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Form RCc-33
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'JI\U2 cPj-7j'-..<3/
Mil 3 1979
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RESIDENT DECEDENT
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
COUNTY OFc;LJ:MI:l~RMNP
IMPORT ANT:
This return must be completed in detail and filed in duplicate, with will attached,. with the
Register of Wills of the County where decedent resided; Return is due, within one year after
date of death, unless an extension is granted hy the Secretary of. Revenue. (Section 703 of
the Inheritance and Estate Tax Act of 1961.)
IN THE MATTER OF THE ESTATE OF
........3.()y.lA!....l"<!t:<!J:".Il1CiI1,.
(State. full name of d~etl.t) .
Late of ..
.....9ll111l>""-J:"l,CiI1,9
}AFFIDAVIT OF
.. EXECUTOR
ADMINISTRATOR
County
County of
Pennsy)"ygnia............... }
55:
CumberJ,.and.. ... .. .....
Beulah R, Sh~.Ci..:f"J~E.....
ot the estate of the above~named decedent being duly sworn, depose S
_trix
Slale of ....
,
llllUllIliKKXOC
and say S
................,
19....,.?~....."J te.s'tate leaving
(Yeat) lxal~'
a last will, copy of which is hereto attached. }
Decedent .oed ..
March
29
(Month)
(Hay)
Name and address of attorney or}
other authoriz~d representative to
whom all correspondence should be
mailed.
SCiIl1lle J,:L.,}U1.c:i<=?,:E:?q:1l:i,~<=..mm...m_
26 South 8thSt:reet:,.. P.O. Box}}2,:L(O!Jl1c>yne,l'AmmJ,Z043
.
That as such .....':.~.':.'?':l:!:E.~.~.............. deponent is familiar with the affairs of said estate and the property
( t;:Hr:lltor.Adminilltrator)
stituting the assets thereof and their fair market value.
That at the time of death there was no safe deposit bux registered in decedent's individual name, or j
with, or as agent or deputy of another, or in decedent's individual name, with right of access by another as
or deputy, with the exception of the followlng:-
con-
ointly
agent
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION
IN WHICH DECEDENT RENTED A SAFE DEPOSIT BOX
Dauphin Deposit Bank .and Trust
West Shore Plaza, Lemovne, PA
Co.
17043
THIS SAFE DEPOSIT BOX RENTED
IN NAME OR NAMES OF
R. A. Peterman
RELATIONSHIP OF, JOINT
HOLDERS TO DECEDENT
That the contents of said saf'e deposit ,box or boxes are i tem1zed under Schedules
return, with the exception of' the fOllowing, fo~ the reasons.hereinafter set forth:
B
of this
That Schedule A attached hereto and made part hereof sets f'orth fully and in detail all the
real property in the Commonwealth or Pennsylvania of which decedent died having an interest therein! It
also sets forth the mortgage encumbrances upon each parcel or rea~ property at the da~e of' death, giving
the amount still due at death, name- or mortgagee, date, rate of interest, and book and page of record
thereof. It also sets f'orth in the colwnris provided therefore the assessed valuation of each of said
parcels, the estimated market value thereof' as of date of death of' decedent.
.'". -;- "-0.
That Schedule B attached hereto and made part hereof' sets forth fully and,.trl'. de'taiC.LBJ..iJpersonal
. .. v . I'r. ../ ~
property wheresover situated owned by the decedent at the time of death; all moneys left:.b.y. ttJe decedent
.... '".~~"" ,//1 ..
at the time of death, whether in decedent's immediate possession, standing to.d~cede~~'s credl~in banks
of deposit, savings banks, trust companies, or other institutions, whether indi~idualiy, or.:: in f.-rust f'or
~ .....
any other person or persons giving also separate~y the accmed interest thereon, if any, down tg:rthe last
J ../ ;, .
interes.t day prior to deceden.t' s death in the case of' savings banks, and to the da~~ of../dep.~d~nt'j~death
in all other cases; all bonds, postal savings, treasury certificates or notes and other'evidence of in-
debtedness of' the United States to the decedent; all obligations, whether by statute or agreement they
are designat.ed as .tax free, of the Uni ted States, or any state, or poli tical subdivision thereof, or of
any f'oreign 'country, which are owned at the time of death; all wearing apparel, jewelry, silverware, pic-
tures, books, works of art, household furn~ture, horses, carriages, automobiles, boats, and any and all
other personal chattels of whatsoever kind or nature, lert by decedent, together with .the f'airly estimated
,market value thereof'; all bondS and mortga_!!es held by decedent and of' all claims due and owing decedent
tat the time of death, and all promissory notes or other in~truments in writing ror the payment or money
of which decedent qierl possessed, of wha.tsoever nature, with interest thereon, if any, giving the face
value and estimated rair market value thereof, and if such estimated fair market value be less than the
race value, it sets forth briefly the reasons for such depreciation as to each i tern; all moneys payable
to the estate from life insurance polici"es carrieo by decedent; all annuity and endowment contracts the
proceeds of which were payable upon the death of the decedent; and all the corporate stocks and dividends
due thereon and unpaid as of the date of' death, bonds an'd accrued interest thereon to the date of dece-
dent's death and other investment securities owned by the decedent at the time of death, with the market
value thereof at such time.
