HomeMy WebLinkAbout01-0176
REV_1500 EX + (6_00)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Holubowicz Pauline
DATE OF DEATH (MM-DD-Year)
DATE OF BtRTH (MM-DD-Year)
OFFICIAL USE ONLY
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FILE NUMBER
~L--DJ- __-1 7 ~
COUNTYCOOE YEAR NUMBER
SOCIAL SECURITY NUMBER
160-16-8636
THIS RETURN MUST BE FilED IN DUPUCATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Return (dateofdeath priorto 12-13-82)
D 5. Federal Estate Tax Return Required
Q... 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch Q)
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12/11/2000 05/18/1918
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
[Xl 1. Original Retum
D 4. Limited Estate
D 6. Decedent Died Testate (Atlach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
D 4a. Future Interest Compromise (date ofdeath afler12-t2-82)
D 7. Decedent Maintained a Living Trust {Atlach copyofTrust)
D 10. Spousal Poverty Credit (dateofdeathbetween 12-31-91 and 1-1-95)
PA 17109
OFFICIAL USE ONLY
50,250.92
26,761.60
1 ,204.27
1 ,204.27
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NAME
Jan L. Brown Es uire
FIRM NAME (If Applicable)
Jan L. Brown & Associates
TELEPHONE NUMBER
717 541-5550
COMPLETE MAILING ADDRESS
845 Sir Thomas Court
Suite 9
Harrisbur
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortga9es & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly OWned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
(6)
(7)
(9)
14. Net Value Subject to Tax (line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE StDE FOR APPLICABLE RATES
15. Amount of line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
X _(15)
26,761.60 X .045 (16)
X .12 (17)
X .15 (18)
(19)
16. Amount of line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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ece en s omDle e ress:
STREET ADD~ESS
, Claremont Nursino & Rehabilitation Center
375 Claremont Drive
CITY I STATE I ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2, Credits/Payments
A Spousal Poverty Credit
B, Prior Payments
C, Discount
(1)
1,204,27
~144:~~
ou
3, InteresVPenalty if applicable
0, Interest
E, Penalty
Total Credits (A + B + C)
(2)
1,204,27
TotallnteresVPenalty (0 + E) (3)
4, If Line 2 is greater than Line 1 + Line 3, enter the difference, This is the OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund (4)
5, If Line 1 + Line 3 is greater than Line 2, enter the difference, This is the TAX DUE, (5)
A Enter the interest on the tax due, (5A)
B, Enter the total of Line 5 + 5A, This is the BALANCE DUE, (5B)
Make Check to: REGISTER OF AGENT
0,00
0,00
0,00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Ves No
a. retain the use or income of the property transferred; """"""""""'"'''''''''''''''''''''''''''''''''''''''''''''''''''' D 00
b, retain the right to designate who shall use the property transferred or its income; """""",,"""""",,"""""" D 00
c, retain a reversionary interest; or """''',,'''''''''''''''',,''''''''', """""""",,"""'" """"""""""""""''''', D 00
d, receive the promise for life of either payments, benefits or care? """",,''''''''''''',,'''''''''''''',,'''''''''''',,'''''' D 00
2. If death occurred afier December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?""""""""""", """"""""""""" ...."""""""""""""""",,,,,,,, 00 D
3, Did decedent own an 'in trust fo~ or payable upon death bank account or security at his or her death? """"",""" D 00
4, Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a benefiCiary designation? '"'''''''''''''''''''''''''''''' """""""""",,,,,. """"""""""""""'''''''''''''' " D 00
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 pe~ury, I declare that I have examined this return, jncludin~ accompanying schedules and statements, and to the best of my knowledge and belief, il is true, correct
and complete.
Declaration of preparer other than the personal representative is based on alllnfonnalion of which preparer has any knowledge,
SIGN E OF PE SEaN ISLE FOR FILING RETURN DATE
-;3-r}!
PA
SIGNATURE
ADORE
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 orforthe use of the surviving spouse is 3%
[72 PS. ~9116 (a) (1.1) (i)),
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S, ~9116 (a) (1,1) (i1)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements tor disclosure of assets and filing a tax return are stHl applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or afier July 1,2000:
The tax rate imposed on the net value of transfers from a deceased 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 value of transfers to or for the 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)(I)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S, ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption,
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
FILE NUMBER
Holubowicz Pauline
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly.owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
2,281.80
Savings Bond Redemption
Check #1254796
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
2281.80
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
EST ATE OF
Holubowicz Pauline
If an asset was made joint within one year of the decedenfs date of death, it must be reported on Schedule G.
FILE NUMBER
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATlONSHIP TO OECEDEN1
A. Paul J. Holubowicz
9 Pine Tree Drive
Mechanicsburg, PA 17055-5568
Son
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JOINTLY-OWNED PROPERTY:
lETIER DATE DESCRIPTION OF PROPERTY %DF DATE OF DEATH
ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUEQF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 1990 Waypoint Bank Savings Account 9,515.32 50. 4,757.66
Acc!. #5500000275
2. A. 1990 PNC Bank Premium Plan Checking Account 24,323.36 50 12,161.68
Acc!. #51-4027-5068
3. A. 1997 300 Shares Harris Savings Bank Stock 3,000.00 50. 1,500.00
Certificate #2819
300 shares @$1D.00/share
4. A. 1990 The First National Trust Bank Checking Account 6,237.08 50. 3,118.54
Acc!. #404961606
TOTAL (Also enter on line 6, Recapitulation) $ 21 537.88
(If more space Is needed, insert additional sheets of the same size)
. .
REV'''''''''''',.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC, NON-PROBATE PROPERTY
ESTATE OF
Holubowicz Pauline
FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
NUMBER A.HACHA.COPYOFTI-lEOEEOfORREALE$T.I>.TE. VALUE OF ASSET INTEREST OFAP~ICABl.E)
1. Cash transferred to Paul J. Holubowicz, son, on December 16,931.24 100. 3,000.00 13,931.24
14,1999
2. Cash transferred to Paul J. Holubowicz, son, on December 12,500.00 100. 12,500.00
27, 1999
TOTAL (Also enter on line 7, Recapitulation) $ 26431.24
(If more space is needed, insert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INI-IERllANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
Holubowi~L Pauline
Debts of decedent must be reported on Schedule L
ITEM
NUMBER DESCRIPTION AMOUNT
A FUNERAL EXPENSES:
1. Funeral Home (Total expenses $7,119.34 - $6,383.69 prepaid = $735.65 due) 735.65
2. Burial marker 150.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number{s) I ErN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attomey Fees Jan L Brown & Associates 1,000.00
3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills of Cumberland County 20.00
( \"'~ '-'L ~ ~ ~)
5. Accountanfs Fees
6. Tax Return Prepare(s Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ 1 905.65
(If more space Is needed, insert additionai sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
EST ATE OF
Holubowicz Pauline
Include un reimbursed medical expenses.
ITEM
NUMBER
FILE NUMBER
DESCRIPTION
AMOUNT
21,012.11
1.
Claremont Nursing and Rehabilitation Center
2.
PA Department of Revenue (2000 Income Taxes)
571.56
TOTAL (Also eoter DO line 10, Recapitulation) $
(If more space is needed, Insert additional sheets of the same size)
21 583.67
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
'-'^" ~.
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustoo(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1. Paul J. Holubowicz Son 1DO%
9 Pine Tree Drive
Mechanicsburg, PA 17055-5568
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 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 II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
JAN L BROWN ESQ
JAN L BROWN & ASSOCIATE
845 SIR THOMAS CT 9
HBG PA 17109
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
04-09-2001
HOLUBOWICZ
12-11-2000
21 01-0176
CUMBERLAND
101
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REV-1547 EX AFP (12-00>
PAULINE
Amount Remitted
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 ~
REv=is4j-EY-AFP--fi"2-:oo1--NoTicE--oF-.rNHEifiTANcE-"-AX-APPRAisEHENT-;-ALrOWANCE-oi-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF HOLUBOWICZ PAULINE FILE NO. 21 01-0176 ACN 101 DATE 04-09-2001
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 EJ
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
S. Total Assets
(1)
(2)
(3)
(4)
(S)
(6)
(7)
.00
.00
.00
.00
2,281.80
21.537.88
26,431.24
(S)
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)
1,905.65
21.583.67
(1lJ
(12)
(13J
(14)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
50,250.92
23.489 32
26,761.60
.00
26,761.60
NOTE:
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
I~ an assessment was issued previously, lines
reflect ~igures that include the total o~ ALL
ASSESSMENT OF TAX:
IS. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rate
IS. Amount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
(1S)
(16)
(17)
(1S)
.00 X 00 =
26,761.60 X 045=
.00 X 12 =
.00 X 15 =
(19)=
.00
1,204.27
.00
.00
1,204.27
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
02-13-2001 AA478010 60.21 1,144.06
TOTAL TAX CREDIT 1,204.27
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.)
