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Home My WebLink About10-19-11 (2)1505610101 - REV-1500 at°~_1°' ' OFFICIAL USE ONLY PA Department of Revenue pennsylvarria oE.,~,»~~.~~ County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN _ PO BOX 280601 Harrisburg, PA iyi28-o6oi RESIDENT DECEDENT ~- ~ ( , ~ ~ ~' D ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI ~~ ~ ~~ 2~~ iJ v f~ of f (ff Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ..5 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW A 1. Original Retum O 2. Supplemental Retum O 3. Remainder Retum (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ( 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 CONFlDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telone Number- ; .. ,.., r ,.,,~. ~-}.. ,,< ,. _ - REGIS#B!=6~IILLS USE ONLY- ~ y ~_,~ ~.. .., First line of address '~ `' y ~. , -„ Y - + ~ ._. Second line of address ~" ~' City or Post Office State ZIP Code DATE FILED Correspondent's e-mail address: ~f~JJ~A~) ~ (~>'t'~(y AIc'"t' Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. TURE OF PE S ESPONSIBLE FOR F LIN RETURN DATE ~r ~~t~ `~~ ~ ~ v ~= SIGNATURE F/ EP~RER~HER THA~RESENTATIVE ~~ ~ r`j r F I T ADD ESS ~j l . rJ ~~kl~'CT' S; ' . S~ci1 t ~ ~f~.'` G-L`~'~'S Y!~`~', /~/~ f 7 ~~ ~ __._.~ 1505610101 Side 1 15D561D101 J ~-{, 4~~-? Paz ~c+ ~ti-os~ pennsyLvania ~ SCHEQULE A i _____-,~_,.-v=~_r_r;::= REAL ESTATE :5T = ~ ~ ~- r-. ~ ---, ~ ; ,-- .-~ FILE NUMi3ER i; a a. ~; v{~rty awrned sai~y' ~- ~s a t~~ -, +n t be repaa`~t ai faar t~aci~e# ~raE~~e. =s ~-+~; ~~ ~ s ~~-s-~' ~'??A price at Hhicfi ProPertY -~ ' - - ---`~,_ a'-- --a = .- -_ ~ _. -_ ~, _ ym,~r w ~"i cry:. _C? a.. ~ 'a'~r_ !cr_+~?~±'~ a~~'ke relevant facts. Reel psa~gerty s ~~^~rr-ears rat r± crf su~vir~ip mist be s~sed osr Sd~edtcfe F. -", - ~ _~ - _'~ -: ~t ? asimed as tenarEt i~ cam: ~ -_ = AT DRTE _"'-0ti -- TOTAL (Also enter on Line 1, Recapitulation.) I $ ~,,~, ~~ t:l ~_,~ 6 ° +~> If more space is needed, insert additional sheets of the same size. REV-1503 EX+ (6-98) _ SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ,-~ ~ .-n ~- FILE NUMBER 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) REV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDI~LE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF ~ FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-field corporation/partnership interest of the decedent. other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. (If more space is needed, insert additional sheets of the same size} REV-1505 EX+ (6-98) ,~~;~ SCHEDULE C-1 ~`~" CLOSELY HELD CORPORATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF _, FILE NUMBER t~ 1. Name of Corporation ~"~ State on Incorporation Address City __ 2. Federal Employer I.D. Number 3. Type of Business 4. ProducUService Business Reporting Year TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK VotingtNon-Voting SNARES OUTSTANDING pAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. ^ Yes ^ No If yes, Position __ Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ................................... ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ..................................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedents death? .................... ^ Yes ^ No If yes,. provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate ap?raisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. Date of Incorporation State Zip Code Total Number of Shareholders (If more space is needed, insert additional sheets of the same size) REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNED~ILE C-S PARTNERSHIP INFORMATION REPORT ESTATE OF ~,,., ~ FILE NUMBER F~ - ----- --- - - __--- 1. Name of Partnership ~ ~~ ~ /.' ~ r:' Date Business Commenced ~4~('r Address Business Reporting Year City 2. Federal Employer I.D. Number 3. Type of Business ProducUService State Zip Code 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. -- PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ _ 8. Was there fife insurance payable to the partnership upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy _ __ _ _____ 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferredlsold __ _ Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. ~ • s' • ~ ~ A. Detailed calculations used in the valuation of the decedents partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addressJes and estimated fair market values. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ {7-97) ~y m7~ CC':":'C":`:"Jt=s~.LTH OF PENNSYLVF,"~'=A i."i~ERiTA,Cv~E TAX RETURN c:-~~,~ DcCtDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE ~Jl= P -~ -. FitE NUMBER ;,II property jointly-owned with right ofi survivorship must he disclosed on Schedule E. (If more space is needed, insert additional sheets of the same size} REV-1509 EX+(t8n SCHEDULE E COMMQNWEALTHt3Fi'EHNSYtVAl+?~ CASH, BANK DEPt?StTS, ~ MISC. 'MHERIT/1NCE TAX RETURN PERSflNAI PRQPERTY ~~~ ~~~~ ESTATE OF , f~, ~ -, FILE NUM )BER ,~.( S'",i~.~ ~." 1 ,.' > .~..a j 'fir-.'~tiJ -L=. # ~.- ~ ~ / r° .. Include the Proceeds of litigation arm' "~ da'e _~ +~ jived bl'the estate. All Property jointlyowrred wglr the right of survivorship must be d'ssclased on Sti~~ed~~te F. ITEM V~L~.E A- ~,''__ NUMBER QESCRIPTION 01= DEATH f r ` ' /i, i A ~ ~, i, " ,-~ `. ... . s ~~fP" f~'~~` P~~'• ~i~j ~- ~ ~ ~: -~ ~ raj=' .:} ~~ -~t:;~~t.~ t~if l11 ~,_~~ {t~~f"v-S^..#"B1lV~ ~4-Yt.`~~`1Z....., ',~-f ".'t 4~fU~r#~~`+~ t~~l=.~.:.(~-~/j%P 4S..I~ P~/d ~ls~'i~'`~~--~L-1~ C"~-°~~:F~~kl._ 4r~, G~~vik~;.