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HomeMy WebLinkAbout05-20-10 (2)15056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~ INHERITANCE TAX RETURN PO BOX 280601 2 1 0 9 1 0 7 7 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ''18 4 36 66 74 08 22 200 9 02 031 90 8 Decedent's Last Name Suffix Decedent's First Name MI C i c o E v a (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust © 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number W i 1 1 i s m L S u n day 7 1 7 7 6 6 9 6 2 2 Firm Name (If Applicable) S u n d a y and S u n d a y First line of address 3 9 W e s t M a i n S t r e e t Second line of address City or Post Office State ZIP Code M e c h a n i c s bur g P A 1 7 0 5 Correspondent's a-mail address: REGISTEI~F WILLS US~ILY -r c :7 r~s ,,~ . ~~ ~ .~ ~.. x~ ~. . '~7:~ -4 _ ~~;. - ~ -„ = i ~.. . f ~ 11; -'+~ E FILED ~~ ~. '. CA 5 ;_ , _. , . , ., r ..:} ~.: ~~1 .~ ,:::::~ 6'"r'3 ~....~ .~~ Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIB TU~E OF PERSON R~SPOLE FOR FILING~E~RN DATE ADDRESS ~ V ~ - - ~ ~ ~ ~- SIGN RE OF PREP ER O ER THAN REPRESENTATIVE Attorney for Estate DAyy~~ ~''l ~9 ~~ai~ ADDRESS '" l ~ / 39 West Main S~~ Mechanicsburg FA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 15056052048 REV-1500 EX Decedent's Social Security Number 1 8 4 3 6 Fi 6 7 4 Decedent's Name EVd C1C0 RECAPITULATION 1. Real estate (Schedule A). ... NOI7E~k110wn~~~~~~~~~~~~~~~~~~~~~~~~~ ~~ 1~' • 2. Stoc!<s and Bonds (Schedule B) .. ~jo~. ]{j-i0~ ................... ~ ~ ~ ~ 2~ • None known 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. • 4. Mortgages & Notes Receivable (Schedule D) ..NOI1e. }~I1QWl1. _ .......... „ 4. • 2 ~ 5 ~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. • 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 2 2 4 1 6 . 3 9 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 3 5 6 7 5 5 4 (Schedule G) O Separate Billing Requested...... .. 7. . 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. ' 5 8 1 1 6. 9 3 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 1 0 9 3 0 • 3 7 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. 4 1 8 9 ~ 7 8 11. Total Deductions (total Lines 9& 10) ................................ ... 11. 1 5 1 2 ~~ 1 5 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12 4 2 9 9 6 ~ 7 8 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 0 0 0 an election to tax has not been made (Schedule J) ..................... ... 13. * 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 4 2 9 9 6 7 8 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable 78 42 996 16 1 9 3 4,8 $ ,, at lineal rateX.o~ . 17. Amount of Line 14 taxable at sibling rate X .12 • 17. 18. Amount of Line 14 taxable at collateral rate X .15 « 18. 1 9 3 4 ~ 8 6 19. TAX DUE ...................................................... ... 19. , 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056052048 15056052048 J REV•1508 D(• (19~ SCHEDULE f COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MASC. IN RESIDENTDECEDENTR" PERSONAL PROPERTY ESTATE OF FILE NUMBER Eva Ciro 21-09-1077 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 ~• I Clothing ~ 25.00 TOTAL (Also enter on line 5, Recapitulation) 15 25.00 /lf mnro enaco is nAAria~l incort ari~iitinnal ahPPtc of the camp ~i~Pl ~ REY 1508 0(: (187) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE F JOINTLY•OUIfNED P~tOPERTY FIDE ff an asset was made joint within one year of the decedent's date of death, h must be reported on Schedule 0. SURVNING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO 4ECEDENT A' Eli Cico, Jr. 8605 Eleuthera Lane Son Fort Myers FL 33907 B. Dorothy Smith 177 East Square Lake Road Daughter Troy MI 48085 ~• Michael Smith 1920 Jan Circle alk/a Michael E. Smith Canton MI 48187 Grandson JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name Of tinanCial Institution and bank axount number or similar Identifying number, Attach deed for Jointly-held real estate. DATE OF DEATH VALUE OF ASSET 96 OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1 • A. Funds in j oint bank accounts in names of Eva Cico and Eli Cico Jr. as joint tenants with Right of survivorship in Pennsylvania State Employees Credit Union Share Description 6/13/07 SO1 ~ Regular Shares 5.17 50% 2.59 6/14/07 S04 Checking 16625.88 50% 8312.94 Accrued interest .12 50% .06 6/14/07 S07 Money Market 22.17 50% 11.09 Accrued interest 8.72 50% 4.36 2. A 0/19/06 Joint checking account #9843137101 in names of Eva Cico and Eli Cico, Jr. as Joint Tenants with Right of Survivorship in M&T Bank 985.01 50% 492.51 Accrued interest 0.00 50% 0.00 3. A 2/12/98 Joint Certificate of Deposit #31003913913933 in names of Eva Cico and Eli Cico, Jr. as Joint Tenants with Right of Survivorship in M&T Bank 3916.46 0% 1958.23 Accrued interest .96 0% .48 (If more space Lr 1 ,/ VT.TJ TOTAL~(Also enter on line 6, Recapitulation) ~ 10782.26 sheets of the same REV-1509 EX • (1-9~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER H an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT D, Robin Smith (Now Robin S. Kneffel) ~ Stephen Cico E. ~. JOINTLY-OWNED PROPERTY: 2539 Crofthill Drive Auburn Hills MI 48326 8 Barlow Drive East Berlin PA 17316 ter on ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number, Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET 96 OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ~ x9~c Brought Forward 21564.49 10782.26 4. B 1 /12/98 Joint Certificate of Deposit #31003913913941 in names of Eva Cico and Dorothy Smith as Joint tenants with right of survivorship issued by M&T Bank 3916.46 50% 1958.23 Accrued interest , 96 50% .48 5. C /14/90 Joint Certificate of Deposit #31003914395560 in names of Eva Cico and Michael Smith as Joint tenants with right of survivorship issued by M&T Bank 6446.38 50% 3223.19 Accrued interest 3.89 50% 1.95 6. D 14/90 Joint Certificate of Deposit #31003914395578 in names of Eva Cico and Robin Smith as joint tenants with right of survivorship issued by M&T' Bank 6446.38 50% 3223.19 Accrued interest 3.89 50% 1.95 7. E 14/90 Joint Certificate of Deposit #31003914395586 in names of Eva Cico and Stephen Cico as Joint Tenants with Right of Survivorship issued by M&T Bank 6446.38 50% 3223.19 Accrued interest 3.89 50% 1.95 ~F'+ZS3L. /L TOTAL (Also enter on line 6, Recapitulation) S 22416.39 (If more space is needed, insert additional sheets of the same size) SCHEDULE G COMMONWEALTH OF PENNSYLVANIA INTER•VIVOS TRANSFERS 8~ INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY ESTATE'OF FILE NUMBER Eva Cico 21-09-1077 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes, ITEM NUMBER DESCRIPTION OF PROPERTY ~Na~OE THE NAME OF THE TRANSFEREE, THEIR REUnONSHIP TO DECEDENT AHO THE DATE OF TRANSFER. ATTACH A coat Of THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION FAaauCASIE TAXABLE VALUE 1. The following listed in trust for Certificates of Deposit issued by M&T Bank in name of Eva Cico Trustee for the following named beneficiaries: 1. Certificate of Deposit # 31003916012261 in name of Eva Cico, Trustee for Michael E. Smith, beneficiary issued 6/4/07 3553.62 100% 553.62 Accrued interest 1.46 100% 1.46 2. Certificate of Deposit # 31003916012279 in name of Eva Cico, Trustee for Stephen Cico, beneficiary issued 6/4/07 ~ 3553.62 100% 553.62 Accrued interest 1.46 100% 1.46 3. Certificate of Deposit #31003916012287 in name of Eva Cico, Trustee for Justin Smith, beneficiary issued 6/4/07 5000.00 100% 000.00 Accrued interest 2.06 100% 2.06 4. Certificate of Deposit # 31003916012295 in name of Eva Cico, Trustee for Jeremy Smith, beneficiary