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Home My WebLink About03-28-13 (2) --� REV��I��O 1505610],43 �{o,_,a, �: OFFICIAL USE ONLY PA Department of Revenue �nnsylvania co�,rEty cade raar F��e r�um� BureauaflndividuaiTaxes �p�TMEN7QFREVENUE PO BOX.280601 INHERITANCE TAX RETURN 21 1�� 4�0 0�? Harrisburg,PA 17128-060'1 RES#DENT DECEDENT ENTER DECEDENT INFORMATtON BELOW Social Security Number Date of Death �ate of BirEh 12 07 2t�11 12 15 193tJ Dec�edent's Last Name Suff"a Decedent's First Name MI H4LLIS LUCY C (If Applicabie)Enter Surv�ving Spouse's Informatian Below Spouse's Last Name Suffix Spouse's First Name MI �it?LL I S Rt�BERT J Spouse's Social SecurityNumber THIS RETURN MUST BE FILED tN DUPLICATE WITH THE RE��STER t3F WIL.�S FILL IN APPROPRIATE OVALS BELOW � 1. 4riginai Returr► ❑ 2. Suppiementai Retum � 3.Remainder Retum(date of death prior#0 12-13-82) ❑ 4. Limited Estate � e��,Future ir�terest Compromise � 5. Federai Estate Ta�c Retum Required (date of death after 12-12-82) � g. Decedent oied Testate � 7 decedent Mairrtsined a Living Trust � 8. Total Numt�r of Safe Deposit Baxes (Attach Copy of Will) (Attech Copy of Trust) ❑ 9. Litigation Proceeds Received � �p,Spousal Paverty Credit(da#e of death � ��,EleCtion to tax under SeC.9113(A) between 12-31-91 and 1-1-95) (AttBCh SCh.Q} CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX IN�MATION SH(Ii�D BE DIRF�TED TO: N�� Daytim��ei�phone N�1tfr#aer rn � SCOTT M D INNER E SQ 71'7�1�1 5$�0 � � x c� REG��L�IJSE�d�TM� � � First line of addfess � � ��' � �� 311? CHESTNUT STREET :� � �,� �' � � �� .�_ �w-r -,� �..�. Second I�ne of address A � Cr� C� �^.7 `�7 DATE�ILED City or Post Office State ZIP Code CAMF HILL PA 17011 correspon�entts e-nnai�addres.s: d�n n e c�10�a t n e#.c o m Under penalties of periury,I declare ttrat 1 have examined this retum,including accompanying schedutes and statements,and to the best of my knowledge and belief, it is true,co�artd comple#e.Declaration af preparer othee than the personal representative is based an atl infamnatian of which preparer has any knt�rtedge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE /��r Robert J.Hollis �QR � � ��1� . ADDRESS 4a rchard Lane,Mechanicsburg,PA 17055 SiGNA RE 0 .' RER aTHER RESENTATIVE pATE � IIIIAm ��„ Scott M[}inner Esq MAR � 1 �013 RESS 3117 Ches#nut Street,Camp Hiil,PA 17011 Side 1 � 151]561�143 15�561�14� � � 1505610243 REV 1500 EX Decedent's Social Security Number DecedenYs Name: H O L L I S, L U C Y C. RECAPITULATION 1. Real Estate(Schedule A)........................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................... .......... 2, 4 4 , 7 3 4 . 8 9 ........................................ 3. CloselyHeldCorporation,PartnershiporSole-Proprietorship(ScheduleC).............. 3. 4. Mortgages&Notes Receivable(Schedule D)............................................................ 4. 5• Cash;Bank Deposits 8�Miscellaneous Personal Property(Schedule E).................... 5. 6. JointlyOwnedProperty(ScheduleF) ❑ SeparateBillingRequested.............. s. 3 6 , 3 0 9 . 3 9 7. Inter-Vivos Transfers 8�Miscellaneous Non-Probate Property (ScheduleG) ❑ SeparateBillingRequested.............. 