HomeMy WebLinkAbout01-0197
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REVl500~+(1-97) ~
COMMON;~~YLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG PA 17128.0601
DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL) use a bJank block to separate words
M. C-":J 0 ,.I A /./J) I It It Y
SOCIAL SECURITY NUMBER DATE OF DEATH
>> BE SURE TOAHSWER AI.L QUESTfOHS ON REVERSE SIDE ANO RECHECK MATH < <
Under penalties of perjury, I declare that I have examined this return, inCluding oo::ompanying schedules and statements, and \0 the best of my knONledge and belief, it is true, correcl
and complete. Declaration of preparer other
!tie" the oersonal reDresentative is based on all information of which DreDarar has any knowledae.
SIGNATU~F!ERSOJ'lRES4SIBLU,ORFILlNrr;TURN .. ADDRES.S R. .
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS
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REV -1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DATE OF BIRTH
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
OF APPLICABLE) SURVIVING SPOUSE'S N.AME (LAST, FIRST, AND MIDDLE INlTlALj
/f)(J)(),J;j- t-D (! i-/" I () tV W .
socw. SECURIl"{ NUMBER
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REGISTER OF WILLS
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15J:-1. Original Return 0 2. Supplemental Return 0 3. Remainder Return (daleo/death prior to 12-13-82)
o 4. Limited Estate 0 4a. Future Interest Compromise (date ofdealh afler 12-12-S2) D 5. Federal Estate Tax Return Required
~6. Decedent Died Testate (Atlach copy of Will) 0 7. Decedent Maintained a Living Trust (MIacl\ copy ofTrutt) _ 8. Total Number of Safe Depos\t Boxes
o 9. Litigation Proceeds Received 010. Spousal Poverty Credit {date ofdeath between 12-31-91 and 1-1-95) 011. Election to tax under Sec. 9113(A) (Attach Sch 0)
THIS SeCTION MUST 610 COMPLeTEP. ALL CORReSP<)NOE~CE. A.l'iO.Co~FIOeNTIAI.TAX INFORMA.TION SHOULD 610 DIReCTED TO:
NAME , J I- ,; COMPLETE MAILING ADDRESS
C-l- . wl}1~J)PN ;....I> 11 t'lJGel-ItNb
FIRM NAME (If Applicable) /1
rJr;tuvtL1..-6? rA-. /7')/'11
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'1
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
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1 5'
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3. Closely Held Corporation,Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly OWned Property (Schedule F)
7. tnter-Vivos Transfers & Miscellaneous Non-Probate Propertj
(Schedule G or L)
8. Total Gross Asselll (total Lines 1e7)
'.2; 3, +0 o. b I
6(;6
733
(8)
S. Funeral Expenses & Administralive Costs (Schedule H)
10. Deb1s of Decedent. Mortga\)e Liabilities. & Uens (Schedule I)
(S)
(10)
11. Total Deductions (total Lines S & 10)
(11) .0 (;
(12) .~J , too .b /
(13) 0 <'
(14) ;L.3 ItD () i- /
((5) " t
(..... S2-~.
.Il& (16) D 0
.15 (17)
(18)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/Sec 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 I
at the spousal tax rate '}. /."
See instructions on reverse side for applicable percentage
16. Amount of line 14 taxable
at6%rate 'OV-I--
17. Amount of line 14 taxable
at 15% rate
"7JJ 9Y x .0
b&b be, x
x
II
18. Tax Due
19.
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DATE
7ju> )01
DATE
Decedent's Complete Addre s:
STREET ADDRESS I ..,., t;,.'. /
U'7~ V /tr-/~.
