HomeMy WebLinkAboutOC1968-1367 - ESTATE OF MATHIESI
Washington
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF ~~UN!Y COLLECTlON.S
COUNTY OF
Form RCC-33
RESIDENT DECEDENT
I~WORTANT:This return must be completed in detail and filed in duplicate,"with will attached,with the
Register of Wills of the County where decedent "resided;Return is due within one year after
date of death,unless an extension is granted by the Secretary of Revenue.(Section 703 of
...the.Jni}erit{1nce..{1n!i .E.l:!tate .~a?C L\ct of l!!f>L)
IN THE MATTER OF THE.ESTATE OF }AFFIDAVIT OF Jessie Backstrom,Informant=:-:~~~~~:;~~~~;~;:~~~il:_::.··::::::=:W6R
Eucutor
..:6..lo.Qffi.~s.J.Q.Q.ffi.,Ro.s~:n.p.g.J;"g,~..J~J.9.9m .,,.," ,,.
,200 Wa shingto.n uTr..:IJS.t.:6..:IJ.:i..lqing ..uu,,.,.,.,..",.,..""",.,u.......u.uu ...
Washington,Pennsylvania 15301
Th t h Informant d "t 0 f 01 0 °th th If 0 f °d t t d th.a as suc eponen IS amI lar WI e a airs 0 sal es a e an e property con-
(11:XI~CU tor-Adminiolrator)
stituting the assets thereof anq their fair market value.
That at the time of death there was no safe deposit box registered in decedent's individual name,or jointly
with,or as agent or deputy of another,or in ·decedent's individual name,with right of access by anot~er as agent
or deputy,with the exception of the following:-
.PennsylvaniaS~"~7 ._-:~~~~~~~:~---------:}'"
Co~~ty of.,kt~t~'?~t~..........................................................................................
...,:.[.....(\"Jessie Backstrom,Informah-t
'-.~'''I •••••••••••••.y•••....•••.•.•.........•....•.•.•..•..•.•.........•....•.••••................,......................................................................,'.•••...•.....•••.:.
Admm!stratot .:/of the estate of the above-named decedent being duly sworn,depose and say.~<,,~J...;~:·S!lRtg!1!fii:!;;;-·····················ii~~.19if~~i{:::::..:•••io,•,,,,oil<,.....f oM.h ..h......"..h.d.}
N~m;::an:address of attorney or'}
other authorized representative to
whom all correspondence should be,
mailedo
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION THIS SAFE DEPosiT BOX RENTED ',.RELATIONSHIP OF JOINT
IN WHICH DECEDENT RENTED A SAFE DEPOSIT BOX IN NAME OR NAMES OF HOLDERS TO DECEDENT
,
That the contents of said safe deposit box or boxes are itemized under Schedules ~of this
return,with the exception of the following,for the reasons hereinafter set forth:
That SC,hedule A attached hereto and made part hereof sets forth full v and in"detail all the
real property in the Commonwealth of Pennsylvania of which decedent died haVing an interest therein.It
also sets forth the mortgage encumbrances upon each parcel of real property at the date of death,giVing
the amount still due at death,name of mortgagee,date,rate of interest,and book and page of record
thereof.It also sets rorth in the columns provided therefore the assessed valuation of each or said
parcels,the estimated market value thereof as of date of death of decedent.
That Schedule B attached'hereto and made part hereof sets forth fully and in detail all personal
property wheresover situated owned by the decedent at the time of death;all moneys lert by the decedent
at the time of death,whether in decedent's immediate possession,standing to decedent's credit in banks
of deposit,saVings banks,trust companies,or other institutions,whether indiVidually,o~in trust ror
any other person or persons giving also separately the accrued interest thereon,if any,down to the'last
interest day prior to decedent's death in the case of saVings banks,and to the date of decedent's death.,J
in,all other cases;all bonds,postal saVings,treasury certificates or notes and other evidence of in-
debtedness of the United States to the decedent;all obligations,whether by statute or agreement they
are designated as tax free,of the United States,or any state,or political subdivision thereof,or of
any foreign country,which are owned at the time of death;all wearing apparel,jewelry,silverware,pic-
tures,books,works 'of art,household furniture,horses,carriages,automobiles,boats,and any and all
other personal chattels of whatsoever kind or nature,left by decedent,together with the fairly estimated
market 'va~ue thereof;all bonds and mortga.~es held by decedent and of all claims due and OWing decedent
at the time of death,and all promissory notes or other instruments in writing for the payment of money
of which decedent died possessed,of whatsoever nature,wi th interest thereon,if any,giVing the face
value and estimated fair market value thereof,and if such estimated fair market value be less than the
face value,it sets forth briefly the reasons for such depreciation'as to each item;all moneys payable
to the estate from life insurance policles carried by decedent;all annuity and endowment contracts the
proceeds of which were payable upon the death of the decedent;and all the corporate stocks and dividends
due thereon and unpaid as of the date of death,bonds and a'ccrued interest thereon to the date of dece-
dent's death and other investment securities owned by the decedent at the time of death,with the market
value thereof at such time.
