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HomeMy WebLinkAbout10-15-09 5D56D41114 REV-1500 ~ (olro5> OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280801 q Harrisburo. PA 17128-0801 RESIDENT DECEDENT ~ ~ 1 ~ Z-Z3 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 184-12-2122 09112008 09251922 Decedent's Last Name Suffix Decedent's First Name MI STUCKEY JACK E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI STUCKEY VERA C Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ® 1.Original Retum 4. Limited Estate ® 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Retum 4a. Future Interest Compromise (date of death after 12-12-82) Q 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 0 3. Remainder Retum (date of death prior to 12-13-82) 0 5. Federal Estate Tax Retum Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number SUSAN J STUCKEY 717-805-39$0 hJ Firm Name (If Applicable) REGISTE WILLS US LY First line of address 68 FAIRFAX VILLAGE Second line of address City or Post Office HARRISBURG State ZIP Code PA 17112 'a "-' O ._ ~ -n -n e:'1 } ~ ~ -~ TJ C1'1 . ~ ~.a ;t: _'c~~~ s¢ _"~ S3 D~E FlLED ~.- { J 1;..: <~ s ,',,~ `--~ _~ `r `-,.1 . -'rt°~ ;t } ::LL :~..1 ,z .~ Correspondent's a-mail address: Under penalties of perjury, I declare that I have examin this re m, incl ing atxompanyirg sch ides and statements, and to the best o my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all infomlatan of which preparer has any knowledge SIG ATURE OF P ON RE PONSIBLE FOR FILING RETURN DATE ADDRESS 68 FAIRFAX VILLAGE SIGNATUR REPAREA OTHER THAN SBURG PA 17112 Z/O 481`1 JONESTOWN ROAD STE 125 HARRISBURG PA 17109 PL IGINAL FORM ONLY Side 1 15D56041114 15D56D41114 J 15056042115 REV-1500 EX Decedent's Social Security Number Decedent's Name: JACK E STUCKEY 18 4 -12 - 212 2 RECAPITULATION f . Reai estate (Schedule A) ........................................... 1. 10 6 0 0 0.0 0 2. Stocks and Bonds (Schedule B) ...................................... 2. NONE 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. NONE 4. Mortgages & Notes Receivable (Schedule D) ............................ 4. NONE 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 2 5 0 0 . 0 0 6. Jointly Owned Property (Schedule F) OSeparate Billing Requested ........ 6. 4 2 210.0 0 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested ........ 7 NONE 8. Total Gross Assets (total Lines 1-7) .................................. 8. 15 0 710.0 0 9. Funeral Expenses & Administrative Costs (Schedule H) ................... 9. 5 6 5 6 . 0 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............... 10. NONE 11. Total Deductions (total Lines 9 & 10) ................................. 11. 5 6 5 6 . 0 0 12. ............................. Net Value of Estate (Line 8 minus Line 11) 12. 14 5 0 5 4 . 0 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ....................... i 3, 0 . 0 0 14. Net Value SubJect to Tax (Line 12 minus Line 13) ....................... 14. 14 5 O 5 4 . 0 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2)x.o 0 145054.00 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 16. 0 • 0 0 17. Amount of Line 14 taxable at sibling rate X • 12 17, 0 . 0 0 18. Amount of Line 14 taxable at collateral rate x ,15 18. 0 . 0 0 19. TAX DUE ....................................................... 19. 0 . 0 0 2p. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0 Side 2 15056042115 15056042115 REV;1500 Ex Page 3 184-12-2122 Decedent's Complete Address: File Number 2009-00223 DECEDENT'S NAME ACK E STUCKEY DECEDENTS SOCIAL SECURITY NUMBER 184-12-2122 STREET ADDRESS 209 THIRD STREET CITY HARRISBURG STATE PA ZI P 17093 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty (1) 0.00 Total Credits (A + B + C) (2) 0.00 Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5) 0.00 (5A) (5B) 0.00 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: a. retain the use or income of the property transferred : ....................................... Y s ~ No ^X b. retain the right to designate who shall use the property transferred or its income : ................ ~ ^X c. retain a reversionary interest; or .....................:................................ d. receive the promise for life of either payments, benefits or care? ............................. ~ ^X 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................. ~ ~X 3. Did decedent own an 'in trust for" or payable upon death bank account or security at his or her death? .. ~ ~X 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 statute does not exemg 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 decedents 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. 217 REV-1502 EX+ (B-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER ESTATE OF JACK E STUCKEY 2009-00223 All real property owned solely or as a tenant In common must be reported et fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. (If more space is needed, insert additional sheets of the same size) 217 REV-1508 EX+(6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMO ER TANCETAX RErURN~IA PERSONAL PROPERTY __ _ _--- ESTATE OF FILE NUMBER ESTATE OF JACK E STUCKEY 2009-00223 Include the proceeds of litigation and the date the proceeds were received by the estate. (If more space is needed, insert additional sheets of the same size) 217 REV-1509 EX+(698) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ESTATE OF FILE NUMBER ESTATE OF JACK E STUCKEY 2009-00223 If an asset was made Joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A. VERA C STUCKEY B. C. ADDRESS 3RD STREET SUMMERDALE PA 17093 RELATIONSHIP TO DECEDENT POUSE JOINTLY-OWNED PROPER TY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANGAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT ~DENTIFVING NUMBER. ATTACH DEED FOR JOINTLY•HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. FEDERATED FUNDS 48,132 50.00% 24,066 2. A SOVEREIGN BANK -INTEREST CHECKING ACCOUNT 14,559 50.00% 7,280 3. A SOVEREIGN BANK -MONEY MARKET 21,728 50.00% 10,864 4. A p 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL (Also enter on line 6. Recapitulation)I $ 42,210 (If more space is needed, insert additional sheets of the same size) Monthly Statement MB 01 005391 23237 H 19 A ~~, ~ For the period ending July 31, 2008 III~1~111~11'~I1~~1111111'~II~~I'~I~~'lll~ll~~~l~l~~~ll~ll'~I~II~ ~ ~~ Page 1 of 2 JACK E STUCKEY VERA C STUCKEY JT TEN 209 3RD ST ~'~ The funds' Senior Officer, who manages the Po Box 2a SUMMERDALE PA 17093-0024 process by which the funds' Board considers the funds' advisory fees, prepares an analysis to assist the Board in this regard, which is summarized in the "Evaluation and Approval of Advisory Contract" for Bach fund that is available at Federatedlnvdstors.com. Portfolio Overview ~~ Important note: TOTAL MARKET VALUE as of 07/31/2008 $48,132.08 Please revievvthe information contained in this statement and promptly report Investor News inaccuracies or discrepancies in writing. This statement is notfortax purposes, but it For the source of Fund distributions as required by federal securities laws, visit should be retained for your records. Federatedlnvestors.com. Would you like to monitor your Federated Funds Visit Federatedlnvestors.com and select MyPortfolios within the Products tab to create a customized portfolio of your Federated holdings. Total returns, price history and much more can be tracked with this easy-to-use tool! Account Iniformation Fund number 2 Account number 11840978 For account questions, balances, yields, etc ~_ call.1-800245-41TO..For_automated phone access call anytime 1-800-245-2999. TTY - Servicefor the deaf and hearing impaired is available