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Home My WebLink About02-21-14 (2) 1505610101 REV-1500 EX(01-10) '� enn5 tvania OFFICIAL USE ONLY PA Department of Revenue P.. _Y County Code Year File Num Bureau of Indtvtdual Taxes INHERITANCE TAX RETURN PD Box 280601 Harrisburg PA 17128-0601 RESIDENT DECEDENT _ ENTER DECEDENT INFORMATION BELOW I l 1 ;4. 0 1 3 d LikA 41119 3 Decedent's Last Name Suffix -Decedent's First Name MI Ti 0 a 71 1 1 1 1 1 = ® 1o � C / ► (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 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 1.Odginal Return O 2.Supplemental Return O 3. Remainder Return(date of death . t _ -- prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) , t ® 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) Ili O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death (=D 11. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number D 44 l 7 / =3 REGIS�iR OF WILLS USE ONLY rr�� r �U^ First line of address �7 -,;- rT L C 3 '=,•r • � rJT H � uT - , �r G Second line of address City or Post Office State ZIP Code a DATE FILED mP HI /I LILI EA 111-7101 / /1 r.M T" Correspondent's e-mail address: L/"y&-,e S Co Am>=&i C/-161L E, Olen Under penalties of perjury,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.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowedge. SIGNATURE OF PERSO{9 RESPOy LE FOR fjUgG RETURN DATE 3Q ADDRESS C k't°S-i nl)+ S-1' • C G rn l0 Q✓1 i l l Y SIGNATURE OF PREPARER OTHER THAN RtPRESENTATIVP DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1 1505610101 1505610101 J 1505610105 REV-1500 EX ' _ & RECAPITULATION 1. Real Estate(Schedule A). ................................... ....... .. 1. 2. Stocks and Bonds(Schedule B) ...................... 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ..... 3. 4. Mortgages and Notes Receivable(Schedule D)................ ....... .... 4. n 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 3 S•,�p 9 . 6. Jointly Owned Property(Schedule F) p Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. Q 8. Total Gross Assets(total Lines 1 through 7)... ........ .:............. ... 8. „ 9. Funeral Expenses and Administrative Costs(Schedule H).......... ......... 9. � , S 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) . ........... .. 10. 1 A A , 11. Total Deductions(total Lines 9 and 10)........... .... ......... ....... .. 11. , i ; 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. ,S 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 ,I at lineal rate X.0 y 5 1 A I A I `f" 16. C� 3 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable 11 C at collateral rate X.15 • 18. 19. TAX DUE ....... ... .... ........... ........................ ........ 19. .. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p t Side 2 1505610105 1505610105 J REV-1500 EX Page 3 Fite Number Decedent's Complete Address: DECEDENT'S NAME STREETADDRESS \ CITY t, STATE p --- ZIP , it Ca 1M Tax Payments and Credits: 1. .Tax Due(Page 2,Line 19) (1) 1 U 3 -3, g / 2. Credb/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 1 Interest (3) O 4. If Line 2 is greater then Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) O 5, If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) I q 3 3 . g I 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? .......................................____......................................................................... ❑ 2 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)(1)). 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 July 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 decedents siblings is 12 percent[72 P.S.§9116(x)(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. REV-1502 EX+(01-14) " _jr1T_ SCHEDULE A to DEPARTMENT OF REVENUE REAL ESTATE INHERrrANCE TAX RETURN - RESIDENT DECEDENT ESTATE OF; FILE NUMBER; All real 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 willing seller, neither being compelled to buy or sell,both having reasonable knowledge 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 it owned as tenant in common, VALUE AT DATE NUMBER OF DEATH DESCRIPTION . 