HomeMy WebLinkAbout08-13-13 (2) J 1505610105
REV-1500IX(m-a1)(Fl)�
OFRCULL USE ONLY
PA�epaRmer�t of Revenue D�Y�� Counry Cotle Year Flle Number
Bureau of Indtvldual Taxes INHERITANCE TAX RETURN
ao sox zsoeo� 2 I l Z I Z 97
Hamsburq PA i7u8-06oi RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Securily Number Date of Death MA�DYYYY Dale ot Birth MMDOYYYY
11292012 11171928
DecedenPs Last Name Sulflx Decedent's First Name MI
PTASZEK BARBARA E
(N Appllesbk)Enbr 8urviving Spouse'a IMormatlon Below
Spouse's Last Name SWfix Spouse's Fiist Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPIJCATE WITH THE
REGISTER OF WILLS
FILI iN MPROPRIATE OVAlB BELOW
� 1.Original Retum O 2.Supplementai Retum O 3. Remaintler Retum(Dale of Death
Pnorto 12-13-82)
p 4. Limitetl Estate O 4a.Fulure Irherest Compromise(dale of O 5. Federal Estete Tax Retum Required
death after 72-12�82) .
f� 8.Decedenl Dietl Testate O 7.Decedent Meinteiired a Living 7rust 0 8. Tofal Number of Safe Deposit Bozes
(Attach Copy of Will) (Altach Copy ot TrusL)
O 9.Lidgetion Proceeds Received O 10.Spousal Poverty Credit(Date M Death O 11. Election M T�under Sec.9113(A)
Between 1231-91 anC 1-1-95) (AGech Schetlula O)
� CORRESPONDENT- TNIS SECTION hNST BE COMPLETED.ALL COIINESPONDENCE AND CONFIDEIRIAL TA7(INFqiMAT10N SHOULO BE dRECTED T0:
Name � � Daydme Telephorre Number
Robert S Pfaszek 717�09-5008 �; � �
G ��r �
Q15TER OF I�LtS U�O
� -17 C) '",� lC�
.T7 y � i..j 1-;��
f- H' �,y
Firet Line of Address t" ;' �'�° W ^'
Ta' U� '''T C r,;?
111 Adams Road � � a` -o - l "'�
c.-� c^ r„ � "^
SecoM Line W Address .r.� c:> -,r '. �.�: c'>
� C.... �_• i:_ fs�
, � N �._.
' � O
City or Post Oflice Slate ZIP Code � �� u' �
Carlisle PA 17015
carsspondanes.-msu aadross:robert.ptaszek�us.artny.mil
Under Penelfba oi perJury.l deck�e tliat I heve exemhred iNs ieWm,kicludi�8 axmWa�N�B schedules end etalmnenb.antl W the best M mY kra�Wetl9e and beliM.
it is tnre.carect end canpble-Dedsratlon d prepaier otlrer tlien the penmel repreeentetive Is beaed on ell infortnetlon of whkh prepeier l�es any knowle0pe.
SIGNA O P��tES LE POR FIUNG RENRN I 3 A�u� Z �3
����_ Q�J °
AODRE3S
111 Adams Road, Carlisle PA 17015-9209
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE � DATE
ADDRESS
PLlAB!YSE ORIOINAL FORM ONLY
Side 1
� 15056101U5 1505610105 J
� b50561�205
REV-1500 EX{FI)
DeoKrdaM's Saci�5ecurity Nurt�er
Decede�es Name: BARBARA E PTASZEK
RECAPtTUTAflON
t. Reai EstsW(Schedula Aj. ...... ............ ........... ............... S, �
2. 5wcka and eonds(SChedu�e e! ....................................... 2. 220.35
3. Ciasety Haitl Caporatinn,Pertnarship w Sole-Proprietorsfiip(Schedule C} ..... 3.
R. Mortgages sntl Notes Receivable{Schedule D)........................... 4. �
5. Cash,Bank Deposits and Misceila�eous Personed Property(Schedula E)... .... 5. 5,758.54
6. Jointly Owned Property{ScheduW P) O Separate 8illing Requested ..,.... 6,
7. Iriter-VWas Ttar+sfars 8 Miacei�aneais F�-ProUata Fropetty . .. .
(ScheduM G) O Separate BiNing Requested........ T. 518.$61.76
8. Total Grow Aassb(totel Lines 1 through 7)............. ....... ......... 8. 524,6�W.65
9. Funerai Expenses and Administra8va Costs(Schedula H}... . ....... ........ 9. 1.2T2.1 Q
7�. Debts ot decedent,Modgage Lia411Nies and Liens(Schedule 1)......... ...... 10. 982.89 �
11. 7oht Daductlons(totai Lines 9 and 14j........................ ..._ ..., tt. 2�255.1$
t2. Net Yalw M Eateb{Une 8 minus Une 11) .. . ........................... 12. 522,385.47
T3. Cher�abis arnf GovemmentaE 6equeatetSec 9113 Tnmis fw wh�h . . . . . ...
