HomeMy WebLinkAbout12-05-13 � 150561�105
REV-1500 Ex ioa-it)(FI) ;j;` OFPICIAL USE ONIY
cs1
PA Department of Revenue pennsylvania
Bureau of Individuat Taxes `"``� �" County Code Year File Number
Po Box z8o6oi INHERITANCE TAX RETURN ' �) ,� .� 1 �G�
Harrisburq,PA i'7128-o6oi RESIDENT DECEDENT � D
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYWY
09/11/2013 04/23/1944
Decedent's Last Name Suffix DecedenYs First Name MI
Thomas Mary C
(If Appiicable)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
� 1. Original Return O 2.Suppiemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82}
p 4.Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust _ S. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Litigation Proceeds Received O 1 d.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'�FHECTED TO;g,7
Name Daytim�lephone Nurrt`ber � t""n
_.. C� C.�
L-J C:? C��
Kimberly A Hawkins _'° �`�?
_ --, _--- ...
k,� =;,-, �
*ra �:7
,� c� �....
RE�"sIS�ER[JF WILLS USE(p#LY�"�y
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First Line of Address c a ;-� �`; � �+ ..;t
164 Faith Circle ` ' r�J 4'' `_,, �u•. �'�
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• .,..-D , c ��'1
' .,. C:',1 __
Second Line of Address "4 .- ; �� �.� ��
, �v �*'
City or Past Office State ZIP Code DATE FILED
Carlisle Pa 17013
CorrespondenYs e-maii address:
Under penalties of perjury,I declare that I have examined this retum,induding accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Deciaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNAT" OF RSON RESP NSIBL OR FILI G RETURN DATE/�
r 1[�
J
ADDRESS `(�'J� �� �j`I�T�/� �NI�f/J � ��. � /�/�
/
SIGNATURE OF PREPAREI2 OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 150561�1�5 15056101,D5 �
J 15056102�5
REV-1500 EX(FI)
DecedenYs Social Security Number
DecedenYs Name: M2n/ C ThOf718S '
RECAPITULATION
1. Real Estate(Schedule A). . .... .. . . . ... ..... ... ... ... ... ..... ... ..... . 1. �.0�
2. Stocks and Bonds(Schedule B) .. .. ... .. .. .... .. .. .. ... .. ........ .. ... 2. 0.0�
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. 0.00
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ... . ... 6. 6,395.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) C� Separate Billing Requested.. ... ... 7.
8. Totai Gross Assets(total Lines 1 through 7}. ........ ... .. .. .. ... ..... ... 8. 6,395.00
9. Funeral Expenses and Administrative Costs(Schedule H).. . .... ... . ... ..... 9. 7,374.00
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I).. ... ... .... .. . 10. 335.00
11. Totai Deductions(totai Lines 9 and 10)... .. ........ .. .. ... .. .. .. ...... . 11. 7,709.00
12. Net Value of Estate(Line 8 minus Line 11) ... ... .. ... . . .. . ......... .. ... 12. 0.00
13. Charitable and Governmental 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. 0.00
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.
16. Amount of Line 14 taxable
at lineal rate X.0_ 16.
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at coliateral rate X.15 18.
19. TAX DUE .. .. ... .. .. .. ... .. . . . . . .. .. .. . ...... ........ .. . ... . . ... .. 19. 0.00
20. FILL IN THE OVA�IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
$ide 2
� 15�567,0205 150561�205 �
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Mary Catherine Thomas
STREETADDRESS
115 Big Spring Terrace
CITY STATE ZIP
Newville. I Pa 17241
Tax Payments and Credits:
1. Tax Due{Page 2,Line 19) (1) 0.00
2. Cretlits/Payments
A.Prior Payments
B.Discount
Totai Credits(A+g) (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 24 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 QNSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
t. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred.......................................................................................... ❑ �
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.12,19&2,did decedent transfer proper�y within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ �
3. Did decedent own an"in trust for"or payabie-upon-death bank account or security at his or her death?.............. ❑ �
4. Ditl 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 disclosure of assets and
f ling 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 imposetl on the net value of transfers from a tleceased chiltl 21 years of age or younger at tleath to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)J.
