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HomeMy WebLinkAbout07-06-11 (2)1505610105 ~ REV-1500 EX (oz-u) (FI) enns Lvania OFFICIAL USE ONLY PA Department of Revenue P Y County Code Year File Number OEVppTNFNi OF REVENUE Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 ~ `~ q R ~ Harrisburg, PA 17128-o6oi RESIDENT DECEDENT °~ ~ ~ ~ ~ I ( t ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMODYYYY 208-42-7497 11 /19/2010 06/28/1952 Decedent's Last Name Suffix Decedent's First Name MI Bell Jean M (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 FILE D IN DUPLICATE WITH TFIE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW (~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return I"Date of Death Prior to 12-13-82;1 O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate ldx Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust U 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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Mary C Bell (717) 737-5419 ,~ c, First Line of Address 235 Green Lane Drive Second Line of Address City or Post Office Camp Hill State ZIP Code PA 17011 REGISTER OF~'Il~ USE ONLY" I . I- -rte ~;,..~ I "' ~ .~.~ ~ Cpl J ~-• ~ - :=C) DATE IFILIED C `' Correspondent's a-mail address: Sagama532@COmCBSt. net r ~r-\r C--> a.l^! f,,...,~ ,. \... ~_.-~ ro C~. f.fi.l ~--s-i --T' u -T ~ :~ ~ -'='i -- -- 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 hats any knowledge. SIGNATU OF ERSON RES SI R FILINC~RETURN DAT= za, ADDRESS 235 Green Lane Dr ve, Camp Hill, PA 17011 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: 208-42-7497 RECAPITULATION 1. Real Estate (Schedule A) .......................................... ... 1. 0.00 2. Stocks and Bonds (Schedule B) .................................... ... 2. 28,371.76 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00 4. Mortgages and Notes Receivable (Schedule D) ........................ ... 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. 96,590.90 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 0.00 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 0.00 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. 124,962.66 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 10,488.00 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 4,357.76 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 14,845.76 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 110,116.90 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 110,116.90 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. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate x .12 110,116.90 17, 13,214.03 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ...................................................... ... 19. 13,214.03 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 ],505610205 150561020~i J REV-1500~EX (FI) Page 3 File Number Decedent's Complete Address: ~ DECEDENTS NAME Mary C Bell STREET ADDRESS 235 Green Lane Drive ------- - CITY Camp Hill STATE ;ZIP PA ~ 17011 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) 13,214.03 Total Credits (A + B) (2) (3) (4) (5) 13,214.03 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Ye;c 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 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 riotE:d in [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) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF: FILE NUMBER: Jean M Bell 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. If more space is needed, use additional sheets of paper of the same size, REV-15p3 EX+ (6-98) SCHEDt~LE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE', NUMBER Jean M Bell