HomeMy WebLinkAbout02-0941
COMMONWEALTH Of PENNSYLVANIA
DEPARTMENT Of REVENUE
BUREAU OF lNDlVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
INHERITANCE AND ESTAT
OFFICIAL RECEIPT
RECEIVED FROM:
BUTLER EDWARD L
58 AUSTIN CT
MURRAY, KY 42071
__Uh__ fuld
ESTATE INFORMATION: SSN: 000-00-0000
FILE NUMBER: 2102-0941
DECEDENT NAME: BUTLER REBECCA C
DATE OF PAYMENT: 10/21/2002
POSTMARK DATE: 10/15/2002
COUNTY: CUMBERLAND
DATE OF DEATH: 08/21/2002
TOTAL AMOUNT P
REMARKS: EDWARD BUTLER
CHECK# 3152
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
REV-1162 EX(11-9
E TAX
NO. CD 00175..:
ACN
SSESSMENT AMOUNT
CONTROL
NUMBER
h_ __.
02142972 I $20.22
I
I
I
I
I
I
I
I
AID: $20.22
MARY C. LEWIS
REGISTER OF WILLS
L
I
A
"
f .."
." :?:
... 0-
~~~~
\
. ~
" -
. ~
..~~
ls~
~H
~~d
~
~
;''11
'f]
h_
.::i
~~
'fJ ~
~~
-
:r-
q-
(j
-
-
.
==
-
I'"
N
(I)
t'"
"
,11}
.....
o
I"
....
COIDIDNIfEAL TH OF PEMrlSVLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 250601
HARRISBURG, PA 17128-0601
*'
ZNFORMATZON NOTZCE
AND
TAXPAYER RESPONSE
FILE NO. 21-0 '141
ACN 021429
DATE 10-07- 02
UY-154SEX AFP "'-01>
TYPE OF
ll"
EST. OF REBECCA C BUTLER
S.S. NO. 224-30-6905
DATE OF DEATH 08-21-2002
" 2 j ;,i Cll,NTY CUMBERLAND
REMIT PAYMENT AND FORMS T
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
EDWARD
58 AUSTIN
MURRAY
L BUTLER
CT ,
KY 42071 C\i'
FIRST CITIZENS NATIONAL BANK has providad the DlilIpartHnt with the informltion listed below which has bun used in
calculating the potential tax due. Their records inclicate that at the death of the above decedent, you were II joint ottner/tHInsfic
this account. If you ful this infor.atian is incorrect, please obtain written corraction frail the financial institution, attach
to this for. ancl return it to the above address. This account is taxable in accordance with the Inherit8l'lCll Tax Laws of the COlI
of Pennsylvania. Questions .ay be answered by calling (717) 787-8327.
COMPLET! PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 0100295507 Dat. 10-02-1989
Est.bl1shtld
Account Balance
Percent Taxable
ADount Subject to
Tax Rate
Potential Tax Due
To insure proper credit to your account,
(2) copies of this notice IIUst accollpany y
payeent to the Register of Wills. Make ch
payable to: "Register of WillS, Agent-.
x
Tax
NOTE: If tax pay.ants are .ade within thr
(3) IIOnths of ac nt"s date of death
YOU _y deduct 5% d. ount of the tax du
Any inheritanc e will beco.e delinq
nine (9) .ooths after the date of death.
x
[CHECK ]
ONE
BLOCK
ONLY
A. ~ above Inforntion ancI 'tax due is correct.
1. You.ay choose to r..it pay.ent to the Register of Wills with two copies of this notice to ob
a discount or avoid interest, Dr you lIBY check box -A- Bnd return this notice to the Register
Wills and an official assess.ent will bs issued by tha PA Departeent of Revenue.
B. D The above asset has bun Dr will be reported and tax paid with the Pennsylvania Inheritance Tax re n
to be filed by the decedBnt"s representative.
C. D The above infoMlEltlon is incorrect and/or debts ancl daductions weNl paid by you.
You .ust co.plete PART ~ and/or PART ~ below.
COUNT
SAVINGS
CHECKING
TRUST
CERTIF.
y of
opy
aalth
~ c..I,Z.'}
~
tP~lj'i
z..l.2;,liz
nt./ II -V
l'
PART
~
TAX RETURN - COMPUTATION
LINE 1. Oat. Established
2. Account Balance
3. Percent Taxable
4. A.ount Subject to Tax
5. Dabts and Oaductions
6. A.ount Taxable
7. Tax Rat.
8. Tax Du.
If you IndIcat. a different tax rate, pleas. state your
relationship to acedent;
OF
1
2
3
4
5
6
7
8
TAX ON JOINT/TRUST ACCOUNTS
x
x
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT
TOTAL (Enter on LIne 5 of Tax Computation)
facts I
.
ID
HOME
WORK
corrM:t .-,d
FJ- 9,s--/O
\.. BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG~ PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEKENT. ALLOIIANCE OR DISALLOIIANCE
OF OEDUCTION" <__AND ASSESSKENT OF TAX ON
JOINTLr HOLD OR TRUST ASSETS
REW-lS41EX 'F II-In
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
12-10.-20.0.2
BUTLER
0.8-21-20.0.2
21 0.2-0.941
CUMBERLAND
224-30.-690.5
0.2142972
AltOunt R...i tted
C
EDWARD
58 AUSTIN
MURRAY
'l.
L BUTLER
CT
KY 420.71
REBECC
MAKE CHECK PAYABLE AND REMIT PAYMENT 0:
REGISTER o,F WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 170.13
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ....
Rifv=is4-i-EX--AFi>-foi-:ozj------------------------------------------------------------------------------ -----
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 12-10.-20.0.
ESTATE OF BUTLER
REBECCA C DATE OF DEATH 0.8-21-20.02
COUNTY
CUMBER LA 0.
S.S/D.C. NO. 224-30.-690.5
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: FIRST CITIZENS NATIONAL BANK ACCOUNT NO.
FILE NO. 21 02-0.941
TAX RETURN WAS:
ACN
0.2142 2
010.0.29550.7
TYPE OF ACCOUNT: () SAVINGS (lO CHECKING ( ) TRUST ( ) TIME CERTIFICATE
DATE ESTABLISHED 10.-0.2-1989
Account Balance
Percent Taxable X
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate X
Tax Due
2,836.61
0..166
472.78
.0.0.
472.78
.45
21. 28
TAX CREDITS:
PAYMENT
DATE
10.-15-20.0.2
RECEIPT
NUMBER
CD 0. 0. 1754
DISCOUNT (+)
INTEREST/PEN PAID (-)
1.0.6
NOTE: TO INSURE PROPER CREDIT
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NO CE
WITH YOUR TAX PAYMENT TO HE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CH K
OR MONEY ORDER PAYABLE T
"REGISTER OF WILLS, AGEN n
AMOUNT PAID
20..22
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
. IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
( IF TOTAL DUE IS LESS THAN $1, NO PAYNENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CRJ, YOU NAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FDRN FOR INSTRUCTIONS. J
21.2
.0.
.0.
.0.
IN THE MATTER
OF THE ESTATE OF
:IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
REBECCA C. BUTLER,
Deceased.
:FlLE NO. 21-02-941
PETITION FOR SETTLEMENT OF SMALL ESTATE
TO THE HONORABLE, THE JUDGE OF SAID COURT:
The Petition of the undersigned respectfully represents:
I. The name, address and relationship of your petitioner to the above decedent are:
Name:
Address:
Relationship:
Thomas H. Butler
332 Blacksmith Road, Camp Hill, P A
Son
17011
2. The above decedent died on August 21,2002 at 7000 Walnut Bottom Drive,
Carlisle, Cumberland County, Pennsylvania 17013.
3. Said decedent died Testate, leaving a Will dated the 26th day of August, 1998, a
copy of which is hereto attached, in which the Executor named therein is Leon E. Butler. Leon
E. Butler predeceased the decedent herein on 03/30/1999. The successor Executor named in
said Will is Thomas H. Butler.
4.
estate are:
The names, relationships and interests of all parties beneficially interested in the
Name
Relationshio
Interest
Sui Juris
Thomas H. Butler
332 Blacksmith Road
Camp Hill, PA 17011
Son
50%
Residuary
Yes
Edward L. Butler
58 Austin Court
Murray, KY 42071
Son
50%
Residuary
Yes
5. No person is entitled to or claims the family exemption of$3,500.00 by virtue of
being a member of the same household as the decedent.
