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HomeMy WebLinkAbout05-22-08 15056041125 REV-1500 E>< (06-D5) PA Department of Revenue Bureau of Individual Taxes County Code Year Ffe Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 0 7 0 6 0 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 2 0 9 2 8 8 8 9 3 0 6 0 7 2 0 0 7 0 8 2 1 1 9 3 7 Decedent's Last Name Suffix Decedent's Fir;>t Name MI Y O H N MAR G! A R E T C (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First IVame MI Y O H N C A R L G Spouse's Social Security Number 1 9 4 2 8 8 8 9 3 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW 1. Original Retum ~ 2. Supplemental Retum ~ 3. Remainder Retum (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required death after 12-12-82) 0 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy ofi Will) (Attach Copy of Trust) 9. 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. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number J A N E M A L E X A N D E R E S Q 7 1 7 4 3 2 4 5 1 4 Finn Name (If Applicable) r> `~~,``' First line of address 1 4 8 S B A L T I M O R E S T R E E T Second line of address 1 City or Post Office State ZIP Code D I L L S B U R G PA 1 7 0 1 9 IST~Of' WILLS ONLY ? _;~~ ~ ,~ f II - --~ ~ 1 - := N - ,,-, .:~; ~, - _ ~. , r~ --I - - DATE FILLS ~ I '° Correspondents e-mail address: jmalexander.148(aifearthlink.net under penames or 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 we, coned and complete. Declaration of preparer other than the personal representable is based on all information of which preparer has any knowledge. SIGNATURE OE PERSON ADDRESS 3709 Hartzdale SIGNA RE OF PREPARER O FOR FILING RETURN ive Camp Hill '14 S. Baltimdre Street Dillsbur PLEASE USE ORIGINAL FORM ONLY Side 1 15056041125 DATE yyPA 17011 J PA 17019 15056D41125 ,~~ 15D56D42126 REV-1500 EX Decedent's Social Security Number ~ecedenfs Name: MARGARET C. YOHN 2 0 9 2 8 8 8 9 3 RECAPITULATION 1. Real estate (Schedule A) ........................................ 1 2. Stocks and Bonds (Schedule B) 9 4 7 • 3 8 .................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................ 4. 5. Cash, Bank Deposits & Miscellaneous Persona! Property (Schedule E) ....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 7. Inter-V'nros Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1-7) ........................... 8. 9. Funeral Expenses & Administrative Costs (Schedule H) ................ 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ 10. 11. Total Deductions (total Lines 9 & 10} ........................... 11. 12. Net Value of Estate (Line 8 minus Line 11) ......................... 12. 13. Charitable and Governmental Bequests/Sec 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. 7 6 8 5. 3 2 6 9 4 7 6. 6 6 7 8 1 0 9. 3 6 1 5 7 9 1. 0 0 3 7 9. 7 5 1 6 1 7 0. 7 5 6 1 9 3 8. 6 1 6 1 9 3 8. 6 1 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 911& (a)(12)X.0 _ 6 1 9 3 8 6 1 15. 16. Amount of Line 14 taxable 0 0 0 at lineal rate X .0 _ . 16 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 17. 18. Amount of Line 14 taxable 0 0 0 at collateral rate X .15 18 19. Tax Due ................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~. C~ ~~ r \ / Side 2 0. 0 0 0. 0 0 0. 0 0 0. 0 0 0. 