7, 10 , 310 . 3 4 8. TotaFGross Assets(total Lines 1-7)........................................................................ 8, 91 , 3 5 4 . 6 2 9. Funefal Expenses 8�Administrative Costs(Schedule H)............................................ 9. 12 , 13 9 . 5 0 10. Debts of Decedent,Mortgage Liabilities,8 Liens(Schedule I)................................... 10. 1 , 2 0 0 . 0 0 11. Tota1 Deductions(total Lines 9&10)................................................................ �� 13 , 3 3 9 . 5 0 12. Net Value of Estate(Line 8 minus Line 11).............................................................. 12. 7 8 , 015 . 12 13. Charitable and Govemmental Bequests/Sec9113 Trusts forwhich an elcction to tax has not been made(Schedule J).................................................... �3, 14. Net Value Subject to Tax(Line 12 minus Line 13)................................................... 14, 7$ , 0 15 . 12 TAX COMpUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at thespousal tax rate,or transfers underSec.9116 (a)(�.�)x .o0 3 6 , 0 0 2 . 6 4 15• O . 0 0 16. Amo�int of Line 14 taxable atlinea�ratex .oa5 4 2 , 012 . 4 8 �s. 1 , 8 9 0 . 5 6 17. Amo�nt of Line 14 taxable at sibling rate X .�2 17. 18. Amo�nt of Line 14 taxable atcollateralrateX .15 18. � ......... 1 , 890 . 56 19. Tax Due................................. ........................................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑ Side 2 � 1505610243 1505610243 � REV-1500 EX Page 3 File Number 21 - 11 - 00047 Decedent's Complete Address: DE EDENT' NAME Hollis, Lucy C. STREET ADDRESS 801 No. Hanover Street CITY STATE 21 P Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 1,8 9 0.5 6 2. Credits/Payments A• PriorPayments B. Discount Total Credits(A +g) (2) 0.00 3. Interest (3) 31.31 4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT. �4� Check box on Page 2 Line 20 to request a refund - 5. If Line 1+Line 3 is greater than Line 2,enter tfie difference. This is the TAX DUE. (5) '�,9 2�.8 7 Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTI4NS BY PLACING AN"X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transferand: Yes No a. retain the use or income of the propertytransferred:..................................................................................... � 0 b. retain the right to designate who shall use the property transferred or its income:.......:::::::::::::::::::::::::::::::::: � � c. retain a reversionary interest;or................................................................................... � x d. receive the promise for life of either payments,benefits or care?.................................................................. � 0 2. If death occurred after December 12, 1982,did decedent transfer property within one year of death without receivingadequateconsideration?.......................................................................................................................... ❑ 0 3. Did decedent own an"in trust for'or payable upon death bank account or security at his or her death?............... � �x 4. Did decedent own an Individual RetirementAccount annuity orother non-probate propertywhich containsabeneficiarydesignation?........................................................................................................................ 