HomeMy WebLinkAbout03-27-14 (4) 1505610105
REV-1500
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
County Code Year_ _ File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN //11
PO BOX 28o6oi ,t !
Harrisburg,PA 17128-0601 RESIDENT DECEDENT jj///l J(� F1 I 711
ENTER DECEDENT INFORMATION BELOW -
Social Security Number Date of Death MMDOYYYY Date of Birth MMDDYYYY
06t17i2013� 11/30/1925
Decedent's Last Name Suffix Decedent's First Name MI j
McClure .1� Francis — 1 LJ
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Su�ffix�� Spouse's First Name MI
NOneY Y..-
Spouse's
Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
( �_.-� REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
CID 1.Original Return q 2.Supplemental Return O 1 Remainder Return(Date of Death
Prior to 12.1342)
- C= 4.Limited Estate O 4a.Future Interest Compromise(date of C=) 5. Federal Estate Tax Return Required
death after 12-12.82)
CC 6. Decedent Died Testate CID 7.Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.) -
C=> 9.Litigation Proceeds Received C7 10.Spousal Poverty Credit(Date of Oeath C=) 11. Election to Tax under Sec.9113(A)
. . Between 12-31-91 and 1-1.95) (Attach-Schedule O)�
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATIO HOULD BE DIMTED It ;
Name Daytime TeRlb a Numb •-_�
Michael Cherewka, Esquire ' (717) 2344DI-> s
en T
REVEgOAYViLL E ONDYC-7
C> O 3
First Line of Address -n 3 `e I7
624 North Front Street -4 ti rn
i
Second Line of Address -
City or Post Office State ZIP Code DATE FILED
Wormleysburg PA 17043
Correspondent's e-mall address:mcherewka@cherewkalaw.Com
Under penalties of perjury,I dedare that I have examined this retum,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 pmpamr has any knowledge.
SG
L E" OM SBLE FOR FIN RETURN DT3E1 �/r
L��
ADDRESS
5 High Street, Enola, PA 17025
SIG P OT ER THAN REPRESENTATIVE DAT£
ADDRESS / L!
624 North Front Street, Wormieysburg, PA 17043
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
J 1505610205
REV-1500 EX(FI)
Decedent's Social Secudty Number
DecedenfsName:, Francis C. McClure
RECAPITULATION
1. Real Estate(Schedule A). ...._.......................'............... 1. 0,00
i
2. Stocks and Bonds(Schedule B) 2, 0.00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 1 0.00
i
4. Mortgages and Notes Receivable(Schedule D) ... .. . .. ..... ... ... ... ..... 4, 0.00 i
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).,...... 5. 17,339.94
6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. ..... 6. 0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested....... . 7. i 61,500.41
8. Total Gross Assets(total Lines 1 through 7). . .. ..... 8. -- 78,840.35
9. Funeral Expenses and Administrative Costs(Schedule H).. ...... ..... ...... 9. 15,949.17
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)........ ... .... 10. '. 1,563.24
11. Total Deductions(total Lines 9 and 10).... . ... . .. . ... . ... ......... ..... 11. 17,512.41 j
12. Net Value of Estate(Line 8 minus Line 11
).............................. 12. 61,327.94
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ... .. . .. . .. .. . .. . ..... .. 11 0:00
14. Net Value Subject to Tax(Line 12 minus Line 13) ......................... 14. f 61,327.94
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or -
transfersunder See.9116 1-___._....._____.__w..,.,..,.__...____...,...._.__...._.,.-,,., ;....___.,._.,.,......._. _......._....,.._.______.._...�...______,.
(a)(1.2)X.o_ 0,00 '. 15. 1 0.00l,
16. Amount of Line 14 taxable
at lineal rate X.0 45 61,327 94 16. 1 2,759-76
17. Amount of Line 14 taxable '.'-,.,,,...."_ .._.-.4�..,_......
at sibling rate X.12 17. r
18. Amount of Line 14 taxable
at collateral rate X.15 ( 18
19. TAX DUE .. ... . .......... .. . .. .. ... ... ... ... .. . . . .. . .. ... . .. . . ... . 19. 2,759.76
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
L 1505610205 1505610205
REV-1500 EX(FI) Page 3 File Number
2]-f3-o779
Decedent's Complete Address:
DECEDENTS NAME
Francis C. McClure
STREETADDRESS '
1000 Grandon Way
CITY STATE ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 2,759.76
2. Credits/Payments
A.Prior Payments 0.00
6,Discount 0.00
Total Credits(A+g) (2) 2,759.76
3. Interest
(3) 2.94
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) 0.00
5. If Line t+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 2,76Z70
Make check payable t0: 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..........................---......................................................... ❑ 0
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ E
c. retain a reversionary interest......................................................................................................--.................. ❑
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?.....................—....—...............—........................................................... ❑ E
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? .....................................................................----.................--................
