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Home My WebLink About08-22-14 (2) t � 1505610105 REV-1500 EX�02_,�,�F�>-0�, OFFICIAL USE ONLY PA Department of Revenue pennsylvania �«.�,��«�a��<< County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 28o6oi �� I�� Harrisburg PA 1�1z8-o6o1 RESIDENT DECEDENT r ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 10/24/2013 10/29/1921 DecedenYs Last Name Suffix DecedenYs First Name MI MASONHEIMER , GLADYS M (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Su�x 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.Suppiemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) p 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required 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 10.5pousal 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 T0: Name Daytime Telephone Number , y DONNA L MCCLOSKEY (747) 888-3561 ,-�,, c7 ° �' REGISTER�F 1�LS USE ONLY � j � � � I".n � �j G'� !9 � First Line of Address -`? ,�. r"' N , � PO BOX 2432 � �-- � N � v .. . �.". ;., c� Second Line of Address '' ? � c� � � � �...� �;::� -r� � � �"' � .-� u, rn : Cit or Post Office State ZIP Code �1ATE.�LED � Y � 1—� U� � ,; IDYLLWILD CA 92549 N 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 ail information of which preparer has any knowledge. SIGNATURE�)PERSON RESPO SI LE FOR FI ING TURN DATE i�L ADDRESS PO BOX 2432 IDYLLWILD, CA 92549 SIGNATURE�PRE REp,� R OTHER THAN REPRESENTATIVE DAT_/ <</�4��«�.L`� �1'4 ADDRESS U KERN AND COMPANY, P.C. 2331 MARKET ST., CAMP HILL, PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 � 150567,0105 1505610105 J � 1505610205 REV-1500 EX(FI) Decedent's Social Security Number oecedent's Name: MASONHEIMER, GLADYS M RECAPITULATION 1. Real Estate(Schedule A). ... ..... .................................... L 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. 16,0�0.00 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 14,418.87 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property 78 097 99 (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets total Lines 1 throu h 7 ................ 8. 108,516.86 ( g )............. 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 12,432.46 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I)............... 10. 11. Total Deductions total Lines 9 and 10 11. 12,432.46 ( )................. ................ 12. Net Value of Estate(Line 8 minus Line 11) ...... ........................ 12. 96,084.40 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ....................... . 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. 96,084.40 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 4,323.80 at lineal rate X.0 45 96,084.40 �g. 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 �$• 19. TAX DUE ................................................. ........ 19. 4,323.80 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0 Side 2 � 15�5610205 150561�205 J _ _ _ REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME GLADYS M MASONHEIMER STREETADDRESS 325 WESLEY DRIVE APT. 3219 --.._...---....------- -----......_..-------...-----._—.........—_...._---------------------- -STATE_...._..---------._.....__.-- ZIP -------........___.....-- ��n PA I 17055 MECHANICSBURG Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 4,323.80 2. CreditslPayments A.Prior Payments __ __ _ ._ B.Discount 0.00 Total Credits(A+B) (2) 3. Interest (3) 0.00 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 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 4,323.80 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred.......................................................................................... � � b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ � c. retain a reversionary interest.............................................................................................................................. ❑ � tl, receive the