.CITY
I t-tLl v) (At;
Tax Payments and Credits:
1. Tax Due (Page 1 Line 18)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
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,).1,.) 5'
Total Credits (A + 8 + C) (2)
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3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + 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 19 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)
8. Enter the totai of Line 5 + 5A. This is the BALANCE DUE. (58)
Make Check Parable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS
BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred; ............" " """""""""""""""""""""'" 0
b. retain the right to designate who shall use the property transferred or its income; ",""""..". 0
c. retain a reversionary interest; or..".."".."."""............"."""""......"........".."..""......"".."..... 0
d. receive the promise for life of either payments. benefits or care? ""'"'''''''''''''''''''''''''''''''''' 0
2. If death occurred on or before December 12.1982, did decedent within two years
preceding death transfer property without receiving adequate consideration? If death occurred
after December 12. 1982, did decedent transfer property within one year of death without
receiving adequate consideration? .............................................................................................. 0
3. Did decedent own an "in trust for" or payable upon death bank account or security
at his or her death? """'"''''''''''''''''''''''''''''W'''''''''''''''''''''''''''''''''''''''''''''''''''''"""...""...."...... 0
4. Did decedent own an individual retirement account, annuity, or other non-probate property? "" I)Q
if 9!.JS-
J.j9,f 7~"'"
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
72 P.S. ~9116 (a) (1.1) (i) provided for the reduction of the tax rate imposed on the net value oftransfers to or for the use of the
surviving spouse from 6% to 3% for dates of death on or after July 1, 1994 and before January 1. 1995.
72 P .5. ~9116 (a) (1.1) (ii) provided for the reduction of the rate imposed on the net value oftransfers to or for the use of the surviving
spouse from 3% to 0% for dates of death on or after January 1, 1995. The statute does not exempt a transfer to a surviving spouse
from tax. and the statutory reqUirements for disclosure of assets and fiiing a tax return are still applicable even if the surviving spouse
is the only beneficiary.
FOR DATES OF DEATH ON OR AFTER JANUARY 1, 1995 - Please answer the following question by placing an "x" in the
appropriate space.
Did the decedent create a trust o;.rimilar arrangement which is solely for the surviving spouse's benefit for his or her entire
lifetime? Yes 0 No liQ
If you answered yes to the above question, the tax on the trust or similar arrangement is postponed until the death of the second
spouse, at which time it will be fully taxable at the rate(s) applicable to the remainder beneficiary(ies). Enter the value of the trust on
Schedule J, Part II, in order to remove it from the calculation of the tax due in this estate. You may wish to file Schedule 0 in order to
make the election available under Section 9113. If the election is made, the trust or similar arrangement is taxed in the estate of the
first decedent spouse, the portion of the trust or similar arrangement which benefits the survivin9 spouse is taxed at the zero tax rate,
and the remainder is taxed at the rate(s) applicable to the remainder beneficiary(ies). If you choose to make the election, you must
attach Schedule 0 to a timely-filed tax return, along with Schedule(s) K andlor M in order to show the apportionment of the trust or
similar arrangement between the surviving spouse and the remainder beneficiary(ies).
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COMMONWEALTH OF PENNS~ LVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
FILE NUMBER
fI7 1M:! J, In <; 1)~;.Iij ,,7)
If an asset was made joint within one year of the decedent's date of deathl it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
RELATIONSHIP TO DECEDENT
ADDRESS
A. IN.tG'J e./yL0)ONJtf..7)
B.
G;; ,f.f} t.JJ J> IV) :.1JC:Wlb];
c.7/fYt.-Lis /)'/ :Pl[s"(o".!
F;'11 '5&'.1/;!!rv6
HI""~P,c'~. O~ ,'171;'/ >j
'3 J-(" f?i.-f;# fA- T10l,/
5~Ma ';) ~1', /<: Y
50,.)
f'ruG .
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JOINTLY -OWNED PROPERTY:
LEITER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FORJQINT MADE Include name of flnal'lcial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. ('If 'f r:-IJ}~t*Tn; tv/'lJJ POP-. 601fT. S€"C .
NO , :):3 7/ 0 t <'11."<f b l/7.F . i '7 5'0 3 f' fI'l / ()
)- f.? If f 'J 5 ~r rV/I>lJ BUi-7P
337/[,1y-3')..</9 7 7 7 7. 5'f >6
NO.
