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HomeMy WebLinkAbout12-06-11 (3)1505610105 REV-1500 Ex ~~'1't~ OFFICIAL USE ONLY PA Department of Revenue P~Yt~a County Code Year File Number Bureau ofI'ndividuatTaxes "`"~°`""`"°` Po box zt3b6oi INHERITANCE TAX RETURN n _ Harrisburg PA ~~;tz8-o6o~ RESIDENT DECEDENT ~~ ~ d1,1 ~p~.Sl ((- ~~ ~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth hIMDDYYYY ~ `~ 9- ©~1- '~ 8 ~l 3 O q ao a o l i ~ a as ~~ ti7 Decedent's Last Name Suffix Decedent's First Name MI (N 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 ~~ 1. Original Return ~^I 2. Supplemental Return ~`~ 3. Remainder Return (Date Of Death Prior to 12-13-82) ~~~ 4. Limited Estate ~^I 4a. Future Interest Compromise (date of ~^~ 5. Federal Estate Tax Return Required death after 12-12-82) ~!~ 6. Decedent Died Testate ~^I 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 ~',='ti 10. Spousal Poverty Credit (Date of Death i.'^~ 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 Daytirne Telephone Number First Line, o/f Address C1 + n vt S ~ ~YY1 S Second Line of Add City or Post Office State ZIP Code ~e~~a..+n~cs~ u~~ PA l 7b ~p r ~~ i REGISTER OR'-B~ USE ONLY Cl) =jj ~ 17 ... n c: 7 ~,3~_.r- !'T7 t ~ ~f; -~~? c~ , .~~ ~`.j :,.... DA'~FlLED _~ r ; ~ ! ~,7 ~- ", ~ :. F _... e- J •7 Correspondents e-mail address: ~ ~ e. Y1VY1(1, ,1(~ ~- ~ C~ m 0. S~" • 'Yl ~ Under penalties of perjury, I dedar$ that I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. D ration of preparer other than the personal representative is based I i a6on~ of which preparer has any knowledge. SIGNA OF P R ON RESP NSIBL_J FI G RETURN CS~~ _~ DATE SIGNATURE OF PREPARERbTHER THAN DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 150561105 1505610105 REV-150b EX (FI) Decedent's Name: ~ 1 Q) 1505610205 Decedent's Social Security Number ~~q-~~-'1~n3 rcc~,Ar~ ~ YUiI IVn 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 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. ,~p l a !~ ?.~ 6. Jointly Owned Property (Schedule F) ~~ Separate Billing Requested ....... g. v 7. Inter-Vvos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) ~^ Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ I ~ 1.1 3 - ~( !~'~ 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~ ~ ~ (~ 6 ~ ~1 TAX CALCULATION - SSE INSTRUCTIONS FOR APPLICABLE RATES Ot 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 taxa le at lineal rate X .0 ~~ 5 ~ ` ~~ ~ ' /~ ~ 16. ~ / _ ~ ' 17. Amount of Line 14 taxable O~ lt~ at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 ~ QQ , ~ tJ 18 ~' ~ b 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ' LJ G n ' p 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. L 1 5 . ~` 11. Total Deductions (fetal Lines 9 and 10) ................................. 11. ~ I _ b ~ , 12. Net Value of Estate (Line 8 minus Line 11) ........ ~ `~'~ ~ ~ ~ , n ...................... 12. pj 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. a~3~.~~ Side 2 L 150561GI205 1505610205 J i ax rayments 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. (1) a n 3 ~. 31 Total Credits (A + E3) (2) pl 3 t . ~~' a (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~ O f •~ ~ 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 "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 benefcary designation? ..................................................................................................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R 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) ()]. 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 ofl 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. REV-1500 EX (FI) Page 3 Flle Number Decedent's Complete Address• ~ I , ant 1 ~ ~ ~ r ~ REV-i5o8 EX+ (u-io) SCI~IEDI~LE ~~ Pennsylvania DEPARTMENT OF REVENUE CASH BANK DEPOSIT INHERITANCE TAX RETURN PERSONAL PROP RESIDENT DECEDENT E S Be MISC. ERTY ESTATE OF: FILE NUMBER: C~C~~iz ~• ~~--e~ma.