en eiectton M fex has no!been mada(Scheduie J) .. .. ..... ............... 13.
74. Nat Wlw Sub}set tp Tez(line 12 minus iine 13) ...............:........ 14. 522,3'85.47
TAX CALCUUtTtON-3EE INS7RUCTfONS F'�t APPIICABI.E RAtES
75. ArrauM of Lirre 14�au9b19
� at t�e spousel tax rate,or
Nensfers under Sec.91 t6 �
�ex�.zy x.a- �s.
18. Amount oT Line 14 faxahle . .. . .. . . . . ....,
ac i+�eai rete x.o� 522,385.47 �g, 23,507.35
17. nmount at une ta ca�caele � . . . . .. . . _. . . . ..
at sibii�tate X.12 t7.
18. Amount of Line 14 te�table � - � � � � - � -
et eollater9l rate X.15 1 g,
59. TN7(DUE ......._....._..._.................................... 19. . . . . x$�SQ7.35
20. Fill IN TNE OYA��YpU ARE REQUESTIN6 A REFUND OF AN 4VERPAYMENT �'t
$Ide 2
� 15d561�205 150561�2d5 �
_ _
REV4500 EX(FI) Page 3 FIN Numb�r Z� � Z / z q 7
Decedent's Complete Address:
DECEDENT'S NAME
Barbara E Ptaszek
STREETADDRESS
111 Adams Road
CITY ! STATE ZIP
Carlisle PA 17015
Tax Payments and Credits:
t. Tax Due(Page 2,Lirre 19) (1) 23,507.35
2. CreditslPayments
A.PrbrPaymeMS 22,443.84
B.Discount 1,132.47
Total Credits(A+B) (2) � 23,576.11
3. Inte2st
(3) 68.76
4. If Line 2 is grealer than Lirre 7+Line 3,eMer the diflerence. This is tlre OVERPAYMENT.
Pn�In rna�on Page 2,una 20 ro r«�wst a re�und. (a)
5. If Line 1 +Li�3 is greater than Line 2,eMer the difference.This is the TA%DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
� . . .. . .. . ... . '.'},,9Ur ,�fc"iv 'uP. . ., . 5°Y�."5°�: Y, `u�.'°',�=�:'4"�,'
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a trensfer and: Yes No
a. refain the use a income ot the property transferred.......................................................................................... ❑ �
b. retain the right W designate who shall use the property Ua�sierred or its�ir�come ............................................ ❑ �
c. reMain a reve�aionary interest.............................................................................................................................. ❑ �
d. receive the promise for life of either payments,benefits or pre?...................................................................... ❑ �
2. N death occurred after Dec.12,1982,did decedent transfer property within oice year of death .
wiMOUI receiving adequete consideratbn?.............................................................................................................. ❑ �
3. Did decedent ovm an�n W sl ta"or payaWaupon-death benk account or securiry at his w her deaM?.............. � ❑ �
4. Did decedent ovm an individual retirement acxouM,annuity or other non•probete property,which
cantainsa be�ciary deagnatron? ........................................................................................................................ ❑ �
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE C AND FILE R AS PART OF THE RENRN.
. . . �� . .. � . �.� . . . >*iTM . . .F .''`, . a. �.+ �'skr .%"�:"�'�;�r.`,.
Fa dates ot dealh on w after Juty 1, 1994,and befae Jan. 1,1995,the tax rate imposed on the net value of transfers to or tor the use of the surviving spouse
is 3 perceM[!2 P.S.§9116(a)(1.1)(i)I•
For dates of death on a after Jan. 1, 1995, the tax rete imposed on the net value of transfers to a tor the use of the surviving spouse is 0 percrc�nt
[72 P.S.§9t16(a)(1.1)(ii)j.The sfatute does rwt exempt a hansfer to a surviving spouse irom tax,and the stalutory requirements for disdosure of assets and
filing a tax reWm ere still applicable even if tlre surviving spouse is the only beneficiary.
Fw dates of death on a after July 1,2000:
. The fax rate imposed on the net value of hansfers from a deceased child 21 years of age or younger al death to or for the use of a naWral parent, an
adop6ve parent or a stepparent ot the chiW is 0 percent[72 P.S.§9116(a)(1.2)].
• The hax rate imposed on the net vahie of transFers to or iw the use of the�CedenPs lineal benefiaaries is 4.5 percent,except as noted in[72 P.S.§9116(a)�1)].
. The tax rate imposed on the net value of transfers to or for the use of the decede�Ys siblings is 12 percent[72 P.S.§9116�a)(1.3)].A sibling is defined,
under Section 9102,as an individual who has at leasl one parent in common with the decedenl,whether by bload w adoption.
�-15�3IX4(bf27
���� s/c�/N� inpupu���s
INHER[TANCETAXNENRN �yVKS Q DVI\DS
RESIDENTDECEDEN7
ESTATE OF FILE NUMBER
BARBARA E PTASZEK 21 12 1297
All VroWKY 1aMM ownad wMh�ipht o(wrvhronh�P mu�t M diM,loNd on SchtluN f.
ITEM VALUE AT DATE
NUMBER DESCRIpfION OF DEATH
1' Ocbber 1981 EE Series Savings Bonds 220.35
70TAL(Alw enter on LJne 2, Re�aplNlatlon) ; z20.35
If more space Is needed,insert addldonal sheNS of the same size
REVa5o8 E%+(o8-u)
j�j pennsylvania �MlpYLE E
YJ �0F1E"�""� CASH, BANK DEPOSITS 8� MISC.
�N�ncr""c�T"Xn�ruR" PERSONAL PROPERTY
RESIDENT DECEDENf
ESTATE OF: FILE NUMBER:
BARBARA E PTASZEK Z� �2 �Z9�
[nGude the proceMs of Iitlqatlon and tlx date the D�Were receNed by Me enabe.
MI V�I+�Y 1aM1Y awnsd wltl�ripM ot�uMvonhiP mwt M dbdowd on StlwduN F.
�M VALUE AT DATE
NUMBER DESCRIP170N OF DEATH
�, Cash 43.50
2. Metro Bank 50 Plus Chedcing Account 0537399727 73.70
3. 2003 Ford Taurus Automobile 2,500.00
q. American Express Tiavelers Checks 150.00
5. Delaware Electric Coopera6ve Capital Credits 78.77
g. Federal Empbyees Group Life Insurance Class Actlon Suft Payment 1.00
7, Renter's Policy Refund 68.01
g, AutortaDile Insurance Re(und 189.95
g, AAA Membership Re(und 12.25
�p, Kitchen tade and chairs 115.00
��, Pots,pans,dishes,kitchenware 30.00
�Z, Sharp carousel microwave oven 12.00
�3. Coffeeemaker-No Resale Value 0.00
�q, Toastermaster toaster 4.00
�5, Emerson radio 5.00
16. Ublity cart 7.00
�7, Couch and mak;hing chair-No Resale Value 0.00
�g, Rocking char 35.00
19. �oRee and lamp taWea 45.00
2p, Magnavox consde television-No Resale Value 0.00
p�, Tablelamps 35.00
22, Four piece bedroom set 220.00
Z3, Cedar chest 25.00
Zq, Seaetary cabinet 20.00
25_ Vacuum deaners 20.00
TOTAL(Also enter on Line 5, RetapiWlatlon) ;
If rtrore space Is�reeded,use additlonal sheets of paper of the same size.
REV-iso8 EX+(08-12)
�pennsylvania �Mtp11LE E
oEVnarnrimmaFnev�r+ue CASH, BANK DEPOSITS 8i MISC.
INHERITANCE TAX RETURN pERSONAL PROPERTY
RESIDENTOECEDEMf
ESTATE OF: FILE NUMBER:
BARBARA E PTASZEK 21 12 1297
Indude the proceeds of Ildgatlon and the date the proceeds were received by the estate.
All p�apeAy�ointly owned wNh ripM of wMvorship�mpt be dhdaad on Sd�aduN F.
