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HomeMy WebLinkAbout10-30-06 REV.1S00 EX + (6.00) * l!! ll:CII) Ui2ll: WIL8 :z:li!.;J UILID IL C COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 OFFICIAL USE ONLY REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENrs NAME (LAST, FIRST, AND MIDDLE INITIAL) Shearer, Geraldine L. DATE OF DEATH (MM-DD-YEAR) I- Z W C W o w C 02-18-2006 (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) 06-22-1925 [!] 1. Original Return [!] 4. Limited Estate [!] 6. Decedent Died Testate (Attach copy of Will) D 9. Litigation Proceeds Received DATE OF BIRTH (MM-DD-YEAR) D 2. Supplemental Return D D D FILE NUMBER II OiuJ COUNTY CODE YEAR SOCIAL SECURITY NUMBER NUMBER qS6' 176-34-9197 THIS RETURN MUST BE FILED IN DUPUCATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach copy of Trust) 10 Spousal PovertY Credit (date of death between . 12-31-91 and 1-1-95) D 3. Remainder Retum (date of deeth prior to 12-13-82) D 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A} (Attach Sch 0) to- Z W Q Z ~ II) ll! D: 8 NAME Jan M. Wiley FIRM NAME (If applicable) Wiley, Lenox, Colgan, & Marzzacco, P.C. TELEPHONE NUMBER 717 -432-9666 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) D Separate Billing Requested 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) z o ~ j ~ l- ii: 00( o w 0::: 11. Total Deductions (total Lines 9 & 10) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 12. Net Value of Estate (Line 8 minus Line 11) COMPLETE MAILING ADDRESS 130 W. Church St Dillsburg, PA 17019 (1) (2) (3) (4) (5) (6) (7) None 5,757.50 None None 16,164.34 None None (9) (10) 13,918.40 1,148.55 cefFICIAIitJSE ~ ~:n C) ijr 0 C,O-o n ~!2 0 1'T1IC) --4 c/) ::1:) _~J -:t:> I :.oj C.:J :"<- m W rTlf"n ::~;:~~ 0 :D C) ;:-J 0 - (') 0 "\7n ~J 0 "::J: ::.!J (1 C r) '.'" :n -. .:. --I f 0 rn 1J. U1 u') (~ W (8) 21,921.84 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subjectto Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. (11) 15,066.95 6,854.89 0.00 6,854.89 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 (16) ~ 16.Amount of Line 14 taxable at lineal rate 6,854.89 x .045 ~ ~ a.. 17.Amount of Line 14 taxable at sibling rate 0.00 x .12 (17) :::E 0 0 18. Amount of Line 14 taxable at collateral rate 0.00 .15 (18) x x ~ 19. Tax Due (19) (12) (13) (14) 0.00 308.47 0.00 0.00 308.47 Copyright 2002 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00: Decedent's Complete Address: STREET ADDRESS 1000 Claremont Drive CITY Carlisle I STATE PA IZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 308.47 0.00 Total Credits (A + B + C) (2) 0.00 3. InterestlPenalty if applicable D. Interest E. Penalty TotallnterestlPenalty (D + E) 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 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) 308.47 (5A) (5B) 308.47 Make Check Payable to: REGISTER OF WILLS, AGENT 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 [!] b. retain the right to designate who shall use the property transferred or its income;.................................... 0 [!] c. retain a reversionary interest; or.................................................................................................................. 0 [!] d. receive the promise for life of either payments, benefits or care?.............................................................. 0 [!] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?. ................................... ................. ................................... ............. ................. 0 [!] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... 0 [!] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................ ..................... ............................ .................... ............ ............. [!] 