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HomeMy WebLinkAbout04-08-111505610105 REV-1500 ~ (02-i1) (FI) OFFICIAL USE ONLY PA Department of Revenue Pennsylvarria DEPARTMENT OF REVENUE County Code Year Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 28o6oi I ~ti Harrisburg, PA i~i28-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2- E/ ( 2- ~ `~ ~ ~'' v ~ 1-- f '~c~ ~' 2~.,-' / ~ ~°' l 12.E f / ~j 3 d Decedent's Last Name Suffix Decedent's First Name Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS (If Applicable) Enter Surviving Spouse's Information Below FILL IN APPROPRIATE OVALS BELOW MI MI __.- ® 1. Original Retum O 2. Supplemental Retum O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ., ~~ First Line of Address Second Line of Address State ~ ZIP Code 1 ~ ~ ~ ~1 , Correspondent's a-mail address: ~/`~ ~= (~ ~ ~ '~-`"j "~'~ ~""~~ `~``t- ,;, l ~ ' ~` City or Post Office REGISTER C~S USE OJFCLY ~`" 1 ~_~ ~]*~ ~.~ i..~ Z3 ".,' F - j ? y~ rn e 1./) r,:~ L,.~ .; ,___ ,_,~ t_...._ - .. D~E FILED `µ - -~ Under penalties of perjury, t 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 co plete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PER ON RE QNSIBLE F R ILING RETURN DATE `" r3 ~- '~~ ~ ~_ ADDRESS ~ ) ~, lr ~ ~ .). ~, }~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY L 1505610105 Side 1 1505610105 J 1=ile Number . ~~% ~ l ~~ ~' ~ ~ 1 r~ ,: r .~ ~~~ -~z-i Lsos61o2os REV-1500 EX (FI) Decedent's Social Security Number ' ~~" 1 ~ ~ ! ~ ~ ~ C.) Decedent s Name: RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. ~,~ 2. Stocks and Bonds (Schedule B) ....................................... 2. ~ ~-•-~ _ ~~~~ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. f_..--~ 4. Mort a es and Notes Receivable Schedule D 9 9 ( } ........................... 4. '"~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ~ `~`r~~ ~--~ , f~~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. ~,..~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets total Lines 1 throw h 7 ( g ) ............................ 8. ~ ~ C' t ~7 L~j 9. Funeral Ex erases and Administrative Costs Schedule H 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. ~t7~d ~ ~ 7,. ~ 11. Total Deductions (total Lines 9 and 10) ................................. 11. ~ ~ ~ -• ~, p~~ r 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ~ ~ ~ ~ (;,;, ~ ~ ~e~~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ' ~ _ an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~_-~ 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_ 15. fJ 16. Amount of Line 14 taxable at lineal rate X .0 __ 16. ~ 17. Amount of Line 14 taxable at sibling rate X .12 17. G 18. Amount of Line 14 taxable 15 l X t ll t t 18 / era . a co a ra e . C. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1,50561,0205 1,505610205 REV-1500 EX (FI) Page 3 File Number ~Z ~~; ,~~~• (,e!.- G ~ ; _ C. Decedent's Complete Address: DECEDENT'S NAME t 'y`am / ~ ~\ STREET ADDRE S CITY STATE ZIP r '~ ~ ~ ~'' 1 ~,~ v~ f , •-fir iT=~-"-- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments _____ B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) ~`_,~ Total Credits (A + B) (2) I`~ (3) ~...~ (4) (5) (. 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 .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the r~et 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 benefiaaries 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. INVENTORY REGISTER OF WILLS OF ~ v ~'" ~~- -~~"`~? COUNTY, PENNSYLVANIA. COMMONWEALTH OF PEl~'N5Y-L,Y'ANIA COUNTY OF SS File NtunUer ~~ 1 f ~ ~~ ~ Persanal Representative(s) of the Estate of J ~ ~~ ~°-~ `~ ~ ''~ ~ '~ - ~'' ~' ' deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets svherever sih~ate and all of the real estate in the Canuuonwealth of Pemisylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the C'onunonwealth of Pennsylvania except that which appears in a ineuioranduin at the end of this inventory. I verify that the stateiuents made in tlus hlven- _ , ~~ ~~ ~~ Cory are true and con~ect. I understand that false state- r inents herein are made subject to the penalties of ~,~~,~ r,., l A-/' , `I; ~ ~ ~ ~cc t' v~t~~" ~~1 l:`{ j ~'~ I8 Pa_C.S. ~ 4904 relating to ~u~swarn falsification to ' authorities. Attorney -- (Name) (S~~preme Court ~ D. No.) (t1 dclress) (Telephone) DATE OF DEATH LAST RESIDENCE DECEDENTS SOC. SEC. NO. FIGURES VIL'ST BE TOTALED (Attarlr additional sheets as needed) I ~ 4 ~i ~-' _~' -2 c~i~ . ____. `~' S : ~ ~.~ ~y`~ ~ ,. ~'~ TOTAL: ~ ~ ~~~"~~ 0.00 NOTE: The Memorandum of real estate outside the Conxuionv~~ealth of Pexxxxsyll•ania xxxay. at the election of the personal represexxtati~-e uiclude the ~•Alxxe of each item. but sxxch fxgxxres should not be extended into the total of die In~•entory. ISPe 20 Pn. C.S. 6 3301 fbJ} Fos~x R~=0.9 reti~. IQ.i3.06 REV-; 502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RFSIr1FNT f)FC;Ff1FNT ESTATE OF FILE NUMBER '~ ~r G i.~ ~/ Q ~ ~ ~'/'Nt L' ~ , ~Gi i ! 5 ~,C" ZQ C (- (~ D i~' 1 All real property owned solely or as a tenant in common must be reported at fair market val e. 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 nronerty which is jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV'-1503 EX+ (6-98) ~: P. SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of urvivorship ust be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (1-97) ,~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDVLE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must be attached for each cl sely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size) 'l: ~~ ~• ~J ~~ C- ~..? 1..'.'-~ `-~ v~. r1. ~ ~'~ . ~L .~--1~ r t 5 .~ ~ ,~' "~ S ~ ~~j .~'~t.., ,~,_._ ~ N' ,y ~' • " "~."C'8t7rn~'lt [:f i!~a Trf~$ II'; --ir1tF_~rl9i (~..;! xli~ n +s,`, i :~ ,,, l~.S. ~r~d~v~dual Inc©me Test Ret urn -- I~t~? rFrS ~ irl i nC:} ' _ P Fcir ilia /~~F ~~h 1-Cjer ?C1iC1 31 ' th t~ . ~ 5 ~fJrr' 1h I 4 ~ .. ~r ~ . : ; , fir b ~i i~: v~1r i7yl N 111ii ` `~ ~' !~ Gilt] , lidlhq '~ ' ~ •a~p+~ ~C ~ ~ " `f~iUr {IYSt n8nl° 3f1c1 Inltl$I a` - ___ ~ h~ IL~ I<Jtt: d5 tJb.`=f Your ;soe'sal sec rit . ( ! ~55, fJ ( ~• l- t ~~ ~ ~ _ u y number ~~~ ~,'~~ If ^~ joint r~turr~, spa~sa`s flr_,t nc-rn~e and i,,itial Last name Spourse's social securit nirmber y ` ~~ x et,~~ra.te instt~,ctrbr;s. L ~ - 4 i-It_~me ~ritJE'es~ (number and streets. if yol-i have : ^ ~ . a r.~. box, sae tn,aructior,;, .T - `1 3 ~ ~ ~-~' ' ~ ~l 7 i~ -~-.----~ r ! ? =~' 2~ A ,t. r'~o. -- ~,~. ~ h , ~ ,/~/t-~.