HomeMy WebLinkAbout02-02-09r 9h0'Ih0950S'C
~ ap!S
9h0'Ch09SOS'C
AlNO W210d ltlNl'JRl0 3Sf1 3Stl31d
SS3a04V
31Va
3nIlV1N3S3ad3a NVHl a3H10 a3at/d3ad 30 3af11t/NJIS
$ ~( `~ r71r ~ o 0
3aa v
lJ 0 - O~°
31V4 Naf113a JNlll 403 3g81S dS3a NOSa3d 30 3af11dNJIS
a6palMOU~I ~(ue sey ~a~eda~d yalyM;o uoi;ew~o;ul Ile uo paseq sl ani;e;uasa~da~ leuosaad ay; uey; gay;o ~aaeda~d;o uol;e~eloaa 'a;aldwoo pue;oa~~oo 'any; si;I
')allaq pue a6palMOU~ ~w;o;saq ay; o; pue 's;uawa;e;s pue salnpayos 6u1~(uedwoooe 6ulpnloul `wn;a~ sly; pawwexa ane
4 13eyl a~eloaP I `tinGad io sanieuad rani ~~
ssa~ppe llew-a s,;uapuodsa~~o~
t
c,
i _~;
~_~__
,:~,,
{
.,
~
,- °- 4311
~~
n
.~ cv arc `-~'
=~ ~ o
C.>
AlNO 3Sn SKIM j0 2131S1°J321
ssa~ppe ~o awl puooaS
~$~1 /,~mNg~~ ooh'
ssa~ppe 1o awl ;sa!d
(algeoilddy~l) aweN uan
~~L.6 9~L~ ~hg kin a~NaN ~~ F/ 4~d~ t7 ,7 ~G~
~aquanN auoydalal awl~ep a1UeN
~Ol 431032114 38 OInOHS NOllb'W210dN1 XVl l`dI1N341dN00 ON`d 30N30NOdS32R100 lltl'03131dW00 381SnW N01103S SIHl -1N3UNOdS3?I?In~
(O yoS 4oeAt1) (96-1-1 Pue L6-L£-Z1 uaann;aq
(y)E116 oaS ~apun xe; o; uol;0413 ~ 11 O y;eap;o a;ep);Ipaa~ ~(}aanod lesnodS 'OL O panlaoaa spaaoad uoge6gld .6 O
_ (lsnal ~o ~(do~ 4oel;V) (II!M bo ~(do~ 4oe33b')
saxoe;Isoda4 aleg;o aagwnN lelol '8 ;sn~l 6ulnl~ e paule;ulelN;uapaoad 'L O a;e;sal pa14;uapaoaa 'g
(Z8-Z1-Z1 ~a}}e yleaP
pannbea uan;ay xel a;e;s3 leaapad .g O 1o a;ep) aslwadwo~;saga;ul a~n;n3 ~eb O 'a;e;s3 pa;lwld 'b O
(Z8-E1-Z1 o;aoud
y;eap 1o a;ep) wn;a~ ~apwewa~ £ O wn;ab le;uawalddnS ~Z O uan a
L a leu!6u0 1 O
M0~38 Slt//~O 31`dR1d021dd`d NI lllj
S~IIM ~O 2131SIJ321
3Hl HlIM 31b~l1dt14 NI 4311 381Sf1W N21f113b SIHl
aagwnN l;unoaS ~epoS s,asnodg
IW aweN ;sn3 s,asnodg wing aweN ;set s,asnodS
mola8 uol;eua~o;ul s,asnodg 6u!n!n~nS ~a~u3 (algeo11ddy;I)
