HomeMy WebLinkAbout05-04-11--~ REV-1500 Ex (01-1°) 15 0 5 61014 3
PA Department of Revenue pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes OEPARTMENTOFREVENUE County Code Year File Number
Po Box.2aoso~ INHERITANCE TAX RETURN 21 0 9 0 0 6 4 3
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
195 16 3877 06 29 2009 08 21 1914
Decedent's Last Name Suffix Decedent's First Name
MI
HICKOK ELISABETH H
(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 INAPPROPRIATE OVALS BELOW
® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest Compromise 5. Federal Estate Tax Return Required
(date of death after 12-12-82) ^
® g Decedent Died Testate ® ~ Decedent Maintained a Living Trust
(Attach Copy of Will) (Attach Copy of Trust) 8. Total Number of Safe Deposit Boxes
^ 9. Litigation Proceeds Received ^ 1 p, Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113 A
between 12-31-91 and 1-1-95) ^ ( )
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name
Daytime Telephone Number
JEAN D SEIBERT 717 236 9301
First line of address
109 LOCUST STREET
Second line of address
City or Post Office
HARRISBURG
State ZIP Code
PA 17101
Correspondent'se-mail address: WZS@n1lndSpring.COI?1
REGISTER OF WILLS USE OAII,Y
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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 NSIBLE R FIj,1PdG RETURN ATE
~; ~'~ r"M
~~ ~'~ Peter H. Hickok
$CDDRE S ~~ l~
5235 Terrace Road, Mechanicsburg, PA 17050
SIGNATURE REP OT f2 THAN REPRESE ATIVE
DATE
Jean D Seibert l-~_~~_~ ~
ADDRE
109 Locust Street, Harrisburg, PA 17101
Side 1
L 1505610143 1505610143
ADDITIONAL Personal Representatives
Hickok, Elisabeth H D SS# 195-16-3877 6/29/2009
Under penalties of perjury, the undersigned declare that they have examined this return,
including accompanying schedules and statements, and to the best of their knowledge and
belief, it is true, correct and complete.
2 Signature -~~~~ 2i2%/J~~~
Name Charles N. Hickok
Address 259 Hidden Valley Road
City, State, Zip
Date
Harris urg
y~~i/
PA 17112
3 Signature
Name
Address
City, State, Zip
Date
4 Signature
Name
Address:
City, State, Zip
Date
5 Signature
Name
Address:
City, State, Zip
Date
6 Signature
Name
Address:
City, State, Zip
Date
1505610243
REV-1500 EX
DecedenPs Name: H I C K O K, E L I S A B E T H H D
Decedent's Social Security Number
195 16 3877
Ktl.Ar I I U LA I I V N
1. Real Estate (Schedule A) .......................................................................................... 1. 8 6 9, 0 0 0. 0 0
2. Stocks and Bonds (Schedule B) ............................................................................... 2. 1 0, 4 7 5. 0 0
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3.
4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4. 1 6 0, 0 0 0. 0 0
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5. 7 6 2 , 1 1 6 . 6 4
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ............. 7, 1, 5 2 2, 7 6 0. 7 0
8. Total Gross Assets (total Lines 1-7) ....................................................................... g, 3, 3 2 4, 3 5 2. 3 4
9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 4 7 , 6 2 6 . 3 1
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 2 0 , 4 6 2 . 7 6
11. Total Deductions (total Lines 9 & 10) ...................................................................... 11. 6 8 , 0 8 9 . 0 7
12. Net Value of Estate (Line 8 minus Line 11) ........................................... .... 12. 3 , 2 5 6 , 2 6 3 . 2 7
..............
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. 3 , 2 5 6 , 2 6 3 . 2 7
~ AA culvlru l A l IUN -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 .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 3, 2 5 6, 2 6 3. 2 7 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
1505610243
146,531.85
146,531.85
1505610243
REV-1500 EX Page 3
Decedent's Complete Address:
cITY
Hickok, Elisabeth H D
851 Oak Oval
Mechanicsburg
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A• Prior Payments
B. Discount
3. Interest
141,400.00
6,842.11
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box 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.
