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HomeMy WebLinkAbout03-21-12 1505610101 REV-15fl0 ex to~-'o, OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes DEV~pf ME~f ~F INHE RITANCE TAX RETURN County Code Year File Number PO BOX z8o6oi RES ~ ~ ~ ~ I Harrisburg, PA i'7i28-o6oi IDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI ~~ c' ~ v ~ / R ~. m v r` ~ rvl (If 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 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 Return Required death after 12-12-82) ~ 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 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number First line of address ~j 5 i~ 5 ~ Ir' t r1 ri ~ ~ c~ t.t. S e ~ C~. Second line of address S City or Post Office State ZIP Code ~~r r~ 5 b ~~r~ ~ A 1 `! i REGISTER OF WILLS lH'sfi ONLY C7 - ' ~ t ~ - t :~ 1 , : ;~_~ ,~: r ,~ rYt~~ ~ di, f ~ - - ~ r-n r-._, - -~ ~~\ ___ ~~ ~_ ~, ' ~ ~ O - - ~) ~_ ~. ^ : . - ~,I~TE FILEDt:',~ F- ~ ~~~ C~ ~~ ' Correspondent's a-mail address: t~ov~_ Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE O PERSON RESPON IBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARE OTHE HAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610101 Side 1 1505610101 ~~ J 1505610105 REV-1500 EX Decedentc'ys Social Security Number Decedent's Name: ~ ~ ` ~C> ~ U RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. ~ • U O 2. Stocks and Bonds (Schedule B) ..................................... .. 2. /? ' U r,7 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ~! (} (,~ 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. (~ ' U ~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. r ,j 3 - .,_ ~ 5;J 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ..... .. 6. U • U U 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property p Separate Billing Requested...... .. 7. (~ • (~ ~ (Schedule G) 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. ' 3 ~ .j ~ • ,~ '~ 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 3 ~ ~ • t> U 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... ... 10. ` O ~ ~ O ( ~" 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. f ~ 3 (p ~ ~ 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. ! "~ ~? C • !f 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 Q • O (j an election to tax has not been made (Schedule J) ..................... ... . 14 Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. l ~ "~ U • 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 16. • at lineal rate X .0 _ 17 . Amount of Line 14 taxable 17 at sibling rate X .12 . 18 . Amount of Line 14 taxable ' , ~ n ({ ~ 18. °` (," '~ • ~ ~' at collateral rate X .15 t ~ 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ ~ ~ • Side 2 1505610105 1505610105 O REV-1500 EX Page 3 Decedent's Complete Address: STREETADDRESS k`~~ /r'' r -~ ~ _1 n e n .,. Ire ~J : v~ o K-~-~ CITY ,rv-~ Tax Payments 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. File Number STATE vii - ~~1~: ~~ ZIP i'ltti Total Credits (A + B ) (1) 3(ns' S~ (2) (~ (3) (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~.{c~ S`1v 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 transferretl :.................................................................................... ...... ^ 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 ^ K ^ without receiving adequate consideration? ....................................................................................................... 3. Did decedent own an ' m 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 ^ X 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(1.2) (72 P.S. §9116(a)(1)]. ~ Section 91t02 asoan ndividual who Ihas attleast one parent nhcommon tw th the decedenbtllw ether by blood or adopt o9116(a)(1.3)]. A sibling is defined, under WILL OF RAMONA M. WEAVER I, Ramona M. Weaver, of Cumberland County Enola, Pennsylvania, declare this to be my last Will and hereby revoke all prior Wills and Codicils. 1 direct that al! my just debts, funeral expenses, gravemarker and administrative expenses shall be paid from my residuary estate as soon as practicable after my death. 2. !direct that all inheritance, estate, transfer, succession and death taxes of any kind whatsoever which may be payable by reason of my death shall be paid out of my residuary estate. 3. I direct that my entire estate be distributed as follows: A. t direct that my entire estate go to Teresa Knox, B. Should Teresa Knox predecease me, I direct that my entire estate go to Christy J. Ward. 4. I appoint Teresa Knox as Executrix of this my last Will. Should Teresa Knox predecease me or cease to act in such capacity, I appoint Christy J. Ward as alternate. 5. The Executrix of this Will shall have the power to distribute my estate in kind or in cash, or partly in either. 