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HomeMy WebLinkAbout06-14-111505610101 ~ REV-1500 Ex ~°1.1°' ~ OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes DEPRRTMENTOFREVENUE County Code Year File Number PO Boxz8o6oi INHERITANCE TAX RETURN ~ ` ' ~ ~ ~` .1 1 Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT ~.J ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 3 6 7~ 3 `1 S 3 l D o ~ ~ o ~ D O 6 ~3 ~~ 6 9 Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ,_ - - d .,, Spouse s Social Security Number ~- ~~_~ -- ~ <, -- THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ...:.. ~ .. ~~..~ ~~ , ~.~ > .~, ~..:w. :. ~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate O 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) prior to 12-13-82) O 5. Federal Estate Tax Return Required Q 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number j, ~A° First line of address X36 ~~: D~~'` Second line of address City or Post Office ~ ~,~lP ~/ L L- Correspondent's a-mail address: R.D . State ZIP Code ~/~ l~Dlr REGISTER OF WILLS USE ONLY r~,:~ C.,) ~ ~ ~ ~~ ~~~ED ~ _ i y _~. 7 ~t =~~ .. v. ~.-- ~~ 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. SIG E OF PERSON RESPONSIBLE FO FILING RETUR _ DATE j~ ADDRESS SIGNATURE OF PREPARER OTHER THAN REP SENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J J 1505610105 REV-1500 EX De)cedent's Social Security Npumber Decedent's Name: l , 3 ;~ ~ ~ ,:,,~ .~ 6 ~~ RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. ~ 6 ~ `~ ~ ~ • d 2. Stocks and Bonds (Schedule B) ....................................... 2. ~----' 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. j ,~ `~ ~ ~ + 7 3 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested........ 7. - 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ ~ 3 ~ ~ : ~ . `7 3 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ~ ~!"`!~ ~ , ~ ~~ 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. ~ ~ 6 ~ ; 7 ~ . ~ Q 11. Total Deductions (total Lines 9 and 10) ................................. 11. ~ ~ ,3 .S ~ S ~ ~ ` 12. Net Value of Estate Line 8 minus Line 11 .............................. 12. , 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. l Q 3 ~ ~ ,. ,~ `~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ . 15. r 16. Amount of Line 14 taxable at lineal rate X .0 ~;~ ~ ~ 3 S 6 . S" `~ 16. ~ 6 ,6 ~~ D :,~ 17. Amount of Line 14 taxable ~`?~' at sibling rate X .12 17. ,ti 18. Amount of Line 14 taxable ~ i"~ at collateral rate X .15 + 18. -~ ,., :. ~ .,, 19. TAX DUE ......................................................... 