HomeMy WebLinkAbout04-01-13 (2) � � 1505610101
REV-1500 EX�°1_i°,
• OFFICIAL USE ONLY
PA Department of Revenue �����a y County Code Year File Number
DEPAPTMENT OFREVENUE
Bureau of Individual Taxes INHERITANCE TAX R�T13RN
PO BOX 280601
Harrisburg,PA 1�i2s-oso� RESIDENT DECEDENT / � � 6 8 7
ENTER DECEDENT INFORMATION BELOW
� � os $ o � ,Z o1 oS °e / 9 � 2
DecedenYs Last Name Suffix Decedent's First Name MI
, t:.. ,
oN �. ,ER . � R I L � �
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
l
_
Spouse's Social Securiry Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Return p 2.Supplemental Return O 3. Remainder Return(date of death
prior to 12-13-82)
Q 4. Limited Estate p 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required
' death after 12-12-82)
� 6. Decedent Died Testate p 7. Decedent Maintained a Living Trust � 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
��
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 1�.^�Election to ta�der�c.�13(A)
between 12-31-91 and 1-1-95) �{�ch Sch.b'f'� � �
CORRESPONDENT— THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFQ�IA N SHOULUBE DIR�T 0:
, Name Da e�l one�umber.� �C3
��� � �
. �
. e �t � ,e �y�F s � � � �.s� � � 1 � � � �
., ..,".;,�.> `�:.._� ,�>i�:':�.,.°�� .' . �«a�. �.;;'^f �,.--. . «.ha .� ;�"�Kt'.��.�ks�'r��i�3���:�^,,,.3:',.�%.'b..Y...is�,+�$,.;;:,,,. -�,.�;,''�adF�; �.
R 19�R O ILLS E-�NLY
� � � � �
C �
c.� � �.... r„� �
First line of address � --�
, „ - r;��'•wc�,;,. W. �tz�� r� �<:-�:. �... >,,� � ���z�.v,.;y�y�a����v,,.� ��€�N� � �„�
� � Q
6 CL Du � � � � a �A � y � � ' �, '�
�
'- . ... ..... ya,:_ _.. .._. .,�...�..� u2?nrrs�x.,�7�',�"� '-..a'�.�ti,�`.��.2 ��X-��,;,�����i�,a���<�..���y,�
,
. <
� '
� ,�
Second line of address
� . ' ,,.,... .. .: �L'� . .n,,'�... ��!���§a� a«� .��a"�, .. ��s;v��w;,m:;�, ,.
�./ , i:u � � � � �A ��;: � � � � � � � � . ,�
� � � � � .� � � .-�.f,.:�,sx. � ...�, � _._ .,_.
'...�,n...,.. �.�. ., , �.,,P,. ����l?s1R.A5.�Yr,� �±,�,��.,..'-"�.,»_..-. � '� t__�
�,
Ci or Post Office State ZIP Code DATE FILED
� � �
� � � � ��S � �
� � � y�9
, � l� � � � 1 7
� e ������i 3� c�s �.� ��, � � � � o�. S� �
; ... ����� � ��� � � �
e� � � � � �3 �
� ..' .� „�H ,.,�,� „ ��,,,,n�3t5'ar-�k.-, .'� ,�..eu.,.�?�'<C.'�:,.�..m.^..:. ...�v=:�-. . a.�fi.�a..�:.�h���';".,,, ,,��;a,� 1:..�c��. .
.. .. . . °�t�k'�.�r;•.,.:� 3r?� � . . .
Correspondent's e-mail address: _, G e�h iel�s 3Q Co�m ca,sfi• �e`
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.
SIGNATUR QF PERSON RESPONSIBL OR LING RETURN DATE
x ' 3 -� -- �
ADDRESS �LL/CLCNT J, IQF, ��N, SJ,.Thrls T�rive, �Q�tl�j��� /"�T' �7���
I
SIGNATU PRE ER R T PR TATIVE DATE
,3 L?/3
ADDRESS CrI�M�L � SH��� ,ii C��Ol�S�" pQq; /1'Ie�ha���Sbu�j �T �7�SS
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610101 1505610101
�
. t
� 1505610105 �
.
REV 1500 EX
Decedent's Social Security Number
/' r [� [��
� �
�� ��
RECAPITULATION
�
1. Real Estate(Schedule A). ............................................ 9. Q
2. Stocks and Bonds(Schedule B) ....................................... 2. � Q
• 3. Closely Held Corporation,Partnership or Soie-Proprietoiship(Schedule C) ..... 3. O
4. Mortgages and Notes Receivable(Schedule D)........................... 4. Q
: 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. r 3 '� �, �p
6. .lointly Owned Property(Schedule F) p Separate Billing Requested ....... 6. ;� � , , Q �
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) p Separate BiHing Requested........ 7. t , �p � a (o
8. Total Gross Assets(total Lines 1 through 7)............................. 8. � �] ,�T � � 7
�.
, 9. �uneral Expenses and Administrative Costs(Scheduie H)........ ........ ... 9. - g � b �p 6 �
10. Debts of Decedent,Mortgage Liabilities,and Liens(Scheduls I) ... ... ........ 10. ,, 9 �p / q
11. Yotal Deductians(total Lines 9 and 10)................................. 11. , g , �Q � $ 3
12. Net Value of Estate(Line 8 minus Line 11) ... ... ... ......... ... . . ....... 12. � � � � � �
13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which
....__
an etection to tax has not been made(Schedule J) ... ..... .... ... ...... ... . 13. . .. ('Q
14. Net Value Subject to Tax(Line 12 minus Line 13) ... . .. ....... ....... .... 14. ' 9.. / 7 � g q
TAX��ALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. ,14mount of Line 14 taxable
�t the spousal tax rate,or _
transfers under Sec.9116 -
(a)(1.2)X.00 � 15. D O
16. Amount of Line 14 taxable
at Iineal rate X.0� �. Q Q 16. O O
17. Amount of Line 14 taxable
at sibling rate X.12 a � � � � 17. 3 4 S I � S
18. Amount of Line 14 taxable
at collateral rate X.15 � O I Z, 2. 18. 4 �p � � �
19. TAX DUE .................. .............. ............ ..... ........ 19. g � � �
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
� 1505610105 1505610105 J
r
r
� 15056],0101,
REV-1500 EX�°1_i°, .
OFFICIAL USE ONLY
PA Department of Revenue P��syivania
oEPAATMENTOFRE�EN�E County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RfTURN ` ` `
PO BOX 280601 / � � Q � 8 7 ,
Harrisburg,PA 1�128-0601 RESIDENT DECEDENT ' ,�. �
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
/ �e �' a � 5b � o os � ga, or � o > os / 9 � 2
DecedenYs Last Name Suffix DecedenYs First Name MI
� oN �. F2 �.T'R � 1 � � � A- � N
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
N l �
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
0 1. Original Return p 2. Supplemental Return O 3. Remainder Return(date of death
prior to 12-13-82)
p 4. Limited Estate Q 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 O 1�jElection to taz=�i�der s�c.m13(A)
between 12-31-91 and 1-1-95) C{l�ch Sch.�f"' � �
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFO�IA N SHOULQ�E DIR�T 0:
Name Day�e�I�Aone�lumbe�..� C�
e � ,4 � L F S �' �y � ,� l. � s � � � 7� �'�7 �-„� �.o �
� . � �, �
R�I�R O'F ILLS U E{�NLY
� "r; ¢'°:
� �— }._-� `�° C3
`�3 � ~ � �
First line of address � _ � �
6 C � ou �' � � � o �- p `�''
Second line of address
/�� �
City or Post Office State ZIP Code DATE FILED
m ,� e � � � � cs Bu � �- P� l � oss9 � 3 �
p � G e�,�i elds 3Q Co�m ca�fi. ►�e f
Corres ondent s e-mail address: _,
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.
