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1505610105
REV-1500 IX(oz-ss) (FI) ~j
nrerere~ nce nwv
PA Department of Revenue ~°.~~..,~:a County Code Year Fqe Number
Bureau of Individual Taxes INHERITANCE TAX RETURN ~ ( i j "(~ D ' ~ ~
PO BOX 28o6ot + '
Harrisbum. PA 1~z28-o6oi RESIDENT DECEDENT
Sodal Security Number Date of Death MMDDYYYY
184-78-0129 ~ ~ 1 Z/31 /2011
Decedent's Last Name Suffix
Burkholder I
FILL IN APPROPRIATE OVALS BELOW
Date of Birth MMtx)YYYY
09/02/1924 ~ -C
cedents First Name
D MI
e
1 `e°rge ~
_ i
Spouse's Last Name Suffix Spouse's First Name MI
It ~
f r~'
Spouse's Sodal Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
~ REGISTER OF WILLS
(If Applicable) Enter SutvNlnM Spouse's Informatlon Below
QD 1. Original Retum O 2. Supplemental Retum 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. Federel Estate Tax Retum Required
death after 12-12-82)
8. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes
(Attach Copy of WNI) (Attach Copy of Trust.)
O 9. Lttigatlon Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. E:lactfon to Tax under Sec. 9113(A)
Between 12-31-91 and 1-1-95) (Attach St~redule O)
CORRESP~IDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE-AND CONFlDENTUL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytlme Telephone Number
Samuel Goodley, Esq. ~ (717) 768-7010 Q ~ ~
REGI8TER OF, USE ONI ~! ,~
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~
~
First Line of Address ~ Cfi~ ~ .
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P.O. Box 474 :7
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C.~ C
Second Line of Address
City or Post Office
State ZIP Code DATE FlLED ..~
CiD ~
Intercourse PA ~ 17534 l
Corrsspondsrtt's e-mail address: Sgoodl@yCa~bgW-law.com
Urrdsr perregfss of pargay, I dseiaro tl~at 1 have exarNnsd this rMum, frrdudirg aoconpanying ar9redulas and , and to ttre hest d my IoroMAadps and beNsf,
K is true, oonr,ct and complete. Dedaratlon of prepsrsr other then the personal ropresentatNra b based an aA intorrtiatlon of which praparor has arty krroMAadgs.
DATE~+ A~' ~^
192 ~aat Main Street, W~iut Bottom, PA 17266
=~tq- ~~
P.O. Box 474, Intercourse, PA 17534 p
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105- 1505610105 J
1505610205
REV 1500 EX (FI)
Decedents Social Basally Number
Deceaenra iuame: George M. Burkholder 184-78-0129
RECAPrTULATION
1. Real Estate (Schedule A) ............................................. 1.
2. Stocks and Bonds (Schedule B) ....................................... 2.
3.
Closely Hekl Corporation, Partnership arBole-Proprietorship (Schedule C) .....
3. }
4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 1
5. Cash, Bank Deposits and Miscellaneous Personal Property {Schedule E)....... 5. 70,265.73
6. Join Owned P F) pa ng eq
tit roperty (Schedule O Se rate Billi R nested .......
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. 70,26$.73
9. Funeral Expenses and Adrriinistrative Costs (Schedule H) ................... 9. 11,907.50
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. 3,890.10
11. Total Deductions (total Lines 9 and 10) ................................. 11. 15,797.60 ~
i
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 54,468.13
13. Charitable and Governmental BequestslSec 9113 Trusts for which
an election to tax has not been made (Schedule J) ........................ 13.
14. Net Vslus 8ubJect to Tax (Line 12 minus Line 13) ........................ 14. 54,468.13
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sea 9116
{ax1.2) x .o_
1B. Amount of Line 14 taxable
at lineal rate X .0 ~. 54,4E
17. Amount of Line 14 taxable ~"
at sibling rate X .92
18. Amount of Line 14 taxable
at collateral rate X .15
15.
1s.
17.
18.
19. TAX DUE ......................................................... 19.
~ 2,451.07 j
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 1505610205 1505610205
O
J
RE~h1500 IX (Fq Paps 3
Decedent's Complete Address:
File Numbsr
E
George M. Burkholder
sTREETADDRESS
192 East Main Street
CITY
Walnut Bottom STATE
PA ZIP
17266
Tax Payments and Credits:
1. Tax Due (Page 2, Lie 19)
2. CreditslPayments
A Prior Payments
B. Discount 122.55
3. Interest
Total Credits (A+ B) (2)
(1) ~ 2,451.07
122.55
(3)
4. H line 2 is greater than Line 1 + Line 3, enter the d'Ifference. This is the OVERPAYMENT.
Fill in oval on Page 2, Une 20 to request a refund. (4)
5. tf Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2,328.52
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 ~ incarrre of the property trensferred ................................:.:....................................................... ^
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. K death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without reoeivirlg adequate consideretion? .............................................................................................................. ^
3. Did decedent own an'kl trust fol' orpayable-upon-death bank accamt or security at his or her death? .............. ^
4. . Dkt deoedeM own an kldividual 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 R AS PART OF THE RETURN.
