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Home My WebLink About01-0784 RBt-1500 EX + (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-1500 DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN FILE NUMBER 0 19Lp HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 21 01 COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Dunkinson, Dorothy A.M. 193-12-6291 DECE- DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE DENT 03/19/01 07/29/1924 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER B 3. Remainder Return CHECK ~ ,. 0",,;"" Rerum ~2 Supplemental Return (date of death prior to 12-13-82) APPRO- 4. Umited Estate 4a. Future Interest Co mpro mise 5. Federal Estate Tax Return Required ~ate of death after 12-12-82) PRIATE 6. Decedent Died Testate 7. ecedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach copy of Will) (Attach a copy of Trust) BLOCKS 9. Utigation Proceeds Received 10. Spousal Poverty Credit (date of death between 011. Election to tax under Sec. 9113(A) 12-31-91 and 1-1-95) (Attach Sch 0) 11d$:$.eQ.milMij$jjilfl{o.oij#jjri.1;;::.if6.b.RijEB.ii*f':~j~Wnt_:i.jiiFb.i.nt.in~.mU1.i_]~.ltt.ti1.o.~ii NAME COMPLETE MAILING ADDRESS COR- Jan M. Wiley, Esauire One s. BaltiIoore st. RE- FIRM NAME (If Applicable) Dillsblrg, PA 17019 SPON DENT '!he Wiley TELEPHONE NUMBER 717-432-9666 None OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) None 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) None 4. Mortgages & Notes Receivable (Schedule D) (4) None 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) None 6. Jointly Owned Property (Schedule F) 0 Separate Billing Requested (6) 7,668.71 RECA- PITULA- 7. Inter-Vivos Transfers & Miscellaneous TION Non-Probate Property (Schedule G or L) (7) None 8. Total Gross Assets (total Unes 1-7) (8) 7,668.71 9. Funeral Expenses & Administrative Costs (Schedule H)(9) 1,500.00 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 1,679.95 11. Total Deductions (total Unes 9 & 10) (11) 3,179.95 12. Net Value of Estate (Una 8 minus Une 11) (12) 4,488.76 13. Charitable and Governmental Bequests/See 9113 Trusts for which an eleetion to tax (13) None has not been made (Schedule J) 14. Net Value Subject to Tax (Une 12 minus Une 13) (14) 4,488.76 SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9118 (aXl.2) X .0 (15) - TAX 16. Amount of Line 14 taxable at lineal rate 4,488.76 X.O 45 (16) 201. 99 - COMPU- 17. Amount of Line 14 taxable at sibling rate 0.00 x.12 (17) 0.00 TATION 18. Amount of Line 14 taxable at collateral rate 0.00 X .15 (18) 0.00 19. Tax Due (19) 201. 99 20. 0 1!QH.~K'!ijti.u.ufryQiji'jij'iREQijt$tjijQii)j~Nb.j)fiiiJ'ivti.ji:ijiiivM'f'"tl .................................... .........:......... .................... . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . ...................... ................ .... ........ ............. ........ .......... ....... ............. .................... ...... ................................. ......................................................... ..................... ....................... ,}:"",:,}',}):,)))::}i{,:r:)))):\:):",,:,),:)))::)));#.'$a','$.)~e?r(tANSweR:AUi;]::!IJ~snPNS.::ONJ~:A'G~JfANP.J~~~o.B.~:MAtliHiIi)':fffffffiffffffi?:':fffi?????:ffi?:::i:!:! o PA15001 NTF 29755 Copyright 2000 Graatland/Nelco LP - Forms Software Only Estate of: Dorothy A.M. n.mki.nson SlH!ARy OF ALlDCATIOOS 'IO BmEFICIARIES Taxable at lineal rate Claude W. Foreman 21-01- 4,488.76 PA REV-1500 EX (6-00) Decedent's Com lete Address: STREET ADDRESS Manor Care Page 2 1700 Market st. CITY STATE PA ZIP 17011 Hill Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prlor Payments C. Discount (1) 201. 