All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) ~~ Great-West Retirement Services ' PO Box 173764 Denver, CO 80217-3764 January 10, 2011 MARY C BELL 235 GREEN LANE DRIVE CAMP HILL PA 17011 RE: Disbursement Confirmation Pennsylvanq ~°°'~°~"'`~ °f Deferred '~ Cornpensation Pro r;am Employee Name: Jean M Beall Plan Number: 98978-01 Plan Name: Commonwealth of Pennsylvania Deferred Compensatic>n Program The details for your current distribution are summarized below. Please note that only the investment option(s) from which funds were drawn are displ ayed, including the ending value. A tax form will be mailed to you by January 3IS` of next year, and must be used in completing ,your tax return. SUMMARY OF TOTALS Total Withdrawal Amount $28,371.76 Total Available to All Receivers $28,371.76 Receiver's Share of Proceeds $28,371.76 Internal Revenue Service Withholding $-5,674.35 Check Amount $22,697.41 BEF 1 - 98978-01 Employee Before Tax Investment Option Beginning Value Distribution Amount Unit/Share Value Units/Shares Distributed Ending Value 60/40 Balanced Fund $5,470.70 $5,470.70 105.696155 51.758742 $0.00 Aggregate Bond Index F~.tnd $3,833.91 _ ___ ___ _ $3,833.91 9.810000 390.816514 _ $0.00 ._ __ Stable Value Fund $19,067.15 $19,067.15 1.871457 10,188.398665 $0.00 TOTAL $28.371.76 $28.371.7~i ~n nn Beginning Value Distribution Amount ]Ending Value GRAND TOTAL $28,371.76 $28,371.76 $0,00 If you have any questions, please contact our Client Service Department at 1-866-737-7457 (I-866-sers457). Great-West Retirement Services® refers to products and services provided by Great-West Life & Annuity Insurance Company, FA;iCore, LLC (FASCore Administrators, LLC in California), First Great-West Life & Annuity Insurance Company, White Plains, New York, and their subsidiaries and affiliates. Great-West Life & Annuity Insurance Company is not licensed to conduct business in New Yorlc. Insurance products and related services aze sold in New York by its subsidiary, First Great-West Life & Annuity Insurance Company. C?ther products and services may be sold in New York by FASCore, LLC. AOI :050510 DEATH FILE DOC TYPE: DISB_STD PNP JPFA DOC ID: 244467094 EV ID: 442537230 IND tD: 3332132 ADDR-Y Page I of i REV-1504 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Jean M Bell Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporationlpartnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size) REV-1507 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER ___. Jean M Bell AN property joiMily-owned with right of survivorship must be disclosed on Schedule F. (ir more space is needed, insert additional sheets of the same size) REV-1588 EX+ (11-io) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDt~LE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE INUMBER: Jean M Bell Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. If more space is needed, use additional sheets of paper of the same size. O N c-~ {~ N U 0 0 N i O V 05TZA •~~lN 9h44h0~ S-SAS 9 ~tI T£ZI v .r.,..,.,..:.,~ ....,~,.:.:..,.,.. ~ _.r. ~ :.. _.:.. N :,..._.._.,., N .... ~„.~,.....a....~ .w. .., _..~ ~ o o > ct `-' ~ t p t o ~ a~ O O ~ ~3 ~ a ~ ~ ~ t i ~ „~ 4 O N ~ ~ ~ ~ np t0 NO N N N N N O -C y,, C N V t0 ~ ~ ~ h0 ''' O 00 ~y o0 0 0 0 0 ~ 'a '~ -- ~ O 3 ~ ~ ~ ~ N ~ t0 ctt .R O O ,~ Q O d `.~ ~ _ _ _.___ Z O ~ u 4 , ? i O b N ~ C~ M A N N ~ O .C' Cfl~ ~ ~ ''~ '~ `-' °° O O ~ 3 M .--+ y H H "'' ~ N ~ 4.0 U ~ O tn0 ~Z bb ci ~ O ~ O tN ~ ~ ~..+ ~. ~..i GO Q ~ -: -., ~ O cp fi C ~ o c ~ 0 ~:. 0. o 00 0 ~ U ~ a D O cVp O ~ ~ ~° ~~ c c a~ ~ ~ ~ o b +~ _ . a~ N v +, 0 ~ ~ ~ ~ ~ ~ j ce O i .. ~ > Y U _J b ,~ .O ~ m v W ~~ Q U ~ ~ U Q ~ t 3 ~ ~ ~ ~ . J W v Q O ~~ WYE W ~ ~-c ~ W m ~ O I- ~ .