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Home My WebLink About01-12-10REV-1503 EX+ (6-98) SCNEDI~LE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER C~A~~oa ~. ~3D~,~er All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. D2\AwAC+2 ~~~ ~I.2`9 OYp~'•~S. ~u N~ 3-k~. ~-F3o S~~,re s P-k ~ 3 „'l "I per s`.A re 1 2433 w ~-IlZ CUSP ~ Z~lSgo~g~lo ) 2. ~eaecP~c~- i~~~h 3'N C~ch2 poN~- Tvr~~ C1ASS p- -7q+~.1y5 ~~-.ac-e S ~+~ ~ (o.Glo per- s~a~e S S2..1, "2.5 ~.szP ~' ~~~} tg5~og 3' ~~~N '~1A~1~C.1`~f..I/L. t?O'V'T. -~I~1C.at`n2 ~t~N~ 1'vWt~ 5'-\`3. °i21 S~t~.c-es w-~' ~ G ,38 Pet- S~~re_ ~ i IDl o q~ ~`5s t' ~ ~ ~01+11'Bs~ ~. Nuv eef.1 ~A ~lvwic~ C,w,\ ~uN~ ~ 12Z S~At-e S Air ~ 12 . l'Z der shame ~ ~ ~ $2 , b8 ~SiP ~t la`lC~(,l~l01 5, b~~et~~eicc~et- P>~ 'P(1.vf.,~c~Pp~~ ~uNQ. e1~s5 A 3$S.15t} ~~ces ~-~ ~ lo,bb ~r sure ~ 1©5,1~ C~.szt~ # t~~3 a~401op ~ pre~c ~e9 s~ oe4~ . 1 O s~Pt-e s A~ ~` "1$ .~i 5 Cv,gzP # tog3S~u3O~ 1g5°I,fi~ ~. ~ec-t~~o~ ~ PR~ Nl~~~oya(~\ ~Ati1~c.- s~oc.4Z, 15 S\nRt-eS 'l?-~- ~ 3 I-'(, v,°O~er s~ ~~e S to ,250 , Ofl TOTAL (Also enter on line 2, Recapitulation) I $ ~ y , ~ ~'~ n 51 (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (197) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHR SIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF •t-' p FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. m~~ ~2NtJ ~ANk~ 3~°~ ~N~~ S~t.~ ~~~1\et-s~vc-~~ PA 1~0~~~ P-ccouN~ tom, IOloto33 . SNdex~ ~~Ne -1`~.Rc~ce.-~ I>ecouN~ . ~1a-~e of C~e+~'t~ Una\wNcc~ r~ Z.S ~ 019 ~ ~'l . ~ See ~'tstt>c~neS s~~ecc~2N~ ~ ZS Ol °1. ~~ '2 • I CAS\, '~ . ~'ewel r `~ 4 • ~Wa CeMe~A~~ ~v~~E~\ `p~S - i10.0~ b5~oo S-~o,,,, i~ ~~CoN ~ pA I 1~ O o0.00 ~' I~~LSNTf re.C2\V ~ ~roM {~~Ll~ CROSS ,\'N~j~(~-1.1 CQ„ 3~~ 1~ N~}~- - ~ce~e,N{ ~~~ No -ak~c ~ec-Satota~ P~Pe'~'~ - ~~v e9 it ~ s~~\\e~- Game TOTAL (Also enter on line STOTAL (Also enter on Tine 5, Recapitulation)~S 'Z. ~O ~ 5 05~ o1"7'Z. ~O ~ S 0 S~ 01"7 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCHEDULE M COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF GR•~~t~N ~ . ~~tN~t- FILE NUMBER ~C Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' ~P~~ ~Cp \-loovet-- ~~yec' ~"i~r~esa\ ~~- ~ 'i`t~~\\9ssLivr~ , ~P1 . ~~So'1. ~l for Se~v~\C~eS Off- ~uNeC-'Pa C\~'rec}~p~` 2~v.~R\M~~sy. ~y~G~\i y for ~~r.-~c-o.l ceJ'e~~-.o~`.~, Qu~tY.o~~v~ ~v~t.s~oc-ir C,cs~s, GPS11~~-~ vlav\~-~ l~lit~C~.-.t~r-y N.7~~c..e..~ ~~k~ eer}~>~~~eS r~r-P.v e c~~N ~ K5 ~ cl es~ , ANA F\.owe+'s . • 2. 13 j s 'reS~Auclasv~ - ~vNe~-t~\ Ye~reS~n~c•¢-~a~CS '~S~ 1'1 3. ~1D~-~,,,.n~.