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HomeMy WebLinkAbout06-15-10 (2)15056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes ,~ County Cotle Year File Numher PO BOX 280601 INHERITANCE TAX RETURN ~ Q Harrisburg, PA 17128-0601 ~~ RESIDENT DECEDENT ~ ~ ~ ~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Decedents Last Name Suffix Decedent's First Name MI S~l~~L .~o2is ~ (If Applicable) Enter Surviving Spouse's Information Below Spouses Last Name Suffix Spouse's First Name MI ~~;~~L~ ~©~~~i G Spouses Social Security Number ~ D ~ 1 ~ 9 ,~ ~ ~ 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 T0: Name Daytime Telephone Number .DA t/ i .D ~ ~ c~ ~ HUGH `7 t '7 73 ~ 3~~3 Firm Name (If Applicable) First line of address 3'~ G~ L;~ 2 ®~ Second line of address City or Post Office Correspondent's a-mail address State ;P ZIP Code REGISTER 9F WILLS USLY C ~ r.:~ - ~C~, f ~ ....~rr ~ ~~ .. .L r ~,~ n~ ~~, -~ (-'; :-7 m D~E'IIILED _ ~~nll W -,--t i i .:1 ., _ _.i - 3 .:? _t-j C _a 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 nd complete. eclaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATUR F PER N R P~IBLE R FILING ETURN DATE C (o /~ ~ili'/ C3 ADDRESS SIGNATURE R~~ RRER T R TH REP NTATIVE 'a DATE ~ / S ~ I ADDRESS ~ : l ~~~~ ~L- /~fG~~' l,. ~vl'i ! C. `~ !~~ / ~U~ PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 U J 15056052048 REV-1500 EX D e cedent's So ci al Security Number ' J // - f - " ~ ~ ` ~ s Name: Decedent RECAPITULATION 1. Real estate (Schedule A) . .......................................... .. 1. U . 2. Stocks and Bonds (Schedule B) ..................................... .. 2. ~ • 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ~ 7 ~~ 11 ~~ V • O ~ 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. ~ s 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. ~ T ~ ~ T ~ ~ a 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ' ~.t ~ ~ ~ ~ .'/~ v 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. ~ ~ ~ ~ . ~ Z' 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. ~ ~ G ~ (!p Z- r 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. ~ ~ ~ r S ( J ~C TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 . 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 • 18. 19. TAX DUE .................................................... .....19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056052048 15056052048 ~• O REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME ~~ ~ i ~~ V s J. STREET ADDRESS I EGG ~ /~~ KIT S~t~2~~~ CITY STAT ZIP C~ m P 1~4 ~ ~ L ~' A i~ o i~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty 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. A. Enter the interest on the tax due. (5) (5A) d 6. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 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: Yes No a. retain the use or income of the property transferred :................................................................................... ....... ^ ^y( b. retain the right to designate who shall use the property transferred or its income : ..................................... ....... ^ c. retain a reversionary interest; or ................................................................................................................... ....... ^ Q d. receive the promise for life of either payments, benefits or care? ............................................................... ....... ^ Q 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................................... ....... ^ K^ 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. REV-1502 EX+ (6-98) _, ~` SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~OR ~5 ~~NEI~ All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. (If more space is needed, insert additional sneers of ine same size REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~~(~cS ~ S(~ELL All property jointly-owned with right of survivorship must be disclosed on Schedule F. {!f more space is needed, inseR additional sheets of the same size) REV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER ~`J ~ ~ ~ S v` ~~J~ L~ Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size) REV-1505EX+)i-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF City 1. Name of Corporation ~ l ll~-~ Address 2 3 4. Product/Service Federal Employer I.D. Number Type of Business FILE NUMBER State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPOR State Zip Code STOCK TYPE Voting INon-Voting TOTAL NUMBER OF SHARES OUTSTANDING PAR VALUE NUMBER OF SHARES OWNED BY THE DECEDENT VALUE OF THE DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. .Was the decedent employed by the Corporation? ^ Yes ^ No If yes, Position Annual Salary $ 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness $ ^ Yes ^ No Time Devoted to Business 7. Was there life insurance payable to the corporation upon the death of the decedent? ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers andlor sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete addressles and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. REV-1506 EX+ (9-00) SCNEDIJLE C-Z PARTNERSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1. Name of Partnership Date Business Commenced Address r l ~ Business Reporting Year City State Zip Code 2. Federal Employer I.D. Number 3. Type of Business Product/Service 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5 PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE pF CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. ^ No REV-1507 EX- (1-97) .:~~` ~~, SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF ~- FILE NUMBER ~O R [ S ~I,, c~/U~, L L Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Z, ~-~-6~ ~~«t) • ~3~~8.5~9 TOTAL (Also enter on line 5, Recapitulation) I $ /~{ ~ ~ 9 ~a . L~ (If more space is needed, insert additional sheets of the same size) REV4509 EX + (1-97) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ESTATE OF FILE NUMBER If 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 InInITI v_nwNFn PRnPERTY: ADDRESS ~~ /a RELATIONSHIP TO DECEDENT 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. VDALUE OFD S3ET % OF INTEREST DATE OF DEATH DECE ENT'S NTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY FILE NUMBER 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 INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIPTO DECEDENT AND THE DATE OF TRANSFER. ATTACH ACOPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IFAPPLICABLE TAXABLE VALUE 1. /~ TOTAL (Also enter on line 7, Recapitulation) ~ $ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCFIEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~. N~1~ ~~n~2~~s~ ~ ~~~SZ. ~Z C~ m p f~-~ t,~, ~~' ~7n r/ B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State Zip 2. Attorney Fees „~ 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees J pC ~,,, ~1 6. Tax Return Preparer's Fees $ ~ ?jq d ~ -' /~ 1~/~ ~~ ~''~GI~' ~/LGri~ ~~~~1 ~. ~13~ o 0 TOTAL (Also enter on line 9, Recapitulation) I $ 0 8 q !. (~ Z (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ~ ~ ~ ` JY~~~ FILE NUMBER ~~ ~~S (If more space is needed, insert additional sheets of the same size) 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) . ~` SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. II 1 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 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-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shei FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAMES} OF LIFE TENANT(S) DATE OF BIRTH. • NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................................ . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH • NEAREST AGE AT DATE OF DEATH TERM OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-1644 EX ~ (3-oa> INHERITANCE TAX - SCHEDULE L COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT IN RESIDENTEDE EDENT N OR INVASION OF TRUST PRINCIPAL FILE NUMBER I. ESTATE OF (Last Name) (First Name) Inniaale Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. I REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Terrn of years income or annuity is payable or Annuitant(s) ` J _ /~ of election C. Assets: Complete Schedule L-1 1. Real Estate ....................... ........$ 2. Stocks and Bonds .................. ........$ 3. Closely Held Stock/Partnership ....... ........$ 4. Mortgages and Notes ............... ........$ 5. Cash/Misc. Personal Property ........ ........$ 6. Total from Schedule L-1 ............. .........................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities .................. .........$ 2. Unpaid Bequests .................. .........$ 3. Value of Unincludable Assets ........ .........$ 4. Total from Schedule L-2 ............. .........................................$ E. Total Value of trust assets (Line C-6 minus Line D-4) .................................$ F. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . G. Taxable Remainder value (Line E x Line F) .........................................$ (Also enter on Line 7, Recapitulation) III. (Month, Day, Year) B. Name(s) of Life Tenant(s) or Annuitant(s) INVASION OF CORPUS: A. Invasion of corpus _ C. Corpus consumed ............................................................$ D. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . E. Taxable value of corpus consumed (Line C x Line D) .................................$ (Also enter on Line 7, Recapitulation) Date of Birth Age on date Term of years income corpus or annuity is payable consumed REV-1645 EX + (7-85) .,~._ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-1 REMAINDER PREPAYMENT ELECTION -ASSETS- FILE NUMBER I. Estate of (Last Name) (First Name) (Middle Initial) II. Item No. Description Value I A. Real Estate (please describe) Total value of real estate (include on Section II, Line C-1 on Schedule L) $ i B. Stocks and Bonds (please list) Total value of stocks and bonds (include on Section II, Line C-2 on Schedule L) $ C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) Total value of Closely Held/Partnership (include on Section II, Line C-3 on Schedule L) $ D. Mortgages and Notes (please list) Total value of Mortgages and Notes (include on Section II, Line C-4 on Schedule L) $ E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property (include on Section II, Line C-5 on Schedule L) $ III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ (If more space is needed, attach additional 8'/z x 11 sheets.) REV-1645 EX+ (7-85) ~' ~ ,, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-1 REMAINDER PREPAYMENT ELECTION -ASSETS- FILE NUMBER I. Estate of (LasT Name) (First Name) (Middle Initial) II. Item No. Description Value I A. Real Estate (please describe) Total value of real estate (include on Section II, Line C-1 on Schedule L) $ B. Stocks and Bonds (please list) Total value of stocks and bonds (include on Section II, Line C-2 on Schedule L) $ C. Closely Held Stock/Partnership (attach Schedule C-1 andlor C-2) (please list) Total value of Closely HeIdlPartnership (include on Section II, Line C-3 on Schedule L) $ D. Mortgages and Notes (please list) Total value of Mortgages and Notes (include on Section II, Line C-4 on Schedule L) $ E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property (include on Section II, Line C-5 on Schedule L) $ III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ (If more space is needed, attach additional 8'/z x 11 sheets.) REV-1646 EX+ (3-84) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I. ~ Estate of II. ~ Item No. A. B iNl-IERI~'AIrICE TAJC SCHEDUI-E !.-2 REMAINDER PREpAYMEN i ELECTION -CREDITS- FILE NUMBER -- (Last Neme) (First Name) (Middle Initia ) _----- T -- -- --- - ~escriptsot3 _ L Amount Unpaid Liabilities Claimed a~c~e~i +~1ro~ ~ g, f=srate, and payable from assets i reported on Sehedule L~i t~Ziec,.<.n i:s'•~ i 'i --- --- -- (inc ~ c ~,° r ~.'~ ~ ' _~n~ ~~- i on Schedule L) ~~~ Unpaid Bequests p~~yable re~~, ,,;;v,n si~~~,s-e~ ~n Sehedule L-1 (please list) i C. Value of assets re~orte~i c } „B" above) that of the trust. Computation as f~.~ii~v~s __ ~'fc~t~~ .t= S i~.,, . , '' ~e ~- on Schedule L) - `r s ,npaid bequests listed under ., ti,r that do not form a part tY G'I~~ L~"^ .UC- ~I -. ~ v,.- TOTAL jAlso enter on_Se+~r~L ~r, 6- - d.~ ~- Li 41f more space is ~A .:~e4~ ^c<c .au?itionai 8'1z x 1 1 sheets.) IS REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet FILE NUMBER This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal _ III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest .........................................................$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% ......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ...........................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$ (If more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99) SCHEDULE N _. ~ ~ SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) INHERITANCE TAX DIVISION ESTATE OF FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1 . Taxable Assets total from line 8 (cover sheet) ...................... . f/- ~~ ............... I 1 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joint Assets with Spouse ............................................................ 