�M VALUE AT DATE
NUMBER DESCRIFRON OF DEATH
�6. Torch floor lamps 45.00
27, Sheets,towels 12.00
Zg. Desk 30.00
pg. Chest of drawers t4.00
30. Gateway computer-No Resale Value 0.00
3�, Ironing board and iron 6.00
3Z, Singersewingmachine 45.00
33. Magazine rack,Metal filing cabinet 10.00
34. Nightstand 15.00
35. �RP magaane reiund 16.00
36. Readers Digest magazine 21und 12.74
37, Woman Day magazine refund 29.67
3g. Consumer RepoAS magazine re(und 4.00
3g. PA Departrnent of Revenue refund 33.00
40. Guidepost magazine retund 7.90
q�, FederallncomeTaxrefund 1,788.05
TOTAL(Also enter on Line 5, Recapitulation) ; 5,758.54
If rtrore space is needeE,use additlonal sheets of paper of Me same slze.
REV4530 E%+(08-09) . �
�pennsylvania SCHEDULE G
UEMRTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHHIIi/�NCETAI(RENRN MISC. NON-PROBATE PROPERTY
RESIDENT DE�DENT
ESTATE OP FILE NUM6ER
BARBARA E PTASZEK 21 12 1297
This uhedule must 6e completed and flled if the answer to any of questlons 1 Mrough 4 on page three of the REVd500 is yes.
�M DESCRIVfION OF PROPERTY DAlE OF DEATX %OF DECD'S E%IXUSION TNNBLE
p[WDE TNE N�ME OF lNE iN�,TlEi0.MEUTIq610Ym OEQOFNf�1No
NUMBER nrconnam�xs�a�ma�mrramcowraxFUar�. VALUEOFASSEf INTEREST rnuuau VALUE
i. Members 1st FCU P�count Number 403-05 ACN 12167266-Thanas F �g,�gp,87 100 19,180.87
Ptaszek,Chikl,30 May 2013
2 Members 1 st FCU Account Number 403-05 ACN 12167267-Robert S �g,�80.e7 100 19,180.e7
Ptaszek,Child,2(1 February 2(N3
3 Members 1 st FCU Account Number 403-04 ACN 12167264-Thomas F p,ppp,3B 100 2,000.38
Ptaszek,Child,30 May 2013
4 Members tst FCU Account Number 403-04 ACN 12167265-Robert S 2 000 38 �00 2 000 3g
Plaszek,Chikl,20 February 2013
5 Members 1 st FCU Account Number 403-41 ACN 12167268-Robert S 4,174.73 100 4,174.73
Ptaszek,Child,20 February 2013
6 Members 1 st FCU P�counl Number 403-42 ACN 12167269-Robert S 15,868.87 100 15,868.87
Ptaszek,Child,20 February 2013
� Members 1st FCU P�count Number 403-43 ACN 12167270-Thanas F 14,409.35 100 14,409.35
Pfaszek,Child,30 May 2013
8 Members 1 st PCU Account Number 403-43 ACN 12167271 -Robert S �4,409.35 100 14,409.35
Pfaszek,Child,20 February 2013
9 Members 1 st FCU Account Number 403-48 ACN 12167273-Robert S 19,838.01 100 19.838.ot
Ptaszek,Child,20 February 2013
�� Members 1 st FCU Account Number 40364 ACN 12167276-Robert S 13,459.19 100 13,459.19
Ptaszek,Child,20 February 2013
�� Members 1st FCU Account Number 403-66 ACN 12167276-Robert S 6,200.17 100 6,200.17
Ptaszek,Child,20 February 2013
�2 Members 1 st FCU Account Number 403-47 ACN 12167272-Thamas F »gsg 5� �00 17,958.51
Ptaszek,Child,30 May 2013
t3 Members 1 st FCU Axouni Number 403-62 ACN 12167274-Thomas F 13,364.14 100 13,364.14
Plaszek,Child,30 May 2013
�4 Members tst FCU Account Number 403-63 ACN 12167275-Thomas F pp,�,B1 100 20,366.81
Ptaszek,Child,30 May 2013
15 Members 1st fCU Account Number 403-65 ACN 12167277-Thamas F g qy��p �pp 9,447.10
Ptaszek,Child,30 May 2013
�s OrrstoNm Bank Acwunt Number 4000036878 ACN 13100947,Thomas F 13,716.30 100 13,716.30
Ptaszek,Child, 19 March 2013
» Ortstovm Bank Account Number 4000036879 ACN 13100948,Robert S �3,�t6.3o 100 t3,��s.3o
Ptaszek,Child,21 February 2013
18. ��0�"�^�nk Hccount Number 4000042564 ACN 13100949,Robert S 5,131.00 100 s,131.00
Ptaszek,Child,20 March 2013
19 Orrsto�m Bank Axount Number 4000042564 ACN 13100950,Thomas F 5,131.00 100 5,t31.00
Ptaszek,Child, 19 March 2013
TOTAL(Also enter on Line 7,Recapitulation) ;
If more space is needed,use addltlonal sheets of paper of Me same size.
REV-1530 EX+ (OB-09) �
�pennsylvania SCHEDULE G
DEPAPTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHEMANCETAXRENRN MISC. NON-PROBATE PROPERTY
RESIDENfDECEDENf
ESTATE OF FILE NUMBER
BARBARA E PTAS2EK 21 12 1297
This schedule must be complebe0 and Bled if the answer W any of quesdons 1 through 4 on page Mree of the REV-I500 is yes. �
DESCRIVfION OF PROPERTY DA7E OF DFA7H %OF DECD'S EXCLUSION TA%ABLE
I7EM a�nucen�wu+eaTMemusr�xee.nnauunasmrroo�exruro
NUMBER n�o�reamusra.ar�a�cor/an�eoEmwaneuar�h. VALUEOFASSET INtERKf �evuew� VALUE
2Ci. Cenfric Bank,Nccount Number 3053618 ACN 13500321,Thomas F Ptaszek, 5,292.45 100 5292.45
Child,9 March 2013
21 Centric Bank,Accrount Number 3053618 ACN 13500322,Robert S Ptaszek, 5,292.45 100 5,292.45
Child,25 February 2013
� Cenhic Bank,Account Number 3055720 ACN 13500323,Thanas F Ptaszek, �3,430.52 100 13,430.52
Chiid,9 March 2013
23 Centric Bank,Account Number 3055720 ACN 13500324,Robert S Ptaszek, �3,430.52 100 13,430.52
Child,20 February 2013
Z4 Vanguard,Axount Number 88014595918 ACN 13500319,Than�F 46,039.61 100 45,039.61
Ptaszek,Child,25 February 2013
ZS Vanguard,Accwunt Number 88014595918 ACN 13500320,Robert S Ptaszek, 45,039.61 100 45,039.61
Child,28 January 2013
� Alli�ce Development Fimd Account Number 22835 ACN 13500232,Thomas 5,393.85 100 5,393.85
F Ptaszek,Child, 11 March 2013
27 Alliance Development Fund Account Number 22835 ACN 13500233,Robert 5,393.85 100 5,393.85
S Ptaszek,Child,l7 January 2013
28 Alliance Devebpment Fund P�count Number 22388 ACN 13500234,Thomas ��,fipp,61 7 00 11,600.61
F Pfaszek,Child,ll Ma�ch 2013
� Alliance Development Fund Accant Number 22388 ACN 13500235,Robert ��,gpp,61 100 t 1,600.61
S Ptaszek,Child, 17 January 2013
� Alliance Devebpment Fund Account Number 72387 ACN 13500236,Thomas 8,202.16 100 8,202.16
F Ptaszek,Child,ll March 2013
31 Alliance Development Fund Account Number 22387 ACN 13500237,Robert 8,202.16 100 8,202.16
S Pfaszek,Chikl, 17 January 2013
32 AmeriChace FCU Account Number 35165 ACN 13500353,Thomas F q,gpgsq 100 4,803.54
Ptaszek,Child,ll March 2013
� AmeriChoice FCU Account Number 35165 ACN 13500354,Robert S 4,803.54 100 4,803.54
Ptaszek,Child,20 February 2013
� Edward Jones Account Number 270-07931 ACN 13500366,Robert S 3g,y�6.23 100 36,2t623
Ptauek,Child,8 February 2013
� Edward Jones Account Number 270-07931 ACN 13500367,Thomas F 35,y�623 100 36,216.23
Ptaszek,Child,8 February 2013
� Susquehanna Bank Aa:ount Number 10005034128 ACN 12168924,Robert S pg,�5p.49 100 29,150.49
Ptaszek,Child,3 July 2013
TOTAL(Aiso enter on Line 7,Recapttulation) ; 518�881•�g
If more space is needed,use addttbnal sheets of paDer of the same size.
REV-1511 EX+ (10-09)
�pennsylvarda SCNEDULE H
OEVARTMENT OFREVENUE FUNERAL EXPENSES AND
INNERIT�N�TAXRETUPN ADMINISTRATIVE COSTS
RESIOFM�ECE�M
ESTATE OF FILE NUMlER
BARBARA E PTASZEK 21 12 1297
DaadaM's Mbb mw!ba royoRad on Sdiaduk I.
ITEM
� NUMBER DESCWVRON AMOUNT
A. FUNERALEXPENSES:
1' Hoffman-Roth Fumeral Home 357.37
z. Chapel Pointe Service 488.00
B. ADMINISTRATIVE COSTS:
1. Persanal Representative Wmmisslons:
Name(s)of Personal RepreSentnNve(s)
Street Address
Ciry State 2[P
Year(s)Commiulon Paid: �
2. � At[omey Fees: .
3. Famlly Exemptlon:(If decedent's address Is not the same as clalmant's,attach ezplanatlon.) .
Claimant
Street Address
City State ZIP
Reladonship of qalmaM to Dettdent
4. Probate Fees: �
5. Acaun[ant Fees: . .
. 6. Tax Retum Preparer Fees:
�. Petiti�on of Letters Testamentary Fee 128.50
e. Estate NotficaUon Fees 190.20
9. Short Cer�ficate Fees 29.00
to. Poslage Costs 24.12
i i. Mambers ist Date of Death Statement 25.00
t2. Inheritance Tax Retum and Inventay Filing Fees 30.00
TOTAL(Also enter on Line 9, Rewpttulation) ; ��Z�2.�9
if more space is needed,use addldonal sheets of paper of the same slze.
REV-1512 EX+(12-12)
�pennsylvania SCHEDULE I
oeanrtrr�+v+*oFnFm+ue DEBTS OF DECEDENT,
�NH�wTU�T,ix ae�uu+ MORTGAGE LIABILITIES &LIENS
aesroerrt o�ceNr
ESTATE OF FILE NUMBER
BARBARA E PTASZEK Z� �2 �29�
Raport Mbb I�rcu�sd by tha dacadaM yrlor[o daM Ma!romslead unyaM-N Ma d�N M duth,indudinq unrolmburad mWlul axyenw.
�M VALUE AT DATE
NUMBER DESCAIPiION OF DFATH
1� Final Telephone Bill 16•81
2. Hartzell Eye Glasses Bill 145.28
3. Chapel Pointe Final Rent 485.71
4. PA Deparhnent of Revenue Sfate Taxes 2012 325.19
TOTAL(Also enter on Line 10, Recapitulation) ¢ 982.99
If more space is needed,insert additlonal sheets of the same slze.
. REV-1513 E%i (01-10)
'�'pennsylvania SCHEDULE J
OEi�PTMfNT 4F XEVENUB
INNHUPINCE TA%RENRN BENEFICIARIES
RESIDR7f bECEDENT
ESTATf 8f: FSLE NBMdER:
BARBARA E PTASZEK 21 12 1297
RELAT[pNSHIP TTO DECEDEHf AMOUNT OA SHARE
t�IMBER liAb4E AHD ADQRE55 6F FERS4N(5)RECfMN6�t9PERTY DO Rbt tbt T�(s} �ESTATE
I TAXABLE OfSTRIBUT[ONS(tndude outrlgM spousai distribudons and transFers under
Sec.4Yld(a)(1.2).]
1. Thwnas F Ptaszek,695,A�e Cfiurt.Mechanics6wg PA 17055 Son 54°k
2. Robert S Plsszek,111 Adams Road,Cadisle PA 17015 Son 50%
ENTEK DOLUR AMOUNTS fOR DISfRIBUT10N5 SHOWN ABO4E ON UNES 15 THRWGH 18 OF REV-1500 COVER SHEEf,AS APPROPRIATE.
� NINi TAXABtE DIStRI�7fI6H5
A. SPOUSAL D[STRIBUTIONS UNDER SECfION 9113 FOR WH[CM pN ELECTION TO TAX IS NqT TAKEN:
1.
B. CHARITpBLE AND GQVERNMENTAL D15T0.18UfI0N5: .
i.
TQTAt.QF PART A-ENTER TO'fAL NOii TAXABLE DISTRFAtITtONS ON LINE 13 6F REV-i5W COVER SHfEL �
If more space is needed,use addidonal sheets M paper of the same slze.