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Home My WebLink About02-0303PETITION FOR PROBATE and GRANT OF LETTERS also known as Social Security No. 0<°3 ~3~ -~ 0 ~'oD/fceased' No. a~l' Og)--- ~O~ To: Register of Wills for the County of Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age iai' older an the execut r ,x in the last wilt of the above decedent, dated J-~.~ ] I,ff.R and codicil(s) dated in the named ,19 (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in O_.L~m~oo_r' I~1 County, Pennsylvania, with h ~ ~ last family or principal residence at ~/~¢~..~'~' LO -~_a-r-~ ~ I'1o. ~1 (list street, number and muncipality) Deceodent, then V~ year~ age, died ~ac'[~ [ ~ , ~~ 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: 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 Pennsylvania $ situated as follows: WHEREFORE, petitioner(s) respectfully.._request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters lt=~7-n rnmv7-,o ~ '4 / (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~> ss COUNTY OF Sworn to or affirmed and subscribed before me this 25th day of MARCH 2002 ~lt~Y C ~g~S ~ ~"~- ~e~-~ter The petitioner(s) above-narc, ed 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. No. ~1- 0~-~0~ Estate Of WIl_LIb/Vl E ROUSE , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW MARCH 26, 2002 xlO~il~r~, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated g2>RIL 13, 7983 described therein be admitted to probate and filed of record as the last will of NILLIg31 E ROUSE and Letters are hereby granted to IRIS L ROUSE FEES Probate, Letters, Etc .......... $. 200.00 15.00 Short Certificates( ) .......... $. jcp $ 5.00 TOTAL __ $ 226.00 Filed . MARCH .25,. 2002 ................. mailed to attorney on 3-26-02 blgRY ~ LE~Vt~egister of Wills ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE IJ'h LAST WILL AND TESTAMENT OF WT~.~.FAM E. ~OUSE I, WILI~IAM E. ~OUSE, of Hampden Township, Cumberland County, Pennsylvania. being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making null and void all former Wills by me at anytime heretofore made. First: I give, devise and bequeath all of my property real, personal and/ or mixed of whatsoever nature and wheresoever situate to my wife, Iris L. Rouse, forever and absolutely. Second: In the event that my wife, Iris L. Rouse, should predecease me, I then give, devise and bequeath all my property real, personal and/or mixed of whatsoever nature and wheresoever situate as follows: (a) My son, Martin, shall have the option to purchase the business and business property at the appraised value; one-third of the purchase price down and the other two-thirds of the purchase price to be paid within five (5) years from the time of pur- chase. (b) Ail the rest, remainder and residue of my estate shall be di- vided into three shares: (1) One share to my daughter, Loveen, her heirs and assigns. (2) One share to my son, Martin, his heirs and assigns. (3) One share to Commonwealth National Bank in trust, neverhhe, less, for my daughter, Lisa, her heirs and assigns. The and all legacies, devises and ,other gifts of principal and income shall be free and clear thereof. Fifth: I appoint Iris L. Rouse to be the Executrix of this my Last Will and Testament and if she be deceased or incompetent to serve, I then appoint Martin Rouse to be the Executor of this my Last Will and Testament. of IN WITNESS WHEREOF, I have hereunto set my hand and seal this day Signed, sealed, published and declared by the Testator above named, as and for his Last Will and Testament, in the presence of us who have hereunto, at his request, subscribed our names in his presence and in the presence of each other as witnesses hereto. (SF~L) -3- LAST WILL AND TESTAMENT OF WIALIAM E. ROUSE haw ROBERT J. TRACE I 11 Locu$~ Street HARRISBURG, PENNA. 17101 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Date of Death: Will No. ~l. - .~X72 ~ Admin. No. To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of t~he 4rpha~ Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on ~ J.17./t.).,~ : Name Ad&ess Notice has now been given to alt persons entitled thereto under Rule 5.6(a) except Date: Signature Address Telephone ~/~) Capacity~t~.. Personal Representative Counsel for personal representative Name of Decedent: Date of Death: Will No.: STATUS REPORT UNDER RULE 6.12 '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 whether ~ra~nistration of the estate is complete: Yes No D 2. If the answer is No, state when the personal representative reasonably believes that the aamlnistration will be complete: 3. If the answer to No. 1 is Yes, state the following: be Did the personal representative file a final account with the Court? Yes No~ The separate Orphans' Cour~ No. (if any) for the ~ersonal representative's account is: __ Date: Did the personal representative state au account informally to the parties in interest? Yes ~], No' [-'] ' c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the. Orpham' Court and may be attached