.3 C /1f') Sl~p Fu N.!J / JRff.7f'
NO 3 37/ t.9'f3~()o 1777. .r/ SO
TOTAL (Also enter on line 6, Recapituiation) $ /I b{,6.6~
(If more space is needed, insert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
fJ1 ft fJy
,j, /lJ i: J);) '" lA '-'-0
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 OFTHE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
ATTACHACOPYOFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IFA??\.ICAilLE\
NUMBER
1. I/lJIJiV' f( E'1/ Il- (t'VJ (: JV T"" r"'rI!>
t- r-fV) TAvs r J I 7 JH's' I () 0 i 1731 "IJ
C~!(/ fJ v, OA&' - ).. <1 C:, ~IO .~
.-/
I iI...?'II'> ttfL6l
C L 1"/7'0.-/ tv . m:;J7 (I Nj/., /?p
/.":V ' 5" Pth)'jC
.) v/l; ,11/ tJo.
TOTAL (Also enter on line 7, Recapituiation) $
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(ij more space IS needed, Insert additional sheets of the same size)
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LAST WILL AND TEST AMENT
OF
MARY JANE MCDONALD
I, Mary Jane McDonald, of West Pennsboro Township, Cumberland County,
Pennsylvania, declare this to be my Last Will and Testament and revoke any and all wills and
codicils heretofore made by me,
ITEM I:
My personal representative shall pay from the residue of my
estate the expenses of my last illness, funeral and burial debts duly allowed against my estate,
and all death taxes (Pennsylvania inheritance tax and federal estate tax) occasioned by my
death and incurred with respect to all property taxed to my estate regardless of whether such
property passes by this Will or passes outside of this Will.
ITEM II:
I bequeath those articles of my automobiles, personal effects,
household goods, and other tangible personalty of like nature (not including cash or
securities), together with any existing insurance thereon, if any, as may be my individual
property and not the property of my Husband or owned jointly by me with him, as set forth in
a separate memorandum which I shall place with my Will to the persons therein designated, If
I shall leave no separate memorandum, or with regard to my automobiles, personal effects,
household goods, and other tangible personally of like nature (not including cash or securities) .
not referenced by such memorandum, I bequeath such property to my Husband Clinton W.
McDonald, if he survives me by thirty (30) days. Should my Husband, Clinton W.
McDonald, not be living on the thirty-first day after my death, I bequeath such tangible
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personalty and insurance thereon to my children, James C. McDonald, Gerald D. McDonald
and Phyllis M. Preston, to be divided among them by my Executor with due regard for their
personal preferences in as nearly equal shares as practical.
ITEM III:
I devise and bequeath the residue of my estate, of every nature
and wherever situate, to my Husband, Clinton W. McDonald. Should my Husband, Clinton
W. McDonald, predecease me, I devise and bequeath the residue of my estate, of every nature
and wherever situate, as follows:
A) 1/3 to my son, James C. McDonald. If my son shall predecease me, I give and
bequeath this share to his wife, Linda McDonald. If Linda McDonald shall also predecease
me, I give and bequeath this share to my then surviving issue.
B) 1/3 to my son, Gerald D. McDonald. If my son shall predecease me, I give and
bequeath this share to his wife Debby McDonald. If Debby McDonald shall also predecease
me, I give and bequeath this share in equal parts to my grandson, Christopher P. Anderson
and my step-granddaughter, Katie Brinsen. If either Katie Brinsen or Christopher P.
Anderson shall be less than twenty-one years of age at the time of distribution, I direct that
distribution of Katie Brinsen' s share shall be to her natural father in a custodial account for
her, and I direct that Christopher Anderson's share shall be deposited in a custodial account
with his mother, Phyllis Preston, as custodian. In either event, the funds shall be paid out to
the beneficiary when the beneficiary attains the age of twenty-one years.
3
C) 113 to my daughter, Phyllis M. Preston. If my daughter shall predecease me, I
give and bequeath this share to her husband, Bradley Preston. If Bradley Preston shall also
predecease me, I give and bequeath this share to her son, Christopher Anderson.
ITEM IV:
I appoint my Husband Clinton W. McDonald and my daughter,
Phyllis M. Preston, as Co-Executors of this my Last Will and Testament. Should either fail
to qualify or cease to act as Co-Executor, I appoint the other as sole Executor. If both shall
fail to qualify or cease to act as Co-Executor, I appoint my sons, James C. McDonald and
Gerald D. McDonald, as Co-Executors of my estate.
ITEM V:
I direct that my Executors and their successors shall not be
required to give bond for the faithful performance of their duties in this or any other
jurisdiction.
IN WITNESS WHEREOF, I, Mary Jane McDonald, have hereunto set my hand and
seal to this my Last Will and Testament, consisting of three (3) typewritten pages, each of
which bears my signature, this ?:ZJ'day of S.J?.A:k''''~ ~.u- ,1996.
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i.- i:c eY~1..#j-J..J (SEAL)
e McDonald, Testatrix
Signed, sealed, published and declared by the above-named Testatrix, Mary Jane
McDonald, as and for her Last Will and Testament, in the presence of us, who, at her
request, in her sight and presence, and in the sight and presence of each other, have hereunto
subscribed our names as witnesses.
.......,.
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COMMONWEALTH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERLAND )
WE, MARY JANE MCDONALD, TAYLOR P. ANDREWS, and
~) ,
f,ob'1/1 {/~>JllIn
, the Testatrix and witnesses, respectively, whose names are
signed to the foregoing or attached instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed and executed the instrument as and for her Last
Will and Testament and that she signed willingly and that she executed as her free and
voluntary act for the purposes therein expressed, and that each of the witnesses, in the
presence and hearing of the Testatrix, signed the Will as witnesses and that to the best of their
knowledge the Testatrix was at the time eighteen (18) or more years of age, of sound mind and
under no constraint or undue influence,
t:1, ,\ (,) J. '-V':'. _ L-;('
I ~ ;;CP"1~ 1~ J.JD HA"'e
Ma. J.i/ McDonald, t~trix
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(JUJtU.).L
, Witness
NOTAR!f.L SEAL
SHELLY\) ';t'!;,,' :;:'T^?yr\;~Uc
CARL:S; E Be:",... ~!, ,__'lA~ro CQliNTY
,A'f Cl.:'MMi$::1t'JI~ L"d;it,~ f\Pt\E. 26, hlS9
Meml!Ot, Pennsylvania Association of Notaries
Jan 31 01 08:24a
McDonald
1-503-268-1083
p.2
Federated
WORLD~CLASS INVES7MENT MANAGER
..
November 2000
1I'11
Ploe tol 1
For Ihe period ending November 30. 2DOO
tnv.storreferenee number: T1N-203610
MARY JANE MCDONALD
JAMES C MCDONALD JT TEN
897 SE 71ST AVE
HILLSBORD OR 97123.7794
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ItJterIt<< at wwwf*M'" ':I.1ntJeSlOl'$.COWI.
nu. Transaction Report CODlhms your 0C00UIIl odIvity for the month,
ezcludlng any IRA lI'lID5adlOll6. 1!Och quatter. you wlI1 receive an
Investment Summary - a comp1ete overview of your tota1 ponfuIio,
including value. IIlcome on<! tr.mSacIiona - for an penomf.1RA on<!
related lUlCOUDI8.
Tbl. hoIlday _ a\Ye a chl1cla gift that can_
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TRANSACjjOrr 01
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For fund /ltrfDmJanc. .,.d &Ufrentyitld, log (JIll>> www.tild"."dRm&f.DruDm.
MARY JANE MCDONALD
JAMES C MCDONALD JT TEN
FEDERATED FD FOR U.S. GOVT SECS. INC A
Fund/Account Number. 337/8899Z93.Accounl Opened 11/17/1989
NASDAQ ticker symbol: FUSGX
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PIlEVIDUS BALANCE IS 01 11/ll1/2lIOO 17.IlIIl.99 7.81
INCDMEIlEINVEST .1M $40.31 7.61 5.2lIIIIl
CHANOE IN IN\IESIMENT VAlUE $111. ZO
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DIIamIber DIvIdMtd Cban(Jr1-ll8cotd ~ B>< 12/21AXJ; Payabk 12/2$00
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GERALD D MCDONALD JT TEN
326 PLANTATlDNAVE '
SOMERSET I(Y 42501-3230
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MARY JANE MCDONALD
GERALD 0 MCDONALD JT TEN
FFOERATfD FO FOR U.S. GOVT SECS, tNC A
FundlA"""unt Number: 33116943299. ACCllllJl1 Opo' '0.:1'11117/_
NASDAQ licke, symbol: FUSGX
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PllI'VIOlJS RAI.ANO'e..f 1111llflOOl 'I $7.6fl638 7.61
INCOMEREINVEsr .04 $-\0.30 1.61 S.ml
CHAKfiE IN IttVfSTMENT VALUE SIll. 19
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Please note IbaJlbtsftmd'3 u ~for lbe perf<>d WIll tIfJPefJt on yoortlela stalemtml.
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708 410 1635 T-014 P.OOZ/DDZ F-D46
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November 2000
"'00.
Pag_ 'of 1
For 1he porioct tndfflt NGRlmbeJ 30. 200G
Invostor reference number: TlN.02DS392
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MARY JANE MCDONALD
PIlVlllS M PRESTON JT TEN
1219 NEAGLE
Nl\PERVILLE Il S0563-25lJ7
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nu. T1':Ia..",on Report """"..... your ac<x>Ullt lld!vIty l<w the DlOIllh.
emudlDg ....y IIl4lrlUl1A1:d_. Ilo.d> quanc:r, you wlII_ III
Inve8lmc:al SIIlIIIllarf - . complele overview of I""" ""'" pOnfoI1o,
IJ>cIucIins value,lDcome and ~_ - for all peoonoI, IRA ami
relatecl8CCOUDlS,
Tb15boli!kY _, sin: a ddJd a fII{t tbat.........
a c:ustodlal accouIlt In a DuI!IW fwxI. Ask obollllhe bene8r8I
for Alnd ,.,.",....&:IJ .ntf oufmltpldllDg tJtI ftpwww,fad,,.,,.tRnVllfDfUom,
MARY JANE MCDONA~ll
PHYlLIS M PRESTON JT TEN
- "FEDERATED-FlH{iRlfs. GOVT SECs,INCi\-"" .... .
FundlAccount Number. 337/SB433DO,Account Opened 11/1711988
NASDAQ deket symbol: FUSGX
""ffrm r,..d,
dim lID
'$ 7fle fund~ I~-day yf814 as q{ ll/3O,IllO
is ~.28",
--'--~.- R~
C'flGams: _
l1J1Jl
111/31
Me'
Tranl,dID" dHarI6tIM ()dhJr 8maurJt ,tf Ih.,.
PIIEV1OUSBALANCEuafl1/D1JlIIllIJ $1,666.. 7.&1
INCOME ftEJNVI'ST ,01 $40. :lO 7.61
CHANGE IN INItt6TMEHTVALUE $111.19
........_....Ut/30IZOOO 'j( fl.m,v.. 7,&1
~ D/&<Idend~-R_l~Moo; /!$ ~1IOO;P'tJIable IV2/l1OOPItxw__ /bUfund'sdluldmds"'tbe~lIIIJl~onyour__.
Shat'8' this ti'I,.,.I:IlDtt
5.2960
YDDlIahatd$CMn.d
1.1lIl7,~
1.011,7020
UIl.71Z1
..II
'1~"7
...._t--.__~I~~U1IIIIIII
TRUST
CHAMBERSBURG
BOILING SPRINGS
MARION
MONT ALTO
NEWVILLE
SHIPPENSBURG
WAYNESBORO
0022 0015 2402
Y
STATEMENT OF ACCOUNTS
33-16602
x
STATEMENT PERIOD
FROM THROUGH
11-14-00 12-13-00 0
PAGE 3 OF 3
. CLINTON W MCDONALD
MARY 3ANE MCDONALD
PHYLLIS M PRESTON
21 RIDGE LN
NEWVILLE PI'. 17241-9721
16 ENCLOSURES
5
INVESTORS SAVINGS
ACCOUNT NO: 08-00707
PREVIOUS DEPOSITS/
STATEMENT BALANCE CREDITS
3.311.53
FROM 11-14-00 THROUGH 12-13-00
WITHDRAWALS/
1 DEBITS
64.91
o
.00
INTEREST
PAID
.00
ENDING
BALANCE
3,376.44
INTEREST PAID THIS YEAR
ACCOUNT/INTEREST INFORMATION
91.23
1'1
DATE ACTIVITY DESCRIPTION REFERENCE
11-14 BEGINNING BALANCE
11-20 NORTHWESTERN MU
BENE PAYMT 001120
B0240460E
12-13 ENDING BALANCE
DEPOSITS/ WITHDRAWALS/
CREDITS DEBITS
00077900000
64.91
BALANCE
3,311.53
3,376.44
3,376.44
***
ANNUAL PERCENTAGE YIELD EARNED DISCLOSURE FROM
ANNUAL PERCENTAGE YIELD EARNED
AVERAGE DAILY COLLECTED BALANCE
INTEREST EARNED
11-14-00 THROUGH
2 . 72%
3,363.46
7.44
12-13-00 .*...
SERVICE FEE BALANCE INFORMATION
AVERAGE LEDGER BALANCE
MINIMUM LEDGER BALANCE
FROM 11-01-00 THROUGH 11-30-00
3,335.33 AVERAGE COLLECTED BALANCE
3,311.53 MINIMUM COLLECTED BALANCE
3,335.33
3,311.53
***********************************************************************************
TIME DEPOSIT
AS OF 12-12-00
fRA -
fYlJt<\
ACCOUNT NO
025-2965702
~ 025-2965703
BALANCE
9,390.63
11,733.95
ANNUAL RATE
6.8000%
6.5500%
DIRECT FARMERS & MERCHANTS TRUST CO
INQUIRIES TO: NEWVILLE OFFICE 9 W BIG SPRING AVE
NEWVILLE PI'. 17241-1301
TELEPHONE: 717-776-2242
00.805 REV 9/86
This is to certify that the information here given is correctly copied from an original certificate of death dul~ filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent fillllg.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
~'-~5~~
Fee for this certificate, $2.00
p
6960004
DEe
4 2000
Date
,) I - 0 I # ,q 7
H105.i43R.....2181
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
liNT
~\
HAME Of DECEDENT lf1f~1. M~. L_t
,. Mary Jane
AGE (lll$l &nhOIYJ uNDER 1 yEAR
....... ""'"
McDonald
SEX
..Female
STATE ~lI.f NUMBER
SOC'3L5ZUR'TY NO~R 8 586
,. - -
ENT
INK
82
UNDER I OM
Houn M\nut..
8IA'THP\..Aa :CAy ~
Detro'f'\!'cf.{1"
VO>.
5.
couNTVC~berland
w. In ""Pe
....
Ie.
SUlMVlHG SPOUSE
i" """.0 QIYlf ma.dWl rwntIl
linton W. McDcnal
15.
DECEDENT'S USUAL OCCUPIQ'K)N
i~-=:.::':o"::'=~:r
nO. Homemaket n~.
DECEDENT'S MAILING ADORE$$(Sl'.... CiyJ'foM'l. S&Ma. ZlpCocte)
DECEDENT'S
ACTUAl
21 Ridge Lane ~ ::~~
Newville, PA 17~41~~~
......
,"-
FRHER"S ""AME (First. MiOdIe. Last)
~ Roy Hanna
IHFClAMAHT.S....""lT't!TInton W.
-
METHOD OF DISPOSITION
_rn C.......,.O
0tMf (Speclfy\
...,.....
McDonald
'1.CO
I :
L
...
I ApptoUnat.
'--
~ onMtaM dmh
I
I
...,ll!:j
~OOo
27. MJIIT I: Ent.,1N diM.....Injur_ 0# compIicarionI wtIich cauMd lhe d..th, Do not emer 1M ~ ollfy!ng. sue" as cafdiac: or respiratory au"'. shoCk Of ,...." faiklfe.
liat onf1 one causct on each line.
PART H:
Othtr s;gnitk:anl condIIioM c:onaibuIing 10 Cltath, buI
not ""'ing in 1M uncIeftying ca.-. p.n in PA.RT I.
DUE 10 toR ASA CONSEQUENCE OF):
WERE "uTOPSY FINOINGS MANNER OF DEATH
-""'Jl.A8L.E PF'1Ofll1O ~
COMPLEllON OF CAUSE 0
OF OE1J'H? ...... Homicide
- 0 ~lfwtSt1gation 0
.,..0 ...~ - 0 Coukl not" determIned 0
DATE OF INJURY
(Monlh. Cay, __I
TIME OF INJURY
INJURY R YlIORK1 DESCRIBE HOW INJURY OCCUAFlED.
.,.. 0 ...0
. 3Gb. M. 3Oc.
PlACE OF INJURV. AI ~, fIIrm. ,....... lactofY. otftce
build'ng. Me. ISpeedv}
a.. Db.~. :JOe.
CERTIFIER fCNCk only 0fWI
.cunlFYlNG Pt1'tSlClAN (Ph)"SClo8l'l CI!f111y1ng CilUH d death""" Another phV$lCoan has pronov~ dearl'l a/'lO Cornpl@tedhem23)
To1hf -.t 0' my know'-dge, ..thoccutNcl due"'" cauM(.)and mannera..tolted..................,.....
o
.PIltONOUNCING AND CEATIFYtNG PHySICIAN IPhV$IClan bolh ;)Ionoune.ng o~attl and cenlfy.ng 10 cause of o~atf'\l
To 1M beet of my knowtH9ft, death OCCUfrM ,.tlhe dme, da'.. and place, and clu. '0 lhe cauM(.) and manne, .. ..a'ed..
'MEDICAL EXAMINER/CORONER
On '" b..is 01 e1laminatlon and/or inve.ngalion, in my opinion, dulh occurred al the time, date, and place, and due to the cause(.) and
manner a, srat.-cl., , . , . , . . . . .. ..,......,...... .,.....,.""".,........... . . . , , , . , , . . . . . . .
31a.
REGISTRJ.Frs SIGNATURE ANO ~ .. ". (".
~ '"1 ~, fS.t \ rd,..\ 10 I
34.
V 6 -<::2 / /- /0
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
':1 f-
r)?--
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
CLINTON W MCDONALD
21 RIDGE LN
NEWVILLE
\ .~
f
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
04-02-2001
MCDONALD
12-01-2000
21 01-0197
CUMBERLAND
101
\;~
REY-1547 EX AFP <12-DDl
MARY
J
PA i p241
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-EX--AFP-Cl"'2=OOY-NOYicE--OF-YN'HEifiTANCE-YAirXpPRAySEMENY-,--AiroWAifcE-OR'-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF MCDONALD MARY J FILE NO. 21 01-0197 ACN 101 DATE 04-02-2001
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)
5. 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)
(5)
(6)
(7)
.00
.00
.00
.00
.00
11,666.66
11,733.95
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governnental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
.00
.00
(11)
(12)
(13)
(14)
NOTE: I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ALL
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax paYllent.
23,400.61
00
23,400.61
.00
23,400.61
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
11,733.95 X 00 =
11,666.66 X 045 =
.00 X 12 =
.00 X 15 =
(19)=
.00
525.00
.00
.00
525.00
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
02-20-2001 AA478045 26.25 498.75
TOTAL TAX CREDIT 525.00
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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