6. Said decedent died owning property (exclusive of real estate and of wages, salary,
pension or vacation benefits) of a gross value not exceeding $25,000.00, which is itemized as
follows:
Item
Amount
General Electric Capital Assurance
- final payment for long term care insurance
1,500.00
American Family Life Assurance Co
- return of unused premium
195.33
Total:
$1,695.33
7. An itemized statement of all claims against the estate is as follows:
(a) Claims heretofore paid by Thomas H. Butler to the following:
Claimant
Nature
Amount
Cumberland Goodwill Fire Co.
102 W. Ridge Street
PO Box 496
Carlisle, P A 17013
Ambulance
23.71
Forest Park Health Center
700 Walnut Bottom Road
Carlisle, PA 17013-3699
Services
2.556.60
Total: $2,580.31
(b) Claims remaining unpaid:
Claimant
Nature
Amount
Commonwealth of Pennsylvania
Department of Public Welfare
P.O. Box 8486
Harrisburg, P A 17105-8486
Claim for
Repayment of
Medical Assistance
8. Petitioner will cause to be paid all Pennsylvania inheritance taxes due on all
property to be awarded. The Pennsylvania Inheritance Tax Return was filed simultaneously
herewith in the Register of Wills Office.
9. All parties beneficially interested in the estate other than the petitioner have
signed the joinder in this petition which is hereto attached.
WHEREFORE, your Petitioner prays that the above property of the decedent be
distributed under Section 3102 of the PEF Code as follows:
(a) In reimbursement of claims against the estate heretofore paid:
Name
Amount
Thomas Butler
1,695.33
Total:
$1.695.33
(b) For payment of claims against the estate remaining unpaid:
Name
Amount
Commonwealth of Pennsylvania
Department of Public Welfare
(c)
the estate.
There are no funds remaining for distribution in accordance with the interests in
GATES, HALBRUNER & HATCH, P.C.
BY ~~ff/.
Cr :i\. Hatch, Esq.
1013 Mumma Road, Suite 100
Lemoyne, P A 17043
(71 7)731-9600
"7J;:..- j( ~
Thomas H. Butler, Petitioner
DATED:"h-c~\\r:.fe.. (0 .2002
VERIFICATION
~
<0 day of \) ~C'e~ \],,!, It . 2002, the foregoing Petitioner hereby verifies,
This
subject to the penalties of 18 Pa.C.s. 4904 (relating to unsworn falsification to authorities), that
the facts set forth in the foregoing Petition which are within his knowledge are true, and as to the
facts based on information received, after diligent inquiry, he believes them to be true.
7L~4
Thomas H. Butler, Petitioner
JOINDER
I, the undersigned, being the sole party, other than the Petitioner, beneficially interested in
the estate of the foregoing decedent, do hereby certify that I have read the forgoing Petition and
join in the prayer thereof.
dk., /f!j 2a72-
Dated
~/~
Edward 1. Butler
ilIast 3lntill aub Qf~stctm~ut
OF
REBECCA C. BUTLER
KNOW ALL MEN BY THESE PRESENTS, that I, REBECCA C. BUTLER, of
Putnam Township, Tioga county, Pennsylvania, do make, publish and
declare this to be my Last Will and Testament, hereby revoking any
and all wills and Codicils by me at any time heretofore made.
ITEM 1: I direct that all of my just debts and funeral
expenses be paid out of my estate as soon after my death as may be
practicable.
ITEM 2: I give, devise and bequeath my entire estate, real,
personal and mixed, wheresoever situate, to my beloved husband,
Leon E. Butler, absolutely and forever.
ITEM 3: In the event that my husband, Leon E. Butler,
predeceases me or dies on or before the thirtieth day following my
death, I give, devise and bequeath the residue of my estate of
every nature and wherever situate to my issue, per stirpes, living
on the thirty-first day following my death.
ITEM 4: I appoint First Citizens National Bank, of
Mansfield, Pennsylvania, guardian of any property which passes,
either under this Will or otherwise, to a minor and with respect
to which I am authorized to appoint a guardian and have not
otherwise specifically done so, provided that this appointment of
(Page 1 of 4 pages)
~c.. ~
RCB
a guardian shall not supersede the right of any fiduciary in its
discretion to distribute a share where possible to the minor or to
another for the minor's benefit. Such guardian shall have the
power to use principal as well as income from time to time for the
minor's support and education (including college education, both
graduate and undergraduatel without regard to his or her parent's
ability to provide for such support and education, or to make
payment for these purposes, without further responsibility, to the
minor or to the minor's parent or to any person taking care of the
minor.
ITEM 5: I nominate, constitute and appoint my husband, Leon
E. Butler, as Executor of this, my Last will and Testament. In
the event that my husband, Leon E. Butler, predeceases me or shall
be unable to qualify as Executor for any reason whatsoever, I
nominate, constitute and appoint my son, Thomas H. Butler, as
Executor of this, my Last will and Testament. In the event that
both my husband, Leon C. Butler, and son, Thomas H. Butler,
predecease me or shall be unable to qualify as Executors for any
reason whatsoever, I nominate, constitute and appoint my son,
Edward L. Butler, as Executor of this, my Last Will and Testament.
ITEM 6: I direct that my Executors named herein shall not be
required to give bond for the faithful performance of their duties
in this or any other jurisdiction.
IN WITNESS WHEREOF, I, REBECCA C. BUTLER, the Testatrix, have
hereunto set my hand and seal to this, my Last Will and Testament,
(Page 2 of 4 Pages)
~ fJ.~.
~
consisting of four (4) typewritten pages, this
~;r<~ ,1998.
<).6 day of
&?~ e. (g~
(SEAL)
REBECCA C. BUTLER
Signed, sealed, published and declared by REBECCA C. BUTLER,
the Testatrix, as and for her Last will and Testament, in the
pres~nce of us, who in her presence, at her request, and in the
presence of each other, have hereunto subscribed our names as
attesting witnesses.
~u~ e
~A.
residing
W~<:;?""(.~lt
at '"'80 l ~..:'I=i I-M J ^ t:l,,-n
~~.G-
II
II
residing at
(Page 3 of 4 pages)
Pr.8.
RC'B'""
ACKNOWLEDGEMENT AND AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA:
ss:
COUNTY OF TIOGA:
~ ~{lIJ~ and
, the Testatr~x in and the witnesses
to the Will the attached or foregoing instrument, who have signed
the instru ent, having been qualified according to law, do depose
and say:
(a) that I, the Testatrix, do hereby aCknowledge that I
signed the instrument as my Will, that I signed it willingly and
as my free and voluntary act for the purposes therein expressed;
and
(b) that we, the witnesses were present and saw the Testatrix
sign the instrument as her Will, that she signed it willingly and
executed it as her free and voluntary act for the purposes therein
expressed; that each of us in the hearing and sight of the
Testatrix signed the Will as a witness and that to the best of my
knowledge the Testatrix was at that time 18 or more years of age,
of sound mind and under no constraint or undue influence.
lftkAA-O-. C. '?JA~
Rebecca C. Butler, Testatrix
(Iff' qMrh ~ Lv:.
witness
~x,~
witnes
Sworn or affirmed
the Testatrix and the
'~r-J
to, subscribed and acknowledged
aforementioned witnesses this
, 1998.
before me by
.;1.6 day of
AQlliJ'AL '7rz.~ :!a))/LP/J
- Notary Public
NoIertal Sell
......""~... Fanwr; ElbIlc
~.........r..p~ 'IlogaO
..,. Com".' II III Eiqllrw ~ 30, 1
.. ""~;Mna AB1 T [..,01.....
(Page 4 of 4 Pages)
,
FOREST PARK HEALTH CENTER
700 WALNUT BOTTOM ROAD
CARLISLE PA 17013.3699
ACCOUNTS RECEIVABLE STA ::MENT
Statement Date: 08131120C
,<
,
Balance Due: 2,556.60
REBECCA BUTLER
clo THOMAS H BUTLER
332 BLACKSMITH ROAD
CAMP HILL PA 17011
l'ilj>li-,,,'j,.,p~te }",';i,'5;ill;'ii;~;s.'e"""IJ"~(lii~'I:E:"'''';'':!l;t~1liAapavsJUni!'!J];'';;'.'"