Make Check Payable to: REGISTER OF WILLS, AGENT.
(3) 0.00
(4) 1,710.26
(5)
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 :....................................
x
c. retain a reversionary interest; or .................................................................................................................. ^ ^
d. receive the promise for life of either payments, benefits or care? ............................. .
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without x
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 p2 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 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 refturn 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 1.2) [72 P.S. §91.16 (a) (1)].
• s tiling is deflnepd under Secfiont9102, as an individual who has at least one parent in oolmmon wi lithe decedent wfiether by blood oAadoption.
File Number 21 - 09 - 00643
ATE
PA
17055
(1) 146,531.85
Total Credits (A + 13) (2) 148,242.11
SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Hickok, Elisabeth H D FILE NUMBER
21 - 09 - 00643
All real property owned sole)y or as a tenant in common must be reported at fair market value. Fair market value is defined as the price
at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having
reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on
schedule F.
Attach a copy of the settlement sheet if the property has been sold.
Include a copy of the deed showing decedent's interest if owned as tenant in common.
ITEM
NUMBER DESCRIPTION VALUE AT DATE OF
DEATH
1 :Real Property situate in Reeser's Summit, Fairview Township, York County, Pennsylvania (Lot 41,000.00
1)
2 I' Real Property situate in Reeser's Summit, Fairview Township,York County, Pennsylvania (Lot I 250,000.00
2)
3 Real Property situate in Lemoyne, Cumberland County, Pennsylvania (East 12th Street) 200,000.00
4 -Real Property situate in Lemoyne, Cumberland County, Pennsylvania (West 12th Street) 80°/D 228,000.00
interest in Value of $285,000.00
5 ~ Real Property situate in Fishing Creek Valley, Middle Paxton Township, Dauphin County, I 150,000.00
Pennsylvania
_ ~ TOTAL (Also enter on Line 1, Recapitulation) ~ 869,000.00
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Hickok, Elisabeth H D FILE NUMBER
21 - 09 - 00643
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION
UNIT VALUE VALUE AT DATE OF
DEATH
1 The Philadelphia Housing Authority Bond No. 3959 5,000.00
Accrued Interest (2 Coupons $118.75) 237.50
2 The Philadelphia Housing Authority Bond No. 3940 5,000.00
Accrued Interest (2 Coupons $118.75) 237.50
TOTAL (Also enter on line 2, Recapitulation) 10,475.00
SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES RECEIVABLE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Hickok, Elisabeth H D FILE NUMBER
21 - 09 - 00643
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE OF
DEATH
1 W.O. Hickok Manufacturing Promissory Note Dtd July 17th , 2000 160,000.00
TOTAL (Also enter on Line 4, Recapitulation) I 160,000.00
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF Hickok, Elisabeth H D FILE NUMBER
21 - 09 - 00643
Include the proceeds of litigation and the date the proceeds were received by the estate. All
survivorship must be disclosed on schedule F. property jointly-owned with the right of
ITEM
NUMBER DESCRIPTION VALUE AT DATE OF
DEATH
1 : PNC Bank Checking Account no. 5004883261
3,251.00
Accrued Interest
0.22
2 Wachovia Bank Checking Account No. 2828
170,158.95
Accrued Interest
4.79
3 Wachovia Bank Checking Account No. 9347
167,226.32
Accrued Interest
35.51
4 M&T Bank Checking Account No. 42787920
79,094.50
Accrued Interest
2.27
5 Federated -Liberty U.S. Government Money Market Account No
8846
. 10,848.30
6 Jewelry and Coin Collection- Appraised Value
42,496.00
7 Furniture -Appraised Value
54,505.00
8 . Silver -Appraised Value
45,805.00
9 2003 Toyota Camry -Blue Book Value
12,300.00
10 Messiah Village Apartment
173,554.78
11 Federal Income Tax Refund
2,600.00
12 PA Income Tax Refund
234.00
~ TOTAL (Also enter on Line 5, Recapitulation) ~ 762,116.64
COMMONWEALTH OF PENNSYLVANIA SCHEDULE G
INHERITANCE TAX RETURN I~+N/~TER-VIVOS TRANSFERS &
RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF Hickok, Elisabeth H D
FILE NUMBER
21 - 09 - 00643
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is ves.
