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BUREAU OF INDIVIDUAL TAXES Penns Ivania inheritance Tax � pennsylvania PO BOX 280601 y HARRISBIMG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE REV-1543 EX DocEXEC(Be-12) And Taxpayer Response FILE NO.2� --��. ��'� ACN 13138021 DATE 07-09-2013 Type of Account Estate of ZELMA M ARMIJO Savings Checking Date of Death 06-08-2013 Trust LORETTA I SOBRITO County CUMBERLAND Certificate 13 RENEE AVE SHIPPENSBURG PA 17257-8237 �`'�`''.. � q � � � � � � � � � � � n � � �'1 �,, f` W � � � � � � �' � � � � Q �, �7 C�� -�I ",1 C''��y '/�''✓'�� -�� ,,,�• �i �.w7 �wn� N�.`AI� /�«y4 - � .. .. .._..:� _ . ... � . , .. . . . �� '4+�,� l .. __. � :. . �.. ... -- .. . _�.'.� . .l..L'"w,... {r..w..�i� `. _ -' \..a✓ � �`'�' � �4� •✓I � . � � ORRSTOWN BANK provided the department with the information below indicating that`at the death of the - above-named decedent you were a joint owner or beneficiary of the account identified. � Account No.103006680 Remit Payment and Forms to: Date Established 11-20-2006 REGISTER OF WILLS Account Balance $4,179.82 1 COURTHOUSE SG�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $2,pgg.gl Tax Rate X 0.045 $94.05 NOTE*: If tax payments are made within three months of the Potential Tax Due , decedent s date of death,deduct a 5 percent discount on the tax With 5%Discount{Tax x 0.95) $(see NOTE*) due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1: Please check the appropriate boxes below. A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was , 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. _. __- __ ____.__�...�___ �_ _:_ _-----._- - .___------ ____,___ ____ _ g �The i�formation is The�above information is correct, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select correct tax rate at right,and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p Changes or deductions The information above is incorrect and/or debts and deductions were paid. isted. Complete Part 2 and part 3 as appropriate on ihe back of this form. E �Ass+et wilf be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representa#ive. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment, and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required, you may attach 8 1/2"x 11"sheets of paper.) Date Paid , , Payee Description Amount Paid -� . ,.� Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), N�°M��'O��c�!!'!��rl}tE°��rC°C�!�!3 fr^�!'!'!fhn fin�'!'l�� !!2S�et��ti^^3^��!:�?' !t��t�':!�fJ�'t3?. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners=33.33%, 4 owners =25%, etc.) b. Next, divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate, please state �� j��.�� ,� your relationship to the decedent: . � � � � � �� , �� 1. Date Established 1 � �� '�.' � �._; � � ��: 2. Account Balance 2 $ � � � �� .., � , 3. Percent Taxable 3 X � �� 4. Amount Subject to Tax 4 $ � 5. Debts and Deductions 5 - � � , „ 6. Amount Taxable 6 � � '� �� : � ; _. �� 7, Tax Rate 7 _X � ` ' � � , � � ��' 8. Tax Due 8 �� °�� .