HomeMy WebLinkAbout11-29-101505610101
REV-1500 Ex ~°1.1°' '
enns lvania OFFICIAL USE ONLY
PA Department of Revenue p Y County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO Box 28o6oi INHERITANCE TAX RETURN
Harrisburg, PA i'Ji28-o6oi RESIDENT DECEDENT ~.. ~ ~ 7 O O D ~`
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
-~~ ~~, 3z~3 ~ I a~`a,oo~ 09o q~ qzZ
Decedent's Last Name Suffix Decedent's First Name MI
o' H N~ o ;~Il f f ~' ~ E` i/ S
(If Applicable) Enter Surviving Spouse's Information Below
Sp~ou)se'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
O 1. Original Return ~ 2. Supplemental Return O 3. Remainder Return (date of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
~
6. Decedent Died Testate
O death after 12-12-82)
7. Decedent Maintained a Living Trust
~
8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
CH~~LES ~' 5~~~"~~S ~ ~ ~ 7 ~ ~ X66 aa.o 5
First line of address
6 C ~ o usER.
Second line of address
O
City or Post Office State ZIP Code
REGISTER ~I~LS USE ~Y
1~1 -`~-
~
r '~ syf~ '~ t
,
~ ~1
- -~ `
..,
-; ~ _ =~
,
-,-, ==i _
,r
DATE FILED ~ '
Correspondent's a-mail address: `+ ~ S ~ ~ olds 3 Q Corn~tst. h~
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, c r ct and com lete. Decla ation of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG F PE S N ESPO SIB E FOR FILING RE RN DATE
ADD ES I~~IV,prT. /Oh~N "' ~ /~ ~ e Rd
` /~~ /7os'S
SIGN T RE OF EPARE~ OT R AN R SEAL T VE ATE
~ f (l~Zfj lam,
ADDRESS C,~~/u.CS ~ Ic~.W / ClOustr
mcc~a,,, ;c s u,~ . PA~ ~~os~'
PLEASE USE ORIGINAL FORM O1~LY
~^~
~.
. t:.7
11
1
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Side 1
1505610101 1505610101 J
_..~
J
1505610105
REV-1500 EX
Deced-/ent's Social Security Number
Decedent's Name: J OF{,NSOIy~ H~L~ s ~ I ~ ~~ 3 Z Z ~,
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1. ~ ~ n ';
2. Stocks and Bonds (Schedule B) ....................................... 2. ~ 3 7 ~ 9 s 9
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. * O '~
4. Mortgages and Notes Receivable (Schedule D) ........................... 4. ~' ~ D
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. « ~ ~
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. • t~` ~
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
7
~ O
(Schedule G) p Separate Billing Requested........ . ~«
8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ 3 7 (0 1 •~ q
9. Funeral Expenses and Administrative Costs (S~hedule H) ................... 9. ~ ~ 0 • Q'Q
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. . ~ O
11. Total Deductions (total Lines 9 and 10) ................................. 11. ~ Q Q s O O '~
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. u ,~ 9 '"1 ~ . ~ J
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which `'
an election to tax has not been made (Schedule J) ........................ 13. - • ~ fl
14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~"~ ~. Q ~ '~ 9
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 ~ `
16. Amount of Line 14 taxable ~
at lineal rate X .0 ~S ~ ~, 9.1 ~ • q ~
16. Q
~ l
~ ~ S ." ~ ~ ~ `
17. Amount of Line 14 taxable
at sibling rate X .12 rs ~ ~ - ~~ `
17. ~~
~ ~ D .
18. Amount of Line 14 taxable y
~ Q
* ~` ~
at coAateral rate X .15 ~
r" . 18. ~ ~ -
~~
19.
TAX DUE .........................................................
19.
~ 7 ,~
, .
