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Home My WebLink About09-09-05 II 217 REV-1500 OFFICIAL USE ONLY RE\'~.1500 EX (6~QO) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RETURN 21-05-0272 DEPT. 280601 FILE NUMBER HARRISBURG, PA 17128-0601 RESIDENT DECEDENT - COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I- Juvenelia Hardina 202-09-5105 z DATE OF DEATH (MM-DD-YEAR) \DATE OF BIRTH (MM-DD-YEAR) W THIS RETURN MUST BE FILED IN DUPLICATE WITH THE C W 3/6/2005 11/14/1915 REGISTER OF WILLS u w (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER C , I!! [R]1 Original Return 02 Supplemental Return 03 Remainder Return (date of death prior to 12~13-82) ",~\2 04. Limited Estate 04a. Future Interest Compromise (date of death after 12-12-82) 05 Federal Estate Tax Return Required 0,,-0 woo [R]6 07. "'O<:.J 0ll:1Il Decedent Died Testate (Attach copy of Will) Decedent Maintained a Living Trust (Attach copy of Trust) - 8. Total Number of Safe Deposit Boxes - <l: 09 010. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 011. Election to tax under Sec, 9113(A) (Attach Sch 0) Litigation Proceeds Received I- THISSECTI6N'MtJSTBECONlPl:EtED.AI1L.C(;)aRESp6t.1DENqJ;',A~P:CPNF1~~1'I~L.1rAXINF()RNlATIONSHOULD $E/ PIRECTED TO: z NAME W COMPLETE MAILING ADDRESS c z Robert G. Frev 5 South Hanover Street 0 II.. FIRM NAME (If Applicable) Carlisle, PA 17013 Ul w Frev & Tilev II:: II:: TELEPHONE NUMBER 0 U 717-243-5838 OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1)NONE r'_J, I~) f'':_''.) ::::J '-'eel 2. Stocks and Bonds (Schedule B) (2) 10,992 . i:J1 . .: ;~ 'I "J) CJ ~, c:> 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) NONE ~:i :.U C~J (4) NONE I 11 4. Mortgages & Notes Receivable (Schedule D) \..0 C:::J 5. Cash, Bank Deposits & MiscellaneDus Personal Property C) (Schedule E) (5) 83,740 -U 1'1 :::L:: 'n C~_::S 6. Jointly Owned Property (Schedule F) (6) 51,470 ,,) I-'n z Dseparate Billing Requested .. 0 W i= <./1 c( 7. Inter-Vivos Transfer & Miscellaneous Non-Probate Property ...J NONE ::l (Schedule G or L) (7) l- e:: c( 8. TOTAL GROSS ASSETS (total Lines 1-7) (8) 146,202 U w a:: 9. Funeral Expenses & Administrative Costs (Schedule H) 8,902 (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) :10) NONE 11. TOTAL DEDUCTIONS (total Lines 9 & 10) (11) 8,902 12. NET VALUE OF ESTATE (Line 8 minus Line 11) (12) 137,300 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election tD tax has not been made (Schedule J) (13) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 137,300 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax Z rate ,or transfers under Sec.9116 (a)(1.2) X .0 (15) - 0 t= 16. Amount of Line 14 taxable at lineal rate 136,300 .045 c( X (16) 6,134 I- - ::l II.. :E 17. Amount of Line 14 taxable at sibling rate X .12 (17) 0 U X c( 18. Amount of Line 14 taxable at collateral rate 1,000 X .15 (18) 150 I- 19. Tax Due (19) 6,284 200 ");I~BJla""aEl!I" '~f!" """ilt!.s;,:":"",,:,:~.,+,,~~,,egM~Hlli :It ., :...~..:_.~.,'.~..~..: ' .,:m.Ny:"'t~,!;fi,' ~'NJQ;B!ir::,,',~ii~;i > > BE SURE TO ANSWER ALL QUESTIQNS'.0N RE.YERSESIOE ,ANO,RECHECK MATH < < II . Juvenelia Harding 202-09-5105 ,217 "Deced~mt's ComDlete Address: STREET ADDRESS 478 "F" Street CITY I~TATE flP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 6,284 2. Credits/Payments A Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C ) (2) 3. I nteresVPenalty If applicable D. Interest E. Penalty 4. TotallnteresVPenalty ( 0 + E ) 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 (3) 5. (4) (5) (5A) (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 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. B. Enter the total of Line 5 + 5A This is the BALANCE DUE. 6,284 6,284 I 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 life of either payments, benefits or care? If death occurred after December 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration? Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? Yes D D D D D D 2. 3. 4. Did decedent own an Individual Retirement Account, annuity or other non-probate property which contains a beneficiary designation? ~ ~ ~ D [R] 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 belief, it is true. and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON ~ESPON LE FOR FILING RETURN '-'(Y\~ ~. l" · ADDr;S7 ci SIGNAT R ~\~o\o F 17()(6 OAT (J, f<4 \10 ( ~ 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. Section 9116 (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 survivin The statute does nol exempt a transfer to a surviving spouse from tax. and the statutory requirements for disclosure of assets ar the surviving spouse is the only beneficiary. n. APj) u _ 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 II or a stepparent of the child is 0%172 P.S. Section 9116(a)(1.2)]. The lax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as notel 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. Section 9116(a)(1. individual who has at least one parent in common with the decedent, whether by blood or adoption. l>S'"' )(1)). II 217 REV-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Juvenelia HardinQ FILE NUMBER 21-05-0272 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 5,000 Pittsburgh-Allegheney Co. Pub. Auth. municipal authority (ave. value per 100: 107.0485) accrued interest on above bond 349 shares Nuveen Pa. Premium Inc. Fund (ave. value for 3/4 and 3/7: 16.06) VALUE AT DATE OF DEATH 2. 