issued 6/4/07 5000.00 100% 000.00 Accrued interest 2.06 100% 2.06 5. Certificate of Deposit # 31003916012435 in name of Eva Cico, Trustee for Trevor Smith, beneficiary issued 6/4/07 5000.00 100% 000.00 Accrued interest 2.06 100% 2.06 6. Certificate of Deposit #31003916012443 in name of Eva Cico, Trustee for Chelsea I. Cico, beneficiary issued 6/1/07 5000.00 100% 000.00 Accrued interest 2.06 100% 2.06 V/ 1 1 V• . V Carried Forward TOTAL (Also enter on line 7, Recapitulation) s-~ 27118.40 (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON•PROBATE PROPERTY ESTATE bF FILE NUMBER Eva Cico 21-09-1077 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY ~NCU:OE THE NAME OF THE TRANSFEREE, THEIR ftE1.AT10N8HIP TO DECEDENT ANO THE DATE OF 1'R/WSFER ATTACHACDPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION FAPPUCABIE TAXABLE VALUE 1. Brought Forward 27118.40 100% 7118.40 7. Certificate of Deposit # 31003916012451 in name of Eva Cico, Trustee for Kaitlyn R. Cico, beneficiary issued 6/4/07 5000.00 100% 5000.00 Accrued interest 2.06 100% 2.06 8. Certificate of Deposit # 31003916012469 in name of Eva Cico, Trustee for Robin S. Kneffel, beneficiary issued 6/4/07 3553.62 100% 3553.62 Accrued interest 1.46 100% 1.46 TOTAL (Also enter on line 7, Recapitulation) ~-~ 35675.54 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDVLE N FUNERAL EXPENSES & • ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Eva Cico 21-09-1077 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1~ Wiedeman Funeral Home 9515.37 B. 1. ADMINfSTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address State Zip 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 4. 5. 6. 7. City Year(s) Commission Paid: Street Address City State _ Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees Register of Wills -Filing PA Inheritance Tax Return Zip 1400.00 15.00 TOTAL (Also enter on line 9, Recapitulation) ~ $ /11 ........ .......... ... ».... J...J .........~ ....I.J.a.......1 ..1.....1.. ..i .......... ...~ ~~+~ nl REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT S`CNE`Dt~l`LE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Eva Cico 21-09 F~MBER 1 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses, REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDI~ILE J BENEFICIARIES ESTATE OF FILE NUMBER Eva Cico 21-09-1077 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)J 1 Except for joint owners sho non Schedule F Beneficiaries of Trust C/Ds 1. Michael E. Smith randson 1920 Jan Circle, Canton MI 48187 3555.08 2. Stephen Cico randson 8 Barlow Drive, East Berlin PA 17316 3555.08 3. Justin Smith reat Grandson 7169 Chadwick Court, Canton MI 48187 5002.06 4. Jeremy Smith rest Grandson 7169 Chadwick Court, Canton MI 48187 5002.06 5. Trevor Smith reat Grandson 7169 Chadwick Court, Canton MI 48187 5002.06 6. Chelsea I. Cico reat Granddaughter 8 Barlow Drive, East Berlin PA 17316 5002.06 7. Kaitlyn R. Cico reat Granddaughter 8 Barlow Drive, East Berlin PA 17316 5002.06 8. Robin S. Kneffel randdaughter 2539 Crofthill Drive, Auburn Hills MI 48326 3555.08 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: 1. 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) REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME Eva Ciro STREET ADDRESS --~--- -------- 148 Easterly Drive (Country Meadows) CITY Mechanicsburg STATE Pennsylvania ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 6. Prior Payments 4~~ ~~ C. Discount ~'~~ 4.49 _. 3. Interest/Penalty if applicable D. Interest E. Penalty (1) 1934.86 Total Credits (A + B + C) (2) Total Interest/Penalty (D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) (5A) (56) 969.71 965.15 0 965.15 Make Check 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: *p~ an incident of j oirit Ownership Yes 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 receiving 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 contains a beneficiary designation? ........................................................................................................................ ^ C-IX IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Y ;~ ~.~~'x1i.~~ "R r- u K ~~~ I`.~Yx. "`~s~`>i~~ '~ h}y. ~;;i ~ ~ ~t :.+ti ,,p~"q~r;. °` & For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or 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) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemrJt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed 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 a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The 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 (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The 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)(1.3)J. Asibling is defined, under Section 9102, as an individual who has at feast one parent in common with the decedent, whether by blood or adoption. REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Eva Cico __ STREET ADDRESS 148 Easterly Drive (Country Meadows) __ _- - _- _ _ IP _ - CITY I STATE _ __ _ZIP Mechanicsburg ennsylvania 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount ~~ ~~ ____ 4$. 4~_ - _ _ Total Credits (A + B + C ) 3. Interest/Penalty if applicable D. Interest -_- - ___ E. Penalty ___ __ __ (1) 1934.86 (2) 969.71 Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 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) 965.15 A. Enter the interest on the tax due. (5A) Q B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 965.15 Make Check 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: *p~ an incident of joint ownership Yes 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 receiving 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 contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or 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) percent (72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed 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 a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The 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 (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The 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)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. v . J. L V V/ L J i • ~.~ ~Y October 9, 2009 Account ~ 8S80.X.X?CXXX oVII,LIAM L. SUNDAY 39 Sr MAiN ST 3'I'E 1 iGHAI~II~SG, PA 17D55-b23 0 Dear MR. SUNDAY: VIA FAX 717.795.7280 The fallowing is the status of l/VA CTOp's accoum with PSl/CU as of the dace of death.. J'oYnt t'>~vin~'s I~`amt E~,Y CICO .)7t -ADDED 0~13r20D7 AS ~OIN'T TENANT W/ROS Rate of Reath 08.22.2009 base of Birth 02.03.1908 Sara Aesctfpt~o-a a date S Ol l~egtils>z`Sharas 06. 3.2t~7 s oa g Os.14.2Q07 5'07 Money M~ket OS,14.2007 'Y'he dividend earned from ranuary 1, 2009 through the d us. 'DV'e do not have safe deposit boxes for our membeJx. $a~uct S 5.17 16,625.88 22.17 ....r-~.._.._.__,. ue of death was 162. 9. TE ,bccrued Dividend $0.00 0.12 8.72 w, le decedent had no loans with Ifyou have nay duescions, please ca11234-8484 in Iii burg ar our toll free. n~nber, (800} 237-7328. At the menu Prompt, ear ~ anti they extansian 2227, Sincerely, Mea'xe Fa ax N~tenaber Service Represeati~tive Finance Support Unit Pence Sso~e )Employees Credit Ynion Mvin Add-eas: 1 Credit Unipn Pbce, H9rriibwg, PA 17110-2990 • 717.234.8484 •800.237.7328 Moil-ng ~deie~ss: P.O. Box 67013, l~ionfsbur~, PA 17146-7413 ~ ?17.777.2104 (FDDJ •800.472.1 %7 (TDD} paecvcam This crsdN union is fsdavl-y inwred by the Nofionol Gsdrt Union Adrnini:bvtion. Equal Opportw+dy lender s~ ~ , 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12~ William L. Sunday Dawn S. Sunday Attorneys at Law 39 West Main Street, Ste. 1 Mechanicsburg, PA 17055-6230 - __,- ~ ; - ._ _ ° ~ ~-1 ~..