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HomeMy WebLinkAbout07-27-09J REV-1500 EX (D6-D5, PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Hamsburg, PA 17728-0601 15056051047 OFFICIAL USE ONLY INHERITANCE TAX RETURN • ^r-v~avrer onrer aurvrving Spouse's Information Below Spouse's Last Name °~"° , Spouse's Social Security Number Suffx Spouse's First Name MI ~.. ~, THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL IN APPROPRIATE OVALS BELOW REGISTER OF WILLS ~ 1. Original Return O 2. Supplemental Return O 4 O 3. Remainder Return (date of death . Limited Estate O 4a. Future Interest Compromise date of Prior to 12-13-82) ( O 5 O 6. Decedent Died Testate . Fetleral Estate Tax Retum Required death after 12-12-82) O (Attach Copy of Will) 7. Decetlent Maintained a Living Trust (Attach Copy of Trust) ~ 8. Total Number of Safe Deposit Boxes O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) CORRESPONDENT - THIS SECTION MUST BE COMPLETED, ALL CORRESPONDENCE AND CONFIDENTIAL TAX IN Name h ) FORMATION S 0 ULD BE DIRECTED T0: xiflT ~`~~~ en a ca ea 9=~. g = gpna t. ,n , g Daytime Telephone Number C ~~'E a .&- ~"' af 7 ` Firm Name (If Applicable) ? e =~-a,R>a>-a ' A ~ TW ~' 0/H49Q .8 4N1' 8etina •Max "~• t a u e A q...®~ 5x+~}oa~ y--~>..»p4,. REGISTER OF x `~ #an.da i~ ¢tx<!~ a S =a A a - ~ I ~ ~ ~ + ~ WILLS LY . xx /~g A U N First line of address s.f'. e V a`" a ~•" ~:_~ ~ Cp o ~ C a ~~ _i!!`a~~,~ a~+a ~4~~xv~xR~Dxax-aa~cs gasi a rJ~ C. i na y q N SSE .~ io a ,._. .ean.o a`!-n».9as>a$ :=~a.a.i.,.a r = 3 G 1~~~ Second Ilne of address a a~'w•..S ~ p M a~ -Cl7X '•~ i 5 §ad$'y.{xg :a „a, a .nt. .... ~aa,~ iadxx +.Fa~.sa:4...+~a =dxe•: ~,: : t I ~ r ~(~-I-1 ~ -i City or Past Office a=•»a, 4»aeI -~C- ~ "'"' °~" R°' a a •~ ~ > State ZIP Code E FILED ~ '~ ~Cx~H~!'}~Ns/~CiSg~uq~R~G~ ;'~•<.,, ~~~~.~ ~ ;7~Di ~ti~. ~, Correspondent's a-mail address:_ ~e.S/J~eIdSJ (yJ L-om CQ~t ~I eG Under penalties of perjury, I tleclare that I hav a amined this return, Including accompanying schetlules and statements, and to the best of my knowledge antl belief, it is true, correct antl complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSO~ESPON$IgLE FOR FILING RETURN X ~`Cr1`-M.~~.c DATE uuRESS KO$FRT ~ E/I'MES 6 S.Z OI d G rD ve Road, Mechanlcsbu-y, /~q ~7aSs SIGNATU F PR RER ETHER T i Rl?P ENTATIVE X ~ ~~ DATE ADDRESS ~~/Ii~I` E SN~tzrOS~ ~~GGLLGG..~~ ~Esq• (o C/o user ~?oad /h~CtiQgiPSdar~. /Did /7oss~ PLEASE USE ORIGINAL FORM ONLY L Side 1 15056051047 15056051047 15056052048 REV-1500 EX Decedent's Social Security Number t k.~N DELI K• :'. ~o ~ ~a 4' (n t;'. !~~ 17 3 Decedent's Name'. ~~~~`~~ RECAPITULATION ~ - Qf O's x~ ~ -, ....... 1 t ,, ,.;, .., . 1. Real estate (Schedule A) ... ......... ......... ~Qf .. 2 v~ ~iEr ~. 