HomeMy WebLinkAbout04-1137
,~V~1500 EX {6.QOI
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128.0601,
REV-1500
Ofi','.iC1AL lJSE ONLY
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
2L-D '::L
COUNTY CODE YEAR
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NUMBER
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DECEDENTS NAME~1ST, FIRST, AND MIDDLE INITIAL)
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DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
:r-"'i I'\. 2..00,-/ cx:t,,"'e.r 2-"7
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Mcu-jO":l-<t.. L. S-To.,,4\~t-
SOCIAL SECURITY NUMBER
.2 oD - 2.2..
(0110
1429
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
~ 1. Original Relurn
D 4. limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
D g. Litigation Proceeds Received
D 2, Supplemental Return
D 4a. Future Interest Compromise (date of death after 12-12-82)
D 7. Decedent Maintained a living Trust (Attach cepy ofTrusl)
o 10. Spousal Poverty Credit (dateefdeath between 12-31-91 and 1-1-95)
o 3. Remainder Return {daleofdeathpriorlo12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Allsoh Soh 0)
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NAME ~ob,...'I'T \..... O'~C-,<.v... \ ~$
COMPLETE MAILING ADDRESS -I-
19 Wcu.+ So.)4-\- ~-t-t-~", \
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FIRM NAME (It Applicable)
TELEPHONE NUMBER
11"7- 2.<{,,\ - <.0473
1. Real Estate (Schedule A)
2, Stocks and Bonds (Schedule B)
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'oF'F'iciAL(JSEOFiLY
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7 Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (tolal Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
(11)
(12)
(13)
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ect;. .3, 'nO)
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(8)
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14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
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SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x,O~ (15)
x.O~ (16)
x .12 (17)
x .15 (18)
(19) -0-
16 Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20,0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS <i 2 S- v'\1c...Jo..., Lo..>ML
CITY
cQ........" \-\-\\l
I STATE 'ffi
I ZIP 170\ ,
Tax Payments and Credits:
1. Tex Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A'.B+ C) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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)
A. Enter the interest on the tax due.
(5A)
B. Enter the total of Line 5. + 5A. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
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; Dr...
d. receive the promise for life of either payments, benefits or care? ..
2. (f death occurred after December 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? .
Yes
o
o
o
o
o
o
.....................0 ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
No
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Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct
and complete
Declaralion of preparer other than the personal representative is based on all information of which preparer has any knowledge
SIGN~IJR!\~ESPON~8LE FOR FILING RETURN
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ADDRESS '
l'i ~""t ~u~ sh<<<2..T
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DAlE
I 2/13/0 '-{
~e0 .5ovt\.- s\)~e...+-
no \'3,
DATE
ADDRESS
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For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 PS 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)
The statute does not exemot 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
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive paren
or a stepparent of the child is 0% [72 P.S. 99116(a)(1.2)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneiciaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as a
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-150B EX- (6-9B) .-
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
FILE NUMBER
Include the proceeds of litigation and tt\e da.te tt\e proceeds. were rec.wed by lhe estate.
All property JolnUy.own.d with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
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~ I, S;-2.S"'
TOTAL (ftJso enter on line 5, Recapitulation) $
(\f more space is needed, insert additional sheets of the same size)
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COMMONWEALTH Of PENNSYlVANIA
INHERITANCE TAX RETURN
RE IDENT DECEDENT
ESTATE OF ~ _ r;:;<~...L.. -.!' r>. r-
\ '^O~~ ",_--=,'o...">-\,,-'
SCHEDULE H
FUNERAl EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
Debts 01 decedent mull be reported on Schedule I,
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. 1"V ,,"~... \ rto"" 't , "Ii,..~. '4 5:1 '-t9 5'" 00
(V\i~!'~ _~r""Qr- ~
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social SeaJrity Numbe~s) I EIN Number of Personal Representative(s)
Street Address
C~ State Zip
Yea~s) Commission Paid:
2. Altomey Fees
3. Family Exemption: (II decedents address is not the same .s claimants, attach explanation)
Claimant
Street Address
C~ Slate Zip
Relationship of Claimant to llealdent
4. Probate Fees
5. Accountanfs Fees
6. Tax Retum Prepare(s Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ C' S I 't9...S
(If more space is needed, insert additional sheets of the same size)
''''''''''''''''''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF -T'l. ...,.
