HomeMy WebLinkAbout09-22-05 (2)
. REV-1500 EX (6-00)
\ I
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
w
I-
~:;!;1Il
OO:~
wl1.0
:I: 0 0
oO:..J
11. III
11.
c(
FILE NUMBER
21 05
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COUNTY CODE YEAR
N\JMBER
0614
I-
Z
W
C
W
o
W
C
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
HACKETT, Jay O.
SOCIAL SECURITY NUMBER
174-05-0514
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
DATE OF DEATH (MM-DD-YEAR)
06/25/2005
DATE OF BIRTH (MM-DD-YEAR)
02/13/1915
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
None
~ 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Retum
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
o 3. Remainder Return (date of d.~th prior to 12-1~2)
o 5. Federal Estate Tax Retum ~equired
8. Total Number of Safe Depo$it Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
NAME
Robert T. Balaban, Esquire
FIRM NAME (II Applicable)
COMPLETE MAILING ADDRESS
630 Lowther Road
Lewisberry, PA 17339
TELEPHONE NUMBER
(717) 932-9565
N-.:)
ct::>
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
5,947.00
:-h
:1:
~7
en
-l::'"'
1,694.42
z
o
~
::J
!:::
Q.
<(
o
w
0::
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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)
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 Govemmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
6,584.90
8,680.36
(6)
7,623.84
(7)
15,265.26
I
(9)
(10)
(8)
6,005.00
579.90
(11)
(12)
(13)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
I 8,680.36
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
z
o
~
.....
::J
Q.
:IE
o
o
~
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x.O _~ (15)
8,680.36 x.O ~~ (16)
390.62
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
_____~______ x .12 (17)
18. Amount of Une 14 taxable at collateral rate
x .15
(18)
(19)
390.62
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS
208 Senate Avenue A t. #506
CITY Camp Hill
STATEpA
ZIP 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
390.62
19.53
3. InteresUPenalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C ) (2)
19.53
TotallnteresUPenalty ( 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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5)
(5A)
(5B)
371.09
A. Enter the interest on the tax due.
371.09
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
ADDRESS
108 Mountainvie Road, Enola, PA 17025
SIGNATUR~A'.OT~EPRESENTATIVE
ADDRESS' ,
Robert T. 630 Lowther
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.......................................................................................... D ~
b. retain the right to designate who shall use the property transferred or its income; ............................................ D ~
c. retain a reversionary interest; or.......................................................................................................................... D ~
d. receive the promise for life of either payments, benefits or care? ...................................................................... D ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ D
DATE
09/21/Q5
PA 1
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
[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 01 &......., , J"'\
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements' ,0 A p.u
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 Yl _. q
ora stepparent of the child is 0% [72 P.S. 99116(a)(1.2)]. \.....1 _ liAs?
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% ['/
individual who has at least one parent in common with the decedent, whether by blood or adoption.
P.S. ~9116 (a) (1.1) (ii)].
Ire still, applicable even if
arent, an adoptive parent,
2 P.S. 9~116(a)(1)].
,
nder Section 9102, as an
I'
REV-1503 EX+ (6-96*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
HACKETT, Jay O.
FILE NUMBER
21-05-0614
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT !!lATE
OF DEAtH
38 Shs. METLlFE, INC., Cusip #59156R10
1,694.42
I
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
1,694.42
I. Historical Quote For: MET
Friday, June 24, 2005
Closing Price: 44.59
Open: 44.41
High: 44.91
Low: 44.30
Volume: 2,511,900
I. Historical Quote For: MET
Monday, June 27, 2005
Closing Price: 44.90
Open: 44.58
High: 44.93
Low: 44.20
Volume: 1,869,200
\ I
REV-1508 EX+ (6-98) .-
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
HACKETT, Jay O.
FILE NUMBER
21-05-0614
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
5,947.00
ITEM
NUMBER
DESCRIPTION
Prepaid/Preneed Funeral Account - Sullivan Funeral Home, 51 N. Enola Dr., Enola, PA 17025
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
6,947.00
~uJ...Lival1 ,c'u,nera.L 110me
; '.',51, N.;, Enola Drive.
)0111~,'i'\1~Z~5.0?02S ·
, ~)
;~';.':;j:~\' f:.f :~~: :;; }~\~ 'i'.,
'".;;" ;,;~.;:';:::~ "'~~~i,!;~;':,':~:.~t1'~_?/}:' ':Y~__,;:"
STATEMENT OF FUNERAL GOODS, AND SERVICES SELEcrnD
Charges are only for those Items that yoll selected ~r that. are' required. If we are required by law or
explain the reason in writing below.;,,: '.,'
If you selected a funeral that may require embalming; such 3$ a funeral viewing, you may have to
ing you did not approve if you selected ngements such ~ irect e t' n or Immediate burial.
For the Service of
... .~', '::~E;;t;;.
:I.', 'I
.,'f" /"'1'
Charge tOl
City
Other clothing
Cremation urn
(Description)
OlliER
$~
'$~
TOTAL MERCHANDISB SBU!CI'BD ...,:.... . . . . . :. .8
C. SPECIAL CHARGES:
Forwarding of remains to
(Funeral Home) i
Receiving of remains from
"""""" ~'::."":' ~ u u;' .
Direct Cremation.. .. .. .... .. $
$
SUB-TOTAL OF SPBCJA.i'"CHARGES . . . ..........C
D.CASHADVANCBD .' I.~<J
OpeningGrave .... ..;...... ...... ~
Cemetery Equipment .............. $~
l.olandDeed .............:......$
Newspaper Notices-Local. . ...;.. ... $
==€::;:~..~...:: . ..
Clergy/Mass Offeting ............. $
Pallbearers. ........ .... ... ... $~
Certified Copies of the J;leath1. . . :'. . . . $L1"T7;;;n
Certificate '1. .W:.h'. f .~..... $~
PoUceEscort...,....... ..... .... $~
Flowers,;,fI.).. 4V. . . . . .. . . . $~
Vault Service ChaIge . . . . . . . . '. ,... $~
$
l<,'..(,ci.~' ,i:l....jr:1. A,n,l $17.:t,6f1
:3S:
SUMMARY OF CHARGES
A. Professional Services, Facilities and
Equipment, and Automotive
Equipment..;......'........... .
B. Merchandise ...................
c. Special Ch3IgeS..................
D. Cash Advances
TOTAL OF ALL SBCI10NS ., . . . . . , . , .. . . . . .... " .. .
