HomeMy WebLinkAbout02-22-06
-
CHARLES E. SHIELDS, III
ATTORNEY-AT-LAW
6 CLOUSER ROAD
Corner ofTrindle and Clouser Roads
MECHANICSBURG, PA 17055
GEORGE M. HOUCK
(1912-1991)
TELEPHONE (717) 766-0209
FAX (717) 795-7473
February 21, 2006
Register of Wills
Cumberland County Court House
1 Court Square
Carlisle, P A 17013
Re: Estate of Virginia F. Brechbiel
No. 21-05-00212
Dear Register of Wills:
Please find enclosed 2 copies of the Inheritance Tax Return along with Check No. 1070,
in the amount of$4,951.91 for the Inheritance Tax, Check No. 1071, in the amount of $290.00,
for the additional probate fee, and Check No. 1072, in the amount of $15.00 for filing fee due.
Thank you for your kind attention to this matter.
Very truly yours,
~;::~ r
Charles E. Shields, III
Attorney-At-Law
CES/mjj
Enclosures
REV-1500 EX (6-00)
REV-1500
COMMONWEALTH OF
. PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
13 R~ CH 81 E' L~ VII(G IN/A F.
DATE OF DEATH (MM-DD-YEAR)
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DATE OF BIRTH (MM-DD-YEAR)
OS- 3/- /9/7
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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IZJ 1. Original Return
o 4. Limited Estate
i25J 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
.
OFF;CLA.L USE: {)NLY
----<.._~"~-
FILE NUMBER
..2L - -pS
COUNTY CODE YEAR
CJ 0 2 1 z
-----
NUMBER
SOCIAL SECURITY NUMBER
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/72/
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
/ 8. Totai Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
NAME
S/f/ELDS
COMPLETE MAILING ADDRESS
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FIRM NAME (if Applicable)
TELEPHONE NUMBER
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
(6)
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
(7)
1.;28
,
11 I.
9. Funeral Expenses & Administrative Costs (Schedule H)
(9)
(10)
7" 8'. .3 ~
ft~S.'7
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)
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)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
Z 15. Amount of Line 14 taxable at the spousal tax
0 0 x.O~
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~ 16. Amount of Line 14 taxable at lineal rate
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Q. 17. Amount of Line 14 taxable at sibling rate x .12 (17)
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0 18. Amount of Line 14 taxable at collateral rate 0 x .15 (18)
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 28060'
HARRISBURG, PA 17128-0601
RECEIVED FROM:
SHIELDS CHARLES E III
6 CLOUSER ROAD
MECHANICSBURG, PA 17055
uh____ fold
REV-1162 EX(11-96)
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ESTATE INFORMATION: SSN: 181-01-1721
FILE NUMBER: 2105-0212
DECEDENT NAME: BRECHBIEL VIRGINIA
DATE OF PAYMENT: OS/20/2005
POSTMARK DATE: OS/20/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 02/20/2005
REMARKS:
CHECK#1022
SEAL
NO. CD 005350
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $4,750.00
,
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TOTAL AMOUNT PAID:
INITIALS: JA
RECEIVED BY:
TAXPAYER
$4,750.00
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REv-1502EX. (1-97)
ESTATE OF
SCHEDULE A
REAL ESTATE
2/-C)S'2/2-
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Bk'ECJf/6/EZ /
Y//fG//f///!
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FILE NUMBER
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged
between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly>owned with right of
survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
~.
j;.AGt '" IMld c.n~I' ~ ""119 sr fA.pprox. 00.70 A-er"l!. ""
Monroe. TOw/lship, Cl.c..mbU'J~ CoLl,n'?Ji Pt-nna., be-;n8
;mp,.olleOl w;ff. t). duJ~Il,'i1a hDUS~ htUl"ng an tLddreLS
eJ 30'1 LDn8tnLAdow .street: m~c,hAni,s:",,~, flll/70SS
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T~f'{z) t-fYJe-f~ L- 11/<<41 U J
@ Sl>O. DO
VALUE AT DATE
OF DEATH
"', ""loa'). 00
., 5'00, DO
TOTAL (Also enter on line 1, Recapitulation) $ ) '" I 5'00, CO
(If more space is needed, insert additional sheets of the same size)
FacetWin Screen Print for recdeeds, from ICAMA_Login" 4/26/2005 9:01:04 AM
DISTRICT: 22 - MONROE TOWNSHIP
CUMBERLAND COUNTY ASSESSMENT OFFICE 2004 BASEYEAR
CONTROL # 22001680
NEIGHBORHOOD: 2271
I
I
jShort Name
I LAST NAME
I FIRST NAME
Ic/o NAME
IADDRESS1
IADDRESS2
IpOST OFFICE:
ISTATE & ZIP:
I
BRECHBIEL, VIRGINIA
BRECHBIEL
VIRGINIA
C/O PAT DAVIS
7652 CARLISLE PIKE
SD: 4 PARCEL: 22-24-0785-008.
I SPEC ID: LOT:
L--.., Tback:
1
PROPERTY TYPE: R I
I
SALES I
DEED BK/PG..... I
DATE OF SALE... I
SELLING PRICE: I
I
J
YORK SPRINGS
PA 17372
Situs: 304 LONGMEADOW STREET
Prop Descrip.: POINT COMFORT
LAND DESC: LAND
LAND USE TYPE:
DEEDED ACRES:
101
.70
I CURRENT
J Assessed
FMV - 159580
C&G -
approved? _>
VALUES
Fair
L -
B -
T -
I
Market "
40000 I
119580 I
159580 I
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Mark E. Hilbert & Associates
05-117M1M
Fie No. 05-117M1M
APPRAISAL OF
LOCATED AT:
304 Longmeadow Street
Mechanicsburg, PA 17055
FOR:
Charles Shields III, Esquire
6 Clouser Road
Mechanicsburg, PA 17055
BORROWER:
Virginia Brechbiel
AS OF:
May 17, 2005 -t:I...L ,J. kf'ort
rib. 20, ~{)s - M tJ!. duff.. vtLtw.
BY:
Mark E. Hilbert
Mark E. Hilbert & Associates
Mark E. Hilbert & Associates
Prooertv Descriotion File No. 05-117M1 M
Property Address 304 Lonofneadow Street City Mechanicsburo State PA Zio Code 17055
Leaal Descriotion See Attached-Tax Report County Cumberland
Assessor's Parcel No. 22-24-0785-008 Tax Year 04/05 R.E. Taxes $ 2000 EST Soecial Assessments $ NI A
Borrower Virainia Brechbiel Current Owner Estate Occuoant: Tx TOwner 1 Tenant r 1 Vacant
.. PrODertv riahts aDoraised IX 1 Fee SimDle 1 Leasehold 1 Proiect Tvoe T T PUD 1 T Condominium IHUDNA onlvl HOA$ NI A IMo.
Neiohborhood or Proiect Name Monroe Township Mao Reference NI A Census Tract 115
Sale Price $ Estate Date of Sale NI A Descriotion and $ amount of loan charaes/concessions to be oaid bv seller NI A
Lender/Client Charles Shields III Esauire Address 6 Clouser Road Mechanicsbura. PA 17055
Aooraiser Mark E. Hilbert Address 219 East Main Street Mechanicsbura PA 17055
Location TI Urban [RJ Suburban D Rural Predominant Single family housing Present land use % Land use change
Built up o Over 75% o 25-75% 0 Under 25% occupancy PRICE AGE One family 61% o Not likely o Likely
$(000) (yr,)
Growth rate o Rapid 00 Stable o Slow 00 Owner 125 Low New 2-4 family 2% o In process
Property values 0 Increasing o Stable o Declining o Tenant 250 Hiah 75 Mult~family 1% To:
Demand/supply 0 Shortage 0 In baIao1ce o Over suppty o Vacant(0-5%) l.r'ii'rl'\l!'t Predominant ~ ,Commercial 1%
Marketina time n Under 3 mos. fXl 3-6 mos. n Over 6 mos. n Vacant (over 5%1 175 T 40 V. Land 1 35%
Note: Race and the racial composition of the neighborhood are not appraisal factors.
Neighborhood boundaries and characteristics: Subiect Prooertv is located alona Lona Meadow Street in Monroe Townshio, Cumberland
. Countv. Pennsvlvania.
.
. Factors that affect the marketability of the properties in the neighborhood (proximity to employment and amenities, employment stability, appeal to market, etc.):
. The subiect propertv has aood access to area emolovment and amenities.
.
..
Market conditions in the subject neighborhood (including support for the above conclusions related to the trend of property values, demand/supply, and marketing time
- - such as data on competitive properties for sale in the neighborhood, description of the prevalence of sales and financing concessions, etc.):
Financina is readilv available from a varietv of sources and with imorovina markets sellers are not reauired to offer sales or financina
related concessions.
. Project Information for PUDs (If applicable) - - Is the developer/builder in control of the Home Owners' Association (HOA)? UYES !KfNO
. Approximate total number of units in the subject project N/A Approximate total number of units for sale in the subject project N/A
Describe common elements and recreational facilities: N/A
Dimensions See Attached Tax-Reoort Topography Basicallv Level
Site area 0.70 Acres +1- Corner Lot TI Yes 0 No Size 0.70 Acres +1-
Specific zoning classification and description Residential Shape Rectanaular
Zoning compliance 0 Legal fX)O Legal nonconming (Grandfathered use) TIlllegal D No zoning Drainage Appears adequate
HiQhest & best use as improved: X Present use Other use lexolainl N/A View Residential
Utilities Public Other Off-site Improvements Type Public Private Landscaping Adeauate
Electricity o 100-AMP Street Macadam 0 0 Driveway Surface Macadam
Gas o None Curb/gutter None 0 0 Apparent easements Typical-Utilitv
Water 0 Sidewalk None 0 0 FEMA Special Flood Hazard Area DYes 00 No
Sanitary sewer ~ Street lights Yes ~ R FEMA Zone "C" Map Date 06/02/92
Storm sewer Allev None FEMA Map No. 420364#
Comments (apparent adverse easements, encroachments, special assessments, slide areas, illegal or legal nonconforming zoning, use, etc.): There are no
aooarent adverse easements encroachments, soecial assessments or zonina that would have a neoative impact on the value of the
subiect orooertv. subiect however to reservations easements conditions and riaht of wa\ of record.
GENERAL DESCRIPTION EXTERIOR DESCRIPTION FOUNDATION BASEMENT INSULATION
No. of Units One Foundation Block Slab No Area Sq.Ft. Roof 0
No. of Stories 1-Storv Exterior Walls Brick CraI'ASpace No % Finished 50% Ceiling Cncld 0
Type (Del./Att.) Detached Roof Surface Composition Basement Full Ceiling C- Tile/Joist Walls 0
Design (Style) Ranch Gutters & Dwnspts. Aluminium Sump Pump Floor Drain Walls Panel/Block Floor Cncld 0
Existing/Proposed Existina Window Type Double-Huna Dampness None noted Floor Vnvl/Concte None 0
Age (Yrs.) 46 Storm/Screens Yes I Yes Settlement None noted Outside Entry Yes Unknown 0
Effective Aae Yrs. I 4-6 Manufactured House No Infestation None noted
. ROOMS Fover Livina Dinino Kitchen Den Familv Rm. Rec. Rm. Bedrooms # Baths Laundrv Other Area So.Ft.
0 Basement 1 1 Sta 1 772
.
Level 1 1 1 1 1 3 2.50 1,678
. Level 2
~
.
i Finished area above arade contains: 6 Rooms; 3 Bedroom sl; 2.5 Bathls): 1 678 Sauare Feet of Gross Livina Area
I INTERIOR Materials/Condition HEATING KITCHEN EQUIP. ATTIC AMENITIES CAR STORAGE:
Floors Hardwood I Good Type H/W Refrigerator 0 None 0 Fireplace(s) # _ 0 None 0
. Walls Dry-Wall I Good Fuel Oil Range/Oven 0 Stairs 0 Patio Large 0 Garage # of cars
Trim/Finish Wood I Good GonditionA va. Disposal 0 Drop Stair 0 Deck 0 Attached 2
Bath Floor Vinyl I Good COOLING Dishwasher 0 Scuttle 0 Porch 0 Detached
Bath Wainscot Fiberolass I Good Central Yes Fan/Hood 0 Floor 0 Fence 0 Built-In
Doors Hollow-Corel Good Other None Microwave ~ Heated R Pool ~ Carport
GonditionA va. Washer/Dryer Finished Sun-Room Drivewav 6
Additional features (special energy efficient items, etc.): None Noted
Condition of the improvements, depreciation (physical, functional, and external), repairs needed, quality of construction remodeling/additions, etc.: No maior
reoairs noted. No evidence of functional or external obsolescence.
Adverse environmental conditions (such as, but not limited to, hazardous wastes, toxic substances, etc.) present in the improvements, on the site, or in the
immediate ViCinity of the subject property: There are no visible or aooarent adverse environmental conditions that would neaativelv imoact
the value of the subiect prooertv.
Mark E. Hilbert & Associates
UNIFORM RESIDENTIAL APPRAISAL REPORT
05-117M1M
PAGE 1 OF 2
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Fanni. Ma. Form 1004 6-93
Idie Mac Form 70 6-93
.
Valuation Section
Mark E. Hilbert & Associates
UNIFORM RESIDENTIAL APPRAISAL REPORT
05-117M1M
File No 05-117M1 M
ESTIMATED SITE ~ALUE. . . : . . . . . . . . . . . . . . . . . . . . . . = $ 75,000 Comments on Cost Approach (such as, source of cost estimate,
ESTIMATED REPRODUCTION COST-NEW OF IMPROVEMENTS: site value, square foot calculation and for HUD, VA and FmHA, the
Dwelling 1,678 Sq. Ft. @$ 38.78 = $ 65,073 estimated remaining economic life of the property):
Basement 1 772 Sq. Ft. @ $ 12.21 = 21,636 In the reoroduction cost of imorovements, Marshall & Swift
. Patio. Sun-Room 4,500 Residential Cost Handbook and local contractors are
. =
. GaragelCarpcrt ~Sq.Ft. @$ 9.76 = 5,153 referenced.
.
. = $ 96,362
. TO"'8"m"'dC,"INi ...... ./........
Less Physical Functional External Est. Remaining Econ. Life:
. Depreciation $5 145 = $ 5,145
Depreciated Value of Improvements . . . . . . . . . . . . . . . . . . . = $ 91,217 Estimated remainina economic life is 30-35 years.
"As-is" Value of Site Improvements. . . . . . . . . . . . . . .... . = $ 3000
INDICATED VALUE BY COST APPROACH. . . . . . . . . . . = $ 169 200
ITEM SUBJECT COMPARABLE NO.1 COMPARABLE NO.2 COMPARABLE NO.3
304 Longmeadow Street 202 E. Winding Hill Road 5 Rife Drive 410 Fairway Drive
Address Mechanicsbur Mechanicsbura PA 17055 Mechanicsbura PA 17050 Mechanicsbura PA 17055
Proximitv to Subiect 1.31 Miles +/- 0.78 Miles +/- 1.41 Miles +/-
Sales Price $ Estate iiii' .i :I}ylY $ 154:900 $ 164 000 $ 164 900
PticeJGross Liv. Area $ 0.00 ill $ 115.94 ill iii[ $ 126.54 ill $ 107.50 ill
Data and/or Inspection C.P.M.L./Assessment C. P.M. L./Assessment C.P.M.L./Assessment
Verification Sources Insoection AaenVTax Records AaenUTax Records AaenUTax Records
VALUEADJUSll/ENTS DESCRIPTION DESCRIPTION T + (-) $ Adjustment DESCRIPTION T + (-) $ Adjustment DESCRIPTION 1 + (-) $ Adiustment
15 DOM ~ 53 DOM , 11 DOM ,
Sales or Financing ,
, I I
Conventional , Conventional I Conventional ,
Concessions , , ,
Date of SalelTime 03/15/05 , 03/31/05 I 12101/04 ,
, , I
Location Suburban Suburban , Suburban , Suburban :
LeasehokWee Sirde Fee Simole Fee Simole , Fee Simole I Fee Simofe ,
, , ,
Site 0.70 Acres +/- 0.52 Acres +/- , 0.28 Acres +/- I 0.34 Acres +/_ ,
I , ,
View Residential Residential , Residential I Residential ,
Desian and Appeal Ranch / Good Ranch / Good I Ranch / Good , Ranch / Good I
, , ,
! 0Jaitv of Cooslructi::n Brick Brick I Brick I Alum / Brick ,
, , ,
Aae 46 Yrs +/- 53 Years +/- : 35 Years +/- : 29 Years +/- I
Good Good , Good , Good ,
Condition I I I
Above Grade T alai I Bdrms I Baths T clal I Bdrms I Baths , T clal I Bdrms I Baths , T atal ' Bdrms I Baths ,
I I ,
. Room Count 6: 3: 2.50 6: 3: 2.00 ' +1,000 6: 3: 1.00 I +3,000 8: 3: 2.00 : +1,000
Gross Livina Area 1,678 SoH 1,336 SoFt. , +3,400 1,296 SaH I +3.800 1,534 SoH I + 1 ,400
. , , I
Basement & Rnished Fuf/ Basement Full Basement , Full Basement , Full Basement I
, I I
. FmIY/Ofce/Bedrm : , Family/Bedroom i
Rooms Below Grade RecRm/Lndrv/Sto -2 500 Familv Room , +500 -1,500
. Functional Utilitv Averaoe Averaoe , AveraQe I Averaoe I
. , , ,
. Heatino/Coolina Oil H/W / ClAir Oil H/W / ClAir , Oil H/W / CIA I Elec BB / CIA I
, , ,
. Averaae Averaoe .- Averaae Averaae
Enemv Efficient Items : : ,
Garaoe/Caroort 2-Car Garaae Off-Street I +10,000 1-Car Garaoe I +5 000 2-Car Garaoe ,
I I ,
Porch, Patio, Deck, Patio Cvrd Patio/Porch I -4,500 Deck/CovrdStoop i -7,500 Patio / Porch , -3,000
. , I
Fireolacels\, etc. , Fireolace ,
Fireolace Fireplace I Fireolace I :
Sun-Room None I + 3 500 None , +3500 None , +3 500
Fence, Pool, etc. , I ,
I I ,
, , I
Net Adi. Itotall X + - '$ 10.900&' 8300., 1400
Adjusted Sales Price
of Comparable $ 165.800 $ 172.300 $ 166 300
Comments on Sales Comparison (including the subject property's compatibility to the neighborhood, etc. ): See Attached Addendum.
ITEM SUBJECT COMPARABLE NO.1 COMPARABLE NO.2 COMPARABLE NO.3
Date, Price and Data None None None None
Source for pria' sales N/A N/A N/A N/A
.,.,;thin vear of aooraisal Tax-Assessment C.P.M.L./Court House C.P.M.L./Court House C.P.M.L./Court House
Analysis of any current agreement of sale, option, or listing of the subject property and analysis of any pria' sales of subject and comparables .,.,;thin one year of the date of appraisal:
The sales comoarison aooroach carries the most weiqht in determinina market value as it is based on historical information and is not
as subiective as the income apProach.
INDICATED VALUE BY SALES COMPARISON APPROACH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 166 000
INDICATED VALUE BY INCOME APPROACH Ilf Aoolicable\ Estimated Market Rent $ N/A /Mo. x Gross Rent Modtiplier N/A = $ N/A
This appraisal is made lET "as is" 0 subject to the repairs, alterations, inspections or conditions listed below 0 subject to completion per plans and specifications.
Conditions of Appraisal: The sales comoarison aooroach carries the most weiaht in determinina market value as it is based on historical
information and is not as subiective as in the income approach nor as deoendent on economic conditions as the cost aonroach.
Final Reconciliation: The market annroach reinforced bv the cost approach is a aood indicator of fair market value. The fact that the seifer is
or is not Davina anv portion of the closina costs has no effect on this aooraisal.
The purpose of this appraisal is to estimate the market value of the real property that is the subject of this report, based on the above conditions and the oerti1ication, contingent
and limiting conditions, and market value definition that are stated in the attached Freddie Mac Form 439/Fannie Mae Form 10048 (Revise\l 6/93 ).
I (WE) ESTIMATE THE MARKET VALUE, AS DEFINED, OF THE REAL PROPERTY THAT IS THE SUBJECT OF llilS REPORT, AS OF Mav 17. 2005
(WHICH IS THE DATE OF INSZ AND THE EFFECTIVE DATE OF THIS REPORT) TO BE' 166.000 .
APPRAISE1I'~~ ~ ~ '" SUPERVISORY APPRAISER (ONLY IF REQUIRED):
Sianature 1:7 Signature oDid oDidNat
Name Mark E. Hilbert 7 . ( Name Inspect Property
Date Report Signed May 17 , 2005 Date Report Sianed
State Certification # RL-000388-L State PA State Certification # State
::Jr State License # RB-029755-A State P A Or State License # State
· Mac Fam 70 6-93 rvfarKEl1ITDert ""&Associates Fannie Mae Fam 1004 6-93
Mark E. Hilbert and Assoc.
PAGE20F2
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REV-l503 Ex. (1-97)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF --a
ok?E~/Y4/EZ,I
j//~6/,AI/A F
FILE NUMBER
...2/- t!) S . 2/2.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
~.
a,s, S-4YfIlfCS i30N/)5} SlE~l€J ~ lJ€lI/oM/IIA-7/tw'S RuNN/NG
Fdom .JULY ,Q7r Tr/Rou'GH oCToI5ER. /'17'1
(S6E: ;JIlINf{;trr Or /rFAf/ZeD j//fLtlES A-TT/fMG1J /lB!!C7J)
bf ~ha~~ ()f 6>1UMD"fJ 5~k,J. mEr L;ck I I1f1G ~
{).,ve. p..i c..~ - 'J.4.D,II1:3
(see pritlt ()~ts tJ,~kd)
.,/O~ '53..2.'1
':I, 3 S'b. sc.f
TOTAL (Also enter on line 2, Recapitulation) $ I '3 I 00 q. 1~
(If more space is needed, insert additional sheets of the same size)
. Savings Bond Calculator
I::: S+Oo.-T6 (j-f V l'j 1ft. i tt 6 feLh b j el Page 1 of 4
Vallie As Of
0212005
Bond Info
EBonds
Results
# Bonds
89
~...--~
Serial Number
L q6366647850e
~. q636663647ge
q6366624980e
q6338081258e
:.q6338069337e
.. q6338057222e
q632723289ge
q632722056ge
. q6327207946e
q6306815195e
q6306802271e
q6304850963e
r. 3((1./ ~~ nile-
q63U48377i7e
q6293350355e
q6293336881e
q6281100592e
q628108687ge
q6256489148e
q6256475457e
q6240359830e
q624034619ge
q6240332436e
q6233452621e
q6233438670e
q6226273976e
q622626449ge
q6212712227e
q6212697967e
Savinc
Update
CALCU
....ftlJl.
Series
Denomination
Serial Number
Issue Date
$25
Total Price
$1,668.75
Total Interest
$8,984.49
Total Value
$10,653.24
YTD In! 5 Q)
$47.! .b'-/Z
Issue Interest Next Final
Issue Date Series Denom Price Interest Value Rate Accrual Maturity
10/1979 E $25 $18.75 $71.15 $89.90 4.00% 04/2005 10/2009
09/1979 E 25 18.75 71.15 89.90 4.00% 03/2005 09/2009
08/1979 E 25 18.75 72.95 91.70 4.00% 08/2005 08/2009
07/1979 E 25 18.75 72.95 91.70 4.00% 07/2005 07/2009
06/1979 E 25 18.75 72.95 91.70 4.00% 06/2005 06/2009
06/1979 E 25 18.75 72.95 91.70 4.00% 06/2005 06/2009
05/1979 E 25 18.75 72.73 91.48 4.00% OS/2005 OS/2009
04/1979 E 25 18.75 71. 86 90.61 4.00% 04/2005 04/2009
03/1979 E 25 18.75 71.86 90.61 4.00% 03/2005 03/2009
02/1979 E 25 18.75 73.67 92.42 4.00% 08/2005 02/2009
01/1979 E 25 18.75 73.67 92.42 4.00% 07/2005 01/2009
12/1978 E 25 18.75 73.66 92.41 4.00% 06/2005 12/2008
11/1978 E 25 18.75 73.41 92.16 4.00% OS/2005 1112008
1 0/1978 E 25 18.75 72.55 91.30 4.00% 04/2005 10/2008
09/1978 E 25 18.75 72.55 91.30 4.00% 03/2005 09/2008
08/1978 E 25 18.75 74.37 93.12 4.00% 08/2005 08/2008
07/1978 E 25 18.75 74.37 93.12 4.00% 07/2005 07/2008
07/1978 E 25 18.75 74.37 93.12 4.00% 07/2005 07/2008
06/1978 E 25 18.75 74.35 93.10 4.00% 06/2005 06/2008
05/1978 E 25 18.75 74.12 92.87 4.00% OS/2005 OS/2008
04/1978 E 25 18.75 77.30 96.05 2.59% 04/2005 04/2008
03/1978 E 25 18.75 77.30 96.05 2.59% 03/2005 03/2008
02/1978 E 25 18.75 95.31 114.06 4.00% 08/2005 02/2008
0111978 E 25 18.75 95.31 114.06 4.00% 07/2005 0112008
12/1977 E 25 18.75 95.31 114.06 4.00% 06/2005 12/2007
11/1977 E 25 18.75 94.99 113.74 4.00% OS/2005 11/2007
10/1977 E 25 18.75 105.28 124.03 4.00% 04/2005 10/2007
09/1977 E 25 18.75 105.28 124.03 4.00% 03/2005 09/2007
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: q6198821561e 08/1977 E 25 18.75 107.76 126.51 4.00% 08/2005 08/2007
q6192519050e 07/1977 E 25 18.75 107.76 126.51 4.00% 07/2005 07/2007
q6192504653e 07/1977 E 25 18.75 107.76 126.51 4.00% 07/2005 07/2007
q618541840ge 06/1977 E 25 18.75 107.78 126.53 4.00% 06/2005 06/2007
q6178584097e 05/1977 E 25 18.75 107.51 126.26 4.00% OS/2005 OS/2007
q6171161650e 04/1977 E 25 18.75 106.28 125.03 4.00% 04/2005 04/2007
"I "3~~203 03/1977 E 25 18.75 106.28 125.03 4.00% 03/2005 03/2007
_> [qel~2 203e
, t.-q6152744615e 02/1977 E 25 18.75 108.78 127.53 4.00% 08/2005 02/2007
!-.q6145127955e 01/1977 E 25 18.75 108.78 127.53 4.00% 07/2005 01/2007
_ q6145113186e 12/1976 E 25 18.75 108.78 127.53 4.00010 06/2005 12/2006
'-' q6136206251e 11/1976 E 25 18.75 108.42 127.17 4.00% OS/2005 11/2006
q6128979251e 10/1976 E 25 18.75 107.19 125.94 4.00% 04/2005 10/2006
.' q6124116076e 09/1976 E 25 18.75 107.19 125.94 4.00% 03/2005 09/2006
v-q6084548817e 04/1976 E 25 18.75 108.24 126.99 4.00% 04/2005 04/2006
;...q6078635555e 03/1976 E 25 18.75 108.24 126.99 4.00% 03/2005 03/2006
" q6077455904e 02/1976 E 25 18.75 110.78 129.53 4.00% 08/2005 02/2006
;.. q606451791ge 01/1976 E 25 18.75 110.78 129.53 4.00% 07/2005 0112006
q6059113700e 12/1975 E 25 18.75 110.77 129.52 4.00% 06/2005 12/2005
q6051619373e 11/1975 E 25 18.75 110.48 129.23 4.00% OS/2005 11/2005
q6025736221e 09/1975 E 25 18.75 109.23 127.98 4.00% 03/2005 09/2005
q6019075625e 08/1975 E 25 18.75 111. 79 130.54 4.00% 08/2005 08/2005
q6019058762e 08/1975 E 25 18.75 111.79 130.54 4.00% 08/2005 08/2005
q6017535985 07/1975 E 25 18.75 111. 79 130.54 4.00% 07/2005 07/2005
q6011305333e 06/1975 E 25 18.75 111. 79 130.54 4.00% 06/2005 06/2005
q6009434734e 10/1975 E 25 18.75 109.23 127.98 4.00% 04/2005 10/2005
q5251380452e 04/1975 E 25 18.75 110.24 128.99 4.00% 04/2005 04/2005
q5247277790e 03/1975 E 25 18.75 110.24 128.99 4.00% 03/2005 03/2005
q5240234942e 02/1975 E 25 18.75 112.82 131.57 02/2005
q5233968078e 01/1975 E 25 18.75 112.82 131.57 01/2005
q5232750957e 12/1974 E 25 18.75 112.84 131.59 12/2004
/ q5227227505e 11/1964 E 25 18.75 213.86 232.61 11/2004
>' q5220704005e 10/1974 E 25 18.75 111.27 130.02 10/2004
;..-q5212346497e 09/1974 E 25 18.75 111.27 130.02 09/2004
.- q520660281 Oe 08/1974 E 25 18.75 111.27 130.02 08/2004
S20~ 392.~31 08/1974 E 25 18.75 111.27 130.02 08/2004
'.,: y5266J 2 J7c
q5200392981e 07/1974 E 25 18.75 11 1.27 130.02 07/2004
q5192552731e 05/1974 E 25 18.75 110.96 129.71 OS/2004
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q5185310623e 05/1974 E 25 18.75 11 O. 96 129.71 OS/2004
'- q5184698345e 04/1974 E 25 18.75 109.73 128.48 04/2004
k q5169033851e 03/1974 E 25 18.75 109.73 128.48 0312004
q5169015j93e 02/1974 E 25 18.75 109.73 128.48 02/2004
~15a7~ l.t:e- E 25 18.75 109.73 128.48 01/2004
