HomeMy WebLinkAbout04-0882
1-
,~II' ;;; "",
I: !i Ii'
I
<:>",(~i~:;' I
",'t', ", 15
~ !It':~!: Cl:
I' u.
~ 'tl '" Cl
"""4. ~ UJ
"S" .J
<l.>'J/Nn ;f"'"'''' :!
11,.,")1 ;,;::.
..
..
..
1.1-,
(~ C\I
\.. ,....
\; .ill
"-.- m
O::lO
C) en .....
(') -l"-
nt.....
~5<t
~U[l.
c:~o;
?"E::;
() O'sJ
.- .s:: (!)
(';J I- T:
. .!= IIJ
..JfflI
I"-
~:
C',J
0_.
O'~
N
Q
'-'.J
vJ
.,-
"
p
I)
. ",. r '"
.- .......
fI.2
~
...... 0\
~ =
.,. :t ~
~~E-- ::
fI.2 "< Oil ,.;;l
~~g ~
"""'l.,,..;!U ~
~ ~~~~
;;j~~;Z;
= 8gE::~
~ I::i ~ ;;Hl",
e~=:ClJd'
$.4 ~... =:
,., CIJ ;;J
=~'Il =
. ~~ ~C'I.l
~"<
=
~
""'"
Cll
U)
~
o
..c:
+>
l-l
~ Cll
o l-l
UruM
~.-l
U) >t tJ' 0
.-I+>U)!-
.-IS:: .-l
.r-! ~ Cll
~ 0 U)
U~<
4-l 0 P..
O'O..c:
s:: +> '
l-l ru l-l Cll
Cll.-l~.-I
+>l-lOU)
U) Cll u.r-!
'r-!.a .-I
J1 e Cll l-l
Cll ~ s:: ru
o::iUOU
o
Eo-
JAN L. BROWN, ESQUIRE'
JACQUELINE A. KELLY. ESQUIRE
'ADMITTED IN PA AND DISTRICT OF COlUMBIA
JAN L, BROWN & ASSOCIATES
ATIORNEYS AND COUNSELORS AT LAW
aLOE ENGLISH GAP
845 SIR THOMAS COURT
SUITE 12
HARRISBURG, PA 17109
EMAIl: jlbassoc@verizon.net
TELEPHONE (717) 541-5550
FACSIMILE (717) 541-9223
BRENDA F. KEPHART, LEGAL ASSISTANT
PAULA K. WHITE. LEGAL ASSISTANT
JUDITH A. EBERSOLE. ADMINISTRATIVE ASSISTANT
September 27,2004
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Re: Estate of Sylvia M. Wiseman
To Whom It May Concern:
Enclosed for filing are an original and two copies of the Inheritance Tax Return for the
Estate of Sylvia M. Wiseman. A check in the amount of$3,917.32 made payable to the Register
of Wills, Agent, for payment of Pennsylvania Inheritance Tax due, and a check in the amount of
$15.00 made payable to the Register of Wills for the filing fee have also been enclosed.
Please return a time-stamped copy of each document in the envelope provided. Also,
Please forward the receipt of payment to my office.
Sincerely,
eke l' tf~
o J';'q~. Esquire cJ
Enclosures
.~,.,...
::! ::f~~
3-'-
cr
c"
d
.t:=.
(/)
[T1
<:J
N
Q:)
-0
N
o
-..j
.
C'YMNlONWEAl TH OF PENNSYLVANIA
OEPARTMENT 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
KELLY JACQUELINE A
845 SIR THOMAS COURT SUITE 12
HARRISBURG, PA 17109
__-..un fold
EST A TE INFORMATION: SSN: 180-07-9161
FILE NUMBER: 2104-0882
DECEDENT NAME: WISEMAN SYLVIA M
DATE OF PAYMENT: 09/28/2004
POSTMARK DATE: 09/27/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 07/06/2004
NO. CD 004434
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $3,917.32
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
CHECK#1238
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
$3,917.32
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REV,-1500 EX + (6-do)
.
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
w
!;(
:.::-1/)
uO:=:'::
wll.U
:1:00
.. O:=..J
~ II.lD
II.
c(
I-
Z
W
C
W
o
w
c
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Wiseman, S Ivia M.
DATE OF DEATH (MM-DD-Year)
DATE OF BIRTH (MM-DD-Year)
OFFICIAL USE ONLY
FILE NUMBER J I
~ I -0':1:.- 0 0 ~~d..
