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Home My WebLink About01-0747 PETITION FOR PROBATE and GRANT OF LETTERS Estate of lIDIle L. fusoev No. also known as AIJI.J& LAu JV!41J &155;'1 To: AL.50 k/-JtJ/v A ~ A JJ,UC '- ' (J IMS~ (/ lI);vl Register of Wills for the DeceaselJf~ County of Ctunberland in the Social Security lVO. 193-36-4022 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of ag.c:. or older an. the1eZe;:;llt or in the last will of the above decedent, dated -.November 1, ~ Ib and codicil(s) dated 21-01-747 named ,19_ (state relevant circnmstances. e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Ctunber land County, Pennsylvania, with h er last family or principal residence at 1000 W. South Street t Carlisle, PA ,(j(}~OlLtH uP t!,I;Co,"", 1.s(",~.,t?A ~ ( ist stree~ umb;; and muncipality) Decendent, then 84 vears of age, died July 11, at Sarah Todd Memorial Home, Carlisle. PA 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: /JO ihJJ ptto'- Decendent at death owned property with estimated values as follows: (If domiciled in POl.) 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: ,~ 2001 37,000.00 NONE $ $ $ $ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters Testamentary (testamentary; administration c.La.; administration d.b.n.c.t.a.) theron. '" 1:i ~ ~ ]3 u '- =c: ~j !p ',,- ~~ ~ ;0 ;n Manufacturers and Traders Trust company, Successor to Farmers Tnl~ t COIT\Pany ~t;j,~ OATH OF PERSONAL REPRESENTATIVE COM~IONWEALTH OF PE~NSYLVANIA I ss COC~TY OF Ctunberland f The petirionens) above. named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the be5t of :he knowledge and belief of petitioner(s) and that as personal represen- tativets) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or a i,firmed and subscribed { before me this 6th... day of ~ AUGUST . P9'2001 . - - ;~~:-'J~,j/b) ~'f~ Regl er / ~ -r::;~9 - 19' COOlpany dQ' ::: l::l - ;: ~ ~ No. 21-01-747 Estate of Anne L. Bussey , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW AUGUST 13 ~J 2001, 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 November 1, 1976 described therein be admitted to probate and ftled of record as the last will of Anne L. Bussey and Letters Testamentary are hereby granted to Manufacturers and Traders Trust Company, Successor to Farmers Trust Company 7/J/~.u.- .,fm'"'''(.t1J'' ) I:)(,,~y ster of Ills FEES Probate}. Letters, Etc. ......... x-pag~s . Short Ceruficates( ) . . . . . . . . . . . Renunciation ................ JCP $ $ $ $ 5.00 TOTAL _ $ 93.00 ... .~V~.'. .l?~. .2.q9~................. 70.00 3.00 15.QQ ATTORNEY (Sup. Ct. 1.D. No.) ADDRESS Filed PHONE ~/~ ~.ytJ-'"$/6~ ,ff l05.RO" R.fS "/8(. This is to certify that the information here given is correctly copied 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. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 p 7578124 No. 21-01-747 me as '5:i:- ~. ~~&.~ Local Registrar .1111 2 6 2001 Date H1OS.14,'JR.".2117 COMMONWEALTH OF PENNSVLVANIA 0 DEPARTMENT OF HEALTH 0 VITAL RECORDS CERTIFICATE OF DEATH RlIll lENT INK NAME Of' DECEDENT If".. "'_. L_, 1. Anne L. Bussey AGE (l..1liI9ldIIyI UNDER 1 YEAR MonlIla Cava 8IRTHPI.ACf lC:.v and Slato ar Fallgn Clu1IryJ $T"" 'II.E NUMBEA SEX SOCIAL SECURITY /lUMBER ;.'emale 1. 193 - 36 PUCt: OF llEAI'H (CI1eCll HOSPITAl.; 1"1*"" 0 DlcI - ",In a ('l1m~rbnn __, lfd.~ :;..-::.-:::'" WOTHER'S NAME (FilII. _. Maoclon SuI_) It. Elizabeth Carter INfORMANTS w.tUNG AOORESS lSlrllll. Ci!v/Town. SbI... Z'1Il Codel 2lIb5Miller Rd. Darien, Conn. 06820 PlACE OF DISPOSITION - Name aI Camelo,.,. C......,Clty Loc.cI'ION - City/Towft. Slot.. rIP Code 0/1 0lMt_. 2 prktowne Cremation Servic ld. York, Pa NAMEAHOAOOAESSOFFACILlTY H ff n R t.h Fun 1 Home 22c219 N. Hanover sg. ~rIl.~re pa-I76 3 LICENse NUMBER D.<rE SIGNED t (UonI\. Day, lUll J,Jlu II zp>. 23b. RN-5J3998-L 230. '7 II ~( 1 / WAS CASE REFERRED TO MEDICAl. EXAMINERICOROHER1 v.. ~ NoD y". UNOER I OM Hours ! UinoII.. 5. 