HomeMy WebLinkAbout04-1114 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96)
F',EPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128 0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 004692
ROGERS JORDAN
19 CREEK BANK DRIVE
MECHANICSBURG, PA 17050
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
........ fold
101 $4,500.00
ESTATE INFORMATION: SSN: 226-44-5098
FILE NUMBER: 2104- 1 1 1 4
DECEDENT NAME: ROGERS EUNICE M
DATE OF PAYMENT: 1 2/06/2004
POSTMARK DATE: 1 2/06/2004
COUNTY: CUM BERLAN D
DATE OF DEATH: 09/07/2004
TOTAL AMOUNT PAID: $4,500.00
REMARKS: ROGERS
CHECK//170
INITIALS: CCP
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
C<?~1MONWEAlTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2B0601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ROGERS JORDAN
19 CREEK BANK DRIVE
MECHANICSBURG, PA 17050
_nnn_ fold
ESTATE INFORMATION: SSN: 226-44-5098
FILE NUMBER: 2104-1114
DECEDENT NAME: ROGERS EUNICE M
DA TE OF PAYMENT: 04/19/2005
POSTMARK DATE: 04/19/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 09/07/2004
NO. CD 005224
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $472.57
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: JORDAN T ROGERS
CHECK# 3885
SEAL
INITIALS: RSK
RECEIVED BY:
REGISTER OF WILLS
$472.57
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
Inventory of the real and personal estate of
-
~Uk.l~.t' ~. 7<19 ~el2s
deceased
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
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ss:
being duly according to law, deposes and says that he
of the Estate of
late of -;T"'"----~-'.-:-_-~--.-. ' ',Cumberland, COl,lnty, ,Pa., deceased and that the
within is an inventory made by . , th~ said "
of the entire estate of said decedent, consisting of all the personal propl!rty and real. estate, except real estate outside
the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value
as of the date of decedent's death. . " ' J
and subscribed before me,
'/fJd~ 1hPIWt~ '\~< "
. Exec:utor. Adm I Iftrator
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Date of Death
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INSTRUCTIONS
I. An inventory must be filed within three months after appointment of personal representatiye.
2. A supplement inventory must be filed within thirty days of discovery of additional assets.
3. Additional sheets may be attached as to personalty or realty
4. See Article IV, Fiduciaries Act of 1949.
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REV-1500
OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
,HARRISBURG, PA 17128.()6()1.
FII:/t NUMBER
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SOCIAl SECURITY NUMBER
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
& ,EUIf-~.t:1l
DATE OF DEATH (MM:01i- AR) DATE OF BIRTH (MM.DD. YEAR)
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~ 1. Original Retum
o 4. Limited Estate
o 6. Decedent Died Testate (AftachoopyofWVI)
o 9. Litigation Proceeds Received
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N\J.IBER
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SoCIAL SECURITY NUMBER
o 2. Supplemental Return
o 4a. Future Interest Compromise (date ofdeath alter 12-12-82.)
o 7. Decedent Maintamed a Li....ingTrust (AllachcopymTrust)
010. Spousal Poverty Credit (date afclealtl betWeen 12-31.91 and 1-1-95)
03. Remainder Retum {dateofde&th prIorkl 12-13-8,2l
o 5. Federal Estate Tax Return ReQuired
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under See, 9113(A) 1""''''''''01
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NAME I
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FIRM NAME ('''''_1
T.!<() rRS
COMPlETE MAILING ADDRESS
(1) ~
(2) I>
(3) LJ
(4) 0
(5) i 69~1. :u
(6) t>
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1. Real Estate (Schedule A)
2, stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-ProprietOrship
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A~eJ,6t.I1,.C.s 611/I,
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Pit 1'?()St!)
4. MOI1gages & Notes Receivable (Schedule Dj
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6, Jointiy Owned Property (Schedule F)
o Se~rate Billing Requested '
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or l)
B. Total Gros. Assets (total lines 1-7)
9, Funeral Expenses & Administrative Cools (Schedule H)
10. Debls of Decedent, Mortgage liabilities, & liens (Schedule I)
11, Total DeductIon. (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (S_J)
TELEPHONE NUMBER
(7) It'(,I'JI.()Z-
.
(9) /(1 :]1- 2 '(
(10) tJ
14. Net Value Subject to Tax (line 12 minus line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
OFFICIA,l.JJSE ONLY
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15. Amount of line 14 taxable at the spousal tax
rata, or transfers under Sec. 9116 (a)(1.2)
16. Amount of line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
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x.olf!: (16) H 5/'17- $'1 " '\
x .12 (17)
x .15 (1B)
(19) , 1'1 '17. f"9
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
20.0
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Decedent's Complete Address:
STREET AOORESS
CITY
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Tax PaYJl:'Ie.nm and. ~redits:
1. Tax Due (Page lUne 19)
2. CreditslPayments
A. Spousal Poverty Credit
S. Prior Payments
C. Discount
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Total Credits (A+ S.' C), (2) d . of'} ~ I"
3. InteresUPenaity ~ appiicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
4. If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
. .
5. If Une 1 + Une 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interesl on the tax due.
S, Enter the lotal of Line ~ + SA. This'is!he BALANCE DUE.
(5A)
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(5B) '/{?1..!'
.
. Make Check Payable to: REGISTER OF WILLS, AGENT
.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"'N THE APPROPRIATE BLOCKS
I. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;ddd.........:......................,................................................... 0
b. retain the right to designate who shail use the property transferred or its income; ....d...................................... 0
c. retain a reversionary interest or..........,........................,..................................................................................... 0
d. receive the promise for life of either payments, benefits or'care? ..:................................................................... 0
2. If death occurred after December 12, 1982, did decedent transl.er property within one year of death
without receiving adequate consideration? ...........,..................................,............................................................... 0
3. Did decedent own an 'in trust fo~' or payabie upon death bank account or security at his or her death? .......'...... 0
4. Did decedent own an Individuai Retirement AcCOUnt" aAl1uity, or othllr non-probate property which
contains a beneficiary designation? .............................,.......................................................................................... ~
No
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IF THE ANSWER TO- ANY 'OF THE ABOvE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of peljury, I declare thai I have examined Ihis return, including accompanyi(lg stI1e<tutes and sta,tairents, aM to the best of my kooHIedge and beI\ei, it is true, correc1:
and comp)ete.
