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Home My WebLink About12-04-091505607120 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue county code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box.2soso~ 2 1 0 5 0 9 6 5 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 204 28 1346 O1 14 2005 12 06 1898 Decedent's Last Name Suffix Decedent's First Name MI GOUGH ANTOINETTE S (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW X^ 1. Original Return ~ 2. Supplemental Retum ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise ~ 5. Federal Estate Tax Retum Required (date of death after 12-12-82) g Decedent Died Testate ~ ~. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) C 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. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ROBERT C. SAIDIS ESQ. 717 243 6222 Firm Name (If Applicable) SAIDIS, FLOWER & LINDSAY First line of address 26 WEST HIGH STREET Second line of address City or Post Office CARLISLE Correspondent's a-mail address: r s a i d i s@ s f l- I a W. C O m 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 all information of which preparer has any knowledge. SIGNATU E OF PERSON RESPO IBLE FOR FILING RETURN DATE Ann G. Broscius p~- - ADD ~~~~ ~~ ~,~~~~~~ a/k/a Ann M. Broscius 301 Somer t Dri ,Shiremanstown, PA 17011 SIGNATURE 0 REP ER THAN REPRESENTATIVE DATE Robert C. Saidis Esq. ~ ~ ~~ ADDR S 26 West High Street, Carlisle, PA 17013 Side 1 L 1505607120 State ZIP Code PA 17013 REGISTE~ WILLS ~ ONLY ~ --r~~ r. : tt~~ ' ' I"~"t . li t ~ t"-? ~;. ~~ ~ .~' ..i f"p"t ~. ~ ~•_~ ~ :,~~ t _ ~ N~~~ >~-T FILED ~~ j ...i C,rr 1505607120 J J 1505607220 REV-1500 EX Decedent's Social Security Number DecedenPs Name: 14 n t O l n e t t e S. Gough 2 0 4 2 8 13 4 6 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. 1 , 3 51.6 4 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 7, 8. Total Gross Assets (total Lines 1-7) ............................._.................................. 8. 1 , 3 51.6 4 9. Funeral Expenses & Administrative Costs (Schedule H) ...................................... 9. 3 , 0 2 5 . 0 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 11. Total Deductions (total Lines 9 & 10) ................................................................. 11, 3 , 0 2 5 . 0 0 12. Net Value of Estate (Line 8 minus Line 11) ............................._.......................... 12. - 1 , 6 7 3 . 3 6 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. - 1 , 6 7 3 . 3 6 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 .o0 0 0 0 15• 0 0 0 16. Amount of Line 14 taxable at lineal rate X .045 0. 0 0 16• 0. 0 0 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17• 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 1 g, 0 . 0 0 19. Tax Due ............................................................................................................... 19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 1505607220 1505607220 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-05-0965 DECEDENT'S NAME Antoinette S. Gough STREET ADDRESS 1700 Market Street CITY Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable p. Interest E. Penalty 0.00 Total Credits (A + B + C) (1) 0.00 (2) 0.00 (3) Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is thet,VERPAYMENT. Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is theTAX DUE q. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is theBALANCE DUE Make Check Payable to: REGISTER OF WILLS, AGENT (4) (5) 0.00 (5A) (5B) 0.00 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; ................................ ^ c. retain a reversionary interest; or ............................._............................................................................. ^ ^x 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 statutedoes not exemota 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-1509 EX+ (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Gough, Antoinette S. 21-05-0965 If an asset was made joint within one year of the decedents date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Ann M. Broscius 301 Somerset Drive Daughter Shiremanstown, PA 17011 B. C. JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH ALUE OF ASSE % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1 A 7/23/1986 Pennsylvania State Employees Credit 2,703.28 50.000% 1,351.64 Union -Account 0204281346-54 TOTAL (Also enter on Line 6, Recapitulation) I 1,351.64 (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 F (Rev. 6-98) REV-1151 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Gough, Antoinette S. 21-05-0965 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name(s) of Personal Representative(s) 2,895.00 Street Address City State Zip Year(s) Commission paid 2. Attorney's Fees Sa1d15, Flower & Lindsay 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 54.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 76.00 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 3,025.00 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Gough, Antoinette S. 21-05-0965 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Ann M. Broscius -Reimbursement for priest, alter boy, organist, soloist, funeral 290.00 assistant, waitress, and church flowers 2 Auer Memorial Home -Urn 375.00 3 Catholic Cemeteries -Grave Opening 325.00 4 George's Restaurant -Luncheon after funeral service 1,400.00 5 Gingrich Memorials -Grave marker 405.00 6 Good Sheperd Church -Funeral expenses-church usage 100.00 H-A Subtotal 2,895.00 Other Administrative Costs 7 Patriot News -Obituary Notice 76.00 H-B7 Subtotal 76.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) o~~/_~c~~ cva /~~_I1Q1 SCHEDULE J COM NHERIETAANCETAXRETURNANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Gough, Antoinette S. 21-05-0965 NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY Do Not List Trustee s (Words) ($$$) I • TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under Sec. ~116(a)(1.2)] Ann M. Broscius Daughter One hundred 301 Somerset Drive percent(100%) -Shiremanstown, PA 17011 of the residue. Total Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 15 00 cover sheet, as app ropriate, II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETS u.uu Copyright (c) 2009 form software only The Lackner Group, Inc. Eorm PA-1500 Schedule) (Rev. 11-08) 't.• 'i; BE IT KNOWN HEREBY, that I, ANTOINETTE SARIANO GOUGH, of the City of Harrisburg, Dauphin Count,, Pennsylvania, being of sound and disposing mind and memory, do hereby make, publish and de- clare this to be my Last Will and Testament, hereby revoking and making null and void any and all last wills and testaments and codicils thereto by me at any time heretofore made. I hereby nominate, constitute and appoint my daughter, ANN MARIE GOUGH BROSCIUS, to be the EXECUTOR of this my last Will and Testament. I give, devise and bequeath my entire estate, real personal and ., mixed, and wheresoever the same may be situate, to my daughter ANN MARIE GOUGH BROSCIUS. IN WITNESS THEREOF, I have hereunto set my hand and seal -t~.s ~ ~~:. i ,,~,.,~ day O f _~,~._,.,% ~; ~ ~ ~~ ~y ~ ~ ~ ~ I~+_ 1 ~ yam, m 'n'-- -' - -~. ~ ~- ~. -•-" ~ __ ~ ~ ,.~..rN ...,~ =_.._, Signature ~,~:~.~~ ~~,~~-~~-M1~n,T.~~~~~'J ..~-'~` ~t-.'- ~~` ATTESTATION: This instrument was by the said ANTOINETTE SARIANO GOUGH, on the date thereof signed, published and declared by ANTOINETTE SARIANO GOUGH, to be her LAST WILL AND TESTAMENT, in our presence and in the presence of each other have hereunto sub- scribed our names as witnesses: .