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HomeMy WebLinkAbout03-0362 REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA PETITION FOR GRANT OF LETTERS Estate of MATTHEWR. LEIBY NO. a~l'"~'"~?~ also known as Petitioner(s), who is/are 18 years of age or older, apply)ies) for: , Deceased Social Security No..211584030 (COMPLETE "A" OR "B" BELOW:) A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut ~ []Decedent, dated and codicil(s) dated named in the Last Will of the State relevant circumstances, e.g., renunciation, death of executor, etc Except as follows, Decedent did not marry, was not divorced and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incapacitated: B. Grant of Letters of Administration (c.t.a., d.b.n.c.t.a.: pendente lite, durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse (if any) and heirs: J Name Relationship Residence NO SPOUSE - NEVER MARRIED SHAWN SNYDER SON AGE 17 DOB: 2/14/86 RANDAL F. LEIBY FATHER 331 PITT STREET ENOLA, PA 17025 (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland residence at 1000 Brid~le Street, Apartment 3, New Cumberland (list street, number and municipality) Decedent, then 36 years of age, died April 18 ,2003 , at 4300 Industrial Park Road, Hampden Township Decedent at death owned property with estimated values as follows: (Location) (if domiciled in PA All personal property ......................................... $ (if not domiciled in PA Personal property in Pennsylvania .................... $ (if not domiciled in PA Personal property in County .............................. $ Value of real estate in Pennsylvania ........................................................................................ $ Total ..................................................................................................................... $ Real Estate situated as follows: None County, Pennsylvania, with his/her last family or principal 1,000.00 1,000.00 Wherefore, Petitioner(s) respectfully request(s) the probate of the Last Will and Codicil(s) presented with this Petition and the grant of letters in the appropriate form to the undersigned: I Typed or printed name and residence Signature RANDAL f. LEIBY 331 PITT STREET ENOLA, PA 17025 Oath of Personal Representative Commonwealth of Pennsylvania County of Dauphin The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer t_he e~t'e.~c~ to I.a~..~, Sworn to and affirmed and subscribed ~' ~'~Z~, ~ RAI~DAL F. LEIBY / / before me this 24th day of April, 2003 DECREE OF REGISTER Estate of MATTHEW R. LEtBY also known as Of WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Deceased No. ~_ I - ~). Social Security No: 211584030 Date of Death: 4/18/03 AND NOW, ., 2003 , in consideration of the Petition on the reverse side hereon, satisfacto'ry proof having been presented before me, IT IS DECREED that Letters I~ Testamentary I~ of Administration ((c.t.a., d.b.n.c.t.; pendente lite; durante absentia; durante minoriate) are hereby granted to RANDAL F. LEIBY in the above estate and that the instrument(s), if any, dated N/A described in the Petition be admitted to probate and filed of record as the Last Will of Decedent. FEES Letters .................................... $ Short Certificates(s) ............... $ Renunciation .......................... $ Extra Pages ( ) ............... $ I.T.R ....................................... $ JCP Fee ................................. $ Inventory ................................ $ Other ...................................... $ C] .00 l© TOTAL ............................. Register of Wills, ¢,- Signature Attorney: CHARLES E. PETRIE I.D. No: 29029 Address: 3528 BRISBAN STREET HARRISBURG PA 17111 Telephone: 561-1939 DATE FILED: CERTIFICATE OF NOTICE UNDER RULE 5.6(a} NAME OF DECEDENT: MATTHEW R. LEIBY DATE OF DEATH: April 18, 2003 WILL NO.: ~ ADMIN NO.' 2003-00362 TO THE REGISTER: I certify that notice of beneficial interest required by Rule 5.6{a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on May 6, 2003 NAME Randall F. Leiby Shawn Snyder ADDRESS 331 Pitt Street, Enola, PA 17025 109 Eby Lane, Middletown, PA 17057 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: NONE DATE: 05 / 06 / 2003 ~f-/~ SIGNATURE NAME CHARLES E. PETRIE ADDRESS 3528 Brisban Street Harrisburg, PA 17111 TELEPHONE (717) 561-1939 CAPACITY: Personal Representative X Counsel for Personal Representative Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 3/15/2005 