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RCc..3a (4-731
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
~13 1978
RESIDENT DECEDENT
COUNTY OF Cumberland
IMPORT ANT,
This return must be completed in detail and filed in duplicate, with all attached, 'with the Register of Wills of the
County where decedent resided; Return is due within nine months after -date of death, unless an extension .is granted
by the Secretary of Re\tcnue. (Section 703 of the Inheritance and Estate Tax Act of 1961.)
Late of
Cumberland
} AFFIDAVI'f OF
~~
~~XAA
County
Surviving Joint Tenant
. IN THE MATTER OF THE ESTATE OF
Bessie May Barnes
lSTATE FULL NAME OF DECEDENT)
Stat. of pennsvl vania
County af Cumberland
} ss,
Cleo Samuel $imons, Son and Surviving Joint Tenant
Administrator
Executor
of th"e estate of the above-named decedent being duly lIwarn, depose
ond.s:oy
Decedent died Sept.o 13, , 19~{tostate leaving ci loat will, copy of which is hereto attached..}
(MONTH) lOAY) (YEAR) Intestate.
Nom. and odd,... af allo,n.y a' } J. Robert Stauffer-Market Square Bldg.,
other authorized reprt'ls.entotive to whom
all correspondence should ~~ n- _ led. !1echanicsburg, Penna. 17055
Joint Tenant
That as such Surviving I deponent is familiar with the affairs of said estate and the property constituting
(EXECUTOR-AOMINISTRATOR) ,
the assets thereof and their fair market value.
That at the time of death there was 'no safe deposit box registered in decedent's individ~al name, ~r jointly. with, or
as agent or deputy of another, or in decedent's individual name, with right .of access by an~ther as agent or deputy, with the
exception of the following: -
N.AME AND ADDRESS OF BANK OR OTHER INSTITUTION
IN WHICH DECEDENT RENTED A S.....FE DEPOSIT BOX
The First ank and Trust om an 0
Mechanjcsbur~. Pa. .,. Main and Market
Sts. Mechanlcsbur Pa.
THIS SAFE DEPOSIT BOX RENTED
IN NAME OR NAMES OF
Bessie Ma Barnes or
leo Samuel Simons
RELATIONSHIP OF JOINT
HOLDERS TO DECEDENT
Son
'-
That the contents of said safe depo~it box or boxes are itemized' under Schedules ME
with the exception-of the following, for the reasons hereinafter set forth:
"
of this' return,
That Schedule A. attached hereto and made part hereof sets forth fully and in detail all the real property
in the Commonwealth of Pennsylvania of which decedent died having an interest therein. It also sets forth the
mortgage encumbrances upon each parcel of real property at the date of death, giving the amount still.due at
death, name of mortgagee, date, rate of interest, and book and page of record thereof. It also sets forth in the
. I
columns provided therefore the assessed valuation of each of said parcels, the .estimated market value thereof
as of date of death of decedent.
That Schedule B attached hereto and made part hereof sets forth fully and in detail all personal property
wheresover situated owned. by the decedent at the time of death; all moneys left by the decedent at the time of
death, whether in decedent's immediate possession, standing to decedent's credit in banks of deposit, savings
banks, trust companies, or other institutions, whether individually, or in trust for any other person or persons
giving also separately the accrued interest thereon, if any, down to the last interest day prieur,to decedent's
death in the cas':e of savi~gs banks, and to the date of decedent's death in all other cases;~~'ll bonds, postal
savings, treasury certificates or notes and other evidence of indebtedness of the United St.ate,s}o the de-
cedent; 'all obligations, w,hether by statute or a'greement they are designated as tax free, of the United.States';:.
. ~ _..
or any state, or political subdivision thereof, or of any foreign country, which are owned at.the time of>d'eafli;:
aU "vearing apparel, jewelry, silverware~ pi~tyr~s, books, works of art, household furniture, horses,vcarr'ia~esJ
_ I' - r ~ ~.~
automobiles, boats, and any '--and all other-personal chattels of whatsoever, kind or nature, left by decedentj.
togethe~\.w,i!...h tpe fairly;.e~ti"!ated J;!}ark.et v~lue thereof; all bonds and mortgages held bY;d:c.ede~t2~d'o.f~!1l
claims due and owing decedent at the time of death, and all promissory notes or other"ins'truments in Writing
for the payment of money of which decedent died possessed, of whatsoever nature, with int~'re'st~t~e;eon, if
any, giving the face value and estimated fair market value thereof, and if such estimated fair.market value be
less than the face value, it sets forth briefly the r'easons for such depreciatio~. as to each item; all moneys
payable to the estate from life insurance policies carried by decedent; all annuity and end~wment "contracts
the proceeds of which wee payable upon the death of the decedent; all and the corporate stocks and- dividends
due thereon and unpaid as of the date of death, bonds and accrued interest thereon to the date of decedent's
death and other investment seCl1' ides owned by the decedent at the time of death, with the-market value there-
of at such time.
tj0
,;(/-1Y~/3
.JJ~ /t- /0'/--.3
~
h/':-
.... Ii _ .
.
In the case of securities of close or family corporations, the values reported are as far as
possible substantiated by financial statements of the corporations, showing the assets and liabilities
thereof as of the date of death. The schedule also sets forth the interest of decedent at the time of
death in any co-partnership or business, and in support of the value of such interest there is annexed to
said schedule, financial statements showing the assets and liabilities of said co-partnership or ~usiness.
A copy of the co-partnership agreement, (if oral, a statement setting forth the nature of the agreement)
together with a statement setting forth the character of the business, its location, and such other facts
pertaining to the business 8S may be pertinent to a fair and just appraisal of the decedent's interest
therein must be submitted. It should also set forth in itemized form, together with the fair market value
thereof, any other property owned or bequeathed by the decedent at the time of death.
