HomeMy WebLinkAbout04-30-10 (2)J 15056051058
REV-1500 ~ (~) ~,.,~ ~Y
PA DepsrYnNl d Rwralis ~„~„ ~ ,~.~ FIS Nurlber
Blreeudlrldl~MialTaas INHERITANCE TAX RETURN
~~ 21 10 0214
Hr,ipuy, R\ 1T128-0ID1 RESENT DECEDENT
EN~EIt DECEDENT IMIr!lRIIATION BELOtIII
soda) s««~exy Nrarlber Data d Dea»I Date d BIM
189-09.4062 02/092010 10/14/1917
Deoederlt's Last Name Sullbc Decedent's Fkst Name MI
Dewaft Eugene A
In MPIb~) E~ Y apotrae's Ydbrmaeon Below
3pouee's Last Name Bollix Spouse's F&st Name MI
Spouse's Social SecteNy Number THIS REIIJRII MUST BE FILED MI DUPLICATE WITH THE
REGISTER OF WILLS
RLL INAPPROPRIATE OVALa BELOW
1. OrglnM RaWm ~: 2. SuppNalsntsl Relum Cw ~ 9. RenWrMer Rebm (dale d death
prior tD 12-13ffi)
~: 4. Lhrrfled Esfals ~a ~a. FuWro InNrest Complanias (dste d c~'~ 5. Federal Estals Tix Relun ReglrNad
death alter 12-122)
8. Dsoederd Died Tietsb ss`7 7. Dsoedsnt MMngYnW a Lhdrlp Tnut _ S. Tidal Number d Bab Dapalt boxes
(Atbadl Copy d WTI) (Attach Cg1Y d TfUet)
_W ~ 9. lJlipalbn Proceeds ReoNwd ~ 10. Spoual Poverty Crodl (dots of death c s. 11. lSMdlon to tax render Sec. 9113(A)
between 12-31-91 and 1-1-®6) (Attach Sch. O)
COR~BPOIgENT - TMi NCTION ^NT BE COlBXE7®. ALL ~ AIO CONFgHf11AL TAX NIFdIMAT10M tlglN.D ~ DUCTED T0:
Name Dsytlrtrs TeNphorrs NuRltler
Tht~nlls A Lake
Finn Nsme (If ApptioebN)
Fbst Ins d address
11071A Hatlghs Church Rd
SeoorM Irle of address
Oily of Poet OMoe
Keymar
(301) 514- c
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LS USE aL'Y
REGISTER ~+ r-r~ - 7
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1
31a1e 21P Code -.. DATE FILED ~ I
MD 21757
Correspondarrl's e-rrrl address: crnas)ramelmx.rror
Urldsr parrllMS d parJret4 I dsotre glat I hew examkrd thisroam. kwitrdrp accolrlparryirp edlsbrlw and ahrrrrwrrb, end b Hrs teat d my bsrrMdYe end beNM,
K b and onrlplsr. DadwMbn d prepww Darr than tM panaW leplesrltathw is tared m M Nilcmreon d which preparer has any blawWt9a.
OF FOR FM.ING RETURN ,DATE .,
~7n ~, A J~tu q /(s ~'i(st s-~-14 l~ ~j'n~a.- ~-^ !J ~ ~ rd-~
SIGNATURE OF PREPARER OTFGR THAN R~ffi7dTATNE
DATE
as acre- U!E ORIGINAL PORM OMLY
Skis 1
15056051058 15056051058
J
15056052059
REV 1500 Fx DeaederrTs SociN s~.uy Number
oeo.aer~r. ~: Eugene A Dewak 189-09-4082
rlecAPrruLATIDN
1. Real sett (Sdrsdrle A) ............................................. 1.
2 Stocks and Bands (Sdrerkrb B) ....................................... 2.
3. Ckmely Held Corporalbn, Partrrsrship or 3da•Propriebrahip (Sdredtrb C) ..... 3.
4. AAorlpspss d Nobs Reoeiwble (Scfredub D) ............................. 4.
5. Cash, Bank Deposits d AA~Neneous Parsorral PmpeAy (Schedile E) ........ 5. 76,638.44
8. Jokitly Owrrsd Properly (Schedule F) Seperab ~n8 Rsquaebd ....... 6.
7. kMx-Vlws Transfers d MlsaNrraorrs Nay-P~absle Pmpsrly
(3chedrrb G) Separate 81Arg Ragrresled........ 7.
