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HomeMy WebLinkAbout05-16-79 j,-')-/J(- -/ " ; " ~) L'. ..67/4-/7 i R'CC-33 (4-73} COMMONWEAL TH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF COUNTY COLLECTIONS RESIDENT DECEDENT COUNTY OF CUMBERLL\ND 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 Re'otenue. (Section 703 of the Inheritance and Estate Tax Act of 1961.) (STATE FULL NAME OF DECEDENT} } AFFIDAVIT OF EXECUTOR S ~~K IN THE MATTER OF THE ESTATE OF Charles F. Brown Mechanicsburg, Cumberland Late of County State of Pennsylvania County of Cumberland Clifford R Rrown and IRAhelle Brown ForRhey, of the estate of the above-named decedent being duly sworn, depose and say -~} '"' Administrator Executor S Decedent died September 2. (MONTH) Name and address of attorney or } other outhorizedrepres.entative to whom all carrespondence should be moiled. (DAY) , 19~{~estote leaving a last will, copy of which is hereta attached. } (YEAR} ~KK9t~ William R. Sunday 39 West Main St., Mechanicsburg, Pa. 17055 That as such Executors deponent is familiar with the affairs of said estate and the property constituting (EX ECUTO R-ADMIN I ST R A TO R} the assets thereof and their fair market value. That at the time of death there was no safe deposit box registered in decedent's individual name, or jointly with, or as agent or deputy of another, or in decedent's individual name, with right of access by another as agent or deputy, with the exception of the fullowing: - NAME AND ADDRESS OF BANK OR OTHER INSTITUTION IN WHICH DECEDENT RENTED A SAFE DEPOSIT BOX Commonwealth Nat. Mcchllnicoburg THIS SAFE DEPOSIT BOX RENTED IN NAME OR NAMES OF RELATIONSHIP OF JOINT HOLDERS TO DECEDENT That the contents of said safe deposit box or boxes are itemized under Schedules with 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 possession, 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 pritDl' 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 deidgnated 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 other instruments 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 or !h, d;"t' of death, bonds and accrued interest thereon to the date of decedent's death and other investm-.:' ; ',' , , -".I by the uecedent at the time of death, with the market value there- of at such time. 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 liS of the date of death. The schedule also sets forth the interest of decedent at the time of death in any co-partnership or business, and in support of the value of such interest there is annexed. to said scherlllle, financial statements showing the assets and liabilities of said co-partnership or business. A copy of t1w co-partnership agreement, (if oral, a statement setting forth the nature of the agreement) together with a statement setting forth the character of the business, its location, and such other facts l'erL;ining to the business as may be pertinent to II fair and just appraisal of the decedent's interest therein Hlllst be submitted. It should also set forth in itemized form, together with the fair market value t11f'I'f.;r, Il11Y other propertJ. owned or bequeathed by the decedent at the time of death, The Sc/7edu/e C attached hereto and made part hereof sets forth a true answer to each inquiry contained tl,"rf'in and in the case of transfers of property, real or personal, within two years of decedent's death, in contemplation of decedent's death, or intended to t~ke effect in possession or enjoyment at or after deatb, said schedule sets forth the nature and value of such property, to whom transferred, the relationship of the transferees to the decedent, the 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 copy of the deed, trust agreement or other instrument creating the trust. Ther.