HomeMy WebLinkAbout12-04-08 (2)J 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.2sosoi 2 1 0 8 0 0 3 0 8
Harrisburg, PA 17128-D601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
322 20 6066 03 05 2008 06 26 1928
Decedent's Last Name Suffix Decedent's First Name -NI
STONECIPHER ADRIAN K
(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
RFC_ICTFR C1G WII I C
FILL IN APPROPRIATE OVALS BELOW
I^ •i 1. Original Return ~ 2. Supplemental Return ~ _] 3. Remainder Retum (date of death
prior to 12-13-82)
!~ 4. Limited Estate ~~ 4a. Future Interest Compromise i Jl 5. Federal Estate Tax Retum Required
(date of death after 12-12-82) -
X ~ 8. Decedent Died Testate I~ ~ Decedent Maintained a Living Trust 2 8. Total Number of Safe De osit Boxes
-- (Attach Copy of Will) I J (Attach Copy of Trust) P
9. Litigation Proceeds Received
CORRESPONDENT -THIS SECTION MU
Name
DAVID J. LENOX
Firm Name (If A licable)
I 1 ~. Spousal Poverty Credit (date of death
!~ between 12-31-91 and 1-1-95) ~,r- 11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
ST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO
Daytime Telephone Number
717 432 9666
PP
THE WILEY GROUP
First line of address
130 W. CHURCH STREET
Second line of address
City or Post Office State ZIP Code
DILLSBURG PA 17019
Correspondent's a-mail address:
REGISTER OF WILLS USE ONLY
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Untler 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,
rt-IS•S(ue, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge.
,SIGNAT~IJRE OF PERSON RESPONSIBLE FOR F ING RETURN DATE
,~...j+~F-~,c G'~S ~ Jan M. Wiley / 7 I h ~ ii
J 13 W. Church St., Suite 101, Dillsburg, PA 17019
Side 1
SI REF PREP OTHER 7H REPRESENT TIVE DATE
' ,~ `-'` David J. Lenox
G
D
7
130 W. Church Street, Dillsburg, PA 17019
15056041147
15056041147 J
J
15056042148
REV-1500 EX
Decedent's Social Secu rity Number
oe~eaenrsName Adrian K. Stonecipher 3 2 2 2 0 6 0 6 6
RECAPITULATION -_ - - ----
1 7 0 6 1 7 7 8
1. Real Estate (Schedule A) ............................................................................. ............. 1.
2. Stocks and Bonds (Schedule B) .................................................................. ............. 2. 3 3 9 9 2 6 3
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3.
4. Mortgages & Notes Receivable (Schedule D) ............................................. ............ . 4.
5 Cash, Bank Deposits 8. Miscellaneous Personal Property (Schedule E) ... ............. 5. 3 3 4 8 2 8 9 1
6. Jointly Owned Property (Schedule F) ~'~ Separate Billing Requested ............. 6.
,,,.,,, .~.,,~ . ~a~~~~~~~ « ivua\,oonllc~u> rv~n-rlwaie rroperry
(Schedule G) j i Separate Billing Requested ............. 7. 1 2 3 4 0 1 1 9
8. Total Gross Assets (total Lines 1-7) .......................................................... ............. 8. 6 6 2 8 4 D O l
9. Funeral Expenses & Administrative Costs (Schedule H) ............................ ............ . 9. 7 6 7 5 2 0 0
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule 1) .................. ............. . 10. 5 2 0 8 5 0
11.
( ) ..........................
Total Deductions total Lines 9& 10 ...................
.............
. 11. 8 1 9 6 0 5 0
12. Net Value of Estate (Line 8 minus Line 11) ............................................... ............. . 12. 5 8 0 8 7 9 5 1
13. Charitable and Governmental BequestslSec 9113 Trusts for which
an election to tax has not been made (Schedule J) .................................... ............ . 13. 1 0 0 0 0 0
14. Net Value Subject to Tax (Line 12 minus Line 13) ................................... ............. . 14. 5 7 9 8 7 9 5 1
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES __ .--- _.
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(12) X .00 0 0 0 15. 0 0 0
16. Amount of tine 14 taxable
0
0 0
16.
0
0 0
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X .12 4 2 7 3 6 8 1 7 17. 5 1 2 8 4 1 8
18. Amount of Line 14 taxable
at collateral rate X .15 1 5 2 5 1 1 3 4 18. 2 2 8 7 6 7 0
19.
...............................................
Tax Due..._ ......................_ ...................
............. 19.
. 7 4 1 6 0 8 8
20. FILL iN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^
Side 2
15056042148 15056042148
REV-1500 EX Page 3 File Number 21-08-00308
Decedent's Complete Address:
DECEDENT'S NAME
Adrian K. Stonecipher
r-- - -_ --- -- --- --
STREET ADDRESS
603 Park Hills Drive
I CITY
Mechanicsburg
- - T_ _ -- - - __ - -__
STATE I ZIP
PA ~ 17055
Tax Payments and Credits:
1. Tax Due (Page 1 tine 19) (1) 74,1 60.88
2. Credits/Payments
A. Spousal Poverty Credit _
g. Prior Payments 63,460.00
C. Discount 3,340.00
Total Credits (A +g+C) (2) 66,$00.00
3. lnteresUPenalty if applicable
D, Interest
E. Penalty
------_----
Total lnteresUPenalty (D + E) (3)
4. 1f Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
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 the TAX DUE. (5) 7, 360.88
A. Enter the interest on the tax due. {5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 7 3 6 0.8 8
Make Check Payable to: REGISTER OF W/LLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.................................................................................. ~ x'
b. retain the right to designate who shall use the property transferred or its income;.._ ................................ x
c. retain a reversionary interest; oc ..........................._......._............................._.._.................... .........._..... x~
d. receive the promise for life of either payments, benefits or care? ......................................._..._............_ x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ......................................._..._..._......................................_................_....... X
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? ...................................................................................................................... I 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, 1yy5, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero
(0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements
for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a
natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent (72 P.S. §9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half {4.5) percent,
except as Hated 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)]. 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.
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ADRIAN
E3E IT RF3'~F.R®, that I, ADRIAN K. S`Il%~CIPIIIIZ, of 603 Park Hi11s Drive, Uoper Allen To~,mship,
;'echarscsburg, Cwnberland County, Perutsylvania, being of sours mind, me;nory and understanding, do make,
public!] a,id declare this as and for cry Last 'dill and Testament, hereby revoking and making null and void
any and all tJi11s and."1'estamen[s and writings in the nature thereof by me at amp time heretofore made.
I'IFSI 1: I direct that all my }ust debts a.-td funeral e,clenses be paid as soon after my demise as
ma9 be corn~etuent.
I"I~21 2• Ali the mst, residue and reminder of my Estate, of whatsoever nat~sre and iaheresoever
situate, whether iC be real, personal or mixed, ~c Liding property over which I have a power of a~ooint-
menz, L give, devise and oequeat?1 unto my wife, RosPJnary D. Stonecipher, absolutely, provided she sutwives
me for a period of thirty (30) days.
I'I'II1 3: Shand my wi,:e, Rosemary D. Stonecipher, predecease me, fail co sun'_ve ne for a period
j ~~f ~ ttlrty (30) days, or should we die simultaneously, i then give, devise and beciuearh nrf entire residuary
~stz~e as follows:
ldJ i give amp ;~equeaClr $I~suaery~S d-~aiaaa: engagement r?n~; unto Sus=~~ ~. Siv"li~h, who
7 ; i1e Godchild of [~ser~ry, if she shall survive my death. ~~1~" "' C~iv'eq'1 ~`(CVY' 'w d ~~ ,
(b) I give a~ bequeath all other personal jewelry ro Earlena Davies Sk1_ut, if she shall.
