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Home My WebLink About10-23-13 (2) � 1505610143 REV-1500 �`�°�-"' PA Department of Revenue OFFICIAL USE ONLY pennsylvania co�cod� Y� Fi�e�un� Bureau of Individual Taxes ��*�+T�� Po Box.2soso� INHERITANCE TAX RETURN 21 13 0193 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 02 04 2013 12 26 1929 Decedent's Last Name Suffoc Decedent's First Name MI NAILOR MARY I, (If Applicable)Enter Survlvfng Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M� Spouss's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WiTH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Retum � 2. Suppiemental Retum � 3, P��der R�2)(Date of Death � 4. Limited Estate � 4a��M��,��e � 5. Federal Estate Tax Retum Required date of death aRer 2-12-82) 0 6' �C�of wiu�te ❑ 7 ��"�� a uving Trust 1 8. Total Number of 5afe Deposit Boxes � 9. Liitlgation Proceeds Reoeived � 10.��P��,��Dea�h � 11.Election to tax u�►der Sec.9113(A) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Dayti�e Telephone�mber WM D SCHRACK III ESQ 71'� �,32 9�3 � r�*t � �, �.-, � c-� .�,., R�S�'EI�F WILLS U�C�Y r�° �`« �y� N �i t`� First Line of Address � L ' x"=' �"� � �' � ` �''� � o c� 124 W HARRISBURG STREET �. � , �-�? '�"+ `'� =� � �n Second Line of Address .�� -�' �~° � _�� --- � t'� � � 3�. ...� G� +C7► DATE FILED � City or Post Office State ZIP Code DILI�SBURG PA 170191268 Correspondent's e-maii address: $chracklaw a('�comcastnet Under pena�of p�rjury.l dedare that I have examined this retum,induding acoompanying schedules and statements,and to the beat ot it is true.coned and oomplete.DeGaration of preparer other than the personal re �'�Y�9e and belief, p�esentaUve is based on ail information of which prepa�+er has any knowledge. SIGNATURE PERSO ESPONSIBL FILING RETURN DATE �� Charles Darr � . , AD RESS 150 Dorsev Lane,Dilisbur�,PA 17019 SIGNATURE THAN REP ENTATNE DATE Wm. D.Schrack III Esq. y� � ADDRE 124 W.Harrisburg Street, Dlilsburg, PA 17019-1268 Side 1 � 1505610143 150561�143 � � 1505610243 REV-1500 EX Decedent's Social Security Number oe�c's N�ns: NAilO�� M11y L. RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................................................................. 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3. 4. Mortgages 8 Notes Reoeivable(Schedule D)........................................................ 4. 5. Cash,Bank Deposits 8 Miscellaneous Personal Property(Schedule E)............... 5. 12 7, 634 . 14 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-V'nros Transfe�s&Miscellaneous I�nq Probate Property (Schedule G) �J Separate Billing Requested............ 7, 8. Total Gross Assets(total�ines 1 through 7)........................................................ 8. 12 7, 634 . 14 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 17,3 0 5. 6 6 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 251 .22 11. Total Deductions(totai Lines 9 and 10)................................................................ 11. 17,5 5 6. 8 8 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 110,0 7 7.2 6 13. Charitable and Govemmentai Bequests/Sec 9113 Tn�sts for which an election to tax has not been made(Schedute J)............................................... 13. 14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 110,0 7 7 .2 6 TAX COMPUTATION-3EE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfe�s under Sec.9116 (a)(1.2)X.00 15. �. 0 0 16. Amount of Line 14 taxable 0 . 0 0 16. 0. 