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HomeMy WebLinkAbout08-10-11J 1505610140 REV-1500 EX ~°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 5 6 3 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 7 7 2 6 1 2 6 2 0 1 2 8 2 0 1 1 1 1 2 2 1 9 1 6 Decedent's Last Name Suffix Decedent's First Name MI E V I N A DOROTHY E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N / A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required ^X 6 D d death after 12-12-82) . ece ent Died Testate (Attach Copy of WiII) ~ 7. Decedent Maintained a Living Trust A 1 8. Total Nurnber of Safe Deposit Boxes ( ttach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORM Name ATION SHOULD BE DIRECTED TO: Daytime Telephone Number D A V I D R G E T Z E S QU I R E 7 1 7 2 3 4 4 1 8 2 ~ _ -~--, ---------- -- -- __--- __ REGISTER OF-WILL USE ONLY ' { .; -~ First line of address t (__~ - - - -_,) ism .: WI X WE N G E R & WE I D N E R ;, , .,_; ~- , - Second line of address t ,~:::; -- j ,T ;. P O BOX 8 4 5 ~~~~ ~~ ~~~'~ City or Post Office State ZIP Code -DATE FILED_J H A R R I S B U R G P A 1 7 1 0 8 Correspondent's a-mail address: dg @tZ@ WWWpaIaW.COt11 Under penalties of perjury, I declare t~iaf f'tt'~~ve examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,6rerr~ct and complete. Decl~rationpf pre~arer other than the personal re resentative i b d ll i ` p s ase on a nformation of which preparer has any knowledge SIGN Uri OF PERSON RESPO LE FOR iyLVU nc i ~niv ~ ...__. ADDRESS 5 SUMMIT DRIVE DILLSBURG SPA 17019 SIGNATURE{JF PREPARER OTI-YFFi THA~EPRESENTATIVE DA E,.~, j ennQ~cc I ~ r _ ; ~ ~ -' ~. ~ ~1 WIX WENGER & WEIDNER, PO BOX 845 HARRISBURG PA 17108 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 _ t:_ 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: DOROTHY E. EVINA 1 7 7 2 6 1 2 6 2 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 and Notes Receivable (Schedule D) ........................ .. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 2 3 2 $ , 7 4 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. , 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property iSchedule G) ^ Separate Billing Requested ..... .. 7. 0 . Q Q 8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 2 3 2 8 7 4 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 11. Total Deductions (total Lines 9 and 10) ............................... 11. 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. 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 - 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 0 Q - 0 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18 19. TAX DUE ......................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610240 2. 7 0 8 1. 8 9 1 8 7 2 9 3. 2 5 2 1 4 3 7 5. 1 4 - 2 1 2 0 4 6. 4 0 - 2 1 2 0 4 6. 4 0 0, 0 0 0. 0 0 0. 0 0 0. 0 0 0- 0 0 1505610240 J REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 11 563 DECEDENT'S NAME DOROTHY E. EViNA BEET ADDRESS -- - -- CHAPEL POINTE HEALTH CARE CENTER 770 S. HANOVER STREET _- -- _ CITY ---------_-- - - -.-- CARLISLE STATE TziP PA 17013 Tax Payments and Credits: t ~ Tax Due (Page 2, Line 19) (1) 2. CreditslPayments 0 00 A. Prior Payments B. Discount Total Credits (A + B) (2) 0 00 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3j Fill in oval on Page 2, Line 20 to request a refund. (4j 0 00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 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 shall use the property transferred or its income; ......................... ...... ^ Q c. retain a reversionary interest; or .................................... . .................................................... ...... ^ ^ X d. receive the promise for life of either payments, benefits or care? ............................ . . ................... ^ ... . 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............. .. ........ ..... ^ X 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? .... ..... ^ 0 4 Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ............................................................................................. ..... ^ 0 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 ~:~r for the use of the surviving spouse i 3 percent [72 P.S. §9116 (a) (1.1) (i)). For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)). • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)). • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §91161a)(1.3)]. A sibling 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 + (Ei-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DOROTHY E. EVINA ITEM NUMBER SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21 11 5f33 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. DESCRIPTION CHAPEL POINTS HEALTH CARE CENTER "PERSONAL CARE ACCOUNT" REFUND I VALUE AT DATE OF DEATH TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) 2, 328.74 328.74 REV-1511 EX+ (1~~ 09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DOROTHY E. EVINA SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS FILE NUMBER 21 11 563 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1. HEELER FUNERAL HOME, NESCOPECK, PA 2. GOOD HOPE COMMUNITY CHURCH 3. MICHAEL'S WHOLESALE MEATS & PROVISIONS (FUNERAL LUNCHEON) B• ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) PAULINE STEVICK Street Address 5 SUMMIT DRIVE City DILLSBURG State PA ZIP 17019 Year(s) Commission Paid: 2011 2. Attorney Fees: WIX, WENGER & WEIDNER (ESTIMATED) 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant 4. Street Address City State ZIP Relationship of Claimant to Decedent Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. ~ CLASS 3 CLAIM OF PA DEPARTMENT OF PUBLIC WELFARE 8. FULTON BANK -SAFE DEPOSIT BOX RENTAL FEE 3, 736.00 100.00 93.75 1,000.00 1,425.00 100.50 20,599.64 27.00 TOTAL (Also enter on Line 9, Recapitulation) I ~ If more space is needed, use additional sheets of paper of the same size. AMOUNT 27,081.89 REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INH=RITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER DOROTHY E. EVINA 21 11 563 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VAOF DEATDHTE 1. CLASS 6 CLAIM OF PA DEPARTMENT OF PUBLIC WELFARE 187,293.25 TOTAL (Also enter on Line 10, Recapitulation} I ~ 187 293.25 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-1J1 pennsylvania DEPARTMENT OF REVENUE INN,_RITANCE TAX RETURN REE (DENT DECEDENT ESTATE OF: DOROTHY E. EVINA SCHEDULE J BENEFICIARIES NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (12).] 1. PAULINE E. STEVICK 5 SUMMIT DRIVE DIL.LSBURG, PA 17019 FILE NUMBER: 21 11 5GG RELATIONSHIP TO DECEDE==N' Do Not List Trustee(s) Lineal ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES i5 THROUGH 18 OF REV 1500 CO'dER 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: AMOUNT OR SHARE OF ESTATE 0.00 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. ...