~ _;It~~:,ive ruy death. M~ ~jC_ C~~ wv~~~ ~.1hi~lrv~- -- ~{~J~ ~CSLI
(c) I give and bequeath the cacique dresser and Ladderbac}c chair. in the pick ~oedroom to
~~a-!~°na i}av:es Ski_ut. n the eve m_ Ear]_ena Davies Skiuc should predecease me, tt.ese ~t~ms si~ll_ go to
Shelton Be 11, or iter :sue. (These two plecc~s aretrom the Artdersor. fay i'.y .-a? went t.o iili_ncis
a co~.~ered wagon_ )
I (d) [ g~~e and a~gl.r`arh all nri crystal. snd cut glass in the_ tutcu ._~ ~ dir~t~ roam at td I
' _, ~-,~ Lal1L1 ~i~ ~__~ti, ~ -'d ..-1 !~~, .. _, Jklut. ,.- _. _'nt EaY i.en3 'auk _,o .~1:_... „<7 OY?_r cn >e_
I.'I'--~1. .~, ;CS .. ~_.]~ ,].~_:_ yO Li '~ae }7CrSi)Il _. ~~._Pd !R nfy OL Ilf `._ C_~ ..... 't lt1[lt, on ClE' :10LCC1111 ~
i"lli, Jr ~ll'i ~S „_> al,rl .. ile '7C aS`~ Cdfid Lc? ~~L .~ ~-..il ,Y ~dlll 3_'d ..e~.d11 „U.,> ~. __
(e) ` ,;r~%e acu Y>;_quea`n ri,.e sot n` Ha.~~and clisites to Susan A_ ,_.~,. w;1o is the :~,d~,ti;d i
~~ _,~r;~ ,i site t~31, s-_ r; 'Eazh. ~`-~G.C)(~ ~~Y`C.laSel~-.~j~,~'yy~i,_,
(~ j arcs I,c~ _,, r`au1 tt,~ s~ of ;:; g __~,_ Jtllage chira, 'i ro ,,. , ;~:r., ;land, - u ;aro.'_ ~~
i ~~rru`u~ss:
.,
ADRIAN K. ."AINFX;IPIIl~1t
' r
- -- _~ (__
L. Hut~~hiivson, who is the Godchild of Rosemary, if she shall survive my death.
(gj I give and bequeath unto each-named Godchild one blAUe' and witite Wedgewood vase from
the Living rocx~~ secretary, if either or tx~th shall. survive ary death. N1~} (~O ~ ~(;(~,/Y\Gr`-'
(h) L give and bequeath the Royal llalcon, "The Professor," on a living roan end cable to
~Q ~ QLx~ e-C~
L re CLeccher Wessale of Tuscola, L1Linois, who gave the piece to Rosemary. If Mrs. Wessale shall pre-
decease me, this '_tem shall go to Earlena Davies Sktut, if she shall survive my death.
(i) I give and bequeath all books and perialicals to be at the disposal of >;arlena Davies
~idut, Genevleve Walsh d._nd !diLladene Stormont for selection of arty items they may be interested in, inclu--
diiti but not limited co, family Bibles and P~ign school and college aruiuals. All hooks and periodicals
[hey do no[ wan[ shai7 go to the ilecYu~ucsburg Public Li.bcaty.
C]1 [ ive and bequeath all personal 1e[ters, faniLy photographs, etc., to be retnewed
by tt~e previously-mentioned sisters in the evear_ they wan[ to claim them, otherwise, they are to be
destroyed or other~.rse disposed of by my Executor.
(k) I give and bequeath all real property owned in Marion County, Illinois, to Florence
Geraldine 5coneci_pher, or her issue, per stlrpes. ~ ~~ ~~ N ~'f~-'~.
(11 I give and bequeath a11. my coin, in the First Federal Savings and Loan Bank Safety
L~posit Bark nn ^1ar};et Streer, C~ Hi1L, Fertslivania, to Florence Geraldine Stonecipher, or her Lssue,
per stir,~e,>. ~ `~ - CC7.~ j ~~~.,~ ~r~ CJr ~13 G~'~Cl~"~ .
(m~7 i wive and bequeath one [housar~d ($1,000.00) dollars in cash to the Harrisburg Area
:{tunane Society ~r ~., successor.
(n1 ;1ve and bequ°at:7 the st_~s ',i;g silver flatware in the First Federal Savictgs and Loan
Sank iafe:_y IY posit i~ot on Flarket Street, Ca,~r tii~i_, .'ennsylvani_a, w}tich may be ta<cen "in kind" by Florence
C;eralcu_~e Stonecip~'.ec, or her issue, c: ~tir_:- , tf she, or they, wish to claim it as a porti~ i:et
or their sure. {"~`~ ~ 1UC7~'1~ ~V,tY\~
(oi ~~ ~_, de~le, and ~x~~{ilea _.i ~.ie ~.r., ~,. seventy f~-ve thousand (S 77 .;i;0. 00) L.~_ar
unto tt~:c ~'~ur,', _~ ~ .<. ~ -oil Bank of '~. ~ <;b~, .._ trusi-, to take care oY srv dogs ar~d cat. ~_r,t~.
Per ~, a t__.~~i _~ ,~.,.c~~i :xetu~o d:-,~~~,~_ ~1y :ry pets m the Bra~xly :ane Kennel on S wi~> "..~....
R-:ad, `r~_P~,rj ~'oi~r,_ sid chat Eucd ~.~?~11 ~,~iais;_ered in such a fasition so that the incane and ~:m_r,
-~_~al nay Lo ~~-~wi ~. ~ Trustee r.r~ :.__ -.jl ~c~~., e care oI rry ~3ogs end cat aid to tom- »a a ._. ,_~_
., ur, __r_~~. ,~ ~,~ ~,- ~ ,m~ ~c ,~[ ~~tirE _, ~rr~, EC~~saty. ~t ~s any desire to pc~ side g_od ^o¢e
,. e c'~ u_ ~,~ dov; anrt rat and to a~;t, _'.:e<. la~rc ~~e_ryuitd; cha[ they need within cne rc~alr oY ~i~r-
Wl'Q1FSS~
,ri ~ p~ '- ---
~< a i C- _ _ ~~l'+-7'tz?~~ /Jj~L''C~,-_ ~~ ,' (SEAL)
___
---
-__._ Y--..----
t1i)RIAN K. S'C[YdNxIPIIE`iZ
cial. feasibility. In the event that the principal and/or interest of my trust is not consumed try the
tine rry last animals die, C then give, devise, and bequeath the glance remaining in my trust unto those
C~rsons as sec forth in my residuary clause of this my Last Will and Testament. ,,p__ {~
~1
~~~1 M ~~S ~.~
(p) A11 zhe rest, residue and remainder of my estate, of whatsoever nature and wheresoever
situate, whether it be real, personal or mi:ced, including pro~rty over which I have a power of appoint-
ment, shall t;e sold '!1y my Executor, and after deduction of all expenses, takes, and fees, etc., shad
~zc eUSe({.
be divided ~xtween rlorence Geraldine Stonecipher, or iier issue, per stirpes, and Earlena Davies Sk1ut.
a G~ c~rern
Ii fsrlena Uavies 5tduc should predecease me, her share shall go to her hushand, Harry Sk1ut. Should
both Eariena and Harry !predecease me, tiie following disposition shall be made of their fifty (~0%) percent
share:
(i) Ten (10%) percent of the fifty (50%) percent share shall go to the College of
St. t~rancis Library, ~oLiet, L1J_irois.
(ii) Ten (CO°ll percent of the fifty (SO%) percent stye shall go to the Tuscola,
Illinois Public Library i.n Tuscola, Illinois, in memory of Idamay and Earl G. Davies.
(iii) Ten (10°x) percent of the fiery (50%) percent share shall go to St. Elisabeth
Arn Seaton Church, U~>per P1.ien Township, Cumberland County, Peru~sylvania.
(iv? ~^re remaining seventy (70%) percent of the fifty (50%) percent share shall go
'.o 'e'1e;rence Geraldine ~toaecLpher, or her issue, per scitZ~es.
I"LY21 4: Burial i;utructions: Nry body shall oe buried ne.,ct to my wife in The Gates of Heaven
Cemetery, un Yorlc 2~ad, ll{~!ier A11en 'fo=,.mship, i"techani.cstxlrg, ?ennsylvania. Christian burial shall h~
i~andled by Myers cline:~u i{otne of Mechaiticsburg, Pennsylvania, tinder the direction of St. Elizabeth <h~a~.
Sea~_on ~:hurch, iJpner :': __._~'. iownship, Cumberland County, Pecuisylvarsa. There sha7.l be no viewing. A
nkd!rac-priced casket zinc`. ;pas vault are requested.
C7NY'1 5= [ ~.I~,L -u~~e,rich try ~ae_erinarian acd/or trust de~rtment all ~y wishes as it re;ates ~;.
r:y ~~~~ ~._~ arxi ~ a __~ sa.,~e shat: oe stricthr atiher~3 ro.
1'fhY4 6: fli ~. c_'~irtinf2er-mined r.,cecu:r. ti so gay all i~Leritarcc, ~;!_ate, succession =u L? ~:v
I .,,... ~,. ~~r~ _ ,u~_i:~ ~~~3' _: ar~c1 iii ad, ro ~.~hich w c ._u or 'one _ ranscer oC anv property passing hey __~.~~r
- ~.e.~./t c_ _,ass .~, _-..-,=u'.i o!. '.n7 der~rse, ana n,ay ce aub)ec~ and co charge such cases ag-rinst cry *c~;.-
j 3 ~_ar~~, tt iv r~,~ _._~.n.or amt none or '_ io~e_;aid taxes, ei_thc• 'ederal or state. or nay
~ s ~x _, >~lairud ~4ded in _, ~co~_s estate, ~.a~r tae arovinion~ of arty Mare or federal Law
,,, ,. -ir :!r :or a~c-~_ ~ aactod, shall be prorated =m!ong t ~~ ~~erso-~s interested in iiry estate to ~,rtom
/ i;1 ^-
__ __.. _- -T _. __--__-___.. _.-_ _.-_
~ A[hZIMI IZ SIC'~IFGT>~4CIIt
such property i:; or may 're transferred or to whom any benefit accrues.
