HomeMy WebLinkAbout12-12-14 (2) , �
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PA Departmen�oOnue pennsy(vania
Bureau of Individual Taxes ` " � �FFICIqL USE ONLY
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Po Box zso5oi INHERITANCE TqX RETURN �o"n�'�code vear -
Harrisbur ,PA 1�128-o6oi File Num
ENTER DECEDENT INFORMATION BELOW RESIDENT DECEDENT 2 � � G
Social Security Number Q
Date of Death ��,Ih�1DDYYYY Date of Birth
201-42-6941 ,y�ti�p�yyYv
08/10/2010
Der.edenYs Last Name 04�25/1950
S�ff�x Decedent's First Name
MI
��f APP�icable)Enter Survivin Shifl@y
g Spouse's Information Be1ow A
Spouse's Last Name
Kazimer Suffix Spouse's First Name
MI
Spouse's Social Security Number Richard
E
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
FILL IN APPROPRIATE OVALS BELOW REGISTER OF WI�LS
�.) 1. Original Retum
0 2.Suppiemental Return
O 4. Limited Estate o 3. Remainder Return(Date of peath
O 4a Future Interest Compromise(date of Prior to 12_13_g2�
a 6. Decedent Died Testate death after 12-12-g2) O 5. Federal Estate Tax Return Required
(Attach Copy of Will) � � Decedent Maintained a Liviny Trust
� 9.Litigation Proceeds Received �Attach Copy of Trust.) — 8 Total Number of Safe Deposit Boxes
� 10.Spousal Poverty Credit(Date of Death
CORRESPONDENT— THIS SECTION MUST BE COMPLETED.ALLtCORRESPONDENCE AND CONfIDENTIAL TA�X INFORMEIection to Tax under Sec.9113(A)
Name (Attach Schedule O)
ATION SHOULD BE DIRECTED T0:
Kari E. Mellinger Daytime Telepnone Number
(717)234-7828
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REGISTERQ�y�LS USE(JF�Cy �
First Line ofAddress �
3513 N. Front Street � � � Q
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Second Line of Address � : t'T1 � t'n
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City or Post Office �� � �
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Harrisburg state ZIP Code snT �Ep �„�,�, �
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PA 17110 � ts1 us p
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CorrespondenYs e-mail address:klllelllllq@r r'marzella.com
Under penaities of perjury,I declare that I have examined this re(urn,including accom 3n m schedules and statements,and to the best of m kno
it is true,cor �and complete.Declaration of preparer other(han the personal representative is based on ali informa(ion of which preparer has an
SIGNAT kE
P� Y 9
�-.��R�D�f RESPON Y wledge and belief,
'w„ r�„�,rFJJ_ING RETURN y knowledge,
ADDRESS �"`""'"" DATE
3513 N. Front Street, Harrisburg, PA 17110 �L /8 �
SIGNATURE OF P�EpqRER OTH[R THAN R[pRESENTATIVE
ADDRESS DATE
PLE�15C U��Ut21Gif�!/�L FOFtt�i QNAI.Y
�ide 1
],50561p1,05
7,505610],05
REV-1513 EX+ (01-10)
j�� pennsylvania SCHEDULE ]
�1 oEr�:�rMervr�F ReveuuE
INHER[TANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF:
Shirley Kazimer PILE NUMBER:
NUMBER NAME AND ADDRESS OF PERSON(5)RECEIVING PROPERTY RELATIONSHIP TO DECEDEN� AMOUNT OR SHARE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under �o Not List Trustee(s) OF ESTATE
Sec.9116(a)(1.2).j
1.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1• Richard Kazimer
100%
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 Of REV-1500 COVER SHEET. $ p
If more space is needed, use additional sheets of paper of the same size.
COMMONWEqLTH OF PENNSYLVANIA
COUNTY OF CUMBERLANp �-� SHORT CERTIFICATE
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I. GL E/VDA FA RNER S TRA SBA UGH
Register for the Probate of WiZls and Granting
Letters of Administration in and for
CUMBERLAND Coun ty, do hereby certi fy tha t on
the 27th day of September, Two Thousand and Ten
Le t ters of ADMIN/STRA T/ON
in common form were _qran ted bv the Regi s ter of
said County, on the
es ta t e of SH/RL EY ANN KAZIMER
lFi�st,Midd/e,Las7J , 1 a t e of HOPEWEL L TO WNSHIP
in said coun ty, deceased, to R/CHARD E KAZIMER
(First,Middle,Lastl
and tha t same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 27th day of Se t
Two Thousand and Ten. P ember
Fi 1 e No. 2010- 00987
PA Fi1e No. 21- 1p- 0987
Da te of Dea th 8/10/2010
S. S. �# 201-42-6941
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�� '�l� G��i r� ���'�.;��.� � ,�
Register Of Wipg '
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eputy
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
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