0 0 at lineal rate X .045 17. Amount of Line 14 taxable atsibiingratex.�2 48, 923.24 �7. 5,870. 79 18. Amount of Line 14 taxable at coliateral rate x.�5 61,15 4. 02 �8. 9,17 3. 10 19. TAX DUE................................................................................................................ 19. 15,0 4 3. 8 9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. � Side 2 L 1505610243 1505610243 � REV-1500 EX Page 3 File Number 21-13-0193 Decedent's Complete Address: DECEDENTS NAME Nailor,Mary L. STREET ADDRESS 825 N. Hanover Street CITY STATE ZIP Carlisle PA 17013-1539 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 15,043.89 2. Credits/Payments A. Prior Payments 9,500.00 B. Discount 500.00 Total Credits(A +e) (2) 10,000.00 3. Interest �3� 4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. �4� Check box on Page 2,Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) rJ,043.89 Make Check Pa able to: REGISTER OF WILLS AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transfeRed:............................................................................... x b. retain the right to designate who shall use the property transferred or its income:.................................. x c. retain a reversionary interest;or............................................................................................................... x d. receive the promise for life of either payments,benefits or care?............................................................ x 2. If death occurred after Dec. 12, 1982, did decedent transfer properly within one year of death without receiving adequate consideration?.................................................................................................................... ❑ 0 3. Did decedent own an"in trust fo�' or payable upon death bank account or security at his or her death?....... ❑ Ox 4. Did dec�dent own an individual retirement account,annuity,or other non-probate property which contains a beneflciary designation?.................................................................................................................. ❑ � IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE C;AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994 and betore Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfe�s to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surv'rving spouse from tax,and the statutory requirements for disdosure of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death o�or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. . The tax rate impos�on the net value of transfers to or for the use of the deoedenYs lineal beneficiaries is 4.5 percent,except as noted in [72 P.S.§9116(a)(1)J. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 peroent[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. Rev-150S EXt(��.t0� SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERRANCE TAX RETURN PERSONAL PROPERTY RE3IDENT DECEDENT ESTATE OF FILE NUMBER Nailor Ma L. 21-13-0193 Include theproceeds of' ion and the date the prooseds wers�ceivedby the eatate. All props�ty j noi tly-ovimed�i ths rl�t ofsurvivorship must b�discios�don sch�duls F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Citizens Bank-Certificate of Deposit#6140825830 15.002.71 2 Citizens Bank-Certlficate of Deposit#6246062682 40,001.81 3 Citizens Bank-checking account#6100746828 18.901.11 4 Citize�s Bank-checking account#6230560023 26.928.51 5 Church of God Home-refund 26,800.00 TOTAL(Also enter on Line 5,Recapitulat�on) 127,634.14 (If more space is needed,addi�onal pages of the same size) Copyright(c)2010 form software only The Lackner Group,inc. FoRn PA-1500 Schedule E(Rev. 11-10) REV-1511 EX+(10-0Y) pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERRANCE TAX RETURN RESIDENTDECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Nailor, Ma L. 21-13-0193 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See continuation schedule(s)attached 12,062.66 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zi� Year(s)Commission Paid 2. Attomev's Fees Wm. D.Schfa�k III Esq. 4,500.00 3, Family Exemption: (If decedent's address is not the same as Gaimant's,attach explanation) Claimant Street Address Cit�r State Zi� Relationshi�of Claimant to Decedent 4. Probate Fees 265.50 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. Other Administrative Costs 477.50 See continuation schedule(s)attached TOTAL(Also enter on line 9,Recapitulation) 17,305.66 Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER _ Nailor, Mary L. 21-13-0193 ITEM NUMBER DESCRIPTION AMOUNT Funeral Exne,�n,s_es 1 Cocklin Funeral Home 12.062.66 H-A 12,062.66 Other Administrative Costs 2 Clerk of Orphans'Court-Release fee 16.00 3 Miscellaneous expenses during period of administration 25.00 4 Register of Wills(Short Certificate,lnventory,Inheritance Tax Returnj 33.00 5 Reserve for future administrative expenses 250.00 6 The Cumberland Legal Journai(estate advertisement) 75.00 7 The Diiisburg Banner(estate advertisement) 78.50 H-B7 477.50 Copyright(c)2002 form soflware only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98) Rw-1512 EX+(12-OS) scHEOU�E � pennsytvania DEBTS OF DECEDENT, DEPARTMENT OF REVENUE INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Nailor,Ma L. 21-13-0193 Rsport debts incurred by the deced�nt prior to death that romain�d unpaid at ths dab af d�dh,ineludn�unrotmbursed n�dMN exp�nsa. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Church of God Home-balance due on monthly fees 152.92 2 Citicard account ending in 4884 98.30 TOTAL(Also enter on Line 10,Recapitulation) 251.22 (If mone space is needed,additionai pages of the same size) Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev.12-08) REV-1513 EX+(01-10� pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Nailor, Ma L. 21-13-0193 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE OUNT OF ESTATE NUMBER PERSOPI(S)RECEIVING PROPERTY DECEDENT �yyo�$� csaa� I TAXABLE DISTRIBUTIONS (include outright spousal ' distributions,and transfers under Sec.9116 a 1.2 1 Charles Darr Brother 1/9 interest 150 Dorsey Lane Dilisburg,PA 17019 2 Marlin A.Darr Brother 1/9 interest 918 Wakefield Avenue Mechanicsburg,PA 17055 3 Ada Joann Ent Niece 1/9 interest 4833 E.Trindle Road,Apt 562 Mechanicsburg,PA 17050 4 Dolores Fickes Sister 1/9 interest 506 E.Elmwood Ave.,Apt 2 Mechanicsburg,PA 17055-4232 5 Frances Freebum Sister 1/9 interest 337T Fox Run Rd,Suite 1 Dover,PA 17315-3770 See continuation schedule attached Continuat�on Total Enter doliar amounts for d�tributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet as a ro riate. NON TAXABLE DISTRIBUTIONS: II• A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHE Copyright(c)2010 form software only The Lackner G�oup,Inc. Form PA-1500 Schedule J(Rev.01-10) SCHEDULE J BENEFICIARIES (Part I,Taxable Distributions) ESTATE OF: Mary L.Natlor 02/04J2013 187-30-0118 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) (�aa) 6 Gerald Nailor Nephew 1/9 interest 325 Randall Avenue Bellevue,OH 44811-1862 7 Kerwin Nailor Nephew 1/9 interest 1427 Gertrude Avenue Ph�nixville,PA 19460-1452 8 Wilmer Nailor Nephew 1/9 interest 1186 6ettysburg Plke Dillsburg,PA 17019 9 Barbara A.Sidle Niece 1/9 interest 14S W.Lisbum Road Bowmansdale, PA 17008 1 I ` JudgelJanet\WILLSINAILOR,Mary(js� f I E I ' I f � �� t .