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Home My WebLink About11-06-14 � 15056101�5 REV-1500EX`°Z_">`�, � enns lvania OFFICIAL USE ONLY PA Department of Revenue PEppq,MExY County Code Year File Number Bureau of Individuat Taxes pINHERITANCE TAX RETURN � � � PO BOX 28o6oi RESIDENT DECEDENT v'�'� �'� �� Harrisburg,PA i'7128-06oi ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 01/06/2011 11/06/1914 DecedenYs Last Name Su�x DecedenYs First Name MI Burtner Rita H (If Applicable)Enter Surviving Spouse's Info�mation Below Spouse's�ast Name Suffix Spouse's First Name MI Burtner Raymond H Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 199-07-6918 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1.Original Return O 2.Supplemental 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) C� 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.Spousal 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 INFORMATIOFF3HOULD BE DIREC�ED Tf�7 rn Name Daytime Tels��"hc�Number�_ �.�� William S. Daniels (717)24�� c., � ``' "�"� ., - � REGIST�R OF IIVILLS ljS'E�ONLY'' ' -� --:.; r; First Line of Address "�' �� _ �.a 1 West High Street `'� � - fi`' �. ,,,� Second Line ofAddress r�� Suite 205 City or Post Office State ZIP Code DATE FILED Carlisle PA 17013 CorrespondenYs e-maii aadress: humeranddaniels outlook.com 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,cor ct and complete.Declaration o reparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATU OF PERSON RE ONSI FO F ING RET RN DATE � �� — ��::�b/ ADD ESS George C. Holland, Exe utor-2594 Dunhaven Glen, Snellville, GA 30078-7331 SIGp�ATU E FPREPARER T AN REPRESEN TIVE ,/�A�� , ��„ -�•o�• G ADDRESS William S. Daniels, Counsel - 1 W. High St., Suite 205, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 � , "�� 1505610205 REV-1500 EX(FI) DecedenYs Social Security Number DecedenYs Name: Rita H. Burtner RECAPITULATION 1. Real Estate(Schedule A). ..... . . ......... .. . . . . ..... .... .. . . . . . . .. .. . 1. 0.00 2. Stocks and Bonds(Schedule B) . .......... . . . . . ..... ...... . . . . . . . .. . .. 2. 0.00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . .... 3. 0.00 4. Mortgages and Notes Receivable(Schedule D) . . .. . . ....... . . . ... . . . . . . .. 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . ... 5. 18,220.00 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. . . . .. 6. 112,281.37 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested... . . . .. 7. 151,891.43 8. Total Gross Assets(total Lines 1 through 7). . . . ........... . . . . . . . . ... . . . 8. 282,392.80 9. Funeral Expenses and Administrative Costs(Schedule H)..... .......... . . . . 9. 41,073.50 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I)........... .... 10. 8,392.18 11. Total Deductions(total Lines 9 and 10). . . .. . . . . . ..... . . . .... . . . . . ...... 11. 49,465.68 12. Net Value of Estate(Line 8 minus Line 11) .. .. . . . ...... ..... . . . . . . . . . ... 12. 232,927.12 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .............. . . . . . ..... 13. 0.00 14. Net Value Subject to Tax(Line 12 minus Line 13) ..... . . . . ... . . . . ........ 14. 232,927.12 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 107,818.35 (a)(1.2)X.0 0 15. 0.00 16. Amount of Line 14 taxable at lineal rate X.0 45 125,108.77 �g. 5,629.89 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE ... . . . ....... . . . ............ . . . . . .. .......... . . . .. .... . . . 19. 5,629.89 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 � 1505610205 1505610205 � REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Rita H. Burtner STREETADDRESS - --.