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HomeMy WebLinkAbout01-0055 c:. REV'500EX.(1971~ COMMtlN;~:YLVANIA DEPARTMENT OF REVENUE DEPT 280601 HARRISBURG PA 17128-0601 DECEDENT'S NM1E (lAST, ARST, AND MIDDLE INITIAL) use it blank block 10 separaee words REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT (0 ~ c2.0.?<___ I FIl.ENUMBER ~ ~ ~ ~ 21 01 COIMYcOOE YEAR 00055 ""."" I- Z W o W o W o Hoover Ralph SOCIAL SECURITY NUMBER T DATE OF DEATH DATE OF BIRTH 164 30 _ 2714 10 I 2B I 00 07 I 04 I 39 (IF APPLICABLE) SUR\lMNG $POUSFS NAAlE (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL seCURIT'{ NUMBER THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS w ,., ~~rn U.'" W"U ,,00 U"'... .... .. .. IiJ 1. Original Retum o 4. limited Estate o 6. Decedent Died Testate_,,,,,"WiIII o 9. Litigation Proceeds Received HlS$l;CTK)N T$l;C:;O NAME ,. ...~ D 2. SupplementalRetum 0 3. Remainder Relurn (daleofdeath prior 10 12-1J.821 D 4a, Future Interest Compromise (dill! ofdealllftr'2-12-82) 0 5. Federal Estate Tax Return Required o 7. Decedent Maintained a Living Trust _, """fTruO) .Q 8. Total Number of Safe Depos~ Boxes 010. Spousal Poverty Cred~I""of"""_"1>31~" "'~1~") 0 11. Election to tax under Sec. 9113(A) (A"'"Soh 01 I,. , I;l~l'lt~ TAlI tNF~lI4AT!OH ~ S OUJ.O BE DIRECTED TO: COMPlETE MAIlING ADDRESS 1 Irvine Row Carlisle, PA 17013 !i: W C z 2 .. W '" '" o U 1. Real Estate (Schedule A) (I) 1~ Stocks and Bonds (Schedule B) (1) 3, Closely Held Corporation,Partnership or Sole-Proprietorship (3) 4~ Mortgages & Notes Receivable (Schedule Dj (4) 5. Cash, Bank Deposits & MisceUaneous Personal Property (5) Z (Schedule EI 0 6. Joint~ Owned Property (Schedule F) (61 ~ 7. Inter-Vivos Transfers & Miscellaneous Non4Probate Property (71 ..J (Schedule G or L) ::l I- 8. Total Gross Assets (total Lines 1c7) ii: cl: 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 0 W 0:: 10~ Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total lines 9 & 10) ,17472 (8) 565 3 , 174'72 6 5 3 1,5 B 6. 2 4 (11) 3 7 ,23 9 . B 9 z o F ~i! 1-':1 .. lii o (J 12. Net Value of Estate (Une 8 minus line 11) 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus line 13) 15. Amount of line 14 taxable at the spousal tax rate . f ~ See instructions on reverse side for applicable percentage 16. Amount of line 14 taxable at 6% rate 17. Amount ofHne 14 taxable at15% rate (12) (13) (37,065 1 7 (14) x .0 (15) x .06 (16) (17) x .15 19. liIlf$Uf{!; ~O :AI;.!I, < < Under penalties of pe~ury. I declare thall have examined this return, including accompanying schedules and slatements, and to the besl of my knowledge and belief. it is true, correct and complete. Declaration of preparer other than lt1e rsonal fe resentative is based on all information of which e arer has an knowled SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS . I Y,- l :cOWLvvL-- Decedent's Complete Address: STREET ADDRESS 1 Irvine Row CITY. Carlisle I STATE I ZIP PA 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) (1) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount Total Credits ( A + 8 + C ) (2) 3. InleresUPenalty if applicable D. Inlerest E. Penally T otallnteresUPenally ( D + E ) (3) 4. If Une 2 is greater than Une 1 + Une 3, anler the difference. This is the OVERPAYMENT. Check box 011 Page 1 Line 20 to request. refund (4) 5. If Line 1 + Line 3 is 9reater than Une 2, enter the difference. This is the TAX DUE. (5) A. Enter the interesl on the tax due. (SA) 8. Enter the total of Une 5 + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN .X. IN THE AP 1. Did decedenl maka a transfer and: Yes a. retain Ihe use or income oflhe properly transfenred;......................................................................... 0 b. retain the right to designate who shall use the properly transfenred or its income;...................................... 0 c. retain a reversionary interest.or.................. ....... ...... ........... ... ... ... ....._.. ... ... ,_ ... ..... .......... ...... .... ... 0 d. receivalhe promise for I~a of either payments, benefrts or care?......................................................... 0 2. If death occunred after December 12, 1982, did decedent lransfer properly within one year of death without receiving adequate consideration?.... .......................... ............ ........... ......... .............. .............. 0 3. Did decederrt own an "in trustfo~ orpayabla upon death bank account or security at his or har death2............... 0 4. Did decedent own an tndividual Retirement Account, annuity, or other non-probata properly which contains a beneficiary designation?....... ........ ................ ....................... ............................ ......... ........ 0 No IXI ~ ~ DSl [2g ~ 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 pefjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and beief, it is true, correct and complete. Declaration of preparer otller than the personal representative is based on al infonnation of which preparer has any knowledge. SIGNATURE OF S SP LE FOR FILING RETUR DATE ADDRESS 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. ~9116 (al (1.1) (i)). For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers 10 or for the use of the surviving spouse is 0% [72 P.S. ~9116 (al (1.1) (ii)). The statute does not exemol a transfer to a surviving spouse from tax, and the statutory requirements f", disclosure of assets and filing a tax return are still applicable evan if the survMng spouse is Ihe only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a decaased 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. ~9116(a)(1.2)). The tax rate imposed on the net vaJue of transfers to orforthe use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate rmoosed on the net value of transfers to orforthe use of the decedent's siblinas is 12% r72 P.S. &9116(a)(1.3\1. A siblino is defined. under Section 9102. as an ""'~""l"'" *' COMMONWEALTH OF PENNSYLVANIA . INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF RALPH T. HOOVER, JR., FILE NUMBER 21-01-00055 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 an Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH Members 1st Federal Credit Union Savings Account # 50030590 174.72 TOTAL (Also enter on line 5, Recapitulation) $ 174.72 (If more space is needed, insert additional sheels of the same size) ""'''''''.,,'''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF RALPH T. HOOVER, JR. FILE NUMBER 21-01-00055 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Ewing Brot:hers Funeral HOlDe. Inc. 3,395.00 B. ADMINISTRATIVE COSTS: 1. P"""""I Representative's Commissions Name of Personal Represenlative (s) SocIal Security Numbe~s) I EIN Number of Personal Represenlative(s) Street Address City Slate Zip Yea~s) Commission Paid: 2. Attorney Fees Duncan & Bartman, P.C. 500.00 3. Family Exemption: (If decedenfs address ~ not the same as c1aimanfs. allach explana1ioo) Claimant Street Address City Stale Zip Relationship of Claimant 10 Decedent 4. Probate Feas Regist:er of Wills Cumberland Count:y 61.00 5. ActOunlanfs Feas 6. Tax Retum PrepaIOf's Feas 7. Cumberland Law Journal Legal Ad 75.00 8. The Sent:inel Legal Ad 68.00 9. CME Cent:ral Medical Equipment: Company 506.65 10. Carlisle Pat:hology Associat:es 10.00 11. Carlisle Communit:y Ambulance 222.00 12. Carlisle Hospit:al 816.00 TOTAL (Also enter on line 9, Recapitulation) $ 5,653.65 (If more space is needed, insert additional sheets of the same size) REV"""'.'''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER RALPH T. HOOVER, JR. 21-01-00055 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. 2. 3. 4. 5. 6. Lowe's Credit Card # 816-0221-6117610 Capital One Kaster Card # 5291-0713-8224-6088 Members 1st Federal Credit Union Visa # 4287-5900-0055-0562 First USA Credit Card # 4417-1227-6019-0869 KBNA Credit Card # 4313-0400-2003-4773 Wards Credit Card # 155-356340 764.33 4,108.97 9,755.63 7,573.36 9,129.11 254.84 TOTAL (Also enter on line 10, Recapitulation) $ 31,586. 24 (If more space is needed, insert additional sheets of the same size) ''''."'',,.,,'''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES 'ESTATEOF FILE NUMBER RELATIONSHIP TO OECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS (indude outright spousal distributions) 1. Ruth E. Hoover wife 100 % 149 N. East Street Carlisle, PA 17013 ENTER DOLlAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON UNES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART n. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV 1500 COVER SHEET $ .. RALPH T. HOOVER, JR. 21-01-00055 (If more space ,s needed, Insert additional, sheets of the same sIZe) PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of RALPH T. HOOVER, JR. also known as Deceased. No. 21-01-55 To: Register of Wills for the County of CUMBERLAND in the Commonwealth of Pennsylvania Social Security No. 164-30-2714 The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl ies for letters of administration on the estate of (d.b.n.; pendente lite; durante amentia; durante minoritate) the above decedent. Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with h is last family or principal residence at 149 N. East Street, Carlisle, FA. 17013 (list street. nwnber. Twp. or Boro.) Decedent, then 61 years of age, died October 28, 2000 m Carlisle, Cumberland County, Pennsylvania ,3 Decedent at death owned property with estimated values as follows: (I f domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: 149 N. East Street, Carlisle, Cumberland County. Pennsylvania $ t...-)1~ $ $ $ Petitioner_ after a proper search hL!!.- ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name Relationship Residence Ruth E. Hoover Hal h T. Hoover III Nan Elizabeth Morrison . wife son dau hter , PA 17013 Holly PA .sle, PA THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration 'in the appropriate form to the undersigned. - 'i u e '0- ._ fit ~~ "'~ c ~.g ~.::: -;~ u- Sa Ci r:: CIO Vi 1f~4 L Ii ~~ Ruth E. Hoover 149 N. East Street Carlisle 9 PA 17013 /6 --~o~- I OATH OF PERSONAL REPRESENTATIVE COMMONWEALm OF PENNSYLVANIA COUNTY OF CUMBERLAND }ss The petitioner(s) above-named swear(s) or affum(s) that the statements in the foregoing petition are true and correct to the best of tbe knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will wen and truly administer the estate according to law. Sworn to or affirmed, an, ,.d ,SUbSCribed J before me this 11 th day of -1 Rutb E. Hoovet: '>m JANU~ .2QQL L",4 t; /I~J"VL-' - /-tr //M{P//,h& /2;;: l ....... ClfJ I .1 CIJ ~o. 21-01-55 Estate of RALPH T. HOOVER, JR., , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW JANUARY 11 x32001 , in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that RUTH E. HOOVER is/are entitled to Letters of Administration, and in accord with such fmding, Letters of Administration are hereby granted to RUTH E. HOOVER in the estate of RAT.PH T _ HOOVER. JR_. , ~' >y&/yf/: ~i///i y:,u},/(7/ -:X);~p4' , egIster of WIlls I FEES Letters of Administration ..... S 18 . 00 Short Certificates( ).......... S 18.00 Renunciation ................ S s 00 JCP S s.oo TOTAL _ S 4(1 00 Filed ..Q~ -; ~.1.-: .. . . .. .. . ... A.D. . 2a.D.l- s . ... Will1.am A. Duncan, ID I 22080 ADDRESS 1 Irvine Row, Carlisle, PA 17013 C/'--- PHONE 717-249-7780 c2d.J!!.c./ ~/c;nA7 o~ (!F ....~~v >) Q(., / tUlO{'.. '~I: ~' l"ll ft.'1I ~I o 103l:l "LI: . . . . . . . . . . . . . . . . . . . . . . . . . . . . , , . . . . . . . . . . . , , . . , , . , , . . . . . . . . . . . . . , . . . . . . . . . . . . , . . . . . . . . . . . . . , . . . . . . 'IML'ls .. .auuI'" pu. (sjasn':l alII 01 anp put 'a:l'ld pue 'al'p 'awlI aliI I' paJJn:l:lO lll.ap 'uo!u,do .low U! 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'" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF RALPH T HOOVER JR , Deceased No. 21-01-55 of 2001 To the Clerk of the Orphans' Court: Enter the claim of CAPITAL ONE Acct. 5291071382246088 In the amount of $4,020.92 , against the above entitled estate. The decedent, who resided at 149 N EAST ST, , CARLISLE died on 10/28/2000 . Written notice of said claim was given to ,if known to claimant, at (Personal Representative or counsel) on March 15, 2001 (Date) {kj~~4J~ (Claimant) Address: 531 0 Eas~ Main Street, Suite 210 Columbus, Ohio 4~213 Claimant's Counsel Address ... ~ ~\ rJ1 ~ e ~ p:J 6 0 rn ~ $ ~ ~ ....- ~ 0 ~ u \f) ~ 6 \f) I ~ ~ ~ ~ g N 0 I >- U 0 ~ 4-> N 0 < r.f) 0 ~ .,...f t:J: U r.f) r- .S 0\ ~ ~ ~ ('() r-- ~ 0 ~ ('() oj I --' Z ~ ..q ,.g 0 ~ t2 ~ t- U ('() ,-...,. ~ ~ lrl t- p... ~ t- ~ 00 U -..-' 4-1 :6 r.f). <1. r.f) ~ Z (/). ~ 8 r.f). 2 :C 6 ~ ~ ~ ~ 0 ~ r- p:J ~ ~ ~ ~ ~ ~ 4. rJ) ~ p:J. u t ST A TE OF PENNSYLVANIA IN RE:ESTATE OF RALPHT. HOOVERJR IN THE PROBATE COURT: CUMBERLAND COUNTY ESTATE NO. 21-2001-00055 STATEMENT OF CLAIM 1. MBNA America hereby presents for filing against the above estate this statement of claim in the amount of $ 9,129.11. 2. The basis for the claim is MBNA account number 4313 0400 2003 4773 which was opened on 9-1-92. 3. The tax identification number of the claimant is 510331454. 4. The name and address of the claimant is MBNA America, 1000 Samoset Drive, Wilmington, DE 19884. 5. This claim IS NOT contingent. 6. This claim IS NOT secured. 1. 7. The last payment made on the account was $ 162.00 on 10-4-00. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief. Executed this 11- day of % ' 2001 ,\\.. 1\0 H \~\ \)L~~Q ~l~ NICOLE FRESE MBNA America Claimant State Of Delaware, County of New Castle IN WITNESS WHEREOF, I have set my hand and notarial seal this ~dayof ~b ,2001 PAMELA J. JOHNSON NOTARY PUBUC STATE Of DELAWARE MY COMM!S~!ON EXP:~ OCl 08, 200~ My Commission Expires: (() } Q } 03 _r~mJA r Notary ub c at X165-1 CUSTOMER INFORMATION SYSTEM * 4313040020034773 * RALPH T*HOOVER$JR CURBAL: 9636.06 CYCLE: 21 N C/O RUTH E*HOOVER CR LIN: 10000.00 STATUS: 5 CHANGED: 01/05/01 ***************************** OCTOBER STATEMENT ***************************** POST -------REFERENCE------- TRAN --------DESCRIPTION------- BC ---AMOUNT--- PAYMENTS AND CREDITS 1004 27854137965 02/12/01 07:42:53 PAYMENT - THANK YOU 162.00CR ***************************** OCTOBER STATEMENT ***************************** PREV BAL - $9149.09 PAY + $162.00 SALE + $0.00 CASH + $0.00 F/C $142.02 = NEW BAL $9129.11 PF10=PAGE FORWARD PFll=TRANSACTION SUMMARY _._--~ 4-@ 1 MBNAIS PF09=NOVEMBER STMT PF18=SEPTEMBER STM 192.168.16.20 PA1=BEGIN AGAIN 1 PA2=SYSTEM MENU HAEA 2/31 E --- CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Ralph T. Hoover, Jr. Date of Death: October 28, 2000 Will No. 2001-00055 Admin. No. To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on December 1, 2000 Name Address Ruth E. Hoover 149 N. East Street, Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except none Date: /-- //- ()! ~~~ Signature Name William A. Duncan, Esquire Address 1 Irvine Row ~~Tli~l~~ ~ft 17013 Telephone (711) 249- 7780 Capacity: _ Personal Representative xx _Counsel for personal representative r G STATUS REPORT UNDER RULE 6.12 Name of Decedent: Ralph T. Hoover Date of Death: October 28, 2000 Will No. 21 01 00055 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1 . Stat~ wpether administration of the estate is complete: Yes~ No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative sta~ an account informally to the parties in interest? Yes~ No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attache this report. Date: /f/-2 & ,(fl! / (~ s William A. Duncan Name (Please type or print) 1 Irvine Row, Carlisle, FA 17013 Address (717 ) 249-7780 Tel. No. Capacity: Personal Representative l~counsel for personal representative (MAH:rmf/AM3) \1 b-;J,o,;t- J COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE S'I- C. v/ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX WILLIAM A DUNCAN DUNCAN & HARTMAN 1 IRVINE ROW CARLISLE DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 07-09-2001 HOOVER 10-28-2000 21 01-0055 CUMBERLAND 101 *' REV-1547 EX AFP Cl2-DD) RALPH T Allount Rellitted PA 17b13 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ RE-Y-=is4-j-EX--AFP--fi'2-:oi)j--NOY-iCE--OF-INHEifiTANCE-Y-AX-A-PPRA-isEifENT~--A[i-oWANCE-(rR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HOOVER RALPH T FILE NO. 21 01-0055 ACN 101 DATE 07-09-2001 TAX RETURN WAS: (X) ACCEPTED AS FILED 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/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) S. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (S) (6) (7) .00 .00 .00 .00 174.72 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) 5,653.65 31.586.24 (11) (12) (13) (14) NOTE: I~ an assessment was issued previously, lines re~lect ~igures that include the total o~ ALL ASSESSMENT OF TAX: IS. Allount of Line 14 at Spousal rate (IS) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 174.72 37.239 89 37,065.17- .00 37,065.17- 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. .00 X 00 = .00 X 045 = .00 X 12 = .00 X 15 = (19)= .00 .00 .00 .00 .00 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, 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" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) o 0. if) ~ .~~ ~ ~ ~ ~ .~ -' o o M Q; -' Q; M if) \0 t:- o-. 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