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HomeMy WebLinkAbout11-19-12 (2) J 1505610105 REV-1500 ex t°~-", (F"' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Nfumbe~r \f ., .. V / L! Bureau of Individual Taxes INHERITANCE TAX RETURN PD BOX z806o1 RESIDENT DECEDENT ~ ~ ' ~ 1 Hamshurc. PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Date of Death MMDDYYYY Date of Birth MMDDYYYY Social Security Number 10/0912011 0111811921 Decedent's Last Name Suffix Decedent's First Name MI CROSSLEY SARA S (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 INAPPROPRIATE OVALS BELOW OD 1. Original Retum 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) OD 6. Decedent Died Testate O 7. Decedent Maintained a Living Tmst ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) Litigation Proceeds Received O 9 O 10. Spousal Poverty Credit (Date of Death r Sec. 9113(A) O 11 ~ . Between 12-31-91 and 1-1-95) Attach Schedule O ( ) ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: COMPLETED CORRESPONDENT - THIS SECTION MUST BE . Daytime Telephone Number Name MONROE E. CROSSLEY (717) 386-9532 First Line of Address 440 BARBARA DR. Second Line of Address City or Post Office MECHANICSBURG State ZIP.Code. PA 17050 REGISTER O~11LLS USE ON7:A r_~ rye T ~ _j Cx7 -,.~ CJ s. ;. . rTl 1 ~C ~ 4d:: _ _ ! i y 7~1- ~ ~ _ J o c _. C7C- ~. O ~~: -_. o D FILED ~~ O .~ C-; ~: ~,-, '°, ' -! 3 `-) ~ rt T Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, inclutling accompanying schedules and statements, and to the best of my knowledge and belief, it is true, corre and complete. do of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT E F PERS R S I E FOR FI G RETURN DATE.' ~ i!~ /L ADD SS 440 BARBARA DR, CHA BURG, PA 17050 cirnlAn RF b PREPARIifR ER THAN REPRESENTATIVE ~A~i~~_ ADDRESS ~ ~ 1200 CAMP HI PA S STE 200 CAMP HILL PA 17011 _ PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J J 1505610205 oeceaent's Name: SARA S. CROSSLEY RECAPITULATION _ _... _......... _.. 1. Real Estate (Schedule A) ...... ........ .......... ................. 1 2. Stocks and Bonds (Schedule B) ......... ............... 2. 979.20 '' 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 30,474.37 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ...... . 6. 7 Inter-Vivos Transfers & Miscellaneous Non-Probate Property . (Schedule G) O Separate Billing Requested....... . 7. 8. 9 ) ................ Total Gross Assets (total Lines 1 throw h 7 ............ . 8. 31,453.57 '' 9. Funeral Expenses and Administrative Cosls (Schedule H)...... ..... . 9. 6 907.42 10. ..... Debts of Decedent, Mortgage Liabilities and Liens (Schedule I)..... . 10 15,965.59 ,_,.___ _~. __.. 11. Total Deductions (total Lines 9 and 10)......... ....... . 11 a ..._ ~.. 22,873.01 ~... _ ... .- w... _. _.. 12. Net Value of Estate (Line 8 minus Line 11) .......... ........ ........ . 12 8 580.54', 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. 8,580.56 ', TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES t5. Amount of Line 14 taxable at the spousal tax rate, or _ - -- ~- ---- transfers under Sec. 9116 15 (a)(1.2)X.0_ 16. Amount of Line 14 taxable at lineal rate X .0 45 386.12 ~ t6 17 Amount of Line 14 taxable ~ '', . ' at sibling rate X .12 17 18. Amount of Line 14 taxable 18 at collateral rate X .15 . 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 388.12 O Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 File Number UeCeOen[5 VVIrIfJ•CaG w.~•`~~• DECEDENT'S NAME SARA S. CROSSLEY STREET ADDRESS _ 440 BARBARA DR. _ _.__ _ . __ I -- _ _-.- _- ----- ____.------i sTATE __ PA zIP 17050 clrv MECHANICSBURG Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (i) 386.12 2. CreditslPaymenls A. Prior Payments _.____ .._ B. Discount Total Credits (A + B) (2) 3. Interest (3) 4. If Line 2 is greater than Line 1 + Llne 3, enter the difference. This is the OVERPAYMENT. (4) Fill in oval on Page 2, Line 20 to request a refund. 