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Home My WebLink About04-19-11\ / `3 _ ~~ ~ ~ ~AO ~~ ~ . c ~ ~ ~ c ~ ~~~ ;off ~~ ~ ~ ~ ~- i i ,~ W M V1 Q o J ~ I~ Q, J d .-~ ~ H N 3 W Q ~ <n a ~ o~ ~" ~ = w x W H J A A ~ ~ v 3 w ,,,t, .~ o ~ z~ 1 ~., ~ ~ O r- aUc~ +,_ rn ~cr» ~ J ~- `~ x o ~ ---- o~ F- ~ •~~ -. U H ~ o a a o ao 0 ~--~ o ~ N o N W N ~ i i X .~ 1~ 0 1~ C/1 rti ~ O .ti N W Woo.-~N o a LL o ti N .r .-~ a a~ M ti ~ ~ 3 ~ ~ ~ A ~ ~ z ~ ° U ' ~ o n ro --~ w Yv~ AwAQ COMMONWEALTH OF PENNSYLVANIA DEPARTMEN70F REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280807 HARRISBURG, PA 7 7 7 28-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 012407 CRONIN SANDRA 18 CUMBERLAND ESTATES DRIVE MECHANICSBURG, PA 17050 Boa ESTATE INFORMATION: SSN: 097-12-8905 FILE NUMBER: 21 10-0199 DECEDENT NAME: KOZLOWSKI FELIX DATE OF PAYMENT: 03/01 /2010 POSTMARK BATE: 03/01 /2010 CouNTY: CUMBERLAND GATE OF DEATH: 10/07/2009 REMARKS: CMECK#1734 SEAL ACN ASSESSMENT AMOUNT CONTROL NUMBER aEV-i ie2 Fx~~ i-see X977.90 TOTAL AMOUNT PAID: INITIALS: CJ RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER File Na. Decedent Docket Entries 21 2010 - 00199 ACTIVE KOZLOWSKI FELIX Page 4 of 4 _ 3/01/10 -------------------------- FIRST ENTRY ------__ -------------------- INHERITANCE TAX PYMT PAID - 814.91 ACN - 09I68I3S RECEIPT - ®012407 POSTMARK DATED - 03/OI/2010 CRONIN SANDRA _ 3/01/10 INHERITANCE TAX PYMT PAID - 9.I2 ACN - 09168134 RECEIPT - CD012407~ POSTMARK DATED - 03/01/2010 CRONIN SANDRA --------------------- 3/OI/10 INHERITANCE TAX PYMT PAID - 153.80 ACN - 09168133 RECEIPT - ®0124b7 POSTMARK DATED - 03/01/2010 CRONIN SANDRA ------------------------------------------------------- Change/De3ete: Position "X" And Press The "ENTER" Key. F2=Done F9~Add Flt=Cance.I F13=Reaeq F17=Top F18=8ott~m J 1505610101 REV-1500 ~tO1dO1 '$~- PA Department of Revenue pennsylvanfa OFFICIAL USE ONLY Bureau of Indlvldual Taxes ""'"""""'°"` Colnty Code Year Fik Number PO BDxs8u6oi INHERITANCE TAX RETURN - , Harrtsbu PA>. Lz8-06os RESIpENT DECEDENT ENTER DECEDENT INFORMATION BELOW SoClal Security Number pate of Death MMDOYYYY pate of girth MMDDYYYY 097-12-8905 10/07/2009 ;04/02/1923 ' _.. ' Decedents t.ast Name . _ ,.._. .... SuRix _ Decedent's First Name MI !Felix Kozlowski (tf Applit:able) Enter Surviving Spouses Enformation Below ' - Spouse's Last Name SuOix ........ - Potlae's First Name _.. MI Spouse's Social Securty Number ` THiB RETURN MUST BE FILED IN DUPIiCATE WITH THE _----_.._ _ ............. . ._........ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW OD 1. Original Rstum O 2. Supplemental Relum O 3. RemNnder Return (date of tleath O 4. Limited Estate prior to 12-13.82) O 4a. Future Interost Compromise (date df O 5. Federal Estate Tax Ratum Requirod death after 12-12-82) O 8. Decedent Died Testate Q 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach copy of WIU) (Attach copy of Trust) O 9, Litigatlon Proceeds RecNved O 10. Spousal Poverty Credit (date of death O 11. F_kctlon to tax under Sec. 9t13(A) between i2-31-91 and 1-1•g5) (AUadt Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED, ALL CORRESPONDENCE AND CONFN)ENTIAL TAX INFORMATION SHOULD BE DIRECTEp T0: Name _ _ Daytlme Telephone Number .. Sandra A. Cronin (717)385-8667 REGISTER OF WILLS USE ONLY First Iine of address 18 Cumberland Estates Secald Tine of address _.. City or Post ONks .' , ..,....... _.... _ _ ,.. State ZIP Code .............. ,.. Mechanicsburg PA ;17050 corrospondenra a-nwR address: sacronin comcast.net under penalties dper)ury, I dec4ro that I have examirred fhle reWrn, induding acoompenying adradules end etstemente, end to the x Is true, corroct end complete. DedfraaM of preparor other then the Deroonel ropro~tatAre (s based on aH Information ~ vfiltFl SIr~yATURE OF Pl7t8AN~E8pq/SIgLE FOR FILING RE7Uau DATE f 0/22/10 18 Cumberland Estates Dr., Mechanicsburg PA 47050 iIGNATURE OF PREPARER OTHER THAN REPRE8ENTATtVE ADDRESS - - PLtsASE USE ORIti1NA1. FORM ONLY Side 1 `„r 1505620101 1505610101 J _J REV-1500 EX 1505610105 Decedent's Social Security Number oepdenrs Nerve: Felix Kozlowski 097-12-8905 RECAPrruunoN 1. ReafEstate(SdiedulsA) ............... .... .......................... 1. 2. Stocks and Bonds (Schedule B) .......... ................ ............. 2. 3, Cbealy HNd Corporation, Partnership WSole-Proprietorship {Schedule C) .... , 3, ..._ . .., , .,...._ ~ ~_~ 4. Mortgages and Notes Receivable (Schedule p) , , , , , , , , , , ................. 4. 5. Cash, Bank Deposits and Mlacellaneaus Personal Property (Schedule E ).. , , , , , 5, 8. Jointly Owned Property {Schedule F) O Separate Billing Requested 8 .. , ... , . 7. Inter-Vtvos Transfers 8 Miscellaneous Non-Probate Property 3,399.14 ( chedule G) O Separate Bliltng Requested., , . , , , , ~, 8. Total Gross Assets (total Unes 1 through 7) .. ................... . . .. . g, ' ' ' 30,399.14 9. Funeral Expanses andAdminfstrative Costs (Schedule H)..... , ........ s . .... . 8,606.27 Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .. _....., . .............. 10. _ 63.19' 11. Total Deductions (total Lines B and 10) ..... ... . .... . ..... . ............. 11. 8,669.46 12. Not Vales of Estate Una 8 minus Line 11 ( ) .. ........... ......,...., tz. 13. Charitable antl Governmental BequestslSec 9113 Trusts for which .......... ' 21,729.68 ...................... an election to tax has not been made Schedule J ( ) ...... _ .................... 13. - .._.. 14. Nst Value Subset to Tax (Line 12 minus Una 13) ....... . ................ ia. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATE 21,729.68 S 15. Amotmt of Una 14 taxable at fhe spousal tax rate, or trenafers under Sac. 9176 (a)(1.2) X .0~ 15. ' 16. Amount of line 14 taxable -"`- "-~----°~~------- --- _.,M... ~~ at lineal rate X .0.48 21,729.68 .' is ; -~_~' . 