HomeMy WebLinkAbout02-17-15 , J Lsos6111o1
REV-1500 "`°' ° �
OFF:QA�OSE ONLY
PA�eparimen[of Revenue penn y v nia
s a
Bureau of Intllvltlual Taxes ' '��" CowtyCode Vear Fle Nr,mber
PO BOxieo6oi INHERITANCE TAX RETURN n I I � O N � �
narrisburq,pneyazx-o6oi RESIDENTDECEDENT L _
ENTER DECEDENT MFORMATION BELOW
Soclal Sewnry Number Da�e of Oeath MA�DOYVYY �ate of Blrih MM��nYV
v2o22 � 1 �t- n9 � �t19a5
DecetlenCs Last Name Sultix DecedenYs First Name � MI
W c � � Z � n s TAf� r � � s
Qf Hpplicable)Enter Surviving Spouse's Information Below
Spouses Last Name Suffix Spouseti Firsl Name MI
N /✓� N � �
Spousa's Soclal Securiry Numbar
THIS RETURN MUST BE FILEO IN Ol1PLICATE WITH THE
REGISTER OF WILLS
FlLL IN AGPROPRIATE OVALS BELOW
m tOli9inalReWm O 25upplementelNelurn O 3. RemaintlerReWm(Da�ao(Dee�h
Prior�0 1&13-82)
p C. Limi�etl Estete O 4a. FUWre In�eres�Compmm�se(dale ol O S Fetleral Estete Tax ReWm Requlretl
dealh afier 12-12�2)
O B. �acetlent Died Tastate O ]. �ecedenl Maln�zinetl a Living Trus: 8. Total Number of Safe Oeposit 8oxas
(AI�ecM1 Copy ot Will) (AVacl�Copy o(TmsL)
O 9. Li�lgalion Pmceeds RecaiveJ O 10. Spousal Povarty Cratlit(Date of Deat� O 1L Bection�o Tax under Sec.9113�A)
Batween 12J151 and 1-155) (AvacM1 SCM1edule O)
CORRESPON�ENi- THIS SECTION MUST BE COMPLETEO.ALL CORRESPONDENCE AN�LONFlOENTIAL TA%INFORMATION SHOOLO 9E OIRECTED T0:
Name Daylime Telephone Number
I I-} Fr� rSR E ti/.�Glz�+ hs -� i � � l � dvs �
� H�yISiEF L`F WI�S L'3L"Z1N�� �
I ?J A m I' � �
Flrsl Llne of Atltlress I � J "� � • � �� �
N , I
21 6 �= � uR Sr,� s� r� s l �+ N �= , �r� �' �
Secontl Gne of Adtlress � 'n �. �
I � � �
c� il
Ci�y or Post Offce State ZIP Cotle _. _ _ 041 C f`.� _ f��t
LNUL /� (�H I � c� 25� � N » T'
�
GorrespondenPse�mailadtlress:
llntlerpanollieso(pe�ury,ItleGareNe�IM1aveera netll�isreWrn.lndutlinge000mpn^Yln�scM1etlWxsantls�e�emenLs,end�ol�ebes�ofmyknowletlgeentlbelle[
I�Is tme.correcl entl oom0�ele.0edara�ion of prepa 1 e��M1an IM1e personel represenletive Is Uasetl on all Informa�ion olwliiG�prepe�e�M1as arry knowlea9e.
SIGNATURE OF PERSON RESPONSIBLE FZ FlLI DAT
— 30 2�� 1y
nooaEss� n �2 � I �� U -1nf�� � � � ISI) �12C� I' � � 7 �uy
G
SIGNATURE OF PREPHRER OTHER THH—�7 ------ DATE� C ��
3 ,�/G�y
no3e�S2 �� >> �tl�6f�y � �� �1�0AI`If✓� ��2 �� I � g � � fd �7 '_
� PLEASE USE ORIGINAL FORM ONLY
Side 7
L J �,
Lsos6111o1 Lsos6111o1
(�
J 15�5611201 � .
aev-isoo ex
Oecedenfs Social Securiry Number
oeceaem'sName: '}
RECAPITULATION
1. Real Eslale(Schedule A). . . ... . .. . . . . . ... . . . . . . . . . .. . .. . . . . . .. . ... . . . 1. O . � �°
2. Stocks ana Bonds(Schetlule B) . .. . . . . . . ... . .. . . . . . .. . . .. . .. . .. . . .. . . . 2. Q • � U
3. Closely Heltl Corpora�ion. Parinership orSole-Pmprietorship(Schetlule C) ... . . 3. y • � V
4. Motlgages antl Noles Receivable(Sc�edule D) . ... . . . . . .. . .. . . . . . .. . . . . . . 4. Q . �U
5. Cas�, Bank Deposits and Mlscellaneous Personal Pmpetly(Schetlule E). . . .. . . 5. O . Q U
6. Jointly Owned Pmper;y(Schedule F) � Separate 6illing Requested .. . . .. . 6. O . Q V
]. Inter-Vivos Transfers 8 Mlswllaneous Non-Proba�e Property
(Schedule G) �CD Separate 9illing Reques�ed.. . . . . . . ]. �. a V
8. Total Gross Assets Ootal Lines 1 thmugh]I. ... . .. . . . . . ... . . . . . . . .. . . . . . 8. �. Q �l
._. _._-__. ___. ._--_ .__ __ ___- __..___._.-'_-_-- /
& Wnerel Expenaes endAdmmieVeWe Costs(Schedule H�_._ .. . . _ . 9. �8 � . p 7
10- �ebts of pecatlenl, Mortgage Llebllltles antl Llens(SCM1etlule I).. ... ... ....... 10. � 'l7 Q z � . ��'�
11. Total �etluctions(total Lines 9 and 10). . .. . ... . .. . . .. . ... . .. . . . . ... . .. . 11. � L.� CI � �j ' ��
12. Net Value of Estate(Line 8 minus Line 11) . . . .. . . .. . . . . . .. . .. . . . . . .. . . .. 12. (� � � J 7, 1 -I
13. Charitable and Govemmenlal Bequests/Sec 9113 Tmsts for wM1icb
an election to tax�as no�been matle(Sc�edule J) . . . . . . . . .. . . . . . . . . .. . . . . 13. �
14. Ne[Value Subjec[to Tax(Line 12 minus Line 13) . . . . . . . . . .. . .. . . . . . .. . . . 14. � c:t � p 'S, U �
TAX CALCULATION-SEE INSTRIICTIONS FOR APPLICABLE RATES
�6. Amoun�of Line 14 teaeble
d��hB SP01162I�B%fd�B�Ol
Iransfers untler Sec.9116
(e)(L21% .0_ . 15. ,
i6. Amounl ol Line 14 taxa�le
at Ilneal rela X D_ . i6. .
19. Amount o(Line 14 taxabie �
etsiblingrate X_12 . 1]. .
18. Amoun�ofLine�4laxable �
at mllateal ra[e X .15 • 10_ .
19. TAX DUE . . . . ..,--�- . .. . . .. . . . . . . . . . . . . . . . . . . . . . . 19. .
20. FILL IN THE OVAL IF VOU ARE REpl1E5TING A REFUND OF AN OVERPAYMENT p
Side 2
L 1505611201 1505611201 J
RELL\SW EX Page 3 Fle Number
DecedenYs Complete Address:
pECEDENT'S NAME
�� � \ � LJIL� 1/� hs -- 2ii -F — �`f �5
-siREErnooREs ,.
2fG �v �,2_sr�tr� Ns � �tr �=
� N� c � _._ ��r
�� Y 5,Al�� Z�P� ?o25
Tax Payments and Credits:
1_ TaxDue(Page2,linelBJ (�) �
2. Credits/Paymenls
A.Pnor Paymenis
B.Discount
TotalCredits�A+B) (2)
3. In�eres�
(3)
4. It Line 2 is grea�er than Line 1 *Line 3,enter�he aifference. This is Ihe OVERPAYMENT.
Fill in oval on Page 2,Line 2010 requesl a re(untl. � (4)
5. If Line 1 a Line 3 is greater ihan line 2.en�er Ihe diRerence.This is ihe TA%DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. �ltl tlecedent maka a Vans�er and: Ves No.
a. retaln I�a use or Income of ihe propetly trans�erred _. _.. ... ... ❑ �
c. re�ain ihe right to desgna�e who shall use Ihe pmperty iransferred or its mcome ._ ... ❑
b �eta ry ' C
tl. rece ve�he prom se for life o�ei�her payments.benefits or care _._ _ _.— - �� I�
2 I(dealh occurred afler0ec. 12, 1982,did decetlent tansfer property wilhin one yearaf death
� 9 9uateconsiderotion? _._... ......_ .._...... ..... ❑ �r�/� �
3. �Id decetlent own an"in imst for'or payabla upon tlea�h bank ecwunt orsecunty at his or herdeatM ...... ❑ L�
1 �itl decedent own an individual retirement accowt,annuity or o�her non-pmbale propetly,which
mn�ainsabeneticiarydesignalon> ..._._. ......... .._..... _.._... .._.._. ❑ �
IF THE ANSWER i0 ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHE�ULE G AND FILE IT AS PART OF THE RETURN.
For tlates o(death on or afler July 1. 1994,and betora Jan. 1, 1995,the tax rate Imposed on the net value of hansters to or for Ihe use of the surviving spouse
is 3 percen�[72 P.S.§9116(a)(1.1)(1)�.
For tlates of death on or afler Jan. 1, 1995, ihe tax rete imposed on ihe ne� value of transfers �o or for Ihe use of the surviving spouse is 0 pement
[/2 P.S.§9118(a)(1.1)(li��.The sta;ute does not exempt a Vansier�o a surviving spouse from tax,antl the staWtory requirements tor disclosure of assets antl
ftling a tax reNrn are 5611 apphcable even if the surviving spouse Is Ihe only beneficiary
For dates of death on or after July 1,2000�.
• The�ax rate Imposed on Ihe net value of�ransiers trom a deceased chtld 21 years of age or younger at dea�h to or for the use of a naNral parenL an
atlopfrve paren!or a stepparen�of Ihe chlld is 0 percent�72 P.S.§9116(a�(L2)�.
