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HomeMy WebLinkAbout04-22-10 (2)15056051058 . REV-15QC1 EX (~-o~, PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes ' Po Box zeo6al INHERITANCE TAX RETURN -~°un~ Code Year File Number .,. _ ..._ arrisburg, PA 17128-0601 ~ RESIDENT DECEDENT 21 09 0742 ENTER DECEDENT-INFORMATION BELOW Socia! Security Number _ Date of Death Date of Birth _.. .._ _.. _; 177-24-6502 :July 28, 2009 _ _ _.. May 30, 1923 __ Decedent's Last Name _ _ __ ___ Suffix Decedent's First Name..... .. _ MI _ ._. _ ... _. _ __ Ro __ _ _ __ _ _ _ _ .Louise __ . ... ~I Applicabiej Enter Surviving Spouse's Information Below ? Spouse's Last Name Suffix _. _ Spouse s First Name _ ._ MI __ .. .. _......._ .,._._.,. F Spouse's Social Security Number_ ..,.._m,.m _.~,_..._- _ _........~ _. _ .. THIS RETURN MUST BE FILED IN DUPLICATE WITH THE _ _ -' REGISTER QF INlL,LS FILL IN APPROPRIATE QVALS BELOW ~r~ 1. Original Return Ca „""~ 2. Supplemen#al Return 3. Remainder Return (date of death w ... 4. Limited Estate prior to 12-13-82} ~~"~,~ 4a. Future Interest Compromise (date of ~ „„;;~ 5. Federal Estate Tax Return Required ~:~~~ 6. Decedent Died Testate death after 12-12-82} {Attach Copy of Will} ~°~~ ~~ Decedent Maintained a Living Trust {Attach Copy of Trust) 8. Total Number of Safe Deposit Boxes ".•:.;k 9. Litigation Proceeds Received tw"V„"~ 10. Spousal Poverty Credit (date of death 'ro,~ 11. Election to tax under S between 12-31-91 and 1-1-95) ec. 9113(A) CORRESPONDENT - THIS SECTION -MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL 7AX lNFORach Sch. O) Name MATfON SFIOULD BE DlREGTED 70: ............ ............ Daytime Telaphane Number .;Andrew C. Sheely, Esquire _ _ _ _ _.~.... 717-697-7050 _ _ Firm Name {lf Applicable) __ . _ __ ..Andrew C. Sheely, Attorney at Law ... ..~._... i. REGsT~R aF wl~.. ~..... ~ °~ ~ LS USLY First line of address _ _ . i C Q c..~ ~_ _._~~ ` ~~ ~~: r ~.J _. , ..127 South Market Street _ .. ~ _~ r . _3 r;,~~ ,-.yr~ S -~ `tom ~.- r'*.F r Y __ ,, _~ . d _t Second line of address - ~ V ~ ~~' \ Fl I' _ _=_:" va ~7 r O .... ..,.. ......., _. Box -; _. _ . City or Post Offrce _ .. _ .... ~ ~ `'"~ ."' _ _ _.. _. _. ..; _ _. , _..._ _ _. _ _ State ZIP Code ~":~ x ~~_..i _ ~~lL~r~ _.. ~_. :Mechanicsburg ..... M,_....._ _. _ _ _ ~,,,, .....~ ...._... __._ .._L,, .._ `PA cv ~.. ~ '.17055 ~ , r _ ____ _ _. _ , _ __ Correspondent's a-mail address: andreWC.Slleely@Ver120rf.net Under penalties of perjury, 1 declare that I have examined this return, including accompanying schedules and stateme it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which nts, and to the best of my knowledge and belief, SIGNATi.1RF.OF PE~ ON RESPONSIBLE FOR FILING RETURN preparer has any knowledge. Kerry L. Roth, Executor, 9 Autumn Drive, DiHsburg, PA 17019 SIGN LIRE OF PR/FpAfi;=,~/pTyE~R~yT~HAN REPRESENTATIVE Anna~cc ~~ Andrew C. Sheely, Esquire, 27 S. Market St., P.O. Box 95, Mechanicsbur P PLEASE USE OR16lNA~, FQRIW ONLY ~ A 17055 1505c505.1.058 Side 1 Pir 2a !a 15056051058 J J 15056052059 REV 1500 EX Decedent's Social Security Number 177 24-i'i5U1 ,. ". wDecedent'slvarns~, _ROth_~~LOUse..~. _ ___.~~...__._.__..__., w_..._ _.__. ....w. v„-,.~,m.~~,,.._. ~n i RECAPITULATION ~__ _ 1. Real estate (Schedule A} . .......................... , . , ....... , . , , .... 1. ~ y_-...,... _ $85,aoo.oo i .,. ,.., ...... . ........... - 2. Stocks and Bonds (Schedule B) ....................... . . . . . ..... . . . ... 