17. Amount of Line 14 taxable 977.84 at sibling rate X .12 17. t8. Amount of Une 14 taxable , -. a lateral rate X .45 18. i9. TAX DUE .... . ........ .. ----1. .........................................19. 20. FILL iN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505b10105 1505610105 977.84 O REV-1500 Ex PaBa 3 FII• Numb•r Decedent's Complete Address: DECEDENT'S Felix Kozlowski BTREErAODRESS ------..~.. 18 Cumberland Estates cm - Mechanicsburg . STATE _ ~p PA I 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments f1) 977.84 A. Prior Payments -_ 997.90 _ .............. (3. Disceunt __ .. ......_........ 3. Interest Total Credits (A + 8) (2) 977,90 (3) 4. If Ltne 2 is greater than Line 1 + Line 3, enter the diRerence. This is the OVERPAYMENT , Fill in oval on Pape 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater then Line 2, enter the diffelenos, This is the TN( DUE . {5) Make check payable to: REGISTER OF WELLS, AGENT: PLEASE ANSWER T'HE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS t. Old deceddrt make a transfer and: a retain the use or income of the property transterred :.................... .................................. es No ^ ................................... b. retain the rind to designate who shall use the properly transferred or its income : ...... ~ x ^ .................... c. retain a rewersiorla Into ................. ry ~ or ................................................................................ x ~ .......................................... d. receive U1e promise for Ilfe of either payments, benefits or care7 ............................ O ~ ............ 2. If deatlr occurred after Dec.12.1982, did decedent transfer .............................. Property wHhin one year of death ~ wiulout receivtnp adequate oorlsideratbn? ................ 3. Did decedent own an'sl trust for" or .......................... pa able-u d th 0 y pon- ea bank account or security at his or her death?,,,,,,,,,,,,,, 4. Did decedent ovrr an individual retkement account annuity or other no b (] , n-pro a~ properly, which contains a benefcary designation? ..................... .................................................................................................. ^ X IF THE ANSWER TO ANY OF THE ABOVE QUESTfONS IS YES, YOU !MUST COMPLETE SCHEDULE G AND FILf IT AS PART OF THE RETURN. For dates of d~th on or attar Jury 1,1994, and before Jan. 1, 1995, fhe tax rate imposed on the net value of transfers to or fo- the use of the surviving spouse is 3 pennant (72 P.S, §911!3 (a) (1.1) ()). 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.i) (i)J. The statute does not exempt a transfer to a surviving spouse fmm tax, and the stabrtory requirements for disclosure of assets and filing a tax return are stHl applicable even H 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 chHd 21 years of age or younger at death to or for the use of a naEural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(12)]. • The tax rate i on the