~Q tij a~"' ~ ~ ~ ~ o w •- \ C ~ ~ m~ a o J ~. ~ .C ,.. m m ' a z W Q Q ~ ~ ~ ~ ~ W ~ v ~1 J ~ ~ N Q W .~ N ~ ~ U N Z Q ~ ~ I+ ~ ~ CL W ~ ~ ch c0 O ei 4-. O N a -; r: ~f siif ~f~~~. ~ ~ ~ ~. •~ ~ IMPORTANT TAX RETURN DOCUMENT ENCLOSED JOINT CKNNER JEAN M BELL ,,. ,.., .. ,. :. ~es~ . , 0208XXXXXX PAGE- 3 ~~ +rsrx~e~,r ~-wr ~'~IVJIt ........ ;~FJ9 1201 ID 01 REGULAR SHARES BEGINNING BALANCE 12/O1 SP1 0016 SP2 ALL FlNANCE CHARC3E <NEW <: .. .: . 3007.21 12~~ 7 PAYMENT . D~ V I1~NII ~~tNU L ' 3{07 41 ' ' A ~E~lj!'~ .f~ Y~~~~ E~E~ 11 ~ ~~~ ~Rd~ 1~~`~1~~.~ `~H~OUGH ~.2/3~f' 10 12/07 PAYMENT. TRANSFER FROM SHARE 07 ~• }0103.86 43111.27 12/07 PAYMENT: TRANSFER FROM SHARE 04 19976.04 63087 31 12/07 :~ PAYMENT TRANSFER FROM SHARE 03 97 00Z . 66090 28 a_ 1j2 ~~jQ7 P~~`ME~I~. TRAt~S~Et~ ~~~M ~kIARE f~2 :.. ~ ~ ~ ](~~ 4 •~ ~~ 4 ~M ~ ~9:< .~ ~ i J iiiJ '~11~~ ;: . .. W.I~'H~~tL $Y ~~~~~ ,. . : Er 9 ,. .... ~~8 ~ ~~~ MY f. V O : v 0 ~' ~ . DIVIDEND YTD: YEAR TO DATE 9 77 12101 ID 02 VACATION SHARES BEGINNING BALANCE - - - - 438.15 12,~0 T PAYMENT . D~V ii~g ~~~ ~ I :. 23 3438 38 : . ~~~A Y1~~ ~A~i~i~0 #t . 4r~~ ~~Q~ ~~~~.1~~~ ~`t#~OU~GH ~.;~~/S~,~J1 ~ 12/07 WITHDRAWAL TRANSFER TO SHARE 01 3438.38- 0 00 12107 ID 02 VACATION SHARES CLOSED . DIVIDEND YTD: YEAR TO DATE ,~ Q~ 12/01 ID 04 NONEYHANDLER BEGINNING BALANCE 12/01 SP1 0016 SP2 ALL ~: 1.2~p:7.... ~ .........PAafti~~i.T== ..~:~1~7~;ttt..:::.:.. _~ .:::.:.::.... ,. 12/07 WITHDRAWAL TRANSFER TO SHARE 01 1207 ID 04 MONEYHANDLER CLOSED DIVIDEND YTD YEAR TO DATE_ .:.: P.O. ~ox6T013 (T11) 234-8484 (Norrish~rq} Harrisb~xg, PA 1 T106-1013 {gip} 737-7328 {~©~o} webs~fie - http://www.psecu.com 0b6223 2355599 ..arvL. ter- V. VU V5r-r-r~rr~x"~~ir~i9~~•~Frrrrr~~rr+~~t3t.r3rr~r~k~+ ~~rr"F ~mr~ 19975.71 0 ~3.,:: 1497~i .~4 .. 19976.04- 0.00 ..,13..17.._ ..:.. :.,.... . .,.. TPEflIGip 120114123110 REV-15(19 EX+ (oi-io) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDI~ILE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: Jean M Bell ]OINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR ]OINTLY HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT"S INTERE5f DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. TOTAL (Also enter on Line 6, Recapitulation) $ 0.00 If more space is needed, use additional sheets of paper of the same size. If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Jean M Beil 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 `ies. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELAADNSHIP TO DECEDENT AND 7HE DATE OF TRANSFER. ATTACH A CDPY OF THE DEED FDR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION {IF APPLICABLE) TAXABLE VALUE 1. TOTAL (Also enter on Line 7, Recapitulation) $ 0.00 If more space is needed, use additional sheets of paper of the same size. RE~r-151,1 EX+ ~1;1_~~ej ~ pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Jean M Bell Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION ___ AMOUNT A. FUNERAL EXPENSES: i~ Parthemore Funeral Home -New Cumberland 7,788.00 Diocese of Harrisburg - Cemetary-Purchase of burial plot/ opening of grave 1,850.00 Saint Theresa Parish -Service and Fees 427.50 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) _ _ Street Address City _______ State ZIP Year(s) Commission Paid: 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address __ ate IP City __ ---- - -- Relationship of Claimant to Decedent 4• Probate Fees: 327.