The URL can be used to link to this page

Home My WebLink About03-24-06 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX( 11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT STARZ JACQUELINE F 10709 MT ZION ROAD GLEN ROCK, PA 1 7327 __nn__ fold ESTATE INFORMATION: SSN: 189-09-4721 FILE NUMBER: 2106-0228 DECEDENT NAME: AREHART EVELYN P DATE OF PAYMENT: 03/24/2006 POSTMARK DATE: 03/24/2006 COUNTY: CUMBERLAND DATE OF DEATH: 12/31/2005 NO. CD 006476 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $3,259.65 I I I I I I I I TOTAL AMOUNT PAID: $3,259.65 REMARKS: J F STARZ CHECK#104 INITIALS: VZ RECEIVED BY: SEAL REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS -l 15056041046 REV-1500 EX (05-04) PA Department of Revenue Bureau of Individual Taxes Dept 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year .\ : t L ! f /"\ \,." File Number - -,'-, i j OA v\ ,j Date of Birth IE i( c? -L/'l~ I / ,;{ 3 / .;( ( ( -5- {:~i( ell c; 11/ Decedent's Last Name Suffix Decedent's First Name MI II k [-JIf} p.r ,..- , t:.VELyN p (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW - 1 Original Return c::> 2, Supplemental Return c::> 3. Remainder Return (date of death pnor to 12-13-82) c::> 4, Limited Estate c::> 4a. Future Interest Compromise (date of <::) 5. Federal Estate Tax Return Required death after 12-12-82) c::> 6. Decedent Died Testate c::> 7. Decedent Maintained a liVing Trust 8. Total Number of Safe DepOSit Boxes (Attach Copy of Will) (Attach Copy of Trust) c::> 9. Litigation Proceeds Received c::> 10. Spousal Poverty Credit (date of death c::> 11 Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 'Sf\c.(xL EL- IN E Firm Name (If Applicable) C T Cl.) Z _J lIh ~~ / 7 #) 3 6' ,3 (( 7 '7 REGISTER OF WILLS USE ONLY First line of address I c' '7 (; fj H-r Zi(/~ RD Second line of address City or Post Office C L E. l\j '1< (. c, K State ZIP Code DATE FILED Pt+- / 1.3,_~'1S'~33 Correspondent's e-mail address: 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 preparer other than the personal representative is based on all information of which preparer has any knowledge. DATE $.);2 sL,/L, Cc, ADDRESS ;JJ(_'}~ P 752 rY~ .r. . (-"'/;,.'. /).~. ~>tCC(){I/IU{,rla ~ J,-/-J;J.().{){.(l(f:/Jj - / /8!;!J 'If. -J;;;d,{fNl ;:YCfl PLEASE USE ORIGII\lAL F..oRM.. 0""'-. ,.:V. _1"'/.';"9 f!)(lI-'!{/.(.e / ;::-'/'fT / / (l ..J (: Side 1 L 15056041046 15056041046 -l .-J 15056042047 REV-1500 EX Decedents Name ---.--," Decedent's Social Security Number RECAPITULATION Real estate (Schedule A). 2. Stocks and Bonds (Schedule B) :< Closely Held Corporation, Partnership or SOle-Proprietorship (Schedule C) 4 Mortgages & Notes Receivable (Schedule D) 5 Cash Bank Deposits & Miscellaneous Persona! Property (Schedule E) 6 Jointi; Owned Property (Schedule F) <::) Separate Billing Requested Inter. ViVOS Transfers & Miscellaneous Non-Probate Property ISched:Jle G) <::) Separate Billing Requested. 8 Total Gross Assets (total lines 1-7). . 2. /:.-:X :J ij' '1. ? S" J .' ,...) 3. . 4 5 'i ; ,J. .if I 6. . 7. 8 ~ /) I '/ I. "( i( .) 9 il j i, 4. 0 I -..,..; 10 f - . , , I 11 .1/ / " /.J (- J -' f . }j ,.. { l 7. J 12. 'j ~ I I -,,' 13 ~I 9 7. .- (' / / -.. 14. j 9 Funeral Expenses & Administrative Costs (Schedule H) 10 Debt~ of Decedent. Mortgage liabilities. & Liens (Schedule Ii -,1 Total Deductions (total Lines 9 & 10). 12. Net Value of Estate (L Ine 8 minus line 11) Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J] Net Value Subject to Tax (line 12 minus line 13 \ TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15 Amount of line 14 taxable at the sDousai tax rate. or transfers cJnder Sec. Si 1 "i 6 (ai'.1 2! X 0___ An"!oJnt of Line ~ 4 taxable at rate XO ~i) 7 ."