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Home My WebLink About01-0421 "v tt - :20" _ ~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX ;>~ of DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN RecOfG C Re~r:;te- JAMES D BOGAR 1 W MAIN ST SHIREMANSTOWN .01 Ole 27 ESQ Ct~J}.Oll Cuinbb ie, " A10 :12 C' .'t ~ ,3;-\ 12-17-2001 SAMPSON 02-06-2001 21 01-0421 CUMBERLAND 101 *' REY-1SQ7 EX AFP ill-DOl M I Allount Rellitted (9) (10) (1) (2) (3) (4) (5) (6) (7) ) CHANGED .00 2J804.31 .00 .00 IJ498.20 5J804.43 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) 10. Debts/Hortgage 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 3,424.72 47.00 (11) (12) (13) (14) .00 X 6,635.22 X .00 X .00 X 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 ~ RE-V-=is4j-ix-AFP--fi2'=ooj--NOYici--OF-'rtiHER-iTA"NCi-YAX-APPRAisiMENT~--Ai:.i-owAiici-oR------------ ----- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SAMPSON M I FILE NO. 21 01-0421 ACN 101 DATE 12-17-2001 TAX RETURN WAS: (X) ACCEPTED AS FILED NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 10,106.94 3 471 72 6,635.22 .00 6,635.22 00 = 045 = 12 = 15 = .00 298.58 .00 .00 298.58 If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. 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 TAX CREDITS: 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. Hortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets NOTE: (19)= PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-27-2001 AA496526 1.03 19.57 10-12-2001 CDOO0384 .00 277.98 TOTAL TAX CREDIT 298.58 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 $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) 'v /6 - c2,;2~ ~ X-.$ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG. PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REV-1601 EX AFP 112-00l ReCOrC8G Re~~Ji~;'-e DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 12-17-2001 SAMPSON 02-06-2001 21 01-0421 CUMBERLAND 101 M I JAMES D BOGAR ESQ-Ol 1 W MAIN ST SHIREMANSTOWN ole- 27 A10 :14 Amount Remitted j'~A..'l7.011 uieit, - Clllnbe;.:2i\-i_~ PA MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLEI PA 17013 NOTE: To insure proper credit to your accountl submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ R'~fv =i 6'ifj-Ex--AFP--(i2-:0(fr------...--iNirERi'~..-ANCE-yAX--STA-fEMENy-ifF-ACCouiff--.-..---------------- -- --- ESTATE OF SAMPSON M I FILE NO.21 01-0421 ACN 101 DATE 12-17-2001 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUEl APPLICATION OF ALL PAYMENTS I THE CURRENT BALANCEI ANDI IF APPLICABLE I A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 12-17-2001 P R I NC I PAL TAX DUE: ...............................................................................................................................................................................m......................................... 298.58 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-27-2001 AA496526 1.03 19.57 10-12-2001 CDOO0384 .00 277.98 TOTAL TAX CREDIT 298.58 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 ., IF PAID AFTER THIS DATEI SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $11 NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "'CREDIT"' (CRJI YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J .~. / {, ' ~,Q~, --/~~; BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z8D6Dl HARRISBURG, PA 171Z8-D6Dl COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REV-1607 EX AFP U2-00) .02 JJ\N -4 P12 :32 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 12-24-2001 SAMPSON 02-06-2001 21 01-0421 CUMBERLAND 01117229 M I SUSAN L SAMPSON 6203 CHARING CROSS MECHANICSBURG PA 1~" G\.ItTlberlO FA Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE1 PA 17013 NOTE: To insure proper credit to your account1 subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ifiv: i6o-i-ix--AFP--fl'2-.:oo1-------...-iNHERITANCE--fAx-sTAfEHE-tif-oF"-AC-couiif--.-..