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HomeMy WebLinkAbout08-31-11 1505610101 REV-1500 Ext°'-1O' PA Department of Revenue ~sYlvania OFFICIAL USE ONLY t~ Bureau of Individual Taxes ~ County Code Year File Number INHERITANCE TAX RETURN PO BOX 28o6oi 1 + " ~ ! ~ ~ ~ ~ ~ Harrisburg, PA iy1~8-o6oi RESIDENT DECEDENT = - . ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 204-22-3253 01 /01/2011 11 /24/1930 Decedent's Last Name Suffix Decedent's First Name Mi KAUCHER JR HOWARD ~ (If Applicable) Enter Sarviving 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 t~ 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 Estate Tax I~etum Required death after 12-12-$2) f.>D 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust d 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust} O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O} CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Andrew H. Shaw, Esquire (717} 243-7135 First line of address 200 S. Spring Garden St Second line of address Suite 11 City or Post Office State ZIP Code REGISTER OF WtLL:i USE ONLY r .~ n ~. r ^ {~ ... _' _ _j ~~ - - :::~ - ,..:, -~, DATE ~lLEiL -~ ~' '~~ -'rl ;-T't ,~:' > .-~-, ~;~ cc, --~,. Carlisle PA 17013 -, ~"i ' > ~ - Correspondent's a-mail address: andreW@aShaWlaW.COm Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,~orcect and complete. Declaration of prepare~ther than the personal representative is based on all information of which preparer has any knowledge. Slf.~tJf~'rURE OF PEjt~$ON~r ESP~N~LE FOR F}(tNG RETURN ~t7ATF 13 S oolhous ewvilie, PA 17241 SIG URE O P R O ER THAN REPRESENTATIVE /~ DATE __ 200 S. Spring Garden St., Suite 11, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610],01 1505610101 REV-1500 EX Decedent's Name: i'iOWBr'd L. KBUCher, Jr 1505610105 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. 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 0.00 0.00 0.00 0.00 94, 328.78 0.00 0.00 94,328.78 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)(t2) X .0 0 0.00 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 90,220.46 1g. 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17 18. Amount of Line 14 taxable at collateral rate X .15 0.00 18 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610105 1505610105 Decedent's Social ;iecurity Number 204-22-3253 3,710.52 397.80 4,108.32 90,220.46 0.00 90,220.46 0.00 4,059.92 0.00 0.00 4,059.92 O REV-1500 EX Page 3 Decedent's Complete Address: 0.00 DECEDENT'S NAME Howard L. Kaucher, Jr. STREETADDRESS --- 770 South Hanover Street CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments ____ B. Discount 3. Interest 0.00 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. File Number Total Credits (A + B) (2) (3) (4) (5) Make check payable to: REGISTER OF WILLS, AGENT. 