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Home My WebLink About10-24-05 REV.1500.EX (6-00) w ~ :.:::$Ul (,JD:::':: WD-(,J zOO (,JD::...J D-al D- el: COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 J- Z W C W o W C REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT I PPlICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, t1{J,j ~ 1. Original Return D 4. Limited Estate D 6. Decedent Died Testate (Attach copy of Will! D 9. Litigation Proceeds Received I- Z W C Z o D- Ul w D:: D:: o (,J -t . 81'. C~t.ltIP;AU.CGAftESPDNOIMOJ;c .' ~ n/CL FIRM NAME (If Applicable) D 2. Supplemental Return D 4a. Future Interest Compromise (date of death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach copy of Trust) D 10. Spousal Poverty Credit (date at death between 12-31-91 and 1-1-95) z o !;;: ~ ::) 0.. ::! o o >< ~ 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 4. Mortgages & Notes Receivable (Schedule D) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested z o ~ ....I ::) t: 0.. < o w ~ 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) FILE NUMBER ~ L -CL~ COUNTY CODE YEAR o ~ ~~_ NU BER SOCIAL SECURITY NUMBER THIS RETURN MUST BE FILED IN DU L1CATE WITH THE REGISTER OF ILLS SOCIAL SECURITY NUMBER D 3. Remainder Return (date of dea h pnor to 12-13-82) o 5. Federal Estate Tax Return equired 8. Total Number of Safe Depo it Boxes o 11. Election to tax under See, 113(A) (Attach Sch 0) COMPLETE MAILING ADDRESS (1) / Y ~:A) / // f t 1 (2) "f)/O-J (3) . r1/O-J (4) nlcc (5) &/sl. ~3 (6) n/ a- (7) n/~ (8) (9) S'{) ~at{# (J{) (10) /7) I~~, .sg 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20.0 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES (11) (12) (13) /l /1.1'\ . -:) 510 ,0< .~ do.. / .:); ,0 /6~'y ~'F I / -1 (14) x.O_ (15) x .0 !::L5. (16) x .12 (17) x _15 (18) (19) , () 3 I ,~:)} if if /, Ii 1 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) Decedent's Complete Address: STREET ADDRESS / q j h (v r / c] h r CITY Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) Total Credits ( A + B + C ) (2) 3. InterestiPenalty if applicable D. Interest E. Penalty TotallnterestiPenalty ( 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) ZIP /" r I . / (i \. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes 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 ~ [Z[ [2j [2J [21 [2] 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 accompanyinR edules 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 infor ation of whic pre parer has any knowledg SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN;! ADDRESS / ,--5/; (,AJYJ h (.J r-1r'1 n d [) Y I SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE a Ii. .A;, ~~f if ;J. , L /H- / I ~ / e., . Xi. / '} () /5 DATE JI) --;J Y-f).) ADDRESS DATE 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 net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(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. .RE~-1502 EX+ (6-9*, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which roperty would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevaht facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION House ~ land (/tJt#'10) In 'fioy+h trhddleton ~u.Jn5hlf) Cum bey/and (J~. PR · L()catc:.d at 1080 earn he r/and {Jr: (Ja...l/s/e Pit. /1013 BI'leu~1 dw€.IfJ~~ 1'JlArcha~cd / '-/~-7't R.rc h d:srd fh ~ v.JIa Y /1 sl e Bw / d" 'j ~ LOd" flSSIt. at fh~ pr1ce./''Y'IJu/6,65. Pd /n full {-g.1g ~ IIome !gutS lO<J11 bJdh Soue~e "3'1 I3ah/( C' ava I tj i?J Car /(5 Ie pfJ VALU AT DATE OF DEATH I~ 0 V'll. (/( I i I 1/4'{,91 j 110m e ttui Ij LoiJn LJ,'th 5overei:Jl Ban I< :J. g / 6, oS' eaua/rj 'RJ, Carlisle PA. D-'C- ~ 6S . (/0 rei (;lIO .c)(~ Apo:x) . eX) >>--~ TOTAL (Also enter on line 1, Recapitulation) (If more space is needed, insert additional sheets of the same size) II ! I I TAX YEAR 2005 TAX AUTHORITY COUNTY/MUNICIPAL ASSESSMENT l3t,490 DATE 03/01/05 BIll lOr 29 4225 TAX COLLECTOR ROBIN K. SOLLENBERGER NORTH MIDDLETON TOWNSHIP 5 HILL DRIVE I I CAAlISLE PA 11013 ~\. ~ I PHONE NUHBER 711-249-0741 D \~ f PENAL TV I ~~\ FlD TAX DISCOUNT FACE NAME/ADDRESS o I nON \ 11..