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of pe~ury, I declere that I heve examined this return, including accompenying 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. SIGNATU OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE Dal earer 104 May Drive DiIIsburg, PA 17019 ADDRESS ADDRESS DATE 130 W. Church St DiIIsburg, PA 17019 ,I () I (). ()I/J 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 rviving spouse is 3% [72 P.S. ~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 0% [72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemDt 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. ~9116 (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. ~9116 1.2) [72 P.S. ~9116 (a) (1)). The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~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. LAW OI"PlCI!. SNELBAKER 6 BRENNEMAN LAST WILL AND TESTAMENT I, GERALDINE L. SHEARER, of the Township of Silver spring, county of Cumberland and Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at any time heretofore made. FIRST. I order and direct that all my just debts and funeral expenses be paid by my Executor, hereinafter named, as soon as conveniently may be done after my decease. SECOND. I give, devise and bequeath all the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situated, in equal shares unto my five (5) children, namely, DOROTHY M. JOHNSON, WAYNE W. MYERS, DALE E. SHEARER, ELVA P. KETTERMAN and GARY L. SHEARER, share and share alike, absolutely and in fee simple. If any of my said children shall predecease me, I order and direct that the share attributable to such deceased child shall lapse without substitution of issue and my said residuary estate shall be distributed in equal shares unto my children living at my death. LASTLY. I nominate, constitute and appoint my son, namely, DALE E. SHEARER, to be the Executor of this, my Last Will and Testament, but if for any reason he should fail to qualify as such Executor or cease so to serve, then and in that event, I nominate, constitute and appoint my son, namely, GARY L. SHEARER, to be the Executor hereof, each and both to serve without bond or other security as a condition of qualification hereunder. IN WITNESS WHEREOF, I, GERALDINE L. SHEARER, have hereunto LAWOl"'P'lCES SNELBAKE~ .. BRENNEMAN set my hand and seal to this, my Last will and Testament which consists of two (2) typewritten pages to each of which I have affixed my signature this ..2/UJL,. day of Yn~ A. D., One Thousand Nine Hundred Ninety-six (1996). ~~.vf!-- ,of? ~~ (SEAL) - Gerald~ne L. Shearer The preceding instrument, consisting of this and one (1) other typewritten page, each identified by the signature of the Testatrix, was on the date thereof signed, sealed, published and declared by GERALDINE L. SHEARER, the Testatrix therein named, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence, an 'n the presence of each other, have subscribed our names itn ,ses hereto. ~/2~ -2- COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF CUMBERLAND) 55. We, GERALDINE L. SHEARER, RICHARD C. SNELBAKER and JANET R. STEGNER, the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last will and Testament and that she had signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the will as a witness and that to the best of his or her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ~~ /~ witness. Subscribed, sworn to and acknowledged before me by GERALDINE L. SHEARER, the Testatrix, and subscribed and sworn to before me by RICHARD C. SNELBAKER and JANET R. STEGNER, witnesses, this ~~ day of rn~ , 1996. <9~~~.~ Nota y Public .....w OP'P'ICE& SNEL.BAKER a BRENNEMAN Notarial Seal Patricia J. Thomson, Notary Public ~nicsburg Bora. Cumberlllnd County My Commission expires Dec. a1. 1998 ~iao<rbar. Penn5'J!vanl3 A.<;l9OCIa!IOO 01 ~ Rev.1503 EX+ (8.98) . SCHEDULE B STOCKS & BONDS cot.'MONWEAL TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Shearer, Geraldine L. FILE NUMBER 21-- All property Jolntly-owned with right of survivorship must be disclosed on Schedule F. ITEM CUSIP VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH 1 Prudential Stock: 75.7566 5.757.50 TOTAL (Also enter on Line 2, Recapitulation) 5.757.50 (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. 