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COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
RESIDENT DE~UPPLEMENTAL REPORT
9-/C-71
RCC-33 (4-73)
'*
~
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'ienue. (Section 703 of the Inheritance and Estate Tax Act of 1961.)
IN THE MATTER OF THE ESTATE OF
CLARENCE M. SMITH
(STATE FULL NAME OF DECEDENT)
Late of
Cumberland
Pennsylvania
Cumberland
} AFFIDAVIT OF.
EXECUTOR
UM~lJK
County
State of
County of
} u,
~JI.U\fOOX
Florence E. Chronister and Mildred W. Zeigler
of the estate of the obove-named decedent being duly sworn, depose
ExecutEric e s
and say
Decedent died
December
12~
(DAY)
, 19~J tutate leaving 0 last will, copy of which is hereto ottached..}
(YEAR) QpKt~
(MONTH)
Nome ond address of attorney or }
other authorized repre...ntotive to whom
all corre..pondence .hould be mailed.
Robert M. Frey
5 S. Hanover St. ~ Carlisle. Pa. 17013
That as such deponent is familiar with the affairs of said estate and the property constituting
( EXECUTOR-ADMINISTRATOR)
the as sets 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: -
I
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION THIS SAFE DEPOSIT BOX RENTED RELATIONSHIP OF JOINT
IN WHICH DECEDENT RENTED A S..FE DEPOSIT BOX IN NAME OR NAMES OF HOLDERS TO DECEDENT
Farmer s Trust Company Clarence M. Smith
One West High Street Florence Chronlster ~ Daughter
Carlisle~ Pa. 17013 Power of Attorney
That the contents of said safe deposit box or boxes are itemized under Schedules
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 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, ,,:hether by statute or agreement they are designated as tax free, of the United States,
or any state, or political subdivision thereof, or of any f(}reign sountry, ~hi.ch.are owned at the time of death;
all wearing apparel, jewelry, silverware, pictures, books, works of !lrt, llOusebold fvrniture, horses, carriages,
'l ' l.. ' 'l ' . 0_ . ,'. .
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 a t such time.
I (/ - p..O!:J- ~ J-
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 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 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 answer 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 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 co~y
of the deed, trust agreement or other instrument creating the trust. Therl~ 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, 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,
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 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 ~ate and place of record of instruments effecting the ~estiture of
real estate and the date ot 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 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.
Subscribed and sworn to before me this .................................
................,../.~.....~....... ...... day of .~............. 19.?.~.......
-_m7f~....{3i~~~~~.~
That the totals of the appropriate columns in Schedules "A", "B", "e", "E", and "F" as directed therein,
have been carried forward and properly registered in the summ~r .
~~~J,~~~/h>
lorence E. Cnronister
Box 5$7 ~ Carlisle, Pa. 17013
;~~J:'f~~~~~r1r
.~.~.....P.~..}.!.....~..~~.g~...~.?:.~...~.....~?.y...~.~~...:.~a .
(City 01" Town and State) 17007
NOTE: Before signing affidavit make sure a~l 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 par~grap~ above relating to Schedule "B" are attached. Also make
certain that column #1 in the "Summary" has been properly completed as above-directed.
RC C-3_4 (4-73) .
COMMONWEALTH OF PENNSYLVANIA
DEP'ARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE uA"
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 r.al property located In the Comma"wealth of Pennsylvania .hould be (1) (2) (3)
de.crlbed by lot and block number, .treet and .treet number, together with DEPARTMENT
a general de.crlptlon of the property, with a reference to the r.cord of the ASSESSED VALUE VALUA TION
conveyance by which -the decedent took title; If a farm .tate numb.r of a- FOR YEAR OF ESTIMA TED CAUTION
ere.; 01.0 .tatement of mortgage encumbranc.. upon each parcel at d.ath DECEDENT'S MARKET VALUE (Do not wrIte
of decedent. Tax.., a.....m.nt., accru.d Intere.t on mortgag.., .tc.,ar. DEATH In thl. .pace)
to be lI.ted on Sch.dul. "F" and mu.t not be deducted from thl. .chedul..
Previously reported
j
!
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.
~
RCC -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 a~counts, 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, mortg4ges, 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 anyundistributed
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. List and describe fUlly VALUE MARKEr V AWE (Do not write in
this space)
1. 1 - $2. 50 gold coin dated 1889 50.00
2. 1 - $2. 50 gold co in dated 1925 45.00
3. 1 - $2.50 gold coin dated 1915 45.00
4. 1 - $2.00 gold coin dated 1925 45.00
5. 1 - $2.50 gold coin dated 1925 45.00
6. 1 - $20.00 gold coin dated 1914 160.00
7. 1 - $20. 00 gold coin dated 1904 160.00
Insert this total opposite "Personal Property", Schedule "B" in X X 550.00 .s SD. () ()
the "As Reported" column on the last page of this return.
I. R. GERALD LACKEY.
;.ng rnilLa,rwith the val ue of gold and
silver coms, do hereby ap;::raise the r~)llO\vjtlg seven goid ..:>GLns Ln;.the
Estate Of ClaretH::E M, Sniith.?s~'CnOws~
1 $2.;;'0 gold coin Q?1ted 188:1
5t). ()t)
'1 S. trv
'/ s: 6V
1 - $2.50 gold coin dated 1925
1 ~ $2.50 gold coin dated 1915
1 - $2. bO gold com dated 1925
1 s. &0
t.j S. 6-0
I 6 ()., o-a
1 - ,$'2. ~';() gold coin dated 1925
1 $20.00 gold coin dated1914
1 - $20. 00 g019 co in dated 1. 904
J fa o. CJ-i)
....-..._->-"_.-~
TOTAL
.S .$-0. (/.0
These appra.isals an are of the date ofjeath of Clarence M. Smith
on J)e<;ember 12, 1972.
August 24, 1979
/1
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.
RCC--'3S
COMMO:\W'EALTH OF l'ENNSYLVANI A.
TRA:'\~FFn I:'\HE!UT/\XCF TAX
SCHEDULE "e"
TH.\NSFEHS
H.ESIDEXT DECEDENT
(1) Did decedent, within two years of'death, make any transfer of any material part of' his estate, without
receiving a valuable and adequate consideration therefor? (Answer yes or no)
(2) Did decedent, within two years of death, transfer property f'rom himself to himself' and another or
others (including a spouse) in joint ownership? (Answer yes or no)__
(3) If the answer to (1) or (2) above is in the af'f'irmative state:
(a) Age of decedent at time of' transfer
(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 therefor which was to take eff'ect in possession or enjoyment at or after his death?
(Answer yes or 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 wi thout receiving a valuable and adequate consideration
theref'or under which transf'eror expressly or impliedly reserves for his lif'e or any period which does
not in fact end before his death:
(a) The possession or enjoyment of' or the right to income f'rom the property transferred?
(Answer yes or no)
(b) The right to designate the persons who shall possess cr enjoy the property transferred or
income therefrom? (Answer yes or no)
(6) If the answer to (5) (b) above is in the aff'irmative, 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 transf'eree's promise to
pay income to or f'or the benef'it of' care of transf'eror? (Answer yes or no)
(8) Did decedent, at any time, transfer property, the beneficial enjoyment of which was subject to change,
because of a reserverl power to alter, amend, or revoke, or which cOllld revert t.o f1ecedent under terms
of transfer or by operation of law? (Answer yes or no)
(9) If the answer to (8) above i3 in the affirmative, was the power to al tel', amend, or revoke the inter-
est of the bepeficiary reserved in the decedent alone or the decedent and others?
(Answer yes or no)
NOTE 1: The answers to these questions should be supporterl by affidavit by the attending ph~"sician 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 \4'hom trll.nsferred, with
relationship of transferees to decedent, if any. Subm:it copy of any trust deed or instrument, if trans-
f'ers 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. VALUATWN
(Dept. Only)
Previously Reported
Insert thts total oppostte "Transfers", Schedule "C" tn the
"As Reported" colunm on the last page of thts return.
~
RCC-37 (12-63)
CO~Il\10:'llWEALTIl OF PE;'.\~SYYL\NIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "D"
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j~;(.!).";;:-";;,!,.",I
'-':":".<'~\'t~"4~~'''~:''''} :.
BENEFICIARIES
BENEFICIARIES AND ADDRESSES RELATIONSHIP f - DATE
(If step-children or I SU~YIVED. INTEREST OF
State full names and addresses of all who illegitimate children DECE,DENl OF BENEFICIARY
aye an interest, vested, contingent or other are involved, set STATE YES BIRTH IN EST..\ TE
wise, in estate) forth this fact.) UR NO
~ , R "
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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
SUMMARY
(Sch. "A")
. ...(Sch. "B")
. (Sch. "e")
( 1 )
(As Reported)
$ previously report~
$ 5~~~90 $
$ $
$ . $
$ $
550.00
$.. $
(2 )
(As Dl'tl'rmin('d)
Gross Taxable Estate
f-
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ell
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RCC-3'5
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE" E"
JOINTLY OWNED PROPERTY
INSTRUCTIONS: This schedule must disclose all property, real and personal, owned by the decedent jointly
with 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
Address and Relationship of Co-Owners, and Place
of Record of Instrument, where Real Estate.
unit
Value
percentage
Share
Estate
Valuation
Previously Reported
Insert this total opposite "Jointly Owned Property", Schedule "E"
in the "As Reported" column on the last page of this return.
DEPARTMENT VALUATION
CAUTION-Do not Write
In This Space.
Value of Value of
Entire Decedent's
property Interest
i!U-nv