0 0 15D56D42126 15D56D4212b REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 07 0604 DECEDENTS NAME MARGARET C. YOHN STREET ADDRESS 3709 Nartzdale Drive CI•~r Camp Hill STATE ZIP PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) $0.00 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + E'~ + C) (2) $0,00 3. Interest/Penafty if applicable D. Interest E. Penalty Total Interest/Penalty (D +E) (3) $0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fi{I in oval on Page 2, Line 20 to request a refund. (4) $0.00 5. 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. (5A) $0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) $0.00 Make Check Payable to: REG-STER 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 : ................................................................. ..... O X b. retain the right to designate who shall use the property transferred or its income; .......................... ..... c. retain a reversionary interest; or ........................................................................................... ..... ^ X ^ 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? .................................................................................. " " ..... ^ 0 or payable upon death bank account or security at his or her death? ... intrust for 3. Did decedent own an ...... 4. Did decedent own an Individual Retirement Acx;ount, annuity, or other non-probate property which Q contains a beneficiary designation? ............................................................................................ ...... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1,1) (i)). For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent (72 P.S. §9116 (a} (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requin~ments for disclosure of assets and filing a tax return are stilt applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or'for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent (72 P.S. §9116{a)(1.2)). The tax rate imposed on the net value of transfers to or for the use of the 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. REV-1503 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA 1NHERfTANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER MARGARET C. YOHN 21 07 0604 Afl property jointly-owned with right of survivorship must be disclosed on ,schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. $50.00 U.S. Savings Bond L60443133EE, dated August 17, 1981 $122.92 2. {$50.00 U.S. Savings Bond no L4141393EE, dated April 15,1980 3. {$200.00 U.S. Savings Bond no. R996393EE, dated ,tune 27,1983 4. {$100.00 U.S. Savings Bond no. C655573EE, dated May 27,1980 TOTAL (Also enter online 2, Recapitulation) S (If mot space is needed, insert additional sheets of the same size) $147.18 $380.00 $297.28 Calculated value of Your raper savings tsona(s~ Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 06/2007 rage i or i 7atai Price 7ata{ Vafue Totai Interest YTD Interest $200.00 $947.38 $747.38 $19.02 Bonds: 1-4 of 4 Serial S eries Denom Issue Next Final Issue Interest Interest Value Note # Date Accrual Maturity Price Rate NA . EE $50 08/1981 08/2007 ? 08/2011 _ _"$25.00_ , $97.92 i _ 4.00% $122 92 NA EE ~ " „ $50: 04/1980;10/2007 04/2010 ~ $25 00 $122 18 ,4 00% "" $147 18 NA " EE „ t" _$100: 05/1980 11/2007 "05/20,10. $50 OO m ..