HomeMy WebLinkAbout04-0191PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of ~t~ ~ag-'rta,~t:=~ ~ o~ It~ta[~-~7't:na No.
also known as To:
l)~--~J~-- ~[l__tl _~ I: 2.a~l Deceased.
Social Security No. lq~-- ~-~' ~_.~M I
Register of Wills for the
County of
Commonwealth of Pennsylvania
in the
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appI
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in ~'~ nn ~-o~4.,ta. ~ i:~ County, Pennsylvania, with
h last family or principal residence at tt;~,/~-
(list street, number and municipality)
Decendent, then ~7~' years of age, died
at
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property $
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows:
Petitioner.__ after a proper search ha__
the following spouse (if any) and heirs:
Name
ascertained that decedent left no will and was survived by
Relationship Residence
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
('.ntff'ff' t-h t.L: ':l~¢a.
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~
COUNTY OF ~ D~ ~_~r/~/ ss
The petitioner(s) above-named swear(s) or affirm(s) that the
statements in the foregoing petition are true and correct to the best
of the knowledge and belief of petitioner(s) and that as personal
representative(s) of the above decedent petitioner(s) w/ill,well and
truly adminis.ter the estate according to law, /~
Sworn to or affirme.~d~ and subscribed c~tY~J/ff///~_~/4 tx,~-Jr~
before me this_ cx--~k~'--'i day of ~ j/
T -- - - ~-~. ,_ ,~ - . ..... / 'T
No.
Estate of ~z~r~-r~c ~
GRANT OF LETTERS OF ADMINISTRATION
, Deceased
AND NOW ~-~ ~ ~. ~'~ a ~_~ ~'~6-'~ ~,~,9c-'~ in consideration of the petition on
· t
the reverse side hereof, satisfactory p~oo~f havi~3g been presented before me,
IT IS .DECREED that ~DqC_P.. 5/ (~ I M ~ >~ ~--~o D
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to '-~3E~,~
in the estate of ('~c-~q-~ r~ ac~
FEES
Letters of Administration ..... $~
Short Certificates( ) .......... $~
(~iation ................ $
TOTAL __ $
Filed .~/___.~. ~ ........ A.D.
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
1.ocal Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
, ~.-.~-.~-
~ Local Registrar
P 9 813 9 31
No. ~ Date
JAN 2 Z304
144 Rev. 1/9t
# 29-185
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
Constance H
Thurston
75 v~,
(Coroner)
DATE O¢ BIRTH BIRTHPLACE (Oty and
(Mom& Day, Yea*')Sk~e o~ F~.e~gm Coumu¥)
Mar 9, 1928 PA
FILE NUMBER
SOCIAL SECURITY NUMBER
Female ~. 198-20-2641
4., 2004
Cumberland Camp Hill
K,.O O~ SUS,.ESS~HOUSTRV
~trW. Cily/~o~,m. Sl~e, Zip Code)
18 1/2 South 18th Street
Camp Hill, PA 17011
FATHER'S NAME (F~, Middle, Lam)
,~[] v. E], ~..~.r,y c,~..
18 1/2 South 18th. Street
White, MC.
White
8URVtWNG ~
(1~ Me. g~,~ maiden rwne)
INFORMANT'S NAME (Type/PrinO
Emery G. Thurston tr.
m~O o~ January 16, 2004
~ll ~M, City/Town, State, Zip CO~)
Cremation Sociecy o~.
~JdE AND ADORESS OF FACILITY Cr emat iol*
4100 gonestown Road
LICENSE HUMBER
)Co~I
TIME ~F DEATH Apr X. DATE PRONOUNCED DEA~ !M~h. Day. Yee~)
,,~,o,~,,~m. 1:00 P ". I=~. Januar7 12, 200~
17. ~ I1 ~,' ..... 7. ~¢~ ~ ~--;~ -:x-~: ~h ~J'~ ~ ~. ~ ~ I~ ~ ~ ~ ~, ~h ~ ~ ~ ,~.~y ~r~. ~ ~ ~ fa~e.
~~ Occlusive Coronary Artery Disease
~)~ a
~ ~ (~ ~ A C~EN~ ~:
e ~ ~ m ~ ~E ~ (~ ~ A C~QUENCE ~:
CAOa~ (Diel~me or imry c.
,esd~ in dealh) IJ~T
JL
PART'i:O0~ _--'.- -'r~--4
no~ eNu,lag Iff the um~efiyt~ cat~e g/~la I~ PART I.
Suicide [] Could n~ be dMmmined [] I~llding. mc. (Sf~ec,ly)
.ausv ~wo~? ~sc.,~.ow uuuuv OCCURU~U.