~ Phone (888) 502-4349 Fax (302)934-2955 December 23, 2009 ~... _ _, ,.~ _ .. _ _ Re: Estate of.• Eva Cico Social Security: 184-36-6674 Date o Death: AuQUSt 22, 2009 Dear Sir or~ Madam: Per your inquiry, I have updated the accounts with the relationship/owner information for each. 1. 7~pe of Account Checking Account Account 1Vumber 9843137101 Ownership (1Vts b, fl E'va Cico, joint primary Eli Cico, Jr, joint-secondary Opening Date 10/19/06, Balance on Date of Death $ 985.01 Accrued Interest $ 0.00 ------ --------=-----------=------------------------------------ ~'otal $ 985.01 2. Type of Account Account 1Vumber Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total Certi, ficate of Deposit 31003913913933 Eva Cico, joint-secondary Eli Cico, Jr, joint primary 12/12/98 Closed $249 $ 3, 916.46 $ 0.96 $ 3, 917.42 ~ ~ i 3. Type of Account Account Number Ownership (Names o, fl Opening Date . , . ~. ,. ,.... ,. f ice on.1?t~te of Der~tlt Accrued Interest Total 4. Type of Account Account Number -, Ownership (Names: o, fl Opening Date Balance on Date of Death Accnced Interest Total 5. Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total Certificate of Deposit 31003913913941 Eva Cico, joint primary Dorothy Smith, joint-secondary 12/12/98 Closed 8/l4/09 3,916.4 $ 0.96 $ 3, 917.42 Certificate of Deposit 31003914395560 Eva Cico, joint prinmary Michael Smith; joint-secondary 2/1490 $ 6,446.38 $ 3.89 $ 6,450.27 Certificate of Deposit 31003914395578 Eva Cico, joint pnzmary Robin Smith, joint-secondary 2/14/90 $ 6,446.38 $ 3.89 $ 6,450.27 6. ~ Type of Account Account Number Ownership (Names of) Opening Date Balance on Dale of Death ~.~_<..r~=_, _ Accrued Interest _ Total 7. Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest `Total $. ~'yp~ of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total Certificate of Deposit 31003914395586 Eva Cico, joint primary Stephen Cico, joint-secondary 2/1490 $ 6,446.38 3.89 - $ 6,450.27 Certificate of Deposit 31003916012261 Eva Cico, Trustee Michael E Smith, beneficiary 6/04/n7 $3,553.62 $ 1.46 $ 3,555:08 Certi, ficate of Deposit: 31003916012279 Eva Cico, Trustee Stephen Cico, Beneficiary 6/04/07 $ 3,553.62 $ 1.46 $ 3,555.08 9. Type of Account Certificate of Deposit Account Number 31003916012287 Ownership (Names of} Eva Cico, Trustee Justin Smith, Beneficiary Opening Date 6/04/07 .,.,. _ . - Balance on Date of Death $ 5,000.00 Accrued Interest $ 2,06 Total $ S, 002.06 T _...~....._.____....._._.._. 10, 7~pe-of Account Account 1Vumber Ownership (Names ofl Opening Date Balance on Date of Death accrued Interest Total 11. Type: of Account Account Number Ownership (Names o, fl ~O~ening Date Balance on Date of Death Accrued Interest Total Certi, ficate of Deposit 31003916012295 Eva Cico, Trustee Jeremy Smith, Beneficary 6/04/07 $ 5,000.00 $ 2.06 $ S, 002.06 _..._._._.__....__...._..._. Certificate of Deposit 31003916012435 Eva Cico, Trustee Trevor Smith, Benef ciary 6A14/t?7 $ S, 000.00 $ 2.06 $ S, 002.06 _, , ~~ f 1 . ~'1 1 ' 1~. ' Type of Account Certificate of Deposit Account Number 31003916012443 Ownership {Names of) Eva Cico, Trustee Chelsea l Cico, Beneficiary Opening Date 6/O1R~7 Balance on Date of Death $ S, 000. DO Accrued Interest $ 2.06 Total $ 5,002.06 ~~.._~ i3°~ ' ~'yPe;ofAccount ' `~e~rnficate of Deposit __~~ __.:: Account Number 31003916012451 Ownership (Names o, fl Eva Cico, Trustee Kaitlyn R Cico, Beneficiary Opening Date 6/047 Balance on Date of Death $ 5,000.00 Accrued Interest $ 2.06 Total $ 5,002.06 14. Type of Account Account Number Ownership {Names o, f} Opening Date Balance on Date of Death Accrued Interest Total' Certificate of Deposit 31003916012469 Eva Cico, `Trustee Robin S Kne, f~e~ Benef ciary 6/04/07 Closed 9/04/09 _ $ 3,553.62 $ 1.46 $ 3,SS5.08 Flease be advised, there was no safe deposit bo~c found for the above decedent. * If upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an acxount number and/or name of any possible joint account holder. For any additional i~ormation on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contact our Mechanicsburg Office # 717-255-2031. Sinc:erely`, u~c~J N issa Sears A 'ustment Services J t'~ iedeman ~"'"" FUNERAL H O t V 1 E 357 South Second Street Steelton. PA. 17113 Phone: 717.939.2344 bannis L Wiedeman, F.D.-Supervisor Fax: 717.939.1999 .betas w. Tagan, F.D. STATEMENT .O F ACCOUNT email: wiedemanfh~comcast.net William a. Siba-l. F.D. usa ~+: wrnon-KroSno~. F.D. www.wiedemanfuneralhome.com September 14, 2009 Mr. Eti Cico, Jr. 60 Northview Drive Mechanicsburg, PA 17050 The Funeral Service of: Mrs. Eva Cico A. CI~~E.~FQR SERVICES <SELECTED: 'i. PROFESSIONAL SERVICES $ 2795.00 2. FACtL:iTIES/SERVICES/EQUIPMENT:$ 390.00 3. AUTOMOTIVE EQUIPMENT: $ 730.00 (A) TOTAL OF PROFESSIONAL SERVICES, $ 3915.00 FACILR{ES AND AU?OMOTIVE B CHARGE F4R MERCHANDISE SELECTED: Casket .............................. $ 2740.00 (Description) 18 Ga. Steel Protective Outer Receptacle •••••••••••••••••••••• $ 1295.00 (Description) Concrete/Poiystyrene Outer burial container••••••••••-•••••••• $ -0- (Description) Acknowledgement Cards ............... $ -0- Register: Book(s) ....................... $ -0- Memory Folders ....................... $ -0- Prayer Cards .... ................... $ -0- Temporary grave marker ................ $ -0- Burial C1othIng ........................ $ -0- Other Clothing ........................ $ -0- Custom Graphic Design & Printing ........ $ _0_ ,.,~__...`.~"oi~:~P.~Y.+ fax .............. $ 285.OU __ $ $ -0- Cremation Um ......................... $ -0- [nterior & Exterior Crucifixes ............. $ -0- Refrigeration . ....................... $ _0_ (B) TOTAL MERCHAND{SE SELECTED ~~ ~~ i~ G~' ~~ ~. C~ ~~.~" G Family $ 4300.00 Owned and O C. SPECIAL CHARGES:... Forwarding of remains to $ -0- (Funeral Home) Receiving of remains from $ -0- (Funeral Home) Immediate Burial $ -0- DirectCremation $ -0= $ -Q~- SUB-TOTAL OF SPECIAL CHARGES .......... C $ •0; D. CASH ADVANCES: Opening Grave .................... $ 975.00 Cemetery Equipment ................ $ - 159.00 Newspaper Notices -Local .......... $ 106.37 Newspaper Notices - Out-of-town . ... $ -0- Telephone 8 Telegrams ............. $ _0- Airfare .......................... $ -0- Clergy Honorarium ................. $ -0" Pallbearers ....................... $ -0- Certified Copies of Death Certificate ... $ 60.00 Crematory Charges ................. $ -0- Organist ......................... ~ -0- Soloist ........................... $ -0- Other $ -p- other $ -0- Other $ -0- SUB-TOTAL OF CASH ADVANCES , , . , , , , , D $ 1300.3' SUMMARY OF CHARGES: A. Professional Services, Facilities and Equipment and Automotive Equipment ....................... $ 3915.00 B. Merchandise ..................... $ 4300.00 C. Special Charges .................. ~, -0- D. Cash Advances ................. $ 1300.37 TOTAL OF ALL SELECTIONS ................. $ 9515.37 LESS PAYMENTS.RECEIVED ................. $ 0.00: BALANCE DUE ............................. $ 9515.37 ~ `, ,~ N1eCt1anlCSbUrq, rH 11U5U Telephone: (717) 761-8880 Resident Statement Date: 10/01/2009 Re: Eva Cico Account#: 88580 Balance Due: Eli Cico 60 Northview Drive Amount Enclosed Mechancisburg, PA 17050 DATE BALANCE FORWARD 49/10/2009 PAYMENT 09/2112009 Pharmacy Charges CURRENT MONTH CHARGES CURRENT BALANCE DUE 91.59 91.59 Thank you for choosing Country Meadows of West Shore 3! Please include the top portion of this bill with your payment by the (4,098.19) 4, 098.19 91.59 91.59 Meadows Associates. For pharmacy questions please contact "Alert" direct at 1-800-266-9954 Resident Name: Eva Cico Account#: 88580 Statement Date: 10/01/2009 wvw';~:a}ertpharmacy.com TATEMENT OF ACC~OUI~T ~ THE TOTAL IS INCLUDED IN YOUR MONTHLY BILL FROM COUNTRY MEADUWS.:DO NOT REMIT TO ALERT PHARMACY. i DatQ 0 9/ 2 0/ 2 0 0 9 ~_~-------~ -_~_ --------_-_--_ _...