1, TOTAL (Also enter on Line 1, Recapitulation,) $ If more space is needed,use additional sheets of paper of the same size. REV-1503 EX+(6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 2, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1504EX+(1-97) SCHEDULE C CLOSELY-HELD CORPORATION, COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP OR IN RESIDAENT DECED N RETURN SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-t or C-2(including all supporting information)must be attached for each closely-held corporation/partnership interest of the decedent,other than a sole-proprietorship.See instructions for the supporting information to be submitted for sole-proprietorships, ITEM NUMBER VALUE AT DATE NUMBER DESCRIPTION OF DEATH I. TOTAL(Also enter on line 3, Recapitulation) $ (if more space is needed,insert additional sheets of the same size) REV-1505 EX+(5.98) 4611 SCHEDULE C- 1 COMMONWEALTH OF PENNSYLVANIA CLOSELY-HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER 1, Name of Corporation State on Incorporation Address Date of Incorporation City State_Zip Code Total Number of Shareholders 2. Federal Employer I.D.Number Business Reporting Year 3. Type of Business Product/Service 4' TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK VottngtNon•Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? .... .. ........... .......... ...... 0 Yes ❑No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ....... .... .... . ..... . ... ..... . .... 0 Yes ❑No If yes,provide amount of indebtedness$ 7, Was there life insurance payable to the corporation upon the death of the decedent? . . .. . ❑Yes ❑ No If yes,Cash Surrender Value$ Net proceeds payable$ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? O Yes ❑ No If yes, ❑Transfer O Sale Number of Shares Transferee or Purchaser Consideration$ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....❑Yes ❑ No If yes,provide a copy of the agreement. 10.Was the decedent's stock sold? ..................................................... ❑Yes ❑ No If yes,provide a copy of the agreement of sale,etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... ❑Yes 0 No If yes,provide a breakdown of distributions received by the estate,including dates and amounts received, 12.Did the corporation have an interest in other corporations or partnerships? . . . . . . . . . . . . . ❑Yes ❑ No If yes,report the necessary information on a separate sheet,including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION A. Detailed calculations used in the valuation of the decedent's stock. B, Complete copies of financial statements or Federal Corporate Income Tax returns(Form 1120)for the year of death and 4 preceding years. C. If the corporation owned real estate,submit a list showing the complete addresses and estimated fair market value/s.If real estate appraisals have been secured,aftach copies. D. List of principal stockholders at the date of death,number of shares held and their relationship to the decedent. E. Ust of officers,their salaries,bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year.List those declared and unpaid. G. Any other Information relating to the valuation of the decedent's stock. (If more space is needed,insert additional sheets of the same size) REV-1506 EX+(9-00) SCHEDULE C-Z ab PARTNERSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF - FILE NUMBER 1. Name of Partnership Date Business Commenced Address Business Reporting Year city State Zip Code 2. Federal Employer I.D. Number 3. Type of Business Product/Service 4. Decedent was a ❑ General ❑ Limited partner. If decedent was a limited partner, provide initial.investment$ 5. .PERCENT PERCENT - - BALANCE OF PARTNER NAME OF INCOME OF OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest$ - 7. Was the Partnership indebted to the decedent? . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . . . . ❑Yes ❑ No If yes, provide amount of indebtedness$ 8. Was there life insurance payable to the partnership upon the death of the decedent? ... . . ❑Yes ❑ No If yes,Cash Surrender Value$ Net proceeds payable$ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? 0 Yes ❑ No If yes, ❑Transfer ❑ Sale Percentage transferred/sold Transferee or Purchaser Consideration$ Date Attach a separate sheet for additional transfers and/or sales. _ . 