HomeMy WebLinkAbout06-19-13 (2) � 1505610105
REV-1500 EX'°'_",�F'>s�'
PA Department of Revenue Pennsylvania OFPICIAL USE oNLv
°°••^,^F^•°�.°°°��= Coun Code Year Pile Number
Bureau of Individual Taxes ty __ ._____, :_._.__^__,._„ __
POBOXa8o601 INHERITANCE TAX RETURN �,"Z-� � � 3 D / � �,
Harrisbura PA i71�8-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW ' '�
Social Securiry Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
, __._..___. _ ._....._ .. __.,.__.... _ ........__..._ _...._ .,.____. ......_._._..._ . . ._ ._____._....._ .._._._.
�__.
C 01/12/2013 '07/23/1932 j
_ 1 _ _ _:
DecedenPs Last Name �� � Suffx DecedenPs First Name � � � MI
.. ,.._ _,_ .._ __ ,.,... ..,.,
Barrick ', Edward �D �
__ ____- -- __ ___.._._ _.: ______
---___- -----_ .__—._ ----___.. _._.
(If Appiicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
��._...._..___ .._._.___..__. ..__.,.....,____. - ' , ' ;
. .. _._._._.__ .___,.._..._., ' '_...._.... . ,._...._..,..._
_..._. __..__.....__.... ..__...._._�__._ __.._....._�...: �_.._....t
Spouse's Soaal Security Number -
...._...__.. . ._...... __ _.___ .___� THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
______.�___ .____._._______� REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Onginal Return O 2.Supplemental Retum O 3. Remainder ReNm(Date of Death
Pnorto 12-13-82)
O 4.Limited Es[ate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
tleath aker 12-12-82)
� 6.Decedent Died Testate O 7. Decedent Maintained a Living Trust _ 8. To[al Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.) '
O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date o(Death O ii. Election to Tax under Sec.9113(A)
Behveen 1231-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOUL�BE DIRECTED T0:
Name Da time Tele hone Number
. .._....... . . .... . . .. ... .__ ,. . .. ... ._ ._. ... . . �` Y_. .. P , . __ _.-,
Ronald E Johnson Esq 1(717)243 0123
_ _._ ._ . ._.,.�____ .__.__._ ...___._.,w__.. __._____._.___�_____._._. .._� �.._n. ___.__.._� _.�_; � _.. _�
R[,61STER OF WILLS 09E�ALY
W �L1 C � O
� � � �.
First Line of Address m = n -I ��
�,._..._...._..__.�_..._.._.�_..__..___.�..,�_._...._____......r�_._.._...._...._..___._._.__.�._.,..____._.._._.._..�.._. � D r !-+ �� :r
E 78 West Pomfret Street I n � � CD � ° p
_.,_.....__.... .___.___...... _.___....... ��. Z . 7c O C�. ,
. __.__..,_.._._ . ... __.._._. �....._._. ___._,._..__—_
Second Lme ofAddress c� -T7 'n � �"'
o �
�..__.__.....__........,..._.......___.____._.____.__......._...._._..__--._.._._.___...._.,___._ _.._....._._._..y � � ,Y„ � -ri
( � O C `— C7
L...w_.____..._._.._..._'__,.___.....�......__._..._.�_....�.._.__....�_._..:..___.._.._.....�.,..; : � N �' M
City or Post Office S[ate ZIP Code "j OATE FILEU'°
. ..... .... ...._ ........ � ... ....'_' . .. . y. . .__ + "rl
�Carlisle � PA �17013 N
Correspondent's e•mail address: fBfOhflSOfl O�P8.f1@�
Under penalties of pequry,I tleclare�hat I have examined this reNm,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is lrue,covect and complete.Declaration of preparer oNer lhan lhe personal 2presentative is based on all information of which preparer has any knowletlge.
SIGNAT�E OF PERSON ESP NSIBLE FOR FILING RETURN TE
� %9,i1G�2... /// >
ADORES / '"� �L/�s
c/o 78 West Pomfret Street, Carlisle, PA 17013
SI F PR A THE ESENTATIVE DATE
�
D RESS
78 West Pomfret et, Carlisle, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610105 1505610105 �
�
J 1505610205
REV-1500 EX(FI)
DecedenPs Social Security Number
..._....._.._._�.__._......._._...._....__._.._._...._.....
oecede�esName: Edwa�d ��Barrick
RECAPITULATION
_..._.. . ....._ .... .......... ... ......
