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HomeMy WebLinkAbout11-26-08 1,5C5~051:047 -~~ ~ EX (06-05) O=FICiAL USE ONLY ~A Deparment of Revenue ,~ 5ureau of Individual Taxes ~~'~-~-~ County Code Year ' FiIP Number P~OBOX280601 ~',r~S`~-.,, 1N~'l~ 't1T,~'~~E I',-s''~ R~~Ui~i~ s' ~ / c~ ~ ~" ~ ~` ~~ ~ Harnsburg; PA 17128-GE01 ~`~~~'' RESIDENT L)EC~~~i~1T ENTER DECEDENT 1NFORP;IAI iOPJ SELO'~+J S~c;ial Security Number Date of Death Date of Birth De i,_L.. ~.. ix .~~ r~~r~t'L:n~ MI K c ~- ~- (If Applicable) Enter Surviving Spouse's Infiormation Below Snnuse's Last Name Suffix Soouses First Name MI Soci.~_ _ a _.~ PJr:~-.~r., FILL IN APPROPRIATE OVALS BELOW THIS RETURN BUST BE FILED IN DUPLICATE WITH THE ~~~~~~~~ ~~ ~~L~s 1. Original Return 2. Supplemental Return ~ 4. Limited Estate 4a. Future Interest Compromise (date of death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death bet~,veen 12-31-91 and 1-1-95) 3. Remainder Return (date of death prior to 12-13-82) ® 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes ~ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone NumbercN,~ ~ ~ ~ ,=~, o Firt f r -~p';~Il~.i ~--mob=ire-~~ .,.~ .. ~` ~ h; ~ ~" ~-~ ~' .~ t ~' Firs li of ~ i-~~~ J~~? l l-~r-h:~ c ! ~~j ser~,~ ~ Ih-~r ~~r~-~. (;its ' ~;il Ci; ~,;<itc; DATE ;=ICED Correspondents e-mail address: ~ t SGl- ~ Z..~~' ~~-~~i"-c~ Ct~y~.~C.• C(?~i"- Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the pErsonal representative is based on all information of which preparer has any knowledge. .y`~iG~ ~ ~ ESFONSIBLE FOR FILING R RN ~~I J'i1 DATE ADDRESS ~ Il SIGNATURE OF PREPARER OTHER THAN RE RP ESENTATIVE 1~ DATE ADDRESS S~'~~ASB ~3SB ®i:lGai~AL EC3~di`Ji C3,~i~."l SId~ 1 1505~051~042 1,5056051,;]47 ~n:~.;, Rw-15oo ~X Dzczdznt's Name: i. Realestaie(SchedU''eA) .......................................... ... 1. '2. Stecks and Bonds (Schedule B) .................................... ... 2. 3. Closely Heid Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 4. Nlortgages & Notes Receivable (Sc'nedule D) .......................... ... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Scheduie E) ..... ... 5. 6. Jointly Owned Prooerty (Schedule F) Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Biking Requested..... ... 7. 8. To#al Gross Assets (total Lines 1-7) ................................. ... 8. 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. 11. T9tal Dociuctions (total Lines 9 & i 0) .. ............................. ... 11. 12. Net Value of Estats (Line 8 minus Line 11) ............................ .. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for vdhich an election to tax has not been made (Scheduie J) ...................... .. 13. 14. Nei Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. TAX CO~IPUTATiON -SEE INS7 UCTIOh15 FOR APPLICABLE RATtS L~.