HomeMy WebLinkAbout02-0359Estate of
Also known as
Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
KARL B. ETSHIED No. o~- I- ~,,,~. '
, Deceased Social Security No.
JANICE W. ETSHIED
174-20-3373
Petitioner(s), who is/are 18 years of age or older, apply(les) for:
(COMPLETE "A" OR "B" BELOW:)
A. Probate and Grant of Letters and aver that Petitioners are the executors named in the Last Will of
~' the Decedent, dated MARCH 23, 1978 and codicil(s) dated
State relevant circumstances, e.g. renunciation, death of Executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of
the documents offered for probate; was not to victim of a killing and was never adjudicated incompetent:
L_I B. Grant of Letters of Administration
(d.b.n.c.t.a.: pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following
spouse (if any) and heirs:
Name Relationship Residence
COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland County, Pennsylvania, with his last family or principal residence at
54 Westerly Road, Borough of Camp Hill, Cumberland County, Pennsylvania 17011
(List street, number and municipality)
Decedent, then 74 _years of age, died March 13, 2002, at Harrisburg Hospital, Harrisburg City, Pennsylvania
(Location)
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property ..................................................................... $ 1,000.00
(If not domiciled in PA) Personal property in Pennsylvania ..................................... $.
(If not domiciled in PA) Personal property in County .................................................... $
Value of real estate in Pennsylvania ...................................................................................................................... $
Total ......................................................................................................... $ 1,000.00
Real Estate situated as follows:
Wherefore, Petitioners respectfully request the probate of the last Will presented with this Petition and the grant of letters in the
appropriate form to the undersigned:
Signature
Typed or printed name and residence
JANICE W. ETSHIED
54 Westerly Road
Camp Hill, PA 17011
21-02-0359
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner above-named swears and affirms that the statements in the foregoing Petition are true
and correct to the best of the knowledge and belief of Petitioner and that, as personal representative of the
Decedent, Petitioner will well and truly administer the estate according to law,
Sworn to and affirmed and subscribed
Before me this ,_,A' d,. day of
hied
No. 21-02-0359
Estate of KARL B. ETSHIED
, Deceased
Social Security No: 174-20-3373
Date of Death: March 13, 2002
AND NOW, APRTL 9th ,2002, in consideration of the Petition on the reverse side
hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters ,/Testamentary [] of Administration
d.b.n.c.ta.; pendente lite; durante absenfia; durante minoritate
are hereby granted to
JANICE W. ETSHIED
in the above estate and that the instrument dated March 23, 1978
described in the Petition be admitted to probate and filed of record as the last Will of the Decedent.
FEES
Letters ...........................
Short Certificate(s) $
Renunciation .............. $.
Affidavit ( ) .................. $.
Extra Pages (1) .......$.
Codicil ............................ $
JCP Fee ....................... $.
Inventory ...................... $.
Other .............................. $.
$ 18.00
12.00
3.00
5.00
TOTAL .........$. 38. oo
Regfster of Wills ' ' ' /'-'
Attorney: RICHARD W. STEWART
I.D. No: 18089
Address: Johnson, Duffle, Stewart & Weidner,
301 Market Street, P.O. Box 109, Lemoyne, PA 17043-
Telephone: 717-761-4540
MAILED LETTERS TO ATTORNEY APRIL 9, 2002
21-02-359
Register of Wills of Cumberland County, Pennsylvania
OATH OF SUBSCRIBING WITNESS
Estate of KARL B. ETSHIED
Also known as
No. 21-02-0359
, Deceased
HORACE A. JOHNSON and JERRY R. DUFFLE
each a subscribing witness to the [] codicil(s) v' will presented herewith, each being duly qualified according to law,
deposes and says that they were present and saw the above Testator sign the same and that they signed as a
witness at the request of Testator in his presence and V' in the presence of each other [] in the presence of the other
subscribing witness(es).
Sworn to or affirmed and subscribed
before me this day of
, 2002,
My Commission Expires: 2006
(Signature and seal of Notary or other official
qualified to administer oaths. Show date of
expiration of Notary's commission.)
NOTE:
To be taken by officer authorized to
administer oaths. Please have
present the original or copy of
Instrument(s) at time of notarization.
his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00 ~
P 80318Sl NAR
No. ~ Date
21-02-0359
os.~4a. ,, ~Ja? COMMONWEALTH OF PENNSYLVANIA ,, DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
I "'--- ~ .... I '--' ] '~ I ' ~ .... I ....... ~ .... ~ I~: --
, 74 ,,.[ . [ : I 1-15-28 I Pittsb~gh,PAl,~,--,~ ~,.,~ ~U I~m ~ ~ ~- ~
~n~. ' ' I I l~. I~. [~ I ~ --~
~ ' [ · · ~ ~N~. (~)
~. 9- C2ty . H~r2sb~9 ~sp2ta1 ~.~.,...~. ·
' '" ~+ ". ,,. Janice ~, Weir
54 Westerly Rd.
Camp Hill, PA 17011
F~]'HER'S NAME (F~sl. M~I(~e. Las~)
INFORMANT'S NAME
Karl W. Etshied
Janice W. Etshied
~ O[,,~. 3-15-02
Married
~,,. ~t~rine M. ~ay
,,. JPF
,..Myers-Harp. er !q-l, 1903 Mkt St, CH, PA 17011
REGiSTRAR'S S/Gt'~.~T~IRE ANO NU'..~' ~'] .'F~/_"~' 'F ......... []
NAME AND ADOFI~_SS C~ PERSON wHO COMPLETED CAUSE O~'0~T H
[llem,27) ry~ ~ ?mi . . / I
21-02-0359
I, KARL B. ETSHIED, of the Borough of Camp Hill,
Cumberland County, Pennsylvania, make, publish and declare
this to be my Last Will and Testament, hereby revoking and
making void any and all former Wills by me at any time
heretofore made.
1. I direct that all my just debts and funeral expenses,
including my gravemarker and all expenses of my last illness,
shall be paid from my residuary estate as soon as practical
after my decease as part of the expense of the administration
of my estate.
2. I devise and bequeath all of the rest, residue and
remainder of my estate, of whatever nature and wherever
situate, together with the proceeds of any insurance thereon,
unto my wife, Janice W. Etshied, provided she survives me by
thirty (30) days.
3. Should my wife, Janice W. Etshied, predecease me
or die on or before the thirtieth (30th) following my death,
I devise and bequeath all of the rest, residue and remainder
of estate of whatever nature and wherever situate, together
with the proceeds of any insurance thereon, in equal shares
unto my then living issue, per stirpes.
4. I direct that any and all taxes that may be assessed
in consequence of my death, of whatever nature and by whatever
jurisdiction imposed, shall be paid from my residuary estate
as part of the expense of the administration of my estate.
5. I nominate and appoint Dauphin Deposit Bank and Trust
Company of Lemoyne, Cumberland County, Pennsylvania, guardian
of any property which passes either under this Will or other-
wise to a minor and with respect to which I am authorized to
appoint a guardian and have not otherwise specifically done
so. Provided, that this appointment of a guardian shall not
supersede the right of any fiduciary in its discretion to
distribute a share where possible to the minor or to another
for the minor's benefit. Such guardian shall have the power
to use principal as well as income from time to time for the
minor's support, maintenance and education (including trade
school, and undergraduate and graduate college education)
without regard to his or her parents' ability to provide for
such support, maintenance and education, or to make payments
for those purposes without further responsibility to the minor
or to the parent or to any person taking care of the minor.
6. I nominate and appoint my wife, Janice W. Etshied,
to be the Executrix of this, my Will. If my wife, Janice W.
Etshied, does not survive me or is unable or unwilling to
act in this capacity, I nominate and appoint my daughter,
Janice L. Etshied, to be the Executrix of this, my Will.
IN WITNESS WHEREOF, I hereunto set my hand and seal
this~ day of h~.~ , 1978.
(SEAL)
Signed, sealed, published and declared by the above-
named Testator as and for his Last Will and Testament in
the presence of us, who, at his request, in his presence and
in the presence of each other have hereunto subscribed our
names as witnesses.
JERRY R. DUFFLE
RICHARD W. STEWART
C. ROY WEIDNER, Jl~.
EDMUND G. MYERS
DAVID W. DELUCE
KALPH H. WRIGHT, IR..
DAVID J. LANZA
MARK C. DUFFIE
KEIRSTEN WALSH DAVlDSON
MICHAEL J. CASSIDY
ROBERT M. WALKER.
21-02-359
LAW OFFICES
JOHNSON, DUFFLE, STEWART ~ WEIDNER
A Professional Corporation
301 MARKET STREET
P. O. BOX 109
LEMOYNE, PENNSYLVANIA 17043 - 0109
VFEBSITE: www.jdsw.com
TELEPHONE 717-761-4540
FACSIMILE 717-761-3015
E-MAIL mailOjdsw.com
HORACE A. JOHNSON
OF COUNSEL
E-MAIL dlw@jdsw.c0m
April 5, 2002
MARY C. LEWIS, REGISTER OF WILLS
Register of Wills Office
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Estate of Karl B. Etshied
Date of Death: March 13, 2002
Dear Ms. Lewis:
Enclosed please find the following documents:
2.
3.
4.
5.
6.
Petition for Probate for the Estate of Karl B. Etshied
Oath of Subscribing Witness signed by Horace A. Johnson and Jerry R. Duffle
Estate Information Sheet
Original Death Certificate
Original Last Will and Testament signed by Karl B. Etshied on March 23, 1978
Check in the amount of 35.00 made payable to the Register of Wills for the
following: (a) $18.00 for the Petition for Probate for assets totaling $1,000.00;
(b) $12.00 for 4 Short'Certificates (3.00 each); JCP fees of $5.00.
Please time-stamp the enclosed copies. Should you have any questions, please feel free
to contact the undersigned.
Very truly yours,
Dana L. Wieseman
Legal Assistant
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent:
Date of Death:
Will No.:
KARL B. ETSHIED
MARCH 13, 2002
2002-00359
Admin. No.:
To the Register:
I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above-captioned estate on
April 11, 2002.
Name Address
JANICE W. ETSHIED 54 Westerly Road
Camp Hill, PA 17011
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except None.
Date: April 11, 2002
Signature
Name RICHARD W. STEWART
Johnson, Duffie, Stewart & Weidner
Address 301 Market St.
P. O. Box 109
Lemoyne, PA 17043-0109
Telephone (717) 761-4540
Capacity:
Counsel for personal representative
JERRY IL DUFFIE
RICHARD W. STEWART
C. ROY WEIDNER, JR.
EDMUND G. MYERS
DAVID W. DELUCE
RALPH H. WRIGHT, JR.
DAVID J. LANZA
MARK C. DUFFIE
MELISSA PEEL GREEVY
MICHAEL J. CA~SSIDY
ROBERT M. WALKER
LAW OFFICES
JOHNSON, DUFFIE, STEWART WEIDNER
A Professional Corporation
301 MARKET STREET
P. O. BOX 109
LEMOYNE, PENNSYLVANIA 17043-0109
'ff/'EB$ITE: www.jdsw, com
TELEPHONE 717-761-4540
FACSIMILE 717-761-3015
F~MA1L mail~jdsw, com
CUMBERLAND REGISTER OF WILLS
Register of Wills Office
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Dear Register:
December 12, 2002
HORACE A. JOHNSON
COUNSEL TO THE FIRM
KEIRSTEN WAI~H DAVIDSON
OF COUNSEL
E-MAIL dlw@jdsw.com
Re.'
Estate of Karl B. Etshied
SSN: 174-20-3373
Date of Death: March 13, 2002
Your File No. 21-02-0359
Enclosed please find the following:
Check No. 8239 in the amount of $40.00. This check represents payment as
follows:
a. $15.00 Inheritance Tax Filing Fee
b. $10.00 Inventory Filing Fee
c. $15.00 Additional Probate Fee.
2 Original Inheritance Tax Returns. This is an Insolvent Estate and the
beneficiary is the Surviving Spouse, thus there is no tax due.
Inventory
Copies of the Inheritance Tax Return and Inventory that we ask that you time-
stamp and return to us.
Should you have any questions, or require any additional information, please feel free to
contact the undersigned.
Very truly yours,
Dana L. Wieseman
Legal Assistant
EV-1500 EX + (6-00)
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
REV-1500
IINHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
FILE NUMBER
21-02-0359
COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
ETSHIED KARL B. 174-20-3373
DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS REI'URN MUST BE FILED IN DUPLICATE WITH THE
03/13/2002 [ 01/15/1928 REGISTER OF WILLS
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
ETSHIED, Janice W.
~ 1. OriginalReturn ~ 2~! SupplementalReturn U
4. Limited Estate . Future Interest Compromise (date of death after 1Z- IZ-8Z)
6. Decedent Died Testate Decedent Maintained a Living Trust 0
(Attach copy of Will) (Attach copy of Trust)
~---] 9. Litigation Proceeds Received ~ 10. SpousaIPoverty Credit
SOCIAL SECURITY NUMBER
194-22-7525
(date of death
3. Remainder Return prior to 12-13-82)
5. Federal EstateTax Return Required
8. Total Number of Safe Deposit Boxes
(date of death between 12-31-91 and 1-1-95)
NAME
Richard W. Stewart
FI RM NAM E (if Applicable)
Johnson, Duffle, Stewart & Weidner
TELEPHONE NUMBER
717/761-4540
Election to tax under Sec. 9113(A)
1
1.
(Attach Sch O)
COMPLETE MAILING ADDRESS
P. O. Box 109
301 Market Street
Lemoyne, PA 17043-0109
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or (3)
Sole -Proprietorship
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
~ Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13.
14.
None
None
None
None
6,415.34
None
-0-
6,919.19
14,606.82
Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
Net Value Subject to Tax (Line 12 minus Line 13)
OFFICIAL USE ONLY
(8) 6,415.34
(11)
(12)
(13)
(14)
21,526.01
(15,110.67)
(15,110.67)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec, 9116(aX1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
(15,110.67)
X .0 0 (15) 0.00
X .0 4_5 (16) 0.00
X .12 (17) 0.00
X .15 (18) 0.00
(19) O. O0
Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
Decedent's Complete AddreSs:
STREET ADDRESS
54 Westerly Road
CITY
Camp Hill
STATE
?A
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
ZIP
17011
Total Credits ( A + B + C )
(1) 0.00
(2) O. O0
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + E ) (3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund (4) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00
A. Enter the interest on the tax due. (SA) 0.00
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 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. retaintheuseorincomeofthepropertytransferred; ......................... ~ ~
b. retain the right to designate who shall use the property transferred or its income; ...........
c. retain a reversionary interest; or ....................................
d. receive the promise for life of either payments, benefits or care? ...................
2. If death occurred after December 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? .............................................. r'~ ~']
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.
Under penalties of perjury, I 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 RESPONSIBLE FOR FILING RETURN Janice W. ETSHIED
~ L~ ^ 54 Westerl Road ~P--
Camp Hill, PA 17011 ..................
~BIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE Johnson, Duffie, Stewart & Weidner DATE
-- -i ......................
For dates of death on or after July 1, 1994 and before Janua~ 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. 9116 (a) (1.1) (i)].
For dates of death on or after Janua~ 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[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 beneficial.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twen~-one 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% [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%, except as noted in 72 P.S. 9116(1.2)
[7~ P.S. S~ ~6(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [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.
Copyright (c) ~000 form software only The Lackner Group, Inc. Form ~-1500 E~ (Rev. 6-00)
REV- 1508 EX + (1-97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
KARL B. ETSHIED SS~ 174-20-3373 03/13/2002 21-02-0359
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
2
3
4
5
6
7
8
9
10
11
12
13
Benjamin Peters, Payment in Full for Dental Services
C.W. Donnelly, Payment in Full for Dental Service
Cash
Charles Acri, Payment in Full for Dental Services
Dr. R.A. Debro, Payment for Dental Services
Gayle Wagaman, Partial Payment for Dental Services
JAMES ROBERTS, Partial Payment for Dental Services
Nancy Schultz, Payment in Full for Dental Services
William Watson, Payment in Full for Dental Services
Dr. Marinah & Dr. Glossner, Payment for remaining Dental Clients
Karl B. Etshied, DDS.
Decedent ran a Dentist Office out of his residence at 54 Westerly
Road, Camp Hill, PA. This residence is a joint asset with his
surviving spouse, therefore is not listed on this Return. The
business address of 111 North 32nd Street was an alleyway behind
the prime residence at the time of his death. Decedent filed
Chapter 11 Bankruptcy and the only asset of the business was the
Client List and sold to a local office. Income taxes for the
past 4 years have been attached.
Harry Stephenson, Payment for Dental Services
Morgan Stanley Money Market Account
Waypoint Bank Checking Account No. 3100003082
65.00
72.00
307.00
72.00
14.00
51.00
275.00
127.00
55.00
2,500.00
525.00
95.87
2,256.47
TOTAL (Aisc enter on line 5, Recapitulation) $ 6,415.34
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1-97)
REV-1510 EX+ I1-97) SCHEDULE G
INTER-VIVOS TRANSFERS &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF
KARL B. ETSHIED SS~; 174-20-3373 03/13/2002
FILE NUMBER
21-02-0359
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
DESCRIPTION OF PROPERTY % OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER.
NUMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE)
1 Morgan Stanley IRA 208.65 208.65 0.00
Beneficiary:
Janice W. Etshied,
Surviving Spouse
TOTAL (Also enter on line 7, Recapitulation) $ 0.00
(If more space is needed, insert additional sheets of the same s~ze)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1510 EX (Rev. 1-97)
EV- 1511 EX +(1-97)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
KARL B. ETSHIED SS# 174-20-3373 03/13/2002 21-02-0359
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
1
2
3
FUNERAL EXPENSES:
Myers-Harner Funeral Homes
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) Jan'ice W. F..TSI-ITF..D
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address 54 Westerly Road
City Cam[3 Hill State PA
194-22-7525
~Zipl7011
Year(s) Commission Paid:
Attorney's Fees Johnson, Duffle, Stewart & Weidner
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Janice W. Etshied
Street Address 54 Westerly Road
city Cam[3 Hill State PA .Zip
Relationship of Claimant to Decedent SUI-viviD. g Spouse
Probate Fees Register of Wills
Accountant's Fees
Tax Return Preparer's Fees
Other Administrative Costs
Cumberland County Register of Wills
The Cumberland Law
The Patriot News -
17011
- Additional
Journal - Estate Advertising
Estate Advertising
Probate Fee
2,030.00
300.00
850.00
3,500.00
35.00
15.00
75.00
114.19
TOTAL (Also enter on line 9, Recapitulation) $ 6,919.19
(If more space is needed, insert additional sheets of the same size)
Copyright (cl 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97)
REV-1512 EX +(1-97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
KARL B. ETSHIED SS:// 174-20-3373 03/13/2002 21-02-0359
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
10
11
12
13
14
A. Leventhal - Removal of Dental Equipment from Office
Andrews & Patel Associates, P.C.
Camp Hill Borough Taxes 1/2 of remaining Debt
Checks clearing after Date of Death
Darby Dental Supply Co., Inc.
Dental Services Group - Muth & Mumma Dental Laboratory
DMF Dental Laboratory, Inc.
Fager Dental Lab
Klm Daughtery - Removal of remaining equipment from Office
incliding plumbing and cabinetry
New Jersey EZ Pass
Verizon Telephone
Waypoint Bank Fee
Waypoint Bank Fee
Web TV
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
265.00
100.00
330.15
2,275.06
295.02
1,320.93
9,488.37
142.73
221.00
25.00
91.61
26.00
1.00
24.95
$ 14,606.82
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97/
REV-1513 EX + (g-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
KARL B. ETSHIED SS# 174-20-3373 03/13/2002 21-02~0359
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
II.
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and
transfers under Sec. 9116(a)(1.2)]
Janice W. ETSHIED
54 Westerly Road
Camp Hill, PA 17011
Wife
Entire Estate
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET
(If more space is needed, insert additional sheets of the same size)
$ 0.00
Copyright (c) 2:000 form software only The Lackner Group, Inc. Form REV-1513 EX IRev. 9-00)
TABLE OF EXHIBITS
A. Last Will and Testament of Karl B. Etshied dated March 23, 1978
Bo
Tax Returns
1. 1998
2. 1999
3. 2000
4. 2001
EXHIBIT A
I, KARL B. ETSHIED, of the Borough of Camp Hill,
Cumberland County, Pennsylvania, make, publish and declare
this to be my Last Will and Testament, hereby revoking and
making void any and all former Wills by me at any time
heretofore made.
1. I direct that all my just debts and funeral expenses,
including my gravemarker and all expenses of my last illness,
shall be paid from my residuary estate as soon as practical
after my decease as part of the expense of the administration
of my estate.
2. I devise and bequeath all of the rest, residue and
remainder of my estate, of whatever nature and wherever
situate, together with the proceeds of any insurance thereon,
unto my wife, Janice W. Etshied, provided she survives me by
thirty (30) days.
3. Should my wife, Janice W. Etshied, predecease me
or die on or before the thirtieth (30th) following my death,
I devise and bequeath all of the rest, residue and remainder
of estate of whatever nature and wherever situate, together
with the proceeds of any insurance thereon, in equal shares
unto my then living issue, per stirpes.
4. I direct that any and all taxes that may be assessed
in consequence of my death, of whatever nature and by whatever
jurisdiction imposed, shall be paid from my residuary estate
as part of the expense of the administration of my estate.
5. I nominate and appoint Dauphin Deposit Bank and Trust
Company of Lemoyne, Cumberland County, Pennsylvania, guardian
of any property which passes either under this Will or other-
wise to a minor and with respect to which I am authorized to
appoint a. guardian and have not otherwise specifically done
so. Provided, that this appointment of a guardian shall not
supersede the right of any fiduciary in its discretion to
distribute a share where possible to the minor or to another
for the minor's benefit. Such guardian shall have the power
to use principal as well as income from time to time for the
minor's support, maintenance and education (including trade
school, and undergraduate and graduate college education)
without regard to his or her parents' ability to provide for
such support, maintenance and education, or to make payments
for those purposes without further responsibility to the minor
or to the parent or to any person taking care of the minor.
6. I nominate and appoint my wife, Janice W. Etshied,
to be the Executrix of this, my Will. If my wife, Janice W.
Etshied, does not survive me or is unable or unwilling to
act in this capacity, I nominate and appoint my daughter,
Janice L. Etshied, to be the Executrix of this, my Will.
IN W-/TNESS WHEREOF, I hereunto set my hand and seal
this Lb day of ~-~ , 1978.
(SEAL)
Signed, sealed, published and declared by the above-
named Testator as and for his Last Will and Testament in
the presence of us, who, at his request, in his presence and
in the presence of each other have hereunto subscribed our
names as witnesses.
z z g
Z
0
Z'
I.-I-
EXHIBIT B
WILDEMAN AND OBROCK, CPA'S
515 S. 29TH STREET
HARRISBURG, PA 17104
(717) 561-0820
APRIL 15, 1999
KARL B & JANICE W ETSHIED
111 N 32ND ST
CAMP HILL, PA 17011
DEAR DR. AND MRS. ETSHIED,
ENCLOSED ARE YOUR 1998 INCOME TAX RETURNS AND 1999 ESTIMATED
TAX VOUCHERS. THE RETURNS SHOULD BE SIGNED AND DATED BY BOTH
TAXPAYER AND SPOUSE.
SPECIFIC FILING INSTRUCTIONS ARE AS FOLLOWS.
FEDERAL INCOME TAX RETURN:
~MAIL YOUR FEDERAL RETURN ON OR BEFORE APRIL 15, 1999.
MAIL TO - INTERNAL REVENUE SERVICE
PHILADELPHIA, PA 19255-0002
YOUR ENTIRE OVERPAYMENT IN THE AMOUNT OF $5,300 HAS BEEN
APPLIED TO YOUR FEDERAL DECLARATION OF ESTIMATED TAX.
PENNSYLVANIA INCOME TAX RETURN:
MAIL YOUR STATE RETURN ON OR BEFORE APRIL 15, 1999.
MAIL TO - PA DEPARTMENT OF REVENUE
REFUND/CREDIT REQUESTED
6 REVENUE PLACE
HARRISBURG, PA 17129-0006
YOUR OVERPAYMENT IN THE AMOUNT OF $110 HAS BEEN APPLIED TO
YOUR STATE DECLARATION OF ESTIMATED TAX.
NO PAYMENT IS REQUIRED.
PENNSYLVANIA ESTIMATED TAX VOUCHERS:
SEPARATELY MAIL VOUCHER 1 OF THE DECLARATION OF ESTIMATED TAX
BY APRIL 15, 1999. ENCLOSE YOUR CHECK FOR $100, PAYABLE TO
PA DEPARTMENT OF REVENUE.
ADDITIONAL ESTIMATED TAX PAYMENTS WILL ALSO BE DUE. PAYMENTS
" 1998
Two-Year Comparison ¥ rksheet ' '
Name(s) as shown on return Social security number
KARL B & JANICE W ETSHIED 174-20-3373
1997Filing Status Married Filing Joint 1998Filing Status Married Filing Joint
1997 Tax Bracket 15.0% 1998 Tax Bracket 15 0%
Schedule B - taxable interest 17. 24. 7.
Sch. C/C-EZ (business income/loss) 31,543. 23,309. <8,234.
~chedule D (capital gain/loss) <2,147.> 0. 2,147.
~axable pensions and annuities 8,781. 0. <8,781.
~axable social security benefits 7,939. 2,817. <5,122.
Other income 0. 5,606. 5,606.
Total income 46,133. 31,756. <14,377.
0ne-half of self-employment tax 2,229. 1,647. <582.
~elf-employed health ins. deduction 0. 1,551. 1,551.
Total adjustments 2,229 3,198. 969.
.
Adjusted gross income 43,904' 28,558. <15,346.
Medical and dental expenses 0. 1,354. 1,354.
Taxes 0. 5,185. 5,185.
Interest (deductible) 0. 7,985. 7,985.
Contributions 0. 308. 308.
Other miscellaneous deductions 0. 5,606. 5,606.
Total itemized deductions 0. 20,438. 20,438.
Standard deduction 8,500. 0. <8,500.
!Income before exemptions 35,404. 8,120. <27,284.
Personal exemptions 5,300. 5,400. 100.
Taxable income 30,104. 2,720. <27,384.
Fax 4,519. 407. <4,112.
Tax before credits 4,519. 407. <4,112.
Tax after non-refundable credits 4,519. 407. <4,112.
Schedule SE (self-employment tax) 4,457. 3,293. <1,164.
Total tax 8,976. 3,700. <5,276.
Estimated tax payments 6,000. 9,000. 3,000.
Total payments 6,000. 9,000. 3,000.
~ax overpaid 0. 5,300. 5,300.
Dverpayment applied to estimate 0. 5,300. 5,300.
Form 2210/2210F (est. tax penalty) 79. 0. <79.
Balance due including 2210/2210F 3,055. 0. <3,055.
Pennsylvania State Return
~axable Income 31,560. 28,939. <2,621.
Fax 884. 810. <74.
9 Estimated Tax Worksheet (keep for ~
· records)
I Enter amount of adjusted gross income you expect in 1999 .............................................................................................
2 · If you plan to itemize deductions, enter the estimated total of your itemized deductions. '1
Caution: If line 1 above is over $126,600 ($63,300 if married filing separately), your
deduction may be reduced. See Pub. 505 for details. · ...............................................
· If you do not plan to itemize deductions, see Standard deduction for 1999 on page 2,
and enter your standard deduction here.
3 Subtract line 2/rom line 1 ..........................................................................................................................................
4 Exemptions. Multiply $2,750 by the number of personal exemptions. If you can be claimed as a dependent on another person's
1999 return, your personal exemption is not allowed. Caution: See Pub. 505 to figure the amount to enter if line 1 above is over:
$189,950 if married filing jointly or qualifying widow(er); $158,300 if head of household; $126,600 if single; or $94,975 if married
filing separately ......................................................................................................................................................
Subtract line 4 from line 3 ..........................................................................................................................................
Tax. Figure your tax on the amount on line 5 by using the 1999 Tax Rate Schedules on page 2. DO NOT use the Tax Table or the
Tax Rate Schedules in the 1998 Form 1040 or Form 1040A instructions. Caution: If you have a net capital gain
see Pub. 505 to figure the tax ....................................................................................................................................
7 Additionaltaxes (see instructions) ..............................................................................................................................
8 Add nes6and7 .....................................................................................................................................................
g Credits (see instructions). Do not include any income tax withholding on this line ..................................................................
lO
11
Subtract line 9 from line 8. Enter the result, but not less than zero .......................................................................................
Self-employment tax. Estimate of 1999 net earnings from self-employment $ 2 7,70 5. ;if $72,600
or less, multiply the amount by 15.3%; if more than $72,600, multiply the amount by 2.9%, add $9,002.40 to the result, and
enter the total. Caution: If you also have wages subject to social security tax, see Pub. 505 to figure the
amount to enter ......................................................................................................................................................
12 Other taxes (see instructions) ....................................................................................................................................
13a Add lines 10 through 12 .............................................................................................................................................
b Earned income credit, additional child tax credit and credit from Form 4136 ........................................................................
c Subtract line 13b from line 13a. Enter the result, but not less than zero. THIS IS YOUR TOTAL 1999 ESTIMATED TAX ............ ~'
14a Multiply line 13c by 90% (66 2/3% for farmers and fishermen) '
15
16
17
4,100
b Enter the tax shown on your 1998 tax return (105% of that amount if you are not a farmer or a
fisherman and the adjusted gross income shown on line 34 of that return is more than $150,000
or, if married filing separately for 1999, more than $75,000) ................................................... 3,70 0
c Enter the smaller of line 14a or 14b. THIS IS YOUR REQUIRED ANNUAL PAYMENT TO AVOID A PENALTY ........................... ~'
Caution: Generally, if you do not prepay (through income tax withholding and estimated tax payments) at least the amount
on line 14c, you may owe a penalty for not paying enough estimated tax. To avoid a penalty, make sure your estimate on
line 13c is as accurate as possible. Even if you pay the required annual payment, you may still owe tax when you file your
return. If you prefer, you may pay the amount shown on line 13c. For more details, get Pub. 505.
income tax withheld and estimated to be withheld during 1999 (including income tax withholding on pensions,
annuities, certain deferred income, etc.) ........................................................................................................................
Subtract line 15 from line 14c. (Note: if zero or less, or line 13c minus line 15 is less than $1,000, stop here.
You are not required to make estimated tax payments.) ...................................................................................................
If the first payment you are required to make is due April 15, 1999, enter 1/4 of line 16 (minus
any 1998 overpayment that you are applying to this installment) here and on your payment voucher(s)
(Nole: Household employers see instructions) ...............................................................................................................
28,086.
20,474.
7,612.
5,500.
2,112.
317.
317.
317.
4,238.
4,555.
4,555.
3,700.
5,300.
Overpayment Applied
5,300.
810401
02-16-99 i
CUT HERE
.e 1040-ES
"° Department °f the Treasury 1999"aymentlvoucher
In ternal Revert ue Service OM B No, 1545-0087
File only if you are making a payment of estimated tax. Return this voucher with check or
Calendar
year
Due
April
1
5,
I
ggg
money order payable to the "United States Treasury." Please write your social security
number and "1999 Form 1040-ES" on your check or money order. Do not send cash.
Enclose, but do not staple or attach, your payment with this voucher.
Your first name and initial IYour last name Your social security number
KARL B ~TSHIED 174-20-3373
,., If joint payment, complete for spouse
Amount
of
payment
· ~ Spouse's first name and initial Spouse's last name Spouse's social security number
~ ~ANICE W ETSHIED 194-22-7525
~ Address (number, street, and apt. no.)
~ llll N 32ND ST
a. City, state, and ZIP code (If a foreign address, enter city, province or state, postal code, and country.)
2AMP HILL, PA 17011
LHA For Privacy Act and Paperwork Reduction Act Notice, see instructions on page 5.
CUT HERE
CUT HERE
1999 2
~ Department of the Treasury
Internal Revenue Service Voucher OMB No. 1545-0087
File only if you are making a payment of estimated tax. Return this voucher with check or I Calendar year - Due June 15, lggg
money order payable to the "United States Treasury." Please write your social security
number and '1999 Form 1040-ES" on your check or money order. Do not send cash.
Enclose, but do not staple or attach, your payment with this voucher.
Your first name and initial IYour last name Your social security number
KARL B ~TSHIED 174-20-3373
. If joint payment, complete for spouse
Amount of payment .~. Spouse's first name and initial Spouse's last name Spouse's social security numbe~
JANICE W ETSHIED 194-22-7525
,~ Address (number, street, and apt. no.)
~ 111 N 32ND ST
a. City, state, and ZIP code (If a foreign address, enter city, province or state, postal code, and country.)
CAMP HILL, PA 17011
LHA For Privacy Act and Paperwork Reduction Act Notice, see instructions on page 5.
CUT HERE
810411
12-15-98 2
*~ ' CUT HERE
~ 1040-ES
I~ DepartrnentoftheTreasur~ 1999VoucherPayment3
Internal Revenue Sew[ce
File only if you are making a payment of estimated tax. Return this voucher with check or
money order payable to the "United States Treasury." Please write your social security
number and "1999 Form 1040-ES' on your check or money order. Do not send cash.
Enclose, but do not staple or attach, your payment with this voucher.
OMB No. 1545-0087
I Calendar year - Due Sept. 15, 1999
Your first name and initial IYour last name Your social security number
KARL B ~TSHIED 174-20-3373
Amount of payment ._'E If joint payment, complete for spouse
~. Spouse's first name and initial Spouse's last name Spouse's social security number
~JANICE W ETSHIED 194-22-7525
~ Address (number, street, and apt. no.)
_~ 111 N 32ND ST
City, state, and ZIP code (If a foreign address, enter city, province or state, postal code, and country.)
CAMP HILL, PA 17011
$
LHA For Privacy Act and Paperwork Reduction Act Notice, see instructions on page 5.
CUT HERE
CUT HERE
.E 1040-ES
L~0 Department of the Treasury
internal Revenue Service
1999 Payment
4
Voucher
OMB No. 1545-0087
File only if you are making a payment of estimated tax. Return this voucher with check or I Calendar year - Due Jan. 18, 2000
money order payable to the "United States Treasury." Please write your social security
number and "1999 Form 1040-ES" on your check or money order. Do not send cash.
Enclose, but do not staple or attach, your payment with this voucher.
Your first name and initial IYour last name Your social security number
KARL B ~TSHIED 174-20-3373
Amount of payment ~ If joint payment, complete for spouse
o. Spouse's first name and initial Spouse's last name Spouse's social security number
~ SANICE W ETSHIED 194-22-7525
~e Address (number, street, and apt. no.)
_e 111 N 32ND ST
$
City, state, and ZIP code. (if a foreign address, enter city, province or state, postal code, and country.)
£AM? HTT,T,, ;PA 17011
LHA
For Privacy Act and Paperwork Reduction Act Notice, see instructions on page 5.
CUT HERE
810421
12-15-98 3
KARL B & JANICE W ETS~IFTM '" . ~
174-20-3373
Form 1040-ES Self-Employment Tax Worksheet
1. Estimated income and profits subject to
self-employment tax ............
2. Multiply the amount on line 1 by .9235 . . .
3. Multiply the amount on line 2 by .029 . . .
4. Social security tax maximum income .....
5. Estimated wages subject to social
security tax ................
6. Subtract line 5 from line 4 ........
7. Enter the smaller of line 2 or line 6 . . .
8. Multiply the amount on line 7 by .124 . . .
9. Add line 3 and line 8 ..........
10. Total estimated Self-Employment Tax ....
Taxpayer
30,000
27,705
8O3
72,600
72,600
27,705
3,435
4,238
Spouse
4,238
Form 1040-ES Adjusted Gross Income Worksheet
1998 Adjusted Gross Income
Add Back: 1/2 of 1998 Self-Employment Tax ....
Change in Adjusted Gross Income ........
Adjustment to capital gains/losses .......
Minus: 1/2 of 1999 estimated Self-Employment Tax.
Estimated 1999 Adjusted Gross Income
1,647
2,119
28,558
28,086
3.1
1040DepartmentoftheTreasb~y-ln' ~,~ven, ueService 1998 '
,,~ U.S. Individual In, ,le Tax Return ~Jg)
,RS Use Only - Do not write or staple in this space.
Label
(See
instructions
on page 18.)
Use the IRS
label.
Otherwise,
please print
o r type.
Presidential
Election Campaign
(See page 18.)
Your first name and initial Last name
L KARL B ETSHIED
~ If a joint return, spouse's first name and initial Last name
LEH JANICE W ETSHIED
Home address (number and street). If you have a P.O. box, see page 18. Apt. no.
111 N 32ND ST
i City, town or post office, state, and ZIP code. If you have a foreign address, see page 18.
CAMP HILL, PA 17011
Do you want $3 to go to this fund? ......................................................................................................
Filing Status
For the year Jan. 1-Dec. 31, 1998, or other tax year beginning ,1998, ending , 19 OMB No. 1545-O074
Your social security number
174i20i3373
Spouse's social security number
194i22 i7525
Check only
one box.
~' If a joint return, does your spouse want $3 to go to this fund? ..................................................................
Single
Married filing joint return (even if only one had income)
Married filing separate return. Enter spouse's soc. sec. no. above and full name here. ·
· IMPORTANT! ·
You must enter
your SSN(s) above.
Yes No Note: Checking
I X I 'Yes' will not
~ change your tax or
I z~ I reduce your refund.
Head of household (with qualifying person). If the qualifying person is a child but not you r dependent, enter this child's
name here. ·
Qualifying widow(er) with dependent child (year spouse died · 19 ). (See page 18.)
Exemptions 6a ] X I Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax return, do not '~ No. of boxes
check box 6a .................................................................................................................. ~andChecked6b on 6s 2
b ~-~ Spouse ~,'¢ ............................................ i¥..) No. ofyour
..................................... " " ' children on 6c
Dependents: / / ;':'! '~ (2) Dependent's social (3) Dependent's (4) V'ff qualify
i' lng child for who:
(1) First name Last name~- .~, security number relationship to child t~xcredl
· :;:' you (see page 19) · lived with you
. i · did not live with
' : i or separation
" i. ' ~ '' (see page 19)
! Dependents on 6c
~ not entered above
:
- Add numbers
! i entered on
d Total number of exemptions claimed .............................................. ....~...i~i.. ................................................... lines above ·
If morethan six
dependents,
see page 19.
Income 7 Wages, salaries, tips, etc. Attach Form(s) W-2 ' ' ...... 7
8a Taxable interest. Attach Schedule B if required ~ 8a 2 4.
Attach b Tax-exempt interest. DO NOT include on line 8a .................................
Copy B of your
Forms W-2, 9 Ordinary dividends. Attach Schedule B if required ........................................................................... 9
W-2G, and 10 Taxable refunds, credits, or offsets of state and local income taxes ......................................................10
1099-Rhere. 11 Alimony received ..................................................................................................................... 11
If you did not 12 Business income or (loss). Attach Schedule C or C-EZ ..................................................................... 12 2 3,3 0 9,
get a w-2, 13 Capital gain or (loss). Attach Schedule D ....................................................................................... 13
see page 20. 14 Other gains or (losses). Attach Form 4797 .................................................................................... 14
15a Total IRA distributions ............... I15a I b Taxable amount (see page 22) 15b
16a Total pensions and annuities ......I 16aI b Taxable amount (see page 22) 16h
Enclose, but do 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17
not staple, any ........................
payment. Aisc, 18 Farm income or (loss). Attach Schedule F .................................................................................... 18
please use lg Unemployment compensation ................................................................................................... 19
FormlO40-V. 20a Social security benefits ............ I 20a I 23,786 'l b Taxable amount (see page 24) 20b 2,817,
21 Other income. List type and amount - see page 24
21 5,606,
22 Add the amounts in the far dght column for lines 7 through 21. This is your total income .................. · 22 3 1,7 5 6.
23 IRA deduction (see page 25) ......................................................... 23
Adjusted 24 Student loan interest deduction (see page 27) .................................... 24
Gross 25 Medical savings account deduction. Attach Form 8853 ........................ 25
Income 26 Moving expenses. Attach Form 3903 26
If line 33 is under 27 0ne-half of self-employment tax. Attach Schedule SE ........................ 27 1
$30,095 (under
$10,030 ifa child 28 Self-employed health insurance deduction (see page 28) ..................... 28 1,5 5 1.
did not live with 29 Keogh & self-employed SEP plans and SIMPLE plans ........................ 29
Inst. on page 36. 30 Penalty on early withdrawal of savings ............................................. 30
31a Alimony paid b Recipient's SSN · : : 31a
32 Add lines 23 through 31a ......................................................................................................... 32 3r 198.
