HomeMy WebLinkAbout03-0104PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of /~.cY]¥/qm~ ]~rO~.~Vn[-r~.ff~. No.
also known as To:
Social Security No. / qd~ - 1~-- ~,,9...oqO
Register of Wills for the
Deceased. County of in the
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appi _~_
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
for letters of administration
on the estate of
Decendent was domiciled at death in C~.PsL~ff~/tq,,4/~9 County, Pennsylvania, with
hi~ lastfamilyorprincipalresidenceat .Y_05' ~'~gT 5~ .fit4/h,,4nE~f2/lL/g-_ P,,Q
(list street, number and municipality)
Decendent, then 7 ~ years of age, died LD~C ~., , ~ ,~..002~
at ]-)/qf~/~,'£~(4,~' HO q'?,'
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.__
the following spouse (if any) and heirs:
Name
after a proper search ha._ff_~ ascertained that decedent left no will and was survived by
Relationship
Residence
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
COVNTY Or ss
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.
Sworn to or affirmed and subscribed
before me this L.'~2, day of
.~-~/1~ ~_~ "Register
Estate of
No.
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW F~_~p_L~ ~w ~-7',~ ~l~)~t~o_~, in consideration of the petition on
the reverse side hereof, sati~sfa, ctory proof having been presented before me,
IT IS DECREED that ' k.~E~r~r~'~ _"-'~e~i~rv.-~
is/a~e entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to
in the estate of
FEES
Letters of Administration ..... $
Short Certificates( ) .......... $ ~.c-_~
~z~iation ................
Filed F..~.. ~. ........... A.
Register of Will
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
RENUNCIATION
In Re Estate of deceased.
To the Register of Will ~s~~-~~VL~,~~(~/~sylvania.
The undersigned . - / ~ t .... / of
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
be issued to
WITNESS
hand this
(Signature)
(Address)
(Signature)
(Address)
I05.905M REV. 4/96
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
1012831
No.
Charles Hardester
State Registrar
Date
-~m5.:~ Re,. Z'a? COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH * VITAL RECORDS
CERTIFICATE OF DEATH
,. ffo~d A. 8oo~ ,. Ma~¢ ~ 193 -- 12 8250 ,. Deeemb~ 20, 2002
205 F~St S~eet Box 82
Albe~t Book.tea
Dennis Bookwalter
MOTHER'S NAME (Fir N. Middle. Mai~e~ ,~'name)
IE. Ko..th e./t.i.e_
~ 205 F~st ~eet~ Box 82~ Smm~d~e~ PA 17093
,,.. PA Crem~orq .,. H~b~g, PA 17109
~. 4100 Jon~town Ro~. ~H~a~b~o. PA 17109
.ICENSI~ NUMBER ~ SIGNED (M(~lh Day ~i~k' ~
Name of Decedent:
CERTIFICATION OF NOTICE UNDER RULE 5.6(a}
Date of Death:
Wi:l No. /V\
To the Register:
~0; ,2,.00 %
Admin. No..2.103- 010~!-
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the O~phans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on IC'~'/Z. Y) ?._rg~ '~ :
Name Address
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: FEL~, ?. Zr~ % ~
Signature
Telephone (7/1) 7 ~ ~_ - ~
Capacity: ~ Personal Representative
Counsel for personal representative
CONNONHEALTH OF PENNSYLVANIA
DEPARTNENT OF REVENUE
BUREAU OF INDZVZDUAL TAXES
DEPT. Z80601
HARRISBURG, PA 17128-0601
ZNFORHATZON NOTZCE
AND
TAXPAYER RESPONSE
FZLE NO. Zl'c~-/~~'/
ACN 03106257
DATE 03-0q-2003
CATHY D CLEGG
BOX 82 ~
205 1ST ST ::~.
SUMMERDALE PA 17093
TYPE OF ACCOUNT
EST. OF HOWARD BOOKWALTER ~--~SAVZNgS
S.S. NO. 193-1Z-BI50 []CHECKINg
DATE OF DEATH 1Z-ZO-ZOOZ ~]TRUST
COUNTY CUMBERLAND E~CERTIF.
REHZT PAYHENT AND FORHS TO:
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17013
PNC BANK has provided the Department with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of
this account. If you feel this information is incorrect) please obtain written correction from the financial institution, attach a copy
to this form and return it to the abovm addrass~ This account is taxable in accordance with the TnharJtanca Tax Laws of tho Commonwealth
of Pennsylvania. Questions may be answered by calling (717) 787-BSZT.
CONPLETE PART I BELOW # # x SEE REVERSE SIDE FOR FILING AND PAYNENT INSTRUCTIONS
Account No. 5080393678 Date 03-10-1995
Established
Account Balance lq, 652. ~0
Percent Taxable X 50,000
Amount Sub.~ect to Tax 7., ~26.20
Tax Rate X .0~5
PotentiaZ Tax Due 329.68
To insure proper credit to your account, two
(Z) copies of this notice must accompany your
payment to the Register of Hills. Hake check
payable to: "Register of Nills, Agent".
NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
you may deduct a 5Z discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
PART TAXPAYER RESPONSE
A. ~zT.ha abova information and tax dua is correct.
You may choose to remit payment to the Register of Hills with two copies of this notice to obtain
CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of
ONE ~ Hills and an official assessment will be issued by the PA Department af Revenue.
BLOCK
/
N The above asset has been or will be reported and tax paid with the Pennsylvania Tnharitanca Tax return
B.
ONLY ~ to be filed by the decedent's representative.
C. [] The above information ms__incorrect and/or debts and deductions ware paid by you.
You .ust complete PART gL~J and/or PART [] below.