84 COUNTY OF De.CTH d\ .. Carlisle ....Sarah Todd Memorial Home IONO OF BUSINESSIINouSTRV Wl<S DECEDENT EYER IN DECEDENT'S EOUCRION U.S. ARI.IEO FORCESf Vea:f5l: No 0 DECEDENT'S USUAl ClCCUPRION ~...:::'c:.. "= ':::::t:r . llL Homemaker llb. Own DECEDENTS IoIAIl..o ADDRESS 1S1r... CiIyfboIn. SIalo. Z''ll Code! Home DECEDENT'S ACTUAl RESlOENCE CSee oMIl\ICllOllI on ""'. Iide\ 12. lfa. SIll. PA 1000 W. South St. 7013 17b. 2001 I :. d. WERE AU"IOPSY FINDINGS AWlAIIl.E PRIOR 10 COMPLeTION Of'CAUse Of' OEArH1 DUe 10 (OR AS A CONSEOUENCE Of): DUE 10 (OR AS A CONSEQUENCE Of): I.IANNE R OF DEATH DATE OF INJURY lMonll.Oay.'lIIar, g o o Hom;cicle o o o _ill -no Pandin9 'n..sttgallOn -~ NoD YeaO -. 2.11. CElnlFlER 1Ch.:lc ""..,. ene, .CERTIFVINC PHYSICIAN ,~c......,...., C6UM d deIlh """" anOOhOt _.an has poonounced ""alh ana complllacl "om 23) To'" be., of "'Y knaw'-dge. dea'" occurred due 10 Ih. CaVH(s) and mann.,.. ,.aled. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nol&J Suicide COUld noI be dll."'''ned 21. "PIlOIlOUNClN<l AND CERTIFYINO PHYSICIAN 'Physic;"" belh ;><onounc"'9 oeelh and Ce<1"yonglO cau.. 01 oea'nl To'he best 01 my Ic.ftOwt.dge. d...... occ"..,ect a. the lame. da.e, and piKe, anti du. 10 the cauM(a) and mannwr .. 8IaIN.. .UEDICAl. EXAIoIINER,CORONER On the b..f. 0' ..amtn.Uon and/or InvestlW.aHon. In my opinion, d.ath oca:urred.. the time, dare. and pllce, and due 10 the cau.e(a) and 11omonn.,.a slallld.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REGISTf\AA'S SIGN..rURE AND t\. ~~~~~ ___ 1~11?t\ICI ~O loIARfTAL STATUS. M_ N_IoIorrIecl._. ~1SPe<:1Iy) (1-4",$+, 4 14. Widow 17c.O ....-..Ilved... RACE . American IncUn. llIaU. WlIIl.. lie. (~l 10. White SURV1VING SPOUSE ,.......-..-- ...,.. C'.Arl i ~l p f~ 2001 21. Of ....11 failur.. I Apptoximal. :::..=: I I I PARllI: OIlIer liQniIIcanI~~ 10 _. buI 1IIll......1nO"'.... unda/lwVlo __ glvoA.. PART I. s TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED. _ 0 NoD ')-COI o u. DATE FILED (....onrh. Day. ""atlJ 34. .: _I. \ \,.~ 1& 3-001 ~-\ '. , - ------ E: ---- Register of Wills Cumberland County Court House One Courthouse Square Carlisle, P A 17013 CERTIFICATION OF NOTICE UNDER RULE 5.6 (a) Name of Decedent: Anne L. Bussey Date of Death: July 11,2001 Will No. 21-01-0747 Admin. No. 21-01-0747 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 September 13,2001. Name Manufacturers & Traders Trust Company As Guardian for Elizabeth Carter Bussey Address 1415 Ritner Highway, Carlisle, PA 17013 Donald S. Bussey, Jr. 5 Miller Road, Darien, CT 06820 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: September 19,2001 Signature /);;d f?"f:f { I David C. Gority, Vic President & Trust Officer Name: Address: Manufacturers and Traders Trust Company 1415 Ritner Highway Carlisle, P A 17013 Telephone: (717) 240-4505 Capacity: Personal Representative cc: Frances Del Duca, Esq. I '-.. --\ \\ LJ ~ . _ c . LAST WILL 21-01-747 I, ANNE LAUMAN BUSSEY, of Carlisle, Cumberland County, Pennsylvania, declare this to be my Last Will and revoke any wills previously made by me. I. I direct that all my just debts and funeral expenses be paid. II. I bequeath those items of my tangible personal prop- erty as are set forth in a separate unsigned memo which I shall place with my Will to the persons therein designated. III. I bequeath all remaining items of tangible personal property to my son Donald Sedgwick Bussey, Jr. and my daughter Elizabeth Carter Bussey, to be divided among them in as nearly ~"eqUal shares as possible. ~ IV. I devise and bequeath all of the residue of my estate ~ of whatever nature or wherever situated, to Farmers Trust Company { ~ i ~t<i ~' \ ",:.1 ~ J ,,\ ~ ~j, to be added to and thereafter treated as part of that certain inter vivos trust created by me on October 25 , 1976, in which Farmers Trust Company is Trustee, to have and to hold IN TRUST for the uses and purposes and subject to the terms and provisions thereof, including any alterations or amendments thereto, or any other inter vivos trust which may be hereafter substituted therefore. V. I direct that my Executor payout of my estate, as a general charge thereon, all costs of administration and estate and inheritance taxes that may be assessed by reason of my death, including interest on such taxes, if any, without deduction of any part of such payment from any bequest or devise made herein, except as my residuary estate may be reduced by reason thereof, and without obligation upon any person to reimburse my estate for any part of any sum so paid. VI. I appoint Farmers Trust Company to be executor of this my will. I direct that my executor shall not be required to file bond in this or any other jurisdiction. /;' .... .. . IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will this /fl9r day of November, 1976. ~.