ITEM
NUMBER DESCRIPTION OF PROPERTY
Include the name of the transferee, their relationship to decedent
and the date of transfer. Attach a copy of the deed for real estate. DATE OF DEATH
VALUE OF ASSET ~~ OF
DECD'S
INTEREST EXCLUSION
(IF APPLICABLE)
TAXABLE VALUE
1 All assets listed below are titled as Elisabeth H D
Hickok Trustee for Elisabeth H D Hickok Trust U/A
dtd 12/09/87 FBO Elisabeth H D Hickok, beneficiaries
are Peter H. Hickok and Charles N. Hickok, her sons
2 T. Rowe Price International Mutual Fund Account No. 11,898.81 11
898.81
40093465434 ,
3 Vanguard Pennsylvania Tax-Exempt Money Market 110,000.00 110,000.00
Account No. 9881861728
4 386 Shares of Alcatel Lucent @ $2.50 per share 962.11 962.11
5 300 Shares of Altria @ $16.47 per share a,9al.oo 4,941.00
6 1449 Shares of AT&T @ $25.06 per share 3s,3oa.7o 36,304.70
7 100 Shares of Autonation @ $17.53 per share 1,753.00 1,753.00
8 26 Shares of Berkshire Hathaway @ $2,816.74 per 73,235.24 73,235.24
share
9 1312 Shares of BP P.L.C. @ $47.96 per share 62,923.52 62,923.52
10 123 Shares of Burlington Northern @ $ 75.25 per 9,255.14 9,255.14
share
11 696 Shares of Chevron/Texaco @ $66.59 per share 46,343.16 46,343.16
12 2007 Shares of Cigna @ $24.38 per share as,92o.s3 48,920.63
13 100 Shares of Colgate @ $71.99 per share 7,198.50 7,198.50
14 1147 Shares of Comcast @ $14.26 per share 16,356.22 16,356.22
TOTAL (Also enter on line 7, Recapitulation) 1,522,760.70
SCHEDULE G
COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TRANSFERS &
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
continued
ESTATE OF Hickok, Elisabeth H D
FILE NUMBER
21 - 09 - 00643
This schedule must be completed and filed if the answer to any of questions 7 through 4 on page 2 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
Include the name of the transferee, their relationship tc decedent
and the date of transfer. Attach a copy of the deed for real estate. DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST EXCLUSION
(IF APPLICABLE)
TAXABLE VALUE
15 400 Shares of Corn Products @ $27.11 per share 1o,aa2.oo 10,842.00
16 90 Shares of Covidien Ltd @ $36.87 per share 3,317.85 3,317.85
17 300 Shares of Cytec Industries @ $18.04 per share 5,412.00 5,412.00
18 46 Shares of Daimler @ $36.89 per share 1,sss.9a 1,696.94
19 24 Shares of Direct N @ $24.25 per share 592.08 592.08
20 252 Shares of DuPont @ $24.90 per share s,27a.ao 6,274.80
21 100 Shares of Eastman Chemical @ $38.09 per 3,aoa.5o 3
808.50
share ,
22 100 Shares of EDS @ $25.00 per share 2,500.00 2,500.00
23 2020 Shares of Equitable Resource @ $35.06 per 70,811.10 70
811.10
share ,
24 4992 Shares of ExxonMobil @ $69.96 per share 349,215.36 349,215.36
25 300 Shares of First Energy Corp @ $39.14 per share 11,740.50 11,740.50
26 150 Flowers Foods @ $21.89 per share 3,282.75 3,282.75
27 100 Genelabs @ $1.30 per share 130.00 130.00
28 1056 Shares of General Electric @ $11.74 per share 12,392.16 12,392.16
29 200 Shares of General Motors @ $1.14 per share 227.00 227.00
30 400 Shares of PH Glatfelter @ $8.53 per share 3,a12.oo 3,412.00
Page 2 of Schedule G
SCHEDULE
G
COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TRANSFERS &
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
continued
ESTATE OF Hickok, Elisabeth H D
FILE NUMBER
21 - 09 - 00643
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
Include the name of the transferee, their relationship to decedent
and the date of transfer. Attach a copy of the deed for real estate. DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST EXCLUSION
(IF APPLICABLE)
TAXABLE VALUE
31 1280 Shares of Halliburton @ $21.11 per share 27,014.40 27,014.40
32 200 Shares of Hawaiian Electric @ $18.79 per share 3,757.00 3,757.00
33 600 Shares of Honeywell Int'I @ $31.94 per share 1s,lsa.oo 19,164.00
34 200 Shares of IBM @ $105.67 per share 21,134.00 21,134.00
35 612 Shares of International Paper @ $14.24 per $,714.$$ 8,714.88
share
36 100 Shares of Johnson & Johnson @ $56.52 per 5,651.50 5,651.50
share
37 2900 Shares of Kimberly Clark @ $52.62 per share 152,598.00 152,598.00
38 337 Shares of Kodak @ $2.88 per share 970.56 970.56
39 207 Shares of Kraft Foods @ $25.58 per share 5,2s5.os 5,295.06
40 116 Shares of LSI Logic @ $4.59 per share 532.44 532.44
41 926 Shares of Medco @ $45.54 per share x2,165.41 42,165.41
42 3840 Shares of Merck @ $27.41 per share 105,254.40 105,254.40
43 400 Shares of Microsoft @ $23.79 per share 9,51s.oo 9,516.00
44 190 Shares of NCR @ $11.94 per share 2,267.65 2,267.65
45 87 Shares of Neenah Paper @ $8.30 per share 721.67 721.67
46 23 Shares of Newmont Mining @ $42.48 per share s77.o4 977.04
Page 3 of Schedule G
SCHED
ULE G
COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TRANSFERS &
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
_. continued
ESTATE OF Hickok, Elisabeth H D
FILE NUMBER
21 - 09 - 00643
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
Include the name of the transferee, their relationship to decedent
and the date of transfer. Attach a copy of the deed for real estate. DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST EXCLUSION
(IF APPLICABLE)
TAXABLE VALUE
47 400 Shares of PPL @ $33.17 per share 13,266.00 13,266.00
48 100 Shares of Pepsico @ $55.06 per share 5,505.50 5,505.50
49 61 Shares of Pfizer @ $15.17 per share 925.37 925.37
50 300 Shares of Philip Morris Int'I @ $42.97 per share 12,s91.oo 12,891.00
51 800 Shares of PNC Financial @ $39.42 per share 31,536.00 31,536.00
52 960 Shares of PPG Industries @ $43.64 per share 41,889.60 41,889.60
53 317 Shares of PolyOne @ $3.01 per share 952.59 952.59
54 134 Shares of Qwest Communications @ $4.11 per 550.74 550.74
share
55 100 Shares of Regeneron @ $17.80 per share 1,7so.oo 1,780.00
56 160 Shares of Telefonaktiebolaget @ $9.69 per share 1,550.40 1,550.40
57 190 Shares of Teradata Corp @ $ 22.85 per share x,341.50 4,341.50
58 468 Shares of Travelers @ $41.04 per share 19,204.38 19,204.38
59 90 Shares of Tyco Electronics @ $18.50 per share 1,665.00 1,665.00
60 360 Shares of Tyco Int'I @ $26.46 per share 9,523.80 9,523.80
61 70 Shares of Unisys @ $1.45 per share 101.50 101.50
62 50 Shares of Varian Inc @ $39.78 per share 1,988.75 1,988.75
Page 4 of Schedule G
SCHEDULE G