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 95.00 7. TOTAL (Also enter on Line 9, Recapitulation) I ~l 10,488.00 If more space is needed, use additional sheets of paper of the same size. REV-1'1~ ~~X~ (:~:-Q~i ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Jean M Bell Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. ' REV-15:3 EX+ (01-10) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: FILE NUMBER: Jean M Bell 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) (1.2).] 1. Mary C Bell sister 100.00% a3L~ ~~-~~~ La,~,e_ ~-~~ 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. TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ 0.00 If more space is needed, use additional sheets of paper of the same size. REV-1514 EX+ (4-09) ~ Pennsylvania DEPARTMENT OF REVENUE Bureau of Individual Taxes PO Box 280601 Harrisburg PA 1'7128-0601 SCNED~ILE K LIFE ESTATE, ANNUITY & TERM CERTAIN (CHECK BOX 4 ON REV-t5oo COVER SHEET) ESTATE OF FILE NUMBER ~T~, t~V`~~~~ _ This schedule should be used for all single-life, joint or successive life estate and term-certain calculations. For dates of death prior to 5-1-89, actuarial factors for single-fife calculations can be obtained from the Department of Revenue. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate below the type of instrument that created the future interest and attach a copy of it to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME OF LIFE TENANT DATE OF BIRTH NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Tc~rm of Years ^ Life or ^ Term of Years ^ Life or ^ Tc~rm of Years ^ Life or Cl Tf~rm of Years ^ Life or C] TE~rm of Years 1. Value of fund from which life estate is payable .........................................$ 2. Actuarial factor per appropriate table ............................................... . Interest table rate - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) ....................................$ NAME OF LIFE ANNUITANT DATE OF BIRTH NEAREST AGE AT DATE OF DEATH TERM OF YEARS ANNUITY IS PAYABLE O Life or ^I Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ...........................................$ 2. Check appropriate block below and enter corresponding number ................ . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (See instructions.) ................................................ . 7. Value of annuity - If using 3.5, 6, or 10%, or if variable rate and period payout is at end of period, calculation is Line 4 x Line 5 x Line 6 ...........................$ If using variable rate and period payout is at beginning of period, calculation is (Line 4 x Line 5 x Line 6) + Line 3 ...............................................$ NOTE: The values of the funds that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return. The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through i.8 of the return. If more space is needed, use additional sheets of the same size. REV-1f44 EX+ (01-10) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L REMAINDER PREPAYMENT OR INVASION OF TRUST CORPUS I. ESTATE OF FILE NUMBER This schedule is appropriate only for estates of decedents dying on or before Dec,. 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust corpus (principal). II. REMAINDER PREPAYMENT: A. Election to Prepay Filed with the Register of Wills on --- -- - (Date) ----- -- --- B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) of Election or Annuity is Payable C. Assets: Complete Schedule L-1 1. Real Estate ...........................$ 2. Stocks and Bonds ......................$ 3. Closely Held Stock/Partnership .............$ 4. Mortgages and Notes ....................$ 5. Cash/Misc. Personal Property ..............$ 6. Total from Schedule L-1 ................................. .............$ D. Credits: Complete Schedule L-z 1. Unpaid Liabilities .......................$ 2. Unpaid Bequests .......................