HomeMy WebLinkAbout04-0475UNIVES'F
Financial Solutions For Life
November 12, '20~#~-
Register of Wills
Cumberland County Courthouse
One Court House Square
Carlisle, PA 17013-3387
Trust Estate of Dr. Robert H. Smith, Deceased
Social Security Number - 350-16-6861
File number 2104-0475
Dear Register of Wills:
Enclosed are two copies of the Pennsylvania Inheritance tax form REV-1500 on the
above captioned trust estate. Also enclosed is our tax payment in the amount of $960.42.
Please send us your Official Receipt for this payment.
Since the majority of the assets were held in Trust with our bank, there was no need to
probate the Will. I am enclosing a copy of the official receipt evidencing our estimated payment
and file number.
Thank you.
JCK:lbg
Enclosure
cc: Michael J. Maransky, Esquire
Marilyn L. Smith
Sincerely,
Univest National Bank & Trust Co. · 14 North Main Street · P.O. Box 64197 · Souderton, PA 18964-0197
(215) 721-2400 · www. univest-corp.com · Member FDIC · Equal Housing Lender
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 0O4644
KAZARY JOHN C
14 NORTH MAIN STREET
P.O. BOX 64197
SOUDERTON, PA 18965-0197
....... foil~
ESTATE INFORMATION: SSN: 350-16-6861
FILE NUMBER: 2104- 0475
DECEDENT NAME:
DATE OF PAYMENT:
POSTMARK DATE:
SMITH ROBERT H
11/17/2004
11/16/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 02/16/2004
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 ~960.42
REMARKS:
TOTAL AMOUNT PAID:
$960.42
SEAL
CHECK# 40380
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
UNIVES';
Financial Solutions For Life
May 12, 2004
.11222--2-
Ms. Frances V. Pierce, Register of Wills
Montgomery County Courthouse
P.O. Box 311
RE~ISTER OF
Norristown, PA 19404-0311
~,or (,j~ al.../~ .. MONTGOMERY C .
RE: Trust Estate of Dr. Robert H. Smith, Deceased
Social Security Number - 350-16-6861
Dear Ms. Pierce:
~' Enclosed is our check in the amount of $4,500.00 representing a payment on account of
the Pennsylvania Inheritance Tax due from the above-captioned Trust Estate. The Inheritance Tax
Return will be sent to you shortly, but we are making the tax payment at this time to take advan-
tage of the 5% discount.
I~~q Please send us your Ofticial Receipt for this payment.
Since the majority of the assets were held in Trust with our bank, there was no need to
probate the Will. A death certificate is enclosed for your records along with a check for $25.00
made payable to Register of Wills to pay for a file number. Please inform us of the Register of
Wills file number you have assigned to this account. Thank you.
JCK:vm
Enclosures
cc: Michael J. Maransky, Escl~[l:e
Sincerely,
Univest National Bank & Trust Co. · 14 North Main Street · P.O. Box 64197 · Souderton, PA 18964-0197
(215) 721-2400 · www. univest-corp.com · Member FDIC · Equal Housing Lender
~ Member FDIC
Trust
Account # Tran # Administrator Date Frequency
21262300 14878050 John C. Kazary 05/12/04
No. 35258
Portfolio Amount
Principal $4,500.00
Trust A/C Name:
Paid To:
Robert H. Smith
Register of Wills, Agent
Taxes - Other
Estimated inheritance tax payment for Robert H. Smith
PLEASE DETACH BEFORE DEPOSITING
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
REV-1162 EX(11-96)
003956
KAZARY JOHN C
14 NORHT MAIN STREET
P.O. BOX 64197
SOUDERTON, PA 18965-0197
........ fold
ESTATE INFORMATION: SSN.. 350-16-6861
FILE NUMBER: 2104-0475
DECEDENT NAME: SMITH ROBERT H
DATE OF PAYMENT: 05/1 9/2004
POSTMARK DATE: 05/13/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 02/16/2004
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $4,500.00
I
I
REMARKS:
TOTAL AMOUNT PAID:
$4,500.00
SEAL
CHECK# 35258
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
MONTGOMERY COUNTY
REGISTER OF WILLS
CLERK OF THE ORPHANS' COURT
COURT HOUSE
P.O. BOX 311
NORRISTOWN, PENNSYLVANIA 19404-0311
REGISTER OV WILLS
CUMBERLAND COUNTY COURTHOUSE
t COURTHOUSE SQUARE
CARLISLE, PA 17013-3387
his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
,~.~-~.',,? FEB 1 7 200t
P 9 8 5 0 212 ~~%~
No. Date
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
,. Dr. Robert H. [~x ]socw. ~ 1~ ~,~,~.t~ ,~,.,~
L---- ........... I -=.---=.,,--'-----.
.Cuaberland Cou.ty ~ppes_~Ll,~; 7 Dos.ood Drive ~--~--
~ite
Medical Doctor I,~ealth Care I,t ~ I,', ~' I ""'~' /,. ~,,~ Martlyn L. Byer
567 Dogwood Drive ~ ,~ Pennsylvania ~ ,~~ Doner ~len To~shto ~
Hechanicsburg, PA 17055 Cumberland ~' ,~~
567 Do~wood Drive, Mechanicsbur~, PA 17055
Grantham Memorial Park ]~Grantham, PA 17027
Joseph A. Smith
L. Smith
~,~
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OFFICIAL USE ONLY
AEV-1500 EX + (6~OO)
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
350-16-6861
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
FILE NUMBER
D
E
C
E
D
E
N
T
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARAISBURG,PA 17128-0601
DECEDENT'S NAME (lAST, FIRST,AND MIDDLE INITIAL)
Smith Dr. Robert H.
DATE OF DEATH (MM-DD-YEAR)
NUMBER
21-04-0475
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
INITIAL
Smith, Maril
X 1. Original Return
X 4. limited Estate
X 6. Decedent Died Testate
L.
549-46-6058
3 R I date of death
. ema nder Return prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
2.
X 4a.
X 7.
Supplemental Return
Future Interest Compromise (date of death after 12-12-82}
Decedent Maintained a living Trust
(Attach copy of Trust)
o
(Attach copy of WllI)
o 9. litigation Proceeds Received
010.
IKI
11. Election to tax under Sec. 91 13{A)
(Attach Sch 0)
John C. Kazar , Trust Officer
FIRM NAME (If Applicable)
Univest National Bank and Trust CO.
TELEPHONE NUMBER
Univest National Bank and Trust Co.
14 N. Main Street, P.O. Box 64197
Souderton, PA 18964-0197
R
E
C
A
P
I
T
U
L
A
T
I
o
N
99-295
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or
SOle-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
B. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (SChedule H) (9)
10. Debts of Decedent. Mortgage Liabilities. & Liens (Schedule I) (10)
11. Tolal Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
1...:,--;'
(8) 501,770.68
(11) 37.712.75
(12) 464,057.93
(13)
(14) 464,057.93
(1)
(2)
(3)
OFFICIAk:l;ISE ONLY
~'_' i
None
2,408.08
-0-
(4)
(5)
None
48,377.37
j'.,"l
..,,:i
(6)
None
450,985.23
20,153.21
17,559.54
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(aX1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.
337,452.24
126,605.69
0.00
0.00
.0 0
.0 45
.12
.15
(15)
(16)
(17)
(18)
(19)
x
X
X
X
0.00
5,697.26
0.00
0.00
5,697.26
0-
Copyright (cl 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
567 Dogwood Drive
CITY I STATE I ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
5,697.26
0.00
4,500.00
236.84
Total Credits ( A + B + C) (2)
4,736.84
3. Interest/Penalty jf applicable
D. Interest
E. Penalty
TotallnterestlPenalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the taX due. (SA)
B. Enter the total of Line S + SA. This is the BALANCE DUE. (5B)
. .. Make Check. Payable to: . . . REGISTER OF WILLS, AGENT . ."