~ .~., (SEAL) / The preceding instrument, consisting of this one page and one other page, was on the date thereof signed, published and declared by Anne Lauman Bussey to be her Last Will, in the presence of us, who at her request, in her presence and in the presence of each other have subscribed our names as witnesses hereto. We, Anne Lauman Bussey, and , the testatrix and witnesses, respectively, whose names are signed to 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 knowledge the testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or 2 /J ? ..( ~ ~ L iA- , ~ ... ... /3'~f t:~~ Witn ss undue influence. Testatrix SUBSCRIBED, sworn to and acknowledged before me by Anne Lauman Bussey, the testatrix, and subscribed and sworn to before me by /) (~ :f ~.6.- and M?tnV;J e (!a't~ . wi tnesses I this day of November , 1976. JOY O. TRAY[R. NOTARY PUall~ ~ ' n ~ CARLISLE BORa, CUMBERLAND COUNTY / Iv t:tt --1M ./ MY COMMISSION EXPIRES DEC. 10. 1979 No ry bllc t' Member. PennsylvaniaAsscciation of Notaries I r r COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-01-747 ESTATE OF ANNE L. BUSSEY, DECEASED ---------------------------------- ---------------------------------- FIRST AND FINAL ACCOUNT OF Manufacturers and Traders Trust Co., Executor -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Date of Death: July 11, 2001 Date of Executor's Appointment: August 13, 2001 Date of First Advertisement of Letters: September 7, 2001 Accounting for the Period: September 13, 2001 to November 20, 2002 -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Purpose of Account: Manufacturers and Traders Trust Co., Executor, offers this account to acquaint interested parties with the transactions that have occurred during this administration. It is important that the account be carefully examined. Requests for additional information or questions or objections can be discussed with: David C. Gority, Trust Officer Manufacturers and Traders Trust Co. 1415 Ritner Hwy. Carlisle, PA 17013 717/240-4505 GROSS ESTATE (Principal Receipts + Income Receipts) 21,606.19 SUMMARY OF ACCOUNT Estate of Anne L. Bussey, Deceased For Period of 08/13/2001 through 11/20/2002 Page Proposed Distributions to Beneficiaries 11 PRINCIPAL Receipts: Per Inventory Filed This Account 1-2 Net Gain (or Loss) on Sales or Other Disposition Less Disbursements: Debts of Decedent 3 Funeral Expenses 3 Administration Expenses 3 Federal and State Taxes 4 Fees and Commissions 4-6 Family Exemption Balance before Distributions Distributions to Beneficiaries Principal Balance on Hand 6 For Information: Investments Made Changes in Investment Holdings INCOME Receipts: This Account 7-8 Net Gain (or Loss) on Sales or Other Disposition Less Disbursements 9 Balance Before Distribution Distributions to Beneficiaries Income Balance on Hand 10 Investments Made Changes in Investment Holdings COMBINED BALANCE ON HAND Current Value .- Fiduciary Acquisition Value 1,742.64 1,742.64 ------- ------ --------------- --------------- 2,410.36 3,271.86 938.59 26,250.00 25,585.74 0.00 60,199.19 0.00 60,199.19 58,456.55 1,742.64 0.00 1,742.64 746.05 0.00 746.05 31.73 714.32 0.00 714.32 2,456.96 SCHEDULE A RECEIPTS OF PRINCIPAL CASH: 08/29/01 Anne L. Bussey Guardianship Acct. - Principal cash per first and final account 08/29/01 Anne L. Bussey Guardianship Acct. - Income cash per first and final account 01/30/02 Anne L. Bussey Guardianship Acct. 02/05/02 Anne L. Bussey Guardianship Acct. 08/13/01 Donald S. Bussey Estate - Income earned to Anne Bussey's date of death 09/10/02 Internal Revenue Service - Income tax refund 10/02/01 Miscellaneous Receipt - Income to date of death from acct. 1,411180607 10/25/01 Miscellaneous Receipt - Proceeds from sale of personal items 05/10/02 Pennsylvania Department of Revenue - Refund of overpayment of inheritance