$ 3. Value of Non Includable Assets .............$ 4. Total from Schedule L-2 ..............................................$ E. Total Value of Trust Assets (Line C-6 minus Line D-4) ...........................$ F. Remainder Factor ........................................ ........... . G. Taxable Remainder Value (Multiply Line E by Line F) ................ ............$ - -_ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of Corpus _____ _ (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Term oi` Years Income or Annuitant(s) Corpus or Annuity is Payable Consumed C. Corpus Consumed ........................................ ............$ D. Remainder Factor ........................................ ........... . E. Taxable Value of Corpus Consumed (Multiply Line C by Line D) ........ ............$ - -_--_ (Also enter on Line 7, Recapitulation) -- REV-16,47 EX+ (02-10) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box qa on REV-15oo) ~~~h~~Qyr-. `,,~ {~ t1LC I~IUMI3tK This schedule is appropriate only for estates of decedents who died after Dec. 12, 1982. This schedule is to be used for all future interests where the rate of tax that will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. rl Will n Trust n Other I. Beneficiaries ` NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right o~` withdrawal within nine months of the decedent's death, check the appropriate box below and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. ___ Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of future interest ....................................................... $ 2. Value of Line 1 exempt from tax as amount passing to charities etc. , (Also include as part of total shown on Line 13 of REV-1500.) ........ $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check one. ^ 6%, ^ 3%, ^ 0% .................... $ (Also include as part of total shown on Line 15 of REV-1500.) 4. Value of Line 1 taxable at lineal rate Check one. ^ 6%, ^ 4.5% .......................... $ (Also include as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate (12%) (Also include as part of total shown on Line 17 of REV-1500.) ........ $ 6. Value of Line 1 taxable at collateral rate (15%) (Also include as part of total shown on Line 18 of REV-1500.) ........ $ 7. Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) ....................... $ If more space is needed, use additional sheets of paper of the same size. • REV-1(=48 EX (02-09) SCHEDULE N Pennsylvania SPOUSAL POVERTY CREDIT DEPARTMENT OF REVENUE Bureau of Individual Taxes PO Box28o6o1 FOR DATES OF DEATH 01/01/92 TO 12/31/94 Harrisburg PA i71z8 _ _ _ ESTATE OF FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1 . Taxable assets total from Line 8 (cover sheet) .............................................. 1 . 2. Insurance proceeds on life of decedent ................................................... 2. 3. Retirement benefits ................................................................. 3. 4. Joint assets with spouse .............................................................. 4. 5. PA Lottery winnings ................................. ............................... 5. 6a. Other nontaxable assets: List and attach schedule if necessary .. 6a. 6b. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) .................................................. . ....... 6. 0.00 7. Total gross assets (Add Lines 1 thru 6) ................................................... 7. 0.00 8. Total actual liabilities ................................................................ 8. 9. Net value of estate (Subtract Line 8 from Line 7) ............................................ 