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Home My WebLink About04-11-14 r .r 1 1505610101 �1 REV-1500 EX(m-act) OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes I. County Cade Year File Number PO BOX 28D6Di NHERITANCE TAX RETURN Harrisburg PA 17128-0601 RESIDENT DECEDENT 1 ENTER DECEDENT INFORMATION BELOW Date of Death MMODYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI CIS u MT1 (if Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Ml ® I I I I I `I:D ❑ Spouse's Social Security Number I � THIS RETURN MUST BE FILED IN DUPLICATE ITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW IS& 1.Original Return O 2.Supplemental Return Q 3. Remainder Return(date of death , .i prior to 12-13.82) Q 4,Limited Estate Q 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12.12-82) G7 6.Decedent Died Testate Q 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Ci 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 11. Election t0 tax under Sec.9113(A) between 12.31-91 and 1.1-95) (Attach Sch.0) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 1Ei61+1k\1dP_1 R SUR OF WIL—Lt US NT CO C3 2 First line of address D i— }_. —H ;Z:; � m F, Inm 1 0 l�'Q ,2 b? P. 54 °' o o I Second line of address a o � -n d C I—+ - C7 t- City or Post Office State ZIP Code _0 DATE MID r � 17107 ITT-0177 TJG 7 ( /� d � � =� Correspondent's e-mail address: 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 knowledge. SlqVATUREOFPER$QI3 RESPONStOLE FL3R FILING RETURN pgTE It ADDRESS I«-lAle.y. /l �Ji-c%a.L�.i ALlny TfIO.7-ir�� Y ,az N lNlae�(n - dy2rct1 P% t7os� SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J 1�v 1505610105 REV-1500 EX / ce Dedent's Name 4e6 A, RECAPITULATION 1. Real Estate(Schedule A). ................................:....... .". 1. 2. Stocks and Bonds(Schedule B) . ...................................... 2. ' 3. Closely Held Corporation,Partnership or Sole-Propdetorship(Schedule C) ..... 3. 4. Mortgages and Notes Receivable(Schedule D)..................... ...... 4. " p 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 6. Jointly Owned Property(Schedule F) p Separate Billing Requested . ...... 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets(total Lines 1 through 7)...... ........ ....... .... .... 8. 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. �•4n 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule 1) ...... ....... . 10. 8 •'7 11. Total Deductions(total Lines 9 and 10). ... ........ ......... ............ 11. 1491,21 •M - 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� N 1 1 Net Value Subject to Tax(Line 12 minus Line 13) ... .... ............... .. 14. 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 .+at linealvate X.0_ 16. 17.1 Amount of Line 14 taxable O r at siblingrafe X.12 • 17. - 18. Amount of Line 14 taxable 18 /7 at collateral rate X.15 l/ 19. TAX DUE .. .. ............ ... ..... ......... ........ ... .... ....... .. 19. .,V 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610105 1505610105 J REV-15Q0 EX Pagb 3 File Number Decedent's Complete Address: DECED 'S N ME // �.`1 nl21 STREE2D/0SSc- )b l� Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) b 2. Credits/Payments A.Prior Payments B.Discount C/ Total Credits(A+B) (2) 3. Interest O (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,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) v 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 1t a. retain the use or income of the property transferred;......................................................................................... El $ b. retain the right to designate who shall use the property transferred or its income;........................................... ❑ lx c. retain a reversionary interest;or.......................................................................................................................... ❑ IN d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ FAI 2. If death occurred after Dec.12, 1902,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ C� 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. El fW 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ 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)(i)]. 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 decedent's siblings is 12 percent[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-1502 EX+ (01-10) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE FILE NUMBER: ;� � � ,40/3 All real property owned sol r as a tenant in common must be reported at fair market value.Fair market va ue 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 if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. to/A TOTAL (Also enter on Line 1, Recapitulation.) $ If more space is needed, use additional sheets of paper of the same size. REV-1503 EX+(6-96) h SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTAT�OF ��, ry/, � FILE NUMBER �,�J /�LC�I,t �7�/, �o1� " aid , UV All property jointly-owned with right of survivorship must he disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. TOTAL(Also enter on line 2, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1504,EX+(1-97) SCHEDULE C CLOSELY-HELD CORPORATION, COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP OR INHERITANCE TAX RETURN RESIDENT DECEDENT SOLE-PROPRIETORSHIP �ESTAT F p FILE NUMBER tX.2t1 Schedule C-1 or C-2(including all Kporting 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 sale-proprietorships. ITEM NUMBER NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. TOTAL(Also enter on line 3, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) 9EV-1505 EX+(6-98) SCHEDULE C- 1 COMMONWEALTH OF PENNSYLVANIA CLOSELY-HELD CORPORATE INHERITANCE TAX RETURN RESIDENT DECEDENT STOCK INFORMATION REPORT ES E FILE NUMBER 020/3 O 1. Name of Corporation �t State on Incorporation Address / I 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 Voting/Non-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? . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . ❑Yes ❑ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . .. ❑ 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? ❑Yes ❑ No If yes, ❑Transfer ❑ 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 ❑ 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. FOLLOWING THE 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,attach copies. D. List of principal stockholders at the date of death,number of shares held and their relationship to the decedent. E. List 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) 13EV-1506 EX+(9-00) SCHEDULE C-Z COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT E T E F FILE NUMBER odqo S 1. Name of PartnershiR 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 0 General ❑ Limited partner. If decedent was a limited partner, provide initial investment$ 5. PARTNER NAME PERCENT PERCENT BALANCE OF 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 0 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? ❑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 decedents death? . . . . . . ❑Yes ❑ No If yes, provide a copy of the agreement. - 11. Was the decedent's 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? . . .. . . .. . . .. . . .. . . . . . .. . . . . . . .. . . .. . 0 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 addresses 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€X+(1-97) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE 0 FILE NUMBER �c�f�-�.O.rcca �� All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL(Also enter on line 4, Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-15oB EX+(ii-io) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE RETURN PERSONAL PROPERTY RESIDENT DECEDENT ' ESTATE 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 Aurnj TOTAL(Also enter on Line 5, Recapitulation) $ p � If more space is needed, use additional sheets of paper of the same size. 55 G REV-15o9 EX+(oi-to) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT EST T OF: FILE NUMBER: � D If an asset beca intly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. B. f�I Y ` 1 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 ESTA OF FILE NUMBER ,Y--k ao�3 ;os� This schedule Wt 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 TIE NAME OF THE TRANSFEREE,THEIR REATIDNSHIP TO DECEDENT AND DATE OF DEATH P/o OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER, ATTACH A COPY OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST (IF APPUCANIE) VALUE 1. fin\ V TOTAL (Also enter on Line 7, Recapitulation) $ If more space is needed,use additional sheets of paper of the same size. REV-1511 1(10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER i2 dw 1wClS"w z-W Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT / A. t FUNEREXPENSE� S: 3a �✓ 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 V 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 O 0 5. Accountant's Fees — 0 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) Ronan Funeral Home 255 York Road Carlisle, PA 17013 Tel: 717-258-9863 Fax: 717-241-4041 Lynn A. Ronan, Funeral Director Friday, April 5, 2013 Mrs.Esther Crawford 310 E. Marble St. Mechanicsburg, PA 17055 Dear Esther, Thank you for selecting our funeral home to provide services for your family during your time of bereavement. I hope that you found our services, so far, to be of the highest standards that we always try to achieve. The following is a summary of the service charges as previously explained and provided in written form on the services for: HELEN L.SCHAFFHAUSER Other Preparation of Body $Incl. Crematory Fee $ Incl. Total Funeral Service Selected Incl Transfer of Remains to Funeral Home $ Incl. OTHER MERCHANDISE SELECTED Casket: Minimum Alternative $75.00 SPECIAL SERVICES TOTAL OTHER MERCHANDISE SELECTED $75.00 Direct cremation TOTAL $ 2,060.00 CASH ADVANCES SPECIAL CHARGES $2,060.00 Certified Copies of Death Certificate $ 36.00 Newspaper Notice Patriot-News $ 107.91 Coroner Fee $ 30.00 CASH ADVANCE TOTAL $173.91 TOTAL OF SERVICES $2,308.91 BALANCE DUE $2,308.91 If there are any questions or concerns that remain unanswered,please call me. C!cc Sincerely, 3 2�� , O Lynn A. Ronan Funeral Director 2 ClWr 'Y RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 9/09/2013 Cumberland County - Register Of Wills Receipt Time : 12 : 01 : 03 one Courthouse Square Receipt No. : 1075494 Carlisle, PA 17013 SCHAFFHAUSER HELEN L Estate File No. : 2013-00957 Paid By Remarks : ESTHER A CRAWFORD DB1 ------------------------ Receipt Distribution ---- -------------------- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 30 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 5 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 102 108 . 