4. 5. PA Lottery Winnings ............................................................... 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. ~_ 6a 6b. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) ........................................................ 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilities .............................................................. 8. 9. Net Value of Estate (Subtract line 8 from line 7) ........................................... 9. if line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part 11. Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. a. Spouse ........... 1a. 2a. 3a. b. Decedent .......... 1 b. 2b. 3b. c. Joint ............. 1c. 2c. 3c. d. Tax Exempt Income .. 1d. 2d. 3d. e Other Income not listed above ........ ie. 2e. ' ~A f. Total .............1 1 f. I 12f. I 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) + (3f) 3f. (= 3) 4b. Average Joint Exemption Income ..................................................... __ If line 4(b) is greater than $40,000 -STOP. The estate is not eligible to claim the credit. if not, continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................... I 1 2: Multiply by credit percentage (see instructions) ........................................... ~ 2 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on fine 18 of the cover sheet . ............................... 3 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................. 4- 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit .Include this figure in the calculation of total credits on line 18 of the cover sheet....... 5• REV-1649 EX + r t-97) SCHEDULE 0 COMMONWEALTH OF PENNSYLVANIA ELECTION UNDER SEC. 9113(A) INHERITANCE TAX RETURN SPOUSAL DISTRIBUTIONS RESIDENT DECEDENT ESTATE OF FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance 8~ Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. DESCRIPTION JALUE Part A Total ~ $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. fIFC!`RIPTI(1N VALUE Part B Total ~ (If more space is needed, insert additional sheets of the same size) DECEASED i r ~~ Department of the Treasury • Internal Revenue Service ~®~ 1040 U.S. Individual Income Tax Return (99> I i Label L For the year Jan. 1-Dec. 31, 2009, or other tax year beginning , 2009, ending , 20 OMB No.1545- 0074 (See lost A a ROBERT E SNELL Your social security number onpgl4.) E DORIS J SNELL -DECEASED 5/20/2009 209-12-9788 Use the L IRSlabel. q6 DAVID DELBAUGH Spouse's social security number H E 34 GALE ROAD 205-22-4469 otherwise, please print R (+Alyjp RILL, PA 1'aQ 11 • You must enter ~ our S N s ve. or type. E Ch ecking a box below will not change Presidential your tax or nd. Election Cam ai n - Check here'rf ou or our ouse if filin 'oint want to o to this fund see a e 14 - You S use s 1 Single 4 t St Fili Head of household (with qual'rfying person). (See page 15.) a ng u 2 X Married filing jointly (even ff onlyone had income) If the qualifying person is achild but not your dependent, enter this Check only 3 Married filing separately. Enter spouse's SSN above 8 f ull name blown child's name h ere. - one box. - 5 I , Qualifying widow(er) with dependentchild (see page 16) rsoxes cnecxea 2 6a X Yourself. If someone can claim you as a dependent, do not check box 6a l on 8a and 8b . . . . . . . . . . . . . . . . . . . . . . . . . . . Exemptions b X S use J onscfwhotlren If more c Dependents: (2) Dependent's (3) Dependent's 4 if qual. lived with you than four {1)Firstname Lastname social security number relationship to child for ~didnotlivewithyou due to divorce dependents, or separation see page 17 (see page 18) Dependents and checl~..., on ec not here - IuI entered above Add numbers on lines d Totalnumberofexem tionsclaimed abov - 7 Wages, salaries, tips, etc. Attach Form(s) W- 2 e I 7 ncom Attach Schedule B if required interest bl 8 T Sa 5 7 31. . e a axa Attach Form(s) b Tax- exempt interest. Do not include on line Sa ~ W- 2 here. Also g Attach Schedule B lt required dividends din O ~ . r ary a attach Forms b Qualified dividends (see page 22) 9b W- 2G and or offsets of state and local income taxes (see page 23) . credits ble refunds 10 T 10 , , axa 1099- R it tax was withheld. 11 Ali received ? - n 11 y mo Attach Schedule C or C- Q iness income or (loss) 12 B 12 1 3 81 . ) . . us Attach schedule D if required. - ~ dal ain or loss 13 C ( ) 13 . a If not required, check here p g Attach Form 4797 ains or (losses) 14 Oth r 14 . g e if you did not 15 tributions IRAdi 15a . bTaxabieamt. 15b s a getaW-2, ns and annuities i P 16 16a bTaxable amt . 16b 10 536. . ens o a see page 22. S corporations, trusts, etc. Attach Schedule E partnerships alties ro al estate l r t 17 R 17 , , y , en a e Attach Schedule F incomeor (loss) 18 F 18 , . arm Enclose, butdo 400 per recipient not attach ment compensation in excess of $2 any 19 U lo m 19 , , y p ne payment. Also, 20 ~ 20a ~ 17 , 8 81 . ~ b Taxable amt (see page 27) . benefits l securit i S 20b 4 8 2 4 . . . y oc a a please use Form 1040• V. 21 Other income. List type and amount (see page 29) 7,820. 1099C CANCELLATION OF DEBT 1 21 17 820. 22 Add the amounts in the far ri ht column for lines 7 throw h 21. This is our to . tal income - 22 3 7 5 3 0 . 23 Educator expenses (see page 29) 23 Adjusted 24 Certain business expenses of reservists, performing artists, and overnment officials. Attach Form 2106 or 2106- Q . Gross fee- basis 24 g Income ~ Health savings accountdeduction. Attach Form 8889 25 Attach Form 3903 enses ex 28 Movin 28 . . p g 27 One- half of self- employment tax. Attach Schedule SE . 27 and qual'rfied plans SIMPLE ed SEP lo 28 Self- em 28 , , p y ed health insurance deduction (see page 30) lo 29 Selt-em 29 p y withd rawal of savings on earl 30 Penalt 30 . y y aid b Recipient'sSSN - 31a Alimon 31a yp 32 IRgdeduction(seepage3l) 32 33 Studentloaninterestdeduction(seepage34) ~ Attach Form 8917 ition and fees deduction 34 T 34 . u roduction activltiesdeduction. Attach Form 8903 mestic 35 D 35 p o h 35 nd 32 throu h 31 3 h 36 g a a roug t 36 Add lines 2 37 Subtract line 36 from line 22. This is our ad usted roes income - 37 3 7 5 3 0 . KBA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 97. Form 1040 (2009) 1040~{2009~ FD1040.1 V 1.25 Form oftwa eCopyright 1998- 2010HR8 TaxGrouD.lnc. Form ~t~ao(2(x>q) ROBERT E & DORIS J SNELL i ono-~ ~_o~ua o,,,e~ Tax and ~ Amount from line 37 (adjusted gross income) . 