PART Tf you /nd/cate a different tax rate, please state your
[] relet/onsh~p to decedent:
TAX RETURN - CONPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. Date Estebl/shed
2. Account Balance 2
3. Percent Taxable 3 ~
q. Amount Subject to Tax q,
5. Debts and Deduct/ons 5
6. Amount Taxable 6
7. Tax Rata 7 X
8. Tax Due 8.
PART
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE DESCRIPTION AMOUNT PAID
TOTAL (Enter on L/ne 5 of Tax Computation) $
Under penalt/es of perjury, I declare that the facts T have reported above ere true, correct end
COltplete to the best of my knowledge end belief. HONE ( )
WORK ( )
TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
GENERAL [NFORHATZON
1. FAILURE TO RESPOND WILL RESULT ZN AN OFFiCiAL TAX ASSESSNENT mith appliceble interest based on inforaation
submitted by the financial institution.
Z. inheritance tax becomes delinquent nine months after the decsdsnt's data of death.
3. A joint account is taxable even though the dacsdent's name Nas added as a matter of convenience.
~. Accounts (including those held batNaan husband and wife) which the decedent put in joint names oithin one year prior to
death are fully taxable as transfers.
5. Accounts established jointly bat.eon husband and .ifs moro than one year prior to death are not taxable.
6. Accounts held by a decedent "in trust for" another or others ara taxable fully.
REPORTZNG [NSTRUCTZONS - PART I - TAXPAYER RESPONSE
1. BLOCK A - if the information and computation in the notice ara correct and deductions are not being claiaed, place an "X"
in block "A" of Part 1 of tho "Taxpayer Response" section. Sign two copies and submit thee with your check for the amount of
tax ta the Register of Nills of tho county indicated. The PA nepertaent of Revenue .ill issue an offi¢iel assessment
(Form REV-lS48 EX) upon receipt of the return from the Register of Wills.
Z. BLOCK B - Zf tho asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance
Tax Return f[[ed by the decedent's ~epresentat[ve, piece an "X" in block "B" af Part [ of ~e "Taxpayer Response" section. Sign one
copy and return to the PA ~epartment of Revenue~ Bureau of Individual Taxes~ Bept ZBa6g[~ Harr[sburg~ PA [7[ZS-g60[ in the
enve[ope provided.
~. BLOCK C - ~f the notice information is incorrect and/or deductions are being c[aimed~ check black "C" and camp[eta Parts Z and
according to the instructions belo~. S[gn t~o copies and submit them ~Jth your check for ~e amount of tax payable to the Register
of Hills of ~m county indicated. The PA Department of Revenue will issue an official assessment (Form REV-15~8 EX) upon receipt
of the return frei the Register of Hills.
TAX RETURN - PART Z - TAX COHPUTATZON
LZNE
1. Enter ~e date the account originally ~as established or titled ~n the manner existing at date of death.
NOTE: For a decedent dying after 12/1Z/BZ: Accounts ahJch the decedent put in joint names aJthin one (1) year of death are
taxable fully as transfers. Ho.ever, there Js an exclusion nat to exceed S5,000 per transferee regardless of the value of
the account or the number of accounts he[d.
if a double asterisk (ax) appears before your first name Jn the address portion of this not[ce, the S5,000 exc[usJon
already has been deducted from ~e account balance as reported by the fJnanc[a] institution.
Enter the total balance a~ the account Jnc[udJng interest accrued to the date of death.
The percent of the account that is taxable far each survivor
A. The percent taxable for joint assets established more than one year prior to the decedent's death:
] O[VZDED BY TOTAl NUHBER OF D~V[DEO BY TOTAL NUNBER OF X [00 = PERCENT TAXABLE
JOZNT OHNERS SURV[VZNG JOZNT ONNERS
ExampLe: A joint asset rag[stared Jn ~e name of ~e decedent and t~o other persons.
] D~V[DEO BY 5 (JOINT BNNERS) DZV[BEO BY Z (SURVZVORS) = .[67 X ]00 = [6.7X (TAXABLE FOR EACH SURVZVOR)
B.The percent taxable for assets created .[thJn one year of ~e decedent's death or accounts oNned by ~e decedent but held
Jn trust for another Jnd[vJdua[(s) (trust beneficiaries):
] OZV~DED BY TOTAL NUHSER OF SURViViNG JOZNT X ]00 = PERCENT TAXABLE
ONNERS OR TRUST 5ENEF[C[AR[ES
ExampLe: Joint account registered in the name of the decedent and tho other persons and established ~JthJn one year of death
the decedent.
[ D[VZOED BY Z (SURVIVORS) = .50 X [00 = SOZ (TAXABLE FOR EACH SURVIVOR)
The aaount subject to tax ([[ne ~) is determined by multiplying the account be[anco ([ina Z) by the percent taxab]e (Zinc 5).
5. Enter ~a total of the debts and deductions ][sted Jn Part
6. The amount taxable (Line 6) Js determined by subtracting the debts and deductions (line 5) from the a.ount subject to tax (Zinc ~).
7. Enter the appropriate tax rate (]ina 7) as determined be[oN.
De~e of Death Spouse Lineal Sibling I Collateral
07/01/9~ ~o 12/$1/9~
01/01/95 ~o 06/30/00 OX 6X 15X
07/01/00 ~o presen~ OX ~.5X~
aTha tax rate imposed on the nat va]am of transfers free a deceased child twenty-one years cf ago or younger at
death to or for the use of a natural parent, an adoptive parent, or a stopparent of the child is
The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children
.hother or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the
natlJra! parents and their descendants, whether or not they have been adopted by others, adopted descendents and their descendants
and step-descendants. "Siblings" era defined as individuals who have at [east one parent in common with the decedent, .hethar by blood
or adoption. The "Collateral" class of heirs includes all other beneficiaries.
CLA[HED DEDUCT[0NS - PART $ - DEBTS AND DEDUCT[OHS CLATNED
Altowable debts and deductions are determined as follows:
A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient
to pay the deductible items.
