Loading...
HomeMy WebLinkAbout03-0061 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION also known as ~ _~~/ To: Register of ~i, ll ,s f~,,or Deceased. County of .... --~-:~¢~Mn the Social Security No.<~ //- ~ ~ ~~ - Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl 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~~~ja~'~---~ County, Pennsylvania, with ~ last family or principal residence at (~.3L~b'c~~ ~L~a~:z~ (list street, number and n~icil~ality) Decendent, then 9.~'~ years of age, died 0~L~r~, ~ ~6~cO~.~ -, 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 ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: , - Nameo ~ ~~ Resi~si~en/cffen/~, //. ~ fi_ (J ,. THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF c~.h~,-~ ~a 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) will well and truly administer the estate according to law. o Sworn to or affirmed and subscribed before me this 16th day of _ o No. 21-2003-61 Estate of ANNA R. GLENN , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW January' 22nd :5~ 2003, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that MIRIAM is/~e entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to MIRIAM M~ '~ MTX~.r,r, in the estate of ANNA R. GLENN FEES Letters of Administration ..... $18.00 Short Certificates(1) .......... $ 3.00 ATTORNEY (Sup. Ct. I.D. No.) Renunciation 2 ............... $10.00 JCP $10.00 TOTAL __ $41.00 ADDRESS Filed .J.saqUOJClf..22Ild ..... A.D. ~ 2003 PHONE SEND L~RS TO ADMiNISTRATOR ON JANUARY 22, 2003. ['his is to certify that the infbrmation here given is correctly copied f'ronl an ori~snal cc:'tilicatc Local Registrar. The original certificate will be forwarded to thc Staid Vilal P, ccords ¢ ~ffqcc for permanent WARNING: It is illegal to duplicate this copy by photostat or photograPh. COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH Anna omaine Glenn ~. Pemale ~. 2ti ~ 22 -- 6666 ,. January 9 2003 , ' Churcht o..m !. , ~,-m Cumberland Cm. ~. Middlesex Twp. ~r~nt ~st~ & ~btl[tati~ ~nter ~"~.~"~.'; ~ite Housewtfe ~ ....Homemaker I',. '~ I,,. ~a [ ....... [,,; Widowed [,~ ~u~ ,..~ Pennsylvania ,~ ~ Middlesex Twp. Clar~nt ~rst~ & ~b. Cntr. ,~o~ ~ Carlisle, PA 17013 ~ ,m.~ Cumberland' ~ ,~,.~~a~~ George Peffer m Emma Victoria Beck m. Mrs. Miriam M. 8ixel[ . m. 225 Meals Drive, carlisle; PA 17013 ~ m~ ~.~ 3anua~7 [5, 2003J~; CTema~ion Soctet7 o~ ~A ~. ~a~tsbuTg. PA ]7109 ~D-Ot 2975-[ ~=~kt~ ~1 ~,[~..~.~s~m~S~., ~11s~g,PA t~[9 ~ ~~,~ ~': ~ _~,. ......................... ~*,~ / ~ _['x~.,~ /~~a ~ ~ 21-2003-6]. RENUNCIATION 2].-2003-6]_ the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters WITNESS hand this day of , 19 (Signature) c (Address) (Signature) - ' (Address) (Signature) (Address) RENUNCIATION 21-2003-6~_ To the Register of Wills of ~-'~~ ~ County, Pennsylvania. The undersigned (~'L-?'L--~ /~ ~--~~~'~ of the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters WITNESS hand this day of ., 19 . ..... , (Address)~~~~~~ (Signature) (Address) (Signature) (Address) CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: 0_~~. ~ Date of Death: /~./- ?- D ~ WillNo. ~:~1~..~- (~ 00 ~ / Admin. No. To the Register: I certify that notice of (beneficial interes0 estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on : Name Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Signature Address~..~ ~~O ~Q-~?.~ Telephone (7[7) ~_ ~. ~ - ~ ~ Capacity:~ rsonal Representative Counsel for personal representative Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 12/01/2004 MIXELL MIRIAM M 225 MEALS DRIVE CARLISLE, PA 17013 RE: Estate of GLENN ANNA R File Number: 2003-00061 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 1/09/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Counsel Judge / Pursuant ~o P~ule 5.12 of the Supreme Couzl O~hans' Co~ [ul~s, I ~epo~ fo~owin~ with mspec~ to completion of the ad~s~afion of ~e above-captioned estate: 1.State~h~e~ administration of the estate is complete: Y~s ~ No ~ 2. If ~e ~swez is No, state when the pezsonal zepzesenmfive masonabl~ thai th~ a~s~afion wi~ be complete: S. ~the ~swez ~o No. 1 is Yes, state the follow~: a. Did ~e p~rsonal r~r~s~nmtiw ~e a ~al accost with ~ Co~? Y~s _ No ~ b. The s~p~ate O~har~' Corot No. (if m~y) for ihe person~ mpmsenm~v~'s accost is: c. Did the personal representative state an account informally to the pm-ties in interest? Yes ~] No c. Copies of receipts, releases, joinders and approval of formal or informa~ accounts may be filed with the Cleric of the Orphans' Court and may be attached to this report. Signature '-:'~: -~-~,=, o Address c-. / Telephone No. Capacity: ~'Personal ~-~ Counsel for personal representative J REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 15056051047 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number Date of Birth ., d _ Suffix Decedent's First Name MI ®~ ~~~ m~ ~ ~. -~>. ~ ~~~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI w ,_,... . Spouse's Social Security Number ti THIS RETURN MUST BE FILED IN DUPLICATE WITH THE . ~„ ~_.~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number - w .,~, r ~ .:,,... .. ~ . , w . , , nn Name (If Applicable) REGIS ~ WILLS ON LI~-. ' i t First Ime of address '• j'_ ~ r i ~ G1A ~ S D ~ ~ L ~ ~ ~ ~ `S ~ ~ ~ ~ ~c`~ -a z ~ , . Second line of address !~- ~ ~ ;~ °-'~ ~, "^ ,. ' .... r , ~ P t Offi Ci ' .~ St t ZIP C d DATE FILED ... ty or os ce a e o e Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief, lt is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE O~ ~EPARr~R OTHER THAN RE~SENTA~ J~%~ ;, n ~ DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 REV-1500 EX Decedent's Name: RECAPITULATION 15056052048 Deced\ent'ts Social Securitv~`Number \1 1 r:~ ~.1.