tax 08/19/02 Pennsylvania Department of Revenue - Income tax refund 08/24/01 United States Treasury - Tax relief -1- 22,365.28 14,430.30 914.00 1.45 1,933.77 1,117.00 12,529.31 1,463.47 3,842.61 1,002.00 600.00 Fiduciary Acquisition Value 60,199.19 TOTAL RECEIPTS OF PRINCIPAL............... -2- 60,199.19 08/15/01 08/17/01 08/31/01 09/04/01 09/13/01 08/14/01 08/27/01 09/04/01 SCHEDULE C DISBURSEMENTS OF PRINCIPAL SCHEDULE C-1 DEBTS OF DECEDENT Pharmerica - Drug expense Pharmerica - Drug expense United Church of Christ Homes Nursing home expense 73.45 66.85 2,270.06 TOTAL DEBTS OF DECEDENT............................. SCHEDULE C-2 FUNERAL EXPENSES Hoffman-Roth Funeral Home, Inc. - Funeral expense Donald S. Bussey, Jr. - Reimbursement for funeral expenses 2,633.86 638.00 TOTAL FUNERAL EXPENSES.............................. SCHEDULE C-3 ADMINISTRATION EXPENSES Register of Wills ~ Petition to probate & short certificates Cumberland County Law Journal Advertising fee Dave Sheibley Trash Removal - Remove debris from Elizabeth Bussey Todd home apartment -3- 93.00 60.00 165.00 2,410.36 3,271.86 09/21/01 10/04/01 03/12/02 11/20/02 09/06/01 10/04/01 12/26/01 06/13/02 07/11/02 11/20/02 The Sentinel - Legal advertising 90.59 Cumberland County Law Journal Advertising fee 15-.00 Register of Wills - Fee to file inheritance tax return 15.00 Reserve - Miscellanous administrative expenses 500.00 TOTAL ADMINISTRATION EXPENSES....................... SCHEDULE C-4 FEDERAL AND STATE TAXES Pennsylvania Department of Revenue - Donald & Anne Bussey 3rd quarter taxes 375.00 Register of Wills - Estimated estate tax payment 25,000.00 Pennsylvania Department of Revenue - Donald & Anne Bussey 4th quarter taxes 375.00 Pennsylvania Department of Revenue - 2nd quarter income tax 500.00 TOTAL FEDERAL AND STATE TAXES....................... SCHEDULE C-5 FEES AND COMMISSIONS Mentzer & Company, PC - Tax preparation fee 285.00 Frances H. Delduca, Esq. - Attorney's fee - TO BE PAID 5,000.00 -4- 938.59 26,250.00 11/20/02 Manufacturers and Traders Trust Co. - Executor's fee - TO BE PAID 20,300.74 TOTAL FEES AND COMMISSIONS...................... .... TOTAL DISBURSEMENTS OF PRINCIPAL.................... -5- 25,585.74 58,456.55 # Units Description PRINCIPAL BALANCE ON HAND Vision Instit. Prime Money Market -6- Current Value or as Noted 1,742.64 Fiduciary Acquisition Value 1,742.64 1,742.64 1,742.64 SCHEDULE G RECEIPTS OF INCOME SCHEDULE G-2 INTEREST Vision Institutional Prime Money Market 09/04/01 10/02/01 10/02/01 11/01/01 11/01/01 12/03/01 12/03/01 01/02/02 01/02/02 02/01/02 02/01/02 03/01/02 03/01/02 04/01/02 04/01/02 05/01/02 05/01/02 06/03/02 06/03/02 07/01/02 07/01/02 08/01/02 08/01/02 09/03/02 09/03/02 10/01/02 10/01/02 11/01/02 11/01/02 9.70 86.31 0.02 52.63 0.29 0.30 38.65 33.56 0.31 0.33 30.63 26.85 0.56 0.62 28.. 74 0.60 27.26 0.62 31.39 31.17 0.60 0.62 31.02 0.62 30.72 0..63 30.81 0.92 31.99 TOTAL INTEREST INCOME..................... -7- 528.47 528.47 Anne L. Bussey Guardianship Acct. 01/30/02 SCHEDULE G-3 OTHER INCOME TOTAL OTHER INCOME........................ TOTAL RECEIPTS OF INCOME............. ..... -8- 217.58 217.58 746.05 11/15/02 SCHEDULE I DISBURSEMENTS OF INCOME Income Commission - Manufacturers & Traders Trust Co. - 10/16/01-11/15/02 31.73 TOTAL DISBURSEMENTS OF INCOME.................. 31.73 -9- 11 Units Description INCOME BALANCE ON HAND Vision Instit. Prime Money Market -10- Current Value or as Noted 714.32 Fiduciary Acquisition Value 714.32 714.32 714.32 PROPOSED DISTRIBUTIONS TO BENEFICIARIES II Units Current Value Fiduciary Acquisition or as Noted Value M&T Bank, Anne L. Bussey Trust Dtd 10/26/76 Vision Institutional Prime Money Market - Residue 1,742.64 1,742.64 1,742.64 1,742.64 1,742.64 1,742.64 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND David C. Garity, Vice President and Trust Officer, Manufacturers and Traders Trust Company being duly sworn, depose and says that the foregoing Account, both as to the items of char~ and discharge,are just and true to the best of his knowledge and belief. . , Seal , . ~at".. " Notary PublK. " CarlIsle Boro. Cumbertand COlIhiY i, My Commission Expires Juty 26, 2OQ.;:;. l Member, Peonsytvalwa.,.".soociationotNc8tee -11- ... IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-01-747 IN THE ESTATE OF ANNE L. BUSSEY, DECEASED SCHEDULE OF PROPOSED DISTRIBUTION Balance for distribution as per First and Final Account $ 2,456.96 Distribution Manufacturers and Traders Trust Company Successor to Farmers Trust Company Trustee of the Anne L. Bussey Trust dated 10/26n6 Principal Cash Income Cash Total for Distribution 1,742.64 714.32 $ 2,456.96 STATEMENT OF THE REASONS FOR THE PROPOSED DISTRIBUTION The above distribution is proposed in accordance with the terms of the Last Will and Testament of Anne L. Bussey. Da COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND David C. GOrity, being duly sworn according to law, deposes and says that he is Vice President and Trust Officer of Manufacturers and Traders Trust Company, the Account of the above named, and that the facts set forth in the Statement of the Reasons for the Proposed Distributio are true and correct. nt and Trust Officer Sworn to and Subscribed before me this /,,'7'1 day of December, 2002. {&1fre~a/ , Seal. 1 ,~atr '. , Notary PUblll.. _ Carlisle Bora, Cumberland countY . .~ My Commission Expires July 26, 2()G.;,- .\ Member, PennsytvaniaASsociation OfNol8l1eS -12- /6- d~9-/~ ~ BUREAU OF INDIVIDUAL TAXES ~ INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG. PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DAVID C GORITY M & T BANK PO BOX 220 CARLISLE '02- /';100 2tl D 1 :-; 1 1\ K ..-' t._ '_ DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04-22-2002 BUSSEY 07-11-2001 21 01-0747 CUMBERLAND 101 * REY-1547 EX iFP 101-02> ANNE L Allount Rellitted ~.;- :..:,; PJCWInl.3 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=isi;j-Ex-AFP--fcff:ozl--No'ficE--oF-i-NHEifiTAifcE-i"-AX-A-PPRA-isEMENT~--Ai:.i-oWAiicE-OR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BUSSEY ANNE L FILE NO. 21 01-0747 ACN 101 DATE 04-22-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED 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 (1) (2) (3) (4) (5) (6) (7) .00 485.898.41 .00 .00 40.792.82 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subiect to Tax (9) (10) 28,996.19 2.785.36 (11) (12) (13) (14) NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 526,691.23 31.781 55 494,909.68 .00 494,909.68 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. NOTE: I~ an assessment was issued previously, lines r~lect ~igures that include the total o~ ALL ASSESSMENT OF TAX: 15. Allount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: .00 X 00 = 494,909.68 X 045 = .00 X 12 = .00 X 15 = (19)= .00 22,270.94 .00 .00 22,270.94 r"A'"Cnl n.............. . (+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 10-11-2001 CDOO0375 1,113.55 25,000.00 TOTAL TAX CREDIT 26,113.55 BALANCE OF TAX DUE 3,842.61CR INTEREST AND PEN. .00 TOTAL DUE 3,842.61CR . 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 FORM FOR INSTRUCTIONS.) \, /6-0/-</9- /Y BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG I PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REV-1607 EX AFP (01-02) DAVID C GORITY M & T BANK PO BOX 220 CARLISLE '02 l\lHY 24 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 05-06-2002 BUSSEY 07-11-2001 21 01-0747 CUMBERLAND 101 ANNE L U :c',7 Allount Rellitted \...:.;:. , PA IfhlSL MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV =il.cfj-i3f-AFP-foi-:ozl-------...--iNifERITANci--fAx--iTAfEMi-tif-crF'-Ac-couiff--.-..--------------- - -- - -- ESTATE OF BUSSEY ANNE L FILE NO.21 01-0747 ACN 101 DATE 05-06-2002 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 04-15-2002 P R I N C I PAL TAX DUE: .nnn.mn.n..n.....................n..nmm..nn.....................n..n.n....m..nn...nn...n..................n...nm...nnmmnnmnmmnnm..mnmnnmmmnn.nmnmnn 22,270.94 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 10-11-2001 CDOO0375 1,113.55 25,000.00 04-18-2002 REFUND .00 3,842.61- . TOTAL TAX CREDIT 22,270.94 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A --CREDIT-- (CRJ, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. J COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1 162 EX(1 1-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT M&T TRUST CO, SUCC. TO: 1415 RITNER HIGHWAY CARLISLE, PA 17013 -------- fold ESTATE INFORMATION: SSN: 193-36-4022 FILE NUMBER: 21-2001- 0747 DECEDENT NAME: BUSSEY ANNE LAUMAN DA TE OF PAYMENT: 10/11/2001 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/11/2001 NO. CD 000375 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $25,000.