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Home My WebLink About11-02-0915056051058 REV- ~ ~ O D EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number INHERITANCE TAX RETURN ~~~~~ ~- -.._.__ ,..~,,_._,,.__._. ..~....._ ~..... , PO BOX 280601 21 08 1077 Harrisburg, PA 17128-0601 RESIDENT DECEDENT , ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ..~..~.._.._....._..__....~..._. _... m....m_.~.......___W._. _-. ,.._.......__._.._....~...__.._._....._._._~~._...~..~._..._.__...__..__~~ 10/26/2008 10/21 /1922 _~._._._._~..~.w~.....~.. .~...~..~...~.~..___~~~.__.~_._~ ~,.~.....~....__......__~._._._._._._._..~.~..._._.___..._... ~.~..~...~.m..._._.m..__.....~..~..._~...~.~_._._~__.~_.___w_ Decedent's Last Name Suffix Decedent's First Name MI Smith 'Raymond A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Spouse's Social Security Number FILL INAPPROPRIATE OVALS BELOW t~ 1. Original Retum L,.:,,,,,3 4. Limited Estate CIIl7 6. Decedent Died Testate (Attach Copy of Will) C..~~ 9. Litigation Proceeds Received Suffix Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS t"~;,D 2. Supplemental Return ~ 3. Remainder Retum (date of death prior to 12-13-82) C.~.3 4a. Future Interest Compromise (date of C~ 5. Federal Estate Tax Return Required death after 12-12-82) C.~3 7. Decedent Maintained a Living Trust _,,,~,~_ 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) C~ 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. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Da ime Tele hone Number ..__..._ ..............w._._._.___._____w-..~___.~...._...-.~_.___._.__.,.__.._.__....._._._........_...___.__.w.-.._.w._.__._..._..__.........._.....w._._...~.._.~~_....._.......,.._........_.-..._..._..._._._ ....~_.._...__..._.._...... p.__..~._._._........_..._.w...___._.._,_._.....___..__...._._.......... ;John M. Eakin (717) 766-3172 ~,*~,, __~_~...._.~..___.__~~__...._._.._..,._.~...__~_._w_..._..___...___._~__._____.~....___...w__...~...~._.~___......_....___._..~...,.._.~._~.._.~_~..~...........w.~.~~..~_.._..~~.~._~ E._....~...__.~_...~..~_.~._. Firm Name (If Applicable) _._.._,.::_~~..`~`.. ... ~:.~:~ _ .................................................... 1.................................. ............ ~ , I REGI F WILLS~E ON ~ •; . • , # ~ ~, ~,y, First line of address ~ ~ ~;K~: ~ .~ :Market Square Building ~ .~ I .. __ _ - Second line of address I ~~F ~ i' t. ,. ...._._......_.__...____ _.._.,_..._..._.__._.._ ..__..__..__.~____._._...__.._..._ _....__.. ____.__. _,_.__ __ _ _. W _.__._.. ...._.._....._...__...._..___..._.....__...._...._... .._.,..__ ~. __.m_.. .._... ,., m...-.~_._ ...,.., M,. ._ ................_........ City or Post Office State ;Mechanicsburg PA ~~as ~: N ..__._..~ ....-......: DATE FILED ~ ...ZIP Code =_.....w..w....__......_._._..__._._.__.___.__...__._.._.._._._._w...__. :17055 Correspondent's e-mail address: a..~ F~~ 1^..3 ,.''T~ 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. Decla ion of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSQ~I ~E~~P LE~OR FILING RETURN DATE ~ ~ 09 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 Decedent's Social Security Number Raymond A. Smith ~ Decedents Name: 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 8 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) c7 Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. 450,673.'14 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. 27,474.52 10. Debts of Decedent, Mortgage Liabilities, & 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 '~""" `~"""""~Fx ,u""""~` `~"""~'~""" """"""""""~""""""""~"` """~"~""~ °"` 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_ 16. Amount of Line 14 taxable at lineal rate X .0 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable 15. 16. 17. at collateral rate X .15 IU,000.00 ! 18 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 38,212.52 10,500.00 48,712.52 150 e 2 L 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: a.~,,,..n..._:l Fil.,.~,_Number...:..:~..~..~~..:~_M.~..~:..:~..~............_, DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Raymond A. Smith 183-12-4006 STREET ADDRESS 206 Ridgeview Drive CITt' Marysville STATE PA ZIP 17053 Tax Payments and Credits: 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? ........................................................................................................................ ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN or ates o 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 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) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDI~ILE B STOCKS & BONDS 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 Perry Bancorp, Inc. 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 Peny __ _ _ 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 Peny 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) SCNEDVLE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Raymond A. Smith 21-08-1077 J()NN M EAKIN EXEC EST OF RAYMOND A SMITH MARKET SQUARE BLDG MECHANICSBURG PA 17055 Jj 3, ~ ' k. c..~., .~ . r ~. Ss4., ~i , i"r.,~~ j)'~~.5•f,~ .fir .'} ~y. ~ s, o .•,I Kt { +,st i # y , ~•~t ~,. a F`. M .y ''XX ~ a' ~ ~i ... ~' ~ , ~ , t"' ~ '~' ~ 'K y . ;$ta +df r.: r iEh: :~ ~' s,r a~ ~tt~ . .~. t +, rt ~, D> s. 26.144 *******419~ 244.1672E ''`~}ate. ~~. }t '}.• 'y k.F., ~ih } y~.~ r ~l. ~*.~ 1 "~~ 3. zY'.s ... ~ y}. , it 'N .1 4 4 N e• ~p~' ,~.r"~~~y*jy~!k #°. Lx::,.i~w .~~` ~' a~.{/~. ~r_,r ... ;~a* L r.~• ~,` . r` ut2t,t,~6?286ii' ~:03L~0026?I: 6.3~03~522?89 509u' Detach Here ~' Detach Here American Stock 71~ansfer American Stock .Transfer &~Trust Co., Ll tN~ORMATION STUB & 7~ust company, LLC ~ ~ ~IVall Street.Stati~ PO ~6ox 9 26144. FIRSTENERGY CORP ~ ~~.: - ~ New York, NY .1..0269-05 SHARES- SOLD TRADE DATE ~ NET PR/ CE /SHARE 914.140 02/12/2009 $50.332000 ACCOUNT NUMBER CHECK NUMBER *******419 244167286 GROSS AMOUNT $46,010,49 ' TAX WITHHELD . ~ $0.00 For security reasons, your .account number on this combined Form 1099/sales ~ FEES WITHHELD check has been -masked: $0.00 JOHN M ~~AKIN EXEC NET CHECK AMOUNT EST OF RAYMOND A SMITH MARKET' SLiUARE BLDG ~ $46,010.49 MECHANt.CSBURG PA 17055 Piease retain this statement yowrrecords. D etach Here ~, IMPORTANT TAX RE TURN DOCUMENT ATT~4CH~~D J, Detach Here PAYER'S federal antlfic#tbn RECIPIENTS federal 1 onttftcatto numbs number a a e o s e: or ex ange OMB No. 1545-0715 Proceeds From 000000000 016264159 02/12/2009 ~ ~ ~ ~ 9roker and PAYER'8 name, sheet address, ty, stab, code and telephone no. . ~o. ~rT Subatttub rsnsactions FIRSTENERGY CORP Form 1090-8 $ • C/O American Stock Transfer & Trust Co., LLC , $, ~, . ~p~ Oc~D• oro«.a. to „~ } 59 Maiden Lane ~ . ~ ,~,~ ~, ~~ New York,.NY~ 10038 s Bartering a er income w Copy ' Phone: 71$-921-8200 ext. 6820 FvrRecipient 0.o area ~ ~~ 'thi i im t t . s S por an t i f ti e ax n orma on JOHN M' EAKIN EXEC ~ ~ d e EST OF RAYMON[~ A SMITH 914:14.0 SHARES. SULQ~ ftirntsl ied c p: MARKET SQUARE BLDG or re ~ u~..~.a ~ ~~~ ~•~•-~"," Internal Revenue MECHANICSBU.RG PA 17055 Service. ff you are . uG d~ o f l 10 ~At~~o.r) on opn agate or loss re req f a a t return, a negligence penalty or other tho n checked, fhe recipient cannot take a loss on atinCitOn maY be their tax return based on the amount In box 2 ...... ^ imposed on you ff his incpme is taxatile .. . ......... .................,..,..,.,.~ ,..,.... ...,-.... -....;i,. r~..,~L+...n• and the IRS deter uetacn Here . American Stock Transfer & Trust Company LLC - ~, INFORMATION STUB Record Date Payable Date 02/06/2009 03/01/2009 Record Date Dividend Rate Certificated Shares 0.5500.000 0.0000 Record Date Account Number Book Shares 0000353435 0.0000 ecord Date R R inv sted ivi end e e Net D d Plan Shares 0.00 914.1400 Dividend Reinvestment Option Net Dividend Paid 502.78 261.44 FIHS C tNtHCaY c;UHr uetacn Here OPERATIONS CENTER . 6201 15TH AVENUE BROOKLYN, NY 11219 Telephone: 800-736-3402 Web: www.amstock.com CURRENT DISTRIBUTIQN YEAR-TO-DATE Gross Dividend 502.78 Gross Dividend 502.78 Taxes Withheld 0.00 Taxes Withheld 0.00 t i n Amount Ne Div de d 27 50.8 Check Amount 502.78 Check Number 301365718 HAYMUNU A SMI I h 49 Detach Here s s l~ ~_ as ~_ ~_ a __ i .~. 