38 3 7 5 3 0 . Credits 39a Check X You were bom before January 2,1945, Blind. Total boxes { ^ ^ } X if: Spouse was bombeforeJanuary2,1945, Blind. checked - 39a 2 Standard b It your spouse itemizes on a separate return or you w ere a dual- status alien, see pg 35 8 ch eck h ere - 39b Deduction for- • People who 40a Itemized deductions (from Schedule A) or your standard deduction (see left margin) , 40a 51 2 61 . check any b If you are increasing your standard deduction by certain real estate taxes, new motor box on line vehicle taxes, or a net disaster loss, attach Schedule Land check here (see page 35) - 40b ^ 39a,39b,or 40b or who 41 Subtract line 40a from line 38 41 (13 7 31 . can be 42 Exemptions. If line 38 is $125,100 or less and you did not provide housing to a Midwestern claimed as a dependent, dis laced individual, multi $3,650 b the number on line 6d. Otherwise, see a e 37 , P PN Y P 9 42 7 3 0 0 . see page 35. 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter - 0- , 43 0 • All others: ~ Tax (see page 37). Check ff any tax is from: a ^ Form(s) 8814 b ^ Form 4972 44 0 . single or 45 Alternative minimum tax (see page 40). Attach Form 6251 45 earareteliling P Y, 46 Add lines 44 and 45 - 46 0 . Ss,~oo 47 Foreign taxcredit. Attach Form 1116 if required 47 Married tiling 4g Creditforchild and de tDndentcareex erases. Attach Form 2441 48 jointly or P P Oualif ying 49 Education creditsfrom Form 8863, line 29 . 49 widow (er), si t,aoo 50 Retirement savings contributionscredit. Attach Form 8880 50 Head of 51 Childtaxcredit see a e42 51 household, ( P 9 ) sa,3so 52 Credits from Form: a ^ 8396 b ^ 8839 c ^ 5695 52 53 Other credits a ^3800 b^8801 c ^ 53 from Form: 54 Add In 47 through 53. These are yourtotal credlts 54 55 Subtract line 54 from Tine 46. If line 54 is more than line 46 enter - 0- - 55 0 . 56 Self- employment tax. Attach Schedule SE Oth 56 er 57 Unreported social security and Medicare tax from Form: a ^ 4137 b ^ 8919 T 57 axes 58 Additional taxon IRAs otherqualified retirement plans, etc. Attach Form 5329 if required 58 ~ ^ 59 Additional taxes: a AEIC payments b Household empioymenttaxes. Attach Schedule H 59 60 Add lines 55 throw h 59. This is ourtotal tax . - 60 0 Payments 61 Federal income tax withheld from Forms W- 2 and 1099. 61 62 2009 estimated tax payments and amount applied from 2008 return 62 63 Making work pay and government retiree credits. Attach Sch M . 63 If you have a Earned income credit EIC qualifying ~ ) 64a child, attach b Nontaxablecombatpayelection 64b Schedule EIC. 65 Additional child tax credit. Attach Form 8812 65 66 Refundable education credftfrom Form 8863, line 16 66 67 Frst- time homebuyercredit. Attach Form 5405 67 68 Amount paid with request for extension to file (see page 72) . 68 69 Excess social secur' and tier 1 RRTA tax withheld (see pa a 72) 69 70 Credits from Form: a ^2439 b^ 4136 c^ 8801 d~8885 70 71 Add lines 61 62 63 64a and 65 throw h 70. These are our total a ments . - 71 0 . Refund 72 If line 71 is more than line 60, subtract line 60 from line 71. This is the amount you overpaid , 72 0 . Direct deposit? 73a Amount of line 72 you want refunded to you. If Form 8888 is attached, check here - ^ 73a See page 73 - b Routing number XXXXXXX - c T e: ~ ^ and fill in 73b, 73c, and 73d, - d Account number XXXXXXXXXXXXXXXX or Form 8888. 74 Amount of line 72 ou want a Iled to our 2010 estimated tax - 74 Amount 75 Amount you owe. Subtract line 71 from line 60. For details on how to pay, see page 74 . - 75 YOU t7We 76 Estimated tax enal see a e 74 76 Third Party ~ you want to allow another person to discuss this return with the IRS (see page 75)? X Yes. Complete the folbwing. No Designee Designee's name Phone no. Personal ID number - HR BLOCK - (717) 392-4882 (PIN)- 36518 Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to th a best of my knowledge and Sign belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer)is Cased on all information of which preparer has any knowledge. Here Yoursignature Date Youroccupation Daytime phone number Joint return? 03 2 LD/D ETIRED See page 15. Spouse's signature. if a joint return, both must sign. Date Spouse's occupation Keep a copy for vourrecords. Filinc ss 3urvivintr SoOUS ETIRED Paid Preparer's I signature Preparer's Frm's name Use Oniy yours if setf_ ~ 1040(2009) FD1040- 2V 1.25 Form oflwareCopyright1996-2010HRBTaxGroup,lric. Date Check if Preparer's SSN or PTIN 3/16/2010setf-emplo ed P00014895 )UP INC EIN 43-1871840 657-0316 Form 1040 (2009) SCHEDULE A ~- Itemized Deductions VIYI GI IYV. 1JYi.1- W/Y G~ ~09 (Form 1040) CS Department of th a Treasury Internal Revenue Service (99) - Attach to Form 1040. - See Instructions for Schedule A(Form 1040). Sttauence No. ~7 Name(s) shown on Form 1040 Your social security number ROBERT E & DORIS J SNELL ao9-ia-9788 Medical Caution. too not include expenses reimbursed or paid by others. d 1 Medical and dental expenses (see page A-1) 1 5 3 5 01. an Dental 3EE ATTACHMENT Expenses 2 Fster amount from Form 1040, line 38 . 2 3 7 5 3 0 . 075) 5%( 3 Multiplyline2by7 3 a 815 . . . . 4 Subtract line 3 from line 1. If line 3 is more than line 1 enter - 0- 4 5 0 6 8 6 . 5 State and local a Income taxes, or b X General sales taxes 5 5 7 5 . Taxes You Paid 8 Real estate taxes (see page A- 5) 6 (See ~" page A- 2.) 7 New motor vehicle taxes from line 11 of the worksheet on page 2. Skip thisline'rfyoucheckedbox5b 7 8 Other taxes. Listtypeand amount- 8 9 Addlines5throu h8 9 575. Interest 10 Home mortgage interest and points reported to you on Form 1098 10 YOU Paid 11 Home mortgage interest not reported to you on Form 1098. If paid to the (See person from whom you bou8ht the home, see page A- 7 and show that page A- 6.) person's name, identifying no., and address - 11 Note. Personal 12 Points not reported to you on Form 1098. See page A- 7 for special rules. 12 interest is 13 Qualified mortgage insurance premiums (see page A- 7) 13 not t 4 Investment interest. Attach Form 4952rf required. (See page A- 8.) 14 deductible. 15 Add lines 10throu h 14 15 Gifts t0 16 Giftsbycashorcheck.Ifyoumadeanygiftof$250or Chanty more, see page A- 8 18 If you made a 17 Other than by cash or check. If any gift of $250 or more, see gift and got a benefft for it, page A- 8. You must attach Form 8283'rf over $500 17 see pageA-8. 18 Carryoverfromprioryear. 18 . . . . . . . . . . . . . . . . . . . . . . . 19 Add lines 16 throw h 18 19 Casualty and Theft Losses 20 Casual ortheft loss es .Attach Form 4684. See a e A-10. ~ Job Expenses 21 Unreimbursed employee expenses -job travel, union dues, job and Certain education, etc. Attach Form 2106 or 2106- Q if required. (See Miscellaneous pageA- 10.) - _~ Deductions (See 21 page A-10.) ~ Tax aration fees re ~ 3 0 8 . p p 23 Other expenses -investment, safe deposit box, etc. List type and amount - ~. 