HomeMy WebLinkAbout04-0686
CERTIFICATE OF NOTICE UNDER RULE 5.6(a)
Name of Decedent:
Troy Eugene Bankert
Date of Death:
May 22, 2004
No. 21-2004-0686
TO THE REGISTER:
I certify that notice of estate administration required by
Rule 5.6(a) of the Orphans' Court Rules was serviced on or mailed
to the following beneficiaries of the above-captioned estate on
July 23, 2004.
Name
Address
EARL H. BANKERT
752 STATE STREET
LEMOYNE, PA 17043
FAYE B. BANKERT
752 STATE STREET
LEMOYNE, PA 17043
Notice has now been given to all persons entitled thereto under
Rule 5.6(a).
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Thomas D. Gould, Esquire
I.D. # 36508
Attorney for the Estate
2 East Main Street
Shiremanstown, PA 17011
(717) 731-1461
Date: Je04 23, 2.tJ"if
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PETITION FOR GRANT OF LETIERS OF ADMINISTRATION
Estate of 7roy EIA.1~"~ B411 ke,.-t
also knoWfl Q$
Dt!Ctased.
Social Securi;y No, :20$ - ~6 - .".t 2
No. -2/- ~LI- to 8' 10
To:
Reeistcr of Wills for tile
County of (",,,,,kIa,,,.,, In the
Commonwealth of Pennsylvania
The petition 01' the undersigned respectfully represents that:
(d.b.a.; pet1dente lite; durante absentiai dutance minortwe)
the above docedent.
Your petitioner(s). who ware 18 years of "lle or older, allpl t
for lette" of adminlstration
on the estate of
Decendent was domiciled at aoath in <:UJI., 1. Q.r
h l.t last family or principal residence at .,r,
D>>::do;n~en
at rU '9
'13 years of age, died
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Count ,l sylv '. with :0
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(list litret:t, number a.'Id m I P\dity) C:C 8
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hla.y .22.. ~' ~ O~ "~f fi
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Deeendent at death owned property with ""timated values as folllows:
(if domiciled in Pa,) All personal property
(if not domiciled in Pa.) Personal property in Pelll!l;ylvania
(If nOI domiciled in Pa.) Persow property in County
Value of real esLate in Pennsylvania
situated as follows: ?!>, .\T.ch- SiHe-r
$
$
$
$ 7~.
p~
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-
PetitioJler--.L after a proper s.arch ha.lLS.-.. ascertaiJled that dcccdeJlt ieft no will and was survived by
the following ,pouse (if any) and heirs:
N""le
,,,K,,,T
II f, a ,,~
, 54rl iL&:,Lr-
oil
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8 Ro"-,,, erz-
V'
elations hip
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Residence
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THEREFORE. petitiOner(s) respectfully request(s) the gran' of letters of administration in the
appropriate form 10 the undersj~ed.
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OAm OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CfJ. t>1 itr I tZtI ,I
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The petitiOuer(I) above-named ,wear(&) Of arf"1nJI(s). that the
statements in the foceiDing petition are.true and correct to the best
of the knowledge ud belief of petitioner(s) and that 18 personal
repwsentativc:(s) of t'" ..... ...... t ... ...
truly adminis,ter the estate aeeordini to law, . ~ ~
Sworn to ot ari';:5'~ ~d sub.cribe<l u-cc ~
before me t ' clay of ,\\, Q{ (
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Estate of 7i-.'1 {;U,IJu,e.
GRANT OF L~HERS OF ADMINISTRATION
Btt"kerl
. Decelllled
AND NOW f).d.. , ;;1{} 0 4/, in comideration of the petition On
the revers. 1l1<1e hereof, satisfa ry proof hpvinll been ll!:_1Iod. before "!S. .
IT IS DBCRBED that re" 'Ij.. Sttnr....'T i/- ~oJ.$l" A. Betlr
Jor'are entitled eo Letters of Administration, ud in actord with such rmding. Letters of Administration
areherebygrlUltedto Sc.# fI. Ba:I1K,..."f ,f- l:>..:I:i.'f I}. 13Jl.,;e.
ill the estate of Ir'V ~"''}#nL !3a"kt-T-
,
FEES
Letters of Administration ,.... ~ '2,<:; . 0\-::>
Short Ccrtil'icate$( ),......... $~
Renunciation """':.s(\'"{5' :~
TOTAL S,!;t"P\ ,0\)
Filed '"J:-:~-:,~o:o* A.D. _
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Register c;f Wi~y-' __. .
lhamllJ' ":15. a fllAh/ 3 (~i"
ATTO&NEY (s... c.. I,D, No,)
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?'3/-/~I' PHONE
RENUNCIATION
~\-o4 - ~fto
In Re Estate of
7f<tJ Y Eu 6eNG 8AN~I3RI
deceased,
To the Register of Wills of
r:/;lIVl/3€ R L-A-,.J D
County, Pennsylvania.
