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HomeMy WebLinkAbout10-16-08 15056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~ INHERITANCE TAX RETURN PO BOX 280601 21 08 0428 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 200-34-9292 01/18/2008 ' 10/23/1944 Decedent's Last Name Suffix Decedent's First Name MI THOMAS GEORGE g (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI THOMAS '; LINDA M Spouse's Social Security Number __ _ _ _ __ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C~3 1. Original Return y 2. Supplemental Return ~"°.,.. 3. Remainder Return (date of death prior to 12-13-82) C,~ 4. Limited Estate 4a. Future Interest Compromise (date of ;„, 5. Federal Estate Tax Return Required death after 12-12-82) C 6. Decedent Died Testate C 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 C`~3 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 TO: Name Daytime Telephone Number David Englehart (717) 761-4646 Firm Name (If Applicable) _ __ ~.., _., ', REGISTER OF;WILLS USE ~4Y Professional Tax Adviso ~-~ "" -_ r First line of address ~: , ~ `__ 704 Lisburn Road Ste 102 ~:,, Second line of address. _ _ _ _ , '., , -n __ - ~ -- __._ City or Post Office State ZIP Code DA7E~F1L1=D " ;: , . ~. ;.. -~ ~ Camp Hill PA .17011 '~ Correspondent's a-mail address: denglehart@prOfinadVinC.COm Under penalties erjury, 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, cor ct d complete. Declaration f preparer other than the personal representative is based on all information of which preparer has any knowledge. SI NAT P E O FOR FILING RETURN DATE AD R SS 8 Bourbon Red Dr Mechanicsburg PA 17050 SIGN T.URE OF P A R O ER AN R VE DATE ADDRESS 10 - 1~ ~ d 704 Lisburn Rd to 102 Camn Hill PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 ~t 15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name: GEORGE B THOMAS 200-34-9292 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. 6. Jointly Owned Property (Schedule F) Separate Billing Requested .... ... 6. ' 154,156.00 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ' 154,156.00 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 7,485.00 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. 13,587.00 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. 21,072.00 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 133,084.00 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. ' 133,084.00 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ...:.,.n.ro _,a...~.. m.......m .,.. ..~_.,.a. ~..,.,..,. 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0 0 129,257.42 '', 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 3,826.58 ' 16. ' 172.20 17. Amount of Line 14 taxable _ __ at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ....................................................... .. 19. 172.20 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 os oa2s _.