. The tax rale Imposed on the nel value of hansfers to or(or�he use of the decedenfs Ilneal bene(iciaries Is 4.5 percent except as no�ad in[72 PS-§9116(a�(1�].
. The tax ra�e Imposetl on ihe net valua of�rensfers to or for the use of the decedenPs siblings Is 12 perceN [72 PS. §9116(a�(1.3)J.A sibling is defined.
under Sectlon 9102,as an indrvidual who has a�least one perent In common wi�h�he decedent,whether by blood or adoption.
�EV-1902:X+ (01-10) �
� �� pennsylvania SCHEDULE A '
����������To������:�� REAL ESTATE
INHERPAVCE iA%RFiI.PN
xescFvi ueceoemr
ESTATE OF: FILE NUMBER:
All reel Oroperry owned solely or es a tenan[ln mmmon mus[be repor[eG at fair market value.Falr market va��c s acfi�ed as Ihe pr:e a[which pmpeny
wou10 be evchaooed betwcen a wiiling buVer ana a wili ng seller,neither being compelleC to buy or sell, bo[h having reamnave rcnawle0ge of[he relevant hcts.
Real praperty that is jointly-awne0 wi[h right af survivorship must be disclosed on ScheOule F.
AIIa�M1 a mpy of[he settlement shce[i([ht property has bee�mltl.
ITEM :nCode a copy of[�e tleetl show:ng tlecedenCs Interes[fi avrnetl as tenant m mTmon. VAW E AT�ATE
NIIMBE3 OF DEATH
DESCRIPTION
, N � � N� N,�
TOTAL (Also enter on Line 1, Recapitulation.) $
I(more space is needed,use a001tional sheets of paper of Me same sixe.
�EV4fr09 EXt�698) I
' � SCNEDULE B
�oMMa�wEA�*�oFPE��s���A��A STOCKS & BONDS
INHERITHNCE TAX RETURN
FESI�ENTDECEDENT
ESTATE OF FILE NUMBEH
All pmperry loin�ly-ownetl with rigAt oi survivorship must be tlisclosetl on Schedule F.
ITEM VALUE AT DATE
Nl1M8ER DESCRIPTION OF DEATH
1
N � � � oN�,
TOTAL(Also enter on line 2, Recapilulation) $
QI more spece Is naedetl.insed atltltllonal e�eete o�ihe same size)
��� �s°°�"',, �" SCREDULE C
� CLOSELY-HELD CORPORATION,
� coMMONwEnirH oF vENNsv�vnNin PpRTNERSHIP OR
��aEsioE�rvrEOECEOEuuR� $OLE-PROPRIETORSHIP
ESTATE OF FILE NUMBEH
Schedule C-1 or G2 Qnclutling all suppotling Informa�ion�mus�be aVechetl�or eac9 closely-0eltl wipo2�ion/par�nershlp Inleres�oI1M1e decetlent,o�her�han e
solepropnemrsM1iO�See inetmctlons for�M1a supporling InPormetion to ba submittetl for sol�pmprietorshlps_
ITEM NUMBER VAW E AT DATE
NUMBER DESCRIPTION OF�EATH
1
� � ✓� �' �' N r
TOTAL(Also en�er on Ilne 3, Recepituletlon) $
Qf more space Is neeaed.inseh atltldional sM1aets of�M1e same size)
REV-050.5 E%�(B98)
a�� SCREDULE C-7
�.,- .
oMMONwEp r oF pENNsy��qN�q CLOSELY-HELD CORPORATE
���EA�T""°ET"xRET°R" STOCK WFORMATION REPORT
aEsioENT oECEOEr�*
ESTATE OF FILE NIIMBEfl
1. Name o�Corporation__ . _�1z�U �i _ State on Incorpara�ion
Address �ate ai Incoryoretion
Ciry _ ._ State .ZipCode . TotalNumberolShareholders
2. Fetleral Employer I.D. NumDer_ _. .. _ Business Feporling Vear
3. Type o�Business_. . _ _ PmtlucUService
4- TYPE TOTALNUMBEROF NUMBEROFSHARES VALUEOFTHE
STOLK VotinglNon�Vating SHARESOUTSTRNUING PARVALUE OWNE�9YTHEOECEOENT OECEOENT'SSTOCK
Common $
Preferred $
Pmvide all righis antl res�ric�ions pretaining�o each class of stock.
5. Was the tlecetlent employed by ihe Corporation? . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Yes ❑ No �
J ��,
Ii yes, Position . N__�_ __Annual Salary $_ Time Devoted to Business
6. Was the Corporation indebted to ihe tlecetlent? . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O Ves ❑ No
If yes, provitle amount oi indebtedness S
]. Was ihere life insurance payable to the corporation upon fie tleath of ihe decetlentP . . . . . ❑Ves ❑ No � iJ � �
If yes. Wsh Surrender Value 3 _ .._ _ Net pmceeds payable$
Owner ai(he policy
8. Did�he tlecetlen[sell or iransfer an s�ock in�his company wi[hin one year prior ro tleath or within�wo years
iithe date of tleath was pnorto 12-31-82? , / .I �
❑ Ves ❑ No Ii yes. ❑Transier ❑ Sale Number of Shares N(� N �—
Trans�eree ar Pumhaser . Considera�ion$ ._ _ Date �
Atlaoh a separate sheec for atltlltional transfars anNor sales.
9. Was there a writlen shareholder's agreement in eHect a��he�ime d t�e decedenfs tleaNP . . ..O Yes ❑ No
If yes, pmvitle a copy oi the agreement !!! n 1
10.Was[he tlecedenYs stock soltl? .. ..... .. . . . . . . . . . ........ . . . . . .... ❑Ves ❑ No ��J I�' �
If yes,provitle a copy o�ihe egreement of sal&e�a
11. Was the coryoration dlssolvetl or liquitla�ed aker�he tlecedents deatM . . . . ... . ❑ Ves ❑ No
If yes.pmvide a breaktlown of disMbutions received by ihe esta�e,including dates antl amounts received.
12. �id ihe corporation have an in�eres� in o�her corpora[ions or pahnerships'+ . . . . . . . ❑ Ves ❑ No
If yes, repotl ihe necessary intorma�ion on a separate sheet, inclutling a Schedule C-1 or C-2�or each in�erest.
• • r • • � �
A. Detailed calculations used in the valuation of ihe tlecetlent's stack � l U ,�l r
/" I_
B. Complete copies of financial statemenis or Fetleral Gorporate Income Tax reWms(Form 1120)for the year oi death antl 4 precetling years.
C. Ii ihe corparation ownetl reel estate,submit a lis�showing ihe complete address/es antl es�imated fair ma�kel value/s.If real estate appraisals have
been securetl,atlach copies.
D. Lis�oi principal slockholtlers at the date oi death,number of shares held antl their rela�ionship to ihe decetlent.
E List o�aHicers,iheir salaries,bonuses antl any o�her benefits received�mm the co`pora�ion.
F Statemen�o�divitlentls paid each yeac List ihose declaretl antl unpaid.
G. Any other iniormation relating�o ihe valuation oi the decedenfs srock.
(If more spece Is neadeQ insert atldi(ionel ehee�s ol�M1e same aize)
aev-isoe ex. �suo1 � �
scNEou�E c-s
PARTNERSHIP
COMMONWENLTH OF PENNSYLVANIA
'""EA'�^"°Er"xAE�°A" INFORMATION REPORT
FESIDENT OECEDENT
ESTATE OF FILE NUMBEfl
._ _ __.__.. ___. .
1. Name of Parinership U r Date Business Commencetl
Address Business RepoNng Vear
Ciry State Zp Cotle
2 Pederal Employer I.D. Number
3. Type of Business Protluct/Sarvice
4. Decetlent was a ❑ General ❑ Limited pariner Ii decedent was a limited pariner, provide inttial invesiment$
5. .:�.PARiNEPNIIME P6pCENY � PEPCHi� OF . ...
�7 OPNiCOIA6 QFOWNEPBXIP CAPIfAk�.ACCOUM
A. I�/ l� I/� .
._ ... .. .. . .. . _ . _ .
��_.
e.
C.
D.
6. Value of ihe tlecetlenYs interest$
7. Was the Partnership inGebtetl to ihe tlecetlent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O Ves ❑ No �����1 /// � /
If yes, provide amounl of intlebtetlness$ �✓ J �
8. Was ihere life insurance payable to ihe paMership upon ihe tleath oi the tlecetlent? _ _ . O Ves ❑ No /
If yes.Cash Surrender Value$ Net proceeds payable$
Ownerofthepolicy � � ��� �� ����
9. Ditl the tlecetlent sell or transfer an interest in this parinership within one year prior to tleath or within rtvo years if iha tlate of tleath was
priorto 12-31-82? � l
❑Ves ❑ No Ifyes, ❑Transfer ❑Sale Percentage VansferreNsoltl � '� (�' �
Transferee or Purchaser Consideration $ Date �
Attach a separate sheet for atltlitional transfers antl�or sales.
10. Was there a written partnership aqreement in effect at Ihe�ime of�he decetlenfs tleath? . . . .. . O Ves ❑ No
Ii yes, provitle a copy of the agreement.
11. Was the tlecetlenfs partnership interest sold7 . .. .. . . .. . . . _ .. . _ _ . . . . . . . .. . . . .. . � Ves ❑ No , /J , r �`
Ii yes,pmvitle a copy of the agreement of sale,etc. 7/ N
12 Was ihe parmership tlissolvetl or liquitla�ed afler the decedenYs dea�h? . . .. . . . . . . . .. .. . .. . O Ves ❑ No /
If yes,pmvide a breaktlown of tlisfibutions receivetl by the estate,inclutling tlates antl amounts received.
13.Was�he tlecetlent relatetl to any oi the partners? . . . .. . . .. . . . .. .. . . . .. _ . . . . . .. .. . .. . 0 Ves ❑ No
Ifyes, explain
14.Ditl ihe parinership have an interest in other corporations or partnerships? . _ . . . _ . .. . 0 Ves ❑ No
Ii yes, reporl the necessary iniormation on a separate sheet, inclutling a Schedule C-1 or G2 for each interest.
� • •• � � �
A. Detailetl calculations usetl in the valuation oi the tlecetlenfs parinership interest J il.
� /7
B. Complete copies of financial statements or Fetleral PaMership Incnme Tae retums(Form 1065)for the year of tleath antl 4 recetling years.
