Loading...
HomeMy WebLinkAbout03-11-111505610105 J REV-1500 Ex coz-11, IFS, . OFFICIAL USE ONLY PA Department of Revenue Pennsylvania DEPARTMENT OG REVENUE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN I ~ ~ I PO BOX 28o6oi (~ I ~ r~ ~ Harrisburg, PA 1'7128-0601 R ESIDENT DECEDENT I I ~ r _ _ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 201-18-6200 ~ 12/26/2010 I 1 08/02/1915 Decedent's Last Name Suffix Decedent's First Name MI ~ Hertzler Margaret R (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C>~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy'of`VI/ill) (Attach `Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ~ Ronald E. Johnson, Esq (717) 243-0123 REGISTER OFJ`~A.IIEC$ USE ONLY'~- <=" I i r. , ~ First Line of Address r - _ : i r~ --- 1' -' 78 West Pomfret Street ~ ` ' \ Second Line of Address `- ' ` ~' ' ! ~- ~ -- _ _a --~ ~ ~ DATE~RILED r : City or Post Office v . State ZIP Code !~ Carlisle ~ ~~ PA ~ 17013 Correspondent's a-mail address: rejohnson pa.net. 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. SIGNATURE OF PE N RESPONSIB E FOR FILIN RETURN DATE 3-~'~r ADDRESS c/o 78 West Po fret Street, C lisle A 17013 S R A ER TH ENTATIVE DATE RESS c/ 78 West Pomfret Str ,Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 ~- ~> _ _-j _ .. .._ -- ~.~ r~ ~ ~..~'3 L} ';~ J REV-1500 EX (FI) rlacPriant's Name: Margaret R. Heltzler Decedent's Social Security Number 201-18-6200 RECAPITULATION __ 1. Real Estate (Schedule A) ............................................. . 1. ~ .~__.___ 0.00 2. Stocks and Bonds (Schedule B) ....................................... ~ 2.i 0.00 i 3. Closel Held Cor oration, Partnershi or Sole-Pro rietorshi Schedule C Y P P P P( ) •.••• 3. ~ 0.00 4. 9 9 ( ) ........................... Mort a es and Notes Receivable Schedule D I 4. ~ 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 3,551.25 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. j 18,449.07 7. P rtY Inter-Vivos Transfers & Miscellaneous OPSe araterBillin Re uested........ (Schedule G) P 9 q 7. + ~ 0.00 I 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. i 22,000.32 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ~ 2,649.05 I 10. Debts of Deced~ent,•Mortgage•Liabilities and Liens {Schedule l) ............ . .: i '10. j I 0.00 11. •••..•• Total Deductions (total Lines 9 and 10) .......................... 11.I 2,649.05 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. i 19,351.27 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .. . ..................... 13. , 0.00 14. J ( ) ........... Net Value Sub'ect to Tax Line 12 minus Line 13 ............. i 14. ~ 19,351.27 , TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 _ 1 5. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ........................................................ . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610205 1505610205 1505610205 O J REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENTS NAME Margaret R. Hertzler STREET ADDRESS 372 West South Street CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 145.13 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) (3) (4) (5) 2,902.69 2,757.56 0.00 0.00 2,757.56 Make check payable to: REGISTER OF WILLS, AGENT. - . _r ~ _.. _.._. r_ .:. _ , ~ . _ ---yam 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 .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or. for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. LAST WILL AND TESTAMENT OF MARGARET R. HERTZLER I, MARGARET R. HERTZLER, of the Borough of Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking all other wills and codicils heretofore made by me. FIRST: I direct that all my just debts and funeral expenses, including my grave marker, shall be paid from the assets of my estate as soon as practicable after my decease. SECOND: I hereby make the following specific gifts, bequests and devises: A. I give and bequeath my automobile and/or a like amount in cash to my great- nephews, DAVID E. LOBATO and