23 24 Add lines 21 through 23 24 3 0 8 . 25 Fster amount from Form 1040, line 38 25 3 7 5 3 0 . 02) 2%( line 25 b l 28 Multi ~ 751. . y y p 27 Subtract line 26 from line 24. If line 26 is more than line 24 enter- 0- 27 0 Other 28 Other- from list on pageA-11. List typeandamount - Miscellaneous Deductions 28 TOtal 29 Is Form 1040, line 38, over $166,800 (over $83,400'If married filing separately)? Itemized XO No. Your deduction is not limited. Add the amounts in the far right column line 40a. - enterthis amount on Form 1040 Also h 28 u 4 th tions f li d D 29 51 2 61 . , , ro g . nes or uc e Yes. Your deduction may be limited. See page A- 11 for the amount to enter. ~~ is,,.,ilclnettniramf~ariwtuctionseventhouohthevarelessthanyourstandarddeduction,checkhere- KBA For Paperwork Reduction Act Notice, see Form 10401nstructiona Schedule A (Form 1040) 2009 1040- Sch A (c2009~ FDA-1 V 1.9 Form Software opyr ght 1996- 2010 HRB Tax Graup, Inc. SCHEDULE B (Form 1040A or 1040) Department of theTreasu Interest and Ordinary Dividends - Attach to Form 1040A or 1040. - See separate Instructions. Name(s) shown on return Your social security number ROBERT E & DORIS J SNELL 2n9-17-Q7f2A 1 List name of payer. If any interest isfrom aseller- financed mortgage and the buyer used Part I the property as a personal residence, see separate instructions and list this Interest interest first.Also, showthatbuyer'ssocialsecuritynumberandaddress - (See separate 3USQUEHANN3~ SANK instructions and SUSQUEHANNA BANK the instructions for Form 1040A,or Form 1040, line 8aJ Note. If you received a Form 1099- INT, Form 1099-OID,or substitute statement from a brokerage firm, list the firm's name as the payer and enter the total interest shown on that 2 Add the amounts on line 1 , form. 3 Excludable interest on series EE and I U.S. savings bonds issued after 1989. Attach Form 8815. 4 Subtract line 3 from line 2. Enter the result here and on Form 1040A, or Form 1040 line 8a - . . . . . . . . . . . . . . . . . . . . . . . Note. If line 4 is over $1 500 ou must corn lets Part III. 5 List name of payer - - -_ Part II _` ~~____ _ _ Ordinary Dividends ~. (See separate ~ _~ _- _____R instructions and the instructions for Form 1040A, or ----- ----- --- Form 1040, line 9a.) _ _-_ -~--« Note. if you __ y- received aForm 1099-DIVor - '~ substitute -- statement from a brokerage firm, list the firm's name asthe - payerand enter - the ord inary dividends shown onthatform. - 6 Add the amounts on line 5. Enter the total here and on Form 1040A, or Form 1040. line 9a - - _ _ - - - _ - - _ - 3 No.1545- ~©09 ichment 5,708. 23. 5,731. 5,731. Amount Note. if line 6 is over $1,500, ou must corn lets Part III. You must completethispart'rfyou(a)hadover$1,500oftaxableinterestorordinarydividends; (b)hada Yes NO Part III forei n account; or c received a distribution from, or were a rantor of, or a transferor to, a forei n trust. Foreign 7a At any time during 2009, did you have an interest in or a signature or other authority over a financial ACCOUntS account in a foreign country, such as a bank account, securities account, or other financial account? and Trusts See separate instructions for exceptions and filing requirements for Form TD F90- 22.1 , X (See b It "Yes," enter the name of the foreign country - page B- 2.) g During 2009, did you receive a distribution from, or were you the grantor of, ortransferor to, a forei n trust? If °Yes " u ma have to file Form 3520. See se arate instructions . X KBA For Papperwork Reduction Act Notice, see Form 1040A or 1040 instructions. Schedule B (Form 1040A or 1040) 2009 1040- Sch B (c2009~ FDB-1 V 1.6 Form Software opy ght 1998- 2010 HRB Tax Group, Inc. SCHEDULE C Profit or Loss From Business OMBNo.1545-0074 (FOrm 1040) (Sole Proprietorship) ~oo~ - Partnerships, joint ventures, etc., generally must file Form 1065 or 1065- B. Attachment Department of t h e Treasury Internal Revenue ervice 99 - Attach to Form 1040 1040NR or 1041. - See Instructions for Schedule C Form 1040. n N ~9 Name of proprietor Social security number (SSN) DORIS J SNELL 205-22-4469 A Principal business or profession, including prod uct or service (see page C- 2 of the instructions) B Enter code from pages C- 9,10, & 11 SALES ANTI UES ~ 454390 C Business name. If no separate business name, leave blank. D Employer I D number (EI N), if any COLLECTORS CORNER E Business address (including suite or room no.) - 3 9 9 CHAPELWOOD DR C' town or ost office state and ZIP code HANOVER PA 17 3 31 F Accounting method: (1) Cash (2) Accrual (3) X Other(specify)- HYBRID G Did you 'materially participate' in the operation of this business during 2009? If "No,' see page C- 3 for limit on losses . X Yes No H If oustartedorac uiredthisbusinessdurin 2009 check here - Income ~ 1 Gross receipts or sales. Caution. See page Ci 4 and check the box'rf: • This income was reported to you on Form W- 2 and the'Statutory employee' box or . - ^ on that form was checked 1 17 5 0 0 . , • You are a member of a qualified joint venture reporting only rental real estate income not subject toself- employment tax. Also see page C- 3 for limit on losses. 2 Retumsand allowances 2 3 Subtract line 2 from line 1 3 17 5 0 0. 4 Cost of goods sold (from line 42 on page 2) 4 17 5 0 0 . Subtract line 4 from line 3 5 Gross profit 5 . includ ing federal and state gasoline or fuel tax credit or refund (see page C- 4) 6 Other income 6 , 7 Gross Income. Add lines 5 and 6 - 7 0 Ex nses. Enter expenses for business use of our home onl on line 30. 8 Advertising 8 18 Office expense 18 . 9 Car and truck expenses (see 19 Pension and profit- sharing plans . 19 page C- 4) 9 20 Rent or lease (see page C- 6): 10 Commissionsand fees 10 a Vehicles, machinery, and equipment . 20a 11 Contract labor (see page C- 4) 11 b Other business property 20b letion 12 De 12 21 Repairsand maintenance 21 p 13 Depreciation and section 179 22 Supplies (not included in Part III) 22 expensededuction (not 23 Taxes and licenses 23 included in Part III) (see page 24 Travel, meals, and entertainment: C- 5) 13 a Travel 24a 14 Fmployeebenefitprograms b Deductiblemealsand (other than on line 19) 14 ° - entertainment (see page C- 6) 24b . 15 Insurance (otherthan health) 15 25 Utilities 25 . 16 Interest: 26 Wages (less employmentcredits) . 26 a Mortgage (paid to banks, etc.) 16a 27 Other expenses (from line 48 on b Other 16b page2) 27 1 381. 