SIGNATURE QF PERSON RESPONSIBL OR F LING RETURN DATE
x ' 3 � - �3
ADDRESS /LL/CLC/✓T � 1QF, .��� S�:.Thr�s 7�r;ve, �a��Ki��j ��1' �7���
SIGNATU PRE ER R T PFd TATIVE DATE
3�i7�3
ADDRESS C�'�/T t�L �, sH��� ,�.� � C��OG�CSL,r' OQ�; �le�h�S��,f�� /�/� �7�SS ��.
� � PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1,505610101 15056101,01 J
�
�.�;
�
;
;
i
i
i
� _
�
�
i /�Y ��l,C u t�}T�oN �2. �sT o� wm. H. rc o y�E72,S�p, � ,
I
�
� al��a ���
; _
� _ __ ___ _____ _ __.__ _ _. ___ ___ _. _ __ -- ..._ .._____ __.__.
__ _ _ _ __. _._ _ _ --_ . _ � _ .
_ _ _ _ _ .
i
SCj►e.o� rs. r,
__ _ --_ ___ __ _ .__ _ _. ___ _. --.- _ _ __ . _ _. _ __ . .. __ . _ . _ _ .
_--_ __ __ ___ __ _ _ _._ _
_ . ____ _T _�e�� _��1.�'J�r_./_n�'xI_ --�--LS o__ ,.__ ____ __.- - -T __/yl�/I�GCrlf S7Fure Q._/��_-
_
� : ___
.... ..__ _...__._._.____ .,�ft/r�s_...j_��._�.... .. _S,_SOS,..8.7_. .... �..��.$�__..._ .__._.... ..__.__ _.Lt�..3.....--�3_,-SS4.39.---.�...�f_6�.?7 . .. _
� . . .........--""... .....,....��. _S._......._...... 3. (/D�"._��.'-.._....w'...���D..DD..... ..... ^� .. DOO��� '�'� ���L4I' Qv
'.. .......... ..... _ .. .__. _. ..,. -'.-� . . _ . . .. ..._...._... ........�.'.`:!!1..�...._.--'.� .� .. _ _..._..._.._...... ._.._.......__......._..,...
,
.. _._... _. _._.___ . . _.__ ._ _ .__ . _...___ _.._. ---_____.._ .___.__..____._.......___�45!1,�.�G1e_ .,__._.__._ ___.._.._.._... ___._----_.__.___. ., _. __. .._:_.-_----- _. __._._
._. _._._.__ _... _. ___ _._ ___ ____ ___ _. _.--- _ _ _____s�_ � __=._.�_a_,3?z��� __ __ ___ -- ----_ _ _ __ ____._. _ _ _
_ ._ __. _. _ _ . _____ _ _.. -- _ ____,SP.1�a�_.N.._ ____ .��._Y.4._�-_�`�_.
� _ _
�
_ _ _ . . .� _ __.. _ _ ._ . ____. _ _ ._ ._._ ._.__.._.S�__._.� ..__..�'..__ ____.._l�r-_�.!�_.__.._.__.._...__.___.._�__.. .______.____.._... _. .__._._ _......
►
._. _ _. ._ _ __ _�___ __._ _____ . _ _ _ _ ---.___ _ ___ _. . _�/�_ _ _� `f�,_�D_�I, 7Q _ _-"a2__ _' �/,_q'Q�f-._�_ ..
� �
._ ___ ___ _ ► a,/_9��. �� .:�_ _ __ ,�, z�5._'3__ _._ _. __ _ _�2�, 9oy._�s _. - �,6as�� _
_ _ _ _ __ ____ __ __ _ ._,._ ._
¢ _ _,____ __ _ _ _
_ __ _ _ __ . __ .
_ ___ __ _ __ _ _
__ __
�
_ .__ ._ ______ _ _ _ lv�iL�._ ._ _ _ .-_ __`f,_ S(Ql, __ ___ -- . _ _ ___ _ ___ _�� �S'�.3S _ __ _ __ _.
_ __ _. . _ . _ _ _ __ _ _
�
� __ _ _ _
._ _._ __ ._ . . !�e_r-�. _._ .. _ _��o�._p�__.._ ._.._----- . ._. _._ _ . ._. . . _ 3,8s�.3q __ - -- _.. .. _
3,000•°O ,moo.�o
. . __ __ . .._ .. .____ _�___- - ____. _._..__..__ _. __ _ ..._.____----._._ .._. _. ...__..__. ____._.___---_ .__.___. _ _ __ _____,� __.._ .._ ... _.._ _ _... . . .. . _ .
-- _. . ___ _. ___ __ __._.__._._ .�l,_. 9ay. SS' �_ ...___..__ _ _-__ _. _._____ ._ _ _ �, 9n�.8s�
-
� �� 7��-?�_--x.i�_-�.�-s!.�s
_ _ . ___. _. _ ._ _ _. _ _...._.�P __�I��.7•Z_..-� '--,_S(o1.91._ ____. . .__.
, _ _ _ _. __ -�- __-- _
�
--_____ ____ ___� _ -___ ____.._ .__ __ �__ ,__ __ __ _ ____ ____ ____ __ _. _ _ ---- _. _____._ _ __.__ ___ __ . ___ _ _ _ _ _ . .
REV-1500 EX Page 3 File Numbe� ����,�—6�7
'; Decedent's Compiete Address:
DECEDENT'S NAME �lLLl�� �. �D/Y�c�� �/Q.
STREET ADDRESS
3�{ N. �T. ✓oH�s ��
CiTY ��P �r� STATE �� ZIP �T D/I
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) �, 0/,3. 2�0
2. Cred�tslPayments O
A.Prior Payments
B.Discount Q
To#ai Credits(A+B) (2) �
3. Interest
{3) , lS.4�o
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+s greater than line 2,enter#he di�ference.This is the TAX DUE. (5) �, 0.3�, ��j
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred:.......................................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income:............................................ ❑ �
c. retain a reversionary interest;or.......................................................................................................................... ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If death occurred after Dec. 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. � ❑
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. l�l ❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ � ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS 1S YES,YOU MUST COMPLETE SCHEDULE G AND F1LE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
' 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfiers to or for the use of the surviving spouse is 0 percent
(72 P.S. §9116.(a)(1.1) (ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax 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 o#transfers from a deceased chiid 21 years of age or younger at death to or#or the use of a na#ural 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.