PETRIE CHARLES E 3528 BRISBAN ST HARRISBURG, PA 17111 RE: Estate of LEIBY MATTHEW R File Number: 2003-00362 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 4/18/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, $~~~ GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge cP . Re~srerofVV~ofCwmberlandCoun~ STATUS REPORT UNDER RULE 6.12 NameofDecedent:~h~w \=t .l~\b~ DateofDeath:--8f.:l l ,~ tloo~ Estate No.: t2 003 '- 0 0 3 Ca ;;{ Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: . Yes ~ No 0 2. lfthe answer is No, state when the personal representative reasonably believes that the administration will.be complete: 3. lfthe answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No ~ b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes a No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached'" this report ./ A. .... / ~CJ:/ Date: t13 -If?:.. C:g- sfgna~e "", ?7. 1:0 7?:tNrCA'/ L~/I~ , E Name ...1'" "-"".'1 :::8 /..01 40~ ;<'5-<; Address ' /~c;, ~~ P /70AS- /,(/;1 Telephone No. Capacity: ~ Personal Representative o Counsel for personal representative ~ 15056041125 REV-15OU EX (06-05) OFFICIAL USE ONLY P~ 1anartment of ~.?at~aniia Bureau of Individual Taxes lNHERlTANCE TAX RETURN County Code Year i=iie Number Po Box 2sosol 2 1 0 3 0 3 6 2 Harnsbunt, PA 17128-0601 RESIDENT DECEDENT ENTER L~E~w'=^EN's IA2F4RM?ATl"u SELOW Social Security Number Date of Death Date of Birth 2 1~ 5 8 4 0 3 0 0 4 1 8 2 0 0 3 0 6 1 0 1 9 6 6 uece=~eni's Lasi ivame L E I B ~' Suffix Decedent's First Name M A T T H E W ivli R €!f Applicable) Erttsr Ss::viving Spo;~se's Entors~:ation gel:;::, Spouse's Last Name Suffix Spouse's First Name Spouse's Socia! Security Number FILL 1N APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WtL.i.S MI 0 1. Original Return ~ 2. Supplements( Return ^ 3. Remainder Return (date of death prior to 12-13-82) 4 t ir~tit?tt Estate n 4a. Futt:re li,±eregr rr,~p,~,r+,n,tan (date of ~ ` Fe~iaral FgtgtP Tax Return Re?;iirr~r! , , death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Wiii) {Attach C opy o f Trust) j_E 7. Lltl~ati~.+n Pf'fJi..eeUJ t~e~IVC^{{ LJ ! l LJ ~-g . y 1~. Jpl7llSai f"VYe~l~+f~ ~iretdit `date Vf dGaih ~ LLLJJJ 11. I_(C'~4t141i l~J la}: lAf 4Uer .}Ei~, ~'.i j(P1j 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 DtRECTED T0: Name DaE~t[me 1`elephone Number C H A R L E S E P E T R I E 7 l? 5 6 1 1 9 3 9 Firm Name (If Applicable) REGISTER OF WILLS USE ONLY ra r: First Tine of address _ --, ~=~ r'~ ~: r_ '~ R R ^ T C R ':. r~T n m A r+ n m _ '~ . Second line of address I ' t N -~ , DAT£ fiLED City or Post Office State ZIP Code H A R R I S B U R G P A 1 7 1 1 1 -.. J i N Correspondent's a-mail address: PetfleLBW~AOL..COnI Under penalties of perjury, I declare that 1 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. 5iGNATU F PE ON ES~Sfe FOR FiLiNG RETURN DATEr ~~ _ p AD ESS 3 ~'>1_ pITT cmR>~;FT ~nTOr,p, p?? i 7 n~ ~. ___ StGNATU~F REPARE OTNER,I~`N REPRESENTATIVE DATE ADDRESS ~:>LCi ~Y51~Pic~iV Sit<EE1 HL'~Y~}{1SY~lik<v L'A l ! l ,.i PLEASE USE ORIGINAL FORM ONLY Side 1 ],5056041],25 150560411,25 J 15O56D42126 REV-1500 EX decedent's Social Security Number ~ecetlenYsName: MATTHEW R. LEIBY 2 1 1 5 8 4 Q 3 Q RECAPITULATION 1. Real estate (Schedule A} ..................... . ........... 1. 2. Stocks and Bonds (Schedule B) ................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages ii< Notes Receivable (Schedule D) ..................... . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E} ....... 5. j 8 ~` 5 ~ 8 6. Jointly Qwned Property (Schedule F} ^ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G} ^ Separate Billing Requested ....... 7. .................. 8. $. Total Gross Assets (tots! Lines 1-7) 2 8 1 5 0 8 9. Funeral Expenses & Administrative Costs (Schedule H} ............... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I} . 10. 11. Total Deductions (total Lines 9 & 10) .......................... 11. 12. Net Value of Estate (Line $ minus Line 11 j ............... ..... 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. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. r?rr?ount cf Li,~., i4 taxabi° at the spousal tax rate. or transfers under Sec. 9116 1C-;. Amr;inf pf t Ine 14 taxahia at lineal rate X .0 ` 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. i b. Amount of Line 14 taxable at collateral rate X .15 1$. 19 Tax Due _ ..... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 5 7 2 4 0 0 ? 