HomeMy WebLinkAbout10-26-101505610101
REV- ~ 500 Ex (oi-io) ~! OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
OF.PgP1MENT CF PF.YFNUE County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
P(7 BOX 28oGo1 j
Harrisburg, PA i~i28-0601 RESIDENT DECEDENT ~ / ,~ Q Q
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
195-07-8966 07/24/2010
Decedent's Last Name Suffix Decedent's First Name MI
HAVERSTOCK MARTIN L
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security NumSer
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 4. Limited Estate O 4a. Future Interest Compromise (date of
death after 12-12-82)
e~ 6. Decedent Died Testate , O 7. Decedent Maintained a Living Trust
(Attach Copy of VJiI{) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
O 3. Remainder Return (date of death
prior to 12-13-82)
O 5. Federal Estate Tax Return Required
~_ 8. Total Number of Safe Deposit Boxes
O 11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPJNt~ENT - THiS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Numk~er
BEVERLY ESLINGER (717) 732-1476
First line of address
3815 MOUNTAIN VIEW RD.
Secur-rd line of address
Lity or Pcst Office State ZiP Code
MECHANICSBURG PA 17050-2131
Correspondent's a-mail address:
r
_. r-T .P
_ ~ ~-:a
Undar penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my M;nowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
cl.^Nln~-1 inr ~r nrr~n.-..1 r~r~~.~.. ~~.~... .- ~~..-. ~.. .. ... __-..-..
1505i~~,[]~r01
Side 1
150561011
~`v`
l!,~~L / S LL;. Y~ ~ 7c~ ~~~~
PLEASE USE ORIGINAL FORM ONLY
J
1,505610105
REV-1500 EX
Decedent's Social Security Number
Decedent's Name:. MARTIN L. HAVERSTOCK 195-07-$966
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1.
2. Stocks and Bonds (Schedule B) ....................................... 2.
3. Closely Held Corporation, Partnership or Soie-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D} ........................... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 187,580.42
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.
$. Total Gross Assets (total Lines 1 through 7) ............................. 8. 1$7,58.42
9. Funeral Expenses and Administrative Costs (Schedule H) ........ ........... 9. 16,808.51
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ... ........... 10. 247.07
11. Total Deductions (total Lines 9 and 10) ...................... ........... 11. 17,055.58
12. NEt Value of Estate (Line 8 minus Line 11) ................... ........... 12. 170,524.84
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. 170,524.$4
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line ~14 taxable
at the spousal iax rate, or
transfers under Se 9116 _ __ __
(a)(1
2)X
0"f~
.
.
! /~/~ r~T. ~T
15. //--
/(i~~3~ ~Q
~
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. ~(v ~~ ~• -- --~
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610105 J
REV-1500 EX Page 3 File Number
necedent's Complete Address:
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
3. Interest
4. I` Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Lire 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
Total Credits (A + B) (2)
(3)
(4)
(5)
Make check payable fio: REGISTER 4F WILLS, AGENT.
25,578.72
25,578.72
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 .......................................................................................................................... ^ 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 0
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 trust for" or payable-upon-death bank account 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 beneficiary designation? ........................................................................................................................ ^ 0
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 Juiy 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
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
f ling 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 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 [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 4.5 pE:rcent, 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 percent [72 P.S. §9116(a)(1.3j]. 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-] S02 EX+ (?.1-p8)
~~ Pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
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.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Ir more space is needed, insert additional sheets of the same size.
REV-15Q3 EX+ (6-98}
scNEau~E s
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
!~~ nwie space is neeaea, inseR aoaiuonal sheets of the same size)
REV-1504 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF FILE NUMBER
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporationlpartnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
tir more space is needed, insert additional sheets of the same size)
REV-1507 EX+ (6-98j
SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX RETURN RECElVABlE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
tir mere space is needed, insert atltlitional sheets of the same size)
REV-1508 EX+ (6-98j
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
MARTIN L. HAVERSTOCK 195-07-896
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
iir more space is needed, insert additional sheets of the same size)
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE:
..~._.__._~ A N D F I L E N 0. 21
BUREAU OF INDIVIDUAL TAXES
Po Box z8o6ol TAXPAYER RESPONSE: ACN 10153587
HARRISBURG PA 17128-0601
DATE 09-24-2010
REV-1543 EX AFP (OB-06)
ELEANOR E HAVERSTOCK
3185 MOUNTAIN VIEW RD
MECHANICSBURG PA 17050-2131
EST. OF MARTIN L HAVERSTOCK.
SSN 195-07-8966
DATE OF DEATH 07-24-2010
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
® CHECKING
TRUST
CERTIF.
CITIZENS BK OF PA provided the Department with the information below, which has been used ire calculating the
potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account.