/
.' -/' .
,
In the case of securities of close or family corporations, the values reported are as fa.. as
possible substantiated by financial statements of the corporations, showing the assets and 11abl1i~les
thereof' as of thH date of death. The schedule also sets f'orth the interest of rlecedent at the tlJ1f! of
death In any co-partnership or business, and In support of the value of such interest there Is annex~ to
said schedule, f:lnanclal statements showing the assets and liabilities of said co-partnership or business.
A copy of thE" co.-partnership agreement, (if oral, a statement setting f'orth the nature or the agreement)
together with a tit8..tement setting forth the ctlaracter of the business, its location, and such other facts
pertaining to the business as may be pertinent to a rair and just appraisal of the decedent's int~rest
therein mllst be submitted. It should also set rorth 1n itemized form, together with the fair market ralue
thereor, any other property owned or bequeathed by the decedent at the time of death.
I
The Schedule C attached hereto and made part hereor sets forth a true answer to each iD1Uiry
contained therei!1 and in the case of transrers of property, real or personal, within two years or deced nt's
death, in contemplation of decedent's death, or intended to t~ke effect in possession or enjoyment ,t or
after death, sajd schedule sets forth the nature and value or such property, to whom transferred the
relationship of the transferees to the decedent, the proportjonate share received by each transfere1 and
all other facts of a pertinent nature regarding said transfers. In the case of transfers intendrd to
take effect in possession or enjoyment at or after death, there is also attached to the schedule aco~y
of the deed, trust agreemen t or other instrument crea ting the trus t. Ther~ is al so se t forth in I said
schedule a list of all property, real and personal, with its value, which passes at decedent's death by
virtue of the exercise by decedent, either individually, or jointly with another, or any power of appoint-
ment vested in decedent, either individually or jointly, by the will, deed, or other instrwnent of anolther,
with a copy of the instrument creating such power attached to the schedule.
That ~'chedule 0 attached hereto and made part hereof sets forth the names aoft addresses or all
persons benefictally interested in this estate at the time of decedent's death, the nature of their: res-
pective interests, their relationship, if any, to the decedent, together with the ages at the ti~e of
decedent's death of' all minors, annuitants and beneficiaries for life under decedent's Will. Itl also
contains a statl~nt showing which of the beneficiaries named in the decedent's will, if any, died ~rior
to decedent, thE! dates of their death, their issue, and the relationship of such issue to the benefidiary.
That Sc"edule E attached hereto and made a part hereof sets forth all property, real and per-
sonal, owned by the decedent jointly with another or others, including intangible, standing in th~ name
of the decedent and others, plus "the date and place of record of instruments effecting the vesti t~re of
real estate and the date of acquisition of personalty, plus the name, address and relationship, it any,
of co-owners to the deceden t.
I
That .Sc"edule F attached hereto and made a part hereof sets forth fully and in detail all debts
and deductions claimed for and on behalf of this decedent's estate, including funeral expenses;paidj
family exemption, where applicable; costs of administration of this estate; counsel fees and rudic~ary's
cOlllnissions paId or to be paid; cost expended for burial trusts, tombstones or gravemarkers, and' reli-
gious services, in consequence or the death of the decedent; debts and claims owing anrl lmpairl at t~me of
death; taxes accrued chargeable for period prior to decedent's death (except those allowed under ~ction
651 of the Inheritance and Estate Tax Act); together with a statement of collateral pledged for obliga-
tions, if any. It is agreed that the fiduciary will present proof of said claimed obligations uppn re-
quest, that if the amount actually paid in settlement of any fee, commission or debt is less than the
estimated amount claiming and allowed, that the same will be reported to the Register of Wills, and that
the amount of ':ax assessed can be reassessed in accordance therewith.
That thetota.lsof the appropriate colunms in Scherlules "A", "B", "C", "E", and "F" as directed tHerein,
have been carr~l_ed-.i'orward and properly' registered in the Summary.
Subscribed EJld sworn to before me this
:'~. --
, ~""r1
~<'c(~t~d~......__......__...
117J~9.l=:t.h......~th....S.t.r.ee.t_..._....._.___.__.
(Street Number)
Lan<:>yIl,E:!.~. ...:E'E:!IlIl!;lY:!Yi3J1,~i:I: ....mJ,?Q4~......
(City or Town and Sto.te)
....__.._Q:l:!:'. .... day of . .q~~IVJf.- 19:1.~.