$247 28 „ __4 00% 297 28 , NA EE ~ $2001 06/1983 q 12/2007 i 06/2013 p $100.00 $280 00 4.18% $380.00 Totals for 4 Bonds'; $200.00 " $747.38 $947.38 Notes NI .Not Issued .._ NE -Not eligible for payment P5 Includes 3 month interest penalty " MA Matured and not earnin interest http:l/www.treasurydirect.gov/BC/SBCPrice 6/22!2007 REV-1508 EX + (6-98} SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER MARGARET C. YOHN 21 07 0604 Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on ~5chedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Sovereign Bank -checking account no. 574111241 $5,903.65 2. ~ 5overeign Bank -account no. 5741.12213 __ _ _ _ _ _ _ ~ $1,781.67 TOTAL (Also enter on line 5, Recapitulation) f ; (If more space is needed, insert addfional sheets of the same size) ~4 Sovereign Bank 1-877-SOV-BANK (1-877-768-2265) wwwsovereignbank.com MARGARET C YOHN Balances STATEMENT OF ACCOUNTS Statement Period 04101!07 TO 08/30/07 STATEMENT SAYINGS ACCOUNT Account # 574111241 Beginning Balance $2Q281.84 Current Balance - ' $0:00 Deposits/Credits + $621.81 Average Daily Balance $20,419.78 " WithdrawalslDebits - $20,903;65 * This balance was calculated for the period begsnning on 05/01/07 and ending on 05/31/07 Interest Paid this. Period ' $ 0.00 ~ .. ,: Annua{ Percentage Y"field Earned 0.00% Earned this Period $ 0.00 Paid Last Year $122.76 Paid Year-To-Date , $`29;28. < "The interest earned and the interest paid may differ depending on when interest is credited to your account. Account Activity Date Description Additions Subtractions Balance 04-01 Beginning Balance $20,281.84 04-20 `DEPOSIT ' $621.81 $20,903.65 05-31 WTHDRWL ~ $15,000.00 $5,903.65 '06-22 :CLOSING TRANSACTION $5,903.65. $0.00 06-30 Ending Balance $0.00 page 3 of3 574111241 REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY FILE NUMBER MARGARET C. YOHN 21 07 0604 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-150U GOVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDETf4ENAMEOFTHETRANSFERFE,THE~RRELATIONSHIPTODECEDENTAN~ TME °nrEOFtRnwsFER. arrncN ncoPr of niE oEEO FoR REAL EsrntE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION (IF nPPUCas~El TAXABLE VALUE 1. Fort Dearborn Life Insurance Company $40,222.01 100. $40,222.01 Company Annuity Contract No. P00000016701 Beneficiary Carl G. Yohn 2. Allianz -annuity contract policy no. 8432912 $11,026.E~2 100. $11,026.52 Beneficiary Carl G. Yohn 3. Allianz -annuity contract policy no. 8430511 $18,228.13 100. $18,228.13 Beneficiary Carl G. Yohn $0.00 TOTAL (Also enter on line 7 Re:apitulation~ ~ 5 69,476.66 (If more space is needed, insert additional sheets of the same size) ' STATEMENT OF ANNUITY ACCOiUNT FORT DEARBORN LIFE INSURANCE COMPANY ® Administrative Office P. 0. Box 655403 Dallas, TX 75265-5403 Owner: MARGARET C YOHN Contract Number: P00000016701 3709 HARTZDALE DR Issue Date: 08-18-2002 CAMPHILL, PA 17011 Annuitant: MARGARET C YOHN NON-QUAI_ GOLDEN FORTIFIER 100 - 2F x~_. TAX INTEREST aINT ACI:OUNT ACCOUNT DATE YEAR PREMIUMS + CREDITED RATE - CHARGES -WITHDRAWALS = VALUE Pre Bal 03-31-2007 40,271.32 1 04-18-2007 68.38 3.500 117.69 40,222.01 2 05-18-2007 113.89 3.500 113.89 40,222.01 3 06-18-2007 117.69 3.500 117.b9 f' X0,222.01 4 06-30-2007 45,52 3.500 40,267.53 TOTALS: 50.00 5345.48 50.00 5349.27 - 540,267.53 The Guaranteed Interest rate credited to the Policy account value is 3.00%. The Current Interest Rats from 08J18/2006 to 08/17/2007 is 3.50%. If you have any questions, please contact a Customer Service Representative at 1-800-538-0379. Agent: MARYJO A FABIANKOVITZ 1009 N BETHLEHEM PIKE PO BOX 458 SPRING HOUSE, PA 19477 (215) 643-3490 CLIENT COPY ~Allianz ~l~ P.O. Box 59060 Minneapolis, Minnesota 5549-0060 1-800-950-1962 August 30, 2007 Re: MARGARET C YOHN, deceased Policy Number: 8432912 Federal Tax Withholding: $47.44 Taxable Amount: $474.41 No. 5080179 Check Date: 08/30/2007 1f Dear CARL YOHN: Please accept our sincere sympathies and thank you for providing the nec essary infornnation to' process your claim. Attached is a check in the amount of $11 026 52 re , . presenting your net benefit. You will be receiving.a 1099-R early next year indicating your gross distribution amount and the taxable amount. o $474.41. f Should you have any questions, please do not.hesitate to contact ou Thank you. y r agent or call the. Claims area at .800 950- ~ ) 1962. Sincerely, Cindy Drawert Claims Examiner C: MARY F~B~.~Iiv'hOV'ITZ ~.OU~~O~~1-~iq , ~hl~a : ~ ~~f~ . P.o: Box s9o6o Wells Far o Bank Ofjro, N:A. „5 HoSP~, Dr1ve ...Check # 5 Van We 0801 7 Minneapolis, Minnesota 55459-0060 . rt, OH 45891 : 9 ; 56-382/412 1-800-950-1.962 _ ~J0008432912 08/30/2007 VOID-AFTER 120 DAYS PAY ~levex 7lsouaa~cd 7wert~y -Six ,rfJZD 52/1 ;, ,C ~; , pw~a waaa~ ~ #~...1 ~ ,026.52 TO THE CARL YOHN RDER O C/O JANE ALEXANDER, ATTORNEY 148 SOUTH BALTIMORE ST DILLSBURG, PA 17019 ~ ~~- P ~- l ~~'000 5080 ~ 79ii' x:04 L 20 38 24i: 96000 188 54n^ - -" - ~~ ----___: ~Allianz ili P.O. Box 59060 Minneapolis, Minnesota 55459-0060 1-8Qt1B~~2007 Re: MARGARET C YOHN, deceased Policy Number: 8430511 Taxable Amount: $0.00 No. 5080178 Check Date: 08/30/2007 Dear CARL YOHN: Please accept our sincere sympathies and thank you for providing the necessary information to process your claim. Attached is a check in the amount of $18,228.13 representing your net benefit. Should ou have an _ __ _ _ Y y questions, please do not hesitate to contact your agent or call the: Claims area at (800) 950-1962. Thank you. Sincerely, Cindy Drawert Claims Examiner C: MARY FABIANKOVITZ #000054478 _ ~ _ `;~~ iw,.....~ . °- __~~.: t ~ cLinc. r.""-V._.. ., x L_::b d:.c+ ...L .i~,., r k~i~ 5s~a k W Its FaFgg~tt„aao Bank Ohio, N; A. , ~+ f' pp P.O: Box 59f~~ '~~r%a~++°V"~Vert OfH r45891 ~h@Ck ~ 50Uo 1 78 Mumeapolis, Minnesota 55459-0060 ss-savatz 1-800-450-1962 00008430511 08/30/2007 VOID AFTER-120 DAYS PAY €u~e¢,j 7lraueard 'Jua ~fuedired 7wexriy ~c~T 3~~ $ ""18,228.13 TO THE CARL YOHN oORDER C/O JANE ALEXANDER, ATTORNEY 148 SOUTH BALTIMORE ST ~ ~' DILLSBURG, PA 17019 ~ ~~'000 5080 l 78i~' x:04 1 20 38 24~: 96000 l88 54~~^ REV-1511 EX + (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS -~" ESTATE OF FILE NUMBER MARGARET C. YOHN 21 07 Q604 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Funeral Home $7,933.00 2. Office of Catholic Cemeteries $825.00 3. Catholic Cemeteries - intemlent $800.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Persona{ Representative (s) None claim Sortial Security Numt>er(syEIN Number of Personal Representative(s) Street Address City State Zip . Year(s) Commission Paid: 2. Attorney Fees lane M. Alexander, Esquire ~ $2,350.40 3, Family Exemption: (If decedenCs address is not the same as claimants, attach explanation} $3,500.00 Claimant Carl G. Yohn Street Address 3709 Hartzdale Drive City Camp Hill State PA Zip 17011 Relationship of Claimant ro Decedent husband 4. Pmbate Fees Register of Wills, Cumberland County $173.00 5 Accountants Fees Samuel D. Thuma, CPA -income tax return $1~•~ 6. Tax Return Preparers Fees 7. Register of Wills -filing Inheritance Tax Return and Inventory $30.00 8. Narumol Alexander -witness fee $25.00 9. Notary fees $5•~ l ~' aJ lo(Zi TOTAL (Also enter on line El, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) fmu~ Generntinrrs... Celebmriug Li)e. Honoring Trnr/irions 1~4/[~ER~ `.