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Home My WebLink About11-21-11J 15p561p143 REV-1500 Ex`°'-'°' OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Cade Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO 60X.280601 INHERITANCE TAX RETURN 21 11 002 66 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 194 20 5047 02 18 2011 02 09 1926 Decedent's Last Name Suffix Decedent's First Name MI FORRY LEE J (If Applicable) Enter Surviving Spouse's Information Belaw 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 O 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required (date of death after 12-12-82) 8 Decedent Died Testate ^ ~~ (Atla ch CoMa of Trust a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Wlq PY ) 9. Litigation Proceeds Received 10. Spousal Povert Credit (date of death 11. Election to tax under Sec. 9113(A) ^ ^ between 12-31 ~J1 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number EDMUND G MYERS (717) 761 4540.. First line of address 301 MARKET STREET Second line of address PO BOX 109 City or Post Office LEMOYNE State ZIP Code PA 17043 REGISTER Of WILLS USEt9NLY ~. i -, i7 ~ _. - t , t _,-.. - , _~ -, - _-, _ , T, .~ _ ,.-, DATE FILED -, ~~, -~ ~._,, '-,:" P Correspondent's a-mail address: eg-Yl((~jdSW.C0111 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. Sandra Balr Lemoyne, PA 17043 ~ Ali R' I~H I~xs J~ r'~u SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ~~~^'~%`-~-- EDMUND G. MYERS ~(~ 1~, ADDRESS 301 MARKET STREET, Lemoyne, PA Side 1 15D561D143 15p561D143 `t J 1505610243 REV-1500 EX Decedent's Social Security Number Decedents Name: Forty, Lee J 194 2 0 5 0 4 7 RECAPITULATION 1. Real Estate (Schedule A) ...................................................................................... . 1. 58 , 000.00 2. Stocks and Bonds (Schedule Bj ........................................................................... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)........ , 3. 4. Mortgages & Notes Receivable (Schedule D) ....................................................... . 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. . 5. 10 , 055.57 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested........... . 6. 7. Inter-Vivos Transfers & Miscellaneous coq Probate Property (Schedule G) u Separate Billing Requested........... . 7. 8. Total Gross Assets (total Lines 1-7) ................................................................... .. g. 68 055.57 r 9. Funeral Expenses & Administrative Costs (Schedule H) ...................................... . 9. 8 , 60 6 . 7 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................. . 10. 19 , 941.51 11. Total Deductions (total Lines 9 & 10) .................................................................. . 11. 2 8 , 54 8.21 12. Net Value of Estate (Line 8 minus Line 11) ......................................................... . 12. ~ 9 , 5 0 7 . 3 6 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule Jj .............................................. . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .............................................. . 14. 3 9 , 5 0 7 . 3 6 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 0 00 (a}(i.2) X .00 . . 16. Amount of Line 14 taxable 39, 507.36 16. 1, 777.83 at lineal rate X .045 17. Amount of Line 14 taxable 00 0 17 0 00 • at sibling rate X .12 . . 