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HomeMy WebLinkAbout08-22-111505610105 REV-15 Q O ex cu2_~~, (t:i~ PA Department of Revenue pennSylVania OFFICIAL USE ONLY Bureau of Individual Taxes °"...,,~~.°.'"'~ County Code Year File Number Pot3oxz8osof INHERITANCE TAX RETURN _ Harrisburg, PA ig12t3-o6o1 RESIDENT DECEDENT .Z % ~ Q / ~ ~ ENTER DECEDENT IAIFORMATION BELOW Social Security Number Date of Death Mh4DDYYYY Date of Birth hIMODYYYY 172-24-8635 11!2812010 07/08/1930 Decedent's Last Name Suffix Decedent's First Nama Mi Jumper Doris ~ (If Applicable) Enter Surviving Spouse's information Below Spouse's Last Name Suffix Spouse's First Name M( Spouse's Social Security Number THIS RETURN MUST BE FILED !N DUPLICATE WITH THE REGISTER OF 1N1LLS FILt_ INAPPROPRIATE OVALS BELOW C>i~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal instate Tax Return Required death after 12-12-tit) ~ ti. Decedent Died Testate (Attach Copy of Will) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust.j 4 8. Total Number of Safe Deposit Baxes C> 9. Litigation Proceeds Received O 10. Spausat Poverty Credit (Date of Death O 11. Election to Tax under Sec. 8913(A} Between 12-31.89 and 1.1-95) (Attach Schedule O) CORRESPONDENT - TH15 SECTION MUST BE COMPLETED, ALL CORRESPONDENCE ANO CONFIDENTIAL TAX INFORMATION SHOULD Btc DIRECTED T0: Name Daytime Telephone Number Ronald E. Johnson, Esq (717) 243-0~ Q - T° r ~. r.,~ .i ' REG187Ett, I~ USELY . _ ~' ` - First Line of Address 78 Wes# Pomfret Street Second Line of Address City of Post office Carlisle ADDFZES CIO 78 le, PA 17013 vur r,si~. rri a r ~-~ s State 2iP Code PA 17013 Slde 1 1505610105 .~ rn ~~ ,- ~ ~ - -- . cry ~ ~,;F ~^ ~ ,- ..,.. 7. g ..~ ~'~ ~ , ~.. may„ ~ ~ DATE FILED 1505610105 J Correspondent's email address: rejohnson@pa.net Under penalties of perjury, l aiedare that 1 have examined this return, including accompanying schedules and statements, and to the hest of my knowledge and belief, it Is true, correct and oomplet scion ion of preparer other than the personal representative is based on all Information of which preparer has any kao-vledge. SIGNATUR SO RESPO 8LE FOR FILING RETURN QA1. J 150561D205 REV 1500 EX (Fi) Decedent's Social Security Number Decedents Name: Doris J. Jumper '172-24-8635 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 199,100.00 2. Stocks and Bonds {Schedule f3) ....................................... 2. 680.22 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, Sank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 24,20'1.35 6. Jointly Owned Property (Schedule F) O Separate Biping Requested ....... 6. 75,157.77 7. Enter-Vivas Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Bllfing Requested........ 7. 19,921.68 t3. Total Grass Assets (total Lines 1 through 7) ............................. 8. 319,06'1.02 9. Funeral Expenses and Administrative Costs (Schedule H} ................... 9. 56,709.78 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. 2,348.66 11. To#al D©ductions (total Lines 9 and 10) ................................. 11. 59,058.44 12. Net Value of Estate (Line $ minus L(ne 11} .............................. 12. 260,002.58 13. Charitable and Governmental t3equests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 0.00 14. Net Value SubJect to Tax (Lfne 12 minus Line 13) ........................ 