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HomeMy WebLinkAbout01-03-12 1505610105 REV-1500 t:x (oz-ar) fl`" PA Department of Revenue Pennsylvania OFFICWL USE ONLY Bureau of Individual Taxes ~`r""T"`"~""`~`"~` Counry Code Year File Numt+er INHERITANCE TAX RETURN PD BDx sBoso> ~i ~ ~ rya ~ ~ .. Harrisburg, PA i~fzB-o6os RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 211-36-0520 02/04!2011 -03/21/1947 Decedents Last Name Suffix Decedent's First Name MI Buddy Mr. George ', (H 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 INAPPROPRIATE OVALS BELOW ~ 1. Original Retum O 2. Supplemental Return O 3. Remainder Retum (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) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (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 i-1-95) (Attach Schedule O) CORRESPONDENT - 7HIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ,Stanley H. Mitchell, Esq. (717) 233-3339 '" ' A: 1 ~cn~ W J ` ~ C7 -,a ~,©~'+ ~. J ~ -'~ ~„ { DATE FILED ~' y _ _ __ _ __ _ 'Harrisburg Pa ; ,17108 First Line of Address 600 N. Second St., Sewnd Line of Address Box 425 Cit or Post Office State ZIP Code Correspondent's e-mail address: Under penalties of perjury I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge antl belief, It is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparar has any knowledge. SIGNATURE OF PERSON JfESPON$IBL~ FpR FILING RF~T'URN ~ DATE ~ SIGNATURE OF P!~ 7~ p ~ ~~ T~H~ ~E ('E ENIeA IV Q `, / L / /1,Q p DATE , ~ ~/ !~ ADDRESS 6t/ D /v (I~C~041 ~. -~f' 3OS . /J 07~~~ t /7.7~ I 1 ~7~D/7 1505610105 Side 1 1505610105 .~. REGISTER i LS USE 4lILY _ y ' '~!' A T' 1 ~, 1'i ._r, Y1 >~7 i \ ~ 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: 211-36-0520 RECAPfTULATION 1. Real Estate (Schedule A) ........................................... .. 1. 2. Stacks 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. 28,175.44 6. Jointly Owned Property (Schedule F} O Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 28,175.44 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 6,229.36 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. 10. 1,820.28 11. Total Deductions (total Lines 9 and 10) ............................... .. 11, 8,049.64 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 20,125.80 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. 20,125.80 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of line 14 taxable at lineal rate X .0 _ 16. 17. Amount of line 14 taxable at sibling rate X .12 17, 18. Amount of Line 14 taxable at collateral rate X .15 20,125.80 1a 3,018.87 1s. rAx DUE ....................................................... ..1s. 3,018.87 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments --_---------_....----_---.----_-- B. Discount 3. Interest Total Credits (A + B) (2) (3} 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) (1) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred .......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "intrust for" 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 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (11-08) Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER All real property owned solely or as a tenanFin common must be reported at~fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned wkh right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. Not Applicable TOTAL (Also enter on Line 1, Recapitulation.) ~; If more space is needed, insert additional sheets of the same size. REV-1503 EX+ (&a6) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER George J. Buddy, Jr., 2011-00284 (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCHEpULE B COMMONWEALTH OF PENNSYLVANIA STOCKS St BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER George J. Buddy, Jr., 2011-00284 All property ~olntly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scwsou~~ c CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER George J. Buddy, Jr., 2011-00284 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sale-proprietorships. (If more space is needed, insert additional sheets of the same size) REV-1505 EX+ (6-98) SCHEDULE C-1 CLOSELY HELD CORPORATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER George J. Buddy, Jr., 2011-00284 1. Name of Corporation State on Incorporation Address NOT APPLICABLE Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number 3. Type of Business 4. ProducUService Business Reporting Year Common I li $ Preferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ................................... ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedents stock sold? ..................................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • •- ~ • ~ A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. ^ No (If more space is needed, insert additional sheets of the same size) REV•1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCMEp1~LE C-S PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER George J. Buddy, Jr., 2011-00284 1. Name of Partnership Address Date Business Commenced Business Reporting Year City *T~}~+ ~1ip$~,T{'~~~,~ State Zip Code 2. Federal Employer I.D. Number 3. Type of Business ProducUService 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No if yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedents death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedents death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • •- ~ • ~ ~ A. Detailed ca~ulations used in the valuation of the decedents partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addresses and estimated fair market values. If real estate appraisals have been secured, attach copies. ^ No D. Any other infomtation relating to the valuation of the decedents partnership interest. REV-1507 EX+ (t-97) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES 8c NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER George J. Buddy, Jr., 2011-00284 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insen additional sheets of the same size) REV-i5o8 EX+ (ii-io) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIILE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY - _ __ ESTATE OF: FILE NUMBER: George J. Buddy, Jr., 201 1-00284 Include the proceeds of litigation 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 ~, Pax Wolid Mutual Funds 25,774.99 Box 9824 Providence RI 02940 Reference No. 3401519727/227 GRACE Mann Insurance Horace Mann P1., pringfield, I11., 62715 o. 995835 93:00 , orace.Mann Insurance 35.4U Horace Mann P1., pringfiels, I11., 62715 iscellaneous Personal Property $1'000.00=, tate Employees Retirement System 238.59 0 N. Third St, Ste., 150 arrisburg, PA 17101 A State Employees Credit Union oint Account w/ Karen Shaffer 113 Sycamore St., arrisburg, PA 17111 Savings 5870.45 checking 3839.70' IRA 40'69.38': $13779.53 TOTAL ~AIsC e~t21'Onlli~e 5, Recapitulation) # 281.7 5 . 4 4 If more space is needed, use additional sheets of paper of the same size. REV-,509 EX.1,.9n SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN FILE NUMBER ff an saset was made joint within one year of the decedent's dab of death, it must be reported on Schedub G. SURVIVING JOINT TENANT(S) NAME A. B. C. JOINTLY-0WNED PROPERTY: NOT APPLICABLE ADDRESS RELATIONSHIP TO DECEDENT ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institutbn and bank account number a similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET Yo OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. TOTAL,(Also enter on line 6, Recapitulation) I S (If more space is needed, insert addKional sheets of the same REV-1510 EX ~ (tA7) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER George J. Buddy, Jr., 2011-00284 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIRREUTIONSHIPTODECEDEN7ANDTME DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION iFAPPUCA~E TAXABLE VALUE 1. NOT APPLICABLE more space TOTAL (Also enter on line 7, Recapitulation) ~ S same REV-1511 EX+ (10-09j pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND [NNERRANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER George J. Buddy, Jr., 2011-00284 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: L The Neil Funeral Home 3401 Market St., Camp Hill. PA 17011 3194.02 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) ____._.,.___.____ ________.____-_--_-__._.-__.._ Street Address ___..____ _._........________....__..._...-.__...._....-._____..__.__.._...__.._.._ City ....._------._._....----.._.__.._..------.._.._._ State ._.._...._.._. ZIP ..---------- Near(s) Commission Paid: 2. Attorney Fees: Stanley H. Mitchell, Esq., 1 9 0 0 . 0 0 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address ---------____.._......