HomeMy WebLinkAbout12-05-13 1505610101
REV-1500 ° °"°' d '
OFFICIAL USE ONLY
Bu Department d Revenue Pennsylvania
County Code Year File Number
Bureau 28o6vidualTaxes a.. INHERITANCE TAX RETURN
PO BOX rg,PA 1. g
Harrisburg,PA 17128-o6oL RESIDENT DECEDENT L77/] l J
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
o X013 0" 1301 9353
Decedent's Last Name Suffix Decedent's First Name MI
(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
t I I I I I I REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
qM 1.Original Return O 2. Supplemental Return O 3. Remainder Return(date of death
`. - r prior to 12-13-82)
O 4.Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
M 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 (=3 11. Election to tax under Sec.9113(A)
IL ' T ./ between 12-31-91 and 1-1-95) (Attach Sch.0)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
C. N � �G PS F 1 I
6 .' V ` REQ;TER OF WILI�:PSE OfOL
s 01 O 2 O
r t
r First line of address M Y c') Cl) o
CI- Ol15ER Oki azM cn � o
Second line of address z u. 7 o
p O O -L'1 'Tl -n
City or Post Office State 21P Code ZbATE FILE-91
/)12: CNlFNlCSB42G P� 1705S9013�5 Nom'
Correspondent's e-mail address: Cegl,%EId s 3 QCmMC.ast ld
Under penalties of perjury 1 declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowedge and belief,
It is We,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
r SIGNAT F PER N PON FOR FILING RETURN DATE
'x _ _ H, _A! — 11
ADDRESS ER C*d2M RNy 6 /)Iva -RiC�e Read, /Vol-)% &ndwicl), 4/H 03.2sy
SIGNATU O PREP ER ER R SE IVE DATE
Y / /t �1 t 1;W 1.7,
ADDRESS CH/0jW&3 E. eS/f/FLOS 2Zr (o Clouser h9d. McChan;es u
b ''9 , sr
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610101 1505610101
J 1505610105
REV-1500 EX �Dece�c4edent''ss Social Security Numbbee`r�
���
RECAPITULATION _
1. Real Estate(Schedule A). .............................. ....... ....... 1. Il �• ��t�
2. Stocks and Bonds(Schedule B) ............
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3.
1,
4. Mortgages and Notes Receivable(Schedule D).......................... . 4. � •0
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. �- = 9 (•rd
6., Jointly Owned Property(Schedule F) p Separate Billing Requested ...... . 6. J "] ']�9 ��•��+
7. inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested..... ... 7. ]•, Q
8. Total Gross Assets(total Lines 1 through 7)................ ............. 8. rr 6r°� �•f 6
9. Funeral Expenses and Administrative Costs(Schedule H)............ ....... 9.
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) ... .... ....... 10. ,`
11. Total Deductions(total Lines 9 and 10). .... .... ........ ... .... ....... .. 11. 6. [jy
l0 A:33
7
12. Net Value of Estate(Line 8 minus Line 11) ......... ... .... .... ....... ... 12. (}
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which - -- .
an election to tax has not been made(Schedule J) . .... .... ... ............ 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) ... .... ...... 14. / R (L�J7 .. /
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 •O a O
(a)(t.z)X.00-- _.JII R /�IJF ,s.
16. Amount of Line 14 taxable - qy� ��1L
at lineal rate X.0� VJ �+�r7�: / 16.
17. Amount of Line 14 taxable ` - - - - '
at sibling rate X.12 �tl 1_ �Q 0 17. T p
18. Amount of Line 14 taxable
at collateral rate X.15 Ai� O 18.
19. TAX DUE .. ..... .......... ... .........•........... ... ....... .....:. . 19. 3 3 3 1l 6
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p-
Side 2
1505610105 1505610105 J
REV-1500 EX Pages File Number 10 a/_/3_576
Decedent's Complete Address:
DECEDENT'S NAME
,4d1N/t RAW C'"N*Ny
STREET ADDRESS
y9os E. 7,Q/yQLE .PoAA CDT !03(0
CITY STATE �Q ZIP
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) f (1) .3 13 3. 67
2. CreditslPayments
A.Prior Payments ai�sD. 00
B.Discount /S-'0.00
Total Credits(A+B) (2) �.3� OOO. na
3. Interest
(3) 0
4. It 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) dd O
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) r�3 3.67
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 transferred;.......................................................................................... ❑
b. retain the right to designate who shall use the property transferred or its income;............................................ ❑
c. retain a reversionary interest;or.......................................................................................................................... ❑
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑
2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑
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 disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after Jury 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate 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(1.2)[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent'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.
