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� � 150561�105
�E�-15 CIO�x(az-t�}{�t} r �
� OFFICIAL USE ONLY
PA�epartment of Revenue PQ���Y�vania n �y j�/�
� � � pEPARTMENT6FpfYENtiE �y��t�1!L/�� Year File Number
� Bureau of Ind�v�duat Taxes
INMERITANCE TAX RETURN � - .; . .._._.,. . ___�_...._... ... ._
� P(�BOX 280�iO3 ��� �
" Narrisburg,PA�.7�z8-o6oi RESIQENT DECEDENT � '
,
__ ..� . __ ,,
ENTER DECEDEN?INFfJRMA710N BELOW
�ocial Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
081Q312012 !08116/1930
_ _ ... . ..... ..
DecedenYs l.ast Name Suffix Decedent's First Name MI
MARTIN MR > HAROLD A
(If Appticable)Enter Surviving Spause's information Belaw
5pouse's Last Name Su�x Spouse's First Name ME
_ _
Spouse's Social Security Number
� THIS RETURN MUST BE FILED IN DUPI.IGATE WITH THE
REtaISTER OF WILLS
� FILL IN APFROPRIATE OVAl.S BEI.OIN
� t"� 1.Original Return O 2.Supplerr►entai Retum p 3. Remainder Return{Date of Death
Priar to 12-fi3-82)
p 4.Limited Estate p 4a.Future Interest Compramise{date of p 5. Federal Estate Tax Return Requi�ed
death after 12-12-82}
O 6.Decedent Died Testate O 7.Decedent Mai�#ained a Lfving Trust 8. Total Number of Safe Deposit Boxes
� (Attach Copy of Wili) (Attach Capy of Trust.}
�
� G� 9.Litigation Proceeds Received O 10.Spousal Poverty Credit{Date of Death O 11. Election to Tax under Sec.9113(A)
� Between 12-31-91 and 1-1-95} {Attach Sehedule O}
� CQRRESP4NDENT- TNIS SECTION MUBT BE COMPLETED.ALL C4RRESPONDENCE AND GONFIDENTIAI TAX INFORMATIO OULO BE QIR�Q T0: �
� Name Daytime Tef�ihd�Number�"'' "� f'r,�
_._.... _�,. . _., _.. _ ...., ..._ .._
. _., __ � _i'�'T
�.
� CHERYL A. MCCRACKEN _ _ _ _ ...,� `� c� -�' n „--r��
_
�
��c�e�� r��.s�,�rE o��t •
.�„ _.
� �
�"`...J � `� � � �
First Line of Address �'� �:� � �"
._ __ _ _ _ . _ �r � -y�
.� ��..,. ,�,,,..
66 MILLERS GAP ROAD � =� � #� �
� �_ _ __ �_.�.,. ....._... ,. r....
Second Line of Add�ess _ _ _ % C� � � .
_ __ ._._ _ . _ c:� "�i
City or Past Office _ _ State ZIP Code DATE FILED
ENOLA ' PA ::17025 '
Correspondent'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 frue,correct and complete,Declaration af preparer other than#he personal representative is based on alt in€ormation of which preparer has any kr�owledge.
SI UR P RSO RESP NSI L.E FOR FILING RETURN DATE
t ' �� �
ADD S
SIGtVATURE C1F PREPARER OTHER THAN REPRESENTATIVE DATE
AODRESS
� PLEASE USE ORIGINAL FORM ONI.Y
z
Side '1
� � 150561,�105 15056101�5 J
�
� `�
� �
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� 150561�205
REV-1500 EX(FI)
Decedent's Social Security Number
oecedent's Name: HAROLD A. MARTIN '
RECAPITULATION
1. Real Estate(Schedule A). ............................................ 1. 0.00
2. Stocks and Bonds(Schedule B) ....................................... 2. �.DO
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. O.00
4. Mortgages and Notes Receivabie(Schedule D)........................... 4. 0.�0
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. : 0.00
6. 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. 7,044.00 ;
8. Total Gross Assets(total Lines 1 through 7)............................. 8. 7,044.00
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. : 2,410.00
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I)............... 10. ' 0.00
11. Total Deductions(total Lines 9 and 10)................................. 11. 2,4�0.�0
12. Net Value of Estate(Line 8 minus Line 11).............................. 12. 4,634.00
.�».. ,.�..__�. �w..-� .. .,,..... m,��,�,.,,. .y rn,,���_�..�_QS .. ...�
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made{Schedule J) ...................... .. 13. ; 0.00 '
14. Net Value Subject to Tax(Line 12 minus Line 13) .............. ........ 14. 4,634.00
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 � _ . ._. . .._ . . ._. __ _..