The Sc~edule C attached hereto and made part hereof sets forth a true answer to each inquiry
contained therein and in the case of transfers of property, real or personal, within two years of decedent's
death, in contemplation of decedent's death, or intended to take effect in possession or enjoyment at or
after death, said schedule sets forth the nature and value of such property, to whom transferred, the
relationship of the transferees to the decedent, the proportionate share received by each transferee and
all other facts of a pertinent nature regarding said transfers. In the case of transfers intended to
take effect in possession or enjoyment at or after death, there is also attached to the schedule a co~y
, .
of the deed, trust agreement or other instrument creating the trust. Ther~ is also set forth in said
schedule a list of all property, real and personal, with its value, which pa~ses at decedent's death by
virtue of the exepci.se 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 instrument of' another,
with a copy of the instrument creating such. power attached to the schedule.
That SChedule 0 attached hereto and made part hereof sets forth the names and addresses of all
persons beneficially 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 time of
decedent's death of" all minors, annuitants and beneficiaries for life under rlecedent's Will. It also
contains a statement showing which of the beneficiaries named in the decedent's will, if any, died prior
to decedent, the dates of their death, their issue, and the relationship of such issue to the beneficiary.
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 the name
of the decedent and others, plus the date and place of record of instruments ef~ecting the vestiture of
real estate and the date of acquisition of personalty, plus the name, address and relationship, if any,
of co-owners to the deceden t.
That Schedule F attached hereto and made a part hereof' sets forth fully and in detail all debts
and deductions claimed f"or and on behalf of this decedent's estate, including funeral expenses paid;
family exemption, where applicable; costs of administration of this estate; counsel fees and fUdiciary's
commissions paid or to be paid; cost expended for burial trusts, tombstones or gravemarkers, and reli-
gious services, in consequence of' the death of the decedent; debts and claims owing and lmpaid at time of
death; taxes accrued chargeable for period prior to decedent's death (except those allowed under Section
6~1 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 upon 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 tax assessed can be reassessed in accordance therewith.
That the totals of the appropriate columns in Schedules "A", "B", We", "E", and "F" as directed therein,
have been carried forward and properly registered in the Summary.
Subscribed and sworn to before me this ..........."......"......".." ~" ,
lId! ..,,y _--Gi~i:'k7/ii(tiJJ))MJ)4.....
. "".""".... ....."....... . day of ' .........."........ 19...1.......... .."".....................".....".............."...".....""....."..................".."...................--....-...
....~4. .'.m' ..4 ~, .~,'r;. [!OiARVPUBlic surR :vhi.~f~~e%~~~!~.~.~..~~......:~~.
-J ;.:.:~L>:'; ~'l.:~(;')CH J-g t 0.1 Survi vorsl11.p
"c"" Cl!uc.rv l:LL.Eas.t....Lo.cus.t....s.t............ .........................
NOTE: Be fore sign ing aff~~~:i~ :a~~ L:~:~ U:~l ;~l~~~ spaces I1~ 1~~~~A'~Ntft: ~Ui!J~iJ,~.?~d are
filled in with details or the word "None", and in case the assets include rare and unlisted securities,
securities of close or family corporations or an interest in any co-partnership or business, that the
data and statements required under the paragraph above relating to Schedule "B" are attached. Also make
certain that column #1 in the "Summary" has been properly completed as above-directed.
SCHEDULE "A"
REAL PROPERTY
*
. ~,.jIo - --... ..... .
RC C.j4 14.; ~I)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT.OF REVENUE
BUREAU OF COUNTY COLLECTIONS
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
"
.'
,
Real property in Pennsylvania, with statement of mortgage encumbrances upon each parcel at death of dece-
dent. Property held by the decedent as tenant jn common with another or other, 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 surviarship or tenancy by entireties should be reported on Schedule "E.")
The roed property located In the Commonwealth of Pennsylvania should be
described by lot and blade number, street and street number, together with
o general description of the property, with a reference to the record of the
conveyance by which the decedent took title; If a farm state number of Q.
eres; olso statement of mortgage encunibrances upon each parcel at death
of decedent. Toxes, assessments, accrued Interest on mortgages, ete.,ore
to be listed on Schedule IlF" and must not be d~ducted from this schedule.
(1)
(2)
(3\
DEPARTMENT
VAlUA TION
CAUTION
(Do no' writ.
In this space)
ASSESSED VALUE
FOR YEAR OF
DECEDENT'S
DEATH
ESTIMA TED
MARKET VALUE
None
None
None
7U11.L/
,.
, -
[.
.,
,.
'.
--+-
,
/
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.
None
!l4Ya
L
Insert this total
the "As Reported"
.
opposite "Personal P~operty", Schedule "B" in
column on the last page o~ this return.
X X
None
'fI-fYU
.
--r
RESIDENT DECEDENT
SCHEDULE "B"
PERSONAL PROPERTY
'*
VOMMONWK\L'l'H OF PENNSYLVANIA
TRANSFER IKHERITANCE TAX
INSTRUCTIO~S: This Schedule must disclose all tangible and intangible personal property owned individually
by the dec~dent, at the time of his death. Property owned by the decedent jointly with another or others
must be li~ted under Schedule "E". Intangible personal property, titled in the name of 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 fact that they are not of the administered estate.
Tangible personal property should be listed first (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 tr.e estate or fiduciary in said capacity, partnership interests, interest in anyundistributed
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, should be listed in this schedule.
Item ITEM UNIT ESTIMATED DEPARTMENT VALUATION
No. List and describe fully VALUE MARKET VALUE (Do not write in
this space)
NO} e - See Schedule "Ett herein. None /2 {'Y!~
.
Insert this total opposite "Personal Property", Schedule "B" in X X None r VY>J.
the "As RelJorted" column on the last page of this return.
~ ....,. - .
RCC-36
COMMONWEALTH OF PENNSYLVANIA
TRANSr~R INHERITANCE TAX
SCHEDULE "C"
TRANSFEItS
.
RESIDENT DECEDENT
(1) Did decedent, within two years of death, make any transfer of any material part of 'hiS estate, without
receiving a valuable and adequate consideration therefor? (Answer yes or no) Yes
(2) Did decedent, within two years of death, transfer property from himself tOihimself 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 affirm~tive state:
(a) Age of decedent at time of transfer 9~ .
