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HomeMy WebLinkAbout05-30-12 1505610101 REV-1500 Ex t°' -'°' ~ PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes ~"""."`"'°`p`°`"°` County Code Year File Number INHERITANCE TAX RETURN PO BOX zi3o6oi Harrisburg, PA 1']128-0601 RESIDENT DECEDENT ~~ / o ~ D S~' ~/ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY i ~7 ~~f 6eo's o s~~aor o cya'~ ~~3z DecedNiits Last N~ime suffix Dc~cdenfs First PJam~~ MI CLo~SE~2 ~/~'HA-2~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ~'~ Sp~nisF ~~~~ial 5~ uril~, Numlx~r THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate p 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 p D C L ~~ s~ /` ~ C .~- L~ Secon/d linnne of address /~ / /7 City or Post Office M~~ ~~-nl~ ~ sBuRG Stateuw ZIP Code /7 REGISTFZR~JF WILLS USE ONLY -, - ., - ., _.~ ___ , .. _, -- .1- t .i r v - '- i _.. "` ~ ., :_; _ - ,.X1A'rE FILED .V. - ~ -~ -T 3 P ~7o ss y-~ ~~ ,~. Correspondent's a-mail address: l.:(.c~1,e/a~s3@ (ort~~asf, /1et 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, corre and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN T OF PERSON RES SIB E OR FILING RETURN DATE X'i /~ ADD E S K~ ~ Y~/ r~/,Q//1/S/N 30/ N. F1ed~~ick ~', hlechan~~eS6N~, P /7oS.S ~- a. s- i~ SIGNAT F P ARE~HER T REP NT VE DATE ~ ~ r ADDR SS CN~¢~2L~S SH/E2/~s' -7n' G C/ouStr Rd. /~BC~l4/li~S~kry, ~~ /7©S,S s ~S~i~ PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J J 1505610105 REV-1500 EX Decedent's Social Security Number /- / /j ~ONSGY Q ~ ' " 'E- ~ ~ "l ~, ~' : (Q (p O S s Name: / i Decedent 4 (~ G~IGI s RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 7 / ! Q ~ • D d 2. Stocks and Bonds (Schedule B) ..................................... .. 2. • 0 O 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. . O O 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. • 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. ~ O a, • 6 7 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. ~ O 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 0 O (Schedule G) O Separate Billing Requested...... .. 7. • 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 7 2 7 O (D 6 7 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. O ~ ~ ~ ~ l0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. D O 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. ~ ~ ~ Q • 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 6 J~ S' (O S • (rS 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which Q an election to tax has not been made (Schedule J) ...................... .. 13. • O 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 6 3 ~ 6 ~ . 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'}~ 6 3 ~ (p S . $ ( 16. ~ G p 7 ,3 • y 17. Amount of Line 14 taxable at sibling rate X .12 . ~ O 17. • D U 18. Amount of Line 14 taxable `, D v ~ ~ at collateral rate X .15 18. 19. TAX DUE ........................................... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ ,~ See Combined Calculafiion stica7~ cc'~'acjled {nr aa~us~'e~ ~giC/cb~e a.n1oKYlt' ~a6, y37.zz X , ayS = ~ l ~~• ~~ ~ Side 2 L 1505610105 1505610105 J (OM ~~ R /.Spy/ ~A-LC l{ L ~} Tan/ S/~~~T ~o ~ aR !6/~tl~¢L ~~ 5 u P P~ E!j?L%N T~¢L /7t/NE,QI?i!-NCE %~4-~' ~~tC.PiYS ~~2 ~ ~~ of ,QrCN ~: C~ouS~_ __ ~i~ NV, ~i ~U -s~ SCHE~tlL~ o~2lG//1/ri9-~ S~IPPL _ ~.l~S T~ ~ __ ~ _ urv~l~i.~-7~ 7/_ qo ~ oo _ __ ~7~ _ ~0~ a o ~ ~ a, 758- ° ~ fi~~a.G7 ~ 3 SGo. 67 F _ ~ _.../6,../93. /~ D ~ _ /6, /9.~-/~ ~ _ ~Nv~ .' .SP~Ou/2tf ~.%/ i1y_~/pS _/"~~ ul3Te~ ~/' SGfe1~ F. Di1 ory,ita/~ O T ?A-t C~2vS5 _ { f P" 9S/. / _ __~ ~ 7a 706. 6 / _ ~ ~ 9;657,5 SCH~D. H __ 38, ..906- .38 ~~, 8yo, 86 __ _ Y7 ~Y~ /S~ ~ f 1,18'0-3/ D /, 20.3/ <n,,,Z D~JucTia~S `}p~ /~~, s 9 f ~ ~yo, ~'6 ~ 5~9, o.?~ ys SUET 1/IQ-LI(C- SK~iJECT ~ %i4f`' ~`1(i 657..~5~ _ _ -y9, m27,Y~ ~ a 6 30.x{0 ~ . I I __ ~ a6, '~37.Z2 NOTICE OF INHERITANCE TAX BUREAU OF INDIVIDUAL raxES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX PO BOX 280601 HARRISBURG PA 17128-0601 CHARLES E SHIELDS III 6 CLOUSER RD MECHANICSBURG PA 17055-9751 • 3'S ~- ' pennsylvarnaf~~ . DEPARTMENT OF REVENUE REV-1547 IX AFP C12-1]) DATE 05-21-2012 ESTATE OF CLOUSER RICHARD E DATE OF DEATH 05-28-2010 FILE NUMBER 21 10-0589 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 07-20-2012 See reverse side under Objections Amount Remitted) MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE -- RETAIN LOWER PORTION FOR YOUR RECORDS E-- REV-1547 EX AFP (12-11~ NOTICE OF INHERITANCE TAX APPR AISEME NT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESS MENT OF TAX ESTATE OF: CLOUSER RICHARD EFILE N0.:21 10-0589 ACN: 101 DATE: 05-21-2012 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED $EE ATTACHED NOTICE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) •00 NOTE: To ensure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account. 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 submit the upper porti~ of this form with your 4. Mortgages/Notes Receivable (Schedule D) C4) •0 0 tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) CS) 2,758.0 0 6. Jointly Owned Property (Schedule F) (6) 16, 193.18 7. Transfers (Schedule G) (7) .0 0 8. Total assets (B) 18,951.18 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (g) 38,906.28 L0. Debts/Mortgage Liabilities/Liens (Schedule I) C10) 1,280.31 11. Total Deductions (11) 40,186.59 12. Net Value of Tax Return ( 121 21 , 235.41 - 13. Charitabl e/Governmental Bequ ests; Non-elected 9113 Trusts (Schedule J) C13) .0 0 14. Net Value of Estate Subject to Tax C14) 21 , 235.41 - NOTE: If an assessment was issued previously, li nes 14, 15 and/or 16, 17, 18 and 19 will reflec t figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) .0 0 X 0 0 - .00 16. Amount of Line 14 taxable at Lineal/Class A rate C16) .00 x 04 5 = .00 17. Amount of Line 14 at Sibling rate (17) .00 X 12 = .