19. , ~: 6 d.6 ~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYM ENT O Side 2 L 1505610105 1505610105 J REV-1500 EX Page 3 I~pcpcipnt's Cemulete Address: File Number ~ `-- 6 Q ~°- l0 7 DECEDENT'S NAME STREETADDRESS CITY O ----- ~ STATE ~ -__T ZI ~ 70 ~~ _-. E~ G~ P Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments _ B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. if Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) ~ 466-~s- Total Credits (A + B) (2) -' (3) ._. (4) _ (~) ~ ~66~6.~ Make check payable to: REGISTER OF WILLS, AGENT. ~m . PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; 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. ~_ ,. . - _e. :~ 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. §911fi (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-1502 EX+ (01-10) ® pe~r~sy~var~~~ ~C~~~~L~ ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN t2EAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: All real property owned solely 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 that 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. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION ~. ~ 03 G~N`l~,e ~'~' '~ d 6 a ~ o o , Da ~'tl/v~~ ~ ~~ l ~v~S ~ l~-G• vF ~ A,IE v~v ~Dla ~SS~ss u~ ~~ T o F ~l'60, ~vo x wKn al ow ~wE G ~ d~Tlo oF' ~~D . a ~~-,~ p~-Tigcf~~D C~ I~a~-~G ~ ~2oP~i~T~ !S ~ Gr~l/G ~oR.EG ~as~ D ©!{~ cS <ll~~%E ~~'T/~- T~ D oE-S' /loo T L~vE ~ lYvv G f/ v~l a ~ ~'' 7~ /~~ Y f'-~ T ~G ~ /~h1 ~T.< < rt- ~a v1,C !.!' ~tiv~tTff L~.r-r T7'~l~lir lvl~`i~T TOTAL (Also enter on Line 1, Recapitulation.) ~ $ ~ ~"~' If more space is needed, use additional sheets of paper of the same size. P.EV--1508 EX+ (6-98) ~~~~~~ COMMONWEALTH OF PENNSYLVANIA CAS~~ $AN~ ~f ~'©SITS, ~ 1V~IiSC. . INHERITANCE TAX RETURN p~~sp~~~ p~(jp` RE510ENT DECEDENT ESTAi>= OF ~ FILE NUMBER Indude the proceeds of litigation and the date the proceeds were received by the estate. Afi property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~, ~S ~~F o~ ~o~ a ~ h~~~, s!o ~~~~oo i ~v~K ~ ~~ d ~ -yj o~o,Ga Gory D! r~o~Y ~ ~ Ova ~.~trF~ /~ r c'~E' P~T~oT !Y~' ~1',. . ~5 Irti vi~V 6S ,~` C ftE'~~l~f 6 ~a `Tr . i~l..t.•~•7f' QED . Cot- ~ ~JIVION /"~ 69A~ , r'~ ~ S~ ~~.~ y~~~7d~ C ~a~--~~~-~~) 3, ~O <D F~'D - ..~ ECG ~ ~ Ti4- x /2GFUit~.D ~~ c1'6 6 , 00 '~~ ~~¢.rff ~~ (,or N ~~ s~ !~ t`fo vl E O F p~GE~l..t'C,D ..~- ~ • 33 .~ ..5~"~ ~~ f}GL P~~So~a} L ~FFEGTS' "i6 ,.5~ ~R.lI'rrll( vi'l RG l4~/'-d )~} vC T!O eY EE ~L. , QEV' O ~~' O F' T!-tE ~o v~ ,~~ 'f~13.OQ j4-tJGTC©!Il E~~ !i0N'T~-CTE.D t,~/ffv u>ovG~p CV~~. Gvan E 7'p ~ ~E" /~i<ovfE ~ PCD¢so Ne9 L ~FF~ ~TJ~ GON-s'~CT~D OF r/s,Ep ~'v~ l Tv~~ ~ ~ii~~~~-~~t=f ~caw~ w rT~ 1-fov_rE jv~Elil Pvle~Ff~4.f'ED,~J GRffFTcl"/'+'~~/v' /Z!D//C/G I.(~Lor.~/~R. ~Q T' VS E p> ~ Wl ,E~ /f R-iY~~1' 'lov G.1' y~- Toot-,dOX J T~ ~8 ~C 1M r" %!~ G , /fl o u~~~E' ~- s }, I/ ~' l`'/~ R-T.l' ~ / ~ ~ ~ST~~ G /yR-ter' F~t~t/<~G ~/~"T u'~ ,~.r~~~ 0°~ Cv/N~ZvaE ~lYG~/VE C 3 S C .R=(~!`~E, j ~ ..f FfD~/,~ ~, ~'--Tc . ,~~ S iyl ~ l4-l R G ~ ~v° J ,~ o `~ ~' ~ ~ Rp cu..t' ~, ~6'IUi IF LL w ~'GG /~G /~~ G /~ RD ~y TiC,~~T~~ -~- f~1 lrc t ~ ~ R~-G ~ -~ !