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Home My WebLink About04-11-06 REV-l5G{lex + (6-00) '* COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONlY FILE NUMBER 2 1 -0 6 0 0 6 7 ""COuNTv~ -vEA~ - - NuMBER- - DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) ... Z W C W o W C Blocher Ira M. DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year) SOCIAL SECURITY NUMBER 1 95- 0 7 - 6 3 7 1 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER w ..... :ll:~1Il (J O::::ll: wll.(J ::J:oo (JO:::..J ~m <( 01/18/2006 03/09/1913 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) D 3. Remainder Retum (date of death prior to 12-13-82) D 5. Federal estate Tax Retum Required _ 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) lXl1. Original Retum D 4. Limited Estate D 6. Decedent Died Testate (AttachcopyofW.) D 9. Litigation Proceeds Received D 2. Supplemental Retum D 4a. Future Interest Compromise (date of death aIler 12-12-32) D 7. Decedent Maintained a Living Trust (AllachcopyofTrust) D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) ..... z w c z o II. III W 0::: 0::: o (J THIS$ECTIONMUSTSECOMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS Anthon J. Foschi 3425 Simpson Ferry Road FIRM NAME (If Applicable) Shumaker Williams PC TELEPHONE NUMBER 717-763-1121 Cam Hill PA 17011 z o ~ ..J ::J I- 0: <( o w ~ 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) OFACIAL USE ONLl 136,823.74 101,057.39 (..."-~ '-..-- (8) 237,881.13 8,211.00 69.95 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ I- ::J D.. :!: o (J X <( I- 15. Amount of Line 14 taxable at the spousal tax rate. or transfers under Sec. 9116 (a)(1.2) 19. Tax Due X _(15) 229,600.18 X .045 (16) X .12 (17) X .15 (18) (19) (11) (12) (13) 8,280.95 229,600.18 16. Amount of Line 14 taxable at lineal rate (14) 229,000.18 17. Amount of Line 14 taxable at sibling rate 10,332.Q1 10,332.01 18. Amount of Line 14 taxable at collateral rate 20. 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT >> BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < C'..\ \ l~\....\) Decedent's omPI ete ress: STREET ADDRESS 213 Walnut Street CITY I STATE I ZIP Sh iremanstown PA 17011 C Add Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 10,332.01 516.60 Total Credits (A + B + C) (2) 516.60 3. Interest/Penalty if applicable D. Interest E. Penalty T otallnterest/Penalty ( D + 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 0.00 9,815.41 9,815.41 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 IXI b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 IXI c. retain a reversionary interest; or ...... -............................................................................................... 0 IXI d. receive the promise for life of either payments, benefits or care? ............................................................. 0 IXI 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................. 0 IXI 3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. 0 IXI 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... 0 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. PA 17055 DATE ~ r 0--0 (, PA 17011 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. 99116 (a) (1.1) (i)l. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to orfor the use of the surviving spouse is 0% [72 P.S. 99116 (a)(1.1) (iill. 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 P.S. 99116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. '99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% 172 P.S.99116(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-15G8 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Blocher. Ira M. FILE NUMBER 21 06 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. 