(Street Number)
(City or Town and State)
It'...,
In the case of securities of close or family corporations,the values reported are as far as
possible substantiated by financial statements of the corporations,showing the assets and liabilities
thereof as of the'date of death.The schedule also sets forth the interest of decedent at the time of
death in any co-partnership or business,and in support of the value of such interest there is annexed to
said schedule,financial statements showing the assets and liabilities of said co-partnership or business.
A copy of the co-partnership agreement,(if oral,a statement setting forth the nature of the agreement)
together with a statement setting forth the character of the business,its location,and such other facts
pertaining to the business as may.be pertinent to a fair and just appraisal of the decedent's interest
therein must be submitted.·It should also set forth in itemized form,together with t;he fair'market value
thereof,any other property owned or bequeathed by the decedent at the time of death.
The Schedule C attached hereto and made part hereof sets forth a true answer to each inquiry
contained therein and in the case of transfers ofproperty,real or personal,within two years of decedent's
death,in contemplation of decedent's death,or intended to take effect in possession or enjoyment at or
after death,said schedule sets forth the nature and value of such property,to'whom transferred,the
relationship of the transferees to the decedent,the proportionate share received by each transfe~ee and
all other facts of a pertinent nature regarding said tran~fers.In the case of t~a.nsfers intended to
take effect in possession or enjoyment at or after death,there is also attached to the schedule a copy
of the deed,trust agreement or other instrument creating the trust.Ther,~is a~so set forth in said
schedule a list of all property,real and personal,with its value,which passes at decedent's death by
virtue of the exercise by decedent,either individually,'orjointly with another,or any power of appoint-
ment vested in decedent,eittfer individually or Jointly,~bythe lYi1-l,deed,or other instrument of another,
with a copy of the instrument creating such power attached to the schedule.
That Schedule D attached hereto and made part hereof ~ets forth the names and addresses of all
persons beneficially interested in this estate at the time of decedent's'death~the'nature of their res-
pective interests,their relationship,if any,to the decedent,together with the ages at the time of
decedent's death of all minors,annuitants and beneficiaries for life under deced~nt's Will.It also
contains a statement showing which of the beneficiaries named in the decedent's will,if any,died prior
to decedent,the dates of their death,their issue,and the relationship of such issue to the beneficiary.
That Schedule E attached hereto .and made a part hereof sets forth all property,real and per-
sonal,owned by the decedent jointly with another or others,including intangible,standing in the name
of the decedent and others,plus the date and place of record of instruments effecting the vestiture of
real estate and the date of acquisition of personalty,plus the name,address and relationship,if any,
of co-owners to the decedent.
That Schedule F attached hereto and made a part hereof sets forth fully and in detail all debts
and deductions claimed for and on behalf of this decedent's estate,including funeral expenses paid;
family exemption,where applicable;costs of administration of this estate;counsel fees and fudiciary's
commissions paid or to be paid;cost expended for burial trusts,tombstones or gravemarkers,and reli-
gious serVices,in consequence of the death of the decedent;debts and claims owing and unpaid at time of
death;taxes accru~d chargeable for period prior to decedent's death.(except.those allowed under Section
651 of the Inheritance and Estate Tax Act);together With a statement of collateral pledged for obliga-
tions,if any.It is agreed that the fiduciary will present proof of said claimed obligations upon re-
quest,that if the amount actually paid in settlement of any fee,commission or debt is less than the
estimated amount claiming and allowed,that the same will be reported to the Register of Wills,and that
the amount of tax assessed can be reassessed in accordance thereWith.
