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HomeMy WebLinkAbout01-0891 /"}-/o - 0 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT * REV-U07 EX AFP Clt-OO) Ftecoroed 0_. ..of Register of VVitls .01 tflV 26 All:48 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 11-19-2001 NULL 04-05-2001 21 01-0891 CUMBERLAND 101 SYLVIA E JAN M WILEY 1 S BALTIMORE ST DIlLSBURG .QIeP;,Q,.: Court 'Cuilberland Co., PA Allount Rellitted 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 ~ REY= i'60-'-EX-AFP-(' i'2=O(ir------...--iNHERITANc'E-TAx-sTA -fEME-NT-ciF-ACCouiif--.i.--------------------- ESTATE OF NULL SYLVIA E FILE NO. 21 01-0891 ACN 101 DATE 11-19-2001 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 11-05-2001 P R I NCI PAL T AX DUE: ........................................................................................................................................................................................................................... 619.27 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 09-27-2001 CDOO0320 .00 619.27 TOTAL TAX CREDIT 619.27 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 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. ) /'l-/o-~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG, PA 171Z8-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX JAN M WILEY 1 S BALTIMORE ST DILLSBURG DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 11-05-2001 NULL 04-05-2001 21 01-0891 CUMBERLAND 101 '* REV-15li7 EX AFP UZ-OD) SYLVIA E Allount Rellitted PA 1'1019 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=is47-EX--AFP-ci2'=oo-f-NOY-iCE-OF-.fNHERiTANCi-TAX-APPRAisEiiENT~--Ai:.LOWAiici-OR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF NULL SYLVIA E FILE NO. 21 01-0891 ACN 101 DATE 11-05-2001 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED I~ an assessment was issued previoUSly. lines 14. 15 and/or 16. 17. 18 and 19 will re~lect figures that include the total of ALL returns assessed to date. 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 R ITS: AMENT DATE 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 .00 .00 .00 .00 32,667.89 .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 Subject to Tax (9) (10) 15,578.38 3.327.95 (11) (12) (13) (14) NOTE: .00 X 00 = 13,761.56 X 045= .00 X 12 = .00 X 15 = T DIS T (+) INTEREST/PEN PAID (-) RECEIP NUttBER AMOUNT PAID PAYMENT MUST BE MADE BY 01-05-2002*. TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax pay.ent. 32,667.89 18.Qnii 33 13,761.56 .00 13,761.56 (19)= .00 619.27 .00 .00 619.27 .00 619.27 .00 619.27 . 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 FOR" FOR INSTRUCTIONS.) September 26, 2001 THE '\VI LEY GROUP Attorneys at La"" Wi ley · Lenox · Colgan · Marzzacco . P.C. Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, P A 17013 In Re: Estate of Sylvia Null, deceased Dear Register: Enclosed for filing please find the inheritance tax return in duplicate, as well as an Estate Information Sheet with regard to the above captioned estate. Also enclosed is a check in the amount of$619.27 representing the tax due, and checks totaling $15.00 representing the filing fee. Please return the recording receipt to my attention in the enclosed envelope. Thank you for your cooperation. Sincerely, jJ Dawn ~elter/ASSiS ant /dg encl. jan M. Wiley · David j. Lenox · Timothy j. Colgan · Christopher J. Marzzacco . Christine J. Taylor 1 South Baltimore Street · Dillsburg, PA 17019 · Phone: (717) 432-9666 . (800) 682-4250 . Fax: (717) 432-0426 Offices in Harrisburg · York . Carbondale ~ (l ~ 0 o ifl cra _,0 ?J -::: ~ ::. f:;-;r cOj qa~ - .