......m_. .A..llk (t~
"~, l.lr",
NOTE: Before 5 ign ing affidav j t make sure all bl ank spaces in the affidavit and schedul es annefed are
filled in with detalls or the word "None", and in case the assets include rl:ire ann unlisted securities,
securities of' close or f'aml1~" corporations or an interest in any co-partnership or business, that the
data anti stR.tmnents requirerl under the pllra~rflph ahove relating to Schedule "B" are attached. AI,so make
cert1:lin that eolwnn #1 in the "SuITJTlary" tlftS heen properly completerl as Il.bove-(l1rected.
Rct-J4 '/4_!;(o.
COM\!ONWEAL TH OF PENNSYLVANIA
O~PARTMENT OF REVENUE
BUR&AU OF COUNTY COLLECTIONS
,TRANSFER INHERITANCE TAX
RESIDENT DECEDE"iI
SCHEDULE "A"
REAL PROPERTY
*'
Real property in Pennsylvania, with statement of mortgage encumbrances upon each parcel at death of dece-
dent. Property held by the decedent as tenantin common with another or ather, should be identified
as to quantum of interest and the estimated value should be that of the decedent's interest only. (Property
held as joint tenants with right of surviorship or tenancy by entireties should be reported on Schedule "E.")
The rllal property located In the Commonwealth of Pennsylvania should be
described by lot Dnd block number, street and street number, together with
a general desc.rlptlon of the property, with a reference to the record of the
conveyance by whli:h the decedent took title; If 0 farm state number of a-
cres; also statement of rnortgoge encumbrances upon each parcel ot death
of decedent. Taxes, assessments, accrued Interest on mortgages, etc.,are
to be listed on Schtldule uFu and must not be deducted from this schedule.
(1)
(2)
(3\
DePARTMENT
VALUA TION
CAUTION
(Do not write
In thl. .pace)
ASSEsseD VALUE
FOR YEAR OF
DECEDENT'S
DEATH
ESTIMA TED
MARKET VALUE
1. Real Estate located at 503 South 3rd Str. 3,530.00~ $31,000.00~~
Lemoyne, Cumberland County, Pennsylvania;
Two story brick dwelling house; decedent
and his wife acquired title to the subjec
premises by deed dated 10 November 1944
and recorded in the Office of the Recorde
of Deeds for Cumberland County In Deed
Book 12, Volume W, Page 197; decedent's
wife, Hazel P. Peterman, having prede-
ceased him on 11 June 1973, the entire
estate vested in the decedent.
.
.
:.,./
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,
3~)ooo.o':'
Insert this total opposite "real property":Schedule "A" in the X X X X X
"As Reported" column on the last page of this return.
$31,000.00
RCC -~5',
'*
C9MMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "B"
PERSONAL PROPERTY
INSTRUCTIONS: This Schedule must disclose all tangible and intangible personal property owned individually
by the decedent, at the time of his death. Property owned by the decedent jointly with another or others
must be 11~ted under Schedule "EN. Intanglbl~ p~rsonal property, titled 1n the name or the decedent, but
payable at death to another or others, including but not limited to P.O.D. U. S. Savings Bonds and tenta-
tive trust accounts, must be listed, despite the f'act that they are not of the administered estate.
Tangible personal property should be listed rirst (e.g. jewelry, wearing apparel, household
goods, and furnishings, boOks, paintings, automobiles, boats, etc.)
Intangible personal property, such as bonds, treasury certificates,. cash on hand and In. bank,.
stocks, mortgages, notes, together with accrued interest or dividends, salaries or wages, insurance pay.
able to the e~tate or fiduciary in said capacity, partnership interests, interest in anyundlstrlbuted
estate of or income from any property held in trust under the will or agreement of another, even though
located outside of the State, at the time of death, snould be listed in this schedule.
Item
No.
ITEM
List and describe f\J.lly
UNIT ESTIMATED
VALUE MARKEr VALUE
DEPARTMENT VALUATION
(Do not write in
this space)
1
2
1976 Chevrolet Nova automobile
isce'llaneous items of personal clothing,
furniture, and household contents
nited States savings Bonds (see attached
schedule)
one-bank sub9rdinated debenture, ~ndustria
alley Bank and Trust Company, certificate
x057844
$2,000.00
1,384.25
3
2,834.9
4
280.0
5
Deposit Bank and Trust company,
#289956
Deposit Bank and Trust Campany,
#13-09652
Deposit Bank and Trust company,
#68-41-732-2
48,0-
6
10,253.6
7
137.3
3 , 093 . 3
8 CCNB Bank, N.A., Account #003-003097-7
9 Harris Savings Association, Account
13909
10 Refunds from Bel16f Pennsylvania
24 July 1978
30 August 1978
11 Refund fram Blue Cross on 23 May 1978
12 Refund of autamobile insurance on
17 October 1978
13 Refund of hameowners insurance premium on
18 October 1978
14 Refund from Gurney Seeds
15 'Columbia Insurance Cam]':>any.accident and
health insurance payment
16 Medicare payment
17 Debenture payments
28 June 1978
17 October 1978
1 December 1978
18 Pennsylvania Railroad Voluntary Relief
Department, contribution refund
All assets titled in the joint names of
Roy A. Peterman and his wife, Hazel P.
