HomeMy WebLinkAbout02-0446
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of Nofley C. (\/e,Jt~J No. 2 J - 02 ~ 4L(1v,
also known as To:
Deceased.
Social Security No. _, 1"" j l"'11' t
Register of ~thCj
County of ... in the
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the execut 0 r
in the last will of the above decedent, dated Fc.hr'&o..y '-1
and codicil(s) dated M"
named
,l9~
I _,County, Pennsylvania, with
~'NI' 3,,<<'04 . 't~~'YJ~lPj .,.1
(list street, number and muncipality) &tQ'J~ of
Decendent, then L <11 j lyears of age, died A,,.-, \ \. , 11'-).001 ,
at tla, Jr... Ma/,aw
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
C.14aa~t,.W
.14' N.
Decendent was domiciled at death in
h ; 1 last family or principal residence at
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvani~
situated as follows: NO
$ <(01 000 ~
$
$
$
WHEREFORE, petitioner(s) respectfully. re,quest(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters rcrf CW\.~~ '1
(testamentary; administration c.I.a.; administration d.b.n.c.t.a.)
theron.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALI" ,OF PENNSYLVANIA l ss
COUNTY OF C~~ J
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
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Estate of
No. 21 - 02. - L..I.!:Jlo
We&:l/tJj N oiiy ~
DECREE 'OF PROBATE AND GRANT OF LETTERS
, Deceased
.J'1,,'Y)1.. . 'd' f h . .
It''J~, 10 conSI eratlOn 0 t e petItIon on
I
the reverse side hereof, satisfactory proof hav~n presented before me,
IT IS DECREED that the instrument(s) date d,14'1 .u, Jo/iJ
described therein be admitted tOilrobate and filed of record as the last will of
and Letters ~"b~~ Id ~
are hereby granted to. fY1q1J i b~
AND NOW
mAY
7
FEES
Probate, Letters, Etc. ......... $ 70.00
Short Certificates( ),....,.... $ 18.00
~ eK;tFa.pages.., $ 9.00
icp $ 5.00
TOTAL _ $ 102.00
Filed 5-7-2002
,.,.. 'oo'i'ie2l' to '~ec '~~' '5'~7':'02'
~;.c~~rllaLi,~,Q~<;-
~ eglster of Wills
11 J/l.. K"", A. 81.ft( (6nqJ
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AITORNEY (Sup. Ct. 1.D, No.)
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IDaslltill aun QI-eslam.ent
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OF
NOTLEY C. NEEDLES
BE IT REMEMBERED, that I, NOTLEY C. NEEDLES, of 221
North Second Street, Wormleysburg, Pennsylvania, being of
sound mind, memory and understanding, do make, publish
and declare this as and for my Last will and Testament,
hereby revoking and making null and void any and all
Wills and Testaments and writings in the nature thereof
by me at any time heretofore made.
ITEM 1: I direct that all my just debts and funeral
expenses be paid as soon after my demise as may be
convenient.
ITEM 2: All the rest, residue and remainder of my
estate, of whatsoever nature and wheresoever situate,
whether it be real, personal or mixed, including property
over which I have a power of appointment, I give, devise
and bequeath unto my grandson, MATTHEW RAY GOOD,
absolutely, provided he survives me for a period of
thirty (30) days.
ITEM 3: Should my grandson, MATTHEW RAY GOOD, fail
to survive me for a period of thirty (30) days, or should
we die simultaneously, I then give, devise and bequeath
my entire residuary estate as follows, to wit:
(a) I give my real estate, situate at 221
North
Second
Street,
Wormleysburg,
Pennsylvania to my former son-in-law, RAY
(b) All the rest, residue and remainder of my
estate, of whatsoever nature and
wheresoever situate, whether it be real,
personal or mixed, including property
over which I have a power of appointment,
I give, devise and bequeath unto my
niece, CARLA NEEDLES.
ITEM 4: I direct my hereinafter named Executor to
pay all inheritance, estate, succession and legacy taxes
of whatsoever nature and kind, to which my estate or the
transfer of any property passing hereunder or otherwise
passing by reason of my demise, may be subject and to
charge such taxes against my residuary estate, it being
my intention that none of the aforesaid taxes, either
federal or state, on any property required to be included
in my gross estate, under the provisions of any state or
federal law now in force or hereafter enacted, shall be
prorated among the persons interested in my estate to
whom such property is or may be transferred or to whom
any benefit accrues.
ITEM 5: I appoint my grandson, MATTHEW RAY GOOD, as
Executor of this my Last will and Testament. Should my
grandson predecease me, fail to qualify, cease to act or
renounce probate, I then appoint RAY C. GOOD, as
alternate Executor of this my Last will and Testament.