- ""\:l3 )7'0 ~...... -.jro S~ ~ro ro .- ~ ~ \~I~ ~m ct. ~ ~ ~Q ~~ ~ "'0 .z . -' >~ ~ . ~r- ?J ro (l ::. (l 0 o Y- ""\:l '(I -:-(joQ~ ~ ~ ~ ~ <e. :::~ ~tA -: If- ("'l ~ ~ -:.- GO...... ,.., ~~...o~ ~ ~ ; ')"so-z - - ~ (') -' :::-lr;;o~ :. o~~tIJ :::.....tflt:l :- ~ ~ .2- :- Co ~ :- e. g ~ ~ S- O' ~ ~ \ \\ \ " ~, ~ \ \ .- -- (' ..,.-J. \ ~ REV-1500 EX + (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-1500 DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN FILE NUMBER ~I HARRISBURG, PA 17128-0601 RESIDENT DECEDENT :1.1 0' COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Null. SVl via E. 199-05-8442 DECE- DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE DENT 04/05/01 07/18/1911 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER B 3. Remainder Return CHECK r Original Return ~2 Supplemental Return (date of death prior to 12-13-82) APPRO- 4. Umited Estate 4a Future Interest Compromise 5. Federal Estate Tax Return Required ~ate of death after 12-12-82) PRIATE 6. Decedent Died Testate 7. ecedent Main1ained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach copy of Will) (Attach a copy of Trust) BLOCKS 9. Utigation Proceeds Received 10. Spousal Poverty Credit (date of death between 0 11. Election to tax under Sec. 9113(A) 12-31-91 and 1-1-95) (Attach Sch 0) :l'HJ$.::~QNMQ$jl:l.g@Q.M#.Uiu.:;p.t~#P'qRRft$PQ&Pf%Ne$i::eQtn~mtf<<liMtA.:KJNf:Q.i:'(MA1iQ..t$H.QU.iltt.tb"~;~~:i NAME COMPLETE MAILING ADDRESS COR- Jan M. Wiley, e one s. Baltimore st. RE- FIRM NAME (If Applicable) Dillsl::urg, PA 17019 SPON DENT Wiley, lenox, Colqan & Marzzacco, PC 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) 32,667.89 RECA- PITULA- 7. Inter-Vivos Transfers & Miscellaneous TION Non-Probate Property (Schedule G or L) (7) None 8. Total Gross Assets (total Lines 1-7) (8) 32,667.89 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 15,578.38 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 3,327.95 11. Total Deductions (total Unes 9 & 10) (11) 18,906.33 12. Net Value of Estate (Une 8 minus Une 11) (12) 13,761.56 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 Subject to Tax (Line 12 minus Line 13) (14) 13,761. 56 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 13,761. 56 x.o 45 (16) 619.27 - 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) 619.27 20. 0 MmepRllatljjHij}('Q~i(ARjj:Jlj~ij~$t.ijG:A::R~UNOQfiAN))ve.8.~AYMe,itit::/ ;.;.;.;.:.;.;.:.:.:.;.:.;.;.;.;.;.;.:.;.:.;.;.:.:.:.;.:.;.:.:.:.:.:.:.:.:.;.:.;.;.: .... ...:.:.:.;.:.....:.:.:.:.:.:...'.'......... .. ..... ............................... . . . .. . . . . . . . . . . . ............................ ... ....,..............................'....................... ..,................................................................................ ........ . . . . . . .. .. . . . . .. . . . . . l 7 - ) 0- S- :::;;:;;:::":':::;:;;:::;;'::;:::;:::;:;:::,:;::;;:;:;::=::::;:;:;:;:;;;;;;:::;:;;::::;;}}(':;:;;;;;;#.i':Ba:$!JBS?rO}i\N$WEBA~t:Q\.J!;$TION$.Q~:PA'Gtlr~\~;NI;tRS~He:G*MAtl4#Kttl}}:~}}}:rtrttt~tt!::% i~!!t~}t1;it)r;ti~; o PA15001 NTF 29755 Copyright 2000 Greatland/Nelco LP - Forms Software Only Estate of: Sylvia E. Null SUMMARY OF ALLOCATIONS 'IO BENEFICIARIES Taxable at lineal rate Gertha V. McClintock 13,761. 56 PA REV-1500 EX (6-00) Decedent's Com lete Address: STREET ADDRESS 613 Ie Bri e Road Page 2 CITY Enola Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount STATE FA ZIP 17025 (1) 619.27 Total Credits (A + 8 + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (0 + E) 4. If Line 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund 5. If Line 1 + Une 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. 