6-9a) OMB No. 1545-0715 1a Date of sale or 1b CUSIP No. 2 Stocks, bonds, ete. Reported to IRS o Gross Proceeds Proceeds From exchenge /744320 Broker and Barter I ~,n.fr" OS/24/06 10 2 $ 5,757.50 ~ Gross Proceeds less commissions Exch."ge Fonn 1099-8 and opt'- P""l-'UIIIf Transactions .. Federal Income lax withheld Account number (see InstruclIons) 7 Description SALE OF STOCK Copy B 0.00 k230030789-4843 PRUDENTIAL COMMON For Recipient This is important tax RECIPIENT'S name, address, city, slate and ZIP code PAYER'S name, address, city, slate, ZIP coda and telephone no. information and is being furnished to the, Internal DALE E SHEARER , COl1rUTERSHARE Revenue Service. If you . - are required to file a 104 MAY DRIVE PRUDENTIAL FINANCIAL, INC. return, a negligence DILLSBVRG PA 17019-9413 P.O. BOX 43033 penalty or other sanction may be imposed on you PROVIDENCE, RI. 02940-3033 if this income is taxable 1-800-305-9404 and the IRS determines thai il has not been reported. " RECIPIENrs identification number PAYER'S Federal identification nUmber Fonn 1099.8 162-36-8209 43-1912740 , DEPARTMENT OF THE TREASURY - INTERNAL REVENUE SERVICE INSTRUCTIONS FOR RECIPIENT ON REVERSE SIDE DETACH BEFORE CASHING CHECK Rev-160B EX+ (8-98) *' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Shearer, Geraldine L. FILE NUMBER 21-- ESTATE OF Include the proceeds of litigation and the dale the proceeds were received by the estate. All property JoIntly-owned wlth the right of survlvorahlp must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Citizens Bank Checking 6100698831: 7,388.96 2 Citizens Bank Savings 6100707490: 2,617.31 3 County Of Cumberland (refund - nursing home): 4,545.00 4 Cumberland Goodwill Fire Rescue (refund): 61.07 5 US Treasury (tax refund): 350.00 TOTAL (Also enter on Line 5, Recapitulation) 14,962.34 (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 E (Rev. 6-98) a Citizens Bank- 525 William Penn Place Suite 153-2618 Pittsburgh, P A 15219 March 30, 2006 S. DAWN GLADFELTER 130 W. CHURCH STREET SUITE 100 DILSBURGPA 17019 Estate of GERALDINE SHEARER Date of Death: Feb 18, 2006 SSN: 176-34-9197 Dear Sir/Madam: In accordance with your request, the attached information sheet has been provided in the above decedent's name as of hislher date of death. ForIL or LC accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 1-888-999-6884 Sincerely, ~~ Robert Roos Operations Services a Citizens Bank'u Account Number 6100698831 Account Title GERALDfNESHEARER Date Opened 4/21/1986 Account Type Checking Principal Balance as ofDOD $7388.96 Interest from Last Posting to DOD $.00 Account Balance as ofDOD $7388.96 YTD Interest to 000 . $8.75 a Citizens Bank. Account Number 6100707490 Account Title GERALDfNESHEARER Date Opened 6/20/1991 Account Type Checking Principal Balance as of DOD $2617.31 Interest from Last Posting to DOD $.00 Account Balance as of DOD $2617.31 YTD Interest to DOD $.80 REORDER 805. u.s. PATENT NO. 5538290. 5575501, 5641183, 5785353. 5984314, 603( 18053 ESTATE OF GERALDINE SHEARER CHECK NUMBER 633398 DATE 04/28/06 INVOICE NUMBER DATE DESCRIPTION GROSS AMT. DISCOUNT NET AMOUNT 4417 GERALDINE SHEARER 03/10/06 PPRD REFUND TO 4545.00 0.00 4545.00 \ Rev-1510 EX+ (6-98) . SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEAl. TH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Shearer, Geraldine L. FILE NUMBER 21- ESTATE OF This schedule must be completed and filed W \he answer to any of questions 1 through 4 on the reverse side of \he REV-1500 COVER SHEET is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % 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 Prudential Financial Annuity: 1.202.00 1.202.00 TOTAL (Also enter on Line 7, Recapitulation) 1.202.00 (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 G (Rev. 6-98) Prudential ~ Financial Scott A. Moyer. LUTCF Premier Agent The PrudentiBllnsurance Company of America 150 Corporate Center Drive. Suite 105 Camp Hill, PA 17011 Tel 717 975-8150. Ext 7134. Fax 717 763-8974 To Jan, .; In Referen:ce to Geraldine Shearer Geraldine had two Life polices valued at roughly 30,000, with 5 children named as primary beneficiaries. She also had a Deferred Annuity valued at roughly 1202.00, with 5 children named as beneficiaries. The company will need each beneficiary to fill out a death claim for the Life Insurance policies and each beneficiary to fill out a death claim for the Annuity. The Beneficiaries are as follows, all in equal shares: Dorothy Johnson Wayne Myers Dale Shearer Elva Ketterman Gary Shearer I have enclosed a death claim form which can be reproduced, to have all beneficiaries fill out and return to Prudential. As far as any stock in Prudential, that is handled by calling Prudential at 