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HomeMy WebLinkAbout02-0902 "'.'.m.,,~, . ' ~COMMONWEALTHOFPENNSYLVANIA DEPARTMENT OF REVENUE DEPT,280601 HA~_R!::;!'I_U~G, PA l?~~~~L REV.1500 INHERITANCE TAX RETURN RESIDENT DECEDENT I 17':"1').'':;'3 .Y I FILE NUMBER 21 001 oCJo;< QQj,JNTY C;9DE_ YEA"L NUM~ER _m_..__ ___ _____ SOCIAL SECURITY NUMBER ~ Z W Q W ~ Q DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SAVITSKY, ELEANOR DATE OF DEATH (MM-DD-YEAR) 07/18/2002 192-14-4902 --TeATE OF BIRTH-tMM.OD-YEARj i 06/0111913 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ISOCIALSEC~~~I~u1~: OF WILLS o 3. Remainder Return (date of death prior to 12-13-82) o 5. Federal Estate Tax Retum Required 8. Total Number of Safe Deposit Boxes o 11.Election to tax under Sec. 9113(A) (Attach Sch 0) (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL) w ~ ~::!:(/) UZ< w~g :t:~..J U~m ~ < ~ o ~ 6. o 9. Decedent Died Testate (Attach copy of Will) Litigation Proceeds Received D 2. Supplemental Retum o 4a. o 7. o .;"," , _ "., ,,}2;'~1.918nd 1-1-95\ ,illlli~~I_ji_i~ .]11,.; 1 Original Retum 4 Limited Estate Future Interest Compromise (dale of death after 12-12-82) Decedent Maintained a Living Trust (Attach copy of Trust) 10. Spousal Poverty Credit (date of death between ''!!i!$illE ..HiM. NAME Edward L. Schorpp - ....~.- ,.-'H iII1IIlNllAQlIliOllI!il!lfll!OTEDl'(l: COMPLETE MAILING ADDRESS 15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec. 9116(a)(1.2) z .045 (16) Q 16.Amount of Line 14 taxable at lineal rate x ~ < ~ ~ ~ 17.Amount of Line 14 taxable at sibling rate 26,173.60 x ,12 (17) ~ 0 U ~ 18. Amount of Line 14 taxable at collateral rate x ,15 (18) ---- 19. Tax Due (19) FIRM NAME (If applicable) Martson Deardorff Williams & Otto Ten East High Street Carlisle, PA 17013 TELEPHONE NUMBER 717/243-3341 1. Real Estate (Schedule A) C)~: 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6..Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (1) None. (2) None (3) None ------ (4) None (5) 8,916.80 (6) 26,591.24 (7) None (9) 8,436.49 (10) 897.95 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 20. 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ! ..,~I j (8) 35,508.04 (11) 9,334.44 26,173.60 (12) (13) (14) 26,173.60 3,140.83 3,140.83 >~'lll;i$_'i:li*il$\liliRiA~~iIWl!liiIIQH$'i:I~!i1~~,l!illlEiiAI'IIlR~lil"ellltl.i~. .~-_.----------:-_ ___ Form REV-1500 EX (Rev. 6-00) Copyright 2000 form software only The Lackner Group, Inc. Decedent's Complete Address: STREET ADDRESS 700 Walnut Bottom Road CITY Carlisle STATE PA I ,ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 3,140.83 157.04 Total Crediis (A + 8 + C) (2) 157.04 3. Interest/Penalty if applicable D. Interest E. Penalty 8. Enter the total of Line 5 + 5A. This is the BAlANCE DUE. (3) 0.00 (4) (5) 2,983.79 (5A) (58) 2,983.79 TotallnIerest/Penalty (D + E) 4. If Line 2 is greater than line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 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. A. Enter the interest on the tax due. Make Check Payable fo: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: 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; or ............................................... ,................................................ .................. d. receive the promise for life of either payments, benefits or care?............................................................. 2. If death occurred after December 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 contains a beneficiary designation?...................................... ....................... ............................. ......................... Yes No ~ I D 181 D 181 D 181 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. DATE . ADDRESS 19 Abbey Court ~arlisle,1'~~(}13 /0-3-0:;;). DATE ADDRESS /0 -3-o~ DATE Ten East Higl) Street Carlisle, PA 17013 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [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 surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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 twenty-one 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% [72 P.S. 99116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116 1.2) [72 P.S. ~9116 (a) (1 )1. The tax rate imposed on the net value of transfers to orfor the use of the decedent's siblings is 12% [72 P.S. 99116 (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. . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I FILE NUMBER 21- - -...-- -- -- ---- ESTATE OF SAVITSKY, ELEANOR Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorshIp must be disclosed on schedule F. ITEM NUMBER I DESCRIPTION VALUE AT DATE OF DEATH 6,522.99 First Union CD #247412041098403, burial account 2 Forest Park Health Center, refund 1,980.93 3 Blue Cross/Blue Shield, refund of premium 262.88 4 Bell Hearing Aid Center, refund 150.00 TOTAL (Also enter on Line 5, Recapitulation) 8,916.80 . SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ------ ,----..- 1 FILE NUMBER 21 - - ---- -..- ESTATE OF SAVITSKY, ELEANOR 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 Vincent Zeladonis 19 Abbey Court Carlisle, PA 17013 Brother JOINTLY OWNED PROPERTY: 2 A see note First Union Savings #3000023887773 (note: This , account was opened 8/17/01 with funds from a First Union account originally made joint in 1992. Account type varied to take advantage of interest rates but was funded with funds from original joint account opened in 1992.) DESCRIPTION OF PROPERTY , F DEAT Incl~d~ n~me <?f~nancial institution and bank .a~count number DATE OF DEATH , D~COD'S; OA0~~0E OF H or Similar Identifying number. Attach deed for JOintly-held real VALUE OF ASSET !INTEREST DECEDENT'S INTEREST lestate. __oj 2,213.211 38,385.641 I , ITEM . LETTER NUMBER 'FOR JOINT TENANT DATE MADE JOINT A 06/13/2000 F&MTrust, checking #33-22548 50% 1,106.61 50% 19,192.82 3 A see note First Union Checking #1010042362274 (note: This account was opened 10/22/01 with funds from joint : savings account, Item 2 herein) 12,583.61, 50% 6,291.81 TOTAL (Also enter on line 6, Recapitulation) 26,591.24 *' SCHEDULEH FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SAVITSKY, ELEANOR FILE NUMBER 21- Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT FUNERAL EXPENSES: Kizis-Lokuta Funeral Home, Pittston, PA 6,987.00 2 Grave marker 250.00 3 Travel and accommodations to prepare for funeral services 412.00 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Social Security Number(s) I EIN Number of Personal Representative(s): Street Address City Year(s) Commission paid Attorney's Fees Martson Deardorff Williams & Otto (estimated) State Zip 2. 750.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent 4. Probate Fees State Zip 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs I F&M Trust research ree 5.00 2 Tollealls 17.49 Total of Continuation Schedule(s) 15.00 TOTAL (Also enter on line 9, Recapitulation) 8,436.49 '* ScheWIe H Funeral Expel s e s & Adnirlistl."ll Costs conli1ued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SAVITSKY, ELEANOR 3 Register of Wills Filiog Fee, Inheritance Tax Retorn I FILE NUMBER 21- - 15.00 Page 2 of Schedule H *' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS __L COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I FILE NUMBER 21 - - ESTATE OF SAVITSKY, ELEANOR Include unrelmbursed medical expenses. ITEM NUMBER 1 Continuing Care RX DESCRIPTION AMOUNT 346.39 2 Lancaster HMA Physicians 22.16 3 West Shore EMS-BLS 529.40 TOTAL (Also enter on Line 10, Recapitulation) 897.95 ~EV.1513 EX+ (9.00) *' SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SAVITSKY, ELEANOR FILE NUMBER 21 - - NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT nn Nnt II_t Tnurtillilll_' I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) Vincent Zeladonis 19 Abbey Court Carlisle, PA 17013 Brother Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover she t AMOUNT OR SHARE OF ESTATE 100% of estate residue II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 91 1 3 FOR WHICH AN ELECTION TO T IV. IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1S00 COVER SHEET f'~l~N "~ Reference 10: clOf:i812 FIrst UnionrWachovia Attn: Account Ve-nfic3tJOl1S POBox 40028 RU:lnoke VA 24022-"7313 A ugmt 20, 2002 MARTSON DEARDORFF WILUAMS & OTTO TEN EAST HIGH STREET CARL1SLE, PA 17013 SUBJECT: Verification / Conftrmationof Account and Balance Infomlation provided for: Customer: ELEANOR SAVITSKY (SSN# 192-14-4902) Date or Death: July IS, 2002 Deposit Account Information Account Type Account Number Date of Death Balance Average Balance'" Date Opened Maturity Date interest Accmed YTD Date Rate Interest Interest Paid Closed ::::ERTIFrCA TE OF DEPOSIT 247412041098403 $6,519.42 3/16/2000 $3.57 $246 90 7/22/2002 LEGAL nTLE: ELEANOR SAVITSKY BURIAL FUNDS ESCROW :::HECKlNG 1010042362274 $12,58262 10/22/200 I $0.99 $4\.74- ~EGAL TITLE: ELEANOR SA VITSKY IfNCENT ZELADONIS ;USAN L. BENNER, POA ~CCOUNT AS TITLED SINCE OPENfNG AVrNGS 1000023887773 $38,347_84 SIl 7/200 I $3730 $540.86 .EGAL TITLE: ELEANOR SAVITSKY 'INCENT zELADONIA CCOC'NT AS TITLED SINCE OPENING ot D\lC \0 system limitations, we can only provide a twelve month average balallce on depository accounts Schedule E, Item 1 and Schedule F, Items 2 & 3 RE: ELEANOR SAVITSKY DATE OF DEATH 7-18-2002 ACCOUNT INFORMATION L-CHECKING SAVINGS ___CERTIFICATE OF DEPOSIT SAFE DEPOSIT SHARES OF STOCK DATE OPENED 6-13-2000 DATE CLOSED STILL ACTIVE ACCOUNT NUMBER 33-22548 ACCOUNT BALANCE AT DATE OF DEATH $2.212.97 ACCRUED INTEREST $0.24 TOTAL ACCOUNT BALANCE $2.213.21 NAME(S) ON ACCOUNT ELEANOR SAVITSKY & VINCENT ZELADONIS & SUSAN L. BENNER POA --------------------------------------------------------------- ACCOUNT INFORMATION CHECKING SAVINGS ____CERTIFICATE OF DEPOSIT SAFE DEPOSIT SHARES OF STOCK DATE OPENED DATE CLOSED ACCOUNT NUMBER ACCOUNT BALANCE AT DATE OF DEATH ACCRUED INTEREST TOTAL ACCOUNT BALANCE NAME(S) ON ACCOUNT ------------------------------------------------------------------ Schedule F , Item 1 LAST WILL AND TESTAMENT OF ELEANOR SAVITSKY I, Eleanor Savitsky ,of the Township of Jenkins, County of Luzerne, and the Commonwealth of Pennsylvania, being of sound mind, memory and understanding, do hereby make, publish and declare this to be my Last Will and Testament, in manner and form following, hereby revoking any and all Will or Wills or Codicils, thereto heretofore made by me. FIRST: I direct that all my just debts and funeral expenses be fully paid and satisfied as soon as conveniently may be after my death. SECOND: I give and bequeath all the household contents and furniture to my sister in law, Peggy A. Zeladonis. THIRD: I give and bequeath all the rest, residue and remainder of my estate to my brother, Vincent Zeladonis, provided he survive me by thirty (30) days. (~< (SEAL) FOURTH: In the event that my brother, Vincent Zeladonis, dies on or before the thirtieth day following my death, then the residuary shall be distributed as follows: A. My sister in law, Peggy A. Ze1adonis 40% B. My brother, Joseph Zeladonis 20% C. My nephew, Thomas M. Zeladonis 20% D. My niece, Susan L. Benner 20% FIFTH: I hereby nominate, constitute and appoint my brother, Vincent Ze1adonis as Executor of this my Last Will and Testament. In the event that my brother, Vincent Zeladonis, ceases to act or fails to qualify as Executor then I appoint my niece, Ssuan L. Benner as alternate Executrix. SIXTH: I direct that my personal representatives shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last "t''?! , , , ~ ,1999. Will and Testament this 1M:: ... The preceding instrument, consisting of this and one other typewritten page, each identified by the signature of the Testatrix was on the day and date thereof signed, published and declared by, Eleanor Savitsky the Testatrix, therein named, as and for Last Will, in the presence of us, who at her request, in our presence and the presence of e other, have su 'bed our names as witnesses hereto. ,- I, .... COMMONWEALTH OF PENNSYLVANIA : COUNTY OF LUZERNE : SS I, Eleanor Savitsky, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes herein expressed. ~. Sworn to and s d before me this K, day of~ ,1999. ~gfAPSP~B~ ~ NOTARIAL SEAL JOSEPHINE M. HOWLEY, NOTARY PUBLIC . ,P'TTSTON, LUZERI/E COU~TY , ~"IY CO~MISS'ON EXPIRES J~~!I.'~nYJ 1f.~!' ' COMMONWEALTH OF PENNSYLVANIA : COUNTY OF LUZERNE : SS We, rl-~ T-~"" ~ 7~ the witnesses whose names are signed to the attached or.ro-;g;;ing instrument, being duly sworn according to law, do depose and say that we were present and saw the Testatrix sign and execute the instrument as her Last Will; that Eleanor Savitsky signed willingly and that she executed it as free and voluntary act for the purposes therein expressed; that each of us in the hearing and signing of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at the time 18 or more years, of sound mind and under no constraint or undue influence. ~ r: ~ ?~A{.~ Sworn to and subscribed be~S~y of ,1999. kAAy~U~ . NOTARI.( s' L JaAf:~~~NHOWLEY. NOTARY PUBUC :n r~w.jJ..'" ,LUZERNE COUNTY "'''''-'-.. ....,,-,.,.~IEXt,I?lr:.'=: ltal"~qy -_i_.';"::;,;;,;",,..:~,,'_~ :'~,~,22.qQ. j COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDlVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SCHROPP EDWARD L ESQUIRE MARTSON DEARDORFF ETAL TEN EAST HIGH STREET CARLISLE, PA 17013 --------fold ESTATE INFORMATION: SSN: 192-14-4902 FILE NUMBER: 2102-0902 DECEDENT NAME: SAVITSKY ELEANOR DATE OF PAYMENT: 10/07/2002 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/18/2002 NO. CD 001695 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $2,983.79 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: VINCENT ZELADONIS C/O EDWARD L SCHORPP ESQUIRE CHECK# 774 SEAL INITIALS: SK RECEIVED BY: REGISTER OF WILLS $2,983.79 MARY C. LEWIS REGISTER OF WILLS /?- '1c2- (..:3 'v BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z8D6Dl HARRISBURG~ PA 171Z8~D6Dl COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE DR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX EDWARD L SCHORPP MARTSON ETAL 10 E HIGH ST CARLISLE DATE ESTATE OF DATE OF DEATH FILE NUMBER 7 COUNTY ACN 11-19-2002 SAVITSKY 07-18-2002 21 02-0902 CUMBERLAND 101 MOunt R_i ti.d *' IE'l-lSUUioFl'Ul-I2J ELEANOR PA 17,013 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS ... REV=i547-Ex-"iiP--loFozY-NoT"icniF-'rriHEifiTANCE-,.-A'x-A!iPRAisEj.iENi:~--"Li-owANCE-Di----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SAVITSKY ELEANOR FILE NO. 21 02-0902 ACN 101 DATE 11-19-2002 TAX RETURN WAS: I X I ACCEPTED AS FILED I CHAN8EO I~ an assess.ent was issued previouslY. lines 14. 15 and/or 16. 17. 18 and 19 will r~lect ~igures that 1nclude the total ~ ALL returns assessed to date. ASSESSMENT OF TAX: IS. AlIOuot of Line 14 at. Spousal rat. US) 16. ~ount of Lin. 14 taxable at Lineal/Class A rat. (16) 17. Anount of Line 14 et Sibling ret. (171 18. Amount of Line 14 taxable at Collateral/Class Brat. (18) 19. Principal Tax Due D TS. RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule DJ 5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule FI 7. Transfers (Schedule G) 8. Total Assets III 121 (31 (41 151 (61 (7) .00 .00 .00 .00 8.916.80 26.591. 24 .00 (81 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Ad.. Costs/Mise. Expenses (Schedule Hl 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total DaducUons 12. Net Value of Tax Return 13. Charitable/Govennnental Bequests; Non-elected 9113 Trusts (Schedule ~) 14. Net Value of Estate Subject to Tax 191 1101 8,436.49 897.95 1111 1121 1131 (14) NOTE: .00 .00 26,173.60 .00 X 00 = X 045 = X 12 = X 15 = T + INTEREST/PEN PAID (-I 157.04 AHDUNT PAID 2,983.79 DATE 10-07-2002 NUHBER CD001695 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. NOTE: To insure proper credit to your accountl subMit the upper portion of this for. with your tax pay.ant. 35,508.04 9.::134 44 26,173.60 .00 26,173.60 1191= .00 .00 3,140.83 .00 3,140.83 3,140.83 .00 .00 .00 ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YOU Ht.Y lIE DUE A REFUND. SEE REVERSE SIDE OF THIS ~nllM ~nD TUC!TD......,.,.......... "