10.Was there a written partnership agreement in effect at the time of the decedent's death? . . . . . . ❑Yes ❑ No If yes,provide a copy of the agreement. 11. Was The decedents partnership interest sold? . .. . .. . . .... . .. . . . . . .. . . . .. . .. . . .. . . .. . . ❑Yes ❑ No If yes,provide a copy of the agreement of sale,etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ❑Yes ❑ No If yes,provide a breakdown of distributions received by the estate,including dates and amounts received. 13.Was the decedent related to any of the partners? . . . .. . . . . . . .. . .. . . .. . . .. . .. . . .. . . . . . ❑ Yes ❑ No If yes, explain 14.Did the partnership have an interest in other corporations or partnerships? .. . . . .. . .. . . . . ❑Yes ❑ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns(Form 1065)for the year of death and 4 preceding years. C. If the partnership owned real estate,submit a list showing the complete addressees and estimated fair market value/s.If real estate appraisals have . been secured,attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+(1-97)43X!" SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL(Also enter on line 4, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-i5o8EX+(u-10) - pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: 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 F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH -Ouv-� . 3 1 Ur5 �� CG,a�r TOTAL(Also enter on Line 5, Recapitulation) $ �J a 8 3 S.& If more space is needed, use additional sheets of paper of the same size. REV-i5o9 EX+(oi-io) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAVIE(S) ADDRESS' RELATIONSHIP TO DECEDENT A. B. C JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL(Also enter on Line 6, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 INCLUDE THE NAME or THE TRANSFEREE,THEIR REIATIONSHIR TO DECEDENT AND DATE OF DEATH 3%OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. �0.i1 (X LA Q`F�Y�S2S TOTAL(Also enter on Line 7, Recapitulation) $ /// 5-00 If more space is needed, use additional sheets of paper of the same size. FUNERAL DIRECTORS LIFE INSURANCE COMPANY PA 963564 6550 Directors Parkway Abilene , TX 79606 1 - 800 - 6'92 - 9515 , APPLICATION ANNUITY Proposed Insure-d-/l uitanntt First Naive x061 Middle Initial +y • Last Name k4 04 + S Sex F Soc Sec No / 3t7 ' 1174 Age Birth Date .'� - a`(— /'12 3 Street City State Zip Owner's First Name N Middle Initial—Last Name 0 a S S,,99��Sec No ��' 'W'L d Street G a l dS City < p-of State Ir/t Zip Primary Beneficiary / i^ U S Relationship _ 'r� , Contingent Beneficiary GJu rwt y-or< Relationship Clao Ultimate Face Amount$ Choose One: O Single Pay O Multi-Pay Life O Multi-Pay Annuity Initial Payment$ Ili SZ27 Scheduled Payment$ Will coverage fund a preneed contract? Yes O No Billing Frequency: O Annual O Semi-annual O Quarterly O Monthly Years to Pay Billing Melhod: O Direct Bill O Coupon Book O Monthly PAC O Credit Card Send Bill To: O Owner O Proposed Insured/Annuitant O Individual Billing O Family Billing SECTION A.—to be answered by all applicants ("You"refers to the Proposed Insured/Annuitant.) I,the undersigned,represent specifically for the purpose of obtaining this coverage the following: 1. Are you now a patient in a hospital'of any kind,or receiving hospice care or within the past 12 months you been advised by a medical practitioner to be hospitalized,but have chosen not to follow that advice? O Yes o 2. Have you received diagnosis or treatment by a licensrdfnember of the medical profession,consulted by you,for a terminal illness or condition,not including HIV/AIDS? O Yes fNo If either of the above questions is answered"Yes",only a single pay annuity policy can be issued. SECTION B.—to be answered by all applicants for Multi-Pay life insurance who answer"No"to all questions in Section A. 1. Are you currently bedridden,confined to a nursing home(including custodial care)or extended care facility,or have you been told within the past 12 months by a medical practitioner that you should be so confined but have chosen not to follow that advice? O Yes ONo 2. Within the last 36 months has a medical practitioner diagnosed you with,or treated you for,any of the following? Cancer-Heart Disorder;Kidney Disorder;Liver Disorderl Lung Disorder;Brain Disorderi Circulatory Disorder; Blood 1'3isorder;Stroke;Alzheimer's;Nervous System Disorder,AIDS,ARC,HIV infection. O Yes O No 3. Name and address of personal physician(REQUIRED). 