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Home My WebLink About08-29-101 1505610142 J REV-1500 °`tO1-'°' I~ n verde OFFICU\L USE ONLY PA Department of Revenue Pe ~ Bureau of Individual Taxes "~"~""'~"`"`~` County Code Year File Number Po sox z8o6oi INHERITANCE TAX RETURN 1~ ( ~ ~1 O~ 3 Harrisburg, PA iTi28-o6oi RESIDENT DECEDENT A lJ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 193-12-9445 05312010 06061914 Decedent's Last Name Suffix Decedent's First Name MI NEWBURY VERNA G (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return Q 2. Supplemental Return Q 3. Remainder Return (date of death prior to 12-13-82) Q 4. Limited Estate Q 4a. Future Interest Compromise (date of Q 5. Federal Estate Tax Return Required death after 12-12-82) ® 6. Decedent Died Testate Q 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Q 9. Littgation Proceeds Received Q 10. Spousal Poverty Credit (date of death Q 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 CONFIDENTUIL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ROBERT M NEWBURY~EXECUTOR 717-652-0304 First line of address 4518 HILLSIDE COURT Second line of address City or Post Office HARRISBURG Correspondent's e-mail address: State ZIP Code PA 17110 REGISTER OF WILLS USE ONLY RECORDED OFFICE OF REGISTER OF WILLS 2010 AUGUST 19 CLERK OF ORPHANS' COURT CUivffiERLAND CO., PA DATE FILED Under penalties of perjury, I dedare that I have examined this return, inducting eccomparrying schedules and statements, snd to the best of my knowledge and belief, It is and complete. l~daretion of preparer other than the personal representative is based on all IMOmwtion of which preparer has any knowledge. NATO F PERSON ESP LE FO LING RETURN /+ ~ DATE 1~ r~J., _ _ ~ 8/9/10 4518 HILLSIDE COU1tT, HARR~S~URG, PA 17110 SIGNATURE OF PREPARER OTHER THAN REPRESEN E ADDRESS DATE PLEASE USE ORIGINAL FORM ONLY Side 1 1505610142 1505610142 ~e REV-1500 EX Decedent's Name: VERNA G NEWBURY Decedent's Social Security Number 193-12-9445 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closety Held Corporaiion, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6 8 , 04 3 •10 6. Jointy Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 6. Total Gross Assets (total Lines 1 through 7) ............................. 8. 68 , 043.10 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 7 , 8 04 • 8 6 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 11. Total Deductions (total Lines 9 and 10) ................................. 11. 7 , 804.8 6 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 6 0 , 2 3 8.24 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. 6 0 , 2 3 8 . 2 4 TAX CALCULATION -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.o45 60, 238.24 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 1505610242 2,710.72 • 2,710.72 O Side 2 L 1505610242 1505610242 REV-1500 E'X Pape 3 Decedent's Complete Address: FIIeNUmber 2010-00636 DECEDENTS NAME Varna G Newbury STREETADDRESS 52 Ceater Drive CITY Camp 8111 STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 135.54 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill fn oval on Page 2, Line 20 to request a refund. Total Credits (A+ B) (2) (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter fhe difrerence. This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. 575.18 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 :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in Wst for' or payable-upon-death bank acxount or security at his or her death? .............. ^ x^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a benefcary 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 Juty 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 applipble 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 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent p2 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficiaries is 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 decedents siblings is 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. (1) 2,710.72 135.54 REV-1502 EX+ (11-08) Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAx RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Verna G Newbury 2010-00636 All real property owned solety or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property If more