{- S'-C- c,~s.,,` 4'~,:~7 ~,.~ rlaku sl_rra the ~, h,)lsl ~b11~„e ~ ld , co Dn line rG i~re3 i 7r1"Bct: City, toevn or post office. state. and ~tP code. If y~~u have a foreign a~_luress r- _ _ otr? in3trLiCtlOn9 F~resicientfai Y / i C..^~ ~"'~ ~~ ~ ~t LL ~ (~ ~ - ~ ~ ~) ( ; Check?r,c. a t~o,t iSF~ioUi vvilf no€ Election CarTtfaaign uli2iige /our 1a# ~F rcrfllricl: ` Checf~ bare if you, or yot,lr spouse if filing faintly, rvarit ";3 to gti try this fL d __ ~IElnC~ St~~l,lS ~ ^ Srngle ~ tii n . d [~ You 1~1 Spnuse .. i i'_?BCf of fiotlsehdlci (~ritfi ~-jt ia~lf ~iri ~ '~' " 2 ~'1'Jiair led filing jointly (even if only orie had incahie} . g i~er ni ~~°° tnstr iir.trur~s j ff ,. ~fleClt r7rify one ~ P,~1~i tied filinca separ,atel~r. Later spo: Ise's SSh'J ;: l~hve { the ct la~r.y~inri person Is a child i,ut r dt your c'epe~ndci~t, enter this f' l dOx'~ _ ~ and full name here 1- ~ ;I d ~ iii~rPle foie: J . 5 ~.. [~ C~uaiifying Lvicla~v(e•rl ~vith dependent cl-~ild -~-^` lrXE'i?lp'`!(StlS If more than fnur dependents, seP liistructioiis old check hero ®[] a _ Yourselif. If soriieoi5e cart claiii~l yoU as a cieperiderit, db noit clibck box 6a : 6 ~~ Dose ~ ~ - . ,, , ty DeReridents; ~ . (2) t1n(.7r:ntit~tl[`r (3) C?efietldriht q {4} / rr t hlltl tlndef ,ifig 17 (l) Fil st na!t~~~ I_~st name ~'~"i.~l Serrlr~~ ^uniber relat(~hshl(~ fn yrjn orte~fltyinq fir rhdd +ex ~~ ie~ilt . ,-- isee page 151 ----- Total iiumf~er of eitetnpt(on.s claiiiied • u rnC,p~~, 7 b'Vages, salaries, tips. etc. Attach Farm{s) 1/tJ-~ . 8 a Taxable iritpre7t. ,4ftach Sciiet_lule f3 if required - . , Attach Form(s) O b Tax-exempt interest. Do not include an ling E#~~ ~ gb I ~ • I VU~2 Fiore, Also a Orc!iinary divfcleiid~. AttacFi Sch~dufe !3 ft required ' attach dorms b Qualified dividends ~ 9b ~ - ~ ~ . W-2C; arid 1099-f~ if fait its Tax;?~hle ief'utid~, c',redits; 6Y offsets of stag ~ttid local i!icrari~e taxes was withheld: 11 ,Alin~~any received . 12 Busihess ificoriie tit (loss): Attacfl Schedule C or G-EZ : , If you dicl not 13 Oapital gain or (less). Attach Schedule D if required, If not required, check here 'Iw [] get a 1N~2, 14 rJth~~l` gahis or (iosseG): Attach Form ~, cJi see page gib. 15a IRA distributions 1ba 2 U Z.r: _ ; . b Taxable amount i~a Pensions and aniiuitles 10a . • b Taxable ainotirit Cnelase, f~ut do 17 Rei~ta) rAaf estate, royalties, partnerships, S corporatloris ; , trusts, etc, Attach 5rfiedufe •E not attach, arty 1$ F~`trrti iiic~oitie or t,los>j: Attach Schedule F , payment. Afsa, 19 llnernployment compensation . please Uses 20ai _ (~ y'C} ,-.~ Soci~11 security benefits (~Oa ~ "3 `~ ~ . ~ Taxaf fe ` Eorm 1040-1/. 21 , Other income: List type and a-7iount ~ aii idiinf , 22 C~airihine tfiE aitiouiit`~ iii the far right cnluiiiii for Nries 7 thi'~iugh r'1. This is yoi.ii' frifal income -~ AC~)UStf:C>~ 23 Educator expenses ~3 ~r`OSS ~~ C~erfair ~l,siiiess ex~ierlse5 of !ESer'vsts, per'ori;iiny ~~rfists. ar,d lncofrne fee-basis gayernment officials. Att~ich ~CI'rri ~10n Of ?t0o-Ez ~~ 25 Heaitl-i savings ar.courit ded~ictiari. Attach Foriii 83',g~ : ~;y 26 t~~lo',~inrj expenses. Attach Form 39173 2g 27 One-half of self-ernpfoyment to:~(: AftacFi ~chedufa 5E 28 Self-employed SEP. SIMPLE, and qu~~lifie~-f pl~ar~s 28 29 Self-ernplayed heriltfi inf:Urance rfacluctfrf1 29 ~{) r,P_.n~]{t'y an early W(tl7draUJal Of SaVlnf_ls 30 - - 31a Alimony j=.>ad b f~ecipieht's SSN ~- ~ ~ Ufa 32 IRA clr=duction 33 _ Stuiviei ~t Icsarl in{erF,st cieduetlon . 32 33 34 Tr.tition and fees. Attach Forr7i 3817 3~ . Clorne~;tic praductrori ~lCtl!~ItiF.S dP.dLlctlC~n. Att<nr:h Foir7; 33.3 34 35 36 Add ~ines~3 through 31 a and 3l throucjh 35 7 $~ Oa 1tl 11 #~ i3 i4 i+3f3 17 ig 10 20f 21 22 _. :36 37 :..wubtr~-ic:t lino 3G from line 2?, This Is yor_Ir adjtisfed ctrass incerrr*Ie 1 f=or aisclasure. Privacy Art, ;3rrd F'af7orwork ~teductian Act Native, see separate iristrtrctinris.~~~~~~,_-3t. ilo 1 i32c:~E~ f~oxas cFiecked oti 6a and 6Ei hJo: of children on 6a whaE ° Ilved with jioif • did iiat l"ve with you due to divorce nh sej5araf[rari (see instructions) Dependenti3 on 60 riot en#zrer!' af~ove Arid rumti,ers on fines above ~, X12. 0 r_--- 'z-ca L`~i I -- 7 "~ I .,...~..,..,~....~~ryy~q y-y + F~'rP:r9 1 ~•iQ 12[;1 Ui ___ ... _ _ _ - _.. _ _ _ pacjb ~_ T~~X 2tnd ~~ Amount from (iris 57 (adjusted grGSS incarimej ~ - - - ' CFierlt ~ ~ You 1Nert? bcii'i~ before Janltat ~, E~Iltidt . Cr~dit~ - - ~ Y 1~~~ ^ ~ T`otal boxes w~ if: [~ Spouse teas born before Januaiy 2 19~G, ^ 1311nd. Gllr?C~C@d M- 39a E~ If your spouse it~rriizt?~ art ~ separate raturi'i c11` you v~:erp ~ dual-sfatus a~ieri, check Mere ` 3~h[~ 40 itemized deductions (froth Schedule A) or }~oirr standard deduc#ion (see irisfructionsj : ~q ~~ Subtrrirt Ilse ~0 froiil Brie ~~ l ~' ~1>l~ "' : 4,2 Exer~npton s. Multiply $3 6517 by ti-ie numi~er oh line t)d ; _. __ ' _. . ~~ ._ . _. 4S ~'aitable rrtcoi~e, Subtract line ~~ fr©m Iing 41 if line 4~ is riis~re ttian firia iii, enter -d= : .~ .: ~,~ 44 Tax See instructions): Check if anjf tax is frorii: a ^ i=orni(s) g81~ b ^ Forrii +9?2 : 44 __ ~~ Alternative mlhirrtutt tax ( _ ~ ~ _ .. _ - see rnstructrc~hs): Attach Forri7 661 ~ _ I i > J i ~~ 4r~ Add irnes ~~ aricJ ~t7 . : , • : , : , iii 45 ~7 F'breigry tax cYedit: Attach ~orrr- 1115 if i:enliired P 47 . _. 4S credit far child ahd depcndeht care e~:penses. Attacfl Farm 2~~f1 ~~ _.._ - _ _. _ _ _ ._ ~~ Ectucatit~i~ credits frr.;rri Fcri-n Eir353, IIY~e ~~ _ _ _. o , ~ 5b F~etiren'}ent sGivirigs contribittiohs credit: Attach Forr77 ~3t3Fi0 5tj _ . _. __ _ _ 51 (:~kiild ta.>c credi'f lsee iristruCtioris) 5i ~~ residential energy credits: Attach Forr-n 560 ~~: __ 3 ~ithar crsc9illi frtrtiri fybi=iiy~ a ^ 3585 b ^ S5tt1 s: ^ _ 5~ 5~ Add lines a tlroucdli 53: 1`hese are y~aur total credits : . : : : , 5 .._ . 1K - . __ ___ _., S'~ Subtract Nr~e 54 frrirr7 Brie 45, if line 54 is nior+~ tfiari line 45, ei7tet -d= , (~•~~~~ 5~ Self-eri~ployment taX• A#tach Schedule 5E _ ___ - . : 5th _ _ ~ '7_L~ .... 5`~ Ui~repr~rtpd social security grid Medicare tax tr-orri ijorrt~; a ^ ~13y ~ [~ $gi~ 57 ~~~~ .. 5f3 Additional ta.k on IRAs, other auali`ied retirement plans, etc. Attach Form 539 it regitir•ed : 5s 53 a [~ f"brlri(sj ttil_~, br~x ~ b ^ ScfiQciufe H c ^ Forrn 5~(3~: lisle tt~ 5~ _ ~ -_. 60 Add lines 55 tl~rou h 5g._This_is our total-.fait _ _ sa, _ . _ __. ~~y~t~rt~~ 51 Federal iricdf-ne tax wlthiield froYri F'orrrrs W=~ arir_i 10' __ _. • _ ___. 