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HomeMy WebLinkAbout10-21-111505610101 REV-1500 ex t01_,°' ' PA Department of Revehue Pennsylvania Bureau of Individua(Taxes oEV~pTME~T~FpINHERITANCE TAX RETURN PO BOX z8o6o>. Harrisburg, PA 1'7128-0601. RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY ,~ ~ ~~ y~~- ~~~ ~ ~~~ Der_e~d/enC~s"'La/st Name Suffix ~'r J °l ~~ (If Applicable) Enter Surviving Spouse's Information Below OFFICIAL USE ONLY County Code Year File Number Spouse's Last Name Suffix Spouse's First Name MI - - Spouses Sor_ial Security Number ' }~ ' ~ ~ ~. - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 4. Limited Estate O 4a. Future Interest Compromise (date of death after 12-12-82) 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ., .:.. . First line of address Second line of address City or Post Office ci~-.Z-r-~ s L-~ Correspondent's a-mail address: State ZIP Code REGISTER OF WILLS USE ONLY C7 r~"' Q ._"__ -a ~ ~ C::) _~a ~ -f -rZ~ \. ~ ~ A.., ~r ~ ~ i_ -- i'~ 7~TE FILED" - ,' 3 A C, ~ r--, i°~` ~ ~-c-l 3 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. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE nnnRFC~ ~ ~ ONLY Side 1 1505610101 1505610101 J~ Date of Birth MMDDYYYY Decedent's First N~3me MI ~~ ° , k / !y, I-~.; I Ste. , ~~~ _ 2~ ~ oAh~c<s~' , _ ~'~~'`- ~ ~~ 3 J REV-1500 EX 1505610105 Decedent's Name: ~~s~~c ~ ~~G~~J~- ~~ . Decedent's Social Security Number _--- 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. ,_ _ , a ' * ' f r'~~:#s` ~ . 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. ~!s , ~i ~, ! x 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ..... .. 6. r 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ' " (Schedule G) p Separate Billing Requested...... .. 7. -~~~ ~ 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. ~~~ ~~ ~ 9. Funeral Ex enses and Administrative Costs Schedule H ................ P ( ) ... 9. O~ ~~ ~~ ~"~ `~~ . ~~~: 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... ... 10. ~ ~ _~, .; , : ~. 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. j .,Z~ 1 I 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. . ~ ~,~ ..r _:- ~ .~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which `'~ °"~ an election to tax has not been made (Schedule J) ..................... ... 13. ~ v 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. ~--, G3. -±i:-- TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ~y (a)(1.2) X .0_ 15. s ~ 16. Amount of Line 14 taxa~ ~ a at lineal rate X 0 ~ ;: 16. •~~ ~~`.~~ ~~~ ~~ ~ ~ " 17. . Amount of Line 14 taxable rk_ ' ~"~` ~ ~ 18 at sibling rate X .12 ~ a, nt of Line 14 taxable ~ A o 17. - _ " ~`~ Y,. ~ ~~ ~~ . _ m u ~ ~ ~ at collateral rate X .15 18. ` b ~ ? ~ ~ ~d 3 ~, , i~ ;: 19. TAX DUE ...................................................... ...19. ~ ~ ,? ` u o„-... r _,.-. , ,... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 1505610105 1505610105 ~. REV-1500 EX Page 3 Decedent's Complete Address: File Number~O / i G7~~ DECEDENT'S NAME ' /~"-' STREET ADDRESS CITY ~ s ~ STATE P ~~- ~ i Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments ____. B. Discount Total Credits (A + B) (2) Interest (3) 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. (4) G -- If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Q ~- 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 N o a. retain the use or income of the property transferred :.................................................................................... ...... ^ r ~ ~1 b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ 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? ........ ...... ^ ~' 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. REV-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER All real property o ed solely or a 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 between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. c~-~,r~ ~ ~~ i ~~~ s~i ~~ ~ ~ TOTAL (Also enter on line 1, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) Sovereign Bank December 14, 2006 Arlene A Hysick 140 W Church Ave. Carlisle PA 17013 Bear Ari~r~e A Ilysick: RE: 4527062131 We have received and applied your payment intended to payoff your loan. However, we were unable to payoff this account since the amount sent is less than the amount required to close the account. In order to properly credit your account and pay it in full, it is necessary for you to remit the balance due in the enclosed envelope within seven (7) days from the receipt of this letter. Per diem interest must be added for any day s beyond the seven days. Balance Due Per Diem Interest $27,451.51 $5.56 If you have any questions, please contact Sovereign Direct Customer Contact Center at 1-877-SOVBANK (1-877-768-2265), from 7:00 a.m. to 11:00 p.m., 7 days a week. Hearing impaired customers may call 1-800-428-9121 (TTY/TDD). Our Team Members look forward to assisting you and are committed to providing you with Sovereign Bank Red Carpet Service (SM). Sincerely, StepFianie ~'ister Cunsumer Luaai Servicing Censer Mail Code: 10-421-CP2 PO Box 12646 Reading, PA 19612 A B/CAS ~~l --/ ~- -~ G ~ ~ Sovereign Bank November 14, 2006 Mr. Stephen M. Hysick, Administrator of the Estate of Arlene A. Hysick 140 W .Church St. Carlisle PA 17013 RE: SHORT SALE APPROVAL LETTER Loan #: 4527062131 --~ Property Address: 140W Church St Carlisle, PA 17013 Dear Mr Hysick This letter will serve as our demand for payment and advises you that Sovereign Bank has agreed to accept a compromise sale involving the above referenced property. This demand should be used by Escrow and/or Title as our formal demand statement. No additional statement will be issued. This approval is exclusive to this offer only. The conditions of approval are as follows: 1. Sales Price is to be Forty-one Thousand Five Hundred and 00/100 ($41,500.00). 2. Sovereign Bank is to receive all excess proceeds from the sale of the property. 3. Realtors' commissions are not to exceed - N/A 4. The seller or his/her agent(s) will not receive any cash from the sale. 5. The current residence and employment address and telephone numbers of the sellers must be provided and verified at closing. N/A 6. A fully executed copy of the HUD-1 Settlement Sheet must be included with the proceeds check. 7. The closing must take place by December 15, 2006. This letter expires on December 15, 2006. SALES PROCEEDS/SELLER CONTIBUTION WILL BE RETURNED IF ALL TERMS AND CONDITIONS HAVE NOT BEEN FOLLOWED. THIS WILL RESULT Sovereign Bank IN A DELAY OF THE TRANSACTION AND/OR POSSIBLE CANCELLATION OF THIS AGREEMENT. Upon closing, please forward the executed document to my attention. The contingencies must be completed and verified prior to Sovereign Bank's execution of a release of lien document. Should there be any questions regarding this matter, please contact me at 800-929-0234, extension 766491. The mailing address is: Sovereign Bank, 601 Penn Street, Mail Code- 10-6438-CC7, Reading, PA 19601. ~ ~` j ; ~: ~.~ . Il A ~~4 _ 4 ~f~ Sincerely, ~ ': ~ ~" s ~ 4 +. " " /~v ~l ~ 1~ is A. Bricker ~ ~ ~ ~ S Banking Officer d,- ~ ~f - r;. ~ ~ ~ . Consumer Default Servicing ~~ ~' ` " cc William Daniels, Attorney at Law-~ cc: Wayne Deakin -Wolfe & Shearer 33 S Pitt St Carlisle, PA 17013 ~~ ,f ~ ~ - {~ ~ _"'~ r 1 f ~~'` 5 f'6~ REV-1508 EX « (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, 8c MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF ~ FILE/NU/MBER ~% ~/ Include the procee s of litigation and the date the proceeds were received by the estate. All property jointly-owned wkh the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ~- ~~ ~~G~~~~ ~ P y~. ~~ ~-~/ ~ ~ ~-~-,3 TOTAL (Also enter on line 5, Recapitulation) $ i ,/ (If more space is needed, insert additional sheets of the same size) =~ SOV~1'elgYl BaIlks" STATEMENT OF ACCOUNTS Stateme~rt Per O7 2 06 TO , 24.08 1-877-768-1143 wuvwsovereignbank.com ELITE CNECKINC '- ~~ ~ ~ ARLENEA HYSICK ACCOUt'li: ~ X67?t?74467 STEPHEN M HYSICK ATTY IFF Balances Beginning Balance $170.67 Current Balance $25.31 ~_ Deposits/Credits + $1,037.34 Average Daily Balance $214.84 ~- ~_ Withdrawals/Debits - $1,182.70 .~._ Interest ,~ Paid this Period " $.0..02 Annual Percentage Yield Earned 0.11 Earned this Period $ 0.02 Paid Last Year $0.04 Paid Year-To-Date $ 0.09 --- `The interest earned and .the interest paid may differ depending an when interest is credited to your account. Checks Posted Check # Date Paid Amount Reference # Check # Date Paid Amount Reference # ' _~ 342 08102 $38.48 618896040 - -- 345* 08/11 $110.80 644935670 - - -- 343 08/07 $141.40 685365940 346 08/07 $110.04 685174160 4 Check(s) Posted = $400.38 An asterisk (*) indicates a skip in sequential check numbers which maybe caused by one of the following: . A check not yet received . A check that was converted to an electronic transaction, which will be listed in the "Electronic Checks Posted" section below. If no checks were electronically converted, this section will not appear. Account Activity Date Description Additions Subtractions Balance 07-25 Beginning Balance $170.67 08-01 CARL1SIzE CORPORA $209.32 $379.99 PENS PMTS AUG 06 037047830 08-02 CHECK 342 $38.48 $341.51 -- - - 08-03 US TREASURY 303 -_ __ $828.00 $1,169.51 SOC SEC 080306 A SSA 08-03 WTHDRWL _ $323.00 $846.51. 08-07 CHECK 343 $141.10 $ 1 page 3 of S 1671074467 SOV8TG1~I1 B~~' STAY E M E N T OF ACCOUNTS Statement Per od 07/25/06 TO 08/2M08 ARLENE A. HYSICK m~rmv7fl~. 34Z 1~0 W CHURCH AVE 16/f01N07 CARLISLE, PA 17013 oA>6--/~ ~ ~~ vArro rRe P/_ ~ 4~P~1.7'1 C. 5 ORPeII OI I $. ~ $., ~$ i 1 ,~ ~ DOLLARS. L L~S•~ Q ,~ 90vereign Bank ~~~ ~ ,~ 3,1340 - 87ao q__ f~_ ~~ ~ ~ -.. .. 1.23137269 U: i67107 44 2 ~' OQ 00003848x' ~F~~maaF7 # ~4~ nRin~m~ ~~R_aa -' -:ARLENE A. HYSICK m-rmMV1o '~ly~ 1M W CHURCH AVE,- 7RiWN0f DARLiSLE, PA 17013 ~~jj• / OA7lA PAY TO 71/l 3 QIIPLR ~~ ~.}a a ~ I III D. spa '.~~ D-LIJ 4 A3'I ~ ~w~ ~ +~'~_ i.r^ r~DOLLAPS LJ w""9..~ ~OVeTel Sank Via: a,¢~~~^~57?4 ~ . w '• ~Yf ~3~ fY' b ~' $'.ir+fs '~1C.'iG6 . ~ 1 c ,~„?I) 14 Q - 7 4139 7GL ~4 /./_~iq~ .~._ pof4 1;2 31 3 7 269 11:- i&7107446 10345 af~0000ii0801r 1671074467 # 345 08/14/06 $110.80 ARLENE A. HYSICC eo-rrlYxna 3 k 3 tMW CHURCfI AYE. iff1W1B CARUBLE, PA 17013 a7E~ G3 P , / - a ~fuaoP~ UGI L, ~~,,1 1 145 I $ ~~~e ~~ ~~~ ~ ~ Id~.`yD LO IANi ~ ~+~ .__~ o _. ... _ -.,. - -'9overeign Bank ~iMP ~~43.4~YQchl_ __ __ .1~l,_N _. *:23i37269N: i67i0744 7x0343- ~Oi4.1i0d 1671074467 # 343 08/07/06 $.141.10 ARLENEA.HYSK:K a-7~afa ~kG - 1.0 W CHURCH AYE. 1fiIWI117 CARLISLE, PA 17013 3~ ~ ~~~ 0 ve.rorPld-,___~~4.~~ QL_~1U4N~ I ~ 1 jD 00 .-a/R~~~R~1d~/m~~alc a~,att2 1 s S+!~G_,__~'LNN.~OYi[ 4a>t c1 'EtIJ OOLLAR3 ~ ~-:«..~. SOY@Pe1~tt B8t]k - - - - ~w.,ta.. - ~~ r -- 1:23i37269i1; i67i0744.7b•0346 a•~(p000-13000.+ 1671074467 # 346. 08/07!06.' $110.00 pale S of 5 1671074467 CARL E. OCKER AUCTIONEER 4401 Philadelphia Avenue Chambersburg, PA 17201 (717) 264-6578 Personal Property Appraisal for Arlene A. Hysick Estate 140 W Church Avenue Chambersburg PA 17201 BEDROOM ONE 3 PC CHERRY BEDROOM SET ........................................................................................... 25.00 CEDAR CHEST ...................................................................................................................... 50.00 GLASS BASKET .................................................................................................................... 10.00 CEDAR BOXES ..................................................................................................................... .. 5.00 PRINCESS HOUSE CANDLE HOLDERS ............................................................................ .. 5.00 MR & MRS CLAUSE CERAMIC FIGURINES .................................................................... .. 5.00 COUNTRY COUPLE ...............................................................................................:............. .. 5.00 CHRISTMAS ITEMS ............................................................................................................... 5.00 BEARS BOXES OF HOUSEHOLD GOODS ........................................................................ 10.00 SEWING MACHINE ................................................................................................................5.00 BEDROOM TWO CHEST OF DRAWERS ............................................................................................................ 5.00 DRESSER W/MIRROR ............................................................................................................ 5.00 BATHROOM 2 BOXES OF BASKETS .......................................................................................................... 5.00 LOT OF COSTUME JEWELRY ............................................................................................ 35.00 2 EMERALD TONE RINGS .................................................................................................. 10.00 CHAMBER POT ...................................................................................................................... . 5.00 DINING ROOM TABLE & 4 CHAIRS ................................................................................................................ 0.00 MAPLE HUTCH ..................................................................................................................... 25.00 LOVE SEAT ............................................................................................................................. 0.00 KITCHEN MICROWAVE AND STAND .................................................................................................. 5.00 BROOM, SCRAPER, SNOW SHOVEL, SPADE, LADDER ................................................ 10.00 WHIRLPOOL APT WASHER ............................................................................................... 20.00 LIVING ROOM 2 MAPLE END TABLES ......................................................................................................... 5.00 MANTEL CLOCK .................................................................................................................. 10.00 WASH RUBBER, PIE BOARD ................................................................................................ 5.00 FLATWARE ............................................................................................................................. 5.00 LAMPS ...................................................................................................................................... 5.00 PRESSED GLASS ................................................................................................................... . 5.00 BAVARIA TEA SET .............................................................................................................. 15.00 BOXES OF GLASSWARE, CERAMIC PCS ...........................................................................5.00 NIC NACS ETC ........................................................................................................................ 5.00 KITCHEN ITEMS, CORRELLWARE .....................................................................................5.00 WALKER ................................................................................................................................ 10.00 TOTAL ...................................................................................................................$325.00 I, DO HEREBY CERTIFY that I have examined the tangible personal property of Arlene A. Hysick Estate, 140 W Church Avenue, , Chambersburg PA 17201 And do value and appraise the same at $325.00 as being fair market Value of said property on this date August 30, 0 i Date $ B Q ~ Carl E. Ocker ~~ Appraiser REV-1511 EX+ (10-06) SCFIEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ~~' ~~~~~~ 3~ °~~~3~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) ____- ~~J ~ ~/ ~ ~ ~ i' e~~-,._ _ _ _ `=%~'v `'~ vV - -- G !~ ~ ,} 1 Street Address ~ 7 ~ _ _~/ _~-+<„~/i-wC. ~,/ / - _ _- - City ~ ~ State Zip ~~~~____ Year(s) Commission Paid: 2. Attorney Fees /~~~~ry~ ~~~ ,, /~ ,~ L ~ /' C,© 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant S~~ f~- d ~ • C.L_~~1~___ ~j ,S'~+~i~ ~i Street Address ~~~- ~~ ,i. ~_ ~~'. - -- City l~ `~'L~/ 1 ~{ State Zip ~ ~-(~'~ Relationship of Claimant to Decedent ~~~ 4. Probate Fees ~~ isTy !'v, 7~~f ~~ 5. Accountant's Fees 6. Tax Return Preparer's Fees TOTAL (Also enter on line 9, Recapitulation) $~ y~?.,i,'~/I (If more space is needed, insert additional sheets of the same size) Hoffman-Roth Funeral Home, Inc. 219 North Hanover Street Carlisle, PA 17013 (717)243-4511 August 25, 2006 William S. Daniels Attorney at Law 1 West High St. Carlisle, PA 17013- The Funeral Service for Arlene A. Hysick 14818-141 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. FACILITY, STAFF, EQUIPMENT Graveside Services _ _ _ $3025.00 FUNERAL HOME SERVICE CHARGES $3025.00 SELECTED MERCHANDISE: Kinsey Casket , $760.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED _ $3785.00 Cash Advances Certified Copies of Death Certificate $36.00 Flowers. $132.50 TOTAL CASH ADVANCES AND SPECIAL CHARGES . $168.50 Total Total Cost , _ $3953.50 TOTAL AMOUNT DUE $39S3.SO This statement is net and payable in full within 30 days of receipt. Please return this portion with your Remittance $ Amount Enclosed Service ID # 14818-141 Arlene A. Hysick REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIEDt~LE J BENEFICIARIES ESTATE OF FILE NUMBER R LATIONSHIP TO DECEDENT AMOUNT R SHARE NUMBER AME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under 1 Sec. 9116 (a) (1.2)] . ~CSfG~n- ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) Hysick Family Addresses Peter Hysick, Jr. 107 W. South St. Carlisle, PA 17013 243-9940 Bertha Minnich 116 W. South St. Carlisle, PA 17013 243-7976 Stephen Michael Hysick 140 W. Church Ave. Carlisle, PA 17013 249-8052 (unlisted) Susie Hurley 201 Old Mall Rd. Royerford, PA 19468 610-792-0617 Sanda Weller 10 Allison Ln. Shippensburg, PA 17257 532-5190 Eddy Hysick 118 Airport Rd. Shippensburg, PA 17257 PLEASE FORWARD Old Address