2. $9,584.36 3. Closely Held Corporation, Partnership or Sofe-Proprietorship {Schedule C) ..... 3.i 4. Mortgages & Notes Receivable (Schedule D) .. . ....... . ...... . ........... 4. 5. Cash, Bank Deposits ~ Miscellaneous Persona! Pro ert Schedule E p y{ }.,...... 5. $83,456.66'.: 6. Jointly Owned Property {Sched~ie F) ~ Separate Biiiing Requested , ...... 6. 7. Inter-Vivas Transfers & Miscellaheous Non-Probate Property ~ "` ~`~ ~ ~"~" `" `~°°"`~~""~""°"~` """"~ `"" ' ~"'" {Schedule G) ~'"~,.~ Separate Billing Requested. , ...... 7. ', 8, .~ Total Gross Assets {total Lines 1-7) ....................... . ............ ~.~~~..W~._..w.~. -~~...~.q,~.-...~,~~...~~.,...~.,.~.....,.~~..,.,a.~..~,..,~.~~~-..~rw~.,.-~.~~, ~~,.~,~..-.~9-._~....~,~..~~ 8. ~,~.~w,., $158 041.02 ...._~~,.. ~ . 9. Funeral Expenses 8 Administrative Costs (Schedule H) .................. . .. 9. ' ~, ~ ,.._, _.,.~ ,... .~.._..,,,.~ ...,~,.,~., ,.~.... $8,117.07'. 10. Debts of Decedent, Mortgage Liabilities, & Liens {Schedule I} .. . .......... . .. 10. $3,005.21 11. Total A®ductions (tote! Lines 9 8~ 10) .......................... . ........ 11. ~ $11,122.28:'' 12. Net Value of Estate (Line 8 minus Line 11) . . . . ........... . .. . ....... . ... ~._........ 12. ....~k_..._ ,..._~,...~. ~.......-~,. ~........_ ~.....w.,. ._ _. . $146,918.74' 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ° '" ~ """ " " an election to tax has not been rt~ade {Schedule J) ....... . . . .. . ... . ....... 13. ; 14; µ Net Value Subject to Tax (Line 12 minus Line 13} ri~M~:.,~...~... w.~....., ,.~. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount- of Line 14 taxable at the spousal tax rate, or transfers, unc+~r cec. 9116 _ _ .. _ _ _ _ _ _ $146,918.74'; 16. Amount of Line 14 able _ ., .w, .._ . ,.. v.,.. _...... _....... ~, ...... .,.... .. ,,.. . at lineal rate X .045 $146, 918.74'. 16 $6,611.34 1 Amoun# of Line 14 taxable ......_ .. . ...... . ....w ..... ,.,. at sibling rate X .12 ~ ~. 18. Amount of Line 14 taxable ~' _".'. _~~,'. "'"` " """""` ' "~' at coNateral rate X .15 18 ,. _, 19. TAX DUE ............... ...... ,.................................19.E $6,611.34`' 20. FILL. IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ::"'",~ 15056052059 Side 2 . 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: __ L o u_ i s___e STREET ADDRESS 127 East Lisburn Road H. Roth ,.; FiIQ ~ly~bQr: ,, . .., ,.. ~ .. ,,,.., .,. 21 ;~ 09 ~' 0742 DECEDENTS SOCIAi. SECURITY NUMBER I77-24-6502 _ __ cITV __ _ STATE Mechanicsburg PA . _ . _ . _ _ ____-- 21 P 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1} $6 611 34 2. CreditslPayments , . _ A. Spousal Poverty Credit _ B, Prior Payments $6, 000.00 C. Discount 315.78 Total Credits (A+ B + C } 3. InterestlPenalty if applicable (2) $6,315.78 _ p. Interest E, Penalty - Tota( InterestlPenalty (D + E } 4, if Line 2 is greater than Line 1 + line 3, enter the difference. This is the OVERPAYMENT. (3) - Fill in oval on Page 2, Llne 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. {5) $295.56 A. Enter the interest on the tax due. (5A} B. Enter the total of Line 5 + 5A. This is the BALANCE DUE . {5B) Make Check Payable ~o: REGlS?'ER OF tNlLLS, AGFI~T ,_ gc~`~~~ ,., . a y 'r I w 3bB~liB .. t '9e . .. ~^xa PLEASE ANSWER THE FOLLt31NlNG 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' ................................................................ ^ to designate who shall use the property transferred or its income : ................................ h s g c. retain a ~ver ionary 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 wi#hout receiving adequate consideration? ........................................... ^ 3. Did decedent own an "intrust 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? .............. 1F THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RET a URN, h f ~, y ~or dates of death on ar after July 1, 1994 and before Janus ~ 1 1995 theta ,:. ~a ~ ~ ~ ~ ~ ~ ~ ~' ~~~ '" ""~'~~~ +~ ` z ~~` s three (3) percent [72 P.S. §9196 (a} (1.1) (i)]. ry ~ ax rate Imposed on the net value of transfers to or for the use of the surviving spouse =or dates of death on ar 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 ercent 72 P.S. §9916 (a) (1.1) (ii)j. The statute does not ex~~mat a transfer to a surviving spouse from tax, and the statutory requirements far disclosure of a sets and fling a tax return are still applicable even if the surviving spouse is the only beneficiary. =or dates of death an or after July 1, 2000; ~he tax rate impaled 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 adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)j. a natural parent, an 'he 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 '2 P.S. §9116{1.2} [72 P.S. §9116{a){1)j. (4.5) percent, except as noted in 'he 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 ~ection 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. § ()(1.3}]. A sibling is defined, under ~ COMMpNWEALTH OP PENN5YLVAN(A DEPARTMENT pF REVENUE BUREAU qF iNtJMDUAL TAXES DEPT, 2$0601 HARAiSBURG, PA 17128-08fl~ RECEIVED FRpM; REV-.1182 EX(11-98? PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT No. ~D o~ ~~~0 ROTN KERRY L 9 AUTUMN DRIVE; DILLSBURG, PA 17019 -------- ~~~d REMARKS: RECEIPT TO ATTY TOTAL AMOUNT PAID: ~ 6, 000. QO CHECK# 999 INITIALS: WZ s~AL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER ACN ASSESSMENT AMOUNT CONTROL NUMBER REV-1502 EX+ (6-98) sc~~~u~~ a COMMONWEALTH OF PENNSYLVANIA READ ESTATE INHERITANCE TAX RETURN RESff?ENT DECEDENT ESTATE OF ~~~~~ FlLE NUMBER Louise H. Roth 21-090742 M~~ ~n~~ f~®~~y vwnea saiery or as a ~~sm m Camllrion must be reported ax fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a wHiing seller, neither being compelled to buy or sell, both havino reasonable knowledge of the relevant facto --.__ ._ ..__....,., ,.~.,.,~, c~~+~ai~~vrrrai JtIGGW W UIC ~JE1~11L SIZe~ . 19~IA~.~~:El~.~.`~ BUMMARX 0~ SAI.MENT ~EATURSS 8ultJact Addrsse 127 E Ltsburit Ind Legal DeacR¢ilsn Deed Book 131 'ape l)2T ~;y M~oltanioaburg Crnmty Curribesiand gds PA alp fade 17064$6AU Cenaue Trart t?~ 1e.aa f4tRp Rei4ronna Metro:28f321t7-4 Sale Pil~a ~ NA paten! Sala NA Rarrawsrlt;tterri NA ~andsr Fatale of l.auibn H. Rath Slzs (BQUaiBFaet) 1,698 ?tlCa (ler $t}Uare Faat ~ ~acanan Average nge 1oa ve~re CandlUan Averepe Total Raanta 8 eedrouma 2 Baum 1 AAPtalear Brett 4eohthaier, PA l~t~ata Cart Gen Appr Dad al Appraised Value 712812009 fly Eatlmata o1 Valus 8 $8.000 Form 38U - ^W1nT()TAL~ appraisal sattuw~re by a la msae, inc. -- t•60t~AUtMOIIE .axDB Result Details http://taxdb.ccpa.net/details.asp?id=42-30-2114-Ofil .&dbselect= I Detailed Results for Parcel 42-30-2114-061. in the 2004 Tax Assessment Database i of 1 I O/ 15/09 2:02 PM RGV_1Gn'1 GY, ~a_~Q~ ~,aiVUt+ai.cu v °.iuc u~ x uui r aNci aavixiga ~~.njut~ j ~.d v ISE" !~. 