-. � �� 9. With 5% Discount(Tax x .95) 9 X � �.�� . �� .,....' ;�,_ �'< , �.: �........ .� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my know!edge and belief. ., � ...---� Work � l 7 '�� " � 'So�-- � , �. � � '� . `- ___ .�....__ -..._ Home 7 l � c�� v7L' r A� n ._.. Taxpayer Signature Telephone Number J��,�,,,� Date J�,a�'1 � IF YOU NEED FURTHER ASSISTANCE, CONTACT PENNSYLVANIA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 _ ._ � _ �� - 'Q.1��lIZ S �Y" �^'��, v r+q I �� !" . �e;t�l�c� b l� b D v �a � � � tf'r�� .O C� � � � � � C>�'�5 � � � ' .. oa .� , � � ;. � � ~ 00 / -� e . �� p S" �� ,�1 0 0 `-. �� , -� _(� . � Q ��,� T� c� M r .o�-�v�a,w�- � � -/ � � , � __ _ _ _ _ _ , United Airlines-View Reservation by Confirmation Number Page 2 of 3 Recomrr�ended:Trip Insurance Allianz Travel Insuronce helps protect you a9ainst expenses should you be required to cancel or interrupt your trip due to medical or other covered reasons affecting yourself or family members.The insurance includes coverage that reimburses paid,non-refundable airline ticket costs,emerqency medical coverage,and more.Limitations apply, learn more. � �; For;49.22,add trip insurance for all passengers. 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Purchase Tr�y Insurance Traveler(s) Mrs.LORETTAISABEL SOBRITO i Mr.EDWARDM SOBRITO Sest A�ipnments: MDT-IAD:56 Sest Assi�nmeMs: MDT-IAD:5C IAD-IAX:29F IAD-LAX:29E LAX-EWR:23F LAX-EWR:23E EWR-MDT:3E EWR-MDT:3D :�•View/Chanqe Seat � ::�•View/Chan�e Seat � ::�•Edit traveler information :�_•Edit traveler information :.�Add Pet(s) :;�•Add Pet(s) ::i•Senarate Traveler(sl :�_•Se�arate Traveler(s) 2 Adults(age 18 to 64) $628.84 Additional�,ixes/Fees ;134.36 . �� Total 763.20 �C � $ � ( i2ece i t .. •'►- � �a 9 g a 9 e P A STP.�.•-.Lil ANvE IJ�1vtEE�t .,, ti N i T E D �, Iss.e Dste: Di AliS 2D13 LltX ATO ; I � � O1 J uJ� &�ege pocurent Deszrip�.ion Qt,y Fees ''k�� M Q W , 2 lSD.OD '','bstsrLsrd !!!!X!!!tXl�ltltX�l�t2�17 Dii2i�4161260 Fi:st � F�c � � � _� o � Ticloiet. iiu�er ':.e��older liwe ' � ¢ O1i235K75311 :��IMRD M SOiRITD � � « �8 ° .-�, � ?otal F:es us� �5�.�Q Leef ir+sit ien: �SZH $ r� � � ' X � £�acess 8oposge Ter�s amd Londitions: ,:arrier i�outing m � � � - Ail �aess b�s�e is s��jeot ta spae svsila�ility. � UA LAX - �� o � . 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Bi�1 � 3.��a P��r�has� $ 27.03 MCMBER �1�1782904407 = SUBTC)1 f�L 1 ; Masfer Car�i #SXX�ki�;h�X��t;c��37 �-�-�*.:--�-----._____.___._._.._________.__ -{ �T,��fE TAX 1 �� ` Auth # 423010 � ��i�� Bottom of Basket , � E 10134 KSWATER *�� 3.59�; ��!_�.�l... �1� ` Lane # 07 Cash�e r # �3.,2 �.�660�OOuaO�� CA R� EMP VA 1 .75' I�IA51 ERCAf�i� � $�1� 0.7!1`�J13 Q$:14 Ref/Seq # 476�28 � ��ottom of Baske Item Count = 1 ��=��*�0:3I - hlrch�9�7255 Term=�01 Iv=G� ,_.._....._..._._.___._..._.�__ ________________ F'�RGNR�E EPS �equence # 07��28 ; � 1599� CANT �OUPE 4.79. �� . 