__-----~-------___.__._. - ~--~-------~ ~'~ CICO, EVA CICOE WEST SHORE III I GRP-2 " 4905 E TKINDLE RD PAGE 1 ~ MECHANICSBURG PA 17050 I Amount Paid PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT 219 NORTH. BALTIMORE AVE. MT.HOLLY SPRINGS, PA 17065 -„ ~,~ III ®~® ~....ACTIV~TY FQR-_ RICO-, EV-A ._._--- _.___._ _ -_ ____-__--r.~CaH _ _~ _ _- _ ___-__ __ __ 18/31/09 7570075 30 CARVEDILOL 6.25 M 01 1.70 .00 1.700 X9/03/09 7570420 10 DORZOLAM/TIMOLOL O1 74.89 .00 74.890 -9/03/09 7570422 2.50 LiJMIGAN 0.03 OPT 01 15.00 .00 15.000 __ ---- - - __ . 00 _ , _ _ - 91.5 9_ __ _ __ -------- - LEGEND TorAL Tax FOR MONTH -_ _ ------_ - __-__== =_ - AMOUNT DUE pious Balance Charges this month Finance Char a ,TOTAL CHARGES Total Payment 8 credits ,~.~,~~ .00 + 91.59 ~- .00 - 91.59 .00 - 91.59 =OR ALL PHARMACY RELATED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 1-800-266-9954 __ Statement Terminology on reverse . PENNSYLVANIA INHERITANCE TAX '~ ~ INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D Po Box z8o6o1 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 EX AFP C08-08) FILE N0. 21 ACN 09167922 DATE 10-23-2009 ELI CICO JR 60 NORTHVIEW DR MECHANICSBURG PA 17050 EST. OF EVA CICO SSN 184-36-6674 DATE OF DEATH 08-22-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. M & T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call !717) ?87-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 9843137101 Date 10-19-2006 To ensure proper credit to the account, two Established copies of this notice must accompany t t th R B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. Account Balance $ 985 O1 paymen o e egister of Wills. Make check • payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to 5 1 NOTE: If tax payments are made within three Tax $ 4 9 2 . months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Due Any Inheritance Tax due will become delinquent $ 22.16 nine months after the date of death. PART TAXPAYER RESPONSE 1 .:..:,iii' .. . ......:..... ~::: ........:................. ::k ,~ :.~.: : r :: ...:.::.:;:.:,::..::::,:..; .:',i~:,~~'f ... ::: :.' "~> 4~;:•, :..~...i ~: :.4#f. :~%:^ A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK 0 N E a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different relationshi t d d t ~f`~'f` `i.'" ~/" `i'~!'iiiic.::.`.':J^.:...::i~ii vi:.::.::::.~:.~..:.::.i:;:.ii::5:::::::i tax rate, please state i~`<,<F.~%:°'"'``' ` {:Ff>='~"~~.{'`• ~::~;:::; ~ ~ ~; ~~'~~ '^`'' 2 p o ece en : , ~ TAX RE TURN COMPUT ATION OF TAX : •~;:.~ ON J :::~::~>:, r.<.,,.:;~; DINT/TRUST ACCOUNTS `" '' -,::i,~: :.,~ <.:,:..~.,.~ f.:<.:,,:,,<< <~~:;::.,:..,<...~:.v;::>::j<:f.<;<;>,,,:: ,f,. LINE 1 . Date Estab fished 1 `;r:'` ~^`` ~ ~: fib;: .••:•F a~~~/~%~'i~..• ~.,~ :.:..;;. 2 . Account Balance 2 $ .. ~... .. . . , ,:~% ,s~,•~ t.~!;';;~'{~.~.%~y~f~~: 3. Percent Taxable 3 X ~ •;~~'>''s~:~, ',,°~~.%~:jT~'~'%%°'%'~%"f~`' 4 . Amount Sub j e c t t o Tax 4 $ .<G~s.„:~y,-~ ~;;><~n>:< ::{~.,,~,::,:.~~.6,~„%r~~< >>< 5 . Debts and Deductions 5 ,F .f~.:;:;,;:::.~::.:; ~`.,~,..~::f:;,: ~>_;<<<<<;:<; 6. Amount Taxable 6 $ ~" ~,' ~,~",~~`~~:~ ~f~%f``>`«~~~> 7 . Tax Rate 7 X ` • ~.~~i~ ;.:,<:;~ v;; ` 8. Tax Due g $ ~f, :.,,,,: ... r,~~; .~i~`%'~'~ ' ~~~4~~i ~~~~~> :.,: ... .:.: ..::.r..; r.. ...f : . :. .... .:; ... « : PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE P AID PAYEE DESCRIPTION AMOUNT PAID GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one Year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk C~*) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one Year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable Cline 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. *The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, Parents, children and other lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually Paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. BUREAU OF INDIVIDUAL TAXES ' PO BOX 280601 HARRISBURG PA 17128-0601 ,- , REY-)543 D( AFP COB-08) ELI CICO JR 60 NORTHVIEW DR MECHANICSBURG PA 17050 PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE AND TAXPAYER RESPONSE FILE N0. 21 ACN 09167921 DATE 10-23-2009 EST. OF EVA CICO SSN 184-36-6674 DATE OF DEATH 08-22-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST a CERTIF. M $ T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. P'!oase call !717: 787-827 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003913913933 Date 12-12-1998 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance 3, 917.42 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 1, 958.71. months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential TaX Due $ 88 • 14 nine months after the date of death. PART TAXPAYER RESPONSE 1 f:. :,, ;:: : : .. y.• ..,. .:::: y,. ~::.: .:>3~:. ::~; :,~:: '•~ . ~+ :~.~ .y~F .. ~ t.::F :'% '. :~. y/~~ ~{, + :: . k„„» Jp•:): i•;:y: ..:.:nom :. ..::•.i/'I '1.%Ji'/ .Gk •%:u ..f A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of ONE Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indfcatin a different 9 tax rate, please state ~•%/'r~.?:' 1i`~%?",:,G :iii,'.. ~" s„: •,~' :~'o d~'' f' ~" /.:'v`~r•.'•^i.'~,.''r'^'f 'icy !.~,;./lr, r.,.:f !~'~' ~~ ~~:~: !y~~:~<'':'''~.` ;. ~ ~'~ ~' ~' relationship to decedent: f %`-~ ~ ~ ' ~"'~~<~:~~''~"~~>%'k;~> TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS :'>.•-<:«<.~:'.~~ ~~ %>~'`s»:.:.,• ~'~~.>->i:<:<;<..::<~«<.~:::>:<>:':>~'~:r{:«•f:<.<:.¢ "~ ~ LINE 1. Date Established 1 .y :.. ~~'• ' '• ~ + .! ~ i%%fl •Mh"%?;' f:,fir:::: .: h,::. :.; .;:..:i am ' G r. ~' •.x%'f'~,>~y'~fk ~ '+:f~~+ri'.;; 2. Account Balance 2 }f df~fs ~ ~` 3. Percent Taxable 3 • '. ., ': 'v •~ ~ 4. Amount Subject to Tax 4 $ • r `~ 'i~'`A:'r~~~'" ;~'':,', ... : .i./, i~ ~ ~ ,~''Y/ jam:?%,~,~~ f ~ f ..Y': . // ~'~ ~ ~~1'~ `~~`~"`°`"'? 5. Debts and Deductions 5 ':,' ~ ` R I 5 : r:":; ' 6. 7. Amount Taxable 6 Tax Rate 7 T .~,;.. r`• .. `.:.:.:.:.:. .:....:.::.:..:::::: Ur. ~ :.: y., r . fit: fi ',:q`: ;~ :~:., ..4, ti rt::~Tc~.:fris~s:9.:.j<>:~w:r<:ss9, . :: :. ~`,:'.::. ;: : ~'' <,f{ < > 8. Tax Due 8 ,n:. /% r ' u%f.. ~'JI%':^ y <Sf, r .:eJ . /::~fI.X, t%:`.~yi i:. f:%:'.`'.: .:G:7•'ii <.:,:::;<. :::: ;::. ::,:: : ; ;: .: < /•: :.::::'/.:`:i':'r:'x: :ryR'riii;::~;<::J:3:::;/,:::::<::::::`::::::5::i:::~::4%ki::t; :::.»:.::i::;•: ~.:;:::;;::. PART DEBTS AND DEDUCTIONS CLAIMED DATE P AID PAYEE DESCRIPTION AMOUNT PAID Under penalties of per]ury, I declare that the facts I have reported above are true, corrreect and complete to the st of my knowledge and belief. HOME C ~~ ) ~ J,3 ~7~ fd ,5~ WORK C ~l 'y ) - ,~ ~-~ ~~ D TAXPAYE S GNATURE TELEPHONE NUMBER AT TOTAL CEnter on Line 5 of Tax Computation) S GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 IX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk C**) appears before your first name in the address portion of this notice, the S3,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one near prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one near of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance Cline 2) by the percent taxable (Line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. *The tax rate imposed on the net value of transfers from a deceased child 21 years of age or Younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, Parents, children and other lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not then have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually Paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND PO BOX 280601 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 IX AFP (OS-08) FILE N0. 