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. 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 January 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)j. The stafute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax retum 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 transfe�s 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. � �..' SCHEDULE B "'� STOCKS & BONDS COMMON W EALTHOF PENNSYLVANIA INHERRANCETAXRETURN RESIDENTDECEDENT FILE NUMBER ESTATE OF HO��IS, �.UC�/ C. 21 - 11 -00047 Ali property jointly-owned with right of survivorship must be disctosed on Schedule F. ITEM DESCRIPTION UNIT VALUE VALUE AT DATE NUMBER OF DEATH 1 110 shares of Wai-Mart Stores, Inc. common stock 58.73 6,460.30 cusip#: 931142103 2 315 shares of the Walt Disney Company common stock 36.895 11,621.93 cusip#:254687106 3 381.8 shares of American Express Company common stock cusip#: 48.53 18,528.75 025816109 4 2,654.872 shares of the Janus S-T Bond Fund D shares 3.06 8,123.91 TOTAL(Also enter on line 2, Recapitulation) 44,734.89 +,. -� SCHEDULE F COMM HER ANCETAXRETURN ANIA JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Hollis, Lucy C. 21 - 11 -00047 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 Robert J. Hollis 401 Orchard Lane Husband A Mechanicsburg, PA 17055 Alan E. Gioger 814 Kenneth Place SE Son B Leesburg,VA 20175-8984 JOINTLY OWNED PROPERTY: DESCRIPTION OF PROPERTY o ITEM LETTER DATE DATE OF DEATH �o OF DATE OF DEATH NUMBER FOR JOINT MADE Include name of financial institution and bank account number UALUE OF ASSET DECD'S VALUE OF TENANT JOINT similar identifying number.Attach deed for jointly-held real estat . INTEREST DECEDENTS INTEREST 1 A, B 10/01/1972 PNC Bank NA checking account 2�4,aa9.00 16.7% 35,742.21 no. 5140029895 2 A, B 10/31/2000 PNC Bank NA savings account s,4o3.00 16.7% 567.18 no. 5003181145 TOTAL(Also enter on line 6,Recapitulation) 36,309.39 . •,. -'� SCHEDULE G COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TRANSFERS & INHERITANCE TAX RETURN RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY ESTATE OF HOIIiS, LuCy C. FILE NUMBER 21 - 11 -00047 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH �D�f EXCLUSIQN NUMBER �►x�ude the name of the transferee,their relationship to decedent VALUE OF ASSET DECD'S (�F qppLICABLE) TAXABLE VALUE and the date of transfer. Attach a copy of the deed for real estate. INTEREST 1 Thrivent Financial for Lutherans variable annuity �,40�.�4 100% 1,401.74 contract[IRA]LC3365826;beneficiary is decedent's grandchild (see attached contract value statement) 2 Thrivent Financial for Lutherans variable annuity a,sos.so 100% 8.908.60 contract[IRA]LC3365829;beneficiary is decedent's grandchild (see attached contract value statement) TOTAL(Also enter on line 7, Recapitulation) 10,310.34 • .,.' 9CI-�IJI.E H •M �w��M coMMOwwEw.TM oF a�NNSr�var�u► INHERITANCETAXRETURN ��'�'w/C�� RESIDENTDECEDENT ��rG FILE NUMBER ESTATE OF H011is, LuCy C. 21 - 11 -00047 Debts of decedent must be reported on Schedule I. ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 Malpezzi Funeral Home 5,792.00 8 Market Plaza Way-Mechanicsburg, PA 17055 2 funeral refreshments/fee for religious service 425.00 B. ADMINISTRATIVE COSTS: 1. PersonalRepresentative'sCommissions Name of Personal Representative(s) StreetAddress City State Zip Year(s)Commission paid 2. Attorney'sFees Scott M. Dinner, Esq. 2,250.00 3, Family Exemption:(If decedent's address is not the same as claimant's,attach explanation) Claimant Robert J. Hollis 3,500.00 StreetAddress 801 No. Hanover Street City Carlisle State PA zip 17013 RelationshipofClaimanttoDecedent SpOUSe 4. ProbateFees Cumberland County Register of Wills 172.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. OtherAdministrative Costs 1 TOTAL(Also enter on line 9, Recapitulation) 12,139.50 . SCHEDULEI � ''� DEBTS OF DECEDENT, MORTGAGE �M COMMOMNEALTHOFPENNSYIVMlW LIABILITIES & LIENS INHERITANCET/UCRETURN ! RESIDENTDECEDENT FILE NUMBER ESTATE OF HO��IS, LUCy C. 21 - 11 -00047 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,i�cluding unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 unpaid coom/board charges-Church of God Home 1,200.00 801 N. Hanover St., Carlisle, PA 17013 TOTAL(Also enter on Line 10, Recapitulation) 1,200.00 r REV•1513 EX+(11-08) . . -� SCHEDULE J COMMN ERITANCE�TAXRETURN�� BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Hou�s, Lucy C. 21 -11 -00047 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER N�►ME AND ADDRESS OF PERSON(S) DECEDENT (Wa�S� �$$$� RECEIVING PROPERTY DoNotUstTrustes(s) I� TAXABLE DISTRIBUTIONS[includeoutrightspousai distributions,and transfers under Sec.9116(a)(1.2)] 1 Robert J. Hoilis Husband 401 Orchard Lane Mechanicsburg, PA 17055 Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate. II� NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN , B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 Thri�ent �ir�ancial for� Lutherans• December 14, 2011 Estate of Lucy Cherie Hollis 401 Orchard Ln Mechanicsburg PA 17055-6142 Subject: Estate of Lucy Cherie Hollis IRA Contract LC3365826 To Whom It May Concern: Thrivent Financial for Lutherans is required by the Internal Revenue(IRS)to report the contract value as of the date of death to the estate of Lucy Cherie Hollis. The IRS form 5498 will be sent to the above address in January of next year. Form 5498 will report the fair market value of the IRA plan to Lucy Cherie Hollis's estate. � . This letter should be retained for income tax purposes when filing the decedent's income tax return. Date of Death: 12/07/2011 Contract Value as of Date of Death: $1,401.74 If you have any questions regarding the above information, please contact your Financial Associate, CHRISTOPHER R VANHART,whose telephone number is 717-525-9535. You are also welcome to call Thrivent Financial for Lutherans at 800-847-4836. �, Sincerely, Death Claims Death Claims&Services Product Services Department, FSO Cc : CHRISTOPHER R VANHART 0165 45433 00 Lucy Cherie Hollis , deceased, Contract#LC3365826, CIF#503435827 � ; ;_. Deceased's Customer ID: 503435827 , • • • ��1"I1��1�t �l�'I��'l�l�l for Luth�rar�s� � December 14, 2011 � Estate of Lucy Cherie Hollis 401 