HomeMy WebLinkAbout04-19-11J 1505610101
REV-1500 ex(°1-'°' '
PA Department of Revenue enns lvania OFFICIAL USE ONLY
Y
P
Bureau of Individual Taxes EP.a.ME
o ~ FAE~Ex~E County Code Year File Number
~ INHERITANCE TAX RETURN
PO BOX 280601
Z" ~ ~ 0 ~ ~ 7 3 S'
Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
Z-O~f 05 6-S 1 7 0 6 0q 24 / O 1! Zit ! ~1 1'`1
Decedent's Last Name Suffix Decedent's First Name MI
C7 R ~4 C t ~ N ~/ ~ F
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 0 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 Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Ro C3 C R Y a C7 R~ c] -1 I ~ 23 ~ 606 7
First line of address
2.l 3 M~RK~'T
Second line of address
atH F~o~~
City or Post Offce
NA(Z~ ~ sr3v ~Ca
srR ~£T
State
PA
ZIP Code
REGIST '~F~WILLS USE ONLY --,_
l '~ ; `.'~
L' ~ ~
~r ~ <,:~
ry
-;
''DATE FILED F'~.7 ~-'O ~
--: a
1, 7 ! ~ 1
Correspondent's a-mail address: I^~ rQC ( @ ec k ert sccl` r-', an s . CV M
Under pena ' erjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is tr ,correct d complete. D laration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
E PONSIBLE FOR FILING RETURN DATE
-~8~~
50 6 D~ u Q ~~ R Ro At D CAMP (-~ l 1.-~- , P nt l7 U 1
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101 J
1505610105
REV-1500 EX
Decedent's Social Security Number
'`° ~ j
Decedent's Name: ~ ~ ` 0 ~ ~ `~ '
RECAPITULATION
1. Real Estate (Schedule A).. `... `.. i..:."...' ..''......:. . `..:.`.. *.... .. 1. ` D • ~'~}
2. Stocks and Bonds (Schedule B) ...................................... .. 2. d • d
' 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ~ • ~ Q
4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 0 • ~ a
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. FJ D 7 ~ . ~ Z
6. Jointly Owned Property (Schedule F) ®Separate Billing Requested ..... .. 6. Q • Q Q
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
arate Billin
Re
uested
Se
h
d
l
G
S
7
~
(~
......
g
q
p
) O
c
e
u
e
( ..
. .
8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. (D ' d 7 ~ . ~ ~,
9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. ~. ~ ~- ~ . 4 3
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. 4 ~j Z ~ 4 -] . 0 3
11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 4 ~ `7 ~ 9 G . 4'
12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ~ . ~ Q
/
13. .Charitable and Governmental BequestslSec 9113 Trusts for which
l
S
h
d
J
d 13 Q
~ 0
) ................... . ..
c
e
u
e
an electiop to tax has not been ma
e ( ..
. .
14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. Q . ~ O
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9118 -
16. Amount of Line 14 taxable n
at lineal rate X .0 _ V Q 0
16. !,
~ • V
17. Amount of Line 14 taxable /~
at sibling rate X .12 V • Q O
17. /1
~ • U
18. Amount of Line 14 taxable //,, //'1~
at collateral rate X .15 V • V ~
18.
Q
• Q (~
19. TAX DUE ...................:........:....:..:...........:.....:. ..19. //
ll
V •
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
1505610105 1505610105
REV-1500 EX Page 3 File Number OO ~ ~ C'
Decedent's Complete Address: J
DECEDENT'S NAME
STREET ADDRESS
' CITY ^ - n~,L~ STATE ~~
ZIP
~~~1~
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
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.
Total Credits (A + B) (2)
(3)
(4)
(5)
(1) O. o0
Q ~ ~O
~.Oo
d.OO
p.ov
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" 1N THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.......................................................................................... ^
b. retain the right to designate who shall use the property transferred or its income : ............................................ ^
c. retain a reversionary interest; or .......................................................................................................................... ^
d. receive the promise for life of either payments, benefits or care? ...................................................................... ^
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 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. §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.