..... ❑
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 172 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
172 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 F2 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(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(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+(12-12) _
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE REAL ESTATE
INHERITANCE TAX RETURN '
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Francis C. McClure 21-13-0779
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 if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION -
1 'None
0.00
j I
I
i
TOTAL(Also enter on Line 1, Recapitulation.) • 0.00
If more space is needed,use additional sheets of paper of the same size., - '
REV-1543 IX+{S•>R) -
]fr pennSyFVama SCHEDULE B
DEPARTMENT 0FREVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Francis C. McClure 21-13-0779
All property jointly owned with right of survivorship must be disclosed on schedule F,
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Nonr------
E---�7� L-=—
-
i
t
TOTAL(Also enter on Line 2, Recapitulation) $ 0 00
If more space is needed,insert additional sheets of the same size
REV-2507 EX+(04-23) -
_rr,L pennsylvania SCHEDULE D
C3�
DEPARTMENT OF REVENUE MORTGAGES & NOTES
INNERRANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Francis C. McClure 21-13-0779
All property Jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION r OF DEATH
r-7.. ;None # I...y.. 0,0
I�
I
I�
:.�� � ..
TOTAL(Also enter on Line 4, Recapitulation) $ 0.00
(it more space Is needed,insert additional sheets of the same size.)
REV-isoS EX+(D$-i2)
IIffpennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, SANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Francis C. McClure 21-13-0779
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
1' 2008 Jeep Compass 10,377.00
�FirstCommonwealth Bank,DuBois,PA,Account#011001146 1 6,962.94
' E
}
r � ; t
,
TOTAL(Also enter on Line 5, Recapitulation) $ L.. 17,339.94
If more space is needed,use additional sheets of paper of the same size.
`C• . p O f
7, ^� . .
r
le
CL 00
B
a to}Crt , C$
� s G y
FE
o
f l�
r« 4;
v♦ /Myam
Kelley Blue Book Page 1 of 2
I r � Ketley Blue Book The Trusted Resource`
j
i
EMIR
VISIT CMC.CCM1
...... ....... ... ......."_- ...._-_.__-----------
_._.-.-...-..- ...........-..-.__
aMWSe e t ... why ads? '1
Your Blue Book-Value j
2008 Jeep Compass
Style:Sport SUV 41)
Mileage:56000
Private Party Value
Excellent Vehicle Highlights
$11,077
Very Good MPG:City 21/Hwy 24 - ! Max Seating:5
$.. - —. Doors:4 ! Engine:4-Cy4 2.4 Liter
Good Drivetrain:4WD - Transmission:Automatic,CVT w/Overdrive
$10,377
i
'-`----'— EPA Class:Sport Utility Vehicles
Fair Body Style:Sport Utility
$9,277 Country of Origin:United States Country of Assembly:United States
Your Configured Options
. ---------
Our pre-selected options,based on typical equipment for this tar.
!Options that you added while configuring this car.
Engine ; Comfort and Convenience Cargo and Towing
4-Gyl,2.4lller - Air Conditioning Roof Rack
Transmission Steering Wheals and Tires
Automatic,M w/Overdrive i Power Staedng Alloy Wheels
Drivetraiq. Tilt Wheel
4WD Entertainment and instrumentation
Braking and Traction AM/FM Stereo -
Stablilty,Control CD(Single Disc)
AB$(4Whee0 Safety and Security
Dual Air Bags
F&R Head Curtain Air Bags
NeW Cars You Might Like
i
2014 Jeep Compass
2014 Jeep PaMot
http://www.kbb.com/jeep/compass/2008 jeep-compass/sport-suv-4d/?pricetype=private-pa... 6/26/2013
ti
REV-Iso9 EX+(oi-Lo) `
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE
INHERITANCE TAX REUR,N JOINTLY-OWNED PROPERTY '
RESIDENT DECEDENT - -
ESTATE OF: FILE NUMBER:
Francis C. McClure 21-13-0779
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVMNG JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. None
JOINTLY OWNED PROPERTY:.