99 Total Credits (A + 8 + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) O. 00 4. If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund (4) 5. If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5) 201.99 A. Enter the Interest on the tax due. (5A) 0 . 00 8. Enter the total of Une 5 + SA. This Is the BAlANCE DUE. (58) 201. 99 ;;;:;;;;;~;::::::::~::::::;::::::::/:i;~:::::~::~i~~i:::;:i:~:~:::ii::~~~:;;;ii:i;i:j:::~::~~~i~~:i::i:ii:::::::::::::::::I~:~::~:;i~::::::::::~:::::~:::::~~::::i:;~:~:::;::ff:;~:0~~~]:i:i~~::Ij~:;JI :0I~i~::~~i;;:j;:::;ii:::ITr~~i'::m~:'::~lli;:ji:::~~~::~I;;i;:;:;:;:::;::~:::~~::~~~~~i~~i~::i::~i~~:;::::;:::::::::;::~:j::;::::::::;::::::~::;:;::;:;::::::::}::;:ii;:~:::::::::::;::::::::::::r:::: ::~::: PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred; ....................................... b. retain the right to designate who shall use the property transferred or Its income; ................. c. retain a reversionary interest; or. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for Hfe of either payments, benefits or care? ..... . . . . . . . . . . . . . . . . . . . . . . . . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .. . 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjuf)/, I cIecIare that I have examined this return including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other tlian the personal representative is based on information of which re er has an knowled . SIGN F PE N FOR FILING RETURN DA~ Yes No ~ I B ~ ~ D/ II} Dill PA 17019 t~TJi~;~::~~::M:U~;!~::~:;i~;r~:ZJ~~[;:~:;~::;:~;~[H~:~:i:~:~:I;:i:j~E:~;~:~:!:::;:~~:F~i~::;b;;~:i;~1:~'~:~:1~:~:~::~~:fitft~::~~::~~::~~l:3Z;~:~~::~nD~~::=:~K::~;:~~::::::'~;;i~i'~g':~~'~~~:::;::~: ~~2)::::::::::i::(::::t:HH;:i [72 P.S.' 9116 (a)(l.l)(i)]. For dates of d....th on or after January 1, 1995, the tax rate is imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. & 9116 (a)(l.l) (ii)]. The statute doe" oot exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S.19116(a)(1.2)]. The tax rate imposed on the net value of transfers to or forthe use of the decedent's 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 orfor the use of the decedent's siblings is 12% [72 P.S. & 9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. o PA15002 NTF 29756 Copyright 2000 Greatland/Nelco LP- Forms Software Only fung! mill nnll ID.eslnm.ent OF DOROTHY A.M. DUNKINSON BE IT REMEMBERED, that I, DOROTHY A.M. DUNKINSON, of 1976 Hershey Road, Elizabethtown, Dauphin County, Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last will and Testament, hereby revoking and making null and void any and all wills and Testaments and writings in the nature thereof by me at any time heretofore made. ITEM 1: I direct that all my just debts and funeral expenses be paid as soon after my demise as may be convenient. ;-,,"".y, ITEM 2: All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, whether i it be real, personal or mixed, including property over which I have a power of appointment, I give, devise and bequeath unto my son, CLAUDE W. FOREMAN, absolutely, provided he survives me for a period of thirty (30) days. ITEM. 3: Should my son, CLAUDE W. FOREMAN, fail to survive me for a period of thirty (30) days, or should we die simul~aneously, I then give, devise and bequeath my entire residuary estate unto THE CHILDREN OF CLAUDE W. FOREMAN, in equal shares, per capita. ITEM 4: I direct my hereinafter named Executor to pay all inheritance, estate, succession and legacy taxes of whatsoever nature and kind, to which my estate or the (WI'I'NESS: ~n2~~ -:}11 . IIa1utt ~ 1J~/A4g~o-l.