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OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128..0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
II 05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
198-32-8894
00451
NUMBER
03-26-2005
12-12-1919
THIS RETURN MUST BE FILED IN DUPLICA TE:WlTH THE
REGISiI"ER OF WILLS
SOCIAL SECURITY NUMBER
~ 1. Original Return
o 4. Limited Estate
~ 6. Decedent Died Testate (Allach
ropy 01 WiI)
o 9. litigation Proceeds Received
o
o
o
o
2. Supplemental Return
4a. Futlll8 Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Allach
ropy of Trust)
10 Spousal Poverty Credit (date 01 death belwlIen
. 12-31-91 and 1.1-~)
o 3. Remainder Return (llate Of death pf1ot'to 12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (AIlach Sell 0)
Copyright 2002 fonn software only The Lackner Group, Inc.
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Cocklin, Miriam B.
DATE OF DEATH (MM-o[)'YEAR)
DATE OF BIRTH (MM-oD-YEAR)
<IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
COMPLETE MAILING ADDRESS
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NAME
Jan M. Wiley
FIRM NAME (If eppIcable)
Wiley, Lenox, Colgan, & Marzzacco, P.C.
TELEPHONE NUMBER
717-432-9666
130 W. Church St
DiIIsbu_rg, PA 17019
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation. Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-VIVos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L) 0 Separate Billing Requested
8. Total Gross Assets (total Lines 1-n
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
'Of=f;ICIAL
I
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~1
. 0 '. :
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99,117.49
13,813.71
85,303.78
31,562.35
53,741.43
0.00
0.00
0.00
8,061.21
8,061.21
None
69,682.08
None
None
29,435.41
None
None
(8)
(9)
(10)
13,673.18
140.53
11. Total Deductions (total Lines 9 & 10)
(11)
(12)
(13)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has
not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCnONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
15. Amount of Line 14 taxable-at the spousal tax rate. 0.00 x .00 (15)
z or transfers under Sec. 9116(a)(1.2)
0 .045 (16)
i= 16. Amount of Line 14 taxable at lineal rate 0.00 x
~
j
Go 17. Amount of Line 14 taxable at sibling rate 0.00 x .12 (17)
2
0
0 18. Amount of Line 14 taxable at collateral rate 53,741.43 x .15 (18)
)(
~ 19. Tax Due (19)
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
FOrJlil REV.1500 EX (Rev. 6-00;
Decedent's Complete Address:
STREET ADDRESS
1 Longdorf Way
CITY Carlisle
ISTATE PA
IZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
8,061.21
0.00
Total Credits (A + B + C)
(2)
0.00
3. InterestlPenalty if applicable
D. Interest
E. Penalty
5.17
(3) 5.17
(4)
(5) 8,066.38
(5A)
(5B) 8,066.38
TotallnterestlPenalty (0 + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVE~PAYMENT.
. Check box on Page 1 Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS.
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.................................................................................. 8 ~:
b. retain the right to designate who shall use the property transferred or its income;....................................
c. retain a reversionary interest; or..................................................................................................................
d. receive the promise for life of either payments, benefits or care?............................................................. 0 x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receMng adequate consideration?..................................................................................................................;... 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?.................. ..... ........... ........ ...... ............. ...... ..... ... ..................... ... ... ... ... .... ..... 0 [!]
IF THE ANSWER TO ANY OF THE ABOVE QUESnONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penaIIles of peIjury, I decI8nI that I Mve examined thi$ return, Induding BCalIllplllIyln scI1edules and slatemenl8, and to the best of my knowledge and beIleI, ft is true, ccrrect and
complete. DecIar8Ilan of IlF8I*'8I' other than the perSonall8presenlative Is basad on aIllnfonnation of which praparar lias any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
J La Cocklin
[!]
~
DATE
203 Greenbriar Lane
DlIIsburg, PA 17019
/-1/-&6
ADDRESS
DATE
3 Klnslngton 5qare
Mechanlcsburg, PA 17050
J-
ADDRESS
130 W. Church 5t
DlIIsburg, PA 17019
1- '-f _C l
For ates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfer$ to or for the use of the
su tYing spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)].
or dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the ~urviving spouse is 0%
[72 P.S. ~9116 (a) (1.1) (Ii)). The statute does not exemot a transfer to a survMng spouse from tax, and the statutory reqluirements for disclosure
of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age Dr younger at death to or for the use of a
natural parent, an adoptive parent, or a stepparent ofthe child is 0% [72 P.S. ~9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P .S.
~9116 1.2) [72 P.S. ~9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116 (a) U.3)]. A sibling is
defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by bloocil or adoption,
llittsllIill attD. QIeshnttent
OF
KIRIAH B. COCKLIN
BE IT REMEMBERED, that I, KIRIAH B. COCKLIN, of 111 Ege
Drive, Carlisle, CUmberland County, Pennsylvania, being of
sound mind, memory and understanding, do make, publish and
declare this as and for my Last will and Testament, hereby
revoking and making null and void any and all wills and
Testaments and writings in the 'nature thereof by me at any
time heretofore made.
I1'EK 1: I direct that all my just debts and funeral
expenses be paid as .soon after my demise as may be
convenient.
11'0 2:
All ~e' re~t, residue' and remainder of my
estate, of whatsoever nat~e and wheresoever situate, whether
it be real, persona~ or mixed,.includfng'pro~erty ~ver which
I have a power of appointment, I give, devise and bequeath,
as follows:
(a) I give one (1) percent of my net estate to FILEY'S
CEKETERY ASSOCIATION, of R.D. #3, Dillsburg,
Pennsylvania, absolutely.
(b) I give one (1) percent of my net estate to THE
CHESTNUT GROVE LUTHERAN CEMETERY, of R.D. #1 York
springs, Pennsylvania, absolutely.
(c) I give one (1) percent of my net estate .to THE
D:ILLSBURG CBHETERY ASSOCIATIQN, wherein my body
will be interred at my demise, with the
understanding that The Dillsburg cemetery
~ l?~ (SEAL)
RID B. COCKLIN
-1-
Association will annually place flowers between the graves of
myself and my husband, Homer Cock~in,. so that the flowers
will be on said situs on Memorial Day as it is celebrated
each and every year after my death; as well as placing a
wreath on said situs each and every Christmas following my
death.
(d) I. give one (1) percent of my net estate to THE
KASOIUC HOMES, of Elizabethtown, Pennsylvania,
absolutely.
(e) I give five (5) percent of my net estate to MARY
PROSSER, providing she survives me.
(f) I give five (5) percent of my net estate to JEAN
PROSSER KEs~,.pr~"Viding she survives me.
(g) I give five (5) per~ent .of my net estate to HARRY
PROSSER, providing he survives. me~
(h) I give three (3) percent of my net estate to TAHHY
PROSSER, providing she survives me.
(i) I give three (3) percent of my net estate to each
of the following persons, per stirpes:
1- JAKES R. COCKLIN;
2. JANE II. RHONE;
3. J. LARRY COCKLIN;
4. LINDA II. GROBER;
5. DONNA C. GROVB;
6. WAYNE . B. MYERS, JR. ;
7. JOHN A. COCKLIN;
" ..
~jd~ (SEAL)
II RIAX B. COCKLIN
-2-
(j) I give twenty (20) percent of my net estate to my
friend, BEVERLY L. DeVORE, pr~viding she survives
me.
(k) I give four (4) percent of my net estate to my
friend, JEAN ST. LOUXS, providing she survives me.
(1) I give four (4) percent of my net estate to
FILEYS-CHRIST LUTHERAN CKUllCK, Dillsburg, R.D.,
Pennsylvania
(m) I give four (4) percent of my net estate to
CHBSTHUTGROVE LUTHERAN CKUllCK, York springs,
"
R.D., Pennsylvania.
(n) I give five (5) percent of my net estate to THE
CARLXSLE HOI;IPITAJ;. .MEDICAL CUB FOtnmATXON. It is
my desire tha,t. such gift 1;>e used to support
Cumberland Crossings Retirement '.community' or
programs for senior citizens.
This. request is
intended to be precatory, not. mandatory.
(O) I give four (4) percent of my net estate to ST.
PAUL'S EVANGELICAL LUTHERAN CHURCH, Carlisle, PA.
(p) All the rest, residue and remainder of my estate
of whatsoever nature and wheresoever situate,
whether it be real, personal or mixed, including
property over which I have a power of appointment,
and which includes the remaining sixteen (16)
percent of my estate, I give to THE AMERXCAR RED
CROSS, specifically to be earmarked for their
Disaster Relief Fund.
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~~~~,~
XRXAX B. COCU.XN
(SEAL)
-3-
ZTEM 3: I direct my hereinafter named Executor to pay
all inheritance, estate, succession and legacy taxes of
whatsoever nature and kind, to which my estate or the
transfer of any property passing hereunder or otherwise
passing by reason of my demise, may be subject and to charge
such taxes against my residuary estate, it being my intention
that none of the aforesaid taxes, either federal or state on
any property required to be included in my gross estate,
under the provisions of any state or federal law now in force
or hereafter enacted, shall be prorated among the persons
interested in my estate to whom such property is or may be
transferred or to whom any benefit accrues.
ZTEM 4: I appoint J. LARRY COCKLIN and WAYHB B. HYERS,
JR., as co-Executors of this my Last W~ll and Test~~ent.
ZTEH 5 :
I direct that my Co-Executors or their
successor shall not be required to give bond for the faithful
performance of duties in any jurisdiction.
ZTEM: 6 :
I direct my Co-Executors to employ JAN H.
WILBY, ESQUIRE, as attorney for my estate, if he is
available.
IN WITNESS WREREOP, I have hereunto set my hand and seal
this ,.t! day of /l-pri I , 1999.
~~_7 13, ~~ (SEAL)
RZAK B. COCnXN -
-4-
COMHONWEALTH OJ' PERNSYLVANIA
SS
COUNTY OJ' YOU
We, KIRIAM: B. COCKLIN JAR K. WILEY, ESQUIRE and
JANICE E. YOCUK, the Testatrix and the witnesses
respectively, whose names are signed to the attached or
foregoing instrument, being first duly sworn, do hereby
declare to the undersigned authority that the Testatrix
signed and executed the instrument as her Last Will and
Testament and that she had signed willingly (or willingly
directed another to sign for her), and that she executed
it as her free and voluntary act for the purposes therein
expressed, and that each of the wi tnesses, . in the
presence and hearing of the Testatrix, signed this Last
will and Testament as witness and t;hat"tCl the !:lest of
their knowledge the Testatrix was at the time eighteen
(18) years of age or older, of sound mind and under no
constraint or undue
Sworn to and subscribed
before me this f-:t:!:: day of .
MY COMMISSION" EXPIRES:
Rev-1503 EX+.I.....)
SCHEDULE B
STOCKS & BONDS
. .
*'
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RElURN
RESIDENT DECEDENT
FILE NUMBER
21-O5~0451
ESTATE OF
Cocklin, Miriam B.
All property joInt1y-owned with light of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 920924107 Van Kampen American Capital PA Quality Mun Tr Fmly 15.03 20,050.02
Van Kampen:
2 920934106 Van Kampen American Capital Tr For Invt Grade PA 15119 13,276.06
- Municipals:
- 15,160.00
3 $20934106 Van Kampen American Capital Tr For Invt Grade PA 15.16
Municipals:
4 920934100 Van Kampen American Capital Tr for Invt Grade PA 15.14 21,196.00
Municipals:
-
TOTAL (Also enter on Line 2. Recapitulation) 69,682.08
,
(If more space is needed. additional pages of the same size)
Copyright (e) 2002 form software only The Lackner Group, Inc.
Form PA~1500 Schedule B (Rev. 6-98)
Rev:1/i08 EX"o(S-9S)
. '
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETVRN
RESlIlEHT DECEDENT
Cocklin, Miriam B.
FILE NJJMBER
21-05-00451
ESTATE OF
Include the proceeds of IIiigation and the dale the proceads were received by the estate.
All property joInt1y-owned with the !tght of eurvlVolllhlp mlM be dlac:IoSed on Khedule F.
ITEM
NUMBER DESCRIPTION
1 Commonwealth of PA (Refund):
VALUE AT DATE
OF DEATH
608.00
2 GE Capital Assurance:
1,939.81
3 Members 1st FCU Checking Account 200132-11:
3,582.14
4 Members 1st FCU Money Management Account 200-132-05:
14,166.73
5 Members 1st FCU Savings Account 200132-00:
25.00
6 National Financial Services, LLC:
318.25
7 National Financial Services LLC:
318.25
8 State Employees Retirement System:
2,086.10
9 Tressler Lutheran Services:
384.38
10 Tressler Lutheran Services:
305.75
11 United States Treasury (Refund):
5,701.00
TOTAL (Also enter on Line 5, Recapitulation)
29,435.41
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
RlIY~1602 EX...,.....)
.
SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMoNWEALlli Of PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Cocklin, Miriam B.
FILE NtlMBER
21-05-00451
ITEM
NUMBER DESCRIPTION AMOUNT
1 Cocklin Funeral Home: 754.50
2 Donna Grove (cake): 46.00
3 Sl Pauls Evangelical Church: 650.00
4 VFW (after funeral luncheon): 500.00
Subtotal
1.950.50
Copyright (e) 2002 fonn software only The Lackner Group. Inc.
Form PA-1500 Schedule H.A (Rev. 6-98)
, .
REV.1111 EX"'l1Z-8ll)
.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Cocklin, Miriam B.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-05-00451
ESTATE OF
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
See. continuation schedule(s) attached
1,950.50
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
B.
J Larry Cocklin Wayne E. Myers Jr.
Social Security Number(s) I EIN Number of Personal Representative(s):
173-32-6242 196-38-0461
Street Address 203 Greenbriar Lane
City DlIlsburg
Year(s) Commission paid
State
PA
Zip 17019
2006
4,950.00
2.
Attorney'S Fees
Wiley, Lenox, Colgan, & Marzzacco, P.C.
4,950.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
Register of Wills:
185.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Other Administrative Costs
See continuation schedule(s) attached
1,637.68
TOTAL (Also enter on line 9, Recapitulation)
13,673.18
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
. '
Rev.'1S02 EX+ iI-H)
.
SCHEDULE H-87
OTHER
ADMINISTRATIVE COSTS
continued
~TH 01' PENNSYl.VANIA
NlERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Cocklin, Miriam B.
FILE NUMBER
21-05-00451
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Cumberland Law Journal (advertise):
75.00
2
Members 1st FCU (estate checks):
12.95
3
MML Investors Services, INc. (Commission, fees, etc. for selling Van Kampen):
1,360.92
4
Register of Wills (filing fee):
30.00
5
The Sentinel (advertise):
158.81
Subtotal
1,637.68
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
. '
Rev:1112 EX+ (8....)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
CCIMMONWEALTH OF PENNSYlVANIA
tlHERlTANCE TAX RETURN
RESIDENT DECEDeNT
ESTATE OF
Cocklin, Miriam B.
FILE NUMBER
21-05..00451
Inc:lude unrelmbursed medica' expenMll.
ITEM
NUMBER DESCRIPTION
1 Continuing Care RX:
VALUE AT DATE
OF DEATH
18.75
2 DiIIsburg Rent A Space:
57.24
3 Graham Medical Clinic:
54.74
4 Judy Campbell, Tax Collector:
9.80
TOTAL (Also enter on Line 10, Recapitulation)
140.53
(" more space Is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-15pO Schedule I (Rev. 6-98)
REV-1513 ex"\8.00)
ESTATE OF
NUMBER
I.
*'
SCHEDULE .J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEOENT
Cocklin, Miriam B.
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
t1istributionsA and transfers
under Sec. ~116(a)(1.2)]
FILE NUMBER
21-05-00451
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
RELATIONSHIP TO
DECEDENT
00 Not Uet TnmlNlla'
1
J. Larry Cocklin
203 Greenbriar Lane
Dillsburg, PA 17019
James R. Cocklin
680 Fickes School Road
York Springs, PA 17372
John A. Cocklin
30 Kimberly Court
ManalafJan, NJ 07726
Beverly L. DeVore
97 Ege Drive
Carlisle, PA 17013
Donna C. Grove
401 North 5th Street
Lemoyne, PA 17043
See continuation schedule attached Continuation
Total
Enter dollar amounts for distributions shown above on lines 5 through 18, as appropnate. on Rev 1500 co~r sheet
Nephew
Three percent
2,431.16
2
Nephew
Three percent
2,431.16
3
Nephew
Three percent
2,431.16
4
Friend
twenty percent
16,207.72
5
Niece
Three percent
2,431.16
25,121.97
51,054.33
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
See continuation schedule(s) attached
31,562.35
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
31,562.35
Copyright (c) 2002 form software only The Lackner Group. Inc.
Form PA.150f) Schedule J (Rev. 6-98)
SCHEDULE J
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
Miriam B. Cocklin 198-32-8894 03/26/2005
Item Name and Address of Person(s) Share of Estate Amount of Estate
Number Receiving Property Relationship (Words) ($$$)
6 Linda M. Gruber Niece Three percent 2,431.16
34 East Ridge Road
Dillsburg, PA 17019
7 Jean" Prosser Hess Cousin Five percent 4,051.93
1095 Town Hill Road
York Springs, PA 17372
8 Wayne E. Myers, Jr. Nephew Three percent 2,431.16
3 Kensington Square
Mechanicsburg, PA 17050
9 Harry Prosser Cousin Five percent . 4,051.93
1179 Myerstown- Raod
Gardners, PA 17324
10 Mary Prosser Cousin Five percent 4,051.93
35 Bushey School Road
York Springs, PA 17372
11 Tammy Prosser Cousin Three percent 2,431.16
21 Courtyard DRive
Carlisle, PA 17013
12 Jane M. Rhone Niece Three percent 2,431.16
40 E. Ridge Road
DiIIsburg, PA 17019
13 Jean St. Louis Friend four percent 3,241.54
236 20th Avenue
Vero Beach, FL 32962
Total 25,121.97
1
Rev.1HZ EX+-.6-.)
*'
SCHEDULE .I-liB
CHARITABLE AND GOVERNMENTAL
DISTRIBUTIONS
continued
COll.NONWEAL TH OF PENNSYLVANIA
NiERlTANCE TAX RE1lJRN
REIIlDENT IlECEDEHT
ESTATE OF
Cocklin, Miriam B.
FILE NUMBER
I 21-05-00451
ITEM
NUMBER DESCRIPTION AMOUNT
1 American Red Cross: 13,648.60
2 Carlisle Hospital Medical Care Fund: 4,265.18
3 Chestnut Grove Lutheran Cemetery Assoc.: 853.03
4 Chestnut Grove Lutheran Church: 3,412.15
5 Dillsburg Cemetery Association: 853.03
6 Fileys Cemetery Assoc.: 853.03
7 Fileys Christ Lutheran Church: 3,412.15
8 St. Paul's Evangelical Lutheran Church: 3,412.15
9 The Masonic Homes: 853.03
Subtotal
31,562.35
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Fonn PA-1500 Scli\edule J-IIB (Rev. 6-98)
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Nationa. l=inanciaf Services LLC
VOUCHER
NO. 312554775
08/01
CREDIT BALANCE
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DETACH THIS PORTION BEFORE CASHING CHECK
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COMMONWEALTH OF PENNSYLVANIA
STATE EMPLOYEES' RETIREMENT SYSTEM
30 NORTH nilRO STREET
HARRISBURG, PA 17101
1-a00.633-5461
www.sers.state.pa.us
June 9, 2005
J LARRY COCKLIN & WAYNE E" MYERS, EX
MIRIAM COCKL~N ESTATE
203 GREENBRIAR LN
DILLSBURG PA 17019
Member SSN: 198-32-8894
Beneficiary SSN: 198-32-8894
Dear Beneficiary:
A check in amount of $2,086.10 will be mailed to you Within two (2) weeks from the date of this
letter. The amount of $0.00 was withheld for FederaJ Withholding Taxes. If you have elected to
rollover then the taxable portion of $0.00 has been transferred to your qualified plans.
This payment represents your designated share of 100.00% in the Final. settlement of the Account
of MIRIAM B COCKLIN with this retirement system.
If the indMduallisted above was a member of the Retirement system before January 1, 1982, their
contributions prior to that date were taxed as part of their gross income at that time. Therefore, no
taxes are being withheld on that portion of their contributions. The difference between the amount of
your payment and your share of the deceased member's non-taxable contributions, if ~ny. .is
taxable for federal income tax purposes. .
This payment has been reported to the Intemal Revenue Service. If a 1099R fonn is not enclosed
with this letter, you will receive one prior to January 31 of next year. with the necessary tax
information regarding this payment Under current law there 'are no Pennsylvania state or local
taxes on any benefits paid from this system.
This letter and the 1099R form that you receive should be kept In a safe place, as you will need the
information when filing your Federal Income Tax Retum. This is the only notice you wiU;receive.
. There is a $5.00 ~harge for each request of duplicate information.
Sincerely,-.' .--'-'.- --. - ... '--.' ." -"-..'--. ...... ..-'- ...--- .------.---..... ..-:.-.._.-.~--...-.-.,.~.-,""-~'-~
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Linda M. Miller, Director
Benefit Determination Division
BEN31FSL
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NO.312517217
VOUCHER
07/19 CREDIT BALANCE
68,321.16
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ACCOUNT NO. APJ5736391
DETACH THIS PORTION BEFORE CASHING CHECK
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TO
THE
ORDER
OF
GGlI0421
LARRY COCKLIN
:WAYNE MYERS PERREP
EST MIRIAM: B COCKLIN
- 203 GREENBRIAR LANE
O'LLSBURGPA 17019,
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SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
MONEY MANAGEMENT ACCOUNT:
Account NumberlSuffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
Estate of: MIRIAM B. COCKLIN
Date of Death: 03/26/2005
Social Security Number: 198-12-8894
~lst
MEMBERS 1st
FEDERAL CREDIT UNION
200132 -00
12/27/2000
$25.00
$.00
$25.00
None
200132 -1.1
12/27/2000
$3,580.44
$1.70
$3,582.14
None
200132 -05
12/27/2000
$14,154.17
$12.56
$14,166.73
None
;L1:S2~RAL CREDIT UNION
Denise A. Wolfe If-
Insurance Services Supervisor
July 19, 2005
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National. Financial Services LLC
VOUCHER
. NO.3 t255477
08/01. CREDIT BALANCE
318.25 .
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