(a)(1.2)X.0_ 0.00 15. 0.00 '
�„ _: .., . : ._u ,._. _ : r.,�.�.w,,_., , ., ��.�,��
16. Amount of Line 14 taxable
at linea�rate X.0 45 208.53 �6. 208.53
_.__. �.. , .. _..... .W,m..�� ...... ..., ....:,.. ..._ ..�..,... �.��.�..,. .... ..�.���.� .�..
17. Amount of Line 14 taxable 0.00 �
at sibling rate X.12 0.00 ' �7, .
.-.,_ ,,,. „ �,�,.... .. am � ._�Tm,...� ....�,r.__ :o-�_._. __x.. ....a�,.r.... . .� .. ... ,�.,�_���„ .... _ A,� ..
18. Amount of Line 14 taxable
at collateral rate X.15 0.00 �$ 0.00 :
19. TAX DUE ......................................................... 19. 208.53
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
� 15�561�205 1505610205 �
REV-1510 EX+(08-09)
� enns lvania SCH EDU LE G
P Y
: DEPARTMENT OF REVENUE INTER—VIVOS TRANSFERS AND
; INHERITANCE TAX REfURN MISC. NON—PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
HAROLD A. MARTIN
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
ITEM INCLUDE THE NAME Of THE TRANSFEREE,THEIR RELATIONSHIP TO DKEDENT AND
NUMBER THE DATE OF TRANSFER.ATfACH A COPY OF THE DEED FOR REAL ESiATE. VALUE OF ASSET INTEREST �t�a�cne� VALUE
1. CHERYL MCCRACKEN,66 MILLERS GAP ROAD,ENOLA,PA 17025; 4,408.80 100 3,000.00 1,408.80
DAUGHTER;CASH TRANSFERS MADE WITHIN ONE YEAR OF DEATH
2 PAM BASESHORE,287 RIDGE HILL ROAD,MECHANICSBURG,PA 17050 4,408.80' 100 3,000.00 1,408.80
DAUGHTER;CASH TRANSFERS MADE WITHIN ONE YEAR OF DEATH
3 KIM RIDER,287 RIDGE HILL ROAD,MECHANICSBUR�,PA 17050 4,408.80' 100 3,000.00 1,408.80
DAUGHTER;CASH TRANSFERS MADE WITHIN ONE YEAR OF DEATH
4 DEAN MARTIN,3 WILD ROSE CIRCLE,CARLISLE,PA 17050 4,408.80' 100 3,000.00 1,408.80
` SON;CASH TRANSFERS MADE WITHIN ONE YEAR OF DEATH
5 SCOTT MARTIN,436 MARKET STREET,NEWPORT,PA 17074 4,408.80 100` ` 3,000.00 1,408,80
SON;CASH TRANSFERS MADE WITHIN ONE YEAR OF DEATH
; TOTAL(Also enter on Line 7, Recapitulation) $ 7,044.Q0
If more space is needed,use additional sheets of paper of the same size.
.�.
REV-1511 EX+(10-C19)
� pennsylvania S�N E C}�.1�E H
I}EPARTMENT O�REVENUE FUNERA� EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE CO�TS
RESIDEM pECEDENT
ESTATE OF FILE NUMBER
HAROLD A. MARTIN
Decedent's debts must be reparted on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
�' FUNERA�EXPENSES 2,4'I O.Qf�
B. ADMINISTRATIVE C{}STS:
L Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
: City State ZIP
Year{s)Commission Paid:
2, Attorney Fees;
3. Family Exemption:{If decedent's address is not the same as claimant`s,attach explanation.�
Claimant
Street Address
City State ZIP
Refiationship of Cla3mant ta Decedent�
4. Prabate Fees:
5. Accauntant Fees:
6� Tax Return Preparer Fees:
7. _
TOTAi.{Also enter on�ine 9,Recapitulation� $.: 2,41 Q.OQ
If mare space is needed,use additional sheets of paper of the same size.