8. Tobl Orws Assab (bbl Lines 1-7) .................................... 8. 76,838.44
9. Funeral Experstes d AdrNnisdatlve Calls (Sctradule H) ..................... 9. 2,859.46
10. Debts a Deosdsrd. ~4wn uebiM.a. d Lbns (&cTradrrb 1) ................ 10. 180.21
11. Tobi Deductions (Dole ones 9 d 10) ................................... 11. 3,019.87
12. Nst lase a Esbls (one s aian one 11) .............................. 12. 73,618.77
13. CharReble end Gorermssrbl BegrreslalSae 9113 Trust Tor Yrldch
an aiec9on b T®r furs not trs~ made (Schedule J) ........................ 13.
14. Nat iTNru Srayaet to Tax (one 12 rrrksrs floe 13) ........................ 14. 73,618.77
TAX COMPUTATION -SEE Ul8TRUCTIONS FOR APPIJCABLE RI-7'ES
15. Aarount a Lfne 14 Taxable
at the spousal bx r~s, ar
transfers under Sec. 9116
(ax1.2) X .0_ 15.
16. Amored a Lkre 14 bxabb
at meal rat X .0 _ 18.
17. Amourd a 1k18 14 texabb
at aibNnQ rob X .12 17.
18. Amount a Line 14 taxable 73
618
77
,
.
at ooNabral rat X .15 18.
19. TAX Due ......................................................... 19. 11,042.82
Z0. FTLL MI THE OVAL IF YOU ARE REQUF8TING A REFINID OF AN OVERlMIYMENT
15056052059 Side 2
L 15056052059
REY-1500 EX Peps 3
Decedent's Complete Addtl+ess:
Fasllunbsr
__ _.
21 '` 10 '0214
otct~Nrs s;ocel sECUwrr 1lUA6EFt
Eugene A Oswalt 188.09-4082
STrtEITADDREBS
801 North Hanover Stroet
Cm
Carlisle SPATE
PA zp
17013
Tax Payments and Crodits:
1. Tax Due (Page 2 Line 19) (1) 11,042.$2
2. ~
A. Spousal Poverty Credk
B. Prior Payments
C• Diswunt 581.18
Total Credits (A+ B+ C) (2) 581.18
3. IntereadPenaKy if applicable
D. kderest
E. PenaNy
lnbreeURerralty (D + E) (3)
4. N lpre 2 is greater than Lkre 1 + line 3, solar the difererroe. This is the OVERPAYMENT.
FBI in owl an Paps 2, lirrs 20 to ngrrset a refwwL (q)
5. ff tlne 1 + line 3 is greater llran Lkre 2, enter the difference. This is the TAX DUE (5) 10,481.84
A Enter the Nterest on the tax due. (5A)
B. Errler the local of Line 5 + 5A This 's the BALANCE DUE, (5B) 70,461.84
Make Check Payable to: REGISTER OF WILLS, AGENT
u
.
~
~~
x
..;
:~ ~
PLEASE AN8WER THE FOLLOVYING QUESTIONS BY PLACING AN "X" IN THE APPROPRUIT'E BLOCKS
1. Old decedent make a trerrefer and: Yw ~
a. retain tiro use w krcorrrs of the properly tranefer-ed :.................................................................................. ^
........
b. remin the right to deelgrrak who sheN use the property trerroferred or Ie krcorrre : ............................................ ^
G retain a reverelorary kMoreet; or .......................................................................................................................... ^
d. receive the prarrhe for INe of either payments, berreAte a care? ...................._................................................ ^
2. ti death aoaxrod a8er December 12,1982, did deoederrt trer-sfer property within one year of death
without reoelvkp adequate oorrideredon? ........................................................................................:..................... ^
3. DM decedent awn an "M tnpt for• or peyade upon death frank account or aepsily at his or her death? .............. ^
4. Did decedent own ~ Individual Retirement Account, annuity, or other rron~proheb property which
canlains a trerre8daty deel~tlon? ..............................
. ^
.