L7Fh1 7: I appoint my wife, Rosemary D. Stonecipher, as Executrix of this my Last Wi11 and Testament.
lwuld my sriEe predecease me, fail to qualify, cease to act or renounce probate, I then appoint Jan M,
~Ji1ey, Esquire, as alternate Executor of this mry Last Will and Testament. Should Attorney Wiley oredecease
ne, fail to qualify, cease to act or renounce probate, I then appoint GoreStates tiamiLton Hank of
!tarrisbur~ as second, alternate F~cecutor of this my Last Will ara3 Testament.
IZrS1 8: I direct that my Executors, guardian, or their successors shall not be required to give
Mond for eiie faithful performance of their duties in airy jurisdiction.
iN WI"R~5S 1J1~RE7DF, I have hereunto set my band and seal this ~~day of ~dedG (/~' ~'
1487.
WI'IDIFSS~
~~
~- ADRIAN K. SiLNE~IRIIIt,//
i
_~- ~ -- ;~ - ;-~, It ~~7i~~~.C
AI.'3}I OF PFta7SYI,VANIA
SS
COIAIfY OP YORK
We, ADRIAN K_ SLYINE~LPEIAt, JAN hL WII.I;Y, ESQlJIRE, and 'ffi2I;SA WAL1~%}-SfiELT H3rnnmu
- ,, the Testator and
the witnesses respectively, whose names are signed to the attached or foregoing instnnnent, being first
duly sworn, do hereby declare to r_he undersigned authority that the Testator signed and executed the in-
scn~ment as his Last ':h11 arx] Testament and that ne had signed willingly <or willingly directed another
co sign for tum), and chat he executed it as his free anti voluntary act for the purposes therein expressed,
and that each of the witnesses, in the presence and hearing of the Testator sighed this Last Wi11 anti
1'escament as witness and rhar rp the best cf their ti,owieuge the Testator was at the time eighteen (18)
years of age or older, of sound mind and under no constraint or ~.u~due influence.
ADRIAN K. S'it~IPflER
~ 1
_ ~_- .t
tt /
t~ i~/
WI7IIESS
Sworn and subscribed,~t~.o 'oefore me
tfti5~~ y Of ~~~~+i"~~~~tl ,
;'387. /
_- --- --- -~_L= _~_.a
NCJPARY FISt~.LC ,' --
MY C(kT1ISSION EXE'LRES:
GtEa~aGE 14E1tii:'Gl' ,_ - _ .,.
UU_Lt z~ ..-;6 ~?Y
Meni6~ ?znn;yr:zn,= _-.". _ ...... CaoiSnes
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REV-485 EX (7-07)
1 48500041,046
~~vri= i~Er~Ql~i i ~ p
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~u~ iNVt~v i SKY t
PA Department of Revenue PLEASE LOSE Of'21GINAL FORM ONLY
Social Security or Death Certificate Number Date of Death County Code Year f de Number
,j ~ ~ ~ c~ ~~ l~~ Lr (~ ~ 3 c' ~ h c c ~ ~. ~ ~' ~" ~,' ~' J U ~'
Decedent's Last Name Suffix First Name MI
ADD! ~~ ~_ D ~ ~r L /N~~l_S.G ~" l~ i ~ ~_"' -- -- ~ ~ ~~-{ CI~l (L.1 1 1 LJ STAT~ :. ZIP CODE
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SA E DEPOSIT BOX
-
~
_
'~ -
NAME ~
~~ ! '
STRE~TADDRESS _ ~ ' ! ~.~~
i;~ti l ~~
3C) ~~Li . t
? 1,t _ - - -11Y ___ _ ---
7~ ~:`a -%~)~ i.'
~ S _,1~ tLIIPCUDE_-
I 6~~~, ~ < e
-
om
NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT j
OF PERSON(S) PRESENT AT THE BOX OPENING
a. NAME/
_ RELA710NSHIP. _;-, p/
- - - __
S7 RFFT ADDRESS ~_ CITY- ST-R,TF 71P CC)1_lF
b. NAME. RELATIONSHIP:
STRF_ET ADDRESS CITY: STATE 71P CODE.
c. NAME:
STRFF_TADDRESS
RELATIONSHIP:
GTY STATE ZIP CODC
- -- -
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
NAME ~~yy
- __
STRE E-l ADDRE SS r^ CITY- S /~E IIF C ODf=
~~ U ~ ~ + C~F"l r~SC~^(i r~~~~ ~~ (~E~-. ~~ ~,U~ 9 ~~~~; C`c'1r ~4 ' ~ ~ t~`J/
- - -
NAME OF PE ON MAKING LAST ENTRY DATE AND TIME O'~ LAST ENTRY
-_-~ ~_e,-~-~-~~ -e-c=~>/-r-------y}g-------w~a' 9 _~~5c~e_~ ~-~~-gym
DATE OF CONTRACT TO RENT BOX NUMB R OF B X ~ TITLE UNDER WHI H BOX IS REGISTERED
NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX
a. N~ljME ~-~~ ~~ `~~ ~~~ ~?~ ~~ b NAME:
-"ii11'' - _ - _ - -
_ _ i -_ _-
- --
S RF `tT AD E SS STP.FFT ADDRESS
- } ~ - -
cl)Y srArF ZlPCOOF an srAtE I~ oF1F_
--- - - -
- _-- _-- -
® NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY
~ ~ ~ ~)
_~
~ y _-_
WAS A WILL IN THE BOX"~ ~__~ YES C~ NO yes, a. Date of will:
_-
l " - __-_
b. Name and address of personal representative. if named in the will
N,AMt
S' RL'~T ADl>~ZI SS CHY
__ - _ _
-----
r_ Name anti address of aiiorney, ii any
NAME
___
S' KF F T ADURtSS CI1Y
SIATL L~~ '_;OIJE
STATE LIP COllt,
48500041,046 4850004],046
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(t) Cash: Report total only. ~ ~ ~y a~w a ~ '
{'L; Stacks: Ust in detail every common or preferred certificate- warrant or other rights found in box. Stocks are to he designated by
Warne of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock
~ (3) Obligations of U.S. Government Number of items date of issue, face value, names in which registered and type of ownership,
i e ,jointly held, payable on death, e[c
(4) Bonds: Designate by name, amount, serial number. or other designation. (Bearer Bonds) ,
(5) Sank and Savings and Loan Passbooks: State name of depositor, number of book. last date appearing in book, name of ba_ nk ',
and branch, and balance.
~ (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible i
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness List and descrihe as fully as possible. i
(8) All other contents.
(9) Return completed form to: DEPARTMENT OF REVENUE I~,
INHERITANCE TAX DIVISION ',
_-_-- -- -- ---- -- PO BOX 280601 ~,
HARRISBURG, PA 1 7 7 28-060 1 i
~ ITEM 1
ITEM DESCRIPTION
NO.
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I i CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD t~ PERSON RECEIVING COPY OF
~EO$RECT AND COiY1PLETE TO THE BEST OF MY KNOWLEDGE AND BE IEE SAFE DEPOSIT BOX INVENTORY:
-- - - -
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NOTE: Attach additional 8'/z" X 11" sheet(sj if necessary or use duplicates of this page of form.