RE11-1508 D(+(1-9�
SCHEDULE E
CAMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS,& MISC. �
INH�EEW p����w� PERSONAL PROPERTY
ESTATE OF �`/�'a� 1� �/o//�,Jr FILE NUMBER �.1^�a_6 87
�7 !� i?
�
Indude the proc�eds of I'diyation and the date the proceeds were reoeived by the estate.All property joiMly-o�with the rigM of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. �fJ�(Gh]�/� D T �OP./'.SO4�t!! C�SGG /�R��lQ/�D/1V �?'�G1i[u�) 3�/6 4��O
y y
�. PA/C /.�ank Ctie��:�c ��t: ,rvo. So 7 00 7 0 939' �zs, 9a�:09
_ � �.
3, „�.,f �¢��r, fn d,v.d. o,s �fC�iy No-� ' �D
(�Sae li4li�a�sh �c fJ"`Gr q�st cliea�,
'�• I1?�/t�l�8 E�s /st �'�. C/z�'�iT c�iu�o nl
� /�e u lai'' �lt!/iil S /�'�l: �. �aS�3�� � OD
� � �
,8. C'�f e� vG�,vs;t` ,it/v. �{�{��'�.3-�a �
� �S, //3. ��
L! �nt. /¢CG/'. fn d.v•u� on l��r ,� �
.
�.�./S
( SP� {/�!fll�t/�1O/� �G��'''Q���'�/
�, f�,�fi� ���`�nd -- Gv�sf.n;�sf�r f'IQfG '���o.zo
�►• �Oi�/jJDAk/G�t�1�t D� t/�LM/!Q. "' �uYf Vtu�7e,ti /�d It�,wit�G � �OQ
t �SD
�.
TOTAL(Also enter on line 5,Recapitulation) $ $��37�� ��
(If more space is needed,insert additional sheets of the same size)
i
,
i
1 .
Fic.��o. zr�a-��7 ,
:
�'Al VE�tI To K y o� �ERSO�!//�L.'Ty_. .__�F...__!,v/LU.�/j1._..,y. IraNG�i�',,./,P.___.._._- ..._ .._
.__. ,
' __ _L.__�P/q!._be�!-�iflqffrrss_._ ._____ _ ___ _ ____._.. _ ..._.. _. _.___ --___._____.. ___._...__ _.. -----..___.__.. _�ia.so
_ _ . _ � --
_ __..__ _ .__��_ __�re�s�r_..��.e_sf_o� _dr�� _ _ __. ..__. ___ _ _ _ __ . _ .. __-- -__ .__ _._., ---_.__.. _._. _._.. ___��S,00
.
�..____._. ._._...3_�.__.�t/%�f__�r�d ... __ __ ___._._ _ _ . _ _ _ ____ _. .__., _.____ . .___._..__..._..._�__ ---._.. .,_ _. . --- .__._.�s=�_ . .
_._. _....._.. .._.__.�.._ _.__-=�_.Ylr�✓._O/a�._?Y,.� _ _... . _._ _ __ _._ .._ ..__ ______... ._ _..___ _____.. .___._..__. __. _... _..._..._.._._ .��_Y�l/ue__ .
_
_ o�_olq� Z�ISY G'�?a%rs_.._
_....... _.... -�---- -. ....._3-_ __.._._� �
_ __. __ ___. _ _.__ __._ _.. f�S,o0
_..._. -- _.__..__�._�_._. o/d..c�csK .. ---._ ___ __ _ �'fo.00
�
7. 3 s/1� o�;�a./Ids ��.00
_ _ _..__.__ .- -- .-_._ .._ ----_._ _.._,__ . ___.__.._.___. ..._ ._. ... _.__ .._.__ _._.....
' . .�:. ....._.a._ _..%�._ ,)��enr �Q/h S_ �.�'
_-..... ... __...... _... . . � � - __.. ._ ._. .._._.._._.. __...... _ _
,DU
; _ . __ ....___1.,__.__ f��l,o GfocK __
: .__..... .. . �•��
O! 7D _ _ _ "� 07.00
__.._ .. _____.__ ,_._..��- . _..�___._._Q�S�______
• -
_._ _
. ��•._._�!?.!.S_�___�t,_ /,�i"IS ut'�IjS�/s _ S;oo
__ ..
� _ _ _ _ _ _
_..
.
_ ..._ _ ___. __ _.!d-_ ..__ �s�%.�q___ ��s__ . _ _
� _ ,c?,O•�o
. . _. .. _ ._. .
' ��• /?�1I19��o�. _. � __ _. _ _. _. _______ _ . __ __ _ __ ....�p,oD
.. _-._....___._. ._._�__.._..�._..__..... ..... ..._. ..._ . __.___ _ . _ .--_..__. _
.. .. .
.. .. ...
...._��: __..�5�../��'Ca� /fGbscl/ZG� �S o0
._Sl,vwrr ;r
..____ _._. _._..�5___ _._____..__._ _ ..�_�_�'_ ._ _ ._ __ _ _ _ ._._ ____..__. __ _ _ . _____ . . __ -- _ ..__ __ .__ . _ ._. _._S:oo _
_.___. _. .. _ .._._/G._�_.�.. �t✓a/�cr ___- -
_ __ ___ ___ �.S".
00
�I aa� !✓��/�r� �;o�
._._... __ .._. _ _....._�.... ---.....___ _...__.._ .. _. __ ...__._ _ _ __ . _ __ ___ _ __ ____ _ ____ . ... __
.
__ _.__ ___ _.. _____.__..___._ . .___._,_. -- _..___.__ _ _ /�G sn
_ _ ___ _ _._ __ . __ _ _____ _._ __ __ _ . _ .. _ _
�
� _.._... ._ . .._.. __._ .__ ___.--
. __ __..____ . __ _ .
I °
-- _ _ __ __ .__ . _ _
___ __ _. _
� �_ . _ __ _ _ __ . _ _
_ _ _
_ �_ _ _ __ _ __ _ _ _
_ _ _ _ _ _ _ _ . _
� . __ . _ _
_ __ _ _ _� _ _ _
�
_ _ _ . _ ___ .. .__ ____ __
. _ _ __ _ __ _ .
;
_ _ _. _ � _ __ _ _ _ ___ _ _ .
._ __ _ __
, _ _ _ _ _
_ ___ __ ___
�
_ _� _ _ _ __ _ . __ _ __ _ _
�
__.__. ____ _ _ ___.._ __ __ __ _ ____ _.
_ .
Jul. 31. 2012 11 :52AM PNC Bank No, 42b6 P. 1
�
�.--_-.--�
� 7�3/�iy,
�
j�M ���•
���� '' . ' .
� � : �,i•i�•,f� •� i,
July 31,2012
Charles E Shields�,Esq
� 6 Clouser Rd
. Mechanicsburg,PA 17055
�; '�Villiam H Kohler Jr
SSN: 165-26-5610 � �
DOD: OS/28/2012
Dear Mz. Sb.i�elds-
�i response to your request for Date of Death(DOD)balances for the customer not�d above; our
records show the following:
Checking Account
� Account#5070070939 Esta.blished: 08/O1/1991
WILLIAM H KO�,ER
DOD balance: S 25,925.09+0.10 accrued interest
Ynterest paid Ol/01/20I2 thru 05/28/2012$ 1.39 YTD
Savings Account
Account�5005852002 Established: 04/07/2009
WILLIAM H KQHLER YTF .