__ 15. Amount of Line 14 taxable at the spousal tax rate; or transfers under Sec. 9116 (a)(1.2) X .0 15 ~'ec°dent's Social Security Number ~~ ~ '- -~ ~' i ~ ~~ ~-, r-r ~_J ~ ~ o ~~ ~ -' -- ~ _ ~? ti~ T ~", ~ ~/ ~ j 16. Amount of Line 14 taxable ,~ ~ ~ ~ _ ~ at lineal rate X.0~~ ~= ~~ ~~~'~,~~7e~ ~~ 16. ~~:~~ ~ ~~i 17. Amount of Line 14 taxable at sibling rate X .12 17, 18. Amount o` Line 14 taxable at collateral rate X .15 1 g. 19. TAX DUE ......................................................... 19. 20. FILL !is THE OVAL IE YDU ARE. REQUESTING A REFUND OF AN OVERPAYMENT ~_ ;r,L ---;, ~~ 1 (' ~ < ~ f'' ~1~~ L ~ 1~5~56Ci5~C1~n 1, ~056~5~u4~ ~. ,~ .-_~~ RED/-1500 EX Fage 3 Fiie Number J -7 p ®etcedent's C®tnplete address: DECEDENT'S NAME _ -_ -__ - - STREETADDRESS --_ - - CITY '~ STATE ;, ZIP ' Tax Payrnents and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments ~ -~ _. ~(aQ, Q ~ C. Discount _ - - _1( ~ ~._~~' _- 3. InterestlPenalty if applicable D. Interest E. Penalty (1) ~~~ ~~3.~~ Total Credits (A+ g + C) (2) ~~ ~~ ~, jar' r 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) (4) ~ ~S. Coq (5) (5A) (5B) Make Check Payable fo: 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? ....... ....... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which 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 is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ~ i SCHEDULE B Y' ~ '~ STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ', RESIDENT DECEDENT ~I ESTATE OF KELLY JR. WILLIAM~J ~~ FILE NUMBER 'I 21 - 2008 - 0852 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER i 1 71 shares of Prudential DESCRIPTION UNIT VALUE 75.45 VALUE AT DATE OF DEATH 5,356.95 TOTAL (Also enter on tine 2, Recapitulation) 5,356.95 i PRU:'Nisj~orical Prices for PRUDErUTAL FINCL INC - Uahoei ~inailce hake 1 of 2 i'. ~" .~`~ ~ :!~ !`~Gre "~~, rar€(`G"Ci;.3 {'~a7 `;~'. "t nl;t ~°I:. VJ E ~,~~~~-~ ~r~, '; i`°~ r ~~~ ~,~", Search B SEARCH Dow '~+` i.~4°J° NasdaO '~' 1.$4°J° Friday, November 7, 2008, 12:53PM ET - U.S. Markets close in 3 Hours and 7 r _ .- ' ~E; .l)3TES ~ rinance SearcF ~~"UEa~El~.[~~ ~EFl~~~Ect~ ~Ci~. ~~~~~ At 12:38PM ET: 33.~Q ~" 5.17 (3.i _ _ _---- ~__~ __~.~ a ,~~ r7_ise'i`cr~tT~Sf~~E ~^-~ - J ~`;? ~c 'C~E..1'~ '~ L~~'7~J17E j~ _ I ~€@s~oricai ~'r~ees SET DATE RAC~GE Start Qafe; jAug '"; >.. .. ~~ncf €9ate: EAug J 3 PRZCes Date Open High ~`-`-`~' E .Jan 1, i''C~:%8 ' 2003 ~, ~0~ Get Prices' Get Historieat Prices for: ~~' ~~' ~- Daily ~' Weekly K =!~ Monthly ~''; Cividends Only .=i"'::t ~ 1-rev ~ ~¢, ~, i Last Low Close Volume Adj Close" 8-Aug-08 73.09 75.89 72.59 75.45 3,779,000 75.45 Close price adjusted for dividends and splits. `' Download i o Spreadsheet ,~ 1 ADVERTISEMEI~~T t~E~~~7 ~~~i~~ .~Tii~SE~C~~ ~-~~ _~:;; C~~? - i t !:.:a~lf1~_ ~ prt CF's`=.1r ~.., ~ ~",t. 1 , ,,,~. _`;_> i f?*_ 1, - , 1 ~ "~=a~ .,.. i.. i 7 - - °'~. -~! + ;;. 4 ~-"= ~ - iii. :. Jli~i?Ifa -~.- ._ '"tai ~"r~* f~ `;t r;u ~ ~ ; ~ I _> r'.'r r it :: 3i v:-~iJ ~i.~ t,, ~ ':~ ...I It:,Y~ roc:: k't. ~~ - ~tr;~:iinance.yailoo.coin/q.%:~~?s=PRU~•:a=0?~:.'~=8~n.