18. Amount of Line 14 taxable 0 0 0 18 0 0 0 . at collateral rate X .15 . . 19. Tax Due ................................................................................................................. . 19. 1, 7 7 7. 8 3 20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-11-00266 DECEDENT'S NAME Forry, Lee J STREET ADDRESS 634 State Street CITY Lemoyne STATE PA ZIP 17043 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 1,777.83 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits (A + B) (2) 0.00 3. Interest (3) 4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box 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. (5) 1'7'77.$3 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 :............................................................................... ^ ^x b. retain the right to designate who shall use the property transferred or its income :.................................. ^ ^x c. retain a reversionary interest; or ............................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ............................................................ ^ ^x Z. If death occurred after December 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?....,.. ^ ^x 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 January 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 fax 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)]. A sibling 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+177-OS) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Forry, Lee J ( 21-11-00266 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 al 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. Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-08) (If more space is needed, additional pages of the same size) F, ~l~TEI"lt TY~T]t u.s tx~rt,T,att of t -~u~ing and ui~n ~Ic>Rr>:fa M IQ A...wv ~I rah 7~ )JY.ri{ Fln~ n i yr..c u ~w i 1. ^Fl-l4 2 ^Frri-W 3. ^~. Uins 4. QUA 5. ^CaN.lrts 6. Rlerlxri~s 7. LoaiNnrt~a 11-OBZ'3C~C 8. Ntrh,7a0elrsu-a~C~Nnrt>~' IS gve ya,a r are G Note: I~rsrrai~d"(po.c7'vaepaidoumdethedcsrc~itayare~vnnFereforirSarrcOmryipor~sardarem[irdtrY.rlinthetaa!s t/1FV2h11JG ttisaairte[ohu~rcJy rrel~false 5araraYSto the ltited 9aresmtlisvaryahersmlarfam Ftrdties t{xa~ mnwmm mn induce a fine and irrpri~rrrrrer[. Fordrt-alssee: Title 18 U S CoA Ssyion 1001 and Salim 101 D. Trt1e64xa~~flelrt~rtSystem Rirrted 11/0$'2011 at 13:04 ~C Q N~ CF e~aane~ Srng Li aril Zehrng Li E NM/E CF Sfl1~2 The fSt~e C1f LEe J. FaTy PDT 634State PA17013 F. NM/E CF LB~I:B2 PJ G ~1YpDpF,~SS 634State9treet, ~~ PA17043 H SETT1BvH~If Pali: A1dt~s Re~au-at RPLE CF ~TtLgvgrT 8Z9 State Street PA17043 ~TTFHUBVro4Te 11/08fZ011 I . J. S~MWftYaF'B~II~STRAN.SF~Cllq~t Kg~INWR1(OFSHIH~STRANSACTIONt 100. CFIVIQ~iTQEFf~MBQ~J1Bi 400.1ANICLIVT'DlETOSA l ~ 101. CYa-Ihaxsal~ 'oe 000.00 401. I~lt-~s~lesprioe 000-~ 102 ~Sarol prcpaty 402 Ftrscr~l qty 103. #dtrnala(Grte1 119308 403. 104. ~. 105. - - _ 405 usUrertts for itgrs 'd seller in addarre tutrrertts for items 'd seller in adsance 106. a /tanntaccs 406. O ftavtt~es 107. iac~ 11/OS!11m12l31/11 6fi90 407. Cou-dytat~es 11iOSf11to12131/11 _ 6l"a90 108. F~na1Ls - `}~ _ 109. shod faces 11/OSI11 to0613Ur12 58225 409. _ stool Laces 11/111 toOC~.j0/12 58225 3 7111 11/UBl11tr~1~ 110. F~fil~ Zfi_41 410. t~fi~_ 11/08(11 to17J3ll11 _ __ 26.41 _ . _ 111. _ _ 411. _ _ 112 412 120.