3 ~_ i~ a Detach Here Dividend- Reinvestment Enrollment Change of Address If you wish to enroll in the Dividend Reinvestment Plan, If you wish to change the address on your account, please complete the a please check the box at the left and sign in the address change form and sign in the designated area below. Please note designated area below. that changes to the registered names on the account may not' be submitted via this method. I hereby appoint American Stock Transfer & Trust Company, LLC For information regarding changes to .the registered name(s), please (AST) as my agent to receive any cash dividends thaf may become consult http://www.amstock.com/shareho/der/sh transfinst.asp or contact payable to me, and to purchase full and fractional shares for my us usingg the information provided above. Your completed address account. I understand that all Plan transactions will be conducted in change forfn should be submitted to: accordance with, and governed by, the Terms and Conditions of the ~ .,•• ~•..••.~~•::•.~•::.:•::••:••~.•::•\~••::~~ ' ' Plan as set forth in the Plan Brochure, a co of which I have ~t •~~~~~ ~•~ received and reviewed. ~~~~:,: • •,,,,:;,:,:::~. •. .::,..,,,,:.,,.,:,,,,:,,,,:,.~;:••:,:.••, .:~;~:-.~>. ~~;'*f~'#~~y .) ,• V..•.NV•.. :.N, •:,,H...Y .,\ ,\ N..•.NY.:..},,,,,,~.,:::.: •. y..~.~ y. ,.T\ : •. ,,. ~ +' ,~••~3j.~.••i;1~1\H~\11111;\~;\\\1;1;\\;;;•t '11:j1ti\•• :;Lti ;•: ~1ti;;ti~ :;`{;1 ;1 ;;tit;\~• 5 ~ ] }}M.\•.,~~~• : \:.'I~.. .J.i~~.Y.'}I:•:•'::•':• ................::~•:; ;"...... ...............•.~........~...•........~,...~.~........~......:.::,.... 1 . .~ ~ ~ . • . ( !~ .,11,• V:.VA,.::.., ... Y.\: ,~„ ,,,,•,H,:•...11:1111; .;11 X11\;\~ 1tiL111\•~•.:+.~•+.11;1;1~ ~;~1;~ ~ 111t~~; 1.::11;!:: ~ ~::; ;•:' 1~ ~ ;~;~.1~\\~. . y ~ . ~ ~ 41ti~.1\;1;111•~.;:\4•:•. ;\1lti\.;;~;`;;';1{}.;;1;•:1~ ~• / •'~\\\\1\\1\1~;,,,1\L~.\1111•~~.1~1`~\ ff ;;. ~ ; .ti , ;• .1;; i } { ~ ~( ] ~ ..~ hMFfrl111 : '111115 1\;;•,.»y •ti11,;\\;1;1\;;1;;' •~„\,:,,•:::,••:\.1; :.1;,V :::` ~L` \` •::;1` ;` ;":' ; ;ti\1\~~ : ,,.., ;. ~,:, , , ,:...,,...,,,;;.,,,:.::»~:..:::::.:,-.,:.~.,.:.::.:..:.:..-.. • ((~}-~ y~]}~=J .{yam ~ 11,.,:,,~.,~..\.\1.,, f :.:• •• Y..:., :::.:.....:, .....:,~. ,,:, ...:.....,:•:: Address Line 1: Address Line 2: 26144 0000353435 ' RAYMOiND A SMITH Ci /State/Zi code:. Please provide us with. your daytime telephone number: Signaturo Date Signature. Date Note. Please sign exactly ae your name or names appear on your ascount. Whin shares are held jointly, each holder must sign, When signing as executor, administrator, attorney, trustee or gwrdian, pleaw give full tkle as such. ff thi signer is a corporation, plsase.sign full corporate name by duly authorized otficer, giving full title as such. M signer is a partnership, please agn in partnership name by authorized person. REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 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 ___ _ __ _ _ _ _ _ _ _ __ ___ ___ __ ......... .......... ......... ............ . . B. 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 s. u;~c~ ~cck.Ph~n ~,p.~,-hnel , ~Iev~St~.F~~'~' I~~' 43.80 7. _ _ __ The Sentinel, estate notice. _ _ _ _ _ _ _ 118.72 s. _ __ __ _ _ __ __ __ The Cumberland Law Journal, estate notice ____ 75.00 . __ .......................... ............ -_ ........................ . Register of Wills -Filing Fee __ _ 0.00 ~ o, Register of Wills -short certificates... _ _ _ _ __ __ 8.00 ~ ~ . _ _ __ Greenawalt & Company, tax preperation __ _ 525.00 12• _ _ _ _ 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+ (12-08} ~ 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. ' 1st 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 size REV-1513 EX+ (11-08) ~ pennsylvan~a DEPARTMENT OFfiEVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ~ SCHEDULE ~ BENEFICIARIES ESTATE OF Raymond A. Smith NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).1 FILE NUMBER 21-08-1077 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE 1 _ I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. __ __ _ __ ,. -~ __ TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER 5HEET. $ If more space is needed, insert additional sheets of the same size.