+' (t~L`~'if~'tv~i~r`:r~u~~~'f 1"~'! ., 7 > a f~' s` ~ ~ r a6. ` ~~~-rt fl~~ =~e~~~~ ~~a •'~~°~~~ ~ ~ llLrll ~I t i ~ i ~ a d ~ #~ >+ af ~ 1. l~.~r $i ~ t" ~C ~e °`','3`c'-t~`^~ + =~1i C'~, ~ !y .~~ '~ '`[ '• i t ~}y / ,( )+~j / ~]j~ ~'y5.r~ ~ • ' t 4 } 9 Y F~- f~ 1 1' 1 °s: t' I ~• t _7 p. i ~ (~,~,~~ ~. '` s ~ 4 ~ ~~ 1Z ~f~~~,~~i1~ ~= c i~ /~2 ~~';,~u';;~z";"3.j ~ r'~: r ~{£=6~ ~~~ j,,=t.~:~ ~, .~i -T I ~.. ~.,?)4, a.., L 'Cl,~ ~ 7 ~'Y't L f, S~.) ~.: a's4-- { (`I !~ j~ t~f~ G;l'C~~ ~ i ~-°~~ ~`~~f •~ ~f ~ .;"fit ~)-l.~ J T ~~ , 7 ... i ,., -% t . ~ #l f -. ,~ i. Tt~TAI (A~o en4er ~ Ane 5, ReCa~lulafi~) ~ S ~ ~ i ? 1 ~l t ~' i', .. ~ ~~ (If rn#xe specie !s r>aeded, Uaert eddltlonei sheets ~ the carne size) AEV-+509IX • (S-9~ SCHEDULE F :.~ __ „+~~:,~,~_-- _:_ *t`.,_,.:~.k,:; J011dTLY-t31~YNED PRQPERTY __ . u~rv~- :~- ESTATE GF FtLE NUI4~ER .. r .~ t{ an asset rues made 10+~ s+Withir+ or?e Y+e~ of tf~e decedasYs dam of death, ~ must be reported on Schedule G, "- ~'Sv.?G'~?tTT~!i-`~~vT;rlti=.4!= ~ _ AQDRESS ~ REIAI;ONSHipTQI~CEDENT 3.: -~ . A ~ ~ _ °°t ~ , ~~ t , ,, i _ , `'~ ~. ~. Inw-ri Y~WNFI~ PRC)PFRTY: ITcM NUA9BER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTI~1 ~ FROF'ERTY {ndude name of 5nancial inSS~tion and t~k accartd nunber or simi{a iden{iymg ~~~. AUach dead for jay-t~eW r+~) ems. DATE ~ DEATH VALUE OF ASSET % OF DECDS a~(TEREST DATE OF DEATH VALUE OF DECEDENT'S WTEREST ~ ` !) (Z /~ ~~1~ , ~~1GSilN ~~~ i}l ~~-/h'' ~~°-,: Gjlu ` ~ y ~ y ~~,~.~y ,~t~~r~~t f ~ a- ~s:;~~~'~T~ ~`cTaF-t'g ~;?f`-~~ rC~.>• ~}~+' t{~'t~~~~ %.°5k f~ ~ ' '' Wit, tom, t~ ~~~y ~ °~ t)~:~c~"C:~:~-; ' S 1}j~~w vY ~,d~t~; ; _i, to rR~ ,F••~,~ ` ?~.s;.`~'3'_-i f'1L•; ;a ?~..u a`t-~~~~- c..J t`' a ~. ~ r ~ ` ^ ", ~ .7 .1.I ,~'-~+.4~.1~'y~lf"? jr ,... ~~i_ .... ~. ~f.~~'i ~ lt,Y t~"~... ,f TOTAL (Also erder ~ line 6, Recapitulation) 5 (If more space is needed, insert additional sheets of the same size) aEV ~~a ~c: t+-sr, CO~A~O?~t"NEALTH OF PENAtSYLVANlA lPfHERiTAhCE TAX REilJf2N SCHEDULE G INTER-VIYOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY ESTATE OF a ,.. FEE iiiliit~ER Thy ~~~I? must 6e core- a?iti `"~ .: ~° a.~s°r~ffi ar. ~~.:.....'_ ' ~ ~ ~< ~ ~ r-"'~ RL~', ? aa~ GJ'.'E=c Sri :c 's :~. ITEM NUh1BER 1ESGR1aT1GN fJf Ft~OFEi2TY R .~.~._:=~:;^aG.~-'z-°:.~,-'.~`g,:da~=~ ~~~a,,a~ ~~-~ =:- .~;~,.x~~~~nr-o~~~.t ~. D~TEC~£EfiT'H VALUE :3F ASSE s' % G~ ~ DEGu~S ~ 4,~iTEREST t~.`v'~SLI?+ - ~ :,~) ' Tt,XnBLEVALUE 1. ~ ,~ , ~.';;;, TOTAL (Also enter on line 7, Recapitul~on) f $ i.% : ,,~; (It more space is needed, insert ad~fiOnal sheets ~ 1t-e same sip) RELi-1511 EXr ~'~-~) scNEOU~ N cca.~a= _.', ,a, ~~~-- c- ~~~: ~ vli.~ca FUNERAL IXPENSES & -=-'~ ; -x ''-`~'' ADNIINISTRATfVE COSTS ESTA'_ C" ,....