8 3 5 ~ 7 1 3 5 5 9 5 i 0 7 4 4 4 ~ a~ 4 4 ~ a Side 2 15D56D42126 15D56D421~6 REV-1500 EX Page 3 Decedent's Complete Address: File Number 0362 Tax Payments and Credits: 1• fax Uue (Page 2 Line 19} 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount InteresUPenalty'if applicable D. interest E. Penalty (1j Total Credits (A + 8 + C) (2) Total Interest/Penalty (D + E } (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fitt in oval on Page 2, Lrne 2U fA request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A} B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 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: Yes No a. retain the use or income of the property transferred : ..................................................................... . ^ b. retain the right to designate who shal{ use the property transferred or its income; ............................. . ^ Q c, retain a reversionary interest; or ............................................................................................... . ^ d. receive the promise for life of either payments, benefits or care? ...................................................... . ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ...................................................................................... . ^ Q 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ . ^ Q 4. Did decedent own an individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................................................................................. . ^ Q 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 January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent (72 P.S. §9116 (a) (1.1) (i)j. For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (Oj percent [72 P.S. §9116 (a) (1.1) (ii)j. The statute doe~not exemat a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are sti[I 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 twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parenf, or a stepparent of the child is zero (O) percent [72 P.S. §9116(a)(1.2)j. The tax rate imposed on the net value of transfers to or for the use of the decedent's linen! beneficiaries is four and ane-half (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 twelve (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-1508 EX + (8-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE QF FlLE NUMBER MATTHEW R. LEIBY 0362 include the proceeds of litigation and the date the proceeds were received by the estate. All oroDerty binW-owned with tight of survhrorship must be disclosed on Schedule F. ITEM VAt.UE AT DATE NUMBER DESCRIPTfON OF DEATH 1. 2000 Federal Income Tax Refund 628.97 2. 12001 Federal Income Tax Refund 3. 12002 Federal Income Tax Refund 4. 12003 Federal income Tax Refund 348.11 819.00 1,019.00 TOTAL (Also enter on line 5, Recapitulation} i $ (if more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~ INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER MATTHEW R. LEIBY 0362 Debts of decedent must be reported on Schedule I. 17EM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ~ MYERS FUNERAL HOME 4,937.00 B, ADMiNiSTRATIVE COSTS: ~. Personal Representative's Commissions Name of Personal Repn~entative (s) WAIVED Social Security Numt>er(s~EIN Number of Personal Representative(s) Street Address Ci(y State Zip Year(s) Commission Paid: 2 Attorney Fees CHARLES E. PETRIE 750.00 3, Fatuity Exemption: (if decedents address is not the same as daimanCs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 37,00 5 Accountant's Fees ~, Tax Return Preparers Fens 7. TOTAL (Also enter on fine 9, Recapitulation) 5 5.724.00 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN scHEOU~E i DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Flee numeeK MATTHEW R. LEtBY 0362 Report debts incurred by gre decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER OESCRIPTfON OF DEATH 1. SNAP ON TOOLS ~,~~•33 2. EUGENE MAYBERRY, ESQ 792.24 3. HOUSEHOLD AUTO 5,402.00 TOTAL (Also enter on fine 10, Recapitulation) I S 7,835.57 (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (9-~) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT OF MA NUMBER NAME AND ADDRESS OF PERSONS} RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [ndude outright spousal distributions, and transfers under Sec. 9116 (a} (1. )2 1. NONE -ESTATE IS INSOLVENT II. FtLE Nt;MBER RELATIONSHIP TO DECEDENT I AMOUNT OR SH, Do Not List Ts•ustee(s) OF ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL 4F PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ~ S (if more space is needed, insert additional sheets of the same size} REGISTER OF WILLS GUMBERLAND COUNTY, PENNSYLVANIA INVENTORY Estate of MATTHEW R. LEIBY No 2 I also known as Deceased 03 0362 Date of Death 4/ 18 / 2 0 0 3 Social Security No. 2115 8 4 0 3 0 Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include alt of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each ttem of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We verify that the statements made in this inventory are true and correct. INUe understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unswom falsification to authorities. Personal resentative: Name of Attorney: CHARLES E PETRIE I.D. No.: 29029 RANDAL F. LEIBY Address: 3528 BRISBAN STREET Dated 11/1$/200$ HARRISBURG PA 17111 Telephone: 717 5 6119 3 9 Description Value 2000 Federal Income Tax Refund 627.97 2001 Federal Income Tax Refund , ~ ^;348.11 - <:.:, _: ; :-~ __ ~_ 2002 Federal Income Tax Refund _ _ `~~ 819.00. " N i _ ~O 2003 Federal Income Tax Refun\ `;,; ~1,019.0~ __l .~ ~ .. . , rv Total 2,814.08 (Attach Additional Sheets if necessary) NOTE: The ilrtemorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. RW-4 STATUS REPORT UNDER RULE 6.12 Name of Decedent: MATTHEW R LEIBY Date of Death: 4/ 18 / 2 0 0 3 Will No. Admin. No. 21 03 0362 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: State whether administration of the estate is complete: Yes .,~~ No 2. If the answer is Nv, slate when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No ___X_.. b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes .X..._ No _ d. Copies of receipts, releases, joinders and approvals of formal or informal accvunts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: 11 /18!200$ ~; ;-;~ i-.° "i _~.:i:. Signature CHARLES E PETRIE Name Please ttype or rint 3528 (BRISBI~N STREET HARRISBURG PA 17111 Address ( 717) 5E11939 Tel. No. Capacity: Personal Representative ~_ Counsel for personal representative { Z ~ ~ ~~ Z- ~~~ ~~~~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE - - N~TLCE OF INHERITANCE TAX BUREAU OF INDIVIDUAL TAXES _-; ApPRAISEMENT, ALLOWANCE OR DISALLOWANCE INHERITANCE TAX DIVISION :. iJ .! ~f 'D$DUCT'iONS AND ASSESSMENT OF TAX PO BOX 280601 HARRISBURG.PA 17128-0601 REV-1547 IX AFP CO1-09) ~~Qg ~AY '~F P~ {~' 3 ~ DATE 04-27-2009 ESTATE OF LEIBY MATTHEW R CLEi~ ,,~ DATE OF DEATH 04-18-2003 ORPHA,'~i~S ^'~~~~~ FILE NUMBER 21 03-0362 (JUP1~~--?' !''I~„ }~~ COUNTY CUMBERLAND 4i _.. CHARLES E PETERIE ACN 101 3628 BRISBAN ST APPEAL DATE: 06-26-2009 HBG PA 17111 (See reverse siefe under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF TWILLS CUMBERLAND C~0 COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~- REV-1547 EX AFP CO1-09~ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF LEIBY MATTHEW R FILE N0. 21 03-0362 ACN 101 DATE 04-27-2009 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) .0 0 NOTE: To insure proper credit to your account, 2. Stocks and Bonds (Schedule B) (2) .0 0 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .0 0 submit the upper portion of this form with your 4. Mortgages/Notes Receivable (Schedule D) (4) .0 0 tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 2,L815.08 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .00 e. Total Assets fig) 2,815.08 APPROVED DEDUCTIONS AND EXEMPTIONS: 5,724.00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 7,8 35.57 11. Total Deductions C11) 13.559.57 12. Net Value of Tax Return (12) 10,744.49- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) .00 14. Net Value of Estate Subject to Tax C14) 10,744.49- NOTE: If an assessment was issued previously, lines 14, 15 and,~or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) •0 0 X 00 = .00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) .0 0 X 04 5 = .00 17. Amount of Line 14 at Sibling rate (17) .00 X 12 = .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 15 _ .00 19. Principal Tax Due (19)= .00 TAY CQRTITTS PAYMENT DATE RECEIPT NUMBER DISCOUN (+) INTEREST/PEN PAID C-) AMOUNT PAID TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE .00 .00 .00 .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE C IF TOTAL DUE IS LESS THAN 61, NO PAYMENT IS REQUIRED. ~ FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE O RFFIINi1_ SFF REVERSE CTnC nc TLJTC FnDM CAD TNCTD11f`T Tf1NC