HomeMy WebLinkAbout09-24-08J 15056041181
REV-1500 EX (06-05)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN ~ ~ O r~ ~~~~
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
181-26-4406 08212007 03201919
Decedent's Last Name Suffix Decedent's First Name MI
DAVIS CARMELA M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return Q 2. Supplemental Return Q 3. Remainder Return (date of death
prior to 12-13-82)
0 4. Limited Estate ~ 4a. Future Interest Compromise (date of Q 5. Federal Estate Tax Return Required
death after 12-12-82)
0 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death 0 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
CHRISTOPHER C. HUMES, CPA 717-576-0833
Firm Name (If Applicable) r~.•~
First line of address
917 MAGNOLIA DRIVE
Second line of address
City or Post Office
ENOLA
State ZIP Code
PA 17025
Correspondent s e-mail address: Chr'1S tOp112r' .Humes@bmC-llp . COm
REGISTE`~ OF WILLS US'E~ONLY__
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:BATE FILED C~J
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 P N R~sPONSIBLE FOR FILIp~ETURN ~ DATE
ADDRESS '~
512 LAMPOST
CAMP HILL, PA 17011
~_,dlli~lr`r~ ntn v I HtK I HAN REPRESENTATIVE
DATE
ADDRESS 09/23/2008
CHRISTOPHER C. HUMES, 917 MAGNOLIA DRIVE, ENOLA, PA 17025
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 15056041181
WK9 P PAN121-001 109
15056041181
J ~
15056042182
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: CARMELA M DAVI S 181- 2 6- 4 4 0 6
RECAPITULATION
1. Real estate (Schedule A) ............................................. 1. O . O O
2. Stocks and Bonds (Schedule B) ....................................... 2. O . 0 O
3. Closely Held Cor oration P rt h'
p a Hers ip or Sole-Propnetorship (Schedule C) . .... 3. 0 . 0 O
4. Mortgages & Notes Receivable (Schedule D) ......................... .... 4. O , O O
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. O . O 0
6. Jointly Owned Property (Schedule F) QSeparate Billing Requested .... ... 6. 5 , 9 91.0 0
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested.... .... 7. 0 , 0 0
8. Total Gross Assets (total Lines 1-7) ................................. ... 8. 5 , 9 91.0 0
9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 5 8 9 . O 0
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. 211. $ 6
11. Total Deductions (total Lines 9 & 10) ............................... .... 11. $ 0 O . $
12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 5 , 19 0.14
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ..................... ... 13. O . 0 O
14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 5 , 19 0.14
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_ 15. O . 00
16. Amount of Line 14 taxable
at lineal rate X .0 45 5 , 19 0.14 16, 2 3 3 . 5 6
17. Amount of Line 14 taxable
at sibling rate X .12 17. O . O O
18. Amount of Line 14 taxable
at collateral rate X .15 , ~ O 0 0
19. TAX DUE .........................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 15056042182
WK9 P PAN12I-002 109
15056042182
233.56
J
RSV-1500 EJC Page 3 File Number 21- 0 7- 0 9 6 2
Decedent's Complete Address:
CARMELA M DAVIS
STREET ADDRESS
801 N. HANOVER STREET
CITY
CARLISLE STATE PA ZIP 1 ~ 013
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) 2 3 3 . 5 6
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments 2 6 9. 6 0
C. Discount
Total Credits (A + B + C) (2) 2 6 9 . 6 0
3. InteresUPenalty if applicable
D. Interest
E. Penalty
Total InteresUPenalty (D + E) (3) 0 . 0 0
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4) 3 6.04
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0 . 0 0
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 0 . 0 0
Makt? Cht?Ck Payable f0: 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 :.......................................................................................... ^
b. retain the right to designate who shall use the property transferred or its income :............................................ ^ 0
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? .............................................................................................................. ^ 0
3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death? .............. ^ Q
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
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 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 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)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
WIC9P PAN32I-003 109
REV-1509 EX+ (6-98)
SCHEDULE F
COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
wiHl~vr
FILE NUMBER
CARMELA M. DAVIS 21-07-0962
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A' PHYLLIS A. DAVIS 512 LAMPOST LANE DAUGHTER-IN-LAW
CAMP HILL, PA 17011
B.