8. Enter the total of Une 5 + SA. This is the BAlANCE DUE. 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 No a. retain the use or income of the property transferred; ....................................... ~ I 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 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. 8 ~ 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 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 perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and behef, it is true, correct and complete. Declaration of preparer other than the personal representative is based on information of which preparer has any knowledQe. S GNATURE OF PERSON RESPONSI L FQR FliNG RET N OAT (3) 0.00 (4) (5) (SA) (58) 619.27 0.00 619.27 ~ ADDRESS Schedule attached - ATURE OF PREPARER OTHER THAN REPRESENTATIVE oJ ;s- s. Baltimore st. , Dillsburg, PA 17019 ~~:FJ~;t~::~:~::~:~r~:t:~!::~:~:ml~::J~:j:~::i:;::m~::~~l::~r~:::~r;:~:~::::j~~:~;t:~::;:i:~:~:~~::K::\r::;:f~::i!~:~:~rJ::~:~::~~~:~:~:~:i~i:::~~:~~~~:;W~~:;~:}~~~~:~i~:;t:;Z:!;:~!~:f~!%iie:i~:~:!!; :~~~!~::i!:;~tHliiftnrrlf [72 P.S. & 9116 (a)(1.1)(i)]. For dates of death 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. 19116 (a)(1.1)(ii)). The statute dne~ nnt p.xempt a transfer to a surviVing spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are stiU applicable even if the survivlng spouse is the on'y 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 forthe 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.ll 9116(1.2) {72 P.S.19116(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. o PA15002 NTF 29756 Copyright 2000 Greatland/Nelco LP - Forms Software Only Estate of: Sylvia E. Null '!he following person(s) are signing the return as representative(s) of the estate: Gertha V. McClintock 513 San'ple Bridge Road Enola, PA 17025 REV-1509 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Sylvia E. Null SCHEDULE F JOINTL V-OWNED PROPERTY FILE NUMBER If an asset was made Joint within one year of the decedenfs date of death, tt must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A Gertha V. McClintock ADDRESS 513 Sanple Bridge Road Enola, PA 17025 RELATIONSHIP TO DECEDENT daughter 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 DECEDENrSINTEREST 1 A 09/12/82 Peoples state Bank Account 10,038.85 50% 5,019.42 #6130017921: 2 A 09/12/85 Peoples state Bank Accolmt 10,033.49 50% 5,016.74 #6130021882: 3 A 08/15/88 Peoples state Bank Account 10,068.96 50% 5,034.48 #6130025984: 4 A 03/20/90 peoples state Bank Account 10,021.50 50% 5,010.75 #6130031657: 5 A 08/05/88 Mellon Bank Account 4,638.19 50% 2,319.09 #142-112-7075: 6 A 04/01/98 Mellon Bank Account 15,517.60 50% 7,758.80 #00355-015672: 7 A 09/04/90 Mellon Bank Account 5,017.22 50% 2,508.61 #220-097385-C: TOTAL (Also enter on line 6, Recacitulation) $ 32,667.89 7 CPA91 NTF 10909 (If more space is needed, insert additional sheets of the same size) Copyright Forms Software Only, 1997 Nelco,lnc. @ P.O. Box 7899 Philadelphia, P A 191 01-7899 Mellon Bank April 30, 2001 The Wiley Group Attorneys At Law 1 South Baltimore Street Dillsburg, PA 17019 Attention: Ian M. Wiley Estate Of Sylvia Null Date of Death: 04/05/2001 SSN 199-05-8442 Dear SirIMadam: In accordance with your request, the attached information sheet has been provided in the above decedents name as of his/her date of death. For IL or LC accounts, contact our Loan Department at 1-800-537-5591. For all other