~~~ TYPE Al~OUIIT AMOUNT AMOUNT I YATES, LLOYD E & ROSE E, ~~~ f-.~e~:r\G.~(J.. 1 CRE 258.49 263.77 290.1 ~ 130 CUHBERLANO DRIVE O'O\~ 'f.,.. CO\..\..'{:.C 2 CLB 23.20 23.67 26.0 CARLISLE, PA 17013 ~ '1.~'j.. 3 TRE 114 . 55 116.89 128.5 16 1094 333 4 TSL 0.00 0.00 0.0 130 CUMBERLANO DRIVE TOTAL 8 404.33 444.1 DUE ON OR AftER 03/01/05 05/01/05 07/01/0 TAX YEAR 2005 TAX AUTHORlTY SCHOOL ASSESSMENT 131,490 DATE 07/01/05 BIll 10 NT 29 4244 Page: 1 Document Name: untitled 6017 10/13/05 RETAIL ~NS BIS4072 i ACCT TYPE ILN ACCOUNT NO. 6817102529 DATE 00/00-00 SEQ.NO. 0 I LINE NO I LN-TYPE 1 SUB-TYPE 0 PLAN-NO 86 SHORT-NAME YATES LLOE STATUS 1 LOCKOUT 0 WARNING 0 PD-TO-DATE 10/19/05 NEXT-REN-DT 06/19/111 LEDGER 502 BRANCH 169 OFFICER WAY DLR 87845-000 COUNSELOR 0 DELQ-RPT LINE SEQ/ NO ENTRY-DT TIME TRAN-AMT DESC EFF-DATE BAL-AFTER PD-TO-D 1 02/22/05 1 123.93 REG-PMT 02/22/05 7277.17 03/19/05 2 03/21/05 1 123.93 REG-PMT 03/21/05 7198.94 04/19/0~ 3 04/19/05 1 123.93 REG-PMT 04/19/05 7123.57 05/19/05 4 05/19/05 1 123.93 REG-PMT 05/19/05 7049.35 06/19/05 5 06/20/05 1 123.93 REG-PMT 06/20/05 6977.89 07/19/05 6 07/19/05 1 123.93 REG-PMT 07/19/05 6901.03 08/19/05 7 08/19/05 1 123.93 REG-PMT 08/19/05 6826.86 09/19/05 8 09/19/05 1 123.93 REG-PMT 09/19/05 6752.16 10/19/05 * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * UPDATE COMPLETED OK LOAN ADMIN. ON-LINE HISTORY BROWSE TRACE-NBR 300106359 300105158 300100621 300100637 300103712 300100635 300100658 300102310 Page: 1 Document Name: untitled LOAN ADMIN. ON-LINE HISTORY BROWSE I I 6017 10/13/05 RETAIL ~N8 BI84072 ~~~~~i~::L;:;:~~p;C::~;~;;~O::~:~;;;;;~~~;:;~;;;2::;~~~E:::~N:~/:8/I06 LEDGER 504 BRANCH 169 OFFICER WAY DLR 87845-000 COUNSELOR 0 DELQ-RPT LINE 8EQ/ NO ENTRY-DT TIME TRAN-AMT DE8C EFF-DATE BAL-AFTER PD-TO-D TRACE-NBR 1 02/28/05 1 188.00 REG-PMT 02/28/05 2973.99 03/28/0 300106528 2 03/28/05 1 188.00 REG-PMT 03/28/05 2815.08 04/28/0 300103716 3 04/28/05 1 188.00 REG-PMT 04/28/05 2657.56 OS/28/0 300101415 4 05/31/05 1 188.00 REG-PMT 05/31/05 2500.19 06/28/0 300104405 5 06/28/05 1 188.00 REG-PMT 06/28/05 2336.64 07/28/0 300101413 6 07/28/05 1 188.00 REG-PMT 07/28/05 2173.13 08/28/0 300101443 7 08/29/05.1 188.00 REG-PMT 08/29/05 2009.42 09/28/05 300103751 8 09/28/05 1 188.00 REG-PMT 09/28/05 1842.48 10/28/05 300101457 10/06/05 0001 CHANGED DONOR ACCT FROM DD 1691013692 - B ENDY 10/07/05 0001 LETTER PRINTED: EPAY CONFIRMATION LETTER * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * * * * * * * * * * * END OF ACTIVITY * * * * * * * * * * UPDATE COMPLETED OK REV.'5IJ3'EX. (1.97) ESTATE OF COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION '\/~ FilE NUMBER TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) II VALUE AT DATE OF DEATH REV-1504 EX+ (1-97) , , * COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF Llo 'Id t- lfa tes Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, qther than a sole-proprietorship, See instructions for the supporting information to be submitted for sole-proprietorships. FILE NUMBER ITEM NUMBER VALUE AT DATE NUMBER DESCRIPTION OF EATH t Yl/~ TOTAL (Also enter on line 3, Recapitulation) $ I I (If more space is needed, insert additional sheets of the same size) REV-1505E)(+ (1-97) SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT L. JI) Yd E C(~te.5 '<\ I &J FILE NUMBER COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Address City 2. Federal Employer I.D. Number 3. Type of Business State Zip Code State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year 1. Name of Corporation Product/Service STOCK TYPE Voting / Non-Voting TOTAL NUMBER OF SHARES OUTSTANDING PAR VALUE NUMBER OF SHARES OWNED BY THE DECEDENT VALUE OF THE DEC DENT'S STOCK 4. Preferred $ $ Common Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? 0 Yes o No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? 