7 Single Pay benefits in the first 12 months may be less than the Ultimate Face Amount.For Multi-Pay Life,if all questions above are answered fully,and the correct answer to all the health questions is"No",you qualify for full coverage.Otherwise,you qualify for coverage which has a limited benefit in the first 1 or 2 ears.For Mu ti-Pa Annul ,benefits are limited until all Scheduled Payments have been made. 1,the undersigned,affirm that the above information is true and complete to the best of my knowledge. I understand that false statements ! or misrepresentations may result in loss of coverage. I agree that no coverage is effective until a premium has been paid and a policy or certificate is issued while the Insured/Annuitant is living. I may return the policy within 30 days of receipt for a full rend.I hereby grant consent for any of the below listed entities to give to Funeral Directors Life In surance Company information about my past or present physical or m ental condition,and health care service rove ded to me. I may revoke m y consent at any tim a by calling 1-8p00-234- 8031. This c onsent sh all apply to any h ealth c are or custodial facility, clinic, practitioner, hospital or medical service plan,calling service plan/ health maintenance organization. I understand that information disclosed pursuant to this consent shall be u sed for the sole purpose o insurance rating,investigating a claim or other insurance activities. I understand the authorization is valid for no longer than 30 months and that I or my authorized representative is entitled to receive a copy of the authorization form.Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,which is a crime and subjects such person to criminal and civil enalties. Does the Proposed Insured/Annuitant have existing life policies or annuity contracts? Wes No Will the Insurance/Annuity applied for replace any existing coverage on the same Proposed Insured/Annuitant? O Yes ®•No 1 If yes,provide company name and policy number(agents:complete required replacement form,if required by yourytate.) i ,ee4a0r5/Law <+ N '7 3 Stature&Consent of Proposed Insured/Annuitant Phone City Wbe Signed State Da Txl 9c r 6,; 1^ far SUr ignature of Owner(ifolher than Proposed Insured/Annuilant) Phone • To the best of my knowledge,the coverage applied for replaces existing coverage. Cl Yes 15-No I certify that all information contained in this application is tore to the best of my knowled a was orded accurately,and that this application wa �si in my pre nc Print Agent Name Agent Signature Agent No. ' npo nCM'fMlppn I—M4Ml ADM.I..e.wnr•/`n...na.... rnpv 1• Gnen, rnpv I. 4nnli�nnt REV-1511 EX+(10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(s)Commission Paid: Z. 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 5. Accountant's Fees 6. .Tax Return Preparer's Fees 7. TOTAL(Also enter on line 9, Recapitulation) (If more space is needed,insert additional sheets of the same size) REV-1512 EX+ (12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER 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. I Y�l fv Uv"10_v r \'I V�c p f�� 1 C1-7, O0 ( 1x -7 15) 5P3Y`I US19'tv-t;t\ o0 TOTAL(Also enter on Line 10, Recapitulation) $ If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-30) `Jpennsylvania SCHEDULE J '��-- DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: 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. - ��i Soh 1� 3 1}�elMC,.I vow 1 SOU k"\\ �1�Pr5 1 �JoZ CheSXU-�- 1 PP (-7G1I (nhGl 60,V/IS a(0 1-- vi Cr ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. REV-1514 EX+(12-a1) SCHEDULE K LIFE ESTATE, ANNUITY COMMONWEALTH OF PENNSYLVANIA & TERM CERTAIN INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4 on REV-1500 Cover Sheet ESTATE OF FILE NUMBER This schedule is to be used for all single life,Joint or successive life estate and term certain calculations. For dates of death prior to 5-1.89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457,Actuarial Values,Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. 