4032 �JATE �MELON 4.99' -'�z�� ;�9036 ROMA NE Z 9g' AU��H# �fi3t�10 � �_�� , _ E 7�3132 VRTY CHEESE 6.49 I NVOI t;� #, 1�i i 5 � � ' (� 1�0 4 8 9 K O S H S P E A F� 5. 9 �1 q �� _._C��-:=�E ��'r� �a�Ai�� .;� 3 3@ 11 .69 } ��-��n 1.i ��:u o t�M ' C0�-:=i�jhTE F R N C H/'.�P; 2.8'� ? 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KuRuil�...rla i��:1y(�t�t�/r+��t Ir�.i: 1 a � .a ------------------____�__----____ y:r4�. 0 9��_ T ------ ��R[;1fE-rlas'ci�r��tut�l�.,�:.1.1t�:�� t �� .�',i�:i;i G_9�y� 1 ' � ��Be9tn Bottom of Basket ;�:�j�n��_-��t��r-, �z,��>r��E,.��r:�.;�: � - ' I �Bott�m of Basket Item Count = 0 i s' ;;,� _y��►'i 4.9��4 T F;��t�+�.-i.utl�rr�:�n��t,��'�.��E.��.��, 1 s .!�'3ti:y U.9�� T E ��134 KSWATER �� • 3.59 Ftir�r��_-t'�:��ei,�:��}��tii��,,r,�>.: t � .;�:;,��, o.��+;i T E46bt��V00000 CA REDEMP V � ` 1 .75 E 5497 FRITO BAKED 11 .59 �;�R►�H��-��:i��r�°,��u��u�'��n�r�,�� r �.� .y�:�� o.94�i� T E 669423 STRBRYLMNAD ' 6.59 w_�.,r;f n��►t�;n;;�F�,�,f�;�i1Y.,:��t c�:; t ; .�sy,� o.sy�� t E 630233 PIRATE BOOT � 5.29 ��cY��tr�t�,tn��>��,�,�;:�� .� yysy o.sy�� t E 51595� M&M RB 9.99 ��ty��t:t�.:��o1s��Y�s��5tt,,:i,+.� i � .�y�=s 0.9993 1 E 64957b FRITO VTY 12,49 ��:�►t��f��t��:�;�h��,yt;��r��c.��r��; t � .y��;� o.s�5� t E____—=4�530�GRANOLA`MIX ____--$_99----_ - �i�sc��n��ni��aa�.��;��r��t � � .a�� o.s�� t } I ��Besin 8ottom of Basket ��t��.r�.��s;cE�,r4c��;�� .s5�r:3 0.9:�9y T ` � �Bottom of Basket Item �ount = 0 ��r�rrr.�.�r.��.�.�.��.1;.r��.��.�� 3 P1asl��:1Gr�]�ii'li,dNf.��}` .. ; ;� ;��!s 6.9�9� T � �.,.,tTtf�,i�ra;�� :� r�,�� ,� ,ys�►� o.s:a�� t TOTAL 6� �8 u,s��t�t�,,��p��7��:�i��.r�� ,,:. ; � ,a .a��i o.s��y r VF EFTIDEBIT 0.2 tun hl�tir�x.�tls�Gtii.,HtU : � i4�.;i { �;,j y;��3'i 0:9':i5� T ---------------------.. �liii(.r��t�,:k�,,�.tt�t�7:,;,t.�„�:;._��,,..tx_�i i � .;�;��i �.g5y.{ r XXXXXXXXXXXX8825 SWIPED 0't/14/y 3 11 :10 PIN USED �p�r,; �a.t r��r,►�.:u��cy��,�:3��:,�; � � .y��i o.y.�y� t Se #: 040637 APP�: 975553 Nart��-1,i,tl�t,�;;t;t�c�i;�?u��-1xi-��, � ;� .c�ty:t+� 0_999y T EF�/DEBIT ResP� AA F��cy!7��:r.i�c��cU��►�,i��.,kia��a � �� .:�s�:� O.9�y� T Tr2n Id�: 319539g27�00 . Merchant ID 99068611 F'df�YI��d�1Crt�ti��'i.;)!:f.'.f Ii�ii';a;t ji'.i i w !Iy�Ni Q 9!iy�; T = . : -. - APPROVED -- �URGHASE ��.;�ti�.�� x��h.,,.,x�.,x.,; .�: ;�: �.��,�:s AMOUNT: �64.28 ��.��: �ii:� u� t,��:t, r�.�., 0686 005 0000000011 003? CHANGE .00 " - - -- TOTAL NUMBER OF ITEMS SOLD - 7' N��;n,a;� �:�?��.,*�,��:��: ►►:<,;�� r�.�.rs CASHIER: WANESSA A. REG�k 5 s��r�: ��Ai�� st:rilE�i - ,irs� f/f�lf►I�lK� 11 :10 0686 05 0037 11 �.::.._.-�-....: .: .... :' ..' .: : .. .._... -- ---- -,. ..... ...�_.�.. ...�. ��.wnrn _. .._ .+.. r,.� � ~ �- �'- ►�- �- ►- f- �- •?1 T �'R .,T. T � .� da C? •D :.0 t0 ."�'.* 7J n1 .?1 �:IJ fJ] CTJ �9] O :G fa �G ('� � :n ::o � fi x� :n rn s `V Si tT] D7 ?! O'f 07 O! O� CD O LD CD S��Tti(Rl. $�1.OG :� flo � o4o0 � � :.� �. �ax .� ��.r� �. �• . _.� .� °C t:�l+�i_ g�2 �I� .'.