Declaration of preparar other than the personal representative is based on all information of whiCh prepa'rer lias any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FllIN RETURN DATE
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ADDRESS . '~ D b P.
SIGNATUREOF~P~~:~~THA~RE;RESE~AfIVE J/JL~'t.I "'J 'fj l'J05i; DATE
ADDRESS
For dates of death on or after July 1, 1994 and before January I, 1995, the tax rate imposed on the, net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. ~9116 (a) (1.1) (i)J.
.,.. ~ . .
For dates of death on or after January t, 1995, the tax rate imposed on the net value of transfers 10 or'for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)],
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are slill applicable even ~
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net vaiue of transfers from a deceased child twenty,me 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% [12P.S. ~9118(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the deoedent's lineal beneficiaries is 4.5%, 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% [72 P.S, ~9118(a)(1.3)]. A sibling is defined, under Section 9102, as an
indMdual who has at least one parent in common with the deoedent, whether by blood or adoption.
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'\. flIEV-1502 EX+ (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
FILE NUMBER
All real property owned solely or as a lenant 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 which Is Jointly-owned with right 01 survivorship must be disclosed on Schedule F,
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also antar on line I, Recapftulation) $
(If more space is needed. insert additional sheets of the same size)
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REV-l503 Ell+ (1-9n
*'
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RE IDENT DECEDENT
ESTATE OF
FILE NUMBER
All property jolntly-owned with right 01 survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 2, Recapitulation) $
(If lT10fe space is needed, IOsert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DE DENT
SCHEDULE C
CLOSEL Y.HELD CORPORATION,
PARTNERSHIP or SOLE.PROPRIETORSHIP
ESTATE OF
FILE NUMBER
Schedule C-! or C-2 (Including all supporting infonnation) must be at1ached for each cIosely-held corporation/partnelShip interest of the _nt, other than a soIe-proprielorship.
See inslruclions (or the supporting information 10 be submitted for sole-proprietorships.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 3, Recapitulation) $
(If IT1Of9 space is needed, insert additional sheets of the same size)
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COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C.1
CLOSEL Y.HELD CORPORATE
STOCK INFORMATION REPORT
ESTATE OF
FILE NUMBER
1, Name of ColpOlalion
Address
City
2, Federal Empioyer I.D, Number
3, Type of Business
Zip Code
State oIlncoIpOIaIion
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
State
ProductlService
4,
TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Cornman $
Preferred $
Provide all rights and restrictions pertaining to each dass of stock,
5,
Was the decedent employed by the Corporation?
If yes, Posttion
D Yes D No
Annual Salary $
Time Devoted 10 Business
6, Was the ColpOlalion indebted to the decedent? D Yes D No
If yes, provide amount of indebtedness $
7, Was there life insurance payable to the corporation upon the death of the decedent? D Yes D No
If yes, Cash Surrender Value $ Nel proc:eed$ payable $
ONner of the policy
8, Did the decedent sellar transfer stock of this company within one year prior to death or within two years ~ the date of death was prior to 12-31-821
DYes D No If yes, D Transfer D Sale Number of Shares
Transferee or Purchaser
AlIach a separate sheet for additional transfe!s and/or seles,
9, Was there a written shareholder's agreemenl in efIect at the time of the decedenfs death?
If yes, provide a copy of the agreement.
Consideration $
Date
D Yes D No
10, Was the decedenfs stock sold? D Yes D No
W yes, provide a copy of the agreement of sale, elc,
11, Was the corporation dissolved or liquidated after the decedent's death? D Yes D No
W yes, provide a breakdown of distributions received by the estate, induding dates and amounts received,
12, Did the corporation have an interest in other corporations or partnerships? D Yes D No
If yes, report the necessary infonnation on a separate sheet, Induding a Schedule C.t or C-2 for each interest,
A, Detailed calculations used in the valuation of the deoedenfs stock,
B, Complete copies 01 financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years,
C, If the corporation owned real estate, submtt a list showing the complete address/es and estimated fair market valuels, If real estate appraisals have been
secured, attach copies,
D, Ust 01 principal stockhOlders at the date of death, number of shares held and their relationship to the decedent,
E, Ust 01 oIlicers, their salaries, bonuses and any other benefits received from the corporation,
F, Statement of dividends paid each year, Uslthose declared and unpaid,
G, Any other infonnation relating to the valuation of the decedenfs stock,
, .
,
REV'1500EX+(9-OO.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMAnON REPORT
ESTATE OF
FILE NUMBER
1. Name 01 Partnership
Date Business Commenced
Business Reporting Year
Address
City
2. Federal Employer 1.0. Number
3. Type 01 Business
State
Zip Code
ProducVService
4. Decedent was a 0 General 0 Umtted partner. If decedent was a lirotted partner, provide initial inves1merll $
5.
A.
B.
C.
D.
6. Value 01 the decedent's interest $
7. Was the partne...hip indebted to the decedent? ................................. DYes 0 No
II yes, provide amount of indebtedness $
8. Was there Iffe insurance payable to the partnership upon the death 01 the decedent? ..... 0 Yes 0 No
II yes, Cash Surrender Value $ Net proceeds payable $
Owner 01 the policy
9. Did the decedent sell or transler an interest in this partnership within one year prior to death or within two years ff the date 01 death was
prior to 12.31-827
DYes ONo
II yes, 0 Transler 0 Sale
Percentage transferred/sold
Consideration $
Transferee or Purchaser
Attach a separate sheet lor addttional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time 01 the decedent's death? . . . . .. 0 Ves 0 No
If yes, provide e copy 01 the agreement.
Date
11. Was the decedent's partne...hip interest sold? ....................................... 0 Yes 0 No
If yes, provide a copy of the agreement 01 sale, etc.
12. Was the partne...hip dissolved or liquidated after the decedent's death? ................... 0 Yes 0 No
If yes, provide a breakdown 01 distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any 01 the partners? .................................... DYes 0 No
If yes, explain
14. Did the partnership have an interest in other corporations or partne...hips? . . . . . . . . . . . . .. 0 Yes 0 No
It yes, report the necessary inlormation on a separate sheet, including a Schedule C-1 or C-2 for each Interest.
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation 01 the decedenfs partnership interest.
B. Complete copies 01 financial statements or Federal Partnership Income Tax retums (Fonn 1065) lor the year of death and 4 preceding yea....
C. II the partne...hip owned real eslate, submll a list showing the complete address/as and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. Any other infonmation relating to the valuation 01 the decedent's partne...hip interest.
, .
.
:REV"507EX+II-97J *
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
FILE NUMBER
All property jointly-owned with right 01 survivorship must be disclosed on Schedule F.
ITEM
NUM8ER
DESCRIPTION
VALUE AT DATE
OF DEATH
,.
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
Indude the prooesds of litigation and the dale the proceeds were racsived by tha estate. All propsrty jolntly-Gwned _ the right ofsurvlvorship mUlt be disclosed on Scbedulo F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. ClteJc'"J a-f'#tI. III1PP"OtJ1iJ, AiI.,,4"It-t 8.".I'-/p"ij :i ~11.~3
1/4NM.t6-,( (J1I1'114$'".I'l1
lI'Ic's"t:AI1~#. ~..,~ ~ :See. .tf*.',,f 1fI..'/1 a-uL
Attt'.v.v./
I/,u~#~ Go' /11'""
J~IM4-/~ ; aM4dll1~,,;t ~ 1t,4~.us; 6~~/..:fS;
/l.4AJ's", ~;nJSi ....t~.
$dIH~ I'~ "Nt-so, ,.uIL~'h1..(.-rl "f),e".t#lJfL
....-~5118 ex+(1-87) .
ESTATE OF
~.
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RE IDENT DECEDENT
7<P~tERS. EaA,'U A.
FILE NUMBER
2.
12.11. .11
-
$ "". t?(J
2 di" ". 0(;)
I.
f"tJ".Q1)
TOTAL (Also enter on line 5, Recapitulation) $"" ~ J 23
(If more space is needed, insert additional sheets of the same size)
*-'UiOIEX+(l-97]
'*
SCHEDULE F
JOINTL Y.OWNED PROPERTY
COMMONWEAlTH OF PENNSYLVANIA
INHERJTANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
. an _ _ ..- joint _In ona year of tho _ni'l _ of doath. ft mull be reported on Sebedule G.
SURVlV1NG JOlNT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
B.
c.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT M.\IlE Include nsna of ftnEl1Cial insIilution a1d bslk account number or simHar identIfylng number. Atta:h DATEOFDEAlH DECD'S VALUE OF
NUMBER TENANT JOINT deedlorjoln1ly-llelcl..._ VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on line 6, RecapitUlation) $
(W more space is needed, insert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INHERJTANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
FILE NUMBER
This schedule must be completed and filed Wthe answer to any of questons 1 through 4 on the reV81Se ~de of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE tw.E Of TIE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AN> THE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSI~ TAXABLE VALUE
ATTACH A COP'( OF THE DEED FOR REAL ESTATE.
NUMBER VALUE OF ASSET INTEREST 'IFAPPUCAlILE
1. Us Il.P6{. Pp)f a.el 11."'{.1l1l~1
ItI ~,,~~ ~-t, I..~'t";-I~I 5'".1/.-11.,. ~,
fJe d.e"h~-/TJ 1Jwt" Sms (/l,6~
tlle.d,,-,w 4...11 1A~ .J1;j./&T~ IW
'1./19/"0/. L ~",.,f ..-t 6~:l1':I 4C1"u't",L ~
II/" RIt>e,4'1l ~~ 2.,tP~ ~A'I"'''' Jr3t ~po rII~a
II)~ ;>'3 20,;;).
/411./ /i4f.,'. r <5"1/.'(/_ C'd : /.,1.
~ 2.<9d 'lid t~,.d !32..4)0
fI/P!,tltld ..; 3 r "5t.UhJ
~~ 2.,..090 IIh ~dd() ~3 2.4:10.
2. I'/<,'}: :f)/?/'-(5 J~T. F..'#/.';~lWwJJ. 1" Bu. ~ e In; ~t fe. C
4- 9i/t-~ fii) ~-1t.2'l-"" 9/1;/11"(. 8e'l1 -
f:vlaM 1-$: ~ S.oh.s ~ ~ fJl} .c,t. I;>) ~'J5(). G
3'1 fJ t1.~~ lib ,')td.~
J. I R/t: tt#2. t(> sl.;t (. 11/ ~JW'v,:S"4M /be Ie..
1n",,/#.i;f, (~2.J){rllr)ti) -I/5:t.Ij"" If) ,6-,,,. "L. 1170 /'l) tf '1. "
11'J/1J'(. 5;,/(. 6e...~ (.'4'~' ~Pl(S~
t J/..-Iu4 tfiV<J ~ 327.? ~, ~s.. Uf:flfA, ~~-~ 91?t;".2.~ I'c 9";Z.C 7
W e..'J'u.''(di#f' :zI11/0,/6)in.62.!
~. 2..( ~.,.- -b1 ~"&c..
3: S2 flv... ''leI> So,,,- 2/zr/or fi) -#,J..,.I#f/rk z 2.5"1. ~ Ido 22-$'1. g
a...t( ~I~ ~-,t4."~.t?> 3 !:A5
t. :112.#<<J e<<sl, a,/,f4 1/'/II)Y -Iv Zi.e-'t S 2Q~,,-'b IIW 2co"-_ h
a""J d.".If4-;b~ -p ~h>J..
TOTAL (Also enter on line 7, Recapitulation) $ 131', 6 '7/.~2.--
4r.
.(J;
tJi
5
or;
..
'8
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.,
(W more space is needed, insert addttional sheels of the same Size)
'.
, AEV-1511EX+(1.Q7)
ESTATE OF
'*
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
~TH DFPENNSYlVANlA
INHERITANCE TAX RETURN
RE NT NT
FILE NUMBER
Debts 01 decedent must be repoIted on Schedule I.
ITEM
NUMBER
A.
1.
2-
~
r
s:
t.
.,
e.
'I
B.
1.
2.
3.
DESCRIPTION
AMOUNT
14t2._
2$ . rI1I
11&. "cJ
~a 't. ~r
.1",".4.:1
,,,tnl. tit)
'1 r. rv
5'''_ q
I~S: n>
2$'~_ '1J
:1.tI~
FUNERAL EXPENSES:
. C.M'f.'dC,,/,,-- J <I_A &Nt.iJ.-...C'
C'W'>I ~'t ..,_
.C... +..,..... -frrc- .rl..,.
#6~f-"'.IIJ'
''''''''''' '1
("''''4!.~ I." r
G,.~4) ~Ac4...:.d...Jr-;"'r;.....,;.;,
~f...., 8-;...( e~"Vc,..
p/WI'-J....... -t u....r~ /lI,T
AIlMINISTRA TIVE COSTS:
PeIsonaI RepresentaIi>e's Commissions
Name of PeIsonaI Representative (s)
Social Security Numbe<(s) I EIN Number of PIlISONlI RllpIeSeI1Iative{s)
StnleI Address
.
. .
'1131.2"(
City
Yea~s) Commission Paid: .
AItomey Fees
Family Exemption: (If decedenfs address is not the same as claimants, allach explanation)
Claimant
Slam
Zip
'"15&
Street Addless
City
ReIalionship of Claimant to Decedent
Stale
Zip
4. _Fees
5. AccounIanl's Fees
6.
7.
Tax ReIum Pnlparer's Fees
a,.,w..~wf 1 ~~ ~-
.I~O
1/1. 6wc.c-~. .41\,(. ,I""'AI"'" 't,:,'
II. 9MtI,. k,,~.- ~ (~'1 -...f (I.;(-i -4... d~'~J
/zr,.-
TOTAL (Also enter on line 9, Recapitulation) $' 1((11.
(ff more space is needed, insert additional sheels of the same size)
'.
REV_'5j2EX.(1_97)~.
' .~
COMMONWEALTH OF PENNSYl VANtA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
FilE NUMBER
Include un,eimbursed medical expenses.
ITEM
NUMBER
1.
DESCRIPTION
AMOUNT
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, inser! additional sheets of the same size)
"
'. REV-1513 EX+ (9-00*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and Iransters under
See, 9116 (a) (1.2))
1,
ENTER DOLLAR AMOUNTS FOR DtSTRtBUTlONS SHOWN ABOVE ON LINES 15 THROUGH 16, AS APPROPRIATE, ON REV-,500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1,
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF AEV-1500 COVEA SHEET $
(If more space is needed, insert additional sheets of the same size)
._--_...~---,-_.~_._-_._.._"---
,.
_"U~,"~ '*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on Rev.1500 Cover Sheet
FILE NUMBER
ESTATE OF
This schedule is to be used for all single life, joint or. successive life estate and term certain calculations. For dates of death
prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5 -1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Will 0 Intervlvos Deed of Trust 0 Other
NAME(S) OF
LIFE TENANT S
DATE OF BIRTH
TERM OF YEARS LIFE ESTATE IS
PAYABLE
o Life or 0 Tenn of Years
o Life or 0 Tenn of Years _
o Life or 0 Tenn of Years _
o Life or 0 Tenn of Years
$
1. Value of fund from which life estate is payable
2. Actuarial factor per appropriate table
hiterest table rate - 031/2% 06% 0 10% 0 Variable Rate
3. Value of life estate (Une 1 multiplied by Une 2)
%
$
NAME(S) OF
ANNUITANT S
NEAREST AGE AT TERM OF YEARS
DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE
o Life or 0 Tenn of Years
o Life or 0 Tenn of Years _
o ute or 0 Tenn of Years
o ute or 0 TennofYears _
1. Value of fund from which annuity is payable $
2. Check appropriate block below and enter corresponding (number)
Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12)
o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( )
3. Amount of payout per period $
4. Aggregate annual payment, Line 2 multiplied by Line 3
5. Annuity Factor (see instructions)
Interest table rate 03 1/2% 06% 0 10% 0 Variable Rate %
6. Adjustment Factor (see instructions)
7. Value ofannul1y -If using 31/2%, 6%.10%, or if variable rate and period payout is at end of period,
calculation is : Line 4 x Une 5 x Line 6 $
If using variable rate and period payout is at beginning of period, calculation is :
(Line 4 x Une 5 x Line 6) + Line 3 $
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on
Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on
Lines 13, 15, 16 and 17.
(If more space is needed, insert additional sheets of the same size)
"
REV-I64A EX. (3.84) INHERITANCE TAX
.
SCHEDULE "L"
COMMONWEALTH OF PENNSYlVANIA REMAINDER PREPAYMENT OR INVASION
INHERITANCE TAX RETURN
RESIDENT DECEDENT . OF TRUST PRINCIPAL FilE NUMBER
I, Estate of
(last Name) (First Name} tMiddle Initiall
This schedule is appropriate only far estates of decedents dying on or before December 12, 1982,
This schedule is to be used for all remainder returns when an election to prepoy has been filed under fhe provisions
01 Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion 01 trust principal.
II. Remainder Prepayment:
A. Election to prepay filed with the Register 01 Wills on (Date)
(attach copy 01 election)
B. Name(s) 01 Life Tenant(s) Date 01 Birth Age on date Term of years income
or Annuitant(s) 01 election or annuity is payable
C. Assels: Complete Schedule L- 1
1. Real Estate S
2. Stocks and Bonds S
3. Clasely Held StodclPartnership S
4. Martgages and Notes S
5. Cash/Misc. Persanal Property S
6. Total from Schedule L- 1 S
D. Credits: Complete Schedule L-2
1. Unpaid Liabilities S
2. Unpaid Bequests S
3. Value al Unincludable Assets S
4. Total from Schedule L-2 S
E. Total value al trust assets (Line C-6 minus Line 0-4) S
~.
F. Remainder foctor (see Table I or Table II in Instruction Booklet)
G. Taxable Remainder value (Line E x Line F) S
(Also enter on Line 7, Recapitulatianl
III. Invasion of Corpus:
A. Invasion 01 corpus (Month, Day, Year)
B. Name(s) 01 Lile T enant(s) Date 01 Birth Age on date Term of years income
or Annuitant(s) corpus consumed or annuity is payable
C. Corpus consumed S
D. Remainder foctor (see Table I or Table II in Instruction Booklet) S
E. Taxable value 01 corpus consumed (Line C x Line D) S
(Also enter on line 7, Recapitulatian)
___'""'__'___M__"___',_,__~___
REV-1Mb EX+ (3-84) INHERITANCE TAX
*
SCHEDULE L-2
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT -CREDITS- FILE NUMBER
I. Estate of
(Last Name) (First Nome) (Middle Initial)
II. Item No. Description Amount
A. Unpaid Liabilities Claimed against Original Estate, and payable from assets
reported on Schedule L-I (please list)
Total unpaid liabilities S
(include on Section II, Line 0-1 on Schedule L)
B. Unpaid Bequests payable from assets reported on Schedule L-l (please list)
Total unpaid bequests S
(include on Section II, Line 0-2 on Schedule L)
C. Value of assets reported on Schedule L-I (other than unpaid bequests listed under
"B" above) that ore not included for tax purposes or that do not form a part
of the trust.
Computation as fallows:
Total unincludable assets $
(include on Section II, Line 0-3 an Schedule Ll
III. TOTAL IAlso enter on Section II, Line 0-4 on Schedule L) $
(If more space is needed, attach additional 8% x 11 sheets.)
~'~7EX'('," '*
COMMONWEALTH Of PENNSYLVANIA
INHERlTANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE M
FUTURE INTEREST COMPROMISE
Check Box 4a on Rev.1500 Cover Sheet
FILE NUMBER
ESTATE OF
This schedule is appropriate only for estates of decedents dying after December 12, 1982.
This schedule is to be used for all future inlerests where the rale of tax which will be applicable when the future interest vests in possession
and enjoyment cannot be established with certainty.
Indicale below the type of instrument which created the future inlerest and attach a copy to the tax retum.
D Will 0 Tnust D Other
I. Beneficiaries
NAME OF AGE TO
BENEFICIARY RELATIONSHIP DATE OF BIRTH NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decedents dying on or after July 1. 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months
of the decadenfs death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such
withdrawal right.
D Unlimited right of withdrawal D limitecl right of withdrawal
III. Explanation of Compromise Offer:
W. Summary of Compromise Offer:
1. Amount of Future Inlerest $
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(also include as part of total shown on Line 13 of Cover Sheet) $
3. Value of Une 1 passing to spouse at appropriale tax rale
Check One 06%, 03%, 0 0%
(alSO include as part of total shown on Una 15 of Cover Sheet) $
4. Value of Une 1 Taxable at 6% Rate
(also include as part of total shown on Line 16 of Cover Sheet) $
5. Value of Line 1 Taxable at 15% Rale
(also include as part of total shown on Line 17 of Cover Sheet) $
6. Total value of Future Interest (sum of Unes 2thru 5 must equal Linel) $
..
(If more space IS needed, Insert additional sheets of the same size)
_-o.EV.,64: EX 11.921 ..
COMMONWEALTH OF PENNSYLANIA
INHERITANCE TAX DIVISION
ESTATE OF
SCHEDULE N
SPOUSAL POVERTY CREDIT
AVAILABLE FOR DECEDENTS DYING AFTER 12131/91
PART I . CALCULATION OF GROSS ESTATE
I FILE NUMBER
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet.
1. Taxable Assets total from line 8 (cover sheet) .................................................................... 1.
2. Insurance Proceeds on Life of Decedent ............................................................................ 2.
3. Retirement Benefits.... ........... ...... ........ .............. ............. ............. ...... ........ .............. ........ 3.
4. Joint Assets with Spouse................................................................................................. 4.
5. PA lottery Winnings ......... ............... ............. ............ .............. ............... ............. ........... 5.
6b.
6a. Other Nontaxable Assets: list (Attach schedule if necessary).. 6a.
6c.
6d.
6. SUBTOTAL (Lines 60, b, c, d) ......................................................................................... 6.
7. Total Grass Assets (Add lines 1 thru 6)............................................................................. 7.
8. Total Actual Liabilities .................................................................................................... 8.
9. Net Value of Estate (Subtract line 8 from line 7)................................................................ 9.
ffline 9is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part II.
PART II . CALCULATION OF JOINT EXEMPTION INCOME. (Attach copies of Federal Individual Income
Tax Returns far decedent and spouse.)
Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19
a. Spouse...................... 10. 20. 30.
b. Decedent ................... lb. 2b. 3b.
c. Joint .......................... Ie. 2e. 3e.
d. Tax Exempt Income..... ld. 2d. 3d.
e. Other Income not
listed above ........... Ie. 2e. 3e.
f. Tatal.......................... 11. 2f. 3f.
4. Average Joint Exemption Income Calculation
4a. Add Joint Exemption Income from above:
(11)
+ (2f)
+ (31)
=
1+ 3)
4b. Average Joint Exemption Income ..................................................................................... =
If line 4(b) is greater than $40,000 . STOP. The estate is not eligible to claim the credit. If not, continue to Part III.
PART III . CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT
ESTATES
1. Insert amount of taxable transfers to spouse or $100,000, whichever is less.......................... 1.
2. Multiply by credit percentage (see instructions) .................................................................. 2.
3. This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet. ............................................ 3.
4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate..... .... ....... ..... ........ .............. ........... ............. ............. .................. 4.
5. Multiply line 3 by line 4 and enter the total here. This is the omount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of totol credits on line 18 of the cover sheet. 5.
n_." h..'..~.________,...___.."_ _..__.....___
<.
~l649EX..ll.a7)
.
SCHEDULE 0
ELECTION UNDER SEC. 9113(A)
SPOUSAL DISTRIBUTIONS
COMMONWEALTH OF PENNSYLVANIA
INHERlTANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Do not complete 1111. schedule unl... the estate Is making the election to tax assetB under Section 9113(A) of the Inheritance & Estate Tax Act.
If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust.
This election applies to the Trust (marital, residual A, 8, 8y-pass, Unified Credit, etc.l,
If a trust or similar arrangement meets the requirements of Section 9113(A), and:
a. The trust or similar arrangement is listed on Schedule 0, and
b, The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,
then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or
similar property treated as a taxable transfer In this estate. ~ less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the
personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to
the amount of the trust or similar arrangement included as a taxable asset on Schedule 0_ The denominator is equal to the total value of the trust or similar arrangement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedenfs
surviving spouse under a Section 9113 (AI trust or similar arrangement
DESCRIPTION VALUE
Part A Total $
PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (AI election to tax is being made.
DESCRIPllON VALLE
Part B Total $
(~more space is needed, insert additional sheets of the same size)
:z. CL
31Last Bill anb ill~stam~nt
OF
EUNICE M. ROGERS
I, EUNICE M. ROGERS, formerly EUNICE M. MIDDLETON, of Fairview Township,
York County, Pennsylvania, being of sound and disposing mind, memory and
unde1..sta:1ding, do hereby make, publish and declare this as and for my Last Will
and Testament, hereby revoking and making void any and all wills or codicils at
any time heretofore made by me.
ARTICLE I
I direct my Executors hereinafter named to pay all legal debts and funeral
expenses as soon after my decease as conveniently may be.
ARTICLE II
I give and devise unto those of my sons, ROBERT M. MIDDLETON, ANDREW L.
MIDDLETON and THOMAS J. MIDDLETON, who survi-,e me, my real estate vacation home
and contents thereof situate in the Borough of LaPorte, Sullivan County,
Pennsylvania.
ARTICLE III
I give and bequeath my automobiles, household and personal effects and
other tangible personalty of like nature (not including cash or securities)
together with any existing insurance thereon, "unto my husband, JORDAN THOMAS
ROGERS, for and during the term of his natural life, and at his death I give
and bequeath the same as follows:
A. My Steinway Grand Piano I inherited from my mother unto those .of my
sons, ROBERT M. MIDDLETON, ANDREW L. MIDDLETON and THOMAS J. MIDDLETON, who ar~
then living.
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B. One each of the framed paintings by my son, THOMAS J. MIDDLETON, and
located in my home in Camp Hill, Pennsylvania, unto those of my stepdaughters,
ELINOR ROGERS, ARABELLA MEADOWS-ROGERS, LOUISA ROGERS and JANE SRONCE McIVER,
who are then living, each to choose the painting she desires.
C. Such other household goods, furnishings and tangible personal ty which
were in my possession prior to my marriage to my husband, JORDAN THOMAS ROGERS,
or which may have come to me from my parents or from my first husband's family,
unto my then-living sons, share and share alike, to be divided among them as
they shall agree. These items include, but are not limited to the following:
1 glass front china closet:
v 2. small antique rosewood bureau;
~ -large antique ball foot chest (in good condition); 7u !<~ ?
~ -large chest (my sewing chest) in poor condition;
V 50 cedar chest given to me by my mother;
, large Queen Anne buffet;
7 --!>"fle-em-ne'l''''<:''l'llou.d..J.LMi..ddl.A~ol' "Iltique);
e rush-bottom side chair;
9 Seth Thomas mantle clock;
10 china lamp decorated in gold and red owned by my parents; and
II the china, glass and silver items including a silver tea service and large
antique insulated water pitcher (a Middleton antique)
D. My remaining household and personal effects and tangible personalty of
like nature, which came into my possession after my marriage to my husband,
JORDAN THOMAS ROGERS; unto those of my three sons and my four step-daughters,
who are then living, to be divided among them in as nearly equal shares as
practical as they shall agree.
:\
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ARTICLE IV
I give, devise and bequeath all the rest, residue and remainder of my
estate, of whatsoever nature and wheresoever situate, unto my sons, in equal
shares, provided that should any of my sons have predeceased me, I give, devise
and bequeath such deceased son's share unto his issue, per stirpes by
representation, and if there be a failure of same, then I give, devise and
bequeath such deceased son's share unto my surviving sons or the issue of
either who may be then deceased.
<
ARTICLE V
In the event that any beneficiary of my Will shall not have reached the age
of twenty-one (21) years at the time for distribution of his or her share, I
give, devise and bequeath such share unto DAUPHIN DEPOSIT BANK AND TRUST
COMPANY, Harrisburg, Pennsylvania, IN TRUST, to hold, manage and invest the
share or shares so received and accumulation of income thereon, and to use and
apply the income and principal, or so much thereof, as, in Trustee's
discretion, may be necessary or appropriate for such beneficiary's support and
education (including college education, both graduate and undergraduate and
vocational training) without regard to his or her ability to provide for such
support or education, or to make payment for these purposes, without further
responsibility, to such beneficiary or to any person taking care of such
beneficiary. When such beneficiary shall reach the age of twenty-one (21)
years, Trustee shall distribute to him or her absolutely the balance of
principal and income accumulated in the Trust as to that beneficiary, which
shall then terminate. In the event any beneficiary dies before reaching the
age of twenty-one (21) years, the Trust as to that beneficiary shall terminate
and the balance of principal and income shall be paid over to my then-living
issue, per stirpes.
ARTICLE VI
During the time any portion of my Estate remains in Trust~ the same shall
not be subject to attachment, levy or seizure by any creditor, spouse, assignee
or trustee or receiver in bankruptcy of any beneficiary prior to his or her
actual receipt thereof. The Trustee shall pay over income and principal as
hereinbefore determined to the parties designated, as their interest may
appear, without regard to any attempted anticipation, pledge or assignment by
any beneficiary, and without regard to any claim thereto or attempted levy,
attachment. sei zure or othe r process. prov ided tha t if any such levy or
seizure, or other process, shall be authorized by law or specific order of any
Court having jurisdiction, Trustee shall not be liable to any beneficiary for
violation hereof by reason of the same.
"
ARTICLE VII
Not~ in derogation or limitation of the powers. authorities and discretion
conferred upon my Executrices by law or elsewhere in this Will, I direct that
they shall have the following authority, powers and discretion:
A. To invest any funds of my estate in any stocks, bonds, notes or other
securities or property, real or personal, notwithstanding that such investments
may not be of the character allowed to fiduciaries by statute or general rules
of law, it being my intention to give them the broadest investment powers
possible.
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B. To sell or otherwise dispose of any property, real or personal, at any
time forming as part of my estate, for cash or upon credit, in such manner and
on such terms and conditions as they may deem best, and no persons dealing with
them shall be bound to see to the application of any moneys paid.
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c. To manage, operate, repair, improve, mortgage or lease for any term any
real estate at any time held or owned by my estate.
E. To distribute in cash or in kind, upon any division or distribution of
D. To borrow money for the payment of taxes or for other proper purposes
in the administration of my estate.
my estate~
F. In general, to exercise all powers in the management of my estate which
any individual could exercise in the management of similar property owned .in
his own right, upon such terms and conditions as to them may seem best, and to
execute and deliver all instruments and to do all acts which they may deem
necessary or proper to carry out the purposes of this my Will.
"
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ARTICLE VIII
~
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I direct that all legacies and devises and all shares and interests in
my
estate, whether principal or income, while in the hands of my Executors, shall
not be anticipated, alienated, or in any other manner assigned or transferred
by the legatee, devisee or beneficiary, and such interests shall be for the
sole and separate use of the legatees, devisees and beneficiaries and shall be
free and exempt from anticipation, execution, attachment or other legal or
equitable processes by or on behalf of any creditor, assignees or Sp~ljSe.
ARTICLE IX
I name, constitute and appoint my husband, JORDAN THOMAS ROGERS, and my
son, ROBERT H. HIDDLETON, Co-Executors of this my Last Will and direct that
they be excused from the filing of bond in connection with their appointment as
such o~ the carrying out of the duties of their offices in any jurisdiction.
and I further direct that they carry out the functions of their office without
application to any Court in any jurisdiction in which they may have occasion to
act. My Co-Executors, while acting in good faith, shall not be responsible for
any loss or depreciation in the value of my Estate, but shall be liable only
for loss resulting from their own willful default or gross negligence. In the
event my hu~band, JORDAN THOMAS ROGERS, fails to qualify or ceases to so act, I
name, constitute and appoint DAUPHIN DEPOSIT BANK AND TRUST COHPANY,
..
,
l
Harrisburg, Pennsylvania. Alternate Co-Executor.
In the event that my son,
ROBERT H. HIDDLETON, fails co qualify or ceases to so act, I direct that the
other Executor, whether it be JORDAN THOMAS ROGERS or DAUPHIN DEPOSIT BANK AND
TRUST COMPANY, shall complete the administration of my EState without the
appointment of a Co-Executor.
IN WITNESS WHEREOF, I have hereunto set my hand and seal, this
day of ~.v{~v 1990.
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EUNICE H. ROGERS
(SEAL)
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APPRAISAL
~
.
lersonal Property of /{;
~ppraised by Chuck E. Bricker
r' Ii _ ITEM.
-()5
VALUE
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APPRAISAL
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Appraised by Chuck E. Bricker AU094-L
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'--Yl WayJ:tqiflJ
p.o. Box 1711. Harrisburg. Pennsylvania 17105-1711
Member FDIC
STATEMENT DATE
9-28-04
EUNICE M ROGERS
19 CREEK BANK DR
MECHANICSBURG PA 17050
017,21
CHECK 21 ACT A NEW FEDERAL LAW EFFECTIVE 10/28/04.
INCREASES EFFICIENCY & SECURITY OF U.S. CHECK PAYMENT
SYSTEM. YOUR NOVEMBER STATEMENT CONTAINS MORE
INFORMATION. QUESTIONS? VISIT WAYPOINTBANK.COM
ACCOUNT TYPE OF ACCOUNT
1000000017 FOCUS FIFTY
AVERAGE BALANCE
2.926.08
PREVIOUS BALANCE
DE POS ITS
WITHDRAWALS
CHARGES
INTEREST
ENDING BALANCE
2.169.05
1.226.73
3.396.03
00
25
.00
*
* . - , , - , - . - - - -INTEREST SUMMARY- -
INTEREST EARNED FROM 9/06/04 TO 9/28/04
DAYS IN PERIOD -
I NTEREST EARNED . < . . .
