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HomeMy WebLinkAbout11-07-11 (2)1505610105 REV-1500 ex toZ_,,, tFt, PA Department of Revenue pennsytvanla OFFICIAL USE ONLY Bureau of Individual Taxes `"""'"`"~°`"`°`""` County Code Year File Number PO Box zso6oi INHERITANCE TAX RETURN ~ I ~ ` O ~ f d Harrisburg, PA 1~1z8-o6oi RESIDENT DECEDENT I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW 199-12-7297 02/27/2011 06/22/1926 Decedent's Last Name Suffix Decedent's First Name MI REBOVICH LOTTIE g i;lf 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 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW m 1. Original Retum ,_ ~ 2. Supplemental Retum ~ ~~ 3. Remainder Return (Date of Death Prior to 12-13-82) ~~! 4. Limited Estate ~,- ~ 4a. Future Interest Compromise (date of ~ ^~ 5. Federal Estate Tax Return Required death after 12-12-82) ~~ 6. Decedent Died Testate ~~ ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safa Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) ~~~ 9. Litigation Proceeds Received ~= ~ 10. Spousal Poverty Credit (Date of Death ~ ^~ 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number THOMAS D. GOULD, ESQUIRE n _.. First line of Address 2 EAST MAIN STREET Sewnd Line of Address City or Post Office SHIREMANSTOWN State ZIP Code PA 17011 Correspondents s-mall address: askalawyefpa17011 @yahoo.COm ~-- O .~_ -_,. REGISTER W SSE ONLY ' ~ ~`-j:j-- :~ ---t -n -1 r_.e, ~ . ~ `~~ DATE FILED `"` 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 wmplete. DeGaretion of preparer other than the pen;onal representative is based on all information of which preparer has eny knowledge. SIG~NyA~T~URE OF/PERSON RESPONSIBLE FOR~ILING RETURN ~t~ • DATE V " ADDRESS 1072 LANCASTER BLVD UNIT #13 CAMP HILL, A 17011 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 1505610205 REV-1500 EX (FI) Decedent's Name: Decedent's Social Security Number ~ ~~ ~~ .. ~ ~~ RECAPITULATION 1. Real Estate (Schedule A) ............................................. L ~~-- ~ ~ J~ ~ ~~ • ~ U 2. Stocks and Bonds (Schedule B) ....................................... 2 '~ (~ 7 ~. ~ / 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. ~~ Q d Q , ( J Q 6. Jointly Owned Property (Schedule F) ~~ Separate Billing Requested ....... 6. / n ~ ~ 3 ~ , 6 t'/ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~^ Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7j ..................... ........ 8. ~ ! g2~ ~ II f~ • 4D~ 9. Funeral Expenses and Administrative Costs (Schedule H) ........... ........ 9. ~~ f ~~'~ 1 / 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ....... ........ 10. 7i ~/y(~ , ~, Q 11. Total Deductions (total Lines 9 and 10) ......................... ........ 11. j3~ 567. 7g' 12. Net Value of Estate (Line 8 minus Line 11) ...................... ........ 12. 3 y3, 3D ~ / 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which I an election to tax has not been made (Schedule J) ................ ........ 13. 14, Net Value Subject to Tax (Line 12 minus Line 13) ................ ........ 14. ~ / i 3 7 ~. ~ t,! TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 ~~ 7 ~ ~ ~ 3 ~ 3 Q 16. !` 3 S~Q, 7 17. / Amount of Line 14 taxable > at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 Decedent's Complete Address: Flle Number 2~- lI - d 3iv DECEDENT'S NAME ' Lo7-riF ~ . ~d8a11~~ ~~ STREET ADDRESS 3 ! s~ssex r2©ad CITY ~ ~ ~,, I ~ STAT~~ ZIP ~0 ~ / Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments _ B. Discount 3. Interest 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. c5) 3: s~o. ys 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 No a. retain the use or income of the property transferred .............................................................................. ............ ^ b. retain the right to designate who shall use the property transferred or its income ................................ ............ ^ c. retain a reversionary interest .................................................................................................................. ............ ^ d. receive the promise for life of either payments, benefits or care? .......................................................... ............ ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................................. ............ ~._.~ 3. Did decedent own an "intrust for~ orpayable-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)J. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 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(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. (1) Total Credits (A + B) (2) (3) (4) REV-1502 EX+ (11-08) ~~'~ji ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER LOTTIE S. REBOVICH 21-11-0310 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged 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 that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1~ 31 SUSSEX ROAD CAMP HILL CUMBERLAND COUNTY PENNSYLVANIA 105,000.00 TOTAL (Also enter on Line 1, Recapitulation.) ; 105,000.00 If more soace is needed. insert additional sheets of the same size. .Illd))`~ OMB Approval No. 2502-0265 ,I-Illi~~,,,; A. Settlement Statement (HUD-1) 1. ^ FHA 2. ^ RHS 3. ^X Conv. Unins. 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: 4. ^ VA 5. ^Conv. Ins. 11278 57012588880 C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agents are shown. Items marked "(p.o.c)" were paid outside the closing; the are sh h y own ere for informational purposes and are not inclu ded in the totals. D. Name & Address of Borrower: E. Name & Address of Seller: F. Name & Address of Lender: Douglas Tierney 10 Sna Lane, Mechanicsburg PA 17055 Estate of Lottie Rebovich, Estate of Lottie Rebovich Fulton Bank , Rebovich One Penn Square 304, Lancaster, PA 17602 G. Property Location: 31 Sussex Road H. Settlement Agent: I. Settlement Date: 09/2V2011 Camp Hill PA 17011 1st Advantage Settlement Services Inc. Disbursement Date: 09/2'V2011 , Lower Allen Township 6375 Mercury Drive, Suite 102, Mechanicsburg, PA 17050 Telephone:717-591-7755 Fax:717-591-7756 Place of Settlement: 6375 Mercury Drive, Suite 102, Mechanicsburg, PA 17050 TitleExpress Printed 09/20/2011 at 4:29 pm by VW 7a0. Gross Amount Due from Borrower 400. Gross Amount Due to Seller 101. Contract sales price 105,000.00 401. Contract sales price 105 000 00 102. Personal ro art 402, Personal ro art , , 103, Settlement charges to borrower (line 1400) 4,448.44 403. 104. 404. 105. 405. Ad'ustments for items aid b seller in advance Ad ustments for items aid b seller in advance 106. Cityltown taxes to 406. Cityltown taxes to 107. County taxes 0912112011 to 1213112011 132.76 407. County taxes 09/21/2011 to 12131/2011 132.76 108. School Taxes 09/21/2011 to 06/30/2012 695.09 408, School Taxes 09/21/2011 to 06/30/2012 695 09 109. Sewer/Trash 09/2112011 to 09/30/2011 9.10 409. SewedTrash 09/21/2011 to 09/3012011 . 9 10 110, 410. , 111. 411. 112. 412. 120. Gross Amount Due from Borrower 110,285.39 420. Gross Amount Due to Seller 105,636.95 200. Amounts Paid b or in Behalf of Borrower 500. Reductions In Amount Due to Seller 201, Deposit or earnest money 2,000.00 501. Excess deposit (see instructions) 202. Principal amount of new loan(s) 65,000.00 502, Settlement charges to seller (line 1400) 12,890.00 203. Existin loo s taken sub'ect to 503. Existin loans taken sub'ect to 204. 504. Pa off of first mort a e loan 205. 505. Payoff ofsecond mortgageloan 206, 506. 207. 507. 208. 508. 209. 509. Ad'ustments for items un aid b seller Ad'ustments for items un aid b seller 210. Cityltown taxes to 510. City/town taxes to 211. County taxes to 511. County taxes to 212. School Taxes to 512. School Taxes to 213. 513. 214. 514. 215. . 515. 216. 516. 217• 517. 218. 518. 219• 519. 