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15056051047
REV-1500 EX (06-05)
PA Department of Revenue '*
Bureau of Individual Taxes. INHERITANCE TAX RETURN
PO BOX 280601
Harrisbur , PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
Suffix
MI
I!1l
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
_ 1. Original Return
C:=)
4. limited Estate
C:=)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
C:=)
2. Supplemental Return
C:=)
-
C:=) 4a. Future Interest Compromise (date of
death after 12-12-82)
C:=) 7. Decedent Maintained a living Trust
(Attach Copy of Trust)
C:=) 10. Spousal Poverty Credit (date of death C:=) 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Tele hone Numb ,....,a
6. Decedent Died Testate
(Attach Copy of Will)
9. litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
C:=)
'",
Correspondent's e-mail address:
Under penalties of pe~ury, I declare that I have examined this return, including accompanying 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.
SI F E 0 PONS LE FOR FILING ~ i,./~E
Pee- (IO~D
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
....J
....J
REV-1500 EX
Decedent's Name: f..
RECAPITULATION
15056052048
1. Real estate (Schedule A). ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3.
4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5.
6. Jointly Owned Property (Schedule F) c::> Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) c::> Separate Billing Requested. . . . . . .. 7.
8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . . . . . 10.
11. Total Deductions (total Lines ~ & 10)...................... ............. 11.
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . : . . . . . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_
16. Amount of Line 14 taxable
at lineal rate X.O_
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
L
15056052048
Side 2
, UI
Decedent's Social Security Number
~
15.
16.
17.
18.
c::>
15056052048
--.J
..1 ex Page' 3
Decedent's Complete Address:
DECEDENTS NAME
File Number
o
fYl A-E:. Q t (JA/ IV ofJ-
STREET ADDRESS
3 3 ~ lv' esI ei DfJ-' V-€- 4p,- 3:l.. L.
eCHiV/6s13 4J{t~
CITY t-
p~
STATE
17 tJ sO
I ZIP
I
I
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount _----1j1~_J "1
3. Interest/Penalty if applicable
D. Interest
E. Penalty
(1 )
:J.. ~Oj~ ~ 0
Total Credits ( A + 8 + C )
(2)
~f-o/, 7/f. ~
,
Total Interest/Penalty ( D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in avalon Page 2, Line 20 to request a refund.
(3)
(4)
(5)
(5A)
(58)
'-- b~~ '1~
t!
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 BALANCE DUE.
~~), lib
Make Check Payable to: REGISTER OF WILLS, AGENT
:.>;~..I__..IIIII
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 if'
c. retain a reversionary interest; or.......................................................................................................................... 0 ~
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 Rr
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 M'
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 Iir
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 if
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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 three (3) percent [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 zero (0) percent
[72 P.S. ~9116 (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 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 zero (0) percent [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 four and one-half (4.5) percent, 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 twelve (12) percent [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.
",-",,,.,,,, .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
a
3.
s
WAC l-f,f!'V(/ It ~ ,ftN ~ 1j n J 4')
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REV-1511 EX+ (12-99) i'
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
1.
FUNERAL EXPENSES:
~~fbMlrt1lrJA1 !/fvA[~' / S'V5:.' ~
A-e.-4..esh ~~ A-t- 1fJ~().fkL~tk ~~"'Jl C:e-
U/1JC.-/1?t!DA.2fftjt; i~7 (rJ~~::;efI...(/ i'~
F-1'6'(4'~5
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State _ Zip
Year(s) Commission Paid:
2. Attorney Fees
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.
7.
Tax Return Preparer's Fees
yHvp...,- ruo-W"I I /fj.A~J. ~JUtIIl, At!J{II#(;}"ff,'Y/)JJ
J r.: P F<t-e-
-(u~frt". .
----
AMOUNT
IISLJ,I:,((;
/JE$/~Krf
d.. L{o,..OO
~q, Lf 0
;/!-'3:,'Oo
19 ~;). (j r;
REV-1S12 EX+ (12-03)
'. '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
FILE NUMBER
ITEM
NUMBER
1.
2..
3#
L/\
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
VALUE AT DATE
OF DEATH
141 I 'St;, 5)-
DESCRIPTION
PPrt-,' , I .!.J t hA 1Uj' eo ,,~ S"k,t/I eeL tJv ~'lJ'}
Be..\I~ .f:.N+~~ fl A.\.s e.S
j'l\-t..c:lt.cAT j OrJ So r:C fS ~ '" fJ V (l.$ , ~ 5 hk., ,\ ~
Pf+A-A-M ~~t~
G
3 cto, ;;s-
PA-\t)
To
$f 3'1 S-2...
.B~.pM '(f I-\-.- \..k,~ ~,5 c- P:-e. c s
e cTl-\- ~J -r ()(J -tl-S - t I ~~lI.:b up
Nt> Dv-x... M -ree..f'1"\, v~, 0 AJ oF- leMe..,
~
tj~1 Dc)
~7~
5
f>J..{Att-#'[ ~ cy
We"IS
31111
TOTAL (Also enter on line 10, Recapitulation) $ J. I S"fe, ,0 {J
(If more space is needed, insert additional sheets of the same size)
My Will- Sept. 20, 1993
I, Edna Mae O'Connor, formerly Edna Mae Vandercoy, (nee
Willis), being of sound mind and body, do hereby write and sign
my last Will and Testament.
I wish for both my children, T. Peter Vandercoy(son) and Susan
Jane Carey( daughter), to be co-executors of my will.
I leave $20,000 dollars in life insurance and a Series EE bond,
worth $10,000 at its maturity date.
As of now, I also have a small amount of cash in a savings
account. I am also, as of now, planning to have most of my burial
expenses paid, thru a pre-payment plan. This is thru the
"Cremation Society of America". Yes, I wish to be cremated at the
time of my death. I have spoken to you, that this is my wish.
I ask that you do not keep me alive on any artificial means. I
want to die in peace and with dignity. Please allow me this wish. I
am not afraid to die, as I know there is a heaven above!t and that
someday, this, will be our fmal meeting "home".
I read somewhere this statement and want you to remember it.
"Do not stand at my grave and weep, for I am not there, I am a
thousand winds away!"
After my immediate expenses are satisfied, I wish to give to my
three adored grandchildren, the sum of$1500.00 each. They are
Christopher R. Haefuer, Jackqueline N.Vandercoy, and Jodi L.
Vandercoy. Also, as a token of my esteem, I would like to give to
Judith S.Vandercoy the sum of $500.00 each for many kindness's
to me. The rest of my estate, is to be equally divided between my
son T.Peter Vandercoy In and my daughter Susan Jane Carey.
Also $1500.00 for my greatgrandson born 3/27/96, Edna
M.O'Connor.
Should one of you preceed me in death, I then want the still
living and present child to carry out my wishes and requests. This
person, Son, or Daughter, shall then become the executor.
Also, by some stoke of fate, should both of my children preceed
me in death, I appoint Judith S. Vandercoy my daughter in law, to
divide equally the balance of my estate, between my three
grandchildren, great grandson Alex M. Haefner & Christopher R
Haefner, Jacqueline N.Vandercoy and Jodi L.Vandercoy.
I have loved you both equally all your lives and I believe that
you know this. No mother could love you more. I pray that you
Susan and Peter stay close to each other, and always be friends, as
well as family. .
I am sorry for any hurt I may have caused you in the past. Your
father and I always loved you both and tried to be good parents.
Please be good to each other and stay happy.
My fmal request is that you have a Catholic Priest, attend my
services. It is not necessary to have a full Catholic mass. Father
Ken Smith of St.J oseph' s Church in Mechanicsburg, will be
someone, who can be of help to you. He is a young priest, who has
been serving mass and communion to us here, at the Towers.
All my love, forever
Mom
Signed and witnessed,
This day of
Date 9/20/03
Edna Mae O'Connor
Witness # 1
Patricia K Bayhoff
Witness #2
Edna D. Diehl
WACHOVIA
DATE: 11/21/06 TIME: 07:51AM
LOCATION: 3404 PAXTON ST
CARD NUMBER: ************7047
ACCOUNT: ACCESS FIFTY
PREVIOUS STATEMENT DATE:
PREVIOUS STATEMENT BALANCE:
INTERIM STATEMENT AS OF:
DATE TRANSACTION DESCRIPTION
11/20 CHECK01609
11/20 CHECK01608
11/16 TRANSFER FROM 28716211236
11/15 CREDIT
11/13 DEBIT
11/10 CHECK01605
11/10 CHECK01607
ATM: 1088 SEQ: 4142
HARRISBURG PA
PAGE NO: 01
1********3007
11/07/06
$800.01
11/20/06
\
AMOUNT
15 . 00- ) /3c::t HA'/1 ~() 1.1I ff! S
30.00- a p , fJ..~1
8878.42+ ~ t B\.U.. CI-tJ>.5> tJOU~",loillL 1l'(.ll'\,UlI\ -
~~g.Jg~ "~~tc..A-" .
Jl.7L:"',W~ ~
34-:-S2-WllaJ~t "J ' ~ ~
------------------------------------------------------------
CURRENT AVAILABLE BALANCE: 59313.35
------------------------------------------------------------
THIS IS THE END OF YOUR STATEMENT
WACHOVIA
TIME DEPOSIT WITHDRAWAL CONFIRMATION
Office Name
Customer Name(s), Address and Taxpayer 10 Number
EDNA M OCONNOR
NJ
Date
11/16/2006
335 WESLEY DRIVE
APT 322
MECHANICsBURG PA 17055
5198126266
CURRENT BALANCE: $8.847.95
+ ACCRUED INTEREST: $30.47
Availlnt WD/PenFree: $214.70
- PENALTY AMOUNT: $0.00
- FEDERAL W/HD DUE: $0.00
- WITHDRAWAL FEE: $0.00
- OUTSTANDING PYMT: $0.00
- TRANSFER TOTAL: $8.878.42
FULL REDEMPTION
CD ACCOUNT NUMBER:
287162112363143
---TRANSFER ACCOUNT INFORMA TION----
ACCT1 : 075 1 DDA /1000590363007
PA AMOUNT 1 : $8.878.42
PAID TO CUSTOMER: $0.00
5Oll51lo4
WACHOVIA
TIME DEPOSIT NOT TRANSFERABLE
Opening Dete
Account Number Taxpayer to Number
ThIs Recellll AcknowIedaeS That The Depositor Named
Below Hal Depositecl1Nlth This Bank The
SUm Of
****************\1010*****
Depositor
Name And
Address
Term
Maturity Date
Interest Rate Per Annum Annual Percentage YIeld Interest Payment Frequency/Period
Interest Payment Disposition
Account to Creel"
PROD-TYPE:
PROMO CD:
Issued by WACHOVIA BANK. N.A.
X
AuthoriZed Signature
X
Date
56lI6IM
-,;;':..
. ,A 1:0 ~JtOOO SO 31: ,600'5 qO 3& !QQ7j"
1/1:...
.,'{}t,_:",.
c::..J;::~
.r........
..
~::~8d1
Consolidated Statement
02 1000590363007 752 40
5 104
54,642
WACHOVIA
10/11/2006 thru 11/7/2006
Access Fifty Checking
Account number:
Account owner(s):
1000590363007
EDNA M OCONNOR
T PETER VANDERCOY III
Account Summary
Opening balance 10/11
Deposits and other credits
Checks
Automated Checks
Other withdrawals and service fees
Closing balance 11/07
$879.82
2,082.31 +
2,045.79 -
114.33 -
2.00 -
5800.01
Deposits and Other Credits
Date Amount Description
10123 2,082.31 TRANSFER FROM 3059980333670
Total $2,082.31
Checks
Number Amount Date Number Amount Date Number Amount Date
1600 48.29 10124 1603 148.60 10127 Total $2,045.79
1601 136.40 10124 1604 1,620.00 10131
1602 1.50 10126 1611* 91.00 10124
* Indicates a break in check number sequence (checks could be listed under Automated Checks)
Automated Checks
Number
1599
Amount
114.33
Date Description
10/16 AUTOMATED CHECK VERIZON ARC CHECK PYMT
CO. 10.2005022221 061016 ARC
MISC 1599
Tota'
$114.33
WACHOVIA BANK, N.A., CAMP HILL
page 2 of 5
. .
CUSTOMER: EDNA M, O'CONNOR
DATE: 10/31/06
FACILITY: BEVERLY- CAMP Hll..L CARE CENTE
ACCOUNT: 5702-01-24522
PHARMERICA c:11>
491-A BLUE EAGLE AVE
HARRISBURG, PA ]7112
PRIMARY PAYOR: INSURANCE
PRIMARY PAYOR: INSURANCE
POLlCY#: 03959
POLlCY#: 03959
PAGE: ] of]
EFFECTIVE DATES: "08/30/06-10/03/06
EFFECTIVE DATES: 10112/06-10/21/06
PREVIOUS PAYMENTS CREDITS: NEW $390.25 :~~CE $390.25
BALANCE: RECEIVED: CHARGES:
DATE I RX NUMBER I DESCRIPTION QTY Bll..LED DUE FROM INSURANCE CHARGES/
AMT INSURANCE ADJUST CREDITS
Balance Forward:
10/12/06 1588641.00 DIGITEK 250 MCG TABLET 14.000 6.35 6.35
10/12/06 1588642.00 DILTIAZEM HCL 180 MG CAP 14.000 24.25 24.25
10/12/06 158e643.00 ISOSORBIDE MN 60 MG TAB S 28.000 42.05 42.05
10/12/06 1588644.00 TOPROL XL 50 MG TABLET SA 14.000 17.60 17.60
10/12/06 1588645.00 PRAVACHOL 80 MG TABLET 5.000 30.65 30.65
10/12/06 1588647.00 PROMETHAZINE 12.5 MG TABL 42.000 24.60 24.60
10/12/06 1588649.00 CITALOPRAM HBR 10 MG TABL 14.000 38.40 38.40
10/12/06 1588655.00 DUONEB 2.5-0.5 MG/3 ML SO 180.000 144.40 144 .4 0
10/12/06 158865"6.00 LORAZEPAM 1 MG TABLET 30.000 28.35 28.35
10/19/06 1593103.00 MORPHINE SULF 20 MG/ML SO 30.000 22.65 22.65
10/19/06 1593856.00 HALOPERIDOL 0.5 MG TABLET 28.000 10.95 \ J 10.95
Amount Due: ~ 390.25
/ ~ l ~ JLI [ bO V
~ II
~~ f
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BILLING QUESTIONS:
08:30 AM - 05:00 PM
PHONE: 800-352-9161
MEDICATION QUESTIONS:
09:00 AM - 04:00 PM
PHONE: 800-994-6337
PAYMENT ADDRESS:
P.O. BOX 6413
CAROL STREAM, IL 60197-6413
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