HomeMy WebLinkAbout10-22-14 � 1505611185
REV-1500 EX(02-11)(FI)
OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 260601
Harrisburg,PA 17128-0601 RESIDENT DECEDENT �� " �LI � �C�C-.'a�
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth nnMDDYYYv
08202014 01241930
DecedenYs last Name Suffix DecedenYs First Name MI
WHISTLER PAUL R
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name M I
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
- - REGISTER OF WILLS
FILL IN APPROPRIATE BOXES BELOW
� 1. Original Return � 2. Supplemental Return � 3� peor to�12r13eg2)(Date of Death
❑ 4. Limited Estate ❑ 4a. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required
death after 12-12-82)
� 6. Decedent Died Testate � 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
❑ 9. Litigation Proceeds Received ❑ 10. Spousal Poverty Credit(Date of Death � ��' Attach Schedule Oer Sec.9113(A)
Between 12-31-91 and 1-1-95) ( �
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
CRAIG A • HATCH, ESQ • 717-731-9600�,�
c� �_-� -., �
RE�6T�OF WILLS USE ONL�'�
R„ :='1 c''� �,? G�
r 4�r c-,a ._�..
_�
;r� — �"� ---1 ���') �"
' ; c'w�
First Line of Address ' N , ''1
.. . rv c�
2109 MARKET STREET � `-'
, -�, , —,,
Second Line of Address , -� �'�
' ---= c�
c.J ' �-r't
State ZIP Code �DATE FILED '
City or Post Office , -r�
N
CAMP HILL PA 17011
Correspondent's e-mail address: C • H A T C H nl H H G L L P • C 0 M
Under penalties of perjury, I declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETUR DATE
CINDIA K • WHISTLER � �- �d��s��
ADDRESS
58 LEBO ROAD C LISLE, PA 17015
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE - _ DATE
CRAIG A • HATCH, ESQ . � �����'`�
ADDRESS
2109 MARKET STREET CAMP HILL� PA 17011
PLEA USE ORIGINAL FORM ONLY
Side 1 �
� 1505611185 1505611185 �
OM4647 3.000
� 1505611285
REV-1500 EX(FI)
Decede�Ys Social Security Number
DecedentsName WHISTLER PAUL R
RECAPITU LATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . _ . . . . . . . . . . . . . 1 $� • ��
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . 2. $0 • ��
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , , , . 3, $� • ��
4. Mortgages and Notes Receivable(Schedule D) , , , , , , , , , , , , , , , , , 4. $0 • 0�
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) , , , , . 5. $� • 0�
6. Jointly Owned PropeRy(Schedule F) � Separate Billing Requested , , , , g, $� • ��
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested . . . . 7. $3 9 ,8 0 6 • �7
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . g, $3 9,8 0 6 • �7
9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9. $1��8 4 • 21
10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) , , , , , , , , , �p, $0 • ��
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. $1,0 8 4 • 21
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . �2. $3 8 ,7 21 • 8 6
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J), , , , , , , , , , , , , , , , 13. $0 • 0�
14. Net Value Subject to Tax(Line 12 minus Line 13) , , , , , , , , . , �a. $3 8��21 • 8 6
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.O� $0 • �� 15. $� • ��
16. Amount of Line 14 taxable
at�inea�ratex.o� $38,721 • 86 �s. $1,742 • 48
17. Amount of Line 14 taxable
at sibling rate X.12 $� • 0� 17. $� • ��
18. Amount of Line 14 taxable
at collateral rate X.15 $Q • �� 18. $� • ��
19. TAXDUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. $1,742 • 48
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 1505611285 1505611285 �
OM4648 3.000
REV-1500 EX(Ft) Page 3 File Number
Decedent's Com lete Address:
DECEDENTS NAME
WHISTLER PAUL R
STREET ADDRESS
UM R AND
CITY STATE ZIP
CARLISLE PA 17015
Tax Payments and Credits:
1. Tax Due(Page 2,�ine 19) (1) $1,7 4 2 • 4 8
2. Credits/Payments
A. Prior Payments $1,6 5 5 • 3 7
B. Discount $8 7 • 1 2
Total Credits(A+B) �2� $1,7 4 2 • 4 9
3. Interest
�3� $� • �0
4. If Line 2 is greater than Line 1+Line 3,enter the difference.This is the OVERPAYMENT.
Fill in box on Page 2, Line 20 to request a refund. (4) $� • �1
5. If Line 1 + Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) $0 • ��
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 . . . . . . . . . O �
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 X
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 ❑ ❑
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 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 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.
OM4671 2.000
REV-1510EX+(08-09) SCHEDULE G
pennsylvania
DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FiLE NUMBER
Paul R. Whistler
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.
DESCRIP110N OF PROPERIY o EXCLUSION TAXABLE
ITEM INCUAETIEW�MEOiTFET2AN5FEREE,THEIRRELATIONSHIPTODECEDEMANO DATEOFDEATH �oOFDECD�S VALUE
NUMBE THEDATE OF TRMSFER.ATTACHACOPV OF TNE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE
�• Edward Jones
Brokerage Acct. No.
37705301
Account transfers on
death to daughter,
Cindia K. Whistler $39,806.07 100.0000 $0.00 $39,806.07
TOTAL(Also enter on line 7,Recapitulation)$ 39 806.07
if more space is needed,use add'Rional sheets oi paper of the same size.
