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HomeMy WebLinkAbout12-16-09 (2)REV-346 x (05-04) 3 4 6 0 0 0 410 4 2 ES7rATE INFORMATION SHEET FOR REGISTER'S OFFICE USE ONLY PA Department of Revenue County Code Year File Number DECEDENT INFORMATION: Enter data as it will appear on all ~ I O q I documents submitted to the Department. Decedents Socal Security Number Date of Death Date of Birth 1831~~~3o io~saoo9 ol~.~i~~~ Last Name Suffix First Name MI TYPE FILING: Fill in oval to indicate the nature of the return to be filed with the Department. O Probate Return O Joint Assets Only O Estate Tax Only O Litigation Purposes (No Other Assets) LETTERS GRANTED: Fill in oval to indicate the nature of the proceedings at the Register of Wills Office. (Attach additional sheets if explanation is necessary.) O Testamentary O Administration O No Letters O Other (Please Explain) ATTORNEY/CORRESPONDENT INFORMATION: Enter all data concerning the attorney or other individual to receive all tax information and correspondence. Last Name Suffix First Name MI 23~ov~vs ~©~1~ ~ Supreme Court I.D. # Telephone Number ~! yt ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ Correspondent's a-mail address: First line of address 7 /`L 0 1~ ~ ~ !7 ~ !~l o V C ~ ~~~ C G Second line of address City or Post Office State ZIP Code ~~~~..~s~~ p~ ~'7~J/3 PERSONAL REPRESENTATIVE INFORMATION: Enter all data concerning the personal representative(s) of the estate authorized by the Register of Wills. Executor/Administrator / ~ Social Security Num er Telephone Number ~~~~'0~~~3 ~1~~~~S~r~~ c Last Name Suffix First Name MI ~ ~ C ~{ ~ N .8 ~. ~ ~ ~. y N .D A .~ First line o f address j ~ '"~ Q O V ~ Q t/ J ~ p~ ~ ~ ~ ST ~ ~, ~T OFFICIAL USE ONLY Second line of address TRANSACTIl~OUNT tv c:~ c~ City or Post Office State ZIP Code ~ ~ fTt Complete general estate information questions and indicate additional personal representatives on reverse ~ ~p ~ > PLEASE USE ORIGINAL FORM ONLY ~ ~ ~ fV .~, ~ ~ Side 1 ~ ' ` 34600D41042 34600041042 J REV-346 EX 34600042043 Decedent's Name: C o-Exec utor/Administrator Social Security Number Last Name First line of address Second line of address City or Post Office Co-Executor/Administrator Social Security Number Last Name First line of address Second line of address City or Post Office Suffix First Name State ZIP Code Decedent's Social Security Number l83 J~~B'~~ Suffix First Name State ZIP Code MI MI GENERAL ESTATE INFORMATION: Enter all applicable data. Did the decedent own real property in PA? ~ Yes O No If yes, Lis/tfthe location(s) and an estimate of/the value(s) for each/j~a/rrce~l. ' r_^~ '/Pf~~ !e~ L~~P_/711I1~j1 e ~f7 /~~/~ Value $ ~TT ~ ~~ ~ Location _~ Location Value $ What is the approximate value of the decedent's personal property? $ Was a bond required in order to obtain Letters Testamentary or Letters of Administration? O Yes ~ No Was the decedent survived by a spouse? O Yes ® No If yes, what is the surviving spouse's full name? Was the decedent survived by other heirs? ~ Yes O No If yes, list their name(s) and their relationship to the decedent below. rp Name ~ lationship G~o~~k~!'r The Departm>~is autho zed by law, 42 U.S.C. §405 (c)(2)(C)(i), to require+disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the information in exchange of tax information agreements with Federal and local taxing authorities. The state law prohibits the Commonwealth's personnel from disclosing confidential tax information except for official purposes. Telephone Number Telephone Number Side 2 34600042043 34600042043