The URL can be used to link to this page

Home My WebLink About10-27-08 (2)15056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ,~~~r ~ INHERITANCE TAX RETURN ~ ~ ~ ~ v ~ ~ ~ PO BOX 280601 '~~~e~, Harrisburg PA 17128-0601 .`~~,,,ry,,,. RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 2c~ Z Zv Zv ~ 1 0 ~ Z~, Z c7C~ 7 ~ 2 ~ 1 l`~ 28 Decedent's Last Narr~e Suffix Decedent's First Narne MI k Pr~ i ~Z ~ fl ~(~ T ~- (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Names MI I~Pr ~TZ ~'CTE~ ~ Spouse's Social Security Number ` ~ ~ D ~ g THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) prior to 12-13-82) O ~. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number All r C' N A E ~ c ~ ~ ~ ~ !aJ ~' ~4 7 ! '7 2 3 z. y`'7 ~ ~ Firm Name (If Applicable) First line of address vL.~ ~v/'T~~ Second line of address ~~v~:r ~T~~~T City or Post Office 1~,~ ~ P f~l L r~~ a i,, R G State s~ REGISTER OF WILLS USE ONLY *~_, ~ --, , - ~ , C.- Q ,.~ _ r~--? <, _.., __ I tti .i, DATE FttEq ~ 7 t y ~ _ ~- .~ ~. Correspondent's e-mail address: ~~~~~~~p~7N~-'~~tr ~C+~ ',~/~1.~1~K,, /YET 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. SIGNA E OF PERSON RESPONS BLE FAO\R FILING RETURN DATE ADDRESS C; u% yQ ~Zi~ !U~`z9~~ S'T~~T /Y~Crr/~I~fU~Gscac.~s~~ /'i ~ ! 7Q.y ~j 9 (, SIGNATURE O P A G~LPR ENTATIVE DATE /G~G~~~J ADDRESS ~~~ ivd~~X ~afT.s~~r G~i+iE'ry/Lr"YSV4~G ~~ ~ ~lJy~ - - - - PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 :15056051047 ~ ~o ZIP Code - 3,5056052048 RE=`/-1500 EX p~ ,// Deccedent's Social Security Number DPr.Pdent's Name' ~~L~ L: ~~~•'~,~ - L C%-L. ~ ~ ~ ~ `t 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) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~'7 y (Schedule (~) O Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ~ ~ ~ ~ a . 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. IG 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. e C ' , i 11 ~ ' ~ 1 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12 `p ~ ~ 4 . 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. b ~ ~ ~ . TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 a~able ,f at lineal rate X .0~ 4J , N ~ . 16. ~L ~ Ct • 17. Amount of Line 14 taxable at sibling rate X .12 .` 17. 18. Amount of Line 14 taxable at collateral rate X .15 •' 18. L ~ ~` 19. TAX DUE ..................................................... ....19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056052048 15056052048 RE`/-1500 EX Page 3 Decedent's Complete Address: Fi{e Number ~~ ~~ / /"Jt"1~~ DECEDENT'S NAME ~'~~,r~T L~ k,~U r Z S-REETACDRESS ~~~ C~'C"r~ tt~~~ 1'~~}~ CITY STATE~r~ ZIP ~ ~ J, ~~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2'rt~' 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments ,G'~7 C. Discount iy~~ Total Credits (A + g + C) (2) G~ 7 3. InterestlPenalty if applicable D. Interest E. Penalty Total InterestlPenalty (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) A. Enter the interest on the tax due. (5A) ,3 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) ~~;1 Make Check Payable to: REGISTER OF WILLS, ,AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN 'fHE 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 : ..................................... ....... ^ ~ , LJ c. retain a reversionary interest; or ................................................................................................................... ....... ^ C~' d. receive the promise for life of either payments, benefits or care? ............................................................... ....... ^ 2. If death cccurred 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? ....... ....... ^ ,- , L~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which / contains a beneficiary designation? ................................................................................................................. ....... ^ ,-~ LJ 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. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX INHERITANCE TAX DIVISIDN STATEMENT O F A C C O U N T PO BOX 280601 HARRISBURG PA 17128-0601 REV-1607 EX AFP (03-05) DATE 0:1-07-2008 ESTATE DF KAUTZ JANET L DATE OF DEATH 0;?-26-2007 FILE NUMBER 2:L 07-0852 COUNTY CUMBERLAND LUCY A DEBORAH ACN 07134258 124 WOODS DR LOT 9A Amount Remitted MECHANICSBURG PA 17055 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS E- --------------------------------------------------------------------------- REV-1607 EX AFP C03-05) ~** INHERITANCE TAX STATEMENT OF ACCOUNT **~ ESTATE OF KAUTZ JANET L FILE N0. 21 07-0852 ACN 07134258 DATE 01-07-2008 THIS STATEMENT IS PROVIDED TO ADVISE DF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 10-15-2007 PRINCIPAL TAX DUE: PAYMENTS CTAX CREDITS): 66.06 PAYMENT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST/PEN PAID C-) AMOUNT PAID 09-17-2007 CD008702 .00 66.06 11-27-2007 CD009D24 .00 66.06 * IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. C IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), TOTAL TAX CREDIT 132.12 BALANCE OF 1'AX DUE 66.06CR INTEREST AN:D PEN. .00 TOTAL D'UE 66.06CR COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT LUCY DEBORAH 124 WOODS DRIVE LOT 9A MECHANICSBURG, PA 17050 ,ono ESTATE INFORMATION: ssN: 202-20-204 FILE NUMBER: 2107-0852 DECEDENT NAME: KAUTZ JANET L DATE OF PAYMENT: 1 1 /28/2007 POSTMARK DATE: 1 1 /27/2007 couNTY: CUMBERLAND DATE OF DEATH: 02/26/2007 07134263 ~ 5115.11 • , ACN ASSESSMENT CONTROL NUMBER REV-1162 EX(11-96) N0. CD 009025 AMOUNT TOTAL AMOUNT PAID: 5115.11 REMARKS: CHECK# 481 INITIALS: CJ sEA~ RECEIVED BY: GLENDA FAI~NER STRASBAUGH REGISTER OF WILLS TAXPAYER COMMONWEALTH OF PENNSYL`/ANIA DEPARTMENT OF REVENUE BUREAU~OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: LUCY A DEBORAH 124 WOODS DRIVE MECHANICSBURG, PA 17055 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX)11-96) NO. CD 009024 ACN ASSESSMENT AMOUNT CONTROL NUMBER lald ESTATE INFORMATION: ssN: zoz-zo-2o4~ FILE NUMBER: 2107-0852 DECEDENT NAME: KAUTZ JANET L DATE OF PAYMENT: 1 1 /28/2007 POSTMARK DATE: 1 1 /27/2007 couNTY: CUMBERLAND DATE OF DEATH: 02/ 26/ 2007 REMARKS: SEAL CHECK# 557 07134258 ~ 566.06 TOTAL AMOUNT PAID: INITIALS: CJ RECEIVED BY: 566.06 GLENDA FAI~NER STRASBAUGH REGISTER OF WILLS TAXPAYER .RP/4509 EX ~ (197) COMMONWEALTH OF PENPJSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~Anl~r ~. K~~ +~ SCHEDULEF JOINTLY-OWNED PROPERTY FILE NUM8ER 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. f:;~,, c.t~y ~~i ~A 1Z~ ~k'~~ sT~ M~CN~lr1C5~c'21:~ J ~'A 17z" 5'1J ~'~'RtJfl~5~~71~1 e. Oar-Tr2~H Ll1 ~Y C. JOINTLY-OWNED 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 nwnber. Attach deed for jointly-held real estate. D,4TE OF DEATH VALUE OF ASSE7 % OF DECD'S INTEREST DATE OF DEATH `lALUE OF DECEDENT'S INTEREST 1. A. ~-~~~'~ J~,1~r'~d(/~ ~k /'~(;~'l1Jl ~1J, `~/~~C't/CAS`/ ~G#. I~j: G 1 ~~~* /~~C?,il, 7~ 2, ~. Ji•!3-~;~' J~'1/i) ,fit ~.~1,x ,gc~a4~,v7 ~~ ~'/~c?~t%~fSU r~J l/~, l7 ~~i~^ 2~5~~'~L'Y ~. 6 ~~;-cr e~ C~~7~1~a"~ ~,3~ zti7 Nu ~3~ ~L y,~ 7St~ ~'.~c'a ~~' :Sl~?,; L• L.. GF l.4Gi %1} 1Z'~ i~',?i~r Sl, f 111~U17~'~~ist'~V'~C;~, f~~ !'7U_'~ ~ ~r?L°~'~K" TOTAL (Also enter on line 6, Recapitulation) I $ /L'j 4:~/ ~, ~°/ (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA DEPARtMENT OF REVENUE INFORMATION NOTICE FILE NO. 21 BUREAU OF INDIVIDUAL TAXES DEPT. 280601 TAXPAYER RESPONSE; AcN 07134264 HARRISBURG, PA 17128-(1601 DATE 08-10-2007 REV-1543 E% AFP (09.00) JOHN LUCY LOT 9A 124 WOODS MECHANICSBURG PA 17050 TYPE OF ACCOUNT EST. OF JANET L KAUTZ ~ SAVINGS S.S. N0. 202-20-2047 ~ CHECKING DATE OF DEATH 02-26-2007 ~ TRUST COUNTY CUMBERLAND ~ CERTIF. F;EMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 MID PENN BANK has provided the Department with the information listed b()low 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 PennsY ).va ^.'~ Q~+os~~r^s n•3y he ansk^^na ~•• calling (7)7l Z87-8317. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 416011089 Date 04-15-2005 To insure drover credit to your account, two Established (2) copies of this notice must accompany your payment to the Register of Wills. Make check Account Balance 20 ~ 103 • 07 payable to: "Register of Wills. Agent". Percent Taxable X 50.000 NOTE: If t:ax payments are made within three Amount Subject t0 TaX 10,051.54 (3) months of the decedent's date of death, TaX Rate X , lj You may de(iuct a 5Y. discount of the tax due. Any inheril:ance tax due will become delinquent Potential TeX DUe 1,507.73 nine (9) months after the date of death. PART TAXPAYER RESPONSE a fAIE:UR.E TQ RESPC1M~i WILL '1~E'SULT IN.. AN OFFICIAL.' TAX ASSESSH~NT'BASEII ON THIS NpTICE`' 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 C H E C K 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. ~he 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 paid by you. You must complete PART 2^ and/or PART 3~ below. PART If you indicate a different tax rate, please state your tIPFIC`ZAL ~jsE ~~[]~'~, ~ pt,~~ 2^ relationship to decedent: PA DEPAR'~MENT o~ ~~V~r~u TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 ''1' 2. Account Balance 2 Z 3. Percent Taxable 3 X '~ 4. Amount Subject to Tax 4 t+ 5. Debts and Deductions 5 - 'S 6. Amount Taxable 6 ~r ,' 7. Tax Rate 7 X ' 7 _'.' ....'. .. '... ..... 8. Tax Due 8 $ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Line 5 of Tax Computation) S 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 ) j` WORK C ) COMMONWEALTH OF PENNSYLVANIA DEPARaMENT OF REVENUE I N F O R M AT I O N N O T I C E BUREAU OF INDIVIDUAL TAXES A N D DEPT. 280601 HARRISBURG, PA 17126-0601 TAX PAYE R RESPONSE: REV-1543 IX AFP (09-00) DEBORAH LUCY LOT 9A 124 WOODS DR MECHANICSBURG PA 17050 FILE N0. 21 ACN 07134263 DATE 08-10-2007 TYPE OF ACCOUNT EST. OF JANET L KAUTZ ^ SAVINGS S.S. N0. 202-20-2047 ^ CHECKING DATE OF DEATH 02-26-2007 ^ TRUSr COUNTY CUMBERLAND ~ CERTIF- REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 Under penalties of perjury, I declare that the facts I have reported abcvefi acre truce^, correct and comj~lete to the best of my knowledge and belief. HOME C „~ )_ (Q -l ~ - a(~~ ~~~ - v ~~ Q ~ ~~,~ WORK C ) TA V.QAVrn nre~i.~r~~r~r TDTAL (Enter on Line 5 of Tax Computation) S COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1543 IX AFP C09-00) INFORMATION NOTICE FILE N0. 21 TAXPAYERNRESPONSE ACN 07134258 DATE 08-10-2007 LUCY A DEBORAH 124 WOODS DR LOT 9A MECHANICSBURG PA 17055 TYPE OF ACCOUNT EST. OF JANET L KAUTZ ^ savlNGs S.S. N0. 202••20-2047 ® cIHECKING DATE OF DEATH 02-26-2007 ^ rRUST COUNTY CUMEfERLAND ^ CERTIF. REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARL]:SLE, PA 17013 COMMERCE BANK 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 Pennsylvania. Questions !nay be answered by cal li r.g (717) 787-8327. COMPLETE PART 1 BELOW ~ * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 536248750 Date 05-01-2003 To insure proper credit to your account, two Established C2) copies of this notice must accompany your $ $ 0 . 7 4 payment to the Register of Wills. Make check Account Balance payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax 440.37 (3) months of the decedent's date of death, TaX Rate X , i5 You may deduct a 5% discount of the tax due. Potential TaX Due Any inheritance tax due will become delinquent 6 6 . 0 6 nine (9) months after the date of death. P~T TAXPAYER RESPONSE FAILURE :T^ RErSPgND MILL R~~ULF. T3V AN CIFF'ICIAL! TAX. ASSESSMENT 'BAS EA ON T.MTS Ntl~TICE', '' A. ® The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with ti+o copies of this notice to obtain C H E C K 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 ~ 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 paid by you. You must complete PART ~ and/or PART ~ below. ,: .. PART You indicate a different tax rate, please state your OFFICIAL ~~ QNLY ~',s~~ relationship to decedent: _ s a TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate B. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 X 4 5 6 7 X 8 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID c Under penalties of perjury, I declare that the facts I have reported above are true, correct and lete to the best o/~f my knowledge and belief. HOME C ~~, ) ~_I1-~~~5 ~L`%U^Z-~~ ~'1 ~ LL C~IJi WORK C ) TOTAL CEnter on Line 5 of Tax Computation) S REV-1511 EX+ (10-06) ~~ ° SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF .~~i~'E7" ~, is/~'i z FILE NUMBER Gl ~v7'Cr~~Z ITEM NUMBER •A. FUNERAL EXPENSES: 1. /Y1~'~rz~ Fi'rL~I~i3i. r'kr~~~ Z. Rc~~~-5 ~G~~~~r?~ Debts of decedent must be reported on Schedule I. DESCRIPTION AMOUNT ~~~ ~~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address Citv Year(s) Commission Paid: State Zip __.___ _ _ 2. Attorney Fees 3. Family E>;emption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City _ __ State Zip ___ _ Relationship of Claimant to Decedent 4. Probate f=ees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7 ~~3iC%~ y3li~ 3~ TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) Myers Funeral Home, Inc. (717) 766-3421 STATF,MENT OF FUNERAL GOODS AND SERVICES SELECTED February 26, 2007 Date of Contract February 27, 2007 Mechanicsburg, Pa. 17050 Charges are only for those items that you selected or that are required. If we are required by law or by a cemf;tery 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 you selected arrangements such as direct cremation or Immediate burial. If we charge you for an embalming, we will explain wliy below. For Services of Janet L. Kautz Date Of Death Charge to Peter A. Kautz Boyd L. Myers Jr., Supervisor 37 East Main Street Mechanicsburg, Pennsylvania 17055 533 Good Hope Road A. CHARGE FOR SERVICES SELECTED: 1. PROFESSIONAL SERVICES Services of Funeral Director and Staff $ 1895.00 Embalming $ 995.00 Casketing, dressing, cosmetology $ 295.00 Other Preparation of body $ 95.00 Hairdresser /Barber $ Autopsy Remains $ SUB-TOTAL PROFESSIONAL SERVICES AI $ 3,280.00 2. USE OF FACILITIES AND SERVICES For visitation !wake service $ 525.00 For funeral ceremony $ 550.00 For memorial service $ Equipment & services for graveside service $ 395.00 SUB-TOTAL FACILITIES AND EQUIPMENT A2 $ 1,470.00 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home $ 350.00 Hearse (Casket Coach) $ 295.00 _ Flower Car /Floral Distribution $ Incl Family Car $ Incl Lead Car /Clergy Car $ 195.00 utility Car ~ $ Out of town transportation $ $ SUB-TOTAL AUTOMOTIVE EQUIPMENT A3 $ 840.00 TOTAL SERVICES, FACILITIES, AUTOMOBILE A $ 5,590.00 B. CHARGES FOR MERCIi.ANDISE SELECTED Casket Majestic $ 1795.00 Other Receptacle $ Outer Burial Container $ Gap Acknowledgment Cards_ $ Register Book $ 65.00 Memorial Folders $ Prayer Cards $ Temporary Grave Markers $ Burial Clothing $ Other Clothing $ Cremation urn $ TOTAL MERCHANDISE SELECTED B $ 1,860.00 C. SPECIAL CH:~RGES Forwarding Remains to other Funeral Home _ $ Receiving Remains form other Funeral Home _ $ Immediate Burial _ $ Direct Cremation $ -SUB-TOTAL OF SPECIAL CHARGES D. CASH ADVANCED Opening Grave/Crypt _ $ Newspaper Patriot _ $ Newspaper _ $ Clergy /Mass Offering _ $ Certified Copies of Death Certificate 10 _ $ Family Flowers _ $ _ - ~ - $ $ Fax (7171 795-7291 C$ 10.00 ; 100.00 60.00 '. 