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HomeMy WebLinkAbout03-20-0915056041046 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 ESIDENT DECEDENT ~' ~ ~ ~ ~ ~~1 Harrisburg, PA 17128-0801 -~ R ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~ ~~ l ~~08 ~~o~ ~q~~ Decedent's Last Name Suffix Decedent's First Name MI Gu ~s~ Do 2vri~'Y ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouses Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return O 2. Supplements! 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) O 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 TO: Name Daytime Telephone Number R ~ G~ R wi G u r s z ~ 1~ ~,6 ~ ~~ ~~ Firm Name (If Applicable) REGISTER OF WILLS USE ONLY First line of address C~ Second line of address ~ -"~ ~ C~ '~: City or Post Office State ZIP Code D~r4~I~ED `. _. -_.. - .-:.:. ,- c.~ ~0 Rk N Ail ~N >D!~ ! 73 7U }.~_ -: Correspondent's a-mail address: )"~ u 1 S ~ 7~ 9 5 © ~~ ht,~ . CLII'r'1 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. SIGN RE OF P RRSON FILING RETURN DATE ADDRESS ,7 l ~ / /1 ~i:2,ti ~~v /(rl _ l~il rk Nr7!!>',/J ~// ~ 7E~1~~ SIGNATURE OF P12EPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15D56041D46 15056041046 REV-1500 EX 15056042047 Decedent's Social Security Number ~~ ~~~ ~ RECAPITULATION ~ 1. Real estate (Schedule A) . ............................................ 1. • 2. Stocks and Bonds (Schedule B) ............................. ....... .. 2 7 - 3. Closely Held Corporation, Partnership,or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. E P h d l S 5 ~ ~? ~ ~ • ~ / 5. u ) ...... roperty ( c e e Cash, Bank Deposits & Miscellaneous Personal .. . 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. (~ ~ C 1 ,`7 / y ~ • 7t, 1 , V , 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedrde G) ~ Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. 1 1 ,3 ~ $ a ~ / 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. .J Cp ,~ 8 , ~ , ~ 10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule I) .............. .. 10. 3 ~ ~ 1 r 6 / 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. ! ~ ~ 6 • ~"'~ 0 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12 1 Q l 3 C7 ' ~ - 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which h d l J b d S 13 ~ O Q ~ Q ) ...................... c u e een ma e ( e an election to tax has not .. . ,• - 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 8 ~ lp 3 ~ . i TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable j / '+~ at lineal rate X .0 ~ V q (p 3 ~ • ~ / ` 16 y O 3 ~ 7 z 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. ~ ~ ~ ~ • ~ 4 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT G® Side 2 15056042047 15056042047 REV-1500 EX Page 3 File Number Decedent's Complete Address: ''~l ~ ~~ ~ J~ y~ - ~~~ - - --_L ,_ _- -u i _ ~ __ STREETADDRESS CITY E ZIP ~,~ r'7c~'s^ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit - __ __._ ------__--- - _ --___ _ B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penaity (1) ~'~, 0 ~ 3c 72 .~ Total Credits (A + B + C) (2) - - --- - Total InterestlPenalty (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) ~ (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? ....................................................................................................... ....... ^ ~t 1~ 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. REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECE DENT ESTATE OF ~ort~~y~l. e ~-n~lS~ FILE NUMBER ,~ ~-~ car " ~~~~ All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH t. Tw~~ ~ ~` Gdu't bc;~~l5 ~ Cashe~ 4~~ c~epcS;~e ~,~ o.? ~~ ' ( ~~a3;-~~ ,~to Inc .~w't * ~ ~ ~ 7~ ~', Y~ ov s o,?c , rcur Ntl ~icv't bcnd5' •- Subm+f~'ed ~y /~zr~ber's 1st .. e.~uhec~ ~ an~a ~ej~c.sited ;~ M~,nbers• l st :4ce't ~ 3i~5"19eQao -~,Ovv,~ TOTAL (Also enter on line 2, Recapitulation) $ ~ 7'~ 9c ~~ (If more space is needed, insert additional sheets of the same size) Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 12/2008 1,225.00 $2,729.40 $1,504.40 $41.60 Bonds: 1-5 of 5 NA: EE ; $1,000 ~ 05/2004 01/2009 05/2034 _ $500.00: $85.20 2.80% $585. 20 ` P5 NA EE $1,000 " 05/2004'.. 01/2009 05%2034 $500.00 $$5.20 , 2.80% $585.20 P5 NA E ~ $100.05/1974: ~ 05/2004 $75.00; .$443.84 $518.84; MA NA, E _ $100 09/1974:_ . 09/2004,. _$75.00_, $445.08. $520.08 MA _ NA ~ E _ _ $100 0.8/1974 08/2004 _ $75.00_. $445.08 $520.08 MA Totals for 5 Bonds , $1,225.00: $1,504.40. $2,729.40 NI Not Issued • NE :Not eligible for payment P5 Includes 3 month Interest penalty MA Matured and not earnin interest Q PNCBANK 040 MECHANICSBURG (041) 2 EAST MAIN STREET MECHANICSBl1RG PA 17055 Cashbox 01 AM * Deposit US Savings Bands 10:55 DEC 31 2008 Account Number XXXXXX1689 Tran Amount $2,729.40 Interest $1,504.40 WJS ID WWSH0412 Sequence Number 00158 Batch 302 Tax ID 195163361 This deposit or pevment is accented subiect to verification and to the rules and regulations of this bank. Deaosits mar not be available for immediate withdrawal. Receivt should be held until verified with your statement. httw//cxnvxx, trPaenn~rlirPCt vnv/RC'/RRf'.PriCP 12/31/2008 _---- .~~~~~;may•~~.. ~_ ~ '~ ~ ~~~.~/lWd~ L~~~. INTEI,ifST'C EASES 20 YE - - FROMISS UE DATE OF i95-16 3361 ~i_i~ 20.0; cr n •. _ _ _ _ H.H .e.n. -._ _.. _. __.._' ~ -i. - ---. _ _ _ _ _ D ~tl ISM ~ '1 ~i , r ~-~ 1 -- .,. _ L ~ .. i. _ _ ~ . I_ ,-.~ - - 1 Mc ~ 1 I ~ 'Y ~ 7 ~ I - _ . .., 5- _~~r ~ _ .. -- itlllLli'~:~lq~i ~ n.- _ _ ~ ~.A ~.~~~i~~7~'diM~-- _ -= ~EE~R}?E~ li~TiERES'~'_ -$ PQ~,.~~`lVAa~ -- 004141033231b0 L 4 ~,`~` L000 6 4 5 9 90 2~~" __ - >~b~=341033231.60 L 4 ~..-i dTPR ESTSEASES 20 YEA - - - FROM -155UE OA3E OF H Z0~3 -- - - ~~ N~._ P~~ 000064599D L~~' I ~,~ i~ SERIES RR ~, SERIES RI-~ o~,P,.,,~.P.,~~,.,~~ ~.~ „-. .. ~~~ ~~ ~V~y=~~ ~N~ER~£T-~J.SES.ZO Y ~%^' i~~~ -. - - - -"-FRIIfs l55UE DAT£ O .__. - -. w=.. I95-16-3361 - 3-=1 2it0_ .. `.C ~~E UE iL n' _ - , - - 1.MO~l,M " YE'wP C ~ ~ iUiiL~'t3' 7l~kT~ h 1~ Z_ ~' _ ~ _ ° t ~EF'ERREQ ]~1~`ERES-7' $ ~Qi.