CEI~IE~.~ (Check or~y
· CERTII~B~ PHYSIC~,N (Physic~n Cal~y~lg ca~e ol d~llh whe,, am p~y~Cm has ~omounced dealh and ~ Im 23)
To the beet M my km)wMd0e, deMh o~ulTed due to the olule(s) and ~ M, it~ted ..................................................... []
' MEI~CAL EXAMINEflJCO~OHER
the balm M exinflnitlon end/er InvelUgat ion, in my ofMnion, dealh ecclured ~t the time, date, end place, and due to the e. eu~e(i) lind
Chief Deputy
Coroner
2004
Todd C. Eckenrode,Chf.Dep,C°roner
6375 Basehore Rd., Suite #1
Mechanicsburg, Pa. 17050 , ,
JRD/June 30, 1992/17858
In Re: Estate of CONSTANCE HOPE THURSTON : ORPHANS' COURT DIVISION
Late of CAMP HILL BOROUGH : COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY
Estate No.: 21-04-191 : PENNSYLVANIA
:
: NO. 21-2004-191
NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT
ORPHANS' COURT RULE
Personal Representative: EMERY G THURSTON
Counsel for Personal Representative:
Date of Grant of Original Letters: 02-25-2004
Date of Delinquency Notice: 06-04-2004
The undersigned, Glenda Famer-Strasbaugh, Clerk of the Orphans' Court, in accordance
with Rule 5.6, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court
Division, Court of Common Pleas of Cumberland County, that neither the above named personal
representative nor the above named counsel for the personal representative have filed with the
Register of Wills or Clerk of the Orphans' Court his, her or its certification required by Rule
5.6(e), Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e),
Supreme Court Orphans' Court Rules, was given by the Clerk of the Orphans' Court on JUNE 6,
2004, and that the ten (10) day notice to file the certification has expired. Accordingly, in
accordance with Rule 5.6(e) the Court is hereby notified of such delinquency and the
undersigned requests that a Court conduct a hearing to determine whether sanctions should be
imposed upon the delinquent personal representative or counsel for the delinquent personal
representative.
Date: 07-13-2004
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
G~eenda Far~er Strasbaugh'-~y'-
Clerk of the Orphans' Court'
A hearing is scheduled for at in Co~oom No. 3. ~e Ce~i~cation of Notice is
filed prior to the he~ng date, ~e he~ng will automatical~
Georg~ ~offir, P~J.
Name of Decedent:
CERTIFICATION OF NOTICE UNDER RULE 5.6(al
Date of Death:
Will No.~'~ O~ L~
TO the Register:
I certify that uotice of (beneficial interest) estate administration required by Rale 5.6(a) of the Orphans' Court Rules was
- OO I '11121 '6~'/c~/~Admin. No.
Jv~f ~'~) ~ooH :
served on or mailed to the following beneficiaries of the above-captioned estate on
Name Address
(3> GR,
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Capacity: _
Signature
Address ~l~-
Telephone
Personal Representative
Counsel for personal representative
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT 280601
HARRISBURG. PA 17128-0601
REV-150t
INHERITANCE TAX RETURN
RESIDENT DECEDENT
CO~t¥~OE ~EA~ N~E~
I--
Z
LU
n
W
LU
n
UJ
~oo
X
DECEDENT S NAME {LAST RRST AND MEDDLE INITIAL/
Thurston Constance
D4TE OF DEATH tMM01_11_2004DD YEAR/ DATEo3_og_192ROF BIRTH IMM-DD-YEAR)
0FAPPLICABLE)SURVVNGSPOUSE'SNAMEILAS}FIRST, ANDMfDD[EINITIAL)
None
SOCIAL SECURITY NUMBER
t98 .- 20 - .2641
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURIW NUMBER
NT)r~ e
~]1 Original Return
[~4 Limited Estate
E~6 Decedent Died }estate ~Attach copy of Will)
~9 Litigation Proceeds Received
E~2. Supplemental Return
[~4a Future Intaresl Compromise {date pi Oeath alia(12-12-82)
~7 Decedent Maintained a Living Trust I^~:h copy of Trust)
[~1 0 Spousal Povedy Credit fdale of dealh be~een 12 31 91 and 1 I 95)
j~]5 Federal Estate Tax Return Required
~ 8. Total Number of Sate Deposit Boxes
E~I 1 Etection to tax under Sec 9113(A) (A~ach Sch O)
NAME Emery G Thurston
None
TELEPHONE NUMBER
717-761-8426
COMPLETE MAILING ADDRESS
Emery G. Thurston
215 North 19th Street
Camp Hill Pa. 17011
1 Real Estate (Schedule A) (1}
2. Stocks and Bonds (Schedule B} (2)
3. Closely Held Corporation, Padnership or Sole-Proprietorship (3)
4 Modgages & Noles Receivable (Schedule D) (4)
5 Cash, Bank Deposits & Miscellaneous Personal Properly (5)
(Schedule E)
6 Jointly Owned Property (Schedule F} (6)
[~ Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (7}
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10 Deb s of Decedent Modgage Liabilities, & Liens (Schedule I) (10)
11. Total Dedu~ions (total Lines 9 & 10)
12, Net Value of Estate (Line 8 minus Line 11)
None
23,627.4~
None ,,:
None
$22,069.58
OFFIC!AL USE ONLY
·
$11, 838.80
(s)
$4,025.00
$57,535.82
$2,107.85
13. Charitable and Govemmental Beguests~Sec 9113 Trusts for which an election lo tax has ~ot been
made (Schedule J)
14 Net Value Subject to Tax (Line 12 minus Line 13)
(1~) $6,132.85
(12) $51 ~ 402.97
H3) None
(14) $51,402.97
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
I$. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec 9116 (a)(1.2)
x .o_ (t5)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sfbling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
x.O
$46,902.97 x12
$4,500.00 xlB
(LC)
(17)
(18)
(19)
$5,628.36
$675.00
$6,303.36
1 0-1 1-04
Decedent's Complete Address:
STREET ADDRESS 11~c'1/~ South 18th S~reet
Camp Hi11. I PA 17011
Tax Payments and Credits: It) $6,303.36
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments None
C. Discount N on e Total Credits ( A + B + C ) (2) None
None
E. Penalty None Total Interest/Penalty ( D + E )
if Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
3, Interest/Penalty if applicable
D. Interest
A. Enter the interest on the tax due.
(3) None
(4) None
(5) _ $6,303.36
(5A) None
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
$6,303.36
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes No
1. Did decedenl make a transfer and:
a. retain the use or income of the property transferred; .......................................................................................... [] []
b. retain the fight to designate who shall use the property transferred or its income; ........................................... [] []
c. retain s reversionary interest; or ........................................................................................................................ [] []
d. receive the promise for life of either payments, benefits or care? ......................................................................
2. If death occurred after December t2, 1982, did decedent transfer property within one year of death
, n~ [] []
without recev ng adeq.~ate consi~erat'o
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 Refirement Acc°unt' annuity' °r °that n°n'pr°bate 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.
Under penaEies of pefjuP/, I declare that I have examined this return, including acc~nying schedules and s[alerr~ents, and Ia ~he besl of my knowledge and b~ief, it is Oue, correct ar~ complete
SIGNATURE OF PF.~ON RESPONSIBLE FOR~G RETURN
ADDRESS 215 N 19th Street, Camp Hill, Pa. 17011
DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
Far 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 3%
[72 P.S. {}9116 (e)(1.1) (i)].
imsed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (t,1) (ii)]
For dates of death on or after Jaceary 1, 1995, the tax rate po ........ ~ ..... ,- ~. ,~;-closure of assets and fi nga tax tatum are still applicable even i
The statute does no~ exempt a transfer to a surviving spouse from tax, aha the statutory requ.um~.,~ .,,. ,~,o
the surviving spouse is the only bene~ary.
For dates of death on er 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 0% [72 P.S. §9116(a)(12)].
The tax rate imposed on the net value of transfers to or for the usa of the decedent's lineal beceficiades is 4.5%, 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 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Sedan 9102, as a~
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX+ (6-98~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF FILE NUMBER
Thurston Constance H 21 04 0191
Afl 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, bath having reasonable knowledge of the relevant facts.
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
NOT APPLICABLE
TOTAL (Also enter on line 1, Recapitulation)
I 0-1 1.! - 0 4 (If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF 'FILE NUMBER
Thurston Constance H 21 04 0191
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM ~ ~ VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
1
2
3
4
MUTUAL FUNDS
Number of
Shares
Asset Value
Per Share
AXP Diversified Bond Fund
Class B (ININX)
1273.297
AXP New Dimension Fund
Class A (INNDX)
71.455
AXP Dividend Opportunity Fund117.740
Class B (INUTX)
AXP Dividend Opportunity Fund 115.126
Class A (INUTX)
4.90
23.90
6.48
6.53
AXP Certificates
AXP Flexible Savings Certificates
Value 2-23-04,9336.78 - 54.33 = 9282.45 Value,l-Il-04
AXP Flexible Savings Certificate
Value 2-23-04, 4880.97 6.63 = 4874.34 Value 1-11-04
6,246.00
1,709.92
762.96
751.77
9,282.45
4,874.34
TOTAL (Also enter on line 2, Recapitulation) $ 23,627.44
10-111.- 04 (If more space is needed, insed additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP or SOLE*PROPRIETORSHIP
ESTATE OF
Thurston Constance H
FILE NUMBER
21 04 0191
Schedule C-1 or C-2 (lncludir~g all supporting ir~formation) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-propdethrship.
See insbuctlons for the supporting information to be submitted for sole-proprietorships.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
NOT APPLICABLE
TOTAL (Also enter on Pine 3, Recapitulation) $
I O- 1 1. - O 4 (If more space is needed, insert additional sheets of the same size)
REV-1507 EX+ (1-97) ~
'~'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF FILE NUMBER
Thurston Constance H 21 04 0191
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
Not Applicable
TOTAL (Also enter on line 4, Recapitulation) $
I 0-1 1_- 0 4 (If more space is needed, insert additional sheets of the same size)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN
RES,DENT eECEDENT PERSONAL PROPERTY
ESTATE OF FILE NUMBER
THURSTON CONSTAN(~R H. 21 ~4 0191
Include the
ITEM
NUMBER
2
3
4
5
6
7
8
9
~roceeds of lit~ation and the date the proceeds were received by the estate. AIl property ~in~ ~h the r~M of su~ivomh must be disclosed on Schedule F.
DESCRIPTION
Checing Account
Account Number
PNC BANK
PO. Box 535230
Pittsburgh, Pa.
51 -4011-9655
15253-5230
Savings Account
Account Number 50-0373-2226
Certificate of
PNC BANK
PO. Box535230
Pittsburgh, Pa.
