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HomeMy WebLinkAbout08-06-12 1505610105 REV-1500 ex toz_~ ~> (FI, PA Department of Revenue enns lvania OFFICIAL USE ONLY P Y Bureau of Individual Taxes t, u ."~ County Code Year File Number ~F INHERITANCE TAX RETURN PO Box z8o6o>. tt 2 rl ~~ ~ I ~ Harrisburg, PA i'71z8-0601 RESIDENT DECEDENT I >Jc `"I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ', 11/24/2011 05/27/1929 Decedent's Last Name Suffix Decedent's First Name MI Cheski Theodore ~ (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) 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 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0; Name Daytime Telephone Number Peter J. Russo (717) 591-1755 First Line of Address 5006 E. Trindle Road Second Line of Address Suite 100 City or Post Office Mechanicsburg State ZIP Code PA 17050 REGISTER OF WILLS USE~LY ~~ r-.a GJ'-'7~t-t r ~- {~? ° G 7 C t ~:! ~ ' r U ~J , C'~ C` bAT~' ILED IV ]~ ._ ~ c>ta Correspondent's a-mail address: rUSSO ~r Om Under penalties of per'u ha ve examined this r including accompanying schedules and statements, and to the best of my knowledge and belief. it is true, correct complete. Dec n of preparer r than the personal representative is based on all information of which preparer has any knowledge. SIGNATUR OF P ES O LING RETURN DATE I Ira ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 "~'- G% _77 c_~, tTl r~..7 f:~ =~•~ _~ ~3 :-t`t O~ J 1505610205 REV-1500 EX (FI) Decedent's Name: Theodore J. CheSki Decedent's Social Security Number RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 2. Stocks 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. 16,593.43 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 914,386.97 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 8. 9 ) ........................... Total Gross Assets (total Lines 1 throu h 7 . 8. 930,980.40 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 17,699.85 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. .. 10. 15,958.27 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 33,658.12 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 897,322.28 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. 897,322.28 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate x .12 897,322.28 17. 107,678.67 18. Amount of Line 14 taxable at collateral rate X .15 18. 1s. TAX DUE .........................................................19. 107,678.67 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 15^5610205 1505610205 REV-1500 EX (FI) Page 3 n_ _~_~af_ /+~ ... L.L.. Ai•leJrecc• 9,747.89 vca.cuc~~a a vv...~..........,...... ___. , DECEDENT'S NAME Theodore J. Cheski STREET ADDRESS 1323 Asper Drive CITY STATE PA ZIP 17007 Boiling Springs Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) (1) 107,678.67 (3) (4) 97,930.78 97,930.78 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 "in 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 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. File Number Total Credits (A + B) (2) BUREAU OF INDEVIDUl~L TAXES NOTICE DF CNHERITANCE TAX INHERITANCE TAX DIVIS]DN APPRAISEMENT, ALLOWANCE OR DISALLOWANCE PO 80X 28061 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON NARRISeurzc PA 17128-0603 JOINTLY HELD DR TRUST ASSETS WILLIAM M FARRELL 1323 ASPER DR BOILING SPRINGS PA 17007-9616 r ~.. w:.. pennsyl~ran~a ~P ~ :; ~,. DEPARTMENT OF REVENUE ' REV-1548 EX AFP {12-11] ~~~ DATE 02-28-2012 ESTATE 4F CHESKI THEODORE J DATE OF DEATH 11-24-2011 FILE NUMBER 21 11-1334 COUNTY CUMBERLAND SSN/DC 189-22-2708 ACN 12100972 APPEAL BY DATE:04-28-2012 (See re>>erse 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 ~ _._ . . REV-1548 EX AFP C12-11) ""-"--"-"""-----""""""""""""""""" NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT DF TAX DN JOINTLY HELD OR TRUST ASSETS DATE: 02-2B-2012 ESTATE OF:CHESKI THEODORE J DATE OF DEATH:11-24-2011 COUNTY:CUMHERLAND FILE ND .: 21 11-1334 S.S/D.C. NO.: 189-22-2708 ACN: 12100972 TAX RETIJRN WAS: CX) ACCEPTED AS FILED C ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: CITIZENS BANK OF PENNSYLVANIA ACCOUNT NO.: 6104512732 TYPE OF ACCOUNT: C )SAVINGS CX) CHECKING C )TRUST C )TIME CERTIFICATE DATE ESTABLISHED 01-01-1981 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due 14,bb6.38 X 0.500 7,333.19 - .00 7,333.19 X_ .15 1.099.98 NOTE: TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF TWIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE AHOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE T0: "REGISTER OF w1ILLS, AGENT." ~TAX~CREDITS: ~ PAYHENT RECEIPT DISCOUNT (+7 DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID D1-20-2012 CD015499 55.00 1.044.98 TOTAL TAX PAYMENT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE "+ IF PAID AFTER THCS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. « IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY SE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. 8'd 868Z6bZL6L ~~eaae~ ~{aE:W 1,049.98 .00 .OD .00 ~8~~60 Z6 08 a~W BUREAU DF INDIVIDUAL TAXES INHERITANCE TA% DIVISION PO BDX 280601 HARRISBURG PA 17128-0601 NOTICE DF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DCSALLOWANCE OF DEDUCT[ONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS WILLIAM M FARRELL 1323 ASPER DR BOILING SPRINGS PA 17007-4616 j,..~~ pennsyLvania ~ ^ DEPARTMENT OFREVENUE REV-1548 EX AFP f12-11} DATE D2-28-2012 ESTATE OF CHESKI THEODORE J DATE OF DEATH I1-24-2011 FILE NUMBER 21 11-1334 COUNTY CUMBERLAND SSN/DC 189-22-27D8 ACN 12100973 APPEAL BY DATE :04-28-2012 (See reverse side under Objections) Amount Remitted ~- MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER DF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE '~ RETAIN LOWER PORTION FOR YOUR RECORDS <"' REY-1548 EX AFP C12-11?-^---------------------------------^-------------------------------- NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 02-26-2012 ESTATE OF:CHESKI THEODORE J DATE OF DEATH:11-24-2011 COUNTY:CUMBERLAND FILE NO.: 21 11-1334 5.S/D.C. NO.: 189-22-2708 ACN: 12100973 TAX RETIJRN WAS: {X) ACCEPTED AS FILED { ) CHANGED -- - -. JOINT OR TRUST ASSET INFORMATION FINANGIAL INSTITUTION: CITIZENS BANK OF PENNSYLVANIA ACCOUNT NO.: 6106311092 TYPE OF ACCOUNT: ( )SAVINGS CX) CHECKING C )TRUST ( )TIME CERTIFICATE DATE ESTABLISHED 01-25-1994 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: PAYMENT -RECEIPT DATE NUMBER OI-20-2012 CD015500 66,254.41 X 0.500 33,127.21 - .00 33,127.21 x .15 4.969.08 DISCOUNT C+? - " INTEREST/PEN PAID (-) 248.45 N07E: TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK DR MONEY ORDER PAYABLE T0: "REGISTER OF WILLS, AGENT." AMOUNT PAID f 4,720.63 TOTAL TAX PAYMENT BALANCE OF TAX DUE INTEREST AND PEN. TDTAL DUE ~ IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ~ IF TOTAL DUE IS REFLECTED AS A "CREDIT"' (CR1, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~'d 868ZLbZL6L ~~e.lae~ ~{aeW 4,9b9.08 .00 .00 .00 ~bL~60 ZL 08 a~W BUREAU DF INDIVIDUAL TAXES INHERITANCE TAX DIYISICIN PO BOX 260601 HARRISBURG PA 17128-060:1 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DF DEDUCTIONS, AND ASSESSMI=NT DF TAX ON JOINTLY HELD OR TRUST ASSETS WILLIAM M FARRELL 1323 ASPER DR BOILING SPRINGS PA 17007-961b •;4 pennsy[vania ~~~r '~ DEPARTMENT OF REVENUE REY-1548 EX AFP (12-171 ~~~~~~ DATE 02-28-2D12 ESTATE DF CHESKI THEODORE J DATE OF DEATH 11-24-2011 FILE NUMBER 21 11-1334 COUNTY CUMBERLAND SSN/DC 189-22-2708 ACN 12100974 APPEAL BY DATE:04-28-2012 (See reverse side under Objections) Amount Renitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SpUARE CARLISLE PA 17013 CUT ALONG THIS