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HomeMy WebLinkAbout05-09-11- ! a J 1505610105 REV-1500 EX (o2-11)(FI) ~~~~ y. PA Department of Revenue pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes BOX 28o6oi CIiPARTMENT OI q:VENUE Count ~J 4J ly Code Year File Number .......... ............... INHERITANCE TAX RETURN Harrisburg, PA x'7128-0601 RESIDENT DECEDENT ~I ~ ( ~ ENTER DECEDENT INFORMATIO . - --' N BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY _ _ __ ____ . 187-16-4555 01/31/2011 07/01/1920 ecedent's Last Name __ ___ __ __ __ Suffix Decedent's First Name MI Hawbaker Jean N _ _ _ __ _ (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 C~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) CID 6. Decedent Died Testate O (Attach Co of Will 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes py ) (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 TO: Name Daytime Telephone Number John M. Eakin _ _ _ _ ' (717) 766-3172 a. . __ __ Mechanicsburg PA ' 17055 _ __ ___ Correspghdent's a-mail address: Under -ties of perjury, I declare tha I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is tr rrect nd complete. De r lion of pr are other than the personal representative is based on all information of which preparer has any knowledge. SIG RE PE ON R SBLE , F ING RETURN DATE . ~~~___ ~- ~ ~ 05/09/2011 2995 E. SIGNATURE Rd., E212, Las Vegas NV 89120 i n,yrv Ktl-~KtSENTATIVE DATE 05/09/2011 ADDRESS Market S re Building, Mechanicsburg, PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1,505610105 1505610105 l ~ ,~ 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: 187-16-4555 RECAPITULATION 1. Real Estate (Schedule A) .................. . ........... ... 1. 2. Stocks and Bonds (Schedule B) ....... ............ . .............. .... 2. 3,715.16 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . .... 3. 4. Mortgages and Notes Receivable (Schedule D) ....................... ... . 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E}... .... 5. 172,993.47 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... 7 I t V ... 6. 173 729 41 . n er- ivos Transfers & Miscellaneous Non-Probate Property (Schedule G) , . O Separate Billing Requested..... ... 7. 44,336.57 8. Total Gross Assets (total Lines 1 through 7) , , , , , , , , , , , , , , $~ 394,774.61 9. Funeral Expenses and Administrative Costs (Schedule H) ..... . .. 9 ........ ... . 20,441.03 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .. 10 .......... ... . 3,175.00 11. Total Deductions (total Lines 9 and 10) ... ............ . .............. . .. 11. 23,616.03 12. Net Value of Estate (Line 8 minus Line 11) ..... . ..................... 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ... 12. 371,158.58 an election to tax has not been made (Schedule J) ..................... .. . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES .. 14. 371,158.58 15. Amount of Line 14 taxable at the spousal tax r<~te, or transfers under Sec. 9116 16. Amount of Line 14 taxable 15. at lineal rate x .0 45 371,158.58 16 17. Amount of Line 14 t;~xable . 16,702.14 at sibling rate X .12 18. Amount of Line 14 taxable 17. at collateral rate X .15 18. 19. TAX DUE ......................... . .............. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610205 1,505610205 16,702.14 O J J 1 REV-1500 EX {FI) Page 3 Decedent's Complete Address: Jean N. Hawbaker STREET ADDRES~ w Gt ~-..S'~. ~,s c ~- ~2d, ~-~ ~ 2 CITY ~~~ a~ Tax Payments and Credits: 1. Tax Due (Page 2, Line 19} 2. Credits/Payments A. Prior Payments 15,000.00 __ -- B. Discount 750.00 3. Interest 4. If Line 2 is greater than Line 1 -F 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. File Number STATE ~~ ZIP ~ q/ O (1) - 16,702.14 Total Credits (A + B } (2) 15,750.00 (3} (4) (5) 952.14 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent snake 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 occurrE~d after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ ^ 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ....................................... ^ ^ . ................................................................................. IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviv~ is 3 percent [72 P.S. §9116 (a) (1.1) (i)j. Ing spouse 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)j. 