08101/2002 - 08101/2002 Patient Uability
0810212002 - 0812012002 Patient Liability
0811312002 - 08113/2002 transfer credit
08113/2002 - 08113/2002 transfer credit
08113/2002 - 0811312002 Payment from statement 07102
Account Number: 21913
Balance Forward: 3, 8.76
C""'lIa'~,~;f'i!ll!!!l!QlJCreditl..}, iI.~ ~_"""J
127,83 3 86.59
2,428.77 5, 15.36
3,768.80 1, 6.56
(3,766.60) 5, 5.36
3,058.76 2, 6.60
TOTAL:
2.556.60
3,058.76
2, 6.60
Payment Due Upon Receipt
Please return one copy of the statement with your payment and retain one copy for your records. This is the oniy copy u will
receive.
Thank you.
FOREST PARK HEALTH CENTER: REBECCA BUTLER 21913.
, ,
.'1 i'~;L;
':j,';:>'
., (-\!~:: l.
C'
1-' ;"j :! n,?
.u;\,'
,...t.):::.
i ~~. '___' ~ .~" _,_
,:',::.TL::"JT ;'~,<i'.'J:.=
;':'!J'f"j
j':",C',', , ~~,
r~: !.
i:'-':',i..'.l._i:':l
~ i
;:-;SL;,::'-u'jC::::
t";f~D I t..~:(":r "_. ")
__i-.:",_ ,_.1::._;::;
-,.'-, >'
),~> :,.'f..
O,:.;~ ,
-: iJIJ~~_,~ ~.
~:;~.Li..~,~
jnF;:jl'!i'
,-' ::'~ l'; I:::.
i .~~
j i..i"f
., r',
'..r..,'\
;'l
(:") t-Vf.'il.l\IU"j ET!TT !.:..\!'-'; F:.u
j-:;~:--<~,:;.
L:;;~':lr:.:L. I ~JL. ....
70 :~.
;:;)
;=0;=,
r;,.-,l'~~~ ,:>:j;-
rl\<.'i \....c)
..'_::'';"
....'-.;",..
:'[;;('1"'" ,-:,'5
,,",
,
f~'.:r : '\ c: (:;; / F i ;'"
'/()O L\iPi:.._j\!:....1"1
i,~rli:~L. I ~3j
!:,"('d!\; i.;fUL'i
.,',-,
'_ ,'. i
L.L
f31.JT
.""";
I __.~; .
i'-:L.
'" ~":',~ C..:J'''' i-'"
__)0 Ii'~--'-
c,.,-:::;:.;:-;;,-:".",
".'U;".I'J: .,
--'-~'------'. -- --._,-- .--- ---'''---- ------
Hl.t Ei.!EROE:l~[:Y ([.._.0 !..;~[U
--'_._-_.~----
,
.'l. .(}
"f i-J'f(:!... C,!,,,!-- ,r:,\'L,:'!-,:-"- i"!"!.r ~-:::
:; ~-- - ! ,
I
--____--L_~____~~__ _'__ __
-~---,--_.-
_.__'______n ___.__ _____.__.. _____,
0~::;C:;:;;;.',:~.,;: ::':j-
,'~ct.:i-:i:--' I
~~rT1 :::~l~r::7TTC~:::-i--:~n L:;~.iTn CI~:j
"iYLD
-------T():? ~:~.;'----'-'-..
/', ;"j ..' , ..:~ / "-: j
~:.'~:
:) .l
:~'!r:.:~\J! t: ~!.i' _~ (.j':::;,,:: 'i qr'!. ~,:'::ijt~ (:'Cl.!Li.::;:
~- u r : ~.! I:;;' .-' r"~: :' ,\jT ::;.; :' if J. ,_ '. :,'~ L ~~..
~--~._---._----._-----
___-..1__ ______
i:Ji....cr-:,S':'=: .-::';:'-1
':"..' ()(:'
',J_ '.'
!o',
.:~[
"":":;i", "i
J.
" -,.'.::
./""'
;---:f~P
I!'
,--....."-.,
-.,';
':~' '!' i:::
~:- ..' '...' ..
-,
~;
,L.::::,"'-.,
ri~:--,,:~,' ____
--- ---- ----'----"-,--_._-- ---
~f~
~~
~
--, --, ---'--"--
Cj Cj >-i ~'tIf~()()O'" .~ (j ~ [ r g 1'>1 (j ! i.
~ J!~~ Ig~~ ~~
~ ~Vl >-iJ!, ",[0 >-i
C') ~ ~ ~ m ~~ '" $;l !)! t::1 0 ~ >-i ~~()e: i! ~ ~ ~ :u ~ '8:
~ 0 OJ! <"l en "'f~o. ~ 0 o ~~S:i~~ ~ ce. g
"'l ~ I:~ e-~ Z' ~ en ':0 f ~ "r! tI1 a .
[~ ~ ;;~.", i oijo"-'
f: IX! E ~ .g. < i a 0 ~ II Vl :::I. ~
E;.,.:J>~ Bo Il~CO" a~~ ~ ~ I. i l!!.tJj-
Cj CO" '>108-
>- < -' c. g '0 gl i ~ Ii;s OoOQ
~ ~ 0 0:....9
.. o "'l ~ . ~ <::< B ~ ~. OQ:9> .. f} Q ;S ~ . VJ 9 B
l:I ~E ~~1' fJQ @C>~ S-VlQ Vl '" ...
>- a 3. .... f/l> ... ~ .. >- ~ M 'tI ~
+ Vl - 00 r ~+~ ~ ~
~ + ~ l:u
Q Q .. C') ~~~ +-~ gj;j ~A~ ~ ~ ~
0
t::I ll~ ,,[ 1 ~u r fJ Ul 8. 8 ~.
>- ~.
+ 0<:: 0 ~ t:l
t= o..j if . O<l
+ '" ;s ~!~lI.1 ~ r.
'" <"l ~
\I ~
_' ~ " " " III III III III !il
'"
III 11I11I III r:p . ~l;~~1 III
~~m~~~~~o ~
'. ..0' . ('i'". . fil
...r:lt-~:~' :".J. . M
r~~ITirWme ~'"":! >-l '>I >-< .., Q 'tI
....0 0 ~~ ~ a
fI)'"":! >-l
~t I. hlf~.ro ~~ ~ ~
~ Vl ~ ~
..1 ~ t ~,.(' Ii. t~ i i ~ ~ 'tI
I ~
5 ~~r t~l- ~ll >~ 0 o~ ~
~ :\JilfBI irli. wi! 8 ~~ a m~
l? ~I IJn ~! i 'i I ~ · ~ ~~ 0 @
z
(') U) ~o n en ~
g ':~ . [.9:f{t'ii ~ ~ s j tl1 lttt"1 PI>
~ 1 [I.tfl.l !/'~tQ~ ~ o~ t::l ~ ~
~ i~llf.l.:lilJj~ '>1:5 ~ ~
. tt~ihi ~.ll.> ~ ~~~; ~ ~ >-i
en 0
. -l t If E.-I C') V)~ '"
00 [il.~'~/l[f~ t::l
.... h
'" r; S' i R t ; f. 1 a I t ~ .., '"
.... '"
,I;> ~ II & :! " If 0
o B'g,o.Qot~~tt. f~ 2
1I th.: J" fI)
i ii!fl4tt[ ~ en
If sJ :. 'll
~ ~ ~ Cj~f~fiw!f!f~ ~~~..~~~ ~1~lrl gW~
g. fl >-l !t ~ ~ 0 0 0 0 ~ ~ ~ ~ ~ g 1[ ~ ~. :. '" '" ;.