__.. DECEDENTS NAME DECEDENT'S SOCIAL SECURITY NUMBER GEORGE B THOMAS _ 200-34-9292 __ _ STREET ADDRESS 8 Bourbon Red Drive __ _ -- _ _ _ CITY STATE ZIP Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 172.20 2. Credits/Payments A. Spousal Poverty Credit - - -- B. Prior Payments 163.58 _--- - C. Discount 8,62 _.. _ __ ___ Total Credits (A + B + C) (2) 172.20 3. InteresUPenalty if applicable D. Interest E. Penalty __ Total InteresUPenalty (D + E) (3) 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 0.00 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 :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ 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? ............................................................................................. ^ ................. 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ^X ^ 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 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. REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER George B Thomas 21 08 0428 if an asset waa made Joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVNING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A• Linda M Thomas 8 Bourbon Red Road Spouse Mechanicsburg PA 17050 B' Andrew L Thomas 905 Greenbriar Drive Mechanicsburg PA 17050 Son C. JOINTLY-0WNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FORJOINTLKIIELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ~' A' 01108100 American Funds Account #64606445 14,964.00 50 7,482.00 2 A 02101!80 PSECUAccount#200349292 35,543.00 50 17,772.00 3 A 02101180 Members First CU Account #128977 12,582.00 50 6,791.00 4 A 08114197 Personal Residence 210,000.00 50 105,000.00 5 B 04118/83 PSECU Account #0188627586 34,221.00 50 17,111.00 TOTAL (Also enter on line 6, Recapitulation) s 154,156.00 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER George B Thomas 21 08 0428 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 DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATEOFTRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE ~ • Lincoln Benefit Life IRA #LBLA122830 133,800.00 100 133,800.00 0.00 TOTAL (Also enter on line 7 Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER George B Thomas 21 08 0428 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Hollinger Funeral Home 6,040.00 Gate of Heaven Cemetary 1,245.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)IEIN Number of Personal Representative(s) Street Address City State Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. Zip Zip TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) 200.00 7,485.00 REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER george B Thomas 21 08 0428 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, Including unreimbursed medical expenses. (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (g-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER George B Thomas 21 08 0428 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE t TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers unifier Sec. 9116 (a) (1.2)] 1 Linda M Thomas 8 Bourbon Red Dr Mechanicsburg PA 17050 Spouse 129,257.42 2 Andrew L Thomas 905 Greenbriar Dr Mechanicsburg PA 17050 Son 3826.58 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROU GH 18, AS APPROPRIATE, ON RE V-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 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) '" ~~er;~7tl+f~f1S Rfl~1"L'~6~~1~? Ope__r_atio_ns > .S_hareholde_r Name__Sear_ch > Search_Results > Account Details Account Va 1 ue by Date Account #: 64606445 .'