REV-i5o8 EX+ (11-io)
s ~ Pennsylvania
',~ DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF:
SCHEI
CASH, BANK DE
PERSONAL
Include the proceeds of litigation and the date
All property jointly owned with right of survi
utsCRIPTION
BQ+k ~epos~ts PSECV~ ~-ktrr~sbW-~~ pA
Tokvtsio,~~ V~~ 14c+al:o~C'assw~e~~D I~laYer
Tiewel ry
C(ufftin~
ki-r~lc-K~ac~3~~ 3~r~n~
Sa-f'elli{,~ Radrd
TOTAL (Also
If more space is needed, use additional sheets of
ITEM
NUMBER
2
3
4
3
6
EE
.TS & MISC.
PERTY
eeas were received by the estate.
must be disclosed on Schedule F.
a t~4 -~i$- b ~l7
on Line 5, Recapitulation) $
~r of the same size.
FILE NUMBER
0 0735
VALUE AT DATE
OF DEATH
2.50.00
l~Zao. 00
Spp. o0
250.00
ZOO•oo
Cc 67~•~z-•
0. $ox 67013 (711) 234-8484 (Harrisburg)
Harrisb rg, PA 17106-7013 (800) 237-1328 (Nationwide)
vKebsite - http://www.~aseeU.~~tsr~
YO STATEMENT LOOKS DIFFERENT.
FIN OUT NHAT THE CHANGES MEAN
TO YOU. VISIT
PSECU.COM/REGULATIONS.
00005261 1 AV 0.335
i~~~lll~~~lll~~~~~~li~~~ll~~l~lli~~~~~~ll~ll~~ll~~~~ll~~~l~l~l
ANNE F 6RACI
506 DEUBLER RD
CAMP HILL PA 17011-2016
06/01 ID O1 REGULAR SHARES BEGINNING BALANCE ~
06/30 ENDING BALANCE
DIVIDEND YTD: YEAR__TO DATE
JONIT OWNER
c
6.13
6.13
0.00
2915.54
:367 ~~: ~~B~ ~#
49.87 2432.41
:::1.64 41;< X546 . $,2
0101 400 065 4
35.00- 2561.82
1149.0a 371Q.82':
005261 40o526t
REV-1511 EX+ (10-09)
~ Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
,~NN~ F, UR~~ ~
Decedent's debts must be repc
ITEM
NUMBER DESCRIPTION
A• FUNERAL EXPENSES:
1 ~ M~b Ta~v1~,n ~ S65 ~ Spr~%~ d~ tel 17Q~ Spr,:~~
Origin L~•~'-clreo^
2. ~e ~~-- iat - IKOc~~ I-~rr~'ab w-~ - G'b i {1.t.ctr y
3, ~-~e p~~ /Qdsl ph~'c..Z'n~wrer - u~b Nd{,
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City __ __
Year(s) Commission Paid:
2~ Attorney Fees:
3• Family Exemption: (If decedent's address is not the same as claimant's,
Claimant
Street Address
City ____
Relationship of Claimant to Decedent
4• Probate Fees:
5• Accountant Fees:
6• Tax Return Preparer Fees:
7.
SCHEDU E H
FUNERAL EXPE SES AND
ADMINISTRATI E COSTS
FILE NUMBER
OG735
irted on Schedule I.
AMOUNT
Zto,33
ce ?ga 16
State __ ZIP
explanation.)
State ZIP
TOTA (Also enter on Line 9, Recapitulation) $
If more space is needed, use additional sheets f paper of the same size.
