HomeMy WebLinkAbout12-30-0915056041169
REV-1540 EX (06-05) OFFICIAL U8E OI~.Y
PB u~eau of ~ T Coesih- Code Y~ Flee NtNnber
pp~ tNHERtTANCE TAX RETURN nn ~ D~D~
Harrisbug,PA17128-0601 RESIDENT DECEDENT o~ 1 U
ENTER DECEDENT INFORMATION BELOW
Social Security Number Dale of Death D~ of Birth
,~'a 6 -~ / 6 - j .~ I~ ~ ~~ - ::2 ~ = .z ~ ~ '7 ,asG - ~ sue- i ~~ z ~
Decedent's Last Name
Suffix Decedent's First Name
~o.t'
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffuc Spouse's First Name
Spouse's Soaal Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
MI
~`~'1
MI
FILL IN APPROPRIATE BOXE8 BELOW
Q 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Umited Estate ~ 4a. Future Interest Compromise (dabs of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
S. Deoeder~t Died Testate ~ 7. Decedent Mined a LiWng Thist 8, Tblel Number of Safe Deposit Boxes
(Attach Copy of W~1) (A#a~ Copy of Trust)
9. Litigetlon Proceeds ReceiMad ~ 10. Spotpial Pov~eity Cred9 (data d deMh ~ 11. Election to tax under Sea 9113(A)
b~-een 121-91 and 1-1-~ (Attach Sch. O)
CORRESPONDENT - TIMS SECf10N ttUST ts'!E COW'LETt~. ALL At+~ t.'Oit~N't1i1t. Ti11X NiFORMATWf! SHOIED t~E DBtECTB3 T4:
Name Daytime Telephone Number
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Firm Name (If Applicable]
First Hne of address
~,/ „x%1,7 C •-<'~ ~' Y ~-'r ~' ~ C f
Second line of address
City or Post Office State ZIP Code
Correspondent's a-rrrad address: •~ ~" l•~fl~`' ~~,~, ~='f, ^~ ~`~} (,.r""~~~~' ~' .~ ~~ ~'1f
REGISTER OF WILLS USE ONLY
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Undue penalties of perjury. l declare that t have examined this return, inducting accompanying sd~edules and statements, and to the best of my knowledge and belief,
it Ps true, correcx and aorrrplelie. Declaration of preparer other than the personal represetrtative is based on aq information of which pnvparer has any krwwieClge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
ADORESS
/ e~"/" ~ C /~ /'I_~ lye' !-~ ~ L"~ L-~.j C-....`f - /~,'r~ ~' G'-U C ~-f r'-y; / >'.'Z ` .!_. s +~ rL .'' l ., ! ~ ~~ .
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056041169 15D56041169
J
15056042160
REV-1500 EX
Decedent's Social Security Number
_ ~- /- v ~- ~ -7 a ~
Decedents Nerve: .::~- E~ ! 1 .y%~i' . .,,,,T ~7' ..J't',~j "` `,"~-ZL-~.---~'~ ~-~'=~=-~~..
RECAPITULATION
1. Real estate {Schedule A) ............................................. 1.
2. Stocks and Bonds (Schedule B) ........................................ 2. ~!'
3. Ckasey Held Corporation, Partnersh~ orSole-Proprietorship (Schedule C) ..... 3.
4. Mortgages 8 Notes Receivable (Schedule D) ............................. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. ,,~;~ ~ t' ~' 'm'
6. Jointy Owned Property (Schedule F} ^ Separate 9iitiirrg Requested - ...... f.
7. Inter-Vivos Transfers & Misoelianeous Noo-Probe Property
(Schedule G) ^ Separate Bing Requested ....... 7.
8. Total Gross Assets (total Imes 1- 7} ..... ........ .. . ............ .. 8. .~' ~ ,/ t3 l5° '~'.,,~
9. Funeral Expenses ~ Admi~stratl+re Costs (Schedule H) ..................... 9.
~
~ cr .~. , .-
a .S
10. Debts of Decedent, Mor~age Liabilities, 8 Liens (Schedule I) ............... 10.
11. Total Deductions (total Lines 9 & 10) .................................. 11. ~' / ~' :.~ ! ~~ s/
r
12. Net Value of Estate {Line 8 minus Line 11) .............................. 12. _s~ ~' 9' ~~. ` % ~-''
13. Chartable and Governmental BequestsJSec 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. ~'r " ~ ~~%~ j c~
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sea 9116
(a)(1.2) x .0 15.
16. Amount of Line 14 taxable
at lineal rate x .0 y.s~ 18.
~. ~~y
17. Amount of Line 14 taxable
at sibling rate x .12 17.