62 201 D estimated tax payments acid amount applied from 2008 return 6 ~`~--_--~ ~~ f~/lakirtq vijai'k pay credit.: Attacf~ Sciieditie M , Ifi you h~~tve s : 6~ _ 6~a Earned income credit (EIC) G4r~ child, attat'>I~t b PJoritairabla +/cir=ribat pity electlatl 5dl~i . Schedl.ile EiC, 65 Additional child tax credit: Attach Form X81 ' _. 65 6~ Arrierlcari opportunity credit frcirtt FCirrri 5t~6~: line 1 ~ , s~ 67 First-tiii~P fi~mebltyer r>redit frcirri Farm 505. line 1 d : . s`7 5~ Af=riciul7t paid wltfi request for exterislest~ to file 5~ 5`~ E;ccess social security ahd tier 1 ~iFiT.q tax v~o(thheld gg ~~ Credit far federal tax city fuels: Atfacii I`artr X105 _ _ 7d _ 71 Crrodits ircrr Forrr-' a ~40g ~ _ - _ ` []8$39 c ^ 880i d ^ 8885 7~ 7~ Add lirips E~1 ! 6~' S3; 6~~a, aria G5 through 71: These ~tre jrouY total ~ia}itrret'tts _ _. _ . . y~ _ `2- v v ,~- l~eft~r~d 73 If lu,e 72 is mare than pine bQ subtract line E30 fron'i hne 7~'. i+his is the amolrnt you overpaid 7 7d~ Ari`tr~urtt of lime 75 you ~rvarif wetunded ft~ ytii~. if Fori~t a)~r)~ is attricfiecl: checi~ here r- - _ - -- - ^ 7~~ . rJit•ect deposit? b routing number - f - _ _- __ cTjpe: ^ Checking ^ 5au(rigs Feu • -~ d Account rtutriber 75 Amount of line 73 you want. ap lied ts, yaur 201'1 estimates! tax i- 75 _ 1 - _ Art't~t~t1Y 7~ ~ mo ated f ~ ~ ~e Subtract Ifne 7~ from iiris 6Ct: Ftr details ran tit~tN to p~iy; see liistr""fictions -~ j~ ~" ] ~ w._ Yowl Cave aic p..nalt see instru~trons 77 _.,. Third ~~rky , ____._ Da you w~int tsi allow another per5br7 to dlscus:s tf~is rr~turrt wltti the IRS !"see ilistrUctlcrr`i>)'~ ^ Yes, Coriiplete belc~+;~; ~~ ^@Si1t~t1EE3 C7eci~nee's f'hci,~ _ n~aii~ ~ C'erson~al idertiflcation -~.-, .~:....^ ~~ ~ Under penalties of ner'ui ~. I de r I 1 care that I tia,ie eXaniirt?d this refurri acid accQn,pany!ng scnedl.~tcs and s+at=i,iFr,}g, allot to the best of nr1 khoi~~fledc~e ~~nd beii~f: Hers tne.~ are true, c!,nect. ar•d complete, bectaration ct preparer fatha! than tnxpayr~r; is i~aser_i stn ah information cif ~nihiclr rp parer Joint return? 1'oiar sighatu a p K has a~~y ki~c•r,~leana: - Date ~'r~_ir rtCr`i.i atibrt See i~a~e 1 ~: ~/ r - p`' Gig+~tiriie pli~,n? n~ tri-iocl~ Kee a cr:i lw . ri. ,,~; ~;,, for yolrY Spouse's sic7n are. If a l nt teturii: botFi must s! n, Da e 31~~~si Spouse's occuhat+bh _ --++ )~7 recorcl.5' J1a-- ~t'uu.~t. s. `'~ ~ e t~ a ~'1 • `,a. , t Tcr!c:• ~- ~ ~{ L~J~t s L^L.~~- ~'-~' f- G'~~ ~ ., .. ~ ~a"~ •- 2. t~-y pc'ild Prlht~rT,ipe Frrebarr!'s nam9 F'ieparar i i `a _ Ire ~rer :~ w~ ~ s ~ ~. ci,~%;-~ [.~ if PTIf•d ~;~ -~~1 p ~ 4 ~~-C~~L,u-~c~l... ~..~ ~• ~~ se-f-er„~f~yPd r USe Csrtly Frrm's name ~" ~~ t .?tea ~.,L `3a ~/ a - _ _ , FRni's EIN - - Frltri'e ~itfdrers IIt* Fcrli; '~ (~~(} ( G 1 %ii SCHEDULE A (dorm 1040) Department of the Treasury Internal Revenue Service (99- I'dema(s/` sfiorh/r1 ari F~rr~ 1 [ itemized C~eductian Attach to Fr~rirl 10401 - See Iristr'uctians for Schedule A (dorm 1040}Y e ECa vQUU~nP u0 nc~t ?rlCllfClE~ tX `ellses relrfilburS~Cf Of p~l~ h th~r4, - ~ Yy~, avid ~ iVle~ifc~il at7c~ dental ex{~enses (sere Ire structior~s) r r C~eint~l Fntefr amount fr`t~ri~ Farm 91740, iir~e ~$ ~xp~nses ~ Multiply line ~ by 7.5eb (:o%~~ _ 3 Y ~ J " 4 Subtract lirip ~ trori~ Br=ie 1 Y if fine 0 IS more than (ire 1, enfer =i~~ , r _ _ _ _ r"~~~i~ You 5 Stag ~?nd I l r J t , , P .. _ _ __ ~ rJea c ~e+vit dr~i ( ~/ C1Y1~ b(yX}~ ~c"3l!CC ~ [~ Ir~icome taXes, Chi' ~ I ~ Y Y i i P 1 J Y t Ca "~ Z.. 1 . - ~ '~ rQnerai - safes t~~xes __ . _ _. . Opal p~;tate texes (see Instructions) Y r r i J f ~ Y Y Y 2/ ~p 7 __ .._ . _.... __. iw rr~ator vehicle ta~;es trciril ilr-?e 19 ref the vucrrkshpet girt Back (tor certzir~ v+i~icles purchasr/d iii ~Ot?0}. Skiff this Ifiie if yeti ch<~cke~! boy ~i3 Y Y r r Y - r r J :, ~ther° tr~~e~Y L1st type and ar~iaur~t b~ _ c1 Imes s thr'r~ue~h ~ ----- _---- --'"-- --------'-._'. Y Y Y I Y Y . ' Irltei'est • ' [ C Y C t i ! • 1d Ho ~e mart ~ e Interest ahd Dints rQ 0c ~ ~ F~ ~parfed to you on Form 1 bid 10 i ! ! Y _.. , F T -1 Yt~c.rf I~a~d ~ `~ Hemp iridrt~a~e Interest r7ht repdrtetl to you ors Forrr7 9 0~~, It ~~ald ~ . Nate tt~ the person trar~~ ~n~htir~~ yt~u hou~ht the ~ibr=ie, SPe instructlcn~ ` . acid sl~o1~,~ that pef'soh s iiar~e, i~#eritifylri0 ndP, ar~d acltlress Your riicirtgage lnter'e~t -------------------------------------------------------------- deductfbfi may l l --------------- -= --~-- ----- __~ -~---- -- ---_--~ --- --• _ 1 '1 ~ ie irriited (set ~ I olrits r~r~t repr~rtect tip yc~u C~r1 ~oi'rP1 109~f Sp€~ if~str'UctlOr'1~ for __ Iristructiar~is)i sppci7l rules . P i F 1 Y 1 Y ) f i ~ i ... 1;~ Niort~a0e ir~sur`arice premit.rrrs (see iristructioi~s) .. .. .. _ , , 1S i4 Ir7vc~stnierit interest. Att~icl~ Fcrrrj 4~5~ it re~ulr•eet, (See instr`urtians,j ~~ 15 Acfr~ Ilr-ies 1 t~ throu0h ~ 4 Y Y r r r _ Gifu tt~ {~;~l"F~ l' Y r Y y , y j _ ik~ lifts by dash ar check. !t yort mz~1e airy ~jrtt of t~~FO br i-rar+~, I , J l See riStrLfctfarlS , - , r Y , Y Y Y Y Y Y r Y Y J J is ' ' ~~7 if you made a 17 C7thpr than icy cash br check. ff ~tr1y 0ift of ~~5t7 uf` mare see _ _ ~Itl anr~ ant ;~ her~~fft for It , Ir"15trlfctiansr - ou I"1"IUS~ attar;i7 Far`i~ ~~~~ If C~\/er' ~~f~~ , ~ "~ , ses In~trttctiori~ iS carryover frar~ prior year Y ~ J I i 6 : - Y 1 ~ Add iiiiFs 10 throuc~il 18 - C~SU'~Ity ~~d Y Y f ~~vv C~+~~y gg . '3.7~Y7 rryy ~^ ~ (., i /. G~ ~,asu~lty C1r tl I~i tt I~St'i(~.~i~, P'S tt t~. ~ih ~arr~ '-}~V`'F, I t7~~ it I~t?~t,?cti~i~i~:~ t Ul/Il LA G~E~Gr~ ~' and ~erfair~ , a c ~1 tJrtreimbr_rrsed ernpiayee expenses-jal3 travel, t_itor~i clues, r , illlisGeilarYattE~ - _ jol~ ecluc~~tini~Y etcf Attach Form ~10C or ~iClO EZ if reCiuirecl, (See instrurfioris:~ F~ ~edntt~an~ ---------------------------=---------- _ ~ 2~ ~~?€ (.7repal`atlar~ fees _ _ Y Y r . r r Y r : J ~,~ Z~ Other ex~rer=ises=-ir`ivestrrterit, sate tfepasit box, efcY List typd ~Ilct amount -~ ------- 2~ Add f i n~ s ~ 1 t h rc~ r..i h~~ -------------------------• 2 ~ , r Y r ~,~ 2~ Eater amount fror7 Fr.~rrr1 9040, lire ~g 25 ~~ ~vlUltlply lime 25 by ~~/n (.17~) f J __ ----- _ 2S ~~ Subtr~ict line ?~ from line ~4Y If line ~C 15 mr;re thar? Ifii ~d, ~ bMEt No'. 1545-007d ......... . ~_~'~ Attai,hmeiit se' Ueriee No; ~7 ~~~__^ Your social secUrify r9iainber ~~ J I ~ .f 3 L. I ._. ~~I ~,14~ I-- ~gl 7 3 i ~~ e L, ~ntRr -b- Y J Y ~7 ter =8 Other'-tr'om fist in instructions. List type and amount Ntis~ei(arteous ---------------------- t3edacrctioi~s ------------------------- -w ~ ,;_~ ..s, ------------------------------- 'v~ct~ ~~ add the ar~acints in the far ri0i°it colurr?ri far' Ilnes 4 thritrc~h ~'0Y plsr~, er~tpr this arriou--it ~~ Iterriix~d a-1 Fc~rri~~ 1 C?