LINE ~> RETAIN LOWER PORTION FOR YOUR RECORDS 4- REY-1548 EX AFP {12-11? NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DF DEDUCTIONS. AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 02-28-2012 ESTATE OF:CHESKI FILE NO.: 21 11-1334 THEODORE J DATE OF DEATH:11-24-2011 COUNTY:CUMBERLAND S.S/D.C. NO.: 189-22-2708 ACN: 121D0974 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: CITIZENS BANK OF PENNSYLVANIA ACCOUNT NO.: 6258346999 TYPE OF ACCOUNT: C )SAVINGS C ) CHECKING C )TRUST CX}TTME CERTIFICATE DATE ESTABLISHED Ob-16-2010 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: 55,891.58 X 0.500 27,445.79 - .00 27,945.79 x .15 4.191.87 NOTE: TO ENSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION DF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE T0: "REGISTER OF WILLS, AGENT." PAYMENT DATE RECEIPT NUMBER - DISCOUNT C~) INTERESTlPEN PA[D (-) - - AMOUNT PAID 01-20-2012 CD015498 209.59 3,982.28 TOTAL TAX PAYMENT 4,191.87 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL ENTEREST IF TOTAL DUE CS REFLEGTE^ AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE S[DE OF THIS FORM FOR INSTRUCTIONS. g~d 8 68Z ~bZL lL IIeJa~~ ~IJ~W ~~6~60 Z6 0£ JAW REV-i5o8 EX+ (u-io) ~i Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Theodore Cheski 21-11-1334 Include the proceeds of litigation and the date the proceeds were received by the estate. en nmeerty iointly owned with right of survivorship must be disclosed on Schedule F. 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N ~ ~ X x ~ X i 5 -O w N '^ ~ L O j > T L ~ ~ C ~ C ~ O ~ - C 1 Ur V = LL U ~ Z ~ N U U Z U Ur J J c G J C N Y C 7 i ~ 3 ~ U L N ~ ~ ~ C U ~ ~ L N ~ N N ~ N L ~ U • T ~ V S L L ~ • Q- ~ ~ N ~ f6 y Y ~ ~ ~ 41 0 1 .. ~ { .C c L 7 f6 D ' v ' 3 i c o T ~ ~ ~ ~ ~ aY+ ~ ~ 7 C ~ ~ Y ~ OC ~O ~ Y .+ + ~ ~ C Q f6 ~ C ~ C N _ [0 7 ~ i dl x O ~ C~' v C ~ O OA I ~ ~ ~ C ~V1 L • I d' J c C Q c d ~ '!/~ „ 8 5 8 8 8 8 8 8 °0 8 8 S 8 8 8 m is n n n n is ~ 8~ °o S~ 8 S voi rv ro~~ e$ o o~$ ra0i r~ o' n n n n n n n ~' m r u~i ti ti .10. d A W N N N N N N p N N N N N N p N N N N N N N N N N N N N N N N N N N S O O O O 8 O O O O O p Sp O O O T n n n n h !~ I~ O N O O rv 0 0 g N N N W tO tD V O O O N O N N N m n n n n n n n Vl N M N N N N ~ n ~ W N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N 0 0 0 8 0~~ o 0 o N .n .n ~ o~ o~ o ~n o o ~n o 0 0 0 0 .n in o o N n n ~ o rv o N o o m ~: m is ~~ o .r n ., o rv v~ o o~~~ .-, 0 0 0 0 .~, is n m N N N N N N N N N N N N N N N N N N N N N N N N N N N N N O N~ O O N in ul O O ^ u~ O N 0 0 0 in in O O in O m rNn n n n O O n n n O rv rv N O N rv n m m M 0 0 0 0 0 0 0 ~U ~G ~O 0 0 0 0 O O ro ~~~.~,~, 880 °8$ °88 X88°8°0888888~~~'^r8~oo0° o ~ a .+ .+ .+ .r .r .. .-i o ri id rv o~ m 0 0 ri N r .-i ,~ in .: .n .: m m o 0 0 0 o e o 0 0 0 0 0' j N n d d V W O O O ~ n~ d H = O d N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N ~ 8 n m m m m e 8 0 ° e o ° °0 8 .°n ~°n .on ~°n ion voi uoi .°n u°i voi voi .°n ° u°i ,°n '^ rv o0 0 0 0 0 0 ° - .+ .~ •+ .~ .+ .. .-i o o .+ .y o .~ .. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 .-~ 0 0 0 0 0 0 0 > ~ d LL N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N .y N w w ei .-1 m .y .i .y rl N .y e-1 .y .y .q .-~ H .y .i ti tp N ~O ~O Op .v .y N of < m ~ ~ ~p 'y .y .v ~r .ti ~ ti r .y .v ° O O O H W ~ m m - v i l V1 W ~ N N O 00 C C O v = N a y v - n i H c m 0 C p ~ p y .~ = m c c ` y~ m : ~ _ g ~ m n y ; v ~ N ~+ 6 a ~ i w a .a-i O m m~ O " v a °' ~ a ry u a ~ Y u ~" v a y v w n N `° °° n c C o d a '^ R a m u t r m - O ~ ~~ Q m ~>~ 0 C N ~ = O _ a a m N ~~ E ~ m v -o a u v~ a '' _~ c ~ ~~ = ~ Y q c ` V O ~ c n C - O O O ~ '° v° w a a v N g O N N~ `~ ~i O > O a__ n ~ i z z o m O« ~ m .a ~ m L ~ c v ,y ~ n a E `m v `u w` m c c ~ . i E o o a r m ~ y 'v ~ 3 ~ E o Y C Y _ V a > > > f ~ 'r O" O' O' o ~ ti n C « = ^ ~ O C C__ A I E E E „ c c y v Q LL O g O O K pip O o~ u« v o m '" m u w m g LL LL„„ ; 1° o°1c m 0 up E Y o ~+°+ 01 c P c - ~ ~ i b o Y i z r L '. a ~ ` o ~ f. ~ r w r o w a w w w i a w w w w~ o `m A w w ~ c a y a n a o.._ ~c, c o o ~ c w E ~o- 'n 'n "n 'a 'n 'n ~ ^ 0 0 ^^ m o c a N N N w o ~ r m v m o - `m q>~~ N N» N N o , "' t ~" o 0 o y n ° m f E~ f f~~- a p° ~ E o 0 ° ~ v c . . __ ~ o. a s O o 0 o ^ ^ w c w v w ~ w i E y-^ w v N O in 7 7 7~~ On d W v W 6~~ W m d v d u d O ^` 3 ^~ ~ w 'w ~ ti LL~ b N r ~ G¢ '^ '^ ~ ~' rv ~ Y l7 l7 C7 l7 l7 C7 l7 u= m om y n e d 1~ n n I d d t H F .mi .mi .~i .~i .~i LL F F LL LL N p O p p p n~ ~~ .~i ti .Pi ~i ° 8 0 ° ° ° S i .ni t0 N ~p ~n op o m 0 ^ m o > ti+ v °' = E z v a °-' ~ Y .~ o o E o A a` ~ o ~ ~ o'aam „ -¢ A d~~ C y Y Y Y ~ m~ m vii ~ _ N 'o ^ ~ p p ~n N Z Z 2 ~in~ u W d V Vl ~~ o^o ~~ .y m N m~ ~O ~D n m O ao m~ m o O Y N .mi H N .~i H .mi .P-i .mi .~i .~i .mi ~ m ti Of n m N Q~ n N .-1 N .-1 .-1 .-1 a '-1 N N ti ti n V1 c 1 r~[ctlp~2~'~ ~- FUNERAL H{)ME ~ Market ~'laza Way • Meclzanicshurg, pA Y7455 Mirdirrel ,,~ MadpeZZi, O-vner Jeremy d Sha,-tzei; Funeral Uireclor (7I7) 697-4596 January 18, 2012 We received a burial benefit in the amount of $1 d0 from the Cumberland County Veterans Affairs off ce, resulting in an overpayment on your account. Enclosed please find a check for this amount. If you have any questions, or if t~ve can be of any assistance, please call. our office at X717) 697-4694. Sincerely, Malpezzi funeral Hame R~~ l~ ~, {~_~ CI1 N O V m N N !JO ~.~ ~' :~. ~~ ~~ :°'. ~,;~: `_+-_'~'•J, ""~ •~~ Customer Receipt Ptease be sure to enter this u transaction in your recorCS. Transaction Date Amount Description A<co~nt Number G~bO ~91J0~84t~i QlOi 07'0211 09:04 QK CK 00F~0 xRXX?!~(70~5 fi1'~.94 Funds from your deposit may not 6e available fw immediate withdrawal. All transactions are subject [o 22089•BI~IVKER B.'0a iM,'PK verificatbn as outlined ii the rules and regulations of :he Bank, Member FDIC Z•d 8L8ZLtiZL6L I~aaae~ ~aeW d£Z~ZO Z6 LL I~f 71/C ~ ~ `~ Z ~ ~ ~ p ~ ~ ~ CUStOFTIer Receipt Flease be sure to enter this transaction in your records. Transaction Date Amount Description Account Number 1 1 ~: i ~~i Funds from your deposit may not be available far immediate vrittdrawal. AU transacttcns are subject to 22089•eUNKcR tuns trNPK Verification as outlined in the rules and regulations of the sank. Member FDIC ti•d 8L8ZLbZL6L ~~a~~e~ ~{aeW e8b~06 ZL 66 I~f 0 b' ~_ M o om LL ~ ''" f" (Y Q ~ o ~ a ! r~ O t m " C r- ~ Z f''1 CD ~ N [''1 Q ~ 4 ~ ~ e, ~ « a o o ' : ' : ~ ~ O Y N ~ • +L Yjy, Q ,y LO Q C ~ Y ,r ~ C` d ro ~, ? ~ r-{ VZ r{ C/} N~ ~U~ ~ Ofs{ ~ u O~ ~ V ~ O ~ is ~ a ~'b~4 OO y- O a '~ p 4 O ~ W Q r~ r-f .O i ~ + , qqq ww ~ ~ cry t4 ?- ~ C~ d 3 ~ p n N s' a 3 W O a ~ ~ ~ N ~ C ~ W ~ 2 ~ f/~ R a ~ o h~c W `" U7 to ~ w ~ - `w ~+ o ~ ~ Z W G Ri r-i CJ CV O d R C? L7 ~ .-~~ ~- A W ~ ~ ~ Q T/2 V W d L O,~ ©f*1 q m ~y (7 Q rl 0 r"f dQ ,~' d ~ ~ i (~7 O ' M ~ ~ .C L m a ~- n °~ ~ a ~ v v! ~ H q ,~ m E ~c .~ o ~ ~ ~: ~ '9 Ei on.> a ~ m@~ ` w w z~~°z u U o ~ c] ~a ~ o oz m m .a ~ (/~ ~O~ ~ C7L7gU0 m ~ ~ `" • ~n H Q +x N ~ ~ ~ W ~ us o o ~ ~ A . ~ O LLI ~ `~ t~ u a z mg ~ s~, v 8 ~ ~ ~ ~ . a - F N , w 0 F ~ ~ L1 LLJ x W o ~ p c ~_ ~ -~ ~~ ~~ o ~ m-o, ~ O~3 Z ~~ ~(u~ N t~~w~ W os O ~ ~ WH ~ O.