2. Stocks and Bonds (Schedule B) .. " " ~ ~ " ~ ~ ", ~ ~ ~ ~ ' " " ~ ' ~ ' ~ " ~ " ~ '~ Q+O r; 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... ~+~ *; a _. ~ Q ~ •~ 4. Mortgages & Notes Receivable (Schedule D) " . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ " ~ ~ ~ ' " ~ ~ ~ 6+40 ~ ~~Q~`~ 5 e; .a~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .. ~ ~ " A 8 O ~; 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... 6 r a,%•~: OjO; 7. Inter-Vivos Transfers & Miscellaneous NO Sepa ester Bilfng Requested...... 7 » d ~. , ;,,_,*, w ~ s jY<<: t. (Schedule G) a GY, `a Qr D~r© ' ... 8 ors-". 8 Total Gross Assets (total Lines 1 7) ~ ~ ~.9 ~~ p g0 • 9 # .,. 9. Funeral Expenses & Administrative Costs (Schedule H) ... ~ " ~ ~ ']* 1~" y,*~ Z3 ~ , ..... 10 .`; >, x8 et8+"R °d2d.°#=.'I ~+ ~"pif~~~f;~ far•~~t+ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)... _ • ,~ Ir ~' P y{' 11 , .... .~t2Fa des "1 rP ~~ ~F ~;~ 11. Total Deductions (total Lines 9 & 10 " O 12. Net Value of Estate (Line 8 minus Line 11) . ~ ~ ~ ~ ~ ~ " ~ ~ ~ ~ ~ ,~ q.~a + +. ` „g O 13. Charitable and Governmental BequestslSec 9113 Trusts for which 13 °yv x,+j A+g4 ¢ g~ J~x~*~ ~~~~C~19{ an election to tax has not been made (Schedule J) ~ ~ ~ ~ ' ~ ' '~ Q~ C . 14. ', . a k..ei r 14 Net Value Subject to Tax (Line 12 minus Line 13) TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15. (a)(1.2) X .OQ_ 16. Amount of Line 14 taxable 16. at lineal rate X .0 ~ 17. Amount of Line 14 taxable 17. al sibling rate X .12 18. Amount of Line 14 taxable 1g, at collateral rate X .t5 ............... 19. 19. TAX DUE ........................................... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~~/Z~ ~~~/ " Side 2 L 15~56~52048 15056052048 O REV-1500 EX Page 3 Decedent's Complete Address: File Number pZ.~~Q~-/y68 - R.~NDEt~ K, FfF!r/E$ STREET ADDRESS - - ~O .T YS CEQ/¢/N/GS --_- __-- clrv - //7 F. /lf~/A/ ST --- ~~GY.~a~csBu~2~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments AS pousal Poverty Credit B. Prior Payments _ p - - - - --- _____ C. Discount - - ~ - - -- - - - - -. - p ---- - - InteresUPenalty if applicable -- ---_ --_ D. Interest E. Penalty - _. ~ - - - - -. - - - _. - _. _..- -_ O -- - - -- STATE --- -- - - P.f (1) Total Credits (A + B + C) (2) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. Thisis the OVERPAYMENT.tal InteresUPenalty (D + E) 3 Fill in oval on Page 2, Line 20 to request a refund. ( ) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (4) A. Enter the interest on the tax due. (5) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (56) intake yCheck Payable to: REGISTER OF WILLS, AGENT O O O O O 0 r~ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN4THE pAPPROPRIATE~BLOCKS i. Did decedent make a transfer and: a. retain the use or income of the property transferred : Yes No ............... b. retain the right to designate who shall use the property transferred or its incom ~ e :............. ....................... 