Peterman, are the sole and exclusive
property of Roy A. Peterman by virtue of
his wife's death on 11 June 1973.
Rebate on real estate taxes due to sale
of property
4,152.4
4.6
21.3
28.0
36.8
211. 8
20.0
/
153.1
19
Insert this total opposite "Personal Property", Schedule "an in X X
the "As Reported" column on the last page of this return.
20
Cash in safe deposit box
1.50
24,826.2
'L.L( \ <(:,26."'2.-0
Total
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DAUpHIN DEPOSIT TAUST COMPANY
Safe Deposit Box Inventory Sheet
Office
. . : l:,lJa.
Date Pl'-,j' l? ,'P
1.
Name of Renter (sl
.. :.. ~\.\-o_.'-'"
Addtass
j6:; . ': ~oL.~ ;:t.
-
" '~U'!,.J, ,....
Zip Coda l'Xl4J
2.
Box Number
IS113
Date Box Rented
;./-:>n/?/ll
. .
Date rent paid to
$/1"0 ~g
,..:. ,
Date notification Sent
Delinquent Rentel due $
Drilling Costs $
3. Instnlctioils: (1) Cash: Report total OnIV; (2) Stock: List ,in det8i1 every common or p,referred certificate, warraoi~or other righlS
found In bo,,:Stocks are to be designated bV name o/companv, certificate number, data of certificate. name in which stock is
registered, number of shares and class of stock; (31 Dbligatioilsof U. S. Government: NUmber of pieces, date of Issue, f8ce yalue
and nariles in whicti iagistered; (4) Bonds: Desigriate by nam,;, amount and sarialnumbar; (6) SaYings Passbook: Name of
depOSitOr, nuiribli, of book, last date of activity, name 0/ bank and balance; (6) Jewelry, coins, stamps, etc.: list' and describe as
fullV as possible; (7) List Deeds, Mortgages, Insurance Policies, ete.; (8) Miscellaneous Items; (9) None: Indicat8 same On sheet.
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,'~ lllrTljlltllN~1 50:! "'. ',d'f~ .:~,:L~,,:,'l":. ,". J.?!;L3 d;wd 1'0/4/11I.
~ ",r:y .' :.'..1' 1.',,\" ,n
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j'j t1c, .- .<!?() CLot~'jrt.'lo:+""".1 i t '/'(.;' 1'1_. A:)'n':.:~?i)i.;5
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L .r)t /tp.''1I1t...:,:",o I.ot', Pi.'!..t.s"tJ.r:t L,;"J:"otr_'i':'':fi ~~J.:lr~'.J.r;'" h\.
~'<; 'On,If>.' r, : oJ ~ OliO I ,0.' ,'. . ,".;",.ou' n ,r : ,ogittr, Hon
~':?l.OO "ez.nl '. : '.d::o{-~~ tqJ-:h 'U"'. J<j61
(~;:>5.0() ;t!~'.f)l '. r-,~t",':!'!,1"n ~:~,~~"t,.t "1961
:?:5.00. :'f.'~~..el 4. ~nt..lt';lli:,~n \.,..~t., l'~(-J.
a. g.do i'c!,,iJl ;. h.t, ;'ii,-ll : 0". 1961
~e:.fA). \ ~r ~~C' j I. ., ~ t t-;rl. n ;)dc. 1 ~?(-l
. ~5.<X1 i'tl~',el. Jt2lIX l"(~t~.n'1'iio~n t:1:1~. 1.JJI
'~~5.0I) ;!n~,~l .:. .;(j~;"!'r.:fnn 'i ..J,_ 1S'~
;'~5_.00 /n~tJl :. "."..t,I.-:ri:l.: U ,en. l~
25.00 L/i.z.el '. jti"~;r;:v,l..I :., .It:b 1962
/~:~;~(~} r(j~,ol i. J. P"~"'~l-~ir:t~ .' r)'i-l It;t6;~
?5.00 ~.t~~('l .J. oPc;oti':-'!J:',il ~'rU1Wt 1~62
/ ' ,,~
;'>',.00 j,o:nl '. '....'t'.rnnn ,jUly, l~'w.
/:~5.00 ,'ll zal ,'. j ~)t, 'I"'" II ,\.;;. lL'{x.
"''i 00 ',__~r;i:",jl. 1'HtI,11'I.J<:n ~ ;.:,r.,-"{.'.' 1.',162
i;;oo :,;';:';1.: ;..'t, l'idl '.,ct... ]<)(>2
25.00 );'\7.01 j'. ;, ,;'1.<".1.1'1/ n ;.ov.. 1(,'62
;25.00 HIllle1 ;'. i-'etN'rn:'n l.ltlC., 1962
2~.OO / i;owl i'. .'d"Tt11'" J!UJ. 1%3
2!1~06/ l;r:lze1 .'. lot"!"dll.II h:I:.. 1~'6J
25,.00 . hnt.e1 F. i'(1t.-"t't1:0 ihr'Gh, 1963
~!5.00;,:;':'.(Jl ". P..t.cl~l"11 IIpT'U, 1~;(,3
;1"'.00 \1/,,1101 l'. ht')l'.",'n' 't,y, 1963. .
We certify Sa': OOpo.it Box Number -- 1 ""t\,, opened this 12th. day of i.I)ril
anil the above reCord 'of contenlS is correct and complete to the best of OUr knOWledge.
\
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Page 2
SAFE DEPoo IT OOX INVENTORY
'-rnstructions:,' 1 CASH:, Report total only. 2 STOCK: List in detail every common or
preferred certificate, warrant or other rights found in box. Stocke are to
bedeeignated by name of cOlllpllily, certificate number, date of certificate,
name.in which stock is registered, number of shares ,and class of stock.
(,3) OBLIGATIONS of U.S. GOVERNMENT: Number of pieces, dates of issue,face
value, names in which registered. (4) BONDS: Designate by name, amount,
serial nUlllber, or otherwise. (5) SAVINGS BANK or PASS rooks: State name
of depositor, nl1mber ".r book, last dHte appearJng in book, name of bank and
branch,and balance. (6) J1!.'WELHY, COINS, STAMPS, MANUSCRIPTS, ETC.: List
ahd describe, as fully as possible. (7) List Deeds, MOrtgages, CUrrent
Insurance Policies or other evidences of indebtedness~_. (8~ All other contents.
Snfo ;}"podt ox 1583-; oy , . ,'etatlllt\D
l"
i
:; ':.00
25.00
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, 25,()()
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25.
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A~~.g;'
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25.00
2-5~00
, 11~:gg
, .00
5.00
,.$.00
25.00
25.00
25.00
;>5~()O
25.00
Hazel F, ,i'"t;'::'(in, ,; tecJ d\:nv, 1~l63
htzel ,j. .i'nt"'1"i~',ll, di tad ,funo, 1963
Hpzel 11. i~et,et-nn,n, {1.ctC'd ,jul~'i 1~t3
ill;zel ,I'. j'p<.. %':I.n, rktGd \l<.~ ).')63
Jir,Zlii l', letd-' I,ll, ((,ted :,r, t., 1.~'6:l
h:.z.el ~-'. l'l,.:~t,(!l'r!i~:,n, .:h'Jtecl. L<.:t., 1(}63
Bllliifll P. j'/1 Wrrud:1 , rll,'ted:ov" 196,3
Hazel 1'. ;'otl)1"""n, 1'\, ted j)eo" 1')63
Hazel I'. l'atcr!~;n, :h!tad, ,hil., j 964
Laool ;\ !n';el"J'.di, ,Il"tod Jl,l::., 1';'64
Hnzel l'.l'lltorlilril, 1).:-1..90 ; 1'.%'., 1964
Hl!z~l '. i"OtGl""l"rt, (1, t~d '1'1'" 1'164
hate!. i'. l'eto.'lW'l\, <:1: ted ; ,rrj, 1964
L',JzOl r, I'oterm:.tl, dctod JurIO, 1964
lu',l\el ,l'ct"l"!',r,ll, d'ted July, 1064
llnzel J. j.,)t;,.,~:!>L TI, 6:, :,od jl~I':., 1964
Hr.se:J, P, j-'/,torm: n,d' tad ,!,"',:t., 1~64
. ;;tl.ze~ I'. r",fjcr1:i''l, dl,t.ed ,;,,"1.., 1')64
i!l.t~ l, rot~l":"'l'li rktod l:ct., '1964
,n r,zol ~'. "f)tt. "'n, rkUld 16".,1964
Iillze11".Il:lt"l'7,.,,'il, I"tad, 1)&0,,1964
Hazel I'. j"ot"."1"Ui; dr,tad J(,n., 1965
i'ill"l 1', et~rt;\:n, d" Gl'ld :t.'iJ, 1967
!illltel I'. ':llt/'r;<j tl, f,ntod:'ov., 1967
\Ill zel i', ,'~)t.:\ 1"'1" Il, c1doc "Ir~, 1961
'ji(:zol ., ; ot01l.1, ,i, cll, t'ia .Juno, lCiM
Bate;!. r. }..)t:~:rn' n, .:}.'I:.CO ~:ec., '~:~~;6e.
lilll'lll J', i 6kl";1' IJ, ,.or l."d IJllC,. ..lc;~
Eaeol .. l'"t, rm"h, arced, 'ny, 1970
hazel 1', Vete) "",1\, ,'"ted :, ;";P~'" 1.970
lilillOl i, j'''1-."rr", 11; <ie.tea 00f)~.19?O
Hallel I'. ,,,t.)t'm:,ll, cl: toil vet" .1970
l:ltV..elj-", j"otf:I'!I!.",n, :l"ted (;ct., 19'7.0
Bazol,;, i'otN'n:.:I, d,.,ted Ict., l~)'IC
II t'Jll8l " J'<;t!:: ',,',n, d,,:"'~d Dec.; 1970 ,
Hazol i"!lul1na ,atN'i>\llli, .;:, tad f;lll, J.97l
.\:6ze1 h.\U1ne. atern"tl, (nted ':oc. ley/l
liallel J. i~')tij1"lnr'n, Noted :iJ.l'ch 10//2
Hazel I'. l'otert'o'.., dated ,lul;U ,1972
hazel I'. ;eteJ'l:l:"&, <.lilted !'ov, 1972
Halle1 : " ullno j';!t',:r!:l"n, ;)" tad iioc. 2972
lIazel l'et,,~:n , detC)d f.cb, 1973
Hb.tel1':,ulll1G l<>t"l'!lInD, ,ktl?d reo. 1973
\
. , ,Andnow this , 12th'd~ of', ,;,prU
certify under penalty of perjury that the
to the best of iiI1, knowledge arid belief.
'?8 ' , '
, 19_____., I hereby
abova record. is correct arid complete
~:'
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'Signa~ , '
Print Name 8M Title,'
NOTE: Use separa.te sheets if necessary.
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"Instructions: .
SAFE DEPOSIT BOX INVENTORY
(1) CASH1Report total only. (2) STOCK: List in detail every cODllllOn or
preferred certificate, warrant or .other rights found in box. stocks are to
be designated by nallie of comp&:lY, certificate nlllllber, date of certificate,
name in which stock is registered, num~er of shares and class of stock.
(.3) OBLIGATIONS of U.S. GOVERNMENT: Number of pieces, dates of issue, facs
value. names in which registered. (I.). BONDS: Designate by name, amount.
serial number. or otherwilF~, (5) SAVlNGS BANI.: 01' PASS BOOKS: Statename
of depositor. nlUllbor of book, IHst date appearing i.n oook, name of bank and
branch. and balance. (6) J1"WElJlY. COINS, S'l'A14PS, AANUSCRIPTS. ETC.: List
and describe as fully as possible.' (7) List Deeds, Mortgages, Cilrrent
Insurance Policies or other evidences .\iLindebte9.!!..'!.2.l!.!,_ (8) AU .other contents.
....,..
SAn: Oi';WSI'l' l(;XKi. 1583- Joy f.. i'DWJ'rlllft
'1'he FollOl'tilii':;Bties :.:. Jonds.- i-,t'ghtorecl to Iioy c, j'\lter\lll:\.
$ 2~ l"01!. 1'",t"'l'mLn, <1,ted ;,pril, 19'14
/125..00 I:OY I.. 1',.t..'i'W'.n, v,.,.ted. IiP.!i..l, 1974
25~00 1:01 J,. ;'"Vrmr'n, !lr-ted JuDe, 19'14
/ 25.00 ;,ny'.;'>, ot'.'~"":'II~ '1, ted JUI1f', i974
25.00 l"y .', l"tl:l11'11I1, 1kWd .Iuly, 1974
/., .
25.00 )'0)' i.. lut,"rt:l:'n. il{';;ed iut" 19'14
/25.00 l'.oy .. ,'(l.t"'l"'.fn. dntad LJet., 1.914
25.00 l'OY Fet..,,.I;)I'rl, <1:'.tod "UI~.. 1974
25.00 hoy '. Fd<~r!~' n, ~!lt.ed l~;:,. 19'14
. 25.00 F6y !I. .ot"",~'rl. dnted J',n. 1975
n. ;.,...00. .... f.oy.. :.Pt.?T':!i! n. d.,.ted f11111. .1.97. 5
25.00 ,oy I'. 'et.o",e' 0, noted.lw).,. 1975
. 25.00 J.oy :\. ) ["t,r.r"1' n, 'j(,i,od l:lIiIC., 19'15
2:5e:0Ci..--- ;"oy .r~. eet,i:rriVin,_ c\r tod .i'u:~.. 1975
. Ii' :2'~ Fo)' ", :'eVr'r~.:", to! u,d ;JUiiH, 1976
25.00 ;.0)' r., i'O\rr,,'/.l'l. .1".:ted ,Junu, 19'76
?5..00.' roy f. ".'1VJT""f', (lrct'.'''d. IUly, 1976
25e,00 liCy I" Vd..'m'r.. o>>ted 'ov. 1976
?5.oo 1..0)', :~;t(,I'I''' Il, ,i. v,d jJ: 0., 1976
25.00 Hey (i. "'Jt':'n'll. rl,.tud .J"f,.l9'n .
25.00 ;:,oy t, j', t"l"n(,LJ. ,1',u)d'" b., 19'77
/1/'.5'..'0..:' (..oil II, .:..."'t"l"J'''. '~.rnta ".d ....<;;..,klh.. 1',.971.