inquiries, please call (215) 553-1585. Mellon Bank, N.A. Deposit Support Services 199-5355 Page 1 of 2 fb Mellon Bank ~onday,Apri130,2001 Account Number Account Title 142-112-7075 Sylvia Null Gertha McClintock Date Opened: 08/05/1988 Principal Sal Int from Last as of DOD Posting to DOD $4,638.19 $0.00 Date Opened: 04/01/1998 Principal Sal Int from Last as of DOD Posting to DOD $15,516.96 $0.64 Date Opened: 09/04/1990 Principal Sal Int from Last as of DOD Posting to DOD $5,000.00 $17.22 00355-015672 Sylvia Null Gertha McClintock 220-097385-C Sylvia Null Gertha McClintock Account Type: DO Account Sal YTD Int to as of DOD DOD $4,638.19 $0.00 Account Type: SA Account Sal as of DOD $15,517.60 YTD Int to DOD $19.72 Account Type: TO Account Sal YTD Int to as of DOD 000 $5,017.22 $98.20 ~ Page 2 of 2 11 PSB June 28,2001 The WIley Group Attorneys at Law 1 S Baltimore St DillsburgPA 17019 Re: Estate of Sylvia E Null SSN: 199-05-8442 Date of Death: April 5, 2001 Dear SirrM:adam: This letter is in response to your request for information regarding the decedent, Ms Sylvia E Null. Ms Null held the following accounts with The Peoples State Bank at the time of her death: ACCOUNT NUMBER CURRENT BALANCE ACCRUED INTEREST DATE OF DEATH BALANCE 6130017921 Opened 09-12-82 $10,000.00 $38.85 $10,038.85 6130021882 Opened 09-12-85 $10,000.00 $33.49 $10,033.49 6130025984 Opened 08-15-88 $10,039.34 $29.62 $10,068.96 6130031657 Opened 03-23-90 $10,000.00 $21.50 $10,021.50 These accounts were owne If you have any questions, please call me at (717) 259-2527. Sincerely, turuL-L J. blt:G.d Eunice L Hilty Deposit Operations Clerk Box 1000 East Berlin, PA 17316-0500 800- PSB-9868 REV-1511 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Sylvia E. Null SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NO. A. FUNERAL EXPENSES: DESCRIPTION AMOUNT 1 Cocklin Funeral Home: 9,068.38 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 C~ S~ffi 3,250.00 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 3,250.00 0.00 4. Probate Fees 0.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 7 Filing Fee: 10.00 TOTAL (Also enter on line 9, Recaoitulation) $ (If more space is needed, insert additional sheets of the same size) 15,578.38 7 CPA11 NTF 10911 Copyright Forms Software Only, 1997 Nelco, Inc. . REV-1512 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Sylvia E. Null Include unreimbursed medical expenses. ITEM NO. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER DESCRIPTION AMOUNT 1 HarrisbJrg Diagnostic (last illness): 2 Hanover Hospital (Last illness): 3 Hanover Fire Co. (Last illness): 4 Penn Township AmWlance (last illness): 5 Brockie Phannatech (prescriptions): 6 Choice Healthcare (last illness): 7 Dr. Rhalid Siddique (last illness): 8 Hanover Hall (last illness): 9 Hanover Cardiology (last illness): 48.90 881. 41 31.23 28.70 25.05 53.63 400.00 1,856.98 2.05 7 CPA12 NTF 10912 TOTAL (Also enter on line 10, Recaoitulation) $ (If more space is needed, Insert additional sheets of the same size) 3,327.95 Copyright Forms Software Only, 1997 Nelco, Inc. . REV-1513 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER Sylvia E. Null No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) AMOUNT OR SHARE OF ESTATE 1 Gertha V. McClintock 513 Sample Bridge Road Enola, PA 17025 daughter 13,761.56 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 TOTAL OF PART II -- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 7 CPA13 NTF 10913 (If more space is needed, insert additional sheets of the same size) Copyright Forms Software Only, 1997 Nelco,lnc.