1800-305-9404 and getting a death claim package from them. Thankyou, . ~/,; d Scott Moyer Y ~ '7 Financial Planning - Investment Advisory Services Variable Life Insurance - Variable Annuities - Mutual Funds Investment advisory services offered through Prudential Financial Planning Services. Securities products offered through Pruco Securities Corporation. Prudential Financial Planning Services is a division of Pruco Securities Corporation, which is a Prudential Financial company, 751 Broad Street, Newark. NJ 07102-3777 REV.1151 EX+ (12.99) *' SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Shearer, Geraldine L. Debts of decedent must be reported on Schedule I. FILE NUMBER 21-- ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached 11,337.40 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 Wiley, Lenox, Colgan, & Marzzacco, P.C. 2,500.00 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 40.00 7. Other Administrative Costs 41.00 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 13,918.40 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1S02 EX+ (6-88) *' SCHEDULE H-A FUNERAL EXPENSES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETIJRN RESIDENT DECEDENT ESTATE OF Shearer, Geraldine L. FILE NUMBER 21-- ITEM NUMBER DESCRIPTION AMOUNT 1 Myers Funeral Home: 11.337.40 Subtotal 11.337.40 Copyright (c) 2002 form software only The Lackner Group. Inc. Form PA-1500 Schedule H-A (Rev. 6-98) ~ Myers Funeral Home, Inc. Boyd L. Myers Jr., Supervisor 37 East Main Street Mechanicsburg, Pennsylvania 17055 (717) 766-3421 Fax (717)795-7291 A standard of excellence in Central Pennsylvania since 1910 Tuesday, February 21, 2006 Mr. Dale E. Shearer 104 May Drive Dillsburg, Pa. 17019 Dear Mr Shearer, Thank you for selecting our funeral home to provide services for your family during your bereavement. I hope that you found our services to be of the highest standards and that they met your needs and those of your family and friends. The following is a summary of the service charges as previously explained and provided in written form on the services for: Geraldine Shearer SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED LESS: Credits granted LESS: Total Payments CURRENT BALANCE Credits Granted: $1,595.0 Package Price Discount $12,932.40 1,595.00 2,000.00 $9,337.40 Interest at the rate of 1.5 % per month ( 18 % per annum) will be added to balance after 30 days. If there are any questions or concerns that remain unanswered, please call me. Sincerely, .l<'? " -/ /L / /~~/ r--v~, Rev-1li02 EX+ (8-88) . SCHEDULE H.87 OTHER ADMINISTRATIVE COSTS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RE11JRN RESIDENT DECEDENT ESTATE OF Shearer, Geraldine L. FILE NUMBER 21-- ITEM NUMBER DESCRIPTION AMOUNT 1 Computershare Shareholder Services, Inc. (fee for selling stock): 11.00 2 Register of Wills, Filing Fee - Inheritance Tax Return: 15.00 3 Register of Wills/Orphans Court, Filing Fee - Petition for Settlement of Small Estate: 15.00 Subtotal 41.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B7 (Rev. 6-98) Rey.1512 EX+ (5.88) . SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COM'.IONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Shearer, Geraldine L. FILE NUMBER 21-- Include unrelmburaed medical expena... ITEM NUMBER DESCRIPTION 1 Carlisle Regional Medical Center: VALUE AT DATE OF DEATH 692.86 2 Cumberland Goodwill Fire Rescue: 61.07 3 Lancaster HMA Physicians: 5.52 4 West Shore EMS: 389.10 TOTAL (Also enter on Line 10, Recapitulation) 1,148.55 (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.11113 EX+ (9-00) *' SCHEDULE .. COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Shearer, Geraldine L. 21-- NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) Do Not US! Trustee(s) I. TAXABLE DISTRIBUTIONS [include outright sr,ousal aistributionSg and ransfers under Sec. 116(a)(1.2)] Dorothy M. Johnson Daughter One-Fifth 1005 George Ave. Rockledge, FL 32955 Elva P. Ketterman Daughter One-Fifth 11209 Butternut Lane NE Cumberland, MD 21502 Wayne W. Myers Son One-Fifth 31 Clover Lane Mechanicsburg, PA 17050 Dale E. Shearer Son One-Fifth 104 May Drive Dillsburg, PA 17019 Gary L. Shearer Son One-Fifth 440 Sample Bridge Road Enola, PA 17025 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)