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Home My WebLink About11-08-13 , . � � 1505610105 REV-1500 EX�02-1',`FI,�' enns tvania OFFICIAL USE ONLY PA Department of Revenue P Fpx ME Y Counry Code Year File Number Bureau of Individual Taxes pINHERITANCE TAX RETURN Po Box z8o6oi 21 12 12 91 Harr;sbury,PA 1�128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 208-42-4397 11/07/2011 01/23/1955 Decedent's Last Name Suffix DecedenYs First Name MI Steever ' Charles E (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number ; THIS RETURN MUST BE FILED IN DUPLICATE WITH THE _ _ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW p 1. Original Return � 2.Supplemental Return O 3. Remainder Return(Date of Death Priorto 12-13-82) p 4. Limited Estate O 4a. Future Interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Paul D. Edger, Esquire (717) 591-1755 � � � �.. , �Ci�TER OF WILLS US�N�B � �. G3 p � c-, Clp .ro � Cl7� :x) First Line of Address � � � � � f�l 5006 East Trindle Road r �'- � � � �' 3" t!� � �, C� Second Line of Address p � � "� 'T► � � �-y `.,.� � Suite 203 � G �. � C'� � !'� DATE FILED ~� rn City or Post Office State ZIP Code � �� Mechanicsburg PA 17050 }' � � CorrespondenYs e-maii adaress: pedger@pjrlaw.com alties ry,I declare t I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it i true,c rect an co D aration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI N E OF R RE SIBL FILING RETURN DATE ADDRESS 500 . Trind ad, Suite 203 Mechanicsburg, PA 17050 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610105 15�5610105 J � 1505610205 REV-1500 EX(FI) DecedenYs Social Security Number �eoeae�c�s Name: Charles E. Steever 208-42-4397 RECAPITULATION 1. Real Estate(Schedule A). . .. . .. .. . ... .. .. . . .. .. .. .. . .. . . . . . . ... .. .. . . 1. ' 0.00 2. Stocks and Bonds(Schedule B) . .. . ... .. .. ... .. . . . .. .. . . .. . . . ... .. .. . . 2 ' 0.00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . . . .. 3. , 0.00 4. Mortgages and Notes Receivable(Schedule D). .. . .. ... .. .. .. ... .. . . .. ... 4. 0.00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). .. .. . . 5. 415.00 ' 6. Jointiy Owned Property(Schedule F) O Separate Billing Requested .. .. . . . 6. 0.00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property ' (Schedule G) O Separate Billing Requested.. .. .. .. 7. 0.00 8. Total Gross Assets(total Lines 1 through 7). ... .. ... .... . .. .. ... .. .. .. .. 8. 415.00 ' 9. Funeral Expenses and Administrative Costs(Schedule H). .. .. ... .. .. . . . .. .. 9. 89.53 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I).. ... .. . ... .. .. 10. 942.00 11. Total Deductions(total Lines 9 and 10).. .. . . . . ... .. .. .. ... .. .. .. ... . . .. 11. 1,031.53 12. Net Value of Estate(Line 8 minus Line 11) .. .. ... . .. .. ... .. .. .. ... .. .. .. 12. 0.00 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . ..... . . .. .. . . ... ... .. .. 13. 0.00 ' 14. Net Value Subject to Tax(Line 12 minus Line 13) . .. .. ... .. .. .. .... . . . . . . 14. -616.53 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0_ 15. 0.00 16. Amount of Line 14 taxable at lineal rate X.0 45 -616.53 16. -27.74 17. Amount of Line 14 taxable at sibling rate X.12 17. 0.00 18. Amount of Line 14 taxabie at collateral rate X.15 �g. 0.00 19. TAX DUE .. .. ... .. .. .. ... . . .. .. . . . . .. .. ... ... .. ... .. .. . . ... .. .. .. . 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 � 1505610205 150561,02�5 � , ' REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Charles Eugene Steever STREETADDRESS 3448 Walnut Street CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2,�ine 19) (1) 0.00 2. Cretlits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferretl.......................................................................................... ❑ � b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ � c. retain a reversionary interest.............................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If death occurred after Dec.12,1982,tlid decetlent transfer property within one year of death without receiving adequate consitleration?.............................................................................................................. ❑ � 3. Ditl tlecedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ � 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ � IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for 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 surviving spouse from tax,and the statutory requirements for tlisclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For tlates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the chiltl is 0 percent�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 percent,except as noted in[72 P.S.§9116(a)(1)]. . The tax rate imposetl on the net value of transfers to or for the use of the decetlenYs siblings is 12 percent[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-15o8 EX+(08-12) � pennsylvania SCHEDULE E DEPARTMENTOFFEVENUE CASH, BANK DEPOSITS & MISC. I""ER'TA"cETAXRET�R" PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Charles Eugene Steever 21 12 1291 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F, ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH �, Internal Revenue Service: 2010-U.S. Individual Income Tax Return 336.00 2011-U.S.Indivudual Income Tax Return 79.00 TOTAL(Also enter on Line 5, Recapitulation) $ 415.00 If more space is needed,use additional sheets of paper of the same size. , ' � DECEASED � � 1040 2010 �o`_ V.$. Individual Income Tax Return (99) �AS Use Only-Do noS write a staple in thig spate. Name, R Fa the yeat Jan.7-Det.31.2070,a oiher tax yem beginning .2010,ending ,2p OM8 No.154 - 74 Address, � Your first name and initial Last name (DEC. 11/0 7/11) Y�6oclaf security number and SSN N CHARLES E STEEVER 208 :92 :4397 T If a Joint return,Sp0US8's flrst nama and initial LBSt nam2 Spouse's saeiai security number � PAUL D EDGER ES UIRE See � Home address(number and street).If you have a P.O.box,see instructions. Apt no. M�xa a�,e me ssN�s��co„e E separate A C O PAUL EDGER 5 0 0 6 E TRINDLE ROAD SUITE 2 0 3 �and on Ilne Bc are correct. instructions. R City,town a posl oKCe,state,snd ZIP code. Checking e boz below will not L Presidential Y MECHANI CSBURG PA 17�5 0 �n�,aa yoW c�a�ar��a. Election Campaign � Check here if ou,or our s ouse if ffling'ointl ,want$3 to go to this fund ..................... �You �S use Filing Status � Single 4 Head af household(with qualifying person).If the qualifying 2 � Married flling jointly(even if only one had income) person is a child but not your dependent,enter this chiid's Check only 3 �Marrled filing separately.Enter spouse's SSN above name here. ► one box. and tull name here. 5 0�uali in widaw er with de endent child 6a Yoursefi.It someone can claim you as a dependent,do not check hox 6a ................................................ ��„°��y� 1 Exemptions b �s ouse ................................................................................................................................. ..... NO.O!chilWen (3)Dependent's i C� �8c who: c Dependents: (z)oaaB�da�c�esceiai underaqe�7 �r�edwnnyo� relatlonahip to (1)First name lest neme eecurlty number yo�. ��„zC�BdH Child �did not Ilve with you tlue to divoree a separation (eee InaWCtlons) Ii more than four dependents,see oepenaents o+,ec instructions and �oc e�te�ea e�o�e check here ► � Add numbers : m rnes d Total numher of exem tions claimed............................................................................................. ............. �c�a ► 1 InCOme 7 Wages,salaries,tips,etc.Attach Form(s)W-2 .............................................................................. 7 15 5 3 0. Attach Form{sy � Taxable interest Attach Schedule B if required ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ................................................ e ..� W-2 here.Also b Tax-exempt interest Do not include on line 8a ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Sb attach Forms 9a Ordinary dividends.Attach Schedule B if required ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 9e W-20 and b Oualifled dividends ..................................... ......... .............. 9b 1099-R if tax was wlthheid. 1� Taxable refunds,credits,or offsets of state and local income taxes,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 10 11 Alimony received ..................................................................................................................... If you did not 12 Business income or(loss).Attach Schedule C or C-EZ ..................................................................... 12 � get a W-2, 13 Capital gain or(loss}.Ariach Schedule D if required.If not required,check here ,,,,,,,,,,,,,,,,,► � 13 see page 20. 14 Other gains or(losses).Attach Form 4797 .................................................................................... i4 15a IRA distributions ,,,,,,,,,,,,,,,,,,,,, 15a b Taxable amount ,,,,,,.,......,.., 15b Enclose,but do �ga Pensions and annuities ,,,,,,,,,,,, 18a b Taxable amount not attach,any .................. 16b 3 3 9. paymenl.Also, �� Rental real estate,royalties,partnerships,S corporations,trusts,etc.Ariach Schedule E ,,,,,,,,,,,,,,,,,,,,,,,, 17 please use 18 Farm income or(loss}.Attach Schedule F .................................................................................... 18 Form 1040-V. �g Unemployment compensation ................................................................................................... �s 5 770. 20a Social securiry benefits ,,,,,,,,,,,, �20a_f � b Taxable amount .................. 20b 21 Other income.List type and amount 21 22 Combine the amounts in the far ri ht calumn for lines 7 throu h 21.This is our total income ......... 22 21 6 3 9. 23 Educator expenses ..................................................................... 23 Certein business expenses oi reservists,peAorming artists,and tee-basls government Adjusted 24 o�ciata.Attach Fam 2706a 2108-EZ ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Z4 G�oss 25 Health savings account deduction.Attach Form 8889 25 Income ....................... 26 Moving expenses.Attach Form 3903 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 26 27 One-half of self-employment tax.Attach Schedule SE ........................ 27 28 Seii-employed SEP,SIMPLE,and qualified plans ........ .. .. .. .. .. ..... 28 29 Selt-employed health insurance deduction ,,,,,,,,,,,,,,,,,,,,, ,, ,,,,,,,,,,,,, 29 30 Penalry on early withdrawal of savings............................. ... , 30 31a Alimony paid b RecipienYs SSN ► : : 31a 32 IRA deduction ........................................................................... 32 33 Student loan interest deduction ,,,,,,,,,,,,,,,,,,,,, 33 .............................. 34 Tuitlon and fees.Attach Form 8917 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 34 35 Domestic production activitles deduction.Attach Form 8903 ,,,,,,,,,,,,,,, 35 38 Add lines 23 through 31a and 32 through 35 ............ . . .............................................................. 38 oi i00 i� 37 Subtract line 36 from line 22.This is our ad usted roa in ome . 37 21 6 3 9. LHA For Disclosure,Privacy Act,and Paperwork Reduction Act Notice,see separate instructions. Forr�,1040�2oio� , 2013/09/19 11:15 :46 2 /6 �,� Interna l Reven�.e �eivice United States Department of�the Treasury This Product Contains Sensitive Ta�.payer Data Wage and Income Transcript Request Date: 09-19-2013 Response Date: 09-19-2013 Tracking Numl�er: 100172384939 SSN Provided: 208-42-9397 Tax Period Requested: Decemh�er, 2010 ` �� 1 Form W-2 Wage and Tax Statement ►, Employer: Em�,loyer ldentificatic�n Nwuber (EIN) : 271656513 KS P.ENEWAL SYSTEMS 542 INDUSTRIAL DRIVE LEWISBERP,Y, PA 17�39-U000 Employee: F.mployEe's Social Secu!•ity Number: 206-92-93�7 CHARLES E STEEVER 3948 WALNUT STREET CAMP HILL, PA 17011-nnq0 Submission Type: Urigin�l document i Wages, Tips and Other Compensatian: $692.00� Federal Income Tax Withheld: 50.00, Social Security Wages: 5692.00 Social Security Tax Withheld: SA2.00� Medicare Wages and Tips: $692.00� Medicare Tax Withheld: $lO.OW Social Security Tips: 50.00 Allocated Tips: $0.00 Advanced EIC Payment: $0.00 Dependent Care Benefits: �Q p,� Deferred Compe�isation: 50.00 Code "Q" Nontaxable Combat 6ay: 50.00 Cc+de "S�1" Empluyer Centributions *_o a H�alth Saving� RCCOUn?: $0.00 C�xie "Y" Deferrals un�_ier a section 40uF, nonaualiiied Deferred 50.00 ' Compensation plan: Code "Z" Income under section 909?, on a nonqualified DeTerre� ;0.00 Compen�ation plan: Cude "k" Employer's Contribution t�� MSA: $0.00 Cude "S" Emplofer's Contribution r_o Sim��1= Acc•ount: ,p,pp Code "T" Expenses Incurred Yer r�i_��liTi�d Ado��ric.ns: cq,p�1 , 2013/09/19 11:15 :46 3 /6 Code "V" ?ncome from F::ercise of non-statutory stock optiens: $0.00 Cc�e "AA" Designated F.o*_h Con*ributions under n Sectin�; 901(k) Plan: $0.00 Cc�e "BB" Designated P.oth Contributions uncter a Section 4U3(b) Plan: 50.00 Code "CC° (Fer employer use only) - HIRE Er.empt Wages and Tips: 50.00 Third Party SicY. Pay Indicator: Unanswered Retirement Plan Indicator: Unanswered Statutory Employee: Nvt Statutory Employee Form W-2 Wage and Tax Statement Em�loyer: Empleyer ldentifi�:ation Numk�ez {EIN) : 363734669 TP.UGREEI7 LIMITED PARTNEP.SHIF E60 RIDGE LAKE BL MSB� 1103A MEMFHIS, TN "58120-0000 Employee: Employee's SOC1R1 Security tdumber: 208-92-9397 CHARLES E STEEVER 3448 WALNUT ST CAMP HILL, PA ]7011-O�iGO SuLmissi�n Type: Griginal document Wayes, Tips anc9 0*_her Comransation: S14,838.00� Federal In��ome Tai WitYiheld: 51,292.00� Social SECU1-ity S�ages: 515,174.00� Sacial Security Ta�_ Withheld: 5990.00� Medicare Wages and Tips: 515,174.00� Medicare Tax Withheld: 5220.00 � Social Security Tips: 50.00 Allocated Tips: 50.00 Advance�9 EIC Faym?nt: 50.00 Dependent Care Benefits: $0.00 DefErred Compensation: $335.00� Code "Q" Nonta::able Combat Pay: 50.00 Code "W" Employer Contribution° to a Health Savings Account: 50.00 Code "Y" Defarrals under a sectien 409A nonqualified Dererred $0.00 Compensation �lan: Code "Z" Income under section 409A on a nunqualified Deferred 50.00 Compensation plan: Code "R" Employer's Contribution te MS.A: $0.00 Code "S" Employar's Contribution to Simple kccount: 50.00 Cade "T" Expanses Incurred for Qualified Adoptioits: 50.00 Code "V" Income from e�ercise of non-st�tutory stock c�p*ions: $0.00 Cc�de "AA" Designatad koth Contributions under a Sec*_ion 401 (k! Plan: 80.00 Code "6B" Dasignated P.oth Contributi�nti uncler a Sec*_ion 4�J3;b) Plan: 50.00 Cxle "Cr" (For employer use only) - HIRE E::empt l4aqes and Tips: 50.00 Third Party Sick Pay Indi:ator: Unanswered Retirement Plar, Indicetor: .