~ ~} ,--, r ~ s t'' .t'' ! .y r /J _, ~ r .- - _ - / ~_ `: ~ ~ IIUIIIJUUIy~ I H 11 I UU'/ V I V IvvV~ [.vi i vcv ,i~uiiuiirriuv~ we(~site ~ i7ttgs://~nn;~rns.~sec~.coev~ USE YOUR PSECU CHECK CARD FOR MORE THAN JUST GROCERIES' PAY FOR DINING OUT ONLINE PURCHASES UTILITY BILLS, AND MORE' I~~iIII~~~IIlit~i~til~~tII~II~i~IiI~~~Ii~I~It~II~~i~~~II~II~~I JOINT OWNER ANTOINETTE S GOUGH ANN M BROSCIUS 301 SOMERSET DR SHIREMANSTOWN PA 17011-6539 o2o4xxxxxx ?::~g7;ATElVIEN'3':f?EF~(OD ::~<:s zi<'~l:Wf1<iy ii:~ `:'~17i'i~5'' 01010 013105 PAGE 1 •• ::~:::.:~::::::::::.~:::.~:::::.:~ . :.~: FINANCE .::::~FA:C?FY:,:::. •.;:Ti~AMSAlG71f~N:::..:..~..~.::.~:.:::::.:Nf=1tY.,::::.~::.:.:::::::;. ......IAN.... ....:.......... . _ .................................. :.~: ,:;:: .::., . .... .. .................................... .>:>:<:.;;~,~:.>:•::>.::~«.::~:.::cflff&D .flit..... .. .... :::::::... ................. ........:..::::..:.::..~:.:::::,....~::::..:::::..,.:.............................:..............:..: •:•: •:::::::::::::. .:::..:: HARQE ..::~1~.AAfd~.........................I!~'~'..................:.:.:..:g}l~.At~tt/~;:;•:~::•;;::~:•>:;:: ........ A ..............1yA : •:::.::....:..................................................:.....:..:::,::..:•::. ~. ~ ::...::....,:..:.............. ..... ......... ~.. ~ .............:.:.::.:. ::..:.................................................................. . .... ..........:......................... RFBI:[ti ..:.... . O1/O1 ID O1 REGULAR SHARES BEGINNING BALANCE 5.03 01/31 ENDING BALANCE 5.03 DIVIDEND YTD: YEAR TO DATE O.OQ_.. _.. 01/03 PAYMENT: DIRECT DEPOSIT US TREASURY 303 970.30 3645.89 TYPE: RR RET ID: 3031736071 01/07 WITHDRAWAL AT ATM... #0.000.7488/W43003.. .....1.0.0,..0.0.-.._._.35.45....89. FROM BROSCIUS,ANN M XXXXXXXXXX SHARE O1 O1/10 WITHDRAWAL VIA HOME BANKING TRANSFER 100.00- 8445.89 TO BROSCIUS ,ANDREW XXXXXXXXXX ..SHARE _ O1_____ ____ TO SIEMON,CHRISTINE XXXXXXXXXX SHARE O1 01/13 CHECK 002180 5543.00- 2702.89 01/15 WITHDRAWAL AT ATM #00009393/W43003 _ __ _ .,__ 5.0.0,.._0.0- 2202..89 FROM BROSCIUS,ANN M XXXXXXXXXX SHARE O1 01/17 WITHDRAWAL AT ATM #00009705/W43003 100.00- 3102.89 ATM STAR NETWORK 5000 LOUISE DR 01/18 PAYMENT: VIA HOME BANKING TRANSFER FROM SHARE 07 5.43 1908.32 01/19 DEP PRENOTIFICATION FROM RAILROADRETBOARD 01/19... CHECK 002182 _ 375 00 .1,533 32 COMMONWEALTH OF PENNSYLVANIA DEPART~NT 1,~'.~tEVENUE INFORMATION NOTICE DEPTAU280601DIVIDUAL TAXES AND FILE N0. 21 HARRISBURG, PA 171za-o6ol TAXPAYER RESPONSE ACN 05144020 DATE 10-24-2005 REV-1543 EX AFP C09-DD) EST. OF ANTOINETT COUGH S.S. N0. 204-28-1346 DATE OF DEATH D1-14-2005 COUNTY CUMBERLAND TYPE OF ACCOUNT SAVINGS ® CHECKIN( TRUST CERTIF . REMIT PAYMENT AND FORMS T0: ANN M BROSCIUS REGISTER OF WILLS 301 SOMERSET DR CUMBERLAND CO COURT HOUSE SHIREMANSTOWN PA 17011 CARLISLE, PA 17013 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you wer® a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this forty and return it to the above address. This account ~s taxable in accordance with the Inheritance Tax Laws of the Comwonwealth of Pennsylvania. Questions may-be 'answered by calling i7i7) 787-8327. - COMPLETE PART 1 BELOW ~ ~ ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No . 0 2 0 4281346 - 5 4 Date 0 7 - 2 3 -14 86 To insure proper credit to your account, two Established C2) copies of this notice wust accowpany your Account Balance 2 703.28 PayRlent to the Register of Mills. Make check ~ payable to: ^Register of wills, Agent^. Percent Taxable X 5 0. 0 0 0 1 351. () 4 NOTE: If tax payments are made within three Amount Subject to TaX , (3) months of the decedent's date of death, Tax Rate X . 