The Depanrnert ~ r ,nr n7 3N, ' Z l~ S ~ §46 r)(2)(C )(Q o gwre d sc~osur_ ti , ~ r ~~r; in cor nac`~on wRh a0ministen~,o ,r-~b ~ ' ~~e , , -_ ~ _
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REV-485 EX (OS-0a~
SAFE DEPOSIT
BOX INVENTORY
PADeparimentofftevenne y8~aoo4~a~+6 ,.~~' ~ '1
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PLEASE USE ORIGINdL F~RM ONLY
Social Security or Death Certificate Number Date of Death County Code Year File Number
3~a aO~D~j~' duo s ~,ov~ ~~ D~a 3a ~
Decedent's Last Name Suffix First ~ i ~ ~ ~M~ ~' ~~
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REQUESTING THE OPENING OF THE SAFE
NAME AND ADDRESS OF PERSON
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b_ NAME: RELATION HIP:
STREET ADDRESS- CITV_ STATE ZIP CODE-
c. NAME. RELATION~HIP-
STREETADDRESS_ CITY- STATE- ZIP CODE-
NAME.AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX iS LOCATED
_-- ---
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NAME OF PER~KIN~NTRY DATE AND T ME OF LAST ENTRY
E7~DATE_ OF CONTRACT TO RENT BOX NU BER OF BOX t T TLE UNDER WHIC BOX IS REQUESTED
- ----
NAME AND ADD ESS O PERSON(S) HAVING ACCESS TO BOX _ _ _ _ _ _ _ __ _ _ _
a. NAM - b. NAME
- _ - __
;if<EETADDRESS STRFEI ADORES`;
;Lv1~~t~Ln ~~ c~ ~ rte- - Jam- ~~o ~ ~ _~ __ __
spy - ---- --- - --- __--- -.._- --- - - _-
911~'.! NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY
WAS A WILL IN THE BOX J t_J ~'ES ;lJ NO If ye~, a_ Uate of v~~ll
h_ tame and addre55 of personal representative, if named In file wi11
NA4'L
51 RFi, f ADDRESS ;:Irv S IAl F- .'u ,:~.IL)L
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c. f4anie and address of attorney, if any
NAt 1F
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4850~041~046
CIIY SLATE l!f ,~_lDi-
485000741046
.ZEV-485 EX
_SA__FE DE_P__O_S1T BOX IN1/ENTO_RY_ _
INSTRUCTIONS
f~~~~ 2 Z_
~f----
{7) Cash: Report total only.
{2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to he designated by
name of company, cedific;ate number, date of certificate, name in which stock is registered, and number of shares and class of stock
(3) Obligations of U_S. Government: Number of items, date of issue, face value, names in which registered and type of ownership,
i e ,jointly held, payable on death, eic.
{4) Bonds: Designate by name, amount, sepal number, or other designation- (Bearer Bonds)
(5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, fast date appearing in book. name of bank
and branch, and balance.
(6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible
(8) All other contents.
(g) Return completed form to: DEPARTMENT pE REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
HARR158URG, PA 171'28-0601
ITEM ITEM DESCRIPTION
NO.
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PEF2~ON RECEIVING DOPY OF
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NOTE Ott- r jddiYional 8'h x 71" she t(s) If -~~ces~3ry ~~ use dupilcates of thls page of form
~i i t ~~~z;,, r,~~ ; ~ I n-ed by 1dw 42 U q40'. r)(~,(L (~) t ~ .rq!,irr ~ 5 ~,s r~~ > , dial Se~;a,~ nw ,~ r, r. rnn i~_ ion wnn admir.~st ~~~ , ,,~ i , ,:,, ` ~ ;sec ~~'. ~ ~~ r ,
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Rev-1502 EX+ (6.98)
SCHEDULE A
REAL ESTATE
COrv8v10NWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Stonecipher, Adrian K. _ 21-08-00308
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would De
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which is jointly-owned with right of survivorship must be disclosed on schedule F.
Copyright {c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 6-98)
(If more space is needed, additional pages of the same size)
-.._-__._.., ...._....,.,.~.~ ~a, Nuul;mer~-~I ..anaooow a;os2
A. Settlement St3teI11eTlt U_S. Department of Housing and Urban Development
_H. Type of loan _!__ OMB A royal No. 2502-0265 ex Tres d ~ 13020091
1 ~IFHA 2. OFmHA 3. ^GOnv. Unins. 6. File Number 7. loan Number 8. Mongage Insurance Case Number
~ 4 OVA 5. ^Conv tits. 08-01-2-06909CAP 200847936
-`-'--Thrs or,,, ,s u e o gerve you a s amen o a se amen cos n pal o an y e s amen agen are shown-
C. mote: n¢ms man<¢tl =(p.o.t.>• w r¢ pale a,Lsiee me cosmq; They are shown n¢re for mrwmarnn purposes ane ar¢ not mdnn¢a m me Inlay. i itfeExprPSS Settlement System
WARNING. Il is a uxne to knowingly mak¢ false slalemenl5 l0 Ne UnHetl Stiles on Uvs or Iher similar fmn. Penanles upon
on~cuon can mcwoe a ane ano Irnpnsonmenl. For aeons see: rue +s u. s. epee s¢cuo ai~o+ ane s¢a~on +o+o. Printed D9130i2008 at t D-.t B lR
0 NAME OFcHORROWER Raymond E. Hunt,Jr. and Timothy P. Ash
ADDRESS 2001 Rupiey Road Camp Hill, PA 17011 _ _ ____
E NAME OF SELLER: Estate of Adrian K. Stonecipher, alkla A. Keith Stonecipher
ADDRESS- bD3 Park Hills Drive, Mechanicsburg, PA 17055 __`-_ _ _
F. NAME OE LENDER: Howard Hanna Mortgage Services
ADDRESS. 119 Gamma Drive, Pittsburgh. PA 15238
G PROPERTY ADDRESS: 603 Park Hitis Drive, Mechanicsburg, PA 17055
N. SETTI.EMENi AGENT: Barristers Land Ahstract Company, Telephone: 717.761.6190 Fax: 717-761-4072
PLACE OF SETTLEMENT 3310 Market Street Camp Hi11 PA 17011
100. GROSS AMOUNT DUE FROM BC
101. GontraIX sales price _ _ _
t_Q2__ personal Propel __- ___
103_ Settlement charges to borrower line 7
104._
106 _ Cityltown taxes _ _
i07. Coun!ytaxes __ 09I301GSto1
108. Schoollaxes 09130IO8to0
K. SUMMARY OF S
400. GROSS AMOUNT DUE TO
401. Contract sales price
nts for items
146.76 4407. Count taxes 09!30!08
1 469.81 408. School taxes _ 09130108
1.21 409- Sewer 09130108
410.
12G. GROSS AMOUNT DUE FROM BORROWER ~
20G. AMOUNTS PAID BY OR ON BEHALF OF BORROWER
?I`1 __De osil or earnest mom ______
2C2 Principal amoun{ p( new loans
204.
200.
206. Preoaids
507.
to
CTION; ___
_ _tis9 000.00
vartce
___ _ 146.76
____ _1469_81
1.21
_____ _ _ 170 fi17.78
-~ ~~-- 12.783.92
209. Ponva•d Commitment Fee 350.00 508.
r 20 3 _ -- _ _-. 509.
I
Adjustments for items un aid b
- --
seller
-
- --
-
Adlustmonfs for items unpaid by seller _
- - - --
---
12 eS - o
es
?+ G~~
Court taxes _
_ _~~
X11 _Gount taxes _ _ _ I
Vi
2 C
o
22
_
ares
- - - - - ~ at
sLfi
axes
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r
J
- I
1~3 713.
-
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_- -
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220_ TO i AL PAID _BYIFOR BORROWER ___~ _ _172 600.00 j -520_TOTAL REDUCTION AMOJNT
DUE SELLER ~ 1',783.92
300. ~
CASH AT SETTLEMENT 40M OR TO BORROW~R _ _
_
600. CASH AT SETTLEMENT TO OR rR0_M_ SELLER
ul ;,~~ s ameant due irn^~ •~or ~w r qe :20~ _____I ` _ _ 179,872 1A I cUt __C oss a•noun d~ 0 5_U~ II G=(,j- - -
~ 170,61.7 7$-'
1~Z
_ n.=_ 120 I
'_2 Touels ~a y+',I :, r ~w _~----;-----
172.600.00 02 L ss reds, .ton a oor; d~ s I„I f'me 520
-- ~~ _-- ~ ---- ~- -
- - -"---~-.-_ ~. - -..
17.783 2
._ _. _~ _,
303.
i'ASH GROM BORROWER
--- -- --- -1-
7 272.14 I 603 CASH TO SELLER
--- ---~---- ---- ----- ---------L----
+52,E33 86 ~'
- ~
~U9.S1 ~. r'~„ :Ci%t Sr I'~99 S..LI _Fi '-~T.i at on con(a1ne0 here n s 3~,I a on ano i~ ne nq Iu - In,n~na i2~.ew2 Serv'ce t vo r~l .u ..~ + ,.,
n,n .
..q ~ rULLy Or off _ 5 u ((r,iS .lens tequ~rotl In L2 P~Orted dnp .IRS be{erm, ~CS'1a . nd5 lnl IJC n repnn Ctl 'fie ,-nr:raJ $a es Yr,Ce J S..r b! V an
~etl .r
~.:=.i71 appve Lansu.u les Ne ~. uss!>ruceerJS pl'nis :r3nsacl'pn
a a. a to No. n r - I - payer eat, -~ ~ b e r,ur r,e_I r ,,.
her ,,, ay es ., n ~ o _. ~~ a .,e.,a e5 ,.nsea oy'aw Uneer penzmes ~7o rwrv.l_ nW tea. .ne-„roper snnwno ss~.e~n~n v._~ a.na re~naen,r .. m,.,, nc,
-r:-,y; lo+,= v~,Uar;ts - -_ I~+I tWi
_ 412 _
14 420. GROSS AMOUNT DUE TO SELLER
500.001 501.