\IT,o.Jnt of L.ine 14 taxable at sirJiing rate X 12 18 ACT'u .inl of Line 14 taxable at cCliaterai rate X 1-5 Jd0.~'l[{./( I G-J ,) c;. ( 5- 19 TAX DUE 15 . / Jf r'/ /- / ~1 I' '. . '-"\ / (' 0~ (" ~- ! i . /; . I ' / / < /1 / .~ ,J I '......) 1 16 '17 18 19 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C) Side 2 L 15056042047 15056042047 --.J Rl:V-15CJO EX Pagt' File Number Decedent's Complete Address: DECEDENTS ~rv'E J 1 I,,-+- ~ ve l':r 1\ I h t~ C'" >tu~ I STREET ADqRESS j ,)- , I ,^ / /, /, ',_ e'!\CZef':'.j /CrLd"ir fft:-c<-!-H] C,->~~Jt4 7 7 c s-: 1-10,) 0 G' e; - ~+- (I H-r.~ Ii ':,) e CiTY STATE " l;a- ZIP -7 /7(,/ ./ Tax Payments and Credits: 1 Tax Due (Pa~e 2 Line 19) 2 Credits/Payments A, Spousal PJverty C;redlt g, Prior Payrlents C Discount (1) ,,~'//.:/ '~i ":_-;./_ I 1-< ,'"" 5 /'( Total Credits (A + B + C ) (2) Iii l' ) 3. ; nteresUPenal,y if applicable 0, Interest E Penalty Total Interest/Penalty ( D + E ) 4 If Llfle 2 IS greater t1an Line 1 .,. Line 3. enter the difference, ThiS IS the OVERPAYMENT, Fillm oval on Page 2, Line 20 to request a refund, (3) (41 If Line 1 + L,n" 3 ,s greater than Line 2, enter the difference ThiS is the TAX DUE, " " /'_ c; '/., ':,' _~) 4_),~_~_~~~_____~_____ 4., Enter tre ,nterest (in the tax due, i5A) 8 Enter the 'otal at Line 5 + 5A ThiS is the BALANCE DUE. (58) ') ') J,,' (/: I. '7 -----~~--~-- ~~ Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACiNG AN "X" IN THE APPROPRIATE BLOCKS oecedent ",ake a transfer and '"ta,n the use or income of the property transferred retan ,he right to CJeslgnate who sllall use the property transferred or its Income retain a reversionary Interest: or, ' ~, receive the ;:Jromlse for life of either payments, benefits or cace" 'f Jeath occurred after December 12, ':982, did decedent transfer property \Nltrin one year of death without receiving adequate consideration? Cid deceden+ ovvn an "In trust for" or payable upon deaTh bank account or secunty at hiS or her death? D'd decedenl own, an indlvldua! Retirement Account. annuity. or othec non-probate property which ccntalns a beneficiary deSignation? , \'es No B .]:J 2S % ~ 2S ;g r;:;-:1 Z" IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates Of dea;i1 on or after jUIY 1, 1994 and before january 1 1995, the tax rate imposed on the net value of transfers to or for the use of the IS three (3) percent [72 PS ~9116 (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 zero (0) percent [72 PS ~9116 (a) 1) (Ii)]. 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 dea:h 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 zero (0) percent [72 PS ~9116(a)(1.2)]. The tax rate Imposed on the net value of transfers to or for the use of the decedent's lineal beneficmies is four and one-half (4.5) percent. except as noted in 72 PS ~9116(1.2) [72 PS ~9116(a)(1)l spoLise The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 PS ~9116(a)(13)]. 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-1502 EX+ (6-98) ~"/~,'~ "6~~)'~ "....",,"j!.W. COMMONWEALTH OF PENNSYLVANIA. IcJHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF 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 priee at '",h,el pr'cpertv would b8 ell:harged between a IYjii,ng buyer and a willing seller. neither being compei:ed to buy or sel!, both flavlng reasonable knowledge of 'he rel'?'Jant fact~ Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. -iTE~-----~------r-~-~- --.------------ ---..----------~T-- VALUE AT-DATE---~--- NUIAB':EL__L DESCRIPTION ---f- OF DEATH ! i I I\, Co/\, L-- TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) @ . \lllerican Funds Year-End Statclnenl I ~ll1LUf\ I - ] k'LL'ml WI' ,)( !, .;' )f!-=) YOllf- f1n;,ulcial adyi~er h )["1 ^ ,- ^" h r\ ~~-;j.." 1\ i! ,I i i i "I,ll, "II II i "I,,! "II , "I j, I j, ,,1,111111 j, I SE~\\/IC[:~ S' Ik.,l \\i..;hes for the :\n\ Year For n101'(, account infonll:tlioll TillS stiltl'lIlellt shows your complete account activity for 2005, su IJiedSl keep It for your tax records, Our online Tax Center ':iJli help you with duplicate tax forms, average cost information, dll Illterijl;IIVe Tax GUide, and more, You can also go on/lIle to IIlake yuu IRA contributions, VISit us at americanfunds, com. . Call your financial adviser . Automated information and services Wl:bsltl: illlll:llCdlllullCis CUIII AITi!: Ii h::ICisLII'I! . Personal assistance - 8 a III S ~1 0 i:,!l: 1St; i [" 8 p. dl =~1:)tl:(li lilllt rVI "llllllll~ln I \ II ) '\ I' .\IUIL\Hl A 01 08 O~ 0' 01848488 ~I 01848488 GI848488 n \1 11~: - i! i IJCJllll ~; r 'I ' Allil! :i-A ;'1] U l)f~ \' liid I T uti; i ~ :..:.~~ _. J. L '\ (ill!" ill \Tstlllent portfolio . \bolll Ibe lile chl!'/ ill Ie/I _ Gluvvth G I u vvlh - d II d- III C lJ IWi 8one! 36,67% 31.19% 32,14% Eilch siice ui tilL' jJit' chart re{!ll'sL'J':s ,I fur olle funr} or t!UJ{U, earn S'/iL'{} Tl7e je~/iJ/}(j YLlr-h)-d;lte di\'ideIld~ and capital gains i \11 ) \ " \j(lII\HI 07 6i848488 , 01 61848488 H H 08 0184848U p., "(1' A. o~ 0184U488 5276 S402 2/ S=2 S 1 'S6~) T uIa i $1 ,775 67 so.oo S! 3S0 IIIIHI! /11'11111, cow.1mjljlj[/lLTH OF PENNSYLVANIA INHERITMJCE TAX RETURN RES DENT DECEDE~H I I SCHEDULE C CLOSElY-HElD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP REV~15J4 EX+ (1~971 ~.,3<,~. ""'r. .. "...,,~{if \: t~; ',~.~1!;.7;" ESTATE OF FILE NUMBER Schsduie C.1 or C~2 (Inc'udlng aU supporting Information) must be attached for each closely-held corporation/partnership Interest cf the decedent. other Iha'1.1 sole~propiletorship. See instructions for the supporting Info'matlon to be submitted for sole~oroprietorsh'ps ITEM ',lUMBER NUMBER i VALUE AT DAit: J--- OF DEA~__~ I I DESCRIPTION 1'. ~_--- ^{ /LC TOTAL (Also enter on line 3, Recapitulation) S (If more space is needed. insert additional sheets of the same size) REV-150:> EX+ (6-98) 'I.' c,'lc;;, ,''I I'k<. \C>i "'" Zl'l' .,~;..;')~::!!b~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Corporation / _____~ State on Incorporation Address ---~-- .___ ______ State____ Zip Code_______ ...__ Date of Incorporation City Total Number of Shareholders 2. Federal Employer 1.0. Number 3. Type of Business _______ Business Reporting Year Product/Service 4. STOCK I TYPE TOTAL NUMBER OF PAR VALUE NUMBER OF SHARES VALUE OF THE Voting/Non-Voting SHARES OUTSTANDING OWNED BY THE DECEDENT DECEDENT'S STOCK Common I $ Preferred I $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? If yes, Position _ Annual Salary $ . . . . .. 0 Yes 0 No Time Devoted to Business 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness $ DYes 0 No 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ ______ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Number of Shares Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....D Yes 0 No If yes, provide a copy of the agreement. _ Consideration $ Date 10. Was the decedent's stock sold? . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? . . . . . . . .. 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. . . . . . . .. 0 Yes 0 No 12. Did the corporation have an interest in other corporations or partnerships? ......... 