045 you may deduct a 5% discount of the tax due. 6 0 . $ 2 Any inheritance tax due will become delinquent Potential Tax Due nine C9) months after the date of death. PART PAYE R S ONSE A R E : 4 .- '~ - ..- ...-. - • ~ ... ...S.T .. ~ ... . .. ++... . ... ::~ 1. ......~.t t T.T ::~~i~ ~ : -.. ...e:.... x :.:^r..... -r...r.~-.- ..- ..... .......:zs'.~ :s.,'z,-...:cT ^.:c''s::i! :c:•s»::^e::: = ::~^'::i»~ :' :s:i~~' :s'.x".^...'^.~'s.:i:r rr.« ::::::c:r.:::iis~-~. x:~-s .ssr:s ~''~ :, t:4;_ :'•:.?i-s..-'~i.'i:e.c' ~eYi't ' :.s: A. ~ The above information and tax due is correct. 1, You way choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interes#, or you may check box ^A^ and return this notice to the R®gister of DNE wills and an official assessment will be issued by the PA Department of Revenue. B L DCK B. ~ The above asset has been or will 6e reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the decedent's representative. C. ~ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART a and/or PART 3^ below. PART If You indfca#e a different tax rate, please state your a relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 f : ~ ~ f ~ ~' 2 . Account Balance 2_ ~ '% f,J° . -~:~~ 3. Percent Taxable 3 X , ~ t~. G~4~. 4. Amount Subject to Tax 4 r. .: . 1~,~,~. ~~~~° 5. Debts and Deductions 5 - :~ Gf ~f . %1' 6. Amount Taxable 6 l! 7 . Tax Rate 7 X . ~ 1 f ~~ 8 , Tax Due 8 /_' PART DEBTS AND DEDUCTIONS CLAIMED a_ DATE PAID PAYEE DESCRIPTION AMOUNT PAID ~ r. /' zs. ~_ i )L~- ~ rC.° 1 ~ j s '" _ - f/f~3-~• _1 ~ ~~~r±r~ i ? ~, ~, ,fl ;S,ry Yj'„t r ~i / i ~ f' -'~,r'r~.'~~ r ~~'/ ~.7 Jr' !~~f J-- t~l~~i /-'..'• 1 -~~:/1~~J. '}r;A`r't ..t,j ~ :..J~ ~ u i w~ t tn'Cer on Line 5 of Tax Computation) 3` 1 H~ ~~ ~t=~s_,. ,,y~~~y~'' Under penalties of perjury, I declare that the facts I have reported above are true, correct and mplete to the b t of my knowledge and belief. '~ ~~// ~~/~/ ,,~`~ HOME C `~~~) ~`%~'~' S, ~~ ~ °~ L 2%"/~~ v/ /l . ~. ~-~:'~:~~'.-C.c`~-:~ WORK C DATE __ _ _- - -- - - ~~ - - _...-- ~r ~ L~ ~ ~ ~ •,~ ~~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PD BOX 28D6D1 HARRISBURG PA 17128-0601 ANN M BROSCIUS 301 SOMERSET DR SHIREMANSTOWN PA 17011 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE DF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS REV-1548 EX AFP tD6-05) DATE D1-24-2006 ESTATE OF GOUGH ANTOINETT DATE OF DEATH 01-14-2005 fILE NUMBER COUNTY CUMBERLAND SSN/DC 204-28-1346 ACN 05149020 APPEAL DATE: 03-25-2006 (See reverse side under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO CDURT HOUSE CARLISLE, PA 17013 CUT ALONG- THIS LINE- '~"~ RETAIN LOWER PORTION FOR YOUR RECORDS - <"~ - -- -~ - ~- ~~ ------------r-w~-----------'~------------------..-----------s----r-.~--a~---.------s--------•~---- REV-1548 EX AFP t03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 01-24-2006 ESTATE OF GOUGH ANTOINETT DATE OF DEATH 01-14-2005 COUNTY CUMBERLAND FILE N0. S.S/D.C. ND. 2D4-Z8-1346 ACN 05149020 TAX RETURN WAS: CX) ACCEPTED AS FILED ( ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: PSECU ,~' ACCOUNT N0. 0204281346-54 TYPE OF ACCOUNT: t )SAVINGS 4C) CHECKING t )TRUST t )TIME CERTIFICATE DATE ESTABLISHED 07-23-1986 Account Balance 2,703.28 NOTE: TO INSURE PROPER CREDIT TO Percent Taxable ~ 0.500 YOUR ACCOUNT, SUBMIT THE Amount Subject to Tax 1,351.b4 -- UPPER PORTION OF THIS__NOTICE ___ _ -- .___ _ __ . _.___ _ D®bts and Deductions - 2, X71.00 _.__ WITH YOUR TAX PAYMENT TO THE Taxable Amount •00 REGISTER OF WILLS AT THE Tax Rate X .45 ABDVE ADDRESS. MAKE CHECK Tax Due •OD OR MONEY ORDER PAYABLE T0: "REGISTER OF WILLS, AGENT." TAX CREDITS: PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN ~1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" t CR), YOU MAY BE DUE A REFUND. CFF RFVFR~F STOF OF THTS FORM FOR INSTRUCTIONS. )