>~ .. _.~., !t 1. Real estate (Schedule A) ......................................... .... 1. , _ . ~ ~ 4:- ~ ~ 2. Stocks and Bonds (Schedule B) ................................... .... 2. ; ' ,~., 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . .... 3. 4. Mortgages & Notes Receivable (Schedule D) ......................... .... 4. ~, ~ O ''= 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .... .... 5. 4 ~~ ~ ~.~.,~ ir f 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ... .... 6. ~ s O 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property "` ~'" '- (Schedule G) O Separate Billing Requested.... .... 7. c ~ -~ ~; ~ ~ s + 8. Total Gross Assets (total Lines 1-7) ................................ .... 8. ' ~ ' ~ ,. _ , ` 9. Funeral Expenses & Administrative Costs (Schedule H) ................. .... 9., / ~ V ~X , :. /~ yy~~ U V 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ .... 10. ~ a ~ J' , ~ 11. Total Deductions (total Lines 9 & 10) ............................... .... 11. ~ © r ~1.. 12. Net Value of Estate (Line 8 minus Line 11) ........ .................. ....12. ~ s ~ ~ ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 'r„ ''; ~' an election to tax has not been made (Schedule J) .................... .... 13. ' f ' ~;~ 14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .... 14. ' v TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 - "° ' ~°'~ ' "s (a)(1.2) X .0_ . (~ O 15. 16. Amount of Line 14 taxable ~~" r ' ' a,~, 3 ~~„ Y at lineal rate X .0 _ 0 "~ 16. 17. Amount of Line 14 taxable '~`''~"'~"`"z at sibling rate X ,12 . ~ C 17. ~ `• ° ' f-~' ~ ''~' ~~` 18. Amount of Line 14 taxable at collateral rate X .15 i ~ ~ ~~ 18. +Ic i 19. TAX DUE ............................. .......................... ..19. ~' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056052048 15056052048 REV-1500 EX Page 3 Fite Number ` Decedent's Complete Address: ~ 1 0~ ° ~~ 1 DECEDENT'S NAME - - -- - _ -- __ STREETADDRES __ -- CITY STATE ^ i ZIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5) (5A) (5B) Make Check Payable to: REGISTER OF WILLS, AGENT ,,~ ~.~, 0 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? ................................................................ ...... ^ 0" 2. If death occurred after December 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (G98) SCHEDULE A COM NOHERWTANCEOTAX RETURLNANIA REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER -~~ be real property owned solely or as a tenant in common mustbe reported at fair market value. Fair market value is defined as the price at which property exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant fads. (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ,TE OF FILE NUMBER ~~~ r ~`~ All property jointlyowned ~ilth right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional 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 FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must be a tacked for each closely-held co~porationlpartnership interest of the decedent, other than a sole-oroorietorshio. See insUuc6ons for the suooortina information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size) REV-1505 Ek+ (8-98) ~, SCHEDULE C-1 CL05ELY-HELD CORPORATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STOCK. INFORMATION REPORT RESIDENT DECEDENT 4. ESTATE F FILE NUMBER 1. Name of Corporation State of Inwrporation Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year 3. Type of Business ProducUService TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK VotinglNon-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................ ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ..:.............................. ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the oolicv 8. Did the decedent sell or transfer 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 $ Date .r-,. Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....^ Yes ^ No - - ._--`=--lf-xes,_provide a..cppy:of the a~ceement. -_ - . -- - -----_..._._ 10. Was the decedent's. stock sold ................................................ ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • ~ ~~ • ~ ~ A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a fist showing the complete addresses and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the .date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed, insert additional sheets of the same size) RfV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT 5 SCHEDULE C-Z PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Partnership Date Business Commenced Address City 2. Federal Employer LD. Number 3. Type of Business Product/Service Business Reporting Year State Zip Code 4. Decedent was.a ^ General ^ limited partner. If decedent was a limited. partner, provide inftial investment $ PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPITAL ACCOUNT A. B. C. D. 6. -Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest solo? ............................. .......... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? .......:. .......... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13, Was the decedent related to any of the partners? ..............:........... .......... ^ Yes ^ No If yes, explain 14. Did, the partnership. have an interest in other corporations or partnerships? .... .......... ^ Yes ^ No if yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest ~ ~ •- • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate appraisals have been secured, attach copies. ............................... ^ Yes ^ No D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (6.98) SCHEDI~ILE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT EST OF FILE NUMBER ~c1rc~ ~ C \~v~n ~~~~w~7~~ All property jointly-owned with rlghtof survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) f COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY Include the proceeds of litigation and the date the proceeds were received by the estate: Ail property Jointly-owned with right of survivorship must be disclosed on Schedule F. FILE NUMBER ~~~ -~~ (Ii more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) 4~ , SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE 0 FILE NUMBER ~\~ nr ~~~~ ~d~ if an asset was made joint within one year of the decedents date of death, It must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. B. C. JOINTLY-OWNED PROPERTY: (If more space is needed, inseR additional sheets of the same size) REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE FILE NUMBER This schedule must be comoleted and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ~~ \ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) ti. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE. H FUNERAL EXPENSES & ADMINISTRATIVE .COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule L NUMBER A. FUNERAL EXPENSES: i. '"T ` `~ ~ ~' U~ e. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Year(s) Commission Paid: 2. Attorney Fees 3.,,,~. , Family Exemption: (If decedent's address is nol the same as claimant's, attach explanation) Claimant SUeetAddress City State _'°:~' _ _ _- ---- 1~1-ationsliip'oTZiaimant'toDecedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Zip .~/, ~ TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) Zip AMOUNT ~ , CEO REV-1512 EX+ (12-03) . K COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE ~~ FILE Revert debts Incurred 6v the decedent nrlor to death which remained unpaid as of the date of death, Including unrefmbursed medical expenses. (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTA'i,E OF NUMBER NAME AND ADDRESS OF PERS~ I TAXABLE DISTRIBUTIONS [nclude outright Sec. 9116 (a) (1 RECEIVING PROPERTY ~I distributions, and transfers under FILE NUMBER ATIONSHIP TO DECEDENT ~ AMOUNT OR SH Do Not Llst Trustee(s) OF ESTATE D 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 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, insert additional sheets of the same size) REV-1514 EX+ (12-03) tr COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5.1-8~, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ WIII ^ Interviyos Deed of Trust ^ Other NAME(S) OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years O Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Terrn of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................................ . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of Ilfe estate (Line 1 multiplied by Llne 2) .......................................$ NAME(S) OF,UFE ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY IS PAYABLE ^ Life or ^ Term of Years - ^ Life or ^ Term of Years __ ~ _ ^ Life or ^ Term of Years ^~Cife or ^ Term of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ................................:.......................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ................:................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1 /2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ...........................................:..... . 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Llne 5 x Llne 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Llne 5 x Llne 6)+ Llne 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shel 0 (It more space is needed, insert additional sheets of the same size) REV-1644 EX + (3.04) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I. ESTq,TE OF INHERITANCE TAX SCHEDULE L REMAINDER PREPAYMENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER 0 ~~ (Last Name) (First Name) (Mlaaie imuai) This schedule is appropriate only for estates of decedents dying on or before December 1z, 1951. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. I REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date or Annuitant(s) of election Term of years income or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate ...............................$ 2. Stocks and Bonds ..........................$ 3. Closely Held Stock/Partnership ...............$ 4. Mortgages and Notes .......................$ 5. Cash/Misc. Personal Property . ................$ 6. Total from Schedule L-1 ......................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ...........................$ 2. Unpaid Beouests ...........................$ 3. Value of Unincludable Assets .................$ .. ...$ ,~„~-~,,,,f~,,,,'[ot^I from Srh .di ile L-~:,, . -~L ........ ... , ..... - - - 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.I INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date or Annuitant(s) corpus consumed Term of years income or annuity Is payable 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-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box 4a on Rev-1500 Cover Sheet) FILE NUMBER ~~ \ This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other I. ~ Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal _ ^ Limited right of withdrawal III. Explanation of Compromise Offer: _ _,. N. Summary of Compromise Offer: 1. Amount of Future Interest .................., ........................................