2,~ 49 •~3
REV-1512 EX+ (12-08)
~~ SCHEDU E I
- ~~ ~ Pennsylvania
DEPARTMENT OF REVENUE DEBTS OF DEC DENT,
INHERITANCE TAX RETURN MORTGAGE LIABILI IES & LIENS
RESIDENT DECEDENT
ESTATE OF
A NNI= F. ~•~~~. ~ I FILE NUMBER
nn~~ ~
~•=r~~ ~ ~~~~~ ~n~urrea oy [ne aecegent prior to death that remained unpaid t the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
~L ./• n OF DEATH
1. C(JMMeilWea.I'~1fJf-'1~nnSY~VQ/1~G~
• l~~ Welfare k.,~
z. e~- ~-la,-~ C'm~,~~ R~t~-~M~~- nom ~.~y
~. CcR.+,berlant/ Crosi,nc~ Rei`ireh,es•~• GSM un;~
~}, ~tr~l K Grjutsf'Wi•~c~ 1?,O.~z"nt.
5. ~A'Qp ~edcare RX plans
• Cu,.n 6,~,, ~ a no( ~ro : si ~ 4.s (2t~i ~~,,~ f - (•o ir! ct.-'
g1.9G
x,69
t6• ~`1
~ Zg,~4
L}. ~ .73
TOTAL (Als enter on Line 10, Recapitulation) $ ~ ~z 5 ¢7. ~ 3
If more space is needed, insert additional sh ets of the same size.
COMMONWEALTH OF PENN YLVAN
DEPARTMENT OFPUBUC LFAR
BUREAU OF PROGRAM 1 GRITY
DNISION OF THIRD PARTY IABILIT
ESTATE RECOVERY PRO RAM
PO BOX 8486
HARRISBURG, PA 1710
November 19, X010
ECKERT SEAMANS CHERIN & MELLOTT LLC
ROBERT A GRACI ESQUIRE
213 MARKET ST 8TH FLR
HARRISBURG PA 17101
Re: A
CIS #
SSN:
Date
Dear Attorney Graci:
ine Graci
170133703
k##-##-6817
>f Death: 06/09/2010
Please be advised that the Department o Public Welfare maintains a
claim in the amount of $482,253.72 against t e above-mentioned estate. This
claim is for restitution of medical assistan e granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412 effective August 15, 1994, as
amended by Act 20-95, effective June 30, 199 Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, name y $14,494.65, was incurred
during the last six months of the decedent's life; therefore, it is a Class 3
claim pursuant to Section 3392 of the Decede ts, Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $467,759.07,
is to be entered as a priority Class 5.1 cla' against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when pa ent may be expected. If the
estate accounting is complete, please provide a co
real estate lease p• py• If the estate contains
p provide co ies of the dee the latest tax assessment,
and a current appraisal, if available.
Si
Terri
Claims
717-77
717-77
ly,
u /~f ~rut.,G
1. Smith
Investigation Agent
'.-6961
'-6553 FAX
Enclosure
RESIQ~NT STATEMENT FROM
CUMBERLAND CROSSINGS
1 LONGSDORF WAY
CARLISLE, PA 17015
717-245-9941
ANNE F GRACI
c/o ROBERT GRACI
506 DEUBLER ROAD
CAMP HILL, PA 17011
Comments _ -_ __ -- __--
E3alange Fa[ward
OG/22/)0 06/13I~D Paymerrt:Chedc#.;',860
OGI08M 0 - 06/08J10 Saks Tax - Ptwne-Basic
06/08/10 - O6J08/10 Phone -Monthly
06/08/10 -06/08/10 Phone -Long Distance
TOTAL BALANCE DUE:
Due Date ACCOUNT NUMBER
07/23/2010 000001
PAID; ~ 6, (,
iyable to CUMBERLAND CROSSINGS
Remit To:
Diakon Lutheran Social Ministries
P.O. Box 8500-1131
Phil~~delphia, PA 19178-1131
592.96
1
1
1
50.38
5629
50.02
FACILITY NAME RESIDENT. NAME
CUMBERLANp CROSSINGS ANNE F GRACi
Statement
AMOUNI
Please make check c
ACCOUNT NUMBER
000001
_. f STATE~iIENT ~FRpM
_.6ER[.AND CROSSNGS
. LONGSDORF WAY
CARLISLE, PA 17015
717 245-9941
tie Date ACCOUNT NUMBER
06!2;12010 000001
PAID ~
CU~ERLAND CROSSINGS
ANNE F GRACI
1 LOt+iGSDORF WAY
CARLISLE, PA 17013
RemS To:
Diakon Lutheran Social Ministries
PO Bon 8500-1131
Philadelphia, PA 19178-1131
Comments ,.