---111___ LAST WILL AND TESTAMENT OF DOROTHY E. EVINA I, Dorothy E. Evina, of Monaghan Township, York County, Fenr,sylvania, being of sound and disposing mind and memory, do rr:ake, publish and declare this to be my Last Will and Testament., Hereby revoking ail Wills and Codicils by me at any time previously rcade. ITEM I: I direct that all. inheritance and estate taxes becc~iing due by reason of my death, whether such taxes may be payaole by my Estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will, whic, is r_ot specifically devised or bequeathed, as an expense and cost of administration of my Estate. My Executor shall have no daty or obligation to obtain reimbursement for any such tax paid by my Eaecu-.or even. though on proceeds of insurance or other property not ~ass~_ng under this Will. ITEI~1_II: I hereby exercise all powers of appointment that I may have at the time of my death in favor of my residuary estate, and -z11 property subject to all such powers shall be included in my Estate . ITEM_IIL: I give and bequeath all my household furniture and firrn=shings, automobiles, books, pictures, jewelry, china, linen, s=_lverware, wearing apparel and all other like articles of househcl or personal use and adornment to my husband, Peter Evina, if he su wives me, or if my husband does not survive me, to my daugr~er, Pauline E. Stevick, of Monaghan Township, Pennsylvania, per ~ tunes. ITEM_IV: I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, to my husband, Peter Evina, if he survives me, or, if he does not survive me, to my daughter, Pauline E. Stevick, per stirpes. Page 1 of 5 ITEM V: In the settlement of my Estate, my Executor shall possess, among others, the following powers to be executed for the best interest of the beneficiaries: (a) To sell either at public or private sale and upon such terms and conditions as my Executor may deem advantageous to my Estate, any or all real or personal estate or interest therein, whether owned by me severally or in conjunction with other persons or acquired after my death by my Executor, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in carrying out any of the powers conferred upon my Executor in this Paragraph V(a) or elsewhere in my Will. (b) Tc pay all costs, taxes, expenses and charges in connection with the administration of my Estate. My Executor shall pay expenses of my last illness a.nd funeral expenses. (c) To distribute my Estate in kind or in money. If any assets are distributed in kind, they shall be distributed at their respective value(s) on the date(s) of their distribution. (d) To retain any investments I may have at my death so long as my Executor may deem it advisable to my Estate so to do. (e) To vary investments, when deemed desirable by my Executor and to invest in such bonds, stocks, notes, money markets, real estate mortgages or other securities or in such other property, real or personal, as he shall deem wise, without being restricted to so-called "legal investments." (f) To mortgage real estate and to make leases of real estate. (g) To borrow money from any party to pay indebtedness of mine or of my Estate, expenses of administration or inheritance, legacy, estate and other taxes. (h) To vote any shares of stock which form a part of the Estate and to otherwise exercise all the powers incident to the ownership of such stock. (i) In the discretion of my Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of the Estate. (i) To distribute my personal property directly to the Guardian of the person of any minor beneficiaries hereunder. Page 2 of 5 (. k) To elect such settlement options as deemed most appropriate by my Executor with respect to any pension, profit sharing or other