PEV.150BE%.I1An .
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE RESIDENT DEEDENTR" PERSONAL PROPERTY
ESTATE OF FILE NUMBER
A0 R, ChR��.uy al-13- 574
Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION
OF DEATH
l4ou5ehold fbtrnis� in4S Inn small afar rnLllf a�- JL�me
in� death, consisteA aP ffw- 91low;n 4 scessab/e ;t'em :
8. a Ixfhnlstere.d Chairs
C. d2 Lamps
J7. ) Co fik-e. Ta b I e
Inisc. FxU ' Pans, �K��zhen u Cnsi �s , efi•
F, I and -7'tible-
07. Ca-A In ware,{° ; 0.00
TOTAL(Also enter on line 5,Recapitulation) $ 0t JD.0 0
(If more space is needed,insert additional sheets of the same size)
REV.t509IX•(ib>t
SCHEDULE F
COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ANNA Av. Ny FILE NUMBER -21- 13- 576
If an assetwas madejoint within one yearof the decedents date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
A. JO)41J 0. CrFRMAN y (D q TOCerl /ana
Son
Ld.ke Orion, MI h4f362
B 'ROSE-VT E. CAT4an,4NY 5CIX yet, 166 1))4j21g! A.dye Road
for/
No--14 64nclai.�A, AV 03.25-jf
C.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of enallcul Institution and bank accT n(number or simtlar identifying number.Attach DATE OF DEATH DEWS VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT51NTEREST
1. A. Jy//6/o/ Membt?LS Isf FCLI
/r) Sm'nys &&t. No 24011o/ ��f, 0,{6.A 16.666 '467`f Y?
111i6/o/ P) CieekingAmei -VD.
f/8, /ro. BS ib.666 '03110/d,.Sy
6/,sJpB (3) Ce,f.A'Cote ROOF No. a 85f0/ ao5, 222.59 /6.666 f3�l, aoy yS
/si FCU
(1) 5cw.n95 Add No. ASY01 ��F,or (0 /6.666 F, 6705 V?
II'rG�ol 2) Ckil(q 40-d. No. oZ&rf0/ ti/8r //o.BS 6.666 310/B Sy
61iz/o8 (3) (�rfiAi ate AC&f Na. ;4 01 VOS, 222.59 146.666 ¢3f 20cl YS
(sec Niyart .3 lkfemenrs Swbm;fly d i r,Ge#X
TOTAL.(Also enter on line 6,Recapitulation) $
(If more space is needed,insert additional sheets of the same size)
REV-1511 EX+(10-06) -
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ANNA M. cW,�AYA�y z/-13- 57,6
Debts of decedent must be reported on Schedule L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
m y6,s. Funeral Nome of Meehan1cAu.r5(y15I,S 't ?Sv) . �5; 515S oD
,�. �qst flarr�abu� Ce.mefary esaffaclu.d ¢� y�yo, oD
3. R&Jclison Hotel for Funeral Lunr-keein 5t y 7 f, 28
`l. Nonora.-mms 400 Cltarfead as P-14, of YuncmI h;//s �`aoo,00
(9ftk 4 Afnerrca 0(tJ:1- Ct rd Vikme.4 •f a6t Car. , 44S Leer,
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions �1
Name of Personal Representatives) Nor / ,APL/e*1d1 r
Street Address
City State Zip
Year(s)Commission Paid, r L q D
Z. Attorney Fees Charles E. 641eks 174C, Eby- (E5/i n.) /p S,D0
3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation)
Claimant NO 0411E A&ZIN1B65'
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
F.%:n9 Feo f �eb,s#r s� . lei//s /S 490
TOTAL(Also enter on line 9, Recapitulation) $
(If more space is needed,insert additional sheets of the same size)
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Page 3 of 6
Transactions continued
rmn"Coon Posaw - Refemme Aaro nt
Date Date Deeu/p*n Number Number Amount ro.
