HomeMy WebLinkAbout04-15-13 (3) i 1505610105
�J
REV-1500 EX(to,u)(R)
OFFICIAL USE ONLY
PA Department of Revenue pennsytvanda
Bureau of Individuat Taxes >..,. Dour Code year File Number
PO BOX 28o6o1 INHERITANCE TAX RETURN
Harrisburg PA 17128-0601 RESIDENT DECEDENT o�
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
' 05/1412012 12/21/1911
Decedent's Last Name Suffix Decedent's First Name MI
Lebo Mildred A
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
NIA
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
(AD 1. Original Return C7) 2.Supplemental Return C=) 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4. Limited Estate O 4a.Future interest Compromise(date of C=:) 5. Federal Estate Tax Return Required
death after 12-12.82)
M 6. Decedent Died Testate C= 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9.Litigation Proceeds Received C=> 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under, Sec.9113(At
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
ry
Michael Cherewka, Esquire (717)23? 701
w '= m
ri
REGI A q-WILLS tiRONLtt7
M f9 W--41
i
First Line of Address rA Z � C11
a7
624 North Front Street = or- 7
Second Line of Address <? o '"rt •+-
r--
-�tt I�
City or Post Office State ZIP Code DATE FILEO�� t:
Wormleysburg PA 17043
Correspondent's e-maN address:mcherewka @cherewkalaw.com
Under penalties of pe I declare that I have examined this fatunl,inc uding accompanying schedules and statements,and to the best of my knowledge and belief,
it is true, orrect an otile.Declaration of preparer other than the personal representative is based on all information of which preparer has any(90WRidge.
SIGNATLRF.0j,t5R%W XRESPO F y� RATURN DATE /J �
AD !jJ f
40 W st 4tuer,Lane, Camp Hill, PA 17 11
SSGNA F AR c1l, R AN REPRESENTATI DATE
3
ADD S
6-4 North Front Street, Wormleysburg, PA 17043
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 �„�
1505610205
REV-1500 EX(FI) Decedent's Social Security Number
Decedent's Name: Mildred A. Lebo
RECAPITULATION _
1. Real Estate(Schedule A). .... . . . . . . .. .. .... ....... .... ..... . ..... . L 0.00
2. Stocks and Bonds(Schedule B) ....................................... 2,
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00
4. Mortgages and Notes Receivable(Schedule D)... .........."...... ..... .. 4. 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)..... .. 5, 5,793.47
5, Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00 !.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested., . .. ... 7. 0.00
8. Total Gross Assets(total Lines 1 through 7).. ............ . ......... .. 8 .__. 6,793.47.
9. Funeral Expenses and Administrative Costs(Schedule H). .. . .. .. . . ... . . . ... 9. 12,887.06
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)_............. 10. 864.02 !.
11. Total Deductions(total Lines 9 and 10). . . . .. . . . ..... . . . .. . . ..... . ...... 11. 13,761.06
12, Net Value of Estate(Line 8 minus Line 11) ....... .......... ............. 12. -7,957.61
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . .. .. . . . . . . .. . .. . . 11 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) ... ..._.. ............. 14. ! ^7,957.61
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 0.00... _.
(a)(12)X.0- 15. 0.00 .
16. Amount of Line 14 taxable ._...... _.__ .. _.._..
at lineal rate X .0_ 0.00 . 16 0.00
....... ,
17. Amount of Line 14 taxable
at sibling rate X.12 0.00 17, 0.00
18. Amount of Line 14 taxable
at collateral rate x.15 0.00 18 0.00
19. TAX DUE . .. ........ .. ........... ....................... 19. _.. 6.00
20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610205
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: I - '4
DECEDENT'S NAME
Mildred A. Lebo
—
--
STE ADDRESS
Claremont Nursing & Rehab Center
1000 Clarergent Road
—-----—-----
CTT STATE ZIP Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A.Prior Payments -- 0-00
B.Discount 0.00
Total Credits A+B (2)— 0.00
3. Interest
(3) 0.00
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. (4) 0.00
5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
Make check payable to: REGISTER OF WILLS,AGENT
V-
1:
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....... .............-.........................................-......... R 0
b. retain the right to designate who shall use the property transferred or its income ... ...............--..........---- ❑ 0
c. retain a reversionary interest ...............---...............-...............--............... .................-............... ❑ N
d. receive the promise for life of either payments,benefits or care?...............................--.................--............. ❑ 0
2. If death occurred after Dec. 12.1982,did decedent transfer property within one year of death
without receiving adisquate 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 beneficiary designation? ........--------...........--.............---................--....... ....... ❑ 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.