. The tax rate imposed on the net value of transfers to or for the use of the tlecedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
. The tax rate imposed on the net value of transfers to or for the use of the tlecetlent's 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.
RvV-�G�2�X-i ;1'-12j
.
`�i`'.;,' pennsylvania SCHEDULE A
' �' DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER;
Mary C Thomas
Ail reai property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a wiiling seller,neither being compelled to buy or sell,both having reasonable knowletlge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1.
TOTAL(Also enter on Line 1, Recapitulation.} $ 0.00
If more space is needed,use additional sheeks of paper of the same size.
REV-.i5o3 EX+(8-i�)
`��k p Y SCHEDULE B
� enns lvania
��� DEPARTMENTOFREVENUE STOCKS & BONDS
INHERifANCETAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary C Thomas
All property jointly owned with right of survivorship must be disclosed on Schedule P.
ITEM VALUE AT D�.TE
NUMBER DESCRIPTION OF DEAThI
1.
TOTAL(Also enter on Line 2, Recapitulation) $ 0.00
If more space is needed,insert additional sheets of the same size
REV-15o8 EX+(o8-1z)
� � z pennsylvania SCHEDIJLE E
DEPARTMENTOFREVENUE CASH� BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Mary C Thomas
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 P.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
TOTAL(Also enter on Line 5, Recapitulation) $
If more space is needed,use additional sheets of paper of the same size.
REV-i5o9 EX+(oi-1o)
� `pennsylvania SCHEDULE F
!�� DEPARTMENT OF REVENUE
INHERITANCETAXRETURN ]OINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Mary C Thomas
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING]OINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A•Carl Thomas 115 Big Springs Terrace son
187-52-0139 Newville, Pa 17241
B'Todd L Whitney 115 Big Spring Terrace none
177-54-2377 Newville, Pa 17241
C.
JOINTLY OWNED PROPERTY:
LEITER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
]TEM FOR]OINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT ]OINT IDENTIFY[NG NUMBER.ATTACH DEED FORJOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'SINTEREST
1. A. 07124/06 MobileHome-212FDR60B900 9,500.00 50 4,750.00
2 B 01/01105 Checking Account,Metrobank Acct#537043077 3,290.00 50 1,645.00
TOTAL(Also enter on Line 6, Recapitulation) $ 6,395.00
If more space is needed, use additional sheets of paper of the same size,
REb'-151{}EX+ �Q�-Oo}
�� ' pennsylvania SCHEDULE G
" oEPARTMENTaFRE�EN�E INTER—VIVOS TRANSFERS AND
I""ERIT""�E T^x RET�R" MISC. NON—PROBATE PR�PERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary C Thomas
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCWDE THE NAME OP THE TRANSFEREE,THEIR RE'uffI0N5HIP TO DECEDENT AND DATE OF DEATH °/a OF DECD�S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATfACH A COPY OF THE DEE�FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPL[CkBLE) VALUE
1. PSERS Annuity dod transfer 9-11-13 226,570.00 33. 75,523.34
Kimberly A Hawkins,Daugher(211-48-0351)
164 Faith Circle
Carlisle,Pa 17013
2 PSERS Annuity,dod transfer 9-11-13 33 75,523.33
Betty Gladfelter(182-60-3041)
1040 Greenspring Rd.
Newville,Pa 17241
3 PSERS Annuity,dod transfer 9-11-13 33 75,523.33
Linda Welsh(190-64-9779)
112 Big Spring Terrace
Newville,Pa 17241
TOTAL(Also enter on Line 7, Recapitulation) $ 226,570.Q0
If more space is needed,use additional sheets of paper of the same size.
HEV-lsr7 ek:+ ;�;�-t�)
"'�'i�5�k pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INNERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OP FILE NUMBER
Mary C Thomas
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES;
1� Fogelsanger, Bricker Funeral Home Inc 6,474.00
2 West Pennsboro Fire Hall-Wake 650.00
B. ADMINISTRATIVE COSTS:
i. Personal Representative Commissions:
Name(s)of Personal Representative(s}
__ __..._._.. - _
Street Address
City.........................-----_---- -------- -State_._._._..—_ZIP
Year(s)Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City -- - - - _...._ __State - ZIP -
Relationship of Claimant to Decedent
4. Probate Fees: 50.00
5. Accountant Fees; 200.00
6. Tax Return Preparer Fees:
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 7,374.00
If more space is needed,use additionai sheets of paper of the same size.