�'�JO " , � � � � � a s � uCBIT iAi;f� �� ' a " " ." � ��2.7� � . _ . . ... 7l�4L�W � ' .. .. ..• ..` ..: -.. . . .. ...�. � . . .. - . 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O O'OQ p p �' O 00 O O � ' C. � � � � : , � �� Cs 0 � # 0 �D OD V � t7f A W N � ,c�„ � � � v .j = Q r- � �f- i �, � p � � � ' N � � � � '-> � � � , � N � _ _ � � � � ,� rn � �� o � � r" -�a OC '.• X � n '"' D ^ �� ,�t� � � � � , XC'�'� �� -C�iC --�-I '�Q �,i � v ��\ � � o =a m c � � , xo� c � •-.• � t v, `� ti wC�/� C� xC -• CJ� t� o r �^- ` � ti� • z o X z ''�*T� rn -.� �. `� _ : � oC . o �� c' �'n -� n ._�, T � . x� CNO�� m � N W �� 1 • � !��} ;�� A . �' � �O � 1'�T7 'V � ' Y tD C+� n � �o o c,�� : � w r,., � ; � �' �; o;a r�n � -� � � � `'��, � �� v �1 V . � � � , �: � � ; � , . � � _ � � � '� 1 ,, 2ff�` T.. � � � \ 1� ! � �.z W � � Q � 4" � Srv'' � � �`: m S' � - N � Q x�,- � CIl � � , � �� O C� � �{ v Z � � CTI -Dj � � o m . 1t to ,-� � 3 '0 __ .. . _. , v � E� � � 2 �:. � � >�s- m v .r► , � : < • .. ... ... ... ... ... .. � D .. .. .. ;^�r ,�!:y�;; .r_ _ ________ ___ APPLICATION AND PERMtT FOR DISPOSITION OF HUMAN REMAINS USE BLACK INK ONLY-MAKE NO ERASURES,WHITEOUTS,PHOTOCOPIES,OR OTHER ALTERATIONS 1A NAME OF DECEDENT-FIRST �1B.MIDDLE �1C.LAST ZELMA ; MARY ;ARMIJO 2.SEX 3.DATE OF BIRTH (MONTH,DAY,YEAR) 4.DATE OF DEATH (MONTH,DAY,YEAR) 5.(FETAL DEA7H ONLI�DATE OF EVENT(�AONTH,QAY,YEAR) F 08/27/1917 06/08/2013 6A.CITY OF DEATH ;68.COUNTY OF OEATH-IF OUTSIDE OF CALIFORNIA,ENTER STATE � SHIPPENSBURG ; PENNSYLVANIA 7A.NAME OF INFORMANT ;78.RELATIONSHIP TO DECEDENT 8A.TYPED NAME AND ADDRESS OF CALIFORNIA- 88.CALIFORWIA LICENSE � LICENSED FUNERAL DIRECTOR OR PERSON NlNNBER-�APPLICABLE � ACTING AS SUCH-STREET NUMBER ANO NAME, LORETTA�. SOBRITO � DAUGHTER cin�,STATE,ZIP CODE - 7C.iNFORMANTS FULL MAIUNG ADDRESS-STREET NUMBER AND NAME,CITY,STATE,ZIP CODE LORETTA I.SOBRITO 13 RENEE AVE. 13 RENEE AVE. SHIPPENSBURG,PA 17257 SHIPPENSBURG,PA 17257 ACKNOWLEDGEMENT OF APPLICANT-i hereby acknowledge as epplicant that I have the 9a�PLIC GNATURE .. �98.DATE SIGNED right to controi disposkion ptxau�t to Health 8 Safety Code Section 7100,�,a a,�c u►e d�:�sa�«, �- � � 07/10/2013 stated herein ia one d tho dispoaitions authorized by He�dt 8 Safiety Code Section 103055. � PERMIT AND AUTHORIZATION OF�OCAL REGISTRAR-ANY CHANGE ISP ITION REQU ES A NEW PERMIT TO S OW FINAL DISPOSITION This permit�issued�acoordanoe with provisions of the Califomia Health and Safaty Code and is the authoriry for the disposition specciffied in thia pertnit.NOTE:This penNt�ives eo�iqht ot disposal outside of Calitomia. 