HomeMy WebLinkAbout02-22-05
RE\I-1500 EX (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
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FILE NUMBER
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COUNTY CODE YEAR
(L~l7_
NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
IS ne C.
DATE OF BIRTH (MM-DD-YEAR)
()_ -1/-1
(IF APPLICABLE) SURVIVING SPOUSES NAME (LAST, FIRST, AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
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4:CS0
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
~. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (dale oldealh after 12-12-82)
o 7. Decedent Maintained a Living Trust (AttachcopyofTrust)
o 10. Spousal Poverty Credit (dale ofdealh between 12.31-91 and 1-1-95)
o 3. Remainder Return (date of death prior 10 12-1J..82)
o 5. Federal Estate Tax Return RequIred
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Anach 5ch 0)
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FIRM NAME (~Applicable)
COMPLET5~G A~~a >t)Il
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0_ ICIAL USE ONLY
1_ Real Estale (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (SChedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6_ Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
(B)
It) lai3.2-q
(6)
(7)
9. Funeral Expenses & Administrative Costs (Schedule H)
(9) --1 S '55. ~L-/
(10) rp
I 'a 55 I ~Y
13J411o '-t5
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(11)
(12)
(13)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
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 (1B) ~Ol ~.I02-
(19)
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
13; '-111. Ll5
19. Tax Due
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
20.0
Decedent's Complete Address:
STREET ADDRESS 5~
CITY
STATE
PIt-
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
Totai Credits (A+ B + C) (2)
3. InteresUPenalty ~ applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enler the differenoe. This is the OVERPAYMENT.
Check box on Page 1 line 20 to request a refund (4)
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5. If Line 1 + Line 3 is greater than Line 2, enter the differenoe. This is the TAX DUE. (5)
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A. Enter the inlerest on the tax due.
(5A)
d..O 10l... (02....
B. Enler the totai of Line 5 + 5A. This is the BALANCE DUE. (5B)
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
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or............................... ... ......................,............... ....,.................... ......................... D
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. If death occurred after Deoember 12, 1982, did deoedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? .............. 0
4. Did deoedent own an Individual Retirement Account~r other non-probate property which
contains a beneficiary designation? .......... ............. ..... ..... ..... ........ ...... ................ ... ........ ................................ ..... .... ~
No
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
DATE
<X -2D-05
liO\3
Under penalties of pe~ury, I declare thai I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, ft is true, correct
and complete.
Declaration of prepare!' other than the personal representative is based on aU information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR6'L~G .RETU.~N
l:>\GWS ~
ADDRESS [) -l
5;7.5 (0 WaSQ\) I'GU
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
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ADDRESS
DATE
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 P.S. ~9116 (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. ~9116 (a) (1.1) Iii)).
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 if
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 parent,
or a stepparent of the child is 0% [72 P.S. ~9116Ia)(1.2)].
The tax rate imposed on the net vaiue of transfers to or for the use of the decedent's lineai beneficiaries is 4.5%, excepf as noted in 72 PS. ~9116(1.2) [72 P.S. ~9116(a)(1)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. ~9116Ia)11.3)1. A sibling is defined, under Section 9102, as an
individuai who has at least one parent in common with the decedent, whether by blood or adoption.
",'''EX-,,," '*
COMNONWEAlTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF /1
"flne C. t;<;recKe (s
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
:21-05-(y:)7
Include the proceeds of lIlIgatlan and the _ the proceeds were reoeIVed by the es1ale. All properly jolntly-owned wIlh tho right of survivorship must be dltclosod on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
ts:ver*,~ ~e CO.
