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HomeMy WebLinkAbout12-05-111505610105 REV-1500 ex t°2-33' (Ff, ~ OFFICIAL USE ONLY PA Department of Revenue pennsytvarde Cou Code Year File Number Bureau of Individual Taxes ~~'""~"`" "~"~` 'm' PD Box 280601 INHERITANCE TA,X RETURN n y ~ I O K L ~ Harrisbur , PA i 128-0601 RESIDENT DECEDENT ~; I U ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY / S.-3 /6 ~1s ~S o~ oq~.v~ ~ /U /.Z 19/6 Decedent's Last Name Suffix Decedent's First Name MI ~f ~j 1~l ~ ~° ~'I ~-/~ ~ ~ ,~ ~' ~I/ cJ (If Applicable) Enter Surviving Spouse's Irtformation Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Soaal Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ,~ 1. Original Return , =~ 2. Supplemental Return ~`~ 3. Remainder Return (Date of Death Prior to 12-13-82) ,_;r 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 Safe 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 - TNIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ,~ ~ ~ . ~1yJ l~ .er K e'~t cz l~ 7 / 7 6 ~/ G 76 0 REGISTER OF WILLS USE ONLY r-. First Line of Address ~ - ~-i ^ Second Line of Address t ~ m I *~ ~ V ., ~ ~ ~ _'~1 ' City or Post Office State ZIP Code DAT€Tlft l~'}~ ~ _,, -_, ~- ~ ~ ~ S~ ~ ~ ~ '~ t 1~~ / 7 3 3 7' ~~ ~~' -~ l - ~ -> - r,-t / ,(~ /~ ~-) t.: Correspondent's e-mail address: / / ~y'f ~- X24 `f 7 ~y p ~ /~~ / I . L D Vy~ _ Under penalties of perjury, I declare that I have examined this return, including a g schedul d statements, and to the best of my knowledge and belief, it is true, cflrrea arxi complete. Declaration of pre other than the personal ive is on all information of whidr preparer has any knowledge. SIGNATURE OF PER N R Ny57~t. ING R~ DATE ADDRESS ~- ,~/ / / _ 2 ~~~ ~rl(~/pGt/'9 rr`,4: ,L eN/t f>~XG!'I^'t~ ~~ ~ 7J.1 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: / t $/G ~ t/. wf L'r v-1 c~ f/~ Decedent's Social Security Number / S`3 / ~~ ~lJ-7~ RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. ~ S-'L~ 7 ~( vU 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 Properly (Schedule Ey..... .. 5. ~~ ~b,~ v O 6. Jointly Owned Property (Schedule F) ~~ Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C Separate Billing Requested...... .. 7. ~/ ~~ r; j ~ ~ O 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. ~ ~j 7 ~ 3 ~ ~~ 9. Funeral Expenses and Administrative Costs (Schedule H) .............. ..... 9. ~I S8~ U U 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) .......... ..... 10. 11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. rJ ~S~ U U 12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. ~ 6 2 ZSU• U U 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................... ..... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................... ..... 