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Home My WebLink About10-20-06 REV-1SOO EX + (6-GO) OFFICIAL USE ONLY REV.1500 INHERITANCE TAX RETURN RESIDENT DECEDENT COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 *' FILE NUMBER II 06 00698 COUNTY CODE Y R SOCIAL SECURITY NUMBER 170-52-2041 NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Myers, Toni A. DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) .- z w Q w (,) w Q THIS RETURN MUST BE FILED IN DUPUCATE WITH THE 07 -15-2006 10-24-1963 REGISTER OF WILLS SOCIAL SECURI1Y NUMBER (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) o 2. Supplemental Return o o o ~ 1. Original Return 04. Limited Estate D 8. Decedent Died Testate (Attach copy of WIll) o 9. Litigation Proceeds Received o 3. Remainder Return (elate of death prior to 12-13-82) o 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes o 11.Election to tax under Sec. 9113(A) (Attach Sell 0) l!! ~ol(lI) ~i:8 :z:i... UA,lD ~ 4a. Future Interest Compromise (date of death alter 12-12-82) 7. Decedent Maintained a Living Trust (Attach copy of Trust) 10 SpOusal PovertY Credit (elate of death between . 12-31-91 and 1-1-05) ... z W Q 2 m II: II: 8 NAME David J. Lenox FIRM NAME (If applicable) The Wiley Group, PC TELEPHONE NUMBER 717 -432-9666 COMPLETE MAILING ADDRESS 130 W. Church Street Dillsburg, PA 17019 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (1) None OFFICIAL USE ONL Y (2) 354.80 (3) None "" 0 c;;:::, ?--= 0 G;) fO (;,,'T"\ (4) None '::.u 0 n C") "") ("') 0 (5) 4,746.55 '0 --'\ .:0 . 17) I'v C::J (6) " :0 (::> f---;-j 16.01 J ,:..>< 0 CJ -0 0 (7) -0- -T1 -'.,l~ -rl _.;... 2J C) (~5,1!1l~ (9) 2,620.00 ...... "';f - (10) 13,631.27 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) z 6. Jointly Owned Property (Schedule F) ~ 0 Separate Billing Requested j 7. Inter-VIVos Transfers & Miscellaneous Non-Probate Property E (Schedule G or L) D Separate Billing Requested ~ 8. Total Gross Assets (total Lines 1-7) fd 9. Funeral Expenses & Administrative Costs (Schedule H) a: 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) (11) (12) (13) (14) 16,251.27 12. Net Value of Estate (Line 8 minus Line 11) insolvent 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 0.00 0.00 15. Amount of line 14 taxable at the spousal tax rate, 0.00 x .00 (15) z or transfers under Sec. 9116(a)(1.2) 0 .045 (16) t= 16. Amount of Line 14 taxable at lineal rate 0.00 x :! ~ a. 17. Amount of Line 14 taxable at sibling rate 0.00 x .12 (17) :Ii 8 18. Amount of Line 14 taxable at collateral rate 0.00 x .15 (18) >< :! 19. Tax Due (19) 0.00 0.00 0.00 0.00 0.00 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 20.0 Copyright 2002 fonn software only The Lackner Group, Inc. Fonn REV-1500 EX (Rev. 6-00: G \ Rev.1603 EX+ (6-98) * SCHEDULE B STOCKS & BONDS COMMONWEAlTH OF fIENlISYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Myers, Toni A. FILE NUMBER 21-06-00698 ESTATE OF All property JoIntly-owned with right of .urvlvo.....'p must be disclosed on Schedule F. ITEM CUSIP VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH 1 Series EE Savings Bond: 354.80 TOTAL (Also enter on Line 2, Recapitulation) 354.80 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group. Inc. Form PA-1500 Schedule B (Rev. 6-98) Calculate the Value of Your Paper Savings Bond(s) Page 1 of2 T reasuryDirect . M.Y...A!;~Q.IJ..o..t~ . Ir~~.~.lJ.ry.S~.!,IrJti~~ &..Pr.Q.9ra.ms . Rese~L~tL{:;ent~ . P.!.