"""';'!"!'h;:!:::~i::i;::,::.~'...]:m:!,.!:;_.l!lm!]:)i!),:!::i!i!i!i!!ii,!:!lllij]:r:li]iiiiiiii::1!1iii!!l1mml!m!11jiilililll!I!!!lllliiIJ!!JIlIIliJ@m!i!::!:i!!!!!!!!!liiiililllllimmmmil!i:!i!!i!ii
!lililllii!iil!!!@jll!illlii!i!liiiiliWWiliilii!!iiimm!WliWliili!!i..i~::::::::~':.;:i!:i~::1i:i:!,,:!':'~:?!!:;i;i:ii::!:;:
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE ElLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; . mix ~
b. retain the right to designate who shall use the property transferred or its income; .
c. retain a reversionary interest; or. . .
d. receive the promise for life of either payments, benefits or care? . . .
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . .
3. Did decedent own an "in trust for" or payable upon death bank account or security at his
or her death?
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property
which contains a beneficiary designation?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
0.00
0.00
960.42
0.00
960.42
o
o
(]]
(]]
m
o
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 per$onal representative 1$ based on all Information of which preparar has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FIl.ING RETURN Univest National Bank and Trust CO. OA.TE
-i~~~~,:~~~;-~~r:~i-~~6tgi-9~'?"--~~~JL-------- II! ['3-{voL{-
DATE
JA,. /) ck .
r/~~... r/ ~---.--.J.
-------~-------- -----------------------------------
For dates of death on or after July 1, 1994 and before January 1, 1995. the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. 9116 (a) (1.1) (i)).
For dates at death on or atter January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0'%
[72 P.S. 9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets
and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116(1.2)
[72 PS. 9116(aX1)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(aX1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Copyright (e) 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6,00)
ADDITIONAL Personal Representatives
Estate of Dr. Robert H. Smith SS# 350-16-6861 02/16/2004
********************************************************
Under penalties of perjury, the undersigned declare that they
have examined this return, including accompanying schedules and
statements, and to the best of their knowledge and belief, it is
true, correct and complete.
Signature
,
f~i;;r ,;7. ~~
Marilyn L. Smith
567 Dogwood Drive
Name
Address Line 1
Address Line 2
City, State, Zip
Mechanicsburg, PA 17055-6176
Date
r l) /:2 J' I C'l
AEV-1503 EX t (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE T/JJ( RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
FILE NUMBER
Dr. Robert H. Smith
SSfl 350 -16 - 6861
02/16/2004
21-04-0475
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1
51.72
VALUE AT DATE
OF DEATH
2,408.08
DESCRIPTION
46.56 shs Fidelity Growth Company - eusip #316200104
UNIT VALUE
Worthless Securities
2 Alert Centre Inc. - cusip f101446T106
3 Eastern Empire Corp - cusip f/276368107
4 Oxidyne Group, Inc. - cusip f/436857106
5 Worleo Inc. - eusip fl981414105
0.00
0.00
0.00
0.00
(If more space is needed, insert additional sheets of the same size)
Copyright (e) 1996 form software only CPSystems, Inc.
TOTAL (Also enter on line 2, Recapitulation)
2,408.08
Form REV-1503 EX (Rev. 1-97)
REV-1504 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Dr. Robert H. Smi.th
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP or SOLE-PROPRIETORSHIP
SSft 350-16-6861
02/16/2004
FILE NUMBER
21-04-0475
Schedule C-l or C-2 (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.
ITEM
NUMBER
1
DESCRIPTION
East Meadow Associ.ates - .960737% i.nterest has a demi.ni.mus
value
VALUE AT
DATE OF DEATH
0.00
2
Iowa II Partners - 1/2 uni.t i.nterest has a demi.ni.mus value
0.00
TOTAL (Also enter on line 3, Recapitulation) $ 0.00
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1S04 EX (Rev. 1-97)
AEV-150B EX t{1-97)
COMMONWEALTH OF PENNSYLVANIA
INHEAITANCET/1V{ RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ITEM
NUMBER
1
DESCRIPTION
Fidelity Savings account #241-383347 - cash balance
VALUE AT DATE
OF DEATH
0.55
2
CNA - refund from cancellation of long term care policy
1,156.82
3
CNA
insurance claim on long term care policy
25.00
4
199 BMW 323i - value based on appraisal by Sun Motor Cars BMW
(see appraisal attached)
14,000.00
5
Coin collection - value based on appraisal by Alderfer Auction
Co. (see appraisal attached)
33,195.00
TOTAL (Also enter on line 5, Recapitulalion) $ 48,377 . 37
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1-97)
REV-1510 EX +(1.97)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Dr. Robert H. Smith
02/16/2004
SS1! 350-16-6861
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM
NUMBER
A
DESCRIPTION OF PROPERTY
INCLUDETH~NAME OF THE TRANSFEREE THEIR
RELATIONSHIP TO DECEDENT AND THE DATEOF TRANSFER.
ATTACH ACOPYOFTHE DEED FOR REAL ESTATE.
Annuities & IRAs:
DATE OF DEATH
VALUE OF ASSET
% OF
DECO'S
INTEREST
EXCLUSION
(IF APPLICABLE)
1
120,023.26
MONY Annuity contract
#B6014-22-20 - payable to
decedent's spouse
2
45,678.79
MONY IRA Annuity contract
#B1200-24-00 - payable to
decedent's trust
3
67,849.85
Univest National Bank and
Trust - individual
retirement account -
#54155800, payable to
decedent's spouse
Accrued income through date
of death - item 3
96.61
B On 6/29/89, decedent
created a trust with Union
National Bank & Trust
Company of Souderton and
Marilyn L. Smith as
Trustees (see attached copy
of Trust Agreement and
subsequent amendments).
Assets in trust as of date
of death are as follows:
Common Stock
1
200 shares American IntI
Group Inc - cusip
11026874107
15,009.00
2
200 shares Cardinal Health
Inc - cusip #14149Y108
13,018.50
3
300 shares Cisco Systems
Inc - cusip #17275R102
7,274.25
4
200 shares Colgate
Palmolive Co - cusip
1/194162103
11,079.50
Total of Continuation Schedu1e(s)
TOTAL (Also enter on line 7, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
Copyright (el 1996 form software only CPSystems, Inc.
FILE NUMBER
21-04-0475
TAXABLE VALUE
120,023.26
45,678.79
67,849.85
96.61
15,009.00
13,018.50
7,274.25
11,079.50
170,955.47
450,985.23
Form REV-1510 EX (Rev. 1-97)
Estate of: Dr. Robert H. Smith
Soc Sec #: 350-16-6861
Date of Death: 02/16/2004
Continuation of Schedule G
(Inter-Vivos Transfers & Misc. Non-Probate Property)
Item Description of Property
1t
Date of Death % Decd Exclusion Taxable Value
Value of Asset Intrst
5
300 shares Comcast Corp New
Class A Sp1 - cusip
#20030N200
8,773.50
8,773.50
Accrued dividend through
date of death - item 9
13,756.50 13,756.50
13 ,153.50 13,153.50
10,410.00 10,410.00
6,578.75 6,578.75
55.00 55.00
13,201. 00 13 ,201. 00
9,161.25 9,161.25
12.00 12.00
8,695.00 8,695.00
11,905.00 11,905.00
11,274.00 11,274.00
6,740.25 6,740.25
15,060.00 15,060.00
68.00 68.00
6 200 shares Conocophi11ips
cusip #20825C104
7 200 shares Deere & Co -
cusip #244199105
8 300 shares Dell Inc.