~n ~ ~ UqI,% ~ ~~ N - ~ ~ ''~ ~ LL ~ x h ~' ~ ~ ~ ~ ~ W a ~ ' ~ W 0 ~ as U C11R , ~ z °u tU Ri i!] i7 m W ` v ,1 „ C ~i e~ gR~H 7 m j 1L N r ~ E iU OMB g O ~ v Q ~ ~ $ , ~C1 W r~ a.r m m 2 W Y Ha ~ O a -ate g~d 8L8ZL~ZL~L ~~a~~e~ ~~ew ~8~~0~ Z6 66 I~f OfdB Appru~rA Na, 7904-0060 Resrwndent 6urdEn' 6 Min"tes f I~I~N~~~~11 1. INSURANCE FILE NUMBER Y16396629 CLAIM FOR QME SUM PA1lMENT ~, INSURANCE POLICY NUMBER GBVERNMENT LIFE INSURANCE 3. NET AMOUNT OF INSURANCE $0.40 ~. FIRET, MIDDLE, LAST NAIVE OF INSURED VETERAN 5. DATE OF TH 8. BENEFICIaRY'S SHARE (FrocaogJ TH140DbRE J CB~SKI ` ~ a1.2 tN3TRUCTION3 WE lr1EE A PHOTt]COPY' OF THE VETERA*I'S i:}EA'C'H CERTIFICATE OR A STATEMETi<T FROM TFtE AT"TENDINCr PHY'SI AN S1,Y0 TEA SE OF C1F.R R S IitEQU1RED FOtt R RDS. !f the beneficiary is a minor or incompL-tcxtt, the perwn having custody of the beneficiary should cgrnple[e the forn7 and give his/1u;r address in Item 10. Ifyou art Signing as the guardian or attorney-in-fact, pleax include a mpy of the coon appointment or pOw+er of attorney. Send this completed Yorm tD: 17epartnnent of Veterans Affairs Regional Office and Jrtsurance Center P.O. Sax 7208 Philadelphia, PA 19101 NOTE: If ou refer, instead of mailin this form, it rna be FAXED to: 1-888-748-5822 7. FlRST, MDDLE 0.ND LAST NAME OF BENEFICIARY (P-~ p r~ira) 8. RELATIONSHIP Tt) INSURED 8. DATE OF BIRTW OF BENEFICIARY ~ I C PS~ ~ 4-~ - ~ . ~ 00. M/TILING ADDRESS (MUST 8E C PLETEDJ - ~ '3 708. eENEF ICIARY'S SOCIAL SECURITY NUMBER r ~ ~ ~ A~s r t ~ ~ r'3,~ Y ~ ~ ~ y" ~ 1 r,4 ~l 10C. OAY7IME TELEPHONE NUMBER , CERTI1r IGATiON: I Gatti that tht above entries are trt-e snd eomect to the best of m knowle a and belief. 11.9 RE OF BENEF RY, FIpUCIARY OR RDIAN 12. tk1TE ~-7 / / ~ !~ DIRECT 81718 DES ED. ATTACH A 1DED CHECK OR COMP TE >Bt.OCKS A THRU E. THE ACCQUNT NUBT BE IN THE INANE OF THE BENEFICIARY. ITEMb "F" NU8T BE COMPLETED. HE BENEt=1CIARY IS A TRUST, ESTATE, ~R REPRESENTED BY A FIDUCIARY, YOU MUST SEND A vOIDEO CHEt;i( FOR THAT SPECIFIC ACCOUNT AND CQMPLETE ITEM O. A. NAML• OF FINANCIAL INSTJTUTION 8. RDUTfNGTRANSITNUMBER (NINdDlGITF16LDJ C. TELEPHONE NUMBER OF FINANCIAL INSTfTUTION D. TYPE E. DEPOSITOR at:000NT NUMBER ^ CHECKING ~ SAVMVC33 F. BENEFICIARY'S SOCIAL SECURrrY HUMBER (REQUIRED FOR DIRECT DEPOSIt~ G. EIN OR IN N4JMB~ (~ R_T~LLST Q~TE ONLY) Prl.eey Act lVaYee; VA sill pot eliaeltee ierena.tla„ eel leatr~ .. r6ii fpm b Mfy rata other than odor Iw bees aaAMitea Yder me Privuy Aet or lA7i ee Tids 7e, Code of Fedptl ReBuWiet" 1.176 fiat rordne Yen idmti11e0 is d`e V A tyfwm olrecadf,?6VA00, Yererana and Aneaad foron f'eraosael U.S. OYVameaenr Life lnesaleco IGaae,lf.VA, and vablielwd is ice Federal Regi++er. YoYr oMi`ation b aetpoald i! ngeieed a dodn Ibis beae9L Oivny ~uytYr aSN esestse iaibresaioe i. voluntary. RaAwl ro pro.li 7+r SSM by inatf wiY eat easuh b fM Basra! efheedits VA will not deny ae mdlvidW benefits far rtfutiia0 to Baavid Mir ar M SSN unkee the dltcleayrr efela SSN it ea~Yind by a Fader( Stature orlaw {e effect grip ro leaeary 1, 1978, end cull is ef~cl. Tie rtaponeat you submit e+a Oonwdwsd 00nfNkelid (301J,S.C. 870 t I. awpadarl BwrMr. We seed Ctit iafoneetio. ro 4saminc yocr aliBrbgi tY [or a death benefit {36 U,S.f. 1017 wed 19l2~ Title J B Unitld Soaoee Cade dlaeri yf ss eel[ far Ihit infam1a11011. we arielaU' But you erHl aced an wer.ye of 6 nbutn ro W hew the ieitNellalla eld tie u6onrrcga, wld eamp~laoe this hest. VA ewslaf eanaaa w IYasaa • talleeriaa of pfllfTSatidn unless a valid OMB Gonad aunfbx'r tGeplayad. Yoa eae rot ragaitod ro afpond m a adleolion o! ialbantdon ir111{e n utntias is l1u dfpitp~ed, YaNd OM[B rnae0l aunebQa awl be bnfpd otl tie OALB Ittltmq Page aY. MfP•JJwww.reBi~Fp,Fpv/pYbI1C~d~P1ZAMeie~. I Fektlrod. ytMl CeA oW I.BOO.YI7-100010 eel leretw~M OC 1Y1efe b feed COnYAptta A rY~tlCwne abp11 lbia 1b111. IF Y~OL! HAVE G1U ESTIONS ABOUT THIS FORN PLEaBE CALL OUR T41_t. FREE lriUN6ER 1.800-869.8477 vA vofeM 28.4123 exesrwG sroclc of vA Foleil Zo.A1a6, wui soaq 9EPr 3410 VMLL f18 LJSiD. Z'd BL8Z6tiZL6L Ileaae~ ~iaeW d80~90 Zl• ZZ Inf Department of Veterans Affairs P.O. Box 720$ Phila., PA 191tl~-7208 JULY 17, 2C12 ESTATE THEODORE J CHESKI JANINE FARRELL EXE 1323 ASPER DR BOILING SPRINGS PA 17007-9616 I~,~III~~IIII~I~II~IIIIIIII~IIIIIII~I~III~II~~~II~I~III~I~~I~I IN REPLY ~EfER! zQ5 FILE NUMBER: V 1639 66 29 2 III ~I IIIII IIII III III INI ~I Ill III Illli~ UI~ ARE AUTHORIZING PAYMENT OF $ 10,385.19 TO YOU FROM GOVERNMENT LIFE INSURANCE POLICY V 16396629. A PAYMENT FOR $ 10,385.13 iS ENCLOSED UNLESS YOU ASKED TO HAVE THE PAYMENT DEPOSITED DIRECTLY IN70 YQUR BANK ACCOUNT. DID YOU KNOW? IF YOU ARE A SURVIVING SPOUSE, PARENT OR CHILD OF A SERVICEMEMBER OR VETERAN, YOU MAY BE ELIGIBLE FOR SURVIVOR BENEFITS FROM THE DEPARTMENT OF VETERANS AFFAIRS. GO TO WWW.VA.GOV/SURVIVORS TO LEARN ABOUT ADDITIONAL BENEFITS TO WHICH YOU MAY BE ENTITLED. *THIS IS A ONE TIME PAYMENT. **THIS REPRESENTS 238 DAYS INTEREST PAID FOR THE PERIOD FROM THE DATE OF DEATH UNTIL JULY 19, 2012. AMOUNT OF THIS ADDITIONAL YOUR SHARE YOUR SHARE DEDUCTIONS FRDM YOUR SHARE AMOUNT AMOUNT OF THIS INSURANCE POLICY INSURANCE AMOUNT LOAN LOAN INTEREST LIEN INSURANCE AWARD (PAID-UPI a AMO b H N0. INSTALLM NO. I !QL 75 NC. INSTALLMENTS ND. INSTALLMENTS A N V - INSTALLMEN T IOAIGINALI PREVIOUSLY PAID THIS PAYMENT AEMAINtNG LATED PAYMENTS PREMIUM REFUND DIVIDEND IV. INTEREST TOTAL DISABILITY DTHER PL PAYMENTS DiJE ~ AQDITIONS PREMIUMS DUE LIE LIEN INTERES PRIOR PAYMENTS TOTAL D15A ILI Y LESS DEDUCTIONS OVERPAYMENTS ~E~UCTIONS a THE TREASURY DEPARTMENT WILL ISSUE A PAYMENT FOR THIS AMOUNT - 10 10.385.19 QUESTIONS ABOUT YOUR INSURANCE? CALL US TOLL FREE AT 1-800-669-8477 OPERATORS ARE ON DUTY MONDAY THROUGH FRIDAY 8:30 AM TO 6 PM EASTERN TIME VA FORM 2g _5$51 SEP 1998 AWARD STATEIIAENT £'d 8 L8Z ~bZL LL Ila~ae~ ~aeW d80~S0 Z L ZZ I~f REV-i5o9 EX+ (oi-io) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDVLE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: Theodore J. Cheski 21-11-1334 If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A• William Mark Farrell 1323 Asper Drive Boiling Springs, PA 17007 nephew-in-law g' Janine M. Farrell C. 1323 Asper Drive, Boiling Springs, PA 17007 JOINTLY OWNED PROPERTY: niece 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 DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 01101/81 Citizens Bank -Checking Acct No. 6104512732 14,331.34 50 7,165.67 2 A 01(25/94 Citizens Bank -Money Market Acct No. 6106311092 66,246.70 50 33,123.35 3 A 06116/10 Citizens Bank - Certificiate of Deposit Acct No. 6258348999 55,890.89 50 27,945.45 4 B Morgan Stanley Smith Barney -Acct 138-74752-11 1,784,183.49 50 846,152.50 TOTAL (Also enter on Line 6, Recapitulation) $ 914,386.97 If more space is needed, use additional sheets of paper of the same size. q •s am ~~a ® l To Whom It May Concern: One Citizens Drive Riverside, RI 01915 This letter is to confirm that William Mark Farrell is a joint account holder with Theodore J Cheski on the following Citizens Bank accounts: Checking # 6104512732 Money Market # 6106311092 Certificate of Deposit # 6258348999 If you have any questions please feel free to contact me at (717)766.4743 Sincerely, l %`'~~~. Robert Mesarick Citizens Bank 2 W. Main St. Mechanicsburg, PA 17055 ~ RBS Pagel of 1 IMIl 12/02/11 IMPACS ACCOUNT INQUIRY 12.51.22 PAGE 01 OF 02 KEY 060-000-0000-6106311092 STATUS 00-NORMAL ACCOUNT TYPE 025 THEODORE J CHESKI SYSTEM TYPE 021-JO INT WILLIAM MARK FARRELL AVAIL BALANCE 66,246.70 1323 ASPER DR DDA AVAIL BAL 66,246.70 BOILING SPRINGS PA 17007-9616 CURR BALANCE 66,246.70 ODP BALANCE SWEEP BALANCE DT OPEN 01/25/94 SIGN 1 TOTAL HOLDS 0.00 OUST ACT 11/01/11 TIN 2 189222708 BANK UNAVAIL 0.00 LAST DEP 10/19/11 CHARGE CARD NO CUST UNAVAIL 0.00 LAST MNT 04/27/11 SPECIAL INSTR NO LAST DEP AMT 86,146.45 NSF TODAY NO MIN DDA BAL 0 OD TODAY NO AVG COL BAL 66,246 CON KITE DAYS 0 MTD AVG BAL 66,246 MMDA IND 1 MTD KITE DAYS 0 CYC ACR INT 10.889832 # AMT TRANS 0 OD LIM QNTX IOD PRJ ACR 10.890000 # CHK ITEMS 0 STOP PAY 0 CHARGE-OFF AMT 0.00 BAL HIST 0 BAL HIST RET 000 NEW BALANCE 66,246.70 I