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HomeMy WebLinkAbout03-26-14 1505610105 REV-1500 Ex(m-rl'IN)� OFFICIAL USE ONLY PA Department of Revenue Pennsylvania - Bureau of Individual Taxes County Code Year File Number PO BOX28o6o1 INHERITANCE TAX RETURN trn O �n Harrisburg,PA 17128-o6o1 RESIDENT DECEDENT �(jl/ I `j 2 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0,2 0 a o/ i a 3 i i 2 Decedent's Last Name Suffix Decedent's irst Name MI �fzawN J R C NARL�S (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 ® 1.Original Return O 2.Supplemental Return O 3. Remainder Rehm(Date of Death Prior to 12-13-82) O 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required m death after 12-12-82) O 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.) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 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 INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number DARLENE L, RHODES 717- 76 c- 71S-F REGISTER tLr VftLS USE d1 f*1 tw �_ O First Line of Address yz, N r7 r ;z M M 3� LoLVCTVIEIAI D��,/ - a °' ;X) I=Second Line of Address ip r1 TI A City or Post Office State ZIP Code •A RED G3 (7T rn � MI~CHAAl1CS $URCs PA 17050 ' Correspondent's e-mail address: Rf1OUES974110VF_R10nLNET 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. SIGN/AT2 05 ON J�tESP IBL F�RF)LING RETURN DATE j/ mss(' � � 17.3 /AS�a a I'� ADDRESS &2 LdAf(TVlFk/ DRIVE , M6LHAN1CSBUR6r� P4. 170So SIGNATU/R�.9(/�PREPARER THE REPRESENTATIVE DATE �— ,""Z,e� - Q 3 ADDRES 3.� Z6A1&V1Ey✓ 17R1u& Mro-IfRA/yes �uR6 PAS 1703.0 PLEASE USE ORIOINA FORM ONLY Side 1 L 1505610105 1505610105 J J 1505610205 REV-1500 EX(Fl) Decedent's Social Security Number Decedent's Name: OIRR4ES f BROWN TR, / RECAPITULATION 1. Real Estate(Schedule A). .................................... ........ I. 2. Stocks and Bonds(Schedule B) . ... ........ ........................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .... . 3. 4. Mortgages and Notes Receivable(Schedule D). .......................... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ... .... 6. DO• 7 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. ,30 08. 7u 8. Total Gross Assets(total Lines 1 through 7)..... ...... .................. 8. .?8 /0 9,9,Z_ 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)........ ....... 10. 02 /,V,0 D 0 11. Total Deductions(total Lines 9 and 10)............................. .... 11. 12. Net Value of Estate(Line 8 minus Line 11) .................. ............ 12. / 3S 316 - 7.2, 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ............ ........ .... 13. :Z)N14 14. Net Value Subject to Tax(Line 12 minus Line 13) .......... .............. 14. #15-, 34, '7,7, 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 q at lineal rate X.0'�5- 3 S 3�6 , 7 2_ 16. � � 5 g/ • zs 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE . ...... . ............. . . . .................. ........ ....... 19. � 5�0 20. FILL FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 J REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME e114RL,5 :T. BR6wyv TR. STREETADDRESS /1060 L'1—ARC1N01V CITY STATE ZIP L'ARL/SLR P4• rl6/3- 805 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) 2. Credits/Payments A.Prior Payments A/0A?ICE S.Discount o 052 6 3 {1//5 89•ZS Total Credits(A+g) (2) � 93•6�1 3. Interest (3) /1/oA/E 4. If Line 2 is greater than Line 14 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) 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.......................................................................................... ❑ ID b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ ED 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?.............................................................................................................. ❑ 