~n at-~II~~IC~1~ Include the proceeds of litigation and the date the proceeds were received by thie estate. All property jointly owned with right of survivorship must be disdosed on Schedule F. ITEM VALUE AT DATE NUMBER QQ 1 ESCRIPTI N OF DEATH 1. ~ C `y0 ~' G~,n t~ ~ CC O UvYI~S ~-O Yh~u ~nr1 ~ ~ ~ ~ ~~ 5 `T~ 7 ? 3.~ ~1 ~C~eckir t ~ ~u~ r s ~ mane (Y-~Y~} n Ile ~ ~ , `1 o~ , T~ t car ~1 rv m ~r~-sb~~ eRia,r Ic~omE s -~1~"111 ~ ~i~ X55, 08 n 3~ Ke ~,na ro ~r, Pry Ye.~ s i cue ~. ~.s t~a.11c~ ~Il - ~ t~ ~I'7. ~a cc ~ t 1. ~. ~(a.5r oY ~(Y~A\~ ~,u~\ ~ Ilt~l~on ~J,rc~lr~ ~ re l l~l• 5~4 U ~j~4-~~; ~ Corr ~e0.\~r ~~'~l ~1 5 '~~~ce~~(~fieot~s ~J~.~'soriA\ ~~ p2rt lOa.tSo ~ ~\~ C lo~e5 W ~~c~ clam e~0 ~o ~, p ts~ ~'~l 0. ~~sS~ 011 aS ~~S ~10.Y1'le. W0.S er~n~e~ ~ ~g IQ~ Y ~,~~~c~5~5 ~ Q~vu R ~ ~ `S `~ c~o c,.etvr~ c~ ~ ,ri-~- i o ~ TOTAL (Also enter on Line 5, Recapitulation) $ I to ~ , of y 3~ If more space is needed, use additional sheets of paper of the same size, ACNE BANK 16 LINCOLN SQUARE PO BOX 3129 GETTYSBURG, PA 17325 OWNERSHIP OF ACCOUNT -PERSONAL PURPOSE ^ INDIVIDUAL ^ ^ JOINT -WITH SURVIVORSHIP (and not as mnaia in common) ^ JOINT - NO SURVIVORSHIP las tenants fn oomronl ^ TRUST -SEPARATE AGREEMENT: ^ REVOCABLE TRUST DESIGNATION AS DEFINED IN THIS AGREEMENT Name end Address of Beneficiaries: OWNERSHP OF ACCOUNT - BUSBIIESS PURPOSE ^ SoLE PROPRIETORSHIP ^ CORPORATION: ^ FOR PROFIT ^ NOT FOR PROFIT ^ PARTNERSHIP ® Estate BUSBIESS: COUNTY 6 STATE OF ORGANIZATION: AuTHOPoZATION DATED: 9/28/2011 DATE OPENED 9/28/2011. 6Y bonnerh INmAL DEPOSrT a 57.773.97 ^ CASH ® CHECK ^ Xfer - ACNB aCd same owrtersttip HOME TELEPHONE # (717) 458-$4IIS BUSINESS PHONE # DRIVER'S LICENSE # SS~t 45605938 E-MAIL EMPLOYER MOTHER'S MAIDEN NAME Name and address of sorttsotte who will always know your krcation: BACKUP WITHHOLDiNO CERTBICATIONS TIN: 45-6a0~3~_ _ __ ® TAXPAYER I.D. NUMBER -The Taxpayer Identification Number shown above (TIN) is my conect taxpayer identification number. ® BACKUP WITHHOLDING - I am not subject to backup withholding either because I hive not been notified that 1 am subject to backup withholdir-g a; a result of a faikxe to report ell interest or ~vidertds, or dte Inte~rtal Reverats Service has notified me that I am ra kxtger subject t~ backup withholding. ^ EXEMPT RECIPIENTS - 1 arrkh an exempt recipient under tfie Internal Revenue Service Regulatfwns. SIGNATURE: 1 artily carer / of jNrjery tM staaerets dtmtM ie tMs eeatiee a.r >rn 1 aw a Bs. prsee • B.s. reelreet allee-. x NUMBER ~ 2454602 CLAIR W LEHMAN ESTATE 9 KINGS ARMS MECHANICSBURG PA 17241 ^ NEW ^ EXISTING TYPE OF ® CHECKING ^ SAVINGS ACCOUNT ^ MONEY MARKET ^ CERTIFK:ATE OF DEPOSIT ^ NOW ^ This is your (check one): EStat@ Checking ® Permanent ^ Temporary account a~eement. Number of signatures required for withdrawal 2 FACSIMILE SI(Y~IATUREIS) ALLOWED ^ YES ® NO [x J SI(NIIATURHS) -The tatdersigrrsd ague to the terms stated on every psge of this form and atdcrawledpe receipt of a completed copy. Ths tmdersigtaed ftrtlrsr autlrorim tM fatanaal instiWtion to verify credit and employment history and/or haw a credR roportiftg agency prepare a credit report on the tardaraigrled, ss hdhridusM. The ahx- adtrwwNdpe the receipt of a twpy and agree to dte faflowitp disclowrefal: ® Deposit Account ® Funds AveilabiCtty ^ Truth in Savings ® Electronic Fund Transfers ® Privacy ® Substitute Checks 111: LINDA E LEHMAN I.D. # 197-40-7312 0.0.6. 10/15J1949 121: GARY L LEHMAN I.D. # 210-445213 D.o.6. 8/21/1953 13): I.D. # D.O.B. (al. I.D. # D.O.B. ^ Autrtwrizea signer rk Accounts OnlYl 1 Lx J I.D.