8atarx~ Forvraid .. - - ----- - -- -_ _ - -- --
1'1 X538 84 - - -_ _
57.538 84,
04130!10 _ 0413W10 Bar6e~nl6eaoly 1 `
04130nD = 04/30/1D
Sales Taz -moons-Ba~s+c :
f 114:00
17;56'1.84. __
04/3011 D : D413Q/70
Sales Tax - Lorg Die
1 ~ 4
_ .2
11,55426
04/30/10 = 04/SQfiD
Phone - 111 OZ 11,554.28
04/30x10-f)4/3Dff0
Pho[1e-LongOis'tence 1
1 523.58.. 11,577.86
05/211'10 -051'11/10-
13talber/Beatd 10.41 11,57$27.
0525/10 - 0525n0 y
Payment Check 111264 1 _ 514.00
~ 11.582.27
-
0525/10 -05!'15/70 Pay~nerrt Check 81604164 11.501.84 190.43
05/27/10 -0527/10
Barber/Beaut
Ch
~
f 537.00 553.43
05/31/1 0 - 05131n0 y
a
e
Sates Tax - Rlwne-Basic 1
1 114.00 x67.43
05/37/10 - 05/31n0
Sales Tax-tong Dis#ance
1 s1-42 y68.$,r
os<31no - o5r31no
Ptwne - Monod ;d.03 568.88
os/3v10 - o5131n0 y
Phone - t.,ong Dta~anoe 7
1 ~.~ ~.~
3D.5o 192.96
TOTAL BALANCE DUE:
=-~woa~ep+~.e.c• rur-ca~~.ai•oc.ow~c~a.Fr-r,.a~u~•sc v - - - ~:,.{
Q~ge 7D-TasDedu~b
7B11JSIILli01 10IgN _ ~
~~~
.~' i~ ~~y is ~,
~ -
%3t" -
f3 ~''
_ ~ 6
~~ ~~
- .~31~ ~~
53"8
~2~
a~
~~
_
-- 3~~.
36 3~ ~
- ~ ~~ 5
f _ ,~_ 3s~` ~.~~ ~.
~4
- <~?~ ~"
,_ ,.
~.~
~
~7
.~
~`
33
y~_
~'
~I
f .
• s
,~-
~d g
1
Darryl K. Guistwite, D.O., Inc.
56 Ashton Street
Carlisle, PA 17015-6914
(717) 609-2639
ANNE F. GRACI
C/O ROBERT GRACI
506 DEi7BLER ROAD
CAMP HILL PA 17011
Date i °'Dest~r3iitton ' i----
F. GRACI ( 314.0)
03/22/10 NIIRSING HOME EST. PATIENT
04/15/10 Ins Pmt-MEDICARE
04/15/10 Adjustment
04/30/10 Rebill-PATIENT
04/30/10
.-
314.0 (1)
~ • ~
Darry! K. Guistwite, D,O., Inc.
56 Ashton Street
Carlisle, PA 17015-6914
04/30/10
~.
314.0
Detach this stub and return with payment.
~~Credrt " - Bafant:e` ~ + Uate"F°-"°~ t
105 00
64.78
24.03
0.00
FOR F. GRACI
314.0)
16.19103/22/10
16.19
JOAN:M, OR..ROBERT A. GRACI 5925
t?li 71T-Z63-#UB3
506 0EUf3tER fiOM
60~81ti/2313 .
,
6AMiP,~H~1.. PA 17411 2018
22: ~~ ~ .
Pay to~he AA _ y _
-Date
su
k
~ ... c
..
-~.~3.YI®
J
.[~-~rrfio _ -
..~ i' Or ~`-~ a~~ a
..
. ~ -~ M rn.a
„
- - ~ .> .a
t,..ae~:
,.. - _
- ar-w-c°.:ae•+U>aeicz °a+t~ ''~ •~'+r .sc.:.or,~. ~wae'r.®reze~,e>ae~x
'v c.
.„r.
s
_ -
-T-:ar~a~mq
.. .N„a~
'~ - Y>=.s:x'~
v .~aar .
°sars~xs
1619 ( C ~ is I 31- ODa ~ 61 0 00 91
Days Over 120 Days .. ~ -
~ . 0 0 0.0 0 16.19 Please
pay Phis
-- - I MedicareRx Plans
~'' ""°~ UnitedHealthcare
P.O. BOX 29300, Hot Springs AR 71903-83pp
Member ID: 0047746351
2018473AQM32S101
THE ESTATE OF ANNE GRACI
CUMBERLAND CROSSINGS
1 LONGSDORF WAY
CARLISLE PA 17013
Premium Amount Past Due: $129.74
Dear Anne Gratz-- _ -
Thank you for your past membership in the AARP M
UnitedHealthcare. We have been pleased to provide
coverage.
07-19-2010
u~eRx Preferred (PDP) plan insured by
with Medicare Part D prescription drug
An amount of $129.74 in premiums remains due for y AARP MedicareRg Preferred (PDP)
account. The amount represents premium due for 30 nths. Because you received prescription
drug coverage for 30 months, you are responsible for aging the premium.
To Pap Your Outstanding Balance
Please choose one of the following payment methods:
1. Call us today at the number below to make a payn
credit card payment, or have aone-time deduction
2. Send $129.74 by 08-19-2010 in the enclosed
your check or money order.
Please detach and keep this
portion for your personal
records.
AMOUNT
PAID ~ t~9. ~ ~
~ Papltlent COUpon
Membership Number
0047746351
Fu st Member Name
Anne Grad
DATE 8'2~-- / a
by phone. You can elect to make aone-time
ie from your bank account
Please include your member ID number on
~ Detac6 Fam Hae ~
Payment is due on or before the due date.
Due Date Amount Due
08-19-2010 129.74
First Member Coverage
A 03
CI~CK ~ D04?746351350009633~350000079555471297408011087 3P
NUMBER S9z G ,
AARP MedicareRg Preferred (PDP)
PO BOX 5840
CAROL STREAM 1L 60197-5840
~~~~u~~nuu~~~~~a~u~~~~~~~~u~~i~n~~~+~~~~n~~
~ _
..rment Coupon
Membership Number
0047746351
First Member Name
Anne Graci
Payment is due on or efore the due date.
Due Da#e Amou t Due
08-19-2010 129.74
First Member Coverage
A 03
0047?46351350009633735D0000795554712974D80~L1087 3P
AARP MedicareRg Preferred DP
PO BOX 5840
CAROL STREAM IL 60197-5
I,II.,Ii,.,,,,lll,l„i,„l,I,I,I„I„i„III, .il,,,l
JOAN ;M . OR ROBERT A GRACI
PH. 712-763-1083 5~6
50.6 DEtfBt.ER ROAD _
CAMP HILL, PA '17011 2016 ._.~.. _
- ®0~811i/23t3
`
~r -l2 "/v ,
Pay to. the
Order of ~~L. s~'{,fet,<;G, ~k!'l~Uy'~Ct^Gr~
~}'}?~/O ~ :
~Z~}' 7 y
For-~,~,. 5~~/ " ~ .a~`i .`- , . ~ ; .. ~ .
