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HomeMy WebLinkAbout01-0233 \>/~- 2/</:-0 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG I PA 171Z8-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04-09-2001 SMITH 05-27-2000 21 01-0233 CUMBERLAND 101 FRANK H KELLY KELLY FINCL SERVICES IN 710 BRIDGE ST NEW CUMBERLAND PA 17070 ~f- c... ,/ REV-1547 EX AFP (12-00> PETER J Amount Remitted CHANGED (1) (2) (3) (4) (S) (6) (7) .00 96.863.00 .00 .00 50.00 1,602.00 .00 (8) 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=is4"j-Ex-AFP-[i"2:oo1--NOTicE--oF-YtiHEifiTANCE-TAiC-APPRAisEMENT~--Ai:.rOWANCE-OR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SMITH PETER J FILE NO. 21 01-0233 ACN 101 DATE 04-09-2001 TAX RETURN WAS: (X) ACCEPTED AS FILED 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 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) 9,914.00 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 98,515.00 10 036 DO 88,479.00 .00 88,479.00 NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: IS. Amount 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. Amount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: .00 X 00 = .00 88,479.00 X 06 5,309.00 .00 X 00 .00 .00 X 15 = .00 (19)= 5,309.00 122.00 (1ll (12) (13) (14) PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 02-27-2001 AA478093 .00 5,309.00 TOTAL TAX CREDIT 5,309.00 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.) ~ff" , -.... COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG, PA 17128-0601 PENNSVL VANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT No.AA 4 7 8 0 93 REV-1162 EX (11-96) RECEIVED FROM: r PETER J SMITt-,! .!:.:, 234 POPLAR AVE f\iUE NEW CUMBERLf\NU. ;'('. "/('.>r"/(l -- FOLD HERE ESTATE INFORMATION: I FILE NUMBER 21-2001-0233 ~_:' ~ ~) f\j 1 D 9' ", ():::: " fJ O'~ (, NAME OF DECEDENT (LAST) (FIRST) (MI) SMITH PE T E F: c DATE OF PAYMENT 2/28/2001 POSTMARK DATE 2/27/2001 COUNTY CUMBERLAND DATE OF DEATH 5/27/20QO REMARKS CHECK# SEAL 5(~L:< REGISTER OF WILLS -~~ ~ ACN ASSESSMENT CONTROL NUMBER AMOUNT L ',) ~~~. ~,j . ~:~ () (;i .. () (,> FOLD HERE ,~...,\'l ".'.""-;111 .' . . 'J " ..... l'\ l. ~ ~ ',jft-;. ,\" .. "\"~ .. ~ . ._ , . J;'" ,,"(..., t ':-.> .. .. . ." . '" ~ ~'f'; 'i~ .~.. .....,",".. 4: .' . t1. - (.......,... $ TOTAL AMO'tJt.JT PAlO. " ". ? -'1 : ." .. ,~:J j~'; '=-; 1\ <.- r) t...~ ~'J ........ ~. ;'.'1" {) ~.'( ;\f ,~' \ " ". . " ", ' , /:(._...;~ ,.._#..' . ~'~ L_ ~:.,,~~;-I :;~:' ,,~<< ( .(' ,-</ RECEIVED BY,,/ ,. {> ,. , ;,,:1 ~ ,~, t' ;;~. \ ~ L!Lb!LUUl lL.j~ PM J REV-1500 OFFICIAL USE ONLY COMMONWEALTH OF //.. - ~I'-I- L PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FILE NUMBER DEPT. 280601 RESIDENT DECEDENT 2.i-~-'- __ .2.3.3 HARRISBURG, PA 17128-0601 COLNTY CODE YEAR f\LMBER DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITVlL) SOCVlL SECURITY NUMBER I- Z Smith, Peter J. 189.03.8046 w DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD- YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE C W 05.27.2000 09.05.1907 REGISTER OF WILLS () W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INrTlAL) SOCIAL SECURITY NUMBER C None w [KJ 1 Original Return 0 2. Supplemental Return 0 3. Remainder Return (date 01 death prior to 12-13-82) ~~(f.I 0 4. Limited Estate 0 4a. Future Interest Compromise (date 01 death after 12.12-82) 0 5. Federal Estate Tax Return Required u"'''' w"-u 0 :1:00 0 6. Decedent Died Testate (Attach copy of Will) 7. Decedent Maintained a Living Trust (Attach copy of TrLSt) 8. Total Number of Safe Deposit Boxes u"'~ - ,,-'" "- 0 9. Litigation Proceeds Received 010. Spousal Poverty Cred~ (date o/death between 12-31-91 ard H95) 011. Election to tax under Sec. 9113(A) (Attach Sch 0) " t- THIS SECTION MUST BE COMPLETEO. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: z NAME COMPLETE MAILING ACDRESS w Cl Frank H. Kell v, EA Kelly Financial Services, Inc. z 0 "- FIRM NAME (If ","'coble) 710 Bridge Street <IJ Kell v' Financial Services, Inc. w '" New Cumberland, PA 17070 '" TELEPHONE NUMBER 0 u 717.774.7536 1 Real Estate (Schedule A) (I) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 96,863 3 Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5 Cash, Bank Depos~s & Miscellaneous Personal Property (5) 50 Z (Schedule E) 0 6. JOintly 0Nned Property (Schedule F) (6) 1,602 !;( D Separate Billing Requested ...J 7 Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) ::::l I- (Schedule G or L) a.. 8. Total Gross Assets (total Lines 1- 7) (8) 98515 <C () 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 9,914 w a::: 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 122 11 Total Deductions (total Lines 9 & 10) (II) 10036 12. Net Value of Estate (Line 8 minus Line 11) (12) 884 7 9 13 Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13) ------ ---- made (Schedule J) -- -- ----- 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 8 8 4 7 9 SEE INSTRUCTIONS FOR APPLICABLE RATES Z Amount of Line 14 taxable at the spoosaltax 0 15 !;( rate, or transfers under See. 9116 (a)(1.2) XO_ (15) I- 16. Amount of Line 14 taxable at lineal rate 88479 X O~ (16) 5309 ::::l a.. 17. Amount of Line 14 taxable at sibling rate X .12 (17) :!: 0 18 Amount of Line 14 taxable at collateral rate X 15 (18) () -- ------------- ----- ----- ---------- ------ >< 19. Tax Due (19) 5309 ~ 20. 