B. You actually paid the debts after death of the decedent and can furnish proof of payment.
C. Debts being claimed must bo itemized fully in Part 3. If additional space is needed, use plain paper B 1/Z" x 11". Proof of
payment may be requested by the PA Department of Revenue.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
CD
REV-1162 EX(11-96)
002304
BOOKWALTER DENNIS
205 FIRST STREET
SUMMERDALE, PA 17093
........ fold
ESTATE INFORMATION: SSN: 193-12-8250
FILE NUMBER: 2103-01 04
DECEDENT NAME: BOOKWALTER HOWARD
DATE OF PAYMENT: 03/18/2003
POSTMARK DATE: 03~08~2003
COUNTY: CUM BERLAN D
DATE OF DEATH: 12/20/2002
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
03106257 $313.1 9
TOTAL AMOUNT PAID'
$313.19
REMARKS: C/O CATHY D CLEGG
SEAL
CHECK//804
INITIALS: AC
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
COHHONHEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. Z80601
HARRXSBURG, PA 171Z8-0601
REV-I~4$ EX AFP [09-a0)
ZNFORHATZON NOTICE
AND
TAXPAYER RESPONSE
FILE NO.
ACN 05106257
DATE 05-0q-2005
CATHY D CLEGG
BOX 82 ~
205 1ST ST
SUMMERDALE PA 17095
TYPE OF ACCOUNT
EST. OF HOWARD BOOKNALTER [] SAVINGS
S.S. NO. 195-12-8250 [] CHECKING
DATE OF DEATH 12-ZO-ZOOZ [] TRUST
COUNTY CUMBERLAND E]CERTIr.
REHZT PAYHENT AND FORMS TO:
REGISTER OF MILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 170I$
PNC BAHK has provided fha Departaant with the information listed balom which has been used in
calculating the potential tax due. Their records indicate that at the death of tho above decedent, you ware a joint omnar/beneficiary of
this account. I~ you faa1 this information is incorrect, please obtain writtafl correction from the financial institution, attach a copy
to this fore and raturn i% to the at.ore addru~s. T;iJs dc~ount i$ taxabZa in accui danc~ ~;[th the Z;;..~.--;-"-~cT.;C
of Pennsylvania. guaatiens amy ba answered by calling (7173 787-8~Z7.
COMPLETE PART ! BELO# # # # SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Accoun~ No. 5080~95678 Data 05-10-1995
Established
Accoun~ Balance lq, 652. q0
Percen~ TaxebZe X 50. 000
Amoun~ SubSec~ ~o Tax 7,526. ZO
Tax Rat:e X . Oq5
Po~en~ial Tax Due 529.68
To insure proper credit to your account, two
(Z) copies of this notice must accompany your
payment to the Register of Hills. Hake check
payable to: "Register of Hills, Agent".
NOTE: Zf tax payments ara made within three
(3) months of the dacedant's date of death,
you may deduct a 5Z discount of the tax due.
Any inheritance tax due Nil1 become delinquent
nine (9) months after the date of death.
PART TAXPAYER RESPONSE
A. ~The above information and tax due is correct.
~-~1. You may choose to remit payment to the Register of #ilia with tho capias of this notice to obtain
-- CHECK a discount or avoid interast, or you may check box "A" and return this notice to the Register of
L ONE '~ Hills and an official assessment Nil1 be issued by the PA Department of Revenue.
BLOCK J B. [] The above asset has been or N~11 be reported and tax paid with the Pennsylvania Inheritance Tax return
ONLY to be filed by the decedant's representative.
C. ~Tha above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ end/or PART ~ below.
PART If you indicate a diffaren~ ~ax ra~a, please s~a~a your
relationship ~o decedent:
TAX EETURN - COMPUTATION OF T~X ON JOINT/TRUST ACCOUNTS
LINE 1. Da~e Es{eblished I
2. Accoun~ Balance ~
$. Percen~ Taxable 3 X
q. Aeoun~ SubSec~ ~o Tax ~
5. Debts and Deductions $. -
6. Amoun~ Taxable 6
7. Tax Ra~e 7 ~
8. Tax Due ~
PART
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE DESCRIPTION AMOUNT PAID
TOTAL (Enter on Line S of Tax Compu~e~Lon) $
Under penalties of perSury, I declare ~ha~ ~he fac~s I have reported above ara ~rue, corrac~ and
complete ~:o ~he bes~: of ay knowledge and bel/ef. HOME C )
NORK ( )
TAXPAYER STGNATURE TELEPHONE NUMBER DATE
GENERAL ZNFORHATZON
1. FAILURE TO RESPOND NZLL RESULT ~N AN OFFICIAL TAX ASSESSHENT .ith spplicsbla intarest based on information
submittad by the financial institution.
Z. Inheritance tax becomes delinquent nine months after the decedent's date of death.
3. A joint account is taxable even though the decedant's name was added as a mortar of convenienca.
fi. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to
death are fully taxable as transfers.
5. Accounts established jointly between husband and wife more than one year prior to death are not taxabla.
6. Accounts held by a decedent "in trust for" another or others ara taxable fully.
REPORTZNG ZNSTRUCTZONS- PART 1 - TAXPAYER RESPONSE
1. BLOCK A - If the information and computation in the notica are correct and deductions are not being claimed, place an
in block "A" of Part I of the "Taxpayer Response" section. Sign two copies and submit them with your check for tha amount of
tax to the Register of Hills of the county indicated. The PA Department of Revenue will issue an official assessment
(Form REV-15q8 EX) upon receipt of the return from the Register of Mills.
2. BLOCK B - If tho asset specified on this notice has boon or will be reported and tax paid with the Pennsylvania Inheritance
Tax Return filed by the decadent's reprasantative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one
copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept Z80601, Harrisburg, PA 171Z8-0601 in tha
envelopa provided.
5. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complate Parts Z and
according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register
of MiIls of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-15q8 EX) upon receipt
of the return frei t~m Register of Mills.
TAX RETURN - PART 2 - TAX COHPUTATION
LINE
1. Enter the date the account originally was established or titled in the manner existing at date of death.
NOTE: For a decedent dying after I2/1Z/BZ: Accounts which the decedent put in joint names within one (1) year of death ara
taxable fully as transfers. However, there is an exclusion not to exceed $3,000 per transferee regardless of tha value of
the account or the number of accounts held.