--------------- - - - --- ESTATE OF SAMPSON M I FILE NO.21 01-0421 ACN 01117229 DATE 12-24-2001 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUEl APPLICATION OF ALL PAYMENTS 1 THE CURRENT BALANCE1 AND1 IF APPLICABLE 1 A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 12-17-2001 P R I NC I PAL TAX DUE: ........................................................................................................................................................................................................................... .00 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 .. IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $11 NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRl1 YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. l '" /b-c2c.2~-~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REV-1607 EX AFP nZ-DD> Rec():'" RG:~J <- DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 12-10-2001 SAMPSON 02-06-2001 21 01-0421 CUMBERLAND 01117229 M I 01 0 I C 17 Pl2:0 1 SUSAN L SAMPSON" 6203 CHARING CROSS MECHANICSBURG RJ;el~-o50 CUmbenfr: PA Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV = ii,"crj-E3f-AFP--f i'2=ool-------...--X NifERi'i"-ANC'E--TAX- sTA"fiMENT-OF-AC-couiff--.-..---------------- -- - -- ESTATE OF SAMPSON M I FILE NO.21 01-0421 ACN 01117229 DATE 12-10-2001 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-25-2001 P R I NC I PAL TAX DU E : ........................................................................................................................................................................................................................... 19.57 PAYMENTS (TAX CREDITS): INT AT REV PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) EREST IS CHARGED THROUGH 12-26-2001 TOTAL TAX CREDIT .00 THE RATES APPLICABLE AS OUTLINED ON THE ERSE SIDE OF THIS FORM.~ BALANCE OF TAX DUE 19.57 INTEREST AND PEN. .24 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE 19.81 SIDE 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. ) i(" '~JI. ..I.. '", .:'.-5 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 INFORMATION NOTICE AND TAXPAYER RESPONSE FI L E NO. 21- 0 J - ~ ~ I ACN 01117229 DATE 04-09-2001 REV-1545 EX AFP (D9-DDl EST. OF M I SAMPSON S.S. NO. 189-12-6240 DATE OF DEATH 02-06-2001 COUNTY CUMBERLAND TYPE OF ACCOUNT D SAVINGS [XJ CHECKING D TRUST D CERTIF . SUSAN L SAMPSON 6203 CHARING CROSS ' MECHANICSBURG P~',~ 11f>6P REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLEJ PA 17013 PSECU has provided the Department with the information 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 feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calliny (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 1206388735 Date 12-14-1992 Established x To insure proper credit to your account, two (2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x NOTE: If tax payments are made within three (3) months of the decedent.s date of death, you may deduct a SZ discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. Tax PART [!] lillil~~i~~~~il1!~!lili~~~~liii!~~~iiiii!::' A. ~The above information and tax due is correct. 1. You may choose to remit payment 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 assessment will be issued by the PA Department of Revenue. [CHECK] ONE BLOCK ONLY B. c=J 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. c=J The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. PART @] DATE PAID DEBTS AND DEDUCTIONS CLAIMED If you indicate a different tax rateJ please state your relationship to decedent: PART ~ TAX LINE RETUF!N - COMPUTATION OF 1. Date Established I 2. Account Balance 2 3. Percent Taxable 3 4. Amount Subject to Tax 4 5. Debts and Deductions 5 6. Amount Taxable 6 7. Tax Rate 7 8. Tax Due 8 TAX ON JOINT/TRUST ACCOUNTS x x PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on Line 5 of Tax Computation) I $ DATE perjurYJ I declare that the facts I have reported aboveJ8~ trMSA, ~ knowledge and belief. . HOME (?i1 ) ff17-t1AO~ ""AJ,,'O/ WORK (1/7) B- . I;? TELEPHONE NUMB R Ib--~~0 --13 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEKENTL ALLOHANCE OR DISALLOMANCE OF DEDUCTION~, AND ASSESSKENT OF TAX ON JOINTLY HELD OR TRUST ASSETS W m )> r n ..... A n ^ $ JJ m s: )> JJ ^ W .,., ~ o I m :D m 0 (') -0 0 Z ::!!m )> 0 0 ~ )> rCf) ---l C (J) s: m-l m Z ---l m m Z~ 0 ---l s: 0 forl ~ nJ~-I "TI n-< )> 'Tl No c: o~ .t'-o 1)0 .....rom ......~ 3 ......0 ,~ 3m I ~ Z () ---l to 0)> rus: ""O~ ro " O":::c rn orri -.J~ trio o 0 )........ :u " -,---l O~ o :D nJ r 0 flJ Z---l ..... s: Cf D 0 0 ! ~ -I CJ ? 0 0 3-r 0 (5 ...... 6 0 ...... )> .t:' -d nJ z ~ - '-'-1 ~ . ""i i1 m tn 2 " ..... 5 :Ii CD (J) ..0 .;:! I I ..... OJ I 0"- m .t' 0 ! ~ U1 C (j') 1> 2' r~ ~ K; C", <:) :;:- w D zr--J r---f I nD tJ) ::D ~.D ..-. c: z -.,..... ~ ,..;..) 1..:1 f';J : n ;.!J ,-: 0 15 Vj ill I I I I I CU R~ I .-J -1J) ESI m ,0 I~ jg] FII 0 i" ---1~ IF FI~ Cf) ~ I ~ I <: TY~;U 3 ~ DA1 rrI D I G) ~ ~ 1-4~ I (fl, -4C,' ACCl m. ---. '-,_ I ;0 '-,_ Pe~ ,r:~ AmCl ~fJ1 -:c~.. .1 Ii' ;. ~e~ :;: 01 . a~ t-l T r- a~ r T a~ ' (.'1 TA~ . ~>, ,~?\ ~.~~, ~- 04-2fi \,' (' l-" () I:> ,.... !Jl 1> 3 lJ U a 2 ;.-' ..~ o U1 C. tfl C UJ 1> Z I :a m (") m :< m c "TI :II o ~ r trJ !;t :3 ""!J tn o Z -l 0 -l )> )> r )> zo~ s: cOm)> 0 0 s:ZWa c ...... OJ:Ilwz Z ..... moS: -l JJr~ ""0 ..... )> -.J -l 0 I''J fU --0 '\} ill 11' ..... -.() . Ul 'J ~ o I m :D m ~ )> s: o c Z -l }( ~ u 'WQ' :::COtDO(') )>mcmo ~~~~~ Ui~~~o rooC:S:Z ~~g~~ .f'> z---l)> -0 oo~ )> <"TI:::c 6:IJo c:m"TI ~<-o '-~m -4CZ ~mti5 m -< en ~ )> Z )> j I\) OJ 6 Ol S z 0 :I: m ." :JJ ." =i - )>"'0 0 Zm - OZ :t> mZ .... )>(J) Z-< :D C~ m m)> 0 (J)Z -4- m )>)> - -4 "'tJ m ..... -4 )> >< Z 9 )> )> .r:a.. <D a> (J1 f\) Ol :0 m :E m I\) m x <b .$ REV-lS48 EX AFP <12-00l J 1 I 1 I 1 I I 1 fO: 1 1 1 ] 1 1 1----- 1 ] t--- 1;- i I 1 ~ I r- 1 ] 1 I I ] ~ I teE tHE I tK I I.. ] I I 1 I I 1 I 1 I -'~,- ~ TOTAL TAX CREDIT 20.55 BALANCE OF TAX DUE .98CR INTEREST AND PEN. .00 TOTAL DUE .98CR t-' -D . U1 -J * IF PAID AFTER THIS DATE, 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. ) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT JAMES 0 BOGAR ESQUIRE ONE WEST MAIN STREET SHIREMANSTOWN, PA 17011 -------- fold ESTATE INFORMATION: SSN: 189-12-6240 FILE NUMBER: 21 - 2001 - 0421 DECEDENT NAME: SAMPSON M I DATE OF PAYMENT: 10/12/2001 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 02/06/2001 NO. CD 000384 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $277.98 I I I I I I I I TOTAL AMOUNT PAID: $277.98 REMARKS: JAMES 0 BOGAR ESQUIRE CHECK#1023 SEAL INITIALS: AC RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS REGISTER OF WILLS c STATUS REPORT UNDER RULE 6.12 Name of Decedent: M. Irene Sampson Date of Death: February 6, 2001 Will No. 21-01-0421 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes x No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No x b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes x No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. Date: 10/12/01 /"l, '- /1 ~ ~ure ~ James D. Bo~r, Esquire Name (Please, type or print) One West Maln St. Shiremanstown, PA 17011 Address (717) 737-8761 Te 1. No. Capacity: Personal Representative x Counsel for personal representative (MAH:rmf/AM3) STONE LAFAVER & SHEKLETSKI ATTORNEYS AT LAW DAVID H. STONE GERALD J. SHEKLETSKI ELIZABETH B. STONE 414 BRIDGE STREET POST OFFICE BOX E NEW CUMBERLAND, PA 17070 www.stonelaw.net OF COUNSEL CHARLES H. STONE JON F. LAFAVER February 13, 2004 TELEPHONE (717) 774-7435 FACSIMILE (717) 774-3869 .'....... ,....."'" .-'-' d J:::,. Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 .." rr1 co - -.1 RE: Estate of Lester E. Slothower No. 21-01-0421 :c .J_'It:l :g N C.J \.0 Greetings: Enclosed please find an original and one copy of the Inheritance Tax Return and Inventory for the above mentioned estate. Please clock in the copy of the Inventory and send it back to my office along with any receipts in the enclosed stamp addressed envelope. Also, enclosed is estate check #1002 in the amount of $3,629.02 for payment of the inheritance tax and estate check #1003 in the amount of $25.00 for filing the return and inventory. Please note the timely postmark of this correspondence. Very truly yours, JJ:;AHR (;~LETSKI ~ David H. Stone ~. DHS/tmb Enclosures > /b-~~b-~ REV-1500 EX + (6-00) CAPB HpRL EplO CRAC KOTK ES C P o 0 R N R 0 E E S N T C o M P T U A T X A T I o N REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER o E C E o E N T COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 DECEDENT'S NAME (LAST, FIRST, AND MIDDL.E INITIAL) Sam son M. Irene DATE OF DEATH (MM-DD-YEAR) OFFICIAL USE ONLY 21-01-0421 YEAR NUMBER COUNTY CODE DATE OF BIRTH (MM-DO-YEAA) SOCIAL SECURITY NUMBER 189-12-6240 THIS RETURN MUST BE ALED IN DUPUCATEWlTH THE Copyright (e) 2000 form software only The Lackner Group, Inc. NA REGISTER OF WILLS so IAl E U I 2. Supplemental Return .... Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach copy of WIIQ (Attach copy of Trust) D 9. litigation Proceeds Received 0 10. Spousal Poverty Crectlt D 11. Election to tax under Sec. 9113(A) (date of death between 12-31-91 and 1-1-95) (Attach Sch 0) ffuf:l'ftIS:SEC:l'ION:MQ$t:'HI<:Ot.!PL~~il~tALt.!;l:;OBR~sjiQNil~NQE!Ji,~ONEiil~N:I'I~L1[:4l(:."Nl;'QRM~j!Q.. ;.UL1)!ijEiQiREC:l'~[)TQ:'... NAME COMPLETE MAILING ADDRESS X ,. Original Return 4. Limited Estate X 6. Decedent Died Testate 1 James D. Bo ar FI RM NAME (If Applicable) One West Main Street Shiremanstown, PA 17011 TELEPHONE NUMBER (1) (Z) (3) R E C A P I T U L A T I o N 1. Real Estate (Schedule A) Z. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) S. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) a. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabil~ies. & Liens (Schedule J) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line a minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Sub oct to Tax (Line lZ minus Line 13) 3 date of death . RelTl8lnc1et Return prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes OFFICIAL USE ONLY (a) 10,106.94 (11) 3 .471. 72 (IZ) 6,635.22 (13) (14) 6 635.22 (15) (16) (17) (la) (19) 0.00 298.58 0.00 0.00 298.58 None 2,804.31 None (4) (5) None 1,498.20 (6) 5,804.43 None 3,424.72 47.00 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate. or transfers under Sec. 9116(aXl.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxabkt at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due ZO. iiiiji;ll~!(:Il.!II;i 6,635.22 X X X X .0 0 .0 45 .1Z .15 Form REV-I500 EX (R.,. 6-00) Decedent's Complete Address: STREET ADDRESS 6203 Charine: Cross CITY I STATE I ZIP Mechanicsbure: PA 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditS/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 298.58 19.57 1.03 Total Credits ( A + B + C) (2) 20.60 3. InterestIPenalty if applicable D.lnterest E. Penalty IN"ii!!1ji ;;Hit:;".:, TotallnterestlPenalty ( 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) A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + 5.... This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT iii:;:ii;;;;;;:;;;;:;:;i;;;;i:;::;;;;;;:;;;;:::::li!!mmmm!!!l!!!!li!l!iii!!ilii!!!!ml11li!!iiil!!lflmll!!ll!liii!!iiiiliiiiliiiiiiiiii!!i:::::i:;;;;:i!ilii!iillmmmmmliii!11J1mmmmmiiiiiiii::iiii:l!!!! (Hmri;:mmmm:!:!i:ii!!!ii:i::::,'~I!::,1:i:':::":!~i1::~:::::!I:::::::"::';""ii:!::immmm!iiiiiil fiLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN ::'~':: IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; . . . . . . . . . . . . . ~ ~~x b. retain the right to designate who shall use the property transferred or its income; . c. retain a reversionary interest; or. . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? . . . . . . . . . 2. If death occurred after December 12. 1982. did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ...... D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 0.00 0.00 277.98 0.00 277.98 ~ ~ ~ Under penalties of perJury, I decMire that I have examined this retwn, lneludlng aeeClmpllnylng schedules and statements, and to the best of my knowledge and belief, It Is true, 'and complete. Declaration parer other than the personal representative Is based on alllnfol1TlllUon of whk:h pl'eparer has any know~ge. URE OF PERSON RESPON/ E FOR FILING RETURN Susan L. Samps on 1 . --~~~~~~~~~~~-;;-%1~-ri650----------'--------- James D. Bogar Esquire One West Main Street ---Shlremanstow;-PA--ri6ii--------------------- \.Cl~ l "2-\.i:l1 iii!mlmmIIW!II!l!ll!liliJ!iilltl!l!lIll!!mmll!!lrl!mm!II!lillliIIW!11!ll]j]ll!IJlllWll!ll!IMlmm!!!iillllillllll!II!W!iii!1JjJlll!!!!!!mmmmmmW]1!1IJlilill!li!limmmmmW1111!ilmm!!!1lllJjlJ]!!l!lJfiill!l !mmmmWWIII!!llilmmmmmlii"ii DATE ~-IA-{)J DATE For dates of death on or a r uly 1, 1994 and before January 1. 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P. . 9116 (a)( 1.1 )(il~ For dates of death on or after January 1, 1995. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 9116 (a) (1.1) (ii}J The statute does not exemDt a transfer to a surviving spouse from tax. and the statutory requirements for discosure of assets and filing a tax return 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 deceasecl child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent. or a stepparent of the child is 0% [72 P.S. 9116 (a)(1.2)} The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%. except as noted in 72 P .5. 9116( 1.2) [72 P.S. 9116(aX 1)} The tax rat. imposed on the net valu. of transfers to or for the us. of the decedent's sib~ngs is 12"!. [72 P.S. 9116(aXl.3)} A sibling is defined, under Section 9102. as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Copyright (c) 2000 form software only The Lackner Group,lne. Form REY...1500 EX (Rev. 6-00) Il:fV-AtJ !x... {1.921 . SAFE DEPOSIT BOX INVENTORY COMMONWfALTH 0' ,eNNSvt.VANIA Dl!PARTMlNT 0' ReveNUl! INHDlTANCI TAX ENVISION DePT. 210601 ......IURG.'A 1712.....' PI.a.. Print or Typ. MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS COUNTY CODE FILE NUMBER SOCIAL SECURITY OR DEATH CERTIFICATE NUMBER 189-12-6240 DATE OF DEATH DECEDENT'S NAME (LAST. FIRST, MIOOl!] Sampson, M. Irene ADDRESS OF DECEDENT (STREEl] (ClT'/] 6203 Charing Cross Mechanicsburg NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX (NAME) James D. Bogar, Esquire 2/6/01 (STREET AOORESS) (CIT'/] One West Main Street Shiremanstown NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE IlOX OPENING a. (NAM!] (RELATIONSHIp) James D. Bogar, Esquire None (STREET ADORESS) (CIT'/] One Wes.t Main Street Shiremanstown b. (NAME) Susan L. Sampson (STREET AODRESSj 6203 Charing Cross c. (NAM!] (RELATIONSHIP) Dauqhter (CIT'/] Mechanicsburg {RELATIONSHIP) (STREET ADORESS) (CITY) NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED (NAME) ALLFRIST BANK (STREET ADDRESS) 5528 Carlisle Pike I NAME OF PERSON MAKING LAST ENTRY Su.:l.~ \...' C;a-{l\c7l1. DATE OF CONTRACT TO RENT sox NUMBER OF SOX ~(q\q(., \\'1 NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. (NAME) N'-oI\\".S~~ (STREET ADDRESS) (STREET ADDRESS) (ClT'/] (, l-O:' C I<$.~ ~~~TE) (ZIP COOE) (CIT'/] \\A-~.e(,u.......\~ l.<.... Pt.. \ "tel S"O NAME AND TITLE OF EMPLOYE TAKING THE INVENTORY {CIT'/] Mechanicsburg DATE AND TIME OF LAST ENTRY .b1Io\ TITLE UNDER WHICH BOX IS REGISTERED .,.....-;:.~...e $"" SC>jo\. b. (NAME) WAS A WIL1. IN THE BOX?=YES "'fNO If y.s, o. Dot. oi will: b. Name and address at penonall'8presentative, if named in the will (NAM!] (STREET ADDRESS) (ClTYI c. Name and address af attorney, if any (NAM!] (STREET ADDRESS) (CITY) (STAT!] PA. (STAT!] PA (STAT!] PA (STAT!] PA (STATE) (STATE) PA (STATEI (STATE) (STATE) (ZIP COO!] 17050 (ZIP COO!] 17011-6 71 (ZIP COO!] 17011637 (ZIP COO!] 17050 (ZIPCOOE) (ZIP COOE) 17055 (ZIPCOOE) (ZIPCOOE) {ZIP CODE} Page of INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and doss of stock. (3) Obligations of U. S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bands) (5) Bank and Savings and Loan Passbooks: State name of depasitor, number of book, last date appearing in baak, name 01 bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deed., Mortgage., Current In.urance Policies or other evidence. of indebtedne..: List and describe as fully os possible. (8) All other content.. ITEM ITEM DESCRIPTION , NO. I n _ - '\hA (f i I , I , ! I i i , i ! I I I , I , I I I I I I ! I . I I I - I II CUTIFY UNDER PENALTY OF ?~Y THAT iiP;.BOVE RECORD IS I PERSO~~ECEIVING COpy OF I CORRECT AND COMPLETE TO TH E OF MY WL!DGE AND BELIEF. SAfe D 051T BOX INVENTORY: !SlGNATURE I ./1' ISlGZ:7 Ill. . I -.\a.~ l\ P, ,,' ;~;-~(. - n ~.. ,1r ~- pqlNT NAME < r . V" I PRINT ~:o_ CFf:~' m :RlME .ax mow. \~~ ....: - ~hhJ !CHECK APPROPRIATE 'ox. ~ ~!l.INT TITLE 'Sl.ut'€<<"'.l>~~' L (0" ' ..- r-: I i~ Execulor(rrix) UAdministrat x) ! ~E~tate Representative U Joint owner of safe deoosit bO;>r; SAFE DEPOSIT BOX INVENTORY REV-1S03 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS & BONDS FILE NUMBER M. Irene Sampson SS/I 189-12-6240 02/06/2001 21-01-0421 All property jointly-ow..... with right of survivorship muot be disclosed on Schedule F. ITEM DESCRIPTION VALUE AT DATE NUMBER UNIT VALUE OF DEATH 1 U.S. Series E Savings Bonds, $75.00 denomination - 12 2,804.31 ea. as per attached statement . TOTAL (Also enter on line 2. Recaoitulation) 2,804.31 (W more space is needed. insert additional sheets of the same size) Copyright (c) 1996 formsoftw.,. only CPSystema, Inc. F.... REV-l503 EX (ROY. 1.97) ..... ~ ~ I I 11I11IIII11111 ~ ~ ~ on .. 