The undersigned
P4yG A R;>ANKt3Rr ~ /SIl..L 1-16>tNKEAr
of
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
OF=- AD/V>/r./I~IR..A-IIt>rI
be issued to ~C-oTT A, I3A-N~/<.r .;. De6~/6' A. !2;A-lfZ
WITNESS
hand this "
day of ..j V- \ '-\
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Notarial Seal
Janet A, Lytle, Notary Public
Lower Allen Twp. Cumberland County
My Commission Expires Dee, 26. 2005
Member, Pennsylvania Association Of Notaries
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(Sigoj1ture)
FA V <;;. A., lOA". '<.t?~r
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(Address
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'1~'J. S/M"l? <;;." U5MOYNC-
(Signature)
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(Address)
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(Address)
HIO~,~()~ REV <JI~(,
This is to certify that the information here given is correctly copied from an original certificate of death duly, filed with me as
Local Registrar, The original certificate will be forwarded to the State VItal Records Office for penn anent hhng,
WARNING: It is illegal to duplicate this copy by photostat or photograph,
Fee for this certificate, $2,00
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10328776
No.
rll05143R.v2l87
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Local Registrar
MAY 252004
Date
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECOROS
CERTIFICATE OF DEATH
5r"TE FltEHUMBEFt
SOCIAL SECURITY NUMBER
." 205 56 _ 9983
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NAME Of DECEDENT (FiB!, MKkIe, L.ut)
1. Troy E. Bankert
AGE (t'lI Bnhday)
BIRTHPLACE (City .nd
St.teor~OilllQnCountry)
Harrlsburg, p.",-O
7. ...
FACILITY NAME (1I nol inltltution, giveltr..t and nombef)
'EX
,Male
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43 Yr..
Y Of DEATH
<
., Dauphin k~arrisburg Harrisburg Hospital
DECEDENT'S USUAL OCCUPATION KIND OF BUSINESS I INDUSTRY AS DECEDENT EVER IN
(.....:::..:donol~::r U,SARMEOFORCES?
UIPock Worker ~yernight Trans. a,YflD No[3.
DENT'S MAlLIN A RE S (Street, atyfTown, Stile, Zip ode) DECEDENT'S
756 State Street ~~~~~E
,..Lemoyne,PA 17043 l:"oo:t::.rl 17b,Counlv Cumberland
F^,,,,~, "'.,.If...,....., ".}
1..~arl H. HanKert
INFORMI'NT'S .tIAM~. y~rinl) 1
~, ~arl H. HanKert
METHOD Of 015 ITlOO
DonIbof1 D Burl. 0 Crwnllion ~emovallfOm SlIle 0
21.. Olh<<(Spedfy)
SIG T EOfFUNE \IlCEUC
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17"Stlt&
PA
Did
decedllnl
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EAIOuQ>d<<110
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RACE-Americanlncfjan. Blacl<,\I\lhit., el
(Speedy)
Whit"
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MARITAlSTATUS-MIIIfi8d,
NeW=,?s~~ed.
ever Married 115.
SURVIVING SPOUSE
(It""",Ito'.mai<lol>n.mo)
17c.DYe"oeceoenth.din
17d.~ ~~tM~:i=oI
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Lemoyne
cilylbom
MOTHE[l'S NAME (F.irll, Mio:lll'.M,idjtn Surname)
1.. J:<'aye 1\. Hlller
~:OR~'l"t}\"t,"e~'~'f''rI;1W~'':''''i':~rl'/'6rrle, PA 17043
PLACE OF DISPOSITION- Nlmt at C.meIllfY, Crematory
orOth...Pl....
21e, BFH Crematory
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( f'f' 116<' I C
UENCOF),
SequentialIyNllCOOdilion1
i1eny,lHdingtoimmedil"
C8UQ, Ellt<< UNDERL YlNG
CAUSE (Ois".. Of itlUlY
lhlItinilial8d.venta
r..u1linliJondu.th) LAST
WAS AN AUTOPSY 'NERE AUTOPSY FINDINGS
PERFORMED? AVAILABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
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TO(ORA.SACON
MANNER OF DEATH
NatUral li<\
Aecident~
D
DATE OF INJURY
1Mon'iI,o..y.y..,)
Homicide
Pendinglnveshgation
Could not be delermmed
D
D
o ~~:CE OF INJURY
b\olding,oto.(SpocdY)
30..
JOb. M
.Alhome,latm, stre8l,tac.lOry, oIIice
YesD NoD
30e.
'1'000
NO[zb
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Suicde
"PRONOUNCING AND CERTIFYING PHYSICIAN (Ph~1k:ian both prOOOl.ll'lOr1g death and certifying 10 caus.e 01 death)
TottM IMst 01 my k.....wledll.. d..1tl oeeurred.tltl.tlm., dat.. and pia.... and due lot h'Uu_(alandm.nn.ru.taled...
"MEDICAL EXAMlNERICORQNER
~:'::rb:::::.~mlnIllOll Indlor Inv"UgaltOll,ln my opinion. d..lh occurred &I In. time, data. and pllee. and due to the cluni\s) and. 0
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REOISTRAR'S SIONATUR~ 11t?