PAID AT 11MB OF OR PRIOR TO
ARRANGBMBNTS ..............
IlAUNCB DUB
REASON FOR
IL ~~B;:?l~~~~I9C~
(Description))./( t:i..llA 1./1'"
Other Receptacle '. ','" .'... ........ $~
(Description)
Outer buri2l container . ~ j~. l!.,F~.'
(Description) . .~
Acknowledgement cards . . . . .. . . ... . . $.iUk-
Registerbook(s).................. $~
Memory folders ........ ". '. . , ; $...liJ...!:::::.'.: ,.
Prayer cards ........... ........ $~
Temporary grave marker. . . . . . . . . . . . $"":::::::':"
Burial clothing ...... '" ..... ..... $_
f agree that I have examined the items of goods and services selected above and. found them to be correct and according to the arrangements I h'a~~ requested. I acknowledge
receipt of a copy of this Statement of Funeral Goods and Services Selected. I represent that I have sufficient funds available for payment of the cash price for the goods
and services selected. I also agree to make payment of $ within days. I agree to be Joindy and severally liable with anyone
signs below. A late chaIge of per month amounting to per year will be applied to the unpaid balance beginning days
from the date of this agreement. I will also pay to the Funeral Director all reasonable costs paid by the Funeral Director to collect amounts I owe under this agreement.
Those costs may include attorneys; fees, CQun ~ and other costs. Any additional services or merchandise ordered or requested after the date of this agreement
be considered JlII110f this a7t an;!)he -;? ~ be reflected on the flnaI bill or statement.
(Seal) .....,.,-,.., @(,.. .
(Pun:haser)
Name
A. CHARGB FOR SERVICES SBLECTBD:
. 1. PROFESSIONAL SERVICES . s;:: . . VJ
Services of Puneral Director/Staff . . . . . , $ /;. l' <<J
Embalming..........,.......... $~__
Other preparation of body
s~rorAi OF PR~~io~sEiM~ , . .Al$~!17(J rJ.
2. FACILfI1ES AND SERVICES
Use of facilities and services for
. viewing (VJsitationlWake) ',...,... $ -'
Use of fadlUles and services" . '" nl.' .",,,
. 'for funentl ceremony. . ,".......... $~ v,/
Use of faelUties and services for -' .
.. Memorial Service .............. .$-
;"Use of equipment and services
for graveskle service . .. .. .' .. .. .. . $ ---
Other use of fa~lies
. . , . ". . .. ..: . ..... . .. . . . . ... . $ -' ''l'.r1 !.r)
SUB-TOTAL OF FAaunBS1EQUIPMENT .........,.A2 $~
3. AlITOM<J11VE EQUlPMENf . .'
Vehicle to transfer~1ns .t~ Puneral Home' ".j) . '().
::Urse(~k~~~' ....;..... ;$/ . "'?/)
Local .... '. ,;!.. .... ...$~
Limousine" I
Local . .. $
=IY~.......................$
Flower car or floral disposition ~
Local ................ . ....$
~I~/cl~.~......... ... $ .1)'
Car for pallbearers
Local .............. ..$
Out of toWn transpoItation . . . . $j}
$ . ...~ ;.v
- "S(J
SUB-TOTAL OF AUI'OM01lVB EQUIPMENT. . . . , . . . A3 $~
TOTAL OF PROFESSIONAL SERVICES, ..'
FAaunBS AND AuroM01lVB
.' .BQUIPMENT ...
. ':". .,,,.
, , ..,....... ."
( ..) '1)7 ~.
. ....,..,.A $ ;I
. 600 Revised 1104
REV-1509 EX+ (6-98)
*'
COMMONINEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HACKETT, Jay O.
SCHEDULE F
JOINTlY-OWNED PROPERTY
FILE NUMBER
21-05-0614
SURVIVING JOINT TENANT(S) NAME
If an asset was made Joint within one year of the decedent's date of death, it must be reported on Schedule G.
RELATIONSHIP TO [pECEDENT
I
A. Nancy K. Otstot
B.
C.
ADDRESS
108 Mountainview Drive
Enola, PA 17025
Daughter-in-law
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 II LUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDE 1'S INTEREST
1. A. 09/06/01 PNC Bank, N,A., 225 N. Enola Rd, Enola, PA 17025 - Checking Account 14,206.91 50_ 7,103.46
:/t'inmRRQ71,i
2 A 09/06/01 PNC Bank, NA, 225 N, Enola Rd, Enola, PA 17025 - Savings Account 1,040.76 50 520.38
:/t'iOOO7?'iR7?
I
I
I
I
I
I
,
I
:
,
I
I
I
I
,
I
TOTAL (Also enter on line 6, Recapitulation) $ 7,623.84
I
(If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
NO. 21 05-0614
05142055
09-01-2005
REV-1543 EX AFP (09- 00)
FILE
ACN
DATE
TYPE OF ACCOUNT
EST. OF JAY 0 HACKETT D SAVINGS
S.S. NO. 174-05-0514 [X] CHECKING
DATE OF DEATH 06-25-2005 D TRUST
COUNTY CUMBERLAND D CERTIF.
REMIT PAYMENT AND Fots TO:
REGISTER OF WILLS
CUMBERLAND CO COURT H USE
CARLISLE, PA 17013 !
NANCY K OTSTOT
108 MOUNTAIN VIEW DR
ENOLA PA 17025
PNC BANK has provided the Department with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of
this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
of Pennsylvania. Questions may be answered by calling (717) 787-83Z7.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5003669714 Date 09-06-2001
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
14,206.91
50,000
7,103.46
.15
1,065.52
TAXPAYER RESPONSE
Tax
x
To insure proper credit to your acco~nt, two
(Z) copies of this notice must accDnfany your
payment to the Register of Wills. M ke check
payable to: "Register of Wills, Agent".
NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
you may deduct a 5Z discount of the, tax due.
Any inheritance tax due will become elinquent
nine (9) months after the date of dB tho
PART
ill
A.
[ CHECK ]
ONE
BLOCK B.
ONLY
C.
[] The above information and tax due is correct. ~
L You may choose to remit payment to the Register of Wills with two copies of this notice '0 obtain
a discount or avoid interest, or you may check box "A" and return this notice to the Reg"ster of
Wills and an official assessment will be issued by the PA Department of Revenue. I
I
[] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance lax return
to be filed by the decedent's representative. I
I
[] The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART
~
TAX
LINE
If you indicate a different tax rate, please state your
relationship to decedent:
RETURN - COMPUTATION
1. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8. Tax Due
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3 X
4
5
6
7 X
8
PART
@]
DATE PAID
PAYEE
DESCRIPTION
,
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
$
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
complete to the best of my knowledge and belief.
TAXPAYER SIGNATURE
HOME (
WORK (
TELEPHONE
)
)
NUMBER
DATE
GENERAL INFORMATION
1. FAILURE TO RESPOND WIll RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based Dn infDrmatiDn
submitted by the financial institutiDn.
2. Inheritance tax becDmes delinquent nine mDnths after the decedent's date Df death.
3. A jDint aCCDunt is taxable even thDugh the decedent's name was added as a matter Df cDnvenience.
4. AccDunts (including thDse held between husband and wife) which the decedent put in jDint names within Dne year priDr tD
death are fully taxable as transfers.
5. AccDunts established jDintlY between husband and wife mDre than Dne year priDr tD death are nDt taxable.
6. AccDunts held by a decedent "in trust fDr" anDther Dr Dthers are taxable fully.
REPORTING INSTRUCTIONS - PART
1
- TAXPAYER RESPONSE
1. BLOCK A - If the infDrmatiDn and cDmputatiDn in the nDtice are cDrrect and deductiDns are nDt being claimed, place an "X"
in blDck "A" Df Part 1 Df the "Taxpayer RespDnse" sectiDn. Sign tWD cDpies and submit them with YDur check fDr the amDunt Df
tax tD the Register Df Wills Df the cDunty indicated. The PA Department Df Revenue will issue an Dfficial assessment
(FDrm REV-1548 EX) upDn receipt Df the return frDm the Register Df Wills.
2. BLOCK B - If the asset specified Dn this nDtice has been Dr will be repDrted and tax paid with the Pennsylvania Inheritance
Tax Return filed by the decedent's representative, place an "X" in blDck "B" Df Part 1 Df the "Taxpayer RespDnse" sectiDn. Sign Dne
CDPY and return tD the PA Department Df Revenue, Bureau Df Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the
envelDpe prDvided.
3. BLOCK C - If the nDtice infDrmatiDn is incDrrect and/Dr deductiDns are being claimed, check blDck "C" and cDmplete Parts 2 and 3
accDrding tD the instructiDns belDw. Sign tWD cDpies and submit them with YDUr check fDr the amDunt Df tax payable tD the Register
Df Wills Df the cDunty indicated. The PA Department Df Revenue will issue an Dfficial assessment (FDrm REV-1548 EX) upDn receipt
Df the return frDm the Register Df Wills.
TAX RETURN - PART
2
- TAX COMPUTATION
LINE
1. Enter
NOTE:
the date the aCCDunt Driginally was established Dr titled in the manner existing at date Df death.
FDr a decedent dying after 12/12/82: AccDunts which the decedent put in jDint names within Dne (1) year Df death are
taxable fully as transfers. HDwever, there is an exclusiDn nDt tD exceed $3,000 per transferee regardless Df the value Df
the accDunt Dr the number Df accDunts held.
If a dDuble asterisk (MM) appears befDre YDur first name in the address pDrtiDn Df this nDtice, the $3,000 exclusiDn
already has been deducted frDm the accDunt balance as repDrted by the financial institutiDn.
2. Enter the tDtal balance Df the accDunt including interest accrued tD the date Df death.
3. The percent Df the aCCDunt that is taxable fDr each survivDr is determined as fDllDws:
A. The percent taxable fDr jDint assets established mDre than Dne year priDr tD the decedent.s death:
DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE
JOINT OWNERS SURVIVING JOINT OWNERS
Example: A jDint asset registered in the name Df the decedent and tWD Dther perSDns.
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 X 100
16.77. (TAXABLE FOR EACH SURVIVOR)
B. The percent taxable fDr assets created within Dne year Df the decedent's death Dr accDunts Dwned by the decedent but held
in trust fDr anDther individual(s) (trust beneficiaries):
1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT
OWNERS OR TRUST BENEFICIARIES
X 100
PERCENT TAXABLE
Example: JDint aCCDunt registered in the name Df the decedent and tWD Dther perSDns and established within Dne year Df death by
the decedent.
1 DIVIDED BY 2 (SURVIVORS) = .50 X 100 507. (TAXABLE FOR EACH SURVIVOR)
4. The amDunt subject tD tax (line 4) is determined by multiplying the aCCDunt balance (line 2) by the percent taxable (line 3).
5. Enter the tDtal Df the debts and deductiDns listed in Part 3.
6. The amDunt taxable (line 6) is determined by subtracting the debts and deductiDns (line 5) frDm the amDunt subject tD tax (line 4).
7. Enter the apprDpriate tax rate (line 7) as determined belDw.
MThe tax rate ImpDsed Dn the net value Df transfers frDm a deceased ChIld twentY-Dne years Df age Dr YDunger at
death tD Dr fDr the use Df a natural parent, an adDptive parent, Dr a stepparent Df the child is 07..
The lineal class Df heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children
whether Dr nDt they have been adDpted by Dthers, adDpted children and step children. "lineal descendents" includes all children Df the
natural parents and their descendents, whether Dr nDt they have been adDpted by Dthers, adDpted descendents and their descendants
and step-descendants. "Siblings" are defined as individuals whD have at least Dne parent in CDmmDn with the decedent, whether by blDDd
or adoption. The "Collateral" class of heirs includes all other beneficiaries.
Date of Death Spouse lineal Sibling Collateral
07101/94 to 12/31/94 3% 6% 15% 15%
01/01/95 to 06/30/00 0% 6% 15% 15%
07101/00 to present 0% 4.5%. 12% 15%
CLAIMED DEDUCTIONS - PART
3
DEBTS AND DEDUCTIONS CLAIMED
AllDwable debts and deductiDns are determined as fDIIDws:
A. YDU legally are respDnsible fDr payment, Dr the estate subject tD administratiDn by a persDnal representative is insufficient
tD pay the deductible items.
B. YDU actually paid the debts after death Df the decedent and can furnish prDDf Df payment.
C. Debts being claimed must be itemized fully in Part 3. If additiDnal space is needed, use plain paper 8 1/2" x II". PrDDf Df
payment may be requested by the PA Department Df Revenue.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 05-0614
05142056
09-01-2005
REV-15~5 EX AFP (09-00)
NANCY K OTSTOT
108 MOUNTAIN VIEW DR
ENOLA PA 17025
TYPE OF ACCOUNT
EST. OF JAY 0 HACKETT [X] SAVINGS
S . S. NO. 17 4 - 05- 0514 0 CHECKING
DATE OF DEATH 06-25-2005 0 TRUST
COUNTY CUMBERLAND 0 CERTIF.
