HomeMy WebLinkAbout01-0150
,"~.'500 ~;"..&) - \4~ -lo QFFOAL. USE ONLY
COMMONWEALTH OF REV -1500
PENNSYLVANIA
OEPARlMENT OF REVENUE INHERITANCE TAX RETURN FILE NUMBER J5~
DEPT. 280601 dCXJ I
HARRISBURG. PA 17128-0601 RESIDENT DECEDENT 21_ - ~
- -------
COUNTY cooe YEAR NUMSER
. .-
DECEDENl'S NAME (LAST. FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
1- Latsha, George S 194-28-8616
Z
w DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM~DD.YEAR) THIS RET1JRNMUST BE FILED IN DUPLICATE WITH THE
C
W 04/02/2003 08/19/1904 REGISTER OF WILLS
bl (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
C
l!! ~1. Original Retum D 2. Supplemental Return D 3. Remainder Return (date of death prior to 12-13--82)
x::~U) D4. D 48. Future Interest CompromIse (date of death lifter 12-12-82) fX] 5. Feeleral Estate Tax Return Required
U"''' limited Estate
wo.U
:rOO D6. Decedent Died Testate (Attach copy of Will) !XJ 7. Decedent Maintained a Living Trust (Attach copy of Trust) _ 8. Total Number of Safe Deposit Boxes
U"'"'
o.lIl D9. D 10. Spousal Poverty Credit (dlle ofd..lh~elwnn 12_31.&1 IncI 1-1.B5) D 11. Election to tax under Sec. 9113(A)(AltilChSCIlO)
0. Litigation Proceeds Received
""
- THIS SECTION MUST BE COMPLETED. ALL CORRESPO~DEiilcE AND CO~FIDE~TIALTAX I~FollI.lATION SHouLD BE DIRECTED'TO: .
~ NAME COMPLETE MAILING ADDRESS
z
w
0 Howell C. Mette
z
0 FIRM NAME (If Applicable) 3401 North Front Street
..
'" P.O. Box 5950
w Mette, Evans & Woodside
'"
'" Harrisburg, PA 17110-0950
0 TELEPHONE NUMBER
U
717-232-5000
-
.. i
1. Real Estate (Schedule A) (1) 0.00 OFFlClAL USE ONLY
2. Stocks and Bonds (Schedule B) (2) 0.00 I
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 0.00 I
I
4. Mortgages & Notes Receivable (Schedule D) (4) 0.00 i
5. Cash, Bank Deposits & Miscellaneous Personal Property 2,178.72 I
(Schedule E) (5)
Z 6. JO Owned Property (Schedule F) (6) 1,475.52 ,
0 I
i= Separate Billing Requested I
:5 7. InterNivos Transfers & Miscellaneous Non~Probate Property (7) 2,060,413.05 ~
::J (Schedule G 0( L)
l-
ii: 6. Total Gross Assets (total Lines 1-7) (8) 2,064,067. ?~_
~ 45,000.34
'.u 9. Funeral Expenses & Administrative Costs (SChedule H) (9)
0::
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 44,004.88
11 Total Deductions (tota) Lines 9 & 10) (11) 89 , 005.2"__
,12 t-.lat Value of Estate (Line 8 minus Line 11) (12) 1 ,975,062.0')
1\
113
1,4
I
Charitable and Governmental Bequests/See 9113 Trusts for which an election to lax has not been
made (Schedule J)
(13)
0.00
Net Value SubJect to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
1,975,062.07
15. Anlount of Line 14 taxable at the spousal tax
rate_ or transfers under Sec. 9116 (a)(1.2)
0.00
1,973,062.07
0.00
2,00D.00
x.OO_(15)
0.00
z
o
i=
"
I-
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~ 117. Al'I1ountofLine14taxableatslblingrate
~ i 1 '3. ,l,i'l"v~'nt of Lint; 14 taxable at collateral rate
~ 110 TaY.. DL'lJ
,-
: IVl
._.~~~
x .15 (16)
88,787.79
0.00
300.00
16. Amount of Line 14 taxable at lineal rate
x.04L-(16)
x 12 (17)
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
(Hi)
89,087,79
> > BE SUR~TO A~S1IV~R ALL QUESTIONS O~ REVERSE SiDE AND RECHECK. MATH < <
2W'le45U1G0
, ,
Decedent's Complete Address:
STREET ADDRE::SS
1141 Columbus Avenue
I f7043
~
I
CllY
Lemovne
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credn
B. Prior Payments
C. Discount
=I~~TE
(1)
89,087.79
0.00
89,528.00
4,454.39
Total Credits (A + B + C) (2)
93.982.39
3. Interest/Penalty if applicabie
D. Interest
E. Penaity
0.00
0.00
Total Interest/Penalty (0 + E) (3)
0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
4,894.60
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)
8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Pa able to: REGISTEROFWlLLS,AGENT
11II,' ~
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 usa or income of the property transferred;. . . . . . . . . . . . . . . [X] D
b. retain the right to designate who shall use the property transferred or its income; . [Xl D
c. retain a reversionary interest or .. . . . . . . . . . . . . . . . . . . . . . . D [X]
d. receive the promise for 111e of either payments, benefits or care? . . . . . . . . . 0 IXJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . , . . . . . . . . . . . . . . . . ., 00 D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? D 00
4. Did decedent own an Individual R.etirement Account, annuity, or other non-probate property which
contains a beneficiary designation? . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . .. D [z]
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
U(lder penalties of perjury. I declare that ( have examined this retum, induding accompanying Ichedules and ltatements, and 10 the best of my knowledge and bellef. II is true. correct
and complete.
Dee\aration of pfeplfer other Ihan the paBona'! representative il based on an information 01 which preparer has any knowledge,
SIGNAlURE OF PERSO RESPONSIBLE FOR FlUNG RElU
t./ yn. \ t
Wormleysburg, PA 17043
SIGNATURE ~ARER OniE! ]^N REPREs~nVE ~ f _
~ r 1 \d . P
ADDRESS
_~ b~ S-q s c, ~~~ t, IJA
DATE
17_(00/ CD)
1 / /I~~
For dat6s of death on Dr after July 1, 1994 and before January 1, 1995, the tax rate impOSed on the net value of transfers to erfor the use of the surviving spouse Is 3%
{72 P.S. ~ 9916 (8) (1.1) {i)l
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to orforthe use of the surviving spouse is 0% [12 P .S. S 9116 (8) (1.1) (li)l
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 retum 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 afthechild is Q%[72 P.S. ~9116{a)(1.2)1,
rhe tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries Is 4.5%, except as noted In 72 P,S. 13 9116(1.2) [72 P.S. ~ 9116(a)(1 n.
rhe tax rate Imposed on the net value of transfers to or for the use of the decedent's siblings Is 12% (72 PS. ~ 3116(a)(1.3)). A sibling Is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, wnettler by blood 01' adoption.