C.
JOINTLY-OWNED PROPERTY:
LETTER DATE
ITEM
NUMBER
FOR JOINT
TENANT
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE
DATE OF DEATH x OF
DECD'S DATE of DEATH
VALUE OF
~ . VALUE OF ASSET INTEREST DECEDENTS INTEREST
~ A. 05/24/06 COMMUNITY BANKS, ACCT. 148005138 ii,9ez.o1 50.0000 5, 991.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
_ TOTAL (Also enter on line 6 Recapitulation)I b 5 , 9 91 0 0
I Oll 109
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (10-06)
ESTATE OF
CARMELA M. DAVIS
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-07-0962
ITEM
NUMBER DESCRIPTION AMC
A~ FUNERAL EXPENSES:
~' GRAVE OPENING
B.
1
2.
3.
4.
5.
6.
7.
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
TOTAL (Also enter on line 9, Recapitulation) 3
(If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
City State Zip
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
Year(s) Commission Paid:
Attorney Fees
Family Exemption: (If decedents address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
345.00
94.00
150.00
589.00
WI(4 P PAN121-013 109
REV-1512 EX+ (12-03)
SCHEDULE I
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT ~
MATE OF
FILE NUMBER
CARMELA M. DAVIS 21-07-0962
Report debts incurred by the decedent prior to death which remained unsaid AQ ~~,he d~-e .,f ,~,a :.._~..~:__ ..__:_~_.__ _, __ ..
~~~ ni~ic Mace is neeaea, mser[ aaainonal sheets of the same size)
REV-1513 EX+ (g-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
CARMELA M. DAVIS
SCHEDULE ~
BENEFICIARIES
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
t TAXABLE DISTRIBUTIONS include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2))
PHYLLIS A. DAVIS
512 LAMPOST LANE
CAMP HILL, PA 17011
FILE NUMBER
21-07-0962
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
DAUGHTER-IN-LA
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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
100
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ 0 0 0
WI(9 P PAN12I 015 109
(If more space is needed, insert additional sheets of the same size)
No . 2007- 00962 PA No . 2 ~- 07- 0962
Estate Of : CARMELA DA V/S
(First, Middle, LasU
Late Of : CARLISLE BOROUGH
CUMBERLAND COUNTY
Deceased
Social Security No: 787-26-4406
____ _9th day of November 2007 an instrument dated
January 7th 2004 was admitted to probate as the last will of
CARMELA DA VlS
/host, Middle, Lastl
late of CARLISLE BOROUGH, CUMBERLAND County,
who died on the 21st day of August 2007 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
PHYLLIS DA VlS
who has duly qualified as EXECUTOR(R/X)
and has agreed to administer the estate according to law, a1I of which
fully appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYL VANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 19th day of November 209~7~
~..
Register of Wills
Deputy
* *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
CERTIFICATE OF
GRANT OF LETTERS
LA5T WILL AND TESTAMENT
OF
CARMELA DAVIS
I, CARMELA DAVIS, of the Township of Hampden, County of
Cumberland and Commonwealth of Pennsylvania, being of sound mind
and memory do make, publish and declare this my Last Will and
Testament in the manner and form following, hereby revoking any
Wi11 or Wills heretofore made by me.
FIRST : I direct my Executor, hereinafter named,`~to pay, ~y
just debts, the expenses of my last illness and my funer~ =~ -_~,_~~
_. ~~
_~ r J ~ !' J
expenses . ~~ ' ~ --
SECOND: I give and bequeath all my jewelry, aut.~airo}~~ile~ ~ _ ~
_.~ - -.
clothing and other purely personal effects, as well as such -~- u~; ~-7`
is ~ ,
household goods and equipment which I may own, to my son, NICK
WILLIAM DAVIS.