JOHN THOMAS FREY, to be distributed by my hereinafter named Executrix in the following manner: My great-nephew, DAVID E. LOBATO, shall be given the first opportunity to determine whether he desires to accept the bequest of my automobile and shall make a decision regarding this bequest within forty-five (45) days following my death and communicate his desires to my Executrix in writing. Should DAVID E. LOBATO desire to accept this bequest of my automobile, then and in that event I give and bequeath said automobile to him and I further give and 'bequeath an amount in cash equal to the value of said automobile as established for Pennsylvania inheritance tax purposes to my other great-nephew, JOHN THOMAS FREY. Should DAVID E. LOBATO reject or fail to accept the bequest of my ~ automobile within forty-five (45) days following my death as provided for herein, then and in that event, my great-nephew, JOHN THOMAS FREY, shall be given +1,A 71P~f n+~r,n,-t„n;+~~ to r~P+a,-m;na....x.al~atl~Pr ti,~ FiPCirPC ~n 'arrPnf tl~;p ~'-P~1?~PC+ ~1f ?Y1v ~.Z1V alVl i •.i IJ l/ V 1 Mall V~ a. •.~ 4rV LLa1aY111•r ~ t • r wlJ~ a .~.I F, _ 1 automobile and shall make a decision regarding this bequest within ninety (90) days following my death and communicate his desires to my Executrix in writing. Should JOHN THOMAS FREY desire to accept this bequest of my automobile, then and in that event I give and bequeath said automobile to him and I further give and bequeath an amount in cash equal to the value of said automobile as established for Pennsylvania Inheritance Tax purposes to my other great-nephew,, DAVID E. LOBATO. Should neither DAVID E. LOBATO or JOHN THOMAS FREY desire to accept the bequest of my automobile as set forth herein, then and in that event I direct my hereinafter named Executrix to sell said automobile and distribute the proceeds thereof in accordance with the residuary clause of this my Last Will and Testament, and neither great-nephew shall receive a cash bequest equal to the value of my automobile. B. C. I give and bequeath all of the following items to my niece, PATRICIA ANN SHEAFER FREY: My Peridot ring My dressing table lamp with clear glass globe My cherry dresser and mirror -- My diamond drop necklace I give and bequeath the following items to my niece, MARY JANE LOBATO: My grandfather clock My TV and stand My Hush Puppy watch My three-diamond lavaliere necklace All of my bedroom furniture except my cherry dresser and mirror D. E. I give and bequeath my garnet earrings to my niece, SUE HERTZLER GEERY. I give and bequeath.my~.dia~nond ring which Aunt Elda gave me to my great-niece, MARY SUZANNA CAMPBELL. F. I give and bequeath my elephant collection, excluding my two large ceramic elephants which I previously gave to my niece, MARY JANE LOBATO, to my great-nephews, JOHN THOMAS FREY and DAVID E. LOBATO, and I further direct that the collection should be equally divided between them by hereinafter named Executrix in her sole discretion. G. T' give and 'bequeath the sum of'Five Thousand ($"5,000:00) I~olTars to my great- nephew, JOHN THOMAS FREY, and I give and bequeath the sum of Five Thousand ($5,000.00) Dollars to my great-nephew, DAVID E. LOBATO. Should either of my great-nephews predecease me without leaving issue surviving, this bequest will lapse, but should they predecease me leaving issue surviving, the bequest provided for herein shall be distributed to their surviving, issue,. per stirpes. H. I give and bequeath my brass student lamp to my great nephew, DAVID E. LOBATO, I. I give and bequeath my china lamp with a figure dressed in Revolutionary-type clothing to my great nephew, JOHN THOMAS FREY. J. I give and bequeath all of my antiques, furniture, household goods, j ewelry and like tangible property not. otherwise specifically bequeathed herein to my niece,, MARY JANE LOBATO. THIRD: I give, devise and bequeath the residue of my estate, of every nature and wherever situate, as follows: A. Three-quarters thereof to my niece, MARY JANE LOBATO provided