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LOCATION - CilyfTown, Stale. Zljl Code
a12rantville, PA
",l;Wg~'f\l"a~!!H408 3rd St New Cumber
17028
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LICENSE NUMBER
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TIME OF INJURY
INJURY AT VIORK? OESCRIBE HOW INJURY OCCURRED
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OFF1C1AL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPl 280601
HARRISBURG, PA 17128-0601
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
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COUNTY CODE YEAR NUMBER
9983
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCiAl SECURITY NUMBER
Ii] 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will]
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (dale 0( death atrer 12-12-82)
o 7. Decedent Maintained a living Trust (AtlacllcopyofTrust)
D 10. Spousal Poverty Credit (d<lle of death belweeI112.31.91 and 1-1-95)
o 3. Remainder Return (dale of death prior \0 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) {Allal;tl Sell oJ
SOCiAl SECURITY NUMBER
205
56
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DECEDENTS NAME (LAST, FIRST. AND MIDDLE INITIAL)
$ 70,000.00
28,971.19
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NAME
THOMAS D. GOULD, ESQUIRE
6,424.43
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COMPLETE MAILING ADDRESS
2 EAST MAIN STREET
SHIREMANSTOWN, FA 17011
BANKERT TROY
DATE OF DEATH (MM-DD-YEAR)
E.
DATE OF BIRTH (MM-DD-YEAR)
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(8)
$ 4,338.40
84,049.64
(11)
(12)
(13)
(14)
x.o_ (15)
x ,0 45 (16)
x 12 (17)
x .15 (18)
(19)
19. Tax Due
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
OFFICIAL USE ONLY
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05 22 2004 09 13 1960
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INITiAl)
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FIRM NAME (If Applicable)
TElEPHONE NUMBER
(717) 731-1461
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$ 105,395.62
88,388.04
17,007.58
17,007.58
765.34
765.34
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule Dj
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5, Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probale Property
(Schedule G or L)
8. Total Gross Assets (total Unes 1-7)
(7)
(6)
(9)
(10)
9. Funeral Expenses & Administralive Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of line 14 taxable at lineal rate
$ 17,007.58
17. Amoun! of Line 14 !axable at sibling rate
18- Amount of Line 14 taxable at collateral rate
20.0
Decedent's Complete Address:
STREET ADDRESS
756 STATE STREET
CITY
I STATE PA
I ZIP 17043
LEMOYNE
Tax Payments and Credits:
1. T2x Due (page 1 Line 19)
2. CredilslPayments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
$ 765.34
Total Credits ( A + B + C ) (2)
3. InleresUPenally IT applicable
D. Interest
E. Penalty
$ 19.81
TolallnteresUPenalty ( D + E) (3)
4. If Line 2 is greater than line 1 + line 3, enter the drflerence. This is the OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund (4)
19.81
5, If Line 1 + Line 3 is grealer than Line 2, enler the difference. This is Ihe TAX DUE (5)
785.15
A. Enter the interest on the tax due.
(SA)
B. Enter Ihe tolal of line S + SA. This is Ihe BALANCE DUE (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
785.15
~~~.~~~Bs1w)J~~~~~{~~~~~~ffitf~B5fi~~1~~~~gqj,%~;%~~~~t~-?~~~f~WL~~itg~~'J~~~:SS>~
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;... ......... m. ... ......h....... ......h.......... ... ... . 0 89
b, relain the right 10 designate who shall use Ihe property transferred or ils income; ... .......... . 0 119
c. retain a reversionary interest; Dr..... m ........... .. ....... ............. ........................w 0 ~
d. receive the promise for life of either payments, benefits or care? h'h.." .. .... ,......................... ,...... ..............., 0 !19
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ... .... ..........,....... ......... ......h...... ...... ...... ........... 0 (iI
3. Did decedent own an "in trust for- or payable upon death bank account or security at his or her death?.. _......... 0 [1g
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ,.. .............. u_... ..........."". ,............. .... ...w._........... ..........h......... 0 Ga
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN,
Under penalties of perjury, I declare Ihallloa\le examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief, il ;s lnJe, correct a~d complete.
Decla rion of preparer other than the personal representative is based on all inlormCllion of which preparer has any knowledge
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5 WEST GREEN STREET APT C
SHTRF.MANSTOWN. PA 17011
SIGNATURE OF P ER OTHER THA EPRESENTATtVE
y).
ADDRESS 2 EAST MAIN STREET
SHIREMANSTOWN, PA 17011
756 GLEN ARDEN DRIVE
LEWISBERRY, PA 17339
DATE
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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 sUNfving spouse is 3%
[72 PS. ~9116 (a) (1.1) (i)],
For dates of death on or aHer January 1, 1995, Ihe lax rale imposed on the net value of lransfers 10 or for the use of Ihe surviving spouse is 0% [72 P.S. ~911u la) (1.1) (ii)
The statute does not exemot 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
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 paren.
or a stepparent of the child is 0% (72 P.S. ~9116(a}(1.2)],
The lax rate imposeU on the net value of transters to orlor the use oflhe decedent's lineal be""ficiaries is 4,5%, excepl as ooled in 72 P,S, ~9116(1.2) [72 P,S, ~9116{a)(1)].