~iCt, Brie ~0 C~~r~uct~orns 3(~ if you elect to itemize decluctioiis eve ~ Y Y Y ~ ~ ~ ~~. .. n tfiougH theta are Ipss th~iri your stanclarcl cipductianf check here , for F'aperwctirk Reductio~-~ Act Notice, See ~crrm 1044 instrt~ctior~s~ - - ,~ C~~t: h~lo: 1 i 1~f5C Scr•~ectule d {Form 'tJ~{al ~~ifi0' S~~EDt1CE C ~y~s ;1~-ca~...~° 1~~ ~ s ~;~ ~- ~~-~:~ __ -~......._.._ Form y04a} Prot or Lass From Business OMI3 No. 1545-0074 (Sole Proprietorship) ~~ O Department of the Treasury - Partnerships, joint ventures, etc., generally must file Form 1065 ar 1065-8, Intemat Revenue Service (s9) -Attach to Form 1040, 1040NR, or 1041. - See Instructions for Schedule C (Form 1040. Attachment Name of proprietor ) Sequence No. QQ i ~ Social security number (SSN~ A Principal business ar professi.on, including product or service (see instructions f'U ~ J ~ ~.r ~ ~ ~ h ) ~, B Enter code from pages C-9, 10, & 1 i C Business name. If no separate business name, leave blank. ~ ~ ,~ D Employer iD number (EIN), If any ~ Business address (including suite ar room no.) - ~1 /U ~ ~ ~ ~'' ~[_, ------------------- City, fawn or post office, state, and ZIP code L - - ----------- !V ~Lr4 I~/a-- 1'"l t~ LS ----------------------- F Accounting method: (1) `~ Cash (2) ^Accrual (3) ^ Other (specify) - - G Did ou "materiatl -----------------------------------------~-- H If ou started or acqu rtedipate" in the operation of this business during 2010? If "No," see instructions for limit on losses [] Yes ^ No Y this business during 2010, check here 1 ~ ....~ . v -- Gross receipts or safes. Caution. See instructions and check the box if: i_ L_J • This income was reported to you on Form W-2 and the "Statutory employee" box on that form was checked, or You are a member of a qualified joint venture reporting only rental real estate ~ ^ i 1 ~-- ~ ~ ~~~ ncome not subject to self-employment tax. Also see instructions for Ifmit on losses ~ 2 . Returns and allowances . 3 Subtract line 2 from line 1 ~ ~ ~ ~ ~ 2 4 Cost of goads sold (from line 42 an page 2) ~ ~ ~ ~ ~ ~ ~ 3 5 Gross profit. Subtract fine 4 from lime 3 ~ ~ ~ 4 6 Other income, including federal and state gasoline or fuel tax credit or refund (see instructions) 7 Gross income. Add Nnes 5 and 6 6 . Expenses. Enter expenses for business use of your home only on line 30 • 7 ~ ~~ ~ 8 9 . Advertising . . 8 ~ ~' 18 Office expense . Car and truck ex enses see ~ ~ ~ ~ ~ p ( 18 ~ (l 19 Pension and profit-sharing plans instructions). 9 (~ G L2- ~- 19 1d , . 20 Rent or lease (see instructions): Commissions and fees 11~ / ~2 S ~ 11 - a Vehicles, machinery, and equipment Contract labor (see instructions) 11 20a "~ ~ " _, ~ "' '~G' 12 b Other business property Depletion 12 20b ~1c5> ~ u - 13 21 Repairs and maintenance . Depreciation and section 179 22 Supplies (not included in Part III) 21 22 / ~ v ~,, "' expense deduction (not 23 Taxes and licenses . 23 2 ! L J 3 ,~ included in Part III ) (See 24 Travel, meals, arid entertainment: instructions) i4 . 13 a Travel . _ - - Employee benefit programs 24a t. f-~ ~ ~ b Deductible meals and (other than on line 1 g) . 14 ~ '~ `'~ 7 - 15 . entertainment (see instructions) insurance (other than health) 15 .G~,,ti7 25 Utilities 24b - ~' .Z-v 16 a Interest: 26 Wages (less employment credits) . Mortgage (paid to banks, etc.) 16a 25 26 b 27 Other expenses (from line 48 on Other 16b 1T page 2) . Legal and professional 27 ~ 4f-~,v -- services . 17 ~ / ~j ~ ^ 28 Total expenses before expenses for business use of home. Add fines 8 through 27 29 Tentative profit or (loss). Subtract line 28 from line 7 . ` 28 - C' ~~ ~~ _ 30 Expenses for business use of your home. Attach Form 8829 ~ ~ ~ ~ 31 Net pro#it or (loss). Subtract line 30 from line 29. ~ ~ ~ ~ • If a profit, enter on both Form 1040, line 12, and Schedule SE, line 2, or on Form 1040NR, line 13 (if you checked the box on line 1, see instructions) Estates d t . an rusts, enter on Form 1041, line 3. • If a lass, you must go to line 32. 31 ~~ 7 ~ ~ '-~ 32 If you have a loss, check the box that describes your investment in this activity (see instructions). • If you checked 32a, enter the loss on bath Form 1040, tine 12, and Schedule SE, line 2, or on Farm 1040NR fine 13 (if you checked th b , e ox on line 1, see the line 31 instructions). Estates and trusts, enter on Form 1041, [ine 3. 32a`~AIf investment is at risk. • tf ou checked 32b, you rt~ust attach Form 619x. Your loss ma be limited 32b ^ Some investment is not at frisk. . For Paperwork Reduction Act Nr~tice, see your tax return instructions . Cat. No. 11334P Schedule C (Form 1040) 2010 Sch,~dule~C (Form 1040) 2010 n___ +s 33 Method(s) used to value closing inventory; a ^ Cost b ^ Lower of cost or market c ^ Other (attach explanation) 34 Was there any change in determining quantities, costs, or valuations between opening and closing inventory? if "Yes," attach explanation . . . . . . . . . . . ^ Yes ^ No 35 Inventory at beginning of year. If different from last year's closing inventory, attach explanation 3g 36 Purchases less cast of items withdrawn for personal use _ . . . 36 37 Cost 4f labor. Do not include any amounts paid to yourself . - - - . 37 38 Materials and supplies . ~ 39 Other costs . . 39 40 Add lines 35 through 39 - . . . 40 41 Inventory at end of year . . 41 -_._, 42 Cost of goads sold. Subtract line 41 from line 40. Enter the result here and on page 1, line 4 Information on Your Vehicle. Gomplete this part only if you are claiming car or truck expenses on lin and are not required to file Form 4562 for this business. See the instructions for fine 13 to find out if you must file Form 4562. 43 When did you place your vehicle in service far business purposes? (month, da S / ~`~ !!~!~ ~/ Y, Year) ~ --- ~ -- ~ --r°---- / ~ O f V 44 Of the total number of miles you drove your vehicle during 2010, enter the number of miles you used your vehicle for: ?