HomeMy WebLinkAbout02-02-79
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R cs.C-33 ~~-7.;l)
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
""T 2 61978
RESIDENT DECEDENT
COUNTY OF CUMBER LAND
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.)
Late of
Cumberland
Pennsylvania
} AFFIDAVIT OF
EXECUTOR
ADMINISTRA TOR
County
IN THE MATTER OF THE ESTATE OF
MAYME L. BALSLEY
(STATE FULL NAME OF DECEDENT)
County of
Cumberland
Barbara B. Coslett, Daughter
}.
State of
xK~~
X&MKiXOOHai
of the estate of the above-named decedent being duly sworn, depose
and soy
Decedent died
September
26.
, 19~{testate leaving a last will, copy of which is hereto attached. }
(YEAR) inte.tate
(MONTH)
Nome and address of attorney or }
other authorized representative to whom
all corres.pondence should be mailed.
(DAY)
Robert M. Frey
5 South Hanover St.. Carlisle. Pa, 17013
That as such daughter deponent is familiar with the affairs of said estate and th.,e property constituting
( EX E CU TO R-A DMIN 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 following: -
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION
IN WHICH DECEDENT RENTED A SAFE DEPOSIT BOX
THIS SAFE DEPOSIT BOX RENTED
INN AM E 0 R N AM ES 0 F
RELATIONSHIP OF JOINT
HOLDERS TO DECEDENT
NONE
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 interest 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 promissory 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 of the date of death, bonds and accrued interes t 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 at 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 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 schedule, financial statements showing the assets and liabilities of said co-partnership or l"tusiness.
A copy of the 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
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 tHe 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 answfr to each inquiry
contained therein 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 take effect in possession: or enjoyment at or
after death, said schedule sets forth the nature and value of such property, to wh~m transferred, the
relationship of the transferees to the decedent, the proportionate Jhare 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, trust agreement or other instrument creating the trus't. Ther.~ is also set forth in said
schedule a list of all property, real and personal, with its value, which pa~ses at decedent's death by
virtue of the exercise by decedent, either individually, orjointly with another, or any power of appoint-
ment vested in decedent, either ird.iyiduall.y. or jointly, by the will, deed, or other instrument of another,
with a copy of the instrument creating such power attached to the schedule.
That Schedule 0 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 r~lationship, 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, and the 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 ~estiture of
real e~tate 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 amI 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 Schedules "A", "B", "en, "E", and "F" as directed therein,
have been carried forward and properly registered in the Summary.
Subscribed and sworn to before me this .................................
...................ds:.g.. . day of .,,~.......... 19......!..?..
dJ~a""c~~....
DEBORAH J. CHDb;HER, No+a;y Pllblir.
Carlis!e, C"..!'~.I,rd Co" ?".
My Commission EXjoires Sept. 5, 1981
..~....ti..~........................
(Executor-Administrator)
" ....,.........,~.q..g~....P:.~.:Y..~!:...g.?.~.r.:.~..............................................
(Street Number)
... ......g.?:E..~.i.~.~.~.~.....?~.~......n..Q..1..~
(City or Town and State)
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 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 relating to Schedule "B" are attached. Also make
certain that column #1 in the "Summary" has been properly completed as above-directed.
, I
RCC-34 14.73)
COMMdNWE'AtrH OF PENNSYLVANIA
DEJ:lARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
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 as 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 (1) (2) (3\
described by lot and block number, street and street number, together wi th DEPA RTMENT
a general description of the property, with a reference to the record of the ASSESSED VALUE VALUA TION
conveyance by which the decedent took title; If a farm state number of 0- FOR YEAR OF ESTlMA TED CAUTION
cres; also statement of mortgage encumbrances upon each parcel at death DECEDENT'S MARKET VALUE (Do not write
of decedent. Taxes, assessments, accrued Interest on mortgages, etc.,are DEATH In this spoce)
to be listed on Schedule "F" and must not b. deducted from this schedule.
NONE -0- /~-C--y[~
/--YL d-"...Q
Insert this total opposite "real prope.ty", Schedule "A" in the X X X X X
"As Reported" column on the last page of this return.
- 0-
R~C -~5 ~
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 fact that they are not of the administered estat~
Tangible personal property should be listed first (e.g. jewelry, wearing apparel, household
goods, and furnishings, books, paintings, automobiles, boats, etc.)