0067 ITEM NUMBER 1. 2. 3. 4. Sovereign Bank CD# 0575135710 Community Banks CD# 348151298 DESCRIPTION Citizens Bank Checking Account #6100705048 Federal Income Tax Refund VALUE AT DATE OF DEATH 8,980.48 107,794.17 19,318.09 731.00 T-OTAL (Also enter on line 5, Recapitulation) $ {If more space is needed. insert additional sheets of the same size) 136,823.74 Sovereign Bank Ira M. Blocher 195-07-6371 January 18, 2006 ESTATE OF SOCIAL SECURITY #: DATE OF DEATH: Account #: 0575135710 Type: In the name of: I M Blocher Date of Death Balance: Int.(YTD) from 1/1/06 to Accrued interest to date of death: Other Info: CD Open date: 4/24/97 $8,980.48 1/18/06 $9.36 $0.00 Page 1 of 1 Communit~Banks Decedent's Name Ira M. Blocher Social Security Number 195-07-6371 Date of Death January 18, 2006 Account Number 348151298 Account Type Time deposit Date Opened 12/05/03 Principal Balance $107,642.81 $ Accrued Interest at Date of Death $151.36 $ Balance at Date of Death $107,794.17 $ Maturity Date 12/05/07 Account Ownership Totten Trust Names of Joint Owners, if any Date Joint Ownership was Established 12/05/03 Interest Rate 3.6900% % Additional Information ITF Robert M. Blocher ,,--'- r'\ / -\ { . 1\ I.' . \ . r\ \ \ ! I \J \\ ~ \:' \ \<-.... ...t\ (\ u-... ,..~~ "-"\-_'.J '\ {'--...<~--\S-~ 'il' ~.\j,,\ Authorized Signature J' . ,;L(~~ \~~ Date ~:E Citizens Bank- Account Number 6100705048 Account Title I M BLOCHER Date Opened 6/6/1966 Account Type Checking Principal Balance as ofDOD $19318.09 Interest from Last Posting to DOD $.00 Account Balance as of DOD $19318.09 YTD Interest to DOD $4.56 REV-1509 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Blocher. Ira M. FILE NUMBER 21 06 0067 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. Robert M. Blocher 2197 Brunswick Avenue Mechanicsburg, PA 17055 Son B Thomas E. Blocher 213 E. Walnut Street Shiremanstown, PA 17011 Son c Steven L. Blocher 437 Campbell Avenue San Francisco, CA 94134 Son JOINTL Y.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 EST ATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. Commerce Bank 45,434.50 50. 22,717.25 CD# 801003 2. B. Commerce Bank 45,434.50 50. 22,717.25 CD# 801004 3. C. Commerce Bank 45,434.49 50. 22,717.25 CD# 801005 4. C. M& T Bank 50,359.71 50. 25,179.86 CD# 31003914467228 5. A. Citizens Bank 15,451.56 50. 7,725.78 CD# 6140710898 TOTAL (Also enter on line 6, Recapitulation) $ 101,057.39 (I' more space is needed, insert additional sheets of the same size) :11 d?h?n~""i't.l~) cff ;Y%o3 C'"/q,irD ~D g~Jf7"" m. ,..f~~ ~f:j('1!. <fJf51 dO 'I ('k~~ /3" r.JIdJ?t/f~ F !I ~O}l!)tJ.s- <'~I'.o ~C!' ~~~")I Z" ii ( .;! 7C.17'L "1 i! H - ' -/ ~ '7$ Y.. S-t:J ~ "T.s; "T311, .s- <1 ~ .rr..s; 931? .?( 9 ~, 13~ 3"3, .y~ " ) PHONe 415 4Cl7 34~ '* ,. INFORMATION NOTZCE AND TAXPAYER RESPONSE FILE NO. 21 06-0067 ACN 06114999 DATE 03-28-2006 TYPE OF ACCOUNT EST. OF IRA M BLOCHER 0 SlVIN8S S.S. 110. 195-07-6371 0 CHECUN8 DATE OF DEATH 01-18-2006 0 TRUST COUNTY CUMBERLAND lil CEITIF. REIIIT PAytIENT AND FOIItS TO; RE6ISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE# PA 11013 _1141 U In I....' STEVEN L BLOCHER 437 CAMPBELL AVE SAN FRANCISCO CA 94134 " I T BANK h.. provided the D_rt.....t IIlth the infar..tlon Ihtell t1.1llt1 whillh 1IlI. tIeen uAd in calculet1nCl the pot.ltgl tax du8. ThlIlr records Inltlat. thet at thto Math Df the ...... d8c8lI8nt. >>ou ...... . joint _r,to.ncot'lcur-y af ths. _aunt. If l/OU feel thl. inforwatJ.. 