COuiiTvCOiiE -YEAR - - NuMBeR- -
SOCIAL SECURITY NUMBER
1 80- 0 7 - 9 1 6 1
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Retum (date of death prior to 12-13-82)
D 5. Federal Estate Tax Retum Required
_ 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
z
o
!;:
...J
:J
l-
e::
<(
o
w
~
z
o
!;:
I-
:J
D..
:E
o
o
~
I-
07/06/2004 01/02/1913
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
[K] 1. Original Retum
o 4. Limited Estate
o 6. Decedent Died Testate (AttachcopyofWilQ
o 9. Litigation Proceeds Received
D 2. Supplemental Retum
D 4a. Future Interest Compromise (date of death after 12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy of TrusQ
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
I-
Z
W
C
Z
o
II.
I/)
W
0:=
0:=
o
U
Harrisbur
845 Sir Thomas Court, Suite12
PA 17109
OFFICIAL USE ONLY
d
~.
NAME
Jac ueline A. Kell
FIRM NAME (If Applicable)
Jan L. Brown & Associates
TELEPHONE NUMBER
717 -541-5550
COMPLETE MAILING ADDRESS
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmental Bequests/See 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)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under See. 9116 (a)(1.2)
X _(15)
91,632.60 X .045 (16)
X .12 (17)
X .15 (18)
(19)
I r/)
i fT1
II:)
13,702.341 f:'l
I ._~
,
34,196.741 ~:~
I ..
49,777.00 I :.:3
(8)
97,676.08
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. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
6,043.48
(11)
(12)
(13)
6,043.48
91,632.60
(14)
91,632.60
4,123.47
4,123.47
0' d t' C
ece en s omplete Address:
STREET ADDRESS
310 Hogestown Road
CITY I STATE PA I ZIP 17050
Mechanicsburg
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
4,123.47
206.15
Total Credits (A + B + C)
(2)
206.15
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( 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. (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 No
a. retain the use or income of the property transferred; ........................................................................... D [ZI
b. retain the right to designate who shall use the property transferred or its income; ........................................ D IZl
c. retain a reversionary interest; or ...................................................................................................... D IZl
d. receive the promise for life of either payments, benefits or care? ............................................................. D [ZI
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?.................... ................... ................. ................................ ...... IZl D
3. Did decedent own an 'in trust for" or payable upon death bank account or security at his or her death? ................. D [ZI
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... D IZl
0.00
3,917.32
3,917.32
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
ADDRESS
PA
ADDRESS
PA 17109
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) (ii)).
The statute does not exemDt 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. ~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%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX + (6-98)
'*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Wiseman Sylvia M.
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
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
13,702.34
CNA Insurance Company
Long Term Care Insurance Reimbursements
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
13,702.34
R,EV -1509 EP< + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
Wiseman. Sylvia M
FILE NUMBER
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Darlene V. Moorhead
310 Hogestown Road
Mechanicsburg, PA 17050
daughter
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 DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST
1. A, 1978 U.S. Savings Bonds (44 in quantity) 10,088.58 50. 5,044.29
See attached Inventory
2. A 12/2000 Members 1 st FCU 28.67 50. 14.34
Savings Account #199532-00
3. A 10/2001 Members 1 st FCU 24,030.18 50. 12,015.09
Investment Savings Account #199532-05
4. A 1993 PNC Bank 3,338.57 50. 1,669.29
Checking Account #5140148675
5. A 1993 PNC Bank 30,907.46 50. 15,453.73
Savings Account #5130253527
TOTAL (Also enter on line 6, Recapitulation) $ 34,196.74
(If more space is needed, insert additional sheets of the same size)
REV-1510 E!X + (6-98)
'*
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Wiseman. Svlvia M.
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.