RcV-:512 cXt ;1'_-12}
���pennsylvania SCHEDULE I
� DEPARTMENTOFREVENl1E DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT UECEDENT
ESTATE OF FILE NUMBER
Mary C Thomas
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• Medical-Cumberland Valley Neph Assoc 7.00
2 Medical-Quantum Imaging 99.00
3 Medical-Carlisle Regional 89.00
4 Homeowners Insurance-Foremost Ins.Co. 140.00
TOTAL(Also enter on Line 10, Recapitulation) $ 335.00
If more space is needed,insert additional sheets of the same size.
- ��" �`��Fl"`°, COMIVIONWEA�L�TH DF �PENNS�(LVAN�A
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,'� ..� • • ",n•' •`��•;• •;"�`_��� �•�.�n� • ..,,... ,�. Y ALTERATIONORERASURE401DS THIS7{TLE�' '�::�1 .:,, 1
'%'����STORE INnA SAFE PLACE-.IF L057 APPLY FDR A.AUPLICATE•At3 �r�.
DEBORAH W PIPER,TAX COLLECTOR TAXPAYER'S COPY
PO BOX 157 KEEP THIS PORTION FOR YOUR RECORDS
PLAINFIELD,PA 17081
TEMP - RETURN SERVICE REQUESTED
� . � � � � �
Ilii�lln,��i�i�iill�il�uu,��i�unuinu�iilll��il�li,�„i�.,
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THOMAS,MARY
BIG SPRING TERRACE#115
NEWVILLE PA 17241
To review the assessment data for this property, go to:
www.courthouseoniine.com>AssessmentOffice>Cumberiand>PropertyRecords.
Then enter conYroi# 46000906 and password CUSYLAKT
_ ., _._ ___.... ... ......._ .......... ....... ..... .._....... . ......._ _..... .... . ... ........ ... ...... ...... .. . ................. .... . ...... . . .......... . .,.... _..
� . � , . � � ' + � • � � :� •�
Payable To: DEBORAH W PIPER,TAX COILECTOR Office Ho�rs: TUES 9AM-5PM�THUR 12-6PM
PO BOX 157 241 KERRSVILLE ROAD,CARLISLE,PA
PLAINFIELD,PA 17081 DEC,JAN,FEB BY APPOINTMENT
CLOSED 4/19&4/24 Bill No: 2122
PHONE(717)440-6680 Bill Date:' 3/1/13
Control N�: 46000906
MAP NO: 46-09-0515-005.-TR02640
Desc: �15 BIG SPRING TERRACE Assessed Value: Land:0 Im rovement:9,500 Total:9,500
Discount Face ena
BIG SPRING TERRACE MHP
LOT 115 Count RE 2.131 $19.84 0.24 26
County Lib 0.143 $1.33 $1.36 $1.50
Munic.R/E 0.2576 $2.40 $2.45 $2.70
Fire Protc 0.25 $2.38 $2.38 $2.38
$1.00 FEE FOR ADDITIONAL RECEIPTS
Tax Payer:
THdMAS,MARY TAX AMOUNT DUE $25.95 $26.43 528.84
BIG SPRING TERRACE#115
NEWVILLE PA 17241 If Date Of Pa ment is on / /13 thr /3 / 3 5/1113 thru 6/30/13 / � 3 ater
• • � �� �� • ••. • .•• ,��• �� • •
_ .. __... ..