0 Yes o No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31-&2? DYes 0 No If yes, 0 Transfer 0 Sale Number of Shares Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. Consideration $ Date 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. DYes o No 10. Was the decedent's stock sold? DYes o No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding yea~ C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate apprais Is have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F_ Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. REV-1506 EX+ (9-00) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF L~ 10 'tel. E YCi8 Y\/~ FILE NUMBER 1. Name of Partnership Address Date Business Commenced Business Reporting Year City 2. Federal Employer I.D. Number 3. Type of Business State Zip Code Product/Service 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ 5. A. B. c. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. 0 Yes 0 No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold Consideration $ Date Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? 0 Yes 0 No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... 0 Yes 0 No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 pr C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. I 11 RE;-1507 EX+ (1-97) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER Llo lid E Yates All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALU:1~T DATE NUMBER DESCRIPTION OF EATH 1. Y1/~ TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1508 EX + 1'-97) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Include the proceeds of litigation. and the date the proceeds were received by the estate. All property jointly-owned with the right of sUNivorship must be disci sed on Schedule F. ITEM NUMBER 1. ~ o L/ S to DESCRIPTION Ba () J{ ()...C-COIA n t: - Ch €c K, ~j Ac c t 1:1 I /t; q I (J I :j /p q ;) LIOjd E. ,Paie5 \ ~l~ t RoSe E. Yates (deceas€t>y' Sa lJ e. rei ~ n i3a r1 1< 1 CaVil Ir,j RJ eeJt lis Ie PI}.. Co~ - hi erQ,urj (- Ct~hJ /IlarCjtu6 /985 Blu..e, G () tPK ) Tru.e 1< "Ch€Urol<rf ;:>IC: '( ilP) / q 8 'I " 13 lae 8bok Boat- - fjlu.md Craft - hsh;n.q ba,d /91.3 l3oor,ra;'er- -Sears - /Q1'3 Sa f ;no!O r 1 f!oaser,o/d 500ds V LUEATDATE OF DEATH / / ~ ,~3 .5't.5'.OO I 9 ~t>. 00 I 5&1. 0" /t'f,ot) 5rJ A) tJ 8 ~{J, 00 :;I TOTAL (Also enter on line 5, Recapitulation) $ 6 ,51. ~ 3 (If more space is needed, insert additional sheets of the same size) 1-877-SQV-BANK (1-877-768-2265) www.sovereignbank.com GENERA liON CHEC~ING GENERA TION CHECKING c;u,t, '1'~I'l1t f=\ !IWi O~) 2Ci OC:; 04 :28 Cl~; LLOYD E YATES Account # 1691013692 ROSE E YATES Former Account # 10026869 Balances Beginning Balance $1,546.23 Current Balance $1,347.41 Deposits/Credits + $1,468.69 Average Daily Balance $1,930.0' Withdrawals/Debits - $1,667.51 Interest Paid this Period" $ 0.09 Annual Percentage Yield Earned 0.0611A Earned this Period $ 0.09 Paid Last Year $O.OC Paid Year-To-Date $0.74 "The interest earned and the interest paid may differ depending on when interest is credited to your account. Checks Posted Check # Date Paid Amount Reference # Check # Date Paid Amount Referent a# 6769 04/07 $20.77 640579370 6775 04/07 $10.77 6405721: 70 6770 04/07 $59.83 641009000 6776 04/05 $222.00 6111261C 50 6771 04/06 $64.36 614823380 6777 04/08 $6.00 617893~ 20 6773" 04/07 $107.63 641448250 6778 04/27 $175.00 6412477 90 -- 6774 04/06 $61.55 614473550 6779 04/28 $54.09 6437141'l 40 10 Check(s) Posted = $782.00 An asterisk (*) indicates a skip in sequential check numbers. Account Activity Date Description Additions Subtractions Balar ce 03-29 Beginning Balance $1,546 23 03-29 INSTALLMENT LOAN $188.00 $1,35$ 23 PAYMENT ACCT NO 681-7102618 , 04-01 US TR'EASURY 310---'- - $907:0FT s'fYi,fffiO. -- $2,265 23 " SOC SEC 040105 ASSA . j 04-01 W PA TEAMSTERS $258.60 bJ'\ T7_ $2.523 83 -t;~~~tL;A/ '- PAYROLL (.04-05 ,J CHECK 6776 $222.00 $2,301 83 04-06 CAPITAL ONE ARC $200.00 $2.101 83 CHECK PYMT 050405 6772 ge 3 of 5 /69/0/3692 ~ - - - ==== ~ - 5!!!!!Bi!!!!!! - - ==== """""""" ;;s;;;;;:;;;:;; - = - - - ~ ===- - ~ ===== == - ==== i!!iilIlillIlii iiiiiiiiiiiii ~ - _113~k:A;3 REV-1509 EX. (\-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY Llo Yd E Yates If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. FILE NUMBER SURVIVING JOINT TENANT(S) NAME ADDRESS RE ATlONSHIP TO DECEDENT A. \}/~ 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 identifying number. Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. '\\ J OJ TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) RDV-1510 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF i ,In Y rl F. Pales SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBA TE PROPERTY FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSIGr TAXABLE VALUE ATTACH A COPY OF THE DEED FOR REAL ESTATE. NUMBER VALUE OF ASSET INTEREST IF APPLICABLE) 1. (\,/~ TOTAL (Also enter on line 7, Recapitulation) $ .. , (If more space IS needed, Insert additional sheets of the same size) REV-1511 EX+ (12-99) . , .~ ESTATE OF SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT L/tJ lfd 1:'-: ~te:5 FILE NUMBER Debts of decedent must be reported on Schedule 1. ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION 1. flarnlJliJn-S!anIGj fb.nera I f/ome, Verona) 111 {etfet-;nj on mOYnt-tment9-blAr;a{ of Oremains Hu.er ,If)emor/a I Horne. q.erernali~() SerVLC~€5 fne. !ldtr/~b(,t ~ PA- ((!,remafion cf fltc ) a 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 -M / a y. /~. i1 I:- St..IAdd"" I ~ rl1~ he r I ill) d Q C City c~ ~ \--1, s I e State .ill- Zip /10 J 3 Relationship of Claimant to Decedent ----DrllJ....~bJe I Probate Fees 4. 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) A OUNT / C},I), {)O I I I 16~s',OO j 600 .00 The New Bethel Cemetery Corporation P. O. Box 67 Verona. Ky. 41092 July 7, 2005 Hrs. Nola Kent 130 CUlllbe.rlaDd Drive. Carlisle, Pl.. 17013 Charles for burial of cremains of Lloyd and RoBe Yates at New Bethel Cemetery, Verona, Kentucky Two @ $ 100 each I $ 200.00 '-"""~ I VIII""""~' , Elli.ton-$tanley Funeral Home. Williamstown, KY. Crittenden, KY. (859) 824-3374 (859) 428.3374 STANLEY MONUMENTS P.O. Box 130 Williamstown. KY 41097-0130 Phone (859) 824-3374 Hamilton-Stanley Funeral Home Verona, KY (859) 485-4885 M~ORIAL CONTRACT Purchaser IY\ R.~, NO l. A N r Order No. Address --1 ~ (!.Ut1\i>UL.f},J]) -:D~,\)" Date.::It: City~lLi~Le. StateAZiP/7~J~ Phone 17:1. Contract is hereby ~lh STANLEY MONu..eNT~rty of Ihe li""~. for mcnumon1al work to ~,'i 1 J.II ~ NE~ ~L.cemeteryat ~"'")',. within~prOXimatelY A-~A..P days from date of acceptance by home office. SUbject to rules and regulations (if any) of sajd cemetery. Design OielMarker I Material _ Base Lettering ... UTTft.1t. ~ J)..6']:&" J ',...J f!.x l'''T'~~ 6 PA~ tt.c. ~ A-~ Fi ,~o&.O ~ t Othel'Work Ap~, ~ QD{)~ ) SFOLL~05E. YATE. ':, N~v. Iq) ~DD3 L L DY:D YATE.. SLETTERED "" monumental work described above is guaranteed against any defects in material and wor1cmanship- Said work with title hereto and right of possession thereof shall remain the property of said party of the first part until in accordance with terms of payment. In defaun of any payment hereunder purchaser licenses said party of the Ii t part or its agents to repossess and remove said monumental work without guilt of trespass or any other wrong and~. thorize and empower them to apply for permit from cemetery superintendent for its removal, if cemetery permit should be ssary, and to take any further steps deemed necessary or expedient and further agree to save them harmless from and un er any entry of repossession and removal, and said monumental work shall be retained or disposed of by said party of the first art, without being answerable to purchaser for it or for any proceeds therefrom. I TERMS OF PAYMENT J/. 