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 nei 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)(1.2jj. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)j. • 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)j. 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-1503 EX+ (6-98) t" SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT t51Alt OF Jean N. Hawbaker All property jointly-OWned with rinhl of m~rvivn'cl.i.........~ ~... J:__I___~ __ .. . _ FILE NUMBER 21-11-0163 -~ - -r--~ .~ . ~~~~~~, n iaci i auuniuna~ sl leelS OT Ifl@ S8fT1@ SIZ@) REV-15o8 EX+ (ii-io) ~, ~ ~ pennsylvania ' DEPARTMENT OF REVENUE INHERITANCE TAX RETURPJ RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ~;. ~~~h~~ vr. -- FILE NUMBER: Jean N. Hawbaker 21-11-0163 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivnrshln n,~~ct do a~~,.~..~,.a ,... ~_~_~._._ .. - ~~~-' - ..r...... ~~ ~~~~~~~, ~~~ a~~~~~~~~d~ Siiee~s or paper or the same size. ,. Btrll'l~ 499 Mitchell Road,. Millsboro, DE 19966 Adjustment Services John M Eakin Market Square Building Mechanicsburg, PA 17055 Re: Estate of Jean Hawbaker ----- ---_. _ -----_.,___ Social Seeur-ity: 18-7-~6-~~55_ Pate of Death: January 31, 2011 Phone 888-502-4349 F ax (302) 934-2955 February 9, 2011 Dear Sir or Madam: Per your inquiry on January 31, 2011, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Account Number Ownership (Names o~ Opening Date Balance on Date of Death Accrued Interest Total 2. Type of Account Account Number Ownership (Names o, f) Opening Date Balance on Date of Death Accrued Interest Total Checking Account 98240080 Jean N Hawbaker Charles Hawbaker (POA) 0622/98 $41.592.43 $ .08 $41,592.51 Checking Account 41772318 Jean N Hawbaker Charles Hawbaker 09/Z8/75 $214, 721.21 $ 1.42 $214, 722.63 .,, ~' 3. Type of Account Certificate of Deposit Account Number 31003918448315 Ownership (Ncz~nes o, fl Jean N Hawbaker Charles Hawbaker Opening Date 09/07/07 Balance on Date of Death $100,000.00 Accrued Interest $ 39.46 Total ........................................................................................................................................................................ $100, 039.46 4. Type of Account Certificate of Deposit Account Number 31003918447797 Ownership (Names o, fl Jean N Hawbaker Charles Hawbaker (POA) Opening Date 02/07/07 Balance on Date of Death $100, 000.00 Accrued Interest $ 55.91 Total $100, OSS. 91 5. Type of Account Safe Deposit Box Box Number/Location 191 S West Shore Plaza Ownership (Names o, f) Jean N Hawbaker Charles Hawbaker . Opening Date 11/01/50 For further account information, closures and/or reimbursement of funds please call-the West Shore Plaza ©ffice at#717-?31-173(}. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement Sincerely, '~ ~, Tammy Spencer Adjustment Services F11111r1 l~iu11. 1' t,~.1.~.~-~x American Funds Service Corn a~i P Y s~ ~~ Post Office Box 22$0 Norfolk, Virginia 23501-2230 americanfi~ncis. com JOHN M EAKIN March 9, 2011 ATTORNEY AT LAW MARKET S~!UARE BUILDING MECHANICSBURG PA 170.55 Re: The Income Fund of America - A Account #9390-75723-06 JEAN N HAWBAKERIDEC'D Dear John Eakin: We recently received your inquiry regarding the balance of the account referenced below. The table below reflects the share balance, per share net asset value {NAV), and total value of the accoe:nt on the date requested: Date Account number Share balance NAV per share Total value O1/31/11 9390-7x723-06 1,796.736 $ 16.81 $30,203.13 Please note that: closed funds within an account may affect our ability to provide an accurate account value on the date requested. Mutual fund share prices vary with the fluctuations of financial market share prices. The prices of the funds are found in the financial pages of most metropolitan newspapers under American Funds in the Mutual Funds listings. If you have any questions, please contact your financial adviser or call us at 800/421-OI80. You can reach one of our service representatives Monday through Friday between 8 a.m. and 8 p.m. Eastern time. Cordially, American Funds Service Company JAN - ~0 - E002 SUN 07:5"SAM I D : PACE : 2 REV-i5og EX+ (oi-io) ~~`i , pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F ]OINTLY-OWNED PROPERTY L tSIATE OF: FILE NUMBER: Jean N. Hawbaker 21-11-0163 If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A• Charles D. Hawbaker 2995 E. Sunset Rd., E212 Son Las Vegas, NV 89120 B. C. JOINTLY OWNED PROPERTY: ITEM LETTER FOR JOINT DATE MADE DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. i. A. 09/28/75 M&T Bank Checking Account #772318, see attached 2. A. 09/07/10 M&T Bank CD #448315, see attached 3. A. 05/02/08 46768 shares Allied Irish Bank Common Stock @$.70 OF DATE OF DEATH DATE OF DEATH DECEDENT'S VALUE OF /ALUE OF ASSET INTEREST DECEDENT'S INTEREST 214, 721.21 50 107, 360.61 100,000.00 50 50,000.00 32,737.60 50 16,368.80 TOTAL (Also enter on Line 6, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. 173,729.41 _- . M&TBar~ 499 Mitchell Road,.Millsboro, DE 19966 Adjustment Services John M Eakin Market Square Building Mechanicsburg, PA 17055 Re: Estate of Jean Hawbaker --_-~-------- --~------- _ -Social Seeu~~ity: 1-57---f6-4-55. - ----- __-. ._ -- Date of Death: January 31, 2011 Phone 888-502-4349 F ax (302) 934-2955 February 9, 2011 L,_ s} Dear Sir or Madam.: Per your inquiry on January 31, 2011, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type ofAccount Checking Account Account Number 98240080 Ownership (Names o,~ Jean N Hawbaker Charles Hawbaker (POA) Opening Date 06/22/98 Balance on .Date of Death $41.592.43 Accrued Interest $ ,Og Total ._. ___-----____.._..-...-......_.___..__.___..____.........._..._.....__. $41,592.51 2. Type of Account Checking Account Account Number 41772318 Ownership (1Vames o,~ Jean N Hawbaker Charles Hawbaker Opening Date 09/28/75 Balance on Late of Death $214, 721.21 Accrued Interest $ 1.42 Total -- --------------------- - $214, 722.63 3. Type of Account Certificate of Deposit Account Number 3100391844831 S a a y ~~ Ownership (Names o, f) Jean N Hawbaker Charles Hawbaker Opening Date 09/07/07 Balance on Date of Death $100,000.00 Accrued Interest $ 39.46 Total $100, 039.46 4. Type of Account Certificate of Deposit _ . Account Number 31003918447797 Ownership (Names o, fl Jean N Hawbaker Charles Hawbaker (POA) Opening Date 02/07/07 Balance ors Date of Death $100,000.00 Accrued Interest $ 55.91 Total _ .......__......_.._........_.. _......... $100, 055.91 5. Type of Account Safe Deposit Box Box Number/Location 191 S West Shore Plaza Ownership (Names o, fl Jean N Hawbaker Charles Hawbaker Opening Dczte I1/01/SO For further account information, closures and/or reimbursement of funds please calY the West Shore Plaza Office at #717-731-1730. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement Sincerely, 'l ~......~.--- t T Tammy Spencer Adjustment Services REV-.1510 EX+ (08-09} ~~~~ ~ .;, pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ,. ESTATE OF FILE NUMBER Jean N. Hawbaker 21-11-0163 This schedule must be completed and filed if the answer to any of questions 1 through 4 on oaoe three of the REV-1500 is vac. Ir more space is needed, use additional sheets of paper of the same size. Allianz Life Insurance Company of North Americ~~ PO Box 59060 Minneapolis, MN 55459-0060 ,-- 800.950.1962 ~ ~ JEAN N HAWBAKER °° 2995 E SUNSET ROAD UNIT E212 LAS VEGAS NV 89120-2772 II~~I~I~I~~~~~II~~I~111~~~~~1~11~~~11~~~1~~1~1~1~1~~~1~1~1~1~1 Allianz ili 2008 Annual Policy Statement For Your FlexDex Annuity `` Annuitant Issue date JEA BAKER 03/03/2003 Policy number Plan type 30718013 Non-Qualified We are pleased to provide this annual statement of your FlexDex Annuity. Your policy val!