62.08
TOTAL(Alsoenteronline5,Recapilulation) $ 82. o~
TOTAL (Also enter on line 6, Recapitulation) $ 101 Oq '5. ~g
(If more space is needed, insert add,tlonal sheets of the same size)
REV-1510 EX+ (6-9B*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DeCEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF /l... . FILE NUMBER
Hfl/Je C. f!:r<<:Ke IS tV11i :#=- J) 1-06-[07
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV.1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY
ITEM INCLlllE TIE Mt.ME Of THE lRAHSFEREE. lHElR RaATlONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBE' THE DATE Of TRAHSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VAlUE OF ASSET INTEREST "APPl"""-" VALUE
,. .-rrRW--\ers ltfe. ~ 4r!(\LH-t(t- 501'5 .53 10010 1 ~'5.
ore.. Ont'\U \4 o.ccom+ \{(
\f\e. I'UM-f A-nne e. ISrEt"Kels
~C.\ccr :
1) ((:liI e.. S. Bam 0-
52S qleaSJ::N 120
car \1 'DIe I PA \10\3
TOTAL (Also Bnter on line 7 Recapitulation) $ 1')0:-115. '5'1,
?3
(If more space is needed, insert additional sheets of the same size)
Of A 0 - -*J
TravelersLt e& nnUlty
A memberof c.t,group
February 4,2005
Diane S. Barna
525 Greason Road
Carlisle, PA 17013
Annuitant: Anne C. Breckels
Account(s): 00000829019469
Date of Death: 01/18/2005
Dear Ms. Barna:
We are very sorry to learn of the death of your aunt, Anne C. Breckels and wish to express our
sincere sympathy at this time.
The Annuity proceeds of$51,000.00 were held to provide 120 monthly installments of $463.23 to
the annuitant. The first payment fell due January I, 1996. Our records indicate that the annuitant
lived to receive 109 monthly payments. Therefore, the remaining II monthly payments ari
payable as they fall due with no right to commute to you, as the beneficiary'~,-\,,;~.nX\~= 50'l?S3
The enclosed Statement of Claim form should be completed and returned with a certified copy of
the Annuitant's death certificate (received). I have enclosed a self-addressed envelope for your
convenience in replying.
Our records indicate that the February 1, 2005 payment in the amount of $463.23 has been paid
electronically to her bank account. This payment was issued after the date of death and was
therefore unearned to Ms. Breckels. Please have this payment returned via check made payable to
The Travelers Insurance Company in the amount of $463 23 so that we may reimburse her account.
If this payment is not returned it will be deducted from the amount that is to be received.
We hope the above information has been helpful to you; however, if you should have any further
questions, please feel free to call us directly at 1-800-515-1075, Monday through Friday from 8:00
AM to 5:00 PM Eastern Time.
Sincerely,
~Cv~~qJ~?
Jane Hopkins
Service Consultant
Benefit Payment Services, 4CP
Travelers Insurance Company
. "",,,,,,,,.,,."*
COMMONWEALTH Of PENNSYLVANIA
INHERlTANCE TAX RETURN
RE IOENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
-A-v\V\ P ('_.
'B\ecKe..\ ~
FILE NUMBER
It)\ \l3L21 ~ -COt
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. c.re.~ E:.*- tJS1= qqi. DO
Z. Ce M-e-te~ G-XfU"S e. foCO.OO
B. ADMINISTRATIVE COSTS:
1. Po""nal Rapresenlative's Commissions
Name of PalSO/l8l Ropresenlativa(s) ~ S. ~
Social Sacurity Numbe~s) I EIN Numbarof Pa""nal e;rlative(s)
StreatAddress ~~ roreacnN
City (\..l6d?J \ S u= SIaIa Pfr Zip \lOr~
Year(s) Commission Paid: 4>
2. Attomay Fees 4>
3. Faml~ Examptio!l: (If decedenfs address is not tha same as c1aimanfs, attach explanation) cp
Claimant
StreatAddress
City SIaIa Zip
Ralationship of Claimant to Decedant
4. Probate Fees l2..Q.oO
5. Accountanfs Fees <P
6. Tax Return Preparer's Fees cp
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7. '11'\~ Ser\-hr\e1 ~ - \->V\ol~l\'\.-J l?q . gLf
N?h ce.
%. PA ~. 1- '\?eJ eV\.ve - 2W-I fA.-)( -ee~ 40. 0-0
q.
TOTAL (Also enter on line 9, Recapitulation) $1~~5.!?Y
(If more space is needed, insert additional sheets of the same size)
,
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AUER MEMORIAL HOME AND CREMATION SERVICES, INC.