LETTER DATE DESCRIPTION OF PROPERLY % DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF
NUMBER TENANT JOINr IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HEIR REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST
- - __--_—. ._} �..._.._._.._ _.__. -
L` A. ,—Y_ None 0.00 ,
E ---- € _
.. El i_-J
E-1
El 1 = i
F-1 17
TOTAL(Also enter on'Line 6, Recapitulation) $ 0.00
• 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 DE EDENTTURN MISC. NON-PROBATE PROPERTY "
RESIDENT DECEDENT ,
ESTATE OF FILE NUMBER
Francis C. McClure 21-13-0779
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. "
ITEM DESCRIPTION Of PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
INO.THE DATE NABAN iRATTAHfAF,OP THEIR RHE DEED 19 ESTATE AtA
NUMBER niEDnreormwsva+. AmaAmProrrnEOEEOwaRf/,te�AEE VALUE OF ASSET INTEREST or nRn.t . VALUE
.1.. IThe McClure Family rrevocable Grantors Trust
Y 61500.41 Y— 100 6.1,500.41
t L
��-- !-�.=�--rte-- °---•:--�-v—.-e-.�—A-=,�----.___... _._�•->-°-!I�I,� �—' t � �'�i1--1-�-
! 1.
r
—
I__ �__ fit•,. - � _.� �_..
4 � 3
,
III
M
! i
L l`
TOTAL(Also enter on Line 7, Recapitulation) $ 6 1,500.41 t;
. _
If more space Is needed,use additional sheets,of paper of the same size. -
Year-End Account Statement DWS
INVESTMENTS
January 1,2012 through December 31,2012 Deutsche Bank Group
m
m
AB 02 025448 91295 B 180 A . . +
lllrlllll,llll�ll"�'111'I'Illllllil"'Illlsllissllll�Irlsllls�s+ � Shareholder Services: (800)728-3337-
7a.m.to7psn.(C7) Mondaythmugh Friday
DAVID F MCCLURE TTEE Automated Asistance 14 hours a day
MCCLURE FAMILY IRRIV GRANTORS TRUST
U/A DTD 07/22/2011 Intemational: Call collect(816)435-7177
5 HIGH ST
ENOLA PA 17025-2720 Ja.m.to 7p.m.(0) Monday through Friday
�C�Web Side: wwwAd investmentsxom
rAr Your Primary Account Number: 26154632
From all of us at DWS Investments, best wishes for a happy and prosperous new year. This statement
reflects all account activity for 2012. please retain it foryour records. Tax forms will be available
through online account access at dws-investments.com in mid-January, and mailed in late January: For
general information about the tax information you will receive, frequently asked questions and more,
visit the Tax Information Center at dws-investments.com. For help with your annual allocation
rebalancing, call the DWS Resource Center at (855)744-3355.
Period Year to Date
Your Portfolio Value 01/01- 1213112012 01/01- 1213112012
Beginning Portfolio Value $68,502.11 $68,502.11
Purchases/Reinvested Distributions $3,116.78 $3,116.78
Redemptions -$10,000.00 -$10,000.00 _
Change in Value -$118.48 -$118.48
Transfers $0.00. $0.00 =_
Ending Portfolio Value on 12/31/2012 $61,500.41 $61,500.41
Your Portfolio by Asset Type
Percent of Asset T}pe Value on Change Value on
Poref Ltv Fund Name 0110112012 + This Period = 1213112012
® 79.92% Taxable Fixed-Income Funds
79.92% DWS GNMA Fund-S 557,589.19 -$8,439.66 $49,149.53
Total Taxable Fixed-Income-Funds $57,589.19 -$8,439.66 $49,149.53
._
20.08% Asset A..llocation Funds ��.. .. . ... .................. .. ..... . . ................................................. . . . _ .. .. . ....
20.08% DWS Global Income Builder Fund-S $10,912.92 $1,437.96 $12,350.88
Total Asset Allocation Funds $10,91292 $1,437.96 $12,350.88
Total Portfolio Value $68,502.11 -$7,001.70 $61,500.41
Your Portfolio Summary by Fund Name
Total Share Price Value on Con Barn Cost Basis
Fund Name Shares Mussed x on 1113112011 = 1213112012 Noncovend Sba vt Covered Shares
Non-Retirement
DWS GNMA Fund-S 3,189.457 $15.410 $49,149.53 $4$446.59 $2,461.97
DWS Global Income Builder 1,309.743 $9.430 $12.350.88 $11,024.76 $654.81
Total Portfolio $61,500.41
Page 1 of 4
025448113
26
REV-1511 EX+(88-13) -
( i f pennsylvania SCHEDULE H
' DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN
RESIDENT DECEDENT ' ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Francis C. McClure ,. 21-13-0779
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER - DESCRIPTION - AMOUNT
A. FUNERAL EXPENSES:
I' f Ralph M.Geer Funeral Home �� 82x38.22
F2 Funeral Reception �W — - 401.00
B. ADMINISTRATIVE COSTS: ---?i
1. Personal Representative Commissions: - +�! 0.00
Name(s)of Personal Representative(s)
Street Address -
city -State ZIP
Year(s)Commission Paid:
2. Attorney Foes:
7,000.00
3. Family Exemption:(If decedents address is not the same as claimant's,attach explanation,)
0.00
Claimant -
Street Address -
City -State_ZIP
Relationship Of Claimant to Decedent
4. Probate Fees: �.11l3071
S. Accountant Fees:
6. Tax Return Preparer Fees:
7. Cumberland Law Journal-Legal Notice r �.� 75 AO
'rMwa .iarnr
8 Sentinel-Legal Notice� � 1 84.95
t-•-- -- _
TOTAL(Also enter on Line 9, Recapitulation) ; 15 949.17
If more space Is needed,use additional sheets of paper of the same size. ,
• ,.eater. _laorm ,��s��
Ralph M. deer Ubel
Funeral Home Funeral Home
9 „.r JwN f6B b7:0 X mD `X.T.Ae &Z—J; td"
Joseph&Needza F.B. 12045 B r" BOX alley Hwy. Must Frank Reed,F.D. ill Bridge Streref
Supervisor Johnsonbur PA 15845
(814)637.5401 Penfield,PA—15849 ' (814)965.2591
STATEMENT OF FUNERAL GOODS AND SERVICES SELF=
Charges am oniY IM these from that yon selected m that art required.Vw em required by law at by a secondary at mandatory in use any Rams we will"pima in
willing behm.
Hyou selrnW a funeral that may require embalming such as funeral with visMall,you may he"to pay fm comalming.Yw do not hove to pay for emlnlming
yon did not approve ifyou Sdemad eoangtm M sum U S direct mormtion or immediate burial.tfM contend for embntmTisg am Ill"Plain why below.
Pm Uugcrvit of &nc.is C. I't?yt"!t_/r!?. Dam ofDdb ✓tone :.Iv aGll
Charyem: ,vied r7tClui-re S Lf04 Jt Fnola 1),9 17ORS' _
A CHARGE FOR SERVICES SELECMD; Men's A Women'.UndmemtMng._f
L PROFESSIONALSERViCES ���[��a I Bmid
ServloesofPanereiDircdm/SIaH.S Nst"•
Embalming........... _....«_._._._S j• Cinnamon mn.._.._........._..__.._....f,,,_
DomeiagdPladng S .9r•' (DenmFptl®)
Washing@ Disinfecting
uazmW as'body. S_„�, r S
SUB-7OTALOFP ROFES SIONALSERVtCES........„„..__AI S,�. TOTALOFMERQiM9iSESEtECFW.._......._..«.......R S � d•
2 FACILITIES AND SERVICES C.SPECIAL CHARGES;
Use of him litim and gaff for Ponoardiag of remains m
.. viewingjJ,{idution/Waku)..._.._S-3sb.- 11 +
Use of hdkilmand naff (Fame d Home)
farfuMnteemmany.._....__...f 3J4. RealvinE Ofrematdshmn
Use of fadiitiesand miff Ire S
mama tal Service..............___..f� (Federal Nome)^
Use of equipment and and Immediate Budd._........._._..........5—
for gnvaside service«_._...........S_ Direct Crossed........................__....