# D.O.B. '-^r-~` 4 ®issz es,k.ra sysums. k,c.. st. cbud. MN fvm, t.~sc-tnz~PA a~lsnooa (page f oP 2J Statement Date: ll/07/11 Account #: 2454602 ~'="AUTO""'3-DIGIT 170 1806 0.6700 AB 0.368 91 42 6nlllndllnnhld6uuldnlh~hdhlullnddnllud CLAIR W LEIHMAN ESTATE 9 KINGS ARWIS MECHANICSBURG PA 17050-2349 803 Page 1 FREE INTERNET BILL PAYMENT. NOW. ALWAYS. Meet your new checkbook. with Internet Bill Payment, you can pay bills and send coney to just about anyone. It's quick and easy - if you can type a few numbers and click with a mouse, you can do it. stop by one of our offices or contact us toll-free 1.888.334.2262. ESTATE CHECKING Account Summary Account # 2454602 Beginning Balance Activity Ending Balance Previous Statement Balance 10/Wu 557,773.97 + Deposits and Other Crediks 1 97.32 -Checks Paid or Other Det>ifs 3 71.79- - Service Charges .00- +interest Paid .00 Ending Balance 557,799.50 Days in Statement Period 27 Account Detail Date Activity Description DeposiWCn3dits Checks/Debits Balance BEGINNING ~ ~~~ 57, 773.97 10-]2 HK ORDERS F I ~ ~ ~ 11.40 57, 762.57 '~ CLAIR W LEWMAN ESTATE 10-14 CHECK # 1 50.39 57, 712.18 10-26 CHECK # 2 10.00 57 , 702.18 i1-01 CUSTOMER pEPOSIT 97.32 57,799.50 ll-07 ENDING BALiANCE 57,799.50 Checks Paid -• k~d"icates slat, in check number Check # Date Amount Check # Date Amount 1 10-14 50.39 ~ 2 10-26 10.00 ~ Total Number aMf Checks: 2 Total Amount of Checks: 560.39 END OF STATEMENT acnb.com • acnbbusiness.com • P.O. Box 3129, Gettysburg, PA 17325 • Phone 717.334.3151 • Toll Free 1.888.334.ACNB (2262) .~ ACNB BANK ""*"""'t'"'AUTO"3-0IGIT 170 1034 0.9920 AB 0.368 5162 IuJIhulllnnlJ~llan~61n11nIn161niindJullu~l CLAIR W LEF~MAN 9 KINGS ARMIS MECHANICS6URG PA 17050-2349 Statement Date: 10/23/ll Account#: 122815 Page 1 803 check out our low rates on have equity lines and loans! use. the funds for any needs you may have --- pay aff high interest bills, build your dream kitchen or pay for tuition. visit acnb.com or stop by one of our offices today. Equal titwsing Lender. Equal opportunity Lender. Member FDIC. ESTEEM CHECKING Account # 122815 Account Summary Beginning Balance Activity Ending BaNance Previous Statement Balance 09/21/11 524,986.33 + Deposits and Other Credil5 .00 -Checks Paid or Other Debits 1 24 , 986.5 5 - -Service Charges .00- + Interest Paid - 22 Ending Balance Days in Statement Period 32 Account Detail S.00 Date Activity Description Deposits/Credits Checks/Debits Balance BEGINNING BALANCE 24,986.33 09-29 INTEREST PAYMENT .22 24,986.55 09-29 CLOSING TRANSACTION 24, 986.55 .00 10-23 ENDING BALANCE .00 Interest Summary From ~9l2?J11 Through 10/23/11 Days in Statement Period 32 Interest Eamed S . 22 Annual Percentage Yield Eamed .05% Interest Paid 7`his Year 56.81 Interest Vlfithheld This Year S.Oo Overdraft Charges / Refur~ds Surnrnarv Description This Cycle YTD Total retumedl item fees .00 _00 acnb.com • acnbbusiness.com • P.O. Box 3129, Gettysburg, PA 17325 • Phone 717.334.31b~1 • Toll Free 1.888.334.ACN6 (2262) ACNB BANK "'""""""'AUTO*'3-DIGIT 170 9476 0.750Q AT 0.365 351 120 ludlbnlllunllddhunldnlhd~dhlnlho66dlud CLAIR W L~HMAN 9 KINGS AF~MS MECHANICSBURG PA 17050-2349 Page 1 803 Check out our low rates on home equity lines and loans! use the funds for any needs you may have --- pay off high interest bills, build your dream kitchen or pay for tuition. visit acnb.com or stop by one of our offices today. Equal housing gender. Equal opportunity fender. Member FDIC. STATEMENT SAVINGS Account # 9080030619 Account Summary Beginning Balance Activity Ending Balance Previous Statement BalancCe 06/30/11 Si, 663.45 + Deposits and Other Credits _~ - Vlfithdrawals or Other Debits 1 1,663.85 - -Service Charges _00_ + Interest Paid .40 Ending Balance S.00 Days in Statement Period 92 Account Detail Date Activity Description Deposits/Cnadits