~!JlJjD.9..~...~IYi!J.9. · IQQJ~ . fQI.m~ HQm~ > Im:!.i'l!.dJ.lill > Io.Q.~ > Calculate the Value of Your Paper Savings Bond(s) TOOLS . SaYi.ll.9s..6QngmC.aJ~y.talQr . s.a'yings...e.Qn~LW.izaId .s..aYj.ll.g.s....6.Qnd....yaJy~...f.iJ~.s . SaYings...6Qnd.ER6..bQf;alQI . Irea.sY.ry...6.i.I..!.S......N.QleS.......6.Qnd.s.......&...TlPS....FR6...bQCal9.r . Ir.easyryH!J..nt . (:sti.m.ati.QIl..CaJf;JJlatQ[s . Savings BO!1JLEarnin..Q.s..ReooJ:.ts · .B.e.d.emp.t.1QJ1.Ia.ble_$. Calculate the Value of Your Paper Savings Bond(s) SAVINGS BOND CALCULATOR Value as of: 0712006 l~fe!'I~J <4) Help Series: Denomination: Bond Serial Number: Issue Date: ...-........-...-...........-......-... EE Bonds II! 500 lit - I HOW TO SAVE YOUR INVENTORY I Calculator Results for Redemption Date 07/2006 Total Price: $250.00 Total Value: $354.80 Total Interest: $104.80 YTD Interest: $7.40 Bonds: 1-1 of 1 Serial # Series Denom d49587088ee EE $500 Issue Date Next Accrual Final Maturity 12/1997 08/2006 12/2027 Issue Price Interest Interest Rate $250.00 $104.80 4.11% Value $354.80 Note I REMOVJ:;J http://www.treasurydirect.gov/BC/SBCPrice 10/5/2006 Rev.1108 EX+ (8-H) '* SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY Cot.NONWEAL TH OF PENNSYlVANIA INHERITANCE TAX RETURN RESI)ENT DECEDENT Myers, Toni A. FILE NUMBER 21-06-00698 ESTATE OF Include the proceeds of litigation and the date the proceeds were received by the estate. All property JoIntly-ownee! with the light of survivorship must be dlacloaed on lIChedule F. ITEM NUMBER DESCRIPTION 1 Members 1st Federal Credit Union Checking Account 246373-11: VALUE AT DATE OF DEATH 812.85 2 Members 1st Federal Credit Union Savings Account 246373-00: 668.60 3 Sale of 1991 Volkswagon: 1.250.00 4 Sale of 1998 Chevrolet Sedan: 500.00 5 Sale of 1998 Ford SW: 280.00 6 Security Deposit Refund: 1.235.10 TOTAL (Also enter on Line 5, Recapitulation) 4.746.55 (If more space is needed, additional pages of the same size) Copyright (c) 2002 fonn software only The Lackner Group, Inc. Fonn PA-1500 Schedule E (Rev. 6-98) REGULAR SAVINGS ACCOUNT: Account NumberlSuffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account NumberlSuffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner PERSONAL SERVICE LOAN: Account NumberlSuffix . Date Account Established Principal Balance at Date of Death Interest Rate Collateral Co-Borrower VISA CREDIT CARD ACCOUNT: Account Number Date Account Established Balance at Date of Death Collateral Name of Joint Cardholder Estate of: TONI A MYERS Date of Death: 07/1512006 Social Security Number: 170-52-2041 MEMBERS 1st FEDERALCllEDIT UNION 111604 -00 11/07/1989 $32.01 $.00 $32.01 Jeffrey Myers 11/17/1990 246373 -00 06/17/2004 $668.30 $.30 $668.60 None 246373 -11 06/17/2004 $812.85 $.00 $812.85 None 246373 -01 10/13/2004 $3,439.62 12.75% Signature! Contractual Pledge of Shares None 4121449994116049 08/27/1993 $5,573.91 Contractual Pledge of Shares None ~E_RS~ST F DE?DIT UNION l1LJ~lP '''~ Denise A. olfe Insurance Services S ervisor September 15, 2006 5000 Louise Drive · P.O. Box 40 · Mechanicsburg, Pennsylvania 17055 · (717) 697-1161 · wwvv.memberslst.org Rev-1S09 EX+ (S-8I) * SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX REl\JRN RESIDENT DECEDENT Myers, Toni A. FILE NUMBER 21-06-00698 ESTATE OF If .n ..... w.. made joint within one ye.r of the decedsnt'. date of delth, It must be reported on echedule G. SURVIVING JOINT TENANT(S) NAME A. Jeffrey Myers ADDRESS RELATIONSHIP TO DECEDENT Ex-Husband 1920 Maplewood Drive Carlisle, PA 17013 B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT ~ATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR ALUE OF ASSET INTEREST DECEDENrSINTEREST JOINTLY-HELD REAL ESTATE. 