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HomeMy WebLinkAbout10-01-12 1505610105 J REV-1500EX (oz-111 (Fl) OFFICIAL USE ONLY PA Department of Revenue D~YlvaMa Coudy Code Year Fla Number Bureau ofindividuatTaxes INHERITANCE TAX RETURN PO BoX 180601 ~ ~ ~ ~ ~( ~~ Harrisburg PA 1711EO6oi RESIDENT DECEDENT (/ 0 / ENTER DECEDENT INFORMIATN)N BELOW Socal Security Number Date of Death MMDDYYYY Date of Birth MIHDDYYYV 07/04!2012 04/08/1939 Decedent's Last Name Suffix Decedent's First Name MI Pleva Roger J (N Applicable) Eller Surviving Spouse's Informatlon 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. Odginal Retum O 2. Supplemental Rebm O 3. Remainder Retum (Date of Death Priorb 12.13-82) O 4. Limited Estate O 4a. Future Interest Cgmpromise (date of O 5. Federal Estate Taz Retum Required death after 12-12$2) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8.. Total Number of Safe Deposit Boxes (Agach Copy of Wi3) (Adech Copy of TnuL) O 9. LRigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election b Taz uMer Sec. 9113(A) Between 12-31bt antl 1-t-95) (Adach Schedule O) CORRESPONDENT - THIS SECTION MUST SE COMPLETED. ALL CORRESPONDENCE AND CONFlDBmAL TAX INFORMATION SHOULD SE DIRECTED TO: Name DayUime Teleptbne Number Richard C. Pleva (410) 757-5395 First Line of Address 965 Magothy Avenue Second Lure of Address City or Past Office Amold Cornsporlasnrs .-mail addrns: Under penalties d perjury, I declare dret I tt is true, correcl~canPbte. Dectarau State ZIP Code MD 21012 is based on all d rmich DATE 10/01/2012 ~v U^ v i !~ P*1 .~ ~ y ~7 ~~ m C~ 985 Magothy Avenue, Amold, MD 21012 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 ]r505610105 J REGISTER OF V~ySE ONLYti S ~~j ~zc o c-2 =D r-. "1 _r ~i'^ I C/l"f' -~ O ~ _, C")G`, 'o p c- .x -L w DAT~ILED v h~ J REV-1500 EX (FI) De~~deM's Social Secudry Number Decedeare Name: Roger J. Pleva RECAPrruunoN 1. Real Estate (Schedule A) ........................................... .. 1. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 3. Closery Held Corporation. PaMership aSole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Sd,edule E)..... .. 5. 6. Jointly Owrs.W Properly (Schedule F) O Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers 8 Miscellaneous NorrProbate Property (Schedule G) O Separate Billing Requested...... .. 7. 8. Total Grose Assets (total L'mes 1 through 7) ........................... .. 8. ~ 7`f©oo.c~ O r ~y~rr^~~ ©. W 1,S8~[, ~3 aao~~3o. sg D. 00 `7 5'$~ a tO e 3g- I S~'. 32a_ (~~ 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. ~ ~J I ~ ~. ~~ 10. Debts of Decedent Mortgage LiaWlities and Liens (Schedule I) ............. .. 10. ~ $' `~ ~R I,Q . Q a 11. Total Deductlons (total L'mes 9 and 10) ............................... .. 11. q 3 '~ ~~~ ~ y 72. Net Value or Estate (Line 8 minus Line 11) ............................ .. 12. ,~ r I J ~l(y ~~ ~ I ~. 4 13. CtreritaWe and Governmental BequeslslSec 9113 Trosts for which an electlon to tax has not been made (Schedule J) ...................... .. t 3. ©. 14. Net Value Sutrjaet to Tax (Line 12 minus Line 73) ...................... .. 14. ~ r ~/ ~ [ ~ I I / . TAX CALCULATION • SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 74 taxable at the spousal fax rate, ar transfers under Sec. 9116 76. Amoneal rate nX 0 5 altle l d (.e f ~ - ? • y ~ ,6. 