ITEM 6: I direct that my Executor shall not be
duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal this
2:2- day of ~ i 1,2 1 1 a 12Aj
WITNESS:
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COMMONWEALTH OF PENNSYLVANIA
.
.
: SS
COUNTY OF YORK
.
.
We, NOTLEY C. NEEDLES, ANGELA N. DOBRINOFF, ESQUIRE
and APRIL L. BROWN, the Testator and the witnesses
respectively, whose names are signed to the attached or
foregoing instrument, being first duly sworn, do hereby
declare to the undersigned authority that the Testator
signed and executed the instrument as his Last will and
Testament and that he had signed willingly (or willingly
directed another to sign for him), and that he executed
it as his free and voluntary act for the purposes therein
expressed, and that each of the witnesses, in the
presence and hearing of the Testator, signed this Last
will and Testament as witness and that to the best of
their knowledge the Testator was at the time eighteen
(18) years of age or older, of sound mind and under no
constraint or undue influence.
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NO~EY . NEEDL~S
CI1~ eld r). I7.J)/y.. (:n~
WITNE S
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( J ~rlA Q. . ~CJI uj)
WITN SS -
Sworn to and subscribed
before me this 2.;)...;. day of
Date of Death:
CERT FICA' I N
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Name of Decedent:
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Will No. O~, Y. ~ '0
Admin. No.
To the Register:
. .,
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on
Address
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Name
~II i..w./o/ (]tJ-,M!
Oat" {llfJf /~I ()d-
Signature
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Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Name
Address /- if
cYmll. f 1/1 ;7frJ/
Telephone ( ) 7/7-/ Gt/f~05() 71
Capacity: _ Personal Representative
%OUO." fo, pe"ooo' "p,,,eo"'"ve
COMMONWEALTH OF PENNSYLVANIA
DI,PARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
OEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX( 11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BLAKE KURT A ESQUIRE
40 EAST PRINCESS STREET
YORK, PA 17403
n______ fold
ESTATE INFORMATION: SSN: 275-12-4868
FILE NUMBER: 2102-0446
DECEDENT NAME: NEEDLES NOTLEY C
DATE OF PAYMENT: 06/23/2003
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 04/09/2002
NO. CD 002720
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $1,473.50
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TOTAL AMOUNT PAID:
$1,473.50
REMARKS: MATTHEW RAY GOOD-C/O KURT A
BLAKE ESQ,POSTMARK UNCLEAR.
CHECK# 1085
SEAL
INITIALS: CW
RECEIVED BY:
REGISTER OF WILLS
..
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
flt-/O .
IREV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
REV-l500EX + (6-00)
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DECEOENl'S NAME (LAST, FIRST, AND MIDDLE INITIAl)
Needles Notle Co e
DATE OF DEATH IMM-DD-Year)
DATE OF BIRTH IMf.I.OD-Yearj
04/09/2002 07/22/1918
(IF APPLICABLE) SURVMNG SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INITIA~
Widowed
[Xl 1. Original Retum
o 4. limited Estale
o 6. DecedentOied Testate (AtlachCOllyofWiIJ
o 9. Litigation Proceeds Received
o 2. Supplemenlal Retum
D 48. Future Interest Compromise {c!*ofdeath alIef 12-12-82)
o 7. Decedent Maintainecl a living Trust [Ak:h copy of Trust)
o 10. Spousal Poverty Credit (dale d dealh between 12-31-91 and 1.1.95)
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THIS SECTION MUST BE COMPLETED. ALJ.; CO
NAME
Kurt A. Blake Es uire
FIRM NAME PfApp_)
Blake & Gross LLC
TELEPHONE NUMBER
717.848.3078
lIENeE AND CONFIIlENTIALTAX.IIIFORMAnON SHOULD BE DIRECTED TO:
COMPLETE MAILING ADDRESS
29 East Philadelphia Street
York PA 17401
p' 0 OFFm'Ili.' EONLY
(1) W
, ,
(2) c-
c.:
;z:
(3) N
W
(4)
36,791.95 u
(5) N
:"':1
(6) N
(7)
1, Real Estate (Schedule A)
2. StocI<s and Bonds (Schedule B)
3. CIose~ Held CoipOration, Partnership or Sole-Proprietorshlp
4, Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Depo~1s & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7.lnter-VIYOS TranstOl' & Miscellaneous Non-Probate Property
(Schedule G or L)
8, Tolal Gross Assets (tolal Lines 1-7)
9, Funeral E,penses & Administrative Cools (Schedule H) (9)
10, Debls of Decedent Mortgage Liabilffies, & Liens (Schedule I) (10)
11. Tolal Deductions (Iolal Lines g & 10)
12, Net Velue 01 Eslal. (Line 8 minus Line 11)
13, Charitable and Govemmental BequeslslSec 9113 Trusts for which an election to tax has not been
made (Schedule J)
(8)
14, Nel Value Subject to Ta, (Line 12 minus Line 13)
SEE INSTRUCTIDNS ON REVERSE SIDE FOR APPlICABLE RATES
15. Amount of Line 14laxable at the spousal tax
rale, or transfers under Sec. 9116 (a)(1.2)
16, Amount ot Line 14laxable al lineal rate
X _(15)
32,744.36 X .045 (16)
X ,12 (17)
X ,15 (18)
(19)
17. Amounlof Line 14 taxable at sibling rate
lB. Amounl of Line 14laxable al oollaleral rate
19, Tax Due
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN QVERPAYMENT
>> BE SURE TO ANSWER AU:.
