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Home My WebLink About06-13-06 REV-1500 EX (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 20~ _086L__ YEAR NUMBER COUNTY CODE ~ z w c w u w o DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Ambrose, Mary E. DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 09/17/2005 05/03/1911 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 215-44-8593 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER w .... ~ Scn U D::~ W CL.U :J: 00 U D::..J CL.al CL. <( [Z] 1, Original Retum D 4. Limited Estate [X] 6. Decedent Died Testate (Attach copy of Will) D 9. Litigation Proceeds Received D 2. Supplemental Retum D 3. Remainder Return (date of death prior to 12-13-82) D 4a, Future Interest Compromise (date of death after 12-12-82) D 5. Federal Estate Tax Retum Required D 7. Decedent Maintained a Living Trust (Attach copy ofTrust) Q 8. Total Number of Safe Deposit Boxes D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) .... Z W C Z o ~ V) W ~ ~ o o THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS Elyse E. Rogers, Esquire FIRM NAME (If Applicable) Keefer Wood Allen & Rahal, LLP TELEPHONE NUMBER 415 Fallowfield Road, Suite 301 Camp Hill, PA 17011 717-612-5801 1. Real Estate (Schedule A) (1 ) 0.00 2. Stocks and Bonds (Schedule B) (2) 456,593.40 0.00 0.00 24,624.58 0.00 C) ~~ ;.''"1 U :; ;1] :::c S- '.~-- :;-t> l-n ro. :z ::0 '.~: c6?~ ,::'::iC")C) C) --;1 C ::0 ---t OFFICIAL USE ONLY ,-....:> c::::> c::::> o~ '- c: -;po 11IM- 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5, Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) w z o i= ~ :::) ~ ii: <( u W 0:: 6. Jointly Owned Property (Schedule F) (6) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 2,310.34 ~ ~v ~ (~~ .' i--, ~;~ 8. Total Gross Assets (total Lines 1-7) (8 ) 8,796.62 8,016.65 483,528.32 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 1 O. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11 . Total Deductions (total Lines 9 & 10) (11 ) 16,813.27 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) ( 12) 466,715.05 46,671.51 ( 13) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14 ) 420,043.54 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax ~ rate, or transfers under Sec. 9116 (a)(1.2) ~ 1 6. Amou nt of Line 14 taxable at lineal rate .... ~ ~ 1 7. Amou nt of Line 14 taxable at sibling rate o (.) 18. Amount of Line 14 taxable at collateral rate X ;:! 19. Tax Due 0.00 420,043.54 0.00 0.00 x .00 _ (15) 0.00 18,901.96 0.00 x .045-- (16) x .12 (17) x.15 (18) 0.00 ( 19) 18,901.96 20. [ZJ CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWERALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < 2W4645 1.000 Decedent's Complete Address' ,. S1REET ADDRESS 402 Bethany Drive CITY I STAlE I ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 1.8,901.96 0.00 1.8,000.00 947.37 Total Credits (A + B + C) (2) 18,947.37 3. Interest/Penalty if applicable D. Interest E. Penalty 0.00 0.00 Total Interest/Penalty (0 + E) (3) 0.00 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) 45.41. 