166.750.001 sae
vv ~+.v urtora~+vcvcwrm~rvi nee !VUTDer Ub-'JI-L-UbyVy ag.`
SETTLEMENT STATEMENT TiueExoress Se!ilemenl System Printed 09/3ot2o08 at to '~ d ~R
L. SETTLEMENT CHARGES _ I RAtu FROM i r-~ rl ~ ~~~otii
-- __ _
700. TOTAL SALESIBROKER'S COMMISSION based on price 5169 OOO.OO~a 6A00=10140.00 -_ _____ _ ~ E30RROWER'S ~ ~~-_LLR~S
Division of cOmmissi0n~line 700) as follows. _ __ _ _ _ FuNOS A? ~ FLw~.,S P,T ~j
701. 5 045.00 to HOWARD HANNA REAL ESTATE „_ _ _ SETTLEMENT sE`r~-n~ENr j
702. 5,095.90 to ERA-NRT iNC. __ _ __ i _ _ _ __
703. Commission aid a! Settlement _ __ _ _ 10 140.OD~
704. Adminlslration Fee to HOWARD HANNA REAL ESTATE 195,00 ___ _
800. ITEMS PAYABLE IN CONNECTION WITH LOAN _ _ _ __
801. Loan Origination Fee % i_ `
802. Loan Discount % _ _ _
803. A araisal Fee to Appraisals by E.J. Koppenhaver LR 350.00 ___ ___ ___
804. Gredil Re r{ to C8C Innovis, Inc. _._ LR 37.00 _
805. Final fns ection Fee _ to Appraisals by E.J- Koppenhaver LR 75.00 ~~'
- - - -------
806. Mortgaqe Application Fee
------ -
- -- - -- --
BOZ Employment Verify to Work Number __ __ LR _15_00 _ ___ __~
808. Flood Cert. Fee _ to FDSI _ _ _ LR ___13.00 ____ _ _ _ _ j
B09. Underwriting Fee _ to Howard Hanna Mortgage Services __ LR 395.00 _ _ _ _ _ I
810. Document Preparation _ to Howard Hanna Mortgage Services _ __ LR _ _200.00 _ _ __ _ ___
811. -- _ -
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE _ _J _ II
901. Interest From 09!30!2008 m 1010112008 a(~5 _ 30.8400 Ida~_ 1 Days LR _ _ _30 64 I _ I,
902. Mortgaqe insurance Premium for- ~ to Department of HUD _ `~_-_ LR 2 868 78 -_ _ _,
903. Hazard Insurance Premium for !o Howard Hanna insurance Services_ _592.00 __ _
904J-_ __
905. ~ -- -- _ _ _
- --
1000. RESERVES DEPOSITE_ D WITH LENDER FOR _ ~ {
---- -
1001 Hazard InSipanra 4 _~$ "n " ' ~ LK ly//.-1 -_ -
.o.e~ nnu
1002. Mort a e Insurance mo. na $ 74.7.5 Imo _ _ __ i
1003. Cfl Pro erl Tax _ mo_ a(~$ ~ ~_ Imo ~ ____ ~
1004. Count Pro rt Tax i0 mo 017 $ 48.13 Imo LR _ _ 481 3D _ ~
--
1005. School taxes 5 mo. (c8 $ 163.16 /mo LR _ ,815 8D
1009. Aggreqa(e Analysis Ad usl intent- to Howard Hanna Mortgaqe Servces LRR~ -712 43 0.00 i
_- _1
1101 Electronic Doc TransmiitaV Fee 1o Barristers Land Abstract General - Hh _ _ ___45 00 _ __ 4
1102 Ovem gh HARGES^'o Barristers Land Abstract Postage -Hbg_ ~ __ _ __13 0~ _ _~
1103. Wire Fee !o Barristers Land Abstract Wire -Hbg_ ~- _ 11.00
1 - ----- - - - --- -- - ----- ~-- _ _
1104- Title insurance binder
11105, Deed Preparation ro The Wi1eV Group POC S _ ___ _~.
tt06. Notary Fees to Lisa Rowe 35.00 .
1107. AtlorneY~s tees
t -- -- --- - - --- - -- ~-- --
includes above dems No: - {
t t08 Title Insurance to Barristers Land Abstract Corn~any _ _ __ _ ' _ 1 203 75 _
~ 1109. Llenderes abo y i!ems ~tio--~ ---166 750 00 - - - -- _~ - --~ - -- ~ - - i
' 1110. Owner's Polio 169 000.00 - 1 20375 ~ ~ 150 00 I f'
1111. End 100 End 300 End 900 ~o Barristers Land Abstract Com an ~ ~
__ - - - ,
1112. - -
-
1113.
-- - --- _ - -_ - - -- - - - - -- --1- -_ - , - _ _
.1200. GOVERNMENT RECORDING AND TRANSFER CHARGES __ __ ___
11201. R2cording Fees Deed $ 48 ~0 - - _ Monde $ SB 50_~ R~! a ~ ~, _ _ _ _ _ 107 00
1_'202. Ci1ylCount taxlstam s Deed 1 690.00
--- Mort a _ - - - ~ - --- - __ 1 690 00-~
~p-- --~ - -gy-e $ .
1 1203. StateTaxlstam~ Deeds 890.00 _ Mortgag ~_ __ ___ ____ 1 69000 _ _ ,
1204. Rec. Release o(Maritsf Clair o Recorder of Deeds - _~ _ - 27 00-J_
_1205. 1 '
' 1300. ADDITIONAL SETTLEMENT CHARGES
r30 ~. Tax C rt+fication o Barristers Land Abstract General Hbg ~ i 5 DO
11302. Pest 8 F,ome fispec!ion___ to POC B - I - - -
3t)3 Nome Warranty __ __ ~ Home Security of America _ __ 419 00 f
--
-- -
3 i4 Junk R~movaf/Hau6~_ r Eugene Shoop ~ QUO ~0
53~. Re ir~bursemen torE~ensc5 '~ Beth Shoff r1,9Z
3~0. Adminstration Fees ~ ERA-NRT, {nc ~ ~ 65 0 I
-- - ~ -- - ---- --- 0
- - -- - _ - -
-- - - -
307, Sewer 7/1/08-9130/08 Upper A11en Townshi~uthority _ __ ~ ~ 12 00 {
I -- - - -- -- __ _ __;.
1400. TOTAL SETTLEMENT CHARGES rente on lines 503 Sec' r i ~9?~ Sep on !'? _ ~' 9,254 3b ~ ~ 2 '83-92
- --_ -,-_
NU[) ::Eft nFiCA`ION OF ~', is -! .~~r, : _! tEft
f Ily d t ¢ HU0. 5y~'+~~ -.~ 0 1 ~e ~P r y'. wt~~3 ..,gyp and •e sld emenl of al pre a, , o sou ss - ,~a~e ~~ ~
Y U 3 log f ~ ~`. ij,~ a tl co9Y O1 UO-~ 5~ le a ~"~ ~~
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N p 5T I C JN r. i.$ O.t AN S' AR (l2M ~ '~*J ~N\ CI.UN ja Cap ¢~l~ ~jz ~},~ 0 ,eS~_ord~ s
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Rev-1503 EX+ (6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERIYANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
Stonecipher, Adrian K. 21-08-00308
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER CUSIP
NUMBER
DESCRIPTION
UNiT VALUE VALUE AT DATE
OF DEATH
1 15 shares of MetLife, Inc. common stack: 57.7100 865.65
2 U.S. Savings Bonds Redemption: 33,126.98
TOTAL (Alpo enter :.n Lane 2, Re~apitu9ati3ny ~ 33,992.63
{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)
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B\Y Mellon Shareowner Services
P.O_ Box 358333
Pittsburgh, PA 15252-8333
Apri 118, 2008
THE WILEY GROUP
ATTG~RNI~Y AT LAW
130W CHURCH STREI=T SUITE l0l
I~ll.LSI3URG PA I7019
RE. .DRAIN K STONECTPH
Dear Sir or Madam:
~ j~~
1~?Y TtiI I~ I.I.ON
Sf-EAREUtNNER SERVI<_Ft
.`Company ;rME"CLII h, INC_ -- - ~- ;
'Name I
;Account IS 1 C)NE:CIPHADRAK0000
Key ;~
ilnvestor ID 806358423132 j
€t
Control ~ 200804 f 50006478
'Number
Thank you for contacting I3NY Mellon Shareowner Services regarding the transfer of shares currently held in the
MetLife Policyholder Trust.