at 1-8b0-358-6930- TTY phone needed. Access to fund information is available at Federatedlnvestors.com. Federated Securities Corp., Distributor aa~ ,n Monthly Statement For the period ending July 31, 2008 Page2of2 Account Detail VisitFederatedlnvestors.comforfund Derformance and currentvields. Information may be obtained aboutthe Securities Investor Protection Corporation (SIPC-, including the SIPC brochure, by contacting them at 202-371-8300 or visiting their web site at www.sipc.org. Liberty U.S. Gov Money Market A JACK E STUCKEY Frad aambar 2 Accauat aamhar 11840978 VERA C STUCKEY JT TEN NASDAtt symbol LUGXX Accgaatopaaad 04/20/1981 so-aayyiald 1.4596 as of 07/31/2008 Divhlapds Reinvested The 30-day yleld reflects actual distributions Capital pains Reinvested paid to you and other shareholders. It includes This accoaat has chackwrNiap prhrilagas. dividends and any shbrtterm capital gains, but does not include any applicable sales charge. Transaction detail Coaflna Trade. Dollar Shan Shahs this Total daH data Trassactioa daacdptloa aalouat price traaiaCtiaa shahs owaad Previous balance as of 07/01/2008 x40,206.62 51.00 40,206.6200 07131 07/31 Income Reinvest 549.44 51.00 49.4400 40.256.0600 Ending balance as of 07/31/2006 =40,256.06 x1.00 40,256.0600 Liberty U.S. Gov Money Market A STATE STREET BANK AND TRUST COMPANY Wad awaMr 2 Account asaibar 9895977 CUST FOR THE ROLLOVER IRA OF NASDAnsywbol LUGXX Accopatopansd 10/05/2001 ~ACX E STUCKEY 30-dayyishi 1.4596 es of 07/31/2008 Oh!id«ads Reinvested The 30-day yield reflects actual distributions Capital galas Reinvested paid to you and other shareholders. It includes dividends and any short-farm capital pains, but does not include any applicable sales charge. Transaction detail Coatirw Trade Dollar Shan Shsns Wis Total daM daU Traasactioa dascriptloa amoaat price traasactioa :hams awaad Prevaus balance as of 07/01/2008 x7,866.34 x1.00 7,866.3400 _ 0.7/31 07/31 Income Reinvest 59.68 51.00 9.6800 7.876.0200 Ending balance as of 01/31/2008 x7,876.02 x1.00 7,876.0200 DST W600.4 (2/Q8) ~'~iSovereign Bank. STATEMENT OF ACCOUNTS ,; Statement Period 08/22/08 TO 09/21/08 1-87T-SOV BANK (1-87T-768-2265) wwwsovereignbank.com gOVEREIQN INTEREST CHECKING x10.33 " - - - - Date # Transactions Fee Total DIRECT DEPOSIT DISCOUNT 09/19!08 1 -5 OD ~. 00 Total 30.00 Account Activity Date Description Additions Subtractions Balance 08-22 Beginning Balance $94.535.35 - - - --• -~ --- .....,.,..... ~to~oa~ SOC SEC 090308 A SSA ~='~ sovereign Bank ~= ,~~ ~,.. STATEMENT OF ACCOUNTS 1-877-SOV-BANK 1-877-7B8-2265 ( ) g wwwsoverei nbank.com Statement Period 08/27/08 TO 09/28/08 MONEY MARKET JACK E s7UCKEY A~c~ount #.921718489 ; SUSAN J STUCKEY BE~tIriC@!3 fleposlts/Credits + $8.81 Avergge Dally Balance ~2i,719.54 -_ . Interest > .. "s--' , "~~ ~~ famed th>~.f'etlad. _ $ 8.81 Paid Last Year $97.21. `The lnten3st earned and the Interest paid may differ depending on when interest is credited ~ your account. _ '' A~ccoutaf Activity -~~ Date - Descrfptlon Additions sutrtractions Balance ~ 08-27 .. t3eginttiny Balance $21,719.54 En ng Balance 1.728.35 3 page of 3 921718489 REV-1511 EX + (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ESTATE OF JACK E STUCKEY 2009-00223 Debts of decedent must be reported on Schedule 1. A. FUNERAL EXPENSES: 1. FUNERAL HOME B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) SUSAN J STUCKEY street Address 68 FAIRFAX VILLAGE City HARRISBURG State PA Zip 17112 Year(s) Commission Paid: 0 2. 3. 4. 5. 6. 