C. Ii the partnership awned real estate,submit a list showing the complete atldressies and estimatetl fair market value/s.If real estate appraisals have
been secured,atlach copies.
0. Any o�her in�ormation relating�a�he valua�ion of�he decedenPs partnership in[eres�.
REV-150]E%.Il�]I
G-`- �„ SCREDULE D
commoNwen�rH oF vErvrusv�vnmin . MORTGAGES & NOTES
�NnEA�rANCErAxaE,uAN RECEIVABLE
aEsoEnr oECEOErvT
ESTATE OF FILE NUMBER
All proper�y lointly-ownetl wi�h right oi surviwrship mus�be tlisclosetl on Schetlule F.
ITEM VA W E AT DATE
NUMBER DESCRIPTIOV OF DEATH
, � �� � � ��
TOTAL(Also en�er on Ilne 4. ReceDiWlation) S
(Ii more spaw Is naetle4 Inse�atldltlona sM1eats of Ihe seme size)
REV-15oN E%i(f3d0)
�� pennsylvania SCNEDULE E
oEP<A.Me�roFAF�F��E CASH, BANK DEPOSITS & MISC.
���Ea�T+r,�F�^x aF*�'a" pER50NAL PROPERTY
aesoen.o��emr
ESTATE OF: FIIE NUMBER:
IncluOe[he proceeds of Iltlga[ion and[he da[e Ihe pmceetls were receive�by[he es[a[e.
All Oroperty]ointly awneE wi[h right of survivorship must be tlisclosetl on Schedule F.
ITEM VA W E NT DATE
NOM9ER DESCRIGTION Of DpEATH
' � �� �b �� �K �l lU i y Q N( b� /' „q_(-(.-F y p 0� � r�
l /1
TOTAL(Also enter on Line 5, RecaDitulation) S
If more space is needeQ use atlditional sheets ot paper oF the same size.
REV-ISo9 E%i(O1d0)
- '�� pennsylvania i SCNEDULE F
u"Ap�""���=r`�4N11� � 70INTLY-OWNED PROPERTY �'
�N�Ex��A��E.�aR�� . �
aes�oenr oeceoeNr
ESTATE OF: FILE NUMBER:
If an asset became joinHy owneE within one year of the decetlent's date ot death,it must be reported on Schetlule G.
SURVIVINGJOINTTENAM(5) NAME(5) ADDRE55 RELHTIONSHIPTODECEDENT
a. � � NI- �U N � —
e.
c.
JOINTLY OWNED VROPERT/:
�t�iFa wre DfSCRIPTIONOFvaOVEarv 'roaF onreoFofarn
]kM WR]OIM1T MqDE MCW�ENAMfOiF,NlWOALINSfRIIiION�N�9PNKFCC0UN1NVNtlENORSIMI'AP OPiEOf�EP�H �ECFDFNYS VAWEOf
NOKBER iENPNi JOIM IOFNiIMN6NOM9ER.PII9CX�ffDi0R;01NiLYXELORERLESiRiG V4WEOFPSSET IMf0.KT �ECE�ENi51NRRE5i
1. A.
�1� N F
TOTAL (Also en[er on Line 6, Recapitulatian) ;
If more space is neeGeQ use additional sheets of paper of the same size.
new�so ex+(oe-o9)
Y� pennsylvania SCHEDULE G
PAATME�* A�� ��F INTER-VIVOS TRANSFERS AND
�N�Ex:,ANCE,�aE.u� MISC. NON-PROBATE PROPERTY
nes�oen oereoevr
ESTATE OF FIIE NUMBER
TM1Is schetlule mus[be mmplete0 and fJeO if the answerto any of qdestlons 1 through 4 on page three of Me REV-15�0 is yu.
DESCRIPTIONOFPROPERtt pATEOF�EATH %OFDECDS E%LWSION TB%PBLE
ISEM iwiaEornic'au+srevem^,a�sorvstiivncceo=.u*nno
NIIMAER �rrvarvs-u an:�-nmvcr�ecfforcxva�Es*nr: VAWEOFASSET IMEREST rvaPvuc�n�i VALUE
1.
� � N i�
�
I
�
�
i,
�
i
TOTAL(Also enter on Llne 7, RecapiNla[IonJ §
I(more space is neetleQ use addt[ional sheets of pa0er of[he same size,
REV-15ll E%+(10-09)
�� pennsylvania SCHEDULE H
oFP�w*MEMOF^E�F��F FUNERAL EXPENSES AND
�xxeurnxarune,unri ADMINISTRATIVE COSTS
aesmexr ceaoErvr
ESTaTE OF FILE XUMBEA
DecedenPs debb murt be reportetl on Schedule I.
REM
NUMBER �ESCRfPRON AMOUNi
n. l �u1 � �uRE51�- k/,`1✓ F�'etU FUNFn'9"c �-�oM� �°RrE� �� his� `7� S'
N d� �[ ��� ,��+ , � �� 3 ofi�t
FR6NTS �� 5� '
7v �+ N' 2
�' '1 - 5' 3Cl ' � 3� � ��UZI. Gc.
C �VNtRB� ��nftc Clr{A/L�`FC �_�—J
� �� ' o.
�HJF6Kenfw2 �'ur� /TisSi�✓�rRv (3�tp �'s�- c µua�N
\ / j6 � � J
'�"111Sfc<<yv, �ufz rUN�RdL
B. ADMINISfRATIVECOSTS: �� �k��r� . .
1. Personal RepresmW[ive Commisslans: � � I
Name(s)o(Persanal Re/presen[ative(s) L' C _W,I, L 1 Y1 S _ __
Stree[Address.Z �V . .�0.i1(C r/fiS6� 1�..L �}�/f
__
CiN�kU� {'� ___ - _. ._ S�nre�uP I "7A 2 S'
Yeaqs)Commisvon PaiO:_�1 U IU b _____ . . . . ___ _
7. Fttomey Fees:
3. Family 6emp[ion: QF GecedenPs aEOress is no,t'th/e wme/as daimanPs,atbrh�plana[ionJ
Claiman[�_(,."t' f� _�"�`f�[}_� S —....- _
s�renaaaress 21 � _F.��L'.R Suvs. Li!-k�- —_. ._.
�h-�-��1 ✓�—_ _. __.._ —_ . ._. ._SUteJ��.ZIPI7D2 �
RNationship of qaimant to DeceGen[��f��.__
4. Pmbate Fees: 2 J �� ��
5. AaoundntFees: � SU. 0 'v
6. Tax ReNm Preparer Fees: Z SV' `' �
I.
TOTAL(Nw enter on Line 9, RerapRulatlon) S
If mae space is neetled,use aEditlwial sheets of Dacer of Ue same size.
� � ,, l ;S o T c v �c� -r�, _ o i_.-� 1,1��4 r
Major H. Winfield Funeral Home, Cor{�.
]OC NwM FrwM1 SVeM,SWlton.PA 17113(]1]I���
�ATE FabruaryT,2014 SERVICENO. p���4
DECEASEO NAM Tariq 0. .VYlliams
DA��9T�pEe sOF�EATH Febmary 3,3014 PLACE OF�EATH evp
fGef&�cnxn�� ff�jpyNa[YOu�eueJ�Mela2�¢Wlre¢mEalnli �urtMq'fJM�q. Ne�YIXaaemalOrybus�:g�yllemswe p WI�NIid�l�
�q e�aaeae mryRy�p �q �� tel'��'�•xn YOVmaYl�areln�wyfamiCelmiM.Yau �a1aw.
peyfaaMalmx59YWEitlrplEPpo'RX�vuYl�e�m9erylem55Wiee5'tli�eGevemelpn mNiate6urel.IfxeJte�NCUlwembelmin8.wexiBeWlaeiwFy
STATEMENT OF FUNERAL GOODS AND SERVIGES SEIECTED
A. CHARGE FOR SERVICES: C. SPE�IAL CHARGES:
Frcfessional Servicss FornaNing oi Rema:ns�o
BasicServircFeeofFuneislDirtwitt $ 1990.00 Immetlie:�aDunal 5 -d
Embalmiy $ 825.00 ReceiNriS of Remains fiom
AtlministraOmFe� $ .]- Crematia� g 1,225.00
Other BOCy Prepa2tions S 425 00 Botly Cwnation g �
$__�1_
Olhar(:ost g �
$ D § �
$ 0- $ �
EQuipmer�t 8 3zao.00 D. CASHADVANCES: 5 � 225ao
Use of Equip/5ta8 fir Viewiig 8l«Furt 8 4]5.0 Cemetery Charges E -0-
8esic Use a!Fadlities 8 -0- NewsPaper Nolice E -�-
Y�ev.irgNisita6on $ -0- Certified CoPies $ 36.00
Olher Use of Fauldies S -0- qergy Horwrenum $ "d
5 -0- Flowers 3 '0.
$ 4]5.00 MatkerFauMaGon S -�-
AulomolivaEquipmant VauftServiceFce S -�-
UseotFadlities $ "�- TentRentai $ -�-
FunerdlCoach $ 2]5.00 ChairRental S -0-
T2nsfero(remainstoFu�alHome $ 34500 �,p�her 3 -O
Removal fw Philatlelp�ie $ 275.00 p,ONer $ -0-
CkigYs Car $ -0' 3.Other 8 -�-
Utilily Vehide 3 '�- § -0.
Limwsirie $ 32500 g _p
Atltlitiw�al Limousiires S '�' g -0-
y �z2o 00
B. CHARGES FOR MERCHANDISE: We chargs you torour services in obtalnirg:
CaskM $ 4]5.00
Rental $ �.�
Outermmairier $ '�' SUMMARV OF CHARGES:
OuterContairier A. CHARGESPORSERVICES $ 4,93500
Vault B. CH.CRGES FOR MERCHAN9ISE S 825.00
AI[ema�eConlainer $ {�_ G. SPECIALCHARGES $ �.2z500
Um $ -0- D. CASHAD4ANCE5 $ 36.00
Registaeook/Cards $ A- E SALESTN(IFAPPLICABLE S -0-
Bunal Cldhirg $ O TOTAL FUNERAL HOME CHARGES $ 'l,021.00
Custom Cobr vnmirg Package g 350.00 LESS CREDIT AND PREPAYMENTS:
Acknawletlgemen[CaNs $ -O� Sernce�isco�nis $ -�'
HeatlstoneorMarker $ -0- Bunallnsurance S -d
Air Tray $ -01- $ -a
Memaial Fddars $ -0- Dovm PaYment $ -4
PrayerCards $ -0- TOTALCREDIT 8 -P
s � g 82500 BqIANCEDUE $ �0^.1.00
me mh�^sN.� me mekx ena � « wre. avial conra:vJ sda � rc8"r�a^•. °f�"�"'�v mzne.e :mmewN�d
�au����:i�aamKUK�+a - �ae.n..
canremon wiN tlna service is Ne eW��%x*itlen vertaniY. Ram'. WaMN Q�� A+a —� �,�_
oyMemanulatlua. Tns 1u�cai lwmemakesrowsaMy. e�resswnnplieC.