The tax rale imposed on the net value of transfers 10 or for \he use ollhe decedent's siblings is 12% [72 P's, ~9116(a)(1.3}]. A sibling is defined, under Section 9102, as al
individual who has at leasl one parent in common with the decedent, whether by blood or adoption.
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RE\~1,5l!2 EX+ {6-98*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
TROY E. BANKERT
FILE NUMBER
21-04-00686
ESTATE OF
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 which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1,
DESCRIPTION
RESIDENCE 756 SATE STREET, LEMOYNE, PA
VALUE AT DATE
OF DEATH
$ 70,000.00
TOTAL (Also enteron line 1, Recapitulation) $ $ 70,000.00
(If more space is needed, insert additional sheets of the same size)
REV-1503 EX. (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
FilE NUMBER
TROY E. BANKERT
21-04-00686
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1,
2.
Amer1can t'unds
Van Eck - mutual
DESCRIPTION
investment account
fund
VAlUE AT DATE
OF DEATH
$ 25,975.82
2,995.37
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
28,971.19
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COMMClNWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
TROY E. BANKERT
FILE NUMBER 21-04 00686
Include the proceeds of Ii1iga1ioo and the date the proceeds wm ~ by the es1a\e, AU property jointly-owned with the right o!survivorship must be diselosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
2.
3.
4.
5.
HOUSEHOLD GOODS
MISC FUNDS
2004 INCOME TAX REFUND
PERSONAL VEHICLE TRUCK
CHECKING ACCOUNT
$
1,122.65
2.365.95
1, 100.00
500.00
1,335.83
TOTAL (Alsoenleron lineS, RecapitUlation) $
(If more space is needed, insert additional sheets of the same size)
6,424.43
REV-';;" EX. ('2-99.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
TROY E. BANKERT
FILE NUMBER 21-04-00686
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. MURRAY FUNERAL HOME $ 2,387.00
B. ADMINISTRATIVE COSTS:
,. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State _ Zip
Year(s) Commission Paid:
2, Attorney Fees THOMAS D. GOULD 1. 500.0
3. Family Exemptioo: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State _ Zip
Relationship of Claimant to Decedent
4. Probate Fees 160.0
5, Accountant's Fees 50.0
6. Tax Return Preparer's Fees
7, Appraiser 60.0
8. Estate checks 11.0
9. Death Certificates 45.0
10. Keys & vehicle advertising 31.3
11. Moving truck rental 94.0
TOTAL (Also enter on line 9, Recapitulation) $ 4,338.4
o
o
o
o
o
o
5
5
o
(11 more space is needed. insert additional sheets of the same size)
'*
REV_ISI2EX.[1.97j
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FilE NUMBER 21-04-00686
TROY E. BANKERT
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
$ 50,452-.92
4,890.48
15,500.00
590.75
6.82
40.79
239.28
79.85
136.05
413.00
910.00
700.00
35.00
714.00
905.00
1,140.00
116.58
197.40
70.63
150.00
6,464.69
25.00
199.90
71. 50
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
PHFA mortgage
PH FA mortgae payments
Pinnacle Health Hospital - Compromised
Credit Union VISA Card
Verizon
Comcast
UGI
PAAWC
PPL
Pulmonary Health Emergency
Nephonlogy Association
Pulmonary Critical Care
Cardiology Diagnoistic Assc
Quantum Ima~ing
S.R. Golgman & Associates
Siegal, Baum, Gunder & Asso~iates
Rental truck -
Borough of Lemoyne - trash & sewage
Carpet cleaning
Pinnacle Health
Real estate closing costs
Associates Cardiologists
Dolan Oil
State & Local taxes
84,049.64
TOTAL (Also enter on line 10, Recapitulation) $
(If l11Qre space is needed, insert addttional sheets of the same size)
'REV-l513 EX+ (9-00)
*
COMMONWEA.LTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
TROY E. BANKERT
ALE NUMBER 21-04-00686
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
See, 9116 (a) (1,2))
1, EARL H. BANKERT FATHER 50%
2. FAYE B. BANKERT MOTHER 50%
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,
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1-
TOTAL OF PART ll- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDlVlDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
GOULD THOMAS 0
2 EAST MAIN STREET
SHIREMANSTOWN, PA 17011
.__u_~_ fold
ESTATE INFORMATION: SSN: 205-56-9983
FILE NUMBER: 2104-0686
DECEDENT NAME: BANKERT TROY EUGENE
DATE OF PAYMENT: 08/30/2005
POSTMARK DATE: 08/30/2005
COUNTY: CUMBERLAND
DATE OF DEATH: OS/22/2004
NO. CD 005737
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $785.15
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$785.15
REMARKS:
THOMAS GOULD, ESQ
CHECK# 305
SEAL
INITIALS: RSK
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
Rf.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU Of INDIiifDiM.CTAX"$r~'~c: .
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
NOTICE Of INHERITANCE TAX
APPRAISEMENT, ALLOWANCE DR DISALLOWANCE
Of DEDUCTIONS, AND ASSESSMENT Of TAX ON
JOINTLY HELD DR TRUST ASSETS
REV-1548 EX AFP (06-05)
, C:
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133668
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
MARY AVERY
6725 OLD BERWICK RD
BLOOMSBURG PA 17815
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS +--
REV=is4S-EX-AFP-loi=osi--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
FILE NO. 21 05-0686
TAX RETURN WAS:
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
ACN
05133668
2202418618
TYPE OF ACCOUNT: ()SAVINGS ~) CHECKING ()TRUST ()TIME CERTIFICATE
DATE ESTABLISHED 10-20-2000
Account Balance
Percent Taxable X
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate X
Tax Due
2,666.29
0.083
222.18
.00
222.18
.45
10.00
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
08 02 2005 CD005644 .00 9.50
TOTAL TAX CREDIT 9.50
BALANCE OF TAX DUE .50
INTEREST AND PEN. .00
TOTAL DUE .50
· If PAID AfTER THIS DATE, SEE REVERSE fOR CALCULATION Of ADDITIONAL INTEREST. .
( If TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
If TOTAL DUE IS REflECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REfUND.
SEE REVERSE SIDE Of THIS fORM fOR INSTRUCTIONS. )
r<t.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIV:IDUAL.'j'''XES'''-'-- "
INHERITANCE TAX DIVISIDN '
PD BDX 2B0601
HARRISBURG PA 1712B-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSMENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP (06-05)
GARY L HESS
355 STONER RD
MECHANICSBURG PA 17055
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133669
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS +--
REV=is4S-EX-AFP-roi=osi--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
FILE NO. 21 05-0686
TAX RETURN WAS:
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
ACN
05133669
2202418618
TYPE OF ACCOUNT:
DATE ESTABLISHED
()SAVINGS ~) CHECKING ()TRUST ()TIME CERTIFICATE
10-20-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
2,666.29
0.083
222.18
.00
222. 18
.45
10.00
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
x
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
07-28-2005 CD005652 .50 9.50
TOTAL TAX CREDIT 10.00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
· IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
Rt.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSMENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP C06-05)
MARY A AVERY
6725 OLD BERWICK RD
BLOOMSBURG PA 17815
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133671
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS +--
REV=is4S-EX-AFP-C03=Osi--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS. AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
FILE NO. 21 05-0686
TAX RETURN WAS:
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
ACN
05133671
4000078406
TYPE OF ACCOUNT: ()SAVINGS () CHECKING ()TRUST ~ )TIME CERTIFICATE
DATE ESTABLISHED 10-01-2002
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
26,300.12
0.083
2,191.59
.00
2,191.59
.45
98.62
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
X
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
08-02-2005 CD005644 .00 93.69
PAYMENT MUST BE MADE BY 01-30-2006*. TOTAL TAX CREDIT 93.69
BALANCE OF TAX DUE 4.93
INTEREST AND PEN. .00
TOTAL DUE 4.93
· IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
I IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" I CR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
Rt:
BUREAU OF INDIVIDUAL .TAXES
INHERITANCE TAX DIVISIDN
PD BDX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSMENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
GARY L HESS
355 STONER RD
MECHANICSBURG PA 17055
REV-1548 EX AFP (06-05)
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133672
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS +--
REV=is4S-EX-AFP-roi=osi--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS. AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
FILE NO. 21 05-0686
TAX RETURN WAS:
ACN
05133672
4000078406
TYPE OF ACCOUNT: ()SAVINGS () CHECKING ()TRUST ~ )TIME CERTIFICATE
DATE ESTABLISHED 10-01-2002
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
26,300.12
0.083
2,191.59
.00
2,191.59
.45
98.62
X
TAX CREDITS:
PAYMENT
DATE
07-28-2005
RECEIPT
NUMBER
CD005652
DISCOUNT (+)
INTEREST/PEN PAID (-)
4.93
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
AMOUNT PAID
94.31
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
· IF PAlO AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
99.24
.62CR
.00
.62CR
RK.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIijOAL'TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE DR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSMENT OF TAX ON
JOINTLY HELD DR TRUST ASSETS
::.)
GARY L HESS
355 STONER RD
MECHANICSBURG PA 17055
REV-1548 EX AFP [06-05)
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133675
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
AmDunt Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS +--
REV=is4S-EX-AFP-r03=Osi--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION, COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
FILE NO. 21 05-0686
TAX RETURN WAS:
TYPE OF ACCOUNT:
DATE ESTABLISHED
ACN
05133675
5000009228
()SAVINGS () CHECKING ()TRUST ~ )TIME CERTIFICATE
02-26-1998
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
4,907.82
0.083
408.97
.00
408.97
.45
18.40
X
TAX CREDITS:
PAYMENT
DATE
07-28-2005
RECEIPT
NUMBER
CD005652
DISCOUNT (+)
INTEREST/PEN PAID (-)
.92
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
AMOUNT PAID
17.48
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
· IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
18.40
.00
.00
.00
Rt.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION ,~
PO BOX 2B0601
HARRISBURG PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSMENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP (06-05)
MARY AVERY
6725 OLD BERWICK RD
BLOOMSBURG PA 17815
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133676
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS +--
REV=is4S-EX-AFP-r03=OSl--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
FILE NO. 21 05-0686
TAX RETURN WAS:
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
ACN
05133676
5000009228
TYPE OF ACCOUNT:
DATE ESTABLISHED
()SAVINGS () CHECKING ()TRUST ~ )TIME CERTIFICATE
02-26-1998
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
4,907.82
0.083
408.97
.00
408.97
.45
18.40
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
X
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
08-02-2005 CD005644 .00 17.46
TOTAL TAX CREDIT 17.46
BALANCE OF TAX DUE .94
INTEREST AND PEN. .00
TOTAL DUE .94
· IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
RA
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
-;,'-,-~ '..-.r.... c-_.". ,"""'c--' ",~.
BUREAU OF INDIVlDUAL.TAXI:S.
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE DR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSHENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP (06-05)
GARY L HESS
355 STONER RD
MECHANICSBURG PA 17055
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133677
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS +--
REV=is4S-EX-AFP-C03=Osi--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
FILE NO. 21 05-0686
TAX RETURN WAS:
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
ACN
05133677
5000009231
TYPE OF ACCOUNT:
DATE ESTABLISHED
()SAVINGS () CHECKING ()TRUST ~ )TIME CERTIFICATE
11-10-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
29,060.12
0.083
2,421.58
.00
2,421.58
.45
108.97
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
X
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
07-28-2005 CD005652 5.45 103.52
TOTAL TAX CREDIT 108.97
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
· IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
I IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" I CR), YOU HAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. )
RA
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVImlllt;T:AXj!S
INHERITANCE TAX DIVISION .
PO BOX 2B0601
HARRISBURG PA 17128-0601
NOTICE OF INHERITANCE TAX
',r APPRAISEMENT, ALLOWANCE DR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSMENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP (06-05)
MARY AVERY
6725 OLD BERWICK RD
BLOOMSBURG PA 17815
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133679
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS +--
REY=is4S-EX-AFP-r03=Osi--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS. AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
FILE NO. 21 05-0686
TAX RETURN WAS:
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
ACN
05133679
5000009231
TYPE OF ACCOUNT:
DATE ESTABLISHED
()SAVINGS () CHECKING ()TRUST ~ )TIME CERTIFICATE
11-10-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
x
29,060.12
0.083
2,421.58
.00
2,421.58
.45
108.97
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
X
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
08-02-2005 CD005644 .00 103.54
PAYMENT MUST BE MADE BY 01-30-2006*. TOTAL TAX CREDIT 103.54
BALANCE OF TAX DUE 5.43
INTEREST AND PEN. .00
TOTAL DUE 5.43
· IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL OUE IS REFLECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
R(
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSHENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REV-1548 EX AFP (06-05)
.J
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133680
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
GARY L HESS
355 STONER RD
MECHANICSBURG PA 17055
CUT ALONG THIS LINE -+ RETAIN LOWER PORTION FOR YOUR RECORDS +-
REV=is4S-EX-AFP-io3=OSj--------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
FILE NO. 21 05-0686
TAX RETURN WAS:
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
ACN
05133680
5000075782
TYPE OF ACCOUNT:
DATE ESTABLISHED
()SAVINGS () CHECKING ()TRUST ~ )TIME CERTIFICATE
11-26-2001
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
9,061.37
0.083
755.08
.00
755.08
.45
33.98
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
X
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
07-28-2005 CDOO5652 1. 70 32.28
TOTAL TAX CREDIT 33.98
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
· IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CRJ, YOU HAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. J
Rf.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
BUREAU OF INDIV:tDUAl'YAXES
INHERITANCE TAX DIYISION
PD BDX ZB0601
HARRISBURG PA 171Z8-0601
"._,' ,'\:--. r~'1
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSHENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
REY-1548 EX AFP (06-051
~9
DATE 09-13-2005
ESTATE OF HESS GINOR H
DATE OF DEATH 04-29-2005
FILE NUMBER 21 05-0686
COUNTY CUMBERLAND
SSN/DC 195-20-6762
ACN 05133682
APPEAL DATE: 11-12-2005
(See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
MARY R AVERY
6725 OLD BERWICK RD
BLOOMSBURG PA 17815
CUT ALONG THIS LINE ...... RETAIN LOWER PORTION FOR YOUR RECORDS 4-
REV=i54S-EX-AFP-r03=05j----------------------------------------------------------------____
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 09-13-2005
ESTATE OF HESS
GINOR
H DATE OF DEATH 04-29-2005
COUNTY
CUMBERLAND
FILE NO. 21 05-0686
TAX RETURN WAS:
S.S/D.C. NO. 195-20-6762
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: COLUMBIA CNTY FARMERS NATL BK ACCOUNT NO.