promise for life of either payments,benefits or care?...................................................................... � � 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ � 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ � 4. Did decedent own an individual retirement account,annuity or other non-probate property,which containsa 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 imposetl 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 suNiving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are sti�l applicable even if the surviving spouse is the only beneficiary. For dates of tleath 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 atloptive 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 decedenYs 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 decedenYs 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 blootl or adoption. REV-i5o8 EX+(o8-i2) � pennsylvania SCHEDULE E DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC. � �� INHERITANCETAXRETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MASONHEIMER, GLADYS M 2� 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 �, WEARING APPAREL 500.00 2. HOUSEHOLD GOODS&FURNISHINGS 1,500.00 3, PREPAID FUNERAL EXPENSE-MYERS-BUHRIG FUNERAL HOME 14,000.00 TOTAL(Also enter on Line 5, Recapitulation) $ 16,000.00 If more space is needed, use additional sheets of paper of the same size. � REV-i5og EX+(oi-io) _��; pennsylvania SCHEDULE F DEPARTMENT OF REVENUE )OINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MASONHEIMER,GLADYS M 2� If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A• DONNA L MCCLOSKEY PO BOX 2432 DAUGHTER IDYLLWILD,CA 92549 B' KAREN M MASONHEIMER PO BOX 469 DAUGHTER FORT MONTGOMERY, NY 10922 C. )OINTLY OWNED PROPERTY: LETiER DA7E DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND&4NK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR lOINTLY HELA REAL ESTATE. VALUE OF ASSEf INTEREST DECEDENT'S INTEREST 1' '�'' 12/31/95 PNC BANK CHECKING ACCOUNT#5140042037 6,139.94 16% 1,022.84 B. 12131111 PNC BANK CHECKING ACCOUNT#5140042037 6,139.94 16% 1,022.84 2. A. 12/31195 PNC BANK CERTIFICATE OF DEPOSIT ACCOUNT#31300259746 6,551.95 50% 3,275.98 3. A. 12/31/95 PSECU SAVINGS ACCOUNT#204037805 1,978.83 50% 989.42 4. A. 12/31/95 PSECU CERTIFICATE OF DEPOSIT ACCOUNT#204037805 2,036.29 50% 1,018.15 5. A. 12/31195 PSECU CHECKING ACCOUNT#204037805 14,179.27 50% 7,089.64 TOTAL(Also enter on Line 6, Recapitulation) $ 14,418.87 If more space is needed, use additional sheets of paper of the same size. � REV-1510 EX+ (08-09) �;-�� pennsylvania SCHEDULE G M� DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER MASONHEIMER, GLADYS M 21 7his schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE ITEM INCLUDE 1HE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND NUMBER THE DATE OF TRANSFER. ATfACH A COPY OF THE DEED FOR REAL ESTATE, VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. METLIFE,CLAIM#21312005960 8,000.00 100 8,000.00 2 METLIFE,ACCOUNT#c0034623180 501.40 100 501.40 3 CUNA MUTUAL GROUP,POLICY#000040041895 69,596.59 100 69,596.59 TOTAL(Also enter on Line 7, Recapitulation) $ 78�097�99 If more space is needed,use additional sheets of paper of the same size. ' REV-1511 EX+ (08-13j � pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER MASONHEIMER, GLADYS M 2� Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES; 1' MYERS-BUHRIG FUNERAL HOME 11,432.46 B. ADMINISTRATIVE COSTS: 1. Personai Representative Commissions: 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,) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5, Accountant Fees: 6. Tax Return Preparer Fees: 1,000.00 7. TOTAL(Also enter on Line 9, Recapitulation) $ 12,432.46 If more space is needed,use additional sheets of paper of the same size. � REV-1513 EX+ (01-10) �: � fr�� pennsylvania SCHEDULE � DEPARTMENT OFREVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MASONHEIMER, GLADYS