space is needed, insert additional sheets of the same size. REV-1503 EX+ (g_98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS S BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Verna G Newbury 2010-00636 All property jointly-owned wkh right of survtvonhip must be disclosed on Schedule F. (If more space is needed, insert addd'ronal sheets of the same size) REV-1504 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF Versa G Newbury 2010-00636 Schedub G1 or G2 (induding all supporting information) must be atladled for each cbseyhekl wrporotioNpartnerehip interest of the decedent, other than a sole-proprietorship. See instrudials torthe supporting information to be submitted for sole-proprietorships. (M moro apace a needed, insert addftional sheets of the same sae) REV-1505 EXi (8-9e) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT FILE NUMBER Varna G Newbury 2010-00636 1. Name of Corporation State of Incorporation Address City 2. Federal Empbyer I.D. Number 3. Type of Business 4. State Zip Code Date of Incorporation Total Number of Shareholders Business Reporting Year Product/Service 5. Was the decedent employed by the Corporation? ........................................ QYes ~ No If yes, Position Annual Salary S Time Devoted to Business 6. Was the Corporation indebted to the decedent? ......................................... ~ Yes ~ No ~ A If yes, provide amount of indebtedness $ fi+~ 7. Was there I'Ife 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 any stock in 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 $ Attach a separate sheet for addRional transfers and/or sales. Date 9. Was there a written shareholder's agreement in effect at the time of the decedeni's death? ....... QYes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's Stock sold? ...................................................... QYes ~ 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 ~Ne If yes, provlle 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. •' ~ • s A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax retuma (Form 1120) for the year of death and 4 preceding years. C. If the corporation 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. Lint 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 benefds received from the corporation. F. Statement of dividends paid each year. List those decared and unpaid. G Any other information relating to the valuation of the decedent's stock. (If mac space is needed, insert additional sheets of the same size) Provide all rights and restrictions pertaining to each class of stock. REV-1506 EX+ (9-00) COMMONNIFALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT FILE NUMBER Verna G Newbury 2010-00636 1. Name of Partnership Address City 2. Federal Employer I.D. Number 3. Type of Business ProducUService Business Reporting Year State Zip Code 4. Decedent was a ^Generel ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. A. 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 'rf the date of death was prior to 12-31-82? ^Yes ^No If yes, ^Taansfer ^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 sok17 .......................................... ^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, incuding a Schedule G1 or C-2 for each interest. e • ~ s s 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. Date Business Commenced ^ No REV-1507 EX+ (8-98) COMMONWEALTH OF PENNSYLVANUI INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF Varna G 2010-00636 All properly Jointlyowned vrith right of aurvivonhip must to disclosed on Schedule F. (If more apace is needed, insert a~dllional sheets of the same sae) REV 1508 FJ(+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, 8r MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Varna G Newbury ZO10-00636 Include the proceeds of litigatbn and the date the proceeds were received try the estate. (If more space is needed, insert additanal sheets of the same sae) REV-1508 El(+ (8-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Vas:na 6 Narrbury 2010-00636 k an asset was made Jolnt wlthln ona yar of the decedeM'a date of death, k must be reported on Schedule G. SURVNINGJOINTTENANT(S)NAME I ADDRESS I RELATIONSHIPTODECEDENT JOINTLY-0WNED PROPERTY: ITEM NUMBER LETTER FOR JOINT lElNNT DATE MADE JOINT DESCRIPTION OF PROPERTY