Intangible personal property, such as bonds, treasury certificates, cash on hand and in bank,
stocks, mortg~ges, notes, together with accrued interest or dividends, salaries or wages, insurance pay-
able to the estate or fiduciary in said capacity, partnership interests, interest In any undistrIbuted
estate of or income from any property held in trust under the will or agreement of another, even though
located outside of the State, at the time of death, should be listed in this schedule.
Item ITEM UNIT ESTIMATED DEPARTMENT VALUATION
NO. Lis t and describe fully VALUE MARKET VALUE (Do not write in
this space)
NONE -0- --~(i~~(-
,
~t.-~'-~
Insert this total opposite "Personal Property", Schedule "B" in X X -0-
the "As Reported" column on the last page of this return.
RCC-36
COMMO\'WEALTIl OF PENNSYLVANIA
TRASSFRR INHERITANCE TAX
SCHEDULE "c"
TRc\NSFETtS
HES IDENT DECEDENT
(1) Did decedent, within two years of death, make any transfer of any material part D1' his estate, without
receiving a valuable and adequate consideration therefor? (Answer yes or no) NO
(~) Did decedent, within two years of death, transfer property from himself to himself and another or
others (including a spouse) in joint ownership? (Answer yes or no) No
(3) I f the answer to (1) or (2) above is in the af'fi rmati ve state:
(a) Age of decedent at time of transfer
(b) State of decedent's heal th 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 therefor which was to take effect in possession or enjoyment at or after his death?
(Answer yes or no) No
(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)
(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 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 enjoyment 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
(G) 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 benefit of care 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 reserven power to alter, amend, or revoke, or which cOllld revert to decedent 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 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 VALUE
(Es tima ted)
DEPT. VALUATION
(Dept. Only)
NONE
-0-
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Insert this total opposite "Transfers", Schedule "C" in the
"As Reported" column on the last page of this return.
-0-
RCC-37 (12-63)
..
COMMONWEAL TH OF PENNSYYLANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "D"
BENEFICIARIES
(
h
BENEFICIARIES AND ADDRESSES RELATIONSHIP SURVIVED
(If step-children or DATE INTEREST OF
State full names and addresses of all who illegitimate children DECEDENT OF BENEFICIARY
aye an interest, vested, contingent or other- are involved, set STATE YES IN ESTATE
wise, in estate) forth this fact.) OR NO BIRTH
Barbara B. Coslett daughter yes entire estate
1004 Drayer Court
Carlisle, Pa. 17013
Deponent fUrther says that all the above-named beneficiaries are living at this time except below:
NAME
DATE OF DEATH
RESIDENCE
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Real Property
Personal Property
Transfers .........................
Jointly Owned Property
.,..... .. ................ ......
Gross Taxable Estate
( 1 )
(As Reported)
-0-
-0-
-0-
9.186.59
SUMMARY
...(Sch. "A") $
..... ( Sch. "B") $..
...(Sch. "C") $...
(Sch. "E")
........................... $..
$......
$...~.}86.59 .
(2)
(As Determined)
$
$
$
$
$
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!lF~mE~T DECEDENT
SCHEDULE "E"
JOINTLY OWNED PROPERTY
CCMMu"iWF\LTH UF l'ENN~YLVANL\
rHi\i',~n:n r "iHEIlI T i\NCE T Y\:
I~srmTTIO!'iS: This scherlule must disclose all property, real and personal, owned by the rlecerlent 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 P~operty, Date of Acquisition, N~me! unit
Address and Relationship of Co-Owners, and Place I Value
of Record of Instrument, ~here _Rea! ~state.. '
percentage Estate
Share Valuation
DEPART~lENT VALUATION
CAUTION-Do not Write
In This Space.
Value of
En ti re
Property
Value of
Deceden t' s
Interest
1.
Standard Savings YLoan Assoc iat ion
Certificate #5553 dated July 26. 1974 / I
in the principal amount of $10. 000. 00. I
Accrued interest to SepteIT}ber 26. 1978'1
in the amount of $185.00/
5 0%
~
5.092.5C
j 09~ ~ ')'l>
J
2. Cumbaland County Nat ional Bank and
Trust Company (CCNB Bank, N.A.)
checking account - $1.144. 69 ~
3. CCNB Bank./ A. savings account
#076073321-2 dated APr~,1.9. 74. in
the pr inc ipal a mount of ~_5. 17 .