7. Attorney Fees 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 Probate Fees Accountant's Fees Tax Return Preparer's Fees 5,128 0 0 178 0 350 TOTAL (Also enter on line 9 R~ (If more space is needed, insert additional sheets of the same size) ~~ ('~ ~ ~~p " ~ 29 SOUTH ENOLA DRIVE r ic~art~on ~J unera (. ome ~J Y~C. ENOLA, PA 17025 v v , (717) 732-0087 MICHAEL G. MUAF:AY SUPERVISOR STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges ue only for those items that you selected or that ue required. If we ue required by law or by a cemetery or crematory to use any items, we will explain in writing below. If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pxy for embalming you did not approve if y lected ~rangettyots such u a direct cremation or immediate burial. If we charged for embalming, we will ex lain by below. For the Service of ~ "; a ~_ C.. Date of Death ~~'` °~ ~/ Charge to: L/ ~ ~ °i' ~.i.S t `i' ~` `1 d U `/ ~ r.~ s ~` 5 ~i17 A7 r . .~-'1~--" ~ ~~ ---- ~:.., e~r~ A. CHARGE FOR SERVICES SELECTED: 1. PROFESSIONAL SERVICES l Services of Funeral Director/Staff .... N' ~ Embalming ...................... f~`;:~ Other preparation of body Other clothing f f f ............................... f SUB-TOTAL OF PROPESSIONAL SERVICES......... Al i 2. FACILITIES AND SERVICES , Use of facilities and services for viewing (Visitation/Wake)...... ... f Use of facilities and services for funeral ceremony ......... ... i Use of facilities and services for Memorial Service ............ ... i Use of equipment and services for graveside service ........... .. f Other use of facilities ............................... f SUB-TOTAL OF FACILITIES/EQUIPMENT ...... ..... A2 f 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home. Local ........................... f Hearse (Coke[ Coach) Local ........... ................ i Limousine Local ........... ....... t Family cu Local ........................... i Flower cu or floral disposition Local ........................... f Lead culclergy cu Local ...........................f Car for pallbeuers Local ........................... f Out of town transportation ......... f f f SUB-TOTAL OF AUTOMOTIVE EQUIPMENT.... .... A3 i TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE ? r,~-, EQUIPMENT ............................... .... A Y r`7~ ' B. CHARGE FO)~ MERCHAN,DISE SELECTED: U Casket ....`.....~^. t~~ ~. ~':... =I( gg. cl (Descriptiony'f v ..~. -~ L.~f nr) _ .~ , Othe eceptacle ................. f (Description) Outer burial container ............. f~~~ (Description) Cremation urn .................. . (Description) OTHER f f i TOTAL MERCHANDISE SELECTED .................. B f C. SPECIAL CHARGES: Forwuding of remains to f (Funeral Home) Receiving of remains from . f (Funeral Home) Immediue Burial ................. f Direct Cremation ................. f f SUB-TOTAL OF SPECIAL CILARGES ................ C f D. CASFI ADVANCED L~~; Opening Grave .............. ... . i Cemetery Equipment .......... ... . f Lot and Deed ................ .... f Newspaper Notices-Laval ..... ... , f~-c) " •- v Newspaper Notices-Out-of--town .... f Telephone & Telegrams ....... .... i Airfare ..................... .... f Cler /Mass Offerin gY g .......... .... !~ , "' `' Pallbeuers .................. .... S Certified Copies of the Dgth Certificate .................. .... f ~'~/ff Police Escort ................. ... f Flowers ....... --:~:^~ i^. , ~! . V ~ ... f ault Service Chuge ...... . .. , f 6• Si4/0i ~S s~.J ~~ f f f ~ ~~ J //~ f SUBTOTAL OF ADVANCES ....................... D i~ ~6' y ~'' We charge you for our services in obtaining: (specify cash advances that are marked-up) SUMMARY OF CHARGES A . Professional Services, Facilities and Equipment, and Automotive Equipment ................ ~ ~ . o a B. Merchandise ..................... f ~ u C . Special Charges .................. f a D. Cash Advances ................... f , ~O . / TOTAL OF ALL SECTIONS .....: .................. f ~ a • ~ PAID AT T[ME OF OR P~R Tq ARRANGEMENTS......?.~ .!r.:.~..!'~: ?. ~' :~.. f 3 c v . •,~ BALANCE DUE ......................,...........f ---- ~ b. ~ Embalming : ...................... t i sY ~..'- Other preFtaration of body ........ ...................... f SUBTOTAL OF PROFESSIONAL SERVICES ......... A 1 i 2. FAC[LITIE~ AND SERVICES , Usc of facilities and services for viewing (Visitation/Wake)......... t Use of facilities and services for funeral ceremony ........... , t Use of facilities and services for Memorial Service ............... f Use of equipment and services for graveside service ............. f Other use of facilities ............................... i SUB-TOTAL OF FACILITIES/EQUIPMENT ........... A2 f 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home. Loral ........................ ... t Hearse (Casket Coach) Local ........................ ... f Limousine Local ..... .................. ... i Family car Local ........................ ... i Flower cu or floral disposition Local ........................ ... f Lead car/clergy car Local ........................ ... i Car for pa.lbearers Local ........................ ... i Out of town transportation ...... ... t s i SUB-TOTAL OF AUTOMOTIVE EQUIPMENT....... . TOTAL OF PROFESSIONAL SERVICES, FACILITIES UVD AUTOMOTIVE trremanon urn .................. ~. ~ (Description) OTHER = f i TOTAL MERCHANDISE SELECTED , .. , ... , . , , • , , • , , . g : C. SPECIAL CHARGES: Forwarding of remains to (Funeral Home) i Receiving of remains from (Funeral Home) t Immediate Burial .............. ... f Direct Cremation .............. .. . f i SUB-TOTAL OF SPECIAL CHARGES .............. .. C f D. CASH ADVANCED Opening Grave ................ / .. i ~/ l; Cemetery Equipment ............ .. i Lot and Deed .................. .. i ~. Newspaper Notices-Local ....... .. t, i, d c~ ., ~ ,C S'7 ~ ~.,.~~ Newspaper Notices-Out-of-town .. .. i Telephone & Telegrams ........ , . , i Airfare ....................... . f - ' ~ Clergy/Mass Offering ............ .. ~~ " ' Pallbearers .................... .. t Certified Copies of the Death Ccrtificuc .................... .. t ~ %5' / i ., ,~ ~, ! f c``"~"°'.~'7r' Police Escon .................. .. i t Flowers ....... -!r4 r~...'! V l ~ , . i au t Service Charge ...... .. , , _ of / SiG iii '..5 -~,'~ ~ Td .-~i t~ s s s SUB-TOTAL OF ADVANCES ........ s .............. - . D i~ SG' v ~' A3 f We charge you for our services in obtaining: (spectjy cash advances that arse marked-up) EQUIPMENT ................................... A ~ 7`7"~ ' B. CHARGE FO~ MERCHANDISE SELECTED~:/ Casket ~ '. !=. ~ •-? !~/ ?. C:--...... Y•~ ~~, d U (Descriptiorty~ v .~~. •~ a,~.~rs~ r „~ Oth ecepncle ................. i (Description) Outer bur, al container ............. Y/~ (Description) Acknowlaigement cards ........... i Register b«>ok(s) .................. It-~ Memory fc>Iders .................. i Prayer cards ..................... it~_ g SUMMARY OF CHARGES A . Professional Services, Facilities and Equipment, and Automotive Equipment ............ ~_~~..2.i+ ~ ~ B . Merchandise ..................... i ~ .~ ~.-%~ C . Special Charges ................. . t D. Cash Advances ................... _~• J TOTAL OF ALL SECTIONS ........................ i ~ ~'~ PAID AT TIME OF OR PAR TO ARRANGEMENTS ...... ?. ~ , !r .:. ~ „?r : ? , <. ~ f .. f 3 c ~ BALANCE DUE .................:'. ..... isC C._~ ~~ REASODI, FOR EMBALMING ~ ` ' . f-; .^ -~ { ' . If any law, comet y, or crertSatory requiremrnps have required the purchase of/ajny of the item/s listed above the law or reguiremrnt is explained below, [agree that 1 have examined the items of goods and services selected above and found them to be correct and according to the arrangemrnts I,have requested. i acknowledge receipt of a copy of this Statement of Funenl Goods and Services Selected. I represent t I have sufficient funds available for payment pf the cash price for the goods and services select~:d. I also agree to a payment of i~~l- within days. I a e to be ' mtl and severe signs below. A late charge of ~ per month amountin to ~ to Y ~Y liable•wlth.anyone Ise who B ~~ per year will be applied to the unpaid balance beginning s da s from the date of this agreement. I wiU also pay to the Funenl Director all reasonable costs paid by the Funenl Diicttor to collect amounts I owe under this agreenteni. Those costs may include attorneys' fees, court costs and other costs. Any additional services or merchandise ordered or requested after the date of this agreemrnt will be considered pan of this agreement and the cost thereof will be reflected on the final bill or statement (~aI) (Purchaser) ----~ ~~tz~" "' '(-=~= °2r~ ~. (Sal) ,/Ifss-~-~.-~~'~ ~ ~~`;~-'l.~ ,-- (Purchaser) (Licensed Funenl Dttector} © Pennsylvanh Funeral Directors Association WHITE Funeral Director YELLOW Fuuetall Dir~pr~J form -600 Revised 4/94 Temponr~ grave marker ........... f~_ Burial clothin ................... i .., RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: 3/06/2009 Cumberland County - Register Of Wills Receipt Time: 15:26:10 One Courthouse Square Receipt No.: 1055983 Carlisle, PA 17613 STUCKEY JACK E Estate File No.: 2009-00223 Paid By Remarks: SUSAN J STUCKEY CJ ------------------- ----- Receipt Distribution ----~-- ------- ------- ---- Fee/Tax Description Payment Amount Payee Name PETITION LTRS ADM 135.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 8.00 CUMBERLAND COUNTY GENERAL FUN JCP FEE 10.00 BUREAU OF RECEIF~TS & CNTR M D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL . FUN Check# 197 ---------------- $173.00 Total Received..... .... $173.00 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 STUCKEY JACK E Receipt Date: 3/06/2009 Receipt Time: 15:31:53 Receipt No.: 1055984 Estate File No.: 2009-00223 Paid By Remarks: SUSAN J STUCKEY CJ ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name RENUNCIATION 5.00 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash $5.00 Total Received......... $5.00 Pa. O.C. Rule 6.12 STATUS REPOT REGISTER OF WILLS OF ~~~-~~r~ COTJV~Y, PE IvTame of Decedent: ~ ~ ~`-C-K ~ Date of Death: c1'~ ~ - O' ~ File Number: aoo y- oazz .~ Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of the above-captioned estate: ~ ~ ~~ 1. State whether administration of the estate is complete:.........'.... • • • • • • • ~ Yes ~ Iv'o 2. If the answeris No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is YES, state the following; a. Did the personal representative file a foal account with the Court? ....... QYes [~'IvTo b. The separate Orphans' Court No. (if any) for the personal representative's accountis: c. Did. the personal representative state an account informally to the parties in interest? .. ............:..........:........ ~'es , ®No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts nay b,e filed with the Cleric of the Orphans' Court and maybe attached to this report. Dnte ~V f b ~- Si,"nalure ojPerson Filing t is Form Capacity: ]Personal Representative ~ ow~sel Nmne ojPerron Filing ibis Form Address ~.~/r~ S~'J w-t V to t '1 ~l'Z. `7i7' wS-3~i.~~ it Telephone c~ Name o Date of ueaul:_ ~ - ~. ~ - L v o ~ File Number: ~ O o ~~ - Q (~ ~ a 3 _- _ Date Letters Granted: ~ ~ (o (Q~ To the Register: Icertify that Notice of Estate Administration. required by Pa. O.C. Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on Name: Address: (If more space is needed, attach separate sheet.) Notice has now been given to all persons entitled thereto under Pa. O.C. Rule 5.6(a) except: Da(e__ ~01 25 J ~ y ~-~~- ~. Signature ojPerson Filing This orm Capacity: impersonal Representative Q nsel Name ojPerson F,hn, this Form 1 ~ / 'T- acs ~ r-i-c~yc V ~ (~ ~~j '-'~-, add, zss // ~~ ++__ p 7'1"L~Y"'~ S o y~ P~ ~1. l~ ZI -7 ~ ~ _ ~'O S- 3 5 8' CJ '~ l TzJephone IMPORTANT NOTICE NOTICE ®~' EST ATE AI~1~i~Ni~TRA'I'1Vi1 P'~J'~.S~li ANT 'I~0 P~. ©.~. R~~~ 5.