~~! _~ ~~~~~ - 00414103323160 l4 ~t 100064 59900~~' -- _ _, _- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHE®ULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY EST TE OF 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 ti 2. ~rt~dent~a ~ ~ivC~o'~~~d ~~iecl~' _ ~~: ~0 ~ _ PIUC Checl~~r~~ ~cc ,~ ~.5U7Qa ~ ~ 6 ~ ~ ~ .7 S ~ ~ ~.Z TOTAL (Also enter on line 5, Recapitulation) ~ $ ~ y 7 ~~ ~ 7 ti if more space is needed, insert additional sheets of the same size) SCHEDULE F ~` JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE 0 FILE NUMBER ~U"rG' ~ IS ~ ~ I - U£~ - j e~ If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVINGIJOINT T~EINANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT 4'-luger ~.J'. l.?1.115~ ~0~~11 ~y ~c~• JQt'~ ~prK ~~ci11c~~, ~ni 17 ~7Q e. I~ra~T-cict .~. ~~t---y ~63Q ~. ~1~~Se arc~e~ ~~~c~. 5 ~c,uy~ter l" I ec~~n i c.s ,~ u, J ~ ~~ l 765;5° c. ~Qrv~~~ ~~ ~uis~ ~~ "~%c~srn~ V'i~~ .l~iUe ~ec,~i ~ , ~G.u9~i~'er >tanics ~!'~, ~~A 17(~5'S JOINTLY-OWNED PROPERTY: EM LETTER FOR JOINT DATE MADE DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH % OF DECD'S DATE OF DEATH VALUE OF dBER TENANT JOINT deed forjointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST ~. a. ?:?•3e~ ~'lemhers ~ st S~aurngs j 2-3Q M~r» bets j s t SCLIj r„~c~s 2~ ~y~~ ~~~~~ ~ 7~ -o Y as,~. i9 a.~ ~,oal. ~a ~ .. ~ ybG ,~ ~ r t ~ 76 _ ~.,5 ~ /6 ~, ~~ _ lrJ~3~ J`1c.mb~.r5 /' st ~rLt~'icce,~e. ~. _ `~ ~vQ7 ~ 76,5' -yl _T 6 ~ 7 95i, ~ f o '~ ~ 3 , ~ ~ 7 ,~ f ti~ G l~ / st ~rf+~tc_a_~ %'~~m~icr'S ) (( 7/1 `) ^}+ o~ ~l~ /'~em~~rs js~ ~'~r~'~icut~ 7 ~ y~ ~ t~ ola~ ~!' l~ 1, 9 v.5 6.OSur,9,~ 0~ --1~ /t'i em ~ ers / s t Cyr ~'r-~~"c~t~. - ~ i99 ~ )' - Ll' ___ 6 ~~ 0~ ,~ ~0~6,70 ~7-03 ~`1em~c~.--s `Sf ~' a-~L~r~ic~ ~e , 9 d 7-v3 /`~~ hem s / s ~ L'e.Y~t ~« ~`e TOTAL (Also enter on line 6, Recapitulation) I $ (If more space is needed, Insert additional sheets of the same size) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY tNHERiTANCE TAX RETURN RESIDENT DECEDENT iTATE OF ,p FILE fdllMt3ER 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 )INTLY-OWNED PROPERTY: REULTfONSHtP 70 DECEDENT N IER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank aceounf number or similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET 96 OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST a. 0 7 -G3 /`le,C,, bzvs ~ st cer~~ ~lr~~te. ~ ~-~ ~`~Cm!7eXS `' S t Cer C,~r~rc:a ~e I ~ ~ooG ~ ~ i.~(Jl~. ~ 6 (JO..:~ U7 ~3 hem ~?~r5 / si- C2~'~r i-r ~ t'~e __ _! ~ ~ ~~ ~ - / aoa.~ ~ o..~ 6C~~.~~ ~ ~3 ~~m bps ~ S t ~~ tf ~;~ ~~ _ 13 u -~ l r~GOS~ ~ 5__ 6 60. d.~ 0'l-c~3 hem bars Jst ~er~~ ~icu to - r /,5 ff -a~ 8 2 st ~~em~ers / Cer~r~rca ~ ~'7 13~.~~ 085 ;~~7.1.3 ~~ 0 ~7~5g-~~ ~ ~ Il v ~~r'~ ,~',~ ~, ~, ~` i ~; 5 was a., °~r~ (~ if" ~l Tl C:Gi ~~' C~ ~~Jr~ °y~~ l ~ ^")C3 ~) ~ CE . W ~1c~ v~d~~tYeG~ Un ll-~~~~~ ~ TOTAL (Also enter on line 6, RerapitDlation) (If more space is needed, insert additional sheets of the same size) i- PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU DF INDIVIDUAL TAXES AND FILE N0. 21 PD. BOX 280601 TAXPAYER RESPONSE ACN 09102735 HARRISBURG PA 17128-0601 DATE 01-16-2009 REV-1543 EX AFP (BB-oB) TYPE OF ACCOUNT EST. OF DOROTHY R GUISE ® SAVINGS SSN 195-16-3361 ^ CHECKING DATE OF DEATH 12-21-2008 ^ TRUST COUNTY CUMBERLAND ^ CERTIF. REMIT PAYMENT AND FORMS TD: ROGER W GUISE REGISTER OF WILLS 925 CLY ROAD CUMBERLAND CO COURT HOUSE YORK HAVEN PA 17370 CARLISLE, PA 17013 MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a Joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please tali G17) 707-e327 with qussiians. COMPLETE PART I BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 7658-00 Date 12-30-1964 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance ~` 2, 343.65 payable to "Register of Wills, Agent". Percent Taxable )( 50.000 NOTE: If tax payments are made within three Amount Subject to TaX $ 1 , 171 • 83 months of the decedent's date of death, TaX Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due ~` 52 • 73 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX AS5E55MENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of C H E C K Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y WWWIII to be filed by the estate representative. C. ^ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL USE ONLY I 1 AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE i. Date Established 1 I 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate ~ X ~ 8. Tax Due 8 '~ 8 PART DEBTS AND DEDUCTIONS CLAIMED r,wrr Dorn PAVFF DESCRIPTION AMOUNT PAID ~wir~~ .,. - ._ _ ~ -- ---- U er penalties of perjury, I declare that the facts I have reported a~b7ov7e are tru//e, c~o(r~rect and o plete to the best f my knowledge and belief. HOME C/~/ ) ~~C~'"4~.1 d ~ WORK C ) _.__ TFI FPFIf1NF NIIMEFR DATE PENNSYLVANIA INHERITANCE T INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D Po Box zaecol TAXPAYER RESPONSE ^PJIRRISBURG PA 17128-0681 1 REV-1543 EX AFP (OB-OB) FILE NO. 21 ACN 09102736 DATE 01-16-2009 ROGER W GUISE 925 CLY ROAD YORK HAVEN PA 17370 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in cal culatins the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C7i71 7o7-8'x27 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 7658-04 Date 12-30-1964 To ensure proper credit to the account, two Established copies of this notice must accompany 4, 002.19 payment to the Register of Wills. Make check Account Balance $ payable to "Register of Wills, Agent". Percent Taxable X 50.000 2, 001.10 NOTE: If tax payments are made within three Amount Subject to TaX $ months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 90.05 nine months after the date of death. P~r TAXPAYER RESPONSE ~ FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE ~~yy B L 0 C K B. {y{ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y 44~~ to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART TAX If indicating a different tax rate, please state relationship to decedent: RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS I 2 +~ 3 X 4 5 6 7 X 8 $ PAD OFFICIAL U5E ONLY ~ AAF PA DEPARTMENT OF REVENUE i 2 4 5 6 7 8 PART DEBTS AND DEDUCTIONS CLAIMED ^3 DATE PAID PAYEE DESCRIPTION AMOUNT PAID O~C~(`AIA TIIDC TGI GP41f11JF MIIMAFR T1ATC TOTAL (Enter on Line 5 of Tax Computation) S U/npd~e/7r, penalties of perjury, I declare that the facts I have reported above are t/r/ue, corrrect and %gdf'p~l.ete to ~~est ofj mY knowledge and belief. HOME C ~~~ ) ~~i.b'~y~.l~~ ,~/~'!