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 - .0 0 19. Principal Tax Due (19)= .00 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 08-13-2010 (0013210 .00 2,992.50 TOTAL TAX PAYMENT 2,992.50 BALANCE OF TAX DUE 2,992.50CR INTEREST AND PEN. .00 TOTAL DUE 2,992.50CR * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTICINS. REV-1470 EX (01-10) f ~ ~rn..Y.:` • ~`~ . ~n enns lvarna ,; p y INHERITANCE TAX DEPARTMENT OF REVENUE EXPLANATION BUREAU OF INDIVIDUAL TAXES OF CHANGES PO Box 280601 1 P 171 -0 0 DECEDENTS NAME FILE NUMBER Clouser, Richard E. 2110-0589 REVIEWED BY ACN Daniel Heck 101 ITEM SCHEDULE NO. EXPLANATION OF CHANGES A 1 The value of this item has been suspended from the appraisement of the return until the final value can be determined. A supplemental return must be filed when the value of the suspended item is determined. ORIGINAL IPBge 1 REV-1502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF , FILE NUMBER ~,~hand F ~~ouser al -~o-s~~ 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 which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. Rea/ ~~fQ~ .s~o% f ,Br~~f w. Lec/if~/er axd L;,ada ~; Lechf/~a~r, ~;~ w,f~ ~ Dec. 9 2oi~ _ ~ ori~:aa/ ~c ~itrA ~r a~efa~%~ ~e SCi'i~ll~ o n - se~ ~~~/e~eat ~Shcef Offa~lea/ ~r~ d~fa~%s o~' ~ ~Sals fi-~ar~sa~~o~_ ¢7~~ gp y, ov TOTAL (Also enter on line 1, Recapitulation) I $ 7/, 90 7 - Dd (If more space is needed, insert additional sheets of the same size) ~~~~~~ fmnFLD1 (3~86)n~ Wmm1<43062 A ~itl~~ ~ U.S a Ftisrg aYf Ltbai Dwelopnrrt Q Twee Ina, C]vBPmroval Pb. 2soe~ F9NAt 1. ^R-14 2 ^FrtiA 3 ~Cknv.liins. 4. VA 5 (krrv.lns SFIeNurrba CL71413 7.LcenNiT6a 77788892 6Wtxtgagelnsratoe(aseNrrba C:hhte: ua,c~lme-~aoc)-wae~netlderie meyssr,wnnaebrir~mP,Paaesaeaentir,a~meu,meld~ ~Q,®,~ibmaa"eY"gm~sls.seeTme~ie~us~~'~~i'bm~e~n ~a'~~`°~`~ Tttl~Settlaiert97sten Rintedl2hfJ8~Xl'11at20.16Fd D.NNVECFBCf3~JJ162 BeCVILLedtt~alerardLindaJ.Ledtfhaler PO~SS 16Sen.Aran PA17056 E NNvE CF 5131H2 Estate of Ridtad E pourer POOF~S 126VIL Gleen PA17055 F.fyWECFLB~Z N~hoBank POCf~S 3801 Pao~on Pa 17111 C: R~TYADCF~ESS 1261K Ciea3Street, Madlalticstxig, PA17056 N 51=T71BVBdf P[~If: Carr~ersbona Lard Trar~!¢r, tn~, TelepFtatfX 717-73P8884 Faoc 717-730.9666 R1~CE CF S£l'RBvBVf: E Trirde PA 17050 I. SETTLBvB~(f DAT1= 12!091~I111 .1 SUTAVIARY OF 80~7S 7RAr6ACilOPt K SIJNVY~FtY aF S9J.9ZS TRM6AICT10Nt 100. Gf'~10fiS ANKXJrR ~ FTm1111 BQd~1Ht 400. f;tm6$ANgl1rR DL~710591Ht 101. CLrd-ad sales ~ 71904.00 401. Cbrir-act sales ~ 71904.00 102 Ftrsorral 402 R3sonal 103. Seffiemert b bannwer 6 9'1576 403: 104. 403. 105 405. far items seller in ad/arioe U~rrBYS to items Seller in ad/arce 105 fazes 405 lazes 107. fazes 12i09H1ro12f31h1 70 407: fazes 12"09'i1tiu12r31P11 3570 106 Sdnd taaes 12108%13o0fi130.r12 76697 4oB. Sdnd fazes 1210Q~11 to06ria12 76fi97 108. Sdnd Tazss 409. Stlnd Taxes 110. 41Q 111. 411. 112 412 120. Gib AM7utJF D1]E P~7N B~Y1Eit G7243 4~ 6ii205SAMJlINT DLETfl SEilB2 70&67 ?DO. ANnlMS PA1D BY ORON Bff1ALF aF Bp3 500. R®UC110NS IN /~llYi' DIE TO SEiJ$t 3h. ' vearr~t 000:00 501. 