1 . " ~ I.tQ ,. _ Jr/" ^ A^ This contract does not include lettering, matefjl. al or work- Contract Price ~ \W ::1_.. - ~~ manshlp except .a specified herein. i F dat' Ch - It is mutually understood that there is no agreement regarding . oun Ion arge this order other than contained herein. I This order is irrevocable and not subject to cancell"*ion or coun- termand after acceptance. , All checks. money orders or drafts of any kind must be made payable to said party of the first part. All payments in cash or otherwise must be made direct to the sai party of tthe first part. Execution of t contract is continge upon stnk's, fire. acci. dents, or weather 0 0 r ntf I , Signed i Total I / StJ. f10 Down Payment Balance on Dal"a~_ ~ STANLEY MONUM N S ~ :=~;I;t:Y ____~m- . _ AUER MEMORIAL HOME AND CREMATION SERVICES, INC. 4100 ]ooestown Road. Harrisburg, PA 17109 . 1-800-720-8221 · fax 717-541-9943 · Shawn E. Carper, Supervisor 4-5-2005 Nola Y. Kent 130 Cumberland Drive Carlisle, PA 17013-1010 Lloyd E. Yates - Deceased SPECI.AL CHARGES X Direct Cr.mation Forwarding R.aalns Receiving Remains Immediate Burial Nationwide Guarantee Program Worldwide Travel Protection TOTAL SPECIAL CHARGES PROFESSIONAL SERVICES Services ot Funeral Director << Statt EJlbalmlng Other Preparation ot the Body Facilities & Statt tor Viewing ($200/hour) Facilities & Staft tor luneral SerVice Facilities & Statt tor Memorial Service Staff << Equipment tor Viewing ($200/hour) Statt & Equipment tor Funeral Service Statf & Equipment tor Memorial Service Private Family Viewing Private Identification Viewing Packaging/Forwarding of Cre.ated Reaain. Personal Delivery ot Cremated Reaains Scattering ot Cremated Remains Other TOTAL PROFESSIONAL SERVICES AUTOMOTIVE EQUIPMENT Removal Vehicle Casket Coach Flower Car Lead Car/Clergy Car Service Vehicle Faaily Car TOTAL AUTOMOTI.VE EQUIPMENT 250479 AB-5 $795.00 $795.0e se.0e $e.e0 MERCHANDISE Register Book Memorial/Prayer Cards Thank You Cards Remembrance Package Casket X Minimwn Oak Alternative Container Burlal Vault Veterans Flag Case Grave/Memorial Marker Other Other TOTAL MERCHANDISE $185.00 $185.00 CASH ADVANCED ITEMS Grave Opening Cemetery Equip.ent Vault Service Charge Newspaper Notice Newspaper Notice Clergy Church/Organist/Soloist Flowers X Crematory Charge X County Coroner Fee X Certified Copies of Death Certificate Other TOTAL CASH ADVANCED ITEMS SUMMARY OF CHARGES Special Charges Professional Services Automotive Equipaent Merchandise Cash Advanced Ite.s SUB TOTAL DISCOUNT TOTAL AMOUNT PAID BALANCE DUE 4-6-2015 $300.00 $25.00 $30.00 $355.00 $795.00 $0.00 $0.0' St85.00 $355.00 $1,335.0' $0.88 $1,335.00 -$1,335.8' $0.80 REV.1512 EX.. (1-97) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS Yd7eS FILE NUMBER ~f COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF L)D'(d t- Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION 1. Home tgLli9 loan UhfdiJ balance tJ;rJ, SouerelSY1 13~h/( CdUa/rj 1:tI Cd~I,'s Ie Pr+ ~ !!ome Ezud:j It;a f) Un poid hd/d'lee w~th SO~t"eI5n Bank Caoa/rj I~d Cal-I, sk p~ 3 Caf;1o l DJ) e - Ace t /;#.5~ q /-1../ 9d.:;' - t53'~ -6/7 (, L/o;jd E f~1Gs f Ros~ E t/ate5 4 ClIlJst: - fJect #613'; -fp 35d -(;~S3 - ?o? 6 Llo:Jd E f/ate-5 f ka5e E rIlte6 II AMOUNT 2/98'. q~ ~~/$,08 ~ CJ.3 ,(p </ YS' '}CJ. Cj~ ./ TOTAL (Also enter on line 10, Recapitulation) $( 8' (If more space is needed, insert additional sheets of the same size) CHASEPERFECTCARDWMASTERCAR~ ACCOUNT NUMBER: 5188 8352 0053 7070 NEW BALANCE $4,570.92 TOTAL CREDIT LINE $8,500 AVAILABLE CASH $3,929 STATEMENT CLOSING DATE 04108105 PAYMENT DUE DATE 05103105 TOTAL AVAILABLE CREDIT $3,929 CASH ACCESS LINE $8,500 Here is your Account Summary: TOTAL $4.245.41 4.85 276.64 53.72 4,570.92 91.00 UV; 1) G i 116 ~/^ ~ ff(,~~ 17' Previous Balance Ii Pa~ems,C~ 1+) Purchaees, Cash, Debits 1+) FINANCE CHARGES 1=) New Balance Minimum Due P ue-P Minimum Payment Due Your charges and credits at a alance: . ... 