14. ~Llj Z Z ~~. (, (, 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 ~ ~G ~ ~ ~~ , ~ U 1B. ~~Q /. O 0 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. 7~~~ OU 20. FILL IN TFfE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ,~ Side 2 L 1505610205 1505610205 J REV-1500 EX (FI) Page 3 Decedent's Complete Address: DECEDENTS NAME STREET ADDRESS ~l ao ,82n t ~'r~.ck /.~1/d ciTV_ /~ ~c-Y/An~~T,~u ~f Tax Payments and Credits: 1. Tax Due (Page 2, Line 19} 2. Credits/Payments A. Prior Payments I ~ l0 7 • ~ 0 ~ • OS B. Discount 9~ C~ __ 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYIAENT. Fi{t 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. Number ?1-11 -D~~/ STATE ~~ ZIP17 i1) 73d/. o0 Total Credits (A + B) (2) (3} (d) (6) a2o6 Sao ~2 ~c~.. rid Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" 1N 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 ......................................................................................................................... ..... ^ 0 d, receive the promise for life of either payments, benefits or care? ................................................................. ..... ^ 2. if death occurred after Dec. 12, 1982, did decedent transfer properly within one year of death without receiving adequate consideration? ......................................................................................................... ..... U 3. Did decedent own art "in trust for" or payable-upon-death bank account or security at his or her death? ......... ..... ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a benefiaary designation? ............................................................. ,© ^ IF THE AN5WER TO ANY OF THE ABOVE QUESTIONS tS 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 stilt 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 benefiaaries is 4.5 percent, except as noted in {72 P.S. §9116(a)(1)j. 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)j. 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N V q ~ .'c, G g q N Z ~ C u o~ O u$ E N E E ~" ~ y ~ q Q G N c 43'ia .~ q m0 O W V V ~~ ~ °v W ~ ,. d ~ O ~ n ` w ~ a ~ •~ C m C j ~ q ~ > > ~ U~ c ~ O O ` ~ ~ «~ a `8 a N a, NI ~f U; i E~ N d = O_ V d Q 0 H c~ yN> Gr N C W ~ ~ ~ a ~~ ~ 0= •~ O O ~~j n c_ p ~ ~O i. ~ ~ c c7 G c.~ z ~ ~=:~a (n O U ~s v~ C A 7 ~ N N_ g NNry F m O V ~~ ~ c N W a o`er a`j@ q c ~ >> V ~ g a `B ~.O~ '3 a, HI 'r U' i ~' y< G~ d ~..rj. 7W r-~ a y~ .-~. U Cz.. 0 ~g O c.~ M ~ N ~ a r REV-i5o8 EX+ (ii-fo) Pennsylvania f.V DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpVLE E CASH, BANK DEPOSITS 8~ MISC. PERSONAL PROPERTY ESTATE OF: - FILE NUMBER: ~~/ten ~ ~~~,-~4,r ~~- 2~-~r-Q~o~ Indude the proceeds of litlgation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION Of DEATH ~- Gl~~~~C~~g ~~c'~ - ~t..5~ -oYSg - ~i~~ I ~3d~. 00 ~~~ / ~Q fox 6~ y ftsh~~f ~ ~~ ~s ~~~ ~. ~,.-t,"f; ~ 4TH a ~c~~ds,~TT #~.