E SIDE AND RECHECK MATti. < <
OFACUII. useOIU /
FILE NUMBER
a. L -lL l.:. J2. 12 .:L :11E-
COIJNTYC~ YEAR NtlWIlEA
SOOAL SECURITY NUMBER
2 75- 1 2 - 4 8 6 8
THIS RETURN MUST BE FILED IN DUPlICATE WITIl THE
REGISTER OF WillS
SOOAL SECURJTY NUMBER
o 3.RemalnderRetum (daleofde8lhpriort) 12-13-82)
o 5, Federal Eslate Tax Retum Requiled
_ B, Total Number of Safe DeposH Bo,es
o 11. Election to tax underSec. 9113(A)_hSChO)
36,791.95
4,047.59
(11)
(12)
(13)
4,047.59
32,744.36
(14)
32,744.36
1,473.50
1,473.50
Decedent's Com lete Address:
STREET AD~RESS
. . 221 North 2nd Street
CITY
Wormleysburg
STATE
PA
ZIP
17043
Tax Payments and Credits:
I. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credil
8. Prior Payments
C. Discount
Total Credits (A + 8 + C) (2)
3. InteresUPenally if applicable
D. Interest
E. Penalty
TotallnteresUPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enfer the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater Ihan Line 2, enler the difference. This is the TAX DUE. (5)
A. Enter the interest on Ihe tax due. (5A)
8. Enter the total of Line 5 + 5A. This is Ihe BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ........................................................................... 0 [ZJ
b relain the right to designate who shall use the property transferred or its income; ........................................ 0 [ZJ
c. retain a reversionary interest: or .,..........................,.,....................................................................... 0 [K]
d receive the promise for life of either payments, benefits or care? ............................................................. 0 [ZJ
2. If death occurred afler December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?...........,........................ ,............................,.,.................,.,.,.... 0 00
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 [ZJ
4. Did decedent own an IndIVidual Retirement Aocount, annuity, or other non-probate property which
contains a beneficiary designation? .................................. ..................................................................... 0 00
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined this relum, including occompanying schedules and statements, en:! to the best of my knowledge and belief, it is true, correct
and complete.
Declaration of pre parer other than Ihe personal representative is based on all information of which prepocer has any knowledge.
I RESPONSIBLE FOR FILING RETURN DATE
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE '
DATE
ADDRESS
For dales of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers 10 or for the use of the surviving spcuse is 3%
[72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate impcsed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)J.
The statute does not exemot 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 dealh on or after July 1. 2000:
The tax rate imposed on the nel 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 0% [72 PS ~9116(a)(1.2)].
The tax rate imposed on the net value of Iransfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted In 72 P.S. ~9116(1.2) 172 P.S. ~9116(a)(I)].
The tax rate Imposed on Ihe nel value at transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(a)(I.3)]. A sibling is detined, under Section 9102, as an
indiVidual who has at leasl one parent in common with the decedent, whether by blood or adoption.
RE'J.'''''''''''~ ~~
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
R rOE TD DENT
SCHEDULE A
REAL ESTATE
ESTATE OF
FILE NUMBER
Needles Nollev Cove
An 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 be exchanged
between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevanllacts. Real property which is jointly-owned with
righ1 of
survivorshiD must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 1, Recapitulationl $
(If more space is needed, insert additionai sheets of the same size)
REV.'~""I"~ ~.
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
R SfOENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
Needles Notlev Cove
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
FILE NUMBER
ITEM
NUMBER
1
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also en'eron line 2, Roca!>'"la'lon) $
(If more space is needed, insert additional sheets ot the same size)
,:,.,~",.",,:.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
R SrOENT DECE ENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP or SOLE-PROPRIETORSHIP
ESTATE OF
Needles Notlev Cove
Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corparationlpartnership interest of the decedent, other than a sme-proprietorship.
See instructions for the supporting information to be submitted for sole-proprietorships.