1 A 11n/1989 Members 1st Federal Credit Union 32.01 50.000% 16.01 Savings Account Number 111604-00: TOTAL (Also enter on Line 6, Recapitulation) 16.01 (If more space is needed. additional pages of the same size) Copyright (c) 2002 fonn software only The Lackner Group, Inc. Fonn PA-1500 Schedule F (Rev. 6-98) - ..--- ..._/..---l11 ........1. IJ..._._IIIL .- FROM : HI CHAEL DE 1 a..ER FAX NO. :717-795-8944 Aug_ 23 2006 11: 57AM P3 - --'--' ---..... \> '~~Q -; $ ~$ \ ,tJ ~\~ JJ ~ ~ -II Y> .D j) ::> ~.~... ~-~'~,.: .. - . - SJ \J \).~ .....fR. ".1 :.V) _, . I - i I r\) to a w to (j') a a =-+_iP-i- ..... f ~"''''''I ...41.0- lJ:lr.tII_11 - FAX NO. :717-795-8944 t=lug. 23 2006 11: 5~ Pi .-- ._-' FROM : MICHAEL DE 1 BLER y ::f ~Q ~1' .. . C!RY1~,.C~:T~~t!;!t~'~L:~:F~:~':~ V_E~~C~,~::,' rn;:::o~q~~~1~i~~:":::~~~~~~}I~:ilr~,:i~'!~Cf~~~t~~~~,c,' '. ~f4IAS1""Il&C''''4Q.~... "'''j '.' 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" f", III.. ,,:J .t":....t....~: -:,.. L . &OIlIOtG\fIiMCLa: . ./f"-. ':'-i",~,: '~.:9 . ~.~,:....~:. '. . . ". '':y.';'' '";i' .' :: =~.r...:; ",,~:"i . ":. ~.{ ~ 'l.-':":)::~.. ,,.~...RYW ,r - 'ii'I;.i~ -,. .: '>:::,::i ..~ ::='=.'l/8M;' :ti: :.:J{ ..,- ".~IICl!.tU:"''';: :.,;. F~..Ll('''A\'OH()lI: . . "\;:i:>'K~:i.leN~~YOAqt:: 1.....~~TIXI :~..':~: t.' ~"" . . ;, ;;i ;.' . ;.i ,~ti :(H;~ ~.~~. ;~~ .~..,,;,.wl ."'.......... .. _ """ ~ -J~~ ;. i,.. i! i... :...... ""~~'.i' ~1 ...... ~_....-...T..."...........:.... ,~...... 'J; .. ~.:l-,"..)::.:.7,..;u.....' . flILIA.'W). '. '. '.' . . '.' :.':' . ..,........ '.' '. ~ : ". '-' ..., ':.' .:\l::..,..it.\.1.. ,,_.,,~ . DATI' ...~. ,":'" .. '. ..:. ;. ~. "~: ':.."~' ~.:~~:;::: $t:CONO LIfH IIIILEA;;EO I)' DtoTl! . IWTHOIIIZED 1'III'IlIIENTA nVE ',' .., ,-, wnaII11D ~'~.HT~TIVi II\' TONI" A;;'"Y-S6 -. 2~2'S:' ENOi,:-i,~~D CARllst~ '~~'170}] .' ,:' J I. .'! ;."'t.:;, .N{f~ ':;;:i}t "'l. . .... . :'. r :~. . '. ~;~*.: .;;.~~\~.' .:.,':' . . . '- ;:: ..~"~.~.... .:~~t:~r . '-;'1 ~.t~ ":(', ... " ,,:,. (!)~~L;' ......., vi T........... : ~. . . ", .,' . ':I~~ I '. ... II.................~. oJ'" ~ ~.-iI.' ~J!!1;i.t ".. ~cN~niiiiocI ...-; it"'" ....olI"iIWMr' '4:__ 'ItlICle. . -~.. o -J W to ex> ~ N ('J1 Rev-1111D EX+ (1-18) '* SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALl1i OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Myers, Toni A. FILE NUMBER 21-06-00698 This schecXJIe must be completed and filed If the answer to any of questions 1 through 4 on the raverse side of the REV-1500 COVER SHEET is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH 'l(, OF DECO'S TAXABLE EXCLUSION NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. 1 Holy Spirit Hosp 401 (k) - decedent under age of 4.919.41 4.919.41 0.00 59 1/2: 2 Pacific Life 401K- decedent under age of 591/2: 50.329.77 50.329.77 0.00 3 PHICO Pension Plan - decedent under age of 59 18.224.00 18.244.00 0.00 1/2: TOTAL (Also enter on Line 7, Recapitulation) 0.