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Home My WebLink About07-12-13 � Lsos61o1os REV-1500 Ex�°r",��>+''� PA Department of Revenue pennsyLvania oFFiC1AL Use ONLY °`^^`^`^"•^F°°^°= Coun Code Year FileNumber Bureau of Individual Taxes ry PO BOXz8a60i INHERITANCE TAX RETURN -_____.� ,._..____, ______..._..._.___.____ HarrisburqPAiyiz8-o6o1 RESIDENTDECEDENT -_� � � ' � �{ ' D� 77 '�. ENTER DECEDENT INFORMATION BELOW �"" Social � I 01/02/2013 �07/06/1926 ._...... ._....... .... . .. ........... i .... . .. . . . I ........ ........... .....�: Decedent's Last Name Suffix � DecedenYS First Name M� �..,...._. .. ._....... . . __. _ ...._.. ._..,...,_......_._._...._.,.. _ , , ._, ....._ __._ Jumper Mabel � E ----- -- --_ .. _.._...._ _,_�.____ ___ � ____� --,.�._.._.__.____ _..� .___ _._. ._ ..: ��_� (If Applicable)Enter Surviving Spouse s Information Below Spouse's Last Name Suffx Spouse's First Name MI . ..... .. ........ ......... ..... _ _ ._. .... _. ...._.._ ... _.___ . .___ �_-_.i 1 .......... .. ...._ ____"._ __..._ __.___....._... ......_.. '. ....__....._.... .. ._. ._.__...,.__ _...__ .. ...__..... ..._,..... .. i._....._� Spouse's Social Secunty Number � ___._.,__...__._.._,.,.._._.______._...., THIS RETURN MUST BE FILED IN DUPLICATE WITH THE i __ ^ ,__ ____._�______.__...I REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Onginal Return O 2.Supplemental Return O 3. Remainder Return(Da[e 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 aRer 12-12-82) � 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes - (Attach Copy of Will) (Attach Copy of Trust.) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credi[(Date of Death O 11. Election to Tax untler Sec.9113(A) Between 1237-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT— THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE UIRECTED T0: Name . Daytime Telephone Number _....._...___.. .....___._._ ...... .......______..,____._...._ ._.___.._..____.._._......._... _ . ...._._.......... .__.'_, �..,_.....__.._..__..._....._ _.._..._..............._.........._....,., Ronald E. Johnson, Esq ' �(71�243-0123 c, __. . _.._ _._.__._ ..__.�_..__ .._._.._ ...____.�.._. _____....__.. _.__� .__.__.._ _... (_.__ ..._._.___ _ .._._�.. ..a' _� �. . _.� _ . - � STER OF M`/ILLS QINLY W C _. p rn � c� :^ cn � First Line of Address � 2* �'" "' � �.,.__��_.....__..._._.___.----..._�_,._�...,.._..._.�..,........__..__�._.�_._._._...__..�..._,_..........._..___�..__�___..,_..�.. � rr, �'—` � m rn i 78 West Pomfret Street � V% � . � "Q �' �..._�_....�---,._._........---...___..._--_._,.m__.._...---__.__.-- � � c c� . .____..�.....__,.__._..._._,: Second Line ofAddress � n � � 1 � �..__......._..__...'.'�.'___.._. .._._......__..__._...____.._...__......._.............____....�..__.,..._..___... . ^ C' -ti � .� yT 4 . �^j � F-+ •� n t (f � � �� 7_...._......_�__.,..�.�._w._...._...-,-............._.___._._..._,..._._�...._....__........_..__............._m..,__._.._......7 �j '-7 DAT�ILE� City or Post Offce State ZIP Code - E ..... . .. .... .. .. . . _ .. __... . . . .... . . _......._.q`. �,7�_ �Carlisle � PA '17013 [ ._ _ � � _. _.�. ______ _,�.----—___..., ! CorrespondenYs e-mail address: fefohnsOn@pa.net Under penalbes of per�ury,I declare that I have examined this retum,inclutling accompanying schedules antl statements,and to lhe best of my knowledge antl belief, it is true,correct antl complete.Declaration of preparer other Ihan the personal representalive is based on all information of which preparer has any knowledge. SIG TURE �PE ON RES ONSIBLE FOR FIL�IN/G RETURN /� /�DATE �J - ^� yfGsL��{�qf'��L6 '/ `� � � S ADD a - C/O�8 est Pomfret Street�rlisle, PA 17013 SI F A R O REPRESENTATIVE � E � D R SS , c o 78 West Pomfr reet, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610105 1505610105 J ��it/ J 1505610205 REV-1500 EX(FI) Decedent's Social Security Number ,_.__._...__............_......____............._....-. oeoeae�rs Name: Mabel E. Jumper RECAPITULATION ............. ......... �.... ... ......... 1. Real Estate(Schedule A). .. ..... .. . .... ... .............. ....... ...... i. i 0.00 �' ..-�..._...�...�....__.m.�.�..............._...�.,.. 2. Stocks and Bonds(Schedule B) . ..... ...... ........... ..... ........... 2. �. 0.00 �� 3. qosely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3, � u.� _,m�.W�m0.00 5i 4. Mortgages and Notes Receivable(Schedule D).... .......... ..... . ....... 4. -I 0.00 ' . _...._....; 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). ...... 5. ��. 8,148.86 ��• ..� _ _�... . �_._n., 6. Jointly Owned PropeKy(Schedule F) O Separate Billing Requested . ..... . 6. ; 0.00 ��. ;___._...._.._._..,�_,.___.._.._._._._._.,__..�._............� 7. IntervVivos Transfers&Miscellaneous Non-Probate Property �: (Schedule G) O Separate Billing Requested........ 7. � 0.00 ; �...-..._..._..,._.�,..__.__..»_....._._..._.-...e.,..�.....,., � 8. 7otal Gross Assets(total Lines 1 through 7)..... . .... ...... ..... . .... .. . B. �. 8,148.86 �� 9. Funeral Expenses and Administrative Costs(Schedule H)... ........ ..... ... 9. � 7,917.92 '� , __..._._....,...._... 70. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I)... ............ 10. '�, 364,300.13 �'. ______"__.._..____.._.___.__..____.._.. 11. Totai Deductions(total Lines 9 and 10)...... .......... . .... . ........ ... 11. ' 372,218.05 �� .............._...�..m.__....e,.._.,.....,....._.__,..._......._.....W..,..._,. 12. Net Value of Estate(Line 8 minus Line 11) .. ..... .......... . ..... . ...... 12. �' -364,069.19 I � - 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which ""'""'°"-'."�°"..".."""`°."""°°'.°�`".`"'"""°"". an election to taz has not been made(Schedule J) . ........... ..... . ..... . 13. I 0.00 : W...,.»�..�_,_._............. 14. Net Value Subject to Tax(Line 72 minus Line 13) ....... . ............ . ... 74. � -364,069.19 � TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 74 taxable � at the spousal tax rete, or - . transfers under Sec. 9116 (-"".-_..,_._._....._..__._..___..__.._..,_....__...._.�, ,,_,__._.,._�_�,_..__�._._.._....w____.__,,.._.___.._,.___, (a)(1.2)X A_ [ i 15.! 0.00 �-. . .. �� ....,�.W.._�_.........�e.._.._.___....._...._...._...._....,......; 16. Amount of Line 14 taxable ""•""°"_°'°'°"'°„.""""»""°.""."" � at lineal rate X.0_ � '�, 16.; 0.00 !�, . � ,._,_.__.�_.....___...__._____�.,._----.--._......: 17. Amount of Line 14 taxable ��.,""".�'""."'-'__.__.._._.._._..._,._._._..,,....�._._._ at sibling rate X.12 I ��, �7,i 0.00 ��. 18. Amount ot Line 14 taxable "__......_,...,_�___....._......................................_...._:. p,_e....................._.,......._____..,._...._.�.�._....,.�...; at collateral rate X.15 q ' . �g.� 0.00 i ..._......_._..__.._.....�.,._......__.._...,�_....._.._._..._._.t :.„:..,A.-,.,,..�..a._._ - i ....A......m.�...�......,..,.��.,.m.......��,�i 19. TAX DUE . .. ........... ....... .. . ........ ............ . .... . .... ... 19.I O.00 i 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 � 1505610205 1505610205 J REV-1500 EX(FI) Page 3 File Number DecedenYs Complete Address: OECEDEN7'S NAME Mabel E. Jumper STREETADDRESS 801 North Hanover Street pN STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (i) 0.00 2. Credits(Payments A.Prior Payments 0.00 B.Discount 0.00 Total Credits(A*g� (2) 0.00 3. Interest (3) 0.00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fiil in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1 +Line 3 is greater ihan Line 2,enter ihe difterence.This is lhe TAX DUE. (5) 0.00 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 lhe use or income of the property transferred.......................................................................................... ❑ � b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ � c. retain a reversionary interest .............................................................................................................................. ❑ � d. receive the promise for Iife of either payments,benefts or care?...................................................................... ❑ � 2. If death occuved after Dec. 12,1982,did decedeM transfer propedy within one year of death without receiving adequate consideration?.............................................................................................................. ❑ � 3. Did decedent own an"in trust for"or payable-upon-death bank account or securily at his or her death?.............. ❑ � 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 6 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 ihe 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 appiicabie even if the surviving spouse is the only benefciary. 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)(12)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefciaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. . The Wx rate imposed on the net value of transfers to or for the use of the decedenPs siblings is 12 percent(72 P.S. §9116�a)(1.3)].A sibling is defned, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. i . . ^ , �(�r�@,.r�, _� ' i . . �L�r�� (��, � � � t .. I, MABEL E. K. JUMPER, of 510 School Avenue, Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and £or my Last Will and Testament, hereby revoking any and all other wills and codicils heretofore made by me. FIRST. I direct that all my just debts and funeral expenses be paid Prom my estate as soon after my death as practically and conveniently may be done. SECOND. I direct that my remains be interred within my family's burial plot located in Westminister Cemetery_ THIRD. I authorize my personal representative to expend funds from my estate, in such amounts as my personal representative shall consider necessary and desirable for the purchase, .erection and inscription of�a suitable marker for my grave. FOURTH. I give, devise and bequeath any and all tangible personal property owned by me at the time of my death unto my husband, Boyd Lloyd Jumper, provided he survives me by thirty (30) days. In the event he fails to survive me by thirty (30) days, I give, devise and bequeath all said tangible personal property unto my children, Boyd Lee Jumper, Shelby Jean Jumper, David Hugh Jumper, and Timothy Ray Jumper, in equal shares per stirpes. FIFTH. I give, devise and bequeath any and all real estate owned by me at the time of my death, unto my husband, Boyd Lloyd Jumper, provided he survives me by thirty days. In the event he fails to survive me by thirty (30) days, I give, devise and bequeath all said real estate unto my children, Boyd Lee Jumper, Shelby Jean Jumper, David Hugh Jumper, and Timothy Ray Jumper, in equal shares per stirpes. SIXTH. I give, devise and bequeath all the rest, residue and remainder of my estate unto my husband, Boyd Lloyd Jumper, provided he survives me by thirty (30) days. In the event he fails to survive me by thirty (30) days, I give, devise and bequeath all the rest, residue and remainder of my estate unto my children, Boyd Lee Jumper, Shelby Jean Jumper, David Hugh Jumper, and Timothy Ray Jumper, in equal shares per stirpes. SEVENTH. I direct that any and all Inheritance, Estate and Transfer taxes impcsed upon my estate passing under my will or otherwise, shall be paid out of the principal of my residuary estate. EIGHTH. I hereby nominate, constitute and appoint my husband, Boyd Lloyd Jumper as Executor of this my Last Will and Testament. In the event of renunciation, death, resignation or inability to act for any reason whatsoever of Boyd, I nominate, constitute and appoint my so_ Boyd Lee Jumper, as Executor of this my Last Will and Testament. I hereby relieve my Executor from the necessity of posting security in connection with his duties, as such, in any jurisdiction in which he may be called upon to act insofar as I am able by law to do so. In addition to the powers conferred by law, I authorize my Executor, in his absolute discretion, to retain in the form received, and to sell either at public or private sale any real or personal property owned by me at the time o£ my death. I suggest that my Executor serve without compensation. rN WITNFSS WHER�OF, S have hereunto s2t .my ;and and seal to this, my Last Will and Testament, consisting o£ two typewritten pages this 22nd day of October, 1990. '��^ l�i /,'/� %;r' (� ai»a':';P.�'?-c%�%_ G� MABELyE. K. JUMPER ,� Signed, sealed, published and declared by the above named Testatrix MABEL E. K. JUMPER as and for her Last Will and Testament, ' in the presence of us, who, at her request, in her sight and presence and in the sight and presence of each other, have hereunto subscribed our names as witnesses. � , "�'��. J i • � ,� � �ti;f� ��' \ �� :�:�_:;�_t >�. .�l _ - f� �� ,� � , � °j .: ,.�' .'.<:: .y�- -: _ ,,:,;. , _• . .;�,� ;�.�, , ..�-- � . �_. .'� ,, COMMONWEALTH OF PENNSYLVANIA: . ss. COUNTY OF CUMBERLAND . I, MABEL E. K. JUMPER, Testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. . �%',>:!/��r r�� c�,ticti�9_%' .i�' MABEL E. K. J'✓.'TN�PER �% Sworn or affirmed to and acknocaledqed before me, by 2dABEL E. K. JUMPER this 22nd day of October, 1990. f � � t � �,, �,ti,.. . �� `�isa2i'_ il�-�'i;,L._� ��\��Z.i..s�. \C:l.w�� C-rGJe!^ °9a/rv'cunii. PJMzryFi�t-.i:: Notary Publ 'c �: �.�SEAL) hry comm`��J"� cu01�ed',d G.u:,t, � U �----.—�;5±-,,,e�;,�,:�:;,,_�,_;�� COMMONWEALTH OF PENNSYLVANIA: � --- . 55. COUNTY OF CUMBERLAND . We, William A. Duncan and Boyd Lloyd Jumper the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw MABEL E. K. JUMPER sign and execute the instrument as her Last Will; that MABEL E. K. JUMPER signed willingly and that MABEL E. K. JUMPER executed as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the will as witnesses; and that to the best of our knowledge, the Testatrix was at that time eiahteen !i8; cr more yeurs of ,:g=, of scund mind and under no constraint or undue influ'ence� � �`4 �'�j '�.�,��! ±._,L.. "�-,-_'- , _ _. ` , � � '-r!i' �. � ir '� :� � �j Z_`' :1F' t ..i•�<��1�`_�_.--'" Sworil or affirmed to and , � � I _ subscribed before me by - Wi:.Iiam A. Duncan and Boyd Lloyd Jumper, witnesses, this 22nd day of October, 1990. � J� .. .?Gc,.��cz.� �-'�.o c_......._c Notary Pu�ic C\ C �SEAL��_______—, � � Pdo+.arialS�al � lNc;r.dy Fd.y 1'��.;r.q,hiotsry Pu6iic I ^��!':>I�3crnuyh.Cum6er;ar•d��•unt�� j?fi�Cc,-urii_sian�xpirss Acg.3, 5='��= REV-i5o8IX+(o8-u) ',��p pennsylvania SCNEDULE E ��• DEPAqTMENTOFREVENUE CASH� BANK DEPOSITS & MISC. INHE0.RAN�TAXRETURN PERSONAL PROPERTY 0.ESIDENT DECEDEMr ESTATE Of: FILE NUMBER: Mabel E. Jumper 21-13-0177 Indude the praeeds of litigation and the date the proceeds were received by the esWte. All property jotntly owned with right af survivorship must be disclosed on Schedule F. IiEM NUMBER VAIUE AT DATE DESCRiPliON OF DEATH �, Metropolitan Li(e Insurance Co.-total control account#4054500729-(see letter att 8,148.46 TOTAL(Also enter on Line 5, Recapitulation) $ 8,148.86 If more space is needed,use additional sheets of paper of the same size. MetLife MetLife Total Control Account PO Box 6300 Scrantoo,PA 18505-6300 800-638-7283 March 5, 2013 Andrews &Johnson Att: Ronald E. Johnson 78 W. Pomfret Street Cazlisle, PA 17013 Re: Total Control Account#4054500729 Metropolitan Life Insurance Company Accountholder: MABEL E JUMPER Deaz Mr. Johnson: In response to your request for the date of death balance for the above referenced Total Control Account, the date of death balance is $8,148.86. If you have any questions or require further assistance,please call our TCA Customer Service deparhnent at 800-638-7283 Monday through Friday, 8:OOam through 6:OOpm ET. Sincerely, TCA Administration Services Note:Metropolitan LiFe Insumnce Company(MLIC)provides adminis[ra[ive services for Total Conkol Accounts established in connec[ion wi[h policies issued by MLIC or by certain of MUC's insurnnce company affilia[es. [ca.0146.rev.02 � REV-1511 EX+(]0-09) �� pennsylvania SCHEDULE H �EPANTN.ENTOFflEVENUE FUNERAL EXpENSES AND INHE0.ITpNCETA%RENRfi ADMINISTRATIVE COSTS 0.ESIDEM DECE�EM ESTATE OF FILE NUMBER Mable E. Jump 21-13-0177 DecedenYs debts must he reported on Schedule I. ITEM NUMBE0. DESCR(P'fION AMOUNT A. FUNERAL EXPENSES: 1' Ewing Brothers Funera!Home 5,939.42 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: . 450.00 Name(s)of Personal RepresenWNve(s) Boyd Lee Jumper Sueet nddress 18 GoodhaR Roed �;ty Shippensburg state PA Z�p '17257 Year(s)Commission Paid: 2013 1,400.00 2. Attomey Fees: 3. Family Exemption: (If decedent's address is not the same as daimant's,attach explanation.) . . Claimant StreetAddress City State_21P Relationship of Claimanc to Decedent 4. Pra6ate Fees: 128.50 S. Accountant Fees: 6. Tax Retum Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulafion) $ �.9��,9z If mare space is needed,use additional sheets of paper of the same size. REV-1532 EX+(t2-12) "�i f pennsylvania SCHEDULE I DE7ARTMENTOFREVENUE DEBTS OF DECEDENT, INNE0.RRNCcTA%0.ENAN MORTGAGE LIABILITIES & LIENS RESIDEM OECEDEM ESTATE OF PILE NUMBER Mabel E. Jumper 21-13-0177 Report debts incurred 6y the decedent prior to death that remained unpaid at the date of death,including unreim6ursed medical exDenses. iTEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• Pa Dept of Public Welfare(see attached) 364,300.13 TO7AL(Also enter on Line 10, Recapitulation) $ 364,300.'13 if more space is needed,insert additional sheets of the same size. �!• pennsylvania OEPARTMENT OF PU84IC WELFARE March 6, 2013 ANDREWS &JOHNSON RONALD E JOHNSON ESQUIRE 78 W POMFRET ST CARLISLE PA 17013-3216 Re: Mabel Jumper CIS #: 910160192 SSN: ###-##- Date of Death: Ol/02/2013 �—�� Dear Attorney )ohnson: Please be advised that the Department of Public Welfare maintains a claim in the amounC of 5364.300.13 against the above-mentioned estate. This claim is for restitution of inedical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 14].2, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $.00, was incurred during the last six months of the decedenYs life; therefore, it is a Class 3 c�aim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $364,300.13, is to be entered as a priority Class 5.1 claim against the estate. Piease acknowfedge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy, If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, �� a�'J��c.�c�.. � i..�t�� Angela D. Carter Claims Investigation Agent 717-772-6612 717-772-6553 FAX Enciosure Bureau of Program Inte9rity � Division of Third Party Liability � Recovery Sec[ion PO Box 8486 I Harr(sburg, Pennsylvania 17105-8486 COMMONWEAL7H OF PENNSYLVANIA BUREqU OF PROGRAM INTEGRITY ONISION Of THIRD PARTY LIA81LI7Y RECOVERV SECTION E:.;'. . t '-_ POlO%!M9 . . . NA1�($BURG.PA 17105a3B6 . . �. �- March 4,2013 ' STATEMENT OF CLAIM SUMMARY , NAME Estate of .IUMPER,MABEL � ID 910160192 MEDICAL " CLASS 3 CLASS 5.1 TOTAL �� INPATIENT .00 .00 .OU - , - OU7PATIENT .00 139.19 139.19 LONG TERM CARE .00 353,350.66 353,350.66 ' DRUG .00 10,810.28 70,610.28 � REIMBURSEMENT TO DPW .00 364,300.13 364,300.13 � COMMONWEA�TH OF PENNSYLVANIA DEPARTMEN70F PUBLIC WELFARE - EIN- 23-6D03113 Page 1 of SS REV-1513 EX+(O1-10) ��pennsylvania SCHEDULE ) � OEFRRTMENTpFNEVENIIE 1NHERITANCE TA%RENAN BE N EFICIARIES RESIOEM DECE�EM ESTATE OF: FILE NUMBER: Mabel E.Jumper 21-13-0177 RELAIIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADD0.E55 Of PERSON(5)RKEIViNG PROPERN Do Not List T�ustee(s) OF ESTATE I 7AXABLE DISTRIBUTIONS[[nclude autnght spousal disMbutions and transfers under Sec.9116(a)(1.2}.} 1. Boyd Lee Jumper, 18 Goodhart Road,Shippensburg,PA 17257 son 25% 2. Timothy Jumper,146 Pine Knob Road,Newville,PA 17245 son 25% 3. David H.Jumper,530 Crains Gap Road,Carfisle,PA 17013 son Zso/a 4. Shelby Jumper,3515 Hillcrest Road,Hartisburg,PA 17109 daughter 25�/, ENTER DOLIAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON L1NE5 IS THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. 11 NON•7AXABLE DIST0.10UTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECf70N 9113 FOR WHICH AN ELECfI�N T�TAX[S NOT TAKEN: 1. B. CHAARABLE AND G�VERNMENTAI D[STRIBUSi0N5: 1. TO7AL OF PART II- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use addi[ional sheeGs of paper af the same size.