18. Amount of tine 14 taxable
at collateral rate x .15 18.
19. TAX DUE ........................................................ 19.
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
15056042160 15056042160
J
REV 1500 EX Page 3
Decedent's Comole~e Address:
F(le Number -
V ~., j ~.. ~ .7 _ v 7 a _7
oECEOENT~s w~ f f _,.}
ST~G 1
CITY
.~L~'-' f~ G /r .. ~ ~ ,,t' ~i*;y L c_ ~ " STIKtE
ice- .r ZIP
,~'~...~' ~ '~
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. CreditslPayments
A Spousal Poverty Credit
t3. Prior Payments
C. Discount
3. IMerestlPenaky if appCu;abte
D. Interest
E. PenaQy
(1) Vc,L ~ ~'r ~~
Total Credits (A + B + C) (2)
Total tnterestlPenafty (D + E)
If Line 2 ~ greater than Line 1 + tine 3, enter the difference. This is the OVERPAYMENT.
Fill in box on Page 2, Lina 20 to request a refund.
5. If tine 1 + Line 3 is greater than Line 2, enter the difference. Thy is the TAX DUE.
A. Enter the intere~ on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3}
(4)
(5A)
(5B)
Make Check Payable to: REGtST~R Of WtiLS, AGENT
PLEASE ANSWER THE FOLLOWING t~UESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent rr(ake a Yar>st~et and: Yes No
a. ref~n the use or income of the property han~emed : .......................................... ^
b. retain the ria(t to desire who shah use the property trarr~err+ed or its i(corrre : .................... ^
d. receive n(e promise for Me of either payrrtents, bene~ a care? ................................ ^
2. ddeath oa~rrred attar oeoerr(ber 12,1982, did decedent trarwier properly w(1hh one year of death
witl,out reoeivtr(g a coneideratia(? ............................. . ....... . ..... . ........ ^ [~
3. Did decedent own an'irr first for"' a payable upon death bank account a secuity at his or her doh? ..... ^
4. Did decedent own an p>diyid(sa! Retirerr(er(tA+ccot(nt, ar(rM(~y, oroll(er r(orfprob~e property wf(icch
cor(~(s a bene~ry desior(? .......................................................... ^
IF THE ANSWER TO ANY OF THE ABOVE QUA !S YES, YOU MUST f,',OMPL.E'i'E 3~flULE G AID FIt.E R AS PART OF THE RETURN.
For dales ~ death on or after July 1,1994 and tetra .tarnrary 1,1995, the taut rafie imposed on the net value of Var(s~s to or for the use of the surviving
spouse is three (3} percer~ [7'2 P.S. §9116(ax1.1.)['}( j.
For dates of death on or after Ja~ntr~ry 1,1995, the tax rate d on the net value of trarmers th or for the use of the s<utaving spouse is zero (O) percent
j72 P.S. §9116(axi.lKn~]. The statute does r(otmaerrrot a harrsier th a spouse from tax, arxl the stah(tory requirements for disclosure of assets and
filing a tax rehnr(are still ~plir~ble even ~ the swing spa~+e ~ the only benefiaary.
For dates of death on or after .ktly 1, 2000:
The tax rate imposed on the net value of harmers Fran a deceased cllrld iw~y-one years of age or yauger at d~ih b or ~x the use of a natural parent,
an adoptive p®rent, or a sent of the dud is zero (0) pen~rrt [72 P.S. §9116(ax1.2)l.
The tax rate imposed on the net value of handers to or for the use of the decedent's beneficiaries is four and one-hailE (4.5j pen~r+t, e~ocept as noted
in ?2 P.S. §9116(1.2) [T2 P.S. §9116(ax1)J.
The tax rate ir(posed on the r>gt rati(e of har(sfas to or for the use of the deoedero's sibs is twewe (12) percent [72 P.S. §9116(aj(1.3)]. A sibUng is
defined, under Section 9102, as an titdividua! who has at leaust one parerdh( oorrHrior(wilfi the decedent, whettrer by bbod a adoption.
REV~1508 EX+ (8-98)
TH of vin
INHERITANCE TAX RETURN
RESENT DECEDENT
SCHEDULE B
STOCKS ~ 80NQS
ESTATE OF FILE NUMBER ~ ~ " 6 '7 - o ~ a 7
t
AB ~opsrt~ jour-o~~eel wRh right of sun-ivo~, bf ~SClo~ea a~ Stele F.
~rtmoraap®oe ~ neeaea. s~ aoa®on~~eets ae~s same a~e1
REV~1508 p(+ (6-98)
co~oTM of PENNSn-
INHERITANCE'IAX RETURN
RESIDENT DECI~i'I'
SCHEDULE E
GASH, BANK DEPOSITS, ~ MISC.