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ r/ 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 dales 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(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-516 EX♦(08.13) REQUEST FOR WAIVER pennsylvania OR 1' DEPARTMENT OF REVENUE NOTICE OF TRANSFER BUREAU OF INDIVIDUAL TAXES (FOR STOCKS,BONDS,SECURITIES OR PO BOX HARRISBU�PA 17128-0601 SECURITY ACCOUNTS HELD IN BENEFICIARY FORM) DECEDENT INFORMATION DECEDENT NAME: LAST FIRST MI BROWN CHARLES J DECEDENT SOCIAL SECURITY NUMBER DECEDENT DATE OF DEATH MM-DD- 02/02/2014 DECEDENT STREET ADDRESS CITY STATE ZIP COUNTY 1000 CLAREMONT ROAD CARLISLE PA 17050 CUMBERLAND CORPORATION FINANCIAL INSTITUTION OR BROKER INFORMATION NAME OF CORPORATION, FINANCIAL INSTITUTION,BROKER OR SIMILAR ENTITY TELEPHONE NUMBER STIFEL NICOLAUS 717 730-1100 zzl FIRM STREET ADDRESS CITY STATE ZIP 214 SENATE AVENUE SUITE 601 CAMP HILL PA 17011 ACCOUNT INFORMATION TYPE OF ACCOUNT: CAPITAL STOCK REGISTERED BOND SECURITY ASSET SECURITY ACCOUNT OTHER ® ❑ ❑ ❑ ❑ ACCOUNT BALANCE(Indude accrued interest through date of death) IDENTIFYING NUMBER OF ASSET 30 308.75 138530606 ACCOUNT TITLE ® ACCOUNT WILL BE FILED ON REV-1500 CHARLES J BROWN TOD ACCOUNT ❑ BILL BENEFICIARIES SEPARATELY BENEFICIARY INFORMATION 1. NAME: LAST FIRST MI RHODES DARLENE L 100 PERCENT TAXABLE STREET ADDRESS 32 LONGVIEW DRIVE CITY STATE ZIP Of)]dal Use Only MECHANICSBURG PA 17050 TAX RATE RELATIONSHIP TO DECEDENT BENEFICIARYS SOCIAL SECURITY NUMBER DAUGHTER BENEFICIARY INFORMATION 2. NAME: LAST FIRST MI SHAFFER ELOISE A 100 PERCENT TAXABLE STREET ADDRESS 449 MT.AIRY DRIVE CITY STATE ZIP OlYdal Use Only QUAKERSTOWN PA 18951 TAX RATE RELATIONSHIP TO DECEDENT BENEFICIARY'S SOCIAL SECUR (UMBER DAUGHTER BENEFICIARY INFORMATION 3. NAME: LAST FIRST MI -PERCENT TAXABLE STREET ADDRESS CITY STATE ZIP OtTela/Use Only TAX RATE RELATIONSHIP TO DECEDENT BENEFICARY'S SOCIAL SECURITY NUMBER Please list additional beneficiaries on another sheet of paper,providing all required information. SIGNATURE OF PREPA ER DAYTIME TELEPHONE NUMBER Instructions for filing this notice are on the reverse side. © MBTBank 499 Mitchell Road,Millsboro,DE 19966 Adjustment Services Phone 888-502-4349 F ax (302)934-2955 Charles J. Brown,Jr. March 14,2014 Darlene L. Rhodes 32 Longview Drive Mechanicsburg,PA 17050-2721 Re: Estate of Charles J. Brown Jr Social Security: 194-16-6152 Date of Death: February 2,2014 Dear Sir or Madam: Per your inquiry on March 10,2014,please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 950267403 Ownership(Names ofi Charles J Brown,Jr. Darlene L.Rhodes Opening Date 11/19/1999 Balance on Date of Death $ 15,601.94 Accrued Interest $ .00 Total $15,601.94 For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds, please call the Highland Park at 717-7373322. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney,Custodian of Uniform Transfers, Representative Payee,or Trustee under a Written Agreement Sincerely, Valarie Mercer Adjustment Services Updated 07/16/08 Branch Number 06113 MANUFACTURERS AND TRADERS TRUST COMPANY CONSUMER ACCOUNT UPDATED CHANGE REQUEST CT ADD/DELETE CUSTOMER MAINTENANCE U ACCOUNT TIME AND ADDRESS OFFICE OF ACCOUNT CHARLES J BROWN JR 6113 1 CiP SARAH L BROWN ACCOUNT NUMBER N DARLENE L RHODES 00000000950267403 0 6 COLUMBIA DR ACCOUNT TYPE CAMP HILL PA 170117633 Product Type: DDA Subproduct Code: H2 CUST 1 SSN: CUSTOMER TYPE CODE: By signing below,I(we)(1)request that M&T Bank open in my(our)names the deposit account¢quested below with the features requested, and (2)acknowledge receipt of, and agree to all provisions of,the Geneml Deposit Account Agreement, Availability Disclosure for Consumer Deposit Accounts, the Specific Features and Terms containing infomrxtion about the account,the applicable fee schedule and,if the account is a Jumbo