........................................................................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FM.E R AS PART OF THE RETURN
For dales of death on or after Joy 1,1994 and trefore January 1,1995, the tax rate imposed on tits net vakre of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. §9116 (a) (1.1) (~].
For dates of death on or attar January 1, 1995, the fart rate imposed on the net value of transfers b or for the use of the surviving spores ~ zero (O) pertterd
fifing a tax lrehxn are .~(ii)j. The statute a transfer 1o a surviving spouse from tax, and the statutory requirerrrertfs for disclosure of assets and
applicable awn it the surviving spouse (s the only beneficiary.
For dates of death on ar after July 1,2000:
The tax rate imposed on the net value of transfers from a deceased child lvrenly-one years ~ spa or younger at death to or for the use of a nadiral prerent, an
adoptive parent, or a stepparent of the d6d is zero (0) peroertt (72 P.S. §9116(a)(1.2)j.
The taz rate imposed on the r>ai wlue of transfers to or for the use of the decedent's lineal bertefiaaries is tour and one~half (4.5) pe-cent, except es noted in
72 PS. §9116(1.2) (/2 P.S. §9116(a)(1)].
The tax rah imposed on tits net wlue of trarrefers to or for the use of the decedent's siblings is twelve (12) percent p2 P.S. §9116(ax1.3)]. A sibling is defined, order
Section 9102, as an individual who has at least one parent in cannon with the decedent, whetlrer by blood or adoption.
WILL OF
EUGENE A. DEWALT
I, Eugene A. Dewalt of Cumberland County, Carlisle,
Pennsylvania, declare this to be my last Will and hereby revoke all
prior Wills and Codicils.
1. I direct that all my just debts, funeral expenses,
gravemarker and administrative expenses shall be paid
from my residuary estate as soon as practicable after my
death.
2. I direct that all inheritance, estate, transfer, succession
and death taxes of any kind whatsoever which may be
payable by reason of my death shall be paid out of my
residuary estate.
' 3. I direct that my entire estate be distributed as follows:
A. I leave my entire estate in equal shares to the
following: 25% to Thomas Lake and Cynthia Lake
or the survivor of either; 25% to Robert Whipp and
Linda Whipp or the survivor of either; 25% to
William Hemp and Sandra Hemp or the survivor of
either; and 25% to Victor Vermillion and Andrea
Vermillion or the survivor of either.
4. I appoint Thomas Lake as Executor of this my last Will. If
Thomas Lake should predecease me or cease to act in
such capacity, I appoint Cynthia Lake as alternate.
5. The Executor of this Will shall have the power to
distribute my estate in kind or in cash, or partly in either.
6. I direct that no Executor acting under this Will shall be
required to enter bond in any jurisdiction.
IN WITNESS WHEREOF, I have reunto set my hand this
22- day of p ~, , 2009.
LAW OFFICES OF
STEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
G~ -_i''
Euge A. Dewalt
The preceding instrument consisting of this and one other page
was on the day and date hereof signed, published and declared by
Eugene A. Dewalt as and for his last Will in the presence of us, who at
his request, in his presence and in the presence of each other have
subscribed our names as witnesses hereto.
~- .
WI ESS WITNESS
LAW OFFICES OF
STEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
Y
State of Pennsylvania
County of Cumberland
ACKNOWLEbGMENT
ss
I, Eugene A. Dewalt, the Testator, whose name is signed to the
attached or foregoing instrument, having been duly qualified according
to law, do hereby acknowledge that I signed and executed the
instrument as my last Will; that I signed it willingly and as my free and
voluntary act for the purposes therein expressed.
~,.
Eug~ a A. Dewal
Sworn to or affirmed nd acknowledged before a by Eugene
A. Dewalt the Testator, this ~2ctay of
-- ,
LVVV • ~AI \IAIV•~{M~I~I<
CeAlsie ~id)rO, Greuirl-ariand `E-. PA
~,~,~~,$~~$ Notary Publ
State of Pennsylvania
County of Cumberland
AFFIDAVIT
ss
We, V~R~INf,~01~i4U AL~L~nd ~~rr.~rc /J/. /'~r~o ,the
LAW OFFICES OF
STEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and say
that we were present and saw the Testator sign and execute the
instrument as his last Will; that the Testator signed willingly and
executed it as his free and voluntary act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of
the Testator signed the Will as a witness; and that to the best of our
knowledge the Testator was at that time 18 or more years of age, of
so nd mind and und~no constraint o undue influence.