<SEAL) DOROTHY . M. DUNKINSON -1- transfer of any property passing hereunder or otherwise passing by reason of my demise, may be subject and to charge such taxes against my residuary estate, it being my intention that none of the aforesaid taxes, either federal or state, on any property required to be included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my estate to whom such property is or may be transferred or to whom any benefit accrues. ITEM 5 : I appoint my son, CLAUDE W. FOREMAN, as ~:,;-":,,, Executor of this my Last Will and Testament. Should my son predecease me, fail to qualify, cease to act or renounce probate, I then appoint my daughter-in-law, PEARL E. FOREMAN, as alternate Executrix of this my Last will and Testament. ITEM 6: I direct that my Executor or his successor shall not be required to give bond for the faithful performauce of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal thiiF-.Ji..J!!l day of .s;p-knJ bJ fl) , 1999. ~ '- :~ ~:;;;;b~ ,f)/J-'d.61l };/j)/1--?ckuW4SEAL) DOROTHY A. M. DUNKiNSON -2- COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF YORK We, DOROTHY A.M. DUNKINSON, JAN M. WILEY, ESQUIRE and PATRICIA A. BELLUSCIO, the Testatrix and the 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 Testament and that she had signed willingly (or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein ~ ~t......"" expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed this Last will and Testament as witness and that to the best of their knowledge the Testatrix was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. ... () ~n-~4! JtJ,~g~"'/hL ~~THY : M. DUNKINSON ~,~~:::~ WITNESS .i" Sworn to and subscribed before me this ~day of .I7J; ~r: df ;~h NOTARy'PUBLIC MY COMMISSION EXPIRES: REV-1509 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dorothy A.M. Dunkinson SCHEDULE F JOINTL V-OWNED PROPERTY FILE NUMBER 21-01- If anaaeet was made joint wI1hln OINt year of the decedenfs date of death, It must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A Claude W. Foreman ADDRESS 27 IIrpala Drive Dillsl:m'g, PA 17019 RELATIONSHIP TO DECEDENT son JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR MADE Include name of financial institution and bank DATE OF DEATH DECO'S VALUE OF JOINT account number or similar identifying number. NO. TENANT JOINT Attach deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1 A 12/10/82 First union 0lec:kin;J Account 13,188.05 50% 6,594.01 ~ 1000302430568: 2 A 12/10/82 Refurd on Joint Account 2,046.20 50% 1,023.10 payment fran HCR Manor Care: 3 A 12/10/82 Refunt . on Joint Account 103.20 50% 51. 60 Payment - Nationwide Insurance: TOTAL (Also enter on line 6, Recapitulation) $ 7.668.71 7 CPA91 NTF 10909 (If more space is needed, insert additional sheets of the same size) Copyright Forms Software Only, 1997 Nelco, Inc. f~N' Reference ID: 157863 First Union National Bank Attn: Account Verifications POBox 40028 Roanoke VA 24022-7313 June 14,2001 THE WILEY GROUP A ITORNEYS AT LAW 1 SOUTH BALTIMORE STREET DILLSBURG, PA 17019 SUBJECT: Verification / Confirmation of Account and Balance Information provided for: DOROTHY A DUNKINSON (SSN# 193-12-7291) Date of Death: March 19, 2001 j Deposit Account Information Account Type Account Number Date of Death Balance Average Balance* Date Opened Maturity Interest Accrued YTD Date Date Rate Interest Interest Paid Closed CHECKING 1000302430568 LEGAL TITLE: DOROTHY M. DUNKINSON CLAUDE W. FOREMAN $13,178.97 12/10/1982 $9.05 $32.34 * Due to system limitations, we can only provide a twelve month average balance on depository accounts. * Date of death balance does not include accrued interest. * If date of death occurrs on a weekend or a holiday, date of death balance does not include any transactions that were made during that time period. June 14,2001 Date Drema Rubinoff Depository Representative Servicenter Associate Title (540)563-7323 Phone Number sss; kt 001032 .11' 0 0 0 ~ ~ 7 L, BOb II' I: 0 L, L, ~ ~ 5 ~ 2 b I: 0 ~ L, 7 2 ~ ~ 7 b ~ L, II' ~., I , '7" '.' .... .... . ''''~'''''''''-:tHEF'AcE0FTi-iTs-op;;~'Nf1iAsfAalJjE-BACKGYRoyfjf:roNi~i8lT~1?