retirement plan in which I am a participant. (1) To do all other acts in the judgment of my Executor necessary or desirable for the proper and advantageous management, investment and distribution of my Estate. ITEM VI: Any person who shall have died at the same time as m~, or in a common disaster with me, or under such circumstances that it is difficult or impossible to determine who died first, or who fails to survive me by ninety (90) days, shall be deemed to have predeceased me. ITEM VII: If at any time any minor child or legally inconpete~nt person shall be entitled to receive any assets hereAnde~, I hereby nominate, constitute and appoint my Executor to a.t as >uardian of the assets payable to such person. Said Uaar:3iar, lay receive and administer all assets authorized by law and ~ha~ have fiall authority to use such assets, both principal and nco~ie, in any manner said Guardian shall deem advisable for the nest interest of such person, including college, university, post gracuate or other education, without securing court order. Said Gua_dian shall have all the rights and privileges as to the Guardianship and the assets thereof as are herein granted. to my Erect.tor as to my Estate and the assets therein. ITEM VIII: I nominate, constitute and appoint my husband., Pete' _,r__na, to be my Executor. In the event of the death., resignation, refusal or inability of Peter Evina to serve as my E~:ecttor, I nominate, constitute and appoint my daughter, Pauline E. Stevic'~c, to serve as Executrix (herein referred to as ~~Exe,uto~ ") in his place. In the event of the death, resignation, ref~.isal, or inability of Pauline E. Stevick to serve as my Executor, 1 romirate, constitute and appoint my grandson, David ~ni, Stevick, to serve as Executor in her place. My Executor and Guardian are specifically relieved from the duty or obligation. of filing any bond or bonds. Page 3 of 5 IN WITNESS WHEREOF, I have set my hand and seal to this my Last wi]1 and Testament, consisting of this, the next, and the prec=ding three pages this j`t ~~~ day of ,~ ~,_ , ~.y_~~ 1999 , ~~:::i:=~ ;f Dorothy E~ Evina SIGNED, SEALED, PUBLISHED AND DECLARED by the above named Test~tr~x, Dorot:ny E. Evina, as and for her Will., in the presence cf us, -rho, at her request, in her presence and in the presence of each otl~:er, have hereunto subscribed our names as witnesses in at~eatation thereof. __ ~ ~ _ _ - -- --=--~ - -' --- - Address ~'G ~~~,~, . r ,- ~+ - r ~% , ' - ` ~ ~~ `t ~j ,~;~'~V ~~j~ 'C" - ~_~__ , 1__ ~_ ,~ r7 ~!S~'f'>" ,~ Y",C ~~~~~o'j i~~ ~~ jam' Address ~~~ l l / ~ ~~4/y(~`{I~,' 1 ~~•\l - -~t ~ ~ IL( 1 ,; _ ) ~~ I ~~ Address ~~~ ~ r~ ~ ~C Il~;~t~ C' f - ~ ~ _ _ . I ~; Page 4 of 5 ACKNOWLEDGMENT ~OMT-IONWEALTH OF PENNSYLVANIA ~~ - S S . COU.TdTY OF .,,. ~ `. _ . I, Dorothy E. Evina, the Testatrix whose name is signed to the attached or fcregoing instrument, having been duly qualified acccrdir_g to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as r,y free and volintary act fcr the purposes therein expressed.. Sworn tc or affirmed and acknowledged before me by Dorothy E`sina, the Testatrix, this !'~r ,, .a ., ~, day of 1j=J' r~, i < r 1999 . {_ ~ Notarial Seal ~ I ! ;u ,-^ t )~ ~i `~" ~ ~-~ i ~ . ~-' Carolyn H. Sider, Notary Public UpperAllenTwp.,CumberlandCounty Dorothy E.