The URL can be used to link to this page

Home My WebLink About04-0440PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of Larry E. Johnson No. also known as To: Register of Wills for the Deceased. County of Cumberland in the Social Security No. 241 - 78 - 8116 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner~), who isXaYr~l 8 years of age or older, appli.e_S~ for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in Cumberland County, Pennsylvania, with h_i_S__lastfamilyorpri~cipalresidenccat-~q~a ~r~kr~c]~ Br~x7~_ M,=~-h~nqt,~hnrc~ (list street, number and municipality) PA, 17050 rte/,t'~ ~cO - --" ...................... Decendent, then 5 8 years of age, died .... ~J_~ ...............................~Iti[ 2 013 2, at Stokesdale: NC Decendent at death owned property with estimated values as folllows: (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: $ Petitioner.__ the following spouse (if any) and heirs: Name after a proper search has ascertained that decedent left no will and was survived by Margaret A. Johnson David L. Johnson Relationship Wife _ Son Residence 3924 Brookridge Dr. Mechanicsburg, PA 4]670 I.awgon Oira]o Paul R_ ,lnhn~nn SOD ]7050 · ~m~,~]~_ CA 92592 315 ~66~h-3rd Ave. Lebanon, PA 17042 THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. 3924 Brookridqe Drive Mechanicsburg, PA 17050 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF CUMBERLAND 3 The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed, and subscribed before me this ~.~ dav of No. Estate of Larry E. Johnson , Deceased GRANT OF LETTERS OF ADMINISTRATION 4 AND NOW .5' 5' 0 ' 31~[2-0XL4, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that Marqaret A. Johnson is/lgr~ entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to Margaret A. Johnson in the estate of Larry E. Johnson FEES Letters of Administration ..... $ tO,Ut/ Short Certificates((p)..~/h ......$ [~j, DO_ &~ma~t~-r...k~.C~.¥ ....... $ I0, O0 ,O~A[ __ $ q la 0 Filed ..................... A.D.--k9~ Ira H. Weinstock (Pc.I.D. #01602) . ATTORNEY (S, up.._.C,t. I.D. ,No.) 800 m. ~econo ~ree~ Harrisburg ~ PA 17102 ADDRESS 717-238-1657 PHONE CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Date of Death: Larry E. Johnson June 26, 2003 Will No. 21 - 0 4 - 4 4 0 Admin. No. To the Register: I certify that notice of (4~~) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on May 6 _. 2 0 0 4 : Name Address Margaret A. J6hnson 3924 Brookridge Dr., Mechanicsburg, PA 17050 David L. Johnson 41670 Lawson Circle, Temecula, CA 92592 Paul E. Johnson 315 South 3rd Avenue, Lebanon, PA 17042 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Da~: May 6, 2004 Signature Name Ira H. Weinstock, Esquire Address 800 North Second Street Harrisburg, PA 17102 Telephone (717 2 3 8 - 16 5 7 Capacity: __ Personal Representative X Counsel for personal representative . f \, '- · '\. PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY UNTIL COMPLETION STATUS REPORT UNDER RULE 6.12 '~ame of Decedent: Larry E. Johnson Date of Death: June 26, 2003 Will No.: Admin. No.: 21-04-440 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect 10 completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. Ifthe answer to No. I is yes, state the following: A. Did the personal representative file a final account with the court? Yes X No B. The separate Orphans' Court No. (if any) for the personal representative's account IS: c. Did the personal representative state an account informally to the parties in interest? Yes X No Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. D. lJate: June 8. 2005 ~ H. ~-,1foei_ Signature (~:'l Ira H. Weinstock, Esquire Name (Please type or print) , 800 North Second Street, Harrisburg, P A 17102 Address 717-238-1657 (I';]AH:rmt/AM3) C__:~J Telephone No. Capacity: Personal Representative c# R.W -27 X Counsel for Personal Representative '> Ira H. Weinstock, Esquire fa. J.D. No. 01602 IRA H. WEINSTOCK, P.C. 800 North Second Street Harrisburg, PAl 71 02 Phone: 717-238-1657 Fax: 717-238-6691 JAN 2 8 2DD5 Attorney for Petitioner IN RE: ESTATE OF LARRY E. JOHNSON IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. NO. /' /"'. 