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Home My WebLink About04-0561COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 004049 JAMES GARY L 134 SIPE AVENUE HUMMELSTOWN, PA 17036 ........ fold ESTATE INFORMATION: SSN: 235-40-5052 FILE NUMBER: 2104-0561 DECEDENT NAME: MORRIS LUCILLE P DATE OF PAYMENT: 06/15/2004 POSTMARK DATE: 06/1 5/2004 COUNTY: CUMBERLAND DATE OF DEATH: 03/15/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $34,000.00 REMARKS' TOTAL AMOUNT PAID' $34,000.00 SEAL CHECK# 724112899 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS June 15, 2004 Glcnda F. Strausbaug, Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 TRUST ESTATE OF LUCILLE P. MORRIS, DECEASED Dear Ms. Strausbaug: Enclosed are an original and two (2) copies of the Estate Information Sheet to be filed for the above-referenced individual. Mrs. Juanita Reda forwarded a check today under separate cover in the amount of $34,000.00 representing the 90-day payment for Pennsylvania Inheritance Tax. Please record the payment and issue a receipt for the same. Additionally, please time- stamp the extra copy of the Estate Information Sheet and return it to me in the enclosed self-addressed, stamped envelope. Thank you for your attention in this matter. If you have any questions, please feel free to contact me. Very truly yours, 1 L. Baker, CP Certified Paralegal C- Enclosures THE ..ESTATE 3ECURITY FORMULA..,. Cheryl L. Baker, CP Certified Paralegal clb~jsdc.com cc' Juanita Reda 134 SlPE AVENUE HUMMELSTOWN, PA 17036 MAILING ADDRESS P.O. BOX 650 HERSHEY, PA 17033 TOLL FREE 1.800.942.3660 TEL. 717.533.3280 FAX 717.533.7771 www. jsdc.com October 15, 2004 Glenda F. Strausbaug, Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 RE: TRUST ESTATE OF LUCILLE P. MORRIS, DECEASED File No. 21-04-561 Dear Ms. Strausbaug: Enclosed are an original and three (3) copies of the Pennsylvania Inheritance Tax Return to be filed for the above-referenced Trust. Please time-stamp the extra copy of the Return and return it to me in the enclosed self-addressed, stamped envelope. I have also enclosed a check made payable to the "Register of Wills" in the amount of Fifteen Dollars ($15.00) representing the filing fee and a check made payable to "Register of Wills, Agent" in the amount of Two Hundred Sixty-six and 53/100 Dollars ($266.53) representing the additional inheritance tax due. If you have any questions, please feel free to contact me. Very truly yours, Certffied Paralegal Enclosures Juanita Reda, Co-Trustee Muretta Yentzer, Co-Trustee THt: sEs ECURITY [K)RM L LA Cheryl L. Baker, CP Certified Paralegal clb~jsdc.com 134 SIRE AVENUE HUMMELSTOWN, PA 17036 MAILING ADDRESS PO BOX 650 HERSHEY. PA 17033 TOLL FREE 1 800942 3660 TEL 717 5333280 FAX 717 533 7771 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF ~NDIVIDUAL TAXES DEPT 280601 HARRISBURG, PA 17128 0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004512 JAMES GARY L 134 SIPE AVENUE HUMMELSTOWN, PA 17036 ........ fold ESTATE INFORMATION: SSN: 235-40-5052 FILE NUMBER: 2104-0561 DECEDENT NAME: MORRIS LUCILLE P DATE OF PAYMENT: 10/18/2004 POSTMARK DATE: 10/15/2004 COUNTY: CUMBERLAND DATE OF DEATH: 03/15/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $266.53 TOTAL AMOUNT PAID: $266.53 REMARKS: CHECK# 6029 INITIALS: JA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV- 1500 EX * ($-00) Co" R E C A P I T U L A T I O N C 0 M T I 0 N COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. Z80601 HARRISBURG, PA 17128-0601 REV-1500 OFFICIAL USE ONLY FILE NUMBER COUNTYCOOE YEAR