to thi~ gnature Address' Telephone No. Capacity: ~Personal Representative [--] Counsel for personal representative 15056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~ INHERITANCE TAX RETURN Dept. 280601 9, Harrisburg PA 17128-0601 RESIDENT DECEDENT ~ ~ ~ ~ U J ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~3~3~ a7a~ 03/~-~a~a2 a 30~/ ~~7 Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N b r Spouse s Social Security um e THIS RETURN MUST BE FILED IN DUPLICATE WITH THE a / I ~,~ ~ ~~ / REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TU: Name Daytime Telephone Number Firm Name (If Applicable) REGISTER OF WILLS USE ONLY First line of address ~-~ a ~ o ~ ~ 4 ~. ~ ~ ~ s ~- ~ t=a ~ ~ r, -,~ Second line of address r - ~ ~ `- `7 -.. -- ~ ra .~ ;. ~ ~~FILED ~~ ~ City or Post Office State ZIP Code - - . P ~ _ r ~ --ra Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, tive is based on all information of which preparer has any knowledge. t l represen a it is true, correct and complete. Declaration of preparer other than the persona IGNATUR F PERSON RE ONSIBLE FOR FILING RETURN ~.~- - DAT 9 ADDRESS ~ (~ ~To~s ~ ~~ ~ SIGNATU P AR OT THAN REPRESENTATIVE DATE ADDR SS Gv/ PLEASE USE O IN L FO M NLY Side 1 15056041046 15056041046 J REV-1500 EX Dacprignt'S Sncial SPCUrity Number ~ ~ ~ 3 ~ ~ ~ U / Decedent's Name: REC APITULATION 1. Real estate (Schedule A) . ........................................... . 1. O ~ 2 • ~ ~ 2. Stocks and Bonds (Schedule B) ...................................... . . l C) h d hi S 3 ! ~ d ~ ~ / • ~ 3. .... u e c e p ( Closely Held Corporation, Partnership or Sole-Proprietors . 4. 9 9 ( ) ............................ Mort a es & Notes Receivable Schedule D 4, . ' CS G 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... . 5. ~J ~ d ~• 6. Jointly Owned Property (Schedule F) C Separate Billing Requested ...... . 6. ~ ~ ~• ~ d 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C Separate Billing Requested....... . 7. O I 3 ~> D ~ ~' v 8. Total Gross Assets (total Lines 1-7) ................................... . 8. . 9. Funeral Expenses & Administrative Costs (Schedule H) .................... . 9. ~ J ~ ~ . ~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............... . 10. Q 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. 7 ~~ ~ . ~ d 12 ~ ~ ~ ~ ~ ~ ~ / 12 Net Value of Estate (Line 8 minus Line 11) ............................ . .. . 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~ D an election to tax has not been made (Schedule J) ...................... .. 13. 14 J n ~? ~ ~ 3 / Q` 7 14 Net Value Subject to Tax (Line 12 minus Line 13) ...................... . .. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 / ~ / ~ 7 ~• ~ / 7 (a)(1.2) X .0 ~ 15. O 6 16. Amount of Line 14 taxable d U 16 U ~ . at lineal rate X .0 . 17. Amount of Line 14 taxable G ~ 17 C~ ~ at sibling rate X .12 • . 18. Amount of Line 14 taxable ,,/I~~~~ • ~ 18 ~ Q d (J at collateral rate X .15 . 19. TAX DUE .........................................................19. 15056042047 • ~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~-~ C)p ~~~ ~ 15056042047 Side 2 O 15056042047 REV-1500 EX Page 3 Decedent's Complete Address: File Number ~//~~ ~~~~ DECEDENT'S A E / ~. __ -_ - STREET A DRES j ~~ CITY _ _ STATE ZIP ./ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InterestlPenalty if applicable D. I nterest _ _ E. Penalty (1) ~--~ ~ _ - _- Total Credits (A + B + C) (2) ' ~ ~ - - _ Total Interest/Penalty (D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) ~~ (q) "_ ~'~ (5) .. 0 ' (5A) '~ (56) °'~ ~ 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 :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death ^ without receiving adequate consideration? ........................................................................................................ ...... 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ....... ....... ^ Did decedent own an Individual Retirement Account, annuity, or other non-probate .property which 4 . contains a beneficiary designation? ................................................................................................................. ....... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent (72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 be (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCFIEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1504 EX+(6-98) SCHEDULE C CLOSELY HELD CORPORATION, COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP OR INHERITANCE TAX RETURN RESIDENT DECEDENT SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER VALUE AT DATE 1. i' C~ G G J/ o/ Q~T ~ U ~C G~ S~rI~-yf C/Ct C'sc%~''G~'~~ TOTAL (Also enter on line 3, Recapitulation) $ ~~(j ~~~ ~ - (If more space is needed, insert additional sheets of the same size) ~- REV-1505 EX+ (6-98) , ' ~ ~ SCHEDULE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Corporation State on Incorporation Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year 3. Type of Business Product/Service 4. STOCK TYPE TOTAL NUMBER OF PAR VALUE NUMBER OF SHARES VALUE OF THE VotinglNon•Voting SHARES OUTSTANDING OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ................................... ^ Yes ^ No If yes, provide amount of indebtedness $ 7 Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $_ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ..................................