~es as of your policy anniversary date are shown below. These values are based on your past policy year pertormance. Detail for policy year beginning 03/03/2007 and ending 03/02/2008 Beginning Accumulation Value $11,394.61 The Accumulation Value is typically a higher value the Index Benefit Credit $675.63 is received after the surrender charge period has Ending Accumulation Value $12,070.24 expired, or if a qualifying annuity option is selected. Beginning Cash Surrender Value l $10,710.93 466 73 $11 The Cash Surrender Value is available should you ue Ending Cash Surrender Va , . select alump-sum payment from your policy. Yield To Date 3.83% Please refer to your policy for more specific information on how to receive the highest value possible. 'I~e appreciate your business. If you need further assistance or have any questions, please do not hesitate to contact your representative directly; or Client Services at 800/950-1962. -"- The Cash Surrender Value above includes any applicable Market Value Adjustment and/or Surrender Charge as of your _ policy's anniversary date. For additional information regarding any Market Value Adjustment and/or Surrender Charge schedule; please refer to your policy. Allianz Life -the future of life insurance, annuities, and long term care insurance. • 11~anz ~ 39561 _ _ ,r ~ ~ ~~ o ~ No. 6411664 All~anz~ ili P.O. Box 59060 Check Date: 02/28/2011 Minneapolis, Minnesota 55459-0060 1-800-950-1962 ,, ,.. February 28, 2011 Re: JEAN N HAWBAKER, deceased Policy/Contract Number: 30718013 Taxable Amount: $2,527.90 Dear CHARLES D HAWBAKER: PIA?se a,cyPat nur sincere s; mpathies and thank you for providing the .necessary information. to process your claim Attached is a check in the amount of $12,527.90 representing your net benefit. ~~~` You will be receivin a 1099R earl next ear indicatin 9 Y Y g your gross distribution. amount and the taxable amount of .,, $2,527.9Q. ,~ w....,.~.....,_.~......- If you have any questions, please don't hesitate to contact your agent or call us at 800.95:0.1962. Claims Team Allianz life Insurance Company. of North America C: ROBERT J LANGAN _~ e_.~__~ .-~,.. . _ - - ~-- _.r .. , . MetLife ~ P.O. Box 10366 ~' Des Moines IA 50306-0366 ~ ' February 25, 2011 CHARLES D HAWBAKER 2995 E SUNSET RD E-212 LAS VEGAS NV 89120 RE: METLIFE INVESTORS USA INSURANCE COMPANY CONTRACT 940140531 _ __ - ---_ _ . ___. --- --- - _OWNEff7EAN N flR1NBAKER _ Dear Mr. Hawbaker: We processed slump-sum distribution representing the proceeds payable to you under the above-referenced annuity. We are sending a check in the amount of $31,808.67 to you under separate cover. The taxable portion of your proceeds is $6,808.67. An IRS Form 1099-R will be mailed to you by January 31, 2012. If you have any questions, please contact your representative or call our Customer Service Center at 1-800-255-9448 Monday through Friday between 8:30 a.m. and 6:30 p.m., ET. Sincerely, Alison Looney Sr. Annuity Representative -Post Issue Processing MetLife Annuity Operations and Services • _ ~ Page 1 of 1 MetLife Investors USA Insurance Company P.O. Box 295 Overnight Address Des Moines, IA 50301-0295 4700 Westown Parkway, Suite 200 1(800) 255-9448 West Des Moines, IA 50266-2266 www.metlifeinvestors.com oo1-os1 s JEAN N HAWBAKER 2002 HARVARD AVE - CAMP HILL, PA 17011 BEGINNING ACCOUNT TOTAL VALUE WITHDRAWN $ 29,686.06 $ 0.00 'Your~`ransaction(s) ~ulringThis -Statemenf -P~eriotl Transaction Transaction(s) Date MLI USA Fixed Annuity XR ~y. I f i Non-Qua~ified a - P:. JEAN N HAWBAKER . .vvv.....v VM.~.~~~frl~ y Statement Period: February 10, 2009 -February 09, 2010 Account Value $30,754. i Full Withdrawal Value $30,477.! Guarantee Period 1 yeas Interest Rate _ 3.6 Death Benefit $30,754.' ENDING ACCOUNT INTEREST EARNED VALUE $ 1,068.70 $ 30,754.76 Dollar Amount of Transaction Messages: Please review this Annual Statement carefully and notify us of any errors. Alt distributions reflected in the section of the statement titled "Your Transaction(s) During This Statement Period" are gross distribution amounts. 