~~NANGCE?:to'YiE~lARTiRe~~ii;tliJR.\'ilif:\i(ql'i"~qF155QOMEM~r:''''''''.."',"'.,.,',......,,,..,,":" "..',,..,.. . ..~......T.fb...Nw. ...to'.....E 'MuTU. A.L. ..1. ~SlJFfA.....'N$; I:!"!lii.~y .... ..... ....[.......,.,.'..,..:,....''.".''']....'. .......... .-"... """. '. "" ..-.,' " pO BOX 2655 . . .. ...... . Ch$ckNC;]: 5801 74.0~L. . 'HARRISBURG .PA 1'7105.2655 '. .'.,'. Dafe, ,..... ,p6--05-200-1 . . ,.. . . policy ~K9tb~r;5~3,7C65~~?~ ..................-..-...., ...,_..'_.....-.... ..,.....'..,.....,....., .9~1~l!!~P{.9~~h~~:Withl&.'~q~Ys ,.... .!t1lt'fi ItoiIlplj,ym..nt \lijl.$.a;ltl'j~iWIi. " ." ..:..lndlcat..t'FQh-:~b:, :.-.,,':,:. . .:; NATIONAL 8ANKQR'PmQJ1'. OEi\F!I;lORN . . ".- . . ., : -. . . pe.4,RsoRN,.M\plil@Am4S.t2.6 ,....:.:.:... :;"'/"a:;:t:;r::;;;;' .... . . .' ." . . Authorized sl~"~4i~ . ., ,. . ".',". . ", ," '." _.",. , ,.n. . ~i~--..~~..........._~~~..;:.li,~~~~~~~.:.....;...i;.~......~:..~:.;:;...".;.;;.;~ '-~-'i-."-;"l.l.~::'~~"'~i.;..~~~';;:;,~'.t.:,,<...;...~~;~~':;'-:'''''';'":' -~~.i~-:::....,~:;:ii"j,;.;.~~::::...: ,~;..;;...~,~.....,~~~~:..,~i;"".~.~,"~;;.~;,.~~i.:.\',;~.:.'~:"hl;..~:;:..:.;.;:.'l:-;;.;.; II' 5 B 0 ~ ? L, 0 1111' I: 0 7 2... ~ 2 11 2 7 I: o 0 ~ . 5 a 2 b II' . REV-1511EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dorothy A.M. Dunkinson SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21-01- Debts of decedent must 1M ITEM NO. A. FUNERAL EXPENSES: on Schedule I. DESCRIPTION AMOUNT None B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) SocIal Security Number(s)/EIN No. of Personal Representative(s) Street Address City State 0.00 Zip Year(s) Commission Paid: 2. 3. Attorney Fees Nan-e: Jan M. Wiley, Esquire Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 1,500.00 0.00 4. Probate Fees 0.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 None TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1,500.00 7 CPA11 NTF 10911 Copyright Forms Software Only, 1997 Nelco, Inc. . FlEV-1512 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dorothy A.M. Dunkinson Include unreimbursed medical eXDenses. ITEM NO. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER DESCRIPTION 1 Internists of Central PA {last illness}: 2 B. Hostetter {IlOrIer repair} : 3 Shipley oil: 4 Nationwide Insurance: 5 Bob Bowers {tax prep.} : 6 Mobile X-Ray Imaging {last illness}: 7 Neighbor Care (last illness): 8 Holy Spirit Hospital {last illness}: 9 Pinnacle Health (last illness): 10 Milton s. Hershey Medical Center (last illness): 11 Dale Fspenshade (lllCMing): 12 GPO Energy: 21-01- AMOUNT 10.36 106.10 152.77 142.40 20.00 28.45 12.29 141.55 96.38 737.37 195.00 37.28 7 CPA12 NTF 10912 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) Copyright Forms Software Only, 1997 Nelco, Inc. 1.679.95 . REV-1513 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES Dorothy A.M. Dunkinson No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY J. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 Claude W. Foreman 27 Inpala Drive Dillsblrg, PA 17019 FILE NUMBER RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) son 21-01- AMOUNT OR SHARE OF ESTATE 4,488.76 ENTER DOLLAR AMTS. FOR DISTRIBS. 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 None B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS None 7 CPA13 NTF 10913 TOTAL OF PART II -- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 Copyright Forms Software Only, 1997 Nelco, Inc. (If more space is needed, insert additional sheets of the same size) FlEV-15O/tEX + (a-OO) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-1500 I .' J 2 ~~- rl DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN FILE NUMBER I~~ HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 21 01 COUNTY CODE YEAR NUMBER DECEDENrS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Dmkinson, Dorothy A.M. 193-12-6291 DECE- DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE DENT 03/19/01 07/29/1924 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 8 3. Remainder Return CHECK ~ ,. 