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 d ....... ^ , , ecedent 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 A ...... ^ ...... ccount, annuity, or other non-probate property which contains a beneficiary designation? ...............__. -_ ............................. ........................................... U IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ~~?~~~~1~~4~~S~a~~"a~a~ias~tg~,~~aai~~~'~~i~~is~~~it~~":e4~~3t'~~°~~~'t~~~i"~~~~4`~~$~~ia~;~,~~~~;tR~~4~4~&`~~a~~~~",~~"~~a~~ailtiaiq~t~°`~ x For dates of death on or after July 1 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of~the su~rv v ng spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ziP - - / 7o ss- REK150E E%•.119)1 SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC, INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY :STATE OF ~~4M~'$~ ~~f~E[[ K FILE NUMBER Include the proceeds of litigation and the date fhe proceeds were received by the estate. All property jointly~owned with the dght of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE ~ OF DEATH 19`jD LINCOLN SemA~,V, v/N yL~vcmB]tSt-Y8/3ool $oLD lo CLIFToA/ L, SrnrfH ~ ~ (SEE S~[Q L~DCKn/ENTS ~ TT/f (~~) SSO. DD ~ IIJPo ~uKPoS~s: PNe B~9~uC A.ceT. Ala. SoC~ 13Z 8~S f~iFS ov~~a2Rw,/, SEF ~Nray o.V sGyecD S, a P.~H /~ lr/~LG~'T / s a0 ~`s o 0 ,~ /NFo MoTF% DES ,Q~7-~ ,¢ 2opM AT Jo Ys CE?AS/N/C t /17 F. /itA~/N ST, , /KEG~yi¢iV/CSBKip6. .¢ee~0iN6tf; Nis ~E2~rc,v,Sc.-ry /~.qs v~ey /~ir~,eF. _ TOTAL (Also enter on line 5 Recapitulation) 15 a-6 ~ 0 0 is needed Insert addlbonal sheets of the same size) No 2923352 A. PA TIi wa w ~I v' a U VEHIC >p L B. w LA m CO SEL F f u a N u n `n N a 2 U n n E ~° U~ xAq > i- Rc U PLATE TO BE ISSUED Bl' DEPARTMENT (PROOF OF INSURANCE MUST SE ATTACHED.) O EXCHANGE PLATE TO BE SSUED BY DEPARTMENT EMPORARY PLATE ISSUED p z BY FULL AGENT O _ O ¢ ._. _. ~« HHA1254 arc 85578 ,.~..._ - _. - ill F a~°~~,~~n3 ~-:5 TAME PA DVPHOTO IDp GATE OF BIRTI COUNTV CODE ~a_ I/~ a ~ 4 I ~ ~ REFER TO COUNTY CODES LISTING ON REVERSE SIDE OF YELLOW COPY VAE PA DVPHOTO IDq GATE OF BIRTH OR SUS. IDp ME pq DVPHOTO IOp DATE OF BIRTH I I COUNTY CODE ~ O GOOD O FAIR TRANSFER OF PREVIOUSLY ISSUED PLATE TRANSFER 8 RENE WAL OF PLATE TRANSFER S REPLACEMENT OF PLATE TRANSFER OF PLATE 8 REPLACEMENT OF STICKER SIRES Month Vear H: JHABE PRICE ///~~~ Kale on Reverse) `/~O! n cc++.. CABLE AMOUNT \/['r~/^~ SALES TAX OUE (see Nwa on geverea). t 1. !E%EMPTIO& iASONCOOE{moat e numbeFlrom }LO 0r0) TOLE FEE LIEN FEE REGISTRATION OR ~'J/ _n~ tOCES3ING FEE 'S !E E%EMPT NUMBER (ASSIGNED BY THE PARTMENT DUPLICATE REG E NO. OF ~~ o COUNTY CODES ON REVERSE SIDE S. TRANSFER FEE ~~ INCREASE FEE I ~- REPLACEMENT FEFI .