220• Total Pald b Ifor Borrower 67,000.00 520. Total Reduction Amount Due Seller 12,890.00 300. Cash at Settlement fromlto Borrower 600. Cash at Settlement tolfrom Seller 301. Grass amount due from borrower (line 120) 110,285.39 601, Gross amount due to seller (line 420) 105,836.95 302. Less amounts paid by/for borrower (line 220) 67,000.00 602. Less reductions in amount due seller (line 520) 12,890.00 303, Cash ^X From ^ To Borrower cppl In 43,285.39 603. Cash ^X To ^ From Seller 92,946.95 ~ Displays • curtemiy vans vme contloi numoae, rvo connaenUaUly Is assu is placlc9Ufe Is maecalpry. I ela IS Oe910nee to provlce II1e pahie9l0 a RESPA cpve,001e0nsacllon wile Inlamlallon 4UMp lee selllementpropes9. Previous editions are obsolete Page 1 of 4 HUD-1 ~• ~ -°• rain rrom rain rrom Division of commission Iine700 as follows: Borrower's Seller's 701• $3,150.00 to RelMax1stAdvantage Funds at Funds at 702• $3,300.00 to Re/Max Realty Associates, Inc. Settlement Settlement 800. Items Pa able in Connection with Loan 801. Our ongination charge (Includes Origination Poin10.000°l0 or $O.OD) $695,00 (from GFE #1) 802. Your credit or charge (points) for the specific interest rate chosen $81.25. (from GFE #2) 803. Your adjusted origination charges (from GFE A) 776.25 804. Appraisal fee to Mark Heckman RE A raise $450.00 P.O.C. B` (from GFE #3) -15.00 805. Credit report to Credstar (from GFE #3) 6.97 806, Tax service to from GFE #3 807. Flood certification to Corelo is Flood Services (from GFE #3) 11,50 808. Inspection Fee to Mark Heckman RE A raisers (from GFE #3) 100.00 900. Items Required by Lender to be Paid in Advance Pa e 2 of 4 HUD-1 Previous editions are obsolete 9 r r ~ r r 4,448.44 12,890.00 *Paid outside of closing by (B)orrower, (S)eller, (L)ender, (I)nvestor, Bro(K)er. **Credit by lender shown on page 1. "'Credit by seller shown on page 1. Com arison of Good Faith Estimate GFE and HUD•1 Char es Char es That Cannot Increase HUD•1 Llne Number Our origination charge # 801 Your credit or charge (points] for the specific interest rate chosen # 802 Your adjusted origination charges # 803 7ransfertaxes # 1203 Char es That Can Chan e Initial deposit for your escrow account # 1001 Da+ly interest charges from # 901 $6.9007Iday Homeowner's insurance # 903 Title services and lenders title insurance # 1101 Owner's title insurance # 1103 Loan Terms Good Faith Estimate HUD•1 695.00 695.00 81.25 81.25 776.25 77625 2,100.00 1,050.00 Good Faith Estimate HUD•1 205.00 164.00 600.00 435.00 40.00 6.97 11.50 11.50 100.00 100.00 956.50 717.47 $ -239.03 or -24.9901 °!° Good Faith Estimate HUD•1 2,200.00 434.96 69.01 69,01 400.00 387.00 937.75 978.75 235.00 235.00 Your initial loan amount is $65,000.00 Your loan term is 15, years Your initial interest rate is 3.8750% Your initial monthly amount owed for principal, interest, and any mortgage $476.74 includes insurance is QX Principal ^X Interest ^ Mortgage Insurance Can your interest rate rise? ^X No. ^ Yes, it can rise to a maximum of %. The first change will be on ! I and can change again every years after I i .Every change date, your interest rate can increase or decrease by %. Over the life of the loan, your interest rate is guaranteed to never be lower than % or higher than %. Even if you make payments on time, can your loan balance rise? ^X No. ^ Yes, it can rise to a maximum of $ Even if you make payments on time, can your monthly amount owed for ^X No, ^ Yes, the first increase can be on / / and the monthly principal, interest, and mortgage insurance rise? amount owed can rise to $ The maximum it can ever rise to is $ Does your loan have a prepayment penalty? 