8: ~ -g: h ~ F:; ~ ~ i i ::;; :;; ~ ~ l;! ~ !l~ "," g. ~ ~ ~ > ~ ~ ~
g R g ~ ri ~ r"" E. s. ~ ~ it ,,~~ ~ 51 IQ ~ ..., a. ~ & ~
~ "-'!l ff ~ ~ ~ o. c. .. &l ~?<! "<j ~ '"d ~ ::r~'
fS Q1 ,-. cs :5 l! a ~ ~ g. ~ 0 ..,). g t::l ~ g '"
~. g!:l: () . ... .... PI' PI' :::I d~! ~ it a'''' 0
e: . e!. ~ M f/l> f/l> U) lJl g, o~iP d~' ...,
b:P fi ~ 8 U) en ~ ~ tI1 Cl" I: 8 tj. g J:>
a. r;--g. ~ ~ ~ s"5'~' '_.I~~~~ ~:: c 1
B ",,< !l S' S' '"' '"' i:; ~ '-l '"'...
~ '" c;i e!.'"''"''>I$ ~~~ '" ~'
.~ i M s:~[~ l ~~~~1~ ~~. ~~
f..JS' a !P 0 l!!.~ I til~eo.15
\ 0 ~ ... l!l.::r '" ~ z .. ~ f/l> ii'
- 1\ "-' ~~ g. If ~ ~ !:l ?< 1:1 ~
J) fIl I f. ~'l. ~~ ~ U~ ~ ~
(l;!~~ ~
."" "" '"",A..: """"''''''' ~Igp~...~ ~
~ ~ ~ ~~~ ~ ~ ~ ~~ ~~ . ~ I.
~g~ U)
SoE~ ~ > ~ ~
~.. to! ... ~ ~ ~
~~~ ~[ Q~~~
~i~ ~g.~Ir'l~~
~g~ Q~13 ~~8~
[;l€jg ~~ ~ W C Q ~
i~~ e ~ : ~ ~ ~ J ~.
~s:~ F CI ~ va 'tI ~
~2~ 8)2ip:~~;~
~~t:10=g'O;~jj
~~~;; ~~~~~~
~~ ~~fr~~~~
~-< ... 0> " ;;J
oolil Ulg ~~J,.
Ill"':;! M. . ~ w
~ ~ ~~ 8~~
. ~ Q 0
rn
Hl.)5.11~: REV, 8/88
{FEE FOR T~IiS
Cf'1c-lc-,CAT[ ~,2Q()
WARNING: IT IS ILLEGAL TO ALTER THIS COPY OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH VITAL RECORDS
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
CERT. NO. T 5 0 2 7 7 7 2
\\llll'(~(l"'otp~
l~Y .~.F'~
"~~7~ IOU. ''-?'"
;"~~"...~.*'-
I[~/ ~ '\~~
~. -, :..
~Wi ';,.,:b.~
.. ".' .' , ' ~
~~~, ,___";;;':_,.r\'*lJ
,<:;,,, /~,,;;,//
~....,,-:.t.9hl- -----,ii\,~ll~,fl
--'~"./"EN1 \\\'I,.,IV
~~f/ff#"",jll
22
e;'t;flc"I',,~ 7'
'"
21-02-941
fl;~,.,;;;;-------~._.
Sex Social Secunty No ;);;2 V - ~ - h 9a"l Date of Death ~.L
Date of Birth .Lt...c,,-J.J; /9/1 . Birthplace ('};-'0~-"'7?/l.." ;:1.'___'___"__
Place of Death 7aJ.o lUafh-w*.~ /4 (5~.lh.nd . .~... Pen
Race__~_~~:::~ation .:t Ll J,~o,", __ Armed F;'c:~~:Ye's'or~~a
Marital Status __LJ.__ ~~~I~ndge~t~sdress3f~ ~ a7~ .....
'"'om,""'_ d4,~) 6<77'6" ""om' D"eo'" If::(j,o fJ:J:.~).---
~~:~af~~t~~~~~~e~t4<~41n#'UA2..'L'r-!l:/-5/sV ~/L-yJt:< J/J - ; _ /19..iJ
- I Ir erval Betwe
Part L Immediate Cause Onset and De
A ~1/ P ~__ ._... _ 2'.L'J
I
I
YlY_aJlia
(a)
~oI + ~J.I~
(b)____
(cI
(d)__
Part IL Other Significant Conditions
I
___,___L_
Manner of Death
Natural Ct---"'Homiclde ']
Accident Pending Investigation ']
Describe how injury occurred:
Suicide
I
!
Could not be Determined
']
Name and Title of Certfier . In;( t{, \ -I ~~4'7a// }1j /0. .
Address_-1f2cJ.J ,if/? ::J:L-.J~~ /-~ /7.,2 st )
(MOJ'DO Caron ,MEI
This IS to certify that the information here given is correctly copied from an or;glnal certificate
of death duly filed with me as Local Registrar. The original certificate will be forwa.ded to the
S,"" ,;", "'"0'" D";c, 'oc ",mo",", ,,'co, ~~1-~d.- '"
~f;a;;o/'F2a~ '''''ooc,,, /
,
~i?2~~
" '" s "".'1
,... 0' I-"~
~. (') (I) tp
mOrl;rtO
....."..... '" .
(';I rl f'I 'rl;
.. rt ~ r'
;7(>.0'"
1"00 H'l ~
\V~g:>:';
'" " I-"
,.... ::I.....
-.J.CfJrt~
O'p<..od. {f.I
,...."
,-"",n
1 " 0
,-"",,,
'-" "
a> "
-.1 ;7
o
"
'"
'"
l...
'2
.,
j;~
;9-
a'"
:<:,::
~c
.,::
1l~
m)>
ZJ3
Zo
~)>
-<9
~~
:;~
~m
...,~
00
t,o
-- ---
~-~
~~
~---""
-
...l
Cl
I<'
I<'
I<'
.s::
Cl
Cl
Cl
Cl
Cl
-
-
-
-
-
== --
- -
.s::S~
cs- --
Cl
-.l
-
l>'
...l
'" -
-.l
""'III
c;')
~\
~\
~
~
~~
C
'2.. '?,
;~
\)\
~\<;?,
~~
:f
o;e
~
...I
)
~
REV-15O(1.EX(6-DO)
OFFICIAL USE ONLY
6
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
/ 7- ("';.... - Ie)
/5-
ALE NUMBER
~l 20~ __~~l
COlJ'JTY CODE YEAR NUMBER
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
~ Butler, Rebecca C.
~ ~ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
~ 08/21/2002 12/28/1911
~ (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
224-30-6905
THIS RETURN MUST BE RLEC IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
w
,...
llC::!(I')
"a:><
w""
,,00
"a:....
...,
:1l
001. Original Return
00 4. Limited Estate
[X] 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
!;:
w
C
Z
o
ll;
~
8
THIS &"(;"~"'MUST BE C~~tiD.llI..l COFi_o..olENCE'Atm ~TAX
NAME OOMPLETE MAILING ADDRESS
Craig A. Hatch, Esq.
FIRM NAME (If Applicable)
Gates, Halbruner & Hatch, P.C.
TELEPHONE NUMBER
D 2. Supplemental Return D 3. Remainder Return (date of death pliorto 12.13-62)
D 4a. Future Interest Compromise (dale of death after 12.12-82) 0 5. Federal Estate Tax Return Required
D 7. Decedent Maintained a Living Trust (Attach copy of Trust) _ 8. Total Number of Safe Deposit Boxes
D 10. Spousal Poverty Credit (dale of dealhbetween 12.31.91 and1.j-95) D 11. Election to tax under Sec. 9113(A) (A1tach Sch 0)
SH~_'IliIlEllT$)TO:
Gates, Halbruner & Hatch, P.C.
1013 Mumma Road, Suite 100
Lemoyne, PA 17013
(717) 731-9600
,. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E) (5)
Z 6. JO Owned Property (Schedule F) (6)
0
5 Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
E (Schedule G or L)
Q. 8. Total Gross Assets (total Lines 1-7)
5
w 9. Funeral Expenses & Administrative Costs (Schedule H) (9)
a:
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
0.00
O.Oll
0.00
0.00
8,781.57
945.53
OFRCIAL USE ONLY
762.47
(8)
9,260.24
10,489.57
2,580.31
(11)
11,840.55
(1,350.98)
0.00
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
(12)
(13)
14. Net Value SubJect to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPUCABLE RATES
15. Amount of Line 14 taxable at the spousal tax
Z rate, or transfers under Sec. 9116 (a)(1.2)
0
!i 16. Amount of Line 14 taxable at lineal rate
..