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 PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS I. Did decedent make a transfer and: a. retain the use or income of the property transferred;. . . . . . . . . . . . . . . D b. retain the right to designate who shall use the property transferred or its income; . D c. retain a reversionary interest; or . . . . . . . . . . . . . . . . . . . . . . . . D d. receive the promise for life of either payments, benefits or care? . . . . . . . . . D 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . .. [X] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D [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. Yes No [X] 00 [X] [X] D [Xl ADDRESS Omaha, SIGNA 1URE OF P DATE 6" ~ DATE S"3/-o~ 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 orfor the use of the surviving spouse is 3% [72 P.S. 99916 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (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 retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age 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. 9 9116(a)( 1.2)]. The tax rate imposed on the net value of transfers to orforthe 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 orfor the use of the decedent's siblings is 12% (72 P.S. 9 9116(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. ~W4646 1000 REV-1503 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS & BONDS Ambrose, Mary E. FILE NUMBER 21-2005-0861 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. Chemalloy Minerals Limited DESCRIPnON VALUE AT DATE OF DEATH 0.23 2 Coeur D'Alene Mines Certificates Dl16043, D108250, D100079, DOO0103 3 Douglas Cnty Neb San & Impt Di Go 4 Dreyfus Muni Bond Fund 5 Franklin Fedl Tax Free Income Fund 131.44 25,016.94 181,397.58 189,840.07 6 Nuveen Flagship Multistate 39,870.09 7 Nuveen Inte~ed Duration Muni Bond 4.82 8 Sarpy Cnty NE Sid234 GO CF WTS 10,122.78 9 Sarpy Cnty Ne Go Var San & Impt Dis 10,067.70 10 ECC International Corp 141.75 2W4696 3.000 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 456,593.40 .!.... ~ o ~ c.:l z )> z )> ~~ J:>.I oi 011 I i i I i o I m 3: )> r r o -< 3: Z m ::IJ )> r (J) r o I G) :D m ~ r- N m c o -t ::x: m :D )> n -t <: :::j < ~ ~I I (D "C CO c: c ~ ! ~ ~ (J) (') m :r (J) ~ en rn I I ~ ~ tn tn o 0 Co) Co) c.n c.n O'l O'l 1\))>2 . C O'l < -...J m O'l m o z @ " r )> G) -0 )> ~ C ?; OJ CJ I o ~ 01 o o 25 O'l 25 01 6~2 oce ~?;~ @~~ ~zz 6CJ-l O'l I m I\:l o ::IJ:o 6 ~ -...J m 0 CJ o C :D )> -l 5 z ~ I\:l C:1 -...J en ~ o ~ 01 o I ~ c.J I\) ~ en ::IJ m Z < m (J) -l ~ o o O'l o 01 c.n-" ~z:D ~o)> ~IZ ~)>p @ z " m CJ r -; X " :D m m o 6 o I\:l ~ c.o o m o I ~ o o I\) ::IJ m Z < m (J) -l 01 25 J:>. o 01 01 0 c plJJ m Om ~ ~~ ~ o C -f @cn g ~~ ffi ~ I OeD o Z o 0'1 ~ ~ ~ ~ ~ I\) 6 ...., o 1 ~ 'j CD :... 0'1 I ~ z m m Ri -f Co (') c.:l g -f :D m Z < m (J) -l :0 (') m 0 Z ~ < m m Z ~ cri c o ~ o -f J:>. m o 01 ~ 0 6 ; CJ1 Z c.J -f ~ ~ 0:> m 'V o :D (1 m :D en co 1:: ~ "C ~ (') :r Q) rn en rn "C c: :D " :I: )> U> m CJ) "1;::::- f! ~ ~. :<- f~ 2'~ -, t:. if - '1;:: t:. er::, t"\: :3 ;::~ :::; <:J- ,-'" [r ~ :::... .~ g ~~ ~ ~ ~. ~ . ~. '"' -'. ~ :; '3 1 ?'