33 Subtract line 32 from line 22. This is your adjusted gross income ............................................. · 33 2 8 ~ 5 5 8,
810001
02-16-99 LHA For Disclosure, Privacy Act, and Papenvork Reduction Act NotiCe, see page 51. Form 1040 (19981
For~O40¢gga) ~L B & JAN'$CF W'ETSHIED ' 1,7'-20,-3373 OMBNo. 1545-0074 Page2
Tax and 34 Amount from line 33 (adjuste~ ,.oss income) .......................................................................................34 2 8 · 5 5 8,
Credits 35a Check if: ~ You were 65 or older, ~ Blind; [~ Spouse was 65 or older, ~ Blind.I :::::::::::::::::::::::::::::::
Add the number of boxes checked above and enter the total here · 35aI 2
Standard ~ b If you are married filing separately and your spouse itemizes deductions
~:~:~:~:~:~:i:~:i:~:
Deduction_L_ or you were a dual-status alien, see page 29 and check here .......................................... · 35b [---]
for Most 36 Enter the larger of your Itemized deductions from Schedule A, line 28, OR standard
People -- deduction shown on the left. But see page 30 to find your standard deduction if you ...................
Single: checked any box on line 35a or 35b or if someone can claim you as a dependent .......................................... 36 20 x 4 3 8.
$4,250 37 Subtract line 36 from line 34 37 8 r 12 0.
Head of 38 If line 34 is $93,400 or less, multiply $2,700 by the total number of exemptions claimed on
household: line 6d. If line 34 is over $93,400, see the worksheet on page 30 for the amount to enter .............................. 38 5,4 0 0
$6,250 39 Taxable income. Subtract line 38 from line 37. If line 38 is more than line 37, enter-0- 39 2,72 0.
Married filing 40 Tax. See page 30. Check if any tax from a ~ Form(s) 8814 b ]-~ Form 4972 · 40 4 0 7
jointly or ...............................
Qualifying 41 Credit for child and dependent care expenses. Attach Form 2441 41
..................
widow(er): 42 Credit for the elderly or the disabled. Attach Schedule R 42
$7,100 ..............................
Married 43 Child tax credit (see page 31) ............................................................... 43
filing 44 Education credits. Attach Form 8863 ...................................................... 44
separately: i 45 Adoption credit. Attach Form8839 ......................................................... 45
$3,550. 46 Foreign tax credit. Attach Form 1116 if required ....................................... 46
47 0ther. Checkiffrom a ~ Form3800 b [-~ Form8396 ii!iiiiiiiiiii?iiii~ii~!iiiii
c ~ Form 8801 d [-~ Form (specify) 47
48 Add lines 41 through 47. These are your total credits .............................................................................. 48
49 Subtract line 48 from line 40. If line 48 is more than line 40, enter-0-. .................................................. · 49 407.
Other 50 Self-employment tax. Attach Schedule SE ............................................................................................. 50 3 · 2 9 3.
Taxes 51 Alternative minimum tax. Attach Form 6251 .......................................................................................... 51
52 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 ........................... 52
53 Tax on IRAs, other retirement plans, and MSAs. Attach Form 5329 if required ............................................. 53
54 Advance earned income credit payments from Form(s) W-2 ..................................................................... 54
55 Household employment taxes. Attach Schedule H 55
56 Add lines 49 through 55, This is your total tax .............................................................................. · 56 3,700.
~:~:!:!:i:~:~:i:i:i:
Payments 57 Federal income tax withheld from Forms W-2 and 1099 .............................. 57
58 1998 estimated tax payments and amount applied from 1997 return ............ 58 9,0 0 0.
Attach 59a Earned Income credit. Attach Schedule EIC if you have a qualifying child ::iii::iiiii::~::i::ii~::~
Forms W-2 b Nontaxable earned income: amount · ;~:~:~:~:~:~:~:~:~:~
and W-2G .................... ?!?ii?!?iii~i
on page 1. and type · 59a
Also attach 60 Additional child tax credit. Attach Form 8812 ............................................. 60
Form 1099-R 61 Amount paid with Form 4868 (request for extension) 61
if tax was .................................
withheld. 62 Excess social security and RRTA tax withheld (see page 43) ........................ 62
63 Other payments. Check if from a [~ Form 2439 b [-'--] Form 4136 ...... 63
64 Add lines 57, 58, 59a, and 60 through 63. These are your total payments ............................................. · 64 9~000.
Refund 65 If line 64 is more than line 56, subtract line 56 from line 64. This is the amount you 0VERPAiD ........................ 65 5·3OO.
~aveit 66a Amount of line 65 you want REFUNDED TO YOU · 66a
directly
:Jeposited! · b Routing number · c Type: [~] Checking [--~ Savings
See page 44
and fill in 66b, · d Account number :::::::::::::::::::::::::::::::::
S6 .... d66d. 67 Amount of line 65 you want APPLIED TO YOUR1999 ESTIMATED TAX · I 67 I 5· 300.
Amount 68 If line 56 is more than line 64, subtract line 64 from line 56. This is the AMOUNT YOU OWE.
You Owe For details on bow to pay, see page 44
Estimatedtaxpena~ty.A~s~inc~ude~n~i....~"~.....~.....~...~.......~.~`~..~.~.......~.``."..~.`ne68...`~..~..~.~....~.~.~.~.~......""~.~6~I ........................... · 68
69
Sign
Here
Keep a copy
for your
records.
Under penalties of perjury, I declare that 1 have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all infom~aUon of which preparer has any knowledge,
Your signature Date Your occupation Daytime telephone
Spouse's signature. If a joint return, BOTH must sign. Date
DENT I S T number (optional)
Spouse's occupation
HOUSEWIFE
Date 9 Check if self- Preparer's social security no.
04/15/9 employed [---] 189 52 1408
EIN 23 "-2198946
Z, Poode 17104--2104
Preparer's
Paid signature
Preparer'sFi.m.sname(or WILDEMAN AND OBROCK, CPA' S
Use Only ycurei, se, f-e~ ~11~515 S. 29TH STREET
ployed) and address HARR I S BURG, PA
810002
02-15-99 5
SCHEDULES A&B
(Form 1040)
Department of the Treasury
Internal Revenue Service
S 9dule A- Itemized Deductic ,
~ (Schedule B is on page 2)
· Attach to Form 1040. · See Instructions for Schedules A and B (Form 1040).
Attachment
Sequence No. 07
Name(s) shown on Form 1040
KARL B & JANICE W ETSHIED
Medical
and
Dental
Expenses
Caution: Do not include expenses reimbursed or paid by others.
I Medical and dental expenses (see page A-l) ......... .S.(~.e......S.~..a...t..e..m.e...n..t......6 ....
2 Enter amount from Form 1040,1ine34 .............................. [ 2 I 2 8 · 55 8 .
3 Multiply line 2 above by 7.5% (.075) .....................................................................
4 Subtract line 3 from line 1. If line 3 is more than line 1, enter -0-
Taxes You
Paid
(See
page A-2.)
6 Real estate taxes (see page A-2) ...........................................................................
7 Personal property taxes .......................................................................................
8 Other taxes. List type and amount
· PERSONAL & OPT 1,007.
Interest
You Paid
(See
page A-3.)
Note:
Personal
interest is
not
deductible.
Gifts to
Charity
Ify0u made a
gift and got a
benefit for it,
see page A-4.
9 Add lines 5 through 8
10 Home mortgage interest and points reported to you on Form 1098 ........................ /10
11 Home mortgage interest not reported to you on Form 1098. If paid to the person
from whom you bought the home, see page A-3 and show that person's name,
identifying no., and address
Points not reported to you on Form 1098. See page A-3 for special ~%~mt 4 12
Investment interest. Attach Form 4952 if required. (See page A-3.) .......... 13
12
13
14
Your social security number
174 20 i3373
3,496
2,142.
1,400
2,778
1,007
7,860
125.
Add lines 10 through 13 ..................................................................................................................... [ 14
15 Gifts by cash or check. If you made any gift of $250 or more, Ii:ii?i!i:![:~ii
see page A-4 ...................................................... S..e...e.....~...~..a...~..e...[~...~..~..t....~ .... I15 3 0 8
16 Other than by cash or check. If any gift of $250 or more, see page A-4.
You MUST attach Form 8283 if over $500 ............................................................ 16
17 Carryover from prior year .................................................................................... 17 19
18 Add lines 15 through 17 ....................................................................... 18
19 Casualty or theft loss(es). Attach Form 4684. (See page A-5.) ...............................................................
lr354.
5,185.
7,985.
308.
Casualty and
Theft Losses
Job Expenses
and Most
Other
Miscellaneous
Deductions
(See
page A-6 for
expenses to
deduct here.)
20
21
22
Unreimbursed employee expenses- job travel, union dues, job education, etc.
You MUST attach Form 2106 or 2106-EZ if required. (See page A-5.)
Tax preparation fees .......................................................................................... 21
~Other expenses- investment, safe deposit box, etc. List type and amount
Add lines 20 through 22 ....................................................................................... 23
Enter amount from Form 1040, I ne 34 ...................... {241 ?~ii~i!!
Multiply line 24 above by 2% (.02) ........................................................................
25
23
24
25
26 Subtract line 25 from line 23. If line 25 is more than line 23, enter -0-
0thor 27 Other- from list on page A-6. List type and amount
Miscellaneous ~Gambling losses 5,606.
Deductions
28
Total
Itemized
Deductions
Is Form 1040, line 34, over $124,500 (over $62,250 if married filing separately)?
NO. Your deduction is not limited. Add the amounts in the far right column for lines 4
through 27. Also, enter on Form 1040, line 36, the larger of this amount or your
standard deduction.
YES. Your deduction may be limited. See page A-6 for the amount to enter.
5,606.
20,438.
LHA For Paperwork Reduction Act Notice, see Form 1040 instructions. Schedule A (Form 1040) 1998
819501
11-02-98 6
WE SINCERELY APPRECIATE THE OPPORTUNITY TO SERVE YOU.
CONTACT ME IF YOU HAVE ANY QUESTIONS REGARDING THESE
RETURNS.
PLEASE
TAX
YOUR COPIES OF THE RETURNS ARE ENCLOSED FOR YOUR FILES.
SUGGEST THAT YOU RETAIN THESE COPIES INDEFINITELY.
SINCERELY,
WE
MICHAEL A. KUNISKY, CPA
~ :, EARNED INCOME
CURRENT MAI£IrqG ADORESS ItC NOT THE SAME AS BELOW} TWP/BORO / / TO / /
! / PR=S=NT
I 94-- ~2--7 5 ~ 5 1998 FINAL RETURN FOR EARNED INCOgE TAX
DLN
WESTAB FORM 531 (REV. 11/98)
1% AMOUNT
JANICE
111 N 32ND ST
CAMP HILL PA 17011 050J CAMP HILL i~0R0
1. W-2 EARNINGS {Ali&ch W-2's) ...........................................................
2. EMPLOYEE BUSINESS EXPENSES {Allach $1ale Schedule UE-I and ReqLliled AltaCllmel.ls) . . 12
3.TAXABLE W-2 EARNINGS (Stihl[ac! Line 2 EOlll ti.e I)
]
6.NET LOSS FROM SELF-EM~OYED BUSINESS. PROFESS ON. OR FARM J6.~6
17.1 SUBTOTAL (Sublracl Line 6 Iron, Li,,e 5) IF LESS THAN ZERO. ENTER ~E~O 17,1
8. NET PROFIT FROM SELF-EMPLOYED BUSINESS. PROFESSION. OR FARM 8
I (Use Li,,e 6 for any N. L ..... ) (A,lach A~ropriale IRS ~h~u,es) ....................................... ~8.~23309
g. ] TOTAL TAXABLE EARNED INCOME AND NET PROFI IS (Add Line 7 er~ 8) ................................. [g'l23309
io.I TAX LIABILI~ I% OF LINE g (Mullip~ Li~ 9 by .01 i,o.I
= == =N=== ========= ======== ==== == ==== ======= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
12. IF UNE11C IS LARGER ~AN LINE lO E~ERREFUNDOUEHERE O 1999 ES~[~ES ,2 67
I r (IlL ....... $'.~, Enter Zero) '-APPLY.-T ....................
~t3 IFLINE IOIS~RGERTHAN .NE/lC PAY UNPAID BALANCE BY A ~R L 5 13
14.15,~ ~YADD INTEREST AND PENAL~ OF 1% PER MONTH OF LINE 13 AFTER APRIL 15 .............
BA~NCE DUE WITH THIS RETURN (Li~e 13 Flus Line 1,1)
CURRENT MAIUNG ADDRESS (IF NOT THE SAME AS BELOW) TWP/BORO/ / TO / /
~ -- / / PnESEN r
~,.L SECU.,.~ coo. TAX BUREAU COPY
~ 17~-2D-5573 I o J1998 FINAL RETURN FOR EARNED INCOME TAX~ DLN
KARL B
111 N 32ND ST
ETSHIED
CAMP HILL PA 17011
2-387-400
~ CAMP HJ:LL 80RO
Schedules A&B (Form 1040) 1998
Name{s) shown on Form 1040. Do not enter name and soci~.
;udty number if shown on page 1.
KARL B & JANICE W ETSHIED
OMB No. 1545-0074 Page 2
Your social security number
174 20 3373
Schedule B - Interest and Ordinary Dividends
Attachment
Sequence No. 08
Part I
Interest
Note: If you had over $400 in taxable interest income, you must also complete Part III.
I List name of payer. If any interest is from a seller-financed mortgage and the buyer used the
property as a personal residence, see page B-1 and list this interest first. Also, show that
buyer's social security number and address ·
HARRIS SAVINGS BANK
Note: If you
received a Form
1099-1NT,
Form 1099-OID,
or substitute
statement from
a brokerage firm,
list the firm's
name as the
payer and enter
the total interest
shown on that
form.
2 Add the amounts on line 1
3 Excludable interest on series EE U.S. savings bonds issued after 1989 from Form 8815,
line 14. You MUST attach Form 8815 to Form 1040 .....................................................................
4 Subtract line 3 from line 2. Enter the result here and on Form 1040, line 8a ........................... ·
Part II Note: If you had over $400 in ordinary dividends, you must also complete Part III.
Ordinary
Dividends
Amount
Amount
Note: If you
received a Form
1099-DIV or
substitute
statement from
a brokerage firm,
list the firm's
name as the
payer and enter
the ordinary
dividends shown
on that form.
5 List name of payer. Include only ordinary dividends. Report any capital gain distributions
on Schedule D, line 13 ·
SCHEDULE C
(Form 1040)
Department of the Treasury
Internal Revenue Service (99)
'rofit or Loss From Busines,,
(Sole Proprietorship)
· Partnerships, ioint ventures, etc., must file Form 1065 or Form 1065-B.
· Attach to Form 1040 or Form 1041. · See Instructions for Schedule C (Form 1040).
OMB No. 1545-0074
1998
Sequence No, U~::~
Name of proprietor
KARL B ETSHIED
A Principal business or profession, including product or service (see page C-1)
DENT I ST / DENT I STRY
Social security number (SSN)
174-20-3373
B Enter NEW code from pages C-8
· 621210~
C Business name. If no separate business name, leave blank. D Employer ID number (EIN), if any
KARL B ETSHIED DDS 23-1574543
E Business address (including suite or room no.) · 111 N 32ND ST
City. town or post office, state, andZIPcode CAMP HILL, PENNSYLVANIA 17011
F Accounting method: (1)l X] Cash (2)1 I Accrual (3)L__] Other(specify) ·
G Did you "materially participate" in the operation of this business dudng 19987 If"No," see page C-2 for limit on losses .............................. ~--T ~e;- [----1 No
H If you started or acquired this business during 1998, check here ............................................................................................................ · ~
lii~!~i!i;ii!ii~iill Income
I Gross receipts or sales. Caution: If this income was reported to you on Form W-2 and the "Statutory employee" box on
that form was checked, see page C-3 and check here .............................................................................. · ~ I 5 i, 5 4 2 .
2 Returns and allowances .......................................................................................................................................... 2
3 Subtract line 2 from line 1 ....................................................................................................................................... 3 5 1,5 4 2.
4 Cost of goods sold (from line 42 on page 2) ............................................................................................................... 4
5 Gross profit. Subtract line 4 from Fine 3 ..................................................................................................................... ~7 5 1 r 5 4 2.
6 Other income, including Federal and state gasoline or fuel tax credit or refund (see page C-3) ................................................
7 Gross income. Add lines 5 and 6 ......................................................................................................................... · 5 1,5 4 2.
[!~!:~iiiiiiii:il Expenses. Enter expenses for business use of your homeonly on line 30.
8 Advert sing ....................................8 19 Pension and profit-sharing plans .................. 19
9 Bad debts from sales or 20 Rent or lease (see page C-5):
services (see page C-3) .................. g a Vehicles, machinery, and equipment ............. 20a
10 Car and truck expenses b Other business property ........................... 20b
(see page C-3) ......... .S...t..i~...~.....7 ....10 5 8 5. 21 Repairs and maintenance ........................... 21
11 Commissions and fees .................. 11 22 Supplies (not included in Part III) ............... 22 2 r 3 1 8.
12 Depletion .................................... 12 23 Taxes and licenses .................................... 23
13 Depreciation and section 179 24 Travel, meals, and entertainment: ::::::::::::::::::::::
expense deduction (not included in a Travel ................................................... 24a
Part )(seepageC-4) ..................... 13 5,099. b Mealsand
14 Employee benefit programs (other entertainment
than on line 19) ........................... 14 c Enter 50% of line
15 Insurance (other than health) ............ 15 836. 24b subject to
16 Interest: ::::::::::::::::::::::::::::::::::: limitations (see page C-6) ...
a Mortgage (paid to banks, etc.) ......... 16a d Subtract line 24c from line 24b 24d
b Other .......................................... 16b 25 Utilities ................................................... 25 1
17 Legal and professional 26 Wages (less employment credits) ............... 26
services ....................................... 17 5 4 5. 27 Other expenses (from line 48 on
18 Office expense .............................. 18 2,823. page 2) ...................................................27 10,169
28 Total expenses before expenses for business use of home. Add lines 8 through 27 in columns ....................................... · 28 2 3,7 9 9.
29 Tentative profit (loss). Subtract line 28 from line 7 ......................................................................................................... 29 2 7,7 4 3.
Schedule C (Form 1040) 1998 Kj~R1',
I?~?~i~iii!l Cost of Goods Sold
B F~HIED
(see ~. _ge 0-7)
174-20-3373
Page 2
33 Method(s) used to
value closing inventory: a ~ Cost b ~--~ Lower of cost or market c [~ Other (attach explanation)
34 Was there any change in determining quantities, costs, or valuations between opening and closing inventory? If
"Yes,' attach explanation ................................................................................................................................................ [~ Yes
35 Inventory at beginning of year. If different from last year's closing inventory, attach explanation .................................... 3~5
36 Purchases less cost of items withdrawn for personal use ....................................................................................... 3~6
37 Cost of labor. Do not include any amounts paid to yourself .................................................................................... 3~7
38 Materials and supplies .................................................................................................................................... 38
39 Other costs ................................................................................................................................................... 3...._~_g
40 Add lines 35 through 39 ................................................................................................................................. 4__~_0
41 Inventory at end of year ................................................................................................................................. 4._.~_1
42 Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on page 1, line 4 ....................................... 42
fi~i~i~i~!it Information on Your Vehicle. Complete this part ONLY if you are claiming car or truck expenses on line 10 and are not required
to file Form 4562 for this business. See the instructions for line 13 on page 0-4 to find out if you must file.
~]No
43 When did you place your vehicle in service for business purposes? (month, day, year) ~' / /
44 Of the total number of miles you drove your vehicle during 1998, enter the number of miles you used your vehicle for:
a Business b Commuting c Other
45 Do you (or your spouse) have another vehicle available for personal use? .............................................................................. ~ Yes
46 Was your vehicle available for use during off-duty hours? ................................................................................................... ~ Yes
47a Do you have evidence to support your deduction? ............................................................................................................ ~ Yes
b If"Yes," is the evidence written? .................................................................................................................................... ~-1 Yes
f:~ii~:~i~?i:i~i:i] Other Expenses. List below business expenses not included on lines 8-26 or line 30.
LABORATORY FEES
DUES & MEETINGS
BANK CHARGES
~ No
~ No
I--] No
[---I No
9,551.
469.
149.
Depreciation and Amortization D~
Asset
KARL B ETSHIED DDS
Description of property
1
Date Method/ Life Line Cost or
Number placed RC sec. or rate No.
· · other basis
In service
1 BUILDING (BUS PORTION)
I'?,iii iii?,ilO9,O5,551 I- 020 119 [ 7, ooo -I
??~::.::?~il0 611 519 812 0 0 DB]7.0 0 115C1 4,4 0 8 -I
5 COMPUTER
i?~iiiiil06.15,981200 DBI5.00 I15 BI 2,755. I
Total Sch C Depreciation
Accumulated
depreciation/amortization
4,408.]
5,460
4,408.I
Basis
reduction
Cu. rr.ent, year
oeoucllon
140.
4,408.
551 ·
5,460.]
5,099.
SCHEDULE SE
(Form 1040)
Department of the Treasury
Internal Revenue Servlce
Self-Employment Tax
· See Instructions for Schedule SE (Form 1040).
· Attach to Form 1040.
OMB No. 1545-0074
lg98
Attachment
Sequence No. 17
Name of person with self-employment income (as shown on Form 1040)
KARL B ETSHIED
Social security number of
person with self-employment
income ·
174i20i3373
Who Must File Schedule SE
You must file Schedule SE if:
· You had net earnings from self-employment from other than church employee income (line 4 of Short Schedule SE or line 4c of Long Schedule SE)
of $400 or more, OR
· You had church employee income of $108.28 or more. Income from services you performed as a minister or a member of a religious order
is not church employee income. See page SE-I.
Note: Even if you had a loss or a small amount of income from self-employment, it may be to your benefit to file Schedule SE and use either
"optional method' in Part II of Long Schedule SE. See page SE-3.
Exception. If your only self-employment income was from earnings as a minister, member of a religious order, or Christian Science practitioner, and
you filed Form 4361 and received IRS approval not to be taxed on those earnings, do not file Schedule SE. Instead, write "Exempt-Form 4361" on
Form 1040, line 50.
May I Use Short Schedule SE or MUST I Use Long Schedule SE?
I DID YOU RECEIVE WAGES OR TIPS IN 19987
Yes
Are you a minister, member of a religious order, or Christian
Science practitioner who received IRS approval not to be taxed
on earnings from these sources, but you owe self-empl0yment
tax on other earnings?
!FN°
Are you using one of the optional methods to figure y0ur net IYes~
earnings (see page SE-3)?
~1tN0
Did you receive church employee income reported on Form W-2 ~
of $108.28 or more?
YOU MAY USE SHORT SCHEDULE SE BELOW
employment more than $68,400? I I
'1
Did you receive tips subject to social security or Medicare IYes~
tax that you did not report to your employer?
YOU MUST USE LONG SCHEDULE SE
Section A - Short Schedule SE. Caution: Read above to see if you can use Short Schedule SE.
I Net farm profit or (loss) from Schedule F, line 36, and farm partnerships, Schedule K-1
(Form 1065) ne 15a ................................................................................................ 1
2 Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065), line 15a
(other than farming); and Schedule K-1 (Form 1065-B), box 9. Ministers and members of religious orders,
see page SE-1 for amounts to report on this line. See page SE-2 for other income to report ............ ~..~...[~...~......8. .... 2
3 Combine lines 1 and 2 .......................................................................................................................................
4 Net earnings from self-employment Multiply line 3 by 92.35% (.9235). If less than $400, do not
file this schedule; you do not owe self-employment tax ................................................................................. ·
23,309.
23,309.
21,526.
6251
A, .rnative Minimum Tax - Indi ,..aais
· Attach to Form 1040 or Form 1040NR.
Name(s) shown on Form 1040
KARL B & JANICE W ETSHIED
OMB No. 1545-0227
1998
Attachment
Seque.ce No.32
Your social security number
174i2013373
I!!ii~i!ii!ii!i!i!il Adjustments and Preferences
I If you itemized deductions on Schedule A (Form 1040), go to line 2. Otherwise, enter your standard deduction
from Form 1040, line 36, here and go to line 6 ...................................................................................................
2 Medical and dental. Enter the smaller of Schedule A (Form 1040), line 4 or 2 1/2% of Form 1040, line 34 ............
3 Taxes. Enter the amount from Schedule A (Form 1040}, line 9 ...........................................................................
4 Certain interest on a home mortgage not used to buy, build, or improve your home .............................................
5 Miscellaneous itemized deductions. Enter the amount from Schedule A (Form 1040), line 26 ..............................
6 Refund of taxes. Enter any tax refund from Form 1040, line 10 or line 21
7 Investment interest. Enter difference between regular tax and AMT deduction ...................................................
8 Post-1986 depreciation. Enter difference between regular tax and AMT depreciation ..........................................
9 Adjusted gain or loss. Enter difference between AMT and regular tax gain or loss ................................................
10 Incentive stock options. Enter excess of AMT income over regular tax income ...................................................
11 Passive activities. Enter difference between AMT and regular tax income or loss
12 Beneficiaries of estates and trusts. Enter the amount from Schedule K-1 (Form 1041), line 9 ..............................
13 Tax-exempt interest from private activity bonds issued after 8/7/86
14 Other. Enter the amount, if any, for each item below and enter the total on line 14.
a Circulation expenditures ... h Loss limitations
b Depletion ........................ i Mining costs .....................
c Depreciation(pre-1987) ... j Patron's adjustment .........
d Installment sales ............... k Pollution control facilities
e Intangible drilling costs ...... I Research and experimental
f Large partnerships ............ m Section 1202 exclusion ......
g Long-term contracts ......... n Tax shelter farm activities ...
o Related adjustments
15 Total Adjustments and Preferences. Combine lines 1 through 14 ............................................................... ·
16 Enter the amount from Form 1040, line 37. If less than zero, enter as a (loss) ................................................ · 16
17 Net operating loss deduction, if any, from Form 1040, line 21. Enter as a positive amount .................................... 17
18 If Form 1040, line 34, is over $124,500 (over $62,250 if married filing separately), and you itemized deductions,
enter the amount, if any, from line 9 of the worksheet for Schedule A (Form 1040), line 28 ................................. 18
19 Combine lines 15 through 18 ..................................................... · 19
20 Alternative tax net operating loss deduction ....................................................................................................... 20
21 Alternative Minimum Taxable Income. Subtract line 20 from line 19. (If married filing separately
and line 21 is more than $165,000, see instruct one ) .......................................................................... · 21
fi?~ili~iiiiil Exemption Amount and Alternative Minimum Tax
22 Exemption Amount. (If this form is for a child under age 14, see instructions.).,~ 23
If your filing status is: And line 21 is not over: THEN enter on line 22:
Single or head of household .............................. $112,500 ........................ $33,750 '~
Married filing jointly or qualifying widow(er) ......... 150,000 ........................ 45,000 22'
Married filing separately .................................... 75,000 ........................ 22,500 .....................
If line 21 is over the amount shown above for your filing status, see instructions.
23 Subtract line 22 from line 21. If zero or less, enter -0- here and on lines 26 and 28 .......................................... ·
714.
5,185.
138.
6,037.
8,120.
14,157.
14,157.
45,000.
0.
KARL B & JANICE W ETSHIED 174-20-3373
Form 6251 (1998) ~
Line 24 Computation Using Maximum Capital Gains Rates
Page 2
Caution: If you did not complete Part IV of Schedule D (Form 1040), complete lines 20 through 2 7 of
Schedule D (as refigured for the AMT, if necessary) before you complete this part.
29 Enter the amount from line 23 ...........................................................................................................................
30 Enter the amount from Schedule D (Form 1040), line 27 (as refigured for the
AMT, if necessary) .......................................................................................... 30
31 Enter the amount from Schedule D (Form 1040), line 25 (as refigured for the
AMT, if necessary) .......................................................................................... 31
32 Add lines 30 and 31 .......................................................................................... 3_~_2
33 Enter the amount from Schedule D (Form 1040), line 22 (as refigured for the
AMT, if necessary) .......................................................................................... 33
34 Enter the smaller of line 32 or line 33 ...............................................................................................................
35 Subtract line 34 from line 29. If zero or less enter -0-. ...........................................................
36 If line 35 is $175,000 or less ($87,500 or less if married filing separately), multiply line 35 by 26% (.26).
Otherwise, multiply line 35 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from
the result ...................................................................................................................................................
37 Enter the amount from Schedule D (Form 1040), line 36 (as figured for the regular tax) .......................................
38 Enter the smallest of line 29, line 30, or line 37
39 Multiplyline 38 by 10% (.10) ..................................................................................................................... ~
40 Enter the smaller of line 29 or line 30 ...............................................................................................................
41 Enter the amount from line 38 ...........................................................................................................................
42 Subtract line 41 from line 40. If zero or less, enter -0-. .........................................................................................
43 Multiply line 42 by 20% (.20) ..................................................................................................................... ~
44 Enter the amount from line 29 ...........................................................................................................................
45 Add lines 35, 38, and 42
46 Subtract line 45 from line 44 ..............................................................................................................................
47 Multiply line 46 by 25% (.25) .....................................................................................................................
48 Add lines 36, 39, 43, and 47 ..............................................................................................................................
49 If line 29 is $175,000 or Tess ($87,500 or less if married filing separately), multiply line 29 by 26% (.26).
Otherwise, multiply line 29 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from
the result .........................................................................................................................................................
50 Enter the smaller of line 48 or line 49 here and on line 24 ........................................................................... ~-
ALTERNATIVE MINIMUM TAX RECONCILIATION REPORT
Social Security Number
IED 174-20-3373
Adjustment
Income
Form 6251
Form 6251, Line 8 Form 6251, Line 9 Form 6251, Line 11 Form 6251, Line 14h Other Adjustment
3
-= 23,309.
138. 138.
~= 23,447. 138.
AE~F~* IA~'IVE MINIMUM TAX DEPRECIATION "-PORT
ASSET AMT AMT REGULAR AMT AMT
DESCRIPTION
NUMBER METHOD LIFE DEPRECIATION DEPRECIATION ADJUSTMENT
KARL B ETSHIED DDS
DENTAL CHAIR AND
4 EQUIPMENT 150DB 10.00 4,408. 4,408. 0.
5 ~OMPUTER 150DB 5.00 551. 413. 138.
** Subtotal ** 4,959. 4,821. 138.
~** Grand Total ***
4,959. 4,821. 138.
Department of the Treasury
Internal Revenue Service
(99)
Exp, .see for Business Use of Yo . HOme I oM..o. 4 . 266
~ File only with Schedule C (Form 1040). Use a separate Form 8829 for each I 998
home you used for business during the year.
Attachment
Sequence No.
66
Name(s) of proprietor(s)
KARL B ETSHIED
I Y0ur social security number
;[74--20--3373
Part of Your Home Used for Business
I Area used regularly and exclusively for business, regularly for day care, or for storage of inventory
or product samples ...............................................................................................
2 Total area of home ............................................ / 2
3 Divide line 1 by line 2. Enter the result as a percentage .................................................................................... [ 3 J %
· For day-care facilities not used exclusively for business, also complete lines 4-6.
· All others, skip lines 4-6 and enter the amount from line 3 on line 7.
4 Multiply days used for day care during year by hours used per day .................. 4 hr.
6 Divide line 4 by line 5. Enterthe result as a decimal amount .............................. J 6 I I!i?~i?~i?~i?~
7 Business precentage. For day-care facilities not used exclusively for business, multiply Fine 6 by line 3
(enter the result as a percentage). All others, enter the amount from tine 3 ................................................... ~ ~ 7
I!i:!!i~?:[~=~i~:~i~:~!t Figure Your Allowable Deduction
9
10
11
12
13
14
15
Enter the amount from Schedule C, line 29, plus any net
home and shown on Schedule D or Form 4797. If more
See instructions for columns {a) and (b) before
completing lines 9-20.
Casualty losses ......................................................
Deductible mortgage interest ....................................
Real estate taxes ...................................................
Add lines 9, 10, and 11 .............................................
Multiply line 12, column (b) by line 7 ........................
Add line 12, column (a) and line 13 ...........................
Subtract line 14 from line 8. If zero or less, enter -0- ...
Insurance ...............................................................
Repairs and maintenance .......................................
Utilities ..................................................................
16 Excess mortgage in~tere.st~
17
18
19
20
21
22
23
24
25
26
27
28
29
3O
31
32
33
Other expenses ......................................................
Add lines 16 through 20 ..........................................
Multiply line 21, column (b) by line 7
Carryover of operating expenses from 1997 Form 8829
Add line 21 in column (a), line 22, and line 23
Allowable operating expenses. Enter the smaller of line 1
Limit on excess casualty losses and depreciation. Sub~
Excess casualty losses ....................
Depreciation of your home from Part III below
Carryover 0f excess casualty losses and depreciation from
Add lines 27 through 29
Allowable excess casualty losses and depreciation. Enter
Add lines 14, 25, and 31
Casualty loss portion, if any, from lines 14 and 31. Cam
~t gain or (loss) derived from the business use of your
than one place of business, see instructions .................. 8 2 ?, 7 4 3.
ilililiiiiii!i!i!iii! (a) Direct expenses (b) Indirect expenses....................
11 2,7 7 8.
17 701 ....................
18 2,118.
19 2,316.
:!:!:i:!:!:!:~:~:?!
2a 4,434 701 ...................
. ,ne4~ ..................... 23
..................................................................................... 24 4,434.
~ 15 or line 24 ................................................................... 25 4,4 3 4.
tact line 25 from line 15 ................................................ 26 2 3,3 0 9.
17 Form 8829, line 49 ...... 29
..................................................................................... 30
er the smaller of line 26 or line 30 31 0 .
..................................................................................... 32 4,434.
~' amount to Form 4684, Section B .............................. 33 0
Intemal Revenue Service (99) ' ' ~ ~
. epYeciation and Amortizati ,
(Including Information on Listed Property) C-
I~ See separate instructions. ~ Attach this form to your return.
OMB No, 1545-0172
1998
Attachment
Sequence No. 67
Name(s) shown on tatum I Business or activit,j to which this form relates Identifying number
/
KARL B & JANICE W ETSHIED ~ARL B ETSHIED DDS 174-20-3373
I!ii!~iii~i!l Election To Expense Certain Tangible Property {Section 179) {Note: If you have any 'listed pr0perty,'c0mplete Part V before you complete Part I.)
I Maximum dollar limitation. If an enterprise zone business, see instructions ......................................................... I 1 8,5 0 0 .
2 Total cost of section 179 property placed in service ..........................................................................................
3 Threshold cost of section 179 property before reduction in limitation .................................................................. 3 $200,000
4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter -0- . ........................................................ 0.
5 Dollar limitation for tax year. Subtract line 4 from line 1. If zero or less, enter -0-. If married filing
separately~ see instructions .............................................................................................................................. ]. 8 · 5 0 0 .
6 a Description of property (b) Cost (bus ness use on y) (c) E ected cost
7 Listed property. Enter amount from line 27 .................................................................. [ 7
8 Total elected cost of section 179 property. Add amounts in column (c), lines 6 and 7 .......................................... 8 4 r 4 0 8.
9 Tentative deduction. Enter the smaller of line 5 or line 8 ................................................. I 9 I 4 ~ ~ 0 8.
10 Carryover of disallowed deduction from 1997 ................................................................................................... 10
11 Business income limitation. Enter the smaller of business income (not less than zero) or line 5 ........................... 11 ] 8
12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 .................................... 12
13 Carryover of disallowed deduction to 1999. Add lines 9 and 10, less line 12 ............ ~ I 13 I
Note: Do not use Part II or Part III below for listed property (automobiles, certain other vehicles, cellular telephones, certain computers, or property
used for entertainment, recreation, or amusement). Instead, use Part V for listed property.
f:iiii~!ii:~!iii:~l MACRS Depreciation For Assets Placed in Service ONLY During Your 1998 Tax Year (Do Not Include Listed Property.)
Section A - General Asset Account Election
If you are making the election under section 168(i)(4) to group any assets placed in service during the tax year into one or more general asset
accounts, check_this .~ox. _See instruction_s ................................................................................................................... ~_
Section B - General Depreciation System (GDS) (See instructions.)
(b) Month and (c) Basis for depreciation
(a) Classification of property year placed (business/investment use (d) Recovery (e) Convention (1) Method (g) Depreciation deduction
in service only - see instructions) period
15 a 3-yearproperty :::::?:?:?:?:?:?::::::?:?:::?:::::?:::::?:?:?::::?:?:?:?:?:?:
c 7-year property
d 10-year property
f 20-year property ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
g 25-year property :%~~ 25 yrs. S/L
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
/ 27.5 yrs. MM S/L
h Residential rental property
/ 27.5 yrs. MM S/L
/ 39 yrs. MM S/L
i Nonresidential real property
/ MM S/L
Section C - Alternative Depreciation System (ADS) (See instructions.)
16 a Classlife ! I 12 yrs. I
b 12-year
S/L
S/L
Form 4562 {1998)KARL B & JA~I ~ ,ETSHIED ' ' 174-20-3373Page2
Listed Property- Automobiles, ,~ertain Other Vehicles, Cellular Telephones, Certah, Computers, and Property Used for
Entertainment, Recreation, or Amusement
Note: For any vehicle for which you are using the standard mileage rate or deducting lease expense, complete only 23a, 23b, columns (a)
through (c) of Section A, all of Section B, and Section C if applicable.
Section A - Depreciation and Other Information (Caution: See instructions for limits for passenger automobiles.)
23a D0y0u have evidencet0supp0rtthe business/investment use claimed? I Z I Yes I I No I 23b If 'Yes," isthe evidence written? ~ Yes ~ No
(a) (b) Date (c) (d) (e) Rec(f)eryCV (g) (h) (i)
Type of property placed in Business/ Cost or Basis for depreciation Method/ Depreciation Elected
3usiness/investment per od
investment 0ther basis Convention deduction section 179
(list vehicles first ) service use percentage use only) cost
Z4 ~roper~¥ usea more [nan ou~'o in a c Uallrlea business use:
~ = 100.00 %
: : o~
25 Property used 50% or less in a qualified business use:
26 Add amounts in column (h). Enter the total here and on line 20, page1 ...................................................... { 26 iii!ii[i!iii!i!ii!ii!i!?iiii[iiii?i?[i!iii!iiiiiiiii!!iiiiii
27 Add amounts in column (i). Enter the total here and on line 7, page I ................................................................................. I 27
Section B - Information on Use of Vehicles
Complete this section for vehicles used by a sole proprietor, partner, or other "more than 5% owner,' or related person.
If you provided vehicles to your employees, first answer the questions in Section C to see if you meet an exception to completing this section for
those vehicles.
(a) 1 (b) (c) (d) (e) (1~
28 Total business/investment miles driven during the Vehicle Vehicle Vehicle Vehicle Vehicle Vehicle
year (DO NOT include commuting miles) .................. 1, 8 0 0
29 Total commuting miles driven during the year ...
30 Total other personal (noncommuting) miles
driven ............................................................... 0
31 Total miles driven during the year.
Add lines 28 through 30 .................................... 1 ~ 8 0 0
Yes No Yes No Yes No Yes No Yes No Yes No
32 Was the vehicle available for personal use
during off-duty hours? .................................... X
33 Was the vehicle used primarily by a more
than 5% owner or related person? .................. X
34 Is another vehicle available for personal
use? X
Section C - Questions for Employers Who Provide Vehicles for Use by Their Employees
Answer these questions to determine if you meet an exception to completing Section B for vehicles used by employees who are not more than 5%
owners or related persons.
Yes
35 Do you maintain a written policy statement that prohibits all personal use of vehicles, including commuting, by your
employees? .................................................................................................................................................................................
36 Do you maintain a written policy statement that prohibits personal use of vehicles, except commuting, by your
employees? See instructions for vehicles used by corporate officers, directors, or 1% or more owners ..........
37 Do you treat all use of vehicles by employees as personal use? ...................................................................................................
38 Do you provide more than five vehicles to your employees, obtain information from your employees about
the use of the vehicles, and retain the information received? .........................................................................................................
No
KARL B & JANICE W ETS~I~ 174-20-3373
Form 1040 Miscellaneous Income Statement 1
Description
ADAMAR OF N.J. INC. - GAMBLING WINNINGS
BALLY'S PARK PLACE - GAMBLING WINNINGS
STATE OF N.J. - LOTTERY WINNINGS
Total to Form 1040, line 21
Amount
2,000.
1,250.
2,356.
5,606.
KARL B & JANICE W ETS~IF% t , ~ 174-20-3373
Form 1040 SOcial Security Benefits Worksheet Statement 2
Check only one box:
A. Single, Head of household, or Qualifying widow(er)
x B. Married filing jointly
C. Married filing separately and lived with your spouse
at any time during 1998
D. Married filing separately and lived apart from your spouse
for all of 1998
1.Enter the total amount from Box 5 of ALL your
Forms SSA-1099 and RRB-1099 (if applicable) ........
2.Enter one half of line 1 .....