�eG/ , 2013/09/19 11:15 :46 4 /6 Statutory Employee: Not Statutory Employee Form 1099-G Payer: Payer's Federal Identification P7umber (FIN) : '?360G3107 COMMONWEALTH OF PA DEPT UF LAROR S IND OFF OF EMPLOYMENT SECURITY BMIS D 108 7TH A27D EORSTER STS HARRISBURG, PA 17121-OU00 Recipient: Recipient's Iden*_ification Number: �OB-42-4397 STEEVER CHARLES E 349't3 WALtdUT ST CAMP HILL, PA 17011-0000 Submission Type: Original document Account Number IOptiunal) : N/A ATAA Paymnr�ts: 0.00 Tax Withheld: 0.00 Taxable Gran�s: 0.00 Unemployment Compensatior,: S5,770.00� Aqricultural Subsidies: 0.00 Frior Year Refund: 0.00 Market gain on Commodity Credit Corporation loan� zeF�aid 0.00 on ar after January 1, 20�)7: Year of Refun�: tdot Set 1099G Offset: Not Refund, Credit, or Offset for Trade or Business Form 1099-R Distributions from Pensions , Annuities , Retire or Profit-Sharing Plans , IR.As , Insurance Contracts , etc . Payer: Payer's Federal Identificarinn Number (FIN) : 521�?1931 T. ROWE PRICE 4555 PAINTERS MILL RD OWINGS MILLS, MD 21117-nppp Recipient: Recipient's Identification Number: ZOa-42-9:;97 STEEVER, CHARLES E 3948 WA,LNUT ST CAMF HILL, PA 17011-�!�i00 , 2013/09/19 11:15 :46 5 /6 Submission TyP°= Original document Account Number (Optio2-,al): 20110A28143100085252 Distribution Code Value: fiarly Distribution, exception applies (Under age 59 1/2) Distribution Code: Z✓ Distribution Code value: N�t siqnificant Distribution Code: Blank Tax Amount Undetermined C�x�e: Not checked Total Distribution Code: Total Distribution SEP Indicator: IAA/SEP/SIMP box not checked Tax Withheld: 567.00� Total Employee Cantributior,s: 0.00 Unrealized Appreciation: 0.00 Other Inceme: 0.00 Grass Uistribution: 5339.00� Taxable Amount: $339.00� Eligible Capital Gains: 0.00 This Product Contains Sensitive Taxpayer Data • � 6 ' F«,,,,oao r�o1o� CFIARLES E STEEVER 2 0 8—4 2—4 3 9 7 Pege Y Tax and 38 Amount irom Iine 37(adjusted grass income) ................................................................................... ... 38 21 6 3 9. Ct'editS 39a Check r 0 You were born before January 2,1946, � Blind. � Total boxes ih � 0 Spouse was born before January 2,1946, [] Blind. checked .,, � 39a b If your spouse itemizes on a separate return or you were a dual-status alien,check here .. ... ► 39b � 40 Itemlzed deductions(from Schedule A)or your standard deduction(see instructions) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 40 5 7 0 0. 41 Subtract line 40 from line 38 ,,,,,,,,,,,,,,,,, ................. ................... ..................................................... a� 15 939. 42 Exemptfons.Multiply$3,650 by the number on line 6d ........................................................................... 42 3 650. 43 Taxable income.Subtract line 42 irom line 41.Ii line 42 is more than line 41,enter-0 ......... ......... ......... 43 12 28 9. 44 Tax.Check ii any tax is from:a�FOrm(s)8814 b 0 Form 4972 , 44 1 4 2 3. ............................................ .. .. 45 Alternative minimum tax, Attach Form 6251 ....................................................................................... 45 as Add lines 44 and 45..................................................................................... ............................ ► 48 1 4 2 3. 47 foreign tax crediL Attach Form 1116 if required ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 47 48 Credit for child and dependent care expenses.Attach form 2441 ................. 48 49 Education credits from form SB63,line 23 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 49 50 Retirement savings contributions credit.Attach Form 8880 ,,,,,,,,,,,,,,,,,,,,,,,, 50 St Child tax credit(see instructions) .,,,,,,,,,,. ............................................. 51 52 Residential energy credits.Attach Form 5695 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 52 53 Other credits from Form: a 0 3800 b 0 8801 c� 53 54 Add lines 47 through 53.These are your total credita.............................................................................. 54 55 Subtract line 54 from line 46.If Iine 54 is more than Ifne 46 enter-0- ...... .. ► 55 1 4 2 3. ......... ......... ........... Other 56 Selt-employment tax.Attach Schedule SE ............................................................................................. 58 Taxes 57 Unreported social security and Medicare tax from Form: a�4137 b 0 8919 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 57 58 Additional tax on IRAs,other qualified retirement plans,etc.Attach Form 5329 if required ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 58 59 a�Form(s)W-2,box 9 b 0 Schedule H c �Form 5405,Iine 16 ,,,,,,,,,,,,,,,,,,,,,,,,,,, 59 80 Add lines 55 throu h 59.This is our total tax................................................................................. ► 80 1 4 2 3. PaymentS 61 Federal income tax withheld from Forms W-2 and 1099 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Bt 1 3 5 9. TATEMENT 3 62 2010 estimated tax payments and amount applied from 2009 return ,._,...,,... 82 63 Making work pay credit Attach Schedula M ............... .............................. 83 4�0. �+yo�ne�a g4a Earned insome credit(EIC) 84a aqualitying .................................................................. Chifd,ettech b Nontaxable combat pay election ............... 64b Schedufe EIC. B5 Additional child tax credit Attach Form 8812 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 65 66 American opportunity credit irom Form 8863,line 14 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 68 67 First-time homebuyer credit iram Form 5405,line 10 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 87 68 Amount paid with request for extension to tile ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 88 69 Excess social security and tier 1 RRTA tax withheld ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 89 70 Credit for federai tax on fuels.Attach form 4136 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 70 71 Cretlits from Form: a�2439 b�8839 c 08801 d 08885 ,,, 71 72 Add lines 61 62 63 64a and 65 throu h 71.These are our total a ments ....................................... ► 72 1 7 5 9. Refund 73 Ii line 72 is more than line 60,subtract line 60 from line 72.This is the amount you overpaid........................... 73 3 3 6. 74a Amaunt of line 73 ou want refunded to you.Ii Form 8888 is attachedt check here ........................ � 74e 3 3 6. Olractdep09H? ROUtinp �� ACCOU�) Sea � b namber �C Type: � Checkinp �Savinqs �d numOer insuuct�ons. 75 Amount of line 73 ou want a Iied to our 2011 estimated tax ......... ► 75 Amount 78 Amount you owe.SubVact line 72 from line 60.For details on how to pay,see instructions ..................... ► 76 You OWe 7� Estimated tax enal see instructions ................................................ 77 Third Party Do you want to allow another person to discuss this return with the IRS(see instructions}? �Yes.Complate below. No Designee Desipnee�:�L I SA M STATLER noone� �17—5 0 6-12 2 2 P�sonal Identiflcatlon neme number fPIN) �,.7�5� Sign Under penal2les of perJury,I declara th t I have exeminetl thls return and accompanying schedules and statements,and to the best o1 my knowledge end beliei,they aze Vue,carrect, and com lete.Dectaration of pieper (other than taupayer)is based on all inlamallon of whlch preparer hes eny knowledge. Here � � AL REPRES �A�IV Yourxcupation Deylfinephonenumber Joint relum7 ( See page 12. ' f 5 I 3 EALTOR Keep a copy Spouse's sipnaWre. int retum,b01h must aign. Date Spouse'e occupation la your recada. PrinlRype preparer's name Pr arer's aignature\� Dete Cfiedc a if PTIN Paid rn sell-employed Preparer LISA M STATLER ISA M STATLER � 10 14 13 00094609 US@ Oilly Firm's�ame ►WAGGONER FRUTIGER & DAUB LLP FUm's EIN► Z 3 :15 S 3 2 4 9 5006 E TRINDLE RD SUITE 200 Phoneno.717-506-1222 02022�a firm's eddress ►MECHANICSBURG, PA 17 0 5 0 . , ' b Form ��0 Statement of Person Claiming OMBtVo.1545-0074 (Rev.Novem6er2005) Refund Due a Deceased Taxpayer Deperiment o1 the Treasury Attachment Internal Revenue Service ► See instructions. Sequence No. 87 Tax year decedent was due a retund: Calendar year 2 O 10�or other tax year beginning ,20 ,and ending ,20 Name of decedent Date oi death OecedenYs socfal security no. HARLES E STEEVER 11 07 11 208-42-4397 Name of person claiming refund Your soclal security number Piease AUL D EDGER ES UIRE print or Hame address(number and sVeet).If you have a P.O.box,see instructions. ApL no. rype 5006 E TRINDLE ROAD SUITE 203 Ciry,town or post o�ce,state,and ZIP code.If you have a foreign address,see instructions. CHANICSBURG PA 17050 Part 1 Check the box that applies to you.Check only one bax. Be sure to complete Part III below. A Surviving spouse requesting reissuance of a refund check(see instructions). B 0 Court-appointed or certified personal representative.Attach a caurt certificate showing your appointment,unless previausly filed(see instructions). C � Person,other than A or B,ciaiminp refund for the decedent's estate(see instructionsl.Alsa,complete Part II. Part II Complete this part only if you checked the box on line C above. Yes No 1 �Id the decedent leave a will?....................................................................................... X ....................................................................... 2a Has a courtappointed a personal representative for the estate of the decedent? ................................................. ............................. ......... .. g b If you answered'No'to 2a,wiA one be appointed? ................................................................................................................................. If you answered'Yea"to 2a or 2b,the personal representative must file for the refund. 3 As the person claiming the refund for the decedenPs estate,will you pay out the reTund accarding to the laws of the sWte where the decedent was a legal resident? ..................... g ........................................................................................................................ If you answered'No'to 3,a refund cannot be made untii you submit a court certificate showing your appaintment as personal representative or other evidence that you are entitled under state law to receive the refund. Part III Signature and verification. All filers must complete this part. I request a refund of taxes overpaid by or on behalf of the decedent.Under penalties of perjury,I declare that I have examined this claim,and ta the best of my knowledge and belief,it is true, orrect,and com lete Signature of erson clalming refund ► Date ► '�/�I� LHA For Privacy Act and Paperwork Reduction Act Notice,aee inatructions. Form 1310(Rev.11-2005) oi2osi os-o�-io 4 11341014 706230 LMS-STEEC 2010.06020 STEEVER, CHARLES E LMS-STC1 , ' e � ' SCHEDULE M Making Work Pay Credit OMB No.1545•0074 (Form 1040A or 1040) �O�O Depertment of lhe Treasury Atteehment Intemaf Revenue Servite (9B) � Attach to Form 1040A or 1040. ► See separate instructions. sequence No.16G Name{s}shown on retum Your soclal securNy number CHARLES E STEEVER 208 ?42 �4397 ! To take the making work pay credit,you must include your socia!securrty number(il rling a jornt return,the number of either you or your CAUTION spouse)on your tax return.A soclal security number does not include an identitication number Issued by the IRS.OnJy the Socia!Security Administration issues social security numbers. I uYou cannot take the making work pay credit il you can be claimed as someone else's dependent or if you are a nonresidenf alien. Important:Check the°No°bax on line 1a and see the instructions if: (a) You have a net loss from a business, (b) You received a taxable scholarship or fellowship grant not reported on a Form W2, (c) Your wages include pay tor work performed whife an inmate in a penal institution, (d) You received a pension or annuity from a nonqualified deferred compensation plan or a nongovemmental section 457 plan,or (e) You are filing Form 2555 or 2555•EZ. 1a Do you(and your spouse if filing jointly)have 2010 wages of more than$6,Q51 ($12,903 it married filing Jointly)? �Yes.Skip Iines 1 a through 3.Enter$400($S00 if married fping jointly)on line 4 and go to line 5. � No.Enter your eamed income(see instructions) ...................... ................ ia b Nontaxable combat pay included on line 1 a(see fnstructions) ....................................... 1b 2 Muttiply line t a by 6.2°..4�(.062) ........... ................... . p ........................................... 3 Enter$400($800 if married filing jointly) ............................................................ 3 4 Enter the smaller ot line 2 or line 3(unless yau checked"Yes"on line 1 a) .. ................................................... 4 4��. 5 Enter the amount from Form 1040,line 38',or Form 1U40A,line 22 ..................... 5 21 6 3 9. 6 Enter$75,000($150,000 if married filing jointly) ................................................ 6 �5 �fl 0. 7 Is the amount on line 5 more than the amount on line 6? �No. Skip line 8.Enter the amount from line 4 on line 9 below. Q Yes. Subtract line 6 from line 5 7 .................................................................. S Muftiply line 7 by 2% (.02) .............................................................................................................................. $ 9 Subtract line 8 from line 4.If zero or less,enter•0• ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 9 4�0. 10 Did you(or your spouse,if Tiling jaintly)receive an economic recovery payment in 20107 You may have received this payment in 2010 if you did not receive an economic recovery payment in 2009 but you received social security benefits,supplemental security income,railroad retirement benefds,or veterans disability compensation or pension benefds in November 2008,December 2008,or January 2009(see instnictions). �No. Enter•0•on line 10 and go to line 11, �Yes. Enter the total of the payments you(and your spouse,if filing jointly)received in 2010.Do not enter more than$250($500 if married filing jointly) . ... ........................... ....................................... 10 . 11 Making work pay credlt.Subtract line 10 from line 9.If zero or less,enter•0•.Enter the result here and on Form 1040,line 63;or Form 1040A,line 40 ....,.,.,, ........................ 11 4 0 0. .......................................................... . •If vou are filinq Form 2555 2555•EZ or 4563 or you are excludinq income from Puerto Rico,see instructions. LHA For Paperwork Reduction Act Notfce,see separate instructions. Schedufe M(Form 1040A or 1040)2010 021511 12-16-70 5 11341014 706230 LMS-STEEC 2010 .06020 STEEVER, CHARLES E LMS-STC1 . � , CHARLES E STEEVER 208-42-4397 FORM 1040 PENSIONS AND ANNi1ITIES STATEMENT 1 T ROWE PRICE AMOUNT RECEIVED THIS YEAR 339 . NONTAXABLE AMOUNT CAPITAL GAIN DISTRIBUTION REPORTED ON SCH D 339. TOTAL INCLUDED IN FORM 1040, LINE 16B 339. FORM 1040 WAGES RECEIVED AND TAXES WITHHELD STATEMENT 2 FEDERAL STATE CITY T AMOUNT TAX TAX SDI FICA MEDICARE S EMPLOYER'S NAME PAID WITHHELD WITHHELD TAX W/H TAX TAX T KS RENEWAL SYSTEMS 692. 21. 14. 43. 10. T TRUGREEN LIMITED PARTNERSHIP 14 , 838 . 1, 292. 466. 303 . 941. 220. TOTALS 15, 530. 1,292. 487. 317. 984. 230. FORM 1040 FEDER.AL INCOME TAX WITHHELD STATEMENT 3 T S DESCRIPTION AMOUNT T TRUGREEN LIMITED PARTNERSHIP 1,292. T T ROWE PRICE 67. TOTAL TO FORM 1040 , LINE 61 1, 359. 