Orchard Ln Mechanicsburg PA 17055-6142 Subject : Estate of Lucy Cherie Hollis IRA Contract LC3365829 To Whom It May Concern: --- - - Thrivent Financial for Lutherans is required by the Internal Revenue(IRS)to report the contract value as of the date of death to the estate of Lucy Cherie Hollis. The IRS form 5498 will be sent to the above address in January of next year. Form 5498 will report the fair market value of the IRA plan#o Lucy Cherie Hollis's estate. This letter should be retained for income tax purposes when filing the decedent's income tax return. Date of Death: 12/07/2011 Contract Value as of Date of Death: $8,908.60 If you have any questions regarding the above information, please contact your Financial Associate, CHRISTOPHER R VANtiART,whose telephone number is 717-525-9535. You are also welcome to call Thrivent Financial for Lutherans at 800-847-4836. , Sincerely, c, Death Claims D�ath Claims&Services Product Services Department, FSO Cc : CHRISTOPHER R VANHART 0165 45433 00 : Lucy Cherie Hollis , deceased, Contract#LC3365829, CIF#503435827 - .. .__.� Deceased's Customer ID: 503435827 .... .��i�� :: �� . .�. - . . .. . � � . . . . -_ . � . .y_:> . . � .r •: . ; . . � � . � .,}, � PfNWSYLVANIA INHERITANC�I"AX euR�►u o� rNOrvrnu�i� rnx�s � �WF�RMATItIN NOTICE '� FI�E N0. 21 12-0047 Pa aox Zao�so� �C'11115�1'IYd1113 AND ACN I21.25650 NARRISBURG PA I7I28-060I DEPAR7MENTOFREVENUE ,TAXPAYER �E�PONSE DATE 04-16-2012 REY-l543 EX AfF t�5-111 , : . TYPE �F ACCOUNT EST. -OF LUCY C HOL.LIS ❑ spv�wss SSN I90-22-2548 � ct��cKixs DATE OF DEATN �2-a 7-2 o i]: ❑ TRUST C�UNTY CUMBER�AND [� CERTT�. REMIT PAYMENT AND �ORMS T0: ALAN E GlOGER REGISTER UF WIt�LS � 814 KENNETH PL SE 1 COURTHUUSE SQUARE �EESBURG VA 20175-8984 CARLISLE PA 17D13 PNC $ANK NA prov#ded Che de�ertment �rfth the infarmation below. rthich was used in catculating the fnheritance t8x due. Records indicate titat at the death of the abave-named decedent, yau were a �o1nt owner/beneficia�y of this account. If you ePe th@ SpOUSe af the deceased and any amount other than zero is reflected below on the Potential Tax Due line. note �o tax mey be due. but you must natify the depart�ent af yaur relationship to the deceased by checking Sox G 1n PART l be'{ow and x�iting "spouse" jn PART 2. If you beiieve �Etse information is incorrect, please obtain written correctian fram the financial institutian. attach a capy to this farm and return it to the ab6ve address. Please ca11 717-787-8327 with questions. CCIMPCETE PART 1 BE�(�W � SEE. REYERSE SI`DE FC}R FIIING AND PAYMENT INSTRUCTICtNS Accour►t Na. 514002�895 Date 10-01-1472 To ensure p�oaer credit to the accaunt, txo ;� Estat�lished copies of this notice •ust acca�var�y ACC4Ut1� $�3,at1C$ 2I4 �}�}� (�Q PayMent to th� Register af Wills. Make check $ ! * payable t�t-"Register cf Wills: Agant". Percent Taxable X ],6.667 NOTE: If tax pasr�ents are �ade within three Ai�aunt Sub�ect to fiaX $ 35�7�t2.2� wonths of the decedent's date of death, Tax R�ate X ,p45 aedu�t a 5 percent da.scaunt on the tax due. Anv inhe�itanae #au due will beco�a delinvu�r�t Ppte�ltial Tax Due � ��1$.�i� nine won#hs after the date of death. pA�t _ , : TAXPAYER RESPt�N�E ak� � .