Vlrithdrawals/Debits Balance BEGINNING (BALANCE 1,663.45 07-29 INTEREST PAYMENT .14 1, 663.59 08-31 INTEREST PAYMENT .14 1, 663.73 09-29 INTEREST PAAYMENT .12 1, 663.85 09-29 CLOSING TF~ANSACTION 1,663.85 .00 09-30 ENDING BALANCE .00 j Days in Statement Period Interest Ealmed Annual Percentage Yield Eamed Interest Paid This Year Interest Withheld This Year 92 5.40 .10% 51.23 5.00 Statement Date: 09/30/11 Acxount#: 9080030619 acnb.com • acnbbusiness.cotn • P.O. Box 3129, Gettysburg, PA 17325 • Phone 717.334.31111 • Toll Free 1.888.334.ACN6 (2262) ACNB BANK ""'*""""'*AUTO*'3-DIGIT 170 3680 0.832a AT 0.365 151 241 h~~Ilh~d16~~~1~hlh~~~~6hJhd~~l6l~dh~d~hd6~d CLAIR W L~HMAN 9 KINGS ARMS MECHANIC$BURG PA 17050-2349 Statement Date: 09/30/11 Account #: 1645773 803 Page 1 check out our low rates on home equity lines and loans! use the funds for any needs you may have --- pay off high interest bills, build your dream kitchen or pay for tuition. visit acnb.com or stop by one of our offices today. Equal Housing tender. Equal opportunity tender. yember FDic. CLASSIC MONEY MARKET ACCOUNT Account # 1645773 Accourrt Summary Beginning Balance Activity Ending Balance Previous Statement Balance 08/31/ll 540,066.98 + Deposits and Other Cred~ls , 00 -Checks Paid or Other Debits 2 40,071.16- - Service Charges .00_ + Interest Paid 4.18 Ending Balance 5 , 00 Days in Statement Period 30 Account Detail Date Activity Description Deposits/Credits Checks/Debits Balance BEGINNING BALANCE 40,066.98 09-21 CHECK # 142 8,947.59 31, ll9.39 09-29 INTEREST PAYMENT 4.18 31,123.57 09-29 CLOSING TRANSACTION 31,123.57 _00 09-30 ENDING BALANCE .00 Checks Paid - • Indicates skit; in check m.nber Check # Date Amount Check # Date Amount 142 09-21 8,947.59 Total Number o~ Checks: 1 Total Amount of Checks.: 58, 947.59 acnb.com • acnbbusiness.com • P.O. Box 3129, Gettysburg, PA 17325 • Phone 717.334.316'1 • Toll Free 1.888334.ACNB (2262? Pennsylvania Act 171- Attachment a Calculation of Private Pay Refunds for Ex iced Residents for Pennsylvania Assisted Living & Nursing Facilities ( for contracts entered into on or after February 7, 2003 for residents who are 60 years of age or older) ~ be completed by business office staff ..., . Resident name: Clair w Lehman Community name & Bevel of care: (choose from drop-down list) Green Ridge Vithage -Nursing'. Birthdate: 12/22/19'i Z Age on move-in date: 93 Move-in date ~' i 2/3/2010 Date of expiration 9!20/2011 Number of days between day the advance payment was posted and the date refund check will be mailed 52 Number of days in the month of expiration ~ 30 Number of unused days that were prepaid 10 Daily ekler care services charge (included in Room- 8 Board rate) $ x.00 Unused elder care charges on which interest is to be paid $ 560.00 Date advance billing paid (from statement or acxount inquiry) ~...m. _ ~ 9121%2011. Month ending date for month of expiration 9/30/2011 Date refund check is to be mailed Interest rate per year 3% Amount of refund (excluding interest) per Ancillary Charge Report and A/R statement; enter amount as a postive amount $ 3,152.69 Interest cak:ulation for interest on elder care services paid in advance $ 2.39 Toil amount to be n3funded ; 3,155.08 Refund To: Resident's Estate or Personal Representative _ .of C~airw..t Address ~.t.ehman Address ~ ..Amts City, State- Zip Cade Mechanicsburg PA 1705Q PRESBYTERIAN HOMES 11/11/2QlY ESTATE OF iNVOtCE UiAA'fE ~ REF ID DESCRIP71pM 9/19/2011 REEC~, EI* GRV REFUND WITH INi'ERFST (ACT 171y W LEHIVIAN 3155.08 0.00 3155.08 CHECS A~+1QIIN3' 53,155.1#8 ~ T~T/4L$ $3~ 155.08 50.00 S3, 155.08 <~ ,, ~~VIERICAN PROGRESSNE u~ a t~xrn n+suwwce coManrrv of Nflnr rows October 24, 2011 '`~~ Linda Lehman And Gary L Lehman C/O Linda Lehitan 9 Rings Arms Iiechanicsburg, PA 17050-2349 