PF1-FORWARD PF14-SVC CHG PF15-RA'.CES http://touchpoint.internal.citizensbank.com/touchpoint/3270/emu13270.htin 12/2/201.1 Page 1 of 1 Command =__> STI1 12/02/11 ACCOUNT INFORMATION 12:50:54 Account 0000 6258348999 Ct12 0 60 Ct13 000 Ct14 000 Ctll O1 CURR Prod Type 312 12 MONTH CD - -- BALANCES ---- THEODORE J CHESKI AVAIL BAL 55890.89 WILLIAM MARK FARRELL Current Bal 55890.89 1323 ASPER DR Closing Bal 55877.11 BOILING SPRINGS PA 17007-9616 Coll Bal 55890.89 Holds 0.00 NEW BALANCE 55890.89 Pledges 0.00 Cust Nbr Dt Opened 06/16/10 ----- DRS / CRS ----- TIN 189-22-2 708 Dt Last Dr 00/00/00 Last Dr 0.00 Short Name CHESKI THEODO Dt Last Cr 06/16/10 Last Cr 55273.68 Branch 292 Officer 292 Dt Last Mnt 01/19/11 Drs Tdy 0 D.00 ACTIVE ----- MATUR ITY ------ Crs Tdy 0 0.00 Period M Incr 012 - -- INTEREST ---- Anne Day 16 Dly Accr 0.076562 Unrdm Accr 1 Accrd Int 1.229284 Prin Dist 0 Proj Accrd 1.23 Auto Renew 2 Redep Int 11.71 Nxt Mat Dt 06/16/2012 YTD Int 314.45 PFl-Fwd PF4-Hist PF5-Redisp PF12-H elp PF14-S/H Inq http://touchpoint.internal.citizensbank.com/touchpoint/3270/emu13270.htm 12/2/2011 Pagel of 1 IMI1 12/02/11 IMPACS ACCOUNT INQUIRY 12.51.34 PAGE 01 OF 02 KEY 060-000-0000-6104512732 MSGS: HLD. STATUS 00-NORMAL ACCOUNT TYPE 052 THEODORE J CHESKI SYSTEM TYPE 022-GO]~D CUSTOMER WILLIAM MARK FARRELL AVAIL BALANCE 13,852.86 1323 ASPER DR DDA AVAIL BAL 13,852.86 BOILING SPRINGS PA 17007-9616 CURR BALANCE 14,331.34 ODP BALANCE SWEEP BALANCE DT OPEN 01/01/81 SIGN 1 TOTAL HOLDS 478.48 OUST ACT 12/01/11 TIN 2 189222708 BANK UNAVAIL 0.00 LAST DEP 12/01/11 CHARGE CARD NO OUST UNAVAIL 0.00 LAST MNT 06/06/11 SPECIAL INSTR NO LAST DEP AMT 337.15 NSF TODAY NO MIN DDA BAL p OD TODAY NO AVG COL BAL 14,791 CON KITE DAYS 0 MTD AVG BAL 14,331 MMDA IND 0 MTD KITE DAYS 0 CYC ACR INT 0.972603 # AMT TRANS 1 OD LIM QNTX IOD PRJ ACR 0.970000 # CHK ITEMS 4 STOP PAY 0 CHARGE-OFF AMT 0.00 BAL HIST 0 BAL HIST RET 000 NEW BALANCE 14,331.34 PF1-FORWARD PF14-SVC CHG PF15-RATES http://touchpoint.internal.citizensbank.coin/touchpoint/3270/emu13270.htm 12/2/2011 ~~>.a~ 0 0 p o o ~ '~ o _ ~ o~ 01 I ~ m n ~ ' Cf! m m ~ a X ~ o ~ ° m g• c m a m ~ o tO a ~= . 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O O O x , ti y O pQ ~ O ^ ~ ~ A C 5 ~ `~ ~ Q Q O`~ fp ~ ~ ~ ~ 5 ~ y /I Q Q ~ Q ~ ` .Z. A y ~ O ~ ~ Q O co x' 5 Ey Q ti ~ n O ~ ~ ~? ~ O O ~• co o-.~; ~ ~ ~ ~ ~~~ AAO~y y ~ A ~ ~ A.`Z ;. m ti '~ o EZ. C ~ ~s ~ y ~ ~ y ~ ~ ~ ~ ~ ~ ~ ~ ti ~ xy O O Ci7 O ~. x ~ ~ ~ W ~~ tL2 ~ ~+ r4~ T~ ~ W Z ~~ ~ ~ N ~ A~ ~ ~ •/ C ' ~ A~ O Z ~ \ / 3 ~ ~D~ ~ ~ ~ W 0 N O ~ i rf a m m ~~o~na~~~ ~~ ~ Q n " o' o a. `~ ~.~o~,~~~ ~~ oq fq rt Q ~ m coo O~ o~~~~~ ~~ `e O ~ A ~ .~ ~ ~ ~ G Ob ~ ~ ~ ~ ~ 3 3 ~ ^.~ n ~ a°~ Alb .7eb s. A ~ p ~ p~ ce ~ ~~, ~~ 5 ~ fC w ^. k ~„ ~ b a O = Q ~ ~ o ~. ~ ~ ~ ~ ~ ~ ~, a ~ ~ ~, o. ~_ lz7 ~ L7 ~ m ~ A b ~ ~ A ~ ~ b ~ ~ O R. ~ s ~ ao ~ b ~ ~e A `0 ~ c~D o ~e o- o b~ ~+~ o 5 ~ y ~ A m ~ Oop'~ ~ Q p ~ ti y n~ n ~ ~• ~ ~ ~ ~ ~ ~ 5 ~ N ~ ^ O ~ r h b c~i~ < i0 O ~ A ~. A <O ~ ~ O ~a.wo ~ ~ ~ ~~i ~ ~b ~ A ~o-~ Y ~ ~ ~ m b ~ ~~oA o :;gym c~; A Ol ~ oa' A. O ~l-~".~~"b ° `~`C ~ ~- o ° = O ~ o ~o "C p~ C1 ~ 't ~ ~, o ~ ~. t~o ~ ~ re ~a~ ~ ~~ ~~ ~ ~ 8y~~a~ o v~ C'~C ~~e ,A~~ Q Ll ~ ' Q ~ K. ~ ~ ~ Q ~ A. a~On~ m a ~: ~ o ~ ~ o A .~ tp 'n ~' y' o ~~ ~o `~ ~ » n ~ ~ • p ~ ~, m ~~y~~ p~ 3 p n A O~RO tp ~ ~ 3 Q ~ y `n 1 co N N d O 0~1 7 :, O m O C m m m ~O j G y O ~~pp VJ T~ W t,~ t„~! Z ~~ N ~ ~ ~ n C ~ ~ ~ ~Q O ~~ N ~ ~ ~ ~ ~ ~ W O N O (p 1 O m m Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Theodore Cheski 21-11-1334 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I' Malpezzi Funeral Home 11.682.57 B. 1. z. 3. 4. 5. 6. 7. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State 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 Fees: Tax Return Preparer Fees: SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ZIP Z[P TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. 2,000.00 4,017.28 17,699.85 ~~ tl.~ Malpe.~zi Funeral Nome ~. ~ ~ ~ 8 Market Plaza Way x ~ (717} 697-4696 Mechanicsburg, P.A 1705 ww~v.malpezzifuneralhome.com Jeremy J. Shanc~r, F'D Michael J. lVlalpexzi, Owner,l4D Kyle C. Knipe, FD December 6, 2011 Janine Farrell 1323 Asper Drive Boiling Springs, PA l ,'Ot]7 The Funeral Service for Theodore J. Cheski We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us ifyou have any questions in regard to this statement. THE FOLLOWING IS AN ITE)`4IZED STATEVtGNT OF THE SERVICES, FACILITIES, AUTOA40TIVE EQUIPMENT, AND ML'RCHANDISE THAT YOt; SF.,LECTED 1'VHEN MAKING THE Ft.'NERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES: Transportation Hearse and Lead Car $220-00 Services of Funeral Director/Staff $4,625-00 FUl\ERaL HOA7E SERVICE CHARGES 54,845.00 SELECTED )<~iERCHANDISE: Poplar Veneer Casket $3,200.00 Sentinel Vault $1,425.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHA\DISE THAT YOU HAVE SELECTED $9}g70,Op AT THE T[A•IE FLNER.4L ARRANGEME\"TS W'ERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS .AS A\ ACCOMMODATION. THE FOLLOVIr'ING [5 AN ACCOUNTING FOR TI-IOSE CHARGES. CASH ADVANCES: Opening Grave $850.00 Cemetery Equipment S14U.00 Certified Death Certit~cates $120.00 i~'ewspaper Notices -Patriot $179.4 Newspaper Notices -Philadelphia $373,12 Clergy/Mass Offerin, $200.00 Organist 5150.00 Flowers S200.00 TOTAL CASH ADVANCES AND SPECL4L CHARGES SUB-TOTAL INITIAL PAYMENT / DISCOUNT i CREDITS TOTAL AMOUNT DUE Z'd 868Z6bZLLL $2,212.57 $lI.G82.~7 $0.00 $11,682.57 Ileaae~ ~{aeW d9i~90 ZL ti6 unf COMA90NWEALTIi OF PENIVSYLb ANIA DEPARTMEN- OF REYERUE BUREAU OF I'JDI'J[DUAL TAXES DEPr.zsoool HARRISBURG. PA 17728-Ofi01 RECEIVED FROM: PENNSYLVANIA INHERITANCE AiVD ESTATE TAX OFFICIAL RECEIPT NO. CD 01598 FARRELL JANINE: 1323 ASPER DRIVE BOILING SPRINGS, PA 17007 --''''-- fdd ACN ASSESSMENT CONTROL NUMBER REV-1162 EX(1'~-961 AMOUNT ESTATE INFORMATION; 5srv: 1e9-22-27os FILE NUMBER; 211 1-1334 DECEDENT NAME: CHESKI THEODORE J DATE OF PAYMENT: 01 j23/2012 POSTMARK DATE: 0 1 120/201 2 COUNTY: CUME~ERLAND DATE OF DEATH: 1 1 /24/201 1 REMARKS: SEAL CHECK#110 12100974 ~ $3,982.28 TOTAL AMOUNT PAID: $3,982.28 INITIALS: CJ' RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER Z'd 818Z 6t~ZL LL paaae~ ~{aeW ag L:60 Z L 08 aaW REV-]il.?. EX» ,12-08) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Theodore J. Cheski 11-1334 Report debts incurred by,the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. -• •~~~~~ ~P,...~ ~~ ~~==~=w ~~~~~~~ auwuonai snee[s or me same s¢e. 189222708 CHESKI THEODORE 1100b19005 PA-40 - 2011 Pennsylvania Income Tax Return ENTER ONE LETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted Label J occupation DECEASE D Ocoupallon rear Resident to pleiMaiYietl, Filing JointlyANarried, FiII ratNy/Final ReturniDeoeased na nt death Z 12 411 1323 ASPER DRIVE '~~ BOILING SPRINGS PA Z70N7 ,~ 2116 0 ~`' 1 a Gross Compensation. Do not indude exempt income, s 2 a bat zone pay and qualifying retirement benefits. See the instructions. :, tb Unreimbursed Employee Business Expenses. 1c Net Compensation. Subtract Line 1b from Ling„a,~.____ ,~ ~~'',~. N Extension. ~,~ ~'~.x ~~ ~d',~,,. N Amended Return. ~~~w,.,~ R idenr.tatus. `~„ ~a~R (.~, 2 Interest Income. Complete PA Schedyt~e A if quired:• 3 Dividend and Capital Gains Distrib.K~orts In e. Compl to PA Schedule B if required. 4 Net Income or Loss from the Operates Qf ~ usines~j`~rofession or Farm. 5 Net Gain or Loss from the Sale, ExcFi`anyor Disposition of Property. 6 Net Income or Loss from Rents, Royalties; @stents or Copyrights. 