REHIT PAYHENT AND FO'~HS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HpUSE
CARLISLE, PA 17013 '
PNC BANK has provided the Department with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of
this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
of Pennsylvania. Questions may be answered by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTI~NS
Account No. 5000725872 Date 09- 06-2001
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
1,040.76
50.000
520.38
.15
78.06
TAXPAYER RESPONSE
To insure proper credit to your acco~nt, two
(2) copies of this notice must accompany your
payment to the Register of Wills. Mbke check
payable to: "Register of Wills, Agen~".
x
NOTE: If tax payments are made wi thlin three
(3) months of the decedent.s date of! death,
you may deduct a 5% discount of the ~ax due.
Any inheritance tax due will become ~elinquent
nine (9) months after the date of de~th.
!
Tax
PART
m
[] The above information and tax due is correct. ;
1. You may choose to remit payment to the Register of Wills with two copies of this notice ~o obtain
a discount or avoid interest, or you may check box "An and return this notice to the Regilster of
Wills and an official assessment will be issued by the PA Department of Revenue. '
B. [] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance T~x return
to be filed by the decedent.s representative. !
C. [] The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
[CHECK ]
ONE
BLOCK
ONLY
If you indicate a different tax rate, please state your
relationship to decedent:
TAX ON JOINT/TRUST ACCOUNTS
PART
~
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8. Tax Due
OF
1
2
3
4
5
6
7
8
x
x
PART
~
DATE PAID
PAYEE
DESCRIPTION
AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation)
$
!
Under penalties of perjury, I declare that the facts I have reported above are true, correct'and
complete to the best of my knowledge and belief.
HOME (
WORK (
TElEPHONE
)
)
NUMBER
DATE
TAXPAYER SIGNATURE
GENERAL INFORMATION
1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable inte..est based on info..mation
submitted by the financial institution.
2. Inhe..itance tax becomes delinquent nine months afte.. the decedent's date of death.
3. A joint account is taxable even though the decedent's name was added as a matte.. of convenience.
4. Accounts (including those held between husband and wife) which the decedent put in joint names within one yea.. p..io.. to
death a..e fully taxable as t..ansfe..s.
5. Accounts established jointly between husband and wife mo..e than one yea.. p..io.. to death a..e not taxable.
6. Accounts held by a decedent "in t..ust fo.." anothe.. 0.. othe..s a..e taxable fully.
REPORTING INSTRUCTIONS
PART
1
TAXPAYER RESPONSE
1. BLOCK A - If the info..mation and computation in the notice a..e co....ect and deductions a..e not being claimed, place an "x"
in block "A" of Pa..t 1 of the "Taxpaye.. Response" section. Sign two copies and submit them with you.. check fo.. the amount of
tax to the Registe.. of Wills of the county indicated. The PA Depa..tment of Revenue will issue an official assessment
(Fo..m REV-1548 EX) upon ..eceipt of the ..etu..n f..om the Registe.. of Wills.
2. BLOCK B - If the asset specified on this notice has been 0.. will be ..epo..ted and tax paid with the Pennsylvania Inhe..itance
Tax Retu..n filed by the decedent's ..ep..esentative, place an "x" in block "B" of Pa..t 1 of the "Taxpaye.. Response" section. Sign one
COpy and ..etu..n to the PA Oepa..tment of Revenue, Bu..eau of Individual Taxes, Oept 280601, Ha....isbu..g, PA 17128-0601 in the
envelope p..ovided.
3. BLOCK C - If the notice info..mation is inco....ect and/o.. deductions a..e being claimed, check block "c" and complete Pa..ts 2 and 3
acco..ding to the inst..uctions below. Sign two copies and submit them with you.. check fo.. the amount of tax payable to the Registe..
of Wills of the county indicated. The PA Depa..tment of Revenue will issue an official assessment (Fo..m REV-1548 EX) upon ..eceipt
of the ..etu..n f..om the Registe.. of Wills.
TAX RETURN
PART
2
TAX COMPUTATION
LINE
1. Ente..
NOTE:
the date the account o..iginally was established 0.. titled in the manne.. existing at date of death.
Fo.. a decedent dying afte.. 12/12/82: Accounts which the decedent put in joint names within one (1) yea.. of death a..e
taxable fully as t..ansfe..s. Howeve.., the..e is an exclusion not to exceed $3,000 pe.. t..ansfe..ee ..ega..dless of the value of
the account 0.. the numbe.. of accounts held.
If a double aste..isk (MM) appea..s befo..e you.. fi..st name in the add..ess po..tion of this notice, the $3,000 exclusion
al..eady has been deducted f..om the account balance as ..epo..ted by the financial institution.
2. Ente.. the total balance of the account including inte..est acc..ued to the date of death.
3. The pe..cent of the account that is taxable fo.. each su..vivo.. is dete..mined as follows:
A. The pe..cent taxable fo.. joint assets established mo..e than one yea.. p..io.. to the decedent's death:
1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE
JOINT OWNERS SURVIVING JOINT OWNERS
Example: A joint asset ..egiste..ed in the name of the decedent and two othe.. pe..sons.
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 X 100
16.7% (TAXABLE FOR EACH SURVIVOR)
B. The pe..cent taxable fo.. assets c..eated within one yea.. of the decedent's death 0.. accounts owned by the decedent but held
in t..ust fo.. anothe.. individual(s) (t..ust beneficia..ies):
1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT
OWNERS OR TRUST BENEFICIARIES
X 100
PERCENT TAXABLE
Example: Joint account ..egiste..ed in the name of the decedent and two othe.. pe..sons and established within one yea.. of death by
the decedent.
1 DIVIDED BY 2 (SURVIVORS) = .50 X 100 50% (TAXABLE FOR EACH SURVIVOR)
4. The amount subject to tax (line 4) is dete..mined by multiplying the account balance (line 2) by the pe..cent taxable (line 3).
5. Ente.. the total of the debts and deductions listed in Pa..t 3.
6. The amount taxable (line 6) is dete..mined by subt..acting the debts and deductions (line 5) f..om the amount subject to tax (line 4).