3. Add the amounts on your 1998 Form 1040,'line' ' - - - - - -7,'8b,'9'thru
14, 15b, 16b, 17 thru 19, 21 and Schedule B, line 2. Do not
include any amounts from box 5 of Forms SSA-1099 or RRB-1099
4. Enter the amount of any exclusions from foreign earned
income, foreign housing, income from U.S. possessions,
or income from Puerto Rico by bona fide residents of
Puerto Rico that you claimed ...............
5.Add lines 2, 3, and 4 ...................
6. Enter the amounts on Form 1040, lines 23, 25 through 31 and
any amount you entered on the dotted line next to line 32.
7.Subtract line 6 from line 5
8. Enter: $25,000 if you checked Box A or , or
$32,000 if you checked Box B, or ........
-0- if you checked Box C
9.Subtract line 8 from line 7. If zero or less, enter -0- .
Is line 9 more than zero?
No. Stop here. None of your benefits are taxable. Do not
enter any amounts on lines 20a or 20b. But if you are married
filing separately and you lived apart from your spouse for
all of 1998, enter -0- on line 20b. Be sure you entered 'D'
to the left of line 20a.
Yes. Go to line 10.
10. Enter $9,000 ($12,000 if married filing jointly; $0 if married
filing separately and you lived with your spouse at any time
in 1998) .........................
11. Subtract line 10 from line 9. If zero or less, enter -0-.
12. Enter the smaller of line 9 or line 10 ..........
13. Enter one half of line 12 .................
14. Enter the smaller of line 2 or line 13 ..........
15. Multiply line 11 by 85% (.85). If line 11 is zero, enter -0-
16. Add lines 14 and 15 ....................
17. Multiply line 1 by 85% (.85) ...............
23,786.
11,893.
28,939.
40,832.
3,198.
37,634.
32,000.
5,634.
12,000.
0.
5,634.
2,817.
2,817.
0.
2,817.
20,218.
KARL B & JANICE W ETsHI' ~ 174-20-3373
Schedule A State and Local Income Taxes Statement 3
Description
Other State and Local Income Taxes
Pennsylvania Tax Payments - Taxpayer
Pennsylvania Tax Payments - Spouse
Total to Schedule A, line 5
Amount
450.
475.
475.
1,400.
Schedule A Points Not Reported on Form 1098 Statement 4
Description
Total to Schedule A, line 12
Amort.
Date Re- Total Period
financed Points /Mos.
Amortization
This Year
02/16/98 2,040. 180 125.
125.
Schedule A Cash Contributions Statement 5
Description
MISCELLANEOUS ORGANIZED CHARITIES
Subtotals
Total to Schedule A, line 15
Amount Amount
50% Limit 30% Limit
308.
308.
308.
Schedule A Medical and Dental Expenses Statement 6
Description Amount
Prescription Medicines and Drugs 454.
KARL B & JANICE W ETsHI-~ ~ ' 174-20-3373
Schedule C Car and Truck Expenses Statement 7
Description
Vehicle Number 1 - 1800 Business Miles @ $0.325
Total to Schedule C, line 10
Amount
585.
585.
Schedule SE Non-Farm Income Statement 8
Description
From Schedule C
Total to Schedule SE, line 2
Amount
23,309.
23,309.
WORKSHEET F
· COMPUTING ESTIMATED PERSO'NAt
RESIDENTS AND NONRESIDENTS
FOR THE TAXABLE YEAR JANUARY 1 - DECEMBER 31,1998
OR OTHER TAXABLE YEAR BEGINNING 1998, ENDING
'tOME TAX FOR
19
A. INCOME (Do not enter losses)
1. Compensation (wages, salaries, tips, etc. NOT SUBJECT TO WITHHOLDING) ............................................................
2. Net Profits from Business, Profession, or Farm ...................................................................................................
3. Interest
4. Dividends
5. Sale or Exchange of Property ...........................................................................................................................
6. Rents, Royalties, Patents and Copyrights .........................................................................................................
7. Estates orTrusts
8. Gambling and Lottery Winnings .....................................................................................................................
9. Total Pennsylvania taxable income (Add lines 1 through 8) ....................................................................................
10. Estimated Pennsylvania tax due (Multiply line 9 by 2.8%} ....................................................................................
B. CREDITS
11. Estimated Pennsylvania tax to be withheld
12. Estimated tax to be paid to other states (PENNSYLVANIA RESIDENTS ONLY) ............................................................
13. Estimated special tax forgiveness to be claimed ...................................................................................................
14. Total credits (Add lines 11,12 and 13} ............................................................................................................
C. TAX DUE Adjusted
15. Estimated balance due (Subtract line 14 from line 10) ..........................................................................................
16. If you have shown on line 30 of the 1998 PA-40, Individual Income Tax Return an
overpayment of tax due to be credited on 1999 estimated tax, you may apply the credit below
17. Computation of Estimated Payments:
840.00
VOUCHER I 2 3 4 TOTAL
D U E DATE 4/15/99 6/15/99 9/15/99 1/15/2000 iiii?iliiii?iiiiiiiiiiiii?ii!iiii!!iiii!?!ii!?ii~!iiiiiii?iiiiiii!iii!iii!
AMOUNT 210.00 210.00 210.00 210.00 840.0E
RECORD OF
PRIOR PAYMENTS
ESTIMATED
1998 OVERPAYMENT 110.00 110.0 E
TAX PAYMENTS
TOTAL 100.00 210 · 00 210.00 210.00 730. DE
DATE PAID
CHECK NO.
Cut AIo~ Dotted Une
1999 PA-40ES DECLARATION OF ESTIMATED
INDIVIDUAL PERSONAL INCOME TAX
174-20-3373 ET 194-22-7525
DUE DATE 01 18 00
ETSHIED 9902512053
1999 PA-40ES
INDIVIDUAL
Cu~lo~ot~edLine
DECLARATION OF ESTIMATED
PERSONAL INCOME TAX
174-20-3373 ET 194-22-7525
DUE DATE
09 15 99
ETSHIED 9902512053
1999 PA-40ES
INDIVIDUAL
..... ~u~l&n~ot~dLine
DECLARATION OF ESTIMATED
PERSONAL INCOME TAX
174-20-3373 ET 194-22-7525
DUE DATE 06 15 99
ETSHIED 9902512053
CutAIon~ot~e~i~e .............
1999 PA-40ES DECLARATION OF ESTIMATED
INDIVIDUAL PERSONAL INCOME TAX
174-20-3373 ET 194-22-7525 DUE DATE
ETSHIED
04 15 99
9902512053
PA 40 - 1998
PENNSYLVANIA INCOME TAX RETURN
Commonwealth of Pennsylvania PA Department of Revenue
9800112055
174-20-3373 ET 194-22-7525
ETSHIED KARL
ETSHIED JANICE
111 N 32ND ST
CAMP HILL PA 17011
lA 5606.00 lB
2 24.00 3
5 0.00 6
8 0.00 9
11 28939.00 12
B
W
0.00
0.00
0.00
28939.00
810.00
EX 0 B 0
A 0 RS R
FY 0 FS J
SC
PN
21100
1C
4
7
10
5606.00
23309.00
0.00
0.00
Local Information. Enter where you lived as of 12/31/98.
School District: C a m p H i 1 1
County: C u m b e r 1 a n d
Municipality: C a m p H i 1 1 B o r o u g h
School District Code: 2 1 1 0 0
Residency Status.
Fill-in only one choice.
R
NR
P
From:
To:
Resident
Nonresident
Part Year Resident
PLEASE FOLD PAGE ALONG THIS LINE
Extension Enclosed, Mark this space
Amended Return, Mark this space
Fiscal Year Filer, Mark this space
Option for a 1999 Booklet.
If you do not want a 1999 Tax
Booklet next year. Mark this space.
Type Filer.
Fill-in only one choice.
S
M
D
Date of Death:
J
Identification Label Change.
Mark this space, if the label you received with this booklet is not completely correct
Or if you did not file a 1997 PA tax return. Do not place label on this form.
Single
Married, Filing Separately
Deceased
Final
X Married, Filing Jointly
la Gross PA Taxable Compensation, from W-2 forms and other statements ............ S...e..e....~.~.~.~.~..~...e..n...t.....~ ....
lb Unreimbursed Employee Business Expenses, from PA Schedule UE
lc Net PA Taxable Compensation. Subtract line 1 b from la
2 PA Taxable Interest Income. Complete and enclose PA Schedule A, if over $2,500 ................................................
3 PA Taxable Dividends Income. Complete and enclose PA Schedule B, if over $2,500 .............................................
4 Net Income or Loss from the Operation of Business, Profession, or Farm ............ S.E~..e....~.~.a...t..e.~l..e..n..~....~ ....
5 Net Gain or Loss from the Sale, Exchange, or Disposition of Property ..................................................................
5,606.00
0 00
5,606 00
24 00
0 00
23,309 00
0 00
PA-40 1998
9800212053
PAGE 2
ETSHIED
KARL B
13 810.00 14 0-00 15
16 844.00 17 0.00 18
19 920.00 20 0 21
22 0.00 23 0.00 24
25 0.00 26 0.00 27
28 920.00 29 0.00 30
31 0.00 32 110.00 33
34 0.00 35 0.00 36
37 0.00
174-20-3373
76.00
0.00
0.00
0.00
0.00
110.00
0.00
0.00
13 Total PA Tax Liability.
Enter you r tax liability from Line 12 on the first page .............................................................................................. 13
14 Total PA Tax Withheld, from enclosed W-2 forms ........................................................................................... 14
15 Credit from your 1997 PA Income Tax Return .............................................................................................. 15
16 1998 Estimated Installment Payments .......................................................................................................... 16
17 1998 Extension Payment ......................................................................................................................... 17
18 Nonresident Tax Withheld from your PA Schedule(s) NRK-1. Nonreisdents only .................................................18
19 Total Estimated Payments and Credits. Add Lines15, 16, 17, and 18 ................................................................ 19
Tax forgiveness Credit. Complete lines 20, 21, and 22. Read instructions.
20 Dependents, Part 8, Line 2 PA Schedule SP ................................................................................................. 20
21 Total Eligibility Income, Part C, Line 11 PA Schedule SP ........................................................ 21
22 Tax Forgiveness Credit from Part D, Line 16, PA Schedule SP ......................................................................... 22
23 Total Credit for Taxes Paid to Other States or Countries. Enclose you r PA Schedule G or RK-1 ............................... 23
24 PA Employment Incentive Payment Credit.
Enclose PA Schedule W, RK-1 or NRK-1 ....................................................................................................... 24
25 PA Job Creation Tax Credit, from enclosed certificate or PA Schedule RK-1 or NRK-1 ........................................... 25
26 PA Waste Tire Recycling Investment Tax Credit, from enclosed certificate or
PA Schedule RK-1 or NRK-1 ...................................................................................................................... 26
27 PA Research and Development Tax Credit, from enclosed certificate
or PA Schedule RK-1 or NRK-1 ................................................................................................................... 27
28 TOTAL PAYMENTS and CREDITS. Add lines 14, 19 and 22 through 27 ............................................................. 28
29 TAX DUE. If Line 13 is more than Line 28, enter the difference here ................................................................... 29
30 OVERPAYMENT. If Line 28 is more than Line 13, enter the difference here .......................................................... 30
31 Refund -- Amount of Line 30 you want as a check mailed to you .......................................................... Refund 31
32 Credit -- Amount of Line 30 you want as a credit to your 1999 Estimated Tax Account ........................................... 32
33 Donation -- Amount of Line 30 you want to donate to the Wild Resource Conservation Fund .................................. 33
34 Donation -- Amount of Line 30 you want to donate to the United States Olympic Committee, PA Division ................... 34
35 Donation -- Amount of Line 30 you want to donate to the Organ Donor Awareness Trust Fund ............................... 35
36 Donation -- Amount of Line 30 you want to donate to the Korea/Vietnam Memorial, inc ........................................ 36
37 Donation -- Amount of Line 30 you want to donate to Breast and Cervical Cancer Research ..................................... 37
The total of Lines 31 through 37 must equal Line 30.
810.00
0.00
76.00
844.00
0.00
0.00
920.00
0
0-00
0.00
0.00
0.00
0.00
0.00
0.00
920.00
0.00
110.00
0.00
110.00
0.00
0.00
0.00
0.00
0.00
PA SCHEDULE 9801212052 I
PA- 0g-98) 1 998
PA DEPARTMENT OF REVENUE
PA TAXABLE INTEREST AND DIVIDEND INCOME
Name(s) as shown on your PA-40:
ETSHIED, KARL B & JANICE W
Social Security Number
174-20-3373
Filing Tip. ~ Caution. Federal and PA rules for taxable interest and dividend income are different. Read the instructions. Make all necessary adjust-
ments for reporting PA taxable interest and dividend income. ~ Filing Tip. If either your PA taxable interest or dividend income is $2,500 or less, you
do not need to enclose a schedule. If your interest income dividend income is more than $2,500, you must enclose a schedule. You may file out a PA
Schedule A or B. You can enclose a federal Schedule B, if you are reporting the same taxable interest or dividend income for PA purposes. You may
also use a PA Schedule I to report the federal amount. The Department of Revenue can verify the amounts you reported on your federal tax return.
PA Schedule A- PA Taxable Interest Income
If your PA taxable interest income is over $2,500, you must submit a schedule. See the instructions in your 1998 PA booklet for what interest is taxable
or exempt. If you need more space, attach additional schedules in this format.
If filing federal Schedule B:
1. Enter the amount from Line 4 from your federal Schedule B .................................................................................... 1. I 2 4.
2. Subtract PA exempt interest that you reported as taxable on federal Schedule B. See the PA-40 instructions .......... 2.
I
3. Subtract your share of non-PA subchapter S corporation interest that you reported on federal Schedule B.
See the PA-40 instructions and PA Schedule B, Line 7 ........................................................................................... 3. I 1
4. Subtract other PA exempt interest. See the instructions. Descdbe or list payer and the amount.
5. Adjusted PA taxable interest. Subtract Lines 2, 3, and 4 from Line 1 ......................................................................... 5.
If you do not have to report any other PA taxable interest, enter the amount from Line 5 on your PA-40, Line 2.
If a shareholder in a non-PA S corporation, see Line 7.
6. Add other PA taxable interest. See the instructions. List each payer and the amount.
7. Enter your total PA taxable interest from partnerships and PA S corporations, if not already included in Line 1 .......... 7.
Total 6. J
Total PA taxable interest income. Add Lines 5, 6, and 7. Include on your PA-40, Line 2 .................................. 8.
24.1
PA Schedule B - PA Taxable Dividend Income
If your PA taxable dividend income is over $2,500, you must submit a schedule. See the instructions in your PA-40 booklet for what dividend income is
taxable or exempt. If you need more space, attach additional schedules in this format.
If filing federal Schedule B:
1. Enter the amount from Line 6 of your federal Schedule B ........................................................................................ 1.
2. Subtract PA "exempt interest dividends" you reported on federal Schedule B. See your mutual fund or investment
fund statement and the PA-40 instructions ............................................................................................................. 2.
3. Subtract your share of non-PA subchapter S corporation dividends that you reported on federal Schedule B.
See the PA-40 instructions and Line 7 ................................................................................................................... 3.
4. Subtract other PA exempt dividend income. See the instructions. Describe or list payer and the amount.
4.[
5. Adjusted PA taxable dividend income. Subtract Lines 2, 3, and 4 from Line 1 .......................................................... 5.
If you do not have to report any other PA taxable dividends, enter the amount from Line 5 on your PA-40, Line 3.
If a shareholder in a non-PA S corporation, see Line 7.
I
PA-40-C (9-98)
Attach to form
PA-40, PA-65 or PA-41
9703112053
COMMONWEALTH OF PENNSYLVANIA
Profit or Loss From Business or Profession
(SOLE PROPRIETORSHIP)
1998 I
SCHEDULE C
PA DEPARTMENT OF REVENUE
Name of Proprietor as shown on PA tax return. I Social Security Number
ETSHIED, KARL B I of Proprietorl74-20-3373
A Main business activity · DENTIST/DENTISTRY ;product orservice · Offices of dentis%s
B Business Name · KARL B ETSHIED DDS
Business address (numberand street) 3-~_~_ 32ND ST
City, State and ZIP Code ~CAMP HILL, PENl~fI~%71~N-I~- ]7 5 il
C Taxpayer Identification Number
23-1574543
C
E Method(s) used to value closing inventory, fill-in the appropriate box:
(1)[~J Cost (2)r---1 Lower of cost or market (3)F-~ Other (if other, attach explanation)
F Accounting method, fill-in the appropriate box: (1)F~ Cash (2)F~ Accrual (3)E~ Other (specify) ·
G Was there any change in determining quantities, costs or valuations between opening and closing inventory? ................................................
If "Yes" attach explanation.
H Did' 3enses for an office in tour home?
a Gross receipts or sales ............................................................................................. 5 1 r 5 4 2
b Returns and allowances
c Balance (subtract line lb from line la)
Cost of goods sold and/or operations (Schedule C-1, line 8) ..........................................................................................
Gross profit (subtract line 2 from line lc) ..................................................................................................................
Other income (attach schedule) Include interest from accounts receivable, business checking accounts
and other business accounts. Also include sales of operational assets. See Instructions Booklets.
Total income (add lines 3 and 4) ·
585
5,099
836
545
2,823
Advertising
Amortization
8 Bad debts from sales or services
9 Bank charges .............................................
10 Car and truck expenses .................................
11 Commissions
12 Depletion ...................................................
13 Depreciation (explain in Schedule C-2) ............
14 Dues and publications
15 Employee benefit programs other than on Line 22
16 Freight (not included on Schedule C-1) ............
17 Insurance ...................................................
18 Interest on business indebtedness
19 Laundry and cleaning
20 Legal and professional services
21 Office supplies .............................................
22 Pension and profit-sharing plans for employee ...
23 Postage ......................................................
24 Rent on business property ..............................
25 Repairs ......................................................
51,542
51,542
51,542
31 Wages ........................................
32 Other expenses (specify):
a LABORATORY FEES
b [~ITES &' MEETINGS
9,551
469
c BANK CHARGES
d Home Of-f~_~ Deduc-ti~)5-
149
4,434
i
Depreciation and Amortization D ,I KARL B ETSHIED DDS
Asset I Description of property
Number Ii!!~!?!i!i!!?!it ,~D~a,.t.e,~ ] Method/] Life J Line I cost or
I~!!!::i::iii] in~r~['ce IIRC sec. I or rate I No. I other basis
Basis Accumulated Cu. rr.ent, year
reduction depreciation/amortization oeouc[ion
7,000.1 I 5,460.1 140.
~,iii~,i~,i~i?,{o 9,0 5,5 51sL l- 0 2 0 Iz 9 [
#DENTAL CHAIR AND EQUIPMENT
=~ii=~;/~ii?]o 61z 519 812 0 0 DB{7.0 0 I]_ 5 C[
COMPUTER
i!iiii?~i?ilO ~,z 5,9 812 0 0 DBIS. 0 0 IZ 5BI
Total Sch C Depreciation
4'408'1 4,408'1 I 4,408.
2,755-I I I 551.
I I I
14,~63.l 4,408.1 5,460.I 5,099.
I I I
I I I
I I I
I I I
I
I I I
I I I
I I I
I I I
I I I
PA-40
Business, Profession and Farm Net ~ncome
Statement
Description
Schedule C
Subtotal
Total to PA-40, line 4
Taxpayer
Amount
23,309.
23,309.
Spouse
Amount
23,309.
PA-40 Gross Compensation and Withholding Statement 2
Description
Income Total
Withholding
ADAMAR OF N.J. INC. - GAMBLING WINNINGS
BALLY'S PARK PLACE - GAMBLING WINNINGS
STATE OF N.J. - LOTTERY WINNINGS
Miscellaneous Income - Subtotal
2,000.
1,250.
2,356.
5,606.
Total to PA-40, line la
Total to PA-40, line 14
5,606.
o 882gI
Department of the Treasury
Internal Revenue Serv ce (g9)
Exp,..seS for Business Use of You. Home
File only with Schedule C (Form 1040). Use a separate Form 8829 for each
home you used for business during the year.
Name(s) of proprietor(s)
KARL B ETSHIED
Part of Your Home Used for Business
I Area used regularly and exclusively for business, regularly for day care, or for storage of inventory i!i~ii~iiii~i!~i~i~iiii!~iiiiii!!
or product samples ....................................................................................................................................... 1
2 Total area of home ..........................................................................................................................................
3 Divide line 1 by line 2. Enter the result as a percentage ....................................................................................
· For day-care facilities not used exclusively for business, also complete lines 4-6.
· All others, skip lines 4-6 and enter the amount from line 3 on line 7.
4 Multiply days used for day care during year by hours used per day .................. 4 hr.
5 Total hours available for use during the year (365 days x 24 hours) .................. ; hr.
6 Divide line 4 by line 5. Enter the result as a decimal amount ..............................
7 Business precentage. For day-care facilities not used exclusively for business, multiply line 6 by line 3
(enter the result as a percentage). All others, enter the amount from line 3 ................................................... I~
Figure Your Allowable Deduction
PA
OMB No. 1545-1266
1998
SA~u~n~'~o. 66
Your social security number
174-20-3373
~t gain or (loss) derived from the business use of your
than one place of business, see instructions .................. 8 2 7, 7 4 3.
..................................................................................... 24 4,434.
,15 or line 24 ................................................................ 25 4,434.
tact line 25 from line 15 ................................................ 26 2 3, 3 0 9 .
..................................................................... 30
er the smaller of line 26 or line 30 ................................. 31 0
.................................................................................... 32 4,434.
/ amount to Form 4684, Section B .............................. 33 0.
8 Enter the amount from Schedule C, line 29, plus an
home and shown on Schedule D or Form 4797. If more t
See instructions for columns {a) and (b) before
completing lines 9-20.
9 Casualty losses ......................................................
10 Deductible mortgage interest ....................................
11 Real estate taxes
12 Add lines 9, 10, and 11 ...............................
13 Multiply line 12, column (b) by line 7 ........................
14 Add line 12, column (a) and line 13 ...........................
15 Subtract line 14 from line 8. If zero or less, enter-0- ...
16 Excess mortgage interest .......................................
17 Insurance
18 Repairs and maintenance .......................................
19 Utilities
20 Other expenses ......................................................
21 Add lines 16 through 20 ..........................................
22 Multiply line 21, column (b) by line 7
23 Carryover of operating expenses from 1997 Form 8829
24 Add line 21 in column (a), line 22, and line 23
25 Allowable operating expenses. Enter the smaller of
26 Limit on excess casualty losses and depreciation. Subtra~
27 Excess casualty losses ....................................................................................
28 Depreciation of your home from Part III below
29 Carryover of excess casualty losses and depreciation from
30 Add lines 27 through 29
31 Allowable excess casualty losses and depreciation.
32 Add lines 14, 25, and 31
33 Casualty loss portion, if any, from lines 14 and 31. Cam
Wildeman and Obrock, CPA's
515 S. 29th Street
Harrisburg, PA 17104
(717) 561-0820
April 12, 2000
Karl B & Janice W Etshied
111 N 32nd St
Camp Hill, PA 17011
Dear Dr. and Mrs. Etshied,
Enclosed are your 1999 income tax returns and 2000 estimated
tax vouchers. The returns should be signed and dated by both
taxpayer and spouse.
Specific filing instructions are as follows.
FEDERAL INCOME TAX RETURN:
Mail your federal return on or before April 17, 2000.
Mail to - Internal Revenue Service P.O. Box 8530
Philadelphia, PA 19162-8530
Enclose your check for $820, payable to the United States
Treasury. Include your social security number, daytime phone
number and the words "1999 Form 1040" on your check.
Also enclose Form 1040-V. Do not attach Form 1040-V or your
payment to your return or to each other. Please leave Form
1040-V and your payment loose in the envelope.
FEDERAL ESTIMATED TAX VOUCHERS:
Separately mail voucher 1 of Form 1040-ES by April 17, 2000.
Mail to - Internal Revenue Service P.O. Box 8318
Philadelphia, PA 19162-8318
Enclose your check for $1,530, payable to the United States
Treasury. Include your social security number and the words
"2000 Form 1040-ES" on your check.
Retain vouchers 2, 3 and 4 in your files and mail to the
above address on or before the dates indicated.
For your refers s we have listed all esti~ ed tax payments
and their original due dates below. Vouchers requiring no
payment should not be filed.
Voucher no. 1 by 04/17/00 ....... $1,530
Voucher no. 2 by 06/15/00 .... ,.'. $1,530
Voucher no. 3 by 09/15/00 ....... $1,530
Voucher no. 4 by 01/16/01 ....... $1,530
PENNSYLVANIA INCOME TAX RETURN:
Mail your state return on or before April 17, 2000.
Mail to - PA Department of Revenue
Payment'Enclosed
4 Revenue Place
Harrisburg, PA 17129-0004
Enclose your check for $90.
Make check payable to PA Department of Revenue. Write your
social security number, daytime phone number and "1999 Form
PA-V" on your check or money order.
Enclose Form PA-V with the return.
Form PA-V to the return.
Do not attach payment or
PENNSYLVANIA ESTIMATED TAX VOUCHERS:
Separately mail voucher 1 of the declaration of estimated tax
by April 17, 2000. Enclose your check for $240, payable to
PA Department of Revenue.
Additional estimated tax payments will also be due. Payments
should be mailed to the following address on or before the
dates indicated.
Mail to - PA Department of Revenue
Imaging and Document Management
Dept. 280403
Harrisburg, PA 17128-0403
For your reference we have listed all estimated tax payments
and their original due dates below.
Voucher no. 1 by 04/17/00 ....... $240
Voucher no. 2 by 06/15/00 ....... $240
Voucher no. 3 by 09/15/00 ....... $240
Voucher no. 4 by 01/16/01 ....... $240
LOCAL EARNED INCOME TAX RETURN:
Mail your local ~return on or before April 17, 2000 to West
Shore Tax Bureau. Dr. Etshied, enclose a check for $40.00
payable to WESTAB.
LOCAL ESTIMATED TAX PAYMENTS:
Mail your vouchers to the West Shore Tax Bureau as follows:
April 15, 2000 ..... $80.00
July 15, 2000 ...... $80.00
October 15, 2000...$80.00
December 31, 2000..$80.00
We sincerely appreciate the opportunity to serve you. Please
contact me if you have any questions regarding these tax
returns.
Your copies of the returns are enclosed for your files.
suggest that you retain these copies indefinitely.
Sincerely,
Michael A. Kunisky, CPA
We
Two-Year Compa'rison' V'" rksheet
Name(s) as shown on return
KARL B & JANICE W ETSHIED
1999
Social security number
174-20-3373
1998 Filing Status Married Filing Joint 1999 Filing Status Married Filing Joint
1998 Tax Bracket 15.0% 1999 Tax Bracket 15
Schedule B - taxable interest 24. 16. <8.
Taxable refunds of state/local tax 0. 94. 94.
~ch. C/C-EZ (business income/loss) 23,309. 33,203. 9,894.
taxable social security benefits 2,817. 4,613. 1,796.
Other income 5,606. 0. <5,606.
Total income 31,756. 37,926. 6,170.
Dne-half of self-employment tax 1,647. 2,346. 699.
~elf-employed health ins. deduction 1,551. 2,287. 736.
Total adjustments 3,198. 4,633. 1,435.
~djusted gross income 28,558. 33,293. 4,735.
~edical and dental expenses 1,354. 2,348. 994.
taxes 5,185. 6,073. 888.
Cnterest (deductible) 7,985. 9,234. 1,249.
~ontributions 308. 600. 292.
Dther miscellaneous deductions 5,606. 0. <5,606.
Total itemized deductions 20,438. 18,255. <2,183.
Income before exemptions 8,120. 15,038. 6,918.
Personal exemptions 5,400. 5,500. 100.
Taxable income 2,720. 9,538. 6,818.
~ax 407. 1,429. 1,022.
Tax before credits 407. 1,429. 1,022.
Tax after non-refundable credits 407. 1,429. 1,022.
Schedule SE (self-employment tax) 3,293. 4,691. 1,398.
Total tax 3,700. 6,120. 2,420.
Estimated tax payments 9,000. 5,300. <3,700.
Total payments 9,000. 5,300. <3,700.
Tax overpaid 5,300. 0. <5,300.
Overpayment applied to estimate 5,300. 0. <5,300.
Balance due including 2210/2210F 0. 820. 820.
Pennsylvania State Return
~axable Income 28,939. 33,219. 4,280.
Fax 810. 930. 120.
Payments 920. 840. <80.
Balance Due Including Pen. & Int. 0. 90.I 90.
1999 ' '
Form 104/ I
Departme~ of tl~e Tfeasu~
Intern: evenue Service
Paperwork Reduction Act Notice.
We ask for the information on Form 1040-V to help us carry
out the Internal Revenue laws of the United States. If you use
Form 1040-V, you must provide the requested information.
Your cooperation will help us ensure that we are collecting the
right amount of tax.
You are not required to provide the information requested
on a form that is subject to the Paperwork Reduction Act
unless the form displays a valid OMB control number. Books
or records relating to a form or its instructions must be
retained as long as their contents may become matedal in the
administration of any Internal Revenue law. Generally, tax
returns and return information are confidential, as required by
Internal Revenue Code section 6103.
The time needed to complete and mail Form 1040-V will vary
depending on individual circumstances. The estimated average
time is 19 minutes. If you have comments about the accuracy
of this time estimate or suggestions for making Form 1040-V
simpler, we would be happy to hear from you.
Form 1040-V (1999)
· DETACH HERE AND MAIL WITH YOUR PAYMENT ·
910681
10-21-99
E
,,s 1040-V
Department of the Treasury
Internal Revenue Se~ice (99)
I Enter the amount you are paying by
check or money order
820
4 Ifa joint return, enterthe SSN shown
second on that return
LHA
Voucher OMB No. 1545-0074
1999
Do not staple or attach this voucher to your payment.
Enter the first four letters of your last name 3 Enter your social security number
Enter y0ur name(s)
KARL B & JANICE W ETSHIED
Enter your address
111 N 32ND ST
Enter your city, state, and ZIP code
CAN? HTT,T,, PA 17011
2vOO Estimated Tax Worksheet (keep for yvur records)
I Enter amount of adjusted gross income you expect in 2000 .............................................................................................
2 · If you plan to itemize deductions, enter the estimated total of your itemized deductions. '1
Caution: If line I above is overS128,950 ($64,475 if married filing separately),
your deduction may be reduced. See Pub. 505 for details. . ...............................................
· If you do not plan to itemize deductions, see Standard deduction for 2000 on page 2,
and enter your standard deduction here.
3 Subtract line 2 from line 1 ..........................................................................................................................................
4 Exemptions. Multiply $2,800 by the number of personal exemptions. If you can be claimed as a dependent on another person's
2000 return, your personal exemption is not allowed. Caution: See Pub. 505 to figure the amount to enter if line I above
is over: $193,400 if married firing jointly or qualifying widow(er); $161,150 if head of household; $128,950 if single;
or $96,700 if married filing separately .....................................................................................................................
5 Subtract line 4 from line 3 ..........................................................................................................................................
6 Tax. Figure your tax on the amount on line 5 by using the 2000 Tax Rate Schedules on page 2. Caution: If you have a net
capital gain, see Pub. 505 to figure the tax .....................................................................................................................
7 Alternative minimum tax from Form 6251
8 Add lines 6 and 7. Also include any tax from Forms 4972 and 8814 and any recapture of the education credits (see instructions) ...
9 Credits (see instructions). Do not include any income tax withholding on this line ..................................................................
10
Subtract line 9 from line 8. Enter the result, but not less than zero .......................................................................................
Self-employment tax. Estimate of 2000 net earnings from self-employment $ ; if $76,200
or less, multiply the amount by 15.3%; if more than $76,200, multiply the amount by 2.9%, add $9,448.80 to the result, and
enter the total. Caution: If you also have wages subject to social security tax, see Pub. 505 to figure the
amount to enter ...................................................................................................................................................
12 Othertaxes (see instructions) ....................................................................................................................................
13a Add lines 10 through 12 .............................................................................................................................................
b Earned income credit, additional child taxcredit, and credit from Form 4136 ........................................................................
c Subtract line 13b from line 13a. Enter the result, but not less than zero. THIS IS YOUR TOTAL 2000 ESTIMATED TAX ............ ·
14a Multiply line 13c by 90% (66 2/3% for farmers and fishermen) ................................................ 14a
b Enter the tax shown on your 1999 tax return (108.6% of that amount if you are not a farmer or
fisherman and the adjusted gross income shown on line 34 of that return is more than $150,000
or, if married filing separately for 2000, more than $75,000) ................................................... 14b
c Enter the smaller of line 14a or 14b. THIS IS YOUR REQUIRED ANNUAL PAYMENT TO AVOID A PENALTY ........................... ·
Caution: Generally, if you do not prepay (through income tax withholding and estimated tax payments) at least the
amount on line 14c, you may owe a penalty for not paying enough estimated tax. To avoid a penalty, make sure
your estimate on line 13c is as accurate as possible. Even if you pay the required annual payment, you may still
owe tax when you file your return. If you prefer, you may pay the amount shown on line 13c. For more details,
see Pub. 505.
15 Income tax withheld and estimated to be withheld during 2000 (including income tax withholding on pensions,
annuities, certain deferred income, etc.) ........................................................................................................................
16 Subtract line 15 from line 14c. (Note: If zero or less, or line 13c minus line 15 is less than $1,000, stop here. You are
not required to make estimated tax payments.) ......................................................................................................
17 If the first payment you are required to make is due April 17, 2000, enter 1/4 of line 16 (minus any 1999 overpayment that
you are applying to this installment) here and on your payment voucher(s) if you are paying by check or money order.
(Note: Household employers, see instructions) ...............................................................................................................
6,120.
1,530 ·
910401
12-20-99 2
CUT HERE
[ 1040-ES
L~O Department of the Treasury
Internal Revenue Service
2000 Payment 1
Voucher
OMB No. 1545-0087
File only if you are making a payment of estimated tax by check or money order. Mail this
voucher with your check or money order payable to the "United States Treasury." Write
your social security number and '2000 Form 1040-ES' on your check or money order.
Do not send cash. Enclose, but do not staple or attach, your payment with this voucher.
Calendar year - Due April 17, 2000
Your first name and initial IYour last name Your social security number
KARL B ~TSHIED 174-20-3373
If joint payment, complete for spouse
Enter the amount you are ~ Spouse's first name and initial Spouse's last name Spouse's social security numbe~
paying by check or ,.,
money order ~
JANICE W ETSHIED 194-22-7525
; Address (number, street, and apt, no.)
1,530 ~ 111 N 32ND ST
~- City, state, and ZIP code (If a foreign address, enter city, province or state, postal code, and country.)
CAMP HILL, PA 17011
LHA For Privacy Act and Paperwork Reduction Act Notice, see instructions on page 5.
CUT HERE
CUT HERE
.E 1040-ES
~ Department of the Treasury
Internal Revenue Service
2000 Payment
2
Voucher
File only if you are making a payment of estimated tax by check or money order. Mail this
voucher with your check or money order payable to the "United States Treasury." Write
your social security number and "2000 Form 1040-ES" on your check or money order.
Do not send cash. Enclose, but do not staple or attach, your payment with this voucher.
LHA
OMB No. 1545-0087
I Calendar year - Due June 15, 2000
Your first name and initial IYour last name Your social security number
KARL B ~TSHIED 174-20-3373
Enter the amount you are ..,If joint payment, complete for spouse
paying by check or .[ Spouse's first name and initial Spouse's last name Spouse's social security numbe~
money order ~
3ANICE W ETSHIED 194-22-7525
~, Address (number, street, and apt. no.)
1,530 ~ 111 N 32ND ST
r, City, state, and ZIP code (If a foreign address, enter city, province o r state, postal code, and country.)
For Privacy Act and Paperwork Reduction Act Notice, see instructions on page 5.
CUT HERE
910411
01-13-00 3
CUT HERE
~ 1040-ES
L~O DepartrnentoftheTreasury 2000 Payment 3
Internal Revenue Service Voucher
OMB No. 1545-0087
File only if you are making a payment of estimated tax by check or money order. Mail this l Calendar year - Due Sept. 15, 2000
voucher with your check or money order payable to the "United States Treasury." Write
your social security number and "2000 Form 1040-ES" on your check or money order.
Do not send cash. Enclose, but do not staple or attach, your payment with this voucher.
Your first name and initial JYour last name I Your social secudty number
KARL B ~TSHIED I 174-20-3373
Enter the amount you ,_~ If joint payment, complete for spouse
are paying by check or ~, Spouse's first name and initial Spouse's last name Spouse's social security number
money order ~
~ ~ANICE W ETSHIED 194-22-7525
e· Address (number, street, and apt. no.)
$ 1,530. ~ 111 N 32ND ST
City, state, and ZIP code (If a foreign address, enter city, province or state, postal code, and country.)
2AMP HILL, PA 17011
LHA For Privacy Act and Paperwork Reduction Act Notice, see Instructions on page 5.
CUT HERE
CUT HERE
E 1040-ES
L~~ DepartrnentoftheTmasury 2000 Payment 4
Internal Revenue Service Voucher
OMB NO. 1545-0087
File only if You are making a payment of estimated tax by check or money order. Mail this [ Calendar year - Due Jan. 16, 2001
voucher with your check or money order payable to the "United States Treasury." Write
your social security number and "2000 Form 1040-ES" on your check or money order.
Do not send cash. Enclose, but do not staple or attach, your payment with this voucher.
Your first name and initial IYour last name I Your social security number
KARL B ~TSHIEDI 174-20-3373
Enter the amount you .'_=If joint payment, complete for spouse
are paying by check or fi, Spouse's first name and initial Spouse's last name Spouse's social security number
money order ~
~ IANICE W ETSHIED 194-22-7525
~ Address (number, street, and apt. no.)
$ 1,530. ~'111 N 32ND ST
City, state, and ZIP code (If a foreign address, enter city, province or state, postal code, and country.)
2AMP HILL, PA 17011
LHA For Privacy Act and Paperwork Reduction Act Notice, see Instructions on page 5.
CUT HERE
_1
910421
01-04-00 4
U.S. Individual Ir TleTax Return 199 ,,~,
Label For the year Jan. 1-Dec. 31, 1999, or other tax year beginning ,1999, ending
{See L
instructions
A
on page 18.) B
Use the IRS ~
label.
.
Otherwise,
please print ~
or t~pe.
Presidential
Election Campaign
(See page 18.)
1
Filing Status 2
3
4
Check only
one box.
5
Your first name and initial
KARL B
Last name
~TSHIED
IRS Use Only - Do not write or staple in this space.
OMB No. 1545-0074
Your social security number
174 i20 i3373
If a joint return, spouse's first name and initial Last name spouse's seci~ s~ri~ number
JANICE W ETSHIED 194!22i7525
Home address (number and street). Ifyou have a P.O. box, see page 18. Apt. no.
111 N 32ND ST
Ci~, town or post office, state, and ZIP code. If you have a foreign address, see page 18.
CAMP HILL, PA 17011
Do you want $3 to go to this fund? ......................................................................................................
If a joint return, does your spouse want $3 to go to this fund? ..................................................................
Single
Married filing joint return (even if only one had income)
Married filing separate return. Enter spouse's soc. sec. no. above and full name here. ·
Head of household (with qualifying person). If the qualifying person is a child but not your dependent, enter this child's
name here. ·
· IMPORTANT! ·
You must enter
your SeN(s) above.
Note: Checking
'Yes' will not
change your tax or
reduce your refund.
Qualifying widow(er) with dependent child (year spouse died · 19 ). (See page 18.)
Exemptions 6a J X JYourself. If your parent (or someone else) can claim you as a dependent on his or her tax return, donor "l No. ofboxe~
[ checked on 6a
check box 6a .................................................................................................................. ( and 613 2
b ~ Spouse ................................................................................................................................ / No. ofyour
Dependents: (2) Dependent's social (3) Dependent's (4,) V'if ~alify'
~n[I child fro'
(1) First name Last name security number relationship to chird taxcmdit
you (see page 19)
who:
C children on 6c
· lived with you
· did not live with
you due to divorce
or separation
(see page 19)
Dependents on 6c
not entered above
Addltnes abovenUmbers· ~
entered on
d Total number of exempt OhS claimed i:. ................. :'i/ ................. ................................
If more than six
dependents,
see page 19.
Income 7 Wages, salaries, tips,etc.j~tta~tForm(s) W-2 '. ............................................................................. 7
Attach 8a Taxable interest. Atta~J~ch;dule B if.requi~ed 8a 16.
Copy B of your b Tax-exempt interest.'BO NOT include on line Sa. ~.
Forms W-2 and 9 Ordinary dividends. Attach.~Schedule B if required ........................................................................... 9
W-2Ghere. Also 10 Taxable refunds, or credit{ of state and loc'al income taxes St]mt 4 St]mt 2 Stm% 3 10 94
attach Form(s) ...............................................................
