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Home My WebLink About09-19-121505610143 REV-1500 Ex(°'_'°' PA Department of Revenue OFFICIAL USE ONLY Pennsylvania County Code Year File Number Bureau of Individual Taxes ~~~~~~ Po Box.28oso1 INHERITANCE TAX RETURN 21 12 0709 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 06 20 2012 09 17 1920 Decedent's Last Name Suffix Decedent's First Name MI MCCULLOH MERLIN I, (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI MCCULLOH BARBARA L Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW 1. Original Return 2. Su lemental Return ^ pp ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 4. Limited Estate ^ qa. Future Interest Compromise 5. Federal Estate Tax Return R ulred (date of death after 12-122) ^ eQ g. Decedent Died Testate ~ pt Main ned a Living Trust 1 (Attach Copy of Will) ^ Ana Gopy otl~rust) 8. Total Number of Safe Deposit Boxes ^ 9. Litigation Proceeds Received ^ 10. ~~~?4~~~~8 d~t (datge5~f death ^ 11. Election to tax under Sec. 9113(A) T (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number EDWARD P SEEBER 717 533 3280 r.a First line of address SUITE C400 Second line of address 555 GETTYSBURG PIKE City or Post Office MECHANICSBURG Correspondent's e-mail address: ep8~JSdC.COM State 21P Code PA 17055 REGISTER OF USE O~ i ~ "+D ~t91 !~ ~ ~ ~ t~ r` ~ ~ c,~ DATE FILED C`~ ~%-~ ~~ r-,~ ~-, ~i Under penalties of perjury, I deGare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. DeGaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG RE F P R~ RES~OjJSI O FILING RF,~JR DATE ^ ''//~I`` (;p^ ~. Michael P. McCulloh I ,. ADDRESS ~ r THAN 1 Edward P Seeber Suite C-40055 Gettysbur PikeCMechanicsburg~A 17055 al~~lid~ DATE Side 1 L 1505610143 1505610143 J PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER McCulloh, Merlin L. 21-12-0709 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. Signature #2 i ~ , ~~ Name Maureen M. Hollmeyer Address1 1017 Smokewood Drive Address2 City, State, Zip Aaex, NC 27502 Date l~ ~ 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: MCCuIIOh, Merlin L. RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 157 , 010.00 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 2 6 9, 2 5 8. 3 6 3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 102 , 932.48 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 1 , 185.43 7. Inter-Vivos Transfers & Miscellaneous t~nq Probate Property (Schedule G) u Separate Billing Requested............ 7. 428 , 058.31 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 958, 444.58 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 34 , 5 7 9.13 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 14 , 875.30 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 4 9 , 4 5 4. 4 3 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 908 , 990.15 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, 908 , 990.15 TAX COMPUTATION -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 .o0 13 , 90 9.52 15. O. 0 0 16. Amount of Line 14 taxable at linealrateX .045 895,080.63 16. 40,278.63 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0.00 18. 0 , 00 19. Tax Due .................................................................................................................. 19. 40 , 278.63 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 1505610243 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-12-0709 DECEDENTS NAME McCulloh, Merlin L. STREET ADDRESS 2 Kensington Square CITY STATE ZIP Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount (1) 40,278.63 Total Credits (A + B) (2) 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box 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. 38,264.70 2,013.93 Make Check Payable to: REGISTER OF WILLS^AGENT. 40,278.63 ~.~~ (3) (4) (5) 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 :.................................. x c. retain a reversionary interest; or ............................................................................................................... x d. receive the promise for life of either payments, benefits or care? ............... . ................................ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without ^ ^ receiving adequate consideration? .................................................................................................................... x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ Q 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~'OU 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. . 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)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Revtli02 EX+ (t t-08) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAx RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER McCulloh, Merlin L. 21 12-0709 All real property owned solely or as a tenant in common must ba reported at fair market value. Fair market value is defined as the nce at which ropert 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. Attach a copy of the settlement sheet K the property has been sold Include a copy of the deed showing decedent's Interest If owned as tenant in common. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Real estate located at 2 Kensington Square, Hampden Township, Cumberland County, PA - 157,010.00 held as tenants in common; Decedent owns a 70% interest; valued per tax assessment common level ratio (224,300 * 1 * 70%) TOTAL (Also enter on Line 1, Recapitulation) I 157 010.00 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-08) Rev-1503 EX+ (g.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS 8~ BONDS ESTATE OF FILE NUMBER McCulloh Merlin L. 21-12-0709 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 1,142.838 shares of Calamos Invt Tr held in RBC Brokerage 12.36 14,125.48 Account No. *19 -valued per workbook dated 7/23/12 2 1,514.181 shares of DWS Portfolio Tr held in RBC Brokerage 9.23 13,975.89 Account No. *19 -valued per workbook dated 7/23/12 3 2,071.031 shares of DWS Secs Tr held in RBC Brokerage 7.5 15,532.73 Account No. *19 -valued per workbook dated 7/23/12 4 2,505.071 shares of Federated Municipal held in RBC 11.41 28,582.86 Brokerage Account No. *19 -valued per workbook dated 7/23/12 5 8,651.006 shares of Federated Strategic V held in RBC 4.96 42,908.99 Brokerage Account No. *19 -valued per workbook dated 7/23/12 8 1,068.083 shares of Franklin Tax Free held in RBC 10.75 11,481.89 Brokerage Account No. *19 -valued per workbook dated 7/23/12 7 4,001.447 shares of Henderson Global held in RBC 6.9 27,609.98 Brokerage Account No. *19 -valued per workbook dated 7/23/12 8 2,070.446 shares of Legg Mason Western A held in RBC 13.5 27,951.02 Brokerage Account No. *19 -valued per workbook dated 7/23/12 9 1,749.497 shares of Oppenheimer PA held in RBC Brokerage 11.34 19,839.30 Account No. *19 -valued per workbook dated 7/23/12 10 1,396.532 shares of PIMCO Funds held in RBC Brokerage 12.36 17,261.14 Account No. *19 -valued per workbook dated 7/23/12 Total of Continuation Schedule See attached page TOTAL (Also enter on Line 2, Recapitulation) 269.258.36 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule B (Rev. 6-98) Rev-1603 EX+ (6.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS ~ BONDS continued ESTATE OF FILE NUMBER McCulloh Merlin L. 21-12-0709 ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 11 1,110.914 shares of Templeton Global Bond held in RBC 12.65 14,053.06 Brokerage Account No. *19 -valued per workbook dated 7/23/12 12 1,524.146 shares of Thornburg Invt Tr held in RBC 18.15 27,683.25 Brokerage Account No. *19 -valued per workbook dated 7123/12 13 741.288 shares of Vanguard Lmt Term Tax held in RBC 11.16 8.272.77 Brokerage Account No. *19 -valued per workbook dated 7/23/12 TOTAL (Also enter on Line 2, Recapitulation) 269,258.36 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1508 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER McCulloh, Merlin L. 21-12-0709 -- _ _ _ _ __ _..._.-_.._.. _.._ ...- ,....., .~... ~..,..,oo..~ ,.o,o ~ owneu uy uiv vsmiv. All property Jointly-owned with the right of survivorship must tre disclosed on schedule F. ~~~ ~~~~~~ ~rpw ~~ nrs~ueU, aaalDOnal pages or cne same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule E (Rev. 6-98) Rev-1508 FJr+~B-88) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER McCulloh Merlin L. 21-12-0709 Kan asset was made Joint within one year of the dscedenYa dste of death, k must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Michael P. McCulloh B C. 524 Lamp Post Lane Son Camp Hill, PA 17011 JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOIN 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 ALUE OF ASSE % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1 A 02/23/2008 Members 1st Federal Credit Union Savings 5.49 50.000% 2.75 Account No. *8-00 -valued per bank letter dated 6129/12 2 A 0 611 212 0 1 1 Members 1st Federal Credit Union Savings 2,365.35 50.000% 1,182.68 Account No. *6-05 -valued per bank letter dated 6/29/12 TOTAL (Also enter on Line 6, Recapitulation) I 1 185.43 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) Rev-1510 EX+ (g~8) SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER McCulloh Merlin L. 21-12-0709 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THE DATE O TROANSFERSATfACFITA CO Y OF THE DEED FOOREREAL ESTATE. DATE OF DEATH VALUE OF ASSET 96 OF DECD'S INTEREST (IF APPLICABLE) TAXABLE VALUE 1 Calamos Invt Tr held in RBC Brokerage Account No. 21,278.53 100.000% 3,000.00 18,278.53 *05 -titled in the Merlin L. McCulloh Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7/23/1 2 DWS Portfolio Tr held in RBC Brokerage Account No. 20,972.96 100.000°/a 0.00 20,972.96 *05 -titled in the Merlin L. McCulloh Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7123/1 3 DWS Secs Tr held in RBC Brokerage Account No. *05 23,326.73 100.000% 0.00 23,326.73 -titled in the Merlin L. McCulloh Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7/23/1 4 Federated Municipal held in RBC Brokerage Account 42,950.71 100.000% 0.00 42,950.71 No. *05 -titled in the Merlin L. McCulloh Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7/23!12 5 Federated Strategic V held in RBC Brokerage Account 64,477.70 100.000% 0.00 64,477.70 No. *05 -titled in the Merlin L. McCulloh Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7/23/12 6 Franklin Tax Free held in RBC Brokerage Account No. 17,224.94 100.000% 0.00 17 224.94 *05 -titled in the Merlin L. McCulloh Irrevocable Trust , funded on 8/10/11 -valued per workbook dated 7/23/1 7 Henderson Global held in RBC Brokerage Account 41,439.94 100.000% 0.00 41 439 94 No. *05 -titled in the Merlin L. McCulloh Irrevocable , . Trust funded on 8/10/11 -valued per workbook dated 7/23/12 Total of Continuation Schedule ee attached page TOTAL (Also enter on Line 7, Recapitulation) 428,058.31 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) - - - Rev-1510 EX+(g_ggl COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY continued ESTATE OF McCulloh, Merlin L. FILE NUMBER 21-12-0709 ITEM NUMBER DESCRIPTION OF PROPERTY THE DATE OF RANSFR RJSATfACIiTA COPY F THE DEED F~OREREAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 8 Legg Mason Western A held in RBC Brokerage 42,005.75 100.000% 0.00 42,005.75 Account No. *05 -titled in the Merlin L. McCulloh Irrevocable Trust funded on 8110/11 -valued per workbook dated 7/23/12 9 Money Market held in RBC Brokerage Account No. *05 26,401.23 100.000% 0.00 26,401.23 -titled in the Merlin L. McCulloh Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7/23/1 10 Oppenheimer PA held in RBC Brokerage Account No. 29,904.04 100.000% o.o0 29,904.04 *05 -titled in the Merlin L. McCulloh Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7/23/1 11 PIMCO Funds held in RBC Brokerage Account No. *05 25,937.40 100.000% 0.00 25,937.40 -titled in the Merlin L. McCulloh Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7/23/1 12 Templeton Global Bond held in RBC Brokerage 21,129.61 100.000% 0.00 21 129 61 Account No. *OS -titled in the Merlin L. McCulloh , . Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7/23/12 13 Thornburg Invt Tr held in RBC Brokerage Account No. 41,568.18 100.000% 0.00 41 568 18 *05 -titled in the Merlin L. McCulloh Irrevocable Trust , . funded on 8/10/11 -valued per workbook dated 7/23!1 14 Vanguard Lmt Term Tax held in RBC Brokerage 12,440.59 100.000% 0.00 12 440 59 Account No. *05 -titled in the Merlin L. McCulloh , . Irrevocable Trust funded on 8/10/11 -valued per workbook dated 7/23/12 TOTAL (Also enter on Line 7, Recapitulation) I 428,058.31 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-7500 Schedule G (Rev. 6-98) REV-1151 EX+~10-05) COM~~QIF~E~~VANIA SCHEDULE H FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER McCulloh, Merlin L. 21-12-0709 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See continuation schedule(s) attached 12,742.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(sl Commission paid 2. Attorney's Fees James, Smith, Dietterick 8a Connelly, LLP 20,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationshio of Claimant to Decedent 4. Probate Fees 557.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1,279.63 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 34,579.13 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER McCulloh Merlin L. 21-12-0709 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Myers-Hamer Funeral Home, Inc. -funeral services 11,300.00 2 Rolling Green Cemetery -grave opening 450.00 3 Theo's -funeral luncheon 992.00 H-A 12,742.00 Other Administrative Gosts 4 James, Smith, Dietterick 8 Connelly, LLP -reservation for estate administration closing 250.00 costs 5 Maureen Hollmeyer -reimbursement for mileage 920.07 6 Michael McCulloh -reimbursement for mileage 46.56 7 Recorder of Deeds, Cumberland County -filing fee for Deed 63.00 H-B7 1,279.63 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 FJ(+ (12-08) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS ESTATE OF FILE NUMBER McCulloh, Merlin L. 21-12-0709 Report detrts Incurred by the decedent prior to death that remained unpaid at the date of death, including unreimtwrsed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Alert Pharmacy Services - unreimbursed prescription bill 39.07 2 Center of Neurological Health - unreimbursed medical bill 168.03 3 James, Smith, Dietterick 8 Connelly, LLP -attorney fees due for estate planning 262.50 4 Members 1st Federal Credit Union Credit Card Account No. *9538 -valued per letter dated 32.50 6/29/12 5 Messiah Lifeways - unreimbursed nursing home bill 8,970.30 6 Messiah Village - unreimbursed nursing home bill 5,402.90 TOTAL (Also enter on Line 10, Recapitulation) I 14,875 30 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV-1513 EXi (11-08) SCHEDULE J conn~~I~~~~~AwA BENEFICIARIES ESTATE OF FILE NUMBER McCulloh, Merlin L. 21-12-0709 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers See attached schedule I ~ Total I 908,990.15 Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS i u ~n~ uF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Merlin L. McCulloh 06/20/2012 355-09-2219 Item Name and Address of Person(s) Number Receiving Property 1 Maureen M. Hollmeyer 1017 Smokewood Drive Apex, NC 27502 2 Barbara L. McCulloh 2 Kensington Square Mechanicsburg, PA 17050 3 Michael P. McCulloh 524 Lamp Post Lane Camp Hill, PA 17011 Relationship Daughter Spouse Son Share of Estate Amount of Estate (words) (a$a) 50% interest in residue 447,540.32 & 1/3 of Irrevocable Trust. NOTE: Entitled to 1/2 of the remaining 1/3 of Irrevocable Trust principal upon surviving spouse's death Life estate interest in 13,909.52 real estate; NOTE: Income beneficiary of 1/3 of Irrevocable Trust 50% interest in residue 447,540.31 & 1/3 of Irrevocable Trust. NOTE: Entitled to 1/2 of the remaining 1/3 of Irrevocable Trust principal upon surviving spouse's death Total so8.9 0 1 1 REV-1574 E7(+ (4-09) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY ~ TERM CERTAIN (Check Box 4 on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER McCulloh Merlin L. 21-12-0709 This schedule should be used for all single life, joint or successive life estate and term-certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a coov to the tax return v r n 1 /90LG Barbara L. McCulloh 04/16/1931 81 ®Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable $ 157,010.00 2. Actuarial factor per appropriate table .08859 Interest table rate - ^ 31/2% ^ 6°~ ^ 10% ®Variable Rate 1.2% 3. Value of life estate (Line 1 multiplied by Line 2) $ 13,909.52 NAME OF ANNUITANT NEAREST AGE AT TERM OF YEARS DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ 'Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable $ 2. Check appropriate block below and enter corresponding number Frequency of payout Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^ Semi-annually (2) ^ Annually (1) ^ Other 3. Amount of payout per period $ 4. Aggregate annual payment. Line 2 multiplied by Line 3 5. Annuity Factor (see instructions) Interest table rate - ^ 311Y% ^ 6% ^ 10% ^Variable Rate 6. Adjustment Factor (see instructions) $ 7. Value of annuity - If using 3 1/2%, 6%, 10% or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 $ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Llne 3 NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule K (Rev. 4-09) NAME OF LIFE TENANT DATE OF BIRTH ~ DATE OF DEATH ~ _ TERM OF YEARS