FILE NUMBER
ITEM
NUMBER
1
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additionai sheets of the same size)
RE~"","II';.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C.1
CLOSEL Y.HELD CORPORATE
STOCK INFORMATION REPORT
ESTATE OF
Needles Notlev. Cove
FILE NUMBER
1. Name of Corporation
Address
Stale of Incorporation
Dale of Incorporation
Cily State Zip Code Total Number of Shareholders
2. Federal Employer I.D. Number Business Reporting Year
3. Type of Busmess ProductJService
4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common $
Preferred $
Provide all rights and restrictions pertaining to each class of stock.
5. Was the decedent employed by the Corporation? DYes o No
If yes. Posifion Annual Salary $ Time Devoted to Business
6. Was fhe Corporation indebted 10 the decedent? DYes o No
If yes. provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? 0 Yes 0 No
If yes, Cash Surrender Value S Net proceeds payable $
Owner of the policy
8. Did the decedent sellar transfer stock of this company within one year pnor to death or within two years if the date of death was prior to 12-31-82?
0 Yes 0 No If yes, o Transfer 0 Sale Number of Shares
Transferee or Purchaser Consideration $ Date
Attach a separate sheet lor additional transfers and/or sales.
9. Was there a written shareholder's agreement in effect at the time of the decedent's death? DYes o No
If yes, provide a copy of the agreement.
10. Was the decedent's stock soid? 0 Yes 0 No
II yes. provide a copy of the agreement of sale, etc.
11. Was the corporation dissolved or liquidated after the decedent's death? DYes 0 No
If yes, provide a breakdown 01 distributions received by the estate, including dates and amounts received.
12 Did the corporation have an interest in other corporations or partnerships? DYes 0 No
If yes, report the necessary information on a separate sheet, including. a Schedule C-1 or C-2 for each interest.
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A Detailed calculations used In the valuallon of the decedent's stock.
B Complete caples of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years.
C If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market valuels. It real estate appraisals have been
secured, attach copies.
0 List of principal stockholders at the date of death, number of shares held and their relationship to the decedent.
E Ust of officers, their salaries, bonuses and any other benefits received from the corporation,
F. Statement of diVidends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's srock.
~"~"'I'"';.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
R NIDE ED NT
ESTATE OF
Needles Notlev Cove
SCHEDULE C.2
PARTNERSHIP
INFORMATION REPORT
FILE NUMBER
1. Name of Partnership
Date Business Commenced
Address Business Reporting Year
City State Zip Code
2. Federal Employer 10. Number
3. Type of Business ProducflService
4 Decedent was a 0 General 0 limited partner. If decedent was a limited partner, provide initial investment $
5. PERCENT OF PERCENT OF BALANCE OF
PARTNER NAME INCOME OWNERSHIP CAPITAL ACCOUNT
A.
B.
C.
D.
6. Value at Ihe decedent's Inlerest $
7 Was the Partnership indebled 10 the decedent? 0 Yes 0 No
If yes, provide amount 01 Indebtedness $
8. Was there lile Insurance payable to the partnership upon the death at the decedent? o Yes 0 No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
9. Did the decedent sell or transfer an interest in this partnership within one yearpnor to death or within two years it the dale at dealh was prior 10 12-31-82?
0 Yes o No If yes, 0 Transfer 0 Sale Percentage transferred/sold
Transferee or Purchaser Consideration $ Date
Attach a separate sheet for addrtional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time of the decedent's death? o Yes 0 No
If yes, prOVide a copy of Ihe agreement
10. Was Ihe decedent's partnership interest sold? 0 Yes 0 No
II yes, provide a copy 01 the agreement of sale, etc.
11. Was the partnership dissolved or liquidated affer the decedent's death? o Yes 0 No
If yes, prOVide a breakdown of distributions received by the estate, including dates and amounts received,
12. Was the decedent related 10 any of the partners? 0 Yes 0 No If yes, explain
13, Did the partnership have an interest in other corporations or partnerships? o Yes 0 No
If yes, report fhe necessary Information on a separale sheet, Including a Schedule C-t or C-2 for each interest
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A, Defailed calculations used In Ihe valuation 0/ the decedent's partnership Interest.
B Complete copies of finanCial statemenfs or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years,
C If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market valuels, If real esfate appraisals have been
secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
""'~m."":~_
..~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
Needles Notlev Cove
All property jointly-owned with the right of sUlVivorship must be disclosed on Schedule F.
FILE NUMBER
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
R~'~>H':'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Needles Notlev Cove
Include the proceeds of litigation and the dale the proceeds were received by the estate. All property jointly-owned with the right of sUlVivorship must be disclosed on Schedule F.