___----------------------- City ---...._ _- ----------------------- State __.._....._....ZIP --. Relationship of Claimant to Decedent _ __--__--_--- a. Probate Fees: Cumberland County Register of Wills 148:50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. The Reverend Paul C.B. Schenk 200.00 Katherine Manucci 1"50.00 Dockside Willies, (Funeral Refreshments) 24.$.14 E ecutrix..Costs (mail charges, stamps,. etc.,) 388.74. TOTAL (Also enter on Line 9, Recapitulation) ~ ~ ~ ~ 9 _ ~ ~ If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIEDYLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER George J Buddy, Jr., 2011-00284 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. John Shaffer $550.00 134 Second St., Harrisburg, PA 17125 (January Rent) Behney Oil Co., 453.94 Lemoyne PA., Horace Mann Insurance I 168.40 1 Horace Mann P1., Springfield, I11., 62715 Pa., Drivers-Vehicle Service ~ 37.00 PPL Electric Allentown, PA ~ 63.85 Pa., American Water 111.16 Box 371412 Pittsburgh PA 15250 Acct., No. 24-1142068-6 Spirit Physician Services Inc., 205 Grandview Ave., # 210 Camp Hill, PA 17011 119.50 Assoc., Cardiologists PC 17.37 856 Century Dr., Mechanicsburg, PA 17055 Azizkhan Internal Medicine Assoc., 37.00 888 Poplar Church Rd., Camp Hill, PA 17011 Comcast 97.71 1555 Suzy St., Lebanon, PA 17046 Verizon Box 15026 Albany, NY 12212 164.25 TOTAL (Also enter on line t0, Recapitulation) $ 1 820.28 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scNEOU~E ~ BENEFICIARIES ESTATE OF FILE NUMBER George J. Buddy, Jr., 2011-00284 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not LlstTrustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [inGude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Sandra M. Tomlinson 50~ 2303 Westfield Ct., Newtown Square PA 19073 Amy Asperi MacDonald 50~ 742 Buttonwood Dr., Springfield, PA 19064 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIEDYLE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shel ESTATE OF FILE NUMBER George J. Buddy, Jr., 2011-00284 This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................................ . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of Ilfe estate (Line 1 muklplied by Llne 2) ......................................$ ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-1644EX•13-oal INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT IN RES DAENTEDECEDENT N OR INVASION OF TRUST PRINCIPAL FILE NUMBER I. ESTATE OF George J. Buddy, Jr., 2011-00284 (Last Name) (First Name) (AKWdIe Irlitiaq This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills d'iiOT APPLICABLE . (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annudy is payable C. Assets: Complete Schedule L-1 1. Real Estate ...............................$ 2. Stocks and Bonds ..........................$ 3. Closely Held Stock/Partnership ...............$ 4. Mortgages and Notes .......................$ 5. Cash/Misc. Personal Property ................$ 6. Total from Schedule L-1 ......................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ...........................$ 2. Unpaid Bequests ...........................$ 3. Value of UninGudable Assets ..................$ 4. Total from Schedule L-2 ....................................:.......:.........$ E. Total Value of trust assets (Line C-6 minus Line D-4) .................................$ F. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . G. Taxable Remainder value (Line E x Line F) .........................................$ (Also enter on Line 7, Recapitulation) ju, INVASION OF CORPUS: A. Invasion of carpus (Month, Day, Year) B. Names? of Life Tenant(s) Date of Birth Age on date Term of years income or AnnuttaM(s) corpus or annuity Is payable consumed C. Corpus consumed ............................................................$ D. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . E. Taxable value of corpus consumed (Line C x Line D) .................................$ (Also enter on Line 7, Recapitulation) P.EV•Ib15 EX+ i~-esl INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TA% RETURN RESIDENT DECEDENT -ASSETS- FILE NUMBER 1. Estate of Geor a J. Budd Jr. , 201 1-00284 (Last Name) (First Noms) (Middle Initial) 11. Item No. Description Value A. Real Estate (please describe) NOT APPLICABLE Total value of real estate $ (include on Section II, Line C-1 on Schedule L) B. Stocks and Bonds (please list) Total value of stocks and bonds S (include on Section II, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) Totol value of Closely Held/Partnership $ (include on Section II, Line C-3 on Schedule L D. Mortgages and Notes (please list) Total value of Mortgages and Notes $ include on Section I1, Line C-4 on Schedule L) E. Cash and Miscelloneous Personal Property (please list) Total value of Cosh/Misc. Pers. Property S (include on Section II, Line C-5 on Schedule L) III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ (If more space is needed, aMach additional 8l~i x 11 sheets.) 