9W46AF 2.000
REV-1511 EX+(0&13) SCHEDULE H
pennsylvania
DEPPRTMENTOF REVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
Paul R. Whistler
Decedent's debts must be reported on Schedule I.
ITEM AMOUNT
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
� Hoffman-Roth Funeral Home & Crematory,
Inc.
funeral bill (balance owed after pre-
paid plan payment) $584.21
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees: $500.00
3. Family Exemption:(If decedenYs address is not the same as claimanYs,attach e�lanation.)
Claimant
Street Address
C�� State ZIP
Relationship of Claimant to Decedent
4. Probate Fees:
5. Accountant Fees:
g. Tax Return Preparer Fees:
7.
None
TOTAL(Also enter on Line 9,Recapitulation) $ $1 084.21
swasAc z.000 If more space is needed,use additional sheets of paper of the same size.
REV-1513EX+(01-10) SCHEDULE J
pennsylvania
DEPARINIENTOF REVENUE BENEFICIARI ES
INHERITANCE TAX RETURN
RESIDEM DECEDENT
ESTATE OF: FILE NUMBER:
Paul R. Whistler
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECENING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[InGude outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
�. Cindia K. Whistler
58 Lebo Road
Carlisle, PA 17015
All of Residue: $38,721.86 Daughter $38,721.86
ENTER DOLLAR AMOUNTS FOR DISTRIBU110NS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
�� NON-TAXABLEDISTRIBUTIONS
A.SPOUSAL DISTRIBUTIONS UNDER SEC110N 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. S $0.00
swasni s.000 If more space is needed, use additional sheets of paper of the same size.
DEATH CERTIFICATE
,, .
�����,. ���������'� ��������/�l��Q� �� �����
W�,�NIN�: It is illeg�l tc� duplic�te this cea�y �y �h�fc�stat �r ph�t�ge�pt�.
Fec 1�n� thi� i�ertilii���e. S(il)O ��.� Thi� i� I�� certit�� tha� the inf��rmation here �i��e�
� �'�''�Q���O�p�� co�rec:tl�� i�> >�d tic�n� ��n ori�inal <'ertif�tcat�� ��f De
��j \�� � � t
,'n� � l '_ dul� filcd u��th �ne a� L��c�l Regitit�a� �I�h� oii�i
:� , �� ��a� ce�7�ficate ���ill he fon��arded to the State A,,
�� y„; �a; Records Office for penna��ent filing.
-� t , �
, ��� r�-� � r �` ) 4�,6� � �>� j��,,: ,/� y � /,,
-----� ��f �' �� � .` C \ _�!9�Tn��`E.�?;��'� �tr1e 6-i.�atsr�r.en�-rnc.r.• Q� '�_r)/!', ;
� - � -
C'ertif�cauon '��uinher "�"""'"� Lvcal Registrar [�ate Issued
�
Type/PrInC In \ , ' COMMONWEALTH OF PENNSYLVANIA�OEPARTMENT OF HEALTH�VITAL RECOR�S
°`�^'""`"` CERTIFICATE OF UEATH
Black Ink State Filc Number:
1.Decetlent's Legal Name(First,Middle,Last,SuHix) 2,Sex 3.Social5ecurity Number 4.Date of Oeath(Mo/Day/Yr)(Spell Mo)
Paul R. Whistler I�Ia1e 194-28-9206 August 20, 2014
Sa.Age-last Birthday(Yrs) 56.Under 1 Year Sc.Under 1 Da 6.Oate of B�rth(Ma/Day/VearJ(Spell Month) 7a. liplsce ty antl Sta Foreign Country)
, Mo�ths Oays Hours Minutes �enn �wp. �A
a84 Jan 24, 1930 76.Blrthpiace�eo�.,cy��
8a.Resitlence(Stale or Foreign Couniry) 8b.R�sid�nce(Street and Number-I�clude Apt No.) Syc.Did Decedent Live in a TownshipT
PA 58 Lebo Rd. +UVes,decedcnt Ilved In Penn
ad-Reside�ce(County7 � =WP�
Cumberland He-Residence(Zlp Code) �No,tlecedent IWed wlthin Iiml2s of city/boro.