::>
0- 17. Amount of line 14 taxable at sibling rate
::E
0
() 16. Amount of line 14 taxable at collateral rate
:l Tax Due
.. 19.
20. [2g
(14)
(1,350.98)
x.O _(15)
x.O _(16)
x .12 (17)
x .15 (18)
(19)
SH.JU ~
"'ECK~~".;~'
2W46451.000
De~edent's Complete Address:
STREET ADDRESS
332 Blacksmith Drive
CITY I STATE I ZIP
CllIIm Hill PA 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credns/Paymenls
A. Spousal Poverty Credn
B. Prior Payments
C. Discount
(1)
0.00
0.00
21.28
0.00
3. InteresVPenalty if applicable
D. Interest
E. Penalty
Total Credns (A + B + C) (2)
21.28
0.00
0.00
TotallnteresVPenalty (0 + E) (3)
0.00
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 10 request e refund
(4)
21.28
5. "Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5)
A. Enter the interest on the tax due.
(SA)
(5B)
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;. . . . . . . . . . . . . . . D
b. retain the right to designate who shall use the property transferred or its income; . D
c. retain a reversionary interest; or ........................ D
d. receive the promise for life of either payments, benefits or care? . . . . . . . . . D
2. If death occurred after December 12, 1982. did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0
3. Did decedent own an -in trust for" or payable upon death bank account or security at his or her death? D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
containsabeneficjarydesignation? . . ... . ... . ... . .. . . . .... . . .. . . .. D IZJ
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined !his return, induding accompanying schedules and statements, and 10 the best 01 my knowledge and bellef.it is true, correct
and complete.
Declarallon of preparer other than the personalrepresentalive is based on a1llnforrnallon of which preparer has any knowledge.
SIGNAlURE OF PERSON RESPO IBLE FOR FILING RETURN
~
ADDRESS ac 8I'IU.
Camp Hill, PA
IGNAlURE PREZ ./
No
[X]
[X]
[X]
[X]
IXI
[X]
oa
17011
RESENTATlVE
DATE
/7/ uro;)....
ADORE
e
Lemoyne, PA 17043
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. 6 9916 (a) (1.1) (i)J.
For dates of death on or after January 1, 1995, the tax rate Imposed on the net value of transfers to or for the use of the surviving spouse Is 0% [72 P.S. ~ 9116 (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 return are stili 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. 69116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiarles is 4.5%, except as noted In 72 P.S. 6 9116(1.2) [72 P.S. 69116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings Is 12% (72 P.S. €i 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.
2W46461.0oo
AEV-1503 EX + (1.97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Butler, Rebecca C.
SCHEDULE B
STOCKS & BONDS
FILE NUMBER
-2002-
All property Jointly.owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1. None
DESCRIPTION
VALUE AT DATE
OF DEATH
0.00
.2W48983.000
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
0.00
REV.1504 EX+ (1-97)
COMMONWEAL TI-l OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE C
CLOSELY-HELD CORPORAll0N,
PARTNERSHIP or SOLE-PROPRIETORSHIP
ESTATE OF
Butler, Rebecca C.
FILE NUMBER
-2002-
Schedule C-1 or C-2 (Including all supporting Infonnation) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-Proprietorship.
See instructions for the supporting information to be submitted for sole-proprieton;hips.
ITEM
NUMBER
DESCRIPTlON
VALUE AT
DATE OF DEATH
1.
2W46972.0oo
TOTAL (Also enter on line 3, Recapitulation)
(If more space IS needed, msert additional sheets of the same SIze)
$
0.00
REV.15Q7 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
FESlDENTDECEDENT
EST ATE OF
Butler, Rebeooa C.
All property jolntly~ned with the rlght of SUrvlvorshlp must be dlacloeed on Schedule F.
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
FILE NUMBER
-2002-
ITEM
NUMBER
DESCRIPTION
VALUE AT
DATE OF DEATH
1.
TOTAL (Also enter on line 4, Recapitulation) $
0.00
2W46AC 2.000
(If more space Is needed. insert additional sheets of same size)
AEV-1508 EX+ {1.~'7}
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
EST ATE OF
Butler, Rebecca C.
FILE NUMBER
-2002-
Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jotntly-owned with the right of Survtvorshlp must be dlsclO88d on Schedule F.
ITEM
NUMBER
1. American
- Return
DESCRIPTION
Family Life Assurance Co
of Unused Premium
VALUE AT DATE
OF DEATH
195.33
2 General Electric Capital Assurance
- final payment for long-te~ care ins.
1,500.00
3 Zwicharowski Funeral Home Account - Prepaid Funeral
7,086.24
2W46AD2.000
TOTALIAlso enter on lineS Rec.n""letion\ I.
(If mora space is needed, insert additional sheets of the same size)
8,781.57
REV-1509 EX + (1-97)
COMMONINEALTH OF PENNSYLVANIA
INI-IERlTANCETAX RETURN
ENT DECEDENT
SCHEDULE F
JOINTLy-oWNED PROPERTY
EST ATE OF
Butler, Rebecca C.
FILE NUMBER
-2002-
If 8n 8s8et W8S made )olnt within one year of the decedent's date of death, It must be reported on Schedule G.
SURVIVING JOINT TENANT'S) NAME
A.Butler, Thomas H.
ADDRESS
RELAllONSHfP TO DECEDENT
Son
332 Blacksmith Road
Camp Hill, PA 17011
B. Butler, Edward L
58 Austin Court
Murray, KY 42071
Son
c.
JOINIL y-oWNED PROPERTY:
""'" DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FORJOINT MADE Include na~~~lllnanclal institution and ~k,~nt number or DATE OF DEATH DECO'S VALUE OF
NUMBER ,,,,^,,, JOINT similar Identl Ino number. Attach deed lor .oinll .held real estate. VALUE OF ASSET INTEREST DECEDENT'StNTEREST
1. All. 04/16/1999 First Citizens National 2,836.60 33.33 945.53
Bank Account 11100295507
TOTAL (Also enter on line 6 Recaoitulation) $ 945.53
2W46AE 2.000
(If more space Is needed, insert additional sheets of same size)
REV-1510 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
EST ATE OF
Butler, Rebecca C.
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
-2002-
This sohedule must be completed and filed jf the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPllON OF PROPERlY %OF
ITEM lOCWDETHE NAAEOFlHETRANSFEREE, THEtR RELATIONSHIP TO DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
NUMBE' DECEDENT.6NO lHE ~O~~.a~r=g:AWACH A COPY OF THE VALUE OF ASSET INTEREST {IF APPIJCABLE
1. COJlIII\Onweal th of Pennsylvania 762.47 100.00 0.00 762.47
Public School Employees'
Retirement System - Pro-rata
payment
2 prudential :Investments 0.00 100.00 0.00 0.00
Contract NUmber A42503 -
Benefits ceased upon the death
of the annuitant
TOTAL (Also enter on line 7, Recapitulation) $ 762.47
(If more space is needed, insert additional sheets of same size.)
2W46AF2.000
REV;1511 EX + (1'-97)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERlTANCETAX RETURN
RESIDENT DECEDENT
ESTATE OF
Butler, Rebecca C.
FILE NUMBER
-2002-
Debts of decedent must be NnOI'tAd on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Zwicharowski Funeral Home, Blossburg, PA 6,246.24
- Funeral Services
B. ADMINISTRATIVE COSTS:
1- Personal Representative's Commissions 1,500.00
Name of Personal Representative(s) Thomas H. Butler
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address 332 Blacksmith Road
City Camp Hill State PA Zip 17011
Year(s) Commission Paid;
2. Attorney Fees Name: Gates, Halbruner & Hatch, P.C. 1,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 0.00
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 0.00
5. Accountant's Fees 0.00
6. Tax Return Preparer's Fees 0.00
7. Filing Small Estate Petition in Cumberland County 14.00
Register of Wills
8 0.00
TOTAL (Also enter on line 9, Recapitulation) $ 9,260.24
2W46AG 2.000
(If more space is needed, insert additionai sheets of same size)
REV.1S12 EX + (1.97)
COMMONWEALTH OF PENNSYL V A.NIA
INHERITANCE TAX RETURN
RESIDENT DECEDeNT
ESTATE OF
Butler, Rebecca C.