That the totals of the appropriate colunms in Schedules "A","B", "C","E",and "F"as directed therein,.
have been carried forward and properly registered in the Summary.
SUbS~~and sworn to a:t:::-;-..;
..·..·······:·..···..·..·~···..>2·~·~19 .
..............................·:..·..·~·~~·~~~..·~~~~~~·~~~TA·~..~·;;~·Ir~~....7 ·..··..
'{COMMISSION EXPIRES Fe-B.8,l~..v
M TON V/ASH-IN.GTON COlt.'N1YWASHING,"
NOTE:Before signing affidavit make sure all blank spaces in the affidavit and schedules annexed are
filled in with details or the word "None",and in case the assets include rare and unlisted securities,
securities of close or family corporations or an interest in any co-partnership or business,that the
data and statements required under the paragraph above relating to Schedule "B"are attached.Also make
certain that colunm #1 in the "Summary"has been properly completed as above-directed.
RCC-38
,'''''''~--..'"':.
CCMMtJNWFALTH OF PENNSYLVANIA
THM\::;FElt TNHFltlTANCE TAX
RF.::.:rnENT DECEDENT
SCHEDULE "E"
JOINTLY OWNED PROPERTY
BSTRr('TIO~S:This schectule must disclose all property;'real and personal,owned by the decedent ,jointly
with another or others,including intangibles,standing in the name of the decedent and others.List
real estate first,as entireties,or joint tenants,giving brief description,as indicated tmder Schedule
"A",plus the date and place of record of instrument effecting vestiture,but do not include entireties
or out of state real estate value in estate valuation column.Personal property should be listed as in
Schedule "B",plus date of acquisition,and the name,address and relationship (if any)of cO-Q"wners to
the decedent.
Description of Property,Date of Acquisition,Name1uni t perce~t~;---£;tate
Address anel.Relationship of Co-Owners,and Place I Value Share Valuation
of Recorel.of Instrument,where Real Estate.I .
DEPARTMENT VALUATION
CAUTION-Do not Write
In This Space.
Value of
Entire
Value of
Decedent's
Property Interest
/000.00(p/'
5;/;;.y/1/2 5,182.9
.vJ-!::J.J~
11/.11/1,'....,.1/2 ~6,000.0Value$12,000.00
'1.Joint held bank account No.
7319,'western Pennsylvania
National Bank,Finleyville
office,William J.Mathies or
Mrs.Jessie Backstrom,opened
7/5/62.Balance as of date of
deatq -$10,365.81
\
2.Real ~state located in Union
Township,Washington county,
Pennsylvania in name of
William J.Mathies or Jessie
Backstrom as joint tenants
with right of survivorship.
(see Deed Book 1088,Page 546)
Insert this total opposite "Jointly Owned Property",Schedule ·"E"
in the "As Reported"column on the last page of this return.I
I
I
Total
RCC1-l?,,(\2-63.)
(,OI\1M~WE..\1:TH OF PENNSYYLANIA'
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "D"
BENEFICIARIES
RELATIONSHIPBENEFICIARIESANDADDRESSES(If step-children or SURVIVED DATE INTEREST OF
(State full names and addresses of all who ill.egitimate children DECEDENT,OF BENEFICIARYSTA'IE YES \,S Eh_a~_'e~an_i_nt_e_r_es_t...::,:.=ve~s-,-t=.;ed::..,...::..:::.co:::..::n:..::t~in.!...g_e_n_t_o_r_o_t_h_er-+_a.::...r~e..:....i_nv..:....o_IV..:....'e_d_._se..:..t_+--_O_R_'\--,;~..,~_-+-~""_B_I_R_T_H _--i IN_E_T_A_T _wise,in estate),forth this fact.)•
\
N/A \
\
I'
Deponent further says that all the above-named beneficiaries are living at this time except below:
NAME DATE OF DEATH RESIDENCE
~IATTER OF THE APPRAISEMENT
OF THE
ESTATE OF
Will
Administration !No.
DO THE
Year .
(Executor-Administrator
must complete "As
Reported"column #1.)