COMMONWEALTH OF PENNSYLVANIA I~+NTER-VIVOS TRANSFERS &
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
continued
ESTATE OF Hickok, Elisabeth H D
FILE NUMBER
21 - 09 - 00643
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
Include the name of the transferee, their relationship to decedent
and the date of transfer. Attach a copy of the deed for real estate. DATE OF DEATH
VALUE OF ASSET ~ OF
DECD'S
INTEREST EXCLUSION
(IF APPLICABLE)
TAXABLE VALUE
63 200 Shares of Varian Medical Systems @ $33.84 per s,7ss.oo 6,768.00
share
64 112 Shares of Varian Semiconductor @ $23.70 per 2,654.40 2,654.40
share
65 268 Shares of Verizon @ $31.11 per share s,33s.14 8,336.14
66 166 Shares of Vodafone Group PLC @ $19.42 per 3,222.ss 3,222.89
share
67 310 Shares of Wells Fargo @ $24.12 per share 7,477.20 7,477.20
68 41.436 Shares of Yum! Brands Inc @ $33.20 per 1,375.47 1,375.47
share
69 2 Shares of W.O. Hickok Mfg. @ $44.69 per share ss.3s 89 38
70 PNC Savings Account No. 8501850747 23,684.01 23,684.01
Page 5 of Schedule G
SCHEDULE, 1H
COMMONWEALTH OF PENNSYLVANIA ~~ ~• _v~
INHERITANCE TAX RETURN A 1'111 A'w p~+Tp /~~ /C /'-^~+~+
RESIDENT DECEDENT !'LLJIY1 IYh7 1 IW 1 1 V G \IlJv7 1 J
ESTATE OF Hickok, Elisabeth H D FILE NUMBER
21 - 09 - 00643
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 Kimmel Funeral Home 2,662.90
2 2 Gals Catering -After Funeral Luncheon 1,086.25
3 Allegro String Quartet -Music at Memorial Service 565.00
4 Romberger -opening vault, engraving stone in vault 2,835.50
5 Bryson Leidech -Photo for Memorial 53.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission paid
2. Attorney's Fees Wion, Zulli and Seibert -- Jean D Seibert 8,250.00
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 Register of Wills 464.00
Filing fee 30.00
Additional probate fee 650.00
5. Accountant's Fees
6. ~ Tax Return Preparer's Fees
7. Other Administrative Costs
1 Cumberland Law Journal -Advertising 75.00
TOTAL (Also enter on line 9, Recapitulation) 47,626.31
C Schedule H
COMMONWEALTH OF PENNSYLVANIA Funeral -'1""' ^"""
INHERITANCE TAX RETURN AdminisfiaUve COfi~ COnllnued
RESIDENT DECEDENT
ESTATE OF Hickok, Elisabeth H D
2 Sentinel -Advertising
3 07-29-09 Wachovia Bank Check Printing Charge
4 08-24-09 Farren Transport -moving company
5 08-30-09 United Locksmith -Lock for storage room
6 08-30-09 Cordier Antiques - Apprasial of furniture
7 09-12-09 - Lowes - insullation for storage room
8 09-12-09 Engle Piano Service -tune piano
9 09-18-09 Jeweler's Bench -Jewelry Appraisal
10 09-20-09 Messiah -August
11 10-02-09 Essis & Sons -Clean carpet in apartment
12 10-08-09 Jeweler's Bench -Jewelry Appraisal (2nd lot)
13 10-09-09 Wachovia Bank -Service Charge
14 11-13-09 RSR Appraisers -All Property for Estate
15 11-16-09 Patricia Gordon, TC School Real Estate Taxes -Old York Road
16 11-16-09 Patricia Gordon, TC School Real Estate Taxes -Pleasant View Road
17 11-16-09 Faith Nicola, TC School Real Estate Taxes -Indiana Avenue
18 11-16-09 Faith Nicola, TC School Real Estate Taxes - 12th Street
19 01-13-10 Wachovia Bank -Safe Deposit Box Rental
20 01-25-10 Jeweler's Bench -Appraisal