6. I direct that no Executrix acting under this Will shall be required to enter bond in any jurisdiction. IN WITNES~W REOF, I have hereunto set my hand this day of ~,,, ~''~.~ , 2011. Ramona M. Weaver LAW OFFICES OF TEPHEN J. NOGG 9 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 ~~ The preceding instrument consisting of this and one other page was on the day and date hereof signed, published and declared by Ramona M. Weaver as and for her last Will in the presence of us, who at her request, in her presence and in the presence of each other have subscribed our names as witnesses hereto. LAW OFFICES OF STEPHEN J. HOGG i9 S. HANOVER STREET SUITE 101 CARLISLE. PA 17013 A .~ ~ j WITNESS ~ ~' WITNESS ACKNOWLEDGMENT State of Pennsylvania County of Cumberland ss I, Ramona M. Weaver, the Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my last Will; that I signed it willingly and as my free and voluntary act for the purposes therein expressed. __ Ramona M. Weaver Sworn to or affirmed an acknow! d d fore me by Ramona M. ~~.~"tatri~~ this-~-day of ~ ,~_~2'~___., 2011. ~~~ ,R,~~„~, F}~~ Notary ublic/A „tea ~, ~~~ , AFFIDAVIT LAN' OFFICES OF TEPHEN J. NOGG 9 S. HANOVER STREET SUITE 101 CARLISLE, P.A 17013 State of Pennsylvania .~ ,~ ~~ ~~ y22.~-~ -~~.~i ~. ,- ss County of Cumberland Mi ~ We, ~i~U^~.\~£ ~v~~~ and fJ C ,~ ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the instrument as her last Wilt; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Will as a witness; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. orn to or affi d ~n sub~cribed t efore me by witnesses, this day of ~C~r!~'`~'l. , 2011. ~~~~>~ ~~~a, oao~~~f~~~~~ ~~ ~~lot ry PubliclAttorne ~9y err. ~',r~ ~ ~~~lsa`.~,~~o~~~ 3, ~13~1 REV-1502 EX+ (11-08) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ~vtl - d~~;3~ tJlAlt 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 that is ]ointly-owned with right of survivershin moor hp ,~~~~i,.wa ,,., c..~,ea..i,. .~ niuie ~Na~e is neeaeo, insert aaaiuonai sneers of the same size. REV-1503 EX+ (6-98) -. SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT tSIAIE VF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (it more space is needed, insert additional sheets of the same size) REV-1504 EX+ (1-97) ..~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER 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 sole-Droorietorshios. (ir more space is needed, insert additional sheets of the same size) REV-1507 EX+ (1-97) ~~ SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 Ex + 11-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHRESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned wkh the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH !'`l ~ c-lu ~ ~k ~ r~~-r '~ /3 , 13 ~. ate" 3~1 fc~.~ 1u-~ S+. ~ ~`s'3 ~1~ Z 7~ 7~ ~-wvi S ~~~.. , ~'~ l 7 l l l TOTAL (Also enter on line 5, Recapitulation) I $ ~ ~ ~ 3~- (Ifmore space is needed, insert additional sheets of the same size) ~ METRO BANK >09369 7027140 OD1 D92b40 RAMONA WEAVER 352 SPRlNGHOUSE RD HARRISBURG PA 17111 Metro Bank 3801 Paxton Street Harrisburg PA 17111-1A18 1-888-937-0004 mymetrobank.com We're here 7 days a week, 24 hours a day at 1-888-937-0004. StatenteM Balance as a# 06108/i t Pitts Lteposits and Other Credits less 3 Checks and Other Debits Plus Interest Patd StatemaM Balance as of O7HOt11 Transactions By Date 50 PLUS CHECKING 2832477574 513,729.74... $0.04 5592.~J 51.74 $13,138;55 Date uescri lion Debit l.retiii Saiance 0611 i 1 H K # 061 .49 3,7Q3:~'~' 08113!11 CHECK # 1066 $499.00 $13,204.21 061t5111 CHECK # 1tl87 $87.40 $13,136 .' 07108111 INTEREST PAYMENT $1.74 $13,138.55 Check Transactions Number Date Amount Number Date Amount Number Date Amount 1 : i OSJ13 $28.48 1088` 06/13 $499.00 1087 8BPt5 $87';44 Items denoted with an "E" are electronic entries and will not have a check image. Items denoted with an "'" indicate processed checks out of sequence. Interest Summary 8aginning tntsreat Rate 4.1596`' Number of Daya in this Statement Period 32 lnterett:t Eat7ted this Statement Period $1.74 Annual Percentage Yield Earned thb Statement Period {APY) 0,15% interest Ptdd Year to Dale $T.84 Fees Summary Tote- ~rdraft Fess this Statement Period - -_ 54. Total Overdraft Fees Year to Date 50.00 Total ~eturrtsd item Fees this Statement tod .$4.00... Total Returned Item Feea Year to Date $0.00 For your convenience, a summary of overdraft and returned item fees appears on your monthly statement. Please note that the overdraft fee summary includes non-sufficient funds fees, uncoNected funds fees and unavailable funds fees. The summary does not reflect refunded or waived items credited to your account. e Cycle Page 1 of 6 REV-7509 EX. (5-97) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ESTATE OF FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. ,11.