-.c=2QC&~d=C7c~..c=8&f=%uQ8&~=d 1 U%/2008 '~ ~ SCHEDULE E r ~ ! CASH, BpA~+NK DEP®pSITS,p&~MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTI INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER KELLY, JR., WILLIAM J 21 - 2008 - 0852 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER 1 Commerce Bank-- Certificate of Deposit 2 Orrstown Bank-- Cerificate of Deposit 3 PNC Bank-- Checking Account DESCRIPTION VALUE AT DATE OF DEATH 50,579.04 96,422.34 42,284.99 x TOTAL (Also enter on Line 5, Recapitulation} 189,286.37 September i 5, 2008 Lisa Marie Coyne 3901 Market Street Camp Hill, PA 17011 RE: Estate of; William J. Kelly, Jr. Tax Identification Number: 198-10-1920 Date of Death: August 8, 2008 ~~, wy , " _ ;~ ,E "9 .,, ~; ~r, ~;; t~ l ~~i ~~~ ~ ~ v E ! t i ~~ --- To Whom It May Concern: This fetter is in reference to decedent account information you requested for the individual listed above. We are able to provide the following: } Account Type'Time Deposit Account Number: 1701359 Date Opened: 03/28/2008 Primary O~,vner: William J. Kelly, Jr. Date of Death Balance: $50579.04 Interest Rate: 3.445% (paid monthly) Date Closed: 69/04/2008 Please feel free to contact me at (717) 412-6127 if I may be of further assistance. Sincerely, ~^ f- ~ ~ ~' .'%~ ~' ~a ~ -- Diana Reynolds Commerce Bank Research Associate/Deposit Services Commerce Bank /Harrisburg; N.A. PO Box 499 3801 Paxton Street Harrisburg, PA 171 ? 1-0999 commercepc.com ~li°f:}i??iQ aC^oli11t8; T~Tumber: Date Opened: Balance at Date of Death: ' Name of Joint Owner, if any: Savants Accounts: Number: Date Opened: Balance at Date of Death: Name of Joint Owner, if any: Ce~-taiicat+es oa' ~e~osat: i~umber: ~G~ ~~ Date Opened: ~~ i ~ Name of Joint Ow~izer, if any: iV ~ j ~' Balance at Date -- ofDeath: ~ ~ ~i ~~ ,. ~~ '°: f ~- - `~ ~ , ®, F ~~ ~ ~ , ~ .. -~ .~ ~~ ~_~. ~~~~ ~~ C Maturi~ Date: ~ i L r~ Interest Rate: ~ ~ ~ ~ ' ~ Interest Paid Quarterly, ~• ~~ Semi-Annual, etc. , ~~/'~ %/~~~ Debts: Estate of: William J. Kelly; Jr. Date of Death: 08/08/08 h Name cyf B auk: Signature of Bank:a~'Savirsgs Assoc. Official I I - r I I''a ~'~ / 7 y ~ ~~ •, ~ 3~5 i~3.~~~.`' t'pti~yyy V yA l~ j~ U V V ~ T 19S I~a.~e CO, ne, ESri. 301 ivlarket 5# Camp HiII, PA 7.7011-4227 ~ ~ i i e RE: 4~illism J belly SSA: 1 ~8-10-1 X20 DDD: 0~-08-200 ~ Dear NSs. Coyne: Ix~ resp€~ns~ to your re.~ues# for Data, of Death (DUD) balances %r the customer noted above, our records shoar the f~Ilovving: ~~etg Accont Account # X140033747 Established: 10-01-1~5~ Y`~ILLL J ~EIJLY JR D©D balance: ~ 42,?77.~~ + 7.10 accrued interest Intexest paid O1-O1-200 thru 0~-0~-2008 :~ 6.55 ~D Please note that t'~is office provid:.s date ofd n= .balances for deposit accounts (IR As, CDs, Cheekin¢~nd Savings). ~'e da a~at pray any ~ci~I tctions ar pde s#~t~men#~. If you no°d assistance ~,~ith any of these itd~s, please, call 1-~8~-P~~-I~A~K (1-%~~-76~-2265) car stoP'~l Your local PNC ~3ar1c bra~ca o~ce~ Nation: FiDancial Services CErter 1'AIC Bank, ~.A. P.