If a double asterisk (xx) appears bafore your first name in the address portion of this notice, the $5,000 exclusion
already has been deducted from the account balance as reported by the financial institution.
Enter the total baIance of tha account including interast accrued to the date of death.
The percent of the account that is taxable for each survivor is determined es follows:
A. The percent taxable for joint assets astablishad more than one year prior to the dacedent's death:
I DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE
JOINT OMNERS SURVIVING JOINT OMNERS
Example: A joint asset registarad in the name of the decedent and two other persons.
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 X 100 = 16.7X (TAXABLE FOR EACH SURVIVOR)
B.The percent taxable for assets created within one year of the decedmnt's death or accounts owned by the decedent but held
in trust for another individuaL(s) (trust benaficiaries):
i DIVIDED BY TOTAL NUNBER OF SURVIVING JOINT X lO0 = PERCENT TAXABLE
OMNERS OR TRUST BENEFICIARIES
Example: Joint account registered in the name of the decedent and two other persons and established within Dna yaar of death by
tho decedent.
i DIVIDED BY Z (SURVIVORS) = .SO X 100 50Z (TAXABLE FOR EACH SURVIVOR)
4. The amount subject to tax (line q) is datereinad by multiplying tha account balance (line Z) by tha percent taxable (line
5. Enter the total of the debts and deductions listed in Part 3.
&. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line q).
7. Enter the appropriate tax rate (lina 7) as determined below.
Da~e of Death Spouse Lineal Sibling Collateral
07/01/9q ~o 12/$1/9q 3X 6Z
01/01/95 ~o 06/30/00 OX 6Z
07/01/00 ~o presen~ OX q.EX~ 12X
NThm tax rata imposed on the nat value of transfers from a deceased child twenty-Dna years of age or younger at
death to or for the use of a natural parent, an adoptiva parent, or a stepparant of the child is OZ.
The linaal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children
whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the
natural parents and their descendents, whathar or not they have been adopted by others, adopted descendents and their descendants
end step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood
or adoption. The "Collateral" class of heirs includes all other beneficiaries.
CLATMED DEDUCTTONS - PART ;5 - DEBTS AND DEDUCTTONS CLATMED
Allowable debts and deductions are determined as follows:
A. You legally ars responsible for payment, or the estate subject to administration by a personal rapresantetiva is insufficient
to pay tha daductibia items.
B. You actually paid the debts after death of the decedent and can furnish proof of payment.
C. Debts being claimed must be item[zed fully in Part 3. If additional space is needed, use plain paper B l/Z" x 11". Proof of
payment may be requested by the PA Department of Revenue.
E-143 EX (3-99)
I I~&l Cathy Clegg
I~]~17'1 PO Box 82
Y ~'* '1Summerdale,
Att~ntion: TIC 340
PA 17093
Z~p Code
PA DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL T~(ES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG PA 17128-0601
h.llhl,h,ilhd~lhdilhmlhilhlmdhlllll
~ EV-1500 EX(6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
I INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONL?~
FILE NUMBER
&L-O /'&'/
COUNTY CODE YEAR NUMBER
Z
UJ
UJ
UJ
DATE OF DEATH (MM-DD-YEAR) ,,.-- DATE OF BIRTH (MM-DD-YEAR)
SOCIAL SECURITY NUMBER
- / - 7
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
[~1. Original Return
[~4. Limited Estate
[-~6. Decedent Died Testate (Attach copy of Will)
[~9. Litigation Proceeds Received
r-~2. supplemental Return
E~4a. Future Interest Compromise (date of death after 12-12-82)
E~]7. Decedent Maintained a Living Trust (Attach copy of Trust)
E~10. Spousal Poverty Credit (date of death between 12-3%91 and t-1-95)
] 3. Remainder Return (date of death prior to 12-13-82)
[~5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
[~] 11. Election to tax under Sec. 9113(A) (Attach Sch O)
I-
Z
u,I
Z
o
LU
0
0
FIRM NAME (if Applicable)
TELEPHONE NUMBER
COMPLETE MAILING ADDRESS
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
~--~ Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(8)
(11)
(12)
USE ONLY
13. Charitable and Governmental Bequests/Sec 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)
(13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2) x .0 __
16. Amount of Line 14 taxable at lineal rate fy, ~'- x .0 __
17. x .12
18. x .15
19.
Amount of Line 14 taxable at sibling rate
Amount of Line 14 taxable at collateral rate
Tax Due
(15)
(16) //
(17)
(18)
(19)
Decedent's Complete Address:
STREET ADDRESS
CITY
STATE ZIP
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits ( A + B + C )
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( B + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(3)
A. Enter the interest on the tax due.
(4)
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (SB) ~/ /2,~ , "~ ~
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; .......................................................................................... [] []
b. retain the right to designate who shall use the property transferred or its income; ............................................ []
c. retain a reversionary interest; or .......................................................................................................................... [] []
d. receive the promise for life of either payments, benefits or care? ...................................................................... [] E~]
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.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
S~RE OF PERSON RESPONSIBLE FOR FILING RETURN
ADDRESS
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
DATE
ADDRESS
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 3%
[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 0% [72 P.S. §9116 (a) (1.1)
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
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 tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §91160.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as a~
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1162 EX(11-96)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
CD 002304
BOOKWALTER DENNIS
205 FIRST STREET
SUMMERDALE, PA 17093
fold
ESTATE INFORMATION: SSN: 193-12-8250
FILE NUMBER: 2103-01 04
DECEDENT NAME: BOOKWALTER HOWARD
DATE OF PAYMENT: 03/18/2003
POSTMARK DATE: 03/08/2003
COUNTY: CUM BERLAN D
DATE OF DEATH: 12/20/2002
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
03106257 $313.19
REMARKS:
C/O CATHY D CLEGG
TOTAL AMOUNT PAID:
$313.19
SEAL
CHECK//804
INITIALS: AC
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
TAXPAYER
CoNNONNEALTH OF PENNSYLVANIA
DEPARTNENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 171Z8-0601
REV-16q5 EX AFP (09-00)
ZNFORHATZON NOTICE
AND
TAXPAYER RESPONSE
FILE NO. 21
ACN 03106257
DATE 03-Oq-ZO03
CATHY D CLEGG
BOX 8Z
205 1ST ST
SUMMERDALE PA 17095
TYPE OF ACCOUNT
EST. OF HOWARD BOOKWALTER [] SAVINGS
S.S. NO. 195-12-8250 [] CHECKING
DATE OF DP. ATN 12-Z0-Z002 [] TRUST
COUNTY CUMBERLAND [] CERTIF.