0 No. ^ Yes, your maximum prepayment penalty is $ Does your loan have a balloon payment? X^ No. ^ Yes, you have a balloon payment of $ due in years on i 1 Total monthly amount owed including escrow account payments ^ You do not have a monthly escrow payment for items, such as property taxes and homeowner's insurance. You must pay these Items directly yourself. Q You have an additional monthly escrow payment of $145.00 that results in a total initial monthly amount owed of $621.74. This includes principal, interest, any mortgage insurance and any items checked below: ^X Property taxes 0 Homeowner's insurance Flood insurance ^ ^ ^ Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender. Previous editions are obsolete Page 3 of 4 HUD-1 _,~_~~~, ;. HUD CERTIFICATION OF BUYER AND SELLER I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, It is a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction. I further certify that {have received a copy of the HUD-1 Settlement Statement. ~/~ Douglas Tierney ate of Lottie Rebovich ' ' '°°~'°`~i'~ Estate of L tie Rebovich Re ovich7- ' The HUD-1 Settlement Statement which f have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this statement. SETTLEMENT AGENT (~ _ ~ Zl ~/ DATE WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM PENALTIES UPON CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: U.S. CODE SECTION 1001 AND SECTION 1010. Page 4 of 4 HUD-1 Previous editions are obsolete ~ ~ .. Name of Borrower: Douglas Tierney Name of Seller: File Number Estate of Lottie Rebovich 11278 TitleExpress Prepared 0 912 012 01 1 at 9:35 am Note: This page is furnished to give you an itemization of the amounts shown on Lines 1101, 1103 and 1104 of the Settlement Statement (HUD-1 ), This page accompanies but is not a part of the settlement statement. If a discrepancy exists, the information shown on the Settlement Statement (HUD-1) applies. Paid From Borrower's Funds at Settlement Paid From Seller's Funds at Settlement 1100. Title Charges Amounts Induded in Line 1101 1101. title services and lender's title insurance 978.75 a. Wire In Fee $ 10.00 b. EmaillDoc Copy Fee 35.00 c. Overnight Delivery Fee-Package 25.00 d. Notary Fee 35.00 e. Closing Service Letter 75.00 $ 180.00 1102. Settlement or closing fee 1103. Owner's title insurance (policy) $ 235.00 235.00 1104. Lender's title insurance (policy) 648.75 $ 798.75 a. Endorsement 900 EPL-Residential 50.00 b. Endorsement 100 (No Violation) 50.00 c. Endorsement 300 Survey 50.00 (Total 1103 + 1104) 1105, Lender's title policy limit $65,000.00 5012742-18783 1106. Owner's title policylimi[ $105,000.00 5011442.21483 1107, Agent's portionof the total title insurance premium $ 878.69 1108. Underwriter's portion of the total title insurance prem. 155.06 (Total 1107 + 1108) 1109. 1110. 1111. 1112. t 1100. Title Char es with Pa ee Total Char a Borrower POC or Credit Borrower Line 1101 Setter Paid 1101. Title services and lender's title insurance $ a. Wire In Fee to 1 st Advantage Settlement Services Inc. 10.00 10.00 b. EmaillDoc Copy Fee to 1 st Advantage Settlement Services Inc. 35.00 35.00 c. Overnight DefiveryFee-Package to 1st Advantage Settlement Services Inc. 25.00 25.00 d. Notary Fee to Vickie Welker 35.00 35.00 e. Closing Service Letter to First American Title Insurance Company 75.00 75,00 1104. Lender's title insurance to 1st Advantage Settlement Services Inc. 79875 798,75 $ 978.75 978.75 ESTATE OF LOTTIE REBOVICH f ~ g/21 /11 ~ Date 9121 /11 BY t Dougl Tierney REPLY TO ri!L4PECT~4NS/RBPORTS ADD~ID fib AG~~' DI+ SALE rx~ ta-m noa.a~a,~,~:a ,igroorrmate~aa s>.ebr. ~ oca~ ~~a~. erxani.Tais~(r~. 2 PZZOP}~l.2TX. dre a ~Y>~- o. d BYTXEIt ~ t,.. as 5 1bA1't~:O A VT 6 7 , Tn~~ily to the following.inaptxtiom~npor 8 rope:fq )ncpecEions. {23~ome 3nspecfio>t, 9 Ptpn(btpg, etc): iQ 12 12 ^ Appraiaat/2Y~ortgagel;eudar sP n 23 onip: cod Infeststion ` ltadoa ^1Leafl~ssea Paint- ^wa~sei,~~e [~ Yudividiral-tfi t.ot Seataga Dlspdsll - ^ l.eriiffexte of Oentpantq ^Property7nsturotrece Qbther: - . ^ omen-: ^ O~rer, I4 I . ^ -.accept: Huyer acoapfs the Proprxey in tfro conditiwa 3:eEteotadia-tiro alcove rapox{{s).- - -- - js -.. -- .._._.... __ -.. .....-- - -~--- _-.....~ _.. .-. ... -_._._..: _ ._-. ._....... --_.._-- --....._. _...__ __ - . 26 2. ^ '1"'~rsx+inate: Beyer totmfnate8 8re Agreexrtart.a#'Sala(onfy ifpmvi~ apt by iha tomms. of ~ie.A.~nearncat). 1T 18 3, ^ Written Corrective Propoaitl: Brryoz accepts the Property and Sexier agneea iv satisfy the tsanra of fire following Written 19 Couecfive:Pmposal($): 20 (A) ^ Cori`eeffbns/ztepairs: sstt~, ~ Salle:' expense, ~t m~ ~efatIgw;ng coirecHons/i to the rronert~-.in.a 21 ~ 22 . 