• a Business ~ ~ , J Z `~' b Commuting (see instructions) ~? ~ ~ --------------- ------------- -- c Other ~ c7 ~/' (`7. ------------------- 45 Was your vehicle available for persona! use during off-duty hours? . . . . .Yes ^ Na 4fi Do you (or your spouse) have another vehicle available for personal use?. . . ~~ Yes ^ No 47a Do you have evidence to support your deduction? . ~~] Yes ^ Na b If "YP_S_" IC fhA Avirlnn,.e ...rt+t....n ------------------------------------------ ----------------------------------------- ----------------------------------------- ------------------------------------------- ------------------------------------------- • ~~a~ vu~er expenses. Enter here and on Schedule C (Form 1040) 2010 ' REV-1505 EX+ (6-98) SCHEDULE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF ~~1. ~ ~ i l~1 i~ r 1. Name of Corporation __ ~ ~ ~ State on Incorporation Address City ____ State Zip Code. 2. Federal Employer I.D. Number 3. Type of Business 4. Product/Service FILE NUMBER '2. v ~ ~ - U (J Q ~ ~. Date of Incorporation Total Number of Shareholders Business Reporting Year STOCK TYPE Voting/Non-Voting TOTAL NUMBER OF SHARES OUTSTANDING PAR VALUE NUMBER OF SHARES VALUE OF THE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred _ ~ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. ^ Yes ^ No If yes, Position _____ Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ................................... ^ Yes ^ No If yes, provide amount of indebtedness ~ 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Safe Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ...^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ..................................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed, insert additional sheets of the same size) REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-.Z PARTNERSHIP INFORMATION REPORT t51A1 E OF °~J 1. Name of Partnership __ Address __ FILE NUMBER Date Business Commenced Business Reporting Year City _ State Zip Code 2. Federal Employer I.D. Number 3. Type of Business Product/Senrice 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold ___ Transferee or Purchaser __ Consideration $ Date _ Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (1-97) c~°y} ., COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ~~ iHi t ur FILE NUMBER All property jointly-owned Wlth ric]ht of survivnrchin miler ho ~~..~„~e~, ,.., ~,.w,..~..~_ ~ - ca U c:~ i ~~~ ,~~~,~ ~~.a,,~ IJ IICCUCU, risen aaaiuonai sneers of the same size) REV-1508 EX + (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHRESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF ' FILE NUMBER 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 NUMBER VALUE AT DATE DESCRIPTION OF DEATH 1. -L.. v v ;~ LAC L~ S r ~•`~'~Y4~~~jtL~% I ~ I Sl ~ c~ ~ . --- r ~ 1C~~(`y l~- " - ,~ ~~ 7 3 ~r~ ` ~~ TOTAL (Also enter on line 5, Recapitulation) I $ ~ ~~ ~~' Z ~ - ~".3 (If more space Is needed, Insert additional sheets of the same size) REV-1509 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FCTATE ~ SCHEDULE F JOINTLY-OWNED PROPERTY F ~ FILE NUMBER '2v ~ ~ -- i~ v v i If an asset was made joint within one year of the decedent's date of death, it must be rep ed on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS A. a V ~~ JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach NUMBER TENANT JOINT deed for jointly-held real estate. 1. A. ~~c;;~. ~ t ~L -- .3 ~ c~ L K~ ~rZi'~-,F~' TC ~~~. ~;~ to ~f 1" DATE OF DEATH VALUE OF ASSET RELATIONSHIP TO DECEDENT OF DATE OF DEATH DECD'S VALUE OF INTEREST DECEDENT'S INTEREST ~f TOTAL (Also enter on line 6, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) RFV-1510 EX+!1 ~7` ~~ ~t ~ At ':~i COMMONWEALTH ': F PENNSYLVANIA INHERITANCE "AX RETURN RESIDENT C~CEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF ~ FILE NUMBER This schedule mint ~e completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM iNaucE Tf E JMBER _ 1. ~~~ nivia aflgt,G W IICCUCU~ uisri~ aaoiuonai sneers or ine same size) REV-1511 EX+ (10-06) ~~ COMMONWEALTH OF PENNSI'LVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ITEM NUMBER A. 1. B. 1 SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS - ~ Debts of decedent must be reported on Schedule I. DESCRIPTION FILE NUMBER FUNERAL EXPENSES: 5 C` yZv >. C.~ ~ ,~ sS r/~ ~. i ~ l -~ ~ ~ ~i~ ~ t `.~t t, ~-~c t~ ~ r -~ ~ , re c ~~-- ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City ____ State _ Zip Year(s) Commission Paid: 2~ Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant ills ~ t~C., D,,,, L ,~0 ~'i 3 ~ v~ Street Address 1 City _____ ~ " __ State Relationship of Claimant to Decedent ~`;I~ ~ ~ A~`j7 4. Probate Fees (~ rim ~Z i 6 iJ Y" L'~t S ~ 2/ r ~ ~~ 5~ Accountant's Fees ~o 6. Tax Return Preparer's Fees ~j ~ ~~~G1 7. ~ ~ AMOUNT ., ~~ ~ ~-_~ 7 . -- ~~ f ta,~ .3 ~- ~-,~ , -- ~, al j s V ~, _ _TOTAL (Also enter on line 9, Recapitulation) $- _~ ~~ ~ "~, ~ ~ (If more space is needed, insert additional sheets of the same size) Zip ' REU-1512 EX+ (12-03) 1 ~`~ ,~.~a COMMONWEALTH OF PENPJSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHE~I~L~ 0 DEBTS ®F DECEDENT, IV!®RTGAGE LIABILITIES, ~ LIENS ESTATE OF = FILE NI~NiBER Report debts incurred by the decedent prior to death which remained unpaid as of th date of death, including unreimbursed medical expenses. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH 1. ~~ ~ ~ ~ ,-- ~,° _ ~ .- /7 ..- - , .". x ~ ~ .~---~J e Cj d~r`~~ ~ ~ C !~' Y~ S ~ ~ ~t: f ` `s (.,r fJ' J'~l ~. A ~/ L~,~s ~" (.L c~ t.1 1._ u i ?i ~ 'L ~~~~ U ~,,;a jr 1 ~..k-r vnL.T - ~ ~! I ,' [. ~ • 7 ~' i~l ~ .S ~ ~ Irv `~= .uns ~ ~~--vi~ - ~ 3 6 3 - . ,~.rt ~7 5 , . - ~ r LM - ~~L`ry ~J ~~in 1,1~~u? ~ ~- Z ~ G 3 ~ io 1 ~`1 I 0 - ~-1 ~ ~, _ ~ ~ ~~ j( ~~ ~ ~- 1~ ~~ ~ ~; k~_~ `~ ~ ~ V~ " ~ Y' TOTAL (Also enter on line 10, Recapitulation) $ ~~ ~"~~ i~) ~! ~, (It more space is needed, insert additional sheets of the same size) ' REV-1513 EX+ (9-00) ~. SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ,~ NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY REL Dol Not List TrOusDtee(s~ ENT ~4MOOF E3 ATE ARE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)j 1. j ~ U i ~ ~~ ~ C ~-,,~-~~ ~~~ L ~ , ~i / ~ 17 ~~ ~~ ~7 is ~ ~- ~'~ ~S 5 ~-.~ _ rv h fL:= w' S . [--.'W'P ' ~ l4 `~ ~ ~;~ ,+1.j t;'' F' 'tiw•, ..Q. (;- ~ ~ ~~' ~ ~ ~~ 2`j .., f ~ ~ ``'Z' ~ U_~h v~-~~~ t~~ ~ - ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, O N 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. ~~;~~1 k B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. (~~~~ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (~ (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) Y COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT CaiAit ur SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shee FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certai calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty i~ax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-~1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other• NAME(S) OF LIFE TENANT(S) I DATE OF BIRTH I NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................................ . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ NAMES} OF LIFE ANNUITANT(S) DATE OF BIRTH I NEAREST AGE AT DATf OF DEATH TERM OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Ti~rm of Years ^ Life or ^ TE~rm of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ................... . Frequency of payout - ^ Weekty (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^ Semi-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6°io ^ 10% ^ Variable Rate % 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets an Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-1644 EX + (3-04) INHERITANCE TAX SCHEDULE L COM NO ER TANCE TAX RETURN ANIA REMAINDER PREPAYMENT RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER 2"~ ~ ~ `~ U i~U ~ ~' I. ESTATE OF (Last Name) (First Name) (Middle Initial) II. This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on B. Name(s) of Life Tenant(s) or Annuitant(s) ~,, ~ N ~~ (Date) Date of Birth Age on date Term of years income of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate .............................. .$ 2. Stocks and Bonds ......................... .$ 3. Closely Held Stock/Partnership .............. .$ 4. Mortgages and Notes ...................... .$ 5. Cash/Misc. Personal Property ............... .$ 6. Total from Schedule L-1 .................... ..................... ...$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities .......................... .$ 2. Unpaid Bequests .......................... .$ 3. Value of Unincludable Assets ................ .$ 4. Total from Schedule L-2 ..................... .................................$ E. Total Value of trust assets (Line C-6 minus Line D-4) .................................$ F. Remainder factor (see Table I or Table II in Instruction Booklet) ............. . G. Taxable Remainder value (Line E x Line F) ........ .................................$ (Also enter on Line 7, Recapitulation) III. I INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) or Annuitant(s) C. Corpus consumed ....................................... D. Remainder factor (see Table I or Table II in Instruction Booklet) ...... . .................. E. Taxable value of corpus consumed (Line C x Line D) ................. . (Also enter on Line 7, Recapitulation) Date of Birth Age on date Term of years income corpus or annuity is payable consumed INHERITANCE TAX SCHEDULE L 1 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN ,ry RESIDENT DECEDENT -ASSETS- FILE NUMBEF; ~~~ ~ " ~''`~'~ ) I. Estate of (Last Name) (First Name) 11 Item No (Middle Initial) . . Description V l a ue A. Real Estate (please describe) ct-~- `J ~.' 1 /l~ o W bL.~2, 2 ~.~~ ~.~G ~ Y 1=~y ~,,y ~ ~'C3 V~.~- ~~I~ 1-~~il , ~~ ~ ~ c7 ~ i Total value of real estate (include on Section II, Line C-1 on Schedule L) ~ s B. Stocks and Bonds (please list) ~~ I - L ~ 1 ' ,lac'. / ~ "~V ~ ~„itw ~/J ~ ~ _ ~ V a ~~~j .L~ ~~I ~ ` cJiS..- ~r t) / ~ I ~ Total value of stocks and bonds (include on Section I1, Line C-2 on Schedule L) S :.~ ~~ ~~ ~~ '7-S C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) Total value of Closely Held/Partnership (include on Section II, Line C-3 on Schedule L) S D. Mortgages and Notes (please list) Total value of Mortgages and Notes (include on Section II, Line C-4 on Schedule L) ~ E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property S (include on Section II, Line C-5 on Schedule L) _ .,r, C°_,,% ~~~• TOTAL (Also enter on Section II, Line C-6 on Schedule L) s (If more space is needed, attach additional 8%s x 11 sheets.) ~ ,% REV-1646 EX+ (3-84) INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN `~ RESIDENT DECEDENT -CREDITS- FILE NUMBER ~--'~' 1 I - ~~~ I ~1 I. Estate of ~--~ ~ V Q (~,,~ ~ ~/Y1 L_ ~ ~ f 3' (Last Name) ---------- __------ - Fi t Name) _ Middle I~~ ~iaj - - - ------ A I?1 - -` ~ _ _-__- - -- Item No. - __ _____ __._-- ' _ Description ---- i O U 11 A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) i i i --- ---- Total unpaid liabilities -- ---'-~~-___.__--___--_____-___ ___ (include on Section II, Line D-1 on Schedule L) _ _ _ _ __ B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) - - ota unpaid bequests r~ (include on Section II, Line D-2 on Schedule L) -- -- _--- C. Value of assets reported on Schedule L~-1 (other than unpaid bequests listed unde "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows i Total unincludable assets (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) (If more space is needed, attach additional $''/s x 1 1 sheets.) RSV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet FILE NUMBER This Schedule is appropriate only for estates of dece nts dying fter December 12, 1982.., This schedule is to be used for all future interests where the rate of tax which will be applicable when the futurE~ interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. 1 1 WI~~ 1 1 Tr~~e.~ I~ Aav_~ I. --- - - -- - - ~ ... v. Beneficiaries ---- - NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO --- NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right ofi withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: -- --- IV. Summary of Compromise Offer: - - 1. Amount of Future Interest .........................................................$__ 2. Value of Line 1 exempt from tax as amount passing to charities etc , . (also include as part of total shown on Line 13 of Cover Sheet) ......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% ......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ...........................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$ (If more space is needed, insert additional sheets of the same size) ' RE></-1648 EX (11-99) ~= .~~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION ESTATE OF SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover shE:et. 1 Taxable Assets total from line 8 (cover sheet) ............................................ 1 (1 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joint Assets with Spouse ............................................................ 4. 5. PA Lottery Winnings ............................................................... 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6b. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) ........................................................ 