For dates of death on or after Juty 1,1994, and before Jan.1,1995, the tax rate imposed on the net value of transfers to or for'fhe 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) (i)]. 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 reium are stia applicable even 'rf the surviving spouse is the onty benefclary.
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 chid is 0 percent [72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value ~ transfers to or for the use of the de~denYs lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(aj(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's sibCngs is 12 percent p2 P.S. §9116(a)(1.3)]. A sl~ling is defined,
under Sectlon 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REWUo8 IX+ (il-lo)
Pennsylvania SCHEpVLE E
DEPARTMENT Of REVENUE CASH, BANK DEPOSITS & MISC.
I""~""~ TA'~'~RN PERSONAL PROPERTY
aESmear DECEDENT
ESTATE OF: FILE NUMBER:
George M. Burkholder 21-12-0117
Indude the proceeds of liitigation and the date the proceeds were received by the estate.
All property jointly owned with right of wrvivorshlp must be disdosed on Schedule F.
1., Orrstovm Bank Checking #103007142 _ __ _ 1,976.81
2` Orrstown Bank Money Market# 103800123 18,473.92 "
,.3. Private k>an b Jason Zimmerman 10,000.00 `:
4 Prmapal balance on loan from decedent financed mortgage ~ 39,675.00
5' Uncashed traveler's checks 140.00
TOTAL (Alsp enter on Une 5, Recapitulation) ~ 70,265.73
If more space is needed, use additional sheets of paper of the same size.
Pennsylvania
ii DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES.AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
George M. Burkholder 21-12-0117 .
DeeedeM's debts must be roported on Schedule I.
A.
I.
.2,
...3=:
B.
1.
FUNER~IL, EXPENSES:.........
.. .........._ ._ ..m _ ....... .......... .... .... .... ..,_ . _....,.
Strad~ing Funeral Home
Weaver Memorial Inc. (Headstone)
m.._.....:_ .... .
Funeral Dinner
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representatlve(s)
Street Address
State ZIP
2,350.00
2. Attorney Fees:
3. Family Exemptton: (If decedents address is not the same as daimants, attach explanation.) 3,500.00 '
gaimant Weaver Burkholder
street Address 192 E. Main Street
qty Walnut Bottom state PA ZIP 17266
Relationship of gaimant to Decedent son
a. Probate Fees: 186.50
5. Accountant Fees:
6. Tax Return Preparer Fees:
~• Executor travel expense -open estate, select headstone, set headstone 104.00
8 Recordingfee - to satisfy outstanding mortgage 42.00
TOTAL (Also enter on line 9, Recapitulation) $ 11,907.50
~Y
Year(s) Commission Paid:
If more space is needed, use additional sheets of paper of the same size.
• REV-1512 EX+ (12-OS)
_ Pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
I""~'T""ce T"X "E71~'' MORTGAGE LIABILITIES 8'e LIENS
RESIDENT DECEDHfT
ESTATE OF FILE NUMBER
George M. Burkholder 21-12-0117
Report dabb Incurred by the decedent prior to death that remained unpaid at the data of death, IncludinE unreimburaed medical expanaea.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1• 'Smartrned, Inc. (medication bill) 227.10
2' Pennsylvania Department of Revenue -Quarterly estimate 28.00
3 Martin Tax Accounting -tax return preparation 85.00
4' 'Outstanding checks written prior to death, cleared after death 3, 550.00
TOTAL (Also enter on Cine 10, Recapitulation) ~ 3,890.10
If more space is needed, insert additional sheets of the same size.
, --RfY 1513 EX+ (O1-10) .
~pennsylvania SCHEDULE ]
DEPARTMENT OF REVENUE
BENEFICIARIES
na,s~rrwcE TAx REn,RN
RESroENr DECEDENT
ESTATE OF: FILE NUMBER:
Geo a M. Burkholder 21-12-0117
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not List Trustee(s) OF ESTATE
I .TAXABLE DISTRIBUTIONS [Indude outright spousal distrihuHons and transfers under
Sec. 9116 (a) (1.2).]
....._.....~._ ......____w._.....w~....... _~.... ..._... ., ...,.............,
L
`Mabel Noti, 282 Rands Church Road, New Honand, PA 17557 g
dau hter
1/10
2 Anna Laid, 70027 West V'~ew Schod Road, FoRuna, MO 650341225 'daughter 1 /10
3 Henry Burkholder, W8598 Broek Road, Thorp, VVI 54771-7726 .son 1/10
,.. ~..
4 _ _. __ ..__ .._w_ ..~ ............ . ........ .... .........
Elizabeth Martin, N13270 Sterling Ave., Withee, WI 54498
'daughter
1 /10
.,.......
5 . u.... m.__ . .. _ ..r,~.......... _ .
:Mary Nott, N16667 Sterling Ave., Withee, VVI 54498
daughter
1 /10
6 EG Burkholder, 165 Hair Road, Newville, PA 17241-9504 son_ 1 /10
7 Ens Hoover, 613 Topton Road, Kutztown, PA 19530-9678 daughter 1 /10
8 .Isaac Burkholder, N13569 FsherAve., Thorp, WI 54771-7802 on 1/10
.m,~. ,.
