HomeMy WebLinkAbout09-28-78
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COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
SEP 2 8 '~i~'!'
t~
RC-C~33 (4~73)
-,
RESIDENT DECEDENT
.,'j. _OJ'
COUNTY OF Cumberland
IMPORT ANT:
This return must be completed in detail and filed in duplicate, with all attached, with the Register of WiHs of the
County where decedent resided; Return. is due within nine q10nths after date of death, 'unless .an extension is granted
by the S_ec~etary of Re'otenue. (Section 703 of t~e. [nher~Ulnce and Estate Tax Act of 1961.)
Late of
Cumberland
. .} AFFIDAVITOF .
EXECUTOR
. .
~JI[
County
IN THE MATTER OF THE ESTATE OF
Rose E. Graham
(STATE FULL NAME OF DECEDENT)
State of
Pennsylvania
Cumberland
} ..:
County of
Dauphin Deposit Bank and Trust Company
XlillMlKIXOOK<XX
Executor
of the estate of the abo"'e~nomed decedent. being duly sworn, deposeS
and GaYS
(MONTH)
7.
(DAY)
, 19~{~estote lea....in~ a.l06t',,;;II, copy of w.hi.~'h' i~ hereto attaChed.:}
(YEAR) Intestate
~ .. .
Decedent died
May
'.' }
Name ond address of..oftarney or .
other .outhoriz:ed representati...e to whom .
all correspondence should ee moiled.
Dauphin Deposit Bank and Trust Company
2 West High Stiee~; Carli~le, ~enrisylvania
i7013
That as such exe cuto r deponent is Jamiliar with the afrairs or .s.aid estate .and the .property cOl1sti tuting
." (EXECUTOR-ADMINISTRATOR) .
the assets thereof and their rair market value.
. , ,
That at the time of death there was no safe deposit box registered in de,cedent' s individual name, or jointly with, or
as agent or depu,ty of another, or, in decedent's individual name, with.right of access. by: another as agent or deputy;'with the
exception. or the Jollowing: -
NAME AND ADDRESS OF BANK OR OTHER IN?TITU~ION T.HIS SAFE DEPOSLT BOX RENTED RELATIONSHIP OF JOINT
IN WHICH DECEDENT RENTED A S.~FE DEPOSIT BOX IN NAME OR NAMES O'F HOLDERS TO DECEDENT
The First National Bank . lio se .l!;'. uranam
9 Bi~ Sprin~ Am"" . Stewart C. Graham- (Deed) Husband
Newville. Pa. 172L..l C. Freemont Graham Son
Marian N. Skellv Dau&'hter
Emily K. Graham Dauahter-in-law
That. the contents of said safe depo~sit box or boxes' ar,e itemized under S~h~dulesA &' !:bf thi~ return,
wi th the exception'of the. following, for the reasons her~ina(te~ set forth:
That Scheelule A attached hereto a'nd made part hereof sets forlli fully and in detail allthe real property
in the Commonwealth of Pennsylvania of ~hic~ decedent died having an interest ther~in. It also sets forth ,the
mortgage encumbrances upon each pa~cel or real property ~'t the d<;ite of dea.th, giving the a~ount still due at
death, name of mortga~ee, date, fate of ~nterest, and book and page of record thereof. It.also s,ets forth in the
columns provided therefore the assessed valuation of each of said parcels, the es.timated, market value thereof
as of date of death of decedent.' , ~..