NUMBER SOCIAL SECURITY NUMBER INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Morris Luctlle P. DATE OF DEATH (MM-DO-YEAR) DATE OF BIRTH (MM-OD-YEAR) 235-40-5052 1· Original Return 4. Limited Estate 6. Decedent Died Testate (Attach copy of Will) (Attach copy of Trust) 1~0, LltlgationProceedsRecelvecl r--il0. Spousal Poverty Credlt (date of deeth between 12-31-91 and 1-1-95) THIS RL='rURN MUS~ BE fiLED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 2~! Supplemental Return U · FuturelnterestCompromlse(dateofdeathafter12-12-82} 5. FederalEstateTexReturnRequlred Decedent Maintained a Living Trust (date of death 3. Remainder Return prl=r to 12-13-82) ~ 0. Total Number of Safe Deposit Boxes ] 11 · Election to tax under Sec. 9113(A) (Attach Sch O) NAME Gary L. James Esq. FIRM NAME (if Applicable) James, Smith, Diettertck & Connelly, LLP TELEPHONE NUMBER 717/533 -3280 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (:~) 3. Closely Held Corporation, Partnership or (3) Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Depos;ts& Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) ] Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. 14. COMPLETE MAILING ADDRESS 134 Sipe Avenue Hummelstown, PA 17036 Non~ 10,180..8~ No~ No~e 3t500.65 None 263,364. 6,266.01 3,698.12 Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) Net Value Subject to Tax (Line 12 minus Line 13) r- O.~ FICIAL USE ONLY (8) (11) (12) (13) (14) 277,045.55 9,964.13 267,081.42 267,081.42 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. 16, 17. Amount of Line 14 taxabla at sibling rate 18. Amount of Line 14 taxable at collateral rate Amount of Line t4 taxable at the spousal tax rate, or transfers under Sec. 9116(aX1.2) Amount of Line 14 taxable at lineal rate X .0 0 (15) X .0 45 (16) 133,540.71 X .12 (17) 133,540.71 X .lS (18) 0.00 0.00 16,024.89 20,031.11 19. Tax Due (19) 36,056.00 Copyrlg ht (c) 2000 form software only The Lackner Group, Inc. ~,~ Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 325 Wesley Drive CITY Mechanicsbur~ 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 D. Interest E. Penalty I STATE I ZIP PA 17055 (~) 0.00 34,000.00 1,789.47 Total Credits ( A + B + C ) Total Interest/Penalty ( D + E ) (3) 36,056.00 35,789.47 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line Z0 to request a refund (4) 0.00 5. If Line I + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 266.53 A. Enter the interest on the tax due. (SA) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (SB) 266..53 Make Ch~ck Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yea No a. retain the use or income of the property transferred; ......................... ~ ~ b. retain the right to designate who shall use the property transferred or its income; ........... c. retain a reversionary 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 without rece v ng adequate consideration? ............................... [] [] 3. Did decedent own an "in trust 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 conta ns a beneficiary designation? ................................ [] [] IF THE ANSWER TO ANY OF THE ABOVE GUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. p.~ - ~ /**) : 7 M_ay_field Road 1 .................... SIGN~EOF~E~ERO~ERTHANREPRESENTATIVE J~es, Smith, Diettertck & Connelly, ~p DATE ~~~ ~ 134 Sipe Avenue .. ' * W~i ,~' -PA-- 'i ~b~-g ....................... (O'Y~- sullying spouse is 35~P.S. 9116 la) (1.1) (i)]. . ........ ,.,a ,u ur ,or the use OT rna For dates of death on or after Janua~ 1, 1995, the ~x rate imposed on the net value of tran~em to or for the use of the sullying spouse is 0% [72 P.S. 9116 la) (1.1) (ii)[ The s~tute does not exempt a tran~er to a suwiving spouse from ~x, and the s~tuto~ require~s for disc~sure of asse~ and filing a tax return are still applicable even ~ the surviving spouse is the only beneficial. For dates of death on or after July 1, 2000: The ~x rate imposed on the net value of transfers from a deceased chi~ twen~-one yearn of age or younger at death to or for the use of a naturaJ parent, an adoptive pare~, or a stepparent of the child is 0% [72 P.S. 9116 la) (1.2)]. The tax rate im~sed on the net value of transfers to or for the use of the decedent's I~neal beneficiaries is 4.5%, except as noted in 72 P.S. 9116(1.2) The tax rate i~osed on the net value of tran~em to or for the use of t~ decedent's siblings is 12% [72 P.S. 911~aX1.3)]. A sibling is defined, under Section 9102, as an i~ividual who has at lea~ one pare~ in com~n w~h the decede~, whet~r by blood or adoption. Copyrlg ht lc) 2~ form software on~ T he Lackner Group, I~. Form R~V-~ ~00 ~ (Rev. 6-~) ADDITIONAL Personal Representatives Estate of Lucille P. Morris SS~ 235-40-5052 03/15/2004 Under penalties of perjury, the undersigned declare that they have examined this return, including accompanying schedules and statements, and to the best of their knowledge and belief, it is true, correct and complete. Signature Name Address Line 1 Address Line 2 City, State, Zip Date Muretta R. Yent r 126 Green Ridge Rd Carlisle, PA 17013 REV- 1503 EX + (1-97) I COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS & BONDS FILE NUMBER Lucille P. Morris SS~/ 235-40-5052 03/15/2004 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBEI: DESCRIPTION UNIT VALUE OF DEATH 1 Various Series EE U.S. Savings Bonds - valued per 10,180.80 printout from PNC Bank - held Jointly with predeceased sister TOTAL (Also enter on line 2, Recapitulation) 10,180.80 pace is needed, insert additional sheets of the same size) Copyrlg ht (c) 1996 form software onry CPSystem~, Inc. Form REV-1503 EX (Rev. 1-97) REV- 1508 EX + (1 -g7) COMMONWEALTH OFPENNSYLVANIA INHERITANCETAXRETURN RESIDENTDECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS,& MISC. PERSONAL PROPERTY FILE NUMBER Lucille P. Morris SS¢/ 235-40-5052 03/15/2004 include the proceeds of litigation and the date the proceeds were rece ved by the estate. All Frop®rty jointl¥-owne¢l with tho right of survivorship must bo disclosed on Schedule F. ITEM NUMBER 1 2 3 VALUE AT DATE DESCRIPTION OF DEATH Bankers Life - refund of health insurance premium Bankers Life - refund of long term care premium Miscellaneous personal property - valued per Trustees TOTAL (Also enter on line 5, Recapitulation) 2,025.65 1,400.00 75.00 3,500.65 (If more space is needed, insert additionar sheets of the same size) copyright (c) 1996 form software only CPSystems, Inc. Form REV- 1508 EX (Rev. 1-97) R~V-lS,0 EX,(1-~?) SCHEDULE G I INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA INHERITANCETAX RETURN MlSC, NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Lucille P. Morris SS~; 235-40-5052 03/15/2004 This scheduh~ must be completed and filed if the answer to an)' of questions 1 through 4 on page 2 is yes. DESCR PTION OF PROPERTY % OF ITEM INCLUDE THENAMEOF THE TRANSFEREE THEIR RELATIONSHIP TO DECEDENT ANO THE DATE O~ TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER ~TACH A COpy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF ~PLICABLE 1 Cremation Society of 898.00 100.00 0.0( 898.00 Pennsylvania ~ prepaid funeral arrangements 