~~t~;~E~°~t:, la<i~~~~~~k Tax ID/SSN: 200-34-9292 Registration: GEORGE B THOMAS & LINDA M THOMAS JT WROS 8 BOURBON RED DR Statements MECHANICSBURG PA 17050-7902 Statements Details Acct Overview Acct Value by Date Transaction_ History Maintenance Histor^ Cost Basis 2007 Tax Summary 2008 Tax $um.m.. a.ry Breakpoint Center: -Rights of Accumulation Phone #: Not On File Mgmt Co: AMERICAN FUNDS Fund Name: FUNDAMENTAL INVESTORS - A View Fund Details Fund Code: 10 Ticker: ANCFX Tota15 CUSIP: 360802102 Accout Account Type: 03 -JOINT TENANTS Enter a price date to retrieve an account value from a previous day. Price Date: 01/18/2008 Current Price Date: Current Net Asset Value: Current Total Shares: Current Value: Top__of_page '~~ Search 09/29/2008 Price Date: $31.6300 Net Asset Value .0000 Total Shares: $0.00 Value: Con..tact Us ~ Dsclai_m..e...r Copyright ©2008 DST Systems, Inc. All Rights Reserved. Covered by US Patent No. 7,275,046 01 /18/2008 $38.5100 388.5690 $14,963.79 rsaiances Account Balances Account Statement is available. Shares REG_U_ LAR SHARES (S01_) VACATI__ON_SHARE .~S02) CH_RISTMAS_SHARES (_S_0.3) CHECKING (SO4~ -_ MONEY MARKET_~507) Loans PSL _L_OAN (L01) Details Pay! VISA LOAN (L09~ Details Pay! Total Balance Details $4,089.89 Details. $4,132.53 Details $571.08 Details $3,758.20 Details $22,991.66 Current Balance $0.00 $0.00 j', '!~ , Y \~ / .i https://homebank.psecu.comBalancesBalances.aspx rag Available Balanc $4 $4 $3 $22 Payment Due D; $0.00 $0.00 02/: 1 /31 /2008 L-1t:l:Vl.LLll JIAIIlIIli;IIY ~+onae aeou-as coNTACT us uev~r z e~,~Eni ; auaLic;,-ionis ~ESO~~PCEs Account Summary Transfers eStatements Bilt Payer Services Visa Loan AppUwtlons My Profile Messages ~ Open a Qeriifica~ and eafT1 a fate w bonus because of ~ pour Platinum lnelnbership! Welcome [o Members 1st Online -Linda Thomas ~{% You last successfully logged in 01/30/2008 11:57AM. Your last unsuccessful login was 11/28/2007 08:03AM rag Announcements Subject Date Welcome, back to_the EASIEST way to do your taxes with TurbpTax~ and Members 1st. 12/14/2007 Accounts Open an Account Account !Description , Available, Balancer YTD Dividend! Prior Year'. Dividends 128977-500 i~I~LARSAVINGS $179.37'' $184.37; __ $0.00' $16.50'' 128977-SOS 'MONEY MANAGEMENT $12,398.00 '', $12,398.00 ! $0.00 $204.32 ! ' Total; $12,577.37', $12,582.37! _ $0.00'.. 5220.82 " Loans Apply for a Loan _ _ _ ~ T- Account 'Deseriptioni Open Date 'j Available Balance) Payment) Due ~ Rate 128977-LOl !, MEQR GAGE I'~ 12/3/1997 ~ $0.00 ; $15,174.05 'I $658.50 i 09/01/2009 6.63% Totals $0.00! $15,174.05, $658.50'. Credit Cards Apply for a Visa Credit Card Visa EZCard info 2v2007 DdEM3ER5 1ST FEDERAL CP.EGIT. UNION M E:,HANICSBU P.G PENNSYLVANIA iN?ERi!E7 TE?dAS ^JF USAGE I PRIVA~,I $TATE~iENi ~ F,°.kUG55EGL'~RI"/;, E:JTER D u:arar enact ~r ~e ~~ iii -_ ~ ~_~~A https;//mlonline.memberslst.org nlineBanking/AccountSummary/AccountSummary.px 1/31/2008 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT: 280601 HARRISBURG, PA 17129-0601 REV-1543 E% ,1FP (09-007 INFORMATION NOTICE FILE NO. 21 TAXPAYERNRESPONSE AcN 08114332 DATE 04-09-2008 ~{~r ' ANDREW L THOMAS 905 GREENBRIAR DR MECHANICSBURG PA 17050-1915 TYPE OF ACCOUNT EST. OF GEORGE B THOMAS ~ SAVINGS $.$. N0. 