2},~ ,~ 1 U~ ~~~ y ,~ ~~ '~~~N~ o , -~, ,,. ~~ Annual Statement 220811011-001-0919 J • ~ , REV-1511 EX+ (10-09) ~: •~ ~~~ ~~~ ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS 1 ESTATE OF FILE NUMBER Jean N. Hawbaker 21-11-0163 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Musselman Funeral Home 6,566.37 2. Rolling Green Cemetary -Grave 1,740.00 B. 1. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representatives} Street Address City State ZIP Year(s) Commission Paid: 2• Attorney Fees: 11,500.00 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 331.50 5• Accountant Fees: 6• Tax Return Preparer Fees: ~• Cumberland Law Journal, estate notice 75.00 $~ The Sentinel, estate notice 198.16 s. Register of Wills -Filing Fee 30.00 _ TOTAL (Also enter on Line 9, Recapitulation) I $ 20,441.03 If more space is needed, use additional sheets of paper of the same size. Rc',t-.,.~'z: EAR {17_-~~1 Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENY ESTATE OF Jean N. Hawbaker Report debts incurred by the decedent nrinr ~., ~e~+ti ~w.,. _,..~_:__~ ___ _ .. . _. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER 21-11-0163 _.._. _......,.., .,~ ~~~~ oau,c JILC. REV-1513 EX+ (01-10) ~ ~ Pennsylvania SCHEDULE ,7 DEPARTMENT OF REVENUE y. INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT FSTaTF AC. Jean N. Hawbaker FILE NUMBER: 21-11-0163 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under ~o Not List Trustee(s) OF ESTATE Sec. 9116 (a) (1.2).) - 1• Danae Hawbaker 2001 Cumbre Court, Carlsbad, CA 92009 Granddaughter 10,000.00 2- Charles D. Hawbaker 2995 E. Sunset Rd., E212, Las Vaegas NV 89120 'Son - Residue of Estate ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 I II COVER SHEET, AS APPROPRIATE, NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: L TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. If more space is needed, use additional sheets of paper of the same size. $ ~ r ~~~zst `~1Uili Ana 'C ~s#ttzttrn# OF JEAN N. HAWBARER I, JEAN N. HAWBARER, of the Borough of Camp Hill, County of Cumber:iand and State of Fennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this my Last Will and Testament. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. I direct that there shall be paid out of my residuary esf ate all estate, inheritance and like taxes together with any interest or penalty thereon imposed by the Government of the United States, or any state or territory thereof, or by any foreign government or political subdivision thereof, in respect to all property required to be included in my gross estate for estate, inheritance or like tax purposes by any of such governments, whether the property passes under this will or otherwise. 3. I give and bequeath the sum of Ten Thousand ($10,000.00) Dollars to my granddaughter, DANAE HAWBAKER. - 1 - s 4. I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, of whatsoever nature and wheresoever the same may be situate, to my son CHARLES DANIEL HAWBARER, absolutely and in fee simple. 5. In the event my son should predecease me, I give, devise and bequeath my entire estate to my granddaughter, DAi~tiE HAWBAK ER. 6. Lastly,. I nominate, constitute and appoint my son, CHARLES DANIEL HAWBAKER, to be Executor of this my Last Will and Testament, and in the event he should for any reason be una ble to act as such, I nominate JOHN M. EAKIN, to be the Executor of this my Last Will-and Testament, in his place and stead. I furthe r direct that no bond or other security be required of m y personal representative to guarantee faithful performance of his duties. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~ ~~ ~ f day of February, 1997 , ~~~ean N . Ha baker ~ Signed, sealed, published and declared by the above JEAN N• HAWBAKER as and for her Last Will and Testamen named presence of us who have subscribed our names hereto astwitnethe at her request, in her presence and in the presence of ea sses, other, ch ~--~ ~ ~-. 21~~ ~~~( i -" ~''~ i 1.1. -