M 21 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• DONNALMCCLOSKEY DAUGHTER 50% PO BOX 2432, IDYLLWILD,CA 92549 2. KAREN M MASONHEIMER DAUGHTER 50% PO BOX 469,FORT MONTGOMERY, NY 10922 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. �-=-� BUREAU OF INDIVIDIlRL TAXES Pennsyivania lnheritance Tax r pennsylvania Po eox zeo6ol DEPARTMENT OF REVENUE w►��sB� rw ��28-060� Information Notice And Taxpayer Response a��s�°��s-�=� FILE NO.21 ACN 13165471 DATE 12-02-2013 Type of Account Estate of GLADYS MASONHE(MER Savings SSN 204-03-7805 Chedcing Date of Death 10-242013 Trust DONNA L MCCLOSKEY County CUM$ERLAND CertifiCate -hf�--S2��' �i�--+:c�i i.c�--�sre°•- `P v� Box 2Y� Z IJ7y�Gv)+� , C,� �i�.�� . PNC BANK NA provided the department with the information below indicating that at the death of the above-named decedent ou wers �joint owner or beneficiary of the account identified. Rernit Payme�rt and Forms to: Account No.31300259746 Date Established 0401-2005 REGISTER OF WILLS Account Balance $6,551.95 7 CAURTHOUSE SGIUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Ta�c $3,275.98 Tax Rate X 0.045 NOTE': If tax payments are made within three months of the Potential Tax Due $147.42 decedent's date of death,deduct a 5 percent discourrt on the tax With 5%Discount(Tax x 0.95) $(see NOTE') due. Any inheritance ta�c due will become delinquent nine months � after the date of death. PART Step 1: Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or 1 am the parent of a decedent who was 21 years old or younger at date of death. Proc�eed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potenfial Tax Due. - --_ _.,..._,.._—_.�,_-- _._.._._--_��_ _..._ ._.__,__ ._�.._.� _..� _, __. : - _w . �_. _ g The information is The above information is correct,no deductions are being taken,and payment will be sent correct. with my response. Proceed to Sfep 2 on reverse. Do not chedc any other boxes. C �The tauc rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select correct tax rate at right,and complete Part � ��/o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes o�deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Retum filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. �. . � , . .� � , . .. . . .• • � . � BUREAU OF INDIVIDUAL TAXES Pennsylvania lnheritance Tax � pennsylvania PO BOX 280601 DEPARTMENT Of REVENUE NARRISBURG PA 17128-0601 information Notice ecv-�zcs Ex o«exec��a-iz� And Taxpayer Response FILE NO.21 ACN 13162449 DATE 11-142013 i ype ot account Estate of GLADYS MASONHEtMER Savings SSN 204-03-7805 Checking Date of Death 10-242013 Trust DONNA MCCLOSKEY Courrty CUMBERLAND Certificate .ADT R97� - �, (�, �DX 2�(32.._ I� �r��v/� , � � 2S�I q PsECU provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or bene�iciary of the ar,�ount identified. Remit Payment and Forms to: Account No.204037805 Date Established 02-07-1989 REGISTER OF WILLS Account Balance $1,97$,83 1 COURTHOUSE SQUARE Percent Taxable X 50 CARUSLE PA 17013 Amou�t Subject to Tax $989.42 Tax�iate X 0.045 NO7E': !f tax Potential Ta�c Due �44,52 payments are made within three months of the decedent's date of death,deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $(see NOTE*) due. Any inheritance tax due wili become delinquent�ine months after the date of death. PA� Step 1: Please check the appropr�ate boxes below. i A �No tax is due. 1 am the spouse of the deceased or 1 am the parent of a decedent who was 21 years old or younger at date of death. Proceed fo Step 2 on reverse. Do not chedc any other boxes and disregard the amount shawn above as Potential Tan Due. --""-g_ _ �i 'rmat rs`_ '__` e a z m rmafit��'ri ' rrec't;�-�aedu-c�'i'on�ar g a en,an"cFpayment wi sen __ correct. with my response. Proceed io Step 2 on reverse. Do not Check any oiher boxes. C �The tax rate is incoRect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select coRect tax rate at right,and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Comp/ete PaR 2 and part 3 as appropriate on the back of tiiis form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritancs tax form Retum filed by the sstate representative. REV-1500. Proceed to Sfep 2 on reverse. Do not check any other boxes. 