Purchases and Adjustments
02/21 02/23 THE WINE'ING BUTCHER-MEREDITH NH 8909 D625 19.90
02/21 02/23 SO LITTLE THYME MEREDITH NH 0011 0625 36.50
02/22 02/25 LRGHEALTHCARE 6035243211 NH 9301 0625 680.97
02/24 02/25 NH LIQUOR STORE#12_ CENTER HARBORNH _ .. ..._ __._0247. __..... _0626. ._. ... . .232.81:.. ...._.......__r .,
02/24 02/25 E.M.HEATH SUPERM'S_ CENTREWARBORNH 2031 0625 64.59
02/26 02/27 E.M. HEATH SUPERM S CENTRE HARBORNH 0603 0625 60.66
02/28 03/01 TASTE OF THAI NORTH CONWAY NH 8627 0625 25.60
03f01 03/01 LANDS END INTERNET 08003324760 Wi 6113 0626 _ 54.00
03/02 03/04 NH LIQUOR STORE#12 CENTER HARBORNH 0563 0625 25.97
03/02 03/04 - E.M.HEATH SUPERM S CENTRE HARBORNH 2472 0625 76.50
03/02 03/04 MOULTONBOROGH IRVING MOULTONBOROUGNH 2836 0625 46,40
03/03 03/05 THE CORNER HOUSE INN 603-2846219 NH 8805 0625 80.32
03/04 03/05 SAILMAKEWS SUPPLY 02285223232 MS 0105 0625 149.52
03/04 03/06 TRAVELOCITY HOTEL RESE 8062569089 TX 4746 0625 96.46
03/05 03/06 NH LIQUOR STORE#12 CENTER HARBORNH 0419 0625 78.94
03/05 03/06 E.M.HEATH SUPERM S CENTRE HARBORNH 9746 0625 49.27
03/05 03/06 RITE AID STORE 4139QG5 NORTH CONWAY NH 9297 0625 23.79
03/05 03/07 THOMAS J MCDONOUGH DMD NORTH CONWAY NH 0022 0625 108.00
03/07 03/08 ESI MAIL PHARMACY S 800-451"6245 MO 3960 0625 10.00
03/07 03/09 GOSHEN CITGO Q39 GOSHEN NY 4813 0625 100.00
03/07 03/09 OUTBACK 3921 MECHANICSSURGPA 7603 . 0625 - 10526
03/08 03/09 EXXONMOBIL 42046813 LAKE ARIEL PA 5726 0625 100.00
03/08 03/11 U-HAULMS-MOTOR&IN#3 HARRISBURG PA 6591 0625 293.76
CHECK OUT DATE 3/11/13 . .. . ._.. .._ ._..... ...__.. _._._....,. _--- ....__._........_..._._._._ ._.. . - .,
03/08 03/11 0 MYERS SUHRIG FUNERAL H MECHANICSBURGPA 8990 =5 4,565.00 ApNIW,
03/08 03/11 -RAMADA LIMITED MECHANI MECHANICSBURGPA 6204 0625 _ 76.84
ARRIVAL DATE 3/07/13
03/09 03/11 EXXONMOBIL 97442859 MARLBOROUGH MA 6672 0625 87.43
03/10 03/11 HAMPTON INNS DANBURY DANBURY CT 4406 0625 113.85
ARRIVAL DATE 3/08/13
03/11 03/12 NH LIQUOR STORE#12 CENTER HARBORNH 0033 0625 108.88
03/11 03/12 E.M. HEATH SUPERM S CENTRE HARBORNH 4463. 0625 133.78
03/11 03/12 ESI MAIL PHARMACY S 800-4515245 MO 2741 D625 10.00
03/12 03/14 SANDWICH ANIMAL HOSPIT N SANDWICH NH 4392 0626 56.00
03/13 03/14 MONMOBIL 97619268 ALBANY NH 5396 0625 54.67
03/13 03/14 E.M. HEATH SUPERM S CENTRE HARBORNH 9176 0625 80.26
03/13 03/14 ESI MAIL PHARMACY S 8004516245 MO .8904 0625 10.00
03/14 03/15 -NH LIQUOR STORE 012 CENTER HARBORNH 0615 0625 49.46-
03/15 03/15 - B8 PARKINSONUNITYWLK 8669923374 CA 3082 0625 50.00
03/15 03/18 THE CORNER HOUSE INN 603.2846219 NH 9506 0625 99.03
03/16 03/18 E.M. HEATH SUPERM S CENTRE HARBORNH 9892 0625 38.18
03/17 03/19 NORTH STATION GARAGE BOSTON MA 0004 0625 15.00