__ — 66 Rolling Drive CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 5,629.89 2. Credits/Payments A.Prior Payments 6,300.00 B.Discount 0.00 Total Credits(A+g) (2) 6,300.00 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) 670.11 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 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 .............................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If death occurretl after Dec.12, 1982,did decedent transfer properry within one year of death without receiving adequate consideration?.............................................................................................................. ❑ � 3. Did tlecedent own an"in trust for"or payable-upon-death bank account or security at his or her deathl.............. ❑ � 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 tleath 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 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 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 imposetl on the net value of transfers to or for the use of the decedent's 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. COMMONWEALTH OF PENNSYLVANIA REV-1162 EX�11-96) DEPARTMENT OFREVENUE BUREAU GF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 1 7 7 28-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 014946 DANIELS WILLIAM S ONE W HIGH STREET STE 205 CARLISLE, PA 17013 ACN ASSESSMENT AMOUNT CONTROL NUMBER _"_____ told '___""__ 101 � 54,500.00 ESTATE INFORMATION: Ssrv: � � FILE NUMBER: 211 1 -0202 � DECEDENT NAME: BURTNER RITA H I DATE OF PAYMENT: 09/09/201 1 � POSTMARK DATE: 09/09/201 1 � COU►vTY: CUMBERLAND � DATEOFDEATH: 01/06/2011 � � TOTAL AMOUNT PAID: 54,500.00 REMARKS: RECEIPT TO ATTY CHECK# 1840 INITIALS: HMW SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS TAXPAYER COMMONWEALTH OF PENNSYLVANIA " " " � REV-1162 EX�11-96) DEPARTMENT OF REVENUE N /� ,J i BUREAU OF INDIVIDUAL TAXES �K r DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 016663 DANIELS WILLIAM S ONE W HIGH STREET STE 205 CARLISLE, PA 17013 ACN ASSESSMENT AMOUNT CONTROL NUMBER ___"'_' told '_____"" ___""' 101 � S 1 ,800.00 ESTATE INFORMATION: ssrv: � � FILE NUMBER: 211 1 -0202 � DECEDENT NAME: BURTNER RITA H � DATE OF PAYMENT: 1 O/1 8/201 2 I POSTMARK DATE: 10/18/201 2 � coUNTY: CUMBERLAND � DATE OF DEATH: 01/06/201 1 � � TOTAL AMOUNT PAID: $1 ,800.00 REMARKS: RECEIPT TO ATTY CHECK# 1110 INITIALS: HMW SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS TAXPAYER i % j i I I � �i II �g7�'� �-� !��f� q� � �. � a �^��`V`��V�� d�n�� 9 �P'�� I� �r�,`,,�e,��] �; � i _ - _ �— i IV. I direct that all taYes that may be assessed in consequence of my death, of i whatever nature and by �vhatever j urisdiction imposed, shall be paid From my � residuary esta�e as a part of the expense of the administration of my estate.. V. I appoint my son, GEORGE C. HOLLAND, eYecutor of this my last will. VL I direct that my executor shall not be required to give bond for the faithful performance of his duties in any jurisdiction. �L T I�v i�ITNESS WHEREOF, I have hereunto set my hand and seal this.�j`�day of September 2010 �SEAL) A H. B TNER The preceding instrument, consisting of this and one other typewritten page identified by the signature of the testatrix, Rita H. Burtner, was on the day and date thereof signed, published and declared by Rita H. Burtner, the testatrix therein named, as and for her last will, in the presence of us, who, at her request, in her presence, and in the prese�ce of each other ha ;e subscribed our names as witnesses hereto. ., ��, r � : � ; ��r,- � r /�/`g jI ��G��L /� .l�°l.;��[-.fi'iC��`"/,� t �.. "�,y'f r-Y ... �r��` i' � � . I�� 1�•/E"" �fff �1,re''!