-;: } ~ ::: ~ EO E .., :::: ~C>c ~'" s~ ~ ~ E:..E; ~ ~ ~ 3 ~ ~ ~- is.: ~ 52 ~ ~ ,5 ~ '" - y ~ ~ g t:."'" ~ ~ ~ ~ s~ ~ ~ ~ - '" ~ ::-~ ~. ~ ~ ~ - ~. ~~: ::.;, ~ 5 t:t:I '" F-- \:) - t:> t::l <:= "" ~ .!i t:> -., t:.... ~ ~ ~ ~ ~ ~ ;:- ;,:~.., E; ~ ~ ~: g ~ "'0 ~ Si E;:'g t ~~. l: ~ ~ ~ ~ \:,) ;:- ;;; c ~ ~: ~ 8 ~ ;:; ~ ::: ., ... l:l ~! ;:; :., ~~ ~~ ~ ~ <;! ~ ~ ~ ~ ~ ~ -..- ! ~ ~ <: ~ ~ c m -i ~ ~ r- ~:' ~ ~ E: ~ ~ ~ ~ ~ - ..;; ~ "" ::::- ~ ~ ~ ~ f2 g ;;; t:... ~ ~ ;l. . ~~ ~. - i ': ~ ~ ~ '; ~ ~,~. ~ i. ~ ~ [.5 '" [ J2 ~ ~ ~ ~ ~ [ ~ -,~ --: 5:; rt ~i ;? ~ :2_- [ ~. ~ ~ ;; ~ ~ ;::;- ~""I '" l::: '" ~ ~ S C <:::,... ~. ~.~ r;;; s, '" ~ ~ ~ ~" ~.~ ...~~ ~ ~ ., :s.;;; I !~ ~ ~ ~ ::; ~ '...,,: <::: S. ~ ~ ~ 13'" ~ ~ "" g ~ .., <:= ~~ ~ ~ c' :: ;:: is... S5~ (J B" ~;,- s. e. ::.;,1;; ~ ~ ~ ~. "' <:J- .., ;:; ~ ~. H ;;; EO ~~ ;:; <:J- g.~ ~~ t::I ~. . :;: ~~ ~ ~ '" '" '" '" g ~ [ ~ ~ ~ ; V:l ~ ~ ;;; ~o ~ '1;:: t:. 0;) '" N 'c- 0; S :::- !.'; <5, <::l ~ ~. !" )> en en m -..of C m -I )> r= ~ <:::t" ~ ~s::: I\)~ C5:o 0>-< ~m m~ Cf)s; -lOJ 0:0 IO mU) ~m m JJ -0 r N > o 8 ~~g [l':l I,Q ::s C1l 00 C ~ I 9 g,iff -..Jij Coeur D'Alene Mines Date of Death: 09/17/2005 Valuation Date: 09/17/2005 Processing Date: OS/23/2006 Estate of: Mary Ambrose Estate Account: 91629 Report Type: Date of Death Number of Securities: 1 File ID: Ambrose, Mary Estate Coeur D Alene Mines Shares or Par Security Description High/Ask Low/Bid Mean and/or Div and Int Adjustments Accruals Security Value l \ ~ I 32 COEUR D ALENE MINES CORP IDAHO (192108108) COM New York Stock Exchange 09/16/2005 4.14000 09/19/2005 4.38000 3.81000 H/L 4.10000 H/L 4.107500 131. 44 $131.44 Total Value: Total Accrual: Total: $131.44 $0.00 Page 1 This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. If you have questions, please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.0.4) RBC Dain Rauscher Date of Death: 09/17/2005 Valuation Date: 09/17/2005 Processing Date: 11/22/2005 Estate of: Estate of Mary Ambrose Account: 91629 Report Type: Date of Death Number of Securities: 6 File ID: Ambrose, Mary Estate Shares or Par Security Description High/Ask Low/Bid Mean and/or Div and Int Adjustments Accruals Securi t Y Value 1) 15230.695 DREYFUS MUN BD FD (26201Q104) COM Mutual Fund (as quoted by NASDAQ) 09/16/2005 11.91000 Mkt 11.910000 181,397.58 2 ) 15611.848 FRANKLIN FED TAX FREE INCOME (353519101 ) CL A Mutual Fund (as quoted by NASDAQ) 09/16/2005 12.16000 Mkt 12.160000 189,840.07 3 ) 3784.536 NUVEEN FLAGSHIP MULTI STATE I (67065L740) PA MUN BD CL A Mutual Fund (as quoted by NASDAQ) 09/16/2005 10.50000 Mkt 10.500000 39,737.63 Div: 0.035 Ex: 09/12/2005 Rec: 09/09/2005 Pay: 10/03/2005 132.46 4) 0.528 NUVEEN MUN TR (67065Q400) INT DR MUNBD R Mutual Fund (as quoted by NASDAQ) 09/16/2005 9.09000 Mkt 9.090000 4.80 Div: 0.0285 Ex: 09/12/2005 Rec: 09/09/2005 Pay: 10/03/2005 0.02 5) 10000 SARPY CNTY NEB SAN & IMPT DIST GO BDS (803737ZP3) Financial Times Interactive Data DTD: 11/01/2003 Mat: 11/01/2005 2.25% 09/16/2005 09/19/2005 Int: 05/01/2005 to 09/17/2005 99.82500 Mkt 99.82900 Mkt 99.827000 9,982.70 85.00 6) 25000 DOUGLAS CNTY NEB SAN & IMPT DI GO BDS (259287W89) Financial Times Interactive Data DTD: 02/01/2005 Mat: 02/01/2006 2.8% 09/16/2005 09/19/2005 Int: 08/01/2005 to 09/17/2005 99.71000 Mkt 99.71200 Mkt 99.711000 24,927.75 89.44 Total Value: Total Accrual: Total: $446,197.45 $445,890.53 $306.92 Page 1 This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. If you have questions, please contact EVP Systems at (818) 313-6300 or www.evpsyS.com. (Revision 7.0.4) Estate Valuation Date of Death: 09/17/2005 Valuation Date: 09/17/2005 Processing Date: 04/18/2006 Estate of: Estate of Mary Ambrose Account: ECC International Report Type: Date of Death Number of Securities: 1 File ID: Ambrose, Mary Estate ECC International Shares or Par Security Description High/Ask Low/Bid Mean and/or Div and Int Adjustments Accruals Security Value 1) 27 ECC INTL CORP (268255106) COM American Stock Exchange 10/14/2003 5.26000 5.24000 H/L 5.250000 .ro~ C:" p'{1 - N/A Last price available on 10/14/2003 $0.00 Total Value: Total Accrual: Total: $0.00 $0.00 Page 1 This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. If you have questions, please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.0.4) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-2005-0861 REV-1508 EX + (1-97) I nclud e the proceeds of Iitlg ation and the date the proceeds were received by the estate. All property jointiy-owned with the right of survivorship must be disclosed on Schedule F. ESTATE OF AlllbroSe, Mary E. ITEM NUMBER 1. PNC Bank CD# 31000076739 DESCRIPTION VALUE AT DATE OF DEATH 14,011.03 5,639.55 2 RBC Dain Rauscher Money Market Account 4,974.00 3 US Treasury, 1040 Re fund TOTAL (Also enter on line 5. Recaoitulation) $ (If more space is needed. insert additional sheets ofthe same size) 24,624.58 2W46AD 2.000 412 768 3458 P.01/01 I "IUV ~ r - '::::'I!JI!J::> e::.l ~ .5b PNCBANK o PNCBAN<. November 8,2005 Cayle D. Swindler 415 Fallowfie\d Road) Suite 301 Camp Hill, PA 17011-4906 RE: Estate of Mary E. Ambrose, deceased SSN: 215-44-8593 000: 9/1712005 Dear Ms. Swindler: In response to your request for Date of Death balances for the customer noted above, our records show the following; . Certificate of Deposit Established 02/26/1997 Account#3l000016739 MARY E AMBROSE OOD balance: $13,998.75 + $12.28 accrued interest Checking Account Established 11/30/2004 Account #5070096602 MARY EAMBROSE DAVID M AMBROSE LINDA A MORGAN DOD balance: $6,931.05 + $.05 accrued interest Please note that this office only provides date of death balances for deposit accounts (IRAs. CDs, Checking and Savings accounts). We do not process any finandal transactions or provide statements. If you need assistance with any ofthese items, please call 1_888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, ~~ Rache lie Wells 1-800-762-1775 P7-PFSC-04-F SOO first Ave. pittsburgh P A 15219 Member FDIC TOTAL P.01 \,'5 N I"- M'\ >..; r- 01) "T .... .c r- 0 -' CO It) E I <"" o:t ..... ..... 00 ~ M ..... N C") ::l 0\ en M c:i t:: tJl M c: S C'::l ..... U) CO .... 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REV-1'51O EX + (1-97: SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT EST ATE OF Ambrose, Ma E. FILE NUMBER 21-2005-0861. Th i s sc h ed u Ie m u s I be compl eled and filed if Ih e answer to any of Question s 1 through 4 on the reverse side of the REV.1500 COVER SHEET is yes I DESCRIPTION OF PROPERTY ITEM \ INCLUDE THE ~E OF THE TRANSFEREE. THEIR RELATIONSHIP TO NUMBER DECEDENT AND THE D~DO:O~~t~~-rACH A COpy OF THE 1. PNC Checking Account 50-7009-6602 made joint with decedent's son, David M. Ambrose and decedent's granddaughter, Linda A. Morgan 11/30/04 The taxable value of $2,31.0.34 represents the decedent's 1/3 interest in this account. The remaining 2/3 ($4,620.76) qualifies for the $3,000 exclusions for transfers within one year of death. DATE OF DEATH 1 VALUE OF ASSET ! 