2 1,826.82 shs Lutheran 17,007.74 [00.00~ 0.0{ 17,007.74 Brotherhood Municipal Bond Fund - held by Thrivent Financial in Accout No. 57-7284353 titled in the name of the Lucille P. Morris Living Trust dated 12/6/95, and any amendments thereto - valued per letter dated 5/26/04 3 M&T Bank Checking Account 9,261.92 100.00% 0.00 9,261.92 No. 72295902 - titled in the name of the Lucille P. Morris Living Trust dated 12/6/95, and any amendments thereto - valued per letter dated 4/26/04 4 M&T Bank Checking Account 0.31 100.00 0.0 0.31 No. 72295902, accrued interest - titled in the name of the Lucille P. Morris Living Trust dated 12/6/95, and any amendments thereto - valued per letter dated 4/26/04 5 Pennsylvania Central 3,748.07 100.00% 0.01 3,748.07 Federal Credit Union - titled in the name of the Lucille P. Morris Living Trust dated 12/6/95, and any amendments thereto - valued per letter dated 4/28/04 6 Smith Braney Account No. 232,448.06 100.00% 0.00 232,448.06 724-05509-18 - in the name of the Lucille P. Morris Living Trust dated 12/6/95 - valued per letter dated 0.00 TOTAL (Also en~r on line 7, Re~=pa..~fi~.) $ 263. 364.10 pace is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1510 EX (Rev. 1-97) Estate of: Lucille P. Morris Soc Sec #: 235-40-5052 Date of Death: 03/15/2004 Continuation of Schedule C (Inter-Vivos Transfers & Misc. Non-Probate Property) Item Description of Property Date of Death % Decd Exclusion # Value of Asset Intrst Taxable Value 6/3/04 O. O0 REV-~9. EX.0-97~ SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF Lucille P. Morris $S~/ 235-40-5052 03/15/2004 FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER 1 2 3 4 DESCRIPTION FUNERAL EXPENSES: Bethany Village Retirement [~ome - funeral luncheon Church folders Cindl Roteman - honorarium Cremation Society of Pennsylvania - cremation services Total of Continuation Schedule(s) ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / FIN Number of Persona~ Representative(s) Street Address City State__ Zip Year(s) Commission Paid: A~orney's Fees James, Smith, Dietterick & Connelly, LLP Farnil¥ Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimantto Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees OtherAdministrative Costs James, Smith, Diettertck & Connelly, LLP - reservation for closing costs of trust administration Juanita Reda - reimbursement for postage and copies Register of Wills, Cumberland County ~ filing fee for Return TOTAL (Also enter on line 9, Recapitulation) AMOUNT 360.00 8.15 75.00 978.00 511.19 4,000.00 250.00 50.00 18.67 15.00 $ 6,266.01 (If more space is needed, insert additional sheets of the same size) Copyright (c} 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97) Estate of: Luctlle P. Morris Soc Sec #: 235-40-5052 Date of Death: 03/15/2004 Item Description Continuation of Schedule H-A (Funeral Expenses) Amount 5 Inter-Mountain Newspaper - death notice in West Virginia 6 Patriot News - death notice 7 Reverend V. Hoover - honorarium 8 Royers Flowers - flowers for funeral services 9 U.S. Post Master - postage for thank you notes 38.33 158.26 100.00 196.10 18.50 511.19 Estate of: Lucille P. Morris Soc Sec ~: 235-40-5052 Date of Death: 03/15/104 Continuation of Schedule H-B5 (Accountant's Fees) Item Description Amount 1 B&L Tax & Accounting Services - income tax preparation fees 250.00 250.00 REV-151Z EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENTDECEDENT ESTATE OF Lucille P. Morris SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, AND LIENS SS# 235-40-5052 03/15/2004 FILE