�'�L�� 4.'�i,.t'.M.,p �''�'' � �'� s� . � r�' / i.ry/ � �f��rlfL`."i��t.7f—�i s�}�!! f/ f�i/ %C �� JG , � �� i REV-15o8 EX+(o8-iz) � pennsylvania SCHEDULE E DEPARTMENTOFREVENUE CASH, BANK DEPOSITS &MISC. INHERITANCE TAX RFfURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Rita H. Burtner 21-11-0202 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 1. 1985 Homes of Merit ID#C271U17850,Title#22993972-Mobiie Home 17,000.00 2. Contents of Mobile Home 1,220.00 TOTAL(Also enter on Line 5, Recapitulation) $ 18,220.00 If more space is needed,use additional sheets of paper of the same size. MANUFACTURED HOME MARI�ET COMPARISON VALUATION YEAR: 1985 MAKE: Homes of Merit ID # C271U17850 TITLE# 22993972 This unit is a 2 bedroom, 2 bath, 14' x 70' Single Wide Manufactured Home with an attached, enclosed porch and an outside utility room. Less one bedroom set, it is fully furnished with older furniture in good condition. It is located in Hidden Cove West, a manufactured home development in Winter Haven,Florida. The physical address is '700 Lake Henry Court. The rental lot upon which it rests borders a canal waterway immediately adjoining the rear of the lot where there is a small wooden dock for boat mooring and access. Hidden Cove West is an older development and is host to many manufactured homes built in the 1980-1990 era. The common grounds, clubhouse,pool, gated entry area, and roadways are attractively maintained, all of which seems to foster a pride of ownership amongst the residents. The gated entry and close proximity of the homes provides a sense of security important to the residents,most of whom are senior citizens. This market analysis valua.tion takes into consideration the aged status of this home and most homes within this community,the depressed sales market prevalent in Florida,the current and recent prices realized from completed sales of homes within this development,market information provided by the resale marketing directar on site at Hidden Cove West, and the fact that this unit is being sold as a furnished, turnkey home ready for immediate occupancy. Comparative Market Value $17,000 - $19,000.00 _-----� �� ` � ; ._._��t.. ` �Uui'li_.. Phil Riner 5-�c,� --i 1 Phii Riner Auctions, LLC- Since 1978 POB 2342, Winter Haven, FL 33883-2342 863-299-6031 MASTER BEDROOM Complete Double Bedroom Set w/Linens $150.00 & Wall Decor. LIV ING ROOM Older Furniture Includes: 2 Recliners, Sofa, Etagere, Lamp, Table w/Lamp,Floor Lamp, Analog TV, Quilt Rack,Rattan Round Coffee Table, Wall Decor, Hall Cabinet w/Wall-Mounted Mirror. $300.00 BREAKFAST BAR 2 Rolling Dinette Chairs, Cream Color,Mexico Import. $ 25.00 KITCHEN Chromcraft Dinette Table w/4 Rolling Chairs & Table Leaf,Misc Small Appliances,Dishes, Microwave Oven, Misc Cookware &Accessories, Whirlpool Stack Washer, Mod#LT7000XTN0, Dryer Ser#MX2613302 (Manuais dated 1988). $250.00 GUEST BEDROOM 5-Draw Chest, 2 Chairs"AS IS", TV Cart, 19" $100.00 Analog TV,Floor Lamp. MISC &PATIO CONTENTS Sparse Bed &Bath Linens. 7 Pcs of Older PVC Patio Furniture,Analog TV w/Cart, 2 Floor Lamps, Rocking Chair. Misc Decor Items on Tabletops &Walls inside home and on porch. $300.00 UTILITY ROOM CONTENTS Sma115-Draw Chest, Metal School Desk, Small Gas Grill "As Is",2 Fern Stands of light weight metal, 5' Wooden Stepladder,Card Table,Misc Yard Tools, Shop Bric-a-brac,2 PVC Chairs. $ 95.00 TOTAL VALUE $1,220.00 REV-isog EX+(ol-io) � pennsylvania SCHEDIJLE F DEPARTMENTOFREVENUE �OINTLY-OWNED PROPERTY INHERITANCE TAX REfURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Rita H. Burtner 21-11-0202 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• Raymond