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HomeMy WebLinkAbout06-25-09 15056D41169 --r' REV-~ VCI~ EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau oflndividualTaxes INHERITANCE TAX RETURN PO Box 280601 Harrisburg ~A 1712E-0601 RESIDENT DECEDENT C / C~~ ~I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 205-26-387 01042009 12101931 Decedent's Last Name SLEBODNICK Suffix Decedent's First Name coRn MI B (If Applicable) Enter Surviving Spouse's Information Betow Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL INAPPROPRIATE BOXES BELOW 1. Original Return , 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Will) U 9 Litigation Proceeds Received MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. becedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 3. Remainder Return (date of death prior to 12-13-82) n 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number FRANK H KELLY E1~ 717.7 7 4 ~5 3 6 rs ~ ..ca Firm Name (If Applicable) REGISTEf~" LLS USE . LY KELLY FINANICAL SERVICES, INC ~~~~ ~ G:~ , ~ ~ ~ First line of address , ' ~ 7c 400 BRIDGE STREET, SUITE #4 ~~ C7 ~Q~ ~"' ^~ Second line of address ' ~ "'~ .. C11 City or Post Office State ZIP Code DATE FILED ____ NEW CUMBF;RI.~AND PA 1'1070 ~~ ._.~_ ~ -; ... :t ~i-i ~ ;, ~~:;f r'. ~~ .:. _-, Correspondent's a-mail address: FRANKKELLY@ KELLYTAX . COM Under penalties of perjury, I,(leclare 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. SIGNATURE OF PER N RESPONSIBLE FOR FILING RETUR~~ /rJ /f~ ~~ .~~~~DATE ~ X16 0 G PINE DRIVE SPRINGFIELD VA 22151 SIG T PREPARER OTHER THAN REPRESENTATIVE DATE AD RE 4 0 RIDGE STREET, SUITE #4, NEW CUMBERLAND PA 17070 PLEASE USE ORIGINAL FORM ONLY 15056041169 Side 1 15056041169 a i Y J 15056042160 REV-1500 EX Decedent's Social Security Number Decedent's Name: CORA B SLEBODNICK 205-26-6387 RECAPITULATION 1. Real estate (Schedule A) ....................................... ...... 1. 2. Stocks and Bonds Schedule B 2. 4 2 3 , 2 41.0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) ....................... ...... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .. ...... 5. 3 2 5 • 0 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested . ...... 6. 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested . ...... 7. 31 , 918.5 0 8. Total Gross Assets (total Lines 1 - 7) ............................. ...... 8. 4 5 5 , 4 8 4 . 5 0 9. Funeral Ex enses & Administrative Costs Schedule H 9. p ( ) ..................... 15 , 2 6 0 . 0 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............... 10. 11 , 6 4 3. 0 0 11. Total Deductions (total Lines 9 & 10) .................................. 11. 2 6 , 9 0 3 . 0 0 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 4 2 8 , 5 81.5 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Sub'ect to Tax Line 12 minus Line 13 J ( ) ........................ 14. 4 2 8 , 5 81.5 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .045 428, 581.50 15. 16. Amount of Line 14 taxable at lineal rate x .0 16. 17. Amount of Line 14 taxable at sibling rate x .12 17. 18. Amount of Line 14 taxable at collateral rate x .15 18. 19. TAX DUE ................................................... ..... 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056042160 Side 2 19,286.17 19,286.17 15056042160 J ~ REV-1500 EX Page 3 Decedent's Complete Address: File Number 21.0 9. 0 0 3 6 DECEDENT'S NAME Cora B Slebodnick STREETADDRESS 7663 Long Pine Drive CITY Springfield STATE VA ZIP 22151 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty (1) 19, 286.17 Total Credits (A + B + C) (2) Total Interest/Penalty (D + E) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box 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. (3) (4) (5) (5A) 0.00 0.00 19,286.17 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 19 , 2 8 6.17 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ................. . ........................ ^ b. retain the right to designate who shall use the property transferred or its income : .................... ^ 0 c. retain a reversionary interest; or ...................... . .................................. ^ x^ d. receive the promise for life of either payments, benefits or care? ................................ ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ............ . .... . ......... . ........................ ~ ^ 3, Did decedent own an "intrust 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-1502 EX+ (11-08) ~ pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT __ ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be 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 that is jointly-owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size. ~ REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) ~ REV 1504 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 Schedule C-1 or G2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size) ~ REV-1505 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Cora Slebodnick 1. Name of Corporation None Address City 2. Federal Employer I.D. Number 3. Type of Business 4. Business Reporting Year 6. Was the Corporation indebted to the decedent? ......................................... Yes ~ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ............ Yes ~ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer any stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? Yes ~ No If yes, ~ Transfer ~ Sale Number of Shares Transferee or Purchaser Consideration $ Attach a separate sheet for additional transfers and/or sales. Date 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....... Yes ~No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ...................................................... Yes ~No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ...................... Yes ~ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? .................... Yes ~ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- ~ • ~ ~ A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT FILE NUMBER 21.09.0036 Date of Incorporation State Zip Code Total Number of Shareholders Product/Service State of Incorporation (If more space is needed, insert additional sheets of the same size) Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? ........................................ Yes ~No If yes, Position Annual Salary $ Time Devoted to Business ~ REV 1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 1. Name of Partnership None Address City 2. Federal Employer I.D. Number 3. Type of Business Product/Service Business Reporting Year State Zip Code 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. ., A. _. ~ B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ......................................... ^Yes ^ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ............ ^Yes ^No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^Yes ^No If yes, ^Transfer ^Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ......... ^Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? .......................................... ^Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ...................... ^Yes ^No tf yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? ........................................ ^Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .................... ^Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •' ~ • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. Date Business Commenced D. Any other information relating to the valuation of the decedent's partnership interest. ~ REV-1507 EX+ (6-98) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 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 I ADDRESS RELATIONSHIPTO DECEDENT A. None B. C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTIONAND BANKACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °h OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) ` REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENTAND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OFASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. M&T Bank Account #79454976 12,575 100 1 ,575.00 2. M&T Bank Account #15004215021061 38,687 50 1 ,343.50 TOTAL (Also enter on line 7, Recapitulation) I $ 31, 918.5 0 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 Debts of decedent must be reported on Schedule [. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~~ Myers Funeral Home, Mechancisburg PA 3,365 B. 1 State ZIP 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: Street Address City State Relationship of Claimant to Decedent ZIP 4. 5. 6. ~. 8. Probate Fees Accountant's Fees Tax Return Preparer's Fees Cumberland County Law Journal The Patriot News 466 10, 248 955 75 151 TOTAL (Also enter on line 9, Recapitulation) I $ 15 , 2 6 0 . 