HomeMy WebLinkAbout06-30-15 � �.y���m��ma 1505614105
ll] ex(o3-ia)trp
REV-1500 OFiIC1AL USE ONLY
Bureau oflnGivitlual Taxes Govnry COEe Vear file Number
Po BOX 280601 INHERITANCE TAX RETURN '�� j��(/y �.
n � b g PA 1]128-0601 RESIDEN7 DECEDEN7 . �� �'� I�"I �� I IJ b �
ENTER OECEDENT INFORMATON BELOW
Socal Secunty Number oa�e or oeam MMO�VYYV pate Of BiR� MMODYYW
� .. ..� .. ... 06212014 ' 08281929 __. __. ._._J
Deceden�s Lasl Name � Sufix�� �acetlan�s First Neme MI
_— ._ _ .—__ 1 I _
MATTOS � .__ _ FR4NG5 __ _J I�
_.__
Qf AppliwEle)Enter SurvNing Spouse's Infortnation Below
Spouse'sLa5lName SURx Spouse's FrsiName .. .... MI
__. . _ . . .____ ___ - . ... _
. _ �. . , ._.._ _.I ILJ
� THIS REfURN MUST BE FILED�IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� t Orginai Remm O ��Supplemental ReWm O 3. Rameintler ReNm(Eala of deaM
pnor b 12-13-92)
p 4.ngncuttura Exemp�on tlate ol p 5. FuNre Interest Gompmmise(Ea[a of p 8. Federal Estate Tu ReWm RequireE
tleatl�on or afier 14d�127 eea�M1 aner 1242-82)
O �� �ecedenl Dletl TesUte O B. �ecetlent Main�ainaE a Living Tmst _ 9. To�al Number of Safa Daposil Boxes
(A��M1�Dvolwill.) (AVacM1copyo(Uust)
p 10. Litiqation Proceetls Recaivetl O 11.NomPmbale Transterae RaWrn O 12. Oefertal/Electlon olSpousel Tmsts
(Sc�edule F antl G Assets Only)
O 13.BusinessAsse4 O ia.SDouse is Sole BenafiGary .
(No Imst inmlveC)
CORRESPONDEM- 1NI5 SECl10H MOSt BE COMPLETE�.ALL LORRESPONDENCE RND CONFlOENiIAL TP%INFORMATION SXOOLU BE OIMEttED ttl:
Name Daylime Telaphone Number
Michael 5.Travis 717-731-9509
._.... .. . .__. _ . __._ .___. .
FlrstLinaotAaaress �� �
.__ .. . .. ... __... . _.. ... ...... .. ... ..
AtlornevatLaw .._._ ._... ':
Secontl Line otACtlress
....____ ._._ ..._ . . . . . .. .
3904 Trindle Road .... . '.
CiryorPoslOBice � � ����� S�ale ZIPCotle
. . ___ .. . . ... .._.. _...
.. __- ____._. _ _.. ._.. _. . . .
�CampHill . .. ... .. ...PA 17_011__ '
CorteaponaenCsemailatldress: ,
REGISTER OF WILLS USEOJILY
c� �
REOISTEROFW 606EONLV � p �� � fil
� f'1
Yn" y+�tv! C CJ �r GJ
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. .; . ._ : . ._ C• _ . . �;
W
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OATE FILm$TMIp
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PLEASE USE ORIGINAL FORM ONLY - � ,'. ��
T
Side 1 ~
L IIIIIIIIIIII�IIII�I��II��II�IIyII�I��IIIIIIIIII�IIIIII y505614105 J �
J Lsas614aas
REV-0SW EX(Fl)
Decetlanl's Social Secu�ity Numbar
oeceaenYSName: �'.,. .......�'.
RECAPRULATION
1. Real E513�B(ScM1Baole A). .. .. . . . . . . . ... .. .... . ..... L '.
z Smcxs ana BOMs(scneauie BJ ........... ... ............. ....... 2 '..... 13954 04..''.
3. Glouly Heltl Coryoretioq PertnersM1ip or Sole-Pmpnelarship(Sc�etlule C) ..... 3. '�.. �''�.
4. Mortgages anC Notes Receivable(ScheEule D) . . ..................._ . ... 4. '��. �
5. Cash,Bank Deposils antl Miscellaneoos Personxl Pmperty(SchaCui=E)....... S �. 13944]BJ'�.
6. Jointly Owned PmpeM(ScheEule F) O Separate Billing Requested ....... 6. �I ����.
]. In[er-Yvoz Trensfars d Miscellaneous Non-Propa[e PropeRy ' �..
(ScheOule 6) O Separete Billing Requestetl... ..... 9. �'�; 101886.�'�,.,
8. Tobl Groaa Asaeb Qo�al Lines 1 I�rough]). ... ...... ........... . B '_ 255288.77�
4 PoneralExpensesanEAtlminisVativaCosts(SCM1etlulaHJ... . . ............. . 9. '��.. ppq37J2i
10. �e�ts of Deccd¢nt,MOrtgege Lie0ili6e5 antl Liens(SCheOUIB 1�.. ......... ... 10 '�� �3$6�92',��.
n. Total oaducnons(mtei�ines e antl i0). . . . . . ...... ..... ...... . .. .. tt ' 36005.64�.....-
�2 He�vaWe ot Es�ate ILine e minus Line nl ... ...._.... . ............ 12 '�.. 219283 13..'...
13. Chanlable anE Govemmental Bapuesis�5ec.9113 Tmsis for which ��. �..
an election[o Gz�as not Oeen matle(Schetlule J) . ......_...... . .... . . .. 13. '��. ��
ia. He�vaWeSUOjedtoTaz(Linet2minus�inet3) ..... ......... ...... .... ib. ''.. 27928313''�
TA%LALCIILATION-SEE INSTRUCTONS FOR qPPLICABLE RATES
15. AmountolLinel4taxable
at iM1e spovul�az rote,or
IrznslersunGer5ec.9116 ...-. ..-.-. .. ��. -.- .--- -.
(a)(1 2)%.0_ - 15. �. �.
16. Amoun�of Line 141axable � ��.' �.
a�imeai re�e x.oqy __ 29283.13�� �s. ��..''. 966774�....,'...
1]. AmowtofLinaldtaxable � � �.
a�siplin9 rote X.12 � p. �� I.
t8. Amount of Line 10 taxeble � � I �, ��.
a�mllale212te X.15 �.'.. 18. ... ..��.
19. TAXDOE.
. . . . . . . . __........... ............_. _...._ i9 986774�
20. FILL IN THE OVAL IF YOU ARE REOIlESTING A REFUNU OF AN OVERVAYMENT p
Under penelLes ol pe�ury,I Cedare I�ava exeminea Mls relum,InGOEIng aaompanyin8 9����las en0 ale�emen6,and lo t�e Des�of my knowlMga anU Eeliel.
X Is true,mrtetl an0 mmD��e. Declaation ol Oreparer o�Fer Nan 0e person responsiEle lor fling�he reWm Is�aSeC on al inlormalion o�wliic�Dreperer�es
anY knowk09e.
SIGNAT PE���ON�S/IjB��,�'[�/O FIL��TURN OATE
PD�RP�S ' � �—�/S
4df11 F�bn\/elley Cn�A �.IonAn'..� OA �9�jd5
SIGNAIUREOFPREPAiEEFOTHERTHANPERSONqESPONSIBLEFORFILINGTHERETURN OAiE
A�ORE55
L umiioiiu�ii�i��ii��i�i�ii��i�iiiiiniiituimi Side2
Lsos6lvzos J
REV 15W EX (FI) Page] Flle Numb�
DecedenYs Complete Address: '
DECEDENT'S NAME
R ` _"
SiREETA��RESS
7 Hanover r �
CITY STpTE ZIP
Tax Payments and Credits:
1. Tax Due(Page 4,line 79) (�I oaa��n
2. CrediL4Paymenls
A.Prior Payments �
B.Discounl
(SeeinsWctions.� TotalCreGils(A*B) (2)
3. Interesl
(3) no nn
4. It Lirre 2 is greater Ihan Lire 1 �G�3,enler Ne diRerence. This is Ne OVERPAYMENT. '
Fill in oval an Page 3,Lina M lo request a rePond � (4)
5. If Line 1 .Line 3 is greater Ihan Line 2,enter Ne tliRe2nce.This is ihe TAX DUE (5) ooSF Fa
Make check payable to: REGISTER OF WILLS,AGENT.
_. . ,. , . ,. _.,.a..N �»�,>�;a�-
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
7. Dk decedent make a Uansfer and: Yes No
a. relain Ue use or inrome of ihe Property UansferteE ............. ._..__. .................._..._..... ❑ �
b. relain Ihe nght lo designate who shall use t�e pmperly Iransferted or its inmme........................................... ❑ �
c. reUin a reversionary imerest __.. .............. .................. .. . .. ....._...... ........... ❑ �
0. receive Ihe P�mise for lite of either paYmenis.bene6ls or care?...._...................................._..._..........._...__. ❑ �
2. If Oeal�occvmd afier Dec.12,1982,did decedent tansfer Dmperry wiNin one year o(death
willwNreceiNngade9uateconsiEe2lion'+_. ......... _.......... ... ... ........................_ ❑ �
3. �iddecedentpvnan'inWstfororpayable-uDon-0ealhbankaxowtorseanryathisorhertleaN?......__.._ ❑ �
4. DiddeceCemownanindividualretirememaccoun�,annuityoro�hernon-proba�eproDeM�w�ich
rontainsabeneficia7Ges9nalonv ...._...... ._.._... _.,,._.. . ,...._..._................... � ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE GAND FILE R AS PART OF THE REfURN.
. , � . ... . .. , . . ,. ._ x. ,�.aai ac3�v;C. .:.
For dates of deaN on or aRer July 1,1994,and before Jan. 1, 1995,the taz rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 pement�72 P.S.§9116(a)(1.7)(i)].
For tlates of death on or afler Jan. i, 1995, ihe t� rate imposed on the net value of transfers to or for the use of Me surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1�(ii)�.The sWNte dces not exempt a transfer to a surviNrg spouse hom tax,and Ne staWtory requiremems kr disclosure of assets and
fling a�az retum are still appllcable even if Me surviving spouse is ihe only beneficiary.
For dates of death on or afler July 1,2000:
. The tae ra[e imposed on Ne net value of irensfers from a deceased child 21 years of age or yrounger at death to or for ihe use of a natural parent,an
adoptive parent or a ste�parent of the child is 0 percent[72 P.S.§9116(a��12�].
. Thetvcrateimposedonlhenetvalueoftransferstoorforiheuseofihe0ecedenPsiinealbeneficiariesis4.5percenl,ezcep�asnotedin�72P.S.§9116(a)(1)�.
. The tax rate imposeE on Ne net value of transfers to or for ihe use of the decedenfs siblings is 12 percent�72 P.S. §9116(a)(7.3)].A sibling is defned,
under Sedion 9102,as an individual who has at leas�one parent in common with Ne decedent,whether by blood or adoptlon.
Penalty and lnterest Calculations
CALCULATION DATES-
3/12/15 TO 6/30/2015
TAX DEFICIENCY $ 9,867.64
CALCULATED INTEREST $ 89.00
BALANCE AS OF 6/30/2015 $ 9,956.64
�StartDver. �
REP:SOJ Exr(0E-15)
�,�Jpennsytvania SCl1EDULE B
- 0@MMEMQFPEVENVE
inxearrnntera<AsruaH STOCKS & BONDS
nEs�oer+roc[Eocnr
ESTATE OF fILE NUMBER
Francis B. Matlos 2014E85
All pmperty loin[ty owne0 wkh riqh[of survivonhip must be tlluloaed an ScheOule F.
�M � VAWE AT DATE
NUMBER OESCRIPTION OF DEATH
1� Undetl States Savings eonds 13,594.04
� TOTpL(Also en[er on Line 2, Recapitulation) S 13,954.04
If more space is neeAM,insert aEditional sheets o(the wme size
PEV-608 Ex�(02-15)
�'i�jpennsylvania SCNEDULE E
'S� oEvu+memornEvu+ue CASH, BANK DEPOSITS & MISC.
x�Ear..ce*�a�ax PERSONALPROPERTV
eesmurt occEoem
ESTATE OF: FlLE NUMBER:
901d_OOfiNS
IntluOe[he praeeJs of IIOga[ion anU Me date[he proceeJs were reaived by Ne esta[e.
111 property IdntlY owned wiN rl9�t of survivors�ip must be tliulose0 on Schetlule F.
�M VAW E AT OATE
NIIMBER DESC0.1P110N OF DEATH
Mouseholtl GOods and FUmishings
� 1810.00
Pmperly rebate check
Z 300
M8T Checkiig acct 028i mntains balance of houu ule praceeds
3 117165.63
Sovereign Bank acct 7065
q 20172.76
TOTAL(AI50 en[er on line 5, ReCaDitula0on) ; �39447.89
If more spaa is needed,use adEltlonal sheets of paper a(the ume size.
, � xmc. p zo¢aoso¢e - eaqe i of a
Prepared by aad retum to�
Murrel R.Walters III, Eaq.
WALTERS &GALI�OWAY, PLLC
54 East Main Street
Mechanicsburg, PA 17055
Parcel No. 10-21-0275�133
CEATIFIB� PROYERTY IOENTIFICATION NOlRERS
PlopeltyAddte99� . io-n-oz�s-i33 - xnesozx xe
3620CheStnutStreet ccaxs n+�msrxx osioz/zoia ax ax
Camp Hill, PA 17011
�i�,.213y Z��+�2�f
MADE THIS c�J day of � , in the year two thousand fourteen(201�.
BETWEEN
FR,ANCIS B. MA4`TOS, by his agent,
JULIE MA1"POS,
Grantor,
�a,
EDWARD MATTOS
Grantee,
WITNESSETH, that in consideration of ONE HUNDRED TEN '1`HOUSAND� � � - -
($110,000.00) DOLLARS, in hand paid, the receipt whereof is hexeby acknowledged,
the said grantor doea hereby grant and convey to the said grantee, hie heirs and
assigns,
, ' xnsc. q zaiaosoie - aa� z ae a
ALL THAT CERTAIN tract or parcel of land and premises eituate, lying and
being in Hampden Township, Cumberland County, Pennsylvania, accordingly to a
survey of George W. Walker, Registered Engineer, dated October 16, 1953, more
particularly bounded and described as follows� �
BEGINNING at a point on the northern side of Chestnut Street, 180 feet of the
northwest corner of the intersection of Chestnut Street and 36rh Street, also at the
dividing line between Lot Nos. 17 and 1S, Block C on the hereinafter mentioned Plan
of I.ots� thence Westwardly along the northern side of Chestnut Street, 60 feet to a
point at the dividing line between Lot Nos. 18 and 19, Block C on said Plan� thence
North 1 degree 34 minutes West, along the same 120 feet to a point� thence North 88
degrees 26 minutes East, 60 feet to a point at the dividing line between Lot Nos. 17
and 18, Blcek C on said Plan; thence South 1 degree 34 minutes East, 120 feet to a
point, the place o£BEGINNiNG.
BEING Lot No. 18, Block C on Plan of Hampden Gardens, said plan being
recorded in the Office of the Rewrder of Deeds in and far Cumberland County in Plan
Book 5, Page 63.
HAVING THEREON EREC1`ED a single family house knowo and numbered
as 3620 Chestnut Street, Camp Hill, Pennsylvania.
iJNDER AND SU&TECT, nevertheleas, to reatrictions, conditions and
easements of prior record pertaining to said premises.
BEING the same premises which 14mothy J. Alleman and Michelle L. Aleman,
husband and wife, by Deed dated Auguet 28, 2002 and recorded in Cumberland
County Deed Book 253, Page 1768, granted and conveyed unto Francia B. Mattoe and
Sally A. Mattos, husband and wife.
Sally A. Mattos died AprIl 9, 2010, whereupon sole title became vested in
FYancis B. Mattos by virtue of the doctrine of survivorahip incident to tenancy by
the entueties. .
Francis B. Yfattos appointed, Julie Mattos, ae his Agent undex a General Power of
AtWrney dated May 5, 2010, which is being recorded herewith.
THIS TRANSACTION IS WHOLLY EXEMPT FROM REALTY TRANSFER TAX AS
IT A CONVEYANCE FROM FATHER TO SON. .
The said grantor hereby covenante and agrees that she will warrant specially
the property hereby conveyed. �
. Inst X 201409018 - Page 3 of 4
IN Wl7'NESS WHEREOF, a¢id grantor has hereunto aet her hand and seal
the day and yeaz firat above written. � .
Signed���and DeL'vesed
in LLc Presence o! ) .
� �/ � � �
) ,a / �il 7��2-A�141/
) \*CIS B. MA1"POS, by his Agent,
) JULIE MA1`TOS
COMMONWEAI.TH OF PENNSYI.VANI A )
ss.
COUNTY OF CU,-Mb�"�-�� �
On tlus, the a`d�"� day of I�yY i ( , 2014, before me, the undereigned
officer, personally appeared JULIE MATTOS, known to me (or satisfactorily prove�
to be the person whose name is subscribed to in the above document as Agent for
FRANCIS B. MATTOS, and acknowledged that she executed the same as the act of
the principal for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
NMMONNFALTM OF PENNSYLVANIA �A n n „ `Q ��
Nounal5eal x�µ,� � u�
Susan L Fbuck,N�bN�blic
"fetlfani6°'"9a'10'�o�K.;axoisry NotaryPublic
��mm��
MNR{N,p[NMl'i VPNU bVtUIIOP Of XOTWJFS
I do hereby certify that the address of the within named gr tee is� �
7 Stone Head Road, Dillsburg, Pep , ]v �' �17 9.
r �
� Attorneyfor rantee
aev�ism ex+ (ozas)
�pennsylvania SCHEDULE G
iy� oErnnmeurorneremle INTER-VIVOS TRANSFERS AND
eEx.wR.xcE,..anva. MISC. NON-PROBATE PROPERTY
sioexr oeceoem �
ESTRTE OF F[LE NUMBER
��4a o -0�a�
i�is scheaule must be comvle[e0 anG filea if the answer ro anY o!questions 1 Mmugh 4 on vage Nree of the REVdsoO is yes.
�ESCRIPiIONOFVROPERiY DATEOFDFATN %OFpECD'S E%CWSION TAXABLE
REM ir�¢�oE�x.rtaram�wEUE,mEvuunorawrmn¢oErrtuo
NUMBER rvFonrtornw�srn. enurv�crrrameneowxxeum�rt. . VALUEOFPSSET It1rERE5T li�uwcuu VALUE
� EdwaN Mattos,son,4/30114 real esUte sale deed atlached'
120 100 000
2005 FoN Tau�us,Alexsis Mattos,grantltlaughterJanuary 2014
y 35 100 3500
Santander Fixed Mnuity 8926 American General Life
3 22707.46 100 227W.46
Linmin Finandal Group 5157
q 799W.17 100 15909.1]
Mi0land Life Insurence Annuity
5 5977027 100 5977021
'appraised$120,000,less 10%cost of sale not incurted,value included
on schetlule E line 3,balance in M8T Checking acmunt
TOTAL(Also enter on Line 7,RecaO��ula[ion) S 101886.84
if more space Is neeGeA,use aEEitional sheets o�paper of the same size.
aev-�su exa (ozas)
�pennsylvania SCHEDULE H
�iT oeaemner+rorxEvn+ue FUNERAL EXPENSES AND
mreu.encer�.rne.uax ADMINISTRA7IVECOSTS
aEsmeM ocaoern
ESTATE OF F2LE NUMBER
�n�e_nnavt _
DtteEent's debb murt be reporteE on Sche4ule I.
REM OESCRIVTION AMOUtiT
NIIMBE0.
A. FUNERAL EXPENSES:
�- 11626.52
PaMemo2 Funeral Home
z Rdlin9 Green Cemetery 1790.00
3 St.Joseph's Churc� 500.00
a CKoste Calenng 1385.00
s Dr Hereshki memonum 150.00
B. ADMINISTAATIVE COSTS:
1. oersmal Representa[ive Cammissians:
isoo.oa
Name(s)of Personal Reoresentative(s��qtr A"=G s -�
Shee[AEtlress �r[j�q
[iry�Ay n ' Swte��ZIP u�45
Year(s)Commission Gaid:
1. Attomey fees: 4000.00
3. Famity Exemptiorc(If deceGenCs aEtlress is not the wme as daimanfs,attach explanafion.)
Oaimant
Shee[ACEress
��ry_ ____ State 21V
Relatlonsbip of Clalman[to DeceGent
0. Probare Fezs: 62620
5. Acmun[ant Fees:
6. Tax Retum Greparer Fees:
860.00
�.
TOTAL(Also en[er on Line 9, RefzOitulation) S p243772
If more spatt is neeAeA,use aEERional shee6 oF paper af Me ume si:e.
0.EV-ISII EX+(02-6)
�pennsylvania SCHEDULE I
. .. oEvnnmenroFneverue DEBTS OF DECEDENT,
AcsmErrtvECEoe�R
� MORTGAGE LIABILITIES & LIENS
ESfATE OF FILE NUMBER
0.eport Eebb inarrM by Me Eecedent prior to Eeath Mat remaineE unpalE at the date ot death,including unreimbursed medlal expenses.
IiEM VAWE PT DATE
NIIMBE0. DESCNPiION OF DEATH
1.
KaMy Ferrard Note 13000.00
2 Millenium Phartnacy 567.92
TOTAL(qlso enter on Line 10,Rxapitulation) ; 13567.92
❑more spare is neeOeG,Insert adtlitional shee[s of the same size.
aev-isi3 Ext(oz-is) -
�:Jpennsylvania SCHEDULE J
��� DfPRflIMEMOFflEVENUE gENEFICIARIES
�.a�,a.
nes�oexr oEceoercr
ESTATE OF. , F[LE NUMBER:
Francis e. Maftos 2014-00685
RELATIONSHIPTOOECEDENT AMOUNTO0.5HARE
NUMBER NAME AND AO�RE55 OF PERSON(5)RECENING DRODERIY Do Nof tivt Tms[ee(s) OF E57ATE
1 TA%ABIE DISiNBMONS�I^tluEe ouMgh[spousal EiSMbutions and tansfers unOer
Sec 9116(a)(L2).�
1. KaNleen Ferrara 320 Exeter Rwd, Devon,PA 19333 daughter 1/8 share
2 Francis Mattos,3403 Echo Valley Road,Manheim,PA 77545 son 1/8 share
3 Denise Mattos, 127 N Marke� Ave,M�Joy,PA 17552 daugh�er � � 1/8 share �.
4 Slephen Matlos,PO Box 40,Sandy Ridge,NC 27046 son 1 B share �.
5 EdwaN Mattos,7 Stone Head Rd,Dillsburg,PA 17019 son 1/8 share �
6 John Mattos,21 West Main St,Shiremanstown,PA 17011 son i/g share�
7 Amanda Range,22 Woodiand Road,Lockhaven,PA 17745 granddaughter 1/8 share �
e Ashley Bmtlowsky,1439 6 St NE,Washinglon,DC 20002 granddaughter ��� 1/4 of 1/8 share �
9 EdwaN Bmdowsky,4 Nittany�nve,Mechanics6urg,PA 17055 grandson � t/4 0(i/8 share
10 Nicholas Bmdowsky,5801 Kleberg Trail,Austin,TX 78747 grendson 7/4 0!1/8 share �
EMER DOLLA0.AMOUNiS FOft DISTRIBUilONS SHOWN ABOVE ON pNES 15 iH0.0UGH 18 OF REV-600 COVER SHEFf,AS APPROPNATE.
I� NON�TA%ABLE DISiNBU110N5
A, SFOUSAL DISiRIBURONS UN�ER SEC110N 9113 FOR WHICH AN ELEQION TO TAX IS NOTTAREN:
1. .. . . . . ... .
B. CHARRABLENN�GOVERNMENTALD6TR[BUTIONS � � � ���
1.
TOTAL OF PRAT D-ENTER TOTAL NON-TA%A&F�ISTRiBUT10N5 ON IINE 13 OF REVa500 COVER SHEEf. j y
IF more space Is needeA,use atldiHonal sheets af paper of Me ume sl:e.
0.ELLt5t3 f%a(Oi�6)
� pennsyNania SCHEDULE 7
ei7 ocrnnmErarorr+e�xue gENEFICIARIES
0.ENRX
0.ESIDEMi DKEOEM
ESTATE OF: FILE NUMBER:
Francis B. Mattos 2014-00685
REUTIONSHIPTODECEDENT AMOlINTORSHARE
NUMBER NAME AND ADD0.E55 OF PERSON(S)AECEMNG PROPERTY Ua Not liet Trustee(s) OF ESTATE
I TA%AALE DIS1N91RION5[IntluEe ootright zpousal Gis[nCv[ions antl[mnsfers untler
Sec 9116(a)(1.2).]
1.
11 Dana Olson(Brudowsky),3382 Domcek Dr,Eagle ML UT 84005 granddaughter . 1/4 of 1/8 share
EMER DOLLAR AMOUMS PoR DISTRIBUTIONS SHOWN FBOVE ON LINE515 iHROUGH IB OF REVd500 COVE0.SHEEf,AS APCROPNATE �
11 NON-TA%ABLE DISTRI&PIONS
A. SPOOSAL�ISfRIBMONS UN�ER SECf10N 91ll FOR WNICH AN ElEQ10N TO TA%IS NOt TAKEN:
1. . .. ... . .
B. CHARITABLE AND GOVERNMENTFL DISrRIBUT10N5: �
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABIF DISTRIBUTIONS ON LINE 13 OF 0.EVd500 COVER SHEEL ;, � � .
It mwe space is nee0etl,use atl0i[ional shee[s of paper of tAe same si:e. ��