0 Will ❑ Intervivos Deed of Trust ❑ Other LIFE ESTATE INTEREST CALCULATION NAME(S)OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH LIFE ESTATE IS PAYABLE E ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years 1. Value of fund from which life estate is payable ... . . . . . . ... . . . . . ... . . . . . . . . ... ...... . . . . .$ 2. Actuarial factor per appropriate table .......... . ....................... ............... Interest table rate—❑3 1/2% ❑6% ❑ 10% ❑Variable Rate 3. Value of life estate(Line 1 multiplied by Line 2) . .......... ....... . ... .... ............$ ANNUITY INTEREST CALCULATION NAME(S)OF LIFE ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY IS PAYABLE ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑Life or ❑Term of Years 1. Value of fund from which annuity is payable . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and enter corresponding(number) ........... .... ......... .. Frequency of payout—❑ Weekly(52) ❑ Bi-weekly(26) ❑ Monthly(12) ❑ Ouartedy(4) ❑ Semi-annually(2) ❑ Annually(1) ❑Other( ) 3. Amount of payout per period .... . ................. ..... .......... . ............. .....$ 4. Aggregate annual payment,Line 2 multiplied by Line 3 ....... .. . ... .. ... ... .. .. ...... . . . . 5. Annuity Factor(see instructions) Interest table rate—❑3 1/2% ❑6% ❑ 10% ❑Variable Rate % 6. Adjustment Factor(see instructions) . . . . . . . . .. . . . . . . . . . .... . ... . . . . . . . .. .. . .. ...... .. . 7. Value of annuity— If using 31/2%. 6%, 10%,or if variable rate and period payout is at end of period,calculation is:Line 4 x Line 5 x Line 6 . . . . ......................$ If using variable rate and period payout is at beginning of period,calculation is: (Line 4 x Line 5 x Line 6)+Line 3 . . . . . . . . . . . .. . . . . . . . . . . . . . . . . ... . . . .... ... . ...... .$ NOTE:The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return.The resulting life or annuity interest(s)should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed,insert additional sheets of the same size) REV-1644 EX-(3-o4) INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER I. ESTATE OF (Last Name) (First Name) (piddle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on (Date) B. Name(s)of Life Tenant(s) Date of Birth Age on date Term of years income orAnnuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Stocks and Bonds . . . . . . . . . . . . . . . . . . . . . . . . . .$ 3. Closely Held Stock/Partnership . . . . . . . . . . . . .. .$ _ 4. Mortgages and Notes . . . . . . . . . . . .. .. . . . . . .. .$ 5. Cash/Misc. Personal Property . . . . . . . . . . . . . . . .$ 6. Total from Schedule L-1 . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . _$ D. Credits:Complete Schedule L-2 1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Unpaid Bequests. . .. . . . . . . . . .. . . . .. . .. . . . . .$ 3. Value of Uninciudable Assets . . . . . . . . . . . . . . . . .$ 4. Total from Schedule L-2 . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . .$ E. Total Value of trust assets(Line C-6 minus Line D-4) . . . . . . . . . . .. . . ... . . . . . ... . . . . . . ..$ F. Remainder factor(see Table I or Table II in Instruction Booklet) . .. .. . . . . . . . . . . . . . . . . . . .. G. Taxable Remainder value(Line E x Line F) . . . . ... . . . .. . .. . .. . .. . . . . . . . . .. . .. . . . . . ..$ (Also enter on Line 7, Recapitulation) - INVASION OF CORPUS: A. Invasion of corpus (Month, Day,Year) B. Names)of Life Tenant(s) Date of Birth Age on date Term of years income or Annudant(s) corpus or annuity is payable consumed C. Corpus consumed . . . . . . . . . . . . . . . .. . . . . . . . . . ... . . . .. . . . . . . . . . . . . . . . . . . . .. . .. ..