4,059.92 0.00 4,059.92 0.00 4,059.92 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 : ...................................... ...... ^ x^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^ Q 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 noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ~~~~~ ~~~ ~~~ ~ ~e~~~~zt.e.~~ With trust in Him who made heaven and earth by His almighty word and gave His dear Son to die for sinners, I HOWARD L. KAUCHER, of West St. Clair, Bedford County, Pennsylvania, commit my eternal soul to the Father in heaven and dispose of what earthly property and responsibility I may have at death as follows, hereby revoking any and all wills and codicils heretofore made by me: 1. I direct my executrix to pay out of my estate all of= my debts, funeral costs and administrative expenses as soon as convenient after my decease. It is my express desire and direction that my funeral arrangements be modest and my burial be as inexpensive as reasonably possible. I want no expensive casket or elaborate funeral services, except such a fitting memorial gathering in a church and modest gravemarker as becomes one who respects the earthly remains of the body God has given him, but knows that as surely as the dust returns to the earth the souls of those who die in the Lord remain not in the grave. I remind my heirs of the lessons contained in Genesis 23 and II Corinthians 5. "0 death, where is thy sting? D grave, where is thy victory?" (I Corinthians 15:55). 2. I authorize and empower my executrix to sell any realty owned by me at my death and not specifically devised or bequeathed herein, at either public or private sale, and to give good and sufficient deeds therefor, in fee simple, as I could do if living. 3. I devise and bequeath all of my estate of every nature and wherever situate to my wife, Elva S. Kaucher, providing she shall survive me by sixty days. 4. Should the gift in Paragraph No. 3 not take effect, I devise and bequeath all of my estate of every nature and wherever situate to my four children, share and share alike, the child or children of any deceased child taking the share their parent would have taken if living. 5. I nominate and appoint Elva S. Kaucher to be the executrix of this my last will and testament; she is to serve as such without bond. Should she die before my death, renounce or refuse to serve for any reason, or die leaving any of my estate unadministered, I nominate and appoint Kerry L. Kaucher, Kenneth L. Kaucher, Kathy D. Davidhizer and Keith L. Kaucher. as substitute executors, also to serve as such without bond, with the same powers as are given herein to my executrix. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~`. day of February, 1988. HOWARD L. KAU R Signed, sealed, published and declared by Howard L. Kaucher, the above named testator, as and for his last will and testament, in the presence of us, who at his request, in his presence and in the presence of each other have subscribed our names as witnesses hereto. i 2 ACKNDWLEDGEMENT AND AFFIDAVIT WE, HOWARD L. KAUCHER, BETZI A. MORRISON and SHAROnI l_. SCHWALM, the testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his Last Will and that he had signed willingly, and that he executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in their presence and hearing of the testator, signed the Will as a witness and that to the best of their knowledge the testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. _.~ HOWARD L. K CHER ~ ~ .~,-~. '; .. BE ZI A. MORRISON ~ , ; SHARON L. SCHWALM ~" COMMONWEALTH OF PENNSYLVANIA: ss. COUNTY OF CUMBERLAND . Subscribed, sworn to and acknowledged before me by HOWARD L. KAUCHER, the testator, and subscribed and sworn to before me by BETZI A. MORRISON and SHARON L. SCHWALM, witnesses, this z.~~t'~ day of February, 1988. .,, r ROG B. IRWIN, NOTARY PUiLT~ CARLISI.£ BORD. CUMBERLAND COUNTY MY COMMISSION EXPIRES OCT. 3, 1988 REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Howard L. Kaucher, Jr. 21-11-0287 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, insert additional sheets of the same size) Free Cheer Account Statement ~Or t~9 Q~'f411~ a~/'f 1~r~#~1'~ bR 0~~5~~1.~ G45~# HtIWAR~# L #CAi.ICNER I}ECF} 1 ALLIANCE DR APT 303 GARLTSLE 6'A I7QI3-~I35 Primary a€~unt numtaer: 5Q-Q~Ab-$6Q9 Pa~L $ 4f :~ Numf~sr of encFwures: t) F,~r 24-tour t~an&ing. and trans~a+~irxra ar intarc~st rate intorrttation, sort ort t© Pf+lC Bank Oniir~e Banking at pr>:ccom. ',~,~ For c€istamersen,ricecall1~88-Pf+1C-BANK Manday - Friday. 7 AM - 9f1 P14V ET Saturday & Surrd;ay; 8 AAA - ~ PisA PT Para servicio en es~trrlai, 9~Bti&-FfQt~4-PfVC Mo~Gnp7 Please contact. us at: A-B88-P'NC-BAfJK Write to: Gu~torrn >etvice pr> ~~,. Ana Pittsburgh PA ta2~tr-9736 V isit us at ~rtc.con~ TC1f3 terminal: 1-813-53 t-1546 /~, ~ @~~ 6'~r txaring iimPaired ctirnts €rrrt ~f'iF~ C~iB~idng lftiil"i.Rll~i~ sRrw~+'~11~ f'iaWard L iCa4CIheC DeGt! Account n€irrrber: Overdraft Protsdeon Provided ~y: Co~tfiret ip'1~ to estatdish Areerdraf# Protretioq gd ~ ',~y/gttte'Mi'+~ 8eginnlrx~ [3epc~siis and Checks era? other finding balance other acid"aftons deductions balance '-!:4''t),;df .(56 3.CNJ ~J,=lt7.f37 Average mr:nthry Charges balance ar~c7 €ees Tra>r~aa+~Rloi>r1 S~trarrnary ~hecf;s ~idf v„trj•awars 7 T~t~s a°ri~ {) Check Card POS sSSgned transa~ctiorss t} PNC Bank GcTq,d t: ~rrs31±'4inn< ~~ Ctleck Cardlt3ankcard P©5 PIN iransadions ~? C?thrir bank I,} ~ICd1f~#~ ~1~1~ irb~~c~ and Sfubsitituti® lhsdcs Ceti flare Reference number ,4nrna:nl paid number Ti>€rre is 1 r~eck listed totaling 53.+90, ~ai1y Ba~tice Qetail ~""- flairs riarance Gate 3alance 171;'13 fit.-f:'U.