HomeMy WebLinkAbout01-0847
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of /(PAllIllJ L, 8AJIlA/NNte r
also known as
No. 21-01-847
To:
Register of Wills for the
County of (U;NtJE/lUl-IU~ in the
Commonwealth of Pennsylvania
Deceased.
Social Security No. /1 ~ - .3;{ - //.8.3
The petition of the undersigned respectfully represents that:
Your petitione@ who i~18 years of age or older, appliES
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Qecendent was domiciled at death in (l. l/,f(t3EIl~I()t:J County, Pennsylvania, wjf.h
h ItS last family or principal residence at IJ./G 'PA-I7E/l. /)VCA.)VEij C!.41t'-'~u=/ ;U~
(list street, number an municipality)
Decendent, then (PO years of age, died VI/IV/: tfl().1
at HIJIUtI ~ V ~ G Nos/) 1179-'- I #11 JVtI.se IJ ~ & i ;t1",.
., ~
~ ~"I
, ,
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows: /1/ tJ ~€4L E.s/7/-rE
6 9 .tJ~ , .56
$
$
$
$
/~s
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF 81J,ftI3€,€u:lAJ/J
} ss
The petitioner(s) above-named swear(s) or affirm(s) that the
statements in the foregoing petition are true and correct to the best
of the knowledge and belief of petitioner(s) and that as personal
representative(s) of the above decedent petitioner(s) will well and
truly administer the estate according to law.
Sworn to ~r affirmed a"fi d subscribed f;L~iff:d~J~~
before me thIS 11 th day of / 'Q)'
SEPTEMBER "ZOOI 3
7~r 0 >j7mU_9-_//~ ~-<t !
R~~rer 00
N ZI-01-847
o.
Estate of /(/J/I/,4U) L, ~.4,fAj##llr
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW SEPTEMBER 13, ZOOI ~_, in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that KENNETH S BARNHART SR AND KENNETH S BARNHART JR
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby-granted to
KENNETH S BARNHART AND KENNETH S BARNHART JR
in the estate of
RONALD L BARNHART
"7~c?$f'W:i:h) /L~ /fl/S--""7'
Ister 0 fills
FEES
Letters of Administration $
Short Certificates( ).......... $
Renunciation ................ $
JCP $
TOTAL _ $
Filed .. 9.-) ~.. .. .. .. .. .... A.D.
40.00
6.00
ATTORNEY (Sup. Ct. I.D. No.)
5.00
51.00
~ZOOI
ADDRESS
PHONE
'r'his is to certify that the information here given is correctly copied from an original certificate of death d~r filed with
Loc:ll Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent 1 mg,
WARNING: It is illegal to duplicate this copy by photostat or photograph.
me as
No.
~,~"~9,lL~.L,,, ~lj;t
Local Registrar
Fee for this certificate, $2.00
p
7402590
JUN 2 4 2001
Date
21-01-847
H 1 05. ; oJ Rev. 2IlJ7
COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
f 'EI,RtNT
IN
~RMAHE"T
IlACK 'HI(
60
Ronald
uNO€R I YEAR
MorohI 0..,.
L.
Barnhart
SEll
2. Male
STATE FILE NUMBER
SOCiAl SECURITY "UMBER
). 172 - )2
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AOE (la.. 1Iir1r>clay)
NAME OF DECEDENT (F~S1. Middle. 'HI
YIS.
UNO€R I Olfll
HOuo1I ! M""""
~E 0# DEATH tC__ Clf"Y Ilt'e .... ,,,.,,,.:.""'" on.- _I
HOSPITAL:
_lien! fA. E~IiIo'" 0
S.
COUNTY OF OE1JH
.. Dauphin
DECEDENT'S USUAl OCCUPIllION
(Give""" oI_k clone,~:2......
El~ct?~h~~c-~e~chic
. llL 11
DECl:DEHT'S IWlIHO ADORESS (SIr.... CilyfIOwn. SlaIot. r'll Codel
145 Porter Avenue
Carlisle,Penna. 1701)
I"
FRHER'S NAME (F;,s,. "'-,.lastl
II. l\enneth S. Barnhart, Sr.
INFORMANT'S .....uE (T~
K.enneth S. Barnhart, Sr.
t.IETHOO OF [)ISPOSl1'~
O - ~ c_.iaft D RemonI,",",Sl".O
Oonetian 01_ (Soecltyl
. 21L
SlGHRURE
....