50 Total Received. . . . . . . . . 108 . 50 REV-1512 Ex+ (12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE 0 FILE NUMBER C_�7 Report debts incu ed by the deceden for to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. qy/� 9 T 1 .(-� O ate— % 11&4, j TOTAL(Also enter on Line 10, Recapitulation) $ 7S �gCD, 9�p If more space is needed,insert additional sheets of the same size. a:. ,. , �,. �. .. ,. 4 � � . � � �� . � . -. REV-1513 EX+ (01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES 9SIDENT DECEDENT ESTATE 0 . FILE NUMBER: AD/3 9SI 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. 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. i ,� ; ... . �, .�., j q .`;r. .4 REVA614 F,X+(12.03) SCHEDULE K LIFE ESTATE, ANNUITY COMMONWEALTH OF PENNSYLVANIA $t TERM CERTAIN INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4 on REV-1500 Cover Sheet ESTATE FILE NUMBER This schedule is to be use all single life,joint or successive life estate and term certain calculations. For dates of death prior to 5-1.89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457,Actuarial Values,Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ❑ wilt ❑ Intervivos Deed of Trust O Other LIFE ESTATE INTEREST CALCULATION NAME(S)OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH LIFE ESTATE IS PAYABLE ❑ Life or ❑Term of Years ❑Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years 1. Value of fund from which life estate is payable .... . .. . . ........ ..... ........ . . . .... . ... .$ 2. Actuarial factor per appropriate table ... . .............. ... ....... .... ...... .... .... .. . Interest table rate—13 3 1/2% ❑ 6% 13 10% ❑ Variable Rate 3. Value of life estate(Line t multiplied by Line 2) .... . ... . . ........ . . ......... .........$ ANNUITY INTEREST CALCULATION NAME(S)OF LIFE ANNUITANT(S) DATE OF BIRTH NEARESTAGE 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) ❑ Quarterly(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—❑31/20% ❑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 .... . ........... .. ....... .$ It 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-1644EX.(3-04) INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER I. ESTAT9,0F (Last Name) (First Name) (Middle 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 or Annuitant(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/Mist. Personal Property . . . . . . . . . . . . . . . .$ 6. Total from Schedule L-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Unpaid Bequests . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 3. Value of Unincludable 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) III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day,Year) B. Name(s)of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed C. Corpus consumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ D. Remainder factor(see Table I or Table II in Instruction Booklet) . . . . . . . . . . . . . . . . . . . . . . . . . E. Taxable value of corpus consumed (Line C x Line D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ (Also enter on Line 7, Recapitulation) 4TV.sau Ex♦D"esl - .. . INHERITANCE TAX bb SCHEDULE L-1 COMMONWEALTH INHERITANCE OF PENNSYLVANIA _ �� tO SAP PENNSYLVANIA REMAINDER PREPAYMENT ELECTION j'"�,/'tM�//J/JS�L RESIDENT DECEDENT -AS$ETS-. FILE NUMBER 1. Estate of ILmt Name) (First Name) (Middle Initial) II. Item No. Description Value A. Real Estate (please describe) - Total value of real estate $ (include on Section II, Line C•1 on Schedule L) B. Stocks and Bonds (please list) Total value of stocks and bonds $ {include on Section II, Line C•2 on Schedule Ll C. Closely Held Stock/Partnership (attach Schedule C•1 and/or C•2) (please list) Total value of Closely Held/Partnership $ (include on Section II, Line C•3 on Schedule L) C. Mortgages and Notes (please list) Total value of Mortgages and Notes $ (include on Section II, Line C•4 on Schedule L) E. Cash and Miscellaneous P nal Pro arty (please list) j 1� 1�T/ IP/ Totol value of asfi/Mist. Pers. Property $ 7 (include on Section II, Line C•5 an Schedule L) J a got 111 TOTAL(Also enter on Sec�Illine C-6 on Schedule L) $ �_ _. (if more space is needed. attach additionnl RU . I I •6..,.t $EV-164C EX- (11-09) �r pennSywania INHERITANCE TAX - OEPARTMEW OF REVENUE SCHEDULE L-2 INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -CREDITS- I. ESTAT �F jJ FILE NUMBER II. ITEM NO. up 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) i 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. i �� i RE -1647 EX+ (02-10) ,jai ' SCHEDULE M Pennsylvania }i! DEPARTMENT or REVENUE FUTURE INTEREST COMPROMISE INHERITANCE TAX RETURN a on REV-1500) RESIDENT DECEDENT (Check Box 4 ) ESTATE PILE NUMBER This schedule is appro to only for esta#es 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 2. 