7 Estate or Trust ]ncame~ COmpiete and ~ bmit PA Schedule J. ,c:~: ~ 8 Gambling and Lottery Winriipgls, Compete and submit PA Schedule T. 9 Total PA Taxable Income. Add [~ the positive income amounts from Lines 1c, 2, 3, 4, 5, 6, 7 end 8. DO Np~ ADD any lasses reported on Lines 4, 5 or 6. '~ .Si 14 Other Deductl4r}s. Enter th~i appropriate code for the type of deduction. N See the instructions ~dditional information. 11 Adjusted PA 7axabie Income. Subtract Line 10 from Llne 9. EC Page 1 of 2 FC L 1100]19005 ^D ^~~^ Z'd 868Z~tiZLIL sor,ool0lstnctName CUMBERLAND VAL 1a 0 1b 0 1c a 2 4834 3 3847b 4 0 5 65925 6 0 7 0 $ ~ ~ 109235 La o 11 109235 1],00119005 J Ileaae~ ~IaeW dLL~bO ZL ~Z add PA~0 - 2011 Social Security Number 11ao~~r9o11 189222708 Name(s) CHESKI THEODORE J 12 PA Tax Liability. Multiply Llne 11 by 3.0T percent {0.4307). 12 3 35 4 13 Total PA Tax Withheld. See the instructions. 1~;; 0 ~";~~: `.. 14 Credit from your 2010 PA Income Tax return. I~~ ~ ~ {~ 2 9 15 2011 Estimated Installment Payments. REV-459B included. 15 4 00 16 2011 Extensbn Payment. ~ 16 0 17 Nonresident Tax Withheld from your PA Schedule(s) NRK-1. (Nonresidents only) ~' , s 17 0 18 Total Estimated Payments and Credits. Add Lines 14, 15, 15 and 17. 18 1029 Tax Forgiveness Credit. Submit PA Schedule SP. 194 Filing Status: D1 Unmarried or Separated 02 Married 03 Decease 19 d 0 0 19b Dependents, Part B, Line 2, PA Schedule SP 19 b 0 0 20 Total Eligibility Income from Part C, Line 11, PA Schedule SP. 20 0 21 Tax Forgiveness Credit from Part D, Line 16, PA Schedule SP. '`~ ~ 21 0 22 Resident Credit. Submit your PASchedule(s} G-R with your ~ PA Schedule{s) G-S, G-L andlor RK-1. y 22 0 23 Tcta[ Other Credits. Submit your PA Schedule OC. 23 0 24 TOTAL PAYMENTS and CREDITS. Add Lines 13, 18, 2t, ~ and 23. 24 10 29 25 USE TAX. Add amount. See instructions. 25 0 26 TAX DUE. Ifthe total of Line 12 and Line 25 is more 1 nt>enterthe difference here. 26 2325 27 Penalties and Interest. See the instructions, nter C ~ ` 27 0 If including form REV-1630/REV-16~; mark the b~ N 28 TOTAL PAYMENT DUE. See the instructio a 28 2325 29 OVERPAYMENT. If Line 24 is more than the~f.ei~t~~~7~ ~ e 25 and Line 27, enter 29 0 the difference here. ,-~ ~ The total of Lines 30 through 36 mu}s~i~qual~ine ? 30 Refund -Amount of Line 29 you wa~„!~ as a ~dt mailed o you. Refund 3 0 0 31 Credit - Amount of Line 29 you waiif ~~,aA~dit to y'f 2012 estimated account. 31 0 ~. ~v 32 Amount of Line 29 you want to ttonate~t'i~Wil urce Conservation Fund. 3 2 0 33 Amount of Line 29 you want to d"on". to th~~ ry Family Relief Assistance Program. 3 3 0 ~~ 34 Amount of Line 29 you want to donate:~a;ltte Governor Robert P. Casey Memorial 3 4 0 Organ and Tissue Do~iation Awareness T,j~sl Fund. 35 Amount of Line 29ryou,want to iionat~ the Juvenile (Type 1) Diabetes Cure Research Fund. 3 5 0 36 Amount of Line29'yota want ta`o~Oj)~be to the PA Breast Cancer Coalition's Breast and Cervical Cancer Research Fund. 36 0 Signature(s). Under panalu0s of perjvy. I (we)~Gare that I (vre) have examined Ihia return, Ndudinq el accxrpany~ng sdiedules and.~.tatemenla, anti Ip the bast ormy {our) baker, they ere ~, tarred and compete, Your Signature 4 ~,~~~":~` Spouse's Signature, if filing Jointly Preparer's Name and Telephone Number Data E-File Opt Out 04131 Firm FEIN 251768200 JAMES E. HOLLAND CPA (717) 763-ia890 Preparer'sPTlN P00725746 Page 2 of 2 L 1x100219011 1Z00219D11 J E'd 868Z6bZL6L IleJa~~ ~1a~W dLL~tiO Z6 1?Z .Idy 201y PA-V PA PAYf1ENT VOUCHER r -.~ 189-22-2708 CN 11D0916D04 PAYMENT AMOUNT CHESKI THEODORE ,~ ~ 2325.DD 1223 ASPER DRIVE BOILING SPRIN Make check or money order PA DEPARTMENT USE ONLY payable tofF~ePennsylvania ], 7 D D 7 Qeparbmerrt of Revenue ~~ -- THE ESTATE Of THEODORE J CHESKI ^~ JANINE FARRELL EXEC '~ 9 $ ' 1323 ASPER DR ~ _ BOEIING SPRINGS PA 17007 fr ~~~ '~~} _ 3~~~~'36Q ''µ i ~ / /(~ C..[ c.~r ~I k' , ' Pay ;o th ~ i~~~~ Date ' t Ord ~ ---- .~ _---.....-._.- T.~ '~/~tiE~J~ ~ ~ /..~ 7 ~"~ l- ~~ 6 Citizens Bak `~ Pennsylvania %~'~~~ ~~~ / ~' ~~` K . i Fo ~J / ~` G~i'f'~1 i ___..- f...T -._ e ~:03 60 7 6 1 50r, E~33987 95n'. ^. i Obi ~ S f b'd 868Z6~ZL6L Ils~ae~ ~1aeW dL6~~0 Z6 ~Z ~dy nFCFASFD7HEt)DORE.I CMESKI 1112d/11 ~ O~O ~epanment of a,e Treasury-Intemel Rauenue Service (99) ° ~0 ~ . U.S. Individual Income Tax Return oILBNo.,Sarroo~e IRS Use Only-0o rat virile ortlepleint~isspace. For the year Jan. 1-Dec. 31, 2011, a othertax year beginning ,ending See S orate instructions. Your first nar.:e M.I. Last name Sufrx Your social security number THEODORE J CHESKI 169-22-2708 1f a joint return, spouse's f rst name M.I. Last name Suffnc Spouse's soelaf security number Home address (numtx'K and street). If you have a P.O. boK see Instructons. Apt rw. . P,Aake sure the SSN(s) above 1323ASPER DRIVE ,-P.,. and onUne6carecorcect. City, town or po91 office, state, and ZIP code. Ifyau have a foreign address, also complete spaces bebw (see Instructions). '('AI Presidential Eltutlon Campaign BOILING SPRINGS PA 17007 CF¢Ckheteifyou,oryourapouseitfilhg Foreign country name Foreign provinoelcounty Foreign postal de_ ~~ ~ wan153 to gob this find. Checking ~bwvalnotchange laokor retund<:;~yr,^ You ~ Spouse Filing Status 1 ^X Single 4 ^ Head of houb~y qualifying person). (see Instructions.) If 2 ^ Married filing jointly (even if only one had income) the qua person ';~ child but not yourdependeM, enter this child's here. <. 3 ^ Married filing separately. Enter spouse's SSN above ~` t"s ,,~~?¢ and fu0 name here. - Ai't~ i Check only one - nom ~:., Last name SSN box. First name Last reme 5 ;, ! ualifyln"g",owteYr}jyrith dependent child Exemptions If more than four dependents, see instructions and check here -^ ryie t3oxes chedled 6a Q Yourself. If someone can claim you as a dependent, do not ch k box 8a ~'' i an 6e ud fib 1 ' tl.i. b ^ Spouse ?' . ~ No. of cMldren G Dependents: ~ ~ ii chile urrder ape .7 (2) Dependent's ~ ePendent' qualifying for chid tax credit social security numlx) relationship u {t) First name fast name Isee insvuc;iora ) i~ ^ .a ±1: D ,,... ^ on 6c who: • lived with you • did not fve with you due to divorce or separation {sea irrstruclions) Dependents on Be not entered above Add numbers on d Tota! number of exemptions claimed Ilrres above - 0 ~~ 1 1 1 InCOfY11e 7 Wages, salaries, tips, etc. Attach Form t~"4~1'~~' 7 8a Taxable interest Attach Schedule B squire 8a 4 834 Attach Form(s) W 2 b Al b Tax~xempt interest. Do not irrd on line 8a ~` ~ Bb I - iers. so 9a Ordinary dividends. Attach Schedu ~ uired ea 36 325 attach Fonns b Qualified dividends . 9b 36 034 W-2G and 1099-R if tax 10 Taxable refunds, credits, or ~ ~al income taxes ~ 10 829 was withheld. 11 Alimony received . _ 11 12 Business income or (Io6 Att edule C or C-EZ ~ ' 12 13 Capita[ gain or (k1ss~.;~~ ach Sc u ~ if required. If not required, check here - ^ 13 68 076 If you d id not t W 2 14 Other gains or (loss9s). A {dorm 47 14 ge a - . ti i t ilia IRA distributions!'~•~"; u' y. 15a ~ , ~ '' b Taxable amount . ~ 15b ns ruc ons. see 180 ``~ : ; ~ Pensions and annu~ilttli~,;"~ 1t3a b Taxable amount . 116b 4 U46 EnGose, but do 17 Rental real ee~t royaft a hips, S corporations, trusts, etc. Attach Schedule E ~ 17 not attach, any 18 :t Farm income or'~s~ti Attachedule F 18 payment- Also, 19 Unemployment compation 19 please use 200 Social security benefits ~ 12oa I 14,71381 I b Taxable amount . 20b 12 553 Form 1040-V, 21 Oth~_~come. List type and amount 21 22 _ Com6lne a amours ' ~n the far right column for lines 7 through 21. __ _ _ This is your total income - 22 126 463 Adjusted 23 :' °... trcator erases :~' . ~ ~. , - 23 ~ . Certain business expenses of reservists, pertorming artists, and , Gro$$ ' fee-basis government officials. Attach Form 2106 or 2106-EZ . 