10 ... . . N I ... N i ... . , ... . l!l . . rJ tit . ... ... ; CapltalOne. . N . . ~ :: Account Summary . PreviOWl Balance I Payments, Cr~itl and Adjustments ~ Transactions : Finance Charges III . ... New Balance : Minimum Amount Due ;; Payment Due Date .. - :: Total Credit Line ~ Total Available Credit .. Credit Line for Cash ... Available Credit for Cash i 12,787.57 1200.00 '.00 116.07 '2,603.64 1711.00 April 19, 2005 110,000 '7,396.36 15,000 15,000.00 At your service To ClID Curtomcr Relation. or to report a lort or rtolen cud: 1-800-955-7070 For free online aCCO\mt .crvice and .pecial alltomcr offen, log on to: ....t PLATINUM MASTERCARD ACCOUNT 5291-4922-6535-6176 FEB 20 - MAR 19, 200 Page 1 of ; Rewn Summary Previous Mileage Balance: Miles this Period: Miles due to expire 04101/05: Redemptions: Ending Mileage Balance: 5,000 o o o 5,000 The mileage information reported here may not reflect all purchases on thi~ statement or recent redemptions. For rewards questions or to redeem miles, please ca~1 the Capital One Rewards Center at 1-877-497-83 J 6. i Pa}'Dlcnu, Credits and Adjultmcnts 1 28 FED PAYMENT RECEIVED - THANK YOU I We will be changing how we allocate payments and credits to your account no IOOner~than ~ur June 200S billing period. As stated in ~ur Customer Agreement, this may include all cation to balances with lower annual percentage rates (A.P.R..) before balances with higher N .R... P1eaae call the number on the back of your credit card if you have questiolll about the sped changes to ~ur account. I 1200.Of RE~-1513 EX+ (9-00. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER NUMBER I RELATIONSHIP TO DECEDENT NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ;0'/d ~ ~ n t- Dd~h ie r /30 Camber land Do( edt-lisle Pff /10/3 1. AMOUNT OR SHARE OF ESTATE I I /t?~ % ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 CQv ER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. Y1JQ. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. Y\ J C'A- TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN . (Check Box 4 on REV-1500 Cover Sheet ESTATE OF Llo <fd E: Pates FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prlior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. i Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to -30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. o Will 0 Intervivos Deed of Trust 0 Other o Life or o Life or o Life or o Life or o Life or 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Actuarial factor per appropriate table ................................................. Interest table rate - 031/2% 06% 010% 0 Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and enter corresponding (number) . . . . . . . . . . . . . . . . . . . . . . . . . . Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12) o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( ) 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ................................... 5. Annuity Factor (see instructions) Interest table rate - 031/2% 06% 010% 0 Variable Rate % 6. Adjustment Factor (see instructions) .................................................. 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Sche ules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 trough 18. (If more space is needed, insert additional sheets of the same size) (Middl Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1 82. This schedule is to be used for all remainder returns when an election to prepay has been filed under t e provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust p incipal. Remainder Prepayment: A. Election to prepay filed with the Register of Wills on (attach copy of election) B. Name(s) of life T enant(s) Date of Birth or Annuitant(s) REV-1644 EX + (3.84) ~;l~~ 't?