0 I CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT I > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < STFPA42021F_1 LjLbjLUUl lL:~~ PM Decedent's Complete Address: STREET ADDRESS zjY- FODlar Ave CrTY I STATE FA I ZIP 17070 New Cumberland Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 5,309 Total Credits (A + 8 + C) (2) 3. InteresVPenalty if applicable D. Interest E. Penalty TotallnteresVPenalty (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 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) o 5,309 A. Enter the interest on the tax due. (5A) 8. Enter the total of Line 5 + 5A. This is the 8ALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT 5,309 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes D D D D D D contains a beneficiary designation? . D [KI 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 perjury, I declare that I have examined this return, including accompan0ng schedules and statements, and to the best of my knO'Wledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PER &ONSI8LE ~ RETURN IV ~ C '-' M (, <L~L...-:> r-J. PA Bridge Street, New Cumberland, FA 17070 No [KI [KI [KI [KI [KI [KI DATE :>.., ~., I /IUIV DATE Fa dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value oftransfers to or for the use of the su,,"ving spouse is 3% [7 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 su,,"ving spouse is 0% [72 PS. ~9116 (a) (1.1) Iii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after 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 PS. ~9116Ia)ll.2)J. 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 noled in 72 P.S. ~911611.2) [72 P.S. ~9116Ia)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% 172 P.S. ~9116(a)(I.3)J. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with Ihe decedent, whether by blood or adoption. STFPA42021F.2 L/L6/LUUl lL:~d PM REV.1502 EX + (1-97) (I) COMMONW'EALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Peter J. Smith All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at 'Nhic/1 property would be exchanged between a willing buyer and a willing seller, neither being compelled 10 buy or selt, both having reasonable knowledge of tne relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH None STFPA42021F 3 TOTAL (Also enter on line 1. Recapitulation) $ (If more space is neeced, insert additional sheets of the same Size) L!Lb!LUUl lL:~d PM REv-1503 EX + (1-97) (f) COMMONWEALTH OF PENNSYLVANIA !NHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Peter J. Smith FILE NUMBER All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. AIM Blue Chip Funds # 5030373350 VALUE AT DATE OF DEATH 96,863 SlFPA42021F.4 TOTAL (Also enter on line 2, Recapitulation) $ (If more space IS needed, Insert additional sheets of the same size) 96,863 L/L6/LUUl lL:jd PM REV-1504 EX + (l-9?) (I) COMMONVV'EALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY.HELD CORPORATION, PARTNERSHIP or SOLE.PROPRIETORSHIP ESTATE OF Peter J. Smith FILE NUMBER Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held COf"poration/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH None SlFPA42021F.5 TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) L!Lb!LUUl lL:~~ PM REV-1505 EX + (1-97) {I} COMMONWEALTH OF PENNSnVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF Peter J. Smith FILE NUMBER 1. Name of Corporation Non e Address City 2. Federal Employer 1.0. Number 3. Type of Business State Zip Code State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year Product/Service 4 TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting { NOll-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? DYes DNa If yes, Position 6. Was the Corporation indebted to the decedent? DYes Annual Salary $ DNo Time Devoted to Business If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? DYes DNa If yes, Cash Surrender Value $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12.31.820 Net proceeds payable $ DYes DNa If yes, DTransfer Transferee or Purchaser Attach a separate sheet for additiOllal transfers and/or sales DSale Number of Shares Consideration $ Date 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement DYes DNo 10. Was the decedent's stock sold? DYes DNo If yes, provide a copy of the agreement of sale, etc 11. Was the corporation dissolved or liquidated after the decedent's death? DYes DNo If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? DYes DNo If yes, report the necessary information on a separate sheet, including a Schedule C.1 or C.2 for each interest THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A B. I C Detailed calculations used in the valuation of the decedent's stock. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid G. Any other information relating to the valuation of the decedent's stock. STFPA42021F.6 L/Lb/LUUl lL;~~ PM REV-1506 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C.2 PARTNERSHIP INFORMATION REPORT ESTATE OF Peter J. Smith FILE NUMBER 1. Name of Partnership None Address City Date Business Commenced Business Reporting Year State Zip Code 2. Federal Employer 1.0. Number 3. Type of Business ProducUService 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ 5. PERCENT OF PERCENT OF BALANCE OF PARTNER NAME INCOME OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? 0 Yes 0 No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? DYes DNa If yes, Cash Surrender Value $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? Net proceeds payable $ DYes DNa If yes, 0 Transfer 0 Sale Percentage transferred/sold Consideration $ Transferee or Purchaser Attach a separate sheet for additionallransfers and/or sales. Date 10. Was there a written partnership agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? DYes 0 No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? DYes DNa DYes DNa If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? DYes DNa If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? DYes DNa If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of inancial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. STFPA42021F7 ~/Lb/LUUl lL:jH PM REV-1507 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF Peter J. Smith FILE NUMBER All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. None TOTAL (Also enter on line 4. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) $TFPA42021F 8 L!Lb!LUUl lL:~b PM REV-1508 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Estate of Peter J. Smith FILE NUMBER 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Cash on Hand 50 TOTAL (Also enter on line 5, Recapitulation) $ (If more space IS needed, Insert addlllonal sheets of the same size) 50 STFPA42021F.9 L!Lb!LUUl lL:~~ PM REV-1509 EX + (1-97) (I) CQMMON\'\IEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Peter J. Smith FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME RELATIONSHIP TO DECEDENT ADDRESS A Peter J. Smith, Jr. :alf Poplar Ave New Cumberland, PA 17070 B. Marylin B. Fu11er-Smit h 23/l Poplar Ave New Cumberland, PA 17070 c Son Daughter-in-1a,^ JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY '10 OF DATE OF DEATH ITEM FOR JOINT MADE InclLde name of financial institution aod bank accollll nIJ11ber or similar identifyirg number. DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT Attad1deedlorJOil1l~-heklrealeslate VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 1995 PSECU Account 0189038046-4 2,019 ~6.67 337 2. A. 1995 Psecu Account 0189038046-1 2,786 ~6. 67 464 3. B. 1995 PSECU Account 0189038046-1 2,785 ~6. 67 464 4. B. 1995 PSECU Account 0189038046-4 2,019 fl-6.67 337 TOTAL (AlsD enter Dn line 6. Recapitulation) $ 1,602 SlFPA42021F10 (If more space IS needed. insert additional sheets Df the same size) L/Lb/LUUl lL:~d PM REV-1510 EX + (1-97) (I) COMMONVv'EALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Peter J. Smith FILE NUMBER This schedule must be completed and filed if1he answer to any of questions 1 through 4 OIl the reverse side oflhe REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERlY %OF ITEM II\CLlDE Tl-E W>ME OF Tl-E TRANSFEREE, Tl-EIR RELATlONSHP TO DECEDENT Af\I)Tl-E DATE DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER OF TRAN5FER ATTACH A COPY OF Tl-E DEED FOR REAL ESTATE VALUE OF ASSET INTEREST (IF APPLICABLE) 1. None TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) STFPA42021F 11 L/L6/LUUl lL:~~ PM REV-1511 EX + (1-97)(1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Peter J. Smith FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. M J McLaughlin Funeral Home 4,964 B. ADMINISTRATIVE COSTS: 1. Persooal Representative's Commissions Name of Personal Representative(s} Social Security Number(s) { EIN Number of Persooal Representative(s) Street Address City State lip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanatioo) Claimant Peter J. Smith Street Address Z3r!/ Poplar Ave City New Cumberland Stale PA Zip 17070 Relationship of Claimant to Decedent Son 3,500 4. Probate Fees 5. Accountant's Fees 1,450 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 9 914 SlFPA42021F.12 (If more space IS needed, Insert additional sheets of the same size) L!Lb!LUUl lL:~~ PM REV-1512 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Peter J. Smith FILE NUMBER Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. 2. Neighbor Care Pinnacle Health 68 54 STFPA42021F.13 TOTAL (Also enter on line 10, Recapitulation) I (If more space IS needed, Insert additional sheets of the same size) 122 ~/Lb/~UUl l~:~~ PM REV-1513 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Peter J. Smith NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Peter J. Smith, Jr. 2JJ~ Poplar Ave New Cumberland PA 17070 2. Frank L. Smith FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Son Son AMOUNT OR SHARE OF ESTATE 50% 50% 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. STfPA42021F14 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 at the same size) L/lb/lUUl ll:~d PM REV-1514 EX + (1-97)(1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Box 4 on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER Peter J. Smith This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. DWill Dlntervivos Deed ofTrust DOther LIFE ESTATE INTEREST CALCULATION NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE None o Lite or 0 Term ot Years o Lite or OTerm of Years o Lite or OTerm of Years o Lite or OTerm otYears 1. Value of fund from which life estate is payable 2. Actuarial factor per appropriate table Interest table rate - 03 1/2% 06% 0 10% 3. Value of life estate (Line 1 multiplied by Line 2) ANNUITY INTEREST CALCULATION $ o Variable Rate % $ NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE o Lite or OTerm otYears o Lite or o Term otYears OLileor o Term otYears o Life or 0 Term ot Years 1. Value of fund from which annuity is payable $ 2. Check appropriate block below and enter corresponding (number) Frequency of payout - o Weekly (52) 0 Bi-weekly (26) o Monthly (12) o Quarterly (4) 0 Semi-annually (2) o Annually (1) o Other ( ) 3 Amount of payout per period $ 4. Aggregate annual payment, Line 2 multiplied by Line 3 5. Annuity Factor (see instructions) Interest table rate 031/2% 06% 010% o Variable Rate % 6. Adjustment Factor (see instructions) 7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 $ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 $ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15,16 and 17. STFPA42021F.15 (II more space is neeced, insert addilional sheets ot the same size) ~/~b/~UUl l~:~b PM REV-1647 EX + (1-97) (I) SCHEDULE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANlA INHERITANCE TAX RETURN RESIDENT DECEDENT (Check Box 4a on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER Peter J. Smith This schedule is appropriate only for estates of decedents dying after December 12,1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. o Will o Trust o Other I. Beneficiaries NAME OF AGE TO BENEFICIARY RELATIONSHIP DATE OF BIRTH NEAREST BIRTHDAY 1,None 2, 3, 4. 5, II. For decedents dying on or after July 1. 1994. if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death. check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right o Unlimited right of withdrawal o Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest $ 2, Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One 06%, 03%, 00% (also include as part of total shown on Line 15 of Cover Sheet) $ 4. Value of Line 1 Taxable at 6% Rate (also include as part of total shown on Line 16 of Cover Sheet) $ 5, Value of Line 1 Taxable at 15% Rate (also include as part of total shown on Line 17 of Cover Sheet) $ 6. Total value of Future Interest (sum of Lines 2 thru 5 must ecual Line 1) $ STFPA42021F.16 (If more space is needed, insert additional sheets of the same size) L!Lb!LUUl lL:~~ PM REV-1649 EX -t (1m) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 0 ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER Peter J. Smith Do not complete this schedule unless the estate is making the election to tax assets under Section 91131AI of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113 (A), and: a. The trust or similar arrangement is listed on Schedule a, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule a, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule a, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangerrent. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule a. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. DESCRIPTION VAlLE None Part A Total $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. DESCRIPTION VALLE STFPA42021F.1? Part B Total $ (If more space is needed, insert additional sheets of the same size) Hl()~H()~ IU-:V'l!o{) This is to certifY that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original cerrilicare will be forwarded to the State Vital Recotds Office for permanent liling. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. c?~ cfn,&k Fee for this certificate, $2.00 Local Registrar .JUN.. P 6GOOG18 Date '1: ,...JI...:"~~.;:, - .,-......... ~.......' . /' .. ", .'..... H'C5T4lRe'.28/ COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT Of HEALTH. VITAL RECORDS CERTIFICATE OF DEATH TYPElPRrNT " PEIlM,lNENT BLACK INK NAMEOfOECEOENT(F~.,.Middl.,l."l " STATE filE NUMBER SOCIALSECURlTYNUMBER OATEOFDEATH''''OtIl/l,o.yh.n , AGEIL...B......lOy) UNDER 1 YEAR M""lhS o..VO BIRTHPlACE (C~v.nd S"'~orForei9nCO\Jnlry) , Male , 189-03-8046 PlACOFOEAl!-1Chodlono"", HOSPITAL 27MAY2000 dl Wilkes-Barre, PA 8oj.P~ie"IO FACIUl'Y t-lAME Iljr>olInSliIul"m, gi... "'ell andnumbor'l Manor Care Health Services ~" R.....enceO ISp.ClfyID , COUNl'Y OF DEATH 92 Yro Cumberland RACE.Am.nc.ni......n alocl< WhO..'" ,SpeClfyI White DECEDENTS US lDCCUPAnOJi 'G...~ondcf_do.edu'inomosl ol.,'lf~"'9'h;<IO""I~se'ellfoed> S~VIVINGSPDUSE j((..~..a... mllCl.."..".. inapplicable " FATHERSt-lAMEIFIfSI,_.L.sl) 18 Peter Smith 'NFORMA"TS NAME (TypeIPml) 234 Poplar Avenue New Cumberland, PA 17070 )7~ COUll'" Cumberland I'~ &1 :h'~~~:~'~':oI Camp Hill MOTHER'S NAME (FirOI,Modd.., Mlode/> S<J,n."",) 19 Anna McCormack INFOfWANTS MAILING ADDI'lESS 1$"..1. C~ylTown, Sllte, Lp COdal o ~ o " < o < .<Oa Peter J. Smith METt-tODOFDlSPOSIT,OJi B~~ 0 C'em~'on 0 Remo.aI ~"'" Slate 0 Oon.~on 0 Olh<lIS.,..,..,.) lIRE UNE~LSERV~EL ENSEEORPERSO G.o,s H ~, amol........2JI-<""I._nc...,~.irlo '"a besl oIm.. pI1v~,'na,....I_"'limeoldelrhto ISignalU'e,,"~Tille) oart<f-,.g"",ol..I'" OATEOF O'SPOSITIOfl (Mon'h,D'y,Ye..-) 2010 234 Po lar Avenue New Cumberland PA 17070 PlACEOFDISPOSITIOJi N.meofC._.",.Crem.to'" I.OCATIQN Ci,.,Town SI.I. Z'DCOde DfOlh.' Place 30MA Y2000 51. Mary's Cemetery HanO\ler Twp.. PA 18702 e . o ~ o ~ w , < Z liCENSE NUWER 2210 FS-013160~L NAME ANQ ADORESS Of fACILITY 22C M.J. Mclaughlin Co. Inc.. L1CEflSE !'lUMBER 142 S. Washington St, Wilkes-Barre. PA 18701,2997 OATESlGJiED IMonlh.O.v.rean ..deoll1 oc<~,,"d _I 'he lim., dal. .ndol"".'IlI\W ,~ TtMEOF OEATH 08:45 PM DATEPROflOUNCEOOEAorMonth.o....vun May 27, 2000 2~ 2~ WAS CASE REFERREO TO MEOlCAl EXAM'NERlCOFlONER' Yes 0 ""}it , 2/ PARTI: En,", Ih. di'U,.s, In)",,", or "mobl",""s wr.;a. t.~...d 'h. de.lh 00 nO! enllflhe nodeoldying....<1>... cardi.c or '.spir;alory ....eS!, .hoc. or h.an f.,",,". Appro.imil. ""'an'Yo"'CI~'" on..c" ,n. ,nlllrV.lb.tween on..tandd..111 PARTn, 0\tI"'...if"'".'candil"""Con"'bu'in9IO~"h ~"' not,..~llon9,nl/'le~nd.nym9cau..gov.n", PART I I: t: !IF OllEn~ASACOJiSEOUENCEOfl t:/1'1f...urIA OliE TO lOR AS A CONSEOUENCE OFl DUE TO\ORASACONSEOUENCEOFj ~ . " ~ " ~ ~ o WERE AUTOP$V FlNDI!'lGS MANNEROFDE.o,TH .o,VAllABLEPR,ORTO if COMPlETION OF CAUSE NaM.1 Hom,ciO. 0 Of OEATH~ Accidenl 0 Pend"'9'nv"S'>g'''on 0 ...0 "Ji6 S~IC"e 0 Co,"ano'~. d.'e,,,,,,,ed 0 OATEOFINJURY IMon'".00y,V."1 TIME OF INJURV INJURY AT WORK' DESCRlBEliOW,i'<jURYOCCURED HSO NOD , ,~ CERTIFIH,Cheoko",yon.1 'CERTIFYING PHYSICIAN lP"ys'c'..<e~,IY'"9 Oil.., oldo.," wn"" IflOll1e,ph,,,,,,.n ....prono""'c.dd..'handcom.,..'.drr""'2ll To lI>e 0e.1 Of...,.no"".do--,d..m O<:cD".d"".lolh.c.....I.I.ndm.nn.'....1 .,.<1 'PRONDUNCLNG AI'lD CERTIFYING PHYSIC'AN (Phv>,c,"n b-omp,onounC/f1g 0..", .ndc.,1<r"ng,oclu.eoloe.lI>l TO'h....IOr...y.nOwl.dg..d..lhO<:cDff.da""-"i...,d...,."dpl.u,..ddu.lot!l.ea~U$('I."dm'nn","Ola'ad " JO. PlACE OF INJURY, A,"omo, rar..., s!<eel. f''''o'l',oJfi<e bD,l(l;r>g, olo ISp<!o~~ I ~. LOCAflONISlre...C."lTownSI"'1 REGlsrRAR'SS'GNArURE'JiDNUMIlER rJ -P. oP---C. ,...."?-W _ ~---' IlfrOI3181K1 "' SIG~AflDTI1lEOFCERTIF'ER J)b /. 'Z.- C....~L(AJ, lICENSE!'lUMeER DATI;.~NED(Mon'".D.,Y<arl o JICO..sO()(."('Ji'"-.t. l1Q~~11-""'-J NAME AND AODRESSOF PERSON WHO COMPLETED CAUSE 01' OEAn-l t".m27) TVQlO,pnn'-r: ". CUl.l.iN} tJ() o "l()} NtJJJ. f "Is/f.. J2 C/1/HP /VIti-I. ~ Il~11 DATEFllEOIMon'nO....e." l!I1' 'YEO'C.o,LEKAMINERICORONER O"'h.b..,.ol......I..llon.ndlo,'nve..i9.'io".inmvOpin;"",d.alhOCCDff.d..th.Um'.dol...JI<l.O'"., ""dd~'IO'h.c"'''(s)...d "'.nn./a....I.d t: /C'/., /In/') WIL.L l~... 682J--Printed. .aDd _~tI!" &ale by TIl~~kDY CO ".SQ Publi" Squarr, \V-;I!r..A:~:.-P... Jae it !llemembereb That I. , PETER JuSEPH SMITll, SEl:Hull 119 NlJRTH DA\>'ES AVEmm t KIHGSTurl, PEril/A. being of 30und and disposing mind, memory and understanding, do make, publish and declare. . this to be my last .iII an;) lJllsfamllnf. in manner and form following, that is to say: \ 'film: I HERBBY GIVE. DKVISE, ArID BEQUEATH ALL PERSC.!AL PRLPERn , REAL ESTATE, BfJll\. AND CIm::KI,lG ACCCUNTSj STlJCKS, GCVEllliMER'l' BVNDS, AUT0MLBILE, ArID ALL CTlillR PCSSES::lICHS TO MY \1IFE, VICLA R., WITH NO RESTRICTIC,MS ell LlJ.lITATIClS. ill TIlE EVliNT THAT MY WIFE SHOULD PRSDEl::EA.SE ME, Tfm{ liY ,,"NS, PETER, JR., AIlD FRANK L. ARE TC DIVIDE EVERYTHnlG EClU~1~ . ~'".,.'~ m~. ".,,',,',"~ "'~W~1~~.;r My Wife, Viola R., Executor '. .. My husband, ~eter J., Ex";Ut~7' r"~' _ ,7 L / VA 'U~U-6""/ ~ <XJ~..d. u,,&:.' -/P "--'<t .;/i___..,.L/: x'~~~ . to be the Execut or 5 of fhts my Last rnil "lJd ~ _ Testamflllt. _hereby r!./JOking ull former Wills and Testaments by me at any time heretofore made, and declaring this to be my last Will alld Testament. !In _hnllss ....e..Oi, [ have hereunto su}j~trtbed mY'I!,fgI1'\ and aJ!i;r;ed lilY seal, day of in the year of Oll" Lord, one thousand June 13th nine hundred 62. the htR/e hereunto, a .request, subscribed our 7. ,1 {-'~ .</ ,/ .-. names i-n"'::'~:.~'---.prese'1Ue and in the presence of earh other, as witnff$SeS hereto. d-? ~_,_<:,'c .,$',:,., T,---- , I, Viola Rita Smith. being of sound mind, hereby name illY husband, Peter Joseph Smith, Sr. heir to all my worldly possessions. Should he predecease me, I leave all property, reel or personal to our two lOV1ng sons, _Peter~~J!)i'rank L. -- ~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. Z80601 HARRIS8URG, PA 17128-0601 *' INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 00139662 09-13-2000 REW-l&4SEXAFPCG7-Gll EST. OF PETER J SMITH S.S. NO. 189-03-8046 DATE OF DEATH 05-27-2000 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS IXJ CHECKING o TRUST o CERTIF. MARILYN B FULLERSMITH 234 POPLAR AVE NEW CUMBERLAND PA 17070 RE"IT PAY"ENT AND FO~S TO: REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 PSECU has providllKl tho Depart_ant with the inforation listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you f8BI this infor_ation is incorrect, please obtain written corraction fr~ the financial institution, attach a copy to this for_ and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the eo..onwealth of Pennsylvania. Questions I18Y be answerllKl by calling (717) 787-8327. COMPLETE PART 1 BELOW . Account No. 0189038046-4 . . SEE Date Established REVERSE SIDE FOR 05-03-1995 FILING AND PAYMENT INSTRUCTIONS Account Balance 2 , 019 . 25 Percent Taxable X 16 . 667 AlIOunt Subject to Tax 336 .55 Tax Rate )( .06 Potential Tax Due 20.19 PART TAXPAYER RESPONSE [!]'iiiiii~I~.liru~Jii~~_~ru_!!l~J~liii.i.~~~.!rni~.qil\.~~!_~i..~iilMl~i.~i~i.~.i,i~ To insure proper credit to your account, two (Z) copies of this notice .ust acco~any your pa~ant to the Register of Wills. Make check payable to: -Register of Wills, Agent". NOTE: If tax pay_ants are llede wi thin thrB8 (3) ~nths of the decedent's date of death, yoU II8Y deduct a SX discount of the tax due. Any inheritance tax due will becOMe delinquent nine (9) ~nths after the date of death. [CHECK ] ONE BLOCK ONLY A. 0 The above infor_ation and tax due is correct. 1. You ~y choose to r~it pa~t to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you May check box "A" and return this notice to the Register of Wills and an official assess-.nt will be issued by the PA Depart.ent of Revenus. B. D The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the decedent.s representative. C. D The above inforMation is incorrect and/or debts and deductions were paid by you. You .ust co~lete PART ~ and/or PART ~ below. PART @] DATE PAID DEBTS AND DEDUCTIONS CLAIMED If you indicate a different tax rate, please state your relationship to deced."t: PART ~ TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent T.xable 4. A~unt Subject to Tax 5. Debts and Deductions 6. AltOunt Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 4 5 6 7 8 X X PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on Line 5 of Tax Computation) , $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME WORK ( ( ) ) TAVP^VCP C:Tr-:I\IATIIDC TCICDunMC I\IIIMDI:"D nATe COMMONWEALTH OF PENNSVLVANIA DEPARTM::NT OF REVENUE BUREAU DF INDIVIDUAL TAXES DEPT. Z8D6DI HARRISBURG~ PA 17128-0601 *' INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 00139664 09-13-2000 IU-15UElIAFPlDl.DD> EST. OF PETER J SMITH S.S. NO. 189-03-8046 DATE OF DEATH 