WARNING: IT IS ILLEGAL TO ALTER THIS COPY OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
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JAN L. BROWN & ASSOCIATES
ATTORNEYS AT LAW
OLOE ENGLISH GAP
845 SIR THOMAS COURT
SUITE 9
HARRISBURG, PA 17109
EMAIL: jlbassoc@ptd.net
JAN L. BROWN*
MARIELLE F. HAZEN
TELEPHONE (717) 541-5550
FACSIMILE (717) 541-9223
*ADMITTED IN PA AND DISTRICT OF COLUMBIA
February 14,2001
Register of Wills
Cumberland County Courthouse
Attn: Cheryl
One Courthouse Square
Carlisle, P A 17013
Re: Pauline Holubowicz
Dear Cheryl:
In accordance with your request, enclosed please find the Estate Information Sheet signed
by Attorney Brown and the original Death Certificate for Pauline Holubowicz.
If you have any questions or require further documentation, please feel free to contact my
office.
Sincerely,
,J '7'r,
1-( 'UJtrU C<.), /bu(>halto.,~~
Kristin W. Buchanan,
Legal Assistant
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Enclosure
lip
JAN L. BROWN & ASSOCIATES
ATTORNEYS AT LAW
aLOE ENGLISH GAP
845 SIR THOMAS COURT
SUITE 9
HARRISBURG, PA 17109
EMAIL: jlbassoc@ptd.net
JAN L. BROWN*
MARIELLE F. HAZEN
TELEPHONE (717) 541-5550
FACSIMILE (717) 541-9223
*ADMITTED IN PA AND DISTRICT OF COLUMBIA
February 13, 2001
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, P A 17013
CERTIFIED MAIL
Re: Pauline Holubowicz
To Whom It May Concern:
Enclosed for filing is the original and two copies of the Inheritance Tax Return for
Pauline Holubowicz. A check in the amount of $1,144.06 payable to Register of Wills, Agent
for Inheritance Tax due and a check in the amount of $20.00 payable to Register of Wills for the
filing fee has also been enclosed.
Kindly return a time-stamped copy for my file in the envelope provided.
Thank you for your assistance.
Sincerely,
/1) I' '1 oJ
41,{.J.U';v LC. .lxLclJa Jtcl/~
Kristin W. Buchanan,
Legal Assistant
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Enclosures
cc: Paul Holubowicz
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Rev-346 EX (8-92)
*'
ESTATE INFORMATION SHEET
FOR REGISTER'S OFFICE USE ONLY
County Code Year
File Number
PA DEPARTMENT OF REVENUE
.1l
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(l~
DECEDENT INFORMATION:
Enter data as it will appear on all documents submitted to the department.
Name (Last) (First) (Middle)
Holubowicz, Pauline
Decedent's Social Security Number Date of Death Date of Birth
1 6 0 I 1 6 I 8 6 3 6 12/11/2000 05/18/1918
TYPE FILING:
Enter check (,( ) mark to indicate the nature of the return to be filed with the department.
D Probate Return
D Joint Assets Only
~ Estate Tax Only
D Litigation Purposes (No Other Assets)
LETTERS GRANTED:
Enter check (,() mark to indicate the nature of the proceedings at the Register of Wills
Office. (Attach additional sheets if explanation is necessary.)
D Testamentary
L::; Administration
~ No Letters
D Other (Please Explain)
ATTORNEY/CORRESPONDENT
INFORMATION:
Enter all data concerning the attorney or other individual to receive all
tax information and correspondence.
Name (Last) (First) (Middle) Supreme Court I. D. #
Brown, Jan L. 67993
Street Address
845 Sir Thomas Court, Suite 9
City State Zip Code Telephone Number
Harrisburg PA 17109 717 541-5550
PERSONAL REPRESENTATIVE
INFORMATION:
Enter all data concerning the personal representative(s) of the estate
authorized by the Register of Wills
iJl88ltterl AetffiiRistrater Fe /' IOr1e J
Name (Last) (First) (Middle) Social Security Number
Holubowiez, Paul J. 2 0 7 I 3 2 15 8 5 5
Street Address
9 Pine Tree Drive
City State Zip Code Telephone Number
Meehan iesburq PA 17055-5568 717 766-1373 i
jl
Co-Executor / Administrator
Name (Last) (First) (Middle) Social Security Number
I I
Street Address
City State Zip Code Telephone Number
Co-Executor / Administrator
Name (Last)
(First)
(Middle)
Social Security Number
Street Address
City
State
Zip Code
Telephone Number
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