~y 3 ~~ 3 «~ ~.c ric~c,~s~r/~e, ~% /6 ~3 3 ~~8.s3'~ .r~ TOTAL (Also enter on Line 5, Recapitulation) # ` 3Z ~6~av If more space is needed, use additional sheets of paper of the same size. r ree unectung Account Statement _ ~ ~ PNC Bank ' f~~ ~f G~ Q For !h~ period 07/1212011 to 0$/0$!2011 002014 HELEN 0 AMMERMAN DECD C/0 LEE AMMERMAN 930 PINETOWN RD LEWISBERRY PA 17334-4773 PNCBANK Primary acoount number: 50-0459-7177 Page 1 of 3 Number of enclosures: 0 For 24-hour banking, and transaction or interest rate information, sign on to PNC Bank Online Banking at pnc.com. ''a For customer servioe call 1-888-PNC-BANK Monday - Friday: 7 AM - 10 PM ET Saturday & Sunday; 8 AM - 5 PM ET Para servicio en espaffol, 1-866-HOLA-PNC MorinpT Please contact us at 1-888-PNC-BANK ® Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 Visit us at pnc.com ® TDD terminal: 1-800-531-1648 For hearing impaired clients only Yee Checking Account Suiinme~y Helen O Ammerman Decd .coount number: 50-0459-7 i77 Overdraft Protection has not been established forthis account. lease contact us if you would like to set up this service. our account is currently OptedAut of Overdraft Coverage. ~ learn more, visit us online at pnc.comloverdraftsolutions glance Summary Innin Deposits and ante other additions 14,306.53 581.62 Checks and other Ending deductions balance 14,443.81 443.74 Average monthly Charges balance and fees 7,433.78 .00 •ansaction Summary _--- Checks paid/ Check Card POS Check Card/Bankcard withdrawels s(gned transactions POS PIN frensactions 1 0 0 Total ATM PNG Bank Other Bank t2nsactions ATM transactions ATM transactions 0 0 0 terest Summary Annual Percentage Number of days Average collected Interest Paid Yield Earned (APYEJ in interest period balance for APYE this period 0.00% 0 .00 .00 As of 08/08, a total of >~2.16 in interest was paid this year. Withholding Interest earned withholding this period year-to•date year-to-date .07 2.15 .07 ?N D M LT01-J 0860056-N 40-N N N N N N-00 2-00377 7 ~ c~ --t cs3 ~ O ~ ~ ~" c* ~ (~ r-r ~ R3 ~{ `t T .. z ,. 3 is ET; ~} ti.-, q t~,3 ~'-~ ~' O n ~ tXx t- t~3 O C:f N '~ fl . Sa ~ ~ ,~~ ~ fr3 r~ O Cr -`. CJ !~3 ~ ~ ~ s"' ~ }.. ~'S ~ *~*} ,V W 4 a ~,\ H-` 2 O .a Z m N -i N a z N D Z om ~ D ~ q m = ~ ~ o n ~ = 2 N nT. Z Z N ~ZXJ ~bm ~~~ ~gD N lit z Z -i ~ O = ~ ^' C!1 m ~ ZND oa.i 9Nm ~~~ mom aaz O c~~ m m N O mf 0 REV-1510 EX+ (p8-09 pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIYOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT - - -- - ESTATE Of q TILE Nt1M8ER ~~~~n ~ T/~r~~-rah 1~i9 21-1-a ~d i This schedule must 6e completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. IhM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF TNF TRANSFEREE, THEIR REUTIDNSHIP i0 DECEDENT AND THE DATE s1F TRANSFER. ATTADi A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECO'S INTEREST EXCLUSION (IF APPUCABLE) TAXABLE VALUE 1, ~1 , ~'~y K t~~ ~1N7tK% f~ f-1aG , l a ~ Cuu ravl 30Si~ ,00 3~ r~~ ~ ~goQ7~~~ ~ ~arrt~ r-us = L , d l~~K/10~ 47~4fe o~t'/aNI't« 9'7-f i fuK.