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Home My WebLink About11-02-09 (3)15056051058 ._.J REV-15 0 0 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year Fife Number Bureau of Individual Taxes INHERITANCE TAX RETURN ~~~~~"~' "~~ ~~".....k..~.._M' ;......_._.~._.~....,.....~.~......,.._.~._... PO Box 2sosol 21 ~ 08 1077 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT {NFORMATION BELOW Social Security Number Date of Death Date of Birth __. _......~.._...._~ _-..._ .............................~........._..._._~.._......., ...._.~.~.._..._....__.._..._.~...~.._._._._._........__...._...._.~.._.._. __..._.......__._...~_._,....~..,._.___.._._ ~..~~...y._.~.~..w.____..w.._..~ 183-12-4006 ~ ; r ~ 10/26/2008 10/21 /1922 __.....~._w_: ___ ~ ~ ~.~.__..._..~._.~~.~ _..~,...w, ~~v..~._~.__ Decedent's Last Name _. ..~.____._._._...~...__.._~...__._..~. _~.__. ..w~_..~._.___.~.~._._.~..~ ~__...._...__.__w...~..... Suffix Decedent's First Name MI :.............. ............ i ,............. ....... _...._.__ .................................... ............................................. ......... r _........... Smith =Raymond A _ ; + ~ .... ......... .......................f ~................... (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse s First Name MI Spouse's Social Security Number ......_._._......._...__~.__ ~.~.w__~__..~~.._..._.___.~._..~__~ ..............~.-..., THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW t~ 1. Original Retum C~ 2. Supplemental Return C~ 3. Remainder Retum (date of death prior to 12-13-82) ~ 4. Limited Estate ~ 4a. Future Interest Compromise (date of C~ 5. Federal Estate Tax Return Required death after 12-12-82) C~'1 6. Decedent Died Testate C~ 7. Decedent Maintained a Living Trust _..._~,._. 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) ~ 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST SE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ~ 717 766-3172 John M. Eakin ~ ( ) ~, .__.__.._..._.._~...~.~...__,.~......~~__...._.__._~..____.._._~M..._....~___._...~._...r__,...~~._~.. __....._~ ~.,_...._..~~._..~.....~._....._._._.._..__ ....____...__.~ ~._.~..W_.__....r.~._ _....__...._..~w_._.~ ................................. ..............................~::..,~c~...... ~.~;~ Firm Name (If Applicable) ............................................... ......... ........ ........ ........ _ ........ _.................._.._......; REGI F WILLS $E ONwK, ~ ~~ `3 ~ 6~ ~ 1 •NC f _~ ~-~ First line of address ~ „: t~+J =`~ ~' ~ tl5~ , rC"';, -; Market Square Building ~ ~ ~ K _. Second line of address i w- ~ ~' _. __ .__ _... _...._.....__m..,_._..._....~, ._..~._~_....,_..._ .._._._.. ~_,..... __ ... ~__ _.... .._ __....~. _._.. .......... ............ ....~ ........ _._ _....._.,. __~.._......._... _ .. y ~ ~, ~ .~ ~ w ~.. .~ N ;: _..._.....,.... ,M._ ._ x .._.~ ._. _..._ ... ~ ... ~. ~._~ M... __....~,_.~....,...._ ~ ATE FILED ~ City or Post Office State ZIP Code ~....____...__......_........__.._._.__._.._..__.___._.._....._._._.__.__._.._....._.__........w Mechanicsburg PA 17055 ................................................................... .. ... .......................... .....__. ...w.... ~_.._... ~...__......~___. ,..._~.._..; Correspondent's a-mail address: Under penalties of pery'ury, l 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. Decla ion of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERS~ P LE OR FILING RETURN DATE ~ Dq ADDRESS Market Square Building, Mechanicsburg, PA 17055 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS Market Square Building, Mechanicsburg, PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV 1500 EX Raymond A. Smith Decedent's Name: Decedent's Social Security Number .................................................................................................................................................. 