N~1// Gsu¢.17fI /G~vr9zo-
Sworn to or a~firme~bscribed to before me by witnesses,
this ?-day of 1~~~ ~-P~- .~, 2009.
....y.~v _.~_w.__..._....__r.~.~..~
NQTAFilAL SEAL
&ephen d. ila~q, Wotary ~V~Piry
Caritsta Coro, ~Currtbationd Co. PQ
11~r CoarnlEebn ~xPCiss SayR~nbst 3, X018
REK1608 Df+ (e-ae~
colrtMONwEA~TH of aEwrevwANw
INHERITANCE TAX RETURN
RESIDENT DECEDENT
s~N~uu ~
cr-sH, B~-~ac ~osrrs, ~ ~usc.
ESTATE OF _ _ FlLE NUMBER
Eugene A Dewatt 21-10-0214
YicYefe eb prooeede or eeeeeon and eie dale aye proceeds ~rere nloeiwd M Ne eelale.
~ war«b larwY~d velar rtpht a senlvaenlp e>e.l a dNdoad on selredule F.
1 M 8 T Beds, One Went High S6reek, Car1Me, PA 17013, 9 aooount, # 707252
2 Members tat Federal Credit lhlion, 5000 Lolriee Drive, MecharlMxburg, PA 17055, axaxt #200714
sevi-rpa aooourlt
oheckhrg ~+~
cer88celes of deposit
3 ~ Relund fiom Ctwrch of Cod Home, 801 N HarloveT St, Carlisle, PA 17013
4 ~ Prepaid finlerel experroea, Frelernal Order of the Ea81ea, CarBale, PA
5 ~ Prepaid fir.terel experlssa, Veterans Admir~atradon
TOTAL (Aho enbr on line 5, Rerxpitukdion) :
(e more spec. a needed, ineaart addrlbnsl s}reela ar ure same afae)
3,806.18
2,129.41
8,284.28
5,380.88
53,052.14
3,585.59
500.00
100.00
78,838.44
_., _..
ACCOUNT N0. ACtbIRIT TYPE STATEMENT PERIOD PAGE
7072+2 CLASSIC CHECKING FEB.04-NAR.03,2010 1 OF 2
00 0 04319N NM I17
9948
EU[~ENE A DEWALT
111)71 HAUGHS CHURCH RD APT A
KE`~MAR MD 21757
HIGH STREET-CARLISLE
A f`f`flil LlT CIIMMADV
•~
ANCE ~ _ _
OT A0O TIONS
zHECKS'-PA
'SUBTRACT ..
EREST PD
BALANCE
N0. AMOUNT N0. AMOUNT ND. AMOUNT
4,031.:L5 0 0.00 4 4 1 ,60 .16 0.00 0.00
AP`f`~f 11 LIT A!`TT~/TTV
_ _
_
E
C R R
A LY
02-04-11 BEGINNINt: bALAe1CE 04,031.15
02-18-10 CHEGM: NUMBER 3502 119.97 3,911.18
02-24-1t~ CHECM; NUtB)ER 3503 155.00
02-24-1t CNEp: NUPffiER 3505 100.00
02-24-1U CHEC1: NUMBER 3504 50.00 3,60b.18
03-03-1t+ CLOSEOUT 3,606.18 0.00
ENDING B,~LANCE 00.00
~~ CHECKS PAID SUMMARY
3502 02-.L8-10 119.97 3503 02-24-10 155.00 3504 02-24-10 50.00
3505 02-'24-10 100.00
t;PRINC IS THE SEASON TO SAVE MITH YOUR MiT CiIECK CARD.
IWRCH FORMARD HITH SPRING SAYINGS AT NATIONAL RETAILERS MNEN YOU USE YOUR CARD
IN STORES, ON THE MEd AND OVER THE PHONE. JUST BE SURE TO SELECT (OR ASK TO USE
YrRJR CARD AS) "CREDIT". PIpC UP A COUPON BOOK AT YOUR LOCAL MBT BRANCH OR VISIT
MHM.MTB.COM/SNOPPING FOR FRESH DEALS ON SPRING SAVINGS.
rA08A [8/071
~.
rr ~1~ .