Deposit
15253-5230
Household Furniture: end table 15.00: end table 20.00
chair 20.00: table and chairs 200.00:pictures 40.00
stool 5.00:
Remaining Household Furniture to charity. No value
House hold Furnishings: lamp 10.00: cooking utensils
20.00: dishes and knick knaks 60.00
Tools: work table 6.00: sander 10.00: grinder 10.00
Plastic tool box 2.00: miter box 15.00:
Remaining Household Furnishings to charity,no value
1988 Ford Escort Sedan,sold
Wearing Apparel- Donated to charity -no value
Costume jewelry- Donated to charity - no value
Hershey Medical Center returned account over
pa~ht'
comcast refund for equipment
TOTAL (Also enter on Pine 5, Recapitulatbr
VALUE AT DATE
OF DEATH
$687.27
$15,433.03
$5,461.59
$433.00
$25.00
$0.00
$0.00
~$15.35
$14.34
$ 22,069.58
10-1]-04
(If more space is need~, insed ~ditional sh~ts of the same size)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF FILE NUMBER
Thurston COnstance H 21 04 0191
If an asset vas 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
A,
NOT APPLICABLE
JOINTLY43WNED PROPERTY:
LETTER DATE DESCPJPTION OF PROPERTY % OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of flnanc~l inslJlut~ and bank accost)! numba~ or similar identifying number. A[lach DATE OF DEATH DEC, D'S VALUE OF
NUMBER TENANT JOINT deed for ioifltybald real estate. VALUE OF ASSET INTEREST DECEOENT'S INTERE.
NOT APPLICABLE
TOTAL (Aisc enter on line 6, Recapitulation) ~ $
1 O- 1 1_.- 0 4 (If more space is needed, insed additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
iNHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
ESTATE OF
Thurston Constance H 21 04 0191
TMs schedule must be compfetecl and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPER~ % OF
ITEM I~UOE ~HE t~E ~ THE T~$FE~E, THOR R~TI~$~P TO ~CE~NT AND THE DATE ~ T~SFE~ DATE OF DEATH DECD'S EXCLUSION TA~BLE VALUE
NUMBER VALUE OF ASSET INTEREST
1.
Mutual Funds
IRA Individual Plan
1 AXP Selective Fund $2785.43 100 NA $2785.43
Class A (INSEX)
2 AXP Global Bond Fund $1243.37 100 NA A243.37
Class A (IGBFX)
~ AXP Short Duration US GOvernment Bond $2871.20 100 NA 2871.20
Class A (IFINX)
4 AXP ~igh Yield Bond Fund $2221.54 100 NA 2221.54
Class A (INEAX)
5 AXP Blue Chip Advantage Fund $ 492.00 100 NA 492.28
Class A (IBLUX)
6 AXP Partners Fundamental Value Fund $1105.11 100 NA 1105.11
Class A (AFVAX)
7 AXP Blue Chip Advantage Fund 727.70 100 NA 727.70
Class B (IDBCX)
$392.17 100 NA 392 17
8 ~XP Dividend Opportunity Fund $ 10~ NA
~lass B (IUTBX)
TOT~(Alsoentermline7, R~apitulation) $11,838.80
1 O- ! .1 - 0 4 (If more space is needed, inset[ additional sheets of the same size)
EV-1511 EX+ (12-99) ~
COMMONWEALTH OF PENNSYLVANIA
iNHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Thurston Constance H.
FILE NUMBER
21 04
Debts of decedent must be reported on Schedule L
0191
ITEM
NUMBER DESCRIPTION AMOUNT
A.
FUNERAL EXPENSES:
Cremation Society of Penna. $1507.00
Conorers Cremation Approval 25.00
Death Certificates 22.00
Opening Grave for burial 255.00
( Greenwood Cemetary, Indiana, Pa)
Grave Marker Engraving 55.00
Transportation Harrisburg to Indiana 90.00
Total 1,954
ADMINISTRATIVE COSTS:
Personal Representative's Commissinns
Name of Per'orCa[Representative(s) Emery G Thurston
174
Social Security Number(s)/EIN Number of Personal Representative(s)_
Street Address 215 N 19th Street
City Camp Hill
Year(s) Commission Paid:2004
16 1485
State Pa Zip 1701
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State __ Zip
Relationship of Claimantto Decedent
Probate Fees
Accounta~'s Fees
Tax Return Preparer's Fees
$1 , 954. O0
$2,000. O0
0.00
0.00
$71. O0
0.00
0.00
TOTAL (Also enter on line 9, Recapitulation) $ $4,025. O0
1 O- 11..- 04 (If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES,& LIENS
ESTATE OF FILE NUMBER
'l'hurston Constance I{. 21 04 0191
Include unreimbursed medical expenses,
)TEM
NUMBER DESCRIPTION AMOUNT
1. McEDICA.L KAFENSES $1 81 6.40
a. ~30/04
b. 4/30/04
c. 4-30-04
d 4-30-04
e. 4-30-04
f. 4 30 04
g 5-31-04
h. ~-28~04
i 8-26-04
Pinnacle Health Hospitals
Hershey Medical Center
Kunckle Surgical Group
Heratige Medical Group
West Shore EMS
Pinnacle Health Hospitals
Quantum Imaging
Pinnacle Health Hospitals
Pinnacle Health Hospitals
$100.83
$264.53
$178.64
$26.23
$44.~8
$909.34
$69.83
$124.52
$97.85
PENSION OVERPAYMENT
February and March,2004 monthly retirement
checks were Direct Deposits made by Zurich to
the decedents checking account. Over
Payments were returned to Zurioh on'5~17-04
$291.45
TOTAL (Also enter on line 10, Recapitulation) $ 2107.85
1 O- 11~ - 04 (If more space is needed, insed additional sheets of the same size)
REV-1513 EX+
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATEOF Thurston Constance H
FILE NUMBER
21 04 0191
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEtVING PROPERTY Do Not List Trustees) OF ESTATE
I
1.
