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HomeMy WebLinkAbout12-06-111505610101 REV-1500 t:x ~°'-'°' ~ PA Department of Revenue Pennsylvania OERARTMFxT OF REVENUE Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX z8o6o1 Harrisbyrg, PA 1'7128-o6oi RESIDENT DECEDENT ENTER DECEDENT INFaIRMATION BELOW REGISTER OF WILLS Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY . ~ 8 ~ Y _ 8' /~ 7l17•fo~,l~ * ~ bD~s;_ :O°-„~ ~ ~ 020 / © 0=9 / 9 sz ®..~ Decedent's Last Name Suffix Decedent's First Name (If Applicable) Enter Surviving Spouse's Information Below 1 Spouse's Last Name Suffix Spouse's First Name m:.; .- a .~o...... i.~__ d . .,~ ~ tit / I-~ ~ ~ Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return OFFICIAL USE ONLY County Code Year File Number ~ ~ j ~~o D o~~ ~' 9 MI C~ MI :$ O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) ~ 6. Decedent Died Te$tate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of 1Mill) (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 SE TION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number CH A-,CGE~ ,~ ~N / ,~~.Ds / l / 7®/ 7`7.(;:020 ~ First line of address ~ c ~ ous F,~ ~o~~ SeJJCO/Ind line of address / V ` 't~ City or Post Office A9 ~' ~ H A- N/ C S 8 u ,~ ~ REGISTER ~ WILLS USE ONLY ~ • T ~ ~ r, r t-,., ~ r'~ ~ m -=:f~~ I ~ - ~-~~r)`~ ,i] --f ~TE FILED f`) ; ~ ~ ~, State ZIP Code ~~ Pft 174~Sy7.3>S Correspondent's a-mail address: liecJ/) / Pilus;~ ® ~~CQsf ~ %fG~ Under penalties of perjury, I de~lare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, c rrect and complete.'Declaration of preparer other than the personal representative is based on all inforrnation of which preparer has any knowledge. SIG RE OF PERSON ON IB FOR FILING RETURN DATE ~~/Z /// AD RESS K/F?l/ ql hipNS~N & 30/ N. Figderiak ~ ~ /y/ Gni csbKr~, /~/'~ /70 5~ SIGNATU PRE~~P~~}} TH HAN ESE E DATE ADDRE /}Rf~FJ ~ VS ~ Dlfst~- t ',/?./ // i /11tch~tnrcS urfi ~ /90s PLEASE USE ORIGINAL FORM ONLY Side 1 15056110101 1505610101 `~=. ~:~ r- , r-. i J REV-1500 EX Decedent's Name: ~~G/1~!/Y~ ^• vSOus~ RECAPITULATION 1505610105 Decedent's Social Security Number 7.1 ~~{ lib©~ 1. Real Estate (Schedule A) ............................................ . 1. ~ ~~ .. .;~, . 2. Stocks and Bonds (Schedule B) ...................................... . 2. ~ ~~ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. *. D . , ~: f 4. 9 9 ( ) .......................... Mort a es and Notes Receivable Schedule D . 4• ' ~`'~'~' .~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)...... . 5. ,~ 7 sfQj ~ 0 y 0 6 Jointly Owned Property (Schedule F) ®Separate Billing Requested ~ .... . 6. !' "~~ ~ 19 , 3 ~- ~ -8 . 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property ted R Billi 7 " ~ ' '~", ~t~a,~,z. ~ N ~~' ,~ ~ ESQ ....... eques ng (Schedule G O Separate . . ~ . , se a;~iSo nv~e ~ vh sclvd /~: . ~ 8. Total Gross Assets (total Lines 1 through 7) ............................ . 8. , - D ' $ ! S I _~ ~ ~`_$ - -- 9. Funeral Expenses and Administrative Costs (S~hedule H) ................. .. 9. , 3 ~ ~ O b ;.. 02 ^ U 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) ............ .. 10. ~ ~ 2°,g~ D ".-3= ~ , . - 11 , ~rr,~x~ , .