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 fonn software only The Lackner Group. Inc. Form PA-1500 Schedule G (Rev. 6-98) 09/25/2006 13:23 7179724861 . Account Infonnation HSHS HR BENEFITS PAGE 01/01 Page 1 of" 1 Bruening, Susan from: Bruening. Susan Sent: Friday. September 22, 2006 11:22 To: 'dlenox@Wlley4u.com' Subject: FW: Account Information $11.."'" E. Bruening Compensation & Benefits Manager Holy Spirit Health System 503 N. 21 st Street Camp Hill, PA 17011 (717) 972-7845 ~b!ueninQ~hsh.o~g From: DJgiantommaso, Jennifer [mallto:.lennifer .Di9Iantommaso~FMR.COM] Sent: Thursday, September 21,'2006 14:06 . To: Bruening, Susan SUbject: Account Information Hi Susan. To follow up on my voicemail, the value of Ms. Myers' account on 7/15/2006 was $4.919.41. If you need any additional information. please do not hesitate to contact me. Thank you, Jennifer Jennifer DiGiantommaso Client Services Manager Rdelity Investments Tax-Exempt Services Company A division of fidelity Investments Institutional Services COmpany, Inc. Phone: (508)787-6351 Fax: (877}800-5712 jennifer.dlgiantomm8so0fmr.com The information in this email and subsequent attachments may conlBin confidential informaticn th6t is intended solely for the attention and use of the ndmed addressee(s). This message or any part thereof must not be disclosed, copied, distributed or retained by any person without sut/JorIz8tion from the addressee. 9/22/2006 v- iliff 09/01/2006 FRI 16:01 FAX 7179207645 key advisors group Pacific Life 9/1/2006 12:32 PM PAGE 8/010 Fax Server 1G009/011 CLAIMAN1' STArrEMENl' Individual as DcsigJ18tcd Recipient IRA: Pre RBD ~PACIFICLIFE . SPECW. ftSTRUCTIONS: Use this space tlt change cutrenl iIwes1ment aIocaIions (0pIiDns 2aM 4) 01 indiCate any apecial handing Instruc:tionI or requests. If you al8 requesting that the death cIain check be 18ftt via overnight or expt8SS mail, .... 6~ your blllng number here.. .. _ ____._ ___ . LOST CONTRACT AFRDAYrr AND AGREEMENT. URIeaa the Contrad ia at1ached.1 affirm INIt a ~ eIfort has been made to locate the original Cotdracl and that it has been lost (JI desI~ed. To the Mst of MY 1wMIedg6 no OM else has 8It1 right, titJe. Of int9re&t in my proportionate share of this of9naI Conlrad. nor has it been assigned. pJedged. 01 encanbered.. . BENEFICIARY INFORMATION (lor ClaIm OptIons 1 and 2 only - Annuity WItI Period Certain, and InhIrIted IRA on BIIID!a eontnct). ~ thlB eectioft wlh 1M infolmation requested bekM 10r 18Gb peIIOn you wi&b 10 dIIignate as beneficiaJy. If a benemiary cIassificaIion is not indicated. the prirMIy c:lassifation for that belMlflCialy wi! be prinlry. UnIIIa odI8IWiIe indlealed. if two or more beneficiaries art duignated IS pIfmaIy or contingent beneficiuies. each beReficlary so ~cI WIt Mn equatr in any death benMd amoutU tilldIor rights granted by the Contrad or allowed by us. The total of aJI benefI: perc:er4agea mU6t equal 1 00% 10r .1 beneficiaries d88ignatec:l as primary beneficiariel and 100% for all beneficiarieS deSignat8cI as COfttIllgent benetildes. If additional beneftclalte& are to be designated. attaCh a separate sheet, signed ~ dated by the OlNMr and include the same Informatbn requested above far each SIICb beneficiary. ..NaM and Add.... Date of S$NI1'IN Relationship BenefICiary . &.netlt % Birth To Owner C_lflcaUon 1m Vi MS ,.. ~ t,eI-.s c.. ~.ftb ~.