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: M & T INVESTMENT GROUP CHECK# 200000491 SEAL INITIALS: DO RECEIVED BY: REGISTER OF WILLS $25,000.00 MARY C. LEWIS REGISTER OF WILLS ..... , STATUS REPORT UNDER RULE 6.12 Name of Decedent: Anne Lauman Bussey Date of Death: 7/11/01 Will No. 21- 2001-00747 Admin. No. 21-2001-00747 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes_X_ No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes X 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 parties in interest? Yes No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: June 16,2003 .ib;u (!.~ ~gnature - [ 7 David C. Gority, Trust Officer M & T Investment Group One West High Street Carlisle, P A 17013 (717) 240-4505 N tn ~ fY") N Capacity: Personal Representative -,. ~ (\'\ ~ , -~ r-'-:' -" ',~" () //' Cumberland County - !{egister Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 ~ Date: 6/10/2003 M&T TRUST CO, SUCC. TO: 1415 RITNER HIGHWAY CARLISLE, PA 17013 RE: Estate of BUSSEY ANNE LAUMAN File Number: 2001-00747 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 7/11/2003 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~ mll/b-; l;d ~, ~ DONNA M. OTTO ~~ DEPUTY REGISTER OF WILLS cc: vPile Counsel Judge ~\~ REI/-1500EXjlJ-OOj COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT w .., :!l:::!!iU) 0"'''' w"g :z:~... 0.... .. "" I- Z W Q W U W Q DECEDENT'S NAME (lAST. FIRST, AND MIDDLE INI11AL) Bussey, Anne L. DATE OF DEATH (MM-OO-YEAR) 07-11-2001 OFFIC!AL IJSE ONLY ~ Ilo-2Lf1- J'i FiLE NUMBER--.-------- 2 1 -0 1 0 7 4 7 cCiUiirvcooe - YEAR- - NUMBER - - - SOCiAl SECURITY NUMBER 193 - 36 4022 THIS RETURN MUST BE FILED IN DUPUCATE WITH THE REGISTER OF WILLS SOCiAl SECURITY NUMBER o 3. Remainder Return (date of 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) (AlIachSGhO) DATE OF BIRTH (MM-DD-YEAR) 05-11-1917 (IF APPliCABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) IlD 1. Original Return o 4. limited Estate o 6. Decedent Died Testate (Altac:ll copy of Will) o 9. Litigation Proceeds Received o 2. Supplemental Return o 48. Future Interest Compromise (dale 01 dealt1 after 12-l2..ij2) o 7. Decedent Maintained a living Trust (AIlacI1copy ofTfUst) o 10. Spousal Poverty Credit (dateoflfeath between 12-31-91 and 1-1_95) 0- Z W o Z o .. .. w '" '" o o COMPLETE MAILING ADDRESS David C. Garity, V. Pres. & Trust Officer NAME M&T Bank, Executor FIRM NAME 1'_1 Manufacturers & Traders Trust Company TELEPHONE NUMBER 717--240.4505 Carlisle POBox 220, 1415 Ritner Highway PA 17013 x.o_ (15) xO~ (16) 22,270 94 x .12 (17) x .15 (18) (19) 22,270.94 z o ~ ;:) l- ii: c( u W It:: 1. Real Estate (Schedule A) 2. StocI<s and Bonds (Schedule B) 3. Close~ Held Corporation, Partnership or Sole-Proplielorship 4. Mortgages & Notes Receivable (Schedule D) S. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Joinl~ Owned Property (Schedule F) o Sepanlto Billing Requested (1) (2) (3) (4) (5) -0- 485,898.41 --0- -0- 40,792 82 (6) -0- 1. InterNtvos Transfers & Miscellaneous Non-Probate property (Schedule G or L) 8. Total Grou_lloIaf Lines 1-7) (7) -.0-- (91 (10) 28.996.19 2,785.36 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debls of Decedent, Mortgage liabilities, & Liens (Schedule I) 11. Total Dedu<:llons (tOlallines 9 & 10) 12. Net Value of Estate (Line 8 minus line 11) 13, Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) z o ~ I-' ;:) Q. :::E o U ~ SEE IHSlRUC1IONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Une 14 taxable at the spousal tax rate, or transfers under~. 