net value of transfers to or for the use of the decedent's lineal benefiaeries is 4.5 percent, except as noted in 72 P.S. §9118(1.2 (72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers io 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 food or adoption. REWL509 EX+ (oi-io) pennsytvania DE-ARTMENT Of REVENUE INFPRITAN[E TAx RENRN RE4[OENr DECtDENr SCNEpVLE ~ ]OINTLY-OWNEb PROPERTY t7MTE OF: -- Felix Kozlowski FILE NUMBER: 2110-0198 It an asset haca~m ioiMly owned within one year of the daoedenYs daq of dastly It must ba SURVIVING 101NT TENANT(S) NAME(S) ~rtod on sd-eduls G. ADDRESS A•.Sandra A. Cronin RELATIONSHIP TO DECEDENT 18 Cumberland Estates Dr., Mechanicsburg, PA 17050 t)aughter i ~ ItEV-tsii Ex• Ilo-o4> Pennsylvania DEPARTMENT OR pEVENUE tNNetttaNCe rAx pETURN RESIDEf(r DECEDENT ESTATE Of Felix Kozlowski De~nt't de6te mutt be raportad on Scheduh I. SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS A• I FUNERAL EXPENSES: I' Myers Funeral Hrane . fimers~ e~„e.,~s.. 1. Personal Representative Commissions: Name(s) of Personal Representative(s) _ Street Address _ city Year(s) Commissbn Paid: State _ _ uP TOTAL (Also enter on Line a !f nwrc space is needed, use addi6onai sheets of paper of the same size, LE NUMBER 110-0199 ......,.. _...,.:..:: 8,606.27 TOTAL (Also enter on Une S0. If more space !s needed, insert addltiona! sheets of the same size. ,.; $;:` 63.19 REV-1513 EX+ (01.10) Pennsylvania SCHEDULE J DEOARTMENT OF REVENUE INHERITANCE TAx RETURN BENEFICIAfRIES RESIDENT DECEDENT ESTATE OF: Felix Kozlowski FILE NUMBER: 2110-0189 NUMBER NAME AND ADDRESS OF PERSON{S) RECEIVING PROPERTY REDonNotSLbt TfurtN ~ ) AMOUNT OR SNARE OF I TAXABLE DISTRIBUTIONS (Include outright spousal distributbas and transfers under ESTATE Sec. 4116 (a) (1.2).j 1. Sandra A. Cronin, t8 Cumberland Estates, Mechanicsburg, PA 17050 Daughter ' ' 7243.23 :s Paul Kozlovuski, 34 Crownview Terrace, Hambu NY 14075 ~' Son :.... ,:. 7243.23 .: Michael P. Kozbwski, 489 Mapleview, Cheektowaga, NY 14225 ;. Son ,. 7243.23 ;: _.. _ . .. ,. _.. i _...... ._, ,. ,.. I - ~ ,: .. `;. ~~ _.::. ENrEK DOLIAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SH Q NON TAXABLE DiSTRTBlRi0N5 AS A PPROPRIATE. A. SPOUSAL 0lSTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECrION TO TAX IS NOT TAKEN: 1. ....... 8, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: I 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVFQ cWCS:TI ~ I •~ If more space is needed, use adddionel sheets of paper of the same size. ,,~ ~ ~ ~ ~ ,~ ~ ~~- ~~~ p ~ennsylvania NOTICE BUREAU OF INDIVIDUAL TAXES'. ~ ~ OF INHERITANCE TAX DEPA INHERITANCE TAX DIVISION -~. A~FRAISEMENT, ~ ~ ~ ALLOWANCE OR DISALLOWANCE RTMENT OF REVENUE YY77 PO HOX 2HH601 - " ' OF DEDUCTIONS, HARRISBURG PA 17121-0681 AND ASSESSMENT OF TAX ON ~ , REV-1548 EX AFP Q2-09) JOINTLY HELD OR TRUST ASSETS 2010 P9AR 26 Pti 12~ 3 i DATE 03-29-2 10 ESTATE OF KOZLOWS I FELIX CLE~~,~ r~ DATE