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE UABILITIES, & LIENS
FILE NUMBER
-2002-
Include unrelmbursed medlcsl exoenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1. CUmberland Goodwill Fire Co., Carlisle, PA - Ambulance Services
23.71
2 Forest Park Health Center
700 Walnut Bottom Road, Carlisle, PA
- NUrsing Home Services
2,556.60
2W46AH 2.000
TOTAL (Also enter on line 10, Recaoitulation) $
(If more space is needed, insert additional sheets of the same size)
2,5BO.31
RE\/-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERlTANCETAX RETURN
RESIDENT DECEDENT
ESTATE OF
B""l-'
NUMBER
I.
Re '"
1.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [indude wtright spousal distritxJtions, and transfers
under Sec. 9116 (a) (1.2)]
Butler, Thomas H.
332 Blacksmith Road
Camp Rill, PA 17011
FILE NUMBER
-2002-
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Son
Son
AMOUNT OR SHARE
OF ESTATE
325.00
325.00
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON- TAXABUE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTlONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
2W46A11.000
2
Butler, Edward L
58 Austin Court
Murray, KY 42071
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART 11- ENTER TOTAL NON- TAXABUE DISTRIBUTlONS ON LINE 13 OF REV-1500 COVER SHEET
(If more space is needed. insert additional sheets of the same size)
$
0.00
R~V-.151.4 EX+ (1-97)
SCHEDULE K
UFE ESTATE, ANNUITY
& TERM CERTAIN
heck Box 4 on Rev-1500 Cover Sheet
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Butler, Rebecca C.
FILE NUMBER
-2002-
This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death
prior to 5-1-89. actuarial factors for single I~e calculations can be obtained from the Department of Revenue. Specialty Tax Un".
Actuarial factors can be found in IRS Publication 1457. Actuarial Values, Alpha Volume for dates of death on or after 5-1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Will 0 Intervlvos Deed of Trust 0 Other
NAME(S) OF
LIFE TENANT S
NEAREST AGE AT
DATE OF BIRTH DATE OF DEATH
TERM OF YEARS LIFE ESTATE IS
PAYABLE
1. Value of fund from which life estate Is payable
2. Actuarial factor per app,!!!E[iate table
Interest table rate - U 3 1/2% 0 6"10 0
3. Value 01 life estate (Line 1 multiplied by Line 2)
Term of Years
Term of Years
Term of Years
Term of Years
10% 0 Variable Rate
%
$
'!lItER
TERM OF YEARS
ANNUITY IS PAYABLE
NAME(S) OF
ANNUITANT S
NEAREST AGE AT
DATE OF BIRTH DATE OF DEATH
1. Value of lund from which annuity is payable $
2. Check appropriate block below and enter corresponding (number)
Frequency of payout - 0 Weekly (52) 8 Bi-weekly (2U Monthly (12)
o Quarterly (4) 0 Semi-annually (2) Annually (1) DOther ( )
3. Amount of payout per period $
4. Aggregate annual payment. Line 2 multiplied by Line 3
5. Annuity Factor (see instructions)
Interest table rate 0 3 1/2% 0 6"10 0 10% 0 Variable Rate %
6. Adjustment Factor (see instructions)
7. Value 01 annulty - II using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period,
calculation is: Line 4 x Line 5 x Line 6 $
If using variable rate and period payout is at beginning of period, calculation is:
(Line 4 x Line 5 x Line 6) + Line 3 $
Term of Years
Term of Years
Term of Years
Term of Years
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on
Schedules A through G of this tax return. The resuITing life or annuity interest(s) should be reported at the appropriate tax rate on
Lines 13. 15. 16 and 17.
(If more space is needed, insert additional sheets of the same size)
2W46AJ1.000
REV.l649 EX. (i-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX REnJRN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Butler, Rebecca C. -2002-
Do not complete this schedule unle.. the estate Is making the election to tax assets undaf Section 9113(A) of the Inheritance & Estate Tax Act.
If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust.
This election applies to the Trust (marital, residual, A, B, By-pass, Unified Credit, etc.)
It a trust or similar arrangement meets the requirements of Section 9113(A), and:
a. The trust Of Similar arrangement is listed in Schedule 0, and
b. The value of the trust or similar arrangement is entered In v.tlole or in part as an asset on Schedule 0,
then the transferor's personal representative may specifically identify the trust (all Of a fractional portion Of percentage) to be included In the election to have such trust or
similar property treated as a taxable transfer in this estate. If less than the entire value of the trust Ofsimilar property is included as a taxable transfer on Schedule 0, the
personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fractioo is equal to
the amount of the trust or similar arranaement included as a taxable asset on Schedule O. The denominator is &Qual to the total value of the trust or similar arranaement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedenfs
survivina scouse under a Section 9113{A' trust or similar arranaement.
DESCAIP110N
VALUE
1 RIA
0.00
Part A Total $ 0.00
PART B: Enter the descriotion and value of all interests included in Part A for which the Section 9113 Al election to tax is beino made.
DESCFIIP110N VALUE
2W46E21.000
Part B Total ~
(If more space is needed, insert additional sheets of the same size)
0.00
FO~ESl PARK HEALTH CENTER
700 WALNUT BOTTOM ROAD
. CARLISLE PA 17013-3699
ACCOUNTS RECEIVABLE STATEMENT
Statement Date: 08/31/2002
"
&
Balance Due: 2,556.60
REBECCA BUTLER
clo THOMAS H BUTLER
332 BLACKSMITH ROAD
CAMP HILL PA 17011
Account Number: 21913
Balance Forward:
3,058.76
[o,lii1'.',.".",!!al!'I:.;]i:,.,....;,....;."";';.!.)',..;~~~pi)o.P .;,}'I'i'I.'.; ";,I'c;1S1tiilPa~IUnilsJi.,;(;;
OSI0112002 - 0810112002 Patient Liability
0810212002 - 08120/2002 Patient Liability
08113/2002 - OS/13/2002 transfer credit
0811312002 - 0811312002 transfer credit
08113/2002 - 08/13/2002 Payment from statement 07102
CIuIl'gai'jiliil,l.);!..l'aY"'aplICra.jjPii~_ Ilala-,,~_ "'"J
127.83 3.186.59
2,428.77 5.615.36
3,76S.80 1,846.56
(3.768.80) 5,615.36
3,058,76 2,556.60
TOTAL:
2,556.60
3,058.76
2,556.60
Payment Due Upon Receipt
Please return one copy of the statement with your payment and retain one copy for your records. This is the only copy you will
receive.
Thank you.
FOREST PARK HEALTH CENTER: REBECCA BUTLER 21913
, <
FOREST PARK HEALTH CENTER
700 WALNUT BOTTOM ROAD
CARLISLE PA 17013-3699
ACCOUNTS RECEIVABLE STATEMENT
Statement Date; 08/31/2002
"
&
Balance Due: 2,556.60
REBECCA BUTLER
c/o THOMAS H BUTLER
332 BLACKSMITH ROAD
CAMP HILL PA 17011
Account Number: 21913
Balance Forward:
3,058.76
. .2Llpays/Units f
r-----aalance ------:
r::-. ....Oale ~.~.______~~!"'!!~En
08101/2002.08/01/2002 Patient Liability
08/0212002 . 08/20/2002 Patient Liability
0811312002 . 0811312002 transfer credit
08/13/2002 . 0811312002 transfer credit
08/1312002.08113/2002 Payment from statement 07/02
Charge . ,,,_L.,,P~ymentlCredit
127.83
2.428.77
3,788.80
(3.768.80)
3.058.76
3,186.59
5.615,36
1,846.56
5,615.36
2.556.60
TOTAL:
2.556.60
3.058.76
2,556.60
Payment Due Upon Receipt
Please return one copy of the statement with your payment and retain one copy for your records. This is the only copy you will
receive.
Thank you.
FOREST PARK HEALTH CENTER: REBECCA BUTLER 21913
, ,
r\\(,.~~
i-'";
/
"',,',
""-:'i.:
".-ri~::n-',Lr~ i_. (JTi
.",,_' '-;-,..i,
-',.j.' ",_1
-,::'-j-"
i;_j ~ljL:_<:::; ..