Please be informed that the above mentioned account registered in the individual name of ADRAIN K
STONh.CLPI I was opened on 04/07/2000 holds 15 shares.
Also the value per share on 03/05/2008 was $57.7100.
Additionally, this letter contains instructions for transferring shares from an account where the owner is deceased
and the estate has bee^ probated. In order to complete this transfer, please submit the following required items
based on the number of shares being transferred:
---__-__ -------- ------ -J
50 Shares or Less _ __ More than SO up to 250 Shares More than 250 S_h_ar_es _
Submit item I (acceptable Submit items 1 through 3 Submit items 1 through 4
without a Medallion or
Signature Guarantee) and Submit items 1, 2, and 4
Required Item 2 __ _ _ ~._
Required Items
1. Completed Transfer of MetLife Shares form (enclosed) signed by the Executor or fluthorized Representative.
2. Inheritance Tax Waiver (f applicable). To determine if an Inheritance 'Tax Waiver form is required to be
filed in your instance, please contact the state Tax Department located in the decedent's state. ofresidence_
The state Tax Department can provide the Inheritance "fax Waiver and further instructions. If the state does
not require an Inheritance Tax Waiver, the Medallion Guarantor must stamp the Transfer of Stock Ownership
form with the following statement: "We certify that this transaction does not require an Inheritance 'fax
Waiver.'•
3. A certified copy of the Certificate of Appointment of Executor(s) dated with one year of the transfer with
original signature and seal affixed.
4. Medallion Signature Guarantee on the Transfer of MetLife Shares form.
Note_ All submitted documents will be kept as part of the permanent record cif transfer and will NOT' be rctilrned_
Please be sure to keep a copy of all submitted documents for your records.
Sena tlu° required items to:
First_Class~Ke istered/Certified Mail
BNY Mellon Shareowner Services
P G Box 358410
Pittsburgh PA 1S2S2-8410
CSR Overnight/Express Mail only
BNY Mellon Shareowner Services
Securities Transfer Services
S00 Ross St.
Room 154-0675
Pittsburgh, PA 15262
If yogi have any additional questions or concerns, please call our Customer Service Center at I -800-649-3593.
If this change also applies to your insurance policy or contract, please contact MetLife directly. You may call
your account representative or the customer service number found on your billing statement. You may also call
the Mctl_.ife Directory at 1-S00-ME'1'LIFE (1-80U-638-5433) to reach the proper office.
Sincerely,
BNY" Mellon Shareowner Sezvic~t
Rev-1508 EX+ t6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Stonecipher, Adrian K. 21-08-00308
InGude the proceeds of litigation and the date the proceeds were received by the estate.
All property jolMlyowned with the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEAThi
1 AARP (refund): 5.75
2 Chase Credit Card (cash back): 8 25
3 Chase Credit Card (refund): 43.66
4 Comcast Cable (refund): 5.60
5 Commonwealth of PA (refund): 323.00
6 Edward Jones Account Number 270-04602-1-1: 30,102.72
7 Erie Insurance (final refunds): 237.00
8 Erie Insurance Group (automobile policy refund): 72.00
9 Erie Insurance Group (homeowners policy refund): 165.00
10 Highmark (refund): 693.84
11 Misc. Personal property (as given in Last Will & Testament): 578.00
12 PSERS (refund): 356.81
13 Sale of personal property & car: 3,911.98
14 Sovereign Bank Savings Account Number 2334025018: 4,291.91
15 U.S. Treasury (stimulus check): 600.00
16 US Treasury (refund): 156.00
Total of Continuation Schedule See attached page
TOTAL (Also enter on Line 5, Recapitulation) 334,828.41
(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 E (Rev. 6-98)
Rev-1508 EX+ (6-98)
SCHEDULE E
CASH, BANK DEPOSITS, & M{SC.
PERSONAL PROPERTY
COMMON WEALTH OF PENNSYLVANIA continued
INHERITANCE TAX RENRN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Stonecipher, Adrian K. 21-08-00308
lTEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
17 Verizon (refund): 25.68
18 Wachovia Bank Checking Account Number ending in 9337: 12,240.16
19 Wachovia Securities Account Number 8113-7773: 49,523.28
20 Wachovia Securities Account Number 81137760: 231,347.77
21 Misc. costume jewelry: 140.00
'T01-AL (Also enter on Line 5, Recapitulation} ~ 334,$28,41
Copyright (c) 2002 form software only The Lackner Group, Inc. Farm PA-1500 Schedule E (Rev. 6-98)
~HdV'IA
Wacho~ is Bank N.A.
Balance Confirmation Services
P O Box 40O?S
Roanoke, VA 24GZ2-731
July 22, 2008
`~'ILEY GROUP
ATTN: S DAWN GLADFEL.TER
130 ~~7 CHURCH STREET SUITE 100
IITTiSRTTR(: Pn 1~Olo
Reference ID: 2511872
SUBJECT: Verification ! Confimlation of account and }3alance Inforruation provided for:
Custo-ner: ADRJA7V KEITH STONECIYEIER (SSN# XX,Y-Xrt-6O6b)
Date of Death: March 5, ?008
Deposik Account Information
Account Account Date of Death Average Date Maturity Interest Accrued YTD Dale
Tvpe Number Balance Balance* Opened Date Rate Interest InterestPald Closed
(,HECKINCr XkRX~X~~\93;7 312,27647 2/I912002 $;_69 516.18 3!232005
LEGAL TCILE- A KLITH STONECIPHER
CLOSING SALANCF.: 312243.46
Kevolvina Credit Lnfonnation
Account Account Date of Death Cred ii Dxtc Datc. Times Legal Titte
Type Number Balance Liruit Opened Closed Late
MASIER~:ARD 3ClXkXXXX.~tiJCXi740
MHNA -Revolvllb credit accounts are no loitoet serv iced by Wachovia Bark. Please contact MHNA at 3p0-177-9131.
VISA XXl~X>;7c~:Y?ck\ 720
MBNA Rey°ul~~uig credit ,iceounts are no IonKer serv iced by ~Vachocia Bank. Please contact MHNA at 500-4 77-v1 ~ f
Chher ~~ccounl Infonnaf ion
Account Acc~.unt Date of Balance i~atc D-ale I,edoer Collec~ai
Tvpe Number Opened Closed
SAFE DEPOSIT \}:~k~YlXl002ti 5%2ai1991
ROY
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Sovereign Bank
ESTA"T F, OF
SOCIAL SECURITY #:
DATE OF DEATH:
A Keith Stonecipher
322-20-6066
March 5, 2008
Account #: 2334025018 Type
In the Warne of: A Keith Stonecipher
Date of Death Balance:
Int_(Y"I'D) from 1/1/2008
Accrued interest to date of death:
Other Info:
Statement Savi
$4,291.91
to _ 3/5/2008
$4.57
$0.00
Account #: 233-239 Type: Safe Deposit Open date:
In the name of: A Keith Stonecipher
Date of Death ~aiarce:
[nt.(YTD) from to _
Accrued interest to date of death:
Other Info: Branch #233 Camp Hill Mall Camp Hill PA 1701 1
Open date: 4/18/1980
4/~Fi/199F
t't3ge i cif 1
APPRAISAL OF ITEMS TAKEN TO JAN W1LEY'S OFFICE FOR ADRIAN STONECIPHER
6TEIWI _' _ _ AMOUN
BRASS LIKE CANDLE HOLDERS _ 3.00 (-~ ~'~ ~~
-- _ _ - ~ __ C ~~ry~
ROYAL DOULTON STATUE _ _ _ 25.00
CHEST OF DRAWERS _ 400.00
2BOX LOTS WITH STEMWARE, DISHES, LOT 10._0.0
TOTAL - ' 438.