~ / ~X/,/7// a ~.~~ WORK C ) PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE ND. 21 Po Box zaB6o1 TAXPAYER RESPONSE ACN 09102737 HARRISBURG PA 17128-0601 DATE 01-16-2009 REY-1543 E% AFP <OB-09) TYPE OF ACCOUNT EST. OF DOROTHY R GUISE ® SAVINGS SSN 195-16-3361 ~ CHECKING DATE OF DEATH 12-21-2008 ~ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: ROGER W GUISE REGISTER OF WILLS 925 CLY ROAD CUMBERLAND CO COURT HOUSE YORK HAVEN PA 17370 CARLISLE, PA 17013 MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (7i7i 707-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 7658-05 Date 04-08-1986 To ensure prover credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 8,324.06 payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax Tax Rate Potential Tax Due $ 4,162.03 )( .045 $ 187.29 NOTE: If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE 0 ,:n FAILURE TD RESPOND WILL RESULT IN AN OFFICIAL TAX A55ES5MENT'' A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above information is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 X 4 5 6 $ 7 X 8 PAD OFFICIAL USE DNLY ~ AAF PA DEPARTMENT DF REVENUE 1 2 3 4 5 6 7 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID rCl CDLInMC MIIMII nnrr TOTAL CEnter on Line 5 of Tax Computation) & U er penalties of perjury, I declare that the facts I have reported above are t//ru//e,~~~~corrrrect and co plete t t e best f my knowledge and belief. HOME C ~~~ ) t~(cb'YLJ~.~ /171 A 1 ~~ ~.~ WORK C ) PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND F I L E Po Box zaasal TAXPAYER RESPONSE ACN HARRISBURG PA 17128-0601 DATE REV-1543 E% AFP (OB-06) N0. 21 09102738 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: ROGER W GUISE REGISTER OF WILLS 925 CLY ROAD CUMBERLAND CO COURT HOUSE YORK HAVEN PA 17370 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call Z7 i7i 7e7-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 7658-41 Date 10-30-20D7 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 67,794.61 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 33, 897.31 months of the decedent's date of death, Tax Rate )( . 045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $` 1 , 525.38 nine months after the date of death. PART TAXPAYER RESPONSE ~ FAILURE TD RESPOND WILL RESULT IN AN OFFICIAL TAX A55E55MENT A. ^ The above information and tax due is correct. Remit pavment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE I~71 BLOC K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return O N L Y w~ to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART TAX LINE If indicating a different relationship to decedent: RETURN - COMPUTATION OF Late Established 1 i -_ tax rate, please state TAX ON JOINT/TRUST ACCOUNTS OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE PAD 1 . 2. Account Balance 2 +~ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 5 6. Amount Taxable 6 '~ 6 7. Tax Rate 7 X 7 8. Tax Due 8 $ 8 - _-___ PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Tev vro rr_-w nor TFIFPHONE NUMBER DATE TOTAL CEnter on Llne 5 of lax Computatlon~ s Under penalties of perjury, I declare that the facts I have reported above are tru/e, correct and o plete to the best, of my knowledge and belief. HOME C~~7~~j(~ w ~~ ~~ WORK C ) PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU DF INDIVIDUAL TAXES AND F I L E PD Box zsosol TAXPAYER RESPONSE ACN HARRISBURG PA 17128-0601 DATE REV-1543 EX AFP (OB-0E) NO . 21 09102739 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: PATRICIA PERRY REGISTER OF WILLS 2630 N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 127010-40 Date 07-03-2006 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 1 , 200.51 payment to the Register of Wills. Make check $ payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax NOTE: If tax payments are made within three $ 600.26 months of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discount on the tax due. Potential Tax Due Any Inheritance Tax due will became delinquent $ 27.01 nine months after the date of death. P~T ~ TAXPAYER RESPONSE FAILURE TU RESPOND WILL RESULT IN AN QFFICIAL TAX A5SE5SMENT ' A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K ONE a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K 0 N B. }~ The above asset has been S~-'` or will be reported and tax paid with the Pennsylvania Inheritance Tax return L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate e. Tax Due OF TAX DN JOINT/TRUST ACCOUNTS 1 2 3 X 4 $ 5 6 $ 7 X 8 PAD OFFICIAL USE DNLY ~ AAF PA DEPARTMENT OF REVENUE 1 2 3 4 5 6 7 8 PART DEBTS AND DEDUCTIONS CLAIMED ^3 ' DATE PAID PAYEE DESCRIPTION AMOUNT PAID / TOTAL (Enter on Line 5 of Tax Computation) S "-'-1 -- -,~:-- -~ ---:.rte.. r:~~-- --- ~~_,. ~~_ ~__~ ~. , co le to tF~e best f jay ~~ XP4VFR STf~NATIIRF yvZedge and belief.---_ - ..-.- ,HOME`-vCy/ ~~) Gf'lp/ ~(C)'/<~7~ , ~ 1/~ WORK ( ) TIATC PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND F I L E PD Box zao6ol TAXPAYER RESPONSE ACN HARRISBURG PA 17128-0601 DATE REV-1543 E% AFP (OB-OB) N0. 21 09102740 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: PATRICIA PERRY REGISTER OF WILLS 2630 N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department wltll the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please tali C7i7i 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 127010-41 Date 06-18-1992 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 12, 111 • 91 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NDTE: If tax payments are made within three Amount SUbjeCt to TaX $ 6, 055.96 months of the decedent's date of death, TaX Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 272 • 52 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, ar check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K B. ~ The above asset has been ar will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART 2^ TAX If indicating a different tax rate, please state relationship to decedent: RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE i. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due i 2 3 X 4 $ 5 6 7 X 8 $ PAD OFFICIAL USE ONLY ~]AAF PA DEPARTMENT OF REVENUE 1 2 3 4 5 6 7 8 PART DEBTS AND DEDUCTIONS CLAIMED ^3 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Undkr enalties of perjury, I e Tare that the facts I have reported a'-byove~J are//tr e~/co/rr~eJct ,a/Dd c m/pl to to the best my k w dge and belief. HOME C /~ / ) (Q ~/ ./ /~`~ ' .. WORK C ) __ _ ... ..~.....~.....- TCI CPLJf7AIG AIIIMAFR TIATF TOTAL Linter on Line 5 or lax Uomputacion~ ~ PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND F I L E Po eox zeocol TAXPAYER RESPONSE ACN HARRISBURG PA 17128-0601 DATE REV-I543 E% AFP (OB-OB) NO . 21 09102741 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: PATRICIA PERRY REGISTER OF WILLS 2630 N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, You were a ioint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please tali 1717) 787-6327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 127010-42 Date 06-18-1992 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 12, 111.91 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $` 6, 055.96 months of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due ~` 272.52 nine months after the date of death. P r TAXPAYER RESPONSE ~ ~ FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of C ONE Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL USE ONk.Y ~ AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1 Date Established 1 1 . 2. Account Balance 2 $ 2 3 Percent Taxable 3 X 3 . 4. Amount Subject to Tax 4 $ 4 5 Debts and Deductions 5 5 . 6. Amount Taxable 6 $ 6 7 Tax Rate 7 X 7 . 8 e 8 D T $ 8 . ax u PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) 6 Un r p alties of p jury, I Clare that the facts I have reported anbove are trucGe, correct /an/d c to the be f m k wledge and belief. HOME 1/` ~ ) 6 L~ ~ y WORK ( ) r.vnw"rn nrruwr ( r TFI FPI-If1NF NIIMRFR iIATF F'tNNJYLVANIA 1NHt=Fi11ANl;t IAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D PD Box 286681 TAXPAYER RESPONSE HARRISBURG PA 17128-6661 REV-1543 EX AFP (BB-BB) FILE N0. 21 ACN 09102742 DATE 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: PATRICIA PERRY REGISTER OF WILLS 263D N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with tho information bolow, which has bean used in calculatin® the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please caii I717i 767-6327 with q::esticns. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 127010-43 Date 06-18-1992 To ensure proper credit to the account, two Established copies of this notice must accompany AcCOUnt Balance 40 payment to the Register of Wills. Make check 6 053 " , . payable to Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to NOTE: If tax payments are made within three Tax $ 3 026 70 , . months of the decedent's date of death, TaX Rate X .045 deduct a 5 percent discount on the tax due. Potential TaX DUe Anv Inheritance Tax due will become delinquent $ 136.20 nine months after the date of death. P RT TAXPAYER RESPONSE A ~ FAILURE TO RESPOND Wltt RESULT IN AN OFFICIAL TAX ASSE55MENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check bax "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above information is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE i. Date Established I 'y 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 S 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X 7 8. Tax Due 8 $ $ PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Line 5 of Tax Computation) $ Un er pe lties of perjur I cla a that the facts I have reported above are t r ue, correct and c m le to the best of kn wle a C ~ > and belief. HOME C7[ ~ ) (p `~' 6 ~~5 ~,~~ WORK C ) Ax Av R ST(;NATIIRE TELEPHONE NUMBER DATE PENNSYLVANIA iNHERITANGE T INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AN D Po Box zeD6a1 TAXPAYER RESPONSE HARRISBURG PA 17128-06D1 REV-1543 EX AFP (OB-OB) FILE N0. 21 ACN 09102743 DATE 01-16-2009 PATRICIA PERRY 2630 N ROSEGARDEN BLVD MECHANICSBURG PA 17055 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (717; 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS ACCOUnt No. 127010-60 Date 07-03-2006 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 1 , 200.51 Payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax NOTE: If tax payments are made within three $ 600.26 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential TaX Due Any Inheritance Tax due will become delinquent $ 27.01 nine months after the date of death. P~T 1 FAILURE TAXPAYER RESPONSE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE BLOC K ~ B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be tiled by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3L_J below. PART If indicating a different tax rate, please state OFFICIAL USE ONL Y ~ AA F a relationship to decedent: PA DEPARTMENT CIF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE i. Date Established 1 1 _ 2. Account Balance 2 $ 2 ~ __ 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 5 6. Amount Taxable 6 $ y 7. Tax Rate 7 X 7 8. Tax Due 8 $ $ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID J- _ TOTAL (Enter on Line 5 of Tax Computation) S Und~r enalties of perj y, I de la re that the facts I have reported a~jbove are true, correct and coryip t to the best ~y o edge and belief. HOME C/~~ ) ~9~~y / ,~,~ - WORK C ~ T PAYER STGNATURE TELEPHONE NIIMRFR nerc t'tNN,YLVANIA 1NHtIt11ANl:t IAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE ND. 21 PD Box 2B0001 TAXPAYER RESPONSE ACN 09102744 HARRISBURG PA 17128-0601 DATE 01-16-2009 REV-1543 EX AFP (OB-OB) TYPE OF ACCOUNT EST. OF DOROTHY R GUISE ^ sAViNGs SSN 195-16-3361 ^ CHECKING DATE OF DEATH 12-21-2008 ^ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: PATRICIA PERRY REGISTER OF WILLS 2630 N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 MEMBERS 1ST FCU Provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call :'17: 787-?327 wi*_~ questic^s. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIDNS Account No. 127010-61 Date 07-03-2006 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 1,2UU.51 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 600 • 26 months of the decedent's date of death, X .045 deduct a 5 percent discount on the tax due. Tax Rate Any Inheritance Tax due will become delinquent Potential Tax Due $ 27 ()1 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX A5SE55MENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of C H E C K Wills and an official assessment will be issued by the PA Department of Revenue. ONE C B L 0 C K B. ^ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ^ The above information is incorrect and/or debts and deductions were paid. Complete PART 2^ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION LINE i. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 X 4 5 6 '~ 7 X 8 +t PAD OFFICIAL USE ONLY U AAF PA DEPARTMENT OF REVENUE I 2 3 4 5 6 7 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) 8 Un~er p nalties of perju y, I ecl re that the facts I have reported a+b~ove are Jtr~uje',7,,c/orrr~ect,/and cpmple a to the~best o k wl ge and belief. HOME C/~~ ) O / / .F, /~Y --,._c WORK C ) rw..oevro crr_ueT~tRF TELEPHONE NUMBER DATE PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INUIVIUUAL TAXES AND F I L E PD Box 2BB6ol TAXPAYER RESPONSE ACN HARRISBURG PA 17128-0601 DATE REV-1543 E% AFP (YB-OB) NO. 21 09102745 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FDRMS T0: PATRICIA PERRY REGISTER OF WILLS 2630 N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsyivania. r^iease call :717) 787-8327 'with 4uestions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 127010-62 Date 07-03-2006 To ensure proper credit to the account, two Established copies of this notice must accompany 1 , 2 ~ ~ . 51 payment to the Register of Wills. Make check Account Balance payable to "Register of Wills, Agent". Percent Taxable X 50.000 NDTE: If tax payments are made within three Amount Subject to Tax $ 600.26 months of the decedent's date of death, TeX Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential TaX Due $ 27.01 nine months after the date of death. P~T TAXPAYER RESPONSE 1 FAILURE TO RESPOND WILL RESULT IN AN QFFICIAL TAX ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE BLOC K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL USE ONLY ~ AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 2. Account Balance 2 +fi 2 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 +~ 4 5. Debts and Deductions 5 5 6. Amount Taxable 6 $ (, 7. Tax Rate 7 X 7 8. Tax Due 8 $ g PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE P AID PAYEE DESCRIPTION AMOUNT PAID ~ / ) TDTAL (Enter on Line 5 of Tax Computation) S Un er nalties of per ry, dec re that the facts I have reported above are true, correct and c m to to she best y now dge and belief. HOME Cy~~ ) ~ ~~- ~~~ ~ ,~.~' WORK ( ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND F I L E Po Box 2eosol TAXPAYER RESPONSE ACN HARRISBURG PA 17128-0601 '~ DATE oC REV-1543 EX AFP (OB-OB) N0. 21 09102746 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: PATRICIA PERRY REGISTER OF WILLS 2630 N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the ^epa rtment with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (7171 767-8b27 with ques~ions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 127010-63 Date 07-03-2006 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 1,2D0.51 payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 50.OOD 6 0 0 . 2 6 NOTE: If tax payments are made within three AIBOUnt Subject t0 TaX y~ months of the decedent's date of death, TaX Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will became delinquent Potential TaX DUe $ 27.D1 nine months after the date of death. P~T TAXPAYER RESPONSE ~ FAILURE TD RESPOND WILL RESULT IN AN OFFICIAL TAX A55E5SMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE BLOC K 0. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above information is incorrect and/or debts and deductions were paid. Complete PART ~2 and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL USE ONLY ~ AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 I 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 5 $ 6. Amount Taxable 6 6 7. Tax Rate 7 X 7 8. Tax Due 8 $ $ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Line 5 of Tax Computation) 8 Under enalties of perj I ecla a that the facts I have reported above are true, correct and 'mp a to the best o k awls ge and belief. HOME C 7/ ~ ) (d ~ / - ~ ~~ ~` WORK ( ) rexpevFR srrNeruRF TELEPHONE NUMBER nerF rC1YPIJILYHPIIH 1P117CR11HIYl.C IHA INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND F I L E Po Box zeB6g1 TAXPAYER RESPONSE ACN HARRISBURG PA 17128-8601 DATE REY-1543 E% AFP (OB-OB) N0. 21 09102747 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: PATRICIA PERRY REGISTER OF WILLS 2630 N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in cal eulating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylva.^.ia. Please call (7I7) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 12701 0-64 Date 07-03-2006 To ensure vroper credit to the account, two Established copies of this notice must accompany 2 0 0 •5 1 payment to the Register of Wills. Make check Account Balance $ 1 , payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 600.26 months of the decedent's date of death, TaX Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential TaX Due $ 27.01 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX A5SE55MENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return D N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART ~ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION LLNE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 __ 2 $ 3 X 4 $ 5 6 $ 7 X 8 +fi PAD OFFICIAL U5E ONLY [~ AAF PA DEPARTMENT OE REVENUE 1 2 3 4 5 6 7 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Line 5 of Tax Computation) S Und r p alties of per? Y, I cl re that the facts I have reported above are truet7, correct'/and co ple to the best Y k wle ge and belief. HOME C7~~ ~ ~~/"~, ~~}~ - WORK C ~ T E SIGNATURE TELEPHONE NUMBER DATE PENNSYLVANIA INHERITANCE TAXI INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AN D Po Box zaosBl TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 E% AFP (OB-087 FILE N0. 