NICUIDE NAME aF FBJPNCIAL INSTTTUTIONNA BANKACCOUNT NUMBER OR SMILAR IDENTIFYaiG NUMBER ATTACH DEED FOR JOIItRY~ELD REAL ESTATE DATE OF DEATH VALUE OF ASSET %OF OECD'S klTEREST DATE aF DEATH VALUE OF DECEDENTS INTEREST 1. A. f' TOTAL (Also enter on line 6, Recapitulation) ~ S (If more space is needed, insert add'dional aheels of the same sae) REV-1510 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS 8r MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Varas G Newbury 2010-00636 This schedub must be campbfed and filed H the answer to any of questions 1 through 4 on the roverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCIUDETHEWJAEOFiHETRANSFEREE,THERREUTIONSHpTODECEOENTAND nfoaEOFrn~wsFEnnnncHncovroFn+EOEEOFannEnLESrA1E. DATE OF DEATH VALUEOFASSET %OFDECD'S INTEREST EXCLUSION lc~rv~~cnsl>:i TAXABLE VALUE 1. f~ TOTAL (Also enter on line 7, Recapitulation) ~ t (If moro space is needed, insen additional sheets of the same size) REV-1519 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES 8 ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Verna G Newbury 2010-00636 Debts of decedent moat tN reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t' Funeral 8xpeasee 6,678.62 Northumberland Memorial Park Cemetery - Grave Stone 350.00 B. t 2. Attorney Fees 3. Fatuity Exemptbn: (If decedent's address is not the same as clawnant's, attach explanation) Claimant StreetAddress City State Relatbnship of Claimantto Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. Nursing Home Care - Homeland Center Return of Uait Here Nat'l Retirement Fuad Check Filing Fees; Notary Feea ZIP 409.24 112.50 254.50 TOTAL (Also enter on line 9, Recapitulation) I = 7 , 804.86 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) StreetAddress City Year(s) Commission Paid: State ZIP (If more space is needed, inseA additional sheets of the same sae) REV-1512 EX+ (12-08) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TA7( RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE Of FILE NUMBER Varna G Nawbnry 2010-00636 Report debb incurred by the decedent prior to death that remained unpaid at the date of death, Including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (i1-08) Pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAx RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF Varga G Newbury FILE NUMBER 2010-00636 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. Robert ffi Newbury Son 50$ 4518 Hillside Court Harrisburg Pa 17110 2 Cheryl D blelaick Daughter 50~ 52 Ceater Drive Camp Hill Pa 17011 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRL4TE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER BECKON 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, # If more space is needed, insert addRional sheets of the same size. REV-ista Ex. (a-ae~ ' '' SCHEDULE K pennsylvania ~i ~ OEFARTMENTOFREVENUE LIFE ESTATE, ANNUITY Bureau oflndivldualTaxes PO Box z8o6oa, & TERM CERTAIN Harrisburg PA ~ysze-o6o~ (CHECK BOX 4 ON REV-1500 COVER SHEET) ESTATE OF FILE NUMBER Varaa Q Newbury 2010-00636 This schedule should 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. 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 below the type of instrument that created the future interest and attach a copy of it to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable .........................................$ 2. Actuarial factor per appropriate table ............................................... . Interest table rate - p 3.5% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ....................................$ 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 - ^ 3.5% ^ 6°h ^ 10°k ^ Variable Rate °h 6. Adjustment Factor (See instructions.) ................................................ . ^ 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 ^ Life or ^ Tenn of Years ^ Life or ^ Tenn of Years ^ Life or ^ Tenn of Years 7. Value of annuity - If using 3.5, 6, or 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 that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return. The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. If more space is needed, use additional sheets of the same size. REV ,844 Ex. c3 °`' INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT IN R SIDENTEDECEDENTRN OR INVASION OF TRUST PRINCIPAL FILE NUMBER 2010-00636 I. ESTATE OF IHEWSQRY V81SNA G (Last Name) (First Name) (Middle Initiaq This schedule is appropriate only for estates of decedents dying on or before December 12, 1882. 