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HomeMy WebLinkAbout11-17-08 (3)~ ~ ' 15056041147 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 Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 8 0 0 2 81 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 187 24 1397 03 03 2008 Ol 23 1931 Decedent's Last Name Suffix Decedents First Name MI BARTEK ELEANOR L (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 X^ 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise ~ 5. Federal Estate Tax Return Required (date of death after 12-12-82) X^ g Decedent Died Testate ~ ~ Decedent Maintained a Living Trust Q 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. betweenP231 gCredat (d; tges~f death ~ 11. Election to tax under Sec. 9113(A) 1 (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number BRIAN C. LINSENBACH ESQ. 717 432 9733 Firm Name (If Applicable) SCHRACK & LINSENBACH PC First line of address 124 W. HARRISBURG ST., PO BOX Second line of address City or Post Office DILLSBURG State ZIP Code r.o REGISTER OLS USE~NLY '-; ~"' t ~ - , , __. ~ N1 ,-` ~ -, C~~ '. _ --t ~ v - ~, . DATE FILED E'"~ i~ r-I-t -=; ~.~ t_.. PA 17019-0310 Correspondent'se-mail address: blinSenbach@COmCaSt.net 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, corcect and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATU E F PERSON RESP SIBLE FOR FILING RETURN f}. DATE ~C /j y~ ~~f~ Nancy Poole ~~ ~ ~ ®~' ADDRESS 1 Oak Avenue, Dillsburg, PA 17019 SIGNATURE OF P RER OTHE N REPRE TATIVE DATE Brian C. Linsenbach Esq. ` ~~ ~ o ADDRESS 124 W. Harrisburg Street, Dillsburg, PA 17019 Side 1 15056041147 15056041147 + ti 15056042148 REV-1500 EX Decedent's name: E I e a n o r L. B a r t e k Decedents Social Security Number 18 7 2 4 13 9 7 RECAPITULATION 1. Real Estate (Schedule A) ............................................................._........................ 1. 2. Stocks and Bonds (Schedule B) .............................__............................__............. 2. 5, 8 7 0. 8 4 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. 2 7 9 , 16 6 . 2 6 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 6. 4 , 6 2 0.41 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 7, 8. Total Gross Assets (total Lines 1-7) ............................._...........................__..... g. 2 8 9, 6 5 7. 5 1 9. Funeral Expenses & Administrative Costs (Schedule H) ...................................... 9. 5 6, 9 3 3 8 8 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 1 3 , 7 5 6.11 11. Total Deductions (total Lines 9 & 10) ................................................................. 11 • 7 0 , 6 8 9 . 9 9 12• Net Value of Estate (Line 8 minus Line 11) ............................._.......................... 12. 2 1 8 , 9 6 7 . 5 2 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. 2 1 8 , 9 6 7 . 5 2 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 .00 0 . 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 0 . 0 0 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 . 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 2 1 8, 9 6 7. 5 2 18. 19. Tax Due ................................................ ............._............................._................. .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 0.00 0.00 0.00 32,845.13 32,845.13 Side 2 15056042148 15056042148 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-08-00281 DECEDENT'S NAME Eleanor L. Bartek STREET ADDRESS 5225 Wilson Lane - #311 CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit g. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty 31,000.00 1,631.58 Total Credits (A + B + C) (1) 32,845.13 (2) 32,631.58 Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is theOVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is theTAX DUE A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is theBALANCE DUE (3) (4) (5) 213.55 (5A) (56) 213.55 Make Check Payable fo: REGISTER OF WILLS, AGENT r c g~ 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 :................................ ^ a 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 statutedoes not exemota 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)j. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. M '~Tlust ill ttx~'(~esttn~r~d ELEANOR L. BARTEK BE IT REMEMBERED, that I, ELEANOR L. BARTEK, presently of 5225 Wilson Lane, Room No. 311, Mechanicsburg, Pennsylvania 17055-6663, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore made. ITEM 1: I direct that my hereinafter named Executrix pay all my just debts, my funeral expenses, and the expenses of the administration of my estate. With this direction, I authorize and empower my Executrix to expend for my funeral expenses and interment such amounts as she may consider necessary and proper, without regard to any limit that may be prescribed by a court of law. ITEM 2: I direct my Executrix to pay all inheritance, estate, succession, and legacy taxes of whatsoever nature and kind, to which my estate, or the transfer of any property passing hereunder or otherwise passing by reason of my demise, maybe subject, and to charge such taxes against my residuary estate. It is my intention that none of the aforesaid taxes, either federal or state, on any property required to be included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my estate to whom such property is or maybe transferred or to whom any benefit accrues. ITEM 3: I hereby give, devise and bequeath my Royal Copenhagen Plates to BETTY MARINO, NANCY POOLE and DOLORES ROSKOVICH, share and share alike. ITEM 4: I further hereby give, devise and bequeath my Finnish glasses to my niece, JUDY JOHNSON. •, ITEM 5: I further hereby give, devise and bequeath my Swiss Chalet Mountain Scene Print and Norwegian Wall Hanging to my niece, BETTY MARINO. ITEM 6: I further hereby give, devise and bequeath my Cuckoo Clock to DORINE HALVERSON. ITEM 7: I further hereby give, devise and bequeath: TWENTY THOUSAND DOLLARS (20,000.00) to NANCY POOLE. In the event that she does not survive me, I then direct this amount be given to Jim Poole, Sr.; FIVE THOUSAND DOLLARS ($5,000.00) to JOHN RADICH. In the event that he does not survive me, I then direct this amount be given to Marilyn Radich; TEN THOUSAND DOLLARS ($10,000.00) to TOM BUCHANAN. In the event that he does not survive me, I then direct this amount be given to Judy Buchanan; TEN THOUSAND DOLLARS ($10,000.00) to ALLAN TYLKA. In the event that he does not survive me, I then direct this amount be given to Cory Tylka; TEN THOUSAND DOLLARS ($10,000.00) to TERRY TYLKA. In the event that he does not survive me, I then direct this amount be given to Pat Tylka; FIFTEEN THOUSAND DOLLARS ($15,000.00) to BETTY MARINO. In the event that she does not survive me, I then direct this amount be given to Carrie Ank; FIFTEEN THOUSAND DOLLARS ($15,000.00) to JUDY JOHNSON. In the event that she does not survive me, I then direct this amount be given in equal shares, to Denny Johnson, Jodi Philips, and Denise Johnson; TEN THOUSAND DOLLARS ($10,000.00) to be given to Judy Johnson to keep for the benefit of DOLORES ROSKOVICH. 2 ~~ ITEM 8: I further hereby give, devise and bequeath FIVE THOUSAND DOLLARS ($5,000.00) to each of the following: JIM POOLE, JR., DONNA WATSON, CABBIE ANK, LIA KIECKHAFER, BRIAN BUCHANAN, JODI PHILLIPS, DENISE JOHNSON, BOB ROSKOVICH, and MICHELE CHOVAN. ITEM 9: After all the foregoing specific bequests have been made, and before the rest, residue and remainder of my estate has been distributed, in the event my net estate has a value in excess of One Hundred Thousand Dollars ($100,000.00), I hereby give, devise and bequeath: FIVE THOUSAND DOLLARS ($5,000.00) to THE UNITED EVANGELICAL j FREE CHURCH, 1420 80`k' Street, Seattle, Washington 98117; FIVE THOUSAND DOLLARS ($5,000.00) to CAMPUS CRUSADE FOR CHRIST, 100 Lake Hart Drive, # 3300, Orlando, Florida 32832; FIVE THOUSAND DOLLARS ($5,000.00) to CHAR-BELLE FREE ~ METHODIST CHURCH, at the corner of Speer & Arch Street, Belle Vernon, Pennsylvania 15012; TEN THOUSAND DOLLARS ($10,000.00) to NEW TRIBES MISSION, 1000 East First Street, Sanford, Florida 32771-1487; and, TEN THOUSAND DOLLARS ($10,000.00) to WYCLIFFE BIBLE TRANSLATORS, P.O. Box 628200, Orlando, Florida 32862. ITEM 10: All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, whether it be real, personal or mixed, including property over which I have a power of appointment, I give as follows: ELEVEN and ONE QUARTER PERCENT (11 1/4 %) to JOHN RADICH, TWENTY ONE and ONE QUARTER PERCENT (21 1/4 %) to NANCY POOLE, ELEVEN and ONE QUARTER PERCENT (111/4 %) to BETTY MARINO, 3 ELEVEN and ONE QUARTER PERCENT (11 '/4 %) to TOM BUCHANAN, ELEVEN and ONE QUARTER PERCENT (11'/4 %) to DOLORES ROSKOVICH, ELEVEN and ONE QUARTER PERCENT (11 '/4 %) to JUDY JOHNSON, ELEVEN and ONE QUARTER PERCENT (11 '/4 %) to ALLAN TYLKA, and ELEVEN and ONE QUARTER PERCENT (11'/4 %) to TERRY TYLKA, provided they survive me for a period of thirty (30) days. ITEM 11: I nominate, constitute and appoint NANCY POOLE to serve as Executrix of this, my Last Will and Testament. In the event Nancy Poole, should predecease me, fail to qualify, cease to act, or renounce probate, I appoint TOM BUCHANAN, as successor Executor of this, my Last Will and Testament. ITEM 12: My Executrix shall be entitled to reasonable compensation based upon the actual responsibilities assumed and performed. ITEM 13: I direct that my hereinbefore named Executrix, or her successor, shall not be required to give bond for the faithful performance of her duties in this or any jurisdiction. NESS WHEREOF, I have hereunto set my hand and seal this ~~~ day of 2006. t~ ELEANOR L. BARTEK The preceding instrument, consistingg of this and three (3) other typewritten pages, was on the day and date thereof signed, sealed, published, and declazed y the Testatrix herein named, as and for her Last Will and Testament, 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 hereto. a: ._.. ate ..~ . j 1 ,~ 4 COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF YORK We, ELEANOR L. BARTEK, the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and Testament, and that she signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix signed the Will as witnesses, and that to the best of their knowledge, the Testatrix was at the time eighteen (18) years of age or older, of sound mind, and under no constraint or undue influence. /' ~ ELEAN R L. BARTE ~'''-~-~ ~~ . .. i., SWORN TO AND SUBSCRIBED BEFORE~E THIS ,~/Q~ DAY 2006. C Janet S. Gore, Notary PubNc 9 Boro. York Cottrrly RAy Convnission Expires Oct 2a, Z006 ~~ ~. re-tsy,va„a r-n car nnrenes 5 Rev-1503 EX+ (8.98) SCHEDULE B Y STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Bartek, Eleanor L. 21-08-00281 All property Jointry•owned with right of survh!orship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 100 shares of Microsoft Corporation 26.86 2,686.00 2 42 shares of Prudential Financial Common stock 75.829467 3,184.84 TOTAL (Also enter on Line 2, Recapitulation) 5,870.84 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Detach Here ~"° ^°A erican Stock Transfer & 7)'tlst Company, LLC 40000 MICROSOFT CORPORATION SHARES SOLD TRADE DATE NET PRICE /SHARE 100.000 09/04/2008 $26.670000. ACCOUNT NUMBER CHECK NUMBER 9000175039 244119963 NANCY POOLE EX UW ELEANOR L BARTEK ATTN BRIAN C LINSENBACH 124 W HARRISBURG ST P O BOX 310 DILLSBURG PA 17019 v~ Y~ ~~ v / ~t b f ~~,~µ'~~ . °" l~ GROSS AMOUNT $2, 667.00 TAX WITHHELD $0.00 FEES WITHHELD $25.00 NET CHECK AMOUNT $2,642.00 Please retain this statement for your records. Detach Here ~, IMPORTANT TAX RETURN DOCUMENT ATTACHED J, PAYER'S federal IdentHicatlon RECIPIENTS Identification 1a Date d sale or eXCtlan9e _ 431-- Detach Here number number ~/~~~$ ~oo~ Proceeds From 911144442 26627**** ~ Broker and PAYER'S name, street address, city, state, ZIP code and telephone no. b CU IP number MICROSOFT CORPORATION 594918104 C/O American Stock Transfer & Trust Co., LLC s ' ~. eta. 59 Maiden Lane $2,642.1 New York, NY 10038 ~ eartarins Phone: 718-921-8200 ext. 6820 NANCY POOLE EX UW ELEANOR L BARTEK ATTN BRIAN C LINSENBACH 124 W HARRISBURG ST P O BOX 310 DILLSBURG PA 17019 Substitute Barter Exchange Form 1099 B Transactions Reported l ^ o~wsPioceads to IRS f ~ oror Roasae~ ba mm~iaaia ~m evUan on~nr 4 Federal lncame Tax V1fitltField Co B e ~~~~ Dort ~~ For Recipient This is important tax informatlon 100.000 SHARES SOLD furnished toei 8 Prafit or (kxsa) reaYzed in 20Qf3 8 Unrealized profit a ) on Internal Revenue open contwcfs-17!31/2007 Sernce. If you are required to ~1 ~ P~ ~ ~~) flle a return, a negligence penalty or other sanction may be imposed on you rnt canno take a ass on if this in me is tax rectum based on the amount in box 2 ~ co taxable and the ou num r nor : IRS determines 40000 9000175039 been reported Detach Here INFORMATION STUB American Stock Transfer & Trust Co., LLC Wall Street Station PO Box 922 New Ynrk NY 1 r17R4_n~Rn --~. Prudential ~------ J __ 000032 - IMPORTANT TAX RETURN DOCUMENT ENCLOSED ELEANOR L BARTEK 1 OAK AVE DILLSBURG PA 17019-8511 IrrrllLr~lllrr~rrrllirlrrlrrlrrlrlrlrrll~rrlllltrrrtrlltll~rl Computershare Computershare Trust Company, N.A. PO Box 43033 Providence, Rhode Island 02940-3033 Within the US, Canada & Puerto Rico 800 305 9404 Outside the US, Canada I7 Puerto Rico 732 512 3782 www.computershare.com! nvestor Holder Account Number 60I~029633436~I INDy~II ~II~II~9~INPY~~YIBRY~ Rrudential Financial, Inc. -Sale Advice / 2008 Tax Fo 1099-B corrected (~ checked) ~ _ t' ~. - `~, Copy B - for`PteCipierit Accounttlumber o02sEi3343s ~ x„ „~ Form 1D99-B - Pro~e2ds, trom,BrolcerYand Barter,Exc~iange Transactions; ~..: 52008 Reapient's kD no 1a7z4i3s7 °° ~ ~ ° ~ ~~ Rayers Federal ID No. 43=1~J~274© Thin f4 fmportard tax and Ia frridsfied to the rnterrial Revenue Seryk6 K ou are Iredt+4 file a rata ~ ~ " -~ - - Y ~ ~e he9l~9~e OMB No _ =.1545 07i5 ~ntalty or other sanctlort~ itnpx~~tati~$ this lntott~e f6°}xxa6le ltd '- SRS tSe6eiitiltles Hiattt fW6hot bead rHported. n r ,~ - t x .. ...v > i~ 1 i 5 ,,,.~y °f ~ ., ~{~~6r><dIM Tr ~5„ry'Mn^yl }?ev2'uM'~e~~ ElirANQR L,$At2~E ~ ~ : . >< '-~..~: + ~ F< f c r ~.~,'r pinrtt „ ,1"C3Ak ~ktiLE ~~>` '~ `-~ ~ ~` v.i~~, . ; , a~.t~ . a `, ~r~ n~ ~~ ~'~ ,,~„ , ~~~` piLGSBIfR~P ~M v~rr ~''+«Ye ~" ~,`r~•vx. ,v+,` ~, ,.k ,~° {` ~~ ~~1."j.,y ~,:4 t ~ r ri ~ ~ ~~- k~ r ,,~ _z }r } ,r aY~ .F>~ i -t L>~ ~5 9,y ".~;~ r y t x a. `'tet,r~ e: .~~.= i x: a ~ yr~~s' Ss > r, i~ • t ~~ G 3 ~:. 4 ~ ~~ ~ tr ~ ~ t,, .,t 'FL ~, ~y~yll~` ''nth ~ +~ ,I~..., ~~. z{ y ice!' i, ,'r~~ 6 ,`1"', ~ 11jjIIIIII } I R -rs ~~, s :~~. ~'a7~xs ~~ateaf Sate ~ ~ ~~"" ^ ~ ,=~ ~` - ~, ~'+~ . Xl;.r. _ ~ ~, - ~1(es~ _> - ~ HQ~DER SERVI ~E{~, ~i RAL' INCOME± ~~~ ~~ 1.~y - ° ~ ~, _;~ ',~{ t ' '{ ~ ~ $bX{~~U'~ '~;if`f~~iITHHEL.U ~r3 , ~ _ Ctlon~ ,~,,I,~ PR~tlfl~E~GEt. .,:.~, ~'' f r "~ ~ '~~ ~. 17284 t~ y~ ~~'~ Puiarshace~g~_ce~s dasf~roc~eda~t ~ n 1'se p~A~freds ~t ~ ~+'C kt ~~~ T2LteNEh fep[~r~t3 Al~h -.~ '~ " "' c ~ t ~-',ti ,.'" 1 , t ~ r>t ~'. -~„ ~ r.yr~ s -- - JJ. _ s Form 1099-B (Keep for your records) Summary Class Description: COMMON STOCK Trade ShareslUnits Price Per Gross Amount Deduction Deduction Net Amount DatelTime Transaction Description Sold I SharelUnit (~) I of Sales ($) I Amount (a) I Type I of Sale (~) 05/201200814:05 Sale 42.000000 75.829467 3,184.84 14.36 Transaction Fee 3,170.48 Computershare Trust Company, N.A., as agent, upon written request, will provide the name of the executing broker dealer associated with the transadion(s), and within a reasonable amount of time will disdose the source and amount of compensation received from third parties in connection with the transaction(s), if any. 71UTX PRU "'~" OO1CD70008 OOHX2E UNITS __. Rev1508 FJ(+ (6.98) SCHEDULE E ' CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Bartek, Eleanor L. 21-08-00281 Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointty-owned with the right of survNorahip must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Holy Spirit Hospital -refund 31.00 2 PNC Bank -checking account #5004415679 2,282.21 3 PNC Bank -checking account #5004618513 10,555.47 4 Refund from NEA Members Insurance Trust 36.20 5 State of Washington Department of Retirement Systems -death benefit 400.00 6 United States Treasury - 2007 Tax Refund 448.69 7 MetLife IRA Distribution 174,279.61 8 MetLife IRA Distribution 91,133.08 TOTAL (Also enter on Line 5, Recapitulation) I 279,166.26 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) 1~ar, 2B, 2008 3:46PM ~PNC BANK 412-705-2747 No. 1162 P, 1/2 s B PI~ICBANC The Thinidng Bchind The Monty March 28, 2008 Schrack ~ Linsenbach Law O$"ices Brian Linsenbach 124 W Hannisburg St PO Box 310 Dillsburg PA 17019 RE: Eleanor L Bartek (Deceased) ', SSN: 187-24-1397 DOD: 03-03-2008 ~ '~ Dear Mr. Linsenbacla: ~II In response to your request for Date of Death balances for the customer noted above, our i records show the following: Checking Account I, i Account# SD04415679 Established 08-15-2005 ELEANOR BARTEK DOD balance: $2,282.21 non interest bearing Account # 5004618513 Established 01-03-2005 ELEANOR BARTEK DOD balance: $10,555.05 + 0.42 accrued interest ~% O O O D O r ^^ w -~] .o r ru W W O 0 r 0 W 0 o ~ .- 0. ~~: ~ ' O O v-~m - O H r. w rom - N raa - w -~ cn7CZ = o w 00 0 = o0 cam . o ~ G W 00 c~mr . ~1 -_ ~ ~ W ~ ~ a D - N O ~ W _ ~ m - o $I Y' ~I 7C - o cn o Na - oc O cn ~ ~0 ~ _ O ~ ~ ~ = ~O Z ~ o` o -t = _ H m o w x ,~ _on N o N W ~ a N w-~ ON a Z C] fi N W n- O b9 ~ :00 (~ ~t D, W ~ x ~ z x o 0 !T7 N OC -n W C W S O~ Z O ~O v 0067 * ° MetLife t ANNUITY BENEFIT SERVICES P.O. BOX 990023 HARTFORD, CT 06199-0023 00067 ESTATE OF ELEANOR BARTEK NANCY POOLE, ADMINISTRATOR 1 OAK AVENUE DILLSBURG PA 17019 Disbursement Processing DATE :04/18/2008. CHECK NUMBER:890A 090012751 CHECK AMOUNT:******$174,279.61 CHECK REF# :Z52-9997833 FOR PAYMENT INFORMATION PHONE: 1-800-842-5642 ^ Detach Check Z52 FOR PAYM~AFT,~IVF(3R2+~A'i'IQ7I`F" P)-HONE 1;800 842~5G4~; _ >s Detach Check +` ~ ~ ~'~-. ~2~W31 i ~; r $9E1A ' (~99n~1 ' 0069 • ~ MetLife ~ ANNUITY BENEFIT SERVICES P.O. BOX 990023 HARTFORD, CT 06199-0023 00069 ESTATE OF ELEANOR BARTEK NANCY POOLE, ADMINISTRATOR 1 OAK AVENUE DILLSBURG PA 17019 Disbursement Processing DATE :04/18/2008 CHECK NUMBER:890A" 090012753 CHECK AMOUNT:*******$91,133.08 CHECK REF# :Z52-0535393 FOR PAYMENT INFORMATION PHONE: 1-800-842-5642 ^ 4 ~ ~ Rev-1509 F,(+ (8-98) r COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF (FILE NUMBER Bartek, Eleanor L. 21-08-00281 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Nancy Poole B. C. 1 Oak Avenue Niece Dillsburg, PA 17019 JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1 A 3/3/2003 PNC Bank -Savings Account 9,240.82 50.000% 4,fi20.41 #5004021338 TOTAL (Also enter on Line 6, Recapitulation) I 4,620.41 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) QbMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF REVENUE INFORMATION NOTICE FILE ND. 21 0$-0281 BUREAU OF INDIVIDUAL TAXES AN D DEPT.28B601 TAXPAYER RESPONSE ACN 08121411 `4RRISBURG, PA 17128-0601 DATE 05-13-2008 REV-1543 IX AFP (09-09) TYPE OF ACCOUNT EST. OF ELEANOR BARTEK ® SAVINGS $,$, NO. 187-24-1397 ~ CHECKING DATE OF DEATH o3-02-2008 ~ ^ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: NANCY POOLE REGISTER OF WILLS 1 OAK AVE CUMBERLAND CO COURT HOUSE DILLSBURG PA 17019 CARLISLE, PA 17013 PNC 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 decadent, you were a ioint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction frow the financial institution, attach a copy to this forty and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Cowwonwealth of Pennsylvania. Guestiony way ba answered by callins C717) 787-B327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 5004021338 Date D3-03-2003 To insure proper credit to your account, two Established <2) copies of this notice must accowpany your payment to the Register of Wills. Make check Account Balance 9,240.82 payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax 4, 620.41 (3) months of the decedent's date of death, Tax Rate X , 15 You may deduct a 5X discount of the tax due. Any inheritance tax due will become delinquent Potential TaX Due 693. D6 nine C9) months after the date of death. PART TAXPAYER RESPONSE '' ~ f. ~ _. _. ..G...g~. i.ccc -c 5 ~ s:- • _ a s - .::-n sr .~ _~~~ ... a„ • : e r •~pv r r .. 222222 ''S 2' F eSvi' ' ~ ': '~ ' ~ ~ 'j' ~ ~ ~ ~ c :2 z 2 . 2 ~.. ~.. itu: 3 A. ~ Tha above information and tax due is correct. i t bt a n o o 1. You ^ay choose to remit payment to the Resister of Wills with two copies of this notice a discount or avoid interest, or you ^ay check box "A" and return this notice to the Register of CHECK Wills and an official assessment will be issued by the PA Department of Revenue. ONE C 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 paid by vou. You ^ust complete PART 2^ and/or PART a below. PART If you indicate a different tax rate, please state your relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Da[a 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 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 b st of my knowledge and belief. HOME C ) T' /~G,G~C7i ~~ WORK C ) ,s' Z J j' -t-~ ..~,wrnor TFI FPHCINF NIIMBER DATE ~ r ~ REV•1151 Ex+ (12.99) ;. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF I FILE NUMBER Bartek, Eleanor L. 21-08-00281 Debts of decedent must be reported on Schedule 1. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Nancy Poole Social Security Number(s) / EIN Number of Personal Representative(s): Street Address 1 Oak Avenue City Dillsburg State PA Zip 17019 Year(s) Commission paid 2008 2, Attorney's Fees Schrack & Linsenbach PC 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 9,123.17 12,000.00 12,000.00 4. Probate Fees 420.00 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. Other Administrative Costs 23,390.71 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 56,933.88 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) ! . w SCHEDULE H-A FUNERAL EXPENSES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Bartek, Eleanor L. 21-08-00281 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-g8) t ~ Rev-1502 EIC+ (9.98) ~, SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Bartek, Eleanor L. 21-08-00281 ITEM NUMBER DESCRIPTION AMOUNT 1 Clerk of Orphans' Court -Release fee 5.00 2 Computershare Trust Company, N.A. -transaction fee/sale of Prudential Financial 14.36 stock 3 Cumberland Law Journal -estate advertisement 75.00 4 Miscellaneous expense during period of administration 35.00 5 Register of Wills -filing fee 15.00 6 Reserve for future administrative expense 3,000.00 7 Reserve for income tax which will be due on MetLife IRA distributions 20,000.00 8 The Evening News (Metro West section) -estate advertisement 148.17 9 United States Postal Service and Federal Express charges for mailing packages to: 98.18 Bette Marino, Paul Radich, Dorine Halverson Subtotal 23,390.71 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B7 (Rev. 6-98) t J • Rev-1512 FJ(+ (8.98) SCHEDULE 1 " DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Bartek, Eleanor L. 21-08-00281 Include unrelmbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Bethany Village Skilled Nursing Facility -account #2303 6,249.72 2 Bethany Village Skilled Nursing Facility -account #2303 6,274.47 3 Bethany Village Skilled Nursing Facility -account #2303 45.00 4 Bethany Village Skilled Nursing Facility -account #2303 105.00 5 Bonnie K. Miller, Treasurer (personal taxes) 9.80 6 Camp Hill Emergency Physicians (last illness) 199.75 7 East Pennsboro Ambulance (last illness) 55.00 8 Hampden Township Ambulance (last illness) 50.00 9 Hampden Township Ambulance (last illness) 25.00 10 Holy Spirit Hospital (last illness) 381.00 11 Mobile X-Ray Imaging, Inc. (last illness) 86.17 12 Quantum Imaging 8r. Therapeutic Associates (last illness) 36.00 13 West Shore EMS -BLS (last illness) 174.50 14 West Shore EMS -BLS (last illness) 64.70 TOTAL (Also enter on Line 10, Recapitulation) I 13,756.11 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV•1513 EX+ (9-00) >F SCHEDULE J COM NOHERITANCETAXRETURNANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Bartek, Eleanor L. 21-08-00 281 NUMBER NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE PERSON(S) RECEIVING PROPERTY Do Not List Trustee s (Words) ($$$) I. TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under Sec. ~116(a)(1.2)] 1 Carrie Ank Grand Niece 5,000.00 1353 Kensington Street Astoria, OR 97103 2 Brian Buchanan Grand Nephew 5,000.00 clo Tom Buchanan 1007 Henry Street Belle Vernon, PA 15012 3 Tom Buchanan Nephew 18,883.85 1007 Henry Street Belle Vernon, PA 15012 4 Michele Chovan Grand Niece 5,000.00 922 Graham Street Belle Vernon, PA 15012 5 Dorine Halverson 10722 3rd NW Seattle, WA 98177 See continuation schedule attached Continuation 185,083.70 Total 218,967.55 Enter dollar amounts for distributions shown above on lines 5 through 18, as appropr iate, on Rev 1500 cove r sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule) (Rev. 6-98) ~1 SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Eleanor L. Bartek 03/03/2008 187-24-1397 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 6 Judy Johnson Niece 23,883.85 118 Lang Street Belle Vernon, PA 15012 7 Lia Kieckhafer Grand Niece 5,000.00 30724 Paseo Elegancia San Juan Capistrano, CA 92675 8 Betty Marino Niece 23,883.85 P. O. Box 1762 Magalia, CA 95954 9 Jodi Phillips Grand Niece 5,000.00 162 Johnson Avenue P.O. Box 185 Pricedale, PA 15072 10 James Poole Jr. Grand Nephew 5,000.00 6 Stillwater Circle Dillsburg, PA 17019 11 Nancy Poole Niece 36,780.60 1 Oak Avenue Dillsburg, PA 17019 12 John Radich Nephew 13,883.85 1205 Randol Mill Roanoke, TX 76262 13 Bob Roskovich Grand Nephew 5,000.00 928 Graham Street Belle Vernon, PA 15012 1 ! ~ a SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Eleanor L. Bartek 03/03/2008 187-24-1397 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 14 Dolores Roskovich Niece 18.883.85 118 Lang Street Belle Vernon, PA 15012 15 Allan Tylka Nephew 18,883.85 13712 Creekside Drive Silver Spring, MD 20904-5418 16 Terry Tylka Nephew 18,883.85 79 Sunnyhill Drive Pittsburgh, PA 15228 17 Donna Watson Grand Niece 5,000.00 P. O. Box 2055 Palatine, IL 60078 18 Denise Johnson Wilhelm Grand Niece 5,000.00 603 King Street Perryopolis, PA 15473 Total 185.083.70 2