~01~1 H- RELATIONSHIP TO DECEDENT TOTAL (Also enter on line 6, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV~1510 EX «(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF n FILE NUMBER I~ct•~cr~ G~-~-~~-- ~~ 1 I - ~ ~~ 3~Y 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'HENAMEOFTHETRANSFEREE,THEIRRELATICNSHIPTODECEDENTANDTHE DATE OF TRANSFER. ATTACHA COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE 1. /~I L N ~ V TOTAL (Also enter on line 7, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER IP~.~~+-~•o- 1.~.~a.~-~- ~ai~ - ~~/a-3~ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Jed NG ©a~ f~x..o ~'i~c~. ~~ Sc.~;e..~c~. C.'a~ ~ -~'Cn..:.. CcJZ. ~ ~i~h. Le'~Q/L,~[~. c,1212. C~'+5't,~ B. 1 2. 3. 4 5 6 7. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: _ Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees J State Zip _ _ __ Zip ~~0 TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) SCIENCE CARE ANATOMICAL DONOR INFORMED CONSENT WILLED BODY RELEASE I hereby offer my body after death 1'or educational or scientific purposes to Science Care Anatomical. I understand that Science Care Anatomical will be responsible for any costs directly related to this donation. I understand that my body is to be used for teaching, scientific research or other conforming purposes and for use in multiple research or educational venues to maximize the benefits of donation, or any other purposes as any nonprofit and or for profit organization involved in facilitating the gift deems necessary, in their sole discretion. The nature of the procedure(s) have been explained to me and I understand that by donating organs and tissues for medical research and education I am consenting to the possible extensive body dissection that may include disarticuiation (surgical removal) of extremities (arms and legs) as well as cephalus (head) and spine. l also acknowledge that no guarar-tee or assurance has been made as to the results that may be obtained from the research or study of organs and tissues. Science Care Anatomical has represented to me that it will treat my body with dignity and respect within the confines of the above stated uses. After my death, I authorize any and all medical personnel having possession of my medical records to release them to Scence Care. I authorize Science Care Anatomical to obtain a complete medical history, autopsy findings, and bkwd samples, as it may deem necessary to ensure the safety of the donation. I understand that such testing may include, but is not necessarily limited to H1V i~ AIDS, hepatitis B & C, or tuberculosis, which may preclude the donation. I understand that all donor information will be coded and that the donation will remain anonymous. I am making this gift freely and voluntarily, without obligation of any kind on the part of the recipient organization and there will be no reward or compensation to my family or me. I understand that partial cremated remains will be returned to thca next of kin who is the highest Isga! ordsr of conserting class upon ~~~ritten reGusst that has been :~ceivsd by Science Gare within 90 days of donation. 1 understand that partial cremated remains do not include tissues that have been recovered for medics! research or educational purposes. I understand that Science Care or its assignee may arrange for the final disposition of such tissues in any manner, subject to applicable law. I understand that under no circumstances will un-cremated remains be returned. I understand that this is a legal document being signed by me (or at my direction by another) in accordance with the. Uniform Anatomical Gift Act or similar laws. I understand that this gift may be revoked or amended by: (1) a signed statement; (2) an oral statement made by me in the presence of two witnesses; (3) any form of communication during a terminal illness or injury that is addressed to a physician; or (4) delivery of a signed statement to Science Care Anatomical. I further understand that this gift is irrevocable upon my death and that no other consent or concurrence by anyone else is required. CSonor's Signature Donor's Printed Name Date Signed Donor Mailing Address: / ~ ~- .v~,~r--tit ~,~ -~ I ~.~ " Telephone Number: ~ / Z ~ ,~.>~'~ ~ ~~~` ~ ~ Witnesses Certification -Two Required The undersigned acknowledge that the donor either: (1) signed this document; or (2) requested another to sign it for him/her since he/she was unable to do so. If signed by another person, we certify that we signed it at the donor's request and in his/her presence and the presence of each other. The donor's acts in signing this document or directing another to sign for him/her appeared to us to be his/he nd voluntary act. .