0 0 (If more space is needed, insert additional sheets of the same size) REV-1'512 EX+ (12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-A513 EX+ (11-08) ~ pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF Cora Slebodnick FILE NUMBER 21.09.0036 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. Paul F. Slebodnick Son .33333334 7663 Long Pine Drive Springfield VA 22151 2. David W Slebodnick Son .33333333 6846 Brindle Heath Way Alexandria VA 22315 3. Cindy Vasiliu Daughter .33333333 534 Allenview Drive Mechanicsburg PA 17055 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, insert additional sheets of the same size. ' REV-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover SheE ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other None ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ............................................. . 2. Actuarial factor per appropriate table ..................................................... . Interest table rate- ^3 1/2% ^6% ^10% ^Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) .......................................... . 1. Value of fund from which annuity is payable ............................................... . 2. Check appropriate block below and enter corresponding (number) ............................. . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^Quarterly (4) ^Semi-annually (2) ^Annually (1) ^Other ( ) 3. Amount of payout per period ............................................................ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ...................................... . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^Variable Rate 6. Adjustment Factor (see instructions) ..................................................... . 7. Value of annuity - If using 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 .................................................... . NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-1644 EX+ (3-04) i INHERITANCE TAX ~ SCHEDULE L COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT IN RESIDENTEDECEDENTRN OR INVASION OF TRUST PRINCIPAL FILE NUMBER 21.0 9. 0 0 3 6 I. ESTATE OF SLEBODNICK CORA B (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. III. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on B. Name(s) of Life Tenant(s) or Annuitant(s) None (Date) Date of Birth Age on date of election C. Assets: Complete Schedule L-1 1. Real Estate .............................. $ 2. Stocks and Bonds ........................ $ 3. Closely Held Stock/Partnership .............. $ 4. Mortgages and Notes ...................... $ 5. Cash/Misc. Personal Property ............... $ 6. Total from Schedule L-1 .................... ................................ $ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ......................... $ 2. Unpaid Bequests ......................... $ 3. Value of Unincludable Assets ................ $ 4. Total from Schedule L-2 .................... ................................ $ E. Total Value of trust assets (Line C-6 minus Line D-4) ............................... $ F. Remainder factor (see Table I or Table II in Instruction Booklet) ....................... . G. Taxable Remainder value (Line E x Line F) ...................................... $ (Also enter on Line 7, Recapitulation) Term of years income or annuity is payable INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date or Annuitant(s) corpus consumed C. Corpus consumed .......................................................... $ D. Remainder factor (see Table I or Table II in Instruction Booklet) ....................... . E. Taxable value of corpus consumed (Line C x Line D) .............................. $ (Also enter on Line 7, Recapitulation) Term of years income or annuity is payable ' REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 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. ^ Will ^ Trust ^ Other L Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. None 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest ...................................................... $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) .. $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% .................. $ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ........................ $ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) .. $ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) .. $ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) .................. $ (If more space is needed, insert additional sheets of the same size) \ , REV-1648 EX (11-99)(I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01101192 7012131194) ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1. Taxable Assets total from line 8 (cover sheet) .............................................. . 2. Insurance Proceeds on Life of Decedent ................................................... 3. Retirement Benefits ................................................................... 4. Joint Assets with Spouse ............................................................... 5. PA Lottery Winnings ................................................................... 6a. Other Nontaxable Assets: List (Attach schedule if necessary) ... 6a. 6b. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) ...........:............................................... 6. 7. Total Gross Assets (Add lines 1 thru 6) .................................................... 7. 8. Total Actual Liabilities .................................................................. 8. 9. Net Value of Estate (Subtract line 8 from line 7) ............................................. 9. If line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part I1. (0) 0.00 0.00 0.00 Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse ...:........ 1 a. 2a. 3a. b. Decedent .......... 1 b. 2b. 3b. c. Joint .............. 1 c. 2c. 3c. d. Tax Exempt Income .. 1d. ~ 2d. 3d. e. Other Income not listed above ........ 1 e. 2e. 3e. f. Total .............. 1 f. 2f. 3f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1f) + (2f) + (3f) _ (=3) 4b. Average Joint Exemption Income ........................................................... _ If line 4(b) is greater than $40,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ....................... 1. 2. Multiply by credit percentage (see instructions) .............................................. 2. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet ................................... 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ................................................................ 4. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet........ 5. ` 'REV-1649 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER Cora Slebodnick 21.09.0036 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 N O n e 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 0. The denominator is equal to the total value of the trust or similar arrangement. Part A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse (If more space is needed, insert additional sheets of the same size) ~ ~ C W ~ U ~ 0 V O ~ ~ 'W ~ VJ ~ 3 w O J T Q ~ U ~ Z ~c Q ~ Z c W Q C 0 u a, ~+ ~, Q ~ 'C ~ C v R ~ T, co d C 0 ~ r ~~°o d C N ~ d ~ ~ M ~ r C y ~ v w (/~ ~ M 7 ~ U y U V Q~ p J ° Q ~ Y 30 ~ ~ U ~ s M ~ ~ ~~ __ ~ ~ U ~ N ~ U , m o ~~ 2 ~ r' ~ N N 'd N ~` a ~ ~ ~ ;a ° M ~ ZLnM ao p V Q J W ' W t~ ap ~ ~ O ~ ~WU ci ~r ~ ~ ;sZmW Uvc ~ ~ G cQpF.- o~o~ ~ U,O w o ~ U o o L = V lL ~t cn Z .~ Z lL o ° Q J ~ ~ _ ° (n Ln otS Q ~ p ~ ,, c ~ o ° U} z°wQ n C ~ f~ O C N N U°Z>a OU ~ n ~ M o P Zm °U' ~ ~ - ~ ~- u ~ r- ^W ~ J Y m = ~ i ~ o ~n <' ~ ~UWO 0 W Ii Z j c4 oU~O a ~ ti cn ~ ~ ~~°ZV °Owz - N N '~.ln (n U N M m Q m J Q Qd.JJ= ~ Xo i o OO~~w t ~i m x ° UH~~n~ y p O O ~zain H .~ a "\ a C L V O 0 N T M 3 C ca vs 0 0 N r R C O . ,.., ^1 ~i-~i ^^~~ h~l ~I N 00 ~ d' CpD ~ ~ ~ ~ rn M N ~' +.~ t~ M I~ 0 v (O ~ ~ ~ r p r ~' ti W CY L C~ L otS a N a~ (n ~ s = ~ O co W U ~ ~ U ~ ~o rn o~ .O L O a ca H N C t6 3 d ~~ ~ O C ~ ~r O ~a I O O N M C t0 V1 N O U ~' r ~~ i ~ M r oc 69 C ~~ ~ r ~ M r U W 1 Q a 3~ ~ c y 'C. 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Q '~ U ~ N Z ~c ~ ~ _ ~ ^Z c 0 c Q = M ~ r- 1f'~ ~ r N r M ~ ~ ~ M O M ct r to Q N ~ M L C O N M a ~ ~ d Z ~ u m y V D ~ O G t S--, L N ~ . ~ ~ a lC > u "" m s .~ N ~ Q 1 m Fes- C ~~ ~ o .o N M • N j O (B 1 ~ ~ U . ~ ~ ~ • m ~ ~m s ~ ~ N O O U U ~ 0 0 N M r O O H d V C ett m a~ c .O V ,O .~ O a ~~ ~~d ;;~E m c o EQ c :,. H W m a m °i Y Aa c~ cfl 0 co M co 0 m O w (~ M co so a~ ~ ~ c ~ ~ ~a a W W U ~ O0~ (~wi ~ ~ C ~~~ i. fn ? C ~ _U W O d i ~ w a R O 3 N Y c 0 a .m 3 i N ~ L w ~v i V ~ s i ~ V O N d t0 a Of O O N to c ea ~p ~ d ~ d i E~~I .