17 Legaland professional services 17 28 Total expenses before expenses for business use of home. Add lines 8 through 27 - 28 1 3 81 . 29 Tentative profit or (loss). Subtract line 28 from line 7 29 1 3 81 . ) 30 Expenses for business use of your home. Attach Form 8829 30 31 Net profit or (loss). Subtract fine 30 from line 29. • If a profit, enter on both Form 1040, Ilne 12, and Schedule SE, line 2, or on Form 1040NR, line 13 ('rf you checked the box on Tine 1, see page C- 7). Estates and trusts, enter on Form 1041, line 3. 31 1 3 81 . ) • If a loss, you must go to line 32. 32 if you have a loss, check the box that describes your investment in this activity (see page C- 7). • If you checked 32a, enter the loss on both Form 1040, line 12, and Schedule SE, Ilne 2, or on 32a X8 All investment is at risk. Form 1040NR, line 13 ('rf you checked the box on line 1, see the line 31 instructions on page C- 7). 32b Some investment is not Estates and trusts, enter on Form 1041, line 3. at risk. • If you checked 32b you must attach Form 6198 Your loss may be limited. KBA For Paperwork Reduction Act Notice, see page C- 9 of the instructions. Schedule C (Form 1040) 2009 1040- Sch C ~2009~ FDC- i V 1.9 ~ Form Software opyr ght 1996. 2010 HRB Tax Group, Ir~c. ~na_~~_ Cost of Goods Sold (see page C- 8) ~ 33 Method(s) used to '+- valueclosing inventory: a ^X Cost b ^ Lower of cost or market 34 Was there any change in determining quantities, costs, or valuations between opening and closing inventory? If "Yes," attach explanation 35 Inventory at beginning of year. if differentfrom last year's closing inventory, attach explanation 36 Purchases less cost of items withdrawn for personal use . 37 Cost of labor. Do not include any amounts paid to yourself 38 Materials and supplies 39 Other costs 40 Add lines 35 through 39 . 41 Inventory at end of year c ^ Other (attach explanation) ^ Yes ^X No ~ 35 ~ 17,500. 42 Cost of s sold. Subtract line 41 from line 40. Enter the result here and on a e 1 line 4 , 42 1 i ~ u u . Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on line 9 and are not required to file Form 4562 for this business. See the instructions for line 13 on page C- 5 to find out if you must file Form 4562. ~ ~. 43 When did you place your vehicle in service for business purposes? (month, day, year) - ~ _____ 44 Ofthetotalnumberofmilesyoudroveyourvehicleduring2009,enterthenumberofmilesyouust><iyourvehiclefor: a Business b Commuting (see instructions) ~_ c Other ____~_ 45 Was your vehicle available for personal use during off- duty hours? ^ Yes ^ No 46 Do you (or your spouse) have another vehicle availablefor personal use? ^ Yes ^ No 47a Do you have evidence to support your deduction? . ^ Yes ^ No ~..,,o.....o ., ~..,..... .., _,..,., 1040- Sch C ~2009~ FDC- 2V 1.9 Form Software opyr ght 1998- 2010 HRB Tax Group, Inc. Form 1045 (2009) ROBERT E & DORIS J SNELL ao9-1a-988 Schedule A - NOL (see page 6 of the instructions) 1 Enter the amount from your 2009 Form 1040, line 41, or Form 1040NR, line 38, minus any amount on Form 8914, line 6. Estates and trusts, entertaxable income increased by the total of the charitable and exemption amount incomedistributiondwiuction ction d d 1 (13 7 31) , , e u 2 Nonbusinesscapitallossesbeforelimitation. Fsterasapositivenumber 2 3 Nonbusinesscapitalgains(withoutregardtoanysection1202exclusion) 3 enter the difference; otherwise, enter - 0- . 4 If line 2 is more than line 3 4 0 , 5 If line 3 is more than line 2, enter the difference; otherwise, enter- 0- 5 0 6 Nonbusiness deductions (see page 6 of the instructions) . 6 51 a 61 7 Nonbusiness income other than capital gains (see page 6 of the instructions) 7 3 8 911 8 Add lines 5 and 7 8 3 8 911 , enter - 0- enter the difference; otherwise than line 8 6 i If li 9 1 a 3 5 0 , , s more ne 9 10 If line 8 is more than line 6, enter the difference; otherwise, enter - 0- . But do not enter more than IIne5 10 0 ital losses before limitation. Enter as a positive number iness ca 11 B 11 p us 12 Business capital gains (without regard to any section 1202 exclusion) 12 13 Add lines 10 and 12 13 enter - 0- If zero or less btract line 13 from line 11 14 S 14 0 , . u 15 Add lines4and 14 15 0 16 Enter the loss, if any, from line 16 of your 2009 Schedule D (Form 1040). (Estates and trusts, enter the loss, if any, from line 15, column (3), of Schedule D (Form 1041).) Enter as a positive number. If you do not have a loss on that line (and do not have a section 1202 exclusion), skip lines h 21 and enter on line 22 the amount from line 15 16 throu 18 g ositivenumber Enter asa lusion 1202 i 17 p . exc on 17 Sect ggter - 0- If zero or less 18 Subtract line 17 from line 16 18 0 , . 19 Enterthe loss, if any, from line 21 of your 2009 Schedule D (Form 1040). (Estates and trusts, enter the loss, 'rf any, from line 16 of Schedule D ) Enter as a positive number (Form 1041) 19 . enter the d ifference; otherwise, enter - 0- ZO If line 18 is more than line 19 20 0 , enter - 0- enter the d ifference; otherwise n line 18 th 19 i li 21 0 , , a s more ne 21 If enter- 0- If zero or less m line 15 20 f t li ~ 0 , . ro ne 22 Subtrac 23 Domestic production activities deduction from your 2009 Form 1040, line 35, or Form 1040NR, line line 15a) m 1041 F l d d i 23 , . or on e nc u 33 (or Enterasapositivenumber ears ssesfromother l f ti Ld d 24 y . or o uc on e 24 NO 25 NOL Combine lines 1, 9,17, and 21 through 24. If the result is less than zero, enter it here and on a e 1, line 1 a. If the result is zero or more, ou do not have an NOL 25 1 3 81) KBA Form 1045 (2009) a. Sch A-1045 009) FD1045A-1 V 1.31 Form Software opyright1996.2010HRBTaxGroup,inc. ELECTION TO WAIVE NET OPERATING LOSS CARRYBACK Name(s) ROBERT E& DORI S J SNELL SSN or EIN 2 0 9 -12 - 9 7 8 8 I elect under section 172(j) of the Internal Revenue Code to waive the carryback period for the net operating loss sustained in tax year 2 0 0 9 , as ind icated below. QX Ali net operating losses sustained during the year. Losses to which the 5- year carryback applies. Losses to which the 4 year carryback applies. i ^ a. Losses to which the 3- year carryback applies. Losses to which the 2- year carryback applies. Taxpayer's Signature Spouse's Signature ('rf a joint Date Note. Once made this election cannot be changed. The election must be attached to your tax return forthe yearof the loss and your return must be filed on or before the due date (plus extensions). ELECTION TO TREAT FARM LOSS AS NOT A FARM LOSS ' I elect to treat the farming loss as, if it were not a farming loss. Taxpayer's Signature Spouse's Signature (ff a joint return) Date Sch A-10450009) FD1045A- 2V 1.31 Form Software opyright 1998. 