3NM T 1 ,F ..., ., M, "
.,oj
iiNIM! -P
.
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) (1)].
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)(11)(fl)].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 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 172 P.S.§91112)].
• 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 F2 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedents 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.
REV-1502 EX+ (12-12)
IVpennsytvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Mildred A. Lebo 21-12-1114
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold
ITEM include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATn
DESCRIPTION
1. None 0.00.
TOTAL(Also enter on Line 1, Recapitulation.) f$ 0.00
If more space is needed, use additional sheets of paper of the same size.
REV-1503 EX,of-vs)
pennsylvania SCHEDULE B
DEPARTMENT OF REVEWE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mildred A. Lebo 21-12-1114
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
_NUMBER DESCRIPTION OF DEATH
r' None 0.00
TOTAL(Also enter on Line 2, Recapitulation) $ 0.00
If more space is needed,insert additional sheets of the same size
REV-1507 EX+(6-98)
SCHEDULE DT
COMMONWEALTH OF PENNSYLVANIA - MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mildred A. Lebo 21-12-1114
All property jointlyyowned with right of survWomWp must he disclosed on Schedule F.
ITEM VALUE AT DATE
_NUMBER - DESCRIPTION OF DEATH
1. None 0.00
TOTAL(Also enter on line 4, Recapitulation) $ 0.00
(If more space is needed,insert additional sheets of the same size)
REV-n5o8 EX,(08-12)
t pennsyivania SCHEDULE E
Ux DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Mildred A. Lebo 21-12-1114
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 diseiosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. M&T Bank,Checking Account#9830243524 5,651,85
2. Reimbursement from Claremont Nursing&Rehab Center 141.62
TOTAL(Also enter on Line 5, Recapitulation) ; 5,79147
If more space is needed,use additional sheets of paper of the same size.
.aka t z+ eihs x * �kffszm sa g'� '�" 3x ppo ails—E ITk ya.� IN `"w
n e i `x,'4 ; i e?`. au a ta!N9>Sys sS ttA: ,kzda w F 3rk# ss e A' ,'�s
AG"C9I81H3�243524 H��B T IRST� -:.: MAY S-JUN.06,20 2� 1AF I
00 0 04303" MM 027
-.__.,_... 13149
- MILDRED A LEBO
�_....v 35 SINCLAIR RD
MECHANICSBURG PA 17055
INTEREST EARNED FOR STATEMENT PERIOD 0.00 BOILING SPRINGS
ACCOUNT SUMMARY
(E! B I G
N0. AMOUNT I NO. AMOUNT MD. AMOUNT
5,fi51.85 0 0.00 p .00 0 0.06 p.p0 5,651,85
ACCOUNT ACTIVITY
_PD5 TING, AE.PRR.IT�S ..fRES GRlECdC& :OF Y
0S-05-12 BEGINNING BALANCE - 05,651.85
ENDING BALANCE 05,651.85
SAVE YOUR CASH FOR WHEN YOU REALLY NEED IT. INSTEAD OF CARRYING EXTRA CASH OR
FUMBLING WITH CHARGE, USE YOUR MST CHECK CARD FOR ALL YOUR EVERYDAY PURCHASES -
-IT'S SAFER AND FASTER!
WHETHER IT'S A BURGER AT LUNCH, GAS, GROCERIES, EVEN MOVIE RENTALS OR A CUP OF
COFFEE - NO PURCHASE IS TOO SMALL FOR YOUR CARD!
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R&2c. S$)3
LOWAjO��I a r ey p P , sa..a s w *.< s x+c >` -4sm aan'k.p, +zL M
{ P9 dtzYx%m2�'
CLAREMONT NURSING & REHAB CTR
1000 CLAREMONT. ROAD
CARLISLE, PA 17013-8805
(717) 243-2031
07/20/2012
Trust Fund
MILDRED A. LEBO 4413
DORIS E. JUMPER
35 Sinclair Road
MECHANICSBURG, PA 17055
Discharged 05/14/12
04/01/12 To 06/30/12
------------ --— —----------------- -----° -° -------------------------------------- °----------
Date Memo Withdrawal Deposits Balance
04/01/12 Balance Forward 104 . 64 104 . 64
04/05/12 APR SS 909.00 1, 013. 64
04/12/12 BC/APR,MAY,JUN (42949) 472 . 83 540. 81
04/15/12 APR NET INC DUE(42916) 391.19 149. 62 '
04/17/12 SHAMPOO / SET (4-9) --42908 12.00 137. 62
04/23/12 SHAMPOO / SET 4-16 (42908) 12 . 00 125 . 62
04/25/'12 APR TV CABLE (42965) 8 .00 117 , 62
04/30/12 interest for recon 04/30/2012 0 . 01 117. 63
04/30/12 HAIRCUT 4-30 (42908) 9.00 108 . 63
04/30/12 SHAMPOO / SET 4-23 (42908) 12.00 96. 63
05/11/12 MAY SS 909. 00 1, 005. 63
05/15/12 MAY NET INC DUE (43037) 864.02 141. 61°
05/31/12 interest for recon 05/31/2012 0.01 141. 62
06/22/12 final interest calculation 141 . 62
06/22/12 Final Withdrawal to Inactivate 141. 62
06/22/12 DORIS JUMPER/CLOSE 1/2 (43152) 70.81 70.81
06/22/12 LINDA TRIVELY- 1/2CLOSE (43157) 70. 81 0 . 00
Ending Balance 0.00
REV-1509 EX+(m-10)
pennsyivania SCHEDULE F
DEPARTMENT OF REVENUE
INHERITANCE TM RETURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Mildred A. Lebo 21-12-1114
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVMNG JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A.
S.
C.
JOINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY % DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND HANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH OM FOR JOMY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS W'EREST
I. A.
0.00
TOTAL(Also enter on Line 6, Recapitulation) $ 0.0
If more space Is needed, use additional sheets of paper of the same size,
REV-1511 EX+ (10-09)
`pennsytvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT -
ESTATE OF FILE NUMBER
Mildred A. Lebo 21-12-1114
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1, Hoffman Roth Funeral Home 11,100.90
2. Chef Exclusive,LLC, Reception 905.86
B, ADMINISTRATIVE COSTS:
i, Personal Representative Commissions; -
Name(s)of Personal Representative(s)
Street Address
City _ _State ZIP
Year(s)Commission Paid:
Z. Attorney Fees: 600.00
3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation,) _ _ _ .0.00
Claimant
Street Address
City_ _ State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 100.50
S. Accountant Fees;
6. Tax Return Preparer Fees:
7, Legal Advertising-Carlisle Sentinel - 104.80
8. Legal Advertising-Cumberland Legal Journal 75.00
TOTAL(Also enter on Line 9,Recapitulation) $ 12,887.06
If more space is needed,use additional sheets of paper of the same size.
. r
219 Norlh HonoverShest
Cortl4e,Penrwilvania 17013
717.243.4511
tab free 1.866.451,4511
Fax 717.243.3723
w w fo&r aldh.com
FUNERAL HOME & CREMATORY, INC. r10@h0ffn1MTCftC=
July 6, 2012
Linda Trively
40 West Lauer Lane
Camp Hill, PA 17011
Statement of Funeral Expenses for: Mildred Alma Lebo
Date of Death: May 14, 2012 Account Id: 16545-111
PACKAGE:
Traditional Funeral Service
TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,650.00
Sub Total: $ 4,650.00
MERCHANDISE:
Casket Province) $ 3,165.00
Outer Container Monarch-Concrete Vault $ 1,420.00
Sub Total: $ 4,585.00
TOTAL FUNERAL HOME CHARGES: $ 9,235.00
CASH ADVANCES
Letort Cemetery $ 1,100.00
4 Certil$66 Death Certificates at$6.00 each ` $ 24.00
Newspaper Notice-Sentinel $ 198.96
Newspaper Notice-Patriot $ 38192
Flowers $ 159.00
Sub Total: $ 1,865.90
Total Funeral Expense: $ 11,100.90
Total Payments Made: $ 9,235.00
Payments Made:
Homesteaders Check 469675 May 29,2012 5,443.46
Anticipated Insurance(disc) Discount May 29,2012 3,450.00
PreNeed Disc Discount May 29,2012 341.54
Balance: S 1.665.90
-------------------------------------------------------------------------------------
Please return this portion with your Remittance.
$ Amount Enclosed
Mildred"Alma Lebo
Service ID#: 1.6546-111
SERVING OUR COMMUNITY SINCE 1907
Chef Exclusive LLC invoice
330 B Louther St
Carlisle,PA 17013 Dale I&'Oice# '"
(717)388-3000 05t17t2012 776
http://www.chafexclusive.com
Net 10
'Linda Trively - Linda Trively
40 W.Lauer Lane
Camp 1611,Pa 17011
717-761.4888
717-543-7314
Jeremy Sunday
ACtlVtty r, k. ' < QUatltiy? {'yat0 " -'�motlnt
•Cold Cuts wt Tea Roils;Turkey,Ham and Roast Beef 50 14.951 747.50T l
•Fresh Fruit Tray 50 0.00 O.00T
•Vegetable Tray 50 0.00 O.00T
50 0.00 O.00T
•Service Feels}Room Rental 1 25.00(( 25.00
•coffee,juice and soda 50 125 62.50T
E
i
Delivering Professional Catering&personal Chef Services SubTotal $835.00
Tax(B%) $48.60
Total $883.60
Payment $883.60
Bat � „ Sa Q0
.��v b�ourmer�r
Carlisle,PA 17013 ,4a(e
780
(717).388-3000 OS/I9/2012
�..._ -j
hupa/w .cheIexcluaive.cam
Net 10
Linda Trively
I
•Orem Beans Salad NNW 1 12.00{ 12.00T
•Macaroni Saladipasta j 1 9.00{. 9.00T
I
1
i
j
I �
E
i
I
!
I
4 F
I
ubTotal( S'21.00
Delivering Professional Cater*&Personal Chef Services 9
......._
____----
Tax(6%)I 51.26
_._ _.._.._ Tota S=.261
Payment $22.26
�a1HtiCefJiig ,__ SO.
RECEIPT FOR PAYMENT
GLENDA FARMER STRASBAUGH Receipt Date: 10/16/2012
Cumberland County - Register Of- Wills Receipt Time: 13 :18:50
One Courthouse Sguare Receipt No. : 1071745
Carlisle, PA 17Q13
LEBO MILDRED A
Estate File No. : 2012-01114
Paid By Remarks: LINDA K TIVELY
CJ
----------------------- Receipt Distribution - -----------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 45 ,00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 .50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 .00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 12 . 00 CUMBERLAND COUNTY GENERAL. FUN
----------------
Check# 6153 100.50
Total Received. . . . . . . . . 9100.50
e�
U
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tale: (717)249-3166 Fax:(717)248-2663
April 5, 2013
Cumberland Law Journal is published every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the official legal
publication for Cumberland County and the legal newspaper for publication of legal
notices.
TO: Michael Cherewka, Esquire
RE: Mildred A. Lebo Estate
Legal advertisements must be received by Friday Noon, All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on the following dates:
March 22, March 29, and April 5, 2013
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 0 .00
Total Amount Due $ 75.00
Payment received by
REV-1512 Ex+(12-12)
pennsytvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENTr
INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Report debts incurred by the decadent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
REM VALUE AT DATE
NUMBER DESCRIF110N OF DEATH
1. Cdtrernont Nursing&Rehab Center 864.02
TOTAL(Also enter on Une 10,Recapitulation) $ 864.02
If more space is needed,insert additional sheets of the same size.
CLAREMONT NURSING & REHAB CTR
i 000 CLAREMONT ROAI3
CARLISLE PA 17013-8805 Statement Date 5/16/2012
, (7-17)243-2031
Please remit payment by 6/1/2012.Thank Services Provided For.
you LEBO,MILDRED A 4413,
DORIS E.JUMPER Admitted:02/01/2004 Discharged: 05/14/2012
35 Sinclair Road
MECHANICSBURG,PA 17055 Pay this Amount: 0.00
Make checks payable CLAREMONT NURSING&REHAB CTR
-------------------------------------.._,...---------------------.-----------------------------
LEBO,MILDRED A 4413 Statement Date 5/16/2012
Date Description of Service Current Balance
05/01/12 BALANCE FORWARD 864.02
PAYMENTS
05/15/12 Payment 43037 -864.0
ROOM CHARGES
05/01.05/31112 Rev Last Mo PP -864.02
05/01-05/13/12 Private Portion 864.0
BALANCE DUE 0.00
REV-1s 13 EX+(01-10)
s pennsylvania SCHEDULE a
bEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Mildred A. Lebo 21-12-1114
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trvat*s) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9118(a)(1.2).)