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- • ~ ~ A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies 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 value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List 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 stock. ^ No (If more space is needed, insert additional sheets of the same size) REd-1506 EX+ (9-00) SCHEDULE C-S PARTNERSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Partnership Date Business Commenced Address Business Reporting Year C{ty State Zip Code 2. Federal Employer I.D. Number 3. Type of Business ProducUSenrice 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. PERCENT I PERCENT BALANCE Of PARTNER NAME OF INCOME , OF OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes ^ 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 year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements 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 addressles and estimated fair market value/s. 1f real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (6-98) ~~~, SCHEDULE D ~~. COMMONWEALTH OF PENNSYLVANIA MORTGAGE5 & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) F?EV-1508 EX+ (6-98) T ~- ~ SCHEDULE E '~~= COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF / ~/ Q ~, ~Ci c,.~-~ ~C~ !ter! 5 ~-- ~ ~ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION j c~,c~i~~~ ~"" ~os~ ~G~~3~ ~~ ~ 3 G~~~~~o~.~ ~~~~ ~ ~ C l~: ~~~L~,T .~ N~~ ~~~~ FfLE NUMBER ~~ -a.3a VALUE AT DATE OF DEATH ~ ~c~oa. ~` a~ S ~C~. ~~ / ~ /~~~ ~~ ~~®.~~ iCt~ TOTAL (Also enter on line 5, Recapitu4ation) $ ~ ~ ~~~ ~~ (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF~~ / // / FILE NnUM,.B~ER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT B. C .IOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % Of DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF ' NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED fOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST S INTEREST DECEDENT _. TOTAL (Also enter on line 6, Recapitulation) 15 ~,~ (~ . (If more space is needed, insert additional sheets of the same size) , REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF 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. ITEM NUMBE DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. TOTAL (Also enter on line 7 Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) _ ~~ ~° ~ SCHEDULE H ~~ COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF , FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: / ~ / (jam B. 1 2. ~ Attorney Fees State Zip G 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address _~Q ' City State Zip Relationship of Claimant to Decedent ~~~, ~ 4. Probate Fees 5. Accountant's Fees Ge 6. Tax Return Preparer's Fees ~ U 7 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Rep Street Address City Year(s) Commission Paid: TOTAL (Also enter on line 9, Recapitulation) $ 7J// ~ (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCFIEDULE J COMMONWEALTH OF PENNSYLVANIA I BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) REV.1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover SheE FILE NUMBER 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 from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME(S) OF LIFE TENANT(S) DATE OF BIRTH • NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................ . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH • NEAREST AGE AT DATE OF DEATH TERM OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ 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 - ^ 3 1/2% ^ 6% ^ 10% ^ 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 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-'saEx+c3-oal INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT IN RESIDENlEDECEDENTRN OR INVASION OF TRUST PRINCIPAL FILE NUMBER I. ESTATE OF (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 provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on ____ (Date) B. Name(s) of Life 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-1 1. Real Estate ...............................$ 2. Stocks and Bonds ..........................$ 3. Closely Held Stock/Partnership ...............$ 4. Mortgages and Notes .......................$ 5. Cash/Misc. Personal Property ................$ ___ 6. Total from Schedule L-1 ......................................................$ 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 D-4) .................................$ F. Remainder factor (see Table I or Table II in Instruction 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. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed 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) REV 1647 EX+ (9-00) SCHEDULE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT (Check Box 4a on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER This Schedule is appropriate only for estates of decedents dying after December 12, 1952. 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. ^ Will. ^ Trust ^ 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 after July 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. ^ Unlimited right of withdrawal ^ 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. (also 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 ^ 6%, ^ 3°l°, ^ 0% .......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% .............................$ (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) REV-1648 EX (11-99)(I) SCHEDULE N s~ !~~,~;~~ SPOUSAL POVERTY CREDIT COMHIONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01192 TO 12131194) INHERITANCE TAX DIVISION ESTATE OF FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1 . Taxable Assets total from line 8 (cover sheet) ............................... ............. 1 . 2. Insurance Proceeds on Life of Decedent ................................... ............. 2. 3. Retirement Benefits .................................................. .............. 3. 4. Joint Assets with Spouse .............................................. .............. 4. 5. PA Lottery Winnings ........................:........................ .............. 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6b. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) ....................................................... 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilities ............................................................. a. 9. Net Value of Estate (Subtract line 8 from line 7) ........................................... 9. If line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part II. Income: 1. TAX YEAR: 19 Spouse ........... a 1a. . b. Decedent .......... 1 b. c. Joint ............. 1c. d. Tax Exempt Income .. 1d. e Other Income not listed above ........ 1e. f. Total ............ 1f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) _ + (3f) (~ 3) 4b. Average Joint Exemption Income ..................................................... _ If line 4(b) is greater than $40,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................... ~ 1 2. Multiply by credit percentage (see instructions) ........................................... 2 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 . ............................... 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate 4. 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....... 5. 2b. 3b. 2c. 3c. 2d. 3d. 2e. 3e. 2f. 3f. REV-~~49 EX+ (6-98) .. }- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE O ELECTION UNDER SEC.9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. Thiselection applies to fhe Trust (marital, 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 the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, the n the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or sim- ilar property treated as a taxable transfer in this estate. ff less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered tc have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. 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 decedent's Part B: Enter the description and value of all interests included in Part A for which the Section yi~;~(A) election to tax Is Deing mane. (If more space Is neetletl, msett aoomonal sheets or the same si~ef Register of Wills of CUMBERLAND County, Pennsylvania Certificate of Grant of Letters No. 2002-00303 PA No. 21-02-0303 ESTATE OF ROUSE WILLIAM E Late of HAMPDEN TOWNSHIP , Deceased Social Security No. 237-36-0701 WHEREAS, on the 26th day of March 2002 an instrument dated April 13th 1983 was admitted to probate as the last will of (ROUSE WILLIAM E late of HAMPDEN TOWNSHIP CUMBERLAND County, who died on the 16th day of March 2002 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, MARY C. LEWIS Register of Wills in and for the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to ROUSE IRIS L who has duly qualified as Executor(rix) and has agreed to administer the estate according to law, all of which fully appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PEr?NSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my Office the 26th day of March 20.02. ,• z __ ~ ~ ,~. gis er o i s **NOTE** ALL NAMES ABOVE APPEAR. (LAST, FIRST, MIDDLE) LAST WILL AND TESTAMENT OF WILLIAM E. ROUSE a. - - o~-3os I, WILLIAM E. ROUSE, of Hampden Township, Cumberland County, Pennsylvania being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making null and void all former Wills by me at anytime heretofore made. First: I give, devise and bequeath all of my property real, personal and/ or mixed of whatsoever nature and