05-- -.5/J cw-J- ~ ORDER AND NOW, this ~day Of~, 2005, upon consideration of the foregoing Petition to Approve Settlement and Distribution of Funds in the wrongful death of Larry E. Johnson, it is hereby ORDERED and DECREED as follows: 1. The settlement of the claim of Petitioner, Margaret A. Johnson, Administratrix of the Estate of Larry E. Johnson, for the sum of Five Hundred Thousand ($500,000.00) from the underinsured motorist claim with Allstate Insurance Company is approved. 2. Margaret A. Johnson, as Administratrix of the Estate of Larry E. Johnson, IS hereby authorized to effect such settlement from the underinsured motorist claim with Allstate Insurance Company and accept the sum of Five Hundred Thousand ($500,000.00) Dollars as set forth in the foregoing Petition in full payment and settlement of the aforesaid claim, which amount shall be distributed as follows: Ira H. Weinstock, P.C. $ 150,000.00 Margaret A. Johnson $ 350,000.00 4. The maximum amount of recovery IS Five Hundred Thousand ($500,000.00) Dollars from the underinsured motorist benefits with Allstate Insurance Company. 5. Margaret A. Johnson, as Administratrix of the Estate of Larry E. Johnson, is authorized to execute and deliver a good and sufficient release of the underinsured motorist claim. 6. The payment of the underinsured motorist claim shall constitute evidence and complete satisfaction of all underinsured motorists claims and demands of whatsoever kind and nature arising out ofthe motor vehicle accident that occurred on June 26, 2003. BY THE COURT: J. (:(:\ ~ri~~t t~ .!7f, r~:--~~~ ~ ~~ .' ~.. .~,,! ~~ 1':"",) i< ~ ...,~:J ~ t ,:.? n l..";;~ _. ~ , ! ." ~C,~:zt4~~ ; "~ ".( ,: .i -~ ~'!.; ; I REV- 1 500 EX (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FZ NIM~EO t-/ 0 ~ '-J Jl_ COLNIY CODE YEAR tUABER w f-, ~:g;(/) UC::~ wc..u IOO uC::-' c..a:l c.. <( I- Z W C W () W C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) JOHNSON, LARRY E DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) SOCIAL SECURITY NUMBER 241-78-8116 THIS RETURN MUST BE FILED IN DlJPUCAlE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER D 2. Supplemental Retum D 4a. Future Interest Compromise (date of death after 12- 12-82) D 7. Decedent Maintained a Living Trust (Attach copy ofTrust) D 10. Spousal Poverty Cred ij (date of death between 12-31-91 ar<! 1 -1-95) I- ffi NAME ~ BARRY E MUSSER, CPA f[ FIRM NAME (If Appicable) ~ HAMILTON & MUSSER, PC, CPA'S c:: ~ TELEPHONE NUMBER u 717-697-3888 EXT 102 D 3. Remainder Retum (date of death prior to 12-13-82) D 5. Federal Estate Tax Retum Required _ 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A)(Attach Sch 0) STFPA42021F.1 06-26-2003 05-23-1945 (IF APPLICABLE) SURVNING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) JOHNSON, MARGARET A [XI 1. Original Retum D 4. Limited Estate D 6. Decedent Died Testate (Attach copy of Will) D 9. Lijigation Proceeds Received COMPLETE MAILING ADDRESS 176 CUMBERLAND PKWY, SUITE 101 MECHANICSBURG, PA 17055 1 , 035 , 752 . 50 x .0-2. (15) 0.00 X.O_ (16) 0.00 x .12 (17) 0.00 X .15 (18) 0.00 (19) 0.00 z o ~ :J I- a: <C () w 0:: 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposijs & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1 - 7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) (1) (2) (3) (4) (5) (6) (7) (9) (10) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS FOR APPUCABLE RAlES z o ~ ~ :J Q. :::E o () ~ 15. Amount of Line 14 taxable at the spousal tax rate. or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 0.00 0.00 0.00 0.00 506,634.00 OFFICIAL USE ONLY 176,085.50 353,033.00 (8) 0.00 0.00 (11) (12) (13) 1,035,752.50 0.00 1,035,752.50 0.00 (14) 1,035,752.50 19. Tax Due 20. D I CHECK HEREIFYOUARE REQ(;ESTING A REFUNQPF.AN OVERPAYMENT I Decedent's Complete Address: , STREET ADDRESS 3 92 4 BROOKRIDGE DRIVE CITY MECHANI CSBURG I STATE PA I ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 0.00 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 0.00 PLEASE ANS'NER THE FOLLOWING QUES110NS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes a. retain the use or income ofthe property transferred; ........................................ 0 b. retain the right to designate who shall use the property transferred or its income; . . . . . . . . . . . . . . . . . .. 0 c. retain a reversionary interest; or ................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 d. receive the promise for life of either payments, benefits or care? ............................... 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? . . . .. 