HomeMy WebLinkAbout11-14-14 , a
REV-1500 EX(02-11) 41 1505610143
PA Department of Revenue y OFFICIAL USE ONLY
p peens Ivania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 13 0989
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
09 05 2013 12 25 1911
Decedent's Last Name Suffix Decedent's First Name MI
PATTISON ANNIE G
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ❑ 2. Supplemental Return ❑ 3. Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a.Future Interest Compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
8 Decedent Died Testate ❑ 7. (e edent Maintained
Tn sd a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) Copy )
9. Litigation Proceeds Received 10.Spousal PovertYYF—]Credit((Date of Death 11.Election to tax under Sec.9113(A)
❑ ❑ between 12-31-J1 and T-1-95) (Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
FOREST N MYERS 717 532 9046
REGISTER OF WILL&USE ONLY
c M
First Line of Address
_ c+7 O
137 PARK PLACE WEST
Second Line of Address i ri
co
rrl
—r7 ^�
City or Post Office State ZIP Code i FIS _
s ry r— M
SHIPPENSBURG PA 17257 --1 r--
w. rn
Correspondent's e-mail address: fnmyers(aD_lawofficeforestmvers.com
Under pe ties of perjury,I declare tha have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true o ect and comple e.D clay Io of preps r other than the personal representative is based on all information of which preparer has any knowledge.
S N OF PERSON RE ON IBL R FILVG U N DATE
N 1 . Bruce A WYRICK
ADDRESS
7 E Walnut Street, Ledo PA 17042
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
-, Forest N Myers li f q3�
ADDRESS
137 Park Place West,Shippensburg, PA
L 1505610143 Side 1 1505610143 J
tel"
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: PATTISON, Annie G
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2. 158 , 752 . 80
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 25, 491 . 60
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 183,452 . 87
7. Inter-Vivos Transfers&Miscellaneous fon Probate Property
(Schedule G) u Separate Billing Requested............ 7. 311,478 . 61
8, Total Gross Assets(total Lines 1 through 7)........................................................ 8. 679, 175 . 88
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 35 , 119 . 21
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10.
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 35, 119. 21
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 644 , 056. 67
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)............................................... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 644 , 056. 67
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.00 15. 0 . 00
16. Amount of Line 14 taxable 0 . 00 16. 0 . 00
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 644f286. 67 18. 96, 643. 00
19. TAX DUE................................................................................................................ 19. 96, 643 . 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑
Side 2
L 1505610243 1505610243 J
REV-1500 EX Page 3 Fite Number 21-13-0989
Decedent's Complete Address:
DECEDENT'S NAME
PATTISON,Annie G
STREETADDRESS
121 Walnut Bottom Road
CITY STATE ZIP
Shippensburg PA 17257
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 96,643.00
2. Credits/Payments
A. Prior Payments 90,000.00
B. Discount 4,736.84
Total Credits(A +B) (2) 94,736.84
3. Interest (3) 25.32
4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 1,931.48
Make Check Pa able 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;............................................................................... ❑ ❑x
b. retain the right to designate who shall use the property transferred or its income;.................................. ❑ ❑x
c. retain a reversionary interest;or............................................................................................................... ❑ ❑x
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑
IxI
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?.................................................................................................................. ❑ ❑x
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the 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.
cu►eil��l�� '*-LgST WILL AND TESTAMENT **
I,ANNIE G.PATTISON,of 320 E.Orange Street,Borough of Shippensburg,Shippensburg,
Cumberland County, Pennsylvania, revoke my prior wills and declare this to be my Last Will:
FIRST: PAYMENT OF EXPENSES•I direct that the expenses of my last illness and funeral be paid
from my estate as soon as may conveniently be done.
SECOND: BEQUEST•I give,devise and bequeath all my property,whether real or personal,tangible
or intangible,together with all insurance policies thereon,unto my nieces and nephews,BMLICEA.
WYRICK,HELENMELL0TTOEVOR;and FRANK G. WYRICK,provided they shall survive me by thirty
(30) days, in as nearly equal shares as possible, per capita and not per stirpes.