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('l ('l ('l N N N ('l ('l ('l N N N ~ ~ 0- 0- <"I <"I <"I <"I <"I <"I <"I ~ d!; r- 0- 0- ~ on on on on on on 0- on ,..: ,..: 00 00 00 00 00 00 00 "" "" J r- r- r- r- r- r- r- r- r- r- r- r- ..... ..... .... ..... ..... .... ..... .... ..... ..... .... .... I .s ~ ... .., I ..; .. ... on on on on on on on on on on on on ... J~ N N N ~ N ('l N N N ('l N N e '" ~ ~ ~ \() ~ ~ ~ ~ ~ ~ ~ ~ on on on on on on on on on on on on .E ~ .... '" " ~ on on on on on on on on on on on on ;::l oS JI r- r- r- r- r- r- r- r- r- r- r- r- - , ~ "'0 .. .....1. C " ! 0 Oil I !Xl , '" U'l' '" Ii ....1 QlJ ~ ~ II c <= ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ .~ <= ~ en I 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- <= ~ r- r- r- r- r- r- r- r- r- r- r- r- 0 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- '" c.. ~ ..... ..... ..... ..... ..... ..... ..... .... ..... .... .... .... e ..... ..... ..... ~ ~ t:: ..... ..... ..... ..... 0; 0; .~ ~ on on r- co co co os 0 0 0 0 0 0 0 0 0 0 0 0 CIl ~ -- II ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ CIl '..J '" N 0 co co 00 ~ ~ ~ r- ~ on ~ ] 1:1 N r- 0 \() 0 0- <"I ~ "" 0- ~ 0 c: .. "" ..... 00 \() N 0 \() ..... on "" 0- 0 ... N <"I "" N "" ~ ~ on \() \0 r- r- f-< ~ III " ..... ..... ..... on II'l on on II'l II'l on II'l II'l CIl <:::l '" .. 0- 0- 0- co 00 co 00 00 00 co 00 co !9 w ... en = ~ ~ ~ on on on on on on on on on ~ 'It oc ..... ..... ..... ..... ..... .... ..... .... .... .... .... .... ~ .. g g g g g g g g g g g g '> ell oj ;,; :/) tE REV-l508 EX + (1-97) COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER M. Irene Sampson SS# 189-12-6240 02/06/2001 21-01-0421 Include the proceeds of liti~tion and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 DESCRIPTION PA State Employees - Retirement payment 02/01-02/06/01 VALUE AT DATE OF DEATH 147.00 2 Part B Medicare - Check 172.20 3 U.S. Treasury - Federal income tax refund 379.00 4 1984 Nissan Maxima GXE S/W - VIN JN1HUOSS8EX048638, per attached appraisal 600.00 5 Contents of home and personal property 200.00 TOTAL (Also enter on line 5, RecaD~u1ation) S 1.498.20 (w more space is needed, insert additional sheets of the same size) Copyright (c) 1996tormooftwoteonlyCPSyslems,lnc. Form REV-1508 EX lR..,l-97) "A Brenner Family Dealership .. 717-697-8400 717-697-9133 FAX BRENNERFAMIL Y.COM ~ Dodge 1812 Paxton St. Harrisburg, Pa. 17014 . 232-4271 QD 1980 Paxton St. Harrisburg, Pa. 17014 232-4271 . ~I""r: ~ 0Ic:Ism0bi1e 2222 Paxton St. Harrisburg, Pa. 17111 238-2552 . . ,'~ . IiilIf:::F G2) 0Ic:Ism0bi1e 4 Parkside Court Mifflin/own, Pa. 17059 436-2161 ~ 4 Parlcside Court Mifflin/own, Pa. 17059 436-2161 . ',\\'" ii',,' '."" ~ BRENI\IER 61"., MAILING ADDRESS: P.O. Box 1019 Camp Hill, PA 17001-1019 STREET ADDRESS: 6271 Carlisle Pike Mechanicsburg, P A 17055 OWNER OF VEHICLE: H. IfZENE S(.j{1PSON VEHICLE IDENTIFICATION NO.: J N / /-{ U 05 S 8 EX 04 B C; 38 YEAR/MAKE/MODEL: 84 N I ~S/l II! M A y / H A r; Y. E f/w . PElf (X "GO, 00 \:>,0< roo. - FAIR ~T VALUE AS OF (insert date of death):$ ~ . COMMENTS: Otlt:cI /1U(ttJ:.-. ('YL,t/J-!- ne~J.- ~h ~ /I/J T J I fZl4 T t/ r fj'19' rI Ir/t t/ fl7/ CZtUYb_ r:Ltl ~ v/~ btUic- /tt-a{. ~Ih/.J Vt'A/'Y :J-hi!/: !'tfflr~ (iw/\ IS w{pfRyad- Vec/~. BRENNER Family of Dealerships 6271 Carlisle Pike Mechanicsburg, PA 17055 8 BACK ON .. AUTO........ DOUG PINTARCH Special Finance Manager 1~ 717-697-8400 717-69709133 FAX l~n-880-8Sn 717.e97-1863 FAX WWW.BRENNERFAMllY.COM (Signatu e) VSL"d etU IF" ~ Vj'/: (Tlt e) REV. 1509 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TJ,X RETURN RESIDENT DECEDENT ESTATE OF M. Irene Sampson SCHEDULE F JOINTLY-OWNED PROPERTY SSfl 189-12-6240 02/06/2001 FILE NUMBER 21-01-0421 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 A. Susan L. Sampson ADDRESS 6203 Charing Cross Mechanicsburg, PA 17050 RELATIONSHIP TO DECEDENT Daughter B. c. JOINTLY-OWNED PROPERTY, LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM OR JOINT MADE Include name of fh"lllnclallnstltutlon and bank DATE OF DEATH DECO'S VALUE OF ECOunt number or similar ldentffylng number. NUMBER TENANT JOINT Attach deed for Jointly-held real estate. VALUE OF ASSET INTEREST bECEDENrSINTEREST 1 A 02/27/80 PSECU - Regular Shares (SI) 8,569.73 50.00r. 4,284,87 Account No. 0189126240 - date of death balance $8,566.09, accrued dividend $3.64 2 A 02/27/80 PSECU - Checking Shares 2,161. 