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-' REV-1500 °` (°'-'°' OFFtC1AL USE ONLY
PA Deparhnent of Revenue Csaay Code Year Fik NumCer
Bureau of InaNMual Taxes INHERITANCE TAX RETURN
Po sox 21X18(11 2 :d 1 1 1 1 6 1
F1arrlsburD. PA 17128-0801 RESIDENT DECEDENT
F71TTJt DECEDENT NIFORNATION BELOVY
Sodal Seadly Number Date of Death AMDYYYY Date of Blydi Msla)YYYy
Decederd's last Name Su1Nz Decedent's First Name~~ MI
K O V L A K NIL M A L
(N Applicable) Enter Survhring Spouse's kdormaHOn Below
Spouse's Last Name SulBx Spouse's Frst Name MI
Spouaek Sodal Seaziy Nwnber
FILL RY APPROPRIATE lWAL3 BELOW
® 1.Original Retum
4. L)mlted Este
® 8. Decedent Died Testate
(Attach Copy aF W81)
9. UBgatlon Proceetls Received
THIS RETURN MUST BE FlLED IN DUPLICATE WITH THE
REGISTER OF WELLS
2. Stpplemerrtal Retum ~ 3. IRemalnder Retum (date of death
pnorb 12-13-82)
4a. FDtDra hderest Coepromtse {dab of ~ 5. IFedarsl Estate Tax Retum Required
de9h after 12-72-02)
7. Decadent tAaintedned a LiWrg Tntst 8.'Total Number of Safe Deposk Bmces
(Atbdt Copy of Tnat)
10. Spousal Poverty GedB (data of death ~ 11. Electlon b tax under Sec. 5113(A)
Dalween 12-31-91 and 1-1-85) (Attach Sdi. O)
CORRESPONDENT -THIS SECTION MIST BE COMPLETED. ALL COR~ONOOICEAND C01
Name
M U R R E L WALT E R S I I I E S Q
First line of address
s 4 E A S T M A I N S T R E E T
SaCOlla Iine Ot 8aafeSB
City or Post Offlce
M E C N A N I C S B U R G
CortespondarKS s-rrW l addrsse:
L 1505610140
LL TAX WFORMATXNI 910ULD BE DIRECTED T0:
Daytlme Telephone Number
7 1 7 6 9 7 4 6 5 0
IRC-0BfER OF SE Ol1f ~ -~
-p
~ SZy. r ~-1 ~7
TC') .~ -~c7
~„
- v, _
~ ~ r ~ !'~_
DA FILED tV ~/J
_
State ZIP Code L
P A 1 7 0 5 5
SWe7
1605610140
1505610240
REV-1500 FCC DeaedenCs Social Saaudty Number
tleoadsl's Name: HILflA L• KOVLAK
RECAPIIULAnoN
1. Real Estate (Schedtie A} ........................................... 1-
2. Stacks and Bonds (Sdredrtle B) ...................................... 2•
3. CNlsely Field Corpvallon, Partnarslrp ar Sole-RopiiabrsMP (Sdred~le C) ..... 3.
4. Mortgages and Hates Remivabla (Schedule D) .......................... 4.
5. Cash, Bank DepaaHs and Miscellaneoua Personal Property (Shcedub E}....... 5.
6. Jdrdly Owned Property (SGredde F) ^ Separate BlNing Requested ....... B.
7. Inter-Viws Tramstters 8 Psaous F~Pro~ Property
(Schedule G) U Separae epkrg Requested ....... 7.
8. Total lsrosa Meets (btal Lines 1 through 7) ........................... S.
9. Fungal Expenses and AdmiNstative Cosffi (Shcedule H) .................. 9.
10. Debts a DacedcnR Ldw~age UabiDies, and Liens (Sdadule I) ............. 10.
11. Tad DsducUorro (btal Lines 9 and ,O) ............................... 11.
12. Net Vdue a Estate (LYte 8 minus Una 11) ................. . .......... 12.
13. Chadtade and Govemmenlal BequestsJSac 9113 Trusts Aor x,dch
an election bD tax has rat then made (Schedule J) ...................... 13.
