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Home My WebLink About12-27-06 .....I 15056041046 REV-1500 EX (05-04) PA Department of Revenue . Bureau of Individual Taxes Dept. 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number Date of Birth Decedent's Last Name Suffix Decedent's First Name I MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS Fill IN APPROPRIATE OVALS BELOW _ 1. Original Return C) 2. Supplemental Retum (:) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c:::l 4. Limited Estate - 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 (:) 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 Telephone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received (:) () 8. Total Number of Safe Deposit Boxes c:::l Firm Name (If Applicable) -0 :x ~ en ~ Correspondent's e-mail address:bea.h1e.rcs~e.pix.net Under penalties of perjury, 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. SIG ~TU F PE N R ONSIS FOR FILING RETURN DATE , 21'IIJ1 Side 1 L 15056041046 150560410Lfb ---I --.J REV-1500 EX Decedent's Name: RECAPITULATION lS0Sb042047 1. Real estate (Schedule A). .... . . . . . .' . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Stocks and Bonds (Sched~le B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . . . 4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . . . . . . . . . .. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . . . 6. Jointly Owned Pr~p~rty (Schedule F) .C) Separate Billing Requested. . . . . . . 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C) Separate Billing Requested.. . . . . . . 8. Total Gross Assets (total lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . .'. , . . . . 10. 11. Total Deductions (totalUnes 9 & 10)...................................11. 12, NetVaJu~C?rE~tate(Line8minus Line 11)..............................12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an electioR. to tax has not been made (Schedule J) . . . ". . . . . . . . . . . . . . . . . . . . 13. 14. NetValue 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 .01L 16. Amount of Line 14 t~~ble 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 15. 16. 17. 18. 19. TAX DUE..................................................... ..... .19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT c:::> L 15056042047 Side 2 15056042047 -1 REV-1500 EX Page 3 Decedent's Complete Address: File Number .:l/-~" - 3ZB DECEDENTS NAME ;)1F5Slc E. pOTICHE?( 1-----..- STREET ADDRESS S:t2S UJILS t)N UfAlE #: ~.32 8E7kAA y J//UA~~ CITY /J1SJIIAN/CS$vl't&- I STATE flit I ZIP /7tJSS- Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayment~ A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) f ".00 o o o Total Credits ( A + 8 + C ) (2) o 3. Interest/Penalty if applicable D. Interest E. Penalty o o (3) 0 (4) 0 (5) ~ l:,9.()D (5A) 0 (58) )C, 9. "0 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. 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. 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;.......................................................................................... D ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 lKI c. retain a reversionary interest; or.......................................................................................................................... 0 ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [2g 2. If death occurred atter December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 [KI 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. 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. 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 zero (0) percent [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 four and one-half (4.5) percent, except as noted in 72 P.S. 99116(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. 99116(a)(1.3)J. 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. .-J 15056042047 REV-1500 EX Decedent's Name: RECAPITULATION 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.lnter-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 9 & 10).. ........... ............. ... '" . . . 11. 12. Net Va.lue ~f 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 .O~ 16. Amount of Line 14 taxable at lineal rate X.O!:l$" 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 Side 2 L 15056042047 Decedent's Social Security Number 15. 16. 17. 18. c::::> 15056042047 -1 REV-1500 EX Page 3 File Number .:<./- ~ ~ - 3 Z B Decedent's Complete Address: DECEDENT'S NAME JIFSSIIE" E: pOTICIlG7t STREET ADDRESS CITY S:l2S WILSON UlAlE #= A'32 gE7kAA Y V1UA-r;~ /J!EOIIAIJI/CS$VI'lG-~-- i STATE Ill! I---~ . ---,------- i ZIP ! 17tJSS- Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payment~ A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) ~ , 9. DD o o o Total Credits ( A + 8 + C ) (2) o 3. Interest/Penalty if applicable D. Interest E. Penalty 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 oval on Page 2, Line 20 to request a refund. o ----- o (3) 0 (4) 0 (5) ~ b9.()f) (SA) 0 " (58) b 9. "0 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 + SA. This is the BALANCE DUE. 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 f:KI c. retain a reversionary interest; or.......................................................................................................................... 0 [Jg 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 [K! 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. 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 isthree (3) percent [72 P.S. 99116 (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. 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 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 zero (0) percent [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 four and one-half (4.5) percent, 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 twelve (12) percent [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. REV-11iln a.. 1'-97) '* SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF po 7/CHE'I(, v'€SS/E FILE NUMBER ~/-t16- 53g E: All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH t')~i!'S7P/RN 4A-A1K - /J?an~uI ~NYeJt /Hent Atu-t. IV~. S"P /)~ "7f OC I (~ f'~LtlIlTiDAI :J>A-7A- Pbv//)E"D JBy &f-AIK A 7r~(!H~ A-eQ.JalU=D INCoME: l>/tJ IrEm I 'IOf) 168'# EO ~ ~. ~ ~ . 'I, TOTAL (Also enter on line 2, Recapitulation) $ I 0 ~ J / 7/# 7 r (If more space is needed, insert additional sheets of the same size) tusip No. ~l '. ,. ~9089R103 fu '!.12g0'1 01 ~71023846 tl24659208 5B55'IA108 60934N62S l?0934N62i ~8002Q370 ~79')')qi(,)" ,j' ...... ..".' ~21908885 9~19:1~11 O~ ~22~0li7'10 ORRSTO\\TN FIN~~ClAL ADVISORS A. T'radition of Excelle1tce ACClHlnt: 5000 167R n 1 t ,JE.SSIE E "OTICHER INVESTMENT HOLDINGS AS OF 4/7106 (000) E}ecuritv Name Shares i Par DOD VALUE DOD PRICE ACCR.UED INCOME ii ~ I \1 ~ a ~ ! ~ ~ ! ~ I r t ~ Ii ~ !i II I ~ I! Ii \1 1i Ii [, Ii Ii II 1: (1 I, II " ;1 :1 Ii i' .1 " II ., 11 II I' ,I Ii I' " i' !; il i! I' ,I II j~ FORWf'lRrJ EM GRO'v"v'TH FED TOTAL RETURN p..o JANUS OVERSE.AS f=LJND LEGG MASON VAL TRUST fv'IELlON BANK CORP FED MONEY MKT.PRI FElJ MONEY MKT.INC OLD MUTUAL MID CAP Z T ROWE PR. NEW ERA V/'-NG HEAL THCARE ADM VANG WELLING FND #21 VG 500 INDEX AQM Cl':1O .") 13 038C $/i 90S :q 15.6'7 1 4\17 1'260 $1:":,,52520 '1 0 3:~ 2879870 $'1 '1.'142.22 38% '114 355,) ~~8722.08 76.27 ::7e.00QO $20.419.20 35.45 2i 81600 $218.16 1 00 774.'1500 $771J.~8 1 00 ,!'25 1360 $8.29299 19.3: 20,116760 $9423.25 46.04 139 802D $e \7'0.0:\ ~8.44 13 9560 $433.89 3 ~ 09 101 i'17C $ i?. , 41.96 119.37 H,tt6.9...4A. $_tO_O...l6JL8_Q $2_9_Q $2.06 $020 $0.73 t3 ... ~~, ~ T . . ~..... ~ . . ~ - ~.~ ...'<- . -..... -:.-:', .'" . ~.~ - - - ~ - - -. ~ ..."",,,,.,,,,, '* SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INH:~~~~~ ;~E~~RN PERSONAL PROPERTY ESTATE OF FILE NUMBER p()7/CII~ I JESS/I: c.. ;l/-C)~- 3sJ' Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of sUNivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH ;t ?' bt!J ' f) () ~. IIIYfJ,lJtl'l/'Y ,f hr.5~hPJfy (see itemize.d j,'st A/lAchet/ J. ~IIC /JANK Aed..,4/p. ~s ()OJ ~s~"- (See r~/~ I h;A it".d' gd/:/t;MIft') CR..EOli FoItDJlFIlNJY/HENr ,eE / e/rt-I3/fAlI< ~ ~S~8'. ~~ 1119,,'12 .3. . TOTAL (Also enter on line 5, Recapitulation) $ Lf.; 0 if. T. <i1- (If more space is needed, insert additional sheets of the same size) ~s7: o;=" oI€SS/€ E: flt!>7/erll!::?€ '/i"/) .. E. 4-fJlJEA/l>tt /J1 . ....________ .._________ '.. ,-:ZALY- €.Al7#tf'.k_... _ .aE...._.._/?L~.,!(;.I1ILt:?c 7 y- . ._--~.----..-.__.__.-------.-.-..-_.-....--.-..-_..--_. --- ..._____.____L._ .____~btAlLI!I6It.-.~/cfic. _._#~/.c~......-...-.-------..--..------------...--...-..__...._..___...__..._._...i-: ,,~_.----- ...__.~_,{~_._'-Aeft}..~.It.~1!'fl h.1!_qestc..MM.dr..!k.cl14' 'c._.__..._.__~R-~_m ..._______ .~J.L.._ __....<<p~~fert!tL_~!~__~4.!J:._d. . .._______._____._____..__...____.__.._.____._ -. ..- ----.~~ ~t'I..______.._ _.______.._~ :2At~L__?l:________...________.__u________.__.____._.......___ ........_.____.. _______.~s-z,_:"_~______. .s: ?;;"k L4~ ..________________..___ __ ____.___.__.__._______.__.__~~u~______ ... ........__LrJAlIlI ;fpm4~..L4!'!R. ~~/~.~.bAeI~.___ . .. _ ....__ 'tS.'" , _.- 'Y ~/J" ~ pI) Zl-~ - $~.8 ----..--------.-- ~_._-_._--."._---~~--------.,._..,~-_._-,...-."..----..-------~--'~------_.__._._-------_._------------~-...._-_.~"".~-'---,.-~---,,~----_._---,.~.._--....-----_.~- __ ______. 7A~l!dlAhP~L_M~.L.JJ.'_C.WLJ.t___II!LL_"f"g.1t_~~.!!1/ .-1--&-----.-.--------- __.____. -hAit Pi heL:.IIMli9_~__~~.$izt!t/._.$N'~/.PAtu~. ~r._______.___..___ ______.____.____~. _~_~~skAhilL.---Je~~t'.o/L-L!Jt:;""~~...4~-~:f-- 4r )/a4t4~ .__._.___._ ____.___...____"'..___ _..tt'/Le___b.~L__~(~tI'ItM...A6I~-.A!~/I-./.'n.._-~~~--~t:. ~~{(~-----._-- . _12.~;,.Lr.....nl..ti..._._____._____.__..__________.____..__.________.-.------. .-.--------.---- _..__________ ___~$er__L.~5_.jULtsleL.._A--.--L#..~~-.!L ~~/l~..&~---------.-.- ________________ -L4_~_CI2IlAL._&LIItItL__~/LLP//~f--~-&~~--.gl('!.ft!'~--.--------- --------- -~~-~-~~~-~------- ______..__..______ __A.~____~~_tU-/J1/A./.ht./.I-.~IK.e..--k!k'-~k.~.--~..-~H --~--_... ----.--~-.-.--.---- ___......___I'N/1L:bL..&dAIIJ"_fdflp'-_~~rc,.~~~t ~---_._.- ____ _._._.______.__... __._._L!zt.eA.tl?t:'.I:.~..___...._._ - ",--"--'-'..-- --- ..---.----. -- ... ..---..-- ..'- - -.---...-.-- .-..-....---..----..---..--..------.---.-----.------.- ...---.-.-... _._.__.._.__ _A'_n'_~_ __..~"__'__'._ .._~.___ _n .._._____~____,___._.n_'__'.____...~_._~'_~_'._._____~___....__~.,___.__.. ._ _. _ ___~_____~_......._,_..,____.~__'. ...___._,.,....-_.,_".__~._~_u_~___.__.__ ",..-. ..,.. ----..-.---.----".-........----.,,--------~------".~-.-"..------~~-- - -~-'"~ --_. ''" --, ---------_.~ --- ...-._....~ ~-- ,"' ,-- - --~.. .. --,,_.. .__._-~--,_... ---. .~.,,- ----- .._..-~ ._- ------- _.~~_._....---_....~ ....,-..__...---... ... ---~.---._....---_.~" ~p~ "I(\'y'-::25-::2I111716 82' '13 F"\.ICSfl\-II< '112 769 3,'15E! P. 111 J. ....111 J. o PNCBAN< May 26. 2006 Charles E. Shields, ill Attorney at Law 6 Clouser Road Mechanicsburg, PA 17055 RE: Estate of Jessie E- Poticher,deceased SSN: 166-07-3785 000: 417/2006 Dear Mr. Shields: In response to your request for Date of Death balances for the custome.r noted above, our records show the following: Checking Account ACCQ'Ullt #5080032522 Established 04/14/1994 JESSIE E POTICHER DOD balance: $3,568.45 (non-in.terest beating) I was unable to locate a Safe Deposit Box for the decedent. Please note that this office only provides date of death balances for deposit accowlts (mAs, CDs, Checking and Savings accounts). We do not process any financial transactions or provide statements. If you need assistance with any of these items, please call1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office.. Sincerely, &ladw1t u}Jh Rae,helle Wells 1-800-762-1775 P7-PFSC-04"F 500 firsl A \Ie. Pittsburgh fI A 15219 Member FOr.C RE\t-1511 EX+ (12-99) . '*' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER ESTATE OF ='"'" ,/~ /,./0 T / e Nt::::fl,. I v€SS IE E; ,Z/-~- 33~ Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: 8. 1. 10, II. /~. DESCRIPTION 1. NEILL F'IIA'EJ(A{ N~/JJF, ~f t!.4JJVJ ~'// ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) PEAl e ~"JO,IF &fA' F ~L.() Social Security Number(s)/EIN Number of Personal Representative(s) Street Address ;19ft) tl)/IV12f;;;ttS aHASE /()I!+' City HN~/"l./S StateAf..b Zip :2/~"/ Year(s) Commission Paid: 2. AttorneyFees ellll/lLES E: 5/t'IEt.DS:Ill: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant ,;PIYR Street Address City State _ Zip Relationship of Claimant to Decedent 4. Probate Fees IJMII pri;/1a! jS5tAe ~t .sho,.t c.U+Jr~'co..tC$ Accountant's Fees :\ D/UIS1iJflN /!JANK ff,/t. Cl.DS€~u:1; IDtiPj /lA-liD, Tax Return Preparer's Fees It>lfl, fJ1f "'I.de.. 5. 6. 7. ;/"~;h;'hll/ I'hJb.,!. /!e~S ,c:, /'nl H~ ;Iii ,fWl's~r pI' IV/lis A"JlitI'f/.f/~ /;, Culltirer/a/'l4 LA,W :TDkrJ14/ /l-e(v~,.h:r;,,/ /~ C a rh:S Ie J&lh '",e / F':t;/I,1,f If. M!,t)u"t ((e;lIIb,.:-A u. .J. If 1II/le4ft 't'1'M1S6 ~ leI1d~ ~eliD ~/kq.) 'J ,. TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) S. 'I. AMOUNT ~ 3~~.~ ~ . S, 16:2 .~I) ." If, " 7 s: 6D II/~N~ ,. /1'1-. 00 f 5()().P() rd.. ()() ,OD ~s: 0() ~ 7S;OO ~/() 7. 99 " ~ ~~~ ~~ $ II, 70S. r.f, (f) '~~ - _J~~~ . fJJ~ I~ ~At? ..,------ /"....~..-.- VI vw~ ,"} . @ ,'ffS~-:h == ~.~4.61 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENt ESTATE OF '?OT!(!,IIEJeJ RfV.1S12 EX. (1.97) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS cL~ss/i: E. ,t/...~~- ~58 FILE NUMBER Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. ,2. 3. ~ s: ,.. 7. ~. IhEl~ /HRJ SPlJ?~ eST ,!JEIYII.5I!PItf) AAI ~tlt;1/ff!E SEif!Y1 U3 I'!. 13S..5b "'6 t:) .~o e/J!~ elll e/l-,e os e /77 tJ/f/l.LJ,s ~ ~;?..7~ ~ . II 9.. .72 ~ 3/. 0 '1 ~LfI.DD ~ :llf s. DO JI )/0/:,9.20 fAAlES te. /V'p/lrpN, ]).. ~A1., OFFICE" ",'SIT ~E7}(AlVY VIl,,f6G S/C/U-GO NuRSING CARE 6671fAIJY VI UA6tr AS$/-s rIFf) L I V I Ai' TOTAL (Also enter on line 10, Recapitulation) $ 'I 7 ~ 1. ~ 3 (If more space is needed, insert additional sheets of the same size) . REV-1513 EX' (1-97) '* SCHEDULE J BENEFICIARIES ESTATE OF NUMBER I. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT f () -r leI/ e;7(1 :Tl:SSI G E": FILE NUMBER ~/-pl;.- 338 AMOUNT OR SHARE OF ESTATE D IS f't:>S,f{.. ()F J 72f.7J1f e:;,e:" I'ERS'DAlI'H- TY As SN /JJVN e:;AJ SeliG b. E. V'Ht:uFj) A-T ~ 1f1Jt:>. DO ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, 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 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) RELATIONSHIP TO DECEDENT Do Not List Trustee(s) 1. fJEN~I'E ~ANEL.UJ ,2. 9//) IV/N're:;f~ (!.HA-SE /()A Y A-h'KItFJ"t..IS / /J/~ 2./'kJ1 NIce!;" 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. CA-U A-'5S11!lJfNe!: FaA/I) II-r /lJE7N/tAJY I/I~I..AGE ~ AlA/rHEA) hI~lJlJsI .3~5" /JJFS{.I?Y Il/J. hlGI!llIfA)le58tl!e6-, ~~ /7(JS"~ TOTAL OF PART n. 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) 1lE'.sIl>Ur; . \ \ ,. 'i , LAST WILL AND TESTAMENT OF .TESSIE E. POTICHER I, JESSIE E. POTICHER, of Bethany Village, Lower Allen Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct that all my jusi debts and funeral expenses be fully paid and satisfied as soon as conveniently may be after my decease. 2. I give all clothing, jewelry and household goods and furnishings in my possession at the time of my death unto my niece, PENELOPE BANELLO, to be disposed of by her at her sole discretion. In the event my said niece predeceases me, then this gift and authority shall go to my niece, PAMELA STEELE. 3. I give all the rest, residue and remainder of my estate unto the CARE ASSURANCE FuND OF BETHANY VILLAGE. 4. It is hereby directed that my executor, hereinafter named, shall pay all inheritance, ~tate, succession and legacy taxes to which my estate or the transfer of any property hereunder may be subject and to charge such tax as part of the administration, payable out of my residuary estate. 5. ~, I nominate, constitute and appoint my niece, PENELOPE BANELLO, to be and act as my sole Executrix of this my Last Will and Testament. In the event of renunciation, death, resignation or inability to act for any reason whatsoever of my niece, PENELOPE BANELLO, I nominate, constitute and appoint my niece, PAMELA STEELE, as Executrix of this my Last Will and Testament. In the event that she is unable or unwilling to act as Executrix I appoint ORRSTOWN BANK to be my Executor in her place and stead. My Executor shall not be required to post bond or security. of IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~~, ,2003. 1~/4 day (1, -4./~L.i' e.. f. f.j6.1.-:GAIJ /---r (SEAL) JE~E E. POTICHER Signed, sealed, published and declared by the above-named JESSIE E. PaflCHER 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 subscribedouf names as wi,tnesses. ~(~7J 5c.k~ 6- 5~~ S \/ =2 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 SHIELDS CHARLES EDWARD III ESQ SIX CLOUSER ROAD MECHANICSBURG, PA 17055 _n_n__ fold ESTATE INFORMATION: SSN: 166-07-3785 FILE NUMBER: 2106-0338 DECEDENT NAME: POTICHER JESSIE DATE OF PAYMENT: 12/27/2006 POSTMARK DATE: 1 2/27/2006 COUNTY: CUMBERLAND DATE OF DEATH: 04/07/2006 NO. CD 007610 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $ 69.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK# 761 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS $ 69.00 GLENDA FARNER STRASBAUGH REGISTER OF WILLS GEORGE M. HOUCK (1912-1991) Register of Wills Cumberland County Court House 1 Court Square Carlisle, P A 17013 Dear Register of Wills: CHARLES E. SmELDS, III AITORNEY-AT-LAW 6 CLOUSER ROAD Corner of Trindle and Clouser Roads MECHANICSBURG. PA 17055 TELEPHONE (717)1 766-0209 FAJ( (717) 795-7473 December 27, 2006 Re: Jessie E. Poticher No. 21-06-0338 Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Jessie E. Poticher Estate as well as Check No. 759 in the amount of $200.00 for additional probate, Check No. 760 in the amount of$15.00 for the filing fee and Check No. 761 in the amount of$69.00 for Inheritance Tax due. I am also attaching two additional copies to be date stamped. Thank you for your kind attention to this matter. CES/mjj Enclosures Very truly yours, "- ~fPM Charles E. Shields, III Attorney-At-Law o C;:;o <;Q '2:00 ;~~~~ , .c- U) ;:x; , ) ('")0 ....,Q-n ....~ c:: '.,J ::0 ~'o-l P ,....., C':) C:I c:T' o I"T't n N -I -0 :It N .. c.n s:- ::0 lJ ,,, r-nq (7) c.... ;:.";:;, ::0 ~-~~ CJ Ion rTl :1:J CJ c-:) C~ . ...1 ..,., _.. -r, ~~,:;o r=rn ~./) 0 -n