LAST WILL AI�ID TES'T�I'
OF
HA�D A. NIARTIN
I, HA�D�D A. NI�►RTIN, of Carlisle, C�mberland County,
Pennsylvania, do h� make my Last Will and Testament and I revoke
alI test.amentary di.spositions heretofore made by me.
I�i I, I direct my Exeeubor to pay all of my just
c�ebts, fi�ral e�enses and ta�oes resulting fran my death as P��-Y
as possible.
ITEM II. I desire to be cremated as directed by my
:
wi.fe, or if she has pred�eceased me, as directed by my old�st living
child,
ITFM I�, I giv� all of my estate, real and-personal, to
my wife, MAI�'�RET A. M��RTIlV, if she survives me. If she predeveases
me, I giv�e my said estate in equal shares to my children, PAi�L�A A.
BASII�O�E, C�L A. McC�1�t, I.�AN A. N�Il�T, KIl�! I. FETi�JW and SCJO'I'r
A. MARTIN. If any child has prec�ec;eased me, but leaves issue
surviving me, the share of the deceased child shall be paid to the
issue in equal shares, subjeet to the provisio�s pertaining to minors
hereinafter stat�d,
� I�++I IV, If any beneficiary under the tenns of this will
i.s ur�der the age of eighteen t 18) y�ears, th+e share of my estate to
which sai.d beneficiary is entitled shall be paid to my daughter,
�
.� A. Mf�cCRA�C.�N, as Guardian arn� Trustee. Trustee shall inv�est
said funds ar� add the �t proc:eeds therefran to the prir�cigal, the
Page 1 of 2 Pa�es
. �
resulting fund to be hereinafter c�esignated as "the Trust Fund." 'I�e
. Trustee shall expend the Tzvst �ind for the support, maintenance, and
education of the beneficiary. t�en said b�neficiazy attains the ag�e
of eiqhteen (18) the Trustee shall pay aver to him or her the entire
balan�ce in the said Fur�d.
I�++i V. I ncminate, c�o�stitute and appoint my wife,
A, MIARTIl�t, to be my E�ecutor. If she is unable or unwilling
to so act, I appoint the aforementiat�ed t�L A. MfoCRACt�Eri to be my
E�ecutrix.
IN 4�fIR�S W�OF, I hereunto set my hand and seal t�o this,
my Last Will and T�estament, this day Of , 1989.
� -�� ���
- �
- �'.����`-'' �
Harold A. Martin
W�e, the undersign�ed, hereby vertify that t��e foreg+oing Will
was sic�ed sealed, pvblished ar�d deciared by the above-named Z�estator
as and for his I�ast Will and Testa�aent, in �he presen�e of us whc�, at
his request ancl in his pres�noe ark3 in tl� presenoe of each other,
hav+e herevnto set our haiu3s and seals the day and year abav+e written,
arld we certify that at the t�.me of t.he executio� tl�xeof, the said
�estator was of soa�aid an�d dispoeing mind aryd a�ry,
wTT.T.TAM �T. NIl�D�T, JR., ES�JIR'E
C�anberry Court
212 North �`hird Street
P.4. eox i1998
Karrisburg, PA 171U$
(717) 233-7691
`
Page 2 of 2 Pac�es
HId5.905�REV.(8/11) .�
. ' This is to certify that this is a true copy of rhe record which is on file in the Pennsylvania Department of Health, in accordance with
the Vital Sta.tistics La.w of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
. � thry//NNiiiiy �WWY�(ti �e��`•-`�'�-`�
'�,��ti OF p f�
oy►��_==__`_'�yJ'i- Marina O'Reilly_Matthew
e
��� __z State Registrar
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_ ��►,p `�-�- � 1`1` ��� I �7 LY IZ
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No. Date
` 7ypt/Print In COMMONWEALTH OF PENNSYLVANIA�4EPARTMENT OF HEALTt1•VITAL REGORDS -
��+��M CERTIFIGATE OF�EATH
srsce r-i�e r�wmeer.