386.12 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. l5) Make check payable to: REGISTER OF WILLS, AGENT. ., ~~; N, , , , ~~ ,..r. ;: x x 6,„ru 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 properly 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 benefciary 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, q.+.. ;~ 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 Vansfers from a deceased child 21 years of age or younger al 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 def ned, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-t~~3 EX+ (bas) . ~i j pennsylvania SCHEDULE B Ll OEPHRTMENTOFREVENUE STOCKS & BONDS INHERTfANCE TAX RETURN PESIDENT DECEDENT FILE NUMBS ESTATE OF 2011-01075 SARA S. CROSSLEY All property Jointly owned with right of survivorship must be disclosed on Schedule F. VALUE AT OF DEF ITEM ~ DESCRIPTION 1 ~ 34 SHS METLIFE STOCK TOTAL (Also enter on Line 2, Recapitulation) I # If more space is needed, insert additional sheets of the same size 979.20 979.20 REV-i8o8 EX+ (o8-u) pennsylvania ~7 DEPARTMENT OF REVENUE INHERITANCE TA% RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: SARA S. CROSSLEY 2011-01075 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ! ^ T' 1, BANK ACCOUNT -1 ST NATIONAL BANK OF MARYSVILLE # 910368 2 BANK ACCOUNT -1ST NATIONAL BANK OF MARYSVILLE # 246069610 3 2011 IRS REFUND RECEIVABLE 4 NATIONAL GUARDIAN LIFE BURIAL TRUST 10,619.54 11,666.00 954.00 7,234.83 TOTAL (Also enter on Line 5, Recapitulation) ; I 30,474.37 If mare space is needed, use additional sheetr of paper of the same size. P.O. BOX B MARYSVILLE, PA 17053 TELEPHONE (717) 957-2196 Sara S Crossley 490 Barbara Drive Mechanicsburg PA 17050 Account Number 910368 Statement Date 11/17/11 Page 1 TYPE OF ACCOUNT--Hometown Checking Statement Summary Beginning Balance 10/07/11 Deposits/Credits 1 Credits Checks/Debits 3 Debits Interest Paid Ending Balance OVERDRAFT / RETURN ITEM FEES 10,669.30 3 1,681.56 12,350.86 6.95 .00 I Total for - I Total I this Period Year to Date I I I I I I I Total Overdraft Fees I .00 I .00 I I I I Total Returned Ztem Fees ( .00 .00 I I I Credits/Deposits Date Amount Description 11/O1 1,681.56 Xxciv Serv From Us Treasury 312F 1695995 W Csf Sara S Crossley Other Debits Date ount Description 11/10 2,197.60 Balance Close Out - Debit /0~9- ~ l~s ohs ~~~-- ~yg76) /o~ q D ~~. ~ MEMBER F.D.LC. Sara S Crossley 490 Barbara Drive Mechanicsburg PA 17050 Account Number 910368 Statement Date 11/17/11 Page 2 Checks/Withdrawals Check# Date Amount Check# Date Amount Check# Date 6431 10/12 99.76 6432 10/19 103.50 Daily Balance Information Date Balance Date Balance Date Beginning Balance 10,669.30 10/12 10,619.54 11/O1 12,197.60 10/14 10,516.04 11/10 .00 P.O. BOX B MARYSVILLE, PA 17053 TELEPHONE (717) 957-2196 Amount Balance MEMBER F.D.LC. P.O. BOX B MARYSVILLE, PA 17053 TELEPHONE (717) 957-2196 Sara S Crossley Monroe E Crossley Jr POA 940 Barbara Drive Mechanicsburg PA 17050 Account Number 296069610 Statement Date 11/17/11 Page 1 TYPE OF ACCOUNT--Free Checking Statement Summary Beginning Balance 10/07/11 Deposits/Credits 1 Checks/Debits 2 Ending Balance Credits Debits OVERDRAFT / RETURN ITEM FEES 11,666.00 2 1,056.00 12,722.00 .00 I I Total for I Total I I this Period I I Year to Date I I I I I I Total Overdraft Fees I .00 I I .00 I I I I Total Returned Item Fees I .00 I .00 I Credits/Deposits Date Amount Description 11/O1 1,056.00 Xxva Benef From Us Treasury 310 10 10 Sara S Crossley Other Debits Date ~knount Description \ 11/10 66.00 Balance Close Out - Debit 11,6 Checks/Withdrawals Check# Date Amount Check# Date Amo unt Check# Date Amount 11/02 1,056.00 MEMBER F.D.LC. T'o it Page 3 014 201402-24 02 41 07 (OMT) 17178603829 From John Toomey N r r Irrevocable Assignment of Ownership to l3L NGL funeral Expense Trust ch6re~n ~afled ~~r~5t°~ National Guatblan Life Insurance Company (Nt3L) PO BOx t 191 Madison WI 53701-1191 Phone. 800 988.0926 ~. Fo• Ho Office Use Only Insured .9-rQ,¢ S ~pSS/~ „_, _„ Polls/ Number~P_L o_2__~O~ . Owner (If other than Insured) Etlective 48 days from the data NGL raceive9thls form, I Hereby assign ownership and change the beneficiary of this policy to the Trust. This transfer, once atfactive, Is made to comply vnlh the requirements of arty applicable elate public assistance and federal public assistance programs. I unoerstand that by [rensfemng ownership of this policy to the Trust, as of the eflechve date I Thispol.uy+saccepledbythe7rustsub)ecltoalltheterrnsoftheTrustwh~chincludespaymentofthepolicyprocaedsfathefune2l expenses, tw-ial and cremation for the Insure/d, as llsteo below +•ny Funeral Home of chrnce is ~~H1C7//1s or ony ether Ftneral HOme as weir interest may appear, ~"moo"~~n'om. nun. or wra-bianY rc nonTchown .+ m• - 2 The change of ovrlership is permanerx and except as staled harem I renounce rrry power to contra ownership of lire pdicy 3. I gNe up any remaining right to cancel tl1e palsy end ~eCeive a ~etum of premum under the Right to Cancel pmvisbn, .q I wanre aN rights urxier the policy Lo surtentler it for cash, tN to obtain a ban against the policy. 5. I grve uppprr the rk7ht to change the beneBaary on this poUcy or rd~s, ,I any, 8 to the State eceeif requiredx by thethe app~l~oah~ Ste'~a'Medc a~id~recadieN PrografomLt IE I~ merit ro e Ste ere~s~rotr requred orap m~ s proceeds ewst after payment to the State, all such excess procaeos shall he paid to the EstNe of the Insured This superseoes arty Beneficary named on my policy app~mCan, and 7 It is my personal otlliga6on to pay all premums due on this policy (if any) and, if my failure to pay premiums results in the lapse of the pvhry, the Ti list wJl have no obligation to pay rtry funeral expenses I may obtain a full copy of Ilia Trust, at any lima, upon written request to: National Guardian Lite Insurance Company (NGL) T1vo Eest Gilman Street Medlson WI 33703 Sf~gr ature of Owner Dste The Trust aa9 pt~hl stgnment and agrees to use the proceeds of the Policy for the payment of funeral expenses Administrator rustee Date Authorized Expense Olreetive Insured hereby expressly authorizes and directs Trustee to expend Trust assets [o sernce or product providers in poymenr Of expenses related +o the provision of the following services and/or products List of poasibla goods and sorvicaa qualifyfng for reimburaamant Basic Services of Funeral Director & Slalf Other Funeral Merchandise Memorial Meal Other Protess+onal Funeral Services Clergy Honorarium Casket Embalming Death Certificates Wtemehve Container Omer Care or Deceased Musicmns Outer Burial Contfliner Dressing/Cosmetology/Cesketing Temporary Marker Other Services Funeral Home FacihGes and/or Staff Services StaUOney Package Transportation Egwprr1er11 & Onver viewingNisitation Obituary Notices Transfer of Deceased Funeral Service Flowers Funeral Vsnicle/Hearse Memcnal Service Clothing Car/Umousine Graveside Service Cemetery Charges Uu6ry/SeNice Vehicle Oilier Opening & Closing of Grave Other Cremation Services ~_ ~_ ..__~ .__ _..__ _.._~ .•s r....,..ewl.s aee.ir..er.4 eu..rtiuuv ntuty For Applicant: I herehV elect to make ihr3 vrBVOCable assignment effecuve immediately I understand that by making this OIQCLOn I gNe uo all rigt)ls iD CanC81 ilia POhCy and ieCerve a fetutn Of pfemlum Undef th8 Rigflt t0 Cenci prDVIaiDO of 1hC policy To make an immediate transfer election please sign here ~~• , __, For Agent: I certify that on I haw explained to ttus insured Ihat by signing the above line, her5ne .s ei ing t it nghT{u ca_rK;ef I~ie policy and assert tTiatTie~heis aware of the consequences of immediate transfer I i indetn;tand that this option should ony be used d'haro is an immediate need to reduce assets in order to qunhy for Medx:oitl . AgerhSignature:_ _ _Date 2591-FET 09/09 SCHEDULE OF BENEFITS AND PREMIUMS CERTIFICATE NUMBER NPL0281021 ISSUED FEBRUARY 2 Group Policy Number GPN 2002-04 ®~ Maturity/ ~~ Certificate Single Expiry Plan Amount Premium Date Single Pay Whole Life $7,007.10 $7,000.09 Life Guaranteed Values Figures based on above Certificate Amount not including future growth. End of Cash or Certificate Year Loan Value 1 5,999.76 2 6,081.11 3 6,163.73 4 6,249.63 5 6,340.94 6 6,438.75 7 6,543.37 8 6,651.63 9 6,755.62 10 6,836.48 11 7,007.10 12 7,007.10 13 7,007.10 14 7,007.10 15 7,007.10 16 7,007.10 Declared Annual Growth Rate: 2.00% Non-Guazanteed Certificate Loan Interest Rate: 8.00% Annually In Arrears Guaranteed Basis Of Values and Paid-Up Insurance: Mortality Table: 1980 CSO Sex Distinct Age Last Birthday Interest Rate: 5.00% Method: 1980 CSO Standazd Nonforfeiture Law Minimum Insured: SARA S CROSSLEY Age: 89 Female Beneficiary: As Stated Tn The Enrollment Form Or Last Recorded Endorsement Certificate Owner: SARA S CROSSLEY C~t~c.~.~r ~ ~-PL D2.8 ~ of ~ NPNCERTSP2002 1/06 Page 3 a b a p A A e n K x ;~ z~ ,~ ~~ O ro no r~ r ny oa ~z b a~ z~ ~ t>y ~ ~?: SUSQI,JNHANNA PA 220 -4- 90-Year Pa,~msat Ltfs whsle T.N.. MwtLly ZReminms Pa.eWefor 20 Yeah - SCHEDULE ,x;. z ~ ~" > ~ ~ z N ~ ~ a d o 'z ro ~ i~ M ~ ~ ~ ~ ro ~ 9 C C ' ~ 7 ,q 2 w F}y /r O y % d p t" red a~ y ~ " V d y o ~ r" ~ t" P ~ ~ ` m ~ ' ~ e O ~ 0 ~ ~ E °z A C~ y r ~C m m PENNSYLVANIA •n.. 1n a.. ~e Porm M1aT. Numbx of Policy Date of Issue Name of the Inaated ApNntgiM- Amount of l Monthly stLSe(ree') Iaeuranae Premium 2876234 M DEC 1 1938 SARA 5 ADAL:S l8 $ 500- $ 1.18 gnats aeanatanaaamp w .we neaeaclary - i9ARGARET ADA~,sS-MGTHER SPACT FOR ENDORSEMENTS eearrmuar< •. ~~„ . ~-~Q . _ // ~ - The clause eat&led "Facility of Payment" oa the fiat pagshereot to hereby modified to resd ea follows: ~ oNAxGBa FO ([~ ~, b ~ WKN MaNT Or' aEYDCATIOM ~~ION3N If the Bmeficiary dpeg not tutrtnder this Policy yvlth dus proof Of death within 3() days after the death Of file Insured, OI $ the . Beneficiary is the estate of the Insured, or is a minor. or din before PI ~ ~ . the Insured, the -death benefit will, upon surrender of this Policy with due proof of death, be paid to the executor or administrator. of the Insured, but is any such case the Company ma i li f ~~~~a~,. ~""e` ~E~ I3 1944 y, s en o payment to the executor or administ t ,5,.~ w~r..>• ra or, pay the death benefit to any person named es Beneficiary, or to nay relative by blood or coaatction by mamage'of the Insured appearing to the Com to be equitably entitled tosuch payment. Theppigi ~1~1q ~ ~~~_ . _. during the minority off 4hq~ ~b~yaQxar~p*o ..:p~yq~at or gran 4ay-P ~. lags ttl4~rtb e~e. F°]jly`+e ~yy~{:{~ tr t ..-.. r- T6a' 1foHIe e4 thtlaaltrai ata~ lll{ y ,,o,de Sul ,yq~ggrsphrge„~ . ,:..::zu ;G :W~~~~~/i~ durt"tma veaie t -~ 4:..E . ~~~ rv..`. .. ~ - - -.. M be ~~~.~~~~ ~_ aa /~ '^ eedicnrp ... .... . 1 a goc.: ra .. . .. ... },o ikYYiAar Wits tho laW al4'IiYe4 [ 1:.. ' ~ sa ia1w, -~ ..~.,... ~. ~:::. v.~ ............. NOTICE TO POLICYHOLDER Please Read Your Policy Carefully. Aa election of Dlractors of the Company is held is New York oa the second Tuesday in April of every odd-anmbered year. The holder of this Policy, after one year from ifs date of iesae, while it remains is force, will have a right to vote either is parson or by prozy oz by mNL For particulars as to how to vote, apply to the Secretary, 1 Madison Avenue, New York, N. Y. Rev-lslt Ex+ Iro-oe) ~ : pennsylvania DEPARTMENT OF flEVENOE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER SARA S. CROSSLEY 2011-01075 Decedent's debts must be reported on Schedule I. ITEM AMOUNT NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1' MICHAEL J. SHALONIS FUNERAL HOME 6,168.92 2 RICE MEMORIAL WORKS 185.00 B. 1. 2. 3. 4. 5. 6. 7. 8 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State _ ZIP 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 _ Z1P Relationship of Claimant to Decedent Prohate Fees: Accountant Fees: Tax Return Preparer Fees: PUBLICATION FEE -ADMINISTRATIVE NOTICE CUMBERLAND COUNTY REGISTER OF WILLS TOTAL (Also enter on Line 9, Recapitulation) I; 400.00 50.00 103.50 6.907.42 [f more space is needed, use additional sheets of paper of the same size. - _ - Michael J. Shalonis Funeral Home 206 Maple Avenue Marysville, Pennsylvania 17053 Fax (717)-957-2077 Michael J. Shalonis, Owner Phone (717) 957-3451 We Care About Service To You Friday, October 21, 2011 Mr. Monroe E. Crossley, Jr. 440 Bazbara Drive Mechanicsburg, PA 17050 Deaz Mr. Crossley, Jr., Thank you for selecting our funeral home to provide services for your family during your time of bereavement. I hope that you found our services, so far, to be of the highest standazds that we always try to achieve. The following is a sutrunary of the service chazges as previously explained and provided in written form on the services for: SARA SUSAN CROSSLEY PROFESSIONAL SERVICES Basic service of funeral director and staff $ 1300.00 Embalming $ 525.00 Dressing, Casketing, and Cosmetology $ 285.00 Total Funeral Service Selected TOTAL PROFESSIONAL SERVICES $2,110.00 FACILITIES, STAFF AND EQUIPMENT S[atf & equipment for church service $ 415.00 FACILITI ES, STAFF AND EQUIPMENT $415.00 AUTOMOTIVE EQUIPMENT Transfer of Remains to Funeral Home $ 200.00 Hearse /Funeral Coach $ 250.00 TOTAL AUTOMOTIVE EQUIPMENT $450.00 OTHER MERCHANDISE SELECTED Casket: Gemi Series Blue $1,095.00 Outer Burial Container Grave Liner $820.00 Acknowledgement Cards $ included Register Book $ included Memorial Folders 150 $ included TOTAL OTHER MERCHANDISE SELECTED $1,915.00 CASH ADVANCES Grave Opening /Closing Chazge $ 500.00 Certified Copies of Death Certificate $ 60.00 Clergy Honorarium $ 50.00 Organist $ 35.00 Newspaper Notice Patriot News $ 398.92 Cemetery equipment $ 185.00 Flowers $ 250.00 CASH ADVANCE TOTAL $1,478.92 LESS: Credits granted $200.00 Discount allowed $200.00 TOTAL OF SERVICES $6,168.92 BALANCE DUE $6,168.92 If there are any questions or concerns that remain unanswered, please call me. Sincerely, Mic ael 1. Shalonis Owner INSCRIPTION ORDER FORM SCE ~E~~l.. SOS 13-31239 _ a dtuision of MEMORIALS Since 1921 421 W. Main Street, New Bloomfield, PA 17068 (717) 582-2512 • Fax: (717) 582-3404 • www.gingdchmemorials.com CEMETERY ~E.- r r fl i ~S LOCATION NAME OF DECEASED S C•2 r e~ -S r C r o s S LETTERING REQUIRED: r ~ ~'e.' /9/s~~ /Ze-~P©x~ -~k.~ dross ~ rases bronze. [ct~(.L.c~tv-~P.at~, FAMILY NAME MEMORIAL ~, r ~~ `' IND. NAMES ON MEMORIAL M~"r~r ~1 ~ TYPE OF MONUMENT ~1 ~ ~ oiF~~ COLOR OF GRANITE ~ a~i o LOCATION: DRAW A PRECISE MAP OF LOCATION OF MEMORIAL ON CEMETERY (Use back of work order if necessary) BILL TO: /ll o n rae ~ . C= r o sS /e..~ J P-' , DATE OF ORDER ~d ~ r Fj,K rc~ ~ r i` V ~ ORDERED BY _ e C~lti A i cS ~ v r cs_T~1~ / TD.I"'D PHON€ # 3S'6 ~ y'S3~ UPON EXAMINING THE ABOVE INSCRIPTIONS, IANE THE UNDERSIGNED, FIND THE SPELLING AND DAT~$ TO:BE CORRECT. THE WORK WILL BE COMPLETED AS IT IS ACCUMULATED. NO SPECIFIC COMPLETION DATE IS GUARANTEED. SIGNED r ~ SIGNED p PRICE $ _, ~6 S' DEPOSIT $ /~- ~~~_/ BALANCE DUE $ / Sst L~ d '/ WHITE-Office YELLOW-P ~ PINK-Customer GOLDENROD-Branch DONALD J. LOGAN, CPA, P.C. CERTIFIED PUBLIC ACCOUNTANT 1200 CAMP HILL BYPASS, SUITE 200 P:O. Box 737 CAMP HILL, PA 17001-0737 TELEPHONE (717) 975-9733 FAx (717) 975-2804 SARA CROSSLEY ESTATE 440 BARBARA DR. MECHANICSBURG, PA I7070 INVOICE FOR SERVICES RENDERED INVOICE DATE -NOVEMBER 19, 2012 Prepazation of PA Inheritance Tax Return 444. Thank you for your business. n~ A~C(~ ~~~~ ~cr~~ ~,4r l~~r~-~ 5~,~~ `"`z _c~,.~~iss~~ ~_ ~ ~~~PrYM ~~ ~ ~~.. -~ l __ ~~ ~~ ~1~,~,~sc~ ~. ~SJ'~c~ .~~~ ~~f Cz RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 CROSSLEY SARA S Receipt Date: 10/12/2011 Receipt Time: 16:01:25 Receipt No.: 1067275 Estate File No.: 2011-01075 Paid By Remarks: MONROE E CROSSLEY JR HMW ------------------- ----- Receipt Distribution ----- -------- -------- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 20.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 40.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN Check# 6432 ---------------- $103.50 Total Received..... .... $103.50 REV-1512 E%+ (12-0E) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE Of FILE NUMBER SARA S CROSSLEY 2011-01075 Report debts Incurred by the decedent prior to death that remained unpaid at the date of death, Including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t CHURCH OF GOD HOME, INC 4,159.14 2 PA DEPT OF PUBLIC WELFARE 9,819.89 3 DONALD J. LOGAN, CPA - 2011 TAX RETURN FEE 305.00 4 FEDERAL CIVIL SERVICE -RETURN OF PENSION 1,681.56 TOTAL (Also enter on Line 10, Recapitulation) I; 15,965.59 If more space is needed, insert additional sheets of the same size. Comments ` jPlease contact Michele Shughart at Ext 3095 with any questions regarding your billing statement. Thank you --- ~ r .~ •i •~ ~ r $0.00 $1,594.80 $2,564.34 $0.00 d $0.00 $4,159.14 Balance Forward 09/30/11 - 09/30/11 rt Check # rt ~l I y~ ~, 09/30/11 - 09/30/11 rt Check # rt n ~ 09/30/11 - 09/30/11 rt Check # rt ~ 10/01/11 - 10/08/11 Patient Liability TOTAL BALANCE DUE: $5,407.51 $5,407.51 $(6,379.68) $11,787.19 $414.51 $11,372.68 $5,965.17 $5,407.51 $(1,248.37) $4,159.14 $4,159.14 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC SARA S CROSSLEY 803018 pennsylvania DEPARTMENT OF PUBLIC WELfA Rf February 7, 2012 MONROE E CROSSLEY JR 440 BARBARA DR MECHANICSBURG PA 17050 ~~~ ~f ~~~~~~~~~ It' ``W Re: Sara Crossley /CIS #: 870280460 SSN: ###-##-3474 Date of Death: 10/09/2011 Dear Mr Crossley: Please be advised that the Department of Public Welfare is attempting to recover the monetary value of any and all eligible assets in the subject estate. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Your responsibilities, as the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to insure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. The Department of Public Welfare maintains a claim in the amount of $9.519.89 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely 59.819.89, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely 5.00, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment and a current appraisal, if available. Sincerely, Carl G. Rinkevich TPL Program Investigator 717-772-6258 717-772-6553 FAX Enclosure Bureau of Program Integrity I Division of Third Party Liability Recovery Section PO Box 8486 I Harrisburg, Pennsylvania 17105-8486 Pennsylvania DEPARTMENT OF PU8L1C WEi FARE March 8, 2012 MONROE E CROSSLEY JR 440 BARBARA DR MECHANICSBURG PA 17050 Re: Sara Crossley CIS #: 870280460 SSN: ###-##-3474 Date of Death: 10/09/2011 Dear Mr Crossley: This is to acknowledge receipt of payment in the amount of $9,819.89 regarding the above-referenced estate. The Estate Recovery Program's claim is satisfied. Your cooperation in resolving this matter is appreciated. Sincerely, Carl G. Rinkevich TPL Program Investigator 717-772-6258 717-772-6553 FAX Bureau of Program Integrity ~ Dlvislon of Third Party Liability I Recovery Section PO Box 8486 I Harrisburg, Pennsylvania 17105-8466 DONALD J. LOGAN, CPA, P.C. 1200 CAMP HILL BYPASS, STE 200 P O BOX 737 CAMP HILL, PA 17001-0737 USA Voice: 717-975-9733 Fax: 717-975-2804 MONTE CROSSLEY 440 BARBARA DR. MECHANICSBURG; PA 17050 INVOICE Invoice Number: 1883 Invoice Date: Apr 3, 2012 Page: 1 Duplcate MONTE CROSSLEY 5 CLAIRBURN DR.. MECHANICSBURG, PA 17050 PREPARATION OFSARA-0ROSSLEY 2011 TAX RETURNS, ESTATE 305:00 CONSULTATION ~p~ . L~ y 1 ~ 1~ ~~ , Subtotal 308.00 Sales Tax Total Invoice Amount 305:00 Ch edc/Cred it Memo N o: ZVERVIEW BANK AND ITS DPE0.ATING DIVISIONS 200 Front Stree4 PO Bax B, Marysville, PA 17053 www.riverviawbankDa.com Sara Susan Crossley Estate Monroe E Crossley Jr Executor 990 Barbara Drive Mechanicsburg PA 17050 Beginning Balance Deposits/Credits Checks/Debits Ending Balance Account Number Statement Date Page TYPE OF ACCOUNT--Free Checking Statement Summary 12/30/11 0 Credits 1 Debits OVERDRAFT / RETURN ITEM FEES 296078510 2/06/12 1 20,567.98 .00 1,681.56 18,885.92 0 i I Total for - I Total I I this Period f Year to -Date I I I I I I I I I Total Overdraft Fees I .00 I .00 I I I I I Total Returned Item Fees I .00 I I I I I .00 I I Date Amount 1/09 1,681.56 Date Beginning Balance 1/09 Other Debits Description Reversal Of 11/01/11 Civ Serv From Us Treasury Daily Balance Information Balance Date Balance Date 20,567.48 18,885.92 Balance Halifax Bank Marysville Bank 3rd & Market Streets ~ 200 Front Street PO Box A PO Box B Halifax Bank XalBax, PA 17032 a119V1~1C Marysville, PA 77053 www.halifaxbankpa.com www.marysvlllebankpa.cam REV-1513 EX+ (O1-10) `~ ~ "~ pennsylvania DEPARTMENT Of REVENUE INHERITANCE TA% RETURN RESIDENT DECEDENT SCHEDULE 7 BENEFICIARIES ESTATE OF: FILE NUMBER: SARA S. CROSSLEY 2011-01075 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. BARBARA HERSHEY, 424 S ENOLA DR, ENOLA, PA 17025 DAUGHTER 979.20 2 THOMAS GRUNDEN, 545 W CUMBERLAND RD, ENOLA, PA 17025 GRANDSON 1000.18 3 JULIE FETROW, 19 BIG HORN AVE, MECHANICSBURG, PA 17055 GRANDDAUGHTER 1000.18 4 ARTHUR CROSSLEY, 478 FRANCIS D, MECHANICSBURG, PA 17050 GRANDSON 1000.18 5 CINDY OVER, 1714 WARREN ST, NEW CUMBERLAND, PA 17070 GRANDDAUGHTER 1000.18 6 JEFFRIE CROSSLEY, 1369 YORKTOWN RD, MECH, PA 17050 GRANDSON 1000.18 7 MICAH CROSSLEY, 3780 LEELA PALACE WAY, FORT MILL, SC GRANDSON 1000.18 8 ALICIA FETROW, 19 BIG HORN AVE, MECHANICSBURG, PA 17055 GREAT GRANDDAUGHT 200.04 9 BROOKE OVER, 1714 WARREN ST, NEW CUMBERLAND, PA 17070 GREAT GRANDDAUGHT 200.04 10 VICTORIA CROSSLEY, 1369 YORKTOWN RD, MECH, PA 17050 GREAT GRANDDAUGHT 200.04 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES IS THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECRON TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. Tf1T/\1 AC DSDT II _ CAITCD Tr1TAl NI(1N_TAYARI F MCTDIRI ITIf1NG /1N I rNF ii fIF Rf\/-1 Gn0 M\/FR CNFFT I S 7580.40 If more space is needed, use additional sheets of paper of the same size. RFV-tst3 Ex+ lot-to> ~ pennsytvania SCHEDULE ,7 INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: SARA S. CROSSLEY 2011-01075 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. QUINN CROSSLEY, 1369 YORKTOWN RD, MECH, PA 17050 GREAT GRANDSON 200.04 2 CAMBRIA CROSSLEY, 478 FRANCIS DR, MECH, PA 17050 GREAT GRANDDFlUG({~ 200.04 3 KAIA CROSSLEY, 478 FRANCIS DR, MECHANICSBURG, PA 17050 GREAT GRANDDAUGHT 200.04 4 KENDELL CROSSLEY, 3780 LEELA PALACE WAY, FORT MILL, SC GREAT GRANDOIq~( 200.02 5 TALLON CROSSLEY, 3780 LEELA PALACE WAY, FORT MILL, SC GREAT GRANDSON 200.02 II ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES IS THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. 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. 1000.16 If mare space is needed, use additional sheets of paper of the same size. ~o ~.. ~, _. ~-,,_; LAST WILL AND TESTAMENT ,~~'-~o c "`- _~, OF m :~'G'J V n, _ , ~ _~ SARA S. CROSSLEY , ~ , , _- _ • D 7 ~~~ C. V' • T I, SARA S. CROSSLEY, of Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking all other wills and codicils heretofore made by me. FIRST I direct the payment of my debts and the expenses of my last illness and funeral from my estate as soon after my death as conveniently may be done. I wish to have a funeral service like that of my husband, at church and with no viewing. I would also like to request that an Eastern Star ceremony be conducted. Further, in this connection, I authorize my personal representative to expend funds from my estate, in such amount as my personal representative shall consider necessary and desirable for the purchase, erection and inscription of a suitable marker for my grave. SECOND I give, devise and bequeath the following: A). I give, devise and bequeath the following: I give to each of my grandchildren $5,000.00 and to each of my great -grandchildren $1,000.00. In the event that any of my grandchildren and/or great -grandchildren predecease me leaving issue who survive me, such issue shall receive, per stirpes, the share that my heir would have received had he or she so survived me. In the event that any of my heirs have not attained the age of 21 years at my death, then my Executor is directed to distribute the amount payable to a minor under this item to a parent of the minor to be held in trust for the minor until his or her 21st birthday, at which time distribution shall be made free of trust. B). I give to my son, MONROE E. CROSSLEY, JR., the corner cupboard which has been in our family for three generations. In the event that he does not survive me, then I give the corner cupboard to my grandson, ARTHUR M. CROSSLEY. If ARTHUR M. CROSSLEY predeceases me or does not want the item, I direct that it be given to THOMAS R. GRUNDON. C). I give my mantle clock to my daughter, BARBARA A. HENRY. In the event that she does not survive me, then I give this item to my grandson, THOMAS