~?I OY,!id~ ~?,•~3i'.81 t~orttte'~'~t1i cc7xls~ctttivty y°t;ar, A'NC' prest~nts thc; ~'hil~del~hia Inter~tigrtaI ~lr~wtlr Sht~~~, ~Vlarc~t ~R-~~, at thy: 1'~I1T1Sy1v6i1i~ ~'e~rtventir:~tt ('enter. Tic~~ts #~r ttte sEtcrw~ can be pstrc~as~€1 at s~leetl'~C Liranches. tFcrrmcrre inf~rrttatic~n, E•isit tJleilaw~ersh€a~k°.a~~m. ~.. Fi4flfv1LT09-Jt~831891-N4Q-PifVNPiNf~•~Ca1-Uttt17d7 ~ Page; 1 Enclosur+~s: O ~~~~ ~~~-~~l ~~ n a~,~ asp . ~~~,~ra~. ~,~,,sr~ r, ~~. ~ ~~~ 43'4t':~ @y ~Y~tB?'ifl,14f18 f~1c711k_C;JR? ~~`**********Al1T(}**P1IXE© AAE~ 175 2171 0.4420 X90 0.382 12 10 56 1-tt~WARl~ L IUIIJCHER i3 SCHQC7LHC)USE tVEt~t4+'I~.E ~'A 17241-'~4t19 I!itl~(~it#it~~#it~~II~IIItlI~Il~~i~~li'lEull~l!!'!"~il~!'~Elid Statement Date: 03/"18J2011 ACCK3UCit ~tlR1~7Bt: D304D7 CYCLE-0i:8 Checking CARFFR~EE CLUB SC.~ ACCOUNT NL~18ER 0t10Q930407 PREVIOUS STATEMENT BALANCE'. AS OF 02/1$/11 ....................... 1,720.x3 PLUS 0 DEPOSITS AND OTHER CREDITS ..................... .0p LESS 0 CHECKS AND CITNER DEBITS ........................ .00 CURRENT STATEMENT BA~LAMCE AS OF Q3/18/11 ........................ 1.720.53 filUMBER OF DAYS IN THEE STATEMENT PERIOD 2$ ~~ ~. Balance By Game Date Balance Date Balances Date Balance Bate Balance 02/ 18 1.7207.53 ___ a _~dciliYiRtY G-f t?V~s'£IFaft and l~+~ii'li+ ~'t~D'i I+ee.S T{7TAL FOR . TOTAL . THIS PERI~7 YEAR-TO-DATE :TOTAL. OVERDRAFT FEES . y.'.00.,•'-----' .00 : TOTA3. t~FTURNEQ ITEM FEES .00_'__..---_._.00 lice l.~ \i~lai~1 ttllEh;'w1" ~* - . Ci L1.: r~ t _~.~~7_l.l~ i i tC~~t~,etti~ ~o,,r,wt :~i:Er,i ~~eyirtf~~ c'~~tll~ IYlarcta L~~ ZL> I d Kennettz L i<aucher ~~ Schoa3 F~fouse Road NewS.~i3e, PA 17241 Re: Apartrnont Entrance Fee Refund for Rev. Howard L. Kaucher Dear w~~, Kaucher Enctosed is the refund for Rev. Hourard L. Kaucher's apartment at Ghapet Paintry. The rai"tend was calculated as fc~llosvs~ C3a#e {]ccupied Z~`1~~'ZQt?9 Data Surrendered 1r'Sr`2Q41 h~ionths C~ccuied 1 t3 Refund CalCUlaton t=ntranceµFee Pasd $ ti2,C}p~ ~p L~:ss Amortization Entrance Fea Paso $ 62,t3~iJ.r3t# Amortization Period (N1c~nlhs} $ 6f].(]C3 ~tontht}+ AT71C1rtiZc9tJtJn $ 1,1333,:33 i<ltonths 1~CCi3pIG-'d 1~ Arz~ortizat'ton Throt~h Surrender Date $ 1$,~rOt3_t}0 Ursarnor[ized Balance ~ 43,413Ct.1313 Early L'Vithdrawrai Assessment Fee (1f}"l~) $ {~,ZQO.o13} Net Arr~ot~nt Refundable (entrance Fee Less Arnoatization and Fae} ~ 3T,2ClCt_C3t~ A copy oT Section ~.4 - Condstions and Due Date fQr Refund Paymants from the l~partment Residency A~rment is enclosed for your reference. Please do not hesi#ate to contact ~~ i€ you have any questions. Sincerely, z r> +~ ~ ~ d ~'t~ 'v, Kent ©. #~eachey~ director of Finance (717) 713-2223 (Phor~e~ k;~s~~~Ctley€~' Ch3L?t",_I l~o3itte.orq ,~ riri~rncnt 4~~r€tr~~unity ttf 3~~~ €'hrititi.an and ~.~9i~sikrn~rsr ,~[G~€x~, u~fu r ~ ~ _:_,UI~L~II_L~.~Y4z12t2 :_~~; ~ 58U•21t7 DA3J` t 5 111A.Ft-1 CHECK AMY. ~2D4,80 lhil~lylCE J`JU~.113EFi 8 w'Cbl~ E7+46L ~F~C7 ti C~1~;;4lJNT +~MiCJ:JM1JT .AGiC)J,iNT rF' ~ .;I~' li~'~N A3d~.l~livtl _• ~..