cusip #24702R101
9 100 shares Exe10n Corp -
cusip #30161N101
10 400 shares General Electric
Co - cusip #369604103
11 300 shares Intel Corp
cusip #458140100
Accrued dividend through
date of death - item 11
12 200 shares International
Paper Co - cusip #460146103
13 200 shares Johnson Controls
Inc - cusip #478366107
14 400 shares MBNA Corporation
- cusip #55262L100
15 300 shares Nokia Corp
cusip #654902204
16 400 shares Pfizer Inc -
cusip #717081103
Accrued dividend through
Estate of: Dr. Robert H. Smith
Sac Sec #: 350-16-6861
Date of Death: 02/16/2004
Continuation of Schedule G
(Inter-Vivos Transfers & Misc. Non-Probate Property)
Item Description of Property
II
Date of Death % Decd Exclusion Taxable Value
Value of Asset Intrst
date of death - item 16
17
200 shares SBC
Communications Ine - cusip
I178387G103
4,975.50
4,975.50
18
200 shares Wa1-Mart Stores
Inc - cusip #931142103
11 ,392 . 00
11,392.00
19
400 shares Wells Fargo & Co
New - cusip #949746101
23,008.00
23,008.00
Accrued dividend through
date of death - item 19
180.00
180.00
Mutual Fund
20
440.926 shares Federated
Kaufmann Fund #066 - cusip
#314172677
2,270.77
2,270.77
Money Market Funds
21
$18.96 Univest National
Bank Money Market Fund -
principal investment fund
18.96
18.96
Accrued interest through
date of death - item 21
0.01
0.01
22
$266.37 Univest National
Bank Money Market Fund -
income reinvestment fund
266.37
266.37
Accrued interest through
date of death - item 22
0.11
0.11
170,955.47
REV-15t1 EX + (1 ~97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Dr. Robert H. Smith
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
B.
1.
2.
3.
SSfl 350-16-6861
02/16/2004
FILE NUMBER
21-04-0475
DESCRIPTION
AMOUNT
1
FUNERAL EXPENSES:
Cocklin Funeral Home, Inc. funeral expenses
6,898.81
2
Baughman Memorial Works Inc. - headstone
989.40
3
Marilyn Smith - memorial service and meal
265.00
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) Univest National Bank
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address 14 N. Main Street, P.O. Box 64197
City Souderton State PA
5,000.00
and Trust Co.
Zip 18964-0197
Year(s) Commission Paid:
Attorney'sFees Fox, Rothschild, O'Brien & Frankel, LLP
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
7,000.00
City
Relationship of Claimant to Decedent
State
Zip
4. Probate Fees
S. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
TOTAL (Also enter on line 9. Recapitulation) $ 20,153.21
(If more space is needed, insert additional sheets of the same size)
Copyright (e) 1996 form software only CPSystems, inc, Form REV-1511 EX (Rev. 1 ~97)
REV.1512 EX + (1.97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Dr. Robert H. Smith
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
SSII 350 -16 - 6861
02/16/2004
FILE NUMBER
21-04-0475
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1 BMW Credit - BMW car loan
AMOUNT
17,559.54
TOTAL (Also enter on line 10, Recapitulation) $ 17,559.54
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97)
REV-1513 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCETIV< RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
1
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and
transfers under Sec. 9116(a)(1.2)]
Marilyn L. Smith
567 Dogwood Drive
Mechanicsburg, PA 17055
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
FILE NUMBER
21-04-0475
AMOUNT OR SHARE
OF ESTATE
ESTATE OF
Dr. Robert H. Smith
SS{I 350-16-6861
02/16/2004
NUMBER
I.
Spouse
Personal prop;
Trust remainder
not disclaimed;
Beneficiary of
Disclaimer
Trust with
income for life
and principal
for maintenance
and support
per Amendment
to Amended and
Restated
Revocable
Trust Agreement
Article VI.
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON- TAXABLE DISTRIBUTIONS,
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
~
TOTAL OF PART 11- 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)
Copyright (c) 2000 form software only The Lackner Group, Inc.
0.00
Form REV-1513 EX (Rev. 9-00)
Estate of: Dr. Robert H. Smith
Soc Sec #: 350-16-6861
Date of Death: 02/16/2004
Item
If
Continuation of Schedule J, Part I
(Taxable Bequests)
Name and Address of Beneficiary
Relationship
Amount or
Share of Estate
Upon death of Marilyn L. Smith:
2
Jean Hunsberger
1112 North Fourth
Philadelphia, PA
3
Shirley Zagorski
335 Clemens Road
Harleysville, PA
Daughter
Street
19123
Daughter
19438
One of two
shares of
trust remainder
per Amendment
to Amended and
Restated
Revocable
Trust Agreement
Article V.
One of two
shares of
trust remainder
per Amendment
to Amended and
Restated
Revocable
Trust Agreement
Article V.
REV-1514 EX.. (9-00)
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on Rev-1500 Cover Sheet
ESTATE OF FILE NUMBER
Dr. Robert H. Smith SS# 350-16-6861 02/16/2004 21-04-0475
This schedule is to be used for aU single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89,
actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found
in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCETfIj{ RETURN
RESIDENT DECEDENT
Copy #1
o Will
IKJ Intervivos Deed of Trust
o Other
NAME(S) OF
LIFE TENANT(S)
DATE OF B[RTH
TERM OF YEARS LIFE ESTATE [S
PAYABLE
Mar 11
L. Smith
07/21/33
71
Term of Years
Term of Years
Term of Years
Term of Years
1. Value of fund from which life estate is payable
2. Actuarial factor per appropriate table
Interest table rate - D 31/2% D 6% D 10%
3. Value of life estate (Line 1 multiplied by Line 2)
$
208,927.17
0.39402
[Jg Variable Rate
4.2 %
$
82,321. 48
DATE OF B[RTH
TERM OF YEARS ANNU[TY IS
PAYABLE
Term of Years
Term of Years
Term of Years
Term of Years
1. Value of fund from which annuity is payable
2. Check appropriate block below and enter corresponding (number)
Frequency of payout - 0 Weekly (52) 0 Bi-weekiy (26)
o Quarter[y (4) 0 Semi-annually (2) 0 Annually (1)
3. Amount of payout per period
4. Aggregate annual payment, Line 2 multiplied by Line 3
5. Annuity Factor (see instructions)
Interest table rate - D 3 1/2% D 6% D 10% D 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
0.00
o
o Monthly (12)
o Other ( )
0.00
0.00
0.0
0.0000
0.0000
%
0.00
0.00
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of
this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15, 16, 17 and 18.
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 2000 form software only The Lackner Group, Inc.
Form REV-1514 EX (Rev. 9-00)
REV-1647 EX +(9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE M
FUTURE INTEREST COMPROMISE
(Check Box 40 on Rev-1500 Cover Sheet)
ESTATE OF
Dr. Robert H. Smith SS# 350-16-6861 02/16/2004
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.
FILE NUMBER
21-04-0475
nWiII rxl Trust nOther
I. Beneficiaries
NAME OF AGE TO
BENEFICIARY RELATIONSHIP DATE OF BIRTH NEAREST BIRTHDAY
1. Mar il vn L. Smith Spouse 07121/1933 71
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. n Limited riaht of withdrawal
n Unlimited riaht of withdrawal
III. Explanation of Compromise Offer:
Mar iln L. Smith is the income beneficiary of a trust valued at
$332,256.14, of which $123,328.97 consists of life insurance
proceeds. Based on her age and our understanding that she has
sufficient income and assets to support her, we consider the invasion
of principal to be unlikely. The remainder, at the death of Marilyn
L. Smith, is to be distributed equally to the two daughters.
Value of Fund Subject to Tax $208,927.17
Life Estate Factor (4.2%) .39402
Value of Life Estate $ 82,321. 48
Remainder - taxable at 4.5% $126,605.69
IV. Summary of Compromise Offer:
1. Amount of Future Interest. . . . . . . . . . . . $ 332,256.14
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) . . . .$ 123,328.97 (life insurance
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One 06%, 03%, []O% . .$ 82,321. 48
(also include as part of total shown on line 15 of Cover Sheet)
4. Value of Line 1 taxable at lineal rate
Check One 06%, [K] 4.5% .. . . . ,$ 126,605.69
(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). ,$ 0.00
6. Value of Line 1 taxable at collateral rate (15%)
(also include as part of total shown on Line 18 of Cover Sheet). , . .$ 0.00
7. Total Value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) . . . .. . $ 332,256.14
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 2000 form software only The Lackner Group. Inc.