10A.AMOUNT OF FEE PAID �10B.DATE PERMIT ISSUED �10C.SIGNATURE OF LOCAL REGISTRAR ISSUI PERMIT � � � � $' 11.00 ; •7/1�/2�13 ;► �/?tlt��e� zC� 10D.ADDRESS OF REGISTRAR OF DISTRICT OF OEATH-IF DEATH OCCURRED IN CALIFORNIA �10E.ADDRESS OF REGISTRAR OF OISTRICT OF DISPOS(TION-IF DIFFERENT FROM 10D � LOS ANGELES CO DEPT OF PUBLIC HEALTH ; 313 N.FIGUEROA ST,#L-1 ; LOS ANGELES,CA 90012 11.AUTHORIZED DISPOSRION(S�-CHECK APPLICABLE ITEMS ' FOR CQRONER'S U8E ONLY ❑x A.BURIAL OR SCATTERING IN A CEMETERY ❑D.SCIENTIFIC USE ❑I. DISPOSITION PENDING-LOCATION OF REMAINS- (INCLUDES ENT0�IABMENT) ❑E.TEMPORARY ENVAULINIENT NAME AND ADDRESS ❑B.CREMATION ❑F. DISINTERMENT ❑C.OISPOSITION OF CREMATED REMAINS �G.SHIP IN TO CALIFORNIA OTHER THAN IN A CEMETERY ❑H.TRANSIT OUTSIDE OF CALIFORNW 1?A NAME AND ADDRESS OF CALIFORNW CEMETERY �12B.DATE BURIED �12C.INTERMENT NUMBER-IF APPLICABLE BURIAL OR QUEEN OF HEAVEN � � SCATTERING IN A � � CEMETERY 2161 S.FULLERTON ROAD �iNCwoES ROWLAND HEIGHTS,CA 91748 ��2D.SIGNATURE OF PERSON IN CHARGE OF BURIAL OR SCATTERING ENTOMBMENT) ' �► 13A.NAAAE AND ADORESS OF CALIFORNW CREMATORY ;138.DATE CREMATED �13C.CREMATION NUMBER-IF APPLICABLE � _ � � COUNTY OF LOS ANGELES VITAL RECORDS 313 N. FIGUEROA ST L1 , LOS ANGELES, CA 90012 DATE ^�/10,'�013 WED TIME 11:52 BURIAL PERMIT $11.00 TOTAL $11.00 CASH $21.00 CHANGE $10.00 ANTHONY 139585 00001 . Catholic Cemeteries Department : _ � �� Archdiocese of Los Angeles �' P.O.Box 226820 07/22I13 07-A397971 Los Angeles,CA 90022-9998 07-QUEEN OF HEAVEN CEMETERY .00 .00 KEEP THIS PORTION FOR YOUR RECORDS �� .�� .00 10.1.24681 MB 0.405 76920S11.ps 387850077 1-1 .OQ .�� liil��rlllli��l�l�ill��liiii,��i��i�u��nillii��il�il�� PATRICIA ALCANTA�R IF YOU BELIEVE THERE IS A DISCREPANCY IN LORETTA I SOBRITO YOUR STATEMENT PLEASE CONTACT THIS OFFICE AT(213)637-7800. 13 RENEE AVE SHIPPENSBURG PA 17257-8237 Contract balance as of: 07/22/13 Next payment due on: 08/13/13 INSTRUCTIONS: Pa E 1 Of�. •WRITE CONTRACT NO..ON YOUR CHECK _ .... ., �,� e .,w� _ •BE SURE TO INCLUDE STUB V1ATH PAYMEN7 07/13h3 SATURDAY SUACHARGE 51797A0 400.00 07h 3/13 LORETTA I.SOBRJTO 105404 400.00 TOTAL CHARGES.................................................................................................400.00 CREDITS...................................................................................................400.00 ADJUSTMENTS........ .............................................................................00 THIS CONTRACT HAS A ZERO BALANCE. NO FURTHER P�4YMENTS ARE REQUIRED. PLEASE KEEP THIS STATEMENT FOR YOUR RECORDS. � THANK YOU! ................................ �,,..,_�..,�..� , ,.,. .,.. . .. ., � _ � =� . :• •. .. ;,..��..,..�. , ,. : ,. . � ; . . _ . .,-„�.„.-�,..�,�,.-...-��,...�_ �--..�.._,...,.,_...._- �,._....�._- ,--.-�.r_�,. . ---��--�. - ,� . _..... . , �, , _ _ ;'� . PAYMENT RECEIPT QUEEN OFHEAVF.1�1 CEMETF�y NO 105404 ` 2161 South Fullerton Road Rowland Heights,California 91748 Contract Cas k#'y . (626) 964-1291 Number(s) S Amount �� `7 �. fi Date� � �� -.� MO#ICC# .� ..��79 / �or . �� ` � fQ� , Received from• � � .,� , �' ..,�. - :� �- ' ��' For the, co t of: � . ..'� � �J � �;,.�G.� � l:� . ,�/' ` � 7 No ns(!f needed), : �� ,. � �� - Totai Receipt ��. `�� r . � �'� Recelv�ed `�.. � °a � �'� # _ 2 � FORM NO.M-N92 � : , '� .... _ .. , .. , ... ... � -.3