'll I'II'I'I 2013 Statement of Real Estate Taxes (;ontrol No:046-002163
Bill D te: 7/01/2013
Assessed Land Improvement Mineral Tatal
qg�E values 0 9,500 0 9,500
DEBORAH W.PIPER,TAX COLLECTOR xomestead Exclusion 9,500-
P O BOX 157 BIG SPRING S.D. Discount Face' Penal
PLAINFIELD,PA 17081 Rates .01263600 2� �o+t
Temp-Return Service Requested SCHOOL R/E i2o-.oa
Homestead Credit 120.04-
.c: ASSESS.NO-46000906
MAP NO: 46-09-0515-005.-TR02640 TAX AMOUNT DUE----> $.00 $.00 $.00
115 BIG SPRING TERRACE .
If Paid Oil or After 7/01/2013 9/01/2'qi3 11/01/2013
If Paid On or Before 8/31/2013 10/31/2�013 12/31/2013
BIG SPRING TERRACE MHP IF TAXES ARE ESCROWED PLEASE FORWARD A COPY TO MORT�AGE CO.
MOBILE HOME CASH OR MONEY ORDER AFTER 12/24/13.RETURN BOTH COPIESOF
, THOMAS MARY BILL AND POSTAGE PAID ENVELOPE IF YOU REQUIRE A RECEIP7.
�ea BIG SPRI�IG TERRACE#115
NEWVILLE PA 17241
-icE TUESDAY 9AM-5PM THURSDAY 12-6PM
uas: 241 KERRSVILLE RD,CARUSLE,PA
DEC,JAN,FEB BY APPOINTMENT
PHONE:(717)440-6680
_/ / $ Return Bill with Payment.For a Receipt,
Tax Coliector Signature Date Paid Amount Paid Enciose a seif-addreased stamped enve�op�
BORAH W PIPER,TAX COLLECTOR BIII NO: Z119
2013 Statement of Real Estate Taxes Contcol No:046-002163
Bill Q�te: 7/01/2013
Aesesaed Land Improvement Mineral Tbtal
/ABLE Values 0 9,500 0 9,�500
DEBORAH W.PIPER,TAX COLLECTOR xomestead Excluaion 9,soo-
P 0 BOX 157 BIG SPRING S.D. Dlscount Fa ' Penal
PLAINFIELD,PA 17081 Rates .01263600 2+t �o$
Temp-Return Service Requested SCHOOL A/E iaa.oa
Homeatead Credit 12 .04-
sc: ASSESS.NO-46000906
MAP NO: 46-09-0515-005.-TR02640 TAX AMOUNT DUE----> • $.00 �.00 $.00
115 BIG SPRING TERRACE '
If Paid On or After 7/01/2013 9/01/9013 ii/01/2013
If Paid On or Before 8/31 2013 10/31 013 12/31/2013
BIG SPRING TERRACE MHP IF TAXES ARE ESCROWED PLEASE FORWARD A COPY TO MORTK'sAGE CO.
MOBILE HOME CASH OR MONEY ORDER AFTER 12/24/13.RETURN BOTH COPIE3 OF
x THOMAS MARY 8���AND POSTAGE PAID ENVELOPE IF YOU REQUIRE A RECEIP�.
VER BIG SPRING TERRACE#115
NEWVILLE PA 17241
NOTICE OF PRQPERTY TAX RELIEF
Your enclosed tax bill includes a tax reduction for your homestead and/or farmstead
property. As an eligible homestead and/or farmstead property owner,you have received
FICE TUESDAY 9AM-5PM THURSDAY 12-6PM . tax relief through a homestead and/or farmstead exclusion which has been provided
�uas: 241 KERRSVILLE RD,CARLISLE,PA under the Pennsylvania Taxpayer Relief Act,a law passed by the Pennsylvania General
DEC,JAN,FEB BY APPOINTMENT Assembly designed to reduce your property taxes.
PHONE:(717)440-6680
� / $ Return Bill with Paynaent.For a Receipt,
Tax Collector Signature Date Paid Amount Paid Enclose a self-addreSSed stamped envelop
� �
If paying in installments use the coupons below to submit payments.If paying in full use ONLY the 1ST coupon below to submrt payment.