~AN1D~lTD.EFi~IVIB~f1~t ~,81i364 420.CANfvUVfD11=T0~1B~ ~ 675156 200. PNI(X.MS PAID BYCi2CN ELF CF B 201. a ~rrt~# 1'OOQ00 500. F~1UC.TI CNS IN PN~I.NT DI.E TO ~ I FR 501. ~ ~ ir1~~~ ._ 202 Ifirtci anurrtcfrteuvloais 203. ~ loat(s} takes abjectto _ 502 ~11ar~ntd>a~estos~la(IirA1400) - 503 6dstirr~ bails) takat s~j~ to ~ .~ _ _ 20~ 504. Paycif cf First tSYil~ - - ___ 5DJ~3t"~ ~11k . 205. _ ~- 2oG. ~ 207. 507. 208. 508. 209. ~ u~rtsfaritars 'd seller u~natsfariterrs 'd seller 210. C3tyftann faces 510. Clty/tann fads 211. tacFS 212 l~rraAs 511. C7.uitytaces 512 Psse~rreits ~_ 07.3. ~ -' 213. 513. Escrvrufcr Mg with ~,ra~gt - ~-~ 214. 514 215. 515. Ziff 516. 217 517. 218. 219. 518. 519. ~.~ l1C~~) 220. TC3fALPWDBYlPCR8Q~B2 100Q00 5120. TL7TALF~UCiICNANKX~ff C~~-iB2 300. C~ShIATSET'iL9VBJTFf~NICi2Tl7BC~OJIB2 301. Oo~anwtduefranbarana(Iine120) X386864 600. CAS-I ATSETfLHVB~ffTOCRFF~MS8.1B2 601. C3o~arartduefD~lla(Iir~420) 675156 302 LESSarour~pad /fabarana Iir1e220 303 CA9iFF~tNB 1 OOQ00 8686 602 Lessred~ctimalruntd~sella (fir~520) 4 603 CA4iTOSH.IB2 % G? .-ct.! ~..3 /"/ `^' SLES117UtE r-0f3v110B3 SB1EF2 SiA1HVENr:l}a iriumxim mrtairEdlvein sirrTnrtart FVCirt m3tim arclis lery furi5iedtothe lrte:rd F2vatE ~svioe. Ifycu are regired tofilear~ur~ a recJigerrs per~ty or oli ls3rtimvvll be irrrs~dmyou iftYis elanis reo}irodto to reported and tfe lFiS damrinesth~I[FES nor been re(Sxtai 'rF~Coriraa ~¢Fhrnd~~dm IIrQ 401 atnve mrf[itUesthe ~ R~meeskatFistrarea~son You are rec7.ired q' IaMO prwir~ the setlarert ag'~rt (Fed Tax ID fib: Zj wth yar aorra2 ta~gs3yg idertifir~im rur6er. If you cb ri2 rrwi~ yorr owed taper ir$tifx~m n.,t r, ya, na,~ t s4az to oval Q o7rrirel r~9es irr7~ y~ IaN l}der r~tiesof pa7uv, I mtiHtrr~ uE n,.e~a ~w~n«, wss~e-rat is ny os.a1 r~aryer id~mrK~,m nnt~a. ~" _"~/~: se-I.F~s~ r~`nmivuur~n>~ss sa.~57 r+rsr= ran~zs: (M us ~zm~avrcFl ~x.slr~ar~DU~nrv~ac>avavr ct7'77 •~t Io.T CRATGIIO~R Fle Nrrber.11-082:1 RNPL Pf't~ 2 Tam Olx~..a-f gietcn Rir+rx111/fR/X111 ~ 1'ifT1~1 (: L SET1l9VBVT - PAlDF7ZC>\A PPIDFFZY~11 Tao. TOTAL SQLESOCNMS9CNbesedan 'ae 000.00= 63D.00 S s IEL~zS DHSionofamiissim line? a;idlans FUf~D6AT FlJrLSAT 701. $ 1890.00 b I~INf~c ICI f~c~ates ~Rev~r>- ~-~~ 702 $ 1740.00 b~ Cdd~nlell~n{~er3~lectF'hdessirnals 703 Qmrission at ~iaret 630.00 8D0.17Hd6 PAYPHF IN OQV~BCi1CN W7}i L(.pN 80'I. L031 ~ Y~a~ Fee ~ LL~ 1 Dart Fee ~. QB(ft ~. ~. ~. ~. 810 I 811. ~PAIDINPD/fV~ g00.IT8V6F~q,J19~BYL6~LS2Tb _ _ 901. Irtt=test Fran 10 - 902 Insua~ Raiiun for nrtldls >n _ 903 I-~acl Ir>s.raioe Raritm far to 9D4. - 905. _ __ 1000. ~D91IDWll•iIB~CHtFCR _ 1001. Fad lrara~oe 2 rro $ hm ~_ ~ _ _ 1002 Ilsi,rare 2 rro CcD~ _ hro - -- 1003: Tic 2 rro @$ /rro _ 2 rro ~$ hm 1001. Tat _. 1005. ,Mirn~F~s~rTats 2r%~S _ hro -- -- 100Q Pr~yssPc~ist~t _ _ 0.00' 0.00 1100 Z1lLEGl- - -- _ _ - 1101. mat or Closim Fee 1102 Ptstr-a3 a Trte ~di _ - _. _ ~ _ ' 1103 Title E~~ rirrfian _ -__ - 1104. Titlelrtaraxe6rrl=s - - ~ 1105 Q~arrat -_ - , ... 1106. Fes 1107. s fees Irxiu~ ~o~e items Nx 1108 Title Ir»a>~ ifl Title goes ~~ IfYjU~.'S tae items Nx 1108. Lgxl~s fbl' 1110. C~uiel's Ri 000.00 -546.08 1111. Fee 1~ QiarrianTranfe' 'rn 5[00 10.00 1112 Cbui~fee to QiarsianTr.~er 'rn 15[00 1113. 1200. ~3D~Iff~IvH~iTF~-0C~~INGAPDi'RPI~FB2 17171. F~3oorri Fees Died $6200 $ : ~e$ 6200 1202 tar/ Died $58D.00 : Mxt $ 530.00 1203 S~eTat/ [k~ed$58000 $ ~-~ 1204. Did $ $ 12(76. D~d$ $ $ pa]l1Cf~L~TiLBVHYT(}iPRC~S 1300 . 