1099-R if tax 11 Alimony received ..................................................................................................................... 11
was withheld. 12 Business income or (loss). Attach Schedule C or C-EZ .....................................................................12 3 3,2 0 3
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here ..................... · ~ 13
If you did not
get a W-2. 14 Other gains or (losses). Attach Form 4797 .................................................................................... 14
16a Total pensions and annuities ...... 16a b Taxable amount (see page 22) 16b
Enclose, but do 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17
not staple, any ........................
payment. Also, 18 Farm income or (loss). Attach Schedule F .................................................................................... 18
please use 19 Unemployment compensation ................................................................................................... 19
Forml040-V. 20a Socialsecuritybenefits ............ J 20a J 25,089 .J b Taxable amount (see page 24) 20b 4,613.
21 Other income. List bjpe and amount (see page 24)
21 O.
22 Add the amounts in the far dght column for lines 7 through 21. This is your total income .................. · 22 37,926.
23 IRA deduction (see page 26) 23
Adjusted 24 Student loan interest deduction (see page 26) .................................... 24
Gross 25 Medical savings account deduction. Attach Form 8853 25 :~:;:~:~:~:~:~:~:~:~
Income 26 Moving expenses. Attach Form 3903 ............................................. 26
27 0ne-half of self-employment tax. Attach Schedule SE ........................ 27 2, 3 4 6.
28 Self-employed health insurance deduction (see page 28) ..................... 28 2,2 8 7.
29 Keogh and self-employed SEP and SIMPLE plans ........................ 29
30 Penalty on early withdrawal of savings ............................................. 30
32 Add lines 23 through 31a 32 4,633.
33 Subtract line 32 from line 22. This is your adjusted gross income ............................................. · 33 3 3,2 9 3.
910001
10-29-99 LHA For Disclosure, Privacy Act, and Paperwork Reduction Act NotiCe, see page 54. Form 1040 (1999)
Form1040(199e) KARL B &, JANIC~ W ETSHIED 17'~-2'0--337'3 0MBNo. 1545-0074 Page2
Tax and 34 Amount from line 33 (adjust,..,oss income) ................................................................................... 34 3 3,2 9 3,
Credits 35a Checkif: ~ You were 65 or older, [--] Blind; ~ Spouse was 65 or older,
Add the number of boxes checked above and enter the total here .................................... · 35a
Standard / b If you are married filing separately and your spouse itemizes deductions
for Most or you were a dual-status alden, see page 30 and check here .......................................... · 35b
People _. 36 Enter your itemized deductions from Schedule A, line 28, OR standard
deduction shown on the [ett. But see page 30 to find your standard deduction if you
Single: checked any box on line 35a or 35b or if someone can claim you as a dependent .......................................... 36 1 8,2 5 5
$4,300 37 Subtract line 36 from line 34 37 15,0 3 8.
Head of ............................................................................................................ ....................
household: 38 If line 34 is $94,975 or less, multiply $2,750 by the total number of exemptions claimed on ::::::::::::::::::::::::::::::
$6,350 = line 6d. If line 34 is over $94,975, see the worksheet on page 31 for the amount to enter .............................. 38 5
39 Taxable Income. Subtract line 38 from line 37. If line 38 is more than line 37, enter-0- . ................................ 3g 9, .5 3 8.
Marriedfilbg 40 Tax. (see page 31). Check if any tax from a r--] Form(s) 8814 b [--~ Form4972 ........................... · 40 I, 429.
iointly or
Qualifying 41 Credit for child and dependent care expenses. Attach Form 2441 41 ....................
42 Credit for the elderly or the disabled. Attach Schedule R .............................. 42
$7,200 43 Ch,d taxcred,t (see page 33) ...............................................................
Married i 44 Education credits. Attach Form 8863 44
separately: ! 45 Adoption credit. Attach Form 8839 ......................................................... 45
$3,600 ~ 46 Foreign tax credit. Attach Form 1116 if required ....................................... 48
c [----] Form 8801 d [--~ Form (specify) 47
48 Add lines 41 through 47. These are your total credits .............................................................................. 48
49 Subtract line 48 from line 40. If line 48 is more than line 40, enter-O- . .................................................. · 49 1,429.
Other 50 Self-employment tax. Attach Schedule SE ............................................................................................. 50 4,6 9 1.
Taxes 51 Alternative minimum tax. Attach Form 6251 .......................................................................................... 51
52 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 ........................... 52
53 Tax on IRAs, other retirement plans, and MSAs. Attach Form 5329 if required ............................................. 53
54 Advance earned income credit payments from Form(s) W-2 ..................................................................... 54
55 Household employment taxes. Attach Schedule H ................................................................................. 55
56 Add lines 49 through 55. This is yourtotal tax .............................................................................. · 56 6,120.
Payments 57 Federal income tax withheld from Forms W-2 and 1099 .............................. 57
58 1999 estimated tax payments and amount applied from 1998 return ............ 58 5,3 0 0.
59a Earned income credit. Attach Sch. EIC if you have a qualifying child
b Nontaxable earned income: amount · [ J ::i::iiiii::iiiiiii::?:i
60 Additional child tax credit. Attach Form 8812 ............................................. 60 :::::::?::::?:::::?:::::?:?:
61 Amount paid with request for extension to file (see page 48) ........................ 61
62 Excess social security and RRTA tax withheld (see page 48) ........................ 62 ::::::::::::::::::::::::::::::::::
63 Other payments. Check iffrom a [-~ Form 2439 b [--'"] Form 4136 ...... 63 :].iiiiiiiiiiiiiiiiiiiiiii::::
64 Add lines 57, 58, 59a, and 60 through 63. These are yourtotal payments ............................................. · 64 5,300.
Refund 65 If line 64 is more than line 56, subtract line 56 from line 64. This is the amount you OVERPAID ........................ 65
Haveit 66a Amount of line 65 you want REFUNDED TO YOU · 66a
directly ..............................................................................
and fillin $6b, · d Account number
67 Amount of line 65 you wantAPPLIEDTOYOUR 2000 ESTIMATED TAX · I 67 I
Amount 68 If line 56 is more than line 64, subtract line 64 from line 56. This is the AMOUNT YOU OWE. i::i::ii?:i::iiiii::iiil
You Owe For details on how to pay, see page 49 .......................................................................................... · 68 8 2 0.
Sign
Here
Keep a copy
for your
records,
Under penalties of perjury, I declare that I have examined this retum and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct,
and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Your signature Date Your occupation Daytime telephone
number (optional)
DENTIST
Spouse's s~gnature. If a joint return, BOTH must sign. Date Spouse's occupatio~
Preparers · Date Check if self- Preparer's SSN or PTIN
Paid signature · 04/1 2 / 0 0 employed ~
189-52-1408
Use OnlyPreparer'sF~rm'sname(°r k WIT,DEMAN AND OBROCK, CPA'S IE~N' ' 23 i2198946
you~ifself-em- p515 S. 29TH STREET I ZlPccde 17104-2104
ployed) and address -- HARRISBURG, PA
910002 6
10-18-99
SCHEDULES A&B
(Form 1040)
Department of the Treasury
Internal Revenue Service (99)
S, eduleA- Itemized Deductic' ;
(Schedule B is on page 2)
· Attach to Form 1040. · See Instructions for Schedules A and B (Form 1040).
OMB No. 1545-0074
1999
~:~eh n%~en~o. 07
Name(s) shown on Form 1040
KARL B & JANICE W ETSHIED
Medical
and
Dental
Expenses
Caution' Do not include expenses reimbursed or paid by others.
1 Medical and dental expenses (see pageA-1) See Statement 8 '~"'J
2 Enter amount from Form 1040, line 34 .........iiiiiiiiiiiiiiiiiiiii'*i"~'i .........
3 Multiply line 2 above by 7.5% (.075)
4 Subtract line 3 from line 1. If line 3 is more than line 1, enter-0-
Taxes You
Paid
(See
page A-2.)
Your social securfty number
174120 i3373
Interest
You Paid
(See
page A.3.)
Note:
Personal
interest is
not
deductible.
5 State and local income taxes .............................. .s...e..e.....S..~...a...t..e..m...~...n...t......5. .... 5
6 Real estate taxes (see page A-2) ........................................................................... J 6 I
7 Personal property taxes .................................................................................... I 7 J
8 Other taxes. Ust type and amount ]iiiiiil
· PERSONAL&OPT 2,015. iiii!i~i~i1
2,015.
9 Add lines 5 through 8 ........................................................................................................................ I 9
12
13
14
4,845.
2,497.
14 2,348.
884.
3,174.
6,073.
9,098.
9,234.
600.
26
~:!:i:i:i:i:i:
~:~:~:[:~:~:~:
27
28 18,255.
136
Add lines 10 through 13 ..................................................................................................................... I 14
Gifts to
Charity
Ify0u made a
gift and got a
benefit for it,
see page A-4.
11 Home mortgage interest not reported to you on Form 1098. If paid to the person
from whom you bought the home, see page A-3 and show that person's name,
identifying no., and address
11
Points not reported to you on Form 1098. (See page A-3.) ............... .S...t...m...t......6 .... 12
Investment interest. Attach Form 4952 if required. (See page A-3.) ........................ 13
Casualty and
Theft Losses 19
see page A-4 ...................................................... ~.e...e....S...~..a...~..e..~.e..~...~.....? .... 15 6 0 0
16 Other than by cash or check. If any gift of $250 or more, see page A-4.
You MUST attach Form 8283 if over $500 ............................................................ '~1'~"
17 Carryover from pdor year .................................................................................... 17
18 Add lines 15 through '17 ............................................................................... 1.
Casualty or theft loss(es). Attach Form 4684. (See page A.5.) ...............................................................
Job Expanses 20 Unreimbursed employee expenses- job travel, union dues, job education, etc.
and Most You MUST attach Form 2106 or 2106-EZ if required, (See page A-5.)
Other
Miscellaneous ·
Deductions
21 Tax preparation fees
22 Other expenses - investment, safe deposit box, etc. List type and amount
23 Add lines 20 through 22 ................................................................................
24 Enter amount from Form 1040, line 34 .............................. 1241
25 Multiply line 24 above by 2% (.02) ........................................................................
26 Subtract line 25 from line 23. If line 25 is more than line 23, enter -0- . ..................................................
(See
page A-5 for
expenses to
deduct here.)
Other 27 Other- from list on page A-6. list type and amount
Miscellaneous ·
Deductions
28
Is Form 1040, line 34, over $126,600 (over $63,300 if married filing separately)?
~] NO. Your deduction is not limited. Add the amounts in the far right column
for lines 4 through 27. Also, enter on Form 1040, line 36.
[--'-] YES. Your deduction may be limited. See page A-6 for the amount to enter.
Total
Itemized
Deductions
LHA For Paperwork Reduction Act Notice, see Form 1040 instructions. Schedule A (Form 1040) 1999
919501
11-22-99 7
Schedules A&B (Form 1040) 1999 ~ ~ OMB No. 1545-0074 Page 2
Name(s) shown on ForTh 1040. Do not enter name and socia
dry number if shown on page 1.
Your social security number
KARL B & JANICE W ETSHIED 174 20 3373
Schedule B - Interest and Ordinary Dividends Attachment
Sequence No. 08
Part I Note. If you had over $400 in taxable interest, you must also complete Part III.
Interest
Ilist name of payer. If any interest is from a seller-financed mortgage and the buyer used the
property as a personal residence, see page B-1 and list this interest first. Also, show that
buyer's social security number and address ·
HARRIS SAVINGS BANK
Note: If you
received a Form
1099-1NT,
Form 1099-OID,
or substitute
statement from
a brokerage firm,
list the firm's
name as the
payer and enter
the total interest
shown on that
form.
2 Add the amounts on line 1
3 Excludable interest on sedes EE and I U.S. savings bonds issued after 1989 from Form 8815,
line 14. You MUSTattach Form 8815 ..........................................................................................
4 Subtract line 3 from line 2. Enter the result here and on Form 1040, line 8a ........................... ·
Part II Note. If you had over $400 in ordinary dividends, you must also complete Part III.
Amount
16.
16.
16.
Ordinary 5 list name of payer. Include only ordinary dividends. If you received any capital gain distributions, Amount
Dividends see the instructions for Form 1040, line 13. ·
Note: If you
received a Form
1099-DIV or
substitute
statement from
a brokerage firm,
list the firm's 5
name as the
payer and enter
the ordinary
dividends shown
on that form.
6 Add the amounts on line 5. Enter the total here and on Form 1040, line 9 .................................... 6
Part III You must complete this part if you (a) had over $400 of interest or ordinary dividends; (b) had a foreign account; or
Yes No
Foreign (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust.
:~:~:~:~$~:~:i:~:i :i:i:i:i:i:i:i:~:i
Accounts 7a At any time during 1999, did you have an interest in or a signature or other authority over a financial i!::iiiii!i!i!~ii:?:i ?::::::::::::::?:?::
and account in a foreign country, such as a bank account, securities account, or other financial account? .................. X
Trusts b If'Yes," enter the name of the foreign country · iiiii!iiiiiiiiii!iii ::::::::::::::::::::::::::::::
8 During 1999, did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? i~ii~ii~iiiiiiiiiiiii!iiiiiii iiii?ii~ii~ii~ii~i?iiii
If "Yes," you may have to file Form 3520. See page B-2 ....................................................................................... X
LHA
927501
lo-11-99
For Papenvork Reduction Act Notice, see Form 1040 instructions.
Schedule B (Form 1040) 1999
SCHEDULE C
(Form 1040)
Department of the Treasury
Internal Revenue Service (99)
Busin
, , ' rofit or Loss From es.-'
(Sole Proprietorship)
· Partnerships, joint ventures, etc., must file Form 1055 or Form 1U65-B.
· Attach to Form 1040 or Form 1041. · See Instructions for Schedule C (Form 1040).
OMB No, 1545-0074
lggg
Attachment ~
Sequence No, U~
Name of proprietor Social security number (SSN)
KARL B ETSHIED 174-20-3373
A Principal business or profession, including product or service (see page C-1) B Enter code fi'om pages 0-8 & 9 ~
DENTIST/DENTISTRY · 621210
C Business name. If no separate business name, leave blank. D Employer ID number (EIN), ifany
KARL B ETSHIED DDS 23-1574543
E 5usiness address (including suite or room no.) · 111 N 32ND ST
City, town or post office, state, andZlPcode CAMP HILL, PENNSYLVANIA 17011
F Accounting method: (1)1 X I Cash (2)1 I Accrual (3)1 I Other (specify) · .....
G Did you "materially participate" in the operation of this business during 19997 If'No," see page C-2 for limit on losses .......................... .-...-~;{'T Yes [~ No
H If you started or acquired this business during 1999, check here ............................................................................................................ · ~
Income
I Gross receipts or sales. Caution: If this income was reported to you on Form W-2 and the "Statutory employee" box on
that form was checked, see page C-2 and check here .............................................................................. · ~ 1
2 Returns and allowances .......................................................................................................................................... 2
3 Subtract line 2 from line 1 .......................................................................................................................................
4 Cost of goods sold (from line 42 on page 2) ............................................................................................................... 4
5 Gross profit. Subtract line 4 from line 3 .....................................................................................................................
6 Other income, including Federal and state gasoline or fuel tax credit or refund (see page C-3) ................................................
7 Gross income. Add lines 5 and 6 .................................................................................................. ·
liii!~ii!iiii!!l Expertses. Enter expenses for business use of your homeonly on line 30.
52,090.
52,090.
52,090.
52,090.
2,570.
8 Advertising ....................................
g Bad debts from sales or
services (see page C-3) ..................
10 Car and truck expenses
(see pageO-3) Stmt 9
11 Commissions and fees
12 Depletion ....................................
13 Depreciation and section 179
expense deduction (not included in
Part 110 (see page C-3) .....................
14 Employee benefit programs (other
than on line 19) ...........................
15 Insurance (other than health) ............
18 Interest:
a Mortgage (paid to banks, etc.) .........
b Other
17 Legal and professional
services .......................................
18 Office expense ..............................
lg
20
a
b
581. 21
22
23
24
1,022
836
Z5
26
425 27
3,760.
28 Total expenses before expenses for business use of home. Add lines 8 through 27
Pension and profit-sharing plans ..................
Rent or lease (see page C-4):
Vehicles, machinery, and equipment ............
Other business property ...........................
Repairs and maintenance ...........................
Supplies (not included in Part III) ...............
Taxes and licenses ....................................
Travel, meals, and entertainment:
a Travel
b Meals and
entertainment
c Enter nondeductible
amount included on line 24b
(see page C-5) ..................
d Subtract line 24c from line 24b
Utilities ...................................................
Wages (less employment credits) ...............
Other expenses (from line 48 on
page 2) ...................................................
in columns ....................................... ·
29
30
31
32
Tentative profit (loss). Subtract line 28 from line 7 .........................................................................................................
Expenses for business use of your home. Attach Form 8829
Net profit or (loss). Subtract line 30 from line 29.
· If a profit, enter on Form 1040, line 12, and ALSO on Schedule SE, line 2 (statutory employees, see page 0-6).
Estates and trusts, enter on Form 1041, line 3.
· If a loss, you MUST go on to line 32.
If you have a loss, check the box that describes your investment in this activity (see page C-6).
· If you checked 325, enter the loss on Form 1040, line 12, and ALSO on Schedule SE, line 2 (statutory employees,
see page C-6). Estates and trusts, enter on Form 1041, line 3.
· If you checked 32b, you MUST attach Form 6198.
1,160.
5,534.
15,888.
36,202.
2,999.
33,203.
~ All investment
325
I I
is at risk,
[-----I Some investment
32b
I I
is not at risk,
LHA
920001
1 O-18-99
For Paperwork Reduction Act Notice, see Form 1040 Instructions.
Schedule C (Form 1040) 1999
174-20-3373 Page2
Schedule C (Form1040)1999 K~L B, ~mSHI~,D
Cost of Goods §old.' (se~_ ge C-6)'
33 Method(s) used to
value closing inventory: a r---] cost b [~ Lower of cost or market c ~ other (attach explanation)
34 Was there any change in determining quantities, costs, or valuations between opening and closing inventory? If
"Yes," attach explanation ................................................................................................................................................ ~ Yes
35 Inventory at beginning of year. If different from last year's closing inventory, attach explanation .................................... 3~5
36 Purchases less cost of items withdrawn for personal use ....................................................................................... 3~6
37 Cost of labor. Do not include any amounts paid to yourself .................................................................................... 3'/
38 Materials and supplies .................................................................................................................................... 3~8
39 other costs ................................................ 3~9
40 Add lines 35 through 39 ................................................................................................................................. 41]
41 Inventory at end of year ................................................................................................................................. 4._!_1
42 Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on page 1, line 4 ....................................... 42
Information on Your Vehicle. Complete this part ONLY if you are claiming car or truck expenses on line 10 and are not required
to file Form 4562 for this business. See the instructions for line 13 on page C-3 to find out if you must file.
~-~No
43 When did you place your vehicle in service for business purposes? (month, day, year) I~ / /
44 Of the total number of miles you drove your vehicle during 1999, enter the number of miles you used your vehicle for:
a Business lr 875 b Commuting c Other
45 Do you (or your spouse) have another vehicle available for personal use? .............................................................................. r~ Yes
46 was your vehicle available for use during off-duty hours? ................................................................................................... ~ Yes
47a Do you have evidence to support your deduction? ............................................................................................................ ~ Yes
b If"Yes,' is the evidence written? .................................................................................................................................... ~'~ Yes
~ No
~ No
~ No
Other Expenses. List below business expenses not included on lines 8-26 or line 30.
LABORATORY FEES
DUES & MEETINGS
BANK CHARGES
48 Total other expenses. Enter here and on page 1, line 27
4,941.
495.
98.
5,534.
920002
10-18-99
10
Schedule C (Form 1040) 1999
Depreciation and Amorti~_ation D~ ' K~RL B ETSHIED DDS
Asset
Number
I Date Method/ Life Line
placed IRC sec. or rate No.
in service
BUILDING (BUS PORTION)
iiii?:?~?~l0 910 515 51SL I- 0 2 0 [19 I
DENTAL CHAIR AND EQUIPMENT
iiiiii~i~i~;!10 611519 812 0 0 DBI7.0 0 I17 I
COMPUTER
i!i~i!i?~ill0 611519 812 0 0DBI5.0 0 I17 I
Description of property
Cost or
other basis
4,408.I
7,000.[
4,408.I
SCHEDULE C- 1
140.
4,408-I
Accumulated
depreciation/amortization
Basis
reduction
5,600.I
55~.1
6,151.I
I I I
I I I
I I I
I I I
f I I
2,755.I
Total .Sch C Depreciation
I I t
[ I I
Cu. rr.ent, year
aeauc[ion
882.
1,022.
916251 #- Current year section 1~.% ].(D) - Asset disposed
05-15-99 *
SCHEDULE SE
(Form 1040)
Department of the Treasury
Internal Revenue Service (99)
Self-Employment Tax
· See Instructions for Schedule SE (Form 1040).
· Attach to Form 1040.
OMB No. 1545-0074
1999
Attachment
Sequence No. 17
Name of person with self-employment income (as shown on Form 1040)
KARL B ETSHIED
Social security number of J
person with self-employment
income · 174 120 i3373
Who Must File Schedule SE
You must file Schedule SE if:
· You had net earnings from self-employment from other than church employee income (line 4 of Short Schedule SE or line 4c of Long Schedule SE)
of $400 or more, OR
· You had church employee income of $108.28 or more. Income from services you performed as a minister or a member of a religious order
is not church employee income. See page SE-I.
Note: Even if you had a loss or a small amount of income from self-employment, it may be to your benefit to file Schedule SE and use either
"optional method" in Part II of Long Schedule SE. See page SE-3.
Exception. If your only self-employment income was from earnings as a minister, member of a religious order, or Christian Science practitioner and
you filed Form 4361 and received IRS approval not to be taxed on those earnings, do not file Schedule SE. Instead, write "Exempt-Form 4361 ' on
Form 1040, line 50.
May I Use Short Schedule SE or MUST I Use Long Schedule SE?
t DID YOU RECEIVE WAGES OR TIPS IN 19997 ]
Il No
Yes
Are you a minister, member of a religious order, or Christian
Science practitioner who received IRS approval not to be taxed
on earnings from these sources, but you owe self-empl0yment
tax on other earnings?
N0
Are you using one of the optional methods to figure your net
earnings (see page SE-3)?
Yes ,.
Yes ~
I D
id you receive church employee income reported on Form W-2
of $108.28 or more?
.0
[ YOU MAY USE SHORT SCHEDULE SE BELOW ]
Was the total of your wages and tips subject to social security lYes.
or railroad retirement tax plus your net earnings from self-
employment more than $72,600?
~No
Did you receive tips subject to social security or Medicare IYes~
tax that you did not report to your employer?
YOU MUST USE LONG SCHEDULE SE
Section A - Short Schedule SE. Caution: Read above to see if you can use Short Schedule SE.
I Net farm profit or (loss) from Schedule F, line 36, and farm partnerships, Schedule K-1
(Form 1065), line 15a ...............................................................................................................
2 Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065), line 15a
(other than farming); and Schedule K-1 (Form 1065-B), box 9. Ministers and members of religious orders,
see page SE-1 for amounts to report on this line. See page SE-2 for other income to report ............ .S..t..l~...~.....~..O..
3 Combine lines I and 2 .......................................................................................................................................
4 Net earnings from self-employment. Multiply line 3 by 92.35% (.9235). If less than $400, do not
file this schedule; you do not owe self-employment tax ................................................................................. ·
5 Self-employment tax. If the amount on line 4 is:
· $72,600 or less, multiply line 4 by 15.3% (.153). Enter the result here and on
Form 1040, line 50.
· More than $72,600, multiply line 4 by 2.9% (.029). Then, add $9,002.40 to the result.
Enter the total here and on Form 1040, line 50.
6 Deduction for one-half of self-employment tax.
Multiply line 5 by 50% (.5). Enter the result here and on Form 1040, line 27 ......... I 6
LHA For Paperwork Reduction Act Notice, see Form 1040 Instructions.
2,346
33,203.
33,203.
30,663.
! 4,691.
Schedule SE (Form 1040) 1999
924501
~-~s-~ 1 1
Al 'native Minimum Tax- Indiv Jals
· Attach to Form 1040 or Form 1040NR.
OMB No. 1545-0227
1§90
Attachment ,.~ ,.,
Sequence No. ~.,~ ~'
Name(s) shown on Form 1040
KARL B & JANICE W ETSHIED
Adjustments and Preferences
2
3
4
5
6
7
8
9
10
11
12
13
14
15
If you itemized deductions on Schedule A (Form 1040), go to line 2. Otherwise, enter your standard deduction
from Form 1040, line 36, here and go to line 6 ...................................................................................................
Medical and dental. Enter the smaller of Schedule A (Form 1040), line 4 or 2 1/2% of Form 1040, line 34 ............
Taxes. Enter the amount from Schedule A (Form 1040), line 9 ...........................................................................
Certain interest on a home mortgage not used to buy, build, or improve your home ..........................................
Miscellaneous itemized deductions. Enter the amount from Schedule A (Form 1040), line 26 ..............................
Refund of taxes. Enter any tax refund from Form 1040, line 10 or line 21 ............................................................
Investment interest. Enter difference between regular tax and AMT deduction ...................................................
Post-1986 depreciation. Enter difference between regular tax and AMT depreciation ..........................................
Adjusted gain or loss. Enter difference between AMT and regular tax gain or loss ................................................
Incentive stock options. Enter excess of AMT income over regular tax income ...................................................
Passive activities. Enter difference between AMT and regular tax income or loss ................................................
Beneficiaries of estates and trusts. Enter the amount from Schedule K-1 (Form 1041), line 9 ..............................
Tax-exempt interest from private activity bonds issued after 8/7/86 ..................................................................
Other. Enter the amount, if any, for each item below and enter the total on line 14.
a Circulation expenditures ... h Loss limitations ..................
b Depletion ........................ i Mining costs .....................
c Depreciation (pre-1987) ... j Patron's adjustment .........
d Installment sales .... ; .......... k Pollution control facilities ...
· Intangible drilling costs ...... I Research and experimental
f Large partnerships ............ m Section 1202 exclusion ......
g Long-term contracts ......... n Tax shelter farm activities ...
o Related adjustments .........
Total Adjustments and Preferences. Combine lines 1 through 14 ............................................................... ·
Alternative Minimum Taxable Income
16 Enter the amount from Form 1040, line 37. If less than zero, enter as a (loss) ................................................ · 16
17 Net operating loss deduction, if any, from Form 1040, line 21. Enter as a positive amount .................................... 17
18 If Form 1040, line 34, is over $126,600 (over $63,300 if married filing separately), and you itemized deductions,
enter the amount, if any, from line 9 of the worksheet for Schedule A (Form 1040), line 28 ................................. 18
19 Combinelines 15through 18 ..................................................................................................................... · 19
20 Alternative tax net operating loss deduction ....................................................................................................... 20
21 Alternative Minimum Taxable Income. Subtract line 20 from line 19. (If married filing separately
and line 21 is more than $165,000, see instructions.) .................................................................................... · 21
Exemption Amount and Alternative Minimum Tax
22 Exemption Amount. (If this form is for a child under age 14, see instructions.)
If your filing status is: AND line 21 is not over: THEN enter on line 22:
Single or head of household .............................. $112,500 ........................ $33,750 ')
Married filing jointly or qualifying widow(er) ......... 150,000 ........................45,000 .~ '"~"
Marded filing separately .................................... 75,000 ........................ 22,500 .....................
If line 21 is over the amount shown above for your filing status, see instructions.
23 Subtract line 22 from line 21. If zero or less, enter -0- here and on lines 26 and 28 .......................................... · 23
24 If you reported capital gain distributions directly on Form 1040, line 13, or you completed Schedule D
(Form 1040) and have an amount on line 25 or line 27 (or would have had an amount on either line if you
had completed Part IV) (as refigured for the AMT, if necessary), go to Part IV of Form 6251 to figure line 24.
All others: If line 23 is $175,000 or less ($87,500 or less if marded filing separately), multiply line 23 by 26%
(.26). Otherwise, multiply line 23 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from
the result ................................................................................................................................................... · 24
25 Alternative minimum tax foreign tax credit .......................................................................................................... 25
26 Tentative minimum tax. Subtract line 25 from line 24 .................................................................................... · 26
27 Enter your tax from Form 1040, line 40 (minus any tax from Form 4972 and any foreign tax credit
from Form 1040, ne 46) ......................................................................................... 27
28 Alternative Minimum Tax. Subtract line 27 from line 26. If zero or less, enter -0-. Enter here and on
Form 1040, line 51 .................................................................................................................................... · 28
LHA For Paperwork Reduction Act Notice, see instructions.
Your social security number
174i20 3373
832.
6,073.
<94.>
179.
6,990.
15,038.
22,028.
22,028.
45,000.
0.
1,429.
0.
Form6251(1999)
11-17-99 '
KARL B & JANICE W ETSHIED, 174-20-3373
Form 6251 (1999)
~ Line 24 Computation Using Maximum Capital Gains Rates
Page
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
Caution: If you did not complete Part IV of Schedule D (Form 1040), see the instructions before
you complete this part.
Enter the amount from Form 6251, line 23 .........................................................................................................
Enter the amount from Schedule D (Form 1040), line 27 (as refigured for the
AMT, if necessary) .......................................................................................... 3--0
Enter the amount from Schedule D (Form 1040), line 25 (as reflgured for the
AMT, if necessary) .......................................................................................... 3'1
Add lines 30 and 31 .......................................................................................... 3__2
Enter the amount from Schedule D (Form 1040), line 22 (as refigured for the
AMT, if necessary) ........................................................................................... 33
Enter the smaller of line 32 or line 33 ...............................................................................................................
Subtract line 34 from line 29. If zero or ess, enter -0- . ..........................................................
If line 35 is $175,000 or less ($87,500 or less if married filing separately), multiply line 35 by 26% (.26).
Otherwise, multiply line 35 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from
the result .........................................................................................................................................................
Enter the amount from Schedule D (Form 1040), line 36 (as figured for the
regular tax) ...................................................................................................... 37
Enter the smallest of line 29, line 30, or line 37 ~
Multiply line 38 by 10% (.10) .........................................................................................................................
Enter the smaller of line 29 or line 30 ............................................................... I 40 I
Enter the amount from line 38 ........................................................................... I 41 I
Subtract line 41 from line 40 ..............................................................~ I 42 I
Multiply line 42 by 20% (.20) ...........................................................................................................................
Note: If line 31 is zero or blank, go to line 48.
Enter the amount from line 29 ........................................................................... 44
Add lines 35, 38, and 42 ................................................................................. 46 45
Subtract line 45 from line 44 ..............................................................................
Multiply line 46 by 25% (.25) ...........................................................................................................................
Add lines 36, 39, 43, and 47 ..............................................................................................................................
If line 29 is $175,000 or less ($87,500 or less if married filing separately), multiply line 29 by 26% (.26).
Otherwise, multiply line 29 by 28% (.28) and subtract $3,500 ($1,750 if marded filing separately) from
the result .........................................................................................................................................................
50 Enter the smaller of line 48 or line 49 here and on line 24 .................................................................................
Forr, 6251 (1999)
glg5gl 1 1 2
11-17-gg '
ALTERNATIVE MINIMUM TAX RECONCILIATION REPORT
Name(s) Social SecuritY Number
KARL B & JANICE W ETSHIED 174-20-3373
Form Adjustment
Name Description Income Form 6251
Form 6251, Line 8 Form 6251, line 9 Form 6251, Line 11 Form 6251, Line 14h Other Adjustment
C- KARL B ETSHIED DDS
* Regular Income 33,203.
AMT Depr Adj 179. 179.
, AMT Net Income 33,382. 179. -
** Total Adj & Pref ** 179. _
919911
05-15-99
ALTEr'"~ATIVE MINIMUM TAX DEPRECIATION
ASSET AMT AMT REGULAR AMT AMT
DESCRIPTION
NUMBER METHOD LIFE DEPRECIATION DEPRECIATION ADJUSTMENT
KARL B ETSHIED DDS
4 ~OMPUTER 150DB 5.00 882. 703. 179.
** Subtotal ** 882. 703. 179.
~*** Grand Total ***
882. 703. 179.
928161 11.4
05-15-99
Form 882g
Department of the Treasury
Internal Revenue Service (99)
Exp( ;es'for Bbsiness Use of lome
· File only with Schedule C {Form 1040). Use a separate Form 8829 for each
home you used for business during the year.
OMB No. 1545-1266
lgg9
Name(s) of proprietor(s)
KARL B ETSHIED
I?~i~i!i~!iii~l Part of Your Home Used for Business
I Area used regularly and exclusively for business, regularly for day care, or for storage of inventory
or product samples .......................................................................................................................................
2 Total area of home ..........................................................................................................................................
3 Divide line I by line 2. Enter the result as a percentage ....................................................................................
· For day-care facilities not used exclusively for business, also complete lines 4-6.
· All others, skip lines 4-6 and enter the amount from line 3 on line 7.
4 Multiply days used for day care during year by hours used per day .................. 4 hr.
5 Total hours available for use during the year (365 days x 24 hours) .................. 65 hr.
6 Divide line 4 by line 5. Enter the result as a decimal amount ..............................
7 Business precentage. For day-care facilities not used exclusively for business, multiply line 6 by line 3
(enter the result as a pementage). All others, enter the amount from line 3 ................................................... ·
Figure Your Allowable Deduction
8 Enter the amount from Schedule C, line 29, plus any net gain or (loss) derived from the business use of your
Your social security number
].74-20-3373
33.00%
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
3O
31
32
33
home and shown on Schedule D or Form 4797. If more than one place of business, see instructions .................. 3 6 ¢ 2 0 2.
See instructions for columns (a) and (b) before
iiiiiiiiiiiiiiiiiiii (a) Direct expenses {b) Indirect expenses
tO .....................
11 4,737
12 4,7 37.
t8 2,404
19 1,513
2t 4,352 ·
..................................... [22 1,436.:
,line41 ........................ 23
..................................................................................... 24 1,436.
15 or line24 ............................................................... 25 ]., 436.
ract [lne25 from fine 15 ................................................
:i:~:i:E:[:!:~:~:i
..................................... 28
8 Form 8829, line 42 ...... 29
..................................................................................... 30
erthesmallerof fine26 or line 30 ................................. 31 0.
..................................................................................... a~ 2~999.
amount to ~orm4~, Section 5 .............................. 33 0 ·
completing lines 9-20.
Casualty losses ......................................................
Deductible mortgage interest ....................................
Real estate taxes
Add lines 9, 10, and 11 .............................................
Multiply line 12, column (b) by line 7 ........................
Add line 12, column (a) and line 13 ...........................
Subtract line 14 from line 8. If zero or less, enter -0- ...
Excess mortgage interest .......................................
Insurance
Repairs and maintenance .......................................
Utilities
Other expenses ......................................................
Add lines 16 through 20 ..........................................
Multiply line 21, column (b) by line 7
Carryover of operating expenses from 1998 Form 8829
Add line 21 in column (a), line 22, and line 23
Allowable operating expenses. Enter the smaller of line
Limit on excess casualty losses and depreciation. Sub1
Excess casualty losses ....................................................................................
Depreciation of your home from Part III below
Carryover of excess casualty losses and depreciation from
Add lines 27 through 29
Allowable excess casualty losses and depreciation.
Add lines 14, 25, and 31
Casualty loss portion, if any, from lines 14 and 31. Carr
line 30. If your home was used for more than one business, see instructions ................................................ ·
[i?~i~:i~i[~ii?~J Depreciation of Your Home
Allowable expenses for business use of your home. Subtract line 33 from line 32. Enter here and on Schedule C,
2,999.
36 Value of land included on ne 35 ..................................................................................................................... 36
37 Basis of building. Subtract line 36 from line 35 ................................................................................................ 37
38 Business basis of building. Multiply line 37 by line 7 ................................................. 38
39 Depreciation percentage ................................................................................................................................. 39
40 Depreciation allowable. Multiply line 38 by line 39. Enter here and on line 28 above ..........................................
Iii!~i?~i~i~il Carryover of Unallowed Expenses to 2000
41 Operating expenses. Subtract line 25 from line 24. If less than zero, enter-0- . .................................................. 41
42 Excess casualty losses and depreciation. Subtract line 31 from line 30. If less than zero, enter -0- . ....................
LHA For Paperwork Reduction Act Notice, see page 4 of separate instruction]s2 Form 8829 (1999)
KARL B & JANICE W~ETSHIFTM ~ 174-20-3373
Form 1040 Social Security Benefits Worksheet Statement 1
Check only one box:
A. Single, Head of household, or Qualifying widow(er)
X B. Married filing jointly
C. Married filing separately and lived with your spouse
at any time during 1999
D. Married filing separately and lived apart from your spouse
for all of 1999
1.Enter the total amount from Box 5 of all your
Forms SSA-1099 and RRB-1099 ................
2.Enter one half of line 1 . .
3. Add the amounts on Form 1040, 1 ne , 8b, 9 through 14,
15b, 16b, 17 thru 19, 21 and Schedule B, line 2. Do not
include any amounts from box 5 of Forms SSA-1099 or RRB-1099
4. Enter the amount of any exclusions from foreign earned
income, foreign housing, income from U.S. possessions,
or income from Puerto Rico by bona fide residents of
Puerto Rico that you claimed ...............
5. Add lines 2, 3, and 4 ............... _ _ .
6. Add the amounts on Form 1040,'lines 23, and 25 thru 3la, and
any amount you entered on the dotted line next to line 32.
7. Subtract line 6 from line 5 ...............
8. Enter: $25,000 if you checked Box A or D, or
$32,000 if you checked Box B, or
$-0- if you checked Box C ...........
9. Is the amount on line 8 less than the amount on line 7?
[ ] No. Stop. None of your social security benefits are
taxable. You do not have to enter any amounts on lines
20a or 20b of Form 1040. But if you are married filing
separately and you lived apart from your spouse for all of
1999, enter -0- on line 20b. Be sure you entered 'D' to
the left of line 20a.
[X] Yes. Subtract line 8 from line 7 ...........
10. Enter $9,000 if you checked Box A or D,
$12,000 if you checked Box B
$-0- if you checked Box C ............
11. Subtract line 10 from line 9. If zero or less, enter -0-.
12. Enter the smaller of line 9 or line 10 ..........
13. Enter one half of line 12 .................
14. Enter the smaller of line 2 or line 13 ..........
15. Multiply line 11 by 85% (.85). If line 11 is zero, enter -0-
16. Add lines 14 and 15 ....................
17. Multiply line 1 by 85% (.85) ...............
18. Taxable benefits. Enter the smaller of line 16 or line 17 * Enter the amount from line 1 above on Form 1040, line 20a
* Enter the amount from line 18 above on Form 1040, line 20b
25,089.
12,545.
33,313.
45,858.
4,633.
41,225.
32,000.
9,225.
12,000.
0.
9,225.
4,613.
4,613.
0.
4,613.
21,326.
4,613.
13 Statement(s) 1
KARL B & JANICE W, ETSHIFTM ~ ~ " 174-20-3373
Form 1040 State and Local Income Tax Refunds Statement 2
Gross state/local inc tax refunds
Less: Tax paid in following year
1998 1997 1996
Pennsylvania
110.
83.
Net tax refunds Pennsylvania
Gross state/local inc tax refunds
Less: Tax paid in following year
27.
Pennsylvania
67.
Net tax refunds Pennsylvania
67.
94.
Total net tax refunds
14 Statement(s) 2
KARL B & JANICE W~iETSHIWTM ~ ~ 174-20-3373
Form 1040 Taxable State and Local Income Tax Refunds Statement 3
1998 1997 1996
Net tax refunds from State and
Local Income Tax Refunds Stmt.
94.
Less:Refunds-no benefit due to AMT
1 Net refunds for recalculation
94.
2 Total itemized deductions
before phaseout 20,438.
3 Deduction not subj to phaseout
4 Net refunds from line 1 94.
5 Line 2 minus lines 3 and 4 20,344.
6 Multiply line 5 by 80% (.80) 16,275.
7 Prior year AGI 28,558.
8 Item. ded. phaseout threshold 124,500.
9 Subtract line 8 from line 7
(If zero or less, skip lines
10 through 15, and enter
amount from line 1 on line 16)
10 Multiply line 9 by 3% (.03)
11 Allowable itemized deductions
(line 5 less the lesser of
line 6 or line 10)
12 Item ded. not subj to phaseout
<95,942.>
13a Total adj. itemized deductions
13b Prior yr. std. ded. available
14 Prior yr. allowable item. ded.
15 Subtract the greater of line
13a or line 13b from line 14
16 Taxable refunds
(lesser of line 15 or line 1)
17 Allowable prior yr. item. ded.
18 Prior year std. ded. available
94.
20,438.
8,800.
19 Subtract line 18 from line 17
20 Lesser of line 16 or line 19
21 Prior year taxable income
11,638.
