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� 1505610143
REV-1500 EX`°2_„> �
PA De artment of Revenue y OFFICIAL USE ONLY
p penns Ivania County Code Year File Number
Bureau of Individual Taxes DEPARTMENTOFREVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 14 ��
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
07 05 2014 08 23 1918
DecedenYs Last Name Suffix DecedenYs First Name MI
CHARCHAN LOUELLA F
(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 Retum � 2. Supplemental Return � 3. Remainder Return(Date of Death
Prior to 12-13-82)
� 4. Limited Estate � 4a.Future Interest Compromise � 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
s Decedent Died Testate � Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received �p,spousal Povert Credit(Date of Death 11.Election to tax under Sec.9113 A
between 12-31�J1 and i-1-95) (Att2ch SChedule O) ( )
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMA�N SHOULD B�IRECTED TO:
Name Daytime TelepF�e`�Number c � rn
DAVID J LENOX 717 2 71�'1�7 5 r"�,,.�� c� Q
� � c-a `'� c,n .:,�
I,, --- �,, - i c:'�
REGISTER OtF„V1q�L��`�1SE QI�LY :,� !,,,,'��
�
_ _ , , �
First Line of Address °�° �.; � rv�'i �
p
8 TRISTAN DRIVE SUITE 3 �,, � <�
_:_:j rn
Second Line of Address � p
" .� ,�7
DATE FILED
City or Post Office State ZIP Code
DILLSBURG PA 17019
CorrespondenYs e-mail address: law(a�davidjlenox.comcastbiz.net
Under penaities ot 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 ali information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ATE
Pp,r„..Jl.o..� . Pamela S. Eichelberger S /ff !�
ADDRESS
182 Chainsaw Road Dilisbur PA 17019
SIG OF P OT THAN REPRE TATIVE DAT
David J. Lenox � /� �
ADD SS
8 Tristan Drive, Suite 3, Dillsburg, PA
Side 1
L 1505610143 150561�143 �
(�V
_ _ _
� 1505610243
REV-1500 EX
DecedenYs Sociai Security Number
Decedent'sName: CF1arCFla11� LOUella F.
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5.
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous�nn;Probate Property
(Schedule G) U Separate Billing Requested............ 7. 9, 85 9. 65
g. Total Gross Assets(total Lines 1 through 7)........................................................ g. 9, 859. 6$
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 2 , 0 68 . 95
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 1, 65 6. 0 7
11. Total Deductions(total Lines 9 and 10)................................................................ ��. 3, 725 . 02
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 6, 13 4 . 63
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. 6, 134 . 63
TAX COMPUTATION-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.00 15. 0 . 0 0
16. Amount of Line 14 taxable
atlinealrateX .045 6, 134 . 63 16. 276. 06
17. Amount of Line 14 taxable
at sibling rate X.12 0 . �� 17. 0 . ��
18. Amount of Line 14 taxable
at collateral rate X.15 � . �0 18. 0 . ��
19. TAX DUE................................................................................................................ 19. 2 7 6 . �6
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side Z
� ],505610243 1505610243 �
REV-1500 EX Page 3 File Number 21-14
Decedent's Complete Address:
DECEDENT'S NAME
Charchan, Louella F.
STREETADDRESS
100 Mt.Allen Drive
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 276.06
2. Credits/Payments
A. Prior Payments
B. Discount 13.80
Total Credits(A +B) (2) 13.80
3. Interest �3�
4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 262.26
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:............................................................................... ❑ ❑x
b. retain the right to designate who shall use the property transferred or its income:.................................. ❑ ❑x
c. retain a reversionary interest;or............................................................................................................... ❑ x
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ x
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?....... �x ❑
4. Did decedent own an individual retirement account,annuity,or other non-probate property which ❑ ❑
containsa beneficiary designation?.................................................................................................................. X
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)j.
For dates of death on or after January 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 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 decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)j.
. 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 blood or adoption.