H. Burtner 66 Rolling Drive Spouse Carlisle, PA 17013 B'George C. Holland, III 2594 Dunhaven Glen Grandson Sneliville, GA 30078-7331 C. Sandra A. Orlando 3304 Montessori PI. Daughter Pensacola, Florida 32504 (continued on Page 2) )OINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OP DEATH ITEM FOR lOINT MADE INCLUDE NAME OF FINANCIAL INSTIfUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT lOINT IDENTIFYING NUMBER.ATTACH DEED FOR]OINTLY HELD REAL ESTATE. VALUE OF ASSEf INTEREST DECEDENT'S INTEREST 1' A' 01I30/80 Real Estate,66 Rolling Drive,Carlisle,PA 17013 157,300.00 50 78,650.00 2. AE 09/01/67 M&T Checking Account,406236 58,910.45 33 19,636.82 3. AE 05l31109 M&T Certificate of Deposit,31003911153400 6,779.61 33 2,259.87 4. C 11/28173 M&T Checking Account,18780202 17,269.78 50 8,634.89 5. B 01115104 M&T Certificate of Deposit,31003913025085 1,195.18 50 597.59 6. J 09/13/83 M&T Certificate of Deposit,31003914380850 1,001.03 50 500.52 7. I 09113/83 M&T Certificate of Deposit,31003914380842 1,001.03 50 500.42 8. H 09113/83 M&T Certificate of Deposit,31003914380834 1,001.03 50 500.42 9. G 09/13/83 M&T Certificate of Deposit,31003914380826 1,001.03 50 500.42 10 F 09113183 M&T Certificate of Deposit,31003914380818 1,001.03 50 500.42 TOTAL(Also enter on Line 6, Recapitulation) $ 112,281.37 If more space is needed, use additional sheets of paper of the same size. Page 2 - Schedule F, Continued ESTATE OF RITA H. BURTNER FILE NO. 21-11-0202 Surviving Joint Tenant(s) Name(s) Address Relationship to Decedent D. Georgann L. Beatty 4036 Leesway Circle Daughter Pensacola, FL 32504 E. Ann B. Travis 66 Rolling Drive Step-Daughter Carlisle, PA 17013 F. Michelle L. (Warren) Stills 3536 Edingham Court Granddaughter Orlando, FL 32812 G. Gina L. Ashton CMR 467 Box 3033 Granddaughter APO AE 09096 H. Lisa C. (Orlando) May 4549 Mentoria G. Granddaughter Pensacola, FL 32504 I. Tara M. (Kennedy) Orlando 8 Winford Place Granddaughter Columbia, SC 29229 J. Anthony L. Orlando 165 Belvedere Drive Grandson Birmingham,AL 35242 � � i W � H , � H N �--� � ^ (� � � � � � '� � 'Z� N � C/) � ^ O � ^ �,� W � � � � � � � ` ' � G=1 •3 F-� � W .3 S� � Q � � � O � C3 .� N ,.�°'°b. H rn H E-� rn f�' •rl (�' •r-I �/ n �n � .� i � .� r� �' '�+. � f� P� �j f� � x � x � � M � � � Q f-� � (Z • � P� � � � � � � • � � � � � � � COMMO EAL H OF PENNSYLVANIA � SS. CO2L92t� 0 -------�- ------- -- - -- -- -- -------- ----------- ' ___ r!__ RECORDED on this-_-------�..y.��'---------- ��of ---�'__'�-_'__-- - - _ _�!✓._.—c-�. �(�'. A. D. Y9 v__�'} in the Recorder's o,f,�'cce of the said County, in Deed Book ,' ; '� Vol. ---�--�---, I'a9e -•-----_=-`---"-=-----��-I _i _ _ Given under my hand anct the seal of the said ofJ'ice, the date above written. , ___._.��:ti...��, .��_�'__�___�________�_,�_, Recorder: • s �a.�v...�..�.,� �ry- �� Q MBTBa.��k 499 Mitchell Road,Millsboro,DE t9966 Adjustment Services Phone 888-502-4349 F ax (302)934-2955 February 23,2011 Re: Estate of Rita Burtner Social Security: 176-10-7187 Date of Death: Januarv 6, 2011 Dear Sir or Madam: Per your inquuy on February 15, 2011,please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1. Type ofAccount CheckingAccount Account Number- 18780202 Ownership(Numes of} Rita Burtne�� Sandra Orlando Raymond Burtner(POA) Opening Date 11/28/73 Balance on Date ofDeath $17,269J8 Accrued Interest $ .00 _.._._.......____..........................--_........_...____.....__....__.........._____ Total $17,269.78 2. Type ofAccount CheckingAccount Account Number 406236 Owner-slaip(Names o.f} Ann Travis Rita Burtner Raymond Burtner Opening Date 09/01/67 Balance on Date ofDeath $58,909.99 Accrued Interest � .46 --------_____..._.