PO Box 130 Pensacola, FL 32591 800-645-4116 ~" www.UrriversalAmericanlnsurancePlans.com - --- - _ -- __ - - - - - - -- Re c Policy Nwptber : -045107469 Policyholder: Clair W Lehman i To Whom It Play Concern: We are sorry to learn of the .passing of Kr. .Lehman, and wish to extend our sincerest condolences to you and your family. ' As per your request, we have cancelled the. above referenced policy effective September 21, 2011. The enclosed check for $97,.32, reflects a rel:und of the unearned premium.. i ._, . Should you have any questi"dns or further concerns, please feel free to contact our office at 1-800-645-4116. Sincerely, HI'iA Policyholder Services cc: Piichael J Clinton 710 Longs Gap Rd Carlisle, PA 17013-8527 P14 REV-1511 EX+ {10-09) ~~ ~~ ~' Pennsylvania DEPARTMENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Cl c~.~ r W . ~--e.~m a.r, _ a. t - ~o"tip - ~ h ~ ; Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A• FUNERAL EXPENSES: 1. Pr~•-~ A~~ ~. B. ADMINISTRATIVE COSTS q -7 ~~ ~ Z ~ L 1. Personal Representative Commissions: ~ ~ ~ ~ Q ~ ~ ` ` Name(s) of Personal Representative(s) r~__1_~ V Q- ~ ~~(\ ~.~.. ~ I ~ O~~ ~`~~- Street Address R.•~e~r City I ' k- _ State ~ ZIP _~~ _p ~ (~_ Year(s) Commission Paid: ~o ~~ __ a.~~ Gc~Yy ~~~ m ~-n ~ ~ aaY e SS o s..• 3• family Exemption; (If decedent's address is not the same as daimant's, attach explanation.) Claimant Street Address City _ __ ,State ZIP Relationships of Claimant to Decedent 4• Probate fees: /~J I l I'~~ 5• Accountant Fees: 6• Tax Return Preparer Fees: ~ 0®, ~ Q ~. ~ 5~w,~e. ~~e-~~ ~ e e. t t , ~ 4 $ ~,a:~~or(~\ Qrob~~~ ice, ~5, ao q ~,l:r a~ Tr~e~~ ~a.re~ o..X Re,~u.v~ Fe ~ t ~, o v to F~\~ h ion Tnvs~~~vr Fec. 15.00 l~ l© ~ec~~ ee~~~~~ea~s ®9G.v~ ~a 6 c.~ La 4, O If more space is needed, use additional sheets of paper of the same size. TOTAL (Also enter on Line 9, Recapitulation) ; ~ ~ ~ ~ ~ ~® i i i' j 1 ~~ I i ~~ ~ a3 CLI1fR W L~IAAN ESTATE (( s M~ii~, PA 17960 ~~Q1~ ~.`1 ~~~ ~•. Dollars el 1~~~~NK ~ C~,~ ~~,~. * ' ~i , ~ ]i0P x:03 i3a9945~: 245~460~ 2+~' 0 L ~~~ ~~~TK • e+ Kovacs _ For ~:0 3130 9 ~} 4 5~: ,• 245.460 2d' 0 i0 2 REC13I PT FOR PAYMENT GLENDA FARMER S~TRASBAUGH Receipt Date: 9./27/2011 Cumberland Coup y Register Of Wills Rec~rpt..Time: 14:19:51 One Courthouse qquuare Receipt No.: 1067129 Carlisle, PA 1'~Q13 LEHIKAN CLA~R W ~ Estate File No.: 2011-01017 Paid By Remarks: L INDA LEHMAN D B ~~'------------------------ Receipt Distribution ---------- `o Fee/Tax Description Payment Amount Payee ------ Name ---- ~ETITION LTRS TE1ST R 90.00 CLIMB `' 15 00 CUM T COUN'1'Y GENERAL , FUN SH T CERTIFICAT~s . B R 8 00 CU ~; AND COUNTY Gr~nzunr. F N JCS FEE AUTOMATION FEE . MBER 23 50 BUREAU LAND COUNTY GENERAL O.F RECEIPTS & CNTR M D - ----- - 5.00 CUMBER LAND COtJNTy;GENERAL . FUN Check# 6103 Total Received......... --- - $141.50 $141.50 Ci.A1R W LEHMAN,i ESTA3'E MECHNd~ PA' 170BD For~.~d~-~ x:03 L30 'I04 i B 3 4~ llMe ~- ~? r ~_: ~~ ._._= jars 6 '~~- 245~460~ 2r 0 i REV-1512 EX+ (12-08) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES A LIENS RESIDENT DECEDENT ESTATE OF ~ FILE NUMBER ~Q~ ~ ~ . ~,e~ rkar~ ~l~o l l - l ~ ~ ~ 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. ~~~,\eni c~.m ~ car m o`c Q~'1~111 Pd 1a~n~1t 50, 3q '~ ~ eh 1'~ 1~ ~L~rr~ Ph~Ym~~ ~P~~i~ Pa ii'j9 t~ 55, 3~ `~ 1 ~C~. ~~~~ TOTAL (Also enter on Line 10, Recapitulation) I $ j (5~ rl ~~~ If more space is needed, insert additional sheets of the same size. ~- _. _ - INVOICE ~09I25/2011 Account Number. GRVN1612~ ClAIR LEHMAN ,yo ~ ~~ 61705GRV s ~+gs Awns PVT _~ Merg PA, 17050 ~~j Amount D~~ , J Amount Paid: Please Detach Here and Return Top Portion With Your Payment ` • lnwioe Date:09/252011, A~:GRVN1612, LEHMAN, CLAtR, Gr+Ben Ridge Wage NC - PFg, A, rU1STYVIT~~OfjA~RRYIT('~~ T~ - X11 - 6348682 -: - - gQ:00 _ ~~t 00487-0¢ot-Ot Sdi~ion 2,5.0.5 MGANt ~ - - --- -- - s -_ . _. 