(b) State of decedent's health at time of making the transfer. (Note 1). - Poor-
(c) Cause of decedent's death. (Note 1). Irreversable Congestive Heart Failure.
(4) Did decedent, in his lifetime, make any transfer of property without receiving a valuable or adequate
consideration therefor which was to take effect in possession or enjoyment at or after his death?
(Answer yes or no)~
(a) Was there any pOSSibility that the property transferred might return to transferer or his
estate or be subject to his power of disposition? (Answer yes or no) No
(b) What was the transferee's age at time of decedent's death? None
(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 fact end before his death:
(a) The posseSSion or enjoyment of or the right to income from th~ property transferred?
(Answer yes or no) No
(b) The right to designate the persons who shall possess or enjoy the property transferred or
income therefrom? (Answer yes or no) No .
(6) If the answer to (5) (b) above is in the affirmative, state whether the right was reserved in decedent
alone or others None
(7) Did decedent in his lifetime make a transfer, the consideration for which was transferee's promise 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 reserved power to al tel', amend, or revoke, or which cOHld revert to decedent Wlder 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) 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 forth 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, if 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 &
ITEM
DESCRIPTION
MARKET VALUE
(Es Uma ted)
DEPT. VALUATION
(Dept. Only)
PLEASE NOTE, NO CREDIT AND(OR CREDIT OR
DEDUCTION IS CLAIMED FOR THE TRANSFER,
THE TRANSFER IS BEING REPORTED AT FULL
VALUE.
ALL THAT CERTAIN House and Lot of Ground
the North side o~East Locust Street in
Ward of the Borough of Mechanicsburg,
County of Cumberland and State of pennsyl
vania, bounded and described as follows:
BEGINNING at a point on the building line of East
Locust Street; thence North along the linE of Lot
formerly of Niles Stambaugh, now or forme,ly of
Samuel J. Zimmerman, 136 feet, more or le s, to
Stauffer alley; thence East alohg said al ey, 24 feet
to line of Lot formerly of George GuswileJ , now or
formerly of Ida Lambert; thence along the line of
said Lot now or formerly of Ida Lambert, South,
136 feet, more or. less, to a point on the building
line of said East Locust Street} thence a ong said
building line, West 24 feet to the place f
BEGINNING. HAVING thereon erected a framE dwelling
House numbered 111 East Locust Street, Mechanicsburg,
Pennsylvania.
BEING the sam~ premises which Katharine Glissinger
Stone's Executrices, by their Deed dated ~ovember 15,
1950 and recorded in the Cumberland CountJ Recorder's
Office in Deed Book "N", Volume 14, Page 599,
granted and conveyed unto Bessie M. Barnes and Cleo
S. Simons, as Joint Tenants with the Right of
Survivorship; and
situate on
the Second
Insert this total opposite "Transfers", Schedule "en in the
"As Reported" colunm on the last page of this return.
9 MrtJ . (J1)
)'
PAGE -l~
" ~.l' -
RCC-36
COMMONWEALTH OF. PENNSYLVANIA
TRANSFER INHERITANCE TAX
SCHEDULE "c"
TRANSFERS
PAGE 2
*~
of SCHEDULE "C"
RESIDENT DECEDENT
Did decedent, within two years of death, make any transfer of any material part of his estate,
ceiving a valuable and adequate consideration therefor? (Answer yes or no)
(2) Di ecedent, within two years of death, transfer property from himself
others including a spouse) in joint ownership? (Answer yes or no)
(3) If the wer to (1) or (2) above is in the affirmative state:
(a) e of decedent at time of transfer
(b) Sta of decedent's health at time of making the transfer. (Note
(c) Cause f decedent's death. (Note 1).
(4) Did decedent, in hi lifetime, make any transfer of property without receiv a valuable or adequate
consideration therefor hich was to take effect in possession or enjoyme at or after his death?
(Answer yes or no)_____
(a) Was there any po ibility that the property transferre ight return to transferer or his
estate or be subje swer yes or no)
(b) What was the transfer's age at time of decedent' eath?
(5) Did decedent in his lifetime make a transfer without rec ing a valuable and adequate_ consideration
therefor under which ~ransferor expres erves for his life or any period which does
not in fact end before his death:
(a) The possession or enjoyment income from the property transferred?
(Answer yes or no)
(b) The right to designate the perso shall possess or enjoy the property transferred or
income therefrom? (Answer yes r no)
(6) If the answer to (5) (b) above 1s in th affirmative, s te whether th~ right was reserved in decedent
alone or others
(7) Did decedent in his lifetime mak a transfer, the considera on for which was transferee's promise to
pay income to or for the bene of care of transferor? (Ans yes or no)
(8) Did decedent, at any time, ansfer property, the bene~icial enj ent of which was subject to change,
because of a reserved po r to alter, amend, or revoke, or which co d revert to decedent under terms
of transfer or by ope tion of law? (Answer yes or no)
(9) If the answer to above is in the affirmative, was the power to alter, the inter-
est of the bene ciary reserved in the decedent alone or the decedent and
(Answer yes no)
NOTE 1: The swers to these questions should be supported by affidavit by the a as
well as a y of the death certificate.
NOTE 2: f anSwer to any of the above questions is yes, set forth below a description
tran erred, it's fair market value at date of death, dates of transfers and to whom tran erred, with
r tionship of transferees to decedent, if any. Submit copy of any trust deed or instrument,
ers are claimed to be non-taxable, also submit detailed statement of facts on which said claim
OTE 3: List applicable property below in manner in which provided in Schedules A, B, or E.
ITEM
DESCRIPTION
MARKET VALUE
(Es time ted)
DEPT. VALUATION
(Dept. Only)
PAGE - 2
BEING the same premises which Bessie M. B rnes, Widow
(the within decedent), by her Deed dated June 25,
1977 and recorded in Deed Book "G",Volume 27, Page
467 in the ClUTIberland County Recorder's Olfice,
granted and conveyed her undivided one~ha]f' interest
to Cleo S. Simons, her son and owner of tee remaining
undivided one-half interest.