- ... _ - FlLE NUMBER Dehts of decedent must be reported on Schedule L apz ~ -- r ~ FUi~ERAt_ EXPENSES: r t'^r"^ ~~~1? B. ~ ADMINISTRATIVE COSTS: 1. Personal Represerdative's Commissions r;~ , Narr>e of Personal Representative(s) i~`='% r~ -y~'~'~`"~'~` Street Address ~'r-L• ~ ~r~~~ S; ~ --- State~_Zrp i ~'~, Year(s) Commission Paid: "` (~ ~' ~ I ~, 2• ~ Attamey Fees 3• ~ Famtiy Exemption: (If decedents address is not the same as dairr~rd's, attach expiaEration} Claimarrt Street Address _ Ciiy Relationship of Claimarrt to Decedent 4- Probate Fees ` 5• Accarntani's Fees 6• Tax Retum Preparer's Fees 7. 6u ' c !li• tt~ ! 2~ ;3. i~+-, rj State Zrp _ ..J {.%. L ~~ ., r ,. t% c~ :_:: ~~-L~i'fFs' l~l'~a-f~1 i''>t'L ~-~+-rr ~+C'~'~tT~i~ f,"'~;~~e72t'T J~'r";'~~,:4L~jyc'~' ~.~ - I'r~ ^~`,7~~~= q?u:`y is:`t' ~ !~~'~l'~7• ~~C-{~L3`l1~'.•~jJ~. C1-7~-it {'~fflii~~-.c~E>~111'`vi~ i~7~ ~~-Zb' Ir r lJ~~~CJ, V%•~C.~.~l v`.1~ v?'°f ~'~1J `(Jcs.l. ~~>;.~ +~~r-L~iJ ;J !~j',~L± qn - i I r v`'L '_i ~ ~ ' - `~' ~'rt/r/Y~ci:.l~~y}~nt ' f~;Frr~,r~~~cJ ~-,~ {, TOTA! (Also enter on 6ne 9, Recapitulation) ( $ .~~. ~L E , =-~.i 'xj~:>. ~ 1ai uL~v tJ r SS ~/ 4~~ 7- ~ 15~ 1S ~J" .fix. ~~ (If more space ~ needed, insert additional sheets of the saran sae) ~i~~~= ~ ~"~~rT~~~ ~~} (~= r J~ f ('~7'ia/L/}n:vN --~RYS~ N-!4G1~-T~r', c Pt~~ (fi4:2>LtSi_'~~'2~ ~~ ~- ~r~ ?-(:~t/~fG CU- ~cZ~S~ot= wic.LS /L -.'~'It ~'{1,tr7f~ f5{}t, -r Ftc-i~%w- ~=~~ j;~',u~ rtS ~'-L'~'iZL`L - ~~'~'L- /~'nJ~ ~}~ t~`~~r~-S ~~ f'tt se, ~ ~lipJ"~'~7 REV-1512 FX'•- (12-03} CDMk10N4VEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEOI~LE i DEBTS Of DECEDENT, MORTGAGE LtAB11.ITtES, 8~ L1EN5 tt ~+ -~1 FILE NUMBER ESTATE OF J~{ ~~) J ~L/C4~` ~-~ 1 T ~~~ ~~~`'~ Report debts incurred by the decedent. prior to death which remained unpaid as of the date of death, including unreimburssd medica4 expenses. :itt;tt t VALUE AT DAB I nccro~o-nnai dF DEATH TOTAL (Also enter on line 10, Recapitubtion) S (ft more space {s needed, insert addltiona! sheets of the name size) L,,~ ~-' REV-1513 EX+ (9-00) ^ COMMONWEALTH OF PENNSYLVANIA INHERfTANCE TAX RETURN RESIDENT DECEDENT SCHEDl~LE ~ BENEFIC1ARtES ESTATE OF i- ,,.,-~ NUMBER I ,. ~a :~. ~; ~~ ~' II NAME AND ADDRESS OF PERSON{S) REGENING PROPERTY TAXABLE DISTRIBt1TI0NS jirx9ude spousal dls>~utions, and transfers under Sec. 9116 {a) {i2)j q -~ L tZ.. ~=Z-4.:.: J ~ ~~'V~taiy+~ 1~'~~~C.4f7~~.1~76r~~Z1 :r~ 1 (c's1 c,:13 ~S F-~04-Z~J74`.~t,~ > • t i t PTT `'ttir t IVt e ~vi~l~ l+r~- ~ ~~"'~ S ~~~ r i ~ ~ f r t%'r"/L-1 Wit' ;oils l~+ [,%E, jam; i~t'~rclla ~tE'- ~1~';.~.';~*.lut~l.~,{.c.~'~i 1~'f)' d~P'~~3~ .f d ~1~ Jv.'4..r~7~ ~'~t~n~.- cB.~:~(v"~'~sv('t1i'~~ei~L.r~Ni~~t~ t't FlLE NUTA9ER RELATIONSHIP TO DECEDENT AMOUNT OR SHAAE Do Not List Trustee(s) OF ESTATE 1 `'~, °I fi~ ,~ ~w-v ice)-r;`?