6:0o _ - c - - s " o:ao" `-i soo -~ we o9rD11201 ~ s3o557a .30.00 ~Trarodamwl ~n za ~ o.~ s soo ~ s o.oo s 6_0o Rx 09105J2011 6348682 90.00 ~~~ Ytialdion Sok,Uo„ 25.0.51AC3r3Ai< S 6.00 c S 0.00 $ 8.00 RX 09f 09112011 6312885 10.00 Humin R t~ieatan Soiuion 100 IN~NTAiAL. ' S 9.00 c ; 0 00 S 9 00 OTC 000022 1501 . . 09J162011 6312885 10.00 liu~in R kijec6on Sa4ian 100 UNRIM~ 3 9.00 c S 0 00 S 9 00 OTC 0000221501 . . Q9/16R011 8348682 90.00 kil~ala0o~e SoY,ron 2.50.5 0087-0201.01 = 6.00 c ; 0.00 # 6.00 RX 09M612011 4015960 1200 Loramepwn oral Tabbt 1 MG ; 4.7$ c i 0 00 S 4 78 RX 00987.0241-05 . . 09V17/2011 2018676 30.00 Iiioiphine Slarele OooS~-ao~a4 S 3.61 c ; 0.00 S 3.61 RX 'vtil.iY t-~ihGY4~ ~~~z~~~ ~. ~~~~~ ~4~`h~ _~ PAY TO THE ORDER OF ~'. C? i '~ I a~a3usls -DOLLARS ~. ~ ,~~ (~ ` .~c~/rcYSdvac, ~~,p~~ ~ ~ ~w ~17~~.~'~~ ' ~:0 3 1 30994 5: 24546 e~ V DATE _~, . l s o. ~ s :_ 32. s 1s. s o. s ~ o.~ L_. ~' ~J _ _ _ M'dlertnitert Pfxy_ Systems NAachanicst so201~ Rom, Stye 110 Mtnrg PA, 17055 tNV01CE 10f25/2011 - M.count Number: cazv~rtsts CLAIR LEF~IAN 61705GRV clo Linda Letanart 91Qrgs Arms PVT ~ PA,17050 `~t10l~tt Dt~e. ~ ~< Detach Herne and RNurn Top Portion Wftlt Your Payment Invoice Deite:101251201'!, Aa~C+RVN1812, LEHMIW, CLAIR, C,reen RtdBe 1/~age Nc - PHI. A. GUtSTlNtTE, oru~ri ' -0828f2019 - 60;i8T2Z 180.06- `~st+soei~n daI Caosuis too MG - 3 250 c ; 0.00 ; 250 RX 16774.0861-01 08x2812011 83021 30.00 1)8taodn Oral Tablet a12S ~ ; 250 c ; 0.00 ; 250 RX 00627-13~/-10 092612011 6302692 30.00 ~ i Tablet 201riG i 250 c ; 0 00 3 ' 250 RX ~ . :0828/2011 60.00 CarvsdilolOralTaDiet6251YiG ; 250 c ; 0.00 ; 250 RX 000930135.01 08128/20'11 63024 90.00 HydrALAZ1bIE Hp Olwl Tablet 50 MG ; 2.50 c ; 0.00 S 250 RX 90111-0328-01 OB2612011 80.00 Claidns Fld aa1 TatAet a1 ru1G ; 250 c ; 0 00 ; 2 50 RX 00228-2127-to . . OB/~62011 6302~JB 30.00 0ta1 Ta61et E~Aended Release 201EQ ; 250 c ; 0 00 ; 250 RX 1 . `08@62011 G~02898 30.00 cckwa Qal Tablet OB td(i ; 8.23 c ; 0.00 ; • 8 23 RX ts31o~1rs-o~ . 08262011 8319584 90.00Oral Tab1at40 MG . ; 250 c ; 00 0 ; 2 50 RX . . 08@6/2011 63191 30.00 ~ t3slarsd Release Particles ~ MG ; 8.61 c ; 0.00 ; 8.81 RX OS/262011 6319715 30.00 ' ~'orat Tablet 2 M[3 ; 2:50 c ; 0.00 ; 250 RX `082812011 6319720 30.00 Oirrrepiride Aral Tablet 4 MIG _ _-- . - 72s6.o1-- -- - _ - - -- - - -- i _-- -2.50- . c ; x.00 . _;__ 250 - . _R)C _ 08126/2011 .6341811 120.00 ~500aAG ~ ; 1.50 ; 0 00 ; 1 50 OTC ao1 80 . . 09126/2011 6349148 3.00 ~~ Tabiat 5DD IAG S 6 00 c ; 0 00 ; 6 00 RX . . . oe126rZO11 6372954 60.00 tivrfvx~rs,e tact oral Tablet 2s btu ; svo c ; ooo s s oo Rx 18714-ooee~ _ 7~ ~~ 1j-~ O .^ D w O r tin .... . -~. eas r u~° - . ~ _ r m s ~a, t_ ~aD a~~ 0 ". ~~_ Y, ~C C~ ~~ 2ott.~oi:~moss ~ Gone-tf~- 00 R.ro Florin- 3YN~/ lfRi 7 . ~~w R t ~M'01. 1~ F' @ ~ ~L a e 5.00000 Std P/C 8+k 10~h Hate` 5. 00000 4.90 5_00 5.50 . S ~ R ~~ i0$ B 4.90 5.00 5.50- . TAX AMOUNTDUE --a ;9.80 510.00 Si 1.00 If laid Ola or alfter 9/oif~0u 9/01/4011 it/ol/20u If PA1d On or Before 8 31 4011 10 31 3011 14 31/4011 x ~: y REV-1513 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: FILE NUMBER: RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AN[~ ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTI NS [Indude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 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 ANU GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PAR7~~ II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. Schedwvle J -Beneficiaries of Estate of Clair W. Lehman All children receive 1/7~' 1 ~ of $F9,$40.24 r~ivus $500 to niece at 15%. Inheritance tax and 3 month discount not deducted. ~~ (A ~I a-~ Robert