RENTT PAYNENT AND FORNS TO:
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
PNC BANK has provided the Department with the information listed below which has been used in
calculating the potantial tax due. Their records indicate that at the death of the above decedent, you mare a joint caner/beneficiary of
this account. If you feel this information is incorrect, please obtain arittan correction from the financial institution, attach a copy
to this form and return it to the above address. This account is taxable in a~cordance Nith the [nharitance Tax Lams of the Comaonwaa[th
of PennsyXvania. Questions may ba ansaered by calling (717) 787-DSZT.
COHPLETE PART 1 BELOW ~ ~ ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5080595678 Date 05-10-1995
Establ!shad
Account Balance lq, 652. ~0
Percent Taxable X 5 0.0 0 0
Amount Subject to Tax 7,526.20
Tax Rate X .0~5
Potential Tax Due 529.68
To insure proper credit to your account, tmo
(Z) copies of this notice must accompany your
payment to tho Register of Hills. Hake check
payable to: "Register of Hills, Agent".
NOTE: [f tax payments are made within three
(3) months of the dacedent's date of death,
you may deduct a 5Z discount of the tax due.
Any inheritance tax due a[11 become delinquent
nine (9) months after the date of death.
PART TAXPAYER RESPONSE
.~-~ 1-
You may choose to remit payment to the Register of Hills with tea cop[as of this notice to obtain
CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of
ONE ~ Hills and an officiat assessment will be issued by the PA Department of Revenue.
BLOCK J a. [] The above asset has been or will be reported and tax paid aith the Pennsylvania Inheritance Tax return
ONLY to be filed by the decedent's representative.
C. [] The above information is incorrect and/or debts and deductions ware paid by you.
You must complete PART [] and/or PART [] balaa.
PART If you /nd/cate a different tax rate, please state your
[] relationship to decedent:
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS
LINE 1. Data Established I
2. Account Balance 2
$. Percent Taxable $ X
q. Amount SubSect to Tax q
5. Debts and Deductions $ -
6. Amount Taxable 6
7. Tax Rate 7 X
B. Tax Due 8.
PART
DATE PAID
DEBTS AND DEDUCTZONS CLAIMED
PAYEE DESCRTPT~[ON AMOUNT PAID
TOTAL (Enter on Line S of Tax Computation)
Under penalties of porSury, I decZara that the facts I have reported above are true, correct and
complete to the bast of ey knowledge and belief. HOME (
WORK ( )
TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
GENERAL INFORHATION
1. FA/LURE TO RESPOND NZLL RESULT IN AN OFFiCiAL TAX ASSESSNENT eith applicable inter;st based on infarmation
submitted by the financial institution.
Z. /nheritanca tax becomes delinquent nine months after the decedant's data of death.
$. A joint account is taxable even though the decedent's name was added as a matter of convenience.
~. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to
death are fully taxable as transfers.
5. Accounts established jointly between husband end eife more than one year prior to death are not taxable.
6. Accounts held by a decedent "in trust for" another or others are taxable fully.
REPORTING INSTRUCTIONS - PART I - TAXPAYER RESPONSE
1. BLOCK A - If the information and computation in the notice are correct and deductions are not balng claimed, place an
in block "A" of Part ! of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of
tax to the Register of Rills of the county indicated. The PA Department of Revenue will issue an official assessment
(Fora REV-lA18 EX) upon receipt of the return from the Register of Rills.
Z. BLOCK S - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance
Tax Return filed by the dacedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one
copy and return to the PA Department of Revenue, Bureau of Individual Tax;s) Dapt 280601, Harrisburg, PA 17128-0601 in the
envelope provided.
S. BLOCK C - If the notice information is incorrect and/or deductions ara being claimed, check block "C" and complete Parts Z and
according to the instructions below. Sign twa copies and submit them with your check for the amount of tax payable to the Register
of Rills of the county indicated. The PA Depart;ant of Revenue will issue an official assessment (Fore REV-1548 EX} upon receipt
of the return from the Register of Rills.
TAX RETURN - PART 2 - TAX COHPUTATTON
LINE
1. Enter the date the account originally was established or titled in the manner existing at date of death.
NOTE: For a decedent dying after 1Z/1Z/BZ: Accounts which the decedent put in joint names within one (1) year of death are
taxable fully as transfers. However, there is an exclusion not to exceed $$,000 per transferee regardless of the value of
the account or the number of accounts held.
If a double asterisk (xx) appears before your first name in the address portion of this notice, the $5,000 exclusion
already has been deducted from the account balance as reported by the financial institution.
Enter the total balance of the account including interest accrued to the date of death.
The percent of the account that is taxable for each survivor is determined as folloes:
A. The percent taxable for joint assets established more than one year prior to the decedent's death:
1 DIVIDED BY TOTAL NUNBER OF DIVIDED BY TOTAL NUNBER OF X 100 = PERCENT TAXABLE
JOINT ONNERS SURVTVZNG JOINT ORNERS
Example: A joint asset registered in the name of the decedent and two other persons.
! DIVIDED BY 5 (JOINT OHNERS) DIVIDED BY Z (SURVIVORS) = .167 X 100 16.7Z (TAXABLE FOR EACH SURVIVOR)
B.The percent taxable for assets created within one year of the dacedent's death or accounts owned by the decedent but held
in trust for another individual[s) (trust beneficiaries):
! DIVIDED BY TOTAL NUHBER OF SUR¥IVING JOINT X 100 = PERCENT TAXABLE
ORNERS OR TRUST BENEFTCIARIES
Example: Joint account registered in the name of the decedent and two other persons and established within cna year of death by
the decedent.