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilities .............................................................. 8. 9. Net Value of Estate (Subtract line 8 from line 7) ........................................... 9. If line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part II. Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3, a. Spouse ........... 1 a. 2a. 3a. b. Decedent ....... , .. 1 b. 2b. 3b. c. Joint ............. 1c,. 2c. 3c. d. Tax Exempt Income .. 1d. 2d. 3d. e Other Income not listed above ........ 1 e. 2e. 3e. f. Total ............. 1 f. 2f. 3f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) + (3f) - TAX YEAR: 19 ~= 3) 4b. Average Joint Exemption Income .... . if line 4(b) is greater than $40,000 -STOP The estate is not eligible to claim the credit If not, continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less .................... . 1. 2. Multiply by credit percentage (see instructions) .......................................... . 2. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet . ............................... 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................. 4. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit .Include this figure in the calculation of total credits on line 18 of the cover sheet. ...... 5• REV-1649 EX+(1-97) SCHEDULE 0 COMMONWEALTH OF PENNSYLVANIA ELECTION UNDER SEC. 9113(A) INHERITANCE TAX RETLIRN SPOUSAL DISTRIBUTIONS RESIDENT DECEDENT ESTATE OF FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust, This election applies to the Trust (marital, residual A, B, EI -ass, Unified Credit, If a trust or slmllar arrangement meets the requirements of Section 9113(A), and: Y~_ etc.). a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0 The denominator is equal to the total value of the trust or similar arrangement, PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's survivin souse under a Section 9113 A trust or similar arran ement. DESCRIPTION - VAIUE PART B: Enter the descri Part A Total (IT more space is needed, insert additional sheets of the same size) ~ ~ ~ r ~ ~' ~ a ~ ~ ~ ~ z •°• `' •"•' tr ~ ~ ~~~ ~~ m ~ ~ ~ A. ~ c..~ ~ ~ ~ d ~ b r C7 " v1 `b n ~ ,~ ~ ~ C C~7 ~ ~7 z ~-- j ~ ~ V ~ ~ ~ °~~~~y o ~ o ~z ~m ma~OO~ ~ w~~~CA" ~ CJZO~~D w ~ 7d ~ ~ y v~ ,.b Cn V ~ ~ ~ ~ b ~ ~ ~ ~~ y x ~ ~ `-C x LAST WILL AND TESTAMENT OF JACQUELYNNE M. LAPITSKY }Ap 6 0 ~ 4 ~,rg ~, ~'~•, ,1, ~, .~, ~'`~ a~ ~~ ~ .~ , _~~ ~ . , ~ .,~ `4~- ,~: O ~~ h I, JACQUELYNNE M. LAPITSKY, of the Borou h of g Lemoyne, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament and revoke any and all wills and codicils heretofore made by me. ITEM I: My personal representative shall a p y from the residue of my estate the expenses of my last illness, funeral and burial debts duly allowed against my estate, and estate taxes occasioned by my death and incurred with respect to property passing by this Will. ITEM II: I bequeath those articles of m auto Y mobiles, personal effects, household goods, and other tangible personal of like n tY afore (not including cash or securities), together with any existing insurance thereon if a property and not the ro er ny' as may be mY individual P p ty of my Husband or owned jointly by me with him as forth in a separate memorandum which I shall lace ~ set p with my Will to the persons therein designated. If I shall leave no separate memorandum o r with regard to my automobiles, personal effects, household goods, and other tan i g ble personalty of like nature (not including cash or securities) not referenced b suc Y h memorandum, I bequeath such property to my Husband, WILLIAM LAP ITSKY, if he survives me by thirty (30) days. Should my Husband, WILLIAM LAPITS KY, not be living on the n ~ _ _ 5 1 .~_ i J 1:1 ~~ c_..,, ~ _ _". '-CJ '~ ~~ _.... ~ ~^ ,~ ` ~ C,", ...,.~ 1~ ; _. __ __ _ 2 yy~ ~' q+. s ~.. .. ` 1~~~ ~`I 4 '~ ~~ ~ `~ .f .~ `~•'~ ` ~ 0 ~~ ~ .e~ ~. ,~,` ~~ ~ ~~ , h thirty-first day after my death, I bequeath such tangible personalty and insuranc e thereon to my children, MATTHEW WILLIAM LAPITSKY and ANDREW STEP HEN I-APITSKY, to be divided among them by my Executor with due regard for their personal preferences in as nearly equal shares as practical. ITEM III: I devise and bequeath the residue of my estate, of eve ry nature and wherever situate, to my Husband, WILLIAM LAPITSKY, providin he shall g survive me by thirty (30) days. Should my Husband, WILLIAM LAPITSKY, redecea p se me or die on or before the thirtieth day following my death, I devise and be ueath the q residue of my estate, of every nature and wherever situate, to my issue, er stair es p p , living on the thirty-first day following my death. ITEM IV: I appoint my Husband, WILLIAM LAPITSKI', Executor o f this my Last Will and Testament. Should my Husband fail to quali or cease tc fY ~ act as Executor, I appoint MATTHEW WILLIAM LAPITSKY and ANDREW STEPH EN LAPITSKY as Co-Executors of my estate. ITEM V: I direct that my Executor and his successors shall not be required to give bond for the faithful performance of their duties in this or an cothe y r jurisdiction. 3 IN WITNESS WHEREOF, I, JAC QUELYNNE M, LAPITSKy, hav ~y hand and seal to this my Last Wil e her~.unto set 1 and Testament, consistin of t typewritten pages, each of which bea g~ hree (3) r `~ ~~ _ rs my signature, this .~; ~-__F.-day of .- ; r. , ..r ~ f ,.-. JacgUelynne ~; La it t + ,~' ~~ 3- -y `~ ` _.(SEAI M p sky, T~statrix.a~-"~° ~ ') r'~ Signed, sealed, published and dec JACQUELYNNE M, LAPITSKY a fared by the above-na presence of us, who, at her rA~„~..~s and for her Last Will and TestTestatrix, rro~~_ _ ~ 'ter si ht and ament, in the g presence, and in the sight and ubscribed our names as wit nesses. COMMONWE~,TH OF PENNSYLVANIA COUNTY OF CUMBERLAND ~ SS. ~, JACQUELYNNE M. I-APITSKY, TAYLOR P. ANDR EWS, and ~ C ~ t qc,.~. ~ ~-~ ~ 1~~ the Testatrix and witnesses, respectively, whose names are signed to the foregoin~ or attached instrument be' ing first duly sworn, do ;hereby declare to the undersigned authority that the Testatrix si ne g d and executed the instrument as and for her Last WiIi and Testament and that she signed willingly and that she executed as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearin of the g Testatrix, signf;d the Will as witnesses and that to the best of their knowledge the Testatr' nr was at the t~rne eighteen (18) or more years of age, of sound mind and uncle r no constraint or undue influence. ~'i racq~elynne' its '~' statrix ~-1 . ,~ _-- _~~~ _ - _, P• A drews, Witness , W>]tness Subscribed, sworn to and acknowledged before me b J / LAI'ITSKY, the Testatrix, and subscribed to and sworn or a ACQUELYNNF; M. TAYLOR P. AND WS and ` f ~ ffirmed to before me; by -_~ ~ !:.'