201'I/~12 ~tnd fates 1n Faith I~icda 1301 99230 . 1302 f~rrtzrseretcftacmtfee is C;<er>3anTransfer 'on 1303. Rrr~lVl~r/~aner tp 10.00 40.00 1400.717fioLS~TiLHVB~1Tpi~S eteranli~res103,~diaiJax1502~on 11930 8 .:10 I+_o r~rnn~~ICN cF etl~rv~ sFt tnz I Fc a ~refi1N ~e~rie+~ed tl'ie I"i-[}1 `.,c4tlarert 3a<urerf a<d to tFQ 6e5 W try Iv'n+Jed~ ar,d hdief, it is a tnc and asr-ate st~erreri of all reonps a-d dsia+~reNs rrer~ on m/ ao:nu"t orb,~rre intlistr~ort lfiither o=rtify~ m~veda ¢p,~oftte Fl.0~l Sdtlarsi3~re[. ~ ~ ~/ /~/f' l Gill ~/~PRNNG ITISACSdNE~DIQJ,JVrV3-Y NYL~FALSESTAIHVFMSID~I'E CIVJIN1~lLEAFlr~EAt~DINFFd SuCt~NEM.FCR CEiAILSnSEE ~J 1CCtW1CT1CN US aOaE SECi1CN'1007 MDSECTICN 1010. s The I-lA1 S~tlerrrli 3atenert Ws~ h I F¢ve Freer 1 i a tn~ aM a¢ir~[e amxit of trtis haY6amon IFa~rerat~dor Il gvrethe fu~to l~d~. ~inamxcl~r~vith itis5atertat. I ~ ~ ~ ~. ~ _._.. ,_~ ,.~ •_.____. % ,~ } ~ ',~ Rev-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Fnrni 1 tac+ .1 ?1 _11 _Ilf19Fr, Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-ownedwith the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Sovereign Bank Checking/Savings Account 5,884.01 2 2001 Mercury Sable Automobile 2,896.00 3 Miscellaneous Personal Property 100.00 4 PA Department of Revenue -Refund 500.00 5 Real Estate located at 634 State Street, Lemoyne, Cumberland County, PA 17043 - 675.56 Reimbursement/Refund of County taxes ($66.90); School taxes ($582.25) and Refuse ($26.41) TOTAL (Also enter on Line 5, Recapitulation) + 10,055.57 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) 2001 Mercury Sable GS Wagon 4D Trade In Values -Kelley Blue Book Kelley t31ue Soak Stec rreusrt ry ~r;~~arf~x: • Horne =• Car val~:es > Mercury > Sable > =001 :~ Category ~ Shfle > Options > ... N; agol i 4 G Page 1 of 4 Popular at KBB.com 10 C<x3lr,t C;srs Under r ~s 18,000 ME'.rC Llfy ~ Sable ~ 1C1U1 ~ yiF ~e+". edit rptinns ;charge ty1e Mileage: 115000 rhanye ~ ! .ke thi cdr Trade-in Value Private Pal't~/ VdIU@ ~~ Excellent `~ _ _ _ _ _ c~?,- r~~:F<. ~~'i0(J ft)Q- ~t't)fSl- iYL'X~ Cllr .®..~ ~........ Vcty Good ' i ~~,s9~ Instant 5`rade-Iel Q~Fer ,. . _ Gcod s.9 ~ ~r~~~ . Awn::::; Fair €~~ Verify Canditicrn 4,~3 - ~ 7 review this car Own It. I_ov~ It _ out of• s How to Get the Most for Your Car ~~~~irf~,~'i ~S r .- Know Your Car' Sell Like a Pro: List Your Car See What Other Specs 10 Expert Tips Online Cars Are Worth Seller's Resources ,~ , I want to list my car for sale ~:'~:~~ ?lace an ad nn kutaTrn:ie~.c~m ~' What if my credit's not pertect? r^J;pty with a s;r:~n.=,lisc nov: How much can I afford? Use ou- warthF~ payrr:er~t calculator Top 10s & News 0 10 Coolest G,rs under $18,000 2011 a li~g'iTrings rrc;m SaraU C.+,rs. Fol.u' new... a Top 10 Family Cars of 2611 r 1°ive GrraY l'.ar D als Read h1are News wh7 ode >=~r Sham Prat t°lY I'ec ritly Vievosd h'~y Saved C'als save h y K86 r'~~dc 110.7:1 Sli;n Iii http://www.lcbb.com/mercury/sable/2001-mercury-sable/gs-wagon-4d/?vehicleid=4747&... 11 / 11 /2011 Trade-In/Sell Values St10W Used Car PIICe$ REV-1161 EX+(10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF I FILE NUMBER Forry, Lee J 21-11-00266 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NU BER A, FUNERAL EXPENSES: See continuation schedule(s) attached 1,225.24 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Sandra Bair Street Address city Lemoyne state PA zip 17043 Yearlsl Commission paid 3,250.00 2. Attorney's Fees JOHNSON DUFFIE 3,250.