,f
OtheruseoffadRnrs S_ K
S_ TOTALOFSPECIALCHARGFS__...._..._.._.__.........0 3_ .
S_ D.CASH ADVANCED: (,7pp
Opening 40osing.:.........................f nag. .
SUB-TOTALOPPACILITMSMUIPb1ENf._ .......-A2 S 7�'' Camet¢ry,Equipment..„..................
5� .
7. AUTOMOTIVEEOUIPMENf Veah Service Charge.................
....._
VcMde to Mail=tsxnalns m Postal Home Inc Ind Dom.__..........._«.«..__.._.f
i¢st.__...__......._......._._._. S ��tnennb*y.
.. I is Newspaper Nmices-OutofTo._.__S �O•
Ncane Ncwspa;= PjyJ•dO.J.
Limousine - Clergy/Mass Offering......................
Y.tb.
tnml......_.....__.__.._...._....5�_ Orgaakt._..._.._.._._._.
......._._......
Famitp pr sin per_....._.__.__.....».._..._.__.S
Iami._._...__......_..........._«...5� h4barax»»..........._....._.........S
Flower car m floral disposition Condbul Copies of the Death '
Incal...................I...........«.......5
Ceni6tte @SW....-.........�....._S �SO, tFnee.
Lid ar/derp w Famnv ass,._._................._..._........5
t.T ar.._._,,.._..._.._.........:_..c..:5 Hair bmttar.............
_........__._S—'-
Carfar)nilbtnen . ....,_._._._S_
Unity __.............».............
5_,,,,
Unity vehicle f
Local,............_.....................
s
Out of town transportation.._.._....S�T�p4Mr
S
S�
SUB-'@TALOFAUTOMOTIVE EQU tPMEKf.................Af S 7570. TOTAL OF CASH ADVANCES........ ........D $
TOTAL OF PROFESSIONAL SERVICES,._ ,„we N.rse yin fm sin aervims In abminir,F
FACILITIES,AND AUTOMOTIVE
..A s 3770. e�rau,emn.,r,..,�er,har a.a n,a.rtw+w)
R.CHARGE FOX MERCHANDISE SELECTED: SUMMARYOFCH"GPS
Cement-___....................._..........SLa” A. Pmfossiovi Smdem,Feciiilim and
(Description) Equipment,and Amnmmive
Egdpmcnt........ ....................._....s 33-770
Other mmpude...................._....S Merchandise,....._._»................_.....5
(Desuipllon) C Spuml Charges....._.----__.....S,,;, .
D. Cob Advsnces..._.......................S -
armbanalaamemer_................f TOrAL OFALL SEC:PIONS.......�.4 ..'1. _.•....$
(Demdplion) .PAITY'ATTYME-Of ON-PRIOR&C- .
Aakwwledgemeat cards pat 2f.._S t .�' (�WeS _Ei+ffM75........._.._........«......... .
................
Mutwirlotdea.._...._.. -,S_ (J(en flevpt lnu.a• BAI.AhCC6 DUR_yy._..»..._..,.„__.... $
..._« _. REAS R"'iIMBAtlRIHG
Temp cards..._..._._.....,.«...........5
Temporary gmve merkv........_....f_ If my kw,eem ,m memelafy mquirrmen have mquircd 1hrt,purrhac
Rosary Badn_....._._....._......._....S_ of any df tae Items Bgcd above fora hw m mgdmment is teuWa d bdew,
'Cnmir' _..__.__......_.»._.._.._..S_ /Sa...rc��r-j�F- ..icI ,,sr
I amse ded i have examined to heoo of teem and s Irss teienW above and toad form is it emmm and a ig to ck amnfcmems I hove rucesed.l acknmordsc mmfpl ar s mpr,
intense telalenanl of Mmral Wade avd¢rvlsaackgslIreprercm IDs1 hieaa9kkm Nee,nibblefs Pa}evmof the wshmin fen thegmda a md"Of Sek.... _P. to mks
ofS Nlar dap strom beat Jsibedeedasrenpy lmDk Nth avypm siKwhomob.,O mere.I.[neweOfa _P.mesh
a1NY0nlvm lea net year will D[app11e4101ho vpmid hotlns hjknlnf_ Np tram tie dneaf nib apeemm.l.[new le mho fusel dbemm al4
«anosbL--ern mN b}ihfumOd dirtmslotalketamoata i owe under rids apeemem.Tteae s4a m}intloh nmmep'Ten,won svnsadallw witf.Act aNittval aeviass
mstchaaike sdesd a requcttM/Jafar Lor/e dtt/e NlhesgeemsN+iithe mmidessd pna(Ntr aErt<mui W cie emilnerzNv3ltae mfkned oalAC nml M]lmshhneM.