APPRAISAL OF ITEMS TAKEN TO JAN WILEY'5 OFFICE FOR ADRIAN STONECIPHER
'.ITEM _ _ _ AMOUNT
BOX #1 DISHES, CUPS, SAUCERS, MIS( __ _ _ 40.00
_ - --- --
BOX #2 CUPS, S&P, GLASS, STEMWARE 35.00
BOX #3 STEMWARE, CANDLESTICKS, MISC. 45.0(3
BOX #4 KNICK KNACKS, STEMWARE, DISHES, MISC. ! _ 20.00
TOTAL 140.00
~t5~~
L(.~-~-
~~~ ~ ; ~~~
~=~-~,
-~L~ ~ ~~
~~'~ `~~ ~ -~ ~ n,
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~ c~~,
__-_ _
s-/ ~~ ~ ~
~~~~}
Wachovia 11/12/2008 3:30 PM PAGE 11/011 F'ax Server
Es[ate Valuaden
A. Keith Stonecipher
Dale of Death: 03/OSf2008 Estate of: A. Keith Stonecipher
valuation Date: 03/05!2008 Account: 8113-7773
Prncessir.g Date: 0?/23f2008 Repert Type: Date of Death
Nusbet of securities: 1
File ID: 81137773
Shares Secl:ncy Mean and/oc Div and .oc Security
or Par Description AighlASL; ho4~/Bid Atljvstments Accruals 'slue
11 Sfi53.35 Cash (CASEI 5,653.35
2} 1895.465 FRANKLT.N SAX FREE TR {354723801: FflP7Ut)
PA T/F LNCM A
Mutual Elrod {as quoted by NASDAQ)
03/OSi2008 10-04000 Nkt
10-040000
31 1500 ING GIABAL EQTY DIV L PREM CPP (95689E107; IGDI
CQN
New York Slack Exchange
03l05I200g 16.y5000 16.54000 N/L
16-745000
n!„: n. 15s E_- n3 r03/2nna v>c- n3~n5t2rna o~y- n3/17/~rnB
Total value:
Total Accrual:
Total: 549,523.28
Portfolio Endnotes
Title:
A KEITH STONECIPftEF
fi03 PARK NIELS DR
NECHAElICS9UAG PA 1?055-4961
18,5!8.43
25,117-50
)34 00
549,289.28
5234.00
Page 1
'[h 1s report was proGucec with Estate'lal, a product of Estate Valuations 6 ?ricinq Systems, Inc. If you have questions,
please to°,tact EvP Systems at ?818) 313-6300 or www.evpsys.com. (Revision 7-0.9)
Wachc>via 1.1/13/2008 10:09 AM PAGE 2/002 Pax Server
Estate Valuation
n. Keitb Stonecipher
Date cf Death: 03:6512008 Estate o:: A. Keith Steneciphet
Valuatton Hate: O3/D5/20D8 Acco unit 6113 7760 / 962O395E29
Processi ng Date: 07/23!2006 Aepoct Type: Oate of Death
Number of Securities: 18
cc^ile ID: 81137766
Sh are= Security Mean and/or Div and Ir.t Security ,
cr Par Description HighlAs Y, LowlBid Adjustments Accruals Vaice
11 38279.67 COtafAND ACCOUNT (CASH) ?8,274.67
HANK DEPOSIT sNEEF OPTION
ACG rllal =-E5
2) 229.Sib B..ACdROCK LARGE CAP SER FDS (09250 J858: MDLVX)
L C VAL FD A
Hctual Ehrd (ag quoted by NA$CAQJ
03/CSl20OE ]6.9400D MkC
16.940000 3,893-08
3} 256.506 ADVISORS INNER CIRCLE r6 (0075h0825; CA6iwKI
CAMBFAR OP INS
Hutual fund (as quoted try NASDAQI
O3/O5i2O06 17.89000 Hkc
17.890000 4,588.89
4} 2O2.b11 COtAHBIA FDS SEfi TR (19765J103; NMTAXI
HAAS 21ST CN A
Hutuai Fund (as quoted by NASDAQ)
03105!2008 19.4100D Hkt
1-0.910900 2,919.62
5) 178.022 FMI FDS INC (302933106: FMIOXI
FOCUS FD
Mutual Fund (es quoted try NASDAQI
03/O5/20OE 28.SD000 Hkt
28.500000 5,073.63
6) 285b.62E FRACIYLIN TAk TREE TA (354723108: FT FIX)
FNSD T/F INC I
Mutual Fund (as quoted by NASDAQ)
O3/O5/2D0H 11.77CD0 Hkt
11.770600 :',522.51
7) 1938.19 GOLDMAN SACKS T.F. (fTXXX)
FS T}(FA MHH iN
03/05,`2008 1.DO000
L 000000 ~,93fi.19
3} 709.976 RA.RRIS ASSOC IN VT TR (913838202; OAlfIXi
OAhT1JSRK INTL I
Hutual 'cLnd {as cTuoted by NASDAQI
03/05/2008 18.63600 Hkt
18.E3060O ]3,124.39
91 128.986 IVY FD 1455E 97429; IGNAX)
GLO3AL NATfI A
Mutual F'u nd {a8 puOLed by NASDAQ)
C3/O5,`20O8 37.74000 Hkt
37.790000 4,844.06
101 227.385 JANUS II1VT FD t471O235flQ: JHiVg1
HIDCP tiAh INST
Hutuai PJnd (as quoted by NASDAQ)
03/OS/Z0O8 21.95000 Hkt
21.950000 4,991.10
11) 367.371 JOLiCS i3A5R INV? FDS 1481370500: JIEIX)
INTL ~Q L1, I
Hutuai FunC (as quoted by NASDAQ}
03/05/2008 41.13000 HkL
43.130000 15,109.97
12) 155.79 5Th'E T:CS HiTTUAL FDS INC 5 4 99 613757: h13PY'f.)
PAFAD:GH FD I
?!utua'_ Fucd {as quoted by NASDAQ)
D3lGSraoa n.IDCOD Ihkt
27.100000 4,991.91
Page 1
'715 cepo__ was produced with ESLateVai, a product of Estate Valuations ~ Pricing Systems, Int. If you have questions,
please contact EVP Systems at {8:g1 313-6300 or www.evpsya.com_ (Revision 7.0.9)
Wachovia 11/13/7.008 10:03 AM PAGE 2/002 Fax Server
gate of Death: 03/05/2008 Esca[e of: A. Keith Stonecipher
valuation Oate: 03/OSi20C8 Account: E.13-77E0 J 9620395825
Processing Date: 07/23f2006 Report Type: Date of Death
Number of Securities: 16
rile ID: B113776C
Shares Security Mean and/or Div and T_nt Security
or Par Description Rlgh/Ask Loa/fi1d AdJusL~nents Accruals Value
13} 104.088 LEGG MASON VALUE TR INC (524659208; LMNVX)
NAV VALUE TR
Mutual Elrod {as cucred ay NASDAQ}
03/05/2008 59.39000 Hkt
59.350000 6,478.79
14) 9049.59 NUVEEN MUN TR 167065Q-000: NUVBSCS
INT DR HUNBD R
Mutual Fund (as quoted by NASDAQ}
03/05/2008 E.7B000 nkt
B,TE00G0 35,999.46
75) 7]7.753 ROYCE FQ IRPRw\1
PREMIER FG W
MUtval Fund (aS cUC Ced by NASDAQ)
03/05/2008 16.92000 Mkt
16.920000 5,376.38
16) 4013.465 SCHROUER SER TR IECB040864; Sl`ffiIXS
MUNI HD INV
Mutual Fund (as quoted by NASDAQ)
D3/OS/20GB 9.55000 nkt
9.550000 38,328.54
17) 223.939 TCW FDS {87239N302; TGCEX}
SELECT EO CE. I
Mutual fund (as cucted by NASDAQ)
03/05/2008 17.16000 Hkt
17.160000 3,842.71
181 151.611 ROWS T PRICE MID-CAP GROWT& FD t779556'_04; RPMG?(}
COM
Mu[ual fund (as quoted by NASDAQ)
03!05/2408 52.26000 Hkt
52.260000 8,448.93
Tcta1 ValuB= $231,347.77
Total Accrual: 53.6fi
?otal: 52 31,351.43
Portfolio F,ndno tes
7"itle:
A KE1TH STONECIPH c"R
603 PARR HILLS DR
YECHAFJI C513URG PR 170$5
Page I
This .`epos*. was produced with 6stateVal, a product of Estate Valuations s Pti:ir,g Systars, Inc. i° you Nave. questions,
please contact EvP Systems at {818) 313-6300 or ~,w.evpsys.com_ (Revision 7.0.4)
.Rev-1510 EX+ (6-98j
CDMMONWEALTH OF PENNSYLVANIA
INHERRANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
Stonecipher, Adrian K. 21-08-00308
This schedule must be completed and filed d the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM utscKlr I Ivro yr rKUrtn I r DATE OF DEATH % OF DECD'S EXCLUSfON TAXABLE
(NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
1 AXA Equitable Annuity Contract Number 38,790.62 38,790.62
095504887 {Willadene 5tarment, beneficiary):
~ ' AXA Ey`iiitable Anriiiiiy Cvi~t~aCt i~ii~i~bGr-
199639263 (Willadene Storment, beneficiary):
3 Wachovia Securities IRA Account Number
8113-7757:
32,543.Og
52,067.49
~~ ~~~ ~Q
NL,JYN. V V
52,067.49
123,401.19
ZOTAL ~Al~o enter online 7, Recapitulations Rev. s-9a>
ace is needed, add+t+onal pages of the same size) Form pA_1500 Schedule G
(lf more sP
The Lackner Group, lnc.