FILE NUMBER
DESCRIPTION OF PROPERTY
ITEM INQ.UDE THE NAME Of THE TRANSFEREE. THEIR RElATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'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. Transfer to daughter, Darlene (August 2003) 31,777.00 100. 3,000.00 28,777.00
2. Transfer to daughter, Darlene (June 2004) 24,000.00 100. 3,000.00 21,000.00
TOTAL (Also enter on line 7 Recapitulation) $ 49,777.00
REV-1511 E!X + (12-99)
.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Wiseman. Sylvia M
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Ronald C.L. Smith Funeral Home 4,278.48
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (5)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attomey Fees Jan L. Brown & Associates 1,500.00
3. Family Exemption: (If decedents address is not the same as claimants, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountants Fees
6. Tax Retum Prepare!'s Fees CPA fee for 2004 income tax return preparation 250.00
7. Reg of Wills, tax return filing fee 15.00
TOTAL (Also enter on line 9, Recapitulation) $ 6,043.48
(If more space is needed, insert additional sheets of the same size)
"","'~~. 'w
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
Svlvi::l M
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 s~usal distributions, and transfers under
Sec. 9116 (a)(1. )]
1. Darlene V. Moorhead daughter 100%
310 Hogestown Road
Mechanicsburg, PA 17050
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, 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 n - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21-C4-CD8S.:>
04141387
10-20-2004
REY-1545 EX AFP 109-00>
TYPE OF
ACCOUNT
[Xl SAVINGS
o CHECKING
o TRUST
o CERTIF.
FORMS TO:
'04
EST. OF SYLVIA M WISEMAN
S.S. NO. 180-07-9161
DATE OF DEATH 07-06-2004
"!~ .'J ?,COUNTY CUMBERLAND
; \L ..)--
REMIT PAYMENT AND
REGISTER OF WILLS
CUMBERLAND CO COURT
CARLISLE, PA 17013
HOUSE
:'!Ov -1
DARLENE V MOORHEAD
310 HOGESTOWN RD
MECHANICSBURG PA 17050
(.,
,,\
MEMBERS 1ST FCU has provided the Department with the information listed below which has been used in
calcUlating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of
this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
of pgnnsylva"!a~ g~Qsti~ns ~ay be 2ns~ered by cal!i~g (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 199532-05 Date 10-19-2001
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
24,030.18
50.000
12,015.09
.045
540.68
TAXPAYER RESPONSE
To insure proper credit to your account, two
(Z) copies of this notice must accompany your
payment to the Register of Wills. Make check
payable to: ftRegister of Wills, Agentft.
x
NOTE: If tax payments are made within three
(3) months of the decedent.s date of death,
you may deduct a 5% discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
Tax
PART
[!]
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
[J The above information and tax due is correct.
1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you may check box ftAft and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
~he above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent.s representative.
[J The abovs information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
If you indicate a different tax rate, please state your
relationship to decedent:
PART
~
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8. Tax Due
OF
1
2
3
4
5
6
7
8
x
TAX ON JOINT/TRUST ACCOUNTS
x
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
I
$
declare that the facts I have reported above are true, correct
and belief.
HOME
(
and ~''t".~.,
ID-;~~'1
DATE
\>-
T
)
WORK (711 ) 54/- 5552
TELEPHONE NUMBER
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX Z80601
HARRISBURG, PA 171Z8-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT. ALLOWANCE DR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
JACQUELINE A KELLY
JAN L BROWN 8 ASSOCS
845 SIR THOMAS CT 12
HBG PA 17109
'()if
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
'") '.' COUNTY
'"ACN
11-29-2004
WISEMAN
07-06-2004
21 04-0882
CUMBERLAND
101
-- 3
*'
REV-1547 EX AFP (09-04)
SYLVIA
M
Allount Rellitted
\ .
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= iS4-j-E;f-AFP--(' oY:oiY-NoYicE--oF-YNHEifiTANCE-TAX -jrpPRAYSEi"-ENT~--ALioWAN-CE-ifR------------- - ---
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF WISEMAN SYLVIA M FILE NO. 21 04-0882 ACN 101 DATE 11-29-2004
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (15)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00 = .00
91.632.60 X 045 = 4.123.47
.00 X 12 = .00
.00 X 15 = .00
(19)= 4.123.47
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
13.702.34
34,196.74
49.777.00
(8)
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 Bequestsj Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
6.043.48
.00
(11)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account.
subllit the upper portion
of this forll with your
tax paYllent.
97.676.08
6.043 48
91.632.60
.00
91.632.60
n~_~.. l+J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
09-27-2004 CDo04434 206.17 3.917.32
TOTAL TAX CREDIT 4.123.49
S BALANCE OF TAX DUE .02CR
INTEREST AND PEN. .00
TOTAL DUE .02CR
. IF PAID AFTER DATE INDICATED. SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
a 1"-
( 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.) ~