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Forrn 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, subrnit a list showing the cornplete address/es and estimated fair market value/s If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed, insert additionai sheets of the same size) REV-1506 EX+ (9-00) ';, I!V/,~;~ ,~~~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Partnership A/I//- Date Business Commenced Address Business Reporting Year City / State Zip Code 2. Federal Employer I.D. Number 3. Type of Business ProducVService 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ 5. PARTNER NAME I !_ERCENT ~INCOME PERCENT OF OWNERSHIP BALANCE OF CAPITAL ACCOUNT ~. -+-- -- -------- -+-- ----------- ! A. B. c. I D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? If yes, provide amount of indebtedness $ DYes 0 No 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $_ _ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold Consideration $ Date Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? . . . . .. 0 Yes 0 No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. . . . . . . .. 0 Yes 0 No 13. Was the decedent related to any of the partners? If yes, explain .___ DYes 0 No 14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . .. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWiNG INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (1-97) SCHEDULE D MORTGAGES & NOTES RECEIVABLE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE OF DEATH C I I DESCRIPTION 1. /~/L' Il'E L TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) I! M8EI' Bank llCCOIJNT NO, I L 4691731 ACCOUNT TT"E ''MolE cL~SSIe C~ECKIN; 1 OF 1 00 4 04345" ~ 021 452 MRS EVELVN P AREHART ~JACQUELINE STARZ 10709 MT ZION RD GLEN ROCK PA 11327 HQ"EHEDOE I ~i~r:,i:' r 7,nru,i ACCOU , 12-113-~5 BEGINNINC BALANCE lZ-05-oS CHECK PMOlU U'H 12-111l-I)S CHfC/( NU"PlER 5"'" 1il.23-~!i CHECK NUMBER ,57'}S 12-27-05 CHECK HUn.IR $7.' 01'O!-06 DFAS-CLEVELAND AI ANN PAV 01-1)5-06 U$ iIIIUSUItY 303 soe SEe I 01-D3,,06 US tltUSU/t'l' 512 CIvIL SU'\! I L EI<<lIHG BALANCE 11.00 50'.4S 371..2 5,907.70 .7,112, U I '7,701.16 I 7,ln.7S I ','ZO,1.1 ' ::~~I 1 !lla.OO li".OO q(,\l.QQ 2,.S8,'+1 -L-. U,UI.1tl. L__M." ..:-~ "I i 5793 12-0.6-0& 51% U-ZiOS 11, DO 5 . ., 01 70 CHECKS PAID SUMMARV 5"4 12-14-05 ,SO'.1Il5 67'5 12-23-0& 371.&2 DO YOUR TA~ES ~ITH TURBOl4X:Rl OMLINEISH', BROVOHT TO YOU IY MITI IT'S EASV, T"e~t Is NO SQFTWA~E TO DOWNlOAP O~ INSTALL. FILE YOUR RETURN ELECTROHI~ALlY TO Q~T YOUR REFUMO FASTER. THE EASVSTEPIRJ INTeRVIEW ASKS SIKPLE tUESTIOH$ AND PLACES YOUR ANSWERS INTO I~ A~PROVED fORMS. THERE IS NO RISK - TRY IT BEFORE YOU PAY! GeT $TARTED AT WWW,~ANOTBANK.COH/TUR&QTAH' TURtoTAX AH~ EASYSTEP ARE RE~ISTERED TRADEMARKS ANb TURBOTAX ONLINE IS A SERVICE HARK OF INTUIT INC. ~~!O(J.l L.l .-I ) C :: ~ L-t '::. Ot ~_ .=- 7' _ :&.I H i.1 SCHEDULE F JOINTLY-OWNED PROPERTY ~";;,;'':':~' n=:;':;,=~~'=';:=~~~"'~'::": ~'tT:_jRi~ "jFr:r:'EN-- FILE NUMBER ESTATE OF if an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. ~'" I I i r:~j,\I\ ~~l\Mi~_ ADDRESS IL c" IL /~ I Lu_ 'i-OV\\JEr; PRC;:'ERTY Lt":Tn,-:_;:, I '.---.---"..-"'.--.'j------'.