183-12-4006 RECAPITULATION 1. Real estate (Schedule A) ............................................. 1 ~ ~ , .~,A~. H. ~ ~~. .~.~a .~ ..~~., ~ . , .,,,. a», , ~.»..._.,~ ..., ~.~ . . 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 8~ Miscellaneous Personal Property (Schedule E) ........ 5. 6. Jointly Owned Property (Schedule F) C~ Separate Billing Requested ....... 6. 7. Inter-~vos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. 480,673.14 9. Funeral Expenses 8~ Administrative Costs (Schedule H) ..................... 9. 27,474.52 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ................ 10. 64,760.93 11. Total Deductions (total Lines 9 & 10) ................................... 11. 92,235.45 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 388,437.69 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ',~,.H.~.,~.~~..~ H..,.~ .,~ ~"~~~~~ ~.~.~.~.„~_.'~"~" ..,w.,.~. t an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .............. ........ 14. 388,437.69 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 .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _. 16. F 17. ...._,.___..~..~.a.._.,..,.V..~.,.....~~,~,..~.~.u,._.,..,..~._w_~.,,...~.~MM.~...,....~~.~M_,.~ Amount of Line 14 taxable at sibling rate X .12 318,437.69 ' A,,.~.....,.~~.M.,A.~~,.~.r.:~s,~». 17. ~a.,~~~...Y...u,.~,.w.~.,.~..~wa.~..~.. ~.~....,.µ,~..,.a,,. 38,212.52 18. Amount of Line 14 taxable at collateral rate X .15 70, 000 00 1 g 10, 500.00 19. TAX DUE ......................................................... 19. 48,712.52 20. FILL IN THE OVAL lF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 L 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: Fi,,~.,I~Number.:...~.::.~:..~.....,.,~~,....~~..~..:::....._.,. 3 F __ DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Raymond A. Smith 183-12-4006 STREET ADDRESS 206 Ridgeview Drive CITY Marysville STATE PA ZIP 17053 Tax Payments and Credits: 1. Tax Due (Page 2 line 19) (1) 48, 712.52 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 654.01 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 49,366.53 A. Enter the interest on the tax due. ~ (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 49,366.53 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ 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? ........................................................................................................................ ~ ^ 1F 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 ,des not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Raymond A. Smith 21-08-1077 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ 13,230 shares First Perry Bancorp, Inc., *See Note 418,795.00 _ __ *Note First Peny Bancorp,lnc. and HNB Bancorp, Inc. consolidated their operations in December 2008 and was thereafter Riverview Financial Corporation. The stockholders of First Perry Bancorp, Inc. received 2.435 shares of Riverview Financial Corporation for each owned, a total of 32,215 shares plus $.05 for a fractional share. On the date of death (October 26, 2008) there was no meaningful market for the First Perry Bancorp, Inc. stock as the consolidation was imminent. Sales of Riverview Financial Corporation __ __ ___ -stock have been infrequent and all in the $13.00 range since consolidation. ___ _ __ __ It is therefore estimated that the value of the 13,320 shares of First Perry Bancorp is the value of 32,215 shares of Riverview Financial at $13.00, a total of $418,795.00 _ _ _ __ _ TOTAL (Also enter on line 2, Recapitulation) $ 418,795.00 (If more space is needed, insert additional sheets of the same size) - REV 1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Raymond A. Smith 21-08-1077 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1.' Michael J. Shalonis, Funeral Home Refund 956.57 2. 