Certificate of Deposit, the Agreement for Telephone Instructions. By signing below, I(we)acknowledge and agree that if the account is opened in the names of two in more individuals,unless the account is a fiduciary or custodial amount,it will be a Tenancy By The Entircties Account With Right of Survivorship if the sole individuals in whose name the account is opened are husband and wife,and,in all other cams,a Joint Account With Right of Survivorship Certification. Under penalties of perjury,I(customer 1)certify:(1)that the number shown on this form is my correct Taxpayer Identification Number(or 1 am waiting for a number to be Issued to me),and(2)that I am not subject to backup withholding because(a)I am exempt from backup withholding,or(b)1 have not been notified by the Internal Revenue Service(IRS)that 1 am subject to backup withholding as a result of a failure to report all interest or dividends,or (c) the IRS has notified me that I am no longer subject to backup withholding,and(3)that 1 am a U.S.person(including a U.S.resident alien). Certification Instructions-You must cross out item(2)above if you have been notified by the IRS that you are currently subject to backup withholding because of anderreporting interest or dividends on your tax return. (Also see Part III-Certification under Specific Instructions on the separate W-9 form.) ZThe IRS does not require your consent to any prevision of this document other than the certifications required avoid backu withholi in . I 0 SIGNATURE CUST I DATE O✓ SIGNATURECUST2 \' /LOVr� 944 DATE O SIGNATURECUST3 DATE O SIGNATURE CUST 4 DATE IDENTIFICATION CUST l: DL 01/11 06465730 PA IDENTIFICATION CUST 2: DL 11/09 12488014 PA ORIGINAL OPENING DATE: 11/19/99 TITLE CHANGE CURRENT TITLE: CHARLES J BROWN JR SARAH L BROWN - NEW TITLE: - CHARLES J BROWN JR - SARAH L BROWN DARLENE L RHODES CUSTOMER ADDED - DARLENE L RHODES 182345864 Original-Account Service WPA008(12/07) BIB U dat6d Ob/:14/11 Blanch Number 06109 IN H MANUFACTURERS AND TRADERS TRUST COMPANY G1 CONSUMER ACCOUNT UPDATED CHANGE REQUEST 06. ADD/DEME CUSTOMER MAT_NTENANCE kH N ACCOUNT TITLE.AND ADDRESS •OFFICE.OF ACCOUNT CHARLES J BROWN 1R 6113 DARLENE L RHODES ACCOUNT WUMBER 32,LONGVIEW DR 00000gD.0950267403 ' MECHANICSBURG PA 170502721 ACCOUNT TYPE Prod'uct.Type: .DDA SubprodualCode: H2 COST 1 .SSN: C.UST6MERTYPECODE: .T3 By sighing.belosk 1(.We)('I)roquest that MBT'Bank open in my(our)names the deposit account'requested bclbw with the features.requeste8, and•(2) acknowledge rcccipt.of, and agree to all pmvisians of, the General Deposit .Accodnt Agreement, A'vailbtiilily:DiscJmvir-lot'C`onidmcr Dgfusit Accounts, the'Specific Fpturd:and Tarns containing information:about the account,ihe:applicable fee schedule and,if the,account is;a.Jumbo'Cerificate.of• Dcposit,'thc Agreement for Telohone liistructibris. By signing below,'L(we).acknowledge'and-agrec•lhat if the account is.opened in the nam=of two ormom•individuits,unless:lhc account.is a fiduciary,or.custodial•account,it wiil.be a Tenancy ByThe-Enlireties Account With Right of.Surviym hipl. the sole'indi'viduals imivhosb name the account is opencd.mc husband and Wife,and,in alllothercascs,a joinl;-Aceount With R'ighi.of Sdrvivorsh'ip' -Certification. Under penalties of perjury,I(customer I)certify:(1)thRuthe number shown on this form.is my" tarred Tazpoycr 18enti6cation Number(or l;am.wdiliag fora number tp'be Issued to me),and(2)that):mn not subject to backup withholdingg beecauWlih)1 nm ekempt+from backup wiihhojding,or,(b) i'have:not been notified by the Internal Revenue e'nice:(IRS),thdl 1 nin subject to backup ailtiholding es.a mull of.a failure to.report.all'interest or dividends, or(c)'the IRS has notified me that 1 am no longer subject to backup withhbldingynnd.