THIRD: All the rest, residue and remainder of my estate
of whatsoever kind and wheresoever situate, I give, bequeath, and
devise to my son, NICK WILLIAM DAVIS. In the event that my said
son does not survive me, I give devise and bequeath my residuary
estate to my son's wife, PHYLLIS DAVIS. In the event that
neither my said son or my said daughter-in-law survive me, I give
and devise my residuary estate to the surviving issue of my son,
NICK WILLIAM DAVIS, per stirpes.
FOURTH: I name and appoint my son, NICK WILLIAM DAVIS,
Executor of this my Last Will and Testament. In the event that
my son, NICK WILLIAM DAVIS, fails to survive me or is unable or
unwilling to perform, I name and appoint my son's wife, PHYLLIS
DAMS as my Executrix. Further, in the event that my daughter-
in-law, PHYLLIS DAMS, fails to survive me or is unable or
unwilling to serve, I name and appoint my granddaughter, JO ANN
DAMS ALEXANDER, as my Executrix. My executor named herein shall
not be required to post bond or any additional security in any
jurisdiction in which he shall be required.
IN WITNESS WHEREOF, I, the undersigned Testatrix, CARMELA
~~
DAVIS, have hereunto set my hand and seal this ~ day of
af'jLfC~~' 200:
CARMELA DAMS
SIGNED, SEALED, PUBLISHED and DECLARED by the above named
Testatrix, Carmela Davis, as and for her Last Will and
Testament in the presence of us, who have hereunto
subscribed our names as witnesses, at her request in the
presence of said Testatrix and in the presence of each
other.
WITNESS:
'~ ~'~~G_
~~~
ADDRES
.~ ~ ;
4
~' ~.~-~-
ADDRESS ~
ACKNOWLEDGMENT OF TESTATRIX
COMMONWEALTH OF PENNSYLVANIA )
SS:
COUNTY OF ALLEGHENY )
I, CARMELA DAVIS, whose name is signed to the attached or
foregoing instrument, having been duly qualified according to
law, do hereby acknowledge that I signed and executed the
instrument as my Last Will; that I signed it willingly; and that
I signed it as my free and voluntary act for purposes therein
contained.
( ,~
CARMELA DAVIS
SWORN TO AND SUBSCRIBED
Before me by Carmela Davis, Testatrix,
this f~
day of (,~'~' 200:
o.tary b ---
Ntstariaf SGa1
Mary C. 'Comisc~i, iV:;~ry Public
Can;p Hiil Baro, t:umbe;land County
My Catnmissian Expires Mar.17, »007
Member, Penc>Sylvania Associaacrn Of Nolaries
AFFIDAVIT OF WITNESSES
COMMONWEALTH OF PENNSYLVANIA }
SS:
COUNTY OF ALLEGHENY )
WE, _/V/~-~r 1.,. ~~V s~ and ~~~, JI~s N, J~- ~,v~S
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and
say that we were present and saw the Testatrix sign and execute
the instrument as her Last Will; that she signed willingly and
that she executed it as her free and voluntary act for the
purposes therein expressed; that each of us in the hearing and
sight of the Testatrix signed the Will as witnesses; and that to
the best of our knowledge the Testatrix was at the time 18 or
more years of age, of sound mind and under no constraint or under
influence.
WITNESS W NHS
SWORN TO .AND SUBSCRIBED
Before me by ~/C/~ ~, ~~ (//S' and ~~/~/LL/S ~ • ..~~' ~lS,
witnesses, this ~fh day of a'yJ~i(Gjl~' ~ 200~-
rotary P,~}~liL~
vv Notarial Seal
Pvi~ry C. Cbmisch, Notar,~ Public
~t~~~~p FIII1 faro, Cumberland Counbj
My>~~mmissian Expires Mor. 1?, 2DD7
Pt1f:'fT1~3Qlr, ~nn~rtV3nia A,scci~tian ; Plotarie:;
BUREAU OF COLLECTIONS &.