3
II
~XABLE DISTRIBUTIONS [include outright spousal distributions, a~ tranCem under
Sec. 9116(a)(1,2)]
Mrs Grace Thurston
% Mr Terry Stiffler
2965 Yellow Creek Drive
Penn Run, Pa. 75765 7234
Mrs Ruth Nelson Warner
104 Expressway Village
Niagra Falls New York
14304
Mr Emery G Thurston
215'North 19th Street
Camp Hill Pa 17011
Sister- law
Friend
Brother
TOTAL OF PART ]1 - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
$.1,500.n0
$3,000.00
[emaining residuary
Estate
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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
$0.00
1 O- 1 1~- 04 (If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
(Check Box 4 on Rev-1500 Cover Sheet)
ESTATE OF FILE NUMBER
Thurston COnstance H 21 04 0191
This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death
pdor 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 on or after 5 -1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
[] Will [] Intervivos Beed of Trust [] Other
, UFEESTATE INTERESTCALCU~T~ON : : ;
NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS
LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE
NOT APPLICABLE [] 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%
3. Value of life estate (Line 1 multiplied by Line 2)
[] 10% [] Vadable Rate %
NAME(S) OF ...... NEAREST'AGE AT TERM OF yEAR~
ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE
[] life or [] Term of Years __
[] Life or [] Term of Years __
[] Life or [] Term of Years __
[] Life or [] Term of Years __
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)
[] Quarterly (4) [] Semi-annually (2) [] Annually (1)
Amount of payout per period
4. Aggregate annual payment, Line 2 multiplied by Line 3
5. Annuity Factor (see instructions)
Interest table rate r-~31/2% []6% [~]10%
6. Adjustment Factor (see instructions)
7.
[] Monthly (12)
[] Other ( )
[] Vadable Rate %
Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and pedod payout is at end of pedod,
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 futura interests must be reported as part of the estate assets on
Schedules A through G of this tax retum. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on
Lines 13, 15, 16 and 17.
1 O- 1 1~- 0 4 (If more space is needed, insed additional sheets of the same size)
REV-}644 8X+ (3-84)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE "L"
REMAINDER PREPAYMENT OR INVASION
OF TRUST PRINCIPAL
FILE NUMBER
21-04 -0191
I. Estate of Thurston Constance H
(Last Name) (First Name) (Middle JnltlaJJ
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.
Remainder Prepayment: NOT APPLICABLE
A. Election to prepay filed with the Register of Wills on
(attach copy of eledion)
(Date)
B. Name(s) of L~fe Tenant(s) Date of Birth Age on date
or Annuitant(s) 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
I. 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)
Invasion of Corpus:
A. Invasion of corpus
(Month, Day, Year)
B. Name(s) of Life Tenant(s) Date of Birth
or Annuitant(s)
Term of years income
or annuity is payable
S
III.
10-Ii-0~
C. Corpus consumed
Age on date
corpus consumed
D. Remainder fader (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)
Term of years income
or annuity is payable
REV-1646 EX+ (3-S4J
,~ INHERITANCE TAX
SCHEDULE L-2
COMMONWEA'T, OF PENNSYLVAN~^ REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN 21 04--01 9
RESIDENT DECEDENT -CREDITS- FILE NUMBER
I. Estate o~hurst°n Constance h
('asr Name) (First Name) (Middle Initial)
II. Item No. Description Amount
A. Unpaid Liabilities Claimed against O6ginaJ Estate, and payable from assets
reported on ScheduLe L-1 (please list)
ENTIRE FORM IS NOT APPLICABLE
Total unpaid liabilities S
(include on Section II, Line D-1 on Schedule L)
B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list)
Total unpaid bequests S
(include on Section II, Line D-2 on Schedule L)
C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under
"B" above) that are not included for tax purposes or that do not form a part
of the trust.
Computation as follows:
Total uninctudable assets S
(include on Section II, Line D-3 on Schedule L)
III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) S
(if more space is needed, attach additional 8Y2 x 11 sheets.)
10-1 ~_-04
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE M
FUTURE INTEREST COMPROMISE
(Check Box 4a on Rev-1500 Cover Sheet)
ESTATE OF
Thurston COnstance H
FILE NUMBER
21 04 0191
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 wilt 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 returm
[] Will [] Trust [] Other
I1.
IlL
Beneficiaries
NAME OF
BENEFICIARY
RELATIONSHIP
DATE OF BIRTH
AGE TO
NEAREST BIRTHDAY
For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exemise a dght 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 dght.