$ D. Remainder factor(see Table I or Table It in Instruction Booklet) . . . . . . . . . . . . . . . . . . . . . . . . . E. Taxable value of corpus consumed (Line C x Line D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ (Also enter on Line 7, Recapitulation) - e,EV.1643 E%+Q4131 - INHERITANCE TAX tb SCHEDULE L-1 COMMONWEALTH INHERITANCE TAX XRPENNSYLVANIA TU LVAN1A REMAINDER PREPAYMENT ELECTION INHERITANCF TAX RETURN RESIDENT DECEDENT -ASSETS- PILE NUMBER I. Estate of £' (Last Name) (fint Namel (Middle I"Zil II. Item No.1 Description Value A. Real Estate (please describe) Total value of real estate S (include on Sect€on 11, Line C•1 an Schedule L) 6. Stocks and Bands (please list) Total value of stocks and bonds S (include on Section It, line C-2 on Schedule t} C. Closely Held Stook/Partnership (attach Schedule C•1 and/or C-2) (please list) Tata)value of Closely He1dlPartnetship $ (include on Section II, Line C-3 on Schedule L) D. Mortgages and Notes(please list) Total value of Mortgages and Notes S (include on Section II, Line C.4 on Schedule L) E, Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pars, Property S (include on Section II, Line C-S on Schedule L) III• TOTAL(Also enter on Section 11, Line C-b on Schedule L} S if mores ace is needed attach additional BYs x 11 sheets.1 REV-1646 EX+ (11-69) f pennsylvania INHERITANCE TAX DEPARTMENT OF REVENUE SCHEDULE L-2 FNHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -CREDITS- I. ESTATE OF FILE NUMBER II. ITEM NO. DESCRIPTION AMOUNT A. Unpaid Liabilities Claimed against Original Estate and Payable from Assets Reported on Schedule L-1 (please list) Total Unpaid Liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests Payable from Assets Reported on Schedule L-1 (please list) Total Unpaid Bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of Assets Reported on Schedule L-1 (other than unpaid bequests listed under'B'above) that are Not Included for Tax Purposes or that Do Not Form a Part of the Trust. Calculation as follows: Total Non Includable Assets $ (Include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ If more space is needed, attach additional sheets of paper of the same size. REV-1647 EX+ (02-10) pennsylvania SCHEDULE M DEPARTMENT or REVENUE FUTURE INTEREST COMPROMISE INHERITANCE TAX RETURN RESIDENT DECEDENT (Check Box 4a on REV-1500) ESTATE OF FILE NUMBER This schedule is appropriate only for estates of decedents who died after Dec. 12, 1982. This schedule is to be used for all future interests where the rate of tax that will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. ❑ Will ❑ Trust ❑ Other I. Beneficiaries NAME OF BENEFICIARY ,RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. S. II. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within nine months of the decedent's death, check the appropriate box below and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ❑ Unlimited right of withdrawal ❑ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of future interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (Also include as part of total shown on Line 13 of REV-1500.) . . . . . . . . $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check one. ❑ 6%, ❑ 3%, ❑ 0% . . . . . . . . . . . . . . . . . . . . $ (Also include as part of total shown on Line 15 of REV-1500.) 4. Value of Line 1 taxable at lineal rate Check one. ❑ 6%, ❑ 4.5% . . . . . . . . . . . . . . . . . . . . . . . . . . $ (Also include as part of total shown on Line 16 of REV-1500.) S. Value of Line 1 taxable at sibling rate (12%) (Also include as part of total shown on Line 17 of REV-1500.) . . . . . . . . $ 6. Value of Line 1 taxable at collateral rate (15%) (Also include as part of total shown on Line 18 of REV-1500.) . . . . . . . . $ 7. Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) . . . . . . . . . . . . . . . . . . . . . . . $ If more space is needed, use additional sheets of paper of the same size. REV-1649 Ex+(08-09) (g' 'J pennsytvania SCHEDULE O DEPARTMENT OF REVENUE INHERITANCE TAXES RETURN ELECTION UNDER SEC21i3(A) RESIDENT DECEDENT (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 2113(A) of the Inheritance and Estate Tax Act, If the election to more than one trust or similar arrangement,a separate form must be filed for each trust. This election applies to the___ Trust(marital,residual A,B,by-pass,Unified Credit,etc.). If a trust or similar arrangement meets the requirements of Section 21131 and: a.The trust or similar arrangement is listed on Schedule 0 and b.The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,then