TAXPAYER SERVICES
PO BOX 281041
HARRISBURG PA ]7128-1041
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
Inheritance Tax Non-Filer Delinquency Notification
PHYLLIS A DAVIS
512 LAMP POST LN
CAMP HILL
~~~~~yq
PA 17011
DATE:
ESTATE OF:
CARMELA
"=~w=. - -
REV-834 AFP (12-04)
07/25/2008
DAVIS
SSN: 181-26-4406
DATE OF DEATH: 0 8- 21 - 2 0 0 7
FILE NUMBER: 210 7- 0 9 6 2
A review of Department records has disclosed that you are responsible for the settlement of
the. above estate, or that you represent the responsible party. The above estate is in a delinquent
status. According to Department's records, as of this date, the inheritance tax return has not been
filed.
The Inheritance and Estate Tax Act mandates the filing of a tax return and payment of all
outstanding liabilities by a personal representative of the estate or a transferee within nine months
of the decedent's death.
If this estate was opened for the purpose of filing a lawsuit, please provide this office in
writing with the court term and docket number of the proceeding. The Department may postpone
any further action regarding the Estate pending the completion of the lawsuit. If there is any other
reason that a return has not been filed, please contact this office.
To avoid further action, a return must be filed within 15 days from the date of this letter.
If the return has been filed recently, please disregard this notice
CONTACT: RETURNS SHOULD BE FILED
AND PAYMENTS MADE AT
Harrisburg Call Center THE REGISTER OF WILLS
(717) 783-3000 LISTED BELOW:
TDD# 1-800-447-3020 (Service for taxpayers ,~~'~
with special hearing and/or speaking needs)
.~5~'1
~ ~~
~~ a~7
°~,~~ ~3
~~~
p~D
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17D13
'~../,~ /' ~L
COMMONWEALTH OF PENNSYLVANIA "' - - - - _ __ _ _ _ _
• DEPARTMENT aF REVENUE INFORMATION NOTICE /-~
BUREAU OF INDIVIDUAL TAXES AND FILE NO'-T;21,`~V~~~LQ~
DEPT. 280601
HARRISBURG, PA nlza-ocol TAXPAYER RESPONSE ACN 907142765
REV-1543IXAFP-(D9-00) - DATE 1U-17-2007
?f,'~,'i ~.~;_~; .-'1) ;'ti i•~,. ~.~ TYPE OF ACCOUNT
- EST. OF CARMELA M DAVIS ~ SAVINGS
_ _ S.S.. N0. 181-26-4406 ® CHECKING
- ~ DATE OF DEATH 08-21-2007 ~ TRUST
r; -~ i )T
`~ ~ ~ COUNTY CUMBERLAND ~ CERTIF.
ice: r,
L.'•.,
REMIT PAYMENT AND FORMS T0:
PHYLLIS A DAVIS REGISTER OF WILLS
512 LAMPOST LN CUMBERLAND CO COURT HOUSE
CAMP HILL PA 17011 CARLISLE, PA 17013
COMMUNITY BANKS has provided the Department with the information 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 information is incorrect, please obtain written correction from the financial institution, attach a copy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
vi Pennsylvania. .~oestim,s may Ge answered by tolling C7i7) 78?-83'<<?.
COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 148005138 Date 05-24-2006
To insure proper credit to your account, two
Established (2) copies of this notice must accompany your
Account Balance 11 , 982.01 payment to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
Percent Taxable X 50.000
Amount Subject to Tax 5, 991 . O1 NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
TaX Rate x . 0 4 5 You may deduct a 5% discount of the tax due.
Potential Tax Due 269.60 Any inheritance tax due will become delinquent
nine C9) months after the date of death.
PART TAXPAYER RESPONSE
:: ~::.t."i13F::E:iZIL~Ei:.;~::~liiic-::a,i rii:rvawia ...........................:...:.:.:......................... .._..........................
A. ~ The above information and tax due is correct.
1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of
0 N E
~ Wills and an official assessment will be issued by the PA Department of Revenue.