� , �xC� �'��CC.� �� I � � � � oF , � � ; MARY L. NAILOR ; i � � , I � , � BE IT R.EMEMBER.ED, that I, MARY L. NAILOR, unremarried widow, presently of � j 1194 Gettysburg Pike, Dilisburg, Carroli Township, York County, Pennsylvania, being of sound � � mind, memory, and understanding, do make, publish, and declare this as and for my Last Will and � Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore made. f ITEM 1: I direct that my hereinafter named Executor pay a11 my just debts, my funeral � ( expenses, and the expenses of the administration of my estate. With this direction, I authorize and � empower my Executor to expend for my funeral expenses and interment such amounts as may be considered necessary and proper, without regard to any limit that may be prescribed by a court of � law. � i I � ITEM 2: I direct my Executor to pay all inheritance,estate,succession,and legacy taxes I � of whatsoever nature and kind,to which my estate or the transfer of any property passing hereunder � , � ; or otherwise passing by reason of my demise, may be subject and to charge such taxes against my , � I , residuary estate, it being my intention that none of the aforesaid taxes, either federai or state, on any property required to be included in m ross estate under the �'` � Y g , prov�sions of any state or federal law i � now in force or hereafter enacted, shall be prorated among the persons interested in m es y tate to � � . , whom such property is or may be transferred or to whom any benefit accrues. , � ITEM 3: I direct that my Executor hereafter named divided my net residuary estate into � nine(9) equal shares, to be distributed as follows: � A. One (1) share unto ADA JQANN ENT, of Camp Hill, Pennsylvania; I ; B. One (1) share unto WILMER NAILOR, of Dillsburg, Pennsylvania; ' i I 1 i � , C. One(1) sha.re unto BARBARA A. SIDLE, of Bowmansdale, Pennsylvania; D. One(1) share unto KERWIN NAILOR, of Broomall, Pennsylvania; E. One(1) share unto GERALD NAILOR, of Ohio; F. One(1) share unto FRANCIS FREEBURN, of Dillsburg, Pennsylva,riia; G. One (1) share unto CHARLES DARR, of Dillsburg, Pennsylvania; H. One(1) share unto DOLORES FICKES, of Wheeling, West Virginia; and I. One (1) share unto MARLIN A. DARR, of Mechanicsburg, Pennsyivania. ITEM 4: I appoint my brother, C.HARLES DAItR, as Executor of this my Last Will and Testament, directing that he not be required to give bond for the faithful performance of duties in this or any jurisdiction. ,, : IN WITNESS WHEREOF, I have hereunto set my hand and seal this �� jrL.t�. day of i� ('E % �' `� -�s��'1 - , 2004. i-;�-- ._ � - ��.___...• ., oC, 4��. MARY . NAILQR The preceding instrument, consisting ot this�and one(1)other typewritten page, was on the day and date thereof signed,sealed, published, and declared by the Testatrix herein named,as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other, have subscribed our names as witnesses hereto. ,� � � OF �'` ,,� e � �_� � � ,�� t ,, ., � ;�', r � �. t _ � :�,y �.,,oF r�..,,� � �--�l��'� ; ,. . , ' Page 2 COMMONWEALT.H OF PENNSYLVANIA • : � C4UNTY OF YURK �• -'� . /' � r %, r ;f /'%`'', We, MARY L. NAILU , :��,� }�.� , � -� '�`F � �2_ c�� :�- , and ,: , ,:. ...��.. �`' ' �'�'� ''�' �--l%:-�:.- �.� , the Testatrix and the witnesses �. (.t-i�' `-.�'. t F L. . � � res eet vel ,whose names are si ned�o the attached or fore in ' P Y g go g instrument,being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signzd and e;�ecuted the instrument as her Last Will and Testament, and that she signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testa#rix signed the Will as witnesses, and that to the best of their knowledge, the Testatrix was at the time eighteen(18)years of age or older,of sound mind, and under no constra.int or undue influence. � c�� MARY �. AILOR �j.=' � / ` :'' ;i'a ,� � ; I �r i SWORN TO AND SUBSCRIBED � BEFQRE ME THIS ��t lf,DAY ,. -`_. �^;`�'r ��_�•�i��.� ,2004. . � r 1�, .�,� � � � �� f : 1 /�:,r �� , J r�� 1 ` +. � � ` �,�'�..� +' ;` �'�"�, �' �� 1�TOTA�tY U �LIC i � �s se� ,�t s.c��,�►p� Df�tx�rg Bc�o,Y+xk Cvt�ty �Y�n+��E�tr�s O�ct.25,2006 A�lember.P�ernsYh►'astifo Assocta�ori Of No�les .�.�,, REV-485 EX(05-04) �, - 4 8 5 0 0 0 410 4 6 SAFE DEPOSIT BOX INVENTORY . PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death County Code Year File Numbe� 187-30-0118 02/04/2013 21 13 0193 __ __ ____. ...... Suffix First Name DecedenYs Last Name M� NAI LOR MAR.Y L. ___ _ _ _ .. . �AODRESS OF DECEDENT STREET: Cl7Y: STATE: ZIP CODE: 825 N. Hanover St. t. 308 Carlisle PA 17Q13 NAME AND ADDRESS OF PERSON REQUESTING TFiE OPENlNG OF THE SAFE DEPOSIT BOX NAME: �. D. Schrack I I I, Esquire STREET ADDRESS: CITY: STATE: ZIP CO : 124 W. Harrisbur St. Dillsbur PA 17019-��L68 � NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING a. NAME: RELATIONSHIP: Char.les.�.,�ars ExecutorLBrother STREET ADDRESS: CITY: STATE ZIP CODE: _150 Dorse�Lane __ Dillsburg PA 1701J b. NAME: RELATIONSHIP: STREETADDRESS: CITY: STATE: ZIP CODE: C. NAME: RELATIONSFi1P: . STREET ADDRESS: CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: � Citizens Bank STREET ADDRESS' 1 ' CITY: STATE� ZIP CODE: 4 S. Baltimore St. Dillsbur PA 17019 . NAME OF PERSON MAKING LAST ENTRY /� DATE AND TIME OF LAST EN7RY , .,:1 f ��/�� i,..��' r��'' l• ?i'�;�:��. � •n ��. <:_,,r� : DATE O CONTRACT TO RENT BOX ' NUMBER OF BOX 1 TITLE UNDER WHICH BOX IS REQUESTED ' • ,%`��• 344 ��/�r �, <=:.� '�; NAME AND ADDRESS OF PER ON(S)HAVING ACCESS TO BOX % ,�, a. NAME :, J b. NAME �/ h '}� ` /1 / / t� �_. � - —�-��f �` �-1'-� '��i �,/ {--c..':A�� _.' _,�_.n�!�7''��-^/.�.-. �.:�,J� j�-Ll.i'_�L,._.. STR�ET ADDRESS: - `'� STR��T ADDRESS�_ / �.---�,, ,,� /�� ( l � `�.(..1(c;'��Y' (k'�'', ir�-c;.)r'Z.. f tJ C?�� -�! � :'� ;_' ,� -• ,� o �. _____ -�t''�------ --�1`-�----��%' --��-�-�-�r----�%�° C��'� , c n STATE: ZIP CODE: CI • � ST T M�P CODE: .. , • .. - ZI n�;'r� . , ._ : - i T�� ..��. L�. (�� ::;' � !��-•`��'.'`%�.,�' �� (:,,`r`y'�.: �"'�,:,� �,.'' r ( ' NAME AND TITLE OF EMPLOYEE 7AKING THE INVENTORY WAS A WI�L IN THE BOX? ❑ YES (�rNO If yes, a. Date of wip: � , �t c;,s� c.:"37 -�-� c l.� . G..<:/....i b. Name and address of personal representative,if named in the wiil "-- NAME� �'�CP�/�r'�(" G"i/t"c�.� <-j C:,f�.•�/,� STREET ADDRESS: � CITY: STATE: ZIP CODE c. Name and address of attorney,if any NAME: STREET ADDRESS: CiTY• STATE: ZIP CODE: � 4850�041046 48500041,046 � REV-485 EX SAFE DEP4SIT BCJX INVENT4RY Pag� of __ INSTRUCTIONS (1) Cash:Report total only. (2) Stocks: List in detail every common or preferred certificate,warrant or other rights found in box.Stocks are to be designated by name oi'company,certificate number,date of certificate,name in which stock is registered,and number of shares and class of stock. (3) Obligations of U.S.Government: Number of items,date of issue,face value,names in which registered and type of ownership, i.e.,jointly held,payable on death,etc. (4) Bonds: Designate by name,amount,serial number,or other designation.(Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor,number of book,last date appearing in baok,name of bank and branch,and balance. (6) Jewelry,Coins,Stamps, Manuscripts,etc:List and describe as fully as possible. (7) Deeds,Mortgages,Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) Atl other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT.280601 HARRISBURG,PA 17128-0601 ITEM NO. ITEM DESCRIPTION . J�;,.��r��'�-i, �'�; f�'._� .�."�C:.} .�,�:�.� �'�'�-�--� � ��-_ C.� '�Z,., � ._ 1 CERTIFY UNDER PE.NALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT AND C PLE E TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY: SIGNATURE ��' _�_ - SIGNATURE ,.�� •,,_ �,,;.%' " s c•,r'`��.�w PRlNT NAME " - f ;`� ,..-r--• PRINT NAME AND CHECK APPROPRIATE BOX BELOW: ! / - ,r�,; _�'��_a��;� �,..%��. RINT TITLE DATE CHECK APPROPRIATE BOX: — 1 -- �! �� []Executor(trix) �Administrator(trix) � � G�� 7 ! � .,'; �' �- ��_ �state Represeniative �Joint owner ot safe deposit box NOTE:Aftach additional 8'/�"x 11"sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law,42 U.S.C.§4Q5(c)(2)(C}(i),to require disclosure of Social Security numbers in connection with administering state tax laws.The Department uses the Social Security number lo identity the decedent and personal rep�esentatives of the estate.The Commonwealth may also use the information in exchange of tax informa6on agreements with Federal and local taxing auihorities.The state law prohibits the Commonweallh's ersonnel from disclosin confiderttial tax infonnaGon exce t for official purposes. ' � , ,ir �� .��: ':>, �� Account Number 6100746828 Account Title Mary L. Nailor Date Opened 6/6/1966 Account T e Checkin Princi al Balance as of DOD $18,900.91 In�terest from Lasi Postin to DOD $ .20 Account Balance as of DOD $18,901.11 YTD Interest to DOD $ .32 � . . �� _. � .. ,� ��r��` �� _,. �� Account Number 6230560023 Account Title M L. Nailor Date O ened 6/8/2010 Account T e Checkin Princi al Balance as of DOD $26,927.76 Interest from Last Posting to DOD $ .7S Account Balance as of DOD $26,928.51 YTD Interest to DOD $1.23 � ' � �� °� ,� � Account Number 6140825830 Account Title Ma L. Nailor Date ened 8/24/2001 Account T e Time De osits Princi al Balance as of DOD $15,000.00 Interest from Last Postin to�OD $2.?1 Account Balance as of DOD $15,002.71 YTD Interest to DQD $7.01 �,� �- �. � ��*y � � : w �. .� :' ��.��' ��' _.. � ` Account Number 6246062682 Account Title Ma L. Nailor Date O ened 5/26/2005 Account T e Time De osits Principal Balance as of DOD $40,000.00 Interest from Last Postin to DOD $i.81 Account Balance as of DOD $40,001.81 YTD Interest to DOD $5.10 � . .. _..__. . �--. ... . _... .. . ._..... . .__.._ . _.._.. . . .. - Vendbr Code: oo�ss�t _ vendor code OO19f14 . Withheia. Nst:Amount Estate of Marv Naelor �,ou�� oi�,,,,� Descrfption Date 2 6,800.00 Invoice No. 0.0 0 0.0 0 07/O1/2013 26,800.00 07012013 Entrsnce Fee Refund � . � s: 26 800.00 0.00 0.00 26,8,0�.00 Check i�: 0000040027 Totai ► ,,,,...�,_...�a�_.�_ ��....� CheckDate: 07/05/2013 . „�..._� ,.,..,.,___ .....__�_.�_..,,_�_ ..�.---�-��_��,___ . . _.,._..,,_.. ... .., .... ,.. . � - ,,,.,. ... ,.� ... . ... _ . ..,. .. ..,. ..,. .. ..,. . �- �� 1�: r' Q�' �•�' � �� ,no�� i� v. � �� mL� 1