32cs+' ~ c~~7"~' Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 08/ 2009 1 a~~ i Vl L Total Price Total Value Tota! Interest YTD Interest $1,812.50 $9, 584.3fi $7,771.86 $241 68 Bonds: i-64 of 64 Serial Issue Next Fina! ~ Series laeraom pate Accrual Maturity Issue Price Tntere~st Interest Rate Value Notr NA E $50'04/1980;.10/2009 , 04/2010 $37.50, $175.1fi' 4.00°/b i $212.66 Na E ~ $50 02/19Q4 02/201t} Q2/201 Q . _ $7.50 . _ $ I79 40 . _ 4.00% ; ... $216.90 EE _ . $50 ; 06/1983 ,12/2009 ; 06/2013 $25.00 _ $76.44.: __ .._..1.,78%..:. ... $iD1.44 ; NA EE $50 06/1983:.12/2009 06/2013 ; $25.00 _ $7fi 44._' . .,.. ,.1.78°ib ;.. . $101.44; NA ` EE $25.00... ......$76.44; i.7$ _.. . . $iQ1.44 NA' EE $50 05/1983 11/2009 05/2013 $25.00 76.44 ~ _. _ $._... _ , 1.78%', _. ; -- $101.44:, NA EE _ ; _ $50,,..05/1983! 1,1/2009 .:..05/2013 $25.00. , .- $76 44 , . _..1.78%': _... _ #1~1.44~ NA EE .$54.'...04/1983 ;10/2009. .. .:. 04/2013:... 25..00.. . $80 fi4 ; o 2.99 ~b _...._ $105.64 NA EE _ $50 04/1983....10/2009 04/2013.', $25,00.; $80.64,, _, 2.99°/b $105.64 , NA EE $50;:03/1483 09/2009 ; 03/2013 $25.00', _ $80 64' 2. 99°/b' $105.64; A EE - ~ .. 1 ... $ $ . ° _,. $105 64 ~ NA EE ~ $50' 02/1983' 02/20 0 .. 02/2013 ~ _. . 25.00 _ .._ 97.02 ~ ~_. _ .... ._. -- 4.00°a ~ ; . . ....... ..~ . $122.02, EE . $50 oz/98~: a2~aolo oz/zo1~ - $25.00 ---~ ~9~.02, - _ .._ .._ . 4.00% ~zz?.o2 . EE . , $50 , 01/1983 ! 01/2010 _01/2013 _ 25.00: ~ _ _ $~~ 02 ; . __ 4.00% .... ; _ ~ az.o2 , NA . EE $50,..,01/1983 ; 01/2010 - ~ 01/2Qi3 25.00 _ ~_ _ $97.02 ; .~ ..4.00%; _ $1?Z.Q2 Na EE $50 12/1982 ;12%2009 i ... _ 12/2Q12 , $25.00 $97.02 A 4.00°rb __.. $122.02 NA; EE . _ __ $Sb ;.12/1982 12/2009 ~ 12/2012 $25.00.... _........$97 O2_ ..4..00% ~iZ2.02 NA ~ EE $50 12/1982...12/2009 12/2012 $25.00. $97.02', . _ ° 4.00 /o . $122,02 NA, EE $50 11/1982 11/2009 11/2012 $25.00 $97,02_. ° 4.00 /o $122.02 _ ~NA _ EE _.-.. 50 ` 11/1982 11/2009 ~ $ ' _. 11/2012 $25.00 . _ $97 02 . - ° 4.00 /a X122 02 - NA' EE $50 ~ 10/1982 10/2009. . ~ 10/2012 $25.00 $102.88 4.00°ib ` _. .. $127.88 _..:.NA ?. - EE 50 ! 10/1982 :10/2009 .. 10/2012. $25.00 $102 88 : 4 00% ~ . $127 88 NA EE $50; 09/198209/2009' 09/2012 , $25, 00 $102.88 . 4 00 /o $127.88 NA EE $50 09/1982; 09/2009 09/2012 $25.00 ~ $102.88. _..- 4.OOp/o $127.88 _ NA EE $50 08/1982' 02/2010 08/2012 ,$25,00 . $105,44 , 4.00% , . $ 130.44„ NA EE $50; 08/1982.: 02/2010 08/2012 $25.00 ., . $1 05.44 - ° 4.00 ib . $13.44 NA EE $50 07/1982 ; 01/2010 ., .07/2012 $25,00 . $.105.44 ; 4. 00°/b _, .. .. $130.44; NA EE $50 07/1982 01/2010 07/2012 ~ ..$25,00 .$105,44; . 4.(f0a/o _ $13.44 NA EE $50 06/1982 12/2009 06/2012 $25,00 $105.44 _ 4.00°ib $130,44. NA EE $50;,06/1982,;12/2009 06/2012 . $25.00 _ $105.44 . 4.00%, _.. _.- .. $,130.44 : NA EE $50.06/1982' 12/2009 06/2012 $25.00 $105.44' 4.00% , .. $130.44: NA EE $50 05/1982 11/2009. _, ...- ..... 05/2012 . $25.00 $105.44 ; 4.00/0 $130.44 NA EE $5D 05/1982 11/2009 .. 05/2012' . $25.00 ..,.. $105.44 4.OO~ib ' $130.44 . NA EE $50:04/1982 10/2009. 04/2012 $25.00 $105.44 _ . 4.00°ib- _ $i3Q.44 $50 03/1982 09/2049 03/2012 ..$25.00 _ $105.44 4.00°ib $130.44.: NA EE $50 03/1982 09/2009 03/2012 $25.00 $105.44; 4.00% .. $130.44 NA _ EE ~ $50 02 1982 02/2010 . 02/2012 $25.00 108.04 ; -_ . ° 4.00 /° ._ $133.04 NA EE $50 01/1982 01/2010.. 01/2012 $25.00 $108.04; 4.00%~ .. _ .. $133 Q4; NA EE . $50 , 01/1982 , 01/2010 01/2012 $25.00 $108.04: ° 4.00 !o . $33 3.04 NA EE $5(f 12/1981 12/20U9 12/2011 $25.00 - $108.04 _ 4,00°rb __ . _ , $133.04 http://www.treasurydirect.gov/BC/SBCPrice 8/21/2009 1;81G1X1'BteCi V alUe O~ z OUr rapCx~ aavi[~pya nu,.