$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) .......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% .......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% .............................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) .......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) .......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) .......................$ (If more space.is needed, insert additional sheets of the same size) REV-1648 EX (11-99x1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01f01192 TO 12131194) ESTA OF ~ FILE NUMBER \~ ~ -' ~~ This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1 . Taxable Assets total from line 8 (cover sheet) 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joint Assets with Spouse ............................................................ 4. 5. PA Lottery Winnings ............................................................... 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6b. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c. d) .........................................:.............. 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilities ...........:.................................................. 9. Net Value of Estate (Subtract line 8 from line 7) ...................:....................... 9. If line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part II. Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 a. Spouse ......... .. 1a. 2a. b. Decedent ........ .. 1 b. -_ ~ -- 2b. c. Joint ........... .. 1c. 2a d Tax Exempt Income .. 1d. 2d. e Other Income not listed above ...... .. 1e. 2e. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 ~ + (2~ - + (3f) 3b. 3d. 3f. (+ 3) 4b. Average Joint Exemption Income ..................................................... _ If line 4fb) is .greater than $40,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................... 1. 2. Multiply by credit percentage (see instructions) .........................................:. 2. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet . ...........................:... 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the 4 decedent's gross estate .................................................:.......... . 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal ~ 5 Poverty Credit .Include this figure in the calculation of total credits on line 18 of the cover sheet...... . REV-1649 EX+ (6-98) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE O ELECTION UNDER SEC.9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE FILE NUMBER ~~ ~ ~ Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & EstateTax Act. If the election applies to more than one trust or similar arrangement, a separate form muss be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the truss or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or sim- ilar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement, The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar arrangement. p~.- o• Fntar the rfacrrintion and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's •4 pr more space is nevuo~, ,~„~„ a..~„~ ....... ........._ _...._ _ ..._ __ , NOTICE OF INHERITANCE TAX pennsy van~a ~ BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION •*~~r~~f~~ ~1D ASSESSMENT OF TAX REV-1547 EX AFP (12-09) PO BOX 280601 -.x* '~ ;;, ~` 4 HARRISBURG PA 17128-0601 ~.'~~ ~~~ ~ ~ !,iIV ~'~ , DATE 05-10-2010 ~~~D MAY 17 P~! ~ ,3~ ESTATE OF GLENN ANNA R DATE OF DEATH 01-09-2003 ~~~~K ~~. FILE NUMBER 21 03-0061 MIRIAM M MIXELL dRPNAN1S ~flUR~ ACNNTY lUOMBERLAND 225 MEALS DR CU~~~~'~~`."~~ ~~. ~ APPEAL DATE: 07-09-2010 C A R L I S L E P A 17 015 (See reverse side under Objections ) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SgUARE CARLISLE PA 17013 CUT ALONG THIS LINE ~- RETAIN LOWER PORTION FOR YOUR RECORDS E~- ------------------------------------------------------------------------------------------- REV-1547 EX AFP C12-09~ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: GLENN ANNA RFILE N0.:21 03-0061 ACN: 101 DATE: 05-10-2010 TAX RETURN WAS: CX) ACCEPTED AS FILED C ) CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) C1) •0 0 NOTE: To ensure proper 2. Stocks and Bonds (Schedule B) (2) .0 0 r_redit to your account, .0 0 submit the upper portion 3. Closely Held Stock/Partnership Interest (Schedule C) (3) of this form with your 4. Mortgages/Notes Receivable (Schedule D) C4) •0 0 tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) .0 0 6. Jointly Owned Property (Schedule F) (6) .0 0 7. Transfers (Schedule G) (7) .0 0 8. Total Assets (8) .0 0 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (q) 4.6 28.0 0 10. Debts/Mortgage Liabilities/Liens (Schedule I) C10) .D 0 11. Total Deductions C11) 4,628.00 12. Net Value of Tax Return (12) 4,628.00- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) .0 0 14. Net Value of Estate Subject to Tax C14) 4,628.00- NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) • 00 X 00 •- . 00 16. Amount of Line 14 taxable at Lineal/Class A rate C16) .0 0 x 0 4 5 = .0 0 17. Amount of Line 14 at Sibling rate (17) .0 0 X 12 - .0 0 18. Amount of Line 14 taxable at Collateral/Class B rate C18) .0 0 X 15 = .0 0 19. Principal Tax Due (19)= .0 0 TAX CREDITS: PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX UE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~~