(Purchoser) L (acre)
(Purchaser) (Umwed Funeral Dimeem)
REV-1512 EX+(12-12) '
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
RESIDENT DE EDENT URN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Francis C. McClure 21-13-0779
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. West Shore EMS
178.25
2. West Shore EMS,ALS 996.78
3. Susquehanna Medicine 20.00
4. Reimburesement to PSERS,Pension 368.21
4
t I
l
F
V • �I
Fz
_.. - ..
TOTAL(Also enter on Line 10, Recapitulation) $i 1,563.24
If more space is needed,Insert additional sheets of the same size. '
I I ;
COMMONWEALTH OF PENNSYLVANIA
PUBLIC SCHOOL EMPLOYEES' RETIREMENT SYSTEM
PSERS Toll-free: 1.888.773.7748 (1.888.PSERS4U)
.n "e 5 N 5th Street Local: 717.787.8540
Harrisburg PA 17101-1905 www.psers.state.pa.us
July 18, 2013 /[
DAVID F MCCLURE
5 HIGH ST
ENOLA, PA 17025-2720 V
RE: Francis McClure
SSN: XXX-XX-7891
Dear Mr. McClure:
The Public School Employees' Retirement System is processing the benefit of Francis
McClure. Please accept our condolences on your loss.
PSERS issued the following monthly retirement benefit(s) prior to processing the death benefit:
Check Date Check Amount
June, 2013 $1,569.74
Francis McClure was entitled to a prorated amount of$1,201.53 for the month of June.
Therefore, please reimburse PSERS $368.21, which represents the total of the monthly benefit
payments and debts (if applicable) listed above, minus the prorated amount. Please make
your check or money order payable to Public School Employees Retirement System.
Please retain this information for preparation of the member's final tax return.
If you have any questions, please contact the PSERS Member Service Center by calling
toll-free 1-888-773-7748 (1-888-PSERS4U). Harrisburg local callers, please use
717-787-8540. To contact PSERS by e-mail, use the following address:
contactPSERS @pa.gov. For your convenience, the Member Service Center is staffed each
business day from 8:00 a.m. to 5:00 p.m. For more general information, you may visit PSERS
online at: www.psers.state.pa.us. i
Sincerely,
�cfQiQ[G Sf[1000 � 4tfQQ,d� ,�etvleouecst ,5'cfdrf�ss
IOilal��Qlll�llllll�lll�lll�ll��llll�l��lllll�lllll���ll��l��llll�l III���III�II�II IIII�IInI�InII�n1111�1111��101111111111111�111�llllll��llllllllll Ili�ll
oimoasasaeo�szoio
° A G
Zv
oa i
ao
i �oe
o ,
, o
Y N
Z.
O
V O
�u I
_ n
� 2
• h S
(� Y
b
U5
o
y V
Y
W � O
C k
ko. t 1
4
i' f
REV-1513 EX+(01-10)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE .
INNEWANCE TAX RETURN BENEFICIARIES '
RESIDENT DECEDENT' '
ESTATE OF: FILE NUMBER:
Francis C. McClure 21-13-0779
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 ,
t ^--- Sec.9116(a)(1.2).)
I. END-aVii1 d FF McClure,5 High Street Enola PA 17025
EJ
El `_
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON L1NE515 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. None - _ 0m
!L ,
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: • '
Y
1 L
T •
TOTAL OF PART H _ 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.
LAST WILL AND TESTAMENT
OF
FRANCIS C. McCLURE
I,FRANCIS C. McCLURE, of the Commonwealth of Pennsylvania, being of sound
mind, memory, and understanding, do hereby make,publish, and declare this as and for my
Last Will and Testament, hereby revoking any and all Wills by me heretofore made, in
manner and form following:
FIRST: No person named herein shall have been deemed to survive me unless
they survive me by thirty (30) days.
