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HomeMy WebLinkAbout12-26-12J 1505610101 REV-1500 Ex(°°-°°~ 1~' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes oEP.a....*~~INHERITANCETAXRETURN CounryCode Year File Number PO BOX z8o6oi "~ Harrisburg, PA t7tz8-o6oi RESIDENT DECEDENT ~ / ~ ~ ' 9 SLiO Date of Birth MMDDYVYY ' / .,, 9 6 Decedent's First Name MI S H E ~ 4. Spouse's First Name MI mf O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 6. 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 untler Sec. 9113(A) between 12-31-91 and 1-1-96) (Attach Sch. O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOUIFD SE DIRECTED T0: Name -, a e T I _ mb e ep one u ~ ~> b .. w ,~ T . ,: ts~ `_7~ ~ d~9~ ~:x: Irl CJJ Y,•J S]7 i) -;'7 First line of address ~~ ~ --~ ~ ca ~,., t 6 c ~ :o; cts ~E-R ao +~~ ~ r, ~ n ._ Second line of address :- + ~ ` i; ,, rr7 // gg r.~ Uo ~ City Of Post OffCe ~ ~~ State ZIP Code DATE FILED ~~/r1~'C~/4yN~/C`iS~u/R,G: ~ >'1~ ` ~./7.,pf'~7~3 Correspondent's a-mail address: C QS/1 /~/cfs 3 ~ C'OdICQ.SL i /JG( Under penalties of perjury, I deGare that I have examined this return, including accompanying schedules antl 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. SIGNATUR F PERSON F~ P$ ONSIBLE FjaR 1=1LING~ DATE ADDRE S'BE Y S k/AdC.f~E' ago N. 29~ ist., C4,Mp N~%/~ PIf X70// Side 1 1505610101 1505610101 J ~~ PLEASE USE ORIGINAL FORM ONLY J REV-1500 EX Decedent's Name: ~fP~hCh '+. Decedent's Social Security Number 1. Real Estate (Schedule A) ..... ....... .......... ........ ......... 1 :, ~ ; t ?:~ ~;u, 2. Stocks and Bonds (Schedule B) ....... .......... ......... ......... 2 `t .~~.. b -. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................ 4. ... .r r. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... .. 5 S = ;x 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... .. 6 ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly 4 ~ 7 (Schedule G) O Separate Billing Requested..... .. :.. '&: qi 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. ` 9 Funeral Expenses and Administrative Costs (Schedule H) ................ .. 9 . 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... .. 10 ^ 11. Total Deductions (total Lines 9 and 10) _ .... ............. )f 3 ... 11. ~~ 12. Net Value of Estate (Line 8 minus Line 11) ........................... h hi . 12 ~. ~ 13. c Charitable and Governmental BequestslSec 9113 Trusts for w . 13 x an election to tax has not been made (Schedule J) - - ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ . ~ ~ ~ is 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. .... 14. ; TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. 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 i6 at lineal rate X .0 17. Amount of Line 14 taxable 17 at sibling rate X .12 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 150561~1~5 O Side 2 1505610105 1505610105 J REV-1500 EX Page 3 File Number ~~~~~" /~Q Decedent's Complete Address: DECEDENTS NAME ~tCiDI1CA ~'. W2IIAGG STREET ADDRESS - - - -- d~o n~, a9f~i St. --/7~ (iQ/1/~ III _ _ _._ ~ STATE PA _ ~P ~7OII Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments __ _ O ___ B. Discount Q 3. Interest 4. If Line 2 is greater than Line i + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (1) ~•ZO Total Credits (A + 8) (2) (3) 77 (a) 0 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) f ~ p, Y9 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; or ................................................................................................................... .... ^ 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" orpayable-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. 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 'rf 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)]. 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. ~_,s~a.,,.4n SCHEDULE E COMMDNWEAL7N OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESIDENTDECEDENT PERSONAL PROPERTY ESTATE OF Wa//ace, gStepleti .~ FILE .zr- r/- ~~'o InGude the Droceeds of lingation and the date the proceeds were receHed q'the esta~. Ail property jolmly.owned tNN the right o(sunivorshlp mutt M tlisclosed on Sehetlule F. ITEM NUMBER ,y DESCRIPTION /r VALUE AT DATE 1. i¢S.s0i1`er~ ~~p~ /~'~ ~,Oi'a/d4,/ a(' Cl4SSrL ~/~Q/y~u OP DEATH Csre /,Sf Qii4r ~p~iJe~/~'a/~tEs afiS2~lied) a~ u. S. T.•easNry ~aFund ah oho// C'/,a~_e~ /~fo !~, 3• r~r,s C'orp., C'/•c~rf D,'s6ursunent- D~'~.tsf kft~c ~a~r (see ~lirihfauf a~tar.~) `f. aOO 8' Clerro Iet ~r%/eradv ~r/rial No, aGC ~K 13A1 a,g/~ 7ootio ~ Fold to L, /~. ~m~"1fi, .<nC.; ra ,/ra</e-%n Creel."t (J=n~ Notes % avol~/ C~Afitsioh, ~ affacled ~I~per~io~,.~ /,'s/s ~e Cusfnmer /i~ (' ry /.~l/eh !ve//act, He ~:s J`~Pe de~edehfs bmlr°w~- w!~ ai eq~admip~s/ra/Srx in !'~~•-J'J wa: /y7 Gt~~i ~r krallef a,/ ~,/v.~() (If more space is needed, TOTAL (Also enter on line 5, Rerapitulalion) I S sheets of the same size) ~, 6 90, ov ~ /,596, ca ¢S 3 b, 77 X2.2, ODO. o0 saz ~~ S '~ `~( ~ 2 ~ CL•45 S rL ~/y r~s~ G n I '~ (~~ qql- s5 /,3t=JAG svo /2 C- ~. ~USS~~'t~ `~3~ (2~ , ~ ~~F~s ~~~~z~~~ ~ n1.S3uL-~vai /S ~AlZ~Ll/tl ~1~~ -e-- Jug m ~~- 1~~~~.2 ~~ ~~~- -mot xr~~rs ~--~ a ws< I So O `~ ~G ~ Oct ~ ~~~ .~v ~ /So.D~ ~ 2~~. o~ ~ 20 S ~ z~~ ~' 3ia ~l2 SY~ZS ~~.~-K.~,tJ ~2D t~ T~..~ Z ~i ~`~ /Cf7~--~~O,C/ p~ l~{ SUBJECT TO APPROVAL BV MANAGER IFT7W2666CEA31 ENTER MY ORDER FOR ONE ZOIZ TYPE PU CUST EMAIL 1100 Market Street, P.O. Box 138, Lemoyne, Pa 17043 ~' "' ' ~ ' "' "" ~„ _ Fax (717) 761-3951 _ MAKE FORD F-2.50 MODEL coLOR LO T12058 _ STOCK NO. _. ' X Tretla-In-I Year zCrV119 Make fUt(U Motlel F_I5D Cd RA Se INo Slack N I t G V 5tlH 1 TNe No. LkanBe Np F Trade-In Yasr Make 0 E~+o~d SILVERADO da GRAY serklNm Stork No. Tale No. Deerre No. 1910.00 N/A 1000.00 00 nnr 7DDY1Y3 °° WESTFIELD INS `°"~Y"° 7175332166 M On Tratle To FACTORY WARgpNiV - TM kpory warrenry conatlnnea ell IN pa wemmka wilh ,. vnllDe 1 the & Re iStMdtlOn Fee m1s uarvueme. rna saner nereby axpreasrv diadelma all waaenn.a, elmer spa=t m lnm eBk d Online Dealer Service Fee enr knelled werrenly d man»antaDiliry p flM1,ass fw a axprescad or impikd kICIW'elg Penkukr pumosa, arM Me seller ndMp assumes Luxu Tax nw aumohzec any doer parson 10 assume for n •^y liabnny in connactbn wm the ulm d mlla NeM'aema. ^ USED CAR WARMNIY-lJSed Car is evrered by a linxNd v,en.ny ur.Md n arparan dwlanall, TOTAL ^ AS IS - mla moor venlNe Is sold "AS IS" wnnout any wsnemy anMr sxpreeseo w impliatl TM RECEIPT NO.: $ pumneser will bear ale entbe expanse of repellirg w correcting elry Oded Mel peeenty axisk w that RECEIPT NO.: may o~er.n Ina ~ank,le. $ 5000. D~ PURCHASFJi'S BALANCE DUE: $ SIGNATURE X USED CAR CONTRACTUAL DISCLOSURE STATEMENT THE INFORMATION YOU SEE ON THE WINDOW FORM FOR THIS VEHICLE IS PART OF THIS CONTRACT. INFORMATION ON THE WINDOW FORM OVERRIDES ANY CONTRARY PROVISIONS IN THE CONTRACT OF SALE. •m Federe/ mgWetbnsyequire YO/ to state the odwneler m" . . ........ ...."`-"'._ ___" I hereby state that the odwrreter mdeege indicated on the vEJIl./B sold of Nle rime of varLSler. CHAF~C~$ BEGIN ON - O2 ~ 12I I Z l./{JFI TO BE REPAID TO 1~ MYes 2. IN MONTHLY Total Mileage Unknown INSTALLMENTS OF $ EACH ON SF1E ~~ 9. Total Cumulative Miles Known to Be Over 100,000 THE MONTH BEGINNING 1 L DAV OF 20 X Cuatonlmr agrees Ihet Mk pdn IndllMe eM d tlIa Ierme entl cmntlltlma m both Ne face erq ravens FON LB SMITH FORD LINCOLN, INC. side hereof. Met Vtls oedp cerKda arM wl»leades arty prior egraemep eM as d ale deM hereof B I NGNAM , STU complaes Ina porrlvlen Mel exduahre ektament d Ina terms d egreemaM relating b Ne augett SALESMAN meners covered hereby. Thle prier atoll nd beoorne bYpMa IMY rme Ov ge tkak h' APPROVED LB. SMITH FO NCOLN INC ~ a""'onzae fBOfBSB"kwe vm me a,ammer a m' erad end Iun nem TIIS piOER IS NO UNLESS mnV bmm Oplwm rmpakl d m CmpV d glk W(IVmd agrnd by Ulnprlied 4991 pe ACCEPTED HERE 11 IIVB M BV Win wnden notice d can Iietlon fo Ina dealer. Cu mmer by hie execution of thk older ecknowbdgss that he by I ~ er~ ai Pe he9 mcdved a true NPY of this Omer. CREDIT APPROyFn ~~~~ ~ CUSTOMER SIGN CO-SIGNER SIGNS X vin ererz+ AOARKII Ima man, RERtYP EX•(t9p COMMONWEALTH (~~= PENNSYLVANW INHERITANCE AK RETURN RESIDEM PL'CEDENT ESTATE OF SCHEDULEF JOINTLY-OWNED PROPERTY Wa/,/ace, ~tep~tn Han assetwas madejoint vrithin one year ofthe decedem's date of death, k must be reported on Schedule G. SURVIVING JOINT TENANT(SI N4ME ADDRESS abo ,v. a9,~ ,rt B. C. JOINTLY-0WNEO PROPERTY: RELATIONSHIP TO DECEDEM MOlhC,Y ITEM NUMBER LETTER fIX2 JOINT TENPM DAT= MADE JOINT DESCR~TN7N OF PROPERTY Indde name dananoal inetiLtion and yank a¢pnl numbers similar idanfiF/ing pumps, Attach DATE OF DEATH %OF DECD'S DATE OF DEATH wed fprjpujtlY'pab real e5laEB VALUE OF ASSET INTEREST VALUE OF OEGEDENIS INTEREST 983 Sw4 3ssS 0 ~ CS CG YR~K4r<a0/! /e/ftr 4#ac/ae f) ~ 6 4 &, 9 / Sofo ~1,&''i9,5`6 a tStivi~,s sheC/: No. ~f0 8 ~1 .3L-DO 020.3/ S'O~o ~rp, /G ,M ,, - ~SeG Y4~k4nOp ~C~/~/ gf//LLLIi~q~) _ TOTAL (Also enter on line 6 Recapitulation) I S a, 8 5 9 6 2 (k more space Is needed, insert additional sheets of the same size) zi- i~ 9~v © 1~~1 ~lilt~ 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Charles E Shields III 6 Clouser Road Mechanicsburg, PA 17055 Re: Estate of Stephen Wallace Social Security: 191-46-1436 Date of Death• July 7 201 ] Phone 888-502-0349 Fax (302) 934-2955 September 21, 2011 Deaz Sir or Madam: Per your inquiry on September 12, 2011, please be advised [Flat at the time of death, the above-named decedent had on deposit with this bank the following: 1. TypeofAccount Account Number Owrtersidp (Names of) Opening Date Balance on Date of Death Accrued lmerest Total Checking Account 9838443555 Betty Wallace Stephen Wallace OlA?4Po5 $5,698.90 $ .01 $5.69891 For any additional lnrormafion on the above accounts, including ownership and my changes, closures md/or reimbursement o[ [nods, pkave®n the liigbinnd rack OIDre et 71717.737.3322 We were unable m orate ooy sate deposit box for Ne above-mentioned decedent This letter does mt mdode any aoronom m which the deceased may base been listed as Power ar Attorney, (.ltslodian of Ihdform 71ar~ers, Repmammtivv:Payee, orTrumee under a Written Agnsrnmt Sincerely, Tammy Spencer Adjustment Services St MEMBERS 1'° FIDF.RAI, CREDTT UNION PRIMARY OWNER: SAVINGS ACCOUNT' Account Number/SUffix Date Account Established Princpal Balance at Date of Death Accrued Imerest to Date of Death Total Pdndpal and Acemed Interest Name of Joint Owner Date Joint Ownership Established LOAN ACCOUNT: Account Number/Suffix Loan Type Loan Collateral Date Loan Established Principal Balance at Date of Death Interest Rate Co-Borrower 'Loan does not have life coverage. Betsy S. Wallace 408436-00 o1/zanon $20.31 $.00 $20.31 Stephan A. Wallace 01/24/11 408436-01• Used Vehicle 2006 Chevrolet Silverado 1500 01/24n011 $22.948.00 5.99% Stephen A Wallace M ERS 1~ FEDERAL R NION Qn~ ~ +~-- anielle A. Kline Lending Insurence Support Specialist September 16, 2011 Estate of: STEPHEN A WALLACE Date of Death: 07/07/2017 Soelal Seturlty Number: 180.70-0862 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org - , ~ SCHEDULE G coMn+oewe«n; ~ =ErNSnvaNm INTER-VIVOS TRANSFERS 8 INHERIT"NDE nx RI TURN MISC. NON•PROBATE PROPERTY RESIDENT I'F CEDI-M ESTATE OF ~~QI~(aC.'~' StepbP.~ iQ. a/- ~~-95ro Thfs schedule mur he cornpietei and filed'rf the a~wer to any of questbns 1 through 4 on>ne reverse side of the REV-1500 COVER SHEET s yes, T--- uexHiHiuXa OF PROPERTY _ ITEM NUMBER ixa!ns ~x-rnuE Ci ixE*s"xs~sa,ixsia aeunoxwn.aoECSOSxrrugixe wrz or.nnxsrEa "ar"c""cow a~rxE Oe¢o rae~¢srnn:. _- DATE OF DEATH VAL EOFA %OF DECD'S INT REST EXCLUSION TAXABLE VALUE 1. l~r~s Corp,-~l,'.n o~ ~mer~ta Re~'reincnt erwrea.e h eeoKnt. jE Th.'s is ~lrodia/eq~ {or ir~FiPrm- Assossrrblt / QT7G~tal G/iSCl05q~ P!lrnp5t•5. 1~CCeq~~ /a/KC i5 _ was /ess /fiam 55"years of aye afrr/ ~`'° ~ had rw ~;ghts of w: J1,drnw</ u~,f~okf SuhslYCnf~' ~c~ta~. ~0~ Or /0997 i5 a~uclaer% TOTAL (Also enter an Iine 7, Recapitulation) I S ~ °~D more space is Form 1099-R CORRECTED it checked I' PAYER'S name, street address, city, state, and ZlP Code 1 Gross tlis[ripution OMB NO. 15x5-0119 Distributions From ARIS CORPORATION OF AMERICA Pensions, Mnuities PAYER ACCOUNT 3966.99 , Retirement or 2a T 2011 Profit-Sharing 270 WALKER DRIVE auDleamdunt Plans, IRAs, STATE COLLEGE, PA 16801 3966.99 Form 1099-R Insurance COntraCt3, etc. ?.1/ TaxaDleamount Total copy Q not determined tlistribu[ion }( PAYER'S federal identification RECIPIENT'S ldentifiw[ion ember number 3 Capital qab pnclutled 4 Federal income tax Report this inCOme on our inbex0a) wimneld y federal tax return. ff this 20-0199732 956-97-1630 $ 693.90 form shows R ECIPIENTS name, address, and ZIP croda $ EmployaecontriDUtions d $ Natunrealizetl federal Income tax withheld in Estate of Stephen Wallace /Dacipnab Roth rnnMDUtions or appr.r3ationb am io ef Ri bOX 4 attach insurance premiums p z sacw es Y , tt1iS COpy t0 c/o Betsy Wallace $ $ your return. 260 N. 29th Street 7 omaibntron tRa 8 anar Camp Hill, PA 17011 coda(s) SIMPLE This iMormation is 9 $ being tumished to 98 Your persvntaga of torsi 9b Total employee ronmbe. the Internal RBVBOOB Service. dlslaeetbn $ 10 Amount aliocapla to lRR within 5 yeaza 11 1st year of tlesip. ROtn contrl D. 12 State tax withheld 13 State/Payer's cbta no. 14 Stab tllsWDudon $ $ $ - Accountnumbar(saeinstructions) 1$ Loral ux wannam 16 Name ollorality 17 Loral tlistribution $ $ JWMumper001 - $ ---------- - _ . - - - - -- $ MGA Oepar[ment of the Treasury--Internal Revenue Service Form 1099-R CORRECT ED 'rf checked PAYER'S name, drwtadtlress, city, stab, antl ZIP CODA 1 Gross dis4ipution OMB NO. 1515-DH9 D{$trlbUt{On$ FrOnl ARIS CORPORATION OF AMERICA Pensions, AIInUif18S, PAYER ACCOUNT $ 3466.99 Retlrement Or 2U11 Profit-Sharing 270 WALKER DRIVE 2e Taxable amount Plans,IRAS, Insurance STATE COLLEGE, PA 16801 $ 3966.99 FGRR 1099-R COntraCtS, eTC. ~ ~ TalmDle amount Tobl copy 2 not dalarminatl dlstributlon $ ' PAVE WStetleralitlantitiption RECIPIENT'S FII@ tills COpy hum Dar ltlentHlcatlon number 3 Capiulpaidpncwded in box 2 ) 4 Fstleralincomsbz with year State a wibneltl r sty, Or focal 20-0199732 956-47-1830 $ $ 693.40 income taX return when RECIPIENTS name, atldrecc, and ZlPCOtle $ Employse contd DU[lona 6 Net unrealised , n;quired. Estate of Ste hen Wallace P /oe.ltputee Retn apprecbebnin conttllwtiona or employaYS Securities insurance premiums c/o Betsy Wallace $ $ 260 N. 29th Street 7 oisMDutlon mu 6 an.r cows( SEP/ Camp Hill, PA 17011 SIMPLE 9 $ 9B Your percanbpe of rota ~ Toblamployea conViDS. dictd DUtion $ 10 Amount albraDN LO IRR WIInIn3 yaMe 11 fat yearof tlaay. Roth contrib. 12 Stab bx witnneltl 13 State/Payola ebb no. 14 Bbts tlismlmuon $_ _ _ _ _ _ $ $ $ $ Attount number(eealnsVUC[iena) 1$ Looltax wi[nMltl 16 Name ai locality 17 Lowltlbtributbn $ ---------- $ JFIMumper001 ----------- MGA Department of the Tmasury--tntarnal Revanus SerWn REV-1511 EX+1+0.061 SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINiSTRATNE CO5T5 RESIDENT DECEDENT ESTATE OF FILE NUMBER -,/allau, ~te~hcn /~. a/-//-910 Debts of Decedent muss be reported on Schedule L ITEM A. I FUNERAL EXPENSES: //'' rmvurvr 1. /Yt yEhS - M~ rh ar F.n P.-A.I n DINE-, DF ~¢,~yy~ Nr~~i ~ ~~ 7/.S / O~ B. ~ ADMINISTRATIVE COSTS 1. Personal Representative's Commissions QQ - Name of Personal RepmsentatNe(s) SJ~U S W4/~QGG (,J,p/YEp Sbeet Address abo N- Zrf~Yj~__-__ cdy - ~~hjn /l/.%/ State P.~ zip /70 / / _ Year(s) Commission Paid: 2. Attorney Fees G'~irtr~e$ ~, ~ilGla/S ~ // O J /"i 00 3. Family Exemption: (If decedenCS adtlressti+s no[ the same as claimant's, adach explanation) Claimant __~~ti J__~A/~/jRCG,/. ~ ~~/~,~j~.~~',' Street Address/n~~~~ a~ /{~ aQ/H as(• - Ciry (.:LL/Jl~i7 /~.// state ~ Lp /7D// __ ReWtionship of Claimant to Decedent ~ j~yy,,..// 11 L. 4. Probate Fees Qatd Dh~i/la~ /53/~L 6~ .N70/'T CClfi~Cd/g,s ¢ 68. So 5~ Accountant's Fees ~/~ ~~oy j {'R~nesfvek f+~ Ateounh' t~ssx~n~+es ~ B. Tax Rehm Preparer's Fees ~t~. (~ / OQ.OD ~. F,i,~~ .F R Gnunc:a,/~on A~d.1i f7'onr/ /o~~bQ.It f et f j:oo 9. ~•%n Fee ~.- 70, oD Ts/iei; ~~ ~LeJ/ittn ~/$, 00 /o• t'Teimbursemw~fs z<o G1¢rles F ~,alcls'~ ta16.So (It more space is needed, insen additional sheets of the same s¢e) TOTAL (Also enter on line 9, Rerspitulation) I S , r, DO RECEIPT FOR PAYMENT GLENDA FARMER STRASBAUGH Cumberland County - Register Of Wills One Courthouse ScTuare Carlisle, PA 17013 WALLACE STEPHEN A Estate File No.: 2011-00940 Paid By Remarks: BETSY WALLACE CJ Receipt Distribution Receipt Date: 9/02/2011 Receipt Time: 15:08:31 Receipt No.: 1066883 Fee/Tax Description Payment Amount Payee Name RENUNCIATION 5.00 CUMBERLAND COUNTY GENERAL FUN Check# 4897 $5.00 Total Received......... $5.00 RECEIPT FOR PAYMENT GLENDA FARMER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 WALLACE STEPHEN A Estate File No.: 2011-00940 Paid By Remarks: BETSY WALLACE CJ -- ` -'------------------ Receipt Distribution Receipt Date: 9/02/2011 Receipt Time: 15:07:57 Receipt No.: 1066882 Fee/Tax Description Payment Amount Payee Name PETITION LTRS ADM JCS FEE 20.00 CUMBERLAND COUNTY GENERAL FUN AUTOMATION FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D SHORT CERTIFICATE 5.00 20 00 CUMBERLAND COUNTY GENERAL FUN ---- . ---- CUMBERLAND COUNTY GENERAL FUN Check# 4895 $ -68 50-- Total Received......... . $68.50 Myers-Hamer Funeral Home, lac. 1903 MARKET STREET CAMP HILL, PENNSYLVANIA 17011 Robert H. Harner, Supervisor Phone: (717) 737-9961 Dustin R. Baker, Funeral Director STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are only (or dmu hems that you ula¢d or that are rryuired. IFwe arc rryvired by 6w or by a cnmtt<q or aemasory m use any irons, we will aplain in wilting below. Uyon sd¢ud a fweral ~hn mry requirz embaming sydaaf funeral withvie-wing, you may have so pay for embalming You do nos have ro pay for cmbalmingyou did nor approve if you xlmed arnngemmaQs such~ az a direct\\crt~~mmmn or immediarc burial. 1(we charged for embaming we will aplain why Mow. For rlu Service of~~[>~(\ ~A /Al~(~r_f = ~a -i-~wal Charge A. CHARGE FOR SERVICES SEI.ECTEP. 1. PROFESSIONAL SERVICES . Smim a(Funcnl Dirmor/SnR .... _. . $ j~~. Embalming ........................ .8 Othv preparauon of body Dressing & Cosmorology ............ $ ~C Cukv Plammcm .................. $G ' SUB-TOTAL OF PROFESSIONAL SERVICES .....A7 f~a~, 2 FACILITIES AND SERVICES Ux of 5cifaies and urvicv for viewing (Vsirarion/Wake) ....... ....E G Uu of 6dities and urviar for Funad ceremony _ ............ ....E/~ Ux of hciliriv and unites for Memoriil Service .............. .... E~ Uu of cquipmcm and urvicv for graveside service ............... ....f/~ Ocher use of htikrics ~ceAm ._... ........_... nn..l .. S '*~ Preparation Room . _ . Y ... Ea IYl " SUB-TOTAL OF FACIDTIES/EQURMENT .... A2 $_ $. AUFOMOTIVE EQUIPMENT Vchidc m vans(cr remilns m Funvil H omc Lord ......... _... _........ ... E Harse{Casket Coach) a L«al ..........._ __.. .. _.. ....4G Flower car or Floral duposkion L«il ......................... ...5~ Lad ruldvgy nr Lod ......................... ~~ ~~ '~ ~~ ...$ LDC:d 8 -_ _. E $ SUB-TOTAL OF AUTOMOTIVE/EQUIPAfF.M „ AE $ \ K I , TOTAL OF PROFESSIONAL SERVICES, FACII.TTIES AND AUTOMOTIVE ~ r~ ~ ~ EQU]PMENT ................................ A f.ar-F'_s.. B. CHARGE FOA MERCHANDISE SELECTED; Casket ......... / _ ... _ ............. Y (Dcunpsion) Oshcr Rcmpradc ............... _.... E (oexription)CMr~c4•pA Oq{ Omv budil wn¢inv ................ $ (Dcuripsion) Acknowkdgunem nrds . ............ _ E Rcgismr book(s) ......... . ...........E Memory folders ... ..... ..... $ Prayer arils ............. ........5 Temporary grave marker ............... E Burial dashing ..... _ ............. _ 8 Other clothing -. -___ E E Dase of Cremaion um _. _......__. _E~ (Desviprion) Um Vault .._... _......... _._. ..$ ~ (Demripuoo) _ OTHEA E~ g TOTAL MERCHANDISE CFI FCIED . I./^ ........... B 5~,~ C. SPECIAL CHARGES: Forwarding of remains to E (Fvncril Home) , Remiving o! remains from b (Funeril Homc) _ Immcdiarc Buriil ................... .E_ Dirm Gcmation _ ... .. ........ • E mss,, ^,~ ,, K~ ~ ~ E P SUH-TOTAL OF ECIAL CHARGES . ((Cm ........... C S~/_LW'w D. CASH ADVANCED: Opining Grave ............ Newspaper Notiv-Lod ~41:al~G.B ~pO Newspaper Novice-Ouoo(-gown ...... .. E AirGm ............................ . $ Clergy/Mass O~ ring ................ .8 Certified Copi fr~e Dn ~th Cmifinrc ~ a~Q P 4~__C~ vch .... . $c.s ~,. ~ Flown .............. _ ......._ .. .5 Vault Servcc Charge ....... _........ . $ Organist ._..._. _ .:. ........... _ .5 Soloist ......... _.........__..... .$ Alsar Scrvicv ....................... Coroner Fcc ........ _..._........ _ . %. .$ Milagc .. _ .......... _ ............ . E SUB-TOTAL OP ADVANCES ............... D fJL` _I~O We charge you For om urvicv in absaining fpnijy rmh advanm r5u arc an,,.Frdap) SUMMARY OF CHARGES A_ Pro(essiorul Services, Facilities aril Fquipmrnt, and Ausom«ivc Fquipm<m ._........_.._..........41nc~, B. Muchandiu ........................ g 00 G Spcciil Charge ....... $yi'YJL y00 ................. $ L~~2~W~ D. Cuh Advances ................ TOTAL OF ALL SECTIONS ....................... Spt~=JS .~ PAID AT TIME OF OR PRIOR TO ARRANGEMEN'T'S .......................... S BALANCE DUE .................................. f_ REASOAL FOR EMBALM/NG I(any Uw, cunerzry. or crtmnory rzquiremenn have rzquirzd the pmchax of any of ¢eany a itc~¢~ ~^ ~em is explvned trlow. C/C 1 ~.` I agrv that 1 have eaami~ed the items ofgoods and urvim xkved above andfomd shun ro he wrrar and according m the arrangemenu 1 have requesaed. 1 xknowlcdgc recaps of a wpy o(this Snrcmem ofFmvil Goods d Smites"., ad. 1 ¢p shat I have sulbciem finds availabh for paymem of she mh price for she goods and unto ulased. 7al~oa~grr~ ro make paymcm o(E shin _~~ daya 1 agme to k jointly and xrenlly liable sh anyone du why signs bebw A lart charge o(E / ya[n per momh amounting m wnO per ynr will be a God ro the m aid balanm be innin - a~~,~L pym rhu agrvmrnr. 1 wrrl~) aLw~~ ~-a she Fwerel Disvsor all reasosu a ss paid by the Fonml Diucror sn wllm amounas Lowe wdrr shu agr¢mcn~TMuscosss may include anomeys'(ees, court cos dothv ros¢Arry additionil units or merchandiuordemd or requv¢d afierihe dareof this agreemem wiRkmnsidered pot of this agree e d t toss on the (nil bill or srarcment. _ J v l Ol (seal `) IDar (Purchaur) (Dccmad unml Diraror REV-7512 E%+(12-03) SCHEDULE 1 coMMaNwEAtTH of aENNSnvANiA DEBTS OF DECEDENT, IN RESIDE TED ~EDENTRN c1 / M,IORTGAGE LIABILRIES, & LIENS ESTATE OF ~~ /~R~G~ Q'/f~/IGh /Y. FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH ' Pa. '~Pr, sf Revenue ~;r C,(oSC eaf P.¢ yo .?oii f~ 6 . o0 d. /11tnf6ws /st /edtrR/ C/2?7;~ /tnivn, fctiic% Lean .lceouitt X0000 ~o6f~f 36-ODO/ (see ercdifors no><:~e of e/ain, 2/fachtd~ t P/mst a/so set Sfahmu-f ~ienr Aluxkrr /st ~~Z, 9Y8.oo affaohed wti:c% s~ioras ucr4cs/ d.T/erect a~ae .~ a:o.d. o.r fisfeq~ /~eiein 4s ep~osee/ to sma//ir RMOUnt on ~~y ~ Su1~Mi5siarl sF C/oi/H ~o D/~ihtn,s'L'Okrt~ TOTAL (Also enter on line 10, Recapitulation) = ~ 2, Qjr Lf DO Qf more space is needed, insert additlonal sheets of Ne same size) St MEMBERS 1s1 FEDF.RAI.CRFDIT UMON Q~I~~ CREDITOR'S NOTICE OF CLAIM ESTATE OF STEPHEN A. WALLACE, DECEASED ESTATE FILE #21-11-0940 To the Orphan's Court Division: Index and make proper entry in your official records of the claim of Members 1" Federal Credit Union in the principal amount of $22,36833, Vehicle Loan account #0000408436-0001, against the estate of Stephen A. Wallace. This claim is filed pursuant to 201'a. C.S: section 3532. The said decedents last known residence was 260 N. 29'" Street, Camp Hill, PA, 17011, SSIN 180-70.4852, died on July 7, 2011. Notice of this claim was provided to Betsy S. Wallace, Administrator for the Estate on September 14, 2011. A copy of this claim is also being provided. ERS 1~ FEDERAL CREDIT UNION Denise A. Wolfe, Len g Insurance Support Supervisor September 20, 2011 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania ]JOSS (800) 283-2328 wwwmemberslscorg REV-15+3 F_Xa !9-001 SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~a11AGe~ Q7L~/J~Ln fr. FILE NUMBER 2 _ // y~o NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) AMOUNT OR SHARE OF ESTATE 1 TAXABLE DISTRIBUTIONS [inchrde outright spousal distributions and transfers under , Sec. 91is (a) (7.2)1 '. ~~3y 5. WQIJace ~.(o~i¢r- ~DO~o ago N. aq K, S~ c~~ y;~~ ~,~ , ~o„ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET It NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART D -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEET $ pr more space Is neerted, Insert additional sheets al the same size) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 ]1280601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX111-961 NO. CD 016964 WALLACE BETSY S 260 N 29TH STREET CAMP HILL, PA 17011 ACN ASSESSMENT AMOUNT CONTROL NUMBER gold ESTATE INFORMATION: ssly: 1so-7o-asez FILE NUMBER: 211 1-0940 DECEDENT NAME: WALLACE STEPHEN A DATE OF PAYMENT: 12/26/2012 POSTMARK DATE: 12/24/2012 COUNTY: CUMBERLAND DATE OF DEATH: 07/07/2011 REMARKS: RECEIPT TO ATTY SEAL CHECK#116 101 ~ 540.97 TOTAL AMOUNT PAID: INITIALS: HEA RECEIVED BY: 540.97 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS CHARLES E. SHIELDS, III ATTORNEY-AT-LAW 6 CLOUSER ROAD Comer of 7Yirulle and Clouser Roads MECHANICSBURG, PA 17055 GEORGE M. HOUCK (1912-1991) December 24, 2012 Register of Wills Cumberland County Court House 1 Courthouse Square Cazlisle, PA 17013 Re: Estate of Stephen A. Wallace No. 21-11-0940 Deaz Register of Wills: TELEPHONE (717) 76G0209 FAX (717) 795-7473 Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Stephen A. Wallace Estate as well as Check No. 0114 in the amount of $15.00 for the filing fee, Check No. 0115 in the amount of $70.00 for additional Probate and Check No 0116 in the amount of $40.97 for the Inheritance Tax due. Thank you for your kind attention to this matter. Very truly yours, ~j r ~~vy / Charles E. Shields, III Attorney-At-Law CES/mjj Enclosures c o ~„ =., ~ rn m ro ^ ~ n o b. r r~r;~ rv ;,,m . T Y'7 ~ .% ~~~' ~~ ~ ` r ~.1 L.l ~e ~ ~'~~ ~4~ (' ~2) ~, .. ... ~ C% "U : s, ~~ ~ ~. N -n