94.
2,720.
22
Amount to include on Form 1040, line 10
* If line 21 is -0- or more, use amount from line 20
* If line 21 is a negative amount, net lines 20 and 21
State and local income tax refunds prior to 1996
Total to Form 1040, line 10
94.
94.
15 Statement(s) 3
KARL B & JANICE W~ETSH~FTM ~ ' 174-20-3373
Form 1040 Refunds Attributable to Est. Tax Paid Following Yr Statement 4
1998
Pennsylvania
State tax paid in follow year 690.
.X
Total state tax paid 1998 920.
Amount Subtracted
State Refund from Taxable Refund
110. = 83.
Schedule A State and Local Income Taxes Statement 5
Description
Other State and Local Income Taxes
Pennsylvania Estimate Payments - Taxpayer
Pennsylvania Prior Year Overpayment Applied - Taxpayer
Pennsylvania Prior Year Estimate Payments - Taxpayer
Pennsylvania Estimate Payments - Spouse
Pennsylvania Prior Year Overpayment Applied - Spouse
Pennsylvania Prior Year Estimate Payments - Spouse
Reduction of State Tax Deduction - State Refunds
Total to Schedule A, line 5
Amount
67.
50.
55.
345.
50.
55.
345.
<83 .>
884.
Schedule A Points Not Reported on Form 1098 Statement 6
Description
Total to Schedule A, line 12
Amort.
Date Re- Total Period
financed Points /Mos.
02/16/98 2,040. 180
Amortization
This Year
136.
136.
16 Statement(s) 4, 5, 6
KARL B & JANICE W~ETSHIFTM ~ , 174-20-3373
Schedule A Cash Contributions Statement 7
Description
WEST CHESTER UNIVERSITY
Subtotals
Total to Schedule A, line 15
Amount Amount
50% Limit 30% Limit
600.
600.
600.
Schedule A Medical and Dental Expenses Statement 8
Description
Prescription Medicines and Drugs
Doctors, Dentists, Etc.
MEDICARE
Medical Insurance Premiums Paid
Self-employed Health Insurance
Total to Schedule A, line 1
Amount
566.
570.
1,092.
1,092.
1,525.
4,845.
Schedule C Car and Truck Expenses Statement 9
Description
Vehicle Number 1 - 1875 Business Miles @ $0.31
Total to Schedule C, line 10
Amount
581.
581.
Schedule SE Non-Farm Income Statement 10
Description
From Schedule C
Total to Schedule SE, line 2
Amount
33,203.
33,203.
17 Statement(s) 7, 8, 9, 10
974461
01-12-00
Cut Aon~l Dotted Line
174-20-3373 ET 194-22-7525 9900913055
ETSHIED
KARL B
JANICE W
ETSHIED
111 N 32ND
CAMP HILL
PA
17011
ST
DEPARTMENT USE ONLY
PAYMENT AMOUNT
$ 90.00
Make check or money order pa~ble to the
Pennsylvania Depa~ment of Revenue
30018117420337300053199912310000000000000005
WORKSHEET Fo'" COMPUTINS ESTIMATED PERSONAL: "'cOME TAx FOR
RESIDENTS AND NONRESIDENTS
FOR THE TAXABLE YEAR JANUARY 1 - DECEMBER 31,1999
OR OTHER TAXABLE YEAR BEGINNING 1999, ENDING lg
A. INCOME (Do not enter losses)
1. Compensation (wages, salaries, tips, etc. NOT SUBJECT TO WITHHOLDING) ............................................................
2. Net Profits from Business, Profession, or Farm
3. Interest
4. Dividends
5. Sale or Exchange of Property ...........................................................................................................................
6. Rents, Royalties, Patents and Copyrights .........................................................................................................
7. Estates or Trusts
8. Gambling and Lottery Winnings .....................................................................................................................
9. Total Pennsylvania taxable income (Add lines 1 through 8) ....................................................................................
10. Estimated Pennsylvania tax due (Multiply line 9 by 2.8%) ....................................................................................
B. CREDITS
11. Estimated Pennsylvania tax to be withheld
12. Estimated tax to be paid to other states (PENNSYLVANIA RESIDENTS ONLY) ............................................................
13. Estimated special tax forgiveness to be claimed ...................................................................................................
14. Total credits (Add lines 11,12 and 13) ............................................................................................................
C. TAX DUE Adjusted
15. Estimated balance due (Subtract line 14 from line 10) ..........................................................................................
16. If you have shown on line 30 of the 1999 PA-40, Individual Income Tax Return an
overpayment of tax due to be credited on 2000 estimated tax, you may apply the credit below
17. Computation of Estimated Payments:
960.00
VOUCHER I 2 3 4 TOTAL
DUE DATE 4/15/00 6/15/00 9/15/00 1/15/2001 ii!~i!~i~i~!i~!i~i!i~i~i!iiii~ii~ii~i~ii!i~i!ii~iii?~ii~ii!~!?!!!i!~i~i~!!!iii!i!i~i=ii!i~ii!!ii~ii~iiiii?i
AMOUNT 240.00 240.00 240.00 240.00 960.00
RECORD OF
PRIOR PAYMENTS
ESTIMATED
1999 OVERPAYMENT
TAX PAYMENTS
TOTAL 240.00 240.00 240.0E 240.00 960.00
CHECK NO. ~!!i~!!~!~i~!~i~!i~i~iii}~i;ii::i::iii::i::!::!::i::!::~!?:!i!i!i!i!~!i:~i
Cut Along Dotted Line
974033
12-29-99
2000
PA-40ES
174-20-3373
INDIVIDUAL DECLARATION
ET 194-22-7525
ETSHIED
KARL B
JANICE W
ETSHIED
OF ESTIMATED
DUE
DATE
0002512053
PAYMENT AMOUNT
$ 240.00
111 N 32ND
CAMP HILL
PA
17011
2000
ST
Estimated
DEPARTMENT USE ONLY
2000 Estimated 2000
Make check or money order payable to the
Pennsylvania Department of Revenue
Estimated
1040Department of the Treasury - Intsm venue Sarvlce 2000
U.S. Individual Inco~... Tax Return ¢g) Jse Only- Do not write or staple in this space.
Label For the year Jan. 1-Dec. 31, 2000, or other tax year beginning ,2000, ending ~ 20 OMB No. 1545-0074
L Your first name and initial Last name I Your social security number
(See .
instructions A ~.RL B ETSHIED 174 120 !3373
on page 19.) B If a joint return, sp0use's first name and initial Last name spouse's social security number
E
UsethelRS L JANICE W ETSHIED 194 122 i7525
label. Home address (number and street). If you have a P.O. box, see page 19. Apt. no. · IMPORTANTI ·
Otherwise, H
E 111 N 32ND ST You must enter
please pdnt R City, town or post office, state, and ZIP code. your SSN(s) above.
o r type. E
Presidential CAMP HILLf PA 17011
Election Campaign
(See page 195
Note. Checking "Yes" will not change your tax or reduce your refund. You Spouse
Do you, or your spouse if filing a joint return, want $3 to go to this fund? ......... · r---] Yes ~ No ~ Yes ~ No
Filing Status
Check only
one box.
Exemptions
If morethan six
dependents,
see page 20.
1
2
3
4
name here. ·
Single
Marded filing joint return (even if only one had income)
Married filing separate return. Enter spouse's soc. sec. no. above and full name here. ·
Head of household (with qualifying person). (See page 19.) If the qualifying person is a child but not your dependent, enter this child's
5 Qualifying widow(er)with dependentchild (yearspouse died · ).(See page 19.)
6a ~ Yourself. Ifyourparent(orsomeone else)can claim you as a dependent on his orhertax return, do not '~
check box 6a ..................................................................................................................
b ~-~Spouse ................................................................................................................................
Dependents: (2) Dependent's soclal (3) Dependent's (4.) V'if qualifY-lng child for
(1) First name Last name secudty number relationship to chird taxcmdi!
you (see page 20)
d Total number of exemptions claimed ............................................................................................................
No, of boxes
checked on 6a
and 6b
No. ofyour
children on 6c
who:
· lived with you
· did not live with
you due to divorce
or separation
(sea page 20)
Dependents on 6~
not entered above
Add numbem ~
entered on
lines above ·
~10001
,~-o9-o~ LHA For Disclosure, Privacy Act, and Paperwork Reduction Act NotiCe, see page 56.
Form 1040 (2000)
Income 7 Wages, salaries, tips, etc. Attach Form(s) W-2 .............................................................................. 7
8a Taxable interest. Attach Schedule B if required .............................................................................. 8a 9,
Attach
Forms W-2 and b Tax-exempt interest. Do not include on line 8a .................................I 8, I
W-2G here. 9 Ordinary dividends. Attach Schedule B if required ........................................................................... 9
Also attach 10 Taxable refunds or credits of state and local income taxes ............................................................... 10
Form(s)
I099-R if tax 11 Alimony received ..................................................................................................................... 11
was withheld. 12 Business income or (loss). Attach Schedule C or C-EZ ..................................................................... 12 3 8 ¢ 0 4 8.
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here ..................... · C~ 13
If you did not
get a W-2, 14 Other gains or (losses). Attach Form 4797 .................................................................................... 14
see page 21. 15a Total IRA distributions ............... 15a I b Taxable amount (see page 23) 15b
16a Total pensions and annuities ...... 16aI b Taxable amount (see page 23) 16b
Enclose, but do 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E ........................ 17
not attach, any
payment. Also, 18 Farm income or (loss). Attach Schedule F .................................................................................... 18
please use 19 Unemployment compensation ................................................................................................... 19
Form 1040-V, 20a Social security benefits ............ I 20a I 25 r 002 .I b Taxable amount (see page 25) 20b 7
21 0ther income. Ust type and amount (see page 25)
21
22 Add the amounts in the far right column for lines 7 through 21. This is your total income .................. · 22 4 5 t' 2 ]. 0 o
:::::~::::::::::::::
Adjusted 24 Student loan interest deduction (see page 27) .................................... 24
Gross 25 Medical savings account deduction. Attach Form 8853 ........................ 25
Income 26 Moving expenses. Attach Form 3903 ............................................. 26
27 0ne-halfofself-employmenttax. Attach Schedule SE ........................ 27 2,688.
28 Self-employed health insurance deduction (see page 29) ..................... 28 2,5 14. i~i~ii~i!~iii~
2g Self-empl0yed SEP, SIMPLE, and qualified plans .............................. 2g
30 Penalty on early withdrawal of savings 30
32 Add lines 23 through 31a 32 5 r 202.
33 Subtract line 32 from line 22. This is your adjusted ~ross income ............................................. · 33
Fo.~1040~?_~ KARL B & JANICE .... ETSHIED 174-7.0-3373 p~e2
Tax and 34 Amount from line 33 (adjusted [~. ~s income) ................................................................................. 34 4 0,0 0 8.
Credits 35a Check if: ~-~ You were 65 or older, r-"] Blind; ~ Spouse was 65 or older, [~ Blind. I
Add the number of boxes checked above and enter the tote here ....................................· 35a I 2
StandardDeductlon ~ blfyouaremarriedfllingseparatelyandyourspouseitemizesdeductions,
for Most or you were a dual-status alien, see page 31 and check here .......................................... · 35b [--'-]
F~eop,s 36 Enter your itemized deductions from Schedule A, line 28. or standard
- deduction shown on the left. But see page 31 to find your standard deduction if you
Single: checked any box on line 35a or 35b or if someone can claim you as a dependent .......................................... 36 1 5 r 0 9 4.
~,40o 37 Subtract line 36 from line 34 37 24,914.
Head of 38 If line 34 is $96,700 or less, multiply $2,800 by the total number of exemptions claimed on
household:
$e,45o line 6d. If line 34 is over $96,700, see the worksheet on page 32 for the amount to enter .............................. 38 5 r 6 0 0.
39 Taxable income. Subtract line 38 from line 37. If line 38 is more than line 37, enter-0- . ................................ 39 1 9 r 3 1 4.
40 Tax (seepage32).Checkifanytaxfrom a r--] Form(s)8814 b [---I Form4972 ................................. 40 2,899.
Married filing
Jointly or 41 Alternative minimum tax. Attach Form 6251 .......................................................................................... 41
wldow[e~:Qualifying ' 42 Add lines 40 and 41 .................................................................................................................. ·..............42 2 r 899 .
$7,350 43 Foreign tax credit. Attach Form 1116 if required ....................................... 43
fillngMarded 44 Credit for child and dependent care expenses. Attach Form 2441 .................. 44
separately: 45 Credit for the elderly or the disabled. Attach Schedule R .............................. 45
$3,675 46 Education credits. Attach Form 8863 ...................................................... 46 :~:~:~:~;:~:~:~
47 Child tax credit (see page 36) ............................................................... 47
48 Adoption credit. Attach Form 8839 ......................................................... .48.
49 Other. Check if from a ~ Form 3800 b ~-~ Form 8396
50 Add lines 43 through 49. These are your total credits .............................................................................. 50
51 Subtract line 50 from line 42. If line 50 is more than line 42, enter-0-. .................................................. · 51 2 r 8 9 9.
Other 52 Self-employment tax. Attach Schedule SE ............................................................................................. 52 5 r 3
Taxes 53 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 ........................... 53
54 Tax on IRAs, other retirement plans, and MSAs. Attach Form 5329 ff required ............................................. 54
55 Advance earned income credit payments from Form(s} W-2 ..................................................................... 55
56 Household employment taxes. Attach Schedule H ................................................................................. 56
57 Add lines 51 through 56. This is your total tax ................................................................................. · 57 8r275.
Payments 5a Federal income tax withheld from Forms W-2 and 1099 .............................. 58
59 2000 estimated tax payments and amount applied from 1999 return ............ 59
e qua,l~yinU r--I'y°u have t-- '0a Earned Inc°me credit (EIC' {iii 60, iii
child, attach / b Nontaxable eamed income: amount · {
Schedule EIC./ and type ·
61 Excess social security and RRTA tax withheld (see page 50) ........................ 61
62 Additionalchild tax credit. Attach Form 8812 ............................................. 62
63 Amount paid with request for extension to file .......................................... 63
64 Otherpayments. Check iffrom a ~ Form 2439 b ~ Form 4136 ......... 64
65 Add lines 58, 59, 60a, and 61 through 64. These are your total payments ............................................. · 65
Refund 66 If line 65 is more than line 57, subtract line 57 from line 65. This is the amount you overpaid ........................... 66
Have~t 67a Amount of line 66 you want refunded to you .................................................................................... · 67a
directly
deposltedl · b Routing number · c Type: ~ Checking ~-J Savings
See page 50
and fill in 67b, · d Account number
eTc.,,nd e?d. 68 Amount of line 66 you want applied to your 2001 estimated tax ......... · I 68 I
Amount 69 if line 57 is more than line 65, subtract line 65 from line 57. This is the amount you owe. · 69 8 r 64 !.
Sign
Here
Keep a copy
for your
records.
Under penalties of penury, I declare that I have examined this retum and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct,
and complete. Declaration of preparer (other than taxpaye~ is based on all inf~n'nation of which preparer has any knowledge.
Your signature Date Your occupation ~ Daytime phone number
1
DENTIST
Spouse's signature. If a Joint return, both must sign. Date Spouse's occupation ~ Maythe iRS disaJss 1his ~Jrn ~ IhS
I ~__~ ~o~ ~ pag~52)?
HOUSEWIFE II A IYes I I No
Preparer's
Paid signature
Preparer's
Firm's name (or
Use
~nly yours if self-em-
ployed), address,
and ZIP code
Date 1 Check if self- Preparer's SSN or PTIN
03/17/0 .m.,oyed I-----I 189-52-1408
WILDEMAN AND OBROCK, CPA'S IFIN 23!2198946
515S. 29TH STREET ,. ...... 561-0820
I
(717)
HARRISBURGr PA 17104-2104
o~oom 6
01-03-01
o 2210
Department of the Treasury
Internal Revenue Service
Underpayment of
Estimated Tax by Individuals, Estates, and Trusts
Ii* See separate instructions.
Attach to Form 1040, 1040A, 1040NR, 1040NR-EZ, or 1041.
Name(s) shown on tax return
KARL B & JANICE W ETSHIED
OMB No.1545-0140
200O
Attachment
Sequence No,
Identifying number
174-20-3373
Note: In most cases, you do not need to file Form 2210. The IRS will figure any penalty you owe and send you a bill. File Form 2210 only if one or more
boxes in Part I apply to you. If you do not need to file Form 2210, you still may use it to figure your penalty. Enter the amount from Part III, line 21, or
Part IV, line 35, on the penalty line of your return, but do not attach Form 2210.
Reasons for Filing - If la, lb, or lc below applies to you, you may be able to lower or eliminate your penalty. But you must
check the boxes that apply and file Form 2210 with your tax return. If ld below applies to you, check that box and file Form 2210
with your tax return.
Check whichever boxes apply (if none apply, see the Note above):
r~ You request a waiver. In certain circumstances, the IRS will waive all or part of the penalty.
See Waiver of Penalty on page 1 of the instructions.
[---'] You use the annualized Income Installment method. If your income varied during the year, this method may reduce
the. amount of one or more required installments. See page 5 of the instructions.
~ You had Federal income tax withheld from wages and, for estimated tax purposes, you treat the withheld tax as paid on the dates it was
actually withheld, instead of in equal amounts on the payments on the payment due dates. See the instructions for line 23 on page 3.
~ Your required annual payment (line 14 below) is based on your 1999 tax and you filed or are filing a joint return for either 1999 or 2000 but
not for both years.
~ Required Annual Payment
2 Enter your 2000 tax after credits (see page 2 of the instructions) ....................................................................................... 2 2 r 8 9 9
3 Othertaxes(seepage2oftheinstmctions) .................................................................................................................. I 3 I 5r 376.
4 Addlines 2 and 3 .............................................................................................................................................. [ 4 I 8 r 275.
6 AdUitiona chi, tax credit ................................................................... I 6 I
7 Credit for Federal tax paid on fuels ................................................................................. I 7 J
8 Add lines 5, 6, and 7 ................................................................................................................................................
9 Currentyeartax. Subtrectlineefromline4 .................................................................................................................. / 9 I 8¢275.
to Multiply,ne 9by9O% (.90) ....................................................................................... I lO I ?, 44 e
11 Withholding taxes. Do not include any estimated tax payments on this line (see page 3 of the instructions) ..............................
12 Subtract line 11 from line 9. If less than $1,000, stop here, do not complete or file this form. You do not owe the
penalty ............................................................................................................................................................... / 121 8r275'
13 Enter the tax shown on your 1999 tax return (108.6% of that amount if the adjusted gross income shown on that return is more
than $150,000, or, if married filing separately for 2000, more than $75,000). Caution: See instructions / 13 I 6 ¢ ! 2 0.
14 Required annual payment. Enter the smaller of line10 or line13 ..................... | 14 I 6 r ].20.
Note: If line 11 is equal to or more than line 14, stop here; you do not owe the penalty. Do not file Form 2210 unless
you checked box Id above.
[=~i~i~l~il] Short Method (Cauti on: see page 2 of the instructions to find out if you can use the short method. If you checked box lb or 1 c
in Part I, skip this part and go to Part IV,)
15 Enter the amount, if any, from line 11 above .................................................................. 15
16 Enter the total amount, if any, of estimated tax payments you made ....................................16
17 Add lines 15 and 16 ................................................................................................................................................ '"'~'~'"
18 Total underpayment for year. Subtract line 17 from line 14. If zero or less, stop here; you do not
owe the penalty. Do not file Form 2210 unless you checked box ld above ........................................................................ 18
19 Multiply line 18 by .05976 ........................................................................ ' ............................................................... lg
20 · If the amount on line 18 was paid on or after 4/15/01, enter-O-.
· If the amount on line 18 was paid before 4/15/01, make the following computation to find the amount to enter on line 20.
Amount on Number of days paid
line 18 x before 4/15/01 x .00025 ............................................................... '"~'
21 PENALTY. Subtract line 20 from line 19. Enter the result here and on Form 1040, line 70; Form 1040A, line 45;
Form 1040NR, line 69; Form 1040NR-EZ, line 27; or Form 1041, line 26 ........................................................................ ~' 21
6r120.
366.
366.
Form 2210
LHA For Paperwork Reduction Act Notice, see page I of separate Instructions.
012501
12-08-OO 6.1
SCHE, OULES A&B
(Form 1040)
Department of the Treasury
internal Revenue Service (99)
Name(s) shown on Form 1040
ule A- Itemized Deduction'
(Schedule B is on page 2)
· Attach to Form 1040. · See Instructions for Schedules A and B (Form 1040).
2000
OMB No. 1545-0074
Attachment
Sequence No. 07
Your $~c;a; security number
174 !20 i 3373
KARL B &
Medical
and 1
Dental 2
Expenses 3
4
Taxes You
Paid
(See
page A-2.)
Interest 10
You Paid 11
(See
page A.3.)
Note: '
Personal 12
interest is
not 13
deductible. 14
Gifts to
Charity
16
If you made a
gift and got a
benefd~ for it, 17
see page A-4.
Casual~ and
Theft Losses
JANICE W ETSHIED
Caution: DO not include expenses reimbursed or paid by others. Ji!!iiii!!iiii!ii~iii{
Med cai and dental expenses (see page A-2) ..........$..e..e......$..t..a...~..e...m..e.n...~......5. .... i j
Enter amount from Form 1040, line 34 .............................. I 2 J 40e 008. iiiiiiiiiii~ii!i~iil
Multiply line 2 above by 7.5% (.075) ........................................................... I 3 /
Subtract line 3 from line 1. if line 3 is more than line 1, enter -0-
5 State and local income taxes .............................. ~..e..e......$..t..a.~.9.m..e..~..t....2. ....
6 Real estate taxes (see page A-2) ...........................................................................
7 Personal property taxes .......................................................................................
8 Other taxes. List type and amount
· PERSONAL & OPT 1,084.
9
Home mortgage interest not reported to you on Form 1098. If paid to the person
from whom you bought the home, see page A-3 and show that person's name,
identifying no., and address
· ...................
Points not reported to you on Form 1098. (See page A-3.) ............... .S...~...t~...~......3. .... 12
investment interest. Attach Form 4952 if required. (See page A-3.) ........................ 13
3,220.
3,0 011f
5 850;I
6 1,976
7
-' 8 lr084.
Add lines 5 through 8 ................................................................... I 9
10,229
136 ·
Add lines 10 through 13 .....................................................................................................................
Gifts by cash or check. If you made any gift of $250 or more,
see page A-4 ...................................................... .$.e..e......~...~..a...~..e...l~..e..n..~.....4 .... L,5J 600.j
Other than by cash or check. If any gift of $250 or more, see page A-4. Iiiii~!!ili!!!i~iii~ I
You MUST attach Form 8283 if over $600 ............................................................J15 1 I
Cern/over from prior year ................................................................................... Jl 7 J I
18 Add lines 15 through 17 ..................................................................................................................... J 18
19 Casualty or theft loss(es). Attach Form 4684. (See page A-5.) ............................................................... J 19
Job Expenses 20 Unreimbursed employee expenses- job travel, union dues, job education, etc.
and Most You MUST attach Form 2106 or 2106-EZ if required. (See page A-5.)
Other
Miscellaneous -
Deductions
21 Tax preparation fees ..........................................................................................
22 Other expenses- investment, safe deposit box, etc. Ust type and amount
(See
page A-5 for
expenses to
deduct here.)
Other
Miscellaneous
Deductions
Total
Itemized
Deductions
23 Add lines 20 through 22 ................................................. ~ .....................................
24 Enter amount from Form 1040, line 34 .............................. 1241
25 Multiply line 24 above by 2% (.02) ........................................................................
26
Subtract line 25 from line 23. If line 25 is more than line 23, enter -0.. ..................................................
27 Other - from list on page A-6. List type and amount
Is Form 1040, line 34, over $128,950 (over $64,475 if married filing separately)?
[-~ NO. Your deduction is not limited. Add the amounts in the far right column
for lines 4 through 27. Also, enter on Form 1040, line 36.
[---] YES. Your deduction may be limited. See page A-6 for the amount to enter.
219 ·
3r910 ·
10~365.
600.
094.
LHA For Paperwork Reduction Act Notice, see Form 1040 instructions.
019501 7
10-18-00
Schedule A (Form 1040) 2000
Schedule~ A&B (Form 1040) 2000 OMB No. 1545-0074 Page 2
Name(s) sl~own on Form 1040. Do not enter name end social sec
~umber if shown on page 1.
Your social security number
J,Z~NTCR W ETSHTRD ;[74 20 3373
Schedule B- Interest and Ordinary Dividends A=~n~ts~,,en~ No. 08
Note. If you had over $400 in taxable interest, you must also complete Part Ill.
Amount
Part I
Interest
I List name of payer. If any interest is from a seller-financed mortgage and the buyer used the
property as a personal residence, see page B-1 and list this interest first. Also, show that
buyer's social security number and address ·
WAYPOINT BANK
Note: If you
received a Form
1099-1NT,
Form 1099-OID,
or substitute
statement from
a brokerage firm,
list the firm's '
name as the
payer and enter
the total interest
shown on that
form.
2 Add the amounts on line 1 .........................................................................................................
3 Excludable interest on series EE and I U.S. savings bonds issued after 1989 from Form 8815,
line 14. You MUST attach Form 8815 ..........................................................................................
4 Subtract line 3 from line 2. Enter the result here and on Form 1040, line 8a ........................... ·
Part II Note. If you had over $400 in ordinary dividends, you must also complete Part III.
Ordinary s List name of payer. Include only ordinary dividends. If you received any capital gain distributions, Amount
Dividends see the instructions for Form 1040, line 13. ·
Note: If you
received a Form
1099-DIV or
substitute
statement from.
a brokerage firm,
list the firm's 5
name as the
payer and enter
the ordinary
dividends shown
on that form.
6 Add the amounts on line 5. Enter the total here and on Form 1040, line 9 .................................... 6
Part III You must complete this part if you (a) had over $400 of interest or ordinary dividends; (b) had a foreign account; or Yes No
Foreign (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust.
Accounts 7a At any time during 2000, did you have an interest in or a signature or other authority over a financial i?~i?~ili?~iiii?~ [~ili~i!~iiiiiii~iii;ii!
and account in a foreign country, such as a bank account, securities account, or other financial account? .................. X
Trusts b If'Yes,' enter the name 0f the f0reign c0untry · il i
8 During 2000, did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust?
If 'Yes," you may have to file Form 3520. See page B-2 ....................................................................................... X
LHA
~27501
10-18-00
For Paperwork Reduction Act Notice, see Form 1040 instructions.
Schedule B (Form 1040) 2000
OMB No. 1545-OO74
2000
SC'EOU'Ec
(Form 040)
Depm~m'~ent of the Treesur~
Internal Revenue Service
F' fit or Loss From Business
(Sole Prop,leto,ship)
· Partnerships, Joint ventures, etc., must file Form 1065 or Form 1065-B.
· Attach to Form 1040 or Form 1041. · See Instructions for Schedule C (Form 1040).
Sequence No. U~
Name of proprietor
KARL B ETSHIED
Social security number (SSN)
174-20-3373
A Principal business or profession, including product or service (see page C-1) B Enter code fl'orn pages C-7 & 8
DENTIST/DENTISTRY · 621210
C Business name. If no separate business name, leave blank. D Employer ID number (EIN], ifany
KARL B ETSHIED DDS 23-1574543
E Business address (including suite or room no.) · 111 N 32ND ST
City, town or post office, state, andZIPcode CAMP HILL, PENNSYLVANIA 17011
F Accounting method: [1)1 X l Cash (2)[ [Accrual [3)1 I Other (specify) ·
G Did you "materially participate" in the operation of this business during 2000? If'No,' see page C-2 for limit on losses .............................. ~ Yes [---] No
H If you staffed or acquired this business during 2000, check here · F-'-I
Iili~il~i!~iit Income
I Gross receipts or sales. Cautlan: If this income was reported to you on Form W-2 and the "Statutory employee" box on
thatform, was checked, see page C-2 and check here .............................................................................. · r--] 1
2 Returns and allowances .......................................................................................................................................... Z
3 Subtract line 2 from line 1 .......................................................................................................................................
3
4 Cost of goods sold (from line 42 on page 2) ............................................................................................................... 4
5 Gross profit. Subtract line 4 from fine 3 .....................................................................................................................
8 Other income, including Federal and state gasoline or fuel tax credit or refund (see page C-3) ................................................
7 Gross Income. Add lines 5 and 6. ·
8 Advertising ....................................
g Bad debts from sales or
services (see page C-3) ..................
10 Car and truck expenses
(see page C-3) ......... S..~.~.t....~ ....
11 commissions and fees ..................
12 Depletion ....................................
13 Depreciation and section 179
expense deduction (not included in
Part III) (see page C-3) .....................
14 Employee benef~ programs (other
than on line 19) ...........................
15 Insurance (other than health) ............
16 Interest:
a Moffgage (paid to banks, etc.) .........
b Other ..........................................
17 Legal and professional
services .......................................
18 Office expense ..............................
28
Expenses. Enter expenses for business use of your home only
609
669
836
475
2
Total expenses before expenses for business use of home. Add lines 8 through 27
on line 30.
19 Pension and profit-sharing plans ..................
20 Rent or lease (see page C-4):
a Vehicles, machinery, and equipment ............
b other business property ...........................
21 Repairs and maintenance ...........................
22 Supplies (not included in Part III) ...............
23 Taxes and licenses ....................................
24 Travel, meals, and entertainment:
a Travel ...................................................
b Meals and
entertainment
c Enter nondeductible
amount included on line 24b
(see page C-5) ..................
d Subtract line 24c from line 24b ..................
25 Utilities ...................................................
26 Wages (less employment credits) ...............
27 Other expenses (from line 48 on
in columns ....................................... ·
29
30
31
32
Tentative profit (loss). Subtract line 28 from line 7 .........................................................................................................
Expenses for business use of your home. Attach Form 8829 ..........................................................................................
Net profit or (loss). Subtract line 30 from line 29.
· If a profit, enter on Form 1040, line 12, and also on Schedule SE, line 2 (statutory employees, see page C-6).
Estates and trusts, enter on Form 1041, line 3.
· If a loss, you must go on to line 32.
If you have a loss, check the box that describes your investment in this activity (see page C-6).
· If you checked 32a, enter the loss on Form 1040, line 12, and also on Schedule SE, line 2 (statutory employees,
see page C-6). Estates and trusts, enter on Form 1041, line 3.
· If you checked 32b, you must attach Form 6198.
55,111.
55,111.
55,111.
55r111.
2,601.
1,263.
4,677.
13,470.
41r641.
3,593.
38,048.
[--'-1 All Investment
32a
is at risk.
~ Some Investment
32b
I I
is not at risk.
LHA
020001
10-25-OO
For Paperwork Reduction Act Notice, see Form 1040 Instructions.
9
Schedule C (Form 1040) 2000
: Schedule,C (Form 1040) 2000 ~ART, B ET
Ii~i~ii~i~i!il Cost of Goods Sold (see page ~,-6)
33 Method(s) used to
value closing inventory: a I-~ Cost
174-20-3373 Pave2
34
35
37
38
40
41
b ~ Lower of cost ormarket c ~ Other (attach explanation)
Was there any change in determining quantities, costs, or valuations between opening and closing inventory? If
"Yes,' attach explanation ................................................................................................................................................ ~ Yes
Inventory at beginning of year. If different from last year's closing inventory, attach explanation .................................... 3,5
Purchases less cost of items withdrawn for personal use ....................................................................................... 36
Cost of labor. Bo not include any amounts paid to yourself .................................................................................... 3.__[_7
Materials and supplies .................................................................................................................................... 3~8
Other costs ................................................................................................................................................... 3(3
Add lines 35 through 39 ................................................................................................................................. 4..--9--0
Inventory at end of year ................................................................................................................................. 41
42
42 Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on page 1, line 4 .......................................
~ii~ii~:~i~l Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on line 10 and are not required
to file Form 4562 for this business. See the instructions for line 13 on page C-3 to find out if you must file.
I---I No
43
44
45
46
47a
b
tli~i~!}iilJ Other Expenses.
T,k13OR~OR¥
When did you place your vehicle in service for business purposes? (month, day, year) · / /
Of the total number of miles you drove your vehicle during 2000, enter the number of miles you used your vehicle for:
Business 1 r 875 b Commuting c Other
0o you (or your spouse) have another vehicle available for personal use? .............................................................................. ~ Yes
Was your vehicle available for use during off-duty hours? ................................................................................................... ~ Yes
Do you have evidence to support your deduction? ............................................................................................................ [] Yes
If "Ye%' is the evidence' written? r~ Yes
List below business expenses not included on lines 8-26 or line 30,
l~] No
J--'-J No
r--1 No
DUES & MEETINGS
BANK CHARGES
48 Total other expenses. Enter here and on page 1, line 27 ....................................................................................
4,097.
363.
217.
4 677
o2ooo2 1 0 Schedule C (Form 1040) 2000
10-25-00
2000 DEPRECIATION AND AMORTIZATION REPORT
KARL B ETSHIED DDS
SCHEDULE C- 1
Reduction In
Asset Date Line Unadiusted Bus % Basis - Basis For Accumulated Current Amount Of
No. BescdpUon Acquired Method Life No. COSt Or Basis Excl ITC, 179, DepreciaUon DepreciaUon. Sec 179 OepreciaUon
Salvage
ZBUILDING (BUS PORTION) 390555SL .020 19 7,000. 7,000. 5,740. 140.
~ :O~P~T~.R D615~8~_OODBS.00 ~7 2,755. 2,755. 1,433.
:~:i:i:!:!:i :~:!:~:!:~:i ::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Total Sch C Depreciation 14,163. 4,408. 9,755. 7,173.
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::: [!~?:!!i::i::i i::i::i::~![::~!i ~!!iii~:-iii!i!!i[iii!~![!!i!!
028102 (D) - Asset disposed
11-01-00
10.1
Schedule C- Two-Year C, :parison Worksheet 2000
Business Name:
~ARL B ETSHIED DDS
INCOME
Gross income 52,090. 55,111. 3,021.
EXPENSES
2ar and truck expenses 581. 609. 28.
Depreciation and Sec. 179 expense 1,022. 669. <353.>
Insurance 836. 836. 0.
5egal and professional services 425. 475. 50.
Dffice ~xpense 3,760. 2,340. <1,420.>
Supplies 2,570. 2,601. 31.
Utilities 1,160. 1,263. 103.
Dther expenses 5,534. 4,677. <857.
Total expenses 15,888. 13,470. <2,418.>
Tentative profit or (loss) 36,202. 41,641. 5,439.
Home office expense 2,999. 3,593. ~ 594.
Net profit or (loss) 33,203. 38,048. 4,845.
10.2
SCHEDULE SE
(Form 1040) Self-Employment Tax
· See Instructions for Schedule SE (Form 1040).
Department of the Treasu~'
Internal Revenue Service (99) · Attach to Form 1 040.
Name of person with self-employment income (as shown on Form 1040) Social security number of
person with self-employment
KARL B ETSHIED income ·
OMB No. 1545-0074
2000
Attachment
s,queno, No. 17
174 !20~3373
Who Must File Schedule SE
You must file Schedule SE if:
· You had net earnings from self-employment from other than church employee income (line 4 of Short Schedule SE or line 4c of Long Schedule SE)
of $400 or more, or
· You had church employee income of $108.28 or more. Income from services you performed as a minister or a member of a religious order
is not church employee income. See page SE-I.
Note: Even if you had a loss or a small amount of income from self-employment, it may be to your benefit to file Schedule SE and use either
'optional method' in Part II of Long Schedule SE. See page SE-3.
Exception. If your only self-employment income was from earnings as a minister, member of a religious order, or Christian Science practitioner and
you filed FormA361 and received IRS approval not to be taxed on those earnings, do not file Schedule SE. Instead, write 'Exempt-Form 4361 ' on
Form 1040, line 52.
May I Use Short Schedule SE or Must I Use Long Schedule SE?
I Did You Receive Wages or Tips In 20001
Yes
Are you a minister, member of a religious order, or Christian
Science practitioner who received IRS approval not to be taxed , Yes
on earnings from these sources, but you owe self-empl0yment I
tax on other earnings?
I
IAre you using one of the optional methods to figure your net J Yes,,.
earnings (see page SE-3)?
F '
I Did you re~ive chumh employee income reported on Form W-2
of $106.28 or more?
No
Was the total of your wages and tips subject to social security
or railroad retirement tax plus your net earnings from self-
employment more than $76,200?
Did you recoive tips subiect to social security or Medicare
tax that you did not repo~t to your employer?
You May Use-Short Schedule SE Below
You Must Use Long Schedule SE
Section A-Short Schedule SE. Caution: Read above to see ff you can use Short Schedule SE.
I Net farm profit or (loss) from Schedule F, line 36, and farm partnerships, Schedule K-1
(Form 1065), line 15a .......................................................................................................................................... 1
2 Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065), line 15a
(other than farming); and Schedule K-1 (Form 1065-B), box 9. Ministers and members of religious orders,
see page SE-1 for amounts to report on this line. See page SE.2 for other income to report ............ $...t.~.....7. .... 2 I 3 $, 0 4 $.
3 Combine lines 1 and 2 ....................................................................................................................................... { 3 I 3 8,0 4 8.
4 Net earnings from self-employment. Multiply line 3 by 92.35% (.9235). If less than $400, do not
file this schedule; you do not owe self-employment tax ................................................................................. · I 4 J 3 5 ~ 1 3 7 ·
5 Self-employment tax. If the amount on line 4 is:
· $76,200 or less, multiply line 4 by 15.3% (.153). Enter the result here and on '~
Form 1040, line 52. ~ [ 5[ 5,376.
·More than $76 200, multiply line 4 by 2.9°,6 (.02g). Then, add $9,448.80 to the result. J ..............................
Enter the total here and on Form 1040, line 52.
6 Deduction for one-half of self-employment tax. Multiply line 5 by 50% (.5). I I "6 8 8
Entertheresulthereandon Form1040,1ine27 ................................................ J 6 J Z,
LHA For Paperwork Reduction Act Notice, see Form 1040 Instructions.
Schedule SE (Form 1040) 2000
10-18-00
6251
Department of the Treasury
Intemal Revenue Se~ice
Alte, , ative Minimum Tax - Indivi( ..als
· Attach to Form 1040 or Form 1040NR.
Name(s) shown on Form 1040
KARL B S JANICE W ETSHIED
OMB No, 1545-0227
2000
Attachment ~
Sequence No. ~'
JYour social security number
17412013373
Adjustments and Preferences
I If you itemized deductions on Schedule A (Form 1040), go to line 2. Otherwise, enter your standard deduction
from Form 1040, line 36, here and go to line 6 ...................................................................................................
Medical and dental. Enter the smaller of Schedule A (Form 1040), line 4 or 2 1/2% of Form 1040, line 34 ............
Taxes, Enter the amount from Schedule A (Form 1040), line 9 ...........................................................................
Certain interest on a home mortgage not used to buy, build, or improve your home ..........................................
Miscellaneous itemized deductions. Enter the amount from Schedule A (Form 1040), line 26 ..............................
Refund of taxes. Enter any tax refund from Form 1040, line 10 or line 21 ............................................................
Investment interest. Enter difference between regular tax and AMT deduction ...................................................
Post-1986 depreciation. Enter difference between regular tax and AMT depreciation ..........................................
Adjusted g.ain or loss. Enter difference between AMT and regular tax gain or loss ................................................
Incentive stock options, Enter excess of AMT income over regular tax income ...................................................
Passive activities. Enter difference between AMT and regular tax income or loss ................................................
Beneficiaries of estates and trusts, Enter the amount from Schedule K-1 (Form 1041), line 9 ..............................
Tax-exempt interest from private activity bonds issued after 8/7/86 ..................................................................
Other. Enter the amount, if any, for each item below and enter the total on line 14.
a Circulation expenditures ... h Loss limitations ..................
b Depletion ........................ i Mining costs .....................
c Depreciation (pre-1987) ... j Patron's adjustment .........
d Installment sales ............... k Pollution control facilities ...
e Intangible drilling costs ...... I Research and experimental
f Large partnerships ............ m Section 1202 exclusion ......
g Long-term contracts ......... n Tax shelter farm activities ...
o Related adjustments .........
15 Total Adjustments and Preferences. Combine lines I through 14 ·
lii!i~Iiiil Altemative Minimum Taxable Income
Enter the amount from Form 1040, line 37. If less than zero, enter es a (loss) ................................................ · 16
Net operating loss deduction, if any, from Form 1040, line 21. Enter as a positive amount .................................... 17
If Form 1040, line 34, is over $128,950 (over $64,475 if married filing separately), and you itemized deductions,
enter the amount, if any, from line 9 of the worksheet for Schedule A (Form 1040), line 28 ................................. 18
Combine lines 15 through 18 ..................................................................................................................... · 19
Alternative tax net operating loss deduction. See instructions ........................................................................... 20
Alternative Minimum Taxable Income. Subtract line 20 from line 19. (If married filing separately
and line 21 is more than $165,000, see instructions.) .................................................................................... · 21
2
3
4
5
6
7
8
9
10
11
12
13
14
16
17
18
19
20
21
[i,~i.~i~i.iI ~xemption Amount and Alternative Minimum Tax
22 Exemption Amount. (If this form is for a child under age 14, see instructions.)
IF your filing status is... AND line 21 is not over... THEN enter on line 22...
Single or head of household .............................. $112,500 ........................ $33,750
Married filing jointly or qualifying widow(er) ......... 150,000 ........................45,000 ~ .....................
Married filing separately .................................... 75,000 ........................ 22,500
If line 21 is over the amount shown above for your filing status, see instructions.
23 Subtract line 22 from line 21. If zero or less, enter -0- here and on lines 26 and 28 and stop here .................. ·
24 If you reported capital gain distributions directly on Form 1040, line 13, or you completed Schedule D
(Form 1040) and have an amount on line 25 or line 27 (or would have had an amount on either line if you
had completed Part IV) (as refigured for the AMT, if necessary), go to Part IV of Form 6251 to figure line 24.
All others: If line 23 is $175,000 or less ($87,500 or less if married firing separately), multiply line 23 by 26%
(.26). Otherwise, multiply line 23 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from
the result ................................................................................................................................................... ·
25 Alternative minimum tax foreign tax credit. See instructions ..............................................................................
26 Tentative minimum tax. Subtract line 25 from line 24 .................................................................................... ·
27 Enter your tax from Form 1040, line 40 (minus any tax from Form 4972 and any foreign tax credit
from Form 1040, line 43) ....................................................................................................................................
28 Alternative Minimum Tax. Subtract line 27 from line 26. If zero or less, enter -0-. Enter here and on
Form 1040, line 41 .................................................................................................................................... ·
LHA For Paperwork Reduction Act Notice, see instructions.
219.
3,910.
37.
4 166.
24,914.
29r080.
29r080.
45r000.
2,899.
0.
Form 6251 (2000)
t 1-06-00 '
17~ .20-3373 Page 2
Form 6251(2000) K~_RL B & JANICF ''~ ETSHIED
Line 24 Computation Using Maximum Capital Gains Rates
29
30
31
32
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
5O
Caution: If you did not complete Part IV of Schedule D (Form 1040), see the instructions before
you complete this part.
Enter the amount from Form 6251, line 23 .........................................................................................................
Enter the amount from Schedule D (Form 1040), line 27 (as refigured for the
AMT, if necessary). See instructions .................................................................. 3__.~_0
Enter the amount from Schedule D (Form 1040), line 25 (as refigured for the
AMT, if necessary). See instructions .................................................................. 3_~1
Add lines 30 and 31 .......................................................................................... 3.__~_2
Enter the amount from Schedule D (Form 1040), line 22 (as refigured for the
AMT, if necessary). See instructions .................................................................. 33
Enter the smaller of line 32 or line 33 ...............................................................................................................
Subtract line 34 from line 29. If zero or less, enter -0-. ................................................................................... ·
If line 35 is $175,000 or less ($87,500 or less if married filing separately), multiply line 35 by 26% (.26).
Otherwise, multiply line 35 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from
the result .........................................................................................................................................................
Enter the amount from Schedule D (Form 1040), line 36 (as figured for the
regular tax). See instructions ...........................................................................
Enter the smallest of line 29, line 30, or line 37 .......................................... ·
Multiply line 38 by 10% (.10) ............................................................................. I ........ ] ....................................
Enter the smaller of line 29 or line 30 ............................................................... I 40 I
Enter the amount from line 38 ........................ I 41 I
Subtract line 41 from line 40 ........................................................................ · I 42 I
Multiply line 42 by 20% (.20) ...........................................................................................................................
Note: If line 31 is zero or blank, skip lines 44 through 47 and go to line 48.
Enter the amount from line 29 ........................................................................... I~0~I
Add fines :35, 38, and 42 .................................................................................
Subtraot line 45 from line 44 ..............................................................................
Multiply Ilne 46 by 25% (.25) ...........................................................................................................................
Add Iinee 36, 30, 43, and 47 ..............................................................................................................................
If line 29 is $175,000 or less ($87,500 or less if married filing separately), multiply line 29 by 26% (.26).
Otherwise, multiply line 29 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from
the result ......................................................................................................................................................... I 49
Enter the smaller of line 48 or line 49 hera and on line 24 ................................................................................. I 50
6251
~g~gl 11 2
10-18-00 '
ALTERNATIVE MINIMUM TAX RECONCILIATION REPORT
Name(s) , Social Security Number!
KARL B & JANICE W ETSHIED 174-20-3373
Form Adjustment
Name Description Income Form 6251
Form 6251, Line 8 Form 6251, Line 9 Form 6251, Line 11 Form 6251, Line 14h Other Adjustment
C- KARL B ETSHIED DDS
AMT ~epr a~j .3..7 :. 37.
*..~ .T. qt.._a..!..~!J ..& _.P....r.~.f......~..,. ............................................... , 37.
019911
11-15-00
ALTERNATIVE MINIMUM TAX DEPRECIATION REPORT
A~sot Date AMT AMT AMT Regular AMT AMT
No. Descdptiop Acquired Method Life Cost Or Basis Depreciation Depreciation Adjustmen~
KARL B ETSHIED DDS
** Subtotal ** 2,755. 529. 492. 37.
*** Grand Total *** 2,755. 529. 492. 37.
028104
10-31-00
11.4
Form · File only with Schedule C (Form 1040). Use a separate Form 8829 for each
home you used for business during the year.
Department of the Treasury Sequence No. 66
Internal Revenue ~S~vice
Name(s) of proprietor(s) Your social security number
KARL B ETSHIED 174-20-3373
ti!~ii~iiiiiiiiil Part of Your Home Used for Business
I Area used regularly and exclusively for business, regularly for day care, or for storage of inventory Iiiiiiiiiii?iiii!!ii~iiii
or product samples ....................................................................................................................................... / 1
2 Total area of home .......................................................................................................................................... ~ 2 I
3 Dividelinel byline2. Enter the result as a percentage .................................................................................... [ 3 I %
· For day-car· faciliti·s not used ·xclusiv·ly for business, also compl·te lin·s 4-6. Fiii?!iii!iiii!!]
· All others, skip lines 4-6 and enter the amount from line 3 on line 7. liiiiiii ii!iiiilil
4 Multipiy days used for day care during year by hours used per day .................. 4 hr. I?iiiiiiii~ii!!i!iiiiiiiil
5 Total hours available for use dudng the year (366 days x 24 hours) ..... 5 hr. I!i~iiiiiiiiiiiiii!iiiii!!ii[
6 Dv de line 4 by line 5. Enter the result as a decimal amount .............................. I 6 ~ Iii~iiii!iiiiiiiii?~iiiiiil
7 Business precentage. For day-care facilities not used exclusively for business, multiply line 6 by line 3 lili!iiiiii?iiii??ii!i[
(enter the result as a percentage). All others, enter the amount from line 3 ............................ · ! 7 I
ti~ii~iiiii!I Figure Your Allowable Deduction
8 Enter the amount from Schedule C, line 29, plus any net gain or (loss) derived from the business use of your
home and shown on Schedule D or Form 4797. If more than one place of business, see instructions
See instructions for columns (a) and (b) before
completing lines 9-20.
Casualty losses ......................................................
Deductible mortgage interest ....................................
Real estate taxes ...................................................
Add lines 9, 10, and 11 .............................................
Multiply line 12, column (b) by line 7 ........................
Add line 12, column (a) and line 13 ...........................
Subtract line 14 from line 8. If zero or less, enter -0- ...
33.00%
9
10
11
12
13
14
15
41~641.
i:i:iiiiiii~i~i (a) Direct expenses (b) Indirect expenses
9
10
1.1 2r949.
12 2r949.
16
.17 147.
.18 1~208.
.19 1~363.
20
21 2~571. 147.
..................................... 22 49.
line 4'1 ........................ ~3
..................................................................................... 24 2~620,
e 15 or line 24 ............................................................... 25 2r620,
[ract line 25 from line 15 .............................................. 26 3 8/, 0 4 8,
)9 Form 8829, line 42 ...... 29
30
tar the smaller of line 26 or line 30 ................................. 31 0,
32 3,593.
amount to Form 4684, Section B .............................. 33 0
16 Excess mortgage interest .......................................
17 Insurance ...............................................................
18 Repairs and maintenance .......................................
19 Utilities ..................................................................
20 Other expenses ......................................................
21 Add lines 16 through 20 ..........................................
22 Multiply line 21, column' (b) by line 7
23 Carryover of operating expenses from 1999 Form 8829
24 Add line 21 in column (a), line 22, and line 23
25 Allowable operating expenses. Enter the smaller of line 15
26 Limit on excess casualty losses and depreciation. ,(
27 Excess casualty losses ............................
28 Depreciation of your home from Part III below
29 Carryover 0fexcess casualty losses and depreciation from
30 Add lines 27 through 29
31 Allowable excess casualty losses and depreciation.
32 Add lines 14, 25, and 31
33 Casualty loss portion, if any, from lines 14 and 31. Cam
34 Allowable expenses for business use of your home. Subtract line 33 from line 32. Enter here and on Schedule C,
line 30. If your home was used for more than one business, see instructions ................................................ · 3 5 9 3
Depreciation of Your Home
35 Enter the smaller of your home's adjusted basis or its fair market value ............................................................
36 Value of land included on line 35 .....................................................................................................................
37 Basis of building. Subtract line 36 from line 35 ................................................................................................
38 Business basis of building. Multiply line 37 by line 7 ..........................................................................................
39 Depreciation percentage .................................................................................................................................
40 Depreciation allowable. Multiply line 38 by line 39. Enter here and on line 28 above ..........................................
41 Operating expenses. Subtract line 25 from line 24. If less than zero, enter -0- . .................................................. 41
42 Excess casualty losses and depreciation. Subtract line 31 from line 30. If less than zero enter -0- . .................... I 42 I
Carryover of Unallowed Expenses to 2001
LHA For Paperwork Reduction Act Notice, see page 4 of separate instruction~2 Form 8829 (2000)
K~.~RL B & JANICE W ETSHIED 174-20-3373
orm 1040 Social Security Benefits Worksheet Statement 1
heck only one box:
A. Single, Head of household, or Qualifying widow(er)
i B. Married filing jointly
C. Married filing separately and lived with your spouse
at any. time during 2000
D. Married filing separately and lived apart from your spouse
for all of 2000
1. Enter the total amount from Box 5 of all your
Forms SSA-1099 and RRB-1099 ................
2. Enter one half of line 1 .................
3. Add the amounts on Form 1040, line 7, 8b, 9 through 14,
15b, l~b, 17 thru 19, 21 and Schedule B, line 2. Do not
include any amounts from box 5 of Forms SSA-1099 or RRB-1099
4. Enter the amount of any exclusions from foreign earned
income, foreign housing, income from U.S. possessions,
or income from Puerto Rico by bona fide residents of
Puerto Rico that you claimed ...............
5. Add lines 2, 3, and 4 ...................
6. Add the amounts on Form 1040, lines 23, and 25 thru 3la, and
any amount you entered on the dotted line next to line 32.
7. Subtract line 6 from line 5 ...............
8. Enter: $25,000 if you checked Box A or D, or
$32,000 if you checked Box B, or
$-0- if you checked Box C ...........
9. Is the amount on line 8 less than the amount on line 7?
[ ] No. Stop. None of your social security benefits are
taxable. You do not have to enter any amounts on lines
20a or 20b of Form 1040. But if you are married filing
separately and you lived apart from your spouse for all of
2000, enter -0- on line 20b. Be sure you entered 'D' to
the left of line 20a.
[X] Yes. Subtract line 8 from line 7 ...........
[0. Enter $9,000 if you checked Box A or D,
$12,000 if you checked Box B
$-0- if you checked Box C ............
[1. Subtract line 10 from line 9. If zero or less, enter -0-.
[2. Enter the smaller of line 9 or line 10 ..........
[3. Enter one half of line 12 .................
[4. Enter the smaller of line 2 or line 13 ..........
[5. Multiply line 11 by 85% (.85). If line 11 is zero, enter -0-
[6. Add lines 14 and 15 ....................
[7. Multiply line 1 by 85% (.85) ...............
[8. Taxable benefits. Enter the smaller of line 16 or line 17 * Enter the amount from line 1 above on Form 1040, line 20a
* Enter the amount from line 18 above on Form 1040, line 20b
25,002.
12,501.
38,057.
50,558.
5,202.
45,356.
32,000.
13,356.
12,000.
1,356.
12,000.
6,000.
6,000.
1,153.
7,153.
21,252.
7,153.
13 Statement(s) 1
KARL. B & JANICE W ETSHIED 174-20-3373
chedule A State and Local Income Taxes Statement 2
escription
ther State and Local Income Taxes
ennsylvania Prior Year Estimate Payments - Taxpayer
ennsylvania Prior Year Balance Due and
Extension Payments - Taxpayer
ennsylvania Prior Year Estimate Payments - Spouse
ennsylvania Prior Year Balance Due and
Extension Payments - Spouse
otal to Schedule A, line 5
Amount
130.
315.
45.
315.
'45.
850.
chedule A Points Not Reported on Form 1098 Statement 3
~escription
!oral to Schedule A, line 12
Amort.
Date Re- Total Period
financed Points /Mos.
02/16/98 2,040. 180
Amortization
This Year
136.
136.
:chedule A Cash Contributions Statement 4
)escription
~ST CHESTER UNIVERSITY
lubtotals
~otal to Schedule A, line 15
Amount Amount
50% Limit 30% Limit
600.
600.
600.
14 Statement(s) 2, 3, 4
K~RL B & JANICE W ETSHIED 174-20-3373
~hedule A Medical and Dental Expenses Statement 5
escription Amount
rescription Medicines and Drugs
octors, Dentists, Etc.
EDICARE
elf-employed Health Insurance
otal to Schedule A, line 1
162.
290.
1,092.
1,676.
3,220.
chedule C Car and Truck Expenses Statement 6
~escription
'ehicle Number 1 - 1875 Business Miles @ $0.325
'otal to Schedule C, line 10
Amount
609.
609.
15 Statement(s) 5, 6
Wildeman and Obrock, CPA's
515 S. 29th Street
Harrisburg, PA 17104
(717) 561-0820
May 8, 2002
Janice W Etshied
111 N 32nd St
Camp Hill, PA 17011
Dear Mrs. Etshied,
Enclosed are your 2001 income tax returns.
should be signed and dated by you.
The returns
Specific filing instructions are as follows.
FEDERAL INCOME TAX RETURN:
Mail your federal return as soon as possible.
Mail to - Internal Revenue Service
P.O. Box 80101
Cincinnati, OH 45280-0001
Enclose your check for $5,665, payable to the United States
Treasury. Include your social security number, daytime phone
number and the words "2001 Form 1040" on your check.
Also enclose Form 1040-V. Do not attach Form 1040-V or your
payment to your return or to each other. Please leave-F~rm
1040-V and your payment loose in the envelope.
Your income tax return includes a penalty for underpayment of
estimated tax from Form 2210 of $216.
PENNSYLVANIA INCOME TAX RETURN:
Mail your state return as soon as possible.
Mail to - PA Department of Revenue
Payment Enclosed
1 Revenue Place
Harrisburg, PA 17129-0001
Enclose your check for $816, payabie to PA Department of
Revenue. Include your social security number and the words
"2001 PA Tax" on your check.
Enclose Form PA-V with the return. Do not attach payment or
Form PA-V to the return.
LOCAL EARNED INCOME TAX RETURN:
Mail your local return by May 15, 2002 to West Shore Tax
Bureau. Enclose a check for $293.91 made payable to WESTAB.
We sincerely appreciate the opportunity to serve you. Please
contact me if you have any questions regarding these tax
returns.
Your copies of the returns are enclosed for your files. We
suggest that you retain these copies indefinitely.
Sincerely,
Michael A. Kunisky, CP~
Two-Year Comparison vorksheet 2001
Name(s) as shown on return I Social secudty number
KARL B & JANICE W ETSHIED I 174-20-3373
2000 Filinq Status Married Filinq Joint 2001 FilinqStatus Married Filinq Joint
2000Tax Bracket 15.0% 2001TaxBracket 15.0%
Schedule B - taxable interest 9. 0. <9.
Sch. C/C-EZ (business income/loss) 38,048. 29,145. <8,903.
~axable social security benefits 7,153. 2,601. <4,552.
Total income 45,210. 31,746. <13,464.
Dne-half of self-employment tax 2,688. 2,059. <629.
Self-employed health ins. deduction 2,514. 2,909. 395.
Total adjustments 5,202. 4,968. <234.
Adjusted gross income 40,008. 26,778. <13,230.
~edical and dental expenses 219. 1,673. 1,454.
~axes 3,910. 0. <3,910.
Interest (deductible) 10,365. 10,297. <68.
2ontributions 600. 125. <475.
Total itemized deductions 15,094. 12,095. <2,999.
Income before exemptions 24,914. 14,683. <10,231.
Personal exemptions 5,600. 5,800. 200.
Taxable income 19,314. 8,883. <10,431.
~ax 2,899. 1,331. <1,568.
Tax before credits 2,899. 1,331.I <1,568.
Tax after non-refundable credits 2,899. 1,331. <1,568.
Schedule SE (self-employment tax) 5,376. 4,118. <1,258.
Total tax 8,275. 5,449. <2,826.
Form 2210/2210F (est. tax penalty) 366. 216. <150.
Balance due (including 2210/2210F) 8,641. 5,665. <2,976.
Pennsylvania State Return
Taxable income 38,057. 29,145. <8,912.
Tax 1,066. 816. <250.
Balance due 1,066. 816. <250.
Departm=, ~t of the Treasury
2001 .orm 1040-v Internal Revenue Service
Paperwork Reduction Act Notice.
We ask for the information on Form 1040-V to help us carry
out the Internal Revenue laws of the United States. If you use
Form 1040-V, you must provide the requested information.
Your cooperation will help us ensure that we are collecting the
right amount of tax.
You are not required to provide the information requested
on a form that is subject to the Paperwork Reduction Act
unless the form displays a valid OMB control number. Books
or records relating to a form or its instructions must be
retained as long as their contents may become material in the
administration of any Internal Revenue law. Generally, tax
returns and return information are confidential, as required by
Internal Revenue Code section 6103.
The time needed to complete and mail Form 1040-V will vary
depending on individual circumstances. The estimated average
time is 19 minutes. If you have comments about the accuracy
of this time estimate or suggestions for making Form 1040-V
simpler, we would be happy to hear from you. See the
Instructions for Form 1040.
Form 1040-V(2001}
· Detach Here and Mail With Your Payment and Return ·
1040-V
Deparb'ne~t of the Treesury
Internal Revenue Service (99)
Payment Voucher
1~ Do nol staple or attach this voucher to your payment or return.
I Your social security number (SSN)
17412013373
4 Your first name and initial
on that retum are paying by
check or
194122 17525 moneyorder
If a joint retum, spouse's first name and initial
JANICE W
Last name
ETSHIED
Last name
ETSHIED
Home address (number and street)
111 N 32ND ST
City, town or post office, state, and ZIP code
CAMP HILL, PA 17011
OMB No. 1545-0074
2001
DollarSsr665 Cents
Apt. no.
LHA
E DECEASED
1'040u.,. Individual Income Tax Return2001 ,. u.o.,,.oo,o,w,.o...,.,..,,_.
Label For the year Jan. 1-Dec. 31, 2001, or other tax year beginning ,2001, ending ,20 OMB No. 1545-0074
(See L Your first name and initial Last name ( De(:::. 0 3 / 1 3 / 0 2 ) Y ..... cial security number
instructions A KARL B ETSHIED 174 i20 i3373
on page 19.) EB If a ioint return, spouse's first name and initial Last name Spouae'a socia~ eecudty number
UsethelRS L JANICE W ETSHIED 194 i22 i7525
label. H Home address (number and street). If you have a P.O. box, see page 19. Apt. no. · Important! ·
Otherwise, E ].].1 N 32ND ST Y0u must enter
please print R City, town or post office, state, and ZIP code. Ifyou have a foreign address, see page 19. your saN(s) above.
or type. E
Presidential CAMP HILLr PA 17011
Election Campaign · Note. Checking 'Yes" will not change your tax or reduce your refund. You Spouse
(See page 19.)· Do you, or your spouse if filing a joint return, want $3 to go to this fund? ......... · [--'-] Yes [-~ No r'~ Yes I-~ No
Filing Status I M
2
3
4
Check 0nly
one box. 5
Exemptions
if more than six
dependents,
see page 20.
Single
Married filing joint return (even if only one had income)
Married filing separate return. Enter spouse's social secudty no. above and full name here.·
Head of household (with qualifying person). (See page 19.) If the qualifying person is a child but not your dependent, enter this child's
name hem. ·
Qualifying widow(er) with dependent child (year spouse died · ). (See page 19.)
~ No. of boxes
8a ~ Yourself. If your parent (or somesne else) cen claim you as a dependent on hie or her tax retum, d0n0t checkboxea ......... pc~eckedonea
b ~ Spouse ................................................................................................................................ ) =~d eb
Dependents: (2) Dependent's social (3) Oependent's (~) V'if qualifY-iha ~iid for
(1) First name Last name secuflty number relationship to chird taxc~dt
you (see page 20)
No. of your
children on 6<=
who:
· lived with you ~
· did not live with
you due to divome
or sepamUon
(see page 20)
d Total number of exemptions claimed ............................................................................................................
2
Income 7 Wages, salaries, tips, etc. A~ch Form(s) W-2 .............................................................................. 7
8a Taxable interest. Attach Schedule B if required .............................................................................. 8a
Attach
Forms W-2 and b Tax-exempt interest. Do not include on line 8a .................................
W-2G here. 9 Ordinary dividends. Attach Schedule 8 if required ............................................ i ............................. .% 9
Also attach 10 Taxable refunds, credits, or offsets of state and local income taxes ......................................... ,,,,.~..~ ~; 10
Form(s) "
was withheld. 12 Business income or (loss). Attach Schedule C or C-EZ ................................... .~.*..%.:~..,;,:i.~: );i'. ".-..!..'i'. 12 2 9, ]. 4 5
Ifyou did not 13 capita~gain~r(~ss)~AttachSchedu~eDifrequired~fn~trequire~chec~J~e~``.`~`......~`. ...... ~ .... ~ E~ 13
getaW-2, 14 0thergans0r(0sses) Attach F0rm 4797 ~ .% ~\ k ~,~ : 14
......................... ~,,~ ........ ~....¥. ~. ...............................
seepage21. 15a TotallRAdistdbutions ............... [15a[ ~, ~. I ~l~Ia.x~ble amount (see page 23) 15b
16a Total pensions and annuities ...... 116a I '~' ~' ':"1' b Taxable amount (see page 23) 16b
Enclose, but do 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17
not attach, any ........................
payment. Also, 18 Farm income or (loss). Attach Schedule F .................................................................................... 18
please use 19 Unemployment compensation ................................................................................................... 19
Forml040-V. 20a S0cial security benefits ............ I 20a I 26,049 -I b Taxable amount (see page 25) 20b 2 r 60].
21 Other income. List type and amount (see page 27)
21
22 Add the amounts in the far right column for lines 7 through 21. This is your total income .................. · 22 3 ]. ¢ 7 4 6
23 IRA deduction (see page 27) 23
Adjusted 24 Student loan interest deduction (see page 28) .................................... 24
Gross 25 Archer MSAdeduction. Attach Form 8853 25
Income 26 Moving expenses. Attach Form 3903 ............................................. 26
27 One-half of self-employment tax. Attach Schedule SE ........................ 27 2 · 0 5
28 Self-employed health insurance deduction (see page 30) ..................... 28 2,9 0 9. !:i~i~i~i!iii!ii!i!!i!~ii!iiiii:'
2g Self-employed SEP, SIMPLE, and qualified plans .............................. 2g
30 Penalty on early withdrawal of savings 30
32 Add lines 23 through 31a 32
110001 .........................................................................................................
~-27-m 33 Subtract line 32 from line 22. This is your adjusted ~lross Income ............................................. · 33 2 6 r 7 7 8
Dependents on 64=
not entered above
Add numbers
entered on
lines above ·
LHA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, se~ page 72.
Form 1 040
Form1040(2001) KARL B & JANI£ W ETSHIED 1 -20-3373
Tax and 34 Amount from line 33 (adjusted gross income) ....................................................................................... 34 2 6 r 7 7 8.
Credits 35a Check if: ~ You were 65 or older, ~ Blind; ~ Spouse was 65 or older, ['---I Blind. I
Standa~
Deduction f~r- i Add the number of boxes checked above and enter the total here · 353 2
I
..................................... ::i:!:!:!:!:i:i:i:!:
· Pesple who ' b If you are married filing separately and your spouse itemizes deductions, or you were a dual-status alien ...... · 35b
checked any 36 itemized deductions (from Schedule A) or your standard deduction (see left margin) 36 1 2 r 0 9 5
box on line 353 .................................. ·
or35b or who :. 37 Subtract line 36 from line 34 37 1 4 r 6 8 3
can be claimed ' ........................................................................................................... ·
as a dependent' 38If line 34 is $99,725 or less, multiply $2,900 by the total number of exemptions claimed on line 6d. If line 34
i is over $99 725, see the worksheet off page 32 ............................................. 38 5 r 8 0 0
, 39 Taxablelncome. Subtract line 38 from line 37.1f line 38 is more than line 37, enter-0- . ................................ 39 8,883.
eAIIothers: I 40 Tax. Check if tax from ar--'] Form(s)8814 bi---] Form4972 ............................................................... 40 1, 331.
Single,
s4,550 41 Alternative minimum tax. Attach Form 6251 .. 41
Head of 42 Add lines 40 and 41 .................................................................................................................. · 42 1,3 3 1.
household,
$6.6eo 43 Foreign tax credit. Attach Form 1116 if required ....................................... 43 :::::::::::::::::::::::::::::::
Married filing44 Credit for child and dependent care expenses. Attach Form 2441 44 .....................
euali~,ing 45 Credit for the elderly or the disabled. Attach Schedule R .............................. 45
S7,600 46 Education credits. Attach Form 8863 ...................................................... 46
Married filing 47 Rate reduction credit. See the worksheet on page 36 St. mt 2 47
48Ch,d taxcredit (see page ............................................................... 48
49Adoption credit. Attach Form 8839 ......................................................... 49 ::::
50 Other credits from: a ~ Form 3800 b r---] Form 8396 iiiiiii!ilili~iiiii~iiiiiii~
c [~ Form 8801 d [---] Form (specify) 50
51 Add lines 43 through 50. These are your total credits .............................................................................. 51
52 Subtract line 51 from line 42. If line 51 is more than line 42, enter-0-. .................................................. · 62 1 r 3 3 1.
53 Self-employment tax. Attach Schedule SE ............................................................................................. 53 4 r 1 1 8.
Other
54 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 ........................... 54
Taxes
55 Tax on qualified plans, including IRAs, and other tax-favored accounts. Attach 5329 if required ........................ 55
56 Advance earned income credit payments from Form(s) W-2 ..................................................................... 56
57 Household employment taxes. Attach Schedule H ................................................................................. 57
58 Add lines 52 through 57. This is your total tax ................................................................................. · 58 5 r 4 4 9.
Payments 59 Federal income tax withheld from Forms W-2 and 1099 .............................. 59
60 2001 estimated tax payments and amount applied from 2000 return ............ 60
Ifyou have L-.. 61 a Earned Income credit (EIC) .................................................................. 613 ::::::::::::::::::::::::::::::
a qualifying I---
/ b Nontaxable earned income ......... l. 61b I [ i!!ii!iiiiiiiiiiiiiiiiiii
ScheduleE]C'/62 Excess socialsecurity and RRTA tax withheld (see page 51) ........................ 62
63 Additional child tax credit. Attach Form 8812 ............................................. 63
64 Amount paid with request for extension to file (see page 51) ........................ 64 .....................
65 Other payments. Check if from ar--]Form2439 bi---]Form4136 ......... 65
66 Add lines 59, 60,613, and 62 through 65. These are your total payments ............................................. · 66
Refund 67 If line 66 is more than line 58, subtract line 58 from line 66. This is the amount you overp aid ........................... 67
oi~t 683 Amount of line 67 you want refunded to you ........................................................... · 683
deposit'/ .........................
and fill in ebb,
68c, and$ed. 69 Amount of line 67 you want applled to ¥our 2002 estlmated tax ......... · I 69 I
Amount 70 Amount you owe. Subtract line 66 from line 58. For details on how to pay seepage52 · 70 5r665.
Third Party Do you want to allow another person to discuss this return with the IRS (see page 53)? I X ] Yes. Complete the following. I I No
Designee
Sign
Here
Joint return?
See page 19.
Designee's Phone Personal identification
name ·MICHAEL A. KUNISKY, CPA no. · 717-561-0820 number(PiN) · 18952
Under penal~es of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they m~ true, correct,
and complete. Declaratio.n of p.reparer (other than taxpayer) l? bas.ed on all information of which preparer has any knowledge.
¥o.rsignature F3_llng as Surv~ng Spo~se~pation 0ey~.phen..u~er
/ pENTIST
Prepamr'$ b Date Check if eatf- Preparar's SSN or PTIN
Paid signa~ r 05/08/*02 er.p,oyed [--] 189-52-1408
Use OnlyPreparer's youre if aef-~- k S
~.~',.*~e(or WILDEMAN AND OBROCK, CPA'S E~N 23 i2198946
~515 29TH STREET Ph°nen°'(717) 561--0820
ployed), address, '
and ZiP code
HARRISBURGr
PA 17104-2104
110002
11-27-O1
2'210
Department of the Treasury
m[ernaJ ~evenue Se~ce
Underpayment of
Estimated Tax by Individuals, Estates, and Trusts
· See separate instructions.
~ Aitacn to Form 1040, lO40A, 104ONR, 104ONR-£Z, or 1041.
Name(s) shown on tax return
KARL B & JANICE W ETSHIED
OMB No.1545-0140
2001
Attachmerff .
Sequence No. t, JO
Identifying number
174-20-3373
In most cases, you do not need to file Form 221 O. The IRS will figure any penalty you owe and send you a bill. File Form 2210 only if one or
more boxes in Part I apply to you. If you do not need to file Form 2210, you still may use it to figure your penalty. Enter the amount from
Part III, line 21, or Part IV, line 37, on the penalty line of your return, but do not attach Form 2210.
Reasons for Filing - If la, lb, or lc below applies to you, you may be able to lower or eliminate your penalty. But you must
check the boxes that apply and file Form 2210 with your tax return. If ld below applies to you, check that box and file Form 2210
with your tax return.
Check whichever boxes apply (if none apply, see the text above Part I and do not file Form 2210):
a r--] You request a waiver. In certain circumstances, the IRS will waive all or part of the penalty.
See Waiver of Penalty on page 2 of the instructions.
b ~ You use the annualized income installment method. If your income varied during the year, this method may reduce
the amount of one or mom required installments. See page 5 of the instructions.
c r--] You had Federal income tax withheld from wages and, for estimated tax purposes, you treat the withheld tax as paid on the dates it was
actually withheld, instead of in equal amounts on the payment due dates. See the instructions for line 23 on page 3.
d ~ Your required annual payment (line 14 below) is based on your 2000 tax and you filed or are filing a joint return for either 2000 or 2001 but
not for both years.
Required Annual Payment
2 Enter your 2001 tax alter credits (see page 2 of the instructions) ....................................................................................... 2
3 Other taxes (see page 2 of the instructions) ..................................................................................................................
4 Add lines2and3 .................................................................................................................................... ~ ............. / 4
6 Additional child tax credit ................. I 6 ]
7 Credit for Federal tax paid on fuels ................................................................................. I 7 I
8 Add lines 5, 6, and 7 .................................................................................................................. ' ..............................
9 Current year tax Subtract ne8from ne4 ................................................................................................................ / 9
lO Mu,t,p ,,negb 9O%(.9o) ..... ] lo I 4,904
11 Withholding taxes. Do not include any estimated tax payments on this line (see page 3 of the instructions) ..............................
12 Subtract line 11 from line 9. If less than $1,000, stop hera; you do not owe the penalty.
Do notflle Form2210 ............................................................................................................................................. ~ 12I
13 Enter the tax shown on your 2000 tax return (110% of that amount if the adiusted gross income shown on that return is more
than $150,000, or, if married filing separately for 2001, more than $75,000). Caution: See instructions ..............................
14 Required annual payment. Enter the smaller of line 10 or line 13 .................................................................................... | 14
If line 11 is equal to or more then line 14, stop here; you do not owe the penalty. Do not file Form 2210 unless
you checked box ld above.
~ Short Method (Caution: See page 3 of the instructions to find out if you can use the short method. If you checked box lb or lc
lr331.
4r118.
5r449.
5,449.
5r449.
8r275.
4r904.
in Part I, sk~'p this part and go to Part IV.)
15 Enter the amount, ifany, fromline 11 above .................................................................. 15
16 Enter the total amount. If any, of estimated tax payments you made ....................................
15
17 Add lines 15 and 16 ................................................................................................................................................
18 Total underpayment for year. Subtract line 17 from line 14. If zero or less, stop here; you do not owe the penalty.
Do not file Form 221g unless you checked box ld above .............................................................................................
19 Multiply line 18 by .04397 (see page 3 of the instructions if you are eligible for relief due to the
September 11,2001, terrorist attacks) ........................................................................................................................
20 · If the amount on line 18 was paid on or after 4/15/02, enter-0-.
· if the amount on line 18 was paid before 4/15/02, make the following computation to find the amount to enter on line 20.
Amount on Number of days paid
line 18 x before 4/15/02 x .00016 ...............................................................
21 Penalty. Subtract line 20 from line 19. Enter the result here and on Form 1040, line 71; Form 1040A, line 46;
Form 1040NR, line 69; Form 1040NR-EZ, line 26; or Form 1041, line 26, but do not file Form 2210 unless
you checked one or more of the boxes in Part I above ............................................................................................. ·
4,904.
216.
0.
216 ·
Form 2210 (2OOl)
LHA For Paperwork Reduction Act Notice, see page 6 of separate instructions.
112501
01-24-02
6.1
SCHEDULES A&B
(Form 1040)
Department of the Treasury
Intemal Revenue Service (99)
S ..,edule A- Itemized Deductio.,s
(Schedule B is on page 2)
· Attach to Form 1040. · See Instructions for Schedules A and B (Form 1040),
OMB No. 1545-0074
2001
Attachment
s~u~=, No. 07
Name(s) ~t~own on Form 1040
KARL B & JANICE W ETSHIED
Medical
and
Dental
Expenses
Caution. DO not include expenses reimbursed or paid by others.
I Medical and dental expenses (see page A-2) ......... S...e..e.....$..~...a...~...e..z~..e...n...t.....5. .... 1
2 Enter amount from Form 1040, line 34 ..............................
3 Multiply line 2 above by 7.5% (.075)
4 Subtract line 3 from line 1. If line 3 is more than line 1, enter -0-. ...............................................
Your social security number
174i20i3373
Taxes You
Paid
(See
page A-2.)
3,681.
2,008.
Interest
You Paid
(See
page A-3.)
Note:
Personal
interest is
not
deductible,
11 Home mortgage interest not reported to you on Form 1098. If paid to t,h.e person
from whom you bought the home, see page A-3 and show that person s name,
· identifying no., and address
11
Points not reported to you on Form 1098. (See page A-3.) ............... .~...t...~..,t-......3. .... 12
Investment interest, Attach Form 4952 if required, (See page Ao3,) 13
12
13
14
5 State and local income taxes .............................................................................. 5 ~
6 Real estate taxes (see page A-2) ...........................................................................
7 Personal property taxes .......................................................................................
8 Other taxes. List type and amount
9 Add lines 5 through 8 ........................................................................................................................ I 9
10,161.
Gifts to
Charity
Ify0u made a
gift and got a
benefit for it,
see page A-4.
136.
Add lines 10 through 13 ..................................................................................................................... I 14
Casualty and
Theft Losses 19
Job Expenses
and Most
Other
Miscellaneous
Deductions
(See
page A-5 for
expenses to
deduct here.)
15 Gifts by cash or check. If you made any gift of $250 or more, iii!ililiiiiiil
see page A-4 ................................................... S. ee .st.~.tem...e.n..t......4 .... ]'~'1 12 5
16 Other than by cash or check. If any gift of $250 or more, see page A-4.
You must attach Form 8283 if over $500 ............................................................ '~1'~"
17 Carryover from prior year .................................................................................... 17
18 Add lines 15 through 17 ..................................................................................................................... 18
Casually or theft loss(es). Attach Form 4684. (See page A-5.) ...............................................................
Other 27
Miscellaneous
Deductions
Total 28
Itemized
Deductions
20 Unreimbursed employee expenses, job travel, union dues, job education, etc.
You must attach Form 2106 or 2106-EZ if required. (See page A-5.)
21 Tax preparation fees .......................................................................................... 21
22 Jher expenses, investment, safe deposit box, etc. list type and amount
23 Add lines 20 through 22 ............................................................................... 23
24 Enter amount from Form 1040, line 34 .............................. 1241
25 Mulliply line 24 above by 2% (.02) ........................................................................
25
26 Subtract line 25 from line 23. If line 25 is more than line 23, enter-0- . .................................................. 2~
~ _Ot h_er_' f_r°3_list °_n_pa._g_e A_'6- ._Ust tY P._e an_d 7_°_u nt ......................... iii!
Is Form 1040, line 34, over $132,950 (over $66,475 if married filing separately)?
[.~ No. Your deduction is not limited. Add the amounts in the far right column '}
for lines 4 through 27. Also, enter this amount on Form 1040, line 36. ' ~ · I 21
~ Yes. Your deduction may be limited. See page A-6 for the amount to enter. J
lr673.
10r297.
125.
12,095.
LHA For Paperwork Reduction Act Notice, see Form 1040 instructions. Schedule A (Form 1040) 2001
1195Ol
10-23-Ol 7
SCHEDULE C I
(Form 1040) I
Departmeht of the Treasury
Intemal Revenue Service (99
Profit or Loss From Busine
(Sole Proprietorship)
· Partnerships, joint ventures, etc., must file Form 1065 or Form 1065-B.
· Attach to Form 1040 or Form 1041. ·See Instructions for Schedule C (Form 1040).
OMB No, 1545-0074
2001
Attachment ~
Sequence No, U~
Name o~ proprietor
KkRL B E?SHIED (Dec. 03/13/02)
A Principal business or profession, including product or service (see page C-1 )
DENTIST/DENTISTRY
Social a~uH~ number (SSN)
174-20-3373
Ent~ ~de ~m pag~ C-7 & 8· 621210
C Business name. If no separate business name, leave blank. O Employer ID number (EIN), if any
KARL B ETSHIED DDS 23-1574543
E Business address (including suite or room no.) · 111 N 32ND ST
City, town or post office, state, andZlPcode CAMP HILL, PENNSYLVANIA 17011
F Accounting method: (1)1 X I Cash (2)1 I Accrual (3)1 I Other(specify) · ................
G Did you 'materially participate" in the operation of this business during 20017 If"No,' see page C-2 for limit on losses .............................. ~ Yes ~ No
H If you started or acquired this business during 2001, check here ............................................................................................................ · ~
Income
I Gross receipts or sales. Caution. If this income was reported to you on Form W-2 and the 'Statutory employee" box on
that form was checked, see page C-2 and check here ....................................................................................... · [~ 1 3 8 r 4 7 8.
2 Returns and allowances · ' ................................................. 2
3 Subtract line 2 from line 1 ....................................................................................................................................... 3 3 8 r 4 7 8.
4 Cost of goods sold (from line 42 on page 2) ............................................................................................................... 4
5 Gross profit. Subtract line 4 from line 3 ..................................................................................................................... ~7 3 8 r 4 7 8.
6 Other income, including Federal and state gasoline or fuel tax credit or refund (see page C-3) ................................................
7 Gross Income. Add lines 5 and 6 ......................................................................................................................... · 3 8 r 4 7 8.
tii~iiiiii] Expenses. Enter expenses for business use of your home only on line 30.
8 Advert sing ....................................
g Bad debts from sales or
services (see page C-3) ..................
10 Car and truck expenses
(see page C-3) ......... S...t;.~.~.....6. .... 6 4 7
11 Commissions and fees
12 Bepletion ....................................
13 Depreciation and section t79
expense deduction (not included in
Part III) (see page C-3) ..................... 4 5 7
14 Employee benefit programs (other
than on line 19) ...........................
15 Insurance (other than health) ............ 7 0 8
16 Interest:
a Mortgage (paid to banks, etc.) .........
b Other
17 Legal and professional
services 4 2 5
18 Office expense .............................. 5 8 8
28 Total expenses before expenses for business use of home. Add lines
lg Pension and profit-sharing plans ..................