wheresoever situate to my wife, Iris L. Rouse, forever and absolutely. Second: In the event that my wife, Iris L. Rouse, should predecease me, I then give, devise and bequeath all my property real, personal and/or mixed of whatsoever nature and wheresoever situate as follows: (a) My son, Martin, shall have the option to purchase the business and business property at the appraised value; one-third of the purchase price down and the other two-thirds of the purchase price to be paid withnn five (5) years from the time of pur- chase. (b) All the rest, remainder and residue of my estate shall be di- vided into three shares: (1) One share to my daughter, Loveen, her heirs and assigns. (2) One share to my son, Martin, his heirs and assigns. (3) One share to Commonwealth National Bank in trust, neverti less, for my daughter, Lisa, her heirs and assigns. The income and as much of the principal as necessary shall be used for her medical aid and drug expenses, in addition to any neces. sities that she might require. This Trust shall continue until my daughter shall reach the age of thirty (30) years, at which time, the aforesaid Trust shall terminate and the principal and any accumulated interest shall be paid over to her. The Truste shall have full trust powers as provided by the laws of the Commonwealth of Pennsylvania. ~ Third: I direct that my Executrix, in addition to and not in limitation of any authority given to it by law, shall have the following powers: (a) For the payment of debts or for any purpose of administration or distribution, power to sell, mortgage, lease, alter, improve partition and exchange all or any of my real estate, at any tim during the continuance in whole or part of the trust under this my Will and at the termination thereof for purposes of distri- bution, selling at public or private sale, for such prices and upon such terms as to cash and credit as it may deem best and to convey good and sufficient title without liability on the part of the purchasers or other persons dealing with my Fbcecu- trix, to see to the application of the purchase or consideratio: monies. (b) To retain, sell, pledge and purchase stocks, bonds, or other personal property. ' Fourth: All inheritance and succession taxes shall be paid out of the principal of my general estate as if said taxes were expenses of administrati -2- and all legacies, devises and other gifts of principal and income shall be free and clear thereof. Fifth: I appoint Iris L. Rouse to be the Executrix of this my Last Will and Testament and if she be deceased or incompetent to serve, I then appoint Martin Rouse to be the Executor of this my Last Will and Testament. ,Z IN WITNESS WHEREOF, I have hereunto set my hand and seal this /3 day of ~:/ 1983. Signed, sealed, published and declared by the Testator above named, as and for his Last Will and Testament, in the presence of us who have hereunto, at his request, subscribed our names in his presence and in the presence of each other as witnesses hereto. -~ ~~ ~ .. .Z' L,(,,. i 4,.Z~. _.;.,.`.~.. .~ -- -3- COMMONWEALTH OF PENNSYLVANIA HARRISBURG DISTRICT OFFICE STRAWBERRY SQ 4TH & WALNUT STS HARRISBURG PA 17128-OIOI IRIS L ROUSIE 6625 WERTZVILLE RD ENOLA PA 17025 Dear IRIS L ROUSIE: DATE: Estate o£ ROUSIE Date of Death: File Number: The above estate is in a delinquent status, as the estate still is not settled. REV-872 FO AFP (OS-08) 8/14/2008 WILLIAM E 3/16/2002 21 02-0303 The Inheritance and Estate Tax Act mandates the filing of a tax return and payment of all outstanding liabilities by a personal representative or a transferee of an estate within nine months of a decedent's death. Department records show that this estate remains open because: AN INHERITANCE TAX RETURN HAS NOT BEEN FILED. The law also provides that any person who willfully fails to file a return required under the provisions of this Act shall be personally liable for a penalty of 25 percent of the tax determined to be due or $1,000, whichever is less. This penalty is in addition to any other liabilities imposed by the Act. Under Act 40 of 2005, additional collection costs including but not limited to fees of up to 39 percent of the amount due, and attorney fees incurred in securing payment, maybe imposed on any liability not paid prior to referral to a collection agency or contract counsel. If this estate was opened for the purpose of filing a lawsuit, please provide the term and docket number of the proceeding in writing to this office so that the Department may postpone any further action. Accordingly, you are directed to file a return and pay all tax due including interest within 30 days from the date of this letter. If you fail to comply with this directive, your case will be referred for enforcement and may result in the filing of a citation by this Department with the Orphans' Court Division of the Court of Common Pleas, requiring you to appear in court to show cause for your failure to comply with the law. In order to protect the Commonwealth's interest, the