FILE NUMBER
21 - 09 - 00643
219.40
17.25
2,673.00
151.00
356.25
57.75
95.40
536.00
1,305.03
435.66
426.00
7.50
7,000.00
2,163.92
751.07
2,040.50
1,614.33
195.00
120.00
Page 2 of Schedule H
~. Schedule H
COMMONWEALTH OF PENNSYLVANIA
Funeral
~&
INHERITANCE TAX RETURN
RESIDENT DECEDENT AdminlstratiVe Costs continued
ESTATE OF Hickok, Elisabeth H D FILE NUMBER
21 - 09 - 00643
21 02-05-10 AMICA -Liability insurance
295.00
22 02-06-10 Tanya Pomeroy, TC County Real Estate Taxes -Fishing Creek Valley
62.32
23 02-06-10 Tanya Pomeroy, TC County Real Estate Taxes -Fishing Creek Valley
46.74
24 03-02-10 Cordier Antiques -Appraisal (2ndlot)
1,947.50
25 03-18-10 Brian RHoward - repair Chinese bench
1,300.00
26 03-18-10- Faith Nicola, TC County Real Estate Taxes - 12th Street
689.13
27 03-18-10- Faith Nicola, TC County Real Estate Taxes -Indiana Ave
871.05
28 03-18-10 Patricia Gordon, TC County Real Estate Taxes -Pleasant View
6.03
29 03-18-10 Patricia Gordon, TC County Real Estate Taxes -Old York Road
45.18
30 07-12-10 Patricia Gordon, TC SchoolReal Estate Taxes -Old York Road
98 88
31 07-12-10 Tonya Pomeroy, TC School Real Estate Taxes -Fishing Creek Road
gg g8
32 07-12-10 Tonya Pomeroy, TC School Real Estate Taxes -Lemoyne
3,259.19
33 08-03-10 United Locksmith -Key for silver chest
430.00
34 11-19-10 Wion, Zulli & Seibert - 1041 Tax returns
144.00
35 12-20-10 McNees -Legal advise on land
601.00
36 01-13-11 Wachovia, Safe Deposit Box Rent
195.00
37 02-20-11 AMICA -Homeowner's Insurance
264.00
38 03-25-11 Engle Piano Service -Tune piano
100.70
39 Recorder of Deeds -Filing fee for 5 deeds
335.00
Page 3 of Schedule H
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Hickok, Elisabeth H D
FILE NUMBER
21 - 09 - 00643
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1 07-19-09 Williams Excavating -Driveway for Reeser's Summit land
1,560.00
2 07-19-09 McNees, Wallace & Nurick - Reeser's Summit legal fees
161.19
3 07-19-09 PPL Electric
23.66
4 07-19-09 Messiah -May-June
11,234.00
5 07-19-09 Alert Pharmacy
246.77
6 08-09-09 Tanya Pomeroy, TC -Fishing Creek Valley School Real Estate Taxes
209.18
7 08-09-09 Alert Pharmacy
62.48
8 08-09-09 Verizon
44.88
9 08-09-09 PPL Electric
16.60
10 08-16-09 Messiah -July
1,556.00
11 08-30-09 AMICA -Liability Insurance
252.00
12 12-09-09Messiah Village Care Giver Fund
5,000.00
13 03-20-10 East Pennsboro Ambulance
96.00
~ TOTAL (Also enter on Line 10, Recapitulation) I 20,462.76
REV•1513 EX+ (11-08)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Hickok, Elisabeth H D
SCHEDULE)
BENEFICIARIES
NUMBER NAME AND ADDRESS OF PERSON(S)
RECEIVING PROPERTY
I~ TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 (a) (1.2)j
1 Elisabeth H.D. Hickok Trust Agreement dtd
12/09/1987, beneficiaries are Charles N.
Hickok and Peter H. Hickok, sons
FILE NUMBER
~ 21 - 09 - 00643
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
DECEDENT (Words) ($~$)
Do Not List Trustee(s)
Sons 1100% of Residue
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 coverlsheet, as appropriate.
II, NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00