If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form
and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of
Pennsylvania. Please call C717) 787-8327 with questions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 6100743691 Date 08-04-1982 To ensure proper credit to the account, two
Established copies of this notice must accompany
payment to the Register of Wills. Make check
Account Balance $ 2, 978.52 payable to "Register of Wills, Agent".
Percent Taxable X 16.667
NOTE: If tax payments are made within three
Amount Subject to Tax $ 496.43 months of the decedent's date of death,
Tax Rate ~( 00 deduct a 5 percent discount on the tax due.
Anv Inheritance Tax due will become delinquent
Potential Tax Due $ . 00 nine months after the date of death.
PART TAXPAYER RESPONSE
0 ,~ : ~ ~.
A. ~ The above information and tax due is correct.
Resit payment to the Register of Wills with two co pies of this notice to obtain
a discount or avoid interest, or check box "A" and return this notice to the ReS~ister of
C H E C K Wills and an official assessment will be issued by the PA Department of Revenue.
ONE
B L 0 C K B. ~ The above asset has been or will be reported and tax p aid with the Pennsylvania Inh(ritance Tax return
0 N L Y to be filed by the estate representative.
C. ~ The above informs ion is incorrect and/or debts and deductions were paid.
Complete PA RT 2~ and/or PART 3~ below.
PART If indicating a different tax rate, please state ~ ~
~.
relationship to decedent:
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS -
LINE 1. Date Established 1 `°
2. Account Balance 2 $ "\
3. Percent Taxable 3 X
.. r .,,
4. Amount Subject to Tax 4 $ ~ ~~~ ~~ ~"" ~ ~ "° '"~~
5. Debts and Deductions 5 '~
~ ~ ~~~'
6 . Amount Taxable 6
7. Tax Rate 7 X
8. Tax Due 8 $
PART DEBTS AND DEDUCTIONS CLAIMED
0
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
complete to the best of my knowledge and belief. u n M G r l
WORK C ~
TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
TOTAL CEnter on Line 5 of Tax Computation) 8
PENNSYLVANIA INHERITANCE TAX
INFORMATION NOTICE
BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21
Po Box 28o6oI TAXPAYER RESPONSE ACN 10153591
NAR~~,$iWR6"'PA 1712 8- 0 6 01 DATE 0 9- 2 4- 2 010
REV-1543 EX AFP (OB-08)
ELEANOR A HAVERSTOCK
3815 MOUNTAIN VIEW RD
MECHANICSBURG PA 17050-2131
EST. OF MARTIN L HAVERSTO~CK
SSN 195-07-8966
DATE OF DEATH 07-24-2010
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
TYPE OF ACCOUNT
SAVINGS
® CHECKING
TRUST
CERTIF.
CITIZENS BK OF P A provided the Department with the information below, which has been used in calculating the
potential tax due. Records indicate that at the death of th6 above-named decedent, you were a point owner/beneficiary of this account.
If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form
and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of
Pennsylvania. Please call C717) 787-8327 with questions.
COMPLETE PART 1 BELOW *!..$EE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
complete to the best of my knowledge and belief. H O M E C ~
WORK t ~
TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
IUTAL ctnter on Line 5 of Tax Computation) $
PENNSYLVANIA INHIERITANGE TAX
INFORMATION NOTICE
BUREAU v~ ;`!9IVIDUAL TAXES AND F I LE NO . 21
Po Box 2ao6o1 TAXPAYER RESPONSE ACN 10153589
HARRISBURG PA 17128-0601
DATE 09-24-2010
REV-1543 EX AFP (08-08)
ELEANOR L HAVERSTOCK
3815 MOUNTAIN VIEW RD
MECHANICSBURG PA 17050-2131
EST. OF MARTIN L HAVERSTOCK
SSN 195-07-8966
DATE OF DEATH 07-24-2010
COUNTY CUMBERLAND
REMIT PAYMENT AND FORMS T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
'T'YPE OF ACCOUNT
SAVINGS
CHECKING
TRUST
CERTIF.
CITIZENS BK OF PA provided the Department with the information below, which has been used in calculating the
potential tax due. Records indicate that at the death of the above named decedent, you were a point owner/beneficiary of this account.
If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form
and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of
Pennsylvania. Please call C717) 787-8327 with questions.
COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 6244729973 Date 09-16-2004 To ensure proper credit to tF)e account, two
Established copies of this notice must accompany
payment to the Register of Wills. Make check
Account Balance 3 $ 0 . 1 0
3 $ 114, payable to "Register of Wills, Agent".
Percent Taxable X 16.667
NOTE: If tax payments are made within three
Amount Subject to Tax $ 19, 063.73 months of the decedent's date of death,
Tax Rate ~( ~ ~ 0 deduct a 5 percent discount on the tax due.
Anv Inheritance Tax due will become delinquent
Potential Tax Due $ . DO nine months after the date of death.
PART TAXPAYER RESPONSE
a
A. ~ The above information and tax due is correct.
Remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or check box "A" and return this notice to the Register of
C H E C K Wills and an official assessment will be issued by the PA Department of Revenue.
ONE
B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
0 N L Y to be filed by the estate representative.
C. ~ The above informs ion is incorrect and/or debts and deductions were paid.
Complete PA RT 2~ and/or PART 3~ below.
PART If indicating a different tax rate, please state
relationship to decedent:
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. Date Established 1
2. Account Balance 2 $ "`'
3. Percent Taxable 3 X
4. Amount Subject to Tax 4 $ °~ ~ ~ ~ ~ ~~ ~~~ "~~
5. Debts and Deductions 5 - ~~ °" ~~ ~ ""' ""
6. Amount Taxable 6 $ '`
~
7. Tax Rate 7 ..
X ~.
8. Tax Due 8
~~ _.;
PART DEBTS AND DEDUCTIONS CLAIMED
a
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
complete to the best of my knowledge and belief. u n M G r 1
WORK C ~
TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
TOTAL CEnter on Line 5 of Tax Computation) S
REV-iso9 EX+ (oi-io)
~ pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
JOINTLY OWNED PROPERTY:
ITEM
NUMBER LETTER
FGR JOINT
TENANT GATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on Line 6, Recapitulation) I $ 0.00
If more space is needed, use additional sheets of paper of the same size.
If an asset became jointly owned within one year of the decedent's date of death, it must be reuorted on Schedule G.
REV-15T1. EX+ (iQ-Q9)
i pennsyLvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
MARTIN L. HAVERSTOCK
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' MUSSELMAN FUNERAL HOME 6,983.52
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City .._._ ___ .......... ..._.
Year(s) Commission Paid:
2
3
4.
5.
6.
7.
State ________ ZIP
Attorney Fees:
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation,)
Claimant
Street Address
City ..._ _.... _.-- _._----....----_._....___._._.--- ...............- State _._. _.
Relationship of Claimant to Decedent
ZIP
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
EXECUTIVE FEES TO BEVERLY ESLINGER
850.00
8, 974.99
TOTAL (Also enter on line 9, Recapitulation) I $ 16,808.51
If more space is needed, use additional sheets of paper of the same size.
`;
~~.
y9y'1 ~.N N ~ ~ ~ ~ yi.
~ ~ y ~ c o ~ y. c'~ v
c -v w `° ~ ~
~ ~
-
~ ~
. ° ~ j-
~
~~ D rn ti ~
~
~
Q
~ ~ o '~ ~ ? ~ °°
-w GO ~ ~
~ W
C
T
= c
p
V'I
C
D
f~D
O ~ T
~
n ~!
O
~~~ ~ ~
~ ~ ~
~• ~
n ~ ~ ~ ~. ~
~
~ E,r:.,:.:
~ ~
r ~ ~ ~ A.~
~j.''
~
~
®
C7 ~ ~ ~ „ ~
j{~t~, _ .~ Ki.a`
~ d H (7 3 O n '~! C1
~ ' ~
N
~rtE x
~ ~ '
•
rt ~ F-' fD U1 G N• fD .
~ ~
~ w
N
rt
rt ._- i
u
D
t L7
~"`ga ~
~ G b
~ ~ ~ n
C~ G
~ to t~J
O ,~
. ~ N 9C ~
Q, 0
O 4
a ~ ~ ~
m K n _• . ~
a C,n w
N ~ ~ rn
rt ~ ~ ~~ .~
h ~• o c
c ~~m
~• cn~n
~ ~r~~
cD
i
U ~ ~. ~ a
n
~ ~
b ~,• cn N.
~ro~
~ ~• ~
i
~,.;; ~ z p. cn
~
c'
;;, ~ C o ..
t,:' ~
;, ~ ~
_'1 ~
. ~'
. ~ ~ O J hj x
o ,,~
a O W .
C
;~: ~ ~ to
o ~ .
• ~ m n ~
`~ ~
~ a
..
w rt
;~
~
~
o
o ~. ~
? rt
. ~
~~~~~ ~ ~
. N ~
.~ ~ N -
W
O '
• CT1 O C1 01 01 U'~ l0
. OOU'1OOD O O
• OOU'tOO O O
.
. .
• O O N 0 0 O O
y
,
;
G
_,
,
,• ~
;; `,C
F
~~ ~
~
~
~
~
~
~
N
,,,,,
~~ 01
l~ I
-' ~1
O
01 ~ ~
;'' t7~ O OD FP .A
,ti' W O W O O N
U'7 O V1 ~ O O
a
:
~ N O N. N' O .