FILE NUMBER
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Pennsylvaina State Bank 5,442.79
010303
2. Pennsylvaina State Bank 5,442.79
010304
3. Pennsylvaina State Bank 5,442.79
010305
4. Pennsylvaina State Bank 5,442.79
010306
5. Pennsylvaina State Bank 5,442.79
010307
6. Montour 0.1 Relund 1,04B.00
7. 1999 Ford Taurus 6,930.00
11,000 miles
Kelley Blue Book
B. Alllirst Checking Account 1,600.00
TOTAL (Also enter on line 5, Recapitulation) $
(if more space is needed, insert additional sheets of the same size)
36 791.95
"~''''''''''':'~
..~
COMMONWEAL IH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
Needles Notlev Cove
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
FilE NUMBER
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
B
c
JOINTLY.OWNED PROPERTY
lETTER DATE DESCRIPTION OF PROPERTY, %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of financial institution and balk account number or simila- identifying number. Attoch OA TE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed forjoinlly-held real eslate, VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on line 6, Recapitulation) $
(It more space is needed, insert additional sheets olthe same size)
REV_1510H'I'-~I).
. " -
.
. .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
Needles Notlev Cove
FILE NUMBER
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 %OF
ITEM INCIUOETHENAMEOf-THETRANSfEREE,THEIRRELATIONSHIPTODECEDENTAND THE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
NUMBER AT,ACH ACOPYOFTHE OEEO FOR REAl ESTATE VALUE OF ASSET INTEREST
IIFAP"-ICABLE)
1.
TOTAL (Also enter on line 7, Recapitulation) $
(It more space is needed, insert additional sheets of the same size)
....""".i'"~~
..~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Needles Notlev Cove
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1 United Health Care paid by Matthew Ray Good 780.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (5) Matthew Ray Good 2,500.00
Social Security Number(s) I EIN Number of Personal Represenlative{s) 191-54-9565
Street Address
City State Zip
Year{s) Commission Paid:
2. Attorney Fees Kurt A. Blake, Esquire 500.00
3. Family Ex.emption: (If decedenfs address is not the same as claimanfs, attach explanation)
Claimant
Street Address
City State Zip
Relationship at Claimant to Decedent
4. Probate Fees 102.00
5. Accountant's Fees
6. Tax. Return Preparer's Fees
7 Advertising paid by Kurt A. Blake 75.00
B. Advertising in The Sentinel paid by Kurt A. Blake 90.59
TOTAL (Also enter on line 9, Recapitulation) $ 4047.59
(If more space is needed, insert additional sheets of the same size)
.
R&.15t2EX'{'-9~) ~~
..~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
Needles Nollev Cove
FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
DESCRIPTION
AMOUNT
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets ot the same size)
R~V'1513EX: '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
"ntlo" r.nvp
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
L TAXABLE DISTRIBUTIONS [,"clude outright spousal dislJibulions, and Iransfers under
Sec. 9116 (a) (1.211
1. Matthew Ray Good Grandson
2. Ray C. Good Former Son-in-Law
3. Carla Needles Niece
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 1 B, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
TOTAL OF PART Il- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
.
"""..,"''''''.
. .
. .
SCHEDULE K
COMMONWEALTH OF PENNSYLVANIA LIFE ESTATE, ANNUITY
INHERITANCE TAX REfURN & TERM CERTAIN
RESIDENT DECEDENT
(Check Box 4 on Rev.1500 Cover Sheet)
ESTATE OF FILE NUMBER
Needles Notlev Cove
This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death
prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Will o Intervivos Deed of Trust o Other
LIFE ESTATE INTEREST CALCULATION
NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS
LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE
OUfeorOTermofYears _
OUfe or OTerm of Years _
OUfe or OTenn of Years _
OUfeorOTermofYears _
1. Value of fund from which life estate is payable $
2. Actuarial factor per appropriate table
Interest table rate- o 3 1/2% 06% 010% o Variable Rate %
3. Value of life estate (Line 1 multiplied by Line 21 $
ANNUITY INTEREST CALCULATION
NAME(S) OF NEAREST AGE AT TERM OF YEARS
ANNUITANTIS) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE
OUfeor OTermofYears_
OUfeor o Term of Years _
OUfeorOTermofYears _
OUfeor OTermofYears_
1 Value of fund from which annuity is payable $
2. Check appropriate block below and enter corresponding (number)
Frequency of payout - o Weekly (52) OBi-weekly (26) o Monthly (12)
o Quarterly (4) o Semi-annually (2) o Annually (1) o Other ( )
3. Amount of payout per period $
4. Aggregate annual payment. Line 2 multiplied by Line 3
5. Annuity Factor (see instructions)
Interest table rate 03112% 06% 010% o Variable Rate %
6 Adjustment Factor (see instructions)
7. Value of annuity -If using 31/2%, 6%,10%, or if variable rate and period payout is at end of period,
calculation is : Line 4 x Line 5 x Line 6 $
If using variable rate and period payout is at beginning of period, calculation is :
(Line 4 x Line 5 x Line 6) + Line 3 $
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on
Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on
Lines 13,15,16 and 17.
