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HomeMy WebLinkAbout10-21-11J 1505610101 REV-1500 °`tO3-°°' 1~ PA Department of Revenue Pennsylvania OFFICIAL USE ONLY OEMRIX[Xi OE REVEXVE IXQUn Bureau of Individual Taxes V ty Code Year file Number PO BOx z8o6oi INHERITANCE TAX RETURN ~ rT~7 ~TT,~ HarHsburq,PAiyizB-o5oi RESIDENT DECEDENT 4~1/' ~1j1`J'~ JQ r Social Se/cur~ity~fNum~berq~ Date of Death MMDDYYYY tDa~te of Bi~rth~MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI ~~ ! (If Applleable) Enter Surviving Spouse's Irlformatlon Below Spouse's Last Name Suffix Spouse's First Name I~ IIIIIIII VIII VIII ill I III ' Spouse s Social Security Number ~' THIS RETURN MUST BE FILED IN DUPLICATE WITH THE WJ 1 ~__~__(~ , REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate prior to 12-13-82) O 4a. Future Interest Compromise (date of Q 5. Federal Estate Tax Return Required death after 12-12-82) I~ 8. Decedent Died Testate (Attach Copy of Will) O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (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 First line of address Second line of address City or Post Office State /SL Daytime Tel1ephone Number • +~ ZIP Cade I ~ ~ C_* C`"3 --~ N -c~ I_E r:' .J 'r. .' k ri c p ~~ Side 1 L 1505610101 REGISTBRX>F WILLS L7 -{~ ;rSC7 I i:. ~ ~ T'r-I ~ -r-r ~TE FILED 1505610101 J Correspondent's e-mail address: Under penalties of pery'ury, I.dedare 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. Dedamtion 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 JC'Q i t.as-s- L. 13Ra i - A DRESS 1. Real Estate (Schedule A).......... . 2. Stocks and Bouts (Schedule 8) .... . 3. Closely Held Corporation, Partnership ~ 4. Mortgages and Notes Receivable (S~ 5. Cash, Bank Deposits and MisceNanea 6. Jointly Owned Property (Schedule F) 7. Inter-Vivos Transfers 8 Miscellaneous (Schedule G) 8. Total Gross Assets (total Lines 1 tfiro 9. Funeral Expenses and Administrative ~ 10. Debts of Decedent, Mortgage Liabilitie 11. Total Deductions (total Lines 9 and 1 12. Net Value of Estate (Line 8 minus Lin 13. Charitable and Governmental Beques an electioh to tax has riot been made 14. Net Value Subject to Tax (Line 12 mi 150561D1D5 ................................. 1. , ................................ 2. rSole-Proprietorship (Schedule C) ..... 3. :dine D) ........................... 4. s Personal Property (Sdiedule E)....... 5. O Separate Biilaig Requested ....... 6. don-Probate Property O Separate Billing Requested........ 7. rgh 7) ............................. 8. ;osts (Schedule H) ................... 9. r f3 , and Liens (Schedule I) .............. 10. ) ................................. 11. e 11) .............................. 12. s/Sec 9113 Trustsfor which Schedule J) ........................ 13. us Line 13) ........................ 14. s 0 t n TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of tine 14 taxable at the spousal tax rate, or transfers under Sec. 9116 "' "' "' "`~°'° ~"' (ax1.2) X .0_ ~'~ ~ 16. Amount of Line 14 taxab at lineal rate X .0 17. Amount of Line 14 t able at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 e 15. 16. 17. 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610105 1505610105 J REV-1500 EX Decedent's Social Secudty Number REV-1500 EX Page 3 Decedent's Complete Address: File Number /~ jO Gj _~/~ V DECEDENTS NAME ~f ~~~~ • STREET 55 ~ ' -' -3Q ~Y~ ~-~'~-- _ clry ~ srArE ~ zi/ ~'Cl 3 Tax Payments and Credits: 1. Tax Due (Page 2, Lme 19) 2. Credits/Payments A. Prior Payments ~/ D'. O'a~i~ B. Discount 3. Interest (1) ~~ Total Credits (A + B) (2) ~©, G~ r ri 4. If line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FNI in oval on Page 2, Line 20 to request a refund. (3) q (~) ~ f-i ---- 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS 8Y 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 :............................................................................... ........... ^ r us! b. retain the right to desgnate who shaA use the property transferred or its income :................................. ........... ^ ~ ' c. retain a reversionary interest; or ................................................................................................ ^ r vt Y~ ............... d. receive the promise for life of either payments, benefds or care? ........................................................... ........... ........... ^ . 