Walnut Bottom
1166 Walnut Eottom Road
Carlisle PA 17013 717-249-4666
Inquiries Call:
DSWALT,EUGESE A
Acct XX3DOSXX714 Date; 03/03/10
Eff: 03/03/10 Time: 3;lBpm
Tlr; 0635
tgithdrwl from REGULAR SAYIIiGS'846067
Prav Bal: 68,846.67
Amount: 0.00
Ssa Bal: p3855S0
Seq:
_68,846.67
Cheok Disbursed
ESTATB OB EUGEBE A DBWALT 00 497981
Ref number:
l7- ~~ ~
Authorized by
ID Source:
^ Drv Lic
^ gigCard
Known
^ Other
10-Year Nom+ Equity Speo:n~ pnaltisslow
as 4.99~c APR! Bo Prepaym
8o Points! go Closing Coots! Aak Eor
details.
EUGENE A OBWALT
St
MEMBERS 1st
FEDERAL CREDrf UNION
Serfd Inquires t0:
5000 Coulee DrNa
PO Box 40
Marhanfeahura, PA 17055
www.m.mb.ralatorg
Main Swkahtaard; (717) 697-1161 or (800)283-2328
EZ CaB: (717) 697-0372 a (800) 283x1972
TDD: (717)697-5312 or (800) 283.2328 ext. 5312
TaleBraneh: (717)795-6D49 or (800)237-7288
EUGENE A DEWALT
C!O THOMAS A LAKE
11071A HAUGHS CHURCH RD
KEYMAR MD 21757
Statement of Accounts
Jan 25, 2010 thru Feb 24, 2010
Account Number: 200714
Balances at a
Ch
ki Glance--' -"`
~
ec
ng: ~, 2s3. s2
Savings: - 2 ~ 135.92
Certificates: 52,979.82
Loans: ' _-~ o . o0
Money Management: 5,376.21
Swipe 5 YTD Reward: o.oo
Page: 1 of 2
Your current Member Loyalty Rewards level is Platinum. ,
Your aggregate balance as of February 1st is;68,771.57.
An aggregate balance of;75,000 and having 3 products
will move you to the Titanium level.
Want to cam some extra cash? Take advantage of our CASH4U referral program.
Ask an associate for details.
CHECKING ACCOUNTS
0011 -CHECKING
Date Trargaetlon DeseriDdon Additions Subtractions Balance
Jan 25 Ba/arrce f=orward 12,568, 23
Jan 29 Check 000116 Tracer 0001390081 4,283.19- 8,283.04
Jan 31 Deposit Dividend 0.100°6 0.58 8,283.62
Annual Percentage Yls1d Famed 0.100X Born Oiro1/2010 through 01/31/2010
Based on Average Oafly Balance of 6, 882.53
Feb 2I Ending Sa/ance 8,283. B2
CHECK SUMMARY
Check * Amount Date Check 8 Amount Date
000116 4,283. 19 Jan 29
SAVINGS ACCOUNTS
0000- REGULAR SAVINGS
Data Transactlon DescrfDtion Additions Subtractions Balance
Jan 23 Balance Pwward 2,128.29
Jan 31 Deposit Dividend 0.35096 0.63 2,128.92
Annual Pencartage Yield Eamed 0.33076 from 01/01/2010 through 01/31/2010
Feb 24 Fnding Balance 2,128.92
0005 - MONEY MANAGEMENT
Date Trar-saction Descriotion AddWons Subtractions Balance
Jan 25 Balance Forward S,3n, ~
Jan 31 DeposR Dividend Tiered Rate 1.99 5,379.21
Annual P+ealcentage Yield Ea-ned 0.41076 irom 01/01/2010 through 01/31/2010
Feb 24 Ending Balance 5,379.21
--- Continued on following Page ---
gt SendingWre6to: Main Switchboard: (717)697-116t x(800)283-2328
5000 t'OYMe ~V8
FS Call: (717) 897.1372 a (800)283.4372
PO Box 40
Jan Z5, 2010 thru Feb
24, 2010
MeehanMe6trg, PA 17055 Tom' (717) 697-5312 a (800) 263-2328 ext. 5312
~ Account Number: 200714
M1'
wwW.mambuslstorg TaNaraneh: Q17)7956049a(800)237-7286 Page: 2af 2
CERTIFICATE ACCOUNTS
0044 - 3 MONTH CERT Maturity Date - Mar 15, 2010