6,931..10 %OF DECO'S INTEREST 33.33 EXCLUSION (IF APPLICABLE) 4,620.76 TOTAL (Also enter on line 7, RecapitUlation) $ 2W46AF 2.000 (If more space is needed. insert additional sheets of same size.) TAXABLE VALUE 2,310.34 2, 310 .34 REV-1511 EX + (1-97) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ambrose, Mary E. Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1. Funeral pianist 2 Ministers at funeral 3 Cemetery sexton 4 Monument Company B. 2W46fi..G 2,000 1 . ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address State Zip City 2. Year(s) Commission Paid: Attorney Fees Name: Keefer Wood Allen & Rahal, LLP 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address State Zip City Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Keefer Wood Allen & Rahal, LLP, reimbursement for estate notice 8 Keefer Wood Allen & Rahal, LLP, reimbursement for postage charges 9 The sentinel, legal advertising 10 PNC, charge for handling wire transfer from Dain Rauscher Total from cont1nuat1on pages.... FILE NUMBER 21-2005-0861 TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of same size) AMOUNT 50.00 300.00 50.00 1,624.00 0.00 5,500.00 0.00 468.00 0.00 0.00 75.00 1.85 129 .77 12.00 $ 586.00 8,796.62 Estate of: Ambrose, Mary E. Schedule H, Part B -- Administrative Costs Item No. Description 11 H&R Block, final income tax preparation 12 Keefer Wood Allen & Rahal, LLP, reserve for out of pocket expenses TOTAL. (Carry forward to main schedule) Page 2 21-2005-0861 Amount 236.00 350.00 586.00 REV,1512 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ambrose, Mary E. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-2005-0861 Include unreimbursed medical expenses. ITEM NUMBER 1. Alert Pharmacy DESCRIPTION AMOUNT 388.62 100.00 2 PA Dept of Revenue 61.00 3 Auer Memorial Home 274.70 4 Alert Pharmacy 32.33 5 Mobile X-Ray 300.00 6 Village of Plymouth 7 C and S Restoration 336.00 8 Mechanicsburg Presbyterian Church, payment of pre-death pledge 900.00 9 Bethany Skilled Nursing 4,994.00 10 PA Department of Revenue, final PA40 1.30.00 11 Holy Spirit Hospital 500.00 2W46AH 2.000 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 8,01.6.65 REV-1513 EX+ (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ambrose, Marv E. NUMBER I. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Grandchildren's Trust c/o David M. Ambrose, Trustee 12706 Westchester Plaza Omaha, NE 68154 1. 2 Ambrose, Robert E. 182 Ambrose Road Stahlstown, PA 15687 3 Ambrose, Kenneth 603 Byron Street Mankato, MN 56001 4 Ambrose, Stephen 277 Clairmont Sterrett, AL 35147 5 Ambrose, David M. 12706 Westchester Plaza Omaha, NE 68154 FILE NUMBER 21-2005-0861 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Grandchildren Son Grandson Grandson Son AMOUNT OR SHARE OF ESTATE 163,350.26 46,671.51 81,675.1.3 81,675.1.3 46,671.51. 