4 ~ 7 Sb. ~ $ 77. Amount of Line 14 taxable ~ ~ at sibling rate X .12 17. J ,r-.,~~ ~• lam/ 18. Amount of Line 14 taxable at cdlaterai rate X .15 18. ~,~7L,r~~ ©~ `~ - 19. TAX DUE._......._ .......................................... ... 19. ~7~y { ~~ 1~> ~ V 20. FlLL IN THE OVAL IF YOU ARE REQUESnNG A REFUND OF AN OVERPAYMENT O 15U56102U5 Side 2 15U5610205 1505610205 REV-7500 EX (FI) Page 3 FIN Num6ar rlnrneinn*'a (`mm~la_4at A[IdIESS: DECEDENTS NAME Roger J. Pleva -- -- - STREETADDRESS 1111 Apple Dr., #10 - _ - cin - __ _ srATE zIP Mechanicsburg ~ PA 17055 Tax Payments and Credits: 1. Taz Due (Page 2, Line 19) 2. CreditslPayments ~,/~ A. Prior Payments _ _ ~~ ~!- B. Discount -- -- __ ~~~' ---.1~--~- 3. Interest 4. If Line 2 is greater than Line 1 + Lira 3, enter the diRerence. This is the OVERPAYMENT. FlII in oval on Page 2, Lida 20 to request a refund. 5. If Line 1 + Line 3 s greater than Line 2, enter the dilfelence. This is the TAX DUE. Total CredBs (A+ B) (2) ~ , J V (. _ S cs) O. DO (4) ©, DO (5) S ~L~~.'77 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 fhe use w incortle of the property transferred .................................................................................... ....... b. retain the right to designate who shall use the property transferred w its income ..................................... ....... ^ ^ c. retain a reversionary iMerest ....................................................................................................................... ....... ^ ^ ^ ^ d. receive the promise fw life M either payments, benefits w care? ............................................................... ....... 2. If death oaurted 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 payablrwpontleath bank account w security at his w her death? ....... ....... ^ ^ 4. Did decedent own an individual retirement acceunL annuity arother rwn-probate properly, which contains a benefidary 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 w after July 1,1994, and before Jan.1,1995, the tax rate imposed on fhe net value of transfers to or tw the use of the surviving spouse is 3 percent [/2 P.S. §9116 (a) (1.1) (i)]. Fw dates of death on w after Jan. 1, 1995, the tax rate imposed on the net value of transfers to w for fire 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 disdosure of assets and filing a tax return are sfill applicable even 'rf the surviving spouse is the only beneficiary. Fw dates of death on w after July 1, 2000: The fax rate imposed on the net value of transfers fran a deceased child 21 years of age or younger at cleath to w for the use of a natural parent, an adoptive parent w 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 w for the use of the decedenTs lineal beneficiaries is 4.5 q~cent, except as noted in [/2 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedenPs siblings is 12 percent (72 P.S. §9116(a)(1.3)]. Asibling is defined, under Secbon 9102, as an individual who has at least one parent in common with the decedent, whether by Hood w adoption. REV-1502 EX+ (11-0R) pennsylvarlia SCHEDULE A DEP~NTMENT OF REVENUE REAL ESTATE INHERITANCE TA% RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Roger J.Pleva 2012-00812 All real property owned solely or u a tanmtt In comma mud ba reported d lair malitat tldue. Fair market vaNue d defined as the Price at which property would be exchanged between a willing buyer and a willing seller, neither bring compelled to buy ar sell, both having reasonable knowledge of the relevant fads. Rut property that 4 jolndy-owned with right of aurvlvorship mud be dlacloud on Schedule F• Attach a mpY of the settlement sheet H the property has been sold. ITEM Include a copy of the deed showing decedent's Interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION t. 3 ooS n~ H 2 (~~ T ~~- I'7~,oooa~ GA-rn P N- 1(L ~, P R- I ~o( TOTAL (Also enter on line 1, Recapitulation.) I ¢ ~7 I~ (~D•00 If more space is needed, insert additional sheets of the same size. REV-1507 EXt (e-99) scNEOU~E o COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENI'DECEDENi ESTATE OF FILE NUMBER Roger J. Pleva 2012.00812 MI property (oIMtyHlwned rdlll rISM of aulvlvoRhlp moat bs dbdoaW on Sehadula F. :M RER DESCRIPTION _ 'Je Ti-eve,l~er~~ ~,s,.~~/h~~e., re-~~. r ~. ~ d~~ l~ -~T ~fiUrar~4 r~~. S. PIS e ~,1o~~s pe.,s,~, ~s-E~n per} ~. ~; ri~ ~xM ~~;o ~~.. TOTAL (Also enter an line 4, Recapitulahon) S (If more space is needed, insell eddlhanal sheets of Me same s¢e) 133.33 i a~.so ~~. ~ '78: ~~ Sn$, l ~ 2-35', 3 a 15$1.73 REVa5D8 EX+ (o8-~z) Pennsylvania SCREfDYLE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS ~ MISC. INHERRANCE TAX RETURN PERSONAL PROPERTY RESIDEM DECEDENT ESTATE OF: FILE NUMBER: Roger J.Pleva 2012-00812 If more space is needed, use addRional sheets of paper of the same sLle. REV-1510 EX+ (OR-09) Pennsylvania OEPPRTNENT OF REVENUE INNERRFNCE TWf RETURN RESIDEmT DECE[IENT SCHEDULE G INTER•VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY :STATE OF Rnnwr-I PI JNBER 2012-00812 Th' h dole must be completed and filed if the answer to any of questions 1 through 4 an page three of the REV-150U is yes. ITEM NUMBER is sc e DESCRIPRON OF PROPERTY mcwoETRE XMIE OrTNE musrv~.>xNa nnsnoxsxorooc~errum w+orTNE OEm roR nrx ESTmc r M » ~ c THE DIaE Ormsxsr a w T DATE OF DEATH VALUE OF ASSEF MI OF t~CD5 INFERESF E%CLUSION vuRlcwe TAXNBLE VALUE . t' - -7- - ~ ~ . ^ ~ ~ .-~F~ n _ I J/ ~t'~(Y)~VI~i-1LrrV~ p1 ~~,, .lJ (~ E s~4~ ~• 1 ~~ ~^~ ~~ O'a'O~ ~O'~ q +T ~{^ J~d~J.J.J• h/'+ J ~ 37as3s r~ ~at,i ek ~= ~ , 3ra~s 3. i ~D ~~- ~ ~ R~4 ~• i~sl~, 4a ~ l~ ~`-~~ y~ f ~/ ~`~0.~ ~' ~1~~ ~) 0 (~l o~~~~ "''"' ~ , ~~~~ 1111 y. ~ ~Q4'1~~- W~ 1 ~(' t_.avl"G d10'n ~JT lr ~) ..~v IR~JT (~ I TOTAL (Also enter an Line 7, Recapitulation) ; If more span H needed, use addltlonal sheets of paper of the same srz~e. f7 7~ 7 ,a-tor 3$ REV-1511 EX+ (10-09) } ~ Pennsylvania tail DEPRRTMENT OF REVENUE mHERTTANCE TAX RETURN RE9DENr DECEDENT ESTATE OF FILE NUMBER RoaerJ.Pleva 2012-00812 DetedeM'a debts moat be roported on Schedule I. A. FUNERAL EXPENSES: s. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Richard C. Pleva _ Street Address _965 M~]ca .Oth~Ave.____ _ ~;N Amold _ Year(s) Commission Paid: _ _ ~ ~~ ~ ___ State .MO_ZIP 21012 _ ___ 2. Attamey Fees: 3. Family EXemption: (If decedent's address is not the same as claimant's, attach eXplanation.) Claimant Street Address __- _... __-_ -___- State_ ____ZIP cny ____ _ _ _ ___ __ _ _ Relationship of Caimant to Decedent __ _ 4. Probate Fees: 5. Accountant Fees: 6. Tax Retum Preparer Fees: ~. ~e~~d~ ~ ~ Aa't T'1~~ `DNTMpS~P,r `~; o~,a.~~,.,s cks~e- Ret-,off w- Ue~tn~•.~ ~n~ii~l t~,5~~-r e_ ar,w-+h.~nP.n~ 3,7~f5• ~ I~ rxo•oc~ y52c , er%~O1 ©r ~/~/ 2 oeo. ~ ©~ ~O 3(x`7. (~O 3 ~' 2-3, c(o TOTAL (Also enter on Line 9, Recapitulation) I; ~ ~ , ~ 3 ~ ~ O a. SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS If more space is needed, use addltlonal sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania SCHEDULE I DEPNflTNENT OF NEVENNE DEBTS OF DECEDENT, rNNEmTnncF rnx RETURN MORTGAGE LIABILITIES 8r LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Roger) Pleva 2012-00812 Report debts incurred by the dacedeM prior to death that remained unpaid at the date of death, including unrelmbursed medidil expenses. t. C%G=1~ M°~~`d~' - ,3 ~~ Ma,-~e~' ~,~ C.~tt~N~, ~i ~(, A4 7 3~ D(ny. 7~ a. ~ M~~ c,~.dt+ - I.~se-d slot-~ f~tm,~~. a,a5 7. ~$ ~. ~~tn~ R~ -~ T~~ 535 no S ~Q,0.~ ~.~.;-F ~~d. I ~.P. d~.,e~ n I I, o7S ~qI fie. ~ert~an ~.esS c~ec~,t~-~ b~k. Ct~~ ~ O~{©. ~ l TOTAL (Also enter an Line 10, Recapitulation) I Q = If more space is needed, insert additional sheets of the same size. r•/ QJ ~~~ ~a REV-1513 EX+ (O1-30) 7i1' pennsylvania SCHEDULE 7 ~ OEPAPTMENTOFPEVENDE BENEFICIARIES INME0.ITANGE TAX RETURN 0.ESIDENT DECEDEM ESTATE OF: FILE NUMBER: R er J. Pleva 2012-00812 REIATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not llrt Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Indude outright spousal distrihutions and transfers under Sec. 9116 (a) (1.2).] q~s ~4~~~ A-~e,,~T,(,~ld ~tp a~©~a al. '~ani eX ~ . ~~eVtl ~-nYl ~ ~~ ME oyt~il~ r`t~'uv,l~cQ ~y M~A~a~h ~. ~ ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON L[NES 15 THROUGH 18 OF REV-1500 COVER S II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUIONS UNDER SECf10N 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NONTAXABLE DISTRIBUTIONS ON LINE 13 OF REV•IS00 COVER SNEET. 4S APPROPRIATE. If more space is needed, use additional sheets of paper of the same size. ~. rfl INVENTORY REGISTER OF WILLS OF Cumberland COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA ~ SS COUN71' OF Cumberland File Number 2012-00812 Personal Representative(s) of the Estate of Roger 7. Pleva deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent. owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandtun at the end of this inventory. [ verify that the statements made in this Inven- tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unswom falsification to authorities. Attorney -- DATE OF DEATH tAST RESIDENCE my 4, 2012 11 I 1 Apple Drive, #10, Mechanicsbtfrg, PA 17055 (Supreme Court /. D. No.) FIGURES MUST BE TOTALED ~Prtx.~~C ~a~'~- 3. '~~ ~p~°p ~ ^-~.-,~; rm~ )cps . ~. t4ss~et~ ~~Q.Q , ~-pled I,q~ ~ ~ S . (Attach addltlonal sheets as DECeoen I ~a sw. acv. ~,. 198-30-0912 ~(~~~~~ ~ I eeoo ~ ., ~ ~~~^~ ~ a~.~o NOTE: The Memorandum of real esmte outside the Commonwealth of Pennsylvania may, at the election of the personal representative include [he value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa C.S. § 3301(6)) Form RW-09 rev. 10.13.06 REV-516 EX + (OB-09) Pennsylvania OEPAPTMENT OF REVENUE BUREAU OF INDiVIDUALTA%F.5 Po sox 380691 eoo1M11Rf PA 1912a-0(101 REQUEST FOR WAIVER OR NOTICE OF TRANSFER (FOR STOCKS, BONDS, SECURITIES OR SECURITY ACCOUNTS HELD IN BENEFICIARY I DECEDENT INFORMATLOn DECEDENT NAME: LAST Pleva DECEDENT SOCIAL SECURITY NUMBER 198-30-0912 DECEDENT STREET ADDRESS j 1111 Apple Drive #10 ~~ MI Roger J DECEDENT DATE OF DEATH (MM-DD-YYYY) 07/0412012 STATE ZIP COUNTY pA 17055 Cumbedand CORPORATION, FINANCIAL INSTITUTION OR BROKER iryFONnwii~n TELEPHONE NUMBER NAME OF CORPORATION, FINANCIAL INSTITUTION, 60.0KER OR SIMILAR ENTITY (717)']30-3306 TD Alrieritrade - Mr. Kevin Johns STATE ZIP FIRM STREET ADDRESS CCfY 114 N. Second St. Hardsburg PA 17101 ACCOUNT INFORMATION OTHER D BOND SECURO ASSET SECURIT~CQUN'r ^ TYPE OF ACCOUNT: CAPITAL STOCK REG[STE O ACCOUNT BALANCE (Tncjyde a[cryed Interest rough Qa[e of death) "~ Y 55 IDENTIFYING NUMB OF ASSET~~ SV t Ot l (Q ON REV•iS O O . BE FILED l UNT WIL ACCOUNT TITLE m~~` ~~ IJ ^ BILL BENEFICII\RIES SEPARATELY 1. BENEFICIARY INFORMATION NAME: LAST Pleva FIRST MI Richard C C~~ -~"~ PERCENT TAXABLE STREET ADDRESS 965 Magothy Ave. 21P orectsl use oRry CITY STATE MD 21012 TAX RATE ArtwN BENEFICIARY'S SOCIAL SECURITY NUMBER RELATIONSHIP TO DECEDENT 180-52-6637 Son Z BENEFICIARY INFORMATION NAME: LAST PIeVa MI FIRST Daniel J ~ PERCENT TAXABLE STREET ADDRESS 304 Mountain Rd. ZIP O~(al Use oidy CITY STATE ME 04048 TAX RATE Arundel BENEFICIARY'S SOCIAL SECURITY NUINBER RELATIONSHIP TO DECEDENT 180-52-8253 Son 3, BENEFICIARY INFORMATION NAME: LAST FIRST MI PERCENT TAXABLE STREET ADDRESS STATE ZIP OlNdal Ike Only CI7V TAX RATE BENEFICIARY'S SOCIAL SECURITY NUMBER RELATIONSHIP TO DECEDENT w~~ Please Ilst addkional beneficiaries m snomer meet a wPa. P•~•^•^•e ~•• •-+-••-- -•°-~------- ~~~ (410)757-5395 SIGNATURE OF PREPARER DAYTIME TELEPHONE NUMBER InstracNms Tor fllinq thls notice are on the reverse side. REV-Safi EX + (08-09) Pennsylvania OEPPRTMENT OF REVENUE &IREAU OF INOMOUAL TA%ES Po sox mono. HAfIRISBURG. PA 1'1f28-0Wa REQUEST FOR WAIVER OR NOTICE OF TRANSFER (FOR STOCKS, BONDS, SECURITIES OR SECURITY ACCOUNTS HELD IN BENEFICIARY FORM) DEGEDtnr lnrvl(1'Iw7avn - MI DECEDEM NAME: LAST FIRST Pleva Roger J DECEDENT SOCIAL SECURITY NUMBER DECEDENT DATE 01' DEATH (MM-DD-YYYY) 198-30-0912 07/04/2012 DECEDENT STREET ADDRESS CITY STATE ZIP COUNTY 1111App-^'•~"'" Mechanicsbum PA 17055 Cumbedand CORPORATION, FINANCIAL INSTITUTION OR BROKER INFORMATION NAME OF CORPORATION, FINANCIAL INSTCRIRON, BROKER OR SIMILAR ENTITY TELEPHONE NUMBER TD Amentrade - Mr. Kevin Johns (717) 730-3306 FIRM STREET ADDRESS CIIY STATE ZIP 114 N. Second St. Harrisbu PA 17101 ACCOUNT INFORMATION TYPE OF ACCOUNT: CAPITAL STOCK REGISTERED BOND SECURE ASSET !iECURITY ACCO OTHER ^ ~ ACCOUNT BALANCE (Include accrued Tote st throw h date of death) IDENTI LNG NU ER 0©~~ / n i / `~ _ L ~ % / ~ 0 MU_ BE FlLED ON REV-15 U HI ~b ACCOUNT `D n ^ ~~~ r ~~ / l7-1417 !(~ frC[~( ^ BILL BENEFlCIARIES SEPARATELY 1. BENEFICIARY INFORMArIDn NAME: LAST Pleva FIRST Richard C PERCENT TAXABLE STREET ADDRESS 965 Magolhy Ave. STATE ZIP OATCIal IkO Only ~, MD 21012 rAX RATE Amokl RELATIONSHIP TO DECEDENT BENEFICIARY'S SOCIAL SECURITY NUMBER 180-52-6637 Son 2 BENEFICIARY INFORMATLVn NAME: LAST playa FRST Daniel J .~('~ _ 7v PERCENT TAXABLE STREET ADDRESS 304 Mountain Rd. STATE ZIP Cilldal Use Only CITY ME 04046 TAX RATE Arundel RELATLONSHIP TO DECEDENT BENEFICIARY'S SOCIAL SECURITY NUMBER 180.52-8253 Son 3. BENEFICIARY INFDRMAIlVn NAME: IAST FIRST MI PERCENT TAXABLE STREET ADDRESS STATE ZIP O/flWal IAse Only CITY TAX RATE RELATIONSHIP TO DECEDENT BENEFICIARY'S SOCIAL SECURITY NUMBER Please list additional beneRNanes on ananer sneer or paper, prarw.ay .....y.... ~ ..........o....... ~~~~ (410)757-5395 II/~~~ SIGNATURE OF PREPARER DAYTIME TELEPHONE NUMBER Instructions for Rling this notlce arc on the roverse slde~.