Date Transaction Description A dditions Subtractions Balance
Jan 25 Balance Forward 12,880.00
Feb 24 Ending Balance 12,890.00
0048 - 80 MONTH CERT Maturity Date - Ju105, 2010
Date Transaction Ossdtption Additlons 3ubtractiona Relents
Jan 25 Balance Forward 3,033.18
Jan 31 Deposit Dividend 4.310% 11.10 3,044.28
Annual Percentage Yield Ean'red 4, 39096 from 01ro1/2010 through 01/31/2010
Feb 24 Ending Balance 3,044.28
0049 - 7 MONTH CERT Maturity Date - Ju115, 2010
Date Transaction Description Additions Subtractlons Balance
Jan 25 Bs/ance Forward 37,203.20
Jan 31 Deposft Dividend 1.340% 42.34 37,245.54
Annual Peroentage Yle/d Eamed 1.35096 from 01/tN/20l0 through 01/31/2010
Feb 24 Ending Balance 37,245.54
YTD SUMMARIES
TOTAL DMDENDS PAID
0000 REGULAR SAVINGS 0.63
0005 MONEY MANAGEMENT 1.99
0011 CHECKING 0.58
0044 3 MONTH CERT 0.00
0046 60 MONTH CERT 11.10
0049 7 MONTH CERT 42.34
Total Year To Date Dividends Paid 62.86
NOTE: Total includes dosed shares
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REV-1511 EX+ (10-09)
Pennsylvania
DEPARTMlNT OP REVENUE
iNNM1TANCe TAX RETURN
RlSID9fT DECeoENr
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
EttTATE OF FILE NUMBER
Eugene A Oswalt 21-10-0214
Dacadent'a debt mast ~ reported on tdradula 1.
.,:..
A.
1.
8.
1.
FUNERAL EXPENSES:
Crertietlon, HoBmen-RoEi F~wieral Home, 219 N Hefaver St, Carlble, PA 17013
Um, HoBmm-Roth Funefal Home, 219 N Hanover St, Csliele, PA 17013
OpeNdoae grave, FbBiTfan-Roth F~feral Home, 219 N Heaver St, CarNsle, PA 17013
(8) oertlAed death oertiAcalse
Nevrepapaer notloe
Corms Fee
AddlEonal Sheet Total
ADMINISTRATIVE COSTS:
Personal Repraerrtative Car-anigions:
Name(s) d Personal Representadve(s)
Street Address
utY
Year(s) Comrt~ion Pekl:
2• ~ Attorney Foes:
Stabs ZIP
3. Femgy Exempdpr (If decedent's address fs not the same as daNnant's, ettath trcpianadon.)
gahnant
Street Addres
~' Stabs IIP
Relatlonahip of ClNmetrt bD DttedeM
4. I Probate Fees:
s• I Acaurdant Fees:
6• I Tbx Return Preperer Fees:
7.
1,690.00
180.00
250.00
48.00
135.96
25.00
382.00
188.50
'tbTAl (AID erder on Una 9, Recapitulatbn) I; 2,869.46
If rrafe Space h needed, Use additbnaf Sheets of papa of the scone size.
Attachment for Schedule H
Estate of
Eugene A Dewalt
Funeral Expenses:
File
21-10-0214
Pianist Fee, Carol Straub
Amount
$ 50.00
Engraving fee for memorial stone, Carlisle Memorial Service, Inc. 185.00
415outh Bedford St, Carlisle, PA 17013
Fee for (3) certifu'd death certificates (spouse)
27.00
Chaplin, Bradley Moore, Church of God Home, 801 N Hanover St, 100,00
Carlisle, PA 17013
Total for Attachment $ 362.00
REV-1512 EX+ (12.08)
pennsylvaMa SCHEDULE I
DE-ARTMENT ov RlvcNUE DEBTS OF DECEDENT,
1NNewTANtx TAX RETURN MORTGAGE LIABILITIES ~ LIENS
Resroarr oECEOENr
OF
Eugene A Oswalt 21-10-0214
~t de6b bwrrtrld b1r tM /eeelerrt psfor to deetlr Net resrrehred unpeW ~ tM dsee of deM14 Irrdedlrr0 wrnlrnbrrred rnedlcN expenw.