ASSESSED for local tax purposes f'or the ~
year 1977 att'~3350.00 . 1"./
Current Market Value is place at $18,000.(0.
Decedent's interest being an undivided
one-half interest only, it is reported
here at one-half estimated market value,
to wit, $9,000.00 which is the full value
which was tr~nsf'erred, the transf'eree or
grantee had already owned the remaining
one-half' interest since November 15, 1950.
./
9000.00,/
9 tn7J. 6>)
)
33,fa
~
13 tt~ 0
")
Insert this total opposite "Transfers", Schedule "C" in the
"As Reported" colunm on the last page of this return.
$9,000.00
PAGE -2~
'-
~ .
RCC-37 (12-63)
COMMONWEALTH OF PENNSYYLANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "0"
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. conti'ft'ge-o"t .br", other are involved, set, STATE YES ,IN, ESTATE
. wise. in est:ate')...... l.. i - ~ ,.1._ forth this fact.)I OR NO ,BIRTH , . "
~ ,
el1"" Samuel Simons aka Son Yes Entire Estate
m"o S. , , r -
Simons ~.~ <0" . -- ~ ..-
111 East Locus t Street - "
M""hanicsburQ', Penna. 170~~
,
}
,.
.. ()
"
"
,
c'
Deponent further says that all the above-named beneficiaries are living at this time except below:
.
NAME DATE OF DEATH RESIDENCE
.. ...,
.s: Ill....
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=t)t:
u.. " 51
S-
~ &!
SUMMARY
.....(Sch. "A")
......(Sch. "B")
......(SCh. "C")
Real Property
Personal Property
Transfers
JointlYOl!!P!ld :P~9pt)~tY JScl:l.~ ..liEn).....
Gross Taxable Estate .
(1 )
(As Reported)
0.00
0.00
....9.000.00
J,.~.170.$0. .
$ .
$..
$..
$ ..
$..
$ ...21.170.5Q
(2)
(As Determined)
$
$.
$
$
$
$
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I' , Statement lor Recipient. of <1lo\9l'Al "'~ I
I C0:..7',IO:';":."':: ~_iH : IAT'C;~;",- ;5{,iJf: Interest Incdme U(2J fI~
, 10 B j.:., i~~~ H SCJ\iAflE I
:1 HAr.~t~!SBi.:~t~~. PA. 17108 4-- Typ~ cr. print PAYER'S Fede identifying number, .
n.06 ~ 95 " ;'S .. name, address and ZIP co
II Rrr,UL~~ 7.3 :CCDUtH NO.
'I I 1 EDrn;nOJ from lovingi and 10...."
ouociotionl. crlldit unionl, etc.
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0005545
OIher int;'llst on bonlc deposih, etc.
(Do I\ot indude 1Mll. 1 (lmol.l:'lt\)
Copy B
For Ret:ipient
:3
Foreign 101{ paid (Applicoblll ~nl)' to
toXfll eligible for ''''oi,," tax mldit)
t
3T9.Cl9
,RECIPIENT'S idllntifyin9 numbor ~
0376005"2228
4
fOfeigl'l Cflllnlly or U.5. Pouenion
R~RN~S RESSIE MAY
111 E ..LOCIJST 5T
MECHANTCSBURG PA
Cl.EO S
00000
~tt;form shows two or morl! recipients, the recipient whose Federal identifyirtg
number is shawl') sn{)\J\d file Form{s) 1087-INT with the Infernol Revenue Servi,,~ for
eoch of the other recipients and provide them with copies. However, a husband or
wife is not required fo file a Form IOe7-INT to show payments for t!-.e ~t\-:er.
I This information is being furnished to Ihe Internol Revenue Service and appropriate
State officials. I
! Tyee 0' e,;" RECIPIENT'S ,om., add,." o,d ZIP tade 000,.. , An "X" i. Ih, UPP" I,ft ,om" inditat.. this i. 0 to".,led lo,m. j
l_,~",~9-INT ___ .~_._,_ _,__.__.__'___ _ ~mentG~Trel$ury-lnt~ ~e~i~ _._ J
-SUBSTI.TUTE FORM I099-DIV U.S. TREASURY DEPA,OTMENT
INTERNAL REVE~,UE SERVICE
DETACH AND RETAIN THIS COPY FOR YOUR INCOM.E: TAX RECORDS
AN O~IG1NAL FOF;lM 1099 HAS BEEN FURNISHED TO INTERNAL.. REVENUE SERVICE
1
I
TO WHOM PAID
MRS.8ESSIE MAY BARNES AND
CLEO SAMUEL SIMONS
111 EAST LOCUST
MECHANICSBURG,PENNSYlVANIA
11055 '
BY WHOM PAID
THE TOLEDO EDISON COMPANY
EDISON PLAZA
300 MADISON A VENUE
TOUDO, OHIO 43652
34-4375005
"
~
~
294.00
. .TA"-P......EFO '/'
. .11D,:,:,T'I"IC"'l"I~'" NO.
,
376-05/2228
5HAREOWNE'R '5
COpy
~DIV'DI!:NDS P.o\ID
;_,::;,'\I...'I","J$ ....lI!:~ft_,.,.
DIV.DIU.a O.$BVR5.NG- ..GE"'T
197
..
969
'FOR COMMON STOCK
THE TOLEDO TRUST COMPANY
~@u lm~(55@u~&~lL~
To"LEDO, OHIO
~O-941-579
[
FORM 1099 Detcch and retain for your records.
U :AXPA~R :ENT. ~o~ F 0, c~~~~O N
1<:174
RETURN
40 94~ 579
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G. M. ACCOUNT NO.
376-05-2228
042-992-0002
OIl/mENDS PAID
~r
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...
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C
BESSIE MAY BARNES t CLEO
SIMONS AS JOINT TENANTS
III E LOCUST
MEeHAN I C S BURG PA
SM1UEL
COMMON
$428.40
E
17055
l
[
"
,.