~ 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 individually, or jointly with another, or any power of appoint- ment vested in decedent, either individually or jointly, by the will, deed, or other instrument of another, wi th a copy of the instr1Ullent creating such power attached to the schedule. That Sc/7edu/e D attached hereto and made part hereof sets forth the names and addresses of all persons beneficially interested 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 al.so contains a statement showing which of the beneficiaries named in the decedent's will, if any, died prior to dec~edent, the dates of their death, their issue, and the relationship of such issue to the beneficiary. That Sc/7edu/e 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 instrl~ents 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 deceden t. That Sc/7edu/e 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 anrl 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 unpaid at time of death; taxes accrued chargeable for period prior to decedent's death (except those allowed under 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 Scherlules "A", "B", "en, "E", and "F" as directed therein, have been carried forward and properly registe!'ed in the Summary. Subscribed and sworn to before me this / t~'A.A-J ast ar Ie St. ....Mechanics.bur.g.,......Pa........l.7.05.5.............._... - 6&xmt~~ ( ) ----~;---~:, 0:2 OJ ....~~C/.~.......... .........Afg1iy;.tA~~~!f~~~~.b6-2~.~~.~~.~or s =~/(C{7, ... day of . ......:............:~Q.;;1....IC:..({L.~.. . .......May..,.. .............. 19.7..9...... .... (t ~7..C"7t/{j(<...';:I i::dj~~;l!{\ 1'1 (',!lllli'!/. t~!J:;ii I {' .~):IC I r' '~-:':!~l f~C,:I.I, rt:ln;:,;~' CriJ";~ty ~..~v C';i"-:'l:n:..<,:..::n E'i'l_'~!:C': (\1. ~::~. 1982 h\"f\~b2r, f\~ns~\vania A~;SUi.:12,lil)n of Nc,tc,r:es 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 anrl unlisted securities, securities of close or family corporations or an interest in any co-partnership or business, that the data and statements required under the paragraph above relatin,g; to Scherlule "B" are attached. ;\lso make certain that column #1 in the "Summary" has been properly completed as above-directed. " 'p'- I I i I I I LAST WILL AND TEST~~~ I, CHARLES F. BROWN, of the Borough of Mechanicsburg, County of Cumberland and State of Pennsylvania, being of sound mind~ memory and understanding, do make, publish and declare this to be my last will and Testament, hereby revoking ~nd making void all former wills, codicils and other testamentary disposition by me at any time heretofore made. 1. I direct my Executors, hereinafter named, to pay as soon as prac- ticable after my decease. all my just debts and the expenses of my last illness and burial. 2. I give and bequeath the sum of Fifty ($50.00) Dollars unto each of my following named grandchildren, James Forshey, Dale Forshey and William Forshey in lieu of a gift for graduating from high school. Should any of the named grandchildren graduate during my lifetime and receive a gift at that time, ~~en and in that event, the bequest shall abate so far as that grandson is concerned. 3. All the rest, residue and remainder of my estate I give, devise and bequeath unto my,cQildren, Clifford R. Brown and Isabelle Brown Forshey, , ~: equally, share and' )Share alike. I'..' ..... 4. I hereby nominate, constitute and appoint my said children, Clifford R. Brown and Isabelle Brown Forshey, and the survivor of them, executors of this my, last Will. I IN WITNESS WHEREOF, I, CHARLES F. BROWN, the Testator, have here- . unto set my hand and seal to this my last will and Testament this jLj1t/~ day of 1975. /)? J r;;o "'~ (~~:j~ /('"d- (7/ C)/l~~ (SEAL) -'- ,."'-~._"- .'''"'T' / ,I .j :~ , '. ~ /-'-P~ -~~I '71YJ~ 'o~a~a~~ sassau~1~ s~ saw~u ~no paq1~osqns o~una~aq a^~~ I~a~~o ~b~a JO aouasa~d a~~ u1 pu~ aouasa~d s1g u1 pu~ ~SanDa~ s1Q ~~ IO~~ Isn JO aouasa~d a~~ u1 ~uaw~~sa~ pU~.111M ~s~l s1~ ~oJ pu~ s~ U~o~g "d sal~B~J pa~u a^oq~ a~~ Aq pa~Bloap pUB pa~s11qnd 'palBas Ipauo1S I .-,1........... L ... --- , \c . . NO VALUE ITEMS 1. Deed for cemetery lot iFl05 Section J Chestnut Hill Cemetery to Charles F. Brown and Dora E. Brown. 2. Customers Monthly Statement and Confirmation of Purchase of ,/10 shares Harrisburg National Bank stock dated April 1968 from Woodcock, Moyer, Frick & French. 3. . Letter from Harrisburg National Bank & Trust Company dated Nov. 25, 1965 re: stock split. 