9. If Line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit If not, continue to Part II. Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR.: 19 a. Spouse ............ 1a. 2a. 3a. b. Decedent .......... 1b. 2b. 3b. c. Joint ............. lc. 2c. 3ci d. Tax-exempt income .... id. 2d. 3d. e Other income not listed above ........ 1e. 2e. 3e. f. Total ............. if. 0.00 2f 0.00 3f 0.00 4. Average joint exemption income calculation 4a. Add joint exemption income from above: (1f) 0.00 + (2f) 0.00 + (3f) 0.00 = 0.00 (= 3) 4b. Average joint exemption income ............... ............................... .......... _ If line 4(b) is greater than $40,000 -STOP. The estate is not eligible to claim the credit. If not continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ........................ ~ 1. 2. Multiply by credit percentage (see instructions) ............................................. ~ 2. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet . ................................ 3. 4. For nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate .................................................... 4. 5. Multiply Line 3 by Line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet........... 5• C~ r.y ~ ~~ ~ ~ _ -- ;.__ ._y rn LAST WILL AND TESTAMENT ~= t? -~ ~ ~ , f . - _ _ w JEAN M. BELL KNOW ALL PERSONS BY THESE PRESENTS, that I, JEAN M. BELL, presently of 1129 Columbus Avenue, Apartment No. 4, Lemoyne, Cumberland County, Pennsylvania, being in good health and of sound and disposing mind and memory, do hereby make, declare and publish this as my Last Will and Testament hereby revoking all Wills and Codicils previously made by me. I declare that I am a single woman and that I presently have no children. ARTICLE I FUNERAL EXPENSES AND FINAL DISPOSITION A. I direct that all the just expenses of my last illness and funeral be paid by my Executrix from my estate as soon after my death as may conveniently be done. B. It is my desire that upon my death my body be donated to any qualified medical facility solely for the purpose of using viable organs for donation and transplantation. Immediately after such donation, I direct that my body be cremated and my cremated remains interred at The Gates of Heaven Cemetery in Mechanicsburg, Pennsylvania. z •s~CEP (0£) ~~iu~ ~q auI san~~na:ns at~s papino.Id `~7~g •~ ~~~~ .Ia~sis FLU o~ `sajigouzo~n~ Bans uo aau~.znsuT Iii L~~IM .Iat~~a~o~ `L~~~ap Buz ~o auzi~ at~~ ~~ unno I ~~q~ sajigoulo~n~ Iii pug ~u~ LI~>;anbaq put? anti I S~'IIgOI~IO.I.11~ III ~ZaIZ2i~' •a~~udo.Idd~ suzaap aLls ~~L~~ .zauuELU ~u~ uT aLU anTn.zns oLIM snnagdau pug saaaiu ~uT uaann~aq pug ~uouz~ ~I apinip .IO ~~zado.Id FLU uT~~a.I o~ ~~I.zoLi~n~ put? uol~a.Tasip ajos an~Lj II~Lis ~.z~y~ .za~sis ,~y~ •s~~p (p£) ~~Iu~ ~q auz sani~~zris ails papino.~d `~tu~nj~suuad `IiIH duz~~ ~o ~I~uasa.Td `~~~g •~ ~2I~'y~I .za~sis Buz o~ `(~LIT~uM a~~.I~das pii~n ou jai an~t~ I asn~aaq .TO uoissiuzo ~q .Iatl~at~M) Itirn siL~~ ui a.zatjnnasia .zou anoq~ o~ pa.zza~a.z ~ui~uM a~~~~das ~u~ ~q ~o pasodsip ~Iani~aa~~a you (a~~~sa FLU ~o anpisa.z at~~~o ~z~d pa.Iapisuoa aq jj~L~s LlaiTlnn `s~unoaa~ xLl~q iI~ Puy ~u>? ~uTpnlaxa) `,~:~xado.zd l~uos.zad ajgi~u~~ pug s~uiLjstu.In~ ploLlasnoLi ~u~~o III TI~t?anbaq pLre ani~ I •g 'q~~ap Buz .Ta~~ s~~P (0£) ~~IK~ uiL~~IM xu~naax`I ~Cuz o~ pa.Ianilap .IO ~q puno~ uaaq you s~Lt auo ~i ~ui~uM a~~.z~das ou jai an~Ll I ~~Lj~ paLUnsa.zd ~jantsnjauoa aq o~ st ~I •~ui~~M ~~u~ uI pa~Iaads suos.rad aLI~ o~ `~C~ut~~.I~~.. r~ruaspa r Li~inn uani~ suza~t aL~~ saquasap pug aLU ~q paLl~is si LjaiLjM `L~~~ap ~I.u ~~ aauaas~xa ut ~ui~i.zM a~~.zEdas pa~~p ~I~uaaa.T ~souz aL~~ ui pa~t~uapi ~~Tado~d j~uos.Iad algi,~u~~ pug