200-34-9292 ~ CHECKING DATE OF DEATH 01-18-2008 ~ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17D13 PSECU 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 of Pennsylvania. puestions may be answered by calling C717) 797-8327. COMPLETE PART 1 BELOW * ~ * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0188627586 Date 04-08-1983 To insure proper credit to your account, two Established (2) copies of this notice must accompany your Account Balance 2, 278 .50 payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 50.000 1 , 139.25 NOTE: If tax payments are made within three Amount Subject to Tax (3) months of the decedent's date of death, Tax Rate x .045 You may deduct a 5Y. discount of the tax due. 0 ~7(3 ~ ~ 5 1.2 7 Any inheritance tax due will become delinquent Potential Tax Due '+"jO nine C9) months after the date of death. PART TAXPAYER RESPONSE 1 ::~:::::::_::~ :::::::::::::::~:::::_.:.....,..........................._.......................................................................... :::::: - ~~;:»::--::..:.:._..._;~T;#~:~~~~~?':[t~ii~#:ll1;t~~.:.:.:R:.~l:E:1"~:::~~1::_:AIi:-~:#~:EE: I;:I~E. ::.:.:.. ..... . . : .... :. ..........: :~:: :_::::::....:.._ ..:.: _:._:_ _-........~.._::..::.:~.::4:::-~.._ :::..:..:.:.....,_.._...........:........_......._...._...._.,•::.:_~.:.::: _.~:.;.:_.:.._.:.,...;.;.;.,.........._.....:...._._.....~_......__.......:: "~#~: _:~!i~,~.~:ES~~.~ E~fi::::B,A~ EII..._q~...._°t`FI:I:~:.:::~EI~fi ......... 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 ~ B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the decedent's representative. C. ~ The above information is incorrect and/or debts and deductions were aid b You must complete PART ~ and/or PART ~ below. p y you. PART If you indicate a different tax rate, please state your - ~'••`•"""' Q relationship to decedent: _'~~r0_~: ~•~••~.•-~-••;;, •~:~• _ TAX RE TURN COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS r~~€'-~':~~''~='_'':~"•~:r~~r=~~ LIkE 1. Date Established 1 :~:,~,.. :~~;~q„~:_ _'€;*.~~s 2. Account Balance ''E-`_~''`'=-•~~•;.`~"~`==`:-s'^"=,~~,•~s~.=`y• 3 . Percent Taxable 3 X ii=sx;~~;~.~ ~;~s_T;.. ~,;_;!~p~~ _:;:;,~~:;;~;;.~ 4. Amount Subject to Tax 4 ~~~ •~"4ys~? '-~r``~~•}'•[S~r~"$a•'`;~; 5. Debts and Deductions 5 - '~`~ `'';`'~~?~'?;# i ~`'-iii i&ii~5~~ a ~~y'~'~i :.~i~ :::2,; :i i' 4v 6. Amount Taxable 6 ~ :~~~~' ~.~'•°` ; ~'' 7. Tax Rate 7 X _ ~, .~ ,~'kh''4 ~n .:, Et:.r'„'.y~ 8. Tax Due 8 , a d'; , PwRr ~~ ~~ ~,~c~~~ '~ ' 'DEBTS <AND DEDUCTIONS CLAIM~n • .Y •~•j4~• ••••~ IIESGRIPTIQN - - ~, E...~.• •-, - AMOUNT,~PAID ~ -3 ~~~k COMMONWEALTH OF PENNSYLVANIA DEPARTMENT of REVENUE INFORMATION NOTICE BUREAU OF INOLVIOUAL TAXES DEPT. 280601 AND HARRISBURG, PA nlza-acol TAXPAYER RESPONSE REV-1543 IX AFP C09-09) FILE N0. 21 ACN 08114331 DATE 04-09-2008 ~L~ ANDREW L THOMAS 905 GREENBRIAR DR MECHANICSBURG PA 17050-1916 TYPE OF ACCOUNT EST. OF GEORGE B THOMAS ®savlNGs S.S. N0. 