~ Q c , W ^ Q J ^ ~ ~j Y U~ UDZ U O ^ W Y m~U }co WWZ ~~ mQm~Y~ QQa~~Yn Rp~~Q~ 00 ~~~ c~F-~~r,~_, 7 ~ c 0 ~U c •r ~-. y C ~ O t6 U ~ O Q 2 .J (/} ~. C W ~° a U ~ 0 - V o?t 0 ~ ~ W l.L w 0 _1 ~ Q f0 U ~ ~ ~ 3 .n C Z ~[ "r Q c o ~ .~ Z c c - LL Q C~ .~ O a C ~ '~ N ~ J d m Y ~`o ,~ .~~ -~.. d d Y Aa C ~ O .+ ~F R N C ~o F- c m ua` eo N c <<~ 10 N ~ n r ~ ~ ~ ~ n :h ~ ~ ~ ~ N 00 69 r' .~ ... ~ ~ ~ ~ ~ ~ l~ ~ L~ lM M ao ch ch ~n VI M` O ~ ~ N M ~ Ln ~ O O O O O O O ao co O ~ ~ ~ 69 rn v (~O ~ N ~t ~ X _ ~ ~ ~ H ~ U ~~ ~ W ~_ ~ ~ ~ J ~ LL ~ ~ ^ L QQ Q~~U~Q }} ~ I_Z~~WF W Z ~ W ~ U ~~d~(nQ CO f~ N O M Ln ~ ~o~m +~ ~' ~ C V A ~Q c w W V V A D N hR N ~" rA ~ J M ti ti 0 r o~ erg ~~ ~ '° d R O O 0 N d! o '.S ~ f°- R N c :~ 0 UJ .a C ~a 3 0 r M ti N N O~ N .... co 0 r r N as ~ o o ~ O M ~ M r r ~ v v 3 O O ~ a ~ °~ °~ o a ~ d 01 a ~, d ~ c a- d d dG N • ~a to U to M t0 O O M r r 6t} W Q ~C. ~_ J `~ off{ N W W w c . 0 .~ • ~'' " ~ y atf u G a ~ ^a 1~~1 ,~ ~ ~; w w a Q ~~ ~ j ~. ,, ~ ~ c m W ~ z_ W W Z O O in o O f` r r O O r r t0 ~O rn rn O O a a 3 ~ ~ ~ ~ ~ U U O^OC C~WC~LL ~~~~_ lai~lQLU ~ Z ~ ~ JUJC: W 0 W C ~~~LL o s~ O O rn rn o 0 i ~ O O M O o D Z LL H W Y Q W Z a W W Q J V H O 0 LL J H w w H Z rn 0 M 0 ^ Z_ ~^ ~Z U W Z ^ -O U~ ~a a w W ~~ w ~~ U ~% ~a ~ } a o ~C a J V J o y W C D ar rn ,~ o 0 0 f7 0 J H o~ 0 0 N c ~a a N t+f i0 O dl~ c' A ~ R ~ 0 Q J ~~ df Q Y ~ U~ U~Z U O ~ W Y m~U }cD Wu.Z ~~ mQm-~Y~ aJMY~ W N Z ~ O O U ~ ~ ti U~3~,~~ :: is .. m ~ ~ c 0 3U C y C ~ 7 O f0 V ~ O Q 2 .J t 7 m C O O ~ ~ O O p M M ~ ~j a ~, ~, d O ~ ~ ~ W -. '. Q ~ ~_ d .~ a A C fl. O V o2f O 01 N ~... O ~_ .a ~ ~ ~ C Y C ~ f0 U A c 0 c Q ~ -'~ `- a ~ ~ ~ ^ ~ ~'` Z i , ~ ~ ' ::Ci ' ~ LL J i '~, W; Q U ~' ~ ~~ ~ C C ~ ~ ~ V ~~ 3 . O O ~; Q mil ~ ;O< Q;: T `„~ ""' a ~ ~ 1 C ~o°oo°o R M O O O Efl O O M O 0 0 0 IR 0 0 M O H Z ~ ~ ~ W W Z ~ ~ ~ W ~ fn ? ~ W W LL V > ~ ~ f!. m ~ Q Q Q ODUC: ~~~~L V o cal`tilQiu d .C ~ J J U. dowwu o ml~~~'S r rnrnrna ,~ oooc D N ~ O C O O M C r r r ~ O O O C .d. OOOd ip OOOC D N ~ O C \O OO ` r ~e-~e O O O C C A ~v m s H V i ~ C .~ i ~ :w i 1 1 f O d >~ ~a a tr O 0 N 7 C e0 ~ ~ w a U ~ 0 u O ~ ~ W u- 0 J >, Q ~ U ~ _ ~ ^Z c O c Q d c E~ i V Q ci ~ O d C N ~ ~ ~ ~ ~ ~ C ~ N ~ 7 ~ Jp QN 0 ti m ~ r LNL r d ~ ;a Z~M g~~ ti p ~ ~ Q J w W ~WU' ~~ m v p ~ ~ U `.' ~Y W ~ ~ Z m G = ~ > ~ O~ p~ W p N 2 C~IL~(nZ.~Z LL U W ',,, ~ J O Q J ~ U ~C ~ c ~ i. O O N ~ ~ ~ WQ YY>d O c N a c~ o QZ~C~ p ~ ti `~ °' `- ~ mp ~ O v O ~ ~ mwm ~W>(n oU p ~ ti Q~ZU cn a c M ~m JZ ~Uxio ~ O~ ~ O ~~ U W~d'W ~ p ~ O ~za~n N 0 .' V a m 3 C V O O N r M ~I ca G ca 0 O N r C O . ~..~ ^I O a ~~ o ~ o t0 M ~ N !' v O O CD ~ Sri ui ~ N u. cY L C 0 a N a~ c~ ~ '= C ~ ~ ~ LL U U ~ 00 ~~ O L!1 O M ~' . N ~O 00 O M M O O O a ~a ca m ti ti C ~ ~ o ~ ~I o v ~ O ~ N ~ ~= Ef} M 7 O ~i a~ 3 m s ~ N m U ~ o v ~~ ~ ~~ - i+ ~ F- c m _ n t~ U ~ N O ~> Q LL a~ ~ O lL ~ L v ~ ~ ~o ,'$~ ~y ~ ~~ N N= mad ~~~ ~~ ~ z Yl m ~ [7 C~Z fMG y N O ~ Z` o Q N > Op L Q N rn.. ~ °ja~Oo tom i~ o, Fi Ul O 'r y c w o :U ~ U ~, ~~ 0 ~ ~ ~ U I~ In ~ ui ~ fA ~ d LL O O O ~ C M M N a ~ E y 3 H ~ ~'' ~ ° ~ _ a~ q~ m m E ~ 3 ~ L Y U C ~ N ~aa ~ ~ ~i (j a `m azo (n Y U ~~U ~ E°°in ~ ~z N J N ry ~I •.r O J j C .y. ? ~0 ~ O N o °' 10 ~E E~_ N ~ ~ r m 'M > ya ~ r , Z, ~ c ~ C n o, m LL ~ ~ V y V ~ m ~p N L YO mm~ ~V~ ~ O O ~ rn T 'O f0 N ~ LL c IC f0 N O 7 7 N ~=y0~ v ?~LL 7 ~ H C~ > > as m ~ w v c Q~ N N E y a C .t E mo QQ L c~U~`o ~ ,a a ~ U ~ Ed O O O ~ `~~V> HH Z ¢LLaSB ~' w Q as rn ~v a r C .g N 1D 0 LL U w O J J Y Y ZV QZ m D ~ W ~ ~ J ~ Q ~ ~ W lL ~„~ Y ~ J m ~ Y ~ Z .-. 3° N~~ .. ~~ ~~ ~ c 0 ~U C N C ~ ~ ~ U ~ p Q = J C W ~0 a U o - V ~ a2f O ~ a W u- r.. 0 J A Q ~ U ~ Z ,[ C ~ _ ~ ^Z c O c Q ~ ~ 0 ~ Q p E co o cn ~ o ~ ° 0 °'c a o c ~ ~ ~ ~ ~ O '~ r M ~ ~ ~ 41 ~ ~ E", ~ ~ V ~ D , p G+ y i S-r ~ ~ ~ ~ ~ •, ~ ,~ y U N ~ 0F°-c 1 i ~ O O ' M ' N I ~- i O N m ~ N ~ U C ' (a i ~ m I 1 ~ ~ C_ ~ ~ fA ~ J O v ~U~. O O N r M r O O H ea d V C 1 ~ f m f ~ I H O ~Iv .--+ c~ . ~..~ .--~ ~iO~I a ~~' ~o~m d mco ~ c v mac a W dd Aa rn v 0 rn t0 EA o~ 0 as ~D d' d! w O ~ ~ O O Imp ~ (~ tD C H 64 M a w w 2 Q U ~ ~ W -~ ~ Q: a i ~ ~ ~ !n ? c ~~U~ ~~a R w y N a w Y d c O a m m N t fA ~o V t H ~o V of O N d eo a O O N C ld 1 ` m A c ~Q N W U w 0 J J O ~Y YU Z_ Q Z m O ~W ~~ J ~ ~~ MY~ (A~ u'~Y~ J O Z '~ >W> ~ N ~ r >U NLLC c m N to ~ C O ~U C y C ~ V ~ O Q 2 J C W '° fl. U o - u > °~ O ~ ~ W LL- ~.. O J T Q ~ U -fl N ~ v1 ~ C Z Y ~' = O Q ~ Z c LL Q C~ O . ~..r ~~ ~1 a «~, Ci '~ i ~ ~ d' i Y •~ l0 C C j o. vF H C 10 H C t O ~ O H C r~ ~ O ~ ~ .-. N ~- ~ ('~ e- ~ O N O N I~ O ap (O l1') O E9 v ~ ~ A 1 ` ~ ~ M °° °' N cD ao ~ of ~ 'o ti ~ N O ~ O 6NR N C^ t'~l p ~ (O M N ~ i ~ O N ~ O O i 0 0 0 0 a0 N 609 M ~ O O ~ ~ • O ~ ;X X Q l~1. i LL LL ~"' ~ J U z ~ ~ o ~~ W~`n fA~ J~ W OZ =QZ H ~'~~~~ . W ~ ~ W ~ ~ ~~U~~Q ~ f~ N O M M M •- v N ao ~ R a of ~'`°ci err £ Q c a W N r LA r ~ C ~ ti .r, r; r N eR O\ O O 0 0 0 O eR c~ w C vF w c F- ev 0 .~ y N .a LL. R E i d0 O /~ r r O i O ti i O M M v• m' ~' i vi Q d~ yC ~ 0 V fn C O O O~ ~O LCD 00 d' J ~~ p _ '? v~ ~- c 0 ~~- W c ti ~ V] ca;. , 3 fn u a Q , ~ C a O ~ .~ ~ Z' G, W ~ w ~R ~ C ~ U ~ :;6i +, :.~ ,,~ ~ W ~ ~c O O ~ ~ O ,~~' ~ O `~ Lf) H Z H ~W Z ~ ~ ~ rn rn i i in o r- M _~ ~_ O O .- ~ t0 (O I ~ ~ i ~ O O W W ~ N a a U U O~O~ c~wc~w ~~~~ ~~~~ UZ~Z ~U~U W ~ W ~ ~LL~LL rn rn ~ O e-- (+') O O ~ O ~ ~ 0 0 M ~n Of eA F i ~ 1 ~ d4 ti ,~ . U ~ W Z 0 ch 0 C7 pZ W p, ~ W UO Z~ U~ pW~ .a Q M d a o~ 0 0 N t0 3 c N trf r- M {O 0 O O 0 O a w W ~~ w ~~ U~ oQ C7 } ~ Q ~~ .~M J o W O ~~ J H O w U w O J O ~ Y Y U Q Z m0 ~W ~~ J ~ Q (q ~ W LL. ~„~ Y ~ Jm ~Yr Z .-. O ~ ~~ N~C C L' ~ ~ C 0 ~ U c ~ c o >>_', V ~ p Q 2 J ~ ~ C W t0 a U o - U o2f O ~ ~ J 7. Q U ~ ~C m _ ~ ^Z c p C Q . ~..~ 1 +l .--~ .~ C~ U l~ d o^o~0 0 ~ ooovo 0 m ~ O O ~ O ~ ~ O ~ cv o ~ -ri O O 0 O O ~n ~ ~ fn U ~w~u = W W ~_ F-~~V ~cn?n Owwu ~~~f=U ld ~~UUC w~000 I i C~QQu ~ ~C W fn fn U i C ~ J J ~ .~~ jWWll m~~~? rnrnrna j O O O C ~`ninoc e- e- M r ~~ ~~~~ oooc o° ac rnrnrna oooc In Ln O G e- e- M Cv O O O C I v C i `° I m ~ L H t0 C) I I ~ w O . ,.., bA ...., ^^~ ~--~i c~ . py U ~~ `~ CC3 O U U 1--1 ~~ a~ v w °~ c ~. w co Q c ~ ~~ ~ o c c+-' ~~~ ~ a~ o00 O N-p O C y 0 ~ ` MMM = M M M N .O ooarnc ~a3c~o N N C ~ V G ~ ~ E 3 c °' a ~~ w p~Ow N ~ N c l1 ~~~ H c ~~.o. ~ c '3 o y ca o o 000 c aaa c ' o c.~ o'' '~ ' vlc~cn ~ o ~ws m d ~ ~ ' ? ZZ2 y 000 ~ o o : c t >.c0 o w ZZZ ~~ ao ~°~,~°' ~ -o w ~ o. cap"-~:? ~ N ~ .~ Q vno~~ O ~ U O ~ _ Y mcNa~ L O (A .y O c ~ ~ U t v `-~ Z'3 c _ Y U ~ v c ~ ' O '-' O O .y t0 c Z v 0 Z ~= ~~~u`~ic v U +~ p 0 ~ O O c m~ Q d O U fdt (~9 = WJW m ~ O N (0 ~ O CC"L""O ~ m p >~ ~ J C >>~ ~ ~w._ ~ ~ O ~ C p } U~'~ ~ ~ J QZQ O o ~ Q ~ ~:.= a ^Ua V Z w~ ~~ .~ } a`~ C 1~0 d 41 V m H E o ~ z~ ~. ~ E Z O~ Z ri O co w; c y p 0 ~ ~ o L O ~ ~ O~ O M C ,. ~~ w N ~ ~ ~ , ~ C ~ N M i • . p +0 l1~ ~69 ~, ~ N ~ ~p y c ~ a~ O , p N C.. j ;rL o ~ O ~ 7 ~ L ~ ~ ` O a~~~ ~ y c to ~ O N U C L N ~ ~ * O;_, N N ~ L O fi O '3L Q' C ~; "' O 00 0000 00 OMO .... e- >+O"'.~0 O yN ~ tq 3 ~ ~°o~~ °u-c°v~°s w.. 3m~~•~ O O ~~E m O ~ p. 7 EA OL.O. ~'7 ~ ,~, c N C O y C~ y~ya~i'3 • L ~ (A ~ ~ ~ N~ O O c ~ ~~ W O d 'O ~ ~ ' L O CO J, O v.-Qj y ~ 7 p "-~ ~C j ~ O ~ Q O 0 3 N y N 7~ to ~ >, d `~~ ?': 0.30 ~~ ~ darn , ao Ems..-". ~ t o f0 ~} V O V >` y~ fC ~~• E w v i L_ O ~ v c N x cO X10 t0 ~N x 3 W ~ aa~ ° m OL y O~~ L O ~ p~ d O Y `~ t6 f0 ~ ~o~ ; '~ujcp ~~~cn o>> c••-x O ~ O co ~ DoE ~ ~ N . mYcoa C .~ t0 V ~[ >,oo U UO~I- e- ~~~ O~ 3 co m ~ = * ca o 0 v d as is a Of O O N 7 C t0 PENNSYLVANIA INHERITANCE TAX EST. OF CORA B SLEBODNICK SSN 205-26-6387 DATE OF DEATH 01-04-2009 . COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. N i T BANK provided the Departaent with the intonation below, which has bean used in ealeulatin/ the potential tax due. Records indicate that at the death of the above-nawad decedent, you ware a iolnt owner/beneficiary of this account. If you Taal th• intonatien is incorrect, please obtain written eorroetien free the financial institution, attach a copy to this fora and return it to the above address. This account is taxable in aeeordanee with the Inherilane• Tax laws of the Coaeanwealth of renna~rlyanla: 'Pie~sa ee23-Ef3't~~ s. -- - --' -.