s~uitjstuzn~ pjoLjasnoL~ FLU ~o suza~i aLI~ ~o Ii>; T~~~anbaq pug ani~ I •~ ~Z"I~1I~IOS2I~d II ~rI~LL2I~ ARTICLE IV RESIDUE I give, devise and bequeath the rest, residue and remainder of my estate., whether real, personal or mixed, of any nature whatsoever and wherever situated, including any lapsed or void legacy, to my sister MARY C. BELL, provided she survives me b;y thirt Y (30) days. Should my sister predecease me or fail to survive me by thirty (3U) diays, the rest, residue and remainder of my estate shall pass to my brother ROBERT E.13E;LL. My sister Mary shall have sole discretion and authority to retain the assets of my estate for her personal use or to divide them among and between my surviving nieces and nephews in any manner she deems appropriate. Should the reside of my estate pass to my brother Robert, he shall have sole discretion and authority to retain the assetsc of m Y estate for his personal use or to divide them among and between my surviving nieces and nephews in any manner he deems appropriate ARTICLE V EXECUTRIX A. I appoint my sister MARY C. BELL, as the Executrix of this Wily. In the event of her death, resignation, renunciation or inability to act in that capacity, thE;n I appoint my brother ROBERT E. BELL, in her place and stead. B• No bond or other security shall be required of any Executrix or Exf;cutor appointed in this Will. 3 ARTICLE VI PAYMENT OF TAXES All estate taxes, inheritance taxes, transfer taxes and other taxes of a similar nature, together with any interest and penalties thereon, payable by reason of my death and imposed with respect to any property, whether or not disposed of by this Wiill, shall ~~d as sooh ~~s practicable out of the residue of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal and caused this, my Last Will and Testament, consisting of six (6) typewritten pages, including; this attestation clause and notary pages, to be executed, declared and published this day of ~~,~'~`. ~~ , 2009. Jean . Bell WITNESSES: ~~ V ~J ~ ++ ~. ~ ~~ Residing at ~ ~~ ~ ~~~ ~~ ~~i~~ ;!~ ,~ ;7 /~ L ,! n / ~ ~ _ ' ' el Residing at "~ r ,a /~ j ~/0 t~ 4 COMNIONWE:_~- I. t ; OF PENNSYLVANIA COUNT' OFDAUPHIN SS. I, JEAN M. BELL, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge ghat I signed and executed the instrument as my Last Will and Testament; that I signed willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ,~;~ ~ ~) !?~~~ Jeans ' .Bell Sworn or affirmed to and acknowledged before me, by JEAN M. BELL, Testatrix, this ~_ day of ~ ~ 2009. ~_ ~ {/ ~ , ifs Notary Public c~~~ni or= PENNSn.v~rw NOTARIAL SEAL MINOY S. a000A+1AN, Notary Punic L ~P ~Twp•. Dauphin Coun 2~, 203 5 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA SS COUNTY OFDAUPHIN We ~-~ c :; ~.~ ` . ~L.~-i-- ~.~~r'~ ; d i ~~ and °_f ~ :-, ~~. ,~ ~ ~`~-; . .l_ 1~ ~~, <, , ? ~_. ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw JE~~T M. BELL sign and execute the instrument as her Last Will and Testament, that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed, that each of us in hearing and sight of the Testatrix signed the Will as witnesses and that to the best of our knowledge, the Testatrix was at the time eighteen (18) or more years of age, of sound ~ and under no c - strai or undue influf;nc;e. 9 ~~ 0"...-,....~ ~~ ~ J ~ ,~ 1~ ' ~_ ~ , ~.__.__..~-' F' '\_ J Sworn or affirmed to and acknowledged before me, by (-, ~;.~~- ~., ~ , ~_ ~., j=-~_ <, ~.~ ~.:, ~ ~~ and ~~ ---.,7 n. ~~ 1~~-:. ~~t~~~,tr.., this ~' -~~~~` ~._ , -, _ -=~ day of r~ ~",~~, L.~ .~.~ , 2009. Notary Public coMMONwEw~rFr of ~r~sr~v~rvr~ NOTARIAL SEAL MINDY S. COOOMAN, Notary pubkc lower Paxton Twp,, Dauphin Coon Commission 21, 203