7. Ente.. the app..op..iate tax ..ate (line 7) as dete..mined below.
MThe tax ..ate Imposed on the net value of t..ansfe..s f..om a deceased ChIld twenty-one yea..s of age 0.. younge.. at
death to 0.. fo.. the use of a natu..al pa..ent, an adoptive pa..ent, 0.. a steppa..ent of the child is 0%.
The lineal class of hei..s includes g..andpa..ents, pa..ents, child..en, and lineal descendents. "Child..en" includes natu..al child..en
whethe.. 0.. not they have been adopted by othe..s, adopted child..en and step child..en. "Lineal descendents" includes all child..en of the
natu..al pa..ents and thei.. descendents, whethe.. 0" not they have been adopted by othe..s, adopted descendents and thei.. descendants
and step-descendants. "Siblings" a..e defined as individuals who have at least one pa..ent in common with the decedent, whethe.. by blood
0.. adoption. The "Collate..al'~ class of hei..s includes all othe.. beneficia..ies.
Date of Death Spouse Lineal Sibling Collateral
07/01/94 to 12/31/94 3/. o/. 15/. 15/.
01/01/95 to Do/3D/DO 0% 0% 15% 15/.
07/01/00 to present 0% 4.5%lE 12% 15%
CLAIMED DEDUCTIONS
PART
3
DEBTS AND DEDUCTIONS CLAIMED
Allowable debts and deductions a..e dete..mined as follows:
A. You legally a..e ..esponsible fo.. payment, 0.. the estate subject to administ..ation by a pe..sonal ..ep..esentative is insufficient
to pay the deductible items.
B. You actually paid the debts afte.. death of the decedent and can fu..nish p..oof of payment.
C. Debts being claimed must be itemized fully in Pa..t 3. If additional space is needed, use plain pape.. 8 1/2" xli". P..oof of
payment may be ..equested by the PA Depa..tment of Revenue.
REV-1511 EX+ (12-99)_
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
HACKETT, Jay O.
FILE NUMBER
21-05-0614
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Sullivan Funeral Home, 51 N. Enola Dr., Enola, PA 17025
5,947.00
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
58.00
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)
! 6,005.00
I
:e1';~~$E;"~:~l"t~~~~:~~}~:::~~~~~~~te
',<' ro;' If you selected a funetal that may ~embahIling; s\icli'2$ a' ful\mfVieWhlg, You may have 10 pay 'for ~1mlng. You do not tbtve to pay for embaJm.. !,';'
'~'~;.~~i!lng you did not applOveif ~selected g~ su,c:It, as . or ~ediate burial. J~.w.e charged for embalming, we will explain why be~;~+ "
f~~~~~e;i~';~~~':~Z~\;" ',' e .' ' ""!J1P:"nt(, elJ'";"t '
. . ";;.:, \1. PROFESSIONAL SERVICES .' / ~:; ~ ?" .:. : '~: '
..;:- ..::,' . ......" ' $ 1!I7J' $"" ,I';. ...~~&::.~~~ '... CrematiOn urn ' $
. .', .. ~ofFuner2lDim:lOr/S..u ...... ~K>"'~ ..:..t, '''''''(Descri~IOn)'':''''':''':X''!',~:''':>,--,
-).' ....! - E.rnbalming ........ ~..::.........:, $~~"''''f:~r~~'..-..,,~' .... :": ... r.......
e:~: ,~:=~: ';'n I " ".:r':~i;(~f~~~!'';;;:~.;~: .;'
..' SUB-rorALOF PROFESSIONAL SERVICES ...... .... '.AI ':.,' . .........:......'..
, ..' . .\. .' C. SPEOAL CHARGES.
. :;..... 2., FAC1UTIES AND SERVICES .' "" I,' f>.;,. :.'.' ',;e".:.'. . Forwarding of remains to., i'
~';V;'1.:,:+:==~eel~~:~,c:\;' _.==' '$~"
,~~,j.. Ji forfunel'alceteD1OlIY ........I.'..$. ... . . <J, ", ','
:S~11"1C~:':;S':::: '.':d;Y?~ ::'""E"7' i '
Other use of fadllties . SUB- TOTAL OF SPECIAi" CHARGES ............... C $_
".......... ...... .,..:....;..... $ __.... . ,.,1......... .)......~.~.;~.:,:.~.;...: D. CASH ADVANCED . l/Of.j-iJ
,,;v Opening Glllve :,..':;; .. .. .. . .'
SUB-rorALOFFAauTII!S~UlPMENT...... ......A2 $. , Cemetery Equipment..... ......... $~
3.AlITOM011Vl!EQUlPMEN\')~':,.", 'c;\-;." ... r Lot and Deed .....:.. ,.....~.$ ,
Vehicl to ~ remalns 1 Puner2l Home I():~";tl;'~',:.> Newsp"per Notlces-Local.. ,.. .. .. $
"Loale......f~.....::':.....:..sj..1J '0 i~.>.. .~:::;::~.' ut.-O::~~..,7.........:..::-::: .' ",
=.(~.ket~:..~." ...:.::~'s&.ScL ,:,'.',r~Y::' =~oii';;;'~'::::...::':::::: ','
,'...~",""Ine...'.... ..... ...',.,.1 sITS"" \ ..,_,' Pallbearers.,.....:.....:,;'...:.,...$_
LlJWU . . " ;' -'~: ~/}I Certified Copies of lh ~th "' . , $
=y~.... ..... .......... ':..... s' -.."J;..;.;.....,:,...... Certl1lcate '1, .W: ~.. . i-.n :~~: ::: $!llliD
., PoliceEscoll .............,:....:..$ .",
disposillon/ '. $~~< I./l ~ )i~ii;~y:-f;. ,:"Flower! /fP.v....... ...,:... $,15'7) .(4'
.., . "'. . ., Vault Service Owge . . . . . . . , , . . . . . '. $~
,Lead car/cl~ car, ;'l.( . ..' , $~
Local ...:............. ...$ "$ , Yl'..b..{.~. ,L,-1"1 /".t;! S'i?.li~rlf"J J:
,'."'Carforpallbearers'.,, . ,;' $~ . ,., ,,:.
.,. Loal .................. $ . " $3= . ..- f.',:
J' '" J .. '," ~ ~ .!
.. :i<~;" .~, ';. Out of toWn lm1spOll3tion ", $: " > .', .' 'Q $ <0..
'>l~';" '. $~, "'5-:'i1 :'SUB-rorALOFADVANCES ..................D $/5tl .