~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE "L" REMAINDER PREPAYMENT OR INVASION OF TRUST PRINCIPAL I. Estate of II. (Dote) Age on date of election C. Assets: Complete Schedule L- 1 ~ 1. Real Estate 2. Stocks and Bonds 3. Closely Held Stock/Partnership 4. Mortgages and Notes 5. Cash/Misc. Personal Property 6. Total from Schedule L- 1 D. Credits: Complete Schedule L-2 1. Unpaid liabilities S 2. Unpaid Bequests S 3. Value of Unincludable Assets S 4. Total from Schedule L-2 III. E. Total value of trust assets (line C-6 minus Line D-4) F. Remainder factor (see Table I or Table II in Instruction Booklet) G. Taxable Remainder value (Line E x Line F) (Also enter on Line 7, Recapitulation) Invasion of Corpus: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) or Annuitant(s) Date of Birth Age on date corpus consumed C. Corpus consumed D. Remainder factor (see Table I or Table II in Instruction Booklet) E. Taxable value of corpus consumed (Line C x Line D) (Also enter on Line 7, Recapitulation) FILE NUMBER Term of years ncome or annuity is fll yable s s s s Term of years income or annuity is ayable s s s I REY.1645 EX + (7.85) INHERITANCE TAX *' SCHEDULE L-' COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN RESIDENT DECEDENT -ASSETS- FILE NUMBER I. Estate of ~.Ie.. ~ L~/() pel IE-- (last Name) (First Name) (Mid~l. Initial) II. Item No. Description Vqlue , A. Real Estate (please describe) I niCe..- Total value of real estate $ (include on Section II, Line C-1 on Schedule L) B. Stocks and Bonds (please list) Y)/ ct Total value of stocks and bonds $ (include on Section II, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) Y1/~ Total value of Closely Held/Partnership $ (include on Section II, Line C-3 on Schedule L) D. Mortgages and Notes (please list) Y11k. Total value of Mortgages and Notes $ (include on Section II, Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) r)/~ Total value of Cash/Misc. Pers. Property S (include on Section II, Line C-5 on Schedule L) III. TOTAL (Also enter on Section II, line C-6 on Schedule L) S (If more space is needed, attach additional 8% x 11 sheets.) REV-I646 EX+ (3-84) INHERITANCE TAX . SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION , INHERITANCE TAX RETURN I RESIDENT DECEDENT -CREDITS- FILE NUMBER I I. Estate of Y:.l f6 -~ L/o lid ttl-- (Lost Nome) (First Nome) (Mide Ie Initial) II. Item No. Description Am ~unt A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L- 1 (please list) V\j{).J I Total unpaid liabilities $ (include on Section II, Line 0-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) ryev Total unpaid bequests $ (include on Section II, Line 0-2 on Schedule L) C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: Y)/~ I I I I Total unincludable assets $ I (include on Section II, Line 0-3 on Schedule L) I III. TOTAL (Also enter on Section II, Line 0-4 on Schedule L) $ I (If more space is needed, attach additional 8Y2 x 11 sheets.) II REV-1647 EX+ (9-00) . . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet ESTATE OF L.lt) if d E Vok5 FILE NUMBER This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vE1sts in possession and enjoyment cannot be established with certainty. I Indicate below the type of instrument which created the future interest and attach a copy to the tax return. I 0 Will 0 Trust 0 Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH A 3ETO NEAREE T BIRTHDAY 1. Y \1 2. 1/8- 3. I 4. I 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdraw I within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the survivi g spouse exercises such withdrawal right. 0 Unlimited right of withdrawal 0 Limited right of withdrawal I III. Explanation of Compromise Offer: Yl/~ I IV. Summary of Compromise Offer: 1. Amount of Future Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ..... .$ I 3. Value of Line 1 passing to spouse at appropriate tax rate ~ Check One o 6%, o 3%, o 0%......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One o 6%, o 4.5% .......................... .$ I (also include as part of total shown on Line 16 of Cover Sheet) I I 5. Value of Line 1 taxable at sibling rate (12%) I I (also include as part of total shown on Line 17 of Cover Sheet) ..... .$ I I I 6. Value of Line 1 taxable at collateral rate (15%) I I (also include as part of total shown on Line 18 of Cover Sheet) ..... .