0",".01 Return ~ 2. SUppleme"'" Return (date of death prior to 12-13-82) APPRO- 4. Umited Estate 4a. Future Interest Compromise 5. Federal Estate Tax Return Required ~ate of death after 12-12-82) PRIATE 6. Decedent Died Testate 7. ecedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach copy of Will) Attach a copy of Trust) BLOCKS 9. Utigation Proceeds Received 10. ~pousal Poverty Credit (date of death between o 11. Election to tax under Sec. 9113(A) 12-31-91 and 1-1-95) (Attach Sch 0) \Nl$ji*Q.1jmh,..$t~;'!:~j$l~l.~#.P.flijJ!Bijb.i.e'f.]*.j!,!~:lt.U.WMin!mIit_ijlii~]!mJji.&.n;'iT<<~; NAME COMPLETE MAILING ADDRESS COR- Jan M. Wiley. . One S. BaltWre st. e RE- FIRM NAME (If Applicable) Dillsburg, PA 17019 SPON DENT '!he Wiley TELEPHONE NUMBER 717-432-9666 None OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) None 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) None 4. Mortgages & Notes Receivable (Schedule D) (4) None 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) None 6. Jointly Owned Property (Schedule F) o Separate Billing Requested (6) 7,668.71 RECA- PITULA- 7. Inter-Vivos Transfers & Miscellaneous TION Non-Probate Property (Schedule G or L) (7) None 8. Total Gross Assets (total Unes 1-7) (8) 7,668.71 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 1,500.00 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 1,679.95 11. Total DeducUons (total Unes 9 & 10) (11) 3,179.95 12. Net Value of Estate (Una 8 minus Une 11) (12) 4,488.76 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax (13) None has not been made (Schedule J) 14. Net Value Sublect to Tax (Une 12 minus Une 13) (14) 4,488.76 SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x.O (15) - TAX 16. Amount of Line 14 taxable at lineal rate 4,488.76 X .0 45 (16) 201. 99 - COMPU- 17. Amount of Line 14 taxable at Sibling rate 0.00 x.12 (17) 0.00 TATION 18. Amount of Line 14 taxable at collateral rate 0.00 x.15 (18) 0.00 19. Tax Due (19) 201. 99 20. 0 !:Qijecl(j11$.!t!jlVio.(#\'RI)~IQo.t~::':~ijp:tlF:AiOiM,~~AvMtKt\1 .................................................................................................,............................................ .. . ..........,.,...................................... .......................................................................................................................................... .................... ................ r::~;:;~:;~:;:;r:tr::r:;~?~::;?;::::;::~:~:::::::;;:;:;;::~:;;;:::::::::~:~;;(:::::r::;;;~r:::;~~~U!!~::$~8.~:[:~::AI\f$Wet{AlX'~QP~N$.:;PNJtA$a:~tA~p~;as..O'H~J~1~tH;g)))):t~~;:~:r~:~:l)::)):rr~tttt :~t;tt:::;:;:t~~:tt~:g o PA15001 NTF 29755 Copyright 2000 Greatland/Nelco LP- Forms Software Only Fstate of: Dorothy A.M. D.1nkinson SUMMARY OF AU.DCATIONS 'ro BENEFICIARIES Taxable at lineal rate Claude W. Foreman 21-01- 4,488.76 PA REV-1'5OO EX (6-00) Decedent's Com lete Address: STREET ADDRESS Manor Care Page 2 1700 Market st. CITY STATE PA ZIP 17011 Hill Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 201.99 Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty (3) 0.00 Total Interest/Penalty (0 + E) 4. If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund 5. If Une 1 + Une 3 Is greater than Une 2, enter the difference. This Is the TAX DUE. A. Enter the interest on the tax due. B.Enter the total of Une 5 ... SA. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT 1. Did decedent make a transfer and: Yes No a. ret~n the ~se or inco~of the property transferred; ................'....................... ~ I b. retam the nght to designate who shall use the property transferred or its mcome; ................. c. retain a reversionary interest; or. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? ......... . . . . . . . . . . . . . . . . . . . . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. B ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .., e9 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . ., 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjuty, , declare that I have examined this return Including accompanying schedules and statements, and to the best of my knowledge and belief, It is true, correct and complete. Declaration of preparer other tlian the personal representative is based on information of which re arer has an knowled SI E OF RS . FOR IlING RETURN DATE ~ I (4) (5) (SA) (5B) 201.99 0.00 201. 99 e9 Dill PA 17019 ~~::r:::::lm:::~~:M1~:~j:rr~:~:B~z~::jei~l~::::;t~~::~~:J::~:!1~~:::3:~:~!:~~::{::::;.~:~i~;:~:~:!::~~;~~~:::i:!:~:~:!:}:)~:~::~~:!:~~}.el\:~:::~:~:i{;~~!:f:!;!::~!:~N~:~:~~::;:~;:j:l:~:~t:;)~J;f:~:: ~:~::l~:~~:~:~::;:~::~tl:tttttt::~tlt [72 P.S. . 9116 (a){i.l)(i)]. For dates of death on or after January 1, 1995, the tax rate is imposed on the net value of transfers to Dr for the use of the surviving spouse is 0% [72 P.S. s 9116 (a)(1.1){ii)]. The statute rln..~ nnt '>XI.mpt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1"2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to orforthe use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S.li9116(a)(1.2)]. The tax rate imposed on the net value of transfers to Drfor the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72.P.S.' 9116(1.2) [72 P.S.S 9116(a)(1)]. The tax rate imposed on the net value oftransfers to or forthe use of the decedent's siblings is 12% [72 P.S. 1 9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood oradoption. o PA1SOO2 NTF 29756 Copyright 2000 Greatland/Nelco LP - Forms Software Only must IIill ann @.eslmn.ent OF DOROTHY A. M. DUNKINSON BE IT REMEMBERED, that I, DOROTHY A.M. DUNKINSON, of 1976 Hershey Road, Elizabethtown, Dauphin County, Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore made. ITEM 1: I direct that all my just debts and funeral expenses be paid as soon after my demise as may be convenient. ITEM 2: , ~,.....~, All. the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, whether I it be real, personal or mixed, including property over which I have a power of appointment, I give, devise and bequeath unto my son, CLAUDE W. FOREMAN, absolutely, provided he survives me for a period of thirty (30) days. ITEM. 3: Should my son, CLAUDE W. FOREMAN, fail to survive me for a period of thirty (30) days, or should we die simul~aneously, I then give, devise and bequeath my entire residuary estate unto THE CHILDREN OF CLAUDE W. FOREMAN, in equal shares, per capita. ITEM 4: I direct my hereinafter named Executor to pay all inheritance, estate, succession and. legacy taxes of whatsoever nature and kind, to which my estate or the (W!TNES5 : ~~.~ '", /_ ~ - ~.<<J --:J-17, It ff1v~ h: 1J~/......~~EAL) DOROTHY . M. DUNKINSON -1- transfer of any property passing hereunder or otherwise passing by reason of my demise, may be subject and to charge such taxes against my residuary estate, it being my intention that none of the aforesaid taxes, either federal or state, on any property required to be included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my estate to whom such property is or may be transferred or to whom any benefit accrues. ITEM 5 : I appoint my son, CLAUDE W. FOREMAN, as ....:.,.