~~r~9•t-t ~~c O. ~i-+1Hr cv rtic a.V / ~oKc;j~ ,r. /-~iry~h LIr6iKj~ri*!~ • ~ lF it .Z. ~e~Qi/G~ 7/~l~aC~4r4~~~l~Z~! ~ i~ I ~S-~ ICS~J I ~f ZS1s. Sr ~~~~'? C-ov 3 9 3 7 ~ituf'T~ ~"'~C ~,,Q2O. ~nrwlc~~~ fr,r,1rf~~{ ~Zy-N ..~' ~~GClI.eK«- ~7`A~t~~Y~itatifl/ 19~Sg /d0 ,jQ2~~ ,~~~~'fG-o~.393~ T~Kf f~~~ : s q-, ~,Gl~ ~ rt/au`t~/ ~/4Htf~~/"~ ~/ ~G!l~irZ<< ~i~~~-c~~inrtifiY ~19as~g ~a p 1y1s~~ ~~~i~~-Oo3 s y9 '~~~ f-~,iGG ~~J 1 TOTAL (Also enter on Line 7, Recapitulation) ~ y /f SZ4 ~• v~~ If more space is needed, use additional sheets of paper of the same size. ~ Fidelity & Guaranty Life Fii~EUTY & GUAR,A~NTY l.iFE iA1SUtRA~ICE Ct)MPAieiY P.C~. i3ox ~2~ 68, Lincafn. PyE 6501 8~ 6.t~22194 ioi`icej ;112.4i~3.CS1~8 tf~xi sv+,vw.fglife..am September 7, 2011 Adella A Wauhop 20 Frelinghuysen Street Belvidere, NJ 07823 STATEMENT OF BENEFITS Policy Number(s) L9097741 Death Benefit $10,228.47 Interest from to at Settlement Interest $0.00 Tax Withholding $0.00 Subtotal $10,228.47 TOTAL $10,228.47 Payee: Adella A Wauhop Taxable Amount for: $1,895.97 An Asset Account checkbook will be mailed to you under separate cover. if you should have any questions, feel free to contact our office at 1-866-702-2194, extension 3365. Sincerely, Kristina Hradecky Life Claims Examiner Fidelity & Guaranty Life Insurance Company Fidafity 3 Guaranty Lite is the markeNn~ name of Fidality & Guaranty Lif= Insurance Company and, in Neve YorM: only, Fidelity & G!laranty Lfe lnsurar.ce Company of New. York. Oniy Fidelity k Uuaranty Lite Insurmcs Company oS N°',v YorR is authorized to ~.eit insurance and annuitiss in ~~ierr 'fora. i=fidelity & Guaranty Lite products are underwritten by Fidelity & Guaranty Lite Insurance Cc~rr!pany in tal states and DC uiY!er thz+n Ndw Y:~rk ;and, fir: !tiow York cnly, Fid%lity & Guaranty Lite tn,urance Company of tVew Vork. M C! M d' T 0 ti Q Z Y U .C U C R. :.i v u C V c E u T T ~ ~ i O + N , O ~ O O ~ ~ O ~ ti ~ 00 ~ o ~ ~ tl') N ~ ~ In In N N ~ In N • W ~ h- (A N O lf) N ~ N Q O ~ 'n ~. ~~ ' ~ ~ ~ J ~~~ ~ 1 `~ J _~ •._~e `bad ~ _.~ ~ ~ v V ~ ~ ~ ~ r~ =_ > ~~ ~~ .. J ~ '"` ~ C.;J~ ~ ~ ~ ~ O ~ O ~ O i Q i ~ Q ~ W m ~ F- Z O H H W -i.. Z W W ~ z ~ } O ~ Q Z CQ w m W J U ~--~ J O d Y U W S U = CO F^ Q Q X W Q D 1- I.L ~ m R~,lRNCE STRNDRRD Life Insurance Company' Check No. 7000 ~$3rJ$ a pRM9company DATE: 08/24/11 ~"T------------------------------------------------------------------------------ POLICY NUMBER:AAMG003937 CHECK AMOUNT 28,732.92 ---_. DEATH BENEFIT 29,258.80 FEDERAL WITHHOLDING 525.88 TAXABLE BENEFIT 5,258.80 BDF 28,732.92 ' OM FINANCIAL LIFE INSURANCE COMPANY LEE O AMMERMAN 930 PINETOWN ROAD LEWISBERRY PA 17339-9773 5991 