Loading...
HomeMy WebLinkAbout08-07-09 15056177120 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN a PO BOX.280601 2 1 ~ / /~7 ~3 Harrisburg, PA 17128-0601 RESIDENT DECEDENT V ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 578 56 1530 12 25 2006 04 11 1935 Decedent's Last Name FLEMING Suffix Decedent's First Name GERTRUDE (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name FLEMING ROBERT Spouse's Social Security Number Firm Name (If Applicable) WEIGLE & ASSOCIATES, P.C. THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 4a. Future Interest Compromise (data of death after 12-12-82) ~ Decedent Maintained a Living Trust (Attach Copy of Trust) MI F MI E f I 3, Remainder Return (date of death prior to 12-13-82) J 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received 1 p. Spousal Poverty Credit ((date of death 11 _ Election to tax under Sec. 9113(A) ^ between 12-31-91 and i-1-95) -- (Attach SCh. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JERRY A. WEIGLE ESQUIRE 717 532 7388 FILL IN APPROPRIATE OVALS BELOW X , 1. Original Retum 4. Limited Estate g Decedent Died Testate (Attach Copy of wll) First line of address 126 EAST KING STREET Second line of address City or Post Office State Z1P Code SHIPPENSBURG PA 17257 r•~a ~ ~- REGISTER~'r~VyILLS U ~ONLY"~" x7 j `= ~:_ ,- ,--~ '7 - =iTI - I " . ~ -..1 ;;~ - A { N _ D/i~E FILED ~ .,~ _~ s;;~ .t Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on atl information of which preparer has any knowledge. V1 ,,RL~-~-p ~ ,~' V"V~ 1 ""v „"V ,", Christopher P. Swann `7 / ~ ldc~ ADDRESS y ~ 1 Gardenia Street, Eldersbu~ , M D 217 $ N NAT RE O PREPARER OTHER THAN RE RE N ATIV DATE Jerry A. Weigle Esquire DDRE 126 East King Street, Shippensburg A 17257 1505607120 Side 1 15g5617712~ J~ 1505607220 REV-1500 EX oecedent'sName: Gertrude F. Fleming _- _ __ _ _ RECAPITULATION 1. Real Estate (Schedule A) ............................................................_....................... .. 1. 2. Stocks and Bonds (Schedule B) ..............................._..,.........................._............ . 2. 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. 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. g. Total Gross Assets (total Lines 1-7) ............................._.._...........................__.... . g. 9. Funeral Expenses & Administrative Costs (Schedule H) ..................................... . 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................ .... 10. 11. Total Deductions (total Lines 9 & 10) ..............................__................................ . 11. 12. Net Value of Estate (Line 8 minus Line 11) .............................._.......................... ... 12. 13, Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................. . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................ .. 14. - --- _ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 0 0 15 (a)(1.2) X .00 . 16. Amount of Line 14 taxable 6 4 3 4 6. 6 3 16 , at lineal rate X .045 . 17. Amount of Line 14 taxable 0 0 0 17 at sibling rate X .12 . 18. Amount of Line 14 taxable 0 0 0 18 at collateral rate X .15 . 19. Tax Due .................................................................................,........_..............,... .. 