1. incor....t. pl.._ obtain ..rltt... aDrraatiDn f~ ttIIo ftn..ailll ln8tituUon, .tteGh · DGPl/ to this fo... and rsturn It to the above lICIdre... 1111. a_t h .xabl. in _ordenc. ..lth the lnhari~ T_ L.. of the c-w..lth of PJDlulYWIla.. _lIuestiGU._.M __-- .........J.1i_....UU~ JQ~ - .-.. ....- .,. ... .....- ____00. "'. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003914467228 Date 10-01-1994 E.t_li8hed 50,359.71 50.000 25,179.86 .045 1,133.09 TAXPAYER RESPONSE Aacaw\t ..1_ Percent T__18 ~t SWlj.ct to T_ T_ ..t. Potantlu T_ Due TD Insara proper o.....it to l/lIUl" _to two (I) copi.. .f thl. notl... ..111: -...-nlI l/OUr ~t to ttIIo ....In.r ~ IIIU.. Maka........ _bl. to.. .....ist80r Df IIl1b. A...t". x x IllITE. If' t.. ..--.ta .,.. ..... wltilin three (5) __the of the ..........t.. __ Df ..tiI, !IOU _lI daduot . 5lC di~t Df tIw talC ...... Anlr 1ntlar I tanoa talc .... will .....-. _U"",*" nine (9) ....th8 after tIw _. of datil. PAIT ill i"r~1J r"":";4"~~<>'''"",,~~~"''''';mtfi'''''~'''''~'''''U-Wi;,"''E~_' ~"":":'-:",,:rc.t.---'_"-~)':"'"J-' ;u _:'I.1.;";i _ fi"iri1 3-C ff:1;lin<;;;t ""~;.I"'.,_r,;lL1: '.if!! ';. j:j", d ;];. . h c. ". - d !}3.. FEEE-g f~ ~~tW.1i; ~~~ ~r{C"::;ji;:~-J~tf;~-f~;'-";-~!:""'!""-f'~.f..,,,~.,~,,"\.~.,.,~ A. 0 The allova Sntor.atJan and talC du8 Sa cor....t. 1. You _ tohoo.. to reait pe_t to tila RqSat.r Df NUla lllti1 twa copS.. of this Illltl.. to obtain a di_unt Dr avoid intera.t. Dr l/DU _ c:hack boll ..".. and nturn thi. nDtl.. tv the ...I.tar af IIS11. and an Dfl'lcJal e..........t 11111 be J...... blt the P& lltIPa~t Df' 1laVanUa. [CHECK ] ONE BLOCK ONLY a. 0 The abova ....t has ...... or ..111 be raportad and tax paid IIlth the Pa"'8lflv...Sa inheritance T_ return to ba fll.. 1Il/ the ........t.. ........aenbtl.... C. 0 ThlI abova 1nfo~tl.. IJ..I....r....t -neIIor d...t. and ......tlan. we'" paid blt _. You _t _opl.ta PART L!J...v0l" PART I!l ballltl. If )IOU Indlcat. . dlff.rant t_ r.t., pl.... .t.t. )lour r.l.tlonahlp to d8cadant: PAIT {!l TAX RETURN - CO"PUTATJON OF TAX ON LlIIE 1. Dat. EstabU.Md 1 2. Account a.l8nCO 2 J. P.rc:ant T.-bl. 5 X .. A.aunt Subj-t to T.x . i. Deltb IInd Decluotl_ 5- 6. Mount T_~1e 6 7. T.x ..t. 7 X .. T_ Due 8 JOINT'TRUST ACCOUNTS PAft {!] DATE PAID DEBTS AND PAYEE DESCRIPTION AMOUNT PAID I 1 TOTAL (Ent.r on Lln. 5 of T.x COIIPut.tlonJ . Under p_ltl.. of perjun, ! cMe1er. tt.t the filet. ! __ .-.ported eba_ .,.. true, cor.-t 8nd -..1.t. to ttw ....t of -:I knoWJ.edste and "'lhf. HOME ( ) WORK ( ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE ~:E Citizens Bank'~ Account Number 6140710898 Account Title IRA M BLUCHER OR ROBERT BLOUCHER Date Opened 3/7/1997 Account Type Time Deposits Principal Balance as ofDOD $15436.54 Interest from Last Posting to DOD $15.02 Account Balance as of DOD $15451.56 YTD Interest to DOD $38.71 REV-1511 EX+(12-99) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Blocher. Ira M. FILE NUMBER 21 06 0067 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Funeral Home 6,139.00 2. Funeral Luncheon 150.