~~ a POOR TOTAL PAIp (ADD 1 THRU B) S. 10 1 ~ 5'~ tt. GRAND TOTAL (ADDS 810) . SEND ONE CHECK IN OSON FOR REPLACMENT ~ THIS AMOUNT "'> I~ O LOST a DEFACED NOTE: 11'NEVER RECEIVED" blo k i O STOLEN osl in a E c s cbecketl, appllwnl mur l cpmpb eFO m MV-0q~ ISSUING I HAVE CHECKED TO DETERMINE HA THE VEHICLE~I8~1)N@IyRED ANO S G NI I MEI II I~ /~^ ) GATE / AGENT ISSUED TEMPORgRY REGISTRATION TO THE ABOVE APPLIC NT, IN U n ~.ll ~ `p' ,p qG 7 (Xy INFORMATION COMPLIANCE WITH ALL APPUCgBLE PgOVIS10NS OF THE VEHICLE ISSUING AGENT IGNATURE ' °-'I` ~ • V CODE AND DEPARTMENT REGULATIONS. ELEP NE 0 G' INJE CERTIFY THAI LANE HAVE EXAMINED AND SIGNED THIS FORM AFTER ITS COMPLETION qND THAT THE INFORMATION GIVEN IS TRVE qND CORRECT IF gNY~XEM~~ IS CIAIMOEp! PURCHASER FURTHER CERTIFIES THAT HE/SHE IS AUTHORIZED TO CLAIM THIB EXEMPTION. IIWE ACKNOWLEDGE THAT LANE MAY LOSE MY/OUR OPERgTING PRWILEGES(S) Oq VEH REGISTRATION(S) FOR FAILURE TO MAINTgIN FINANCIAL RESPONSIBILITY ON THE CURRENTLY REGISTERED VEHICLE FOR THE PERIOD OF REGISTRATION. IANF. ACKNOWLEDGE THgT LANE ~ BE SUBJECT TOA FINE NOi EXCEEOING$S.OpO qND IMPRISONMENT OF NOT MORE THAN TWO ~ qR3 FOR ANY FALSE STATEMENT THAT IhVE MAKE ON THIS FORM. U 1ST SgneNra of Frsl Purchaser or AUllprizetl Signer ASSIGN- /~ Telephone No. w MENi SigneWre ofCO-PU¢beaer/illk of AUlhorizetl Signer U ( ) END SignaWre of Becontl Purchaser or Aemonzeh Signer ASSIGN MENT ignaWrea o- urmaser Ills of Ihorize Telephone NO. goer ( ) H.Q o NOTE: IFACO~PURCHASER OTHER THAN YOUR SPOUSE IS LISTEDAND YOU WANT THE TITLE TO BE LISTEDAS'JOINT TENANTS WITH RIGHT OF SURVIVORSHIP'(ON DEATH OF ONE OWN p .Wi G TITLE GOES TO SURVIVING OWNER.) CHECK HERE O. OTHERWISE, THE TITLE WILL BE ISSUED g5'TENANTS IN COMMON' ION DEATH OF ONE OWNER, INTEREST OF DECEASED OWN ~ I- ~ GOES TO HISIHER HEIRS OR ESTATE.) 2 C ~ LO NOTE. IF THE VEHICLE IS TO BE USED ASA DAILY RENTAL OR LEASED VEHICLE, CHECK THIS BLOCK O. IF BLOCK IS CHECKED. COMPLETE AND ATTACH FORM MV-1L. ~ i SI C_ERTIFLCATE OF TITLE FOR A YEFi1CLE I -.~~~~~. ne~unr I GVWR ~ .••.::.,..: GCWR :.::c:ll • TITLE BggN06 ODOMETEq BFgiU6 O. gCTUAUMILEApE ~~ 1=MILEApE E%CEE091ryEMEGNrypgL 4'Y LIMITS R~=NOT'THE gCFUAL MILEAgE ' -- u'~' ~ ~ , 9. NpT THE gCTUgL MIEEAOEOWMETEq :' RBQISTEgED OWNEq(3) . ' -TgMFEPINp.VEflIFIEO ' '0=E%EMFTFgOM DOIXgETEgDI6CLO6UflE „ ` L ~ ;R~Dtp+E:L ' EAMES a =Arms E~vEHIC"L u"~;'r'E MA Z.N;S`T a.cueelD V6wcLE D .:LOLLP.CTIBLF VEHH:LE ' ?M'EC?IIA'NTCS'BURG R P -ouroFCOUNmr -O •OgIOINgLLY A MFpD Fpq:NDN~D$ .DI6Tg1aUgON - H dgpPJOVLTUgFL VEHICLE ' L . LCppINp VEHNXF F . I6Nlg6.q PoLICE VEHICLE q • flECCN6igUCTEO~ . ~ ~ ~ ` ` 9 ..aigEET qOD ~ ' ' T =gECpVEgEO THEFT'tVEXICIE FIg6T:416N FAVOROF' v=Y6HICt6 LONigtl6pF196UEpbN f W=FLWOVEHICLE 6ECOND LIEN FAVOP pF. % •d6Mw6 q TA%I ' 5`1'' ' 2 k j ~ ~~ x-` Fm3j'OEI~g6LEA560 -Ile eecolM bMOW 1 Il61ed upon II led on DI the Xml Ilan 0e Xrot II