200-34-9292 ^ CHECKING DATE OF DEATH 01-18-2008 ^ TRUSr COUNTY CUMBERLAND ^ CERTIF. REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 PSECU 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 of Pennsylvania. Questions may be answered by calling C7771 7p7-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0188627586 Date 04-08-1983 To ihsure proper credit to your account, two Established C2) copies of this notice must accompany your Account Balance 490.21 payment to the Register of Wills. Make check payable to: "Register of Wills. Agent". Percent Taxable X 50.000 245.11 NOTE: If tax payments are made within three Amount Subject to TaX L3) months of the decedent's date of death, TaX Rate ~t X .045 You may deduct a 5% discount of the tax due. d/~~~`}~ ~,.9S~lE 11.03 Any inheritance tax due will become delinquent Potential Tax Due 'ji nine C9) months after the date of death. ~i PART TAXPAYER RESPONSE ......._. _. _.:._.,......_...: ....... . _........ _........_.._._......._.__.._.,:~1i'~.."~;~S~~.ENfi....HA~~~....#1II......T.N.I:S.....~E#i° ::: 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 Wills and an official assessment will be issued by the PA Department of Revenue. ONE BLOCK B. ^ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART 2^ and/or PART ^ below. I f You indicate a different tax rate , lease s ::......................................r:.,,.....,.,.:~:::::::;:_«::::::: ~:::::;:::~::::::~;i~ :::a-:~;;:_:-.,~~-..:.....,.....,.,.,.,,:..; PART p tote your "'-'~''` _ } _ _ ..._.~ ^_ .: ~~ ^ relationship to decedent: ~:- .~.., - -~,::~ ...._.. .......,:..,,~__::~:::z,...~....., _ _._ ..,...._.5- ......, ....... - _o i<w$:c a'i eiT'=5'`iz~'`i"i9i5:£:i°a .mx;v T°^-'~io_.-::.-vv..~ ~ c: ~T:s:: ,:~...5:: _~:: TAX RETURN - C 0 M P U TA T 0 -~€~:=•e:s~-::~-~:; ~~;<<-:-ss~ ;:s_:ra::=r.:--R ~~€€€~~_ R. .;;r: tea: ~;::__.:~ ::: N OF TAX ON JOINT/TRUST ACCOUNTS ~~ = r~ a ~- - ~•:-_::~._•_~,.:::__;=:~_:_: LINE '_ . D =! e E r t o b 1 i s h a C ) ';::~:$€~ ~ ~s:<: :iir's .~!s== x;~.€i xa!s• - - ...._._ .......... 2 . Account B a n - °€5'~,=i - '~~<~ 1 a c e 2 _ - G:i!~ ~~~::'-:,€~ '~:._,.. z=N.;s~ =~ ~'{>:_ '-- ~'s~°x:`:3=3==.,~:~~_ :::- .... ....,::::-:::~ ,emax,www~+ww,m~w~i.R,i,iaR,w,R ' mimR,wi. :::, _:,~:, ::::::~ :._....~.-~- i;=_i,i~s;e~ sip ii:i5~~:si:- " .~ ".:.:.:.::. ;~+~~ ..... 3. Percent Taxable u''•' :..,:~ "~ 3 X ..::...:.__ ,:~!e-:.:;ors;:~:=_.~;_=.a :......:..:::~::-....,r:... _ :;!;`~'~~ - 4 . Amount Sub ' e c -'e=`:~ Eii:°:€€ ~~'~€:; :~ ai:;, : '=a°_~;: t t o Tax 4 :::: -', - _.. _ ;• .:... - - - .. ~,,? ~.`•'i=`~-iii '.,':e=si4€a';=;. r -:::,_ r..::::.::c:::a.:a:::ci'--'iSiiS[:Pc's?:5]si4: ,gcoii:c~::::::::iub e'i:-~e~a?:av_ 'c :. ei 5 . Debts and Deductions 5 - - ti:'-~aii=:;:i5;,::;:=.:~=r >=e:::e:=:;s;. ,rg:=4 ;=_`"s~ ~5:"::: _: =RR;~`~=.~~-,._'=._'.€ a 6. Amount Taxah y~ - - :s~=~ ~~':z.-mss'`=_iri' .:: ,::: ~ic;'C-...r'-_-'.cv=:tiS~~~ee~^.rir'ie'i~=iaae?';'.-:"i~i<Si~ a.; ?La_e2'ii~! x~_es'i..,.~ ,,~.:$§ ,~3, 7 . Tax Rate 7 X - : ~, ~ ;r,~ :_~::::,<<~~:_.::.....v, ..............._.,. -::ems ~=~=~ ~._~~ .>x.~:e, ..__._._..._.. ,;z~~.w+~i,.w,ir~iw,w~:iii.' ~"iwiwpwdi:~. Fiaidwiwii~ ......_..__..... ~a,-..,..._ :................. ...._......:: ~~:::...~,,.... ~ ,.~:::::i,:,4 ... 8. Tax Due B .........._4 :::::..:.::.....:....:.~:.: -....- _ •:. .......... ...............:: s:x.....................:..:......_.:::r:::::r.::.::::za..:-...cd:.c:::_-:;SSi;;i55i2iiiSiieSi ii;S!#2;i;ic iii? PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and ~ co=` ete ~:. J' ` to thglbest of knowledge and belief. / ) _~ HOME C 7/ % ) `~ a ~~ ~~•J ' ~ \ ~I~ ' /L -. J , ~/ ~\'ht I ,,-,.