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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
RESIDENT DECEDENT
NOV 2 7 '8
COUNTY 1~1 CUMBERLAND
IMPORTANT:
This return must be completed in detail and filed in duplicate, with all attached, with the Register of Wills of the
County where decedent resided; Return is due within nine months after date of death, unless an extension is granted
by the Secretary of Rnenue. (Section 703 of the Inheritance and Estate Tax Act of 1961.)
(STATE FULL NAME OF DECEDENT)
} AFFIDAVIT OF
EXECUTOR
County ADMINISTRATOR
IN THE MATTER OF THE ESTATE OF
HAROLD E. WETZEL
lat. of CUMBERLAND
Stat. of PENNSYLVANIA
County of NORTHUMBERLAND
} ..,
AdministratorS
Rhoda M. Bossler and Ethel E. Welker
of the ..tat. of the abov.-nam.d d.c.d.nt being duly sworn, d.pa..
Executor
and say
(MONTH)
Nom. and addr... of attarn.y or }
ath.r authorlz.d r.pr....ntativ. to whom
all corr..pond.nc. should b. mail.d.
(DAY)
19 ~{M1M". ~..-1... w U.1r eop,..ef .....leI.-le ...... ........... ' }
(YEAR) int.stot.
Decedent died
May
25
MYRON M. MOSKOWITZ, ESQUIRE
2 E. Indepenaence Street, Shamokin, Pennsylvania 17872
That as such Administrators deponent is familiar with the affairs of said estate and the property constituting
(EXECUTO R-ADMINISTRA TOR)
the assets thereof and their fair market value.
That at the time of dea th there was no safe deposit box registered in decedent's individual name, or jointly wi th, or
as agent or deputy of another, or in decedent's individual name, with right of access by another as a,gent or deputy, with the
exception of the following: -
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION THIS SAFE DEPOSIT BOX RENTED RELATIONSHIP OF JOINT
IN WHICH DECEDENT RENTED A SAFE DEPOSIT BOX IN NAME OR NAMES OF HOLDERS TO DECEDENT
NON I
That the contents of said safe deposit box or boxes are itemized under SchedulesN/A
wi th the exception' of the following, for the reasons hereinafter set forth:
of this return,
That Schedule A attached hereto and made part hereof sets forth fully and in detail all the real property
in the Commonwealth of Pennsylvania of which decedent died having an interest therein. It also sets forth the
mortgage encumbrances upon each parcel of real property at the date of death, giving the amount still due at
death, name of mortgagee, date, rate of interest, and book and page of record thereof. It also sets forth in the
columns provided therefore the assessed valuation of each of said parcels, the estimated market value thereof
as of date of death of decedent.
That Schedule B attached hereto and made part hereof sets forth fully and in detail all personal property
wheresover situated owned by the decedent at the time of death; all moneys left by the decedent at the time of
death, whether in decedent's immediate pos session, standing to decedent's credit in banks of deposit, savings
banks, trust companies, or other institutions, whether individually, or in trust for any other person or persons
giving also separately the accrued interes t thereon, if any, down to the last interest day prior to decedent's
death in the case of savings banks, and to the date of decedent's death in all other cases; all bonds, postal
savings, treasury certificates or notes and other evidence of indebtedness of the United States to the de-
cedent; all obligations, whether by statute or agreement they are designated as tax free, of the United States,
or any state, or political subdivision thereof, or of any foreign country, which are owned at the time of death;
all wearing apparel, jewelry, silverware, pictures, books, works of art, household furniture, horses, carriages,
. ~
automobiles, boats, and any and all other personal chattels of whatsoever, kind or nature, left by decedent,
together with the fairly estimated market value thereof; all bonds and mortgages held by decedent and of all
claims due and owing decedent at the time of death, and all promis sory notes or otherinstruments in writing
for the payment of money of which decedent died possessed, of whatsoever nature, with interest thereon, if
any, giving the face value and estimated fair market value thereof, and if such estimated fair,market value be
less than the face value, it sets forth briefly the reasons for such depreciation as to each item; all moneys
payable to the estate from life insurance policies carried by decedent; all annuity and endowment contracts
the proceeds of which were payable upon the death of the decedent; all and the corporate stocks and dividends
due thereon and unpaid as of the date of death, bonds and accrued interest thereon to the date of decedent's
death and other investment securities owned by the decedent at the time of death, with the.market value there-
of a t such time.
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In ,the case of securities of close or family corporations, the values reported are as far as
possible substantiated by financial statements of the corporations, showing the assets and liabilities
thereof as of the date of death. The schedule also sets forth the interest of decedent ~t the time of
death in any co-partnership or business, and in support of the value of such interest there is annexed to
said schedule, financial statements showing the assets and liabilities of said co-partnership or Qusiness.
A copy of the co~partnership agreement, (if oral, a statement setting forth the nature of tne agreement)
together with a statement setting forth the character of the business, its location, and such other facts
pertaining to the business as may be pertinent to a fair and just appraisal of the decedent's interest
therein must be submitted. It should also set forth in itemized form, together with--tl1e' fair "market value
thereof, any other property owned or bequeathed by the decedent at the time of death.
The Schedule C attached hereto and made part hereof sets forth a true answer to each inquiry
contained therein and in the case of transfers of property, real or personal, within twoyears-~f dec-edent's
death, in contemplation of decedent's death, or intended to take effect in possession or enjoyment at or
after death, said schedule sets forth the nature and value of such property, to wnom-transferred, the
relationship of the transferees to the decedl,!n't, tl\e_ proportionate share received .by each. transferee and
all other facts of a pertinent nature regarding said transfers. In the case of transfers intended to
take effect in possession or enjoyment at or after death, there is also attached to the schedule a co~y
of the deed,-frust agreement or other instrument creating the trust. Therp. is also set 'forth in said
schedule a list of all property, real and personal, with its value, which passes at decedent's death by
virtue of the exercise by decedent, either individu~lly, orjointl~ with another, or any power of appoint-
ment vest~d in decedellt, either individually or jointly, by the will, deed, or other instrument of another,
with a'copy of the instrument c~eating $uch~ower attached to the schedu~e.
That Schedule D attached hereto and made part hereof sets forth the names and addresses of all
persons beneficially intepested in this estate at the time of decedent's death, the nature of their res-
pective interests, their relationship, if any, to the decedent, together with the ages at the time of
decedent's death of all minors, annuitants and beneficiaries for life under decedent's Will. It also
contains a statement showing which of the beneficiaries named in the decedent's will, if any, died prior
to decedent, the dates of their death, their issue, andthe relationship of such issue to the beneficiary.
That Schedule E attached hereto and made a part hereof sets forth all property, real and per-
sonal, owned by the decedent jointly with another or others, including intangible, standing in the name
of the decedent and others, plus the date and place of record of instruments effecting the vestiture of
real estate and the date of acquisition of personalty, plus 'the name, address and relationship, if any,
of co-owners to the decedent.
That Schedule F attached hereto and made a part hereof sets forth fully and in detail all debts
and deductions claimed for and on behalf of this decedent's estate, including funeral expenses paid;
family exemption, where applicable; costs of administration of this estate; counsel fees and fudiciary's
commissions paid or to be paid; cost expended for burial trusts, tombstones or gravemarkers, and reli-
gious services, in consequence of the death of the decedent; debts and claims owing and lmpaid at time of
death; taxes accrued chargeable for period prior to decedent's death (except those allowed lIDder Section
651 of the Inheritance and Estate Tax Act); together with a statement of collateral pledged for obliga-
tions, if any. It is agreed that the fiduciary will present proof of said claimed obligations upon re-
quest, that if the amount actually paid in settlement of any fee, commission or debt is less than the
estimated amount claiming and allowed, that the same will be reported to the Register of Wills, and that
the amount of tax assessed can be reassessed in accordance therewith.
That the totals of the appropriate columns in Schedules "A", "B", "C", "E", and "F" as directed therein,
have been carried forward and properly registered in the Summary.
GRACf. N. P ,,1'{, (Street Number)
N01ARi iu,jC p
Sh.:~~:~,,~~~~u:P~:'~:. "'~'~'~~rci;;.J~"'i~:-Y~~~~~r"~'?~'?..7....................
NOTE: Before signing affidavit make sure all blank spaces in the affidavit and schedules annexed are
filled in with details or the word "None", and in case the assets include rare and lIDlisted securities,
securities of close or family corporations or an interest in any co-partnership or business, that the
data and statements required lIDder the paragraph above relating to Schedule "B" are attached. Also make
certain that column #1 in the "Summary" has been properly completed as above-directed.
y of ...N.qv.g!1:lp..~.!,........................... 19.7..~.......
RC 0034 (4-73). .
. COMMottWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
TRANSFER INHERITANCE TAX
RESIDENT DECI!DENT
SCHEDULE "A"
REAL PROPERTY
*
Real property in Pennsylvania, with statement of mortgage encumbrances upon each parcel at death of dece-
dent. Property held by the decedent as tenant In common with another or other, should be identified
as to quantum of interest and the estimated value should be that of the decedent's interest only. (Property
held as joint tenants with right of surviorship or tenancy by entireties should be reported on Schedule "E. ")
The real property located In the Common_alth of Penn.ylvanla .hould be
de.crlbed by lot and block number. .treet and .treet number. together with
a general de.crlptlon of the property. with a reference to the record of the
canveyance by which the decedent took title; If a farm .tate number of a.
ere.; 01.0 .tatement of mortgage encumbrance. upon each parcel at death
of decedent. Taxe.. a.....ments. accrued Int.re.t on mortgage.. etc..are
to be lI.ted on Schedule "F" and mu.t not be deducted from thl. .chedule.