~5.00 iC\::;. t'ot.m,,,.,,. (~,itnd 'J'ch, 1m
25.00 '01 .'. I ;.term'l"i tinted .JUIin. 1977
25.00 f..ot )\. J.'ot"'l'lllln, dated So:>pt., 19'77
25.00 I'oy I.. ...~t"r"'. fl, d,.tod (lec., 1m
25.00 hoy ".. fet.,." il, ~!'t.ed ,1"r.. 197e .
25.00 l,oy", peter:'Hl. '""'v;d ~"l',rchi 19'7g
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Andncr..> this12th.d~ ot APrU
certif}r, ~er 'penalty ot perjury that the above record
to the best ot mt ,knowledge and belief.
, 19 78.i hereby .
is correct and complete
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slgnatur
Print Name end Title
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COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
SCHEDULE "c"
T RAN SFEfiS
*~
RESIDENT DECEDENT
(1) Did decedent, within two years of'death, make any transfer of any ma.terial part of his estate, without
receiving a valuable and adequate consideration therefor? (Answer yes or no) no
(2) Did decedent, within two years of death, transfer propert.y from hlmself. to himself and another or
others (including a spouse) in joint ownership? (Answer yes or no) no
(3) If the answer to (1) or (2) above is in the affirmative state:
(a) Age of decedent at time of transfer
(b) State of decedent' 5 heal th at time of maklng the transfer. (Note 1).
(c) Cause of decedent' 5 death. (Note 1).
(4) Did decedent, In his lifetime, make any transfer of property without receiving a valuable 01' adequate
consideration therefor which was to take effect in possession or enjoyment at or after his death?
(Answer yes or no) no ______
(a) Was there any possibility that the property transferred might ret~rn to transferer or his
estate' or be subject to his power of disposition? (Answer yes or no)
(b) What was the transferee's age at time of decedent's death?
(5) Did decedent in his lifetime make any transfer without receiving a valuable and adequate consideration
therefor under which transferor expressly or impliedly reserves for his life or any period Which does
not in f'act end before his death:
(a) The possession or enjoyment of or the right to income from the property transferred?
(Answer yes or no) no
(b) The right to designate the persons who shall possess or enjoy the property transferred or
income theref'rorn? (Answer yes or no) no I"
(6) If the answer to (5) (b) above is in the affirmative, state whether the right was reserved In decedent
alone or others
(7) Did decedent in his lifetime make a transfer, the consideration for which was transferee's prolnise to
pay income to or for the benefit of care of transferor? (Answer yes or no) no
(8) Did decedent, at any time, transfer property, the beneficial enjoyment of which was subject to change,
because of a reserverl power to a1 ter, amend, or revoke, or which could revert to decedent under terms
of transfer or by operation of law? (Answer yes or no) no
(9) If the anSwer to (8) above is in the affirmative, was the power to alter, amend, or revoke the inter-
est of the beneficiary reserved in the decedent alone or the decedent and others?
(Answer yes or no)
NOTE 1: The answers to these questions should be supported by affidavit by the attending physician as
well as a copy of the death certificate.
NOTE 2: If answer to any of the above questions is yes, set rorth below a description of the property
transferred, it's fair market value at date of death, dates of transfers -and to whom transferred, with
relationship of transferees to decedent, if any. Submit copy of any trust deed or instrument, lr trans-
fers are claimed to be non-taxable, also submit detailed statement of facts on which said claim is based.
NOTE 3: List applicable property below in manner in which provided in Schedules A, B, or E.
ITEM
DESCRIPTION
MARKET VALUE
(Estimated)
DEPT. VALUATION
(Dept. Only)
.
t0~
Insert this total opposite ~Transfersff, Schedule "C" in the
"As Reported" column on the last page of' this return.
"
)lCG~37 (12-63)
COMMONII'EALTH OF PENNSYYLANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "0"
t\
BENEFICIARIES
\
h
BENEFICIARIES AND ADDRESSES RELATIONSHIP SURVIVED
(If step-children or DATE INTEREST OF
.State full names and -addresses of all who illegitimate children DECEDENT OF BENEFICIARY
ave an interest, vested. contingent or other are involved,. set STATE YES IN ESTATE
wise, in estate) forth thlS lact.) OR NO BIRTH
T.""" M "^r"""n; araiid-dauahtc l,- ues 12"31-48 !':l 000.00 cash benue
512 Haldeman Avenue
New Cumberland, PA 17070
Karen S . Mohler grand-daught€ b:- yes 3-19-52 Sl,OOO.OO cash beques
802 qherwood Drive
"
"1"", erland PA 17070
Beulah R. Sheaffer daughter yes 7 -2-24
-
117 North 9th Street
Lemovne PA 17043
Harold C. Peterman s'on ves 3-10-23 These two beneficiari
3516 walnut Street share eaua11v in the
Camp Hill, PA: 17011 remainder of the
iQd+a+e "fter the cas!1
beauests have been
deducted.
,
.
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Deponent further says that all the above-named beneficiaries are living at this time except below:
NAME
DATE OF DEATH
RESIDENCE
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SUMMARY
. ....(Sch. "A")
...n.(Sch. "B")
......(SCh. "C")
Real Property
Personal Prc,perty
Transfers
Gross Taxable Estate .
( )
(As Det 'rmined )
(1)
(As Reported)
$n .
$n
$n ..
$..
$nn
$n
$
$
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$
$
$
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z
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:"~~C-38
RESIDENT DECEDENT
SCHEDULE" E"
JOINTLY OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
INSTRUCTIONS: This schedule must disclose all property, real and personal, owner! by the decedent jointly
.....i th another OJ' others, including intangibles, standing in the name of the decedent and others. List
real estate first, as entireties, or joint tenants, giving brief description, as indicated lmder Schedule
"AIf, pluS the date and place of record of instrwnent effecting vestiture, but no not include entireties
or out of state real estate value in estate valuation column. Personal property Should be listed as in
Schedule "B", VIus date of acquisition, and the name, address and relationship (if any) of cO-OWners to
the decedent.
Description of Property, Date of Acquisi tion, Name unit pe reen t age Estate DEPARTJAENT VALUATION
Address and Relationship of Co-Owners, and PI ace Value Share Valuation CAUTION-Do not Write
of Record of' Instrument, where Real Estate. In This Space.
6& ~ (X 2Y ~ (X ><< :< ~ XX Value of Value of
v ~
>Oc 'X Entire Deceden t' s
0< :)0 2; property Interest
None
/
,
N~
Insert this total opposite "Jointly Ownerl Property", Schedule 'E'
in the "As Reported" column on the last -page 01' this return.
.-
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COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.O. BOX 2970
HARRISBURG
17105
IN YOUR REPLY Pl..EASE
REFER TO
R E V-5 t6 (a-78'
Inheritance Tax Division
NOTICE OF FILING OF APPRAISEMENT
Beu1ah~. Sheaffer
117 North 9th St.
T.Qmn)'I:le P A 170.'1.
(Executor or Adm ini strator)
In Re: Estate af
Poy:A. PeterJllaB
Cumberland
Caunty - File Na. ?1_7R_?~1
Dear
Yau are hereby natified that the 0",; g; n" 1
appraisement in the estate af Roy :A. PPTP",m"n
has been filed in the office of the Register of Wills of r.llmh..",l "nn
County on 28 March , 197~, Soid opproisement reflects the following
valuations:
Real Estate_ $31.000.00
Persana I Property 24.82:6.20
Transfers None
Jaintly Owned None
Total $55.826.20
As to such tax that is paid within three ;"onths from date of death, a five (5%)
percent discaunt is allowable. As to any tax that remains unpaid after nine (9) months
(fifteen months when death occurred from December 22,1965 to June 16, 1971, inclusive;
and twelve months when death occurred prior to December 22, 1965) from date of death,
interest at the rote of six (6%) percent per onnum is charged.
Any porty in interest who is aggrieved by this notice may object thereto within
sixty days after receipt of said notice as provided oy Section 1001 af the Inheritance and
Estate Tax Act af 1961, 72 P. S. 2485.1 DOl, P. L. 373.
Leo
Date
Signed
t=~.~
26 March 1979
Title Admini~T'Y';.'lt-;vP nf=-F.;('oJ"
'-
Nate: This is nat a bill.
~ .
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REV..-457 (S-78)
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.O. BOX 2970
HARRISBURG. PENNA. 17105
COMMONWEALTH OF PENNSYLVANIA
RESIDENT INHERITANCE TAX
APPRAISEMENT
28 Harch 1979
DATE
COUNTY Cumberland
FILENO. 21-78-231
Whereas, Roy A _ P",t"erman late of Lemovne
in the County of Cumberland Commonwealth of Pennsylvania, having died on
the 29th day of Harch 19 ~,sei2ed and possessed of an estate
subject to Inheritance Tax under the laws of the Commonwealth of Pennsylvania;
. Therefore, I, Le 0 Full': i ni t i , an appraiser duly appointed according to law,
having been designated to make a fair and conscionable appraisement of the said estate, and to assess and fix the cash
value of all annuities and life estates growing out of said estate, hereby file the following appraisement:
In the event that any future Interest In this estate is transferred in possession or enjoyment to collateral heirs of the decedent after the expiration
of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer inheritance taxes at the lawful collateral
rate"on any such future interest.
DESCRIPTION OF ASSET , UNIT APpraisement
vALUES Made for Inheritance
Tax pu rposes
. . $
P.~' ,,~...~...o . 31 000 00
Personal Property . 24,826. 20
'1',.,~nsfers None
Jointlv Owned "^~O
Total S~5 8"6 "0
I
,
.
,
.
-
,
Have been duly sworn according to law, I do hereby certify that the above appraisement is made in conformity
with the law on this ?R+h day of ~1ar"h ~ 19 lL.
l..e...'F~~
Appraiser
(Numbe( and Street)
H.::l,...,.,;Q'h"""e;
.
(Post Office)
. Penna.
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