132.50 ' SUB-TOTAL OF CASH ADVANCED D $ 302.50 We charge you for our services in obtaining the following: NONE SUMMARY OF CHARGES TOTAL ABOVE ITEMS (A,B.C.D~ $ 7,752.50 Sales Tax (if App)_~ir __ % _ $ 0.00 TOTAL OF ALL SECTIONS $ :7,752.50 LESS: Payment Made $ 857.50 LESS: Credits Pending $ LESS: Credits granted Package Price Discount $ 1,695.00 BALANCE DUE Mar 29, 2007 $ 5,200.00 A late charge of 1.5% per month on the outstanding balance (annual,;ate of 18%) will be added to the balance. ~ ~d5~°' '~ REASON FOR REQUIRED SEP:VICES OR MERCHANDISE Family request viewing Cemetery requires outer burial container DISCLAIMER OF WARRANTIES Our funeral home makes no representations or warranties regarding caskets or outer burial containers. The only warranties, expressed or implied, granted in connection with goods sold with the funeral service are the express written warranties, if any, extended by the manufacturer thereof. No other warranties. including the implied warranties of merchantability or fitness for particular purpose are extended by the seller. I agree that I have examined the items of goods and services selected above and found them to be correct: and according to the arrangements I have requested. I acknowledge receipt of a copy of this Statement of Funeral Goods and Services Selected. I represent that I have sufficient funds available for ayment of the cash price for the goods and services selected. I also agree to make payment of $ 5200.00 within 30 days. I agree to be jointly and severalty Fable with anyone else who signs below. A LATE CHARGE of 1.5% per month (18% er annum) wi~lf e)-applied to the unpaid balance beginning 30 days after the date of this contract. I will also pay the Funeral Director all reasonable costs paid by the Funeral Director to collect amounts I owe under this agreement. Those costs may include attorney fees and court costs. Any items requested after the date of this agreement will be considered part of this agreement and will be reflected on the final bill (Seal) ruary 2 , 007 Purchaser S' ntr Date (Seal) Purchaser o L. s .Lice ed Funeral Di or ROYERS'S FLC4~IERS 6520 CARLISLE P MECHANICSBURG, PA Ph: 697-7777 REG #1 Clerk#; 325 KIM 06/27/2J07 Transaction: 31788 08:50 Ln# Pn Oescr 1 20 FUNERAL Validated order __ Wty Amount _ Ext Am: 1 40.00 40.00. j 9505 Pho & Del: 5,95 ~ Discount: 0,00 1 Coupon; 0,00 ~ Tax: 2,76 Total: 48.75 Tender: 60.00 Cash Change: 11,25 Thank-You For Your Patronage Order Number: 9505 Delivery Uate: 06/28/2007 Recipient; BOOORF 'ddress: 0 MYERS FH }y/State; MECHANICSBURG FA REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~~n'~~T ~.. k/~v iZ FILE fJUMBER 2l-~~'- Gf~.~Z RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAA4E AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Listl"rustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)1 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. ,~;" 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) LAST ~'~'ILL AND TESTAMENT KNOW ALL MEN BY THESE PRESENTS, that I, JANET L. hAUTZ currently residing in Mechanicsburg, Cumberland County, Commonwealth of Pennsylvania, being in good health and of sound and disposing memory do hereby make, declare and publish this as my Last Will and Testament, hereby revoking all former Wills and Codicils heretofore made by me. FIRST: I direct that all of my debts not barred by tl7e statute of limitations, expenses of~my last illness, funeral expenses, costs of administration and claims allowed in the administration of my estate shall be paid by my Executor hereinafter named, from my estate as soon after my decease as shall be found convenient. SECOND: I bequeath my automobiles, household and personal effects and other tangible personalty of like nature (not including cash or securities), together with any existing insurance thereon, to my husband, PETER A. KAUTZ. In the event that: PETER A. KAUTZ should predecease me or not be living on the thirty-first day following m.y death I give, devise and bequeath my tangible personalty to DEBORAH A. LUCY. In the e~,~ent that DEBORAH A. LUCY should predecease me or not be living on the thirty-first day following my death I give, devise and bequeath my tangible personalty to JOHNNY LUCY. THIRD: I give, devise and bequeath the rest, residue and remainder of my estate, whether real, personal or mixed, and of any nature whatsoever and wherever situate, to my husband, PETER A. KAUTZ. In the event that PETER A. KAUTZ sho~_ild predecease me or not be living on the thirty-first day following my death, I give, devise and bequeath the rest, residue and remainder of my estate, whether real, personal or mixed and of any nature whatsoever and wherever situate, to DEBORAH A. LUCY. In the event that DEBORAH A. LUCY should predecease me or not be living on the thirty-first day following my death, I give, devise and bequeath the rest, residue and remainder of my estate, whether real, personal or mixed and of any nature wha~soever and wherever situate, to JOI-IN"?vY Lt1CY. FOURTH: I hereby nominate, constitute, and appoint PETER A. KAUTZ, as Executor of this, my Last Will and Testament. In the event that PETER .?,. KAUTZ shall predecease rne, or be unwilling or unable to act as my Executor, as aforesaid, then I nominate, constitute and appoint DEBORAH A. LUCY as Executor of this, my Last Will and Testament. In the event that DEBORAH A. LUCY shall predecease me, or be unwilaing or unable to act as my Executor, as aforesaid, then I nominate, constitute and appoint JOHI\(NY LUCY without necessity for posting security regardless of state of residence, as Executor of this, my Last Will and Testament. All references to the Executor herein shall be applicable to said substitute Executor. FIFTH: My Executor shall have, in addition to the powers and authority conferred upon him b,i law, the following additional powers and authority: To sell at public or private sale, exchange, transfer, partition, give options upon, lease, mortgage, pledge or otherwise dispose of any property, real or personal, at any time constituting a portion of my estate, and upon such terms and conditions as the Executor shall deem wise. 2. To invest any money at any time in such bonds, stocks, notes, real estate, mortgages, life insurance, annuities or other securities, or such property, real or personal, as the Executor shall deem wise, without being limited by any statutes or rule of law regarding investments by the Executor. To retain, without incurring any liability, as inves~~ments, any property owned by me at the time of my death, as long as my Executor may deerr~ it wise, and even though such property is not the kind of property an Executor would purchase as an investment; and even though to retain such property might violate sound diversification principles. 4. To cause any security or other property which may constitute a portion of my estate to be issued, held or registered in the Executor's o~~m name, or in the name of a nominee, or. in such form that title will pass by delivery. Cy To consent to the reorganization, consolidation, readjustment of the financial structure, or sale of the assets of any corporation or other organization, the securities of which constitute a portion of my estate, and to take any action with reference to such securities which, in the opinion of the Executor is necessary to obtain the benefit of any such reorganization, consolidation, readjustment or sale; to exercise any conversion privilege or subscription right given to my Executor as owner of any securities constituting a portion of my estate resulting from any reorganization, consolidation, readjustment, sale, conversion or subscription. To pay all costs, taxes, charges and expenses in connection with the administration of my estate, including such compensation to the Executor which shall be in accordance with established fees throughout the period of administration of my estate. 