the transferors personal representa- tive may specifically identify the trust(all or a fractional portion or percentage)to be included in the election to have such trust or similar proper- ty treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0,the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0.The denomi- nator is equal to the total value of the trust or similar arrangement. PART A:Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 2113(A) trust or similar arrangement. _ Description Value Part A Total $ PART B: Enter the description and value of all interests included in Part A for which the Section 2113(A) election to tax is being made. Description Value Part B Total $ If more space Is needed,use additional sheets of paper of the same size. REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA No. 2013- 01290 PA No. 21- 13- 1290 Estate Of: VIOLETRRHOADS /First Middle.Lesd Late Of: SILVER SPRING TOWNSHIP CUMBERLAND COUNTY 0 Deceased Social Security No: 171-38-1176 WHEREAS, on the 9th day of December 2013 an instrument dated September 29th 1976 was admitted to probate as the last will of VIOLET R RHOADS (First,Middle,Lestl late of SILVER SPRING TOWNSHIP, CUMBERLAND County, who died on the 22nd day of November 2013 and WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARYto: LOU ANN MYERS and DIANA R DAVIS who have duly qualified as EXECUTOR(RIX) and have agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURTHOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 9th day of December 2013. A W egLSt,,,,,' 1 s ep ty **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) RECORDED OFFICE OF REGISTER OF WILLS 1013 OEC 9 AM i l 06 CLERK OF LAST WILL AND TESTAMENT OF VIOLET R. RHOADS ORPHANS' COURT CUMBERLAND CO., PA I, VIOLET R. RHOADS, of the Borough of Mechanicsburg, County of Cumberland and State of Pennsylvania, being of sound and dis- posing mind, memory and understanding, do make, publish and de- clare this my Last Will and Testament. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done . 2. I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, of whatsoever nature and wheresoever situate, to my husband, Ray G. Rhoads, absolutely and unconditionally. 3• In the event that my husband, Ray G. Rhoads, should predecease me, or should he die at about the same time as I do, such as in an accident cormon to both of us, then in such event, ,I give and bequeath my entire estate, of whatsoever nature and wheresoever the Esame may be situated, to my three children, to wit, Diane R. Lowe, Lou Ann Myers and John R. Rhoads, share and share alike. I nominate, constitute and appoint my daughter, Diane R. Lowe, guardian of the estate of my son, John R. Rhoads, for and during the term of his minority and do hereby authorize, empower and direct said guardian to expend the principal as well as the' income of my said son's estate to erasure his comfortable care, support, main- tenance and education, particularly directing her to expend said funds in providing my son with a college education cr other technical -1- or professional training after he graduates from high school, without the necessity or requirement on her part in securing a prior Order or Decree of Court before doing so. I further direct that my daughter, Diane R. Lowe, be permitted to serve as guardian of the estate of my son, John R. Rhoads, without posting bond or other security. LASTLY, I nominate, constitute and appoint my husband, Ray G. Rhoads, Executor of this my Last Will and Testament, and in the event that my said husband should predecease me, or should he be unable or unwilling to serve in such capacity for any reason, then in such event, I nominate, constitute and appoint my two daughters, Diane R. Lowe and Lou Ann Myers, Co-Executrices of this my Last Will and Testament in his place and stead. IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of September, A. D. 1976. (SEAL) Violet R. Rhoads Signed, sealed, published and declared by the above named Violet R. Rhoads, as and for her Last Will and Testament, in the presence of us who have subscribed our names hereto as witnesses, at the request of said testatrix, in her presence and in the presence of each other. -2-