21 ACN 09102748 DATE 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: PATRICIA PERRY REGISTER OF WILLS 2630 N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information hel aw, which has been used in calculating the potential tax. due. Records indicate that at the death of the above-named decedent, you were a .joint owner/beneficiary of this account. It you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (?171 787-x327 with questicns. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 127010-65 Date 07-03-2006 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 1 , 20 0 • 51 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax Zy` 600.26 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 27 • O1 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of C H E C K Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART ~ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due 2 3 X 4 5 6 7 X 8 PAD OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE 2 3 4 5 6 7 8 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID /l TOTAL (Enter on Line 5 of Tax Computation) S Under enalties of perj ry, I cl a that the facts I have reported abov~'e7 are/t(r}ue, co/r'reJct a/nod eomp to to the best kn wle a and belief. HOME C ~~/ ) (cs L ~-U' /~7 - ~ ~ ~ WORK C ) ....~... .~ e.rnuwrnor TFI FPFIf1NF NIIMRFR i)ATF PENNSYLVANIA INHERITANCE T INFORMATION NOTICE BUREAU DF INDIVIDUAL TAXES A N D Po Box zaocal TAXPAYER RESPONSE HARRISBURG PA 17128-06D1 REV-1543 E% AFP COB-OB) FILE N0. 21 ACN 09102749 DATE 01-16-2009 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: PATRICIA PERRY REGISTER OF WILLS 2630 N ROSEGARDEN BLVD CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST X^ CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. rlease call (7171 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 1270 1 0-66 Date 07-03-2006 7o ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 1 ~ 200 • 51 payable to "Register of Wills, Agent". Percent Taxable X 50 . D00 NOTE: If tax payments are made within three Amount Su b.7ect to Tax $ 600.26 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Anv Inheritance Tax due will become delinquent Potential TaX DUe $ 27 • O1 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE BLOC K C B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL USE ONLY ~ AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LiFiE i. Late Established I 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5 Debts and Deductions 5 - 5 . 6 Amount Taxable 6 $ 6 . 7. Tax Rate 7 X 7 8. Tax Due 8 $ 8 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID r _ TOTAL CEnter on Line 5 of Tax Computation) S Under enalties of perjury, eclare that the facts I have reported abo)ve7 are truge",7co/rrec[t'and c mpl to to~the best my kn ledge and belief. HOME// ) ~ L /'(7~7~ _ WORK ( ) AY nvrn CT!_IdATIIR TELEPHONE NUMBER DATE ~~ PENNSYLVANIA INHERITANCE T INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AN D PD BDx zaocDl TAXPAYER RESPONSE HARRISBURG PA 17128-06D1 REY-1543 EX qFP (00-08) FILE N0. 21 08-1291 ACN 09105379 DATE 01-27-2009 ** ROGER W GUISE 925 CLY ROAD YORK HAVEN PA 17370 EST. OF DOROTHY R GUISE SSN 195-16-3361 DATE OF DEATH 12-21-2008 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE-SI'D~E"F9~FILING AND PAYMENT INSTRUCTIDNS Account No. 7658-43 Date Established To ensure proper credit to the account, two copies of this notice must accompany payment to the Re i t f W-11 Account Balance g s er o 1 s. Make check $ 57, 134.26 payable to "Register of Wills, Agent". Percent Taxable X 100.00 Amount Subject to NDTE: If tax payments are made within three Tax $ 57, 134 26 . months of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discount on the tax due. Potential Tax Due Anv Inheritance Tax due will become delinquent $ 2, 571.04 i n ne months after the date of death. P RT TAXPAYER RESPONSE A 1 FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE BLOC K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ® The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3LJ below. PART If indicating a different relationship to decedent: tax rate, please state ~ 0 FFICIAL USE 0 NL Y ~ AAF PA DEPARTMENT OF REVENUE RE TURN - COMPUTATION OF TAX ON JOINT/TRUST 4000UNTS PAD LINE 1. Date Established 1 I 2. Account Balance 2 $ = . I) ~o ~I i _ 2 3. Percent Taxable 3 X ~ . G ~ q 3 4. Amount Subject to Tax 4 $ // +y )7 ~ 4 C~' /a / 7 4 5. Debts and Deductions 5 ~ 5 6. Amount Taxable 6 $ ~ r.q r- ~ ~y,7 Gy /~..~~ 6 7. Tax Rate 7 X o `' ~ 7 8. Tax Due 8 $ r '. 8 PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID DATE TOTAL CEnter on Line 5 of Tax Computation) S er penalties of perjury, I declare that the facts I have reported above are /t/r}~~e~,/cc~o,(rrect and o plete tt"he b~e t of my knowledge and belief. HOME C 1~/ )~C,~G ~`"r'~CJ.,Z C,tf)O~! .~/Y X/J11:~ WORK ( ) REV-1511 EX+ (10-06) scNE©uLE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF ' FILE NUMBER ~ ~ ~-~~ ~ u isp ~~ - (~ ~ °- !~ I Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ~/ Q ~ C~ ~{J / / i/ ~-/ ..S ~ K /~ lr'I u / t /V / ~ ~ ~e ~/ ! >~/~/CS p f.G+~f EP / I (~ ~( ~ 4 9~G,va 5~e (j~Q1~/~Cr ~dr r ferraized ~- 5ooa~ua Cofepos~t) e-X -/15eS' ~' ~ 9yQ.U0 ~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees 3. 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 ~ ~ ~ ~ , U 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. ~S~t~ 1~~~,~~ ~~~ttr~U~ News) i 9y. 73 `i. F~ ~,n Fee, 1 5.00 icy, I~eadStc~i°~~ engrta~v~:yr~ (C-~iay,riclr' ~'1~~r~tc~~s~ f ~ U. ~~ TOTAL (Also enter on line 9, Recapitulation) $ ~ $ a r/" (If more space is needed, insert additional sheets of the same size) four Generutinn.c_. C~cleh~nl~irrg (iJe, HonnrinS TRi adinoCr.c 1 V ~r,~~111~.,~ funeral ~6me, C.~nc. City Other clothing STATEMENT OF FUNERAL GOODS AND SERVICES SE][.ECTED Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain in writing below. if you selected a funeral that may require embalming, such as a funeral with viewing, you may have [o pay for embalming. You do not have to pay for embalming you did not approve if elected arrangements such as a diref~rem~ ation or immediate burial. 1F we charged for embalming, we will explain why below. For the Servic f ~U i2 t1 I ~ ~ , ~"V 1 ~~ Date of ath 20 t~ /n~ `/ ( /~--?i" ~~y Charge to: ~ Oct eiL. ~ 2-~ C ~...--t tf` t o,•t,l~. ~~ f}t/c?~-J ~~ l `7 J~'~d A. CHARGE FOR SERVICES SELECTED: I. PROFESSIONAL SERVICES --~~`` Services of Funeral DirectorlStaff ... , S~-~+ ~` Embalming ..................... . S J~-~-C Other preparation of body .............................. 8 -~ ( SUB-TOTAL OF PROFESSIONAL SERVICES ......... A 1 5~ FACILITIES AND SERVICES Use of facilities and services for ~ `' viewing (VisitationlWake)...... ~ ... Use of facilities and services -•~ ~ for funeral ceremon y .......... S .. Use of facilities and services for Memorial Service ............. .. S -r Use of equipment and services -t~ ~ ~ ` ~ for graveside service ........... .. S ~ - Other use of facilities .....................Q ...... S `X-..a~ SUB-TOTAL OF FACILITIESIE UIPMENT ........... A2 S ~.t~~ AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home Local ........................... S Hearse (Casket Coach) ~~a Local ........................... S_ - Limousine ,~ Local ........................... S Family car Local ........................... S Flower car or floral disposition Local ........................... r ~,, 5 1-/~C.~ Lead ~~aarr(clerg car Locat~.~j~ c.t,~ . s v~ 5~~c~-- Car For pallbearer Local ........................... 8 •-- Out of town transportation ......... E3~, 8 S State BOYD L. MYERS, JR., Sttpen>~ 37 E. b1AIN STREET ntECHANICSBURG, PENNSYLVANIA 17nS; (7{7)766-3421 S c Cremation urn ..... . (Description) OTHF,R 5 (• ~ ~,J~c.l. TOTAL MERCHANDISE SELECTED .................. B S C. SPECIAL CHARGES: Forwarding of remains to S (Funeral Home) Receiving of remains from S (Funeral Home) Immediate Burial ............. .... S Direct Cremation ............. .... S S SUB-TOTAL OF SPECIAL CHARGES ................ C S _ D. CASH ADVANCED Opening Grave ...............: .. S~ t'-~ Cemetery Equipment ............ .. S~_;~"' Lot and Deed .................. .. S - Newspaper Notices-Local ....... .. 5~,='' Newspaper Notices-Out-of-town .. .. S i 30. ~'~- Telephone & Telegrams ......... .. 8 -• Airfare ....................... .. S -- Clergy/Mass Offering ............ .. S i ~ ~' '~- Pallbearers .................... .. S --- Certified Copies of the eath Certificate ... /.~~ ~c ........ .. S 7 ~ ~ i Police Escort .................. S °' .. Flowers ...... . ............... .. 5 ~i- Vault Service Charge ...... . ..... .. b S S S S S $ .. } ~ j t ~ `~ SUB-TOTAL OF ADVANCES ........ ............... D St SUB-TOTAL OF AUTOMOTIVE EQUIPMENT........ A3 $ We charge you for our services in obtaining: T01'AL OE PROFESSIONAL SERVICES, (specify cash a~y^cJes~bat are ruarked-rep) FACILITIES AND AUTOMOTIVE c~~ hh EQUIPIlIENT ................................... A S ~~~i B. CHARGE FOR MERCHANDISE SELECTED: C, Casket ........................ S~~ (Description) °. 1 ~ C fy- ~ .s.o L. Other Receptacle ................. ~ (Description) • ~ r-a:.t Outer burial container ......~.. ~ _~ (Description) S /1-2L~ ~^ Acknowledgement cards ........... 8 _ _ Re istrr books `~~ g l 1 .................. S cbiemory folders .................. 5 ` Prayer cards ..................... , SUMhiARX OF CHARGES A . Professional Services, Facilities and Equipment, and Automotive ui E ent ~y S~~ q pm .................... B. Merchandise ........ . ......... . .. .. S~~• `31t C . Special Charges ................ .. S --- ~ r?tZ D. Cash Advances ................. .. S t iii ~~ ~~ TOTAL OF ALL SECTIONS ........... ~ .. .. S ~~ (~ PAID AT TIME OF OR PRIOR TO~'fL~- om ~ tC ©C? C' a t ARRANGEMENTS .............. BALANCE DUE ................ t . ....~ j . y..~..... 5 .. . ............... 50 r L'. SON~I~R EM NG /~ If any law, c tetery, or crematory require ments have required the purchase' of any of the irep.\s listed above tl 1• w or requirement is explained below. C._.9~..~_1~ ~:~'lx~ ~~.:i 1 agree that [have examined [he items of goods and services selected above and found them to be correct and according to the arrangements f have requested. l acknowledge receipt of a copy of this Statement of Funeral Goods and Sen•i es ~ ected. 1 represent t#,-t~ave sufficient funds available for payment of the cash price for the goods and services selected. 1 also agree to mals~y}ymenFef-B- within , .S~ days. t agree to be jointly and severally liable with anvo else who signs below. A late charge of ~ .'S 'fir per month amounting to t per year evil[ be applied to the unpaid balance beginning _~_ days from the date of this agreement. I will also pay to the Funeral Director all reasonable costs paid by [he Funeral Director to collect amowtts I owe under this agreement. Those costs may include attorneys' fees, court costs and other costs. Any additional services or merchandise ordered or requested afte the date f this agreement will he considered part of this agreement and the cost thereof will be reflected on the final bill or statement. g~ (Seal) ~ ~ ~ Z.- ~..e~/t3 (Purchaser) (p (Seal) (Purchaser) ,,i' (tcensed Funeral ~ ector) \VHITE- Funer t Dirtcux YELLOW - Cuctomcr j ~ ~~ ~ l i \ ~Y Temporary grave marker ........... S ~ Burial clothing ................... S/5 ~^~~= COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scaE®u~E , 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. ITEM NUMBER DESCRIPTION VALUE AT DATE OF pEATH ,. /`1 ~a~ulr ('ire IVur~ra~ l~vrne CCcr~,p %~~ /1) ~'.~, .~ y~~ ~~ _._. _.