ITEM ~,., ~ ~ .. ,,.,~
1 • I Cumberland GoodwlA EMS, PO Box 12910, Philadeiptria, PA 19176.0910, transport fee I 87.00
Continuing Care ftX, 28 S 2nd St, Newpat, PA 170741401, phamracp
73.21
TOTAL (Also enter on Urre 10, Recapltulatlon) I # 180.21
If more space h rR~ded, Insert additlonel sheds of the same she.
Cumberland Goodwill EMS
PO BOX 12910, PHILADELPHIA, PA 19176-0910
(800)369-7544
Patient name: DEWATL, EUGENE
EUGENE DEWATL
Church of God Home
801 N HANOVER ST
CARLISLE, PA 17013
Run number: fasese
Date of call: frzarzo~o
Time of call: 15:33
Caller:
From: Carlisle Regional Medical CerKer
TO: Church of God Home
Primary payor: Aetna
MEBFGFNN
Secondary payor: Patient Pay
Description
Stretcher Van 1 Way
Mileage
1 80.00
4 1.75
r ~r ~f
•. ~ti~' V
PAY THiS BILL ONLINE AT WWW EMSBILLPAY.COM
OR CALL THE NUMBER ABOVE TO PAY BY PHONE
Check # Quantity Unit price Payment date Amount
80.00
7.00
PLEASE PAY THIS AMOUNT: 587.00
r.nP~TTNtJTPdG' CARE. RX
~- <_; ..~
"` SEGt3h1U ST
rvr~~~~oRi~ 4'A ~7ai~
r7 ~_ G7 t ~~ tl t t.' 1~ t.: L; :1 t., E• : C T r' ~`r .~ f. ~: F• ~ ~ t? .
;.:4. G} T t a, 6-€'>~}_)> H~:; t~'r~l_1i-~ C ({ a-t E".IFaL}
i-'T'F. 'Y :L C:Uc ;7 c31;y i'YCE
~;ici its;~ i2:~1~st?t',, ... ::,~:;_t .i:n i ~ amr~unt -----
`~~ -1d(0
f
(. ~L~ctic..l U
tltU Amount
3. 21
r:~. ~?:t
(''3';'(; D!JE` F'~St Duty' f'a~t; Uue
E; t. i-. ~- ~• n is ;:'s i. - cC? a a ;~ _. , i -'=~~i d s ;~ s ~:rri+ tj a u
t:~t1E.S,i...~t_1hfS Pt_LA~;E: ~;f~L!_. i. ->;t3i}- ,..~::;~-='-'-~"= E~ 1': 1:3D~}
REV-1513 EX+ (11-08j
pen]nsylvarria SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INNlRIrANCE TAX RETURN
RESIDBrf OEC®lrlT
- _.
ESTATE OF FILE NlR+tiEER
Eugene A DewaH 21-10-0214
RELATtONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not Lbt lfrrataa(a) OF STATE
i TAXABLE DISTRIBUTIONS [Include outright SpousN disdibutlons and trarefas order
Set. 9116 (a) (1.2).]
1. Thomas A Lake,11071A Haughs CMxdt Road, MD 21757 nephew 12.5%
Cynthia A Leke,11071A Haughs Church Reed, Keyrnar, MD 21757 niece 12.5%
Sandra Hemp, 3928 Soudtview Ct, JelOereon, MD 21755 niece 12.5%
Wiliam Hemp, 3928 SouUrview Ct, ,ieifereon MD 21755 nephew 12.5%
Lkda Whipp, 4003 Jeifereon Pike, Jetiereon, MD 21755 niece 25%
Andrea VemYNion, 502 East F St, Bntnawidr, MD 21755 niece 12.5%
Vkdor VemriAbn, 502 East F St, Bnutewk;k, MD 21755 nephew 12.5%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LAVES 15 THROUGH 18 OF REVd500 COVER SHEET, A S APPROPRIATE.
II NON TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTTRIBURONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX 15 NOT TAKEN
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - EN1ER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COYER SHEET. ;
lr more space a nccaea, nsert aciaeonei slxlfs of the same she.