OF DEATH 10-07-2 09 ~ N'S ;COURT ORPH FILE NUMBER 21 10-0 99 , , ((;;II II ^ /,~ Dp ~ COUNTY CUMBERL ND ,, SANDRA CR~ NIH SSN/DC 097-12- 905 ACN 0916813 18 CUMBERLAND ESTATES APPEAL HY DATE:'05 8-2010 DRIVE (See reverse side und4r O ecp'ons) MECHANICSBURG PA 17050 At•ount Ra~ittad MAKE CHECK PAYABLE AN REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE ~ CARLISLE PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ---------------------------------------------------------------------- - REV-1548 EX AFP C12-09) ------------------- NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANC OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSET DATE: 0 ESTATE OF:KOZLOWSKI FELIX DATE OF DEATH:10-07-2009 OUNTY:CUMBERLAND FILE NO.: 21 30-0199 S.S/D.C. NO.: 097-12-8905 I ACN: 09168134 TAX RETURN WAS: CX) ACCEPTED AS FILED ( ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 18 035-11 TYPE OF ACCOUNT: C )SAVINGS CX) CHECKING ( )TRUST ( )TIME CERTIFIC TE DATE ESTABLISHED 02-20-1999 Account Balance 405 35 NOTE: TO ENSURE PROPER CREDIT TO Percent Taxable X 0 500 YOUR ACCO NT, SUBMIT THE Amount Subjaet to Tex 202.68 UPPER POR ION OF THIS NOTICE Debts and Deductions - •00 WITH YOUR TAX PAYMENT TO THE Taxable Amount 202.68 REGISTER F WILLS AT THE Tax Rata r 45 ABOVE ADD ESS. MAKE CHECK Tax Due 9 12 OR MONEY RDER PAYABLE T0: TAX CREDITS: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMBER DISCOUNT Ca) INTEREST/PEN PAID C-) AMOUNT PAID 03-01-2010 CD012407 .00 9 12 I TOTAL TAX PAYMF~N' 9.12 lALANCE OF TAX E .00 INTEREST AND PEM .00 TOTAL DUE .OD ~ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ^ IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY HE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. .. r ~ i ^~,~ ~-~ ~ ~pennsylvania BUREAU OF INDIVIDUAL TAXES ~- -•+..~.S~+TICE OF INHERITANCE TAX DEPARTMENT OF REVENUE INHERITANCE TAX OIYIS[ON ,.~ ~ pPp1pA(SEMENT, ALLOWANCE OR DISALLOWANCE PO 80X 288681 ' ~- LOF DEDUCTIONS, AND ASSESSMENT OF TAX ON '', REV-1548 EX AFP Q2-891 N11RRI58UR6 PA 17128-0681 JOINTLY HELD OR TRUST ASSETS 201D MAR 26 PM 12~ 37 DATE 03-29-2 IlD CLEF:; CF QRPN?.P~! S COUPT SANDRA CRO ~~ '" - ~ • 18 CUMBERLAND ESTATES DRIVE MECHANICSBURG PA 17050 ESTATE OF KOZLOWS I FELIX DATE OF DEATH 10-07-2 09 FILE NUMBER 21 10-0 99 COUNTY CUMBERL ND SSH/DC 097-12- 905 ACN 0916813 APPEAL BY DATE:~05 8-2010 (See reverse side undlr O ecHons) Awount Rewitted MAKE CHECK PAYABLE AN REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE ~1 RETAIN LOWER PORTION FOR YOUR RECORDS ---------------------------------------------------- REV-1548 EX AFP C12-09~ ------------------ -------------------- NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOW NC OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST AS~ET DATE: _ g_ ESTATE OF:KOZLOWSKI FELIX DATE OF DEATH:10-07-2009 OUNTY:CUMBERLAND FILE NO.: 21 10-0199 S.S/D.C. NO.: 097-12-8905 ACM: 09168133 TAX RETURN WAS: CX) ACCEPTED AS FILED ( ) CHANGED ~ JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 8 035- TYPE OF ACCOUNT: CX)SAVINGS C ) CHECKING C )TRUST C )TIME CERTIF'IC TE DATE ESTABLISHED 02-2D-1999 Account Balance Percent Taxable Awount Subject to Tax Debts and Deductions Taxable Awount Tax Rate Tax Dua TAX CREDITS: 6,835 48 X 0 500 3 417 74 - 00 3 417 74 Y 45 153 80 NOTE: TO ENSURE PROPER CREDIT TO YOUR ACCO NT, SUBMIT THE UPPER PbR ION OF THIS NOTICE WITH YOuR TAX PAYMENT TO THE REGISTER F WILLS AT THE ABOVE AbD ESS. MAKE CHECK OR MONEY RDER PAYABLE T0: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMIER DISCOUNT C~) INTEREST/PEN PAID C-) AMOUNT PAID i 03-01-2010 CD012407 .00 153.80 ', TOTAL TAX PAYN BALANCE OF TAX * IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. , IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. 153.80 .00 .00 V ' ^~^^^ ~~~ ~ ICE OF INHERITANCE TAX pennsylvania~ BUREAU OF INDIVIDUAL TAXES f~ i k,hi;3~~ ~s~ DEPARTMENT Of REVENUE INHERITANCE TAX DIVISION ENT, ALLOWANCE OR DISALLOWANCE PO 6W: 266f01 :_`'~'`~~` ~ ((p~ IiI DNS, AND ASSESSMENT OF TAX ON REV-15ae IX AFP [12-09) HARRI56URG PA 17126-Oi01 ~ ~-.~7:J i~tl Vi IITLY HELD OR TRUST ASSETS 2010 APR -9 ~ IQ: 4~9 t+1.Ci1~~ SANDRA CRO~D~ 18 CUMBERLAND ESTATES DRIVE MECHANICSBURG PA 17050 DATE 04-05-2010 ESTATE OF KOZLgWSKI FELIX DATE OF DEATH 10-07-2009 FILE NUMBER 21 10-0199 COUNTY CUMBIRLAND SSN/DC 097- 2-8905 ACN 0916135 APPEAL BY DATE:06-04-2010 (See reverse side and r 06jections) Amount Remitted MAKE CHECK PAYABLE ND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SgUARE CARLISLE PA 17013 CUT ALONC THIS LINE "'B RETAIN L WER PORTION FOR YOUR RECORDS ~ REV-154! EX AFP C12`09~--" -----------~ " --------------------------`----------_____------__ NOTICE OF INHERITANCE TAX APPRAI EMENT. ALLOWANCE OR DISALLOW NCE OF DEDUCTIONS, AND ASSESSMENT OF TA~ ON JOINTLY HELD OR TRUST AS~ETS ~ DATEe ne_nC_7n,n ESTATE OF:KOZLOWSKI FILE NO.: 21 10-0199 IX _~pATE OF DEATH:10-07-2009 ' COUNTY:CUMBERLAND S.S/D.C. Nq.: D97-12-89D5 ACN: 09168135 TAX RETURN WAS: CX) ACCEPTE~ AS FILED C ) CHANGED JOINT FINANCIAL INSTITUTION: MEMBERS 1ST TYPE OF ACCOUNT: CX)SAVINGS ( ) DATE ESTABLISHED 03-01-1999 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREnrrS. NOTE: TO ENSUE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTE~2 OF WILLS AT THE ABOVE A~DRESS. MAKE CHECK OR MONE~ ORDER PAYABLE T0: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMBER OIS INTEREST UNT C+) PEN PAID (-) AMOUNT PAID 03-01-2010 CD012407 .00 814.91 i TOTAL TAX PAYNE T 814.91 BALANCE OF TAX UE .00 INTEREST AND PE .00 TOTAL DUE .00 ^ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ^ IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. TRUST ASSET INFORMATION ACCOUNT NO.: 0.82035-05 ING C )TRUST ( )TINE CERTIFICATE 0~ __~ NOTICE OF INHERITANCE TAX pennsylvania~ ^UREAU OF INDIVI ~ ~ ~RAISEMENT, ALLOWANCE OR DISALLOWANCE pEPARTMEP(TOFREVENUE INHERITANCE TAX DIVISI -~~'! ~"-~~C~ubF DEDUCTIONS AND ASSESSMENT OF TAX Po ^OX 2^ef01 Lv~~-.