Form REV-1647 EX (Rev. 9-00)
AEV-1649 EX +(1/97)
COMMONWEALTH OF PENNSYLVANIA
INHEAITANCET/J:)( RETURN
RESIDENT DECEDENT
SCHEDULE 0
ELECTION UNDER SEC. 9113(A)
(SPOUSAL DISTRIBUTIONS)
ESTATE OF FILE NUMBER
Dr. Robert H. Smith SS# 350-16-6861 02/16/2004 21-04-0475
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 Disclaimer Trust Trust (marital, residual A, B, By-pass, Unified Credit, etc.).
If a trust or similar arrangement meets the requirement of Section 9113(A), and:
a. The trust or similar arrangement is listed on Schedule 0, and
b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,
then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election
to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included
as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or
similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on
Schedule O. The denominator is equal to the total value of the trust or similar arrangement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving
spouse under a Section 9113 (A) trust or similar arran ement.
DESCRIPTION VALUE
1
Univest National Bank and Trust Co. and Marilyn L. Smith,
Trustees for the Robert H. Smith Disclaimer Trust FBO
Marilyn L. Smith with remainder to two daughters.
332,256.14
Part A Total
PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is bein
DESCRIPTION
332 256.14
made.
VALUE
1
Univest National Bank and Trust Co. and Marilyn L. Smith,
Trustees for the Robert H. Smith Disclaimer Trust FBO
Marilyn L. Smith with remainder to two daughters.
332,256.14
Part B Total
332,256.14
(If more space is needed, insert additional sheets of the same size)
Copyright (cl 1996 form software only CPSystems, Inc.
FormREV-1649 EX (Rev. 1-97)
Sun Motor Cars BMW
6643 Carlisle Pike, Mechanicsburg, PA 17050
February 25, 2004
To whom it may concern,
$
Telephone
717/69Z2300
800/470.8133
Website
WWW.sunmotorcars.com
Facsimile
717/69Z0836
Sun Motor Cars BMW appraised Mr. Robert Smith's 1999 BMW 323i VIN#
WBAAM3337XFP52377 on February 25,2004. We feel the current value of this car
with 56,269 miles to be $14,000.00.
Sincerely, ...
?~~
Brad Pittenger
Sales Manager
PERSONAL PROPERTY APPRAISAL REPORT FOR:
MARILYN SMITH
567 DOGWOOD DRIVE
MECHANICSBURG, PENNSYLVANIA 17055
AT THE REQUEST OF:
MARILYN SMITH
567 DOGWOOD DRIVE
MECHANICSBURG, PENNSYLVANIA 17055
PURPOSE:
FAIR MARKET VALUE
COMPLETED BY:
RICHARD BRINCKMAN
CONSULTANT FOR
SANFORD A. ALDERFER AUCTION COMPANY, INC.
501 FAIRGROUNDS ROAD
HATFIELD, PA 19440
Miscellaneous U.S. & Foreign coins. S10.00
3 Silver Eagles & miscellaneous coins. 20.00
1999 Silver proof Eagle. 50.00
IS Morgan, II Peace Dollars. 150.00
1798 8 Reale Mexico. 20.00
1805 8 Reale. 20.00
5 ~ 1945 1/10 oz. Mexico. 100.00
9 Piece SBA Dollar Set. 15.00
Mint Sets
2-1965 15.00
1-1966 5.00
1-1967 10.00
2-1979 5.00
2-1980 5.00
2-1981 15.00
2-1984 5.00
2-1985 5.00
2-1988 10.00
2-1989 10.00
4-1990 10.00
2-1991 15.00
2-1992 5.00
2-1993 10.00
2-1995 20.00
1996 10.00
1997 30.00
1998 10.00
Proof Set
1968,69, 2-70, 71. 30.00
1972,73,2-74,75,76. 35.00
2-1976 3-piece Silver. 20.00
2-1977,78,2-79. 25.00
2-1980,2-81,2-82,3-83. 30.00
2-1984,2-85,2-86, 1986 President Set. 50.00
2-1987,2-88,2-89,2-90. 35.00
2-1991,2-92,2-92, Silver. 40.00
2-1993,2-93 Silver. 60.00
2-1994. 30.00
2-1994 Silver. 60.00
1-1995. 50.00
1-1995. 50.00
1995 Premier. 50.00
2-1996,1997. 40.00
1997 Silver. 50.00
1998, 1998 Silver. 30.00
2001 & 2003 Silver. 50.00
2-1986 Liberty Proof. 15.00
Gold
1994 $5. 60.00
1999 $5. 60.00
Part Sets
Indian Cents. 100.00
Lincoln Set. 25.00
Liberty Nickel Set. 20.00
Buffalo Nickel Set. 10.00
Jefferson Nickel Set. 10.00
Silver Eagle Set. 50.00
$21 Silver. 80.00
1787 Mass cent bent. 80.00
Half Cents
1-1794 600.00
1-1795 600.00
1-1797 (1 above 1) 50.00
1-1800 40.00
1-1803 50.00
1-1804 Plain 4 90.00
1-1804 Spiked Chin 50.00
1-1804 Spiked Chin 70.00
1-1805 50.00
1-1806 90.00
1-1807 40.00
1-1808 50.00
1-18099/6 70.00
1-1809 50.00
1-1810 50.00
1-1811 300.00
1-1825 50.00
1-1826 40.00
1-182813 Stars 50.00
1-1828 13 Stars 50.00
1-182812 Stars 30.00
1-1829 40.00
1-1832 30.00
1-1833 40.00
1-1834 30.00
1-1835 30.00
1-1849 100.00
1-1850 20.00
1-1851 50.00
1-1853 90.00
1-1854 50.00
1-1854 200.00
1-1855 80.00
1-1856 300.00
1-1857 100.00
Large Cents
1-1794 100.00
1-1795 500.00
1-1796 50.00
1-1797 140.00
1-1798 200.00
1-1800 40.00
1-1801 140.00
1-1802 100.00
1-1803 50.00
1-1803 50.00
1-1804 900.00
1-1806 60.00
1-1808 90.00
1-1809 150.00
1-1810 70.00
1-1811 250.00
1-1811 30.00
1-1812 30.00
1-1813 60.00
1-1814 60.00
1-1816 200.00
1-1817 70.00
1-1818 40.00
1-1819 20.00
1-1820 240.00
1-1821 650.00
1-1822 15.00
1-1823 50.00
1-1824 20.00
1-1825 300.00
1826,1827,1828,1829,1830,1831 85.00
1-1832 130.00
1-1833 10.00
1-1834 100.00
1834,1835,1836,1837,1838,1839,1839 130.00
1839,1839, 1839, 1840 60.00
1840,1841,1842,1842 80.00
1843, 1844, 1845, 1846, 1847, 1848, 1849 120.00
1850,1851,1852,1853,1854 80.00
1-1855 40.00
1-1855 40.00
1-1856 30.00
1-1856 20.00
1-1856 20.00
1-1857 150.00
Indian Cents
1857,2-1858 40.00
1864-L 80.00
1-1864 20.00
1-1865 15.00
1-1866 30.00
1-1867 30.00
1868, 1869 40.00
1-1870 30.00
1-1871 50.00
1-1872 40.00
1-1873 20.00
1-1874 25.00
1-1875 30.00
1-1876 80.00