ACN
05133682
5000075782
TYPE OF ACCOUNT:
DATE ESTABLISHED
()SAVINGS () CHECKING ()TRUST ~ )TIME CERTIFICATE
11-26-2001
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
x
9,061.37
0.083
755.08
.00
755.08
.45
33.98
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
X
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
08-02-2005 CD005644 .00 32.28
PAYMENT MUST BE MADE BY 01-30-2006~. TOTAL TAX CREDIT 32.28
BALANCE OF TAX DUE 1. 70
INTEREST AND PEN. .00
TOTAL DUE 1. 70
· IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU HAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. )
Rf.
IN THE MATTER OF THE ESTATE
OF TROY E. BANKERT,
DECEASED
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO. 2004-00686
PA NO. 21-04-00686
STATUS REPORT UNDER 6.12
Pursuant to Rule 6.12 of the Supreme Court Orphan's Court
Rules, I report the following with respect to completion of the
administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes
x
No
2.
If
the
no,
state when the personal
answer
lS
representative reasonably believes that the administration will be
complete:
3. If the answer to No. 1 is yes, state the following:
a. Did the personal representative file a final account
with the court?
Yes
No
x
b. The separate Orphan's Court No. (If any) for the
personal representative's account is:
c. Did the personal representative state an account
informally to the parties in interest? Yes
x
No
d. Copies of receipts, releases, joinders and approvals
of formal or informal accounts may be filed with the Clerk of the
Orphans' Court and the Estate Settlement Agreement is attached to
(~. .
this report.
C)
c>
~M~. ~/
Thomas D. Gould
Attorney for Administrators
I.D. # 36508
2 East Main Street
Shiremanstown, Pa 17011
(717) 731-1461
cry
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IN THE MATTER OF THE ESTATE
OF TROY E. BANKERT,
DECEASED
t'"
IN THE COURT OF COMMQij PLE~=.~
OF CUMBERLAND COUNTY, ..~l-mSYr8~IA~
ORPHANS' COURT DIVISIONj 01 -
.~'
NO. 2004-00686 I
_1
PA NO. 21-04-00686
" .-~,
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(~)
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ESTATE SETTLEMENT AGREEMENT
( '.'
THIS AGREEMENT, made this
6 ~ day of ,-~+~'-<r
C::J
o
, 2005.
WITNESSETH:
THE CIRCUMSTANCES leading up to the execution of this
Agreement are as follows:
1. TROY E. BANKERT (the "Decedent"), died intestate on May
22, 2004 t and Debbie A. Bair and Scott A. Bankert were duly
qualified with the Register of Wills of Cumberland County,
Pennsylvania, as the Administrators (the "Administrators") of the
Decedent's probate estate (the "Estate")
2. The Decedent died having no wife and no children,
pursuant to Pennsylvania intestate law, the distribution of all of
the Decedent's estate is to be made equally to Decedent's parents,
EARL H.
BANKERT
and FAYE B.
BANKER T ,
collectively,
the
"Beneficiaries") .
Whereas, Faye B. Bankert died on September 8,
2004 and Scott A. Bankert, her son, was appointed Administrator of
her estate.
3. The Beneficiaries desire the Administrators to settle the
Estate informally in order to avoid the expense and delay involved
with the formal adjudication of a First and Final Account by the
Orphans' Court Division of the Court of Common Pleas of Cumberland
County, Pennsylvania (the "Court").
'.
4. The Beneficiaries desire to forever settle and compromlse
any and all claims and rights which they may possess, now or
hereafter, in the Estate and to confirm their acceptance of the
Informal Account (the "AccountU), attached hereto as Exhibit "A"
and incorporated herein by this reference, and the Schedule of
Proposed Distribution (the "Schedule"), attached hereto as Exhibit
"BU and incorporated herein by this reference. The Beneficiaries
desire that the distributions, as set forth on Exhibit "B," be in
full satisfaction of their rights in the Estate.
5. The Beneficiaries wish to release the Administrators and
to indernnifythem against any and all claims that may be asserted
against the Estate or the Administrators after the date hereof.
6. The Administrators are willing to settle the Estate
informally in consideration of the indemnifications hereinafter
provided by the Beneficiaries.
NOW THEREFORE, in consideration of the foregoing and intending
to be legally bound, jointly and severally, the Beneficiaries, for
themselves, their successors and assigns:
1. Represent and warrant that they have read and understand
this Agreement and confirm that the facts set forth above are true
and correct, to the best of their knowledge, information and
belief.
2. Declare that they have sufficient information to make an
informed waiver of their right to a formal accounting with the
Court, and do hereby waive the filing and auditing of the same.
"
3. Acknowledge that the distributive share or amount set
forth on the Schedule shall be in full satisfaction of their
respective entitlements under the Will.