`,,~~~~ ~
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
O
Side 2
1505610105 1505610105
_ _ _ __ _
I~' REV-1500 .EX Page ? File Number a,/ ~ Q 7`~ 38
Decedent's Complete Address:
DECEDENT'S NAME
- ----- __
STREET ADDRESS
`Jo ~,o/a•- /~r2,
-- -/ f,,~ _ _ /~-- - /
CITY /'/~L(/ (~LC/Al~~'le~~t~
- _
STATE ~~ ZIP
~ ~a 70
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments >D
A. Prior Payments _ --
B. Discount ~
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
c1) 1.4as.~o
Total Credits (A + B) (2)
(3) 35~. 9S
(4) ~
(5) ~~ a a8'O , o ~
---r
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.......................................................................................... ^
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 trust for" or payable-upon-death bank account or security at his or her death? .............. ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ....... ................................................................................................................. ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994, and before 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 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 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 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
REV-1503 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. ~ : S . S ~ 1l!/-lGS I'~oN~s - ~7zl~T ~' ~ ~ IZecuP 2. ~
a• U. 5. s~viut.~s '~~ _ 5~4 ,~ Gieor~P 1L, a7 ~
~~~,~ s - P~2 ~ 7~~n~Zc~t~ ~it~u~-T~o~ ~ ~ry~-~r~""~ I1, 0 3 7. ~~
3. u. s. s,4-r~~~s ~o~vs .- s~~ES E; Gnu P ~ ~3
~. Nos -- ~~R ~ ~~~1tZ~ ,l~if~itit-T<o~rl ~~'T ~~ ~6oi 3S
/N Fo No ~': /11 FL v~N ~HN~DA~ PQa~ FC~7~~ CIS W ~'~
J~~Z ~ ~~,INSo~ , AEC~~IT ~f~EZ~I ~N~F~o~
7,~F ~~cs o~ 7~tls (-~~~xo/!/l~J~t~ !N elD~r r
TOTAL (Also enter on line 2, Recapitulation) ~ 'T 3~ 7~ ~, g!
(If more space is needed, insert additional sheets of the same size)
Calculated Value of Your Paper Savings Bond(s)
Calculated Value of Your Paper Savings Bond(s)
Calculator Results for Redemption Date 11/2006
8/13/10 11:00 AD
~"a rie ~ot~ tai oa nr~l ~ ~~teret
$1,350.00 $9,771.60 $8,421.60 $348.00
Bonds: 1-24 of 24
~.ria ~~~x~ ~e~
' I:e Enai
~ s
~~~~
1~lrst ~
~r°~st
~
~~
~
K208703553E
..... _ ............ ~ M .. ' E
; ..... , .
$75 ~
;..04/1977
:..04/2007
04/2007
$56.25
;
$349.74 " o
4.00 /o
$405.99
K208703391E
E
$75
; 04/1977
;.04/2007 .
04/2"007 , ,_
.
$56
.25 _,., _
349 74
~4 00% .. ....:....
$405.99 ......:....
K208703322E
, E
, _
_. $75
,04/1977
._.04/.200.7
; 04/2007 ,
.
F
$56
25
.
: ~~~
$349.74. o
4.00 /o
..
$405.99
..
K208703125E
. E
$75
" 03/1977
.,03/2007 „
:03/2007 ~ .
_
.
.
$56.25 = .....
__.
$
349.74 ;
4.00%
$405.99
K208703060E '
..... . . . ....... ~ E
~
$75
, 03/1977 ._03/2007
: _03/2"007 ;
...
$56.25 t
.. .
.. _ ..
$349.74. o .
4.00 /o :
$405.99 _ _
K208271897E ~
. _ _. _ :.: ~ ....., ., ... E
.
$75
:03/1977
._03/2007
03/2007:
$56
.
25 ~ .....
$349.74 o
4 00 /o
...
$405.99
.
K208271827E '
... ...... .. E
_ , $75
03/1977
03/2007 w ~
:
03/2007 :
_
_
$56
.25 _, ".
$
349.74: ~ ~o
4.00 /o
$405.99
K208271740E
... E
$75
" 02/1977
02/2007 .
_ "
02/2007 ° .,
$56.25 ~ ,
"
..
$349.74
4.00% .. ..... _ , .
$405.99 .
K208271534E E
$75
02/1977
..02/2007
. 02/2007:
_.