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: 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 Term of years income or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate .............................. $ 2. Stocks and Bonds ........................ $ 3. Closely Held StocWPartnership .............. $ 4. Mortgages and Notes ...................... $ 5. Cash/Misc. Personal Property ............... $ B. Total from Schedule L-1 .................................................... $ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ......................... $ 2. Unpaid Bequests ......................... $ 3. Value of UninGudable 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. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed 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) REV-1847 Ex+ (&00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Vsz-aa G SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet FlLE NUMBER 2010-00636 This Schedule is appropriate only for estates of decedenb 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. [-7 Will n Trust n 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 8 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exerdses 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 s Ouse 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 Ili 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) .. $ B. 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 sheep of the same size) Rlv-164$ ac (oz-a9) SCHEDULE N Pennsylvania DEPARTMENT DF REVENUE SPOUSAL POVERTY CREDIT Bureau of Indlvtdual Taxes PO Box z8o6o: FOR DATES OF DEATH 01/01/92 TO 12/31/94 Harri M 1 1z8 ESTATE OF FILE NUMBER Varna G Newbury 2010-00636 This schedule must be completed and filed if you checked the spousal poverty credit box on the wver sheet. 1 . Taxable assets total from Line 8 (wver sheet) .............................................. 1 . 2. Insurance proceeds on life of decedent .... . ......................... . .............. . .... 2. 3. Retirement benefits ................................................................ 3. 4. ]olnt assets with spouse . . ............................... . ............................ 4. 5. PA Lottery winnings ................................................................. 5. 6a. Other nontaxable assets: List and 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. ~' "11 ~ ........... 8. Total actual liabilities ...... . ................... . ... . .......... . ... . .................. 8. 9. Net value of estate (Subtract Line 8 from Line 7) ............................................ 9. If Line 9 Gv greater tlran ;200,000 -STOP. The estate Is not ellglble to claim the credit. If not, wntinue to Part II. •~' ~ • • • ~ Inwme: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse ............. la. b. Decedent ........... lb. c. Joint .............. lc. 2c. d. Tax-exempt Income .... Id. 2d. e Other income not listed above ......... le. 2e. f. Total ..............I if. l 12f. l 4. Average joint exemption income calculation 4a. Add joint exemption Income from above: (lf) + (2f) + (3f) 3ci 3f. 4b. Average joint exemptioninwme ........................................................ if llne 4(b) is greater than;40,000 -STOP. The estate Is not eli9ib/e to claim the credit. If not continue to Pai (3) 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ....................... . 1. 2. Multiply by credit percentage (see instructions) ................ . ............................ Z, 3. This Is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the wver 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 S Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet ............. REV-1849. FJ(+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER Versa G Newbury 2010-00636 Do not compleb fhb schedule uMesa the estate la making the election t0 lix assets under Section 9113(A) of the Inherihna tE Fatale Tix Act If the ebdion applbs to more than one trust or sim9ar anangement, a separate form must be filed for each trust. This ebdion applies to the Trust (marital, residual A, B, By-pass, Un~ed Crodit elc.). It 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 whob ar in paA as an asset on Schedub 0, then the trensteror's personal represenbtive may specficaly identify the trrst (all or a fractional portion or percentage) to be included in the ebdion to have such trust or similar propeAy treated as a taxabb transfer in this estate. H bas than the entire value of the trust or similar propeAy is included as a bxebb transfer on Schedub 0, the personal roprosenbthro shall be considered to have made the ebcGon only as to a frodbn of the trust or similar arrangement. The numerator of this frodwn is equal to the amount of the trust or similar amangemeM included as a taxabb asseton Sdredub 0. The denominator b 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 decedents surviving spouse sit a~cu ~rca ~}e~tttmettc I+ VERNA G. NEMBURY+ ofi the Citr of Shamokin, County of Northumberland and Commonwealth of Pemsrlvania+ beind of sound and disposind mind. memory and understandind+ do make+ publish and deciere-thls instrument. as and for. mr Last Mill and-Testament+ hereby revoking and making null and-void.all forma. wills and. testaments or papers in the nature thereof pr me at anY time heretofiore made. FIRST. I direct mr hereinafter named Executer to Rar all mr lust debts and funera-I.expenses. I direct that mr body be decently interred and that mr funeral 6e in accordance with ap-.situation i-ti life. SECOND.. A11 the rest. residue and remainder: of mr estate+ real •. personal and mixed+ whareseaver.situate and ot-whatever the same midht consist. I ~ive+ devise and bequeath unto.mr son. ROBERT M. NEMlAt1RY+ and mr dau8hter+ CHERYL D. MELNTCK+ in enual shares+ share and share alike+ to have and to hold unto themsefves+ their heirs and assisns. THIRD. I name+ constitute and appoint np- son. ROBERT M. NEiIf81JRY+ to 6e the Executor of this+ mr Last Will and Testament+ and excuse him from filind a bond. IN WITNESS NHEREOF+ I+ the said VERWl4 6. NEMBURY+ have to this+ mr Last Will and Testament+ subscribed Inr name and affixed mr seal+ this lbtfi .day of Julr+ A.D.+ 1984. l,Q,i/,z~,`. e a nrr (SEAL Sipned+ sealed+ published and declared br the said VERNA 6.'NY+ as and fur her Last Mii1 and- Testame~t~ in the rresence of us+ who, at her request and in her presence and in-the presence ofi each others hereunto subscrib our`naRie s attestirut wit s. Statement HOMELAND CENTER 1901 N FIFTH STREET HARRISBURG, PA 17102 Telephone: (717) 221-7900 Statement Date: 06/01/2010 ROBERT NEWBURY 4518 HILLSIDE COURT HARRISBURG, PA 17110 Re_:___VERNA _Ci NF.WRTTRV Account Nr: 2561 ---------- Date --------------------- Description -------- Days --------- Rate ----------------------- Charges Payments --------- Balance ---------- --------------------- Quant -------- --------- ----------------------- --------- 05/12/10 CUT/SET/STYLE 1.00 20.00 20.00 20.00 05/12/10 WELCOME PACK COMP. -1.00 5.00 -5.00 15.00 05/19/10 PERMANENT 1.00 25.00 25.00 40.00 05/26/10 SET AND STYLE 1.00 15.00 15.00 55.00 05/30/10 PERSONAL SUPPLIES 1.00 4.33 4.33 59.33 05/30/10 FOOD SUPPLEMENTS 1.00 24.71 24.71 84.09 05/30/10 INCONTINENT PRODUCT 1.00 46.20 46.20 130.24 05/31/10 PREMIUM SEMI-PVT RM 1 279.00 279.00 409.24 ~b~ ~1~~1,b o~~a ~~ JERRE WIRT BLANK FUNERAL HOME Jerre Wirt Blan1~ Owner 395 STATE STREET SUNBURY, PA 17801 (570)286-5655 Funeral expenses of Verna G. Newburg 52 Center Drive Camp Hill, Pa. Basic overhead and staff charge Facilities and staff for funeral at funeral hm. Removal from Harrisburg Hearse Flower/lead car Embalming Casketing Casket Memorial folders Ack. cards , Register book Slippers Costs we paid for you: Tent Shamokin newspaper Harrisburg paper 10 copies of d.c. Flowers Total cost ~ ~ ~' ~,, 4 p.~~,. ~ ~o I ~ ~° 5/31/10 $825.00= 595.00° 225.00 °' 175.00 b 65.00 r 585.00 160.00 2205.00'- 33.00 3.50<` 15.00 12.95. 120.00 90.00 361.17 60.00 548.00 $6078.62 ~ao, 00 G.G~Fr,GZ ~~..~. UHNRB 333 WESTCHFSfER AVE VPf~'lE Pi.AINS, NY 10604 Fa/'Nee+ii~ S!e'riC! RCl~eatd ~wwaMs 3-DI6It 170 23111 0.3820 AT 0-354 I~N~~MMN~~Nr~u1~4~~1Ui , VERNA' MEYBIIRY 130 52 CENTER M CAMP HILL, PA 17013-7L31 CK ~~a3 ~. ~+ D ~,~ l' ~ ~~la ~~ ~2i2j s~-ssoo - - - ~ ~ 2~ B~ ~ D~reBm& 000 OAO r. I.