- DtSCRIPTION OF PROPERTY "ame 'Jf tinanclal Institution and bank account number or similar identifying number Attach , deed for ,'olntly-neid real estate '--"--1"---'--- I DATE OF DEATY VALUE OF ASSET --"-"-'~"'- 0/0 CF Cl:::CDS 1~,nERES' :.. i I I I I I I I i TOTAL [Also SOI~' SO 1;" 6, Re"p;j"'at;ot_~-' , (If more space is needed, insert additional sheets of the same size) Ewing Brothers Funeral Home, Inc. 630 South Hanover Street Carlisle, P A 17013- (717)243-2421 January 8, 2006 Jacqueline Starz 10709 Mt. Zion Road Glen Rock, PA 17327 The Funeral Service for Evelyn P. Freeman Arehart We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES. AUTOMOTIVE EQUIPMENT, AND MERCIIANDISE TIIA T YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. I. PROFESSIONAL SERVICES Services of Funeral Director/Stafr. . . . . . . FUNl;RAL HOME SERVICE CHARGES SELECTED MERCHANDISE: Cloth Covered Casket, . . . . . . . . . . . . . . . . . . . . #5 Regular Scaled OBC. . . . . . . . . . . . . . . . . . . . THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED . . . . . . . . . . . . . $3695.00 $3695.00 $795.00 $995.00 $5485.00 Cash Advances Opening Ciravc. . . . . . . . . Clergy/Mass OtTering. . . . . . . Certilled Copies of the Death Certificate. Organist, . . . York Daily Record Sentmel. , . . Ilalrdresser TOTAL CASH ADVANCES AND SPECIAL CHARGES. $1045.00 $125.00 $42.00 $125.00 $188.10 $168.80 $35.00 $1728.90 Total Total Cost $7213.90 SUB- TOTAL INITIAL PAYMENT / DISCOUNT / CREDITS TOTAL AMOUNT DUE $7213.90 4901.14 ~H12.'7& ~,- I/lC/l""ut e j)~ ~ e ~ IS e Lc t-0 ! Thc unpaid balance over 45 days is subjected to a 1.00 % service charge per month - 120000 % per annum. ~ve,.-ec/ {,t~ck~ /~~/2Z7" .c/O 3f1/!/Jf;J/~ ~,_ If ~ f~ t~:~:J~ Svb'vV€ 1/ A~t:fCJ ~ .dP/Ve~./ (7u/h~ ~c,......,.;.7 V /"r C-O 4' 7?? CJ,j 7dr/tL 2)~ Member of National Funeral Directors Association RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 AREHART EVELYN P Estate File No. : Paid By Remarks: Receipt Date: Rece=)-pt Time: Recelpt No.: 3/15/2006 11:11:42 1043667 2006-00228 JACQUELINE STARZ RSK ------------------------ Receipt Distribution ---------------------___ Fee/Tax Description PETITION LTRS TEST WILL SHORT CERTIFICATE JCP FEE AUTOMATION FEE Check# 6125 Total Received......... Payment Amount 90.00 15.00 8.00 10.00 5.00 Payee Name CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN $128.00 $128.00 /) .~ ;) . (, , . i'.. cJl.:::d.--- r d ,f).if .~'J (AU Ilk,- \ c) ,}CC(:>. , (. , , I' fv\ , \.cclL\..:1+ C(' C., >f<-\~~ ,'~\r~~ ~"'-f):Lccl ~ l' 'CY'!\') '--~ J .\ .: ( I. JVLLLL./:!:.L\l.N.LUM .PHCY. ~VC~ . .l:!:A~'L,,~ ~ UM.LLL./::!:.N.N.LUM WAY I ~'l'.I:!:j U U./::!:.NULA I J:'fi. .L I U L.:J DATE: R.x .QTY. ......... g~} N,!MEl:J ii 'T.U.)N "lDBl ..."'. "r'Pt<'M --, *** PREVI )US BALANCE 217.70 ** TI IS AMOUW PAsr DUE ** - I .OG \S) } .J - \ vc0 '" ~ ( \ 0--" '\ '\ {,t.; ,. ,:>R ',- (L [\v ~ .t;L L;~ Q.~Jr l/ .00 I I I I I 3.271 I I I 1 TOTAL/TAX PREVIOUS BALANCE 217.70 + CHARGES ~nus MONTI! .00 + YTD FIN CHARGE 3.27 TOTAL PAYMENTS & CREDITS .00 220.97 PLEASE REMIT PAYMENT TO: MILLENNIUM PHARMACY SYSTEMS, INC. 12450 PERRY HIGHWAY, SUITE 200 WEXFORO, PA 15090 RE\/-1517 EX-*" :12-011 , SCHEDULE I I ! DEBTS OF DECEDENT, i I MORTGAGE _L1~Bll~~~~_~~IEN~ I \0 ~.~,~ ~~$>> l)Cf"r.,10NWEAL TH OF PFNNSYL VANIA 'r,HERITMiCE TAX RETURN I,ESIDENT DECEDENT ESTATE OF FILE NUMBER --~---------~--~.~._.._----_._--~.__._,~---_._---~_.- Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses --n:EM----~-- ----- ----------------------------------------------------------r----;;ACUE;TDAT-E--- Nur:1BER i DESCRiPTION : OF DEATH --- ----- -r----- ----------------------- -- ---------------------------..----------- -----1----------------------- ! ! ;L'(' )L'c~- i __1_ i --.---,--------..~--------- I TOTAL (Also enter on line 10, Recapitulation: $! I (If more space IS needed, insert additiona! sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. h$l~t~+ II~': ~S-\t\,\..I--. _ / (. 7 { ( I / )}I- ;21(:) f\- 12:-, / C~ L;. n Cc (\ 'Y\ -~)A 1-7 3.)../ .). -\ \ \: ~ \~t~\:: ~\:~~ t. \\ '\ \\ ,~, ,_ ___ , (S. S ~\,(\_ \\ lL,\.. s Tt~ 't ~ C _ h \:..' ~ 'C$ t<c\. (' <.,,-, \\ :)", - 9+\ . \ -(c. \ .~ '] ....) L~( {) ':\ \1?-(\ \ \e >'. .' \L\) \\eip..,L ts.r ~.\..C C ~-t S \.i l l~. ~ "i, l-.!:l. \ \ ~ ~,C' ,~') j \ 5 p\\ l ~\ \.. \'> -\~F \ \ ~ k$' t\. -) C' L\ - $)C' k" b \\ '.-"E \\ U E ,"\ \.,. \ _ " t, \~' '\ .",,_ \ ")""\""{:-'\\(' "._ \'-- \'-- '. J .:} \ \3 Cc FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s) -,-. '\ . \ I i )\\t.'c \\:..\:Z ,- -- J \~ \cA~~ " C,\n ,,,-"', (I \L' lC\ \ (~\--CU,~.' (\ \'-'- ~ c\. AMOUNT OR SHARE OF ESTATE \ l.G 'J)3c\ C\i~- \ ll' 3:~/ \ C is ;:.~ I l./ ( c),~.~ \ l'C, .. - ~" 1.)-5 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. , TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) .~,t.,D. ., . ~'l' .,~ .~ COMMONWEALTH OF PENNSYLVANIA INHER!TANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on REV-1500 Cover Sheet) ESTATE OF FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. ActJariai factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. D Will D Intervivos Deed of Trust D Other LIFE ESTATE INTER~ST CALCULATION I NEAREST AGE AT TERM OF YEARS NAME(S) OF LIFE TENANT(S) i DATE OF BIRTH DATE OF DEATH LIFE ESTATE IS PAYABLE ------ D Life or D Term of Years - D Life or D Term of Years - D Life or D Term of Years D Life or D Term of Years - D Life or D Term of Years - 1. Value of fund from which life estate is payable. . 2. Actuarial factor per appropriate table .. Interest tabie rate - D 3 1/2% D 6% . . . . .$ D 10% D Variable Rate % 3, Value of life estate (Line 1 multiplied by Line 2) ............. .$ ANNUITY INTEREST CALCULATION NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY IS PAYABLE D Life or D Term of Years -~ D Life or D Term of Years D Life or D Term of Years - D Life or D Term of Years - 1. Value of fund from which annuity is payable. . . .................................$ 2. Check appropriate block below and enter corresponding (number) Frequency of payout - D Weekly (52) D Bi-weekly (26) D Quarterly (4) D Semi-annually (2) D Annually (1) 3. Amount of payout per period . . . . . . , , . . . . . . . . . . . . 4. Aggregate annual payment, Line 2 multiplied by Line 3 D Monthly (12) D Other ( ) ..$ 5. Annuity Factor (see instructions) Interest table rate - D 3 1/2% D 6% D 10% D Variable Rate % 6. Adjustment Factor (see instructions) . . . . . . . . 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ....... ................. . . . . . . . . . . . . . . . . . . .$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed. insert additional sheets of the same size) REV-16AA EX + (3-8A) ~~~~ ."'-,~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE Ill" REMAINDER PREPAYMENT OR INVASION OF TRUST PRINCIPAL FilE NUMBER I I. i Estate of (Lasl Name) (First Namel (Middle Initial) II. This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. Remainder Prepayment: A. Election to prepay filed with the Register of Wills on (attach copy of election) B. Name(s) of Life T enant(s) Date of Birth or Annuitant(s) (Date) Age on date of election Term of years income or annuity is payable C. Assets: Complete Schedule L- 1 1. Real Estate 2. Stocks and Bonds 3. Closely Held Stock/Partnership 4. Mortgages and Notes 5. Cash/Misc. Personal Property 6. Total from Schedule L- 1 D. Credits: Complete Schedule L-2 1. Unpaid Liabilities 2. Unpaid Bequests 3. Value of Unincludable Assets 4. Total from Schedule L-2 s s s s s s s s s E. Total value of trust assets (Line C-6 minus Line D-4) F. Remainder factor (see Table I or Table II in Instruction Booklet) G. Taxable Remainder value (Line E x Line F) (Also enter on Line 7, Recapitulation) III. Invasion of Corpus: A. Invasion of corpus s s s (Month, Day, Year) B. Name(s) of Life Tenant(s) or Annuitant(s) Date of Birth Age on date corpus consumed Term of years income or annuity is payable C. Corpus consumed D. Remainder factor (see Table I or Table II in Instruction Booklet) E. Taxable value of corpus consumed (Line C x Line D) (Also enter on Line 7, Recapitulation) s s s ".EV.16.d5 EX + (7-85) INHERITANCE TAX * SCHEDULE L-l COMMONWEALTH OF PENNSYlVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN RESIDENT DECEDENT -ASSETS- FILE NUMBER I. Estate of (Lost Nome) (First Nome) (Middle Initioll II. Item No. Description Value A. Real Estate (please describe) Total value of real estate S (include on Section II, line C-1 on Schedule L) B. Stocks and Bonds (please list) Total value of stocks and bonds S (include on Section II, line C-2 on Schedule l) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) Total value of Closely Held/Partnership S (include on Section II, line C-3 on Schedule l) D. Mortgages and Notes (please list) Total value of Mortgages and Notes S (include on Section II, line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property S (include on Section II, line C-5 on Schedule l) III. TOTAL (Also enter on Section II, line C-6 on Schedule l) S (If more space is needed, attach additional 8% x 11 sheets.) REV-1646EX+ (3-84) I . I COMMONWEALTH OF PENNSYLVANIA I INHERITANCE TAX RETURN I RESiDEt-H DECEDENT I INHERITANCE TAX SCHEDULE L-2 REMAINDER PREPAYMENT ELECTION -CREDITS- r- I I. L~state _~1_____________ _____________________ ; (Last Name) (First Name) (Midd!e Initial) --i----------~------ ----- -----,---------------- II. I Item No. i Description : Amount '----------1-------------------------------- ---------------.------+- ..------------------- i i A. Unpaid Liabilities Claimed against Original Estate, and payable from assets: i 'reported on Schedule L- 1 (please list) I : FILE NUMBER ___L..__________________ __ ! I ~--- -- - ------------------1 ot-;;T~_;paid liabilities --------rs------------- i i (include on Section II, Line D-l on Schedule L) I i- ---i= - ----------,.-c-----------c..---~-------~---------------------+--,.------ - c-c :- ---====~ ,--~~-~~pa~d Bequ~~-;:-p~~ab!e from ~-~~~-repor;ed-~~Schedule-L:](;~i~;~~eli-:t)-~------ -~=-=--=~- I ! I I I i i I I I I I I I l_____ r----- i i I I I I I I I I I f--------- ------------------------------------------------------------ -- ------ ---1--- -- -------- I Total unpaid bequests IS -----=-t==~=~~=c==========c=~~~_~_.on S~c!~~n=ll,=L~~_D-~ on ~_~~edule LL-'===-~c=~=====.==== -- i C. Value of assets reported on Schedule L-l (other than unpaid bequests listed under: "B" above) that are not included for tax purposes or that do not form a pari of the trust. Computation as follows: I i r------ Total unincludable assets ---------h------------- --t _ __I =,,----------,--------(include on Seclion II, Line ~_ on_Sched':'.~~l.==----+-===--==-=cc I I I ' _1!!....1 TOTAL (Also enter on Section II, Line D-4 on Schedule L) -..1~____ (If more space is needed, attach additional 8Y2 x 11 sheets.) REV~1647 EY, !9~OO) C>. 3. JJ ~~\Wf ~)\ ~O'~" ~$'b",' COMM'='NWEALTH OF PENNSYLVANIA I~HERITANCE: TAX RETURN RE:S!DENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE ESTATE OF (Check Box 4a on Rev-1500 Cover Sheet) i FiLE NUMBER -~_.- ~_.~---~ ----- This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedl'le is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possessio'l and enjoyment cannot be established with certainty Indicate below the type of instrument which created the future interest and attach a copy to the tax return o Will 0 Trust 0 Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY , -- ----- ---+._-_.