BEVERLX J Z�v�MER..MAN
DOD balance: S 5,50�.85+0.02 accrued interest
Interest paid 0�1/O1/2012 thru OS/28/2012 �0.22 YTD
Please note tha�this office provides date of deatb balances for deposit accounts(1�i.As,Clls,Checking and
Savi�gs). We do not process any financiat transactions ot-prnvide statements. If you need assistance with
any of these items,please ca.11 1-888-PNC-BANK(1-888-762-2265)or stop byyour local PNC Bank branch
office.
Sincerely,
National Financial Services Center
PNC Bank,N.a. °� �
Member FbrC � �
Page 1 0�'2
,��/ 7/tS/�: w�. �.sn��r c�c..
�
J
�
MENiBERS 1't
FIDERAL CREDIT[7NION
a'
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 442543-00
Date Account Established 12/08/2011
Principal Balance at Date of Death $5.00
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $5.00
Name of Joint Owner None
CERTIFICATE OF DEPOSfT:
Account Number/Suffix 442543-40
Date Account Established 12/08/2011
Principal Balance at Date of Death $25113.42
Accrued Interest to Date of Death $22.15
Total Principal and Accrued fnterest $25135.27
Name of Joint Owner None
MEMBERS 1ST FEDERAL CREDIT UNION
�.���°�./ ►��
Tessa L Klugh
���uT
Lending Insurance Support Specialist
July 24, 2012
Estate of: William H Kohler
Date of Death:05/28/2012
Social Security Number: 165-26-5610
�
5000 Louise Drive • P.O.Box 40 • Mechanicsburg,Pennsylvarua 17055 • (800)283-2328 • wwwmemberslstorg
REY-1510 D(•(1�8�
SCHEDULE G
.
INTER-V1VOS TRANSFERS�
COMNIOMNEALTH OF PENNSYLVANiA
INHERITANCE TAX RETURN MISC.NON-PROBATE PROPERTY • .
RESIDENT DECEDENT �
ESTATE OF • • FILE NUMBER
w,��, a� N �,.ti��� ,T. a�-�a-���
This schedule must be completed and filed if the answer to any of questions 1 fhrough 4 on the reverse side of the REV-1500 COVER SHEET is yes.
i'
DESCRIPTION OF PROPERTY °�OF
ITEM ���TME"^"'E°F TM�r�^"S�'t�.THEIR RELA710NSHlP TO DECEDENTAND TF�DATE Of TRANSFER DATE OF DEATN DECD'S EXCLUSION TAXABLE VALUE
ATTACFi A COPY OF THE OEEO FOR RFJ�L ES7ATE,
NUMBER VALUE OF ASSET INTEREST Fna��cne�E
�� prYC �3a�k, � Ttis� f�r Sari��s /�2►�
�Y'o, ,S'vo.s�s'aoo�. ����6• '�/�/���9�
�
For �eYGry f. Z;�.me+'Mar+, �-ki, ,
� �
�ran er t �i d�o� 5,.S"d s",�S /oo� --o -- S,sn-5'. �.�
�
.?. �CCr, i�lf � d o•c% an L��i Nc./ .O Z �e�� --p- .o z.
/��e� Yalu�non �ffcr� ��ac.�u��
3. �e�-L..��t /¢itllau� C'sn/S�ac.� /?�ol(0 7 F ��, .$.Sb--�f �eo,u — o � 39
y �,.�.��.
,
�`s �ta,.�a.f nepr�i�s a/ecea°e�ts ��oti
��� an.�u.� ,�4'e�d f. h.s �o��,r,
{�e% �C.i►ks,1a�, w�a �✓�a�e��seq'�iti,,
�!�/j�!-�1 T�/lZe �1G /il�i•r�'��Iiorrl�o�
�'�!B :h CO{y�Q,f �/os� �f'/'�Pl�if! AP�C�Ghi�
: .��/ , , ,
/1Cli,��J.s s�s�t�'� �1.//i.cc�►� Sr�, 4s
�i s �/'�IG�1`�c��rr _ r!� /'rG'�I%A� A� e�
r
�ve «.�r'w•rf� o f� Qu�' ,o�o� �'e
� �
li�S c�t�r�i. ��S if uLS� �r a
� �
G�,o,cl l�al�t a/S oh �rirc �?ave � !�-
����P� :� `l/� ,GIll�2 a1�c�rt� D��''
Q�7'DrI�' GLf' l/lll�tG �'ll ll'Gcla/S' '
.� w��
Dlt�^ C/�/� ,SQ.�cI �s �i� /Y.�So�ra�l
� o�. y y
�
• � � - - �• � � y � oa�.�D �3�.��
� ����i/1�G �w�� f J �.� lo ���iCPalf s�re� �� DOD.o� l00 0 3i i
.
�
S�sfGr �,
;� il�e �w/, l �'� G,�f �v �e Z:/��- q
,�' L � � `'�I' ,�o�,oo �`� 000.�o
• ,a�D lOo !o . •
me�man, {�-�,r w►�, S�-an er � �/oe� �,o00
q
TOTAL(Also enter on line 7,Recapitulation) S � 3�a a�
.
(If more space is needed,insert additional sheets of the same size)
f
j 1
)
( _
� .
l
� � .
. _.. ........... ..... ..__ _ __-- --�..___ . �._.._._.._.__. _ _......___......__ _ _ _.. _
. _ .._ �,��c���
__� _ _ _ __ .
_. . __ __ _ __ _____ ._ ______ _ . _ . . _ . _ ____ __._ _.. �. _._ _ . __
__ _ _ � �
� � �
__ . _ _ . _.� __ ...__ .______ �_.._ .__. ._ .___ �. __ ___ _. � _ _ _Q__. �s�._�i. _._.._ _._._____. .. . . . __ _
D�� f 36
... _ _ _ _ _ . _----_f.�v-_ k___�S ,_7/ .-=____ . ...o.S' ,�. _ ___ __. _ _ _ _ .___.__ _..---. ___ ___ ._. ._.__..._ ___ .
f..
.. . . _. ---.. .---- ..__._._ _ . _ _ _ . __ _ __. _ .._ __.. _ _ _
.
_. _ _ __ _ __ .__ ��__�_.._ �-__----�_ .__. .�__._._._.__ � _��.__ ___.�:��_._ --_�_�-- .__ _. a� ._,.�--..--- _ _ _.
} � . .
a
___ .._ .. ....___ �.. _._�/J. .._.. .._ . a___ _. _._�_.�u-s� _A _____.�__.--'��i�.1IC������',�_._ _. .. .._. ._. . _.._..___._..____._. _.._. _. _
.