0 t-\~'"0 ::tl..,.I..,('l)('l)0 .IU ..,e:.en ~El en
en 0
~~(;':l '"0e:...,
IU ;..,0>:0--.en '"0'0~~0-'..,('l)
~o ..,
;-''0 -<
tr1 ('l)..,
en ........'<IU....('l)'
.~'-..~
WILLIAM J.MATHIES
Deceased
Late of ...lrin1eyville,Pa•.................................
REPORT AND APPRAISAL
Commonwealth of Pennsylvania
ST")I:,1 .:!::~11.1/SJY:;CluU.'U'Vt/,'TD'5Srw
o~3 -'1/.:)
'"
~\
,n:...
:>;r.
:>en
ott_
(;tv.,.........~
::::lr.c..
::tl('l)-
";j-0-..,c;c............
trJ Iii.~,"c:~
~:>~w ~g;~~?'"?'"?'".""::~\...:=.g~---
~-(fi-(fiffi
,~i
~:;.~:~!
-(fi-(fi-OO-(fi~-(fi
.-(fi -(fi ... .~.~:,,~<~:.~~,~.~,
~:~:''''-..:;......;
.~:
~.
:~:
Ie:;e:.:;gP-U
washinqton
o~=Ik'd
County of
THE SUM OF .,$.{£{~.:.:,z(j
"lJ::d~,Register of Wi II..Age.!
/DEDUCTIONS ALLOWED IN
...
STATEMENT OF DEBTS
AND DEDUCTIONS
", 1 '"
REGISTER OF WIllS
OFFICE OF THE
AND AGENT OF THE COMMONWEALTH
OF _W_a_s_h_i_n_g-='--t_o_n ',.....COUlVTY
Form RC C·10
ESTATE OF _W~i:.:l::..:l~l=.·=a~m~J~.--..:..M::a::...;t::.:h=ic.=e:...::s::...-_lATE OF _....:F~i..:.:n;;::l:..:e:..:y...v..;....;;;;i;.;;l:..:l__e~,___"P;..;a;.:...;;..._
//,-?/./C september 25,1968DATEOFFILINGAPPRAISEMENT__,;../--=::IU~"a0~/_--"?c:2....!:~:.......__DATi OF DEATH __--"'........-'-_
DATE NO.OF NAME OF PAYEE REMARKS AMOUNTVOUCH~JI
..
9/26 68 Walter L.Kennedy Funeral Funeral bill 1 096 80
Home ,
9/30 68 Finleyville Flower Shop Flower spray 42 40
·r,');..-·:.Kurtz Monument cuttino stone 14 00
First Presbyterian Church Balance on pledqe 25 00
Bloom Bloom,Rosenberg &Attornevs'fees 50 00Bloor
:-;;;t+~ooPt/j/016r,
-I i
J I-----
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF WASHINGTON
I.Jessie Backstrom HEREBY CERTIFY.THAT.TO THE BE8T OF
(l.S.l
ROWENE EBELING NOTARY PUBLIC 7
MY COMMISSION EXPIRES FEB.8,19!Hl
WASHINGTON,WASHINGTON CQUNW
SWORN AND SUBSCRIBED eEFORE ME THIS 8th'~:I October ,-.18 68~-"--'-"-IL P&-k~--
INHERITANCE TAX PURPOSES.
MY kNOWLEDGE AND BELIEF,THE FOREGOING IS A JU~l A"I0 TRU E STATEMENT OF DEBTS,FUNERAL EXPENSES AND EXPENS!:l!I 01"
ADMINISTRATION SUBMITTED TO THE ESTATE OF Wl llam J.Mathies DEC£A8ED,AS DEDUCTIONS FOR
~-all,/1'>12--&u~~OAYOf'~.
....j.J
'....t ...~
"
.,-
\..~
..'
,.
i.
I"
,I
"
I.
"
,..
,'';)
c...
C •
....J-1
-........
o
-y'---r-
rr;
t:J
I ".1
.;
[";i i .I.,'
,,.
RCC-81 (2-64)
.'....~-:.'
COMMONWEALTH OF PENNSYLVANIA
•DEPARTMENT OF REVENUE .