~ THIS NOTICE DOES NOT MEAN THAT I'OU WILL RECEIV ANY :~•10NEY OR PROPERTY FROM THIS ESTATE OR OTHERWI. E Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died ~vithout a will, wlletller you will receive any money or property will be determined by the intestacy lativs of Pennsylvania. BEFORE THE REGISTER OF WII..LS, COUIv-TY OF ~ kw~..t0..*,r ~ ~..~~ , pENNS~ZVANLA IN RE: ESTATE OF ~i..cllc,. ~ $-~.~„~ ,Deceased File Number ao n ~ - ~ o ~`Z3 T0: a^ ~_ (Beneficiary) _ (Address) Please take notice of the death of the Decedent and the grant of Letters to the personal representative(s) named below. The Decedent died on the day of S.-tr .(..¢~,,,~(2~ v i l -~ Zc9 y~' , a resident of ~`'""~S~u 1 a.-w-~ County, PA. The Decedent died: ~ testate (with a will) or intestate (without a will). You may have a beneficial interest in the estate as follows: l O b °? a (If additional space is needed, use separate sheet) The name(s), address(es) and telephone number(s) of all personal representatives appointed are: NAIvIE ADDRESS TELEPHONE 7 ~ ~- $o ~".~ 3 ~ ~ ~ - Sys a,.,,.~ 3' . , lc,,,~ L ~ ~C~ w~t~ U ~ ll ~ ~- ., l~4¢,~a s ~ u +~ ~G-- {~~ ~ Z ~ ~ z._ If the Decedent died testate, the will has been filed with Office of the Register of Wills of C~ ~ ~s C, ar l ~,.~,.P County.. If the Decedent died intestate, a Petition for the Grant of Letters of Administration was filed with the Office of the Register of Wills of County. The Register's address is __ ~ ti...~ ~ w~ ~kS.,~ S$ ~~_ ~ ~: s i-C r°iA 11 O ~ . 7 ~ 7 ' a y ~ ` 6 3 yS- and telephone number is _ ~ . A copy of the Will or Petition may be obtained by contacting the Register of Wills and paying the charges for duplication. Dale_ r~ j ~'~aq Capacity: ^ Personal Representative O Counsel for Personal Representative . ~~~ Signature ojPerson Filing Il s Form Name ojPu•son Firing this Form address Telephone COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND estate of JACK E STUCKEY SHORT CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 6th day of March, Two Thousand and Nine, Letters TESTAMENTARY in common form were granted by the Register of said County, on the late of EAST PENNSBORO TOWNSH/P lFiisf, Middle, Lestl in said county, deceased, to SUSAN) STUCKEY rF%rsr, arwdle, casrl and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 6th day of March Two Thousand and Nine. File No. PA File No. Date of Death S.S. # 2009- 00223 21- 09- 0223 - 9/11/2008 184-12-2122 egister s <. '- ep tY NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL y"•n~ TDC+DEPARTMENT OF THE TREASURY FIJI ji~~,7INTERNAL REVENiJE SERVICE CINCINNATI OH 45999-0023 JACK E STUCKEY ESTATE SUSAN J STUCKEY EX 68 FAIRFAX VLG HARRISBURG, PA 17112 Date of this notice: 02-27-2009 Employer Identification Number: 26-6798806 Form: SS-4 Number of this notice: CP 575 B For assistance you may call us at: 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBEF. Thank you for applying for an Employer Identification Number (EIN). We assigned you EIN 26-6798806. This EIN will identify your estate or trust. I:f you are not the applicant, please contact the individual who is handling the estate or trust for you. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. Based on the information received from you or your representative, you must file the following form(s) by the date(s) shown. Form 1041 12/15/2009 If you have questions about the form(s) or the due date(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. if you need help in determining your annual accounting period (tax year), see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at .issue). Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. To obtain tax forms and publications, including those referenced in this notice, visit our Web site at www.irs.gov. If you do not have access to the Internet, call 1-800-829-3676 (TTY/TDD 1-800-829-4059) or visit your local IRS office.