6 STATEMENT(S) 1, 2, 3 11341014 706230 LMS-STEEC 2010 .06020 STEEVER, CHARLES E LMS-STC1 , . DECEASED • E �ss) ,� U.S. Individuai Income Tax Return 2011 pM8 No.1545-OO7d �RS Use Only-Do not write a staple In thla epace. Fa the year Jan.1-Oec.31,2017,a ot�ar lax year beglnnln8 .2p 1 t,entling � ,y0 See se rate instructions. Your first name and initial Last name (DEC. 11/0 7/11) �our eociel seeuriry numbar CHARLES E TEEVER 208 :42 :4397 If a joint return,spouse's first name and initial Last name Spouse's social seewiry numDer Home address(number and street).If you have a P.O.box,see instructions. Apt.no. �n�B e�,e,na ssro�a��o�e C 0 PAUL EDGER 5 0 0 6 E TRINDLE ROAD SUITE 2 0 3 •end an Ilne 8c ara cortect. City,town a pas!oHite,state,end 21P code.If you have a foraign address,also complete spacea below. Presidential Electlon Campelgn Check here if you,n ow apouse MECHANI CSBURG PA 17�5� �t liling pintly,War,s s��o go io this tuntl.Checking a box below Foreign country name Foreign province/county Foreign postal code w111 not chanpe ywr tez p refund. 0 You 0 S ouse Filing Stetus � Sinple 4 Head of household(with qualiiying person).If the quali(ying 2 � Married filing jointly(even if only one hatl income) person is a chiid but not your dependent,enter this child's Check only 3 � Married filing separately.Enter spouse's SSN above name here. ► one box. and full name here. ► 5 ��uali in widow er with de andent chfld 6a Yourself.If someone can claim you as a dependent,do not check bax 6a eox��'�`� 1 Exemptions ............................................:... on e�a�d eb b �$ OU88 ................................................................................................................................. .... No.o}children �p i on Bc who: c Dependents: �z)oepe�ae�c's soclal (3elDationshe�to underape 17 ��d wlth you (7)F6st name Last name security number P ualilyinqfOrtAiid you �yx��g�j� •did not live with you due to divace a separatlon (see mswcttons) If more than four dependents,see Dapendenta on Bc instructions and not entered abova check here ► � Add numbers on Nnas d Total number oi exem tions ciaimed.................................................................................................... ....... �o�a ► 1 ineome 7 Wages,salaries,tips,etc.Attach Form(s)W-2 ........................................ ..................................... 7 2 218. 8a Taxable interesL Attach Schedule B if required ................................... ...................... 8a Attach Form(s) b Tax-exempt interesG Do not include on line 8a ......... .......... .. . 8b W-2 here.Also 9a Ordinary dividends.Attach Schedule B if required ..... .. ....................... 9a attach Forms b Oualified dividends ..................................... gb ......... . . W-2G and �p Taxable refunds,credits,or offsets of state and local income taxes........................................... �p 1099-R If tax was withheld. 11 Alimony received ................................................................... .............................................. 11 12 Business income or(loss}.Attach Schedule C or C-EZ �p ................................................ If you did not �3 Capital gain or(loss).Attach Schedule D if required.If not required,check here .....................► Q 13 get a W-2, 14 Other gafns or(losses).Attach Form 4797 ........................................... ......................... ............... 14 see instructions. 15a IRA distribulions ..................... 15a b Taxable amount ,,,,,,,.,..._.,_.. 15� tBa Pensions and annuities ..,,,,,,.,,. 18a b 7axable amount ........ .. ...... 1gb 18. 17 Rental real estate,royalties,partnerships,S corporations,trusts,elc.Attach Schedu►e E ....................... 17 Enclose,but do �g Farm income or(lass).Attach Schedule F 18 notattach,any .................................................................:................ . payment Also, 19 Unemplayment compensation ................................................................................................... �s 8 235. pfease use 20a Sociai security benetits ......,,.._, ( 20a I I b Taxable amount .................. 20b Form 1040-V. 2� Other income.List type and amount 2� 22 Combine the amounts in the far ri ht column(or Ifnes 7 throa h 21,This is our total income ......... 22 1� 4�1. 23 Educator expenses ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, P3 .................................. ... Certeln 6usinesa expensas o!reservlsts,perfaming artlsts,end lee-beeis gavemment 24 AdjuStSd 24 ofliciefs,Attech Fwm 2108 or 2108-EZ ................................................... Gross p5 Health savfngs account deduction.Attach Form 8889 ,,,,,,,,,,,,,,,,,,,,,,,, 25 Income 28 Movinp expenses.Attach Form 39Q3 ............................................. 28 27 Deductible part of sel(-employment tax.Attach Schedule SE,,,,,,,,,,,,,,,,,, 27 28 Seli-employed SEP,SIMPLE,and qualified plans ..... ....... . pg 29 Self-employed health insurance deduction ........... .. „ . ... ... .,,.,..... Zg 30 Penalty on early withdrawal of savinAs,,...,,.., ................................... 30 31a Alfmony paid b RecipienYs SSN ► 31a 32 IRA deduction ........................................................................... 32 33 Student loan interest deduction .................................. .... „ 33 34 Tuition and fees.Attach Form 8917 ...,.,... . .. .................................... 34 35 Domestic production activities deduction.Attach form 8903 ,,,,,,,,,,,,,,, 35 36 Add Iines 23 through 35 ....................................... .. . ......................................................... 38 ��000i�� 37 Subtract line 36 from line 22.This is our ad usted ross incame ............................................ a� 10 471. LHA For Disclosure,Privacy Act,and Paperwork Reduction Act Notice,see separate instructions. Fam 1040�2o>>y • � 2013/09/19 11:01:25 2 /7 �� Int�t�a�1 Rev�n�e S�rvice Umted States Department af the Treasury This Prcduct Contains Sensitive Ta:spayer Data Wage and Income Transcript Request Date: 09-19-2013 Fesponse Date: 09-19-2013 Trackiny Numl:�er: 100172384429 SSN Provided: 2U�-92-9397 Taz Period Requested: Dec6mber, 2011 Form W-2 Wage and Tax Statement Employer: Employer ldentification Numk�er (EIN): 271656513 I:S RENEWAL SYSTEMS 592 INDUSTRIAL DRIVE LEWISBERRY, PA 17339-0000 Employee: Employee's Social Security Number: 206-42-9397 CHARLES E STEF.VER 3498 WALNUT STREET CAMP HILL, PA 17011-006U Submis�ion Type: Original document wages, Tips and Other Compensation: 52,198.0(� Federal Income Tax Wit]Zheld: $0.00 S�cial Security 4Tages: S2,198.00� Social Se��urity Ta:t Withheld: g�Z,pp� Medicare Wages and TZFJS: 7L 198.00� Medicare Tax Withheld: '531.00� Social Security Tips: 50.00 Allocated Tips: $0.00 Dependent Care Benefits: 50.00 Deferred Compensation: $p.Op Cxie "�" Nontaxable Combat Pay: :0.00 C�xle "W" Employer Contribu+_ions to a Hualth Savings Account: 50.00 Cx�e "Y" Deferrals under a section 909A nonqualified D�ferred 50.00 Compensation plan: C�xle 1O1 Inceme under section 909A on a nonqualified D?ferred 50.00 Compensation plan: C�xle "F." Empluyer's Contribution t�� MSA: $0.00 r�.]� "S" Em��loyer's Contribution to Simple AcCOUnt: $0.00 C�x1e "T" E.:perises Incurrecl Zcr Qualilied AdoF�tior�s: :0.00 �c�3e "V" IncomE from a�.ercise of non-staturory sr,;�:{; opr_ions: 50.00 � : 2013/09/19 11:01:25 3 /7 Code "AA" Desiqnated P.oth Conlributions under a Section 4011k) Plan: $0.00 Code "BB" De�ignated Roth Contrik�utions under a Section 903(b) Flan: 50.00 Code "DD" Cost c�f Employer-Spensor?d Health Coverage: 50.00 Code "EE" Desiynated ROTH Contributions Under a Governmental Sectian $0.00 957(b} Plan: Third Party Sick Pay Indicator: Unanswered Retirement Plan Indicator: Unanswered Statutory Employee: Not Statutory Employee Form W-2 Wage and Tax Statement Employer: Empleyer ldentification Plumber (EIN): 275993854 BARkUS V DICf:S °,FORTING GUODS QSF PO BOX 225R PARIBAULT, MN 55021-On00 Einployee: Employee's Secial S=��urity Number: 208-42-9397 CHARLES E STEEVER 3998 WALNUT ST CAMP HILL, PA 17011-2749 Submission Type: Origina] documFnt Wayes, Tips and Gther Compensation: $20.00'� Federal I1'1CGIDE Tax. Wi*.hheld: 55.00 '� Social Security wages: 520.�0.� Social Security Tax Withheld: 50.00,� tdedi��are Wayes and Ti�s: 520.00 tdedicare Tax Withhelcl: $0.00 Social Security Tips: 50.00 Allocated Tips: $0.00 Dependent Care Benefirs: 50.00 Deferred Compensation: 50.00 Code "Q" Nontar_able Combat Pay: $0.00 Code "W" Em�:�loyer ContributienG to a Health S�vings Account: 50.00 Code "'l" DefErrals under a sECtion 909A nunqualified Deferred $0.00 Compensation plan: Code "Z" Income under section 409A on a nonqualified Deferred cp,00 Compensation plan: Cc�de "R" Employer's Contribution to MSA: 50.00 Code "S" Employer's Cuntribution t_J Simp1F Account: $0.00 Code "T" E::penses Incurrecl for Qualified Acioptions: 50.00 Code "V" Incem? from �rercise of non-stat�a*_ory stock options: 50.00 Cade "AA" Designated koth Contributions under a Sectica� 901(};) Plan: 50.00 Cc�de "BB" Desiynated Roth Contributions under a Section 903(b) Flan: 50.00 Code "DD" Cost of Employer-Sponsorecl Health C_�verage: 50.00 Cude "GG" Designated F.OT}I Cc�ntrik�utior,s Under a Gev�rnmental Secti��n 50.00 957(b) Plan: Thirtl Farty Sick Fay Indi�:ntor: Unanswered : 2013/09/19 11:01:25 4 /7 Retirement Plan Indicator: Unans�ierad Statutory Employee: Not Statutory Employee Form W-2 Wage and Tax Statement Employer: Employer ldentificatien Number (EIN): 2759?3859 BARRUS V DICKS SFORTING GOODS QS PO BOX 225B FARIBAULT, MN 55021-0000 Employee: Employee's Social Security Number: 208-42-4397 CHARLES E STEEVER 3448 WALNUT ST CAMP HILL, PA 17011-0000 Submission TyPe: Amended document Wages, Tips and Other Comper�satia�: S0.00 Federal Income Tax Withtield: 50.00 Social Security wages: 50.00 Social Security Tax Withheld: $0.00 Medicare Wages and Tips: 50.00 Medicare TaY Withheld: 50.00 Social Security Tips: 50.00 Allocated Tips: 50.00 Dep?ndent Care Benefits: 50.00 Deferred Compensation: 50.00 Code "Q" Nontaxable Comba*_ Pay: 50.00 Code "W" Employer Contributions to a Health Savings Account: ;0.00 Ccxle "Y" Deferrals under a section 409R nonqualified Deferred $0.00 Compensation plan: Code "Z" Income under section 409A en a naiqualifiei] Deferred 50.00 Compensation plan: Code "R" Employer's Contribution to MSA: 50.00 Code "S" Employer's Contribution to Simple Account: 50.00 Code "T" Expenses Incurrecl for Qualified Adoptions: 50.00 Code "V" Income from exercise of non-statUt�ry stcck options: 50.00 Code "T,A" Designated Roth Contributions under a Section 901(k) Plan: $0.00 Code "BB" Designated Roth Contributions under a Se��r_ion 903(b) Plan: 50.00 Code "DD" Cost of Employer-Sponsored Health Coverage: 50.00 Code "EE" De�ignated ROTH Centributions Under a Gcvernmental Section 50.00 457(L-) Plan: Third Party Si�k Pay Indicnt��r: Unansorsred Retirement Plan Indicator: Unanswered Statutory Employae: t7et Statutory EmFloyee Form 1099-G � - 2013/09/19 11:01:25 5 /7 Payer: Fayer'� Fe�eral I�entification Number (FIN): 2350�3107 CC>MMONWEALTH OF PA DEPT OF LABOR & IND OFF OF EMPLOY?dENT SECCfRITY BMIS D 108 7TH RND FORSTER STS HARRISBURG, PA 17121-OQ00 Recipient: Recipient's Identiiication Number: 208-92-4397 STEEVEF. CHARLES E 3496 W?,I,PJUT ST CAMP HILL, PA 17011-U0�)0 Submission Type: Original document_ Account Numk,er (Optional! : N/A ATAA Fayments: O.�p Tax. Withhsld: 0.00 Ta}:able �3rar�ts: 0.00 Unemployment Comrensatiun: 58,235.00� Ayricultural Subsidies: 0.00 Prioi Year Refund: O.pp Market gair, on Commc�ity Credit Corporation loaiis repai�� Q �p or� or aitar January 1, 200"7: Year af i;?fund: Not Set 1099G Offset• Nvt Refur�d, Credit, ur Offset for � Trade or Business Form 1099-R Distributions from Pensions , Annuities , Retire or Profit-Sharing Plans , IRAs , Insurance Contracts , etc . Payer: F�ayer's Federal Idenriiication Number (FIN): 521981931 T. ROWE PRICE QM 92?G 4515 �AINTERS MILL RD UWINGS MILLS, MD 21117-0000 Recipient: Recipient's Identilication Numher: 208-92-4397 STEEVER, CHARLES E 3998 WALNUT ST CAMF HILL, PR 17011-OOUO Submis�ion Type:. Ori9.ina1 dacumenr_ . Account Number (��ptianal) : 2(11209261313000�8552 Distrib�ation Code Value: Early Distribution, �::ception applies (Under ag� 5� 1/21 Distributi�_�n Cod�: � Distributi��n Cod� �nlue: 1JOt �ic1111f1Cc�nt ' �. 2013/09/19 11:01:25 6 /7 Distribution Code: Blank Tax Amount Undetermined Code: Not checked Total Distribution Code: Total Distribution Eirst Year Roth Contribution: 0000 SEP Indicator: IRA/SEP/SIMP bo� n�t checked Tax Withheld: 0.00 T�tal Employee Contributions: 0.00 Unrealized Appreciation: 0.00 Other Income: 0.00 Gross Distribution: '� 518.00 J„ Taxable Amount: $18.00 Eligible Capital Gains: 0.00 Amount to IRP.: 0.00 This Product Contains Sensitive Taxpayer Data - Fam7040(2011) CHARLES E STEEVER 208-42-4397 Peea2 Tax and 38 Amount from line 37(adjusted pross income) ....................................................................................... 36 1.0 4 71. Credits 39a Check �You were born before January 2,1947, 0 Blind. Total boxes s��aa�a ii: � 0 Spouse was born before January 2,1947, �BI(nd. � checked,,, ► 38a :ea�ctio�rw- b If your spouse itemizes on a separate return or you were a dual-status alien,check here ► 39b Paople who ��• cneck e�y q0 Itemized deductiona{from Schedule A)or your standard deduction(see Ieft margin) ................................. 40 5 8 0 0. box on line 3se a sse or 41 Subtract Ilne 40 from Iine 38 Wno��ea ............................ ............................................................................... 41 4,6 71. clalmed es e qp Exemptlona.Multiply$3,700 by the number on Iine 6d ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, deAendent. ........................................... 42 3 7��. 43 Taxable fncome.Subtract line 42 from line 41.If line 42 is more than line 41,enter-0- ................................. 43 9 71. 44 Tax.Check if any from: a 0 Form(s)8814 D 0 Form 4972 c� 962 election ........................ 44 9 6. 45 Alternative miolmum tax. Attach Form 6251 ....................................... . ... ...................... . .. .... ....... 45 •nu ocn�g: 48 Add lines 44 and 45......................................................... Singiew ...............................i......................... � 46 96. Martled tflin8 47 Foreipn tax credit Attach Form 1116 if required ....................................... 47 separetely, ae,soo 48 Credit for child and dependent care expenses.Attach Form 2441 .................. 48 Martiad fiiing 49 EducaUon credits from Form 8863,line 23 p�niN a ............................................. 49 Oualiying 50 Retirement savings contributions credit Attach Form 8880 ........................ 50 widow(er�, s>>,soo 51 Chfld tax credit{see instructians) ..................... ........... ........... . 51 Neeo or 52 Residential enargy credits.Attach Form 5695 ,,, ,,,, Sy nousenold� ...... .Q ......... ..... 