HomeMy WebLinkAbout08-29-05 (3)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
WILEY LENOX COLGAN & MARZZACCO
1 SOUTH BALTIMORE STREET
DILLSBURG, PA 17019
____u__ fold
ESTATE INFORMATION: SSN: 210-30-0716
FILE NUMBER: 2105-0242
DECEDENT NAME: SMITH BARBARA L
DA TE OF PAYMENT: 08/18/2005
POSTMARK DATE: 08/17/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 02/20/2005
NO. CD 005708
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $82.17
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$82.17
REMARKS:
CHECK# 228
SEAL
INITIALS: CCP
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
Register of Wills of
Cumberland
County, Pennsylvania
INVENTORY
Estate of
Barbara L. Smith
No.
Date of Death
21-05-00242
-~Lfeceased-
Social Security No.
02/20/2005
-_...._--._-----_._---~
210-05-0242
also known as
Sandra K. Mulder
- ______ ____ __" _. ___n______.______
The Personal Representative{s) of the above Estate, deceased, verify that the items appearing in the following Inventory
include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania
of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of
the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except
that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory
are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S.
Section 4904 relating to unsworn falsification to authorities.
1.0. No.:
~~I1_~'_\'\Iil~~_
06298
Personal Represent~
___________ Signature: km~--
Sandra K. Mulder
Signature:
Attorney:
Firm:
Wiley, Lenox, Colgan, & Marzzacco,
~-'C._------ -
Signature:
Telephone:
130 W. Church St
. [) i1Is_~u rQ...f>>A...~7~~9____
717 -432-9666
Address: 66 Clemens Drive
DiIlsburg, PA 17019
----.._-----
Telephone: 717-432-5555
Address:
Dated:
08/16/2005
Personal Property
Cas h...............................................................................................
Miscellaneous Property................................ ..... ..... ......................
Stocks/Listed.................................................................................
Stocks/Closely Held......................................................................
Bonds.............................................................................................
Partnerships and Sole Proprietorships .....................................
Mortgages and Notes Receivable...............................................
73,1~.72
25('-':00
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Total Personal Property.........................................
\.D
73,392.72
Total Real Property................................................
Total Personal and Real Property.........................
Total Out-of-State Real Property..........................
REV.1500 EX + (6-001
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OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
II 05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
NUMBER
.--
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W
C
W
o
W
C
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Smith, Barbara L.
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM.DD-YEAR)
02-20-2005
11-04-1938
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST AND MIDDLE INITIAL)
~ 1. Original Return
o 4. Limited Estate
[!] 6. Decedent Died Testate (Attach
copy of Will)
o 9. litigation Proceeds Received
o
o
D
o
2. Supplemental Return
00242
210-05-0242
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
4a. Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10 Spousal PovertY Credit (date of death between
. 12-31.91 and 1-1.95)
o 3. Remainder Return (date cfdeath pricrtc 12-13-82)
o 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
....
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NAME
Jan M. Wiley
FIRM NAME (If applicable)
Wiley, Lenox, Colgan, & Marzzacco, P.C.
TELEPHONE NUMBER
717-432-9666
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
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) 0 Separate Billing Requested
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)
COMPLETE MAILING ADDRESS
130 W. Church St
Dillsburg, PA 17019
(1) None
(2) None
(3) None
(4) None
(5) 73,392.72
(6) 157.67
(7) None
(9) 19,489.92
(10) 7,234.54
OFFICIAL,JJSE ONLY
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(8)
73,550.39
(11 )
26,724.46
46,825.93
0.00
(12)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has
not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(13)
(14)
46,825.93
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
20.0
0.00
2,107.17
0.00
0.00
2,107.17
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Copyright 2002 form software only The Lackner Group, Inc.
15.Amount of Line 14 taxable at the spousal tax rate, 0.00 x .00 (15)
z or transfers under Sec. 9116(a}(1.2)
0
i= 16.Amount of Line 14 taxable at lineal rate 46,825.93 x .045 (16)
<(
.--
:J
c. 17.Amount of Line 14 taxable at sibling rate 0.00 x .12 (17)
:!:
0
u 18. Amount of Line 14 taxable at collateral rate 0.00 .15 (18)
>< x
~ 19. Tax Due
(19)
Form REV-1500 EX (Rev. 6-00;
Decedent's Complete Address:
STREET ADDRESS
Country Meadows
CITY Mechanicsburg
I STATE PA
IZIP 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
1,923.75
101.25
Total Credits (A + 8 + C)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + E)
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
5. If Line 1 + Line 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 Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
(1 )
2,107.17
(2)
2,025.00
(3)
(4)
(5) 82.17
(5A)
(58) 82.17
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. retain the right to designate who shall use the property transferred or its income;.................................... 0 [!]
c. retain a reversionary interest; or.................................................................................................................. 0 [!]
d. receive the promise for life of either payments, benefits or care?.............................................................. 0 [!]
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ............................................ ..................................... ............ ...... ........ ............ 0 [!]
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... 0 [!]
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?.................................................................................... ................ .......... ....... 0 [!]
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 pe~ury, I dadare 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 than the personal representative is based on all infonnation of which preparer has any knowledge.
SIGNA E OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Sa a K. ulder
66 Clemens Drive
DiIIsburg, PA 17019
ADDRESS
TUR O~ PREPARER OTHER THAN REPRESENTATIVE
M. iley . \ n.
~ \.A-. . L,-.J ~
ADDRESS
130 W. Church St
DiIIsburg, PA 17019
DATE
<;;/lU, OS
, OAT
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. 99116 (a) (1.1) (i)].
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. 99116 (a) (1.1) (ii)]. The statute does not 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. 99116 (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.
99116 1.2)[72 P.S. 99116 (a) (1)].
The tax rate imposed on the oet 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.
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ffiant Bill ann [[~51am~nt.
OF
BARBARA L. SMITH
BE IT REMEM"'RED, that I) Barbara L. Smith) of R. D. 2,
D' , b C l' Township, York County, Pennsylvania, being ot
J.~..Ls urg, arro
d .mi d _~ory and understanding) do make) publish and declare
soun n , roo---
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 situated) whether it be real,
personal or mixed, including property over which I have a power of
appointment) I give, devise and bequeath unto my husband, Clyde J.
Smith, absolutely, providing he survive$ me for a period of thirty
(30) days.
ITEM 3: In the event that my husband, Clyde J. Smith,
predeceases me or dies on or before the thirtieth day following my
death, I devise and bequeath all of my estate of every nature and
wherever situate to my issue per stirpes living on the thirty-first
day following my death.
ITEM 4: I appoint The Commonwealth National Bank, of Harris-
burg, Pennsylvania, guardian of any property which passes either under
this will or otherwise to a minor and with respect to which I am
authorized to appoint a guardian and have not otherwise specifically
done so, provided that this appointment of a guardian shall not super
sede the right of any fiduciary in its discretion to distribute a
share where possible to the minor or to another for the minor's
benefit. Such guardian shall have the power to use principal as we]
~M'Z'Uti/ k ~~2$6
ARBARA L. SMITH
(];/J1/J! /7J&;ffiLfnt /
Rev-1S08 EX+ (6-98)
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH Of PENNSY\.VANIA
INHERITANCE TAX RETURN
RESIOENT DECEDENT
Smith, Barbara L.
FILE NUMBER
21-05-00242
ESTATE OF
Indude the proceeds of litigation and the date the proceeds were received by the estate.
All property jolntly-owned wtth the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Country Meadows (refund): 3.833.20
2 Dr. Sanford (refund): 48.91
3 Heritage Medical (refund): 31.92
4 Nephrology Assoc. (refund): 116.71
5 Physicians Group (doctor refund): 27.00
6 Pinnacle Health (refund): 80.82
7 PNC Bank Checking #5140198058: 189.21
8 Readers Digest (refund): 6.99
9 Smith Barney Account #724-08525-1-2-364: 67.632.96
10 Social Security: 1.175.00
11 Sofa and chair, bookshelf, kitchen table & chairs: 250.00
TOTAL (Also enter on Line 5, Recapitulation)
73.392.72
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
Rev-1509 EX+ (6-98) *'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIOENT DECEDENT
SCHEDULE F
JOINTLY -OWNED PROPERTY
ESTATE OF
Smith, Barbara L.
FILE NUMBER
21-05-00242
If an ISset was made Joint within one ysar of the deeedenrs date of death, It must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME
A. Joseph E. Smith
ADDRESS
11 I) Maplewood Drive
Beaver, PA 15009
RELATIONSHIP TO DECEDENT
Son
B. Amanda Jo Smith
110 Maplewood Drive
Beaver, PA 15009
Granddaughter
C. Thomas Michael Smith
110 Maplewood Drive
Beaver, PA 15009
Grandson
JOINTLY OWNED PROPERTY:
DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM LETTER INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH
FOR JOINT MADE DECO'S VALUE OF
NUMBER TENANT JOINT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSET INTEREST DECEDENTS INTEREST
JOINTLY-HELD REAL ESTATE.