4100 Jonestown Road. Harrisburg, PA 17109.1-800-720-8221. Fax 717-541-9943. Shawn E. Carper, Supervisor
250098 JL5
1-18-2005
Mrs. Diane S. Barna
525 Greason Road
Carlisle. PA 11036
Anne C. Breckels - Deceased
SPECIAL CHARGES
X Direct Cremation
Forwarding Remains
Receiving Remains
Iuunedlate Burial
Nationwide Guarantee Program
Worldwide Travel Protection
TOTAL SPECIAL CHARGES
$795.00
$195.00
PROFESSIONAL SERVICES
Services of Funeral Director & Staff
Embalming
Otber Preparation of the Body
Facilities & Staff for Viewing ($200/hour)
Facilities & Staff for Funeral Service
Facilities & Staff for Memorial Service
Staff & Equipment for Viewing ($200/hour)
Arrange/Deliver Asbes To National Cemetery
Staff & Equipment for Memorial Service
Private Family Viewing/Witnessing Cremation
Special 48 Hour/Weekend Cremation Service
Packaging And Forwarding Cremated Remains
X Personal Delivery of Cremated Remains
Scattering of Cremated Remains
Medical Documents/Courier Fee
TOTAL PROFESSIONAL SERVICES
$55.00
$55.00
AUTOMOTIVE EQUIPMENT
Removal Vehicle
Casket Coach
Flower Car
Lead Car/Clergy Car
Service Vehicle
Fam! ly Car
TOTAL AUTOMOTIVE EQUIPMENT
$0.00
,,'
MERCHANDISE
Register Book
Memorial Folders
Thank You Cards #
Remembrance Package
Casket
Cardboard Container
Cremation Container
Urn Burial Vault
Veterans Flag Case
Grave/Memorial Marker
Other
Other
TOTAL MERCHANDISE
$0.00
CASH ADVANCED ITEMS
Grave Opening
Cemetery Equipment
Vault Service Charge
Newspapers
Newspaper
Clergy
Church/Organist/Soloist
Flowers
X Crematory Charge
X County Coroner Cremation Approval Fee
X Certified Copies (11)
DNA Preservation
TOTAL CASH ADVANCED ITEMS
$300.00
$25.00
$22.00
$347.00
SUMMARY OF CHARGES
Special Charges
Professional Services
Automotive Equipment
Merchandise
Cash Advanced Items
SUB TOTAL
$795.00
$55.00
$0.00
$0.00
$347.00
$1.197.00
DISCOUNT
-$200.00
TOTAL
$997.00
AMOUNT PAID
1-18-2005
-$997.00
$0.00
BALANCE DUE
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RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17G13
Receipt Date:
Rece~pt Time:
Rece~pt No.:
1/26/2005
09:19:54
1039269
BRECKELS ANNE C
Estate File No.:
Paid By Remarks:
2005-00077
DIANE S BARNA
JA
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST
WILL
CODICIL
AUTOMATION FEE
SHORT CERTIFICATE
JCP FEE
Check# 258
Total Received.... .....
60.00
15.00
15.00
5.00
24.00
10.00
----------------
$129.00
$129.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
~ANCE ADDRESS I BILL TO
SENTINEL - LEGAL DIANE BARNA
P.o. BOX 130, CARLISLE, PA 17013
AD NUMBER I CLASS SALESPERSON BILLING DATE LINES
280237 10 PUBLIC NOTICES 29 02/16/05 23
AD DESCRIPTION START DATE STOP DATE
ESTATE NOTICE LETTERS TESTAMENTARY 01/29/05 02/12/05
PUBLICATION INSERTIONS RATE NE T AMOUNT GROSS AMOUNT
3 THE SENTINEL - LEGAL 3 LGL 83.49
TOTAL AD CHARGE 83.49
3 PROOF OF PUBLICATION 01PRF 6.35
PREVIOUSLY PAID -89.84
DAYS RUN
PURCHASE ORDER PAY THIS AMOUNT .00 .00*
Anne C. Brecke1s
RETAIN THIS PORTION FOR YOUR RECORDS
. AFTER 03/18/05
MESSAGE:
Thank you for advertising with The Sentinel.