14. 260,002.58 TAX CALCULATION • SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Llne 14 taxable at the spousal tax rate, or transfers under Sec. 9115 16. Amount of Line 14 taxable at lineal rate X .0~ 260,002.58 16. 11,700.12 17. Amount of Line 14 taxable at sibling rate X .12 17. 1 t3. Amount of tine 14 taxable at collateral rate X .15 1g, 19. TAX DUE ......................................................... 19. 1'i,700.12 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OP AN OVERPAYMENT p Slde 2 L 1505610205 15056102D5 J REV-1500 EX {Fi) Page 3 Decedent's Complete Address: File Number DECEDENTS NAhtE Doris J. Jumper STREETADDRESS 1528 Terrace Avenue C17Y Carlisle STATE PA IIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19} 2. CreditslPayments A. Prior Paymenfs B. Discount 3. Interest a. if Line 2 is greater than tine 1 + Line 3, enter the difference. This is the OVERPAYMENT. t=ilt 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 pUE. (1} 11,700.12 Total Credits (A + B } (2} (3) (a} (5) 11,700. ~! 2 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSVIIER THE POLLOVVING 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 ............................................................................................................................... ^ ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Rec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ r 3. Did decedent own an "in trust farms or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent awn an individual retirement account, annuity or other non•probate property, which contains a beneficiary designation? ........................................................................................................................ ~ ^ 1F THE ANSWER TO ANY 0~ THE ABOVE QUESTIONS #S YES, YOU MUST COMPLETE SCHEDULE G AND I+ILE IT AS PART OF THE RETURN. For dates of death on or after Juiy 1,199, and before Jan.1,1995, the tax rate imposed on the net value of transfers to or #or the use of the surviving spouse is 3 percent (72 P.S. §9116 {a} (1.1} (i}j. 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 PS. §9118 (a) (1.1) {ii}j. The statute does not exempt a #ransfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still appiicabfe even if the surviving spouse is the only beneficiary. For dates of death on or after Juty i, 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. §9118(a)(1.2)j. • The tax rate imposed on the net value of transfers to or for the use of the decedent's Pineal beneficiaries is ~.5 percent, except as noted in [72 P.S. §9116(a}(1)j. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent (72 P.S. §9118(a)(1.3}j. 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. rtn+-is02 ex+ {t t-as} ~ ~ :~ pennsy[vania SCHEDULE A DEPARTMENT OF REVENUE IriHERfTANCE TAX RETURN REAL ESTATE RESIDE~Yr DEtEOEliT ESTATE O>F __ t:ILE NUMBER Doris J. Jumper 21-10-1268 All real property awned 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 bettiveen 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 faintly-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 dntlude a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUtdBER OF DEATH DESCRIPT30tJ 1• I ALL THAT CERTAIN tract of land situate in the Bororagh of Carlisle being Lot o. 89 and the southern 40 feet of