24 Income X25 Health savings account deduction. Attach Form 8889. 25 2¢ ~;t .,Moving expenses. Attach Form 3903. 26 27 `•4;D9duC~lbie part of self~rrtployment tax. Attach Schedule SE , 27 28 Self-employed SEP, 51MPLE, and qualified plans 28 29 Self-employed health insurance deduction 29 30 Penally on early withdrawal of savings 3D 310 Alimony paid b Recipient's SSN - 310 32 IRA deduction 32 33 Student ban interest deduction 33 34 Tuition and fees. Attach Form 8917. 34 35 Domestic production activil'les deduction. Attar Farm 8903. 35 36 Add lines 23 through 310 and 32 through 35 3fi 37 SubVact line 36 from line 22. This is your adjusted gross income . - 37 126 4B3 For Disclosure, Privacy Act, and Paperwork Reduction Aet Notice, see separate instructions. Fam ~ O4Q (2011 } I HTA} 9'd 818ZL17ZLLL Ile~.le~ ~IaeW dL 6~~0 ZL bZ ady Forrn 104o(2otiJ THEODORE J CHESKI 1B9-22-2708 Paee 2 T d ~ Amount from line 37 (adjusted gross income}. 38 126 463 ax an Credits 39a Check ^X You were born before January 2, 1947, ^ Blind. Total boxes if; ^ Spouse was born before January 2, 1947, ^ Blind. ~ checked - 39a 1 Standard Deduction for- b If our Ouse itemizes on a se orate return or - y ~ P you were actual-status alien, check here.. 39b ^ 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) 40 48,280 • Pecpla who check an 41 Subtract tine 40 ftom line 38 41 78,183 y boa cn line 42 Exemptions, Multiply $3,700 by the number on line 6d . 42 3,700 36a or38b or who can be 43 Taxable income. Subtract line 42 from line 41. If line 42 IS more than line 41, enter -0- r`p . 43 74,483 clamed as a 44 Tax (sea instn,ct:ons). Check y any from: a ^ Farm(s) 8814 b ^ Form 4972 c ^ 962 election ~'~. 44 5,997 dependent, see 45 Alternative minimum tax (see instructions}. Attach Form 6251 ~ ~ f 45 instructions ~ 46 Add lines 44 and 45 ~~w~~ a~ 46 5,997 Air others 47 Foreign tax credit Attach Form 1116 if required 47 : 5 ; ~. single or 48 Credit for child and dependent care expenses. Attach f=orm 2441 48 '. :~. `~~,'~ rtartietl filing separately, 49 Education credits from Form 8863, line 23 4 .,~: ~;:-~ se,aoo 50 Retirement savings contributions credit Attach Form 8880 • '~ rdarned riling ioirxyor 51 Child tax credit (see instructions). 51+u r ; oualifying wIdOW(erl, st~soo Head a` na.serold 52 Residential energy credits. Attach Form 5695. 52 53 Other aedits from Form: a ^ 3800 b ^ 8801 c ^ ,r 54 Add lines 47 through 53. These are your total credits . .i ~~ ~ ~ ~~ 4 5 se,soo 55 Subtract line 54 from line 46. If line 54 is more than Gne 46, enter -0- .- 55 5.992 OtF1er 56 Self~mploymenttax. Attach Schedule SE 56 57 Unreported scoot security and Medicare tax from Form: a437 i~ ' 919. _ 57 Taxes 58 Additional tax on IRAs, other qualified retirement plans, etc. ach Form 5 9 if required 58 59a Household employment taxes from Schedule H . 59a b First-time homebuyer credit repayment. Attach f=orm 5405 N wired . 59b 60 Other taxes. Enter code(s) from instructions fi0 fit Add lines 55 throw h 80. This is our total tax . ,4r . 61 5 992 Payments 62 Federal income tax withheld from Forms W-2 099 62 35 63 2011 estimated tax payments and amount a om 2010 return 63 If you have a fi4a Earned income credit (EIC) 64a qualifying b Nontaxable combat pay election . 64 ' ' '. child, attach 65 Additional child lax credit. Attach Fo 65n Schedule EIC. 66 American opportunity credit from Form 886 14 . _ 68 67 First-time homebuyer credit fro 67 66 Amount paid with request for exte~n o l 68 fig Excess scoot security am 1 RRT~` withheld 69 70 Credit for federal tax on s. ch For 6 . 70 71 Credits from Form: a ;~~'' 2439 8839 c ^ 8801 d ^ 8885 TI 72 Add lines tit 63 64 `elttd row h These are ur total a manta . - 72 35 73 If line 72 is man tin ,subtr ln@ 81 from line 72. This is the amount you overpaid . Refund ~ - T3 74a Amount of line 73' " ant r ~ -to you. If Form 8888 is attached, check here. - ^ ~ 74a - b Routing number ~~ ., - c Type: ~ Checking ^ Sauings Direct deposit? i See - d Accounl~~?umber y.J~- instructions. Vic;"."~. 73 Amount ofJjne. 73 you "~t applied to your 2012 estimated tax - 75 , : Amount 76 ARloynt yotlli` Sfraci line 72 from line 61. For details on how to pay, see instructions . - . ..,. 76 5 957 rvu uwe rr tsumatea tax.PenalttFCsee instructions] I 77 I I Third Party „ ., Do you want to eIIPw another person to discuss this return wnh the IRS (see instructions)? ^K Yes. Complete below. -^ No Designee Qeev9nee's ~ Phone Personal identificatbn nflit~e'a..,. - JAAIIES E. HOLLAND I no. - (717) 763890 number (PIN} - 17007 Slg n a Uneer penattres of perjury, 7 dedare that I have examined this return end accompanying schedules and statements, and :o the best of my knwNedge and Here belief, they are true, correct, and complete. Declaration of preparer {other than ta~ayer) Is based on all information of which preparer has any knowledge. Joint return? See Your signature Date Your occupatbn Daytime phone number instructions. DECEASED Keep a copy for your records Spouse's signature. ff a joint return, both must sin. Date Spouse's occupation If the IRS sent you a, Ideetlt/ Pnlectia: . PIN. ents~ it here seeinst Paid PrinVType preparers name Prep nature ~ ~ Date Check ~ if Pith Preparer JAMES E. HOLLAND ' ,; 4!13/2012 seB-employed p00725746 Use Only t=firm s name - JAMES E, HOLLAND C ' Firm's eIH - 25-1768200 Firm s address -7 WEST MAIN STREE SHIREMANSTOWPA 17011 Phone no. (7171763-6890 Form 1I~40 r2p11) 9'd 868Z6~ZL6L IleaJe~ ~(Je(N d86~~0 Zl bZ Jdbr 22~ a Underpayment of OMBNG.,SdS-~,4D Form Estimated Tax by Individuals, Estates, and Trusts ~Q~'~ DeFe~tmsnt o(lha Treasury - See S@p8ratl@ InstruetlOn3. Attachment Internal Reu~enue 9e~vl°a - Attach t0 Form 1040 1040A 1040N 1040NR-E2 or 1041. Stx{uence No. 0$ Name(s) shotim on tax return Iderrtifying number THEODORE J CHESKI 189-22-2708 Do You Have To File Form 22'14? Complete lines 1 through 7 below. Is line 7 less than $1,000? Yes Do not file Form 2210. You dkq not awe a penalty. N o ~'' You do not owe a Pep>$ ;,~". ');file Form 2210 (but Complete lines 8 and 9 below. Is line 6 equal to or more Yes ii box E in Part I I applies, you mt7s~'file page 1 than line 9? ai Form 2210. :_~~r'm, ~` No ~ a You may owe a penalty. Does any box in Part I I below apply? YeS - You must file •0. Does box B, C, or D in Part II a I ? No No ` ' '" W~{`~` You must figure your penalty. Do not file Form 2210. You are not required to figure You are nat , quired to fig ~e your penally because the IRS your penalty because the IRS will figure it and send will figure it a end yo bill for any unpaid amount. If you a bill for any unpaid amount. If you want to figure yak ~~ fig ~ ay use Part Ill or Part IV as a it, you may use Part III or Part IV as a worksheet and wo eat and teryouyr penalty amount on your tax return, enter your penalty amount on your lax return, but do b le on a 1 of Farm 2210. not file Form 2210. Re aired Mnual Pa ment ~ ,~ 1 Enter your 2011 tax after credits from Form 1 D40, line 55 ee instructio ' t fill ng Form 1fl40) 1 5,992 2 Other taxes, including self-employment tax (see instru s) . 2 3 Refundable credits. Enter the #otal of your earned in credit, additional child tax credit, American opportunity credit (Form 86tH, line 14), fi~im ~ ebuyer credit (Form 5405, line 10), credit for federal tax paid on fuels, adoption cred refundab it for prior year minimum tax (Form 8801, line 27), health coverage tax credit, edit date led under section 1341(a)(5)(B) (see instructions) . .. . . . 3 4 Current year tax. Combine lines 1, 2, and ,stop; you do not owe a penalty. Do not file Form 2210. . . . . . . 