SECOND: I direct that all my just debts,testamentary and funeral expenses be paid
as soon after my decease as conveniently may be paid.
THIRD: All the rest,residual and remainder of my estate, both real and personal,
of every kind and nature and wheresoever situate, of which I shall die seized, possessed, or
entitled, I give, devise, and bequeath unto my beloved wife, GLADYS M. McCLURE, for
her sole and absolute use, in fee simple, forever.
FOURTH: In the event GLADYS M.McCLURE should predecease me, or should
we both die as the result of the same accident, or in a common disaster, then and in such
events,I give,devise and bequeath all the rest,residual, and remainder of my estate, both real
and personal, of every kind and nature and wheresoever situate, of which I shall die
seized, possessed, or entitled, to my son, DAVID F. McCLURE, for his sole and absolute
use, in fee simple, forever.
FIFTH: In the event DAVID F.McCLURE should predecease me,I give, devise
and bequeath all the rest, residual, and remainder of my estate,both real and personal, of
every kind and nature and wheresoever situate, of which I shall die seized, possessed, or
entitled, equally to my daughter-in-law, MARY JO McCLURE, grandson, KEITH
McCLURE, and grandaughter,MELISSA McCLURE,or the survivor(s) thereof share and
share alike.
SIXTH: I hereby nominate, constitute, and appoint my beloved wife, GLADYS
M.McCLURE,as Executrix of this my Last Will and Testament, and further confer upon my
said Executrix full power and authority to sell or mortgage any and all of my real,personal,
or mixed property, at public or private sale, upon such terms as to my Executrix may deem
advisable. I do further order and direct that my said Executrix be not required to give bond
in this or any,other jurisdiction.
SEVENTH: In the event that GLADYS M. McCLURE should predecease me, or
should renounce or fail to qualify, then in such event, I nominate, constitute, and appoint
DAVID F. McCLURE as Executor of this my Last Will and Testament, and I hereby confer
upon my said Substitute Executor the same powers and authority as heretofore conferred
2
upon the primary Executor. I do further order and direct that the Substitute Executor named
herein be not required to give bond in this or any other jurisdiction as such Executor.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 15th day of
December, 1994.
FRANCIS C. McCLURE
SIGNED, SEALED,PUBLISHED,and DECLARED by the above named FRANCIS
C. McCLURE as and for his Last Will and Testament, in the presence of us, who were
present at the same time, aihd who, at his request and in his presence, and in the presence of
each other, all being present at the same time,have subscribed our names as witnesses hereto.
902 Beaver Drive DuBois PA
TNESS DRESS
WI-�S ADDRE
I,FRANCIS C. McCLURE, the Testator, sign my name to this instrument this 15th
day of December, 1994, and being first duly sworn do hereby declare to the undersigned
authority that I sign and execute this instrument as my Last Will and Testament, and that I
3
sign it willingly, that I execute it as my free and voluntary act for the uses and purposes
therein expressed and that I am eighteen(18)years of age or older, of sound mind and under
no constraint or undue influence.
FRANCIS C. McCLURE
DAVID J. HOPKINS and GLADYS M. MCCLURE, the witnesses, being first
duly sworn, do each hereby declare to the undersigned authority that the Testator signs and
executes this instrument as his Last Will and that he signs it willingly, and that each of us
states that in the presence and hearing of the Testator, he/she hereby signs this Will as
witness to the Testator's signing, and that, to the best of his/her knowledge, the Testator is
eighteen (18) years of age or older, of sound mind, and under no constraint or undue
influence.
WITNESS
WITNESS
4
COMMONWEALTH OF PENNSYLVANIA )
:ss:.
COUNTY OF CLEARFIELD )
On this, the 15th day of December, 1994, before me, Jacqueline S. Ciamacco, the
undersigned officer, personally appeared FRANCIS C. McCLURE, the Testator, and
GLADYS M. McCLURE and DAVID J. HOPKINS, witnesses, known to me (or
satisfactorily proven) to be the person whose names are subscribed to the within instrument,
and acknowledged that they executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Y PUBLI-
Noteti:l
- 3ocueS�e S..Ge^-:moo,Na"cy Fib
iyC�ZxEe-_i E 6rw J"-GW4.1
' �ti IJTF.:.-Si.�In�C 24�.ii6V
5