\ I'\:ll-- 1'-.
SCHEDULE J
BENEFICIARIES
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FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
L TAXABLE DISTRIBUTIONS (include outnght spousal distnbutlons) ~11~ZS
1, l?c>~""T' q. S-n...~~q~r SOr\...
1'2.. 1-.1""<..0''''' U-Ie.. ~c,c
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ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNOER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART n. ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ I,SZS-
(If more space is needed, insert additional sheets of the same size)
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Thi.~ is to certify that the information here given is correctly copied from an originai certificate of death duiy filed with me as
1.11cai Regislrar. The original certificate will be forwarded 10 the State Vilal Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photosJat or photograph.
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Fec for this certificate, $2.00
P 10527970
.1111212004
Date
,. 74 YB
COU>>Tl' Of DeATH
Cumberland
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT Of KEAl.TH . VITAL RECORDS
CERTIFICATE OF DEATH
STATE ~ll.ENUMBEII
;110!l,143RItV,2J87
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NAMEOf DECEDENT ~FlrI.\, M~. \..n\)
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AGE (La" Blrlhdlly)
Thomas R. Stauffer
'EX
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Male
SOCIAl.. ~ECURITY NUMBER
,20U _ 22 _ 6170
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CITY. BORO. T\'VPOF DEATH
E. pennsboro TWp.
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BIRTHPLACE {~1lI'Id
SI8I,orForeiQl1Country}
Hbg., PA
11-..0 :':''''~ID
RACE _ AmeriCl!n Irldi8ll Black. W'lile, el
(Speclly) ,
".
White
OECEOENT'S USUAl OCCUPATION
{of.:...~le~_ .-
111. Inventory Control 111:1, Distributing
OECEO . MAlLIN AOORESS (SIrHf. CilylTown. Slale, ip Coda) oeCEDENT'S
825 Meadow Lane ~~~~~NCE
(Seeirllln.x:\iOrls
OI1Olhllrlide)
KIND OF SUSlNESS IINOUSTRY
MARITAL STATUS. MlIITied.
Ne....rM.rried Wtdowed,
Divorced (Spetify)
14.Married
SURVIVING SPOUSE
(1Iwrfe,\Ii". ""Ideo o..".!
Raymond W. Stauffer
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17b.COUnt-.Cumberland :::~P? 17d.D ~~~~i=O/
MOTl-IER'S NAME (flrp, MIOCIa, Maiden Sumama)
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INFORMANT'S MAiliNG ADDRESS (Slrae!. CilylTown, SI818, ZIt"""')
,~.825 Meadow Lane Cam Hil PA 17011
PlACE OF DISPOSITiON. NIlITI' 0/ CemlllBfY. Cr.1TI81ory LOCATION. CllylTown. SlalB, Zip COOlI
or 0Ih1lr Placf
17'. rn Yfl.decad$flfhvedifl
15.Mar . orie
Hampden
Williams
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"Camp Hill, PA 17011
",lylboro
fATHER'S NAME (Firlt. Middle. Lall)
...
INF MANr NAME yptJPrifll)
Edith Sleigh
OATE OF OISPOSlTION
\M_o.,.YoII)
7-23-04
'~ENSE~~'~ 5- L
,...
21'. E.