2. 3. 4. 5. II. For decedents who died on or after July 1, 1994, it 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. C] 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% . . . . . . . . . . . . . . . . . . . . $V_ (Also include as part of total shown on Line 15 of REV-1500.) 4. Value of Line I taxable at lineal rate Check one. ❑ 6 0/a, ❑ 4.5% . . . . . . . . . . . . . . . . . . . . . . . . . . $ (Also include as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate (1.2°/x) (Also include as part of total shown on Line 17 of REV-1500.) . . . . . . . . $ 6. Value of Line I 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. BEV-7849 eX+(08-09) Mpennsylvania SCHEDULE O DEPARTMENT OF REVENUE INHERITANCE TAXES RETURN ELECTION UNDER SEC.2113(A) RESIDENT DECEDENT (SPOUSAL DISTRIBUTIONS) ESTATE O FILE NUMBER Do not complete this schedulvAless 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 2113(A)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(Al 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. . 4 i. 1" _ � i � _ i ., l .. � r _ .. x i i �, INVENTORY REGISTER OF WILLS OF COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA �O/3 G 'y/yam [fin COUNTY OF SS /0/ / 10 I(File Number Personal Representative(s)of the Estate of deceased,depose(s)and say(s)that the items appearing in the following inventory Include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent,that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memoorrj-a�n/ndumm at the end of this inventory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- p ments herein are made subject to the penalties of 1S Pa.C.S. § 4904 relating to unswom falsification to authorities. Attorney-- (Name) (Supreme Court I.D. No) (Address) (Telephone) DATE OF DEATH LAST RESIDENCE )ECEDENT'S SOC.SEC.N0, FIGURES MUST BE TOTALED o7D5-Z)<I a �ge/v3 3a 96o v/ (Attach additional sheets as needed) TOTAL: (p p 0 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each item,but such figures should not be extended into the total of the Inventory. (See 10 Pa. C.S.§3301(b)) Form RW-09 rev. 10.U06 ��y � iA .- ��l � � � T I. . �y r... .. .... '� :=i.w { ij �, (� L_.._. RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 9/09/2013 Cumberland County - Register Of Wills Receipt Time: 12 : 01 : 03 One Courthouse Square Receipt No. : 1075494 Carlisle, PA 17013 SCHAFFHAUSER HELEN L Estate File No. : 2013-00957 Paid By Remarks : EESTHER A CRAWFORD ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 30 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 5 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN ---------- ------ Check# 102 $108 . 50 Total �Received. . . �./.r. $108 . 50 -V FOFE A CRAWFORD 05-N 1872 HER A CRAWFORD WIM13 E MARBLE ST PH.717-7667341 Os HANICSBURG,PA 17055 �D o2U DATE THE P4. J 10�. u/�P I $ /1/11 55Ann l a�n.e ol, Ao� 'i lly.Y, .2_.L�BaI_A. ./.�61,uARS 8 METRO MM (� BANK � ry/ FOR J3d=y ~ �:03L30i8 61: 032063 n' L872 pennsylvania DEPARTMENT OF PUBLIC WELFARP February 19, 2014 ESTHER CRAWFORD 310 E MARBLE ST MECHANICSBURG PA 17055 Re: Helen Sc'naffhauser CIS #: 810141347 SSN: ###-##-0491 Date of Death: 03/23/2013 Dear Ms. Crawford: This letter is to advise you that according to the information you provided to our office regarding the assets of the above-referenced estate, the Department of Public Welfare will accept the balance, namely $3.255.92 remaining in the estate for payment of our existing claim. Please have the check made payable to the Department of Public Welfare and forwarded to my attention at the address listed below. Your cooperation in resolving rhis.rnatter is appreciated. Sincerely, r� Nathan L. Snyder rPL Program Investigator 717-772-52606 '.'... -7'172-E553 FAX r Bureau o`Prcgram lntegnry ; ati,wo�;f"I:herd Racy Oabiitty I Recovery Section PO 8,x 8"86 1 NOITISJU'C.✓onn:viaarJa +J iU5 8486 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 9/09/2013 Cumberland County - Register Of Wills Receipt Time : 12 : 01 : 03 One Courthouse Square Receipt No. : 1075494 Carlisle, PA 17013 SCHAFFHAUSER HELEN L Estate File No. : 2013-00957 Paid By Remarks : ESTHER A CRAWFORD DB1 ------------------------ Receipt Distribution - -------------------- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 30 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 5 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 102 , $108 . 50 Total Recesved. . . . . . . . . $108 . 50 Jti.w /Of T A all FESTHER WFORD 05-96 1872 RAWFORD s01801a ST PH.717-76&7341 Re RG,PA 17055 f/. ' �(' ��. $ % /7 17i L LLARS METRO I/ //BANK R. 1:0313018 61: 032063 6 1872 --_� �_ 6 \ S-- r .=:.�; �� Y�. �r�_. �� r... ' � �: " _ nr, `�`` V y� `n A ]� 8� � �T � O � m� O mN �� J �� o �� w �� a��_ a m n _ Z� D � °o{'�} zm-z�tn m-�nm m�� coots..a �� z• roman -1 •NG� (� J� y. m =D � fn to �