~ - ,,y b ~ ~ ~ 6 ~ y ~ 11. Total Deductions (total Lines 9 and 10) ............................... .. ; , 1 ,_, ,~ .. ~ ,: ,. ... ,; ~:.. ~ t :~ 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12 13 Charitable and Governmental Bequests/Sec 9113 Trusts for which " "W c ' "' ' "' ":' ''}"' `''s "' . an election to tax has not been made (Schedule J) ...................... .. 13. ~ ~ - O d 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ?~ ©~~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 '°"° '°"°~' 01Z ~ ~ ~~ D (a)(1 2) X f""° 15. ~ ""~~. i. ~ ~": ~+ - ~ ' O G'y~ 16 . . Amount of Line 14 taxable ~" ` - ~~ 'r,~ ~ ;~" ~ 1 t "~ ~ - "1 ~ . ° 0 O at lineal rate X .0~ i ~ 16. ? ~ ~ ~ - ~ - 17. ~ ~ ...,fir.. _'_'..~~.~:..` Amount of Line 14 taxable ~' ~ O 17 .. _ ~ ~ O at sibling rate X .12 " . ' `~~ '~'- 18. ~ Amount of Line 14 taxable © ~ 18 ~ 0 O at collateral rate X .15 t. K .. ~. {-rte. ~.N.4, .. ~. ' . ~ 0 19. ............:.......... TAX DUE ............................. .. .. 19. ., a _ , 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 J REV-1500 EX Page 3 Decedent's Complete Address: File Number ~~--~~-5~ 9 DECEDENT'S NAME Richard E. C/duscr --- --- --- -- - STREETADDRESS /a~ E7 W G rCC/1 ~t- CITY ~ STATE ~~ ~ ZIP ~~~~~ /11echQni~sda Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments '¢~, 99e~ Sb B. Discount rt /S7, S~ 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, inter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, IJine 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) D '~lut~e rwtc : !vc are ncf r~utsti~ a r-e.lund acf >~i%s ~i~ as ~~ be,/:eye ~aymeie,~' !Hill br 3grkwl~trt irk ~ @/ox ~r»xi~,~y ~ ~e 4/no~u-t ~/~,i~ala/ t' Make check payable to: REGISTER OF WILLS, AGENT. ~ :a. h~ osde q! PLEASE ANSWER THEj 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; or .......................................................................................................................... ^ d. receive the promise For life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "im trust for" or payable-upon~ieath 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 d{'signation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABpVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1B95, 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 dges 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 v81ue 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 IP.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has ~t least one parent in common with the decedent, whether by blood or adoption. (1) Q Total Credits (A + g) (2) '~ 3, /,S D. pO (3) ~ REV-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER 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 which is Jointly~wned with right of survivorship must be disclosed on Schedule F. ITEM I I VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ,~/~ ~l ~Gf ~OiEL~G O~ /anal ,!'/lr~ Ana i/1~ j0/'D!2'/!IC/7fS ~~~a aree/~ 6~a~:.r~ ~ address ~' ~z~ !~. G/'ten ~`. in ~ .Qorok4`, c~ /~~~fiarl~~'s~tll~. CuHtr bar/~nd(ou~~ji . ~~~fy~I~~fllA !~/LiiG~? i S /store Parfitr~/a r/y desCr~,6e~ i~ ~ia~ Cerfa,n deed ~re~ 1r e9~af ~i13f1'W GhOff C'o. , .r ~eans~/r~ua ~,I~bota~eir, ~ /f/Gltitrd E. (~~oaser ~icll ,E7,~6~ f~: ~/oaser, !.s w, ~~ a~~~a/ ~~ yf ~z, /97/ u~ r~ u~ra~e~ !~i ~ Dire D~ 1~ /Pc°('o~a~c.- o~ ~~'s ~' ~ ~r ~u~der~a~r~ ~dun~, ~nns~l- V~a Gti /~eec/ ~Dk "~7',' Vol a~ prye /~6 ,~ ,~ ,~ a;scuss;oa w,~ ~ro~y ,~ ~~.~ ~ ~ yo,: s, o~v/o . ,¢f flit C~~ d><.-l•~ C~~u,ty .errs L'SE' i~iir~~aA+, Gtae a~~ ~;s h:t9 ~r <s ~rssef as u~tde~.r/arpd ~uu/ u./lPS/intc>/~ed . 4~1cc ~ 9tf ~t ~~p~y l~Q/ue~ tea' ~o%/ `/e s/i~~ ~c ~/'/Xa~y ~ Fie, u//!i rG'/~o~~ii~9 ~i i5 !r'SSG'~~ Gr~ttC~ ~l s ~ls~e ~Zq~ G,~ ~~bpra~J/'ii~'TC !f¢~uC 1~'OI~S OrJ Q' Sk~1 jo%fa~ ~~l~i~. TOTAL (Also enter on line 1, Recapitulation) ~; u/JOtjf;; acrd (If more space is needed, insert additional sheets of the same size) REV~1508IX • (19~ SCHEDULE E COMMONWEALTFIOFPENNSYLVANIA CASH, BANK DEPOSITS, $c MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER I~Q-'char~ ~. C/ouser a~-~o - s~ 9 Indude the proceeds of I'diyation and the date the proceeds wen; received by the estate. All property jointly-owned with the right of survhrorship must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION Q OF DEATH 1 • (~P,~Tn~f1~, u. ~, TrCasurr ~ C foSGou,t' IO~D PP,~-SOna! Si'LCOMG 7"~ ta00• oO ~. /99S F~a~ ?ruct , v/n/ /FTE'F /SNX .~N g 69 ~z 1 Soc.D 7b 7]irto?.s/y C~ouSE~ ® ~~~ ooo. °O '`a~ ~o•or ('sue ~etrxtnt arfitcJurl~ /h~'scel/~totrs G'o%r~s A~tp~ Currc~s c~c ~3. 00 ~{. M+sc~Ila,n~us Housclt.old ~u.rn-s~-ngs and isms ~ Nofi~ f&e m ority of i~tms in ~ hausG ~bolonq~l ~ ~~cedu~~' J ion ~Vi ll~i R ~/ ~ 1^6Si G~~ f~iu•t ~ Q,1S0, ~¢. ~leC~ic /Q~inC!' Chair f ~~• o0 ,Q. 7G~GvjSio~1 '~ 75: ao C' . /loll ~p G~e~Sk ~~rrss ~oarc~l ~ '~.Z b• a~ ~. ~RS.~i%r1q ~aC~iirlt old /11a/fnss ~ ~~ Sprin s -- ~t~ ~ no va,1u~ ~v~oQ - o0 9 ~'' ~ oild kn~ %ablrs ¢~D~oo TOTAL (Also enter on line 5, Recapitulation) S oZ, 758, °o (If more space is needed, insert additional sheets of the same size) I Timothy F. Clouser accept the terms of the transfer of the truck. I will assume ownership of the truck as part of my inheritance and acceplt that the agreed upon amount is $2,000. ~k:3-8-11 Timothy F. Clouser ~` MOTs RIAL SEAL (31NA I, Notary Public Camp HiH ,Cumberland County My Commission pire6 February 12, 2014 e~' •, } . VyY~bbebt.i ./~4 ~~.ax l ~!'.. ,. ~ ~~, t.. b ;~, COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF CUMBERLAND ) SS: `~'>C:~ aEV-~sa3 oc. l»n SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF -/ G FILE NUMBER a/ /Q` .S~q ff an asset was made joint within one year of the decedent's date of death, R must be reported on Schedule G. 3a/ N. Fs+ederiaL Sf' A~Ceh~t/- i CS~-arg, PA /7o s S /y1~~iJic'S.d tsr9, ~i¢ /7o SS' RELATIONSHIP TO DECEDENT ADDRESS SURVIVING JOINT TENANT(S) NAME A. KR~7H~eYN ,T. NtlNS4V~~2 B. R ~CHR-aD e. t".LauSl~i?, .lit'. c. JOINTLY-0WNED PROPERTY: daughter aon REM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include dame of financial institution and bank account number or similar identifying number. Attach deed jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ,. A. ~f~/o9 /71E~h9BL~2S /sT' F,~», cREn/r u/Y~o~/ /iu~: ~) S,wi~yts ~~= .-/o• z 992 ~!-vo f rya. ~y Sbyv ~y~2/. Lz .?. /f. ~ ~~09 (f3) ~hecX%nq /~ ~/v. Ly~LB~- ~I d ~ 7~7, t~ SDya ~35aF,~f 3. !