~ut~1 c..d ~t ~~ ~~ . r~ ~~~ NA EE _ $50' 12/1981,12/2009' 12/2011,... NA : EE $50 ,12/1981;:12/2009 , 12/2011,,, NA ~ EE _ $50 l 1/ 1981,11/2009 11/2011 NA EE $50 ], 1/1981; 11/2009 1I/2011 NA:_ EE . $5009/1981'09/2009;_ Q9/2011., NA EE _ $50; 08/1981_; 42/2010 OB/2011- NA~ EE $50; 07/3981; Q1/2010 07/2011,_ NA' \ EE $50, 07/1981 01/2010 . 07/2011 NA EE ~ , $75 07/1981'..01/2010 07/2011 NA EE $75 06/1981 ~ 12/2009 06/2411, NA EE '; $75,05/1981;11/2009; 05/2011; NA EE $75 04/1981.10/2009 ; 04/2011. NA EE $75.03/1981 09/2009. 03/2011. NA EE $75 ~ 02/1981; 02/2010 02/2011 NA EE __ . , $75.,12/1980 ~ 12/2U09 , 12/2010.., NA! EE $75 ~ 11%1980 ;11/2409 ii/2010' NA , EE $75 ; 10/1980 ].0/2009: 10/2010 NA EE , _ $75 { 09/1980': 09/2009: 09/2010 NA EE $75 08/1980 02/ZOIO 0 08/201 NA EE $75 07/1980' 01/2010 . _ 07/2010 NA ; EE $50 07/1980 01/2010 ;. .07/2010 NA E $50 , 06/1980 12/2009 ~ 06/2010 NA E , $50 05/1980 , il/2009. 05/2410 , NA _ E $50 04/i980' 10/2009 04/2010 To#a!s for E-4 Bonds ' Notes NI Not .Issued _._.. NE Not eliglbie fx~r payment _. P5 Includes 3 month Interest penalty MA Matured and not earnin interest http://www.treasurydirect.gov/BC/SBCPrice $25.00'. ...$108 04 .. 4.OOpib _~. X133.04, . . $25_.00 ... $108.04; _4.00°/a : $133.04_, _$25.00 $108.04: 4,00%' 133.4 _. ..$25,00 $108.04._ 0 4.00 /o ~ $133.04; __$25,00 _ $.108.04: 4.00% $133.04! $25.00; $110.70; 4.00% X135.74 ,.. 25.00 $ 110,70 $ 4.00 /o ° , X135.70 ..$25.,00 . $110.70.,. _ _ ,.4.00% __ . _ $135.7 , _. $37.50 $166.05. 4.00% $203.55 $37.50; $166.05_ 4.00¢/°; . ,. $203.55] __, $37.50 $.166.05 _. , ...4.00% _ . $Z~3.55 $37.50 $175.11 4.00°~a' 212.fii„ $37.50 $175.11: 4.00°Ib ! $12.61 $37.50 , $179.37. 4.00%a' $216.87 _$37.50;_,_ _.. ~179.37* . _4.00%_4_ _216.87,_._, ,.. $37,50' $179.37 4.00°~' .. $216.87' ~ $37.50'. ., $ 199.11 4.OOa/o $23fi.61, .... . . _ $37.50 . .. $199.11.:.. _4.00% , . . . . $336.61 $37.50 _ _$203.85 4.00°!°! $241.35 . .... . _$37.50., $203.85; 4.00°ib _ ... . .. $241.35: _ . - $25..00 ; 135.90 ~ $. - , 4.00 /o __ _.. ° 160.90 $ _ . _ ...., $37.50 $1?7.32_, . ,,4.00%' $214.82 ........... ..$37.50. $177.3.2:. . 4.00% $214.82,.......... ......$37.50; $.175.16; 4.00% _ $2.12.66::. . 1,812.50: $7.771,86 ~ 89.584.36 8/21 /2009 REV-1508 EX+ (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, Ot MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ART ESTATE OF Louise H. Roth Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F FILE NUMBER 21-09-0742 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Decedent's vehicle -1988 Chevrolet sedan, VIN 1 G1 LT51 W9JY518690 $250.00 2. Citizens Bank -checking account #610067-539-4, principal and accumulated interest $46,327.66 3. Citizens Bank -Money market account #610642-485-7 $14,582.33 4. Cash -various denominations $140.00 5. Decedent's personal contents at residence $1,500.00 6. Verizon -refund $10.00 7. Decedent's 2008 Real Estate rebate $300.00 8. Decedent's 2009 Federal Income Tax Refund $346.67 TOTAL (Also enter on line 5, Recapitulation) $ I 63,456.66 _ (If more space is needed, insert additional sheets of the same size) III I III I I II - fiet~rn to top of pale. ~ ~ • L.. L 9- V Lr. 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Ca{t Gikfzans'spp~ciac, dedicated Gold Cuskomer sen~i~ce line anytime for aaaountinfo-ntr~tlon, carnarrt ra`tas, and gnawers to your questions. u5oaz aR2a~ ~.oU~s~ N R~TW ~2T k l.I SBUR;~ Ra ~i;ct~a,wxcs~ua~ wa ~~o~~~~s4o gummery: --- . P~~~ ~.. 