56.
25
_.
$349.74
.00%
405.99:
K208271374E E
.
$75
.02/1977 ;
__02/2007 ~
"
02/2
007: ,
$56.25 _
$349.74 o
4 00 /o
$405.99
K208271318E
...:. _ ~ ...., :
E
$75
....02/1977 _
....02/2007 _
.
:..02/2007: .
_
....$56,.25:
_ .
..
$349 74
o
'~ 00 /o
..., : .
.:..
$405.9
9 ; . _
K208271251E'
. _
y E
$75
01/1977 ;.01/2007
:.01/2007
~ ....$56.,25 , .
_
349
74
$
. .
4.00% .
$405.99 .
K208271043E E
75
0.1/_1977 :
.,01/2007
1/2007 "
56..25 _ ,
~ .
...
$
349
.
74
_..
4.00%
.
$405.99
...:...:.
K207049967E'
_ _. _„ E
$7,5
:01/1977
01/2007
_ ,01/2.007:
$56.25 .
,
.
$349.74
4.00%
$405.99
K207049806E
. E
. $7.5 ;.01/,1977 01/2007 .01/2.007: $56.
25: $349.74 4 00% $405.99
K207049734E
E
$75
0,1/1977 :
.01/2007
.01/2.007 ; .
$56.25:
$
349.
74
4.00% _
$405.99
.
K207049527E .'
..... _ ~ . _ .... E , " $75 .12/1976: ,.12/2006 12/2"006 ;
....$56..25 ; „ _
_
.
~
$349.74 .
... ~o
`I 00 /o ,
__.. ~ _
$405.99 .. .
K207049456E
,... . , E
_ $75
12/1976 :
12/2006
12/2006 .'
$56,.
25
$
349
.7
4 _,
4 00% .. w . _ . .
$405.99
K207049283E E $75 " 12/1976 12/2006 _
° 12/2006 - _
_$56
.25 .
.
,
.
$349.
74 ; 4.00% ' $405.99
K207049208E' E
$75
...12/.1976
12/2006
12/2006:
_ ~ _
$56
.
25
. ,
$
349.
74
4 00%
$40
5.99
K207049154E E
.
_ $75
.11/1976.
„,.1.1/2006 _„ , .
.
„ $56.25: .
_
$356.70 "
.
$412.95
MA
K206251959E
E "
$75 ;
11/1976
,
` 1.1%2006 -^ , ,
" $56.
25 ~.. .~ .
$356
70 . _ . .. ..... _.. M _. ~ .~ ..
$41
2.95 ' ~ .. _ .
MA
K206251774E '
,. E _ $75 ' _.,11/1976 ~
_ .
_ . ..._11/2006 ,
,
$56.25 :" , "
"
$356.70 ,
$412.9
5 " MA
K206251698E.
. _ E
$75
11/1976 '
11/2006 ~ .. ..
...$56..,25 ;
70
,. _ $356. .
$412.95:
MA
Totals for 24 Bonds $1
,350.00 ,
$8,421.60 ` __
$9,771.60 ;
~e
NI Not Issued
_, _ _ _ _
NE Not eligible for payment
P5 Includes 3 month interest penalty
MA'Matured and not earnin interest
http:/ /wvow.treasurydirect.gov/BC/SBCPrice
Page 1 of
Calculated Value of Your Paper Sav"rgs Bond(s)
//L`J/ lU x:43 YM
Calculated V~~lue of Your Paper Savings Bond(s)
Calculator Results for Redemption Date 11/2006
$1,518.75 $11,037.96 $9,519.21 $357.75
Bonds: 1-27 of 27
K206251626E . E $75 ~ 10/1976 10/2006 $56.25 $352.71 $408.96 MA
K206251424E E $75 10/1976 10/2006 $56.,25 $352.71 $408.96 MA
K206251359E ~ E $75 10/1976 10/2006 $56.25 $352.71 $408.96 MA
K206251185E ' E $75 ' 10/1976 10/2006 $56.25 $352.71 $408.96 MA
K206251115E ' E $75 10/1976 10/2006 $56.25 $352.71 $408.96 : MA
K203915920E . E $75 09/1976 09/2006 $56.25 $352.71 $408.96 ' MA
K203915849E ` E $75 ., ..09/1976,,, _ 09/2006 $56.25 $352.71 $408.96 MA
K203915665E E $75 09/1976. 09/2006 $56
.25 $352.71 $408.96 MA
K203915602E E $7.5. 09/1976 09/2006 ,
$56.25 $352.71 $408.96 MA
K203915386E
E
$75
08/1976
08/2006
$56.25
$352.71 .. .