Lo# No. 90 on the Plan of E.ots known as Valley Meadows and having thereon erected a two story dwelling house known and numbered as 1528 Terrace Avenue, Carlisle, PA 17013. See Cumberland County Deed Book Z, Volume 30, Page 730. Cori B. Jumper died June 19, 2008 thus vesting foil fee simple title in Doris J. Jumper Assessed value TOTAL {Also enter an line f, Recapitulation.) ~ $ 199,100.00 199,100.00 [f more space is needed, insert additional sheets of the same size. REV 1503 EX+ (8-98) `~ SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT OECEOENT ESTATE OF FILE NUMBER Doris J. Jumper 21-10-1268 All properfy )olntly~owned with right of survlvorshlp must be dlsciosed an Schedule F. (Ii more space is needed, insert additianat sheets of the same size) REV-1737.4 EX + (6-08) ~ ~ ~ pennsylvan~a DEPARTMENT OF REVENUE INHERITANCE TAX RETURN NONRESIDENT DECEDENT SCHEDULE E, PART 1 ~~sc~LLAN~ous PERSONAL PROPERTY ESTATE OF F[L.E NUMBER Doris J. Jumper 21-10-1268 Part 1 musi include all tangible personal property having its sites in Pennsylvania. Examples ofi tangible personal property are jewelry, furniture, paintings, etc. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. Complete Part 2 on reverse side ONE.Y when the proportionate method of tax computation is elected. ITEM NUMBER DESCRIPTfflN VALUE AT DATE OF DEATH ~ • Checking acct no:1479581-M&T Bank {see letter attached} 583.77 2 2006 Bu'sck Rendezvous SUV -proceeds from sale 10,800.00 3 Public safe of personal property and funiture -gross proceeds: $9,146.00 5,264.30 Less: safe expenses: $3,901.60 = X6,244.40 Less:personai Imes sold at sale owned by Kathy Gorka and Greg Jumper $980.10=$5,264.30 (see attach) 4 State Farm Insurance -second and final payment by homeowners insurance company for storm damage 6,918.52 requiring a new roof. The roof of the home owned by the decedent at 1528 Terrace Avenue, Carlisle, Pa was extensively damaged during a hail storm in May 2010. Her homeowners insurance company, State Farm Insurance, estimated her total toss at $13,895.00 and made an initial payment of $6,476.48 to the decedent prior to her death. This sum was placed in her accounts which are reported herein. See attached statement of foss. The total cost of the replacement of the roof is reported in Schedule H, item 29 5 Dr. Bronstein - medicat refund 2,34 6 Commonwealth of PA -retirement 496.74 7 State Farm Insurance -auto insurance refund 135.68 PART 1 TOTAL 24,201.35 PART Z TOTAL {From reverse side.) $ 0.00 24,20'1.35 TOTAL (Also enter on Line 5, Recapitulation.) $ {!f more space is needed, use additional sheefs of paper of the same size) REV 1737-4 EX + (6-08) REVERSE ~ ~ pennsy[vama DEPARTMEfiT OF REVEiYUE INHERITANCE TAX RETURN NONRESiDE~fT DECEDENT SCHEDULE E, PART Z M~scELLANEOUs PER50NAL PROPERTY Use Schedule 1=, fart 2, ONLY (or proportionate method of tax computation, ESTATE: OF FtL.E NUMBER Doris J. Jumper 29-90-9268 Part 2 must include all tangible personal property located outside Pennsylvania and ail intangible personal property wherever located. A11 property jointly-owned with fhe right of survivorship must be disclosed on Schedule F. elf mare space is needed, use addi#ional sheets of paper of the same size) Q Mt~TBank 499 Mitchell Road, Millsboro, Dl3 199b6 Adjustment Services Andrews and Johnson 78 Vest Pomfret Street Carlisle, PA 17013 Re; Estate of Doris Jumper Social Security: 172-248635 Date of Death: November 28, 2010 Phone 888-542-4349 Fax (302} 934-2955 January 25, 201 [ Dear Sir or A~adam: Per your inquiry on January 11, 2011, please be advised that at the time of death, the above-named decedent had on deposit «'ith this bank the following; I . 