~ ~1J' S1JB.TOTALOF AUCOMOl'IVEEQVIPMENT: "';..:. ~.:.A3 $~ ';:,.'~'
i~~:~~~f~~,~~~~~=;:~r
::. "l"'')~'' c..Ju:t..2I. $,...1'-. 41fS!'~. ,...$,-i.l!:l..l, ',' . and ' fQ,tl,i..:'
"~W- (Desajon)iJ' ~t .' ....... ... ,<<~~':'I;,:,:/,; Equipment, AutomotiVe' 3J9():.ii" ,.,'1";
jL. . ..,:.,.' )~:~;'~~::::::::::::::::::::IJ~'-"'(Q ..:,.':;jl't~:;;
,It.;...:;......:...~l,.:..~.:,..~,..:,....,i.~:..,...."......,;;Ei.::d~,I:;~;~.;"'" :~ D~~,;,.'~' ,S7'r( " "
~ . ~ ,,:"" "'~;"AlUlANGEMENTS ..,................."......:,:.. $ 59i.1'7 "0,'
";""/,; Adcnowledgemerttcalds.... ....' ,'... Slll/(...r ~,' 7,,:.("." BAUNCllDUE ...., ,..,..:......:....... ..... $~-
::'J,; ~~~: ::::::':::::;.::.::: ~~.,,::,;::t'.?;~:~:~i{:,... .:::,::E~~~~~~!~~';
'".;...,:~.:'.:",:.':~.'.;~.~~..,.:..,' :. Temponry Brotve marker . . . . . . .. . '.. . s--=::::::::- ",' '~,' ':'. of ony of the Items &led above, the law or requirement lsexpjained bdaw; <;:+,". ;,::.!",: ',: .
-'~ Burial clothing . . . . . . ,~. . . . . . . . . . .. s_ < '.<:',. _/ , '.;~--
~:<;i;": ':S( . . .' ., ".:;~:*:'
," , I agree tIw I hove examined the kems of goods and services ..Jetted above and found them to be conea and according to the arrangements I hove requested. I acknowledge
;;.,:'. " EeOeipt of a copy of this Slatemen\ of Funer2l Goods ond Servicea Selected. I represenr tIw I hove suffident funds available for p"yment of the cash price for the goods :,,','.
. ;, ':'.' .f:. and aeMces seleaed. I aJ.o agree to make paymeru of $ . within . days. I agree to be jointly and severaUy liable with anyone else who '.
I, " ....,';',aigns below. A late charge of per month amounting to per year wUl be applied to the unp"ld balance begirutirtg days.:'
~"" \,:' ,.; from the date of this agreemertt. I will aJ.o p"y to the Funer2l Dim:lOr all roasooable COOlS paid by the Funeral Director to coUect amounts I owe under this agreement; ..
,,' . "'. .J Those C05lS may Include attotney>' f.... court toSlS and other toSlS. Nrf WdlUonal services or merchandise ordered or requested after the date of this agreement will
: :.' :,\ ~ ~ldered P>16f this a~ ~~~ be ~ on.~ flna1 bill or 5latement. .
",......li.:(Seal) ~ ;;; a;l-::~ '. . ~. 6. O~
i,;,'~;i::?:::,;:... y~) '. .............;", .. ~ ;..o.te) \ I {}C~ .....i
"'k,.,_ . ~).... -uJce~el1ll~U--~' ,:Y~i',;.:
.....,....fW-.I~AMx:iIdM ~j{~.).~' wtm1!Puneralo... YEIJ.OWPunedl~'. PlNXQJIKldIet:::..,"J~.~.,:\.lf
~:.jonn.600 Revised 1/04 .',' . :'. '. " . .'.\:;;~{::'!f
~-:-:~'.',~<d. f . ',,' .. ,~- ". 'T:..:.,;;...u:J.r:.~~j
II
,
~i
RECEIPT FOR 'PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Receipt Date:
Receipt Time:
Receipt No. :
7/11/2005
11:55:14
1041234
HACKETT JAY 0
Estate File No. :
Paid By Remarks:
2005-00614
I J OTSTOT
VZ
Fee/Tax Description
PETITION LTRS TEST
WILL
SHORT CERTIFICATE
JCP FEE
AUTOMATION FEE
Check# 0191
Total Received.........
Receipt Distribution -----------------4------
Payment Amount Payee Name
20 . 00 CUMBERLAND COUNTY GENEijL FUN
15.00 CUMBERLAND COUNTY GENE L FUN
8.00 CUMBERLAND COUNTY GENE L FUN
10.00 BUREAU OF RECEIPTS & C TR M.D
5.00 CUMBERLAND COUNTY GENE L FUN
---------------- I
I
$58.00 !
$58.00 I
\ I
REV-1512 EJ(+ (12-03)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HACKETT, Jay O.
FilE NUMBER
21-05-0614
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DBATH
1.
Hospital billslDr. bills
579.90
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
579.90
REV-1513 EX+ (9-00)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
HACKETT, Jay O.
FILE NUMBER
21-05-0614
RELATIONSHIP TO DECEDENT AMOUNT ORISHARE
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 (al (1.2)] ,
1 Ivan J. Ot5tot, 108 Mountainview Drive, Enola, PA 17025 Step-son 1,056.52
I
I
2 Nancy K. Ot5tot, 108 Mountainview Drive, Enola, PA 17025 Step-daughter-in-Iaw 7,623.84
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHElET
" NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
I
I
I
I
I
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I
I
I
I
I
I
I
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00
(If more space is needed. insert additional sheets of the same size)
" " '''. L~""" , 11
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Lllcal Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
","(~(1~'otpll----_
.,/~/~4'.i'\
(", ~ - .. ~.. ~ \~\
I'~~_"" \?~
~ -==,1 f, .a:':z.~
~C=L -- ._~
:::c...J. -~~, ;.:b,...
\~ ,. 'I. . ~
'>.*' . '~,'" *~
\':. ~\ ---~-- /~...... ~
I;' ~~ ~'. '~,~
~~A~~/
----)9!MEN1 Il't ~~"""
"'''''''''~~U''N,""I,j"lj
~;?~..
Local Registrar
Fee for this certificate. S6.00
Jl.IN , '" 2005
Date
105.143 Rev. 2/67
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
STATE FilE NUMBER
NAME OF DECEDENT (First, Middle. last)
Jay O.
SEX SOCIAL SECURITY NUMBER
Hackett Male 174 05 _ 0514
2. 3.