BUREAU OF COUNTY COLLECTIONS
INHERITANCE TAX DIVISION
NOTICE OF FILING OF APPRAISEMENT
JESSIE BACKSTf~M Informant
IN YOUR REPLY PLEA8E
REFER TO
'37-155-2
j
In Re:Esta te of ~W:.;..:I:;;;;L:;;;;L:;;;;I::.AM:::;1:.....:;.J..:.._'MA=T::.:H:.:.:I::.:·l!B=__
_____W_A...:.S.:.:H.::;IN:.:.:G::..:T:...:O::.;N~County -File No.63-68-1367
Dear Mrs.Backstrom:
You are hereby notified that the original
appraisement in the estate of William J.V~thies
has been filed in the office of the Register of Wills qf Washington
County on October 21 ,19~.Said appraisement reflects the
following valuations:
Real Estate _--'-_
Jt.Held ~__---'1~1::.j".=:18~2:<..!•..L91=--_
Transfers _
Total ---,-__1=1=...'""1~8l..=2........J.9.1__
As to such tax that is paid within three months ,from date of
death,a five (5%)percent discount is allowable.As to any tax that
remains unpaid after one year from date of death,interest at the rate
of six (6%)percent per annum is charged.
Any party in interest who is aggrieved by an appraisement may
appeal therefrom as provided by law.
Dat e ...:....-..:::O..:::c..:::t.:::.o.:::.b.:::er~2==1!::.J,L..-:l"..9~6~8~__
DATE OF DEA.TH:
September 25,1968
Note:This is not a bill.
Sigrie#le~r2l:.~Titl~W.R.C~EF APPHA~
\.
I'lCC-39 '\06-6;)
·COMMONWEAL TH OF PENNSYLVANI~
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
l.fATHIES;WILLIAl'-1 J.
FILE #63...68-1367
September 25,1968
SUMMARY
nBPonT OF INHERITANCR TAX APPRAISER
duly appointed Inheritance Tax Appraiser in and for the County of
,Pennsylvania,do respectfully report that I have appraised
property as reported in the foregoing return at the values set forth
the last column to the right in Schedules "A","B","C"and "E".
~:..J.:....:...---~~~I
INHERITANCE09-25-68
10-21-68
the real and personal
opposite each item in
Dated:
FILE #63-68-1367
I!the undersigned
#63 Washington
REPORT OF THE REGISTER OF WILLS
I,the undersigned duly elected Register of Wills in and for Washington
County,Pennsylvania,do respectfully report that I have allowed deductions in the amounts
claimed b;y deponent,except as to those i terns where a greater or lesser amount is set forth
in the last column to the right in Schedule "F",which greater or lesser amount represents
the sum allowed as a deduction.11,,/2;-4~~tf';.,A ~~'A1
Dated:10-2]-68 ~~-~~~LL
REGISTfR OF WILLS
VALUE AS REPo~rED VALUE AS APPRAISED VALUE AS REAPPRAISED
$'-$$,-,------
",
INVENTORY
Real Property (Schedule A)
Personal Property (Schedule B)
Transfers (Schedule C)
J oint-Held Property (Schedule E)
TOTAL GROSS ASSETS
LE~~Debts and Deductions
(SCHEDULE F)
ClEAR.VALUE OF ESTATE
11,182.91._
11,182.91._
~,228.2Q:=
9,954.71_
11,182.91
11,182.91
1~228.20=~-=========.-
9,954.71
======:=
Valuation of life estates or
annuities . . . • • . . •*-----
ESTATE TAX ASSESSMENTS $------
CO~WUTATION OF TAX
TOTAL TAX BALANCE
PAID
FOR USE OF REGISTER ONLY
Tax'on *.__!)%
T~x on $~l~~
Tax 'on ~9,954.71 ~
Tax on $.__lPi%
Exemptions :=(:::)
Total Estate _
TOTAL TAX
Less tax previously paid
;BALANCE
Less 5%of tax if paid within
3,months after death
JALANCE OF INHERITANCE TAX DUE
Add'interest at rate of 0%froril
to
AMOUNT OF ESTATE TAX ASSESSED
Estate tax paid
BALANCE DUE
Add interest at rate of 6%from
to
$-----'"-'-'----~------$__5.L.<9u..7o.!.:.2=8::....·_
$
$-----
$======~=*------
$======,=
*-----do~)------
(*)As evidenced by Charita~leExemption
Certificates issued by the ~~cietary
of Revenue.
$--------
$-------
$-------
*-------$---------$
FOR USE OF REGISTER ONLY,ADJUSTMENTS
NOTE:Where subsequent adjustments are made to the above computat.ion of tax by the
negiste~of Wills,for proper reason,same should be noted below,with short
explanation.
Will
Administration !No Year .
IN THE
MATTER OF THE APPRAISEMENT
OF THE
ESTATE OF
WILLIAM J.MATHIES
Deceased
Late of f :;U~q:'.F,;XJi:r..L.4.E..
County of ...WA~.l:~I.:N.(}TQN .
Commonwealth of Pennsylvani:,l
REPORT AND APPRAISAL
{'
I Fonn:RCC-2,
COMMONWEALTH OF PENNSYLVANIA DATE ..................Q.c.t.ob..e..r......21J .....1.96.B..................
I .DEP,ARTMENTOF REVENUE RESIDENT INHERITANCE TAX COUNTY ...........................~~.~..~~.~.~~...........................:BUREAU OF COUNTY COLLECTIONS ~..r
HARRISBURG.PENNA.17127 APPRAISEMENT FILE NO................??=.~.~::::~.??..?..:......................................
,
Whereas,....................................w.~~.g.~....~.~....!:'1:~~.h.~~.~..................................................late of ..............................~.~!}.~.~Y.Y.~.~~.~..........................................
in the County of .....................................~~.~~.~~~.?~................:................................:............Commonwealth of Pennsylvania,having died on
the ..................................?.5....~h............................................day of ........:....$.~p.t~P.~.r...................................19....9.?.,seized and possessed of an estate
subject to Inheritance Tax under the laws of the'Commonwealth of Pennsylvania;
Therefore,I,W.R.Chaney an appraiser duly appointed according to law,.....................................................t.i.................................................................................,
having been designated to make a fair and conscionable appraisement of the said estate,and to assess and fix
the cash value of all annuit~es and life estates growing out of said estate,hereby file the following appraisement:
In the event that any future interest in this estate is transferred in possession or enjoyment to collateral heirs of the decedent after
the expiration of any estate for llfe or for years.the Commonwealth hereby expressly reserves the right to appraise and assess transfer
inheritance taxes at the lawful collateral rate on any such future interest.
,-Unit AppraisementDescriptionofAssetValuesMadeforInheritanceTaxPurPOleS
$
..JT.HELD:
Joint held bank acct.No.7319,Western Penn.
National Bank.Finlevville office William J.
Mathies or Mrs.Jessie Backstrom 5,182.91 ,
Real estate located in Union Twp ••Washin,gton
County,Penn.in of William J.Mathies ,mamo or
Jessie Backstrom as joint tenants with right
of survivorship (see Deed Book 1088.page 5J...6)6.000.00
11 .182.91 11.182 ~n
.,...',
:.
Total ,-11,182 ~l
:
,.
-.
J..
'.,
"
I
form~;V~~hbl:~::~hi:W<>rrl~~~~:~~o~~e~*~r~~;is;:}i?:
AppraIser
;:;V;::'~~;;';';j.~:~~~./1 (PoSt 0 eel
~~.
..........................~'l.A$.tI.r.IiJG.'r.QN...............................c aUllty
RESIDENT INHERITANCE TAX'APPRAISEMENT
Estate of
WILLW1 J.IVlATHIES.....................
Deceased.
Late of
FIIf.L.EYVIl.LE..........................................................................
Date of Death,$..l:mt..f.:l.ID.9.~.:r ?5..,J.9.9.$.
Appraisemel!t Docket Vol.,.3.7.:.>::.:.
Page,J.5..5::?No 9.J..~.9..$.~l1.9.7..
Filed in Register's Office,Ogt..<?l;>.E:l:r.?;J,.J J99..$.
Amount of tax due,$..
DEPARTMENT OF REVENUE
Received,
Examined and Approved,..
Wrote abo.ut Appra.isement,
Appeal f"om Appraisement,.
.~,.
Entered and charged,
~:e-:.
-."..~
,~
_",I
'c..:.~.~
-.:'!t'"
«<
'*'
1ft.5 .JII
RESIDENT DECEDENTS
File No 63...69...1357
COMMONWEALTH OF PENNSYLVANIA~9FormRCC-4-RI-3-66
Date Octobor 25,19 68
No.979043 OFFICIAL RECEIPT
Transfer Inheritance and Estate Tax
Office REGISTER OF WILLS.,t{ASHINO TON Pal
tlA SHlNOTOtl County,ss:Received from Jessie J3ackstrom.Infomant
~~1~.Jl~miD.tft~e.U'J)I.~~~)of the estate of Y.rrr,J·IA~~J \FAT1!!t?S
who died ~c:ct~m'l;:-e~25,19-6..8.-,the sum of F'!VE ummmm sIX'rY-SIDTEN and 42/1(10 -Dollars,
being TRANSFER INHERITANCE TAX and/or ESTATE TAX due the Commonwealth as follows:
Appraisements Made and Filed Computation of Tax
NOTE:Thi9 Tripilcate Receipt to be retainsd by the Register of Wills cmd filed in Ilumerlcal
sequellce for audit purposes.'
i!:<\??~
$========
"....4j/'
--,~,j~
MOORE BUSINESS FORMS,IHC••ELMIRA.N.Y.
Less five per centum of tax if paid 29 86
within 3 months after date of death $,0
SEAL
Balance $_
597.28
Total'Tax $.
Less Tax Previo~slyPCrld (if any)$==========
-,
Amount of Estate Tax Assessed under
the Act'of May 7,1927.$_
Total $567,42
*As evidenced by Charitable Exemption Certificcles'issued by the Secretary of
Revenue under Act of May 28,1956,P.L.1757,effective June I,1957,as amended
by Act No,381,approved July II,1957,and Act No,207,1961,Section 302,
Add interest at the rate of %
from _
to --;-..,.--
Tax on $5%$
"·Tax on $10%$
Tax on'$9,954.11 G~Xl $
Tax on $15%$
Exemptions.*$
Total Estate $
31..155..2
$------
$U.182,.91
. $11,182.91
I
$1,228.20
$9.954.71
Valuation
VCiIuation
$,-------
$,------
Total
-.
!1[[R30 [PJ[LO@!A\1[[
Date
Date
Jt~Beld $11.182.91
$-----...,.--
Total
Total Gross Assets
Less Debts c:ind Expenses of
Administration
Real Estate
Personal Property
Clear,Value of Estate
Valuation of Life Estates or Annuities
Date 19__$.--------
________19_·_'~$=======
Estate Tax Assessmentsr I J ..
Date . .19__$----_-,,-.-
________19_'_'.~$===============
~I.l ~,~;\•
,NOTE:In accepting the !Tansfer inheritance tax on future estates.prior to the death ofthelifetenantortenantforyears,as evidenced by,this receipt,it is understood that the Com-
monwealth shall not be precluded or.prevented from hereafter assessing additional inheritancetaxatthedeathofthelifetenantortenantforyearswheneveritappearsthat9uchadditionaltaxmaybelegallydueandcollectibleforanyreasonwhatsoever.
'"
FORM RCC-4-RI
TRANSFER INHERITANCE and/or ESTATE TAL
RESIDENT DECEDENTS.
RECEIPT
37 155 2.Z>,
'DocketL-__~Page -,I~,jn_ce _
.'
Estate oLi -'-_
OFFICE OF REGISTER OF WILLS
WASHIIIDTON,
Pa------,\)o"r-e=t=c=t::-b~~-=r--.:o2r5-t.---_T6ri"g.
Date,19__
SIGNED AND SEALED AS PROVIDED BY
SECTION 1201.ACT APRIL 9.1929.P.L.343
AS AMENDED BY ACT MAY 15.1945.P.L.528
Register of Wills
1201 (g).,Act of April 9.1929.P.L.343.as amended.viz:-"To receive from Registers -of Wills all duplicate re-ceipts for taxes paid to them by executors or adminis-trators and to charge the Registers receiving the money
with the amount receipted for.The original of each such
receipt shall be signed and sealed by the Register of
Wills and transmitted to the executor or administrator.whereupon it shall be a:proper voucher in the settlementoftheestate.In no event shall the executor or adminis-trator be entitled to a credit 'in his account by theRegisterunlessthereceiptissosignedandsealedbytheRegisterofWills,"
Fill in below name and address of person to whom
tax receipt is delivered: