HomeMy WebLinkAbout09-05-13 � 15Q5611184
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10222012 OA161932
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PERRY Dt7LLY E
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REl31STER 8F WII.LS
FILL IN APpROPR1ATE OVAL{�ELOW
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COltlllMOqOBIT-1fM��lCSION YUtT�E COINM,l7�.ALI.COItlIp�ONOlNC!AND CQIMIDB11YIl L11f MlCMIIATlOM NIOtRQ!!DIII�TlD T0:
l+Mm� C�ydms Tii�phOns P�t
FRANK H KELLY EA 71�.774. 7�3:6 �,. ��
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520 HZLLSIDE R4AD, NEW CUIYIDERLAND PA 17070
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RECAPRULATWN
1. tt�tl EpMr(8ds�duN A}. ............................................ !. ,
2. 910CIn�rM 9tlnM(SdM�dub B) ....................................... Z. .
3. Ck7��y FNW CorpmaMon.Par6rt�hlp a Soit�ProprN�nhN�t3cMduM G) ..... 3. .
4. Mottppw�nd NolN R�ahnbN(8cMduN D)........................... 4. .
8. CrpM.BnMC D�posih and IAhaiNnwus P�nanri Pmp�Ay iBehWUM E)....... 3. .
e. JdrdM Owmd Prap�nY(8diwuM F7 O s�p�t BMNn�t wOw�Md .....,. e. 5 r $6 Q.5 0
T. IMNrr-Vlras Ttt�tns 6 M�Mon-Arobrb PtopMty
t8CM0ub t� O S�1p�nM 81Wq R�4u�p�6........ T. .
8. To1M Ora«M��a poaN un�t t��aqn r�............................. 8. 5, $60.50
9. Fun«.i�xpmw ara�am�nrtr.nw Co.a isdraur M..... .............. 9. 6� 9 4 6.0 0
�o. o.as or o«»d.m,�w u.a�nws..na u•m►tsa,.du�.i�.............. ia. 1,155.Q d
71. ToW wduGdon�iww t.Nw 9 ane 10)................................. 11. 8, 101.00
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TAX CIILCULAiWF!-!EE NNTIKICTWIi/fOR APf1.ICAM.t RAT6i
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17. Amaud ad L�N 14�M �
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1B. MnouM M UrwM 14 t�xab4r
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19. TAX OUE........... ............................................ .. 1Y. 0.OO
24. FIIl N!TME OVAL�YOU Ail�ttEqUlSTINO A REF!}ND OR AN OYl11tAYMENT (�
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New Cumberlaad PA 1'1070
Tax Paym�nta aed Crfdits:
2. T�tt�lirN19} 1�) 0.00
a ihia P.ymrrite
8.Oheat�rt
ToWCndlbt�l+8) (2) 0.00
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S. N I.kw t«LkN 3 b p�Mlr Van I.Y»2 m0�rths dNMwbs.Thh It 1M TAX OUE. (5J 0.40
h�ake d�eck #o: REGISTER�WI�l.S,AC�NT.
PLEABE ANSYYER THE fOLLQIMNt#QUE8TIONS 8Y PI.ACUKi AN"X"IN THE APPROPRGITE BLOGKli
1. Oidd�atWRrtWr�atrM�IMarid: .................................................. Ws No
a. �IYn tlM uw a Ywpn�d tl»pra�wAy h�Nm4........................................ � �]
b. nw,e.�qraawa,.rwi,oa�w�..m.p�a.rrw�na«�ir,00�»;.............................�....._. C7 �
....
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d. nalw tlM ponir f4r M�d NMMr��1NrMIY ar qn9...................................................................... � '�,�
2. M dMtli aapMnd dMr D�C.12.19lZ,did d�adMk 4�mkr pq�ly wNhin om yMr d d�Mh
tvitlmrRnoWigad�qu�Moo�dratlon2........................._.........._._...,.........._......».................._.......»............... � (�
s. rHd e�aA�nt own m'In twt�er or�bn�c�aura n Na�xy rt nY a tir derdtt.............. O (;d
1. Uld d�adMk awn m Nw11NaW iatlnnNnt�omuk,am�ily a Wher nafpmlwY piopMlX wl�Ch
co�in�Wa�AdrY�? ..........._..._....„......................._................._.._..................................._........... ❑ �
���t ro�nr a�n+e,�o�ou�sria�a�nEa,rou w�co�rr�re�o�no�rr�a a�r o�r�a�rww.
Far d�Mt d d�Mh an or ailer,i�iy 1.196�F��d baibrs,lqn. 1, 1996�the tex t�t h�paad on C�e net v�e�tetuhr�b a fa ths uee af tlfs u�D apo�ue
b 3 prank[/2 P.3.§Y116(e)(1,1}m].
Far MMi d dwlh an or aher Jn. 1� 1896. the fec �alt Yiper�ed ort tM mM vMur M h�neNn b or (ar tA� +w of tlK wtWvfrp epouw !t 0 Derowrt
(72 P.S.§@118(a}{t.t)�.TM�lalde dait rat exempt a�6a a�D apcims fiom�,mid�e etekAOiy�rernerds ta�edoe�a of a��d
fAinp a tnt rokm ero tM�DDM�I�N ewn it flMb a�+rviyiW epoiae ie tlte ordY�Y•
Fa dNee d dedh on a ollx JWy 1,2000:
• TM fpt teM impcNd m fN nrt+wiuet ot 6ytfden frcm e d�C�rp�d drNd 21 yemt�8�e d'y0wget�de�t 60 ot 6p`rir tae �`a n�ril pxet�, ot
adoptlw Wr+nt a'e sappwnt otthr d�Id is 0 p�roxrt(72 P.3.�N9(aXt.2}j.
• Tlw►t�nc�Ynpurnd on IM nat valus othrie(eia b a tor Ihe we of Mie deondent'a iad bendld�rler k 4.5 perqent,ezcept ae�aYd in(M P.S.�118(eN�)1�
• Tfa ta�c�Mnpo�d on iM�rakas at ir�ntsrt M or for ths we�tl»d�ceden!'�aibWg�h 12 pera��nt�72 P.S.�t118(a}(1.3)a.A Ie�ed,
� �mder Sedion St�,ae u�Y+�i�wta tree at leat pre permt in tamntpn vv�tlie deoedeM,wiwriM►bY oiooe a adoPlW+w.
IIEV•1602IX+f01•1�
�ptr+nsylvani� SCH�DULE A
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,„„�,,,�,�.,�,�, r�►� EsT�r�
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Dolly E. Perry
All nN Ns/wtr ewiM rM�h a w�qro�t M�awR M n�W�t hk MM1at vYw.Nk mulut wlw k dMnad a tM prla rt whkh q�aprry
x�d lae pxCha�d btltwMn�xMMnp Ouya md�wN�p aN�y�Mr b�Mp mm�d W buy a�N,both naon�i�lapwi�dyt�G�e rdwa�K hd�.
pN�tlrt M}N�tlr-�weN wNr ei�Mt d wnhaN�e�rt M iMr7�sa fd�k f.
AtqcA�copy M tM s�ttlemeM sheek If tM prop�rq he�been mld.
l�ABER lnch�Nt a aPY d tla dMd�owMp dw.rdNrt's IMarort M meneQ n anmt 1�cammon, v���T�
DFSCRtPttp#
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TOLLL(Also eMar on une 1,aecaplwlatlon.) �
tf mant spau�needed.�sert sddkiaW dMdks d U�e s�e�.
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�PM�� SCHEDt1lE B
INII�lITANCE TAX RETURN STOCKS d� BOND3
RE�tIT DECEpENT
ElTAT!OF PN.E
Dally E. Perry
A1 pOpN#Ipll�aw�Nd w�41e�At Of M4vNw�ily!M�t M d10M7�N aa SdMdl�F.
� VAIUEATMTE
rawe�t � oFO�t�
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I
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M ma�rp�a Y n��dd.YwM1�ddwaW MwkdlMf�Nct
R�""°'E"`"M°°' SCHEDULE C
CLQ$E�Y-HEI.D CORPK3RAT�N,
ca��owwe,LLni uF r�rx+e�n.ww� PARTNERSHIP OR
'��,�"" SOLE-PROPRlETOR8HlP
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nollv E. Parrv
9d�ultGt aG2{YiduinQMUppaWpiAwawkn}map6tMYdrtlfar�aAdo�h�tlao�poi�i�tdtlrdwdM�,otl�ew�•
�.3�i Yr6twiiont talu wppaAtnp idontMMwr to tN w6mH�d#or�r.
� VALUEATp�TE
M�t oEacnwrwH aFO�n+
t Nona
I
T07AL(Ab�an M 3,R�dipll�Yan) i
(Mma�p�a M n�b.YrM Wdlbn�YMwN dtlrtr�rkn!
._._... .� ■
REV-iSOS Dt+(11-11)
SCHEDULE C-1
��� CtO�EtY-H�'tD iX}RPORAT!
�����»� STOCK INFORMATION REPORT
ae�ert oeceoerr
ES'TATE� �.E MI�R
Dolly E. Perry
t. N�ot Cprpontlon Nane �a�pqpq�
�� Uab d Irw:qrpaNk�n
CHY ShN_,,, ZIP Cods 'IbW Nun1�r ol3hwholdM�
2. F�dKN Errpby�r ID F�rt�bM 8u�a tt�portkq Yirr
3. Typ�of 8� ProducNS�nia
4.
�» s
�+ :
PraYkM tl rfpMs and ra�tidbnE p�rWnYfQ b a�di t�ra ot pock.
5. ihYS th�d�ad�M�npby�d bY itr eapar�tlon? . ... ... ..... . . ...... . . ... .. .. .... . D'hs ❑Na
H Yw, Paidon Mrwd Srlrwy S 'lirtr D�wiMd b BwlrMw
8. YMn itk caparaticn Md�d to tM tNo�d�rt? ... ....... ......................... CI ls�s ❑Nc
H Y«, pmvW�amouM d IrwlMibMdr�i
7. 4Na tlrnu Xfi Guunwro�p�yWM b tt+�oorpor�Yar�On ihs daitlr of Uwi dra�d�t7 ..,.. C�Y�s p Mo
if y�s,Cu�h Surnndlk 1lN�n� Pl�t proc��dt Payabis=
Owrrr d tlr�poYcy
8. Otd tl�s d�o�d�nt aM or hurt�'�in tlds car�xry vr�ar�yar prbr ta dMih or rrN�n Mro yws
M th�d�M ot d�atli wu prior b 12-31-82?
O r« t7 No n y«, O rrama.r o siwr Nuwrw.r a snu..
Trarnt�ra�ar Pwchwr Caaid�ratbn S ck�M
Alfaeh a s�rw sMK tar addlNo�d trand�rs and/or wMa.
8. NM th�n r wrMhn�wnhotlw'�p�rn�rk in�R�ct�t tlr wn�al tl»dsadwrCs dwlh9 .... O Yss O No
if 1NS.Provkk s coPY W!M pr�nt
t0.wtis tA�d�nr�podc w�d'► ..................................................... O Yw O No
B yN�pwkN�oopy d tlw apwnrM d twN.el�
11.Ni��eapor�n rl�h+ed W Yqedd�d rdMr ihs drad�nts d�h? .................... �Yei C]Nc
Myaa,Pravkir e bnYWa�rn ddMhfiudars waMd by tlMr a�hb,Mdu�Mrq dMM r�d�a�b�cNwd.
11�.Gid IM caporNion h�w�n iMwNt in otM►eorPoraNwM or WrUw�hip�? .. ........... p Yp p Nc
rr S'+�.+�P�ths n�as�ay M�etnatla�an a apuat��M�t, •SchW W�Gt ar G2 for�clr�t.
1L D�d�tmd h CN vak+Mion of 1fMt d�a�d�t�`s ai0dt
B. Qanpbw r�upiN d fY�xidd�hMNrwnY a A�tf�ni oapaM�k�canw t�c�4mM(Fam 1120)for IM ywr d d�Mh+Mnd iae pr�adlrp Ywra
C. MtlrcapaaMmawrod+wleWM,a�tmkaNNSMOwirglh�mrpMMadd�sphrt�nd�dfairrtrrlqtvYUW.Ifn�1�Y��pptN�Mrt
� b�n a�ar�d�a�h q,�a.
D. I.Nt of qWfcy,W a�oddpkl���t Cwr dtl�W dwrM,nuiWwr ot shre�MW and Mrk rNMbmfiyf�to tla d�ad�rk.
E. I.ht W oMowa.�wir s�bormas�d�xr�r otlnr h�rMlNs nodwd 6om tl�s ootparalion.
F. St�rnarlt d diridMwlu W�aarh ysK.t»t Uw71r d�drred wW ur�ki.
a. My ollw iniorrrrtlon taletYq eo tl�s vaMUtlan of tM d�asd�rH's dOGc
{Ilmote qror Y nwd�d.Nwrt addXiaml�dYw�t sisr.}
-- I I�1 I I�I
REV-1506 IX+(12-13) ,
�pM��� SCHEDULE C-2
o.�r.�.a��+w PARTNERSNIP
�*��+�+�+ INFORMATION RlPORT
wesme�r oec�netr
E3'fl►TE Of F�.E tNAliElt
Dolly E. Perrv
t. N�ms pt Parfianh�None p���
Addreq �q�p yy�
�K11 +3LM LP CotM
2 Feditt4 Empbyu ID Mumi�r
3. 'lyp�of 8utirwp Product/3avios
4. D�oedart tws a O tt3�wi O tknpad p� N d�o�nt wn a NmiMd P�:p��d��itlM kivs�tnnrt i{
5,
�
8.
C.
D.
9. Vih»ot ths d�nd�eM's lrrhrsat i
7. Wu tlw prrhMnhip Ind�bE�d ED tM d�a�d�oC! . .. . .. . . . .. . . . .. . . . .. . . . .. . . . .. .... O Yrs O No
If yN,proYldt atnCUtrt of indWbdnw f
9. Haa nNn IM.�murw,a p�ya�l.to n,.p.raisrsl,ip upon n,.d�«,Ma�a m.a�aea.rK�...... O ve� O No
It Ys�.CMh Sur�ndiM VNU�f !hl P�WY�:
Oxrtwr ot tlMF poRcy
9. Did tlr dwu�d�nt w�M a tr�mwr�n InMrat in tl+a p�rbrnhip wiThM on�yw p�ior ro dplh a wNhin lwo y�H tlw drl�ot duM�wa
pAorto 12-31�YJ
(�Yes O Nb if}vm►. Q Tr�ahr �SW Psrare�p�handrrodhok!
Tromfsnr or Purdrrawr Con�rtllon i D�b
Atheh a�epxaEa th�ut for addMknal tramlWs mdlor qlu.
10.tMls#tuf a tMriN�n pnftr�ah(p aprMtrwN kt sAsd a#Mw tkrr ottha tMa�danYi dMlh? ...... Q YN Q NO
�r y..,aorw..aopy a n,..p�..m�t.
11. V1N�Ut�droWrN's p�rYrriip N�t wW7 ......................................... p Yet O i�
N yas,povkM a aopy W tlr ap+r�rrerrt atsWr��c.
12.Wlr Ih�prVNrN�ip dM�oNW or IltwildM�d NIK th�d�aW�nt's WMtl�7 .................... O Ya O No
n y...ww�a+.a.rcaown a a�uuon.rsoetiae cy a�.ea�.,�,arp aa.s ara man,�s�eahr.d.
,atiwn»aw.a■Kn�aram�yaa,.�u»�.7 ...................................... �re• aHo
Ir yu,sxpl�Mn
u.Did tix p�trwat�p tnva�hMr�t�oth�r ao�paatlorn w p�rh�a?............... O YeK O Na
tf yu�nport ms�r p�brnr�uo�on�ap�iq+Nk�dudlrq a SedwlduY Gi ar C-Z tor�ach inlen�tt.
i A flMYMd�I�pn uNd in�wN�dMfs d�dwtt't P�R i�.
� B. OarqyY anpi�s of 11nlridd�a fstleral{wtrw�Mp incarre f�c isWnr(Fam 1066)br tlr1 yar d derlh and Tar'q'�adYq Yans.
C. Nllflp�fbMM�OMMIdtMINtiM�Nl6R1(tillklFlO!MIIIQ�M�ld�M�1M#fldl�11�1d�Y'RIM1tlkWhJNi.Mit�i��pf�IMkhi4!
bNt1�lqXl��itl�l O�QIK
D. My o1Mr inkmrtlon ro4Hlnp b tlra valwtlon otths dre�M�ri's prbxnNNp InW�t.
RLhk1 e07 EXt(ILYq
SCH�DU�,E D
cowaww�urH oa���a MORTGAt3ES 8 N8Tf3
��� RECENABLE
��af �m�
Do11Y E. Perry
Alt MaOMq�Jo�l�rowlM Mtl�Ayk of Nm�Fm�dAp�t M�IaiO�M aa 3aMiMM i.
�M VAWE�TGITE
�t o��ara� oFO�ni
1. None
! TOTAL fAlro enM�'on b�,R�qp�itlon) 1
(Hmon Wra Y n«e�0.YwA rddMoiW dwY dtlr wn�tip)
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11l3/41L7R 0lC20tlR
El�I'AT!�s �
Pally E. Herry
tnduM tM praaead�ot Iltlqido�end CM Mh the proce�d�wara recNved by tlw e�tea.
1i�Pte�rl�r�aNq�r oterd wMA rlokt of fueMlranhip�urt W�rJe�tl oa�E.
� YALUE AT pA'TE
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if rtpi!�eae k tkldld,troe ad�tlOnOt aMlb of peplt W HM Sitlta s@!.
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�pe�tnsylvaMa SCHEDUl.E F
�`"�"�""`"°`""`�"" JOINTLY-0WNED PROPERTY
���
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�n►�of ��
DollY E. Perri
M�n�M�trwaw�JoMtwi�aaM+�rotilMd�ad�nCs AMtatd�Ml�,k1�tM npaW aa�eh�diMG
SURVMNfi�pMfl'TEtlFM(8)WAE A001�88 RELA71pN8liWT00ECE0EN1
ti Timothy W Perry 5418 Ridgewood Aeights Son
Wilimington, NC 28403-4817
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JONf1LY�PROP6t1Y:
senat wn oacis+w�aniaan xa ahaaunr
�+e� roR.iorrt r�a �nrrearrwHC�wsnunaxaiow�uccou+r�ea�arae aaeaFa� accmeira wun
M�riee iewutr .uNr cm+nFVw+o�rn�.,vaa+omaa.arm.r+aarsnsnae wia�aFxEr nrea� aa�emt�
1. ti 04.15.1971 Benk Account - Wella Fargo
M10861971585?4 $$6 50 433.Q0
2. B. 06.3i�.2010 Ba:sk Acoount - Welis Farqo
N3000201968799 10,855 50 5,427.50
TOTAt(AMoenMM'onlneB,ReqpN�l�tlon) { 5,860.50
(Hmon p�a M rrtlM,Mwt�dEIIbnMMiw4 dlMwn�Ys)
�
�
L
.._ .. .. . 1� An
RE4�1610EX+(ObOY) ����O��C ^
�� iFITER-VNOS TRANSFERS d►
��Y�w
��� NMSC, NON-PROBATE PROPER"FY
��
Ea�,te af r�.��u�t
Dally E. Perry
T1dt�drdiMmwtEtaonqYMdmd�d Ntiitwwrb+rtldquMtloir i MMOtqf�lanf�rnwin tldidtlM 1�Ktl40Dl�V&t�Bf Y yM.
O�HACItlrPTI01110F PROP@iTV
I'IB�I wcuo�nawveananuwreis,n+a�w��m�Nwmoec�rrw DATEOFDEATN %OFOECp'9 IXq.US10N TA%ABLE
MJMdER nNwnan�wr�.erna�cawanEOmow��esant NILUEOFASSET q�rtEREBT �r�wucu�,q VM4uE
1. Norie
i
roru.W�o«�wanrui,a�r�� s
�e ma.w•�•r�r�aa,wwn.aduaw wwa a uu,.n.�c.)
REV-7611 Df�(70-0Y)
SCHEDULE H
��� FUNERAL EXPENSE8 8
��*�� ADMINI8TRATNE COSTS
��
�aa�a� �Muie�t
Dolly E. Perry
D1lY dd�C�dMk n1u1t W Ipeflld onlCMdli�L
1i91
��R �� AMOUNT
A FUNENALEXPENBES:
�' Parthanora Funeral Home, New Cumberland, PA 2,596
B. ADMINIBiRATNE COSTB:
f. P�narllYpw�nYtlntiCammYMon
wn.dwnawa�wMU1
sewa4d�
�r srr zw
'/wldCmimlrbnPNa
2. ANpnyFw
3. f�rEs�nq�Orc(Md�wdm(ytldw�knaltlrwn�rdYm�M'ti�WMs�Y�Wlan) 3.500
CYYntl Donna Henkel
9bMtAdbw 510 Hilladie Road
CqrNew Cumberland �PA Z�17070
RMMbiNipdCWmntbO�adM1 Daughtei
4. Rab�Y Fw
S. AaoomYnl'�Fw
8. T�xRMmRprKYFw 850
7.
TOTAL(ANoenlxanlne9,Reapl4iMlbn) = 6,946.00
(Hmowipa 4 nod�d,NwilaAdMaW M�Y dtlr u�qn)
i w �.�
t�/-0612 EX�(1�0l) .
SCHEDU4E I
���� cwEats oE oe��,
��*��,� Mo�rcu►ae �.r�►ei�es a ��a
��
�xn� ��
Dollv E. Perrv
�w.e a.re�rwwrw w a.r.c.eMe�ner a a.Na e�e�.�n.rwa r�.a.e au e.a a awa,r�aah w�►.w.wr..e�n.aer..�.nw.
rr�n vu�,rr a�n�
r� o�cu�toH oF o�nr
1. Weet Share EMS, Camp Hill, PA 1,155
TOTAL(Also enter an Une 10,Recapftulatlon) { 1,155.00
�rtwre spaoe b n�ed.�aat st�ab�tht sime�Za.
'- I I I
NEV•ib13 EXa(01•iC1
�pen�l�r SCHEDULE J
tw�,��„� s����cv►�es
��
�r,�n c�: �s��
Doll E. Per
0.EUTl�NIP iq D��ENT AMWNR OR SHARE
NUMBBt NAI1E AND AOORBS Of PtRSON{5}NEC0VtM6 PNOP�ERTY fk Net tit TewM�(f} OF�TATE
t TAXAltf DL��TRifUROMS(Fndud�a�rfpM�ausM t��utlana and tramMa urtdr
S�t.9116(�)(1.2).]
1. Linda L. Henkel Dnnqhter .25
New Cumbc�rland PA 17070
2 William Thomas Perry 9on .25
3 Timothy Wayne Perry Son .25
4 Cizeqory Lane perry San .25
ENfER DOt1AR ANOINfiS FOR DLSTRNUTSOpS SfWWN AiQYE ON i74YES 15 T11ACU6Ff i$OR REY-SSC4 COY9!SHEET,AS APPR�PWiATE.
� NC11-'TAXAN!(�SiRAUROlIS �
l4 5Pd1S11L DISIRIlUr10NS UIb9l SECTION 9113 FON WHICH AN EIEC�ION TO TAX IS NOT TAKEN:
1.
B. QIARITAlLE AND GOVENNMENTAL DI5TR1BlITlONS:
i.
TqTAL OF!'ART II-ENTER TOTAL NON•TAXA9LE DISTRIBUTIONS ON UNE 13 Of REV-I500 COVBI SHffT, #
lt mms ap�e is t�aded,� �Aasis at paper d'tfit sune sixe.
111
�N4�Y�767�IX�(4Aij scN�o►uu K
, ���a tIFE ESTATE.ANNUITY
Po°t"""�„�r""' 3 TEtiM CERtAIN
wnuewq P�a�,�6or (cNCCK e07I 4 ON REw�ao COVEII sNq1')
El17{7E Of fIGE
Do11y E. Perry
This stlktlula should he used for aIN slnpk-INl�1dM M Sutcesdva IMe eateh And brm-cert�k�dalltlatn.for datas ot daedf prior to 5-1-89,
a�fat tettots for sk�e-Bfe a�tloro tet be obtained ltam tlte De�rtrnent oF Rt�ua.
Attuarlei/attars cuf be fotmd in FRS PubRmtlon 1457�Adwti#i Vakrur Aipt�1hWrM fa dates Gt cieath from 5-2-89 ta 4-30-99,
and In ANph Volume/or de0�s of deeth Mom 5-1-94 end tfiereeRer.
Indcalrl bdar the typa af inmtrument thet aestad tiv�NWre Interat and attad�a aopy W R to the taz reWm.
0 YM� � Inbnhtai dNd ot Tnat ❑ Otl�r
xone ��a �T��Y"�^+
O LMe or p Tam��Yeers
❑ure o� o�rn+a re.�,
�LXe or 0 Term�Y�s
O ute or ❑Te�m M Yaus
i. Y�#f�d from whkh���peyaMiA .. ......... . . . .. ............ ....... ......#
2. AttwAei fector par appropriat�tidls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . .
IrKa�t taWe rete-(�3.5% [I 696 ❑10% p YerleOk ItMe 'K
�. XNw ot qMi ul�6R(i,�i�N�d by G�r 2} ... ......... ... .. ...................#
p LNa or Q l�rm of Yers
p i.ife w O 7erm at Years
❑tNa or O Tirm M Ya�s
p iXe a O Term at Yea�s
1. Yalue at 1ut�d ham whkfi annWty Ns PaYabk ..... ......... ... ......... ... ....... .. .. ...#
2. Chadc appropriate bbcic beiaw and enter corrmpondiny number . . . . . . . . . . . . . . . . .
�+�a��wr�—❑ w..icy(s�) ❑ eEw..�b(za) ❑ �mb(tz)
0 ou�FM{�} ❑ s«n�u�uY tx) ❑ nn�ua�7{t? ❑�r( }
3. AmouM of p�yout pMr p�riod .. .. ...... . .. . . . .. . .. ... . . . ... . . . ... .. ... . .. . . . ... . . . . ..�
1. Aqyp�hr�nnwl pwym�n►, Limr 2 multlpNwd by LNN 8 . . .. .. . ... . . . ... . . .. . ... . . . .. . . . . . .
5. Ar+nu�t P�r taw�buctloru)
InM�ui twbN na—C13.8% ❑896 ❑1096 ❑W�M Ra1� %
8. Adlwhnrnt Fada(8�In�fnrctlaiu.j . . . . .. . . . ... . . ... . . . ... .. . . .... . ....... . . ...... ..
( 7. YW�of smw�r—If tnkg 3.5,6,or iQ96,Or�varia6l!r�e mtt pOriod
' {1!}/OU�IS iI dld��190dr CiIQ1IdCI0fl it LIM 4 Y UM�7[UM d . . . . .. .. . . . .. . ... . . . .. ... . ��
If usiny vaNabk raN arni perind payout Is at beylnning of period, cakculadon is
(t�fxtM�Sxi�wb}+tkMt3 . . . . .. ............ ... ..................... .. ...5
Nd7E: The values d fhe funds Mat cresbe the above future inUere�mu#be repated a�part aP the e�tade af�ats on Schedule5 A throuph G af the
tax roWm.The reaultlrg Me ar m�nuity IMerest ehwid 4e rapated at the approprtitr Wc rate an LJ�ea 13 and 15 tivwyh 18 d tha rtum.
Ff mpre spece�nmmded,�se a�onM diaets d tlte 9ane atze.
a��aw o�.�o��io1
INMlR1TANCL�TAX
���� SCN�DULE �
�T"�'"�"�" RlMAINDlR PRlPAYMlNT
�D�"r OR INYASIOM Of TRUST CORPU�
i. esr�►re o� ri�e NuM�eR
Doll 8. Per
Thb seh�duls i�appropHtb aniy for aitala W d�adants dytnq on ar b�for�Die. 12, i9t2.
Thfs schedule Is to be used for all romaindar retums when an elactlon to propay has been filed under the provlslons of
S�tlae 7i4 ot tM Inharkane��nd l�Ortf Tax/�r.t ot 19M3 or W report the fnvasbn of trust corpus {principai).
II. RlMA=NOlR PRIlPAYMlN'1':
A. Electlon to Prepay Flled with khe Register oP Wllls on None
{patej
B. Name(s) of Life Tenant(s) Date of Birth Aqe on Date Tertn of Yeers Income
or An�ultant(s� of Electlan or Annulty Is Payable
C. Ass�s: Com�Schnduia L-i
1. Re81 Esteta . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Stqcks and 8onds . . . . . . . . . . . . . . . . . . . . . .$
3. Ciosely Heid StodyPertnership . . . . . . . . . . . . .#
4. Mortyages and Noees . . . . . . . . . . . . . . . . . . . .;
5. CashlMisc. Pc�sonal Property . . . . . . . . . . . . . .#
6. TokalfromSchMubL•1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .#
D. Crctfiks: Canaate Sd�nduie l-2
1. Unpsid Liabilftles . . . . . . . . . . . . . . . . . . . . . . .$
2. Unpald Bequaats . . . . . . . . . . . . . . . . . . . . . . .#
3. Value at Non tndudaWe Assets . . . . . . . . . . . . .;
4. ToWI from Schedule L-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
E. Total Value of Trust Auets(Line C-6 minus Une D-4) . . . . . . . . . . . . . . . . . . . . . . . . . . .j
RRemeinderFactar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
G. Taxabk Rtmain�Vaiva (Multlpiy t3� E by Une F} . . . . . . . . . . . . . . . . . . . . . . . . . . . .#
(Also enter on Line 7, Recapitulatlon)
III. tNYA320N�CARr173:
p. Invasion of Corpus
(Month, Day, Yearj
B. orMnuitatrt{f���} Date of Bitth C�a�,f � �m`�,iti i Pay°bi+e
Consumed
i
C. CorpusConsumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .#
D. RdnainderFacta� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
H. Taxable Value af Corpus Conwmed (Muftiply Une C by Line D) . . . . . . . . . . . . . . . . . . . .x ,
(Also enter on Line 7, Re�capltWadon)
REV-1M6IX�(It-0Y)
INNlRITAMlC!TAX
�,��a SCHEDULE L-1
°�""�T��"" RlMAINDER PRlPAIfMlNT ELECTION
�roECeoeHr
-A9flTl.
I. lSTAT! O� RL! NUM�lR
Doll 8. Per
II. MM NO. DlSCIlIIRON VAW�
A. Real Ertate (Please descrlba.)
None
Totsl Value of RaN Estate ;
(Indude on S�tlon II, Una G3 on SchaduN LJ
B. Stoda and Bonds (Wease Iist.)
7aa1 Velw ot Stocks arb Bonds ;
(Induds on Sadlon II, Lina G2 on Scheduk LJ
C. GosNy Neld SbxWPartnershiP- Pleaae Iist. (Attad� Scheduk C-1 and/or G2.)
Total Value ot QotNy Held/PartneBhlp ;
(Indud�on Sectlon II, Line C-3 on Scheduk L.)
0. Mortpaqa a�d Notea (Wease Il�t.)
T�al Value of Morb�ya and Notes ;
(Induda on Secdon Ii, Line C-4 on Sdhdul� L.)
E. Cash and Miscellaneous Perwnal Property (Please Ilat.)
Total Value of C�h/Miscallaneous Penonal Property #
(Indude on Sectbn lI, lJne C-5 on Sd�aduk L.)
III. TOTAL (Alw enter on Sectlon II, Une C-6 on Schedule L) ;
I/morc spaa is needed, stfach addftional sheets oi paper of tFk same slze.
�
REV-1!b E%t(11-0i)
INME1l1'fANC!TAX
����� $Ct1EDULE 1.-2
�M� RLMAlNDEQ PRlPAYMlNT ELlCRON
-CR�DITi-
2. l:TAT! O� FIL! NUM�lR
Doil F. Per
22. ITlM tlO. titlCRIPiT�! AMOUNt
A. Unpaid Liabllldas Galmed ayalnst OAglnal C�state and Payabk from Asaek�
Rmportad on Sd�eduk l-1 {p#�s Iist?
xone
Total Unpeld UaMlltla $
pndudt on S�tfat II, Ut�t D-i at Sthedult�)
8. Unpsid Bequasts Payabie irom Asseb Reported on 5chaduie t-1 {piease ilat)
Tocai UnpaW 8epuaats �
(tnduda on Secdon II, IJna D-2 on Scheduk L)
c. Ysiue d Asants R�orked a�Schedu�L-i {ott�tlun unpald beq�ts li�!
undar"8'above}that aro Not induded tor Te�c Purposes or ttfat Do N�Fortn
a pert of the 71vst
Calculatlon as Mlbws:
I
T� Non IrxiudAbk Asssb S
(indude on Sec�n II, Lint D-3 on Sttieduk �}
III, TOTAL(Alao aiUSr on Section A, UMS D-4 on Scheduk L) ;
if mW'!3paa t8 needed� OttACtt additi0flai��papa'��StIt11!Sizt.
w
0.!V•Sd/7 llt+(pb10)
sc►r�ou« M
���� ������
�����
RESI04NT DECEDlNT (CI1�Ck��OII�Y'�a00)
lSTATE Qf FIIE MUMRIt
Dolly E. Perry
TM��N Is�proprlab�+only for�s of d�ad�nb who�d�f0�r MC. 12. SYt�.
Tt�c scheduie k to he u�d f�a�i f�e iMera�s wMra the�t ot ta�c tluK v�i be app�kabie when the fuWro intercst+�s�t
poe�esaWn aW an,�pymant annot ba ea�ebibhM witl�artaiMy,
Indkate babw tM type of ImtrumeM thet created the Nture Interest And attxh a cqpy to the tex retum.
WIB 7nut OtlNr
2. Mn�tidni�
NAME OF BENEFIQAttY RELATIONSHIP DATE Of BIRTH AGE 70
NEAREST BIRTHDAY
1.Nane
�
�.
4.
S.
II. For deoMaMS who dhd on or aR�r]uly i, 1994, N e wrvlvinp spowe a�ordead or IntaMs to eacardae�Mghc d widMrawal wldrin
Nne montlu of Me dac�nYx�h,check dx�bm�b�ow�fd attach a cap�!�tl�e dow��whldr Nro wrvhrinyl tpause
e�rcHes wd�wkNdraw�ri�k.
UnNmibd M wkhdrawal LImNr�d ri M M wklMrwwal
III. 6�tlon ot C�ompromNf oRrs
IY. lmnmeY ot CompromhMr Ofhr:
i. Amount of futurc Inhra�t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . S
2. Yak�e of t1tM 1 ax�t from Wx as amcuM pa�inp W tharltlas,dc.
(Aita indude�DaK ot t�shown an ilrro 13 of REV-fSO�.j .. .. .... �
3. V�ua of Llne 1 passinp W spouse ak approprlade tax raGe
Chack ene. O 6'14, � 3%, 0 Q9(e .. .... . . .. .. .. . .. .. .#
� (A�a induda a�t+��'�ai shovnt qn tlne iS ct REV 15�.)
4. Vslue of Llne 1 taxable e�Ilneal rede
Check ona. O 6%, 0 4.5% . . .. . .. . . . . . . . . .. .. . .. .. .. ;
(AMio Uxiude u P�ot Wt�i sNornt af tk+e 16 af REY-2500.)
s. vslue a une a taxsele�ala�ng rete(12%>
(Alto Indude eB Wrt ot 6ctsl shown on Line i7 Of REV-15W.) . . , , . . . . ;
6. Ma�a une i w�e�R �r�tis%)
(Aka induek a�P�ot OoRai ahown on E,kis 18 of REV-i5t}0,} .. .. . .. . ;
7. TatM wlue of futurc Intereat(wm ot Lines 2 thru 6 must eqwl Une iJ . . . . . . . . . . . . . . . . . . . . . . . S
U more spaca ts need�d.�ae addrilonal�haeb M p�par�du�e aiu.
��"y`�'�`�A" SCHEDULE N
jiT��� SPQUSA� ROYERT'Y CREDIT
ro e�� ro�a►�n or oeuni nioi�ri m s�n��
e�nrAS�or fn.e Nur�eit
Doll E. Per
7hb W�Ye mwt bs omn�ilked and nNd M you chedud tlN xpo�aal povrty vadR bwc on tlr caw aheet.
1 . T1z■.a.masmwnomue.e(crov.r�h.u) ...... .. . .... .. . . ........ . ....... . . ........ ... i .
2. [nwrrai,n w«wd.on al�a a.aane ................................................... 2.
3. PetliamenkbenMb .. . . .. . ........ ... ...... .. . ... ... . .. . ... ... ...... . ..... .......... 3.
4. JdntauetswkhspouH .............................................................. �.
5. PAtotOeiy winnirqs .................. ............................................... S.
6�.Otlwr randut�bla�ped:Lbt aW illach xheduN M n�nwrv .. 6�.
6b.
6G
6E.
6. SUBIOfAL(LMa 6��4,G d) ..... ......... . ....... ........ ........... . ......... .. . .... 6.
?. �tal qmn a�iels{Aa!t�tns i C�U 8} ................................................... 7.
8� Tod aQµM M�biNWt ... ... ... ...... . ...... ............. . ..... . .. ..... ........... .... 8.
9. NK wNM d Wab{S�btr�ct Lin�t hwn Lkw 7) ............................................ .
9't+h!4/i lN�q •�'f0�.Thtl11101 Y ttlt 9t t�ilt tlN osl�1f+qG m11�91N b ANt$
h�mnfr. 1. TAX�ff 2. TAXt'G�i! 3. TAXt'!�if
a. SPowa .... ... ...... 1�. 2M. 3a.
b. 6��dxN ........... fb. 2b. �.
t. IoIM .. ......... . .. lc. 2c, 3d
d. T1ort�t It��ane .... id. b!. 3d.
a Otl�r incanM not
Ilrted above .... ..... le. 2a. 3e.
f. TaW .............. it 2f. Y
4. AV��i,jQkR�1f�IpfitM�if1001M OIOYIitlm
�i. Add�OkK lMMlfpl1011 NIC011M R'0111 11�14Yl:
t�f} �F(2f} t(.'� �
(t3�
Ib.AvxpekiMk�l�cane ........................................................ •
6f�ta� ,7tM !r . M tltetewilGB' za+rOtwrmlYrtt,¢
( 1. Itqat amOUnt af ta�wWa ViMas 6D apame or�100,C00:wifkheuer Is I�p ........................ t,
� 2. MuItlWY by uadk Pac�G9e(ses irr4rucdois) .. . .. .................. ................... ... 2.
3. Th4 b tlM mlount d tlx RMMkrt Spo�ud iMerkY CreOk.Inchda tlik MJ11n
u,n,a Wodenon a cou�asats on une�a a sne mrir ahaee. ................................. 3.
4. Wr�arqaddat+b,ader Uk ratlo ai`tha dacadaik'a 4ros estsb in PA Oo tM vaWa dlfiC 4.
derodent9 grais a#�Oe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
S. Multlp4y W�a 3 by Une 4 and aKar tlfe tahi hera.7Ab k tlM�mount af tlk NonrasWerK Spous�l
iavaty Gadit.I+ttkNe if�k i�we�tht Wa�tian d�aa�orr l�fe 18 d the arap'aAeet. .,........ 5.
1 ! I 1
REW/d1Y EXa(d'p!1
8CHEDULE O
��TM��� ELECTION UNDER SEC. 5113�Af
���� (8POUSAL D{STRIBUTION8)
�►tE af �«uwee�
Dollv E. Barry
Doaatea�pMlsiNt�drdWsun�ih�MYMp�lM�bloca�MM�M�M1�}oftlrifM�na�6iY IIU�Ap.
�ihe M�tlbn�M ma�lrn an�tut a�niMr m�pMwA,�aprih tam an�t bNMd br�,fi that.
ThN MWkn MlpMtb tlN TnM�mM61,mtlWll4 B,Btprr�UiYME CnhM,ilc.).
M�huMa�ImMrrmqrn�MnwMlMnquYwn�w d8�r�qn9113N)�rMt
i TMtrukaNn�iYr�Im�ntkNNldm9dNdiiO,ar�!
0. TMrdu�oilMWrtatlnlrrnrqrnNA4rnM�dlnwMMaNpMla#naMOnScMAiO,
M�n IMYwwroitiPnaW n�uiM�p�dAeM'kMnly IM YuM(M a�hdbnM P�aMM�Mq�►M b�IneMid�wl tntM N�aYan b hw+wrh 6wt arNM�rprqrly h�Mrd
•#YpOitiaaM�'b#itsM�M.NYrMnNt�vMSd1M6uMaWmlrprapMlyitYidmdtl�Nr�EN4arwron8dNAY�0,1rP�nonMnP�MV�1 W sanqtlr�dbNrt
mrMiktiYaLlinoMli�b a*rtMand6ffialw�YNr�tTM nun�MMOrotpd►kae�on it�rlbtlrMnDUtot�eYatatlrt�irMnrgr�rtY�dd�d r�WN�Narrtort
Se1w�MiMO.iMN�YrbrY priblMblMvMrdMr hMaMNW rmM��.
P.rck EnYr n»aMaiplftr►.a va�ur a�I�m�b,ean maen�e ma n«f�aa.,rg.rdlee.a kc�on�wMc►+p�.w nie aeadenr�wrviv+n�i�po�.
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARN�M,i: It Is iitegai ta dupllcaEe th€s eopy by photasEat ar pfiatograph.
Fee for[his cartificatc; $b.00 ��N ThSs is w certi£y that the infocmation here given
4,l�-- �'f,y,y carrectCy copied Erom an originai Certiticate of Deai
� K"LL=;� ' `�,f. du(y filcd with me as L.oca[ Registraz, The origia
,, certificate wilt be forwarded ro the State Vit.
�. Reeords qffioe (at}�nanent filing,
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Certifrcation Number �ENT OE �
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LAST WILL AND TESTAMENT
af
DOLLY ELIZABETH FINLEY PERRY
T, Dolly Perry presendy residin$ at 540b Ridgewood Heights Drive,
Wilmington, NC, 28403, being of full age and sound and disposing mind
and memory, hereby make, publish and deciare this to be my Last Will and
Testamen�
FIRST: I hereby revake any and all Wills and Codicils by me
anytime heretofare macis.
SBCOND: I direct that all of my just debts mzd fixneral exgenses be
paid aut af my Estate as sac� as practicable after my death.
TFiIRD: a I am presently not married.
, b. I am the parent af the fallowing childlchildr�n
1. Linda Lau Perry Henkel 2. Willaam Thomss Perry, III
3. Timothy Wayne Perry 4. Gregory Lana Perry
FdURTH: I hetsby give, devise aad beq�eath aIl of my Esiate, real,
personal and mixed, of every kind and nat�ue whatsoever and wherescever
situated, W my beloved chiidrea, per striges {at na less thau 21 years of age}
in the follawing manner.
1. �44,000.00 to Linda Lau Perry Henlce�, or if she should predecease
me, ta l�r estate or to her daughter, Heather Anne Henkel Ceja f�
loaxas made to me and for payoff of ine mortgage on my home.
2. 'I7�e b,alance to be divided e4uallY {t►Y 4) ffid distribtrtcd to my
be2oved children, per stripes {at no less than 21 years af age).
FIFTH: T nominate and a�rpoint Linda I.ou Periy Henkel as Executrix
of this will. In tbe svent she shall predecease me or fails to serve as such
Executrilc, then in such event, I nomnaate and appoint William Thomas
�. III. executor of!�my Last Will and Testament. F fiuther direct t3�t
no appaintee hereunder sbatl lse required to give �y bond for the faithfui
performance of his or her duties. `
SIX'TH: I give to my ExecutorlExecutrix, authority to exercise all the
pawers, duties, rights and immunities conferreci upon fiduciaries by law with
fiill �ower to sell, to mortgage and ta lease, and to invest and re-invest all or
any part of my Estaie an such terms as he/she deems best.
THIS IS PAGE ONE OF TWO IlJITIALED BY ALL CHII..DREN
PAGE TWO CC}NTAINS FULL WITNESS SIGNATtJRES
I I-III�I
F
WiTNFSS WHEItEC}F, I h�ereunta set my hand t�is��da3'
0 20� �
E ' Finley Perry) �
NN
, ��� w,y� .
(v�'�ss S'�Hae) ` a ,�oTppy`�'�F :
My c�smissit�e� � =
UBLiG
�;s�e;�;��d���irY'1�e'at�ur�t��, as��hr�,yt�,��a G��s
�ir^�i�er:ta�. __-� iu�� ��; ��� i�t�...,,,«w„�,.
�wr^��a�d;���ar�r�a�f�err��ne�o�d
+�aee��aa ' �+vi�mess+e�, t�e t��ye�last v�ritten�bov�.
/ �31(�111�j'8t /C�� C.4rv:A4e G.'"rQ G„r,qj
/f'.� �� �1 � �r�-,� �.a 1Y3"�„�--
G-c�u.y�(Li�e✓ vv � �..e.ty.,�i �',�Sidlli$8t S'4/�'l#:+�,�.rei.� l�c,l,1.,
�P,/ • '� ' '!l/(' �Cc{J'�!7
�� Lf 1 rL. ... • `
�"''�?��=�.�it�!,,�� �g aL/l7+j/1�2.«✓ izJ
��q j � W�' �r`'-...,,.J.t ZhVtZ
<�✓�w tJ?�...�uYUa,.. �E�` R�.Sidil�g 8t G It t+f,c�b,►�..�r- �
� •SfvcE�CA 9,�"7Uo
a S:�" � .
' TTiLS IS PAGE TWO OF TWQ.
PAGE ONE CONTAINS TEXT OF LAST WII,L ANU TESTAMENT.
.
, �
' � COPY AP' A RFC'ARD QF BIR"fH
P1ace of Birth Doz#K-$aamro!'C M�.
t�iid'a Atame �1�! �#saheLh 8l.tY].et
Daee:ct"Liirdi_ '�P�1 16. 1932 c� � C�olor �
L�,.cr �rumba af Number at Clu7dnan
p
3#t?tt�nrn �' �n'tr9_ � -'i'his Mat�er Naw t�viag.-
Fsthsr of Child � Mother of(�l1d
Maiden
��,... linns l�r�+ry linl.+rr Diamr �3.d�nd lbbtl.s tiss,�
�� N pg� 39 Colar W �^� �
Bird�pis�cr �s1t — Reei$tncr �i�e.7Gtta`o2'L
��yg,,,�..,,=- Barar.l�'eseralt �„__. Airds_y�la�oe"�.� +�,�..�-^=�r—�:..—
� �
Stree* No - ()ccapatio
p��h E�hiarer —
Name and addra�e� PhYaician (or othv � O. Hsw�1t. 11.�.
p�raon)reportinB,this birth
Usa when received by cown c1er1� '�+T �3. �
i hel+eby cxrtify thec ehe sbove ra:ard;e corp�ct to she be.c of my kamdedge and belief.
::_ ��)
$i�sp ir. Bjner ........__. ., _ ,��,k.,�._ �b+tis'�rs1't Maine
__
��i��■�ri ,. i���
��
I HEltESY C�Ti�Y t�at the faeg�nt�ie a tr+�:copy ot a ncord oi birth on 5k st Nrc DIvlaon af�tal
�'� � ,
p'�'TESI^m1�"�/��-» � , State ReQistrar� by�16�'� --+ �'�
8zst�e d Msiae J+r� 2. 1959
Depattntsnt o!fIealth aad WeNsu�e I3atc Iru�
vs-ca i rxno>
�s� ; . . � 1
�..::__ _...__ __.. _ _ ._ _—� _. .__
i
Po i° z e�'��i`YiD1ML"�E$ Pennsylvania lnheritance Tayc �pennsylvania
WJMIS�URC PA 17174tli01 Information Notice DEPARTMBNTOFREVENUE
Arxf Ta�tpB�yer Response �•-,�.,��G,„.,:>
FtLE NO.22
ACN 18135236
DATE 06�28-2073
Type of Account
Estate of E D PERRY �SBVir�
SSN 006•40-7660 Chedtiny
Date of Death 1 p-22-2012 Truat
TIM07HY W PERRY CouMy DAUPHIN Certificate
5418 RID6EWOOD HE26HTS
WZCMIN6TOM NC 26403-4617
wEUS ��►�co provided#he department with ihe information baiow indicating #hat at the deatlr of the
above-named decedent u were a aint owner or beneflci af the account identified.
A�e�n�nt No.3DOOmi98e79s �p+�Y�t+�rd Fcmu to:
DNs EshWiihsd 08�0�-2010 REGISTER OF WII.LS
Account Balance $14,885.OD 101 MARKET STEET.ROpAA 103
Petcent Ta��asbii� X 50 FI�RR�3BtItit3 PA t71fl1
Amount Subject to Tasr 5 442.50
T�uc Rate X r�� ;— ���. ��
Potential T�Dt� 18.38 ._��_7.:�L__ ��nts are m�within ttrree mo�ths of the
dece�rrPs da#e at+�ath,deduct s 5 peroern discaunt on the kax
WRh 5%Discount{Taac x 0.95} Q� • due. My inheritance tax due will become delinquent nine rnanths
after the date of deeth.
pA� StBp 1: Piasse check the appropHate boxas below.
y
A �1�t�wt is due. !am tha spouse af!ha daceaaed�(am tt�e peront cf a decxdent wha was
21 yeara oid or younger at daM of death.
Prerceed ro Step 2 on rev�se. Do not check any other boxes and dis�egarcl the amount
sfrown abows as Poten[ia/Tar Due.
g �"ttre iMorrnation is The above informaf�n is oarect,no deduotlons are kyeing tsken,and peyment wiA be sent
corcect. with my response.
Pmcned to Step 2 on roverae. Do npt chedr eny other boxes.
G �The ta�c rata is ir�correct. y�( 4.59a i am a iineal beneficisry{parent,chi�1,grancichiid,eto.)of fhe decessed.
(Sefect correct teu rete at /"\
right,and complete Part � 12% �am a sibling of the deceased.
i 3 on reverse.)
� 15%, A!i other reiatipnships(fnciudi�g none}.
p ❑Churiges or deductions The informatior�abave is incomact andtor debts and deductior�were paid,
listed. Comp/ete Fart 2 end p�t 3 as�mopriate aa the b�ot this fam.
E �Asset wil!be reptyrted o�r The above-identified asset has baen or wfll be r�orted and tau paid with the PA Inheritance Ta�c
inheritance ta�c form Retum flletl by the esteta representativs.
REV-1500. Proceed to Step 2 ar rewrae. Da not check sny other baxes.
PCease sign and date the bacic of ttte form when finished.
Po;� ;,,;01"°'"� t"�E' Pennsylvania lnheritance Tayc � pennsytvania
W�RRIY�URC PA 17t2!-qiPl Information Natice DEPARTMENf OF REVBNUE
ircr-iw¢x m�ue iu-u:
Ar�TaxpayerRespanse
FILE Nd.22
ACN 13135236
DATE 08-26-2013
Type of Account
Esiste af E D PERRY �w�
S.SFI OOB•40"788Q t'ihedClAg
Date of Death 10-22-2012 Trust
TIMOTHY W PERRY CouMy DAUPHIN CertNicate
5418 RID6EWOOD HETGHTS
WILMINBTON NC 2E403-4bIT
9t�LLS fARCO provided the departmer�t with tMa iniarmation below indicating that at the deattr of the
above-named decedent ou were a 'oint owner or beneficia nf the account identlNed.
ACCOttnt No.3000301968T9S Rsmit F'#yenent uK!Farms M:
D�b Est�q�hsd 08-03-2010 REGIfk7ER OF Nf11.L3
Account Belance $10.885.00 101 MARKET 31'EET.ROOM 103
PBrCetit Taxat7te X 54 HARRISBUR(`a PA 17101
Amqunt Subject to Taac S 5,4d2.5p
Teuc Rate X � 1/S ��,. �t�
Patential Ta.c 0� gI PeYmerris are made wlthin three rrrpMha of the
� dee�dent`s date oi de�.deduct a 5 perCgrrt disCOUrrt an the tau
9
Wtth 5%diecouM{fsu x O.S5y see N07E�_ _ due. Arry inheritance tax due will become delinquent nine moMhs
after the date of deeth.
Pa� S#!1� f: Please check the approprlete baxes beiow.
t
A [�No Wc �d�e. i am tt�e apouas af#he dec�aed or M am the parent of a decedsnt who was
21 years cid or your►gsr ai date of death.
Proceed ro SYep 2 on revpiae. Op not check eny other boxea and disiegard the amaunt
shown abow as PoMnNal Tax Dun.
g �1'he infortnatian is The atiave ihfomtalloni is eanect,rro dedtictians aro being taken,and p�ment wilt be s'eM
carect. with my rosponse.
Proceed ro SYep 2 on reverse. Do not check any other boxea.
G � tasr rate is ir�comect. ��il'�I 4.5% !am a tirreal benefiaary{parent,chi�,grandchild,etc.)of the deceased.
(Sebct conect tau rate at ' `—��
right,and compleke Part � 12% I am a sibling of the deceased.
on reversa.)
' � 15% AIi other ralatiansh�,(includi�nqne).
� ❑Changes or deductions The informalion abqve is inconect andlor debts and deductions ware paid.
Iis#ed. Car�ete Part 2 a�part 3 as sppropriete wt ihe bedt of ttus fam.
� �Aaset will be reported on The above-identlfied asset has been or will be reported and tau paid wifh the PA inheritance Tau
inhertta�ce iax fam Retum fNed by the esiaie r�'esenta6ve.
REV-15Qd. Proceed to Step 2 on reverse. Db not check any oNrer troxes.
Ptease sign ar�d3te the back of the farm when finished.
tURf�IU OF INOIYIDWL TAXES Penns Ivania lnheritance Taic '�pennsylvania
ro �m� :.ecu Y
INRMIS�UtC PA 1717l-tlf01 Information Notice DEPAMMENT OF REVENUE
�EY-D{1 fI p1AlK tN-lt}
And Ta�cpayer Response FtLE N4.Y1
ACN 13735235
DATE p&26-2013
Type of Account
Esffite of E D PERRY ����
SSN 008-40�7660 �}����g
Date of Death 10-22-2012 Trust
TIM07HY W PERRY CouMy DAUPHIN CertiNcate
5418 RYOGEWOOp NEI6HTS
WILNIN6TON MC 28403-4bE7
r�y� s FARCB provided the departmerrt with the infarmation below indicating ttrat at tFre death af the
above-named decedent ou were a ' int owner or benefici nf the account identified.
Ac�ount No,tce619?ts8SN1 �dt t�ymsnt ana Fom�s w:
WES EshWl�sd Oh1li-1971 REGI87'�R OF WILLS
Account Bel9nce $866.00 1U1 MARKET 37EET.ROdfN 103
PercenY Tauable X 50 HARRi�URti PA 17t01
Amount Subject to Taac $q33.pp
Tau Rate X 0.150 � NQ�•: r���ymants are made within three months of the
Poteniiei Tau Due S�+D6 decede�Ys da�a#deatlt,dedt+et a 5 percent diecount on the tsx
With 5%Oiacaurrt{Tarc x 8.95) �{gee� due. Any inheritat�teu due wiii become deiinqueM nine mo�rths
atter the dete of deafh.
�A� S#8p 1: PMase chmck the approp�iate baxes below.
t
A �Na ta�r is due. t am ihe spouse oi the decaeaed or F am#4e paront of a decxdent who was
21 ysars aid�yaur�ger at data of death.
Prpcead to SYap 2 on reverse. Do not chedc any other krares and disregaM the amount
shawn above as PotenNal Tax Due.
g �Trie infotmatian is T'he a6ove infotmation is correct�no deth�ctior�s are tseing taken,and psyment wlll be sent
correct. with my respo
ro Step 2 on revarse. Do not chedc eny other boxes.
� ❑The t8u ra#e is incorrect. 4.59b 1 am a lir�eai t�eneficiarY(Parent,cFtiid,9randChiid,eta.)of ihe deceased.
{SelgCt cortect ta�c rate at
right,and complete Part � y� I am a sibling of the deceased.
3 on reverse.)
( � 16% AII other reiatlo�sh�(incp�di�none}.
Ip ❑Changes or deducUons "fhe information abovg is incorrect and/or debts and deductions were pak).
listed. Complete Part 2�part 8 as�te on the bads af tt�s tam.
E �Asaet will be reported on The above-ideMified asset haa been or will be repprted and taur paid witlr the PA Inheritance Tau
inheritanc�tax form Ratum filed by the estate represeniative.
REV-150d. Proc�eRd ta Step 2 rm reverse. Do not check arty other boxes.
Piease sign and date the back of the farm when finished.
�;� ;�,;;�YiDO"� T""E$ Pennsylvania lnheritance Tan �'Pennsytvania
WIRRISWRC P� 1T17e-C{O! Information Notice DEPAR7'MEMOFREVHNUE
Atid Taxpetyer Respanse ItlY-iN1[%AN]!C{M.2!)
FILE NO.22
ACN 13135235
DATE 0&26-2013
Type of Account
Estaie ot E d PERRY ���
SSN 006-40-7$66 Ctteckirtg
Dete of Death 1Ch22-2072 TrUBt
TIMOTHY W PERRY CouMy DAUPHIN Certiflcate
5416 RIQ6EWO4p HEIBHTS
WIlMIN4T4N NC 284Q3-4617
MELLS FARCO provided#he department with the+niarmgtion below indicatinq that at tFre death of the
above-named decedent u were a oint owner or beneficf of the account klentiffed.
Acoa+nt NO.105614T158S74 R��1�Fom»M:
dets F�abN�hsd OM15-1871 RE(i1STER OF WILLS
Aawunt Bslanoe $886.00 tUt IAAF11fET 37'EET.ROOAA 103
Petcent TaxaWe X r,�p ��i PA t7101
Amount SubjeCt to Teu q�.pp
Tau Rate i
PoteM+e!Ta�c Oue NOTE': N tax payments are made within three r�r�tha of Uta
9ecedenNa da#e of destl+,daduct a 5 pmcent discaunt on the tau
ea e
With 5%Diecount tTa�c x 0.95} �e�p'�E' �, q�y�nheritance tex due wlli become deiinquemt nine months
after the date of daath.
PART St$p �: Plltl��ChlCk#la ApprOptlAt6 bi1XE�blIQW.
t
A �F#o ta�t is dta�. t am ttat apouas of the dsc�sed ar i am the paren#of a decedent who was
21 yasrs oid or younper at date af dsatl�.
Prc�.roed to Stap 2 on reverse. Do not check any other 4oxes and disrogard the amount
shawn above aa Potende/Tax Due.
g �"the infiotrn8tiai is 7t�e atiove infwrrtallori is cortect,na deductians are being taken,and payment will be sent
cortect, with my responee.
P�yed ro 5tep 2 on re�yrse. Do not chedr any other 4oxes.
C The tau ra�i8 incOrract. � 4.b% I ttm a Iineal b8neficiarY(PareM,Ghi�,$rendChild.etc.}of the deCea�ed.
SebCt Cortect t8n rats at
M,and complete Part � 12% I am a sibling of the deceased.
3 on revarsa.)
� 15% AIt other rataN�sFtips(ir�cluding none).
�j ❑Changes or deductions The information above is incarrect andlor debts ami deductions were peid.
tisted. Gor�Part2 and p�t 3 as on fhe b�c ot ihis trxm.
E �Asset will be reparted on 1`he above-idenHfied asset hae been or will be reported and tau paid with the PA Inheritanae Tax
i inhe�ar�ca t�form RattKn f�ed by tt�eatate representath�e.
REV-1506. Pmceed to Step 2 orr m�rerae. Do rrot chedc any ather 6oxes.
' Ptease sign and date the back of the form whe�fin�ed.
���, { ����'
� 'r�� A FamilyTradition of Caring°
PARTHEMORE Funeral Home & Cremation Services, Inc.
Mis.Lisu3a Henkei t0122120F2
510 Hiilside Roed
New Cwnberland PA l70')0
1303 Btidge StPeet For the Servicea of Dolly E.Pary
P.O.Bnx 431
New Cumberland,PA 17070 H'e sinaerely apprecrate the confidence you have placed in us and will contiaue to aagist you in every way
PFI:{717)774-7721 we can. Pleese fa!frce to contact us if yrru have any qusstions in regard to this statemenG TAe faltowing
is an itani�statement af the savicxs,fscilities,automotive equipmerst and m�chandiae that you seleetcd
FX:(717}774-554b whrn making the funeial artangamrnts.
www.pdrthemofe.com . ~�
Terms Due dete Account#
�rv Net 30 t ii2IR012 2012087.2
DescripUon Amount
SERVtCES&MERCHANDISE D.00
Gllbert W.Parthemore
Founder Direct Cremation 2,32Q.�6
GilbOrt 1.Parthemo�e Total Scrvices end Mcrchandise 2,320:00
Supervixor
CASA ADVANCE ITEMS O.t�
Stephen K.Parthemore
President,CFSP Death Nodce,Wilmington Moming Smr 190.28
17 Certified Copies pf Death Certificau 1 p2,OQ
Bruce R.Parthemore Casnty Camna Fee,Crcmation Anthorizatian 30.00
Pre-Need Coordinator,CPC
Tasi Cash Advancss 322.28
[mmediate Pay Discount-'fhsnk youl -46.40
Professionat Memberships:
I
� D�aors��
k t .M u r rt
{3rder�ftt,E �
.