1. Real Esfate(Schedule A). ........... ........ ........ . .... ........... . 1. ��:� 0.00 ��i
, ._.�.,w.__....�.._�..._s....
2. Stocks and Bonds(Schedule B) .................. . ........... ..... .... 2. : 0.00 I
: ............a_.d....._...�.__..........,-.,._.._.__..„,
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ... .. 3. i � 0.00 I
., �._.�,_..._........
4. Mortgages and Notes Receivable(Schedule D)....... .......... . .... ..... 4. '� 0.00 ;
, �._....v......_...__.....,
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)...... . 5. : 174,750.69 �
k .._......_.........._....-,.�.............._.._...m.�......
6. Jointly Owned Property(Schedule F) O Separete Billing Requested .... ... 6. �' 0.�0 �.
7. Inter-Vivos Tran3fers&Miscellaneous Non-Probate Property . ' -�v""'...��'.""�."""'."-"`""._""^`""".'"'""".".
(Schedule G) O Separate Billing Requested.. . ..... 7. - 0.�� I
;__._.....-._,....__�._..,._...�......__.._..._..._._.....__,
8. Total Gross Assets(total Lines 1 through 7)... ... .... . ..... ............. 8. . 174,750.69 �I
9. Funeral Expenses and Administrative CosGS(Schedule H)............. . ..... 9. �-. 3,$78.50 ��
.._..___.._.._....,_.._.......,....�..........._.._....___....._........_....._,,
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I)... ............ 10. ' 4,668.61 I.
w__._. ____ ...__�._..�_._.�,� .. _
11. ToWI Deductions(total Lines 9 and 10)...... .. . ....... ..... ........... . 11. '�, $,b47.11 {
,..._.............._....._.._......_..._....,........_......,........._...,.�,...�.�:
12. Net Value of Estate(�ine 8 minus Line 11) .. ....... . .......... ..... ..... 12. I 166,203.58 �
� 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which °'�"�""""""""�"'"""'""°°"'°"""'""""°""
an election to tax has not been made(Schedule J) ....... ..... . .... . ...... 13. i 0.00 'i
..�,...._....._.�._......._...�...�__._..,.�. ..
14. Net Value Subject to Tax(Line 12 minus Line 13) ....... ........ .... . .... 14. ; 0.�0 ���
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 74 taxable
at the spousal tax rate,or
transfers under Sec. 9116 (-,.."._._.._..�_._......�_..�._._.._�_....., ;..__...__._._..�....,___._.__.,___.____..._._..____.
(a)�1.2)X A- i �-: 15.; ' :
16. Amount of Line 14 taxable t.__..,._......�..__...,.:.,_...._.........._...,._...._....__�..-.: Y..___._....,.,__.,.�.._...._._.�._..�..._..__..__..�_..._..
at lineal rate X A_ � , 16.;.....^-._...._..._......_.._......._...,.,,„.,_ ___... �
17. Amount of Line 14 taxable ����� ������ � �������-`��" �., �..
at sibling rate X.12 3 �. ��,i . '
�.....:........_........._...»......,....,...............,....,.�_............._..,.... � -:
18. Amount of Line 14 tazable } 166,203.58 : ;-�W���.T..H..^..^.���..mm�Y��.�^.e'mµ�� .
at collateral rate X.15 i �g,i 24,930.53 �-
t.�.._...._.�........___,_._.._._.._,..._.._.__..._�._.._,._..v �..........__..e..�....._........_.................m....�.,�.._.m
. 19. TAX DUE ......................... . . . .................... ..... ..... 19.; 24,930.53 '�.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. p
Side 2
L 150561�205 1505610205 �
REV-7500 EX(FI) Page 3 Flle Number
Decedent's Complete Address:
DECEDENTS NAME
Edward D. Barrick
STREETADDRESS
2017 West Trindle Road
CIN STATE 21p
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Paqe 2,Line 19) (1) 24,930.52
2. Credits/Payments
0.Prior Payments 22,800.00
B.Discount '1,200.00
3. Interest Total Credi4s(A+B) (2) 24,000.00
(3) 0.00
4. I�Line 2 is greater than Line 1 +Line 3,enter the difference. This is lhe OVERPAYMENT.
Fill in oval on Page 2,Line 20 to requesl a refund. (4) 0.00
5. If Line 1 +�ine 3 is greater than Line 2,enter the diRerence.This is the TAX DUE. (5) 930.53
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
7. Did decedent make a Uansfer and: Yes No
a. relain Ihe use or income of the propeAy transferred.......................................................................................... ❑ �
b. retain the right to designate who shall use the property transterred or ils inwme ............................................ ❑ �
c. retain a reversionary interesl .............................................................................................................................. ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If dealh occurred aRer Dec. 12,1982,did decedent transfer property wifhin one year of death
without receiving adequate consideraUon?.............................................................................................................. ❑ �
3. Did decedent own an"in trusl fo�'or payable-uponEeath bank account or security at his or her death?.............. ❑ �
4. Did decedent own an individual retirement accouni,annuity or other nan•probate property,which
conlainsa beneficiary designalion? ........................................................................................................................ ❑ �
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
. ... -- - - -- _ _ _ . . ..- —_ _ - - -...
_ _ ---- - - - - - -
For dates of death on or after July 1, 1994,and before Jan. 1,1995,the tax rate imposed on the net value of transfers to or tor 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 taz rate imposed on the net value of transfers to or for lhe 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 lax,and the slatutory requirements for disclosure of assels and
filing a tax retum are still applicable even if the surviving spouse is lhe only beneficiary.
For dates of death on or after July 1,2000:
. The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at deafh to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
. The tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal benefidaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
. The taz rate imposed on the net value of transfers to or for the use of the decedenCs 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 wifh the decedent,whether by blood or adoplion.
LAST WILL AND TESTAMENT
OF
EDWARD D. BARRICK
I, EDWARD D. BARRICK, of South Middleton Township, Cumberland County,
Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby malce,
publish and declaze this as and for my Last Will and Testament,hereby revoking all other wills and
codicils heretofore made by me. �
FIRST: I direct that all my just debts and funeral expenses,including my grave
mazker, shall be paid from the assets of my estate as soon as practicable after my decease.
SECOND: I give, devise and bequeath the residue of my estate, of every nature
and wherever situate, to my friend, PEGGY L.V. RUSSELL. Should my friend, PEGGY L.V.
RUSSELL,predecease me,then in that event I give,devise and bequeath the residue of my estate of
every nature and wherever situate to my daughter, KARLA A. NICKERSON.
THIRD: I d'uect that all t�es that may be assessed in consequence of my death;
of whatever nature and.by whatever jurisdiction imposed,shall be paid from my residuary estate as a
part of the expense of the administration of my estate.
FOURTH: I nominate, constitute and appoint, PEGGY L.V. RUSSELL,
Executrix of this my Last Will and Testament. Should PEGGY L.V.RUSSELL,fail to qualify or
cease to act as Executrix,I appoint my daughter,KARLA A. NICKERSON,Executrix of this my
Last Will and Testament.
FIFTH: I direct my Executrix and her successors shall not be required to give
bond for the faithful performance of their duties in this or any other jurisdiction.
IN WITNESS WHEREOF,I have hereunto set my hand and seal to this,my Last Will an�
Testament,consisting of one(1)typewritten pages,each identified by my signature,this /� !�-
day of June 2003.
b��SEAL)
Edwazd D. Barrick �
Signed, sealed,published and declazed by the above-named Testator,Edward D. Barrick as
and for his Last Will and Testament, in the presence of us, who, at his request, in his sight and
presence, and in the sight and presence of each other, have hereunto subscribed our names as
wimesses.
�
� � i �/l_.__
.
COMMONWEALTH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERLAND )
I, EDWARD D. BARRTCK, Testator, whose name is s+_�ned to the attache3 ar foregoir.g
inshument, having been duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will and Testament;that I signed it willingly; and that I signed it
as my&ee and voluntary act for the purposes therein expressed.
Sworn or affumed to and acknowledged before me by Edward D.Barrick the Testator,this
� z- day of June 2003.
�
(SEAL)
d ar �D. Barrick, Tes tor
�
Notary �ubli
NOTARIAL SEAL (
SNELLY SEXTON, Notary Puhllc
Catlisle Boro, CumberlAnd County
My Commission Expires P,prll 2H, 2007
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERLAND )
We, RONALD E. JOHNSON and T�'.y��r � t-h�lr�;Nj , the witnesses
whose names aze signed to the attached or foregoing instnunent, being duly qualified according to
law,do depose and say that we were present and saw Testator sign and execute the instrument as his
Last Will and Testament; that Edward D. Barrick signed willingly and that he executed it as his
fiee and voluntary act for the purpose therein expressed; that each of us in the hearing and sight of
the Testatoi signed the Will as witnesses; and that to the best of our knowledge the Testator was at
that time 18 or more yeazs of age, of sound muid and under no constraint or undue influence.
and�S m or af,�rmed to and subscribed to before me by RONALD E. 70HNSON
„ �,� 1� (��;�F ai.�� , witnesses this ("� day o J 2003.
, ' ��� � SEAL)
R nald E. J „� ess
i
(SEAL)
�� ,�/� Witness
�
Notary Public (
NOTARIAL SEAL
SHELLY SEXTON, Notary Public
Cadisle Boro, Cumbedand Couniy
My Commission Expires April 26,2007
R�-�5o8IX+(o&u)
�iZ pennsylvania SCNEDULE E
��� DEPAHTMEMOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITAN�TA%RENRN PERSONAL PROPERTY
0.ESI�EM DECEDENT
ESTATE OF: FILE NUMBER:
Edward D. BaYY►G�C. 21-13-0101
'Include the praeeds of litigation and the date the praeeds were received by the estate.
All property Jointly owned with rtght of survivorship must be disclosed an Schedule F.
�M VALUE AT DATE
NUMBER DESCRIPTION
OF DEATH
1. Checking account no:9833005227-M8T Bank(see letter attached) 171,163.71
Z 4 guns as set forth in appraisal attach
1,224.90
3, Wellspan Medical Group•refund 74.08
q, Cemetary lot-CumbeAand Valley Memorial Garclens(see letter attached) 2,288.00
TOTAI(Also enter on Line 5, Recapitula[ion) $ 174,750.69
If more space is needed,use addiUonal sheets of paper of the same size.
� MBr�Ba111�
499 Mitchell Road,Millsboro,DE 19966 Adjustment Services
Phone 888-502-0349
F az (302)934-2955
February 6,2013
Andrews & Johnson
Attorney at Law
78 West Pomfret Street
Carlisle,PA 17013
Re: Estate of Edward D. Barrick
Socia] Security:
Date of Death: Januarv 12 2013
Deaz Sir or Madam:
Per your inquiry on January 30,2013,please be advised that at the time of death,the above-named decedent had
on deposit with this bank the following:
1. TypeofAccounl CheckingAccount
AccountNumber 9833005227
Ownership(Names ofJ Edwm�dD.Bmrrck
Opening Date 06/02/2003
Balance on Date ofDeath $171,163.14
Accruedlnterest $ ,Sy -
Total ----------------------------
$171,163.71
For any addifional information on[he above accounts,including ownership and any changes,closures and/or reimbursement of funds,
� pleasera11t6eSroneridgeat717-240-4524.
We were unable to locah eny safe deposit boz for the above-mentioned decedent.
This letter does mt include any accounh in which the deceased may have been tisted as Power of Attorney,Custodian ot Unitorm Transfers,
, RepresenfativePayee,orTrusteeunderaWrittenAgreement
Sincerely,
Valarie Mercer
Adjustment Services
,
. ,_, . r;. . ,, -, -
. , . , .. ... ,,. . „ ,. _., . . .
,� ,:..:, , �
� -;
[NVOICE
��-� ������� ����r'����
a
SOCb T�O ) SHIP TO
/� °I�''E?�R CA. ta �US�—e �� "—o�—G)'/ �
t AODRESS J � ,� ! I - - AD�DRESS�� � �
� i��} I� (�S � ���(tt-2_ �� /ti kJL`�i�L_�`rc �'f`lI�!".� ,
- ' CITY,STATE,ZIP J� - ' - qN,STATE,ZIP � ' -"�� '
� c+c--' lc I�..n !-�� 7 ��
� CUSTOMER OFDER NO. " 'SOCD BY ' TERMS F0.8. DATE
�``;f-:� -�-I--� , i 1'�t.C--� C,1�-e.)
� � ORDERED SHIPPED DESCRIPTION. PRIQE� UNIT AMDUNT
. �� � t ,..t�� �, � �'i� �'� �� � �—P /% �.-�
� ._ � 1 �- ,�. - __ ; � � __._ ` . _ _, � � �,� �
"7 � �i
.. ff \ _.�. � � �-`. ,s �7 � ! ' C` o �1
)
-�.�- � —�— — --- �
4 � � �r��.� J , �;�9 `;5_
�� ) n � c ' .� � � ��-�,a �:� _ .
— � � � �«�
�x.e- K T?, ` _i \
') i � '� c� 1�._.. —
-- �-�, �_ �-� � � _ �� . � —�
� �1�. ,h t' V , , r-. -� i
., - � - , _. • - • ,
'�1r P. G aG hn�, ,�, .o �\ �'T'ti�
�- P. , ,� • — . — —
���5840
w . �,A... .. �.�_' .. � . . .-. .,, . . , . .. . . . .
, t. : .., ...... � '. _' ..,,.�._�:_�:_
-�:
.�.
�. _ .a
• '� - < ����_/, ���s ��? #�`-:=.. .� �� Jx � ,- -
��
.STOIVEMOR PP. RTNERS L _ P_
Cum6erland`vatCey MemoriaCcjarrfens 1921 �,itner.7f'�kway CarCuCe, rl'A 17013
�hone: 717-243-3541 �Fax;717-243-4495
i- z3 -i3
To Whom It May Concem: ,
The following person(s) own property and/or merchandise at our cemetery. The values listed
below aze current with today's selling prices and apply to this cemetery only.
At the time of purchase, all of the items with our cemetery were and aze irrevocable. If you have
any questions or concems,please do not hesitate to contact me. Thank yon.
S cer ly,
. V ""`
Ginny A. Weller
Administrator
N.��S>��� D ���� - D�..
PROPERTYOWNED I SD�
�
Ln�_����pp�.�, 2`17C , '��
� �
PROPERTY VALUE � 22-48.°°
MERCH. OWNED �—
�IA
MERCH. VALUE "�/'�
DATE PAID IN FULL /!-zG-6 Z
Osiris Holding of Pennsylvania,Inc.
aev-isi� ex+��o-o?�
�,j'�i pennsylvania SCHEDULE H
OEPAflTMFNT OfqEVENUE FUNERAL EXPENSES AN D .
INNERfTANCETq%0.ENRN ADMINISTRATIVE COSTS
AESIOENrDECEDEM
ESTATE OF FILE NUMBER
Edward D. Barrick • 21-13-0101
Decedent's de6ts must be reported on Schedule I.
ITEM
NUMBER � DESCRIF�ION AMOUNT �
A. FUNERAL EXPENSES:
�'"� �-���'.� -_ .,��-�• `.... .�_W..___.... �.ur�.��.�._...._.-z... _a,_;� ��
! �
�."-�. ?�S`�..� _:�;'r �"'.��. _ -,.�' ......-s �-LY....-Y_rr � "
� . -_ .: S - ....�. .�" C_...L`..j1 �.���
�`.-^ t'� .�.a:..._.^...a-^'�= �.r��...'�,�: _..._Y"+�.._�Y.'— . -..�..�... ^�:-z ..,..r --� - .F-.�.-_ ( +�jiJ�IIM�:
� " _�..� � -�...�T .
�f 1m�.�T .:."'�j����DY ""-. .:5.2:�:.T1:. ... �......�-�-..�s�.:i.�.:�.�.5 �F'+.�� '1�.�..5<..�1 4'M!1l�I�M/!Y/Y��
_�, _ .�.�. .�. ...��..��..� .. .... .�_ ..r.� �... .� �r..
r
�.�.�� i...��.� ... .�-�.�� .��_....�. .�.'- .u���W��
�� �_..� _ .�W..�.__,_..�..._..,..�__.__..._.�.�-�__.__.._ .� ��:..��
. _ _ _ — - —_ _ _ __ �=—�_� �'°�.'°°'°,o.�.d."�
_. ____ __ �.._..,�__.._
� e. ADMINISTRAIIVE COSTS: �
1. Personal RepresenWtive Commissions: `��~��� •
Name(s)af Persanal Representative(s)
StreetAddress
City - SWte 2[P
� Year(s)Commission Gaid:
a
Z• Attorney Fees: � . � 3 3,000.00 '
3• Family Exemption: (If decedent's address is not the same as daimant's,attach explanatlon.)
Glaimant ,
Street Address ' `
City '� SWte ZIP
� —
Relationship ofClaimant co Decedent
4• Prabate Fees: �� 353.50
. .� __
5� Accountant Fees: .
�.. _ .�
. +�wwm.w,._
6. Ta:Retum Preparer Fees�x_ 25.00
_ u. �. _� ...__....._._.._....�,._....�. --- - ----__.._._._
�• Reserve for closing and axounting 500.00�
• � �--.—__��.-_-.:-_=- .�,�� ...�....�.::r.._�.�_:.,—.__:�-`.�:�_,�w.._._..., ��---
, r.....f ..:._.�_;.-.�::�.-._� �.. __..._ __._...._._._.._ _.. ._.._ _._.... i �..�.ti..�
`L.- ........_...,._._..._._ :. _.._. ^� �����
! _.l €�..._..__._._.._....__.._.__ r.�.__ _�___�...:..:=-..._"._.:::.,..�_�-._ _...� �,,..a,,,.��.,,,.���..,.«�
�J .'�`�....._._._.....�_.—`.._ ._ y..._.=__`_-..—�� _. .. �. �.__._..�=�.._....._ �_ . .......:�4��l 8 �
�..� �_ _ � __..___.__.-�.___ __._ _ .l�.._...---...-.--__.-. -- _ _.____���I �`�`""3
.
TOTAL(Also enter on Line 9, Recapitulation) ¢� ___ _ 3,878.50�{
-�a
If more space is needed,use additional sheetr of paper of the same size.
0.EV-1511 EX+(]2-12)
�pennsylvania SCHEDULE I
7r��� DEPARTMEMOFREVENUE DEBTS OF DECEDENT,
INHERITANCETA%RETURfi MORTGAGE LIABILITIES & LIENS
RESIDEIR DECE�ENT
ESTATE OF FILE NUMBER
Edward D. Barric 21-13-0101
Repart dehts Incurred by the decedent prior to death that remained unpaid at the date of death,Including unreim6ursed medical expenses.
ITEM VALUE AT OATE
NUMBER DESCRIP�ION
OF DEATH
1 Wellspan Medical Group-medical bill 74.08
2. Wellspan Behavioral Health•medical bill 180.29
3. Geriysburg Hospital ��� 95
4. Geriysburg Intemal Medicine•medical bill 1.65
5. Gettysburg Diagnostic Imaging,PC•medical bill 5.08
6. Gettysburg Hospitai 33.38
7. Wellspan Behavioral Health-medical bill . 59.84
e. White Rose Ambu 393.45
9. Wellspan Medical Group•medical bill 165.94
10. Gettysburg Intemal Medicine-mediral bill q gs
t'1. Transilions Health Care-final nursing home bill 3,638.00
TOTAL(Also enter on Line 10, Recapitulation) $ 4,668.61
If more space is needed,insert additlonal sheets of the same size.
REV-1513 EX+(01-10J
;,ji��pennsylvania SCHEDULE ]
Ly OEPAFTMENTOFqEVErvUE
1NHERfTARCE TAX RENRfi BE N E FICIARIES
RESIDEM DKEDENT
ESTATE OF: FILE NUMBER:
Edward D. Barrick 21-13-0101
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY RE o�NOts ist Tr�u�stee(s)M AM00 ESTATE ARE
I TAXABLE DISTR[BU7fON5[indude outnght spousal distribu[ions and tansfers under
Sec.9116(a)(1.2).]
1• Peggy L.V.Russell,2017 West Trindle Road,Carlisle,PA 17013 companion 100%
ENTER DOLtAR AMOUNT$FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEEf,AS APPROPRIATE.
11 NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTi0N5 UNDER SECfION 9113 FOR WHICH AN ELECTION TO TAX[S NOT TAKEN:
1.
B. CHARRABLE AND GOVERNMEMAL DISTRIBUTIONS:
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRiBUTfONS ON LINE 13 OF REV-1500 COVER SHEEL ¢
If mare space is needed,use additional sheets of paper of the same size.