23 24 ZS - 26 r~.-- 27' See attached Proposal s - 28 ~'- (B) L7 Credif+ Scllar wilt credit S towards the costa of eoaectionshrepairs to the Prope~(ty, as acceptable to 30 the mortgage lt?tdor(s), ifauy.. . 3 2 (G') ^ Seiler AsslS> :Ballet ea5ist 3s Gliari~d in~ $ ~ 0z 3~0 9~>hs ~uxcbase Pace,. 32 ma7cimrtm, toward l~s cos0a as peed by the mortgage 1e2tdar(s); ff~nq. 33 •~ D) © Seftlemenf Date: Settienoe~t date 9s cl~aaged from to 34 . ~ p . pnrahase Price: Purchase price is tmm $ to~$. _~6..- .~....._ ~ ^..-MortgagcA~mu,~lortgege emgm-tis •,~ ad$ofm yp ^ Other: - p ~ .rte _ - .. 37 •• - .- .. . ~ r ~ .. .- .. -.. .. 39 40 ~,~~ _... ----_ - - - 42 4. ^ Change of Tiara )Par3od(sj {chatigisg of arty tium period ice the Ament of Sale does not camstitnte acceptance of the 113 i'roperty wrlass otherwise stated): T1me-pectoris stated in the A~emen# of Saxe aze cba>uged as :Folfoyva: A4 (~.) 7~e tioro period in panrgreph ,lino- of the A,groemerr# ofSalo: ie chaq~cd to 45 The tiuoe 'od in h li>u ~~ of fire ..--- - ~) lam? t»t~P , . Agz~mett} of Sala is cteanged io 116 tC) -ire limo penod in parag>;ap#t ~, littt3 of flte ~igeat.of Sate la .cl~iged to `. 47 48 All other to _ ca~Iditions of the ~igreement of Girlie remain me g d o~nd effect. 49 -I~k s0 W2TN&S,S ~ DATE 52 32 wTYIV1~SS $'CTXktR bA'1:~ 53 54 wl'.[7'!ES'S BT3XER _~ bATi: SS - ~~ 3b VVlT1~.SS f ~ ®~ SELLIt)i ~ DATE 58 w13.'N]t.SB S7~LBit v ~ -OATS 59 - -- --- GO ~'iTTILSS Ss>.f.7~ B,~ t1r' ~ I~PYRIC~tPSyLYAPAAA830G7ATfOH.0Y8&1L~OR9®YOQS ~- Panrisylv_anta At~ciaNon of REALTI6RS' 09loS RHAAAX Plitt AiMrb~e-PA 6375Mac~y Drl~oetWtcihuq, Pk 17058 19atir 717~fi T749 TlmoBgrCe~{to - WWkroOAMA{17J(lFom~4pgp~opM'I807dAfteaRl~BRigA.Fta9e~i~(ti~i9it14~fr.~T(~~ t MEMBERS 1ST FEDERAL CREDIT UNION . P.O. BOX 40 • MECHANICSSURG, PENNSYLVANIA 17055 j~jo, 0000643899 Acct: XXXXXXX946 Teller: 2048 Date: 09/20/11Time: 11:17am ------------------------------------------------------------------ See receipt for reference ------------------------------------------------------------------ Check Number: 00 0000643899 Purpose Amount $3,000.00 Pay to DOUGLAS TIERNEY St No. 0000643899 M ~i MR R 1St ~ Issued By. Moneygram Payment Systems, Ina ~'s~`-'"+L~1`~ + ~~~~ P.O.8ox9476, Minneapolis MN 55480 •FEDERAL CREDIT [JNION Drawee: Boston Safe Deposit & Trust Company I':O. Box 40 Boston. MA s Mechanicsburg, Pennsylvania 17055 5-709/~ 10 ~ DATE 09/20/11.. *** THREE THOUSAND DOLLARS-.AND 00 CENTS **~ ;. $3,000.00 -PAY EXACTL-Y~' 3 s °O O O ~Dof{ars Q O Cents e.. ~. ~ ~ ~ ~ OFFICIAL CHECK Drawer. MEMBERS,IST FEDERAL CREDIT UNION To rliE DOUGLAS TIERNEY QRDER OF TWO SIG~N'AT~UR~ES~RE~Q~UI~REID FOR CHECK OVER 32,500.00 11'000064389911'' ~:0 l 100 70 9 211:0 L600 l 130,?8 211' REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER LOTTIE S. REBOVICH 21-11-0310 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) Please Note: Your Sale Proceeds Check is Attached OMB NO. 1545-0715 BROKER'S Name, Address, ZIP Code, 2011 Proceeds From Broker and Barter Exchange Transactions Federal Identification Number and Form 1099'6 Instructions for Recipient Telephone Number: Brokers and barter exchanges must report proceeds from transactions to SUbstitUte COPY B FOR RECIPIENT you and to the Internal Revenue Service. This form is used to report The Bank of New York Mellon "`IMPORTANT TAX INFORMATION"` these proceeds. 