2EV-1646 EX+ la.s4i INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN RESIDENT DECEDENT -CREDITS- FILE NUMBER I. Estate of Geor a J. Budd Jr. 201 1-00284 (Last Name) (First Name) (Middle Initial) II. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) NOT APPLICABLE Total unpaid liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) Total unpaid bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: Total unincludable assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L $ (If more space is needed, attach additional 8'/s x 11 sheets.) REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCNEpULE M FUTURE INTEREST COMPROMISE ~ on Rev-1500 Cover SI FILE NUMBER Georae J Buddy, Jr 2011-00284 This Schedule is appropriate only for estates of decedents dying aRer December 12,1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. g, NOT APPLICABLE 4. 5. IL For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal IIL Explanation of Compromise Offer: N Summary of Compromise Offer: 1. Amount of Future Interest .........................................................$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% ......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ...........................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$ (If more space is needed, insert additional sheets of the same size) ~~-,~E>i.lrsa COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN OF SCHEDULE 0 ELECTION UNDER SEC. 9113(A) FILE NUMBER Georgg J Buddv Jr 2011-00284 Do not complete this schedule unless the estate is making the electlon to tax assets under Section 9113(A) of the Inherkance 3 Estate Tax Aet If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and; a. The trust or similar arrangement is listed on Schedule 0, and Not Appl i cabe b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0 The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. Part A Total I $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is (If more space is needed, insert additional sheets of the same size) PAX ~ I For Tomorrow® Pax World Mutual Funds September 19, 2011 SANDRA M TOMLINSON 2303 WESTFIELD COURT NEWTOWN SQUARE PA 19073 Reference Number: 3401519727/2274150 Account: 0040-XXXXXX 1757 Dear Ms. Tomlinson: This letter is in regard to a recent inquiry. As of the close of business on February 4, 2011, the above referenced account was valued at $25,774.99. This value is based on a balance of 1,105.274 shazes at the Net Asset Value (NAV) price of $23.32 per share. Changing mazket conditions may cause the NAV price to fluctuate on a daily basis. Therefore, the account value is subject to change. If you have any questions, please contact Shareholder Services at 1-800-372-7827. Our representatives are available Monday through Friday between 8:00 a.m. and 6:00 p.m. Eastern Time and will be pleased to assist you. We also invite you to visit our website at www.paxworld.com. Sincerely, Paula Therriault Investor Services Associate PO Box 9824, Providence, RI 02940 ~ 800.372.7827 ~ www.paxworld.com Pnxaoo (siio> tot s ~® Mixed Sources Product group 4om vnlHnanpad lomb end otMr contrdbd aartaa Printed on FSC certified paper PSEC~ November 18, 2011 KAREN L SNAPPER GEORGE J BUDDY 3113 SYCAMORE ST HARRISBURG PA 17111 Dear Karen Shaffer: As of February 4th, 2011, your account balances were as follows: (S1) Regular Share $5,870.45 (S4) Checking Share $3,839.70 As of February 4t", 2011, the balance of an IRA (S50} owned by George J Buddy was: (S50}IRA $4,069.38 If you have any questions, you may reach us T a:m. to 5 p.m. Monday through Friday or Saturday 8 a.m. to noon at our toll-free numberS00.237.7328. Please enter 5 and then 5 again at the menu prompt to speak with a Member Service Representative. Sincerely, .DAVID (436) --- - __ __---- Member Service Advisor' - Member Services Pennsylvania State Employees Credit Union 1 Credit Union Place, P.C). Box 67013, Harrisburg, PA 17106.7013 •800.237.7328 • »psecu.tom THIS CREDIT UNION IS FEDERALLY INSURED BYTHE NATIONAL CREDIT UNION ADMINISTRATION. EQUAL OPPORTUNITY LENDER.