R. GRUNDON. D). I give the oil painting of Klearvue Farm to my son, MONROE E. CROSSLEY, JR. In the event that my son does not survive me, then I give the item to my grandson, JEFFRIE A. CROSSLEY. E). I give the set of white china dishes with a silver band and my copper kettle to my daughter, BARBARA A. HENRY'. In the event that my daughter does not survive me, then I give this item to my granddaughter, JULIE S. FETROW. F). I give my set of Pfaltzgraff China (Yorktowne pattern) and my silver service to my daughter, BARBARA A. HENRY. In the event that my daughter does not survive me, then 1 give these items to my granddaughter, CINDY M. OVER. G . I ive m red anti ue rockin ~ y y ~ chair t~ my sin, M~NR~E E. CR~SSLEY, JR. In the event that my son does not survive me, then I give this item to my grandson, MICAH J. CROSSLEY. H). 1 give all my jewelry in equal shares to CANDICE CROSSLEY, BARBARA A. HENRY, SUE GRUNDON, CINDY M. OVER, AND JULIE S. FETROW with the exception of my diamond engagement ring and Eastern Star ring, which shall be given to BARBARA A. HENRY. If the beneficiaries of my jewelry cannot agree to its division, then I direct my Executor to divide the items among the forenamed beneficiaries as he deems to be fair and equitable. I). I give all my remaining articles of personal or household use, including automobiles, together with any insurance relating thereto, to my children as survive me, to be divided among them as they may agree or, in the absence of agreement as my Executor may think appropriate. My Executor is authorized to sell any property referred to in this Item and divide the proceeds equally if he believes it is appropriate. THIRD I give the residue of my Estate, real and personal, in equal shares, to my son, MONROE E. CROSSLEY, JR. and my daughter, BARBARA A. HENRY. In the event a child does not survive me but leaves issue who survive me, such issue shall receive, per stirpes; the share that child would have received had he or she so survived me. FOURTH I nominate, constitute and appoint my son, MONROE E. CROSSLEY, JR. as Executor of this my Last Will and Testament. Should my son fail to qualify or cease to act as Executor, I appoint , of this my Last Will and Testament. I relieve my personal representative from the necessity of posting security in connection with his duties as such in any jurisdiction in which he may be called upon to act insofar as I am able by law to do so. FIFTH In addition to the powers conferred by law, I authorize my Executor in his absolute discretion: A. To retain in the form received, and to sell either at public or private sale any real or personal property. B. To manage real estate. C. To invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification. D. To exercise any option or rights arising from ownership of investments. E. To compromise claims without court approval, and without the consent of any beneficiary. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of four typewritten pages, the first three which bear my signature in the margin for the purpose of identification, this the ~g day of ,-~7j l ~ i~~;~ll±'_ 1998. '_'-`^"' (l ~ (SEAL) Sara S. Crossley Signed, sealed, published and declared by the above named testatrix Sara S. Crossley, as and for her Last Will and Testament, in the presence of us, who, at her request, in her sight and presence, and in the sight and presence of each other, have hereunto subscribed our names as witnesses. a ~.3 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND We, Sara S. Crossley, iCi~a~ ~ I>;B and ~• n~~~the testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument of her Last Will, and that she signed willingly and that she executed as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as witnesses, and that to the best of their knowledge, the testatrix was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. Sworn to and subscribed before me this /b day of ~ b~u4~y 19Q~ -'~~~/~_ Notarial Seal Angela F Under, Notary public Carlisle 8oro, Wmbadanr! County My Comm(ssion Expires Oct. 7, p000 Lltit~~.~ ~ U o, ~ ,