'-
_
~. ~ 3-138:1,1 16i:59 26. ~04.5(3_~53
_ w ..
~..,_ _:
.,,
_9.9w. .
..
RESIDENT STATEMENT FROM
CUMBERLAND CROSSINGS
1 LONGSDORF WAY
CARLISLE, PA 17015
717-245-9941
Statement D
03/31!2011 e Due Date ACCOUNT NUMBER
04/23/2011 000001
• = ~ $47.73
AMOUNT AID $
Please make check
ANNE F GRACI
c/o ROBERT GRACI
506 DEUBLER ROAD
CAMP HILL, PA 17011
to CUMBERLAND CROSSINGS
Remit To:
Diakon Lutheran Social Ministries
P.O. Box 8500-1131
Philadelphia, PA 19178-1131
Comments
Date Description D I
ays Charges/ Payrne~s Balance
:Units (Craditj
Balance Forward $47.73 $47.73
TOTAL BALANCE DUE:
$47.73
FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
~~ ~unrr-~~ w ur..~..~........ ..~.. . _ ._ ._ _ _- - -'
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
estate of ANNE F GRACI
(First, Middle, Lastl
in said county, deceased,
SHORT CERTIFICATE
I, GLENDA FARN R STRASBAUGH
Register for the Probate of Wills and Granting
Letters of Admin stration in and for that on
do hereby certify
CUMBERLAND Count ,
the 21st day of uly, Two Thousand and Ten,
Letters TESTAME TARP
in common form w re granted by the Register of
said County, on the
late of D/CK/NSON TOWNSHIP
to ROBERT A GRACI
(First, Middle, Lasd
and that same has not since been revoked.-
IN TESTIMONY WHEREOF, I have hereunt
seal of said office at CARLISLE, PENNSYLVp
Two Thousand and Ten.
File No. 2010-00735
PA Fi 1 e No . 21- 10- 0735
Date of Death 6/09/2010
S . S . # 204-05-6817
NOT VALID WITHOUT ORIGINAL SIGNA
set my hand and affixed the
A, this 21st day of July
AND IMPRESSED SEAL
~ ;;~ .> e, . a; , ,r
LAST WILL AND
I, ANNE F. GRACI, of Havertown, Delaware County, Pennsyl-
Will, rev king any prior Wills and
vania, declare this to be my
Codicils.
I. Debts:
I direct payment of the ex~
and funeral from the assets of my esta
II. Gift, Devise and Bequest
I give, devise and bequeai
nature and wher-ever situated, to my sc
JOSEPH J. GRACI and ROBERT A. GRACIr
my sons fail to survive me, I give hi.
per stirpes. If a deceased son does
time of my death, my deceased son's s
ly among my surviving sons or the iss
other children as may then be decease
nses of my last illness
h my estate, of whatever
ns, LAURENCE P. GRACI,
n equal shares. If any of
share to his living issue,
.ot have living issue at the
pare shall be divided equal-
ie then lining of such of my
i, per stirpes.
III. Minorite or Disabili~:
Any share of my estate, r proceeds of insurance,
which becomes distributable to a ben ficiary who is under a dis-
nz~er the age of twenty-one (21) years, hall be held in trust by
my Trustees, during such incapacity or u~til such beneficiary at-
tains'the age of twenty-one (21} years, s the case may be. My
Trustees may apply such beneficiary's sh re of either principal
or income for the support, education and maintenance of such
beneficiary directly without leave of Co rt or the intervention
of; a guardian.