1 3 8 3 7 1 b. 7 0
3 4 4 1. 5 3
1 3 8 7 1 6 0. 2 3
1 6 2 9 4. 1 7
2 8 4 4 8. 4 2
4 4 7 4 2. 5 9
1 3 4 2 4 1 7. 6 4
14. Net Vdue subsea to Tu (Line 12 mYus L9re 13) :. .............. .... .. 14. 1 3 4 2 4 1 7. 6 4
TAX CALCULATION - SFE NISIRUCTIONS FOR APPIICABIE RATES
15. Amount a Lkle 14 taxede
at the spousal tax mte, or
transfers under Sec. 9116
16. Amount a Una 14 taxable
1 3 4 2
6
4 1 7
4
6 0 4 0 8.
7
9
at Nneai rate x .ods . ts.
17. Amounl a Una 14 taxable ~
~ ~ 17 ~• 0 0
at sl6iirg m1a X .12 • .
18. Amount of Una 141axade
0 0
~
0
0
~
at coLateral rate X .15 18. "
19. TAX DUE ...................................................... 19.
20. FLL IN THE OVAL IF 1(011 ARE fN:QIlEST1NG A REFUND (>F AN OVERPAYM@,T
6 0 4 o b. 7 9
Side 2
1505610240 1505610240 J
REV-1500 IX Pa9a 3
Decedent's Complete Address:
Fae Nunber
21 11 1101
DECEDENT'S NAME
HILMA L. KOVLAK
_
__ ______
STRFfI' ADDRESS
COUNTRY MEADOYVS
4837 E. TRtNDLE ROAD
CITY STATE ZIP
MECHANICSBURG PA 17060
Tax Payments and CredNs:
t Taz Due (Page 2, Une 19)
2. CredilslPayments
A. Prior Paymads ~•0~•~
8. Discount 2.700.00
(1) 60.406.79
Tafal Credits (A +B) (2) 58.700.00
3. Interest
4. a lice 2rs greeter itrarr Una 1 +Une 3. enter the dNkterx>B. This (s the 01~RPAYtYIEMT.
FAI In oval on Pie 2, Uns 2a fo request a tehaM.
(3)
(4) 0.00
5. If IJna 1 +Une 3 is greabr than Una 2, eider Ere digerance. This fs ire TAX DUE. (5} 3.708.79
Make check payable b: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOVMING QUESTIONS BY PLACNIG AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent mal®a harmer and: Yes No
a. r~ainihausearirean~eattheptaperlyhansferred; ......_ ................................_-°°................. ..._
b. retain the dgM b designate vArosfrat use are property hansferred a Its Irrcaae : .......................... .....
c. retain a reverslarary Interest; a .......................................................................................... ......
d. receive the promise for life d eahar pays, benefl~ a care9 ................................................. ...... ^
2. If death oaurred after Deramber 12,198'1, did decederd tanebr propedy whin orre year of deaN
wilhoutreceiringadequatecorrsideratlon? ................................................................................. ......
3. Did decedent owm an'n toot br" orpayable-upon-death bank account a secudty al his a her death? ... ...... ^X
4. Dd decedent awn an hdridual rearemad aaaunt annufty a other nart~robffie properly, vdrk;h
a 6errefloary designaliar? ............................................................................................ ...... ^
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 a after July 1,1084, and before Jan. 1, 1995, lire toot tab inpoeed on Ne net vahre of transfers b a fa the use of the suviving spouse is
3 percent [/2 P.S §9116 (a) (1.1) O].
For dates of ~elh on a after Jan.1,199F,, the fax r~ imposed on ire rtM valrre of transfers b a kx the uae of the urrvkdng spou~ is D ~rcent
(72 P.S. §9116 (a) (1.1) (fi)]. The slaWle does Trot emrrgt a transfer b a surNvhtg spouse fran tax, and ire staWtory requirements for disclosure of assets and
filing a tax return are sW applicable even i the surviving spouse h the only toeneirdery.