20 Rent or lease (see page C-4):
a Vehicles, machinery, and equipment ............
b Other business property ...........................
21 Repairs and maintenance ...........................
22 Supplies (not included in Part III) ...............
23 Taxes and licenses ....................................
24 Travel, meals, and entertainment:
a Travel
· b Meals and
entertainment ..................
c Enter nondeductible
amount included on line 24b
(see page C-5) ..................
d Subtract line 24c from line 24b
25 Utilities ...................................................
26 Wages (less employment credits) ...............
27 Other expenses (from line 48 on
· page 2) ...................................................
through 27 in columns ....................................... ·
29
30
31
32
Tentative profit (loss). Subtract line 28 from line 7 .........................................................................................................
Expenses for business use of your home. Attach Form 8829
Net profit or (loss). Subtract line 30 from line 29.
· If a profit, enter on Form 1040, line 12, and also on Schedule SE, line 2 (statutory employees, see page C-5).
Estates and trusts, enter on Form 1041, line 3.
· If a loss, you must go to line 32.
if you have a loss, check the box that describes your investment in this activity (see page C-6).
· If you checked 32a, enter the loss on Form 1040, line 12, and also on Schedule SE, line 2 (statutory employees,
see page C-5). Estates and trusts, enter on Form 1041, line 3.
· If you checked 32b, you must attach Form 6198.
lr559.
175·
852.
2 081.
7,492.
30 986.
1,841.
29 145
~ All investment
32a
I I
is at risk,
~ Some investment
32b
ia not at risk,
LHA For Paperwork Reduction Act Notice, see Form 1040 instructions.
Schedule C (Form 1040) 2001
120OO1 10-26-O1
8
Schedule C (Form l040) 2001 ~ B . .SHIED (DEC. 03/13/02) 174-20-3373 Page2
Cost of Goods Sold (see page C-6)
33 . Method(s) used to
value closing inventory: a I I Cost b I I Lower of cost or market c I I Other (attach explanation)
34 Was there any change in determining quantities, costs, or valuations between opening and closing inventory? If
'Yes," attach explanation ................................................................................................................................................ [~] Yes I I No
35 Inventory at beginning of year. If different from last year's closing inventory, attach explanation .................................... 35..~_
36 Purchases less cost of items withdrawn for personal use ....................................................................................... 36
37 Cost of labor. Do not include any amounts paid to yourself .................................................................................... 37_._
38 Materials and supplies .................................................................................................................................... 38..~_
39 0the r costs ...................................................................................................................................................
40 Add lines 35 through 39 ................................................................................................................................. 40_.q__
41 Inventory at end of year ................................................................................................................................. 41___
42 Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on parle 1, line 4 ....................................... 42
fi:~:~i~:~l Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on line 10 and are not required
to file Form 4562 for this business. See the instructions for line 13 on page C-3 to find out if you must file.
43 When did you place your vehicle in service for business purposes? (month, day, year) · / /
44 Of the total number of miles you drove your vehicle dudng 2001, enter the number of miles you used your vehicle for:
a Business 1 r 8 7 5 b Commuting c Other
45 Do you (or your spouse) have another vehicle available for personal use? .............................................................................. ~ Yes
46 Was your vehicle available for use during off-dub/hours? ................................................................................................... ~ Yes
47a Do you have evidence to support your deduction? ............................................................................................................ ~ Yes
b If'Yes,' is the evidence written? .................................................................................................................................... ~ Yes
r--'l No
~ NO
i'--] No
fiii~i~iiiiiJ Other Expenses. List below business expenses not included on lines 8-26 or line 30.
LABORATORY FEES
CPR COURSE
2r056.
25.
2 081
48 Total other expenses. Enter here and on page 1, line 27
9 Schedule C (Form 1040) 2001
2001 DEPRECIATION AND AMORTIZATION REPORT
KARL B ETSHIED DDS
SCHEDULE C- 1
Reduction In
~,et Date une Unadjusted Bus % Basis - Basis For Accumulated Current Amount Of
No. Description Acquired Method Life No. Cost Or Basis Excl ITC, 179, Depreciation Depreciation Sec 179 Depreciation
Salvage
ZBUILDING (BUS PORTION) 090555SL .020 16 7,000. 7,000. 5,880. 140.
4 20MPUTER 0615 ~8200D£ 5.00 17 2,755. 2,755. 1,962. 317.
Total Sch C Depreciation 14,163. 4,408. 9,755. 7,842. 457.
128102
lO-O3-ol (D) - Asset disposed
9.1
Schedule C- Two-Year omparison Worksheet 2001
Business Name:
KARL B ETSHIED DDS
INCOME
~ross income 55,111. 38,478. <16,633.
EXPENSES
2ar and truck expenses 609. 647. 38.
Depreciation and Sec. 179 expense 669. 457. <212.
Insurance 836. 708. <128.
Legal and professional services 475. 425. <50.
Office expense 2,340. 588. <1,752.
Supplies 2,601. 1,559. <1,042.
Taxes and licenses 0. 175. 175.
Utilities 1,263. 852. <411.
Other expenses 4,677. 2,081. <2,596.
Total expenses 13,470. 7,492. <5,978.
Tentative profit or (loss) 41,641. 30,986. <10,655.
Home office expense 3,593. 1,841. <1,752.I
Net profit or (loss) 38,048. 29,145. <8,903.i
9.2
SCHEDULE SE
Oepartment of the Tmasur~ J
internal Revenue Service (99} J J~' Attach to Form 1040.
Name of person with self-employment income (as shown on Form 1040)
Self-Employment Tax
See Instructions for Schedule SE (Form 1040).
KARL B ETSHIED (Dec. 03/13/02)
Who Must File Schedule SE
You must file Schedule SE if:
OMB No. 1545-0074
2001
Attachment
Sequence No. 17
I
Social security number of
person with self-employment
income ~ 17412013373
· You had net earnings from self-employment from other than church employee income (line 4 of Short Schedule SE or line 4c of Long Schedule SE')
of $400 or more or
· You had church employee income of $108.28 or more. Income from services you performed as a minister or a member of a religious order
is not church employee income. See page SE-I.
Note: Even if you had a loss or a small amount of income from self-employment, it may be to your benefit to file Schedule SE and use either
"optional method" in Part II of Long Schedule SE. See page SE-3.
Exception. If your only self-employment income was from earnings as a minister, member of a religious order, or Christian Science practitioner and
you filed Form 4361 and received IRS approval not to be taxed on those earnings, do not file Schedule SE. Instead, write 'Exempt-Form 4361 ' on
Form 1040, line 53.
May I Use Short Schedule SE or Must I Use Long Schedule SE?
J Did You Receive Wages or Tips In 20011
J No
Are you a minister, member of a religious order, or Christian
Science practitioner who received IRS approval not to be taxed
on earnings from these sources, hut yOU owe self-employment
tax on other eamings?
IAre you using one of the optional methods to figure your net lYes.
earnings (see page SE-3)?
I Did you reoaive church employee income reported on Form W-2
of $108.28 or more?
¥o. May use Shed Schedule SE Below J
~ Yes
or railroad retirement tax plusyour net earnings from self-
employment more than $80,400?
Did you receive tips subject to social security or Medicare
tax that you did not report to your employer?
You Must Use Long Schedule SE
Section A-Short Schedule SE. Caution. Read above to see if you can use Short Schedule SE.
I Net farm profit or (loss) from Schedule F, line 36, and farm partnerships, Schedule K-1
(Form 1065}, line 15a ..........................................................................................................................................
2 Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065), line 15a
(other than farming); and Schedule K-1 (Form 1065-B), box 9. Ministers and members of religious orders,
see page SE-1 for amounts to report on this line. See page SE-2 for other income to report ............ .~...t..~..~....? ....
3 Combine lines 1 and 2 .......................................................................................................................................
4 Net earnings from self-employment. Multiply line 3 by 92.35% (.9235). If less than $400, do not
file this schedule; you do not owe self-employment tax ................................................................................. ~
5 Self-employment tax. If the amount on tine 4 is:
· $80,400 or less, multiply line 4 by 15.3% (.153). Enter the result here and on '~
Form 1040, line 53.
· More than $80,400, multiply line 4 by 2.9% (.029). Then, add $9,969.60 to the result.
Enter the total here and on Form 1040, line 53.
6 Deduction for one-half of self-employment tax. Multiply line 5 by 50% (.5).
Enter the result here and on Form 1040, line 27 ................................................ I 6
LHA For Paperwork Reduction Act Notice, see Form 1040 instructions.
2r059-
29r145.
29,145.
26,915.
4r118'
;chedule SE (Form 1 040) 2001
124501
10-23-01
10
6251
Department of the Treasury
Intemel Revenue Service (99)
Alternative Minimum Tax - Individuals
· Attach to Form 1000 or Form 1040NR.
OMB No. 1545-0227
2001
Attachment ,,A
Sequence No. ~Z
Name(s) shown on Form 1040
KARL B & JANICE W ETSHIED
Alternative Minimum Taxable Income
b Depletion ........................
c Depreciation (pre-1987) ...
d Installment sales ...............
e Intangible drilling costs ......
f Large partnerships ............
g Long-term contracts .........
h Loss limitations
I If you itemized deductions on Schedule A (Form 1040), go to line 2. Otherwise, enter your standard deduction
from Form 1040, line 36, here and go to line 6 ...................................................................................................
2 Medical and dental. Enter the smaller of Schedule A (Form 1040), line 4 or 2 1/2% of Form 1040, line 34 .........
3 Taxes. Enter the amount from Schedule A (Form 1040), line 9 ...........................................................................
4 Certain interest on a home mortgage not used to buy, build, or improve your home ..........................................
5 Miscellaneous itemized deductions. Enter the amount from Schedule A (Form 1040), line 26 ..............................
6 Refund of taxes. Enter any tax refund from Form 1040, line 10 or line 21 ............................................................
7 Investment interest. Enter difference between regular tax and AMT deduction ...................................................
8 Post-1986 depreciation. Enter difference between regular tax and AMT depreciation ..........................................
9 Adjusted gain or loss. Enter difference between AMT and regular tax gain or loss ................................................
10 Incentive stock options. Enter excess of AMT income over regular tax income ...................................................
11 Passive activities. Enter difference between AMT and regular tax income or loss ................................................
12 Beneficiaries of estates and trusts. Enter the amount from Schedule K-1 (Form 1041), line 9 ..............................
13 Tax-exempt interest income from private activity bonds issued after August 7, 1986 ..........................................
14 Other. Enter the amount, if any, for each item below and enter the total on line 14.
a Circulation expenditures ... i Mining costs .....................
j Patron's adjustment .........
k Pollution controlfacilities ...
I Research and experimental
m Section 1202 exclusion ......
n Tax shelter farm activities ...
o Related adjustments .........
15 Total adjustments and preferences. Combine lines 1 through 14 ........................ 5 2_ 7
16 Enter the amount from Form 1040, line 37. If less than zero, enter as a (loss) ...... 1 4
17 Enter as a positive amount any net operating 10ss deduction from Form 1040, line 21 ......
18 If Form 1040, line 34, is over $132,950 (over $66,475 if married filing
separately) ~nd you itemized deductions, enter the amount, if any, from line 9
of the worksheet for Schedule A (Form 1040), line 28 .......................................
19 Combine lines 15 through 18 ...........................................................................................................................
20 Alternative tax net operating loss deduction (see instructions) ...........................................................................
21 Alternative minimum taxable income. Subtract line 20 from line 19. (If married filing separately
and line 21 is more than $173,000, see instructions.) ..........................................................................................
Alternative Minimum Tax
22 Exemption amount. (If this form is for a child under age 14, see instructions.) j??iiiiiiii!ii!!iii!i
IF your filing status is... AND line 21 is not over THEN enter on line 22...
Single or head of household .......................... $112,500 ........ $35,750 '}
Married flling jointly or qualifying widow(~;i ........ 1 150,000 iiiii]ii]i]iiiii ........ 49,000 } J 22J
Married filing separately .............................. 75,000 ....................... 24,500 J .....................
If line 21 is over the amount shown above for your filing status, see instructions.
23 Subtract line 22 from line 21. If zero or less, enter -0- here and on lines 26 and 28 and stop here .............. J 23 J
24 Go to Part 111 of Form 6251 to figure line 24 if you reported capital gain distributions directly on Form 1040, line 13, J J
or you had a gain on both lines 16 and 17 of Schedule D (Form 1040) (as refigured for the AMT, if necessary). J J
All others: If line 23 is $175,000 or less ($87,500 or less if married filing separately), multiply line 23 by 26% (.26). J J
Otherwise, multiply line 23 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from the result J 24
25 Alternative minimum tax foreign tax credit (see instructions) ................................................ J 25 J
26 Tentative minimum tax. Subtract line 25 from line 24 J 26 J
27 Enter your tax from Form 1040, line 40 (minus any tax from Form 4972 and any foreign tax credit J J
from Form 1040, line 43) ............................................................................................................ J 27 J
28 Alternative minimum tax. Subtract line 27 from line 26. If zero or less, enter-0-. Enter here and on J J
Form 1040~ line41 .......................................................................................................................................... J 28 J
9481
11-03-01
LHA For Paperwork Reduction Act Notice, see instructions.
10.1
· Your social security number
174 20 13373
669.
<142.>
15 210.
15r210.
49,000.
0.
0.
~rm6251~001)
Form 6251(2001) KARL B & JANICE W ETSHIED 174-20-3373 Page 2
{iii~iii~?~i] Line 24 Computation Using Maximum Capital Gains Rates
Caution: If you did not complete Part IV of Schedule D (Form 1040), see the instructions before
you complete this part.
29 Enter the amount from Form 6251, line 23 .........................................................................................................
30 Enter the amount from Schedule O (Form 1040), line 23, or line 9 of the
Schedule D Tax Worksheet on page D-9 of the instructions for Schedule D
(Form 1040), whichever applies (as refigured for the AMT, if necessary)
(see instructions) ............................................................................................. 30
31 Enter the amount from Schedule D (Form 1040), line 19 (as refigured for the
AMT, if necessary) (see nstruct OhS) ............................................ 3.~_1
32 Add lines 30 and 31 .......................................................................................... 3_...~2
33 Enter the amount from Schedule D (Form 1040), line 23, or line 4 of the
Schedule D Tax Worksheet on page D-9 of the instructions for Schedule D
(Form 1040), whichever applies (as refigured for the AMT, if necessary)
(see instructions) ............................................................................................. 33
34 Enter the smaller of line 32 or line 33 ...............................................................................................................
35 Subtract line 34 from line 29. If zero or less, enter ~-. .........................................................................................
36 If line 35 is $175,000 or less ($87,500 or less if married filing separately), multiply line 35 by 26% (.26).
Otherwise, multiply line 35 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from
the result
Schedule D Tax Worksheet on page D-9 of the instructions for Schedule D
(Form 1040), whichever applies (as figured for the regular tax)
(see instructions) ............................................................................................. ~ 37
38 Enter the smallest of line 29,1ine 30, or line 37.1f zero, gotoline44 . .
39 Enter your qualified 5-year gain, if any, from !
40 Enter the smaller of line 38 or line 39 ... | 40
41 Multiply line 40 by 8% (.08) ..............................................................................................................................
42 Subtract line 40 from line 38 ...........................................................................
43 Multiply line 42 by 10% (.10) ............................................................................. I ........ i ....................................
44 Enter the smaller of line 29 or line 30 ...............................................................
45 Enter the amount from line 38 ...........................................................................
46 Subtract line 45 from ne 44 ..............................................................................
47 Multiply line 46 by 20% (.20) ...........................................................................................................................
If line 31 is zero or blank, skip lines 48 through 51 and go to line 52. Otherwise, go to line 48.
48 Enter the amount from line 29 ........................................................................... 48
49 Add lines 35, 38, and 46 ................
50 Subtract line 49 from line 48
51 Multiply line 50 by 25% (.25) ...........................................................................................................................
52 Add lines 36, 41,43, 47, and 51 ........................................................................................................................
53 If line 29 is $175,000 or less ($87,500 or less if married filing separately), multiply line 29 by 26% (.?.6).
Otherwise, multiply line 29 by 28% (28) and subtract $3,500 ($1,750 if married filing separately) from
the result
54 Enter the smaller of line 52 or line 53 here and on line 24 .................................................................................
Fom~ 6251 ~2om)
119591
11-27-01
10.2
ALTERNATIVE MINIMUM TAX RECONCILIATION REPORT
Name(s) Social Security Number
KARL B & JANICE W ETSHIED 174-20-3373
Form Adjustment
Name Description Income Form 6251
Form 6251, Une 8 Form 6251, Une 9 Form 6251, Une 11 Form 6251, Line 14h Other Adjustment
C- KARL B ETSHIED DDS
~? .]~D.r....A.d_j. ...................... <142- > <142. ,
** Total Adj & Pref ** <142.>
119911
05-15-01
ALTERNATIVE MINIMUM TAX DEPRECIATION REPORT
Asset Date AMT AMT AMT Regular AMT AMT
No. DescripUon Acquired Method Life Cost Or Basis Depreciation Depreciation Adjustment
KARL B ETSHIED DDS
** Subtotal ** 2,755. 317. 459. <142.>
*** Grand Total *** 2,755. 317. 459. <142.>
128104
05-15-01
10.4
o 882g
Department of the Treasury
Intemal Revenue Service
Expenses for Business Use of Your Home
~ File only with Schedule C (Form 1040). Use a separate Form 8829 for each
home you used for business during the year.
OMB No. 1545-1266
2001
Name(s) of proprietor(s)
~ B ~.TSHT~.D (Dec. 03/13/07_)
Ii?i~!~??ii?~l Part of Your Home Used for Business
Your social security number
174-20-3373
I Area used regularly and exclusively for business, regularly for day care, or for storage of inventory
or product samples ....................................................................................................................................... 'i "'
2 Total area of home ...............
3 Divide line 1 by line 2. Enter the result as a percentage ................................................
· For day-care facilities not used exclusively for business, also complete lines 4-6.
· All others, skip lines 4-6 and enter the amount from line 3 on line 7.
4 Multiply days used for day care during year by hours used per day .................. 4 hr.
5 Total hours available for use during the year (365 days x 24 hours) .................. ~ hr.
6 Divide line 4 by line 5. Enter the result as a decimal amount ..............................
7 Business precentage. For day~=are facilities not used exclusively for business, multiply line 6 by line 3
(enter the result as a percentage). All others, enter the amount from line 3 ...................................................
l~i~ii~iiiiiil Figure Your Allowable Deduction
Enter the amount from Schedule C, line 29, plus any net gain or (loss) derived from the business use of your
home and shown on Schedule D or Form 4797. If more than one place of business, see instructions ..................
See instructions for columns (a) and (b) before
completing lines 9-20.
Casualty losses ......................................................
Deductible mortgage interest ....................................
Real estate taxes
Add lines 9, 10, and 11 .............................................
Multiply line 12, column (b) by line 7 ........................
Add line 12, column (a) and line 13 ...........................
Subtract line 14 from line 8. If zero or less, enter -0- ...
Excess mortgage interest .......................................
Insurance
Repairs and maintenance .......................................
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
30,986.
21 1,841. 397.
line 41 ........................ 23
..................................................................................... 24 1,841.
15 or line 24 ............................................................... 25 1 r 8 4 1,
:ract line 25 from line 15 .............................................. 26 2 9 r 14 5.
..................................... 27 :::::::::::::::::::::::::::
10 Form 8829, line 42 ...... 29
:er the smaller of line 26 or line 30 ................................. 31 0.
..................................................................................... 32 1, 841.
amount to Form 4684, Section B .............................. 33 0.
Utilities
Other expenses ......................................................
Add lines 16 through 20 ..........................................
Multiply line 21, column (b) by line 7
Carryover of operating expenses from 2000 Form 8829
Add line 21 in column (a), line 22, and line 23
Allowable operating expenses. Enter the smaller of line
Umit on excess casualty losses and depreciation. Subtr.
Excess casualty losses ................
Depreciation of your home from Part III below
Carryover of excess casualty losses and depreciation from 2t
Add lines 27 through 29
Allowable excess casualty losses and depreciation. Enter
Add lines 14, 25, and 31
Casualty loss portion, if any, from lines 14 and 31. Carr
line 30. If your home was used for more than one business, see instructions ................................................ ~.
f!!~:P~ii~i~ii~:l Depreciation of Your Home
Allowable expenses for business use of your home. Subtract line 33 from line 32. Enter here and on Schedule C,
1 841
35 Enter the smaller of your home's adjusted basis or its fair market value ............................................................I 35
36 Value of land included on line 35 ..................................................................................................................... I ~36
37 Basis of building. Subtract line 36 from line 35 .................................................................................................
38 Business basis of building. Multiply line 37 by line 7 ..........................................................................................
39 Depreciation percentage ............................................................... I 39
40 Depreciation allowable. Multiply line 38 by line 39. Enter here and on line 28 above .......................................... I 40
I!!i~!i~iiit Carryover of Unallowed Expenses to 2002
41 Operating expenses. Subtract line 25 from line 24. If less than zero, enter -{3- . .................................................. ~
42 Excess casualty losses and depreciation. Subtract line 31 from line 30. If less than zero, enter -0- . ....................
120301
1~-08-01 LHA For Paperwork Reduction Act Notice, see instructions. 1 1 Form 8829 (2001)
KARL B & JANICE W ETSH' ~ 174-20-3373
Form 1~40 Social Security Benefits Worksheet Statement 1
Check only one box:
A. Single, Head of household, or Qualifying widow(er)
X B. Married filing jointly
C. Married filing separately and lived with your spouse
at anY time during 2001
D. Married filing separately and lived apart from your spouse
for all of 2001
1.Enter the total amount from. Box 5 o~ all your
Forms SSA-1099 and RRB-1099. . . .............
2. Enter one half of line 1 . . .
3. Add the amount's on Form 1040, lin '----'7,'8b,'9'thr°ugh'14,''
15b, 16b, 17 thru 19, 21 and Schedule B, line .2. Do not
include any amounts from box 5 of Forms SSA-1099 or RRB-1099
4. Enter the amount of any exclusions from foreign earned
income, foreign housing, income from U.S. possessions,
or income from Puerto Rico by bona fide residents of
Puerto Rico that you claimed ...............
5.Add lines 2, 3, and 4 ................
6. Add the amounts on Form 1040, lin~s'23, and 25 thru 3la, and
any amount you entered on the dotted line next to line 32.
7.Subtract line 6 from line 5 ...............
8. Enter: $25,000 if you checked Box A or D, or
$32,000 if you checked Box B, or
$-0- if you checked Box C ...........
9. Is the amount on line 8 less than the amount on line 7?
[ ] No. Stop. None of your social security benefits are
taxable. You do not have to enter any amounts on lines
20a or 20b of Form 1040. But if you are married filing
separately and you lived apart from your spouse for all of
2001, enter -0- on line 20b. Be sure you entered 'D' to
the left of line 20a.
[X] Yes. Subtract line 8 from line 7 ...........
10. Enter $9,000 if you checked Box A or D,
$12,000 if you checked Box B
$-0- if you checked Box C ............
11. Subtract line 10 from line 9. If zero or less, enter -0-.
12. Enter the smaller of line 9 or line 10 ..........
13. Enter one half of line 12 ...............
14. Enter the smaller of line 2 or li~e'13 ..........
15. Multiply line 11 by 85% (.85). If line 11 is zero, enter -0-
16. Add lines 14 and 15 ....................
17. Multiply line 1 by 85% (.85) ...............
18. Taxable benefits. Enter the smaller of line 16 or line 17 * Enter the amount from line 1 above on Form 1040, line 20a
* Enter the amount from line 18 above on Form 1040, line 20b
26,049.
13,025.
29,145.
42,170.
4,968.
37,202.
32,000.
5,202.
12,000.
0.
5,202.
2,601.
2,601.
0.
2,601.
22,142.
2,601.
12 Statement(s) 1
KARL B & JANICE W ETSH~ rD 174-20-3373
Form 2040 Rate Reduction Credit Statement 2
1. Enter the amount from Form 1040, line 39. If
line 39 is zero or blank, stop; you cannot
take the credit ...............
Enter the amount shown below for your filing
status
* Single or married filing separately - $6,000
* Head of household - $10,000
* Married filing jointly or qualifying
widower(er) - $12,000
Is the amount on line 1 less than the amount
on line 2?
No. Enter: $300 if single or married filing
separately; $500 if head of household;
$600 if married filing jointly or
qualifying widow(er).
Yes. Multiply the amount on line 1 by 5%(.05).
Enter the result
4. Enter the amount from Form 1040, line 42 .
5. Add the amounts from Form 1040, lines 43
through 46. Enter the total .....
6. Subtract line 5 from line 4. If the result is
zero or less, stop; you cannot take the credit .
7. Enter the smaller of line 3 or line 6 ....
8. Enter the amount, if any, of your advance payment
(before offset). If filing a joint return,
include your spouse's advance payment with yours .
9. Rate reduction credit. Subtract line 8 from
line 7. Enter the result here and, if more
than zero, on Form 1040, line 47 ......
1,331.
8,883.
12,000.
444.
1,331.
444·
600.
Schedule A
Points Not Reported on Form 1098
Statement 3
Description
Total to Schedule A, line 12
Date Re- Total
financed Points
02/16/98
2,040.
Amort.
Period
/Mos.
180
Amortization
This Year
136.
136.
13 Statement(s) 2, 3
· KARL B & JANICE W ETSHIED 174-20-3373
Schedule A Cash Contributions Statement 4
Description
WEST CHESTER UNIVERSITY
Subtotals
Total to Schedule A, line 15
Amount Amount
50% Limit 30% Limit
125.
125.
125.
Schedule A Medical and Dental Expenses Statement 5
Description Amount
Prescription Medicines and Drugs
MEDICARE
Self-employed Health Insurance
Total to Schedule A, line 1
541.
1,200.
1,940.
3,681.
Schedule C Car and Truck Expenses Statement 6
Description Amount
Vehicle Number 1 - 1875 Business Miles @ $0.345 647.
Total to Schedule C, line 10 647.
14 Statement(s) 4, 5, 6
KARL B & JANICE W ETSHIED 174-20-3373
Schedule SE Non-Farm Income Statement 7
Description
From Schedule C
Total to Schedule SE, line 2
Amount
29,145.
29,145.
15 Statement(s) 7
174461
12-27-01
174-20-3373 ET 194-22-7525 0100915057
ETSHIED
KARL B
JANICE W
ETSHIED
111 N 32ND
CAMP HILL
PA
17011
ST
DEPARTMENT USE ONLY
PAYMENT AMOUNT
$ 816.00
Make check or money order payable to the
Penns~vania Depaffment of Revenue
PLEASE
DO NOT USE YOUR
LABEL
0100115054
2OO1
PA-40
PAGE 1 OF 2
174-20-3373
ETSHIED
ETSHIED
111 N 32ND ST
CAMP HILL
ET 194-22-7525
PA 17011
KARL B
JANICE W
EX 0 RS
A 0 FS
FY 0
XX
SC 21100
PN
lA 0.00 lB 0.00 1C 0.00
2 0.00 3 0.00 4 29145.00
5 0.00 6 0.00 7 0.00
8 0.00 9 29145.00 10 0.00
11 29145.00 12 816.00
P LE~"F~'G ~A~ALONG THIS' LInE
Local Informatlon. Enter where you lived as of 12/31/2001
School District: C a m p H i I 1
School Code: 2 1 1 0 0
County: Cumberland
Municipality: C a m p H i 1 [ B o r o u 9 h
Residency Status. (Mark the Correct Space)
R X Pennsylvania Resident
NR Nonresident
P Part Year Resident
From: D
Extension, (Mark this space)
Amended Return, (Mark this space)
Fiscal Year Filer, (Mark this space)
Type Flier. (Fill-In only one choice)
S Single
J X Married, Filing Jointly
M Married, Filing Separately
F Final Return. Indicate Reason:
?.~ Deceased
To: Date of Death . ~-' ,'~
la Gross Compensation See the instructions '":"~i'~'"'~?\~"~ ~'~ ,a
. . ............................................................ .,...%..~ ....~ ..........................
lb Unreimbursed Employee Business Expenses. See the instructions ................. ,. ':~' ~."~-,.. ~. ~ lb
..........................
lc Net Compensation. Subtract Line lb from Line la .~ ' lc
2 Interest Income. Complete and submit PA Schedule A, if over $2,500 ...................................................................... 2
0.00
0.00
0.00
0.00
3 Dividend Income. Complete and submit PA Schedule B, if over $2,500 ................................................................... 3
4 Net Income or Loss from the Operation of Business, Profession, or Farm ....... .S..e..e.....~...~..a...~..e..~...~...D-..~....~ ............. 4
0
29,145
.00
.00
5 Net Gain or Loss from the Sale, Exchange, or Disposition of Property ...................................................................... 5
6 Net Income or Loss from Rents, Royalties, Patents, or Copyrights ........................................................................... 6
0.00
0.00
7 Estate or Trust Income. Complete and enclose PA Schedule J.
.............................................................................. 7
8 Gambling and Lotte~yWinnings.
0.00
0.00
Total PA Taxable Income. Add only the positive income amounts from Lines lc, 2, 3, 4, 5, 6, 7, and 8.
DO NOT ADD any losses reported on Lines 4,5, or 6.
29,145.00
10 Contributions To Your Medical Savings Account. See the instructions ................................................................... 10
211 Adjusted PA Taxable Income. Subtract Line 10 from Line 9 .................................................................................. 11
0.00
29,145.00
PATax Liability. Multiply line 11 by 2.8% (0.028). Also enter on Line 13, page 2 .................................................... 12
816.00
0100115054
EC FC
0100115054
0100215052
2OO1
PA-40
PAGE 2 OF 2
ETSHIED
KARL
13 816.00 14 0.00 15
16 0.00 17 0.00 18
19 0.00 20A 0 20B
21 0.00 22 0.00 23
24 0.00 25 0.00 26
27 0.00 28 816.00 29
30 0.00 31 0.00 32
33 0.00 34 0.00 35
36 0.00
B 174-20-3373
0.00
0.00
0
0.00
0.00
0.00
0.00
0.00
13 Total PATax Liability.
Enter your PA Tax Liability from Line 12 on Side 1 ........................................................................................ 13
14 Total PA Tax Withheld. See the instructions ................................................................................................ 14
15 Credit from your 2000 PA Income Tax Return .............................................................................................. 15
16 2001 Estimated Installment Payments .................................................................................................. 16
17 2001 Extension Payment ......................................................................................................................... 17
18 Nonresident Tax Withheld on your PA Schedule(s) NRK-1. (Nonresidents only) ................................................... 18
19 Total Estimated Payments and Credits. Add Lines15, 16, 17, and 18 ................................................................ 19
TAX BACK/I'ax Forgiveness Credit. Complete lines 20a, 20b, 21, and 22. Read instructions.
20a Filing Status: Unmarried or Separated Married Deceased 20a
20b Dependents, Part B, Line 2 PA Schedule SP ................................................................................................. 20b
21 Total Eligibility Income, Part C, Line 11, PA Schedule SP .................................................................................. 21
22 TAX BACK/Tax For,qiveness Credit from Part D, Line 16, PA Schedule SP. 22
23 Total Credit for Taxes Paid to Other States or Countries. Submit your PA Schedule G or RK-1 ............................... 23
24 PA Employment Incentive Payments Credit. Submit your PA Schedule W, RK-1 or NRK-1 ..................................... 24
25 PA Jobs Creation Tax Credit. Submit your certification or PA Schedule RK-1 or NRK-1 ........................................... 25
26 PA Research and Development Tax Credit. Submit your certification or PA Schedule RK-1 or NRK-1 ......................... 26
27 Total Payments and Credits. Add lines 14 and 19 and 22 through 26 ......................................................... 27
28 TAX DUE. If Line 13 is more than Line 27, enter the difference here ................................................................... 28
29 OVERPAYMENT. If Line 27 is more than Line 13, enter the difference here .......................................................... 29
The total of Lines 30 through 36 must equal Une 29.
30 Refund - Amount of Line 29 you want as a check mailed to you .......................................................... Refund 30
31 Credit - Amount of Line 29 you want as a credit to your 2002 estimated tax account ........................................... 31
32 Donation - Amount of Line 29 you want to donate to the Wild Resource Conservation Fund ............................... 32
33 Donation - Amount of Line 29 you want to donate to the United States Olympic Committee .................................. 33
34 Donation - Amount of Line 29 you want to donate to the Governor Robert P. Casey Memorial
Organ and Tissue Donation Awareness Trust Fund ..................................................................................... 34
35 Donation - Amount of Line 29 you want to donate to the Korea/Vietnam Memorial Inc ..................................... 35
36 Donation - Amount of Line 29 you want to donate to the Breast and Cervical Cancer Research Fund ................... 36
816.00
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0.00
816.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Under penalties of perjury I (we,) declare that I (we) have examined this return, Including all accompanying schedules and statements, and to the best of my
(our) belief they are true, correc[and complete.
Your Signature~ Date: Your Occupation:
DENTIST
Spouse's Signature, if filing joinUy: Date: Spouse's OccupatJon:
HOUSEWIFE
Preparer or Comoanv Name. other than taxoaverCsL basee on all mt0rmat;ion ct which the oreoarer nas any I(n0wledge.
Pr,epamr or Company Name (Please Pdnt~: Date:. Telephone Number.
WILDEMAN AND OBROCK, CPA'S 05/08/02 (717) 561-0820
174002
12-27-01
Signature (Optional):
0100215052 0100215052
0103115051
PA Schedule C
Profit or Loss From Business or Profession
(SOLE PROPRIETORSHIP)
PA-40 C (O9-O1)
PA DEPARTMENT OF REVENUE
Attach to form PA-40, PA-20S/PA-65, or PA-41
Name of Owner as shown on PA tax return.
ETSHIED, KARL B (Dec. 03/13/02)
^ Main businessa~ivity · DENTIST/DENTISTRY
2OO1
OFFICIAL USE ONLY
SCHEDULE C
Owner's
Social Security Number 1 7 4--2 0-3 3 7 3
· product or service · Offices of dentists
B Business Name · K~_L B ETSHIED DDS
D Business address (numberand street) 11_1__N 32ND ST
Taxpayer Identification Number
23-1574543
City, State, andZIPCode ~AMP HILL, PENNSYLVANIA 17011
E Method(s) used to value closing invento[y, fill in the appropriate box:
(1)F--~ cost (2)F--] Lower of cost or market (3)r-'-] other (if other, attach explanation)
F Accounting method, fill in the appropriate box: (1)F~ Cash (2)F-] Accrual (3)F'] Other (specify) ·
G Was there any change in determining quantities, costs, or valuations between opening and closing inventory? ................................................
If '~es" attach explanation.
H Did foran officein
C
1 a Gross receipts or sales .............................................................................................3 $
b Retumsand allowances
c Balance (subtract Line lb from Line la) ............................................................................................................... 3 8,4
2 Cost of goods sold and/or operations (Schedule C-1, Line 8) ..........................................................................................
3 Gross profit (subtract Line 2 from Line lc) ..................................................................................................................
4 Other income (attach schedule) Include interest from accounts receivable, business checking accounts ..................................
and other business accounts. Also include sales of operational assets. See Instructions Booklets.
5 Total income 3 and 4 . ·
7 Amortization ................................................
8 Bad debts from sales or services .....................
9 Bank charges ............................................. 31 Wages
10 Car and track expenses ................................. 6 4 7 32 Other expenses (specify):
11 Commissions ............................................. a LABORATORY FEES 2,056
12 Depletion ................................................... b CPR COURSE 25
13 Depreciation (explain in Schedule C-2) ............ 457 c H_-o_-m_-e_--O-f~i~_~-D_e_d_u_c_~- 1,841
14 Dues and publications d
15 Employee benefit programs ether than on Line 22 e
16 Freight (not included on Schedule C-1) ............ f
17 Insurance ................................................... 7 0 8 g
18 Interest on business indebtedness .................. h
19 Laundry and cleaning ....................................
20 Legal and professional services 4 2 5 j
21 Office supplies ............................................. 5 8 8 k
22 Pension and profit-sharing plans for employees I
23 Postage ...................................................... m
24 Rent on business property .............................. n
25 Repairs ...................................................... o
26 Supplies (not included on Schedule C-1) ......... 1,5 5 9 p
:)7 Taxes ......................................................... 1 7 5 q
:)8 Telephone ................................................... r
29 Travel and entertainment Reduce expenses by the total business credits claimed
30 Utilities 8 5 2 33 (for example, Employment incentive Payments Credit) on
...................................................... ~ your PA-40,
34 Total deductions (add amounts in columns for Lines 6 throu(~h 32r) and deduct Line 33 ................................................. · 34 9,3 3 3
35 Net profit or loss (subtract Line 34 from Line 5). Enter total here and on the PA tax return. Loss
If a net loss fill in the box and enter the loss on the PA tax return, r-~ 35 2 9,14 5
0103115051 SIDE1 0103115051
Depreciation and Amortization Detail
KARL B ETSHIED DDS
Description of property
Asset
Number ~ .?~t~e,~ I Method/I Life Line I Cost or I Bass Accumulated Current ear
~ in~;~ceI ,.csec. I or rate I No. I otherbas,s I reduction depreciation/amortization deductlYo~n
4 COMPUTER
........... ~06~15~98~200D~5.00 17 2,755. 1,962. 317.
· otal 8ch C
I I I
09-04-01
# - Current year section 179 (D) - Asset disposed
9
?A-40 Business, Profession and Farm Net Income Statement 1
Description
Schedule C
Subtotal
Total to PA-40, line 4
Taxpayer
Amount
29,145.
29,145.
Spouse
Amount
29,145.
Statement(s) 1
o 882g
Department of the Treasury
Internal Revenue Service
Expenses for Business Use of Your Home
File only with Schedule C (Form 1040). Use a separate Form 8829 for each
home you used for business during the year.
PA
Attachment
S~u~ce No. 66
Name(s) of proprietor(s)
KARL B ETSHIED (Dec. 03/13/02)
l!!i~!~?~i?~i!l Part of Your Home Used for Business
1 Area used regularly and exclusively for business, regularly for day care, or for storage of inventory iiiiiiiiiiiiiiiiiii
or product samples ....................................................................................................................................... I 1
2 Total area of home ................................................. l 2
3 Dividelinel byline2. Enter the result as a percentage ................................... [ 3
· For day-care facilities not used exclusively for business, also complete lines 4-6. Iiiiiiiiiiiiiiiii::ii
· All others, skip lines 4-6 and enter the amount from line 3 on line 7. liiiiiiilili!ii[iiiii
4 Multiply days used for day care during year by hours used per day ................. 4 hr. li!ii!!iiii?!iiiiiiii
5 Total hours available for use during the year (365 days x 24 hours) I 5 I hr. t!ii!!i!!ii?!iiii~i?ii
6 Divide line 4 by line 5. Enter the result as a decimal amount I 6 I li;ii!i!iiiiiiiiiiiiii
7 Business precentage. For day-care facilities not used exclusively for business, multiply line 6 by line 3 ~i!iiiiiiiiiiiiiilill
(enter the result as a percentage). All others, enter the amount from line 3 ...................................... ~ ~ 7
I~;i~ii!~i?!!il Figure Your Allowable Deduction
Enter the amount from Schedule C, line 29, plus any net gain or (loss) dedved from the business use of your
home and shown on Schedule D or Form 4797. If more than one place of business, see instructions
See instructions for columns (a) and (13) before
rYour social security number
].?4-2O-33?3
30 986.
completing lines 9-20.
9 Casualty losses
10 Deductible mortgage interest ....................................
11 Real estate taxes
12 Add lines 9, 10, and 11 .......................................
13 Multiply line 12, column (b) by line 7 ........................
14 Add line 12, column (a) and line 13 ...........................
15 Subtract line 14 from line 8. If zero or less, enter -0....
18 Excess mortgage interest
17 Insurance
18 Repairs and maintenance .......................................
19 Utilities
20 Other expenses ......................................................
21 Add lines 16 through 20 ..........................................
22 Multiply line 21, column (b) by line 7
23 Carryover of operating expenses from 2000 Form 8829
24 Add line 21 in column (a), line 22, and line 23
25 Allowable operating expenses. Enter the smaller of line
26 Limit on excess casualty losses and depreciation. Sub1
27 Excess casualty losses ...........
28 Depreciation of your home from Part III below
29 Carryover 0fexcess casualty losses and depreciation from 2
30 Add lines 27 through 29
31 Allowable excess casualty losses and depreciation. E
32 Add lines 14, 25, and 31
33 Casualty loss portion, if any, from lines 14 and 31. Cart
17 397.
18
· ~9 lr841.