PERSONAL PROPERTY
---
ESTATE t~ Fq.E NUMBER ; L / - c --7 _ ~, -~ 6 7
~ a tt~tw„ afa ~e d~ ~e ~ -ea t~- ~e ems.
AN ~rop~'~I.ioinlh-~d+~+~~~P aWw#be~ioadon S~bsdule F.
RED-1511 EX+ (10-06)
COMMONWEALTH OF PENN.SYI.v9~WiA
INHERITANCE TAX RETURN
RESa?ENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES ~
ADMINISTRATfYE COSTS
ESTATE OF F~.E NUS ~ / - U ~ ! ~ .7 v ~
~~
D~bls of disat asst be t+spotbd an SdNdWa L
DpN AIAOUNT
A. FUNERAL E~(PENSES:
1. ~ iI :~ .:; ; .J' ~-' r/~'~:¢tc /1 ~.... /~/c, . ~i /-`^ .r'':'' r~l ~.rti t. _.5:~1~ w: t' ~= I ~3 ~- .~ ~. S~ +S~
.~ i , r` f / . - = • ~ i ~ L ~ t` ! ~.r/`2y ~ T- r'`I t t,, ~~ J ..l ~, c / /1 T i c: _y~ ~"~" ,ri ~C'j i u c.-
;;;_. i:. /~ !f P_~ 5 'l`am'"
~' ,
~ :~
B.
1.
Stale ZIP
2. IVlomey Fees
3. Famiy Exernpior>: (if de~oederrt's address is nd ~e same as mss, arch e~lartat!lon)
Clairaa~
SkaeetAddress
Cdy Slate ZP
Relatiorrahip of C to Decedent
4. Probate Fees
5. Aooormfant's Fees
6. Tax Reiun Preparer's Fens
. ~.; .- f C- ~~'' !~~-,/!~ Tip .. - '' , ~ -- ~ ! r
TOTAL (Ako ever on wle 9, Rec~iion) ~ i
(If more space is needed. insert addihonai sheets of ~e same alas)
ADMINISTRATA/E tYfSTS:
Personal erRdire~ Canmissiors$
Name of PersonM Reprosenfalire(s)
Stn~stAddress
Year(s) Coon Paid:
•---
REU~1513 pC+ (9-00)
SCHEDULE J
~o~o~a-TM of '~w+"a BENEFfC1ARIES
INHER~I'ANiCE TAX RET1XtM
RESIDENT DECEDENT
ESTATE OF
Flt.E Nt1~ER
~. ~ -. O ~ -- u '' G
RELATION~NPTO DECEDENT AMtriJIVT OR SHARE
NUI~ER NAYEAND ADDRESS OF ) RECEIIANG PROPERTY Do Not l~tT OF ESTATE
[ TAXABLE aSTRS [include ou~igN apouwi diNnbu~ons.and 1~siara ender
Sea 9ii6(axl2jj
/•~ ~' 6 ~ f r~ b G, Ci G' :~% !.a r'~ : ti I
~ C rL/ ~ ~~
r
ENTER DOI.IJIRAYOUNTS FOR aSTRIBUi'IONS SHOMIiN1ABOVE ~ LFNES 15 THROUGH 1 8. AS APPROPiBATE.ON RE11~1500 COVER SHEET
[I NON{-T~IXIIBI.F OiS"fRIBtJT10NS:
a SPOUSAL aSTRIBUTIONS t~VOER SECTION191i3 F+OR YYF~f~i/INt ElECTtON To TAX tS NOT BEING tAADE
e. c~wRrra~EANDGOtENTALasTi~euraNs
TOTAL DEPART tt -ENTER TOTALNON-~+1XA8l.E aSTR18UTI0NS ON L~ 43 OF RE1~1v0(! COVER SHEET ~
(X more apace is needed. inert eddNonar:>~ ot>!~s semis s¢ey
~ _ Q_7 _ ~7 ~ `7
1V1st;.a 3
Statement of Trust Interests
February, 2000
At the time MetL.ife demuh,afiaes, you wiN be aAocated shares of Metl.ife, Inc. Corntnon Shock, what wB be held for you in the Metlife PotcyhokierTnist.
The number of Tn,~st It~teresis you own is equal to the nun~er of sfiares of Metl.Oe, Inc. Common Stock held for you ~ the Trust
This StafiemeM of Trust tr~erests you how many Trust lrrberests you wiN own at the lime Mettife demudralizes (in other words, how many
shares of MetUfe, Inc. Common Stock wi0 be to you and held for you ~ ~ Trust).