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. Bethany Village Care Assurance Fund c/o Bethany Village 325 Wesley Drive Mechanicsburg, PA 17055 2W46A11.000 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) 46,671.51 $ 46,671.51 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 ROGERS ELYSE E 415 FALLOWFIELD ROAD SUITE 102 CAMP HILL, PA 17011-4906 _____u_ fold ESTATE INFORMATION: SSN: 214-44-8593 FILE NUMBER: 2105-0861 DECEDENT NAME: AMBROSE MARY E DATE OF PAYMENT: 12/13/2005 POSTMARK DATE: 12/12/2005 I COUNTY: CUMBERLAND DATE OF DEATH: 09/17/2005 NO. CD 006096 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $18,000.00 I I I I I I I I TOTAL AMOUNT PAID: $18,000.00 REMARKS: CHECK# 3123 INITIALS: JA RECEIVED BY: SEAL TAXPAYER GLENDA FARNER STRASBAUGH REGISTER OF WILLS METTE, EVANS & WOODSIDE .--' ATTORNEYS AT LAW H A R R IS 8 U R G. PE N N 5 y.~ A NJA. '7108 - 0 7 2 9 ------=--' ~ast ~ill aun Q[2zhtm2nf OF MARY E. AMBROSE I, MARY E. AMBROSE, of Lower Allen Township, Curnberland County, pennsylvania, do make, publish and declare this to be my Last will and Testament, hereby revoking all wills and Codicils bv me at any time made. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such ta:;~es may be payable by my estate or by any recipient of any property, shall be paid by the Executor out of the property passing under ITEM III of this Will, as an expense and cost of administration of my estate. The Executor shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not passing under this will. ITEM II: I give and bequeath to my sons, ROBERT E. AMBROSE and DAVID M. &~BROSE, or the survivor of them, absolutely and in fee simple, all of my household furniture and furnishings, books, pictures, jewelry, silverware, automobiles, wearing apparel and all other ar'ticles of household or personal use or adornment and all policies of insurance thereon, to be divided between them as they shall agree. ITEM III I give, devise and bequeath the rest, residue and remainder of my estate, not disposed of in the preceding portions of this Will, as follows: Page 1 - r ..' r.;/:: :?:. (i) TEN (10%) PERCENT to my son, ROBERT E. AMBROSE; (ii) TEN (10%) PERCENT to my son, DAVID M. AMBROSE; (iii) TEN (10%) PERCENT to BETHANY VILLAGE CARE ASSURANCE FUND, Mechanicsburg, Pennsylvania; (iv) THIRTY-FIVE (35%) PERCENT to the then living issue of my son, ROBERT E. AMBROSE, per stirpes; and (v) THIRTY-FIVE (35%) PERCENT to the then living issue of my son, DAVID M. AMBROSE, per stirpes. Division of the residue shall be made after the payment of all applicable death taxes, including, but not limited to Pennsylvania inheritance taxes. ITEM IV: In addition to powers given by law, the Executor shall have the following discretionary powers, effective without court order: (a) To retain any property received by the Executor; (b) To sell real estate for any purposes, publicly or privately, for such prices and on such terms as the Executor deems proper, without liability on the purchasers to see to application of the purchase moneys i Page 2 ,-:;;.~ /" <<-/ ,..