~G ~~S'E !{~ j-,D C T ~'Gts1,l. (. .rN 7"Ea2 Ets" ~ vN Ch<Gc~ </YG' r9 ~ ~ ~ T : ~' , o,~ ~.3~ '~ S~l~ 7~ i OTAL (Also enter on line 5, Recapitulation) ~ ~ ~ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (OS-09) ® p~ir~s~~~~~~~~ ~~~L~ ~` DEPARTMENT OF REVENUE ~~Tit~-~~~~+~ T~~~i~~ ~~~ INHERITANCE TAX RETURN ~~~~~~ ~®~_r°~S;~3gATC P~®~r`~T~( RESIDENT DECEDENT ESTATE Or ~iLE NU~3i3ErZ .s ~~ ~,~ ,~~ ~~R TAG ~ a ~-~o -~ « ~z~ This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIDNSFQP Tn DECEDENT AND NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. ~/~ /q-- -- iyl.~ ~ F~~ ~ C RFD ! T vNlvN l~ o ~~- ~ j o 0 1 a o ~ O T R ~"NSFE R~E~' .- ~7"O dt rYl1 ~.E ~/~ I~ L y -- ~ /Qu'it f,~ c~~FE !FR`D• Dt~GTGy o~ l~lo~o _ ~~ P~v Y~ ~ CC- P~a~J f R°v~~~ v a g3. ~~ ~o ~ ~ o o G' a. ~O3~d~ p~~N ~-RV s'~G . R.~terlS-F~~~ ~-~"(~ ftQl~E ~A-R.LY - FoR,u~E rv~ FE ~- TFIZ ~D. 8 ! a Ec T!- y aN~ ~~!/~/ O F /~G~ ~ `~` ~~ ll P°~ A~"T~' aT DES , SEE ~~c ff-. G - ! ~ ~E~r~ C~fzT ~~ ifi~~. ~~rY uJlT~`D~~v~L Vl~v~.D' 8 ~ s v Q~~Ec=T To P~K~ L ~! Ff. TOTAL (Also enter on Line 7, Recapitulation) 5 I 0.00 If more space is needed, use additional sheets of paper or the same size. G!-~~•D v c~ G - ~ R-~~ fta G -~ L®GAL ~EG1~'TI~A1~'~ ~ERT11=1ATIC)1~1 G1= ~7EAT1-I WARNING: It is illegal to duplicate this c®py by photostat or photograph. ~~e for this certificate, $6.00 _ P 1~8Q4971 Certification Number rr~ryl///~ /~~/~~~e~.~ ,ttt`''~`~a~~~ ~~~?s ~/ - ~` q ~.. , 'i ~ I t• .~+ v~3 ~. -- __- \9~~'1ENT ~~~~''ttt ,,,,,,,,1„!llyrl This is to ce~~tify that the inforniation here given is correctly copied from ~In original Certificate. of Death duly tiled with (ne as Local Registrar. The original. certificate will be forwarded to the State Vital [2e:cords Office for perrnanent filin~~. .~ OC T 0 51010 LG7vt2- !~ _.~._ I-,Deal Regist.r~~~r late Issued REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS PRINT IN 1ANENT CORONER'S CERTIFICATE OF DEATH ,KINK See instrUCtlons and exam lea on reverse ;'E ~ 7- ~ ri ~ ~ p ~ STATF FII F Nl IMRFR 1. Name of Decadent (First, rttiddle, last, sudtx) 2. Sex 3. Social Secudry Ntmtiler 4.Oate of Death (Month, day, year) Steven A Bartron Male 1 3 6 - 7 0 ~+ 3 9 5 3 October 1 2010 5. Age (Leer Birthday) Under 1 year Under 1 da 6. Date of Birth (Month, day, ar) 7. Birthplace (City end state a lore gn cotxary) 8a. Place of Death (Check only one) Mrntna Days htourc ksrnnu Hospital: Other: Yrs. ~T~~f N• J• ^ Inpatient ^ ER I Out Bent pe ^ DOA ^ Nursing Home Residence ^Other • Specify: Bb. County of Death 6c. City, Bo Tw of Death 6d. Facility Name Qt not frtatiMion, give street and number) 9. Was Decedent of Hispanic Origin? ~ No ^ Yes 10. Race: American Indian. Black, White, etc. • (If yes, specity Cuban, (Sped/y) Cumberland East Pennsboro 203 Center Street