n,.n.,r;nnt ic) 2002 form software on4y
Wachovia 11/12/2008 3:18 PM PAGE 19/021 Fax Server
Estate valuation
A. aeith Stonecipher IRA
Date of Death: G3f051200E Estate of: A. t<eith Stonecipher
Valuation Date: 03/05/2006 Account: 8113-7757 / 157020900952333
Processing Dzte: 07123!2005 Report Type: Date of Death
Nu.~nber of Securities- 23
File ID: 81137757
Shares Security Heaa and/or Div and Int Security
or Par Description bleb/Ask i.ovfBid Adjustments Accruals Value
11 364.47 EYERGREEti MHEY MAAh~T FUND CLASS S (CASH) 364.-07
Accrual D.14
1 21 95.0$5 ALLIANCERERNSTEIN [N'fLVAi,UE FD (01891_',400; ABIYX)
AD4ISOR CL
Hutual Furd ias quoted by NASDAQ)
0310512008 20. 27000 Mkt
20.270000 1,527.37
3) 107.235 BRI DGEWAY FD INC 1108747403: 9RSIx1
OLTRA SML MIiT
MULUal Ftind ;8S QUOLed by NASDAQ)
03105!2048 15. 60000 ":kt
15.600000 1,672.87
9) 273.917 ADVISORS INNER CIRCLE FD (0075wOB25; CAHWY.1
CAHBIAP OP ?NS
Mutual Fund (as quoted by NA80A(})
03/05/2908 17. 99000 Kk[
17.890000 4,891.43
51 55.16£ CON EN 6 STEERS INTL ALTY FDINC 419248H40ll
CL I
Mutual FLnd .as quoted by NASDAQ)
0310512406 15. 10000 Mkt
15.100000 833-01
5} 323.496 DODGE 6 COX INCOME FD {256210105; DODiX)
CON
Mutual Fund ;as quoted by NASDAQ)
03/45/2008 :2. 52000 Mkt
12.520000 4,049.54
7) 547.36 GOLDMAN SACRS TR {FS21XX)
FZNL SQ M4K IN
03/DS/2008 1. 00000
1.000000 507.36
B) 394.497 NGTCHKIS 6 WLLEY FDS (44134A768; NWCIXI
CORE VALUE I
Mutual Fund ias quoted by NASDAQ)
03/05l20G8 :0 .57000 Hkt
10.570000 4, 169. 8s
91 136.272 3ULL~S flAER INV'T FDS {46L370B72; .rETLx)
INTL EQTY ]I I
Mutual Fund {as quoted by NASDAQ)
03/05/2006 ]5 .82000 Hkt
15.82000D 2,155.82
10) 259.053 JULi[f5 OAER IN'TT FDS {J3GIX)
TOTAL RETCRtI I
Mutual Fwd {as quoted by NASDAQ)
03/05/2008 13 .32000 mkt
13.320000 3,583.79
11) 71.614 KEELEY FDS INC 1987301103; KStvx)
SML CAL VALU A
MuLUdl ''untl ta5 quoted by NASDAQ)
03/05/20DB ?6 .aaDOO Mkt
26.D90000 1,870.09
iZ) 250.262 HAINSTAY FUNDS (MDYLxI
HI YLD CORP i
Mutual Furd ias quoted by NASDAQ)
03/0S/2~008 5 .92000 Mkt
5.920000 '.590.75
Page 1
This report vas produced ulth Est ateval, a product of Estate Val;ations 6 Pricing Sys*_e7s, Inc. If you have questions,
please cnntac[ EYP Systems at (8181 313-6300 or ~M.evasys.com. 1Revision 7.0.9)
REV-1151 Ex+ (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE 7AX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Stonecipher, Adrian K. 21-08-00308
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION
NUMBER AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Jan M. Wiley
Socia! Security Number(s) ! EIN Number of Personal Representative(s):
Street Address 130 W. Church St., Suite 101
City Dillsburg State PA Zip 17019
Year(s) Commission paid
12,917.61
21,862.50
2. Attorney's Fees The Wiley Group, PC 21,862.50
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
4. Probate Fees Register of Wills: 855.38
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 19,254.01
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 78,752,00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1502 EX+ (6-98]
SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
Stonecipher, Adrian K. 21-08-00308
Copyright (c} 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-98)
Rev1502 EX+ t6-98)
SCHEDULE H-B7
OTHER
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVAN{A
INHERITANCE TAX RETURN
continued
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Stonecipher, Adrian K. 21-08-00308
ITEM
NUMBER DESCRIPTION AMOUNT
1 Closing costs from sale of real estate: 12,783.92
2 Cumberland Law Journal (advertise estate): 75.00
3 M8T Bank (service charge): 14.00
4 Register of Wilts {filing fee): 30.00
5 The Sentinel (advertise estate): 182.56
6 Victor Bahn (mowing): 342.00
7 Victor S. Bahn (house clean-up): 665.50
8 Victor S. Bahn (mowing): 328.00
9 Victor S. Bahn (mowing, cleaning): 225.00
10 Wachovia Bank (drill lock box): 125.00
11 Wachovia Securities (fees to obtain date of death values of accounts): 83.90
12 Willadene Storment (house cleanup, sale work, reimbursements, housesitting): 4,399.13
Subtotal ~ 19,254.01
Copyright (c) 2002 form software only The Lackner Group; Inc. Form PA-1500 Schedule H-87 (Rev. 6-98)
Rev-1512 EX+ {6-98)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
CONWIONWF.ALTH OF PENNSYLVANW
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Stonecipher, Adrian K. 21-08-00308
Include unreim6ursed medics{ expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 AT&T Mobility: 197.15
2 AT&T Universal Card: 91.67
3 Cardmember Services (mastercard): 45.64
4 Center for Kidney Disease: 135.00
5 Comcast Cable: 190.96
6 Erie Insurance (homeowners): 311.00
7 Martin A. Yohn, Sr., Tax Collector: 566.05
8 Marlin A. Yohn, Sr. Tax Collector: 1,918.81
9 PPBL: 581.26
10 Quantum Imaging: 6.01
11 UGI Utilities: 493.85
12 United Water Company: 95.36
13 Upper Allen Township: 224.00
14 Verizon: 264.74
15 York Waste Disposal: 87.00
TOTAL (Also enter on Line 10, Recapitulation) I 5,208.50
(1f more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedu4e t (Rev. 6-98)
REV-1513 EX+ (9A0)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Stonecipher, Adrian K. 21-08-00 308
NAME AND ADDRESS OF RELATIONSHIP TO
DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY
Do Not Llst Trustee(s) (Words) ($$$)
I- TAXABLE DISTRIBUTIONS [include outright spousal
and transfers
distributions
,
under Sec. 9116(a)(1.2)]
1 Carol L. Hutchinson Other 65.00
104 Tahoma Rd.
Lexington, KY 40503
2 Susan A. Sivulich Other 75.00
6258 Southridge Terrace
Harrisburg, PA 17111
3 Farlana Skl~~t Sict+Pr_in-Law 152;404.76
Walnut Grove Village
1095 Twilight Drive
Morris, 1t 60450
4 Witladene Storment Sister 275,366.44
240 Indiana
Salem, IL 62881
5 Genevieve Walsh Sister 151,951.58
16526 Walnut St.
Fountain Valley, CA 92708
Total 579,862.78
Enter dollar amounts for distributions shown above on fines 1 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
See continuation schedule(s) attached 1,000.00
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE i3 OF REV-1500 COVER SHEE I I -I,VVU.Vu
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98}
Rev-~ 502 EX+ ~6-98)
COMMONWFAL7H OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J-IfB
CHARITABLE AND GOVERNMENTAL
DISTRIBUTIONS
continued
ESTATE OF FILE NUMBER
Stonecipher, Adrian K. 21-08-00308
Copyright (c} 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J-IIB (Rev. 6-98)
Jan M. Wiley
David ). Lenox
THE WILEY GROUP
Attorneys at Law
December 3, 2008
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
In Re: Estate of Adrian K. Stonecipher
File Number 21-08-00308
Dear Register:
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Enclosed please find the inventory, status report, and inheritance tax return in duplicate regarding
the above captioned estate. Also enclosed is a check in the amount of $7,360.88 for the balance
of the tax due, and a check in the amount of $30.00 representing the filing fee.
Please note the postmark date to ensure the filing of the return and payment of tax is made
the nine-month time period.
I would appreciate if you would return the receipts to my office. I am enclosing aself-addressed,
stamped envelope for your use.
Thank you for your cooperation.
Sincerely,
Dawn Glad ter, Lega Assistant
/dg
encl.
130 W. Church Street, Suite 101 Dillsburg, PA 17019 Phone: (717) 432-9666 (800) 682-4250 Fax: (717) 432-0426
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