W. Lehman . , , 4 ~ Son 1/7`n 84 Mohawk Road Newville, PA 17241 717-776-5548 161-32-8068 Edgar D. Lehman Son 1/7`n 23026 live Alder Chugiak, Alaska 99567 907-688-3607 206-32-0790 John W. Lehman Son 1/7tn 77 Long Lane Richfield, PA 17086 717-694-0255 295-42-6267 Linda E. Lehman Daughter 1/7tn 9 Kings Arms Mechanicsburg, PA 17050 717-458-8408 197-40-7312 Donna Howell Daughter 1/7cn 226 Stillwater Road Freeport, FL 32439 850-880-6164 191-46-1622 Gary L. Lehman Son 1/7tn 327 Shed Road Newville, PA 17241 717-776-3024 210-44-5213 Michael R. Lehman Son 1/7tn 3158 Main Street Crestview, FL 32536 850-902-0565 175-48-6969 Norma Garrick Niece $500. or $428.75 at; 15% minus .5% 28 Kough Road Newville, PA 17241 717-440-4725 211-58-3052 REGISTER OF V~VILLS CUMBERLAND ICOUNTY PENNSYLVANI~- CERTIFICATE OF GRANT OF LETTERS No. 2011- 01017 PA No. 21- 11- 1017 Estate Of: CLA/R WLEHMAN ~~ ~ Late Of : HAMPDEN TOWNSH/P CUMBERLAND COUNTY Deceased Social Security No : 199-0;7-7873 WHEREAS, ion the 27th day of September 2011 ari instrument dated December 4th 2009 was admitted to probate as the Last will of CLA/R W LEHMAl1I' /Fist MiaUAe, Lastl Late of HAMPLpEN TOWNSH/P, CUMBERLAND County, who died on tie 20th day of September 2011 an WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of WiIIs in and for CUMBERLANb County, in the Commonwealth of Pennsylvania, hereby certify that 1" have this day granted Letters TESTAMENTARY to: L/NDA LEHMkIN and GARY L LEHMAN who have duly. qualified as EXECUTOR(R/X) and have agreed to administer the estate according to Iaw, aI1 of which fully appears'. of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNS~YL VAN/A. IN TESTIMbNY WHEREOF, I have hereunto set my hand and affixed the seal of my office c"bn the 27th day of September 2011. ~~~ ~,s . o .~ ,~ D ~ (-~(~ (,~piLSC~~ * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) ~~ LAST WILL AND TESTAMENT + I, CLAD W. LEHMAN, of Lower Mifflin Township, Cumberland County, Pennsylvania,) being of sound and disposing mind and memory„ do hereby make, i ~ publish and d$clare this to be my Last Will and Testament, hereby revoking any and all i former Wills o~` Codicils made by me. 1. I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and fall inheritance taxes (whether such taxes may be payable by my estate or by any reciplient of any property) shall be paid from my residuary estate as soon as practicable after my decease and as part of the administration of my estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not passing under this ' - Wilt. ' 2. I give the sum of Five Hundred Dollars ($5.00) unto my niece, NQRMA - -_ ~~ j BARRICK. ~ ~ ~! - - .__ y' -~ ,~, ~ - - - cn ~~ --..~ .. ~~ ~i -~- :-,_ -_, -ri t°.' Page 1 of 5 3. All the rest, residue and remainder of my estate, both reaN and personal property, i a es, o is n as o ows o: a) My son, ROBERT W. LEHMAN; b) My son, EDGAR D. LEHMAN; c) MY son, JOHN A. LEHMAN; d) ~ daughter, LINDA E. LEHMAN; e) NNy daughter, DONNA D. HOWELL; f) ~ son, GARY L. LEHMAN; g) ~Y son, MICHAEL R. LEHMAN i 4 1 nominate, constitute and appoint my daughter, LINDA E. LEHMAN, and my son, GARY A. LEHMAN, as Executors of my estate. In the event either of them shall be unable or unwiMling to serve in such capacity, then the other shall act alone. 