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. IX] 0 IF THE ANSWER TO AN( OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this retum, 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. SI JURE OF P SON RE ONS LE FOR FILING RETURN L. No [Xl [Xl [Xl [Xl [Xl [Xl DATE ~ 11... 1.-l>oS- DRIVE, MECHANICSBURG, PA 17050 DATE '" t,.lO} PKWY SUITE 101, MECHANICSBURG, PA 17055 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 3% [72 P.S. ~9116 (a) (1.1) (i)l. 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 0% [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 0% [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 4.5%, 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 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. STF PA42021F2 " REV-1502 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF LARRY E JOHNSON All real property owned solely or as a tenant in common must be reported at fair mar1<et value. Fair market value is defined as the price aI which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER FILE NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. STFPA42021F.3 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1503 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF LARRY E JOHNSON FILE NUMBER All property jointJy-owned with the right of survivOIShip must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. VALUE AT DATE OF DEATH STFPA42021F.4 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1504 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP or SOLE-PROPRIETORSHIP ESTATE OF LARRY E JOHNSON FILE NUMBER Schedule C-l or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest ci the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. STFPA42021F.5 TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1505 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF LARRY E JOHNSON FILE NUMBER 1. Name of Corporation Address City 2. Federal Employer I.D. Number 3. Type of Business State Zip Code State of I ncorporati on Date of Incorporation Total Number of Shareholders Business Reporting Year Product/Service 4. STOCK TYPE Voting / Non-Voting TOTAL NUMBER OF SHARES OUTSTANDING PAR VALUE NUMBER OF SHARES OWNED BY THE DECEDENT VALUE OF THE DECEDENT'S STOCK Common Preferred $ $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? DYes D No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? DYes D No If yes, Cash Surrender Value $ Net proceeds payable $ DYes DNo Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes D No If yes, D Transfer D Sale Number of Shares Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. Consideration $ Date 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? DYes D No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? DYes DNo DYes DNo 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? DYes DNo 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 retums (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete addressles 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. STF PA42021F.6 REV-1506 EX + (1-97) (I) COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF LARRY E JOHNSON FILE NUMBER 1. Name of Partnership Address City Date Business Commenced Business Reporting Year State Zip Code 2. Federal Employer I.D. Number 3. Type of Business Product/Service 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ 5. PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? 0 Yes 0 No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? o Yes 0 No If yes, 0 Transfer 0 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? If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? o Yes ONo o Yes ONo If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. 14. Was the decedent related to any of the partners? o Yes ONo If yes, explain DYes DNo Did the partnership have an interest in other corporations or partnerships? If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. Detailed calculations used in the valuation of the decedent's partnership interest. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. If the partnership owned real estate, submit a list showing the complete addressles and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. STF PA42021 F.7 REV-1507 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF LARRY E JOHNSON SCHEDULE D MORTGAGES & NOTES RECEIVABLE FILE NUMBER All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. VALUE AT DATE OF DEATH STF PA42021F.8 TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1508 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF LARRY E JOHNSON 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 1. 2 3 4 5 6 WESCO WAGON Guardian Life Insurance - life insurance proceeds Reading Teamsters - life insurance proceeds Local Teamsters - life insurance proceeds Allstate - wrongful death settlement proceeds American Funds - Roth IRA 500 102,259 50,000 2,000 350,000 1,875 STF PA42021F.9 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 506,634.00 REV-1509 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF LARRY E JOHNSON SCHEDULE F JOINTLY-OWNED PROPERTY 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 A. MARGARET A JOHNSON B. c. JOINTLY-OWNED PROPERTY: ADDRESS 3924 BROOKRIDGE DRIVE MECHANICSBURG, PA 17050 FILE NUMBER RELATIONSHIP TO DECEDENT WIFE LETTER DATE DESCRIPTION OF PROPERTY '10 OF DATE OF DEATH ITEM FOR JOINT MADE Incll.de name of financial insti!l.tion arxl bark accOlrrt IlJ/Tlber or simiklr identifyil'9 runber. DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT Attach deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. RESIDENCE 3924 BROOKRIDGE DRIVE 153,690 50 76,845.00 A HOME CONTENTS 3924 BROOKRIDGE 28,685 50 14,342.50 A 1998 FORD EXPEDITION 8,300 50 4,150.00 A 3/98 1998 VOLKSWAGE JETTA 6,000 50 3,000.00 A FIRST UNION MONEY MARKET ACCOUNT 11,926 50 5,963.00 A FIRST UNION CHECKING 4,805 50 2,402.50 A AMERICAN FUNDS 138,765 50 69,382.50 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL (Also enter on line 6, Recapitulation) $ 176,085.50 STFPA42021F.10 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF LARRY E JOHNSON SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM I~LillE M NOME OF M TRANSFEREE, MIR RELA-nOf\SHP TO DECEDENT MIJ M DATE DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER OF TRANSFER. ATTACHA COPY OF M DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST OF APPLICABLE) 1. 401k, MARGARET A JOHNSON, WIFE 115,423 100 15,423.00 2 IRAs, MARGARET A JOHNSON, WIFE 44,839 100 44,839.00 3 Pension, MARGARET A JOHNSON, WIFE 192,771 100 92,771. 00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL (Also enter on line 7, Recapitulation) $ 353.033.00 S-nF PA42021 F.11 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF LARRY E JOHNSON FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: 1. DESCRIPTION AMOUNT B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attomey Fees 3. Family Exemption: (W 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 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. STF PA42021 F.12 TOTAl (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 : REV-1512 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF LARRY E JOHNSON FILE NUMBER Include un reimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION AMOUNT STFPA42021F.13 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1513 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF LARRY E JOHNSON SCHEDULE J BENEFICIARIES 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 THROUGH 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 $ 0.00 STF P A42021 F.14 (If more space is needed, insert additional sheets of the same size) ,. REV-1514 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Box 4 on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER LARRY E JOHNSON This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. D Will D Intervivos Deed of Trust D Other NAME(S) OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS DATE OF DEATH PAYABLE 1. Value of fund from which life estate is payable 2. Actuarial factor per appropriate table Interest table rate - 03 1/2% 06% 0 10% 3. Value of life estate (Line 1 multiplied by Line 2) o Variable Rate % o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years $ $ NAME(S) OF ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT DATE OF DEATH 1. Value of fund from which annuity is payable 2. Check appropriate block below and enter corresponding (number) Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) o Quarterly (4) 0 Sem i-annually (2) 0 Annually (1) 3. Amount of payout per period 4. Aggregate annual payment, Line 2 muttiplied by Line 3 5. Annuity Factor (see instructions) Interest table rate 031/2% 06% 010% 6. Adjustment Factor (see instructions) 7. Value of annuity -If using 3 1/2%, 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 $ o Monthly (12) o Other ( ) o Variable Rate % TERM OF YEARS ANNUITY IS PAYABLE o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years $ 0.00 $ $ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15, 16 and 17. (If more space is needed, insert additional sheets of the same size) STF PA42021 F.15 -' 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 LARRY E JOHNSON This schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. o Will 0 Trust 0 Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. 0. 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. 0 Unlimited right of withdrawal 0 Limited right of withdrawal m. 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 06%, 03%, 00% .......................... $ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One 06%, 04.5% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 Taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ........... $ 6. Value of Line 1 Taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ........... $ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . $ 0_00 STF PA42021 F.16 (If more space is needed, insert additional sheets of the same size) .' ~EV-1649 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 0 ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER LARRY E JOHNSON 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. This election applies to the 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, then 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 similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to 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 O. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. DESCRIPTION VALLE Part A Total $ 0 . 0 0 PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. DESCRIPTION VALLE Part 8 Total $ (If more space is needed, insert additional sheets of the same size) 0.00 STFPA42021F.17 08-29-2005 JOHNSON 06-26-2003 21 04-0440 CUMBERLAND 101 APPEAL DATE: 10-28-2005 ( See reverse side under Objections) Amount Remitted I I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE _ RETAIN LOWER PORTION FOR YOUR RECORDS _ REY:is47-EX-AFP-io3:0si-NOYiCE-OF-iNHERiYANCE-YAX-APPRAiSE"ENY~-ALLOWANCE-OR--------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX LARRY E FILE NO. 21 04-0440 ACN 101 ~~~~~~A~~ :A~D~~v~I~~J~m~~~~D OFFICE CF PO BOX 280601 ,n~:h (' '" \ ': HARRISBURG PA 17128-0601;" - COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE DR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ZCJ51~U'~ 30 PH I:: 22 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN C_E?< C:~ BARRY E,.Jd~E~'\ , ' HAMILTO"'a MUSSER 176 CUMBERLAND PKWV MECHANICS BURG PA 17055 ESTATE OF JOHNSON '* REV-1S47 EX AFP (06-05) LARRY E TAX RETURN NAS: 1 X) ACCEPTED AS FILED ) CHANGED DATE 08-29-2005 I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will rrilect ~igures that include the total lI'f Ab.!:. returns assessed to date. ASSESSMENT OF TAX: IS. Aaouni. 0-1 Line 14 at Spousal rat. (15) 16. Amount of Line 14 taxable at Lineal/Class A rat. (16) 17. AItO...,t of Line 14 at Sibling ....t. (17) 18. AMount of Line 14 taxable at Collateral/Class Brat. (18) 19. Principal Tax Due TAX DIT RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held stock/Partnership Interest (Schedule Cl 4. Mortgages/Notas Receivable (Schedule DJ S. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets 11) (2) (3) (4) IS) (6) (7) .00 .00 .00 ,00 506.634.00 176.085.50 353,033.00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Ada. Costs/Misc. Expenses (Schedule 11) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule X) (10) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governnental Bequests; Non-elected 9113 Trusts (Schedule ~J 14. Net Value of Estate Subject to Tax .00 .00 Ill) 112) 113) 114) NOTE: 1,035,752.50 X ,00 X .00 X .00 X NUN8ER INTEREST/PEN PAID 1-) AMOUNT PAID DATE ~ TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE NOTE: To insure proper credit to your account I sub.it the upper portion of this for. with your tax pa~nt. 1,035,752.50 00 1,035,752.50 .00 1,035,752.50 00 = 045 = 12 = 15 = ,00 .00 .00 .00 .00 119)= .00 .00 .00 .00 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YDU HAY 8E DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.l