5,352 42 5,598 TOTAL (Also enter on line 2 Recaoitulation $ (If more space is needed, insert additional sheets of the same size) 1 0 992 II AT RIAt-1508 EX ~'(1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Juvenelia Hardin!:) FILE NUMBER 21-05-0272 Include the proceeds of litigation and the date the proceeds were received by the estate. ALL PROPERTY JOINTL Y.QWNED WITH THE RIGHT OF SURVIVORSHIP MUST BE DISCLOSED ON SCHEOULE F ITEM NUMBER 1. 2. 3. DESCRIPTION Susquehanna Bank Account No. 284742606 Merrill Lynch Money Market Account DN Provident Bank 5% CD accrued interest on above account Firstbank of PR CD accrued interest on above account VALUE AT DATE OF DEATH 4. 3,325 12,043 39,848 173 28,326 25 5. TOTAL (Also enter on line 5 Recaoitulation $ (If more space is needed, insert additional sheets of the same size) 83 740 II 217 REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Juvenelia HardinQ 21-05-0272 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule GJ SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Mari E. Harding 578 "F" Street Carlisle, PA 17013 Daughter B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT IOENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET I DECEDENT'S INTEREST INTEREST 1. A. 578"F" Street 1 02,940 50.00% 51,470 , TOTAL (Also enter on line 6. Recaoitulation $ 51 470 (If more space is needed, insert additional sheets of the same size) II 217 REV-1511 EX+(12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Juvenelia Hardinq ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Grave marker 100 2. Funeral expense to Hoffman Roth Funeral Home 2,339 3. Obituary 122 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 2,500 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Mari E. Hardinq Street Address 578 "F" Street City Carlisle State PA Zip 17013 Relationship of Claimant to Decedent Dauqhter 3,500 4. Probate Fees 302 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Final medical bill to Dr. Hartzell 20 8. Filing fees; short certificates 19 TOTAL (Also enter on line 9 Recaoitulation $ 8902 Debts of decedent must be reported on Schedule I. (If more space is needed, insert additional sheets of the same size) II 217 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER J . H d' 21 05272 uvenella ar mo - - RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions. and transfers under Sec. 9116 (a) (1.2}) 1 Douglas Stugart, P. O. Box 247-B, Allenwood, PA 17810 nephew 1,000 2 Mari E. Harding, 578 "F" Street, Carlisle, PA 17013 daughter 100% of remainder 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0 (If more space is needed. insert additional sheets of the same size) , I Detailed Results for Parcel 06-19-1643-170. in the 2004 Tax Assessment Database DistrictNo 6 Parcel_ID 06-19-1643-170. MapSuffix HouseNo 578 Direction Street FSTREET Owner! HARDING, JUVENELIA & MARl E Owner2 PropType R PropDesc Liv Area 1188 CurLandVal 15230 CurlmpVal 87710 CurTotVal 102940 CurPreiV al Acreage 0.18 CIGrnStat TaxEx 1 SaleAmt 81000 SaleMo 5 SaleDa 22 SaleCe 19 SaleYr 90 DeedBkPage 00340-00690 YearBIt 1972 HF _File_Date 10/19/2004 HF _Approval_Status A I~ ::r -I OO~~"O :z: ::I: ~ ::T 0 OO:I: ~ 0 o ow ..... III W ~~~C!~ Will,&.. ~ Will.... tIl '"0 ...... ........." J> .........Cll - :...:... ::J 0 o III C -0 OIllZ 0 o III "0 0 ~ ..." ~ ~ ::I. ...... ~ .... r- ~ ~ w ::I. 0 ...... UI ...... ..., N N ... N N N 0 '"0 3 0 '< 0 0 8 ~ ..... III 0 g "n~ 0 "0 0 Z - ~ n- Ul Ul N~=1 Ul ;a ." Ul Ul e: "0 o' 0 .... < 0 ::J :: -6- Vt < ~ I'TI ::I. ""'I _..Cll E I'TI 0 - ::T 0- N e: Z ..... 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Q . ~ . 9 ~ \\\!~\ ".... ~ 0 .... ~ ~ ~ i1 ~ ~ "-I % -4 ~ ~\1H ~ 0 0' ~ rn !:p ~ .,.- ...." '\ ~;. :'. '.1- .... . ~~~<~~'"I -I . . ~' ;; ':'.\ .... . 0 \E\ \ ~ ,;. "I :~ \ ~ (:: ''<. ~. tl.. ~ \;~ ,,~ ,;; ~I ;:\- ~" .; 1:. ~, '. S ..~ .~ r ~ ~_ ~~\~1h '{}. ,".' \.<' ,,".. ~" 9, ~.