~-,. ~ " ~+~!j I (~ R1Y-1547 EX AFP (12-1 ^) IMRRIS^UR6 PA 17126-Of ~ ~•.•J "~ ~•~~ r~,. ~~J i ~~, "' DATE 12-27~,-2D10 ~."1l \. 10~~~ ~~ ~I`1 .i' .r 1~ ESTATE OF KOZLdWSKI FELIX G,LER~ ~r DATE OF DEATH 10-07-2009 ORPi-U~P,'~ r' • FILE NUMBER 21 10',-0199 vC~.1RT COUNTY CUMBERLAND SANDRA~~~~r, %;r_~•, PA ACN 101 id CUMBERLAND EST APPEAL DATE:', 02-25-2011 MECHANICSBURG PA 17050 (See reverse siderr~ederObftetioA+s) Ataount Remitted i MAKE CHECK PAYABLE ND REMIT PAYMENT T0: REGISTER OF WIL S 1 COURTHOUSE SQ ARE CARLISLE PA 1 013 CUT ALON_C THIS LINE ~- RETAIN LOWER PORTION FOR YOUR RECORDS REY-1547 EX AFP C12-101Di$ALLOWANCENOFRDEDUCTIO g APPRAISENENT, ALL"~ ""---""--"""""-"""- AND ASSESSMENT OF~TAXCE OR ESTATE OF) KOZLOWSKI FELIX FILE N0.s21 10-0199 ACN: 1101 DATE: 12-27-2010 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CNANBED ~' APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Rul Estate (Soho dins A> (1) .00 2. Stocks and Bonds (Schedule ^) NOTE: To ensure proper C2) .00 credit to your account, 3. Closely Nsid Stock/Partnership Interest (ScM dulo C) (3) x.00 subwit the upper portion 4. Mort^apes/Notes Receivable (Schedule D) of tAis forty with your (4)_ ~. 00 tax paywent. 5. Cash/^ank Deposits/Misc. Personal Property (Seheaule E) (5) .00 6. Jointly Owned Property (Schedule F) (6) 30,399 14 7. Transfers [Schedule 6) (7) 00 d. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: (^) 30 399 1• 9. Funeral Expenses/Adw. Costs/MSsc. Expenses (Schedule N) (9)- R.6DA1 ~~ 10. Debts/Mortpa^e Liabilities/Liens (Schedule I) (10)~ 6a~19 ll. Total Deductions ' 12. Net Value of Tax Return iii (11) 8.669.46 13. Charitable/Bovernwental Degwstst Non-sleeted 9113 Trusts (Schedule J) x',(12) 21s729.68 14. Net Value of Estate Sub7eet to Tax ',(1S) -DO !(14) _ 21,729 68 NOTE: If an essess~snt wss issued previously, lines 14, 15 and/or 1 17. 18 and 19 will reflect figures that include the total of ALL returns assesse~ to date. ASSESSMENT OF TAX: 15. Awount of Line 14 at Spousal rate (15) .00 ~ 00 e 16. Awount of Line 14 taxable at Lineal/Class A rate (161 71-~ 9 ~(A •00 17. Awount of Line 14 at SSb11n^ rate ~ 045 977.84 nn- _nn x 12 .00 1^. Awount of Line 14 taxable at Collateral/Class ^ rate C1^) .00 X 15 19. Principal Tax Due .00 TAX CREDITS: ~ (19). 977.84 PAYMENT RECEIPT ISCOUNT (+) DATE NUM^ER INTEREST/PEN PAID (-) ANOUNT PAID 03-01-2010 CD0124 7 .OD .17 INTEREST IS CHARGED THROUGH 01-11-2011 TOTAL TAX PAYME T AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX UE •07 REVERSE SIDE OF THIS FORM 977.77 INTEREST AND PE 19.92 TOTAL DUE 997.69 • IF PAID AFTER DATE INDICATED, SEE REVERSE iF TOTAL DUE IS REFLECTED AS A "CR DIT" (CR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~US F T L 5 ~A /~ F i L 5 f~ . , ~~~~1111 y \~n~/~ 1 Q ~ w .`v ~~` bd? % ;` k., a ~~ 1 _ ~ti •ti •+~ •~s 1 t T~ ~~r ~~~ ~ti ~~ ~~t t.,y f*1~ .,-- ~:a ~~. .,,; :, M ~~ W- F