~wpBroHe~dR 0.00 000 TaW Be~efr U230 56230 ^ ~' Fadaal Ta= 0.00 0,00 • 8YbTac Q00 Q00 ~ ouo 0:00 ~ 0.00 000 NBTC~CICAOIOUM 11].50 SiL~ ~»>< B900109SI ~ ~ 1663104 CieekR+rc 03pU10 f -P~eue~re~fa~t~WrOraalslerb~alilSrTHEPUMDd~erd~sllirior~aAecYd6e{oM SmdAlLocsra6a~b~aaDoreabibz Plere6sa~neb si~1W fosrsregierd Ck HEnE Gt Here ---------------------- ------------- --- - -r- 1~ VEtiNANL~V~)RY D[raierlo- B90020JS1 ------ ------- -- - 1~01~ NRFP ---- ---- C~ab ..... ^ AODRiSB CHANGE N6W ADDRBBS: Rieat Addiar C1ty ~ T,p SIONATUAE: DATE 'N(7fE Ifwa~eoeiYSlr'sbyis1516d~estlobwiewi6sa61ebadya~reaineierJtbyourtaaad6ea 0 nEA~rH r~o~cATTOx Payee:dooesed D.reura.r~ ~Ay' .3f _ .ZD/D o~Mr(spY;.k ___•= rte sY =_*** odu2; IN , /~L~r.41a~,~ mow! ~xL`Ctili~R~ Piol N.sa I.aNase RaLeierr4b Payr X518' 1{i~[.5.7~ C6as!!T _ ~ilRR;se~,e~ /~~_ 1711 ~ 7f7- GSl - D3aN .- ~~ _ /1 Cry ~ ~ tiP~ TilNioeeNo -- ~ _ RECEIPT FOR PAYMENT GLENDA FARMER STRASBAUGH Receipt Date: 6/23/2010 Cumberland County - Register Of Wills Receipt Time: 12:12:02 One Courthouse Square Receipt No.: 1061632 Carlisle, PA 17013 NEWBURY VERNA G Estate File No.: 2010-00636 Paid By Remarks: R~ERT M NEWBURY ------------------------ Receipt Distribution Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 135.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 40.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBFF~n~ COUNTY GENERAL FUN INVENTORY 15.00 CUMBERLAND COUNTY GENERAL FUN --- Check# 1319 ------------- $233.50 Total Received......... $253.50 Fac 6~ESrs AFTf~I ~ue-EitlK- c R x a ~ ~ ~ = ~ ~ m `~~` ~ _~ r ~.~ ~ ~ R oz $ = _ . A __ `= b n m Q m~ ~ c z ~ * ~ ° o ~ m --r -~ ~ ~ ~ i. , ~ o :~ - :a - ~ ~ o r~ _ _ ~ ,- -- S7 - _ A v sti F.. T ~ ~ ~ w `~ N O w o ,..-__ 1_ - rn A. a -: ~ - ~, ,:~ -- 6 1~ 1~ c = 5 0 o O ~- ; 2956 State Ronte 61 j~ ~~1 SUNBURY, PENNSYLVANIA 17801 ~®~ UIl$~~~lCll~]tH~ ~~IIffi®II'Il~ ~Elll:'~ OFFICE PHONE: S70/286.2008 ¶ }~~ j~ ~IIIlQII 1~'ll~illlN®ll~flIlffi MEMBER OF THE INTERNATIONAL CEMETERY FUNERAL ASSOCIATION AND PENNSYLVANIA CEMETERY FUNERAL ASSOCIATION 6/7/10 Dear Mr. Newbury, Pet Haven Cemetery Cremation Estates Private Family Estates In order to complete the Name/Date Scroll on the Memorial for Verna Newbury... _, Would you please check the inscription, spel_zag,. an,. ates e_ow. If everything _is correct vlease sign where indicated and forward this with a check for ${zii.UO tv Northumberland Memorial Park. Please take note of the Restoration Program illustrated in the enclosed brochure. If this would be of interest make a check mark below before you return to our office. Since the manufacturing process for the scroll can take up to two months, please return this order as soon as possible, so that we can insure a prompt completion of your memorial. ~ gas a 3 Sa, a ~a 'l I i4 NAME: Verna G. 1914 2010 Sincere thanks, NORTHUMBERLAND MEMORIAL PARK SI Restoration "WHERE THE MEMORY OF BEAUTIFUL LIVES WILL BE KEPT BEAUTIFUL ALWAYS" 16:07:55 14 JUL 2010 AAA CENTRAL PENN Receipt # 07PR-3797-69 SUNDRY RECEIPT Teller LT7 Reference # 1141887 Issued 14 JUL 10 04:07pm Club# Member# ROBERT M NEFIBURY 195-0392871 4518 HILLSIDE CT 717 652-0304 HARRISBURG, PA 17110-3346 Product Amount Domestic NOTARY FEES (NF) 1 ® 2.00 2.00 Payment Due 2.00 C Payment 2.00 DON'T MISS OUT! Join the 1,000's of members"who have saved hundred's of dollars on their Auto & Home Insurance. Call or visit your local AAA Central Penn Office for a free quote. Date: •621/2010 Dauphin County NO. 0228430 Time: 01:17 PM Receipt Page 1 of 1 Received oF. Cheryl Melrich $ 4.00 Four and 001100 Dollars Notary Regiahation Total: Amount 4.00 4.00 G Payment Method: Cash Amount Tendered: 4.00 Stephen E Farina ,Prothonotary I Clerk: LGARCIA Bv: Deputy Clerk OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS COUNTY, PENNSYLVANIA Estate of e Deceased C~fCP~Lr//,~ 1i /'~i///~~~ and /!/s filla~iFS //7P.//1% G/ ~-' ~,. ,^ (each) being duly qualified according to law, depose(s) and say(s) that she / he J they was /were well- acquainted with and am/are familiar with the handwriting and signature of the decedent, and that the signature of ~ `/~i.Gl ~ _ .UB~.~''~ to the fore oing instrument purporting to be the Last Will and Testament/Codicil of ~,F,~,~Q,~1 ~ [z. is in his/her own proper handwriting. Executed in Register's OJ~ce ~_ ~~ ~~ to ) Sworn to or af~inned and subscribed before me this o~/ ~' day of o~0/D_ ~~ Deputy for ~/j~T 10/~j~ FormRW-0( rev.f0.1i06