03/17 03/19 SPORTS GRILLE BOSTON BOSTON ' MA 5434 0625 66.49
03/18 03/19 LINDT CHOCOLATE#411 NORTH CONWAY NH 0150 0625 - ' " " ' ' 20.00
03/18 03/19 HANNAFORD#0253 MEREDITH NH 5948 0625 67.28
03/1S 03/20 DELANEY$HOLE IN THE W NORTH CONWAY NH 7893 0625 8.71
03/18 03/20 THE WINE'ING BUTCHER-MEREDITH NH 2694 0625 14.43
03/19 03/20 PAYPAL MOSSBROWNCO 4029357733 MN 5962 0625 119.95
03/20 03/21 RITE AID STORE 4139QO5 NORTH CONWAY NH 9662 0625 16.23
03/22 03/23 GENERAL WAXAND CA NORTH HOLLYWOCA 9290 0625 85.92
03/21 03/25 SHELL OIL 116681372QPS NORTH CONWAY NH 7663 0625 49.04
03/23 03/25 LEMON CRASS MOULTONSOROUGNH 0691 0625 210.04
. $8,728. ,
I
continued Transactions
Ihmmctbn Postmg Reremnce Account
Oeta Bato Oesntydon Number Number Amount rob
Purchases and Adjustments
04/18 04/19 NH LIQUOR STORE#57 CENTER OSSIP NH 0084 0625 220.68
04/18 04/19 VALULAND FOOD STORE CENTER OSSIPENH 7329 0625 43.84
04/18 04/20 y EAST HARRISBURG CEMETE HARRISBURG PA 1996 0625 1,940.00-WrnC1'&Zy
04/18 04/20 LRGHEALTHCARE 6036243211 NH 1601 0625 2,261.10
04/19 04/22 MYER HRIG FU H MECHANICSBURGPA 8998 0625 a` ..00 F—ru Al
04/21 04/22 BB SAVE THE BAY 866&923374 CA 6435 0525 50.00
04/22 04/23 HANNAFORD#0352 NORTH CONWAY NH 4954 0625 27.70
$22,935.61
Fees
.........4?{111.,_...._..._ L12....._.._..._......FOREIGN TRANSACTION FEE_......._... ............__. 5897 0625 3.89
C
04/11 04/13 FOREIGN TRANSATION FEE ........_................______........1359.._._......_...-..0625_._ 2.83
04/11 04/13 FOREIGN TRANSACTION FEE 0193 0625 2.70
04/14 04/15 FOREIGN TRANSACTION FEE 2394 0625 15.25
04/14 04/16 FOREIGN TRANSACTION FEE 4794 0625 0.75
04/14 04/16 FOREIGN TRANSACTION FEE 4786 0625 0.75
TOTAL FEES FOR THIS PERIOD
Interest Charged '
04/23 04/23 _ Interest Charged on Purchases 0.00
04/23 04/23 Interest Charged on Balance Transfers _ 0.00
04/23 04/23 Interest Charged on Dir Dep&Chk CashAdv O.Ob
04/23 04/23 Interest Charged on Bank Cash Advances 0.00
TOTAL INTEREST FOR THIS PERIOD $0.01
Total fees charged in 2013 $24.3$
Total.interest charged in 2013
Important Messages
Please review your enclosed annual"Billing Bights"and"Privacy Notice"information for yobr account.You can also review thin information online if,you have
registered your account in Online Banking..
Interest Charge Calculation
Your Annual Percentage Rate(APR)is the annual Interest rate on your account. _
Annual Promotlonsl Promotlonal Promotional Balance Interest
Percentage Transaction Offer 10 Rate Until Subject to Charges by
Rate .Type _ Interest Transaction
Rate Type
Purchases 10.99ty $0.00 $0.00
_ promctional APR 0.0016 POR, WT D6L6-L07WR Jan 2014 $0.00 $0.00
Balance Transfers 10.99%V $0.00 $0.00
Direat Deposit and Chook Cash 19.994V $o.DD $0.00
._ ... . Advances .... . .