4 5 992 5 Multiply line 4 by 90% (.90) . *. . . . 5 5,393 6 'J~,tthholding taxes. Do not include r~mate tax p ~nts. (see instructions} . 6 , 35 7 Subtract fine 6 from line 4. 1f less:an $1 , sto ;you do not owe a penalty. Do not file Form 221D 7 5 957 8 Maximum required annual payme ~'ba..,. on p ear's tax (see instructions) . 8 0 9 Required annual payment ~Eftter kh Ile ~' line 5 or line 8 . . . 9 0 <•.. ~. Next: Is line 9 more than line 6? , X No. You do not owe a anal ~' ^ p ty. ~t?ot file Form 2210 unless box E below applies. ^ Yes. You may otlre,~ penalty, but dnot file Form 2210 unless one or more boxes in Part II below applies. . If box B, C, or D''a~plies, you r1~si figure your penalty and file Fotm 2210. . If box A or.~_applies.~~„it~no,{,~,,~ C, or D) file only page 1 of Form 2210. You are not required to figure your penalty; the IRS will figurt~=it-ard sendj+~°2''~ilf for any unpaid amount. If you want to figure your penalty, you may use Part III or IV as a worksheet 2nd enter your penalty on your tax return, but file only page 1 of Form 2210. Reasons for Filirt~. Check applicable boxes If none apply do not file Form 2210 A ^ You requesiia,,waive~Ir,3.~~see instructions) of your entire penalty. You must check this box and file page 1 of Form 2210, but you'gi"~ rlpt'Fequired to figure your penalty. B ^ You request a waiver {see instructions) of part of your penalty. You must figure your penalty and waiver amount and file Form 2210. C ~ Your income varied during the year and your penalty is reduced or eliminated when figured using the annualized income installment method. You must figure the penalty using Schedule AI and file Form 2210. D ^ Your penalty is lower when figured by treating the federal income tax withheld from your income as paid on the dates it was actually withheld, instead of in equal amounts on the payment due dates. You must figure your penalty and file Form 2210. E ~ You filed or are filing a joint return for either 2010or 2011, but not for both years, and line 8 above is smaller than line 5 above. You must file page 1 of Form 2210, but you are not required to figure your penalty {unless box B, C, or D applies). For Paperwork Reduetlon Act Notice, see separate instructions. Fcm; 22'f~ (2011) IHra~ L'd 868Z6tiZL6L Ileaae~ ~IaeW d66~~0 Z6 ~Z ady oe~artment of the Treas~» ; 20,E ~ Internal Revenue Sen-ice ~ Use ;his voucher when making a payment with Form 1040. • ^: ~:t :t;r!e Ihis vouches or your payment to Form 1040. ~ rAake your check or money order payable to the "Unfted States Treasury." YJri;e your Social Severity Number (SSN) on your check or money order. THEDD6RE J CHE5KI 1323 ASPER DRIVE ~OTLING SPRINGS, PA 17007 Form 1040 y ~ ay; ~ ~ ~: ~: `: ~::~ ::..' Amount you are paying Dollars by check or money order - 5 , 9 5 115 Internal Revenue Service P . 0. Box 371708 Hartford, CT 06176-0008 189222708 AL CHES 30 0 201112 61^ ~`'~ ' TY - "` i rie EST~IITE OF THEODORE J CNESKI ~ ~ ~ JANINE f~ARRELL EXEC , ~ 3-~s,sr192 ; ~,j 1323 ASPEN DR ,~~ ~~~ ~ I BAILING SPRINGS PA 17007 ~~ Pay iC iha ~/ / ,~ 'I L J .. ~---_.- ~_ ~' ' ~~ Citizens E~~„!' r:^, :~t Pennsylvania ~~ ~ ~ ?-• ~j r....r .. ~ t J • V L J J 1 Y 8'd 868Z6~ZLLL ----- ~---.. date ~I $~;f~~~~ C ~~ 7. n ti ~ i,~i - f:~ ~'.':; _. ~: I / .. Ileaa~3 ~Ia~W dOZ~bO Z6 bZ .Idy X13 Mid Ai~lantic Benefits Deparfinent One River Place ~Imington, DE 09801 December 16, 2011 The Estate of Theodore Cheski 1323 Asper Drive Boiling Springs, PA 17007 RE: Theodore Cheski 199-22-27a$ To Whom it May Concern: We have received report of the death of Mr. Cheski on 11124111. ~ l04 ~~~. Mr. Cheski received a monthly pension benefit as a retiree under the AAA Mid- Atlantic Defined Benefit Pension Plan. At the time of his retirement, he selected a Single Life Annuity form of pension payment. Upon his death, no further benefits are payable. Because Mr. Cheski's death was in November, the December check in the amount of $337.15 must be returned to the trust. Please make your check payable to AAA Mid-Atlantic and send to my attention at the above address. We appreciate your attention to this. debt of Mr. Cheski's estate at your earliest convenience. When one becomes available, please forward me a copy of the death certificate; an original is not necessary. If you have any questions, please feel free to call'me'at 302-299-4301. Sincerely, -~ Meiiss -J. chweizer Senior Pension Analyst ., . 9~d 81.8Z6bZL6L Ileaae~ ~aeW dL6~90 Z6 ~l unf JAMES E. NQLLAND, CPA 7 West Main Street Shiremanstown PA 97097 Phone: 797-763-6890 Fax: 797-763-6889 Thursday, May 24, 2012 Cheski, Theodore 1323 Asper Drive Boiling Springs PA 17007 Attention: Mark Farrell Client No; 25062 Invoice No: 5241261 For preparation of the 2011 Individual Income Tax Returns. $ 165.00 Hours Tax Services Individual Income Tax Returns 4(13/2012 0.75 3/28/2012 1.50 3/30/2012 1.00 Assemble Tax Retuns 4/1312012 0.50 Scan Support Documents 4/7f2012 0.33 $ 165.00 THE ESTATE OF THEODORE J CHESKI JANINE FARRELL EXEC 1323 ASPER DR BOILING SPRINGS PA 17007 - ~~/L Pay t~ Ih I/.,"~~ 121 ~-~e~5/aso i L/V~<J 2B2 Date -; ~ /~~~ -__.---~ _ Dollars Citizens Bank `~ "'" ' Pennsylvania ~U;;~~~ ~` ~. .' ~._. w l Far =+-_... 1:03607 1,50: 6233 ~709Su^ OL2 Finance charges assessed @ 1% per month on all open amounts. Please include your client number on your check. Thank you. Ol'd 818ZL~ZL6L Ileaaa~ ~Ia~W dL6~80 ZL ~6 ~~f o I ~. ~ r '0 a O ~~ ~~ 2 D ~ m a ~ ~ + A' i i ~ ~ '~ (i1 Ul }, q ~ ~'. ~ ~ 00 ~ N ~ ~ ~ N Imo- m 'U 3 r ~~ ~~ 7 ~. ~ ,~ rn ~ ~' ~D , D ~ n: d~ ~ ~~ ~ II ~~ ~ ~ d ~ ~ r n> ~ ~ r ~ .a; ~ ~' ~ _ ~~ A' ~ m N ~~ H x ~ ~, ~ ~ ~ ~ 00 ~ ~ ~ I rn ° ~ m cfl m ~' ~, ~'+' ,; ~~ m ~ i ~ L II ~J~ ~I ///r a ~' iri ~ yy ° b. o o c~ ~ ~, O ~ ~ r_ ~ ~' ~ C m i ti - _J ~ '% ~j v' w~N;* N~~. 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YS tIi [ l'~ ~ I ,-+ -~ ~ i ~ t G ! I r 1 C3 -~ i ~ ~_ ! m :~ I z I c~ ~ I I ~-` -C I n~ ~ t C f ~~ i '"t] I T{ I I i i I i ~j I ~~~ ~..i ~ tL. I i W ~J 1 w ra ~ } t.J~~ i 7 1 O d3 t,~l Rfi I C ~ EJ W i i 1 r; r_1 ~'' L. ~ CL:1Z}~" ~-+ R~ ~ nt H Lam.. ~~~1~ c~ >r ~ '17 ~"I nt rr~ m y~ ~n 'C~ ~7 ~ E7 ~ Z7 ;t] 2 ~ :-+ b 1'rl M t~- ~z-rrn ~ ~-~ ~-: m n ~ E3 rr ~ ~ ~ N~ rt ffl Ol G ~~ x ~ ~~ ~ "D (fl -! ~I ~ ~a ~ ~ ~ :~ ~- r -a trl C G, ~ .-t o [~ - Paz o- o n ~ c~ N ~ tri G 47 ~-~ ~ ~.i [f1 :G --; X3 !`-1 ~! tt1 -Li z ~7 ~ x --i .. ;fir /G O ~ O ~ ~P ~ m M Cp `z a ~ Q a L U w ° F- o n o U ~ ~ ~ a ` z ;a o u~ o t- ~ r a ~ ~ ~ o N F- v, ~C w ~~ ~ ~ Z O z o ~~~ ~, ~ ~ ~ ~ n ~ o>Q a o ~ ~ ~~~ ~~r ~n~o o O O N ar ~. C.? .~ 0 H D ~ a a 'U _W Z 0 ~ O W pC ~ E~ w' W U_ W OLL ~~, Y .U I ~ H~ U ~ = W a V1 ~ ~ 4 ¢ N~N W J a ~~ ~r ~.1 z J v O ~ W W Q V_ S~ o W ti ~ ~ ~ ~ N m N r F G W W a m ~ V ~ Z O Q Z ~ V W U y ii! ilk ~ ~ ^ ~ O w u W w 2 ~ U w ~ v a z z ~ us ~ '~ ~ ~ a Q a a ~ 0 ti r 0 r a J J_ 4 U r N W H a 3 D z H J [n N W W O L" c N O m v N ~_ N w ~ssia~ 100 MOUNT ALLEN DRIVE, 1~1ECHANICSBURG, PA 17055 JANINE FARRELL 1323 ASPER DRIVE BOILING SPRINGS, PA 17007 Form PB-fit ~~ ~~~ ~~ RESIDENT # UNIT STMT. DATE 111105 064 ~V 11/3012011 RESIDENT S Mr. THEODORE CHESKI TOTAL AMOUNT DUE $2 79$.00 DATE DUE 12131/2011 DATE - DESCRIPTION RATE Days/ Units CHARGES CREDITS BALANCE Balance Forward 0.00 x** Nursing Care x** 11/21/2011 RM/ BRD -NURSING -SEMI-PVT 314.00 7.00 2,198.00 2,198.00 11115-11/21 11/21/2011 AIR MATTRESS 11/15-11!21 4.00 7.04 28.00 .2,226.00 11/23/2011 R!l~I/ BRD -NURSING - SE1i1I-PVT 282.00 2.00 564.00 2,790.00 11/22-11123 11/23/2011 I I i i AIR MATTRESS 11/22-11/23 ----- --...---- ____ -- 4.00 _- - 2.00 _ 8.40 2,798.00 f RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 111105 2,798.00 4.00 0.00 0.00 0.04 $2,798.00 KtJlUtly I NAMt ~1C. "THEODORE CHEShI FermP6-o, NIq Please make check payable to Messiah Village. 