. Cemeter
NAMIi fiND ADDRl;.~S OF FACILlT~
2k Myers-tiarner NI,
LICENSE NUMBt:.R
Harrisbur PA
1903 Mkt St, CH, PA 17011
OATESIGNED
(MOf1I!1.o.y, Year)
TolhabllllotmykrK:M'ledge.deathoccurTll<le!!helime.d-'SfldpllCel!aled
(Sigt\aIure an(\T~la)
23a,
TIME OF DEATH
1.3D
OIharsigflltlC$"llCOl1dib0l11 lIlbutinglodulh,bul
IlQlrelUllingiflll1eufldet1Ylngcausegivenll'lPAflTI
27."AR.ll: -.....__...ju...""~l<>n.1OtrloIh.....N""'_< Do_<OQt.rlll...-ol..rln!l....
L..I.....~_...........__.
....r<Ilac:""....plr1ll<l<y......I..h.,..othurl...lluH.
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. Approximllle
:lfllBrv'lllIIlwee
: 0I11et and delllh
F
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Sequenli8lly ~II eor1dib0l18
rf8f1y.leadingloimmediatll
ClIUIe Enlar UNDERLYING
CAUSE(Di..81eoril'ljuty
that niU.r.d events
lesullingondeatl1)LA$T
WAS AN AUTOPSY 'MORE AUTOPSY FINDINGS
PERFORMEO? AVAlLA8LE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
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Suicide
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OATE OF INJURY
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TIME OF INJURY
INJURY AT 'IvORI<? DESCRlliE HOW INJURY OCCURRED
MANNER OF DEATH
NalLKal
Accidan!
H<lmICide
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PlACE OF INJURY
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30b. M
.Alhoma.larm.8lreel.'eClory.ClfIice
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LOCATION (SiTee!, CilyrrOwn. Slate)
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SIGNATURE AND TITLE OF CERTIFIER.
........~i31b.
LICENSE NUMBER
.0 31C.1111 () (7/,,, ';/, _.' Id' 31d. J.1/'/ /?', /.
NAME AND ADORESS OF PERSON Ir'oHO COMPlETED CAUSE OF OEATH
(Uem27)TYpeO(PrirIl/,,~ '.f ~ ,/ 'I " (~..t 1.'~. r'-f"
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yeaD NoD
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pOI()dmglflve.tlgllllon
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281. tab.
CERTlFlER {Cheo::l<only one)
.~~':tr."J:tOJ~~'r~~Jiu':.~:rhc:.:~a':.,:::;:.r::r":-:=I:r~3:t.'X~~~eh~~r.~.d_~.I~~~.~.~~.~.~.i.I~~?~J..
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CouI<lnolt>edel8rmln8d
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'PROHOUNCIHO AND CERTIfYING PHYSICIAN (PIlYliciar1 bOlh pronouncinll deillh arld t:Ortifying fO cause 01 death}
To tl1tI b..t 01 my knowllldga. 6eUh OCGurnd at th. time. dlle, and plllu. Ifld dUI tclltia uueel(alafld mlfln.r II .tltld...
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'MEDICAL EXAMlNERJCOftOMER
On tile blele 01 h;lmtlllllon Ind/or Investlgltlon, In my oJllnlon. dealti OCGurnd II 1M lime. date. afld pllu. and due to !he Gauue(e) afld
mIllllerae.tatlld..
311.
REG ,
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MYERS-HARNER FUNERAL HOME. INC.
1908 MARKET STREET
ROBERT H. HARNER
SUPERVISOR
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Mrs. Marjorie L. Stauffer
825 Meadow Lane
Camp Hill PA 17011
Services for Thomas R. Stauffer
July 24, 2004
Cremation with Vielo'ing and Service
Charges for Merchandise Selected
Casket
Urn
Cash Advanced
Newspaper Notice/Local
Clergy (2)
Certified Copies
Flowers
Coroners Fee
Wreath
Total due within thirty days, please:
CAMP HILL, PENNSYLVANIA 17011
J,.OCALLY OWNED AND
OPERATED
Augus t 7, 2004
$ 700.00
325.00
$ 100.00
200.00
30.00
40.00
25.00
250.00
n /-;; A _ ~ ,,~T ;p" _Ii/;,~
l ~..-,.-~~ (T~- ,.