ANNUAL PERCENTAGE YIELD EARNED
INTEREST PAID THIS YEAR; T;> T'
INTEREST WITHHELD THIS YEAR ..".:
:":i'\:~::<<"<:::':;;k":",::.,,,,,::,
- - - - - - - - - - TRA~sACrieNsUMMARY-
,~l}EPOSITS/
. ,'(<CREDITS
:~,~':1tl2,2' 6- ~~ 7 3
*
22
.25
,15 %
2.27
.00
TRANSACTION
DATE DESCRIPTION
9/09 DEPOSIT
9/10 CHECK 1693
9/14 CHECK 1694
9/14 CHECK 1695
9/28 CLOSE OUT WITHDRAWAL
9/28 INTEREST PAYMENT
- - *
DATE
1693 9-10
1694 9-14
.25
- -CHECKS
AMOUNT
9.80
275.00
9.
275.
100.
3011.
BALANCE
3395.78
3385.98
3110.98
3010.98
.25-
.00
NO.
PAID-
NO.
DATE
1695 9-14
~ - - *
AMOUNT
100.00
.
---:.),
THANK YOU FOR BANKING AT WAYPOINT BANK
POO-5lJ2 (Ml2)
CustomEr SErvicE ToIl-FrEE 1-866-WAYPOINT (1-866-929-7646) . In York ArEa 7r7 /815-4500
. -... . .. .' -, . .-.www.waypointbank.com
~ fltl'lffW
December 6, 2004
Tom Rogers
19 Creek Bank Dr
Mechanicsburg PA 17050-1814
Dear Tom Rogers:
We are responding to your request for information about Eunice Rogers's account with
Fidelity. The table below lists the account holdings and values as of09/07L2004,
Fidelity accoupt 2BK-715700: EUNICE M ROGERS - TRADITIONAL IRA
SecuritvI>escription CUSIP Quantity Unit Value Market Value
Fidelitv Growth & Income 316389204 313.143 $36.22 $1l,342.04
Total Value $11,342.04
We hope this information is helpful. For questions concerning account holdings or
instructions on how to transfer the ownership of the accounts, please call our Inheritor
Services Group at 800-544-0003 between 9:00 A.M. and 5:30 P.M. Eastern time Monday
through Friday or visit our website at www.fidelitv.com.
Sincerely,
Fidelity Investments
Our file: W026371-30NOV04
Brokerage Services provided by Fidelity Brokerage Services LLC, Member NYSE, SIPC
Clearing. custody, and settlement services by National Finandal Services LLC. Member NYSE. SIPC
P.O. Box 770001, Cincinnati. OH 45277-0034
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USAA. \iSA.~ INVESTMENT MANAGEMENT COMP.~.;W
9800 l'ndericksburg Road S:tn Antonio. TX 78288
Puge 3of3
INVESTMENT ACCOUNT STATEMENT
Statement Pc nod: 01/01/2004 - 12/31/2004
,--
CustoDIer Mh'ice
ToucbLine">
Websire-
1-80(J-531-81-U
1-800-53 1-8777
\1'WW.usaa.com
Dllte T r.msaction Description Symbol Slwre SJmre Amount
Quantity Price
01/08 Cash Recet\ W/F REC 42901054532 $I). II
02/02 Qual Txbl iv TYCO INTERNATIONAL LTn TYC $1.03
02/02 Dividend Reinv TYCO INTERNATIONAL LTn Tye 0.038 26.78000 -$1.0
03/01 Sell TYCO INTERNATIONAL UD TYC 0.703 28.17 $19.7
03/01 Disbursement CREDIT BALANCE - $2.269.7
03:01 Sell TYCO INTERNATIONAL un TYC 82.000 28.17 :1>"2.259.8
'8ll'" SETI YNNN.Q57191- lU96. BllP.JBIl45.....AGE1.NOOOGj. DTOI01 11~O;Dl
1111111111111111111111111.
-..:--:----.::::d
--
.__.._..,.~.-
BUREAU OF lNOIVlllUlOC(f~r~. r,rrln~,~c
INtERITANCE TAX DIYISldNCJ0, 1~..r'.:.:LJ 'JII!l..../L Li
PO BOX 280601 . ,.....,
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
'*
REV-16D7 EX AFP [03-05)
Zone 1.!'-' 1n f)..,el, :'.: ?o~
Ul.J j,,;..J,J \) '.J '-
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
08-08-2005
ROGERS
09-07-2004
21 04-1114
CUMBERLAND
101
EUNICE
M
0:-::: r.-, 1':-
JORDAN T(',R'OGERS
14 CREEKvBANK DR
MECHANICSBURG PA 17050
A.aunt R8IIi tted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account I submit the upper portion of this for. with your tax pay~nt.
CUT ALONG THIS LINE
--+ RETAIN LOWER PORTION FOR YOUR RECORDS
-
---------------------------------------------------------------------------
REV-1607 EX AFP (03-05)
~~~ INHERITANCE TAX STATEMENT OF ACCOUNT KKK
ESTATE OF ROGERS EUNICE M FILE NO. 21 04-1114 ACN 101 DATE 08-08-2005
THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A S~ARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PRO~ECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 07-12-2005
PRINCIPAL TAX DUE: 5,197.59
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
12-06-2004 CD004692 236.84 4,500.00
04-19-2005 CD005224 .00 472.57
07-25-2005 REFUND .00 11.82-
TOTAL TAX CREDIT 5,197.59
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00
.
~
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1,
NO PAYMENT IS REQUIRED.
IF TOTAL IIUE IS REFLECTED AS A "CREDIT" (CRI,
YOU HAY BE DUE A REFUND. SEE REVERSE SIDE DF THIS FORM FOR INSTRUCTIDNS. I
.