THIRD: RESIDUE OF ESTATE • I give, devise and bequeath all the rest, residue and remainder of
my estate unto my nieces and nephews,BRUCEA. WYRICK,HELEN MELLO TT DEVOR;and FRANK
G. WYRICK,provided they shall survive me by thirty(30)days,in as nearly equal shares as possible,
per capita and not per stirpes.
FOURTH: PROTECTIVE PROVISION • To the greatest extent permitted by law, before actual
payment to a beneficiary,no interest in income or principal shall be(i)assignable to a beneficiary or
(ii)available to anyone having a claim against a beneficiary.
FIFTH: DEATH TAXES • All federal,estate and other death taxes payable on the property forming
my gross estate, whether or not it passes under this will, shall be paid out of the principal of my
Law office of probate estate just as if the were m debts, and none of those taxes shall be charged against an
rorzr<.sr N.i111'�RS p l Y Y g g � Y
x k beneficiary. This provision shall not apply to any property over which I have a general power of
137 Park Place West
Shippensburg,PA 17257 appointment for federal estate tax purposes.
(717)532-9046
i
SIXTH; MANAGEMENT PROVISIONS • l authorize my Executor, as follows:
A. 1Retain/Invest: To retain and to invest in all forms of real estate and personal property,including
common trust funds,mutual funds and money market deposit accounts and certificates of deposit,
regardless of any limitations imposed by law on investments by executors or any principle of law
concerning investment diversification;
B. Compromise: To compromise claims and to abandon any property which, in my Executor's
opinion,is of little or no value;
C. Borrow: To borrow from and to sell property to others, and to pledge property as security for
repayment of any funds borrowed;
0. Sell/Lease: To sell at public or private sale,to exchange or to lease for any period of time, any
real or personal property and to give options for sales or leases;
E. Capital Changes: To join in any merger,reorganization,voting-trust plan or other concerted action
of security holders, and to delegate discretionary duties with respect thereto;
F. Distribute: To distribute in kind and to allocate specific assets among the beneficiaries(including
any custodian hereunder) in such proportions as my trustee may think best, so long as the total
market value of any beneficiary's share is not affected by such allocation.
These authorities shall extend to all property at any time held by my Executor or my Trustee and shall
continue in full force until the actual distribution of all such property. All powers, authorities and
discretion granted by this will shall be in addition to those granted by law and shall be exercisable
without court authorization.
SEVENTH: EXECUTOR - I appoint my nephew,BRUCEA. WYRICK, Executor of my Will. In the
event of the death,resignation,renunciation or inability of my nephew to act as Executor, I appoint
HELEN MELLOTT DEVOR, Executrix of this, my Will. In the event of the death, resignation,
renunciation or inability of my niece to act as Executrix, I appoint FRANK G. WYRICK, Executor of
this, my Will. Neither my Executor, nor any successor shall be required to give bond.
i
IN WITNESS WHEREOF, I have hereunto set my hand and seal thisday ofPV—�L
1999.
(SEAL)
ANNIE G. PATTISON, Testatrix
In our presence,the above-named Testatrix signed this and declared it to he her will,and now,at her
request and in her presence and in the presence of each other,we sign as witnesses:
Aeax
COMMONWEALTH OF PENNSYLVANIA
:SS
COUNTY OF FRANKLIN
I, ANNIE G. PATTISON, having been duly qualified according to law, acknowledge that I
signed the foregoing instrument as my Will, and that I signed it as my free and voluntary act for the
purposes therein expressed.
Re
ANNIE G.PATTISON,Testatrix
We,ANNIE G.PATTISON,the Testatrix in and the undersigned witnesses to the Will,the
attached or foregoing instrument,who have signed the instrument,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 and execute
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 witnesses and that to the best of our
knowledge,the Testatrix was at that time eighteen or more years of age,of sound
mind and under no constraint or undue influence.
ID
ANNIE G. PATTISON, Testatrix
Witness
Witness
Subscribed, sworn to or affirmed,
and acknowledged before me by the
above-named Testatrix and by the
Z.. witnesses whose names appear on
this 2�lay of AzziU , 1999.
Notary Pu lic
NOTARIAL SEAL
FOREST N MYERS,NOTARY PUBLIC
BOROUGH OF SHIPPENSBURO FRANKLIN COUNTY
MY COMMISSION EXPIRES DEC 17 2001
Rev-1603 EX+(6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PATTISON,Annie G 21-13-0989
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 Beistle Company-common 778.2 158,752.80
TOTAL(Also enter on Line 2, Recapitulation) 158,752.80
(If more space is needed,additional pages of the same size)
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B(Rev.6-98)
Rev-1508 EXa If 1-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PATTISON,Annie G 21-13-0989
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Orrstown Bank#692360-checking account-date of death balance 18,515.17
2 Healthcare Center-refund 6,750.00
3 PSERS-retirement income 226.43
TOTAL(Also enter on Line 5, Recapitulation) 25,491.60
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10)
Rev-1509 EX+(01.10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PATTISON,Annie G 21-13-0989
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. Bruce A WYRICK 7 E Walnut St Nephew
Lebanon, PA 17042
B. Helen Mellott DEVOR Niece
C.
JOINTLY OWNED PROPERTY:
LETTER DATE
DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOIN MADE (NUMBER OR SIMILARNCLUDE NAME OF nANCIAL IDENTIFYING(TUTION AND BANK NUM ER.ATTACH DEED OUNT FOR DATE OF DEATH DECD'S DECE ENT'S NTEREST
VALUE OF
NUMBER TENANT JOINT JOINTLY-HELD REAL ESTATE. VALUE OF ASSE INTEREST
1 A 07/27/2001 Citizen's Bank*0854-CD 61,732.73 50.000% 30.866.37
2 A 07/27/2001 Citizen's Bank*0854-CD; interest to date of 2.28 50.000% 1.14
death
3 A 09/03/1990 Citizen's Bank*7386-CD 13,228.13 50.000% 6,614.07
4 A 09/03/1990 Citizen's Bank*7386-CD;interest to date of 0.81 50.000% 0.41
death
5 A 03/07/1990 Citizen's Bank*7394-CD; interest to date of 2.14 50.000% 1.07
death
6 A 04/04/1988 Citizen's Bank*7440-CD 10,347.34 50.000% 5,173.67
7 A 04/04/1988 Citizen's Bank*7440-CD; interest to date of 0.06 50.000% 0.03
death
8 A 10/03/1989 Citizen's Bank*7831 -CD 1,264.87 50.000% 632.44
9 A 10/03/1989 Citizen's Bank*7831 -CD;interest to date of 0.06 50.000% 0.03
death
10 A 05/26/1995 Citizen's Bank*8677-CD 35,611.12 50.000% 17,805.56
Total of Continuation Schedule ee attached page
TOTAL(Also enter on Line 6, Recapitulation) 183,452.87
I (If more space is needed,additional pages of the same size)
Copyright(c)201 Oform software only The Lackner Group,Inc. Form PA-1500 Schedule F(Rev.01-10)
Rev-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT continued
ESTATE OF FILE NUMBER
PATTISON,Annie G 1 21-13-0989
If an asset was made joint within one year of the decedent's date of death,it must be reported on schedule G.