-...., Executor of this '~y Last will and Testament. Should my son predecease me, fail to qualify, cease to act or renounce probate, I then appoint my daughter-in-law, PEARL E. FOREMAN, as alternate Executrix of this my Last Will and Testament. ITEM 6: I direct that my Executor or his successor shall not be required to give bond for the faithful performauce of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand this.. J/.t!!. day of ..:sP.p/<-n1 b..J 11 ) and seal , 1999. ~ - \-:~~b~ ,/J#J-{dl:tll JJIi)~~Mt44SEAL} DOROTHY A.M. DUNKJ:NSON -2- COMMONWEALTH OF PENNSYLVAN:IA SS COUNTY OF YORK We, DOROTHY A.M. DUNK~NSON, JAN M. WILEY, ESQU~RE and PATR~C:IA A. BELLUSCIO, the Testatrix and the 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 Testament and that she had signed willingly (or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the -~1.~_. witnesses, in the presence and hearing of the Testatrix, signed this Last will and Testament as witness and that to the best of their knowledge the Testatrix was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. .]>'0 {} (te-~4! /)1,fk.f:#o/hL ~?THY : M. DUNKINSON ~<(:'~:::c0 WITNESS Sworn to and subscribed before me this ~day of jfu:; !t~~9~ NOTARY PUBLIC MY COMMISSION EXPIRES: ~EV-1509 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE Of Dorothy A.M. Dunkinson SCHEDULE F JOINTL V-OWNED PROPERTY FILE NUMBER 21-01- " anuset was made Joint within on. year of the decedenfs date of death, It must b. reported on Schedule G. SURVIVING JOINT TENANT(S} NAME A Claude W. Foreman ADDRESS 27 Impala Drive Dillsburg, PA 17019 RELATIONSHIP TO DECEDENT son JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH Include name of financial institution and bank ITEM FOR MADE account number or similar identifying number. DATE OF DEATH DECO'S VALUE OF JOINT NO. TENANT JOINT Attach deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1 A 12/10/82 First Union Olecki.ng Account 13,188.05 50% 6,594.01 ~ 1000302430568: 2 A 12/10/82 Refun:i on Joint Account 2,046.20 50% 1,023.10 paynent fram HeR. Manor Care: 3 A 12/10/82 Refunt;oo Joint Account 103.20 50% 51.60 paynent - Nationwide Insurance: TOTAL (Also enter on line 6, Recapitulation) $ 7,668.71 7 CPA91 NTF 10909 (If more space is needed, insert additional sheets of the same size) Copyright Forms Software Only, 1997 Nelco, Inc. f~N' Reference ID: 157863 First Union National Bank Attn: Account Verifications POBox 40028 Roanoke VA 24022-7313 June 14,2001 THE WILEY GROUP A TIORNEYS AT LAW 1 SOUTH BALTIMORE STREET DlLLSBURG, PA 17019 SUBJECT: Verification I Confmnation of Account and Balance Information provided for: DOROTHY A DUNKlNSON (SSN# 193-12-7291) Date of Death: March 19,2001 .~: .','''i ~ Deposit Account Information Account Type Account Number Date of Death Balance Average Balance* Date Opened Maturity Interest Accrued YTD Date Date Rate Interest Interest Paid Closed CHECKING 1000302430568 LEGAL TITLE: DOROTHY M. DUNKINSON CLAUDE W. FOREMAN $13,178.97 12/10/1982 $9.05 $32.34 * Due to system limitations, we can only provide a twelve month average balance on depository accounts. * Date of death balance does not include accrued interest. * If date of death occurrs on a weekend or a holiday, date of death balance does not include any transactions that were made during that time period. June 14,2001 Date Drema Rubinoff Depository Representative Servicenter Associate Title (540)563-7323 Phone Number sss; kt 001032 .11' 0 0 0 ~ ~ 7 L. a 0 b II' I: 0 L. L. ~ ~ 5 ~ 2 b I: o. L. 7 2 ~ ~ 7 b ~ L. II' " ,j7 ..w~~i!.~~=:f~+~~',:..,...~.,.;(....I'..':.l.i,~,..-."..:.:Y~'W~~~~::~;;~~~~~~PoqQMEW;~47"7"~:"1'~9:"~"~'" :': ~\~~ti~~+~$~~tl~~~~~~~i..'i"..