~embez~ FDIC Page 1 of 1 ~~ ' ~> ~'~ ~ SCHEDULE G . ~ ~ INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA RA INHERITANCE TAX RETURN ~ MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT I ESTATE OF ,I FILE NUMBER I KELLY, JR., WILLIAM J 21 - 2008 - 0852 __ This schedule_must be completed and filed if the answer to an of uestions 1 throug h 4 on age 2 is yes. DESCRIPTION OF PROPERTY ITEM DATE OF DEATH % OF ~- Include the name of the transferee, their relationship to decedent and the date of transfer. NUMBER I Attach a copy of the deed for real estate. VALUE OF ASSET DECD'S EXCLUSION TAXABLE VALUE (IF APPLICABLE) I ----- - INTEREST 1 I 1 ~I Wachovia Bank--IRA-- Certificate of Deposit 123,271.73 1 i 123,271.73 ~! (Children are Beneficiaries) ~ 2 i Wachovia Bank-- IRA--Certificate of Deposit ~ 123,271.73 123,271.73 (Children are Beneficiaries) 3 ;Wachovia Bank--IRA--Certificate of Deposit ! 123,271.73 123,271.73 (Children are Beneficiaries) ~ 4 ~~ Wachovia Bank--IRA--Certificate of Deposit 123,271.73 i ! 123,271.73 (Children are Beneficiaries) 5 Wachovia Bank--IIZA-Certificate of Deposit 1,247.33 1,247.33 (Children are Beneficiaries) M i _.- TOTAL (Also enter on line 7, Recapitulation) ~ 494,334.25 at iP.i~i:e.l ~~i;0/L~~v~ ~:%2.1~ Ail P.~.GE 2/i~lJ,~ FAX ~%y v~?^ ~~~.f_.".~~J, kefeJZnce ID: 35GS2fi0 l~'3C11G:')3 x33711: l~.r'~. B31ffi1C'~ Cant)rlltataGn S1'4'JC2.5 ~ P ~ FiaX '~l•`t12~ Roaro~a, VA 24022-7313 Septel~ber 10, 2008 COYI~E ~ COYi~lE r'~TT(}ILv-EYE r'~T I.AW X901 b~1AP.KET STREET GaliRP HILL, PA 17(311 SLIB3L,C"T: Veritica~an / Canfimiatian of Accouni and Balance Information providzd for: Custo,~ler: i~'I~.LIA~ J LLB' J~ {SSN# ~S:~X-~-1920) Late of Death: An~ust 8, 2008 I~es~asit Account ~n~'orrnatioa~ Acrnui~i Accowri DaieufDcafih AF~ernae Date Maiuriiy InteJ~st Accrued I'rD Date Type NaJn~e-r Balance BaLlnce'~ Qpened Date Rate Interest Inteia~ Paid Closed L~~ X7iXXX~ iX~X~6'_8 $1?3,271.73 X4!1311958 $o45.?S $2,757.hb IF(}~LTITIE: WIL:LL3Ivf J I~LLFJR For Beneficiaryy Claim Form uifonnatioJr ptea~ call 1(8ooj73o=1390. A'~ ?fX~~kii_~~~."ti%i363D $123,27L?3 4,/1it1933 $o45.ZS $2,?~7.66 -- LECr ~L TTTLE: Z~'II.Ll~M J ILLY JR For Beneficiary Claim Form infarmatioq please call i(Stib)?4ti-4390. IPA Y~K.~~YXKX3aJ-! $12'3,371.73 ~!13~1958 $b45.28 $'?,757.G6 IFCi ~.L TiiLF: ~'~'II_LL~RI J I~,LLY JR For Beneficial}"Claim Form infonnatiorJ, please calf i i3tih I?3ti11390. 11'~A Y~YX_~~i`;XX.~Y3ti52 $123,71.73 4/13/1938 $b45.2S ~2,757.i~6 L.EC3LTITLE:1','ILLL~d J ALLY JR For Benefcian° Claim Farn inTonrJarion, please call I(Stitil?361J390. 1P~ YXX.X_X_X_u1XXY3GiJl $1,'47.33 4'1311983 $3.53 $3b0.D0 8;17,~OG3 LEGAL TITLE: `~~ II.LL~i J k'ELLI' JR f For Bena?ciaryClaimForm inlarmatloq pleasz. calf 1(SOhj?56~t590. u_ iGl ~~~a ~ . ~;2 . 15 ~~~ P~:CE 31 u~~,~ r ~1. 