Q��._ __ _______�_--- ._.. __. _ ___ �!��_._ ___.._.._ _----.__.. ___......__ _.._._,_.._ __..__..... ............. ......._ _ __ ._
_. _ . . ._ ._ __.. .�_._..__ � ,
' �
_.. ___.. __.. . .___._ ._. _ _ --�Y� _._.._ __ . ...__._ .._.__.._ _ .__ _.__.__ ..____ _ ___._ _... . _ ___ _._. .. _..__ . __...__.._.__ __.. _
. .
; � _.
__._._. _ _. ._ j_ ._ . _._ -__.____. __ . _ . ._. ,-- _,���s%� �
I ._ ______ _ __ ___ � - _ . __ ._._._ _
_ I p __. _ _ ._
_ _ ____._ _ _
: _._ _�_��_q_3� , X.• os = �a. �� _
� �
_ _ __
__..__ . __ , .._ _ _
, _ __ _ _ __
. _ _ _ __ __ �;.a.��._�� _
---- �r, �� .
_. _ __ _ _ �__..._�._ _ _ __ ___. _ ._ __.___ _ _ __ .
� . .� �s`�
._ __ __ _ ,__ _�,. _ __ _ ___ _. _ _ .__ _ __ _ . _,
_ . _ __. _ __ _� _ .___._ ._ _ _ _ _ _ _ ____ _ _ ._____ ._. . _ .
i
: _ _ . __ .._. ---_ __ _ . .__ . __ __ ___.._.__. ___ _ ... _
._..._... _ _ . .__ . . .__._._ ... .
; _ _. _ _ __ _. __. _
I
;
` . ._.... _-_ _.. _......- �.___ _. .___ ___.. . . _ __ _ _. _....___ ___ _. ......_._ . _ .__ _ _
_ ___._. _ .__._ �_ _. ..___ _..______.__ _._ ____ _:__ . _ ___ _ _ _ _ __ ___ ___ ._ __ _ _....__.. . _ . _. .
(
0
�
_ _ _ _ _ _ _ __ _ .__ _ _ . __ . _ _ _ _
�
_ _ . _ _ _ _ _ .._ _ _ ____ _._ _ _ _. __ _ _ _ _ _ . ._ . _ __. _ _
__ _._ .. .. _ __. _� ___... ._. --__._._._ . _. _. _.._._. .__ ___ _ _ __ _ . _ _ _ __ _ _ _ _. __ ._ __ _ _ __ _____ __ _ _
i
MetLife investors USA
P.O.Box 14593
Des Moines IA 50306-3593 � �
�� ' . �
July 15,2011
WILLIAM KOHU= Copy to:
MARK SHARRAR
�— 1924 FISHER ROAD PNC INVESTMENTS
MECHANICSBURG PA 17055 2 E MAIN ST
MECHANCISBURG PA 17055
- - --- �� RE: ME�LlFE�INVESTORS-US/!!NlSURANCE COIUIP�N�I GONTRACT l7000't67 - -
OWNER Helen Kirkman
Dear Mr. Kohler:
I have processed your income payment request from the proceeds of the above-referenced contract. Your
proceeds represent your portion of the Account Value of the contract in the amount of$4,508.21. You will be
provided with a quarterly payrnent of$253.71 for 5 Years. The first payment is due August 1, 2011, and
will be mailed to the address listed above. �
The value of policy 17000167 as of the date of death,December 8,2010,was$13,268.65
Our records now show the following information for the payout policy:
Owner: William Kohler
Primary Ben�ciary: Millicent Stare
Contingent Ben�ciary: None Designated
Your form instructed me to withhold taxes based on a withholding election of °single with one allowance";
however,the Federal tax table indicates that no withholding is necessary for this election. No Federat income
taxes have been withheld.
Please note that you may choose a specfic dollar amount to withhold from each annuity payment by
completing line three of Form W-4P. I have enclosed a blank Form W-4P for your use in making a new
withholding election if you choose to do so. If you need any assistance in the completion of this form,please
feel free to contact our office.
I have enclosed your Annuity Agreement,which supplies addifional details of the income payment request.
The Agreement and this letter should be placed with your original Annuity Contract.
I have also enclosed a copy of MetLife's privacy policy. The Financial Services Modemization Act has
brought a number of changes to the financial services industry. In conjunction with those changes, MetLife is
required to tell customers how personal information that the institution maintains about them is treated. Our
commitment to protecting your privacy is not new. We will continue to safeguard your privacy and
confidentiality of the information you provide us.
MetLife investors USA Insurance Company �1- �1(�_- �
P.O. Box 295 00249 �'�K�` '
Des Moines,IA 503Q6-0295 �
�-�.:�r.��-�- -"
��t�� e����������.„
MILLICENT J STARE �
34 N ST JOHNS DR
CAMP HILL, PA 17011-1929
Date: 09-12-2012 Customer Service: 1-800-343-8496 Check No: 061281112 -.
C.ontract No: 17000167BSG
REGULAR PAYMENT
Gross Payment 253.71
a .
0
N
a
� '
0
0
a
c
c
0
m
O
0
0
O
Complete for Change of Address and Retum to Address Above:
NAME:
ADDRESS:
CITY: STATE:
ZIP CODE: CONTRACT NO.
�:�:�: t �
;r' SIGNATURE: DATE:
_ __ _ _ _ _ . _ : _ _ _ __ __. ................... ..... .................................._. ....
���>.. > :
. .�:� -.
, :: : �
:
;
M���:� ,���������
$
,.. ... : : �
54-�937/213
;.: ,;. . .. .::
>
MetLife'1"nvestoYS�USA Ins�tranEe Cti�npany ' �`:`. �' � `
P.O. Box 295 Ch�ck Number
Des Moines,�A 50306-0295 061281112
Two Hundred Fift Three and 71/104�Dollars ` - " ` �� "°'v�'°'�°°e''s
; y _, ' ; .;� From Date.oi Isaue
, . .;.> ....::.:<.; .:_: ., ... ,..
_,; .....::.
Pay to xhe Order of: 09-12-2012
<
..: _..:•.:..:.., . ,._ ,
_ : .: . , ;
.
.,.
> .. :. : :. -> _ ,
*����.�.�*���253.71
:.. .
MILLI��NT J.�TA#�E .
;_.
JPMorgan Chase Bank,�N.A. " �
6oa0 Tarbe�l Road �4 N ST JOHNS DR
Syracuse, NY 13206 CAMP HILL, PA 1 701 1-1 929 �
AUTNORItED SIGNATURE
+�0.6 L_�2� � � � 2��' �:0 2 � 30_9� ?:9�: ''60 �B 9 3�70��`
REV-1511 EX+(10-06) '
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
tNHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF , � FILE NUMBER
KoHL�i , G������t� k, ��2, z/- i�-68�
Debis of decedent must be reported on Schedule L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: Q
1. /4uLl� CI''l,/1�l1�/1 �YiGL,$ O� !-��IrIQ� �i�tC. ��IRdCG o�ttG ��.39./Z
-�. �i'ei„�6�ntn��nf � /I'l./���e��` �'�r•� �i' �Oar�i� ��y�cnf �n � ,�
�'gs
C�sts o� cr�jl�al�i�o�
3;-. Ka►-»s 4Kal�f y �ar/�i' �iher.t,f /rk4� '�-7L./St
� llro��/es Irlsw�r3 'a31.•39
S Dax �srOYQ �'cr�ns,F�a�vers �`
6. lv /x��t�s r ou� {�r �cnpa-al �Ylca/ �/, 99
� � u� �/. �S�
B. ADMI�STRATIVE COSTS:
1. Personal Reaesentative's Commissions .
Name of Personal Representative(s) /�li���l.�IJ� .T p/TI[rG f� ���.DD
!