21 ACN 09168054 DATE 10-23-2009 ROBIN S KNEFFEL 2539 CROFTHILL DR AUBURN HILLS MI 48326 EST. OF EVA CICO SSN 184-36-6674 DATE OF DEATH 08-22-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. M 8r T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003914395578 Date 02-14-1990 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 6,450.27 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 3 s 225.14 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. 145.13 Anv Inheritance Tax due will become delinquent Potential Tax Due $ nine months after the date of death. PART TAXPAYER RESPON E ..... r .:. . ,... ::..r.....:r.;.....;:.:,:..,,. . ~. 1 :}" . /: ~yy~, ~y •5.a..: ~^ a~ .;,. .:..............:a::;:.... ,:.::::.:.::..:...... r..... r ::...:.:..::::::..:......: :::.:;.;:::.:.... r ' r~~ A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of ONE Wills and an official assessment will be issued by the PA Department of Revenue. BLOCK B. ®The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3~ below. If indicatin a differs :'FF~ •~.~~~<;:"" ~ " PART 9 nt tax rate, please state ~~~~~ :` "'~ .>:. •~'r /'4: . r:'AA r: ~, ~. : •''f•S: 2 relationship t o decedent : f., ,:~<:,: r: :•.r•. ; .,.. f •~';.. ~;' ,~~ ~~~:~•:`;:•:: :.,/... f :; 1.. . r1. ?t?{:.jc::,~ f~~f f f,;%F r, •.:ek.S~%rf,:r,.,rrrc.o : ;.<f:.::.:..:.:;~r.. TAX RE U - T RN C OMPUTAT 0 I N OF TAX ON JO INT/TRUS T ACCOUNTS >~~, ~'' .,'; .; ` >: ,~:;: `%~'y'+> ~.. ..~~ :' ''y ,ff'":f :`d% ,~4.~r f '•qir re` % .ri:. 9 •:s:: /.•. 1.7irt :t r . 9o- .r : 9.#; ,•~f . LINE 1 Date ~`.~ r:,, r Established 1 .9: . }}: /r %.•r {: . ~:. ,: f:. 'rj, ~G~~~r rte: ~f;~.Jf:~P ,.~;~f~}.h~;,r:,:~..;G;;.f.,n: <'f•.`•. 2. Account Balance 2 $ : `~ r~~ •:~.'rF,y:~%?:'~•~r~~.:»i%'~~ r /'.' ~ '::~: :.r`' r.:HEr~Ir'lr~ i;'•v.'<o .,f:,:3r X :'~r.',::.4. r C:'•: !•:Ff.;'~yl:;;/.r:::~.~:~.Y'r:.fyr.6~''•':r'.`."::.:i?f 3. Percent Taxable 3 ,~;:r,i;,~.. ,~~,99 .:~•. ~~:h'. :: ~'. r.lro- ~.:~'::~:.:..,. r'Fr lrr: ^.,+::if.''} .•r'.~e~r".>o i:Okr. ~:'.rr `~f tj'~~.~:fYt`r.,:.~:. cf: .;5•.,f',v~'J.:.:%%'r k .ri.: ~ l .rr,: r./:,;c.:< s~i/:.,~:.. Ala:` r. ~.: 4. Amount Su $ ~:% r s. .'..r`:: :,s;: ,-~,~,.es',f.: bject to Tax 4 .~i,v ` :, ~::: ,r:,.:>; - ,~. ':~f;;:,;f~':'>:~~5'3yr;~;:s~ 1c,,•.~,r..s.<.:r::,,~'~r.~.:~r,_,,.~ .:`~•.~' `lr .~7:1: „f ,,.:u~r°...`r'r..6r.".r:`.?.?S.`•:f:.z:::hl:'s%' .,:.:r.::,"r 5. Debts and Deductions 5 f. .s..~...~..~:......;:.. .~.,3,+g.;yr ,rte .. :~ rr r :PFii' :'.r;3': 6 4 `:~ : %L'4"i:~ .c~':2,. .r:ry:.. :.rl..~ r: ~r~' ,~., ~' r.r .:.r>~~ .r::. r~i/.:. :;:. :. rf~~ 6. Amount Taxable 6 •:~,,:v,,,, :y.r .~`r r ~ r.:}.r,~ r.~r, : •7, ,y S'/•. `•'i::: ~,~'~F~ .:.i 'iii: f~~'-' i9 7 . Tax Rate X a; •:.'!.`' ,.:fi' .. ~~:%'l'".'.~sY ~/.` . Y;{~.<{l~{`~~`,~` %;•,a~,f.~{%g'?;~':,:"iSi::#::?:>";>::<:: ~ ~.. ,;:<~ f` ..:f,. .~:.~ r `~'.%:.9 :r "7 r 3'<Y l':E: :::~3Y ':r '::C::::7{i'~:: .'r•'.':.5'.`:?:~y'r.:[:.:.'•..s:.::.::.~::. T ? r rr , 1~~%r n % :rrF>.': ~+;::,.;: fj,~,L~,'/.L~`.~^;,r i~~!'I. :';:I.::~::::::;y}•:k;:: ; ~::Yqi~ :iy;: 8 . Tax Due 8 :>„~,,. .. ~~: :..; :.4". .'%..: .: f:.: :•;::F.:. r:..?::. ~:<.::/ PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the est of my knowledge and belief . HOME C ~ ) r ~~ .2 ~~ ~5~/J~,~ WORK C T/'7) 76G •- o~w~i -~ ~ /~ AXPAYER IGNATURE TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) ~ GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk C**) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one Year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax Cline 4). 7. Enter the appropriate tax rate (Line 7) as determined below. *The tax rate imposed on the net value of transfers from a deceased child 21 nears of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children whether or not then have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIWAL TAXES A N D Po Box 2eo6o1 TAXPAYER RESPONSE HARRISBURG PA 17128-0681 REV-1565 EX AiP (08-0!> FILE N0. 21 ACN 09168051 DATE 10-23-2009 STEPHEN CICO 8 BARLOW DR EAST BERLIN PA 17316 EST. OF EVA CICO SSN 184-36-6674 DATE OF DEATH 08-22-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST © CERTIF. M A T BANK provided the Department with the information below, which has been used in cal cul.ating the potential tax due. Records Indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this'account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Cowwonwealth of Pennsylvania. Please call (717) 787-827 with questions. COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003914395586 Date 02 - 14 - 1990 ~ 7o ensure proper credit to the account, two ~~ Established copies of this notice must accompany Account Balance 6 450 27 paywent to the Register of Wills. Make check , . ,-,~ payable to Register of Wi11s, Agent . Percent Taxable X 50.000 Amount Subject to Tax ~- 3 225 14 NOTE: If tax payments are wade within three . ~ wonths of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Duo $ 145 13 Any Inheritance Tax due will becowe delinquent . nine wonths after the date of death. PART TAXP AYER E R S P 0 N S E ,:~ .... : ~~:.~.....;., f .,.»r ;.:»; r ' ~.~ ,;; ;~~ ~,... ~ ~,~~.L. , ~,T ~~ AN c~~~IC~a~~ rA:x. ASS'ESSINENT RES A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with twa copi es of this notice to obtain CHECK 0 N E a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assesswent will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return O N L Y to be filed by the estate representative. C. ~ The above information is incorrect and/or debts and deductions were paid. Cowplete PART 2~ and/or PART 3~ below. PART If indicating a different tax rate, please state ~F'. r F , ~}F'FICZAL ~$~ OM~ Y ~ a relationship to decedent: . A ~'A. I~E:P`~RTM'ENT qF REYENItE ~~ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ~ ~.. -;A.O.z . ..:. LINE 1. Date Established 1 ~U f-° t' 2. A c c o u n t B a l a n c e 2 $ '~ }iM~111411111111fl1~11i I wlY iii~r)Ty...~ 3. Percent TaxablQ 3 X ,,~ :!s~'#€'~~$ ~~, , ' ~~"' ...-~~ n riwiifwrrwi~~ . r i rM, r ~ 4. Amount Subject to Tax 4 ~ ~~ a ~ i ini ,,., ~'~ ~ . > .m.,,r' "'F^ ~~~~~'~ ~~ s .. , ': 5. Debts and Deductions 5 - ~ .. :.:.. :. .. 2i .f Z , ~x ~ ,....,..., ,.,~., ~~:';...,,. ~.,.' .;. f 6. Amount Taxable 6 ~ , asx,:s sis tt aza Sf s#sn; ~:,f H«f ~. ~~~~ r, =x : 7. Tax Rate 7 X r:' Ws. ~{3 t~ ~ ''~ 8 . T a x Duo 8 ,~` ,~~ '~' :;; '{ ;: :. ~u~~ ( :¢~ a ~'fk if~S.f n i.~ ... ... . > ~ IQ ,t .,{&,P...3. 5 ......; !, ~ f' .Sf,xtoba...a ....>. .., ... ..... PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, corrLect and co plate to the b t of my knowledge and belief. H 0 M E C ) ~T ,~ ;~iiy W O R K C 7~ `' ~ 7 fo -~ ~ Yi o'~ .~ TAXPAYE SIGNATURE TELEPHONE NUMBER iorA~ cEnter on Line 5 of Tax Computation) 8 BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 ,~~.~~. ,- `~ : _' ~1, ~_ .., REV-1543 EX AFP <08-OB) PENNSYLVANIA INHERITANCE INFORMATION NOTICE AND TAXPAYER RESPONSE TAX FILE N0. 