__":,~ { '-' i~~ y: . W ~' .;.. % . ") ~ GO .c. ,ii ~ III Il> 01> () "" \D 0 ~ . \DO C ~ 0 "" ~ 0 ell OJO 9, tV tV ~ ~ ell OJ 0 tV tV C 0 0 ~ 9;- 0 0 lJ' Hoffman-Roth Funeral Home, Inc. 219 North Hanover Street Carlisle, P A 17013 (717)243-4511 March 25, 2005 Mari E. Harding 578 "F" Street Carlisle, P A 17013- The Funeral Service for Juvenelia "Juvy" Harding 14483-42 II We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. (A) OUR SERVICE: CREMATIONPACKAGE#3...... .'. FUNERAL HOME SERVICE CHARGES SELECTED MERCHANDISE: Acknowledgement Cards. Visitor Register . . . . . Memorial Folders. . . . . THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THATYOUHAVESELECTED . . . . . . . . . . . . . Cash Advances Newspaper Obituary Notice - Sentinel. . . . . . Newspaper Obituary Notice-Daily Hampshire Gazette. Clergy Offering . . . . . . . Certified Copies of Death Certificate. Flowers. . . . . . . . . . Coroner Authorization Cremation Fee. TOTAL CASH ADVANCES AND SPECIAL CHARGES. Total Total Cost . TOTAL AMOUNT DUE This statement is net and payable in full within 30 days of receipt. ~ t ..' $1790.00 $1790.00 $20.00 $25.00 $25.00 $1860.00 $126.00 $75.90 $75.00 $72.00 $106.00 $25.00 $479.90 $2339.90 $2339.90 " LAST WILL AND TESTAMENT OF JUVENELIA HARDING I, JUVENELIA HARDING, widow, of 578 "F" Street, Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament hereby revoking and making void any and all Wills by me at any time heretofore made. 1. I direct my hereinafter named Executrix or Executor to pay all of my just debts and funeral expenses as soon after my death as may be found convenient to do so. 2. I declare that I am currently unmarried and that I have one (1) child by my deceased husband, which child is my daughter, Mari E. Harding. 3. I give and bequeath the sum of $1,000.00 to my husband's great-nephew, Douglas Stugart, whose mailing address is Box 247-B Allenwood, Pennsylvania 17810. 4. All of the rest, residue and remainder of my estate, real, personal and mixed, and wheresoever the same may be situate, I give, devise and bequeath to my daughter, Mari E. Harding, her heirs and assigns, provided that she shall survive me by a period of ninety (90) days. In the event that my said daughter should predecease me or fail to survive by the aforesaid period of ninety (90) days then in such event all the rest, residue and remainder of my estate, real, personal and mixed, and wheresoever the same may be situate, I give, devise and bequeath to my husband's great-nephew, Douglas Stugart, his heirs and assigns. 5. Should any person less than 21 years of age be entitled to a distribution of my estate, the share that person would otherwise have received shall be paid to my hereinafter named Executrix or Executor. 6. I hereby nominate, constitute and appoint my daughter, Mari E. Harding, as Executrix of this my Last Will and Testament but should she predecease me or fail to qualify or cease serving as such, then in such event I nominate, constitute and appoint my husband's great-nephew, Douglas Stugart, as alternate or successor Executor. I further direct that neither of them shall be required to post any bond to secure the faithful performance of her or his duties in the Commonwealth of Pennsylvania or in any other jurisdiction. 7. In addition to the powers conferred by law, my Executrix or Executor hereinbefore named are empowered: a. To invest any part of the trust corpus in such securities, investments, or other property as may be deemed advisable and proper, irrespective of whether the same are authorized for the investment of trust funds under the laws of any governing jurisdiction. b. With respect to any corporation, the stocks, bonds, or other securities of which may be held, to vote in person or by proxy on any shares of stock; to consent to the merger, consolidation or reorganization of such corporations; to consent to the leasing, mortgaging or sale of the property of any such corporations; to make any surrender, exchange or substitution of such stocks, bonds or other securities as an incident to the merger, consolidation or reorganization of such corporations; to pay all assessments, subscriptions and other sums of money which may be deemed wise and expedient for the protection and maintenance of the proportionate interest of the investment in such corporations; to exercise any option or privilege which may be conferred upon the holders of such stocks, bonds, or other securities of such corporations either for the conversion of the same into other securities or for the purchase of additional securities, and to make any and all necessary payments which may be required in connection therewith; and generally to have and exercise as to all such stocks, bonds and other securities, the powers of an individual owner who is not under trust obligation. c. To hold the trust corpus in one or more consolidated funds in which separate shares shall have undivided interests. d. To sell at public or private sale for cash or upon credit, or partly for cash and partly on credit, and upon such terms and conditions as shall be deemed proper, any part or parts of the trust ~state, and no purchaser at any such sale shall be bound to inquire into the expediency or propnety of any such sale or to see to the application of the purchase moneys arising therefrom. e. To keep on hand and uninvested such money as may be deemed proper and for such period as may be found expedient. TI " 'v f. To compromise, settle or arbitrate any claim or demand in favor of or against the trust estate. g. And authorized in the discharge of fiduciary duties, to employ counsel and to determine and to pay such counsel reasonable compensation which shall be charged against the principal or income of the trust fund, and shall further be entitled to charge against the principal or income such other reasonable expenses and charges as may be necessary and proper to incur for the proper discharge of fiduciary duties and for the proper management and administration of the trost estate. h. In making any division of property into shares for the purpose of any distribution thereof directed by the provisions of the trost, to make such division or distribution, either in cash or in kind, or partly in cash and partly in kind, as shall be deemed most expedient, and in making any division or distribution in kind may allot any specific security or property or any undivided interest therein to anyone or more of such shares, and to that end may appraise any or all of the property so to be allotted and the judgment as to the propriety of such allotment and as to the relative value for purposes of distribution of the securities or property so allotted shall be final and conclusive upon all persons interested in the trust or in the division or distribution thereof. i. Authorized to register any shares of stock or other assets of any trost in their own names or in the name of a nominee. j. To retain any investments or mutual funds which I may own at the time of my death and in addition to invest any part of the Trost corpus in such mutual fund or mutual funds as may be deemed advisable or proper, irrespective of whether the same are authorized for the investment of trust funds under the laws of any governing jurisdiction. 8. All powers, duties, and discretionary authority granted to my Executrix or Executor may be exercised without posting any bond and without obtaining any order or approval of any court, and without any notice to or consent of anyone. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament written on two (2) pages, this 2 I'" day of Sf'/f~.", t. ~ , 1995. ~~. ~veneIia Harding' (SEAL) Signed, sealed, published and declared by Juvenelia Harding, the Testatrix above-named, as and for her Last Will and Testament, in our presence, who, in her presence, at her request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. IT A?cJ ~.-U. . . 1fJ~ t{V; f CERTIFICATION OF NOTICE UNDER RULE 5.6 (a) Name of Decedent: Juvenelia Harding Date of Death: March 6, 2005 Will No. Hie- L I - 0"') - 0 L 7 C Admin. No. To the Register: I Certify that notice of beneficial interest required by Rule 5.6 (a) of the Orphans' <;ourt Rules was served on or mailed to the following beneficiaries of the above-captioned estate on Name Address See Attached List of Beneficiaries. Notice has now been given to all persons entitled thereto under Rule 5.6 (a) except No Exceptions. Date: March 16, 2005 <;apacity: ".' ~) Personal Representative X Counsel for personal representative -J --; . ~ v-- ;.j; ~:f~):: 1 \...0 -'"1 ~,~ :~:::J - ,--'1 :TJ (-) n--l r",_J G.:J -..J l' 217 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER J r H d' 21 05 272 uvenela ar /nO - - RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF,ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Douglas Stugart, P. O. Box 247-B, Allenwood, PA 17810 nephew 1,000 2 Mari E. Harding, 578 "F" Street, Carlisle, PA 17013 daughter 100% of remainder 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0 (If more space is needed, insert additionai sheets of the same size) 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 FREY ROBERT G 5 S HANOVER STREET CARLISLE, PA 17013 nnun fold ESTATE INFORMATION: SSN: 202-09-5105 FILE NUMBER: 2105-0272 DECEDENT NAME: HARDING JUVENELlA DATE OF PAYMENT: 09/09/2005 POSTMARK DATE: 09/09/2005 COUNTY: CUMBERLAND DATE OF DEATH: 03/06/2005 NO. CD 005787 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $6,284.00 I I I I I I I I TOTAL AMOUNT PAID: $6,284.00 REMARKS: CHECK#105 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WillS