1-1877 800.00
1-1880 30.00
1-1908-S 50.00
1-1909-S 300.00
Lincoln Cents
1909 S VDB 800.00
1909-S 50.00
1909-S 50.00
1910 S, ll-S, 13-S, 14-S, 15-D 30.00
1914-D 180.00
1-1922 80.00
1931-S 40.00
Two Cent Pieces
1864, 1869, 1867, 1869 20.00
1-1864 30.00
1-1864 50.00
1-1865 20.00
1-1865 40.00
1-1866 20.00
1-1866 30.00
1868,1868,1870,1871 40.00
1-1872 50000
Three Cent Nicke]s
1-]865 60.00
]865,67,68,69,70 20.00
]-1871 20.00
1872,73,73, 74, 75,76 30.00
1-1879 40.00
1-1880 70.00
1-] 881 10.00
1-1882 60.00
1-1883 150.00
1-1886 300.00
1-1887 200.00
1-1888 50.00
1-1889 80.00
Three Cent Silver
1-1851 30.00
1-1851-0 20.00
1852,53 10.00
1-1854 140.00
]-1855 40.00
1-1856 20.00
1-1857 20.00
1-1858 60.00
1-1859 40.00
1-1861 100.00
1-1862 50.00
Shield Nickel
1866 Rays 100.00
1867 Rays 140.00
1867,68,72 20.00
1-1870 80.00
1-1871 35.00
1-1873 25.00
1-1873 25.00
1-1874 20.00
1-1875 40.00
1-1876 100.00
1-1881 160.00
1-1882 10.00
1-1883 10.00
1-1883 25.00
Libertv Nickels
1-1883 10.00
1-1884 50.00
1-1885 300.00
1-1886 130.00
1-1888 150.00
1-1912-S 90.00
Buffalo Nickels
1913 TI & TII 10.00
1913 D TI 10.00
1913 D TI 20.00
1913 D TII 100.00
1913STII 250.00
1914-S 100.00
1914-D 100.00
1915-D 40.00
1916-D, 1916-S, 1917-PD & S 70.00
1918-PD & S 60.00
1919-PD & S 90.00
1920-D & S 20.00
I 924-PD & S 40.00
1-1921 20.00
1921-S 400.00
1925-PD & S 20.00
1926-S & 315 20.00
1937 D, 3-Legged 400.00
Bust Half Dime
1-1829 40.00
1-1830 20.00
1-1831 40.00
1-1832 30.00
1-1833 20.00
1-1834 20.00
1-1835 20.00
1-1835 40.00
1-1836 20.00
1-1837 20.00
Seated Half Dime
1-1837 40.00
1-1837 80.00
1-1838 80.00
1-1839-0 20.00
1-1840 10.00
1841,47,49 20.00
1-1842
40.00
1-1845
10.00
1-1848
10.00
1-1850
80.00
1-1851
30.00
1852,56,57
20.00
1-1853
30.00
1-1853
100.00
1854,1854-0,1855, 1855-0, 185~71,72, 1857-0
110.00
1858, 1858-0, 1859-0, 1861, 1862
50.00
1-1872-S
100.00
1-1873-S
10.00
Bust Dime
1-1820
10.00
1-1827
20.00
1-1829
20.00
1-1831
15.00
1-1832
80.00
1-1833
120.00
1-1834
25.00
! 1-1835
1-1836
10.00
20.00
Seated Dimes
1840, 1843, 1845, 1845-0, 1847
1-1848
1849-0,1850,1853,1854
1-1854-0
1856,1857,1857-0,1858,1859-0,1861
1862,1868, 1869-S, 1873,1874,1875
1875-CC
1-1876
1-1876-CC
1-1877-CC
1882, 1883, 1884, 1885
1-1886
1887, 1887-S, 1888, 1889, 1890, 1890-S, 1891, 1891-0
1891-S
70.00
50.00
50.00
100.00
80.00
11 0.00
10.00
10.00
10.00
50.00
40.00
20.00
80.00
50.00
Mercury Dime
1929-S
1-1935
1-1936
1937-S
1-1941
1-1943-S
80.00
40.00
30.00
30.00
20.00
20.00
1-1944-D 40.00
Quarters
1-1901 80.00
1935,39,43-8,99, Dime 1949-8 30.00
Commerative
1936-D Arkansas 60.00
1936-8 Bay Bridge 100.00
Bust Half
1-1810 40.00
1-1819 40.00
1-1823 35.00
1-1825 50.00
1-1826 50.00
1-1827 35.00
1-1828 35.00
1-1829 70.00
1-1830 140.00
1-1831 35.00
1-1832 60.00
1-1834 60.00
1-1835 35.00
1-1838 35.00
Seated Half
1-1853 35.00
1-1854-0 20.00
1-1855-0 50.00
1-1856-0 60.00
1-1861 70.00
1-1876 100.00
Barber Half
1898-S 50.00
1-1901 15.00
1902-S 10.00
1-1903 10.00
1904-0 10.00
1907-0 10.00
1908-D 200.00
1909-0 10.00
1912-S 10.00
1913-S 10.00
Walking Libertv Half
1917-S.1918-S 5.00
1-1919 80.00
1920-S 10.00
1-1920 25.00
I 929-D 50.00
1-1936 25.00
Walking Libertv Half
1-1937 40.00
1940-S 40.00
1-1943 25.00
1943-S 30.00
1945 & 45 30.00
1945-D 25.00
I 946-D 40.00
Franklin Half
1948-D, 50, 51, 53-S, 61 40.00
Trade Dollar
1878-S 70.00
Morgan Dollars
1878- 7TF 20.00
1878-7TF 20.00
1878-S 10.00
1878-S 20.00
1878-S 10.00
1878-CC 80.00
1878-CC 150.00
1879-8 20.00
1880-CC 120.00
1880-CC 300.00
1881-8 20.00
1881-0 10.00
1881-CC 300.00
1881-CC 300.00
1882-8 20.00
1883-0 20.00
1883-CC 60.00
1883-8 20.00
1884-0 20.00
1884-0 20.00
1884-0 20.00
1884-CC 100.00
1884-8 30.00
1885-0 20.00
1885-CC 250.00
1885-8 40.00
1-1886 20.00
1-1887 20.00
1887-S 30.00
1-1888 20.00
1891-S 30.00
1892-0 10.00
1894-0 150.00
1897-S 15.00
1898-S 40.00
1-1899 50.00
1899-0 20.00
1-1900 20.00
1-1901 40.00
1-1902 15.00
1902-0 20.00
1-1903 40.00
1-1904 20.00
1904-S 80.00
1-1921 10.00
1-1921 10.00
1882-0, 82-S, 85, 88-0 40.00
89,90,96,96,97 50.00
1878, 1878-S 15.00
1881-S, 98, 98-0 20.00
Peace Dollar
1-1921 40.00
1-1921 40.00
1-1922 10.00
1-1922 10.00
1-1923 10.00
1-1924 10.00
1-1925 10.00
1928-S 20.00
1-1935 20.00
1-1935 20.00
I 926-D&S 20.00
I 927-D, 1934 20.00
1922,24,25 20.00
1922,23,25 20.00
Gold
1856-$1 100.00
1858-$1 100.00
1860-$1 100.00
1891-CC-$10 250.00
1901-S-$10 200.00
1906-D-$10 200.00
1878-$20 400.00
1898-S-$20 400.00
1904-$20 400.00.
1904-$20 400.00
1927-$20 400.00
Gold Eagles
1/10 .oz 30.00
1/1 0 .oz 30.00
2000- Y. .oz 90.00
1994- Yz .oz 200.00
1986- 1 .oz 400.00
1986- 1 .oz 400.00
1988- 1 .oz 400.00
1988- 1 .oz 400.00
1995- 1 .oz 400.00
1996- 1 .oz 400.00
TOTAL $33,195.00
I certify that, to the best of my knowledge and belief:
1. The statements of fact contained in this report are true and correct.
2. The reported analyses, opinions, and conclusions are limited only by the
reported assumptions and limiting conditions, and are my personal,
unbiased professional analyses, opinions and conclusions.
3. Alderfer Auction Company is in the auction business and their only
interest in this property would be to offer our services as auctioneers on a
commission basis on any items the above wishes to sell.