� i h :f � �� ,,,�t�`r..��F,��,��..��' ��.��,`"�'t��.'��.L`��.,��tkY<��:�!n��` A. �The above infarnation �nd ta�c due is correct» Re�it aayeen# ta the Registe.r af Wil�s Kith #ao copies of this notice to obtain CHECK a discount.or �void interest, ar return this notice to the Register of Wills and an official axsesseent will b+a issued by the PA Departwent of Revenue. tINE BLOCK 6. �he above asset has been or aall be reparted and tax t�aid with the Penr�sylvania inheritante tax rgturn ONLY fi2ed by the estate representative. C. � The abave inforsa ian is incorrett and/or debts and deduc#ions were paid. CawPlete RART �2 andlar PART 3� beloRt. PART If indicating a different tax rate, please state �'� �� , ��' ��" relationship ta decedents ��,�� °��Yj� �' `�a�" b�� 2 �. x�� z� ^� �, *� '� �.� . . . � . . . . . z� � °1��' w&�a.� �. x ❑ � � �� f�i�r`� ��srx�'a`�� ."�"�' ��3.,. ��e.�. - TAX RETUt�W' � CAICU�ATIt}N �F TAX ON JDINTfTRUST AGCOUhtTS �J�� `�� '°r��r =� LINE 1. Date Established 1 ��'� '�� `�`�� . . ..m �]._ r 4 rh ..i ,� a x „�'w '�ts�i.�aE� h a�. y, . »ff,,..2"1 i T. �. Account Balance 2 �°�v� � `a r�r�''�� e��'`�'�`� 4 � .'��► � >..a�Zl s�� s ��', '�n� «e`m'� �' , . c � k ��9a'��`�,�"'�i1�" .A'z�..'�"x��Ac��'^'sdy��.�.:.� � �wit. ,§ 3. �ercer�si. Taxabi� 3 x �� 3 4. Amount Sub�ect to Tax 4 � •��^'� ��"�'�"5`�� `��'�� '�`.�T�4',.z �,°^ �'�� ,�+s��.�:'?zaa�;`� '� '�3fi � ,.�i. Debfis r�iS� �@tfUCt3.t}CIS ;l � ' �x� S,k^ s5s;:;3a�.a`�s�c ��'��u�� v�� #��y� � . . . . . �i�'rr��.yw�. aw'�,Y�a"�,w.e'�.�£" �,,,.;�q?FY'��'�:�C«; �.� �, . b. Ameun# TaXable 6 �`��.��.�� <��.w �v�,��Y�� '� '' �� .,. . 3�t��,� �� 1� ��;Y x� �� . � � 7. Tsx Rate 7 � � � � ��•�,��'�� : x .�� ^� .: �� ^Fy�'�.3�'�.F�"��'�tk !.�d`�a�. r�"' a��"�auY �ts.io.�,a.�' s. r,�x 8�,� $ $ ��;.��.�ti��: ��.�� _�. �.;._. � ;.�x� �x� _.�:�� pART DEBTS AND DEDUCTIONS CLAIMED � � DATE PAID _. PAYEE DESCRIPTIQN AMt3UNT FAID TO7A1. tEnter ort Line 5 of Tex ComPutation� S �Under penalties of per3ury, i declare that the facts I reported above are true, correct and complete _to the best�of �Y knowl.edge and belief. HCIM� C.�1 � } Z.��'" �3 �� : , . woRK c s; � 2�- �3 S'�� . � . . �r t��Ir1�-��i:�+i� A�T..►�.1 r.�.•..,..— � . . . . . . � h��:.�. � j� PEHNSYI..VANIA IirINERtTANCr �"�TAX ■u�En,u oF �Na�v�oua� r�ucES INFORMATION NOTICE � FI�E No. 21 12-Op47 Po aax aao�oi pennsytvania AND ACN 12125b52 HARRISBUR6 PA I712$-ObQ2 pEPAR7MENTOFREYENUE TAXPAYER RESPONSE DATE 04-1b-2ti12 . REY-1543 EX AFP(05-11) . TYPE OF ACCOUNT EST. OF LUCY C NOLI.IS � SAVINGS $SN 19(1-22-2548 . ❑ CHEC�cIN� DATE OF DEATH 12-07-20I1 ❑ ;��T GOUNTY CUMBER�AND Q ��'FF• REMIT PAYMEFtT AND FORMS T0: ALAN E �Lt�GER REGISTER OF WILLS 814 KENNETH P� SE 1 Ct3URTH0USE SQUARE �EESBURG VA 201fi5-8984 CAR�ISLE PA 17U13 P N C BANK NA provided the department with the information below, which was used in calculating the lnheritance tax due. Records indicate that at the death of the above-named decedent, you xere a joint ownerlbeneficiary of this account, If y0U 8i"� th8 Sp0US2 of the deceased and any amaunt other than zero is reflected below on the Potentlal Tax Due line, note no tax may be due, but yau �nst natify