[] Unlimited right of withdrawal [] Limited right of withdrawal
Explanation of Compromise Offer:
Form is not Applicable
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 r-16%, I-']3%, [] 0%
(also include as pad of total shown on Line 15 of Cover Sheet) $
4. Value of Line 1 Taxable at 6% Rate
(also include as part of total shown on Line 16 of Cover Sheet) $
5. Value of Line 1 Taxable at 15% Rate
(also include as part of total shown on Line 17 of Cover Sheet) $
6. Total value of Future Interest (sum of Lines 2 thru 5 must equal Line1)
(If mom space is needed, insert additional sheets of the same size)
10-11_-O4
SCHEDULE N
SPOUSAL POVERTY CREDIT
(AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91)
ESTATE OF ~hu~stoR Constance h FILE NUMBER 21 04 91
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) ....................................................................
2. Insurance Proceeds on Life of Decedent ............................................................................
3. Retirement Benefits .........................................................................................................
4. Joint Assets with Spouse .................................................................................................
6a. Other Nontaxable Assets: List (Attach schedule if necessary)..
Entire Form Is not applicable
PA Lottery Winnings ......................................................................................................
6b.
6. SUBTOTAL (Lines 6a, b, c, d) .........................................................................................
7. Total Gross Assets (Add lines 1 thru 6) .............................................................................
8. Total Actual Liabilities ....................................................................................................
9. Net Value of Estate (Subtract line 8 from Jlne 7) ................................................................
If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part
I c ]__ TAX YEAR 19 2.
nt 2b.
2c.
d. Tax Exempt Income ..... ld 2d.
e. Other Income not
listed above ........... le. 2e.
f. Total ..........................lt. 2f.
4. Average Joint Exemption Income Calculation
4a. Add Joint Exemption Income from above:
(If) + (2f) + (3f) =
(+ 3)
4b. Average Joint Exemption Income ..................................................................................... =
If line 4(b) is greater than $~i0,000 . STOP. The estate is not eligible to claim the credit. If not, continue to Part III.
'1.' ' I~ser~ amount of taxable transfers to spouse or S 100,000, whichever is less ..........................
Multiply by credit percentage (see instrudions) ..................................................................
3.This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credils on line 18 of the cover sheel .............................................
4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of lhe
decedent's gross estate ..................................................................................................
J 0-1 'Ii- 0.~uhiply line 3 by line 4 and enter the total here. This is the amount of he Nonres dent Spousal
' Poverty Credil. Include this figure in the calculation of total credits on line 18 of the cover sheet.
Summary of Accounts by Product
Mutual Funds
Account number Value one year ago Value last statement
$19,088.17 $20,595.30
OWNERSHIP TOTAL ~,159.52 $9,171A4
0011 2824 2354 7 002 $6,018.41 $6,171.28
0020 6824 2354 4 002 $903.65 $1,5~4.99
0022 3824 2354 3 002 $625.70 $708.23
0040 68,24 2364 2 002 NOt applicable Inactive
0042 3824 2354 1 002 $611.76 $696.94
OWNERSHIP TOTAL $10,92~.65 $11,423~6
· 0010 5824 2354 6 002 · $2.712.32 $2,755.18
H)012 2824 2354 5 002 $1.102.83 $1,186.46
',~012 4824 2354 3 002 $2,832.45 $2,847.68
'0012 5824 2354 2 002 $1.773.5t $2.121.34
~0013 1824 2354 4 002 $372.09 $456.49
~0017 5824 2354 I 002 $819.05 $1,017.14
~ 0023 1624 2354 3 002 $553.46 $675.38
~0030 6824 2354 S 002 $441.t8 Inactive
0032 3824 2354 2 002 $321.76 $364.19
CONSTANCE THURSTON
AXP DIVERSIFIED BOND FUND CLASS B
AXP NEW DIMENSIONS FUND CLASS A INNDX
AXP DIVIDEND OPPORTUNITY FUND CLASS B IUTBX
AXP NEW DIMENSIONS FUND CLASS B INDBX
AXP DIVIDEND OPPORTUNITY FUND CLASS A INUTX
CONSTANCE THURSTO# IRA
AXP SELECTIVE FUND CLASS A, IRA
AXP GLOBAL BOND FUND CLASS A, IRA IGBFX
AXP SHORT DURATION U.S. GOVERNMENT FUND CLASS A, IRA IFINX '
AXP HIGH YIELD BOND FUND CLASS A~ IRA INE~X
AXP BLUE CHIP ADVANTAGE FUND CLASS A, IRA IBLUX
AXP PARTNERS FUNDAMENTAL VALUE FUND CLASS A, IRA AFVAX ~.~
AXp BLUE CHIP ADVANTAGE FUND CLASS B, IRA IDBCX
AXp NEW DIMENSIONS FUND CLASS B. IRA I#DBX~*
AXP DIVIDEND OPPORTUNITY FUND CLASS B, ~RA IUTBX
(~edificates
CONSTANCE THURSTON
;LEXIBLE SAVINGS
FLEXIBLE SAVINGS
OWNERSHIP TOTAL
0006 0412 3832 3 001
0008 0412 9790 7 001
IRA/CESA Plan Contributions
Plan CONSTANCE TH URSTON
Owner IRA Plan
Plan Made for 2004 $0.00
Contributlona Rollover 2004 $0.00 '
Current value
$21,382.7'1 ~ ~'2~
$9,495.65
$6,265.72 *,/.