21 ACN 09168047 DATE 10-23-2009 JUSTIN SMITH 7169 CHADWICK CT CANTON MI 48187 EST. OF EVA CICO SSN 184-36-6674 DATE OF DEATH 08-22-2009 COIINTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. M & T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call f717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003916012287 Date 06-04-2007 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 5, 002.06 Payment to the Register of Wills. Make check payable to Register of Wills, Agent . Percent Taxable X 100.00 NOTE: If tax payments are made within three Amount Subject to Tax y~ 5, 002.06 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 225.09 nine months after the date of death. PART TAXPAYER RESPONSE /. ,~W H9l.:::. f:../.}F~.:::) x:...... : ......:.:.....:..:..r...:.::::.o:.:o: ^::.:::::.::::.:::::::.::.... .....:........:.:..:~.~:::P;;:;JSy::Y:.::::::::::~::::::i:i:;':i ~::::i:::: ~::::::<Y'r.::::2:0;:. ,. .... . ....:::. .::..:.......... ~:: i :. :..y. :::..:. .. ;: ~: ~.. :..:: r::::'i" ::.::: o. : .':. .y~/k{ yyq~~ :''fl~'~ !r ,t y. •,?.: A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount ar avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. BLOCK B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3~ below. ~':il i::<:%~"vii ::i:v4:n:Y~:':'::?i:Ypri..: ~'v..ivii:::::::::d::}:':~?is:::.i:i::_::}:}n:iY:::w.:::nii: %..::?:::.~n~:. PART If indicating a different tax rate, please state :~y~f~•.~ >,`.~:;,:F ''><:ji°:' '~~~~• ~9 r e l a t i o n s h i t o decedent : •..: .;~,' ~• ~` ~` ,.~l~. ,.,.:.: e.~ir.•r:.s%:., P . r ~ i... ~ ~`s .,,, .; M P U T :::: ::<..<:::.:::: :. :.:.::.:::~..: :.:: .: ...: TAX ~:~~. : RETURN ;:~ .. ;:<..:;:.::..:;::<,<::,> ,::><:::>~>:_:<< CO F TAX ON JOINT/TRUST ACCOUNTS ~:. t;, :>~=t, w (ia' :if~ :f....3 •...fi':.s .y LINE 1 . Date Established 1 ;~ .,? .h': . • :,~~:. , ,,~;::.t,>.~:~.F~f,;::~:<~;;,,.;>.::.;<`<! `.'Z /'' :"t' :~':f j;~,~ '%r": ;ids>'i":;~::>s 2. Account Balance „p;;•, f ,~',~::.<:.<. 3. Percent T a x a b l e 3 X ~, :::.,.~:s ,~~ {..~.: r~~:f f~;%.;~.. ~,:;;: Y=:,:,;: ~ :: .gl'•P . 'k9 . ,r r,.,j ;'% Y 1:~ 4. Amount Subject to Tax 4 $ ~r~~,.• ~~1'~,~~,~;~'~`: ::~f,:, •~N ` 5 . Debts and Deductions 5 - ~+~~~ ::'`~..:: ~'~ '~~r~d,:,?`c~%.'."'.c~,. ~~%;~ ,rr'.:: ,y. •:'~;y'%'=%a ,.ter 9`.~i,.„ ~.:.:~,.. f xa::.:::~rrfi:a>;,x;;.:;;.~ 6. Amount Taxable ~~ y`` ~'' ~' ''F•"'''f' . b,r r ri,i:~)~`,:F "~ir%4~f/,..: •'/:~3f Fl.+'r..~.'f.;'rY}s :may' ;yj~a,.',:~'A;;~,:~:r~`.,/~u,.:.,`:,.., d;`:'fr'.''..,<, ,.,..,, <~<` 7. Tax Rate 7 X ~,. ~:::$,~:,:E•;t,,.r~:,,;,,f.>~ff,;:.,:~~;~f.<v.~~. :~:,~°~.>`~<,,:<,.~< 8 . ~ . •, j:.'l , ~s'co,`l:• `,~*~.,,4i.:s~~%!j~<;?'?,;:"'„''::~.'S.C '.Yc::'''.:':`.<:%:.::`d Tax Due 8 ,~ . .•r:`~F,.. ,.,::., <...~..:r..,~ n.:~.:a,::,.~:.:,:,~:>,:,:•,.•.:;.•<,;.::,~,~~,,:~,•.,.>:.<;:,,;>:,,;;;:;.: 6.<iR•<•i'Y.e :i :..~.... PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the b st of my knowledge and belief . HOME C ~~ 7 ) /IOfC '-r 7 18 ~ lid WORK C 7f ~ ) ~" ,( ~* ~QR ~~- ~XPAYER S GNATURE TELEPHONE NUMBER DA E TOTAL CEnter on Line 5 of Tax Computation) S GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one near of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account ar the number of accounts held. If a double asterisk C~*) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one Year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one Year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance Cline 2) by the percent taxable (Line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4). 7. Enter the appropriate tax rate Cline 7) as determined below. *The tax rate imposed on the net value of transfers from a deceased child 21 Years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. PENNSYLVANIA INHERITANCE TAX EST. OF EVA CICO SSN 184-36-6674 DATE OF DEATH 08-22-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 ' INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND PO BOX 280601 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 IX AFP C08-08) TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. M & T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS ONE BLOCK B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the estate representative. Account No. 31003916012295 Date 06-04-2007 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 5 002 06 payment to the Register of Wills. Make check , . payable to "Register of Wills, Agent". Percent Taxable X 100.00 Amount Subject to Tax $ 5 002 06 NOTE: If tax payments are made within three , . months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 225.09 Any Inheritance Tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE ... „~.: ~•%~.. <.;~~::. :.s ~~;~.:: :~~ ~,<:ry ;<:~,: Y;:.: .~: ~~.:,, ..~ . : . :: l : ' ~ ~~~ .... BNfi; ff . : .:.ny .I! y%:::.~.%%%Y:i:.::::.::::n~ ...............:::..:.~n~.: . ::llisv:v::;;v•u:::.:Kr;p :l :..1...%%:;:..::.:.::Fors:Y...;:.%:<:::::.!,:::<::::;%%::. ' :u. •~..: ...... ........::::.::. .:.:::n:.: ::.~:.~:::..:. .::.::.:: ....::n.::.::.~:::t:.:... ...:.:.:.;.:::.~..:.:.. .. A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and r eturn this notice to the Register of Wills and an official assessment will be issued by t he PA Department of Revenue. 0 DATE PAID PAYEE DESCRIPTION C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3~ below. RT indicati n a d iffer ent 9 o x rate lea s e s t p ate :...,., ,;:. "~ l •~..~. •!: ~?.~ :.:, ;•,` ';~ "~~<< y r ..,~/'i: ~r f~Llfe ,..,~,,,, .: ,j7 ' r ::r%. ~z ; ~ F' 2 r e lationship to decedent. u l.l .. x; .~.~ . :, ,.~{.,,.,:::Y~ :<:.,,;;;~,,:: TAX RETURN COMPUTATION OF TAX 0 N JOINT/TRUST ACCOUNTS r .f :. ,:»i .::r:•::Y:.. .r l:J%:.`'lii`:?:>'y ~f~.:'.:;f~~~i:^:~~•. •ri'%`"S?<f.Y~r.'s~°.~:':,:'i:. ..~ :5>:c::~y;^:':`:c•r.3": .:.~%F.:',5:::%:.::::;.:;:.:....::1~„ri,::.':r. r•~1~::.r::; ~'e?:lr`ly,~.,..r :': :.s~:::.:<,.:~:..<::%:.,~,,~.<:.....:.:::.:h<.::::::~.;<< ~ ~ "`"~ "` LINE 1 . Date d E s t a b l i s h e 1 ~,; : _ %%' ~~~ f ..•:f.~~ ~f `~~ ~`~" `''~~`y``" :.. r. a ..:. 2. Account Balance 2 $ l . !. f ~ ~~il,%~'~~.~ s~.r~;.<; : :: 3 . Percent Taxable 3 rf,,.,, r • r Y ' ~ : ` . l.. ... ,:~:<~~%:~`«::::<:;»: 4 . mount Sub e c t t o Tax 4 j if %J"/ H S :i:: r. r:.. .:rr+•~: .... f:.5. : :.. :, ,.F::;<: .' !.: a~"l .Y. l. ..:.• :• ~%:s:•:: lv. . . ebts and Deductions 5 ~ ,,:. .r . :::: . . : ~;l :r v :~:~f~ f!c%~f:4 ?k'{:IYIG~ '%:i//rn :.:/ l "Y .'l?~:{:~?t: :r ~l:%: f'y% ;/.~f..~~~ ~~1 ~ ,:;.~:,: ,~~; ! . f . .. ~:1,, ~::: /° :: f,,; / , :'r} ,Jl }::: l; '~y+~ , , : ::. : ., . : : , ' ` . mount Taxable $ . : y : { ~{ ~:~ : `:f": /' ~ ` yY~~i!r:/. r<H:l rh.:: I:M f,•{:2::Yi.Y"•`'r%1::. vy:<? .~' ,Y~~;,a;2,~:;..~ <~Y' `~;1:~,k.,,<:r,~~;~so;::Y„Y;:<<Y% ~,r~>r`<;• :; . ax Rate X y Y..~ Y!:;~ll: '.t6`<' %y„ s`i:'? Ykf~: rl~ . Il~:/ ,.,./•1::: n%.t`.:Yl:: .:Yr~J/'` o`a`•b ~'Yr,::;:3'<`;i`% s s~! f,: ,mss;, Y.~:,,:~<:s:• ,..,: <'<~:: . x Due 8 $ ~ Y •I r •..'l ;.fl: rl •~. <f~ ~: T}y ~; .: ;:f: ':~% !l 'l: :./'ei ! f. l'f:5il.:.+':~4`~%i:' :!'~:pl .. ~•l` : ~~`'r`:3:i•`:•`G:.`S:o:,J.,.:vs:'%:•r.: :c> xf., .:~ :,~;s:.: l ~r, f £ r~`:, :, l .: :u: zl. !r: >;:,:• ~...: : .::..: ,, :.> : : . : : PART DEBTS AND DEDUCTIONS CLAIMED AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and ~fcom~plete to the st of my knowledge and belief . HOME (r~ ) 7 ^ ~~ ~~if' „9'i ~ ~' ~ WORK C 7/ 7 ) ~~ A ~ ' a~ ~ TAXPAY R SIGNATURE TELEPHONE NUMBER . D DA E JEREMY SMITH 7169 CHADWICK CT CANTON MI 48187 FILE N0. 21 ACN 09168046 DATE 10-23-2009 IUTAL ctnter on Lane 5 of Tax Computation) ~ GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk (*~) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one Year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIYING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable far assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one Year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax Cline 4) is determined by multiplying the account balance (Line 2) by the percent taxable Cline 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, dopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent~n common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually Paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. PENNSYLVANIA INHERITANCE TAX ' ~ INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND F I L E Po Box zao6ol TAXPAYER RESPONSE ACN HARRISBURG PA 17128-0601 DATE REV-1543 EX AFP COB-08) N0. 