4. Release, remlse, quitclaim and forever discharge the
Administrators, their heirs, personal representatives, successors
and assigns, from and against all claims that they, as legatees of
the Estate and in connection with the Estate, had, now have or may
in the future have in connection with the Estate.
5. Agree to refund, on demand, all or any part of any
aforesaid distribution,
which has been determined by the
Administrators, or by the Court, or by any court of competent
jurisdiction, to have been improperly made.
6. Agree to indemnify and hold harmless the Administrators,
their heirs, personal representatives, successors and assigns, from
and against any and all claims, loss, liability or damage (whether
or not related to the negligence of the Administrator) that may
hereafter be asserted against the Estate or against the
Administrators.
7. Agree to execute such other or additional documents as
may be necessary to effectuate the agreements set forth herein.
8. Acknowledge that this Agreement shall be governed by and
cons trued In accordance with the laws of the Commonwealth of
Pennsylvania.
'.
9. Consent to the Court exercising personal jurisdiction
over them In any suit or action arising out of the enforcement of
this Agreement.
IN WITNESS WHEREOFt the Beneficiaries have read and agreed to
the terms and conditions set forth in this Estate Settlement
Agreement and intending to be legally bound hereby placed their
hands and seals.
~~ 0. ~
WITNESS
&j)/; ~
EARL H. BANKERT
.~~fi).~
WITNESS
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
,--rh
On this, the ~'- day of '~ 2005, before me, the
undersigned officer, personally a peared EARL H. BANKERT and SCOTT
A. BANKERT, known to me (or satisfactorily proven) to be the
persons whose names are subscribed to the within instrument, and
acknowledged that they executed the same in the capacities and for
the purposes therein contained.
IN WITNESS WHEREOF, I hereunder set my hand and official seal.
j)l. lJ'
71 iN LIT}. jfiuJJ
Notary Publlc
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Leola M. Gould. NotaJy PublIc
ShIremanstown Boro. Cumberland County
My Commission expires Apr. 29. 2008
Member, Pennsylvania Association Of Notaries
INFORMAL ACCOUNT
ESTATE OF TROY E. BANKERT
ITEM
VALUE AT DEATH
ASSETS:
Residence - 756 State Street, Lemoyne $
stocks & Bonds $
Personal property, cash & financial accounts $
70,000.00
28,971.19
6,424.43
Total
$ 105,395.62
DEBITS:
Funeral & Administration Expenses
Debts, liabilities & expenses
PA Inheritance Tax & interest
$ 4,338.40
$ 84,049.64
$ 785.15
Total
$ 89,173.19
Net Value of Estate at time of Death
$ 16,222.43
The value of the stocks, bonds and financial accounts has
fluctuated during the administration of the estate and a final
value will be determined at the time of actual distribution.
A
... '.
PROPOSED DISTRIBUTION OF ASSETS
OF
ESTATE OF TROY E. BANKERT
BENEFICIARY
SHARE
50%
Earl H. Bankert
Faye B. Bankert
50%
Total
100%
B
11-14-2005
BANKERT
05-22-2004
21 04-0686
CUMBERLAND
101
APPEAL DATE: 01-13-2006
( See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
9~!_~~9~~_!~~~-~~~~------~___~g!~!~_~9~g~_~9~!!9~_~9~_Y9y~_~g~9~~~__~____________________
REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
TROY E FILE NO. 21 04-0686 ACN 101
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
INHERITANCE TAX DIVISION ""rr~','"\"'" i', n-r-10\= r',L OF DEDUCTIONS AND ASSESSMENT OF TAX
PD BOX 280601 Hh,AJ\-:;r::; 'Ji",',I._h_ "f
HARRISBURG PA 17128'0601 --",_,....' C'
2005 NOV 18 ANll: 36
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
~llilJ\ OF
THOMAS D G !M~ COURT
~H~R=~~~S trfL"::i;~" f;b11
ESTATE OF
BANKERT
REV-1547 EX AFP (06-05)
TROY
E
TAX RETURN WAS: (X) ACCEPTED AS FILED
} CHANGED
DATE 11-14-2005
I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
IS. Amount of Line 14 at Spousal rate (IS)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
U}
(2)
(3)
(4)
(S)
(6)
(7J
70,000.00
28.971.19
.00
.00
6.424.43
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequestsj Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
UO}
4,338.40
84.049.64
UlJ
U2}
U3}
U4}
NOTE:
.00
17,007.58
.00
.00
X 00 =
X 045 =
X 12 =
X 15 =
U9}=
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
105,395.62
88.388 04
17,007.58
.00
17,007.58
.00
765.34
.00
.00
765.34
. ~"'-' ,,"'.."'.... (+j AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
08-30-2005 CD005737 19.81- 785.15
TOTAL TAX CREDIT 765.34
BALANCE OF TAX DUE .00
INTEREST AND PEN. .01
TOTAL DUE .01
· IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. ~ ~
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DU'V'
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)