Loading...
HomeMy WebLinkAbout07-09-13 1505610105 REV-1500 Ex(o3-"'tF1' ' OFFICIAL USE ONLY PA Department of Revenue p,.,ennsylvania Bureau of individual Taxes , INHERITANCE TAX RETURN County Code Year File Number PO BOX 2606o1 r\ / ^ Harrisburg,PA 17128-o6o1 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY I v 2gk 2ol 2i . o5-o 4 1 428 Decedent's Last Name Suffix Decedent's First Name MI WOLFS ANNA S (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI i Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 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.) O 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 Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number - �f"vCr+a�_T Leo 9S6 II REGISTEk-UF WILLS SE ONLY r.= First Line of Address - = ri r' P d ux (v3 is Second Line of Address Z7 LEA-)U- 5I �r City or Post Office State ZIP Code - RATE FILED " sa4P� PA- Correspondent's I , IIZOIS C-)e-mail address: Under penalties of perjury•1 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 OF PERSON RES,93DNSIBLE FOR FILING RETURN DATE - _ ,7064%u ran© � ,La Z-3-0 ADDRESS 3G3� B/ l G��� S Nassa L, 17/7 i ;1- `7-3-! SIGNATURE P SPARER HE AN R PRESE�NNTATIVE DATE 11 , S ADDRESS --Po P)a &cf5 , zj PLEASE USE ORIGIN L FORM ONLY Side 1 L 1505610105 1505610105 1505610205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. Real Estate Schedule A. ....... ... ..... ... .. ... ... ....... ........ ... 1. 2. Stocks and Bonds(Schedule B) .. . ..... ... .. .. ...... ..... .......... ... 2. � 1 Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . ... 3. 4. Mortgages and Notes Receivable(Schedule D). ... . ...... . .. ..... ..... ... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).... ... 5. ! 3 Z '7 O S . 00 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. .. ... 6. l 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property i (Schedule G) O Separate Billing Requested... . .... 7. 8. Total Gross Assets(total Lines 1 through 7)..... ........ .. ... .. ...... ... 8. 9 3 , 9. Funeral Expenses and Administrative Costs(Schedule H)... .. .. . ._. __. . 9. 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). ... ....... .... 10. 1 Z 3'10 . cc> 11. Total Deductions(total Lines 9 and 10)... ... .......... ..... ... .... ... .. 11. � � � 1 �C.�C� 0z' I 12. Net Value of Estate(Line 8 minus Line 11) . .. ..... ... .. .. ... ... .... ... . . 12. J co S 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which �y an election to tax has not been made(Schedule J) ... .. ... .. .. ........ ... . 13. y _ 14. Net Value Subject to Tax(Line 12 minus Line 13) ... ... .... ... ..... .. . ... 14. 7 5 , (ps� TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 r (a)(1.2)X.0_ 15. 16. Amount of Line 14 taxable at lineal rate X.0� '�5 t �BPS ,of � 16. 17. Amount of Line 14 taxable v at sibling rate X.12 i 17.j 18. Amount of Line 14 taxable I at collateral rate X.15 19. TAX DUE . .. ... ... . ... ... ... .. ... .. . .. .. .. .. ....... .. 19.:i 3 JOZ N2� 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610205 1505610205 J REV-1500 EX(FI) Page 3 File Number a 013_ OOh c Decedent's Complete Address: Js co DECEDENTS NAME STREETADDRESS 100 VNOV,v_T 1� LLCA) 1p12i VL crry NEL1iANt�St3Ur2� I STATE zIP17 0-25 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 3 u 5r Z '`'!'Z' 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 3. Interest (3) 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 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 3 r 3 82. 4 Z 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.......................................................................................... ❑ rz b. retain the right to designate who shall use the property transferred or its income............................................ C3 c. retain a reversionary interest .............................................................................................................................. ❑ 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?.............. ❑ t0 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 IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].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 return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in F2 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. FEY-1R.A8 EX•l1An SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHER(TANCE EC RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF r� FILE NUMBER VV as Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. mE1Q0 eftAD' CANELYC-U,( # 52.3034I-I I 2• (Yt�TQo �A�� SRVtnxoS � L(3tYJ{$447 3371 , 79 Z.Z� �{Ib8"•z� 3 QSFj v sA�t �s 01-1V xx xex `/ Q2 TOTAL(Also enter on line 5,Recapitulation) $3-2- , -78q (If more space is needed,insert additional sheets of the same size) CIO } . a : \ � j 2 z . . m z ® % \ ` k ƒ( f > ƒ \ ( ® \ } \ ¢\ 2 ) \ / G § d§ > . }3 \ 0 03 . } \ . / y - . 2 •w"�r .[3a Y'did m^':s^s3nwe,klu„ r.,��Wil4 hG§RVht. ,:,�.,; 5 en:. �, ,,s.'�I92� ]+-r--, ,s.n.,H .'3� �:a—. •.,.anmwr _wGG.. c6 Y , a. ,ova a t 54a C l i s i iN 3A t1 i c Pennsylvania State Employees Credit Union P.O. Box 67013 Harrisburg, PA 17106-7013 Member Number: 0174"•"• PSE@Umi 800.237.7328 psecu.com Statement Period: 01101/13 to 01/31/13 Direct Inquiries regarding preauthorized electronic page Number: Regular t of 2 transfer or account errors to the above address. Account Balances at a Glance Total Shares: $0.00 Total Certificates: $0.00 40386 1 AV 0.360 00.569 00.054 T119 P1 148 Total Loans: $0.00 ANNA S WOLFE 5011 AMELIAS PATH W MECHANICSBURG, PA 17050-8344 grrgrlllhllnnllrmrlluluhrllrlhullllrllllllrrrrrlrld 000662 06 015268 001 D BALANCE MO� P:r r 0/O NOI ANNUAL FEE TIVITY 9,9 NOINACTIVITYEEE APR �('[ ANNU.LL PERCENTAGE RATE PSE*I VISA for c.mploto program dot.11s. YEAR TO DATE INFORMATION Description Amount Total Dividends Year to Date $1.78 SHARES Posting Effective Transaction New Date Date Transaction Description Amount Balance REGULAR SHARES ID 01 01101 Beginning Balance 5.29 01111 Payment:Account Adjustment: 164.15 169.44 01/11 2012 Relationship Reward(RR) - ------07/11---- -- ---$159.15 of-2012-RR is-dividend------- 01/11 $5:00 of 2012 RR is MISC income - 01/30 Payment: Dividend 0.01 169.45 Annual Percentage Yield Earned 0.110%from 01/01/13 through 01/31/13 Based on Average Daily Balance of 105.56 01130 Payment:Transfer From Share 04 22,298.82 22,468.27 01/30 Withdrawal By Check -22,468.27 0.00 01/31 ID 01 REGULAR SHARES Closed Ending Balance 0.00 Dividend YTD: Year to Date 0.01 CHECKING ID 04 01/01 Beginning Balance 22,297.05 Ot/30 Payment: Dividend 1.77 22,298.82 Annual Percentage Yield Earned 0.100%from 01/01/13 through 01/31/13 Based on Average Daily Balance of 20,858.53 01/30 Withdrawal Transfer To Share 01 -22,298.82 0.00 REV-1510 EX+(09-09) �J'pennsylvania SCHEDULE G �7 DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF NNA WOLFL FILE NUMBER A ao (3 -C)oc�S(O 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. ITEM DESCRIPTION OF PROPERTY INCUOETHE NANE Oi IFIE TPMSFEREE.THns REUnaysHioroDEacexr AND DATE OF DEATH % DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COVE OF THE DEED NA SEx ESTATE. VALUE OF ASSET INTEREST OF ArsucNxE) VALUE 1. TOTAL(Also enter on Line 7,Recapitulation) If more space is needed,use additional sheets of paper of the same size. Pennsylvania State Employees Credit Union P.O. Box 67013 Harrisburg, PA 1 71 06-701 3 Member Number: 0174****** PSE@Ui 800.237.7328 psecu.com Statement Period: 12/01/12 to 12131/12 Direct inquiries regarding Preauthorized electronic Page Number: Regular 1 of 2 transfer or account errors to the above address. Account Balances at a Glance Total Shares: $22,302.34 Total Certificates: $0.00 y.... 00.545 00.061 Total Loans: $0.00 rts: ANNA S WOLFE 5011 AMELIAS PATH W MECHANICSBURG, PA 17050-8344 000625 01 016864 001 ��yp• `� Y ,V Y �Qc/ra� A SAVE TELL YOUR FRIENDS & FAMILY ABOUT YOUR CREDIT UNION. ►�,vi; YEAR TO DATE INFORMATION Description Amount Total Dividends Year to Date $25.14 Total Nontaxable Dividends Year to Date $3,825.46 Total IRS Withholding Year to Date $5,022.69 SHARES Posting Effective Transaction New Date Date Transaction Description Amount Balance REGULAR SHARES ID 01 12/01 Beginning Balance 529 12/31 Ending Balance _ 5.29 Dividend YTD: Year to Date 10.36 CHECKING ID 04 12/01 Beginning Balance 22,295:16 12/31 Payment: Dividend 0.100% 1.89 22,297.05 Annual Percentage Yield Earned 0.100%from 12/01/12 through 12/31/12 Based on Average Daily Balance of 22,295.16 12/31 Ending Balance 22,297.05 Dividend YTD: Year to Date 14.78 CERTIFICATES Trans Post Fees or Transaction New Date Date Transaction Description Charges Amount Balance ID 54 60 MONTH IRA CERTIFICATE 12101 Beginning Balance 60,941.60 12/12 Payment: Dividend 87.97 61,029.57 Annual Percentage Yield Earned 4.900%from 12/01/12 through 12/11/12 �t'G REV-1511 EX+ (10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Q�� S uFE x013 —ocos(v Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' A uer CVun *0- Z`7 O'i• o z- IA4) YKmL ob SesL�& -bu .\ spY Ci 00* N- 04-cs— Mo- — bor`"k 9 vcrrL" l0?-0' ♦ $. <— 7YlooY4,— �. `1 PF040 A -? O O' B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address city State ZIP Year(s)Commission Paid: 2. Attorney Fees: rY\• S INJGAY�ri`r (000 . `d 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 11 . 5. Accountant Fees: 6. Tax Return Preparer Fees: 1'-ar4" SchEVC�£V���b¢.✓ 320 D' 7. q0D TOTAL(Also enter on Line 9, Recapitulation) $ (c, �5c[•a� If more space is needed, use additional sheets of paper of the same size. REV-1512 Ex+ (12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF NR S Wort C FILE NUMBER N a yi -CODsCO Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE _ NUMBER DESCRIPTION OF DEATH s-on z_ r�� .��o a �vfa rt.vn4vl� 1m� rsEvncv �� 3 30. (� . ovv`ni C�' Y vvycc'I TOTAL(Also enter on Line 10, Recapitulation) $ 2—I 380'co If more space is needed, insert additional sheets of the same size. PAUL D. DALBEY, DPM 5 KACEY COURT, SUITE 202 Closing Date: 10/18/2012 MECHANICSBURG, PA 17055-9222 (717) 591-1336 Balance Due: $15.00 Patient: ANNA WOLFE 6132 Bill To: PAUL D. DALBEY, DPM ANNA WOLFE C/O MARK FE 5 KACEY COURT, SUITE 202 5011 AMELIA'S PATH WEST MECHANICSBURG, PA 17055-9222 MECHANICSBURG, PA 17050 Page: 1 PAUL D. DALBEY, DPM ANNA WOLFE 5 KACEY COURT, SUITE 202 222 MESSIAH CIRCLE MECHANICSBURG, PA 17055-9222 63W MECHANICSBURG, PA 17055-6100 Account Number: 6132 Closing Date: 10/18/2012 Date: Code: Description: Charge: Credit: 11-Sep-2012 99307 NURSING CARE FOCUSED INTERVAL $50.00 Paid by Insurance/Adjustments $35.00 DUE FROM PATIENT $15.00 s Total Due From Patient $15.00 Charges Marked " Have Appeared on a Previous Bill Your prompt payment is appreci Current Over 30 Days Over 60 Days Over 90 Days Total Balance $15.00 $0.00 $0.00 $0.00 $15.00 ALEI A FINANCE CHARGE OF 1.50 t PER MONTH 21t Holly Baltimore Ave AN ANNUAL PERCENTAGE RATE OF 18 .01) OR A PwviMncY SERVICES,INC.C. MtHolly Springs, PA 17065 ( Responsive. Innovative. Reliable. 800-266-9954 (717)486-86004INIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED wmv.AlertPharmacy.com ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE STATEMENT OF ACCOUNT IF YOU RECEIVE A NEW INSURANCE CARD FOR YOUR PRESCRIPTIONS BE SURE TO SUPPLY US WITH A COPY. Date 10/31/2012 - -7 PMT DUE. . 11/28/12 (� WOLFE, ANNA WOLFA2 30 DAYS . 50 . 06 MARK WOLFE GRP-7W /O� 03 5011 AMELIA' S PATH WEST PAGE 1 k MECHANICSBURG PA 17050 Amount Pais' PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT ALERT PHARMACY SERV. 1NC.219 NORTH BALTIMORE AVE. MT HOLLY SPGS, PA 17065 DATE Rx NUMBER QTY. DESCRIPTIO14 � •t� a •lL\ ** ACTIVITY FOR WOLFE, ANNA -WOLFA2 - -081206 10/0d/12 7995820 240 GUAIFENESIN DM SY 01 * 2.47- .00 2 .47- 10/08/12 7995819 20 MUCINEX 600 MG 01 * 9.84 .00 9.84 10/08/12 7995820 240 GUAIFENESIN DM SY 01 * 4 .73 .00 4 .73 10/08/12 7995821 90 IPRATR-ALBUTEROL 01 9. 91 .00 9.91c 10/08/12 7995822 14 DOXYCYCLINE 100 M 01 2. 13 .00 2.13c 10/19/12 7979733 527 POLYETHYLENE GLYC 01 10.00 .00 10.000 10/20/12 7992511 8 DOCUSATE SODIUM 1 01 * 2.39 .00 2.39 10/20/12 7977776 8 FUROSEMIDE 40MG 01 1.38 .00 1.38c 10/20/12 7977777 8 POTASSIUM CL 20 M 01 4 .16 .00 4 . 16c 10/20/12 7977778 8 OMEPRAZOLE 20 MG 01 2 .17 .00 2 . 17c 10/20/12 7977779 8 ASPIRIN 81MG CHEW 01 * 2 .33 .00 2 .33 10/20/12 7978083 8 DIGOXIN 125 MCG 01 1.93 .00 1.93c I PAST JUE YOUR ACCOUN rib ",)^ain)Et= 5d1l P r . (A PLEASE PIE-NI r ., TOI)AY � 11 Z� rZ i . 00 31 . 68 16 . 82 LEGEND NON-LEGEND TOTAL TAX FOR MONTH FOR MONTH -- - - Previous Balance Charges this month Finance Char a ••e•i v.ym••e as C.•au• AMOUNT DUE- 52 . 53 + 50 . 97 + 1 . 00 - 104 . 50 - 2 . 47 102 . 03 FOR ALL PHARMACY RELATED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 1-800-266-9954 Statement Terminology on reverse STATEMENT OF ACCOUNT B SNOWDRIFT PHARMACY SERVICES OF EASTERN PA 6990 6990 B SNOWDRIFT ROAD, 1ST FLOOR - ALLENTOWN,PA 18106 PAGE: 1 01. 1 ACCOUNT NO: 1039.534 INVOICE NO: STATEMENT RETURN SERVICE REQUESTED 30905-U846 DX NO: KOPDX INVOICE DATE: 09130/12 0046480101 FACILITY: 1039 EMERITUS OF CREEKVIEW PHONE: 877-670-6323 PATIENT NO: 534 You may also view/pay your bills at: PATIENT NAME: WOLFE,ANNA https://myomniview.omnicare.com AMOUNT DUE: 18.00 TAX: 0.00 rrllll�lll111��1�llllll1111�111111111��Illll�l�llrllrll�l'�'I�II� WOLFE, ANNA C/O MARK WOLFE DUE DATE: 10/30/2012 5011 AMELIA'S PATH WEST MECHANICSBURG, PA 17050-8344 AMOUNT DUE: 18.00 30905-U846•TM409UD5R002789 3M409XUWA:1.1 KEEP TOP PORTION FOR YOUR RECORDS-RETURN BOTTOM STUB WITH PAYMENT III]11111111 gin I:11111m1111101111111111111 - WOLFE, ANNA 1039 EMERITUS OF CREEKVIEW .Tror4ont 1039.534 09/30/12 DATE RX N0. ITRANS I DESCRIPTION _ _ PHYSICIAN] __NDC NO._ _ ._,QUANT _A AMOUNT (TYPE rap Messages FINANCE CHARGES are calculated at a MONTHLY PERIODIC RATE OF 1.50%(ANNUAL RATE OF 18.00%)based upon an unpaid balance outstanding 30 days or more. PREVIOUS BALANCE CHARGES FINANCE CHARGE TOTAL CHARGES PAYMENTS & CREDITS AMOUNT DUE 18.00 0.00 0.00 18.00 0.00 18.00 30905-UB46•TM409UD5R002789 TO INSURE PROPER CREDIT, DETACH AND RETURN THIS PORTION IN THE ENCLOSED ENVELOPE. 55023 ❑Please Check If above address is Incorrect and Indicate change on reverse aide. IF PAYING BY MASTERCARD,DISCOVER,VISA OR AMERICAN EXPRESS,FILL OUT BELOW. CHECK CARD USING FOR PAYMENT ACCOUNT NO: 1039.534 ❑ ❑ s: ❑ ❑ INVOICE NO: STATEMENT MASTERCARD DISCOVER VISA ° AMERICAN EXPRESS DX NO: KOPDX CARD NUMBER INVOICE DATE: 09/30/12 FACILITY: 1039 EMERITUS OF CREEKVIEW SIGNATURE EXP.DATE PATIENT NO: 534 PATIENT NAME: WOLFE,ANNA _ AMOUNT DUE: 18.00 �i TT t .PT .I il�m�r��L�UI>IiL� Il�lrrllrlllll�rIII 11111111'11111 Jill I1'11111111111111���Irllrlr OMNICARE PHARMACY SERVICES OF EASTERN PA AMOUNT ENCLOSED $ P.O. BOX 740391 CINCINNATI, OH 45274-0391 000001039a53410STATEMENT3000KOPDX90000018003 REV-1513 EX+ (01-10) pennsylvania SCHEDULE DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: NONA S- U)I)Lf�E a013-00050 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON($) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec. 9116(a) (1.2).] p JAN ( Z• 5%a 1. (0'VIt(L)[- R-.t.JO(-F'C—, fjL i Y'A CMAN1 002f-1 64 I d'° z. (eV+cR uA Va p�(SS, x ��S. ,"IL 8 e P w� d a�h1c 1 Z,5 `(o /��� ImccVwr.�c.st�.,a,t�� t l D55 3. Y".,j w'. R4'.1 , x(91 T-Ywl.i aV. ZUUV. �`� hkr I Z.$ ('krn-oa ,AF f�gK3 4. -r"L fY)• tabs lQoca a,a�h.4-cr 1Z-•S`�o n (�,,,rsb Q4 Ili ttz S Sl¢3$ V-DCn.�£S If E. 1` - jc'�j YZ. (a ,r' _ L' I�Jbn , I°a tlltt (a• �'�'�"'k' �j. worry, IZ2o )rylO�r��i-„..Ui4....J U[Vt.� So ,. (Z-S� p rt_S 7. 7 �Nn �ar1E, Qc�.(sel� '734w Y�lobl`� C44.£L �o-���'Y£✓ V1 t�Al�� t, ON L4 SO4” � 1/'nr� R- �sk�- , �tcas 5 hfll�s Is�vtL �,�h-F�✓ Iz.S%a ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH IS OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size.