I. Linda K.Trively,40 Lauer Lane,Camp Hill,PA 17011 Daughter 1/8
2. Sue A.Raffield, 13210 Vernon Drive,Cypress,TX 77429 Daughter 1/8
3. Alice E.Feister,94 Schlouch Road,Mohnam,PA 19540 Daughter 1/8
4. Doris E.Jumper,35 Sinclair Road,Mechanicsburg,PA 17050 Daughter 1/8
5. Donald R.Lebo,5071 NW 66th Place,Ocala,FL 34482 Son 1/8
6. James W.Lebo,913 Lancelot avenue,Mechanicsburg,PA 17055 Son 1/8
7. Janet M.Brymesser,1640 Leidigh Drive,Boiling Springs,PA 17007 Daughter 1/8
8. Carolyn M.Ross,204 North 32nd Street,Camp Hill,PA 17011 Daughter 1/8
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
i 0.00
B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
0.00
TOTAL OF FART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0.00
If more space is needed,use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
OF
MILDRED A. LEBO
I, MILDRED A. LEBO, a resident of 1534 Leidigh Drive, Boiling
Springs, Cumberland County, Pennsylvania being of sound mind,
memory and understanding, do hereby make, publish and declare this
to be my Last Will and Testament, hereby revoking all wills and
Codicils heretofore made by me.
ITEM 1: I direct that all my just debts, the expenses of my
last illness and funeral expenses be paid as soon after my decease
as the same can conveniently be done.
ITEM 2: I direct that there shall be paid out of my residuary
estate all estate, inheritance and like taxes together with any
interest or penalty thereon imposed by the government of the United
States, or any state or territory thereof, or by any foreign
government or political subdivision thereof, in respect to all
property required to be included in my gross estate for estate,
inheritance or like tax purposes by any of such governments,
whether the property passes under this Will or otherwise,
excluding, however, any property over which I have a taxable power
of appointment, provided, however, that no residuary beneficiary
shall by reason of this provision be denied the benefit of any
deduction, credit, favorable rate of tax or other benefit which by
law enures to such beneficiary.
MILDRED A. LEBO
1
LAST WILL AND TESTAMENT
OF
MILDRED A. LEBO
ITEM 3 : I give, devise and bequeath all of the rest, residue
and remainder of my estate, real, personal and mixed, of whatsoever
kind and nature, and wheresoever situate at the time of my death,
in equal shares, unto my children, ISABEL A. SHUMBERGER, DORIS E.
JUMPER, JAMES W. LEBO, BETTY J. WERTZ, DONALD R. LEBO, JANET M.
BRYMESSER, CAROLYN M. ROSS, LINDA K. TRIVELY, SUE ANN RAFFIELD and
ALICE E. FEISTER, provided, however, that they survive me and are
living sixty (60) days after the date of my death.
ITEM 4: I hereby nominate, constitute and appoint my
daughter, LINDA K. TRIVELY, Executrix of this my Last Will and
Testament, with full power to do any and all things necessary for
the complete administration of my estate, and direct that no bond
or other surety is required of her in this or any other
jurisdiction for her performance of this office.
If and in the event that my daughter, LINDA K. TRIVELY, does
not survive me and is not living sixty (60) days after the date of
my death, or does not complete her duties as Executrix, then and in
such event, I hereby nominate, constitute and appoint my children,
DORIS E. JUMPER and JAMES W. LEBO, Co-Executors of this my Last
Will and Testament, with full power to do any and all things
necessary for the complete administration of my estate, and direct
MIL RD D A. LEBO
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LAST WILL AND TESTAMENT
OF
MILDRED A. LEBO
that no bond or other surety is required of them in this or any
other jurisdiction for their performance of this office.
ITEM 5: If any provision of this Will or of any Codicil
hereto is held to be inoperative, invalid or illegal, it is my
intention that all the remaining provisions thereof shall continue
to be fully operative and effective, so far as is possible and
reasonable.
IN WITNESS WHEREOF, I, MILDRED A. LEBO, the Testatrix, have to
this my Last Will and Testament, typewritten on three (3)
consecutively numbered pages, subscribed my name and affixed my
seal this J70t day of
47 cil � {SEAL}
Signed, sealed, published and declared by the above named MILDRED
A. LEBO, as and for her Last Will and Testament, in the presence of
us, who have hereunto subscribed our names at his request, as
witnesses hereto, in the presence of the said Testatrix, and of
each other.
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