$ I 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ..................... .$ I I (If more space is needed, insert additional sheets of the same size) II REV.1648 EX (1.92) r. . W COMMONWEALTH OF PENNSYLANIA INHERITANCE TAX DIVISION ~ ,AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91 ESTATE OF i E ~ Ie I FILE NUMBER '/0 'I. d.s This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. . . SCHEDULE N SPOUSAL POVERTY CREDIT 1. Taxable Assets total from line 8 (cover sheet) .................................................................... 1. 3. Insurance Proceeds on Life of Decedent ................Y)/.. ................................................ 2. Retirement Benefits.... .......... .... ..... .... ......... ..... ... ... ... .... .. ~........ .......... ............. ...... ... 3. Joint Assets with Spouse ................................................................................................. 4. 2. 4. 5. PA Lottery Winnings.................... ............. .................... ........ ......... ............. ........ ........... 5. 6d. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6b. 6e. 6. SUBTOTAL (Lines 6a, b, c, d) ......................................................................................... 7. Total Gross Assets (Add lines 1 thru 6)............................................................................. 7. 8. Total Actual Liabilities .................................................................................................... 8. 9. Net Value of Estate (Subtract line 8 from line 7)................................................................ 9. If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part II. PART II _ CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income Tax Returns for decedent and spouse.) Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse...................... 10. b. Decedent ................... lb. 2a. 3a. 2b. 3b. c. Joint .......................... 1c. 2e. 3c. d. Tax Exempt Income..... 1d. e. Other Income not listed above ........... Ie. 2d. 3d. 2e. 3e. f. Total.......................... If. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: 2f. 3f. (If) + (2f) + (3f) = . 3 4b. Average Joint Exemption Income ........ ........... ... ......... ........ ........... .... ,..... ... ,.. ...... ....... ...... = If line 4(b) is greater than $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part /II. . . .. . . .. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less.......................... 1. 2. Multiply by credit percentage (see instructions) .................................................................. 2. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. ............................................ 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate....................... ........ .......... .......................... ...... ............. ............ 4. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. 5. II ~".~."., . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 0 ELECTION UNDER SEC. 9113(A) SPOUSAL DISTRIBUTIONS [/0 C(d E ~ reS Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate lax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, Bv-pass, Unifie~ Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to hill e such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on 6 hedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this frac(i n is equal to the amount of the trust or similar arranaement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or simile r arranaement FILE NUMBER ESTATE OF PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to! he decedent's surviving spouse under a Section 9113 (A) trust or similar arranqement. DESCRIPTION VALUE Yl/a." I Part A Total $ ! PART B: Enter the descriotion and value of all interests included in Part A for which the Section 9113 (A) election to tax is] einq made. DESCRIPTION VALUE ))/ U- Part B Total $ (If more space is needed, insert additional sheets of the same size)