9.Ever In US Armetl Forces7 10.Marital Status at Time of Deeth �Marrled Wfdowed 11.Surviving Spouse's Name(If wife,give name prior co Flrst marrbgej
�Ves (�No �Unknown 0 Dlvorced O Never Married �Unknow
12.Fafher's Name(Flrst,Mlddle,Las<,5uffix) 13.Mother's Name Prlor to Firsi Marriage(Flrst,Mlddle,Las�) '
Harry M. Whistler Maude Ke1so
14s.Info�mant's Name 1ab.qelatlonshlp to DecetlenS 14c.In�ormsn�'s Malling Atldrcss(St�eet and Number,City,5late,21p Gode)
Cindia K. WYiistler Dau hter 58 Lebo Rd. , Carlisle, PA 17015
t-'�' _ _ _ _ _ _ _ _ ,y _ _ _ _ _ _ _ _ _ise. .c�a eac cn�c or,y,one
If Death Occurretl in a Hospltal: -13 Inpatlent ' � �If Death Occurred Somewhere Oihe�Than a Hospital: �Hospice Faclllty �De�edenYs Home
� O Emergency Room/Outpatient O Deatl on Arrlval O Nursing Home/Long-Term Care facility �Other(SpecHy)
lSb.FacllitY Name(If not Ins2iriilon glve street and number) ,ISc.City or Town,Stste, 'd 21p Code 15d.County ot Deeth
Cariisle Regiona� Medical Center Carlisle, PA 17015 Cumberland
y 16a.Meihotl a7�isposl[ion �] B�rial � Cremation 16b.Date of Dispoz�tio� 16c.Place of�Isposltion(Name of cemetery,cr�matory,or ofher place)
� O a�",o�a�+.o�.,s�ec� p oo�ac�o� Aug 25, 2014 Huntsdale Cl-iurcti of tYie Brethren Cemetery
,€ o o�ne.csa��nv)
2 16d.Location of Disposltlon(Clfy or Town,Siate, ntl 21p) 17 . nafure of Fu�e 1 Serv�Licen e rs n I harge of Intertnent 17b.Ucense Number
�y Carlisle; PA 17015 011932L
o llc�a�eynd ComQ_Isce Address o1 Funeral Faclllty
O Iman-xotti Funeral Home & Crematory, 219 North Hanover Street, Carlisle, PA 17013
�' 19.Decedent's Educatlon-Check the box thai bast descri�es the 19.Decedent of Hlspanic Origin-Check�he 20.Dee�den�'s Ratt-Check ONE OR MORE ra s to Intlicefe what
�-- highea[degree or level 07 school completed at the time of deaYh. boz that best describes whether ihe Oecedent the tlec�tlent consldercd hlmseN or herself to be.
O Bth grade o�less is Spanizh/Hispanic/WHno. Check the"No" �Whlte � Kor�an
� No diploma,9th-12th grad� boz If dacede�t Is�ot SpanlshM�spanic/LaSino- O Black or African American Q Vletnamese
�] High school graduate or GED completed No,not Spanlih/Hispa�ic/LaHno � Ame�ican Indian or Alaska Nailve � Other Asian
� Soma college crsdiL but no degiee Yes,Mexican,Mexican American,Chlcano Q Aslan Indlan O Mative Hawalbn
[] Assoclate deQree(e.g.AA,AS) �Vss,Pu�Ko Rican � Chinese Q Guamanian or Chamorro -
� BacAelor's degree(e.g.BA,AB,BS) � Ves,Cuban � Fllipi�o � Samoan
� M�ste�'s de`re�(e.g.MA,M5,ME�Q,MEd,MSW,MfiA) O Yes,oth�r5psnfsh/Mispanic/lafino O Jsp�n�se O Other Paciflc Islandar
0 Doctorate(e.g.PhD,EdD)or GrOtessional degree (Speclly) � Other(Specify)
.MO DDS DVM lLB JO
21_Decedenc's Single Rett Self-Oeslgnation-Cfieck ONIV ONE to i�dicace wM1ac the decedent considered himself or henelf co 6e. 22a.D�ceAent's Vsual Occupatlon-Intllcate type of work
�White O lapanesc � Samoan don�during moat o1 working Iife. DO NOT USE RETINED.
Black or African American � Kor�an � Other Paclflc Islander Farmer
B �American Indian o�Alaska Native O Vletnamese O Do�'f Know/No!Sure
.� �Asian Indlan �Other Aslan Q fiefused 22b.Klntl o�Business/Industry
� � Chlneze O Nattvc Hawalian O Other(Specl(y)
� Fillpl�o � GvamanlanorCl�amo�ro Farming
ITEMS 23a-23 MUST BE COMPLETEO 23a.Date Pronounced Dead Mo D�y/Yr 236.Signa[ure of Person Prono�ncin{D [h(Only when applicable 23c.License Num ar
BYPERSONWHOPRONOUNCESOR �-/Z�/ZQ�� y¢_ � J
CERTIFIES DEATH
23d.��gZned(�Day/Yr) 24.Time of Death �� ��' � ��'��7v 3 Zz L_
Q O/� q � Sg 25.Was Medlcal Examiner or Coroner Contatted? � v�s �B--No
CAUSE OF UEATH � qp^roxim�te
26-PaR 1_ Ent�r the choln of� nts--dlseases,Injurl�s,or mplicatlons-tha<dir�ccly c ed ch�d�ath. DO NOT en<er termin�l e uch a artl�ac• �st, � al:
respiratory a�rest,or ventriculs�flbrillatlon witho�[showinQ the etlology. DO NOT ABBREVIATE. EnS�r only one cauze on/�Ilne.cAtltl atlditlonsl Il�es If nec�ssary. � Onset fo Deeth
IMMEDIATECAVSE -------> �CJ�%!�' /G/'-S/ I�i(/ / Q� Y ��/`V/'-� 1
(Flnai dise�s�or eondltion Due to(or as a consequence o�: 1
.<,,,i��.,s�•,e�.cn� b. C 6��G>�Ci�c /L�'S-�//L�t To.f2 Y F�o��G/�/2-/G� �
�
S�qu�ntlally�Ist candl[lons, Due to(or as�cansequence of): �
If any,leading ta the c �
n,c�a o.,Ifne a. Ent�r thee ��G!/ �' /L.�'��f� Fi•�/L�//L�" ;
UNOERLYING CAUSE Due to(or as a consequence o�:
� (disease or InJ�ry that �
FInitiated�he events resulting d._ .��� T_��i�L ��/���G-��j/O�.J �
In d�ath)LAST. Du�Lo(ar as a co�sequence ofl: �
�
s 26.PaK 11. Enter other i nifi nt c ndi i n Cin th buf not resuliing i�the�ntle�lying cause given in Part 1. 27.Was an autopsy perforr�r T
� O ves �
� 28.Were avcopsy fi�dings avallable
m to complet�[h�cause of de�thT
� 0 Ves o
� 29.If Female: 30.Did Tobacco Use Contribute to��ath] 31.Man�e�of Death
Q Not pre`nant withln past year 0 Ves � Pro6sbly �'Tletur�l ' � Homlclde
O Prc6^ent K[Ime of death � No .�Unknown � Aecldent O P��ding InvesHgatlon
� � Not pre{nant,but pregnant within 42 tlsys ot death � Sulcltle � Coultl noi be tleterminetl
r � Not prc`nant,but pre{na�f 43 days to 1 yeer before dea�h 32.Da<e of InJury(Mo/Day/Vr)(Spell Month)
� Unknown If pregnant within the past year � 33.Tme of InJury
34.Place of InJury(e.g,home;ronstructlon slte;farm;school) 35.locatlon of InJ�ry(Streef antl Number,Clty,County,5[afe,21p Cotle)
36_in)ury at Work 37.IfTransportetion In)ury,Speclfy: 38.Describe How Injury Occurred:
� Ves � Orlver/Operstor � Pedestrian
� No � P�ssenge� � O[her(Specify)
H9s.CerYlfler-physlcian,certiFled nurse pracSltioner,medical examiner/coroner(Check anly one):
� Certl7yln`only-To the b�tt o1 my knawledge,d�ath o retl due co the ca�se(z)a�d m stated.
��Gro ncins&CeKifying-Ta che 6est of my knowletlae,deaih occurred at the cime,date�and place,and due to che ca�se(s)anE manner scaced.
� MeAicsl Examine�/Coroner-On the basls o7 examination and/or invezciga2lon,in my opinion,deafh o red ac�he Sime,datt,�nd pl�ce,antl tlue to the cause(s)antl man s(atetl.
S1anaSure o7 certHler: '�/� Title of certlFler; �td u«.,,�N„mb«:_rrp n7�t3 Z L G-.
39b.Name,Address and Zlp Code of Person Completing Cause of Death(Item 26) 39c.Oate Signed(Mo/OW/v)
��u�s a.--,��rE'�1cC, 3 6/.�L6Y.s,v�,�'� S PQiRIG /Z O c,��CJSL�/?�- /7oi.i �/2 dl2 0/�f
40.Roglstrar's Dlstrict Numbe� 41.Registrsr's SigCnature 42.Reglrt�ar File DeiC Mo Day �J
� G�..tie�.�s��[- e�[--
� 43.Amendments
f
Z
PA REV-1500
SCHEDULE G
INTER-VIVOS TRANSFERS and
MISCELLANEOUS NON-PROBATE
PROPERTY
Edward Jones
CC7S�'OMER NAME: wt�rGrnrF�" pAi]I, �_ - DES�'�DTA�ZON: 88TAT�S
ACCOIINT N'EJMAER: ��,-05901 HRANCFi #: Q3772 DA�: _0�/�.3/207.2
�pWARD JON�S BENEFICIARY DESIGNATIQN FORM
An authorized representetive for the Account Molder (such es a guardian, conservator, or anorney-in-fact), may
not have authoriry to designete, change or revoke the beneficie�+ea of thls Account without e court order, or
documentation speciflcally�rersting the autharity to do so. lf it is determined that said authorized representetiva
dld nat h$ve the authority to designate, chenge or revoke the benefici�ries of thfs Account, then said
deslgnatlon, change or revacation shali be invalid.
P�tIMARY B��IEFIC�ARY D�SrGN�.TTOt�7S:
A 100.00$ Name: CTNDZA K �PHIATTa�kZ Re7:at�.onshi�: Noi'i-spdu�e
' Te.x Zt]/SSN: dt'� �ile D08: 92/25/1.960
Ad.dresa: 58 Lebo PhAzae: 717-243-509fl
Carlisle, PA 17015
CQN�'IDid�NT B�FZC�ARY DSSIGN,A,�IO�N'8:
No continger�.t sene��.oz�ry w�.�.l be enti�].ed to a di�tribution anlea� �he Gorreeponding
Pximaxy Beneficiary �redeceases tkte AccQuat fYo�.der or disc�.a�ms.
A 10 0,p o� Name: ,7At�s Go&�ARla
Tax tD/SSN: � £ile DOB: 02/25/199p
Addresa: 127 xearshey
shippezxeburg, PA �.7257
ENA OF BENEFICIARY D�$IGNA1`1QN
I�I�lll��I�(l�Ll�I���I�li�l�I Rfli l���I�I��I I���Il�l 0�1 I���N!N�II����IIII
2012021310406P1610202US P8g@ 2 Of 2
(Rev. Aug 2011)
,�,,,�;�����;�4�,�'�,� p�e�r���r��ra���n��
.�1
o-E��azr��w7 or- R�ver��re
flUlxVau�W P�aP!'u'[FYU�'l TUX@!��
August 28, 201.4
Edward Jones
Suite 103
1 Valiey Street
Carlisle, PA 17p1�-3193
Re, Estate o�: Paul R Whistl�r
Soc(al Security Number: �.94-28�9206
t=ile Number: N/A
Dear Sirs:
The DepartmEnt issues this waiver for the following securiCy held in ben�flciary Pormat by the
decedent. The security will be subject to Pennsylvania inheritance tax, 7he Departimen� wifl
issue an informarion natice to kh� �ransfer�e af the potential Pennsylvania inheritance tax
due For this ass�t. A copy oF this waiver is to be used by you to na�ify �he tiransfer agent
�hati the reporting requirements of Section 6411 of the Probate Estates and Fiduclarles Code
(Title 20, Chapter 64, Pennsylvania Consolidated Sraru�es), have been satis�ied.
Name of Company: Edward Jones
Type of Account(s): Securixy Account
ID Numb2r(s) 37705�01
Ac�ount 8alance(s): $39,806.07
Sincerely,
�-'` ����:19�-� \
Ambe Heimbach
Inh�ri�ance Tax pivision
_..._..__._........_.......-------...---�--.._................. .... .
....- ----------.._.__...---�--..._._. ..
.........--------
Jc.p�:�rtrri��rit ot' R�v��1�.aE� � PO (�ox 1£�O6t)l� M71i•ii��t:,i.irg, PA .".�"!."1.t3 �, ?;r�7fil.Ei677 � wt��w.r`R�v�^nuF!.^itc;tC'.�}a.n�;
dllREqU UF INDIVIDUAL TAxEs Penns Ivania lnheritance Tax � � p�nnsylrrania
No eoX 28u6a1 y
HARRISBURC PA 271Z8•U601 Information Notice DEPHq7MENTOF REV�NUE
iaev•�peSY EX Lvuexec<UY-12)
And Taxpayer Response ��LE NO.21
ACN 145p6136
DATE 09-OS-2014
Type of Account
Estate of PAUL R WHISTLER Seourity
SSN 194-28-9206 SEC Acct
Date of Death OS-20-2014 Stock
CrNDTA K WHISTLER CpUnty CUMBERLANI7 Bonds
58 LEBO RD
CARLTSL� PA 17015�9326
EDWA�d �oH�s provided the department with the informatidn below indicating fihat a#the death af the
above-named decedent ou were a 'oint owner or beneficiary of the account identifiQd.
Account No.37705301 �temit Payment and Forms to:
Date Established RECyIS7'�R OF WIl.LS
Account Balance $39,806.07 1 COUHTHOUSE SC1UAFtE
Percent Tax�ble X 700 GARLIBLE PA 1�0'I3
Amqu�t Subject t0 Tax $39,806.07
7ax R�te X 0.045 NOTE'� If tax payments are made within three months of the
PoCential 7ax Due $1,791.27 daced�nt's date of death,deduct a 5 porcent discount on the tax
With 5%Discount(Tax x 0.95) $(See NOT�") due. Any inherit�,nCe tax due will become dQlinquent nine months
after the data oF death.
P��7 St'�p 1 M Pleasa chec�c the appropriate boxes below.
1
A �Na tax is due. r am the spouse of the deceased or 1 am the parent of a decedent who was
21 ye�rs old or yaunger at date of death.
Proceed to Step 2,on r�verse. Dp not check any other boxes and disregard the ampuni
shown above as Potenti�!Tax Due_
� �The.information is The abovE inform3tion Is correct, no d�ductions are being taken,and payment will be sent �� �
correct. with my response.
Rroc�ed to Step 2 on reverse. Do noi check any pther boxes.
� �7he Tax rato is incorrect. � 4.5°/, I am a lineal beneficiary(parent,child,grandGhlld,etc.)of Yhe deceased-
(SBIACf COrrOCt t3X fBtE 1t
right, and complete Part � y�qo I am a sibling of the deceased.
� on reverss.)
� 15% All other relstionships (ir,Cluding nonQ).
p �Changes or deductions 7he information above is incorrect and/or debts and deductions were paid.
listed. Comp/ete Part P and part 3 as appropriate on the back of Chis form.
E �Asset wiN be reported on The above-idenCified asset h�s been or will be reporfed and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by Che estate representative.
REV-1500. Proceed Co Step 2 on r�verse. Do not check any other boxes.
Please sign and date the back af the form wher�finished.
PA�� Debts and [�eduGtions
2
Allowable debts and deductions must meet both of th�e following criteria:
A. The decodent wa�leqally responsibl�For payment,and the estate is insufficient to pay the deductible IYems.
B. You pa�d the debts after the deaCh ot the decedent and can furnish proof of payment if requestad by the deparCment,
(If additivnal space is required,you may�tt&ch 81/2"x �1"sheets of paper.)
DaCe Paid Payee Description Amount 1'aid
7otai Enter on Line 5 of Tax C&Iculation $
�ART Tax Calculatian
� If you are making a correction to the establfshment date(LYne 1)account bal�nce(Line 2),or percent t�xable(Line 3),
please obtaln a wHtten correciion from the ftnancial institutlan and attach it to thfs form�
1. �nier the date tho account was established or titlod as it existed at the date of death.
2. �nter the total bafance of the acCaunt including any interest accruod at the date of doaih.
