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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
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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 $POUSFS NAAlE (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL seCURIT'{ NUMBER
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
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IiJ 1. Original Retum
o 4. limited Estate
o 6. Decedent Died Testate_,,,,,"WiIII
o 9. Litigation Proceeds Received
HlS$l;CTK)N T$l;C:;O
NAME
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D 2. SupplementalRetum 0 3. Remainder Relurn (daleofdeath prior 10 12-1J.821
D 4a, Future Interest Compromise (dill! ofdealllftr'2-12-82) 0 5. Federal Estate Tax Return Required
o 7. Decedent Maintained a Living Trust _, """fTruO) .Q 8. Total Number of Safe Depos~ Boxes
010. Spousal Poverty Cred~I""of"""_"1>31~" "'~1~") 0 11. Election to tax under Sec. 9113(A) (A"'"Soh 01
I,. , I;l~l'lt~ TAlI tNF~lI4AT!OH ~ S OUJ.O BE DIRECTED TO:
COMPlETE MAIlING ADDRESS
1 Irvine Row
Carlisle, PA 17013
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1. Real Estate (Schedule A) (I)
1~ Stocks and Bonds (Schedule B) (1)
3, Closely Held Corporation,Partnership or Sole-Proprietorship (3)
4~ Mortgages & Notes Receivable (Schedule Dj (4)
5. Cash, Bank Deposits & MisceUaneous Personal Property (5)
Z (Schedule EI
0 6. Joint~ Owned Property (Schedule F) (61
~ 7. Inter-Vivos Transfers & Miscellaneous Non4Probate Property (71
..J (Schedule G or L)
::l
I- 8. Total Gross Assets (total Lines 1c7)
ii:
cl: 9. Funeral Expenses & Administrative Costs (Schedule H) (9)
0
W
0:: 10~ Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total lines 9 & 10)
,17472
(8)
565 3
,
174'72
6 5
3 1,5 B 6. 2 4
(11)
3 7 ,23 9 . B 9
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12. Net Value of Estate (Une 8 minus line 11)
13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus line 13)
15. Amount of line 14 taxable
at the spousal tax rate . f ~
See instructions on reverse side for applicable percentage
16. Amount of line 14 taxable
at 6% rate
17. Amount ofHne 14 taxable
at15% rate
(12)
(13)
(37,065
1 7
(14)
x .0
(15)
x .06
(16)
(17)
x .15
19.
liIlf$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
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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
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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.
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Ruth E. Hoover
149 N. East Street
Carlisle 9 PA 17013
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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-'
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~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-
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Will1.am A. Duncan, ID I 22080
ADDRESS
1 Irvine Row, Carlisle, PA 17013
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PHONE
717-249-7780
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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
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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.)
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