$1,712.78
$764.13 '~z.
$752.92 ~ '
$~6.~
~ ~ $732,~
$~2.~
$13,725.25 $14,092.87 $14~217,75
$13,72~.25 $14,092.97 $14,217.76
$8,987.39 $g,248.18 $9,336.76
$4,737.86 $4,844.79 $4,880,97
2t
Suzanne
Lunemann
09/23/2004 11:33 AM
Subject:
Richard L Mccarthy/FieldNVH/AEFA@AMEX
CONSTANCE THURSTON
Thank you for your recent inquiry regarding CONSTANCE THURSTON's accounts. These are the values of the
accounts as of01/11/2004.
Mutual Funds
Account Number Total Value # of shares
01058242354 6 002
01128242354 7 002
01228242354 5 002
01248242354 3 002
01258242354 2 002
01318242354 4 002
01758242354 1 002
02068242354 4 002
02238242354 3 002
~'02318242354 3 002
03238242354 2 002
04238242354 I 002
$2785.43
$6246.00
$1243.37
$2871.20
$2221.54
$492.28
$1105.11
$1709.92
$762.96
$727.70
$392.34
$751.77
Asset Value Per Share
318.618 8.730
1273.297 4.900
180.199 6.900
585.384 4.900
771.720 2.870
62.631 7.860
222.805 4.960
E 71.455 23.930
.3 117.740 6.480
95.124 7.650
60.546 6.480
q~15.126 6.530
Certificates
Account Number Total Value # of shares
00804123832 3 001
00804129790 7 001
not available
not available
Asset Value Per Share
The date of death values provided are for estate tax purposes and are not a value to be paid. Accounts may be
subject to market fluctuation as governed by each product. Please note that the values indicated for any Life
Insurance product(s) reflect the gross death benefit at date of death, not the cash value.
We appreciate the opportunity to be of service to you. Please contact us if you have any questions.
Sincerely,
Suzanne Lunemaun
Death Seltlements Processing Team
70100 AXP Financial Center
Minneapolis, MN 55474
888-723-8476, option 1, 3, 1
his is to certify that the information here given is correctly cop~ed from an origina~ certificate of death dul3 filed with me as
Local Registrar. The original certificate will be forwarded to; the State Vital Records Office for permar, ent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
P 9813924
!,oca} Registrar (/
,.., ' )ilr
No. Date
# 29-185
COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF HEALTH * VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
Thurston · Female ,. 198-20-2641 4. January 11~ 2004
~-~ ~Mar 9,1928 Iseltn, PA ~.~ [~o.~
, 18 I/2 South 18th. Street
Cumberland Camp Hill . ~,~.~.~.
I,,,. , .41oo
'1~'~"*~"~ "-'" "-r_-. ~ ' I
~ [~. 1:00 P ~ ~. January 12, 2004
Chief Deputy
2004
Todd C. Eckenrode,Chf.Dep. Coroner
6375 Basehore Rd., Suite ~1
Mechanicaburg, Pa. 17050
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENTOFREVENUE
BUREAU OFINDIVlDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
REV-1162 EX(11 96)
NO. CD 004484
THURSTON EMERY G
215 NORTH 19TH STREET
CAMP HILL, PA 17011
........ feid
ESTATE INFORMATION: SSN: 198-20-2641
FILE NUMBER: 2104-01 91
DECEDENT NAME: THURSTON CONSTANCE HOPE
DATE OF PAYMENT: 1 O/12/2004
POSTMARK DATE: 10/12/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 01/11/2004
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $6,303.36
REMARKS:
CHECK//7A
SEAL
TOTAL AMOUNT PAID:
INITIALS: JA
RECEIVED BY:
$6,303.36
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
BUREAU OF IND.rVTDUAL TAXES
TNHERITANCE TAX DIVTSTON
PO BOX 180601
HARRISBURG, PA 17118-0601
EMERY G THURSTON
215 N 19TH ST
CAMP HILL
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHER.rTANCE TAX
APPRA.rSEHENT, ALLONANCE OR D.rSALLONANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
PA 17011
BATE
ESTATE OF
BATE OF DEATH
FILE NUMBER
COUNTY
ACN
12-15-2004
THURSTON
01-11-2004
Z1 04-0191
CUMBERLAND
101
Amoun~ Rami{:ted
CONSTANCE H
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THXS LXNE ~ RETAIN LOWER PORTZON FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLOWANCE OR DISALLOWANCE OF BEBUCTZONS AND ASSESSHENT OF TAX
ESTATE OF THURSTON CONSTANCE H F]:LE NO. 21 04-0191 ACN 101 BATE 12-15-2004
TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVAT]:ON CONCERN]:NG FUTURE ]:NTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Es{:a{:e (Schedule A) (1)
2. S{:ocks end Bonds (Schedule B) (2)
$. Closely Held S{:ock/Par{:nership Zn{:eres{: (Schedule C) ($)
q. Hor{:gages/No{:es Receivable (Schedule D)
E. Cash/Bank Daposi{:s/Misc. Personal Proper{:y (Schedule E) (S)
6. Joln{:ly Owned Propar{:y (Schedule F) (6)
7. Transfers (Schedule g) (7)
8. To{:al
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expanses/Adm. Cos{:s/Misc. Expanses (Schedule H) (9)
10. Dab{:s/Mor{:gage Liabili{:ias/Liens (Schedule .r) (10)
11. To{:al Deduc{:ions
12. Ne{: Value of Tax
O0
627 44
O0
00
22~069 58
O0
11z858.80
(8)
4,025.00
NOTE: To insure proper
cradi{: {:o your accoun{:,
submi{: {:he upper por{:ion
of {:his form wi{:h your
tax paymen{:.