~~ ~
~\
y,
,~, ;
;
<~`
~, ,.
~„
..
`
,i ~` ~ ~ ~
~
J^
o ~ r ~~~ 1 > .!. rr ,r .! e'f :"iir ~F<.J,.~ lfi~rf.IiJ'~~~~4
. e'c'~e .[...tt}i _ ... .. .. .: n .. - A J)a r. r>~, .~' .
e`h • ~.c~zs ~{,~
.1.. <: r'k5
~
~y'I~..:4,~i`.-:;:.. :. <~1~~ ti
r\:. zt{t ~ :
.,.titi ~. ., ,.
: .. ... F.. ~r e, rrta t
....,.
.,. .. . . -
REV-~5t2 EX+ (12-CS)
~ pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MARTIN L. HAVERSTOCK
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses,
tr more space is needed, insert additional sheets of the same size.
~~ ~
,~ D
`° i
~I n~i
~ ~ J
I N
f~D ~
n ~
N N
~ ~
~ v
-+
I~ oo OD
O ~
O
N
O ~
~ ~
~ ~
I
~h
0 0 0 0 0 0 0 0 0 0 0 0 0 ~.
~ ~ ~ ~ ~ ~ rn rn rn rn m rn rn
h-' N N N O O N N N N N N N
dl ~P W W l0 N l0 ,~ rA N N N lD (~
I-' N N N N N N N N N N ~-' N ~....~
0 0 0 0 0 0 0 0 0 0 o a o C
H
oD ~~ooaooo~~~~~~~h~ ~
N rn rn N N N rn ~ rn rn rn h~ ~
N rn rn N N ~-' coo o rn m m h~ ,~ ~3
w rn rn w w w ~fl ~ h~ to o h~
~ ~ ~ ~ ~ ~ o N ao ~ ~ o ~ ~~ ro
O O O O O O CJ h-' Ol N N N~ x
l0 Ol W l0 lD l0 Cf1 ~A J 00 W lD ~ ,~JJ
J N W ~] J ~.] Ut F-' N N N N
N O O O O O N
O O O L~ ~ K
~ ~
H ~
o a~~ o 0 0~ ~ o o~ c
~ ~ ~ ~ ~ ~ n ~ n ~ C ;~ x
c~n~ rorov~iv3it~nOGxtn~i~t~i~ z
r~-r ~ H h-hi cn O H Z ro n
H z z~~ Z t~' o ro~ :h ~ ~d N
4~ ~ ~ ~ G1 G1 4~ r7 Q ~ t%i o H
l3TJ '~~ G7 4~ t'7 CrJ trJ O ~ ro i H Z
t~ x ~ ~ ~ ~~ r ro y to 7 . ~
FZ-] O y H H c~ C~~ G~1 x
~ ',~ h-1 C!1 O
ro
0 0 0 0 0 0 0 0 0 0 0 0 ~' H
N N N h-' N !-' N N h-' N N N ® 3
x- ~ ~ ~+ ® ~
CrJ
i
C
~ ~
~ N t~
~ ~~ N Fa rn ti
W Q1 ~.] N W W W CIJ W W ~P N Q`, ~ ~ y
lT1 J O 00 Ul C11 Ul N l0 l0 01 W N x
O W 01 O O O O ~!~ 00 J l0 F~' d`. O
i i i i ti
r
I ~
I ~
rd
(Jl ~7
Qp H
z
b
. G
0 0 0 0 0 0 0 0 0 0 o a a rn
O O O O O O O O O O O O O In
~P N
EP ~~ N rA 61 N
W 01 ~] N W W W W W W ~A N O1
In J O OJ lf1 lJ7 Ul N lD l0 Ol W N
O W Ql O O O O ~~ O J l0 N Ol
REV-1513 EX+ (02-10)
~ ~ Pennsylvania SCHEDULE ~
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
MARTIN L. HAVERSTOCK
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. MARGARET A. GURRELL 400 DELAWARE AVE. MARION OH.43302 DAUGHTER 42530.20
2. JAMES M. HAVERSTOCK 514A MOUNTAIN RD. DILLSBURG PA 17019 SON 42530.20
3. JOHN E. HAVERSTOCK 6823 OLD SOLOMONS ISLAND RD. SON 42530.20
FRIENDSHIP MD. 20758
4. BEVERLY L. ESLINGER 3815 MOUNTAIN VIEW RD. DAUGHTER 42530.20
MECHANICSBURG PA 17050
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 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. I $
If more space is needed, use additional sheets of paper of the same size.