'Ch~rktsig page 2 Circle Gold Summery account Account Na+nbor 9nlance laal~rcie I,UUZSE H RATH '~.Adt SRatement Thic SUtam~et C~rc[e iGo[d ~heclrtig w/~ni~re~t 6~aas~,~~~-~ 44,952.16 46,327.66 14,58..13 ~4,5t12.~~ Total Dapo:it Mler,c~e 6Q,9G9.99 za, aaa. as Total RslettotusNfp eNemce 6a,6a7. a3 rb0,909.99 uaPVSIT BALANCt Ch~ckfnp Circle Gold Ciiecidng w/Xnterest 610x67-539-4 Circle Gall Money Market b1a642-485-7 -- Monthly cambined balance to waive manthty fee is Your montlzly cambined balanGFl this statement period is ~ircl~ -~~~~ ~~~n~rn~ ~~~~~~~. t1F ~' Beginning-,7 ult6 i8 2oa'~9 thrau~h Jwrty ~y, 3fiQ9 Memhar FDIC Q ~quel hloueinq Londor Cltixens Bank -g~t}~77:~-Tai;~!' ~o~ 3 Call GiHAena' s ~ecfa4, dedicated Gaid taatomar service line any time far account iMormation, cairrent n~.te~, and answers tc your questions. Beginning June 18, ~oo~ . ti~roug~l~ J:w[y 17, 2009 Checl~in+~ 4UblMARY Barlar~a i~al+~ul~tfon 61alanaR Arevious Bai,anre 44,952.16 Average Daly ~9aianGa Checks ~ .00 - Withdrawa~ks 360.51 - lntares! Deposfts & Addit~ans 1, 734.12 a- Current ~Fi~teresr Race Interest Raid ~ 1.89 + Annum Perrent~ag~ Yield Eamed -- ~._ ....,~...~_ .. . _ .. fut'~ent ~B;~lance .........,...~ ..... _ :.:,~~ 4b , 321.66 ~ _...~~,mhaT a ~~Da s IrTreresr Earyrer~! _ ._ _ ~ ~ Interest Farned Interest Paid this Year ~~I ~C~111.~. I~~CCtL~C~i'~ ~~~r~~~>1~Gnt I.uu~ar. ri~ r~u r ri Cfircla Gold Checkfin~ w/~n~re~k 614067-5394 . d5~b . 059Gr W.... _:- ..... ........ 9~1 .. _ .M.~ .....~..... _. ?.89 aG.6l TRANSACTION _. I}RTALIs wfithdrawi~~~ Other withdrawals Date Amoun! DeacrtpNon 07/01 57.53 Camcast Central Cen~tra~ PA 070109 23631501 07/p7 07 49 20.73 Pal Ea Elec Svc 090707 3412074o02ws / 07/13 19.25 2b3.00 Verizan Paymentrec 074909 717760+829,83 Shipley623z Retail 090713 ~i37100 Deppsit~ ~ Ad+dfitiuns Date AinAnnt Dsscription 06/24. 932.40 .115 Treasury 303 Sac Sec Ab2409 06/30 802,12 f'A Treasury Dept Annultar~t 090630 interest Rate Amasrnt Description 41/17 1.89 Interest Daily Balance DAte Ob/24 4b/30 6elante Rad4 Aa1AnCR Rat~- Ba11MCa 45,884.16 07/07 4b,b08.02 07/13 46,325.7? 46 68b 28 07/01 ~ , . 07/09 46,588.77 07/17 46, 327. bb 4b,628.15 Prsviaus Blanca 44, 9~2. a;6 ~_ Tot+~i WkRdrswa[a 360.51 Totmi Depasfts i! A~itians 1,734.12 * Total tntorsst P~td _., ... ~......_ .1:89 CawnM Ratanae 46,327.bb Member FQIC .1~al Fquel Housing l-nde~ ~he~k~-n~ ~1c~pur~ ~N$ai~~?7~~7373 of 3 Cell Citi~mns's ~•ciel, dedicated Gold Customer asrvlre line Any time fi~sr account i~ormatlc-n, currant rates, end answers to-your questions. ~~r~lnning 3une ~~, 2~ thra~i~h Julyr 3.7- 2Q0~9` CheCkf n-g SWMMARY Baianca Calculation 8atdn+~ Praviaus f3alancP 14,~B1.13 Ave1i'age Qa1ly Qata»ce 1,58.1.1 Checks .pp W#thdrawals ~ .OA - tn~i~resr* Deposits ,~ Additions . pa .~ Curreni .t»rerrest Rain , ~Ogb Interest Paic# 1, 20 .~ Annum PQr~ce»inge 17etd far»ed . ,1p9b Current Barlan~ ..___. - ~~,.5&~,..~3 _~ 1~umber o,~ Days I»terest Earnad 3iI I'»terast F_amad 1.20 ~T»teresi Paid this Year 1.56 TRANSACTIQN t?ETAl#.S Interest Date Amount oestrtption 07/17 1.20 Interest Dat4y Balance oats Batarrce data 6eUece Qew BAtaince 07/17 14, 5ii?.. 33 -- WS FROM C~TI~~NS --Introducing the Cirrle Giald Mortgage Advantage{TM). Get 1/8°lo off already historically law mortgage rates when yc~u opf~n a Circle Gaid Check ng(R} account with automatic payment. As a mortgage. and Citizens Circle Gold Banking{R customer you'll erl}ay benef#ts such as ijaving your monthly checking maintenance fees waived, our Circle Gold-Savings account, credit card offers withgreat razes