WJ.S DECEDENT EVER IN
U.S. ARUEO FORCES1
.....~ NoD
13.
17..51_ pennsy van~a
DECEDENT'S
ACTUAl.
RESIDENCE
!See "*""""""
on_.. _I
Cumberland
citylb
171t.
1 01"
. 0
WJ.SCASE REFERRED TO:O EXA""NERlCOROHE~ Nour"'"
fe.
....-.-.
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PART H:
Olhe< ,.__CflIIlriboJIIngIO ..11II.
""'......Ing in lIMo ~ _ giwft in
j
[ :
WERE AU"lOl'SY FlNtllHGS
_t.A81..E .-R1Ofl1O
COMI'\.ET1ON OF GAUR
OF OERH1
_0
MAHNER OF DEATH
rt:
D
o
TIME 0# INJURY
INJURY AT WORK1 DESCRIBE tfON INJURY OCCURAEO.
_II
Hom_
P.neling ~11on
_ D NoD
-
NoD
SUicide
Could "'" be ""'._
... 20. :no
CEln'IfIEll.CI\ecll on., cnet
.CEln'IFYlNC "",,SICIAN (Ph_ e~ cause d <Seam _ .....- "...."".an hIS Ilf~ ..8ltlllNl completed Item 23)
To........o''''yknow&edge. de.tttoccu".... due 10"". ".uM(t).nd m....n.,.. Itllted................................................
"I'AONOUNClNG ANO CERTIFYING 'HYSICIAN (Ph...."'" boII1 "",nounc:"'9 Oea'" """ C""'v"'91o ""_ '" ae.""
To.... be1rtof"'yknowtedOft. ..lhoc.cu,..ed .tthe~. 4.'.. and p'aca, and duetotttecauM(I) and manr\er.. tlll.lId............. ......
'MEDICAL EXAMINER/CORONER
Oft the b..I. ol...mln.llon .ndJo< in....lIg..';on.ln my opinion, dutll QCcurr.d II III. lime, d.I., and pl.ee, and due 10 'he caUse(I).nd
_ al Itlted. . . . . . . . . . .. . . . . . . . . . . . .. . . . . . . . . .. . . .. . . . . 0 .. . . 0 . . 0 .. . . . .. . . . . . . .. . . .. . .. .. .. . .. .. . .. . .. . . . . . . .. .
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CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent:
RONALD L BARNHART
Date of Death:
JUNE 20, 2001
Will No.
Admin. No.
21-01-847
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
Name
Address
KENNETH S BARNHART SR
145 PORTER AVE CARLISLE. PA
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
DaW: SEPT. 11, 2001
Signature
Name 6J( ~:r)/y4~$~ !fJa.~;:ph/r 2
Address
Telephone (
Capacity: ~ Personal Representative
_Counsel for personal representative
~ 10.--
lnventory of the real and personal estate of
~OIJ/l1-/J i, I!JAIfIV}'/4~ r
~
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Ii- ~{p 771 ,;J. I ~ ~ I
~. mET /.IF~ II/IIES7MEAJr -Sj/of/tE.s
10f nwsr Infe.resrs (! ao.,1oje/l VQt.lJ~ Jf,;J'I/~1
H ia~b'" S9{,g-5777
deceased
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
IHHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
KENNETH S BARNHART SR
145 PORTER AVE
CARLISLE PA 17d1~
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
:~.; COUNTY
ACN
10-29-2001
BARNHART
06-20-2001
21 01-0847
CUMBERLAND
101
'*
REV-1547 EX AFP (12-00)
RONALD
L
Allount Rellitted
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 ~
ifE-Y=iStrj-Eif-AFP--fi'2-:o0"r-NOY-iCE--OF-INHEifiTANCE-Y-AjrA-PPRAisEiiENT~--Ai.i-owAirCE-c)i-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BARNHART RONALD L FILE NO. 21 01-0847 ACN 101 DATE 10-29-2001
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)
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 Subject to Tax
(9)
UO)
.00
3.280.09
.00
.00
3.676.27
.00
.00
(8)
9,280.00
4.172.25
(11)
(2)
(3)
(14)
(5) .00 X 00 =
(16) .00 X 045 =
(7) .00 X 12 =
(8) .00 X 15 =
(19)=
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax pay..ent.