IV. Protective Clause:
The interests of the beneficiaries hereunder shall
-not be subject to anticipation or to vo
alienation until distribution is actual
O. Tales:
All estate, inheritance,
tary or involuntary
made.
cession and other taxes
imposed or payable by reason of my Beat , together with any in-
terest and penalties thereon, with resp ct to all property com-
prising my gross estate for such death ax purposes, whether or
not such property passes under this Wil , shall be paid out of my
residuary estate as if such taxes were
without apportionment or right of rei
such taxes to be paid at such time or t
advisable.
inistration expenses,
rsement. I authorize all
s as my Executor deems
-2-
4 :: y;j :,
{,j
Y
~ ~~
~, ~ ~~ ~tOr ~ S pp+~erS .
owers g anted by law, my Executor
In addition to the p
shall have the following powers, exerci able without Court ap-
proval, until final distribution has be n made:
A. To accept in kind and r tain any property which I
death without regard to ny principle of diversifi-
may own at my
urchase a y form of property without
cation, and to invest in or p
restriction to legal investments for f duciaries.
B. To sell at public or p i.vate sale, to exchange or
real r personal property and to
lease for any period of time any
give options for sales and leases.
C. To compromise claims.
D, To make distributions in cash or in kind.
E. To borrow money and t pledge or mortgage any
real or personal property.
pil: Tru_ s_S= I appoint m daughters-in-law, RAREN GRACI,
Trustees of
LYNN GRACI and JOAN M. GRACI (also kn wn as Shawn),
an Trusts established herein with r spect to their respective
Y
are unable or unw'lling to serve or continue
children. If they
to serve as Trustee, I appoint my Ex cutor as Trustees of the
respective trust.
-3-
,}
a.i`, _.
F -. ~.
- - ` ~.
1.~
~~~~~ It
_ A _
°. - ,r ualified according
44 '~, the undersigned, having bee duly q instrument as my
acknowledge that I signed the f regoing
tiO laj"'` ned it as my fxee a d voluntary act for the
rill. and that I slgressed.
~rposes therein exp
~i°~'!~
Test trix
ualifie
having been duly q
We
according to law, depose
l
x
e
,
nd sa that we were present and saha~
a Y
will; and t as her fee
it
signed
she
t each
th
going instrument as her
tary act for the purposes the
l a
ressed;
ein exp
uest signed the will
re
un
and vo
us in her sight and hearing and at
t of
f
q
er
ur knowledge she was
o
as witnesses; and that to the bes
s of ag , of sound mind and under
ear
that time eighteen or more y
undue influence.
no constraint or
SUBSCRIBED, d
~D,f'Wit
eFb ess
y
ed before m
and acknowle g
med testatrix and by
~~,
the above-na
ear /~
~-~---~-~ ~--
the witnesses whose names app
K~ 1988.
' -
opposite on ~~~~ ,~
Wit ess
_ ~ ~ _ -_-
I
-.
~ub 1
-- •=
{
""" • t Gam.. _. .:`~ t
REV-1513 EX+ (01-10)
Pennsylvania SCHEDULE
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF:~ I / A' ~ ~ ~ ~ /~ C
!V /v NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
NUMBER
I TAXABLE DISTRIBUTIONS [Inclu$e o 9196t(a) (lsz) jistributions and trans ers
1• (~0i~f A. (~rctc i
506 D~ublcr Rand
L+ar+p I-I~~li~ PE't 1101!
~ . J"vs~ h f, C,fuc. l
I04 ~'^ e~q~ rw e
~'xf~ ~ I a34r
.~, ph; ~,'P C~rac t
22.2 I" 1: ller S-tree~-
60¢ (>opla~ ~otx~f
~~, Lutes dafe, PA tR44G
II
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Soy
so r1
C1rar~c~+~ld
G~„d~,;ld
a~-scxfh
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T ROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTIO TO TAX IS NOT TAKE
1
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRI
If more space is neeaeo, use
~S ON LINE 13 OF REV-1500 COVER SHEET. I$
sheets of paper of the same size,
FILE NUMBER:
00~ 35
AMOUNT UR SnHrct
OF ESTATE
6/1G- {'~11
One-{find
I one - 5 i xi-f,
a~~°