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1lIlY.1AIEll+.... * REV-1500 OFFICIAL USE ONLY 1
Cot./MONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN FILE NUMBER
DEPARTMENT OF REVENUE RESIDENT DECEDENT 21 2006 00739
OEPT.2l10801
HARRISBURG, PA 17128-0601 COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
GROSZ, VANCE B 184-26-2663
...
z DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPUCATE WmnHE
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w 08/15/2006 02/13/1928 REGISTER OF WILLS
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Q (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
181 1. Original Return 0 2. Supplemental Return 0 3. Remainder Retum (date of death prior to 12-13-82)
~ 0 4. Limited Estate 0 4a. Future Interest Compromise (date of death after 0 5. Federal Estate Tax Return Required
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uii!ll: 12-12-82)
WIL8 181 6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a Living Trust (Attach 1 8. Total Number of Safe Deposit Boxes
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ulLal of WiN) copy of Trust) -
~ 0 9. litigation Proceeds Received 0 10. Spousal Poverty Credit (date of death between o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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Ivo V. Otto III, Esquire
IRM NAME (If applicable)
Martson Deardorff Williams & Otto
LEPHONE NUMBER
717/243-3341
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
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COMPLETE MAILING ADDRESS
Ten East High Street
Carlisle, P A 17013
(1 ) None
(2) 46,302.45
(3) None
(4) None
(5) 10,655.34
(6) None
(7) None
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(8)
56,957.79
(9)
(10)
4,789.87
7,530.32
(11)
12,320.19
44,637.60
(12)
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)
(13)
(14)
44,637.60
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
~ 16. Amount of Line 14 taxable at lineal rate x .045 (16)
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IL 17. Amount of Line 14 taxable at sibling rate 33,478.20 x .12 (17) 4,017.38
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8
g 18. Amount of Line 14 taxable at collateral rate 11,159.40 x .15 (18) 1,673.91
19. Tax Due (19) 5,691.29
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
J
Decedent's Complete Address:
STREET ADDRESS
1000 West South Street
CITY
Carlisle
I STATE PA
I ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
5,691.29
284.56
Total Credits (A + 8 + C)
(2)
284.56
3. InteresVPenalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + 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.
8. Enter the total of Line 5 + 5A. This is the 8ALANCE DUE.
(3) 0.00
(4)
(5) 5,406.73
(5A)
(58) 5,406.73
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;.................................................................................. ~ I
:: ~::::~ ~h~e~~~~i~~:~s:~~~~s~~~. .~.~.~.I~. ~~~. ~~~.:.~~.~.~.~.~~~~~~~~~~~. ~.~.i.~~. .i~~~~~:::::::::::::::::::::::::::::::::::::
d. receive the promise for life of either payments, benefits or care?..............................................................
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 peljury, I declare that I hava examined this retum, Including eccompanying schedules and stetements, 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.
ADDRESS
905 West Louther Street
Carlisle, P A 17013
DATE
IIII!;/ ()e,
905 West Louther Street
Carlisle, P A 17013
ADDRESS
ADDRESS
Ten East HigQ Street
Carlisle, P A 17013
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. ~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. 99116 (a) (1.1) (ii)). The statute does not exemot 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% [72 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.
*
SCHEDULE B
STOCKS & BONDS
COMMONINEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF GROSZ, VANCE B
I FILE NUMBER
21 - 2006 - 00739
All property jolnUy-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF
NUMBER DEATH
1 118.573 sh Delaware Balanced Fund A Class (246093108) 17.37 2,059.61
2 150.482 sh DWS Growth & Income Fund-S (811167105) 22.23 3,345.21
3 20197.36 sh Blackrock Liquidity Fds (09248U619) 1.00 20,197.36
4 387.466 MTB Group Fds EQ Index I I (55376T882) 10.71 4,149.76
5 1810.778 MTB Group Fds US Gv Bd I I (55376V705) 9.14 16,550.51
TOTAL (Also enter on line 2, Recapitulation) 46,302.45
*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF GROSZ, VANCE B
I FILE NUMBER
21 - 2006 - 00739
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
1 Cash in safe deposit box
DESCRIPTION
VALUE AT DATE OF
DEATH
10.00
2
United Church of Christ Homes, credit balance
3,808.34
3
Highmark Healthcare Insurance, premium refund
42.75
4
Highmark Prescription Drug Plan, premium refund
14.16
5
Genworth Financial, Long Term Care Insurance, coverage 8/9-14/06
714.00
6
M&T Checking #711187
6,066.09
TOTAL (Also enter on LIne 5, Recapitulation)
10,655.34
*
SCH3JlI.E H
R..N:RAI... EXPENSES &
AIlVINS1RAl1VE COSTS
CotJNONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GROSZ, VANCE B
I FILE NUMBER
21 - 2006 - 00739
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
1 Hoffinan-Roth Funeral Home, balance 699.77
2 Carlisle Memorial Service, monument lettering 195.00
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 Martson Deardorff Williams & Otto (estimate) 3,550.00
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 Register of Wills 102.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Stock valuation report 3.10
2 Filing fee, inheritance tax return 15.00
Total of Continuation Schedule(s) 225.00
TOTAL (Also enter on line 9, Recapitulation) 4,789.87
*
Schedule H
Funeral Expenses &
Mnini&bdlNe Cos1s continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GROSZ, VANCE B
I FILE NUMBER
21 - 2006 - 00739
3
Additional probate fee
75.00
4
Reserved for miscellaneous filing fees and expenses
150.00
Page 2 of Schedule H
*
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF GROSZ, VANCE B
I FILE NUMBER
21 - 2006 - 00739
Include unrelmbursed medical expenses.
ITEM
NUMBER
1 PharMerica, balance on account
DESCRIPTION
AMOUNT
31.47
2
Belvedere Medical Corporation, balance after insurance
25.36
3
PharMerica, outstanding check on date of death
77.35
4
United Church of Christ, outstanding check on date of death
7,396.14
TOTAL (Also enter on Line 10, Recapitulation)
7,530.32
REV-11113 EX+ (9.00)
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GROSZ, VANCE B
I FILE NUMBER
21 - 2006 - 00739
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE
n", N'"
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1 C. Freeman Grosz Brother 1/4 estate residue
959 Redwood Drive, Mechanicsburg, P A 17055
2 Mark L. K. Grosz Brother 1/4 estate residue
502 Gale Street, Mechanicsburg, PA 17055
3 Jane G. Keller Sister 1/4 estate residue
905 West Louther Street, Carlisle, P A 17013
4 John D. Grosz Nephew 1/4 estate residue
1373 Willow Mill Road, Mechanicsburg, PA 17055
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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
LAST WILL AND TESTAMENT
I, VANCE B. GROSZ, of Middlesex Township, Cumberland County,
Pennsylvania, being of sound and disposing mind and memory, do
hereby make, publish and declare this to be my Last Will and
Testament, hereby revoking any and all former Wills or Codicils by
me made.
1.
I direct that all my just debts, funeral expenses,
testamentary expenses and all inheritance taxes (whether such taxes
may be payable by my estate or by any recipient of any property)
shall be paid from my residuary estate as soon as practicable after
my decease and as part of the administration of my estate. My
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.
2.
I give, devise and bequeath all of my estate, both real and
personal property, in equal shares, unto my brothers and sister, C.
FREEMAN GROSZ, C. ~~ROSZ, MARK L. K. GROSZ, JANE MADELINE
KELLER, and my nephew, JOHN D. GROSZ, absolutely.
I//dJ. ~
V.B.G.
Page 1 of 4 Pages
3.
I nominate, constitute and appoint my said sister, JANE
MADELINE KELLER and her husband, RAYMOND C. KELLER, or the survivor
of them, as Executors of my estate.
4.
I direct that my Executors shall not be required to file a
bond to secure the faithful performance of their duties in any
jurisdiction.
5.
I authorize and empower my personal representative, in their
sole and absolute discretion, to purchase or otherwise acquire and
retain any investments of which I die seized or any real or
personal property of any nature; to sell, lease, pledge, mortgage,
transfer, exchange, dispose of or grant options in regard to any or
all property of any kind forming a part of my estate for such terms
and such prices as they may deem advisable; to borrow money for any
purposes connected with the protection and preservation of my
estate; to mortgage or pledg~ any real or personal property forming
a part of my estate or to join in or secure the partition of same;
to compromise any claims or demands of my estate against others or
of others against my estate; to make distribution in kind and to
cause any share to be composed of cash, property or undi vided
fractional shares in property different in kind from any other
t:~ .1J.
V.B.G.
Page 2 of 4 Pages
I
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share; and to execute and deli ver such instruments as may be
necessary to carry out any of these powers.
IN WITNESS WHEREOF I have hereunto set my hand and seal this
cfIJ/Ynday of
~., 1991.
~tJJJJ.~
Vance B. Grosz
(SEAL)
SIGNED, SEALED, PUBLISHED, AND DECLARED by the above-named
Testator, as and for his Last Will and Testament, in the presence
of us, who at his request, have hereunto subscribed our names as
witnesses thereto, in the presence of the said Testator and of each
other.
~p~~
Page 3 of 4 Pages
. .
1\__
COMMONWEALTH OF PENNSYLVANIA )
: SSe
COUNTY OF CUMBERLAND )
I, Vance B. Grosz, Testator, 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; that I signed it willingly; and
that I signed it as my free and voluntary act for the purposes
therein expressed. tV' ~ tB ~q
Vance B. Grosz
Sworn or affirmed to and acknowle~ed before me by Vance B.
Grosz, the Testator, this 6l.il#1 day of lJ~' 1991.
NO~~C eX ~LA.JJ
Nctalial Sua ~
Conino L My81'S, Notary P.lblic
COMMONWEALTH OF PENNSYLVANIA ) Carlisle Boro,CurnberlmdOoonty
: SS . My Oommiss~ El\p!res May 27, 1f*!1
COUNTY OF CUMBERLAND )
We, ~ m. A~~..( Sf~'Wl 1-. 6/tJ7J?Ylj
the witnesses whose names ~e signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and
say that we were present and saw Vance B. Grosz, the Testator, sign
and execute the instrument as his Last Will; that the Testator
signed willingly and that the Testator executed it as his free and
voluntary act for the purposes therein expressed; that each of us,
in the hearing and sight of the Testator, signed the Will as
witnesses; and that to the best of our knowledge the Testator was
at that time 18 or more years of age, of sound mind and under n9
constraint or undue influence.
/0 ~ 1-1,-,'" ~,~.
/"____.A."'3/e.. ~ PA I-?O/~~
.
Sworn or affirmed to and subscribed before me this ~LlMday of
9-~' 1991.
Page 4 of 4 Pages
Notarial Seal
Cooino L Myers, Notary ?-!blic
Carlisle &ro, Cumbefland County
My C.orn>l1!~siM E'<:pitt.'$ May 'T.l, 1001