6oxtss seeifistrudions 202 Rind arranldrewloens 47500 502 SetllerrsY tosdla Ine1400 .03 203 6dsti faien b 503, 6d ' ' s tal®ra to 204. 504. dFrsttitrt !:[x3t 205. 505 316. 505 377. ShcaAmisfaloe 1 06 507. ShcerHssistanoe 1 08 316. 506 209. 509. for hens seller for ilerrs seller 210. tares 510. fazes 211. fazes 511. f~aes 212 Sdnd fazes ~ 512 Sand faces 213. Sdnd Tazas 513 Sdnd Taxes 214. 514. 215. 515. 216 515 217• 517. 216 516 219. 519. 2ZQ.'POf/iL PAID BYlFOR BOF3~JN6t 613.08 520. 7QfA1 REDIJCiIpd ANbl1Jl' DlE Sa162 1889.11 300.C1>vSF1ATgTfL9YB~7TFT4a1AdR7l~BORI ~Y162 600.~ASFIATSETRHUBYf70QtFiaplASHl62 301. doss arrart due from baroNer ne 1 43 601. Civas amxrt due b seller ire 706.67 302 Lem anwts bonaner ire 237 08 602 Less reduction arrant due seller ine 1889.11 303.C/\SFIFfmMBOFif~OVt6~ 17009.35 603CASHTOSEIlE12 61817.96 smnn>rExxanraeaselats-rnTasir: Tretrmmonm-rredr~aer~lsnput~~o-+arrelu~ad~smrgnnis,mmmerrar~l~.e.e~.~m rr~ouaere~,eneo~a~m,n rigACiaos {~~elry o atla sacflm WII OaMpmalm you M Ws Ibn4 rac}lretlb 6srepv0af aitl Ris IRS~brHrm tlel A hssra heal r~uteC The Corb-ad SAS Rlm cles fed m Yre A~aam91s1®4ieDaes FymeabdUb taieadvt Wu ae n~}inad hylavb pwfde heseltlarat eft (Fed TeK ID1~b:251~51e21) Wlhyurmreti IIm~~a klawtlk~tlm nurba. tl youtlo nd rrwtde W+mrred ~a s ItlerEllr~m mirha, yvu neybe silted b W Q atrti9 pa~ltles Inp®edhy let U~rtrpaielUasd pajuy, l tertllydie[ tlienurEa shpY1 m tlis 91~arat isrtyoonert lmpas k]aitlRr~lm rvrha. TIk_-__ ! - Sfl1SYS~5K3Wlii~57: / SH16~S) hEW hyY4K3P~S ~" SH1.6YS) F7~t:f~E h1lv~S. M MA RvAasaanvnaemadda us o~a~tn~rrc>=t-~sNCawu~wotle.~,srr SETiLBVBJf STATHNB~(T rom,Fan i c~ ny Fiarl~mlc43D52 FlIe Nrrber. 0.11413 RNAL PK~ 2 TitkFxrExc ~INar~sY 9Aarn Rir~aA 12JOWXNt a121T1RIQ_ L SEPiIJ9YBJTCFIiN~;ES PAIDFFiCM PAIDFtiCM 700. TC3TALSNES~BF10F~iSQ:Mv1S9CNLtasadm 'oe 904.00= 314 BORf-i0/~i'S ga i ~cxg Cltisiondom7rission ine asidloAS Rl~D6AT t~l~D6AT 701. 31424 b MCVIdI®r sETrLB~HVT gTrtJ3va~fr 702 b 703. Gbrnrissim at Sealerrert 314.1rt 704. Boker Fee b M G V1611aer 19500 800. ftBV6 PAYABLP IN OpV~IION W7F1 LA4N 801. Loan Fee /a61~Uo Baic 89500 802 Lnen D~ait 803 Fee b JoMrsan .QG 400.00 50.00 804. Qe6t b Shctims 1383 806. Flood Ckn b Vlbllers Fduueer' Rr>arlciai Services 6.00 80& 807. 80& 809. 810. 811. 900. fiHlilS Ii®C3Y LB~[)8271D~ PAI IN ADVMICE 901. tieerest From 1 b 2 : ZQ219 23 16h 9012 ir~rane F4ariFrn br 0 rrvt b 903. Fi~adtrsuanoe PlerriFm for 12 b 9tabe Fartrllrsuarne .0.G 45500 903. 90fi _ 1000. 1t1fiHLBFO13t 1001. F~ard treirance 3 nn 37.9Q /nn 11376 1002 haranoe nu /mo 1003 Tau r% hro 1004. Tau 11 mx 47.21 hro _ 519.31 1005. Sdnd tees 7 m~ Cdi3 11411 hro 796. 