2O
.................................................................................... 24 1 r 84=1
; 15 or line 24 ............................................................... 28 1 r 841
ract line 25 from line 15 ............................................... 28 2 9 r 14 5
0 Form 8829, line 42 ...... 29
er the smaller of line 26 or line 30 ................................. 31 0
.................................................................................... 32 ]r 841
! amount to Form 4684, Section B .............................. 33 0
34 Allowable expenses for business use of your home. Subtract line 33 from line 32. Enter here and on Schedule C,
line 30. If your home was used for more than one business, see instructions ................................................ ~ i r 8 4 1.
liii~ii~]!!iiiil Depreciation of Your Home
35 Enter the smaller of your home's adjusted basis or its fair market value ............................................................ 35
36 Value of land included on line 35 ..................................................................................................................... ~36
37 Basis of building. Subtract line 36 from line 35 ................................................................................................
38 Business basis of building. Multiply line 37 by line 7 .........................................................
39 Depreciation percentage ................................................................................................................................. 39
40 Depreciation allowable. Multiply line 38 by line 39. Enter here and on line 28 above ..........................................
40
JilPJ~iJ Carryover of Unallowed Expenses to 2002
41 Operating expenses. Subtract line 25 from line 24. If less than zero, enter-0- - .... I 41 J
42 Excess casualty Josses and depreciation. Subtract line 31 from line 30. if less i~;~l":~;i~;';n'~';~:"*'.'..'.'.'.'.'.'.'.'.'.'.'..*.'.'.**.. I 42 t
120301
~1-08-m LHA For Paperwork Reduction Act Notice, see instructions. 1 ]. Form 8820 (2001)
1. W-2 EARNINGS (Attach W-2's) ................................................... 1.
2. EMpLo.¥EE BUSINESS *ExpENsEs (Attach State Schedule UEJl a~l R~ir~iAU'ach~e~)''.~.' .,':. ,,~* .~ '.' .' :. ";' 'i-' ;'. ~"~'~:.. ? J, J. ;'~ 2. ' ..... ·
~. TAXABLE W-2 EARNINGS (Subtract Line 2 from Line 1) ....................................... 3.
OTHER. ;: TAXABLE ....... EARNED INCOME (No Ints~;est, Dividends or uaemplo~ment Benefits, Altach Suppo~n~ Documents) ~ i- .-* · '.'; ~' .; ~ ,~ · 4~ .
5. TOTAL TAXABLE EARNED INCOME BEFORE NET PROFITS (Losses) FROM SELF-EMPLOYMENT ................... 5.
(Add Line,, 3 and 4)
'.i : . (Use Line B for any Net Profits) (AttachAp~[opdatelR$Sche~ule$),.. ';' '*, :, '.: ,-.! t. i '.'...' '.¥..-':::- %, ..:;': .,'..' ,r ' . "'. .... '-,'
7'. SUBTOTAL (Subtract Line 6 from Line 5) IF LESS THAN ZERO, ENTER ZERO ............................. ?,
';~, j'. ?(Use Uae $ for any Net Losses) (Attach Al~ropriats IRS Schedules). L':: ,.,... '.~ ", :2 :' "..i.: '. ~, -.., ,;-,?,~; ,: ,:'"i'~ :' ::~ ',' ;:'.-'. '.'~;, "; .';:;..:;
g. TOTAL TAXABLE EARNED INCOME AND NET PROFITS (Add LJae 7 and 8) .............................. g, 2 9 ]. ~,-~
1~, ' :' .......... :'"~"'"'~'?:~ ............... '" '~"~'T'~'"~..' .......... .~. ?'~"~:~,;:?~ '~--~-:.' :,"~,-;?"- ?'"'?-~'?-'-.' :"ri '.' ',.i'~.' ~'~c¥w--'-:'?"' '.'.'. ';:;' '~.c?',.-'~7:'?.- -;,-; · r :?~.-- ~- -.r~ .........
11. CREDITS: A. ENTER TOTAL 1% TAX WITHHELD BY EMPLOYER ..................................
B. ENTER QUARTERLY PAYMENTS MADE TO THIS BUREAU ..............................
IF MNE 11C IS LARGER THAN MNE 10, ENTER REFUND DUE HERE ?; W"';?;.:':./~";2-~ '.:; .- .~ 5 :.;:?~.':;-';;~ ~'~?~ ~, :. ; , ; '.~ ~' .; . 12~ ~" '.,~ "-?'%"72~::;;':~'~'~" -*'?* ~"'~':7'~'...' ,, .~i; ~.,':
.,~: '-';: Of L~ than $1.00 Enter Zero) , ,. ,; -... , ~ ;;: ':, ,- :~ , ~:.? :.:~ ::..~', ?;;7:'.i:~'. '~.."/~' .~: ·, ~..i~. ~.' .~.; . '~ '; .',:~ , ~. ~:' ~ ' . · . . " , ,;: ..,'.:.
13. IF LINE 10 IS LARGER THAN LINE 11C, PAY UNPAID BALANCE BY APRIL 15 ............................ 13, ~) 9 ].
(If Less than $1.00. Enter Zero)
15. PAY BALANCE DUE WITH THIS RETURN (llne 13 plus Line 14) .................................. 15, 2
OLD MAILING ADDRESS - LIST ~V'tNG INFORMATION ~OR 2001 TAX YEAR BELOW TWP/BORO PERIOD LIVED HERE
/ / TO / /
/ / PRESENT
,:Ff T HEREON IS CORREC
TAX PREPARER'$ NAME TELEPHONE NUMEER OATE TAXPAYER'S SIGNATURE TELEPHONE
17:~-20-3373 Q 2001 FINAL RETURN F0R EARN~ED I~C0ME TAX ~,~
WESTAB FORM 531 (REV. 11/01) ,,~ _ .-%, ~¢...~:. '-.~,"~-~'~"-"- ' !
.,..,~ '~ ~ .,_.
REFERENCE NO.
................................. :;: '~': ::: - '" ~, L O ',12 :;: ::: ¢' - 0 = c ......
2-3e7-~00
KA.=.I ~TSF. ZE~. (DECEASED 3/13/02)
~$D OUR RECORDS ~DICATE THAT YOU
050 C:~.~'~..
CA~P ~LL ?A 17' 1~
,-- 3_.~-2920
01276'~
Register of Wills of
CUMBERLAND
INVENTORY
County, Pennsylvania
Estate of KARL B. ETSHIED
also known as
, Deceased
Janice W. ETSHIED,
No. 21-02-0359
Date of Death 03/13/2002
Social Security No. 174-20-3373
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned
no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this
Inventory. I AVe verify that the statements made in this Inventory are true and correct. I/VVe understand that false statements herein
are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Personal Representative
Name of ~ ~
Attorney: Richard W. Stewart Signature: '
I.D. No.'. 18089 Signature: Ja~tf, ce, A~
W.
ETSHIED
Address: P. O. Box 109
Address: 54 Westerly Road
Lemoyne, PA 17043-0109 Camp Hill, PA 17011
Telephone: 717/761-4540
Telephone: 717/737-5980
Dated:
Description
(See continuation page(s) attached)
(Attach additional sheets if necessary)
Value
Total: 6,415.34
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative.
include the value of each item, but such figures should not be extended into the total of the Inventory.
Prepared by the Pennsylvania Bar Association
Copyright lc) 1996 form software only CPSystems, Inc. Form #RW-7 (1992)
Estate of:
Date of Death:
County:
KARL B. ETSHIED
03/13/2002
Cumberland
INVENTORY
CASH:
Benjamin Peters, Payment in
Full for Dental Services
C.W. Donnelly, Payment in Full
for Dental Service
Cash
Charles Acri, Payment in Full
for Dental Services
Dr. Marinah & Dr. Glossner,
Payment for remaining Dental
Clients Karl B. Etshied,
DDS.
Decedent ran a Dentist
Office out of his residence
at 54 Westerly Road, Camp
Hill, PA. This residence is
a joint asset with his
surviving spouse, therefore
is not listed on this
Return. The business
address of 111 North 32nd
Street was an alleyway
behind the prime residence
at the time of his death.
Decedent filed Chapter 11
Bankruptcy and the only
asset of the business was
the Client List and sold to
a local office. Income
taxes for the past 4 years
have been attached.
65.00
72.00
307.00
72.00
2,5OO.00
Dr. R.A. Debro, Payment for
Dental Services
14.00
Gayle Wagaman, Partial Payment
for Dental Services
51.00
Harry Stephenson, Payment for
Dental Services
525.0O
JAMES ROBERTS, Partial Payment
for Dental Services
275.00
Morgan Stanley Money Market
Account
95.87
Nancy Schultz, Payment in Full
for Dental Services
127.00
Waypoint Bank Checking Account
No. 3100003082
2,256.47
William Watson, Payment in
Full for Dental Services
55.00
6,415.34
TOTAL RECEIPTS OF PRINCIPAL ...............
6,415.3A
-2-
BUREAU OF ZNDZVZDUAL TAXES
TNHER][TANCE TAX DZVXSTON
DEPT. 180601
HARRTSBURG, PA 17118-0601
COHNONNEALTH OF PENNSYLVANZA
DEPARTNENT OF REVENUE
NOTZCE OF ZNHERZTANCE TAX
APPRAZSENENT, ALLOWANCE OR DZSALLOHANCE
OF DEDUCTZONS AND ASSESSNENT OF TAX
RICHARD N STENART
JOHNSON ETAL
PO BOX 109
LEHOYNE
PA 17045
RE¥-1547 EX AFP (01-0S)
DATE 03-05-2003
ESTATE OF ETSHIED KARL B
DATE OF DEATH 03-13-2002
FZLE NUNBER 21 02-0359
COUNTY CUHBERLAND
ACN 101
Aeoun4: Rom/4:4:ed I
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
RESISTER OF NILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THZS LZNE ~ RETA]:N LONER PORTZON FOR YOUR RECORDS ~
REV-1547 EX AFP (:01-03) NOTZCE OF ZNHERZTANCE TAX APPRAZSENENT, ALLONANCE OR
DZSALLONANCE OF DEDUCTZONS AND ASSESSNENT OF TAX
ESTATE OF ETSHTED KARL B F]:LE NO. 21 02-0359 ACN 101 DATE 03-03-2003
TAX RETURN HAS: (X) ACCEPTED AS F/LED ( ) CHANGED
RESERVATZON CONCERNTNG FUTURE /NTEREST - SEE REV~.AS£
APPRAZSED VALUE OF RETURN BASED ON= ORIGINAL RETURN
1. Real Es4:a4:o (Schedule A) (1)
2. S4:ocks and Bonds (Schedule B) (2)
3. Closoly Held S4:ock/Par4:norship Zn4:eros4: (Schedule C) (3)
~. Nor4:gages/No4:os Receivable (Schodule D) (~)
5. Cash/Bank Deposi4:s/Hisc. Porsonal Propor4:y (Schedule E) (5)
6. Jo/n4:ly O~ned Proper4:y (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. To4:al Asse4:s
APPROVED DEDUCTZONS AND EXENPTZONS:
9. Funeral Expenses/Ada. Cos4:s/M/sc. Expanses (Schedule H) (9)
10. Deb4:s/Mor4:gago Liab/1/4:/es/L/ons (Schedule ~) (10)
11. To4:el Deduc4:/ons
12. Ne4: Value of Tax Re4:urn
6;415.3~
.00
.00 NOTE: To /nsure proper
.00 cred/4:4:0 your accoun4:,
.00 sub.i4: 4:he upper por4:/on
.00 of 4:h/s fora w/4:h your
.00
(8)
6,919.19
14~606.82
(11) 21.52~.0]
(12) 15,110.67-
15.
NOTE:
Cher/4:ablo/Governmen4:al Boques4:s; Non-elec4:od 911:5 Trus4:s (Schedule J) (13) . O0
Ne4: Value of E s4:e4:e Sub.~ec4:4:0 Tax (1~) 15,110.67-
'r.f an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that lnclude the total of ALL returns assessed to date.
ASSESSNENT OF TAX:
15. Aeoun4: of L/ne 1~
16. Amoun4: of L/ne 1~ 4:axable a4: L/noal/Cless A ra~e
17. Amoun4: of L/no lq
18. Amoun4: of L/ne 1~
19. Principal Tax Due
TAX CREDZTS:
PAYH~NT RECEIPT DZSCOUNT
DATE NUNBER ZNTEREST/PEN PAZD (-)
(1~), .00 X O0 = .00
(16). .00 X 0~5 = .00
(17) . O0 x 12 = . O0
(18) .00 x 15 = .00
(19)= . O0
AHOUNT PAZD
TOTAL TAX CREDZT
BALANCE OF TAX DUE
ZNTEREST AND PEN.
TOTAL DUE
ZF PA/D AFTER DATE INDICATED, SEE REVERSE
FOR CALCULAT/ON OF ADD/T/ONAL INTEREST.
.00
.00
.00
.00
( TF TOTAL DUE TS LESS THAN $1, NO PAYNENT IS REI~UTRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDIT' (CR), YOU NAY BE DUE
A REFUND. SEE REVERSE STDE OF THZS FORH FOR ZNSTRUCTZONS.)
JOHNSON, DUFFLE, STEWART & WEIDNER
VENDOR: Register of Wills
(OURREF..O. I YOU. INVOICE NUMBER I INVOICE DATE I
139 Etshied ITI 12/12/2002
12/12/2002
CHECK NO: 8239
INVOICE AMOUNT I AMOUNT PAID I DISCOUNT tl
40.00 40.00 0.00
STATUS REPORT UNDER RULE 6.12
Name of Decedent: KARL B. ETSHIED
Date of Death: MARCH 13.2002
Will No. 2002-00359 Admin No.
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rule, I report the
following with respect to completion of the administration of the above-captioned estate:
1. State whether administration ofthe Estate is complete:
Yes
No
x
2. If the answer is No, state when the personal representative reasonably
believes that the administration will be complete: Approximatelv 6 months due
to the discoverv of new assets.
3. If the answer to No. I is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes
No
x
b. The separate Orphans' Court No. (if any) for the personal
representative's Account is:
c.
parties of interest?
Did the personal representative state an account informally to the
Yes No X Surviving Spouse sole
beneficiary
d. Copies of receipts, releases, joinders and approvals offormal or
informal accounts may be filed with the Clerk of the Orphans' Court and may be attached
to this report.
Date: February 8, 2005
;fl/&4}
Signature
L'~~
RICHARD W. STEWART
Name
JOHNSON, DUFFIE, STEWART & WEIDNER
30 I Market Street
P.O. Box 109
Lemoyne, P A 17043
(717) 761-4540
Capacity: Personal Representative
(x) Counsel for Personal
Representative
J
Cumberland County - Register Of wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 2/02/2005
STEWART RICHARD W
3RD & MARKET STREETS
P. O. BOX 109
LEMOYNE, PA 17043
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing will become delinquent on: 3/13/2005
Your prompt attention to this matter will be appreciated.
Thank You.
r~~
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
cc: File
Personal Representative(s)
Judge
~
Curnberla.nd Count~{ - Register of ~^!ills
One Courthouse Square
Carlisle; PA 17013
Phone: (717) 240-6345
Date: 2/02/2006
STEWART RICHARD W
3RD & MARKET STREETS
P. O. BOX 109
LEMOYNE, PA 17043
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by:
3/13/2006
Your prompt attention to this matter will be appreciated.
Thank You.
Si~s:erely '_
#b~lt~aMJ~~
/' ,i
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
cc: File
Personal Representative(s)
Jud.ge
""'"
-
./
/./
//
,p--
In Re: Estate of
ETSHIED KARL B
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 2002-00359
NOTICE OF FAILURE TO FILE STATUS REPORT
Personal Representative: ETSHIED JANICE W
Counsel for Personal Representative: STEWART RICHARD W
Date of Decedent's Death: 3/13/2002
The Orphans' Court record indicates that neither the above named personal representative
nor the above named counsel for the personal representative have filed with the Register of Wills
or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme
Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court
Orphans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Report.
If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of
such delinquency and the undersigned will requests that a Court conduct a hearing to determine
whether sanctions should be imposed upon the delinquent personal representative or counsel for
the delinquent personal representative.
Date:
4/3/2006
~~~
t,. .'
..
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
~
. ...
/
In Re: Estate of
ETSHIED KARL B
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUrvIBERLAND COUNTY
PENNSYLVANIA
NO. 2002-00359
NOTICE OF FAILURE TO FILE STATUS REPORT
Personal Representative: ETSHIED JANICE W
Counsel for Personal Representative: STEWART RICHARD W
Date of Decedent's Death: 3/13/2002
The Orphans' Court record indicates that neither the above named personal representative
nor the above named counsel for the personal representative have filed with the Register of Wills
or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme
Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court
Orphans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Report.
If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of
such delinquency and the undersigned will requests that a Court conduct a hearing to determine
whether sanctions should be imposed upon the delinquent personal representative or counsel for
the delinquent personal representative.
~~~
," "
Date:
4/3/2006
..
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
Register of Wills of Cumberland County
STATUS REPORT UNDER RULE 6.12
Name of Decedent:
kA-RL
P:>
ErSHtcD
Date of Death: \\.\A Rc.~
I '3, .:L 0 Co' ~
Estate No,:
r::J 00 -:J -. co 3~-7
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following
with respect to completion of the administration ofthe above-captioned estate:
1. State whether administration of the estate IS complete:
Yes 0 No I~r
2. If the answer is No, state when the personal representative reasonably believes that
the administration will be complete: _~&;>..,"( ""'^ A\-.~ ~ 1 4" yV) tJ '" if;(.So
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes 0 No 0
b. The separate Orphans' Court No, (if any) for the personal representative's
account is:
c. Did the personal representative state an account informally to the parties in
interest? Yes 0 No 0
c. Copies ofreceipts, releases, joinders and approval of formal or informal
accounts may be filed with the Clerk ofthe Orphans' Court and may be
attached to this report,
Date:
tf)~/o~
('~ Lv
Y'gna~re ' '-
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Name
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2' rSHI ~ I::>
.rJ'i Lv.&. <;,TtRi.-j \'"204.1
Address C! A (Yl P +l ' " f-..., P Ii- j I t. ; I
(?/7.) J ,=$ 7 -~--f?r::;
telephone No.
Capacity: ~ersonal Representative
ITCounsel for personal representative
-r#
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 2/20/2007
KOPE SHANE B
4660 TRINDLE RD
SUITE 201
CAMP HILL, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by:
3/13/2007
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
~~ ,A-;;-f,,"_ .P,
. ~a~
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Personal Representative(s)
~
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 2/20/2007
ETSHIED JANICE W
54 WESTERLY ROAD
CAMP HILL, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
wills a Status Report of completed or uncompleted administration.
This filing is due by:
3/13/2007
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
~~~
1._/
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
q)
Pa. O.C. Rule 6.12 STATUS REPORT
REGISTER OF WILLS OF t l,(l'l ~(..r \~V\ rJ COUNTY, PENNSYLVANIA
Name of Decedent: Kat' I 15 E I ~ ..'e J
Date of Death: 0 -~ I J '0 / b G1- File Number:
2 ()()"2 - (J 0 7 ~
Pursuant to Pa.O.c. Rule 6.12, I report the following with respect to completion of the administration of
the above-captioned estate:
1. State whether administration of the estate is complete: . . . . . . . . . . . . . . . . . . .. DYes 'iNO
2. If the answer is N-o, state when the personal representative
reasonably believes that the administration will be complete:
O I 'ZoA~
() ~V().^f f v
3. If the answer to No.1 is YES, state the following:
a. Did the personal representative file a final account with the Court? . . . . . .. DYes ~o
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
^'(/J
c. Did the personal representative state an account
informally to the parties in interest?.. . . . . . . . . . . . . .. .' . . . . , . . . . . . . . -',Yes DNo
d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be
filed with the Clerk of the Orphans' Court and may be attached to this report.
Dale
3l/ l!i.{ 7-a rJ-:t-
Capacity: ersona Representative ~unsel
S'ylr~ ~ ~ tv ~\e .
Name of Person Filing this Form (
1"0 (t.l~ en;)
Address,
. vi/ie
20 J ( ~ II/a, fA (to r(
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Tekphone .
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FormRW-JO rev. /0./3'06":
~
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 2/11/2008
KOPE SHANE B
4660 TRINDLE RD
SUITE 201
CAMP HILL, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July I, 1992, the personal representative or his counsel, within two
(2) years of the decedent1s death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing lS due by:
3/13/2008
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
'~
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Personal Representative(s)
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
phone: (717) 240-6345
Date: 2/11/2008
ETSHIED JANICE W
54 WESTERLY ROAD
CAMP HILL, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
AE, per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July I, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing 18 due by:
3/13/2008
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
Pa. a.C. Rule 6.12 STATUS REPORT
REGISTER OF WILLS OF Ole u.-h.e....l O-.A....l COUNTY, PENNSYLVANIA
Name of Decedent:
:=DR. ~A\R l
~. E+sh('ed
Date of DeatII:=-=roARc.i--r~~OZ5~Tile NumDei:-760~---:::'~' 3~ 7'
Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of
the above-captioned estate:
I. S tate whether administration of the estate is complete: . . . . . . . . . . . . . . . . . . .. 0 Yes ~;}
2. If the answer is No, state when the personal representative
reasonably believes that the administration will be complete:
GfPI1<D~ I '-L. a. .t-t'" l, &, tIvJ ~-tf?3.
3. If the answer to No. I is YES, state the following:
a. Did the personal representative file a final account with the Court? . . . . . " DYes DNo
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
e. Did the personal representative state an account
informally to the parties in interest? ............................... DYes DNa
d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be
filed with the Clerk of the Orphans' Court and may be attached to this report.
Date0J
':'.1
6 3~ / i~ I c; ~
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NallIe of Person FJ/ing this Form
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Address (
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Telephone .. ./
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For/l1 RW-lO rev. 1013.06
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone:(717) 240-6345
Date:
2/17/2009
c's r.~
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KOPE SHANE B ~~~
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4660
TRINDLE RD - ~
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201
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RI?: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
A~> per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
St1PREME COURT RULES DOCKET NO. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 3/13/2009
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincere]:;y,
N r ~
pp ; ~.
'~~,~i f 7
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Personal Representative(s)
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone:(717) 240-6345
Date: 2/17/2009 r.,
C~ ~~~
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ETSHIED JAN I C E W ; -~ ~ -^~ .- r'
-~ ~:~ r..., r
54 WESTERLY ROAD :
CAMP HILL, PA 17011 __~
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RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET N0. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 3/13/2009
Please feel free to contact this office with ary questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sindrely,
,~ ~
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
- ---- -- -
- __
REGiSTi/R OF ~~"iLLS OF COU_~fTY, PEN:~+SYL~;'?.N?_=~
Nal:ie of Decede•:.t: j\ ~ ~ ~--
Date of Death: ~ ~ ! 3~~ ~~ _ File Number: ~-- --
p,,,,,,,,,, ,,,++,~ D., n (-` D„lo ~ 1 ~ T ,•o n,-+ time f,~lln~x,ino ~u ith recp er.i_ 1_n nnmr~l P_.tlotl Qf t}l e, ad1111T11Stl ati pll of
the above-captioned estate:
f'
1. State whether administration of the estate is complete :.................... Yes p 'No
2. If the answe>~is No, state when the personal representative
reasonably believes that the administration will be complete:
3. Ifthe answer to No. 1 is YES, state the following:
~ ....... ]Yes No
a. Did the personal representative file a final account with the Court.
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
c. Did the personal representative state an account [] No
informally to the parties in interest? ............................... flYes
d. Copies of receipts, releases, joinders and approvals of foT7nal or informal accounts maybe
filed with the Clerlc of the Orphans' Court and maybe attached to this report.
~- __ , ~,
~, ~; ~ ~, t ;~;r~.~~. W Lx.`~.r
Dn~e
Signature of Person Firing the Form f
Capacity: [Personal Representative F~Counsel
~~ ~` ~~ Nnme of Persai Filing this Form
i , ~ ~ ~ - ~ tt Ih
=1'~_,~ i't~~ ~~J Address
Telephate
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Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013 ,-;, ..,
Phone: (717) 240-6345 '' ~ ~"~~~ =~-r '',!`.
.:
ZQiD FED 17 PM 2~ 24
Date: 2/16/2010
KOPE SHANE B
4660 TRINDLE RD
SUITE 201
CAMP HILL, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
C(_ERK ~J1r
ORPH~~~'S ~'(('~~(.~RT
CUti~~ f'r ~ rrlrt! r /~
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 3/13/2010
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
Glenda Farne:r Strasbaugh
Clerk of the Orphans' Court
cc: File
Personal Representative(s)
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
~ `4 1, ~~,~ ' ~ s~~ lam'
aJ1•
n
2010 FEg t 7 p~ 2:25
Date: 2/16/2010
Cf.f:RY ~,;;
()RBI-!~'t~V'S CCUr~T
ETSHIED JANICE W
54 WESTERLY ROAD
CAMP HILL, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, N0. 103
SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 3/13/2010
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
Glenda Farne:r Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
R~C1STiP~ 0: `ViLLS OF
COU'vTi', FLvTiSYLV ~\Ir'1
Name of Decedent:_~~? •• [~ ~* Y?L ~_.- L'____--~ Slf~~ ~ ~ _.-
~ 2eb2 -03~~9
Datz a Deatll:~ ~ rile Iv'u:Tber:
D... ._~ ~„ D.. (1 r^ D .lo ~ 17 T . ,~-f thn f.`ll~~:rino ~;:;th _-~cp?r_t to rntTrl~`,ir~n of Lhe a~nliniitYatioll of
1 lllsU.lal aV L 4. v.\.•. 1\~uv V. ~, + ae~v .v • ••J -
the above-captioned estate: .
1. Mate whether administration of the estate is complete :...........:.... • . • • O Yes ~No
2. If the a~isweris No, state when the personal representative
reasonably believes that the administration will be complete:
3. If the answer to No. 1 is YES, state the following:
a. Did the personal representative file a final~account with the Court? ..... • • Yes ~]No
b. The separate Oi~hans' CourtlvTo. (if any) for the personal
representative's account is:
c, Did the personal representative state an account
iufo.r_Zally to the parties in interest? .:...... ......... ~ []1'es QNO
d. Copies of receipts, releases, joinders and approvals of formal or infonnat accounts may'oe
fled with the Cleric of the Orphans' Court and maybe attached to this report.
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In Re: Estate of
ETSHIED KARL B
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 2002-00359
NOTICE OF FAILURE TO FILE STATUS REPORT
Personal Representative: ETSHIED JANICE W
Counsel for Personal Representative: KOPE SHANE B
Date of Decedent's Death: 3/13/2002
The Orphans' Court record indicates that neither the above named personal representative nor the above
named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans'
Court his, her or its Status Report required by Rule 6.12, Supreme Court Orphans' Court Rule and that the
requisite notice, pursuant to Rule 6.12, Supreme Court, Orphans' Court Rules, is hereby given thaf you have ten
(10) days to file the Status Report. If the required 6.12 form is not filed in accordance with Rule f.12 the Court
will be notified of such delinquency and the undersigned will request that a Court conduct a hearing to
determine whether sanctions should be imposed upon the delinquent personal representative or counsel for the
delinquent personal representative.
Date: 4/20/2010
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
Distribution: Personal Representative
Counsel for Personal Representative
Estate File
2010 APR 20 AM f0~ !
CLERK OF
In Re: Estate'of ~RPH~~~~ C~~~j
CU~fR:~ ~ ~1v~ C;~ . PA.
ETSHIED KARL B
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 2002-00359
NOTICE OF FAILURE TO FILE STATUS REPORT
Personal Representative: ETSHIED JANICE W
Counsel for Personal Representative: KOPE SHANE B
Date of Decedent's Death: 3/13/2002
The Orphans' Court record indicates that neither the above named personal representative
nor the above named counsel for the personal representative have filed with the Register of Wills
or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme
Court Orp~ s' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court
Orphans' Court Rules, is hereby given that you have ten (10) days to file the Status Report. If
the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of such
delinquency and the undersigned will request that a Court conduct a hearing to determine
whether sanctions should be imposed upon the delinquent personal representative or counsel for
the delinquent personal representative.
/~~r-- / `--~
Date: 4/20 t~~~2?t,~C/,~~2~e~.b ~a~.~
/2010
Glenda Farner Strasbaugh ~--
Clerk of the Orphans' Court
Distribution: Persona] Representative
Counsel for Personal Representative
Estate File
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One Courthouse Square
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Phone: (717) 240-6345
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Date: 2/ls/2o11 CUMPFR! ,~~~ C()., PA
KOPE SHANE B
4660 TRINDLE RD ~
SUITE 201 ''
CAMP HILL, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Re~clrt by
Personal Representative under Rule 6.12 is due on the beldw listed
date . ' '
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RU~~$S, NO. 103
SUPREME COURT RULES DOCKET NO. 1, for decedents dying onlclr after
July 1, 1992, the personal representative or his counsel, ',within two
(2) years of the decedent's death, shall file with the R lister of
Wills a Status Report of completed or uncompleted admini gyration.
This filing is due by: 3/13/2011 ',
Please feel free to contact this office with any questio~s you may
have. If you have already filed your Status Report, ple~sle disregard
this notice.
Sin erely,
~ ~~~~
~~
Glenda Farner Str~sjbaugh
Clerk of the Orph ns' Court
cc: File
Personal Representative(s)
nd ~ourity Rl~~~st~f'__~~ Wi11'.s ~'~. ~-
One Courthouse Square
Carlisle, PA 17013
Phone: {717) 240-6345 ~~~
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Date : 2 / l s / 2 011 CUM F~=..~~~#~ ~~ p~
ETSHIED JANICE W
54 WESTERLY ROAD ''
CAMP HILL, PA 17011 ~I
II
~,
RE: Estate of ETSHIED KARL B I~~~
File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Re a,rt by
Personal Representative under Rule 6.12 is due on the be aw listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RU ~S, NO. 103
SUPREME COURT RULES DOCKET N0. 1, for decedents dying on ar after
July 1, 1992, the personal representative or his counsel within two
(2) years of the decedent's death, shall file with the R gjister of
Wills a Status Report of completed or uncompleted admini t~ration.
This filing is due by: 3/13/2011
Please feel free to contact this office with any questio~s', you may
have. If you have already filed your Status Report, ple s~,e disregard
this notice.
Sincerely,
~~
s`'tfi~~~a~~ <
Glenda Farner Strs~baugh
Clerk of the Orph nls' Court
cc: File
Counsel
_ _ _ __
Cumberland County - Register Of Wily;
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 3/22/2011
KOPE SHANE B
395 ST JOHNS CHURCH RD
SUITE 101
CAMP HILL, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
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This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, N0. 103
SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 3/13/2011
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
w
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Personal Representative(s)
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone:(717) 240-6345
Date: 3/22/2011
ETSHIED JANICE W n
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54 WESTERLY ROAD A?`v
CAMP HILL, PA 17011 ~,~
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RE: Estate of ETSHIED KARL B
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File Number: 2002-00359
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 3/13/2011
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
4
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
Pa. O.C. Rule 6.12 STATUS REPORT
REGISTER OF WILLS OF Cumberland
COUNTY, PENNSYLVANIA
Name of Decedent: Karl B. Etshied
Date of Death: 3/13/2002
File Number: 2002-00359
Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of
the above-captioned estate:
1. State whether administration of the estate is complete :.................... ~ Yes ~ No
2. If the answer is No, sTaii=when the personal representative
reasonably believes that the administration will be complete:
3. If the answer to No. 1 is YES, state the following:
a. Did the personal representative file a final account with the Court? ....... Yes. ~ No
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
c. Did the personal representative state an account
informally to the parties in interest? .........................
Yes ~N
......
o
d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be
filed with the Clerk of the Orphans' Court and may be attached to this report.
Date 4/20/11 ° (~ , ~p~~
Sign a of Person Filing this Form
.~~ Capacity: Personal Representative Counsel
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Janice W. Etshied
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~ Name of Person Filing this Form
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!~'~ 54 Westerl Road
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v Camp Hill, PA 17011
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FormRW-/0 rev. 10.13.06 `\' 'V
Reset .
PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVA1~tIA
Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in
support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appropriate form:
Decedent's Information File No: ~ ~' y ~ ~ ~ '3 5
Name: KARL B. ETSHIED (Assigned by Register)
a/k/a:
a!~/a: Social Security No:: 17420-3373
a/kla: Age at death• 74
Date of Death: March 13 2002 State) with his/her last
Decedent was domiciled at death in Cumberland County, °e""Q"t`ania (
principal residence at mty, Township or Borough Coaety
Street address, Post Office and Zip Code
,~„ °---. ~ Cumberland PA_
Camn iau+ n~+~u~=
Decedent died aC 54 Waste City, To~roahip or Borough County ~u
Street address, Post Ottice and Zip Code
Estimate of value of decxdent's property at death: S
. All personal property S
If dotnfttif~ fn Pennsyfvanfa.. • • • • • • • • • • • • • • • • ' ' ' ' • • ~ • • ,Personal property in Pennsylvania
If not dotniclfed fn Penrtsyfvrrnfa ................ • • • • • ' ' .Personal property in County ~
If not dontfclled fn Pennsylvania ....................... ................................... S 157.6R0_il(L,
Value of rest estate fn Pennsylvanfa ...................... .
TOTAL ESTIMATED VALUE.... E 157.680.
Camp Hill Borouglt Gyitilberland
Real estate in Pennsylvania sit~ted at 54 Westerl Road qty, Township or Borough Coaaty
(Anach additional sheets. f necessary.) Street address, Post Office aad Zip Code
~"~ A. Petition for Probate and Grant of Letters Testamentary
Petitioner(s) aver(s) hdshe/they isiare the Executor(s) named m the last Wtll of the Decedent, dated March 23, 1978 and Codicil(s)
thereto dated
State relevsat circarostsaces (ag. reaanctatton, dsath ojexscutar, ata)
Except as follows: after the execution of the instrumept(s) offered for Probate Decedent did not marry, was not divorcee
divorce proceeding wheroin the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8), and
adopted; and Decedent was neither the victim of a killing nor ever adjudicated en incapacitated person.
Q NO EXCEPTIONS Q EXCEPTIONS
B. Petition for Grant of Letters of Administration (I ~ a P~ b ~la~ b:n.c.t.at pendente ills,
If Administration c.~a. or db.n.c.~a.,
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ar aparty~t ptutc~
have a ~ borri,~
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to a endin divorce proceeding wherein the grounds for divot~e had been. established as defined
Except as follows: Decedent was not a party P $
in 23 Pa. C.S. § 3323(8) end was neither the victim of a killing nor ever adjudicated an incapacitated person.
NO EXCEPTIONS ®EXCEPTIONS
Petitioner(s), after a proper search haslhave ascertained that Decedent left no Wiil and was survived by the following spouse (if any) and heirs (attach
additional sheets, if necessary):
Name ..~.«......o...
Janice L. Bolton Daughter 483 Country Club Rd.
1
Karl B. Etshied Son 54 Westerly Road
Janice Etshied, deceased August 21, 2011 Wife 54 Westerly Road
Came Hill. PA 1701 l
Page 1 0
Fans RW-o1 rev. lo/Il/zoll
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF Cua-berland
Official Use Only
Petitioner(s) Printed Name Petitioner(s) Printed Address
Janice L. Bolton f/k/a Janice L. Etshied 483 Coun Club Road Cam Hill PA 17011
The Petitioner(s) above-named sweats) or affirm(s) the statements in the foregoing Petition are true and correct to the best of the knowledge and belief
of Petitioner(s) and that, as Personal Representative(s) of the Dec a t, the~Peti ' t 'Il well and truly administer the estate according to law.
Sworn to or affirmed and subscribed before Date ` 2 7 •~ Z
me y of D t
sy:
For the RegLtter
BOND Required: Q YES ~'NO
FEES:
Letters ...................... S
( ])Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other ••••••
Automation Fee .............. .
JCS Fee .....................
$
TOTAL .....................
se
Date
Date
To the Register of Wllls:
Please enter my appearance by my signature below:
Attorney Signaturo:
~•
Printed Name: Brid et M. Whitl , Es . ~
Supreme Court ~ ' ~
ID Number: 33580 - Z ::a
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Firm Name: SkarlatosZonarich LLC
Address: ~
~jaD•jg~~ PA 17101 ~ --' "p
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Phone: 717-233-1000
Fax: 717-233-6740
Email: 1...s•nnynrtornevpnflji(!t~ rmn _
DECREE OF THE REGISTER
Estate of KARL. B ETSHIED
a/k/a:
AND NOW, _,e~~ in consideration of the foregoing Petition,
satisfactory proof having been pres n ed fore me, 1(T IS DECREED that Letters of Administration DBNCTA
are hereby granted to Janice Bolton f/k/a Janice L. Etshied
in the above estate ami (if applicable) that
the instrument(s) dated
described in the Petition be admitted to probate and filed of r cord as the last W ill (and Codicils of Decedent.
egister of W'lls
Form Rw-oa ,•ev. ~attnoir ge 2 of 2
File No: a f " ~'~ - D35 9
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SkarlatosZonarich LLC ~ "'
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Bridget M. Whitley, Esq. ~ T C ~ O
Skarlatos & Zonarich Building
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17 South Second Street, 6`h Floor
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Harrisburg, Pennsylvania 17101 V-~
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Telephone: (717)233-1000 '~
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Facsimile: (717) 233-6740 Oc
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Email: bmw@skarlatoszonarich
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Attorney for Janice L. Etshied Bolton, ~
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Administrator d. b. n. c. t. a. of the ~
Estate of Karl B. Etshied, deceased
REGISTER OF WILLS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 21 - 02 - 0359
ESTATE OF KARL B. ETSHIED, DECEASED
PRAECIPE TO ENTER APPEARANCE
TO THE PROTHONOTARY:
Kindly enter my appearance as attorney for Janice L. Etshied Bolton, Administrator,
d. b. n. c. t. a. of the Estate of Karl B. Etshied, deceased in the above captioned matter.
SKARLATOS & ZONARICH LLc
Dated: June 28, 2012
By:
Bridget .Whitley, Esquire
Identification No. 33580
17 South Second Street, 6`h Fl.
Harrisburg, Pennsylvania 17101
(717) 233 - 1000
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone:{717) 240-6345
Date: 2/14/2013
KOPE SHANE B
395 ST JOHNS CHURCH RD
SUITE 101
CAMP HILL, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
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This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, N0. 103
SUPREME COTJRT RULES DOCKET N0. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 3/13/2013
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this noticE~.
Sincerely,
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Personal Representative(s)
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone:(717) 240-6345
Date: 2/14/2013
WHITLEY BRIDGET M
SKP•RLATOS & ZONARICH LLP
17 S 2ND ST 6TH FLOOR
HARRISBURG, PA 17101-2039
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
Dear Sir/Madam:
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This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below .listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 3/13/2013
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Personal Representative(s)
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone:(717) 240-6345
Date: 2/:14/2013
BOLTON JANICE L
483 COUNTRY CLUB ROAD
CAMP HILL,, PA 17011
RE: Estate of ETSHIED KARL B
File Number: 2002-00359
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Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Regist;er of
Wills a Status Report of completed or uncompleted administrat;ion.
This filing is due by: 3/13/2013
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
~~
Pa. O.C. Rule 6.12 STATUS REPORT
REGISTER OF WILLS OF _ ~ V~ YY1 ~ ~ I /(~ ~ COUNTY, PENNSYLVANI A
Name of Decedent:
Date of Death:_ ~ ' ~ 2j ~ ~i ~ File Number: c~ ~ ~ <~ ~Q ~ J
Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of
the above-captioned estate:
1. State whether administration of the estate is complete :.................... Yes ^ No
2. If the answer is No, state when the personal representative
reasonably believes that the administration will be complete:
3. If the answer to No. 1 is YES, state the following:
i
a. Did the personal representative file a final account with the Court? ....... `Yes ^ No
b. The separate Orphans' Court No. (if any) for the personal ~n /S
representative's account is: ~q1X U ` ~ v
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c. Did the personal representative state an account ,,,~
informally to the parties in interest? ............................... 'Yes ^ No
d. Copies of receipts, releases, joinders and approvals of formal or informal accounts tnay be
filed with the Clerk of the Orphans' Court and may be attached to this report.
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FormRW-/0 rev. l0.l3.OG
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483 Country Club Rd
Camp Hill, PA 17011
March 12, 2013
Cumberland County Register of Wills
Glenda Farner Strasbaugh
One Courthouse Square
Carlisle, PA 17013
Re: Estate of Karl B. Etshied
File # 2002-00359
Dear Ms. Strasbaugh:
Attached is the completed form RW-10 for my father's estate. I reopened his previously closed estate in
2012 for the purpose of transferring the house deed correctly to my mother so that I could then sell my
mother's house. This was the only purpose~gf reopening his estate. The estate had been previously
closed.
I asked the attorney I used to reopen his estate if there is anything else that I need to do. Their
instructions were- just complete this form and send it in.
If I am required to do anything further to permanently close my father's estate- please let me know.
In addition to my phone # 717-503-2517, I can be reached via email: purpleparis06Ca~vahoo.corn.
Thank you,