the department af your relatianship to the deceased by checking Box C in PART 1 belaw and writing "'spouse" in PART 2. lf you believe the inforatatian is incorrect, please obtain written correctio� from the €inancial institution, attacn a capy to this form and return it to the above address. Please call 717-787-8327 with questions. CLIMPLETE PART 1 BELOW * SEE REYERS� SIDE F4R FILIN6 AND PAYMENT INSTRUCTIONS Accaunt No. 5003I81145 Date 10-31-2000 To ensure p�ooer credit ta the account, two Established capias of this notice wust accowpany ACCaunt Balance 3 �t1�3 p0 ��i8°t ta the Register of irti2ls. M'aka chock v'�f` � • payable to Register af Wills: Agent . , Pe�cent Taxable X 16,667 Amount Subject to Tax �,► !�b7«3$ NOTEx If tauc pay�entsfare Nade within threa ■ontfis of the decedent s data of dea#hr Tax Rate �( .045 deduct a 5 percent discaunt on the ta�c du�. Potential Tax Due $ 25�52 At►X inheritance tax due xi21 beco�r� dalinquent nine wonths after tha data of death. paRT TAXPAYER RESPQNSE � `G.a .:.. ,�h -�,`�4 'Y � k �h �.. . S . . p Y' S t: E'"� 4 ��. . � ��..��x��s�� :��..�r��:��,��x��.x > �� F . ,... �'�w��'da..... ��,,."�y.a��w�(:�1.Ss.;.. �+^.,..,i`i t�',�.'?�.x.,?'+.::1<.�...,,4".��<�f Rav r e.:l�.�..a�r�.., FaY .,�.'�.. ..>�..�''�'.��k� �, �e � . r v.�:F4� d�� '�.s< . *V� `�".,.1,_ �;�f,l��,:a.:SX,a . A. � The abave ir►for�atian and tax due is carrect. Re�it pay�ent to the Register af Wi21s with two copies of this notice to abtain C H E C K a discount or avoid i�terest, or return this notice to the Register of Wills ar�d O NE an afficial assess�ent will be issued by the PA Depa�r�tMen# of Revenue. B L C1C K B. The BISOY@ a;se# has besn or will ba reported and tau paid aith the Psnnsylvania inheritance tax retur�n 0 N�Y filed tpr the estate representative. , , " C, � Tha abave informa ian is incorrect andJar^ debts and deductions were paid, Co�plete PART �2 andlat^ PABT � bela+. PART If indicating a different tax rate: please state ��,�,��"��,;��:��s "� # F � � � ' �:. . 2i relationship to decedent: ��x�'��r ""� '"��w� <�' k'� � " a� ��"r��}��, ��',�� , Y ��t �''`�`x°�`i'��k�'�*i�r�d.r�+'��'� , y � ' r � TAX RETURN - CAI.CUTATIt3N CiF TAX CiN J[1INTlTRUST ACCOUNTS � �� .��x�� ,�,�� .iNE 1. Date Established 1 ��g �` ` "R �� tr��i,�,et�y�.��,.Y`� 2. Account Balance 2 -� '��, �`�� a ��~��v � �.� 3. Percent Taxeta3o 3 X `�� a�'� ��`4`� '� . .�,��,��;•.�s.� ��- 4. Amaunt Subiect to Tax 4 � ��,�".-,:<°��,�{�'• ��.v e �r� 5. Debts and Deductians 5 - �� `.� .�� '� ",`° . ..� � 6. A�ount Taxable 6 � � .�< � ,� ��G ��}' $ � `� ��. .�� '�;�� / �y �4 +eR�,A�'�"'�tn'1� *.A . ^�r•�'4 7. �8 X �3 t@ 7 Il 5a F a� x�`.. �n'�� fi'f 3r�e�'� � ` �'�.�>�'...i k£�°'�'. �� ".. $. Tax Due � � �'�'x��e r�3v'�'roa�s&�im ^'fia;��..��.� - �r:.;K,i� ..'w:a s7 .....�i�aF' .v�9�"k,s„ .�. Fa�� DEBTS AND DEDUGTIONS CLAIMED � DATE PAID PAYEE DESCRIPTI[}N AMOUNT PAFD 70TAL tEnter on Li.�e 5 of 'fax Co�Pu#ation� S Under per►a2ties of per,�ury, I declare that the facts I reparted above are true, correct and comPlete to the best .of �aY knaw edge and be2ief. HOME C S �'� � Z•S�'� —d�Z"3 �#I_ t . J�J+i r±�r.:.. Wnolf ! .__ . *► � •� . , r^� ,..�. ... __ . w nn.A t i