4. My compensation is not contingent upon the reporting of a predetermined
value or directions in value that favors the cause of the client, the amount
of the value estimate, the attainment of a stipulated result, or the
occurrence of a subsequent event.
5. My analyses, opinions and conclusions were developed, and this report has
been prepared, in conformity with the Uniform Standards of Professional
Appraisal Practice.
6. I have made a personal observation of the property, unless so noted, that is
the subject of this report.
7. No one provided significant professional assistance to the person
signing this report.
<:'" ~"
~~
Richard Brinckman
Consultant for Alderfer Auction Co.
..,
'w
~
~
Date of Death:
Valuation Date:
Processing Date:
02/16/2004
02/16/2004
02118/2004
<t
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.
Shares
or Par
11
2)
31
41
5)
6)
1)
81
9)
IO}
Security
Description
200 AMERICAN INTL GROUP INC 1026874107)
COM
NYSE
02/l3/2004
021:7 /2004
200 CARDINAL HEALTH INC (14149YIOB)
COM
NYSE
02/13/2004
02/17/2004
300 CISCO $YS INe (17275RI02l
COM
NASDAQ
02/13/2004
02/17/2004
200 COLGATE PALMOLIVE CO (194162103)
COM
NYSE
02/13/2004
02111/2004
300 COMCAST CORP NEW (20030NZ00)
CL A 8PL
NASDAQ
02/13/2004
02/17/2004
200 CONOCOPHILLIP$ (20825C104)
COM
NYSE
02/13/2004
02/17/2004
200 DEERE & CO (244199105)
COM
NYSE
02/13/2004
02/17/2004
300 DELL INC (24702RIG1)
COM
NASDAQ
02/13/2004
02/17/2004
100 EXELON CORP (30161NIOl)
COM
NYSE
02/13/2004
02/17/2004
Sstate Valuation
High/ASk
75.40000
75.66000
65.51000
65.15000
24.45000
24.48000
55.75000
55.58000
29.33000
29.95000
68.89000
69.50000
65.30000
61. 80000
35.09000
34.95000
66.00000
66.22000
Estate of: Robert H. Smith
Account: 21262300
Report TyPe: Date of Death
Number of Securities: 20
File ID: 21262300
Lowlsid
Mean andlor Div and Int Security
Adjustments Accruals Value
74.39000 H/L
74.73000 H/L
64.00000 H/L
65.05000 H/L
23.94000 H/L
24.12000 H/L
55.01000 H/L
55.25000 H/L
28.72000 H/L
28.98000 H/L
67.90000 H/L
68.84000 H/L
63.77000 H/L
66.20000 HIL
34.36000 H/L
34.40000 H/L
65.26000 H/L
65.67000 H/L
Div: 0.55 Ex: 02/11/2004 Rec: 02/15/2004 Pay: 03/10/2004
400 GENERAL ELEC CO (369604103)
COM
NYSE
02/13/2004
02/17/2004
33.17000
3_~ .19000
Page 1
32.72000 H/L
32.93000 H/L
75.045000
65.092500
24.247500
55.397500
29.245000
68.782500
65.767500
34.700000
65.787500
33.002500
15,009.00
13,018.50
7,274.25
11,079.50
8,773.50
13,756.50
13,:53.50
10,410.00
6,578.75
55.00
13,201.00
This re?ort was produced with EstateVa1, a product of Zstate Valuations & Pricing Systems, I~c. If you have questions,
please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.0.0)
02/16/2004
02/16/2004
02/l8/2004
Date of Death:
Valuation Date:
Proc€5sing Date:
111
121
131
14)
15)
161
171
181
191
20)
8state of: Robert H. Smi~h
Account: 21262300
Report Type: Date of Death
Number of Securities: 20
File ID: 21262300
Shares
or Par
security
Description
LO;..r!Bid
Mean and/or oiv and lnt Security
Adjustments Accruals Value
High/AS~:
300 INTEL CORP (458140100)
COM
NASDAQ
02/13/2004
02/17/2004
31.19000
30.89000
29.86000 H/1
30.21000 H/L
Div: 0.04 Ex: 02/04/2004 Res: 02/07/2004 Pay: 03/01/2004
30.537500
9,161. 25
12.00
200 INTL PAPER CO (460146103)
COM
NYSE
02/13/2004 43.68000 42.92000 HIL
02/17/2004 43.89000 43.41000 H/1
43.475000 8,695.00
200 JOHNSON eTLS INC (4783661071
COM
NYSE
02/13/2004 59.93000 58.88000 H/L
02/17/2004 59.99000 59.30000 H/L
59.525000 11,905.00
400 MBNA CORP (55262L100)
COM
NYSE
02/13/2004 28.29000 27.6aOOe HI!...
02/17/2004 28.71000 28.06000 H/L
28.185000 11,274.00
300 NOKIA CORP (654902204)
SPONSORED ADR
NYSE
02/13/2004 22.59000 22.05000 H/L
02/17/2004 22.74000 22.49000 H/1
22.467500 6,740.25
400 PFIZER INC (7170811031
COM
NYSB
02/13/2004 37.79000 37.25800 H/1
02/17/2004 37.96000 37.60000 H/1
37.650000 15,060.00
Div: 0.17 Ex: 02/11/2004 Rec: 02/13/2004 pay: 03/05/2004 68.00
200 SEC COMMUNICATIONS INC (78387GI03)
COM
NYSE
02/13/2004
02/17/2004
25.75000
24.89000
24.80000 HIL
24.07000 H/L
24.877500
4,975.50
200 WAL MART STORES INC (931142103)
COM
NYSE
02/13/2004
02/17/2004
57.33000
57.84000
56.19000 H/L
56.48000 HIL
56.960000
11,392.00
400 WELLS FARGO & CO NEW (949746101)
COM
NYSE
02/13/2004
02/17/2004
57.85000
57.85000
57.06000 HIL
57.37:00':' H/L
oiv: 0.45 Ex: 02/04/2004 Re:::: 02/0612004 Pay: 03/01/2004
57.520000
23,008.00
180.00
440.926 FEDERATED EQUITY F~S (314172677)
KAUFMANN CL A
NASDAQ
02/13/2004
5.15000 Bid
5.150000
2,270.77
Pc.ge 2
This report was produced with EstateVal, a product of Estate Valuat:ons & Pricing Systems, Inc. If you have questions,
please contact EVP Systems at (8181 313-6300 or www.evpsys.com. (Revision 7.0.0)
Date of Death:
Valuation Date:
Processing Date:
02116/2004
02/16/2004
02/18/2004
Estate of: Robert H. Smith
Account: 21262300
Report Type: Date of Death
Number of Securities: 20
File 1D: 21262300
Total Value
Total Accrual
Total $217,051.27
$315.00
$216,736.27
Page 3
This repcrt was produced with EstateVal, a ?roduct of Estate Valuatio~s & pricing Systems, Inc. If you have questions,
please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.0.0)
"
'.
'-......,1'
AMENDMENT TO AMENDED AND
RESTATED REVOCABLE TRUST
This Amendment is made on this d day Ofr~ll.~003, by and
between ROBERT H. SMITH of Bucks County, Pennsylvania (hereinafter called "Settlor") and
MARILYN L. SMITH and UNION NATIONAL BANK AND TRUST COMPANY OF
SOUDERTON (hereinafter collectively called "Trustees").
WITNESSETH:
WHEREAS, on June 29, 1989, Settlor created a Revocable Trust which he subsequently
amended on July 25, 1991, and Amended and Restated on Aplil 3, 1998 (as amended and
restated, the "Amended and Restated Revocable Trust"); and
WHEREAS, Settlor desires to amend the Amended and Restated Revocable Trust by this
document; and
WHEREAS, under the terms of said Amended and Restated Revocable Trust, specifically
Article XIX, Settlor reserved the light to amend said Trust Agreement.
NOW, THEREFORE, Settlor, with the approval of the Trustees, hereby amends the
Amended and Restated Revocable Trust as follows:
1. Settlor hereby revokes Article ill, and substitutes the following:
"III. Dispositive Provisions - Upon Death of Settlor.
