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� 1505610143
REV-1500 Ex�o2-��) `�" OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENTOFREVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 14 5� �
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Sociai Security Number Date of Death Date of Birth
Suffix OecedenYs First Name MI
MURSCHEL WILLIAM w
(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
❑X 1. Originai Return � 2. Supplemental Return � 3. Remainder Return(Date of Death
Priorto 12-13-82)
4. Limited Estate qa.Future Interest Compromise � 5. Federal Estate Tax Return Required
❑ ❑ (date of death after 12-12-82)
O 6 Decedent Died Testate � �� q8tacdheCopy�of Trust)a Living Trust � 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will)
� 9. Litigation Proceeds Received � 10.belween12V31�31 a�dit�(DatS�f Death � 11.Election to tax under Sec.9113(A)
9 (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
E�_ �'
�7
REGIS�R�WILLS l��$E O��
� `L7 � � O
First Line of Address � � r- � `'Y' �
;�. � �"? � � rcan
-.,� c� -., w ��� �
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Second Line of Address "�t "�7
�C C � � — '.?7
�: �pATE FILEB ►"' h
City or Post O�ce State ZIP Code � Vy 0
'^�7 '*7
CorrespondenYs e-mail address:
ii s trueecorr1ect andecompleteeCDeclaihatio h of preparer other than the�personal represent i ve Iscbased on al�l Information�of whlch prepare�fhas any knowledge.belief,
SIGN RE OF PE ON RESPONSIBLE F FILING RETURN DATE
�
David M Wieseman
ADDRESS
PO Box 4 New Cumberland PA 17070
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
� Side 1 J
1505610143 1505610143 �
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3�iST RILIT A�iD TSSTAi�i� f
OF '
� - - WII�I�fM W. MiJRSCHEL ;
<
I� WILI.IAM W• M[JRSCHEL of Lower Allen Township,
Cumberland Coun.ty, Pennsylvania, declare this to be my Last
Will and Testament, hereby revoking any will previously made
by me. °
I. I direct the payment of all nny just debts and
funeral expenses out of my estate as soon as may be
praetical after my death. �
. � t
II. I devise and bequeath all of my estate of d
whatever nature and wherever situate as follows- �
. �
i
A- I bequeath t11e sum of Five H�dred
; Dollars {$�pp.p0) each to zra.y ��cEase3 wi-�e's
it
t
4�3�3Q.^.�,'i l i�r�, �_.`� �.� �. � +.
�,' a �'�� � �� �� �
3, � ' � -' - , �. N� `ns�}�_.
t0 tCi�T �321C�C�lI�C�P.Ii s C�ARI',1'$ A�j.�$g t �T T3� � �'
and BRIAN RASH, and to m�r step-grandson, PHII�LIP .3.
RASH.
B. I direct that all of the rest, resi.due .
and remaznder of my es�ate shall be paid to my
stepdaughter, CAROL W. SMITH, or if she is deceased to
I.aw Offices of
Saidi3 her son; DAVID WI8S8L�T.
SU�V1II
���� III. I ?have intentionaliy made no provision for my
35.INozch 12rhSma stepson, FRED A. WIESEMAN, because he has been
s��400 provided for
�oyn�,PA 1�443
in other ways.
Page 1
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�'� .. �:°�.�3�3E3�� � ���–.��s��-:-�.�.f �� �_ �-
° WIESEMA'�T, as Executor o� �his � ���� �3�� �d Testamen.�. -
� Shouid DAVID M. WZI�SEMAN fail to qualify or cease to aci as `
�
such, then I appoint my stepdaughter, CAROL W_ SMITH, to act
�ri t�is-capaci��r.—�y persona��-represenfa�ive sfial�ot-be^--�� "-�-
required to post bond in this or any jurisdietion.
IN WITNESS WHEREOF, i have h reunto set my hand and
`� .
seal on this, the .��` day of ��-��u1: , 2012.
�
'� e �,...i�r �1 �� tS�+)
WiT1z W�Mu�sci�el"
Signed, sealed, published and declared by WII�LIAM W.
MURSCHEL, Testator therein named, on this and ane (1) other
� sheet of paper as and for his Last Wili and Testament, in
o�r gresencn; �h�, i:3. his �reser�ce, at his ra�iest, an� i�
the presence of each other, have hereunto sttbscribed our
n.ames as attesting witnesses. .