^ _ t r Witness ignature Witness Printed Name Date Signed Witness Signature Witness Printed Name Date Si ned r~ Qocument Disposition: Your gift is important to those who study or research disease. To help make this gift effective it is recommended that this document be filed with other important papers or given to a family member, legal guardian or close friend. Facsimile Signatures: The delivery and completion of this document may be effectuated by the use of telecopylfacsimile or electronic transmissions and the signature(s) created thereby shall be considered an original signature, binding on the party signing, transmitting or delivering this document by telecopy, facsimile or email as conclusive evidence of his or her signature, as if such signatures were original signatures. tf this form is sent by sle~ronic transmission, the sender adopts the document received as a duplicate original and adopts the signature produced by the receiving fax machine as the sender's original signature. ~ Locations Serving Nationally Toll Free: 800-417-3747 www.sciencecare.com FORM ICs 11.9.OS REV-1512 EX+ (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ~i,~ rte. {~~;h'rt.U~. ~ /1 Cal ~ 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. ~l Icy ~n ~ ~~~r~L°,~ilt4/~ ~,.,~ (may ~~: X7.7 ~~~~ fi ~ ~~~~ ~~'~ TOTAL (Also enter on line 10, Recapitulation) $ I V ~ •~ ~ (If more space is needed, insert additional sheets of the same size) ~ ~ , REV-1513 EX+ (9-00) .~ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~G1.MOIY~LL In1~LLCI~/t~ FILE NUMBER c?vil - ~1~3~5 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. x TC~^`„r'~ ~'`~ ~~ nn ~I ~IlL. ' U Up~o .• 1 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 $ o (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 ESTATE OF SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shei FILE NUMBER 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 NAME(S) OF LIFE TENANT(S) DATE OF BIRTH • NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ 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 life estate (Line 1 multiplied by Line 2) ......................................$ NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH • NEAREST AGE AT DATE OF DEATH TERM OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years j` ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below a d enter corresponding (number) ......................... . Frequency of payout - ^ We ly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^ Semi-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per peri d ........................................................$ 4. Aggregate annual paym nt, 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-1644 EX -. is-oa> INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT INHERITANCE TAX RETURN RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER I. ESTATE OF (Last Name) (First Name) (Middle Initial) 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 on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable f;; 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 Unincludable Assets .................$ 4. Total from Schedule L-~ ......................................................$ E. Total Value of trust assets (Line C-6 minus Line D-4) .................................$ F. Remainder factor (she Table I or Table II in Instruction Booklet) ........................ . G. Taxable Remainder value (Line E x Line F) .........................................$ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(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) REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet FILE NUMBER This Schedule is appropriate only for estates of decedents dying after 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 th ax return. ^ Will ^ Trust ^ Oth I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a rviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the ap ropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right o withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: `,. IV. 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) RF.V-1649 EX +(L97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE 0 ELECTION UNDER SEC. 9113(A) SAL DI FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. 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 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, regardle~ of location, which pass to the decedent's survivina spouse under a Section 9113 (A) trust or similar arrangement. / VALUE Part A Total $ PART B: Enter the descri tion and value of all ' terests included in Part A for which the Section 9113 A election to tax is bein made. DES IPTION VALUE Part B Total ~ (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX~11-96) N0. CD 015736 KNOX TERESA 352 SPRINGHOUSE ROAD HARRISBURG, PA 17111 -------- fold ESTATE INFORMATION: ssrv: 2os-2o-3043 FILE NUMBER: 211 1-1238 DECEDENT NAME: WEAVER RAMONA M DATE OF PAYMENT: 03/21 /201 2 POSTMARK DATE: 03/21 /201 2 couNTY: CUMBERLAND DATE OF DEATH: 06/23/201 1 REMARKS: CHECK# 3659 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 5265.56 TOTAL AMOUNT PAID: 5265.56 INITIALS: CJ SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS