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HomeMy WebLinkAbout04-1075 CQMMONWE TH OF PENNSYLVAN A REV 1162 EX(] 1 96) ©EpAR TFT~EN~ = REVENdE PARR SBURG PENNSYLVANIA RECEIVED FR INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004657 RADCI. FF DAVID H 20 ER~: :)RD ROAD SUITE 200 LEMO'~ NE, PA 17043 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 $5,000.00 ESTATE IN IRMATION: SSN: 18401 8168 :ILE NUME R: 2104-1075 DECEDENT NAME: ZERBY JOHN GARDNER DATE OF F ~YMENT: 11/23/2004 POSTMAR DATE: 11/23/2004 COUNTY: CUMBERLAND DATE OF ATH: 08/23/2004 TOTAL AMOUNT PAID: $5,000.00 REMARK J ZERBY ECK# 127 INITIALS: VZ SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS Rtv-l500 EX + (\-00) W. '.' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-ll601 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) I- Z W C W o W C REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT ZERBY J. GARDNER SR. DATE Of DEATH (MM-DD-Y,ar) DATE OF BIRTH (MM-DD-Year) OFFICIAl USE ONLY FILE NUMBER 5 ..L.L-~..L __LQJ_ COUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER 1 84- 0 1 - 8 1 6 8 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER w !C ,,-co u"''' w~u :J:o::9 u.... .. < 08/2312004 10/26/1913 (IF APPUCABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) JANE M. ZERBY 00 1. Original Retum o 4. Umiled Estate 00 6. Decedent Died Testate I_"""Y~\'M) o 9. Litigation Proceeds Received o 2. Supplemental Retum D 4a. Future Interest Compromise (daleof death after 12-12-821 00 7. Decedent Maintained a living Trust (AltachcopyofTrust) D 10. Spousal Poverty Credit (dale ofdeath betoveen 12-31-91 and 1-1-951 D 3. Remainder Retum (date ofdealh prior 10 12-13-82) o 5. Federal Estate Tax Retum Requirad _ 8. Total Number 01 Sale Deposn Boxes o 11. Election to tax under See. 9113(A) __ "" 0) THISSEcnON MUST BE COMPLETED. ALL CORRESI!ONOENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS DAVID H. RADCLIFF ESQ. 20 Erford Road, Suite 200 FIRM NAME (U AwI<able) RADCLIFF LAW OFFICE P.C. TELEPHONE NUMBER 717 236-9318 Lemo ne PA 17043 ... z w Q Z Q .. co w '" '" o u (1) (2) (3) (4) (5) OFFIC~SE ONLY C' ] CJl (r: z o i= <( ...J :J l- ii: <( o w 0:: 1. Real Estate (Schedule A) 2. Stocf<s and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Bole-Proprietorship 4. Mor1gages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly OWned Property (Schedule F) o Separate BUllng Requested 7. Inter-Vivos Transfars & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Admin.trative Costs (Schedule H) 10. Debts 01 Decedent, Mortgage Liabilities. & Liens (Schedule I) 11. Total Deduction. (total Lines 9 & 10) 12. NelValue of Estate (Line 8 minus LIne 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for wh~ an election to tax has not been made (Schedule J) .0 :;'J ~p ~~ l::j("} <:>:::0;::, c= ::D :'J --I 0.00 .'> ::r: ::;::.,"' -:::: () w ._~ -ry -- (6) (",) .r- CT\ I 128,009.58, (7) (9) (10) (8) 128,009.58 11,420.28 260.00 0.00 X ~(15) 0.00 116,329.30 X .045 (16) 5.234.82 0.00 X .12 (17) 0.00 0.00 X .15 (18) 0.00 (19) 5,234.82 14. Net Valu. Subjectlo Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o i= <( I- :J D. ::ii o o >< <( I- 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (aXl.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate (11) (12) (13) 11,680.28 116.329.30 18. Amount of Line 14 taxable at collateral rate (14) 116.329.30 19. Tax Due 20. 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE suRE TO'ANSWER ALl.. QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < o d it' C I t Add ece en 5 omple e ress: STREET ADDRESS 5225 Wilson Lane, Aot 41 08 CITY I STArE I liP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 5,234.82 5 000.00 261.74 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits (A + B +C) (2) 5,261.74 T otallnteresUPenalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a retund (4) 5. II Une 1 +Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total 01 Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 0.00 26.92 0.00 O.DO 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 01 the property transferred; ........................................................................... 0 [RJ b. retain the right to designate who shall use the property transferred or its Income; ........................................ 0 [KJ c. retain a reversiOl1lll)l internsl; or ...................................................................................................... 0 [RJ d. receive the promise for life of either payments, benefits or care? ............................................................. 0 [RJ 2. If death occurred after December 12, 1982, did decedent (ransfer property within one year of death without receiving adequate consideration?.............................................................................................. 0 [RJ 3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. 0 [KJ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... [RJ 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I decln that I have exanined tJ:lis ~bJm, includj~ accompmying ~ules and statements, and to the best Of my knowledge and belief, it is true. correct and complete. Declaration of prepnr other th.., the personal representative IS based on all mfoonation of whICh preparer has any knc:Mledge. SIGNA TUR OF PERSON RESPO SIBLE FOR FlUNG RETURN DATE .r s:- tl;> SIGNATURE PA 17055 DATE ~ >- IPS ADDRESS PA 17043 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate Imposed on the net value 01 transfers to or lor the use of the surviving spouse is 3% [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 01 transfers to orfor the use 01 the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)). The slatute does not examot a transfer to a surviving spouse from tax, and Ihe statutory requirements for disclosure 01 assets and filing a fax retum are still applicable even il 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 twenty-one 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% [72 P.S. ~9116(a)(1.2)1. The tax rate imposed on the net value 01 transfers to or for the use ot the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) 172 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedenrs siblings is 12% [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 adopfion. REV-1509 EX,+ (6.98) . *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTL Y.OWNED PROPERTY ESTATE OF ZERBY J GARDNER SR FILE NUMBER 21 04 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Jane M. Zerby 5225 Wilson Lane, Apt 4108 Mechanicsburg, PA 17055 Spouse B c JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION ANO BANK ACCOUNT NUMBER OR SIMIlAR DATE OF DEATH OEClJS VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEOENTSINTEREST 1. A. (All other property was joint with surviving spouse) 0.00 50. 0.00 TOTAL (Also enter on line 6, Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1510 EX.+ (6.98) *' SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON.PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ZERBY J GARDNER SR FILE NUMBER 21 04 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 ~ yes. DESCRIPTION OF PROPERTY ITEM INClUDE THE NAME OF THE TIWlSFEFlEE. THEIR RElATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH ACOPYOFTHE DEEOFORREAL ESTATE. VALUE OF ASSET INTEREST VALUE (IFAPP\JCABLE) 1. J. Gardner Zerby Living Trust, Dated May 15, 2000 128,009.58 100. 128,009.58 TOTAL (Also enteron line 7 Recapitulation) $ 128 009.58 (If more space is needed, insert additional sheets of the same size) REV-1511 EX,+ (12-99) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ZERBY J GARDNER SR SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 04 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers-Harner Funeral Home 2,794.00 Ashland Cemetery 550.00 Funeral service (Minister & Organist) 300.00 Funeral Luncheon 536.28 James R. Gingrich Memorials 100.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Jane M. Zerby, Trustee 2,000.00 Social Security Numbe~s)IEIN Number of Personal Representative(s) Street Address 5225 Wilson Lane, Apt 4108 City Mechanicsburg State PA Zip 17055 Yea~s) Commission Paid: 2005 2. AlIomey Fees Radcliff Law Office, P.C. 3,000.00 3. Family Exemption: (If decedents address is not the same as daimanfs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountants Fees 6. Tax Return Preparer's Fees 7. Filing fee - Inheritance Tax Return 15.00 8. Merrill Lynch - Estate Account Fee 125.00 TOTAL (Also enter on line 9, Recapitulation) $ 11 420.28 (If more space is needed, insert additiooal sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent ZERBY, J. GARDNER, SR. Decedent's Name Page 1 21 04 File Number Schedule H - Funeral Expenses & Administrative Costs - 81 ITEM NUMBER DESCRiPTION AMOUNT B. ADMINISTRATIVE COSTS: Personal Representative's Commissions 2. Name of Personal Representative (s) John G. Zerby, Jr., Trustee 2,000.00 Sodal Security Numbe~s)IEIN Number of Personal Representathfe(s) Street Address 66 Ulz Drive City Hanover State PA Zip 17331 Yea~s) Commission Paid: 2005 SUBTOTAL SCHEDULE H.B1 2,000.00 REV-1512 EX' + (6-98) *' SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ZERBY J GARDNER. SR FILE NUMBER 21 04 Include unrelmbursed medical expenses. ITEM NUMBER DESCRIPTION 1. Radcliff Law Office, P.C. VALUE AT DATE OF DEATH 260.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 260.00 REV.,513EX.'. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER "^' "'I> ?1 04 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIYING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS pndude outright s~usal dis1Jibutions. and transfers under Sec. 9116 (a)(1. )] 1. John G. Zerby, Jr. Lineal 58,164.65 66 Ulz Drive Hanover, PA 17331 2. Florence Ann Davis Lineal 58,164.65 1501 Dalwen Green Court Matthews, NC 28105 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOYE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REY-1500 COYER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEiNG MADE 1. B. CHARITABLE AND GOYERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REY.1500 COYER SHEET $ (if more space is needed. insert additional sheets of the same size) Last Will of J. GARDNER ZERBY I, J. GARDNER ZERBY, of Mehcanicsburg, Cumberland County, Pennsylvania, make this Will and revoke all of my prior wills and codicils. Article One My Family I am married and my spouse's name is JANE M. ZERBY. All references to "my spouse" in my Will are to her. The names and birth dates of my children are: JOHN G. ZERBY, JR., born October 30, 1939 FLORENCE ANN DAVIS, born November 4, 1942 All references to my children in my will are to these children, as well as any children subsequently born to me, or legally adopted by me. ~ Oh'-P PeS Page 1 Article Two Distribution of My Property Section 1. Pour-Over to My Living Trust All of my property of whatever nature and kind, wherever situated, shall be distributed to my revocable living trust. The name of my trust is: J. GARDNER ZERBY, JANE M. ZERBY, and JOHN G. ZERBY, JR., Trustees, or their successors in trust, under the J. GARDNER ZERBY LIVING TRUST, dated May 15, 2000, and any amendments thereto. Section 2. Alternate Disposition If my revocable living trust is not in effect at my death for any reason whatsoever, then all of my property shall be disposed of under the terms of my revocable living trust as if it were in full force and effect on the date of my death. Section 3. Testamentary Trust If my spouse survives me, I authorize my personal representative to establish, with the assets of my probate estate, if any, or with any property distributed to my personal representative from my Trustee, "3 testamentary trust (or trusts) for the benefit of my spouse aijd my other beneficiaries under the same terms and conditions of my revocable living trust as it exists at the date of my death. I appoint the Trustee and successor Trustee named in my revocable living trust as the Trustee and successor Trustee of my testamentary trust( s). The Trustee of my testamentary trust( s) shall have all the administrative and investment