~ ~I~9/o'?' (~~) ~Cu°~•~ aF ~JOs,t n~o, d99~S'1-~f 3 ~3a, 8'26,6~f Sbf~ '~~ s, ~~ 3.3z ~ (D~easC ~t ; ~i~'s C. D. taws cs{tb/;s{~cd on Sf i~~09 l~i~~i is ~'~ ~:n ont year o~ ~° ' ~ yo~v~ver, ~%s ores ~ot+rchase~r,~, d ~•d • . .6a~k {ran sk+" o~ /Conies 4 Al~i/Z°G~ in1'~M- ~irp- Ili 4~/Y,sa~~/ ~~/ Csf,-~r/iSfie~/ ~IL~LK' S gG~OK/l~ ih TfL'/N / ~/~J a~e/~t° , S~I~i/7l , T ie~/nrle fAa o>~ one -/~a/F ow~rsl.;o l~t~ ~~ryy ,T. ~ Huns•i1~L°~' %/t {7~LSC /noilies i5 ,rte 6u%t9 ~~/~ as a l fe ~ii~r •~f ~ ~/f ~ ~ f ~ ~ • d G, size o~ ier m~ S ~va~ d//lrady hers e1~>~/Iu/.it/ 6ac~ ~ ~/iv~°. d ~7r 76q->aI nt ~ Add~~ioN,tl in~r, note : Ttem ~`Ct,,,) R oS aKd 7~em a7r 769- ~+ J Tw Ras a ~ ~i ~iG~14r~ F. Gott5a.~ Should b~ loi Iled Sapax'- o i~ ~ Saone has no~' alt~eady betrl done. r~ as ' / nt . kh. a~~d TOTAL (Also enter on line 6, Recapitulation) 15 ~ 6, rf 4 3. ~ S (If more space is needed, insert additional sheets of the same size) •~--r• SAVINGS ACCOUNT: Account Number/Suffix Date Account Establishecjl Principal Balance at Date of Death Accrued Interest to Date pf Death Total Principal and Accrui:d Interest Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account Number/Suffix Date Account Established! Principal Balance at Dated of Death Accrued Interest to Date pf Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CERTIFICATES OF DEF~OSIT: Account NumbedSuffix Date Account Establishep Principal Balance at Date of Death Accrued Interest to Date 'of Death Total Principal and Accruled Interest Name of Joint Owner Date Joint Ownership Eskablished St MEMBERS 1St FEDERALCREDTT UN[ON 299261-00 01/20/2007 $842.06 $.38 $842.44 Kathryn J. Hunsinger 01120/2007 299281-11 01/26/2007 $717.23 $.05 $717.28 Kathryn J. Hunsinger 01 /26/2007 299281-43 08/19/2009' $30,806.13 $20.51 $30,826.64 Kathryn J. Hunsinger 08/19/2009 * Transfer of Funds froiht Savings Account 299281-00 271769-00 09!19/2005 $93.38 $.02 $93.40 Richard E. Clouser Jr. 05/01/2006 271769-11 09/19/2005 $69.86 $0.00 $69.86 Richard E. Clouser Jr. 05/01/2006 C~ete.~.,a. ~, MEMBERS 1~ FEDERAL CREDIT UNION Leig~ Stallings ~~~~ p Lending Insurance Support Specialist July 22, 2010 Estate of: Richard E. Clouser Sr. Date of Death: 05/28/2d'10 Social Security Numbelr: 177-24-6605 5000 Louise Drive P.10. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org REV-1511 EX+ (tb-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER /~i`Ghar~ ~; L'/mUSer a/-/o - Sd~9 Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A• 1 FUNERAL EXPENSES: . rnt,~ /~1' _ __~,~i~ ~o~C dT ~~a/1L: GAS ~l.L~ , P/¢ ~'W/I ~~z ~ s~.lr~ ~, /7DLt4 ~0/p4~~rS, 1'~ilf re~ltal -~w' Gva,Cc ~oAtr~ d ~ /3a. 00 3. rich M~rno!'%c~l , lo~cbs{~~e p~ r: ~'~n 0 -- ~ ~/~o, o0 ~( ?, C. ~enJnty, C/of~tes ~IV 6u~y deeeu~~e+~f :n ~ 37, 9S ~: Pea.l~,rs mower .She p ~r Bower sGor~tis ~~ ~ur~cra,/,/ ~ 3 Ta„S~ (_ G/c,,., /yl.%~/t,.s SeU, ~ ofor•!4 w~~lv~ise .Z yi, 98 7 (~+ ,~rl. /~G ef~Dir~fS c>~o/'~ ~ /~/. OS B. ADMINISTRATIVE COSTS: ~: CriQ.)y~' J~q/.5,~%e, ~r lua,~le lt1/1G/i[,es~ ¢ /QS 9B 1. Personal Representative's Commissions Name of Pehsonal Representative(s) ~ei.~1e 4 n .1: H u.tlsi nger ~s o ~~, 6b StreetAddre~s o~/ N.~'Y`GdCPIGIt( Sf ; , City_ INCC.h~tI9/C$~h[rq State~Zip /7o5S' Year(s) Comjnission Paid: 2• Attorney Fees l.,rlQ.f7G~ ~, o~-e~~75 Ti ~5, ~',Z9. bb 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) / ~ Claimant ~~/j~~/~/~ C~~lSG"' ~ ~ su~ .3 . , StreetAddre$s /,f 6 ~!/, ~ ~~' City /~Pe/i~tn %cs6~s/•y State ~_ Zip / 70 SS Relationship pf Claimant to Decedent cS'D/) 4• Probate Fees ~ Dri9.h~ rSSKG p~ ShOr'r' CG-f'r ri•en~~ ~ ~ S3.Sn 5• Accountant's Fees ~~~d ~~I~eST1CJG , A''f:~01AXLI+rMf ~S~° yf~S l ~ ' ' f 6• . nseow~ loY~, P~ y0, vr. c f Tax Return Prepared's Fees ~,r ~ /D~1, PA~ ~l , tt. (e$~/)'prJ 3So,oo ~ 3S7J.a0 ~. Cwrnbe~-land L~~ 3'bkrnal~ ~5{'. Q,d~crf_ '~7S oo $. eu,rl;slk Se~f'~ntl, Elf; advert. , ~13y,~ty ~1 • ~ ~ I ~ ny ~ ~ i~es~, ~ st"a- o>~ I,u'~ l l s f- ~ s- o p ~O• A-dd'~ ~ona.l pro6~ -Fires. ~ ~12 b.90 See CDnftinua,~'oy~ ~~) TOTAL (Also enter on line 9, Recapitulation) $ J~~ 906, ~ 8 (If more space is needed, insert additional sheets of the same size) ~_Z ~, sc~r~,~. ~% p. 3 i s e~i~ ,y. _o O- ~L.a __ . •. ~i~- Myers Funeral Home, Inc. Boyd L. Myers Jr., Supervisor 37 East Main Street Mechanicsburg, Pennsylvania 17055 (717) 766-3421 Fax (717) 795-7291 A standard of excellence in Central Pennsylvania since 1!)10 Thursday, August 5, 2lti10 Kathryn J. Hunsinger 301 N. Frederick Street Mechanicsburg, PA 17055 Dear Kathryn, Thank you for selectin our funeral home to provide services for your family during your bereavement. I hope that you found ur services to be of the highest standards and that they met your needs and those of your family and frie ds. The following is a summary of the service charges as previously explained and provided in written forrln on the services for: Richard Elmer Clouser SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED $12,232.00 LESS: Credits granted 1,452.00 LESS: Total Payments 10,780.00 PLUS: Items ordered later 124.10 CURRENT BALANCE $124.10 ~ .a ;: ,:~~ ~~r~-'~ Credits Granted: $222.Oa Early Pay Discount $1,230.00 Package Price Discount ~ t ~, ~ ~~ ...:... PLUS: Items ordered 1~ter ~ ~ ~ 2nd Day Newspaper 124.10 ~ 1 ~ -~ 5 ~' Interest a~ the rate of 1.5 % per month (18 % per annum) will be added to balance after 30 days. ~ If there are any questions or concerns that remain unanswered, please call me. Sincerely, G~~ Ik f !f i /rtirb_ : ~rv,Aii,T w.v e~,b~ /.r~ilf~tGli ~G~ ~y~ /u.~~° A li f `~~ ~~ I . in REV-1512 EX+(12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ~~Ghard ~ ~~IL~~UMB~9 ESTATE OF C`D(,($~- ~ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unrei~nbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH ' Pe'~ '`is ~ s3 3, Nadioa w,~~ ~~ ~isur.) ~a ~ 7• sq y. ucz. "/733 ~. ( Dr, y~~~ k~lmore ~,~sao ? I k!i/l~' l~i~l ~efG1"/nor ~liAip y ~a y3, Go ~v:itd,.~j fl;/l Vi~thary Cl~/r~~ O ~~`G . X10 4 i tar/GS ~. O~iiGlia/s t11, ~~/im~ esft.~l`e ~/a~~,i~• `.~` - ~ ~ 2.70 TOTAL (Also enter on line 10, Recapitulation) $ J 2 $p ~ 31 (If more space is needed, insert additional sheets of the same sizel REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDI~LE J BENEFICIARIES FILE. NUM6ER ~`!~^ 5.89 ESTATE OF ~~~rd ~. fA~o1lSei~ NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TA~;ABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under 1. Sec. 9116 (a) (1.2)] ~?e bosh I~ ~z % ~' ca0att~/~ ~',~- ~~ `~95Fx L~,~crr~ ])r-• , /-larr;sbt~rl, ~~ I7~o9 a. /la f~ r f-n ~7" Buns%nycr o~a.uc/ l~tC~- L~~ 30/ N. FiYkdtrick St, ~echan, c s 6scr~, ' S P.¢ /7dS ~l~ 3 Sin /j?ecllanicS~k~j, Gfiaen ~Sf' /ab w ~s ~ , . S y~ 5~, Tino~i C%us ~r• y soh 2.Z Conr~l' Dr., Lle~j-l: s lam, l'/f /70 ~3 II ENTER DOLLAR NON-TAXABLE [ A. SPOUSAL DI 1. FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET )NS: NS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE ANiD GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II ~ ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF RICHARD•E°. CLOUSER a.k.a. RICHARD ELMER CLOUSER I, RICHARD E. CLOUSER, a.k.a. RICHARD ELMER CLOUSER, currently of 126 West Green Street, Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. L I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. I direct that my real estate, consisting of my residence and an additional lot be sold at public or private sale. My Executrix, in her sole and absolute discretion, may select the manner of sale she deems best. 3. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, is to be divided and distributed in four (4) equal shares amongst my herein named WILLIAM T. CLOU5ER children, to wit: DEBORAH A. DOZIER, I{ATHRYN J. HUNSINGER, and TIMOTHY CLOUSER. In the event that any of my said children fails to survive me, his or her share, as the case maybe, shall be proportionally divided amongst those named above who do survive me, er ca i a. FOR PURPOSES OF CLARIFICATION: my son, RICHARD E. CLOUSER, has been left out by design and not by accident. 4. I nominate, constitute and appoint my daughter, gATHRYN J. HUNSINGER, to be the Executrix of this my Last Will and Testament. In the event that she is unable or unwilling to act as Executrix, I appoint my daughter, DEBORAH A. DOZIER tb be Executrix in her place and stead. In the event that she is unable or unwilling to act as Executi er duecot'that thYnsha 1 not beMequired to file CLUUSER, to be Executor. in her place and stead. I furth bond or other security in the Office of the Register of Wills for the.purpose of administering my Estate. WITNESS WHEREOF, I have hereunto set my hand and seal this ~_ day of __, A.D.2007 `, G ~ EAL) C~~~ ~' ~~9~ j"~ HARD E. CLOUSER U~4 ~,T~ f AL) a.k.a. RI R CLOD 1 Signed, sealed, published and declared by the above-named RICHARD E. CLOUSER, a.k.a. RICHARD ELMER CLOUSER, as and for his Last Will and Testament, in the presence of us, who at his request and in his presence, and in the presence of each other, have hereunto subscribed our names as witnesses. ~~ ~ 2 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE }~ ~ ~-~ REV-1162 EX~11-96) BUREAU Of INDIVIDUAL TAXES ~ ~~~~"'"""~{` F" /~ DEPT. 280601 ~ '~"+ HARRISBURG, PA 17128.0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 013210 HUNSINGER KATHRYN J 301 N FREDERICK ST MECHANICSBURG, PA 17055 ACN ASSESSMENT AMOUNT CONTROL NUMBER fold TOTAL AMOUNT PAID: REMARKS: RECEIPT TO ATTY CHECK#116 INITIALS: WZ SEAL RECEIVED BY: 52,992.50 GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER