HomeMy WebLinkAbout07-22-15 (3) i i u �i� i
� 1505611185
REV-1500 EX(02-11)(FI)
PA Department of Revenue OFFICIAL U3E ONLY
Bureau of individual Taxes County Code Year file Number
Po eox 2aoso� INHERITANCE TAX RETURN 2 0 15 0018 4
Harrisbur9,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYVY Date of Birth MMDDYYYY
11012014 07291973
DecedenYs Last Name Suffix DecedenPs First Name MI
MCQUOWN RICHARD T
(If Applicabie) Enter Surviving 5pouse's Information Below
Spouse's Last Name Su�x Spouse's First Mame M I
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
- - REGISTER (3F' WILLS
FILL IN APPROPRIATE BOXES BELOW
� 1.Original Return � 2. Supplemental Return � 3. Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a. Future Interest Compromise{date of ❑ 5. Federal Estate Tax Return Required
death after 12-12-82)
� 6. Decedent Died Testate � 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes
(Attach Copy of�II) (Attach Copy of Trust.)
❑ 9. Litigation Proceecis Received ❑ 10.Spousal Poverty Credii(Date of Death ❑ 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
�v
J • STEPHEN FEINOUR 717-231�3010 c'
�
� � rn
REGI3T�0 ILLS US�IY ;;"� �
C'� —r7 � r-- ;:r� �7
.�_� p
First l.ine of Address _ � �_f,� N ;r7 rn
�._ N �;�t '��
200 N• 3RD ST• � ~` `_' "
_r ,_, —q -,•1 'Ti
Second Line of Address -, �:.� -,, � r �
: �,, y�' c�
18TH FLOOR � � ' N ` �'
City Of Post Office State ZIP Code `y�A�FILED �
00
HARRISBURG PA 17101
correspondent's e-ma��address: S F E I N 0 U R a�N S S H•C 0 M
Under penaltles oi peryury,I declare that I have examined this reWm,inGuding accanpanying scheduies and statements,and to the best of my knowledpe and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information ofwhich preparer has any knwAadge.
SIG E PERSON IBLE iIING DATE
'f• /$•ZQ/
a�
177 WH EY LAN� WESTERVILLE, OH 43081-3670
SIGNATURE 0. AR OTHER REPRESENTATIVE DATE
--��.___.__ O
ADDRESS
200 H RD ST• , 18TH FLR HARRISBURG, PA 17101
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505611185 OM46473.000 1505611185 J
i ' i i ei� i
Estate of Richard T. McQuown 161-64-6018
Executors (Paqe 1)
Name Christine A. Phillips
Address 1177 Whitney Lane
Westerville, OH 43081-3670
Tax ID 161-64-5972
I I'lll II 11■ . 1
J 1505611285
REV-1500 EX(FI)
DecedenYs Social 5ecurity Number
�ecedent'sName: MCQUOWN RICHARD T
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . �. 15 8,3 01 • 0 D
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . 2. 0•��
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , , , , 3. 0 •��
4. Mortgages and Notes Receivable(Schedule D) , , , , , , , , , , , , , , , , , 4. 0•�0
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E) , , , , , 5, 4 2�O 8 9 • 0 0
6. Jointly Owned Property(Schedule F) � Separate Billing Requested , , , , g, Q •�Q
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(schedu�e G) � Separate Billing Requested . . . . �. 10 3,9 0 6 •0 0
8. Total Gross Asseb(total Lines 1 through 7) , , , , , , , , , , , , , , , , , , 8. 3 0 4,2 9 6-0 0
9. Funerai Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . s. 2 6,0 9 5•��
10. Debts of Decedent, Mortgage Liabilities,and�iens(schedu�e I) , , , , , , , , , �p. 2 01,512 •�0
11. ToW I Deductbns(total Lines 9 and 10), , , , , , , , , , , , , , , , , , , , , ��, 2 2 7 i 6(]7,��
12. Net Value of Estate(Line 8 minus Line 11) , , , , , , , , , , , , , , , , , , , �2. 7 6,6 8 9 •0 0
13. Charitable and Governmentai Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J), , , , , , , , , , , , , , , , �3. 0•0 0
14. Net Value SubjecttoTax(Line 12 minus Line 13) , , , , , , , , , , , , , , , 14. �6,689•00
TAX CALCU�ATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)�1.2)X.O� 0•�� 15. �•0�
16. Amount of Line 14 taxabie
at�inea�ratex.o� 76�689•00 �s. 3�451•00
17. Amount of Line 14 taxable
at sibling rate X.12 �•0� 17. Q•�0
18. Amount of Line 14 taxaWe
at collateral rete X.15 �•�� 18. �•0�
19. TAXDUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 3,451���
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Idl
Side 2
� 1505611285 1505611285 �
OM4848 3.000
iuii u ti� �
REV-15oo EX(FI) Page 3 File Number
DecedenYs Complete Address: 2 0 15 0 018 4
DECEDENTS NAME
MCQ OWN AR
STREET ADDRESS
UMB LA D
CIN STATE ZIP
NEW CUMBERLAND PA 170
Tax Payments and Credits:
1. Tax Due(Page2,Line 19) ��; 3,451-00
2. Credits/Payments
A. Prior Payments �•0�
B.DisCount �•o a
Total Credits(A+g) (2; �•��
3. Interest
(3) �•��
4. If Line 2 is greater than Line 1+Line 3,enter the difference.This is the OVERPAYMENT.
Fiil in box on Page 2,line 20 to�equest a refund. (4) �•��
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the 7AX DUE. (5) 3,4 51•0�
Make check payable 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 No
a. retain the use or income of the property Vansferred . . . . . . . . . . . . . . . . . . . . . . . . ❑ �
b. retain the right to designate who shall use the property transferred w its income . . . . . . . . . . ❑ �
c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ �
d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . ❑ �
2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : a �
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death7
4. Did decedent own art individual retirement account,annuity,or other non-probate property,which
contains a beneficiary designatlon? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after Juty 1,1994,and before Jan. 1, 1995,the tax rate imposed on the net value of trensfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i}].
For dates of death on or after Jan. 1, 1995, ihe tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.$9116(a)(1.1)(ii)].The statute does not exempt a transter to a surviving spouse from tax,and the statutory requlrements for disclosure of assets and
filing a tax retum are still applicable even if the surviving spouse is the only benefiGary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 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 percent[72 P.S.§9116(a){1.2)J.
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use oi the decedenYs siblings is 12 percent[?2 P.S.§9116{a)(1.3)]. A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by bloo�or adoption.
OM4871 2.000
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REV-1502 EX+(12-12)
pennsy�vania SCHEDULE A
�EPAR'TA�NT OF REVENUE
INI-ERITANCE TAX RENRN REAL ESTATE
RESIDENTDECEDENT
ESTATE OF: p��E NUMs�R;
Richard T. McOuown 20 15 00184
All real property owned solely or aa a tenant in common must be reported at fair market value.Fair market value is defined as the price at wfiich property
would 6e exchanged between e willing buyer end a willing seller,neither being compelled to buy or sell,both having reasonable knawledge ofthe relevant facts.
Real property that is JoinUyowned wlth right of survivonhip must be disclosed on Schedule F.
Attach a copy of the sefllement sheet itthe prop�ly has been sold.
ITEM include a copy of the deed showing decedents interest if ovmed as tenant in common. VALUE AT DATE
NUMBER DESCRtPTION OF DEATH
1. Real Estate located at 409 16th Street, New
Cumberland, PA 17070
DOD Value based on Tax Assessment Records 158,301
TOTAL (Also enter on Line 1,Recapitulation.) 5 158,301
2wass5 z.000 If more space is needed,use addiGonal sheets of paper of the same size.
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REV-1508 EXa(08-12I
pennsylvania SCHEDULE E
OEPARTbENTOFREVENUE CASH, BANK DEPOSITS 8 MISC.
�r�c���RN PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
Riehard T. MeQuown 20 15 00184
InGude the proceeds of litigation and the date ihe proceeds were recei�red by the estate.
All ro ert ointl owned with ri ht of survivorshi must be disclosed on Schedule F.
�M VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1• Belco Credit Union Checking Acct. 4,677
Interest accrued to 11/1/2014 1
2 Pentagon Federal Credit Union Share Acct. 65
3 USAA Savings Acct. 22
4 Tangible Personal Property 1,500
5 2014 Tacoma 20,000
6 Life Inaurance Refund 258
7 Belco Community Credit Union Savings Acet. 1,013
Interest accrued to 11/1/2014 1
8 Final Paycheck including Leave Payouts from
Bureau of Commonwealth Payroll Operations 13,241
9 Federal Income Tax Refund 2014 1,311
70TAL(Also enter on line 5,RecapitulaUon) 3 42,089
2wasno 2.00o If more space is needed,use additional sheets of paper of ihe same size.
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REV-1510EX+(0&09) SCHEDULE G
pennsylvania
DEPARiIu�NfTOFREVENUE INTER-VIVOS TRANSFERS AND
INFfRITANCETAXREIURN MISC.NON-PROBATE PROPERTY
RE.SYDB�fT DECEDEPfT
ESTATE OF FILE NUMBER
Richard T. Mc4uown 20 15 00184
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM NLlADETFfW�MEOFtFE7RAN5FFREE,TFFJRR9ATIO1�lSF#PTOOECEDEMMD DATEOFDEATH %OFDECD'S EXCLUSION TAXABLE
riunnBE 71£OY4EOF7WY�FFAATfFdiACOPYOFTlEDEEOFORREALESTATE VALUEOFASSET IPffEREST nFnPPucne�e� VALUE
�� PSERS Retirement F�nd 103,906 100.0000 0 103,906
TOTAL(Also enter on tine 7,Recapitulation)$ 103,906
If more space is needed,use additional sheets d paper d the same size-
8W48AF 2.000
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REW1511EX+(0&13) SCHEDULE H
pennsylvania
OEP.�2TMENTOFREVENUE FUNERAL EXPENSES AND
MIHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESmENfDECEDENT
ESTATE OF FILE NUMBER
Richard T. Mc4uown 20 15 00184
Decedent's debts must be reported on Schedule I.
(TEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
�. MeCabe Funeral Home
Viewing and Cremation Costs 5,578
Total from continuation schedules . . . . . . . . . 2,275
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 8,000
Name(s)of Personal Representative(s)Christine Phillips
Street Address 1177 Whitnev Lane .__
City Westerville State OH zIP 43081__
Year(s)Commisslon Paid:2015 __
2. Attomey Fees: 6,000
3. Family Exemption:(If decedenYs address is not the same as claimanYs,attach explanati�.)
Claimant _
Street Address __
�jty State ZIP _
Relatlonship of Claimant to Decedent __
4. Probate Fees: 4 5 6
5. Accountant Fees:
6. Tax Retum Preparer Fees:
7.
1 Cumberland Law Journal
Publication of Estate Legal Notice 75
Total from continuation schedules . . . . . . . . . 1,711
TOTAL(Also enter on Line 9,Recapitulation) S 2 6 095
3W46nG 2.000 If more space is needed,use additional sheets of paper of the same size.
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Estate of: Richard T. McQuown 20 15 00184
Schedule H Part 1 (Page 2)
Item
No. Description Amount
2 Oliver T. Korb & Sons, Inc.
Monument £or grave 2,275
Total (Carry £orward to main schedule) 2,275
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Estate of: Richard T. MeQuown 20 15 00184
Schedule fi Part 7 (Page 2)
2 Enders Insurance Associates
Bond for Administratrix 520
3 Kemba Einancial Credit Union
Membership fee to set up Estate Account 5
4 The 3entinel
Publication of Estate Legal Notice 106
5 Reimbursement to Administratrix for
travel fees incurred in traveling to
Harrisburg to open estate at the
Regiater of Wills 980
6 Cumberland County Register of Wills
Additional probate fee due to
underestimation o£ assets at time o£
filing Petition for Probate 100
Total (Carry forward to main schedule) 1,711
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REV-1512 EX f(12-02) ,
pennsylvania SCHEDULE I
OEPARTMEMOF REVENUE DEBTS OF DECEDENT,
INHEPoTANCETAXRETURN MORTGAGE LIABILITIES�LIENS
I�SmENTDECEDENT
ESTATE OF FILE NUMBER
Richard T. MeQuown 20 15 00184
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical enpenses.
�T�M VALUE AT DATE
NUMBER QESCRIPTION OF DEATH
�• Barclaycard
Final credit card bill 756
2 Capital One Auto Finance
Account balance at DOD 23,242
3 U.S. Bank National Asaociation
Judgment for Mortgage Default 176,987
4 New Cumberland Borough
Final Sewer/trash invoice 212
5 PPL Utilities
Final Electric bill 254
6 PA American Water
Final Water bill 61
TOTAL(Also enter on Line 10,Recapitulation) S 201 512
2W48AH 2.000 If more space is needed,insert additionai sheets of the same size.T
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REV-1513EX+(01-10) SCHEDULE J
pennsylvania
DEPARTMEM OF REVENUE BENEFI CIARI ES
INFERRA�E TAX RETURN
RESIDENTDECEOENT
ESTATE OF:
FILE NUMBER:
Richard T. Mc uown 2 15 00184
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSQN(S)RECEIVING PROPERTY Do Not List Trustee{s) OF ESTATE
I TAXABLE DISTRIBUTIONS[InGude aitright spousal distrlbutlons and trensfers under
Sec.9116(a)(1.2).]
�. Thomas B. McQuown
21$ Perry Street
Punxsutawney, PA 15767
One Half of Residue: 38,345 Father 38,345
2 3heila M. McQuown
@094 Rte 555
Weedville, PA 15868
One Half of Residue: 38,345 Mother 38,345
EMER DOLLARAMOUNiS FOR DISTRIBUf10NS SI�WN ABOVE ON LIt�S 15THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
�� NO�TAXABLEDISTRIBUTIONS
A.SPOUSAL DISTRIBUTIONS UN�R SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
6.CHARITABLE AND GOVERNMENTAL DISTRIBUi10NS:
1.
I
TOTAL OF PART li-ENTER TOTAL NON-Tl1XABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 CI�VER SHEET. $ 0
9W46A1 2.000 If more space is needed,use additional sheets of paper of the same size.
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� U8M FEOERqL SAYIN(iS BANK
�xV`� C�
Aprif 8, 2095
Christine Phillips
1177 Whitney Lane
Westervilte, OH 43081-367Q
Re: Estate of Richard McQuown
Dear Ms. Phillips,
This leiter is in response to your attomey's recent request for account irrformation
regarding the Estate listed above.We did not have your written authorization to release
account information to Nauman Smith, so we are forwarded the requested irtformation
to you.
Checking account 14115441 was registered in the names of Richard T McQuown wifh
no joint account holders or designated beneficiariss. The date of death value was
$22.9Q with $0.{}0 of unpaid accrued interest. This account was opened on Apri! 13,
2009 and closed an March 77, 2015.
If you need additional informatior�, please call 1-800-531-1045, ext, 7-3355 Monday
through Friday, 7:30 a.m. to 6:00 p.m., C.S.T.
Sincerely,
�.��, .s��
Monica J. Sampson
Bank Suniivor Relations
USAA Federal Savings Bank
vsna F�s,,,��B� usnn sa.�n�s�
]0730 McDeanott Freeway 3773 Howard Iiughes pkwy Ste 290N
San AnOonio,TX 78288-0544 L�4 Veges�NV 89109 USAA Relocetion Services.Tne.
(800)5312265(22Q)4568000 (840 �-� 10750 McDermctt p�,ap
FD1C INSURED FDIC 1NSURED S°n��nio,TX 7828g-0553
(8A0)531-7742
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g,.
y�: CommOnvreakh of PennsylVania
, State Empioyees'Retlrement System �
""'' 30 NOr1h Third bkeet,Suite 150
;� `.�,.`„��..:_::;.: ? . Fiarrisbury.PennsylvaNB 17101-t716 s`' ��
� �• . ,�-' Telephone:t-80p$33{�G7
www.Mrs.pa.qov "
Fax:717-787-'S868
Aprif 21,2U15
,
CHRISTlNE A PHILLIPS EXECUTRIX
RICHARD MCQUOWN ESTATE
1177 WHITNEY LANE
WESTERViLLE OH 43081
RE: RICHARD T MCQUOWN
SSN: XXX-XX-6018
The State Employees'Retirernent System(SERS)has raceived the short certificate you submitted for the Estate of
Richard T.Mcquown,the benefiaary in the above referenced aocount.
Please complete the enclosed Release and Indemnification Affidavit,have it natarized and retu�n it to SERS at the
above address as soon as possible. Once this completed affidavit fs received, SERS wiil process the payment for the
�nal settlement of this account.
The following information is provided far your reference:
Death benefit payable to yau: �103,906.16
Taxabie Portion: �1Q3,906,16
Non Taxable Portion: $p,pp
If you have any questions or ne�i assistance,please contact the nearest field otfice at 1-800-633-5461,select optbn 3.
Sincerely,
�� �.
�����
Debra G.Murphy,Director
Disabiiity&Death Benefits Section
Benefd Determination Division
Enclosures
��^�3A I iilill Illli IIIII#fl II III(I If ill lllli IIIII I{II!IIIII IIIII illll III!Illl
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I
ELC�O
COMMUNITY CREDIT UNION
Decedent Account Information(On Date of Death)
Belco Community Credit Union
1. Name(s)in which the account was held: Richard T.McQuown i
2. Account Number: 896159
3. Total Account Balance as of Date of Death: $5,690.15 —�
Balance Accrued Dividends Date Opened
Regular Savings $1,013.14 $1.29(O1/Ol/2014-11/O1/2014) 12/14/2011
Holiday Club $
IItA $
Money Market $
Checldng $4,677.01 $1.34(O1/O1i201411lO1/2014) 12/14/2011
Money Market $
Certificates:
Certificate Number, Balance Accrued Dividcnds Date Opened
$
$
$
$
$
$
4. Name(s)in which Safe Deposit Box was held: None
5. Date the box was initially rented:�� ��
6. Branch address at which the box is located:
. . -,�.•. -�`I�}: �... . .. _ :e� .: _. .
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..
- �
E]�CO
' COMMUNITY CREDIT UN10N
7. Loan Information:
Balance Interest Rate Date Opened
Line of Credit $
Visa $
Home Equity Fixed $
Auto Loan $
HELOC $
Home Equity $
Misc.Loan $
8. Miscellaneous:
. . _ . -11.�.. �1���•il [_ w . . :�6 Sd_ . �t. . .
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Property Mapper
Cumberland County, PA
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Copy�ight 2011 Esri.All tights reserved.Thu Nov 13 2014 04:26:25 PM.
409 16TH STREET
PIN:26-23-0543-362B
Deedbook:200930930
Owner. MCQUOWN,RICHARDTHOMAS
Land Use Code: 101
Property Type:R
Acreage: 0.16
Square Feet: 1926
Taxable Status:T
Clean&Green Status:
Land Assessed Value#:42900
Building Assessed Value;:117000
Total Assessed Value$: 1599D0
Sale Pr�ce;: 159900
Sale Date:Tue Sep 1 2009 08:OO:OQ PM
Year Built: 1980
Munidpality: NEW CUMBERLAND 2ND WD
Height in Stories:
Type of Dwelling: DETACH
Primary Exterior:Wood
Basemeni Percentage:
AirConditioning:NO
Total Rooms: 6
Bedrooms:3
Full Bath: 2
Half Bath: 1
1v� , _, ,
it�:i,au.�i� �
s'' �,.
� BUREAU OF COMMONWEALTH PAYROLL OPERATIONS
DECEASED PAYMENT WORKSHEE7
Date Submitted: 4/Bl2075
Employee Name:Richard T.McQuown
Personnel Number.00532064
71N Number.47-6813232
Payee Nart�: Estate of RicharrJ T.McQuown
Payee Address: 1177 Whitnay Lane,WesterviNe,OH 430$1
Taxable Non Taxeble
PPE Hours Gross Tofals PPE Houre Gross Totais
+� ry rtime
M�sceilaneous Payments
5alary 10/24/2014 75.00 52,108.00 50.00
5alary 11/7/2014 37.50 51,054.50 ;O.pO
�.� ao.00
so.00 so.00
w.00 so.00
so.ao so,00
�o.oa �o.00
Tofa!Salary Due 33,t63.50 50.00
Leave P outs
nual 224.88 56,323.63 50.00
Personal 7.50 $218.90 �0.00
Sick 127.50 53,585.30 ap,OQ
Hoiiday $Q.pp ap.pp
ComP $0.40 50.00
$�.00 50.60
Tote!Leave Pa uts �10,119.83 50.00
Less Gross Ove enta
Canversion Pay $0.00 S0.00
Sa1ary/Overtime �0.00 50.00
Pre Tax Medical 542,18 50.00
Dther $0.00 50.00
Tote!Grvss Ove nts (�42.1 S 50.00
DeducHons
Supplemental Life SB.OB 50.00
Medicat Hospiial Peraantage $24.10 50.00
Social SecurityMledicare a0.pp a0.pp
Long Term Disabillty �11.1Q $0.00
Retiremerrt 5139.81 50.00
Tofa!Deducfions Owed $175.09} 50,00
Tota!Due Beneflclary/Estate i13,066,Ofi 50.00
ZtOs9 Ad ustrnent Amount
Total Deductions Owed 5175.09
To#at RdJusimant Amourit 5175.09
1099 Arr�ounf ;13,241.15 Non Taxable Amount SO.Od
Raviaed N'l3�b7