5~3'V~i 4 ~~ D o safe Deposit Box found for c.nromer. ~, ~~ Date ci death balance does net include accruui interest. Ii datz of death occun-s on a ~t-ezkend or a holiday. date of death batancz does rot irctude miy transactions that were made during that time period. "~' r At11y Gragbitl Setvicenter ~ssociatz Phone.: f~Oj3~3-7323 4:x~_ a~ Y k ~ ~ ~ ~ SCHEDULE M j - FUNERAL EXPENSES & '~ COMMONWEALTH OF PENNSYLVANIA i INHERITANCE TAX RETURN ~~~~~~~~~ ~~ RESIDENT DECEDENT ESTATE OF KELLY, JR., WILLIAM J ~ FILE NUMBER 21 - 2008 - 0852 Debts of decedent must be reported on Schedule I. ITEM i DESCRIPTION II AMOUNT NUMBER A, i FUNERAL EXPENSES: 1. Niell Funeral Home, Inc. I 11,060.28 i 2. Rolling Green Cemetary--grave openning and closing, headstone engraving I~ 1,570.00 3. ~ Reception-- West Shore Country Club 2,350.45 4. Honorarium I 500.00 B. i ADMINISTRATIVE COSTS: 1. ~ Personal Representative°s Commissions ~ Social Security Number(s) / EIN Number of Personal Representative(s): Street Address ~ City State Zip Year(s) Commission paid 2, j Attorney's Fees Coyne & Coyne, P.C. 3. I! Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Cumberland County Register of Wills 5 6 Accountant's Fees Tax Return Preparer's Fees 7. Other Administrative Costs 1 Legal Advertisement-- Cumberland Law 3oumal 2 I~! Legal Advertisment-- Patirot News 10,000.00 280.00 75.00 134.21 Total of Continuation Schedule(s) 5,830.00 TOTAL (Also enter on line 9, Recapitulation) ' 31,799.94 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Sc~iedule H Funeral E~er~ses & ActninistrativeCosucontinued ESTATE OF KELLY, JR., WILLIAM J i FILE NUMBER 21 - 2008 - 0852 3 Postage 4 I, Travel, Lodging and Meals for Executor 5 Tolls Calls I 6 ~ Mileage for Executrix 7 Income tax Preparation Fee I 8 I, Broker's Commission for Stock 9 ~ Reserves 10 Filing Fee for Inheritance Tax Return 11 ', Inventory Filing Fee 200.00 3,000.00 100.00 100.00 300.00 100.00 2,000.00 15.00 ~ 15.00 Page 2 of Schedule H . 'i ~ SCHEDULEI r ~ DEBTS OF DECED~+ENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA ~I LIABILITIES, & LIENS INHERITANCE TAX RETURN ~ RESIDENT DECEDENT ESTATE OF ~ FILE NUMBER KELLY, JR., WILLIAM J 21 - 2008 - 0852 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION _ _ AMOUNT 1 Uncleared Checks 12,956.20 2 Continuing Care RX 437.88 3 Chase Credit Card 30.00 4 West Shore•EMA 130.00 r TOTAL (Also enter on Line 10, Recapitulation) I 1.3,554.08 FEV-1513 EX+ (9.60) ~ '"~ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ~ _ i ESTATE O~ I FILE NUMBER KELLY, JR., WILLIAM J 21 - 2008 - 0852 RELATIONSHIP TO AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE Do Not List Trusteejsa' I. ', TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 ~ William J. Kelly, III Son 1/5 of Residual Estate i 2 Aru~e Marie Dormer i i ~ Daughter 1/5 of Residual Estate , 3 ! Claire M. Walker Daughter 1/5 of Residual Estate 4 ~~ Elizabeth M. Williams Daughter i 1/5 of Residual Estate 5 ~ Barbara F. Bushey ~ Daughter 1/5 of Residual Estate Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: IA. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT 'BEING MADE 'B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS i Y I TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEEIT