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HomeMy WebLinkAbout04-09-13 (2) 1505610101 REV-1500 EX(ui-1e' �! n lvania OFFICIAL USE ONLY PA Department of Revenue Pe! ..1 County Code Year File Number Bureau of Individual Taxes PO BOX 28o6Dt INHERITANCE TAX RETURN ' Harrisburg PA 171z8-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social "o s , ' o ,,/ 0 8 1 5 / / 9 !, Decedent's Last Name Suffix Decedent's First Name MI (If Applicable)Enter Surviving Spouse's Information Below Spouses Last Name Suffix Spouses First Name MI Spouse's Social Security Number « _ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW go 1. Original Return O 2. Supplemental Return O 3. Remainder Return(date of death prior to 12-13-82) p 4. Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) p 9. Litigation Proceeds Received O 10. Spousal Poverty Credit(date of death C 11. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOD BE DIRECTED TO: Name D�tlme Teleph u r A �o. � C}H .F k LSE & 5H ! L'D5 !, �i n STER OF WI E ONLY cr, Q CJ First line of address _ o o 'n f 6 C L DUF IZ R,o Second line of address rrT 111 ll.., s 9* N DATE FILED City or Post Office State ZIP Code ! 'C!, SB G Pfd I,7�0 5.59 7 3 5` Correspondent's e-mail address: Cesk ie lds 30 Comc as1: net Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATU OF PERSONy.�RESPONSIBLE FOR FILING RETURN DATE x _.f 4 r . f a r. X�(1 ' -77 ADDRE y RA , 76 Greenspri777q-D1-:, MGC.han1C5 ur9, e-4 174SAP SIGXATUZR OTHE ESE E DATE if ADDRESS CNf}/1LE F.. -Sff/h7jCS-_.111i fV CZPU.S&YRel, Me-cT4me.S Nryj Y* IZOS.S PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610101 1505610101 1505610105 REV-1500 EX Decedent's Name: C A C YI e RECAPITULATION Q1. Real Estate(Schedule A). .. .. . . . .. . .. . . . . . .. .. . .. . .. . . . . ..: .. . 2. Stocks and Bonds(Schedule B) . . .. . .. .. . . .. . . .. . .. . . . .. . .. 2 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . .. . 3 { Q Q 4. Mortgages and Notes Receivable(Schedule D) . . . .. . . . .. . . . . . . . . . .. . 4 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). .. . . . 5 Li 4 6. Jointly Owned Property(Schedule F) p Separate Billing Requested . . . . . . 6. t y 2 .3 ✓D 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested 7 s 9 y 8. Total Gross Assets(total Lines 1 through 7). . . . . . . . . . . . . . . . . . . . . . . 8. 9. Funeral Expenses and Administrative Costs Schedule H ' 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . .. . 10 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 4 1 3' 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 _. l b 7 / 7 k 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which "* an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . . 13 0 D 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . 14 '_'� 6` 7 `j .7 - e, TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 •- �;^ s (a)(1.2)X.OQ_ ` t °°. 15 16. Amount of Line 14 taxable at lineal rate X .0 0 16. Q 17. Amount of Line 14 taxable ? at sibling rate X .12 ` 7 / 17 b 18. Amount of Line 14 taxable at collateral rate X.15 " z a Q 18. Q FM go 19. TAX DUE .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . .. . .. . . . . . . . . . . 19. b 9 06 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610105 1505610105 J REV-1500 EX Page 3 File Number Z Decedent's Complete Address: DECEDENTS NAME STREET ADDRESS q j ! FFal ----- i?Y. _ ------ .. ._ ..._-------_..11 STATE —. . ZIP CITY - �- -- . Me,chwniosb! , ( Pf# 170.40 Tax Payments and Credits: 04,49b 1. Tax Due(Page 2,Lire 19) (1) .�� 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B} (2) %g p, 00 3. Interest 4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 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:.......................................................................................... ❑ LC} 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?...................................................................... ❑ Gy 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 ,dd� contains a beneficiary designation? ..........__.............................._........................._......_..................___.............. L1 LV 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 not value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116(a)(1.1)(it)].The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and fling a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. CHARLES E. SHIELDS,III ATTORNEY--AT-LAW 6 CLOUSER ROAD Corner of Trindle and Clouser Roads MECHANICSBURG,PA 17055 GEORGE M. TELEPHONE (717) 766-0204 (34]2-744]}91) FAX (717) 745-7473 August 21, 2012 ' Register of Wills Cumberland County Court House I Courthouse Square Carlisle, PA 17013 Re: Estate of Carrie O.Rock No.21-12-0739 Dear Register of Wills: Please find enclosed Check No. 101 in the amount of$2,280.00 for estimated Inheritance Tax for the Estate of Carrie O. Rock. Thank you for your kind attention to this matter- Very truly yours, < Charles E. Shields,III Attorney-At-Law CES/rnjj Enclosure eo-Txea✓aa,s 101 PAY TO .aYir+yl't-' d4 t.V.f t�..Yda 1 QQ C-0 (>RDER OF RS LJ o�.... Sovereign Ban$NA. PART OF THE SAWANDER EGROUP Mwo F1 A.Ke.i� ` 3" t: 23137269 i1: 1921035226u' 1 i !, E�i•• DF L.6/z/Z!F O� �2c�K ,�lt,E wv. 2//2-67.35 i sto 1 �C2r ae Wiz, 5'67.17 . . ..._ . . ._. _.._ ...._. . . . _. ._ . . .. ._.- ... N -1we U,(147) ab SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE ENT RETLIRN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER 2w—/x_07.3 Ce.rrie m, i�noK 9 Include the proceeds of rftadon and the data the proceeds were mceNed by the estate.AS property)DlMly w^%W with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 7. eairtyal �efurtd, Sarah T >E oad Home, of Uri;sfe f2S,7o NS Trc4s4ry Ar do// /�c•s ns/ �C. Tw.X 2, 7f 6.0,0 3. oSaA W .Zfeins W Arso/iely 4,1' Hears //see/,on th7/i2 f/3 Y 75- 71s 7141 ¢5"6 9,Oo ' (.SEL .4ucfaCn pf77G7G ej,& ollo rwl) Ruatptrtm TIna8/T Re"d x/0.28 S• /oarh+l /Qei/nbrrrre-moitt , Gcn;hd Healthcare (,. dlh k/ PA.v eol mom 41W —L.1 Torn. Ar;'nuify 4;oM 4(n,' .d Or' D�ratiq (3 mos.) "t, 6- 67. b5 7. r-,n4/ pQyx0ot Ibm oi�-to,�j 7�� �yom Inmy a( of omk/fa �l, 98 9, G 6 Y. Ar6a0Vefnt6erAw&1t Amw Alkhia/ o�- 014ako L 6 , GO Y. AW ACAflyd 16VIN plot- "/66 -Zb TOTAL(Also enter on line 5,Recapitulation) $ (H more space is needed,insert additional slits of the same size) . BACKGROUND AND CONTAINS MULTIPLE SECURITY FEATURES SEE BACK FOR DETAILS 'm THIS CHECK HAS A J�swy. x IP 44 4 5 6nl 1:031000S031: 2000013098 i 3 3HO United Church of Christ Homes DATE CHECK NO. AMOUNT 074756 30 North 31 st Street,Camp Hip,PA 17011-2913 07/05!2012 74756 825.70"' MEMO INVOICE DATE INVOICE NUMBER AMOUNT DISCOUNT NET RE&IDENTREFUND 66/122012 102382 825.70 825.70 SARAH TOOD HOME EST:C.ONEIDA ROCK> ,3h 99 s."s" �r j �� r,.