rMOkel moat IoM m,lluc Title to ,the Buroeu ol'.Mwo +e V x=~~ DATE ~ r anwlee w11X 4he ppn>prlele lwm enOlee. BV :AUTHOgIZEO REPgE6ENTATrvE MAILING;A6Dg6 SECOND LIEN gELEASED Sg _ ~ . , .:. - oars , OOOA00 pY R'ANDELL K C EA M E., AUTHDRIZED gEPRESENTATIVE _59 £ MAIN ST ME.CIIANICSBURG PA ] 905 q S'!'deXlN..e of me dale m McNe Ina onmei rosoms pl Ina PenmylvenM Depenmenr RLLEN .. : I Tro .ppXelbn moan IoM Ihn Pemonlel w wmpeny gamed oar. d m m :dl N geld D D I EH L E R MI L N . v p . o wl I u owner I' ' ~ ~ I ~ t , 6ecremrr or T}pgB1prlatiou ' t ( 1 • BUB6CRISED ANDr WORN tOIB6POR~l E: Rapp Pprchasar ether than your s o I _ r r ~ O _. p uaB s Ilstetl entl 'Da Iletatlpea ',lolnt Tenenta Wllh gl ht L 1 ( l Cr v q g D SUrvivprahlp On tlaq hepf,. nne . :oaurvlYing awns[.) CHECK HE ~ E O ll ~ l ~ . :wl R ,I be lse us tl es Of~amTep,4'Itae Q4B - Tenants In Common" (pn tleelh l ~ I o ;onp owner,:Intere64of ' tleceeeed owner gees to hla/hei heirs pr estate) FIST LIEN GATE: ~ IF.NO LIEN CHECK ~ F~ p ,1 ~ '~•B•Smlth`Ford-LIO "" Ix M . I6i UENHOLDEP C- ~p err InT O 1 ~ :C9~ S7SLB 6TREET (~ ~ W ~ ~~ M W Q W ~ ^ CITY - ----~~ 6TATE Zlp T ~j (~ V ' ^ ` IF THI6IS AN EIT, CHECK HEgE ^ NOTE: FIN gEOUIREG FINANCIAL ' 11 TM INSTITUTION NO. Wdpn•a Mnev wMa eppNykn omnu xe .exMe a.rcoe e6w ~ Mlvl o 2ND LIEN DATE: ~ IF NO LIEN ewl M . on ee Q , CHECK 1~ -2ND LIENHOLOEq. 'I' ~ T STREET / F"~ CITY -~~. ~ Sro gEnf co.ppglgNTmiLe OCeuilpgFEO 9lorveq STATE ZIP IF THI616 qN ELT. CMECY. HEgE gNgNCIAL t NO ^ TE: FIN REQUIRED INSTITUTION NO •~ _ . _ _ _ , , A • • • • • 1 ~gilnrl TYPE OR PRINT)pRINT) Cert na mH.a ASSIGNMENT OF TITLE - ea ~°~a"na;;~';"x", o,,,, - UWe cemly 1 me bem of mw `x I apramPl mn nepmemr rasa ng J-'.~ ~ ~ ~.1 TK~Tles en0lellecls lM1e acluel Tleape OI IIIP Vahlel¢. pnless one PI IhP IMlowing hoxea a checkatl'. Ls NOT the acluel mileee¢. ^ R¢Ileols Ibe Pmowl of mlleapa v^ o^'ll. J~ WggNING'. Otlomemr tlle0repl cl ev.0ss Ol lie mechwllcel Hmlls mnbrance antl Nal lho ownenhlp is h p_.B-Smith Ford_Linc-Mere inc. -~ ~= ~ /Wp IIIIY 10 1110 0901 0 Y:iE i5 v f' '~ x miles antl ~allecls Ne duel mAOepe of ilia veM1lcle. unless Ona 011hP 1011 wile oozes is cheMert ~ Is NOT the aduel mlleay0 Helleda me emoum nl mll0egc v^'mnrmWe gNING10tlOmeler tll9oeepl In axc0ae of lla lnechnnicel limns antl that the Ownemhlp.ls h TO BEFORE MEND SWORN MHt I F\/ : ~ ^ miles antl re11ec151110 actual mlleapa BI Ile Ve111clei unless one of the lollowing boxes m chech¢0. Is NOT Ina Bcuml mlleapa rl Relleds Irye am0unl bl mlleeye iL J IyggNING: Gtlomelm tlieaepl u in nl 1 h 01'Imlls -s ry i n nl nmrnt<n nbrencL antl lh011h0 awnom1111 TO eEFOREMEND SWORN X~mXea PnU rellecls the acluel mileage Ol llm verylcle. s checcYntl. mess the purchaser is a registered tleeler bottling the vehicle IDr resale. ?