'[-;C":L(,'-',-.';"-"",
",..." T ,- I
.~~:.:~L' ,:: '-'_1'1(: ~..
,", i.~ "; :'::,: ::~: r::,
'-',",.
u- ''-..
.!,
;IV':~ "-
.. ~!....::::;-
"J-:;
.,/f.:-,:....
,.
-2::)1',;
.'('i
i,)('ji...., ,!--l E::l.JT::;:';l !'\1..:
i.:j ::~. L. L ':31.. ! ,.
(::; !~::..3 .~ C i-'.1 f~'
!"iC!'
.,
;.-.---,",-
;: 1:' i :. !.u ~:"',
Jnd !';-'
",.'
V";/",L i,,-nr-: . I --]1." I l-:',:.\l
,,'..'
... !'.; !-'fi__:1...
;,;!;'.',
'_." ~_, n. , ~ ,
:,-':1(,L. J
7{",';
,=Cj-j
I"'~? j '~):
_'~';::JJ-;-
I \ i:~ r:::r'i!:' (~;:;>f:h_;i,.
(I:.:i u L,.:~i ':..
.U
l.""}(:"
LI"
'-'Ii ".1
.. L..I-: 'ir..:,~:::I..:::~- :- i,! J '~~
: !
1-'
-:,,--!{-, (i()
~''':::~ ~
'-'~~L:i-
,Li'
l; !:';:;L~;;:;' -. ;::L\-;: 'I<
i"!'::\,i it'
i.:.! i' ~ ': '::: ii i.~'. ( . ;, ,I . OJ t,!.
/1::-
,'-'
" '-j-;~>
!-Ui .',!
1,':-:'
!"!;:::j'-i"!
Ii! ."
':c"
,.
'u.,',,"
H.____L
'----.~....__:,sc
., .J";;:::'-'.:,.
'j!_J~;,;:j ~__
';'..0,~:~_
rOHMONW~ALTH OF PENNSYLVANIA
'DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEP1\. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21
02142971
10-07-2002
REV-15'3UAFPU'-DOl
.
EST. OF REBECCA C BUTLER
S.S. NO. 224-30-6905
DATE OF DEATH 08-21-2002
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
IX] CHECKIHG
o TRUST
o CERTIF.
THOMAS H BUTLER
332 BLACKSMITH RD
CAMP HILL PA 17011
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
FIRST CITIZENS NATIONAL BANK has provided the Deparbent with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, YOU were a joint owner/beneficiary of
this account. If yoU feel this inforBation is incorrect, please obtain written correction from the financial Institution, attach a copy
to this forB and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonweaith
of Pennsylvania. Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 0100295507 Oat. 10-02-1989
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
2,836.61
16.667
472.78
.045
21. 28
TAXPAYER RESPONSE
To insure proper credit to your account, two
(2) copies of this notIce BUst accoBpany your
paYBent to the Register of Wills. Make check
payable to: "Register of Wills, Agentn.
x
NOTE: If tax paYBents are made within three
(3) Bonths of the decedent's date of death,
YOU may deduct a 5~ discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
Tax
PART
IT]
..
[ CHECK ]
ONE
BLOCK B.
ONLY
c.
o The above inforllation and tax due is correct.
1. You .ay choose to rellit paYBent to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or YOU lIay check box nA" and return this notice to the Register of
Wills and an official assessment will be issued by the PA Departllent of Revenue.
c=J The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent's representative.
o The above infor.ation is incorrect and/or debts and deductions were paid by you.
You must co.plate PART 0 and/or PART ~ below.
PART
~
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
If you indicate a different tax rate, please state your
relationship to decedent:
PART
~
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent Taxable
4. A.ount Subject to Tax
S. Dsbts and Deductions
6. A.ount Taxable
7. Tax Rate
8. Tax Due
OF
1
2
3
4
5
6
7
8
x
TAX ON JOINT/TRUST ACCOUNTS
x
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Entsr on Line S of Tax Computation)
I
$
Under penalties of perjury I I declare that the facts I
co.plete to the bes of my knowledge and belief.
;?'~# ~ E~.
AXPAYER SIGNA URE
HOME
WORK
TE
and
/0/6/02-
DATE
~ ~ 8~i~~~[~~ ~~~~t~ i~~IM ~~;r
~ ~ >-l}t", ~ 0 0 0 o!\ ~~\!l@S! c: e.t}$._. "" So
;1. ... > '" CD ~...., ...., ...., ...., >n OZ ,,!:l a CD ~ ... 0 0 "
2'0 () ~ t-''-'' .. ,Zl,Zl'>l>(\-f "'1;\ '" ,.. s \1'" '" >....,....,
..1lU ~HUH~~~~U.~~':' HJ
. OJ ,.-.. =;:;l , ~ g ~ ~ 0. ~ ~ Q." Iii;>- g g a a ..
~ 5. g ~ t"l . .. .. P1' pP g d ~ f6 ~~ I rt ~ ~ a R
\!!! e.~ M P1'P1't/lt/lg,2"'~\P In
,g ~ ~ ~~~~~~ ~f6~ ~ i. g' ~ 1
: a~. g ~ ~ Ci' Ci'~' ,_-,~ ~ ~ Sl!!.'
) ~. QS.ti C"l n g' g' ~ '< n, ~ ~ '< '-\ ~ W
_ g t"l e!.Q()g R t t;;Io~~ V> 3-
i p ::r:~l:f"~ GP~c:;;1"" sa
: ~~. g ti 8 e.~' f~!:1~3i l:1l.
\ ()~ CD~'P-- ooz... P1' iO'
- " '-" fd R- t/l ~ ~ Q ~ ~
~) ~ w ~ ~ l~....~grJl' a:
. III i 3. ~. g.' ~ u ~ € ;
g e. ,., ~2 >
~ ~ l~ ~ IA IA IA IA IA !~~*~ ~ IA ~
.~ ~ ~ ~~~~ \0~ ~s ~~f~ \
I'~
'-\ ~
~
~~~
~~~
~~~
~li
~~R
~~~
r"
~C3
;>-C:
n'
Clo~
tll"'~
5
.. '"
. ~
-
V>
.-j
> ..., "'C
~~ ',i;:~:<l~
~~ a~~~
~g.~~(')~~~
Qs.at/l~~
"'-1 )o'Q' r+ W ""J
~~ ~ ~ ~ (; ~
(I) ~ ~ o' ~ ~ ~ l:'i1
e~gl!~~~'
QFCDIn"tl~P'~
MC"l~P:P'~~~
I:;Otl:lv>o:~-J,~
O=.a ",tTl~~
~ ~ !\.f> (cl.", ~
~S~ ~i;;,~
~~ ~~b~
~~ ~t>j~~
Q
t/l
i i
~i,.ili
::I,",:l! l;I.
~~[ g
~~i ~
~ " -
'" :a c
~ (') 8
~ ~ t
()
I!l
Q.
U>
8 ~ i. i g\>(\ 8
.-j~~~~O .-j
~s(')~e.~ ~
~ i~f}0~
~ ~~. Ii i
? l In
" M
II t/l
l~ e
g (i
~. ~
!f t:l
\JQ
i. III
U>
III i - ~~~~, r
C5 ~ !~I~i~ii w~
C"l~ ~ ~t/ll ~~~~~~~rn~gMg.-jo
~ 0 t"l {j\!\ -l:lEt'T1' I"-
t"l ~ P .f; ~ ~ '" fl' ~ (") l ;;!
~ tl:l E 1\ 'd'" ~ Ii @ ~ !! ~ t-'
a ~ I '" ~.,:~ ~ i ~ ~I g ~ ~. ~ ~
;;! ~ tsl~ ~. g -:.\gUQr-"2~ [t"l;:;l
t-' .. = 2: 1 0 ~ Itl 1:;' "'" (;); ... M t"l t/l
> = ~ ~ I:\' r- ~OQ ..."" " 6- (I) M M
~ ~ '..' {I} } 0~ rP~ll ~~n ~
;!) c.. ~~_~ ~o. I ~~ ~t1~. n
~ ~~ ti4~ JA~ ~@8~ ~ ~
~ f)~ :t. p-~~ a ~
.~ \r}t >-l [ · ti1
l'; ~ ~: -~ ~ ~ ~: ~ ~ ~ 11 ~ i ~
," '~ r," ~"ll~~~r ?~
i' ~ ~ ttt[l{t\11~IH5
g ~lq ~~~ wli~wt2
,,1 ~ 'f~~"i\ 11. fa~li~
g t t~~ 1~~-R~~9~
~ ~w ~ ~ Ii f.~Ig:l5.li ~
~ ~iii.i\f~l\ili~~
,.~'.a [.'f~ll~I!~~Sii~
'K~n ! ~ i a.1l '" Ii' If:a ~ ~
~:a.8.. ~t.~ !11.:tll!i ~
W:1l l 1\.llll\i!l
\lli'hi ~;,th.~
ha _~ t\ ~l!!.~ c;J
d Cl it~ ~tU ,i}U ~
~ ~~~[w~i lB~~~
..C> ~ t i B ~ li [ ~ K' II ti1
o t~t~~l:i~I~:i~
t l FIJ(6\it ~
R' ~ll!. t'!8.U[
t"'t-i
Vio
~t-i
~~
>~
~~
;i~
('j
M
~
VIE;
~
....
~~
......
~
(f)
'rl >-< t-i
~@ 0
t"'~ ~
~ en ~
Q~ ~
ffi~~
~o (j
';"'M
tnt:l
~~ ~
~Q
~~~iVl
\J \ b
>-l
o
>-l
?;
g
a
~
V>
'l:l
a
~
~
.-j
o
.-j
?;
~
?:l ~
~ ~
~. ~
tl ~
::} .-j
t/l 0
~rr!
\ i
v>
"-
JAAfJ"
IN THE MATTER
OF THE ESTATE OF
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
REBECCA BUTLER
Deceased.
: FILE NO. 21-02-0941
~RD~
AND NOW, TO WIT: This ~ day of
.2003, upon consideration
of the foregoing Petition and on motion of the attorney for the Petitioner, it is ordered that the
property of the decedent be distributed under Section 3102 of the PEF Code as follows:
Thomas H. Butler be allowed to deposit the checks received from General Electric
Capital Assurance Co. and the American Family Life Assurance Co. as reimbursement of
expenses paid on behalf of the decedent; and it appearing that there are no funds remaining for
distribution in accordance with the interests in the estate, it is further
Ordered that this decree of distribution shall constitute sufficient authority to all transfer
agents, registrars and others dealing with the property of the estate to recognize the persons
named herein as entitled to receive such property without administration, and shall in all respects
have the same effect as a decree of distribution after an accounting by a personal representative.
BY THE COURT,
CRAIG A HATCH
GATES ETAL
1013 MUMMA RD STE 100
LEMOYNE PA 17043
NOTICE OF INHERITANCE TAX
APPRAISEMENT, AllOWANCE OR DISAllOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FilE NO.
COUNTY
ACN
03-03-2003
BUTLER REBECCA
08.21-2002
21 02-0941
Cumberland
101
\,. /J- 9s- /D
eUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128.0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT
RegIster of Wills
Cumberland County Courthouse
Carllsla. PA 17013
CUT ALONG THIS LINE q RETAIN LOWER PORTION FOR YOUR RECORDS <=>
. 'REY-154"" EX'(Oe:S7fi>c' ......' ".. 'Notic'E'i:fF'INHERi'f A'NCE'Tji;XAPPRAiiiEME'Nf, .ALl.OWA.....CEOR.' ....... .,...,. ..,.
DISAllOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
BUTLER REBECCA C FILE NO, 21 02_1 ACN 101
TAX RETURN WAS: ACCEPTED AS FILED 0 CHANGED
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/Parlnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Depositsl Misc. Personal Properly (Schedule E)
6, Jointly Owned Properly (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 9,260.24
10. Deb\s/Mortgege Liabilities/Liens (Schedule I) (10) 2,580.31
11. Total Deductions (11)
12. Net Value o!Tax Return (12)
13, Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13)
14. Net Value of Estate Subject to Tax (14) ,I 3
NOTE: If an assessment was Issued previously, lines 14, 15 and/or 16. 17 and 18 will reflect flgures
that include the total of All returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 taxable at Sibling rate
18. Amount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
PAYMENT
DATE
10-15-2002
ESTATE OF
DATE 03 .2003
(1)
(2)
(3)
(4)
(5)
(6)
(7)
0.00
0.00
0.00
0.00
8,781.57
945.53
762.47
(8)
NOTE: To In
credit to your
submit the u
of this form
tax payment.
1048 57
1184 . 5
-135.8
o
o
o
(15)
(16)
(17)
(18)
0.00
0.00
0.00
0.00
X.OO
X .045
X.12
X.15
(19)
RECEIPT
NUMBER
CDO01754
DISCOUNT (+)
INTEREST/PEN PAID .
0.00
AMOUNT PAID
20.22
.. 71' pnn AP'1'BR DAD INDICATBD I sa RBVBRSB
PeR CALCULATION OF ADDXTIOMAL IN'l'BRBST.
TOTAL TAX CREDIT O.
BALANCE OF TAX DUE 20. CR
INTEREST O.
TOTAL DUE 20. CR
(II' TOTAL DUB IS IoBSS THAN $11 NO PAYIIEN'l' IS UQutRBD.
IF TOTAL DUB IS UFLBCTlm AS A CRBDIT (CR) 1 YOU KAY B DUB'
A DFmm. SD UVElWB SIDB 01' THIS FORK FOR INSTRtJ'CTI S. )
/~- 96---:.. /0
\ 'UREAU Of INDIVIDUAL TAXES
\.. .MHERIT1'- '<<:.E TAX DIVISION
DEPT. 280601
HARRISBURG, PA 171za-D6D1
COMMONWEALTH OF PENNSYLYANIA
DEPARTMENT OF REYENUE
L BUTLER
CT
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
REV~UM Ell AfP Gl-UJ
EDWARD
58 AUSTIN
MURRAY
03-11-2003
BUTLER
08-21-2002
21 02-0941
CUMBERLAND
224-30-6905
02142972
AIIO....t R...itt.d
REBECC C
KY 42071-0000
MAKE CHECK PAYABLE AND REMIT PAYMENT 0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
---------------------------------------------------------------------------------------------------------
REY-1604 EX AFP (01-03)
__ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS --
DATE 03-11-2003
ESTATE OF BUTLER
REBECCA C DATE OF DEATH 08-21-2002
COUNTY
CUMB LAND
FILE NO. 21 02- 0941
ADJUSTMENT BASED ON:
S.S/D.C. NO. 224-30-6905
ADMINISTRATIYE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: FIRST CITIZENS NATIONAL BANK ACCOUNT NO. 0100295507
ACN
0214 72
TYPE OF ACCOUNT: () SAYINGS (X) CHECKING () TRUST () TIME CERTIFICATE
DATE ESTABLISHED 10-02-1989
Account Balance .00 NOTE: TO INSURE PROPER CREDIT TO Y R
Percent Taxable )( 0.166 ACCOUNT, SUBMIT THE UPPER PO ION
Amount Subject to Tax .00 OF THIS NOTICE WITH YOUR TAX
Debts and Deductions .00 PAYMENT TO THE REGISTER OF W LS
Taxable Amount .00 AT THE ADDRESS SHOWN ABOYE.
Tax Rate X .45 MAKE CHECK OR MONEY ORDER PA BLE
Tax Due .00 TO: "REGISTER OF WILLS, AGE . "
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
. If PAID AfTER THIS DATE, SEE REVERSE fOR CALCULATION OF ADDITIONAL INTEREST.
( If TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. If TOTAL DUE IS REFLECTED AS A "CREDIT" ICR),
YOU HAY BE DUE A REFUMD. SEE REVERSE SIDE OF THIS FOHN FOR INSTRUCTIONS.)
REV_1410 EX (6-88)
'* INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENTS NAME REBECCA C. BUTLER FILE NUMBER 210. 0
941
REVIEWED BY ACN
Phyllis Hoch 021429 2
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
ADJUSTED ABOVE ACN TO ZERO. REPORTED ON PROBATE RETURN.
ROW Qe 1