$408.96
MA
K203915320E' E
$75
08/1976
08/2006
$56.25
$352.71
$408.96
MA
K203915253E ; E
. $75 08/1976 08/2006 $56.25 $352.71 $408.96 ` MA
K203915100E E
$75:
08/1976
08/2006
$56.25
$352.71 ...
$40
8.96
; MA
K203915013E E 75 '
$ 07 1976
/ 07/2006 $56.25 $352.71 ,
$408.96 . MA
K205545810E E $75 07/1976 07/2006 $56.25 $352.71 $408.96 MA
K205545740E
.. E
$75
07/1976
07/2006
$56.25.
$352.71 .. _ _ .. .
$40
8.96 ,
; MA
K205545581E' E $75. 07/1976 _07/2006 $56.25' $352.71 _
.
$40
8.96
: MA
K205545520E: E $75 07/1976 07/2006 $56.25- .
$352.71 .
$408.96
; MA
K205545348E E 75 ;
~ 06 1976
/ _ 06 2006:
/ $56.25 $352.77 $409.02 . MA
K205545293E
E
$75
06/1976 `
06/2006:
$56.25
$352.77 . _ ._
$409.02
' MA
K205545166E E $75 06/1976 06/2006 $56.25 $352.77 $409.02 MA
K205545101E' E $75 06/1976 06/2006 $56.25 $352.77
......$409.02:
MA
K205545038E E $75 05/1976 05/2006 $56.25 $351.87
$408.12
MA
K203932874E E $75 05/1976 05/2006 $56.2.5
$351.87
$408.12
MA
K203932818E E
$75
05/1976
05/2006
$56.25
$351.87 . _.._ ..._
$408.12
MA
K203932685E E
,„
$75:
05/1976
05/2006
_ $56.25
$351.87
$408.12
MA
K203932612E : E
$75
05/1976
05/2006
$56.25
$351.87 _ . ~.,....~ ._ .
$408.12
MA
Totals for 27 Bonds_
$1,518.75
$9,519.21 ..
$i1,~C137.96
~& g~~ :,° r ~..,
NI -Not Issued
NE Not eligible for payment
P5 Includes 3 month interest penalty
__ _ ...
MA Matured and not earnin interest
http: / /www.treasuryd irect.gov/ BC/SBCPrice
Page 1 of
__-- -
Calculated Value of Your Paper Sav'nr~s Bonds}
Calculated Value of Your Paper Savings Bond(s)
Calculator Results for Redemption Date 11/2006
$3,543.75 $22,960.35 $19,416.60 $786.30
Bonds: 1-63 of 63
~ K212977288E
E
$75
07/1978
01/2007
07/2008
$56.25
$240.21
4.00% ,.,
$296.46
', K212977103E E $75 06/1978 12/2006 06/2008 $56.25 $240.15 4.00%~ $296.40
'' K212977042E E $75 06/1978 12/2006 06/2008 $56.25 $240.15 4.00°/~ $296.40
K212483868E E $75 06/ 1978 12/2006 06/2008 $56.25 $240.15 4.00% $296.40
'~, K212483808E E $75 .06/1978 12/2006 06/2008 $56.25 $240.15 4.00°/~ $296.40
' K212483754E E $75 05/1978 05/2007 05/2008 $56.25 $245.31 4.00% $301.56
K212483557E E $75 05/ 1978 05/2007 05/2008 $56.25 $245.31 4.00°/~ $301.56
K212483486E E $75 05/1978 05/2007 05/2008 $56.25 $245.31 4.00%~ $301.56
K212483322E E $75 05/1978 05/2007 05/2008 $56.25 $245.31 4.C)0°/a $301.56
K212483272E E $75 04/1978 04/2007 04/2008 $56.25 $250.56 3.92% $306.81
K212483062E E $75 04/1978 04/2007 04/2008 $56.25 $250.56 3.92% $306.81
K212389999E E $75 04/1978 04/2007 04/2008 $56.25 $250.56 3.92% $306.81
K212389840E E $75 04/1978 04/2007 04/2008 $56.25 $250.56 3.92% $306.81