~urreral C~'ome, ~7nc. BOYD L. MYERS, ,/Ry Supervisor 37 E. MAIN S'T'REET MECHANICSBURG. PA 17055 (737)766-3421 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are on{y for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain in writing below. If you selected a Funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if elected arrangeme-n+ts-such as direct ere ion or immediate burial. IF we charged For embalming, we grill exp4ajn wh7V b,.elo For the Ser/v~ce of ~ ' ' ~/ ~ RJLP t~/ ~ ~ ~C HfVJ Date of Death ~_ r [ "~A Charge to: \ : R„il- )` U (--1 N 3 ~ ~ rl ~~ lk~t-.'1'Z'0/kt. yE ~ii: JF_ ~~C(~ Name Address City State A. CHARGE FOR SERVICES SELECTED: 1. PROFESSIONAL SERVICES Services of Funeral DirectorlStaff .. fZ_- mot-' Embalming .. .......... ..... .. f~L Other preparation of body f -~' AI f~~ SUB=TOTAL OF PROFESSIONAL S ERVICES......... ? FACILITIES AND SERVICES Use of facilities and sen--ices for ~~,~,r^~_ ~ ~ N viewing (V isitationlWake). _ ' ' Use of facilities and services L ~' for Funeral ceremony f lJse of facilities and services for Trc-~ Memorial Sen•ice ..:. ...... .... f Use of equipmenrand services F~ ' ~- for graveside service ........ .... 8 -.r ~ Other use of Facilities - - -r L SUB-TOTAL OF FACILITIES/EQUIPMENT ...... .. A2 f~ i. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Hv~ Local .......................... Y Hearse (Casket Coach) ~ S ~- Local ......................... . r~r - Limousine Local ............. f Its" Family car Local .................. ... ... Flower car or Floral disposition -T' ~~ f -+A~- Local ......... ..... . . ...... Lead carlc r y car ~~ e` ti J ~NL~ .... r' Local.... ~ Y Car for pallbearers Local .................. b `-" Out of town transportation ... .... I f r SUB-TOTAL OF AUTOMOTIVE EQUIPMENT Other clothing f f Cremation urn .. .............. f (Description) OTHER TOTAL MERCHANDISE SELECTED... f B f~) ~~ ~ C. SPECIAL CHARGES: Forwarding nF remains to f (Funeral Home) Rrcciving of remains from f (Funeral Home) Immediatr Burial .. .. ........ f Direct Cremation . f f SUB-TOTAL OF SPECIAL CHARGES . .... .. ....... C f_ D. CASH ADVANCED Grave enin O f~Y .. ... .... g p m C E i . ~ f -0' emetery qu pme Lot and Dred .. ... _ ......... ~ f~.~ Newspaprr Notices-Local ....... . f ~_ Newspaper Notices-Out-of-town... . d "' Telrphone & Telegrams f "- Airfare ................ ...... . f -' ClergyhVkwsOffering . f j~• °'~ Pallbearers ..................... . f ~"-' Certified Copies of~he Dearh Y ~ y- ~. .. ~? ~ ... .. ......... Certificatc f~1S:- Police Escort ... .... f - Flowers .. - `"" f~ Vault Servicr Charge ............. . f f f f f f f X153 G'' ~-{~_ f SUB-TOTAL OF ADVANCES ....................... D f A3~+yw We charge you for our services in obtaining: q (specify cash adnarrces that~'e marked-up/ f~95s~ ~~1111"'_ SUMMARY OF CHARGES A. Professional Services, Facilities and Equipment, and Automotive uy, Equipment ................... .. f~ %~• B . Merchandise . ... ~ - ``~ f ,~~- C. Special Charges .................. f D. Cash Advances . ...... .......... f ~~ `'~ TOTAL OF ALL SECTIONS ............. .......... f r L.,17J-'~ PAID AT TIME OF OR PRIOR TO ARRANGEMENTS . ... ...... ................... f BALANCE DUE ........... ...................... f SON FOR EMBAL ING _ !f any law, ce ten', or crematory requirements have required the purchase of any of the ite a listrd above t law or requirement is explained below. p u ~-~-~,L , n.- Lea ~ .~ ~t-.~.-<-~. TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE EQUIPMENT ................................... A B. CHARGE FOR MERCHANDISE SELECTED: it 1 ~Y~ .~.. ... ... . . Casket ......... ..... f r :~ Other Receptacle ... ....... ..... f (Description) ~ ....... Outer burial cory3iner ..... f f0 .- ` (Description) ~~~~'' ~,t~-~ --~--- Acknowledgement cards .... ~ Register book(s) ... ........ f Memory folders ...... ..... Prayer cards ... ...... ..... ..... f Temporary grave marker .... . ..... 1 Burial clothing .............. ..... f I agree that I have examined the items o(goods and services selected above and found them to br correct and according to the arrangements 1 have requesred. I acknowledge receipt of a copy of this Sntement of Funrnl Goods an~rviFes/Selrcted. I represent thatlhC~avr suffirirm funds available for payment of the cash price (vr the goods and services selected. 1 also agree }o maJce paymtnt trF'f 1t--- ~~' within ~~ dat•s. I agree to be joint{1' and severally liable with ariv ne else who signs belvw. A late charge of O____l°"y ptr mooch amounting to a per year will be applied to the unpaid balance beginning 3~, days from the da[r of this agreement. t will also pay to the Funeral Director all reasonable ms[s paid by the Funeral Dirrcror m collect amoums t owe under this agreement. Those costs may include attorneys' fees, court costs and other costs. Any additional services or merchandise ordered nr rc ested after the date of this agreement will be considered part of this agreement and thr cost therrof will be reFlected on the final bill or starement. ~ ~i (Seal) d ~ ~,.~ (Pure er) (~ / (Seal) !'rr ~ -r Purchaser) (icrnse Funeral Direc W HYTE-Fun<ral Direcerr Y W-Cme+mer ~ r7 'Tr-F O °-' Office of Catholic Cemeteries s~ALES CONTRACT Diocese of Harrisburg DATE --'~~~~' `" ~ , `- ~~+~ PO Box 3651 Harrisbur Penns Ivana 17105' CEMETERY"~~- j,~jr/~,t1 CEMETERY# Phone (7g7) 657 4804 A/N-_~_P/N A/R NAME ~~/~G 3'"lJ/~''/~ PHONE ( ) '~~-~~~7` ADDRESS ~~~1~.r~i~/17~~~C~ ~~? ..CITY ~',~/~'irV~1.~ STATE ~''~9 ZIP CODE /~Q~~ - ----1n~e~n~.~paEes -.~'~. - -C~3 ~~~11~-~~D, ~_- '~--Price:.:--..- : -$,~~D. caU_- Bronze Memorials.. , .... (c~ $ 2. Down Payment........... /~S~D~GI~ Size Granite :.Foundation, ..... @ $ 3. Unpaid Balance(1=2) ...: , :Burial Vaults . .:....... @ $ , 4. Finance Charge...... , , , ,Crypt- Spaces:.......... @ $ 5, Deferred Payment (3+4) , . Niche Spaces ......:... @ $ ----_.- 6: Total. Price (1 +4) .. .... ,~~5~fJ, ~ Other.. $ 7. Approx. Monthly Payment Section ~ LotGrave(s) ~°~'Z-~ 8. Number of Payments ... . Building. Side -.Crypt or Niche 9. First Monthly Payment Due Selection must be made within 30 days or cemetery will make choice. 