05-27-2000 COUNTY CUMBERLAND TYPE OF ACCOUNT lXJ SAVINGS o CHECKING o TRUST o CERTIF. MARILYN B FULLERSMITH 234 POPLAR AVE NEW CUMBERLAND PA 17070 REHIT PAYHENT AND FORHS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 PSECU has provided the Depart.'lnt with the infor.ation listed below which has been used in calculating t:he potential tax duB. Their records indicate that lit the doath of the IIbove deC8c1ent~ YOU were a joint owner/beneficiary of this account. If you feel this infor~tion is incorrect~ please obtain written correction fr~ the financial institution~ attach a copy to this for. and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Co..onwealth o~ Pennsylvania. Questions .ay be answered by calling (711) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0189038046-1 Dat. 05-03-1995 Estab1 ished To insure proper credit to your account~ two (2) copies of this notice IIUst accOllpany your pay-.nt to the Register of Wills. Make check payablG to: "Register of Wi1ls~ Agent... Account Balance 2}785.91 Percent Taxable X 16.667 A.ount Subject to Tax 464.33 Tax Rate X .06 PotenU.l T.x Due 27.86 PART TAXPAYER RESPONSE [!] lr:i~:!l'~~~.~.~i~:mn~~!!i_llrn~}~.~~gi~r,]~.~.a.ii!i"'/'l.il.~~.~. NOTE: If tax pay_nts are .ade within three (3) .onths of the decedent"s date of d..t:h~ you mBY deduct a 5Z discount of the tax duG. Any inheritance tax due will beCOM delinquent nine ('J) IIOnths after the date of death. [CHECK ] ONE BLOCK ONLY A. 0 The abovG inforllation and tit)( due is correct. 1. Vou .ay choose to r..it pay-.nt to the Register of Wills with two copies of this notice to obtain a discount or avoid int.rest~ or you ~y check box "A" and return this notice to the Register of Wills and an official asses~nt will be issued by the PA DepBrt.ent of Revenue. B. 0 The above assGt has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the decedent.s representative. C. 0 The above infor.atiDll is incorrect and/or debts and deductions .,ere paid by you. You .ust c~lete PART ~ and/or PART ~ below. PART @] DATE PAID DEBTS AND DEDUCTIONS CLAIMED If you indicate a different tax rate} plaase st.te your relationship to decedent: PART ~ TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. A.ount Taxable 7. Tax Rate 8. Tax Due OF 1 2 3 4 5 6 7 8 x TAX ON JOINT/TRUST ACCOUNTS x PAYEE DESCRIPTION AMOUNT PAID , TOTAL (Enter on Line 5 of Tax Computation) I $ Under penalties of perjury~ I dec1are th.t the facts I have reported above are true, correct and COMplete to the best of my knowledge and belief. HOME WORK ( ( ) ) TAvnA""~1O C'Tro..AT.'n.... ......... ........II....U... u..~............ ClJMl10NIrlEAL TH OF PEtIl!SYL VANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 *' INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 00139665 09-13-2000 REY-l54S EX U', (17-IU EST. OF PETER J SMITH S.S. NO. 189-03-8046 DATE OF DEATH 05-27-2000 COUNTY CUMBERLAND TYPE OF ACCOUNT [X] SAVINGS D CHECKING D TRUST D CERTIF. PETER J SMITH JR 234 POPLAR AVE NEW CUMBERLAND PA 17070 REMIT PAYMENT AND FORHS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 PSECU has provided thlill DlilP8rtlKlnt with thlill infor.ation listlilld balow which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you _I"'. a joint OWfJer/b....ficiary of this account. If you feel this info~ation Is incorr.ct, pl.sse obtain written correction fr~ thIiII financial institution, attach a copy to this for. and r.turn it to thlI above addr.ss. This account is taxable in accordance with the InheritancCl Tax Laws of thlill COIlllOn...al th of PClnnsylvania. Questions .ay bCl answered by calling (717) 787-83Z7. COMPLETE PART 1 BELOW . Account Mo. 0189038046-1 . . SEE Date Established REVERSE SIDE FOR 05-03-1995 FILING AND PAYMENT INSTRUCTIONS Account Balance 2,785.91 Percent Texable X 16.667 A.ount Subject to Tax 464.33 Tax Rate X .06 Potential Tax Due 27.86 PART TAXPAYER RESPONSE ITII~illi!~i~_i!~.__iml"lli!'.~rlii.!!,gm!_g:.!iir.iii~..~.~..ill.i\!~I~lli.~.mll To insure proper credit to your account, two (2) copies of this notice IlUst SCCOllParlY your paYll8l1t to th& Register of Wills. Hake check payable to: "Register of Wills, Agent-. HOTE: If tax paYHnts are llade within thru (3) aonths of thlill d.cedent.s date of death, YOU ny deduct a SZ discount of the tax due. Any inheritance tax due will beCDR delinquent nine (9) .onths after the date of death. [CHECK ] ONE BLOCK ONLY A. 0 The above inforution and tax due is correct. 1. You.ay choose to r..it p~t to the Register of Mills with two copies of this notiC8 to obtain a discount or avoid interest, or you .ay check box -Aw and return this notice to the Register of Wills and an official asseSSMent will be issued by the PA Depart..nt of Revenue. B. 0 The above asset has been or will be reported and tax paid with the Pennsylvania InheritanC8 Tax return to be filed by the decedent.s representative. C. 0 The above inforMation is incorr.ct and/or debts and deductions were paid by you. Vou MUSt c~plete PART 0 ancl/or PART ~ below. PART ~ DATE PAID DEBTS AND DEDUCTIONS CLAIMED I~ you indicate a dif~er.nt tax rate, please state your relationship to decedent: PART ~ TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. A80...,t Subject to Tax S. Debts and Deductions 6. AftOUnt Taxable 7. Tax Rat. 8. Tax Due OF 1 2 3 " S 6 7 8 X TAX ON JOINT/TRUST ACCOUNTS X PAYEE DESCRIPTION AMOUNT PAID , TOTAL (Enter on Line 5 of Tax COMPutation) I $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the bast of MY knowledge and belief. HOME WORK ( ( ) ) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 . INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 00139663 09-13-2000 RfW-1S4S ex 'F' (01-DII EST. OF PETER J SMITH S.S. NO. 189-03-8046 DATE OF DEATH 05-27-2000 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS [Xl CHECKING o TRUST o CERTIF. PETER J SMITH JR 234 POPLAR AVE NEW CUMBERLAND PA 17070 REHIT PAYHENT AND FORHS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 PSECU has provided the Depart.8I"It with the inforntion listed below which has been used in calculating the potgntial tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If YOU feel this infor..tion is incorrect, please obtain written correction f~ the financial institution, attach a copy to this for. and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the eo..onwealth of' Pennsylvania. Questions .ay be. 8ns_red by calling (717) 787-83Z7. COMPLETE PART 1 BELOW . Account No. 0189038046-4 . . SEE Oat. Established REVERSE SIDE FOR 05-03-1995 FILING AND PAYMENT INSTRUCTIONS Account Balance Percent Taxable Amount Subject to Tax Tax Rat. Potential Tax Du. x 2,019.25 16.667 336.55 .06 20.19 To insure proper credit to your account, two (2) copies of this notice IlUst BCCCMIPany your pey-.nt to the Register of Wills. Make check payable to: WRegister of Wills, Agent-. x NOTE: If tax pay.ants are .ade within three (3) ~nths of the decedent's date of death, you ..y deduct a 5X discount of the tax due. Any inheritance tax due will bec~ delinquent nine (9) ~nths after the date of death. PART TAXPAYER RESPONSE [!)1!r!r~I'~I.r~!.!m'..ml~~~!'J~"1ijf,!~liim.mi.!g~Pi!r~_m__m!~m!.i!i!IMII~_~m~1 A. 0 The abo"e infor..tion and .tax due is correct. 1. You .ay choose to r~it pa~ent to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or YOU May check box wA~ and return this notice to the Register of Wills end an official asses~nt will be issued by the PA Depart-.nt of Revenue. [CHECK ] ONE BLOCK ONLY 8. D The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax: return to be filed by the decedent's representative. c. D The above info~tion is incorrllCt and/or dobts and deductions ware paid by you. You ....st cOllplete PART 0 and/or PART @J below. PART ~ DATE PAID DEBTS AND DEDUCTIONS CLAIMED If you indicate a different tax rat.s please state your relationship to decedent: PART ~ TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. A.ount Subject to Tax 5. Debts and Deduct ions 6, A.aunt Taxable 7. Tax Rate 8. Tax Due OF 1 2 3 4 5 6 7 8 x TAX ON JOINT/TRUST ACCOUNTS x PAYEE DESCRIPTION AMOUNT PAID I $ I TOTAL (Enter on Line 5 of Tax Coaputation) Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of .y knowledge and belief. HOME WORK ( ( ) ) "rr-. r-.............. ......n........ .....T. A AIM pg. 2 of 2 January 1. 2000 - December 31. 2000 FUN D S@ Individual Account Transactions PETER J SMITH TOO PETER J SMITH JR POST TRADE TRANSACfION DOLLAR SHARE TOTAL DATE DATE DESCRIPTION AMOUNT PRICE SHARES SHARES 01/01/00 01/01/00 Balance Forward 1.727.672 02/01/00 02/01/00 Systematic Withdrawal $ -3.500.00 51.16 -68.413 1.659.259 03/01/00 03/01/00 Systematic Withdrawal $ -3.500.00 51.40 -68.093 1.591.166 03/31/00 03/31/00 Systematic Withdrawal $ -3.500.00 55.72 -62.814 1.528.352 05/01/00 05/01/00 Systematic Withdrawal $ -3.500.00 53.95 -64.875 1.397.289 06/30/00 06/30/00 Systematic Withdrawal $ -3.500.00 53.99 -64.827 1.332.462 07/11/00 07/11/00 Full Transfer Out $ .00 .00 -1,332.462 .000 5030373350 515 No Automatic Investments No Automatic Exchange Account Number Fund Telephone Redemption No Telephone Exchange Yes Dividends Capital Gains Reinvest Systematic Withdrawal Reinvest No Account Number Fund Dividends & ST Capital Gains .00 .00 L T Capital Gains Taxes Withheld 5030373350 515 QTR $ YTD $ .00 .00 .00 .00 ~UI ml~ ~~~~~~~~~ m~ .. G 2 2 3 3 5 fl " V ..