Mexican, Puerto Rican, etc.) White 11. Decedents Usual lion (Kind of work d one tlud most of waki kte. Do rat state retired 12. Was Decedent ever in the 13. Decedent's Eduralbn (Specify Doty highest grede comp leted) 14. Marital Status: Married, Never Monied, 15. Surviving Spo use (II wife, give maiden name) Kind of Work Truck Driver Kind of Business /Industry C--Pare Co[~pany U.S. Amred Forces? ]Yea ^ND Elementary /Secondary (0.12) 12 College (1.4 or 5+) Widowed, DNoroed (Specr!y) Divorced • 16.Oecedent's Mailing Address (Street, city /town, state, zip code) Decedent's pA Oid Decedent East Pennsboro Live in a A t al Re id 17 St l 203 Center St . " Enola PA 17025 s c u ence a. a e 17c. Yes, Decedent Lived in Tw Ctsnberlatbd Township? 17d. ^ No, Decadent Lived within p 17b. county ~ Actual limits of Ciry / Boro 16. Father's Name (First, middle, last, sudiz) 19. Mother's Name (FrsL middle, maiden surname) Glenn Bartron Patricia Karcher ZOa. Intortnant's Name (Type /Print) 20b. Intomtartts MaNing Address (Street, city I town, state, zip code) Glenn W. Bartron 836 Erford Carp Hill, PA 17011 • 21a. Method of Disposition ~.yemBdOn ^ Donap~ • 2tb. Date of Dispoattbn (Month, day, year) 21c. Place of DisposNion (Name of cemetery, aemalory or other place) 21d. Location (Ciry /town, state, zip code) ^ Burial ^ Removal from State ~ crematlon a Donation Atdtwttxed ^ Other • Specify: + Aledieal Examiner I Caonerl Yea ^ No October 6 2010 s Hollinger Crt?Qlatory Mt . Holly Springs, PA 17065 ~ 22a. Signature of Funeral Service lkertsee (w parson ailing as such) .License Number 22c. Name and Address of Facility • - _ FD 012774-L Richardson mineral Home Inc. 29 S. Enola Dr. Enola, PA 17025 • Canplele Hems 23a•c oMy en certifyktg 23a. To the of knowledge, deem occurred at the time, date and place stated. (Signature and tide) 23b. License Number 23c. Date Signed (Month, day, year) physirtien b rat available at time m death to eerily cause of deem. _. .' dams 24.26 must be completed by person 24. Time of Deam 25. Date Proriouriced Dead (Month, day, year) 26. Was Case Referred to Medical Examiner /Coroner for a Reason Other than Cremation or Donation? • who pronounces death. A rX. 6:30 P.M' October 1 2010 Yes ^No CAUSE OF DEATH (Sae instructions and examples) t Approximate Interval: Pad II: Enter other sienUlcanl cnnddbns cantdbutinq to deem, 26. Did Tobaxo Use Contribute to Death? Clem 27. Part I: Enter the chain of events -diseases, injuries, a complicatlons -that direly caused me death. DO NOT xder terminal events such as cardiac anest, I Onset to Death but not resulting in the undedying cause given in Part I. ^ Ves ^ Probably respiratory anesl, a ventricular Nbrillation without stowing dte etiaogy. List only one cause on each Noe. ~ IMMEDIATE CAUSE (Fi l di i ^ No ^ Unknown na sease or corbNion resulting in death) ~ 29. II Female: -~ a. Gunshot to Chest ^ Due to (or as a consequence of): ~ Nol pregnant within past year Sequentially Nat conditions, if any, b ~ lead'xg to me cause listed on line a ^ Pregnant at time of death . Due to or as a con Enter the UNDERLYING CAUSE ( sequence oQ: ~ Not pre nt, but pr ^ gna egnant within 42 days (disease a injury that initiated the c r events resuding m death) LAST. r of death Due to (or as a consequence oQ: r ^ Not pregnant but pregnant 43 days to 1 year d ~ before death ^ Unkrawn if pregnant within the past year 3oa. Was an Autopsy Sob. Were Autopsy findings 31. Manner of Deat7 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Otx;urred Int ant tone 1 S e 1 f In f 1 i c t e 32c. Place of Injury: Home, Fann, Street, Factory, Pedomied? AvaNable Pdor to Canpletion of Cause of Death? ^"ware' ^"amicide ctober 1 2010 Gunshot -Hand un Ollice Building, etc. (Specityl Home ^ Yes y~7~j No ^ Yes ^ No ^ Aatident ^ Pending Invesligetian 32d• Time ~ injtxy Aprx 32e. Injury al Wak? 321, If Transportation Injury (Spedly) 32g. Location of Iryury (Street, city /town, state) ` ~ Suicide ^ Coukf Nol be Determined ^ Yes ~ No ^ Driver /Operator ^ Passenger ^ Pedestrian 6:30 P. M. ^other-spedy Conte eat, Enola, PA 33a. Certifier (check only one) • CertNying physletan (Physician certitying cause of death when andlx:r physician has pnxaunced deem and completed Item 23) 33b. Si nature a ~ ~ To the bast of my knowledge, death occurrod due to the cauee(a) end manner es staters_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ - Y~Y-E•lG•- ~ G--' .,1= - ----'E or one r • Pronouncing end csrtgying physidan (Physirian both pratouncing deem and certityirtg to cause of deem) To the best of m knowl d d th d h ^ 33c. License Numlx3r 33d. Dale Signed (Monet, day. year) y e ge, ea occurre at t e time, date, and place, end due to the cause(s) and manner as shlerL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Medical Examiner f Coroner ~/ On the beats of i ti d I i i October 4 , 2 010 ezam ne on an or nvestigat on, In my opinion, death occurred at the time, date, and piece, and due to the eause(a) and manner es stated- 1~1 ~ ~ a r of P led Ca of Deam rem 27 T /Print ~1dot~d t~ °r'"~' ~ r~ ~ ~ ~~e 35. Registrer's Signature tiler Number ~ , / ~• 1 - ~ I ~l I ~I ~ I r I 3s~ to FN i ,day, year) 4 . c c nro e, or r 6 3 7 $ Bas oho r e Rd . , Suite ~~ 1 ~ ~J f G+ Mechanicsbur Pa. 17050 v Disposition Permit No. U ~ ( Q''~/ ~ / REV-1511 EX+ (10-09) ®~ ° p~~~~~~~~~~a DEPART~~IENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ~~~~~~ r~~E~.~L ~'~PE~S~~ ~~d3 A~~~~V~S~'~T~'~/~ ~CaST~ ESTATE OF ~ FiLE P1UM8ER Decedent's debts must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ~IGEtAo~Dso~ci ~c~ic/~R~ L ~owt~ , E/Ya~ft~ ~~ ~~ ~S-,~"d= ua C C~Ewn R7'/D'~/ ,r ~~p2 «7 vt~ cv~,c~~ ,~v~~f~ F~a.D r-~12 ..Z'~~EO<~rE F~t~v1~~y !'