(3)Nat Item a.VS.persdn(including:a_UA renidenl:alien). CerttUcatibh Instructions-'Yon must cross-oui iiem.,(2),abo4c ifyou have been notified by IWIFS;lhalyou.are currently subject to baekdp Withholding because.ot underreporting interest,or dividends on-your ta%:retuin. (Alsoaec Part III—Certification under'Specificdnstructions•on the separaWW-9(form;) _ The IRS does not requ(rc4our consent to any'provision of this document other thawthe certifications.required tb'ovoid back u Witkholdin :. ' SIGNATURE CUST I za&zz .1006- DATE SIGNATURE'CUST2 // GLGC/ DATE SIGNATURE CUST'J DATE SIGNATURE6CUST4. DATE ' IDENTIFICATION C)STI:MAE 63/11 PI7296682 DEATH ' IDENTIFICATION CUST2: ORIGINAL.OPENING DATE: 1,Qi9/99 ' TITLECHANGE " CURRENT TITLE:. CHARLES J BROWN JR. , 'SARAH L.BROWN .DAk NE L.RHODES NEW TITLE: CHARLES J BROWN JR DA'RLENE-L.RHODES CUSTOMER DELETED SARAH L BROWN 205127624 , Oiiginal-AccounYServices WPA0011(05111) CI W REV-i5o8IXf(0&12) J pennsylvania SCHEDULE E eliill DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INMEWANCE TM 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 2) A/A TOTAL(Also enter on Line 5, Recapitulation) $ If more space Is needed,use additional sheets of paper of the same size. REV-1509 E%+(Di-io) 7 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. v SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT AS D,4)g4CAjC L, R/NODC3 gz �Gr'V1SL77�Di i'77TIJ= - MFC,VA.✓/cs3u,4�,/ i JOINTLY OWNED PROPERTY: - LETTER DATE DESCRIPTION OF PROPERTY - % DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTnVnON AND BANK AODOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF NUMBER TENANT )DINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST L. A. 07-7-04 f LM T BAAI 7-&AtT- Cff£<'K7�vU gecauN7- / _ __Il y .-_J CK/Ny03/3D29Ss Aaro�vTtk9soz67Ya? B.sL_y3�i �{ �560%9y SO OYl�� �0�-97 ❑ � � R � ❑ 1-1 ❑ o El k. E, ❑ ❑ +�_�,r-- ❑ F7 L-A Lj 0 TOTAL(Also enter on Line 6, Recapitulation) $ 7 0�,9� If more space is needed,use additional sheets of paper of the same size. REV-150 EX+(08-09) 17pennsylvania 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. ITEM DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE,THEIR RRADONWPTO DECEDENT AND DATE OF DEATH % DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TPAF6NR. ArIkOl A tour OF THE DEO FDA REM ESTATE. VALUE OF ASSET INTEREST OF,VNI VALUE 1. ST/FEL/N/COLAUSGO•//AICOR pORRTED W3o,3a8.7S /000/7 y730130$.7S, roz) AeojuAjr P 385-3-0606 .2/5/ SENATE AVE. sa/760/ f OAMp ///LL/PA- 170// //COOO"T- SAtAmeE 19x F z/311y .. . 4- i 17 I i 1 f TOTAL(Also enter on Line 7, Recapitulation) $ 3 Ol 3 B Q.7,f-e-00— If more space is needed,use additional sheets of paper of the same size. TfJ/s /s ?oD ff�'¢orr,vT�Q/u/3853-0606 G. David Bias/Henry J. Pofi 2/7/2014 11:14 AM Stifel Nicolaus Co.. Estate of Charles J. Brown Date Of Death Values - 0210312014 Shs. Holdings Close Total 1.) 120.000 Frontier Communications Corp. 4.42 530.40 2.) 500.000 Verizon Communications Inc. 46.41 23,205.00 3.) 6,573.350 IBP-Insured Bank Product(Money Market) 6,573.35 Approx. Value 30,308.75 "This performance summary is designed to provide information to help you evaluate your investments. The information and statistical data contained herein have been obtained from sources we believe to be reliable, but no independent verification has been made, and Stifel Nicolaus& Co. does not guarantee its accuracy and completeness. Consequently, you must rely on your monthly Stifel Nicolaus& Co. statements and trade confirmations as your official record of transactions with us." 1 REV-1511 EX+ (08-13) 0 pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER C�-/ARIES .%. fjR�Itwlnl JR. . Decedent's debts must be reported on Schedule I. - ITEM NUMBER _ DESCRIPTION AMOUNT _ A. FUNERAL EXPENSES. 1 �J uAE, RE_CEFT_/d J $OLO/$T_SF�C/RL MUS/C _S.d[ND-SY.ST,Eh1 OP_E? YOK = Q G=d Lij I /ylYEQS $uHR_!y_FLN6RAL //aHC �xTRp FXPENS��A6ovE�uveRA� L �jZ�O3_o�� B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: `NON Name(s)of Personal Representative(s) Street Address City State ZIP ' Year(s)Commission Paid: - .. 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) NONE Claimant Street Address City state—ZIP Relationship of Claimant to Decedent 4. Probate Fees: NOME 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. 771 7Z TOTAL(Also enter on Line 9, Recapitulation) If more space is needed,use additional sheets of paper of the same size. REV-IS12 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Cf/ARCES T. ,BR,9wAj TR. Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,Including unreimbursed medical expenses. REM VALUE AT DATE NUMBER DESCRIPTION OF DEATH f14ER7- PNARMACy I Z' CRP/TAL ,BLUE CIROSS �CHCeK#3aZ/� 021911'1 - P 1AW1geLE HEALTN_N/GD-. GROUP .O 114 (ChWLxF3a13) rACILrv— — I -- !_ �• 6✓ES7- SHORE .F--MS 03141/ .(('NF_cK�3a2`fl yja204.S� S CRYSTAL NAG<LTT CPR. az�y���/ �//FCK3o�zz)aPllEP4Faria✓ tzi oZ00 .00 ! �o e1-AREM0AJL /✓URS/.t/!y NOMECAR[/SLP/F�A._CCNECk!/,30 -7) 4�j37S0-00 1 TOTAL(Also enter on Line 10, Recapitulation) / 0_0.00 l ✓ If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) [ ]pennsylvania SCHEDULE 7 �l DEPARTMENT OF AEVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: - FILE NUMBER: - cia,4R4r-s ,T ,8 OWit/ 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).) F---- -Y ----i - 7 - 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: F B. CHARTABLE AND GOVERNMENTAL DISTRIBUTIONS: - 1 F-1 1 �j TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ DAM- 1 � If more space is needed,use additional sheets of paper of the same size. .. •mod N O O vJ D r 3 A z D V D a r 2 rn �...., E m z u o N 0 i r> N } LAST WILL AND"TESTAMENT OF CHARLES J. BROWN L CHARLES J.BROWN,now domiciled in Cumberland�County,Permsylvania declare Phis' to be my Last Will. I revoke all other Wills and Codicils that I may have previously made. ti s F Article I My just debts and expenses of.my last illness,funeral,and administration ofmy estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance,estate,and succession taxes(including interest and penalties thereon,but not including any generation skipping tax) payable by reason of my death shall be paid out of and be charged generally against the principal-of my residuary estate without reimbursement from any person:- I7is provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appoiritment:, i Article III I give, devise and bequeath my tangible personal property in accordance with any memorandum which I have either handwritten or signed,located with my Will or with my valuable papers and found within 30 days of the probate of my Will. Gins may only be to persons who survive me or to organizations which exist at my death,and if there is a conflict,the memorandum having the latest date shall govern. To the extent no such memorandum is found, or all of my tangible personal property is not disposed of pursuant thereto-my t=Zibi¢M,;Dnai VmM,:si=ll be I added to my residuary estate and pass under Article IV hereof. C Article IV All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate,I give,devise and bequeath according to the following: A. ONE-THIRD (1/3) of my estate to be held in trust for the benefit of my wife, SARAH L. BROWN, currently of Cumberland County, Pennsylvania,to be held, managed, and administered according to Article V herein. In the event SARAH L.BROWN predeceases me or fails to survive me by thirty (30) days, then her share shall be distributed outright IN EQUAL SHARES to my daughters: DARLENE L. RHODES, currently of Cumberland County, G Pennsylvania,and ELOISE A.SHAFFER,currently of Bucks County, Pennsylt ania.Per&irprs: and B. TWO-THIRDS(2/3)of my estate to be distributed outright IN EQUAL SHARES to my daughters: DARLENE L. RHODES, currently