For dates of danOr on a after Juty 1,2000:
• The tax rata imposed on die net vBua d twnsfers tmm a deceased child 21 years of age a yaager at death b a for Iha use of a naturB parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)).
• The fax tab hnposed on ire net v~ue d tratrsfas b a for the use of the decedents lirreal beneficiaries is 4.5 percent, except as rpEsd in
72 P.S. §9116(12) (72 P.S. §9110(a)(1 }).
• The tax rata imposed on ire net value of trensias b or for ire use of the decederd's abAngs's 12 percent (72 PS. §9116(aN1.3)). A st~6ng is defined, under
Section 9102, as an individual who ties at least are gent in cotrvtron wah t~ decedent, whether by bbod a adoption.
REV-1508 EXt (it-0Oj
Pennsylvania SCHEDULE E
DEi'ARTAENTOF REVENUE
CASH, BANK DEPOSITS, & MISC.
~ ~r~~"~ PERSONAL PROPERTY
ESTATE OF: F4E NUMBER:
HILMA L. KOVLAK 21 •li 1181
Induda9ie dIIU9atlon~dtiBdebQwptaoeedsnerereoaNedMtlte~.
A5 ropMy awmdw8h dsmvNasl~pr mnl6e dYcb~ed on 9chdufe F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
SUSQUEHANNA BANK _
50,017.52
130
2. SUSQUEHANNA BANK 2,884.70
122
3. ORRSTOWN BANK 8,745.93
942
4. ORRSTOWN BANK 75,089.99
251
5. MERRILL LYNCH 123,444.24
023
6. WELLS FAROO 400,501.88
943
7. WELLS FAROO 348,299.43
952
8. ALLIANZ 25,458.57
801
9. ALLIANZ 38,415.19
425
10. ALLIANZ 10,223.51
845
11. ALLIANZ 149,627.09
178
12. ALLIANZ 299.68
720
13. ALLIANZ 875.30
197
14. ALLIANZ 960.b3
831
15. AMERICAN FUNDS 924.86
419
18. AVIVA 87,788.83
DEATH BENEFIT
TOTAL {Abo solar on Una 5„ Recapl0ulatlon) { f
Continuation of REV-15001nheritance Tax Retum Resident Decedent
HILMA L. KOVLAK
Decedent's Name
Schedule E -Cash, Bank Deposits, 8 Mice. Personal Property
21 11 1161
Flle Number
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
17. TRANSAMERICA 65,877.38
ANNUnY
18. BETHANY VILLAGE 5,084.88
REFUND-NUR~NG HOME
19. MUTUAL OF OMAHA 757.32
REFUND
20. PENNSYLVANIA DEPARTMENT OF REVENUE ggg,p0
2011 INCOME TAX REFUND
21. U.S. TREASURY q 208,00
2011 INCOME TAX REFUND
22. TRANSAMERICA 10,050.00
LONGTERM CARE INSURANCE
8/8/2011 -10N 3f2011
SUBTOTALBCHEDULEE 88,883.58
ORAIID TOTS ~~~ E S 1 383 718.70
REV-1508 E%« (Oi-1D)
Pennsylvania
DEPARTAffNT OF REVENUE
RESIDENT cECr:oENr
SCHEDULE F
JOINTLY-OVYNED PROPERTY
HILMA L. KOVLAK 21 11 1161
M nn seat rru made Johdly owned wBNn one year of the decedenlPa dde of death, ~ mnst be Teporled on l±ehedule G.
U1NE
MO 20879
OECEDEFfT
AnDRESs
suRVwwc mwT TF11Axr(s) wwEts)
A. DANIEL L KOVLAK
8.
C.