(1 )
(2)
(3)
DEPARTMENT
VALUATION
CAUTION
(Do not wrIte
In thl. space)
ASSESSED VALUE
FOR YEAR OF
DECEDENT'S
DEl. TH
ESTIMATED
MARKET VALUE
1. Real Estate municipally numbered 3014
Harvard Avenue, Camp Hill, Cumberland County,
Pennsylvania as more particularly described in
the deed recorded in the office for the Recording
of Deeds in and for Cumberland County, Pennsyl-
vania in Deed Book 0, Volume 11, page 172.
Sold 9/27/78
.i. II IV A }f~ d E f?.
6/,.
5,440.00
3o,000.00J..o~~/O()C. cO
.541.;0
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ft!J / co
TOT AL.
30,000.00
Insert this total opposite "real property", Schedule "A" in the X X X X X
"As Reported" column on the last page of this return.
30.000.00
Rec -35 .
.
RESIDENT DECEDENT
SCHEDULE "B"
PERSONAL PROPERTY
'*
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
INSTRUCTIONS: This Schedule must disclose all tangible and intangible personal property owned individually
by the decedent, at the time of' his death. Property owned by the decedent Jointly with another or others
must be listed under Schedule "E". Intangible personal property, titled in the name of' the decedent, but
payable at death to another or others, including but not limited to P.O.D. U. S. Savings Bonds and tenta-
tive trust accounts, must be listed, despite the f'act that they are not of' the administered estate.
Tangible personal property should be listed f'irst (e.g. Jewelry, wearing apparel, household
goods, and fUrnishings, books, paintings, automobiles, boats, etc.)
Intangible personal property, such as bonds, treasury certif'icates, cash on hand and in bank,
stocks, mortgages, notes, together with accrued interest or dividends, salaries or wages, insurance pay-
able to the estate or f'iduciary in said capacity, partnership interests, interest in anyundistributed
estate of' or income f'rom any property held in trust under the will or agreement of' another, even though
located outside of' th~ State, at the time of' death, should be listed in this schedule.
Item ITEM UNIT ESTIMATED DEPARTYENT VALUATION
No. List and describe full y VALUE MARKET VALUE (Do not write in
this space)
(\J 0 (\4...
N 0 N E - 0 -
Insert this total opposite "Personal Property", Schedule "B" in X X N 0 C\L..
the "As Reported" column on the last page of' this return.
,
~CCI" 30.
COMMONWEALTH OF PENNSYLVANIA
TRANSr~R INHERITANCE TAX
SCHEDULE "c"
TR1\NSFERS
RESIDENT DECEDENT
(1) Did decedent, within two years of death, make any transfer of any material part...j;l.f his estate, without
receiving a valuable and adequate consideration therefor? (Answer yes or no) I~U
(2) Did decedent, within two years of death, transfer property from himself to himself and an~ther or
others (including a spouse) in joint ownership? (Answer yes or no) NO
(3) If the answer to (1) or (2) above is in the affi[~~~ive state:
(a) Age of decedent at time of transfer I~/A
(b) State of decedent's health at time of making the transfer. (Note 1).
(c) Cause of decedent's death. (Note 1).
(4) Did decedent, in his lifetime, make any transfer of property without receiving a valuable or adequate
consideration therefoN which was to take effect in possession or enjoyment at or after his death?
(Answer yes or no) 0 .
(a) Was there any possibility that the property transferred might return to transferer or his
estate or be subject to his power of disposition? (Answer yes or no) NO
(b) What was the transferee's age at time of decedent's death? N/A
(5) Did decedent in his lifetime make any transfer without receiving a valuable and adequate consideration
therefor under which transferor expressly or impliedly reserves for his life or any period which does
not in fact end before his death:
(a) The possession or enjo~ent of or the right to income from the property transferred?
(Answer yes or no) No
(b) The right to designate the persons who shall possess or enjoy the property transferred or
income therefrom? (Answer yes or no) NO
(6) If the answer to (5) (b) above is in the affirmative, state whether the right was reserved in decedent
alone or others N/A
(7) Did decedent in his lifetime make a transfer, the consideration for which was transferee's promise to
pay income to or for the benefit of ca~e of transferor? (Answer yes or no) NO
(8) Did decedent, at any time, transfer property, the beneficial enjoyment of which was subject to change,
because of a reserved power to al ter, amend, or revoke, or W~bCh could revert to decedent under terms
of transfer or by operation of law? (Answer yes or no) .
(9) If the answer to (8) above is in the affirmative, was the power to alter, amend, or revoke the inter-
est of the beneficiary reserved in the decedent alone or the decedent and others?