Deadlines for in-column legal advertisements: Monday is Friday at
11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon;
Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 Noon; Sunday
is Thursday at 12 Noon.
If you have any questions regarding your Legal bill please call
Tammy Shoemaker 243-2611, ext 203.
Fax your legals to 243-3754, attention Tammy Shoemaker
You can also EMAIL yourlegaltoClassifiedads:classified@cumberlink.com
Please send a cover letter including your name and address as an attachment
DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
THE SENTINEL - LEGAL
POBOX 130 CARLISLE PA 17013
Anne C. Breckels
. .
AD NUMBER ClASSO 51 ART DATE STOP DATE
280237 PUBLIC NOTICES 01/29/05 02/12/05
AD DESCRIPTION BilliNG DATE TElEPHONE NUMBER
ESTATE NOTICE LETTERS TESTAMENTARY 02/16/05 717-249-4750
GROSS AMOUNT OF
.00
DUE AFTER 03/18/05
TOTAL AMOUNT DUE
.00
ENTER AMOUNT ENCLOSED
DIANE BARNA
525 GREASON ROAD
CARLISLE, PA
17013
.,70J3R"
20200000002802370000000000000000000000000000005
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PA-40 2004 (09-04)
Pennsylvania Income Tax Return
PA o..-thllllt ci Revenue. Harrisburg, PA 17129 OFFICIAL USE ONLY
PLEASE PRINT IN BLACK INK. ENTER ONE LETTER OR NUMBER IN EACH BOX. FILL IN OVALS COMPLETELY.
Your SocIal Securlty Number Spouse's Social Security Number (W II1lng jointly) = I!xfenolon. _ !he Instruotlonl.
~t.f - 22..-4,:>01
Last Name
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c...
Suffix
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. Your First Name
~N\e
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city, ccu~lry ~nd .
ZIP Code in lot,;"!1 ~
Spouse'S First Name
MI
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Spouse's Las. Name .. Only W different from Last Nama above
8uffit<
First Une of Addf8Sll
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Second Line of Add.....
CtIy or Post Offtce
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State
~
ZIP Code 3
nOI
Daytima Telephone Number
School Code
"1l"1 -24:q~ '-n5D
;1..\ 0 '50
.
1 a. Grose Compansa1iOn. 00 not Include exempllncome, such as combat zone pay and
qualifying retirement _ts. See the Instrucllons. ............................. 1a.
1b. Unrelmbursed Employee Business Expanses. ................................. 1b.
1c. Net Compansellon. Subtrad Line 1b from Line 1a. . .. . . . . . . . . . . . . .. . . .. . . . . .. . .. 10.
2. Interesllncome. Complete PA Schedule A W required. .......................... 2.
3. Dividend end CapiIaI GeIns DloIrIbutIons Income. Complete PA _Ie B W required. .. 3.
4. Net Income or Loss from the Operation of 8 Business. Profession. or Farm. ." 0 4.
5. Net Gain or Loss from the Sa"'. Exchange. or DlspoaIlIon of Property. .......
"ass
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6. Net Income or Loss from Rents, Royalties. Patents. or Copyrights. .......... "'" 6.
=
7. Estete or Trustlnc:ome. Complete end submij PA Schedule J. .................... 7.
8. Gambling and Lottery Winnings. Comp"'te and submit PA Schedule T. ............. 8.
9. Total PA TUJlble Income. Add only the positive income amoun... from Lines 1c. 2. 3,
4. 5, 8, 7, and 8. DO NOT ADO any losses reported on lines 4. 5. or 6. .. . . . . . . . . .. . 9.
10. Medical Savings Account. CAUTION: See the instrucllon.. Enter the amount from
your Federal Income Tax return. 00 not dedud medical expanses or Insurance. 10.
= __Soelhe_
_Idoncy -.. Fill'" only one oval.
_ R Pennsylvania_ant
= N NllfU8Iidenl
= P Parl-Yaar_nthom
_,_ 12004 to _,_ 12004
Filing ..... Fill in onty one oval.