B L 0 C K
O N L Y B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inherita
T
to
be filed by the decedent's representative. nce
ax r
eturn
C. ~ The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART If you indicate a different tax rate, please state your
relationship to decedent:
TAX RETURN - COMPUTATION
LINE I. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8. Tax Due
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3 X
4
5
6
7 X
8
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
complete to the best of my knowledge and belief.
HOME C )
WORK C )
TAXPAYER STGNATl1RF TELEPHONE NUMBER
DATE
PART DEBTS AND DEDUCTIONS CLAIMED
0
DATE PAID PAYEE DESCRTPTrnN ....,,,..~ .,.__
CO~aMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE .. - ~ -.- - -
' BUREAU OF INDIVIDUAL TAXES - ~ ~ -~
DEPT. 280601
HARRISBURG, PA 77128-0607
P,ECEIVED FROM:
DAVIS PHYLLIS A
512 LAMPOST LN
CAMP HILL, PA 17011
--- fold
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ESTATE INFORMATION: ssN: psi-26-44os
FILE NUMBER: 2107-0962
DECEDENT NAME: DAVIS CARMELA M
DATE OF PAYMENT: 1 O/ 24/ 2007
Pi~STMARK DATE: 10/23/2007
COUNTY: CUMBERLAND
DATE OF DEATH: 08/21 /2007
-~ REV-1162 EX(11-96)
- _. ..:f
. (
N0. CD 008845
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
07142765 ~ 5269.60 '
TOTAL AMOUNT PAID:
5269.60
_.
REMARKS: PHYLLIS A DAVIS
_ _
....
CHECK# 1153'
...~ , . INITIALS:. - DM
..
.. _~
I-
~~- sEAC RECEIVED BY: GLENDA EARNER STRASBAUGH
:. .
,,...
4.; , ,.;. - REGISTER OF WILLS. __
TAXPAYER -
RECEIPT FOR PAYMENT
GLENDA FARMER STRASBAUGH Receipt Date: 11/19/2007
Cumberland County - Register Of Wills Receipt Time: 11:54:56
One Courthouse Square Receipt No.: 1050635
Carlisle, PA 17613
DAVIS CARMELA M
Estate File No.: 2007-00962
Paid By Remarks: PHYLLIS A DAVIS
WZ
------------------- ----- Receipt Distribution ----- ------__ _______ ____
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST
WILL 60.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE
JCP FE 15.00
4.00 CUMBERLAND
CUMBERLAND COUNTY
COUNTY GENERAL
GENERAL FUN
FUN
E
AUTOMATION FEE 10.00
5.00
-------- BUREAU OF RECEIPTS
CUMBERLAND COUNTY & CNTR
GENERAL M.D
FUN
Check# 1201
-----
- --
$94
00
Total Received..... .
.... $94.00
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~ f~r;e li>?' Ihis cLrrtificate tih.Orl
P 138227.4
('crUllc:ui(,n '~un~hu
~IOS~1J3 REV 11;2006 ..
TYPE; PRINT IN
PERMANENT
Bl ACK INN
,Ilj'rp~SH OF~pF~ This is to certify that the information here given is
xlt'~~5,:- \~J'- conectl~ copied from an original Certificate of Death
;~ q~/ ~l-_; duly filed with me as Local Registrar. The original
~~ ~ z, ~utificalc will he 1~I:Trwr.lyded to the Stale Vital
~' ~ a Records Office for permanent ,Filing.
j
II~~I'
.exxu~i
_oral Kcgistrar Date Issued
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instruetlDns anA e><amnlna ors .n.,n.cnk
- JlgIt FILL NUMBER
1 Name W Decetlenl (First, middle. lass. suhrx) 2. Sex 3. $ockl Secunty Number 4. Data of Death (Mnith, day, year)
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Carmelo M. Davis
181 - 26 - 4406 August 21
2007
5 A
L
t Bi
htl
,
ge (
as
n
ay) Untler 1 year Urrder 1 day fi. Dale of Binh (Month, day, year) 7. Binhpace (City antl sYk or Iwo coumry) 6a. Place of Deem (Check Dory one)
eurxn: Days Haur• Minutos
Hosplel; ,O~---l,n{{er.
88 Yra. March 20, 1919 Braddock, PA ^ Inpabem ^ ER / O
t
ti
^ D
u
pa
ent
OA LJ Nursing Nome ^ Resitlenca ^Omer spenty:
fib County of Death &. City. Boro, Twp. of Death gd Facility Name (If rat inshlulpn
give sbcel antl rwmfxr)
,
9. Was DBCBdenl Of Hispanic Origin? x[7w No ^ Yes 10. Race. 0.merx:an Indian. Black
While
ac
,
.
pl yea speaty canon, I Spac~ryj
Curtlberland Carlisle Church
of God Home Mnxkan
P
n
R
.
,
ue
o
ican, etc) White
t1
Deced
t'
U
l O
.
en
s
sua
ccu alpn Nmtl of work done tlurin most of wakin Ye Do not stale refired 12. Was Dewdem ever in me 13. Derndents Educatron (Spedty Dory highest grade compleletl) 14
Marital Status: MarneQ N
M
1
.
ever
arned
5. Survwmg Spouse (It nice, give maiden name)
Kind of Work Kind of Business. Industry U.S Armed Fo
r
c
e//s? Elementary! Secondary (0-12) College (1 ~4 or 5+) Wrtlowed, Divorced ISpecA)'j
,
,
~_
Home maker Home ^Yea L!JNO 10 W100Wed
Ul1M/tLA
'
Ifi Decedent
s MaJrng Address (Street, city; lain. slate. np codej Dwedenl's OW Decedent
Pennsylvania
A
tu
l R
W
7
c
a
es
erse 1
a. stale
^ve in a 17c ^ es. Decatlem Lived in
ggO1 O th TDwnanip? Twp
Street ,7DCounl
~~rland I7d N
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y
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anlLiyadwdnm
3
ar
ar
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e
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e pA
Actual Lasts of Cny / Bwo
18 Father s Name (Fist. rtaMle, last, sudix)
'
IB. Mother
s Name IRrsl, mgtlle, marten surname)
Nicola Melocchi
Nicoletta Nucci
20a Informant s Name (Typo ~ Print)
'
20h Informant
s Mailing Address (SDeet city /sown, slate, zp cotle)
Ph llis Davis
512 Post Lane Cam Hill, PA 17011
2ta Methotl of Disposition Cremation ^ DOnaiion 21 D. Date of DisposiDOn jMOnm, tlay, year) 21 c. Place Ot Disposiibn (Name 01 cemetery, crematory a Diner place) 2/tl LOUdiIUn jGry I Town. sidle. Pp co08)
^ Banal ^ R
l I
S
t
emova
ron
tale
Was Crertallon or DOnelion Aulnalzed
^ Omer-SVeeiN I byYSdkdExeminsr7Cownar7 Gdyaa^Nn August 22, 2007 Hollinger Crematory Mt
Holly S
rin
s
PA
.
p
g
,
22a. Signal a of Funeral servke L~pGAea ( at a hog a5 sacs) 226 Lkanse Number 22c. Nana arM Address of Fxilily 8 Market Plaza Way
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,
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FD-011667E Mal zzi Funeral Home Mechanicsburg, PA 17055
Cumplae Items 23ac only w ca ng 3a To the Desi of my kitowlcdge. deals occurred alma lime, date and plaza staled ISgnalure arM line) 23b
license Numbe
.
physmian is rat avaikble el a of tlealli to
r 23c Dale Signetl iMonm, day, year]
canify eaaae 01 deem. ,h e~ ~ y~~ i >v A- ~ ~ ~~ ar'
~~
~
.
ar ~
~ or;
24
Time of Death
u
2J 2ti
.
ems
muss be cwnplwed by person
t 26. Date Prorouricetl Deatl (Month, day, year) 26. Was Case Referred to Medical Examiner /Cornier for a Re Omer than Crelnatron or Donaiion?
who pronounces tlealn i I`~ AM ~l ~ ~~~ ^yes ~Nu
d
CAUSE OF DEATH (See lnauuctions end exam a)
z Approxinala Imerval: Pan II: Enter other signiManl cmdil Ons EglgyypOg)ggeajp, pg, pp Tobacco Use CcolnWle to Deno?
ham 27 Pan 1. Enter Ise chain yf kvenl5-diseases, inlunea or compligirons - Ihal directly caused Ise deals DO NOT enter lerriinial events such as cardiac aresl
, Onset to Ueaih Oul not resulhrg in the underlying cause given in Pan I ^ Ves 1-~ Probaay
respralory arrest. or venincular librslahon without showing Ilia euaogy list only ono cause On h lira. }~
JIQ-L['G llrrkrov:n
IMMEDIATE CAUSE `Pout Disease or ^
Wih
lW
~
cor
on raw
g in deals) -~ ~ U.. n~~ ~.l C \ ,~,Z_ ~~
a
C~ \ ( ~/ 1/~- ~ 29. II Femak'.
`
Due to (w as a can a oil.
^ Not peynant wirnn pall year
Sequenliagy hsl contlilions. ddrry b
^ Pregnant al lime of tltlath
leddii to Ise Cauae Ysled Uri lino a Due lU 0
Enter the UNDERLYING CAUSE (r as a consequence olj. [-~ Not preyr,am, but pruynarn wefnn 42 days
Idise~s
ST.e
es~mn
Y
dam L
c
r
g
en
n
ddeals
A
Due lU for as a consequ0nce aj.
^ N01 pregridnl, Out piagndnl J3 days l0 1 year
d
l Oelore deem
r
^ Unkrawn A preyriaiil wilnin fh0 pall year
30a 1Vas an Autopsy 30D Were Autopsy Fintlings 31. Manner of Deeln 32a Dale a Inryry (Month. day, year) 320 Describe lbw Injury Occurred 32c
Pkce of Inju
Pedunrced? A
Home Farm
street
F
a
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P
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.
ry
,
.
v
i
e
e
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or
ac
ory,
Umpklian Once Building, etc. (Specryl
Ne
utral ~] Hortucirk
a Gauss of Duam?
i
~
n Yes ~ No ^ Yes ^ No ^ Aaudanl [~ Penany Investigauwr 32d. ima a Inlury 32e. injury al Wwk? 321. I( Transponntron Injury [Sperry) 32g. Laalion of Inury (Street, oly /town. slate)
^ Yes ^ No ^ Drwerf Operator C senger Petleslnan
• ^ Suicide ^ Cuultl Nul Ca Deleinened
M
Omer SpecJy.
33a CemJ.ai Icneck only w:el 33b Si nature T
9
• Cerbtying phy IPn i ly g a 1 d 'll a a II pl V V d death and co nVlUletl Item 2d)
To Ise be I I y k kdgs d In d d I Ih aus (j d
``~r
~
~ O
MI d
____________ _______________z'
• Pronouns- g and art tyl g phy 'e' n PI b'It p y - } y ~ I death // ``
vi d t d n I ) ~
e
T Ise bet 1 y k ledg d In tturred t the 1 ,dot and place a rd duo Io Ise cause(s) and manor as sNled
Ll 33c se ina:r
33d. Dale Sigriatl IMO m Jny. yu;,ri
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M dcalE IC
lO ~ S - ~ /
O
~ Z ~
0 Ise Da ' 1 nation antl / w mveshg Ion. in niy spin on. tlealh occurred al the lima, sale and place and tlue IU Ise souse(s) and manner as sMled ^ (
7J Name and Address of Perso i Wno C,ompkled Cause a Deutn Ilte m L71 T Pnnl
ype r
3: R ~ s.yi -i d C~shi<t Nr •~ jj
- ~'. Odle Filed jMOnih, tley, yawl `
~ ~ ~ ^ v LL"i` ~ • I ~
I d. ~ j ~ (X I 1 I o1 I a~~7 saa~~~~t P- S, • (
" ~ d O s~
Disposition Pernul No ~j •]~