Ilf more space is needed, insert additional sheets of the same sIZe)
REV.1644 EX + (3-84)
~ '* INHERITANCE TAX
SCHEDULE "L'
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT OR INVASION
INHERITANCE TAX RETURN
RESIDENT DECEDENT OF TRUST PRINCIPAL FilE NUMBER
I. Estate of Npprllp~ Nntjpv rnHo
(Last Name) (First Name) (Middle Initial)
This schedule is appropriate only for estates of decedents dying on or before December 12, 1982.
This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisi
01 Section 714 of the Inheritance and Estate Tax Ad of 1961 or to report the invasion 01 trust principal.
II. Remainder Prepayment:
A. Eleelion to prepay liled with the Register of Wills on
(attach copy of election) (Date)
B. Nome(s) of Lile Tenant!s) Date of Birth Age on date Term of years income
or Annuitant(s) of election or annuity is payable
C. Assets: Complete Schedule L-l
1. Rea I Estate $
2. Stocks and Bonds $
3. Closely Held Stock/Partnership $
4. Mortgages and Notes $
5. Cash/Misc. Personal Property $
6. Totallrom Schedule L-l $
D. Credits: Complete Schedule L-2
1. Unpaid Liabilities $
2. Unpaid Bequests $
3. Value of Unincludable Assets $
4. Total from Schedule L-2 $
E. Total value of trust assets (Line C-6 minus Line 0-4) $
F. Remainder lactor (see Table I or Table II in Instruelion Booklet)
G. Taxable Remainder value (Line E x Line F) $
(Also enter on Line 7, Recapitulation)
III. Invasion of Corpus:
A. Invasion of corpus
(Month, Day, Year)
B. Nome(s) of Lile Tenont(s) Dote 01 Birth Age on date Term of years income
or Annuitant(s) corpus consumed or annuity is payable
C. Corpus consumed $
D. Remainder factor (see Table I or Table II in Instruction booklet) $
E. Taxable value of corpus consumed (Line C x Line D) $
(Also enter on Line 7, Recapitulation)
ons
.
REV.1645 EX + 13-8.4) INHERITANCE TAX
: SCHEDULE L-l
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT -ASSETS- FILE NUMBER
I. Estate of Needle~ Notlev. COVA
(Last Name) (First Nome) (Middle Initial)
II. Item No. Descriation Value
A. Real Eslale (please describe)
Total value afreal eslate $
(include an Seclion II, Line C-] an Schedule L)
B. Stocks and Bands (please lisl)
Talal value of slacks and bonds $
(include on Section II, Line C-2 an Schedule l)
C. Closely Held Slack/Partnership (attach Schedule C-l and/or C-2)
(please list)
Talal value of Closely Held/Partnership $
(include an Section II, Line C-3 an Schedule L)
D. Mortgages and Noles (please lisl)
Total value of Mortgages and Noles $
(include an Section II, line C-4 on Schedule L)
E. Cash and Miscellaneous Personal Property (please list)
Tolal value of Cash/Misc. Pers. Property $
(include on Section II Line C-S on Schedule Ll
111.1 TOTAL (Also enter on Section II, line C-6 on Schedule L) 1$
(If more space is needed, attach additional 81/2 x 11 sheets.)
.
REVt1646 EX + (3-84j INHERITANCE TAX
.. SCHEDULE L-2
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN -CREDITS- FilE NUMBER
RESIDENT DECEDENT
I. Estate of N I NntlF!v r~"o
(last Nome) (First Namej (Middle Initiol)
II. Item No. Description Amount
A. Unpaid liabilities Claimed against Original Estate, and payable from assets
reported on Schedule L-l (please list)
Total unpaid liabilities $
(include an Sectian II, Line 0- 1 on Schedule l)
B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list)
Total unpaid bequests $
(indude on Section II, Line 0-2 on Schedule L)
C. Value of assets reported on Schedule L-l (other than unpaid bequests listed under
"BlO above) that are not included for tax purposes or that do not form 0 port
of the trust.
Computation as follows:
Total unincludable assets $
(include on Section II, Line 0-3 on Schedule L)
I
III. TOTAL (Also enter on Section II, Line 0-4 on Schedule l) $
(If more space is needed, attach additional B'/, x 11 sheets.)