al ftt~.~ dbe~ ~J 0/
It t1ctv;~ f II q$',~
L o/(J tY'l 0 '1
TELEPHON,E
717-787-9961
$ 3,825.00
$ 1,025.00
$ 645.00
~5,495.V
P~11'11
~ qf/D
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YELLOW BREECHES OUTFITTERS
"A Classic Fly Shop"
2 E. First St. P.O. Box 200
BOILING SPRINGS, PA 17007
(717) 258.6752
NAME
IOA3ep\J.\. ~ooy
\'YI A f...:)O e\~ "C>-tPluf.Cc.---<<-.
\f\eF\OcW I, P',o(\c.
~lt\ ~ IIDr
CUSTOMER'S ORDER NO,
I PHONE
'.
SOLD BY
00
00
"0
D~
dO
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THANK YOU
TAX
RECEIVED
TOTAL
eaccompaniedllythisllill.
._Ca11
1-IlOO-225-6380
2708 .
-'
THOMAS R. STAUFFER
825 Meadow Lane
Camp Hill Penna. 17011
(1) Savage 24V-A ,222 120 Gage Full Ser# B234061 $145.00
With Weaver K- 2 . 5 Scope $ 65.00
Total $210.00
(2) Winchester 1300,12 Ga. Mossy Camo Stock Ser# L2975968 $185.00
(3) Ruger Black 357 Mag. 6.5 BBL. Blue Ser # 36 - 12098
$200.00
(4) Ruger Mark II 22LR. 5.5 BBL Nickle I Walnut Grips Ser#218-43922 $165.00
With Leupold M8 - 2X Scope #133949 $ 75.00
Total $ 240.00
(5) Ruger Bear cat Older model Ser # 90 - 03206
$ 190.00
TOTAL $1025.00
Estimation By :
HirarT\ Allison ( Owner)
Shireinanstown Sport Shop
5 N. High St.
Shiremanstown PA. 17011
(717) 761-4679
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
BUREAU OF INDIVIDUA-::("~lCES--'.
INHERITANCE TAX OIVISIllt!.='=:\: .
PO BOX Z80601
HARRISBURG PA 171Z8-0601'
NOTICE OF INHERITANCE TAX
APPRAISEMENT, AllOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REV-1547 EX lFP 112-041
(\:->.'
ROBERT ~)ijiJRIEtiESQ
19 WEST SOUTH ST
CARLISLE PA 17013
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
02-21-2005
STAUFFER
07-19-2004
21 04-1137
CUMBERLAND
101
THOMAS
R
Allount Relli Hed
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REv:r!~.E;t.AFp..r51"::'6~n..NaTYcE.oF.iNIiErtfflJicl.YAx.A.pflRA.isElr€N'~..Ai:towANCE.OR......_.........-
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF STAUFFER THOMAS R FILE NO. 21 04-1137 ACN 101 DATE 02-21-2005
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
1,525.00
.00
.00
(8)
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
1,525.00
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-alected 9113 Trusts
14. Net Value of Estate Subject to Tax
(9)
(10)
5,495.00
.00
(11)
(12)
(13)
(14)
5.495.00
3,970.00-
.00
3,970.00-
(Schedule J)
NOTE:
I~ an assessment was issued previOUSly, lines 14, 15 and/or 16, 17, 18 and 19 will
r~lect ~igures that include the total o~ abb returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (lS)
16. Amount of line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class Brat. (18)
19. Principal Tax Due
TA C DIT:
.00 X
.00 X
.00 X
.00 X
00 =
045 =
12 =
15 =
(19)=
.00
.00
.00
.00
.00
DATE
NUMBER
INTEREST/PEN PAID (-)
AMOUNT PAID
~
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
.00
.00
.00
.00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS lESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)