~ E THE MILEAOEIN CONNECTION WITH THE TRANSFER OF OWNERSHIP. FAIW RE _. IAV RESULT IN FINES OR I~MPPIRONMENi'. FIRST MIDDLE NAME t' L G ~, ~~T C' j ~ ~f-~-e~ r~ s°. ~ ~ I~ LO~PURf.HP9EP ~ '~ DI 6TREEi ~. lA ADDPE96 r ~J t` 1 ` LRy ~~ PUPCMABE PRICE ~. ~ STATE 21P OR DIN ~~~. p.. m / -' Ci m N I m CO~PUPLHA6ER 61pNATURF / I u PURCHA6ER ANDIOF ~ ~- ~ rZ ~~ ~ CO~PURCHASER MUST m q OP INT1 Al E r ~ ~ ~ ~ '~//~/q/~ ,/ I =_ __ _ - N 0. eo $IONATURE OF CO6 EP I p SELLER AND/OR L~ GS'. ) ~ C0~9ELLEP MUST 1n HANDPRINT NAME HERE C V C1r N • r, LAST ' FIRST MIDDLE NAME ~ N PURCNABER OP FULL ____ -FS$ N M r CO~PIIRCHASEP ~ fiTREET ~ ' gDOPE55 U' - clrv --- -- a PURCHASE PPICE ,rrPTe nP __ on mrv ____ n 4 0 PURCHA6ER 61DNPTURE -'- ~ CO~PUPCH E 91 NATUP[ PUPGHP6EP ANDIOq - CO~PURCHMSER MUST __ _ NA DP INTNAME ERE 91GNATU~ ~ ~ I V. SELLER MUST HANOPPINTNAME HERE ¢ C • m FIgST MIDDLE NAME U' LAST ~' m PURCHA6ER OR FDLL ~~--- BUSINE69 NMIE I LO~UPCNASEP -- ~ -_ R %Y I STPEET -- -- r- Ibyi ADDPE59 --- n. cm__-_ PuBDHns'e m!¢:E ~~' 9TATF zm ~oR UI_ _ PIIPDINEERAIBNA URE ~ R- CE 1910NniUP'- _ p' PURCHASER ANOIOH "~ CO~PURCHASER MUST _ -- c HA P IPTIAI ~ BBNANRE Of E LEIt --~ $ELLEBMUST ~~ HANDPRINT NAME HERE _ tD LAST FIRST MIDDLE NAME m. PURLHA9ER OR FULL -__ _ - ---- C~ BUBINES6 NAME _- e 01 Ilia lollowing boxes LO~PUPOHASEP - ~, Is NOT Ibe Bd081 mAeege. 9' aflHelleCls llreemWnlNmllaOpe r WggNING'. Utl0mBI01 tlI0G0ponry fiTgEET ------ -; An BxceOS of lla mecnenlcel limbs L- P,is --- pj tlber cetllly lM1el lbe VebMle ie tree of any encbmOmnce eW lbm ins rwnerslli boreby ADDRE95 -- -- -- rtetl to Ih0 personls) or IM1e Oe01er 1181etl. CRY j --~~ PIIPCHASE PNIC[ TO B FORE MEND SWORN iF FOR STATE EIP D. TITLING FEES 5 nw-as ~~-s~~ CanBWMalearN RuaNpaewa- _. erParNw+a aAd ~par h'an Baawu el.reoarrTiNtAUy ama'hae~suen Rarthnre0.`PA IIIOA tst6 NOTIFICATION OF A851GNMENT/CORRECTION OF VEHICLE TITLE UPON DEATH OF OWNER Pbun rwd.ALL Inlormedon on reveres elde before completing lorm. Va`xclo '~' FOq BUgEAU UeE nNtY ~, Rpnfrazron mnim I ^ Owwtership is being traruslerred to or by Surviving Spouse -who is co-owner. 2. ^ Oxnership is being transferred to or fry a Joint Tenant with right of survivorship. 8. ^ , Uvnersflip is fxaipg trensterted to or by SVM11VIng ~$()pabe - Wh015 not Co-owner HERS-:Uet name, Ngneture (Pert Y only), adtli lAWE1S) le!'hdn r9^eV+iucMOlirb a. ^ Ownership is being titled in the estase. 5 ^ Ownership is being translened to or by aY heirs. Ltst all heirs in Section D. 5. ^ Ownership is being Vanslerred W or.by surviving spouse a adult child(ren) to whom vehide is givenbY decedent's will wNrh is not to be probated. rhfp and ape o1 Wf frofre. (In conjuncyon with Aulgnment W Tltb) ACCRF55 RE~ATxlwatlla AGE '1 (!VE) oettifydtal I (4VE), together with the above person(s) who have ezecutetl the assignment block on iho tills mnednrta al gldae heks of:tlae deeBdent:entl hereby jdin in the transfer o1 ow7rerahip of the above descdbad vehige m the person(s) indicated in L7e assiplman! do~c on the title. hA.YC(57 he+b rctrprsnp settee 911e b GYA"aRE i X _ I nueFi`SS flEU710N&4.W AGE X X A~ Mdzs wr f:0YM19aAnN ExNgATpN OATF - ~-+..n - ta;rrocx one) ueath Cerdhcate r 1, Certilicate,ol Death (must be aaeched) 2. ^ Certificate of Death hom pepanmenl of Dofensa (must be attached) InaUM.~ roar Coarny Poxr I.wo almwnxopn chat 4NM rr?AY~6 ^Y:w. Warm xWa4arr lxran:W raeVOrebary anlMWrrea! hWM'+WVn or rW:lalu regalrrwrru brraaare ra N'a9~ero0 xaN•Je la rho oxoE o! rePrgemion. Owner Slpn I:ro X s o' X AFFIDAVIT OF PA17Ai3~T DEBTS 1 horeby state under oath that all debts of dae decedent have lasso Paid 59wue of •un+ve0 aCavae w rlwl My r~ r.v. ~ www rs competed by aaendnp physician or funeral diactor. 3. ^ I Cen !y that dad on _. rye d Deceacrn bignaun d goenarg Rrpia,en or F Wwrl LYieaw RMr ksro xzaOlY as it aWe~r: ~e rerpnona hanCer ! Cekx]'.Kansx Nr.~pal D:wa u~snco N~rmor MESSENGER NO. REV-1311 EX+(1p-gg) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ^_ - RESIDENT DECEDENT Debts of decedent must be reportetl on Schedule I. g SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS A. FUNERAL EXPENSES: utJCRIP710N 1 HoLG/N6t71 FuN~~,gG NolmE .R-iYD CRE/.Y~Tif.¢y ai-o~_66$ 02, aS9. °O S. ADMINISTRATIVE COSTS: 1 ~ Personal Representative's Commissions Name of Personal Representative(s) ~ZO/,3~,'j ~. ~~~~ Social Security Number(s)/EIN Number of Personal Representative(s) Street Atldress (v SZ OLD G,p1,yF /~~D city MECNi¢N/CSF.~6(,p(, State/"19' Zip /70SS Year(s) Commission Paid: '------ 2. Attorney Fees CHI ~(F$' E, s y~~. ~Q. 3. Family Exemption: (II decedent's address is not the same as claimant's, attach explanation) Claimant /j/p O,{/F E'L!G'//jLE Street Address City State _ Zip Relationship of Claimant to Decedent ~-- 4. Probate Fees qw/ origigal i SSGt ~ ~~ Cerl'il~cafes S. Accountant's Fees 8. Tax Return Preparer's Fees /~rlvertrsin~ lM Cu.rwb~~ ja,, Tnu,rwal t, ~faert;s,',,J n; Carl;s/c ~enf;nel 9, Filinq Fce ~O /re~isfG' 6f Wi//f /o, g¢1mbu,-semc,~!- ~ Ck«rl~s F Shr r- PoS~, Cerf;~,ed Ma;lin~s,~, (cs~.)Ilt ~~ 'Oleofoeop,ts, TOTAL (Also enter ~~ rye o r,_ to more space is neetled, insert additional sheets of the same size) Go/¢~V~ P ,555, 78 NoNt~' X57, oD X75, op '// 8', 72 f/S, 00 '°a~ ~ pitulation) ~ $ Dtf, 00 REVa$12 E%a (72.03) ES7AT COMMONWEALTH DF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, includin FILE NUMBER .ZI- o p -G I:~ iEM MBER g unreimbursed medical expenses. DESCRIPTION VALUE AT DATE PNC ~yFeK~nrc ~r"T No. 5'00; /~~ ~~ S~ ~~,~~~ ~ OF DEAiH (sct affiEra/ /e/1`er of P.uc ~~t,(' ~ S/, // ~~~~ ~. G'audenz~a , Gdcst Shore of eoMmon Re.' F,'nes, V~esf~h,,{7os1,eT. C -2I-CR-ooo3 la y- zr~os, C'nmm. u. Eames TOTAL (Also enter