34 50.00r. 1,080.67 (S4) Account No. 0189126240 - date of death balance $2,160.73, accrued dividend $0.61 3 A 12/14/92 PSECU - Regular Shares (SI) 7.97 50.00r. 3.99 !\ccount No. 1206388735 - date of death balance $7.97 4 A 12/14/92 PSECU - Checking Shares 869.80 50.00r. 434.90 (S4) Account No. 1206388735 - date of death balance $869.49; accrued dividend $0.31 - TOTAL (Also enter on line 6. Rec.p~ulation) $ 5,804.43 (K more space is needed inserl.dd~ional sheets of the same size) Copy~ghl (e) '996torm_ only CPsyst...., Inc. Form REV-l509 EX (Rev. 1-97) PSECilt, the financial /ink March 9, 2001 Account # 0189126240 JAMES D. BOGAR ONE WEST MAIN ST SHlREMANSTOWN, PA 17011 Dear MR. BOGAR: The following is the status ofM. IRENE SAMPSON's account with PSECU as of the date of death. Joint Owner's Name Date Established Date of Death Date of Birth SUSAN L. SAMPSON, JOINT TENANT WIROS 02271980 02062001 12201923 Share(s) Balance Accrued Dividend Regular Shares (S 1) $8,566.09 $3.64 Checking Shares (S4) 2,160.73 0.61 Loan(s) Balance Accrued Interest Personal Service Loan (Ll) $ 0.00 $0.00 VISA (L9) 0.00 0.00 The dividend earned from January 1,2001 through the date of death was $45.32. We do not have safe deposit boxes for our members. The following is the status of SUSAN L. SAMPSON's prefix-1206388735 account with PSECU as of the date of death ofM. Irene Sampson. Joint Owner's Name Date Established Date of Death M. IRENE SAMPSON, JOINT TENANT WIROS 12141992 02062001 Share(s) Regular Shares (S I) Checking Shares (S4) Balance $ 7.97 869.49 Accrued Dividend $0.00 0.31 The dividend earned from January 1,2001 through the date of death was $3.03. If you have any questions, please call 234-8484 in Harrisburg or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, Meacle F~i . Member Service Representative Finance Support Unit PENNSYLVANIA STATE EMPLOYEES CREDIT UNION Main Address: 1 Credit Union Place, Harrisburg, PA 17110.2990. (717) 234-8484 . (800) 237.7328 Mailing Address: P.O. Box 67013, Harrisburg, PA 17106-7013. (717) 777-2100 (TOO). (800) 472-1967 (TOO) Web Address: www.psecu.com Savings federally Insured up to $100,000 by the National Credit Union Administration. REV-1511 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF M. Irene Sampson SS!; 189-12-6240 02/06/2001 FILE NUMBER 21-01-0421 Debts 01 decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES, 1 Beverage Express - Items for funeral meal 43.00 2 Cremation Society of PA - Services rendered 150.00 3 Giant Food - Funeral meal 181. 44 4 Gingrich Memorials - Head stone 657.00 Total of Continuation Schedule(s) 722.00 B. ADMINISTRATIVE COSTS, I. Personal Representative's Corrvnissions Name of Personal Representative(s) Social Security Number{s) I EIN Number of Personal Representative(s) Street Address City State Zip - Year{s) Commission Paid: 2. Attorney's Fees James D. Bogar Esquire 1,312.50 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip - Relationship of Claimant to Decedent 4. Probate Fees S. Accountant's Fees 6. Tax Retum Preparer's Fees 7. Other Administrative Costs 1 Pep Boys - Inspection of car 58.28 2 Register of Wills - Copy charge 0.50 3 RESERVES: Costs to conclude administration of Estate including 300.00 filing fee for PA Inheritance Tax Return, First and Final Account and preparation of Personal Income Tax Returns and payment of possible tax due - TOTAL (Also enter on line 9. Recapitulation) $ 3,424.72 (ff more space is needed. insert additional sheets of the same size) Copyright (c:) 1996 form *Jftware only CPSystems.lne. Fonn REV-ISII EX (Rev. 1-'7) Estate of: M. Irene Sampson Soc Sec #: 189-12-6240 Date of Death: 02/06/2001 Continuation of Schedule H-A (Funeral Expenses) Item II Description 'Amount 5 Mt. Calvary Episcopal Church - Services and minister 350.00 6 Mt. 01ivet Cemetery - Burial expense 250.00 7 Stephenson's Flowers - Altar spray 53.00 8 The Grossery - Items for funeral meal 69.00 722.00 REV-1512 EX..