�`'L�v 4 y;y, 'P,� jrr �. ,x �#` •; . ....wx4:�s ..�,., w .,......w.. e.i..,�... ._ u,v _±3. . ��S .. ... ,i, sue.. ...,. .,..� t.: <_.c. .._. 1ua, �`1� w�.•s .a• w1..: .._ S 682,837,286 000 +' x Chock No. ' 06 0412 72 SAN FRANCISCO; EA 3158 34635892. 3158 34635892 20090900` I Q';OROCK K4k$: CYTAX REFUND :!fir« ` •�Inulli9nN�••• dll9hirh•1••IIiPi4�I,hfy���lX��F ,, 'ppisof C 0 ROCK . ' � :... 1000 W SOUTH ST CARLISLE PA 17013-2722 � S****2796*60 YORI-AFTER ONE YEAR Mioclaa!�. Na.Kr rt1�4 1:00000051,81: 31.6358925n• 040612 RRk.✓s' R.rs -t�7 � r23� 7`0 �Ft a• xs t CP\4 at 0Q-t7-2@12 mww. hzars. ram MAARxS AUCTION 717`432^8246 Settlement PEGGY HAFER Page . 1 Seller: 76 76 GREEN SPRINGS DR MECH PA 17050 Item Description Price Qty Total ----------- ------------------------------------------------------------------------ ~ FLAMINGO 1 4^00 ^ BASKET OF CHRISTMAS Cg" S 1 2^ 00 ` PAC MAN TRAY 1 6.00 - CUP AND SAUCER LOT X 5"00 - WINTERS REST PICTURE 15.00 - JEWELRY LOT 25^00 ~ CROCK ~ AS IS 1 0^ 2500 ^ "lGHT t 3. NZ ` BELL 1 7. 00 AtNTERWJCD PF'0LTZGRAFF 1 4 " 1111 PYREX DISHES 1 5.0e. - FLATWARE SET IN BOX 1 20^00 - CERAMIC TREE 2. 00 - Box lot ^ mmvice - pots - 1 2^00 Pans - Box lot ~ pictures - VCR 1 6°0et /remote - Box lot ^- glassware - 1 1.00 baking pans - kniok/khacks ~ Box lot ~ ldirt devil - 1 3. 00 misac items - Box lot - basket - snowman 1 6.00 - fall decrne`tions - Tin - box lot ~ table 1 4" 00 clothes - Box lot - cassettes - 1 . 1°00 candles ' shades - Box lot ~ lightds - shades 1 4" 00 ~ Christmas lights - Box lot - blankets case ~ 1 4.00 oil - M/M dispenser - Box lot ^ Christmas ~ 1 0" 50L�0 dishes - Box lot ` clock - crate lot 1 1^50 ^ miso items - Pox lot ^ kitchen items - 1 6.00 stack wall pictures - Dux lot - thermn- bags - 1 0°5000 cord Items: 26 Amount : 134"75 Commission at 40^ 000% 53^ 90 Less adjustments: ~53"90 ----~-----~ Net due to seller . 80. 85 w+w. haars. rom HAAR' S AUCTION 717-432-8246 Date : 07-27-2012 www. haars. cam HAAR' S AUCTION 717--432-83246 Settlement LEGGY HAFER Page: Seller: 76 76 GREEN SPRING DR MECH PA 17050 Item Description Price Qty Total Wall rack-stool 1 1. 50 2 chairs 1 2. 00 Organizer 1 3. 00 Walker-stools 1 1. 00 Mirror 1 4. 00 - Tub seats-stand 1 0.500 Cooler 1 4. 00 Sweeper 1 1. 00 Rug 1 4. 00 - Broom-picture 1 2. 00 Pai:io table '_ 1. 00 -- Floor Light 1 1. 00 Air conditioner 1 25. 00 -- Air conditioner 1 17. 00 Floor light 1 4. 00 Mirror 1 4. 00 Potato bin 1 1. 00 Paper shredder-cd holder 1 2. 00 Hamper 1 0. 2500 - Luggage 1 0. 7500 - Microwave 1 2. 00 File cabinet 1 8. 00 Bookcase 1 7. 00 Corner shelf - 1 5. 00 -- Floor light 1 2. 00 Tv 1 5. 00 Cabinet 1 1. 00 - Kids chair` 1 55. 00 - Stand 1 0. 7500 Hat rack 1 12. 00 Santa 1 1. 00 Swivel rocker 1 5. 00 Rug 1 25. 00 - Stand 1 4. 00 - Coffee table 1 20. 00 - Glider- rocker 1 10. 00 -- Cart 1 1. 50 - Sofa - 1 20. 00 - Drop leaf table 1 15. 00 - Rocking chair 1 25. 00 - Curio cabinet - 1 80. 00 - Stand 1 5. 00 - Dry <--ink 1 25. 00 - Step table 1 1. 00 - Patio chair 1 1. 00 Vie : 07-27- 2012 www. haars. com HAAR' S AUCTION 717-432--8,'_'46 Settlement PEGGY HAFER page: Seller: 76 - 76 GREEN SPRING DR MECH PA 17050 Item Description Price Qty Total - Stool 1 4. 00 - Ironing board 1 4. 00 - Clock 1 1. 00 - Bedroom suit 1 140. 00 Items: 50 Amount : 569. 00 Commission at 40. 0005 227. GO FUEL SURCHARGE 10. 00 Lest_ adjustment - 237. 60 Net die tG s eller: 3.'51. 40 www. iiaai-s. com HAAR' S AUCTION 717-432-8246 SCHEDULE F COMMONYJEALTF fi FYENNSYLVANIA JOINTLY-OWNED PROPERTY INHERTANCI. '+'A%RETURN MfXNI[ECEDENT ESTATE OF FILE NUMBER Cgrri - a Roe,K Nan and was nude joint%athin one year of the decedem's date of dooft It now be reported on Schedule 0. SURVIVING JOINT TERANT(SI NAME ADDRESS RELATIONSHIP TO DECEDENT A' pEv6y G. HoIrETi' '76 Gre,Grts4)rin9 Dr. S rsfor I11CGE'XLYT�CS br+tt�, PF} I7a S`O B. C. JOINTLY-OWNED PROPERTY: LETTER IATE DESCRFnMOFPROPERW %OF DATE OF DEATH ITEM FCRJOINT I:AIDE Include name of financial iraeedWn eM hank account oumh9r or drinder identift nUmhar.Attach DATE OF DEATH DECOS VALUE OF NUMBER TENANT JOINT dead fiat piney-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST ,. A. 916146 S4'#'gv jsah hank cAer-ge'ny , No. a33 103 7604 d 170,bS :At 10. /' ? f , a yl vf40 Sj.VNfeA rn Ba es.'t Np. 233 S ZS /04(3 PrincipR/jai�f f73�tdL' Zilt. 10.0.2 1E.�,t/73. 88 SUIo ;"4231. 9'f / t3Ct Y+tIXaJJiX �! eI"' 4stAG�jBarj TOTAL(Also enter on line 6,Recapitulation) $ d tf 3 ;r.7,3 6 (If more space is needed,insert additional sheets of the same size) i Sovereign Bank ESTATE OF Carrie Oneida Rock SOCIAL SECURITY#: 165-26-5520 DATE OF DEATH: May 27,2012 Account#: 2331037604 Type: Checking Open date: 9/6/1996 In the name of: C. Oneida Rock or Peggy G.Hofer Date of Death Balance: $46,170.65 Int.(YTD)from 1/1/2012 to 5/14/2012 $1.45 Accrued interest to date of death: $0.19 Other Info: Account#: 2335251043 Type: Time Deposit Open date: 4/21/1998 In the name of. C. Oneida Rock or Peggy G. Hofer Date of Death Balance: $2,473.86 Int.(YTD)from 1/1/2012 to 4/30/2012 $0.37 Accrued interest to date of death: $0.02 Otherinfo: e Page 1 of 1 SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT 'STATED' FILE NUMBER CAYrs& p, (�.00K Z—a739 Deals of decedent mast be reported on Schedule L - ITEM _ NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: lnyer,�• Buhr;j runeral game of 1H&44A;aJurq far b�o,S& B. ADMINISTRATIVE COSTS: i. Personal RepresentatNO's Commissions L ''1 d Name of Personal Reepfrreesentative(s) _� Horror W rr1 Va nA Street Aftm_._.d �_� _ City �(.(,`,.j'�Q�1('�SDLL Yn1_ State�_2ip �7d� Years)Conanissiot Paid: O f 2. Attorney Fees Charkli E. dHr P.(cW Sr � �) 0 ",c,,/.105 3. Family Exemption:(e decedent's address is Trot the same as claimant's.attach exptanation) Claimant /✓O OWAF E' lalgtr - NONE Street Address v --- ---- - City State Zip —_ Reletiensnip of Claimant to Decedent 4. Probate Fees stlrl S64 Cer-h- eat'es "&.3.SD 5. Accoentanfs Fees (}j' J-,,tftce �6a rdnex, //f R 131&--k,7W ptro. c.low- 6. Tax Retum Preparer's Fees oat 10rpi RR YP/ 1,9w, Af -,// l AD.00 7. defetr-t;srn4 in �ambu l:rear �sW/ 7ournaJ ?5,oo 8'. r�4vlGrf%se✓� /fin �w,r,•L 9. IIAq Fe /o t rTefr'S& ok rt/ills �15.1J0 /o. /fWW,1 onrr/ d v 6R7e' Fee )" -s-. E)D /l• />re,rrt�ursemt�t tv Cltrs E. „$/Jr`ejaarr � {ar vezlrat�an ta�o.rto fact to Aorere_ n aii1WV4-j&ok (see coo/i�.s/ieo-0 l/ TOTAL(Also ertter on tine 9,Recapitutation) (If more space is needed,insert additional shoals of the same size) 3 Al'ov,_/lu �nr fo iss ?ns s ��Sec__/�tc_rea^_"��l/1?�nl_I'f __. _- m4.nf _tea,-_4r ri x d r; + � n2 Peggy Hofer ' OEM INVOICE 76 Greenspring Drive Mechanicsburg,PA 17050 invoice Number: 10393 - Invoice Date: May 27,2012 JJJ Paga: 1 C. Oneida Rock May 27,2012 Net 30 Days Wiliam t:Christopher - --- — v ` SSO Body Disposal $2,220.00 r FSE Facilities, Staff and Equipment $ 834.60 V Vehicles i .851.E M Merchandise CA-Newspape Cash Advance-Newspapers $i 435.00 CA-Clergy Cash Advance-Clergy CA-Cie rgy Additional Cash Advance-Clergy S ; 75.00 CA-Death Cen 10.00 Cash Advance-Death Certificates $ `6.09 $?60.00 CA-Rowers Cash Advance-Flowers $ 150.00 CA-Organist Cash Advance-Organist ' ! $ 125.00 CA-Coroner Fr Cash Advance-Coroners'Cremation Fee $ 25.00 CA-Reception Additional Cash Advance-Reception ..,�'� $ 150.00 CA-Cemetery ' Additional Cash Advance-Cemetery $ 740.00 Insurance Payment was$2,49144. r Sava$3y4-.80-by.p +ing this itvoicebyThursday,June 26, i 2012 tpoW Tliwk you for allowing us to serve you md your fmnil Subtotal _ $6,505.00 We gladly accept the following forms of payment: Shipping $ 0.00 Cash,Check, Visa,MasterCard,Discover,American Express Sales Tax $ 4.00 Kindly make your check payable to: Total Invoice Amount $6,505.00 Myers-Buhrig Funeral Home and Crematory Payment7Credit Applied'- % $4:49344- Past due accounts are subject to interest charges of 1.5%per month. Walking with Those in Grief Robert"Rob"L.Buhrig,Jr.,rn,sutax .-William"Bill"L.Christopher,FD Phone- am 766.3421 - Fax; im)795.7291 - 37 East Main Sveet - Mechanicsburg PA 17055 - www.Myers-Buhrig.com - Directors©Myers-Buhriggcom • REV-1512 EX,(12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF /� ftC D � K FILE NUMBER 1 OG 11-/A 073 9 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death,Including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1_ 1h;l1mi'a/m Phamey 4,- Grays 60zih: /.? 3. 71 .� AiIIC/Iik/If �/or Orkys (F11111.7- f/35.Y6 3. NOnAa 14;4Klc1 Ldndlo.d, dtd1 kn arri rs $to 300.00 y Ppc (z Av0f:.) flg7.97 5. IAn.4-ed AGC ins. X101 70 01 �, (.�. $. TrCpSkfrr �ar ipersona� ..ZvLtorne , `f 1 g,Gc 7� �a °'r4't- °t U�WPY6u� �vr !r f 9*1, GG TOTAL(Also enter online 10,Recapitulation) (If more space is needed,insert add'Nonal sheets of dre same size) REV-.1513 EX-(11-0E) � pennsylvania SCCHCEC•D�fUnL•ECC3 DE PAR rMENT OR REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Cclrne p, Q2Drk 24 0-739 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSONS)RECEIVING PROPERTY Do Not Ust Trustees) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.2116(a)(1.2).] 1. '�EGGy G. NoFE2 n SiSf-er YZ 76 Grewsprin4 'Dr. , Mee-6n#esbur9, PA OO 17 D So .t CARR/- SuE FAQ AFS n i ec c y2 (p 52 O/d Grnye Rd., M6Ch4n"c56u,y, PA I7osS ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBURONS 1. TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,insert additional sheets of the same size. LAST WILL AND TESTAMENT OF C. ONEIDA ROCK a.k.a.CARRIE ONEIDA ROCK I,C.ONEIDA ROCK a.k.a.CARRIE ONEIDA ROCK,unremarried widow,currently of 19 Fieldcrest Drive,Mechanicsburg,Silver Spring Township,Cumberland County, Pennsylvania,being of sound and disposing mind,memory and understanding,do make,publish and declare this my Last Will and Testament,hereby revoking and making void any and all prior Wills and Codicils by me at any time heretofore made. L I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. Ail the rest,residue and remainder of my Estate,real,personal and mixed,whatsoever W wheresoever situate,I give,devise,and bequeath to my sister,PEGGY G.HOFER,and my niece,CARRIE SUE EAMES,in equal shares. 