�N�eapGm memske�artlrorwlerEurulca�laner. un,0
BillingTo aresa isms Reason(arEmbWminy
716 Four Swsans Lane �'n —ry' - �
Emia,PA 17026(777�J78-0461 �� �1, ' . .
�nereMegrea ne��laveavn:ea�neabo.emmeaxanse�danamemammn.aanaxmiungmmeami �aqu aeaena��aebr+�dx am"ipla,mq�imis
memY+ndumarHaqeemaiLllierebY�tivllluvealfitlenlNtlseMeeceLak9�YewiaObtrcWN�a�Paradliereb'eF�xqmwn onXryeidamaal�
ke efS 1.03100 rdtlin 1 Jafi AlabNv9eaQ O.OQ6M+�mnN���yq b OAMPaIRaueWlitlbtle�rya tlbalencebep
Ne oftlYsxP�� A^YaEd4vul�wn+MeMi�atlnalw MeEaYdtltis vNbeomsEmatlW�afWaW��enO mYNaeolwll
ee �r.�s����� i�x�w.xae.m�i�re�amee '�n�Rl ee��4t�w�`"'m�'",4+�'m��a�ror��eaKo�,m.ww�m:��un
i�
�_.�'a� Qebtl RMationsMp b
�os9�James N.Tale � � Ralativnsh:p b Deceamd Irn�nals �n�
NemeaiNnera'Iromeiepresentelrve �r v J
v
The Gre�tter Zion 1VIissionary Baptist Church
� 'T Y Charles R.hleilc��r., Pcstar c =
212 NarcS Pm;•cz;Avcicc
FarisSu:;, Pcans�!vania lllG9
Cnvrch�i n 5:40_-3
Fax (71�..d74Z_I
FUNERAL SEP,VICE 8 EXPc.LIS= CONmnaCT FOR NOCIME:d9F?5
/
NzKE OF DECEASED _ �F!/\ I 4' G(// �6� %l��j,S
FGTIERP.L TO BE (on,at)
DP.TE: -[ljil/ �1GrTL7. !/.oZi �/ � �
PLP_CE: ��j�y2��C�i'� �/yL�
TIME: Fznily Hour ��� ��/¢� Funeral r�� ��/a��J�[,
F£ES n
��G'' ��
FL�i£R?L - ,§�g�gp/� (t'e � --�
RE��.ST: Yes `� No
=P Y�E��S�, -£ees zrz zs follows: "' Gj ,OG���'��''� �
/�'�G�„�f."r,�iC�G���SaLf tY-6�i761r
����-e�' . �6c»��j�o ��� � �C� , �'�
��z q ,f'..�z , s� �--�"�'� 6�� o
oa,a�o
Fees ta ce pzid before the czt= oP Service. - �p� . ���°��,/"�J `
r�# Ld�Z 8 ��
-Cpy �jex-esa �1:��1,1:�ai�vJ
� � �eh Z61/1�
F?SfILY REPRESENTATIVE ^-O"''u'" DaTE -T
� / 1� 0 �J G..�
Ch'LRCkF REP�SE.ATI . � �� � � - DATE G�i O � /
C
�
Easy To F+n�! — Hard To Far�zt'
Dote: February I I. 2014
� � � � � Invoice# TEW001
Client: Theresa E. Williams
Larry A Colbert
To: fieresa E. Williamz
216FourSeaSonsLone
Enola. PA 17025
Siaff Member Service Payment Terms
Lorry Colbert Musician for Funeral Full payment hos been received
Services
Do}es Description Price Line Total
Februory I I,2014 Pianist $I50.00 $150.00
Subtofal $ 150.00
Balance Due $ 0.00
Thank vou for vour business!
RECEIPT FOR PAYMENT
LISA M. GRAYSON, ESQ. Receipt Date: 4/29/2014
Cumberland County - Register Of Wills Receipt Time: 14 :54 :39
One Courthouse Square Receipt No. : 1077834
Carlisle, PA 17Q13
WILLIAMS TARIO A
Estate File No. : 2014-00419
Paid By Aemarks: THERESA E WILLIAMS .
DB1
- Receipt Distribution ---------——----------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 135. 00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 5. 00 CUMBERLIiND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
SHORT CERTIFICATE 20 . 00 CUMBERLAND COUNTY GENERAL FUN �
AUTOMATION FEE 5 . 00 CUMBERLAND COUN'1'Y GENERAL FON
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15. 00 CUbIDERI�AND COUN'TY GENERAL FUN
"""""'__'_'
Check# 1042 $218 .50
Total Received. . . . . . . . . $218 . 50
RECEIPT FOR PAYMENT
____________'______
_______________"__
� LISA M. GRAYSON, ESQ. Receipt Date : 6/27/2014
Cumberland County - Register Of Wills Receipt Time: 13 :23 : 07
One Courthouse Square Receipt No. : 1078413
Carlisle, PA 17013
WILLIAMS TAItIQ A
Estate File No. : 2014-00419
Paid By Remarks: THERESA E WILLIAMS
}A7W
------------------ Receipt Distribution -------------------
Fee/Tax Description Payment Amount Payee Name
SHORT CERTIFICATE 15 . 00 CUMBERLAND COONTY GENERAL FUN
________________
Check# 1049 $15 . 00
Total Received. . . . . . . . . $15 . 00
AAA.mm
2301PA%TONCHUROIROAD
HARRISBURG,PA,17110
Tel:717 6574264
O1 MAR 2014 11:18 AAA CENTRAL PENN
Receipt : 07YR-9875-33/PW7 RECEIPT
THERESA E WILLIAMS 938 195 865727900 6 BA
216 FOUR SEASONS LN Mem Since: 1995
ENOLA, PA
17025-2133
Re£erence �escziption Amount Domestic
1. SUN 1582767 NOTARY FEES (NF) .
3 @ 2.00 OS 6.00
Total 6.00
C Payment 6.00
1. SON NOTARY FEES
DON'T MI55 OOT! Join the 1,000's of inembers who have saved hundretl•s
o£ dollars on their Auto d Home Insurance. Call or visit your local
AAA Central Penn Office for a free qucte.
�o you Show your Membership Card at the following locations:
Tangen Outlets, New York 6 Co. , Payless Shoes, LenscraRers,
NAPA, Reebok Outlet Stozes
I£ you do, your savinqs will be 108 or more.
Go to AAA.com Eox a complete listing.
AAA.cam
2301 PAXTON CHURCH ROAD
HARRISBURG,PA, 17110
Tel:717 65�-2244
. __ .. . . .. ._..
29 APR 2019 16:13 AAA CENTRAL PENN
Receipt : 07PR-9925-53/TG1 RECEIPT
THERESA E WILLIAMS 938 195 865727900 6 BA
216 FOUR SEASONS LN Mem Since: 1995
ENOLA, PA
17025-2133
RefeiencE OesciiptiOn Amount Oomestic
___'_________'___ _________________'__________________ ______ ________
1. SON 1602187 CLAIMANT'S STATEMENT
NOTARY FEES (NF)
1 @ 2.00 US Z•�a
Total 2.00
C Payment 2.00
____""_______'____
1. SUN NOTAftY FEES
DON'T MISS OUT! Join the 1,000's o£ members who have saved hundred•s
of dollars on their Auto s Home Insurance. Call or visit your local
AAA Central Penn OfEice for a free quote.
_________'______'__'
Do you Show your Membexship Card at the following locations:
Tanger Outlets, New York 6 Co., Payless Shoes, LenscraEters,
NAPA, Reebok Outlet Stores
If you do, your savinqs will be 108 or more.
Go to AAA.com for a complete listing.
AAA.com
2301 PN(TON CHIIRCH ROAD
HARRISBUftG,PA,I7110
7e1:717 657-2240
11 JUN 2019 15:25 � AAA CENTRAL PENN
Receipt : 07PR-9961-58/PW� RECEIPT
THERESA E WILLIAMS 938 195 Bfi5727900 fi HA
216 FOOR SEASONS LN Mem Since: 1995
ENOLA, PA
17025-2133
Neference Description Amount Domestic
___'_____________ ________'___________________________ ______ ________
1. SON 1617619 NOTARY FEES (NF)
1 @ 2.00 a5 2.00
Total G.UU
� C Payment 2.00
1. SUN NOTARY FEES
DON'T MISS OOT! Join the 1,000's of inembexs who have saved hundretl's
of tlollars on their Auto 6 Home Snsurance. Cali ox visit your 1oc31
AAA Central Penn OEfice for a free qmte.
____________________
Oo you Show your Membezship Card at the following locations:
Tanger Outlets, New York 6 Co. , Payless Shoes, Lenscrafters,
NAPA, Reebok Outlet Stozes
IE you do, your savings will be 10$ or more.
Go to AAA.com Eoz a complete listing.
0 0�ti a �N
x oz
y O B U
� ti O .TI 0000� (0
O 000 -� 3N d
•+ n# 4i m O O 3 -�
d [] G �
. f y � w �(O f -i 2 SS �
N O [D IO - 6 O
� =i c N
m �n
--� m m
� m m �0 x a� �
(n `� � � �n � sn �
00 Of � ry �\
(�l� O [�i� f � [.�.tro � M l(�J}
oo� , of m � „'
N N N �(�/}
-� O(� O O(D � �O [n .'� �
J A OYDC�i O O -1 ��
.. � _ ._._�.�yp .mx. _
. .- ' -.�F-. :jle.y_
. . - .-. \i] � _I�n. .� . .�. .
'C4G l
L�IH- (J.i �_ :FYIJ �NN �
_'v. . ..� '�-. Li .� � � v
- F. 1 : - . - ' ar 9fiE v > v ,, d
' — — _—
��TM�F �'���� R E C E I P Y 67-
OEPAfRMENT Of REVENUE
p�E�o F� �/ DATE NeNune.a(J
l. r l � � f �TN ORY �cqq
qpqiF.55 � 1 Q�'�'1 WT
(GV9 lTlaly / �
a I 6 f'ou oh .nt�s
NAOUM
FOX�'NE V/�RlILUlARS
���� 3 �° � �` �I � 5. W� ,�,�
o � Pm�' ��iy-S I /'� q
Inwica I O✓' n/O` / � f/ ��
�� I
F�vD INDEX CODE
�--r--� � � � SOLRCE CODE O
�lJll I �
NOTE: 1
A SP2AR.s'!E aECg�Tf IS R�Q��p�gp FOR EpCH 1NpEX CODE ��
CEPPRiMEM �
�
�M�.��. e ,o��
1FIFMroNE MINBER I I � VV ' S
/lJ
eiFa�pev.,m5� CI�YOR TIIIS IS NOT q IJCENSE
d Q � � � - - _
_� - 3
W � O j T - - _ m m
O Ot = _ _ � _
� � x - vo = - LL �E�^ o .; g � oe y a=po a
e a z _ O 0 �3 - _ � c U a
m � - _ - � � e � �' m 4 .
n � = - _ _ - - „r H m n ; '- _
C tt > a�v O � m w w 3 �_ V � - O o 2 N 3 � v�� O a
r
� � f
; � � 5
w n
,�—� i E b Z 6 Z b 8 L O L l # _
_ �"�.'s�^��.�'�"�d."-°::�ii�„w a��� o
�- m..� .w�+��..������
� w��..aimm.a...�w.w000,.0.. w� n
em�.d�.pnw�..oa _
_ ¢ IN3� NV aNtl S�JtlI�ZZ 00'ZZ$ 4I£�90 la EZI600 Nll 5669LE 17tl z_
p 'w�•siicgq{zAe�ozu�u�als�9 o1o5 �uattiq OPO'OT �ana �p�eas y
y ay pue vew u.�ezi ul 7uauAed ,}u ,{nc,�a paaiue.ien6 �yaE pire 2
= siI7q �nu.( Tje .a,} a.�;naas sluau,ce� �o;tUi uaalsapl nau azla A�1 rn
QT'�� V A ' ,.irvw8� -(/� G
� �
. . •
v ec = c
- — s. � ,.s «3� � _
� = L a � � - 'n o'
m ' � _ _ ^ �m m "' jo n5 m ''
_ a � _ � ` o �: � m - = _
:7 v i� � � C J - a .n
� � :D � n -' N � ✓J L �T N n ..
^Gv - > � � .� _
0 y ^ _ ^ � _
�l. ' ' � � y .1
n Y
) C � �^ L �=�` = ,•..4. � j __
.� \ � q � T � � D N
� 1� � T U
Gi S � V - � �
� 7N n � f
.. 9 = � O � S^ pl
� � � rO 9 2 N al
y � w
_ ' � � Z �
- -__
� � - � Page 1 of 1
Share and Loan List
Account #######840 Tariq Williams
Account T General Membership No Relationship
YP��
'1'c�e 13irthdAic titiN HomcPhonc
�lcmbcr 1
TARIQ WILLIAMS Primary 09/24/1985 k##!-##-#### 717-364-7576
"1'HERESA� WILLIAMS Joint 08/07/1964 #H#-##-####
IOSEPH K WILLIAMS Joint 07/17/1964 ###-##-tk###
216 FOUR SEASONS LN
ENOLA, PA 17025-2133
ti6arc Ucscrip(inn Maturitc U�dc Acailnblc Balancc
50001 SAVINGS 0.00 5.00
S 0040 CHECKING 508.68 508.68
a��e � /—,r= /� NO_ .
�e�.�arm�� f��7rt� ul�l(�'�N� 5-a• � .
ame�����c�� .�'t'i,-.
m,payme„coi �oY2 /'}CCo'�u}gY, G
Q cx�� Q o.aeev Q m a�� �merx x
m e�e /A/
num paltl I,Om a'����.-�T � —
am �- ��
'�SC 156Y5
de�e� /� /2��N0. _ . _
receivedfrom�HFr�ra �.J;��,�ar, s 2So :' .
ama�� � Nu„dt.l1 �i�i—
fm peymenl at U I` L L/'-/Nn
O�sn O mo�er �� (�j�a s
ome, m
amoum aue
���w�e i�m� �o
W u—�'
�am � � scnsnvs
urv�isiz ex+ pz-oe)
�� pennsylvania SCHEDULE I
oE=aF�Mr��o-aEvc�+uE DEBTS OF DECEDENT,
�'."Ea�-"v�ET^*�E��a" MORTGAGE LIABILITIES & LIENS
IIISIDEYiDECE�ENi
ESTATE OF FILE NUMBER
Repar[debts incurre0 by the EereCen[prior to death that remained unpaiE at the tla[e of death,induding unreimburseO meEical expenses.
ITEM VALUf AT DATE
PIOMBER D'SCRIPTION OF DEPTH
� S � � �e.. �� � � --
�sk�r?t .iNFonrt� �r�N 5'Fedr«, L� �
I ,}r �lG. G9
5E«NnnRr n�n�u � sr-a v�-« �� � � I �{� `��2� g�
Srr�No� ny /7���� � S�� v��«, u � ---� 3 � ��, j3
� G75- l5
SF roNnnnr IY/��zi1�l- S �����_s�L� c � i
Sf c�Nn� ny hAnl« 1- S - � � �Z y; `1`'F
�'� jES �f�/� ctlEl�
TOTAL (Also enter on Gne 10, Recapi[ula[ion) $
If more spa�e is neetled, insert adtllUonal sheets of ine same size.
_ i��r��w�u��i� 004�,
❑ Natiomuide`
Insurence
NATIONWIDE INSUfiANCE
F O BOX 30000
RALEIGH NC 2]6564003
1-800-<21-3535
PolicyHolder. T W��LIAMS ClaimKey: 58 37 E 4fi570o 02-02-14 01
Policy Number: Check Number: 5e223o74
CorrtractNumber. Checkissued: 05-22-ta NPMc
Below Check Covere Items IndicateC
FULL PAYMENT OF t0000.001S FOR THE INJURY OR INJURV RELATED �OSS SUSTAINED
BE EIFITS CCSVES AGE bF TARI�AND IS BEING PAID UNDER THE ACCIDENTAL DEATH
IF YOU HAVE ANY�UESTIONS REGARDING YOUR CLAIM, PLEASE COMACT YOUR CLAIMS
REPRESEMATIVE.
N
O
A
O
O
O
N
M
O
O
f>bpR2o fA'��2�.
i�ii��iaw���ir� o��z
❑ Nationwide
Insurance
NATIONWIOEINSURANCE
P O 80X 30000
RALEIOH NC 2]656-1003
1-B00-G21�3535
Policy Holder T wl LL I aM5 Clalm Key: 58 37 E 965700 02-02-I a o 1
Policy Number: Check Number: 58223075
COn[faC[ Numbec CheCk ISSUed: 05-22-14 NPMG
Below Check Covers Items Indicatetl
FULL PAYMENT OF g1,500.00 IS FOR THE INJURY OR INJURY RELATED LOSS SUSTAINED
BY WILLIAMS, ESTAYE OF TARIQ AND IS BEING PAID UNDER THE FUNERAL BENEFITS
COVERAGE.
IF YOU HAVE ANV QUESTIONS REGAflDING YOUR CLAIM, PLEASE CONTACT YOUR CLAIMS
REPRESENTATIVE.
m
N
O
N
v
O
0
0
N
M
O
a
flmvrh bu6 Rnbvn Cachinn �nd Rmn Fnr Vnnr Ror..r.1 �����srzom
CUMBERLAND COIJN"1'Y PROBA'fE COURT
1 COURTHOUSE SQUAR�ROOM 102,ATTN: REGISTER OF WILLS
CARLISLE PA 17013
In the Estate of TARIQ WILLIAMS, Deceased
Cue No. 2014-00419
Release of Claim
The claim submitted in the above-captioned Estate on behalf of Navient in the amount of
$14,716.69 for account number�x�c�x0109 has been paid by the Estate for a pro-
rata amount of$4,69991. This Release of Claim is executed to acknowledge dischazge of
the claim against the Estate and to release the estate and the Personal Representative of
the Estate from all further liability with respect thereto, unless before the Estate is cbsed,
additional asse[s are found, and funds are available to pay the remaining balance on the
origiaal claim filed.
Agent of Claimant
Address: PO Box 1370
Reynoldsburg OH 43068-6370
Telephone: (877) 714-3739
Date of Release: 11/06/2014
Reference No. 3729040
Probate Specialist: ACtS�� �• �Og��
Estate Information Services, LLC `
� �;:.
PO Box I370 - �
Reynoldsburg,OH 43068-6370 Huurs:M-TSam-9pm,W-ThBam-]pm,FBarn-SpmEST
Deccased Account Collection Ageucy
Yo0 F�ee:(877)714-3739 Phoue:(614)729-1740 Pmc:(614)861-7017 www.probate<aze.com
OB/21/2014
THERESA WILLIAMS
216 FOUR SEASON LANE
HNOLA,PA I7I25
RE EstateOf: 'IARIQ WILGAMS �
Creditor Nsme:SECONDARY M1tP.RKET SERVICES,LLC
Account Type:STUDHM LOAN HE Amount of DcbC$14,716.69
Account Number:x=.=.saar.rQ�ag Reference tl3727040
Dear THERESA WILLIAMS:
Pursuant to our telephone conversation on 08,�20/2014,payment artangemrnts were made for ihe abwe account.
Please see�eversc for the oayment scheAule.
Please mail the payment ro our office with the ettached cwpoq or you may visit our secure website at
htm�//www.probate-care com/gaymen[ro process the payment clectronicalty at no addifional cos[. Please mte,there
is no personal liabiliry to you associaled with auy balance owed on this account fiom your personal azsets orjointly
owned asseLs.
Fstate Infortnalion Services is writing this letter to you because you represen[ed to our office that you are the penon
responsible for accepting estate daims,paying any outstanding bills for TARIQ WILLIAMS out ofthe asseLs ofthe
esrate,or handling any financial or busi�ess affairs for TARIQ WILLIAMS.
Should you have any questions,or if you believe you have received this letter in ertor,please feel free to contac[this
office at the toll-free number listed above.
Esla(e Informatian Servicu,LLC is a debt calfectian campany. Tha u'an a(tempt m collec(a deb(frnm the assets
aflhe eslafe ojTARIQ WILLIAMS and any informalion obmined will be vsed for[ha!purpose. CaHs may be
monitared or rerorded for qvality assvrance pvrposu.
Sincerely.
ESTA"!E INFORMA'IION SERVICES,LLC
ec:EdiN Deen,LeRal Assistant
Cut along this lin: —
PleaseMakeCheckPayableTo: � �
SECONDARY MARKET SERV ICES,LLC
Mail Payment Ta: ^�L"��-,��.�� .M1�. .'�.
Eslate Infoimation Services,LLC. DebrorName:TARIQ WILLIAMS
PO Box I770 Reference#:3727040
Reynoldsburg OH 43068-6370 Amaunt Due:$I4,716.69
CUMBERLAND COUNTYPROBATE WURT
1 COURTHOUSE SQUARE ROOM ]02, A7TN: REGISTER OF WILLS
CARLISLE PA 17013
In the Estate of TARIQ W iLLIAMS,Deceased
Case No. 2014-00419
Release of Claim
The claim submitted in the above-captioned Estate on behalf of Navient in the amount of
$14,472.97 for account number xacxxxaccx�0102 has been paid by the Estate for a pro-
rata amount of$4,620.11. This Release of Claim is executed to acknowledge discharge of
the claim against the Estate aud to release the estate and the Personal Representative of
the Estate from all fudher liability with respect thereto, unless before the Estate is closed,
additional assets are found,and funds are available to pay the remauung balance on thc
original claim filed.
Ageot of Claimant
Address: PO Box 1370
Reynoldsburg, OH 43068-6370
Telephone: (877) 714-3739
Date of Release: I 1/06/2014
Reference No. 3727039
Probate Specialist: '���� �` 8�99�
Estate Information Services, LLC ��
� � �
PO Box 1370
Reynoldsburg,OH 43068-6370 Ho��s:m-r s,m-v�,w-�rn aa�-apm,e s�-spm esT
Deceased Account Collecdon Agency
Yoll F�ce:(877)714-3739 Phoue:(614)729-1740 Faac:(614)86I-7017 www.probatecaze.com
asmizoia
THERESA WILUAMS
216 FOUR SF.ASON LANE
F,NOLA,PA17125
RE Pstate Of:TARiQ WILLIAMS
Credim�Nzme:58CONDARY MARICET SERVICES,LLC
Accoun[7ype:STUDF,Nf LOAN HE Amount ofDebe$14,472.97
Account Number:'•"•"""*0102 Reference#:3927039
Dear 771ERESA WILLIAMS:
Pursuant ro our telephone comersation on 08Y102014,payment arrangements were mede for the above accowt.
Please sce reverse for the payment schedule.
Please mail the payment to our office with the atteched coupoq or you may visit our secua website at
h 'lto//www.p b t - m/py t to process the payment electronically at no additlonal cost. Please note,there
is no personal liability to yoo associated with any balance owed on this account from your personal assets or jointty
owned assets.
Estate Infolmation Services is writing�is letter to you because you representW to our office Wat you are the persou
responsible for acccpting estare claims,paying auy oulstendivg bills for TARIQ WILLIAMS out of the assets of the
estatq or handling any financial ar business affaiis for TARIO�LL[AMS.
Should you have any questions,or if you believe you have received this letler iu erroG please feel @ee to co�lact Nis
ofice at ihe toll-fiee number listed above.
Esla(e In(ormation Services.LLC is a debt ca/lection compnny. This is an ottemA�to rollecl a debt(�om the asselt
ofthe eslate ojTARIQ W/LLlAMS arsd any information obmirced wil!be usedfor that purpose. Calls may be
monitored or ruorded for qualiry atsu�ance pvrpasw.
Sincerely.
ESTATE MFORMA'tION SERVICES,LLC
cc:Cdith Deeq Legal Assistant
-- Cuf el0ug[hiS lin
PleaceMakeCheckPayableTo: �� .
SECONDARY MARICEI SERVICES,LLC
Mail Paymeut To: � ,.•"n.�.,�.��„�.., .u..
Esmre Inlortnetiav Services,LLC. DebmrName:TARIQ WILLGIMS
PO 8ox 1370 Reference#:3727039
Reynoldsburg,0[1 43068-6370 Amomt Due:$14,472.97
CUMBERLAND COUNTYPROBATE COURT
1 COURTHOUSE SQUARE ROOM ]02, ATTN: REGISTER OF WILLS
CARL]SLE PA 17073
In the Estate of TARIQ WILLIAMS,Deceased
Case No. 2014-00419
Release of Claim
The claim submitted in the above-captioned Estate on behalf of SECONDARY
MARKET SERVICES, LLC in the amount of$3,675.15 for account number
xxxxarxxx�t0110 has been paid by the Estate for a pro-rata amomt of$1,173.19. This
Release of Claim is executed to acknowledge dischazge of the claim agains[the Estate
and to release the es[ate and the Personal Representa[ive of the Es[ate hom all furtlier
IiabiliTy with respect thereto, unless before the Estate is closed,additional assets are
found, and funds aze available to pay the remaining balance on the origival claim filed.
Agent of Claimant
�- Address: POBoz1370
Reynoldsburg, OH 43068fi370
Telephone: (877) 714-3739
Date of Release: ll/04/2014
Reference No. 3727041
rrobace s��tatisr. qnna C3. Ba99s
Estate Information Services, LLC � ; ,,, ,,,
PO Box 1370
Reynoldsburg,OH 43068-6370 Ho�@:M-r e�-vpm,w-ih a�,-��,F�x�-spm esr
Deceased Account Collection Agency
Toll Free:(877)714-3779 Phoce:(614)729-1740 Fan:(614)861-0017 www.probate-care.rom
OB/2I/2014
'C}IERESA WILLIAMS
216 FWR SEASON LANE
HNOLA,PA17125
RIi Esmte Of.TARIQ WILLL4M5
Credi[orNaznc:SECONDARYMA2KETSGRVICES,LLC �-
Account Type:STUDENT LOAN HE Amount of Debt$3,675.15
Aceount Number:"*`•«arr«�+Ol ID &eference M3727041
Dear THERLSA WILLIAMS:
Ymsnant to wr telephone comersation on 08/20/2014,payment ar(ang�ents were made for the above account.
Please see mverse for ihe paymrnt schedule.
Please mail the paymrnt ro our office with the attached wupoq or you may visit our secure website at
htto'//wvno proba�g-�are mm/navment to pmcess the payment electronically a[no additloml wst Please mte,thue
is no personal liability ro you associated with any belance owed on this accou�t from your personal azsets orjointly
owned azsets.
Estate Infortnation Servicu is wnting this letter to you because you represented to ow of5ce lhat you are the person
responsible for accepting estate claims,paying any outstaoding bills for TARIQ WILLIAMS out of fie asscts of the
esfate,ar handling eny financial or business affairs for 7ARIQ WILLIAMS.
Should you have any 9ues[ions,or if you believe you have received Wis le[ter in eaoy please fml fiee to contact�his
office at lhe lo0-free number li5ted above.
Esmre Information Serviees,L/.0 is a debt collection company. This 's an a((empt m cof(ec!a debf from the assets
oflhe estate ojTAR7Q WILLIAMS and any injormafion obmined will be vsed for that pvrpnse. Ca(!s may be
monitared or recorded for 9vality assurance purposes.
Sincerety,
ESTATF.INFORMATION SERVICES,LCC
cc:Edith Deeq LeRal Assistant
Cut alonR this lin
Pleau Make Check Payable To: �
SECONDARY MARKET SERVICES,LLC
.�.�.��.;,,.,:.��.,..._.��., .ii,
Mail Paymeot To:
Esfaro Information Services,LLC. Debtor Name:TAAIQ WiLLIAMS
PO Box 1370 Reference#:3727041
Reynoldsburg,OH 43068-6370 Amount Due:$3,675.15
CUMBERLAND COUNTYPROBATECOURT
1 COURTHOUSE SQUARE ROOM ]02, ATI'N: REGISTER OF WILLS
CARLISLE PA 17013
1�the Estate of TARIQ WILLIAMS, Deceased
Case No. 2014-00419
Release of Claim
The claim submitted in the above-cap[ioned Estate on behalf of Navient in the aznount of
$3,160.13 for account number�c�c0101 has been paid by lhe Estate for a pro-
rata amount of$1,008.79. This Release of Claim is executed to acknowledge discharge of
the claim against the Estate and to release the estate and the Personal Representative of
the Estate from all fuRher IiabiliTy with respect thereto, uuless before the Estate is closed,
additional assets are found, and funds aze available to pay the remaining balance on the
original claim filed.
Agent of Claimant
Address: PO Box 1370
Reynoldsburg OH 43068-6370
Telephone: (877) 714-3739
Date of Release: I 1/06/2014
Refereuce No. 3727038
Proba[e Specialist: ,�nC�r� �� ��g�
Estate Information Services, LLC ` ��
PO Box 1370 �
Reynoldsburg, OH 43068-6370 Huurs:M-T%vn-9pm,W-Th Sam-"Ipm,F Pam-Spm EST
Deceased Accomt Colleceon Agency
Toll Frer(877)7143739 Phone:(6I4)729-ll40 Fae:(614)Sfi1-7019 www.probatecare.wm
08/21/2014
THERESA WILLIAMS
216FOURSEASON LANE
F.NOLA,PA 17125
RIi Fstate Of. TARIQ W[LLIAMS
Creditor Name:SECONDARY hL4RKE'i SERViCGS,LLC
Account Type:STODENT LOAN}IE Amount of Debt:$3,160.13
Account Number:"•"':a.ss.0I0I Reference#:3727038
Dear THERESA W[LLIAMS:
Pursuant[o our telephone comersadon on 08/20/2014,payment armngements were made for Ne a6ove acwunt.
Please see mverse for the payment schedule.
Please mail the payment ro our office with the attached coupoq or you may visit our secure website at
htt ./hnw+,grobare-care coMpayment ro process the payment electronically az no addirional cost. Pleau note,tLere
is no personal Iiability to you associeted with any balance owed on tltis accouut&om your personal assets orjoinUy
owned assets.
Gstare Infoimation Services is writing this letter to you because you represented to our office ihat you are the pe2o�
responsible for accepting es�ale claims,paying any outstanding bills for TARIQ WILLIAMS ou[ofthe assets ofthe
esmte,or haodling any finencial or business at£airs for YARIO K'�LUAMS.
Should you have auy questlons,or if yw believe you have received this letter in erzor,pleaze feel Gee ro wn�act this
of5ce at the toll-fiee number listed above.
Estate ln�ormatian Servicu,LLC is a debt col(ec(ion mmpany. This ir an a[tempt m col/ect a deb(J'iom/he aste(s
of(he ulate ofTARlQ WfLLIAMS and ony info'mation obmined wil/be usedfor tha+purpose. Ca(!s may be
mortitored or recordedfor qualiry assuronce purposes.
SincerelY.
E57'ATE iNFORMATION SERVICES,LLC
ca Edith Deen,Legal Assistan[
Cut along this lin —
PleauMakeCheckPayableTo: �- � - -
SECONDARY MARKET SERVICES,LLC
.,..�..�,..,.,,:�,. ,�.��._.u..
Mail Payment To:
Esmte Information Servica,LLC. Debtor Name:TAAIQ W[LLIAMS
PO Boz 1370 Reference q:3727038
Reynoldsburg,OH 43066-6370 AmountDue:$3,160.13
Ksa uis Ex—(oi-io;
� pennsylvania SCHEDULE J
°"°"�"`��o�p`�`��` gENEFICIARIES
��,nE��.FN::E.A,uE,�aN
aesm=Nr oE�Eoervr
ESTATE OF: FILE NUMBER:
REUTIONSNIPTODECEDENT AMOUNT045HARE
VUI-0BER NAME APID AD�RESS OF PERSON(5)RKEIVIN6 P0.0GERTV Do Nof List Tms[ee(s) OF ESTATE
I -AYJ�BLE�I4RIBUTIONS [Indctle ouMgM spousal tlistnbutions ana[ra�sfers unGer
Sec 9ll6(aJ (1.2).]
1.
EMER DOLNR AMOJNTS FOR DISTRIBUTIONS SPOWN AAOVE ON LINE515 THAOU6H 1B OF REVd500 COVR SHEET,AS FPPROPRIATE
�� NON-TAXABLE�ISTRI9UTIONS
A. SPOUSAL�ISTAI9UTIONS UNDER SEQIOIV 9113 FOR INHICh AN ELE�ION TO'AR IS NOi TANEN:
1.
B. CNARITABLE AN�GOVERNMENTA_DI4RIBUTIONS'.
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE �ISTRIBl1TI0N5 ON LINE 13 OF REVd500 COVER SHEET. S
If more space is neeGeo, use atlditional sheets of paper af the same slze-
���,"`�`"�°" � SCREDULE K
LIFE ESTATE, ANNUITY
COMMONWEALTHOFPENNSYLVANIA & TERM CERTAIN
INHERITANGE TA%RETURN
aesioemr oeceoervi Check Box 4 on REV45��Cover Sheet
ESTATE OF FILE NUMBEP
This schetlule is lo be usetl for all single life,joint or successive life estate antl term certain calculations. Por tlates of tleath prior to 5-1-8&.
actuarial facrors for single life calculations can be obtainetl irom the �epartment oi Revenue,SpeciaHy Tax Unit.
AcNarial factors can be�ountl in IFS Publication 145Z Actuarial Values,Alpha Volume!or tlates oi tleath irom 54-89 to 4-30-99.
and in Aleph Volume for tlates of tlea�h irom 5-1-99 and ihereafter.
Intlicate the type of instmment which created the luWre interest below and atlach a copy to the tax reWrn.
❑ Will ❑ Intervivos Deed of Trust ❑ O[her
.
NRME�S)OFLIFETENAfir�S) OATEOFBIFTH NEpPESTAGEAT TEHMOFYEAPS
DATE OF DEFTH LIFE ESTATE IS PAVABLE
❑ Life or O Term of Vears
❑ Lite or O Term of Vears
❑ Lite or 0 Term of vears
❑ Life or O Term oi Vears
O Life or 0 Term o�Vears
1. Value oi funtl from which life estate is payable . . . . . . . . . _ . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Actuarial facbr per appmpriate table . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interest table rata-0 3 V2% ❑ 6% ❑ 10 i ❑ Varlable Ra�e o
3. Value of Iife es[ate(Line 1 multiplietl by Line 2) . . . . . _ . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .$
. �
NAME(S)OF LIFE ANNUITANT�S) DATE OF BINTH NERPEST RGE AT TEflM OP YERflS
UATE OF DEATH ANNUITV IS PAYABLE
❑ Life or 0 Term ofYears
❑ Life or �Term of Vears
❑ Life or �Term of Vears
❑ Life or �Term o�Vears
1. Value of funtl�rom which annuiTy is payable . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Check appiopriate block below antl enter corresponding (number) . . . . .. . . . . . . . . . . . . . . . . . . .
Frequency of payout-� Weakly(52) ❑ Bi-weekly (26) ❑ MONhty(12)
❑ �uaherty(4) ❑ Seml-annually (2) ❑ Annuelly(1) ❑Other( )
3. Amoun�ofpaYou�perperiod . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
4. Aggregate annual paymern, Line 2 mul�iplietl by Line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Annuiry Factor(see insVudions)
Interesitablerate-031i2% ❑ 6% ❑ 10% ❑VadableRete ie
6. Atljuslmen� Factor(see instmctions) . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
]. Value o�annuity- If uaing 31/2%, 8%, 10%,or I�variable rete end period
payout is at end ot periotl,calcula�ion is Line 4 x Line 5 a Line 6 . . . . _ . . . . . . . . . . . . . . . . . . . .$
If using variable rate and periotl payoutis at beginning ol periotl,calculation is:
(Line 4 x Line 5 x Line 61+ Line 3 . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
NOTE:The values of ihe funds which create the above WNre interesis must be repohed as pah of the estate assets on Schedules A ihmugh
G of ihis�ax retum.The resulting life or annuiry interest(s) shoultl be reporletl at the appmpriate tax rate on Lines 13 antl 15 through 18.
Qf more spece Is needeQ inse�eddi�ionel sbeets ol the same size)
aev-�ean �+ (oi-ia)
7 i'pennsylvania lNHERITANCE TAX
��� SCHEDULE L
wNea�rnrv�ernxaeruarv REMAINDER PREPAVMENT
aesmenroeceoemr OR INVASION OF TRUST CORPUS
I. ESTATE OF FILE NUMBER
This schedule is aDP�opriate anty for es[ates of decedents dying on or before Dec. 12, 1982.
This schedule is to be used for all remainder returns when an election m prepay has been filed untler the provisions of
Section 714 of the Inheritance and Estate Tax Act of 1961 or[o report the imasion of trust mrpus (principal).
II. REMAINDER PREPAYMENT:
A Election [o Prepay Filed with the Register of Wills on � �
Date)
B. Name(s) of Life Tenan[(s) Date of Birth Age on Da[e Term of Years tncome
or Annuitant(s) of Elettion or Annuity is Payable
C Asse[s: Complete Schedule L-1
1. Real Es[ate . . . . . . . . . . . . . . . . . . . . . . . . . . .$ �j
2 Stocks and Bonds . . . . . . . . . . . . . . . . . . . . . .$ �
3. Closely Held Stock/Partnership . . . . . . . . . . . . .$ _ �` '
4. Mort9a9es and Notes . . . . . . . . . . . . . . . . . . . .$ �"'
5. Cash/Misc Personal Property . . . . . . . . . . . . . .$ _ _ Sp�' ° ".
6. Total fram Schedule L4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
D. Cretlits: Complete Schedule L-2
1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . ., . .$
2. Unpaid 6equests . . . . . . . . . . . . . . . . . . . . . . .$
3. Value of Non Indudable Assets . . . . . . . . . . . . .$
4. Total from Schedule L4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
E Total Value of Trust Assetr (Line G6 minus Line D-4) . . . . . . . . . . . . . . . . . . . . . . . . . . .$
F. Remaintler Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
G. Taxable Remainder Value (MW[ipty Line E by Line FJ . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
(AISo enter on Line 7, ReCapitula[i0n)
III. INVASION OF CORPUS .
A. Invasion of Corpus
(Month, Day, Year)
B, Name(s) of Life Tenant(s) Date of Birth Age on Da[e Term of Years Inmme
or Annuitant(s) Corpus or Annuiry is Payable
NI � Consumed
C. Corpus Consumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
D. RemainderFactor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E. Taxable Value of Corpus Consumetl (Mul[iply Line C by Line �) . . . . . . . . . . . . . . . . . . . .$
(Also en[er on Line 7, Recapitulation)
REV-1665 EX� Q F09)
�
J, � INHERITANCETAX
�y� pennsytvania ' SCHEDULE L-1
.a . � � . .
:rvnea,-Rrce�,ixarcm REMAINDER PREPAYMENT ELECTION
PESL691JECE,Ci.\f
-ASSETS-
I. ESTATE OF FILE NUMBER
II. ITEM N0.'� DESCRIPTION VALUE
�: A R=al Estate !Please Oescri6e.)
�, ( J�
i Total Value of Rezl Estate $
' ([ntlude on SeRion II, Llne Gl an Schedule L.)
�B. Stocks and eonds (Please Ils[.)
� � ��
To[al Value of 5[acks and Bonds $
QnduCe on Section II, Line G2 an Schedule L) �
� C. Closely Held Stock/Partnership- Please GSL (At[ach Schetlule C-1 and/or G2.)
N � �
� Total Value of Closely Held/Partnership y
(Indude an Section II, Line C-3 on Schedule L.)
�, D, Mortgzges and Notes (Please IISC)
� � �
I
Total Value of Mor[gages an0 Notes $
Qnclude an Section II, Line C-4 on Sdiedule L)
E. Cash and Mlscellaneous Personal Property(Please Ilst.)
i C �sla � � d�lhl�l� e„�� S ��?NsFerud SU8' � �
' �f-� �`I l� -v �n��
I, Total Value of Czsh/Miswllaneous Personai Property 5
QncluGe on Sectlon Ii, Gne C-5 on Srhedule L.) 5 U�' " `
III. TOTAL (Also eoter an Section ➢, Line G6 0o Schedule l.J � 5
If more space is oeetletl, a[ca�h addi[ional sheets of paper oftne same size.
KtV-16a6 _x— (II-U9)
� 1NHERITANCETAX
�7�1 pennsylvania SCHEDULE L-2
sa� � M�� ��,.��
imFeFrrnrvceraeeerur� REMAINDER PREPAYMENT ELECTION
aesiaervroeceoervT
-CREDITS-
I. ESTATE OF FILE NUMBER
II. ITEM NO. DESCRIPTION AMOUNT
A. Unpaid Liabili0es Claimed agains[ Origmal Esta[e and Payable Pram Assets
Reported on Schedule L-1 (please lisq
I � / ,'C
�� �'
i
Total Unpaid Liabilities $
(indude on Section II, Line D-1 on Schedule L)
B. Unpaid Beques[s Payable from Assets Reported on Schedule L-1 (please lis[)
I �
U � �
Total Unpaitl Bequests S
(include on Sec[ion II, Line DQ on Schedule L)
C. Value of Asse[s Reported on Schedule L-1 (other than unpaid beques[s listed
under"B" above) [ha[ are No[ Induded for Tax Purposes or[hat Do Not Porm
a Part of the Trust.
Calculation as fallows:
� � � ���
To[al Non Includable Assets $
(Include on Section II, Line D-3 on Schedule L)
III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $
If more space is needeQ attach additianal sheets of paper of the same size.
urv in.i� ra- .u, �i
4 SCHEDULE M
' �� pennsylvania
oE�<�.MEN. F�E�=Ni�� , FUTURE INTEREST COMPROMISE
wNearamcFraxaFTuarv
eFs�oFv1 o=rFOFmr (Check Box qa on REV-a5oo)
ESTATE OF FILE NUMBER
This schedule is appropriate only for estates of decedents wha AieA aker Dec. 12, 1982.
This s�hetlWe is ta be usetl for all future in[eres[s where[he ra[e of[ax tha[will be applicable when [he ruture mterest vesrs in
passesson and enjoyment cannot be established wi[h certa'mty.
Intlicate below the:VPe oF Instrument that aeated che fuNre incerest antl attach a m0V �o the ,ax retum.
❑ Will ❑ Trust ❑ Other
I. Beneficiaries
NAME OF BENEFICIARv RELATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
1.
2.
3.
4.
5.
IL Por decedencs who dieG on or aker 7uly 1, 1994, i"r a surviving spouse eaercised or inrends[o exercise a right ef�wthtlrac+al wrthm
nine months af[he de:edent's tleaCh. check Me apPropria[e box belmv and a[tach a mpy af[he cocumen[in whio� Ihe wrvrvny spouse
exercises mch wlthd2wal righ[.
❑ Unlimited right of withdrawal ❑ Limited right of withdrawal
III. Ezplanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amountoffutureinteres[ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
L Value of Line 1 �empC fmm tax as amount passing ro chanaes, etc.
(Alm mdudc as part of rotal shown on �ine 13 of REV-1500.) . . . . . . . . S
3. Value o` Line 1 pazsing ta spause at appropriate tax rate
Check ane. ❑ 6%, ❑ 3°/, ❑ 0% . . . . . . . . . . . . . . . . . . . . 5
(Also include as part of ro21 shown on Llne 15 of REV-1500.)
4. Value of Line 1 taxable atlinealra[e
Check one. ❑ 6°i�, ❑ 4546 . . . . . . . . . . . . . . . . . . . . . . . . 5
(Also inclutle as part of mtal shown on Cine l6 of REV-1500.)
5. VaWe of Line L taxable at sibling a[e(129�a)
(Also mducc as psrt of;ota� shmvn on Line ll of REV-1500.) . . . . . . . . 5
6. �alue oP�ne t 2aable a[mllateral ra:e (ISeo)
!qlso inGucc as part of Coal shown on Line 18 of REV-1500.) . . . . . . . . 5
7. Total vaWc of`utcre mteres[ (sum of Lines 2 thru 6 mus[ equal Line 1) . . . . . . . . . . . . . . . . . . . . . . . 5
If more spam Is neetled, use addltional shee[s of paper of[�e same slze.
aev-is�e ex+�ae�os7
� pennsyNania SCNEDULE O
wrvEPITNNCETa%ESnt70arv ELECTIONUNDERSEGiss3(A)
FESi�ervi oeceoervT (SPOUSAL DISTHIBOlIONS)
ESTATE OF FILE NUMBER
�o not complete this schetlule unless [he esWte is making [he electian to tax assets untler Sec[ion 3113(A) o( the Inhentance and
Estate Tdz Ac[.
If Ihe elec[ion ro more[han one trust or slmilar arrangement,a separate form must be filetl for each trust.
Thls elec[lon applies ro[he Tmst(madtel, residual F, 6, by-pass, UnlFled Credlt,etc.).
If a tmst or similar arrangement meets the requirements of SeRion 2113(A)antl:
a.The hust or similar arrangement is lis[ed on S�hedule 0 anG
b.The value of the hust or similar anangement is entered in whole or in part as an asset on Schetlule 0, then the[ransferor's personal represen[a-
tive may specificalry identiry the[msf(all ar a fractianal portion or percentage)ro be Inclutled m the elecclon ro have such trust or similar proper-
ty hea[ed as a[axabie transfer in[his esta[e.If less[han the entlre value of the hust ar similar pmpeM is Intludetl as a[axable tmns(er on
Schetlule q the personal representa[ive shall be mnsiEered to have ma0e the electian only as ro a fraction of the trust ar similar arrangement.
The numerator of thls lraclion is equal ro the amount of Me trust or similar a«angement intluded as a taxable asset an Schedule 0,The Oenomi-
nator is equal to Ihe total value of Ne[rus[or similar arrangemen[.
PART A: Enter the description and value of all interests, both taxable and nomtaxable, regardless of location, which pass to the
decedent's surviving spouse under a Section 2113(A) trust or similar arrangement.
oew�onon vai�e
� 1 �
Part A ro[al $
PART B: Enter the description and value of all interests included in Part A for which the Section 2113(A) election to tax is
being made.
ouvlpnoo vawe
rI � ��
I
Part B Total $
[f more space is neeGeQ use a0di[ional sheetr of paper oF the same sire.
DEPARTMENT OF THE TRF.ASURY ��
F(NANCIAL MANAGF.MENT SERVICE
� P. O. BOX 1686 .
o BIRMINGIIAM,AL 35201-1656
THIS IS NOT A BILL
PLEASE RETAIN FOR YOUR RECORDS
I lll9/14
�, , %Tf1ERESA E WII.LIAMS
^ � TARIQ WILLIAMS DECD
216 FOUR SEASONS LN
� ENOLA,PA 17025-2133
As authorized by Federel law,we applied sll or part of your Federal paymen[to a deb[you owe. The
govemment agency(or agencies) collecfing your debt is listed below.
U.S.Departmen[of Educa[ion - - - - �� 7W Num: 17fi-72-3624
c/o AES/PHEAA TOP Ttace Num: 10929473F
P.O.Box 8(47 Acct Num: PA 176723624
Harrisburg . PA 17105-8147 Amount This Crediror. 51437.00
� Creditor: OS Site:PA
717-720.3400 (800)233-0751
. PURPOSE:NomTax Federal Debt
The Agency has p,eviously sent notice to you at the last address known ro the Agency. That nofice
explained ihe amomt and type of debt you owe, [he rights available [o you, end that[he Agency intended
ro collect the debt by intemepung any Federal paymeots msde to you, including tex rofunds.lt you
believe your payment wss redaced in error or if you have queatlons nbout t6is debt,you must
contact the Agency at the oddress and telephoee number shown above. 7Le U. S. Department of
the Treesury's Financial Management Service cannot resolve issues Iegarding debts with other agencies.
\Ve tvill ferward the money taken fro�n ymit Federal payment to the Agency to be applied m yovr deb[
balance; Lowever, [he Agency may no[receive[he funds for seveml weeks after the paymen[date. If you
intend to contact Ne Agency, please have t6is notice evailable.
U. S. Department of the Treasury
Financial Menagemeu[ Service
(S00)3043107
TELECOMMUNICAI'IONS DEVICE FOR Tf�DEAF(TDD)(866)297-0517
PAYMENT SUMMARY
PAYEE NAME: %TffERESA E WILLIAMS
PAYMENT BEFORE REDUCTION: $1437.00 PAYMENT DATE: I Ul7/14
TOTAL AMOUNT OF THIS REDUCTION: S 1437.00 PAYMENT TYPE:Check
PAYING FEDERAL AGENCY: Internal Revenue Service SPI.IT REFtJND CODE:
(See Insen on Tac Refund Offsets for Additional Information)
YOROFFICIALUSEONLY: �01305109291JJ}2]E)I�fi6JOD1089]SOBIALTR.PoI%TH0005J3 �
RLO]09 �
RECC;:� -- . , . . ,= CF
a �... -.. , . �
� � w � �,
u �
r � �� � �
NOH'<o ao „ ""' f E9 �7 � 27
aa��_f v, _
<
Haw o
; � LL _
o,�;,,
c� ..
%�
���@ � J � �' .�n
J � �
_j ', 0
� ��
C'
�V —
� � �' c1
J �
_ � � �.l -� c '
_ "� � 1�
- '" J I- �
� ,
,�, �, �,
- � J
� V � �
— o
o � �
rv
-- o � � �/
—_ �
.a
-- m
� .-i,. �_ �,:r��ac,r,a�.�
� ww�sdsn}e sn�rsi�
3J/AL35lVlri3OInd 5I31�15 0311N0
,� �1VYY�
� �C H.. �� (ni�l�..101�� `
�^" O N
w 'a O
� �
( � OL
= b �