IW auaeN ;s~!~ s,;uapaoaQ xi}ynS auieN ;sed s,;uapaaa4
yu!8 bo alea 4leaa 3o a;ed aagwnN l~;unoag leloo
S
t MO138 NOIlb~W2103NI 1N3U303Q 2131N3
T? ~ 7_ l ~ (~ ~ ~ 1N3a3~3a 1N3aIS321 1090-8Z111t/d'6~ngsweH
N21f11321 Xb~l 3~Nb~1R13HNl 109o8Z';daa
aagwnN a~i~ ~ea~ apo8 ~(;uno0 ~ '- saxel lenplnlpul ~o neaang
anuanab ~o;uaw}~edad yd
AlN0 3Sn 1`0'181330 (b0-50) X3 oOC ~ ~~~ ^-
~ 9s6 ~ -~S s ~~, 07
aPo~ dIZ a;e]S aoi1~0 lsod ~o ~L!~
J
15056042047
REV-1500 EX
Decedent's Soci2al/S/ecurity Number
Decedent's Name: / ~ ~ ~/
RECAPITULATION
1. Real estate (Schedule A). '. ` ....................................... ... 1.
2. Stocks and Bonds (Schedule B) .................................... ... 2.
3. Closely Held Corporation, Partnership or Soie-Proprietorship (Schedule C) .. 3.
4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. ~ 6 ~ 1 • q 7
6. Jointly Owned Property (Schedule F) G Separate Billing Requested .... ... 6. •
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested..... ... 7.
8. Total Gross Assets (total Lines 1-7) ................................. ... 8.
9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. t ~ ~
~•~ ~
10
D
bt
f D
d
t
M
rt
Li
biliti
& Li
h
l
I
S
d
1 //
p
~ / ~ ~ b
. e
s o
ece
en
,
o
gage
a
es,
ens (
) .............
c
e
u
e ...
0.
11. Total Deductions (total Lines 9 & 10) ................................ ... 11. ~ ~g $ •~
~3 ~
12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. /
•
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ..................... ... 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. ~ ~,,3 l .7
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0 15.
16. Amount of Line 14 taxable ./
at lineal rate X .0 ~ ~ ~ 7 .`'~ ~
16. !'
~ 07 ~.7
17. Amount of Line 14 taxable
at sibling rate X .12 . 17.
18. Amount of Line 14 taxable
at collateral rate X .15 • 18.
19. TAX DUE .........................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056042047
Side 2
3~ ~, ~f
O
15056042047
CTC-~~~.
REV-1508 EX ~ (197)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF L FILE NUMBER
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
5 Ovt/le,'g,~i ~3~Nr ,gtCavvt /osS%7~'22.G ~
TOTAL (Also enter on line 5, Recapitulation) $ 1 C5 /~`
(If more space is needed, insert additional sheets of the same size)
~~,,.~~ T
~ ~ ~ ~~
~
~ o
m O~
Q m m~ Y
~ ~
ar~r ,' E„~ m m
'~ y.. ~ ~ m ~._
~, ~
v ~ Z
~
s . .:
~s-sr 1.~1
~1
~ ~ tin
c ~~
[++ Q ~ mo
~~ ~
'~r ~~ ~ O
~`, m
~°- ~
m
~~
_
fir- Z.
~
S2
e
i;,) ~ ~~
~-d,
> ~
. ~ ~~
~
[¢9 '~;<
~; ~,~
-::,,,a.
'~
r/
V
.
-
,.y
w
O
3
m ~
"
O
Z
mm D m ..
~
C~ D
_
a ~m~
3
N /~1~~
W
Z
O C
m OO ~~A ~~
~: ~/
~ ~
°~
O
REV-1511 EX+ (10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES Sc
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTAT~EpF FILE NUMBER
M iC ~ t4 Nl9 ~I,y G/B A K!r/ ~ -
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: 6' O, ~j p
,. Gam,,, ~~ ~,¢~, a y
y• d o
Ctk~ .~;c ~, .~~ a o v• v D
.~• ~ ~~ gS• yo
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) N /~
Ctraot Aririrass _. -
2
3.
4.
5.
6.
7.
City State Zip
Year(s) Commission Paid:
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant k / ~
Street Address
City State _
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
TOTAL (Also enter on line 9, Recapitulation) I $ ~ ~ 9~, of d
Zip
(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
oe....h aotit~ i~r~~r~ad n~ the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
(If more space is neeaea, insen aoamonai sneCw ~~ ~~~~ ~a~~~~ ~~~w
NEWVILLE CGMM. AMBl.1LANCE C/C) PROMED SERVICES, INC.