----------------------------------------- Tottrl $58,910.45 3. Type of�Iccount Certificate ofDeposit � Account Number 31003913025085 Ownership(Names o.f} RitaHBurtner _ George C Holland Opening Date 01/I S/04 Balance on Date ofDeath $1,171.97 Accrued Inte�•est $ 23.21 . ---- ---------_------------- --____._.....______..----. . __� _._._ Total $1,195.18 4. Type ofAccount Certificate ofDeposit Account Number- 31003911152400 Ownef ship(Names o� Ann B Ti avis Rita Burtner Raymond HBurtner Opening Date OS/31/09 Balance on Date ofDeath $6,779.61 Accrued Inte�est $ 30.01 ___..___...._...___......_...___.._._..___..___�_..__...__...._._............... Total $6,809.62 5. Type ofAccount Ce��ificate ofDeposit Account Number- 31003914380850 Ownership(Names o� Rita Bu�-tner Anthony L Orlando Opening Date 09/13/83 Bnlance on Date ofDeath $1,000.00 Accrued Interest $ 1.03 - ----- -------- ---------------__---__--------- Total $1,001.03 6. Type ofAccount Cer-tcficate ofDeposit Account Nurnber 31003914380842 Owrtership(Names of) Rita Burtner Tara MKennedy Opening Date 09/13/83 Bc�lance on Date ofDeath $1,000.00 Accrued Interest $ 1.03 _....____._------................__----------------.._---.._..._�_.__. Total $1,001.03 7. Type ofAccount Ce�7ificate ofDeposit Account Number 31003914380834 Ownership(Names of} Rita Bu��tner Lisa C Orlando Opening Date 09/13/83 Balance on Date ofDeath $1,000.00 Accrued Interest $ 1.03 Total $1,001.03 8. Type ofAccount Certificate ofDeposit Account Number 31003914380826 Ownership(Names of} Rita Burtner Gina L Aslzton Opening Date 09/13/83 Balance on Date ofDeath $1,000.00 Accrued Interest $ 1.03 Total $1,001.03 9. Type ofAccount Certificate ofDeposit Account Number 31003914380818 Ownersliip(Names o� Rita Burtner Michelle L Warren �pening Date 09/13/83 Balance on Date ofDeath $1,000.00 Accrued Interest $ 1.03 Total �I,OOI.03 For farther account information,closures and/or reimbursement of funds please call the Harrisburg Main Office at#'717-255-2070. We were unable to locate any safe deposit box for the above-mentioned decedent. Th;s letter does not include any acrnunts in which the deceased may ttave been Gsted as Power of Attorney,Custodian of Uniform Transfers, Representative Payee,or Trustee under a Written Agreement Sincerely, Tammy Spencer Adjustment Services REV-1510 EX+ (08-09) � pennsylvania SCHEDULE G � DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND INHERifANCE TAX REfURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Rita H. Burtner 21-1100202 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. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEfR RELATIONSH[P TO DKEDEN�AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE Of TRANSFER. ATfACH A COPY OF 7HE DffD FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. Allstate Select 2000 Annuity,GA0753325 151,891.43 100 151,891.43 TOTAL(Also enter on Line 7, Recapitulation) $ 151,891.43 If more space is needed,use additional sheets of paper of the same size. �e.'. -'�i. ,t�� ! ! ��'!v F��tate I S I N�viil!�::'�nce ContpanY '�� t�'eteQhcne: t•800-755..'i2:5 ��. PO Box 8601�1 Fsx: 1-tlH6-829-1�08 Dalias,1'X 75265•4191 February 4, 2011 GEOfiCaE CHALMERS HOI.I.ANb JR a . 4s�� v>: r � ,� �"''"?i""" 2594 OUNHAVEN GL�N !��"�'`,'�� ,#.��'�;��;�� SNELLVILLE GA 3U07$ HARQLD J05EPH BESHAW M&T SECURITI�S, INC. 1 W HIGH 3T CAALISLE PA 170t3•2951 {71�241•77$7 RI�: �riqinai Ailstate�Select 2000#GA07'S3325 Your New AIl8tate�,Sei6wt 2pp0 iiAC108K646C Dear George Chatmers Nalland Jr: Yalr ciaim has been processed. as yau requssted, we h3ve de�osited you�death benefit funds directly into your bank account. The tirst table represents the antire beneiit vafue under the original contract as of th�e dat� of settlement, as we►!as any transactions ti�ai rnay have occurred on 4hat daie. ie,I�k��a 3 �:'�"r�. 6 L,�Q.A�a{!'��> S ,�:, 9..,�t�;;�e t �,�+�k d '. ;'.� � �q"�:�'y .J r4..: �R' � . ,� -'t: �r y,{��y�� !c.i��,..f i `I d Fr �.��T <� P,.t".t'i N'�"'��4 n�Q�ry r.F.�e,i,7�' ^' .��M.�,' Y -`��'�;'$' : "�R �."+'�. ��, � ev.t�`',C*:•K �.�,7Sr�:��,�' >� i �:�Fi� Trsnsaciion Yransactior� Investmene Units tor this Transactian Tr�an t�ate Yype Alternative Transactian Unit Vs1ua Amount 02/04/11 Total Clairr� ALIC FlX�D ACCOURlT ONE YEAR N/A �3/A $-44,95091 02f0�1lh t To1al Claim ALIC FIXFD ACC�UNT Qf�E YEAR PJiA N,°A $-85,00��/ �2104J11 7ota! Claim AIIC FlX�O ACCOUN7 ��NE YEAR N/A N/A $->>,579� 02/O4J11 Total Cia�m AUC �1XED ACCOUNT ON� YEA�i N/A tJ/A $-30,359.70 Ts�o second table cenfi;rns the investment atismat+ves to which yaur portiar of the benefit valuo has bEen a�inr.;ated. -f�lease� revie�r the iriforrn�fion below. It yau have any qu�stions conceming these allocations; please caniact us at 1•8G0-�'55-5275. �N y' � y ,�J �N�r ��,`�F��, '!�r��: i . .. .r, n•.. ,r� „� .�� .� � t i�:.��s � ;� fF ��' 3 �;v �' _'��r x �� J, � �� ;�s''�F�'�w�u��e�� ,� aa� � '� 'P .�i ..i � �...+y .v;�6 ;��'.'�TM ir. "��i �r ti. »�. Transaction Transactian lnve�tment Unita for thia Transactinn Trsn�saction Date Type Alternative Tr�nsaction U�i4 Yalue Amount 021t}4�t 1 Transfer 7o A�IC FtXEa RCCOUNT ONE YEAR N/A N/A ��4,963b7 02/04/11 Transfer Ta ALIC F1XE0 ACCOUN7 ON� YEAR N!A N!A $21,667.13 02I04/11 Tra��sier To ALIC FIXED ACCOUNT ON� YEAR N!R N/A �3,859�'i U2/04/11 Transfer To AL1C FiXEp ACCOUN'�ONE YEAR N/A N/A �iU,119� Your Totai Annuity Vaiue as of 42/04/11 $0.00 y'F� " w;��, � o��oasE.rva� � � �� W�v4 REV-1511 EX+ (08-13) ' � pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FU N E RAL EXP E N SES AN D INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Rita H. Burtner 21-11-0202 Decedent's debts must be reported on Schedule i. ITEM NUMBER DESCRIPTION AMOUNT A, FUNERAL EXPENSES: 1� Bronze Memorial 1,550.00 2. Burial 8,250.00 3. Hospitality,etc. 6,902.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 8,934.00 Name(s)of Personal Representative(s) G20f�e C. H0118f1d, Jr. Street Address 2594 Dunhaven Gien city Snellville _ _ state GA ZIP 30078 Year(s)Commission Paid: 2. Attorney Fees: 9,684.00 3• Family Exemption: (If decedenYs address is not the same as claimant's,attach explanation.) 3,500.00 Claimant Raymond H. Burtner street address 66 Rolling Drive City Carlisle _.state_PA ZIP 17013 Relationship of Claimant to Decedent SpOUSe 4• Probate Fees: 153.50 5. Accountant Fees: 0.00 6. Tax Return Preparer Fees: 0.00 �• Appraisal Fee for Personal Property 225.00 s. Advertising 375.00 s. Reserve 1,500.00 TOTAL(Also enter on Line 9, Recapitulation) $ 41,073.50 If more space is needed,use additional sheets of paper of the same size. RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 2/14/2011 Cumberland County - Register Of Wills Receipt Time : 15 : 32 : 38 One Courthouse Square Receipt No. : 1064430 Carlisle, PA 17613 BURTNER RITA H Estate File No. : 2011-00202 Paid By Remarks : GEORGE HOLLAND CJ ------------------------ Receipt Distribution ------------------______ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 20 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 8 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 1038 71 . 50 Total Received. . . . . . . . . �71 . 50 ��b. 10. 2012� 4: 24PM Gwi�nett OB/GYN No. 8031 P. 1/1 ; �''•'�, a--��t/�c L,� • � . � � . 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(�90� . � . �..�. ...h .u.<� - . . ..�.,,�.... ......_ . . ... . .._ . ��- ,t ....... ..._.. - .� -----^ � . - ; �� ... ..... . ... . . . ..... . . .... . ... .... ._.... .. . . . .. ......_........._.. ....... .._..,..._ . ..... - --.. _. _.._ .._ .. _. .. :;. .. . ; . ._ ........ .... . .. .. . . . ..... . . . .. ... :. ... :.. . .. .....__.._...._.._.. .. ....----.--- . ......_._._ _ � �� .�,�. Nov. 29. 2Q11 5:41PM Gwinneff �B/GYN No. 9989 P. 3 SALES CONTRACT Office of Cafihol ic Cemeteries DA7E °�, -� \ �� ( N° 2 6 5 7 Diocese of Harrisburg � f� PQ Box �651 CEMETERI��-S� �`��"�-' CEM�TERY#�_ Harrisburg, Pennsylvania 17105 Phone (717) 657-4804 A/N �. P/N A�� —___ NAME �o �e � t��'^� PHO�hI� (�'�1� q`l�. -`.a�' `�? ADDRESS �S "1'� C�U�.' �'�.,..a�'`' ��t" CITY S'�� v�� S7ATE �� ZIP CODE��'$ . _�_ Interment Spa.Ces . . . . . . . C� $� 1, Price. . . . . . . . . . . . . . . . � J.� G � z emorials. . . . . C� ��`$ `��5�' 2. Down`PayPnent�. . . . . _ _ ` j J`� � 6ron e M 5ize��1 �..�.) ��..�. �� --,;..a �---� Granite Foundation. . . . �1j`�```�_ $�_ 3, Unpaid Bala.nce(1-2) . . . . . C� � C...:��• �� 4. Finance Char e. . . . . . . . . h� � �"`� Burial Vautts, . . .•. . . . . '.`�'�'� $� g Crypt Spaces . . . . . . . . . . C� $ � 5. Deferred Payment (3+4) . . y � Niche S aces . . . . . . . . . . � . $� 6. Total Price (1+4) . . . . . . . . L��'�r�� •i P Other $ 7. Approx. Monthiy Payment Section � Lot��G ave(s)___L— 8. Number of Payments . . . . ,..,_.w Building Side� � � Crypt.Qr Niche�� . 9. �irstMonthly Payment Due Selection must be made within 3(1 day;or cemetery Will make cho�ce. 10. Af1ftU3l PefCerltdge Rdt2 Tiie payment is due o�the date stated above and the remaining payments on the same day of each succeeding month. Buyer may prepay in advance the full amaunt due without penalty and will be entitled to a proportiondte refund of tne unearned finance charge. Upon default in the payment of any installment due hereunder fo�a penod in excess of one hundred twenty(�20) days, Seller may, at its vption,void this agreement and retain all payments made by Buyer as liquidated damages. euyer hereby acknowledges receipt of an exact executed copy of this agreement at the time of execution herecf. Before any buriai is permitted in this lot, or any memorial placed o►►�thiS fot,the price•of the grave and memorial must be paid in full. � The PUrChdSer(5) ag�ee(s}to abide by all rules and regulations of.�the cemetery now In forCe as well as any rules and regulations which may hereafter be adopted. Said rules and regulations ma,y be seen upon request at the Seller's office. Upon fulfillment of the conditions�of this agreement and receipt of all the above destribed payments, Seller agrees and binds itself to convey to the Buyer, by its cemetery easement, for interment purposes only, the above mentioned number�f sites, . .. , . � . . . . YOU,THE PURCHASER,.MAY"CANCEL THI$7RANSACTION 9Y WRITTEN NOTICE AT ANY TIME PRIOR TO MIpN�GHT OF T HIRD B INESS R THE.DATE OF TH1S TRANSACTIO � BY �� / ��Yi sC.�. (Authorized Representative) � (Purthaser's Signature) NO710E' See other side for additional infprmation. (Co-purchaser's Signature) REV-1512 EX+ (12-12) � pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES &LIENS RESIDENT DECEDENT ESTATE OF PILE NUMBER Rita H. Burtner 21-11-0202 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� Humer and Daniels Law Office,Personai Affairs Instruments 250.00 2. Sales Commission,Sale of Mobile Home 1,500.00 3. Insurance Premiums 629.00 4. Lot Rent 3,438.94 5. Repairs 161.05 6. Registration 120.49 7. Utilities 921.07 8. Maintenance 514.25 9. Management and Cleaning 857.38 TOTAL(Also enter on Line 10, Recapitulation) $ 8,392.18 If more space is needed,insert additional sheets of the same size.