~----_.-.._.. --- 1. I i ,--- ,-- ------t-------------- ----------+- -------- I I ---- ---+ - --- ---- ---- --j------ --- I ! - -------- -------, t---- ----- -------------1'----------- --:- I ! , -----r----- ----'---- ---------~-- -- _~___ i 5. 1 i i -~For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawalv\lithin I 9 nlonths of the decedent's death. check the appropriate block and attach a copy of the document in which the surviving spouse I exercises such withdrawal right ! 0 Unlimited right of withdrawal 0 Limited right of withdrawal ---IIftE~Pla~ati~~Of C~~p~omise Off~--------------- '-- - -- -- -- - IV. , Summary of Compromise Offer: 11, Amount of Future Interest. . . . . . . . . . , . , . . . . . . ,$ 2, Value of Line 1 exempt from tax as amount passing to charities, etc. (also Include as part of total shown on Line 13 of Cover Sheet) . _ . . . .$ 3, Value of Line 1 passing to spouse at appropriate tax rate Check One 0 6%, 0 3%, 0 0% . . . . . . (also Include as part of total shown on Line 15 of Cover Sheet) " .$-------- 4 Value of Line 1 taxable at lineal rate Check One 0 6%, 0 4.5% (also Include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also Include as part of total shown on Line 17 of Cover Sheet) 6 Value of Line 1 taxable at collateral rate (15%) :also include as part of total shown on Line 18 of Cover Sheet) '" .$-,~--,---- .$----------,- . , . .$--~---------- 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) s (If more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99, ~.., y ~,\ J.}H.r~ ,~~.~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) ESTATE OF I FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. PART I - CALCULATION OF GROSS ESTATE ... . .. . ...... . ........ . 1. ". . ..... . .... . .......... . ..... . 2. ..... . ... . ... . .... . ... . 3 ........ . ...... . . - . . . . . 4. . . ...... . ... . . . ... . 5. 6a. 6b. ~; 6d. ........ . ...... . .. . 6. .. . ................ . .... . ... . 7. ... . . . ................. . 8 ............ . . . . - . . . . . . ...... . 9 to claim the credit If not, continue to Part II. PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income Tax Return for decedent and spouse.) Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse 1a. 2a. 3a. b. Decedent 1b. 2b. 3b. c. Joint ....... . 1 c. 2c. 3c. d Tax Exempt Income 1d 2d. 3d. e Other Income not listed above ....... . 1e. 2e. 3e. -- I. Total 11 21. 31. Taxable Assets total from line 8 (cover sheet) 2. Insurance Proceeds on Life of Decedent .... 3 Retirement Benefits 4. Joint Assets with Spouse 5. PA Lottery Winnings 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6 SUBTOTAL (Lines 6a, b, c, d) 7. Total Gross Assets (Add lines 1 thru 6) 8 Total Actual Liabilities . . . . . . . . . . . . 9. Net Value of Estate (Subtract line 8 from line 7) . . . . . . . . . . . If line 9 is greater than $200,000 - STOP. The estate is not eligible 4. Average Joint Exemption Income Calculation 4a. Add JOint Exemption Income from above: (1 f) + (2f) + (3f) (.,. 3) 4b. Average Joint Exemption Income If line 4 b reater than $40,000 - STOP. The estate is not eli 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less 1. 2. Multiply by credit percentage (see instructions) 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. . . . . . . . . 2 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit Include this figure in the calculation of total credits on line 18 of the cover sheet. 4. 5