2010HR6 Tax Group, Inc. Supportiaq Schedules 2009 Name: ROBERT E & DORIS J SNELL SSN: 209-12-9788 ----------------------------------------------------------------------------- Schedule A Liae 1 - Medical Expenses 'Description a. Amount ---------------------------------------------------------------------------- PHYSICIANS 4,521 PRESCRIPTIONS 2,341 MANOR CARE SHILLED CARE FACILITY 44,462 PERSONAL CARE 538 SOCIAL SECVRITY/RAILROAD RETIREMENT - MEDICARE INSURANCE PAYMENTS 1,639 Total ~. 53,501 ~. J o_ 0900112137 PA- 40 - 2009 Pennsylvania Income Tax Return ENTER ONE LETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted Label 205224469 SNELL DORIS DAVID DELBAUGH 34 GALE ROAD CAMP HILL 717 737 3283 J Occupation RETIRE D Occupation ,. PA 17011 21100 1 a Gross Compensation. Do not include exempt income, such as combat zone pay and q ualifying retirement benefits. Seethe instructions. 1 b Unreimbursed Employee Business Expenses. 1c Net Compensation. Subtract Line 1b from Line ia. 2 Interest Income. Complete PA Schedule A if required. 3 Dividend and Capital Gains Distributions Income. Complete PA Schedule B if required 4 Net Income or Loss from the Operation of a Business, Profession, or Farm. 5 Net Gain or Loss from the Sale, Exchange, or Disposftion of Property. 6 Net Income or Loss from Rents, Royalties, Patents, or Copyrights. 7 Estate orTrustlncome.CompleteandsubmitPAScheduleJ. 8 Gambling and Lottery Winnings. Complete and submit PA Schedule T. 9 Total PA Taxable Income. Add only the p~s`itive income amounts from Lines 1 c, 2, 3, 4, 5, 6, 7, and 8. DO NOT ADD any losses reported on Lines 4, 5, or 6. 10 OtherDeductlons.Entertheappropriatecodeforthetypeofdeduction. Seethe instructions for add'Rional information. 11 Adiusted PA Taxable Income. Subtract Line 10 from Line 9. N Extension. N Amended Retum. R Residency Status. PA ResidenUNonresidenUPart-Year Resident from to D Single/Married,FlingJointly/Married, Fling Separately/ Final Return/Deceased Date of death 0 5 2 0 0 9 N Farmers. School District NameC A M P H I L L 1a 0 1b 0 1c 0 2 5708 3 0 4 -1415 5 D 6 0 7 0 8 0 9 5708 10 D 11 5708 EC Page 1 of 2 FC 0900112137 m ~ ~ m 0900112137 ,~ J 0900212143 PA-40-2009 Social Security Number 205224469 Name(s) SNELL DORIS J 12 PA Tax Uability. Multiply Une 11 by 3.07 percent (0.0307). 13 Total PATax Withheld. See the instructions. 14 Creditfromyour2008PAIncomeTaxretum. 15 2009 Estimated Installment Payments. 16 2009 Extension Payment. 17 Nonresident Tax Withheld from your PA Schedule(s) NRK-1. (Nonresidents only) 18 Totai Estimated Payments and Credlts. Add Lines 14,15,16 and 17. Tax Forgiveness Credit. Submit PA Schedule SP. 19a Fling Status: 01 Unmarried or Separated 02 Married 03 Deceased 19b Dependents, Part B, Line 2, PA Schedule SP 20 Total Eligibility Income from Part C, Line 11, PA Schedule SP. 21 Tax Forgiveness Credlt from Part D, Line 16, PA Schedule SP. i 22 Resident Credit. Submit your PA Schedule(s)G-Rwithyour PA Schedule(s) G- S, G-Land/or RK-1. 23 Total Other Credits. Submit your PA ScheduleOC. 24 TOTAL PAYMENTS and CREDITS. Add Lines 13,18, 21, 22, and 23. 25 TAX DUE. If Line 12 is more than Line 24, enter the difference here. 26 Penalties and Interest. See the instructions. Enter Code: if including form REV-1630, markthe box. N 27 TOTAL PAYM ENT DUE. See the instructions. 28 OVERPAYM ENT. If Line 24 is more than the total of Line 12 and Line 26, enter the d ifference here. The total of Lines 29through 35 must equal Une 28. 29 Refund - Amount of Line 28 you want as a check mailed to you. Refund 30 Credlt - Amount of Line 28 you want as a cred it to your 2010 estimated account. 31 Amount of Line 28 you want to donate to the Wlld Resource Conservation Fund. 32 Amount of Line 28 you want to donate to the M flltary Family Relief Assistance Program. 33 Amount of Line 28 you want to donate to the Governor Robert P. Casey Memorial Organ and Tissue Donation Awareness Trust Fund. 34 Amount of Line 28 you want to donate to the Juvenile (Type 1) Diabetes Cure Research Fund. 35 Amount of line 28 you want to donate to the PA &east Cancer Coalition's Breast and Cervical Cancer Research Fund. Signature(s). Under penalties of perjury, I (we)declarethat 1 (we)have examined this return, including all accompanying schedules and statements, and to the best of my (our)beliet, they are true, correct, and complete. Your Signature ~ Spouse's Signature,'rffilingjointly Prepar Name s~1 Te h~pne ~~u~m~~b,,er~ `~,~ .~4~ z~~~ Date HRB AX GROU INS (71?) 657-0316 Page 2 of 2 L 12 175 13 0 14 0 15 0 16 0 17 D 18 0 19a 00 19b 00 20 0 21 0 22 0 23 0 24 0 25 175 26 D 27 175 28 0 29 0 3D 0 31 0 32 0 33 0 34 D 35 0 Frm FEIN Preparer'sSSN/PTIN 431871840 P00014895 0900212143 0900212143 ,~,) J 0901910026 PA SCHEDULE W- 2S Wage Statement Summary 2~~9 PA- 40 Sch edule W- 2S OFFICIAL USE ONLY (09 091 ill on of PA Non- RIS J SNELL 1205-22-441 Use this schedule to Iist and calculate your total PA taxable compensation and PA tax withheld from all sources. Part A Instructions: List each Federal Form W- 2for you and your spouse, 'rf married, received from your employer(s). In the first column enter Tfor the taxpayers Social Security Number that appears first on the PA tax return and enter S for the second or spouse SSN. From the Fomts W- 2, enter each employersfederal identification number. Enterthe amountsfrom the Forms W- 2 in each column. IMPORTANT: You do nothaveto submitacopyof your Form W- 2 if you earned all your income in Pennsylvania and your employer reported your PA wages correctly and withheld the correctamount of PA income tax. You must submit a copy of your Form W- 2 in certain circumstances. See the PA Schedule W- 2S instructions for a list of when a copy of a W- 2 is required. Part B I nstructions: List each source of income received during the taxable year on a form or statement other than a Federal Form W- 2. Enter eachpayersname.Listthepaymenttypethatmostcbselydescribesthesourceofyournon-employee compensation. Enterthe amount of other compensation that you earned. If the form or statement does not have separately stated amounts, enter the amount shown in both Federal and PA columns. IMPORTANT: You must submit a copy of each form and statement that you list in Part B, whether or not the payer withheld any PA income tax and regardless of whether or not the income was taxable in PA. CAUTION: The federal and Pennsylvania (state) wages may be different in Part A and Part B. If you need more space, you may photocopy this schedule or make your own schedules in this format. Part A - Federal Forms W- 2 T/S ElNfromBoxb