4. ~~ceipt dated Jan. 7, 1975 for Commonwealth National Bank stock when turned in to remove name of Dora E. Brown who died Dec. 10, 1974. . . RC C-34 (4-7 ~ COMMONWEALTH OF PEN~SYLVANIA DEPARTMENT OF REVENUE BUREAU OF COUNTY CbLLECTIONS TRANSFER INHERITANCE TAX RESIDENT DECEDENT 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 os joint tenants with right of surviorship or tenancy by entireties should be reported on Schedule "E.") The real property located In the Commonwealth of Pennsylvania should be described by lot and block number, street and street number, together wi th a general description of the property, with a reference to the record of the conveyance by which the decedent took title; If a farm state number of a. cres; also statement of mortgage encumbrances upon each parcel at death of decedent. Toxas, assessments, accrued Interest on mortgages, etc.,are to be listed on Schedule "F" and must not be deducted from this schedule. (1) ASSESSED VALUE FOR YEAR OF DECEDENT'S DEA TH 1. ALL that certain house and lot of groun~ sitaute on the West side of South York St. in the Borough of Mechanicsburg, Cumberlani County, Pennsylvania, being Lot No. 33 in the General Plan of Lots made by the Heirs of John Coover, deceased, bounded and de- scribed as follows, to wit: BEGINNING ~t a metal post on the West side of said South York St. at corner of Lot No. 31 on said Plan of Lots, which sai~ post is 118.47 feet Southward from West Keller St.; thence by said South York St., South 5 degrees 00 minutes East 35 feet to an iron pin at the corner of Lot No. 35 on Plan of Lots hereinbefore mentioned; thenc by line of said Lot No. 35 on said Plan of Lots, now or formerly owned by Carrie Yohn, South 85 degrees 00 minutes West 125 feet to an iron pin at a 20-ft. public alley; thence by said public alley North 5 degrees 00 minutes West 35 ft. to an iron pin at corner of Lot No. 31 on the aforementioned Plan of Lots; thence along said Lot No. 31 now of Louis Rice, North 85 degrees 00 min utes East 125 feet to a metal post at the point and place of Beginning. HAVING thereon erected a two and one-ha f story dwelling house known and numbered as 308 South York Street. The aforesaid description is made in ac cordance with survey made by D.P.Raffens- perger Assoc., dated Dec. 22, 1978. BEING the same premises which George W. Kauffman and Elnora Kauffman, his wife, by their Deed dated March 27, 1925 and record d in the Recorder's Office in and for said Cumberland County in Deed Book "B", Vol.lO Page 107, granted and conveyed unto Charle F. Brown and Dora E. Brown, his wife. The said Dora E. Brown died Dec. 10, 1974 wherl _ upon title vested solely in the said Charll s F. Brown whose Executors are the Grantors herein. UNDER AND SUBJECT to such rights-of-way and easements as may now exist upon, over, along and through said premises, if any there be. Valued at Sale Price '-.....'"'-:;. Insert this total opposite "real property", Schedule "A" in the X X X X X "As Reported" column on the last poge of this return. (2) ESTIMATED MARKET VALUE /,/' 31,000.00 31,000.00 (3) DEPARTMENT VALUATION CAUTION (Do not write In this spece) ,/""'" ~l,OC(: .:_, 'lee -3,,;> . HESInF'\'T DECEDENT SCHEDULE "B" PERSON AL PIWPERTY rmL\c[ONWR\LTH OF PENNSYLVANIA TR\NSFER INl-lERIT:\NCE TAX I NS'l'RlIC'l'lONS: This Schedule mus t disclose all tangible and intangi ble personal prope rty owned individually by tne decedent, at the time of his death. Property owned by the decedent Jointly with another or others lH1St be listed un de I' Schedule "E". Intangible personal property, titled in the name of the decedent, but payable at death to allothe." or others, including but not limited to p.a.D. U. S. Savings Bonds and tenta- tive t;'ust accounts, must be listed, despite the fact that they are not of the administered estate. 'l'angitde personal property should be listed first (e.g. jewelry, wearing apparel, household goods, and i'uraishings, books, paintings, automobiles, boats, etc.) Intangible personal property, such as bonds, treasury certificates, cash on hand and in bank, stocks, mortgages, notes, together with accrued interest or rlividends, salaries or wages, insurance pay- able to the estate or fiduciary in said capacity, partnership interests, interest in anyundistributed es tate of or income from any property held in trust under the will or agreement of another, even though located outside or the State, at the time of death, should be listed in this schedule. I tern I No. I 1. ITEM List and describe fully UNIT ESTIA~TED VALUE MARKEl' VALUE DEPARTMENT VALUATION (Do not write in this space) 2. 86 h reS The Commonwealth National Bank'J Cer~~~.#14050 dated Jan. 8, 1975, $25.00 Sale Price Two (2) U.S. Savings Bonds Series E in names of Mr. Charles F. Brown or Mrs. Dor E. Brown (died Dec. 10, 1974) I $25.00 No. Q6660l329 E Aug. 1942 174.01 $25.00 No. Q20468l624E Feb. 1944 70.44 One (1) $25. U.S. Savings Bonds Series E. in names of Mrs. Dora E. Brown (died l2/ld 74) or Mr. Charles F. Brown I $25.00 No. Q20468 1923E Feb. 1944 170.44 Certificate of Deposit #14 1484 issued bY1 Commonwealth National Bank in face amoun of $15,000. on June 5, 1975 to Charles F. Brown with interest at 7.25% payable I every 3 months Maturity date June 5, 1979 I Accrued interest ICertif. of Deposit #14 2649 I Commonwealth National Bank [of $6,000. on Dec. 31, 1977 Brown with interest at 7.5% 13 months i Maturity date Dec. 31, 1983 I Accrued interest [Certificate of Title for 1969 Cadillac I sedan, Serial # B 9245015, Title # D 2178 ,1570 I At Sale Price IFive (5) $20.00 Travelers checks issued by ,First National City Bank I 3677-802-698 , 699 [ 700 701 702 .~ 3QlO. 00 74.01 70.44 3. 4. 10.44 5. issued by the in face amount to Charles F. payable every 15000.00'1 271.25 I I I I 6000.00 80.53 6: ,.",-'" 1000.00' 7. 8. I I 'ITWO (2) Travelers checks issued by Americ IExpress Company, $50.00 each , HZ 15 675 - 892 and 893 'I'Dividend dated August 1, 1978 - Commonwealth ,National Bank i IChecking Account #142-192014-9 in Common- I ,wealth National Bank ICash on possession I 100.00 100.00 9. Carried Forward 43.00 173.951 3.721 26,037.78 10. 11. Insert tl~is total opposite "Personal Property", Schedule "H" in X X ~he "As Reported" colurm on the last page of this return. . nee -27,? ~ CmL\IONWK\LTH OF PENNSYLV;\NIA TRANSFER INHERITANI'E TAX nESIDE:~T DECEDE;-.;T SCHEDULE "B" PERSONAL PROPERTY ,....... ~;l.,',,~'~ , ,,' yJ~} ..1/,., pj. ''(~;)'" I KS'l'hL'CTIONS: TIns Schedule must disclose all tangible and intangi ble personal property owned individually by tJ1e decedent, at the time of his death. Property owned by the decedent jointly wi th another or others n;ust be list'Hi unde!' 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 tnlst aecounts, must be listed, despite the fact that they are not of the administered estat(!. 1'angibl e personal property should be listed first (e. g. jewelry, wearing apparel, household goods, and f'ur::J:Lshings, hooks, paintings, automobiles, boats, etc.) Intangible personal property, such as bonds, treasury certificates, cash on hand and in bank, stocks, mortgages, notes, together wi th accrued interest or dividends, salaries or wages, insurance pay- able to the estate or fiauciary in said capacity, partnership interests, interest in anyundistributed estate of' or income from any property held in trust under the will or agreement of another, even though located outside at' the State, at the time of' death, should be listed in this schedule. I tern Nc. ITEM List and describe fUlly UNIT VALUE Brought Forward 12. Evergreen Passbook Account #140-0011240-3 in Commonwealth National Bank, balance on date of death I Accrued interest I 13. Savings Account #154 183 in Cumberland Valley Savings & Loan Association Balance date of death Accrued interest 14 Proceeds - Prudential Life Policy # 65- 857-071 payable to estate 15 Refund - West Shore TV Cable 16 Proceeds - Sale of household goods and furniture and other personal property sold at public sale 17 1967 Ford truck at sale price 18 1037.443 United Income Fund 0.0951 19 Refund - excess insurance premium 20 10 shs. Cumberland Valley Cooperative Assoc., Preferred - Redemption price Cumberland County Vol. Firemans Assoc. Account Receivable (Metzger) Penn Treaty Life Ins. Co. - Hospitalization 0.00 21 22 23 24. Insurance Management Specialists, Inc. Refund, excess premium ES'l'I MATED MARKEr V AL1JE DEPARTMENT VALUATION (Do not write in this space) 26,037.78 9,045.56- 87.65 -- 470.03 5. 8~1 ! . .'- 1'- 844.05'1 6.31 I I 8,~:::::r I 10,472.99, 83.00, 100.00! 50.001 I 315.321 200.00,1 I i 52 . OO'~f I I I I I I I Inser t this total opposi te "Personal Property", Schedule "B" in ~h8 "As Report0d~ co',umn on the last page of this return. x X -~~, 56,830.38' 5G O.')c, )'-" 'RCC- 3S Ct)\IMO\VVl-iAI.TH (iF PE\\SYLUNIA THA\:-::FFit r-\l:FltrTA\l'F TA\ SClrEDCL1<: "c:" T H\NC: FEllS ~~, ~1'g,~ ~ '" "'H'~' \:c:~-:::l. . 1l.;;'Yft<J;, ". r\ ~1;,(~.,J:V>,l , ~;;.-;;,~.~ nES rm:\T m:r1:])I'~\T (1) Did decedent, within two years of death, mdke any transfer of any matpri,ll part of his estate, without receiving a valuable and adequate consideration therefor? (.