JOINTLY OWNED PROPERTY
DESCRIPTION OF PROPERTY %OF DATE OF DEATH
LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DECD'$
ITEM FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER.ATTACH DEED FOR DATE OF DEATH VALUE OF
NUMBER TENANT JOINT JOINTLY-HELD REAL ESTATE. VALUE OF ASSE INTEREST DECEDENT'S INTEREST
11 A 05/26/1995 Citizen's Bank*8677-CD; interest to date of 0.20 50.000% 0.10
death
12 B 05/29/1990 Citizen's Bank*9087-CD 6,531.09 50.000% 3,265.55
13 B 05/29/1990 Citizen's Bank*9087-CD; interest to date of 0.08 50.000% 0.04
death
14 A 04/02/2007 Orrstown Bank#103800223-money market 74,985.48 50.000% 37,492.74
account-date of death balance
15 A 01/05/2009 Orrstown Bank#4000030656-CD account- 38,439.55 50.000% 19.219.78
date of death balance
16 A 07/11/2012 Orrstown Bank#4000044279-CD account- 124,759.73 50.000% 62,379.87
date of death balance
TOTAL(Also enter on Line 6, Recapitulation) 183,452.87
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule F(Rev.01-10)
Rev-1510 EX+(08-09)
SCHEDULE G
pennsylvania INTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PATTISON,Annie G 21-13-0989
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THINCLUDE
DATE OF NAME
ACH THEIR COPY OF THE DEIED FOR REAL ESTATE. VALUE OF ASSET T ANDINTEREST (IF APPLICABLE) VALUE
1 3,917.076 shares of Blackrock Funds-PA Municipal 40,345.88 40,345.88
Mmk B,CUSIP#091927251
2 8,973.081 units of Federated Fixed Income Securities- 89,820.54 89,820.54
Stratg Income F-date of death balance,CUSIP
#31417P809
3 M&T Bank Money Market-Income-date of death 21,898.62 21,898.62
balance
4 M&T Bank Money Market-Principal-date of death 85,116.14 85,116.14
balance
5 3,777.148 units of Rowe T Price Tax Free Income 36,373.94 36,373.94
Com,CUSIP#779576107
6 3,642.987 units of SEI Tax Exempt Trust-PA 37,923.49 37,923.49
Municipal Portfolio A,CUSIP#784118507
TOTAL(Also enter on Line 7, Recapitulation) 311,478.61
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule G(Rev.08-09)
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX
RESIDENT DEC ENTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
PATTISON,Annie G 21-13-0989
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
Fogelsanger-Bricker Funeral Home -funeral bill
9,749.90
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State ZiD
Year(s)Commission Paid
2. Attorney's Fees Law Office Forest N Myers 24,165.31
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State ZiD
RelationshiD of Claimant to Decedent
4. Probate Fees 388.50
See continuation schedule(s) attached
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 815.50
See continuation schedule(s)attached
TOTAL(Also enter on line 9, Recapitulation) 35,119.21
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
PATTISON,Annie G 21-13-0989
ITEM
NUMBER DESCRIPTION AMOUNT
Probate Fees
1 Register of Wills of Cumberland County-additional Short Certificates(4) 20.00
2 Register of Wills of Cumberland County-Probate fee 260.00
3 Register of Wills of Cumberland County-filing fee for Will 15.00
4 Register of Wills of Cumberland County-JCS fee&auto fee 28.50
5 Register of Wills of Cumberland County-Short Certificates(7) 35.00
6 Register of Wills of Cumberland County-filing fee for Inheritance Tax Return 15.00
7 Register of Wills of Cumberland County-filing fee for Inventory 15.00
H-B4 388.50
Other Administrative Costs
8 Cumberland Legal Journal-estate advertisement 75.00
9 News-Chronicle-estate advertisement 88.25
10 Orrstown Bank#692360-reduction in Date of Death balance due to check(s)clearing post- 64.54
death
11 PA Dept of Revenue-Income tax 2013 230.00
12 PSERS-return of overpayment(due to death) 188.62
13 Trinity Pharmacy-medical bill 169.09
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98) f
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
PATTISON,Annie G 21-13-0989
ITEM
NUMBER DESCRIPTION AMOUNT
H-B7 815.50
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PATTISON,Annie G 21-13-0989
NAME AND ADDRESS OF RELATIONSHIP TOSHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do e
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Helen Mellott DEVOR Niece One-half of the
112 Roxbury Road net distributable
Shippensburg,PA 17257 estate
Bruce A WYRICK Nephew One-half of the
7 E Walnut Street net distributable
Lebanon, PA 17042 estate
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
t
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group,'Inc. Form PA-1500 Schedule J(Rev.01-10)