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Home My WebLink About01-05-06 (2) REV-1500 EX (6-00) REV-1500 OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 05 0656 COUNTY CODE YEAR NUMBER I- Z W C W U W C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Swartz, Kay M. SOCIAL SECURITY NUMBER 186-28-4108 DATE OF DEATH (MM-DD-YEAR) OS/24/2005 DATE OF BIRTH (MM-DD-YEAR) 11/21/1935 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) N/A W I- :.:::!!;l/l ull:::':: wo..u :I: 00 ull::...J 0.. III 0.. <( ~ 1. Original Return D 4. Limited Estate D 6. Decedent Died Testate (AtlachcopyofWiII) D 9. Litigation Proceeds Received D 3. Remainder Return (date of death prior to 12-13-82) D 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) D 2. Supplemental Return D 4a. Future Interest Compromise (date of death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attac" copy of Trust) D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) I- Z W C Z o 0.. l/l W ll:: ll:: o U THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS Andrew H_ Shaw, Esquire Andrew H_ Shaw, Esquire FIRM NAME (lfApphcable) 61 West Louther Street Carlisle, PA 17013 TELEPHONE NUMBER (717) 249-1177 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) OFFICIAL USE ONLY 0.00 0_00 0_00 0.00 4,134.07 (1) (2) (3) (4) (5) z o ~ ...J :J !::: a. < u w ~ 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) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) (8) 1,272.29 407.13 (11) (12) (13) 1,679.42 4,899.65 0.00 i........' (.; , (6) 2,445.00 0.00 (7) c,:) L..i 6,579.07 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) (9) (10) 13. Charitable and Governmental Bequests/See 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) (14) 4,899.65 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ ~ :J Q. :!: o U >< ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0 (15) 0.00 (16) 220.48 (17) 0.00 (18) 0.00 (19) 220.48 16. Amount of Line 14 taxable at lineal rate 4,899.65 X.O 45 17. Amount of Line 14 taxable at sibling rate x .12 18. Amount of Line 14 taxable at collateral rate x .15 19. Tax Due 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < RK. Decedent's Complete Address: STREET ADDRESS One West Penn Street CITY Carlisle I STATEpA I ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 220.48 0.00 0.00 0.00 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits ( A + B + C ) (2) 0.00 0.00 0.00 TotallnteresUPenalty ( 0 + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) 220.48 0.00 A. Enter the interest on the tax due. 220.48 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;......................................................................................... 0 IKJ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 IKJ c. retain a reversionary interest; or.......................................................................................................................... 0 [KJ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [iJ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 IKJ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [K] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 IKJ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief. it is true, correct and complete. Declaration of pre parer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATU~ OF PERSON .RESPONSIBlE FOR FILlNXETURN (~." ~"I~ ~~ ADDRESS~ () 324 Zion Road, Newville, PA 17240 SIGNA;tJRE OF ~~~}R THAN REPRESENTATIVE /~/f ~~ ADDRESS 61 West Louther Street, Carlisle, PA 17013 DATE 1- >-()~ DATE /-~ ;-06 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. S9116 (a) (1.1) (i)]. For 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 surviving spouse is 0% [72 P.S. S9116 (a) (1.1) (ii)J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return 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 or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 PS. s9116(a)(12)]. 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. S9116(1.2) [72 PS. s9116(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. s9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1 Members 1st Federal Credit Union - Account Number 237625 VALUE AT DATE OF DEATH 2 1983 Chevrolet EI Camino - Poor Condition - Does not run 3,934.07 200.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 4,134.07 Send Inquires to: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.members1st.org Main Switchboard: (717) 697-1161 or (800) 283-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TOO: (717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (717) 795-6049 or (800) 237-7288 MEMBERS 1st FEDERAL CREDIT UNION 8697 1 AV 0.278000 17393-8697 111,111,1,111",1,1111111",11,11111111.1.1,111.1111,1111",11 KAY M SWARTZ 37 KENWOOD AVE CARLISLE PA 17013 ..- - = = '->- iiiiiiOiiiii = "'- -.J 0- .. Statement of Accounts Mar 01, 2005 thru Mar 31, 2005 Account Number: 237625 Account Balances at Checking: Savings: Certificates: Loans: Money Management: a Glance: 1,178.59 2,798.63 0.00 0.00 0.00 Page: 1 of 2 We have partnered with Carlisle Events to provide you with the opportunity to attend one of their events free of charge! See the enclosed insert for more information. / 1 G h'~~~ ~.' ~ /.f6 ~ 1 r:e . Pit't /- CHECKING ACCOUNTS 11 - CHECKING Date Mar 01 Mar 01 Mar 04 Mar 04 Mar 07 Mar 07 Mar 08 Mar 08 Mar 09 Mar 17 Mar 21 Mar 22 Mar 22 Mar 23 Mar 23 Mar 24 Mar 25 Mar 29 Mar 29 Mar 30 Mar 31 Mar 31 M1ST01 Transaction Descri tion Balance FOlWard Deposit Transfer From Share 00 Check 001202 Tracer 0304012487 Check 001201 Tracer 0304010882 Check 001207 Tracer 0307100658 Check 001204 Tracer 0307027983 Check 001206 Tracer 0308005078 Check 001205 Tracer 0308028290 Check 001203 Tracer 0309002979 Check 001209 Tracer 0317010927 Check 001211 Tracer 0321005334 Check 001:?12 Tracer 0322013411 Check 001214 Tracer 0322017468 Deposit Transfer From Share 00 Check 001213 Tracer 0323002122 Withdrawal at ATM #636083 ATM RGNLlMAC 20 EAST HIGH STREE CARLISLE PA Check 001210 Tracer 0325015820 Withdrawal at ATM #061550 ATM RGNLlMAC 20 EAST HIGH STREE CARLISLE PA Check 001208 Tracer 0329014625 Withdrawal at ATM #134380 ATM RGNLlMAC 20 EAST HIGH STREE CARLISLE PA Check 001215 Tracer 0331008006 Ending Balance Continued on following page - - - Additions Subtractions Balance 1 , 905 .79 838.21 2,744.00 25. 10- 2,718.90 44.84- 2,674.06 200.00- 2,474.06 377.00- 2,097.06 14.80- 2,082.26 23.07- 2,059.19 307.00- 1 ,752. 19 4.21- 1 ,747 . 98 73.77- 1,674.21 10.00- 1,664.21 47.82- 1,616.39 390.00 2,006.39 10.00- 1,996.39 201.00- 1,795.39 9.80- 1,785.59 201.00- 1,584.59 200,00- 1,384.59 201.00- 1,183.59 5.00- 1,178.59 1,178.59 rv 1st ~M!J~~ll~ 17394-8697 Mar 01, 2005 thru Mar 31, 2005 Account Number: 237625 Page: 2 of 2 .. 'V_ ~ ~ 'V_ ~ ~ "'- .... :>- .. Check # 001201 001202 001203 001204 001205 001206 001207 001208 CHECK SUMMARY Amount Date 44.84 Mar 04 25.10 Mar 04 307.00 Mar 09 377.00 Mar 07 23.07 Mar 08 14.80 Mar 08 200.00 Mar 07 200.00 Mar 29 15 Checks Cleared for 1,352.41 Check # 001209 001210 001211 001212 001213 001214 001215 Amount 4.21 9.80 73.77 10.00 10.00 47.82 5.00 Date Mar 17 Mar 25 Mar 21 Mar 22 Mar 23 Mar 22 Mar 31 WITHDRAWALS AND OTHER CHARGES Date Mar 24 Mar 29 Amount Description 201.00 Withdrawal at ATM 201.00 Withdrawal at ATM 3 Withdrawals and Otl1er Charges for 603.00 Date Mar 30 Amount Description 201.00 Withdrawal at ATM DEPOSITS AND OTHER CREDITS Date Mar 01 Amount Description 838.21 Deposit Transfer 2 Deposits and Otl1er Credits for 1,228.21 Date Mar 23 Amount Description 390.00 Deposit Transfer SAVINGS ACCOUNTS 00 - REGULAR SAVINGS Date Transaction Description Additions Subtractions Balance Mar 01 Balance Forward 2,751.27 Mar 01 Deposit ACH CIVIL SERV 858.21 3,609.48 10: 3121736156 Mar 01 Withdrawal Transfer To Share 11 838.21- 2,771.27 Mar 23 Deposit ACH SOC SEC 415.00 3,186.27 10: 3031036030 Mar 23 Withdrawal Transfer To Share 11 390.00- 2,796.27 Mar 31 Deposit Dividend 1.000% 2.36 2,798.63 Annual Percentage Yield Earned 1.0{)(J% from 03/01/2005 tI1rough 03/31/2005 Mar 31 Ending Balance 2,798.63 YTD SUMMARIES TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 11 CHECKING 6.44 0.00 Total Year To Date Dividends Paid NOTE: Total includes closed shares 6.44 M1ST02 I ACCOUNT 2204274 I FARMERS NATIONAL BANK NUMBER OF NEWVILLE - A DIVISION OF ADAMS COUNTY NATIONAL BANK ACCOUNT OWNER(S) NAME & ADDRESS NEWVILLE PA 17241 KAY M SWARTZ ESTATE 324 ZION ROAD OWNERSHIP OF ACCOUNT - PERSONAL PURPOSE NEWBURG PA 17240 o INDIVIDUAL 0 o JOINT - WITH SURVIVORSHIP (and not as tenants in common) o JOINT - NO SURVIVORSHIP (as tanants In common! o TRUST - SEPARATE AGREEMENT: o REVOCABLE TRUST DESIGNATION AS DEFINED IN THIS AGREEMENT Name and Address of Beneficiaries: IXkNEW o EXISTING TYPE OF o CHECKING o SAVINGS ACCOUNT o MONEY MARKET o CERTIFICATE OF DEPOSIT o NOW XX ESTATE CHECKING This is your (check one): I I IXkPermanent o Temporary account agreement. Number of signatures required for withdrawal 1 OWNERSHIP OF ACCOUNT - BUSINESS PURPOSE FACSIMILE SIGNATURE(S) ALLOWED? DYES IXXNO o SOLE PROPRIETORSHIP [X ] o CORPORATION: o FOR PROFIT o NOT FOR PROFIT o PARTNERSHIP IXk ESTATE SIGNATURE(S} - The undersigned agree to the terms stated on every BUSINESS: page of this form and acknowledge receipt of a completed copy. The COUNTY & STATE undersigned further authorize the financial institution to verify credit OF ORGANIZATION: and employment history and/or have a credit reporting agency AUTHORIZATION DATED: prepare a credit report on the undersigned, as individuals. The undersigned also acknowledge the receipt of a copy and agree to the terms of the following disclosure(s}: DA TE OPENED 08/02/2005 BY BS 1Xk0eposit Account IXXFunds Availability XXI Truth in Savings INITIAL DEPOSIT $ 3,934.07 IXkElectronic Fund Transfers fi Privacy XXI Substitute Checks o CASH o CHECK 0 0 HOME TELEPHONE # [X ;-~CLVC'~~~_ ] BUSINESS PHONE # (1) : DRIVER'S LICENSE # E-MAIL BETTIE J FULTON EMPLOYER 1.0. # 196-48-4094 D.O.B. 6/23/57 MOTHER'S MAIDEN NAME [x 1 Name and address of someone who will always know your location: _ (2): I I - 1.0. # D.O.B. BACKUP WITHHOLDING CERTIFICATIONS [x ] TIN: 20-6609865 (3): IXk TAXPAYER 1.0. NUMBER - The Taxpayer Identification Number shown above (TIN) is my correct taxpayer identification number. I.D.# D.O.B. IXk BACKUP WITHHOLDING - I am not subject to backup [x ] withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all (4): interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding. o EXEMPT RECIPIENTS - I am an exempt recipient under the 1.0. # D.O.B. Internal Revenue Service Regulations. o Authorized Signer (Individual Accounts Only) SIGNA TURE: I certify under penalties of perjury the statements checked in this [x ] section and that I am a U.S. person (including a U.S. resident alien). x~~Gut X<:,s--'d --err- (Date) FORM 11.0.# D.O.B. ~@ ~1992 Bankers Systems, Inc., St. Cloud. MN Form MPSC-LAZ-PA 4/19/2004 ({)8.Qe 1 of 21 REV-1509 EX+ (6-98) SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Bettie Fulton 324 Zion Road Newburg, PA 17240 Daughter B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 1995 Subaru Legacy Station Wagon 4,890.00 50% 2,445.00 TOTAL (Also enter on line 6, Recapitulation) $ 2,445.00 (If more space is needed, insert additional sheets of the same size) REY-1511 EX+ (12-99)* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT FUNERAL EXPENSES: 1. 0.00 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions 0.00 Name of Personal Representative( s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City . State Zip Year(s) Commission Paid: 2. Attorney Fees 1,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 0.00 Claimant Street Address City State .Zip Relationship of Claimant to Decedent 4. Probate Fees 53.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 7. Legal Advertising 219.29 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1,272.29 REV;1512 EX+ (12-03) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unrelmbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Commonwealth of Pennsylvania 58.50 Carlisle Hospital 151.70 Department of Veterans Affairs 21.00 West Shore ALS Services, Inc. 43.78 Moffitt Heart Associates 15.76 PPL Electric 30.20 Sprint 25.12 Allied Interstate 46.54 Belvedere Medical Center 14.53 2 3 4 5 6 7 8 9 407.13 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) _~. ~ <$> "'J,,~ ,~.\.W.J...J"!. ~~~~~_ 't~.il.~"'Sw~,- . 1~e-~,'C..'\.0J--\.e,.......~",_ .,,\' . ~ I .:;.... /.......,. ,!>~UoT'-~"""'''''b....~yr,.hll<lD M \\ \ IT'> '., ~~ .__ ..,.,._".' ..... ~ \ I \ "-. ., i ~'::'-~~o.p" I ~.~ -., . . I $ ~s:W !~'I"> ':-\l...Alq"'C~~Ei'l;\...S~\l'~ 6l 5f-. ; ~Afi.ws OOUNIY:' . . . '! .. g NAT1CftW\LIo\NK '. ., I Fa --~ "'" ~~ 0'A~j / . ':O:lBO'HI,SI: 220-1,2'1-1,00 '--:' ~. .-0000028500....::: .,r. .~... Check Image - 08/29/2005 7-Y'"-'-''- S ~~234~i::J66TOo*e1"/32. ~ cb~+~~~~",,~,l~. ~ 'q.l,ol ,....- . ~. 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I N.\'J1(l'oW.&t.Nl . , I .... -=-.........~..._ ~htl ~J / . t:D 3 ~ 3D ~ ~.. 5': ~ ~D-" ~ 7_'"'' ..,,-/ lb . lDDDDD 28 500l ( ~. ........ . Check Image - 08/29/2005 c "" <0 .:e~ .. r-:'~ ~~E~8::: ~,.:;~ t:;~;......~ .:=~ . :":~..,J .<3~i1~8 .. 60. ",,;: Page 1 ~ f ~~~ = ~,;':;",~~::Wii!;!ii . ~ .. I II li!HHi ~ ~~ ~ ! '" Check Image - 08/29/2005 MONEY ORDER Z 039251298 MONEY ORDER Z 039251299 FILL IN THIS STUB AND SAVE FOR YOUR RECORD FILL IN THIS STUB AND SAVE FOR YOUR RECORD DATE AND AMOUNT w 0: w I I U j:': w o DATE AND AMOUNT w ffi I I U ~ o JUt~ i l?i 2005 B0.20 $0.&9 T o T o F o R F o R PURCHASER:mg"'RECEIPT DRDEfl COMPAt/y COMPANl O~ flEW YORK, INC USA,INC PA 11001-886, I )~ PURCHASER:mg"RECEIPT CVS does not refund/cash money orders (except where required by law, including MI) PLEASE SEE TERMS ON REVERSE SIDE DATE/AMOUNT 7~J90',?'7B80 i DBS NN 06/02/2005 $14.53 27249164601646 7990778801~ . DETACH HERE' CVS does not refund/cash money orders (except where required by law, including MI) PLEASE SEE TERMS ON REVERSE SIDE DATE/AMOUNT Q6/02/2005 $46. 5"! 7'1907"1'8800 OB5 NN 2724.91t,'-!-601 t.4.::' 7990778800~ . DETACH HERE . CVS does not refund/cash money orders (except where required by law, including MI) PLEASE SEE TERMS ON REVERSE SIDE DATE/AMOUNT 7'7'90778797 06/02/2005 Ot:~) NN $-251\ 12 :2";'249 h~.460 1646 7990778797~ . DETACH HERE' 01 "'C)' a G~ a: "'0 ::>(.) I-w Ula: Ula: -::> ~~ ~ wa: wo "'... EMPLOYEE ~( rt-O t~ (\,"'0 y::>(.) Jil- w ""7J: : u;:::> r 11-0 >- ~~ ~"'... EMPLOYEE ./ - - Cl 01 01 EMPLOYEE r RE"-1513 EX+ (9-00) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Bettie Fulton - 324 Zion Road, Newburg, PA 17240 Daughter 4,679.17 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET 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 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size)