BIRTHPLACE (Cily and PLACE OF DEATH heel< I n in IOJ 'on olh
State or Foreign Country) HOSPITAL
Reedsville,Pa ,........0 ERIOu.........o DOAo
7. aa.
FACILITY NAME (If not insulution. give street and number)
DATE 0 D~TH (~th. Day, Year)
;25;05
A,
1.
AGE (Lasl Birthday)
90
Yrs.
ae.
Carlisle
5.
COUNTY OF DEATH
ab.
Cumberland
1&.
FATHER'S NAME (First. Middle, Last)
la.
INFORMANT'S NAME (Type/Prinl)
201.
METHOD OF DISPOSITION
Burial KJ C(~mation ~emoval from State 0
Other ISpeedy)
FU LS VIC
17b. Countv
Did
decedent
live in a
Cumberland lowns/lip? 17d.o ~u,=~7\:;:;~ot
MOTHER'S NAME {Fksl, Middle. Maiden SUfname~
19. Hattie .
INFORMANT'S MAILING ADDRESS (S~",', CIl'flTown. Slale, ~ Code) 1 7 rl2 5
20b. 108 Mtn View Dr., Enola, Pa 1.\
PLACE OF DISPOSiTlON- Name of Cemetery, CremllOry LOCATION - Cil'flTown, S Ie, Zip Cod.
or Other Place I
21e.Oak CQI., Pa
MARITAL STATUS - Mimed,
Never Married. Widowed.
DiVOlced (Specify)
14~idower
17e. rn Yes, decedent lived in East Pe
SURVIVING SPOUSE
(If wit., gw. maidM name)
DECEDENT'S USUAL OCCUPATION
(GcftV~l~~~'r.~~ ~.u~n;:t::)t
KIND OF BUSINESS /INI ,USTRY
108 Mtn View Dr
Enola Pa 17025
DECEDENT'S
ACTUAL
RESIDENCE
(See instructions
on other stde)
twp.
I
arylboio i
Reed A.
Hackett
Ivan Otstot
o
2005
27. PART I: Enl.' the dla......, InJurl.. or ,ompllc:atlona which caUl" the da.&th. Do no. antar the mOd, 0' dylne. ...u;;h.. cudt" ()f r..pkMoty an'.t, .l'Ioc. or n...., failure. : Approximate
U., only one cau.. on .,ch IIna. . interval between
: onset and death
C- t>:R6lJ"Pv~ ? c..u l.~
1J/,;t.rA;5 ,;;-
a.
Sequentially list conditions ! be.'
if any, leadU\g to Unmed.ate
cause. Enler UNOERL YING
CAUSE (Disease or injury
thai initiated events
resulting on death) LAST d.
WAS AN AUTOPSY WERE AUTOPSY FINDINGS
PERFORMED? AVAILABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
QUE TO (OR ~S ,., CONSEQUENCE. OF}:
1-1 rf!.?t7"_.. (p../
QUE TO (OR "S ,. CONSEQUENCE OF)
DUE TO (OR AS A CONSEQUENCE OF):
Yes 0
MANNER OF DEATH
Natural 0' Homicide 0
Accident 0 Pending Investigation 0
Suicide 0 Coukf not be delennined 0
DATE OF INJURY
(Monlt\, 0&1. Yurl
TIME OF INJURY
INJURY AT WORK? DESCRIBE HOW I JURY OCCURRED.
esO NoD
281. 2ab.
CERTIFIER (Cheel< only one)
.~~~J~F:':~tGor::~1'~~~~~S~~:~C:~~~i~~cr-du~: to: ~h:~-=~:r~~r~~a~sh:t~r~~?~~~.~~~~.~~~..~~~.~~~~.i~~.~.~~?... ...... .... ....
29.
301. 30b. M.
PLACE OF INJURY. Al home. farm. slreet. factory, office
building, .Ie, (Speclfy)
30..
30d,
LOCATION (51''''', CIl'flTown, 5 ale)
301,
SIGNATURE AND TITLE 0
Yes D No [t(
NoD
.PRONOUNCING AND CERTIFYING PHYSICIAN (Physician bOth pronouncing death and certifying \0 cause of death)
To the b.., of my knowledge. d..th occurred at the time. date. and place. ilnd due to the cilus..(a) and manner as ..tat.d........
EO (Month. Day. Year)
~
I
I
I
,
j
'MEDICAL EXAMINER/CORONER
On the baals of eumln.tlon andlor Inv..tlgatlon, In my opinion, dealh occurred at the time. date. and plilU, and due to the cau..s(s~ and
31ar:'ann.r .s stated ...... ...... ........ ......Oo........... ........ .... ......... ... ......... ............ ... ......... .... ..... ...... ............ ........ ........ ... ....... ....... 0 32. Il"3o
DATE FILED (Month. Day, Year)
~ I"A 17~L S-
Wpll/j/I
tilE'
11
LAST WILL AND TESTAMENT
OF
JAY O. HACKETT
I, Jay O. Hackett, 208 Senate Avenue, Apt. #506, Camp Hill, Pennsylvania 17011, being of
sound mind and memory, do hereby make, publish and declare this to be my Last Will and
Testament.
FIRST:
I hereby revoke all Wills and Codicils thereto by me at any time heretofore
made.
SECOND:
I direct that all my legal debts, my funeral expenses and the costs of
administration of my estate be paid as soon as practicable after my death. I direct that my Executor
and Executrix payout of my estate, as a general charge thereon, all inheritance, estate, succession
and other taxes, together with any interest or penalty thereon assessed by reason of my death (With
regard to all properties and assets subject to such taxes, whether or not such property and assetslpass
under this Will.
THIRD:
I give, devise and bequeath my estate, real, personal or mixed, tangible or
intangible, of whatsoever kind and wheresoever situated, together with any property to which I may
have any power of disposition or appointment and whether acquired during or after my lifetime, to
my step-son, Ivan J. Otstot, provided he survive me for a period of thirty (30) days.
FOURTH: Should my step-son, Ivan 1. Otstot, fail to survive me for a period of thirty
(30) days, then I give, devise and bequeath the rest of my estate, real, personal or mixed, tangjble
or intangible, of whatsoever kind or wheresoever situated, together with any property to which I
I'
may have any power of disposition or appointment and whether acquired during or after my
lifetime, to my step-daughter-in-Iaw, Nancy K. Otsto1.