I DIVIDED BY Z (SURVIVORS) = .50 X 100 = 50Z (TAXABLE FOR EACH SURVIVOR)
The amount subject to tax (line ~3 is determined by multiplying the account balance (line Z) by the percent taxable (line
5. Enter the total of the debts and deductions listed in Part 3.
6. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line
7. Enter the appropriate tax rate (line 7} as determined below.
Date of Death Spouse Lineal ; Sibling ~ Collaterai
07/01/9fi to 12/31/9~ SX 6X 157. 157.
01/01/95 to 06/30/00 OX 6X 15X 15X
07/01/00 to prosont OX fi.SXM 12X 15X
mThe tax rate imposed on the net value of transfers from a deceased years age younger at
death to or for the usa of a natural parent, an adoptive parent) or a stepparent of the child is OZ.
The lin;al class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children
ahether or not they have been adopted by others, adopted children and step children. "Lin;al descendents" includes all children of the
natural parents and their descendents, whether or nat they have been adopted by others, adopted descendents and their descendants
and step-descendants. "Siblings" are defined as individuals ;ho have at least one parent in common aith the decedent, eh;that by blood
or adoption. The "Colleterml" class of heirs includes mil other beneficiaries.
CLAIHED DEDUCTIONS - PART S - DEBTS AND DEDUCTIONS CLAIHED
Allocable debts and deductions are determined as follows:
A. You legally are responsible far payment, or the estate subject to administration by a personal representative is insufficient
to pay tho deductible items.
B. You actumlly paid the debts after death of the decedent and can ~urnish proof of payment.
C. Debts being claimed must ba itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of
payment may ba requested by the PA Department of Revenue.
REV-1508 EX + (1-97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
~s~,~o~>/ou~ ~p Book ~,~,'?£CK ~,,~.u~.~.
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
I
I VALUE AT DATE
NUMBER I DESCRIPTION
7.
TOTAL (Also enter on line 5, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
Of DEATH
REV-1511 EX * (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ES '^TEOF HO f/ItP BOOK
Debts of decedent must be reported on Schedule I,
FILE NUMBER
ITEM
NUMBER
5.
6.
7.
DESCRIPTION
FUNERAL EXPENSES:
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Secudty Number(s) / EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, pttach explanation)
Claimant ~ /~
Street Address ~ ~) ¢
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Retum Preparer's Fees
TOTAL (Also enter on line 9, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
AMOUNT
REV-15~'3 EX+ (9-00~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
FILE NUMBER
ESTATE OF WO ~o ~ gO0 r ~ ~) L 7-E~
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a)(1.2)]
I
1.
I]
1.
CLE.6:G
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
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 $
(If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2806O1
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
CD
REV-1162 EX(11-96)
OO2515
BOOKWALTER DENNIS H
P O BOX 82
205 FIRST STREET
SUMMERDALE, PA 17093
........ fold
ESTATE INFORMATION: SSN: 193-12-8250
FILE NUMBER: 2103-0104
DECEDENT NAME: BOOKWALTER HOWARD
DATE OF PAYMENT: 05/01/2003
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 12/20/2002
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $1,112.78
TOTAL AMOUNT PAID:
$1,112.78
REMARKS: DENNIS H BOOKWALTER
SEAL
CHECK# 906
INITIALS: JA
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
~UREAU 'OF ZNDZVZDUAL TAXES
INHERITANCE TAX DIVZSION
DEPT. 280601
HARRZSBURG, PA 17128-0601
DENNIS H BOOKWALTER
205 1ST ST
SUMMERDALE
COMMONNEALTH OF PENNSYLVANZA
DEPARTMENT OF REVENUE
NOTZCE OF INHERZTANCE TAX
APPRA/SENENT, ALLOHANCE OR DZSALLO#ANCE
OF DEDUCTZONS AND ASSESSHENT OF TAX
R~CO~'G(~ ('~:~ ~ Of DATE
Re~:.': '~: ~ ~/~g ESTATE OF
DATE OF DEATH
FILE NUHBER
'03 23 Al0:27COUNTY
ACN
PA
05-26-2005
BOOKNALTER
1Z-ZO-ZOOZ
21 03-OlOq
CUMBERLAND
101
Amoun~ ReeLt~ed
REV-i$~i7 EX AFP COl~OS)
HONARD A
HAKE CHECK PAYABLE AND REMZT PAYMENT TO:
REGISTER OF MILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THZS LINE ~ RETAZN LONER PORTZON FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03) NOTZCE OF ZNHERZTANCE TAX APPRAZSEMENT, ALLONANCE OR
DZSALLONANCE OF DEDUCTZONS AND ASSESSMENT OF TAX
ESTATE OF BOOKNALTER HONARD A FZLE NO. 21 03-010q ACM 101 DATE 05-26-2003
TAX RETURN HAS: ( ) ACCEPTED AS FZLED (X) CHANGED SEE ATTACHED NOTICE
RESERVATZON CONCERNING FUTURE ZNTEREST - SEE REVERSE
APPRA]:SED VALUE OF RETURN BASED ON.' ORIGINAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
:5. Closely Held Stock/Partnership Tnterest (Schedule C) (:5)
4. Hortgagas/Notas Receivable (Schedule D) (4)
5. Cash/Bank Deposits/HLsc. Personal Proper~y (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
APPROVED DEDUCTZONS AND EXEMPTZONS:
9. Funeral Expenses/Adm. Costs/Misc. Expanses (Schedule H) (9)
lO. Debts/Mortgage Liabilities/Liens (Schedule Z) (10)
11. Total Deductions
12. Net Value of Tax Return
1:5.
14.
Charitable/Governmental Bequests; Non-elected 911:5 Trusts (Schedule J)
Net Value of Estate Subject to Tax
.00
.00
.00
.00
200.00
35;167.00
.00
(8)
383.00
.0O
NOTE: To insure proper
credit to your account,
submit ~he upper portion
of *his form with your
~ax payment.