Blaek Ink --
� 1.DaeedenYs 1.aL�i IV�m�tFfrs4 Mlddls:Lss4 SufRx) �� . . . 2.Sa 3.Sodsl 5�eurhy Numbsr a:Dsie of Daaifi tMai/DaY �)ISP4N MoI
Harold A_ Martin 163-22-4559 August 3, 2012
Sa.Ass-Last 9M'thd�t+lYn Sb.Wnder 1 Y�r Sc.U�d�r 1 B.Wt�M 91ret� . /1►ar)t3{x1�Morrti+) '7a•�BiKhpl�oe{c�r sod Stst�ot For�isn Com+t*Y) �
, � �o�� � Ha,r, �,,,� Lancaster PA
g� y=s, Aug� 1 6, l 9 3 0 �-s►•�+�w•o•t�«+•��r� Z.anc s
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..... . .-..�.. .. � QNo.decad�rK INed wichM Iln+lts of , �1�Ylboro• .
r 1 nd a���re..,�.a�n�•� 5 O
9.Ev�e�In t75 Arrraed Forces7 10.MarNal Status a[Tfrn�of O�alh � MarrNd- 11.SurvM*�i��s Na�(tt wK�.�!�nsreu prfor to NrsY rr�rrfat!)
Yes �No �Unimown 0 DWo►c�d �Mev��M�rried �Uolcnown - - �
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� Hubert A_ Hazel -
34a.InfonnsM s Name . •14b.RelsUOrnhiP m Deceden[ isc Intormanc's�Nlatpng Addrass(Straac and Numb�r,CttY.Stat�.2tP CodQ)
� � g Cher 1 A Dau 2at 6 6 Mi�1e lers Ga Rd_ Eno1 '1 7 O Z 5
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,� r � E . Room/OutpaWe+t - Oead an ArrNal ('�NUrsin� Term Gn Fae1NtY � Other I 1
; 15b.FaeNttY NsrrN iK not Instleutlon.BNe stre�at and-m+m - , . i5c.CKy or Tow��.Staes,and Z{p Gede � lsd.Ceue►�Y of�DeaM�
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("�R�rr.oval fcom Stab �Dorutbn .
; ����,y� Au �8 201 2 Hcllin er FH/Crematory�
� i6d.locatbn of DhP��1�hY or To�✓n.State sr�d Z�I � 17s. ne of Funeril SeMel.. ...._...Pa�son in Cfisrsa of IM�rKfNft 17�Liwnas Numb�r
Mt.Ho11y Springs, PA l 7065 _ ' FD-d'1 '1 932-L
17c.Narne s�+d coRfaleDe Adar.ss or wn.ra�P,a�lc�+ �
Mt. Fiolla S rin�s PA '1?065
a$ 18.�D�aadenc's Edueatlon- tMe bao��that b�s[�dascrib�s tfie 19.D�ada�s of Hispanlc O�iSM-Cfiadc sh� -�- � 20.D6oadaM's Rsee-Ghecic ONE OR MWIE races to Indlefte whai
r°- hish�st desres or lewl of seltooi aomP��at the tlrrK of dsath. bo+c that bast d�urt�cfiar tl�a d�c�dent �� elfa da�dent ow�sider'ed!►Imself or fiarssif po be.
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p No arpbm..9tn-iztls�aae " ewc M decea�m�s noc spsntshlttlsw�/��w. p s�sdc or.�frfcan nmertesn �
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• MD OVM LLB!D - �
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�Whtte � �bp�ewe O Samoaa dOnB durint mos!ot wakina(ifl.DO NOT USE R£TtRED.
]61adc or Afticarf Am�rlcan =]Korssn 0 Otlfer Paclflc lsler+d�r � - -
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p s�s�an�.,eN., p ocn.�s�... O R�� �se.Kr+d or nausi.v
� p a,�„� p Nacwe►�awa�ian O�(sv�v)
p Flxpmo ��•+•������m«� Trans ortation/Trucicin
� - /TEMS=9�-=23d MYST HE tOMPLETE�. 23a_Data .Si�nstur� �Pe►sw►PronourKM6 . t�h�wti��PW�ble 23e.Ucense Num
� 6Y�R9OM tllfli0 PRONOIMC�OR � .
c�tw�s oEwTM alt ,_ .�
.w»+�•�+..a Msr.�.�� . -...n. w�� . .
; �+.. < �' .+•
. '--� . - . . 25.Was Medieal 0ramin�r o�Cororx�Gontaetad? . -� Yes �0'No .
cnuse oF o�►TM _ ,.oP.�.�n.
2B.Psri 1.Ent�r the lseaaes,inJuries,or m�*+Wieatbnv-tAat dlractN uuaad the deatf�.00 1VOT n��r terminai�v�ents�sd�as ordiac�►*as[ � IMaeval:
rasplraLory ar►esc,or ventrlcuiar flbRqsLbn wlelwuc showlr�tF�e etb�otY.DO NOT ABBREVIATE.Ertter only one nuse on s pne.Md addltlw�al ItsKS if necessary a Onset to Oeath
IMMEOIATE CAUSE -� a_��y�j�ra��VN 1�►�'lwrf St��fn� o►f`�I '�C! A��-Cl�b`�Ah�g� !
(Ftnd disa�ass or eonditlon Ou�to(or as a ooenequenoe o�e �
rmultl�ln dlaM) . . . . . . .. .
b_
� qun+tldN liu oo�dkions. . � Dut Lo(oir as a wnsequencs o�: __ . . . . . �
. if an1F.t�atlM+t to tl�s�uss '
- Iisted on Une a.Enier!he c
UNOERLYIM6 GAUSE Oue to{or as a oons�4uee�oe o�: � . .
� (disasl6 OfInJYrY Lhat £
Initi�tae!t)fa sver�ts resultint d. ;
m death�tJtsr. oue to(or as a conseqvenoe o�. �
� � 26.Par[iL EnLer other sltniftcant condttiw�s contributint co d�ath buC�ot resulting 1n the underlyi�causa given in Part 1 � � . - 27.Was an autopsy pMwtnedT .
� 2Q.V1/ef!avcoPsY �dMSs availa
; � � - .. ' . � m tomplata the c�iva af daath7 .
� . O Y�s No - .
29:if Fe�»i1C 30_Oid Tobaeco Use CoMiibuta to O�athT - �-31.Msnn��of DasLA�
E O Noc�.,.o:w�en�o wn r� O��s O�•bhr �L.aa:u.a� p No.nkwe
S O prK�=st Nme of death Ig'No p uo�., O�. ���+s��
� p Noi prasnant,euc p.�e�e.a++c w�tMn 42 asys or aean, / p su�aae p couw.tot ee datenn�ned
� �Not P�Fant.but P��rt 43 days to 1 Y�ar be�foee daath 32.Daie ofi/nl�+rY(�M��Y/1�r)(SPdI MonM) � � .
�UeHafown N prst�arrt wttAln tlfe P�t 1^eu � 33.1'Ima oT Injury - � . . �..
� 94.Wsce of�INurY(a-t.home:me�stra+etton stte:1arn.:scf+ool) - 3S.Lneation ofln7urY(Sbwt.......Numb�r,�City�Stat�e,Zip Cod�) . �
36.I�Sury ai Worlc 37_If Tra�+spwtatio�inlury.SpocifY: 3S.DescMbe How lnJury Oceumed:
n Y� o o�w��roa.� o��
O� O��s•� o�t�ti�
` � 39a.CertMer(Check only one):
0 Cerdl�ri�t DMs��ia�-To Tha best of eny iv�owfadt�.dea!!�aeaxr�d due to MQ oaise(s)ae►d rrwnr�er seftad... . .
���+�i����Yi�t PhYsidan-To Me best e�f mY�fe,desttE oocurred a!tl�s tlma.date,s�d pbce,snd dus to tlte cause(s)snd mannK sestad
p�Medicsi 6�aminaN -[ilE+ehe atiw+.s or�v�dor�i�+*rW oW�b�,d�stl►yoe�/eu)rc�d.a/c�tlx tlrr�,dat�,a�+d P�aoe,and due to tlr causa(s)and m�nn�r ststad
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