~- (c) To compromise controversies; (d) To distribute income or principal in cash or in kind, or partly in each, at valuations fixed by the Executor at such times as are deemed appropriate; (e) To hold investments in the name of a nominee; and (f) To undertake all other acts in the Executor's judgment deemed necessary for the proper and advantageous administration and settlement of my estate. ITEM V: Any person who shall have died at the same time as I shall have, or in a common disaster with me, or under such circumstances that the order of our deaths cannot be established by proof, or within thirty (30) days of my death, shall be deemed to have predeceased me. ITEM VI: I hereby nominate, constitute and appoint my sons, ROBERT E. AMBROSE and DAVID M. AMBROSE, to be the Execut.ors, herein collectively referred to as "Executor". The Executor is specifically relieved from the duty or obligation of filing any bond or other security. IN WITNESS WHEREOF, I have set my hand and seal to this, my Last will and Testament, consisting of this and the preceding two (2) pages, at the end of each page of which I have Page 3 ......:' ~ :<~ i..{ ":;7 (;(_ _ also set my initials for greater security and better identification this '--' day of ',.i/Vt. 19"'~". ......7-.~-,'(tL{ ,,? (,~(. ':"'(.~ ,/ :..-] .?i.~_.~.J......~.-" - .... (SEAL) MARY E. / AMBROSE ! We, the undersigned, hereby certify that the foregoing will was signed, sealed, published and declared by the above-named Testatrix as and for her Last will and Testament, in the presence of us, who, at her request and in her presence and in the presence of each other, have hereunto set our hands and seals the day and year first above written, and we certify that at the time of the execution thereof, the said Testatrix was of sound and disposing mind and memory. (.--....-c (' , l C'''''-. "., ~\-.-. ._~' ":1.~_ \ ~ \ ~~~. ~'\ (' '-... :; '''-..,' . -----..~~ "~~~i"{'/ /';:'?x~ti;L2;";;>/{'~'SEAL) '. ,'. _,~._' u.' L...... // /' . - -. _)o('-~~. .~j,,, a:;',P' ( SEAL) Residing at \~.:.=-?- ''r-~~\-,cr-\:'--<~. \. --~-,..__. , ~, ... ~."~~". ~" \-\C,.\ \-,,-~- ~--\ \ \)~ \-.~ -\ \\~ ~ ~ . .j //' ;'~~~ I>;:; l';/J::- /~~ _ ( .....L_ Res 1- dl n g at.. ,..1 f,' ,./'. .;.' ;;..; A:'"'-'-"__J',' r._-I/ r-t' ,/ /;? ~c.--~/ /' '-... '-'-,J'-' ,;' '- ._J. ~y /~>;a:..,:(;/:i.l (c:L'(ji~_ / ') Residing at /[!~.>,. /-). . L ,.,~: ,~. . /" ,'. J... /;/, \ .1..l-'7','-,/.' 1\...1-'; (<t '.~' j j --J ,.:~~ ~,"','-~~.; <;:-j f /"' (" // ../') ,./" / .' .,r/ ..~,,..,,,,,,...'7 -/ ;// / " , I ~ k ...'.-{' ( SEAL) .. ......) iL.<'.~;~. ; /CJ/( \ \ \ J ../ ,.~~ ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF / 't{ /;21,- .L, i S8: If MARY E. AMBROSE, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. -'.;5"~~':;(<tL1 (3J ~ (:t~1:..[<-/l~.,~. ~LE1-.L- MARY' E. ;AMBROSE (SEAL) Sworn to and subscribed befor.e. me this ~? c.t.:.... day fit, , /1" r- 1 99' i/ o .i1i"'i\.j -/. ,7 '1[ "/" '- ' j. /:; /) ff111 .~. ~ ..L-.....-- I '. " / ... 1 ;.- .'~ /'" .f''/ .' .,' T ;,..t.. /; .,\..-. '. ~.. . . f i I., .f / L'l"..1.' Lt./(/ \ 'r....{ i //:' ( I "'- LJ " '~.;{ ',o- " ~. / '.':,,1"- 7~' "-- Not~ry Public . My Commission Expires: ( SEAL) i /' Notarial Seal Margaret L Boyd, Notary Public . Harn~b~rg, Dauphin County L-!