19. Decedent's Social Security Number 578 56 1530 2,614.71 74,615.72 77,230.43 11,371.80 1,512.00 12,883.80 64,346.63 64,346.63 0.00 2,895.60 0.00 0.00 2,895.60 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505607220 1505607220 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 -- DECEDENT'S NAME Gertrude F. Fleming - __ STREET ADDRESS 145 Outlook Pointe -- --- ---_. -- ~-STATE ~ ZIP CITY Shippensburg PA 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InterestiPenalty if applicable p. Interest E. Penalty 0.00 337.19 485.00 (1) 2,895.60 Total Credits (A + B + C) (2) 0.00 Total Interest/Penalty (D + E) (3) 822.1 9 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is theOVERPAYMENT. (4) Check box on Page 2 Line 20 to request arefund - -- 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is theTAX DUE (5) 3, 71 7.79 A. Enter the interest on the tax due. (5A) __- -- B. Enter the total of Line 5 + 5A. This is theBALANCE DUE (5B) 3 , 7 ~ 7 , 7 9 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 :............................................................................. ~, x~ b. retain the right to designate who shall use the property transferred or its income :................................ ~ _~ !~-x c. retain a reversionary interest; or ..............................__...,........................__............................__................ ~ ~ I~ d. receive the promise for life of either payments, benefits or care? ........................................................... I ~ xl 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without .. ~ .................................................................................. ~ - rX receiving adequate consideration ................................ ~, ~_ 3. Did decedent awn an "in trust for' or payable upon death bank account or security at his or her death?......... ~ j ~~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................................................................................................ ~ x] ~] 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 statutedoes not exempts 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)]. 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. Rev-1508 EX+ (6-98j SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF - (FILE NUMBER Fleming, Gertrude F. I 2~-- Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1510 EX+ (6-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Fleming, Gertrude F. 21__ 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 DES IP P TY INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INl"EREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Pennsylvania Municipal Retirement System - 13,354.52 100.000 13,354.52 beneficiaries two (2) sons, Christopher P. Swann and Steven P. Swann, each received $6,677.26 2 TIAA/CREF Account -beneficiaries two (2) sons, 14,531.64 100.000 14,531.64 Christopher P. Swann and Steven P. Swann, each received $7,265.82 3 TIAA/CREF Annuity Account -beneficiaries four 46,729.56 100.000 46,729.56 (4) grandchildren, Peter A. Swann, Caroline S. Swann, Steven R. Swann, and William A. Swann, each received $11,682.39 TOTAL (Also enter on Line 7, Recapitulation) 74.615.72 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1151 EX+~12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES ~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Fleming, Gertrude F. Y1__ ITEM DESCRIPTION AMOUNT NUMBER q. FUNERAL EXPENSES: See continuation schedule(s) attached B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid 2. Attorney's Fees See continuation schedule(s) attached 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. I Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7,356.80 1,000.00 7. Other Administrative Costs 3,015.00 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 11,371.80 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Fleming, Gertrude F. 21-- ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Auer Memorial Home and Cremation Services, Inc. 2,106.80 2 Auer Memorial Home and Cremation Services, Inc. -cemetery monument 3,500.00 3 Church Rental and Reception 500.00 4 Funeral Plot and opening of gravesite 150.00 5 Memorial Bench 1,100.00 H-A Subtotal 7,356.80 Attorney Fees 6 Weigle 8 Associates, P.C. -partial fee payment 160.00 7 Weigle 8~ Associates, P.C. -balance of fee 840.00 H-B2 Subtotal 1,000.00 Other Administrative Costs 8 Register of Wills, Cumberland County -filing PA Inheritance Tax Return 9 Steven Swann travel expenses -for funeral, and administrative responsibilities Ni-67 Subtotal 15.00 3,000.00 3,015.