NOTE:
35,367.00
(111 :~sR. §0
(l~') 34,98~. O0
(15) . O0
(14) 34,98q. O0
]:f an assessment vas &ssued previously, 11nes 14, 15 and/er 16, 17,
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX: 15. Amount of Line lq
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rate
18. A.ount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Duo
TAX CREDZTS:
PAYHENT J R[C[/PT
DATE NUMBER
03-08-2003
05-01-2003 CD002515
PAYMENT MUST BE MADE BY 09-Z0-Z003~.
18 and 19 ~ill
1,q, q2.q5
131.83
.00
131.83
( ZF TOTAL DUE TS LESS THAN $1, NO PAYMENT ZS REQUTRED.
ZF TOTAL DUE TS REFLECTED AS A "CREDZT' (CR); YOU HAY BE DUE
A REFUND. SEE REVERSE SZDE OF THZS FORM FOR ZNSTRUCTZONS.)
OI$COUNT
ZNTEREST/PEN PAZD (-)
16.q8
.00
TOTAL TAX CREDZT
BALANCE OF TAX DUE
ZNTEREST AND PEN.
TOTAL DUE
313.19
1,112.78
ZF PAZD AFTER DATE INDICATED~ SEE REVERSE
FOR CALCULATZON OF ADD/T/ONAL /NTERESTo
AHOUNT PAZD
(15) .00 X O0 = .00
(16) 3q,98q. O0 X Oq5 = 1,57~.28
(17) .00 x 12 = .00
(la) .00 x 15 = .00
(19)= 1,57q.28
RESERVATION:
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADMIN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December 1Z, 198Z -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
To fulfill the requirements of Section ZlqO of the Inheritance and Estate Tax Act, Act Z$ of ZOO0. (TI P.S.
Section 9160).
Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side.
--Make check or money order payable to: REGISTER OF NILLS, AGENT
A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications are available at the Office
of the Register of Hills, any of the Z5 Revenue District Offices, or by calling the special gq-hour
ansaering service for forms ordering: l-BgO-56Z-Z050; services for taxpayers with special hearing and / or
speaking needs: 1-800-qq7-$020 (TT only).
Any party in interest not satisfied aith the appraisement, allowance, or disalloaance of deductions, or assessment
of tax (including discount ar interest) as shown on this Notice must object within sixty (60) days of receipt of
this Notice by:
--written pretest to the PA Department of Revenue, Board of Appeals, Dept. Z81091, Harrisburg, PA 171ZB-10Z1, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. lB0601, Harrisburg, PA 171Z8-0601
Phone (717} 787-6505. See page 5 of the book[et "'Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-150I) for an explanation of administratively correctable errors.
If any tax due is paid within three (5) calendar months after the decadent's death, a five percent (SI) discount of
the tax paid is allowed.
The 1SI tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of
six (6Z) percent per annum calculated at a daily rate of .OO016q. All taxes which became delinquent on and after
January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 198g through gOOS are:
Interest Daily Interest Daily Interest Daily
Rate Factor Year Rate Factor
Year Rate Factor Year
1982 ZOZ . 000548 1987
1985 16Z .000~58 1988-1991
198q llX .000501 199Z
1985 152 . 000556 1995-199~
1986 lOX . O0027~ 1995-1996
--Interest is calculated as folloas:
INTEREST = BALANCE OF TAX UNPAID
9Z .O00Z~7 1999 7Z .00019Z
11Z .000501 gao0 BZ .oaogl9
9Z .OOOZq7 2001 9Z .OOOZ~7
7Z .O0019Z 200Z 6Z .00016~
9Z .O00Z~7 2003 5Z .000157
X NUHBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent mill reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
REV-1470 EX (6-88)
INHERITANCE TAX
COMMONWEALTH OF PENNSYLVANIA EXPLANATION
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES OF CHANGES
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENTS NAME
Howard A. Bookwalter FILE NUMBER
REVIEWED BY 2103-0104
John Kuchinski ACN
101
ITEN
SCHEDULE NO. EXPLANATION OF CHANGES
E 1,2 These jointly held accounts have been moved and correctly reported as non-probate
assets on Schedule F (Jointly Held Assets) taxable to the surviving joint owner, Cathy D.
Clegg.
H B3 Reduced to $200.00. Family exemption can only be claimed against assets subject to
will or intestacy.
ROW Page 1
BUR£~(J OF ZNDTVZDUAL TAXES
INHERITANCE ,'AX DIVISION
DEPT. Ze0601
HARRISBURP,, PA 17128-0601
COMNONWEALTH OF PENNSYLVANIA
DEPARTNENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAZSEHENT, ALLO#ANCE OR DZSALLO#ANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
RE¥-1547 EX &FP (01-OS)
DENNIS H BOOKWALTER
205 1ST ST
SUMMERDALE PA 17095
CUT ALONG THIS LINE
DATE 05-Z6-Z005
ReC~?-~ !i~.~ Of ESTATE OF BOOKWALTER
Reo;~:! .... J, ,.,,!13 DATE OF DEATH 12-20-2002
FILE NUMBER 21 05-0104
COUNTY CUNBERLAND
'03 MAY 28
HOWARD
Amoun'~ Rem ~.'t'l:ed
A.
UMAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGZSTER OF WILLS
CUH~ERLAND CO COURT HOUSE
CARLISLE, PA 1701~
RETAIN LOWER PORTION FOR YOUR RECORDS ~ .