powers given to my Trustee in my revocable living trust and any other powers granted by law. My Trustee shall be under no obligation to distribute property directly to my personal representative, but rather may distribute such property directly to the Trustee of the testamentary trust(s). Any property distributed to my testamentary trust( s) by the Trustee of my revocable living trust shall be ~~M Page 2 distributed by the Trustee of my testamentary trust(s) in accordance with the terms and conditions of my revocable living trust as it exists on the date of my death. Article Three Powers of My Personal Representative My personal representative shall have the power to perform all acts reasonably necessary to administer my estate, as well as any powers set forth in the statutes in the Commonwealth of Pennsylvania relating to the powers of fiduciaries. Article Four Payment of Expenses and Taxes and Tax Elections Section 1. Cooperating with the Trustee of My Living Trust I direct my personal representative to consult with the Trustee of my revocable living trust to determine whether any expense or tax shall be paid from my trust or from my probate estate. Section 2. Tax Elections My personal representative, in its sole and absolute discretion, may exercise any available elections with regard to any state or federal tax laws. ~~ fG~f Page 3 My personal representative, in its sole and absolute discretion, may elect to have all, none, or part of the property comprising my estate for federal estate tax purposes qualify for the federal estate tax marital deduction as qualified terminable interest property under Section 2056(B)(7) of the Internal Revenue Code. My personal representative shall not be liable to any person for decisions made in good faith under this Section. Section 3. Apportionment All expenses and claims and all estate, inheritance, and death taxes, excluding any generation-skipping transfer tax, resulting from my death and which are incurred as a result of property passing under the terms of my revocable living trust or through my probate estate shall be paid without apportionment and without reimbursement from any person. However, expenses and claims, and all estate, inheritance, and death taxes assessed with regard to property passing outside of my revocable living trust or outside of my probate estate, but included in my gross estate for federal estate tax purposes, shall be chargeable against the persons receiving such property. Article Five Appointment of My Personal Representative I appoint JANE M. ZERBY to be my personal representative. If JANE M. ZERBY cannot act, or is unwilling to act, I appoint, in the order named, the following successor personal representatives: First, JOHN G. ZERBY, JR.; then Second, FLORENCE ANN DAVIS. I direct that my personal representatives not be required to furnish bond, surety, or other security. ~~~ Page 4 1 have InItialed all of the pages of this Will, and have signed it on September 12, 2002. iif/ffi' ~t. Le~ J. DNER ZE Y SIGNED, SEALED, PUBLISHED and DECLARED by the above-named Testator, J. GARDNER ZERBY, as and for his Last Will and Testament in the presence of us who, at his request, in his presence and in the presence of each other, all being present at the same time, have hereunto set our hands as witnesses. Name ObJ/lfl.1/ {J' :i' '-.1 ' V i , /-L'~f\"'...<-<.:~ ....Lk..."J Name . 1rCft~ M Page 5 COMMONWEALTIIOFPENNSYLVANIA ) ) ss. COUNTY OF CUMBERLAND ) I, J. GARDNER ZERBY, Testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed this instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. itctL'~ J. G R ZERBY" Sworn or affirmed to acknowledged before me by J. GARDNER ZERBY, Testator, the / rJ~ay of September, 200;:--_~ _ ~Ut~,~ e/~ Notary Public (SEAL) NOTARIAL SEAL RolleI1a l. RadcIIII. Notary Public ~ Bor~. Gounlyol Ccmlertand My CommIssion Expir8s Jan. 211. 2llO5 ~. COMMONWEALTH OF PENNSYL VANIA ) ) ss, ) We, O",u/i) 1I.~bC.L'~~, and (J/;erl':;;'-<<'e~,jJ'ne'Jt~/"'- . witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw J. GARDNER ZERBY, Testator, sign and execute the instrument as his Last Will and Testament; that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; and that to the best of our knowledge the Testator was at that time eighteen or more years of age, of sound mind and under no traint 0 undue influence. ~(ItI?:1{ o. . ~ 7 ~ D Sworn or affirme to and subscribed to before me by ))/HI/ /) JJ~) (.LI r,c andfl'::k,~ Sou I()V b('OW2V , the witnesses, this /A IA day of September, 2002. ~~I~L ./ Ruh~ COUNTY OF CUMBERLAND (SEAL) fIT 0XkM 'l'-~-= NOTARIAL sEAL''"'Pa~r 6 Roberta L Radcliff, Notary Public Wmmleystlurg Bcrough, County of CUIl'.ber1aolJ My Commission E..'pires ..:!.an. 3!J. 2005 -- ~"",(-.r~;~'-.~ ,.--~~r\"- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE DR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 2B0601 HARRISBURG PA 1712B-0601 REV-1547 EX AFP (06-05) ~ ,,' ,~. ", /"-;:'" , , I, i'~ : J DATE 09-26-2005 ,C " ESTATE OF ZERBY JOHN G , DATE OF DEATH 08-23-2004 FILE NUMBER 21 04-1075 COUNTY CUMBERLAND DAVID H RADCLIFF ESQ ACN 101 RADCLIFF LAW OFFICE APPEAL DATE: 11-25-2005 20 ERFORD RD STE 200 ( See reverse side under Objections) LEMOYNE PA 17043 Amount Remitted I I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 ~~!_~~9~~_!~!~_~!~~______~___~!!~!~_~Q~!~_~Q~!!Q~_EQ~_YQY~_~!~Q~~~__~____________________ REV-lS47 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF ZERBY JOHN G FILE NO. 21 04-1075 ACN 101 DATE 09-26-2005 TAX RETURN WAS: ( X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account, 3. Closely Held stock/Partnership Interest (Schedule C) (3) .00 submit the upper portion of this form with your 4. Mortgages/Notes Receivable (Schedule D) (4) .00 tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) .00 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) 128,009.58 8. Totel Assets (8) 128,009.58 APPROVED DEDUCTIONS AND EXEMPTIONS: 11,420.28 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 110) 260.00 11. Total Deductions (11) II . liBO 28 12. Net Value of Tax Return 112) 116,329.30 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 113) .00 14. Net Value of Estate Subject to Tax 114) 116,329.30 NOTE: IT an assessment was issued previously, lines 14, IS and/or 16, 17, 18 and 19 will reTlect Tigures that include the total oT ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 115) .00 X 00 - .00 16. Amount of Line 14 taxable at Lineal/Class A rate 116) 116,329.30 X 045 = 5,234.82 17. Amount of Line 14 at Sibling rate 117) .00 X 12 = .00 18. Amount of Line 14 taxable et Collateral/Class B rate 118) .00 X 15 = .00 19. Principal Tax Due (19)= 5,234.82 TAX CREDITS: r......~... "~..~...rl 1+, AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 11-23-2004 .... CDo04657 261.74 5,000.00 09-19-2005 REFUND .00 26.92- TOTAL TAX CREDIT 5,234.82 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 pi. TOTAL DUE .00 " IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) BUREAU OF INDIVIDUAll.;::~XES'!f~n r,r-r:r::: INHERITANCE TAX DIVISION""-" J '.,_1.... \.., , '."- PO BOX 280601 ' HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT REV-1607 EX AFP (03-05) ,r-- DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 10-03-2005 ZERBY 08-23-2004 21 04-1075 CUMBERLAND 101 JOHN G 20C5 OCT 28 Pli} 3: 23 DAVID H RAnCLIFF ESQ RADCLIFF'LAW OFFICE 20 ERFORD RD STE 200 LEMOYNE PA 17043 Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ...... RETAIN LOWER PORTION FOR YOUR RECORDS +- --------------------------------------------------------------------------- REV-1607 EX AFP (03-05) *** INHERITANCE TAX STATEMENT OF ACCOUNT ... ESTATE OF ZERBY JOHN G FILE NO.21 04-1075 ACN 101 DATE 10-03-2005 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 09-19-2005 PRINCIPAL TAX DUE: 5,234.82 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 11-23-2004 CD004657 261.74 5,000.00 09-19-2005 REFUND .00 26.92- TOTAL TAX CREDIT 5,234.82 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 IE IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) 0('