1009. b M3tro I -09220 0.00 1100. TtiLE 1101. rent of Fee 1102. Pbstr-ad ct Title Search 1103. Title 6ePriretim 1104. Title IrFSranoe finder 1105. Edocfee b LardTrarlsfer forRY11C 2500 110Fi Foes b Ftarxi Lenlaer 2500 20.00 1107. sfees mdtdes abase i[ers Nx 110fi Title lrsrarce b Oorr>erstone Lard Traisfer for RYi1C 91575 ududes above items Noy 7109. terriers Ri' 17500 -600.75 1110. O~nrers Ri' 71904.00 -90.00 1111. Lire 1108 irdudas Erxlaserrert b 1001300r811Ci~L tt 12 Tic G13rt F~iMxrsenat b Currlerstorle Lard Trarf3fer for RYI1C 10.00 1113 GarierNUre FEe b Conterstane LandTrasfer for RVfIC 1500 1200. QOd@MYB~If RBOOIipNGMD7RM6F132CFil~ 1201. FeesOeed 52.00 78.00 •F~lease 130.00 1202 taod Deed 9.04 719.04 1203 Sta~Taoo' Deed 9.04 719.04 1204. f)aed 1205. Lbed ~ F~lease 1300. A~g71pVM_SEllLBUB~if 1301. ParoeJ Identifier fees b Reoartler of Deeds 20.00 1302 2011 Fac b TaxCdlet3ar 623,,28 1303. 2011-12 Sdnd tic b L Hedrad 1$0.6,2] 1304. tsnowfQ Irtrritane Tic b Select Lard Transfers for RY11C 06325 1400. 710f/IL SEl'TL9VB~if erFlarm lines 1 Saotim J acct Sedim 91576 451. Fan c~tnacanw cF ar~st an szis~ in®e ~,na~mr,arwi~tism,a,te~emmaeerdRRyyF.nwe~aerdm~.n~aae„aa~a~rera~Ydan~emr,~a,dem,a~,Fa~mRy~.ti ab/RHYI taeetlivtFNY~Oftatllypglh~etBOBNedao~dlhaHD79atlarat;78brrart VWWJNC3 fi15A6~3VETOFPJTMrdLV AW~FW..E SiATB.HJfSTOTf ThaFiI?7 ~errst 9garet wiY~Irarapapaedlaaaue aidem~aBae~rYdris urr®srAn3sa.Fnasa~arwsw~n~xrMr+s~r~n~urriaorr.~crFw aa,aactim in~ameaeaw~~a,an.mmcaam,aaati~mnawnwameFe,ec awucy~~AfNEMDMii6Q.bBJT rr>3oerarss~nnEia usacat_sr~nw~mi owsecnwima can= REV-1508 EX * (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MSC. INHRESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF ~ r FILE NUMBER R~~hu-~ ~. C~ousGr a2/-/O -.s8 f Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. Reim6arstm~~~ mn nom-~Q~~ ~lias~otrt 7~2,~res doer ~'~{~/.~cnf ~~ at~a~h~d- ,8- L!/JG 7vS SGLIDOI ~~s 3s, 70 ~7c6, ~i7 TOTAL (Also enter on line 5, Recapitulation) I $ ~j0 a, G7 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF ~'GI ~~ ~. ~/b~~~ FILE NUMBER a' _ U , .S~~I '1 1 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT _ A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City _ State _ Zip Year(sl Commission Paid: 2. Attorney Fees 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 4. Probate Fees 5~ Accountant's Fees 6. Tax Return Preparer's Fees S. Z~c/ t~ ~XrU~ISe (,l~SoC%a~~ w~~ cfa~e 0~ ~<e4~ ~c51~at /Oer ~el~/emen f Shect afta~hed. /, ~f3&.D8 ~ . L; ~e X03, ~om~, ~ ss%an ~ /h . ~. Wa /k~~ , ~eQ /f ~` a C_ l.;ne 7o~f, ~iokir Tnr~sachoh j'u ~ /~1, C. ~Q/fir, ~Ga/t,, ~~9S o (~~ CaA~i~huaAO/t vhee~ afta~~ic~/ ) TOTAL (Also enter on line 9, Recapitulation) $ ~, ~~~, ~ro (If more space is needed, insert additional sheets of the same size) r.Z S~• ~ L~oAfiA. ~Sh~tef ~~P/11__~ : ~_ _ _L:ne _ / /oG ~of4ry Fees __ ~ 2~* ~ ~. L%~e __ /~~Z 7,~ C'e~f, f: ~~:rnl~arse~reH ~ _ _ _ ¢/e~..o~ _ F ~~e ~do3 IQea/ F,S~,e,~ %ray~,S„~i- %S ~7~9 0~ G ~%~e /30~ ~ f3ar~ yP,G'~a~ lyr_ ~O/l~o~, / /Two _ % f 6a?3, z3 l !~. i i I, f r ~;~~ 130 ,~r y ~/~i 1.~l'ol/et~~ __ ~S(~roa/ _ %X ~ So6.27 SCHEDULE J COMMONWEALTH CF PENNSYLVANIA BENEFICIARIES INHERITANCE. TAX RETURN RESIDENT DECEDENT ESTATE OF R~G,h4rd ~. C~n!lSe1r FILE NUMBER ~-/o- S89 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER RIAME 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. ~~ bara.h ~Q-. Doz - tn- c;(a~ct4/~ ~~t- ~5F `~9 5Fx LrincP.r~ 1>r. , l~{arrs~rtsr~, ~~ /7l09 ~. /la /~'ar~•n ~7.' Buns%ngCr' v~auy fetes- ~J~ 30/ N. Frru~crick St, /I?ec1-a•r ~ c s dk,-~, ' P.¢ i7d5S 3 Lr/~%/~i~,/~r T. C/o~scr son y4~ /ado w. Graes~ ~S/.; 01'Iec.J~artics~a-Yj, Ps ~ s T %no/~y r^ /D t! s ~r doh Y~- 2~ ~o' nci/ ~t , e~tr/; s lc~ Oif / 7D ~3 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) LAST WILL AND TESTAMENT OF RICHARD-E. CLOUSER a.k.a. RICHARD ELMER CLOUSER I, RICHARD E. CLOUSER, a.k.a. RICHARD ELMER CLOUSER, currently of 126 West Green Street, Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. I direct that my real estate, consisting of my residence and an additional lot be sold at public or private sale. My Executrix, in her sole and absolute discretion, may select the manner of sale she deems best. 3. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, is to be divided and distributed in four (4) equal shares amongst my herein named children, to wit: DEBORAH A. DOZIER, KATHRYN J• HUNSINGER, VYILLIAM T. CLOUSER and TIMOTHY CLOUSER. In the event that any of my said children fails to survive me, his or her share, as the case may be, shall be proportionally divided amongst those named above who do survive me, per capita. FOR PURPOSES OF CLARIFICATION: my son, RICHARD E. CLOUSER, has been left out by design and not by accident. 4. I nominate, constitute and appoint my daughter, KATHRYN J. HUNSINGER, to be the Executrix of this my Last Will and Testament. In the event that she is unable or unwilling to act as Executrix, I appoint my daughter, DEBORAH A. DOZIER to be Executrix in her place and stead. In the event that she is unable or unwilling to act as Executrix, I appoint my son, WILLIAM T. CLOUSER, to be Executor in her place and stead. I further direct that they shall not be required to file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. WITNESS WHEREOF, I have hereunto set my hand and seal this .~x*~ day of ~, A.D.2007 EAL) ~i~~' ~ f~y~-: ~ ARD E. CLOUSER ~ a.k.a. RI L ER CLOD Signed, sealed, published and declazed by the above-named RICHARD E. CLOUSER, a.k.a. RICHARD ELMER CLOUSER, as and for his Last Will and Testament, in the presence of us, who at his request and in his presence, and in the presence of each other, have hereunto subscribed our names as witnesses. 6~~ ~ ~-- _ ~~ ~ ~n v ~ N p W ~ ~o Q N ° ~ a ~ ~ ~ cn o ~ o W w _ , ^ V• ~ W -o ~ ~• O pro-~- Z ~~ Q N O Q ~'~ J } ~ N = • ~ ~ F- ° o ~ J 0 O U cnao ~ ~~~~~ ~ o ~¢~°'_ ~ ~~=w ~ W ~ H J o ••^^ V• ~ W ~ N ~ ~ m ~ ~ a - ~ ~~OpC= W ~ U Q = ~ ~ ~ o~ OC U .- U w o ~ =~0° cno~v O ~ wiz Z _ ~ w ~ U cD ~ - ~ 3 _ i ~ ~ ~~. ~~ +1 1 .~ S K { - w r ~ _ ~; ~t H ~ ~ . ,,F `f~ y r ~ ~''~'" ~~ r p ~ - ~ j.A ~ ~ h ~ ~. ~ i ~~~s j ..c 5 f r= ,~,~ 4 ~~ ~~~ S a ~ • 4 W - f~ ~[ ' r 6 fiy'i ~ r r F ~, w ~f - . ~ r ' ,~ i ~ ~~ ~ ~ ~ ~ ~ ti~ _'r m~ ~, ~ ~ ~+ t '' ~ j • - _ ' ~ ~` k 7. ~' y ~ K .~ `~ Airy ~ v ~ - ~7 Y ,. '~~ roys;`~ ? r.:; -^~ k ;7 i~i~.~ cif ~ ,~. ~'a