-- __ COMPLETE PART 1 BELOW x SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 15004215021061 Data 08-02-2007 To ensure proper credit to the account, two Established copies of this notice oust seeospany Account Balance 38 686 81 payaent to the Reoister of Mills. Make chock ~ . , payable to "Rooistor of Wills, Anent". Percent Taxable X 50.000 Aaount Subieet to Tax ~ 19 343 41 NOTES If tact vsysonts an aade within thrs• , . aonths of the decedent's date of death, Tax Rat• )( ~ Ofjj dsduet a 5 percent discount on the tact dw. Potential Tax Due ~ 870 45 Any Inheritane• Tax due will beeoae delinquent . nine aonths after the date of death. P T AYER RESP SE © A. ~ The above intonation and tax duo is correct. Roait pasraent to the Register of Mills with tro eopios of this notice to obtain CHECK a discount or avoid interest, or chock box "A' and return this notieo to the Rooistor of ONE Mills end an official assesaeont will b• issued by the PA Dwartaent of Revenue. BLOCK ~. ~ Tho above asset has boon er will be reported and tax paid with the Pennsylvania Inheritance Tact return ONLY to be filed by the estate representative. C. ~ Tho above info ion is ineor a and/or debts and deductions wore paid. Coavlet• PART r 2 ond/or PART ~ below. PART It indieatind a different tax rata, please state relationship to decedent: _ _ _TAX RETURN -_CO_MPUT_ATION_OF TAX ON JOINT/TRUST ACCOUNTS LINE I. Date Established 1 _ ~~ V 2. Account Bslance 2 = 3. Percent Taxabl• Z X 4. Aaount Subject to Tax 4 5. Debts and Deductions 5 - 6. Aaount Taxabl• 6 ~ 7. Tax Rata 7 X e. Tax Du• B ~ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and eowplet• to the best of ^y knorledCe and belie}. HOME C ) WORK C ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE INFORMATION NOTICE WREAU OF INDIVIDUAL TAXES AND PD oaoc 2oo'oI TAXPAYER RESPONSE w1RItISBURG PA 1712-eiAl acv-~sa a r- ceru~ PAUL F SLEBODNICK 7663 LONG PINE DRIVE SPRINGFIELD VA 22151 FILE N0. 21 09-0036 ACN 09122535 DATE 04-07-2009 . PENNSYLVANIA INHERITANCE TAX ' ~ INFORMATION NOTICE WREAU OF INDIVIDUAL TAXES AN D Po ~aoc 2iit•1 TAXPAYER RESPONSE FMRRISfURC PA 1712`-•i01 air-IS4i 0[ AF- (~MM) FILE N0. 21 09-0036 ACN 09122536 DATE 04-07-2009 PAUL F SLEBODNICK 7663 LONG PINE DRIVE SPRINGFIELD VA 22151 EST. OF CORA B SLEBODNICK SSN 205-26-6387 DATE OF DEATH 01-04-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAYINGS ® CHECKING TRUST CERTIF. N i T DANK provided the Departwnt with the inforaation below, which has boon used in ealeulatino the potential tax duo. Reeerds indicate that at the death of the aboro-naaed decedent, you were a joint wnor/bonofieiar7l of this account. If you tool tM inforaation is ineorroet. please obtain written correction frog the financial institution, attach a copy to this fore and roturn it to the above address. This aeeeunt is taxable in accordance with the Inheritance Tax laws of the Coaaorrealth of - - PihA3hllVilfia.-"-F2iafi" Eall C71?r 7i7 2327 ~iitT~' quisti3as. - - ~-- `-" "- ~ "`" -` - - ~ - - - ' ~- COMPLETE PART 1 BELOW ~e SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 79454976 Dato 08-02-2007 To ensure proper erodit to tM account, two Established eopiss of this notice oust aeeaeeaner Account lalanee 12 574 84 payaent to the Reoister of Mills. Nalco ehed( ~ . , payable to "Rooistor of Mills, Apent". Percent Taxable X 16.667 Aaount Subieet to Tax # 2 095 85 NpTE: If tax payaents an ^ade within three ~ aonths of the decedent`s date of death, Tax Rate X .045 deduct a 5 percent discount on tM tax dw. Potential Tax Duo ~ 94 31 Any InMritanee Tax due will beeeae delinquent . nine months after the data of death. P T PAYE RE ONSE ~ 1 A. ~ The abere inforaation and tax due is correct. Resit payaent to the Reoisler of Wills with twe copies of this notieo to obtain CHECK a discount or avoid interest. or eMek boot "A" and return this notieo to the Register of ONE Mills and an official assessaent will be issued by the PA Deparhent of Revenw. BLOCK •. ~ The abovo asset has boon or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate ropresentative. C. ~ Tho aboro infora ion is ineorr et and/or debts and deductions Moro paid. Coapleto PART 2~ and/or PART 3~ belor. PART If indicating a different tax rata, please state relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Dat• Established 2. Account Dalanee 3. Percent Taxable 4. Aaount Subject to Tax 5. Debts and Deductions ~. At,ount Taxabl• 7. Tax Rate D. Tax Due PART DATE PAID PAYEE OF TAX ON JOINT/T~.__A000U~I~ 1 2 3 X 4 5 6 ~ 7 X s ; __ DEBTS AND DEDUCTIONS CLAIMED DESCRIPTION AMOUNT PAID Under penalties of perjury. I declare that the facts I have reported above are true, comet and complete to the best o~ ay knowledge and belief. HOME C ) WORK C ) TAXPAYER SIGNATURE TELEPHONE NUMBER DAT~- APR. 6.1009.10:31AM-~1 R_ITEAID CORP 71~ 130 8113._. ,.,, , ~ ?~ ~+N0.1154'R EP• ~ e9'~ • • . 