~~qq WORK C'7~7 ) c~I~`1~.~`~1 ~/ TAXPAYER SIGNATURE TEL P E HONE NUMIER 'SATE TOTAL (Enter on Line 5 of Tax Computation) S e COMMOMVEALTH OF PENNSYLVANIA ~ DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND DEPT. 280601 TAXPAYER RESPONSE HARRISBURG, PA 17128-0601 REV-1543 IX ,1FP (09-001 FILE N0. 21 ACN 08114333 DATE 04-09-200.8 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. EST. OF GEORGE B THOMAS S.S. N0. 200-34-9292 DATE OF DEATH 01-18-2008 COUNTY CUMBERLAND ANDREW L THOMAS 905 GREENBRIAR DR MECHANICSBURG PA 17050-1916 REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 PSECU 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 point 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 of Pe-ns~lvar.ia. Cu~stions may ti_ ansti:sred by __lling !717) 787-??2'. COMPLETE PART 1 BELOW * * ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0188627586 Date 04-08-1983 Account Balance [ BLOCK ~ B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the decedent's representative. C. The above information is incorrect and/or debts and deductions were paid by you. You must complete PART 2^ and/or PART 3^ below. Established 31,455.44 To insure proper credit to your account, two C2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 50.000 15, 727.72 NOTE: If tax payments are made within three Amount Subject to Tax C3) months of the decedent's date of death, Tax Rate X .045 you may deduct a 5Y. discount of the tax due. Any inheritance tax due will become delinquent Potential Tax Due 707.75 nine C9) months after the date of death. PARr TAXPAYER RESPONSE .......... ..... ..... .....:..:.:. _...:....r...:::_:: :-~~::::::>~::_~-::::x:--:~::..: _.:::.__;~?'~l~i_:.~t~~::;::R;~:tl:(ti,fi:::~IN:::::A~1-::I1:E:E:I:~AI::~:::: ~..::::r .. , ....: :: ::~ ::: .:: ::::.. .:::.::::::::. :: :::: ~::.:::::::: ......................_....._.....~::>:~:~~:.......r,.:.:...,......._.r.. r__..__~_...__....:.:.:.:.:.:.::::.-..:.r:~::~:~::,.:.:..........................,..................-...._.................:.:~'~€::~:~i~~:R~S~N.E~fi....BAS.EL~....I~~1.:~::TN:I ::, :.: ... ...... S.. ~1fl:TI-~E...... A. ^ The above information and tax due is correct. 1. Vou 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 ONE Wills and an official assessment will be issued by the PA Department of Revenue. PART If you indicate a different tax relationshi to d rate, P ease s a e Your :.... .......~.,..4 ,._.:...;...,._..__ ...... '"'-""' ''~--~ •~--'~'~~-• <°-•r-•~•~•-~~~_- -- - ~::._.~ ~ _:,~;€::=:€~sisdtn!!"s:'; _.._..,..^;; _~... _.:t..... ._..: ~: -_:.., ... ~ r'• ~ ~ ~~ ""'''~'"' ' ~~ ~ ': ~~`~~~= ' • p ecede nt: ., :~ : • : ~ : ,,_ -1~'._ ::::~ ~~,:_::::: ~~:=°-V •_ - ~ii.:;::s,$r~~~€'s=:~i ~•€O~Y~'~.-_.€~:nW •~€0€=sL°•:M;:,:~:: ,,- .::::s:: ..~ TAX RETURN _ _ _ r'~~~~~_~...~:#~`~~€ ~:=~~s; , ~ -~:'~ ~:_~ ~~'. ~ == ~ - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ~: ~:~;_ ~ €€ ~s=~~..s € ~ ~ ~€~a'~-':'~_=:~:-'-•~;_.'=:-5' €~:_:~,:~~==::==t°s:=R=€~?s€;~::€::=s'a~=:a.•= :;: uo ~o r5.tlU1151,CY 1 ~ ~7 ~a/ ~~ w~ : a ..e.. ._..-. ~~`5..... . 4•.:-:: : :-:~'44'iv.:. =s : ~3 ' 5 i _ . . _ .. . ... . ., ~. . n.e.:..,s::::~i':vSoi2 s~_•2i';•.i5e:e S:. :;;3v:emcce :::::or:e:::::: ~ ... 2 . Account Balance _ ~ i ;~~~ .. ...._._.,_...:^ ~~'-:rr:ic.4:, _ , _..-s .r:a-x:~ ~i~:.i5 r_.r ci'2v:Fr ;i.. _......___.... .._. ,.G,,..r,;_,,~;:~ =:_,~,r_...:.. ' _._....a_.::::.. .~-~ -- 3. Percent Taxable 3 X d,~~ ..;....... .... _ - -- __ _ ~:~':=~T ~~~5~; 4:n,,:~_~ _„~;- tea' ~_~a~~::~ ... ^ 4. Amount Subject to Tax 4 ~ `` - 2ii5:~:'--:::3Y:; ::: """"""°" •-• ='`-r"'='~'`-•==`:.`•--' _~~ ~ -- -- 5. Debts and Deductions 5 - r j ~ ~ ::::~::v::::::!::rr;-:;s fs:iii:~~'°i55li'i'i'.'u,'.,a'ii~i~Fr'i;::F::~ iFiEEiESE ~'e':6,;["?."-a"5te5'3 ri:i -'~=FeEB~ sii .-.... co:._:: 'S`.-;...ar:.'"iSieF.... - is.'c~'.co. - .~.:?xir=: ~---• t.... `'..:::: ~:=• ~`:rr-s::=ryP•r~~' •- ~ _ ............. . ......,:r:s:-::: r 6. m oun t T le 6 ~ ~tll ~ :::~ ......._..,,r:~..rE :: ........:.:.....:.. ... - .~ .eiii,:.r~L F ^,: .............. v _ r, . . - - ~Ls: - - - .._- ............. r:: ~ ,~ • ,:: :?;tip":G=s~€::• -- ~ M 7 . Tax Rate ' 7 X r. ~~'{ ................_: .::. ....:. , ..._....~.._... ....,.,.........4....,._.....__...._._ - - - _ ~_~;a::~:=~ ~ ~;:_ s~:_r.~ ~ ~...s.~ ~~_ :_::::!:::::~ ... :...:...::.;-':::_ ."k`s;ai::rr~ .,.e n: ~"rr~us~' @,.s~•'.":.:.::` '~ o:: ._.~~.r..r.~ ~ri:E.:.:.:.:.:,:r:_~.~ z~3r~::o:rdr;.,.: 225?r.~ 6`!'--''u'.s3ec:-.-c3 :4:~rv':c.?r p -v::iF':m ..... ' ... ::::.-:e:-.~_.. .... 8. Tax Due p ...._..a::.:s::.,.:h..._..._ ....................... ................... .._...., _..._.-.....-._x-` r~rSF:._.rx.sn.:.r•:::::.:~ 4~a.°:....s~..-:, -..-r..-3;s".: err ~ ~ :''ei=:5~_'e?« _..._._. .....K....._:,::::::.:._....::_...c .1'~`„4•'•.'s:;s.1 .,... .:,~. ......._...._. :.:.::::::........_............._......... PARr - DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRTPTTf1N AMllIlA1T GATT vl a oFs ~ e ~ ~ e. ' K oo aaao$ oIl F' - . ~. S`f, ( f Q C ~ ~, ~L a rd . „ ~ 1 'l.~ C.C~ ' ~~ ~~ U~tu~.n ~ ' "~ ,..,.~ .~ ,~ , ,. ~1 ,u ~ Vi lax computation) s ~C~e115 ~.J ~ Under penalties of perjury, I declare that the facts I have reported above are true, correct and comp i°A to he best of my knowle a and belief. J 1 ~~+~~~?~ HOME C l ~1 WORK C7( ) c~('~'dSv9 / O XPAYER SIGNATURE TELEPHONE NUMBER AT ~ s ~ PSEC~ ANDREW L THOMAS GEORGE THOMAS DR MECHANICSBURG PA 17050-1916 MEMBER NUMBER STATEMENT DATE 0188XXXXXX i 01/31/08 F0. Box 67013 (717) 234-8484 (Harrisburg; Harrisburg, PA 1 71 06-701 3 (800) 231-1328 (Nationwide) website - htip://wwvd.psecu.com 3 JOINT OWNEFI Number Amount Number Amount Number Amount Number Amount 000796 115.16 010908* 246.00 012611* 725.00 000797 127.36 012104* 381.35 122611* 1100.00 * Asterisk next to number indicates skip in number sequence Post Eff Description Amount 01/01 ID 07 MONEY MARKET Beginning Balance -01/05 Payment: via Home Banking Transfer From Share O1 12000.00 DIVIDEND RATE CHANGED FROM 3.93$ TO 3.49$ ' 01/31 Payment: Dividend 3.490$ 98.29 Annual Percentage Yield Earned 3.950$ from 01/01/08 through 01/31/08 01/31 Ending Balance *** - --------------------------------- ANNUAL PERCENTAGE RATE 6.490% *** Periodic Ra - -- te ;Daily) Post Desc ion Principal FIN CHG Fees O1f04 I 51 REAL ESTATE EQUITY LOAN Beginnin Balance 01/04 e ccount us men 12000.00 0.00 01/04 Payments Transfer From Share 01 0.00 59.74 01/29 Payments via Home Banking Transfer From Share 04 375.00- 0.00 01/31 Ending Balance A Payment of 234.74 is due on 03/01/08 Balance ', 19402.85 31402.85 i ~~~fs~-Yil'~lj, 31501.14 I f~ 31501.14 ; 0.54083$ Balance 0 12000.00 12000.00 ~. 