. REv.,:47EX,I*
SCHEDULE M
FUTURE INTEREST COMPROMISE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Check Box 4a on Rev.1500 Cover Sheet
FILE NU MBER
ESTATE OF
Needles Notlev Cove
This Schedule is appropriate only for estates of decedents dying after December 12,1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in
possession and enjoyment cannot be established with certainty.
Indicate below the type of instrument which created the future interest and attach a copy to the tax return.
D Will D Trust D Other
I. Beneficiaries
NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decedents dying on or atter Juiy 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within
9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse
exercises such withdrawal right.
D Unlimited right of withdrawal D Limited right of withdrawal
III. Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amount of Future Interest .... . ........ ........ ......... ..... . ..... . . . . . . . $
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(aiso Include as part of total shown on Line 13 of Cover Sheet) ......$
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One 06%, 03%, 00% ........... .. . . . $
(also include as part of total shown on Line 15 of Cover Sheet)
4. Value of Line 1 taxable at lineal rate
Check One 06%, 04.5% .... . . . . . . . . . . . . . . . . . . $
(also include as part of total shown on Line 16 of Cover Sheet)
5. Value of Line 1 taxable at sibling rate (12%)
(also include as part of total shown on Line 17 of Cover Sheet) .. . . . . $
6. Value of Line 1 taxable at collateral rate (15%)
(also include as part of total shown on Line 18 of Cover Sheet) .. .- . . $
7 Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) .... ........ . .. ..... $
(If more space is needed, insert additional sheets of the same size)
.VV.1648 ': 11.921 ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX DIVISION (AVAILABLE FOR DATES OF DEATH 1/1/92 to 12/31/94)
ESTATE OF I FilE NUMBER
Needles Notlev Cove .
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet
SCHEDULE N
SPOUSAL POVERTY CREDIT
PART I - CALCULATION OF GROSS ESTATE
1. Taxable Assets totol from line 8 (cover sheet) .
1.
36 791.95
2.
Insurance Proceeds on Life of Oecedent d.
2.
3. Retirement Benefits.
3.
4. Joint Assets with Spouse.
4.
5. PA Lottery Winnings.
5.
60. Other Nontoxable Assets: List (Attach schedule if necessary) .
6a.
6b.
6c.
6d.
6. SUBTOTAL (Lines 60, b, c, dl .
6.
7. Total Gross Assets (Add lines 1 thru 6) .
7
36791.95
8. Total Actual Liabilities ................ 8.
9. Net Value of Estate (Subtract line 8 from line 7) ......................................................................... 9.
If line 9 is greater than $200000 - STOP The estate is not eligible fo claim the credit If not continue to Part If
36.791.95
PART II _ CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income
Tax Returns for decedent and spouse.)
d. Tax Exempt Income.
e. Other Income not
listed above.
I. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19
10. 20. 30.
1 b 2b. 3b.
1, 2" 3c.
ld. 2d. 3d.
Ie 2.. 3..
11. 2t. 31.
Income:
a. Spouse..
b. Decedent.
c. Joint.
f. Total...
4. Average Joint Exemption Income Calculation
40. Add Joint Exemption Income from above:
(11)
+ (3n
=
+ (21)
(-;- 3)
4b.
Average Joint Exemption Income. .............
If !irle 4(h) is greater thon $40000 - STOP. The estate is not eligible to cloim the credit If not/ continue fa Part III
=
PART III _ CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT
ESTATES
1. Insert amount of taxable transfers to spouse or $100,000, whichever is less
I.
2. Multiply by credit percentage (see instructions) .
3. This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet. ..................... .
4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedents gross estate.
5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet.
2.
3.
4.
5.
R:V''''''~'''''. SCHEDULE 0
. .
COMMONWEALTH OF PENNSYLVANIA ELECTION UNDER SEC. 9113(A)
INHERITANCE TAX RETURN (SPOUSAL DISTRIBUTIONSI
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Needles Notlev Cove
00 not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) 01 the Inheritance & Estate Tax Act.
II the eleclion applies to more than one trust or similar arrangement, a separate form must be filed for each trust.
This eleclion applies to the Trust Imarital, residual A B, By-pass, Unified Credit, etc.).
If a trust or similar arrangement meets the requirements of Section 9113(A), and:
a, The trust or similar arrangement is listed on Schedule 0, and
b. The value of Ihe trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,
Ihen the transferor's personal represenlat,ye may specifically Identify the trust lall or a fractional portion or percentage) to be included in the eiection to haye such trust or
similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the
personal representalive shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator 01 this fraction is equal to
the amount of the trusl or similar arranqement included as a taxable asset on Schedule O. The denominator Is equal to the total value of the trust or similar arrangement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedenfs
survivina SDouse under a Section 9113 IAl trust or similar arrangement.