2. K death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate considerafan? .............................................................. . ^ 3. Did decedent own an "in trust for" or payable-upon-death bank awoun# or security at his or her death? ... ........... ^ 4. Did decedent own an individual retirement account, armuity or other non-probate property, v~Rrich contains a beneficiary designation? ................................... ^ 1:7~ IF THE ANSWER TO ANY OF THE ABOVE QUESTWIiS 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 perct~tt [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rah imposed on Uu; net value of trar~fers to a for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The sta#ute does not exempt a transfer to a surviving sparse from tax, and the statutory requirements for disclosure of assess and filing a tax return are sUN applicable even if the surviving spouse is the orUy beneficlary. For dates of death on w after July 1,2000: • The tax rate imposed on Use 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 s#epparent of the childd is 0 percent [72 P.S. §9116(a}{1.2)]. • The tax rate imposed on the net value of trans#ers to or for the use of the decedent's lineal beraficiaries 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 bbod or adoption. C~Op17 I, JOSEPHINE R. BROWN, of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. I. I give, devise and bequeath all of my estate of every nature and wherever situate to my son, FORREST L. BROWN, providing he shall survive me by thirty days. Il. Should Forrest L. Brown predecease or fail to survive me by thirty days, I give. devise and bequeath all of my estate of every nature and wherever situate to my sister, CONSTANCE E. HILL and my brother, WILLIAM B. BROWN, in equal shares, or to the survivor of them living on the thirty-first day following my death. III. All federal, state and other death taxes payable because of my death, with respect to the property forming my gross estate for tax purposes, whether or not passing under this !, will, including any interest or penalty imposed in connection with such tax, shall be considered a i part of the expense of the administration of my estate and shall be paid out of the principal of my estate without apportionment or right of reimbursement. IV. I appoint my son, FORREST L. BROWN, executor of this my last will. Should my son fail to qualify or cease to act as executor, I appoint my friend, CHARLES E. HALL, JR., as executor of this my last will. C~Oo pl7 V. I direct that my executor or his successor shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~ S~iflK~~Ct ~ 2GoY. of , (SEAL) JOS PHINE R. BROWN The preceding instrument, consisting of this and one other typewritten page identified by the signature of the testatrix, JOSEPHINE R. BROWN, was on the day and date thereof signed. published and declared by JOSEPHINE R. BROWN, the testatrix therein named, as and for her last will, in the presence of us, who, at her request, in her presence, and in the presence of each other have subscribed our names as witnesses hereto. ~` - .~ ~ ~: /' ~l yf~f .Q i ~04'G ~~irtJ"~sic/ /2~ ~~it,d rv~'i~r ~ / 3 3 Z.LJ ~~" YD % ~~~.~ ~~ ~~Sid'~,~~~ ~i~ /~~3~~ y REV-1502 EX+ (8.98) SCFItDUL~t A , ,, . coMMONwEALTN OF PENNSYLVANU REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~ ~ FILE NUMBER All ~prop~ ty o naao S~ D or a a bnan~ common must ba nportad at fair markN valve. Fair market value ~ ~ ~at whk~©n would be exchanged between a wallop buyer and a willing sailer, neuller trairq compelled to buy a eeu, troth having reseauible knowledge of tlw relevant tads. Rest properly whleh Ia jolnUy-owned wMh rlpht of i}urvivorehlp moat bra dbclased on Schedule F: iTr:u VALUE AT GATE t. ~in~l~,~(,irn~l~ plw4.lirns ~~ 8,3o~r^Gm~~+n'~-tr~ti+, 175,000.00 Cc,~ ~~,~-~ , P~ i7u~3 . ~~~~ boob ~~-01 ~c~~e 3~ ~"SS~ SSoCS Pin Cc I ~ oCr.-19 - /LY3 - /~3 Y ' '. .' ~ ~ n TOTAL (Also enter on one 1, Racapitialatlon)~S 17 S U o D . y o m mac apace s needed, k,ea,t.daaonr eheele m ~. s.nle elu) 1 s. w. B.ma Real t~aa i Appoleel 8ervicee Ar a. oa-01>ro 4~/~/. 4 1 . ewT^-w• IAIt111am 8. t>•niea, tcequin Y WNt Miph Street CerlkN, PA 1701 FYe Number: Oa-012a In accoMance with yourrequsst, I haw appnipad the real property at: ' t10 FranWin Street " Grlble, PA 17013 The Purpose of th4 pPPti~ ~ to develop an opinion of tM daAned valve of the subject property, a Improved. The property rights appraised are the fie simple intrtrest In the site and Improvements. In my opinion, the defined velus of the property as of Febrwry 1, 200a la: 1176,000 _ One Hundred Seventy-Five Thouearei Dollere The attached report eontaine the dacript(ort, analysis End supportive data for the conclusions, final opinion of velue, descriptive photographs, assignment conditions and appropAab certMiatlons. ". RnPectfuli~y wbmHad, 8bven W, Berra, SftPA, 8811, ASA CertiSed Oier»ral Appraher HEV-1508 E%. (7-9~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ~reN°° Indude the proceeds of litigation and the date the proceeds were received by the estate. All propNty Johltlyy.owned vIINh tM right of wrvivorahip must be discbsed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH L ".fie, / c..: }' _ a ~ .W ' 4 .P ... Y N~ "~* ~ t.~ f "~ .. .d . "nr' ~ ~_i ,(F~. t6a~ ~ y !Y d ~ Ja f F . : ~i e /..0'1 _ ~~~y JAI :"" v . .. ~ ,.~,ra ~, ~s ,~'1 ~ { y ~, .a.., J I I ~ more space is needed, insert TOTAL (Also enter on line 5, Recapitulation) I S a ,~;,'~ , ~'. ~;.:~j I ~. r sheets of the same size) .~'~~ , ~.~~~ ..rte" ~, ~:-a.; .~ ,~ ,~- jf ~ ~ `; ~ ~ ~ ;, ,~ r i 1 ~ ~~ I r a s i ~ ~ ~ 01 '~ r /4 ~ zd yLr (/ fj,~ ~ . -. i --- (~ ~ _ { it ~ i~ ~ O~ r t O"'G/ ~ ~ l ~ ^ O ~~ ~, ~~~^ .~ a~ c~ ~~ p'`' I ~ ... r ii~ j ! ~~ i Cy r ~~ ~ f ~ _ __ ~Q ~,. ~; ;i ~~ . . ._. ~ Li ~/ /n-~'' (//J ll ...~~2K~~ I C~Oti~- > . ti ,~ / -- ~T _ -- ------ . j C~~"!l/Y .