on line 10, Recapitulation) $ q (If more space is needed, insert additional sheets of the same size) ~, R y~. a/ ~~ t.eaetec the war August 22, 2008 Charles E Shields Attorney at Law 6 Clouser Rd Mechanicsburg Pq 17055 RE: Raudel] K Eames SSN: 202-46-6173 DOD: 03-15-2008 Dear Mr. Shields: N!. )~41 f, In response to your request for Date of Death (DOD) balances for the customer noted shove, our records show the following; Checking Account Account # 5005132865 RANDELL K EAM$S Established; 04-09-2007 DOD balance; $ _.gl.]] + 0.00 accrued interest '''t'his account had a negative balance at the time of death. please t7ote that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking and Savings), We do not process any t3nanc;al transactions or provide statements, )f you need assistance with any of these items, please call J-888-pNt;.gANK (1-8$8-762-2265) or stop by your local PNC $ank branch office. Sincerely, National FiuauciaJ Services Center PNC Bank, N.A. Member FDIC REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX gETURN RESIDENT DECEDENT NUMBER I a. ~.4/riFS, ~~fNDE2L ,K NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers untler Sec. 9176 (a) (1.2)1 T inn n1arya N ~¢ ~°73 Attcd Ce>'al ~lQnad .~lir'pPens6u.~, P.f i7as7 Phy//:s ~T. /ftarfn ~'/ ~'ndePendcece d~7rr've •Sti;~j~easda,q, ~J,¢ i92s7 65a O/d Grave iQQ! /j9eCh~niCSdkr~, ~I,f /7°s5' rat NUMBER -~~ a~-o~ -G6 ~ ATIONSHIP TO DECEDEM Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE SiSfer y3 ~ 2.a_rp Sister ~ro~ Y.~ h.e¢ zzro r3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, 0 I REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 7. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART 71 _ ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE to nr or„ ..,.,. more space is needed, insect additional sheets of the same SCHEDULE J BENEFICIARIES .,vvtn JNEET ~ $ o ~~ ~ a ~ J ~ a - ~-• ~ ~ a £ ~ O W ° ~o a W a ±"t~-.a ~ ~ "~ C c ~ m -~ ~¢ //~ N O O Q m V~ ~ N } ~ N _= LL N Q°' m~E ~ ~ ~ M ~zC7M UINUc~i J JO~O a J N~:= ~ ~ LL~~ ~ ~n - d ~ J = ~ W ^ F-W~y Ii ~ LL Q ~ m ~ J ~ W~oQ- N o w ¢U,-V w o, o =¢m ~~~ O ~ w f. ~ ~~a Q . ~~~ y CHARLES E. SHIELDS, HI ATTORNEY-AT--LAW GEORGE M.HOUCK (1912-1991) 6 CLOUSER ROAD Corner of Trindle and Clouser Roads MECHANICSBURG, PA 17055 TELEPHONE (717) 766-0209 FAX (717) 795-7473 July 23, 2009 Register of Wills Cumberland County Court House 1 Courthouse Squaze Carlisle, PA 17013 Deaz Register of Wills: Re: Estate of Randell K. Eames No. 21-08-0668 Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Randell K. Eames Estate as well as Check No. 1996, in the amount of $15.00 for the filing fee. Thank you for your kind attention to this matter. Very truly yours, Charles E. Shields, III Attorney-At-Law CES/mjj Enclosures h~ ~9 O Q ~p ~)~^ ~ ' Y .~,arn tV ~:: ~.ri `>~ ~ - ,c- } --- '.