.s3~ ~~ B. I ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: /' ' , l Name(s) of Personal Representative(s) ,~ ~~N/~ !~ ~ ,('~ ~-I~T/2olS/ Street Address ~,3,(, /-./~-Fp~Q,.>D rQ city _ _G/rl wIO /f /L ~- state /~/`~ zIP __1761` Year(s) Commission Paid: ~O // /flfr7Eto~Y Dv1~ ~Bl'LlD~ ~ I`~~G• ; Pl~~ CIZE~~~c~-v~ 2. Attorney Fees: p ~a a ~. I~UUA-GG€ 7' ~ G`f4~P ~f~~! ~~ 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: C L~ A~C-'/2Gf3~ CTS' yQ~G • v~ f~~~-~ 5. Accountant Fees: ff 1ST</V(-t'~T-/I.A~TO/~ D C~ ACC Y ~ . 6. Tax Return Preparer Fees: /4D i'fjj!!Y~ CSTi~FT~6L, ~/C~Pl4-R'E~ 7. I ..S r F f~-T7 ~Cff . /~ -,~. ~. lda~. oa lGO•.~'c' 7,S-o~ ~o gg• 00 d D ~ ~ ~ ~ S~~ TOTAL (Also enter on Line 9, Recapitulation) ~ 6 s`f 6~~ If more space is needed, use additional sheets of paper of the same size. ~ST"h T~ ®~ ~.S`T~dEN 14~ ,~~~.T~.oN ~'C~~DVL~ i~ `r~ ~},D~;/ERTIS~ ~Ooa Cff~v~ S-!D Plv ~O~ S~G~' -/~-T~oT 1~~~.~ v ~ G. !F f' C ~v. . R.E'OA-~ R 'd 3 s-< o T!~-~/c ~ ,~'o .ZT cov G~ ~~ ~JoG~ ~fFx J To PSG- ¢ PA-cvc To ~f7'dP s~'~.vrGE ~d~-,~~5 ~~~~X ~'itli'/~~N ~ C?° '~'?N~` (3~c~) OF j~F~FR1'~DS ~.ENV~i C ~'!47"!oN d ~ f~ ~1~~ D~ ~-ST~ T~ ~~ P!¢TR. ~a T ~~ ul - ~'T,~-~Tf /~/o TIFF o,I~ (' G' ~ C.l~i~"~~.5 ~--~~ ~~~77~~ ~~ c~llc/6 /q-cc `T_ G ~ ~~~. J S~t/fl~a~! T~~~~ ~~X ~`LE ~` ~ ~-- ! o - ~d 7/ ~ ~„s: 30 m~r~a l~ ~a3~~3/ ~~ `ty` ~ 7~ is -r s-~ o~ 7?~ ~~` i 3 ~ ~~ ~~ ~~ i~" ~U ~ 6 6 ~ os_ __--- REV-1512 EX+ (12-03) DEPARTMENT OF REVENUE ~, ~y~ ~ S ~~ ©~~`~~`~~ ~ ~ INHERITANCE TAX RETURN I~V~'li7~f~7~ ~~A,~$~~~'~'~'~C,` ~,, ~..J.*j~~ RESIDENT DECEDENT ESTATE OF FILE NUNii3ER Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. /1I'I0~7"G ~ G E otY p'~o.,~ ~F-~TE2 ,3-T. E/t%G t9 ~ f'~ o ~~~ i o p~,<F~ - ~o ~~r ~` ~s ~ ~ asp ~ !.s"~ ~6 ?~ 6 ~~ J ~PI2dP~R T ~ t,t' ~~ ~'OR-F'GGO.Sv R.~ ~ , P ~/ LLt RI' ~- CO'f~~~ /~f~.P'oC i~ Tom, ~~/PP A-OG E , N Y r~ ~~'C• S, CO~cGcTloN ~GElS~T Fot2 G ~ Ii-~oeYE~ a~N~ RrE~ # / ~ 7 J 73 S'g ,3, 1/1.sig - N'l..1 <s`~ FE~A, C R . t>n~t o~v~ ~~ o G ~ ~ /~ • ~ f ~. 3 G l~ Cc 'T. ~" ~d ? a D ~Q o ao ad o~ 3 y `~ - I'p- /9-wl c~2r ~~4-tt/ u,~c= ~2 ~v `t ~~ ~? l ~ : p ~'~v v~r~ ril~-o~l.a ~~ t ~. ~7 ~• c QCs -- co~~~c~~a~v ~-~ ~~,~ r .-~,~ PAL- E~~R~ ~ ~, a7 ~~ P~ ~G-'P'T v~ /d.~t~c,~v~ ~ aoo~ .~-N~. 7"~K 1 ~~~. 3 6 SS- ~,v. ~[~~YVR~ Tex ~QvR-~/~-v - avo ~ riYc- Ti9-X' '~3~ • q3 ~' G F~LIVtY.l' QO/io ?'Gv'~• -- SwF r2 - ~©,3 ~~l~T~ Q -~T. ~.5~~ ~D 70TAL (Also enter on Line 10, Recapitulation) ~ ~ rs-6 ~o If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.~).J 1. G G-~trrev GU• ~6~R1 R.aN S~ 36 /~ R ~aRD rQ ~• ~ ~'~~ `~O C6q-u~ P f~l GG ~ ®~ / 70 / / ~- P/~Th-~GC~ ~~cJR~ ~FT~II ~ K ~! a ~ ~f/~wT~diervE ~~t~`E ~ ~Tart/~ Gu/V. S.r'7~-`f ~rJ~f O Tff~2 ~~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. ~~~~~ ~ 70TAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size.