that should she predecease me her share shall be distributed to her issue per stirpes living at the time of my death. B. One-eighth thereof to my niece, PATRICIA ANN SHEAFER FREY provide that should she predecease me her share shall be distributed to her issue per stirpes living at the time of my death; and C. One-eighth thereof to SAMUEL B. HERTZLER and ELEANOR HERTZLER, his wife, or the survivor of them FOURTH: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. FIFTH: I nominate, constitute and appoint my niece, MART' JANE LOBATO as Executrix of this my Last Will ~anci Testament. Should my niece, MARY JANE LOBATO fail to qualify or cease to act as Executrix, I appoint my great nephew, DAVID E. LOBATO, Executor of this my Last Will and Testament. SIXTH: I direct my Executrix and her successor shall not be required to give bond for the faithful performance of their duties in this or any other jurisdiction. r~T ~'~nrT1~~~S ~~vuF~Fn~ I ha~re hereunto set my hand and seal to this, my Last Will Testament consisting of five (5) typewritten pages, each identified by my signature, this day of ,~`~~~ 2005. '~~ (SEAL) M aret R. Hertzier Signed, sealed, published and declared by the above-named Testatrix, MARGARET R. HERTZLER, as and for her Last Will and Testament, in the presence of us, who, at her request, in her sight and presence, and in the sight and presence of each other, have hereunto subscribed our names as witnesses. COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. I, MARGARET R. HERTZLER, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affumed to and acknowledged before me by MARGARET R. HERTZLER, the Testatrix, this ~ day of ~_ ~ ; ~; ~~~ :- 2005. y NQ`fARii0.L ~~A~ SHELLY SEXT'C7N, Notary Public Carlisle Boro, Cumberland County My Commission Expires April 26, 2007 (SEAL) Margaret ROHertzler, Testatrix ~~ (, i~ / 1 f ~. / ,,. ~, . Notary Pubic AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) We, RONALD E. JOHNSON and i ~k ~ - r _ r ` -.! ~ -.-,.:__ I. ,-~~`~ ~~:!> ,the witnesses whose names are signed to the attached or foregoing`instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her Last Will and Testament; that MARGARET R. HERTZLER signed willingly and that she executed it as her free and voluntary act for the purpose therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. S«~orti or affirmed to and subscribed to before me by RONALD E. JOHNSON and ~;~ ~ ;. ~~~%_'~-~~ ,, ` ~,: ~ -~'~,,.~ - ,witnesses, this t day of ~~ ~'- _ _ 2005. J SEAL) NOTARIAL SERI, SHELLY SEXTON, Notary Public Carlisle Boro, Cumberland County My Commission Expires April 26, 2007 r,. i ~. •• ,^ '; j '~.f `. (SEAL) REV-15o8 EX+ (ii-io) ...~ ~~ ° pennsylvarna DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Margaret R. Hertzler Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. If more space is needed, use additional sheets of paper of the same size. r 3~~ +~m j J' S" a ~' ~ ~~ 3 ~ ~A~r~_ "~~V ~ a 824 s'~ *~e~ ~_ N. Cp ~ L ; EpE r CARLISLE ST, (717) 249-A 1 T013 35 DATE: 31 ~ ~~ ~ n . T _ r ~. CUSTOMER'S ORDER NO. i NAME: ~= _ _ V `.- ADDRESS Q_ J SOLD BY CASH ~ COD CHARGE ON ACCT ~ . 1 MDSE RET D PA[D OUT- :::j ~- ON• DESCRIPTION ,= ~ ' ~=. y ~ _ PRICE -AMOUNT ~i y - `"'..y ~C°~' 1 -~.~ f - psi -.. ~ ~, ~ ~ L - ~ ~" ~ . } e - - $ i ! - ,-~ .~: _ 70 , r. All claims and retu rned goods MUST be accompanied b f R ~ ECEIVED 13Y - y this 6111. ~ ,~ ARM ~~ S8847-CL Du • ~, plicat . e • 58947-CL Triplicate _ ` ©1959 Rediform '~ ~.. Thomas G. Thom so p n ~`~,1'1f1.gtl~S 52 West Pomfret Street • Carlisle, PA 17013 ,, (717) 243-5495 • (717) 249-4321 ~~is~ __ cowdance@epix.net ~~ Date ~/~r/- ~z l ~ o / ~ M ~~~ r~ /G i1 ~ / d b •4 3 ~~ sow ~~ ~~ ~~2~s~e , ITEM ITEM DESCRIPTION PRICE NUMBER TOT~1 pRir_~ Property will be sold in ordinary course of purchaser's business under Tax License No. DATE SIGNED ~ cerury inai unless ~ advise you to the contrary in writing all property pur- chased above is tax exmpt because: REV-15og EX+ (o1-io) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F ]OINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: Margaret R. Hertzler ]OINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT pgTE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE'NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °k of DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 08/28/98 checking account no: 3740169564-M&T Bank (see letter attached) 585.25 50% 292.63 2. A 12/20J99 saving account no:189721-00-Members 1st FCU 762.00 50% 376.00 3. A 04/17/06 checking account no: 189721-11-Members 1st FCU 9,085.88 50% 4,542.94 4. A 01114/00 certificate of deposit no:189721-42-Members 1st FCU (see letter 26,475.01 50% 13,237.50 attached to items 2-4) TOTAL (Also enter on Line 6, Recapitulation) I $ 18,449.07 If more space is needed, use additional sheets of paper of the same size. Tf an aeept haramP ;eintly owned within one veer of the decedent's date of death, it must be reported on Schedule G. M&TB~ 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Phone 888-502-4349 F ax (302) 934-2955 January 25, 2011 Andrews and Johnson 78 West Pomfret Street Carlisle, PA 17013 Re: Estate of Margaret R Hertzler Social Security: 20i-1~-6200 Date of Death: December 26, 2010 Dear Sir or Madam: Per your inquiry on January 11, 2011, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total Checking Account 3740169564 Margaret R Hertzler Mary Jane Labato 0828/g8 $585.25 $ . DO $585.25 For further account information, closures and/or reimbursement of funds please call the Stone Hedge Office at #717-240-4524. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney, Ctistodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement Sincerely, I'; .-~, ''~ / ` •L Tammy Spencer Adjustment Services St MEMBERS 1St FEDERAL CREDIT UNION SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established 189721-00 12/20/1999 $751.85 $.15 $752.00 Mary Jane Lobato 12/20/1999 189721-11 04/17/2006 $9,085.23 $.65 $9,085.88 Mary Jane Lobato 04/17/2006 189721-42 01 /14/2000 $26,453.45 $21.56 $26,475.01 Mary Jane Lobato 01 /14/2000 E BERS 1sT FEDERAL .EDIT UN ON,. . ~~-- Danielle A. KI ne Lending Insurance Support Specialist January 13, 2011 Estate of: MARGARET HERTZLER Date of Death: 12/26/2010 Social Security Number: 201-18-6200 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmembersl st.org REV-1511 EX+ (10-09) .:a . pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Margaret R. Hertzler Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~' Hoffman Roth Funeral Home -balance due 179.88 2. Janet Lush -catering for funeral luncheon 800.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 1,500.00 2. Attorney Fees: 3. Family Exemption: (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: 5. Accountant Fees: 6. Tax Return Preparer Fees: ~• National Life -reimburse annuity overpayment 58.00 s. PA State Employees Retirement System-reimburse overpayment 46.17 s. H&R Block -final income tax return preparation 50.00 ~ o. Register of Wills - PA Inheritance Tax Return -filing fee 15.00 TOTAL (Also enter on Line 9, .Recapitulation) I $ 2,649.05 If more space is needed, arse additional sheets of paper of the same size. " REV=15T3"EX±"(01=10} ~`~~a Pennsylvania SCHEDULE DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Margaret R. Hertzler RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER "NAME AND~ADDRESS~GF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] i. Mary Jane Lobato, 372 West South Street, Carlisle, PA 17013 niece 2,675.00 2. Patricia Ann Sheaffer Frey, 325 Washington Lane, Carlisle, PA 17013 niece 230.00 3. Sue Hertzler Geery, 22 Waverly Road, Darien, CT 06820 niece 0.00 4. David E. Lobato, 556 Hillcrest Dr, Carlisle, PA 17015 great nephew 150.00 5. John Thomas Frey, 327 Franklin Street, Carlisle, PA 17013 __ _ great nephew 150.00 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUG H 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, use additional sheets°of~papernf~the same~size. '