~Y Comm!SSlon Expires June 27, 1996 ~/it;::Yl~i. F-'ennii:j,'lvania ~ation of Notaries AFFIDAVIT COMMONWEALTH OF PENN.SYLVANIA ;/ (/- . . // / S S : I,.....l..! I Ujf"t-/l COUNTY OF (',. . , '. . /--' "- We, 'r-' ( .'--,,' . \ ,-. ~\ \ and , /-' . ( ;:, \ (- I~" '~"- ~I;" (. \) c-~~_~,,\ .\ \. ". \(''''''' -', _._~-; the Witnesses whose names are i..,,- .f" .: ...) .i~'~ i(,~/:". <4 .._' .,.,,~_.;/ .;' ... p :..' --, ~ ;7 ,,~\ 1:<-~~'';:;-;'' t' / signed to'> the att,iched or foregoing instrument, being duly qualified according to law, do depose and say that we we~e present and saw Testatrix, MARY E. AMBROSE, sign and execute the instrument as her Last Will and Testament; that Testatrix signed willingly and that she executed said will as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the will as Witnesses; and that to the best of our knowledge the Testatrix was at that time eighteen (18) or more years of age, of sound mind and under.....,no constraint or undue influence. (-';" (\ ('",-'\ (\' \_ \<-:."\ ~~ ...r . _~~ ki\. ._-~\. C....:A. .,~---\ wi tne s s \..., ,-' " "'~-~-~~..' // // (--'.(:"~-';'~7 "'--'),"'] . ... .\- "/'" . +!;~:.~,.~~tf: ~ ~/;:~? /:4:;>-~g'~,o - -",^, '-'? / l/ ./ /--/j;.i' a r ~ ~...-" ":':. ,.- . -- . Witness .'-----~~) /- /' } ~- J.~((~ Witn'ess ~~ ---""""-----_../' ,/.- ~t! j \ ~ \ J ....-/ Sworn to and.sub~qlibed ~~fO!-"1{:~,:hlS ,r ;~:,7"~ay :/-~)/~l/i ~ /-/ / ;~ .{> _.~/I ./;;;',, .' _ ./ j,"-~/ /f '.;--/ {. "L L ./ .-j''' /\.-.I/, ,- <-/ .-: r / /' I !,~..'l/ >~:;r v - ," :> \ ,---...t,., y {-." '-- \ Not'ary Public ( SEAL) I 1M Notarial Seal arg~re! l. Boyd, Nota P b/' M Harnsbun./. Dauph,'n cryo U IC v r-.. . ,~ un -' ,-,-0, nrn:ss!cn E'~i"e~ J ty "":~:-.::-:--:-~_~.,.;:, une 27, 1996 II 1G,I ;0';1. Penn~:yI-\t;ani.:;:l.Jl~,; ti -......::.3. 011 or My Commission Expires: Addendum to Last Will and Testament I, Mary E. Ambrose, as of the date noted belo-w. do amend my Will as follows: All proceeds that were directed to the children of my son, David M. Ambrose, Sr., according to the original will dated ~ f( \ J ~ er ~ are not to be distributed but placed in a trust for the educatioo and special needs of the grandchildren of David M. Ambrose~ Sr. David M. Ambrose, Sr., or his designee, will act as the trustee and his decisions are considered as absolute, final and complete. The type of trust is to be determined at the time of the execution of my Will according to what form best accommodates the proceeds as of that date. The intent is to maximize the proceeds that will accrue to the trust beneficiaries and minimization of tax impositions. 1r? ~iJ: t, ~ Mary Ambrose 1:J./3/ jotl Dated ~jA/f~ r . Witness Great Grandchildren: Meredith (David and Debbie) Kira and Elise (Linda and Patrick) Anna and Natalie (Keith and J enefer) Ashley and Blake (Corey and Gina) Sophie G amie) J~..r~ n J l.I_Ji ~ ....._:..~ _~.d I_~R) lbt~~ Children that are born subsequent to this document to the above name families. I have made my wishes known by initialing each of the lines to which I desire the proceeds of my will to be directed. All other changes~ deletions, or additions, are likewise noted. 11t ~~ M~. Ambrose ~I~/Y~ Witness 12 1~ I ~ Dated as of