In~llln~lul~n~l~~l.tn~~inln~ll~n~n~lu~~~~l~n~~nl~i Statement Closing Date: 9/1/2011 Account Number: 40299091 Customer Service Code 207 ACCOUNT INFORMATION Balance Last Statement 0.00 Balance This Statement 0.00 SUMMARY + CREDITS 10,022.58 - CHECKS and DEBITS 10,022.58 ENDING BALANCE 0.00 RATE HISTORY CURRENT INTEREST RATE 1.00096 INTEREST CREDITED YEAR-TO-DATE 4.12 ACCOUNT TRANSACTIONS DATE DESCRIPTION 08!04 DEPOSIT-CASH EFF 08-03 DEPOSIT 08118 CK# 101 09101 CREDIT-INTEREST 09/01 DEBIT-ZERO BAL CLOSE CUSTOMER SERVICE Contact Information: OM Financial L'Ife Insurance Company P.O. Box 81497 Lincoln, NE 68501-1497 Phone: 1-888-513-8797 8:00 AM to 5:00 PM, Central Time, M-F AMOUNT BALANCE 10,018.46 10,018.46 10,018.46 0.00 4.12 4.12 4.12 0.00 ~~ ~~~ ~~~sll " ~,~~ t ~". ~'~ 704- 4 Page 1 REV-I51i EX+ (10-09) ~~i Pennsylvania iii DEPARTMENT OF REVENl1E INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS C~IAIt Ur /~/G~ ~ ~~~ ~r~~h FILE NUMBER j7 P/9 2 / - 11 -D ~d 1 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. i. FUNERAL EXPENSES: ~~~G2zr~ rrKG~r/ fr~.'~.c.. G,~G~fc'o y L'aA !'yc.~ Tp ~s d~~~f c~r'h~ 3 Z.sl~ ~fG ~. /~GIY/oir~fl I~/H'1~r ~~'~~/Gi~'c ~~r~'PG~kb / ~.~SS j . ~ 1~, ir~~.rrc.., Cirtl /~~ ~S /,2S Ll• ~ c,~G / /~C~i'¢Gr-iir~ u'C'C~4lf ?G V . ~G l~N, •h f , ~ ~ qU QQ ffjj /~Lv' R~Gt ~Kd~dws e. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City _ _ State ZIP _.__ _ Year(s) Commission Paid: __ z• Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City _ _ State ZIP __ Re{ationship of Claimant to Decedent 4• Probate Fees: S• Accountant Fees: 6. Tax Return Preparer Fees: ~+J~i/s cap j. -~ur '~~z~s~ '~22 2 TOTAL (Also enter on Line 9, Recapitulation) I ~ yg~.~ d d If more space is needed, use additional sheets of paper of the same size. MalpezZi ~une~al Home 8 Market Plaza Way Mechanicsburg, PA 17055 Jerem~~ J. Shartzer, FD June 21, 2011 Lee Ammerman 910 Pinetown Road Lewisberry, PA 17339 Michael J. Malpezzi, Owner, FD (717) 697-4696 www.malpezzifuneralhome.com K}~te C. Knipe, FD The Funeral Service for Helen L. Ammerman We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. i. PROFESSIONAL SERVICES: Direct Cremation $2,095.00 FUNERAL HOME SERVICE CHARGES $2,095.00 SELECTED MERCHANDISE: Transporter Cremation Container $165.00 Alternate Container $ 150.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $2,410.00 AT THE TIME FL'IvERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN' PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES: Certified Death Certificates $60.00 Newspaper Notices -Patriot $452.17 Newspaper Notices -Easton $227.50 Newspaper Notices -Clearfield $107.25 TOTAL CASH ADVANCES AND SPECIAL CHARGES $846 92 SUB-TOTAL INITIAL PAYMENT /DISCOUNT /CREDITS TOTAL AMOUNT DUE $3,256.92 $o_oa P~ -------------- - - - - - -- - 53,256.92 ?IG~~ /~~%~ Invoice nvoice Number. Bill ~sved by: Eagles Ridge Golf Club nvoice Date: July 08, 201 I 122 wm. Cemetery Road Curvvensville Pennsylvania 16833 Goff Shop: (814) 236-3669 Fax: (814) 236-3765 E Ma~7: eaglesridgegolF@aoLcom o: Ship to (If different address): Ammerman Same 30 Pinetown Rd. ' berry, Pa. 17339 17-691-6'760 SALESPBR,SON ORDER NO. DATE SIIIPPSD SHIPPED VIA F.O.B. TERMS JCF '~ DESCRIPTION UNIT PRICE TOTAL SO Adult meals $14.95 5747.50 3 Child Meals 57.50 522.50 SUBTOT $7'70.00 SALES TAX % 0.0696 sAt.ES T $46.20 SfIIPPING f3 HANDLIIV N/ ~3~~~~cs BALANCE DUE UPON RE $954.80 *Please make Check or Money Order payable to: ,, Eagles Ridge Golf Club If payment has already been made, or if you feel there is an error with your account, please contact the Golf Club at once. ,- ~~.o~ ~~ ~~3~z ~~ ~i REV-1513 EX+ (Oi-10) ~`'i Pennsylvania i)EPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: FILE NUMBER: NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under 116 (a) (1.2).J Sec. 9 1. /,- // ` ~dG/~Gi' ~. G!/C(K ~O / ~,(6!!~~f ~~ ~ L _/ oLI~C T'~~r~( ,~~ ~.r/~ir9 h~ yr~ sf-_ s.. ~GG C1. ~f'1~N 1Gr'l~Lt4~ X30 /J,~e~~v~/ ~~' . Pte{ t~.3.39 ~~Isb~,- Sc>iti ~ o-~~ ~~irc~ ~ , . ~ P~~~Way .-jrr ~t~ ',~~,-~ Sfaf~ GU%~ P~ X680 ( 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. 4 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. If more space is needed, use add'Rional sheetr of paper of the same size. i Last Will And Testament Of He%n Ammerman REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 201 1- 00801 PA No . 21- 1 1- 0801 Estate Of : HELEN O AMMERMAN /First, Middle, Last) Late Of : SlL VER SPRING TOWNSHIP CUMBERLAND COUNTY Deceased Social Securi ty No : 153-16-4575 WHEREAS, on the 19th day of July 2011 instruments dated: May 23rd 2005 September 9th 2009 were admitted to probate as the last will and codicil of HELEN O AMMERMAN (First, Middle, Lasil late of S/L VER SPR/NG TOWNSH/P, CUMBERLAND County, who died on the 9th day of June 2011 and, WHEREAS, a true copy of the will &codicil as probated is annexed hereto THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: LEE O AMMERMAN who has duly qualified as EXECUTOR(R/Xl and has agreed to administer the estate according to law, all of which fu11y appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 19th day of July 2011. egister of l 1~ 1 et?(ity **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) '~ ,/ ,~ ,( ]'y ~L,t~~/A~r 1..~'~ .i~.,F~Li Il L'ryl lli fd x't'" -, ~~~ i, 1tK~ela t:>. ,~mrllc;r-lt~an; ;~r`.-'~ ~L.cllaJ-iicsburg. l~enns~;-lvania, revol{e m-~~ fc~rrller ~'iii€; azic~G:~il~ils aim ~ "=, ~ ~L j~ cle~iare this to ~~e :n~, i,ast '~:~ill and Testal~nent. ~ -~- r,=, _--- _~~ ~~ - :. IL3EN~~IFI~'_~TI®N ~F F.AtiIIL`~' ~~ ~ = ,=~ 11 , ?"i~Trl't;S t)t 1 ~~ ~.:t`±sicirE'n are t~!