Department of Revenue may also file a lien in Cumberland County. RETURNS SHOULD BE FILED AND CHECKS MADE PAYABLE TO: REGISTER OF WILLS, AGENT Sincerely, Crystal Caraway Direct any questions regarding this estate to: (717) 787 - 3837 DEPARTMENT OF REVENUE HARRISBURG DISTRICT OFFICE STRAWBERRY SQ cc: 4TH & WALNUT STS HARRISBURG PA 17128-0101 105.305 32E~' 9I8G This is to certify that the information here given is correctly copied from an original cert~cate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 Local Registrar P 8032105 No. N1AR 19 2002 Date taaaey.,IB, COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (Coroner) STATE FILE NUMBER NAME OF DECEDENT (FtrsL Mbtlle, Last) SEX SOCIAL SECURITY NUMBER DATE OF DEATH (Mash, Day, Year) +~ William E Rouse x. Male x. 237-36-0701 •. March 16, 2002 AGE (Last Brtebay) UNDER, YEAR UNDER 1 DAY DATE OF BIRTH M th Y D BIRTHPLACE ICny antl F i S C PLACE OF DEATH jChe [:k only one - see msthx:uwts on other vtle) Months De ya Hours Minutes on , ear) ay, ( tale or ore gn wntry) HOSPITAL: OTHER: 75 vrs. Mar. 4,1927 NC HOOkerton In anent ^ ERlOutparient ppA ^ Nwsirtg qMr p Homa ^ Reafdence ^ (Specity) ^ s. s. , ~. a. ' COUNTY OF DEATH CITY, BOR DEATH FACILITY NAME (II not insotutron, give sneel and number) WAS DECEDENT OF HISPANIC ORIGINS RACE -American IMian, Black, Whne, etc. No ® Yes ^ if yes, specify Cuban, ISpecey) Cumberland East Pennsboro Holy Spirit Hospital Mexican Puerto Ri n t , , e ca c. 8c !d WHlte ~ Bb 9 . . . . 10. DECEDENT'S USUAL OCCUPATION KIND OF BUSINESSIINDUSTRY WAS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STATUS ~ Monied SURVIVING SPOUSE (Give kintl d work done during rtaD U.S. ARMED FORCES7 S i aN li hest c radu com eted Never Monied, Wbowed, (If rode. give maiden name) d workaq 8fe; do rat use refired) Yes ® No ^ Elememary/Sewndary Cdlege Divorced ISpecily) 12t1`Y'z> ,t-<er5., M 3rried Iris L Burri Gr ce Market P i t i . s o ,,.. r r e ar „b. ,z. n ,.. , . DECEDENT'S MAKING ADDRESS (Street, CkylTown, Stale, Zip Cafe) DECEDENT'S Penns lvania ~ Hanq~den ACTUAL ,7a State y Did 17 Y d d li d i 6625 Wertzville Road . e. ea, ece em ve n trop. RESIDENCE decedent Pa 170 25 EnOla 0 ~ ~ raj 's to nsn , , ip? No, decoaem k~ed Cumberland ^ ,8. 170. caw, tTd. wehin actualamnsd ceylDDro FATHER'S NAME (Fast. Mbtlle, Last) MOTHER'S NAME (Fist, M~tlda, Maaert Surname) P,bner Rouse Mary K. Eason ,s ,g INFORMANT'S NAME(TYpelPrint) MaYtlIl ~llSe INFOa7d4DlZ:$Mq(La`~nu~ESS~(L`reeLT~ n, to Z. Cgpeill, PA 17011 t1 METHOD OF DISPOSITI O N GATE OF DISPOSITKN PLACE OF DISPOSITION-Name of Cemetery, Crematory LOCATION-CiryRown, Stale, Zip Code 77 (f ~~ BuriallJ Cremetion^ Removalfrom State^ (Monet, Day, Year) or gher Place - ~~~^^ gh.r(Specsy ^ 3-22-02 Indiantown Gap National C. Annville PA xta. 21b. xic. , 21d. • SIGNATURE OF FUNERAL SE E LICEN ER ING AS SUCH LICENS ~~ NAME AND ADDRESS OF FACILITY ' z2a. at4~t,.4f ' S-L xzb. 220. T CH PA 17011 Complete game 23e<only n c•rtilying To the oast of my knowledge, death occurred at the eme, date orb place slated. LICENSE NUMBER DATE SIGNED _ pnysictien is not availebb ims d cbath to (Sgnature and tole) IMOnth, DaY. Year) cartily uwe of deatR ' x9a. 23b. 23c. ' Itama 2428 must be rbmpu,aO OY TIME OF DEATH DATE PRONOUNCED DEAD (Month. Day. Year) WAS CASE REFER REDTO MEDI LEXAMINERlCORONER7 • personwlalxonouncesdeatn. March 16 2002 12:10 P Yea ~ No ^ , ~, sa. M. xs. 27. PART I: Enter tM diseases, injuries a complicetbns which caused the death. Do rat emer the mode of dying, such u cardiac p respiratory arrest, shock or bean IaiWre. )Approximate PART II: gher spnilkant condiriona contributing Io death, Wa Lint only plc cause on each line. ~ inlenal between not resubi in the undo rig rlyirp cause given in PART 1. I onset and deem IMMEDIATE CAUSE (Final i d'~pCOntltl10n Atherosclerotic Cardiovascular Disease resWtagin deem)-y a. OUE io (OR AS A CONSEQUENCE OF): i SaquemiaBy l'slcptditMlne b. 8 arty, t••dktg a knmediale DUE 10 (OR AS A CONSEQUENCE OF): I cause. Enter UNDERLYING r CAUSE (Disease a injury c. ' mar initiated events DUE TO (OR AS A CONSEQUENCE OF): ~ rruupmg in deaep LAST 1 tl. • WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OFINJURY INJURY Ai WORK? DESCRIBE HOWINJURV OCCURRED. PERFORMEDS AVAILABLE PRIOR TO (MOnm, Day, Year) COMPLETION OF CAUSE ~ ^ OF DEATHS NaWral Homicide Yes ^ No^ Accident ^ Pending Investigatbn ^ 30b. M. JOc. , Ves ^ No Yea ^ No ^ PUCE OF INJURY - At home, term, street, factory, oNice LOCATION (Sheet. CsyR wn, St ) Suicitla ^ Coua rat De determined ^ Duading, stc. (Speedy) 28a. 28b. 2s. 30s. x01 CERTIFIER (Check pay one) SIGNATURE AN 7 'CERTIFYING PHYSICIAN (Physician cerkryktg rouse of death woen andhar physician has prorxwnced deem antl cwnpletetl Hem 23) ^ t ~ C OTOnI'_ r To,M beg o, my kr,owlWpa, deem oecrarad dw b iM uuaa(a) and manner u agtsd .................. ................ ................... 