4 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you: If you have any gnestians or concerns about ,your bill, please address them directly to Fiscal Seri~ices at 790-8220. 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'a c9 ~'~.~ C d oOtO C7 F~~O ~ ~ d n' o ~W~ I O n ~~!? . \ F-' LQ 4~ O ~ cn o o NhN','bO rp d - ~ orn,aa ocr, ~ ~~ ~ ~ ~ ~ ~,' ~ ~ °! ~ F, m 1 ( ~ ~' N ~ , ' '~ m ~ ro ~ a ~ " ~ ~ oWN ' o m ~ ~O O ~o _ c 'OryQ uyi ODO Or•' Jh~ ~ Q a~t7= Q N W~ Q ~a I w ~~ ~ I ~ w~A ° ~~a~' si mc ~~ N D w @~~ Q1 fD .tea m O O w 00 O c CJl N O A 'V n~ (D ~_ V N ~_ .o Storage Receipt Page 1 of 1 Customers Receipt No: Tuesday -1117/2012 - 2:10:52 PM 811055-00003907-00038616 WILLIAM FARRELL U-Haul Mining 8~ Storage of Mechanicsburg, 811055 1323 ASPER DR 4725 Gettysburg Rd BOILING SPRINGS, PA 17007 tVlechanicsburg, PA 17055 (717) 763-7677 ROQ JI ION THRU PAID AMOUNT 180 1ST STAGE DEL (POSTED JAN) $15.00 180 1t)X10X9 INTERIOR 1 STREET CLIMATE 2/12/2012 ~ $114.95 180 EXTENDED ACCESS 2!12/2012 ~ $5.00 Paid Total: $119.95 Unpaid Total: $15.00 Tax PA 6°/a: $6.90 Fee Total: $141.85 0108 PCHK $126.85 Payment Total: 5126.85 Account Balance: 515.00 X Customer's Signature X Employee's Signature (DAVID) Thank you for being a Premier Customer Ctub member! Next time make your payment online at www. uhaulstorage.com. NO DRIVING. NO MAILING. NO HASSLE. - continue - https:/lwww.webselfstorage.com/customer receipt.aspx?FromClassic=Y&AutoPrint=True... 6/I5/2012 Z'd 868Z1~ZL6L Ileaae~ ~1aeW d9t~~ti0 ZL 5L un~ Storage Receipt Customers Receipt No: 811055-000034(}7-OE}038890 WILLIAM FARRELL 1323 ASPER DR BOILING SPRINGS, PA 17007 RQOM pESCRIPTION 160 10X10X9 INTERIOR 1 STREET CLIMATE 180 EXTENDED ACCESS Page 1 of 1 Wednesday - 2!812012 - 1 2:21:06 PM U-Haul Moving & Storage of Mechanicsburg, 811055 4725 Gettysburg Rd Mechanicsburg, PA 17055 (717) 763-7677 THRU PAID MOUNT 3/12/2012 ~ $114.95 3/12/2012 ~ $5.00 Paid Total; $119.95 Unpaid Total: $0.00 Tax PA 6%: $6.90 Fee Total: 5126.85 0112 PCHK $126.85 Payment Total: $12fi.85 X Customer's Signature Account Balance: $0.00 x Employee's Signature (DAVIT) Thank you for being a Premier Customer Club member! Next time make your payment online at www.uhaulstorage.cam. NO DRIVING- NO MAILING. NO HASSLE. - continue - https:/lwww.webselfstorage.com/customer receipt.aspx?FromClassic=Y&AutoPrint=True... b/15/2012 8'd 8~8Z1~ZL6L Ileaae~ ~1aelN d9b~~0 Z6 SL un~ Storage Receipt Customers Receipt No: 811055-00003407-00039230 1MLLIAM FARRELL 1323 ASPER DR BOILING SPRINGS, PA 17007 ROOM DESCRIPTIQ~ 180 10X1 OX9 INTERIOR 1 STREET CLIMATE 180 EXTENDED ACCESS X Customer's Signature Page I of 1 Thursday - 3/8/2D12 - 3:98:01 PM U-Haul Moving & Storage of Mechanicsburg, 811055 4725 Gettysburg Rd Mechanicsburg, PA 17055 (717) 763-7677 RU PAID AMOUNT 4!12/2012 ~ $114.95 4/12/2012 ~ 55.00 Paid Total: $119.95 Unpaid Total: $0.00 Tax PA 6%: $6.90 Fee Total: $126.85 0115 PCHK $126.65 Payment Total: $126.85 Account Balance: S0.00 X Employee's Signature (CLARENCE) Thank you for being a Premier Customer Club mernberi Next time make your payment online at www.uhaulstorage.corn. NO DRIVING. NO MAILING. NO HASSLE. - continue - https://www.webselfstorage.com/customer receipt.aspx?FromClassic=Y&AutoPrint=True... 6/15/2012 b'd 818Z6bZL6L Ileaae~ ~1aeW d9b~b0 Z6 5L un~ Storage Receipt Customers Receipt No: 811055-00003907-00039613 WILLIAM FARRELL 1323 ASPER DR BOILING SPRINGS, PA 17007 ROOM DESCRIPTION, 180 10X10X9 INTERIOR 1 STREET CLII-AATE 180 EXTENDED ACCESS X Customer's Signature Page I of 1 Wednesday - 411 112012 - 1 2:21:21 PM U-Haul Moving & Storage of Mechanicsburg, 811055 4725 Gettysburg Rd Mechanicsburg, PA 17055 (717) 763-7677 THRU PAID AMOUNT 511212012 ~I $114.95 5J12/2o12 ~ $5.00 Paid Total: $119.95 Unpaid Total: $0.00 Tax PA 6°!0: $6.90 Fee Total: $126.85 0116 PCHK 5126.85 Payment Tatal: $126.85 Account Balance: $0.00 X Empbyee's Signature (CLARENCE} Thank you for being a Premier Customer Club member! Next time make your payment online at www.uhaulstorage.cam. NO DRNING. NO MAILING. NO HASSLE. - continue - httpsalwww.webselfstorage.com/customer receipt.aspx?FrornClassic=Y&Aut~Print=True... 6/1512012 5d 868Z6~ZL6L Ileaaa~ ~1aeW d9t~~~0 Z6 9L un~ Storage Receipt Customers Receipt No: 811055.00003907-00039922 WILLIAM FARRELL 1323 ASPER DR BOILING SPRINGS, PA 17007 ROOM QESCRIPTION 180 10X10X9 INTERIOR 1 SPREE-i' CLIMATE 180 EXTENDED ACCESS x Customer's Signature Page 1 of 1 Monday - 5/7/2012 - 2:20:20 PM U-Haul Moving & Storage of Mechanicsburg, 811055 4725 Gettysburg Rd Mechanicsburg, PA 17055 (717) 763-7677 x THRU PAID AMOUNT 611 212 0 1 2 ~l $114.95 611 2120 1 2 ~ $5.00 Paid Tatal: $119.95 Unpaid Total: $0.00 Tax PA 6°l0: $6.90 Fee Total: $126.85 0119 PCHK $126.85 Payment Total: $126.85 Account Balance: $0.00 Employee's Signature (CLARENCE) Thank you for being a Premier Cusfxxner Club memberl Next time make your payment online at www, uhaulstorage.com. NO DRIVING. NO MAILING. NO HASSLE. - continue - hops://www.webselfstorage.cam/customer receipt.aspx?FromClassic=Y&AutoPrint=True... 6/15/2012 9'd 868Z6~ZL6L IleJae~ ~1aeW d9~~ti0 Z6 86 un0 Storage Receipt Customers Receipt No: 811055-00003907.00040262 WILLIAM FARRELL 1323 ASPER DR BOILING SPRINGS, PA 17007 ROOM DESCRIPTION 180 10X10X9 INTERIOR 1 STREET CLIMATE 180 EXTENDED ACCESS Page 1 of 1 Tuesday - 6/5/2012 - 3:58:37 PM U-Haul Moving & Storage of Mechanicsburg, 81 1055 4725 Gettysburg Rd Mechanicsburg, PA 17055 (717) 763-7677 THRU PAID AMOUNT 7!12/2012 ~ $114.95 7!i 2/2012 ~ 85.00 Paid Total: $119.95 Unpaid Total: $0.00 Tax PA 6%: $6.90 Fee Total; $126.65 0120 PCHK $126.85 Payment Total: $126.65 X Customer's Signature Account Balance: $0.00 X Employee's Signature (CLARENCE} Thank you for being a Premier Customer Club member! Next time make your payment online at www.uhaulstorage.com, NO DRIVING. NO MAILING. NO HASSLE. - continue - hops:/Iwww.tivebselfstorage.com/customer receipt.aspx?FromClassic=Y&AutoPrint=True... 6/15;2012 L'd 8 ~8Z 6~ZL LL IleJaa~ ~IaeW d1~~~0 Z L 5 L un~ Customers Receipt No: 8'1145 5-A~ 42907-o00~Q G7G VNiLLIAM FARRELL 1323ASPER DR 6OILING SPRINGS, PA 17007 ROOM DESCRIPTION 180 10X1 OX9 INTERIOR 1 STREET CLIMATE 180 EXTENDED ACCESS Thursday- 7!5!2012 - 2:31:18 PM U-Haul Moving & Storage of Mechanicsburg, 811055 4725 Gettysburg Rd Mechanicsburg, PA 17055 j717) 763-7677 THRU PA 8I12J2012 ~ 8112!2012 ~ AMOUNT $114.95 X5.00 $119.95 $0.00 $6.90 '~1?G,85 $126.85 1•'l?U.85 Pald Total: Unpaid Total: Tax PA 6°k: Fee Total: 0122 PCHK P.iyment Total: Accow-t Balance: x Customer's Signature '~OAO x Employee's Signature (CLARENCE~ Th.~dc yon for being a Preii~ler Cclsiomer C1t~h member: Next time make your payment online at w+"~w.uhauisiorage.com. NO DRMNG. NO MAILING. NO HASSLE. g~d 8l•8ZlbZLIL lla~~e~ ~aew e8i~~06 Zl• 66 Inf REV-1513 EX+ (O1-10) i Pennsylvania SCHEDULE ] ~' DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Theodore J. Cheski 21-11-1334 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. Henry Cichaczewski, 5899 Troy Villa Blvd, Huber Heights, Ohio 45424 brother 20% 2 Stephanie Pazienza, 60 Hines Farm Road, Cranston, RI 02921 niece 20% 3. Phyllis Gutzmirtl, 5556 Jared Drive, Center Valley, PA 18037 niece 20% 4. Gloria Johnston, 57 Titus Court, Richboro, PA 18954 niece 20% 5 Janine Farrell 1323 Asper Drive, Boiling Springs, PA 17007 niece 20% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS 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 is needed, use additional sheets of paper of the same size.