~ej~a t~171i"TIeI`i31an ~'althd)p, ~,ee ~~. :'-'iITililerlTlan_ atl~ _Ql :6~ ;~,'22111@T"rltaLi ~~orgar~ All ? e~ereJ~rces in this ~~v'ill tc~~ "my children" are references to the above-;iamc~ ~~~.iidren ~R~I`I(~I,Ia P,~l'MENTS OF DEBTS ANI~ E;XPENSF:S 1 Ct:~ ®CT that TTI~` fiL'.>t dE;l)ts_ rttrteral eXpellSeS. and C.~r)enS~'S t>~ 1a51: 1llnesS i7e tIr>% 13~is~ 'tC)J"Il [irt ~':?t~2t~;.. ARTI~"~F~ IIl DISPOSI`FIQ~~ [;d~' PROP~Ia I'"~' ~.esadua ~ ~~tat~, ~ di:~-a;,t tlla% m~; residuary estate tae distributed to rYl~, rilitcilren) in e~~tr;a? ~,nales. "f l-1er~ arc outstalldillg lc,al~s to .cruise Amtnerman'vtorgarl, totaiirig ~a,~3t3~~.~ar~.; {~~hictJ ;she needs ~`. ~ 1-e~ay ~~~s ~l~e estate (See at4acled ~~ocumentatio~lj. Ifs chile of mine do>es nc3f sur~~ive J-ne, such decc.ase;i child', share shall be distributed i=? equal Shares tc~ the children o~`such decea5eci child wl7.o sur~`l~e €~,c °>v ri~.lit ;~;~ ~-epresentaticJ~. ii'a child oflilille does llot survive me and has nQ children ~~v"ho sun~ive mc, such deceasd ~hrld's snare sh~li b~ distributed in equal shares to m_y other children,, if an~~, cr tQ their resp Cti~,e children ~?y ~"J,.;Ilt tl~ rel7r~:^~t:lltatJ(~il. It 11L Cflild Q~ J~iline SUr`~'1~'eS lYtC, and li~?7C?t',',,', C`:~ ?'?~' deceaSe(1 "~ '~+-en :ACC stxlvived b~~ crl;il~l~ren, my residuary estate shall be distributed to rn~= heirs-at-law, their lE2el;titles and 2espectiveJShare ~~ be determined under the laws Qf the State of3 ennsy°JVania, then X11 F ~~'~:c,~.. a~ if di~:d intestate at file tame fired for distribution under this prQVisiclrl l4.R~I~I~E k 6' NC)NIN,-~'I"ICIN OF 1<~F;(:I~'T()It rlc~&llirlate ~ee ~~ -~1'T1nleriTlan. s`.)f i.ey~~lsberr`~. ~'ennSyly'ar?r: ttS tll.'. L~.Xet;Utor, V4itl"+.~1t a1{?Ells ()r S~~'tir'st~`,~- it Y:_ee ~..~lnmer€lan does not sersre for env reason, l nonrJate Brian i~-au~lop. ~~t" i~eba~,a>n, l''enrisyi~allia t:~ Mfr;: ttJe ~.necutc~r. ~vJthout J3oncl or securlt~r. ~~RTI~`I:I:: ~' ?`+¢y `G~E°~'.lit~ifi. IP cz,li:i.tlCli`i t4? UtlJes"' ~(;)Ve'G'r 5 ana aUtllQrJtY ~1'arttf;d b}' law t)1` neCe45al'~, 4 r :ip~,~?"C?}~I':~Zt aC~_++" ~~;?~cr ~l~Iilllif^stl'2?li~~:,., Sllali ~1at%~~ i.lle i`if?11t and ~Q!~;`er t4~ i.':Se, sE:l~, 1T2G;1-t<ti.;,c1~~., )r C..7tSIC:'~,x-1St.. C'i1Cl:l1'1~eP ~i,1T,, J"eel Crr personal l>rcl3erty t~2at may be ZnCiuded lJ'? n'1_y' ~-'Strltt', e~'itll'JUt ®rC$E:r Ci~' CtTI?i`t %l's7~t ,,.~tf CJC,Gk il)tiCB ~(? a.:FUli~. '"+~\' l=.)YeCUtO:' SCci31 ?lad ~ the 1-Jzsllt tCt adn111llSter tl'3~' eS~at' tiS1Cr~ ' 4~1~i)i~r4"1~' `'s.~nSLtx~E'i"`w ~',~`. ,'a.`. '`independent` prai?ate ore ,uvaient legislation designed c7 opelaR: witl-€tau unnecesyr~l-'d~ illler~entioll b4 t?le ;.}rebate cs3r`~ ~~ ~a,__._"_ K ~~ -?rZz..'"a ? 'r~ f'9 ~}ICl ~~cT?l.~Gi. i:tC ':itSCS £?S:•~t~t ;v +slc; x:~rd~,':9~3~15':}t ti`..S ~~'1±% ~s~ ??;,.., ~. is> 1."mot <.. ,®.----~ i~ ~','id. 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