53 se.soo 53 Other credits from Form: a�3800 b Q 8801 c 54 Add lines 47 through 53.These are your total credits,,,,,,,,,,,,, ........... .., 54 .............. ........................ . 55 Subtract line 54 from line 46.If Iine 54 is more than Ilne 46 enter-0- .................................................. ► 55 9 6. Other 56 Self•employment tax.Attach Schedule SE . . .. ...................................... 56 ................................................. . Texes 57 Unreported social security and Medicare tax from Form: a�4137 b 0 8919 ................................. 57 58 Additional tax on IRAs,other qualitied retirement plans,etc.Attach Form 5329 if required .,,,, „ . .... .............. 5g 59a Household emplayment taxes irom Schedule H , 59a ......................................... ..................................... .... b First-time homebuyer credit repayment.Attach Form 5405 if required ,,,,,,,,,,,,,,,,,,,,,,,, ................................ 59b 80 Other taxes.Enter code(s)from instructions 80 61 Add tines 55 throu h 60.This is our totat tax................................................................................. ► Bi 9 6. Payments a2 Federal income tax withheld from Forms W-2 and 1099 .............................. 62 5. 83 2011 esiimated tax payments and amount applied from 2010 return ,,,,,.,,,... 83 uYO�na�e 64a Earned(ncome credit(EtC) ........... ..... .. . e q�a��y��g . . . ............................................ 64a 17 0. �n�m,ana�n b Nontaxable combat pay election ............... � 64b � Schedule EIC. BS Additfonal child tax crediL Atlach Form 8812 .......................................... 85 68 American opportunity credit from Form 8863,line 14 ................................. 66 67 First-time homebuyer credit from Form 5405,line 1D ................................. 87 68 Amount paid with request for extension to fife .......................................... 88 89 Excess social security and tier 1 RRTA tax withheld ................................. 89 70 Credit for federal tax on fuels.Attach Form 4136 .......... ... ..... 7p .................. . T1 Credits from Form: a 02439 b 08839 c 08801 d�8885 71 72 Add Iines 62 63 64a and 65 throu h 71.These are our total a ments ...................................... ► 72 175. Refund 73 If line 72 is more than Ilne 61,subtract line 61 from line 72.This is the amountyou overpaid........................... 73 79. 74a Amount of line 73 ou want refunded to you.If Form 8888 is attached check here ........................► 7qa ']9, Oirect deposll7 ROUtinp dtcounl See � b number �C Type: �Chakinq Q Savinqs �d numbe7 insaucuona. 75 Amount of line 73 ou want a lied to our 2012 eatimated tax ......... 75 Amount 78 Amount you owe.Subtract line 72 from line 61.For details on how to pay,see instructions ..................... ► 7g You Owe 77 Estimated tax enal see instructions ..... ......................................... 77 Third Party Do you want to allow another person to discuss this return with the IRS(see instructions)? Yes.Complete below. Na Designee nesmaee's�L I SA M STATLER noone� �1�_5 0 6-12 2 2 number fPIN1��n�tion�1�0� Sign Under peneftles of perjury,I dee are that I have examined thla return antl accompanying schetlules and stetements,and to the best ot my knowledge and beliel,they ere 7ue, cortect,and co te.Declar on oi preparer(other than t�peyer)is besed on all Infamatlon ot whtch preparer has any knowledge. Here You etur Det Your oetupatlon Daytime phone number .loint ratum7 j��s (?j EALTOR See instructions. Keep e copy Spouse gnatur0.I1 n!return,bOth must algn, Dete Spouse's xcupation H the IRS sent ou en IdenC r m fp your ProteGtion PIN, racords. enter it here PrinVType preparer's neme Pre er's signature==�"'v`.^J`^ Dete Check ii PTIN Paid ` rn sal}-employed Preparer LISA M STATLER SA M�STATLER C�F110 14 13 00094609 USe Orlly Fo-m's neme ►WAGGONER FRUTIGER & DAUB LLP F'vm's EIN► 2 3 :15 S 3 2 4 9 5006 E TRINDLE RD SUITE 200 Phoneno.717-506-1222 ��o°�� F�m�eeac�aas ►MECHANICSBURG, PA 17050 Form 1310 Statement of Person Claiming OMB No.1545-0074 (Rev.November 2005) Refund Due a Deceased Taxpayer Department o1 the Treasury Attachment Intemal Revanue Service ► See instructions. Sequence No. 87 Tax year decedent was due a retund: Calendar year 2 011,or other tax year beginning ,20 ,and ending ,pp Name of decedent Date oi death Decedent's social security no. HARLES E STEEVER 11 07 11 208-42-4397 Please Name of person claiming refund Your social security number prfnt AUL D EDGER ES UTRE or Home address(number and street).If you have a P.O.box,see instructions. Apt,no. type 5006 E TRINDLE ROAD SUITE 203 Ciry,town or post office,state,and ZIP code.If you have a foreign atldress,see instructions. CHANICSBURG PA 17050 Part I Check the box that applies to you.check oniy one box. Be sure to complete Part Iil below. A Surviving spouse requestinp reissuance of a refund check(see instructions). B 0 Court-appofnted or certified personal representative.Attach a court certificate showing your appointment,unless previously filed(see instructians). C nX Person,other than A or B.claiminp refund for the decedenYS estate(see instructions) Also complete Part II Part II Complete this part only if you checked the box on line C above. Yes No 1 Did the decedent leave a wi111........................ ............................................................. X ........................................................................ 2a Has a court appointed a personal representative for the estate of the decedent? X ................................................ b If you answered"No"to 2a,will one be appointed7 ......................................... .............................................................................. ......... If you answered'Yes°to 2a or 2b,the personal representative must file for the refund. 3 As the person claiming the refund for the decedenYs estate,will you pay out the refuntl according to the laws of the state where the decedent was a legal resident? X ............................................................................................................................................. If you answered"No`to 3,a refund cannot be made until you submit a court certificale showing your appolntment as personal representative or other evidence that you are entitled under state law to receive the retund. Part Iil Signature and verification.All filers must complete this part. I reqoest a refund ot taxes overpaid by or on behalf of the decedent.Under penalties of perjury,I declare that I have examined this claim,and to the best af my knowledge and belief,it is true,c rrect,an lete. Signature af peraon claiminp retund ► � Date ► LHA For Pr(vacy Act and Paperwork Reduction Act Notice,see instructians. Form 1310(Rev.11-2005) 112091 05-07-11 4 13571014 706230 LMS-STEEC 2011. 05090 STEEVER, CHARLES E LMS-STC1 OMB No.7545•1829 Fam$867 Paid Preparer's Earned Income Credit Checklist 2011 Department ol iho T�easvey ►For more Information about Form 8867,see www.Irs.gov/form8867 A��echment Internal Revenue Service To be com leted b re arer and filed wlth Form 1040 1040A or 1040EZ. seyuence No.177 Taxpayer name(s)shown on retum Taxpayer's social security number CHARLES E STEEVER DEC. 11 07 11 208-42-4397 For the definitions of the following terms,see Pub.596. •Investment Income •Quality(ng Child •Earned Income •Full-tfine Student Part I All Taxpayers 1 Enter preparer's name and PTIN ►L I SA M STATLER P 0 0 0 9 4 6 0 9 2 Is the taxpayer's filing status married fifing separately?..................................... 0 Yes �No ....................................................... � If you checked"Yes"on line 2,stop;the taxpayer cannot take the EIC.Otherwise,continue. 3 Does the taxpayer(and the taxpayer's spouse if filing Jointly)have a soclal security number(SSN)that allows him or her to work or is valid for EIC purposes?See the instructions before answering ...................................... .. �Yes Q No ► If you checked"No"on line 3,stop;the taxpayer cannot take the EIC.Otherwise,continue. 4 Is the taxpayer filing Form 2555 or Form 2555•EZ(relating to the exclusion of foreign eamed income)? ........................ �Yes �No ► If you checked"Yes"on line 4,stop;the taxpayer cannot take the EIC.Otherwise,continue. 5 a Was the taxpayer a nonresident alien for any part of 2011? �Yes [�No ....................................................................................... ► If you checked"Yes"on line 5a,go to line 5b.Othenvise,skip line 5b and go to line 6. b Is the taxpayer's filing status married filing jointly? ....................... ........... �Yes �No ....................................................... ► If you checked"Yes"on line 5a and"No"on line 5b,stop;the taxpayer cannot take the EIC. Otherwise,continue. 6 fs the taxpayer's investment income more than$3,150?See Rule 6 in Pub.596 before answering ................ �Yes �No � If you checked"Yes"on line 6,stop;the taxpayer cannot take the EIC.Otherwise,continue. 7 Could the taxpayer,or the taxpayer's spouse if filing jointly,be a qualifying child of another person for 2011?If the taxpayer's filing status is married filing jointly,check"No."Othervvise,see Rule 10(Rule 13 if the taxpayer does not have a qualifying chiid)in Pub.59S before answering ..................... �Yes [X� No ................................................................. ► If you checked"Yes"on Ifne 7,stop;the taxpayer cannot take the EIC.Otherwise,go to Part II or Part III whichever a lies. LHA For Paperwork Reduction Act Notice,see insVuctions. Fam SB67(2011) 120501 01-09-72 5 13571014 706230 LMS-STEEC 2011. 05090 STEEVER, CHARLES E LMS-STC1 � Form8B87(2011) Cgp�LES E STEEVER 208-42-4397Pfl�2 Part II Taxpayers With a Child Caution.H there is more than one child,complete lines 8 through 14 for Child 1 Chlld 2 Child 3 one child before going to the next column. 8 Child's name ........................................................................................... . 9 Is the child the taxpayer's son,dauphter,stepchild,foster chifd,brother,sister, stepbrother,stepsister,half brother,half sister,or a descendant ot any ot them? ..,,., 0 Yes �No �Yes 0 No 0 Yes �No 10 Is eRher of the following true? • The child is unmarried,or • The child is married,can be claimed as the taxpayer's dependent,and is not filing a jolnt retum(or is filing R only as a claim for refund). .................. �Yes �No 0 Yes �No �Yes 0 No 11 Did the child live wkh the taxpayer in the United States for over half of the year'T See the instructions before answertng. ................................. ........... �Yes Q No �Yes 0 No �Yes �No 12 Was the child(at the end of 2011)•• • Under age 19 and youngar than the taxpayer(or the taxpayer's spouse, if the taxpayer files jointly), • Under age 24,a full•time student,and younger than the taxpayer(or the taxpayer's spouse,if the taxpayer files jointty),or • Any age and permanently and totally disabled? ,,,,,,,,,,,,,,,,,, 0 Yes 0 No �Yes 0 Mo Q Yes �No .................. ►If you checked"Yes"on lines 9,10,11,and 12,the child is the taxpayer's quaiifying child;go to line 13a.If you checked"No"on line 9, 10,11,or 12,the child fs not the taxpayer's qualifying child;see the instructions for line 12 on page 4. 13 a Couid any other person check"Yes"on lines 9,10,11,and 12 for the child7 �Yes 0 No �Yes �No �Yes �No ►If you checked`No"on line 13a,go to line 14.Otherwise,go to line 13b. b Enter the child's relationship to the other person(s) .................................... c Under the tiebreaker rules,is the child treated as the taxpayer's qualifying Yes No Yes No Yes No child?See the instructions before answering. .............................. �Don't know �Don't know ' ............... 0 Don t know ►If you checked"Yes"on line 13c,go to Ilne 14.Ii you checked"No," the taxpayer cannot take the EIC based on this child and cannot take the EIC for taxpayers who do not have a qualifying child.If there is more than one child,see the Note at the bottom of this page.If you checked"Don't know,"explain to the taxpayer that,under the tiebreaker rules,the taxpayer's EIC and other tax beneffts may be disaliowed.Then,if the taxpayer wants to take the EIC based on this child,complete lines 14 and 15.If not,and thare are no other qualifying children,the taxpayer cannot take the EIC,including the EIC for taxpayers without a qualifying child;do not complete Part III.If there is more than one child,see the Note at the bottom of this page. 14 Does the qualifying chiid have an SSN that aUows him or her to work or is valid for EIC purposes?See the instructions before answering ,,,........, []Yes �No �Yes 0 No �Yes 0 No ►If you checked"No"on line 14,the taxpayer cannot take the EIC based on this chitd and cannot take the EIC for taxpayers who do not have a qualltying child.If there is more than one child,see the Note at the bottom of this page.If you checked"Yes"on line 14,continue. 15 Are the taxpayer's earned fncome and adjusted gross income each less than the timit that applies to the taxpayer for 2011?See Pub.596 for the limit ......................................................................................................... Yes � No ►If you checked"No"on I1ne 15,stop;the taxpayer cannot take the E�C.If you checked"Yes"on line 15,the taxpayer can take the EIC. Complete Schedule EIC and attach ft to the taxpayer's retum.If there are two or three qualifying children with valid SSNs,list them on Schedule EIC in the same order as they are listed here.If the taxpayer's EIC was reduced or disaliowed for a year after 1996,see Pub.596 to see if Form 8882 must be filed.Go to line 20. Note.If you checked"No"on line 13c or 14 but there is more than one chifd, complete lines 8 through 14 for the other child(ren)(but for no more than three qualify(ng children).Also do this if you checked"Don't know"on line 13c and the taxpayer is not taking the EIC based on this child. i2osoz oi•os•�2 Fam8867(2ot�) 6 13571014 706230 LMS-STEEC 2011. 05090 STEEVER, CHARLES E LMS-STC1 F�„eae��o„i CHARLES E STEEVER 208-42-4397Paee3 art 7axpayers �t out a ua i ng i i6 Was the taxpayer's main home,and the main home of the taxpayer's spouse i(flling jointly,in the United States for more than half the year?(Military personnel on extended active duty outside the United States are considered to be living In the United States during that duty period.See Pub.595.) ........................... � Yes � No ►If you checked"No"on line 16,stop;the taxpayer cannot take the EIC.Otherwise,continue. 17 Was the taxpayer,or the taxpayer's spouse if filing jointly,at�east age 25 but under age 65 at the end of 2011? ............ � Yes � No ........................................................................................ ............................................................. ►Ii you checked"No"on Iine 17,stop;the taxpayer cennot take the EIC.Otherwise,continue. 18 Is the taxpayer,or the taxpayer's spouse if filing jointly,eligible to be claimed as a dependent on anyone else's federal income tax retum for 2011?If the taxpayer's filing status is married filing jointly,check"No" � Yes � No ..................................................................................................................... ................................ ►If you checked"Yes"on line 18,stop;the taxpayer cannot take the EIC.Othervvise,continue. 18 Are the taxpayer's earned income and adjusted gross income each less than the fimit that applies to the taxpayer for 2011?See Pub.596 for the limit [�X Yes � No ...................................................................................................... ►If you checked"No"on line 19,stop;the taxpayer cannot take the EIC.If you checked"Yes" on line 19, the taxpayer can take the EIC.If the taxpayer's E!C was reduced or disallowed for a year after 1996, see Pub.596 to find out if Form 8882 must be tiled.Go to line 20. art ue i igence equirements 20 Did you complete Form 8867 based on current information provided by the taxpayer or reasonably obtained by you? � Yes � No ...................................................................................................................................................... 21 Did you complete the EIC worksheet found in the Form 1040,1040A,or 1040EZ instructions(or your own worksheet that provides the same intormation as tha 1040,1040A,or 1040EZ worksheet)? ....................... � Yes � No .................................. 22 Did you comply with the knowisdge requirements?(I'o comply with the knowledge requirements,you must not know or have reason to know that any information used to determine the taxpayer's eligibility for,and the amount of,the EIC is incorrect.You many not ignore the implications of information furnished to or known by you,and you must make reasonable inquiries if the iniormation tumished appears to be incorrect,inconsistent,or incomplete.At the time you make these inquiries,you must document in your fifes the inquiries you made and the responses you received.) .._.....,,,, � Yes � No 23 Did you keep the fopowing records? • Form 8867, • The EIC worksheet(s)or your own worksheet(s), • A record of how,when,and from whom the information used to prepare the form and worksheet(s)was obtained,and • Copies of any documents provided by ihe taxpayer and on which you relied to complete the form and the worksheet � Yes � No ...................................................................................................................................................... ►If you checked"Yes°on lines 20,21,22,and 23,submit Form 8867 in the manner required,and keep the records described on line 23 for 3 years(see instructions),you have complied with ali the due diligence requirements. ►If you checked"No"on lines 20,21,22,or 23,you have not complied with all the due diligence requirements and ma have to a a$500 enal tor each failure to com I . Form$$$7(2011) 120503 01•09-12 7 13571014 706230 LMS-STEEC 2011.05090 STEEVER, CHARLES E LMS-STC1 . .CIiARLES E STEEVER 208-42-4397 FORM 1040 PENSIONS AND ANNtJITIES STATEMENT 1 T ROWE PRICE AMOUNT RECEIVED THIS YEAR 18 . NONTAXABLE AMOUNT CAPITAL GAIN DISTRIBUTION REPORTED ON SCH D 18. TOTAL INCLUDED IN FORM 1040 , LINE 16B 18. FORM 1040 WAGES RECEIVED AND TAXES WITHHELD STATEMENT 2 FEDERAL STATE CITY T AMOUNT TAX TAX SDI FICA MEDICARE S EMPLOYER' S NAME PAID WITHHELD WITHHELD TAX W/H TAX TAX T KS RENEWAL SYSTEMS 2,198. 67. 44. 92. 32. T BARRUS V DICKS SPORTING GOODS QSF 20. 5. 1. 1. TOTALS 2 , 218 . 5. 68. 44. 93. 32. 8 STATEMENT(S) 1, 2 13571014 706230 LMS-STEEC 2011.05090 STEEVER, CHARLES E LMS-STC1 REV-15ll EX+ (08-13) � � � pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Charles Eugene Steever 21 12 1291 DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: l. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City_ State________ZIP_.__ Year(s) Commission Paid: z• Attorney fees: 14.53 3. Family Exemption: (If decedenYs address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 75.00 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL (Also enter on Line 9, Recapitulation) $ 89.53 If more space is needed, use additional sheets of paper of the same size. MARJORIEA.WEVODAU GLENDA FARNER STRASBAUGH � � FIRST DEPUTY REG157ER OF WILLS '� r AND ' ,'�;' � ! ±' KIRK S.SOHONAGE,ESQ CLERK OF ORPHANS'COURT • � '� � � � � SOLJCITOR .asrrv.�n � REGIS'TER OF W1LL3 AND CLERK OF THE ORPHANS' COURT COUNTY OF CUMBERLAND ONE COURTHOUSE SQUARE CARLIStE, PA 17013 (717�240-6345 FAX(71'�240-7797 INVOICE Bill To: InvoiceNo: 4492 Invoice Date: l0/16/2013 PAUL D. EDGER, ESQUIRE Estate of CHARLES E.S7'�EVER SOOG EAST TRIN!DLE RD Estate No: 21-12-1291 SUITL-' 203 oe, MECHANICSBURG, PA 17050 Qty Fee IJescription Fee Total 1 Additional Probate 75.00 $75.00 Total: $75.00 Checks should be made payable to the Register of Wills.Terms: Net 30. Please retum one copy of this invoice with your payment. Thank you. � REV-1512 EX+(12-12) � pennsytvania SCHEDULE I DEPARTMENTOFREVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RES[DENT DECEDENT ESTATE OF FILE NUMBER Charles Eugene Steever 21 12 1291 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• Internal Revenue Service(previously thought to be,and listed on previous return as,$2,000.00): 2005-U.S. Individual Income Tax Return 911.00 2010-Pennsylvania lncome Tax Return 17.00 2010-Camp Hill Borough Return 7.00 2011-Pennsylvania lncome Tax Return 6.00 2011-Camp Hill Borough Return 1.00 TOTAL(Also enter on Line 10, Recapitulation) $ 942.00 If more space is needed,insert additional sheets of the same size. 2013/09/19 11:23 :14 2 /7 �� I,�ni�� t��D��nt�ft�� '��a��ar� This Product Contains Sensitive Taxpayer Dat.,� � Account Transcript Request D�te: [�'�-19-20i3 Respozisc DatP: 09-1�i-?01:; Tracking Numbei: 1001723E'�4429 FORM NUMBER: 1040 � TI�?� PERIOD: D�c. 31, =U05 TA7:PAYER IDENTIFICATIOtd 1�TUMBER: 208-4�-93L�i CH?�RLES E STEEVER �448 �r�ALNLJT ST CAMP HILL, P� 17011-2744'-4E1 -- ANY MINUS SIGN SHOWN BELO�i�T SIGNIFIES A CREDIT AMGUPdT --- ACCOUNT BALADICE: 0.00 ACCRUED INTEREST: 911.00 A� OF: Sep. �0, 2013 ACCF.UED PENALTY: C�.00 A� OF: Sep. 30, ?013 ACCOUPdT BALANCE PLiJS ACCRUyLS (this is not a ��ayoft am-vuntl : 911.00 ** INFGRMP.TION FP.OM THE RETURN OR. A� ADJUSTEI7 *� EXENIPTIONS: � �1 FILII�G STATUS: Single ADJUSTED GROSS INCOME: `��'�"�� TAXABLE INCOME: 15,532.U� TAX PER. RETrIRN: 5,571.00 SE TAkABLE ITdCOME TA1CP�,YER: 23,247.Q0 SE TAXABLE IDICOME SPOUSE: O.Oo TQTAL SELF EMFLOYMEPdT TA2�: �3,557.00 F:ETUF�N DUE DATE OR RETUF..Pd RE�EIVED DATE iWHICHEVER IS LATER) Apr. 15, 2006 PROCESSING DATE May 29, 2006 TRANSACTIONS CODE EXPLANATION OF TFtANSACTION CYCLE DATE AMOUNT 150 Tax rPt,�rn filed 20062006 05-2�-2006 $5,6�1.00 2013/09/19 1.1:23 :14 3 /7 ��%� z�,�zi—i_i—i��o�—` �,'[i Pavm?nt with return 04-20-2006 -$20C.00� 1'76 Fenaity for _�ot �,i:e-payin� taa 20062008 05-29-2005 $22'7.46 275 Penalty for late payment of tax 20052008 O5-;'�-2005 $54.71 � 196 Interest_ charged for late payment 20062008 05-29-2005 $46.36 9'71 Ir.stallrnent acJreement �sta�lished 08-11-200h $O.CO 670 Yayment 09-27-200b -557.00 670 Payment 10-27-200� -$100.�0 670 Payment_ 11-24-2G06 -S100.Cia 6?[! Payment 12-29-200� -5100.G0 67i} Paym�nt 01-28-2GJ� -$100.C�� 670 E��yment 03-01-2007 -,S10C1.00 67U Payment_ U3-29-Z�07 -S10U.OU 670 Payment C�-30-20G7 -$100.00 ?06 Creclit transferred in from 04-15-2007 -525.61 1040 200612 73e Interest credited to your account 04-15-2007 -54.39 10�0 200612 670 Payment 05-25-2007 -5100.00 670 Payment 06-29-2007 -5100.00 570 Payment 07-27-2G07 -$1C�G.00 6"0 Paym?nt 9�-30-200� -$lOC.OQ 6?U Payment 09-2�-2007 -$100.00 6?P� F'ayment 10-3Q-2007 -5100.C10 6�0 Yavment 1'1-29-20U7 -$lOC1.00 6?0 Payment 12-31-2007 -5100.00 2013/09/19 11:23 :14 4 /7 670 Payment 01-28-2008 -5100.00 Gi0 Payment 02-2°-20U8 -5100.G0 670 Pajrment 03-?6-�006' -$1�O.OG 670 Fayment Q4-29-7_��OS' -$1G0.00 706 Credit tiansferred in fiom U4-15-2�JOo -$242.00 1040 200712 67Q P�yment 06-02-200£i -5100.00 �i,,F i='redi' tr;��i.�Terr�=d in trrr.t 0?-14-�Ou8 -S�OO.G� 1i�9'J ini��1=' 670 Paymerit Ci6-30-2008 -$100.00 67G Payment (�7-2�-2008 -$1U0.40 570 Payment 09-02-2008 -$100.C10 670 Payment 10-Ob-200�s -$100.00 b70 Payment 11-10-2008 -$100.00 67C1 Payment 01-05-2009 -5100.00 670 Payment 0:�-27-200a -$50.OG 67C� Pavment 04-30-2009 -$5�.00 670 Payment 06-04-2009 -$50.00 Ei0 Payment 06-27-2�69 -$5G.00 r��i) Pa�ment u?-3p-2009 -r50.00 6?0 Payment 09-02-2GOU -550.00 670 Payment 09-28-2009 -550.00 2Q13/09/19 11: 23 :14 5 /7 7G6 Credit t_ransferred in from 04-15-2009 -$905.00 1040 �OiJ31'� 67� Payment 11-Oa-?OC9 -$50.00 670 PapmEnt i?-09-2C09 -$50.00 E��O Pa•��ment '�1-13-�=01U -550.00 b70 Payment 03-01-201Q -$50.00 6�0 Payment � 04-28-2010 -$50.00 706 Credit tran�ferred in frc�m 04-15-201G -$890.00 1040 200912 971 Tax period block_ed fiom automated levy progr��m �?-��6-2010 $0.00 971 I�To 1oncJer iii inst<�llment agreement statuU �J7-12-2010 50.00 971 Coll�ction ciue process Notice of Intent to Levy -- 07-1:J-20'10 $0.00 issued ��11 Coileetion due �rocess Notice of Intent to Levy -- 07-17-L010 $0.00 return receipt signed �71 Installment agreement est�blished 07-2G-2010 $O.OQ 670 F'�yment 0'0-25-201f -$7.00 67J Fayment �10-ii4-2010 -$50.U0 672 P.er.moved r�ayment 0'a-25-2010 $�i3.UO � CIVIL PENI3LTY 241001 Z08-4�-9397 6i� Payment 0�--'5-2010 -54;.00 5?G Payment 10-28-2010 -55�.00 6?C! Payment 11-29-2010 -$50.00 670 Payment 12-27-201Q -$50.00 276 Penalty for late payment of tax 20110408 02-07-2011 $3L 47 570 P�vment 01-31-2011 -550.00 276 PPnalty for latE paymerit of t�x 20110�08 G2-21-2011 $50.00 67� E'ayment 03-28-2011 -$50.00 276 Penalty for late �ayment of ta� 20111408 04-18-20ll $50.00 67G Payment 04-28-2011 -$50.G0 2013/09/19 11:23 :14 6 /7 276 Penalty for late paYment of taY 2011190� 05-23-2011 550.00 271 Reduced or removed penalty for late payment n� tai: 07-18-2011 -$23h.18 290 Addition�l tax assessad 2011?�08 0?-18-2011 $0.00 � n,'a 0��254-579-0753��-1 1_i6 =titere-t _k_arc;eel for late Ia,,�:nent �'�112�G8 0%-18-'_(!ll $�3b.18 !�1 P;r�tic� i:;su�-� 0?-18-'�011 $0.00 CP 002i 5��1 Pa,,r.i�nt 0?-01-2Q11 -550.00 196 Interest ch�rgea fcr late payment 2U112808 07-25-LO11 S5U.00 530 Balance due accoun� currently not collectable 08-12-2011 50.0� 9?1 Pdo lanc�ar iu inst�llra�nt a�reement status OS-12-2011 �90•OQ Tl-�is Product t��ntains sensitive Tax�aayer �ata �� 1000118032 � PA-40-2010 Pennsylvania lncome Tax Return ENTER ONE LETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted Labef 208424397 N Extens�on. S T E E V E R N Amended Return. C H A R L E S E Occupation R E A L T 0 R R Residency Status. PA ResidenVNonresidenVPart-Year Resident Occupation from to S Single/Marrietl,Fifing Jointly/Married, Fiting Separately/Final Retum/Deceased Date af death CO PAUL EDGER 5006 E TRINDLE ROAD S N Farmers. MECHANICSBURG PA 17050 SchoalDistrictName CAMP HILL 21100 1a Gross Compensation.Do not include exempt income,such as combat zone pay and 1 d 16 2 0 5 qualifying retirement benefits.See the instructions. SEE STATEMENT 1 1b Unreimbursed Employee Business Expenses. 1 b � 1 c Net Compensation.Subtract Line 1 b from Line ta. 1 C 16 2 0 5 2 Interest Income.Complete PA Schedule A if required. 2 0 3 Dividend and Capital Gains Distributions Income.Complete PA Schedule B if required. 3 Q 4 Net Income or Loss irom the Operation of a Business,Prafession or Farm. 4 � 5 Net Gain or Loss from the Sale,Exchange or Dispositian of Property. S 0 6 Net Income or Loss Trom Rents,Royalties,Patents or Copyrights. 6 � 7 Estate or Trust Incoma.Complete and submit PA Schedule J. 7 � 8 Gambling and Lottery Winnings.Complete and submit PA Schedule T. 8 0 9 Tatal PA Taxeble Income.Atld only the positive incame amounts from Lines 1c, 9 16 2 0 5 2,3,4,5,6,7 and 6.DO NOT ADD any losses reported on Lines 4,5 or 6. 10 Other Deductlons.Enter the appropriate code for the type of deduction. N 10 0 See the instructions far additional infarmatlon. 11 Ad)usted PA Taxable income.Subtract Line 10 irom Line 9. 11 16 2�5 o�aooi ,i-ss-,o CCH EC Paye 1 of 2 FC L 1000118032 m m 1000118032 J . 2013/09/19 11:15 :46 2 /6 �� I�.t�rna 1 Rev�nu� S+�-rvice United States Department of the Treasury This Product Contains �ensitive Taxpayer Data Wage and Income Transcript Request D2te: 09-19-2013 Response Date: 09-1.9-2013 Tracking Number: 100172384929 SSN Provided: 'L08-�72-9�97 Tax Period Requested: DecemY,er, 2010 , �.� ' ` I •r, Form W-2 Wage and Tax Statement ►. Employer: Em�,loyer ldentification Number (EIN) : 271656513 i;S RENEWAL SYSTEMS 592 INDUSTRIAL DRIVE LEW7SBERP.Y, PA 17339-0000 Employee: Fmployee's Social Security Number: 208-92-9397 CHARLES E STEEVER � ;498 WALNUT STREET rAMP HILL, PA 17011-n090 Suk,mission Type: Original document/ wages, Tips and Other Compensation: 5692.00� Federal Income Tax Withheld: $0.00/ Social Sacurity Wages: 5632.00 S�cial Security Ta� Wi±hheld: SQ2.00� Medicare Wages and Tips: $692.�0� Medicare Tax Withheld: $10.00� Social Security Tips: $0.00 Allocated Tips: 50.00 Advanced EIC Payment: 50.00 Dependent Care Benefits: $O.O�J Deferred Compensation: ;0.00 Code "Q" Nontaxable Combat F�ay: S0.00 Cede "W" Employer Contribution� *_� a Haalth Savings Account: 50.00 Code "Y" Deferrals under a section 909A nonqualified Deferred ;0.00 ' Compensation plan: Code "Z" Income under �ection 409A on a nonqualified Deferred 50.00 Compensation plan: Code "R" Employer's Contribution t�� MSA: $0.00 Code "S" Employer's Contribution to Simpla Account: ;0.00 Code "T" Expenses Incurred f�r Qtialifi�d Adc�ptians: 50.00 . 2013/09/19 11:15 :46 3 /6 , CodE "V" Income from exercise of non-sY_atutory stock o��tiens: $0.00 Code "AA" Designated �oth Conr_rihutions under n Section 401(k) Plan: 50.00 Code "BB" Designated Roth Contributions under a Section 9U3(b) Plan: 50.00 Code "CC" (Fot employer use ��nly) - HIRE Er.empt WaRes and Tips: S0.00 Third Party Sic}: Pay Indicator: Unanswered P.etirement Plan Indicator: Unanswered Statutory Employee: Not Statutory Employee Form W-2 Wage and Tax Statement Employer: Employer ldentifi�:ation Num1-�es (EIN) : 363739669 TP,UGREEN LIMITED PARTNEP,SHIP E60 RIDGE LAKE BL MSfs2 11U3A MEMFHIS, TN �8120-0000 Employee: Employee's Social Security tdumk�er: 208-92-9�97 CHARLES E STE6VER 3448 WALNUT ST CAMP HILL, PA ]7011-n400 Submissi�n Type: Uriginal document Wages, Tips and O*_her Compensation: S14,838.00� Federal In��ome Ta:; Wittiheld: S1,292.00� Soc:ia'_ Security Wages: 515,174.00� Social Security Tax withheld: S940.00� Medicar? Wages ancl Tips: 515,174.00� Medicare Tax WithhPl�.l: S220.00 � Social Security Tips: 50.00 Allocated Tips: $0.00 Advanced EIC Payment.: 50.00 Dependent Care Benafi?s: $0.00 Deferred Compensati��n: $335.00� Code "Q" Nonta::able Combat Pay: $0_00 Code "W" EmployEr Contributions to a Health Savings Account: $0.00 Code "Y" Deferrals under a section 909A nonqualified Deferred 50.00 Compensation plan: C�xle "Z" Income under section 909A az a nonqualified DefErred $0.00 Compensati�n plan: Code "R" Employer's Contribution te MSA: $O.UO Code "S" Employer's Contribution te Simple Account: 50.00 Code "T" Expanses Incurred for Qualified Adoptions: 50.00 Code "V" Incom? from e�erci�e of nen-statutory stock opticns: $0.00 Cc�de "AA" Designated �o*_h Contributions under a Sec*_icm 901 (k) Plan: 50.00 Code "BB" Designated Rotl-� Contributions ur,der a Section 903(b> Plan: 50.00 Code "CC" iFor employer use only) - HIRE E::empt Waqe� and Tips: $0.00 2hird Party Sick F�ay Indi:ator: Unansv�ered Retirement Plan Indicator: ye�� . 