5. I direct ghat my Executors shall not be required to fib a bond to secure the faithful performance o~ their duties in any jurisdiction. Page 2 of 5 ~(~l- I authorise and empower my Executors, in their sole and absolute discretion, to j purchase or otherwise acquire and retain any investments of which l die seized or any any na u ase, p e, mortgage, zransrer, ~~i exchange, displose of or grant options in regard to any or all property of any kind ~~ forming a part ~f my estate for such terms and such prices as they may deem advisable; to borrow money for any purposes connected with the protection and preservation o~ my estate; to mortgage or pledge any real or personal property forming ' a part of my estate or to join in or secure the partition of same; to compromise any claims or demands of my estate against others or of others against my estate; to make distribution in find and to cause any share to be composed of cash, property or undivided fraction shares in property different in kind from any other share; to employ agents, attom~ys and proxies and to delegate to them such power as my Executors consider desirable and to pay reasonable compensation for such services and may be i rendered by swch agents, attorneys and proxies; and to execute and detNer such instruments aS may be necessary to cant' out any of these powers. In addition, I direct that my Executors shall have the power to conduct an inventory of any safe deposit box necessary to the administration of my estate. Page 3 of 5 ~`-1~~- 7 IN WITNESS WVHEREOF I have hereunto set my hand and seal this ~_day of December 209. !/~~QS,~ c!/ ,s (SEAL) CLAIR W. LEHMAN SIGNEp, SEALED, PUBLISHED AND DECLARED by the above-name Testator, as and for his Last Will and Testament, in the presence of us, who at this request, have hen:unto sub~ribed our names as witnesses thereto, in the presence of the said Testator and ~f each other. ~ ~ (~ ~~ ~~ Page4of5 ~-~~ r COMMONWEIALTH OF PENNSYLVANIA ) :SS. COUNTY OFI iUMBERLAND ..._--- '', , ~..~~~'c~:.'~C~A2~, the Testator and the witnesses, respectively, whose names are sighed to the foregoing instrument, being first duly swom, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his last Wi11 and thhat the Testator has signed willingly, and that the Testator executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the Will as a witness and that to the best of hisJher knowledge the Testator was at the time eighteen years of age or older, of so~nd mind and under no constraint or undue influence. Testator Hess ~'` _ ~ % ~ L~ Witness Subscribed, swom to and acknowledged before me by GLAIR W. LEHMAN, the Testator, and subscribed and swom to before `7~-fC"i~'1'aS G~ i~Nc ~' and ,~ !.~ ,the witnesses, this '`~ day of December 2009. ~ARY P s~,r oant~aa 1;.'uson, Nor ~c ~ H~risbwg, Da~pbdn County v c~x:xi,i~„ emt~w. Ym.~. A ". Page5of5 HIOS_R05 RED' fUi/U'i LOCaL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 P 17726376!, Certification ]Number - I ----- This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent tiling. ~ ~~~c~~erane~ S~' 2 ~ 2011 Local Registrar Date Issued H1os1l3 REV 112056 ' COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TYPE / PI6Nf M ~ CERTIFICATE OF DEATH ~l(~ '.. (See InsRUCtloras and exemplsa on reverse) STATE FlLE NUM9ER w 0 1. Nems d OsasdeM (Free, niadr, rat eu6a) 2. Sex 3. SorJd Saaxhy Number !. Der d DedN (MaiM. deY. Y•x) Clai W. Lehman 199 -0'7 -7873 r 5. Ap (tad BNSmey) Under I Under i B. Dda d BIM Mwdh, 7. aM date a Ba. Wa d Deem Chad a oa M°""' °ryi 9 3 "~""" 12/22/1917 Newville PA "°'P"" -°tl1e/C r~ ^ irewtled ^ ER r oupdem ^ Don L'~~+H Nome ^ Raemaria ^ omx ~ svay m. cauay a Deem e<. cny, a Deem ea Feday Name In nd Nennaa,lrw• sued ana numWr) s. was Dxeam. a lHepxaa aqm? ~ ~ ^ vas 10. Rao.: Amedan Nrda,, eMdt, wNNe, dc. Cumberland Wes Pennsboro 'v,~( ~ ~ P1"°'eD"~r"ed'' P Rl k M m M i to 1 td Ge/l o ar4 e .) e cen, u 11. Deaded'e Uxel d wok tl ore d Me. Do rql der n /2 Wes Deadest sax a me 13. a Edaatlan ( aNy nq~en grade oonp rledl 14. Maa Seem: Married, Nmx MuMd, 15. 9aWUeq 9pa ee IH rdb, gs maiden none) Nemd Wok Kbd t~Bweeee/hmueey U.s. Nmed Farad Elemenrryl (P72) " Cabge (1~a5t) Widowed, Diadaed IsPxwrl ' Farmer A riculture ^y„ ~~ widowed 18. 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