���,--� `� ����� - �� �--'.� ��, ���. ���
Name Address '
I 72�t�
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S11t�iS Name Address '�����
. .
Sl�Ilivan
&Rogers
635 Nordi 12rh Su�ett
Suitc 400
Lemoyne,PA 17043
Page 2
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WE, the undersigned, the Testator and the w�t����es,
respectively, whose names are signed to the foregoir�g
instrument, being first duly sworn, do hereby declare t€� �I�.�
undersigned authority that the Testator signed and execu�e€� �
the instrument as his Last Will and Testament and that he �
signed wilTingly (or willingly directed another to sig� ;or
him) , and that he executed it as his free will and voiunta?�r
act for the purposes therein expressed, and that each of the
witnesses, in the presence and hearing of the Testator
signed the Will as witnesses and that to the best of their
knowledge the Testator was at that time eighteen years of
age or older, of sound mind, and under no constraint or
undue inf luence.
ir�iZTiam�W.��Mur�'c e�l� Testator
����� Y ` LR� ����,i
Witn ss �
�! '-��- ���'�- /�..�-
w�tness '
Subscribed, sworn to and acknowledged before me by
the Testator, and sub �ribed and s, rn to before me by both
witnesses, this _��ay of ���j , 2012 .
� ;
�
� � ��
Law Offices of
$��s � , ID No.�06262e, Esq.
Sullivan
&Rogers
635 North 12rh Streec
Suite 400
Lemoyne,PA 17043 i
Fage 3
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�' �'�'w� ��` ����� � ;�� � � �:
� I, Jah�. E. ���.�e, �ssquire, a n�ember o� t�� �� a� t�e
highest court of said state, Supreme Court attorne� lic��e �
no. 06262, certify that I was personally present when WI� i
,
W. MURSCHEL, Testator, executed his Last Will and Testame�.t
dated :�(�J�tJu r� , 2 012, in the presence of
��t.r��t S� �C �C�i.� and �1f�C�� �tl�t��'���.�'v� , who were
l .�
witnesses thereto.
� � �
� �r �� E. Slike, `�squire
Da e JO'
g�
�'� �ubscribed, swarn to and ackr�owledc�ed before me by �ahr� :
E. Slike, Esquire, this =�'` day of � ��J t�Cr M , 2�12. '
P
� �
�
Nota ub�'ic ;
�.� '
coMMOr�w���oF�NSnvANU►
�� NOTARlAI SEAL � '
KELLY R.NOWELL.Notar�t Pub�C ;
, lemoyne Boro.,Currd�tand s
My Commissron�xp'Kes �14 _ -
Law offices of `
Sa.idis �
Sullivan _- __ _' -
&Rogers
635 Nor�12ch SQee� ��
Suice 400 �
Lemoyne,PA 17043 �
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Page 4
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� 1505610243
REV-1500 EX
DecedenYs Social Security Number
Decedent'sName: MU�SCFI@I� Wllllam W 174 18 1409
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Heid 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. 2 , 677 . 47
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 5, 448 . 25
7. Inter-Vivos Transfers&Miscellaneous I�nq Probate Property
(Schedule G) U Separate Billing Requested............ 7, 2 9� 999 . 45
g. Total Gross Assets(total Lines 1 through 7)........................................................ g. 3H � 125 . 17
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 11 , 1�6. �8
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 3 6'4 . 16
11. Total Deductions(total Lines 9 and 10)................................................................ ��. 11 ,4'�0 .24
12. Net Value of Estate(Line 8 minus Line 11).......................................................... �2. 2 E, 654 . 93
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. Z 6, 654 . 93
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABIE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 �5 O . ��
(a)(1.2)X.00
16. AmountofLinel4taxable 2g� ggg , 45 �6. 1 ,349 . 98
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . �� 18. 0 . 0�
19. TAX DUE................................................................................................................ 19. 1� 349. 98
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
� 1505610243 1505610243 �
�£��-�.���;•-�.:��.�_..����:�,-����,�, .�.�,o-,��:�:R,�,.,�u�. �. -�x�-� �, , ��
REV-1500 EX Page 3 File Number 21-14
Decedent's Complete Address:
DECEDENT'S NAME
Murschel,William W
STREET ADDRESS
P.O. Box 4
CITY STATE ZIP
New Cumberland PA 17070
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 1,349.98
2. Credits/Payments
A. Prior Payments
B. Discount 67.50
Total Credits(A +B) (2) 67.50
3. Interest �3�
q, 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) �,2$2.4$
Make Check Payable to REGISTER OF WILLS, AGENT.
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s��� � � � ��>r\� "' ��i/, �"�x %>..
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:.................................. ❑ �
c. retain a reversionary interest;or..............................................................................................................
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 ❑ ❑
receivingadequate 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 individuat 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.
i ��. 3 i +� ia � ,.._ ._ i '� ,� ::�i0 ��.�/�'y�j�z��F1''r '�.
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,,,,�;se,... -... �r.�.�.u... , :�,.�,,, , �.;,, i, .........,� . ,.., , ��� ..
For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent�72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the suroiving 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)].
. 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.
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Rev-1508 EX+�17-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Murschel,William W 21-14
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-ownedwith the right ofsurvivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 PNC Checking Account 57.00
2 Emeritus Nursing Home-Refund on Account 2,179.00
3 Penn Treaty-Refund on Account 316.10
4 United Healthcare-Refund on Account 125.37
TOTAL(Also enter on Line 5, Recapitulation) 2,677.47
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10)
�_ �_� ::���� . .�� � .��- _ f�,��� � � _ . � .-.�,
Rev-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENTOFREVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Murschel,William W 21-14
If an asset was made joint within one year of the decedent's date of death,it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
A. David M Wieseman PO Box 4 Grandson
New Cumberland, PA 17070
B.
C.
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANKACCOUNT DATE OF DEATH DECD'S DECED NT'S NTEREST
NUMBER FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER.ATfACH DEED FOR VALUE OF ASSE INTEREST
TENANT JOINT JOINTLY-HELD REAL ESTATE.
1 A 07/18/2012 PSECU Checking Account-This joint 10,896.49 50.000% 5,448.25
Account was the only asset owned by the
Decedent with which debts had to be paid
from. A copy of the PSECU statement
showing Date of Death Value and Debts taken
from Account is Attached
TOTAL(Also enter on Line 6, Recapitulation) 5,448.25
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule F(Rev.01-10)
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BUREAU OF INDIVIDUAL TAXES PennS�/IVar1IS II�I�@rltal�C@ TaX • � p�••••Sy{.V�1���
PO BOX 280601 ' DEPARTMENT OF REVENUE
HARRISBURG PA 17128-06 01 Information Notice
� "- � REV-1543 EX OocEXEC (OB-12)
And Taxpayer Response FILE NO.21
ACN 14130210
DATE 05-30-2014
Type of Account
Estate of WILLIAM MURSCHEL Savings
SSN 174-18-1409 X Checking
Date of Death 05-10-2014 Trust
DAVID M WIESEMAN CountyCUMBERLAND Certificate
115 CATHERINE CT
LEWISBERRY PA 17339-9581
PsECU provided the department with the information below indicating that at the death of the
above-named decedent you were a joint owner or beneficiary of the account identified.
Account No.8399312894 Remit Payment and Forms to:
Date Established 07-18-2012 REGISTER OF WILLS
` '° �` 1 COURTHOUSE S�UARE
Account Balance ������ ;<,
Percent Taxable X 50 CARLISLE PA 17013
Amount Subject to Tax $5,448.25
Tax Rate X 0.045
Potential Tax Due $245.17 NOTE": If tax 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) $(see NOTE') due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART Step 1 : Please check the appropriate boxes below.
1 �
A �No tax is due. 1 am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Sfep 2 on reve�se. Do not check any ofher boxes and disregard the amount
shown above as Potentia/Tax Due.
g �The information is The above information is correct, no deductions are being taken,and payment will be sent
correct. with my response.
Proceed to Step 2 on reverse. Do not check any other boxes.
C �The t�x rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child, grandchild,etc.)of the deceased.
(Select correct tax rate at
right, and complete Part � 12% I am a sibling of the deceased.
3 on reverse.)
� 15% All other relationships (including none).
p �Changes or deductions The information above is incorrect and/or debts and deductions were paid.
listed. Comp/ete Part 2 and part 3 as appropriate on the back of this form.
E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please sign and date the-back of the form when finished.
History Page 2 of 2
Date Transaction Description ,4maunt Balance Check(Misc.
Sh�w previaus 3U d�y$
2479262G9L3SGY6KK 5912
Sp�ciaity
05/02/2014 BILLPAYER CHECK 050211 FOR
$127.50 WAS MAILED TO CRAIG
LAHAR DMD.
Nicimame:ORAL SURGEON
05/OS/2014 CHECK 042810 TRACE: -$15.00 s��� �� H "� 2�310
0000754113
Niclmame: Emeritus Beauty Shop
05/12/2014 CNECK 050211 TRACE: -$127.50 $10,768.99 �J50??3
,r�q _ 0001145856
d.(' Nickname:ORAL SURGEON �t(KS C���!� �(� p�-y�
05/13/2014 CHECK 000128 TRACE: -$171.87 $10,597.12 CQ�1�E
0000995530 �en 4t5 1(�tll1 Yi'� Q{"fCl' �
r�,-1
05/19/2014 CHECK 000129 TRACE: -$5,000.00 $5,597.12 C�C�t�12�-�`
0000784215 �,�u�,Q,,�Mq.1�1��� i'�tY t�a.� }`�11'1t.
OS/20/2014 CNECK 000130 TRACE: -$182.08 $5,415.04 GQG�30
0000775136 'rl f�►�y �,U,t114'�
OS/21/2014 DEPOSIT BY CHECK $2,179.00 $7,594.04
OS/29/2014 BILLPAYER CHECK 052905 FOR
$43.20 WAS MAILED TO CAPITAL
QTY DENTAL CENTER.
05/31/2014 DEPOSIT DMDEND 0.100% $0.79 $7,594.83
%%APY EARNED 0.10%
OS/O1/14 TO 05/31/14%%APYE
AVG DAILY BAL 9,318.22
06/02/2014 CHECK 000131 TRACE: -$5,924.00 $1,670.83 ���131
OOQ0786933 MUI�,Q.IYricU'15 fi U,!(,�,r0..p �'b�1'ti(•
06/03J2014 ELECTRONIC BILL 0003 FOR
$21.59 WAS SENT TO VERIZON
06/03/2014 DEPOSIT BY CHECK $125.37 $1,796.20
06/OS/2014 WITHDRAWAL VERIZON -$21.59 $1,774.61
TYPE: E-BILL CO: VERIZON
06/05/2014 CHECK 052905 TRACE: -$43.20 $1,731.41 �}5�9t�5
���5� �,-�� c.�t y o���
06/17/2014 DEPOSIT BY CHECK $316.10 $2,047.51
Show next 30 days
https://homebank.psecu.com/History/History.aspx?ID=SO4 6/18/2014
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Rev-7570 EX+(OB-09)
SCHEDULE G
pennsylvania lNTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Murschel,William W 21-14
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
NUMBER 7HE DATE OF TR�ANSFER.SATTACNTA COPY OF TIHE DEIED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 ING Annuity Contract -Beneficiary: David M. 17,576.84 17,576.84
Wieseman
2 ING Annuity Contract -Beneficiary: David M. 12,422.61 12,422.61
Wieseman
TOTAL(Also enter on Line 7,Recapitulation) 29,999.45
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule G(Rev.08-09)
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REV-1511 EX+(�0-09)
pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
R SEDENTDEC ENTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Murschel,William W 21-14
DecedenYs debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
q, FUNERAL EXPENSES:
See continuation schedule(s) attached 11,106.08
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
3, Family Exemption: (If decedent's address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zin
Relationshi�of Claimant to Decedent
4. Probate Fees
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
TOTAL(Also enter on line 9, Recapitulation) 11,106.08
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09)
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SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Murschel,William W 21-14
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex ep nses
1 Musselmans Funeral Home 10,924.00
2 Trinity Lutheran Church-Funeral Reception 182.08
H-A 11,106.08
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
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Rev-1512 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Murschel,William W 21-14
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 Capital City Dental 43.20
2 Checks Clearing After Date of Death 299.37
3 Verizon Telephone 21.59
TOTAL(Also enter on Line 10, Recapitulation) 364.16
(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)