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zia Relationship of Claimant to Decedent 4. Probate Fees 403.49 5. Accountant's Fees 6. Tax Return Preparer's Fees 75.00 7. Other Administrative Costs 402.97 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 8,606.70 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Forry, Lee J 21-11-00266 ITEM NUMBER DESCRIPTION AMOUNT Funeral Ex ep nse~ 1 Flowers for Funeral Service 65.24 2 Gravemarker Fees 160.00 3 Mt. Olivet Church & Cemetary & Minister Fees 1,000.00 H-A 1,225.24 Other Administrative Costs 4 Cumberland County Recorder of Deeds -Filing of Satisfaction Piece on Mortgage 50.50 5 Cumberland County Register of Wills -Filing Fees for Inheritance Tax and Inventory 30.00 6 The Cumberland Law Journal -Notice of Estate Administration 75.00 7 The Patriot News Co. -Notice of Estate Administration 155.10 8 U.S. Post Office 19.29 9 UPS Store -Miscellaneous Administrative Expenses 73.08 H-B7 402.97 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+ (12-OS) scHE~uLE f DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Forry, Lee J 21-11-00266 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 Allstate Homeowners Insurance 170.74 2 Allstate Insurance -Automobile 112.85 3 Chase Credit Card 3,788.96 4 Citgo Credit Card 358,00 5 Dish Network -Residence 37.47 6 Faith Nicola -Real Estate Taxes -Residential Real Estate 452.22 7 PA American Water ~ Residence 502.10 8 Penn Waste ~ Residence 145.00 9 Pennsylvania Department of Transportation -Automobile Registration 36.00 10 PP&L Electric Company ~ Residence 56.60 11 Real Estate ~ 634 State Street, Lemoyne, Cumberland Co. PA 17043 -Settlement Charges. 5,277.30 12 Sandra Bair 350.00 13 Shipley Oil Company 363.00 14 Sovereign Bank Line of Credit Account No. 4539700103 2,831.41 15 Sovereign Bank Loan 5,323.45 16 UGI _ Residence 120.41 17 VA ~ Newington 16.00 TOTAL (Also enter on Line 10, Recapitulation) I 19,941.51 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) SCHEDULE J COM IN~ ER TANCE~ ~ RETUYRNANIA ECEDENT BENEF~L` ~AR~~S RESIDENT D ESTATE OF FILE NUMBER Forry, Lee J 21-11-00266 NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY Do Not List Trustee s (Words) ($$$) I TAXABLE DISTRIBUTIONS (include outright spousal • distributions, and transfers under Sec. 9116 a 1.2 1 Joshua P. Bair Grandson Specific Bequest 1465 Worthington Park Blvd. of $500.00 Westerville, OH 43081 2 Kyle J. Bair Grandson 1/3rd of residue 2 Hancock Street Apartment 313 Quincy, MA 02171 3 Matthew L. Bair Grandson Specific bequest Lemoyne, PA 17043 of Automobile; 1/3rd of residue 4 Sandra J. Bair Daughter Specific Bequest Lemoyne, PA 17043 of $1,000.00 5 Shane M. Bair Grandson 1/3rd of residue Lemoyne, PA 17043 Total Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 15 00 cover sheet, as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUI IUNS UN LINt 1 ~ Ur Ktv- I ovu wvcrc ancr. i I Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) 1'^' y DC ~. f ~ ~= i p "" ., "'; ~.~ ~:~ w ~ ~. ~ - ~ w v ~ p w ~ w U ~ va ~r~ w O Fr- ~M _ w ~ o ~ ~ s w .v o z ~~ C W F- ~ W ~ ~ O ~ U cn ~ m g J w ~ ¢ O - ~ w ~ ~ U Z a O U ~~ O H