~i~laK~ ~erm~,s-~c~\ ~.,r1~- c~~+A•~e ~~~G-`~p~-~ 325,OD B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions - U- Name of Personal Representative(s) Street Address City State Zip _ Year(s) Commission Paid: 2 3 4. Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address Cih' State Relationship of Claimant to Decedent Zip Probate Fees - ~,~~1 A K8- C~u N~ 5. I Accountant's Fees 6• Tax Return Preparer's Fees Z. ES-1 A~ ~ N `o~'~ c cam. ~`~ GP,k: orc~ ~ML1~` Awa~ ~,.AW ,oUrN ia` C~-~1~s1e Se~,~~ ~Ne9- - -O - ~ - 33~ d o0 . "D _ - ~- '15.ob g t .~,~4 TOTAL (Also enter on line 9, Recapitulation) I $ ~ ~ t ~ ~ b • ~ Z (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (~ 2.03) ' 'COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDt~LE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF /~ ~ ~vn~~N ~. ~ ~b~ NE.' ~ FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical aYnansas (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNED~ILE J BENEFICIARIES ESTATE OF FILE NUMBER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not LlstTrustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. CPTL C. ~O~N2'~ SON 50 ~o 1O2 Cer~e~ Ave, 2. ~DoNN4. ~... ~'c-ng~VS ~3~~ s~~~~. ~>,w~le~ho~N R~A~ ~PU~~~.~ 50 70 ~ec~u~Ao.~iCS~iur~ , ~~ \-1t~50 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ - ~ - (If more space is needed, insert additional sheets of the same size) N Temp-Return Service ° Requested 0 MID PENN BANK Making things happen jor you.. 349 Union Street • Millersburg PA 17061 MPEN :~ '~ $ .~ PAGE: 1 ACCOUNT: 106633 11/13/2009 DOCUMENTS: 1 rr~~~~n~~~~nn~r~r~~nnr~r~~~rtr~n~~~nr~r~n~n~r~r~r~~~ 000622 0.8099 AT 0.357 TR00004 CLAYTON E BOHNER-CNTRY MEADOWS <C> 15 6342 S POWDERHORN RD 0 MECHANICSBURG PA 17050-2087 1 *** F I N A L S TAT E M E N T INDEXED MONEY MARKET ACCOUNT 106633 0 N N N ~O O 0 0 ~o rn 0 0 0 0 0 N N t0 O O N O .ct N O O O O N O Z ~2Y W O a r\ ~ N ------------ DESCRIPTION DEBITS CREDITS DATE BALANCE BALANCE LAST STATEMENT ............................... 10/15/09 25,019.87 CLOSING WITHDRAWAL 25,019.87 10/28/09 .00 BALANCE THIS STATEMENT ............................... 11/13/09 .00 TOTAL CREDITS (01 .00 TOTAL DEBITS (1} 25,019.87 THE DISCLOSURE PERIOD FOR THIS ACCOUNT IS 10/16/09 THRU 10/27/09. - - - - - - - - - - I N T E R E S T - - - - - - - - - - INTEREST PAID 2009:. 19,87 - - - ITEMIZATION OF NSF PAID AND RETURNED ITEM FEES - - - THIS PERIOD YEAR TO DATE NSF PAID ITEM FEE: .00 .00 NSF RETURNED ITEM FEE: .00 .00 OVERDRAFT FEES: .00 .00 Phone: (717) 692-2133 or (717) 896-3140 NOTICE: iEtt eo w wv~'w.midpennbank.com • Member FDIC Ses reverse aide for important information.