21 09168045 10-23-2009 EST. OF EVA CICO SSN 184-36-6674 DATE OF DEATH 08-22-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: TREVOR SMITH REGISTER OF WILLS 7169 CHADWICK CT CUMBERLAND CO COURT HOUSE CANTON MI 48187 CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. M 8~ T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address.. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call :717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003916012435 Date 06-04-2007 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance ~- 5, 002.06 Payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 100.00 Amount Subject to Tax $ 5, 002.06 NOTE: If tax payments are made within three months of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discount on the tax due. Potential Tax Due Any Inheritance Tax due will become delinquent 225 • 09 nine months after the date of death. PART TAXPAYER RESPONSE 1 :. ,..,..:.;....:, .::....:,.......,.,. ...... ....,.; ~;<<; t .t::~x.< :.: ,:: ...::<.n: ~::::<. :: <.: . ,~ ,.:.:, <f~ :..:.<<> i~., :.: y~y." y~,..y. :.: <:>::... .~: : 2 :..::: , ~y~.~ y~~y~, ~: ''~'. .Y yY .. s :.. y ...:.....:... ... ....r ... ....... ..~ .......~ .::. ~::..::::.:.:, ....:. A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ® The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART L.__I below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 2 3 X 4 5 - 6 $ 7 X 8 $ PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION eMn~~Nr porn Under penalties of perjury, I declare that the facts I have reported ab7ove are true, correct and complete to the st of my knowledge and belief. H 0 ME C /~ 7 ~ ~ ~D ~~. ~S WORK ('I/` ~ .~ v? ~ -S /~ / O TAXPAYE S GNATU E TELEPHONE NUMBER AT ~~~~~ .~n~er on pine 5 or iax Computation) $ GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one near prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with Your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one year of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk C**) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one near of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one Year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax Cline 4) is determined by multiplying the account balance (Line 2) by the percent taxable (Line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable Cline 6) is determined by subtracting the debts and deductions Cline 5) from the amount subject to tax Cline 4). 7. Enter the appropriate tax rate (Line 7) as determined below. *The tax rate imposed on the net value of transfers from a deceased child 21 Years of age or Younger t death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children whether or not then have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not then have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent a A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually Paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of aavment may be requested by the PA Department of Revenue. PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D PO BOX 280601 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 EX AFP (08-08) ROBIN S KNEFFEL 2539 CROFTHILL DR AUBURN HILLS MI 48326 FILE N0. 21 ACN 09168052 DATE 10-23-2009 EST. OF EVA CICO SSN 184-36-6674 DATE OF DEATH 08-22-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. M 8r T BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (717? 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003916012469 Date 06-04-2007 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 3, 555.0$ payment to the Register of Wills. Make check payable to "Register of Wills, Agent". Percent Taxable X 100.00 NOTE: If tax payments are made within three Amount Subject to Tax $ 3, 555.08 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 159.98 nine months after the date of death. PART TAXPAYER RESPONSE 1 4 :r .«ux'r. ,~•%r ;:: f rr ::,,f;:y:.:fir,.:.::. r r:: ,,;;;: ~~ a g~% : : f. fi .:'~r.'+`':.. Ivh.n?'.. n /r::.......::/ .v .:.:.: .x n.:n:::..w.~ ::::..:::::::.:.:..:pi::i:::i':ii::::::::.::::: n. a: :.G rr r.:.: :• r/%~;.:1' r:. : :. /.1~.....:. vv'/.:{.f:.r::~;::%vrw:n~.~iiii.:niiii?iiiii::ni:5i.:~':.~:.~n~::n :::::.:....:...r.....n~.:~:::.:.:i: i::.~... ................: A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3L_1 below. .:::: a:y. ;..r.....r..:.;.,.,./ If indicating a different tax rate, please state :«:;;:;;,,;,~a~~:;/;`%yry.~,y . •,•;,,: PART ~;>.~~: r~,..~ '! ;~:{ relationship to decedent: .f~,~. ,'~:r,''`~ ;~ri~r. y:,.~.,,.~:. ,•r,'u.<f ..:.;< .r r. r n ft ; f'r' .'+%!r `:i :.:~}••: :~.::,:.:...IO~,:...: f"!.,G..:.;v..~k~~~~h.:.r::¢ .:b.':::isv:.::?::::n:::9..::.r....Ir:::;. ~:;'::::: ::.,:s.. :.f:: ,::~::,.F:: ..::s;:.~::..:::,,.s.•..:...~...:rr. TAX RETURN COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS :;~ •`%i1; /` "rf``/..r,GJ` . 4;J r $.~ // n`r'4`r.{'!:/~:'ll: r;9::'~N:.' '9,rrr. `'%.•n,7%WfY"k:'%u.L'::r°...i:+/f.'.':. '';"k``%:c' LINE 1 . Date Established 1 ,;;,¢~r:.; r::rr,~`'r.~:'~sr:~: ft%< •,,•.,;~%3'•<•"`°, <>'.<>:. f r`3:r+:r% :,~' :.'.~:Fr a"Y r. r:.4 ,~r:.'`~...::^::?Yi.':':::::5 ~~`:sr"':'f:f/` r%'r.~~s: ;sf .f`!r/ r:;/"a'.r:~~•;..%'%€.~%!;rr`•s,.»F: 2. Account Balance 2 $' ~ '~~~~ ~ fN ' •`°~~ ~''~ •s ` ~: 3. Percent Taxable 3 X,• ,~; ".r: • 3r `•:. y"o • :,•; r:. H"h•' 'i f ii:/ I+ •'•B':ri rMoto`~:^>'~'s:r~:":?~:.:::::'s~>%%';>?<' :. :r..::.:..,. .b I1~.. ~/r ;~' 4. Amount Sub ect to Tax 4 ~ 7 ::.s': ,;.r: :~. r ;r e': <y« ?:y<:> ;;~,, .4:G ~ CC` f~ :r~~'t.',.~i~S'`•yfr`':< ~ rr.::.s:`,v t: :.>~ai< <,:r~.<;:'s::~i::;:,.. <zs 5 . Debts and Deductions 5 r. , ~.: r• ~. •~ :.: .'.~`.. ~".,.,"•.;,.'. `. >`„".;.;`'.. .l:~ ' '~r 7 rp r~,/. S + i>:yY: Cif' ~:'`1.,4,~5'.ii':i'+':NN.i`i'"i ~: ~ ~::i::%i ~ ~:;. 6. Amount Taxable 6 $ ,';>s,~ n~: ~'"~~'`'"''"~ ` ~"''`• '~ ^ r '.r:,. X ~ ' l ,..~i .~f ~i~rf`r/fl?fi..'r:Gyer :`.~/~r~f~/ti`~ `r,`i~ ~` ~ 7. Tax Rate 7 a ~ ~~r ;~:r •:. .f ~~:.~f Ffrf~lr 'y.,`!^.`v:~rN.,^1.~,r,~r ~~<: :'.:~',?~•"r~5:.>~':~oz•Yra~iy.~`:Y~..^•.::~~;::% ~ir r •J~'~`~`'r: .ii'o``'t~~.`~9.:.•.~r''.'~~'':9~~o-•~9::r.;.3~/`.:.i~.`6~~.'.`~'..'~'trj%; ': •'%";f:ir;:: 8 . Tax Due 8 $ 'r,.;, r:~~ ~ .~ s :r~~~~ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the b st of my knowledge and belief. H 0 M E C ~ ~ ~/~~ iJ ~S7ri~'(r WORK C 7 ~ 7 Q.~ ~ /~ ~~7 TAXPAYER S GNATURE / TELEPHONE NUMBER DATE TOTAL (Enter on Line 5 of Tax Computation) S GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one near prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died afterl2/12/82, accounts the decedent put in joint names within one near of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk C**) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one Year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED BY 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable Cline 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax Cline 4). 