7}~pe of Accorsrtt Accortrrt Nurrrber Otivrrersltip {Natrres o~f} Operrirrg Date Bala~rce orr Date of Deatlr Accrzsed lute, est Total Clrec~rirtg Accornrt 1079581 Do>•is J Junrper Carl EJru,rper- 1 D/~0/09 ,583.77 ~ .00 $583.77 For further account information, closures andlor reimbursement of funds please call the Stone Hedge Olliice at #717-244.4524. a't'e were unable to locate any safe deposit box for the abo~•e-mentioned decedent. This letter does not include any accounts ib which the deceased n~a?~ ha~~e been fisted as Po`~•er of Attontey, Custodian of Uniform Trsuu#'ers, Representati~•e Payee, or'I~ustee under a written Agreement Sincerely, r C/i t Tammy Spencer Adjustment Services `~"""'" Statement of Loss ~H1Vf.Nt ~ Name of Insured Doris J Jumper Claim Number 38P893645 Coverage A -Building Limit of Liability ~ 282,000.00 Description Amount State Parm Est#mate ~ 13,885.00 r.~._ _..~. ..~ - - __ -. _ _ . ----- - -- $ _ ___ ~-- $ ___ .~.~... ..._... ...._._..Y.._._._._. ~__ ~.. Coverage B - Gontents Limit of Liability ~ Tatat A $ '13,895.00 ~ _ ___~_ $_ Coverage C -Loss of Use Limit of Liability $ Description Comments/Supplements: David Blum Name December 'I, 2410 Dale _...__ TotalB ~ 0.00 Arnowtt $~ Iota= C ~ 0.00 Total A+B+C ~ 13,895.00 Plus Special Coverage $. Tota! Loss ~ 13,895.00 Less Depreciation - Cov A ~ __ Less Depreciation - Cov B ~ Subtotal ~ 13,885.00 less Deductible $ 500.00 Less Prior Payments ~_.__,._.,,,,. _ _ 8,476.48 Total Payable $ 6,918.b2 1001309 1Q4658.12 03-17-2010 f~EV-1~jD9 EX+ (01-10~ :. • ~ ~ ,~~ pennsylvarna DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER; Dori$ J. Jumper 21-10-1268 If an asset became jointly owned within one year of the decedent's date of death, it must be reported vn Schedule G. SURVNING JOINT TENANT{S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. Kathy J. Gorka 460 D Street, Carlisle, PA 17013 daughter B' Gregory L. Jumper C. JOINTLY OWNED PROPERTY: 125 Alburn Drive, Boardman, OH 44512 E son IrEM NUMBER LEFTER FOR ]DINT TENANT DATE NAOE JOf NT DESCRIPTION OF PROPERTY It7CLUDE NAHE OF FINANCUL IICSTtMION AHD BANK ACCOUYT HUHBER OR SIMII.AIt IOE.YTIFYING NUMBER. ATTACH GEED FOR 70INTLY NElO REAL ESTATE. DATE 4f 0£ATY) VALUE OF ASSET °!o OF DKEDENTS ItrTEREST GATE OF DEATH VALUE OF OECPOEHT'S IIrTEREST ~' A' 03/28/86 Savings acct no: 48655-00-Members 1st FCU (see letter attached) 12,604.37 50 6,347.19 2 A 03128186 Checking acct no: 48655-91-Members 1st FCU (see letter attached) 13,773.18 50 6,886.59 3 B 09!10107 Checking acct no: 35-18280-F&M Trust (see [otter attachedf 700.