and more.Call our exclusive castomer service number and start saving on yoewr monthly mortgage payment: 1-888-a 14-2300. --i_aoking for high y#e ds and easy access to ,your cash savings? Look na further! Citizens Dank offers savings and mans;y market accoarnts with great races and the peace of mind of Ff)IC insurarrce,~'IMheti~er you r3rre~ji~st starting out ar~laoking to pi`~serve your liquid cash deposits, we have an account to suit ycsar needs. Far mo~•e infarrnation, to open an account, ar add to your existing valance, visit yr~ur local branch today ar call 1-804-773-7373. Member FDIC, See a banker nr Fi)IC coverage amounts and transartion limitations. --The TruFix Student Loan From Citizens Bank. Featuringg a choice of repayment plans, ti3e TruFit Student Loan provides eligible students and families with financing alt>~rnatives after they've maximized grants, schalarsh#ps and federal loan options. Discuss your needs with our education finance specialists today at '1-888-333-012$, www.cidzensbank.cam/TruFftStudent. --Start prat+PCting ,your identity today. Monitor any inquiries or changes made to your credit report, view your,creditscare and receive your first month of PrivacyGuard far just $1. For details or to eriioil call 1-86c. 957-4A79. PrivacyGuard is offered by Trilegfant Carporatian, its affiliates acid providers {c~7llectively, Trilegiant). Citizens Bank is not responsible or liable for the: services pravidecl by Trileg#ant. LOIJi;SF H R~Tfi Circle C+aEd` I~ran~y M'~"h~t 61.Ofi42-4l;5-7 Pravlowe fiance 14,581.13 total tntarost P,rld ~/' 1:.20 rGaYrs~nt Aetaece 14,582.33 MerrnUe~ FDIC .Q Equnl Na+,aing Lantler Rev-i~~.t. Ex+ (to_o~~ ~ Pennsylvania DEPARTMENT OE REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ~~~.~. ESTATE OF Louise H. Roth ITEM DUMBER A. 1. SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS FILE NUMBER 21-09-0742 Decedent's debts must be reported on Schedule I. FUNERAL EXPENSES: Myers Funeral Home 2~ Funera! Luncheon -Brothers Restaurant B• ~ ADMINISTRATIVE COSTS; 1. Personal Representative Commissions: Name(s) of Persona! Representative(s) Kerry L. Roth street Aadress 9 Autumn Drive City _Dillsburg ___ State PA ZIP 17019 Year(s) Cammissian Paid, Z• Attorney Fees; Andrew C . Sheely, Esquire 3• Family Exemption; (If decedent's address +s not the same as claimant's, attach explanation.) Claimant Street Address City _ ____ State ZIP Relatiansh p of Claimant to Decedent 4• Probate Fees: ~• Accountant Fees: 6. Tax Return Prepa~er Fees: ~• Brett Lechthaler, Certified Appraiser -appraisal fee 8• Filing Fee 9• Reserves to conclude Estate Administration TOTAL (Also enter on Line 9, Recapitulation) ~ $ If more space fs needed, use add~t~ona! sheets of paper of the same Size. $5,035.00 $365.07 0.00 $1, 500.00 302.00 $300.00 $1s.oo $600.00 8,117.07 RSV-:151.2 EX+ (~.~-0~) ~ ~ pennsylvan~a SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ~~ Louise H. Roth 21-09-0742 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. Ir more space is needed, insert additional sheets of the same size. RrtE srn tr°s #nr~ of rtartsa REV-1513 EX+ (g-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BART Louise H. Roth RELATIONSHIP TO DECEDENT NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) I TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) 1. Kerry L. Roth, 9 Autumn Drive, Dillsburg, PA 17019 Son FILE NUMBER 21-C)9-0742 AMOUNT OR SHARE OF ESTATE 1 Cl0% Rest, residue of FctatP ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size) Return to top of page. r LAST WT.T.