Cathy Clegg
P.O. Box 82
Summerdale, PA 1Z093
'03 I'tAY 28 ill :15
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-1162 EX(11-96)
CD O02619
BOOKWALTER DENNIS H
P O BOX 82
SUMMERDALE, PA 17093
........ fold
ESTATE INFORMATION: SSN: 193-12-8250
FILE NUMBER: 2103-01 04
DECEDENT NAME: BOOKWALTER HOWARD
DATE OF PAYMENT: 05/28/2003
POSTMARK DATE: 05~27/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 12/20/2002
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $131.83
TOTAL AMOUNT PAID:
$131.83
REMARKS: DENNIS H BOOKWALTER
SEAL
CHECK# 912
INITIALS: JA
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
BUREAU OF ZNDZVZDUAL TAXES
'rNHERTTANCE TAX D%VZSTON
DEPT. 280601
HARRISBURG, PA 171Z&-0601
COMNONNEALTH OF PENNSYLVANZA
DEPARTMENT OF REVENUE
'rNHERZTANCE TAX
STATEHENT OF ACCOUNT
DENNIS H BOOKWALTER
205 1ST ST
SUMMERDALE PA ~7~95
'03 JJ?, 20,,,'¥", : 'iO
DATE 06-09-2005
ESTATE OF BOOKNALTER
DATE OF DEATH 12-ZO-200Z
FZLE NUMBER 21 05-010q
COUNTY CUMBERLAND
ACN 101
Amoun'~ Remi'l:*l:ed
REV-i&O? EX AFP CD1-03)
HONARD A
MAKE CHECK PAYABLE AND RENZT PAYMENT TO:
REGISTER OF MILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
NOTE: To Lnsure proper cred/~ ~o your account:, subm/~ ~he upper portion of ~:his fore wJ~ch your ~:ex payment.
CUT ALONG TH'rS LZNE ~ RETA'rN LONER PORTTON FOR YOUR RECORDS *~
REV-1607 EX AFP (01-03} ##~ ZNHERZTANCE TAX STATEMENT OF ACCOUNT ~
ESTATE OF BOOKNALTER HONARD A FZLE HO. Z1 05-010q ACN 101 DATE 06-09-2005
THZS STATEMENT TS PROVTDED TO ADVTSE OF THE CURRENT STATUS OF THE STATED ACN TN THE NAHED ESTATE. SHONN BELON
TS A SUMMARY OF THE pR'rNc*rpAL TAX DUE, APPL'rCATTON OF ALL PAYMENTS,, THE CURRENT BALANCE, AND, TF APPLTCABLE,
A PROJECTED TNTEREST F*rGURE.
DATE OF LAST ASSESSHENT OR RECORD ADJUSTMENT: 05-Z6-ZO05
PRINCIPAL TAX DUE: ...........................................................................................................................................................................................................................
PAYHENTS (TAX CREDITS):
1,57~.Z8
PAYMENT RECEIPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID ¢-) AMOUNT PAID
05-08-2005
05-01-2005
05-Z7-ZO05
CDOOZ$Oq
CDOOZ515
CDOOZ619
16.q8
.00
.00
313.19
1,112.78
131.83
ZF PAID AFTER TH/S DATE, SEE REVERSE
SZDE FOR CALCULATZON OF ADDZTZONAL ZNTEREST.
{ ZF TOTAL DUE IS LESS THAN $1,
NO PAYMENT 1S REQUIRED.
IF TOTAL DUE 1S REFLECTED AS A "CREDIT" (CR),
TOTAL TAX CRED'rT
1,57q.28
BALANCE OF TAX DUE .00
ZNTEREST AND PEN. .00
TOTAL DUE .00
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THTS FORM FOR TNSTRUCTTONS.
PAYNENT:
Detach the top portion of this Notice and submit with your payment made payable to the name and address
printed on the reverse side.
-- [f RES[DENT DECEDENT make check or money order payable to: REGISTER OF NZLLS, AGENT.
-- If NON-RES[DENT DECEDENT make check or coney order payable to: CONNON#EALTH OF PENNSYLVANIA,
REFUND (CR): A refund of a tax credit, ahich ams not requested on the Tax Return, amy be requested by completing an
"Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications are available at
the Office of the Register of Nills, any of the Z5 Revenue District Offices or from the Department's lC-hour
ansaaring service for fores ordering: 1-800-56Z-Z050; services for taxpayers with special hearing and ! or
speaking needs: 1-800-¢¢7-30Z0 (TT only).
REPLY TO:
Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Bureau
of individual Taxes, ATTN: Post Assessment Revie~ Unit, Dept. ZSOGO1, Harrisburg, PA 171Z8-0601, phone
(717) 787-6505.
DISCOUNT:
If any tax due is paid within three ($) calendar months after the decedent's death, a five percent (SI) discount
of the tax paid is allowed.
PENALTY:
The 1SI tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period.
INTEREST:
Interest is charged beginning ~ith first day of delinquency, or nine (9) months and cna (1) day from the date of
death, to the date of payment. Taxes ~hich became delinquent before January 1, 1982 bear interest at the rate of
six (Gl) percent per annum calculated at a daily rate of .00016¢. All taxes which became delinquent on and after
January 1, 198Z will bear interest at a rate ahich Hill vary from calendar year to calendar year ~ith that rate
announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOO3 are:
lnterest Daily Interest Daily Interest
Year Rate Factor Year Rate Factor Year Rate
Daily
Factor
1982 ZOZ .0005¢8 1987 9Z .O00Z¢7 1999 7Z .000192
1983 16Z .000¢58 1988-1991 11Z .000501 2000 8Z .000219
198¢ XXZ .000301 199Z 9Z .000Z¢7 ZOO1 9Z .000Z¢7
1985 13Z .000356 1993-199¢ 7Z .00019Z ZOOZ 6Z .00016¢
1986 IOZ .00027¢ 1995-1998 92 .0002¢7 2005 5Z .000137
--Interest is calculated as folleas:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
STATUS REPORT UNDER RULE 6.12
Name of Decedent:
Date of Death: p~C.
Will No.
^dm n. No. 2; -- 03 - 0]0
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, ! report the following with respect to completion of
the administration of the above-captioned estate:
State whether administration of the estate is complete:
Yes~ No__
2. If the answer is No, state when the personal
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 {epresentative file a final
account with the Court? Yes No~ .
b. The separate Orphans' 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 ~ No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date:
Signature
Name (Please type or print)
Address ~
Tel . No.
Capacity: ~ Personal Representative
(MAH:rmf/AM3)
~Counsel for personal
representative