$7 50 350.44 4 B 04!24106 Money Management acct na: 70-98413-F&M Trust (see letter attached} 123,147.09 50 61,573.55 TOTAL (Aiso enter on Line 6, Recapitulation) ($ 75,157.77 If mare space is needed, use additional sheets of paper of the same s}ze SAVINGS ACCOUNT: Account NumbedSuffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account NumberlSuffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued interest Name of Joint Owner Oate Joint Ownership Established IRA SAVINGS: Account Number/Suffix Date Account Established Principal Balance of Date of Death Accrued Interest to Oate of Death Total Principal and Accrued Interest Name of Beneficiary 49658-40 03/28/1986 $12,691.55 52.82 Si 2,694.37 Kathy J. Gorka 11!2212008 49565-11 03/28/1986 513,772.56 5.62 513,773.18 Kathy J. Gorka 11/2212008 a9s6s-10 04111 !1986 519,915.79 55.89 519,921.68 Kathy J. Gorka 50°!0 Gregory Jumper 50% M M RS 1sT FEDERAL C DIT U ~~~~~- ant [e A. Kline tending Insurance Support Specialist January 13, 2011 Estate of: DORIS J. JUMPER Date of Death: 11!28!2010 Social Security Number: 172-24-8635 5000 Louise Drive P,O, Box 44 A~echanicsbtug, Pennsphrania 17455 ($00} 283-2328 ~~~~-~vmembexslst.org January 25, 2011 Andrews & Johnson Attorneys at Law 78 West Pomfret St Carlisle, Pa 17013 RE: Doris J. Jumper To Whom It May Concern: In reference to the above customer, our records show the enclosed information to be accurate as of today's date. If I may be of any further assistance, please contact me. Sincerely, ~ ~~~~ ~~~ ~- Brenda Hahn Deposit Operations Clerk 717-261-3668 717-264-6116 888-264-6116 P.0. Box 6010 Chambersburg, PA 17201-6010 ~1AI A hlr+I A I C of 117ln~tc+ rnnaR nrnnl c vn~i v~tn-~t ~- ~ o o ~ ~ O U REV-1Si4 EX~} (43-09} ~ ~ ;~ pennsyEvan~a SCHEDULE G ~EPAR:MENTOFREVENUE INTER-VIVOS TRANSFERS AND iNNeR1YANCE7AXRE7URN MISC. NON~PROBATE PROPERTY RESiOENT DECEDE~'YF ESTATE OF FILE NUMBER Doris J. Jumper 29-90-9268 This schedule must be completed and flied if the answer to any of questions 1 through 4 an page three of the REV-i5U4 is yes, ITfM NUl+fBfR OfSCRIPTION OF PROPERTY i~:ClGOE 7}iE NA.'{E CF T?fE TR,I'tiSFEAEE, ~}1E1~ NEiAT10tiSNiF TO DKEOfYT f:i4 TttE QATE Of TR,L'iSfE~. AT7ACM A CCPY Cf ThE DEfO F02 EtE'41 E51ATE. DATE OF DEATH VALUE OF ASSET °.b OF DECD'5 INTEREST EXCLUSIOPJ [F Ilt'lrcl$lE TAXABLE VALUE i. IRA account no:49655-1Q-Members 1st FCU 19,821.68 100 19,921.68 Established: 4111!9 986 Beneficiaries: Kathy J. Godca - 50% -daughter Gregory Jumper - 50% -son (see letter attached to Schedule F) TOTAL (A4so enter 4n Line 7, Recapitulation) $ ~ 19,929.6$ If more space is needed, use additional sheets of paper of the same slze~, REV-1511 Ek+ {IO-t~9) r ~ ' pennsytvania NCH EDU LE H DEPARTtrfPJT OF REVENUE FUNERAL EXRENSES AND ]P7HERITANCETAXRETt1RN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris J. Jumper 21-10-1268 Decedent's debts must be reported an Schedule I, ITEt•1 NUMBER ©ESCRIPTION AfdOUNT A. FUNERAL. L:XPENSES; 1' Hoffman-Roth Funeral Home -funeral 9,017.27 2 Westminster Cemetary -opening and closing burie! plot 1,595.00 3 United Methodist Church -church services and luncheon following services '188.07 8. 1. ADPIINI5TRATIVE COSTS: Persona{ Representative Commissions: Name(s) of Personal Representative{s) Street Address Gty Year{s) Commission Paid; 2. Attorney Fees: 8,600.00 3. Family Exemption: {If decedent's address Is not the same as cialmant's, attach explanation.} Claimant Street Address ~. 5. ~. 7. s s 10 11 12 City _ State _... Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: PP&L -electric bill UGI -gas bill Comcast - Gnal N cable bill Borough of Carlisle - waterlsewer bill Walmar# -automobile repairs Bank service charge -checks 393.50 250.00 65.'16 178.2'1 31.00 70.24 52.60 18.95 TOTAL {Also enter on Line 9, Recapitulation) ~ ~ 56,709.78 State ZiP ZIP If more space is needed, use additional sheets of paper of the same size. SCHEDULE H -continued Funeral Expenses, Administration Costs and Miscellaneous Expenses ESTATE OF Doris J. Jumper FILE NUMBER 21-10-1268 13. State Fann lnsuraa~ce -automobile ins-irance $394.41 14. PP&L -electric bill $64.12 15. UGI -gas bill $148,81 16. Carlisle Borough Tax Account-2001 borougl~/county real estate taxes $995.69 17. PP&L - elech•ic bill $50.44 18. UGI -gas bill $94.73 19. Neils - lZOme repairs $41.20 20. PP&L -electric bill $32.85 21. Big Knob Services LLC -- tree services $3?5.00 22. UGI -gas bill $37.49 23. Commonwealth of PA -- lost vehicle title fee $22.50 24. Kathy Gorka -reimbursement for lawn mower gas, trash bags, etc. $100.00 25. Big Knob Services LLC -tree removal as a result of stone damage $760.00 2G. Real estate conuuission $11,946.00 27. Transfer tax $1,991.00 28. UGI -gas bill $25,21 29. PP&L - elech•ic bill $37.87 30. Borough of Carlisle -- water/sewer bill $72.90 31. PP&L - elech•ic bill $25.18 32. E.W. Wenrick - dumpster;•ental made necessary for major repairs $497.00 33. UGI -gas bill $18.02 34. PP&L -electric bill $62.88 35. Gene A.1bliller Custom Builder -replace roof on 1528 Terrace Avenue -paid Ill hvo installements {see Schedule E, Item 4) $ t 5,344A0 36. Carlisle Borough Tax Account - 201 l school real estate taxes $2,266.20 31. UGI -gas bill $16.98 32. East Pero~sboro Volunteer Fue Dept -table rentals for public sale $30.00 33. Overnight mail expe~ise $31.00 34. Register of Wills - PA Inheritance Ta:c Rehire filing fee $ 15.00 35. Reserve for closing and accotintiug $750.00 TGTt~L {also enter oa line 9, Recapitutuioa) see page 1 REV•15I2 EX+ (12-~5) ~ ~ pennsyEvan~a SCHEDULE I f)EPARTf4EN7 of REVENUE DEBTS OF DECEDENT, iNNERITANCETAX RETURN MORTGAGE LYABILITIES & LIENS RESfDENT DECEDENT ESTATE OF pYl.E iVUMBER Doris J. Jumper 21-10-1268 Report debts Incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. if fnore space is needed, Insert additianai sheets of the same size. REV-1513 EX+ (41-1©) ~ ~ ~ pennsy[~ania SCHEDULE J DEPARTMENT pf RE~JEttUE 3NHERCfANCE TAX RENRN BENEFICIARIES ResiaEYr ofcEOCNT ESTATE OF: FxLE NUMBER: Doris .f. Jumper 21-10-1268 RELATIONSHIP TO DECEDENT AhiOUNT OR SHARE NUMBER NAME AND ADDRE55 OF PERSON(S) RECEIVING PROPERTY Da Not !#st 'trustee(s) OF ESTATE Y ~ TAXABLE DISTRIBUTIONS (Include outright spousal distributions and transfers under Sec. 911b (a} (1,2}.) 1. I 2 3 4 5 6 7 8 II Kathy J. Gorka, 460 D Street, Carlisle, PA 17013 Gregory L. Jumper,125 Atburn Orive, Boardman, OH 44512 Michael Gorka,129 N Monroe St, Apt E, Belfont, PA 18823 Timothy Gorka, 3113 Homestead Dr, Erie, PA 16560 Ryan Jumper,125 Alburn Drive, Boardman, OH 44512 Emily Jumper,125 Alburn Drive, Boardman, OH 44512 Roche! Jumper, 7370 Pine Fork Road, Quinton, VA 23141 Benjamin Jumper, 7370 Pine Fork Road, Quinton, VA 23141 daughter son grandson grandson grandson granddaughter granddaughter grandson ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOI'UN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE I)ISTRIBUTiONS ON LINE 13 OF REV-1500 COVER SHEET. ~ $ 113 113 116of113 116of 113 116of113 1/6of113 1 /6of113 116of113 If more space is needed, use additional sheets of paper of the same size.