K212389771E E $75 04/1978 04/2007 04/2008 $56.25 $250.56 3.92% $306.81
K212389575E E $75 03/1978 03/2007 03/2008 $56.25 $250.56 3.92% $306.81
K212389506E E $75 03/1978 03/2007 03/2008 $56.25 $250.56 3.92% $306.81
K212389346E E $75 03/1978 03/2007 03/2008 $56.25 $250.56 3.92% $306.81
K212389280E E $75 03/1978 03/2007 03/2008 $56.25 $250.56 3.92% $306.81
K212389071E E $75 02/1978 02/2007 02/2008 $56.25 $306.87 4.C10% $363.12
K212318999E E $75 02/1978 02/2007 02/2008 $56.25 $306.87 4.00% $363.12
K212318838E E $75 02/1978 02/2007 02/2008 $56.25 $306.87 4.C10% $363.12
K212318759E E $75 02/1978 02/2007 02/2008 $56.25 $306.87 4.00% $363.12
K212318692E E $75 01/1978 01/2007 01/2008 $56.25 $306.87 4.C10% $363.12
K212318492E E $75 01/1978 01/2007 01/2008 $56.25 $306.87 4.00% $363.12
K212318425E E $75 01/1978 01/2007 01/2008 $56.25 $306.87 4.00% $363.12
K212318240E E $75 01/1978 01/2007 01/2008 $56.25 $306.87 4.00°/a $363.12
K212318170E E $75 12/1977 12/2006 12/2007 $56.25 $306.87 4.00% $363.12
K211706965E E $75 12/1977 12/2006 12/2007 $56.25 $306.87 4.00% $363.12
K211706902E E $75 12/1977 12/2006 12/2007 $56.25 $306.87 4.00% $363.12
K211706726E E $75 12/1977 12/2006 12/2007 $56.25 $306.87 4.00°/a $363.12
K211706657E E $75 12/1977 12/2006 12/2007 $56.25 $306.87 4.00% $363.12
K211706447E E $75 11/1977 05/2007 11/2007 $56.25 $313.11 4.00% $369.36
K211706381E E $75 11/1977 05/2007 11/2007 $56.25 $313.11 4.00°/a~ $369.36
K211706304E E $75 11/1977 05/2007 11/2007 $56.25 $313.11 4.00%~ $369.36
K211706127E E $75 11/1977 05/2007 11/2007 $56.25 $313.11 4.00%~ $369.36
K211706062E E $75 10/1977 04/2007 10/2007 $56.25 $346.50 4.00%~ $402.75
K210229846E E $75 10/1977 04/2007 10/2007 $56.25 $346.50 4.00%~ $402.75
K210229773E E $75 10/1977 04/2007 10/2007 $56.25 $346.50 4.00%~ $402.75
http: / /www.treasurydirect.gov/BC/SBCPrice
Page 1 of 2
Calculated Value of Your Paper Savings Bond(s)
O/4/ 1V L.VV nvi
K210229609E E $75 10/1977 04/2007 10/2007 $56.25 $346.50 4.U0°/, $402.75
K210229546E E $75 10/1977 04/2007 10/2007 $56.25 $346.50 4.00°/, $402.75
K210229324E E $75 09/1977 03/2007 09/2007 $56.25 $346.50 4.00°/, $402.75
K210229249E E $75 09/1977 03/2007 09/2007 $56.25 $346.50 4.00°/, $402.75
K210229072E E $75 09/1977 03/2007 09/2007 $56.25 $346.50 4.00°/, $402.75
K210202986E E $75 09/1977 03/2007 09/2007 $56.25 $346.50 4.00°/, $402.75
K210202779E E $75 08/1977 02/2007 08/2007 $56.25 $346.50 4.00°/~ $402.75
K210202705E E $75 08/1977 02/2007 08/2007 $56.25 $346.50 4.00°/~ $402.75
K210202634E E $75 08/1977 02/2007 08/2007 $56.25 $346.50 4.00°/~ $402.75