~";f~~".f!i:;:'I~({i.1* . lil.l.'1I. t ~ I. II .i~ ,.:tll. h~ .l.IlllfiJ'i IlI..nn .ltlill. l.J..Hlf . '.. . DOROTHY M DUNK I!liSQN c/o CLAUDE FOR.EMAN 'n 2TIMPAlA P:R' . '. D ILLSSjJR'G. . ." :, ..... , . . .'. < .... . ~:jl/1:::;'~~:';I::")!'lI"I~,j'I!';"JJ/i,ild\l!f '., .~.i.:.:.!.~.l.r~.b.{q:..i..:':LAiut(tlbof.:.r.r,iz:8!..:.,.sl...li....I..~.<..'.:.l.1...:.;.::.*'.....ii.;.W'. ..,.. ~TlqNAL E!~~:R~'P:~iM< o.EA>9~OR~ :PE4RBORf'f,~~9li!~A~48'1~~: '" ""~"''' .:..o:;...i~~.4~'.h.i'~"....~:."..,:,..~:...~: ,~1.~;.io.~~..~~.::,._::.:~;,.; ;ili" '-",:: ..~.;.'.,'\<I'H~~...-.,~,:..... "'-'~C': ~:l)'.'~~..r:.i:..,...;.i..::- ~.,...,...,,:.J'.,;.;,.,,<~~..s..,. ~..~~-:'..,:..~;;, :.1;:;,~;.,;0~~1.'~:''''~I''~~~.d;;..~.~,:",~,~;;,~",;",,;,:'~.~br..::::.'':~~' ..... ,.$**** il;la.2'ti: III 580 ~ 7 L. 0 11111 I: 0 7 2 l, ~ 211 2 ? I: 00 . . 58 2 bill REV-1511'EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dorothy A.M. Dmki.nson SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21-01- Debts of decedent must be reDOI1ed on Schedule I. ITEM NO. DESCRIPTION A. FUNERAL EXPENSES: AMOUNT None B. ADMINISTRATIVE COSTS: 1. Personal Representative's Com~ssions Name of Personal Representative(s) Social Security Number(s)/EIN No. of Personal Representative(s) Street Address C~ ~~ 0.00 Zip Year(s) Commission Paid: 2. 3. Attorney Fees Name: Jan M. Wiley, Esquire Family Exemption: (If decedent's address is not the same as claimanfs, attach explanation) Claimant Street Address 1,500.00 0.00 CIty Relationship of Claimant to Decedent ~ate Zip 4. Probate Fees 0.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 None TOTAL (Also enter on line 9, RecaPitulation) $ (If more space is needed, insert additional sheets of the same size) 1,500.00 7 CPA11 NTF 10911 Copyright Forms Software Only, t997 Neleo, Inc. REV-1512 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dorothy A.M. Dunkinson Include unreimbursed medical expenses. ITEM NO. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER DESCRIPTION 21-01- AMOUNT 10.36 106.10 152.77 142.40 20.00 28.45 12.29 141. 55 96.38 737.37 195.00 37.28 1 Internists of Central PA (last illness): 2 B. Hostetter (l101er repair) : 3 Shipley oil: 4 Nationwide Insurance: 5 Bob Bowers (tax prep.) : 6 Mobile X-Ray Imaging (last illness): 7 Neighbor Care (last illness): 8 Holy Spirit Hospital (last illness): 9 Pinnacle Health (last illness): 10 Milton S. Hershey Medical Center (last illness): 11 Dale Espenshade (ll'OWing): 12 GPU Energy: 7 CPA12 NTF 10912 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1. 679. 95 Copyright Forms Software Only, 1997 Nelco, Inc. REV-151$ EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES Dorothv A.M. Dunki.nson No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 Claude W. Foreman 27 Inpala Drive Dil~, PA 17019 FILE NUMBER RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) son 21-01- AMOUNT OR SHARE OF ESTATE 4,488.76 ENTER DOLLAR AMTS. FOR DISTRIBS. 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 None B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS None 7 CPA13 NTF 10913 TOTAL OF PART II -- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 Copyright Forms Software Only, 1997 Nelco, Inc. (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: WILEY JAN M 1 S BALTIMORE STREET DILLSBURG, PA 17019 _____n_ fold ESTATE INFORMATION: FILE NUMBER: DECEDENT NAME: DATE OF PAYMENT: POSTMARK DATE: COUNTY: DATE OF DEATH: REMARKS: JAN WILEY ESQUIRE CHECK# 4704 SEAL REV-1162 EX(11-96) PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SSN: 193-12-6291 21-2001- 0784 DUNKINSON DOROTHY A M 08/22/2001 00/00/0000 ~ POS1MAKR DATE CUMBERLAND 03/19/2001 NO. CD 000184 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $201.99 I I I I I I I I TOTAL AMOUNT PAID: INITIALS: VZ RECEIVED BY: REGISTER OF WILLS $201.99 MARY C. LEWIS REGISTER OF WILLS