9 ~._.._.. _ . _ _.....:.._. _ .....~._ .,_... _ . .. ... ........... .
'.Weaver Burkholder, 192 E. Main St, Walnut Bottom, PA 17266
son
1 /10
10 ;Lucy Sensenig, 4200 Rt.14A, Penn Yan, NY 14527 !,daughter 1/10
...... ......._ , ....._........__. _.m.. _ .
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH
18 OF REV-1500 COVER SHEET, A
S APPROPRIATE.
II NON TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS.
1.
TOTAL OF PART II - ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I ~
If more space 15 needed, use additional sheets of paperof the same size.
G^ ~
LAST WILL AND TESTAMENT
OF 0 p
GEORGE M. BURKHOLDER
I, GEORGE M. BURKHOLDER, Earl Township, County of Lancaster and Commonwealth of
Pennsylvania, being of sound mind, do declare this to be my last Will, hereby revoking any and all Wills and
Codicils by me at any time heretofore made.
ITEM I. APPOINTMENT OF PERSONAL REPRESENTATIVE. I name, constitute and appoint
my son, WEAVER G. BURKHOLDER, Executor of this my last Will. In the event my said Executor
predeceases me or dies before my estate is settled, or if for any reason he is unable or unwilling to serve in that
capacity, I then appoint my daughter, LUCY G. SENSENIG, Executrix in his place and stead. My Executor
or Executrix shall hereinafter be referred to as my "Personal Representative."
ITEM II. PAYMENT OF DEBTS AND FUNERAL EXPENSES. I order and direct my Personal
Representative to pay my just debts and funeral expenses as soon after my decease as may be convenient.
ITEM III. DISTRIBUTION. I give, devise and bequeath all of my estate, both real and personal,
unto my wife, ELIZABETH H. BURKHOLDER. Should my wife predecease me or die within thirty days of
my death, I direct my Personal Representative to hold a family auction of my tangible personal property with
the proceeds therefrom to be added to and distributed as part of my residuary estate.
I give, devise and bequeath all the rest, residue and remainder of my estate, both real and personal,
absolutely, unto my children, in equal shares, the .issue of any deceased child to take the share of such
deceased child, per stirpes, and in the event any child dies leaving no issue surviving, I then give the share
to which such deceased child would have been entitled if living unto my surviving children.
ITEM V. PAYMENT OF DEATH TAXES. I direct that all estate, inheritance and`other taxes in the
nature hereof, together with any interest or penalties thereon becoming payable because of my death, with
respect to the property constituting my gross estate for death tax purposes, whether or not such property passes
under this Will, shall be paid from the residue of my estate; and no legatee or devisee or any person having
a beneficial interest in any such property, whether under this Will or any Codicil thereto or otherwise, shall
at. any time be required to refund any part of such taxes. Taxes on future interests maybe prepaid.
ITEM VI. GUARDIAN OF THE ESTATE. I appoint my Personal Representative Guardian of the
Estate for any minor beneficiaries of mine, whether under this Will or some other instrument, such Guardian
being empowered to receive assets for such minor of any kind whatsoever. My said Guardian shall have the
power to use so much of the income and principal of such assets for any such minor as is necessary, in the
discretion of my Guardian, for such minor's education, medical care and support, taking into consideration all
other sources of income available to such minor.
ITEM VII. WAIVER OF BOND. I direct that none of the fiduciaries appointed under this instrument
be required to give bond.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of
A.D., 2001.
(SEAL)
George urkhol er
THI5 INSTRUMENT, consisting of three (3) typewritten pages, was by the above-named Testator, on
the date hereof, signed, sealed, published and declared to be his last Will and Testament, in the presence of
the undersigned, who, at his request, in his presence and in the presence of each other, have hereunto
subscri their names as 'tresses.
residing at ~
~..LPu. j ~.~.-, t t ~~ o,t ,~ residing at
2
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF LANCASTER
. SS:
We, George M. Burkholder, JAI'i'I
~,
and ~) Ia G . ~Ui ~i ho~X the Testator and the witnesses, respectively, whose names
are signed to the attached or foregoing instrument, being first duly affirmed, do hereby declare to the
undersigned authority, a Notary Public, that the Testator signed and executed the instrument as his last will
and-that he had signed willingly, and that he 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
witness and that to the best of his or her knowledge the Testator was at that time eighteen (18) years of age
or older, of sound mind and under no constraint or undue influence.
Testator
rge urkholder
witness
~..~Cc~ ~. !-~~~~~~~ Witness
Subscribed, ai~iimed to and acknowledged before me, a Notary Public, by George M. Burkholder, the
Testator, and subscribed and al~irmed to before me by S' q rY-uP_l A, Gocnl ley ,Ti
andi~~a ~i. t~t(~i h~ic~r .witnesses, this 4~ day of Tunes AD pool.
Notary Pu is
irA~~ry Publb ~ _ .
~ ~ Exptne .brrre~2,y2003 .
Member, ~~ira Ase~~ d
Notaries
3 ._