SUeet Address 3� �' �� �D�f/��s �J'%✓8
City /.� State �,/¢ Zp /7a//
-�
Year(s)Commission Paid:
� �bN► ��a.ttb S /�ffD1' S k!G't C4 �a a ��1 d /!sa? e.
b/as no an�1 !9d C� � 4t % s��i�e �i�fJ. �
2. Attomey Fees t� Ct�" CS �. ������ fJ� 3� �i16�.0�
3. Family Exemption:(If decedent's address is not the same as Gaimant's,attach explanation)
Claimant ND OA/� �L/�/,t3L� ND/►I'�
Street Address
City State Zip
Re{ationship of Claimant to Decedent
4. Probate Fees Q,�tc� Ol"� ir1o� /St NG ♦f S�ol�f Qe/"l/j�jC�t/Cs ��3,S'�
�
5. AccountanYs Fees �
C r��q/nn l�o�an� C�sr�crntNt�� S Ch., ,���n fk,rt�
� h1echah�CSbar fr,{�- Clast�cf/oyD,��fG� /o�f� �Y/ ��{SG•o°
6. Tax Retum Preparer's Fees �eS�iM J
7. �d✓ertisrn ;n Cu,�+btr�a,�d L�w �urna� s
L � , �S°D
$, ��l��ri%si�1/ i�1 �a N�is�C oSt.Ii�i/9►C/ �I�7.DG
U
�. fa.oo �-�� � ,��e ��k ��.o0
!o, �dd,�i o�al roda� f ���'s/e�r � �d�!/s �/D 5,o0
� � �
��. �il'/1 � 1� �2��5/�r p� `i/il/s l�.DD
a n r . .
!�, ��iM�ar�e/nP,�l�s c��Qr�eS �E oS����� � �� �os��, G�C��- ��p0•oo
i �
i o Q c ,
TOTAL(Also enter on iine 9,Recapitulation) � � L{6�p. ��
(If more space is needed,insert additional sheets of the same size)
���ATjON s�y,c� F �E�S�V�� 1NC.
� R CREMATION SERVICES O ,
� �P � .A�
•OA ,�G• 4100 Jonestown Road•Harrisburg,PA 17109• 1-800-720-8221 •Fax 717-541-9943•Shawn E.Carper,Supervisor
pP�'NSYI,VAN��, ...".-W--
a, r. �-, ;� � �
. ~ M � N OM d 4 �~ .
� �p O N O d' � � r� .
�p �D � "i�-
�y .�+
O �
O �
Q O� �
�C � o
�-' °o O
� � ° � � �,�.....,a ..��. 12 0 6 0 l S P—5
� �
Q N o
o m � 5 �
•--s � V .��. V
o �
a �
� o�+ � � 0
a' v �
� � � /^6+ ty,� �p � - Q
�-� _� � o o � ° � � May 29, 2012
�� � � � � � �� � �
0
Mrs . A1.illicent J . Stare
34 North S�. Johns Drive
Camp Hill , P� 17011
William N . Kohier , Jr . — Deceased
SPECIA� CHARGES
X Direct Cremation $1 ,595.0@
Nationwide Guaran�ee Program
Worldwide 7ravel Protection
TOTAL SPECIAL CHARGES $1 ,595.00
PROFESST�NAL SERVICES
X Services of �uneral Director & ��taff Tncluded
Other Preparation of the Body
Facilities & Staff for Memorial Service
Staff & Equipment for Memorial �ervice
Witnessing the Cremation
Private �amily Viewing
Packaging/�orwarding of Cremated Remains
X Personal DeiiveryiCoordination to Nat' 1 C�m. $85 .00
Scatterin� of Cremated Remains
TOTAL PROFE5SIONAL SERVICES $85.00
AUTnMOTIVE EQUIPMEMT
Removal Vehic��
Lead Car/Clergy Car
Famiiy Gar
Service Vehicie
TOTAL AUTOMOTIV� EQUIPMENT $0.00
..- � .
MERCHANDISE
Register Book
Mernorial Cards
Thank You Cards
Remembranc� Package
Alternative Container i �
X Ivory Plastic Urn $35 .@0
X 2 O�d Glory Keepsake Urn �"""'�110.00 .
Veterans F1ag Case
GravefMernoriai Marker '
TOTAL MERCHANDISE $145.00
CASN AD�,lAiVCED ITEMS
Grave Opening
Cemetery Equipment
X Harrisburg Patriot News $Z29 •12
Newspaper Notice
Va�lt S�rvic�: Ct�arge
X Cl�rgy $125 .00
Church/Organist/Soloi�t
Flowers
X Crernatory Charge Inciuded
X Lebanon County Coroner Fee $25.@0
X 6 Certified Copies ofi Death Certificate $36 .00
X Honor Guard $100.00
TOTAL CASH. ADVA�tCED ITEMS $415 . ].2
SUMMARY OF CHARGES
Speciai Charges $1;595 .00
Professional Serv�ces $85.00
Automotive Equipment $0.00
Merchandise $145 .0�
Cash Advanced Items $415.12
SUB 70TAL $2,240.12
CREDITS —$256 .00
AMOUNT PREPAID D�te May 23, 2012 —$1 , 745 .00
TOTAL $239 .12
AMOUNT Pr�ID Date May 30, 2012 —$239 . 22
BALANC� DUE �$0.00
THIS STATEMENT MAY NOT REFLECT ALL NEWSPAPER CHARGES
3 �
� �
�
CREMATION SOCIETY OF PE1V�1� �:
GENERAL PRICE LIST
- r These prices are effective January I>1999 buc are subjecc co change witbout nocice.
?he goods and services shown below arr those we can provide co our cusromers.You may choosc only the items you desire,however,any
arrangemrnts you selecc will indude a chazge for our basic serviccs and overhead_If legal or oc}xr requiremencs mean you must buy any
items you did not spccifitally ask for we will explain the re�son in wricing on che statemenc we provide describing the funeral goods and
secvices you sdecred.
PROFESSIONAL CRE1KATlON SERYICF.S
The cost of our basic professional scrvices and overhead includr,Rcmoval of deceased anywhere in Pennsylvania,documenc prcpararion,care,
shelter and refrigeracion of deteased.cremacion process wich our cemporary cardboard concaincr for che remains,obtain and file deach
cercificare,acsistance co place obitnary,and nocice to Social Security and Vecerans Adminiscracion.
� 1. Direct crcmation for a MEMBER S 895.OA
2. Direcc cremation for a NON-1b1EMBER 1025.OU
3. Special 48 hour or weekend ctemarion service(Add to�I1 or#2) 125.00'
4. Medicat documen�s/Courier fee SS.�
�� 5. Membc�ship regiscracion fee(Non-refundabic) + 3�.00
6. Payment book processing fee(Non-refuadable) : Z5-�
7. Nacionwide guarantee program(This opcion provides rhe services you}iave selecced anywl�ere in che Z75.00
Concinenral Uniced Scua�
8. Woddwide rravel proceccion plan(This opcion provides the services you have seleaed while[raveling 275-�
oucside of che Concinental Uniced Srares) "
9. Private family idrntification and/or wi�nessing cremacion ar crematory(Includes cremation con�ainer) 125.00 '
FINAL DISPOSITION
10. Pick up cremared remains ac one of rhe Sociery's off,ces wi�hin 7 days in eicher our No Chatge
concainer or your container
11. Packaging and forwarding cremaced remains anywhere;n che Concincncal Uniced Sraces '�5.00
12. Express Mail(Add co#I 1) ZS.00
13. Arranging wirh a cemecery for burial of cremated remains(Does not indude ceme[ery charges) �•�
l4. Arranging,packaging and forwarding cremaced remains co a nacional or pri•.are cen::tery
for burial(Combinacion of#I1 and#13) �'�
I5. Scactering cremaced remains on che land or a�sea 1�•�
15. Burial of cremaced remains ar sea(Indudes culcured marble urn) 395-0�
1►LERCl�il1VDISE .
17. Regiscer book �'�
18. Memorial folders(]00) '�S*�
19. Prayer cards(l00) 4S'�
20. Thank you cards(2S per box) 5.00
21. Do-It-YourulFMemorial service(Indudes:1 regiscer book,100 memorial Folders 55.�
or 100 prayer cards,and 2 bwces of chank you cards)
�22. Ums are available from s35�00 co 52,536.00.Um#�_selecred ��t�
(A com lece lisc will be provided ac one of che Sociery's offices)
P
23. Cenified copies of che Pennsylvania deach cercificac��_C�s2.00 each �v��
�
24. Cremacion concainen are availabe from s25.00 co$495.00.Concainer# selecced
(A complecc lisr will be provided at one of the Sociecy's offices)
25. Proceccive um burial vault(Air and warer cighc) 2�-�
In mosc areas of[he councry,scace or laai law docs na require chac you buy a
concainer co surround che remains or caskec in che gravc.Howcver,many ccmeceries requirc
char you have such a concainer so tMn�che grave will not sink in.Either a graveliner,burial
vaulc or um burial vaulc will sacisfy chese requiremmts_
Total$
Embelming:Wc do noc provid�embalming servica.However,you should lcnow embalming is noc required by law occepc in cerrain spec;al caxs. Fmbalming may
be n�ccssary,however,if you xlecc ccntin funcral azrengemencs,such�a funcral with a vicwing.If you do na wanc embalming,you iauaJly have rhe righ[ro
choose an arrangemrnr�1nc does noc rcqwrc you co pay for ic,such u direct crrroation or immediace burial.
lf you wan�co arrange a dinn cremacion,you can use a cremacion con�aincr.Crcmation conraincn rncau thc body and csn bc made of maccrials like cardboard,
fibrrboard oc composition materials(werh or wichouc an oucside covering)_We provide a plauic body concai�c ac no cxcn c}nrge.
"Ibis liu does rwc ituludc ccnain icrrnc cl�ac you mny ask us co buy for you.'I'he prices for chosc irrms will be shown on yout bill at�d the Statetnent of Goods u�d
Scniccs Sclected.We chargc you for our scrvices in buying chese icems.
REV-1512 D(+(12-03) '
SCHEDULE 1
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE UABIUTIES� at LIENS
RESIDENT DECEDENT
ESTATE OF �D/ ��t,. �/�III4IYI H. ��''. FILE NUMBER
�'� � , a r��z-�� �7
Repo�t debts incurred by the decedent prior to death which remained unpaid as of the date of death,including unreimbursed medica!expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
t ,¢.�'�GI" G�,D,q! Cleara.��e �i �e6i� CA�rA� T��' C�c�iin J�[rGIT—
r �scc D�/r(� ��k � t�m�t' �gb./9
a�/ be�i� �,o,q! a,� l��i1�t f �
a::���
TOTAL(Also enter on line 10,Recapitulation) s q6, �q
(!f more space is needed,insert additiona!sheets of the same size)
; ,'`
Total Banlzing Statement
� For th�period 05/16/1012 to 06/16/2�
�For 24hou�information,sign on to PNC Bank Oniine Banidng WILLIAM H KOHLER � . „
on pnc.00m. Primary a000urrt number:50-7007-0939 / ,
Accoumt nuumber.50-7007-0939-contmued Page 2 of 6
/nterest Summary � As of 06/15,a total of�1.61 in interest wa
Mnual Pencerrtafle Number of d paid this year.
ays Averaye collected Interest Paid
Yield Eamed(APYE) in iMerest period batance for APYE this pertod ��
0.01�: �1 26,387.66 .22
/�CbY�� Q@tAi� _
n�o��.a���aaa��s � n,ere were 3 Deposits and Other Addition:
Date `Amount Description totaling$1,OZ2.22.
06/Ol 978.00 Direct Deposit-Xxsoc Sec
US Trea�ury�03 XX?��5610A
06/Ol 44.00 Direct Deposit-Xxv-a Benef
US Treasury 314.XXX7�?�,5610 00 17
06/15 22 Inferest Paytnent
Checks and Substitute Checka �
Check Date Reference Check Date Reterence
number AmouM paid number number Amourrt pafd number
2140 941.60 05/25 ossoss2so 214�* T 200.00 05/25 5��795358
2141 1,000.00 05/21 s�o782s�8 .
"Gap in checksequence 'T'Tel{er Cashed Check There were 3 checks listed totaling
�2,741.60.
Banlong/Check Card Wtthdrawals and Purchases
o�ate amoi,rrt oescrtp«on There were 7 Check Card/Bank card PIN PC
05/17 46.84 POS Purchase Wal-Mart#1886 Mechanicsbur PA purchases totafing$456.25.
05/18 87.12 4358 Check C.ard Purchase Ashcornbe Farna&Greenh
05/21 1720 POS Purchase Hess 38285 Camp Hill PA There were 5 other Banking Machine/Chec!
Card deductionstotaling$243.39.
05/25 83.38 POS Purchase Wal-Mart#1886 Mechanicsbur PA '
" 05 25 54,�6 POS Purchase Wegruans Mechanicburg PA � --,�
..�......,.r-._,,, ...__ _�.:._ _._.�__ _, _. ,�,��;�cr- :
05/29 76.14 POS Purchase.Karns Quality Mec6anicsbur PA �
; 05/29 46.11. 4358 G`heck Card Purchase Srnartstyle Mechanicsb ./(��?'"����
; 05/29 31.39 4358 Check Card Purchase Noggies Green 12600029 y��,-�
� 05/29 21.99 4358 Check Card Purchase Oakgrove Farm s 'S'`�S�s..-- . �
� _
; 05/30 96.19 POS Purchase Wal-Mart Super Mechanicsbur PA �"'+•l i�'' �
� 05/30 81.44 POS Purchase Wegrnans Mechanicburg PA �'��'y� � z
' .