2013/09/19 11:15 :46 4 /6 Statutory Employee: Not Statutory Employee Form 1099-G Payer: Payer's Federal Identification Number (FIN) : 2�6003107 COMMONWEALTH OF PA DEPT C>F LABC�R & IND OFF OF EMPLOYMENT SECUkITY' BMIS D 108 7TH AND FORSTER STS HARRISBURG, PA 17121-0004 Recipient: Recipient's Iden*ification Number: 208-92-4397 STEEVER CHARLES E 39 A 8 WALt7UT ST CAMP HILL, PA 1701I-OOl�O Sut�mission Type: Original document Account Number IOptiunal) : N/A ATAA PaymGrits: 0.00 Tax. Withlield: 0.00 Taxable Grants: 0.00 Unempluyment Compensation: 55,770.00� Agricultural Subsidies: 0.00 Frior `lear Refund: 0.00 Market gain on Cvmmodity Credit Corporation loans repaid 0.00 on ar after January 1, 2007: `lear of Refund: lfot Set 1093G Offset: Net Refund, Credit, or Offset for Trade ot Business Form 1099-R Distributions from Pensions , Annuities , Retire or Profit-Sharing Plans , IRAs , Insurance Contracts , etc . Payer: Payer's Federal Identificatinn Number tPIN}: 521981931 T. ROWE PRICE 4555 PAINTERS MILL RD OWINGS MILLS, MD 21117-OU00 Recipient: P.ecipi2nt's Identifics*_ion Number: 208-4?-A:;��7 STEEVER, CHARLES E 3998 WALNUT ST �AMF HILL, PA 17011-4�i00 . 2013/09/19 11:15:46 S /6 Submission Typa: Original document Account Plumber (Optional) : 20110928143100088252 Distribution Code Value: Early Distribution, exception applies (Under age 59 1/2) Distribution Code: 2'� Distribution Code Value: Not significant Distribution Code: Blank Tax Amount Undetermined Code: Not checked Total Distributivn Code: Total Distribution S�P Indicatar: IRA/SEP/SIMP box not checked Tax Witlzheld: $67.00� Total Empl�yee Contributions: 0.00 Unrealize� Appreciation: 0.00 Other Income: 0.00 Gross Distributi�n: 5339.00� Taxable Amount: 5339.00� Eligible Ca�ital Gains: 0.00 This Product Contains Sensitive Taxpayer �ata � 1000218048 � PA-40-2010 Social Security Number 208424397 Namefs} STEEVER, CHARLES E (DEC• 11/�7 12 PA Tax Liability.Multiply Une t i by 3.07 percent(0.0307). 1� 4 9 7 13 Total PA Tax Withheld.See the instructians. 13 4 8 7 14 Credit from your 2009 PA Income Tax return. 14 � 15 2410 Estimated Installment Payments. 15 0 16 2010 Extension Payment. 16 � 17 Nonresident Tax Withheld from your PA Schedule(s)NRK-1.(Nonresidents only) 17 � 18 Tatal Estfmated Payments and Credits.Add Lines 14,15,16 and 17. 18 � Tax forgiveness Credlt.Submit PA Schedule SP. 19a Filing Status: 01 Unmarried or Separated 02 Marrled 03 Deceased 19 a 00 19b Qependents,Part B,Line 2,PA Schedule SP 19 b 0 D 20 Total Eligibility Income fram Part C,Line 11,PA Schedule SP. 2 0 0 21 Tax Forgiveness Credit from Part D,Line 16,PA Schedule SP. 2 7, 0 22 Resident Credit.Submit your PA-Schedule{s)G-R with your PA-Schedule(s)0-S,a-L and/or RK-1. 2 2 0 23 Total Other Credits.Submit your PA Schedule OC. 2 3 � 24 TOTAL PAYMENTS and CREDITS.Add Lines 13,18,21,22 and 23. 2 4 4 87 25 TAX DUE. If Line 12 is more than Line 24,enter the difference here. 2 5 1� 26 Penalties and Interest.See the Instructions. Enter Code: L 2 6 7 If including form REV-1630/REV-1630A,mark the box. N 27 TOTAL PAYMENT DUE.See the instructions. STMT 2 2 7 17 28 OVERPAYMENT.If Line 24 is more than the total of Une 12 and Line 26,enter 2 8 0 the difference here. The total oi Lines 28 through 35 muet equal Une 28. 29 Refund--Ameunt of Line 28 you want as a check mailed to you. Refund 2 9 0 30 Credit--Amount of Line 28 you want as a credit to yaur 2011 estimated accoun� 3� 0 31 Amount of Line 28 you want to donate to the Wild Resource Conservation Fund. 31 � 32 Amount of Line 28 you want to donate to the Military Family Relief Assistance Program. 3 2 0 33 Amount of Line 28 you want to donale to the Governor Robert P.Casey Memorial 3 3 0 Organ and Tissue Donation Awareness Trust Fund. 34 Amount of Line 28 you want ta donate to the Juvenile(Type 1)Dfabetes Cure 3 4 0 Research Fund. 35 Amaunt oi Line 28 you want to donate to the PA Breast Cancer Coalition's Breast 3 5 0 and Cervicai Cancer Research Fund. $IQI12tUf2�S�.Under penalties of perjury,I(we)declare that I(we)have examined this retutn,including ell accomp nying schedules end staiements,and the best of my(our)ballef,they are true,correct,end complete. You ignature Spouse's Signature,if fifing jointly E-File Opt Out N Preparer's Name elephon mber Date �o �`t FirmFEIN 231583249 WAGGONER, FRUTIGER & DAUB, LLP 717-5 0 6-12 2 2 Preparer's ssN�r�N P 0 0 0 9 4 6�9 o�aaoz ,,.zs-,o CCH Page 2 of 2 � 1000218048 1000218048 J . � 1001910023 PA SCHEDULE W-2S Wage Statement Summa PA-40 Schedule W-2S(09•10)(I) 2�1� OFFICIAL USE ONLY Summary of PA Taxable Employee,Non-employee and Miscellaneous Compensation Name shown first on the PA•40(if filing jointly) 5oclal SeCUrity Number(shown first) STEEVER CHARLES E DEC. 11 07 11 208-42-4397 Use thls schedule to list and calculate your total PA taxable compensatfon and PA tax withheld from ail sources. Part A Inatructions:List each Federal Form W-2 for you and your spouse,if marriad,received irom your employer(s).In the first column enter T for the taxpayer's Social Security Number that appears flrst on the PA tax return antl enter S tor the second or spouse SSN.From the forms W-2,enter each employer's federal identification number.Enter the amounts from the Forms W-2 in each column.IMPORTANT:You do not have to submit a copy of your Form W-2 it you earnad ail your income in Pennsylvania and your employer reported your PA wages correctly and withheld the correct amount of PA incoma tax.You muet aubmit a copy of your Form W-2 in certain circumstances.See the PA Schedule W-2S insVuctions for a list of when a copy af a W-2 is required. Part 8 Instructions:List each source of income received during the taxable year on a form or statement other than a Federai Form W-2.Enter each payer's name.List the payment type that most closely describes the source of your non-employee compensation.Enter the amount oi other compensation that you earned.If the form or statement does not have separately stated amounts,enter the amount shown in both federal and PA columns. IMPORTANT:You must submit a copy of each torm and statement that you list in Part B,whether or not the payer withheld any PA income tax and regardless of whether or not the income was taxable in PA.CAUTION:The federal and Pennsylvania(state)wages may be different in Part A and Part B. If ou need more s ace ou ma hotoco thfs schedule or make our own schedules in this tormat. Part A-Federal Forms W-2 T/S Employer's identfticatfon number from Box b Federal wages Medicare wages PA compensation PA income ta�c from Box 1 from Box 5 trom Box 16 wRhheld from Box 17 T 27-1656513 692. 692. 692. 21. T 36-3734669 14 838 . 15 174. 15 174. 4b6. Total Part A-Add the Penns Ivania columns 15 8 6 6. 4 8�. Part B-Miscellaneous and Non-employee Compensation from Federal Forms 1099-R,1099-MISC and other statements YOU MUST SUBMIT COPIES OF EACH FORM OR STATEMENT LISTED IN THIS PART A. B. C. D. E. F. a. H. T/S Type Payer name t099R code Total federal amount Adjusted plan basis PA compensation PA tax withheld T I ROWE PRICE 2 339. 339. Total Part B-Add the Pennsylvania columns 3 3 9. TOTAL-Add the totafs trom Parts A and B 16 2�5. 4 8 7. Enter the TOTALS on your PA tax return on: Line 1a Une 13 Payment type: A. Executor fee B. Jury duty pay C. Director's fee D. Expert witness fee a�a�s� E. Honorarium F. Covenant not to compete Ci. Damages or setllement for lost wages,other than personal fnJury ,o-�e-,o H. Other nonemployee compensation.Describe: CCH I. Distributlon from employer sponsored retirement,pension ar qualitied deterred compensation plan J. Distributlon irom IRA(Traditional or Roth) K. Distribution from Life Insurance,Annuity or Endowment Contracts L. Distribution lrom Charitable Gitt Annuities � 1001910023 1D01910023 J ' PA-40 GROSS COMPENSATION AND WITHHOLDING STATEMENT 1 DESCRIPTION INCOME TOTAL WITHHOLDING MISCELLANEOUS INCOME - FROM SCH MC 339. 339. 0. KS RENEWAL SYSTEMS 692. 21. TRUGREEN LIMITED PARTNERSHIP 15,174. 466. WAGES RECEIVED - SUBTOTAL 15,866. TOTAL TO PA-40, LINE 1A 16, 205. TOTAL TO PA-40 , LINE 13 487• PA-40 BALANCE DUE STATEMENT 2 DESCRIPTION AMOUNT BALANCE DUE BEFORE INTEREST OR PENALTY 10. LATE PAYMENT INTEREST 1• LATE PAYMENT PENALTY 1• LATE FILING PENALTY 5• BALANCE DUE AFTER INTEREST AND/OR PENALTY ON PA-40 17. STATEMENT(S) 1, 2 �. � � • CAMP HILL BOROUGH GENERIC Local Earned Income Tax Return �O�O Your social security number 7axpayer's name and address 2 0 8-4 2-4 3 9 7 STEEVER, CHARLES E(DEC. 11/07/11) Spouse's social security number C/0 PAUL EDGER 5 0 0 6 E TRINDLE ROAD SUITE 2 0 3 part-year dates MECHANICSBURG, PA 17050 from �o 7axpayer from to Spouse Tex a erlJoint S ouse Income �, 15 866. 1. Gross earninps reported on W-2's ........................................................................ 2. 2. Allowable nonreimbursed employee business expense ............................................. 3 3 9. 3. Other incomeAoss ......................................... 3. ................................................... 4. 4. Losses irom business,profession,farm,etc............................................................ 5 16 2 0 5. 5. Taxable W-2 earnings ....................................................................................... 8. 8. Net income/loss from business profession,farm,etc .......................................... ...... 7. TOTAL TAXABLE EARNED INCOME ....................... 7• 16 �O 5. Tax Computation e. 2.0 0 0 0 % % 8. Tax rate............................................................................................................ 9 3 2 4. 9. TAX LIABILITY ................................................................................................ Payments and Credita 10. Taxwithheld...................................................................................................... 10. 317. 11. Estimated tax PaYments....................................................................................... 11. 12. Credit for priar year overpayment 12' 13. Credit for tax paid to Philadslphia........................................................................... 13. . 14. 14. Credit tor tax paid to other states........................................................................... 15. Other credits...................................................................................................... 15. 16. TOTAL PAYMENTS AND CREDITS ........................................................................ 16. 317. Re(und or Amount Due �. 17. Tax due............................................................................................................ 17. 18. Occupational/other taxes 18' .................................................................................... 19. 19. Interest ...................................................................................................... 20. Late penal�Y...................................................................................................... 20. 7. 21. Amount due...................................................................................................... 21. 22. Overpayment �Z' ................................................................................................... 23, Amount applied to next year's estimated tax ............................................................ 23• 24. AmOUntduewithreturn ...................................•.••.•.••..•••.••••...AMOUNTYOUOWE 24. �• 26. Amounttoberetunded ...........................................................................REFUND 25. MAIL THIS RETURN T0; CUMBERLAND COUNTY TAX BUREAU 21 WATERFORD DRIVE SUITE 201 MECHANICSBURG, PA 17050 Under enalty of perjury,I declare that I h e examined the return and to the best of my knowledge and belief,it is true,correct,and complete. ��'�I S" r Taxpayer's ' ure Date Spouse's Signature Date LISA M STATLER 10/14/13 Wagganer,kutl�ge�&Daub,LLP Prepared by Other Than Taxpayer Date 5Q06 E Tdndl6 ROad Suite 200 WAGGONER, FRUTIGER & DAUB, LLP Mechanlcsb�u�rg PA 17050-3647 71T-506-1222 oso°•'�0 5006 E TRINDLE RD SUITE 200 MECHANICSBURG, PA 17050 2 11341014 706230 LMS-STEEC 2010. 06020 STEEVER, CHARLES E LMS-STC1 • • 2013/09/19 11:15 :46 2 /6 ��Int�rna l Re��nue S��vice United States Department of Che Treasury• This Product Contains Sensitive Ta�_payer Data Wage and Income Transcript Request Date: 09-19-2013 Response Date: 09-19-2013 Tiacking Number: 100172384929 SSN Provided: 208-42-4"s9'7 Tax Period Requested: December, 2010 I �� I Form W-2 Wage and Tax Statement ►. Em�loyer: Employer ldentificatiun Number (ETN) : %71656513 F:S RENEWAL SYSTEMS 592 INDUSTRIAL DRIVE LEWISBERP.Y, PA 17;39-U000 Employee: &mployEe's Social Security �'umber: 208-A2-9397 CHARLES E STEEVER 3948 WALNUT STkEET CAI�IP HILL, PA 17011-0090 Submissicn Type: Uriginal document i 4Jages, Tips and Other Compensa*_ion: Sb92.00� Federal Income Tax Wir_hheld: 50.00, Sucial Security Wages: 5692.00 Social Security Ta� Withheld: S42.0�� Medicare Wages and Tips: 5692.00� Medicare Tax Withheld: $10.0� Sucial Security Tips: 50.00 Allocated Tips: 50.00 Advanced EIC Payment: 50.00 Dependent Care Benefits: $p.pp Deferred Compensation: ;0.00 Code "Q" Nontaxable Combat Fay: 50.00 Code "S+i" Employer Centributions t:� a H�alth Savina� Acr_ount: $0.00 C�xie "Y" Deferrals under a secticn 90��A nonqualified Deferrea ;0.00 � Compensation plan: Code "Z" Income under sectior, �]09A on a nonqualified Deferred 50.00 Compen�ation plan: C�xle "k" Employer'� Contrihution ko hiSA: $0.00 C�xie "S" Employer's Contribution r_,, Sim�.�le Account: ;0.00 Code "T" Expenses Incu_*red ior Q�.�alifi�d Ado��tions: 50.00 . . 2013/09/19 11:15 :46 3 /6 Code "V" Income from exercise of non-statutory stock oprions: S0.00 Code "AA" Designated koth Contributions �nder a SeCtlot] 901(k) Plan: $0.00 Code "BB" Designated P,o*_h Contributions under a Section 903(b) Plan: 50.00 Cc�e ^CC" {Fer empluyer use only) - HIRE E•r.empt Waqes and Tips: 50.00 Third Party Sick Pay Indicator: Unanso�ered P.etirement Plan Indicator: Unanswered Statutory Employee: Not Statutory Employee Form W-2 Wage and Tax Statement Employer: Employer ldentifi�:atian Number (EIN) : 363734G69 TRUGREEN LIMITED PARTNEP,SHIP E60 RIDGE LAKE BL MSS2 11U3A MEMFHIS, TN �9120-OU00 Employee: Employe2's Social Security tlumber: 208-92-9397 CHARLES E STEEVER 3448 WALNUT ST CAMP HILL, PA ]7011-OGGO Submissi�n Type: Original document Wages, Tips ane� Other Com�ensation: S14,838.00� Federal Ir,come Ta:; Witt�held: 51,292.00� Social Se�urity tlages: S15,174.00� Social Security Ta:: withheld: S940.00� Medicar? Wa7�s and Tips: 515,174.00� Medicare Tax 4lithhel�: 5220.00 � Social Security Tips: 50.00 Allocated Tips: 50.00 Advanced EIC Payment.: $0.00 Dependent Care Benefits: 50.00 Deferred Compensation: 5335.00� Code "Q" Nonta�.able Combat Pay: 50.00 Code "w" Employer ContriUutions to a Health Savings Account: $0.00 Code "Y" Defarrals under a section 90gA nonqualified Deferred 50.00 Compensation plan: C�xle "Z" Income under section 409A on a nonqualified Deferred $0.00 Compensation pla�i: Code "R" Employer's Contributian te MSA: SO.UO Code "S" Employer's Contribution te Simple Account: 50.00 Cade "T" Expenses Incurred for Qualified Adoptions: $0.00 Code "V" Income from e:ercise af nen-statutory stock c�ptions: SQ.00 Code "AA" Designated Foth Cantrihutions under a Sectic�n 401 (1:) Plan: 50.00 Cade "BB" De�ignated Roth Contributions under a Section 9U3(b} Plan: $0.00 Code "CC" iFor employer use only) - HIRE E::empt Waqes and Ti�s: 50.00 Third Party Sick Fay Indicator: Unanswered Retirement Plar, Indicator: Yes� . . . 2013/09/19 11:15 :46 4 /6 Statutory Employee: Not Statutory Employee Form 1099-G Payer: Payer's Federal Identification tJumber (FIN1: 236t)U3107 COPIINONWEALTH OF PA DEPT OF LAROR & IND OFF OF EMPLOYMENT SECUkITY BMIS D 108 7TH APdD FORSTER STS HARRISBURG, PA 1�121-OUO�� Recipient: Recipient's Iden*_ification Number: �08-92-4397 STEEVER CHARLES E 399i3 WALI7UT ST CAMP HZLL, PA 17011-�O1�0 Submission Type: Original document Account Number (Optiunall : N/A ATAA Paym�nts: 0.00 Tax. Withheli�: 0.00 Taxable Grants: 0.00 Unemployment Compensation: 55,770.00� Agricultural Subsidies: 0.00 Frior Year Refund: 0.00 Market gain on Commodity Credit Corporation loar,s re��aid 0.00 on ar after January 1, 'L007: Year of Refund: Not Set 1099G Offset: 17ot Refund, Credit, or Offset for Trade or Business Form 1099-R Distributions from Pensions , Annuities , Retire or Profit-Sharing Plans , IRAs , Insurance Contracts , etc . Payer: Payer's Federal Identificatinn NumL�er (FIN): 5219R1931 T. ROWE PRICE 9555 PAINTERS MILL RD OWINGS MILLS, MD 21117-nG00 Recipient: Recipient's Identifica*_ion NumL-�er: 208-92-9�97 STEEVER, CHARLES E 3498 WALNUT ST CAMF H?LL, PA 17011-Oi!�?0 . � . 2013/09/19 11:15:46 5 /6 Submission Typ=: Oriqinal document Account Number (Optional) : 20110928143100068252 Distribution C�de Value: Eazly Distribution, e�ception applies (Under aqe 59 1/2) Distribution Code: 2✓ DistriUution Code Value: Not siqnificant Distribution CodE: Blank Tax Amount Undetermined C�e: Not checked Total Distributian Code: ToCal Distribution SEP Zndicator: IRA/SEP/SIMP box not checked Tax Withheld: 567.00� Total Employee Contributions: 0.00 unrealized Appreciation: 0.00 Other Inceme: 0.00 Gross Distributien: $339.00� Taxable Amount: $339.00� Eligible Capital Gains: 0.00 This Product Contains Sensitive Taxpayer Data f • � 1100119021 � PA-40-2011 Pennsylvania lncome Tax Return ENTER ONE LETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted Label 2 0 8 4 2 4 3 9 7 N Extens�on. S T E E V E R N Amended Return. C H A R L E S E Occupation R E A L T 0 R R Residency Status. PA ResidenVNonresidenVPart-Year Resident Occupation from to D Single/Married,Filing Jointly/Married, Filing Separately/Final Return/Deceased oate of deatn 110 711 CO PAUL EDGER 5006 E TRINDLE ROAD S N Farmers. MECNANICSBURG PA 17050 schoo�oistrictName CAMP HILL 21100 ia Gross Compensation.Do not include exempt income,such as combat zone pay and 1 a 2 2 3 6 qualifying retirement benefits.See the instructions. SEE STATEMENT 1 1b Unreimbursed Employee Business Expenses. 1 b 0 tc Net Compensation.SubUact Line ib from Line 1a. 7,C 2 2 36 2 Interest Income.Complete PA Scheduie A If required. 2 0 3 Dividend and Capital Gains Distributions Income.Complete PA Schedule B if required. 3 0 4 Net Income or Loss from the Operation of a Business,Profession or Farm. 4 0 5 Net Gain ar Loss from the Sale,Exchange or Disposition of Property. 5 0 6 Net Income or Loss from Rents,Royalties,Patents or Copyrights. 6 0 7 Estate or Trust Income.Complete and submit PA Schedule J. 7 0 8 Gambling and Lottery Winnings.Complete and submit PA Schedule T. 8 0 9 Total PA Taxable Income.Add only the positive income amounts from Lines 1c, 9 2 23 6 2,3,4,5,6,7 and 8.DO NOT ADD any losses reported on Lines 4,5 or 6. 10 Other Deductions.Enter the appropriate code for the type of deduction. N 10 D See the instructians for additianal information. 11 AdjustedPATaxablelncome.SubtractLinelOfromline9. 11 2236 iiaoai �a-zz-ii CCH EC Page 1 of 2 FC � 1100119021 � m 1100119021 � , 2013/09/19 11:01:25 2 /7 �� Intei�na 1 R�v�nue S ervice United States Department of the Treasur� This Product Contains Sensitive Taxpayer Data Wage and Income Transcript Request Date: 09-19-2013 Fesponse Date: 09-19-2013 Trackiny Numher: 100172384929 SSN Provided: 2U8-92-9:i97 Tax Period Requested: December, 2011 Form W-2 Wage and Tax Statement Employer: Employer ldentification Number (EIN} : 271656513 KS RENEWAL SYSTEMS 592 INDUSTF;IAL DRIVE LEWISBERRY, PA 17�39-0000 Employee: Employee's Social Security Number: 208-42-9397 CHARLES E STEF.VER 3948 WALNUT STP.EET CAMP HILL, PA 17011-OOfjU Submission Type: Original document 4lages, Tips and Other Cempensation: 52,198.0f� Federal Income Ta� Withheld: $0.00 Social Security Wages: $2,198.00� Sorial Security Ta:c Withheld: S92.00� Medicare Wages and Tips: ;2,198.00� Medicare Tax Withheld: 531.00� Social Security Tips: $0.00 Allocated Tips: 50.00 De�endent Care Benefits: 50.00 Deferred Compensation: 50.00 Cxle "¢" Nontaxable Combat Pay: 50.00 C�xie "W" Employer Centribu+_ions to a Health Savinys Account: $0.00 C�xie "Y" Deferrals under a section 409A nonqualified Deferred 50.00 Compensation plan: C�xas "i" Inceme under section 909A on a nonqualified D?ferred 50.00 �om�ensation plan: Code "F," Empluyer's Contribution t�� MSA: $0.00 rode "S" Employer'� Contribution to Simpl? Account: 50.00 C�xie "T" Expenses Incuried ior QualiYied Ado�:�tions: 50.00 CcK3e "V" Income from �r:ercise of non-sta*_u*_ory s*_ock options: $0.00 , 2013/09/19 11:01:25 3 /7 Code "AA" Desiqnated P.oth Contributions under a Section A01(�) Flan: 50.00 Code "BB" Designated Foth Contrit�utions under a Section �03(b) Plan: $0.00 Code "DD" Cost of Employer-Sponsarect Health Coverage: 50.00 Cade "EE" Designated ROTH Contrik�utia�is Under a Governmental Section 50.00 457(b) Plan: Third Party Sick Pay Indicater: Unanswered Fetirement Plan In�licator: Unanswered Not Statutory Statutory Employee: Employee Form W-2 Wage and Tax Statement Employer: Empleyer ldentification Number (EIPJ): 2�5493859 BARkUS V PICKS ;,PORTING GOODS QSF PG BOX 2258 FARIBAULT, MIJ 55021-0000 Employee: Employee's Social Sacurity Number: 208-42-9397 CHARLES E STEEVER 3998 WALNUT ST CAMP HILL, PA 17011-2799 Submission Type: Original document Sdages, Tips and Uther Compensation: $20.00'� Federal Zncame Tax Wi*_hheld: $5.00 '� Sor_idl Security Wages: S20.00� Social Security Tax Withheld: $0.00 1 t4edicare Wayes and Tir�s: 920.00 Medicare Tax Withhelrl: 50.00 Social Security Tips: S0.00 Allocated Tips: 5�.00 Dependent Care Benefits: S0.00 Deferred Compen.ation: 50.00 Code "Q" Nonta}:able Combat Pay: 50.00 Code "W" Employer Contributions to a Health Savings Account: ;0.00 Co�e "Y" Daferrals under a section 909A n�nqualified Deferred 50.00 Compensation plan: Code "Z" Income under section 409A un a nonqualifiad Deferred ;0.00 Compensation plan: Cc�de "R" Employer's Contribution to t�ISA.: $0.00 Code "S" Employei`s Contributi��n to Simple Accuunt: $0.00 Code "T" E�penses Incurc�d for Qualified Acloptiens: 50.00 Code "V" Incom? from ��.ercise of non-statutcry stock options: S0.00 Code "AA" Designated koth Contributions under a Sectic•n 901(4:) Plan: 50.00 Code "BB" Designated Foth C�ntrik+utions under a Sectien 903(b1 Plan: 50.00 Code "DD" Cost of Employar-Spon�ored Health Coverage: 50.00 Code "EE" Designate�i F.OTFi Contril_�utions Ur�dec a Gevernmental Section 50.00 457(b) Plan: Thir�l Farty Sick Pay Indi�:ator: Un«nstirered . 2013/09/19 11:01:25 4 /7 Retirement Plan Indicatoz: Unanstirered Statutozy Employee: Not Statutory Employ?e Form W-2 Wage and Tax Statement Employer: Employer ldentificatien Number (EIN): 275993859 BARRUS V DICKS SFORTING GOODS QS PO SOX 2258 EARIBAULT, MN 55021-0000 Ernployee: Employee's Social Security Number: 20E-42-9397 CHARLES E STEEVER 3448 WALNUT ST CAMP HILL, PF� 17011-0000 Submission Type: Amanded �iocument Wages, Tips and Other Comperisation: 50.00 Federal Income Tax Withheld: 50.00 Social Security Wages: $0.00 S�cial Security Tax Withheld: $0.00 Medicare Wages and Tips: $0.00 Medicare Tax Withheld: 50.00 Social Security Tips: $0.00 Allocated Tips: ;0.00 Dependent Care Benefits: 50.00 Deferred Compensation: 50.00 Code "Q" Nontaxable C:ombat Pay: $0.00 Code "W" Employer Contributions to a Health Savings Account: 50.00 Cc+de "Y" Deferrals under a section 909R nonqualified Deferred $0.00 Compensation plan: Code "Z" Income under section 409A on � nonqualifie�l Deferred $0.00 Cc,mpensation plan: Code "k" Employer's Cantribution to MSA: 50.00 Code "S" Employer's Contribution to Simple Account: 50.00 Code "T" Expenses Incurrecl for Qualified Adoptions: ;0.00 Code "V" Income from exercise of non-statutory stocY, options: 50.00 Code "AA" Designated Roth Gontrik�utions under a Section 401(k} Plan: $0.00 Code "BB" Desiqnated Roth Contributions under a Se��tion 903(b) Plan: 50.00 Code "DD" Cost of Employer-Sponsored Health Coverage: 50.00 Code "EE" Designated ROTH Centributions Uncier a Go•,�?rnmental Section 50.00 957(b) Plan: Third Party Sick Pay Indicatnr: Unanswered Retirement Plan Indicator: Unanswered Statutory Employea: Not Statutory Employee Form 1099-G , 2013/09/19 11:01:25 5 /7 Payer: Fayer's Federal I�entification Number (FINy: 235003107 COMMONWEALTH OF FA DEPT OF LABOR +� IND OFF OF EMPLOYTdENT SECURITY BMIS D 106 7TH AND FORSTER STS HARkISBURG, PA 1'7121-0000 Recipient: Recipient's Identificatien Number: 208-92-4397 STEEVER CHARLES E 3498 47ALP�UT ST CAMP HILL, PA 17011-0000 Submission Type: Originai documen* Account Number fOptional? : N/A ATAA Fayments: 0.00 Tax Withheld: 0.00 Ta}:able Grarits: 0.00 Unemployment Comrensati�n: 58,235.00� Ayricultural Subsidies: 0.00 Prior Year Refund: O.nQ MarY,et gair� on G�mmcdity Cre�9i*_ Corporation loans repai�� 0.00 er, or azt?r January 1, 2007: Year c�f P,�fur�d: idot Set 1099G OffSe.*.: Nat Refund, Credit, or Offset for Trade or Business Form 1099-R Distributions from Pensions , Annuities , Retire or Profit-Sharing Plans , IRAs , Insurance Contracts , etc . Payer: F•ayer's Federal Identificati.on Number (FIN): 521481931 T. FOWE PRICE UM 429U 4515 PAINTERS MILL RD GWINGS MILLS, MD 21117-0000 Recipient: Recipient's Identification Number: 208-92-4397 STEEVER, �HARLES E 399� WALNUT ST CAMF HILL, PA 17011-0000 Submis_°•ion Type:. Orig.inGl document Account Number (Optionali : 20120926131800088552 Distribution Ccde Value: Early Distribution, axception ap�lies (Under aye 59 1/2) Distributic�r, Cer.la; Z Distribution Cr_��e �alue: tic�t S!i(111f1Cdnf .. 2013/09/19 11:01:25 6 /7 Distribution Code: Blank Tax Amount Undeterminerl Cxte: Not checked Total Distribution Code: Total Distribution First Year Roth Contribution: 0000 SEP Indicator: IRA/SBP/SIMP bo:: nat checked Tax Withheld: p,pp Total Employee Contributions: 0.00 Unrealized Appreciation: 0.00 Other Income: 0.00 Gross Distribution: g � is.00r, Taxable Amount: 518.00 Eligible Capital Gains: 0.00 Amount to IRP.: 0.00 Tl�is Product Contains Sensitive Taxpayer Data 1100219037 � PA-40-2011 L Social Security Number 20842439? Name(s) STEEVER, CHARLES E (DEC• 11/07 12 PA Tax Uability.Multiply Line 11 by 3.07 percent(0.0307). 12 6 9 13 Total PA Tax Withheld.See the instructions. 13 6 8 14 Credit irom your 2010 PA Income Tax return. 14 0 15 2011 Estimated Instailment Payments.REV-4598 incladed. N 15 0 16 2011 E�ension Payment. 16 0 17 Nonresident Tax Withheld from your PA Schedule(s)NRK-1.(Nonresidents only) 17 0 18 Total Estimated Payments and Credite.Add Unes 14,15,16 and 17. 18 � Tax Forgiveness Credit.Submit PA Schedule SP. 19a Filing SWtus: O1 Unmarrled or Separated 02 Married 03 Deceased 19 a �0 19b Dependents,Part B,Line 2,PA Schedule SP 19 b 0 0 20 Tutal Eligibiilty Income from Part C,Line 11,PA Schedule SP. 2� 0 21 Tax Fargiveness Credit from Part D,Line 16,PA ScheEule SP. 21 0 22 Resident Credit Submit your PA•Schedule(s)0-R with your PA-Schedule(s)�-S,G-L and/ar RK-1. 2 2 0 23 Total Other Credits.Submit your PA Schedule OC. 2 3 � 24 TOTAL PAYMENTS and CREDITS.Add Lines 13,18,21,22 and 23. 2 4 6 8 25 USE TAX.Add amount.See instructions. 2 5 0 26 TAX DUE.If the total of Line 12 and Line 25 is more than line 24,enter the diHerence here. 2 6 ], 27 Penalties and Interest.See the instructlons. Enter Code: L 2 7 5 If including form REV-1630/REV-1630A,mark the box. N STMT 2 28 TOTAL PAYMEHT DUE.See the instructions. 2 B 6 29 OVERPAYMENT.If Line 24 is more than the total of Line 12,Line 25 and Line 27,enter 2 9 0 the difference here_ The totai of Lfnes 30 throuph 36 musi epual Line 29. 30 Retund--Amount of Line 29 you want as a check mailed to you. Refund 3 0 0 31 Credit-•Amount of Une 29 you want as a credit to your 2012 estimated account. 31 0 32 Amount of Line 29 you want to donate to the Wfid Resource Conservation Fund. 3 2 0 33 Amount of Line 29 you want to donate to the Military family HeHef Assiatence Program. 3 3 0 34 Amaunt o(Line 29 you want to donate to the Governor Rabert P.Casey Memorial 3 4 � Organ and Tissue Oonation Awareness Trust Fund. 35 Amount of Line 29 you want to donate to the Juvenile(Type 1)Diabetes Cura Research Fund. 3 5 � 36 Amount of Line 29 you want to donate to the PA Breast Cancer Coalftion's Breast and Cervical Cancer Research Fund. 3 6 0 . SIQ�8tU�2�S�.Under penaltfea ol perjury,I(we)declere that I(we)hflve examinetl thia return,IncluOing alt eccompanying schedules end tamenta,and the best ol my�ou�)belief,they are Vue,carect,end complete. Your Signature Spouse's Signature,if filing jointly Preparer's Name an eleph ber Date E-File Opt Out �o (� � WAGGONER, FRUTIGER & DAUB, LLP FirmFEIN 231583249 717-5�6-1222 Preparer'sPTIN P00094609 ,�aoo2 ,2•22-„ ccH page 2 of 2 L 1100219037 1100219037 �,,,� , � 1101910022 PA SCHEDULE W-2S ' Wage Statement Summa PA-40 Schedule W-2S(OS-11) 2�1� OFFICIAL USE ONLY Summary of PA-Taxable Employee,Non-employee and Miscellaneous Compensation Name shown first on the PA•40(if�ling Jointly) SoClal SeCUrity Number(Shown firSi) STEEVER, CHARLES E (DEC. 11/07/11) 208-42-4397 Use this schedule to list and calculate your total PA-taxable compensatian and PA tax withheld from all sources. Part A Instructlons:List each Federal Form W-2 for you and your spouse,if married,received from your employer(s).In the first column enter T for the taxpayer's Social Secur(ty Number that appears flrst on the PA tax return and enter S for the second or spouse SSN.From the Forms W-2,enter each employer's Tederal identification number.Enter the amounts from the forms W-2 In each column.IMPORTANT;You do not have to submit a copy of your Form W2 it you earned all your income in Pennsylvania and your employer reparted your PA wages correctly and withheld the correct amount of PA income ta�c.You muat submit a copy of your Form W-2 in certain circumstances.See the PA Schedule W-2S instructions for a list of when a copy oi a W-2 is required. Part B Instructions:Ust each source of income received during the taxable year on a form or sWtement other than a Federaf Form W-2.Enter each payer's name.List the payment type that most closely describes the source of your non•employee compensatian.Enter the amount of other compensation that you earned.If the form or statement does not have separately stated amaunts,enter the amount shown in both Federal and PA columns. IMPORTANT:You must submit a copy af each farm and statement that you list in Part B,whether or not the payer withheld any PA income tax and regardiess of whether or not the income was taxable in PA.CAUTION:The federal and Pennsylvania(state)wages may be different in Part A and Part B. If ou need more s ace ou ma hotoco this schedufe or make our own schedutes in this format. Part A-Federal Forms W-2 SEE THE INSTRUCTIONS FOR WHEN TO SUBMIT FORM S W2 T/S Employer's identification number irom Box b Federal wages Medicare wages PA compensation PA income tax from Box 1 from Box 5 from Box 16 withheld from Box 17 T 27-165b513 2 198. 