E_ q 15 7 65 01/1974
- q5146779988e 12/1973 E 25 18.75 109.73 128.48 12/2003
q5146051083e 11/1973 E 25 18.75 113.01 131. 76 11/2003
/- q5138252121e 10/1973 E 25 18.75 113.01 131.76 10/2003
q5048547227e 12/1972 E 25 18.75 109.58 128.33 12/2002
". q5048539777e 11/1972 E 25 18.75 109.30 128.05 11/2002
1.-- q5014142200e 07/1972 E 25 18.75 109.02 127.77 07/2002
c/ q5014134492 06/1972 E 25 18.75 107.79 126.54 06/2002
/q5005261736e 05/1972 E 25 18.75 107.44 126.19 OS/2002
~~~DI ~'~ ~7e. 04/1972 E 25 18.75 107.44 126.19 0412002
>~: q2 01 6 37,
y q2630 148721 e 03/1972 E 25 18.75 107.44 126.19 03/2002
~'q2617370842e 02/1972 E 25 18.75 107.42 126.17 02/2002
1/ q2610507945e 01/1972 E 25 18.75 107.13 125.88 01/2002
q2610500011e 12/1971 E 25 18.75 107.91 126.66 12/2001
02599154081e 11/1971 E 25 18.75 107.61 126.36 11/2001
/ q2593238108e 10/1971 E 25 18.75 107.61 126.36 10/2001
q2593230084e 10/1971 E 25 18.75 107.61 126.36 10/2001
q2591691137e 09/1971 E 25 18.75 107.61 126.36 09/2001
q2585785045e 08/1971 E 25 18.75 107.61 126.36 08/2001
q257801792ge 07/1971 E 25 18.75 107.31 126.06 07/2001
View 10 I Viewing Bonds 1-89
le(end
Note Description
NI Not Issued
NE Not Eligible for Payment
P5 Includes 3-rnonth interest penalty
MA Matured and Not Earning Interest
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4/1/2005
MetLife Stock Account Information System
Perform another Search
Results for Social Security Number "xx-xxx-1721II
as of April 14, 2004
Investor 10
806464421023
Policy
xxxxx6342
SSN Certified?
Shares
58
Yes
Number of Certified Shares. . . . . . . . . . . . . . . . . . . . . . . . . . .. 58
Number of Uncertified Shares. . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
~
W ~,-)
--=-=--
~--~
Total Shares. . . . . . . . . . . . . . . . . . . . . . . . . . .. 58
Cs ~~[ ~ {rv ~ ~~t"" ~
C ~ '<C-"-<--C" ~ ! c:.'J< < <---'-"=~ >C
L~(-i-tf\'~+-~
--
~
l5
https:/ /www.nefapps.nefn.comIDemutShares/ default. cfm
Page 1 of 1
4/18/2005
MET: Historical Prices for METLlFE INC - Yahoo! Financc
V( f.. G" / IIJ I A- 8l!ECH t3 I t;Z.
4/26/05 4:01 PM
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MetLife Inc (MET)
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Start Date: I Feb
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~ I f171200! Eg. Jan 1, 2003
* If23I200!
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CJick H.re;
for AtiiiPPf ~o~ .
PRICES
Date Open High Low Close Volume Adj Close*
23-Feb-05 40.43 40.62 40.03 40.50 1.469,100 40.50
22-Feb-05 40.85 41.01 40.10 40.14 2,685,500 40.14
18-Feb-05 40.55 41.09 40.33 4108 2,576,100 41.~
17-Feb-05 41.38 41 .40 40.41 40.42 2,338,800 40.42
* Close price adjusted for dividends and splits.
I iJ :illl';(J'/ II~ext I Last
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ziti/OS"
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF -D. Y1 , LJ
DKE(]f!o/EZ /
REV.1&l8 EX. (1-97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
I
FILE NUMBER
t'l/f'G/ A///f r:
c2/-tJS - 2/2
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
.:2..
.~.
4f:
s.
t..
DESCRIPTION
~efuntl 1M j1e1"SMa/ /tJ9'tJ II?,S A7ekrl1 hr ~,,~
Rekd p~ - AI~
'AeFuYlcJ GG Yk'IJtg 'Ba.Mk} 3. C. PUltl~
C I TI Z.C;N,J BANI(
,4. S4tlIIV6S A-e~:r. #, 'II/- o/~ 7f' 9z
11. IAlT: A-etll. ~ .1>.~..tJ. 4f".-'1-.
~, CHECklN6 ~C:r. AID, ~/O 070 .30 .37
(SElF 1/,f/-tAUf-7jl14' LeTre7l O~ ~/nZ/ii]l/S I!J#AlK 11-7r;1-t!HSV).
199/ f:ord 7Q.urus
l+ems of Per.sona.l.f-y (.see :rnve.rUO') a.JrD.du.J)
VALUE AT DATE
OF DEATH
...c ~/ ~. Po
~
9.S[)
,. Lf~, 76.
"
/ ~/ 3~7. 'I'
~ s: 2!'
,: 1 35. 9/
,J.
/7 aot). t)D
~] JIL{.Z:;>
I
TOTAL (Also enter on line 5, Recapitulation) $ :1./, (), 1. / "
(If more space is needed, insert additional sheets of the same size)
III 2 :l 0 b 7111
P 932,276,155
'tY/ ,r)v~,
1/1. _ -'--'
;, ,,' "i
-.,;..,-..... v,J~'Jv'rf
Check No.
":.;;-; ':-14';
'fIt l1f~ "';
"<=~~:
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04 15 05 3 AUSTIN, TEXAS 2306 88007227
2306 88007227 20092800 130 OBREC PHILA TAX REFUND
1...1111'11..11, 111.1..1.111111.1.1...111.1..1.1,1.,.1.11.11.1
PATRICIA V DAVIS
VIRGINIA F BRECHBIEL DECD
7652 CARLISLE PIKE
YORK SPRINGS PA 17372-9524
DEPOSIT TICKET
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PROPERLY ENDORSED
TOTAL ITEMS
12/04
27
$****410*00
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':0000005.8.: 880072 270111 0 L,O L,O 5
~~ Citizens Bank
Pennsylvania
DATE
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:JEPOSITS ,\1AY ~IOT dl:::WAllABLt': FOR IMMEUIArE \"'lTf-1DHA~','Al
ESTATE OF VIRGINIA F. BRECHBIEL
PATRICIA V. DAVIS, EXE.
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JCPENNEY
P. O. BOX 964
~TLANTA GA 30301-9998
P3V
000000465 0001777124
0406 011
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VIRGINIA BRECHBIEL
C/O CHARLES E SHIELDS,III
6 CLOUSER RD
MECHANICSBURG PA 17055-9735
Dear
07/12/05
VIRGINIA BRECHBIEL
Your satisfaction is very important to us. Therefore, attached please find the credit
balance refund check from your account.
Thank you for your business.
Sincerely,
Customer Service
CKCWQ6 02.28.05
Please detach before negotiating check
GE Money Bank
RE:
CG88 8901 06319247
CHECK NO.
0001777124
51-44
119
JCPENNEY
FORTY FOUR AND 76/100 DOLLARS
DATE OF CHECK
07/12/05
PAY TO THE ORDER OF
VIRGINIA BRECHBIEL
C/o CHARLEs E SHIELDS, III
6 CLOUSER RD
HECHANICSBURG PA 17055-9735
CHECK AMOUNT
$44.76
Fleet Bank CONNECTICUT, N.A.
HARTFORD, CONNECTICUT
~!ff
11.0 0 0 .. 7 7 7 .., 2 "'". I: 0 .' ... gOO... ... 51:
70 28011"
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525 William Penn Place
Suite 153-2510
Pittsburgh, PA 15219
January 3, 2006
CHARLES E SHIELDS III
6 CLOUSER ROAD CORNER OF TRINDLE & CLOUSER RDS
MECHANICSBURG PA 17055
Estate of V IRG [NL\ IIZECHB !I::L
Date of D:ath: Feb'=(J. =005
SSN: ]81-01-1721
Dear Sir/Madam:
In accOI'dance with your request, the attached inlormatiu!1 sheet has been provided in the above decedent's
name as of his/her date of death.
For IL or LC aCCOU!1ts.:ontact our Loan Depart!~lent at l-ROO-70S-6680. F)r all other inquiries. please
call ]-8 S S -999-()8 8c;
Sincerely,
/ >, LI'~' '. j), ,. /' i
L tk I, ('- '-1 L' '. I v {, '-f
. /1 /
Carole Gmggiy ,) . _
Operatiulls Services
f
(' '.
~ e
Account Number 6140167892
Account Title VIRGil'JIA F BRI~CHBIEL
Date Opened 11/1511971
Account Type Savings
Principal Balance as of DOD $18347.46
Interest from Last Posting to DOD $5,28
Account Balance as of DOD $18352,74
YTD Interest to DOD $35,86
"".e'.'
~.
'fit
CLOSED 3/18/05
Account Number
Account Tille
Date Opt::led
Account Type
Principal Balance ~IS (J! DOD
Interest from Last Posting to DOD
Account Balance as 01' DOD
YTD Interest to DOD
6100703037
VIRGINIA F BR:::CHBIEL
5/] 5/] 9S0
Checking
$135.91
$ .00
$135.9J
$ .00
Schedule E
Items of Personalty
Virginia Brechbiel
Livin!! Room
Upholstered chair
Stool
Round table
Lamp
Vase
Pair of small end tables
Set of table lamps
3 seater couch
Upholstered massage chair
Small square table
Small drop leaf
2 Upholstered chairs (@ $20.00 each)
Old RCA TV
TV Cabinet
Knick Knacks (essentially junk values)
Set of TV lap trays (misc. not a set)
Rocking Chair
Wall mount eagle
Small table
Small table clock
Assorted World Books yearbooks, cookbooks, etc.
Square moon table for corner
TOTAL LIVING ROOM
Dininf! Room
Wheely tray
Plastic organizer
4 Chairs purchased at JC Penney
Wood chair
2 Padded wooden chairs from JC Penney
Small dining room table - only 1 leaf
Pressboard cabinet I bar
Old reproduction of "Last Supper"
TOTAL DINING ROOM
Hallwav
Small square table with planter
TOTAL HALLWAY
$ 20.00
2.00
8.50
5.00
1.50
5.00
9.50
50.00
30.00
2.00
25.00
40.00
5.00
40.00
4.00
2.00
8.00
1.50
1.00
1.00
5.00
2.50
$ 248.50
$ 1.00
1.50
8.00
5.00
5.00
18.00
2.00
2.50
$ 43.00
$ 3.00
$ 3.00
Page 1
Kitchen
Toshiba TV $ 20.00
Reproduction wall clock 1.00
Old kitchen table - Formica top 5.00
4 Kitchen chairs - JC Penney 1.00
Refrigerator 50.00
Kitchen utensils, etc. 5.00
Steel tray with wheels 1.00
TOTAL KITCHEN $ 83.00
Bedroom 1
lC. Penney bedroom suite $ 75.00
Miniature Highboy reproduction 15.00
Small filing cabinet 1.00
Pressboard cabinet 2.00
TOTAL BEDROOM 1 $ 93.00
Bathroom 1
Old clothes hamper $ 1.00
Waste can 0.25
TOTAL BATHROOM 1 $ 1.25
Bathroom 2
Waste can $ 0.25
TOTAL BATHROOM 2 $ 0.25
Bedroom 2
4-piece bedroom suite - modest quality and size $ 65.00
Roll top desk reproduction (pressboard) 20.00
Butler dish - dimes, quarters, etc. 97.25
2 lamps and knick knacks 2.50
Quilt rack 6.50
Old upholstered chair 2.00
Book rack 2.50
TOTAL BEDROOM 2 $ 195.75
Bedroom 3
4-piece bedroom suite - modest quality $ 67.50
Owl lamp 1.00
TOTAL BEDROOM 3 $ 68.50
Sunroom
One table and 6 chairs $ 65.00
Old sewing machine 25.00
Small table 4.00
TOTALSUNROOM $ 94.00
Page 2
Basement
Recliner chair
Old sofa
2 old upholstered chairs and stool
2 end tables
Folding wooden table with eagle
Old round table and 4 chairs
Old extension table
Assorted Christmas decorations
Old washer and dryer
Lawn mower
TOTAL BASEMENT
$ 15.00
20.00
18.00
1.00
3.00
45.00
35.00
25.00
15.00
85.00
$ 262.00
Avon Costume Jewelry
$ 2.00
GRAND TOTAL
$1,114.25
Page 3
~""~.,"" ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
8leEelf8/el, Vlt<.Ctl'l/,1 F
FILE NUMBER
:U-os- 212-
This schedule must be ccmpleted and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RElATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
ATTACH A COPY OF THE DEED FOR REAl. ESTATE. VALUE OF ASSET INTEREST IIF APPLICABLE)
NUMBER
1. 5YMt:.tra ,4I1(1U;~ VOOOO"()8~O ! /ooic JI
SO, 2/0/7;1. -0- ~ 2./0. 7:Z
( See Va/uonon Ie. er Qt+-lJ.cheJ)
..t -r;.~,. ster IVj~;'l one. ( I) ~ of delL Ht.
10 ~ rtUlJ dttLl~"t~r CS ue. frn" /V1 c. C a. r1j
lDtfi7 1) tI \LIYJ ~ A.r
NorfolK, VA- 335"1 B ~ IDOTo I".. I!Il: ~
G:f{ by clv ck. Lf, ()()O,OO "5,OOf). I,ooo.<<l
TOTAL (Also enter on line 7, Recapitulation) $ 51" ;}/O/ 7~
(If more space is needed, insert additional sheets of the same size)
.
SYM~TRASM
FINANCIAL
April 29, 2005
Charles E. Shields, III
6 Clouser Road
Mechanicsburg, P A 17055
RE: Symetra Annuity V000040880 for Virginia Brechbiel, Deceased
Dear Charles E. Shields, III:
The date of death value on the above-mentioned annuity was a follows:
Date of Death Value
February 20, 2005
$50,210.72
We have received Beneficiary Option Form. It is currently being reviewed by a Claims
Examiner. Please allow 10 business days from the above date for their request to be processed.
Thank you for providing the certified copy of the death certificate. Weare now returning the
original to you.
If you have any questions, please call us at 1-877-SYMETRA or 1-877-796-3872. Press option
2 for Retirement Services and then option 3 for the lRAlNQ Department to speak to a
representative.
Sincerely,
Individual Retirement Plans
Retirement Services
Symetra Insurance Company
II
VL-flOO2iLlF (,1/04
REV-1511EX. (1-97)
ESTATE OF
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
'E,eE0Y~Ja/ H/f't5'/AI//f
F
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
1.
.7.
:3
DESCRIPTION
FUNERAL EXPENSES:
myer:s lU/Zer4/ ~me 1)/ /J1ee/UI//IC5'.lJU'l
;Ji/J1~.s ,f. ~':1Jr;cJ, /}feJ1(I)";a./s. i>r /11 oS (!/'; / 6~h
Cost 01 FLt.nU"Q.,1 rn~o.l
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
2.
3.
4.
5.
6.
7.
8'_
Cf.
I;.
fl.
1.2.
W AlII E"D
Social Security Numbe~s) I EIN Number of Personal Representative(s)
Street Address
City
State
Year(s) Commission Paid:
Attomey Fees Chllr/u. E. <::Shle/~ 7il
Family Exemption: (If decedenfs address is not the same as c1aimanfs, attach explanation)
Claimant /VtJ/f'G
Street Address
City
Relationship of Claimant to Decedent
State
FILE NUMBER
Zip
Zip
Probate Fees rw.J or;il1a' iS$Lt~ of .short cert,'r;'co..t-e.s
Accountanfs Fees '"
'f JCt"e+ Et71ck6~11, H fR 7S{oc.k of nl€e..Ltl.lM;c.sb~5
TaxRetumPreparer'sFees "P~ 1040, Pit 1P, /04-1, fJlf If' (e$h;"'A~)
IJ-d/lfl'tiS/n'l 1'1 Cu.m kr/tLJ1d law Jburl1a/
u
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t(l1tf~/ WIl far
fJjJ~L.
MpllrtJe IWfJ- /J1t(/J/c,iJ,d /l-p(~pr;Iy;.Jetuer (C!.81tIJ", )
TOTAL (Also enter on line 9, Recapitulation) $ d 8, 7 tf I. 3 G.
(If more space is needed, insert additional sheets of the same size)
2/~~ S. 2/~
AMOUNT
~
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~
/ L:>o. DO
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NONE
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF -0
-D'R Et]lI~ /EZ,/
REV-1512 EX. (1-97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
!.///fC;/AI//f F
-21- os . 2/2..
FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
:2.
3~
'I.
s.
G.
7.
3".
1.
((1,
I I.
12.
DESCRIPTION
AMOUNT
'I
.270 ~o
<t
7~(),3/
~
Llf,o/
.x c. Ii""er C,...ee/.'-! Card.
J. J SKe./~~- ,t;e/ 1/:/
&/J/Ct1 51 tkJ It
tt/J/fetl haler
,tJ /l L
hrs rJrect'f {'arc!
.,.
~S.o7
.,
..57. 97
~
.2LJ, f)O
~73. 55
7' ~ '/'1
~ 1..j 2. t, b
PLf 2. (,h
rel';zp/J
A- r ~ T &1lSt(1tl1~ L i!4.5i'7j
U/t/Cqst ~h~.
~IJ1Cf{st 6{~/(..
J. c . Pe" n e:J Cre..cl; t C a..rd
S e.ClrS eo..l Clr'l C e.
Su-I/"c.~s
~s 35.t-f
~;) 5Lf. 77
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (1-97)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
'R>((,E CH t!J( el,
VIII. G-IIf)M F.
I
FILE NUMBER
d-1-OS.2/2-
AMOUNT OR SHARE
OF ESTATE
ESTATE OF
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
RELATIONSHIP TO DECEDENT
Do Not list Trustee(s)
1. III-Ill/CIA I/. .])/!-Y/S
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ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, 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
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOT AL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
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