If you warrt to buy more shares of MetLife, Inc. Common Stoclc to be heM for you in the Trust, yam, should use ttu= form pried below to submit
a Purchase Ir~sUuction. You are only ehgibte to purdtas8 additional shares ti you are being aib~ed less than 1,Ot>Q shares. Stock oaa be
parehased laroalM the Piisq~sse sRd Sail Prolram oa the first tra~Rl day ieltariRl ~e 90th day a~ the date Metl:ife'a demutualization
ire. Pmei~ase hatne9sRS rowirsd hebre ~e pie belies reftl RM he wed aaUl the canUaeRaemeat of the
parehese program. if you want to s~ the sieares of Metlrfe, inc. Common Stock held for you in the Trust, you should use the form printed on
the reverse sale of this page to subnat a SNI irisht~tion. Stack held ~ the bat caR he soM air the IPO i~rYudiea is eempleted, which
shoatd he Ro mere them 39 lays a1ler~e plm efle~lre dMe. SeN ta~eas reefed hire ~e sad pro~111 hegiat rritl eat he prolmased
eRtil the meat of ~e sale program. Ali such pun:hases a~ sales w~ be on a commission-free basis.
AuROf' s-alsrr i~eei ;v
LOTS MAY 6tN~ERT a
460 6RENTIrATER RD of
CAMP HILL PA Well-2sA6 `~
I~~~~~~~~~~~i~~~~~~~~~~~N~~~~~i~~~~~~~~~~i~~~~~~~~ll~~~~ll~~l
131e~se Vie; sere the aor~ect ~~dtlres:- appears in
tiae ~{~i~t~a~~ at the a~r~r:tape if you are
sol~raitti~~ a ~arehase €~r Sale Instruction.
Otte atta+thed "s~asiroctiart t:ard :t entities the
o~°~ct a:iress tar eat.l~ t3~~~e at transaction.
LL2
N59692
PLEASE RETAIN FOR YOUR RECORDS
Neme LOIS MAY GtMIBERT
RE.$~in IhiS Ellit~3b~r ~~~~ "~° Investor ID 8065 2304 0679
fl~ture reference
Number of Trust Interests ~s8_ `?
Sequence Number M002974033
PLEASE READ THE IMPORTANT INFORMATION ON THE BACK OF THIS FORM AND IN THE ENCLOSED BROCHURE
Use ONLY if a transaction is requested. Il~fess yrw ri:M to iRi9ate a ~, ae aeNea is required.
PURCHI~SE IMSTRUCTIQ~1 8065 2304 0679 change ~ ~~'
(See reverse side t~ ~ SEt_L~
LOIS MAY GtlliBERT
ChaseMellon Shareholder Services
PO Box 382200
Pittsburgh PA 15250-8200
~usj~i~t~tts~s~s~s~s~~ssr~n~sss~r~~~u~~~us~~sis~~sst~fsi~~
Please be awe this addr+~s appears in the
envelope r~+dow far Pun~es ONLYI
iii ~natur4- (N address befia chanced)
Make check, In U.S. dollars, payable te:
MetLife Purchase Program
Amount Enclosed
Mi~mum investment X250.00 (except as
• described in the enclosed brochure
Y ~m ~r arw ~r s ~~ w w P.O BOX X995
Hamiaburg, Pennsylvania 17111-0999 ~... ~ -~ ~ -7 _ ~ 7 ~ 7
~~~~ 1-888.9ST-0004
o~s4o~nr,r~Nasas
LOIS M JASEK
JOHN A PLESIC POA
PO BOX 712
CAMP HILL PA 17001-0712
We're here 7 days a weep 24 hours a day at 1-888-93~ ~IU4.
50 PLUS CHECKING 0536323132
Transactions BY Date
Date Description Debt CraK Balance
.. ,,
.. >.
_ .:
:~,
;~ ,
...: '58,186.07 ; _:
..
0T/09J0T CHECK 8 27Z .,0 ~ ~ % r~ " ~ a r ~-r ~ ~ _ ~'
- ;.,_
~.- . -
CHECK~#773 aj,~ • f~x'J' ~; -: ~ r°" .;: b -~.._ :,. , -'-
~OTI08107
::, 3757
:.... :.... :.. ..~ - . . ~
o
,349.0
T . rD
... .:... ... ... .....
_.: 11.06 Sa,350.13
0T/1l!!OT INTERE8T PAY~AENT ~
ons
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e`i
ransac
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1
Number Dste Amount umber Dade Arnou~N NsMaber Dale Amount
;... ... - - _ .::
`271 .~~6125 "3'~0-00 - ~ . ~ 272 07109 273 ~:;
360.00 ~ <871D9. '_3787
--. '-_0'15'1
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