1st National Bank of Marysville Account # 12,990.69 3. ' Cash 6.00 4.' '.Church of God Home, Patient's account 245.19 5. ' Highmark Refund 422.90 6. Progress Energy 347.20 7. .1st Energy Corp __ _ _ __ 46,513.27 8. 2008 State Income Refund 276.70 9. 2008 Federal Income Tax Refund 119.62 '~ ~~' 4: ~'~ ~ _~~ - ~~ •sr,. ~ ~ . .. .... , i e ,N 1 •``vkx ~ +., ~ ~ A '~ ~ } A J. ~G r k'•'`,Jp• ~q~ s J.s . ~. i _ ' ~~" r4 `• 9 ,F ..•,{•,:i': ir• ~~"~ i' +~y"'~r 11 Y. 4 ..+ k~'?ii• .1' , .y qA ,F`r - --- (p'o . a f•~; a• { '4~a,• ~p ,~+w~ ~s a y4' +J .~ r $ s a ¢ a .,,~ ~ ... ~, ~ A ! f ., i 7. { ~` ~ '~ ~d'^ r t +~.~ s~ '"+. w +f' (i 'YJ z •~ ~e , > ~I .x "i:r. sr k _. i • F 5,~ i - "~ '~.•~ •+~ ,S{ tAiy (" •::: kt ~:.r+r "S+~•• ~ti. a.• r 4 g ~l i~t ~ r* s tf r',a { ~ A4' , i .~ ..; ~ ~ . 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Y1 Ti'~. tyf~t+~'er.,~"s~~'yy ~ d ~ y,~ ~,wz~,yfl'•~ ~ ~"' { ~n°, ..~t`syt~ Frf °J~' '~' a r ~"tl}~' i p} ~ ~t4'~i' " ' ,r'`'~.p s ~~r:,tr"~ ST OFRAYIyp XEC _.•~.:~ sir .•:J~ ~. ~'~~,~ ~ ~,.~'~4~,'~'~ Jf#F1t~, ;Y~~~tY'~y}Ff Yi.}~.t' ~ t,,..• . NIARKE7 SQUAB D A SMrTN •~- { : fi~ ` .,,~:: ~ ~_ ~~~ ~ t f ~ , E BLDG ~. .~- t ~~' ~'.~ r'1~,~~' ECHANI - f ~~' ~' , CSB11R fi ~ .. yy / . t a4 a .G -f N .w-'~ ~ ~ JJ~. ;*~~`' ~'' 2055 ~' ~ Mt r. K. yt.. ~.~'.., ~ ~ ~ ~ ~ * *' * . - ~ ; ,e;.f k 4 s . y~,yF y.~N,yy~~ a. t, ~t'Q"r~ ' J`~r-~ ~ ~~'YOy+ A I ~.M .. -'. ~F,'J~y.`A., ~.•n { ~tvV'~ MA',1 ~a•S3~J~y•Y~ ~ i, ~;v °i.7. t , ti j ,.. .. ... Detach Here ~ ~ 3 i ~' ~ ~ 2 6 ? j; 6 .. - 3p~,52~?B9 SQ '. •ftmerica~t JStock 73•Q 9 t dc° Est Corn ~~er ~f 7J' • 26)44 Pony, LLC , F1RST~NERG Y C ~N~~RMq T101y SHARES SOLD ORP STUB , ... ~ , detach Her American Stock Transf e TRADE DATE. 914.140 er &. Trust • NETPRjcEi~ y • Via!! Str ' +GO• AccoUNTNUMBER 02/72/2009 ~`.,:.. N p h'ARE P@er•Stc x $50.332000 ew G p, NY 7 ***k"""419 0269-0; CHECK ssAMp~Nr NUMBER F©r security reasons 244) fi72$ $46~ 0 7 0, 49 . check has been 'mas' your account nu 6 ked: mbar on this co TAx WiTHHE~Q mbrned Form 1099~saIeS • JOHN M ~~AKIN. ~ ~ ~ $0.00 EST OF RAYN1pNpBC . N-ARKE7` A SM(TH FEES ....,,„1--..._ MEGMgNIC BORE B WLTHHELD RG PLDG X0.00 A 7 7055 NE•T CHECKAM~UNT '_`..:..----- $46, 0 7 0.49 Detach _~'--•~ . Here __~_____ • ~ s ~~ rM ~;O~T.a ---_-.__~~~ Please rata '~«• o ~~~~ n~sNT Tqx REr ~ . (~R -n thjs stateme PAY~`sn~,s °~°tovo~ooo ~ ~ , 8 ° DG1G~M~~r -'-`" •_ Your records. ni F r 4-, state, code1626475~ @ °r ex ange oM~ ~~(:F{~ j~ ~ -``'"'`--'-. ---- IRSTENERG.Y snd tete "0• tsa~.o~~s ~ Detach CCaRP phone no. Q?/12/2p09 Here C/Q,gmericajY' Stock Tra -,°. ~ ~~/~ ProCe 11tew aldeo Lane ~1Ster ,~ V~ ads From York Trust Co. s, subs Broker and i'hone: ~ , .NY' 10038 ~ LAC s. °.. r~ `t ~ Bar7 r ~`chan~,,~ 1$-921-820U 'mnsacaon: ezt. 5820 $ as ~ } tO~ti..~«,, E$ HN M e ~co~ P'°0~~ r.., corrrn;~M .no qa~a-, OAK/N E~(EC o. ° ~S w T QF RAYMOND ~ °PY MARKET ~ ~ SMI~'t-1 " ~s" MESH QUgRE es ~ ~ For Recjp~ent AI11t~SBURG P~aG A 17p55 0~ 914••14 ~ ~s ~ jmA~nt ~, 0 SHARES tax jnfon~nad n f)Lp~ ~ b vn ~~...,1 Oi, ~P+n ,~~ a 3enrjrnat Revenue ~ •~~~~°f t°g° oe. M you are re requ~d __ their ~ e ~ ~jo a ~, ~ t~utll ., nattrn ~' the •aAient °an ..............••. ~:.•..• not tak - tad _ - ~ • .. °n ~'• snount ° a ass on penal s$~gence -- ~ •........ ~ bax 2 • .. sa ~ or other ,....:,..: ~.,... ^ -ktjon maybe - - ~ is jncom~ Oq YaU'jf American Stock ~'ranl~er ~ ~'ust Gornpany LLC s .. a aai S >~ ~. A a ~~----- ~' .. ,.,. INFORMATION STUB Record Date 0/2009 PaYabie Date CertRi flea ed Shares 03/01/'2009 Dividend R R E r D! 7RIB TI N 0•.0000 Record Date ate 0.5500000 Gross Dividend Book Shares Account. Number. 