4 W. MAIN STREET
SHIREMANSTtJViIN, PA 17011
1-866-678-6855
patient Bill
Page: 1
Printed: 12/12/08 13:31
ID: Newv-2548
HEL.EE~A FiAW3AKER
GREEf~I RIDGE VILLAGE
210 BIG SPRING RD
Newvilie, PA 17241
Patient: HELENA HAWBAKEI~
Claim Number: ~~780089®"sagnosis 1) 7£3.05
~S~S: ~ k ~1~!~~C'j'' ,~ (G.} 3'-~~3~(i~ i., ~, ~, ~ ~. -FLE1 :..~~~._~J~ J
0310/21-10/21/08 WSAA0888EH ly
Procedure: MILEAGE -ADDITIONAL
E'atient 7otal~~:
DOB: 03/22/1915
ID: 2548
240.00 20 200.00
240.00 __._ 200.00 0.00
DOB: 03/22/1915
0.00 0.00 200.00
0.00 0.00 200.00
Total Ameunt Due By Guarantor: 200.00
200.00
200.00
~', #lo~
2 Zv ~~
Monthly Phone Statement
Statement Date Range 111112008 to 1113012008
Facility: Green Ridge
Account Number
Total Cost of Calls Made
1254:~U/~~1
$o.oo
Monthly Phone Charge $23.67
Sub-Total Amount $23.67
State Sales Tax -Basic $1.42
State Sales Tax -Usage $0.00
State Sales Tax Total $1.42
Pay This Amount $25.09
Phone Number (717) 776-8465
Total Cost of Calls Made $0.00
Phone Number Surcharge $23.67
Total Cost for Number
$23.67
Helena Hawbaker
Phone
Detail Listing of Calls Made
No Billable Calls were made
Monday, December 01, 2008 Page 1
RESIDENT STATEMENT FROM
GREEN RIDGE VILLAGE
SWAIM HEALTH CENTER
210 BIG SPRING ROAD
NEWVILLE, PA 17241-9486
717-776-8256
Statement Date Due Date
11/30/2008 Upon Receipt
$3,446.59
ACCOUNT NUMBER
61549G RV
AMOUNT PAID $
HELENA V HAWBAKER
c/o MILDRED AUGHENBAUGH
400 HIGHWAY 1283
LORIS, SC 29569
Please make check payable to GREEN RIDGE VILLAGE
Remit To:
GREEN RIDGE VILLAGE
PO BOX 34309
NEWARK NJ 07189-4309
Please detach and return this pcr Zion with your remit*.ance tc the 4ddress above.
Comments
If you have received new insurance cards for 2009, please provide copies to the Business Office. Thank you!
a'te Description ,~ ,Days/ ~ Rate- ; Balance
C as g ~~ Payments '~
~
I ~ .Units -~ ~., Y
(Cretlit): ~_.
~ :`
Balance Forward $434.78
11 /21 /08 - 11 /21 /08 Pmt. from 10/31 /08 Stmt. Check # 2273 $434.78
10/15/08 - 10/15/08 Transportation Attendant 2 $(20.00) $(40.00)
10/28/08 - 10/28/08 Manicure 1 $14.00 $14.00'
11/01/08 - 11/01/08 Transport Van-Mileage Rate 28 $0.65 $18.20 Y'
11/01/08 - 11/01/08 Transport Driver-Hourly Rate 2 $20.00 $40.00 /
11/05/08 - 11/29/08 Co-Ins Room/Board-Self Pay 25 $128.00 3,200.
11/06/08 - 11/06/08 Transport Van-Mileage Rate 56 $0.65 $36.40 /
11/06/08 - 11/06/08 Transport Driver-Hourly Rate 2.25 $20.00 $45.00 '~
11/25/08 - 11/25/08 Shampoo 8~ Set 1 $14.00 $14.00 /
11/25/08 - 11/25/08 Facial Hair Removal 1 $2.50 $2.50 ~
11/26/08 - 11/26/08 Transport Van-Mileage Rate 56 $0.65 $36.40 /~
11/26/08 - 11/26/08 Transport Driver-Hourly Rate 2 $20.00 $40.00 /
11 /27/08 - 11 /27/08 Meal Tax 2 $0.42 $0.84 /
~
11/27/08 - 11/27/08 Guest Meals-Lunch 2 $7.08 $14.16
/
~
11/29/08 - 11/29/08 Telephone 1 $25.09 $25.09
u0
TOTAL BALANCE DUE: $3,446.59
i
~~~~
FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
SWAIM HEALTH CENTER HELENA V HAWBAKER 61549GRV
REV-1513 EX+ (9-OOj
-, SCHED~ILE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
1 TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
/~ Q A J f ~c/ f ~2 ~ Utz a70
~/~ /~~kU
~v n; S, sc Z 9 S~ 9
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
11 NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $
(If more space is needed, insert additional sheets of the same size)
I, HELENA V. HAWBAKER, of 820 Lisburn Road, Apartment 301, Camp Hill,
Cumberland County, Pennsylvania 17011, do hereby make, publish and declare this to
be my last last will and testament, hereby revoking all wills heretofore made by me.
1. I direct my personal representative to pay all of my debts, funeral and
administrative expenses as soon as convenient after my decease.
2. I authorize and empower my personal representative to sell any realty
and/or personalty owned by me at my death and not specifically devised or bequeathed
herein, at public or private sale or sales and to give good and sufficient deeds and/or
bills of sale therefor, in fee simple, as 1 could do if living. My representative is
authorized and empowered to engage in any business in which 1 may be engaged at
my death, for such period of time after my death as seems expedient to said
representative.
3. I give, devise and bequeath all of my estate of whatever nature and
wherever situate to my daughter, Mildred A. Aughenbaugh, or if she is deceased, then
to her children, share and share alike..
4. I nominate and appoint Mildred A. Aughenbaugh and James
Aughenbaugh to be the co-personal representatives of my estate, to serve without
bond.
6. 1 suggest that my persc^a~ *e^~ess^:a'~~~~e retain the services of Harold S.
Irwin, III, Carlisle, Pennsylvania in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ day
of May, 1998.
~s' j~~'
HELENA V. HAWBAKER
(SEAL)
Signed, sealed, published and declared by the above-named person as and for
a last will and testament, in our presence, who at said person's request, in said
person's presence and in the presence of each other have hereunto set our names as
subscribing witnesses.
i~ ~~(
~s, i~~
ACKNOWLEDGMENT AND AFFIDAVIT
WE, HELENA V. HAWBAKER, GAY L. IRWIN and HEATHER A. BARBOUR,
the testatrix and witnesses respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that
~e testatrix signed and executed the instrument as her last will and that she had
- _ ! -.. - y ~ _=~~= s~= eYe~- ~e~ ~* as per free ar?d voluntary act for the purpose
-e--- exoressed, a^d :,sat ea:.~ of is^.e ;.~~~ ,asses, in he presence and hearing of the
testatrix, signed the will as a witness and that to the best of their knowledge the
testatrix was, at that time, eighteen years of age or older, of sound mind and under no
constraint or undue influence.
rs~ l~ j/lf
HELENA V. HAWBAKER
/~f ~ Lr
GAY L. IRWIN
~~ /~~
HEATHER A. BARBOUR
COMMONitVEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
:ss:
Subscribed, sworn to and acknowledged before me by HELENA V.
HAWBAKER, the testatrix herein, and subscribed and sworn to before me by GAY L.
IRWIN and HEATHER A. BARBOUR, witnesses, this ~~r- day of May, 1998.
l~ ~ ~ ~
Notary Public
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NA
-_ -
STREETADDR SS
--~--
CITY - ~
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit _ _ _ _ __ -
B. Prior Payments _ _.
C. Discount
File Number
STATE en n .
(1)
Total Credits (A + B + C) (2)
zlP~~ay~
3 ~.s.
3. InterestlPenalty if applicable
D. Interest _ _ --
E. Penalty __ _
- Total InterestlPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
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. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 3 p7 S, C/ /
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 consitleration? .............................................................................................................. ^
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 PARIT 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.