Accrued interest to September 26. 1978.
in the amount of $14.45
5 0%
/
572. 35/
./
1-7/);3')
50%
jfJ--?"j
729.8'1 /4,^ ~.& 1,
-....-..,...
i
I '!?-'),/fl
4. Carlisle Building and Loan Asn. Full
Page Savings Account #342 dated
January 3, 1973. in the Jlrincipal
amount of $2. 500. OO.~ccrued interest
to September 26. 1978. in the amount I
of $31.48 /' I
50%
.1,265.74 V-
/'J-' r:7t/
5. Carlisle Building and L~sn.
Certificate No. 08-850 dated Sept. 28. ,/
1973. in the principal amount of $1,000.00.
Accrued interest to Septerrjber 26, 1978,
in the amount of $l(?, 66 /'
5 0%
I
508. 3~ /
I
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t
1-04- 33
6. Carlisle Building and L~ Asn. I
Certificate No. 09-2932 dated Jan. 20, I,
1977. in the principal amount of
$1. 000. 00. Accrued mterest to
September 26. 1978. in the amount of
$17.86
100%
1. 017. 86/~
!
/0/1, flk
All of the above accounts were in the names
of Mayme S. Balsley and Barbara B.
Coslett.
TOTAL
!
i
i
i
t
9. 186.591
I
I
Insert this total opposite "Jointly Owned Property", Schedule "E"
in the "As Reported" column on the last page of this return.
'Q i
_Cl,l ~(,.~ \ I
*
R E V-518 18-78)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.o. BOX 2970
HARRISBURG
17105
IN YOUR REPLY PLEASE
REFER TO
Inheritance Tax Division
NOTICE OF FILING OF APPRAISEMENT
Barbara B. Co81ett
1004 Dreyer Court
GarlJ.ale, FA 11013
(Executor or Administrator)
In Re: Estate of
"-"'~l.aci
.L!.).tl& L. 1a1tI187
County - Fi Ie No. U 7.; ..;..i J9
Dear
You are hereby notified that the OId8*r"'ll
appraisement in the estate of lla.~ 1.. ..1.1."
has been fi led in the office of the Register of Wi lis of ~,"_l."
County on ~ J'Hnlal"1 ' 19-JJ-, Said appraisement reflects the following
valuations:
Real Estate
Personal Property
Transfers
Jointly Owned
Total
lIMe
trio..
--
',186."
$',166.59
As to such tax that is paid within three months from date of death, a five (5%)
percent discount is allowable. As to any tax that remains unpaid after nine (9) months
(fifteen months when death occurred from December 22,1965 to June 16,1971, inclusive;
and twelve months when death occurred prior to December 22, 1965) from date of death,
interest ot the rate of six (6%) percent per annum is charged.
Any party in interest who is aggrieved by this notice may object thereto within
sixty days after receipt of said notice as provided by Section 1001 of the Inheritance and
Estate Tax Act of 1961, 72 P. S. 2485-1001, P. L. 373.
Date ., T'.,t. ."':11~~.' 19 Signed L~
c=-- .~
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'~G
Title ~'bi::..l.strat.1Ye Offiear
L---
-..-.,..
Note:
This is not a bi II.
RfiV-457 (8-78)
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.O. BOX 2970
HARRISBURG, PENNA. 17105
COMMONWEALTH OF PENNSYLVANiA
RESIDENT INHERITANCE TAX
APPRAISEM ENT
DAT L -1.. Februarv 79
COUNTY Cumberland
FILE NO. 21::-78-0589
Whereas, Mayme L. Balsley late of Borough of Carlisle
in the County of Cumberland Commonwealth of Pennsylvania, having died on
the ?f;rh day of C::opromho... 191.8....., seized and possessed of an estate
subject to Inheritance Tax under the laws of the Commonwealth of Pennsylvania;
Therefore, I, T.~o F1I111ini ti , 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
$
'D~~1 ....~...~...~ "'T~_~
.1 ~ Nnnl'>
Nnnl'>
Jointly Owned 9 186 59
Total $9 186 S9
Have been duly sworn according to law, I do hereby certify that the above appraisement is made in conformity
with the law on this 2nd day of Feb;uary. _ 1979_ .
L-~ \:- l J.JL.., ~
() Appraiser
(Number and Street)
H""......i"'hll...g
(Post Office)
, Penna.
~
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