480 Washington Blvd. This is important tax information and is being Jersey City, NJ 07310 furnished to the Internal Revenue Service. If ta. Date of sale tb. CUSIP Number you are required to file a return, a negligence 09/20/2011 59156R10 13 5160382 penalty or other sanction ma be im osed on - Telephone: 1-800-649-3593 y p you if this income is taxable and the IRS 2. Stocks, Bonds, etc. 4. FEDERAL INCOME TAX WITHHELD determines that it has nol been reported. $1,078.49 $0.00 TO WHOM PAID ,/ Gross Proceeds REPORTED TO IRS ~ Gross Proceeds less commission and options premiums PATRICIA L REBOVICH EX UW 7. Description LOTTIE S REBOVICH 1072 LANCASTER BLVD APT 13 METLIFE, INC. MECHANICSBURG PA 17055-4470 Investor ID Recipient's Identification Number on File 125357661825 906163932 Box 1a. -Shows the trade date of the transaction. For aggregate reporting, no entry will Box 4. -Shows backup withholding. Generally, a payer must backup withhold at be present. a 28% rate if you did not furnish your taxpayer identification number to the payer. Box 1b. -For broker transactions, may show the CUSIP (Committee on Uniform Security See Form W-9, Request for Taxpayer Identification Number and Certification, for Identification Procedures) number of the item reported. information on backup withholding. Include this amount on your income tax Box 2. -Shows the proceeds from transactions involving stocks, bonds, other debt return as tax withheld. obligations, commodities, or fon~rard contracts. Losses on fonnrard contracts are shown Box 7. - Shows a brief description of the item or service for which the proceeds or in parentheses. This box does not include proceeds from regulated futures contracts. bartering income is being reported. For regulated futures contracts and forward Report this amount on Schedule D (Form 1040), Capital Gains and Losses. contracts, "RFC" or other appropriate description may be shown. Fpr inquiries about your account, contact BNY Mellon Shareowner Services, MetLife's Transfer Agent: Telephone: 1-800-649-3593 U.S. Mail: E-Mail: metlife@bnymellon.com MetLife Internet: www.bnymellon.comishareowner/isd c/o BNY Mellon Shareowner Services PO Box 358447 ' Pittsburgh, PA 15252-8447 YOUR ACCOUNT HAS BEEN CLOSED. THE ATTACHED CHECK REPRESENTS THE FULL VALUE OF YOUR ACCOUNT. " IMPORTANT TAX RETURN DOCUMENT ATTACHED ^ s REV-i5o8 EX+ (ii-io) ~ ` Pennsylvania SCNED~ILE E DEPARTMENTOF REVENUE CASH BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: LOTTIE S. REBOVICH 21-11-0310 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survNorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1.' Mist household goods 1,000.00 TOTAL (Also enter on Line 5, Recapitulation) $ 1,000.00 If more space is needed, use additional sheets of paper of the same size. REV-1509 EX+ (oi-io) ~i Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDt~LE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: LOTTIE S. REBOVICH 21-11-0310 If an asset became jobrtly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVMNG JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. PATRICIA L. REBOVICH '1072 LANCASTER BLVD UNIT #13 !DAUGHTER 'MECHANICSBURG, PA 17055 8. C. 70INTLY OWNED PROPERTY: m?t NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTIIIITTON AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % of DECEDENTS INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. 1994 Member's 1 st acct # 11116759 738.37 50' 369.19 2. A. 2005 ' 'Memberslstacct#141065-11 4,199.55 50 2,098.78 3. A. 1994 'Member's 1 st acct # 141065-05 4,908.33 50' 2,454.17 4. A. 2006 Member's 1st acct # 141065-40 1,818.91 ` 50 909.46 TOTAL (Also enter on Line 6, Recapitulation) ($ 5,832.64 If more space is needed. use additional sheets of oaoer of the same size. -r~- ~_ NOTICE OF INHERITANCE TAX Pennsylvania ,- ~~ - BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE 7AX DIVISION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE PO BOX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON REV-1548 EX AFP (12-16) ~- HARRISBURG PA 17128-0601 JOINTLY HELD OR TRUST ASSETS DATE 06-27-2011 ESTATE OF REBOVICH LOTTIE S DATE OF DEATH 02-27-2011 FILE NUMBER 21 11-0310 COUNTY CUMBERLAND SSN/DC 199-12-7297 PATRICIA L REBOVICH ACN 11116759 1072 LANCASTER BLVD #13 APPEAL BY DATE:08-26-2011 MECHANICSBURG PA 17055 (See reverse side underObjectio~ts) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS F~ REV-1548 EX AFP (12-10)-------------------------------------------------------------------- NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 06-27-2011 ESTATE OF:REBOVICH LOTTIE S DATE OF DEATH:02-27-2011 FILE NO.: 21 11-0310 S.S/D.C. NO.: 199-12-7297 COUNTY:CUMBERLAND ACN: 11116759 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 141065-00 TYPE OF ACCOUNT: (X)SAVINGS ( ) CHECKING ~ )TRUST C )TIME CERTIFICATE DATE ESTABLISHED 06-21-1994 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: 738.37 X 0.500 369.19 - 369.19 .00 x .045 .00 NOTE:. TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE T0: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMBER DISCOUNT i+) INTEREST/PEN PAID C-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION DF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX INHERITANCE TAX DIVISION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE Po BDX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON HARRISBURG PA 17128-000l JOINTLY HELD OR TRUST ASSETS PATRICIA L REBOVICH 1072 LANCASTER BLVD #13 MECHANICSBURG PA 17055 Pennsylvania` DEPARTMENT OF REVENUE~° REV-1548 EX AFP (12-10) DATE 06-27-2011 ESTATE OF REBOVICH LOTTIE S DATE OF DEATH 02-27-2011 FILE NUMBER 21 11-0310 COUNTY CUMBERLAND SSN/DC 199-12-7297 ACN 11116760 APPEAL BY DATE:08-26-2011 (See reverse side under Objections) Amount Remitted ~ MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE '^"'~' RETAIN LOWER PORTION FOR YOUR RECORDS F"' ------------------------------------------------------------------------------------------- REV-1548 EX AFP (12-10) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 06-27-2011 ESTATE OF:REBOVICH LOTTIE S DATE OF DEATH:02-27-2011 COUNTY:CUMBERLAND FILE NO.: 21 11-0310 S.S/D.C. NO.: 199-12-7297 ACN: 11116760 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 141065-11 TYPE OF ACCOUNT: C )SAVINGS (X) CHECKING ( )TRUST C )TIME CERTIFICATE DATE ESTABLISHED 09-12-2005 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due 4,199.55 X 0.500 2,099.78 - 2,099.78 .00 ~ .045 .00 NOTE: TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE T0: "REGISTER OF WILLS, AGENT." TAX CREDITS: PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID C-) TOTAL TAX PAYMENT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE .00 .00 .00 .00 ~ IF PAID AFTER THIS DATEr SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ~ IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. Pennsylvania ~mm BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX pEPARTMENT OF REVENUE INHERITANCE 7AX DIVISION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE _ PO BOX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON REV-1548 EX AFP (12-10) NARRISBURC PA 17128-0601 JOINTLY HELD OR TRUST ASSETS DATE 06-27-2011 ESTATE OF REBOVICH LOTTIE S DATE OF DEATH 02-27-2011 FILE NUMBER 21 11-0310 COUNTY CUMBERLAND SSN/DC 199-12-7297 PATRICIA L REBOVICH ACN 11116761 1072 LANCASTER BLVD #13 APPEAL BY DATE:08-26-2011 MECHANICSBURG PA 17055 (See reverse side under Objections) Amount Remitted ~ '--~ MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE '-"> RETAIN LOWER PORTION FOR YOUR RECORDS <'~ REV-1548 EX AFP (12-10)-------------------------------------------------------------------- NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 06-27-2011 ESTATE OF:REBOVICH LOTTIE S DATE OF DEATH:02-27-2011 FILE NO.: 21 11-0310 S.S/D.C. NO.: 199-12-7297 COUNTY:CUMBERLAND ACN: 11116761 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: MEMBERS 1ST FCU ACCOUNT NO.: 141065-05 TYPE OF ACCOUNT: C)USAVINGS ( ) CHECKING ~ )TRUST C )TIME CERTIFICATE DATE ESTABLISHED 06-21-1994 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: 4,908.33 X 0.500 2,454.17 - 2,454.17 .00 x .045 .00 NOTE: TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE T0: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMBER DISCDUNT (+) INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. +~ IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~- ~_ pennsylvania~ ~-: BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX DEPARTMENT aFREVENUE INHERITANCE TAX DIVISION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE PO BOX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON REV-1548 EX AFP Q2-10) HARRISBURG PA 17126-0601 JOINTLY HELD OR TRUST ASSETS PATRICIA L REBOVICH 1072 LANCASTER BLVD #13 MECHANICSBURG PA 17055 DATE 06-27-2011 ESTATE OF REBOVICH LOTTIE S DATE OF DEATH 02-27-2011 FILE NUMBER 21 11-0310 COUNTY CUMBERLAND SSN/DC 199-12-7297 ACN 11116762 APPEAL BY DATE:08-26-2011 (See reverse side under Objections) Amount Remitted ~ MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV-1548 EX AFP C12-10)-------------------------------------------------------------------- NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 06-27-2011 ESTATE OF:REBOVICH LOTTIE S DATE OF DEATH:02-27-2011 COUNTY:CUMBERLAND FILE NO.: 21 11-0310 S-' TAX RETURN WAS: (X) FINANCIAL INSTITUTION: MEMBERS TYPE OF ACCOUNT: ( )SAVINGS DATE ESTABLISHED 10-30-2006 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: 5/D.C. NO.: 199-12-7297 ACN: 11116762 ACCEPTED AS FILED C ) CHANGED JOINT OR TRUST ASSET INFORMATION 1ST FCU ACCOUNT NO.: 141065-40 C ) CHECKING C )TRUST CX)TIME CERTIFICATE 1,818.91 NOTE: X 0.500 909.46 - 909.46 .00 x .045 .00 TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE T0: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID C-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ~ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS- REV-1511 EX+ (10-09) j i~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER LOTTIE S. REBOVICH 21-11-0310 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. fl1NERAl EXPENSES; I' Malpezzi Funeral Home 11,310.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) ____ _____ Street Address City State ZIP Year(s) Commission Paid ~• Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address _____„__ ______ City _ . -- . _ . -. State .----- ....... ZIP Relatlonshlp of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. Real estate commission on sale of home e, Real estate taxes s, Real estate insurance ~o.' !Real estate utilities »., :Real estate home repair credit 12.' Misc closing expenses for home sale 1,5oo.oa 293.50 6,450.00 476.01 392.57 990.11' 3,000.00 1,715.00. TOTAL (Also enter on Line 9, Recapitulation) I $ 26,127.19' tf more space is needed. use additional sheets of paper of the same size. MEMBERS 1ST FEDERAL CREDIT UNION . P.O. BOX 40 . MECHANICSBURG, PENNSYLVANIA 17055 NO. 0000572542 Acct: XXXXXXX~o Teller: 1788 Date: 12/30/lOTime: 11:28am ---------------------------------------------------- See receipt for reference ------------------------------------------------------ Check Number: 00 0000572542 Purpose SHARE WITHDRAWAL Amount $11,310.00 Pay to MALPEZZI FUNERAL HOME OR PATRICIA REBOVICH St MEMBERS 1St •FEDERALCREDTT UNION P.O. Box 40 Mechanicsburg, Pennsylvania 17055 No. 0000572542 Issued By. !! n ;y,an Pa;-e- S, -< ~ ` i~~ DrhVe: Ens:;. ~~a -=__ ~ -=-- -_- -_ - - - - * * * ELEVEN THOUSAND THREE HUNDRED TEN pOL~ KS : _.~ " ~ _ ~ _ ~ - - - - - ***"CENTS *** -_ ___- -_- PAY EXACTLY' 11 ~ 31 O Doitars O O Cents __,~- ' =_ „_ _ THE MALPEZZI FUNERAL HOME OR DER OF PATRICIA REBOVICH -, - J ~~~ _~ _ - ; 11'0000 5 7 2 5 4 211' ~:0 i X00 X09 2~:0 ~ 600 1 l 304 7B 211' REV-1512 EX+ (12-OS) ~r Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT __ ESTATE OF FILE NUMBER LOTTIE S. REBOVICH 21-11-0310 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, Including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1' '.Medical expenses, including nursing home 7,440.60 TOTAL (Also enter on Line 10, Recapitulation) # 7,440.fi0 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (O1-10) Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: LOTTIE S. REBOVICH RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• PATRICIA L. REBOVICH Daughter 79,343.3Q ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: L TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size.