; i 06/Ol 56.78 4358 Check Card Purchase Smartstyle Mechanicsb �/�'��
�.,.;,.�:.,..�,..,,:_.:...-._��_._ __.. � _ -, . _ ..._
Online and Electron�e Banlrnfg Deductions There were 2 Online or Eledronic Banlang
�ata AmouM '�escria�on , Deductions totaling$9SOA0.
06/05 978.00 Direct Payment-Revecsal
US Trcasury 303 X���?�5610A �
06/05 2.00 Direct Payment-X3�XX��X2311 �'�
Priority 50 Plu 0631488
Daily Balancs Detail
Date Balance Date Balance Date Balance Date Balance
05/16 �8,355.29 05/21 27.204.63 05/30 25,571.83 06/15 25,557.27
05/17 28,308.95 05/25 25,925_09 06/Ol 26,537.05
05/18 28,221.83 05/29 25,749.4�i 06/05 25,557.05
FORM166R-0i
REV-1513 EX+(9-00)
� SCHEDULE J
. COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF • � EILE NUMBER
w�l/,Q� k. kati/�, �'r. a�-i�_ 687
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not ListTrustee(s) OF ESTATE
I TAXABLE DiSTRIBUTIONS[include outright spousal distributions,and transfers under
Sec.9116(a)(1.2)l
,. S EvF��y z�ltl/I�E�/�I�A� eK-w:F�,,�� y�
�,� �Orr�� �`fr�,9U- t �
55l0 /ylo��t b/ood
/Ylec%an��sdkr , Ps� /7oss
9
-- si..ster y2-
a. /ni�c�cF,N7' �; s�i3�2E
��{ Sf. To�r�s �ri�e
Can�P �:�/, �i9� /70�/
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18,AS APPROPRIATE,ON REV-15W COVER SHEET
n NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRlBUTIONS UNDER SECTION 9i13 FOR WHICH AN ELECTION TO TAX IS NOT BEtNG MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
t.
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DtSTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET �
pf more space is needed,insert additional sheets of the same size)
LAST WILL AND TESTAMENT OF WILLIAM KOHLER
1,WILLIAM KOHLER,currendy of l 924 Fisher Road,Mechanicsburg,Cumberland County,
Pennsylvania,being of sound and disposing mind,memory and understanding,do make,publish and
declare this my Las[Will and Testament,hereby revoking and making void any and all prior Wills and
Codicils by me at any time heretofore made.
1.
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.
All the rest,residue and remainder of my Estate,real,personal and mixed,whatsoever and
.wheresoever situate,I give,devise,and bequeath to be divided and distributed as follows,to wit:
A) Fifty(SO%)percent to my ex-wife,BEVERLY ZIMMERMAN,currently of 5510
Moreland Court,Mechanicsburg,Pennsylvania.
B) Fifty(50%)percent to my sister,MILLICENT J.STARE,currendy of 34 SL:Johns
Drive,Camp Hill,Pennsylvania.
In the event my said ex-wife predeceases me,then her share shall go to my said sister. In the
event my said sister predeceases me,then her share shatl go to my said ex-wife.
3.
FOR PURPOSES OF CLARIFICATION:I have several children. Their omission
herefrom has been by design and not by accident or oversight.
Additionally,my children are absolutely not to serve as Executor or Administrator of my
Last Will and Testament under any circumstances,by representation or otlzerwise.
4.
In the event that any of my said children shall twdertake to contest this,my Last Will and
Testament,in any way,form,or manner whatsoever,I direct that any shaze to which they may be
arguably entitled shall be forfeited and shall be divided and distributed among the other beneficiaries
in the proportions as set forth above. I further direct that,insofaz as I am legally authorized to do so,
my said Executrix and her counsel are to seek the payment of any attorney's fees and caurt costs
incurred in a defense of this,my Last Will and Testament,from such contest or similar proceeding.
5.
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.
6.
I nominate,constitute and appoint my sister,MILLICENT J.STARE,ta be the Executrix
of this my Last Will and Testament. In the event that she is unable or unwilling to act as Executrix,
I appoint my ex-wife,BEVERLY ZIMMERMAN,to be Executrix in her place and stead. I
. %f�ic,�� � (
Page 1 ��
fiu-ther direct that they 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,I have hereunto set my hand and seal this 31� day of
�--- ,A.D.2010.
�� ! (SEa�.)
WILLIAM KOHLER _
Signed,sealed,published and declared by the above-named WILLIAM KOHLER,as and
for his Last Will and Testament,in the presence of us,who at his request and in his presence,and in
the presence of each other,have hereunto subscribed ow names as wimesses.
.
� �
r
Page 2
CHARLES E. SHIELDS, III
ATTORNEY-AT-LAW
6 CLOUSER ROAD
Corner of Trindle and Clouser Roads
MECHANICSBURG,PA 17055
GEORGE M.HOUCK TELEPHONE (717) 766-0209
(1912-1991) FAX (717) 795-7473
March 27, 2013
Register of Wills
Cumberland County Co�rt House
1 Courthouse Squaxe
Caxlisle, PA 17013
Re: Estate of William H.Kohler,Jr.
No.21-12-0687
Dear Register of Walls:
` Please find er�closed for filing 2 copies of the Inheritance Tax Return for the William H.
Kohler, Jr. Estate a�well as Check No. 4 in the amount of$15.00 for the filing fee, Check No. 5
• in the amount of$105.00 for additional Probate and Check No.6 in the amount of$8,031.66 for
the I�nheritance Ta�due.
Thank you for your kind attention to this matter.
Very truly yours,
,
,
�harles E. Shields, III
Attorney-At-Law
CES/mj j
Enclosures
. c� I.,�
�
� � � � �
� �� � � �
� � � � � �
� � � � � �
�
eao � � '� `�
c� � .� ,�r
: � �--� .,.�,,... ,�.�
A, —� �-.. �— �
��'1 �
0 Ct� 4
`�
�
.�,.
tt} st �:
O ��!'�� W �
� III� I r��N � ,,,�
a. � � _ .`"""
� �
Q N �` _ ° _ �
� �
a o ' +ti. r }- �
� � a � � �
W �u
,. .___
•u
uW. •� • 'ti`' '�' � {� Q `
..+..
� �.'^° i � � (� �- � ..w�.
°z - J >- � ; ` �
Q � � � � M _ .�
�
W -�- " � �„� US � CJ M — ..:..
� � _ �
�,
�� � � J = � � �
4 *- � E -� 0 0 = .....
a � - .�
i- W
o �
'�', 1�• _ „4,
R!! N� u • �j U V3 r = '^"-�-
CK3 i ' "'
a �� -� � �- Za �t ..�
� � �. C� a ..�..
�
�
� �c�o m � � trJ = W _ �
o W � �„_, J - ,�.
V r ^ � W = J =
Q � Q � =
O. � � W = V �
(� � � [� U *- t� _
= W � =
= � m ■r
u� � � Q
� u., z �-- _
� o = �
`s
� � � V3
�
�
r-
�
�
�
�.n
c�
r+�
0
0
0
0
r-
a-
�
a
a
.._....,_ o
N