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+(6-98) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Fleming, Gertrude F. 21-- Include unreimbursed medical expenses. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Fleming, Gertrude F. 21-- NAMEAND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) Do Not List Trustee(s) I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] 1 2 3 4 5 II. Caroline S. Swann 1957 Gardenia Street Sykesville, MD 21784 Christopher P. Swann 1957 Gardenia Street Eldersburg, MD 21784 Steven R. Swann 7077 San Sebastian Circle Boca Raton, FL 33433 William A. Swann 7077 San Sebastian Circle Boca Raton, FL 33433 Peter A. Swann 1957 Gardenia Street Eldersburg, MD 21784 See continuation schedule attached Enter dollar amounts for distributions shown above on lines NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FC BEING MADE Grandchild Son Grandchild Grandchild Grandchild 15 through 18, as approF IR WHICH AN ELECTIO B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1/4 of Annuity 112 TIAA/CREF and pension 114 of Annuity 1/4 of Annuity 1/4 of Annuity Continuation Total ~riate, on Rev 1500 coy V TO 'TAX IS NOT 11,682.39 8,808.54 11,682.39 11,682.39 11,682.39 8,808.53 64,346.63 er sheet TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule) (Rev. 6-98) ~GFlEQ!!~E J The BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Gertrude F. Fleming 12/25/2006 578-56-1530 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 6 Steven P. Swann Son 7077 San Sebastian Circle Boca Raton, FL 33433 1/2 TIAA/CREF, 8.808.53 pension Tota I 8.808.53 Q M&TBank 499 Mitchell Road. Millsboro. DE 19966 Mail Code DE-MB-12 Phone (888)502-4349 Fax (302)934-2955 April 21, 2009 Weigle & Associates Attorneys at Law 126 East King Street Shippensburg, Pennsylvania 17257-1397 Re: Estate of Gertrude F. Fleming Social Security: 578-56-1530 :. Date of Death: December 2S, 2006 Dear Sir or Madam: Per your inquiry dated April 15, 2009, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 9840558754 Ownership (Names o,~ Gertrude F Fleming* Opening Date 12/29/05 Balance on Date of Death $ 2, 614.43 Accrued Interest $ 0.28 Total $ 2, 614.71 Please be advised, there was no safe deposit box found for the above decedent * If upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or name of any possible joint account holder. For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contact our Walnut Bottom Office # 717-532-2414. Sincerely, C ~~~ l~ Tracie Hare Adjustment Services 7 ~ ~ --~~i ^ CORRECTED (if checked) PAYER'S name, street address, city, state, and ZIP code i Gross distribution OtvB No. ',5a5-6119 Distrib~t~ic~ds ~r~:iE Pensions, ~n-:~i~ies, $ 6 677.26 C)~ ~~ ~ietii^efT~e4i~ ~,~ Prafif-~F~rir~g 2a Taxable amount j C~ ~ PianS, ~F€.~sS, Penna. Municipal Retirement System ins:srence P.O. Box 1165 $ 6,677:26 Form 1099-R Contracts; enc. Harrisburg, PA 17108-1165 2b Taxable amount Total ~c,P~, C not determined ^ distribution For Pecipient's PAYER'S federal identification RECIPIENT'S identification 3 Capital gain (included 4 Federa4 income tax F~ieCOCCi number number in box 2a) withheld 23-7377753. 216-96-8848 - 0 00 ~ $ . RECIPIENT'S name, address, and ZIP code 5 Employee contributions 6 Net unrealized /Designated Roth appreciation in contributions or employer's securities insurance premiums Mr. Christopher P. Swann $ 0.00 $ 1957 Gardenia Street 7 Distribution code(s) sE / 8 Other T i f SIMPLE h s in ormation is Eldensburg MD 21784 q. ~ ~ on being furnished to , o the Internal 9a Your percentage of total 9b Total employee contributions Revenue Service. distribution ~0 % $ 1st year of desig.:Roth contrib. 10 State tax withheld 11 State/i~ayer's state nd: 12 State distribution 01-019-3 N $ - -- ~ Carroll Valle Borou -- ----------------------- $ ---------------------------- -~ ------------------- Account number (see instructions) 13 Local tax withheld 14 Name of locality 15 Local distribution Fleming, Gertrude (578561530) -$------------------------- ----------- ---------------- -$-------------------- Form 1 O99-R (keep for your records) Department of the Treasury -Internal Revenue Service ~. Z _~et..c~ 7 ~z ~ .~ - .. .,..... r_.. _._. _ .. .. -. ~ _ ~ . _, .. PAYER'S Federal identification number RECIPIENT'S identification number 13-1624203 216-96-8848 PAYER'S name, street address, city, state, and ZIP code TEACHERS INSURANCE AND ANNUITY ASSOC. 8500 Andrew Carnegie Blvd. Charlotte, NC 28262-8500 RECIPIENT'S name, street address (including apt. no.), city, state, ;and ZIP code 0273634'02 AT 0.459 ~~AUTO T2 O 0006 21784 ~u~r~nr~~~rn~~n~n~u~~~r~r~r~u~u~~~n~n~r~~~ua~r~~u~ CHRISTOPHER P SWANN 1957 GARDENIA ST ELDERSBURG MO 21784 LGGZ ul pazua~o~,~.,,,~. ,_ PAYER'S Federal identification number 13-1624203 PAYER'S name, street address, city, state, TEACHERS INSURANCE 8500 Andrew Camegie BI Charlotte. NC 28262-8500 RECIPIENT'S name, street address (includi 0273634 02 AT 0.459 ~n~r~n~~~~ur~~n~u~n~r~~~r~r~~ CHRISTOPHER P SWAA 1957 GARDENIA ST ELDERSBURG MD 217E First Year of Designated Roth Contributions ... r --.4" v .JI }r-~ .~..,,.,_ SI3.!12i6., _.....,..,, 1 Gross distribution 2a Taxable amount OMB No. 1545-0119 2007 $ 2679.21 $ 2679 21 Form 1099-R 2b Taxable amount ^ . Total rr**~~ Distributions not determined distribution LJ From Pensions, 3 Capital gain 4 Federal income tax Annuities, (included in box 2a) withheld Retirement or Profit-Sharing $ $ 401 .90 Plans, IRAs, 5 Employee contributions/ 7 Distribution IRA / Insurance Designated Roth contributions code(s) sEP/ Contracts, etc. or insurance remiums p SIMPLE This information is being ^ fumished to the Intemal $ 0 . ~~~ 4 Revenue Service. 9a Your percentage of 9b Total employee contributions ~O~Y C total distribution For Recipient's i, $ ecords 10a State tax withheld 11 a State /Payer's state no. 12a State distribution $ 214.35 MD 033-9204-3 ~$ 2679.21 10b State tax withheld 11 b State /Payer's state no. 12b State distribution ~ $ 13 Local tax withheld 14 Name of locality 15 Local distribution ., :~:, ., as 9GGG w algexa, siz:~atap ssa~;:a/s5ulu.lee snla suol,l,,,,.,;,co RECIPIENT'S identification number 1 Gross distribution 2a Taxable amount OMB No. 1545-0119 216 - 96 - 8848 2®07 $ 4586 61 $ 4586 61 Form 1099-R snd ZIP code . . 2b Taxable amount Total ^ ^ Distributions qND ANNUITY ASSOC not determined distribution From Pensions, . /d 3 Capital pain i l d ? b 2 4 Federal income tax Annuities, . nc ( u e In ox a) withheld Retirement or Profit-Sharing $ $ 687.98 Plans, IRAs, 5 Employee contributions/ 7 Distribution iRA / insurance Designated Roth contributions code(s) sEP/ Contracts, etc. Ig apt. no.), Clty, state, and ZIP code or insurance remiums p SIMPLE This information is being ^ fumished to the Intemal $ D ~ 00 4 Revenue Service. 'AUTO T2 O 0006 21784 9a Your percentage of total distribution 9b Total employee contributions COPY C r~rr~r~n~r~~r~i~rn~~~~n~ For N Recipient's i $ Records 4 - 5988 1 Oa State tax withheld 11 a State /Payer's state no. 12a State distribution $ 366.91 MD 033-9204-3 $ 4586.61 10b State tax withheld 11 b State /Payer's state no. 12b State distribution S S First Year of Designated 13 Local tax withheld 14 Name of locality 15 Local distribution Roth Contributions ( rtn: n! 0a<Ila1BEJEd3aJ DUE 9007. Ill aoEW .. .. PAYER'S Federal idenfrfication number RECIPIENTS identification Hum 13-1624203 213-51-9409 ~JOU . , .,..dG uI algE::et ' bar t Gross distdbution 2a Taxable amourrt OMB No. 1545.0115 20D7 Form 1099-R PAYER'S name, street address, chy, state, and ZIP cotle , S 7804.67 s 7804 .67 TEACHERS INSURANCE AND ANNUITY ASSOC. 2b Taxable amount Total not determined ® distdbution ^ Distributions From Pensions, 8500 Andrew Came IQ Blvd. g 3 capital pain (included in box 2a) 4 Federal income tax wNhheltl Annuities, Charlotte NC 28262$500 Retirement or , proof-snaring ~ 5 g plans, IRAs, ~ - 5 Employee contributions/ 7 Distribution IRA I Insurance _ Designated Aoth contdbtfions cotle(s) sinic~ Contracts, etc. RECIPIENT'S name, street address (inclutling apt. no.), city, state, and ZIP cotle or insurance premiums ms mio„m,a, s eema © w,:.nw m m. rc,rom., = 5 4 nw. ve s,~.. _ _ 0273629 02 A T 0.459 "AUTO T2 0 0006 21784 9a Your percentage of 9b Total employee contributions total distdbution COPY C 11 1 {u{r{nr{{{m{{u{u{a{r{r11{r{u{u{r{n{u{r{r{m{r{{n{ FOr PETER A SWANN(MINOR) Recipient':; 1957 GARDENIA STREET "a s Records ELDERSBURGH MD 21784 - 5988 10a Slate tax withheld tta State /Payer's state no. 12a State distribution , 5 MD 033-9204-3 g 7804.67 ~ 1 10b State tax withheld 77b State! Payees state no. 12b State distdbution 1 5 ~ 5 First Year of Designated 73 Local tax withheld 1.4 Name of bcality _ 55 Local distribution ~ Roth Comributions LOrJZ w pazua:aPJEUaaJ ,.,._ ,,,,,~ . - -'~ __.____ _.. ___.._.__.....,..,.. ,. ~ ...... -~ - ~" . .........~,,; ~, n.,,,,n cunn~-,1 ~tziGC aye Jaoun sasen lsow ul) uogdaa;;a urmou,i PAYER'S Federal identification number RECIPIENTS idenlNication number 1 Gross disdbution 2a Taxable amount OMB No. 1545-Ot1E 13-1624203 213-51-9409 ~ ZOQ7 PP.YER'S name, street address, city, state, and ZIP code - s 3877.72 S 3877.72 - Form 1099-R 2b Taxable amount Total ® ^ Distributions TEACHERS INSURANCE AND ANNUITY ASSOC. not determined distribution From pensions, 8500 Andrew Carnegie Blvd. 3 Capital ggain (incuded in box 2a) 4 Federal income tax withheld Annuities, Charl tt NC 28262$ D Retirement or o e, 5D Protit-sharing ~ ~ S 5 Plans, IAAS, 5 Employee conMbutionsr ' 7 Distribution iRA r Insurance ~ _ Designated Roth contributions code(s) seR' SIMPLE ~ Contracts etc. RECIPIENT'S name, street address (incWding apt. no.), city, state, end ZIP code I or insurance remiums p ~ m~:,iamam~ a e,,,na lum¢M] t ,n I S 4 o nlem¢' e Reverwe sen,~E __ 0273629 02 AT 0.459 "AUTD T2 O OOD6 21784 9a Your percentage of 96 Total emoloyee contributions total distribution ~ COPY C { { { {{{ {{ { { { { { { { { { { { { { { { {~ ~ Him w nnnri rlunru urruii u For I Recipient's PETER A SWANN(MINOR) ~ 1957 GARDENIA STREET I r {ro Records ELDERSBURGH MD 21 784 - 5988 _ 1 Da State tax withneldj 11a State /Payers state no. ~ 12a State distriouiion _ Is MD 033-9204-3 ~'s 3877.72 ~~ 105 State ;ar, v.~ithheld.~ 110 State 'Pager= scat=_ nc- i 12; State ci=_~a!~ti,- ~ 15 Pi>: "ea' of Des?Hated 13 Lac2i tax withheld ~ 14 Name o Ixzli'}' 115 Local distribuf~or` ... Rotn Contribution=_ A... } ~~ ti~~ i ~~ :. tiR r ` ~ca. ~s.~:e O U .b ~ a ~ N ~~ n r- " % a~ - °- sit` ~_ ~ ~ ~ s--- ~ r ¢ ~' ~ cc,=__ ~ ~ d CJ m ~ ~ p pa _. c~i G a N ~ ~ cV O ri O N g ~~ g ~ ~ v a w -' H 3 ~ ~ N 1~1 a [n ~ _ O ~ ~ Cj1 y ~ GA _.. O C~] L