2 198. 2 198. 67. T 27-5493854 20. 20 . 20. 1. Total Part A-Add the Pennsylvania columns 2 218. ($. Part B-Miscellaneous and Non-employee Compensation from Federal Forms 1099-R,1099-MISC and other statements YOU MUST SUBMIT COPIES OF EACH FORM OR STATEMENT LISTED IN THIS PART A. B. C. D. E. F. Ci. H. T/S Type Payer name 1099R code Total federal amount Adjusted plan basis PA aompensation PA tax withheld T I ROWE PRICE 2 18. 0. 18. 0. Total Part B-Add the Pennsylvania columns 1$. TOTAL-Add the totals from Parts A and B 2 2 3 6. 6 8. Enter the TOTALS on your PA tax return on: Line ia Line 13 Payment type: A. Executor fee B. Jury duty pay C. Director's fee D. Expert witness fee ��a�3, E. Honorarium F. Covenant not to compete G. Damages or settlement(or lost wages,other than personal injury �o-os-�� H. Other nonem lo ee compansation.Describe: ccH p y I. Distribution from employer sponsored retfrement,pension or qualified deterred compensation plan J. Distribution from IRA(Traditional or Roth) K. Distribution from Life Insurance,Annuity or Endowment Contracts �. Distribution from Charitable GiR Annuities � 1],01910022 1101910022 J PA-40 GROSS COMPENSATION AND WITHHOLDING STATEMENT 1 DESCRIPTION INCOME TOTAL WITHHOLDING MISCELLANEOUS INCOME - FROM SCH MC 18 . 18 . 0. KS RENEWAL SYSTEMS 2 ,198 . 67. BARRUS V DICKS SPORTING GOODS QSF 20. 1. WAGES RECEIVED - SUBTOTAL 2,218 . TOTAL TO PA-40 , LINE 1A 2, 236. TOTAL TO PA-40 , LINE 13 68. PA-40 BALANCE DUE STATEMENT 2 DESCRIPTION ,z�p� BALANCE DUE BEFORE INTEREST OR PENALTY 1. LATE FILING PENALTY 5� BALANCE DUE AFTER INTEREST AND/OR PENALTY ON PA-40 (. STATEMENT(S) 1 , 2 :� g • ' CAMP HILL BOROUGH • GENERIC 2011 Local Earned Income Tax Return Taxpayer's name and address Your social security number 208-42-4397 STEEVER, CHARLES E(DEC. 11/0 7/11) Spouse's social security number C/O PAUL EDGER 5006 E TRINDLE ROAD SUITE 203 MECHANICSBURG, PA 17 0 5 0 Part-year dates from to Taxpayer from tp Spouse Ineome Tax a eNJoint S ouse 1. Gross earnings reported on W-2's ........................................................................ 1. 2 218. 2. Allowable nonreimbursed employee business expense ............................................. p, 3. OtherincomeAoss ............................................................................................. 3. 18. 4. Losses irom busin8ss,profession,tarm,elC............................................... q, 5. Taxable W-2 earnings ............................... ......... ......... ......... ............ s. 2 2 3 6. 8. Net fncome/loss from business profession,farm,etc ...................................... ...... . g, 7. TOTAL TAXABLE EARNED INCOME ............................................... ......... .. ....... 7. 2 2 3 6. Tax Computaiion e. Tax rate............................................................................................................ e. 2.0 0 0 0 � % 9. TAXLIABILITY ................................................................................................ 9. 45. Payments and Credits 10. Tax withheld...................................................................................................... 10. �4. 1 t. Estimated t2x payments....................................................................................... 11. 12. Credit far prior year overpayment ................................... .. .... ... .................... 12. 13. Credit for tax pa(d to Philadelphia........................... ................... . .. ..... ......... .... 13. 14. Credit for tax paid to other states........................... ... ... .................. .. ..... ......... 14. 15. Other credits...................................................................................................... 15. 16. TOTAL PAYMENTS AND CREDITS .................................... ....................... ........ . 16. 4 4. Retund or Amount Due 17. Tax due............................................................................................................ 17. 1. 18. OccupatfonaVother taxes .................................................................................... 18. 19. Interest ......................................................................................................... 19. 20. Late penalh...................................................................................................... 20. 21. Amount due..........................................................:........................................... 21. 1. 22. Overpayment ................................................................................................... 22. 23. Amount applied to next year's estimated tax ............................. .............. E3, 24. Amount due with return , ,,..,...AMOUNT YOU OWE 24. 1. ............... ......... ......... 25. Amount to be refunded ...........................................................................REFUND 25. MAIL THIS RETURN T0: CUMBERLAND COUNTY TAX BUREAU 21 WATERFORD DRIVE SUITE 201 MECHANICSBURG, PA 17050 Under penalty of perJury,I declare that I h e examined the return and to the best oT my knowledge and belief,it is true,correct,and complete. V �o,,� 10 �5�� Taxpayer's SIA� Date Spouse's Signature Date Waggoner Frutlger 8�Daub LLP LI SA M S TATLER 10/14/13 8Q06 E Tr�ndle Rpad gu�e�tpp Prepared by Other Than Taxpayer Date M8Ch8R(CSb-U��g pp�7p5p.3gq� WAGGONER, FRUTIGER & DAUB, LLP 7�7^��'1Z2� s-°o°;, 5006 E TRINDLE RD SUITE 200 MECHANICSBURG, PA 17050 1 13571014 706230 LMS-STEEC 2011. 05090 STEEVER, CHARLES E LMS-STC1 .` 2013/09/19 11:01:25 2 /7 �� Itlt�rna 1 Rev�nue ��rvice Umted States Department ofthe Treasur�r This Product Contains Sensitive Taxpayer Data Wage and Income Transcript Request Date: 09-19-2013 Response Date: 09-19-2013 Tracking Number: 1001723R4429 SSN Provided: 2U8-42-4397 Tax Period Requested: December, 2011 Form W-2 Wage and Tax Statement Ernployer: Employer ldentification Number (EIN): 271656513 KS RENEWAL SYSTEMS 592 INDUSTFIAL DRIVE LEWISBERR]', PA 17339-0000 Employee: Employee's Social Security Number: 208-9�-9397 CHARLES E STEF.VER 3998 WALNUT STFEET CAMP HILL, PA 17011-0000 Submission Type: Original document i�7ages, Tips and Other Compensation: 52,198.0[✓ Federal Income Tas; Withheld: 50.00 Social Security 4Jages: 52,1�8.00� Sor_ial Security Tax Withheld: g92_00� Medicare wsges and Tips: 52,198.00� Medicare Tax Withheld: 531.00� Social Security Tips: 50.00 Allocated Tips: 50.00 Dependent Care Benefits: $0.00 Deferred Compensation: S0.00 Cxie "Q" Nontaxable Combat Pay: $0.00 Cude "W" Employer Centributions to a Health Savings Account: $0.00 Code "Y" Deferrals under a section 409A nonqualified Deferred $0.00 C�mpensation plan: C��de "°" IncemF under section 409A on a nonqualified Deferred $0.00 Compunsation plan: C�xle "F." Empluyer`s Contribution t�� MSA: S0.00 Code "S" Employer's Contribution to Simple Acc��unt: 50.00 Code "T" Ex.penses Incurietl 2cr QudllYled Adoptior�s: $0.00 �rr.(e "V" Income from e::ercise of nun-statu*_c�ry stocY options: ;O.OG .` 2013/09/19 11:01:25 3 /7 � • . . Code "AA" Designated P.oth Cnntributions under a Section 901(�) Plan: 50.00 Code "BB" Designated kath Contributions under a Section 903(b) F1an: $0.00 Code "DD" rost of Employer-Sponsored Health Covera7e: 50.00 Cc,de "EE" Desi�nate�i RO:H Contributions Under a Governmental SECtioil $0.00 957(b) Plan: Third Party Sick Pay Indicator: Unanswered Retirement Plan Irn9icator: Unansw?red Statutory 5mployee: Not Statutory Employee Form W-2 Wage and Tax Statement Employer: Employer ldent.ification Pdumber (EZP7) : 275993859 BARkUS V DICKS SPORTING GUODS QSF PG BOX 2258 FARIBAULT, MN 55021-np00 Employee: Employee's Social Security Number: 208-92-9397 CHARLES E STEEVER 3498 WALNUT ST CAMP HILL, PA 17011-2744 Submiss9.on Type; Oriqinal document Wayes, Tips and Gther Compensation: $20.00� Federal In�ome Tax Wi*_hheld: 55.00 '� Social Security Wages: $20.00-� Social Security Tax withheld: $0.00,�, Medicare Wages and Tips: 520.00 Medicare Tax Withhelr.i: $0.00 Social Security Ti�s: 50.00 Allocated Tips: 50.00 Dependent Care Benefi*_s: 50.00 Deferred Compen�ation: 50.00 Code "Q" Nontar:able Combat Pay: 50.00 Code "t4" Employer Contributiens to a Health S�vings Account: 50.00 Code "Y" Daferrals under a section 909A nonqualifiEd Deferred 50.00 Compensation plan: Code "Z" Income under section 409A on a nonqualified Deferred ;�.00 Compensation plan: Code "R" Employer's Contribution to MSA: S0.00 Code "S" Employer's Contribution r� SimNle Account: 50.00 Code "T" 6:r�enses Incurred fer Qualified Adoptions: $0.00 Cade "V" Inceme from �r_ercise of non-statur�ry stock options: 50.00 Cc�de "AA" Designated F:oth Contributions ur�der a Section 901(kf Plan: 50.00 Cade "BB" Desigr,ated F:oth rontributions under a Section 903(b) Plan: 50.00 �ode "DD" Cost of Employer-Sponsored Health Coverag�: 54.00 Code "EE" Desiqnated F.OTH Contributions Under a Gov�rnmental Section $0.00 95�(b) Plan: Third Farty Sick Pay Indi��ator: Unanswered ; 2013/09/19 11:01:25 4 /7 .� .. , . Retirement Plan Indicator: Unansoaered Statutory Employee: Not Statutory Employee Form W-2 Wage and Tax Statement Eznployer: Employer ldentificatien Number (EIN): 2759?3859 BARRUS V DICKS SFORTING GOODS QS PO BOX 2258 FARIBAULT, MN 55021-0000 Employee: Employee's Social Security Number: 20E-42-9397 CHARLES E STEEVER 3948 WALNUT ST CAMP HILL, PA 17011-0000 Submission Type: Amended ��ocument Wages, Tips and Other Compensation: 50.00 Eederal Income Tax Withheld: 50.00 Social Security Wages: ;0.00 Sc,cial Security Tas; Withheld: 50.00 Medicare Wages and Tips: $0.00 Medicare Tax W.ithheld: 50.00 Social Security Tips: $0.00 Allocated Tips: ;0.00 Depsndent Care Benefits: $0.00 Deferred Compensation: 50.00 Code "Q" Nontaxable Combat Pay: $0.00 Code "W" Emoloyer Contri�utions to a Health Savings Account: 50.00 Code "Y" Deferrals under a section 909A nonqualified Deferred $0.00 Compensation plan: Code "Z" Income under section 409A en � nonqualifiea Deierred $0.00 Compensation plan: Code "P," Employer's Contribution to MSA: 50.00 Code "S" Employer's Cantribution to Simple Account: $0.00 Code "T" Expenses Incurrec! for �ualified Adoptions: :0.00 Code "V" Income from exercise �f non-�tatutary stock options: $0.00 Code "T,A" Designated Roth Contributions under a Section 401(k) Plan: $0.00 Cede "BB" Designated koth Contributions under a Se��tion 403(L) 'Plan: $0.00 Ccx3e "DD" Cost of Gmployer-Snonsored Health Coveraqe: 50.00 Coda "EE" De�ignated ROTH Con*_ributions Under a Governmental Section $0.00 457(b} Plan: Third F'arty Sick Pay In�li�:ator: Unanswered Retirement Plan Indicator: Unanswered Statutory Employaa: ?lot Statutory Emplayce Form 1099-G 2013/09/19 11:01:25 5 /7 Payer: FayEr's Fe�eral Identification Number (FIN): 255003107 COMMONWEALTH OF PA DEPT OF LABOR & IND OFF OF' EMPLOYMENT SEC[JRITY BMIS D 108 7TH AND FORSTER STS HARkISBURG, PA 17121-0000 Recipient: Aecipient's Identification Number: 2U8-92-4397 STEEVEF CHARLES E 3948 FJ�I,P7UT ST CAMP HILL, PA 17011-QOUO Submission Type: Original dec»ment Account Number lOptional! : N/A ATAA Payments: 0.00 Tax Withheld: 0.00 Tar:ablP ��rants: 0.00 Unemployment Comrensatiun: $8,235.00� Ayricultural Subsidies: 0.00 Priar Year Refun�l: 0.00 Market gain on C��mmi�ity Credit Corpozation loans repaid or, or aitar January 1, 2007: O.�JO lear ��f r;efur�d: Not Set 1o99r, <�ffse*.: Not Refwlcl, Czedit, or Offset for Trade or Business Form 1099-R Distributions from Pensions , Annuities , Retire or Profit-Sharing Plans , IRAs , Insurance Contracts , etC . Payer: F•ayer's Federal Identiiication 1Jumber (FIN): 521481931 T. R04IE PRICE QM 429G 9515 YAINTERS MILL RD OWINGS MILLS, MD 2111�-0000 Recipient: Recipient's Identiiication Numher: 208-92-9397 STEEVEk, CHARLES E 3448 WALNUT ST CAMF HILL, PR 17011-OOUO Submis�ion Type: Original d�cument Account Number (Optionali : 2Q120426131�000�,8552 Distribution Code Value: Early Disr_ribution, �:;cepti��n applies (Under age 59 1/21 Distributic�r, Cede: 2 Distribu*_i_�n Code Vnlue: Hc�t �].�:�Ill.LlCdllr 2013/09/19 11:01:25 6 /7 .. , �'• . Distribution Code: Blank Tax Amount Undetermined C�xle: N�t checked Total Distribution Code: Total Distribution First Year Roth Contribution: 0000 SEP Indicator: IRA/SEP/SIMP bo�: nat checl:ed Tax Withheld: 0.00 Total Employee Contributions: 0.00 Unrealized Appreciation: O.OU Other Income: 0.00 i Gross Distribution: 518.00�, Taxable Amount: 518.00 Eligible Capital Gains: 0.00 Amount to IRP.: 0.00 This Prcxluct Contains SensS.tive Taxpayer Data RFV-1513 EX+{01-10) �" pennsylvania SCHEDULE � DEPARTMENT OFREVENUL INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Charles E. Steever 21 12 1291 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRE55 OF PERSON(5)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1,2).] 1• Marilyn B.Klinger FirstCousin $1,383.47 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: L TOTAL OF PARF II- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size, 1 ' V LAW OFFICES OF PETER J.RUSSOP.c. PETER J. RUSSO, ESQUIRE ATTORNEYS AT LAW ASHLEY R. MALCOLM, PARALEGAL KATHLEEN MISTURAK GINGRICH, ESCZUIRE*" DEREK M. STROUPHAUER, PARALEGAL LINDSAY GINGRICH MACLAY, ESQUIRE�� LAURIE L.WATSON, PARALEGAL PAUL D. EDGER, ESCZUIRE THOMAS D. GOULD, ESCZUIRE �`ADMITTED IN PA&NJ Thursdav, November 7, 2013 Glenda Farner Strasbaugh, Register Register of Wills & Clerk of Orphans Court One Courthouse Square Room 102 Carlisle, PA 17013 RE: Estate of Charles E. Steever Docket Number: 2012-01291 Dear Ms. Strasbaugh, Enclosed herewith, please find one (1) original and three (3) copies of the Supplemental Revenue-1500, check number 103 in the amount of Fifteen and 00/100 ($15.00) Dollars as payment for the requested filing fee. Kindly file the original, time-stamp the remaining copies, and return same to our office in the self-addressed, postage pre-paid envelope I have provided for your convenience. Thank you for your attention to the enclosed. If you should have any questions or concerns, please feel free to contact our office. V 1 yours, Derek . 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