- __
Rev-1510 EX+(OS-09)
SCHEDULE G
pennsylvania lNTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Charchan, Louella F. 21-14
This schedule must be completed and Tiled if the answer to any of questions 1 lhrough 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THE DA E OF TR�ANSFER.SATTACFITA COPY OF TH�E DEIED�OREREAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 Dort FCU Account 936784(TOD to two daughters, 9,859.65 9,859.65
Pamela S. Eichelberger and Shirley F. Liddell:
TOTAL(Also enter on Line 7, Recapitulation) 9,859.65
(If more space is needed,additional pages of the same size)
Copyright(c)20Q9 form software only The Lackner Group, Inc. Form PA-1500 Schedule G(Rev.08-09)
REV-1511 EX+��O-09)
pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
R SEDENTDECEDENT URN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Charchan, Louelia F. 21-14
DecedenYs debts must be reported on Schedule I.
�TEM DESCRIPTION AMOUNT
N MBER
q, FUNERAL EXPENSES:
See continuation schedule(s) attached 1,169.41
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid
2. Attorney's Fees David J. Lenox 750.00
3, Family Exemption: (if decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zi�
Relationshio of Claimant to Decedent
4. Probate Fees
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 149.54
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 2,068.95
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Charchan, Louella F. 21-14
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Exnenses
1 Allen Funeral Home: 162.61
2 Shirley F. Liddell-reimbursement for tombstone engraving,funeral luncheon,grave site 1,006.80
open/close:
H-A 1,169.41
Other Administrative Costs
3 Dort FCU-wire transfer fee: 28.00
4 UPS: 60.77
5 US Postal Service: 60.77
H-B7 149.54
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
�Rev-1512 EX+(�2_OS)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OFREVENUE
INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS
' RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Charchan, Loueila F. 21-14
Report debts incurred by the decedent prior to death that remained unpaid at the date af death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Messiah Village: 1,656.07
TOTAL(Also enter on Line 10, Recapitutation) 1,656.07
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Charchan, Louella F. 21-14
RELATIONSHIP TO
NUMBER NAME AND ADDRESS OF DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
PERSONISI RECEIVING PROPERTY (Words) ($$$)
Do Not ist Truste s
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
Pamela S. Eichelberger Daughter 3,067.32
182 Chainsaw Rd.
Dillsburg, PA 17019
Shirley F. Liddell Daughter 3,067.32
27110 Jones Loop Rd.,#92
Punta Gorda, FL 33982
Tota I 6,134.64
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev.01-10)
Dor t �� � �� Federal
CREDIT UNION
July 11, 2014
To Whom It May Concern:
The balances on account 936784 for Louella Charchan at Dort Federal Credit
Union on July 5th, 2014 were as follows:
Primary Shares: $2001.30
Share Draft: $2887.97 -� q ,�'S`g .�'S
Po'•� .
Savings Plus: $4970.38
If you were to have any further questions, please feel free to contact me at the
phone number listed below.
Thank you,
�
f
athy Osborn
Senior Teller
Dort Federal Credit Union
810-244-6671
2845 DAVISON ROAD
FLINT,MI 48506
P.O.BOX 1635
FLIM,MI 48501-1635
810-767-8390
Fx: 810-424-3787
www.dortonline.org
H105.805 RHV(9/11) . -
LOCAL REGISTRAR'S. CERTIF��ATION OF DEATH
WARNING;'It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00 „„���"' This is to certify that the information here given is
��,n�'�p�jN OF pf�; correctly copied from an original Certificate of Death
�����`'0`1`� = y`�L, duly filed.with me as Local Registrar. The original
a�_ == zi � certificate will be forwarded to the State ViCal
�° n� Records Office for permanent filin
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,
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P 20824525 . `=o�,�,q91 .- �EP�?,,, � BZ���
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Certification Number ' ""�°��"""�������'1 Local Reg Date Issued
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