7. To determine what is "income" and what is "principal" hereunder, and my Executor's decision thereon shall be final; and to purchase securities at a premium or discount, and to apply or charge said premium or discount against income or principal as the Executor may determine. The Executor may make payments to or on behalf of any person who is the beneficiary hereunder but in no event, however, shall payments be made to any creditor or other such person because of anticipation of payment by the beneficiary, and any such claim made by wa.y of anticipation by the beneficiary shall be of no validity or legal effect. To borrow money from any person, firm or corporation, including any corporation acting as an Executor hereunder, for the purpose of protecting and preserving or improving my estate hereunder; to execute promissory notes or other obligations for amounts so borrowed. 10. To employ legal counsel, accountants, brokers, ins,-estment advisors, custodians, managers and other agents and employees and to pay reasonable compensation out of my estate or any funds held hereunder to which said compensation is attributable. _- ~- _ ~. '!F , j `~ ...~. 11. To carry on any business owned or controlled by me at my death for whatever period of time my Executor shall think proper, and my Executor shall have the power to do any and all things my Executor deems necessary or appropriate, including the power to close out, liquidate or sell the business at such time and upon such terms as my Executor shall deem best. 12. To do all other acts in my Executor's judgment necessary or desirable for the proper and advantageous management, investment and distribution of my estate. SIXTH: I direct that all transfer and inheritance taxes, statf: or federal, assessed because of my death, whether the fiords, property or insurance proceeds to which such taxes are attributable pass under this Will or got, shall be paid out of my residuary estate; that my Executor pay, or provide for payment of all such taxes at such time, or times, and in such manner as my Executor deems best. IN WITNESS WHEREOF, I, J_4NET L. IfAUTZ, the Testator to this, my Last `g'ill and Testament, typewritten on six sheets of paper which I have identified at the bottom of each page by my signature, hereunto set my hand and seal the _~ day of ~Q,-. 2006. J . ET L. ICA UTZ The preceding instrument consisting of this and five other typewritten pages, each identified by the signature of the Testator, JAl~'ET L. IiAUTZ, this day and date thereof signed, published and declared by JANET L. I~.4 UTZ, the Testator therein named, as and for her Last Will, in the presence of us who, at her request, in her presence, and in the presence of each other have subscribed our names as witnesses. (? ~- 4 COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND ' I, Jtll'~rET L. It:AUTZ, Testator 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 the purposes therein expressed. .z~1 ~~ 7~ca..~v~ JANEt~' L. I;A UTZ Sworn or affirmed to and acknowledged before me by JANET L. ICAUTZ, Testator, the _~_ day of fC/~r , 2006. (SEAL) Notary Public COMMONWEAL ~ N 0*- K~l"AIiVSYLVANIA No,aria Seal Michael Cherewka, Notary Public Wc~rnleysburg Boro, Cumberand County My Commission Expires Apr. 27, 2009 Memk~er, Fannsylva.ni^, ,n..r:;,np;~,:irr- of t~lotaries COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND We ~_`j~ >,-~ ~ ~ ~2. ~c~'~ and r16Z ~. CSC),-}~Q ~(~I ,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 Testator sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and volt.tntary act for the purposes therein expressed; that each of us irrthe hearing and sight of the Testator signed the Will as witnesses;-and that to the best of our knowledge the Testator was at that time eighteen or morf; years of age, of sound mit1.C1 and under no constraint or t.tndue influence. `Tura. ~~~. (~at~d~" 1 Sworn or afftmed to and subscribed to before me by ~4~'L G~~,,~tr~t------and _ f Tr~[~ ~/~• ~~i witnesses, this ~~' day of ~ , 2006. ~_. (SEAL,) ~~~~~ ~~-- Notary Public COMMONWEAL`I"N OF NCNiejYLVANIA Notatial Seal Michael Cherawka, Notary Public Wrxmleysburg Boro, Cumberland County 5 h1y Commission Expires Apr. 27, 2009 Member, Pennsylvania 5_=..~~^is~~~~~ of Notaries