(Answer yes or no) NO
NOTE 1: The answers to these questions should be supported by affidavit by the attending physician as
well as a copy of the death certificate.
NOTE 2: If answer to any of the above questions is yes, set forth below a description of the property
transferred, it's fair market value at date of death, dates of transfers and to whom transferred, with
relationship of transferees to decedent, if any. Submit copy of any trust deed or instrument, if trans-
fers are claimed to be non-taxable, also submit detailed statement of facts on which said claim is based.
NOTE 3: List applicable property below in manner in which provided in Schedules A, B, or E.
ITEM
DESCRIPTION
MARKET V AWE
(Es tima ted)
DEPT. VALUATION
(Dept. Only)
NON E
- 0 -
f\it>t\Q....
Insert this total opposite "Transfers", Schedule "C" in the
"As Reported" column on the last page of this return.
N OnL-
RCC:37, (}2-6J)
CO!\(l\lO:'<JWEAL TIl OF I'EXNSYYLANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "0"
BENEFICIARIES
\
h
BENEFICIARIES AND ADDRESSES RELATIONSHIP SURVIVED DATE INTEREST OF
(If step-children or
State full names and addresses of all who illegitimate children DECEDENT OF BENEFICIARY
ave an interest, vested, contingent or other are involved, set STATE YES IN EST.'\. TE
wise, in estate) forth this fact.) OR NO BIRTH
Dorothy M. Wetzel wife Yes 7/30/1911 ALL
3014 Harvard Avenue
Camp Hill"Pennsylvania
"
Deponent further says that all the above-named benericiaries are living at ,this time except below:
NAME DATE OF DEATH RESIDENCE
-
NON E
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SUMMARY
Real Property .......... ....... ..... ......... ................... .............. (Sch. "A")
Personal Property ............................... ................................... (Sch. "B")
Transfers ...... ........... ........................ ....... ............. ........... (Sch. "C")
Gross Taxable Estate
( 1 )
(As Reported)
$
$
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(2)
(As Determined)
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RCC-38
RESIDENT DECEDENT
SCHEDULE" E"
JOINTLY OWNED PROPERTY
'*
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
INSTRUCTIONS: This schedule must disclose all property, real and personal, owned by the decedent jointly
wi th another or others, including intangibles, standing in the name of the decedent and others. List
real estate first, as entireties, or joint tenants, giving brief description, as indicated under Schedule
"A", plus the date and place of record of instrument effecting vestiture, but do not include entireties
or out of state real estate value in estate valuation column. Personal property should be listed as in
Schedule "B", plus date of acquisition, and the name, address and relationship (if any) of co-owners to
the decedent.
Description of Property, Date of Acquisition, Name unit percentage Estate
Address and Relationship of Co-Owners, and Place Value Share Valuation
of Record of Instrument, where Real Estate.
DEPARTMENT VALUATION
CAUTION-Do not Write
In This Space.
Value of Value of
Entire Decedent's
Property Interest
t\.l 0 nL.
NON E
- 0 -
Insert this total opposite "Jointly Owned Property", Schedule "E"
in the "As Reported" column on the last page of this return.
(\\ n N-
20 February 1979
1!tEV-4e7/<8-78)
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.O. BOX 2970
HARRISBURG, PENNA. 17105
"",
COMMONW~AL TH OF PENNSYLVANIA
RESIDENT INHERITANCE TAX
APPRAISEMENT
DATE
COUNTY
FILE NO.
Ctnnherland
21-78-0467
Whereas, Harold E. Wetzel late of Carno Hill
in the County of Cumberland Commonwealth of Pennsylvania, having died on
the ?l..f"h day of MSllY 19 u...., seized and possessed of an estate
subject to Inheritance Tax under the laws of the Commonwealth of Pennsylvania;
Therefore, I, Leo Ful~initi , an appraiser duly appointed according to law,
having been designated to make a fair and conscionable appraisement of the said estate, and to assess and fix the cash
value of all annuities and life estates growing out of said estate, hereby file the following appraisement:
In the event that any future Interest In this estate is transferred in possession or enjoyment to collateral heirs of the decedent after the expiration
of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer inheritance taxes at the lawful collateral
rate on any such future Interest.
DESCRIPTION OF ASSET UNIT Appraisement
VALUES Made for Inheritance
Tax Purposes
$ ~n nnn nn
D~_1 -
- ._1 - "T~
- T\1nn ",
,In"lnr IV fl...".,.",,;! None
'T'nf"Sll1 <:':In nnn nn
,
Have been duly sworn according to law, I do hereby ~tify that
with the law on this 20th day of F brua
c.J A_.
e above ap~raisement is made in conformity
, 1979_.
.......\.,-~' - "-"..
Appraiser
Harrisburg
(Number and Street)
(Post Office)
. Penna.
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