3tb. • LICENSE NUMBER DATE SIGNED (Month, Day. Year) •PRONOUNCINOANOCEATIFYI/NIPNYSICIANIPhYs~cienoomprorwuroatgtleelharWCertilyin9tocausedtleatli) To tl,a Oast of mY krrowlWpe, death ouumd al Nre tkne, rlau, and ptace, and dw to tlta crtrualal and martrrsr as autM .......................... ^ xic. March 1 8 200 2 Std. f . _ . _ _ NAME ANO ADDRESS OF PERSON WHO COMPLETEDCAUSE OF OEIITH ' (Item 27)Type or Print Michael L. Norris Coroner MEDICAL tJ(AMINERICORONER • On tM lyaals of axamina0on arM/or Inwstlystlon, to mY oplnlon, daatlt oeeumd at tM tlms, date, end place, end due to tAa cause(s) end ~ , 63 7 5 Ba s eho r e Road , Suite ~~ 1 manmra.out.a ................,.....................,.................................... ...... .. Mechanicsburg Pa 17050 . a,.. . , az. ' REGISTRAR'S SK3NQURE AND N ~~ ~r-w,~'S..(r~s~.y ~ / DQE FI (Munro, Day. Year) // ~ ~ L 31. N (/ 51 SCHEDULE C ~ Profit or Loss From Business (Form 1040) (Sole Proprietorship) - Partnerships, joint ventures, etc., must file Form 1065 or Form 1065-B. Department of the Treasury Internal Revenue Service (99) - Attach to Form 1040 or 1041. - See Instructions for Schedule C (Fon Name of proprietor OMB No. 1545-0074 2002 Attachment .... Social security number (SSN) WILLIAM E ROUSE 237-36-0701 A Principal business or profession, including product or service (see page C-1 of the instructions) B Enter code from pages C-7, 8, 8 9 GROCERY SALES - 445100 C Business name. If no separate business name, leave blank. D Employer ID number (EIN), if any ROUSE'S MARKET 23-1636990 E Business address (including suite or room no.)- ... .6625 WERTZVILLE ROAD ................................................................. Cit ,town or ost office, state, and ZIP code ENOLA PA 17025 F Accounting method: (1) Cash (2) Accrual (3) Other (specify) - .............................. G Did you "materially participate" in the operation of this business during 2002? If "No," see page C-3 for limit on losses Yes n No H If you started or acquired this business during 2002 check here .......... - n Part T Income 1 Gross receipts or sales. Caution. If this income was reported to you on Form W-2 and the "Statutory employee" box on that form was checked, see page C-3 and check here .... ............ - ~ 1 98 255 2 Returns and allowances .................................................................. .... 2 3 ................ Subtract line 2 from line 1 3 98 255 4 Cost of goods sold (from line 42 on page 2) 4 90 003 . . .... . . .. ...................... . . . ........................ .... 5 Gross profit. Subtract line 4 from line 3 .................................................................... .... 5 6 including Federal and state gasoline or fuel tax credit or refund (see page C-3) SEE STMT Other income 1 6 10 081 , 7 Gross income. Add lines 5 and 6 - 7 18 333 Part 11 Ex enses. Enter ex enses for business use o f our home onl on line 30. 8 Advertisin 9 ..................... 8 19 Pension and profit-sharing plans 19 9 Bad debts from sales or 20 Rent or lease (see page C-5): services (see page C-3) , . 9 a Vehicles, machinery, and equipment 20a 10 Car and truck expenses b Other business property 20b (see page C-3) .. 10 319 21 Repairs and maintenance 21 439 11 Commissions and fees 11 22 Supplies (not included in Part III) 22 145 12 ........... Depletion 12 23 Taxes and licenses 23 1 349 13 Depreciation and section 179 24 Travel, meals, and entertainment: expense deduction (not included a Travel ..... . .................... ..... 24a in Part III) (see page C-4) 13 446 b Meals and 14 Employee benefit programs entertainment (other than on line 19) 14 c Enter nondeduct- 15 Insurance (other than health) 15 1 63 6 ible amount in- chided on line tab 16 Interest: (see page C-5) a Mortgage (paid to banks, etc.) 16a d Subtract line 24c from line 24b 24d b Other 16b 25 Utilities ...... 25 2 884 17 ............... Legal and professional 26 Wages (less employment credits) 26 4 368 services 17 27 Other expenses (from line 48 on 18 Office ex ense 18 a e 2 27 6 800 28 Total expenses before expenses for business use of home. Add lines 8 through 27 in columns - 28 18 38 6 29 Tentative profit (loss). Subtract line 28 from line 7 ........................................................... ..... 2s 5 - 30 Expenses for business use of your home. Attach Form 8829 .... , ..... 30 31 Net profit or (loss). Subtract line 30 from line 29. ~If a profit, enter on Form 1040, line 12, and also on Schedule SE, line 2 (statutory employees, enter on Form 1041, line 3. Estates and trusts see page C-6) 31 -53 , . •If a loss, you must go to line 32. 32 If you have a loss, check the box that describes your investment in this activity (see page C-6). ~If you checked 32a, enter the loss on Form 1040, line 12, and also on Schedule SE, line 2 32a All investment is at risk. (statutory employees, see page C-6). Estates and trusts, enter on Form 1041, line 3. 