JCYEAR 2013 DATE �/OlI2O13 BILL# 2119 TAXYEAR ZO13 DATE 7��1�2013 BILti� 2119 TAXYEAR 2013 DATE ���1;�2�13 BILLli 2119
\YABLE TO PAYABLE TO � PAYABLE TO =
_BORAH W.PIPER,TAX COLLECTOR �� DEBORAH W.PIPER,TAX COLLECTOR � DEBORAH W.PIPER,TAX C�LLECTOR �
O BOX 157 P O BOX 157 � P O BOX 157 �
.AINFIELD,PA 17081 � PLAINFIELD,PA 17081 � PLAINFIELD,PA 17081 �
�NTROL# �Ap� � CONTROL# �� �� CONTROL# �� �
�6 002163 46-09-0515-005.-TR02640 � 046 002163 46-09-0515-005:TR02640 � 046 002163 46-09-0515-p05:TR02640 �
� �� DESC P��e
t 5 BIG SPRING TERRACE � 115 BIG SPRING TERRACE � 115 BIG SPRING TERRACE �
�� � H SCHOOL
G S RLNG S.D. � B13 G SPR NG S.D. a �` BIG SPRING S.D. �
�X PAYER � TAX PAYER � TAX PAYER �
� THOMAS,MARY �� THOMAS,MARY �
iOMAS,MARY —
ST WITH FIRST OR FULL PAYMENT 2ND PWITH SE OND PAYMENT 3RD PWITH THIRpUP�N CMErU�PON
$.00 ON OR BEFORE 8/31/2013 $.00 ON OR BEFORE 9/30/2013 $.00 ON OR B�ORE 10/31/2013
STALLMENTSCANNOTSTARTAFTER 8/31/2013 $.00 AFTER 10/31/2013 $.00 AFTER la/31/2013
OR
1LL PAYMENT AMOUNT PAY BY
DISCOUNT � .00 8 31 2013
FACE .00 10 1 2013
PENALN $.00 12/31/2013
/ / $ �
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E T RO MeUo Bank
3801 Paxton Street
Harrisburg PA 17111-1418
BAN K mymetroba k.com
>11�72 3543849 �01 �92140
MARY C THOMAS
OR TODD L WHITNEY
BIG SPRING TERRACE LOT 115
NEWVILLE PA 17241
We're here 7 days a week,24 hours a day a19-88&937-0004.
� 50 PLUS CHECKING 0537043077
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COMMONWEALTH OF PENNSYLVANIA
� � PUBLIC SCHOOL EMPLOYEES' RETIREMENT SYSTEM
� PSERS Toll-free: 1.888.773.7748 (1.888.PSERS4U)
`K' 5 N 5th Street Local: 7'�7.787.8540
-w�"�'"`� Harrisburg PA 17101-1905 www.psers.state.pa.us
October 17, 2013
KIMBERLY HAWKINS
164 FAITH CIR
CARLISLE, PA 17013
RE: Mary Thomas
SSN: X;XX-XX-3464
Dear Ms. Hawkins
The Public Schooi Employees' Retirement System (PSERS) has finalized the
processing of the death benefit of Mary Thomas.
!r� 7 t� 10 h�asiness d��a payrrae!?� �n thP ar-no��?t �f�75,523.4� �!il1 be sent to
ORRSTOWN BANK CUST M THOMAS IRA. The breakdown of the payment is as
follows:
$75,891.89 Taxable Portion Rolled Over
+ $0.00 Tax-free Portion Ro11ed Over
� - $368.46 Debt Amount
$ 75,523.43 Net Benefit Payment
PSERS reports all benefits paid and taxes withheld to the IRS. You may incur
penalties if you pay less than 90 percent of taxes due before filing your yearly tax
return. PSERS cannot provide tax advice. We recommend that you contact a
local IRS office or a qualified tax advisor for tax advice.
PSERS issues an IRS Form 1099-R by the end of January for the preceding cal�;ndar
year. The form will indicate the total gross benefits paid to you, the taxable portion of
the benefits, and any amounts withheld for federal income tax. You will need this
information to file your tax return.
No Pennsylvania state or local taxes are payable from your PSERS benefit. If you live
outside Pennsylvania, contact your state and local tax authorities to determine your
liability.
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Oxrstown Bank
Shippensbusg, PA 17257
Phone: 717-532-6114
Bus Date: 10/30/2013 �
B=anch/Telle= 0006/0110 `
10/30/2013 11:04:29
Dat� �-' :nted: 11/03/2013