~- L...C :cam- ~'~ day of .~~cc ~r ~ , 1994. ¢~ ~ ;r'~~ =-~ Witnesses, this r ~`. ~~, Notary Public x'~(SEAI~) R~()TA~E;~L SE4L ERt~i'l~t,~ !_. ~n~li!tl~. P1GT.A.~Y PUBU~ ~~A.Fi.ly~ F ~~~• C~~BERL'L~JO C4iit~1'Y t,~Y r:r,~:~~~~c~rJfr E.KPiR~S J1~.~!!.''1tRY 6, 1ggg Y FORM 93--0. C. DIVISION IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: ESTATE OF Estate No. 21-11-014 JACQUELYNNE M. LAPITSKY (Deceased) CLAIM To the Clerk of Orphans' Court Division: Index and make proper entry in your official records of the claim of Bank of America, (Claimant) account #5490351024001326, in the amount of $_18,326.10 against the estate of the above named decedent. This claim is filed under Section 732 (b) (2) of the Fiduciaries Act of 1949 as amended. The said decedent, who resided at 125 N ENOLA DR. STE. 204A ENOLA PA 17025, died on 12/30/2010. Written notice of this claim was given to WILLIAM LAPITSKY. (Personal representative, if any, or counsel). 3806 HEARTHSTONE RD.. (Claimant) Bank of America Estate Unit DE5-014-02-03 1000 Samoset Drive Wilmington, DE 19884 877-767-9383 (Claimant's Address) IN RE: ESTATE OF JACQUELYNNE M. LAPITSKY Deceased No 21-11-014 Bank of America Fee $ Filed Attorney Form 93 Bank of America, Estate Unit DE5-014-02-03, 1000 Samoset Drive, Wilmington, DE 19884 2/17/2011 Reference: Enclosed claim for Client Name Bank of America Client Account Number 5490351024001326 Balance Owing $18,326.10 Regarding: Decedent's Name JACQUELYNNE M. LAPITSKY Estate /Docket Number 21-11-014 Date of Death 12/30/2010 Social Security Number 201289700 HETRO BANK >02112 6738535 001 092140 JACQUELYNNE M LAPITSKY D/B/A CHANDLER ASSOCIATES 125 N ENOLA DR STE 204-A ENOLA PA 17025 Metro Bank 3801 Paxton Street Harrisburg PA 17111-1418 1-888-937-0004 mymetrobank.com ,~ ~-~~ ~)~~li ~- ~ ~ ~~ ~~ t N O O O O O O O N O O O O ~t N N O O ('7 M (D N '- N O 31 Cycle NOTE :SEE REVERSE SIDE FOR IMPORTANT INFORMATION Palle 1 of 4 _~ Member FDIC METRO-ROLL Metro Bank 3801 Paxton Street BANK Harrisburg PA 17111-1418 1-888-937-0004 mymetrobank.com >01003 6759254 001 092140 JACQUELYNNE M LAPITSKY 3806 HEARTHSTONE RD CAMP HILL PA 17011 We're here 7 days a week, 24 hours a day at 1-888-937-0004. -..x ~_~ .~~ TOTALLY FREE CHECKING 05131 0497 5tat~ment:8atence as of 1?J12/10 ~~ $ ~.~~ 'Pius 1 Deposits and Other Credits X4,000.00 ~~ ~, tess 5 Checks end Other Debits ~~Q Stat~ament BatanGe as of 01/11/11 X0.00 Transactions By Date ~-----''~ Date Description ~-De`b' Credit Balance '1; 2!291'! *'~ CU~TG!'dli=Ft'L`EP051T ' _, 12/30/10 WEB FR DDA TO DDA 000513232199 ~ X4,000.00 54,042.07 $1,000.00 TFR -.w~~ $3,002.07 12/31/1Q POS WECMANS 6416 CAR $51.34 52,950.73 RF#00383812/30 ,200642 MECHANiCBURG,PA 12/31/10 VISA HARRISBURG AREA $55.00 '~-~~ RF#011457 12/31 131633 HARRISB _T,----._.~ $2,895.73 ,~ URG,PA / ~.~^`W,,r 01/03!11 .WEB FR DDA TO DDA 800512080457 52,50QA0 $395.73 TFR 01/04/11 PAID/RETURN ITEM FEE $395.73 $0.00 Fees Summary ' Total Qverriraft Fees this fitatement Period ~~~ Total Overdraft Fees Year to Date $0.00 Total Returned Item Fee$ this St~-tement Period $o.oo Total Returned Item Fees Year to Date $0'00 $0.00 For your convenience, a summary of overdraft and returned item fees appears on your monthly statement. Please note that the overdraft fee summary includes non-sufficient funds fees, uncollected funds fees and unavailable funds fees. Total fees are reduced by fee refunds that have been credited to your account. Important Notice: Total Overdraft Fees Year-To-Date and Total Returned Item Fees Year-to-Date in the Fees Summary box above are inclusive of all fees incurred from January 1, 2010 through December 31, 2010. Year-To-Date fees will reflect only 2011 fees beginning with your next statement. With Pay Anyone, a FREE feature of Metro Online Bill Pay, you can send payments to anyone just by using their email or cell number--in as fast as one business day! Not enrolled in Bill Pay? Visit mymetrobank.com and click "Online Banking.." Looking for a credit card with an amalzingly low interest rate, no annual fee and no late fees? Introducing the Metro Bank Personal Visa® Credit Card, America's Next Great Credit Cardl Apply at your nearest store or call 800.296.1015. ~ ~ Cycle NOTE :SEE REVERSE SIDE FOR IMPORTANT II~FORMATION F~age 1 of 2 METRO-ROLL _ Member FDIC '~ETRO BANK >06848 6738542 001 092140 JACQUELYNNE M LAPITSKY D/B/A CHANDLER ASSOCIATES 3806 HEARTHSTONE RD CAMP HILL PA 17011 Metro Bank 3801 Paxton Street Harrisburg PA 17111-1418 1-888-937-0004 mymetrobank.com -,r..-- C, V~ We're here 7 days a week, 24 hours a day at 1-888-937-0004. ~ BUSINESS CHECKING 051 232199 ~~, y $11,8$~.8~ $13576,97 .. ~" Date Description Debit .. Credit Balance .:' .. v, . , 77~.11-~ ~~ a 12/01/10 CHASE EPAY $100 00 JACQUELYNNE M LAPITSKY . $2,277.15 al~~ ~ ~y ,. ,i~a ° sx~s~.ns 12/02/10 UNUM AMERICA INS PREM $82.54 ~~ $2 179.52« Jacquelynne M Lapltsky . , w, :; ~.~.- $~11]l.Qq $1,B79.~~ 12/03/10 VISA SASS SALON DAYS $42 RF#000154 12/02 171729 MECHANICSBURG,PA .00 $1,637.52 ~- . `~ n -, -... - +i f ia7~VV.~L ` 12/03/10 VISA SASS SALON DAYS $18.00 $1 580.12 ` ` RF#00015712/02 031915 MECHANICSBURG,PA , ~ . ,. 12/06/10 CUSTOMER DEPOSIT X50-00 $1,645.92 ~ ~ ~ ~~ ~ ~ r ~_ $45.54 $1,600.36 ~ ~ 12/06/10 POS CVS 02321 02321- $32.14 a $1 568.24 s ~ RF#133827 12/05 141835 Harrisburg,PA , ~. ' .. 4 S`~J.,~'J 't9 ~'1,553 ~ ,. ,. ,a, ~y ~ . E, 12/07/10 VISA STAPLES 00 ...~ $47.69 ro :. , $1 505.50 a C RF#067832 12/06 064308 CARLISLE,PA , ~a~ _• :.. +~; $1;462.04 12/07/10 AMAZON INTERNET $15.56 $1 446.48 Lapitsky Jacquelynne , 1~lg7/'I'Q A~YIA~t M~FTI~ 515.83 $1,43?.&S 12/07/10 AMAZON INTERNET ~~ $15 63 ~ ~ Lapitsky Jacquelynne . $1,415.22 31 Cycle NOTE :SEE REVERSE SIDE FOR IMPORTANT INFORMATION Page 1 of 8 METRO-ROLL Member FDIC Transactions By Date ~ ~ r~1 j -' ~~ c~ J - .. ~-- ~._.IHC~^"'O CD ~ T N W L7 Q: ¢ a. :- ~ N [n cn ~--•~F- r~l~ OOJ.... .Z ~N n-~'"-"of~~ Zf~c~ ~ /~Q' 1i ~ ~ cn a. cr¢ to {f~° O ~ ~ CL i ~ ¢ <L ^ U ~~ ~~~~ ~_ ~~~ ~~ M ~~ o r~ ~..~ -' '_'~- ~~ N V r ~ a IQ+ ya, N w~ o ti ,Q, h ~n P ~. R -.. ,. J3 ~ 4~.~ ~ i `:^ t 4~y 1 ` ~. x ~.~.u~ ~ ~i ~ ..sue.. l ...f+ r ''yy++ ' ~L... - .. ,. ~- r ~~ ~~ ~= ~ :~ •a ~°1 ~~ ~~ ~ R 1 > V t\ ~/ ~y 1 ~ ^1) ~ .J ~~ j~ ~ O ~ V r ~ U W r~ -~ LC~o ~~~ y Q~ h H O ~ Z H