~.. P.iJk~~3J39C~L~i_r,_tr~ F3-A.IrSF2_it -7rbn an ,. .... ,~.__ DRrRGLEAP~kS-~1°~if1 ~4 Z5?2u t4!'i3 1x111 r -'~ v ;~ ~ ,~ ~, _~ ,~ ~ ,~. /^ "' G~ _~ f i t, .. _i ~ s- 3 ~~ 1' 11' i ~, ..- t~ f' ~ i _ it-p ~ ,~1~ 4 / ~ (f _ ~'~/~ ~ ~ ~ ~ ~ ,- ,~ i..^ , ~~ ` ,;" t, " i~: ,+ ~~~ `~ _ r~ r.. ,i ~ . `S ~~ t,% ~ {"+i fir' . ~ ~' ' .~' 1 tt r ;<. ~~r.5~~ ~~t .~ ~~ Y ~6 '~~ ~. {~ ~~,r". ~ ~, ~, 1..- REIr-1511 EX+ (1G-09) ~~i pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBEIR Howard L. Kaucher, Jr. 21-11-0287 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A• FUNERAL EXPENSES: 1' Hoffman Roth Funeral Home 2,439.02 B. 1 z. 3. 4. 5. b. ~. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City _ __ _. State Year(s) Commission Paid: Attorney Fees: Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City -._ ---- -_ State -- Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: ZIP ZIP 900.00 294.50 77.00 TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. 3, 710.52 REt~-lslz i-xr ;iz o~; Pennsylvania SCHEDULE I DEPARTMENT °F' REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBEIR Howard L Kaucher, Jr. 21-11-0287 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. it more space is needed, insert additional sheets of the same size. ~'~-~-~l Pc~~~~ at carr~$r~ TiU ~. !~r~M1dfSL'E~2 ~~REPT CfiRi_iSLE. PR, 1 T093 ?rtr. I~oe~:~rd L. l{~uchcr kenneth [.. Iraucher (3 `~cht-ol H~us~ Rd. ~~~m~~iil~, .r~ 1721 =~.~~~~a C2UESTICJNS? BALL: {7] 7) 2~t)-13b3 S ENT # i R UNiT STMT. CJATf~ ~ 1 ~28~ BF'1"-303 0~?p1I2p11 ~1r. Iictw~xrd 1.. 1{aunc~>r T©TAL AM{~UNT DUE _ X210.32 ~~ GATE ©UE _['~n Receipt ~?ETACH A~l~3 RET~lRN THIS FQRTI£}N V~IITI~ YC3l~R R1=1~91TTANCE '~ _..__ _~.~ _-- __ _ _ a~,~~N? ~~~i~-~E~ I3A~'E t7ESCRIPTIQIV Days! ` CHARGES CREiDI~S B,4L,ANCE units. Balance ForK'~ird ~ -~~~, 0 21p.32 :,. - ~, r I i RE5IDE~J'i" # CLlRREt«1' ~ t3~`ER ~G AVER Fit) C?1rEFt ' OL'ER 12t) ~~~ TQTAL AOAbi1l+IT OUE 1328?I U.QO 21p.32 O.tl(1 O.pO f~.d-p SIp,3~2 RESIDENT NAME 'dir. II4~vard L. Kaucher ~~-~~~c,, fiIIAI'EL POI~ti7"E :a.T CA.Ri,IS.LI~., 77U S. H.41~%O'4~R STREET, C.IRLISL:E, P~ I7{II3 *t .mss ~~~~~J(j~~~.li1~C.` Fayme~tt C3ptir~ns 8c ~c-ntact In#t~ ~urren# Cl~ar+ges ~4#-A-Glance Msanihly Stat~rsteni January 1~3, ~C}17 T ~~~ ~ ~~ V ~c;ccruia# 9+lUmb~r ~ri ~-~~s-o~zs~~~s :~, ------ f?~taii St<xe ir+ V'cr33r Area ~ RL~S~E Ger+turyl.ink Senrirces 7~La1 2t~29~"~ ,.:n~~:i. C~. ~ s~ _ ____....- _~~ `<7~- C ,. ~_:; c, ~ r • ~ t~_,~,3r;r to~E arrtl [Sptic~sal Services -Page •t.~D J iy O~lfa~~ - -_ E ;1 [ ~ ~ _ "'lF~ ti.t,~ ~!€r~as:cn3crt Ling Dist~ne:e -Pare: 3 23.313 ~--_ f'ay 6}~ ~Fi ~~a~ '~7~- ;:;;:a Taxas atui Seir~3iargr~s F~yr: ~ 6,54 ~~ste~r;~ar 5~rvice -~ ~_ _3a~, ra " 3"otai Gr~lrrerrt Changes $. f~e~air Service Ir~tarn~t Adcfrass ~~~T~E~; ~1f1_~~ ~.t:;J'rtlri ~.:i jr.:'ctia Frra4~i6~~ Sa~a3tcz~. P~w,~i~~?ait~ $a ,Kt1ju~€rr{{~~~e}}riyyt~ryry. SS ~. -~kl.f_(. l~ft,1~,~1~ ~~~~~ -- ~ai~t~~:~e~ "`nt~~ Current wharc.