6,956.36
13.45? ?Ii
6,495.89-
.00
6,495.89'"
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
· IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIP' (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
c
STATUS REPORT UNDER RULE 6.12
Name of Decedent: ;(PAJALIJ L. g/fi,u)flAte r
Date of Death: JVJfi6 ZtJ I 200/
will No.
Admin. No.
21-01-847
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 v-- No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No L-- .
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
L--
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date: 9 -J I <-- {J. /
s?~~7t=-2 c7/YrM~~
/-rl3lJ)JETJ! S. 841l1U#1Itu: Sf(,
Name (Please type or print)
/'1S- IbIlTER liVE. .(J/fIetiSLEJ (J4
Address / / /1tJ/3
( 717) tX L/3 - ~5 d!:"
Tel. No.
Capacity:
~personal Representative
Counsel for personal
representative
(MAH: rmftAM3)
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REV. 1500 EX (6-OO}
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST. FIRST. AND MIDDLE INITIAL)
BIlItA/I-iIlJe T
DATE OF DEATH (MM-DD- EAR)
L,
!?/JAI/it.1J
DATE OF BIRTH (MM-DD-YEAR)
1940
-';l() - A-~()I II - ~4-
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
MY;
0' 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy 01 Will)
o 9. Litigation Proceeds Received
OFFICI.4.L USE ONLY
FilE NUMBER
..:;, L - CL L
COUNTY CODE YEAR
--a..~L
NUMBER
SOCIAL SECURITY NUMBER
/7.
-..a~
/1.3 .3
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 2. Supplemental Return
o 4a. Future Interest Compromise (dale 01 deall1 after 12.12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trusl)
o 10. Spousal Poverty Credit (daleoldealhbelween 12.31.91 and 1.1.95)
o 3. Remainder Return (dale of deall1 prio< 10 12. I 3-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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~i:aIS[SJ:<;:rrO~;...IJ$RBE;.cPM_PLErED:';ALLCORRESPONDENCEAND CONFIDENTIAL TN( INFORMATlON~HOULD BE DIRECTED TO:
NAM S g /1IlAJI-I/7;er .s. COMPLETE MAILING ADDRESS
EAlAJE7lI . 1(, iLlS pllllff~ /f1/5,{JUE
FIRM NAME (If Applicable) 7
{!/l-/CU.s LE; fJ/I /7~/ 3
TELEPHONE NUMBER
71 -
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
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IX:
3. Closely Held Corporation. Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule 0)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 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)
(6)
(7)
(9)
(10)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at oollateral rate
19. Tax Due
OFFICIAL USE ONLY
(8)
9QlJ'(). tJ()
~/7~ I ~S-
6 95(, 1.3~
(11)
(12)
(13)
/.3 J ~5 tZ.. JlS
d
(14)
.f7'
x.O_ (15)
x.O_ (16)
x .12 (17)
x .15 (18)
(19) .6
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
~..J~S.E;':~fPE;'ANDI{(e:qHE.C~lMf(
20.0
. R:.
Decedent's Complete Address:
STREET ADDRESS
/~s h,eTC~ /.Ji/E"uVE
C'TY(]/lIlLlcSLE I
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
p
Total Credits ( A + B + C ) (2)
3. InteresVPenalty if applicable
D. Interest
E. Penalty
TotallnteresVPenalty ( D + E ) (3)
4. If line 2 is greater than line 1 + Line 3. enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(SA)
(5B)
if
Make Check Payable to: REGISTER OF WILLS, AGENT
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.......................................................................................... 0 B"
:: ;:::~ :h~e:;:i~~:~s:~~~::~:~..~.~~~~. ~~~.~~~.~~~~~.~. t.~~.~.s~~.~~~ .~~. i~~. ~~~.~.~.;.::::: ::::::::::::::::::::::::: :::::::::::::: B ~
d. receive the promise for life of either payments. benefits or care? ...................................................................... 0 ~
2. If death occurred after December 12. 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 0'"
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 G1"
4. ~~~~::e~~~~~i:~ I~:~~::;:o~~ti:~~.~~.~~~.~.~.~...~n.~.~i.~:. ~~. .~.~~.~.~.~.~~.~:.~~~~~~.~~.~.~.~. ~~~~~.. ........... ... ...... 0 G'"
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 peIjwy. I declare lhall have examined lhis relUm. induding accompanying schedules and statements, and to the besl of my knowledge and belief. it is true. correct and
complete.
Declaration of preparer other lhan lhe ~al representative is based on aU information of which preparer has any knowledge.