~~-.J~~i'/Lice .Gf["~~Cs~ ---~V -.J i! ~ i r '' - ~i ~ ~~ t, ~ --- i ~ /~ ,e~i w~ - / ~ , - ~, - I ~~~..~t..~,.~~ ~r-~~.~~2 Ate. -- - i ' d`' ~ -- i ~ r ~ ~ -~-a~c ~~ ~' -- ;, ,J i ~ _---~-~ - ~L'i _ - ,~ w _Gs G ', .. 41~ ~ V ii _ i' ~ - I' ~, f -~y~ ~~ f ~` ~ ~ I ~_ i~ i, ., ~~ ~~~~0'~~ j ~i i ~ ' ,~ ~ _ G 'I ;~ ~~ ~ ~, ~~ r i ¢,.. i 7 I nn'' I' K~~~ I 7' ~I ~ '~~ AI~~ ' ' ~i~ ~ ~~ ~7~ri~iY~~gr~~~..~K~ ~ L1 ~ ~v~4 / ~ = ? ` r! /~ ~ ~, ~. r ~~ ~ . . ~ ~ ,~ ~ 11 ~~~ ~ ~ ~ l~ ~, ~~ y` , ~~ /~Z - ~, /o ~~ r ~ ~~ ~t~ ~ tZ7 ~ . ~ - ~r ~~"~ Ij ~'!'~ '7 i~ ~~ _ ~ r l7 ~ ~~.. ~~ ~ ~ ~ -- r ~G -- - c. '~ ~~ ~d ,~ - ,~ ~ - -''' r„ ~-. :.:. ~~ i ~~ ~ ~ ) 4 ~ _ ~~~/ i I ~. t~ , .~~.• !rr~ r' /~ ~: ~"'" ~~114 ~~ ~.-~-.~ ~ ~~ ~~ D ~/ .~ ,, ~ -_.. ~y~ mow: e : ~'~iL/. ) -- _ ~~ ~ _ _ _ ____ ~ _ __-.- --------- r ~~-G,.~ ~~C G:iiri?aGGC~ - ~ ¢. ~~ ~~' _. _ _T, --- __ _. _.. ~ - /' ,. r -- -~- ~ t Ir r ~~ r~ ` -_ - -- - --' ~~~ / 2 L~ /~ • --- 1, 005.00 + ~ eo~•oo+ ~f 318.00 + X77 388.00 + 106.00+ ~, _. _.. ^ 1\ ..~.~. ___ _ _.. YV-- ~ gQ~~ aG /x __~ gp~ - - ~ - ' _ 2~6P4• 0 • * ------- - __ ---, -- -- -- ___. -----------~ r __ Re~~scs cx • ti.sn SCHEDULE F COMMONWEALTH OF PENNSI ~VANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ..~'~ ~ N an asset was made Joint within one year of ttis dscedsrd':dab of datll, M must De nporbd on Schedub G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. ~ C'^~ <• „~ ~ ' 4 9 a ~ ,.. ~,...' .~"~.- ~ ;6 ;~ ~ f ~ ~~ B. ~~~ C. JOINTLY-0WNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of finandal InsfiWdon and yank aorqurd number ar similar klantHylnp number. Attach deed for jointly-fleldte~aetBM DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST DATE OF DEATH VALUE Of DECEDENT'S INTEREST 1. A. +~'1 `~~ y /m/// p ` ~ /(~'j ~~ y~Jrv.:. °r~ r~` ~ J '~._ ,`•f ~* ~ TT ~ ~ v.~`J] ~j'~/r.V lil~ V T~ ~r ~~~ ~) ~~ 1 4 -.. 7 ~~ / ) `~ J ~~ - ' ~'°`~,. ~ ~I^+ ~s w,/~~ ~. T V ~ .,Y ~, 1.J °'% 3 r .. `'~ 9 6~. F ..~~I ~ M.~ ~!.aA ~.:J, isa' ./~~`S ii + ~~~ s y .. ¢. {}~Jh ,y~ iA' 4.+L ~. ~~ .nT 1~`. . +~~ .~ 1 /y~- ~ ~~ `, s^f A T~ ,r- t .~..~~,•...'.. v~.w~v~~m~v v, ~~w0'J~IYIOYVII~ ~ ~/s / J ~/~, 'p (It` RI018 S~CB IS fISEdBd, In88fl addlbOR21811~3 Of tllB BFUne SIZE) / PENNSYLVANIA INHERITANCE TAX PNC BANK NA provided the Department witA the inf ormetion below, which has bean used in eelculatinp tho potential tax due. Records SndieaL• that •t th• death of the above-nomad decedent. you ware a joint owner/banal ieiary of this account. If you teal the information is incorrect, please obtain written correction from the finanei el institution, attach a copy to this ton and return it to the above address. This account is taxable in accordance with the Inheritane• Tax laws of the Commonwealth of Pennsylvania. Please call (71'7) 707-p3't7 with questions. COMPLETE PART 1 BELOW A SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 09-0138 Po cox zeoeol TAXPAYER RESPONSE ACN 09113359 FNRRISBUR6 PA 17120-0601 DATE 03-09-2009 ssv-isa ex Irv coe•en TYPE OF ACCOUNT EST. OF JOSEPHINE R BROWN ^ snvINSs SSN 186-24-9794 ^ CHECKING DATE OF DEATH 02-01-2009 ~ TRUST COUNTY CUMBERLAND ® CERTIF. REMIT PAYMENT AND FORMS TD: FORREST L BROWN REGISTER OF WILLS 1243 FRANKLIN ST CUMBERLAND CO COURT HOUSE CARLISLE PA 17013-4909 CARLISLE, PA 17013 Account Balance ~ 20,457.85 payment to the Register of Wills. Make cheek payabl. to "Reps ater of Wills. Agent". Percent Taxable X 50.000 $ 10,228.93 NOTE, If tax payments era ^ade within throe AIIIOUnt Sub~act to Tsx months of the decedent's date of death. Tax Rate )( . 045 deduct -a 5 perunt discount on the tax due. $ 4 6 0 .3 O Any Inheritance Tax due will become delinquent Potent181 Tax Due nine months after the date of death. P~T TAXPAYER RESPONSE 1 A. ~ Ths above information and tax due is correct. Remit Deyment to the Reoister of Wills with two copies of this notice Lo obtain CHECK a discount or avoid interest, or ehaek box "A^. and return this notice to the Rspister of ONE Wills and an official assessment will be issued by the PA Department of Revenua. BLOCK B.~ The ebova asset has boon or will 6e reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the estate reprosentative. C. ~ Tha ebova inforr~~^~~ ttion is incorrect and/or debts and deductions ware paid. Cwplet• PART ~ and/or PART ~ below. PART If indicating ^ different taz rata, plaasa state relationship to decadent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Establishod 1 2. Aetount Balance 2 3. Parcant Taxable 3 X 4. Amount Subject to Tax 4 5. Debts and Deductions 5 - 6. Amount Taxable 6 7. Tax Rata 7 X 8. Tax Dua 8 $ ~ P~T DEBTS AND DEDUCTIONS CLAIMED 3 Account No. 000031300310562 Data 02-22-2007 io ensure proper credit to the account, two Establishod copies of this notiu oust aeeomparor Under penalties of periury. I declare that the facts I have reported above era true, correct and complete to the bast of my knowledge and belief. HOME C ) WORK C ) '~~ TAXPAYER SIGNATURE TELERHDNE NUMB R DATE DATE PAID PAYEE DESCRIPTION AMOUNT PAID PENNSYLVANIA INHERITANCE T INFORMATION NOTICE lUREAU OF INDIVIDUAL TAXES AND PD aox zaoeol TAXPAYER RESPONSE HARRISEURG PA 17128-0601 eev-ssca cx acv :os•eu FILE N0. 21 ACN 09108158 DATE 02-12-2009 TYPE OF ACCOUNT FORREST L BROWN PO BOX 1062 CARLISLE PA 17013 EST. OF JOSEPHINE R BROWN SSN 186-24-9794 DATE OF DEATH 02-01-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORKS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 ® savlNGs CHECKING ^ TRUSr CERTIF. MEMBERS 1ST FCU provided the Department with the infonation below, which has bean used in celeulatine the poNntial tax dw. Records indieats that at the 'death of the above-nand decadent, you ware a joint ownarlbeneficiary of this account. If you feel the infonation is incorrect, please obtain written correction frw the financial institution, atteeh a copy to this fon and return it to the above addreaa. This account is taabl• in aeeordence with th• Inheritance Tax laws of th• Conmonwealth of Pennsylrenia. Piease call CT17) 717-aS27 with nuestiors. COMPLETE PART 1 BELOW ^ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 50698-05 Dat• 09-28-1998 T Account Balance Percent Taxable Amount Subject to Tax Tax Rate Potential Tax Dua Established $ 2,866.39 X 50.000 S 1,433.20 X .045 $ 64.49 rani f o ensure vroper credit to the account, two eopiea of this notie• mu:t accompany payment to the Register of Wills. Mak• check payable to "Register of Wills. Agent-. NOTE: If to payments era made within three months of the decedent's date of death. deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinouent nine months after the data of death. A. ~ The above infonation and tax duo is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or chock box "A" and raturn this notice to the Register of Wills and an official aasassment will be issued by the PA Department of Revenue. CHECK ONE BLOCK ONLY PART a TAX The abova asset has baan or will be reported and tax paid with the Pennrilvania Inhoritanea Tax raturn to be filed by the estaN representative. C. ~ Tha abova infor ion is incorr et and/or debts end deductions were paid. Complete PART 2A and/or PART 3~ balov. If~indicating m different tax rata, please state relationship to decedent: RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Gate Established 1 2. Account Balance 2 ~ 3. Percent Taxabl• 4. Amount Subject to 7sx 5. Dobts and Deductions 6. Amount Taxabl• 7. Tax Rate 8. Tax Duo 3 X 4 5 6 7 X 8 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION ~ AMOUNT PAID rorAL CEnter on Lino 5 of Tax Computatlon) t Under penalties of perjury, I declare that the facts I have raportad abova era true, carrmct and complete to the best of my knowledge and belief. HOME C WORK TAXPAYER SIGNATURE TFI FPHONF NIINBFR na F INFORMATION NOTICE BUREAU OF INDIYIDIML TAXES AND FILE N0. 21 Po cox zeocol TAXPAYER RESPONSE ACN 09108159 Fy1RRISBUR6 PA 17128-0601 DATE 02-12-2009 acv-tsa oc ecr coe-ou PENNSYLVANIA INHERITANCE TAX EST. OF JOSEPHINE R BROWN SSN 186-24-9794 DATE OF DEATH 02-01-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST ® CERTIF. MEMBERS 157 FCU proviQed the Dapartaent with the inforwetion boles, which has bean used in ealeulatine the potential tex due. Records indicaL that at the death of the above-need daeedent,you wero a joint owner/beneficiary of this account. If you foal the infonation is incorrect, plaaae obtain written correction frees the finanelal institution, attach a copy to this fen and return it to the abovo address. This account is taxable in accordance with the Inheritance Tax lava of the Coawom,eelth of Pennsylvania. Pleasecall 1717) 7a7-4327 with questions. COMPLETE PART 1 BELOW ^ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 50698-44 Data 09-28-1998 T Account Halanee Parent Taxable Amount Subject to Tax Tax Rate Potential Tax Due Established $ 21,780.17 X 50.000 $ 10,890.09 X .045 S 490.05 o insure proper erep,c co cna account, two envies of this notice wust aecowpary pavwant to the Re0lster of Wills. Make chock payable to "Register of W311s, Agent". NDTE, If tax paywents an ^sde within three wonths of the decedent's data of death, deduct a 5 percent discount on the tax due. Any Inhe ritanc• Tax due will becowe delinquent nine wonths of tar the date of death. 2. Account Halanco 3. Percwnt Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rata 8. Tax Du• LINE 1. Date Established 1 - A. ~ The abovo inforwetion and tex due is correct. Rawit paywent to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest. or check box "A" and return this notice to the Register of C ONE ~ Wills and en official assesswant rill be issued by the PA Departwent of Rovonuo. BLOCK B. ~ The shove asset has been or -w ill ba reported and tax paid rith the Pennsylvania Inheritance Tax return ONLY to be f31ed by the estate npnsentat ive. C. ~ Tho abovo infor~~a_~tion is ineorr ~ct and/or debts and deductions ware psid. Cwplet• PART LJ and/or PART IJ below. PART If indicatlnH a dlffarwnt tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS 2 3 X 4 5 6 S 7 X 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Lino 5 of 7sx Cowputation) ~ Under penaltlws of perjury, I declare that the facts L have reported abovo are true, correct and eonpleto to the best of wy knowledge and belief. HOME C ) WORK ( ) TAXPAYER S GNATURE TFI FPHf)NF NIIMAFR nAT~ FORREST L BROWN PO BOX 1062 CARLISLE PA 17013 ' PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 Po Box zeosal TAXPAYER RESPONSE ACN INRRISBUR6 PA 17128-0601 09108160 acv-csss~arv cos-eu DATE 02-12-2009 EST. OF JOSEPHINE R BROWN SSN 186-24-9794 DATE OF DEATH 02-01-2009 COUNTY CUMBERLAND REMI7 PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST ® CERTIF. FORREST L BROWN PO BOX 1062 CARLISLE PA 17013 MEMBERS 1ST FCU provided the Departaant with the intonation bales, which has boon used in ealeulatin6 the potential tax des. Records indicate that at the death of the above-named decedent, you were a saint owner/bsrofioiary of this account. If rou feel the intonation is incorrect, please obtain written correction frog the financial institution, attach a copy to this ton end return it to the above address. This account fs taxable in accordance with the Inks ritane• Taz laws of the Coaomrealth of PannsYlvanir. Please call (717) 767-8]27 with questions. COMPLETE PART 1 HELOW r SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 50698-45 Data 09-28-1998 T Account Balane• Percent Taxablo Amount Subject to Tax Tax Rate Potential Tax Due Established 21,448.26 X 50.000 $ 10,724.13 9 rnmi J LINE 1. Date Established 0 ensure proper credit to the account, two copies of this notice oust aeeoaosror payaent to the Ra6lster of Wills. Make cheek payable to "Register of Wills, Agent^. NDTEc If tax peyaents era made within three months of the decedent's date of death. deduct a 5 portent discount on the tax due. Arty Inheritance Tax due will becoae delinquent nine aonths after the date of death. A. ~ Tho above information end tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C HECK a discount or avoid interest, or check box "A" and return this notice to the Register of ONE Wills end an official assessaent will be issued by the PA Departaent of Revenue. BLOCK ~ B. ~ Tha above esaet has bean or w311 ba reported and taz void with the Pennsylvania Inheritance Tax return ONLY to be filed by the estate npn sentative. C. ~ The above info a ion is ineorre and/or debts and deductions wore paid. Complete PART ~ and/or PART 3 below. PART If indicating a different tax rata, please state a ralationshlp to decadent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS 2. Account Balance 3. Percent Tmxable 4. Amount Subject to Tax 5. Debts and Deduetiona 6. Amount Taxablo 7. Tax Rste 8. Tax Dua 1 2 g a X 4 $ 5 6 7 X a $ PARr DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID i TOTAL CEntar on Line 5 of Tax Computation) Under panaltiea of perjury, I declare that the facts I have reported above are true, correct and complete toth• bast of my knowledge and belief. HOME C ) WORK ( ) TAXPAVFR CTf:NATIIRF TFI FPNfINF NIIN RFR f1A TF INFORMATION NOTICE ' ' puREAU OF INDIVIDUAL TAXES AND Po cox zepsol TAXPAYER RESPONSE FMRRISEUR6 PA 17128-0601 esv-lass sx AFr <ee-ou PENNSYLVANIA INHERITANCE TAX EST. OF JOSEPHINE R BROWN SSN 186-24-9794 DATE OF DEATH 02-01-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: TYPE OF ACCOUNT SAVINGS CHECKINg TRUST ® CERTIF. FORREST L BROWN REGISTER OF WILLS PO BOX 1062 CUMBERLAND CO COURT HOUSE CARLISLE PA 17013 CARLISLE, PA 17013 MEMBERS 1ST FLU proridtld the Oepartaant with the inforaation below, which has bean used fn calculating the potential tea duo. Records indieat• that at the death of the shove-need decadent, you ware • ioint owns r/beneficiary of this account If You foal the infonation is incorrect, Dlaasa obtain written corraetion frog the finaneiel institution, sttseh a copy to this fora and return it to the above address. This account is taxable in seeordenca with the Inharitane• Tax laws of the Couonwealth of Pennsylvania. Please call Q17) 707-8327 with auostions. - COMPLETE PART 1 BELOW a SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS C ONE BLOCK !. ~ Tha abovo asset has boon or will be reported and tax paid with the Pennsylvania Inheritance Tsx return ONL Y to be filed by the estate raps sentative. C. ~ Tha abovo info ion is incorr et and/or debts and deductions were paid. Complete PART r 2 and/or PART 3~ below. PART If indicating a different tax rata, ploas• state relationship to decodent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS Account No. 50698-52 Dat• 09-28-1998 To ensure proper credit to the account, two Established copies of this notice oust aeeoaparo Account Balance ~ 21 215 29 primant to the Register of Wills. Make chock " . . payable to Register of Wills, ApenL". Porcant Taxable X 5D.OD0 Amount Subject to Tax ~ 1D 607 65 NDTE, If tax priunts an ^ada within three . , aonths of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential Tax Due $ 4 7 7.34 Any Inheritance Tao due will becoae delinquent nine aonths after the data of death. P r TAXPAYER RESPONSE ~ 1 A. ~ The above information and taz due is correct. Remit priaent to the Register of Wills with two co pies of this notice to obtain CHECK a diacount or avoid interest, or chock box "A" and return this notice to the Register of Wills and en official assessment will be issued by the PA Department of Revenue. LINE 1. Date Established- 2. Account Balanea 3. Porcant Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rata 8. Tax Duo PART ^3 1 2 3 X 4 # 5 - 6 T X e $ DEBTS AND DEDUCTIONS CLAIMED Under penalties of perjury, I declare that the facts I have reported above era true, correct and complete to the bast of my knowledge and belief. HOME C. __ ) WORK C ) n FILE N0. 21 ACN 09108161 DATE 02-12-2009 DATE PAID PAYEE DESCRIPTION AMOUNT PAID PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND PD emc zeosol TAXPAYER RESPONSE INRRISBURG PA 17128-0601 REV-156b E1[ AFP [ee-ee) FILE N0. 21 ACN 09108162 DATE 02-12-2009 FORREST L BROWN PO BOX 1062 CARLISLE PA 17013 EST. OF JOSEPHINE R BROWN SSN 186-24-9794 DATE OF DEATH 02-01-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAYINGS CHECK LNG TRUST ® CERTIF. MEMBERS 1ST FCU - provided the Oepertmant with the intonation below, which has bean used in dlculatine the petentiel tsx duo. Records indieat• that at the death of the sbovo-naaed decedent, you were a ioint owner/bonafieiary of this account. It you fool the intonation is incorrect, please obtain written correction frog the financial institution, attach a copy to this fora and return it to the sbovo address. This seeount is taxable in aceordenee with the Inheritance Tax laws of the Comaonwealth of Pennsylvania. Plena call C717) 767-8327 with questions. COMPLETE PART 1 BELOW ^ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 50698-53 Dat• 09-28-1998 To ensure proper credit to the account, two Established copies of this notice oust aeeoapa[N Account Belanc• $ 21,.078.30 vayment to the Register of Wills. Make check " payaDl• to Raaistar of Wills, Agent". Percent Taxable X 50.000 Amount Subject to $ 10,539.15 NaTE) If tax psyments era made within three Tax months of the decedent's date of death. Tax Rate X .045 deduct a 5 percent discount on the tax due. Potential TaX Due Anv Inheritance Tax due will becoae delinquent #` 474.26 nine nonths attar the data of death. P T TAXPAYER RESPONSE ~ 1 A. ~ the above information and tax due is correct. Resit paYmant to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or chock box "A^ and return this notice to the Register of C ONE ~ Wills and an official assessment will be issued by the PA DeDertment of Revenue. BLOCK B. '^ The sbovo asset has bean or will be reported and tax paid with the Pennsylvania Inheritance T t ONL Y ax re urn to be filed by the estate representative. C. ~ Tha above Snfor a ion is ineorr ct and/or debts and deduction r id a s wa e pa . Complete PART 2 snd/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Dat• Established 1 - 2. Account Halanco 2 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 6. Amount Taxable 6 ~ 7. Tax Rata 7 X e. Tax Duo 8 ~` PART DEBTS AND DEDUCTIONS CLAIMED a DATE PAID PAYEE DESCRIPTION AMOUNT PArn WDRK C ) Under penalties of perjury, L declare that the facts I have reported above are true, correct and complete to the bast of my knowledge and belief. HOME ( ) n i PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE 9UREAU DF INDIVIDUAL TAXES AND FILE N0. 21 N11RRI~89UR66PA 17128-0601 TAXPAYER RESPONSE ACN 09108163 asv-tssa sx ova coo-aa DATE 02- 12-2009 FORREST L BROWN PO BOX 1062 CARLISLE PA 17013 MEMBERS 1ST FCU provided ~th• Department with the intonation below, which has bean used in csleulatinp the potential tax due. Records indicate that at the death of the above-nomad decadent, you ware a Joint owns Nbenefieiary of this account. If you Taal the. infonation is 3neorrect, please obtain written correct ion frw the financial institution. attach a copy to this form and return it to the above addrosa. Th1s account is taxebl• in accordance with the Inharltanee Tax laws of the Cowonwaalth of Pennsylvania. Pieasa eels (717) 797-9327 with euaationa. COMPLETE PART 1 BELOW x SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 50698-55 Date D9-28-1998 To ensure proper credit to the account, two Established copies of this notice must aeeompsrer Account Halanc• _~ 30,570.61 pavunt to Nha Register of.Wills. Make chock Dayabl• to Ra9lstar of Wills, A9ant". Percent Taxabi• X 50.000 Amount Subject to Tax B 15,285.31 NOTEI If tax payments era made within throe months of the decedent's data of death, Tax Rate X . 0 45 deduct a 5 percent discount on the tax due. Potential Taz Due g 687.84 Any Inha ri tance Tex due will become delinquent nine months after the date of death. P~r TAXPAYER RESPONSE 1 A. ~ The above information and tax due is correct. Remit payment to the Ra9lstar of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or chock box "A" and return this notion to the Rapister of C ONE ~ Wills and an official aasasamant will ba issued by the PA Department of Revenue. BLOCK 9. ~ Tha above asset has boon or will ba reverted and tax paid with the Pennsylvania Inheritance Tax return ON L Y to be f11ed by th• estate representative. C. ~ Tha above informs ion is incorr Fc~t and/or debts and deductions wore paid. Complete PART ~2 and/or PART 3LJ below. PART If indieatin9 a different taz rate, ploaso state valet! hi t d EST. OF JOSEPHINE R BROWN SSN 186-24-9794 DATE OF DEATH 02-01-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST ® CERTIF. one p o •codent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LIN-e I. Date Establis hod 1 2. Aoeount Balsnce 2 # 3. Percent Taxable ; X 4. Amount Subject to Tax 4 5. Debts and Deductions 5 9. Amount Taxable 6 7. Tax Rata 7 X 9. Taz Du• H ~ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID T07AL CEnter on L1no 5 of lax Computation) Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowlodpe and belief. HOME C ) n i _ / WORK C ) TCI ~~ ` REV•1511 EX+(10.05) 1, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ' RESIDENT DECEDENT SCNiDULE N FUNERAL EXPENSES & ADMINISTRATNE COSTS ESTATE OF FILE NUMBER Qrvwn . ~ws~nh ~ nc. Q. ~ 2/ iae3 ~~ ~ A. B. 1 Debts of drradent must be roported on Schedule L R DESCRIPTION FUNERAL EXPENSES: ' 1. ~wh ~ ~k~S NwsPr~-c~ ~ , .~~ ~9 ~~~ ~~~A ADMINISTRATIVE COSTS:. Peracnai RepresentatNe's Commisafons Name of Personal Repreaentadve(s) Street Address City . Year(s) Commission Paid: 2. 3. 4. 5. s. ~. _ Stale ZIP tv, OL o, 5 ~ ~~ o_~, ~~ L 9 ~j; c~ Attorney Fees Fam~y Exemptlorl: (K decedent's addrea is not the aame as deimant's, attach explanatlon) Claimant Street Addroae . ~y State Zip Relatbnahipnnot Claimant ro De_cendent 1 Probate Fees +L~~ C~~1. ut ' W (~ t~ •Aeeea+~rltbfeea -~ --- - ~7 "~"s I~l,.t S'wr4,nt. ~ -~~-~is~.l t~ls , I ~. IA M V.f/~ I W1'lG~ ~..f,~W J D tv1 ILGv~ '" ~ ~~ ~' (~S ` t~(~l'ti~SC~ off' (?,~iSvn~,l ~1.La~+~ . F~pprct<~sc~l t~' 2ec~( ESQ , ~S Sit J~. -~Z,X' •S~F} I.i ~ ~'F~ TOTAL (Also enter on Iine 9; Recapitulation) S (B moro apace b needed kleat addhidnM attests q Uw aeme size) 13, ~~~ 4a.oo ~~, ,, /J~~. 7S o0 ~U,~ . oG _, . ~,~ "c~~~ ~~ ~i :_ . 8. W. Bamtt tisal txtats i Appraisal Ssrvica """""` INVOfCE "'""""' FIN tixnbar: Oi-012e py00/=000 Wllllam & Danlsls, Esquln ~ ' 1 Want Miph Stnst l,u1NN, PA 17013 Invoiq t : 01.0121 Order Data :. - 03/0612006 Ra6rwlodCsaa i PO Nwllbar: 830 Fnnklln 8lrsst Csrlisls, PA 17013 . Apprnlsal Ssrvios~IGacount of i76. _ 326.00 =•~: ~ _ Imola Total S 326.00 `Stela SaNa Tax ~ S 0.00 S I 76.00) ! Amount Dw _ ~ ) / S 260.00 Tama: PayaWa Upon t~plpt ~ PIaaN, rshnnas Cis flla number ., ~. PNaa Make CMt* PayabN To: S. W. t3smtt t2sal Estate i Appraisal 8srvtoss ,:. 606 South Ftanovsr 8tnst Grtisls, PA 17013 Fad, LD. af: 236616604 YOUR SINGLE SOURCE...ProfNSipM1, t~IIeNM Ssrvico .: . TF4INK YOIJ _ _. + 3,. s,, ,~. REV-1512 EXt (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scNEOU~E i DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER 1 r _ ~i Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed ediwl expenses. ~~~ ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH 1. ,~o.- ' /`^ ~ /'.. Y f ~.' T y~.p. Wn.'. YiV Y" ~ .,,r- ~''w.., ~'r+'' ~~ J/ iY~ Ji.. ~¢y ~~s"~ \ ~ ~M!i~ y~,Ir } y~' f~~~~,yv ,~.. d. ~ ~ Md w t ~ a~w3 ,~,~', t TOTAL (Also enter on line 10, Recapitulation) S I „~~~--.~ ;,~ ~~ I (If more space Is needed, insert additwnal sheets of the same size) ~yi ~ 3/10/11 Chk # Cardiology Diagnostic, LLC $1.82 v Kinetic Imaging $14.79 824 -1- ~ ~ G Z Allyn G. Perkins $78.00 791 Alexander Spring Rehab $15.98 821 $17.02 ~79t; Bronsteirl7effries ~ $22.05 $10.58 759 ~~ Carlisle HMA Physician Manangem $64.49 800 $36.26 784 $27.15 781 +03 $1~~ 861 Carlisle Regional Medical Center . $27.56 780 . $7.83 /~7~i~~~ = 795 802 $18.62 798 ' Cumberland Goodwill FireRescue $83.50 ~~ $434.50 ~ 869 m . Masland Associates $45.00 893 $77.42 797 Millenium Pharmacy Systems $330.41 785 Penn Rehab Assocs $347.27 Cumberland County General Fund $12.00 811 Carlisle Borough Tax Account $5.50 808 ~~~ $755.84 ~ ` ~ Todd Home $4,940.00 '~? $474.04 793 - ~ $159.54• 818 $6.32 \869 West Shore EMS $169.61 787 ' $795.91 801 ' $121.97 ~ ~"" i PPL Borough of Carlicle ~~ ~~ ' $407.00 822 $232.40 823 ~,GG $62.25 82~ ~~ ~4~-;~. o p-Q /3. ~! ~ ~ ~c~oz-os- '~ r ~` " ` ; r:. / ~, 5~9. ~ ,~ ~ . / `__ ,:~ a ~ ~ , ~. fir` ,~,. ~ .~_ ._ -~ i ,.._~i" 4/26/11 Chk # Service/Part Paxton's $185.50 1047 Bathroom Vanity Flooring America $30.74 1048 Bathroom Carpet HomeMender $530.00 Bathroom Demolition $720.00 970 Bathroom Rehab Jones Plumbing $309.54 Toilet removal & Installation 796 ReBath $7,990.00 1000 Bathroom Rehab X9,765.78 "' NAME ADDRI _CITY QUAN ~G' DESCRIPTION N~?y~~ °i/ ~~~~ AMT. ~~ TOTAL ORDER DATE _ DELIVERd' DATE TOTAL TAX GRAND COUNTER TOPS • KffCHENS • CARPET t2~ easT s7AEET CARLISLE, PA 17013 /y J~ '''' C''71~~~z 2``45-2092 /~~~v~ INVOICE. ~G ~~~R _Zl _ /!A J! ! ___ _ - CUSTOMER SIGNATURE ,.:~, ,,. ;~. ,~ 4', ~ J k;~' V ~ Yom. t.,a:'. !~ ~i ~~ " Forrest Brown Sept 18, 2009 P.Q. Box 1062 Carlisle, Pa 17013 Work performed at 830 Franklin St. Remove wall covering and flooring in bathroom of master bedroom. App~`s~aiant to base floor and install 3/4 inch plywood. Install new shutoff valves on supply lines at vanity. Materials and labor: $ 630.00 Paid in full Sept 14, 2009.... Thank you, . ~. ..I''C _, ~%f Bennis Stone Dennis A, Sterne # 5 Persimmon Drive •,k Boiling. Springs, PA, 1700? ~ (717) 258-3089 homemenderdenny@aol.cam -- ~--~ ~1 To: ', Job: ~ ;: , ., ~ , .- ~ " ~ __ u_ ,. ;. -j s / ~ ,.. N ~ ~ ,, f, . ~ ;~~ ~ r.,~ .. +~ ~ i`~ .1~, k ~.. . _._,~ Y Please check: ^ Visa ^ Mastercard ^ Cash ^ Check # ~ ~~'~.~ Card # "~ :~ =~ --- Si nature .- ~ `""~ ~' °"~ ~`1= .!'~ Ex .Date Thahk You foP 11O11t bIISIheSS~ Pay this Amount Total -~ ~, ,~ Jdhes Plumbing, Inc. ~~S pI.UMBIb~ Phone: (717) 249-4714 Fax: (717) 249-0153 INVOICE 354 A Street `O ~p~ fa~ a-mail: info@jonesplumbinginc.com Carlisle, rA 1701 ~l ~ www jonesplumbin5inc.com c ~ ~~ s ~ ~ `: ~.: s = ~ L/U AMieinated Inslsllatmn St:hedale FMease note that r7Mther the Ir7deper7deney owned i9e-Bem Franch7se car Re-Bath, LLC are reaponsbie far stsrtlflnish delays resutl- kg tram events beyond their contrd including, but rot dmded b, acts of nature, governmental actions, manufachmngldelivary deays ~~,~ .'' , ~^~; ` ` ~~ caused by tlWd parties, dsmsge to merchandise. labor atrrceslunrasl Your ffnancirg, any incorrect iniormadon Yau provide. bpel . Start Date '~ v" / - / `~~ ' ~ wroumbrerges on Your property. Your property's ron-conformance wig: zoning regulatiorm or budding txtde requiremenla, hid- derJUnbresesn physical hazardous mndea:s (inedrtlkrg, but not dmibd ro, e~L hazards such as mold, asbestos and lbd " ~ { '~ .- ~= r3~""~ peiN) at Yeur service address. Your noncompibnes weh fhb Agreement, or Cheops Orders. The Independently owned Fie•Betlr Fnish Date: '`vh;. ~ ~.1~ ~.`~,. Frarchbe reserves the fight to terminals urs Agreement andror requhe b:stader b discarWnue tnatatbtion given arty d the Ioregoing corWitl0ne. r.,. ,: "iron"/"Yonr"means the enstomer identified above. 9nstaYation"means the instalation services speegkd in this agreement. 9ndependently Owned Re-Bfrth ffauchise" or"Profb::fanai" moans an btdtrpeaderd ctmtraotor artlrorited by Re-Bath', LLC (Ycen:ed and huared as required by Re-Batlr, lLC and appkable hw) and ibe sontraetor^s emplayeec, agents and sub~ttractors. "AgreemerK" m this Special Servkas/Itoma Improvement Agrttemtmt between Yoe and Tba IndeptlndenBy Owned Re-tialh kanshh~s, (inferolrangeffiI~ referred to as 'Ra-Bath", which ineludea this page, the OeneralTerms and Conditlons fellowhlg ihh page, the State Supplemtad, the Imroice or Spedficstiorw and anon other dot:amtrtri: expressy made a part of this Agreemtfrd. Plwse sea this Apreemeats Reneral Terms and Conditions for additional dtrfbtKbrls. • By signing btrbw, You authtufie (a) The Independtatty Owned Rs-Bath Francht:a to perform ba>at~imr andMr (b)order and arrange fix the deivery of 4~ order mt,rchandise, including special order mortdrandtse that may be custom made, as specgkd th this Agrtremtart. You understand this Agrewntan sonstRutes the en1M understanding btdvreen You and Re-BaBt and may on~r be amended by a Change Order signed by Re-Bath (ar 6y Indepefadently Owned Rs-Batlr FranchBe or is author6ed repre:entatitre oa Re-Bath's behalf) and Yor. This Agreemertt expressly wper- sedes eM prior wrBlen or verbal agreements. or representations made by Rs-Bath, independently Owned Re-Bath Fanchh~e; Yoe, tx arryone site. Except as set forth in this Agreemerd, Yar agroe thero are no oral or written repreaentatbns or Mducements, express or impBed, th any way comllithning thb7 Agrtrerntrm, and Yon expressly dbxlMm theM existence. Do not sign 161atk or incomplete. (Independtnty Owned Re-Bath kanehiee's permNtbtg rotor` motion may need to 6e provided b You later.) By s~ning, Yon at:tcnowbdge that You have read, understand, and accept thi: Agreement th Bs taltirely. Yon further tadmowledge reeehrinp a complete copy. Keep h to protect Your legal rights. pggepted by:: °. Indeperldem Re-Bath & More quplkxble: % 2g5Centetvlleww~~ReBadM t ~m cusron~rssionawm• . , oats n~-299-aezz PAeoosos6:1'he oHitial ngiahvtion number of Re- SUbmgted by: ^ 8sies Asaecgte ^ IaWIx RsprMe 13Nh fk Max can bevnified by calling the Oflfa of the ~,. Attorney (3eaaal d t-88e-.. - __ --_-_. r_.,.~ X ~ .r~ ~~~, .. MwtptdRSOwlaattliurK PNWPRINTYour N7me it Fill sera (9ndr MPdeaMa Bolt Meve i~oaaearerspresemuesa ogmrure ~k. uae oleTnmtmort: White - Re-Bath Copy Yellow -Customer Copy Plnk - Re-t3ath & More Copy Cuebrr:sr Agreernud (2!7/07) ~• state zi i._ Cuaroaterb Daytime Tel. fVo. Customer's C-veNr7p Tel. tVO. Cuetonrerb Ddverb License No. a State MentNkstbn No. .r t3iii To FoRest Brown 830 Franklin St. Carlisle, PA 17013 Quantity Description Rate Amount 7,990.00 7,990.00 Invoice Date Invoice # 12/168009 205641 Torms: Due Upon Rexipt Total 57,990.00 Payments/Cn3dlts 5-1,000.00 Balance Due ( $6,990.00 /~/b ~/ C+~'~ ~~ Please pay from this invoice. Thank you! ~ ;: . 'REV•1513 EX+ (9.00) • ~* ~ SCMEDUL! J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIF,S INHERRANCE TAX RETURN 9 RE310ENT DECEDENT ESTATE OF FILE NUCIIBE ~ovJn _Jns~ h~n.~ e. ~G - RELATIONSHIP TO DECEDENT AMOUNT SHARE NUMBER NAME AN4 ADDRESS OF PERSON(S) RECEIVING PROPERTY ~ Do Not List Trustss(s) OF ESTATE I TAXABLE,DISTRIBUTK)NS (irldude ouMght spousal distributions, end hensfe-s under Sec. 9118 (e) (1.2)) _ L f? - ~ ~t3 ~~ ~r„~ S-~- • Po. box /oU~, Cc~ 1~51~., PA ~?rar3 II I~ ENTER DOLLAR AMOUNTS FOR. DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1600 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIpNS ON LINE 13 OF REV 1500 COVER 6HEET s (N more epsa is neede4 trlsat alddlUorlsl shseb of t11e sems siu) - • ~.._ y~~'