32b Some investment is not ~If you checked 32b you must attach Form 6198. at risk. For Paperwork Reduction Act Notice, see Form 1040 instructions. Schedul e C (Form 1040) 2002 DAA ;~,~ WILLIAM E ROUSE 237-36-0701 Schedule C (Form 1040) 2002 GROCERY SALES Paoe 2 Part IIF ; Cost of Goods Sold (see page C-6) 33 Method(s) used to - vatue closing inventory: a ~ Cost b ® Lower of cost or market c a Other (attach explanation) 34 Was there any change in determining quantities, costs, or valuations between opening and closing inventory? If "Yes," attach explanation ~ Yes ® No ............................................................................................. . 35 Inventory at beginning of year. If different from last year's closing inventory, attach explanation 35 7 9 2 83 ........................ 36 Purchases less cost of items withdrawn for personal use .................................................. 3s 82 781 37 Cost of labor. Do not include any amounts paid to yourself 37 38 Materials and supplies 38 39 Other costs ........................................................................................... 39 40 Add lines 35 through 39 40 162 0 64 41 Inventory at end of year 4 7 2 0 61 42 Cost of oods sold. Subtract line 41 from line 40. Enter the result here and on a e 1 line 4 42 90 003 Part (VF!° Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on line 10 and are not required to file Form 4562 for this business. See the instructions for line 13 on page C-4 to find out if ou must file. 43 When did you place your vehicle in service for business purposes? (month, day, year)- 44 Of the total number of miles you drove your vehicle during 2002, enter the number of miles you used your vehicle for: a Business .................................. b Commuting .................................. c Other ................................... 45 Do you (or your spouse) have another vehicle available for personal use? Yes No ................................................. 46 Was your vehicle available for personal use during off-duty hours? Yes No ........................................................ 47a Do you have evidence to support your deduction? Yes No ....................................................................... b If "Yes " is the evidence written? Yes No Part V ° Other Ex enses. List below business ex enses not included on lines 8-26 or line 30. TELEPHONE ..................................................................................................... 109 MISCELLANEOUS ....................................................................................................................... 55 .INOME TO .NEW.. OWNER ......................................................... 6 6 3 6 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE ~, ' NO~'IC~ 'QP'~,~NNIERITANCE TAX BUREAU OF INDIVIDUAL TAXES APRF~AfiSEMENS, AL.L~OI~QrNCE OR DISALLOWANCE INHERITANCE TAX DIVISION OFD -I?Ell~J'CT'I'6NS AND 'ASSESSMENT OF TAX PO BOX 280601 HARRISBURG PA 17128-0601 REV-1547 EX AFP (06-05) ~Lv? ~ ~~ ~ ~ ~ ~~~ ~/~TE 12-08-200$ ESTATE OF ROUSIE WILLIAM E ~E,-w DATE OF DEATH 03-16-2002 (~pv'.-jC,~\~' r;`~ ;~~' FILE NUMBER 21 02-0303 ^`I,,'j~ ~ ''• r ," ^; ~~OUNTY CUMBERLAND MARTIN H ROUSE ACN 101 2707 WALNUT ST APPEAL DATE: 02-06-2009 CAMP H I L L P A 17 011 (See reverse side under Objections Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE -~-~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ______________ ----------------------------------------------------------------------------- REV-1547 EX AFP C03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF ROUSIE WILLIAM E FILE N0. 21 02-0303 ACN 101 DATE 12-08-2008 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) C1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) ~y) ,00 credit to your account, 110,054.00 submit the upper portion 3. Closely Held Stock/Partnership Interest (Schedule C) C3) of this form with your 4. Mortgages/Notes Receivable (Schedule D) (4) .00 tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 2 8,4 02.61 6. Jointly Owned Property (Schedule F) C6) 350.0 0 7. Transfers (Schedule G) (7) .0 0 8. Total Assets fig} 138,806.61 APPROVED DEDUCTIONS AND EXEMPTIONS: 7,511.00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) .00 11. Total Deductions (11) 7,5] 1.00 12. Net Value of Tax Return (12) 131,295.61 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax ~l4} 131,295.61 NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 14 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 131,295.61 00 .00 15. Amount of Line 14 at Spousal rate C15) X _ - 16. Amount of Line 14 taxable at Lineal/Class A rate C16) • 00 X 045 = . 00 17. Amount of Line 14 at Sibling rate (173 •00 X 12 .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 = .00 19. Principal Tax Due X19}= .00 IAA I.RGLIIJ' PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID C-) AMOUNT PAID ~ IF PAID AFTER DATE INDICATED, SEE REVERSE --- --• .-,~, nrrnN of ADDITIONAL INTEREST. TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 1 C IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS RE4UIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE _- e ccGUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) `