° ~~~~~= ~~~~' S f ~z ~ ij ~ t~l~`~t `~~f ~-'' r C~ tar ( !C: `' 1= ~ ~ f ~v 7~- f~ `~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON ONES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 TOTAL OF PART Il -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-150Q COVER SHEET' $ (If more space is needed, Ir-sert addhional sheets of the same size) REV-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Sheet ESTATE OF ;-. FILE NUMBER / This schedule is to be used for ail single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME(S) OF LIFE TENANT(S) DATE OF BiRTN NEAREST AGE AT DATE OF DEATH TERM OF YEARS LfFE ESTATE 1S PAYABLE ~~~ ~ ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................ . interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ • NEAREST AGE AT TERM OF YEARS NAMES} f)F LIFE ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6} + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law __ - Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, vlz: Au;;llst 12, August 19, and August 26, 2011 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Dougherty, John J., deed. Late of Camp Hill Borough. Executor: Austin Dougherty 218 Bailey Street, New G~unberland, PA 17070. Attorney: Albert J. Hajjaz, 1300 Mazket Street, Suite A, Lemoyne, PA 17043. .~ , .._-- /` Li Marie Coyne, Editor SWORN TO AND SUBSCRIBED before me this 26 of August, 2011 ~, _. Notary N JTAkIAL~Si_,~L~-~ ~"_~ .-~-~ '~'~DEBGRAH A COLLfNS Notary Aubiic CRRLtSLE BOROUGH, CUi!nBERLANO COU~~TY, IV{y Commission Expires Apr 28, 2B? 4 N PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tackle Cox, Sales Director, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13~, 1581, since which date THE SENTINEL has been regulazly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): August 6, Auk-ust 13 and August 20, 2011 COPY OF ti OTICE OF PUBLICATION Affiant further deposes that he she :~ not interested in tie sub~ec ~''?ctiCr ~~° ~_e aforesaid notice or adj-erhsi`~ ~n t, and that all allegations ?,ri ate o-e~~~.` statement as EsrarENO-rtcE to time, place .^:a ~~i=_~a~-~r of publication Letters Testamentary have been granted on the Estate of JOHN J. DOUGHERTY, deceased, late of Camp Hip Borough. Gumbertand County. Pennsylvania. to the undersigned Exeoutor. Ai: persons having claims against the Estate are requested to present them it writing, and al! persons indebted to the Estate are requested to make immediate payment to: Austin Dougherty, Executor 218 f3aiiey Street New Cumberland, PA 17070 or Albert J. Hajjar, Attorney 1300 Market Street, Suite A Lemoyne, PA 17043 are true. ~-' 1' f +j i ~' /'..d ~ f' I v. ~ / L ,~ i '~r/ U NIy commission expires: Nc,Ti;z;nt sFr,L BAMBi ANN HECKcPdDORi'd No,ary Public CARLISLE BOROUGH, CUtv1BERLAND CNTY illy Commission Expires Jan 27, 2014 ,~;`_ Notary Public