1 '~ 7 ~, a . f• + 1 . IJ it •~ Y r ~ r ' } 4 •1 •• •• .i ~• ,~ • rr11{~` ~ 1 • .y, 1 ~f~'• . ' • ' •. t .f• • •y • rr 1. .r• • J . • / .. • ~ • .. ~ • • • .. .) r ~ ) {{ 1 !Y V~ {y )jj ~ .~y ~7 ~Jr .. • • •' '•' 'll, . • , •i. ii y1j~ • 7+/~~ 1. .. ll.y. •r .f~~ • r • :: ••j iy;'.• .~•, ~••/ ~ l ,• ,i r. . 1~ • • • 7~ • i iy~l~/Y:7 ~' • i • '1 '11 y'~.~t }I ,'•,l r 2 :~ ~~„• ' • I ` r s_ ,i~~~.i.~//111111 ' ~ r • ~ ~ 1• • r ( , • • 1 • 1 • r , 1: '' ~. . .. 1. r .. 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I~p~•.i, •~ .' ="6• t ~i f ~~ •' • 1 ' .• ~ ( •1 '.f•~•~'111' i~~ . i • '.]~ •• ~~ •:1•,3 'il••r ry 1 ,'r' •r'4• Y. •1 w r• ~ • • • ~ rli'•• ~~ •r~j' ~y ~•J~P• ' ~1 •t•,. ryl i••7 1•f ~ • •. . . • •;•F N . / r r + '1•• .M rip f•• r ' I~ t• y r r • : ~r• 1^!]~ • If• 1 ~, ~t 1. 4 j ~• • • ~ry~yi • • • '~ r ' •1 rf r••~ , f T r J ; 1 I r '• j r • r S r ~ 1 •~ ~1~~*~•~,•1~,,~~~~ i~JA~. ~1N'/.ri~,.~.t. ••i+~~y~i.~~ i }i~••1•• r~.Sjr~,~~ tier .•`•.•yN6•••'.r • ~ +i11"•T • r •; ••r/ ••r • • !~~/y ~• ~ r r • . . • , • ~r~ . r T• '~{.. r i , `~ . Kelly Financial Services, Inc. 400 Bridge Street, Ste 4 New Cumberland, PA 17070 717.774.7536 717.774.4802 (Fax) Bill To Estate of Cora Slebodnick C/O Paul Slebodnick 7663 Long Pine Drive Springfield, VA 22151 Invoice Date Invoice # 6/1/2009 7367 Description Amount Preparation of U S Estate/Fiduciary Income Tax Return for tax year 2008 10,248.00 Preparation of U S Estate/Fiduciary Income Tax Return for tax year 2009. This return will be completed in 525.00 February/March 2009. This return will generate a loss called "an excess estate deduction" which will be applied to each of the beneficiaries individual tax returns at the time of the filing of the 2009 individual tax return. Preparation of U S Individual Income Tax Return for tax year - 2008 254.75 Preparation of U S Individual Income Tax Return for tax year - 2009 Final Return 175.00 Refund for missed 90 day prepayment -965.00 Tota I $10,237.75 1 `r • ' ~ ~ s ~ i ~ * ~~ ~ ~~ ¢ _ , ~~~~ ~ Form Pb-01 ~ \/~ L_~AC31~ 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 QUESTION37 CALL: X7171697-466f..- RE ID UNIT . DA ' 20803 031 W 12/31/2008 R S PAUL SLEBODNICK Mrs. CORA B. SLEBODNICK 7663 LONG PINE DRIVE SPRINGFIELD, VA 22151 TOTAL AMOUNT DUE 59,349.57 DATE DUE 01/31/2009 DATE DESCRIPTION RATE CHARt3ES CREDITS BALANCE Balance Forward 8,833.90 12/15/08 PAYMENT RECEIVED -THANK YOU!!! 8,833.90 0.00 11/10/08 *** Nursins Care *** WEST SHORE EMS TRANSPORT 251.07 1.00 251.07 ... 251.07 FROM MV TO 800 POPLAR CHURCH 12/31/08 RM/ BRD -NURSING -SEMI-PVT 272.00 31.00 8,432.00 8,b83.07 12/31/08 OXYGEN 17.50 31.00 542.50 9,225.57 12/31/08 AIR MATTRESS 12/01-12/31 4.00 31.00 124.00 9,349.57 RESIDENT #~ CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 20803 9,349.57 0.00 0.00 0.00 0.00 X9,349.57 RESIDENT NAME Mrs. CORA B. SLEBODNICK Fom, ve-0, MIA A 1'/~ finance charge mny be assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill, please s~ddress them directly to Fiscal Services at 790-8220. Thank You! ` ~ i~SSl2~ \/~ L-L_AC~ ~ 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 Farts P8-01 QUESTIONS? CALL' (7171697-4666 RE I NT # U IT START. DATE 20803 031 W 01/31/2009 PAUL SLEBODNICK Mrs. CORA B. SLEBODNICK 7663 LONG PINE DRIVE SPRINGFIELD, VA 22151 TOTAL AAAOUNT DUE 51,174.00 DATE DUE 02/28/2009 DATE DESCRIPTION RATE ~~ CHARGER CREDITS SAL.AHCE Balance Forward 9,349.57 01/15/09 PAYMENT RECEIVED -THANK YOU!!! 9,349.57 0.00 01/04/09 *** NursinE Care *** RM/ BRD -NURSING -SEMI-PVT 272.00 4.00 1,088.00 1,088.00 01/04/09 OXYGEN 17.50 4.00 70.00 1,158.00 01/04/09 AIR MATTRESS 01/01-01/04 4.00 4.00 16.00 1,174.00 RESIDENT ~ CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 20803 1,174.00 0.00 0.00 0.00 0.00 51,174.00 RESIDENT NAME Mrs. CORA B. SLEBODNICK F0""~'O1 A 1•/. tlnnnce char=e mny be assessed on accounts for which payment has not been received by the due date. Thank you: I f you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! • ,~ ~r G C G G G G '` ~ ~ ICJ N OA N 4p N OA N GA N 00 N OO ' ~l1 ~G N M ~ Q L L L C ~[ C ~G C ~C C ~L C ;C C ~L tip M M M M L .~ ~ U ~ U +~+ U ~ ~ ~ ~ ~ ~ ~ C .Y ~ M ~ M ~ M ~ M U ~ V ~ +r ~ +.+ ~ +r ~ L U L U .= U L U L U L U O ~ u v v v ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ v v v v ~ } ~ } L L L .~ t L } C C C C C C ~ ~ ~ ~ ~ ~ ~n ? ~ N ~ c0 ~ E ~ E ~ M M GJ ~ i i. 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