9116 (a)(1.2) 16. Amount ofUne 14 taxable at lineal rate 494,909.68 11, Amount of Une 14 taxable at sibling rate 18, Amount of Line 14 taxable at collateral rate 19. Tax Due 20. IlD CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT mK ~. ., o OFFICj8 SE ONLY f--..J 1:'1 <} ('f (8) 526,691.23 (11) 31,781.55 (12) 494,909.68 (13) -()- (14) 494,909.68 Decedent's Complete Address: STREET ADDRESS c/o Sarah Todd Memorial Horne LOOO W. South Street CITY Carlisle I STATE I ZIP PA 17013 Tax Payments and Credits: 1. Tax Due (Pagel Unel9) 2. Credits/Payments A. Spousal Poverty Credit B. prtor Payments C. Discount (1) 25,000.00 1,315.79 Tolal Credits (A+ B + C) (2) 3. InteresllPenalty n applicable D. 'nterest E. Penalty TolallnterestlPenalty ( 0 + E ) (3) 4. If Une 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund (4) 5. n Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) (SA) A. Enter the interest on the tax due. 22,270.94 26,315.79 -0- 4,044.85 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred;.......................................................................................... 0 b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 c. retain a reversionary interest; or.......................................................................................................................... 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 2. n 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 'jn 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 No I!I I!I [K] [K] IXJ [K] !Xl IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. AD RESS c/ M&T Bank - Tru t Department, POBox 220, 1415 Ritner Highway, Carlisle, PA SIGNATURE OF PREPARER 0 ER THAN REPRESENTATIVE DATE 17013 ADDRESS - r 1 For dates of death on 01 after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of lransfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)]. For dates of death on or after January I, 1995, lI1e tax rate imposed on Ihe net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)). The statute does not exemot a transfer to a surviving spouse from tax, and the ~tatutory 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 I, 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 natura' paren( an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use oflhe decedents lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12% [72 P.S. ~9116(a)(1.3)J. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ""'-'~.i191l. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Anne L. Bussey 21--01--0747 All real property owned solely or al a tenant in common must be reported at fair maBet vatue. Fair mar'Ket value IS defined as the price at which property would be exchanged between a wiJUng buyer and a willing seller, neither being compelled to buy or sell, both having reasonable kI1ow1edge of the relevant facts. Real property which is jolnUy-owned with right of survivorshiD must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH -0-- NONE TOTAL (Also enter on line 1, Recapitulation) $ --0 __ (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT REV-l!mEx+(l-gn ESTATE OF '* SCHEDULE B STOCKS & BONDS FILE NUMBER Anne L. Bussey 21-01-0747 All property jolnlly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE OF DEATH 1. DESCRIPTION 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 500 shares AT&T Corp. common stock AT&T Dividend Ex. 6-27-01 payable 8-1-01 160 shares AT&T Wireless Group common stock 600 shares Be11south Corp stock 300 shares Eastman Kodak Co. common stock 850 shares Halliburton Hldg. Co. common stock 2000 shares Lucent Technologies Inc. common stock 2000 shares Pepsico Inc. common stock 500 shares Potlatch Corp. cornman stock 1000 shares Procter & Gamble Co. cornman stock 1500 shares Suntrust Bks Inc. common stock 800 shares Verizon Communications common stock Verizon Dividend Ex. 7-6-01 payable 8-1-01 600 shares XCEL Energy Inc. common stock EXCEL Energy Dividend Ex. 7-5-01 payable 7-20-01 1800 shares Allied Irish Bks PLC-Spn ADR 25,000 par US Treasury Note 5.875% Maturity 11-30-01 $10,185.00 18.75 2,549.60 24,318.00 13,291. 50 27,412.50 11,940.00 90,420.00 16,042.50 68,050.00 94,275.00 44,540.00 308.00 17,496.00 225.00 39,600.00 25,226.56 TOTAL (Also enteron line 2, Recapitulation) $ 485,898.41 (If more space is needed, inseri additional sheets of the same size) REV.,""",."." .- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT OECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF Anne L. Bussey FILE NUMBER 21-01-0747 AD pnIpe11y jolnlly-ownod with 11I1 right of su_hip must be dilclosod on _ule F. ITEM NUMBER DESCRIPTION 1. None VALUE AT DATE OF DEATH 0- " TOTAL (Also enter on line 4, Recapitulation) $ -0- (If more space is needed, insert addltionai sheets of the same size) REV.l!i08 EX. (1-91) '* SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERJTANCE TAX RETURN RJESlDENT DECEDENT FILE NUMBER 21-01-0747 ESTATE OF Anne L. Bussey Include \he proceeds of litigation and \he dale \he proceeds were received by \he estate. All property joln1ly-owned with tho right of sUlVivo",hlp must be disclosed on Schedule F. ITEM NUMBER 1. VALUE AT DATE OF DEATH DESCRIPTION Manufacturers & Traders Trust Company Guardian For Anne L. Bussey under Court Order dated 10-19-87 $36,795.58 2. 3. Farned Income to date of death from Donald S. Bussey Estate 1,933.77 US Treasury - 2000 Federal Income tax relief refund 600.00 1,463.47 4. Proceeds from sale of personal property TOTAL (Also enter on line 5, Recapitulation) $ 40,792.82 {If ....^rft "......... i.. "'~M i........... ...rfrfitl".....l ..h............ "I tho "'........... ",,"'t,,\ REV"",,'I'I"9". COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTL Y.OWNED PROPERTY ESTATE OF Anne L. Bussey FILE NUMBER 21-01-0747 If an asset was made joint within one year of the decedent's date of death, ft must be reported on Schedule G. SURVIVING JOINT TENANT(S} NAME ADDRESS RELATIONSHIP TO DECEDENT A. N / A B. c. JOINTLY -OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF OE,o\TH ~TEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Altcr::h DATE OF DEATH DECO'S VALUEQF NUMBER TENANT JOINT deed for join~y-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. NONE -0- TOTAL (Also enter on line 6, Recapitulation) $ -0- -- (If more space is needed, insert additional sheets of the same size) REV.1511 EX+ (12-99) _ . '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Anne L. Bussey FILE NUMBER 21-01-0747 Debts at decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Hoffman-Roth Funeral Home, Inc. Donald S. Bussey, Jr. - Reimbursement for frmeral expenses $2,633.86 638.00 2. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Represenlafive!s) M&T Bank 20,300.74 Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 1415 Ritner Highway, POBox 220 City Carlisle State ~ Zip 17013 Year(s) CommissiOn Paid: 2002 2. Attorney Fees Frances H. Del Duca, Esquire 5,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Stafa_Zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wills . 93.00 -0- -0- 75.00 90.59 165.00 5. Accountanrs Fees 6. Tax Return Preparer's Fees 7. Advertising CostS: Cumberland Law Journal The Sentinel 8. Dave Sheibley - trash removal from Todd Apartment pd. 9-4-01 TOTAL (Also enter on line 9, Recapitulation) $ 28,996. 19 (If more space is needed, insert additional sheets of the same size) AElj'.IS12EX.(I-l71 '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF .....SYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Anne L. Bussey 21-01-0747 Include unl1!imbu~ed medical expenses. ITEM NUMBER 1. DESCRIPTION Pharmerica - prescription drug expense AMOUNT $ 140.30 PA Department of Revenue - Qrt1y income tax estimate 2,270.06 375.00 2. 3. United Church of Christ Homes - nursing home expense TOTAL (Also enler on line 10. Recapitulatkm) $2,785.36 (If more space is needed. insert additional sheets of the same size) . . - REV-15UEX.(l-17l '*' SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYlVANIA INHEMANCE TAX RETURN RESIDENT DECE NT ESTATE OF FILE NUMBER Anne 1. Bussey RELATIONSHIP TO DECEDENT NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Us! Trustee(s) L TAXABLE DISTRIBUTIONS (indude outright spousal distributions) 1. Intervivos trust of Anne L. Bussey 1. dated October 25, 1976 2. Donald S. Bussey, Jr. son 3. M&T Bank Guardian For Elizabeth Carter Bussel. daughter 21-01-0747 AMOUNT OR SHARE OF ESTATE 100% of residue $731.74 $731. 74 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE. ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX is NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV 1500 COVER SHEET $ (If more space is needed, Insert additional sheets of the same size)