3. In the event that my said sister,PEGGY G.HOFER,should predecease me,then her share is to go to her husband,BURTON E.HOFER In the event he has also predeceased me,then to my niece,CARRIE SUE EAMES. In the event my said niece,CARRIE SUE EAMES,has predeceased me,then her share herein,however derived,shall go to my brothers,who survive me,they currently being: ALBERT D.GILL,GEORGE FRED GILL,and JOHN IL GILL. 4. It is my intention that beneficiaries named before or after the date of this Will on my life insurance,annuities,individual retirement accounts(IRAs),in Trust for or joint bank accounts and any other assets for which I may designate beneficiaries will receive such investments and that my Will provisions shall not control such investments. 5. 1 nominate,constitute and appoint my sister,PEGGY G.HOFER and her husband BURTON E.HOFER,to be the Co-Executors of this my Last Will and Testament. In the event that both one of them are unable or unwilling to act as Executors,I appoint my niece, CARRIE SUE EAMES,to be Executrix in their place and stead. I further direct that they Page t shall not be required to file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. IN WITNESS WHEREOF,F have hereunto set my hand and sea]this �-r day of February,AD.2012. {SEAL} C.ONEIDA (SEAL) a.k.a.CARRIE ONEIDA ROCK Signed,sealed,published and declared by the above-named C.ONEIDA ROCK a.k.a.CARRIE ONEIDA ROCK,as and for her Last Will and Testament,in the presence of us,who at her request and in her presence,and in the presence of each other,have hereunto subscribed our names as witnesses. Page 2 C.ONEIDA ROCK a.k.a.CARRIE ONEIDA ROCK,the testatrix 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 the instrument as my Last Will;and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by C.ONEIDA ROCK a.k.a. CARRIE ONEIDA ROCK,the testatrix,this )f r;(�day of February,A.D.2012. Q, to (SEAL) C.ONEIDA ROCK fl..t - CUB (SEAL) a.k.a.CARRIE ONEIDA ROCK �u-P �v. / Notary Public We, Ro6'Rt A. F_A-MGS and S�fAN the witnesses whose names are signed to the attached or foregoing instrument,being duly qualified according to law,do depose and say that we were present and saw the testatrix sign and execute the instrument as her Last Will;that the testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed;that each subscribing witness in the hearing and sight of the testatrix signed the Will as a witness;and that to the best of our knowledge the testatrix was at that time 18 or more years of age,of sound mind and[order no constraint or undue influence. Sworn to or affirmed and subscribed to before me by f6,6-441- A hy,...e( and J' -f4 , rJG7zicic C%MMPh=MM=PB#AMVAW dated this tjf� day of February,A.D.2012. rW N.DWW H"V WAc ram MWOMP*.w offbat"c"Q oaanNwMe as zk=' 'it nwmcrsa�, P 4a / �it r�6 P)-JI27 C01NIgN * . i mI PMM Sia JAi�7 � ¢'rRr� a>sowtraia... 4171 w9c_oe,� pR: X71 z v 9 ?ao S rW N.Dick iiesr rwr M.M iAttllbara�.,Um0�baltbwp' �Mwwe �r n ross o1�Public 1 Page 3