~ ~ _... ,, 1. ~~-~~ ~I~J/32 /J I l/ ~ I C TOTAL (Also enter on line 10, Recapitulation) $ ,5 ~ ~ « i (If more space is needed, insert additional sheets of the same size) Health Care & Retirement Corporation HCR ManorCare R.W. Guise, Executor 925 Cly Rd. York Haven, PA 17370 MANORCARE HEALTH SERVICES -CAMP HILL 1700 MARKET STREET CAMP HELL, PA 17011 (717)737-8551 _ Dorothy Guise #2479 DATE'OF _ DESCRlP7lON OF SERVICE CHARGES. SERVICE 09/01/08 Medicare A Co-insurance 9/1-9/30/2008 $128/day $3,840.00 10/01/08 Medicare A Co-Insurance 10/1-10/712008 $128/day $896.00 12/01/08 Room and Board 1211-12/31 /2008 $6,169.00 12/20/08 Reverse Room and Board 1211-12/31/2008 12/20/08 Room and Board 12/1-12/20/2008 $3,980.00 12/01/08 Oxygen Concentrator Rental 12/1-12/20/2008 $360.00 12/01/08 Intermit lncont Fee @$4.09/day 12/1-12/20!2008 $81.8C 12/01/08 Simple Wound Treatments 16 @ $1Q00/each $160.OC 12/08/08 Payment 12/8/2008 PAYMENT DUE UPON RECEIPT ~ ``~~ ~~ a ~~ ,~ ~ ~r ~~ AMOUNT DUE :CREDITS $ 6,169.00 $ 6,069.00 $15,486.80 $12,238.00 $3,248.80 Account Summary Previous Balance ........................................................................................................................................................... $ 137.29 Payments Posted ............................................................................................................................................................. $00.00 Unpaid Balance ................................................................................................... $137.29 Total Current Charges ...............................,......................................................... $0..00 Total Amount Due in USD :........................................................................................................................................ $ 137.29 Please see billing details on the following pages '`~ ` ~ _.~+,[~/ --- Important Message: How Do You Jitterbug? Share your Jitterbug story with us online and you might be selected to appear in our next Jitterbug commercial! Simply visit ~~.r~J~.~itt~t~~~tar~°aWi°3~a1~n~1\~~ and submit your story today! DATE RX i~JO. ~ Dt=SCFtIPTION ~ i-r ~~a). -- ~ - -- __ _-- - ,, _- _ 12/26/2008 i PAYMENT Statement: 282297 Check: 5540 95.26CR 11/23/2008 3672155 IPRATR-ALBUTER 0.5-3MG/3MLC30] 00185-7322-30 ! 180 ML 25.31 C ~ RX 12/01/2008 3585739 SIMVASTATIN 20 MG TABLET" 55111-0199-05 i 30 EA 1.93 C RX 12/01/2008 3654517 LORAZEPAM 0.5 MG TABLET r` 00781-1403-05 ; 45 EA 1.18 C RX 12/01/2008 12/05/2008 3803779 ~ 3744208 ~ DIPHENHYDRAMINE 25 MG CAPS Y DIURIL 250 MG/5 ML ORAL SusP ~ f1. 00182-0492-10 j 65649-0311-12 i 30 237 EA I ML 0.54 7-03 C c RX Rx ~ 12/05/2008 3761163 CHLORTHALIDONE 50 MG TABLET ~ 00378-0213-01 ~ 75 EA 3.87 C RX 12/06/2008 3605869 I HYDROCODONE-APAP 5-500 TABLET ~;~ ~ ~ 00406-0357-05 i 15 EA 0.92 ! C RX 12/08/2008 3605869 HYDROCODONE-APAP 5-500 TABLET ~ "~ 00406-0357-OS % 15 EA ' 0.92 C RX 12/10/2008 3672155 IPRATR-ALBUTER 0.5-3MG/3MLC30] ~. ~ 00785-7322-30 ~I 180 F1L 25.31 C RX 12/10/2008 3775068 ASPIRIN 325 MG TABLET" ~ ~ " 00182-0444-10 ! 30 EA I 4.41 OTC 12/13/2008 3585744 ~ FERROUS SULFATE 325MG TABCFC] 00182-4028-10 ', 30 EA 4.44 OTC 12/13/2008- 3585748 ! ADVAIR 250-50 DISKUS 00173-0696-00 ! 60 EA 43.71 C RX 12/15/2008 3585748 ADVAIR 250-50 DISKUS 00173-0696-00 60 EA 43.71 ~ C RX 12/16/2008 3654517 LORAZEPAM 0.5 MG TABLET 00781-1403-05 45 EA 1.18 ~' C RX 12/17/2008 3585742 DILTIAZEM HCL 120 MG CAP [D 00228-2588-50 30 EA 6.89 C RX 12/'1.7/2008 3676600 ~ KLOR-CQN_M20 TABLET" 00245-0058-01 60 EA _6_.29 C RX 12/18/20081 3847401 ERYTHROCIN 250 MG FILMTAB 00074-6346-20 ~ 4 EA 0.47 C ! RX 12/19/2008 3849685 AZITHROMYCIN 250 MG TABLET 00781-1496-68 ', 6 EA 5.13 ,. C RX 12/19/2008 3849758 HYDROCODONE-APAP 5-500 TABLET 00406-0357-05 15 EA 0.92 I C RX 12/20/2008 3852577 ACETYLCYSTEINE 10% VLC3X10ML] 00517-7510-03 30 ML 7-69 ', C RX 12/21/2008 3853858 MORPHIroE SULF 20 MG/ML SOLN 58177-0886-01 i 30 ML 3.73 ', C RX - MESSAGES --- - Finance charges are calculated @ monthly periodic rate of 1.5% (or a minimum _ of $1.00 per month) for a total annual rate of 18%- The charges listed on this invoice do not reflect any balance billed to your insurance. • ~ •~ 95.26 ~ - 95.20 J - O.GO - 0.00 0.00 i ~ 195.58 ~ 0.00 195.58 -- 1 !30/2009 _. SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE O ` I I /J FILE NUMBER ')) (j ~Q rU~ `7 L r r (~7 (rl tSG s~G / ~ ~ l) l o~ C~ NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1- O7a'L-r)c,-c~ %. Derr ~G 3c~ /V /~~s` ~r~e ~J~d %yecJxr~~ ~ bk,rr ~ r ~-' :~ da _ 2 '12agu (J Gufse. ~';~5 Gj ~d, ~or~ r~uU~~,~~ 1~3>0 So r,fir V !a _ .~~ ~~E ~ At It!u; ~r• ly~aniCS~ u~,~l~ f7o,5's' a le,r :X~l `b v 1 ruck y ~~ 1.~(?~z11l~er a~t~ `r'on0}} ~d• NarJisbu-~ ,~~ 171/a ra etr _ y ~ ~ ~, l o ~~ 5 . e re " /7 . St d Lr' 1885 ~', d~~ti S`~- ~u kerdda ~ ~'~ 8 Q:,215 ~ rc1 -° ~ a t ~~ `la G ~£ J r zct e~i ~ ~~~ tcz. llr; Chi. ~./ ~i~e ~ira ~a. , ~P/~ 17s d,~ ~rc a~a ~ t r ~ o ~ ~ lu 7. ~1~enj4mi0 ~~ ~i~fS~ tit 2 u, ~. Ca r n !e ~A is"itJ6 - , y 7 0 ~ v2~' ~~ g , •Te s.~ ~ cam. L. ' }~~~-r K ~5.zl7 (~Ja a>1cJhe.~% Four t /~~.Yr~sbu v'" t ~ loq ~ .~ d } a Jr- c q. . ~~~ W . ~~ ~s ~. ~ ~~ ~ 74ru y D .~' ~ d ~ i~ ~ e~ct : • or Ytc~ so ~ ro I~~~a. N~ ~zrry' y2,5z D (.J~tyuocJh'i~~ Cour~ lt~.rriS'bu,r~~~A t710Q Ci2~d dccu ~l~r ~ '~ v ~S ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUf10NS SHOWN A OVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICM AN ELECTION T O TAX IS NOT BEING MADE t. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. ~rvs ~ ~iur.~ v~ ~o ~ ~~ec~r~~~lcsbuvc~,~~) ~ j Ud ~ 00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I ~ ~0~. (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 01 1025 GUISE ROGER W 925 CLY ROAD YORK HAVEN, PA 17370 -------- told ESTATE INFORMATION: SSN: ~ 95-~ 6-3361 FILE NUMBER: 2108- 1 291 DECEDENT NAME: GUISE DOROTHY L DATE OF PAYMENT: 03/20/2009 POSTMARK DATE: 03/20/2009 couNTY: CUMBERLAND DATE OF DEATH: 1 2/21 /2008 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 54,033.72 TOTAL AMOUNT PAID: REMARKS: CHECK#107 SEAL INITIALS: AJW REV-1162 EX111-96) 54,033.72 GLENDA EARNER STRASBAUGH RECEIVED BY REGISTER OF WILLS REGISTER OF WILLS •' m ~ YZJ O W ~~ ~n. r .-' ..~. ~~ r D7 W r .t7 O O r ~~~ Ci t o~ d~C~ ~ m~ fi ° ~ + /~ ao~ ~~rc~ y '~ ~. N °~ ~ °,~. Z~ `f~- - ~'.. ~~ ~.:°~ z~, '~ .~ ~~ ~~ ~ ~: ~, ~' ~ ~.' ~. ~ ~'', 0 0 o `~Z o. ~y od ~o O ~~ ~~ m .... '~ C w ~~: f~ '~. ~ ~~ O v