URE OF PERSON RESPONSIBLE FOR FILING RETURN
\
DAT5-,.
'f-/I-tJ /
ADDRESS
115" h/l~ 4eAJUE, OIlJeLi,sLE) ~/I-
SIGNATURE OF PREPARER OTHER THAN REPRE~ENTATIVE '
171)13
DATE
ADDRESS
.~.>:~~_'_r.f..:.....~J,:.:~~~t ~\l'.3;!:~:.~:;".:,..~,l:~"'\ '~". :i;.t- f ~~" ~,,;1:;..';:_(I, -<:~":J ,:~~:~~-.~':!':~;.:!:-;~~~ - .:'-.:>:' -". ~~-;..;:.;: ' ~" ,.~,c-::;';;".~'t!.~'"';--~~':
'. "';, ~ ~ ,...\r;....r .:_ ;').~ .~; - < \~~~-~~t.;i?/,G-k~i'~,~.--)1~4
For dates of death on or after July 1. 1994 and before January 1. 1995. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. ~9116 (a) (1.1) (i)l.
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (iill.
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax 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. ~9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~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 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.
_tv-15038<.-(197) ~
., ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
FILE NUMBER
All property jointly.owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
kEF tiP'€" .
ItJ9 T1WST IAJTEIlGS- rS @ $.;JO,IO eA-t!_1I V/l/-WE
.4 ,;z. tf tJ. 09
TOTAL (Also enter on line 2, Recapitulation) $ r::9 ~ .f'tJ , tJ '1
(If more space is needed, insert additional sheets of the same size)
REV-I508 EX -+ (1.97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
. ,
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
I{ $ T ~n/JK (!f./E{!KilJ c:-.4&!/J/J1.J r
iI: Oil!, 77/ ;;?/S31
VALUE AT DATE
OF DEATH
06' 7b; d- 7
TOTAL (Also enter on line 5, Recapitulation) $ ~ t; 74:> ' ~ 7
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99) _
~~
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
IfOAJ4l6
1E/lIeV)'/- /I R. T
L.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
FUNERAL EXPENSES:
FI/ 11 ~fUl-t,- (001)5 /h7iJ .s~ VI ~ E S
1.
WESTMIA/~rcrr (!EMEl7I--I<Uf FEE $
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State _ Zip
Year(s) Commission Paid:
2.
Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
AMOUNT
~ t. &/5. &0
;? (; r; ~-. b-O
11/
q).. /? (). 170
.
REV-1512 EX. (1.9?)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
f()lJl}tjJ L. 841f?11J1I,4,e T
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
d.
.3.
1-
$.
b.
7.
8,
q
(o.
tf.
DESCRIPTION
AMOUNT
Et.4d6
.stt&,~
.3~:;. ~
la~~. 3~
II 7 7. Lf 0
tu "0
fY.' o-c
Ig~ 13
I 1-3 ' .z(j
3..:z.c:l
J 7- ()()
e t/ J{~E1f,UJ-A//J- r; tJOlJUJI tL /1M IlUU.<J ~E
f!L;1i~tAlJ/) - WOIJa1ltL /f~g()t4A..16t:
&;~LI:St.E /l,L S.
fJIAlIJ/1tlt.E I/E/J/fIJ //oSfJ'~L
{!fi,fl)/O -V/7SWL/it€.- St/JeGlU+L IN'S'/"""':
/!f/}.::iL/l/U/j IlsstJe.//1rES
~OPF/rr fJE/lSE (LiA1 Ass(J(!. I,Ue.
/ .)
I€ltole ;fe6t()~A-L J,fEiJl&;L {!EA.lTCI€..
RJVER.6.llJe ANesTIli:S/-4 Assoc.
-DR. l(e1ilf S .flJMJfo~ N,lJ .
BEI1C!JJIJ NELJ/(!A-L 6&;up
TOTAL (Also enter on line 10, Recapitulation) $ /11'72. 2.;S'
(If more space is needed, insert additional sheets of the same size)
. REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
If () IJ It- Lfj
f3IlJflNIlIt~ T
L.
NUMBER
I
RELATIONSHIP TO DECEDENT
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s)
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
11 FAJAJEl7-! S,
13#IUJ)//I-/2.T Sf2-
/
FIJ-17!EJ2-
AMOUNT OR SHARE
OF ESTATE
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, 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 1I- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)