HomeMy WebLinkAbout01-0451
PETITION FOR PROBATE and GRANT OF LETTERS
Estate ojPECE/>/,tJ ,.f ....JVECE,e
also known as
No. 21-01-451
To:
Register of Wills for the
, Deceased. County of CP/';,;gE~LAN',t) in the
Social Security No. I~:J -.:It' - /.FJ 7 Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the execut
in the last will of the above decedent, dated '7//;1 19~
and codicil(s) dated 7 /
/?IX
named
,~-
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in W/1LfE"e.t#H'~ County, Pennsylvania, with
h h'EA1 last family or principal residence at c~~~"s/~f#Z~' .
C"~ ~6-~___~_ _~_~.rEX Zi'~) /7~ 7
(list street, number and muncipality)
Decendent, then 8"7 years of age, died /.7 //-Iy' MCJ , 19
at cLAA'/'7t:)NT Alu"e.r//~c::- ~/'7E ,,.
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$ /~ ~CJJ t?~
$
$
$
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters 7;€"fT;9/'7A'#T,!f,fY
(testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
theron.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA 1.- ss
COUNTY OF CL/hL5'&~/lHbl J
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
Sworn t...o or affi.rmed and su bscr. ibed ~ b~ c: ~~ ~
before me this 4th day of llV/N' r:' A/A'~?iFA:.f v~
~ ~y )flJ2001 ~
ji A2 'f1a/cP~/I//l~~ -~ ~
. Register,' _ ~
No.
21-01-451
Estate of
REGENA R SWEGER
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW MAY 7 19:200 1 ,in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated JULY 10, 1996
described therein be admitted to probate and filed of record as the last will of
REGENA R SWEGER
TESTAMENTARY
EDWIN C WALTERS
and Letters
are hereby granted to
,
'/7 lIllYC5f:///+fJiLj ,120 /~o/
/ ,> Re . ter of Wills v
FEES
Probate, Letters, Etc. .........
Short Certificates( )..........
~;~~~i~ion ................
JCP
$
$
$
$ 5.00
TOTAL _ $ 45.00
......... .~):'. .4.,. .?PPJ............
25.00
6.00
9.00 _
ATTORNEY (Sup. Ct. 1.D. No.)
ADDRESS
Filed
PHONE
HIO"i.805 REV 9!~()
This is to certify that the information here given is correctly copi~d fran: an original certificate of death dul~ filed with
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filmg.
me as
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
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Fee for this certificate, $2.00
P 7021979
DEe 1 S 2000
Date
21-01-451
15.1 <31lew. 2117
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
SEll
SWln.l.....
SOCIAl. SECUlllrt NU"H"
DIn! DP IIRTK
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CaJtl~le, PA 17013
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DUE 10(011 AS ACONSfOUENC€ Of):
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DAtI! Of' INJUAY
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2'.
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...DleAl EXAMINER/CORONER
On.... b.... o' ..amlneUon and/or lnw..UgI.lon.1ft my opInlon. death occurred at the lime. d.... and place, and due to the CIUN(') and
......... ..ltatM.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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004119-00003/1une 6, 1996/EGMINLB/53843
21-01-451
\
YE&st Dill &ub illtst&nttut
OF
REGENA R. SWEGER
I, REGENA R. SWEGER, of Lower Allen Township, Cumberland County, Pennsylvania, being
of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as
and for my Last Will and Testament, hereby revoking and making void any and all Wills or Codicils at
any time heretofore made by me.
ARTICLE I
I direct the payment of all my legal debts, and the expenses of my last illness and funeral from
my Estate as soon after my death as conveniently may be done.
ARTICLE II
I give, devise and bequeath all the rest, residue and remainder of my estate, of whatsoever nature
and wheresoever situate in equal shares as follows:
1. One share unto my brother, ARLINGTON S. CLOUSER, Glen Burnie, Maryland,
provided he survives me.
004119-OOOO3/Iune 6, 1996/EGM/NLB/53843
2. One share unto my brother, HARRY L. CLOUSER, Missouri, provided he survives me.
3. One share unto my brother, DONALD S. CLOUSER, Missouri, provided he survives
me.
4. One share unto my sister, KATHRYN McCLEARY, Mechancisburg, Pennsylvania,
provided that should she predecease me, I give, devise and bequeath her share unto her then-living issue,
per stirpes by representation.
5. One share to be divided equally among the following of my nieces and nephews, LOIS
E. SUHR, RICHARD C. WALTERS, and EDWIN C. WALTERS, who survive me.
ARTICLE III
I name, constitute and appoint my nephew, EDWIN C. WALTERS, Executor of this my Last
Will and Testament. Should my nephew, EDWIN C. WALTERS, fail to qualify or cease to so act, I
name, constitute and appoint my niece, LOIS E. SUHR, Alternate Executrix to complete the
administration of my Estate. I direct that no fiduciary appointed herein shall be required to post bond
for the faithful administration of the duties required in any jurisdiction.
- 2 -
004119-00003/1une 6, 1996/EGM/NLB/53843
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and
Testament, this 16~ay of ~ ' 1996.
i/I h 1
t2~1- ~ It. ~~~
RE A 'R.~ SWEGER I '
(SEAL)
Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will
and Testament, in the presence of us, who at her request, in her presence and in the presence of each
other, have hereunto subscribed our names as witnesses.
iluAiJ ~/
--,'I tl~ua, I ~~i
- 3 -
004119-00003/June 6, 1996/EGM/NLB/53843
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
We, REGENA R. SWEGER, "f\ ~~~'=~
Testatrix and the witnesses, respectively, whose names are sign 0 the attached or foregoing instrument,
being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and
executed the instrument as her Last Will and that she had signed willingly and that she executed it as her
free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence
and hearing of the Testatrix, signed the Will as witness and that to the best of his/her knowledge the
Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue
influence.
~, (/- R ~)J~~#~
RE NA R. SWEG R
~{bn~
Witness
'/{~,-J'U~
WItness
Subscribed, sworn to and acknowledged before me by REGENA R. SWEGER, Testatrix, and
.~ ~, ~'(s;:' and '''\\~~ ~ ~
witnesses, this \ ~ ~ day of ~ ' 1996.
'~M~ ~
Notary Public - C..2J ~->
NOTARIAL SEAL
DIANNE LENIG, Notary Public
lemoyne Borough Cumberland Co.
My Commission Expires Dec. 21,1997
- 4 -
REV-1500EX(6-001
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
;0->> 9 ~.3
REV-1500
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Eo E; ".f.EC'cM
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
/.:1 - I~ - ;tda~ /0 ,- c1-
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
OFFICIAL USE ONLY
~
D 1, Original Return
D 4. Limited Estate
~ 6. Decedent Died Testate (Attach copy o/Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a, Future Interest Compromise (date 0/ death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
o 10, Spousal Poverty Credit (daleo/death between 12-31-91 and 1-1-95)
FILE NUMBER
~.L-L2.L
COUNTY CODE YEAR
o "I -.r.1 _
NUMBER
SOCIAL SECURITY NUMBER
/~3 - .PI
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date 01 death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
~ 8. Total Number of Safe Deposit Boxes
o 11 Election to tax under Sec, 9113{A) (Attach Sch 0)
COMPLETE MAILING ADDRESS
/7'37 CbC/(L/.=Yf /7,F,t?/JiPt,j ..?lA".
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NAME c:
LOW/,!(/'
FIRM NAME (If Applicable)
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OFFICIAL USE ONLY
(8)
/5.3'7. .7.:z.
TELEPHONE NUMBER
7/'/ -J.
(11)
(12)
(13)
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
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/.119,7.:1-
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(14)
C)
(1)
(2)
(3)
(4)
(5)
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5, 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
(Schedule G or L)
(7)
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(6)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
(9)
(10)
,;1.()~J: tJt:)
/3.39. 7.:1..
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (ScheduleJ)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax CJ
rate, or transfers under Sec. 9116 (a)(1.2) x.O_ (15)
16. Amount of Line 14 taxable at lineal rate .tJ x.O_ (16)
17. Amount of Line 14 taxable at sibling rate 0 x .12 (17)
18. Amount of Line 14 taxable at collateral rate 0 x .15 (18)
19. Tax Due (19)
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUNO OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS ~
r--L/l..eE
CITY
c;:;
/3
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
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c)
Total Credits (A+ B + C) (2)
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3.
InteresVPenally if applicable
D.lnterest
E. Penally
(3)
(4)
(5)
(5A)
(5B)
()
C)
4.
TotallnteresVPenalty ( D + E )
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
5.
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes
.....0
o
o
o
No
o
~
16
It:I
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1. Did decedent make a transfer and:
a. retain the use or income of the property transferred;...................... .................................. ....................
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? .............. ............................ ........................... .................. ........ 0
3. Did decedent own an Min trust for" or payable upon death bank account or security at his or her death? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................... ....................... ...................... .......................... 0 [6
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 pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge 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 PERSON RESPONSIBLE FOR FILING RETURN
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ADDRESS
IY'J'7 c:aC~Lp'y.r hE/lLJo4/ "oR
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
~c)d./N'C ,y,e/,<'/Cf ~d'1.
,
ADDRESS
For dates of death on or after July 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%
172 P.S. 99116 (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 surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)].
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% 172 P.S. 99116(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.S. 99116(1.2) 172 P.S. 99116(a)(1)J.
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. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an
Individual who has at least one parent in common with the deceden~ whether by blood or adoption.
'~'''~.,'''' '*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
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
NUMBER
1.
DESCRIPTION
C#'ECk/NC 4cc~t/,t>/r 17 'ir3:13 - ~73.r
,lJL.Lr/-€f.r .8..9# k'
,p.tt:J. fjpx I~/.:J-
/l/l~//7<)~e ~P. ./1..tCJJ
/
VALUE AT DATE
OF DEATH
/339. 7...2-
TOTAL (Also enter on line 5, Recapitulation) $ / S 3 /. ;;:z..
(if more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99) _
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
Debts of decedent must be reported on Schedule I
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES: AMOUNT
1. C -fE;'J/7;1/ //0 N' s;,C/cTY OF ~" 90S-: eX?
~" /lE/Jo~//9~ - d/1/7,C.J R. (7/NR lea' /'l,E/7o..eIA'Lf 7.t1c>. ()t)
3, c;J,.oE'H c;;e/7Vc ~ C~OfE - S#OO/'.J C1:/7Er/JI€.Y J/t'JO. 00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) C,OW/,v C kM~rE~r
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address /"11'/ C:::;;;,-,;i( t.c Y J' hrA1,o,,<.:I ./.?.e/I/C
City .80/L/A/~,p/,v~S "_.,_State~Zip /?C!O 7
Year(s) Commission Paid: cJ
2. Attorney Fees 0
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 0
5. Accountant's Fees a
6. Tax Return Preparer's Fees 0
7.
TOTAL (Also enter on line 9, Recapitulation) $ .J..OLl..J: 00
(If more space IS needed, Insert additional sheets of the same size)
REV_151,o,EX+II097J*..
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COMMONWEALTH OF PENNSYLVANII\
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
StJ.e"6",&;l ;f,e6,t:/V/1 .If.
,
FILE NUMBER
..// - c:J1-cJ-,/,f/
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
DESCRIPTION
Ca/'1/'7<7N'it/e,p~77V t?.F ;?.4/ t)E"P.T. c:1,:- /b.(J.L/C kkL,F//;eE
AMOUNT
/339, 7.2-
TOTAL (Also enteron linE 10, Recapitulation) $ /3:19. 72
(If more space is needed, insert additional sheets of the same size)
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CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: ;f1 ~C>.:::A/A ~ 0Wc(;;:."E..e
Date of Death:
/.:1 - /Lj- .;2C'~CJ
Will No. dE 1- c:J / - C1 ~.s- I
Admin. No.
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on /,}. - Af""- .;1000 :
Name
Address
PW//I/ C . ~LrE~.r /y'1? 4C~LEYf'/7~-'?.oPU /J"e &vL/~'~A?/Q'~~';"
1')d:17
/(/IrlT~YN E /YcCL.$4"eY' ??~L;.58U.eNRA~n 'irc17 Uh'p#~~ /h. /?a//
!/IIMY L. LL~t.JSJ:."/( 6.JJ E. JTI7TE Jlt:1X .t'lb /7/JIfJ##LL ~O ~.FJ~CJ
I?lcll;J~b C k//9Ln:~ fC) 80)( 9'~ AI~ /JUrr#kJ/};./~~1 I
tOIS E, ~A~E 0/1:1- ~Lf~H....s7:- JE~.r$'Y S#~.e .tho 177~C}
, '
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: tJ7 - of..J- .j()O/
~~::-. c::~
Signature
Name ~W//v C W4L.rF"eJ
Address /~.J7 ~C~L..E/f hE4?'~ /J.,(J.
IlcJ/L/#6 S;'R/,v'C:r. /h. /7L.'t!Y7
,
Telephone (717) ..tsY"" - (J / I~
Capacity: ;./"' Personal Representative
_Counsel for personal representative
G
STATUS REPORT UNDER RULE 6.12
Name of Decedent: "e/:?cr"c/S//? ;f 5~/':"'~C;:E/t
Date of Death:
/..2 - /"/- ~dCJC>
Will No. cJ / - t::J I - c:J 4:/J /
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"-- 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 ;--
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 part ies in i nteres t? Yes";- 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.
Da te: :7 - .,1S-- ;1aCJI
~~C'~~
Signature
E"L;w,-,v C ~LTE-ef
Name (Please type or print)
I"/J7 ~c A~;U;'.Y.f' /76"'"/1//i!?";'/ ,t],.e.
/l~/~/#c;:J.,o;e//./c..J; ~4. /7dCl'7
Address
(/Il) ./F:?- YI/~
Tel. No.
Capacity:
~ Personal Representative
Counsel for personal
representative
(MAH:rmf/AM3)
.,/ /6-L~<:2-9--3
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z8060l
HARRISBURG, 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
08-27-2001
SWEGER
12-14-2000
21 01-0451
CUMBERLAND
101
... I
EDWIN C WALTERS
1437 COCKLEYS MEADOW DR
BOILING SPRINGS PA 17007
'*
REY-1547 EX AFP nt-aOl
REGENA
R
Amount Remitted
) CHANGED
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
1,339.72
.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 ~
REY=is4j-i3CAFP-n'2:0oY-NoYici--oF-YNHiifiTANcE-YAx-APPRAisiii'ENT~--Ail-oWANCE-OR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF SWEGER REGENA R FILE NO. 21 01-0451 ACN 101 DATE 08-27-2001
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)
5. 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/Governnental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
NOTE: I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ALL
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS.
(9)
(10)
2,045.00
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
1, 339.72
3.384 7?
2,045.00-
.00
2,045.00-
14, IS and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
.00 X 045 =
.00 X 12 =
.00 X 15 =
(19)=
1.339.72
(11)
(12)
(13)
(14)
.00
.00
.00
.00
.00
.
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .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 FORH FOR INSTRUCTIONS.)