2W46461,00e
REV-1508 rX+ (1-97)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESlOem DEceDEm
SCHEDULE E
CASH. BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Latsha, George S
FILE NUMBER
21-2003-
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right of survivorship must be dl.closed on Schedule F.
VALUE AT OATE
OF DEATH
2,178.72
ITEM
NUMBER
1. Accrued and
U/W Blanche
DESCRIPTION
accumulated income, trust
H. Latsha
2W4f'lAD2.000
TOTAL (Also enter on line 5 Recapitulation' $
(If more space is needed, ir\sert additional sheets of the same size)
2.178. 72
RE'V.1509EX+(1.97)
COMMOMIVEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
IDENT DENT
ESTATE OF
Latsha, George S
SCHEDULE F
JOINTL V-OWNED PROPERTY
FILE NUMBER
21-2003-
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
A. Latsha, David T.
ADDRESS
RELATIONSHIP TO DECEDENT
Son
85 Greenwood Circle
Wormleysburg, PA 17043
B.
c.
JOINTL V-OWNED PROPERTY:
ITEM Lrne< DATE DESCRIPTION OF PROPERTY %QF DATE OF DEATI-i
FOR JOINT" MADE Include nllme of financial institution and bank lICCOunt number or DATE OF DEATH DECO'S VAlUE OF
NUMBER T""'" JOINT slmilllr identl"'in" number. Attach deed fof ioinUv-held reIIl eatlte. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A Checking Account 11641468 29,764.53 50.00 14,882.26
PNC Bank, NA
2 A Money Market Account 6,457.71 50.00 3,228.86
11820079
PNC Bank, NA, including
accrued intereset of $.92
3 A Less outstanding checks (33,271.20) 50.00 (16,635.60)
against these accounts of
$33,271.20, which includes
the three $11,000 gifts
dated 03/22/2003 reported
as Items 3, 6 and 11 on
Schedule G
TOTAL (Also enter on line 6 Recanitulation) $ 1,475.52
(If more space Is needed. insert additional sheets of same s12e)
2W46AE2,OOO
REV-151O EX + (1-97)
SCHEDULE G
INTER.VlVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWE;ALTH OF PENNSYLVANIA
INHERITANCE TAX RETIJRN
RESIDENT DECEDENT
ESTATE OF
Latsha, Georqe S
FILE NUMBER
21-2003-
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.
DESCRIPTION OF PROPERTY
ITEM lNClUDE1HE w.ME OF lHETRANSFEREE, THEIR RELATIONSHIP TO
NUMBER DECEDENT AND THE ~~Ot.J.Rt'~~AWACH A COPY OF THE
1, Revocable Trust established
May 22, 2002, David T. Latsha,
Trustee.
Assets listed on attachments
G-l and G-2.
2
Ti.na T. Latsha,
Granddauqhter-in-law
Cash 12/19/2002
3
Felicia Latsha, Great
Granddaughter
Cash 03/22/2003
4 David T. Latsha, Son
Cash 01/21/2003
5 David T. Latsha, II, Grandson
Cash 12/19/2002
6 Cory Latsha, Great Grandson
Cash 03/22/2003
7 Wendy Latsha, Granddaughter
Cash 12/19/2002
8 Christopher Latsha, Grandson
Cash, 12/19/2002
9 Dan Forvee, Grandson
Cash 12/19/2002
10 Sherry Forvee, Granddaughtex:
Cash 12/19/2002
11 Brad Latsha, Great Grandson
Cash 03/22/2003
DATE OF DEATH
VALUE OF ASSET
1,726,413.05
%OF
DECO'S
INTEREST
100.00
5,000.00 100.00
11,000.00 100.00
300,000.00 100.00
5,000.00 100.00
11,000.00 100.00
5,000.00 100.00
10,000.00 100.00
2,500.00 100.00
2,500.00 100.00
11,000.00 100.00
EXCLUSION
t1F APPUCABLE'
0.00
3,000.00
3,000.00
3,000.00
3,000.00
3,000.00
3,000.00
I.
3,000.00
2,500.00
2,500.00
3,000.00
TOTAL (Also anter on line 7, Recapitulation) $
2W46AF2.000
(If more space Is needed, insert additional sheets of same size.)
TAXABLE VALUE
1,726,413.05
2,000.00
8,000.00
297,000.00
2,000.00
8,000.00
2,000.00
7,000.00
0.00
0.00
8,000.00
2,060,413~05
[,3:'.:'1." Ii?,} lla'~io!1
Date of Death:
Valuation Date:
Processing Date:
0'/0212003
0'/0212003
11/0'/2003
Attachment G-1
Date of Death Value
Shares
or Par
Security
Description
High/Ask
11
36908.993 FRANKLIN TAX FREE TR (354723702J
HI YLD T/F A
NASDAQ
04/02/2003
2)
53422.614 FRANKLIN TAX FREE TR (354723801)
PA T/F INCM A
NASDAQ
0'/02/2003
3)
4859.086 SCUDDER INVT MORGAN GRENFELL (81116P675j
STRM MUN BDINV
NJ\S DAQ
0'/02/2003
'I
29718 VAN K~~PEN PA TAX FREE INCM FD (920902103)
CONE
NASDAQ
0'/02/2003
51
11259 VF.N KP.MPEN TR INVT GRADE P.ll. (920934106)
COM
NYSE
04/02/2003 17.21000
Total Value:
Total .l\.ccrual:
Total: $1,692,969.27
6)
33,443.780 Blackrock
Money Market Institutional
Class
Total Value to Schedule G
Low/Bid
10.24000 Bid
10.44000 Bid
10.37000 Bid
17.28000 Bid
17.24000 H/L
Estate of: Latsha, George S., Estate of
Account: File #11825-0001
Report Type: Date of Death
Number of Securities: 5
File 10: Latsha.George.estate
Mean and/or Oiv and lnt Security
Adjustments Accruals Value
10.240000
377,948.09
10.440000
557,732.09
10.370000
50,388. n
17.280000
513,527.04
17.175000
193,373.33
$1,692,969.27
$0.00
1.00
33,443.78
$1,726,413.05
'J,
~EV.'511 EX'~ (1.97)
COMMONVVEAllH OF PENNSYLVANIA
INHERITANCE TAX RElURN
REStDENTOECfOENT
ESTATE OF
Latsha, George S
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
21-2003-
o bta fd d
. 0 ece ent must be rer:aorted on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAl EXPENSES:
1. Myers Funeral Home 3,438.00
2 Rcyers Flowers 292.49
3 Pastor and music 400.00
4 Rolling Green Cemetery 672 . 50
5 Reception 518.63
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions 0.00
Name of Personal Representative(s)
Social Security Number(s) I E!N Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees Name: Mette, Evans & Woodside 20,000.00
3. Family Exemption: (11 decedent's address is not the same as claimant's, attach explanation) 2,178.72
Claimant Latsha, David T.
Street Address 85 Greenwood Circle
City Wormleysburg Stale PA Zip 17043
Relationship of Claimant to Decedent Son
4. Probate Fees 0.00
5. Accountant's Fees Name: Boles, Grove & Metzger 17,500.00
5. Tax Return Preparer's Fees 0.00
7.
TOTAL (Also enter on line 9, Recapitulation) $ 45,000.34
2W46AG 2.000 (If more space is needed, insert additional sheets of same size)
REII-1512 EX'" (1-97)
COMMONVYEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESlOE>IT DECEDENT
ESTATE OF
Latsha, George S
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
FilE NUMBER
21-2003-
Include unreimburaed medical exoenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
30,966.95
1, Internal Revenue Service - gift tax 2001
2 Internal Revenue Service - interest on Item 1
2,818.83
3 Internal Revenue Service - penalties on Item 1
10,219.10
2W46AH2,OOO
TOTAL {Also enter on line 10, Recanitulation\ $
(If more space is needed, insert additional sheets of the same size)
44 ,004.88
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REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMOM'VEAL 1H OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
" ?1_?nn~_
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(a) OF ESTATE
I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers
under Sec. 9116 (a) (1.2)]
1. Latsha, Brad Great Grandson 8,000,00
2 Latsha, Wendy Granddaughter 2,000,00
3 Trust "A" U/A OS/22/2002 Revocable Trust 1,639.586,55
4 Latsha, Cory Great Grandson 8,000,00
5 Latsha, Felicia Great Granddaughter 8,000.00
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 16. AS APPROPRIATE, ON REV-150Q 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
,.
TOTAL OF PART n - ENTER TOTAL NON-TAXA.BLE DISTRIBUTIONS ON LINE 13 OF REV.1500 COVER SHEET $ 0.00
2W46AI1,OOO
(If more space IS needed, Insert additional sheets of the same size)
.,.:.~. "J',,~
EstatQ of: Latsha, GeorgQ S
Page 2
21-2003-
Schedule J PiS.r.t 1 -- Bene;ficiaries
Item
No.
Name and Address of Person(s) reoeiving property
Relationship
Amount or
Share of Estate
6
Latsha, Tina
Granddaughter-in-law
2,000.00
7
Latsha, II, David T.
Grandson
2,000.00
8
Latsha, Christopher
Grandson
7,000.00
9
Latsha, David T.
85 Greenwood Circle
Wormleysburg, PA 17043
Son
298,475.52
, I' . , ) I
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Agrtttntni af wrns!
TIllS AGREEMENT OF TRUST, made and entered into this ~ day
of '11'1~ ' 2000,. hy and between GEORGE S. LATSHA.- as Grantor,
hereinafter referred to as "Grantor", and DAVID T. LA.TSHA,
'Gl:'
'.,.t,.
assets mo.sfu. By descnoed in
"~~~"
~;.:~
~
and
f being relieved of business cares and
worries and of the manage
Grantor's property and, for those reasons, among
others, i~ desirous of placing the active management and control of such property in the
hands of Trustee.
NOW, THEREFORE, in consideration of the mutual covenants and
agreements herein contained, it is agreed by and between the parties hereto as follows:
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ARTICLE I: Grantor doe~ hereby transfer and convey to Trustee the assets
listed on Schedule "A," attached hereto and made a part hereof, which said assets are
hereinafter referred to as the '"Trust", receipt of which assets hereby is acknowledged by
Trustee, and Trustee, in consideration thereof, agrees to hold and arlmini!;ter said assets
and any additions thereto, as Trustee, IN TRUST NEVERTHELESS, for the following uses
and purposes:
such portion or al
(a)
same; collett the income
but not less
lifetime.
(b)
ee shall pay to Grantor
e TIust as such income beneficiary
(c) Trustee may also expend so much of the principal of the
Trust as, in its discretion, may be necessary and/or advisable to
supplement all income of Grantor in order to provide support and
maintenance, including medical, hospital, nursing and nursing home care
for such beneficiary.
'/---'
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Cd) Upon the death of Grantor, Trustee shall pay over to the
Executor of Grantor's estate so much of the principal as shall be required to
pay all specific bequests provided in Grantor's Will an~ inheritance and
estate taxes, funeral and administration costs which may be incurred with
respect to Grantor's estate; Thereafter, Trustee shall, if Grantor
predeceases Grantor's son. DAVlD T. LA TSHA, divide
remaining assets,
proceeds from' or on account of insurance poliCies
death of Grantor, and any other as
. r referred to as
the "principal") into two
in trust and
constitute
'~I)~\
'Trust A" arlf&.'Trust B";
"'fit.1~
~
t A" that fraction of the
e a sum equal to the amount of the
generation-skipping
r exemption as provided in Section 2631 of the
Internal Revenue Code of 1986, or any comparable legislation in effect at
the time of Grantor's death and then available after consideration of
generation-skipping transfers made by Grantor during his lifetime and the
allocation of the generation-skipping transfer exemption made by Grantor's
Executors to such generation-skipping transfers and of whim the denom-
inator shall be the value of Grantor's residuary estate. For purposes of
- 3 -
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establishing such fraction, the values finally fixed in the Federal estate tax
proceeding relating to Grantor's estate shall be used.
"Trost B": The balance of the principal not placed in "Trost A"
shall be placed in "Trost B". If Grantor's son predeceases the Grantor, all of
the principal shall be placed in "Trust .8".
ARTICLE II:
lyto "Trost A";
(a) ,
. -...\
~";;:~"
'.::t~-~
in convent\but not
YID T.LATSHA(the
"Beneficiary"},
om the date of Grantor's
e to time, pay to the Beneficiary
ohhis Trust as is necessary for the proper
support, maintenance and medical care of the Beneficiary.
(b) Upon the deafuof the Beneficiary, or if said the Beneficiary
predeceases Grantor, then upon Grantor's death, the Trustee snalr convey
and pay over aU of the remaining assets, to one or all, or less than all of the
Beneficiary's issue (and for the purpose hereof, an adopted chird shaIl be
'~-J.-: _...____._.~.;. __....~. ___ -,-- --- _.n ..~_...-...-"----' ,- -
_,Z~msidered to be the child of the adopting parent). in such amounts Of
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proportions,and in such lawful interest or estates, whether absolutely or in
trust, as the B.eneficiary may have directed, either by instrUment filed with
the Trustee during his lifetime exercising this Power of Appointment or by
his Last Will and Testament.
(c)
any reaso pt validly
'!)14~':
~~
ring his li(~le, or in
c. "
~
of the Beneficiary, the
. onnhereto and any
.
accumulations of 1
s to the Beneficiary's sons, DAVID
If either DAVID T. LATSHA, 11 or CHRlSTOPHER G. LATSHA
is not then living, his share shall be paid to his then living issue, per stirpes.
If there is no such then living issue, his share shall be pard to the survivor
of them, or the thenliving issue of the survivor of them, per stirpes, if
neither of them are then living.
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ARTICLE m:
The following provisions snaIl apply to "Trust B":
(a) The Trustee shall pay the net income in convenient but
not less than annual installments to Grantor's son, DAVID T. LATSHA (the
"Beneficiary"), during his lifetime, commencing from the date of Grantor's
Beneficiary
(b}
e shall pay to
death.
e
g.
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(c)
or, upon the death of the
Beneficiary, theT
Ii pay over alLot the remaining
m, or-corporation or corporations, Of to the
estate of the Beneficiary, in such amounts or proportions, and in such
lawful interest'.orestata, whether absolutely or in trust, as me Beneficiary
shall direct, either by instrument filed with the Trustee during the
Beneficiary's lifetime, exercising this Power of Appointment, or by the
Beneficia.ry's.1ast Will and Testament.
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(d) If the Beneficiary predeceases the GrantQr, or if the foregoing
Power of Appointment is for any reason not validly exercised by the
Beneficiary, in whole or in part during the Beneficiary's lifetime, or in the
Beneficiary's Last Will and Testament, then upon me death of Beneficiary
or upon the death of the Grantor If the Beneficiary predeceases the
Grantor, the remaining assets shall be distributed uno
ITEM II
ARTICLE IV:
party or If ,.,.C~ n, from time to
.-c:~"':.~
. sets, by wm~r otherwise;
""~
time, with the co :
d as often as any beneficiary hereunder~
to whom payments ofincom
rincipat are herein directed to be made, shall be
unable to act, or shall lack ability, or in the sole judgment of the Trustee, shall otherwise.
be unable to apply such payments to the beneficiary's own best interest and advantage,
the Trustee shall make any portion of such payments in anyone or mareof the following
ways:
(a) Directly to such. beneficiary;
(b) To the.Legal Gl1a~rli'lT\l)f such beneficiary;
,~-.!'..J
)
""..
- 7 -
(c) To a relative of such beneficiary, to be expended by such
relative for the benefit of such beneficiary; or
(d) By Trustee expending the same for the benefit of said
beneficiary.
ARTICLE VI:
No part of the income
a1 of the property held
under this Trust shall be subject to attachm
assignee Dr truStee-or receiver i
to his or her actual
receipt thereof.
"t~~~
e and the ~cipal to the
r~~
.~
, without regard to any attempted
p~ herein desi
der the Trust, and without
regard to any c1aimth
, attachment, seizure or other pro<::ess
against said beneficiary.
ARTICLEVll;.
The Trustee shall possess, ~mong others, the following
powe~;
(a) To vary or to retain investments, when deemed desirable by
the Trustee, and to. invest in such bonds, stocks, notes, real estate
mongagesorsecurlties or iii stichbthef property, real or personal as the
- 8 -
!
t
i
I
,~_I-
1\\'
"
)
"
/
Trustee shall deem wise, without being restricted to so-called ''legal
investments".
(b) In order to effect a division of the principal of a Trust or for
any other purpose, including any final distribution of a Trust, the Trustee is
voluntarily or-'
beneficiaries and Trusts created here
value of any share is not
,r
~
,~!'
~-m~
n any real '~. re, the
~
mmate partitions of lands,
distributi
utuaI deeds,
as wide powers as can be
(e) To sell either at public {)f private sale and upon such terms
and condilionsas the- Trustee may deem advantageous to the Trust; any or
all real sufficient deeds or other instruments to the purchaser or
purchasers, conveying a fee simple title, free and clear of aUtrusr and
without obligation or Halillfty oftIle purchaser or purchasers to see to the-
applicaticiliot'ilie-pw-clUise money, or romakeinquiry into the validity of
- 9 -
., .
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said sate of sales; also; to make, execute, admvwledge and deliver any and
all dee~ assignments. options or other writings which may be necessary
or desirable in carrying out any of the powers conferred upon the Trustee
in this paragraph or elsewhere in this instrument.
(d) To mortgage Teal estate, and to make Ie
extendfng beyond the term {)( the Trusts hereunde
(e) To borro
including \ Trustee, to
~.~
T~<:;
gn and pl~assets of a
-'i~
pay indebt
(f)
xpenses and charges in connection
a Trust, including a reasonable compensation to
agents.
(g) In the discretion of the Trustee, to unite with other owners of
similar property in carryi11g out any plans for the reorganization of any
corporation or company whose securities form a part of a Trust..
(h}
To vote any shares of stockwbich form. a parr of a Trust.
~-
- 10-
1-, _
(i) To assign to and hold in trust: an undivided portion of any
asset.
G) To place and carry any asset of the Trust in the name of a
nominee.
(k)
.'\~
To do all other acts in the judgment
;t,
~;
~
. . e deemed
necessary or desirable for the-prop
investment and illstribu
rantor during Grantor's lifetime
odifY, alter or revoke this
Agreement In whole or i
ARTICLE IX:
Any person woo shall have died at the same time as
Grantor, or under such circumst<ulces that the order of deaths cannot be established by
proof, or within thirty (30) days of Grantor's death, shall be deemed to have-prede<:eased
Grantor. Any person (Other than Grantor} who sbalI have died at the same time as any
then recipient of income or unde1' such circumstances that the order of deaths cannot be
established-by proof, shalt be deemed to have predeceased such beneficiary.
.11-
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COMMONWEALTH OF PENNSYl,VANIA :
55:
COUNT'lQr' ~
.
d
On thiS, the ~ day-of --11'.L~ ' 2000, before me, a Notary
Public, the undersigned of1ieer, personally appeared GEORGE S. LATSHA, known to me
(Of satisfactorily proven} to. be the person whose name is subscribet:l to.the within
instrument, and acknowledged that he executed the sam~foll~ purposes therein
Nrritiiin t'>d.. . . ;~
_ _ . ... - "-- . ~'~'i-'
IN WITNESS WHEREOF,
otarial seal.
NiitaiiaHleai
RoxArl<j@M.Rosarta, NoImy ~
SUsqu.h~na T~hin County
MY Commi$sJon ,res I'eb. 24, 2003
Member, PennsyiVaiiiii AsS6claUon 01 No~
'1--....].:
)
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COMMONWEALTH OF PENNSYLVANIA :
55:
COUNTY OF CtJMBERl..AND
On this, the ~nd day of '1YJO.Lf- ,2000, before me, a Notary
PtlbUt, the tifidemgned offieer, personally appeared GEORGE S. LATSHA, lmoWfl to me
(or satisfactorily proven) to be the person whose name is subscribed to the within
instrument, and acknowledged that he executed the same for the purposes therein
contained.
IN WITNESS WHEREOF, I have hereunto set my hand and notarial seal.
" ;. ~ -."
:\:..~ ....
;"ji;-.
~;.
.'
P ~{]I)clrl1- /vi I I~J~
Notary Public
~-
,:..)-J:
"'.
0;-"....
..~ "
Notarial Seai
RoxAndra M. Rosario, NolaI}' Publif:
Susquahanna T~.. Dauphin County
My Commisslof' E-xpires Feb. 24, 2003
MAmber, PennsylVanla Association at Notana!':
.'.".,.
209000_.
)
ARTICLE X:
Upon the death or resignation of the Trustee or upon
his inability or refusal to serve, the successor Trustee shall be such one or more
individuals or a corporation which he shall appoint by Instrument in writing during his
lifetime or by his Last Will and Testament. If no such designation is mad@., the O'IPl'''''.Of
Trustee shall be DAVID f. IATSHA, Ii and CHRlSTOPHER G. IATSHA. No Trustee
acting hereunder shall be required to give any bond or other security.
IN WITNESS WHEREOF, GEORGE S. LATSUA 2.nd DAVID T.
tATSHA have hereunto set their hands and seals on the day and year first above
written.
Gl\ANTOll;
/1fe.,,)P ~wo 0 J,..,.._
itness.
4~ f~Jz~EA1)
GEORGE S. LATSHA
TRUSTEE:
ATTEST:
rtL?r&--g;tdOO~_ ~
(SEAL)
.="....,.""~, ,.... "'_'._'/" ".,~ ...~.,_ ~~"..,,__.. n. ~__,~., '~_'__
.12-.
\---. "
, \'.
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.
ARTtr.t.R X~
Upon the. death or resignation of the Trustee or upon
hisinabiUtyor refusal to serve, the successor ~rusteeshan be such one or more
individuals or a. corporation which he shall appoint hy instrument in writing during his
li:fetimeor by hfs Last will and Testament. It no such designation is made, the SULLeSSUr
Trustee shall be DAVID T. lATSHA, II and CHRlSTOPHER G. LATSHA. N(T Trustee
acting hereunder shall be required to give any bond or other ~ty.
~
.." -. ~ -~---~?
IN WITNESS WHEREOF, . - """ nd DAVID T.
.iffk
r first above
'~~i-,~
~~;~
'~;
LATSHA havtthereunt(T set th
written.
" .
,... / 4., "'.12~
. e~SEAL)
GEORGE S. tAfSHA
ATTEST:
fJ1Q,yh,
TRUSTEE:
(SEAL}
'.........--.....-
- 12-
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
METTE HOWELL C
POBOX 5950
3401 N FRONT ST
HARRISBURG, PA 17110-0950
-------- fold
ESTATE INFORMATION: SSN: 1 94-28-861 6
FILE NUMBER: 2101-0150
DECEDENT NAME: LATSHA GEORGE S
DATE OF PAYMENT: 03/05/2004
POSTMARK DATE: 03/02/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 04/02/2003
NO. CD 003642
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
04103172 I $66.17
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
'REMARKS: DAVID T LATSHA
CHECK# 2401
SEAL
INITIALS: AC
RECEIVED BY:
REGISTER OF WILLS
$66.17
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX( 11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
METTE HOWELL C
POBOX 5950
3401 N FRONT ST
HARRISBURG, PA 17110-0950
_n_nn fold
ESTATE INFORMATION: SSN: 194-28-8616
FILE NUMBER: 2101-0150
DECEDENT NAME: LATSHA GEORGE S
DATE OF PAYMENT: 06/26/2003
POSTMARK DATE: 06/25/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 04/02/2003
NO. CD 002744
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $89,528.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
CHECK# 1144895
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
$89,528.00
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
- ,-" -. .-.:- /-',"-r:nr' ('.'
BUREAU OF I~P.:(V.~A~. T~Xf;~\,)t i.,.-
INHERITANCE TAX lit.VlSION- (\
PO BOX 280601 ; . '.
HARRISBURG PA 17128-060i
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF DETERMINATION AND
ASSESSMENT OF PENNSYLVANIA
ESTATE TAX BASED ON FEDERAL
ESTATE TAX RETURN
REV-485 EX AFP ClZ- 04)
2 G Q:~ ..J ,:~~ ~"'.~ t Lt
",
C'i I
'.'.. "')9
~'I. .)
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
01-17-2005
lATSHA
04-02-2003
21 01-0150
CUMBERLAND
201
GEORGE
S
HO~LL-C'MEtTE
METTE ETAl
PO BOX 5950
HBG
Amount Remitted
PA 17110
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
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 FILES ~
RE-V:483--EX-JrFP--{oi~-oj)-----.-i-NO-ficE--OF--DETE-RMINJrflo-N-ANj)-AS-SESS-HENT-----------------------------
OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN ..
ESTATE OF lATSHA
GEORGE
S FILE NO.21 01-0150
ACN 201
DATE 01-17-2005
ESTATE TAX DETERMINATION
1. Credit For State Death Taxes as Verified
46,524.76
2. Pennsylvania Inheritance Tax Assessed
(Excluding Discount and/or Interest)
84,433.90
3. Inheritance Tax Assessed by Other States
or Territories of the United States
(Excluding Discount and/or Interest)
.00
4. Total Inheritance Tax Assessed
84,433.90
5. Pennsylvania Estate Tax Due
.00
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
-IF PAID AFTER THIS DATE, SEE REVERSE SIDE (IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED
FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE
DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
~s'L
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
r""l - F-" ;".' ", ...... .. ~.., .~.... '-r--, ,:V..,~
BUREAU OF l"~~~~J~l:J~L )"tA)(E$)~
INHERITANCE TAX-DIV1SION
PO BOX 280601
HARRISBURG PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEKENTL ALLOWANCE OR DISALLOWANCE
OF DEDUCTION~, AND ASSESSMENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP (12-04)
z :: =:~ ,~~; ~ '.' ~- t t..:.
l). r!,;9
,-,. ~;
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
01-10-2005
LATSHA
04-02-2003
21 01-0150
CUMBERLAND
194-28-8616
04103175
Amount Remitted
GEORGE
S
CH~:tsro G LATSHA
85 GREENWOOD CIRCLE
WORMLEYSBURG PA 17043
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
Rifv=is4-s-i)f-AFP--Coi-:oil------------------------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 01-10-2005
ESTATE OF LATSHA
GEORGE
S DATE OF DEATH 04-02-2003
COUNTY
CUMBERLAND
FILE NO. 21 01-0150
TAX RETURN WAS:
S.S/D.C. NO. 194-28-8616
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
ACN
04103175
FINANCIAL INSTITUTION: PNC BANK
ACCOUNT NO.
5003550174
TYPE OF ACCOUNT:
DATE ESTABLISHED
( ) SAVINGS (x> CHECKING ( ) TRUST ( ) TIME CERTIFICATE
06-25-2002
x
.00
0.333
.00
.00
.00
.15
.00
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
x
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
~ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ·
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU HAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. )
'J
c: ...
Q.. .:;,
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
BUREAU OF INDlfttoUAt1'A)(ES-:-('[
INHERITANCE TAX I nMstOM ......, ! ,_'t_
PO BOX 280601 .-..-",
HARRISBURG PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEKENTL ALLOWANCE OR DISALLOWANCE
OF DEDUCTION~, AND ASSESSKENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP <12-D4)
l; .;
,'\ ,)
< ........
tj
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
01-10-2005
LATSHA
04-02-2003
21 01-0150
CUMBERLAND
194-28-8616
04103174
Amount Remitted
GEORGE
S
( "
DAVID' R LATSHA
85 GREENWOOD CIRCLE
WORMLEYSBURG PA 17043
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
RE\i:is~8-Ex--AFP--foi-:ojl------------------------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 01-10-2005
ESTATE OF LATSHA
GEORGE
S DATE OF DEATH 04-02-2003
COUNTY
CUMBERLAND
FILE NO. 21 01-0150
TAX RETURN WAS:
S.S/D.C. NO. 194-28-8616
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
ACN
04103174
FINANCIAL INSTITUTION: PNC BANK
ACCOUNT NO.
5003550174
TYPE OF ACCOUNT:
DATE ESTABLISHED
( ) SAVINGS (Xl CHECKING ( ) TRUST ( ) TIME CERTIFICATE
06-25-2002
x
.00
0.333
.00
.00
.00
.45
.00
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEV ORDER PAVABLE TO:
"REGISTER OF WILLS, AGENT."
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
x
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
~ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ~
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( eR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
s'"
Q..'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INij.lV~DUAL..!A~~~~.C:t~
INHERITANCE TAXQJV;(SlON" - .
PO BOX 280601 .
HARRISBURG PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENTL ALLONANCE OR DISALLONANCE
OF DEDUCTION~, AND ASSESSMENT or TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP tl2-04)
I "'"} . 1 ;
: 39
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
01-10-2005
LATSHA
04-02-2003
21 01-0150
CUMBERLAND
194-28-8616
04103173
Amount Remitted
GEORGE
S
DOROJHE J ANDERSON
85 GREENWOOD CIRCLE
WORMLEYSBURG PA 17043
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
RE-v;i5ir8-Ex-~FP--roi-:ojl------------------------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 01-10-2005
ESTATE OF LATSHA
GEORGE
S DATE OF DEATH 04-02-2003
COUNTY
CUMBERLAND
FILE NO. 21 01-0150
TAX RETURN WAS:
S.S/D.C. NO. 194-28-8616
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
ACN
04103173
FINANCIAL INSTITUTION: PNC BANK
ACCOUNT NO.
5003550174
TYPE OF ACCOUNT:
DATE ESTABLISHED
( ) SAVINGS (x> CHECKING ( ) TRUST ( ) TIME CERTIFICATE
06-25-2002
x
.00
0.333
.00
.00
.00
.15
.00
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
x
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. *
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( eR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
y.
"'-) , ~
<;l-
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE or INHERITANCE TAX
APPRAISEKENTL ALLONANCE OR DISALLONANCE
OF DEDUCTION~, AND ASSESS KENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP <01-03)
DAVID T LATSHA
85 GREENWOOD CIRCLE
WORMLEYSBURG PA 17043
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
05-17-2004
LATSHA
04-02-2003
21 01-0150
CUMBERLAND
194-28-8616
04103172
GEORGE
S
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1548 EX AFP (01-03)
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 05-17-2004
ESTATE OF LATSHA
GEORGE
S DATE OF DEATH 04-02-2003
COUNTY
CUMBERLAND
FILE NO. 21 01-0150
TAX RETURN WAS:
S.S/D.C. NO. 194-28-8616
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
ACN
04103172
FINANCIAL INSTITUTION: PNC BANK
ACCOUNT NO.
5000820079
TYPE OF ACCOUNT:
DATE ESTABLISHED
()C) SAVINGS ( ) CHECKING ( ) TRUST ( ) TIME CERTIFICATE
12-22-1997
x
.00
0.500
.00
.00
.00
.45
.00
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
03-02-2004 CD003642 .00 66.17
05-10-2004 REFUND .00 66.17-
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
S INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER THIS DATE. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. *
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
'1
\ l~'
\) v
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEKENT~ ALLOHANCE OR DISALLOWANCE
OF DEDUCTION~, AND ASSESSKENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP (01-05)
HERBERT E COY
214 GOODHART RD
SHIPPENSBURG
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
05-31-2004
COY
02-02-2003
21 03-0150
CUMBERLAND
205-09-1368
03125059
Amount Remitted
HARRY
H
PA 17257-9656
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
RE-v=is4-s-EX--AFP--fol-:031------------------------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 05-31-2004
ESTATE OF COY
HARRY
H DATE OF DEATH 02-02-2003
COUNTY
CUMBERLAND
FILE NO. 21 03-0150
TAX RETURN WAS:
S.S/D.C. NO. 205-09-1368
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
ACN
03125059
FINANCIAL INSTITUTION: CITIZENS BANK OF PA
ACCOUNT NO.
6140760011
TYPE OF ACCOUNT:
DATE ESTABLISHED
( ) SAVINGS ( ) CHECKING ( ) TRUST (X> TIME CERTIFICATE
03-20-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
10,024.45
0.500
5,012.23
.00
5,012.23
.15
751.83
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
x
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
INTEREST IS CHARGED THROUGH 06-08-2004 TOTAL TAX CREDIT .00
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 751.83
REVERSE SIDE OF THIS FORM INTEREST AND PEN. 19.31
TOTAL DUE 771.14
5 · (
IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
7
vL
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE NO. 21 01-0150
ACN 04103172
DATE 02-06-2004
REV-1543 EX AFP (09-00>
'04 M!\r~-5
DAVID T LATSHA
85 GREENWOOD ,CIRCLE
WORMLEYSBURG~~' PA 17043
r~\;{T
P t:b6f:::1
,
f?!,:"
~;//
;"-.
EST. OF GEORGE S LATSHA
5.S. NO. 194-28-8616
DATE OF DEATH 04-02-2003
COUNTY CUMBERLAND
TYPE OF ACCOUNT
(XJ SAVINGS
D CHECKING
D TRUST
D CERTIF.
F--
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
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 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
~f Pen~sylv2nie. g~estiQ~s ~3~ h~ an5~ArAd hy C91l;ng (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5000820079 Date 12-22-1997
Established
PART
[!]."
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
To insure proper credit to your account, two
(2) copies of this notice must accompany your
payment to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
x
x
NOTE: If tax payments are made within three
(3) months of the decedent.s date of death,
you may deduct a 5% discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
Tax
[CHECK ]
ONE
BLOCK
ONLY
A. [J 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
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.
B. c=J The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent's representative.
C. [J The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
x
If you indicate a different tax rate, please state your
relationship to decedent:
PART
~
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
8. Tax Due
TAX ON JOINT/TRUST ACCOUNTS
OF
1
2
3
4
5
6
7
8
x
PART
@J
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE DESCRIPTION
AMOUNT PAID
r
I
TOTAL (Enter on Line 5 of Tax Computation)
I
$
~
----
Under penalties of
complete to the best of
-----... .-.....~
~...L-X' ../ .
TAXPAYER SIGNATUR
perjury, I declare that the facts I have reported above are true, correct and
my knowledge and belief.
HOME ( )
WORK ( )
TELEPHONE NUMBER
DATE
'BUREAU OF INDIVIDUAL TAXES
~ INhtRITANCF TAX DIVISION
DEr".. 280~...
HA~ISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
02-24-2004
LATSHA
04-02-2003
21 01-0150
CUMBERLAND
101
HOWELL C METTE
METTE ETAL
PO BOX 5950
HBG
'04 !:-Ed l7
I"" 1 (\
! .\ J
_L l
P A Ifl ~ J:ti>::_
_;, PA
/
~I
REV-1547 EX AFP [01-05>
GEORGE
S
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
R i-v: iS4j-Ex--AFP--foY=oi-r-NcfficE--ciF-YNHEifiTAifcE -"-Ajr"PPRAI SEMENT-,--ALi-ciwAifcE-cfR'--------- -- - - - - --
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF LATSHA GEORGE S FILE NO. 21 01-0150 ACN 101 DATE 02-24-2004
TAX RETURN WAS: ( ) ACCEPTED AS FILED
SEE ATTACHED NOTICE
( X) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
2,178.72
1,475.52
2,060,413.05
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
42,821.62
44.004.88
(11)
(12)
(13)
(14)
(9)
(10)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
2,064,067.29
86 826 50
1,977,240.79
.00
1,977,240.79
NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00 = .00
1,977,241.79 X 045 = 88,975.84
.00 X 12 = .00
.00 X 15 = .00
(19)= 88,975.84
rA'n~1'I1 1'(~"'~~t"1 nT"rnll~T l + J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
06-25-2003 CD002744 4,448.79 89,528.00
TOTAL TAX CREDIT 93,976.79
BALANCE OF TAX DUE 5,OOO.95CR
, INTEREST AND PEN.
.00
v' TOTAL DUE
5,000.95CR
{~
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) -~~
RE:V-1p'J [, '~-88' -
~"" '\.-
..
fk
~~
,..>. - :>i
:~-._,
:J~
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME
T
INHERITANCE TAX
EXPLANA liON
OF CHANGES
George S. Latsha
FILE NUMBER
Sheila Megonnell
ACN
2101-0150
101
REVIEWED BY
ITEM
SCHEDULE NO.
H B-3
EXPLANA liON OF CHANGES
The claim for the family exemption has been disallowed. The claimant must be a spouse
or if no spouse, a parent or child living in the same household as the decedent as of the
date of death.
J 6
Changed tax rate from 15 percent to 4.5 percent since a granddaughter-in-Iaw is a lineal
beneficiary.
"r
--.,
/'
ROW
Page 1
\ BUREA'~ OF INDIVIDUAL TAXES
"".. r~:.HER:n~CE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
03-08-2004
LATSHA
04-02-2003
21 01-0150
CUMBERLAND
101
HOWELL C METTE
METTE ETAL
PO BOX 5950
HBG
'04 l'liil\ 12
P 1 :<8
\,~
P A Clll (t'1.0
Amount Remitted
REV-1595 EX AFP (01-05)
GEORGE
S
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
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 ~
RE-v=is9-j-Ex--AFP--foi-:031------.-i-iN-HERi-fANc-€-TA-i-RE-CORD--ADj-USTM-€Ny--i.-----------------------------
ESTATE OF LATSHA
GEORGE
S F I L E NO. 21 01 - 0150
ACN 1 01
DATE
03-08-2004
9113 Trusts (Schedule J)
ADJUSTMENT BASED ON:
VALUE OF ESTATE:
ADMINISTRATIVE CORRECTION
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Administrative Costs/
Miscellaneous Expenses (Schedule H)
Debts/Mortgage Liabilities/Liens (Schedule I)
Total Deductions
Net Value of Tax Return
Charitable/Governmental Bequests; Non-elected
Net Value of Estate Subject to Tax
10.
11.
12.
13.
14.
TAX:
15. Amount of
16. Amount of
17. Amount of
18. Amount of
19. Principal
TAX CREDITS:
Line 14 at Spousal rate
Line 14 taxable at Lineal/Class A rate
Line 14 at Sibling rate
Line 14 taxable at Collateral/Class B rate
Tax Due
(1) .00
(2) .00
(3) .00
(4) .00
(5) 2,178.72
(6) 1,475.52
(7) 2,060,413.05
(8)
(9)
(10)
45,000.34
44,004.88
(11)
(12)
(13)
(14)
2,064,067.29
89,005.22
1,975,062.07
.00
1,975,062.07
.00
88,877.79
.00
.00
88,877.79
'"' ,...n, 1'(~"'~.Lt'1 l+J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
06-25-2003 CD002744 4,443.89 89,528.00
02-27-2004 REFUND .00 5,000.95-
03-05-2004 REFUND .00 93.15-
TOTAL TAX CREDIT 88,877.79
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
~
(15)
(16)
(17)
(18)
.OOX 00
1,975,062.07X 045=
.OOX 12 =
.00X15 =
(19)
* IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
REV.1470 EX (6-88)
........ r..
INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME
FILE NUMBER
REVIEWED BY
ACN
2101-0150
101
LATSHA GEORGE S
J Paul Dibert
ITEM
SCHEDULE NO.
H B-3
EXPLANATION OF CHANGES
ALLOWED AS THE SON OF THE DECEDENT LIVED WITH THE DECEDENT UNTIL AFTER
HIS DEATH AND THEN MOVED INTO THE ADDRESS LISTED ON SCHEDULE H
ADDITIONAL REFUND IN THE AMOUNT OF $ 93.15 IS BEING PROCESSED.
';
/
ROW
Page 1
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
REV-1607 EX AFP (01-03)
DAVID T LATSHA
85 GREENWOOD CIRCLE
WORMLEVSBURG PA 17043
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
05-24-2004
LATSHA
04-02-2003
21 01-0150
CUMBERLAND
04103172
GEORGE
S
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
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 ~
R'fv = i 6ifj-E:3fAFP--foY:03Y------..i:--iNifiRITANCE--TAx-sTA-fEMENT-OF"-AC-couiff--.-..--------------- - - - - --
ESTATE OF LATSHA GEORGE S FILE NO.21 01-0150 ACN 04103172 DATE 05-24-2004
THIS STATEMENT IS PROVIDED TO ADVISE OF 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: 05-10-2004
PRINCIPAL TAX DUE: ........................
.00
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
03-02-2004 CD003642 .00 66.17
05-10-2004 REFUND .00 66.17-
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
. IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
~ ( IF TOTAL DUE IS lESS THAN $1,
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REflECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
(\ 1<
~, S I L.
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that I, GEORGE S. LATSHA, of
the Borough of Wormleysburg, Cumberland County, Pennsylvania, have made, constituted
and appointed and do hereby make, constitute and appoint my son, DAVID T. LATSHA, my
true and lawful attorney-in-fact, for me and in my name and on my behalf to do and perform
all matters and things, transact all business, make, execute and acknowledge all contracts,
orders, deeds, writings, assurances and instruments which may be requisite or proper to
effectuate any matter or thing appertaining or belonging to me, including the right to make
gifts, to create a trust for my benefit, to make additions to an existing trust for my benefit, to
claim an elective share of the estate of my deceased spouse, to disclaim any interest in
property, to renounce fiduciary positions, to withdraw and receive the income or corpus of a
trust, to authorize my admission to a medical, nursing, residential or similar facility and to
enter into agreements for my care, to authorize medical and surgical procedures, to sell or
transfer ownership of insurance policies on my life, to enter any safe deposit box I may own,
to represent me in all matters involving federal, state, and local taxes, and to sell or transfer
any real estate, stocks, bonds or other securities, or other items of tangible or intangible
personal property which I may own, with the same powers, and to all intents and purposes
with the same validity as I could, if personally present; hereby ratifying and confirming
whatsoever my said attorney shall and may do, by virtue hereof.
This Power of Attorney shall not be at1ected by any disability on my behalf,
including the event that I become incompetent to handle my affairs.
In the event that incompetency proceedings concerning my estate and/or person
are commenced at any time hereafter, I nominate the attorney-in-fact appointed by this Power
of Attorney for consideration by the court having jurisdiction of said proceedings for
appointment as the guardian of my estate and/or person, and I request said court to make its
appointment in accordance with this nomination, except for good cause or disqualification.
IN WITNESS WHEREOF, and intending to be legally bound hereby, I have
hereunto set my hand and seal this ' . t day of . I /, 19--.,
WITNESS:
r
..i f
. .
/
(SEAL)
/':.,l
'/~
(SEAL)
t.
GEORGE S. LATSHA
COMMONWEAL TH OF PENNSYLVANIA:
SS:
COUNTY OF
-'
'"
On this, the _ day of {." , 19~; before me, the
undersigned officer, personally appeared GEORGE S., LA TSHA, who being duly sworn
according to law, deposes and says that the foregoing Power of Attorney is his act and deed
and that he desires the same to be recorded as such.
IN WITNESS WHEREOF, I hereunto set my hand and notarial seal the day
and year aforesaid.
Notary Public
My Commission Expires:
(SEAL)
15054_1
- 2 -
DECLARA TION
I, (0 -eOV8 Co S. Iv ~..; ~ h C2 , being of sound mind, willfully and ....oluntarlly
nake this declaration to be followed if I become incompetent and can no longer take part in decisions for my
)wn future. Tbis declaration reflects my firm and settled commitment to refuse lifesustaining treatment
.loder the circumstances indicated below.
If tbe situation sbould arise in which there is no reasonable expectation of my recovery from physical
Hsability, I request tbat I be allowed to' die and not to be kept alive by artificial means or "heroic measures,"
: direct my attending pbysician to witbbold or withdraw liCesustaining treatment that serves only to prolong
the process of my dying.
1 direct that treatment be limited to measures to keep me comfortable and to relieve pain, including
any pain that might occur by withholding or witbdrawing lifesustaining treatment. In addition. if I am in
the condition described above, I feel strongly about the following forms of treatment:
I ( ) do ( I do not want cardiac resuscitation.
I ( ) do (~ do not want mechanical respiration.
I ( ) do (I) do not want tube feeding or any other artificial or invasive form of nutrition (food) or
hydration (water).
I ( ) do (\^ do not want blood or blood products.
I ( ) do (j) do not want any form of surgery or invasive diagnostic tests.
I ( ) do (~ do not want kidney dialysis.
I ( ) do (I) do not want antibiotics.
I realize that if I do not speciflcally indicate my preference regarding any of the
forms of treatment listed above, I may receive that form of treatment.
I ( )do(v( do not want to make an anatomical gift of all or part of my body subject to
~.tollowing limitations, if any:
I (0 do ( ) do not want to desig,nate another person as surrogate to make medical treatment decisions
T.
address
be incompetent and in a terminal condition or in
of surrogate (i f applicable):
L 'i3 f~ h ~ - I / Y I (0/ u WI h u!' If V ~
of substitute surrogate (if surrogate designated a
a state of permanent unconsciousness.
for me if I should
.Name aod address
I}t!..
to serve):
A~
I make this
declaration on the I / ~ day of ;--; /; yv d Yy. , 199'1.
Declarant's signature: ~~~~
Declarant's address: 'i5~ reen wood CI YC /e I /u"oYIIWI,,? bv,,; I ;-~ ",
declarant or the person on behalf. of aod at tbe direction of tbe declarant knowingly and voluntarily
is writing by signature or mark in my presence.
(' tM.v-71
,
(~
~
II.J-I I~
Address '
1/-J.j iJ
iV - r j c; \
Address