,_ 8 Single
= J M8ITfed, Filing Jolnlly
= M Mantad. Filing Saporalaly
C'.:) F l=1nel Return. Indicate reallOn:
= D~.
Data 01_ 12004
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5.
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11. Adjusted PA TUJlbIe Income. 5ubtracl line 10 from Une 9. .... ...,............. 11. ,_\.,,~,,~_. 2::._.._oJ? 3
Side 1
EC
Fe
0FFtC1Al. UIE ONLY
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DIfDD22DD1/l
PA.40 2004
.SocIaI Sec<II1ty Number shown first
OFFICIAL USE ONLY
12. 40 .00
.
13. .
---~_._---_.
14. .
15. .
16. .
17. .
16. .
Dependenls, Part B, Line 2,
19b. PA Schedule SP. ...........
;.i
Namo(o)
12. PA Tu UIIbIUty. Multiply line 11 by 3.07 pon:ent (0.0307). . . . . . . . . . . . . . . . . . . . . .
13. Total PA Tax Withheld. See the instrucl10n0. ..................................
~
.....r--
S! 114. CredU from your 2003 PA Income Tax retum. .................................
itl
~ 115. 2004 Eatim_lnstaJlment Payments. ......................................
0-01
8 116. 2004 Extension Paymant. . . . ..... . . . . . . . . .. . . . . . .. . . . .. .. . . . . ... . . . . . . . . . . ..
~I
~ : 17. Nonraaidanl Tax W1thhald from your PA Scheelule(.) NRK-l. (Nonresidents only) ....
ffl L116. T_I EstImated paymenta and Credits. Add Lines 14, 15. 16, and 17. . ... . . . . . .. .
.-.,. --
T.x Forgive..... Credit.
198. FIling Stalus: <:::> ~"'= or = Marrtad
20. Total EIIgIbIIIy Incoma from Part C, Li1e 11, PA ~Ie SP. .
= Dec:_
.
21. Tlox Forg....n_ C..- from Part D. Line 16. PA Schadule SP. ................. 21.
.
22. R_ CredU. SublnU your PA Schadula(.) G and/or RK-1. . . . . . . . . . . . . . . . . . .. 22.
.
23. Total OtherCredUs. SublnityourPASchadule DC. ........................... 23.
.
..... 24. TOTAL PAYMENTS and CREDITS. Add Lines 13. 18, 21, 22. and 23. ............. 24.
.
-- 25. TAX DUE. If Line 1210 mora \tIan Una 24. errter \tIa dlffarenca hera. . . . . . . . . . . . . . .. 25.
." ." ,. ,I
26. Pen'" lIInd In_. See the Inslruellena.
If attachlng fonn REV-1630, fillln this oval .......................... = 26.
--127. TOTAL PAYMENT. Add Lines 25 and 26. ........... ................ ......... 27.
28. OVERPAYMENT. If Llna 24 Ie mora than tha totel of Lina 12 and Line 26, anter tha
dlfferencahera.......................................................... 28.
The toml of Lln. 2lI through 35 muat aqual U... 28.
29. Aafund -Amount of Line 2~ you want as a check mailed to you.. . . . . . . . REFUND 29.
30. Credit - Amount of Line 28 you want as a credU to your 2005 astIm_ account. .... 30.
4:0
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.
.
--~Q---~QQj
.
.
.
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I 31. Amount of Line 28 you want to donate to tha Wild _.... C......I'VlIUon Fund. . .. 31.
-I
~ I 32. Amount of Line 28 you want to donate to tha Unltsd s_ Olympic Comm_. ... 32.
2 J 33. Amount of Line 28 you want to donate to tha Governor Robert P. CaBay Memorial
!;{ J Organandn..uaOonaUonAware_TruBtFund.. .... .................... 33.
%1
01
...;:1 34. Amount of Line 28 you want to donate to the K__ M_IInc. ........ 34.
I 35. Amount of Une 28 you wan!. to donate to tha Breaat and Carvtca' Cancer
L_~rc.hFund................................ ............. ............ 35. .