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Numbe~s)/EIN Number of Personal Representative(s) Street Address City State Zip Yea~s) Commission Paid: 2. Attomey Fees Shumaker Williams, PC 1,500.00 3. Family Exemption: (If decedenfs address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Cumberland County Register of Wills 422.00 5. Accountanfs Fees 6. Tax Retum Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 8,211.00 (If more space is needed, insert additional sheets of the same size) FOllr Genera/ion..... .cetebratillg Life. Honoring T/'aditions BOYD L MYE S R S . MYERS . R , J ., upervlsol 37 E. MAIN STREET MECHANICSBURG, PA 17055 untJrtf/ ~mtJ, @na (717) 766-3421 , 17 a: STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED A~a-u4- - -- Charg~s ar~ only for thos~ items that you select~d or that are required. If w~ are requir~d by law or by a cemet~ry or cr~ any it~ms, w~ will ~xplain in writing below. If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if 0 cted arrangements such as a i ct cremation or immediate burial. If we charged for embalming, we will ~~I in Wh~IOW. II II ~ - 0 ~~~~ Q~~ ~~~ili- (,Dc"k.d. 'Z I 'i'1 ; Ie.. .. Address . Charg~ to: A. CHARGE fOR SERVICES SELECTED: I. PROFESSIONAL SERVICES Services of Funeral Director/Staff .... ~ Embalming. . . . . . . . . . . . . . . . . . . . .. ..~ Other preparation of body SUJi-'TO~~L O~ 'PRO~ESSIO~A'L SER~I~~... AI I3;...,L 2. FACILITIES AND SERVICES Use of facilities and services for L viewing (Visitation/Wake). . . . . . . . . ~ Use of facilities and services for funeral ceremony . . . . . . . . . . . . .~ Use of facilities and services for L Memorial Service ............... I ~ Use of equipment and services L for graveside service. . . . . . . . . . . .. I ~c Other use of facili.ties "iA, SU8-To~~L OF FACi':ITIESiEQuipMEN;~.... A2~ 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home. Local. . . . . . . . . .. .. . . . . . . .. . . . ... a:;,~ Hearse (Casket Coach) Local. . . . . . . . . . . . . . . . . . . . . . . . . . . 'iIisi- Limousine Local. . . . . . . . . . . . . . . . . . . . . . . . . . . '&.d..... Family car Local. . . . . . . . . . . . . . . . . . . . . . . . . . . I--==:- Flower car or noral disposition Local........................... ~ ..' I- I- Cremation urn . . . . . . . . . . . . . . . . . .. 1_ (Description) .........!..........~,-._- OTHER I_ I- 1- 200a &JJ TOTAL MERCHANDISE SELECTED.................. B 1_ ;;..- C. SPECIAL CHARGES: Forwarding of remains to I (Func.ral Home) Receiving of remains from I (Funeral Home) Immediate Burial. . . . . . . . . . . . . . . .. I Direct Cremation. . . . . . . . . . . . . . . .. I I SUB.TOTAL Of SPECIAL CHARGES. . . . . . . . . . . . . . .. C 1_ D. CASH ADVANCED t Opening Grave .................. I ~ Cemetery Equipment. . . . . . . . . . . . .. I ~. Lot and Deed. : . . . . . . . . . . . . . . . . .. I~ ~ Newspaper Notices-Local ......... I ~ Newspaper Notices-Out-of.town. . .. I---===-. Telephone & Telegrams........... 1_ Airfare. . . . . . . . . . . . . . . . . . . . . . . .. 1_ ClergylA4:iili Offering. . . . . . . . . . . . .. 1..JQ..fJ.:. ~ Pallbearers. . . . . . . . . . . . . . . . . . . . .. 1_ Certified Copies of the ..Qr,th ..~;I d ;rI Certificate..... .I~.~,,..-...... I~ Police Escort . . . . . . . . . . . . . . . . . . . . 1_ Flowers .... . . . . . . . . . . . . . . . . . . . . 1.LJ..L-ft:!:L Vault Service Charge. . . . . . . . . . . . .. 1..:.-......- RECEIPT FOR PAYMENT ------------------- ------------------- -GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Receipt Date: Receipt Time: Receipt No.: 1/23/2006 11 :5():131 1043145 BLOCHER IRA M Estate File No.: Paid By Remarks: 2006-00067 R BLOCHER VZ Fee/Tax Description PETITION LTRS TEST SHORT CERTIFICATE JCP FEE AUTOMATION FEE WILL Check# 1164 Total Received......... Receipt Distribution ------------------------ Payment Amount Payee Name 60.00 32.00 10.00 5.00 15.00 ---------------- $122.00 $122.00 CUMBERLAND C.OUNTY -GENERAL FUN CUMBERLAND COUNTY -GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN REV-1512 EX + (6-98) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Blocher. Ira M. FILE NUMBER 21 06 0067 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION 1. West Shore EMS VALUE AT DATE OF DEATH 49..77 2. State Income Tax Due 20.18 TOTAL (Also enter on line 10, Recapitulation) $ 69.95 (If more space is needed, insert additional sheets of the same size) ~ WEST SHORE EMS - BLS 205 GRANOVIEW AVE. SUITE 211 CAMP HilL, PA 17011 Phone #: (800) 367-0512 Federal Tax 10: 23-2463002 ~~~) WEST SHORE EMERGENCY MEDICAL SERVICES PATIENT NAME: IRA BLOCHER 137996W PATIENT NUMBER: CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: 46266 IBAl 137996W IBAl 12/23/2005 09:15 AM HOLY SPIRIT HOSPITAl HOLY SPIRIT HOSPITAl MESSIAH VilLAGE INSURANCE: SENIOR BLUE - NO CON"' YWK195076371 ROBERT BLOCHER 2197 BRUNSWICK AVE MECHANICSBURG, PA 17055 REASON(S) FOR TRANSPORT HIP INJURY INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT Stretcher One Way Transport A0999 1.0 82.98 82.98 Transport Van Mileage A0999 7.0 3.09 21.63 Oxygen Administration A0422 1.0 53.48 53.48 fA7 i/ c;2 jJf,)t ~ () rcy3 Total Charges 158.09 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Insurance Payment - SENIOR BLUE - NO CON"' 20404161 02108/2006 108.32 Total Credits 108.32 PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ~ r S49.7;'-D RETURNED CHECK FEE - $31.00 "'-"'''''>w COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER Blocher. Ira M. 21 OF: 0067 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. Robert M. Blocher Son 1/3 2197 Brunswick Avenue Mechanicsburg, PA 17055 2. Thomas E. Blocher Son 1/3 213 E. Walnut Street Shiremanstown, PA 17011 3. Steven L. Blocher Son 1/3 437 Campbell Avenue San Francisco, CA 94134 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 II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500COVER SHEET $ (If more space is needed, insert additional sheets of the same size) SHUMAKER WILLIAMSp.c. WRITER'S DIRECT DIAL: 717.909.1657 WRITER'S EMAIL: foschi@shumakerwilliams.com LEGAL AND BUSINESS COUNSEL April 10, 2006 Glenda Farner Strasbaugh, County of Cumberland, Register of Wills CUMBERLAND COUNTY COURTHOUSE One Courthouse Square Carlisle, P A 17013-3387 RE: Estate of Ira M. Blocher No. 2006-00067 PA File No.: 21-06-0067 Social Security No.: 195-07-6371 Dear Ms. Strasbaugh: We enclose, for filing, on behalf of our client the Estate of Ira M. Blocher, a completed REV -1500 Inheritance Tax Return, Resident Decedent, with all supporting documents and the Estate Inventory. We submit the Return to your office in duplicate as requested in the Department of Revenue's instruction booklet for the same. Attached to the Return is a check in the amount of $9,815.41 for the inheritance tax that is due. Also, enclosed is a check in the amount of $15.00 as payment of the filing fee for the tax return. Once you have computed any additional amount due for the probate fee, please forward an invoice to the attention of the undersigned and payment will be sent promptly. We also enclose one (1) extra copy of the Return and Inventory, and request that you time stamp these copies and return the same with our messenger. Should you have any questions, please do not hesitate to contact me. By Anthony J. Foschi AJF /raf Enclosures cc: Robert Blocher, Executor CORRESPONDENCE PO BOX 88 HARRISBURG. PA 17108 PHONE: 717.763.1121 FAX: 717.763.7419 STATE COLLEGE, PA 814-234-3211 TOWSON, MD 410.825.5223 YORK, PA 717.848.5134 mail@shumakerwilliams.com