\nsw('r yes 01' no) No (2) Did decedent, within two years of death, transfer properLY from himself to himself and another or others (includi ng a spous,~) in joint ownership? (Answer yes or no)~_ (:J) If' the answer to (1) or (2) above is in the affirmative state: (a) Age of decedent at time of transfer (b) State of' decedent's health at time of' makin,~ 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 adeljUate consideritLion therefor which was to take effect in possession or enjoyment at or after his death? (Answer yes or no) NO . . (a) lias there any possibility that the property transferred might return to transferer or 1;1s estate or be subject to his power of disposition? (Answer yes or no) (b) What was the transferee's age at time of decedent's death? (5) Did decedent in his lifetime make any transfer without receiving a valuable and adequate consideration therefor tmder whi ch transf'~ror expressly or impl iedly reserves for his life or any period which does not in faet end before his death: (a) The possession or enjoyment of or the right to income from th{' property transferred? (Answer yes or no) NO (Il) 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 (7) Did decedent in his lifetime make a transfer, the consideration for which was transferee's promise to pay income to or for the 1enefit of' care of transferor? (Answer yes or no) NO (8) Did decedent, at any time, transf'er property, the beneficial enjoyment of which was subject to change, because of a reserverl power to al ter, amend, or revoke, or which cOllld revert to rlecedent under terms of transfer or by operation of law? (Answer yes or no) 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 resel'ved in the decedent alone or the decedent and others? (Answer yes 0 I' no) ~OTE1: The answers to these questions should be supporterl by affidavit hy the atten,Ung 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 descriIltion of the property transferred, it's fair market value at date of death, dates of transfers and to whom transferrell, with relationship of transferees to rlecedent, i.f 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. 'iOTE 3: List applicable property below in manner in which provided in Schedules A, lJ, or E. ITEM l1ESCIUPT ION MARImT VALliE (Es tima ted) DEPT. VALUATION (Dept. Only) NONE NONE Insert this total opposite "Transfers", Schedule "C" in the "As Repor ted" co lunm on the 1 as t page of this return. NONE \"--' t~. ,. REV-453 (8-78) COMMONWEAL TH OF .PENNSYL VANIA TRANSFER INHERITANCE TAX RESIDENT DECEDENT SCHEDULE "0" BENEFICIARIES BENEFICIARIES AND ADDRESSES RELA TI ONSHIP (State full names and addresses of all who (H step-dJ.ildren or SURVIVED DATE INTEREST OF have an interest, vested, contingent or other- illegi tima te children DECEDENT OF BENEFICIARY wise, in estate) are involved, set ST ATE YES BIRTH IN ESTATE forth this fact.) OR NO James Forshey Grandson Yes A ug:.2.l962 $50.00 401 North Market St. Martinsburg, Pa. 16662 Dale Forshey Grandson Yes F ~b. 22 1961: $50.00 401 North Market St. Martinsburg: Pa. 16662 William Forshey Grandson Yes M ar.8, 1967 $50.00 401 North Market St. M",.,...t-; n Q.....".,...a p,q IF.F.F.? Clifford R. Brown Son Yes Dec. 30, One-half (1/2) 302 East Marble St. 1924 of residue Mechanicsburg:. Pa. 17055 Isabelle Brown Forshey Daughter Yes June 20~ One-half (1/2) 401 North Market St. 1933 of residue Martinsburg, Pa. 16662 Deponent further says that all the above-named beneficiaries are I iving at thi s time except below: NAME DATE OF DEATH RESIDENCE None ~ PC ~-3.. RESIDENT DECEDENT SCHEDULE" E" JOINTL Y OWNED PROPERTY COM\IONWEALTH OF PENNSYLVANIA TRANSFER INIIERITANCT TAX INSTR(}CTIONS: This sclH'dule must disclose all property, real 3.11,1 personal, owned h,\ the" ,', ,it'n\ ,;ointly with another ur others, including intangibles, str,nding in the name of the clee,'d.)nt. ;'11<1 "i:,p,',. List real estate first, as entireties, or Joint tenants, giving brief' rlescription, as indicat.ed tmop!' ~khedl11e "A", plus the date /ind place of record of' instrument effecting vestltllrp, but. do not include ent'n,ties or out of state real estate value in estate valuation column. Personal property shoulrl be listed as in Schedule nil", plus date of aCijuisi tion, and the name, address and relationship (if any) of' co-owners to the decelien t. Description of Property, Date of Acquisition, Name Unit percentage Estate DEPARTMENT V iU,lj AT 10 N Address and Relationship of Co-Owners, and PI ace Value Share Valuation CAUTION-Do not WI' iLl' of Record of Instrument, wllere Real Es tate. In This Space. /> y Value of Value of I<,'n ti re Deceden t's Property Interest None None Insert this to tal opposite "Jointly Owned Property", Schedule "E" 1'0 C'~ None in the " As Reported" co 1 UI1'D'l on the last page of this return.