That Scheelule B attached hereto and made parI hereof sets forth fully and in detail. all personal. p~?perty ~ '.,
wheresover situated owned by the decedent at the time of-.death; all moneys left by"the decedent at the- time of-
lI' . .
death, whether in decedent's immediate possession, standing to decedent's credit in banks of depp'sit, 'saying"s-'
'. . " , ..' ...'-'" "",
banks, trust companies, or other institutions, whether individually, or in trust for any other person or persons'"
giving also separately the accrued interest thereon, if any, down to "'the' last interest d~y pricrt'to~ecc?dent's?
death in the case of savings banks, and .to the date .of decedent's death in all other cases; all bonds;:postal ::
, . -
savings, tre.asw:y certificates or notes and oth~r evidence 'of in~ebtedness of the United Stat~~:t?..'t~e de'~;:
cedent; all obligatio~~__, whether by st~~ute or agree~ent they are designated as tax :free, of the Un~red .Slates,
or any state, or political subdivision thereof, or of any foreign country, which are owned at the time of death;
.tII...
all >.vearing apparel, je.welry, _ silverware, pictures, books, works of art, household rurniture, horses, carriages,
automobiles; boats, and any'and all other personal chattels of whatsoever, kind or nature, left by decedent,
together with the fairly; estimated rnarke.t value thereof; all bonds and mortgages heM b~ decedent a~d'of all
claims due and owing decedent at the time of death," and 'all promissory notes or other"instruments in writing
for the .payment of money of which decedent died' pos's~ssed, of what~oever nature, with inte~est thereon, if'
any, giving the face value and. estimated rair'market value thereof, and if such esti"~ated fair,market value be
less than the face value, it sets forth briefly the reaso.ns fo~ s~ch d~preciatioI1:,"as to .each item; all moneys
payable to the estate from life insurance policies carried by'decedent; all annuity' and endowment contracts
the proceeds of which were payable upon the death of the decedent; all and the corporate stocks and. dividends
due thereon and unpaid as of the date of death, bonds and accrued interest thereon to the date of decedent's
death and other investment secl'['jties owned by the decedent at the time of death, with the,market value there-
of at such time.
- .
~""~ ';.,. "';.
..-'. ...
. ,
.. ~
.... ~
,
~
.
In the case of' securities of close or family corporations, the values reported are as far as
possible substantiated by financial statements of the corporations, showing the assets and liabilities
thereof as of the date of death. The schedule also sets forth the interest of decedent at the time of
death 1n any co-partnership or business, and 1n support o~ the value of such interest there 1s annexed to
said schedule, financial stlLtements showing the assets and liabilities of said co-partnership or huslness.
A copy of the co-partnership agreement, (if' oral, a statement setting forth the nature of' tne agreement)
together with a statement sHtting forth the character of the business, its location, and such other facts
pertaining to the ousiness as may be pertinent to a ~air and just appraisal o~ the decedent's interest
therein must be submitted. It should also set forth in itemized form, together with the ~air market value
thereof, any other property owned or bequeathed by the decedent at the time of death.
The Schedule C attached hereto and made part hereof sets forth a true answer to each inquiry
contained therein and in the case of trans~ers of property, real or personal, within two years of decedent's
death, in contemplation of decedent's death, '..or intended to take effect in possession or enjoyment at or
after death, said schedule sets forth the nature and value of such property, to whom transferred, the
relationship of the transf'er'ees to the decedent, the proportionate share received by each transferee and
all other facts of a pertinent nature regarding said transfers. In the case of transfers intended to
take eff'ect in possession 01. enjoyment at or after death, there is also attached to the schedule a cony
of the deed, trust agreement or other instrument creating the trust.'. TheTl''l is also set forth in said
schedule a list of all property, real and personal, with its value, which pa~ses at decedent's death by
virtue of' the exercise by decedent, either individually, or jointly with another, or any power of appoint-
ment vested in decedent, either individually or jOintly, by the will, deed, or other instrwnent of another,
with a copy of the instrument creating such powe'r attached to the schedule.
That Schedule D at.tached hereto and made part hereof sets forth the names and addresses of all
persons beneficially interes.ted in this estate at the time of decedent's death, the nature of their res-
pective interests, their relationship, if any, to the decedent, together with the ages at the time of
decedent's death of all minors, annuitants and beneficiaries ~or lire under decedent's Will. It also
contains a statement showing; which of the beneficiaries named in the decedent's will, if any, died prior
to decedent, the dates of their death, their issue, and the relationship of such issue to the beneficiary.
That S.:r.edule E attached hereto and made a part hereof sets forth all property, real and per-
sonal, owned by the decedent jointly with another or others, including intangible, standing in the name
of the decedent and others, plus the date and'place of record of instruments effecting the vestiture 'of
real estate and the date of acquisition or personalt~, plus the name, address and rela~ions~ip, if any,
of co-owners to the decedent.
That Scr.edule F attached hereto and. made a part hereof sets f'orth fully and in detail all debts
and deductions claimed for and on behalf of this decedent's estate, including funeral expenses paid;
family exemption, where applicable; costs of administration of this estate; counsel fees and f'udiciary's
commissions paid or to be paid; cost expended for burial trusts, tombstones or gravemarkers, and reli-
gious services, in consequence of the death of the decedent; debts and claims owing anri unpaid at time of
death; taxes accrued charget~le for period prior to decedent's death (except those allowed under Section
651 of the Inheritance and :H:state Tax Act); together with a statement of collateral pledged for obliga-
tions, if any. It is agreed that the fiduciary will present proof of said claimed obligations upon re-
quest, that if' the amount actually paid in settlement of any fee, commission or debt is less than the
estimated amount claiming and allowed, that the same will be reported to the Register of Wills, and that
the amount of tax assessed ean be reassessed in accordance therewith.
That the totals of' the appropriate columns in Schedules "A", "an, "e", "E", and nFn as directed therein,
have 'been carried forward and properly registered in the Summary.
. ~.
. -
SUbscriood and sworn to before me this """""""'"'.,,,,,......,.,
- ' J!
......~~54 "day Of....:2y~,.19"7L,,
.........:OifY.LiI~~""""""""
Dauphin Deposit Bank & Trust Company
Nbtary Public, Carlisle, Cumberland Co.
My Commission Expires February 13, 1979
~",,1aL..9. ~
A ssit'(E;;;;;;t;;~JibimtntiictaiMTTru'st'''''()'f'fi c er
?1:l."l.:?:t."J.I~g.l}..?.:t;,l.:.E'lE'l.:L.."..,........."._.._,
(Street Number)
.....c:.~:r:l::~S.:l::t:lI.~':l~:l::?~}}..,",.
(City 01' Tow" aM St4te)
NOTE: Before signing affidavit make sure all blank spaces in the aff'idavit and schedules annexed are
filled in with details or the word "Nonen, and in case the assets include rare and unlisterl securities,
securi ties of close or famHy corporations or an interest in any co-partne.rship or business, that the
data and statements requireli under the paragraph above relating to Schedule nB" are attached. Also make
certain that cohurm #1 in the "Sunmary" has been properly completed as above-directed.
}~CC-34 (H54)
. COMMONWEALTH OF PENNSYLVANIA
. DEPMTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "A"
REAL PROPERTY
--
Real property in Pennsylvania, with statement of mortgage encumbrances upon each parcel at death of dece-
dent. Where property held as joint tenant or tenancy by entireties, report an Schedule "E", Property held by
the decedent as tenant in cammon with another or others, should be identified as to quantum of interest and
the estimated value should be that of the decedent's interest only.
The real property located In the Commonwealth of Pennsylvania should be
described by lot and block number, street and street number, together with
a general description of the property. with a reference to the record of the
conveyance by which the decedent took title; if a farm state number of a-
cres; also statement of mortgage encumbrances upon each parcel at death
of decedent. Taxes, assessments, accrued Interest on mortgClges, etc.,are
to be listed on Schedule "Fit ond must not be deducted from this schedule.
(1)
(2)
(3\
aEPARTMENT
VA LUA nON
CAUTION
(Do not write
In this space)
ASSESSED VALUE
FOR YEAR OF
OECEOENT'S
DEATH
ESTIMA TED
MARKET VALUE
,~ story frame dwelling, known and numbered
as 54 South High Street, Newville, Pennsyl
vania, more fully described in Deed dated
August 22, 1969, between Mark E. Garber,
Executor of the Estate of Bruce M. Bowman
and Stewart C. Graham & Rose E. Graham,
recorded in Cumberland County Deed Book
"I", Page 860.
Appraised Value
28,500.00~~i; )00. d~
~1.J..~
J..1+A/J.
'7o/,O
~
',(3 () ()
~;-
)./)
I
If; jdO.aJ
Insert this total apposite "real property", Schedule "A" in the X X X X X
"As Reported" column an the last page of this return.
28,500.00
ReC-35
RESIDENT DECEDENT
SCHEDULE "n"
PERSONAL PROPERTY
~~
""'.
I. t\
,
CO~~IONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
INSTRUCTIONS: This Schedule must disclose all ta.ngible and intangible personal property owned individually
by the decedent, at the time of his death. Property owned by the decedent jointly with another or others
must be listed under Schedule "En. Intangible personal property, titled in the name o~ the decedent, but
payable at death to ~nother or others, including but not limited to P.O.D. U. S. Savings Bonds and tenta-
tive trust accounts, must be listed, despite the ract that they are not o~ the administered estate.
Tangible personal property should be listed .first (e. g. jewelry, wearing apparel, household
goods, and furnishings, books, paintings, automobiles, boats, etc.)
Intangible personal property, such as bonds, treasury certificates, cash on hand and in bank,
stocks, mortgages, notes, together with accrued interest or dividends, salaries or wages, insurance pay-
able to the estate or f'iduciary in said capacity,. partnership interests, interest in anyundistributed
estate of" or income from .any property held in trust under the will or agreement of another, even though
located outside of the State, at the time of death, should be listed in this schedule.
Item
No.
ITEM
List and describe fully
UNIT
VALUE
ESTIMATED
MARKEr VALUE
DEPARTMENT VALUATION
(Do not write in
this space)
Cash found in home
Petty cash refund from Presbyterian Homes
Garage rent due May I, 1978
Refund check from Capital Blue Cross
Refund check from Dana P. Brandt -
Personal Property Ins.
Medicare Insurance - Claim check
P . Blue Shield - Claim check
romissory Note - Between Stewart C.
Graham & Rose E. Graham and Marian N.
Skelly & J. Conrad Skelly dated 11-20-5
Id Pocket Watch - Sale price
arious coins - Sale price
Furniture & Furnishings - Sale price
3.32
33.32
4.00
9.35
3. .3 ~
'} 3..J .,.....
~.(J }-
9.J
I'fJ) 0
J '}-. 'l'tJ
It.lO
I. P. CO. 0 ()
~ "17ft
J..~/.()()
{/ ,~(,. 'It)
1.
2.
3.
4.
5.
6.
7.
8.
14.00
32.40
8.10
9.
10.
11.
1,200.00
47.50
241.00
5.546.90
~ J 3 ~ f?
Insert this total opposite ftPersonal Propertyft, Schedule "8ft in
the "As Reported" column on the last page of this return.
X X
7,139.89
RCC- 3&
c-m!'lIOIi'\1CALTH OF PEliNSYLVANIA
T1UNSFEll INHERITANCE TAX
SCHEDULE "c"
T!l~NSFEnS
~\
~
Rc":SIDENT DECEDENT
(1) Did decedent, .wit.hin two years of death, make any transfer of any material part .n.f' his estate, without
recei.ving a valuable and adequate consideration therefor? (Answer yes or no) No
(2) Did decedent, within two years of death, transfer property from himself to himself and another or
others (including a spouse) 1n joint ownership? (Answer yes or no) No
(3) If the answer to (I) or (2) above is 1n the affirmative state:
(a) Age of decedent at time of transfer
(b) State of decedent's health at time of making the transfer. (Note 1).
(c) Cause of decedent' 5 death. (Note 1).
(4) Did-decedent, in his lifetime, make any transfer of property without receiving a valuable or adequate
consideration therefor which was to take effect in possession or enjoyment at or after his death?
(Answer yes or no) Yes
(a) Was there any possibility that the property transferred might return to transferer or his
estate or be subject to his power of disposition? (Answer yes or no) Yes
(b) What was the transfereets age at time of decedent's death?
(5) Did decedent in -h1.s lifetime make any transf'er without receiving a valuable and adequate consideration
therefor under which transferor expressly or impliedly reserves for his life or any period which does
not in fact end berore his death:
(a) The possession or enj~yment of or the right to income from the property transferred?
(Answer yes or no) ~o
(b) The right to designate the persons who shall possess or enjoy the property transferred or
income theref'rom? (Answer yes or no) No
(6) If the answer to (5) (b) above is in the affirmative, state whether the right was reserved in decedent
alone or others
(7) Did decedent in his lifetime make a transfer, the consideration for which was transferee's promise to
pa~' income to or f'or the benefit of care of' transferor? (Answer yes or no) No
(8) Did decedent, at any time, transfer property, the beneficial enjoyment of which was subject to change,
because of a reserved power to al tel', amend, or revoke, or which could revert to decedent under terms
of'. transfer or by operation of law? (Answer yes or no) No
(9) If the answer to (8) above is in the affirmative, was the power to alter, amend, or revoke the inter-
est of the beneficiary reserved in the decedent alone or the decedent and others?
(Answer yes or no)
NOTE 1: The answers'to these questions should be supported by affidavit by the attending physician as
well as a copy of the death certificate.
NOTE 2: If' answer to any of' the above questions is yes, set forth below a description of the property
transferred, it's fair market value at date of death, dates of' transfers and to whom transferred, with
relationship of' transferees to decedent, if any. Submit copy of any trust deed or instrument, if' trans-
fers are claimed to be non-taxable, also submit detailed statement of facts on which said claim is based.
NOTE 3: List applicable property below in manner in which provided in Schedules A, B, or E.
ITEM
DESCRIPT ION
MARKET V ALOE
(Es tima ted)
DEPT. VALUATION
(Dept. Only)
1. Trust with Dauphin Deposit Bank and Trust
Company, as trustee
(Copy attached)
Principal Cash
1669 Shs. Dauphin Deposit Corp. stock
334 Shs. Farmers Trust Co. stock
James R. Johnson et ux mtg. pt. 7t%
Dauphin Deposit Bank and Trust Company,
Statement Savings account
661.22 /' ,,/. P. 'J-.
53,825.25 ::::-~..3/$l".r. ~f'
10,688.00."- /~/ ",.,. oC
1,447.18 /1 ~'I'7. If'
I,
4.000.00 /11,. ()OO. tJO
'lj/ /;)./, 6~
Insert this total opposite "Transf'ers", Schedule "e" 1n the
"As Reported" column on the last page of' this return.
$70,621. 65
· vRCC-37- (12-63)
.
COMMONWEALTH OF PENNSYYLANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "0"
~___:'_ t\
~
BENEFICIAI)IES
(
h
BENEFICIARIES AND ADDRESSES RELA TIONSIIIP SURVIVED
(If step-children or DATE INTEREST OF
State full names and addresses of -all who illegitimate children DECEDENT OF BENEFICIARY
aye an interest. ..vested" contingent or other are involved, set STATE YES IN ESTATE
wise in estate). forth this fac!.) OR NO BIRTH
C. Freemont Graham Son Yes Adult _ Real Estate - 54 S.
33 Parsonage Street High St.., Newville,
Newville, Pa. 17241 I '''. '" -!-I: "- lce
" 'of residue.
Marian N(. Skelly Dau!>'hter Yes Ad ul t 1/2 balance of residu
17 Parsonage Street
Newville. Pa. 17241 -
Nancy Anita Skelly Granddaughter Yes Adult Bal. $1,000. bequest
'71'7 01 rl Lan ",,,,,t,,... Rnad pro-ra~ under
~ -. - t
. u.".. .",
Bryn Mawr. Pa. 19010
Johanna G. Skelly Reeder Granddaughter Yes Adult Bal. $1. 000. beouest
R. D. # 4. Box 468 pro-rated under
. -- -
Newville. Pa. 17241 . u"..~.. ~~t
J. DOUP'las Skelly Grandson Yes Adult Bal. $1. 000. beouest
17 Parsona!>'e Street pro-rated under
Newville, Pa. 17241 u ""W",'" v. unUl",m "'''"
Melissa Ann Skelly Granddaughter Yes Adul t Bal. $1. 000. bequest
17 Parsonap'e Street pro-rated under - t
,,~ . - -
.
Newville. Pa. 17241
Eleanor J. Graham Getzke Granddau!>'hter Yes Adult Bal. $1. 000. beouest
-n "I East 9th Street pro-rated under
Ocean City. N. J. 08226 ""w<U" I.i. -\.Ire "'5\>
Stewart Gareth Graham Grandson Yies Adul t Bal. $1. 000. beouest
52 S. Hi!>'h Street ~ pro-rated under -
- -
Newville. Pa. 17241 .~ .~. " v. U". ~~"
,
.
.'
.
e
.
Deponent further says that all the above-named beneficiaries are living at this time except below:
NAME
DATE OF DEATH
RESIDENCE
.
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o .
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V): C
02 IV e
Os aJ .:
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<: E ~
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<.~'"
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o ~ <.
~ 0 0
~ E fr
~ 0::
SUMMARY
Real Property ..... ......................{Seh. "A")
Personal Property .. .."."'.. ...{Seh. "B")
Transfers .......... . ........... .. ..(Seh. "C")
Gr9ss Taxable Estate ..
(1 )
(As Reported)
$..:2$,500,00
$ . .7,),39,$9
$ ....'!O,.(,2.1.,6~
$
$
$ ...lQ6,261..g
(2)
(As Ddermined)
$
$. .
$.
$..
$..
$..
b
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<. ~ ~
oj ... ~ (1): ...
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RCC-38
llESIDENT DECEDENT
SCHEDULE "E"
JOINTLY OWNED PROPERTY
IJ*,,,
~
.
CQMMONWE~LTH OF PENNSYLVANIA
rH,\NSFl,1\ INHEllI rANCE TAX
I~STRrCTIOKS: This schedule must disclose all property, real and personal, owned l)y the decedent jointly
wit.h another or others, including intangibles, standing in the name of' the decedent and others. List
real estate first, as entireties, or Joint tenants, giving brief description, as indicated nncler Schedule
"An, plus the date and place of record of instrument effecting vestiture, but do not include entireties
or out of state real estate value in estate valuation column. Personal property should be listed as in
Schedule "B", ll1uS date of acquisition, and the name, address and relationship (if' any) of co-owners to
the decedent.
Description of Property, Date of Acquisition, Name I vnlt percentage Estate DEPARTMENT VALUATION
Address and Relationship of Co-Owners, and Place I Value Share Valuation CAUTION-Do not Write
of Record o~ Instrument, where Rea~ Estate. ! In This Space.
y ><X ~ = 8:i Yx :x 'X ~ Value of Value of
0< ><X ::>0 :sc< 0< X> Deceden tis
<< Y> Y ~ Entire
x: 'V .'V ^" XX! ><X ~ X> 'X XX! :i<< y, x> Property Iriterest
.
None
',1.' iN JNE
..
I '"-
I
I I
I I
,
I I I
Insert this total opposite "Jointly Owned Property", Schedule "E"
in the" As Reported" colwnn on the last page of this return.
-0-