Federalwages Medicare wages PA compensation PAincometax from Box 1 from Box 5 from Box 16 withheld from Box 17 A- Part B - Miscellaneous and Non- employee Compensation from Federal Forms 109 R, i l)99- MISC and other statements YOU MUST SUBMITCOPIES OF EACH FORM OR STATEMENT LISTED IN THIS PART A. T/S B. T e C. Pa ername D. 1099R code E. Totalfederalamount F. Ad'usted Ian basis G. PAcom ensation H. PAtaxwithheld I ObiMODiG11EALTH 7 1 813 0 0 0 Total Part B- Add the Penns ivania columns 0 0 TOTAL - Add the totals from Parts A and B 0 0 EntertheTOTALSon ourPAtaxreturnon: Une1a Line 13 Payment A. ExeCUtorfee B. Juryduty pay V. UlrecrOf STee v. r~Nc~irrm~ca~~co type; E. Honorarium F. Covenantnottocompete G. Damagesorsettlementforbstwages,otherthanpersonalinjury H. Other nonemployee compensation. Describe: I. Distribution from employer sponsored retirement, pension orqual'rfied deferred compensation plan J. Distribution from IRA (Tradftional or Roth) K. Distribution from Lrfe Insurance, Annuity or Endowment Contracts L Distribution from Charitable Gift Annuities 0901910026 0901910026 PA SCHEDULE A/B 0901210021 Interest Income/Dividend Income PA- 40 Schedule A/B (~-09)(I) 2009 OFFICIAL USE ONLY If you need more space, you may photocopy . Name shown first onthe PA- 40 (if filing jointly) Social Security Number (shown first) DORI3 J 3NELL 205-22-4469 CAUTION: Federal and PA rules for taxable interest and d ividend income are different. Read the Instructions. If your taxable interest and dividend income are each $2,500 or less, you must reportthe income, but do not need to submR any schedule. If either your interest income or dividend income is more than $2,500, you must submR a PASchedule Aand/or B. w _ oA_ w~ s In4erect Inr~nma (Sea theinstructions.l rn-wnw.r vv~ ~ A VV~~rrv~~ .. - -~-_~~-- '----- - - - 1.3V3 VEHANNA BANK 1. 5 708 00 2. Total Interest Income. Add all amounts lis ed (including amounts on additional schedules). 2. 5 7 0 8 0 0 3. Distributions from Life Insurance, Annuity, or Endowment Contracts included in federal taxable income. 3. 0 0 0 4. Distributions from Charitable Gift Annuities included in federal taxable income. 4• 0 0 0 5. Distributions from IRC Section 529 Qual'rfied Tuition Programs for non educational purposes. 5. 0 0 0 6. Distributions from Health /Medical Savings Accounts included in federal taxable income. 6. 0 0 0 7. Interest income from PA S corporations and partnership(s), from your PA Schedule(s) RK-1. 7. 0 0 0 a r..*si us_ TaYah~e i nterast t ncome. Add Lines 2, 3, 4, 5,6 and 7. Enter on Line 2 of your PA- 40. 8. 5 7 0 8 0 0 IMPORTANT: Capital Galns Distributions are dividend income for PA purposes. PA SCHEDULE B - PA- Taxable Dividend and PA-408(09-09) Capital Gains Distributions Income ~seethein~cructions.) 1 1' -- ~ 2. Total Dividend Income. Add ail amounts listed (including amounts on additional schedules). z• 3. Capital Gains Distributions- Seefnstructlons 3. 4. Dividend income from PA S corporation(s) and partnerships, from your PA Schedule(s) RK-1. 4• 5. Total PA-Taxable Dividend I ncome. Add Lines 2, 3 and 4. Enter on Line 3 of your PA- 40. 5• 0901210021 0901210021 J 0903114530 PA- 40 Schedule C - 2009 (09- 09) Profft or Loss From Business or Profession (Sole Proprietorship) L 2 0 5 2 2 4 4 6 9 D O R I S J S N E L L Method of Inventory Cost, Dower of cost or market, O=Other C SALES ANTIQUES Accounting Method : A=Accrual, C=Cash, 0-0ther 0 ,. COLLECTORS CORNER Homeoffice expensesdeducted N 4 5 4 3 9 0 Business out of existence Y Anychangeindetermining N 399 CHAPELWOOD DR quantities, costs or valuations HANOVER PA 17331 1 a. Gross receipts or sales 1 A 17 5 0 0 2. Cost of goods sold/operations 2 17 5 0 0 1 b. Returns and allowances 1 B 0 3. Gross profit 3 ^ 1 c. Balance 1 C 17 5 0 0 4.Other Income (subm it statement) 4 0 5.Total income 5 0 6. Advertising 6 0 28. Supplies (not included on Sch C-1) 2 8 0 7. Amortization 7 0 29.Taxes 29 0 8. Bad debts fromsalesorservices 8 0 30.Telephone 30 0 9. Bankcharges 9 0 31.Travelandentertaimnent 31 ^ 10. Car and truck expenses 10 0 32. Utilities 3 2 0 11. Commissions 11 0 33. Wages 33 0 12. Costdepletionnot%depletion 12 0 - 34. Other expenses (specify): 13a.Regulardepreciation 13A 13b.Section 179 expense 13 B 14. Dues and publications 14 15. Other employeebenefitprograms 15 16. Freight (not on ScheduleC-1) 16 17. Insurance 1 7 18. Intereston businessindebteness 1 8 19. Laundryandcleaning 19 20. Legal and professional services 2 0 21. Management fees 21 22. Office supplies 2 2 23. Pension and prof it-sharing plans 23 24. Postage 2 4 25. Rent on business property 2 5 26. Repairs 2 6 27. Subcontractor fees 2 7 s. 34 A B C D E F G H I J K 0 34.Totalotherexpenses 34 0 35.Total expenses 3 5 0 36.Reduceezpensesby tot albuslnesscredits 36 0 37.Totaladjustedexpenses 37 38. Net profit or loss 3 8 0 A STORAGE 0 B 0 c 0 D 0 E 0 F G H 0 I 0 J 0 K 0 0 Page 1 of 2 0903114530 0903114530 1381 0 0 0 0 0 0 0 0 0 0 1381 1415 0 1415 -1415 J 0903214540 PA 40 Schedule C- 2009 Social Security Number 2 0 5 2 2 4 4 6 9 Nameofowner DORIS J SNELL SCHEDULE C-1 -Cost of Goods Soid and/or Operations 1. Inventory at beginning of year ('rf different from last year's inventory, include explanation) 1 17 5 0 D 2a. Purchases 2 A 0 2b. Cost of items withdrawn for personal use 2 B 0 2c. Balance (subtract Line 2b from Line 2a) 2 C 0 3. Cost of labor (do not include salary paid to yourself or subcontractor fees) 3 0 °' 4 0 4. Material and supplies 5. Other costs (include schedule) 5 ~ 6. Add Lines 1, 2c,3,4and5 6 17500 7. Inventory at end of year 7 ~ 8. Cost of goods sold and/or operations (subtract Line 7 from Line 6) Enter here and on Part I, Line 2 8 17 5 0 0 SCHEDULE C- 2 - Depreciation (See Instructions) 1. Total Section 179 depreciation (do not include in items below) 1 0 2. Less: Section 179 depreciation include in Schedule C-1 2 D 3. Balance (subtract Line 2from Line 1). Enter here and on Part II, Line 13b 3 0 4. Other depreciation: Description of property Date acquired Costorotherbasis DeoWableron arbW egos Methdoe of~cam nuting Lifeorrate ~pUiisaear for P Y P Y (a) (b) (c) (d) (e) (~ (g) Buildings 4A 0 0 0 Furniture/fixtures 4 8 0 0 0 Trans. equipment 4 C 4D 0 0 0 Machinery Other (specify) STORAG 4E 06032003 459 0 MACRS 7 21 SCANNE 4F 07022004 ,. 138 0 MACRS 5 4 DIGITA 4G 07012004 319 0 MACRS 5 9 4H 0 0 0 4I 0 0 0 4J 0 0 0 4K 0 0 0 4L 0 0 0 4M 0 0 0 4N 0 0 0 40 0 0 0 4P 0 0 0 5. Totals 916 5 3 4 6. Depreciation included in Schedule C- 1 6 ~ 7. Balance (subtract Line 6 from Line 5) Enter here and on Part II, Line 13a 7 3 4 Page 2 of 2 0903214540 0903214540 °.