of Cumberland County, Pennsylvania, and ELOISE A.SHAFFER,currently of Bucks County,Pennsylvania- However,if a beneficiary does -2- i , � 1 i � not survive me by thirty(3G)days,b=:=a es s'xsw-�'� s stnive tzx by la- (3_)mss,t� descendants shall receive,Per Sthpes, the share the beneficiary would have received had he or she survived me by thirty (30) days. Article V In the event that a Trust is created for the benefit of my wife,SARAH L.BROWN,by or as a result of any part of this Will,the terms and conditions of the Trust for the benefit of SARAH L. + BROWN shall be as follows: A. To expend and apply so much of the net income and so much of the principal of the Trust as the Trustee shall consider advisable for the support, health, and care of SARAH L. jBROWN for the remainder of her lifetime. B. In the event of SARAH L. BROWN's death, the trust shall terminate, and the remaining income and principal of the trust shall be distributed outright IN EQUAL SHARES to my daughters, DARLENE L. RHODES and ELOISE A. SHAFFER,Per Stirpes. ! C. No beneficiary or remainderman of this Trust shall have any right to alienate, encumber,or hypothecate his interest in the principal or income of the Trust in any manner,nor shall any interest be subject to claims of his creditors or liable to attachment,execution,or otherprocesses of law. Article VI In order to cant' out the purposes of the Trust established by this Will for the benefit of SARAH L. BROWN, the Trustee, in addition to all other powers granted by this Will or by law, -3- shall luxe rho .._ VW'ified r±lwWbem in this Will: (a) to retain in the form received and/or to sell either at public or private sale,any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in ail forms of property without being confined to legal investments.and without regard to the principal of diversification. (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file fiduciary/income tax returns and pay the tax due for any year for which such a return is required, (g) to make distributions in cash or in kind,or in both,and to determine the value of any such property, (h) to employ any attorney,investment advisor,or other agent deemed necessary by my Executor; to pay from my estate reasonable compensation for all their services, (i) to conduct along with or with others,any business in which I am engaged in or have an interest in at the time of my death, (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed, and (k) to make unlimited gifts from the trust to my child(ren), including the Trustee hereunder, or to a trust for the benefit of my spouse or my child(ren). The amounts and nature of -4- i Qualified according to law_SCaZ;�'t�,:�y��t,:�;i;,,�;.�,_. „�.�„_,,;_,..� �:�•�y�•.��� ±N�,..—� I! that 1 signed it willingly as my free and voluntary art for the purposes ld;erem expressed_ Sworn to or affirmed and acknowledged before me by CHARLES I BROWN,the Testator, on M 2004. A Diary blic CHARLES J.BR I Notarial Seat Marielie A Hazen, Notary Rrbtic (may of Ho7burg, nauphin County MY commission Expires Sept 23, 2006 :a We,the undersigned witnesses who signed the foregoing instrument,being duly qualified according to law, depose and say that we were present and saw the Testator sign and execute this instrument as his Will; that he signed and executed it willingly as his free and voluntary act for the purposes therein expressed;that each of us in his sight and hearing signed the Will as witnesses,and that to the best of our knowledge,that he was at that time eighteen (18)years or more of age,of sound mind, and under no constraint or undue influence. Sworn to or affirmed and Iti subscribed to before me k {air . j V1 y and t 99. lYlr jitne s witnesses,on 2004. 7 r s tary Pu tc ._� r �• Notarial Scal C, oflHarrisburgn naopahin Public r' ! . MY Commission Expires Sept 23. 20136 r r ?.; _ 1