15.
NOTE:
57,535.82
AHOUNT PAID
6,$05.$6
TOTAL TAX CREDIT
BALANCE OF TAX DUEI
ZNTEREST AND PEN.
TOTAL DUE
Char1{:abla/Governmen{:al Beques{:s; Non-elected 911:5 Trus{:s (Schedule J) (1:5)
Ne{: Value of Es{:a{:e Sub,ac{: {:o Tax (lq) 51,402.97
Zf an assessment Nas issued previously, 11nas 14, 15 and/or 16, 17, 18 and 19 N111
.00
.00
.00
5,628.36
675.00
.rF PAID AFTER DATE .rND.rCATED, SEE REVERSE
FOR CALCULATION OF ADD.rTIONAL /NTEREST.
6,305.36
.00
.69
.69
( ZF TOTAL DUE 'rs LESS THAN $1, NO PAYHENT .rS REI;iU.rRED.
'rF TOTAL DUE .rS REFLECTED AS A "CRED.rT" (CR), YOU HAY BE DUE
k REFUND. SEE REVERSE S.rOE OF TH.rS FORH FOR TNSTRUCT'rONS.] ~..~
reflect figures that lnclude the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amoun{: of L/ne lq a{: Spousal ra{:e (1E) .00 X O0 =
16. Amoun{: of Line lq {:axable a{: Lineal/Class A ra{:e (16) .00 X 045 =
17. Amoun{: of Line lq a{: Sibling ra{:e (17) 46,902.97 X 1Z =
18. Amount of Line lq {:axabla a{: Colla{:ara1/C1ass B ra{:a (18) 4,500.00 X 15 =
19. Princi:)al Tax Due (19)=
TAX CREDITS
PAYNENT RECEZPT DZSCOUNT
DATE NUHBER .rNTEREST/PEN PA.rD (-)
10-12-2004 CD004484 .00
Z,107.85
(11) ~ .1~2.85
(~2) 51,402.97
RESERVATION:
PURPOSE OF
NOTICE:
PAYNENT:
REFUND (CR):
OBJECTIONS:
ADNZN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December 11, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life er for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the 1aclu1 Class B (collateral) rate on any such future interest.
To fulfill the requirements of Section ZlqO of the Inheritance and Estate Tax Act, Act 13 of 1000. (71 P.S.
Section 91~0).
Detach the top portion of this Notice and submit with your payment to the Register of gills printed on the reverse side.
--Make check or money order payable to: REGISTER OF NZLLS, AGENT
A refund of a tax credit, which was not requested on the Tax Return, amy be requested by completing an
"Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-131$). Applications are available
online at awa.revenue.state.pa.us~ any Register of Hills or Revenue District Office, or free the Department's
Z~-heur answering service for forms orders: 1-800-$61-2050; services for taxpayers ~ith specie! hearing and/or
speaking needs: 1-800-qq7-3010 (TT only).
Any party in interest not satisfied ~ith the appraiseent, allowance or disallowance of deductions or assessment of tax
(including discount or interest) as shone on this Notice may object aithin 60 days of the date of receipt of this notice
by filing one of the following:
A) Protest to the PA Department of Revenue, Board of Appeals. You say object by filing a protest online at
waa.boardofappeals.state.pa.us on or before the expiration of the sixty-day appeal period. In order for
an electronic protest to be valid, you must receive a confirmation number and processed date from the
Board of Appeals aebsita. You may also send a written protest to PA Department of Revenue, Board of Appeals
P.O. Box Z81021, Harrisburg, PA 17118-10Z1. Petitions may not be foxed.
B) Election to have the matter determined at the audit of the account of the personal representative.
C) Appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, P.O. Box 180601, Harrisburg, PA 17118-0601
Phone (717) 787-6505. Sea page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-1501) for an explanation of administratively correctable errors.
If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5Z) discount of
the tax paid is allo~ed.
The 15X tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (61) percent per annum calculated at a daily rate of .00016q. All taxes which became delinquent on and after
January 1, 19BI mill bear interest at a rate which mill vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through ZOO4 are:
Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year
1982 207, .0005q8 ~-8-1991 117. .000301 ~
1983 167. .000¢38 1992 97. .O00Zq7 ZOOZ
198~. 117. .000301 1993-199~ 7Z . O00zgz 2003
1985 131 .000356 1995-1998 97. .0002~7 ZO0~
1986 107. .OOOZ7~ 1999 77. .000191
1987 107. . O00Z7~ logo 77. .000191
--Interest is calculated as follo~s:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
Interest Daily
Rate Factor
9Z .0001¢?
67. .00016¢
57. .000137
CZ .000110
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.