DESCRIPTION VALUE
Part A Total $
PART B: Enter the descriotion and value of all interests included in Part A for which the Section 9113 IA) election to tax is beina made,
DESCRIPTION VALUE
Part B Total $
(If more space is needed, insert additional sheets of the same size)
r
I
.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
.
Needles: Notley, Coye
Paqe 1
Schedule H - Funeral Expenses & Administrative Costs - 84. Probate Fees
ITEM
NUMBER
DESCRIPTION
AMOUNT
SUBTOTAL SCHEDULE H.B4
1'1-t.~ /- /0
"\, BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REV-1541 EX AFP (01-03)
'_:'.J I
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
CD-~NTY
ACN
09-22-2003
NEEDLES
04-09-2002
21 02-0446
CUMBERLAND
101
NOTLEY
C
.,";"",
U.;
_OJ
KURT A BLAKE ESQ
BLAKE & GROSS
29 E PHILADELPHIA ST
YORK PA 17401
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-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF NEEDLES NOTLEY C FILE NO. 21 02-0446 ACN 101 DATE 09-22-2003
TAX RETURN WAS: (X) ACCEPTED AS FILED
CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3)
4. Mortgages/Notes Receivable (Schedule D) (4)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
.00 NOTE: To insure proper
.00 credit to your account,
.00 submit the upper portion
.00 of this form with your
36,791.95 tax payment.
.00
.00
(8) 36,791.95
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
(9)
(10)
4,047.59
.00
(11)
(12)
(13)
(14)
4.047.1i9
32,744.36
.00
32,744.36
If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rate
18. Amount of Line 14 taxable at Collateral/Class B rate
NOTE:
.00 X 00 .00
32,744.36 X 045 = 1,473.50
.00 X 12 .00
.00 X 15 .00
(19)= 1,473.50
(15)
(16)
(17)
(18)
19. Principal Tax Due
TAX CREDITS'
.
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
06-23-2003 CD002720 .00 1,473.50
BALANCE OF UNPAID INTEREST/PENALTY AS OF 06-24-2003 TOTAL TAX CREDIT 1,473.50
BALANCE OF TAX DUE .00
INTEREST AND PEN. 33.31
TOTAL DUE 33.31
* 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.)
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF INOIVIOUAl TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BLAKE KURT A ESQUIRE
29 E PHILADELPHIA STREET
YORK, PA 17401
___nn_ fold
ESTATE INFORMATION: SSN: 275-12-4868
FILE NUMBER: 2102-0446
DECEDENT NAME: NEEDLES NOTLEY C
DATE OF PAYMENT: 10/10/2003
POSTMARK DATE: 1 0/09/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 04/09/2002
NO. CD 003106
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $33.31
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: KURT A BLAKE ESQUIRE
CHECK# 22448
SEAL
INITIALS: AC
RECEIVED BY:
REGISTER OF WILLS
$33.31
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
//'-6/-/0
'<. BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. ZB0601
HARRISBURG, PA 171ZB-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
*'
REV-16D7 EX AFP IOI-OS)
KURT A BLAKE ESQ
BLAKE & GROSS
29 E PHILADELPHIA ST
YORK PA 17401
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
1l-03-2003
NEEDLES
04-09-2002
21 02-0446
CUMBERLAND
101
NOTLEY
C
t .::
Allount Rellitted
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, subllit the upper portion of this forll with your tax paYllent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REv=i6"ifj-Ex-AFP--roY--03Y------...-iNHERITANcE-Ti3f-sTATEMENT-CrF'-ic-coi:iN"T--...---------------- - - ---
ESTATE OF NEEDLES NOTLEY C FILE NO.21 02-0446 ACN 101 DATE 1l-03-2003
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: 09-22-2003
PR I NCI PAL TAX DUE: .................................................................................................................................................................................
..........................................
1,473.50
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
06-23-2003 CD002720 .00 1,473.50
10-09-2003 CD003106 33.31- 33.31
TOTAL TAX CREDIT 1,473.50
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. )
Status Report Under Rule 6.12
Name of Decedent:
Date of Death:
Estate File No.:
Notley C. Needles
April 9, 2002
2002-00446
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the
following with respect to completion of the administration of the above captioned estate:
1. State ~ administration of the estate is complete:
Yes~ No
2. If the answer is No, state when the personal representative reasonably
believes that the administration will be complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative f,~-a final account with the
Yes No ~
Court?
b. Did the personal representative state an account informally to
the parties in interest? Yes ~ No
Copies of receipts, releases,,joinders and approv~ of formal or informal accounts
may be filed with Clerk of Orphan s Court and may/~hed to this report.
30rh day of March, 2004
Kurt A. Blake, Es
lphi~'
29 East Phflade S~eet
York, PA 17401
848-3078
~X~Counsel fo'r perso~
representative