~iEvlna, Testatrix nRy commission Expires Oct. 22, 2001 ~-, Member, PennsyP~ania Association of Notaries ~ Notary °Public My Commission Expires: (SEAL) AFFIDAVIT COMNONWi;AI TH OF PEIVVSY'LVANIA ~ - SS. COUN IY C ~' _ i-wry ~ ~=~ , We, ~_'.2 ~ t r~~, , (~ ._ ~ ~ ~. and ~ _ e -J 2- _ l_ r c ~ c ~-~~ ~ ~~ ! r-€ ~~ -fi4r_~• ~eel__ the witnesses whose names are signed to the attached cr foregoing instrument, being duly qualified. acccrdi::g to law, do depose and say that we were present and saw the ~es_atrix sign and execute the instrument as her Last Wi11; tact the Testatrix signed willingly and executed it as her free and. vclu~ttary act ;=or the purposes therein expressed; that each subs,ribir:g witness, in the hearing and sight of the Testatrix, signed she Wi11 as a witness; and that to the best of our knowledge, the Testatrix was at that time 18 or more years of age, of s_~urd mind ar:d under no constraint or undue influence. Sworn to cr affirmed and subscribed to before me by ' , ,~ „ ~- ' ~ r , t2GC« ~'; ~,. n ~ and _- -- --- ~~t _~r ~ ~~ L~'~~-~=- ---~ witnesses, this ~_.-', day of )~<-~,. ~;,r~, 199, ,~~~ ~~ w~Jt s~ ~ - ~r ~~~ ~~ Witness ~ - witness ~~ ~~1 Notary/Public My Commission Expires (S EAL~ ) Notarial Seal Carolyn H. Sider, Notary Public ~PPer Allen Twp., Cumberland County My Commission Expires Oct. c^2, 2001 Member, Pennsylvania Association of Notaries Page 5 of 5 J ~ REV-485 EX (05-04) SAFE DEPOSIT 48500041046 BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certifcate Number Date of Death County Code Year File Number 177-26-1262 01 /28/2011 21 11 563 Decedent s Last Name Suffix First Name E~91 EVINA DOROTHY E © ADDRESS OF DECEDENT STREET: CITY: S- 4TE ZIP CODE 770 S HANOVER ST CARLISLE PA . 17013 NAME AND ADDRESS OF PERSON REQUESTING THE OPENI NG OF THE SAFE DEPOSIT BOX NAME. PAULINE STEVICK, EXECUTOR STREET ADDRESS: CITY: STATE ZIP CODE 5 SUMMIT DR DILLSBURG ?A 17019 NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING __ a. NAME: RELATIONSHIP: PAULINE STEVICK EXECUTORIDAUGI-I?EF; ----- -- STREET ADDRESS CITY: S1 aTF: ZIP CODE. 5_SUMMIT DR__ __ _ DILLSBURG PA 1 7 019 b. NAME: RELATIONSHIP: . . _ _ STREET ADDRESS CITY: S i ATE: ZI° CODE c. NAME: RELATIONSHIP: __.__ _ STREET ADDRESS. CITY 3' ATE __ ZIP CODE NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: -- FULTON BANK _ _ _ _ ~TP.EETADDRESS: CITY: S ..TE ZIP CODE: 866 N U.S. SOUTH ~ DILLSBURG PA 17019 ~N PE ~ __ __ SON MAKIN L ST TRY ,. GATE AND TIME OF LAST ENTRY ~ ~ ,t { ®GATE OF CO TRACT TO RE i BOX ~tJUM E,$ OF BOX T LE UNDER I BO R~ QUESTE'D ~ ' NAME A DDRESS OF PE ON ( ) HAVING ACCE SS TO BOX j ,y ~ t r ~ I S I Ftt~ I ACJDRF9.Y,~ t CIT ~ , STATE: ZIP C~E a- CITY: ~ ~T~S ~` ~ ZIP CGDE: ~ _ ) ~ / NAME AND TITLE OF EMPLO E T ING THE INVENTORY ~ Jir ~ ~ ~~AULINE STEVICK, ECUTOR -- ~WAS A WILL IN THE BOX? ^ YES ~NO If yes, a. Date of will: r ~' -- -~ _ -°~- c~2 G}'.t~~ -- t b. Name and address of personal repre entative, if named in the will ~~ ~ ..~r ~~ NASA E: '! ~ STREET ADDRESS: CITY: ST,-TE: ZIP CODE. c. Name and address of attorney, if any NAME: STREET ADDRESS: CITY _ TE: ZIP CODE r 'y L~U~-~-~~, 48500041,046 48500041,[:46 REV-485 EX SAFE DEPOSIT BOX INVENTORI~' Page___Of N STRU CTI O N S -- ------- __ (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are :~ be designated by name of company, certifcate number, date of certificate, name in which stock is registered, and number of shares and class of stocK (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registerec and type of ownership. i.e., jointly held. payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearinc, in oook name of bank and branch, and balance. (li) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe a fully as possible, (8) All other contents. I (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION I DEPT. 280601 HARRIS6URG, PA 17128-0601 I - J -- - -- -TEM ITEM DESCRIPTION NO. ~t ~ , ,., ' - - -~ - _''L't--Z~' _ _. --- __ ~.~~ ~~ ~ / t ~ '~ -_ _ --_ -_ .- T - -_._ __.__. __ _. ___ ___ ... __-- - ____~ _- ~~ -~..) ~ ~F L I .. l ~ /! ~ i _. _ __._. __.__ ,.. ,~. _._ ___ - _ _ _ __ _.w _. ~ . ~ ~yL1'- - / __ ~ ~ i -~rt-~~i =-E~~_ ~C~,*,.,~ / D - , .sC -s?-- ,~.--~' L C `-~' c~-i f ~ ~ ' ~ .. . ._ . -- _ -- ~ _ j - ~..3 ~~ ~~ _ ° __ _ - 0 ~~-/// ,,/ ~-f/ , 1 ~ } _ __ _ . 1 `f'ig ~~ - >3 ~ s.~"~-n ~..t,,e.~~'.__~.-~-~ ,z.~f -,,c.~.~„t,~,~,v__~__ ~ .~ ~ ' .z.~ - -~.~ ~_ c~.eL,~.e.-~ .-, ~ c ~.~~r ~ zip' __ ---- - - -~- .~` I CERTIF UNDER PENALTY O CORR AND COMPLETE T PER RJR T AT THE A VE RECORD IS THE B OF MY KNOWLEDGE AIJD BELIEF. PERSO ECEIVIN OF SAFE POSIT BOX N TORY: SIG 'rU r ~ _ __ _~__ SIG U P INT Nr ME INT t`IAME AND CHECK APPROPRIATE BO,C BELOb'- ,. PAULINE STEVICK PRINT Ti ~LE ~ DATE PAULINE STEVICK ~!J -J CHECK APPROPRIATE BOX. ~1j ,L~-CI, }/7 / EXECUTOR / /~/~/ ,, ~ Executor(trix) ~ Administrator(trix) ~a~`i ~ Estate Representative ~ Jolnt owner of sate d. pc=_ Cot. Q"t- - - NOTE: Attach additional 8'h" x 11" sheet(s) if necessary or use duplicates of this page of form. ~', ~'' -',~ The Department is authorized by law• 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering stale lax laws. Th Depart use he Social Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the information in exchange of tax informatiigrents ' i F ' ((LLLL~ ' w tn etle ral and ~ f •ocal taxing authorities. The state law prohibits the Commonwealth s personnel from disclosing confidential tax information except fer of:cial purposes ^J 1. -rte ~~~ ~ ~~ ~/ ~.~.-e'L"~fi-t~ ~- i :-~_t~~l _.._r _ WIX, WENGER &WEIDNER A PROFESSIONAL CORPORATION THOMAS L. WENGER RICHARD H. WIX ATTORNEYS AT LAW DEAN A. WEIDNER STEVEN C. WILDS 508 NORTH SECOND STREET ' ROBERT C. SPITZER THERESA L. SHADE WIX Of Counsel DAVID R. GETZ POST OFFICE BOX 845 STEPHEN J. DZURANIN HARRISBURG, PENNSYLVANIA 17108-0845 JEFFREY C. CLARK PETER G. HOWLAND Suburban Office: (717) 234-4182 4705 DUKE STREET A~~so Member Massec0usetts Bar FAX (717) 234-4224 HARRISBURG, PA 171093041 (717) 652-8455 www.wwwpalaw.com August 9, 2011 - - ,~ ~ n Glenda Farner Strasbaugh, Register of Wills ~ ` :. - Cumberland County Courthouse , ° ~-r. r? ~' One Courthouse Square _ - _~ .~r~-1 ~~ _.~ ~ ~.==n Carlisle PA 17013-3387 = ~ ,~, ~-, , _, Re: Estate of Dorothy Evina ~~-+ ~~ ~' .~„ Estate File No. 21-11-0563 " ~. Our File No. 2604-15699 Dear Ms. Strasbaugh: We enclose the following documents for filing on behalf of the above-captioned estate: 1. The original and one copy of the Inheritance Tax Return; 2. The original and one copy of the Inventory; and 3. Our check in the amount of $30.00, made payable to the "Register of Wills," representing your filing fees. Please process these documents at your earliest convenience and return time- stamped copies to our office. Aself-addressed, stamped envelope is enclosed for your convenience. Thank you for your assistance in this matter. If you have any questions regarding the above, please call me. Sincerely, WIX, WENGER & 1~VE1~-NER f t By: ~~~~° ise B. Williamson Paralegal /dbw Enclosures cc: Ms. Pauline Stevick David R. Getz, Esquire _ ~~ dam' ,yF~ Icy `, r ~ ~ ! "r K4i _ _ ~ r~ y_. ~ .a~~"4`'. - E y tx a 3 t~ ' ~ i f c.~ r,~'~i,F¢h ~~ ui r a Y ^'t k' 7r '~ ~1 I bbr~~ 3A i ~~ +Y i~ t ' ~q~. C '~ 1R, 1 1. `. 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