7. Enter the appropriate tax rate (Line 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present 0 percent 4.5 percent * 12 percent 15 percent *The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent. The lineal class of heirs includes grandparents, parents, children and other lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue. 05/19/2010 ' 00:36 717772012 INHERITANCE TAX PAGE 01/07 vrt; 1 REpARTMENT Ot= REVENUE To Bii1 Sunday FAX 717-7'~~-72$U PHONE ~ ~ ]- 7f~-922 &E HARD Copy TO fp~~ow ^ FROM Rubin gaff PAGES '] uAr~ May 19! 2~1o CC We could not print out copies of the information T~ofice and taxpayer ~sponse, so I am faxing the closest document to what you were requesting. Questions, call 717-705-Z~~~. FAX T,t}fg Ong ~5 ir}>~ g~1y fQr the use gf the Indlviduai or f~lltitY tD which it is addres9ed, and may tbntaln information that Is privileged, Confidential and exempt from distiOSUre under appilcebie iew. Il the reader of this message is trot the Intended retiaient or the employees ar ages responsible for defiveririg ffie message fc5 ~E . intended recipierif, j+6ii are firre$y fiat#;ed t~a# any d~s~#rrst#arr, ciist~illutiort or t~3py:r~g s~f fh#s tE}}s!~rr~us~1~U~+!~ is stsktl~r ~~1~ite4: tf y8~ I?avd- *~±~!-9 this ~n,mu~.ieat~an lr~ error, pease notify vs lmmsdiatety by telephone, end return the original message to us at the above address via the U.S. Postal ServiC2. Thank you. £~e~t~ment of R~yen~ ~ DQ ¢Q~ ~~Q~~1. 1 •H~rrlsburg, PA 17128) 717.7DS.Z326 J www.nevenue.state.pa.us 1 ' ~5i i 9i 1~i ~ ~1PJ: 3b ~i~7~1~14i1 ~NHEk~THNC~ SAX ~1"1K- ~~/ ~~ COUNTY/FILE 21 09-1077 DATE OF DEATH 08-22-2009 CICO EVA ACN 09.6$053 SSN 184-36-6674 *'***'ACN 09166053 **** STATUS NOT 10-16-2008 ACN CREATED 10-16-2009 i~Of~7 - PROBA'T'E ASSES' TRACKING DTE 0 8 - 2 2 - 2 010 INTEREST DATE 0 5 - 2 3 - 2 010 BANK CREATION D'I'E 12 -12 -1998 *** SURVIVING OWNER/BENEFICIARY *** *** FINANCIAL IN9TITUTZOXU' *** SMITH DOROTHY M & T BANK 332 GLEND~,i,E DR TYPE - TIME CER~'IFICATE CAMP HILL PA 17011 ACCT N0. 31.003913913941 SSN 20U-24-1997 FIN INS ID = 002979 *~****~~t***+r****~~r**~-~r*******************~~*****~*******~**~***~********~~**~t~r'k * * * ~ Ii~'ORfi~IA'ITOI~ ~NCS'~3C~ ~R~CESSED 10 -16 - 2 0 0 9 DLN ~- 091680-53 NOTICE DATE ~.0-23-2009 ENTERED 425 10-16-2009 O1 I~CCOUNT BALANCE AT 50.000 PERCENT TAXABLE 3,917.42 1,958.71 02 DEBTS AND DEDUCTIONS .00 X33 fiAXABLE AMO~~` (i,ii~i~; Oi iii; Ozj 1, 958 , 71 0 ~ TAX DL1E = LINE 0 3 AT . 0 4 5 TAX RATE ~, , 9 5 8.71 $ 8.14 ******,~***********,k,~,+~r*******,r*********~r******~t*,r*~r**~r********** **~r+t******,r*,rrr* ** MORE ** =+1 PAGE 30 051a~/2010 •00:35 7177720412 INHERITANCE TAX PAGE 05!87 COUNTY/FILE 21 09-1077 DATE OF DEATH 08-22-2009 C~~`O ESA ACN 09168049 SSN 1~4-36-66'4 ACN 09166049 **** STATUS NOT 10-16-2009 ACN CREATED **** 10-16-2009 . NON-PROBATE ASSET TRACKYNG DTE 08-22-2fl1b IN~'EREST DATE 05-23~Z010 BANK CREATION DTE 02-14-1990 * * * SURVIVING OWNER jBENEFICIARY * * * * ~''~ ~`fNANC~A~ li~1SfiIT~7"TTvN x * * SMITH MICHAEL E M & T BANK 1920 JAN CIR TYPE - TIME CERTIFICA'~E CANTON Mz 48187 ACC'X' NQ. 31003914395560 SSN 373-64-5388 ~~N Ifi1S gD = Ot~29'39 ******************************~r*,rw*,~,r****w,~****************,r**** ~************,r* **** INFORMATION NO'Z'ICE PROCESSED 10-16-2009 ALIT ~ 091660-49 NOTICE DATE 10-23-2009 EIJTERED 4Z5 10-1-20c~~ 01 ACCOUNT BALANCE AT 50,000 PERCENT TAXABLE 6,450.27 3,225.14 02 DEBTS AND DBDUCTIONS ~00 03 TA~ABI,E AMOUNT (LINE O1 MINUS 02) 3,225.14 04 TAX DUE = LINE 03 AT .045 TAX RATE 3,225.J.~ 145.13 ****+t*~-***********+r****,~**+~rt*******~*****************,~,~********x~ ***rr**,r******** ** MODE ** =+1 PAGE 21 illJ 171 LCJ1G CJ CJ: 3b f1 f f fLU'41L 11Yf1LR11lilVt.rt. 1H~ f Ham. CJ'i/ CJ/ `COTJ~TTY/FILE 21 09-1.07? DATE OF DEATH 08-22-2009 CICO EVA ACN 0916$04$ SSN 184-36-6674 ~~~~ Cn'fLN Q7yV8V48 *~i~ STAI~TO N~1~ 3~'1V'LV~~ At.'N C~riAlEL 1V"1~-t~~~~ NOt~ = PROBATI? A~' o~'T T~CKII~~ LTE J n r 2 2 s 2 01 Q Ik~'£EREST DATE ~5 = 2 3 s 2 y 2 Q BANK CREATION DTE 06-04-2007 *** SURVzVz~TG OWNER/BENEFICIARY *** *** FINANCIAL INSTITUTION *** $MST'H MIGHAEZ, E M & T BANK 13 2 0 SAN CIR TYPE - T~t~ST C.A~+T'z'O~1 MI 48167 ACCT NO. 31003916012261 SSN 373-64-5388 FIN TNS ID = 002979 *' ~" * * zNFORMF~TION NOTICE PROCESSED 10 -16 - 2 0 0 9 D~ - 11916 8 8 - 4 $ NO'1~T CE DAfiE ~. 0 - 2 ~ - 2 0 0 9 ENTERED 425 10-X6-2009 Q 1 PsCC£?~7NT BP.LP~CE aT 54 . n 0 Q PE~RC'E~' ~rax~-aDE. 3 , 5 55.0 $ '! ? ~ 7 7 . Q2 DEBTB AND DED~JCTION~S f 109 0 3 ~A_L E AMOK f T 1~~?~ 0 ~. ~IN~S g~ 1 1; 7 7 7= 5 4 0 4 TAX DtTE = Z,, INE 0 3 ,p,T . 0 4 5 TAX RATE 1, 7 7 7. 5 4 7 9. 9 9 **~r,~*~r~r**~r~r,~*~r**~r***~r**** ~r****,r**#**********w,t************~.***rr*,t******,t*~t***** ** MORE ** =+1 PAGE 19 C(3UNT~/FILE 21 09-1077 DATE OF DEATH OB-22-2009 CICO LAVA ACN 09168050 SSN 184-36-6674 **** ACN 09168050 **** STATUS NOT 10-16-2(?tJ9 ACN CREATED i6-16-2609 NON-PROBATE ASSET TRACKING DTE 08-22-2010 INTEREST DATE 05-23-2010 ~Ai~T~C CR~A`I`TON D'~ v` 4 - 0 4 - 20 G7 *** SURVIVING OWNER/BENEFICIARY *** CICO STEPHEN 8 BARLOW DR EAS'E' BERLIN PA 17 316 *** FIATANCIAL INSTITUTION *** M & T BANK TYPE - TRUST ACCT NC . 310 0 ~ 93.6 012 2'9 9 SSN 195-52-4210 FIN ZNS ID = 002979 **** INFORMATION NOTICE PROCESSED 10-16-2009 DLN - 0916@0-50 PIO'TICE DA'I`S i0-23-2009 ENTERED 425 20-16-2009 01 ACCQ~~NT BALANCE 1~T 1 ~} 0 s 0 9 FERC~NT ~'~?~ LE 42 D~D'I'S AND D~DUCT~QNE Q~ TAXABLE AMOUNT ALINE O1 MINUS 021 04 TAX DUE = LINE 03 AT .045 TAX RATE ** MORE ** ~+Z 3; 555, 0$ 3, 555.08 .00 3,555.08 3,555.08 159.98 +t*,r******,~*~***************+r**~t**** PAGE 23 COUN'~X/FILE 21 09-1077 DATE OF DEATH 06-22-2009 CICO EVA ACN 09168044 SSN 184-36-6674 '"~~"~'~ Alf ~J1~$c544 '~*** STATUS NOT 10-16-2009 ACN CREATED 1.0-1.6-2009 NON-PRQBATE ASSET TRACKING DTE 08-22-2010 INTEREST DATE 05-23-2010 RANI{ CREATION DTE 06-04-2047 *** SURVI~IING OWNERJBENEEZCIARY *'~** *** FINANCIAL INSTITUTION *** CI Ltd CHELSEFi L ~1 ~ ~` I:iAN1C 8 BARLOW DR TYPFs - TRUST EAST BERLIN PA 173x6 ACCT NO. 31003916012443 ~~1~ I9~-7a-553 FIN INS ID ~ fl©2979 ~~~ww,k,k,r****w******~*~****~****#~~~t14***~,k+-~******+k,k~l~r,t*,t*~***~+k*****~r,k**1F1F+4****t-r,a **** ii~Ft3RirIATiON NOTICE ~OCESSED lb-3~-2009 DI,~1 - 091680-44 NOTICE DATE 10-23-2009 ENTERED 425 10-16-2009 01 ACCOUNT BALANCE AT 100.00 PERCENT TAXABLE c~ 2 l3E'$'PS A~ii3 i3Ei?UC'Ti (3i~g 03 TAXABLE AMOUNT (LINE OZ MINUS 027 0 4 fiA~ 15UE : ~ ENE t~ 3 Afi . 0 ~ 5 ~`~C RATE 9E ii~Tr4if~'~r~9Fir~t~Tr*ig~~iiir~iicirir3rf~iF~frirtttir~r~iir~iiFiti~irir~i~ti~itf[~ir~ ** MORE ** =+1 5,002.06 5,002.06 .00 5,002.06 5, 002.06 225.09 ~rir~i~iryfr~r~iirir~i~eitTr~r~ii~Ftftiie~irriir*~rittfirir~Gi~iir~~4ii PAGE 11 VJ/ 1 J! LViV VV• JV ~ i ~ ~ ~ LL' COUNTY/FILE 21 09-1077 T~a. ~• .. .~. . .. .. .vim .. .. DATE OF DEATH 08-22-2009 CICO ~.~ ... EVA ACN 09166043 SST x.84-36-6674 **** ~.~`~T 0915043 **** STATUS NOT 10-16-2009 ACN CRFATE~ 10-1.-200 NON-P~'t0EAx8 ASSET TRACKING DTE 08-22-2010 INTEREST DATE 05-23-2010 HANK CREATION DTL 06-04-2007 *** SURVIVING OWNER/BENEFICIARY *** *** FINAATC~IAL INSTITUTTON *** CTCc3 ~€AITL~''i~3 R M & ~` BAi~K $ SARLOW DR 'Z'~tPE - TR.US'~ EAST BERLIN QA 2737.6 .ACCT NO. 310039160124l5I, SSN 164-76-1465 FIN INS ID = 002979 x,~*,~,~**,~******x*x***x,~**x *****x*~xx**,~*,~,~*******************~-***,~*xx***x***x**x ~ # # ~ Ii~FO~MtMATiOi~ A3~3'Ii CE PRUC~S~ED i G - 3 6 - 2 0 0 ~ DLN - 091680-43 NOTICE .DATE 10-23-2009 ~~cE~E~a 425 ~o-16-zoos t3 3 ACCt3UNT BAirANC E AT 10 Q . t3 0 ~$RC EN3' '~AKASi,E 5, v 0 2. 0 6 5, t3 0 Z. 0 6 02 DEBTS AND DEDUCTIONS .00 03 TAXABLE AMOUNT (LINE O1 MINU9 02j 5,002.06 04 TAX DUE = LINE 03 AT .045 TAX RATE 5,002.06 225.09 ~~Te~r*~de~eir~r~ir~iF~f~riYiririe~F~~tFyF~ik~ir ~~ir~irir~r~Fr*~kirx+ir~w~r~'r~rwiir~ir~r~rw~r~~r~y'r~r~F~rirw~~r~Y~ir~ic~ir~TelF+tr~4~ir+~riF~~+TttF*+k~+k ~~ Mt3~FtE *~ =+i FRGS 9