1 A&B 10/26/1992 PNC Bank Savings Account 258.51 33.333% 86.17
#5130001661:
2 A&C 10/26/1992 PNC Bank Savings Account 214.50 33.333% 71.50
#513000168&:
TOTAL (Also enter on Line 6, Recapitulation) 157.67
(If more space is needed. additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule F (Rev. 6-98)
o PNCBAN<
March 22, 2005
Jan Wiley
Attorney at Law
130 W Church St.
Dillsburg, P A 17019
scp
RE: Estate of Barbara L Smith (Deceased)
SSN: 210-30-0716
DaD: 02-20-2005
Dear Ms. Wiley:
In response to your request for Date of Death balances for the customer noted above, our
records show the following:
Checking Account
Account #5140198058
Established 03-01-1970
BARBARA L SMITH
DaD balance: $189.21 Non interest bearing account
Savings Account
Account #5130001661
Established 10-26-1992
JOSEPH E SMITH
AMANDA JO SMITH
BARBARA L SMITH
DaD balance: $258.49 + $0.02 accrued interest
Account #5130001688
Established 10-26-1992
JOSEPH E SMITH
THOMAS MICHAEL SMITH
BARBARA L SMITH
DOD balance: $214.47 + $0.03 accrued interest
Page 1 of2
Please note that this office only provides date of death balances for deposit accounts
(IRAs, CDs, Checking and Savings accounts). We do not process any financial
transactions or provide statements. If you need assistance with any of these items,
please call1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch
office.
Sincerely,
~ .::?~-~
Erica L Schlegel cr
1-800-762-1775
P7-PFSC-04-F
500 First Ave.
Pittsburgh P A 15219
Member FDIC
Page 2 of2
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SMITH BARNEY....
cltlgroupJ
April 7, 2005
JAN M. WILEY, ESQ.
The Wiley Group
Attorneys at Law
130 W. Church Street
Suite 100
Dillsburg, PA 17019
RE: Estate of Barbara L. Smith
Account #724-08525-1-2-364
Dear Attorney Wiley:
The account of Barbara L. Smith was opened on 6/26/03. It
was a single retail account. It is the only account she
holds at Smith Barney.
I have attached the date of death values as of 2/20/05 for
the Estate of Barbara L. Smith. The prices are the average
prices from 2/18/05 and 2/21/05 since 2/20/05 was a Sunday.
If you have any further questions, please do not hesitate
to contact me at 780-1751.
Sincerely,
~/f1. lJt~
Ann M. Dunkelberger
Senior Sales Assistant
To Lonnie A. Friedman
Senior Vice President -
Investments
lamd
Enclosures
Citigroup Global Markets Inc. 11 North 3rd Srreer, 2nd Floor Harrisburg. PA 17101 Tel 717 7801700 Fax 7172332090 Toll Free 800 2371700
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SMITH BARNEY....
cltlgroupJ
ESTATE OF BARBARA SMITH
SANDRA MULDER, EXECUTRIX
ACCOUNT #724-08525-~-2-364
DATE OF DEATH VALUE AS OF 2/20/05
DATE OF DEATH VALUE
QUANTITY DESCRIPTION VALUE 2/20/05 2/20/05
13,186.35 BANK DEPOSIT
PROGRAM $ 1.00 $13186.35
2,856.74 EVERGREEN ADJ. RATE 9.38 26796.22
FUND
86.194 SALOMON BROTHERS 12.78 1101.55
BALANCED FUND
831.743 SB APPRECIATION CL C 14.45 12018.68
184.63 SB FUNDAMENTAL VALUE 13.92 2570.16
CL B
13,000.00 GINNIE MAE SERIES 92.00 11960.00
2003-57 4.5% 4/20/33
TOTAL VALUE AS 2/20/05:
$67632.96
THE INFORMATION HEREIN HAS BEEN OBTAINED FROM SOURCES WE BELrvE TO BE RELIABLE, BUT DO
NOT GUARANTEE ITS ACCURACY OR COMPLETENESS.
Citigroup Global Markets Inc. II North 3rd Street, 2nd Floor Hartisburg, PA 17101 Tel 717 780 1700 Fax 717 233 2090 Toll Free 800 237 1700
Rev.1502 EX+ (5-98)
.
SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Smith, Barbara L.
FILE NUMBER
21-05-00242
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Cocklin Funeral Home:
9.335.38
2
Joan Trostle (funeral luncheon):
143.06
Subtotal
9,478.44
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
REV-1151 EX+ (12-99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Smith, Barbara L.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-05-00242
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
See continuation schedule(s) attached
9,478.44
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
B.
Sandra K. Mulder
Social Security Number(s) I EIN Number of Personal Representative(s):
193-46-4618
Street Address 66 Clemens Drive
City DiIIsburg State
Year(s) Commission paid 2005
See continuation schedule(s) attached
PA
Zip 17019
3,675.00
2.
Attorney's Fees
See continuation schedule(s) attached
3,675.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
181.00
See continuation schedule(s) attached
5. Accountant's Fees
6.
Tax Return Preparer's Fees
85.00
7.
See continuation schedule(s) attached
Other Administrative Costs
See continuation schedule(s) attached
2,395.48
TOTAL (Also enter on line 9, Recapitulation)
19,489.92
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
Rev-1502 EX+ (6-98)
*'
SCHEDULE H-B1
PERSONAL REPRESENTATIVE'S
COMMISSIONS
continued
COMMONWEALTH OF PENNSYLvll.N1A
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Smith, Barbara L.
FILE NUMBER
21-05-00242
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Sandra K. Mulder, Executrix:
3.675.00
Subtotal
3.675.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B1 (Rev. 6-98)
Rev-1502 EX+ (6-98)
*'
SCHEDULE H-82
ATTORNEY'S FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Smith, Barbara L.
FILE NUMBER
21-05-00242
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Wiley, Lenox, Colgan, & Marzzacco, P.C.:
3,675.00
Subtotal
3.675.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B2 (Rev. 6-98)
Rev-1502 EX+ {6-981
SCHEDULE H-84
PROBATE FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Smith, Barbara L.
FILE NUMBER
21-05-00242
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Register of Wills:
181.00
Subtotal
181.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B4 (Rev. 6-98)
Rev-1502 EX+ (5-98)
.
SCHEDULE H-B&
TAX RETURN
PREPARER'S FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Smith, Barbara L.
FILE NUMBER
21-05-00242
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Boreman & Bobb (tax preparation):
85.00
I
Subtotal
85.00
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B6 (Rev. 6-98)
Rev-1502 EX+ (6-98)
*'
SCHEDULE H-87
OTHER
ADMINISTRATIVE COSTS
continued
COMMONW~THOFPENNS~VAN~
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Smith, Barbara L.
FILE NUMBER
21-05-00242
ESTATE OF
ITEM
NUMBER DESCRIPTION AMOUNT
1 Cumberland Law Journal (advertise): 75.00
2 Register of Wills (filing fee): 30.00
3 Social Security Administration: 1.175.00
4 The Sentinel (advertise): 191.48
5 US Treasury (tax): 924.00
Subtotal
2.395.48
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
Rev-1512 EX+ (6-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
CO~ONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Smith, Barbara L.
FILE NUMBER
21-05-00242
ESTATE OF
Include unrelmbursed medIcal expenses.
ITEM
NUMBER DESCRIPTION
1 Ambulance Services:
VALUE AT DATE
OF DEATH
193.78
2 Assoc. Cardiologist & Cardiac Diagnostic:
7.05
3 Cardiovascular Associates:
14.12
4 Charles Inners, MD:
142.17
5 Comcast (cable):
14.95
6 Country Meadows (assisted living):
1.333.00
7 Dialysis Clinic, Inc.:
85.94
8 East Shore Surgical:
87.26
9 Harrisburg Gastrology and Jackson Gastrology:
130.48
10 Health South (rehab):
931.08
11 Hematology & Oncology:
226.90
12 Internists of Central PA:
532.34
13 Kauter & Thatch Physicians:
38.38
14 Kimberly-Clark (return pension payment):
367.82
15 Kunkel & Assoc. Physicians:
7.06
16 Moffit & Pease Physicians:
375.17
17 Nephrology Assoc.:
342.57
18 OSL DBA Orthopedics:
70.63
Total of Continuation Schedule(s)
See attached page
TOTAL (Also enter on Line 10, Recapitulation)
7,234.54
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
Rev-1512 EX~ (6-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Smith, Barbara L.
FILE NUMBER
21-05-00242
ESTATE OF
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
19 Physicians of Rehab: 35.50
20 Pinnacle Health Assoc.: 1.449.25
21 Prism: 50.92
22 Pulminary & Critical Care: 96.88
23 Riverside Anesthesia: 20.72
24 Sanford & Roumm Physicians: 196.04
25 Susquehanna Suggeons & Mousour: 37.47
26 The Wiley Group (previous bill): 400.83
27 Verizon: 46.23
TOTAL (Also enter on Line 10, Recapitulation)
7.234.54
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
. .
REV 1513 EX+ (9~O)
*'
SCHEDULE .. I
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith, Barbara L. 21-05-00242
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not Ust Trustee/sl
I. TAXABLE DISTRIBUTIONS [include outright sfrousal
aistributions. and ransfers
under Sec. 9116(a)(1.2)]
Sandra K. Mulder Daughter one-third
66 Clemens Drive
Dillsburg, PA 17019
Joseph E. Smith Son one-third
110 Maplewood Avenue
Beaver, PA 15009
Robert A Smith Son one-third
10300 Sage Creek Drive
Galena, OH 43021
Total
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 T J\)( IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 6-98)