11625.00 11625.00 ; _ .. J . Hollinger Funeral Home 8~ Crematory, Inc. Eric L. Hollinger, Supervisor January 24, 2008 Linda Thorrras 8 Bourbon Red Drive Mechanicsburg, PA 17050 The Funeral Service for George B. Thomas: We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. Professional Service Cremation Package F -Cremation with memorial service $3495.00 Merchandise Rosemont Cherry Casket 935.00 Tree Urn -slate 395.00 15 Bookmarks @ $3.00 each 45.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. Cash Advances Newspaper Notice -Sentinel ~ $185.00 Newspaper Notice -Patriot 338.00 Newspaper Notice -Oil City Derrick 105.00 Certified Copies of Death Certificate (10 @ $6) 60.00 Cumberland County Coroners Authorization 25.00 ~ =1'~ Flowers -Family Spray 132.50 ', 1=~ ~..~ v ,~'L~ Rev. Richard P. Waldron 325.00 ~1., rid 1 ~~ _ Current Balance: ~.. ~ ~ - 6040.50 ~ _ g -_ _ ~tMOREAVENllE • MOllNT E-IOLL1' SPRINGS. PENNSYLnANIA 17065 • (717) 486-3433 • FAX (717) 486-3215 -_ - = -- `" ~-""`= - www.hollingerfuneralhome.com _ ___ _ ., _ _- _ _ ._ .. J Je 1it~ ~ /vs!+ •i/`a/JiavY~'Y~ /~ ~ 'a3 3 pdy~ Gam' s° . ~ i / ~'v.~2 a'?~~.~ :i °sis.i7 L~ i'.3 ~ y ~~.ro it ~l1 ~ ~ ~,: 3'r' it ~ JL7~a~9 ~~~ ~~~ ~~~ ~~ ~~ a~ ./ o _ ~ry~~}r,~9~~pp,,/r~~~~~~3y~L~.av~¢~/~~?~~yi~ ~T"~i~ -~/~i~,~t"~~r"~v~~~j3v ~5~4~.~~~a~~:~7~~~~ ~~a~q~~r', tYZ~dL ldrvri F~i~3'&~F ~~xi C7 ~~ ~:!'u~ ~~~~.~_ L?•o ~~~~+"u~ ' LTV~c.R~i Yi Pi~,~~/ ~~''A ?/f~~L~° t~~~$ ~~~ ~~~~~~ ~~a~~~~~~ ~ ~~~y~~~fi~° ~ ~~~~o ~~ , ~~ ~.~~~ ~~ ~ ~~a ~~~ ~~o~~ ~d-~ ~~~~~ ~~~~~ ~~~ ~~~~~~~~~ ~~~~~~ ~~~~~ ~w~a mar ~~ ~~ ~~9 ~~~~ ~, ~~~L ~y~ ~~~ ~~~ ~~a' Lincoln Benefit Life Company P.O. Box 94212 Palatine, IL 60094-4212 Telephone: (877) 499-6418 Facsimile: (866) 635-4523 March 14, 2008 Linda M. Thomas 8 Bourbon Red Drive Mechanicsburg, PA 17055 Re: George B. Thomas Contract No: LBLA122830 Dear Mrs. Thomas: LINCOLN BENEFIT LIFE AN ALLSTATE CONI PANY We have been requested to complete IRS Form 712 with regard to the above referenced contract. The purpose of Form 712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain date (usually the owner's date of death or date of transfer of the contract). This contract is an annuity contract, which is not reportable on IRS Form 712. The following information is provided for estate purposes only as of the date specified: Date of Death: January 18, 2008 Annuity Value* as of Date of Death: $ 133,800.01 Cost Basis: $ 0.00 Annuity Value* as of March 14, 2008: $ 133,681.76 Named Beneficiary: Linda M. Thomas *The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. If you have any questions, please contact me at 1-877-499-6418 Ext. 86223. Sincerely, ~~/ Jonathan Tong Sr. Claim Examiner ~:`a, .~ ~ _ _ ._T. ,. _ ~_ :~.: _ ...~; L7 ¢ 2 W M ~ / M N N L7N ~F oo~- .z 6.R./W 'ate' f cn ~-Q ~o o o ~ o x '~---~ -~~ ~~ ~ M o 1 n ~~~ w r ~ ~ c' o a c O N O O 0 ~ ~ r_ f_ . .~ ~ ~ ~ ~_•- ~ = . - ~~~__ ~_:7 = .. U ==~ -~ ~ ~:~ _ -~ 0 P_ 4 ~ P ~ ~ n ~ .c+ J •w vJ 2 H ~ O M J r - Oo _~U~ -w~Q _OQ~ =w~~ -~wcn ~ m J (~ ~ ~ - W ~ Q -~UU