Upon the death of Settlor, if Settlor is not survived by his spouse, and if
the assets passing under his Will are insufficient to pay all or any paJi of the bequests set fOlih in
AIiicle FOURTH thereof, Settlor hereby gives and bequeaths the sum of FNE THOUSAND
DOLLARS ($5,000.00), or the portion thereof which is not satisfied with assets passing under
Settlor's Will to each of Settlor's grandchi]dr~n, including ANNE ELIZABETH ZAGORSKI,
LAURA MARIE ZAGORSKI,. and ANDREA MADEL YN HUNSBERGER, and any other
grandchildren Settlor may have, who survive him. If any grandchild of Settlor has not yet
attained the age of twenty-one (21) years then such bequests shall be held by the grandchild's
parent who is the child of Settlor, in some form of federally-insured investment, to be distributed
to the grandchild when he or she has attained the age of twenty-one (21) years. In the event that
the grandchild's parent who is the child of Settlor is not then living, Settlor's Trustee shall hold
said funds under the conditions of this Article III.
The general bequests in this Article III have also been made by Settlor's
spouse in a Revocable Trust created by him and/or in his Will. It is the joint intention of Settlor
and his spouse that said bequests be made by the survivor of the two of them so that, in the event
that they die simultaneously, these distributions should not be made from both of their trusts or
estates, but shall be made from the trust or estate which will derive the greatest death tax benefit
or split between their trusts or estates, if that is more beneficial. If the payment of these bequests
afford no greater benefit to one of their trusts or estates as opposed to the other, then payment
shall be made from Settlor's trust or estate."
2. Settlor hereby revokes Article N, and substitutes the following:
"IV. Dispositive Provisions - Specific Devise of Real Estate.
Upon the death of Settlor, if Settlor is not survived by his spouse, and if
this trust owns an interest in the real property located at 335 Clemens Road, Harleysville,
Pennsylvania, Settlor gives the interest in said property to his daughter, SHIRLEY ZAGORSKI,
2
as follows: Settlor's Trustees shall obtain an appraisal of the value of said property. Five
percent (5%) of the appraised value and the amount of any mortgage existing on said property
shall be subtracted from the appraised value to determine the "adjusted value". One-half (1/2) of
the adjusted value of the property shall be allocated to SHIRLEY ZAGORSKI's share of
Settlor's residuary estate passing under Article V hereof, whether the interest in said property
passes through this trust or under Settlor's WilL"
3. Settlor hereby revokes Article V and substitutes the following:
"V. Dispositive Provisions - Residuarv.
All the rest, residue and remainder of Settlor's estate shall be given to
Settlor's spouse, MARILYN L. SMITH, if she survives Settlor. If she does not survive Settlor,
the then remaining principal and undistributed income that passes under this Article V shall be
distributed equally to Settlor's children if they survive him; otherwise, to their issue per stirpes.
However, the share of SHIRLEY ZAGORSKI shall be distributed subject to the provisions of
Alticle IV of tl1.is Trust. If any child of Settlor's is not then living and has left no lineal
descendants then surviving, that cl1.ild's share shall be divided into two (2) or such smaller
number of equal shares so as to provide for the following distribution:
A. One (1) share to that child's husband, ifhe is then surviving, and if
he is not then surviving, this gift shall lapse.
B. One (I) share to Settlor's other child, if she is then surviving, and
if she is not then surviving, then to her issue, per stirpes, and in default thereof, to the contingent
beneficiaries named in Aliicle VII hereof."
4. Settlor hereby revokes Article VI and substitutes the following:
3
"VI. Disclaimer Trust. If Settlor's spouse, MARILYN L. SMITH, makes a
qualified disclaimer within the meaning of Section 2518 of the Internal Revenue Code of any
portion or all of the gift to her under Article V ofthis Trust, all of the property so disclaimed
shall be given, devised and bequeathed to Settlor's Trustee, IN TRUST, to be held, administered
and disposed of as follows:
A. During the lifetime of Settlor's said spouse:
1. All of the net income therefrom shall be paid to Settlor's said
spouse in montllly or other convenient installments.
2. As much of the principal of this trust may be invaded by Settlor's
Trustees (excluding Settlor's spouse), in their sole and absolute discretion, as they may, from
time to time, deem necessary for the maintenance and support of Settlor's spouse in the station of
life to which she is accustomed at the time of Settlor's death.
3. In the event that Settlor's spouse should, in the exclusive judgment
of Settlor's Trustees (excluding Settlor's spouse), become mentally or physically incapacitated,
Settlor's Trustees (excluding Settlor's spouse) are authorized, in tlleir exclusive discretion, to
expend from income or principal such sum or sums as may be necessary for Settlor's proper
care, maintenance and support, directly, without the intervention of a guardian or committee.
B. Upon the death of Settlor's spouse, the then remaining principal and any
undistributed income that passes under this Article VI shall be distributed according to Article V
of this Trust."
5. Settlor hereby revokes Article VII and substitutes the following:
4
"VII. Contingent Beneficiarv.
If Settlor is not survived by his spouse or any lineal descendants or any of his
sons-in-law, or if any trust created under this Trust Agreement should terminate by reason of the
death of the beneficiary thereof, and at the time of such termination, none of Settlor's lineal
descendants, or any sons-in-law are living, or if for any other reason any part ofthis Trust should
become available for distribution, then such principal and accumulated income shall be divided
into four. (4) or such smaller number of equal shares so as to provide for the following
distribution:
A. Two (2) shares to MESSIAH COLLEGE, located in Grantham,
Pennsylvania, to be added to the ROBERT H. and MARILYN L. SMITH Fund and such other
Funds that are in existence which were created by Settlor and Settlor's spouse during their
lifetimes, in the discretion of the College;
B. One (I) share to BRETHREN IN CHRIST FOUNDATION, located in
Grantham, Pelmsylvania, to be added to the ROBERT H. and MARILYN L. SMITH Pastoral
Training Fund and such other Funds that are in existence which were created by Settlor and
Settlor's spouse during their lifetimes, in the discretion of the Foundation;
C. One (1) share to BOARD FOR WORLD MISSIONS, located in
Grantham, Pemlsylvania, to be added to such Funds that are in existence which were created by
Settlor and Settlor's spouse during their lifetimes or, if there are no such Funds, then for the
general purposes of the organization."
6. Settlor hereby rev:okes ."..rticle VIII and substitutes the following:
5
,-
"VIII. Minor and/or Disabilitv. Unless otherwise provided herein, any income or
principal payable to any beneficiary who is a minor or who, in the sole judgment of the Trustees,
is mentally or physically incapacitated, shall be held in a separate trust by Trustees during such
minority or incapacity. Trustees are authorized, in their sole discretion, to expend from income
or principal such sum or sums as may be necessary for the proper comfort, care, maintenance and
support of such minor or incapacitated beneficiary, directly, without the intervention of a
guardian or committee, or Trustees may pay the same to any persons having care or control of
said beneficiary or with whom the beneficiary resides, without any duty on the part of the
Trustees to supervise or inquire into the application of the funds by any person to whom payment
is so made. Any income and principal not so expended by Trustees shall be retained by the
Trustees and paid to the beneficiary upon termination of the incapacity (including minority), or
to the estate of the beneficiary if he or she dies while still a minor or incapacitated, unless
otherwise provided herein. For purposes of this Trust, whenever the term "minor" or "minority"
is used, a person shall be deemed to have attained majority when such person reaches the age of
twenty-one (21) years and shall be deemed to be a minor so long as such person is under the age
of twenty-one (21) years, any statute now or hereafter in force to the contrary notwithstanding.