3. Enter the percentage of the account that is taxabl2 to you.
a, �irst,determino the percenta�e qwned by the decedent.
i. Account5 th�t are he�d"in trust for"another or others were 100%vwned by tho decedent.
ii. For jo�nC accounts established more than one yoar prior to the date of death,the perCentage taxablo is 100%divided
by the l'otal number of ownors including thE decedent. (�or example:2 owners�5Q%,3 owners=3�.33%,4 owners
=2S%,etc.}
b. Next,divide the d�cadont's percentage qwned by tho number of s�rviving owners or benEficiaries.
q. The amount subject to tax is determined by multiplying the aCcount balanca by the percent taxablo.
5. Enter the total of any debts and deductions claimed From Part 2.
6. The amount taxable iS detetmined by subtracting the debts and deductians from the amount subJecC to tax.
7. Enter the appropriate tax rate From$tep 1 �ased on your rel8tionship to the decedent.
If;ndicating a different Cax rate,pleass state
your relationship ta the decedent:
i, bate EstBbfished 1 '
2. Account Balance 2 $
3. PerCent Taxable 3 X —
4. Amount SubjeCt to Tax 4 $
5. Debts and Deductions 5 •
6. Amaunt T&xable � $
7_ Tax Rate 7 x
$. 7ax Due 8 $ �
9. With 5% Discount(Tax x.95) 9 X
S#ep.2� Sign and date below. F3eturn TWO comploted and signed copies to the�tegister of�Ils iisted on the frpnt oi this form,
along with a Check for any payment you are making. Checks must be made pay&bl�to"Rogister of Wiils,Agent." Do not send
payment directly to Che Departmont of Revenue. ,
Under penalty of perjury, I deolare that the��cts I h�ve reported above are true,correct and com�lete tp the b�si of my knowledge and
belief.
'� Wark
Home
Taxpayer Signature Telephono Number Date
1�' YOU NEED FURTH�R ASSISTANCE, GQNTACT PENNSYLVANIA DEPARTM�N7 OF REVENUE
I?ISTRlCT OFFICE, OR THE INH�RITANCE TAX GIVISION A7 717-7$7-8327, SERVICES FUR
TAXPAY�RS WITH SPECIAL H�ARING AND/QR SPEAKING NEEDS ON�.Y: 1-$Op-447'�3020
PA REV-1500
SCHEDULE H
FUNERAL EXPENSES and
ADMINISTRATIVE COSTS
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�a�dss�_.F'rarw�ay�.�.ar�a i 71:�13
�17.�.��7
��I ire�er 1_�d��..�.;�.�71
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, �'�. i�eto+�»oHrnwwoi�h�r.orr�
CJar�D�++trzsH.Hut�ax�—�Clvrs�xa�t 1bS�i���.�.,'���scd�t T'i�+�,F�,bnuu��—;5�ttip��vroc .
��'r,3hal�r��,�,aiI�ir�t�r T,�tvid EFa�lm�—k�a�,ai i7�i9ac�lr,r '
, `
September 5, 2014
Cindia K.Whistle�
58 Lebo Road .
Garlisle, PA 17015 . �
Statement of Funeral Expenses for: Paul �2. Whistler
Date of Death_August 20, 201�4 � Account!d: 17'276�201
PACKACE:
Traditionaf Funeral SErvice
TRADI710NAL FUN�I�AL SERVICE PACKAG� $ 5,1�0.00 � '
Sub`�otal: $ 5,150.qp
MERCFIANDlSE:
Casket: S`�erling $ 2,960_QO
outer Container: Cave Proaf Rox ` $ 1,575.00
Sub Total. $ 4y.�35.00
TOTq�.�I�NERAL�(�B�A�CHARG�$: $ 9,fi85.00
CASH qpVANCES:
Huntsdale Ghurch of the Brethren Cemetery $ 70a,p�
15 Certified Death Certificates at$6.00 each $ 90.00
Newspaper Notice-Sentinel $ �g9,21
►Vewspaper NoticE-Valley Times Star � 5Q.00
Clergy $ 900_p0
�lowers $ 159.Q0
Flower Delivery Charge $ 6.3�
Sub Total: $ �(,40�4.56
Momestaaders Check 4696$5 Sep�, 2014 9,447_24
Total Fr�neral�xpense. $11,089.�6
Preneed Discount: � -1,058.17
�'atal Payments Made: $ 9 447.24
Balance: $ 584.21
'�G� ���Q1 ,�
�r ��� �
**� END OF ATTACHMENTS ***
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING{�IF�R�aj�t�,A�t�r�i�a��his copy by photostat or photograph.
F�E�;�c;-;� ,- '�'.'dLLS
Fee for thi� cer�ific.Ate, `�fi.O0 %"""'�=-. Thi� is to cu�tify that the inform�ition hcie gi�en is
�H Of p
���� ��� �2 �� ,,�`'�--�fy�;� coirectly �opied from an o�iginal Certifi��te of Death
�,'�p� ���; dul�� filcd w'ith mc as Loc�il Registrar. Thc uriginal
��r,- ' ;`�. .��-���'� �' z; cutificate will be forw�arded to the State Vital
, .
o}��[y ( � �' a; Records 0lfice ('or �crmancnt t�ilin«.