502.78 0.0000. Record pate 0000353435 Taxes Withheld Plan Shares Net Dividend Reinvested 0.00 Dividend Relnvestme~ QP00 0.00 Net Dividend Amount Net Dividend paid 502,78 261.44 FIRST`ENERGY C ORP 502.78 Check Amount 502.78 Detach Here RAYMOND ASMITE-! +D'vidend ReinVeStment Enr l p You we e~ enrol! in the Dividend R rnlv?~1ellt tease the box stment Plan, designated area below. at the left and si 1 hereb 9n in the (AST} ~ m point American -Stock Tr payable to Y agent to receive an artsfer $ Trust Com me, and to purchase full and fr account. !understand Y cash dividends that m y bei,ome accordance with that all Plan tr ~Onal shares for m and g4Vemed b ~sactions wil! be conducted in Plan as set forth in the plan B~tichureerms and Conditions of the received and reviewed. a co •: •:::•.:,.•:..•,•• ..,,,, . pY of which l have `1111•••:1 .1 •• ••. 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Address tine 1: Address l,rae 2: CI /State/ZI code• uetaCh Here 4PERA7IQNS CENTER 6201 157H AVENUE BROOKLYN, NY i 1219 Telephone; 800-738-3402 Web; www.amstock.com YE R-T pq~ Gross Dividend 502.78 Taxes Withheld o.oo Check N b 301365718 Cf~an e of Detach H !f You wish to chan g Address address chan e ~ the address on that chart esg corm and sign in the desj r account, please corn submitted via this method istered gnated area below, plate the names on the Please note For into account may not be rmation regardin consult htt 9 changes to .the us usin p'~f~'•amstock.com/ registered g the informatior- Shareholder/sh transfinsta e(s)' ple~e change f provided ho °~ s above. 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When shsres p ~~ by authorized Mr is a corporation art ~~ ioi Date person. ~ please.siQn ruit C°~P N tt ^~^ide bmust sign, Y duly ~suthol~~d o~j car tt as executor administ giving foil titii as suchmtor, attorney, tr signer is s ere 49 --- --1 -1 ~".`i'; ~1` . ~ -: i REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDI~LE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Raymond A. Smith 21-08-1077 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES; 1' -Rice Memorial Works, Marker _ __ 125.00 . __ __ _ __ __ _ _ __ _ __ __ _ _ _ _ , ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 16,000.00 Name of Personal Representative(s) John M. Eakin Social Security Number(s)/EIN Number of Personal Representative(s) 189-18-6991 streetAddress'Market Square Building city' Mechanicsburg .state PA zip 17055 __ __ _ _ __ _ Year(s) Commission Paid:':. part 2009 part 2010 2. Attorney Fees 10, 000.00 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. Probate Fees 464.00 5. Accountant's Fees 6. LL~~G(' ~l~ti'~r1 ~'ptt.-(irt~l , l~~t~5t~,~i't' Iac~ 43.80 7. _ _ _ _ _ __ _ The Sentinel, estate notice _ _ 118.72 s. The Cumberland Law Journal, estate notice 75.00 s. Register of Wills -Filing Fee 30.00 10. ' Register of Wills -short certificates __ _ _ _ 8.00 ~ 1. __ _ _ __ :Greenawalt & Company, tax preperation 525.00 ~ 2. Perry County Times, Newspaper Ad __ 85.00 , TOTAL (Also enter on line 9, Recapitulation) $' 27,474.52 (If more space is needed, insert additional sheets of the same size) ' REV-1512 EX+ (12-d8} r pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Raymond A. Smith 21-08-1077 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH __ 1 ~ :Harrisburg Pharmacy 113.93 2. Hospice of Central Pennsylvania 14,625.00 3. 1st National Bank of Marysville Line of Credit # 800002911 50,000.00 4. ' 1 st National Bank of Marysville, bank box 22.00 __ __ _ __ __ __ _ _ _ _ _ _ __ _ __ TOTAL (Also enter on Line 10, Recapitulation) $''! 64,760.93 If more space is needed, insert additional sheets of the same site. REV-1513 EX+ (11-08) ~ Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Raymond A. Smith 21-08-1077 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I I TAXABLE DISTRIBUTIONS (Include outright spousal distributions and transfers under 1. 2. 3. '' 1.. 1. If more space is needed, insert additional sheets of the same size.