SlGNATURE(S). Under __ of poojury. I I-l _ ..... I (wo) have .....Inod lhlo .......... IncludIng aN _ponying achod.1oa and
atatementa, .nd to the beet of belief,.... true, conwc:t, M1d
Your Signature Dale Spouse's Signature. if ii'ing jointly
.
.
.
.
~ ..... Preparer or Company Nama, oIher ""'" _yor(O), basad on all ~ of _Ihe Pf'8Il8rar haa any
~ I . D," (
o PLEASE DO NOT CALL ABOUT YOUR REFUND UNTIL EIGHT WEEKS AFTER YOU FILE.
SIda2
Date
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0401210018
PA leHIDUU A . .
_and
_nd Incomo
PA~ AI8 (0!Hl4) 2004 OFFICIAL USE ONLY
tf you need more space, you may photocopy these schedules or prepare your own schedules in these fonnats.
Name shown ftr81 en II1e PA~ (even W ftHng jointly) Social Security Number (ehown ftrol)
CAUTION: Feder'8f and PA rules for taxable interest and cltvidend income are different. Read the Instructions.
W your _ _ and dMdond In"""" ... uch $2.500 or 1oIs. you .....t report II1e Income. but do not I1lMld ID sobm" any schedule.
W _ your _ income or dMdond income is more I!1IOl $2.500. you must _ a PA Schedule A & B.
PA~ A (0!Hl4)
PA leHIDULI A . PA Taxabl. Interest Inco..
1. PA Taxable Interest Income. 8M the IMtruCtlona. 1.
.~
n'\P r !';. 'L U> Ii"'l'l\ ~",-r I '!J I. :J,f...c;., ~-...
f
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2. Totat InteNN Income. Add 81 amounts listed Undudlna amounts on additional 8chedules\, 2.
3. Interest income from PA S Corporations and partnershlp(s), from your PI. Schedule(.) RK-1. 3.
... Total PI. T8X8bIe InterHt Income. Add Lines 2 and 3. Enter on Line 2 of your PA..tO. 4. I.:;Z("')'Z If"",
PA~ II (0!Hl4)
IMPORTANT: Capital Gain Oletrtbutione ere dlvklend Income for PI. PUrpoSH.
PA leHIDULI . - PA Taxabl. Dlvlcl.ncl ancl
Capital Gains Distributions Inco..
1. PA Taxable 0tvIdend Income. See thIllnetructlo..... 1.
2. Total DIvkIend Income. Add aM amounts listed (induding amounts on additional schedules). 2.
3. Capital Gains Distributions. See lnatruction. 3.
.. DMdend income from PA S oorporatIon(s) and partnerships, from your PI. Schlldule(.) RK.1. 4.
5. Total PA Taxable DIY..-nd Income. Add Unes 2. 3, and 4. Enter on Line 3 of your PA-tO. 5.
L
0401210018
0401210018
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~""~.\,.".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT OECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Is
NUMBER
L
I FJ,l.f NUMBER
-:p;. l- 05 -007
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include oulright spousal distributions)
l\3
( ~;3;~'ltl)
L-~T\Y\€- ~, t-\uAt
0l't\ q \ S' ff--1hv( Lane.....
til~laY\c\s (\Ct0Cl-\) Co
2- \::>lQJ\e.. s, \6cu- IV a..
'525 q IT'Q ~N Ro.
carhSlt I PA \/013
3 "30 me 5 <;. 6 Re.fl)A
C( 1 (p Di ~bSS. LaKes e:,\V d
\Qr-pON ~f\.CI)1 ~ L- 3Lt(pgq
tVlece..
1.
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fVl ec.~
l\-3
(~'3. 3 70')
~
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CS5.S 1&)
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON UNES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON.TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV 1500 COVER SHEET $
(If more space Is needed, Insert additional sheets of lhe same size)
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
}
55:
D\Me S. fSA~rv(.:l
being duly c.,WOR-N according to law, deposes and says that She l S -tf\e. executrIx
of the Estate of An V'I e c . &-pr Xe..l S-
late of 1ll..~J2e(\n~.D__JltLtl~____ , Cumberland County, Pa., deceased and that the
within is an inventory made by 'b\()np S. &A1?JlJA_, the said pxecu-trIX
of the entire estate of said decedent, consisting of all the personal prop.rty and real estate, except real estate outside
the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value
as of the date of decedent's death.
~W/')R.N
and subscribed before me,
lP' ?.[D5
b\OML.S &o.J't.MD.. _
Executor. Administr.tor
5';1-5 (O(("JlSorJ
e.Af \Isle PA
Address
Rd
nOr~
Date of Death
l8
Day
(2J
Month
') .J)() 5
V.a,
INSTRUCTIONS
I. An inventory must be filed within three months after appointment of personal representative.
2. A supplement inventory must be filed within thirty days of discovery of additional assets.
3. Additional sheets may be attached as to personalty or realty
4. See Article IV, Fiduciaries Act of 1949.
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Inventory of the real and personal estate of
A-rw\e C. 61PCKO \ So deceased
memkers .4-5+ -reckrOL cred~-T UMOtJ
~o-=t\1 39
iTAvelers Ltfe ~ Fr0(\U~*d-
S1er~ ~~a'~~
~0'f5 53
82. 0 8
l\
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: f1.n()e (!. Brec K e.1 s
1~18-D5
2/- 05 - 0077
Date of Death:
Admin. No.
,~OD5 - ODD 77
Will No.
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on I - Z~ -05 :
Name
Address
L'Illne /3.' HvJ1r
qqq/ s. Rr--Ih.uA LoJ.ne..
Hl~/11 QfldS RQf'LCi1) (b ~I3D
-.JAmes S. MlCfIJ{i
Cillo c'IpreC;S L4Ke-s ~Ivd '
,UfP;fV Spnn9:5i PL3408C/
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
{:)tCtne s. 611RiV/+l5etP)
Date:
Signature
U\OJALS 15QJVv\..O.-
C)
Name 't:>\A1\J~ <;. (;A-/C.fUA
f)aS 6reO:bY K d.
Address
\,.. \.
","'-
"h-C
0.0 r u.sl1> P-A- llOl3
Telephone ('111) 2-4.fl- 4'l 50
0J
('..J
!", ~:
Capacity: A Personal Representative
_Counsel for personal representative
v
January 26, 2005
Mrs. Lynne B. Hunt
9991 s. Arthur Lane
Highlands Ranch, CO 80130
Dear Mrs. Hunt:
You have been named as a beneficiary in the Last Will and Testament of Anne C. Breckels.
As Executrix of Mrs. Breckels estate, I am in the process of settling her affairs. Once all required
filing is completed with Department of Revenue, State of Pennsylvania and all necessary estate
taxes are paid, I will issue you a check in the amount of your inheritance as specified in
Mrs. Breckel's will.
If you have any questions, please contact me at the address below.
Sincerely,
\!:t(U{t5 ~
Diane S. Barna, Executrix
525 Greason Rd.
Carlisle, PA 17013
717-249-4750
January 26, 2005
Dr. James Barna
916 Cypress Lakes Blvd.
Tarpon Springs, FL 34689
Dear Dr. Barna:
You have been named as a beneficiary in the Last Will and Testament of Anne C. Breckels.
As Executrix of Mrs. Breckels estate, I am in the process of settling her affairs. Once all required
filing is completed with Department of Revenue, State of Pennsylvania and all necessary estate
taxes are paid, I will issue you a check in the amount of your inheritance as specified in
Mrs. Breckel's will.
If you have any questions, please contact me at the address below.
Sincerely,
1AaM..S ~
Diane S. Barna, Executrix
525 Greason Rd.
Carlisle, P A 17013
717-249-4750
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BARNA DIANE S
525 GREASON RD
CARLISLE, PA 17013
_nn___ fold
ESTATE INFORMATION: SSN: 064-22-4501
FILE NUMBER: 2105-0077
DECEDENT NAME: BRECKElS ANNE C
DATE OF PAYMENT: 02/22/2005
POSTMARK DATE: 02/22/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 01/18/2005
NO. CD 004971
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,012.62
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$2,012.62
REMARKS:
CHECK#107
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WillS