~L ~Nll TESTAI~?'f•;NT bF LO~T:I'SE ~i. HOTH T, T.10TTlS~' T-i. ;BOTH, of th® ~i.:~.lage of F3owrma,nsdale, 7'ownshi.p ©f.' Upper A7.3.ea~, C:o~~t~ty of Cumber~.and and ~3tate of. Pennsyl.van3.a, being •xf :3oYaxad r~.nd. dispos~.n~; mind., m®mory and und~rsta.nd.~.n~, do ~.ak~:, publish and declare this my Last W:3.1.1. a.nd Tc~eta~r,ent. 1.. . I direct the payment of all. trzy dust debts a.nd funeral. e~xl>®nsE~w a.s soon after my decerxsc~ as the ss,me can he convena.ently doneo ~~. r J g:Lve~, dev3.sa grid be~gi.z©ath al.l. tho rest,. r®si.dl~.e and rematnd®r of my estate, of whatsaeve.r~ raa,ture aanci wh®resoe~rM.r s:Ltuat®, to my- husbrxnd, John E. Roth, hie he:Lrs and aasigr3s„ absolu't~sly e~.nd unaond:i. ti.onal.ly. 3v In the event that my sa~.d hu.,sband, ~Tohn ~,. Roth, sh.Qz:~;l.d prede~c~o~xss m.e, or akxoui.d he d~.e~ a~ about th® ar•~me time aq :f: do, such as in a.n. aacsiderit common i,:o botk~ of us„ th®n .i.n .~u.cla event, is g3 vc~, devi.sc~ and b®qYx®ath my emir. a estate, o:~' wh+~.•Lsocve.r nat;ru.e~ ~~nd wher®soev®r si~~aat®, to my scan, Kerry Its Rath, h3.s heirs a,.rad ass3.gns, s.baolutely and. uracond.itional.l.y. 9hr-ul.d my husband, t7ah:ra E. floth, pr. edeQeaae me, ox~ d:Le at ak~r~ui. the same t:~me as I do, such as 3.xi a. common disaster, s,nd shot~7.d my son, K®rry L, Rt~t:h, also have p:red.ece~as®d me, •~Ya.e~n i.n sU.ch event, l give a.rad bdque€xth my carat~3.re~ estate to my da.~~ght®r--in-~ls.w, Dc~n~.se f2oth, a,nd. gray grs.ndchildren wh3.ah ~ r+nap have at the tame of my decoase, ghs,.re a.nd share a13.ke, it he~3 ng ~i~ intention that my said ds~ixg;~,•Fer--3.n-law and. ~;rs,radcki3.:I,dre.n ~l~ c~aah r~3caive s.:ra actual sh~ara 9.n mp~ eatata, arac~. in th:~s r©epact also, ~:'or th® plzrpos® of f~ar.,ili.ts,tia1g the se~ttlamaaZt and gust distrii~~u.ti_on of my ~:~t~•t~, _~ atzthorize a:rzd ®mpowe~r my ~xecaz.tri.x h®rein~;iftar, named, to sell. zany- and all r. as.l estate which I' xnmy own at th© times o:~ any deac~ase, tit o3.th~,r publ~.c or pri,vata sa1.~ or sal~~tsk L.tti.STLY, l nom~t.natc~, c;onst,itute and a.pp4,int my hta,sban~., .John ~~ Roth':, ~xoautor of •rh~~s xray last Wi.1.3 and Te:stamant, and in the th® avF~xat that my sr~~i.d husband should predacaas® me, or .~:~:,:o~ald h~, b® u:na~~~7.a or unwi.l.l.in~; to st~.rve in such ca.pac3.ty for ax~y ,~~eason, th®n irl stash. avant, .T. nomi.nafe, r,oi7st3 tuts and appoint nay qQn, Kerry I . Roth., Txe~cutor of this m.y last Wi11 and T.es.tamen~: in hip place end st®ac~., and sh.ou_]_d hoiah my husband, Joh.xz E. Roth9 and my son; Ker,1a^y L, Roth, prodecaase ma, or should th.oy be jznr~.b"~® t;o s®rve in such. caapac3.ty as my par. sonal represc~xatat3.v® foa:~ fa.ny rasson, th®n ~.:~ su.ch ~;ve;rtt, T xaom~.na•ta, aons~:itute and ap~~c~tnt my d.auF•kat®r-in-~.aw, 33®n~.sa Roth, Fxacutr.:4.x of this any last, lni3.1.1 and 'Sa, t~ament, i.n traeir place and s•te~zd. '1"r WTTNFSS WH.~REOF, T hr~.vc h®r. eaunto set any hand and ~+aa.1. this ~?~~ day of Apr3.I, A, :~. 1.971.. Louise I-~. Roth _2- ' ~ ~.~ne~d, sealed, xn.z~bl3shed and dec]_ared by the abov© Warn®d, Llou~.se l~, Roth, aq s.nd fox' lae.r lust Wi:tl and Testsz next, in tYae prese~:nce o~ us, who have subsc.r3_b~d our names hpx'eiao at the 1'esgues~ o.f said ~estat.r.:ix, in her ~ presence s.nd i;rz t,r~e Ares®.nca of each a~hcar~ ,r _... ,~ -~ ~,,..,..,, ~r..~. ,,. ._..,.,,,_.~._...._..,M.._,,.r. ~.....„...~,..~.~ -~ 3