7. Settlor hereby revokes Paragraph A of Article XI and substitutes the following:
"A. All federal, state and other death taxes, and interest and penalties thereon,
which may be imposed or payable by reason of Settlor's death witl1 respect to any property
included in Settlor's estate for tax purposes, whether or not passing under this Trust Agreement
or Settlor's Will, shall be paid from the principal or corpus of the Disclaimer Trust established
under Article VI hereof without apportionment or right of reimbursement; provided, however,
6
.'
that no IRA proceeds or qualified retirement plan benefits shall be used to pay such taxes except
to the extent required by law or to the extent that there are no other assets available or remaining
to pay such taxes. In the event there are insufficient assets in the Disclaimer Trust to make such
payment, or there is no Disclaimer Trust, the full burden of such taxes wi!! fall on the Settlor's
residuary estate passing under Article V hereof without apportionment or right of
reimbursement. "
8. Settlor hereby revokes Paragraph J of Article XIII and substitutes the following:
"J. To borrow money from any source without liability on the part of the
lenders to see to the application thereof and to mortgage or pledge any property."
9. Settlor hereby revokes Paragraph N of Article XIII and substitutes the following:
"N. Trustees shall pay all of the expenses incurred in the administration of the
trusts created hereunder; however, no IRA proceeds or qualified retirement plan benefits shall be
used to pay expenses incurred with respect to the administration of any assets other than the said
IRA proceeds or qualified l"etirement plan benefits. Trustees shall allocate payment of such
expenses between income and principal in accordance with the Pennsylvania Probate Estates and
Fiduciaries Code; however, those expenses which are not clearly allocable to income or principal
shall be allocated by Trustees as they deem advisable in their sole discretion."
7
"
10. In all other respects, Settlor hereby ratifies and confitms the A1nended and
Restated Revocable TIUSt.
IN WITNESS WHEREOF, Settlor and TlUstees have hereunto set their hands and seals
the day and year aforesaid.
Witness:~1~
Witness: ~ 9 ~
Attest:
~
-; - ,. -' . rJff?ce./
Title of Officer
(CORPORATE SEAL)
SETTLOR:
4~k-,/~<,,:d)?1.j (SEAL)
ROBERT H. SMITH
TRUSTEES:
~~d.~
MARILYN L. SMITH
UNION NATIONAL BANK AND TRUST
COMPANY OF SOUDERTON
/1
.., /
,// --V /
B{~~~n;C:: ' ~~dA:iL:e_
/ //f.o{'.4T(~fA'6"Z-
Title of Office _ /
8
COMMONWEALTH OF PENNSYLVANIA:
S5
COUNTY OF MONTGOMERY
On this / -3 day of ~' , 2003, personally appeared
before me, a Notary Public in and for the above Couuty and Commonwealth, ROBERT H.
SMITH and MARILYN L. SMITH, who acknowledged that they executed the foregoing
instrument for the purposes therein contained.
IN WITNESS WHEREOF, I have hereuuto set my hand and official seal.
(E~~0-
- 'J
I NOTARIAL SEAL
MARY K. WARD, Notary Public
Upper Gwynedd Twp" Montgomery County
! My Canmi..ion E<pires Se~tember 5. 2005
~.-,- .
9
, .
COMMONWEALTH OF PENNSYLVANIA:
ss
COUNTY OF MONTGOMERY
On this J liD. day of J(H1LW,-~ ' 2003, before me, a Notary
Public in and for the above County and Commonwealth, personally appeared
LoVY'cdre. S, i?:>IA~hV'~, who acknowledged himself to be the
--TV-lASt- Dtf\ u V- of UNION NATIONAL BANK AND TRUST COMPANY
OF SOUDERTON, and that he, as such officer, being authorized to do so, executed the within
instrument for the purposes therein contained by signing the name of the Corporation by himself
as such officer.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
~l~~~rl1~
Notarial Seai
Kimberley A. Snyder, Notary Public
Souderton Boro, Montgomery County
My Commission Expires Mar. 7, 2005
Member, PennsylVaniaAssociationot Notaries
10
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
-_ IIDTICE DF INHERITANCE TAX
BUREAU OF INDIVlDUAif~,S;r::uf\ nt:,'!rr: Fir-APPRAISE"ENT, ALLOWANCE DR DISALLOWANCE
IIIHERITAIICE TAX DlVISmlt..___ '._: - .'" , ,,-- ,~, OF DEDUCTIONS AND ASSES~~ OF T'v
PO lOX 2ID681 ;~, ,;. ',_0'_,-,.",- ......" I _
HARRISBURG PA 17121~D6Dl' ,
'*'
REV-15~7 EX AFP (03-05)
CLERi( OF
OR;)L~A 'ore'
JOHN C ~~A~Y -
UNIVEST NATL BK I TR
PO BOX 64197
SOUDERTON PA 18964
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
04-25-2005
SMITH
02-16-2004
21 04-0475
CUMBERLAND
101
_t R_ltted
RIIBERT
H
7fH1C
>r-<.il.ftl
29 Ni I?: G I
. j,.<.,.,
MAKE CHECK PAYABLE AND REMIT PA~MENT TO:
REGISTER OF WILLS
CUMBERLAND CD COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ,
11r-"1!C,."ft.m.m~1.Wm!l!.!ft!'.!MWWIM!'t.'tW.IWllTftrar:.'lft:tWI_.W.............. ...
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF SMITH ROBERT H FILE NO. 21 04-0475 ACN 101 DATE ,04-25-2005
TAX RETURN liAS: I X J ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R_1 Eot.t. I_X. AJ
2. stock. ond Bonds I_I. BJ
'3. C10..1y Hold StocklPartnsrship Int.r..t I_I. CJ
.... Nort_sINot.s _h...1. ISchedu1. DJ
5. CashlB_ JIapodtsINisc. P.rsona1 Property I_I. EJ
6. Jointly _ pr_rty I_I. FJ
7. Transf.rs lSelwdul. 8)
8. Total As..ts
I J C_ED
III
12J
13J
I...J
15J
I6J
17]
.00
2.408.08
.00
.00
48.377.37
.00
450,985.23
18J
NOTE: T~ insure proper
eNdl t ~o your IM:CO\mt I
_it~... _ porUon
of thi-i fo.... with your
tax .......t.
,
SOl, 770.68
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. F.....-al _..."Ada. Costs""isc. Expan..s IS.....du1. HJ I9J
10. D...tslNort_ U...iUU.....Uans I_I. II I10J 17.559.54
11. Total IladucUon. I1ll ~7. 712 7'i
12. Net Va1us of Tax Return 112J 164,057.93
13. Charlt"'l."Bovarnaantal Baquast.; Non-.lectad 9113 Trust. ISchedul. J} 113} .00
1.... Net V.1us of Estat. S\Djact to Tax I1"'J ,64,057.93
NOTE: If an ........nt w.. i.su.d pr.viau51y, 1in.. 14, 15 and'ar 16, 17, 18 and 19 wi11
r8f1.ct figures 'thllt 1nc1uds the tat.l Of AY. returns a......d ta dllt..,
ASSESSMENT OF TAX: .
15. A_t of Uns 1... at Spousal rat. 115J 337,452.24 X 00 =
16. _t of Lins 1...tax...1. at UnaaUCx... A rat. 116J 126,605.69 X OCi5 =
17. _t of Uns 1'" .t Sibling rat. U7l .00 X 12 = I
18. _t of Uns 1'1 t_1. at Co1X.t.raUC1a.. Brat. 1181 .00 X 15 =---J
19. Principal Tax _ 1191: I
20,153.21
.00
5,697.26
.00
.00
5,697.26
DATE
05-13-2004
11-16-2004
_ER
CD003956
CD004644
INTEREST/PEN PAID I-J
236.84
.00
ANOUNT PAID
4,500.00
960.42
~
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
15,697.26
I .00
.00
.00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION DF ADDITIONAL INTEREST.
I IF TOTAL DUE IS LESS TIWI $1, NIl PAYIlENT IS REllUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRJ, YOU NAY BE DUE
A REFUND. SEE REVERSE SIDE DF THIS FORM FOR XNSTRUCTIONS. J