Banc Cash Advances 24.999V $0.00 $0.00
APR Type Oefinhfots:Promotional Transaction Types:PUR.Purchase,Wt Non.6ank VAre Transfer;Oeffy Interest Rate Type:V.Venable Rate{rate may vary)
Page: 1 of 1
Radisson Hotel Harrisburg
rt / 1150 Camp HiA aypaw-Camp HM.PA 17011•Phwo(717)-763-7117-•Fax(717)-76&7120
Date Printed:6/1/2013 Banquet Check CHECK#: 32,404
Account: Radisson Social 2013 Event Date: 6/1/2013
Post As: Celebration of Life Contact Mr. John Carmany w
Address: Phone: (248)814-9431
Fax:
On-Site:
Coordinator. Neil Hodes, CMP,CHS
Payment Method: American Express
:..:. .. : . ...:. :. ...c
.:,: .., . . . :. ._ ...:.:... :.:.:.:::, : ;Pn e: > `; . Amount:
Quantrty Food
35 Custom Lunch Buffet(3 Entrees) 22.00 Per person 770.00
.................................°°-----°..._................. ............ .... ---.- ......-°......•............... .._... Subtotal: 770.00
Service Charge%: 19.00 146.30
Tax%: 6.00 54.98
Total: 971.28
Amount
Room: Veranda Function: LUN
------•--------------------------- •------ subtotal: 0.00
Tax%: 5.00 0.00
Total:
.............. ------(I------ -.7----- -------------------- ---------------------------------(0 -------------------------------- ...............
i
Client S g lure �O�� Q . rn N y Date
Room No. : 9017
in of Life(Maye Carrnany) Arrival : 06-01-13
states Departure : 06-04-13
Page No. : . 1 of 1
Folio No. : 206815
INVOICE Conf. No. : 2591378
Membership No. Cashier No. 18
AIR Number
Group Code 06404-13 . 04:31:58 PM EST
Company Name
Charges Credos
Date Text
06-01-13 Banquet Charge 971.28
06-04-13 American Express 97128
XXXXXXXXXXX6006 )0(=
Total 97128 971.28
Balance 0.00
Club Carlson: A faster way to a free night stay at over 1000 Carlson hotels worldwide.
Enroll and learn more at the front desk or at dubcarison.com
Thank You For Staying With Us
I agree that my IWWty far this b81 is not waived and agree to be held personally responsible In the event that Ore indicated person,company or
association fells to pay for arty portion or the full amount of these charges. ,
Guest Slgnsture
Radimon Hotel Harrisburg
1150 Camp Frill Bypass
Camp Hill,PA 17011
Telephone:(717)763-7117 Fax:(717)763-4518
www.mdisson.com/comphillpa
REV-1512 EX+(12-03)
SCHEDULE 1
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN
RESIDENT DECEDENT MORTGAGE LIABILITIES, & LIENS
ESTATE Of
*NA,t,� �t,�444 e FILE NUMBER
-21-1-?-S76
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death,including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION - VALUE OF DEATH
OF DEATH
1. CAI 441 SY0/ '4 4.2,ss1
•?• 14 iL70A) S. /14"it2.S//EY IMM, CT/Z P•vYS. (A15Ha1G� " //Y`•b Z
3. /y1.SHA/c it 3Y.92
b7J/vI a Ic 100.00
fs: LoklkW AU6G /Il �rnS Flo S 3,20
6. G.9h10 H/GL �inER'6. PF/YS. .2/,S S'D
7. C,#&P -Y14I F1VCW B_ P.4'yx %,26.65
9 01U/t/✓1-if#J` 1*h6/N6 X7.56
9• Not y -X 6116,57
JK ZNFO W67; BY Jr 7-054, U7"
hA5- I3EE/1* 4.77WA, / ^0 /11i xAE,O P&R
IrEs )*,< aawxivlENC6
TOTAL(Also enter on line 10, Recapitulation)
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REV-1513EX+(9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF *NN,4 FILE NUMBER
fit. el""All 91-13 -S7,6
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)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. J-OHnI d. yz
6 y 7weeq1 La,je
LaKe Orion, &/ y83&2
/�odE71T C CAP_, , vY son yz
Nnr}I o�ui�lu�.��i, ,va oaz s4
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18,AS APPROPRIATE,ON REV-1500 COVER SHEET
If NON-TAXABLE DISTRIBUTIONS: -
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
i.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART 11—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ONLINE 13 OF REV-1500 COVER SHEET $
(If more space is needed,insert additional sheets of the same size)