FIFTH:
In the event my step-son, IvanJ. Otstot, and my step-daughter-in-Iaw, Nancy
K. Otstot, fail to survive me for a period of thirty (30) days, his or her interest in my estate sh<itll be
distributed to Randall J. Otstot and Stacy M. Balaban, my step-grandchildren, share and share ~like.
In the event Randall J. Otstot and Stacy M. Balaban, my step-grandchildren, shall fail to surviv~ me,
his or her interest in my estate shall be distributed to his or her then living children at the time of
my death in share and share alike. Should Randall J. Otstot or Stacy M. Balaban fail to survi~e me
and fail to have living children at the time of my death, such share shall then lapse and such intierest
in my estate shall then be distributed in share and share alike to my step-grandchild, either Rahdall
J. Otstot or Stacy M. Balaban.
SIXTH:
My Executor and Executrix shall have the following powers in additi~n to
those vested in them by law and by other provisions of my Last Will and Testament, applicablle to
all property, whether principal or income, including property held for minors, exercisable without
court approval, and effective until actual distribution of all property:
I
1. I direct that my Executor and Executrix and their successor(s), shall n~t be
required to give bond for the faithful performance of their duties in! any
jurisdiction.
2. My Executor and Executrix shall not receIve compensation for the
performance of their functions hereunder during the period over which their
services are performed.
2
\ I
3. To allocate receipts and expenses to principal or income or partly to each as
they from time to time thinks proper in their discretion.
4. To borrow money from any person or institution and to mortgage or pledge
any or all real or personal property as my Executor and Executrix in: their
discretion shall choose, without regard for the dispositive provisions of this
instrument.
5. To compromise any claim or controversy.
6. To make distribution in cash or in kind, or partly in cash and partly in kind,
and in such manner as they may determine, and at valuations finally ~o be
fixed by them.
7. To invest in all forms of property (including stock or other securities and
common trust funds and mortgage investment funds), without restrictipn to
investments authorized for fiduciaries, as they deem proper, without rttgard
to any principle of diversification or risk.
8. To retain any or all of the assets of my estate, real or personal, including any
shares of stock or other securities I may own, without restrictioin to
investments authorized for fiduciaries, as they deem proper, without rE1gard
to any principle of diversification or risk.
9. To sell at public or private sale, to exchange, or to lease for any periqd of
time, any real or personal property and to give options for sales, exchanges
or leases, for such prices and upon such terms or conditions as they deem
proper.
3
l'
10. To exercise any law-given option to treat administrative expenses either as
income tax or as estate tax deductions, without regard to whether the
expenses were paid from principal or income.
11. All shares of principal and income hereby gIven shall be free :from
anticipation, assignment, pledge or obligation of the beneficiaries and ai11Y of
them, and shall not be subject to any execution, attachment, le~y or
sequestration or other claims of the creditors of said beneficiaries or ahy of
them.
SEVENTH: I do hereby make, constitute and appoint my step-son, Ivan 1. Otstot, an~ my
step-daughter-in-Iaw, Nancy K. Otstot, the Executor and Executrix of this my Last Will! and
Testament. Should either one or both fail to qualify or cease to act, I appoint my 4tep-
grandchildren, Randall J. 018tot and Stacy M. Balaban, to fill the remaining vacancy or should poth
fail to qualify or cease to act, Executor and Executrix of this, my Last Will.
EIGHTH: I direct that my Executor and Executrix, in their discretion, to engage any law
I
firm to represent my estate and to handle any and all matters related to the administration, pro~ate,
etc. of this my Last Will and Testament.
4
I'
IN WITNESS WHEREOF, I, Jay O. Hackett, Testator above named, have hereunto
subscribed my name and affixed my seal this ,;Zi day nf .)tLtV(~ ,2002.
(SEAL)
~ 0' 'f(cL-e.;!.-V;Z:V
0ay . Hackett
Signed, sealed, published and declared by the above-named _Testator, Jay O. Hackett, as and
for his Last Will, in the presence of us and each of us, who, at his request and in his presenc~ and
in the presence of each other, have hereunto subscribed our names as witnesses thereto the day and
year Jast written above.
Name
Address
/()~ JI{~ ~ ~
&~/ fJ~ { 7&;2, S-
~ "
Yk~Af(f~'~
WI SS
/ /
'j/A ~
~~~~"7 <-[{r',<,
"
WITNESS
,/, '. ,
a~ t"ic
'2/0",-
1 'j
'./ '"/.,,
'/"1
/1'
/"
L,,-
C~:'{{'i
(((
[1 .:
/(r.:,C
~ / /-1
~ ).' ,,'I .1;'( . ,/;1-
: /r'\' '\
I / L L .
5
I'
STATE OF PENNSYLVANIA:
SS
We, N4IVCY KO-pTGI
and
<''';''- :J' )/) :'/J
\ ') J;, (v ./- i
j)~ I L/(r
,the
witnesses whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw Testator sign and execute the
instrument as his free and voluntary act for the purposes therein expressed; that each subscribing
witness in the hearing and sight of the Testator signed the Will as a witness; and that to the best of
our knowledge the Testator was at the time 18 or more years of age, of sound mind and undbr no
constraint or undue influence.
~<~l
4'?
", /j~,<---j;{:: CL::::.-/
,.. -
" WITNESS
--;7'77, ,; /, ;
.-- / (..-c...J_ -- (.. <-^--.
Sworn or affirmed to and subscribed to before me by d ANt <..( K-' (jTS10/
and 5 If iiJ~\'Cl}- /YI I L t{~ , witnesses, this {) '7 ftday of jv1ere h
2002.
N!1~V#
7
NOlarial Seal
Donald F. Swilzler, Jr.. Notary Public
BaSI Pcmnsboro Twp.. Cumberland County
My Commission Expires Aug. /3, 2005
Member, PennsytvaniaAssocialion01 Notaries
l'
~
ST ATE OF PENNSYLVANIA:
SS
I, Jay O. Hackett, the Testator, whose name is signed to the attached or foregoing instrument,
having been duly qualified according to law, do hereby acknowledge that I signed and executed the
instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary
act for the purposes therein expressed.
Sworn or affirmed to and acknowledged before me, by Jay O. Hackett, the Testator, this
;)9-11,
day of f1c;rct,
,2002.
NO&1d #/
Notarial Seal
Donald F. Switzler, Jr., Notary Public:
East Pennsboro Twp., Cumberland Courlt
My Commission Expires Aug. /3. 200$ Y
Member, PennsylvaniaAsSOCialiOnof Not&fes
6