NUMBER Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 Alert Pharmacy - unreimbursed prescription medication 2 3 Bethany Village Retirement Home - unreimbursed nursing home care Veri Care - unreimbursed medical bill 9.91 3,664.25 23.96 TOTAL (Also enter on line 10, Recapitulation) 3,698.12 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-151Z EX (Rev. 1-97} REV~1513 EX * (9-00) COMMONWEALTHOFPENNSYLVANIA INHERITANCE TAX RETURN RESIDENTDECEOENT ESTATE OF Lucille P. Morris SS~ 235-40-5052 NUMBER 2 SCHEDULE J BENEFICIARIES II. 03/15/2004 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [Incl.® o~rlght spousal d[strlb~fo~, a~ Juanita Reda 7 Mayfield Road Mechanicsburg, PA 17055 Muretta R. Yentzer 126 Green Ridge Road Carlisle, PA 17013 Jill A. Kent 1412 Eden Ridge Circle Birmingham, AL 35244 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Sister Niece Niece FILE NUMBER AMOUNT OR SHARE OF ESTATE 1/2 of Residue 1/4 of Residue 1/4 of Residue ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 0.00 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) Copyright (c) Z000 form software only The Lackner Group, Inc. Form REV-1513 EX (Rev. 9-00) THE [~ JAMES SMITH DIETTERICK & CONNELL¥ LLP __ Hershey, PA 17033-0650 h"llh"llh,,,,,Ih,lh,,Ih,,Ihh,h h,,llh,,,,,ihlh,I Glenda F. Strausbaug, Register of Wills Cumberland County Courthouse I Courthouse Square Carlisle, PA 17013-3387 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXE!l)C('(\Q:-,T, r;::::!(T OF INHERITANCE TAX DIVISION P:""JUII'..I'".i.., '..' I h,.,,,, NOTICE OF INHERITANCE TAX PO BOX ....., . AffQA',tSEMENT, ALLOWANCE OR DISALLOWANCE HARRISBURG~ PA 17128-D601 ' : " Ot""bEDUCTIONS AND ASSESSMENT OF TAX 200S JAN 10 Mi 9: 1+ 7 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN GARY L JAMES JAMES ETAL 134 SIPE AVE HUMMELSTOWN ClERi( OF ORPHJ\N'S COURT ..",,,~~,_,, r,,\ E-.WlWib:-"" ! ,', 01-03-2005 MORRIS 03-15-2004 21 04-0561 CUMBERLAND 101 * REV-1541 EX AFP (09-041 LUCILLE P Amount Re..itted PA 17036 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ___ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV:i54-;-Ex--AFi'--fiiY:Ur-iliiYici--o,:-'i:"NHERYfAircrTAX-A-PPRAisEHEilT~--ArrOWAiicE-ifri----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MORRIS LUCILLE P FILE NO. 21 04-0561 ACN 101 DATE 01-03-2005 TAX RETURN WAS, (X I ACCEPTED AS FILED I CMANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. stocks and Bonds (Schedule Bl 3. Closely Held stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable {Schedule DJ 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (11 (2) (31 [41 (51 (61 (7) .00 10.180.80 .00 .00 3,500.65 .00 263,364.10 (81 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ abh returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate C17} 18. AMount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due C DI S: NOTE: (91 (101 6,266.01 3.698.12 (111 (121 (13) (141 NOTE: To insure proper credit to your account) subMit the upper portion of this form with your tax payment. 277,045.55 9.964 13 267,081. 42 .00 267,081.42 .00 .00 133,540.71 133,540.71 X 00 = .00 X 045 = .00 X 12 = 16,024.89 X 15 = 20,031.11 (19)= 36,056.00 T NUMBER C0004049 CD004512 . INTEREST/PEN PAID (-I 1,789.47 .00 DATE 06-15-2004 10-15-2004 AMOUNT PAID 34,000.00 266.53 ~1 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 36,056.00 .00 .00 .00 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS TMAN $1, NO PAYMENT IF TOTAL DUE IS REFLECTED AS A "CREDIT" A REFUND. SEE REVERSE SIDE OF THIS FORM IS REQUIRED. [CRI, YOU MAY BE DUE C If FOR INSTRUCTIONS. I -bf\