NOT NE'GOTIABLE
GENERAY, MOTORS CORPORATION
Ne\", York, N. Y. 10022
38 -0572515
[ TO ~~:OMPAID
BY WHOM PAID
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(2, M... ,() .... ~(iJ. , .. 'D' .., ..L_1t- 1:3 Jr77
k~' >, ~J~.,. () D~ j",:'>':::--- ~-.r-O~I \, Page 2
.
SAFE DEPOSIT OOX INVENTORY
"",
i Instructions: (1) CASH: Report total only. (2) STOCK: List in detail every cOllllllOn or
. preferred certificate, '.rarrant or other rights found in box. Stocks are to
. be designated by name of company, certificate number, date of certificate,
name in which stock is registered, number of shares and class of stock.
(3) OBLIGATIONS of U.S. GOVERNMENT: Number of pieces, dates of issue, face
value,names in which registered. (4). BONDS:. Designate by name, amount,
aerial number, or otherwise. (5) SAVlNGS BANK or PASS BOOKS: State name
of depositor, number of book, last date appearing in book, name of bank and
branch, and balance. (6) JEWELRY, COlNS, STAMPS, MANUSCRIPTS, ETC.: List
and describe as fully as possible. (7) List Deeds, Mortgages, Current
Insurance Policies or other evidences of indebtedness. (8) All other contents.
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?tA E I3t1A1Jg IN I/.~ AlA-NC't!){/:2J?O .3I+MuEL 3n1M$ p. () fJ f;{'S'; )( t f3ItRAtE$
"
ESTAElUSHED 11359
DAVID B. COOVER
PRE51DENT
TI-IE,Q"~
V BANK AND ThUST CO.
MECHANICSBURG, PENNSYLVANIA 17055
November 23, 1977
J. Robert Stauffer, Esquire
Market Square Building
Mechanicsburg, PA 17055
Re: Estate of Bessie May Barnes
Date of Death: September 13, 1977
Dear Mr. Stauffer:
We
information
DBC:C
1.
have searched our records and found the following
concerning the above named decedent:
./'
Checking account #110-179-9 opened jointly with
Cleo Samuel Simons on Decembe~~1957.
Date of death balance - $755.~.~
Regular savings account #500-144-1 opened
jointly with Cleo Samuel Simons prior to 1960.
Date of death balance - $272.62.~
Accrued interest on date of death - $2.04.~
Other savings passbook accounts - None
Safe deposit box #657 opened jointly with
Cleo S. Simons on June 30, 1948.
Capital stock - None
Time Certificates - None.
2.
3.
4.
5.
6.
Very truly yours,
4~u~,~~
David B. Coover
President
~'c>
.,
. ~~~
"
Co I h i~
mmonwea t /,1 ~
N . I B k ,""7 'Y"A
ationa an Jf;'<~r><~
,.~J'~
November 22, 1977
J~ Robert Stauffer
}~rket Square Building
Mechanicsburg, PA. 17055
Re: Estate of: Bessie' May Barnes
Dear Mr. Stauffer:
, ,In reply to your letter dated'Nove~4, 1977 on the above estate,
the regular ~~gs account #14-0005545-~ balance as of September '13,
is $9,158.5~ accrued interest is $65.B6. This account is jointly held
with Bessie May Barnes and Cleo S. Simons.
1977
If you have any questions, please feel free to contact us.
Very tLu1y yours,
/%<~'<'4(/-~
" "--~
Robert Ta1a1ai
Assistant Vice President
and Credit Officer
RT/cg
'~
,-
,
The Commonwealth National Bank, 10 South Market Square, Harrisburg, Pa. i7108 (7171564-9500
'-- .
. -.. -.
COMMONWEALTH OF "PENNS'YL VA'Ni(:"q ~. "
.. DEPARr.II.~NT.OF;,RI2YENUE,!~;),'h~\Jf::/;:,:,; ",f';>;;:~..."" .. ".
,. i,BUREAUO.FCOUtlnC9LLgT!ONS,',~'REdEJVEO .' ,\",).t~.,"',<"';";".
. '. ,. :"';.;i:~;;{,'" .'";:;!~~tf{~;',:'i:!~~~1~t;rt~~:~,:',.,,::':~c~~;~~1~'~~~EONlbN~}{j';~:'?~;:>;
'.". "'. ...............".''''~.''......d.''.N 23 A.' DH '77 ,,".
.: -.' . ..:;.:.~~~~A~}S,.q~.':(~.;::~~:.~.r:~-:~;:,;:\l:,'::::-~':'-::':1~t)f)i~;t~:: QV .-' - - '.":~:. ;f{_~ ',I . - :: _. '"'. ,\ .~-~.;.;
NOTE: TO BE SUBMITTED IN TRIPLICATE
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REPORTING FINANCIAL INSTITUTlOW
ADDRESS ',> '0;." ,.
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CommonwP::Jl rh N::Jt'inni\1 'R.1:lInk\' ';' ,:'
"10 South Market. Square ":"t' .' ..
..
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Harrisburg, PA.
. ~;. .
zip CODE
171011
. . , . '. .' .
Pursuant to S~etion 742; Pe~nsylvonio I~herltanceand Estate TaltAct 0*'1961, w.
h~r~with submit th~ following r~port: .
i,':
", . .
.~ ". -
I~~~~~:~:~~~~~~I;.T; TR~STII~:-~6~~545_3;,':(:1;,i::ir\'~;:.' ."
",: NAMES ON' A CCO UN TO'R." .,:,i:;;:":;',..<(-;:~!;;i;t~*';f~!:;~it:.{e,~;,1!:;t:~'" "
~ INVESTMENT BesSie May"'Barnes & CleoS:,;SimOtis...." ",,-... ","',
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DATE OF DEATH.
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..... ','"9:"13-77 '.'
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,. DECEASED JOINTDEPC1~I:Crt. TRU~JEE. .
". OR IN,VESTOR ~~._Bessie May Barnes' .'
".: . ~
,"<y". ,'..
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ADDRESS III E.' Lo"uilt
Mechanicsburg,
"~I"~ '",'
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Str,:pr :,
PA.
C1..1ID:hp.rland"
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. SURVIVING DEPOSITOR.
:_r.
BENEFICIARY OR INVESTOR
...<..t:- .
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ADDRESS
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"';';'-'RElATIONSHIP .TO DECEDENI,
Unknown
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DATE INVESTMENT WAS ESTABLISHED'
'WITH THE SURVIViNGC'EPOSITti'R....
BENEFICIARY OR INVEH0R.__c:':.
:-;
3-7-42 .
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BALANCE, INCLUOIHG INTEREST
PAYABLE, AT DATE OF DEATH S
T......gr~t't -
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
RECEIVED
BUREAU OF
COUNTY COLLECTIONS
JAN 23 II 42 ~H '18
',,'.
" ,~"
.,
RCC-43(5-7b) .,
'., ..
NOTE: TO BE SUBMITTED IN TRIPLICATE
REPORTING FINANCIAL INSTITUTION
ADDRESS
mb."" ii'~'l'.,t nQ,'1tt & 'tYtist CSl1lplm1
J~!Wl. ~ Merltat fLj:-tU~ot~
liiOl.'lh$\1ea'ln1t'El. rt..
ZIP CODE '.1QS$
Jni'J.UUf l<)~ 1918
Pursuant to Sectian 742, Pennsylvania Inheritance and Estate Tax Act of 1961, we
herewith submit the following report:
ACCOUNT NO. OF JOINT, TRUST OR
INVESTMENT DEPOSIT
NAMES ON ACCOUNT OR
INVESTMENT
111'\..179""'" $OO-'~~...;t.
Bessie ~&a.. 0100 8arnu~1 S~
DATE OF DEATH
r;""'!"tl\''''~e:t 1.1. 1971
DECEASED JOINT DEPOSITOR, TRUSTEE
OR INVESTOR !l$eaie B~!l
ADDRESS 'I B 'f1l. r .oc"ttt ~b0(l't;
t$eeha\".1~$bttt'St 1'...
SURVIVING DEPOSITOR,
BENEFICIARY OR INVESTOR ,Clel!l ~a!lltli1.'l S1mens
COUNTY
ZIP CODE
C"mbet'len4
11O$S
ADDRESS!'!...""'" ~"'al>>ve
RELATIONSHIP TO DECEDENT
rrh~Q~
DATE INVESTMENT WAS ESTABLISHED
WITH THE SURVIVING DEPOSITOR,
BENEFICIARY OR INVESTOR 'R"If'",~ "'960 1'01' <lMoIcl!\guad ne.'\l'U\ga
BALANCE, INCLUDING INTEREST QhOGld.t\g...-$ 7S~.81
PAYABLE, AT DATE OF DEATH $ l'lntti"V ...... ,:l'?;( ~').,
///-. -.y /'
"~h~>-:~:';:;:/ /~. ..//J;.-,,_.-~<- -
SIGNATURE' ~
nnhA~~ C! rl\v3: ~TtQjp
TITLE
SQoretQi5'.w:I!l'OO,SlU>er
- 0 -. -
RCe-U (4-77' BANK NO.
COMMONWEALTH OF PENNSYLVANIA !500...11l4...1
DEPARTMENT OF REVENUE
NOTICE OF DECEDENT ACCOUNT STATUS DATE FILED 3123/78
Submi tin trupl icote within 10 days after knowledge ot STATUS'OF ACCOU~: NO: (JOINT. TRUST, OR INVESTMENT
the death. . <.'- -' .
.I~" A'""M~U U ,'~
.... '.C~f\
- , ~. .
RETURN COMPL ETED NAMES ON ACCOUNT SOCIAl. SECURITY NUMeER(SJ
-
FORMS TO LOCAL COUNTY 130lHlie .a";\1'l.lOi'J 3 76"G;;"'~;li:!8
INHERITANCE TAX OFFICE Clso 6flltuo1. 'Simordl
SURVIVING DEPOSITOR (Beneffclary) INFORMATION DECEOENTINFORMATION
NAME R EL.A T10NSHIP NAME DATE OF DEATH
Glao Sm;Hl&l . $ '.l1'lrJM TO DErJmN T. lless:i.s al9.m(iH'1 9/:t1>/77
u , ' .<llfl,'l.
ADDRESS ADDRESS .
111 E. tor.unt'Wc '.- . U1 'i'h Lf,\l.>\tS tl /} to.. . "' ..."",, . ~ ,,~
Moeha."l;l.c:::''bUl.''S~ 'PA 110.55
CITY C"l{;:NTb '
Me oht\1'\lO!lbuVl1h ... 1m" ~X'le...d
, ZIP C"DE 1 70S5
BANK/INSTITUTION ADDRESS BALANCE OF ACCOUNT AT DOD $
.
Tho .F i l'st; l'lilt:l!~ &. iJlt>uet. <leh INTEREST ACCRUED AND COLLECTIBLE AT 000 $
Jl!Mn & Ml'l.rttGt i:lts. TO_TAL _ $ ;,,,,, L'"
f,lachnn1o;;l!:rlti"g, .PA ),.,/05$ BANK AUTHORIZATION
I HEREBY CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS A
CORR"ECT REPRESENTATION OF INFORMATION IN OUR FIL.ES IN ACCORD
WITH SECTION 742 PI B:: E TAX ACT OF 1961.
SIG,N~/~ DATE
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..DlloP ps'pun~ ...~. psuxe .ou ..op ~.DDp to .IUH .~
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11"'1' uO'.D~'H"u oM '.uno~~D."''' ......""no .0 'OA,,,,n.
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to GlDp .~ '.o...d ps'DD~.p .'" to ."D. .~. I.IA,I t-"~
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..... 10 euo pUO 1_"0.10 "_"OUD .I0f flR.II U! luo....d .10 uO.I.d
D to .IUD. .~ ., '0 OJ'M p.D p.oq.n~ .D~ ""'0 n...... ..0tU
.0 0'" to ....D. .'" ., DI.OAIA....d ., PS.D~I .o,.n.,...,
ID!~.D.'t D., ps."A., .0 ps.,.odop ., ADuDIU UO'UA..