,lOtttiLY-0WK®PROPERiY:
ITEN
NUMBER LETTER
FOR JgNT
TENANT DATE
M40E
.IOINT OESglIRIONOFPROPF.RTY
INgLDE NAME OF FINANCVtIN&TITUf10N AND 84NfA000UNT NU1,wERgi 31MLM
a7E41TIFYINGNUMBER ATTAgi DEED FORJgNTLY#ID REAL ESTATE
~4TEOf Ofh1N
VALUE q=A93Ef rsoF
DECEOENI'S
61TERE9T DATEDFOEnrN
VALE OF
OECEDENPSINTERE37
1. A. 2009 M&T BANK 8,883.06 60. 3,441.63
TOTAL (Also enter m IJne 6, Reaapkulatlon) I S 3.441.63
If smm apace is needed, useaddMonel sheers o(pgoerof the same eke.
REV-1611 F>C~ (10-08)
Pennsylvania
pEPARrhB!( OF REl'BAIE
MF1EF9iANCE TAX RET7pV1
RESCENTOECEDEM
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
HILMA L. KOVLAK 21 1'f 1181
OeeMeeCs tlebb instls repdbA ec Sclrotlute L
ITEM
NUMBER DESCRIPTION AMOUM
A. FUNERAI.EXPENSES:
1. MYERS-BUHRIG FUNERAL HOME 10,089.00
2. FUNERAL LUNCHEON 801.87
B. ADMINISTRATIVE COSTS:
1. Personal RepnssetHafire Commissions:
rlema(s)dPeremal Rep~ade&e(s) DANIEL L. KOYIAK
S6eetAd6ms 18501 FONTANA LANE
CfY GAITHERSBURG Sorts PA Zp
Ye~(s)Consrieda~PalG (RENOUNCED)
p, A16prs:T Fesa: MURREL R. WALTERS, RI
3, FetnMESer<p6bn:(Ndeoedenfseaa~ms>ssdtlreeemeasdainsanfs,asach~bnasai)
CbimaM
SseetAddroee
cnr sorb _
RebsomMp d Cbprontb Demdenl
4. PmbeleFess: CUMBERLAND COUNTY REGISTER OF WILLS
5. Aacunbm Fees:
6. TasRelumPrepeserFess: ALFRED WHRC0M8 P.A.
7
3,900.00
21P
1,058.50
445.00
TOTAL ~ order m Une 9, Recapiddalim) I S 18.294.17
It more space b neadad, use addltlonal sheet d paperd the ssme slm.
REV-1512 EX+(12~)
Pennsylvania
DEPARTAIENf OF REVENUE
NIHERffANCE TAXRETUIBJ
RE90Eff~ CfCPDEIn'
SCHEDULEI
DEBTS OF DECEDENT,
MIORTGAGE LIABILITIES, 8 LIENS
HILMA L KOVWK 21 11 1181
Report debts intoned 6y the deudaM pdorto death tlgt reaxined unpaid at the dale of death, tndudMg onnttmbmead mad1W a~p~aoa.
REVd513IXi(01-00)
Pennsylvania
INV~IaTANff TAX RETINtfI
RE9DENTOEQ~EOlr
NUMBER NAMEANDADDRESSOF
i TAXABLE DISTPoBUTIONS rydud
1. DANIEL L. KOVLAK
18501 fONTANA LANE
GAITHERSBURG, MD 20879
Z. VINCENT M. KOYLAK, JR.
108 KINGSTON AVENUE
BEILMAWR, NJ 08031
u~at
15 THRDUGH 18 OF
t
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEPC
8. CHARRABLEANDGDVERIMENTALDfSTRIBUf10NS:
1.
SCHEDULE J
BENEFICWRIES
RECEIVING PROPERTY ~ Do Not
uil dieh6utlole and translels under
OF ESTATE
TE
TOTALfIFPARTII-ENTER TOTALt10t~4TAXABLEfMSTRI8UTI0tISONlKJE130FftEV-1500 COVERSF~Ef. _
It more space is Ireeded, use addidal~ sheds of paper of tl1e same sine.