(1-97) COMMONWEAl.TH OF PENNSYLV,t.NIA 1NHERIT ANeE T,,;x RE1URK RESIDENT DECEDENT ESTATE OF M. Irene Sampson SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, AND LIENS SSf! 189-12-6240 02/06/2001 FILE NUMBER 21-01-0421 Inelude unreimbursed medical expenses. ITEM NUMBER 1 DESCRIPTION West Shore EMS - Transport from hospital AMOUNT 47.00 TOTAL (Also onto' on line 10, RocaD~ulalion) S 47.00 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form softwllre only CPSystems, Inc:. Form REV-1512 EX (Rev. 1-97) REV-1513 EX + (9-00) COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES M. Irene Samoson 55" 189-12-6240 02/06/2001 NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY I. TAXABLE DISTRIBUTIONS [,...,_outrigh'_ distributions..... transfers under Sec. 9116(a)(1.2)] 1 Sally L. Konetski 2867 Crescent View Lane Charlotte, NC 28269 2 Susan L. Sampson 6203 Charing Cross Mechanicsburg, PA 17050 RELATiONSHIP Do NoI List Trustee(.) Daughter Daughter FILE NUMBER 21-01-0421 , r OR StiARE OF ESTATE One-half (1/2) of rest, residue and remainder of Estate One-half (1/2) of rest, residue and remainder of Estate ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18. AS APPROPRIATE. ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same si2e) Copyright (c) 2000 form software only The Lack.ner Group, Inc. 0.00 Fo'm REV-1513 EX (Rev. '-00) ~ .~ ~ ~ \~ LAST WILL AND TESTAMENT OF M. IRENE SAMPSON ~ ~ I, M. IRENE SAMPSON, of 6203 Charing Cross, Mechanics- burg, Cumberland County, Pennsylvania, make, publish and declare this as and for my Last will and Testament, hereby revoking all other wills and Codicils heretofore made by me. FIRST: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, in equal shares, to my daughters, SUSAN L. SAMPSON and SALLY L. KONETSKI, provided that should any of my children predecease me, I give and bequeath such child's share unto her issue per stirpes by representation, and if there be a failure of same, then I give and bequeath such deceased child's share to my surviving child as provided herein. SECOND: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all proper- ty, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments.far transfer of the property and to receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real estate a~d to enter into agreements conge~ing the partition, subdivi- sion, improvement, zoning or management of real estate and to impose or extinguish restricttons:on real estate. (Cl To compromise any claim or controversy and to -e."'" abandon any property which is of little or no value. (D) To invest in all forms of property, including stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privilege given by the Federal and other tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named benefici- aries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for investment purposes. J (I) To select a mode of payment under any qualified ~ retirement plan (pension plan, profit sharing plan, employee ~ stock ownership plan, or any other type of qualified plan) to the ~ extent the plan or the law permits them to do so, and to exercise ~ . any other rights which they may have under the plan, in whatever ~ manner they consider advisable. ~ THIRD: I direct that all inheritance, estate, trans- . fer, succession and death taxes, of any kind whatsoever, which ~ may be payable by reason of my death, whether or not with respect J ~ to property passing under this Will, shall be paid out of the ~~ principal of my residuary estate~ ._~ FOURTH: I nominate and appoint SUSAN L. SAMPSON, Executrix of this, my Last will and Testament. In the event of c- ~ t~e death, resignation or inability. to serve for any reason whatsoever of the said SUSAN L. SAMPSON, I nominate and appoint SALLY L. KONETSKI, Executrix of this, my Last will and Testament. 2 - -- - I direct that my Executrix, and her successors, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last will and Testament, this sr day of 0~tvjA..bF1~.-i-, 1995. , ""1 { , /lJ, ~ ..//anvb-dd?; M. IRENE SAMPSON ;J (SEAL) Signed, sealed, published and declared by the above- named Testatrix as and for her Last will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. /) ():f;', ,j-W;.j {~,"'i";df. <J ~'l-eh'1 (J (). 4t1/Z~.::t ~/ Address Address 3