~r,'~ filt- Ie.,. Qt Primary /~ :)/;6 N/!I'V 4"/( Pd Q Contingent ~",.I's/~ . Pq 17Q/~ j i I ! C Primary j C eontmgent o Primary o Contingent Cl PrimaIY I o Contingent Jf'SD.3/A"L17 cs J6 -Individual, IRA, Pre RBO (6J03) PIge 6 of 8 PHICO Insurance Company (In Liquidation) One PH/CO Drive (17050-2797) P. O. Box 85 Mechanicsburg, P.A. 17055-0085. Tel 800.382.1378 717.766.1122 PH I"CO (In Liquidation) August 30, 2006 Mr. David Lenox, Esquire The Wiley Group 130 W. Church 8t Suite 100 Dillsburg, P A 17019 RE: Estate of Toni A. Myers Dear Mr. Lenox: As per Y(}Uf request, the following information is being provided for the estate of Toni A. Myers. Ms. Myers has a benefit due to her estate from the HAP Pension Plan. The HAP Pension Plan Date of Death Value - $18,224.00 Defined Benefit Plan Date of Hire - 2-10-1986 Date of Term - 6-30-2002 Please contact me if you require additional information. Judith A. Seitz Manager, Human Resources 717-766-1122 ext. 220 REV-1151 EX+ (1Z....) *' SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Myers, Toni A. Debts of decedent must be reported on Schedule I. FILE NUMBER 21-06-00698 ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) I EIN Number of Personal Representative(s): Street Address City State Zip - Year(s) Commission paid 2. Attorney's Fees The Wiley Group, PC 2,085.19 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 90.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 444.81 See continuation schedule(s) attached TOTAL (Also enter on line 9. Recapitulation) 2,620.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1102 EX+ (8-N) '* SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued COIioNONWEAL TH OF PENNSYLVANIA INHERITANCE TAX REl\JRN RESIDENT DECEDENT ESTATE OF Myers, Toni A. FILE NUMBER 21-06-00698 ITEM NUMBER DESCRIPTION AMOUNT 1 Cumberland Law Journal (advertise estate): 75.00 2 Jeanette's Cleaning Service: 120.00 3 Register of Wills (filing fee): 30.00 4 The Sentinel (advertise estate): 158.81 5 Vital Records (additional short certificates): 61.00 I Subtotal 444.81 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B7 (Rev. 6-98) Rev-11112 EX+ (8-88) *' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF I'EN'lSYLVANIA NERlTANCE TAX RETURN RESIDENT DECEDENT Myers, Toni A. FILE NUMBER 21-06-00698 ESTATE OF Include unnlmbursed medIcal .xpen.... ITEM NUMBER DESCRIPTION 1 Car Insurance: VALUE AT DATE OF DEATH 352.00 2 Comcast (cable tv): 177.56 3 Embarq (telephone bill): 74.59 4 ERI/BonTon (credit card): 1.014.38 5 Kohl's Department Store: 150.49 6 Members 1st Federal Credit Union (payoff credit card): 5.648.38 7 Members 1st Federal Credit Union (payoff loan): 3.439.62 8 Nextel (cell phone): 288.07 9 Old Navy Deparatment Store: 70.91 10 PP&L: 467.19 11 Rent, September, 2006: 800.00 12 Rent, Water and Sewer, August, 2006: 1.001.88 13 Vehicle Maintenance: 146.20 TOTAL (Also enter on Line 10, Recapitulation) 13,631.27 (If more space is needed. additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule I (Rev. 6-98) REV-1513 EX+ (8-00) '* SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NUMBER Myers, Toni A. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal aistributions,l and transfers under Sec. ~116(a)(1.2)] Jeffrey Myers 1920 Maplewood Drive Carlisle, PA 17013 Jeffrey Myers 1920 Maplewood Drive Carlisle, PA 17013 Shea P. Myers 1920 Maplewood Drive Carlisle, PA 17013 RELATIONSHIP TO DECEDENT Do Not Uat TruateeC.' FILE NUMBER 21..Q6..Q0698 SHARE OF ESTATE AMOUNT OF ESTATE (Words) ($$$) I. Parent of Minor Beny Jordyn L. Myers Parent of Minor one-third Beny, Ryan E. Myers one-third Son one-third Total Enter dollar amounts for distributions shown above on lines 5 through 18, as appropnate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98)