1"11_�_� _.�� .�.�J �l�a� aL� L��t. ..l aL_ t�..r.. ...L.�... 1:.�:..4...J BUREAU OF INDIYIDWL TAXES Pennsyivania inheritance Tax � pennsylvania PO BOX 280601 DEPARTMENI`OF REVENUE HARRISBI�tG PA 17128-0601 Information Notice sev-is�s¢x n��c cea-iz� And Taxpayer Response FILE NO.21 ACN 13162450 DATE 11-142013 i ype of Account Estate of GLADYS MASONHEIMER Savings SSN 204-03-7805 Checking Date of Death 10-242013 Trust DONNA MCCLOSKEY Courrty CUMBERLAND X Certi�cate ��.z z��n �cr-r�crr� z�c .•.re•. rv nn f? o, P>pX Z�l3Z lb ��.w1L-� , cf� �rZ�Y� 4 i.: P, SECU provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary af the account identified. Remft Payment and Forms to: Account No.204037805 Date Established 12-17-2007 REGtSTER OF WlLLS Account Balance $2,036.29 1 COURTHOUSE St�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $1,018.15 Tax Rate X 0.045 NOTE": If tax payments are made within three months of the Potential Tax Due $45.82 decedent's date of death,deduct a 5 percent discount on the tax With 59�o Discount(Tax x 0.95) $(see NOTE') __ due. Any inheritance ta�c due will become delinquent nine months after the date of death. PA� Step 1 : Please check the appropriate boxes below. � A �Ido tax is due. I am the spouse of the deceased or I am#he parent of a decedent who was 21 years old or younger at d�te of death. Proceed to Step 2 on reverse. Do not chedc any otherboxes and disregerd the amount shown above as Pofential Tax Due. -- g e in c�rsna�orrr, - e a e�n—Trr►a`�it'�srs s o -rrect;no�u��orrs ar��e'ing'ta en �fnd p�yment vin�5e sent---' - � correct. with my response. Procesd to Step 2 on reverse. Do not che�k any other boxes. C �The tax rate is incorrect. � 4.5°� I am a linea!beneficiary(parent,child,grandchild,etc.)of the deceased. (Select correct tax rate at right,and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as apprr�riate on the back of this form. E �Asset wfll be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Plaaen cinn anr)rlat�a thc hark nt thc fnrm �mhnn finicheri .�.�. BUREAU OF INDIViDUAL TAXES Pennsylvania lnheritance Tax � PennS�/I.Vat118 PO e0X 280601 DEPARTMENT OF REVENUE HARRISBUR6 PA ��za-o6o� information Notice And Taxpayer Response q�-lu3�oo�E,��..-12� FILE N�.21 ACN 13i62448 DATE 11-14-2013 i y�ot Account Estate of GLADYS MASONHEIMER Savings SSN 204-03-7805 Checking Date of Death 10-242013 Trust DONNA MCCLOSKEY County CUMBERLAND Certificate A�,R�-;—�T _��.�r n�ncv�a r-nv��c_ �,c� , �j o� Z�( 32 i��w�L�, G� q2�✓`.f � s c provided the department with the information below indicating that at the death bf the above-named decedent you were a'oint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.204037805 Date Established 02-07-1989 REGISTER OF WILLS Account Balance $14,179.27 1 COURTHOUSE S(�UARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $7,089.64 Tax Rate X 0.045 Potential Tax Due $319.03 NOTE': If tax paymen#s are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5%Discount(fax x 0.95) $(see NOTE') due. My inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or 1 am the parent of a decedent who was 21 years old or younger at date of death. P�oceed to Step 2 on reverse. Do not chedc any other boxes and disregard the amounf shown above as Pofential T�Due. - o �s °- e a v in orma on is correc,no u t�ns are emg taKen,and payment will be sent � correct. with my response. Proceed to Siep 2 on reverse. Do not check any other boxes. C �The tax rate is incorrect. � 4.5°� I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select correct tax rate at right,and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the badc of fhis form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Fieturn filed by the estate representative. REV-1500. Proceed fo Step 2 on reverse. Do r+ot check any other boxes. f11��'� �!�� —_J J�a_ aL_ L��I" �taL� f�'.Y "".L�� L•�!_V_J 4 BUREAU OF INDIYIDWIL TA7CfS � enns lvania �n � �o6ai Pennsylvania lnheritance Tax p y lURRISBllR6 PA 1�128-6601 Information Notics ��ENT OF REYENUE �1f-1t{i F1I OKEIIBL/N-12) And Taxpayer Response FlLE NO.21 ACN 13165473 DATE 12-02-2Q13 i ype oi Hccount Estate of CLADYS MASONHFIMER Savings SSN 204-03-7805 Chedcing Date of Death 10-242013 Tn,st KAREN M MASONHEIMER Cour+ty CUMBERLAND Cert'�'icate a o�� _�._-S—L.!�__i �i n� . . -�_ .yr:-� �� (n��yA-n��r f�A1� �v, �c�� y�� -^oceT N�,oNT�n�� , N� : �� -- --- - - �p-�( 2�--°�-��--i -— -- . �- -- ---- -- - __ _- ----— -- - -- ---- aNC, BaN� provided the department with the information below indicating that at the death of the above-named d�ent ou were a'oint owner or b�efia of the aocount identifi�d. Rem�Payrt�ent and Porms to: Account No.5144042037 Date Eatablished 01-01-y878 REGISTER OF YVILlS Account BalanCe $6,136.94 1 C4URTHOUSE S(#UARE PerceM Taxable X 16.667 CARU.St.E PA 17013 AmouM Subject to Tax $1,022.84 Tax Rate X 0.045 NOT�": If tax payments are made within three morrths of the P��^�� $�•� decedent's dabe of death,deduct a 5 perc�nt discount on the tau With 596 Discount(Tax x 0.95) $isee NOTE') due. llny inhetitance tax due vrili bec:ome delinquent nine months after the dais of death. p�� Step 1: Pl�se chec�c the appropriate boxes beicw. A [�No tax is due. i am the spouse of the deceasecl or i sm tl�e parent of a decedent who was 21 years old or younger at date of de�th. Pnx:eed to SYep 2 on rev�erse. CJb not d�ecic arty other boxes and disregarrl the amouni shrnm abnv�as Patential Tax Due. B The in#orma�on is The above information is correct,no deducuons are being taken,and paymeni wili be sent correct. with my response. Proceer!to Slep 2 on+�v�erse. D�o nof d�edc any ofher boxes. C �The ta�c rate is incorrect. � 4.5% 1 am a lineal beneficiary(parerrt,chiid,grandchiid,etc.)of the deceased. (Select correct tax rate at right,and compiete Part � ��y I am a sibling of the deceased. 3 on revers8.) � 159� Ail other relationships(inc{uding none}. p �Changes or deductions The irtformation above is u�co'rrect a�nd/or debts and deductior�s were paid. tisted. Comp/ete Parl2 and parc3 as a)pp�riate�the,badc oithis form. E �Asset will be►�eported on The above-identified asset has be�or will be reported and tax paid with the FA Inheritance Tax inheritance tax form Retum filed by the estate represeMative. REV-1500, Proceed to Step 2 on r�v+erse. Do not chedc any other bo�res. r►�_ _ _ _ '_' ' '._ _t '�_a' 'L' L__�' _[aL_ t__.Y "'1_^_ t'._'_L_J BUREAU 0� INpIVIDUAL TAXES Pennsylvania lnheritance Tax � pennsylvania PO BOX 280601 HARRISBUR6 PA 17128-0601 Information Notice DEPARTMENT OF REVENUE And Taxpayer Response `�-'�`j�`�"�``•s.12� FILE NO.21 ACN 13165472 DATE 12-02-2U13 Type of Account Estate of GLADYS MASONHEIMER Savings S5N 204-03-7805 Chedcing Date of Death 10-242013 Trust DONNA L MCCLOSKEY Courity CUMBERLAND Certificate •p T9'I'TPC'S'T� . rv ueruw �rrcn��nr o• »ncc_zcni n�ee��fu�s��o�w � �e �awev �se ■ (�, �, 6oX Z`(32 � 17�r�WIL17� C/� �9Z5`� 9 PNC BANK NA provided the department with the information below indicating that at the death of the above-named decedent ou were a joint owner or benefic+a of the account identi�ed. Remit Payment and Forms to: Account No.5140042037 Date Established 01-01•'1978 REGISTER OF WILLS Account Balance $6,136.94 1 COURTHOUSE SQUARE Percent Taxabie X 16.fi67 CARLISLE PA 'f7013 Amount Subject to Tax $1,022.84 Tax Rate X 0.045 NOTE': If tax payments are made within three months of the Potentiat Tax Due $46.03 decedenYs date of death,deduct a 5 percent discount on the ta�c With 5�o Discount(Tax x 0.95) $(see NOTE') due. My inheritance tax due will hec�me delinquent nine months afier the date of death. p�� Step 1: Please check the appropriate boxes below. A �No tax is due, i am the spouse of the deceased or 1 am the parent of a decedent who was 21 years old or younger at date of death. Proc�eed to Step 2 on reverse. Do nof chedc any other'boxe�and disregard the amount shown above as Potential Tax Due. ..._.�,� _ __ _ �._..^ ___ . �_ _�—�..____ __ _ _ _ _ - - -- _. ___ _ B The info�ination is- The above information is correct,no deductions are being taken,and payment wiil be sent coRect. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select correct tax rate at right,and complete Part � �p�o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incoRect andlor debts and deductions were paid. listed. Comp/ete Part 2 and part 3 as appropriate on the back of this forrn. � �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Retum filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. ►11�___ _.�.� _�J J�a� tL� L'_1" _laL_ L_..'__ ""L_" I!_'!_L_J . e �2 � CUNA MUTUAL GROUP ` Non-Qualified Variabie Annuity CMFG Liie Insurance Company getttement Options for �� Non-Spouse [VNSNQ] Date Prepared...................................November 4, 2013 Valuation Date..................................November 1, 2013 Policy Number.......................................004040041895 Taxable Benefits........................................'324,277 ��roW .74 Cfaim Number..............................................131029020 Nontaxabie Benef`rts....................................545,318.85d��i � Name of Deceased...................Gladys M Masonheimer Death 8enafit Value............................................"$0.00 Date of Death......................................October 24,2013 Currerrt Contract Value............................."589,5Sfi.59 CurreM Deposrt lnterest Rate...............................2.0°� Guarar�teed Interest Rate.....................................3.5°� Ben�ciary Karan M Praskevitz,Donn$L McClos- key 'The varl�anrwlryr vadue is irn�eated in va►aus subeacounts,Trie Tauable Ben�Deafh 8ene�t Value,end Crx�nt Conbact Va�e sham are based on the net ;nvesrment perfarm�of 1he suGecx�rrds on N�e vea,aKon oete nas rrnre wur d�ge d�jr.clair,bey►e1Ns paia wNr ee rhe�reafer oraaea►►aeneTit v�ue or Gument Conbact Vef�e a�the date prooiofd�afh is recehred Below are the setNemeM options available to you as the beneficiary. Please consult your personal tax advisor regarding the tax consequences of these options. .....................................................................__ �t: •�:r •.�: ':'r' .._.. ..i.: �y� J� �ie - :i::i:,::::::i.::.i:�i:=::: eEi:� i;'c.:.:[:CE(i.;iF.i.i.E'r.:�i:.i. �E: 1 i� .�. ....,. �� . . `� . �� . .... . :�!s�: �. ..,��. .. ~r' . � . . . "i:� •� �'i:�'• . ��^�i�'�7T'!'�� . .iii. ....:':.�.�.�.....:._..:':.................:........ . � .. . .....:.:.:.: . ..:.�.�::. .... .:'::':':•:':':':':':':•:':' .: . . ......... ..................... . VVfh these optrons,the Taxabie 8enefit amou»t shoxm above wil!be deferred ur�try a leter date. 1. Beneficiary transfers the value as a 1035 Exchange to a Non-Qual�ed Beneficiary Annuity Contract • This option muSt be st3tected and processed prio�to the 1st anniversary of the decedeM's date of death. • The existing annuity Contred is te�ninated and the value is transferred as a 1035 Exchange to a Non-Qualified Benefiaary Contrad. ■ The amount transferred wiil be the Greater of the Death Benefit value or Coritrad value. • You must elect anc!begin taking life expedancy withdrawals priorto the 1st anniversary of the decedeMs date of death. You must receive the entire annual amount by December 31st of the year in which you begin taking with- drawals. � Life expedancy withdrawals will be caiculated based on the appropriate singie life expec[ancy factor. You must receive a witridrawaf every year. If you fail to withdraw ihe annual life expectancy amount by December 31st of a calendar year,there may be adverse tax consequences. The eMire contract value in sxcess of the investment in the contract(cost basis) may become taxabie in 1he year of the missed withdrawal. ■ Wrthdrawals follow deterred annuity taxation rules. All taxabie benefits are paid first and nun taxable benefRs (cbst basis)paid last. Withdrawats ar�e not subJect to the IRS 1096 eariy withdrawal penarty. ' If you choose to make additlonaf withdrawals,they may be subject to surre�der char+ges. To choose the option above, comp/ete and retum tlre endosed claimant fam and provide one of the fo�owing: (1)an apFlication for a new CMF6 Cife Jnsurence Campeny contred. A completed NQ Benefrciary Annu�y Cont�ect�isdosure(CLS-523)and NQ Beneflciary Life Expectancy Wf�hdrawal irom VA(CLS-524)tE�rms,or(2)extern�J03S Exchange forms to move the value to a oQntract writh another company. Befiors you ietum�rour vompleted paperwnrk,meke sure you have checked the num6ered box on the daimant form thet conesponds to yourchace and indicate the company narne and aontrect numberthe val�re is b�ng transferred to. 2. Beneficiary transfers lfie value to a �ixed Interest Supplemental Contraat as a Non-Qualified Bene- ficiary Accour�t ■ This option must be seleded and processed prior to the 1st anniversary of the decedeM's date of death. • The existing annuity contrad is terminated and the furxls are deposited in a fnced interest account. • The amount depasited wiB be the greater of the Death Benefit value or the Current Cont�ad value. ■ Surrender charges are wanred and additional purchase paymeMs are not allowed. • �omputershare '�" �� ' � Computershare � PO Box 43006 � � Providence,RI 02940-3006 � 11�IPF�RTANT Ti�iX RETURN DOCUM ,;:�>EI��l,=t7� D �m USA,US teaitories&Canada 800 649 3593 � „y„ �, r ._,� .w,x�, ,�_.�_��.,.. ��_ Outside USA,US territories 6 Carrada 201 680 6578 � "'AUTO"SCH 5-DIGI717o50 00003U10008076 0 0 b 0 7 6 Hearing Impaired(TDD) 201 680 6611 — ��i�h�h�i�m��iliiilllidi�l��lril��drlili�lill' wuvuv.computershare.conVnvesta� = � Reapien# � GLADYS M MASONHEIMER .= 325 WESLEY DR APT 3219 Holder Acxount Number = MECHANICSBURG PA 17055-3504 C0034623180 I N D = = itecad pate OS Nov Z018 _. --.._ _..._.�, _— - _____.____ _. Please see reverse for important information. — __""' __ __-__- -.--- - -_-� _ . ._ OOICSOOOS.DamLngAdvl�T[._PGI.MEII..022506 60887/0080T6/008076/G �IetL-ife; lnc.- Combined Payment Advice l�013 Tax Fo� 4�99�D�/ � ' � ��jf��@� Account Number C0034623780 Form 1099-DN-Dividends and Distribuut��ons 2013 Copy B-For Recipient Rec��t�s ro N°'�na��n �M�� Payers FedarallD No. 51-6516987 'thb is Impoitara t�c Wamadon�d is being tumhhed to the IMemai Revawie Servloe.If you are roqubed�01de a�um,a negQgenca OMB No. 1545-0110 PBndtY or oUrr sancdon may be Imposad on you H tlds incane is�e and tl�e IRS deteimines tFnt&i�as►wR been iepa�d. pepaYnsr ot be TreawY•�emel Reuamie 9nrks Recipient GLADYS M MASONHEIMER . 325 WESLEY DR APT 3219 MEGf�IWICSBURG PA 17056�3504 ia To1al Ord'mary � Qualiked 3 Nondividerd 4 FEDERAL INCOME e Foreign Tax 7 Faeic,�Cou�ty 8 Cash LiqiedaEon Dividends($) Dividends{S) Dislribu6ans(S) rAx vnnlHEi.o{;) Paid(S) a U.S.Pes.session pis6i.(�I Payer's Details 10.10 10.10 0.00 d.00 0.00 COMPUTERSHARE AS CUSTODIAN OF THE METLIFE POLICYHOLDER TRUST PO BOX 43006 PROVIDENCE RI 02940 Form 1099-DN (Keep for your records) Metlife PolicyholderTrustAnnual Statement a�Y�o�a��: �.ao Record I Payable I Security I Total Trust I Dlvidend I Cwrerd I D��n ( � I Tofal I S�� Date Date Descriplion Interests Rate Distribution Amou�(E) {� �a�� Record Date 06 Feb 2013 13 A�lar 2013 TRUST IM'ERESTS 10 ;0.18500 1.85 0.00 1.85 375.70 37.57000 09 May 2013 13,hm 2013 TRUST INTERESTS 10 �0.27500 2.75 0.00 2.75 405.90 40.59000 09 Aug 2013 13 Sep 2013 TRUST INTERESTS 10 =0.27500 2.75 0.00 2.75 497J0 49.77000 �Nov 2013 13 Dec 2013 TRUST INTERESTS 10 50.27500 2J5 0.00 2.75 501.40 50.14000 Year-To-Date PaM 10.14 0.00 _ _ . _. .�.., ..