'AIIDnp'A'p., .UOps~p .'" Aq PI.~ ...no~~v (t
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....... os p.o
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...no~~v .1u'A"S .U!Or (L
'1961 :10 .l::lV xn 3.lnS:I OMV
:I::lKY.lIUHMI :IH.l :10 l:~l MOI.l::l:lS
:.0 p..,nbo.o "I'odo. V
- ..,
.
RCa-42.(40077) BANK NO.
COMMONWEALTH OF PENNSYLVANIA . '0 -,~. 9
DEPARTME NT OF REVENUE .J..~_. --.1 ...-
,
CATE FILED
NOTICE OF DECEDENT ACCOUNT STATUS 3/"-/"'''
'".> lu
Submitin truplicote within 10 days alter knawl ed ge ot STATUSOF ACCOUNT NO: (JOINT, TRUST, OR INVESTMENT
the death. J'Oj,nt ,,' " ,
E" '""" u.. e
BM'01~ 2.960 . ,
RETURN COMPL ETED NAMES ON ACCOUNT SOCIAL SECURITY NUMBER(S)
BGoCl:\.a t}'wnM j"'t .~"~ "'''''8
FORMS TO LOCAL COUNTY (....'..v;J~.e;..4i. f
INHERITANCE TAX OFFICE OleO S tun\;l.iJl So lmone
SURVIVING DEPOSITOR (Beneficiary) INFORMATION-. DECEDENT INFORMATiON
NAME RELATIONSHIP NAME DATE-OF DEATH
:1&0 SI1.'11usl i;l:Un,.na TO DECEDENT.
~iny,nGwn 2er.ts~" niliMil!lll Of'. 71/'1'1
ADDRESS - . ADDRESS
lU. .E.LQC\wt fst.. Ul.I&. loM\lSt St. ...""....,.,. ..
\techanicabm:>Sj F" l1(;l~~t
.. . ,
CITY Co~TY lan,
Mechnn1osburg. Uliibt.lli:(1. .. d
ZIP 'f~$;i
BANK/INSTlTUTI.ON ADDRESS. BALANCE OF ACCOUNT AT 000 $ . ~.\,;)
. ~ . INTEREST ACCRUED AND COLLECTIBLE AT 000 $
'rho First. n;~IIr. t:, 1':'twt . CQ. TO_T"AL $ 'It;t; .81
Main & M~rket'ets. BANK AUTHORIZATION
M$ehon1embt1~. !'ii 1 '70$'$ I HEREBY CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS A
CORR-ECT REPRESENTATION OF INFOR,MATION IN OUR FILES IN ACCORD
WITH SEC TION 742: PIS. E TAX ACT OF 1961.
SIG~~:Z 10m I
3/.#'1 72' I
I
..
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'(P'PPO 11.0qd"1I) ..'(OG:S),
..olloP ....pun~ "'~I .....x. IOU "'Op ~.OIp JO -II '~I
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8"')0 auo PUD 1.18""0 .10 ".'fIOUD .I0j Iln... U! suoNed 10 uO....d
D JO .UlDU .~ UI .0 'JlM pUD puoqln~ UD~ ..~O .UO.._ "0..
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RCC-3B
COMMONWEAL TH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE" En
JOINTLY OWNED PROPERTY
,-
PAGE - 1
INSTRUCTIONS: 'Ihis schedule must disclose all property, real and personal, owner! by the rlecedent jointly
wi th another or others, including tntangibles, standing in the name of' the decedent and others. List
real estate first., as entireties, or joint tenants, giving brief description, as indica.ted tmrler Schedule
flA", plus the oate and place of record of instnunent effecting vestitllre, but do not include entireties
or out of st:lte real estate value in estate valuation column. Personal property should be listed as 1n
Schedule "B", llh.1S date of acquisi.tion, and the name, address and relationship (if any) of co-owners to
the decedent.
(1
Description of' Property, Date of' Acquisltiqn, Name
Address and Relationship or Co-Owners, and Place
of Recorrl or Instrument, where Real Estate.
xV", ~ X> ~ % g& 6( Ol: XX :x
X ;0<: X:x xX ;oc X % Y\.
IV
..<:.. /
) '~ne Hundred Twenty-six (126) shares
of Common Stock of General Motors
Corporation, registered in the name
of Bessie May Barnes and Cleo
Samuel Simons, as Joint Tenants wit
the right of Survivorship, as
follows:
Certificate No. L33-668 dated June
21, 1957 for 84 shares; and
Certificate No. G29-70l dated
September 24, 1965 for 42 shares,
for total of 126 shares............
unit percentage
Value Share
<<xxx
%
<X XX:><
Estate
Valuation
;0.
OX
>0<)><>
~7,'n
1;8.2
/'
) 5at r3~)
(2) One Hundred Forty-seven (147) share
of Common Stock of The Toledo Ediso
Company, registered in the names of
Bessie May Barnes and Cleo Samuel
Simons as Joint Tenants with the
Right of Survivorship and not as
Tenants in Common. as follows:
Certificate No. TC24977 dated May
15, 1959 for 100 shares;
Certificate No. TC049145 dated
December 27. 1961 for 38 shares; an
Certificate No. TC035917 dated ~S.Of~ 71:.'~
March 1, 1963 for 9 shares, ~
a total of 14'7 shares........'-...... '25.7) 5at
(3) Checking Account No. 110-179-9 with
The First Bank and Trust Company of
Mechanicsburg, Pa., registered in the
names of Bessie May Barnes or Cleo
Samuel Simons and opened as a Joint A count
on December 1, 1957. Balanc~as of
Sept. 13, 1977 was $755.87~
) Savings Account No. 500-144-1 with
The First Bank and Trust Company of
Mechanicsburg, Pa., registered in the
names of .Bessie May Barnes or Cleo S!ilI ue1
Simons and opened as a Joint Account
prior to the year 1960. Bal~ce as oj
Sept. 13, 1977 was $272.62vr
Interest accrued on 9/13/77 was $2.0if
) Savings Account No. 14-0005545-3 wilh
The Commonwealth National Bank, regisiered
in the names of Bessie May Barnes and Cleo
S. Simons as Joint Tenants with the Right
of Survivorship. Opened as a Joint Ac count
on March 7, 1942. Balance .as of Sept 13.
1977 was $9.158.50./ &nz. 1,5.9'"
. .
,
5at
(4
5at
(5
5at
~.
Insert this total opposite "Jointly Owned Property", Schedule "E"
in the It As Revorted" _column on the last 'Page of this return.
SCHEDULE "E" - PAGE 1
DEPARTMENT VALUATION
CAUTION-Do not Write
In This Space.
Value of Value of'
Entire Decedent's
Property Interest
~ 5 b~" . H i eX 7t)~
)
/:' "-
18~ 3)-:;/Q.9/
377.94'/
l36'3b~
1.02.
/'
4579.25;
J~.'13
~~./tf. 1f ,
li9()(,'41
377 1~
\3~.3(
\~O~
'11519~{
3.;)_9~
"Z .. /~)
'.
RCC-3a
RESIDENT DECEDENT
SCHEDULE "E"
JOINTLY OWNED PROPERTY
COMMONWEAL TH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
PAGE - 2
INS-!RUC'flONS: This schedule must disclose all property, real and personal, owned by the decedent. jointly
with anot.her or others, including intangibles, standing in the name of the decedent and others. List
real estllte-first, as entireties, or joint tenant~" giving brief description, as indicated lmder Schedule
"A", plus the date anel place of record of instrument effecting vestiture, but cia not include entireties
or out of state real estate value in estate valuation column. Personal property should be listed as in
Schedule "B", l11us date of acquisition, and the name, address and relationship (11' any) of co-owners to
the decedent.
Description of Property, Date of Acquisition, Name
Address and Relationship of Co-Owners, and Place
of Recorel of Instrument, where Real Estate.
unit percentage
Value Share
Estate
Valuation
DEPARTllENT VALUATION
CAUTION-Do not Write
In This Space.
Value of Value of
Entire Decedent's
Property Interest
y
~ 0<
><X~
y ::x
;0<:
X;&
:x
)<)1:><
<>
f50<~
(6) Eight (8) $$0.00 denomination and'
Ten (10) $2$.00'denomination, Series
E, U. S. Savings Bonds, registered in
the names of'Bessie May Barnes or
Cleo Samuel Simons, all issued during
the years 1942 through the years 194$
inclusive, having a total value of
$1762.80 on Sept. 13. 1977. An
itemized list of the Bonds is
submitted herewith.
I
50:6
881.40 5 7 f7, 00
~1'1, 50
.
Insert this total opposite IIJointly Owned Property", Schedule .:!': ~.
in th~ "As Re'Ported" column on the last -page of this return. Q.?!.J.9.5~
SCHEDULE "E" - PAGE 2
~ : -.
"
RCC~81 (6-73)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
HARRISBURG
17127
IN YOUR REPLY PLEASE
REFER TO
Inheritance Tax Division
NOTICE OF FILING Dr APPRAISEMENT
Cleo samue~ Slmons
111 East Locust Street
Mechanicsburg, Fa. 17055
(Executor or Administrator)
In Re: Estate af
Bessie May Barnes
Cumberland
County - Fi Ie No. 21-78-0013
Dear Mr. Simons:
You are hereby notified that the original
appraisement in the estate of Bessie May Barnes
has been fi led in the office of the Register of Wi lis of Cumberland
County on March 16 , 19~, Said appraisement reflects the following
valuations:
Real Estate
Personal Property
Transfers
Jointly Owned
Total
None
None
$ 9,000.00
12,188.49
$21,188.49
As to such tox that is paid within three months from dote of death, a five (5%)
percent discount is allowable. As to any tax that remains unpaid after nine (9) months
(fifteen manths when death occurred from December 22, 1965 ta June 16, 1971, inclusive;
and twelve months when death occurred prior to December 22, 1965) from dote of death,
interest at the rote of six (6%) percent per annum is charged.
Any party in interest who is aggrieved by this notice may object thereto within
sixty days after receipt of said notice as provided by Section 1001 of the Inheritance and
Estate Tax Act of 1961, 72 P. S. 2485.1001, P. L. 373.
Date March 16, 1978 Signed ~ k. .}J.AA->~
Title Chief Appraiser
'-,
Note: This is not a bill.
R C C-2 (2-64) ~
....~... ..
,COMMONWEALTH OF PENNSYLVANIA
RESIDENT INHERITANCE TAx
APPRAISEMENT
DATE
March 'iJ.6. 1978
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
HAR RISBU RG, PENNA, 17127
COUNTY
Cumberland
FILE NO.
21-78-0013
Whereas, Bessie May Barnes late of Mechanicsburg
in the County of Cumberland Commonwealth of Pennsylvania, having died on
the 13th day of September 19--2Z., seized and possessed of an estate
subject to Inheritance Tax under the laws of the Commonwealth of Pennsylvania;
Therefore, I, Ira K, Gleim . 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 foIlowing 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.
UI1It Apprnisement
Ducrlptlon or AlSet Valulll Made ror Inheritance
Tax Purpoles
REAL ESTATE NONE $ NONF
PERSONAL PROPERTY NONE NONRI
TRANSFERS $9,000.00 Ql10n Illl
JOINT-HELD PROPERTY 12,188.49 12 188 4q
TOTAL ESTATE $21,188.49 ~21 ,18R 4Q
~~ . -
.
'.
.
.
. ,
.,
.,
-- ,
, , i_.' ,
" , . - ,
- .
.";'.'.
.
, - ,
,
-
Having been duly sworn accordin~ to law, I do hereby certify that the above appraisement is made in con.
formity with law on this 1 th day of March., _ /7. 19~.
, ,,:'k--cA _ Ir. ./'if....et2-<--o.--:.....
AppralBef
(""'I\'; "'4 ~..t)
rrl.S urg Penna.
(Pc.t OtI!et) ,
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