Golden Rule
Totat sz,s�s.ss
Payments/Credits so•oo
�
Balance Due sz,s9s.gx �
�
i
� WEST SHORE EMS - ALS ---
20S GRANDVIEW AVE � p��R INi
CAMP HILL, PA 17011-1708 ON REVERSE&DE
O� Phone#: (800) 367-0512 Federal Tax ID: 23-2463002
EMFRGHNCY Mh_DI(',4L Sf^:RVICEiS
PATIENT NAME: DOLLY PERRY INSUMNCE: MEDICARE B TIME
TRICARE FOR LIFE TIMP
CALL NUMBER: ���SO7OA pq7E pF pp�; 08/10/2011
FR�: 510 HILLSIDE RD
70: HARRISBURG HOSPITAL
DOLLY PERRY ���� '
CIO LINDA NENI�L TovLL Cw�RaES: 1022.06
570 NILLSIDE RD PAYMENTS/AD,1usTMENTS: SS0.00
NEW CUMBERLAND,PA 17070 PLEASE PAY TH�S AMOUN7: 472.OB
DETACH ALONfi PERFORATION AND RETURN Sfl18 WITH PAYMENT
_.__. . . ..._.._. _..._.. ._ _..._. __.. ._..... __._ .......... _. .. _...._
�Q1�C�INh9� GiW�fFfl"Y 11NFf P�I1CB A1ApUPff
ALS EMERGENCY LEVEL 1 A0999 1.0 987.62 gg7,gp
20G1T TUBING A0394 1.0 14.72 14.72
ANCaIOCATH(1424) A0394 1.0 8.72 6.72
EKG ELECTRODE3(1) A0398 10.0 0.80 8.00
EXTENSION SET 8"NEEDLELESS A0394 1.0 12.52 12.52
GLUCOSE BLOOD A0394 1.0 7.08 7.08
NSS 0.9% t000cc Bag A0394 1.0 3.48 3.48
OP SITE A0394 1.0 1.92 1.92
Total Chargss 1022.08
� ' C��pP�l0l�lt'lF.M1�"IY�iT .. ��. �T' PIt�"Ml�ITD71T'E � . Ati/OUlff '. ' .
Private Payment/Check 1157668805 09/10/2012 50.00
Private Payment/Check 1151304256 07/11/2012 50.00
Private PaymeM/Check 1148018922 OB/08/2012 50.00
_ Private Payment/Check 1144725098 05/09/2012 50.00
Total All Other Credits 350•pp
Total Crodlb 550.00
PLEASE PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT --► j47p,p4
RETURNED CHECK FEE-$31.00
�� .9v
PATE�1 NMAE: PERRY;DOLLY ��� �10N/QIZOi2tA �p��'7^�J
_ iJ�
IMPORTANT MESSAGES: THANK YOU FOR YOUR PAYMENTI We appreciate you
keep your account currenH
WEST SHORE EMS-ALS 205 GRANDVIEW AVE CAMP HILL, PA 7 7011-1 708
���� WEST SHORE EMS - ALS
205 GRANDVIEW AVE a�°�R i I
---
CAMP HILL, PA 17011-4708 � l��
���E�. � Phone#: {800) 367-8512 Federal Ta�c ID: z�-zaeaoos �����DE
GMfNGF.'NCY MIiU1CAl.Sf?RVICI'.S
PAt7ENT NAME: DOLLY PEftRY pryg{�p�ryC€: MEDICARE$ 71M►E
TRICARE FOR IIFE TIMP
c�u�Nur�eeR: 1114503A DATE bF CALL• 08/02/2011
��: $i0 HlLLSlDE RD
Fp; HARRtSBURG HOSPITAI
�tfNT�tlM�Y
C�ILY P�RRY
C/O LINDA HENKEL ToTAL CHAROES: ���'�
510 HILL$IOE RD PAYMENTS/AD,lUSTMENTS: 700.pq
NEW CUMB£RLAND,PA 170T4 P�EAS�pAY TH�AMOUNT� 3�.�
DETACHALCN�PERFlDR4TlONAND AETfJRM STUB'N9TH PAYMEtVT
_ ._.. ... ._ . _ ._ _...._ . ......... ...._.�
�1tlf�tf�4*ii14i10R � tIMITPl�t AM�ICIU►iT
ALS EMERCiENCY LEVEL 1 AQ999 1.0 967.62 gg7,g2
ANGIQCATH{14-24} A0394 1.6 6,72 6.T2
EKG ELECTRdDES(1} A0398 10.0 0.80 8.00
EXTENSION SET 8`NEEDLELESS A0394 1.0 12.52 12.52
NEBULIZER AtI422 1.6 3.84 3.84
CSP SITE A0394 1.0 1.82 i.82
PROVEtdTll.W/NACI.SOLUTIQN A0394 1.0 1.72 1•72
SALINE PREFILIED SYRINGE A0394 1,0 2.58 2.58
Totai Chargsa 1004.Qp
C�'iCONOFiMY�IEkT �t pT�YM6MF'Wt78 M10UNT
Pdvate Payment!Check 115'7688805 09l10/2012 50.00
Ptivate Psyrt�ent!Check 115d850535 OSt1312412 150.OQ
Private PaymeM!Chack 1151344258 07/11/2012 50.00
_ Private Payment/Check 1148018922 08/OB/2012 50.00 _
Tatei Alf C7ther Credlt3 40Q.{?Q
Tatal Crodits 700.80
PI.EASE PAY THIS AMQUNT-INYOlGE QUE UPQPi FIEGEIPT --► ��p�,gp
RETURNEd CNECK FEE-$31,00
lMi�NTNi4ME PERRY,G14LtY CALL'NWA� �'I'��LSO�A p�p�p��
fl8120/2072
IMPORTANT MESSAGES: TNANK YOU FOR YBUR PAYMENTt Ws appreciate yaur efforta to
kaep your accaunt currenti
WEST SHORE EMS-A!S 205 GRANDVIEW AYE CAMP HILL, PA 17017•7708
� WESTSHORE EMS - ALS
205 GRANDVIEW AVE � a�� N
CAMP HILL, PA 17011-1708 l -- -- -
Phone#: (800) 387-0512 Federal Tax ID: 23-2463002 ON HEVERSE SIDE
��
i-�ea�F�<�v nae�ica��,ea��«�es
PATEt�T NAME: DOLLY PERRY INSUpANCE: MEDICARE B TIME
TRICARE FOR LIFE TIMP
cnu NuMeea: 1117176A DATE OF CALL• 09/14/207 7
FROM: �NORCARE HEALTH SERVICES
TO: HARRISBURG HOSPITAL
DOLLY PERRY ���
C/O LINDA HENKEL TOTAL CHARQES: 977'�
St0 HILLSIDE RD PAYMENTS/ApJU3TMENT3: 450.00
NEW CUMBERLAND, PA 17070 PLEASE PAY THIS AMOUNT. 52�'90
DETACN ALWVO PEHADMTION AND RENRN SNB W?H A9YMENT
, _. .. . . .... .. . .. . . ...... .__ _.. . .. __.. ._........ __.___ _...... ..._.._.. ..._............. __._
�II�l101�OF QIIAl10E K�tlAff!'�1'Y UNIT PIIICE /�MIOUMT
ALS EMERGENCY LEVEL 1 A0998 1.0 967.82 gg7,gp
EKG EIECTRODES(t) A0398 4.0 0.80 3.20
GLUCOSE BLOOD A0394 1.0 7.08 7.08
Tolal Chargss 977.90
. .. O�ESR�TIOM OF RIIYMEHr�: �. .. ����.� �C�T� IMkYMI�IT DATE: � � �. �� AMDUNT � ' . ..
Private PaymeM/Check 1157688805 09/10/2012 50.00
Private Payment/Check 1151304258 07/11/2012 50.00
Private Payment/Check 1148018922 06/08/2012 50,00
_ Private Payment/Check 1144725098 05/09/2012 50.00 _
Total AII Other Credits 250.00
Total CrodFts 450.00
PLEASE PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT —► ' :52Y,gQ'
RETURNED CHECK FEE-$31.00
Mk'11Et1iN11N�: PERRY..DOLLY � . .�. . . CALLNUNICElC �� 1'I1T�T8Ai� . . . . . AMOUMTPAU� . .
09J2(N2012,
IMPORTANT MESSAGES: THANK YOU FOR YOUR PAYMENTI We appreelate your etforts to
keep your axount currentl
WE3T SHORE EMS-ALS 205 GRANDVIEW AVE CAMP HILL, PA 17011-1708