11��YEpq��' V +�;��. .ie1 .. '�*; � C
_ � 20 �1 � 52. 6 � c���� �_R ;� t .�;��A,���E�,a�,� z�A.� au
-.,MfNT a -�
nii///����II''j11 n
Certification Number Loc�ll Rcgistrar Date Issu�d
�
Type/Prini In ` . ". COMMONWEALTH OF PENNSVLVANIA�DEPARTMENT OF HEALTH�VITAL RECOR�S
Pef'^a"e"` CERTIFICATE OF DEATH
Black Ink State File Number:
1.Oecetlent's Legal Name(First,Middle,Last,Suffix) 2.Sex 3.Social Sec�riSy N�mber 4.Date of Dea�h(Mo/Day/Vr)(Spell Moj
Paul R. W1-iistler rSale 194-28-9206 August 20, 2014
Sa.Age-Last Birthday(Yrs) 56.Unde�1 Vear Sc.Under 1 Da 6.Date of Birth(Mo/�ay/Vear)(Spell Month) 7a.g7�thplace ty antl Stat� Foreign Country)
Months Days Hours Minutes YeRR WP� YA
'p�+ $4 Jan 24, 1930 7b.Birthplace�cou.,cy)�
Sa.ftestdence(Sfate or Foreign Country) 86.Residence(StreeY and Number-incl�de Apt No.) 8c.Old Decedent Live in a TownshipT
PA 58 Lebo Rd. �Ves,decedent Ilved In Pann c�,..P.
8d.Residence(County) �
Cumberland 8e.Residence(Zip Code) 0 No,decedent Ilved within Iimits of c(ty/boro.
9.Ever In US A�metl ForcesT 10.Ma�ital Status at Time of Death �Married Wldowed 11.Surviving Spouse's Name(If wife,give name prior to flrst ma�riage) 3
�Yes [�No �Unknown 0 Divorcetl � Never Marrie!f �Unknown
12.Father's Name(Flrst,Middle,last,Suffix) 13.Mother's Name Prior to First Marriag<(First,Middle,Last) - �
Harry M. W2iistler Maude Ke1so .
14a.Informant's Name 14b.Relatlonship to Decedent 14c.Informant's Malling Atldress(Street and Number,City,State,Zip Code) r
Cindia K. Whistler Dau 1-iter 58 Lebo Rd. , Carlisle, PA 17015
G - - - - - - - - ,y - - - - - - - - -isn.v a�e o oeac c eo o.,Yo�e - - - - - - - - - - - - ^
If Death Occurred in a Hospltal: - L] Inpatienf ' - �If Oea[h Occurretl Somewhere Other Than a Hospital d Hospice Facliity Z]Decetlent's Home �
� Emergency Room/Outpatient � Dead on Arrival � Nursing Home/Long-Term Care Facility O Other(Specify) „
ae' SSb.Faclliry Name(If not institutlon give streeS and number) '15c.Ctty or Town State,and Zip Code 15d.Co�nty ot Death
Carlisle Regiona� Medical Center Carlis�e, PA 17015 Cumberland
LL 16a.Mechod of Oisposition �] Buriai � Cremation 166.Date of Dispositlon 16c.Place of Dtsposition(Name of cemetery,crematory,or oiher place) �
$ p Removal from State o oo�acio� Aug 25, 2014 Huntsdale Church o£ the Brethren Cemetery �
� p ome�(sPe�irv>
Z 16d.LocaCion of Disposition(City or Town,Sta2e, nd 2ip) 17 . nat�re of Fune 1 Servlc Licen e rs n i harge of Inierment 1]b.Lic Number �
y� Carlisle, PA 17015 � 011932L 1
�
o llc nd Com lete Atldress of Funeral Facill2y
I�o�££aman-PRotl-i Funeral Home & Crematory, 219 Nortli Hanover Street, Carlisle, PA 17013
18.Deceden['s Education-Check the box that best describes the 19.Oecedent of Htspanic Origin-Ch¢ck the 20.Decedent's Race-Check ONE OR MORE races to indtcat¢what
� highest degree or level of s<hool completed aS She time of death. box that best descrlbes whecher the tlecedeni the tlecedent considered himself or herself to be.
� Bth grade o�less is Spanish/Hispanic/Latino. Check ihe"No" (�WhiCe � Korean
Q No diploma,9ih-12Sh grade box If decedent Is not Spanish/Hispanit/Latino. � Black or Afrlcan American � Vietnamese
�] High school graduate or GEO completed No,noY Spanish/Hispanic/Latino �Ame�Ican Indian or Alaska Native � Oiher Asian
� Some college credit,but no deg�ee �'es,Mexican,Mexican American,Chicano p Asian Indian O �lative Hawailan
0 Associafe degree(e.g.AA,AS) �Yes,P�erto Rican �Chinese � Guamanian or Chamorro �
Q Bachelor'S degree(e.g.BA,AB,BS) � Ves,Cuban O Fllipino � Samoan
� Master's degree(e.g.MA,M5,MEng,MEd,MSW,MBA) 0 Yes,other Spanish/Mtspanic/Latino �Japanese 0 OfFer PaciFlc Islander
� Doctorate(e.g.Ph�,EdD)or Professlonal degree (Specify) � OSher(Specify)
.MD DDS DVM LLB,JD
21.Decedent's Single Race Self-Designation-Check ONLY ONE to Indicate what the decedent conside�ed himseif or herseif fo be. 22a.Decetlenf's Usual Occupatlon-Indicate type of work
L�Whi[e �Japanese � Samoan done during mosY of working Iife. DO NOT USE RETIRED.
[j Bla<k ar African American � Korean � Other Pacific Islander Farmer
9 0 American Indian or Alaska NaYlve �Vletnamese � Don't Know/Not Sure
�Aslan Indian O o�her Asian � Ref�sed 226.Klnd of Business/Industry
� � Chinese 0 Nafive Hawalian 0 Other(Specify)
� FIIlpino � Guamanlan o�CFamo��o Farming
ITEMS 23a-23d MUST BE tOMPLETED 23a.Dafe Pronounced Deatl(Mo/Day/Vr) 23b.SignaSure of Person Pronouncing Oeaih(Only when applicable 23c.License Number
BY PERSON WHO PRONOUNCES OR �-/ZQ/��/� ��JJJ c�_ �) I
CERTIFIES DEATH � �� iy'0 7y 3 2 2 L
23d.Date Signed(Mo/Day/!V1r) 24.Time of Death C2
��ZQ Z�/( Q � `�6 �� 25.Was Medicai Examiner or Coro�er Contacted7 � Ves �-No
CAUSE OF DEATH � Approximate
26.Part I. Enfe�the chain of e ents--diseases,Injurfes,o mplications-that dlreciiy ca�sed The deaih. DO NOT enter terminal events such a ardlac arrest, � Interval:
respirafory a��est,or ventricular fibrillatlon wlShout showing the etloiogy. DO NOT ABBREVIATE. Enter oniy one cause o/n a Iine. Add additional Ilnes if necessary. 1 Onset to�eath
IMMEDIATECAVSE --- > ��/(�f�l � /L/=S/ ���� G7� Y �i� /`V/�-� �
(F�nal tlisease o contlltlon Oue to(o as a consequence of):
�es�ic�„a��death) Gs����iCi�e 2�'S��//?_�To./2 Y f�rJ`�G l�/L�� �
b. �
I
Sequentially Ilst condiCions, Due to(or as a consequence vf): �
If any,leading co ihe cause �
iisiea o„line a. Enter the ��Gli �iP' /�.�'iv'i'� �'��/�-!//L��
�
UNOENIVING CAUSE � Due to(or as a conseqtience of):
�, <a�seas�o�in�7u ncnac T/�/�-� /�'l�/2/G_�-r/�iC� ,
initiated the ve ts resulting d. i�
¢ in death)LAST. Due to(or as a con equence f): �
ij 26.Part 11. Enter other sI¢niflcant conditions conTributin¢to death but nof reS�iting in the untlerlying cause given In Part I. 27.Was an autopsy pertorm ?
J
O Yes No
� 26.Were a�topsy flntlings avallabie
[o mplat�thc c of d¢athT
��o ve: ala-�
29.If Female: 30.�id Tobacco Use Contrib�ie to Deaih? 31.Manner of Oeath
E 0 Noi pregnant within past year � Ves � Probably RJ`Flatural ' � Homicide
� Pregnant at time of deaYh 0 No ,g�Unknown O Accident Q Pending Investigation
°�' Q Not pregnani,b�t pregnant within 42 days of death � Suicide � Could noi be determined
� � Not pregnant,but p�egnant 43 days fo 1 yea�before death 32.Date of Injury(Mo/Day/Vr)(Spell Month)
� � Unknown if pregnani wlfhin She past year 33.Time of Injury
34.Place of InJury(e.g.home;con5iruction site;farm;schooi) 35.Location of In)ury(Street and Number,City,County,Sta[e,ZIp Code)
36.InJury at Work 37.If Transportation InJury,Specify: 38.oescribe How Injury Occurred:
0 Yes � Drivcr/Operator O Pedestrlan
� No 0 Passenger � Other(SpecifyJ
39a.Certifier-physiclan certifled n e practitloner,medical examiner/co r(Check only one):
� Certifying only-To the best of my knowledge,deaih occurred due to the cause(s)and mann¢r stated.
�6ro ncing R Certifying-To[he best of my knowledge,deach occurred ai the tlme,date,and place,and due to the cause(s)and manner siated.
0 Medical Examiner/Coroner-On the basis�of e�xamin/a�/tlo>n and/or�nvescigation,In my opinion,deafh occurred ac the time,dace,and place,and due to the causa(s)and manner stataC.
Signatu�e of certifler� '��-GI��Z� Title of certifier: ��b License Number:/'�'�G�7�".3 Z Z L
39b.Name,Address and Zip Code of Pers Completing Cause of Death(Item 26) 39c.Date Signetl(Mo/Oay/Y)
�liL/�/S Z��!�l�CC 3 E/�GE'}�.a-�cioF-/L S PR il✓G 2 9 c.�.e USL�/2�- /70i.i �/2¢�2 Q/S
� 4D.Registra�'s OlsSrici Numbcr 41.Registrar's Signature 42.Registrar FIIe Date(Mo Day r)
� �-le:.,��l.'Fa�..1.t..1e�e- e,c-- 6
� 43.Amendmenis
�
. " � �.( ( n�( H 305-143
DlsposiNon Permit No. �"rlo L`��" REV O]/2012
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