J" A J\.J /\.'/ ,S L L ,,4, .- L. . 7 t-/ , I~,r I-I V Ie lA.,! j) ,- M cL if 1":..1"" C.". b~ .~S . t' All (; c~-() D{\ U (j h TefL. B. C. ,- JOINTLY.OWNED PROPERTY: LETTER I DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT M~DE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMIlAR DATE OF DEATH DECO'S I DECED~~; I~EREST NUMBER TENANT JOINT lDEl'lTIF'fll'lD NUMBER, ATTACH DEED FOR JOINTlY-HELD REAL ESTATE. VALUE OF ASSET INTEREST 1, A. (/~C'c:., p~ e C/ 4...- 2-'2.qj ,5 l,) C Z. 2. (j 1.3> - C'l '" '" 3",23';i , I :). C}- ~ "', S c ,,, ej( -f2. Jlj iv ;', :\ JJ ,,' -- C~-II/XJb 4<; II" 'i{l ~-.td ,.:: (} i ft, ?/.C ~,q TOTAL (Also enter on line 6. Recapitulation) $ /9 /l!? . co (If more space is needed, insert additional sheets of the same size) ------------------------------------------------------------ Pennsylvania State Employees Credit Union 1 Credit Union Place Harrisburg, PA 17110 717-234-8484 ------------------------------------------------------------------------------ JOHN N HARCLERODE Account: 016Jj6~~j~ Post ==============:======================~=================================~=~=~== Amount New Balance Effect Transaction Description ------------------------------------------------------------------------------ ------------------------------------------------------------------------------ 01/01 01/02 01/02 01/02 01/20 01/01 01/02 01/10 01/10 01/10 01/20 01/01 01/20 ID 01 REGULAR SHARES Balance Forward --------------------------- 39.68 Deposit: US TREASURY 312 1,904.85 1,944.53 TYPE: CIVIL SERV ID: 3121736156 CO: US TREASURY 312 Ending Balance -----------------------------------------1,944.53 ID 04 CHECKING Balance Forward ------------------------------ 2,568.22 Draft: 001225 2,200.0n- 368.22 Draft: 001226 23.63- 344.59 Processed Check - VERIZON ARC TYPE: CHECK PYMT ID: 2005022221 Ending Balance -------------------------------------------344.59 ID 07 MONEY MARKET SHARES Balance Forward ----------------------- 2.19 Ending Balance ---------------------------------------------2.19 "''", '/,....n.-" , -.-J L..: c,. -- J:<. \:': / Ji} ,"_ ./ '34 .tJ Ie... Page: 1 Document Name: untltiea DDHIST Demand Deposit Display History 6017 02/27/08 Acct 0571127649 Alpha key HARCLJNJ01 Request ALLT~~ Last strnt 02/08/08 S --Date-- ----Description----- -Serial Nbr- -Reference- ------Amount------ * 01/03/08 DAILY BALANCE 16,849.16 * 01/08/08 CHECK 591 06431500090 (35.00: * 01/08/08 DAILY BALANCE 16,814.16 * 01/09/08 INTEREST CREDIT 00000000000 1.53 * 01/09/08 DAILY BALANCE 16,815.69 * 01/25/08 CHECK 594 06232703480 (7,495.00 * 01/25/08 CHECK 597 06178009160 (300.00 * 01/25/08 DAILY BALANCE 9,020.69 * 01/30/08 CHECK 593 06136701910 (51.93 * 01/30/08 DAILY BALANCE 8,968.76 * 02/01/08 CHECK 595 06153909030 (421.35 DDDHISTREQ DDDHISTBAL DDDMAIN DDDACCT DDDINT There is additional Information before and after this page. GN20000IO: COMMAND ===> F2=Retrieve F3=Exit F7=Backward F8=Forward F4=CRFwindow