K210202452E E $75 08/1977 02/2007 08/2007 $56.25 $346.50 4.U0°/~ $402.75
K210202372E E $75 07/1977 01/2007 07/2007 $56.25 $346.50 4.U0°/~ $402.75
K210202144E E $75 07/1977 01/2007 07/2007 $56.25 $346.50 4.00°/~ $402.75
K209077979E E $75 07/1977 01/2007 07/2007 $56.25 $346.50 4.00°/~ $402.75
K209077913E E $75 07/1977 01/2007 07/2007 $56.25 $346.50 4.00°/0 $402.75
K209077851E E $75 07/1977 01/2007 07/2007 $56.25 $346.50 4.00°/0 $402.75
K209077661E E $75 06/1977 12/2006 06/2007 $56.25 $346.56 4.00°/~ $402.81
K209077598E E $75 06/1977 12/2006 06/2007 $56.25 $346.56 4.00°/0 $402.81
K209077428E E $75 06/1977 12/2006 06/2007 $56.25 $346.56 4.00°/~ $402.81
K209077360E E $75 06/1977 12/2006 06/2007 $56.25 $346.56 4.00°/0 $402.81
K209077300E E $75 05/1977 05/2007 05/2007 $56.25 $353.76 4.00°/~ $410.01
K209077113E E $75 05/1977 05/2007 05/2007 $56.25 $353.76 4.00°/0 $410.01
K209077050E E $75 05/1977 05/2007 05/2007 $56.25 $353.76 4.00°/0 $410.01
K208703874E E $75 05/1977 05/2007 05/2007 $56.25 $353.76 4.00°/0 $410.01
K208703811E E $75 04/1977 04/2007 04/2007 $56.25 $349.74 4.00°/~ $405.99
K208703609E E $75 04/1977 04/2007 04/2007 $56.25 $349.74 4.00°/0 $405.99
Totals for 63 Bonds $3,543.75 $19,416.60 $22,960.35
NI Not Issued
NE Not eligible for payment
P5 Includes 3 month interest penalty
MA Matured and not earnin interest
http:/ /www.treasurydirect.gov/BC/SBCPrice
Page 2 of
REV-1511 EX+ (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE H
FUNERAL EXPENSES &
~-DMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
f~~r~-~ S. ~ h~~~So,~/ a f, 0 7- 38
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B.
1
2
3
4.
5.
6.
7.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State -
Year(s) Commission Paid:
Attorney Fees 1~4~1GS ~• ~ ~eG~i3 ~-
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State _
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
g7aS, 00
~jS, o0
TOTAL (Also enter on line 9, Recapitulation)1$ q9 ~ • ~~
(If more space is needed, insert additional sheets of the same size)
Zip
Zip
REV-1513 EX+ (9-C10~
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
~.! NDf} RJF~ vbJ~NSON- ~~ ~a u ~,~~ f
~ too n
8 Mcty~ %eld ,Pd .
/1'~~C~tan~CS~Hr~C, PA loo SS
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE i3 OF REV-1500 COVER SHEET ~$
(If more space is needed, insert additional sheets of the same size)
per' fz~EZ~'~.i ~'. ~~Y~~S~~~~
~~.~~~ ~ ,
~~
- `.~' ~L~li1~L~~~~~~!l~ ~~ KL~ ~C~~.ll~~,/Gr /~ %~21~ G~.l,/ ~i i~~~ _ ~ ailt/d ~~
//~i'1 GG~~~~i~j~(~C-'-LL/3o -
,O