~es 7"+ntai ,4n~cx~rxt Dare C}C~ i 2&.34 s~..~.._..y1jy/~(~ ~yyy.(~~~ ygBr~ ~~YrYT t:~~rr~ert ~;har~~es t~P E3~,r' 02/021't'1 ~- I# re~eevetl after Febr°uar~+ ~: S28.fi9 - ~t~~b~ x~.y~i~ ,`'~ j -~` ~~~ ~ l } ~, Ephrata Medical Equipment . ___ 1Q81 Sham Aver~u~ Ephrata, PA 17522 ILAUCNER, }iGtWARt7 L CkiAPEL r?aI~uTE AT CARt_ISLE, f RLL15~7N CIRIVE APT 3G~3 CARt15!_i±, PA 1 r'f~13 Summary St:aternent [SATE; ~'Jecir~escfayF lan~r~r}~ 1~)~ ?t'lll __.._-...__.. ........ .. i ~ak~ P~+yment To: -~____..__~ Ephrata medical Eguipme~it 1115 Ridge Aw~e~~~e, Ste 3 Ephrata,, PA 1717.2 (~'lI} :335-Of~96 IDate ~of :Invoice '' I'~em ©escxipfion ~ Charges r~e~iits jltem :Custcrrner (5eru~ce 1 Atumb+~r .~. ~ Balance `B~alan+c+e ?,t6/1fl~J9 2117t~7 1 ~C:vr~~.'~+~tt*rhtc:w4;rf. $35~.OCi, 31.4.84 ~'~5.1t~ $~3`~.1!: ?,~~i/2Ei~9 111789 1 ~.:c~~~f.°;t,t~~rr~ey~~~~r~:, ~35D.Ci[7', s~1~.~4 c.:?~1 .t~ ?,w`i lis _3/6f1g09 111791 1 ~~.'r.,r~c.'~ t~trr hi~sv €rPC~ ,351 (?G}' a;134.f's4 ~ ~~i.`j lr ~':~S.lti . ~4i~6/2CJ09 i ~ 112793 ' 1 !r-srs~- ~ r~t~r r~~, i.€~ I 354.0(, $314.13=1 i w35.~f~ ~ X35,16= 9~'S/ZO1t] Z14;?i 1 G'~p~Cc~mp~ict X131.50; $if9.OtJ S1h.50 $18.50f Pa4'17 &'rt~:i(1 F~ttOU13l ~i'~.4141i ~(~.uu E ~~,}.[~{} !fi~,(`~(S _ __ _.. ._. 1 _. ~ Ciisbomer Balance I s1S9.24 C~mn1C'n~&: ~~.._. t ., 9.j anr., wyr=_ i~7f~` ~v~t_ai'i:.Ci ci'se }~~2]'~f~i~iCl ~~ U4.iC. ~i (ii rl yO~L.~ ., z.e~u'f e7i:..,tr ~i.~ et3,~~tL[7 ~IC~^ ~ai4_. - G~i~w J=1iJ,:*~ ,j ~r~wt. x.,. }four responsibility. Payrrrer~~ rece~veci ~€~er if l~fli t~~v~ nr~t yNt t~eer~ appii~ ts~ pc~r~r acuc~~~nt ~~~f twili €~ot;~pp~ar nr~ fhe statement9. TI}r~r,i< Yc~u for your t~t~siness! ~-t~ PAY BY CREDIT Cfi,R13. Credit Card ~` I ?` _ -- __ f _ _ _ _ E~:p. ©ate_ _ _', Diti~t V-~~Qtic._ 1~ayrrar.•r~i Ar77;~tsr;q '~^Je dc~ ix~t e~cetal Ame=can E>,~+ress l?lea..v ~ipe~}:: ~~,l.~E~`~t4~t~t~~~lat~u ~~1 ilic r k ~` ~ E3T-5iJh1ST-17a3i f'}e'ctur~ik~t~3;~t~ ~t}~ktr ~ ~ ~- '' '!)t+x ~+ai~r~~u 11111^9 ~k~wrrtiF ~ r... ~..~ _ REV-1513 EX+ (OL-10) B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: ~ Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT BENEFICIARIES ESTATE OF: FrLE NUMBER: Howard L. Kaucher, Jr. 21-11-0287 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~ Kenneth Kaucher, 13 Schoolhouse Rd, Newville, PA 17241 child $21,540.14 2. Keith Kaucher, 604 S. Middlesex Rd, Carlisle, PA 17015 child $21,540.14 3. Kathy Davidhizer, 107 Second Ave., Altoona, PA 16602 child $21,540.13 4. Kerry Kaucher, 1023 Sycamore Rd, Graham, NC 27253 child $21,540.13 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I$ If more space is needed, use additional sheets of paper of the same size.