10. Annual Percentage Rate The. payment is d,ue on the date stated above and_the remaining payments"on -the same day of each. succeeding month. " Buyer may prepay in advance the full amouht due without penalty and will be.entitled to a proportionate refund of the unearned finance charge.. Upon default in the payment of any. installment due hereunder fora period in excess of one hundred;twen Seller may atits;optron, void this agreement and" retain all.paymeri s made by Buyer as liquidated damages (120) days, Buyer hereby acknowledges receipt of an exact executed copy of this agreement' at the time of execution hereof. _ Beforeany burial is permitted in this lot, or ariy-m"emorial placed on this lot, the price of. he:graye and> memorial must.be' ~` paid in' full The Purciiaser(s).agree(s) to abide by alf rules and regulatroris of the cemetery now in_fo.rce as well as"any rules and regulations which-may, hereafter be adopted~,~:Said rules andkregulatio~s may be'seen„upon request"at the; Sell~er.'s ~~ffice. Upon fulfillrr~ent'of'tfie conditions of fl}1"s agreernPnt and rec~rpt of-`al~~h'e abo~~e descnbe'd payments; "Seller agrees acid binds rts~lf'to convey tothe Buyer by` its cenietery% easement, for intermen"t purposes only, tfie';'above` ~entioried~number of~ ~~ sites. YOU, THE' PURCHASER; `MAY CANCEL: THIS' TRANSACTION BY WRITTEN NOTICE AT ANY TIME PRIOR TO MIDNLGHT OF THE THIRD BkJSWESS~DAY AFTER,THE DATE OF THIS TRANSACTION. _: BY , ' f' ~ (Authorized R ntative) (Purchased `` ignature) NOTICE: See other side for additional information. (Co-purchaser's Signature) , Z ~ ~ ~ N U ~ `~ C ° O ~ r_ Q E ~~ ~ Q ~ ~ v Li ~ ~ O a m W `° U ~ O C m 'E ~ o ~ o `_ J Q O \V~ m W a ;z `~' ~, m E '~`~ _~ E~ ~ w ~ o ° t ::. rW co 0 W 4 ~ W ~. > ~. ~, ~} ~ ~ © '.'"G' N Q ~ C ~ N LL T .r c m E ~ o a> m ~ ~ ~ W Q m = ~, ~ ~ ~ Q _ ~ 3 ~U 3 p ~ F.Q ~_ > m f- V m ., ~" '~ ro ~ r ~~ ~ ° o 'y ~ti ~, ~ _~ ..,~ ~~, ~'` ''t ti ~~ `~ ~, N +!~ ~ -~ :mil\]~~1 ~ ~ ~~ - may- N ~y m~~ 0 ,~~. ,,~ C ~~ „N O ~` fQ ~ ~ ~ m ~ ~ C C '~ J Q ~ ~ C ~ - a ~ ~ o` ~' U ~ ~ m ~ ~ ~ v L ~ Q ~ J 0 z N fA Q i'° O ~ _ ~- ~ ni L L O O O U m m ^ (J.I ~ ~ 0 ^ ^ ~ ~ Q Y ~ ~ } ~ U a 0 ~ m o ~ ~ C Z a~ z C z a~ n o ~ o w • ~ m ~ °' U ` ~ J ~ ~ } U. E t ° 7 o ~ b z ~ ~ L a, ~ Y ° 0- ~ m`G U E ~; ;, ~~ ~, . ~ u., o a m +.~. Q ~' v n n ~ C ~ ~ ~ ~`. ~ m D T <Cf O ~. _ v~ C7 ~ Rf ° m a. ~ O ~ ~. _ m m - ~a E a~ C ~.~ E ° ~ ~ (J ~ ~ ~ O a ~ ~ ~ V V ci ~-' ~.1 ,~ ~ ~ ~ Q ~ -~ ~ m~ o m ~ v m, ~~ ~ Y Z ~ +~ ~~ ~ - . ~ YYY ~ v ~ _ C ~ c N ~ ~ L ~ ~~ ~ E `~ U ~ ~` Q ~ ~ vv V in m _~E n m, ~ ~.~ m \ ~ ~ O E >. U REV-1 S12 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERfrANCE TAX RETURN SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS ESTATE OF rat rrumestrc MARGARET C. YOHN 21 07 0604 Report debts incurred by the decedent prior to death which remained unpaid as of the date of deaths, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Heritage Medical Gnwp -Expenses of last illness $18.00 & $13.56 $31.56 2. ~ Qcard -debt of decedent 3. ~ Quest Diagnostic -expense of last illness 4. I Samuel Thuma, CPA -preparation of 2007 Individual Tax Returns TOTAL (Also enter on line 10, Recapitulation) S (If n+ore space is needed, insert additional sheets of the same size) $145.82 $2.37 $200.00 75 REV-1513 EX + (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARGARET C. YOHN 21 07 0604 RELATIONShIIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [ndude ou ' ht spousal distritwtions, and transfers under tr ~ Sec. 9116 (1.2)1 (a 1. Carl G. Yohn Spousal 3709 Hartzdaie Drive 100°~ 01 residue Camp Hill, PA 17011 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET Ij. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX lS NOT BEING MADE 1. None B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. None TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S (If more space is needed, insert additional sheets of the same size) ~~t zll `~est~men# ®f ,Margaret ~. ~a~jn I, Margaret C. Yohn, of the Township of Lower .Allen, County of Cumberland and Commonwealth of Pennsylvania, being of sound mind, memory and understanding, do hereby publish and declare this to be my Last Will and Testament, hereby revoking and de<:laring null and void any and all Wills and Codicils heretofore written by me. TTEM I. I direct that all my just debts and funeral expenses be paid as soon after my demise as may be convenient to the proper administration of my estate. TTEM II. I give, devise and bequeath my entire estate remaining after payment of debts and funeral expenses to my husband, Carl G. Yohn, if he be living at the time of my death and survives me for a period of thirty (30) days. TTEM III. If my said husband should predecease me or fail to survive me for a period of thirty (30) days, I then order and duect my hereinafter-named Executors to convert my entire estate into cash at either public or private sale, whenever in their discretion it may be most expedient for the proper administration of my estate. In the event of such conversion, I authorize my said Executors to execute a good and sufficient Warranty Deed to the purchase of any real estate of which I may die seized, in the same manner and capacity as I could if living. ITEM N. I direct that all inheritance and estate taxes be paid on the proceeds of the above conversion and on all the rest residue and remainder of my estate from the residue of my estate prior to further distribution. ITEM V. I direct that my hereinafter named Executors distribute all th~~ rest, residue and remainder of my estate, including the proceeds of the above-mentioned conversion, as follows: a) One-fourth ('/.) of residue to be divided equally between :my two (2) children: Debra Kassahun and Dennis Yohn, per stirpes and not per capita. b) Three-fourth ('/.) of residue to be divided equally between my two (2) children: Dana Yohn and Denise M. Douglass, per stirpes and not per capita. ITEM VI. I nominate, constitute and appoint my husband, Carl G. Yohn, as Executor of this my Last Will and Testament. Should he predecease me or be unable or unwilling to serve, I then nominate, Page 1 of 2 constitute and appoint my two (2) children, Dana Yohn and Denise M. Douglass, or the survivor of them, as Executors in his place and stead. I direct that my Executors shall not be required to post bond other than their personal assurance for their duties as Executors. IN W77'NESS WHEREOF, I, Margaret C. Yohn, have hereunto subscribed my hand to this .:-~ .t 1; ~Y my Last Will and Testament, this _ :~1~ day of ,~,; ~ - ~- t' , 2007. .~ _, i >_ ;> ~ . Margaret C. Yohn ''~' '~' ~ '~ SIGNED, PUBLISHED and DECLARED by the above-named Margaret C. Yohn, as and for her Last Will and Testament in the presence of us, who at her request and in her presence and in the presence of each other, have signed our names as attesting witnesses hereto. /f ~fa'.e§iding at ~ 3'~.f~':. J' -1t - .., . ~--~ l r~ /~~~'J~ ~,_,l ' ~~ ~. ~~5 - residing a't! "~-~.~ ~~,~~~ ~ '- Page 2 of 2