HomeMy WebLinkAbout94-00220
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ~UMBERLANO
} II,' , ul
ss I; '111:;
'Cjd Iilill'.l I) ,1 :19
CIl:, ,Ill
Cum: '"'" I'A
The petltloner(s) above.named swear(s) or afflrm(s) that the
statements in the foregoing l,etltlon are true and correct to the best
of the knowledge and belief of petltloner(s) Rnd that as personal
representatlve(s) of the above decedent petltloner(s) will well and
truly administer the estate according to law.
subscribed
~
Reg/sler
$--1: ~'IA_
I
No. 21 - 94 - 220
Estate of
FIONA M. BLOSSER
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW MM C ~ 10. 19-9.L, In consideration of the petition on
the reverse side hereof, satlsfactor~ proof having been presented before me,
IT IS DECREED that JACK I, BLOSSER
Is/are entitled to Letters of Administration, and In accord with such .findlns, Letters of Administration
are hereby granted to
JACK I, BLOSSER
FIONA M. BLOSSER
In the estate of
FEES
Letters of Administration ..... $
Short Certlncates(3) """".. $
Renunciation "....""."... $.
JCP $ li.nn
TOTAL _ L_19..oo
Flied." .M~QCH.. JO....... A,D. IL9L
25.00
9,99
ATIORNBY (Sup. Ct. 1.0. No.)
ADDRBSS
rHONB
Mailed letters and order to Administrator on 3-10-94.
ff?
I tIlOS, 121lf;V ~-OU
n.tfOH Hils
~EAlIFIC"IE UOOl
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WAIlNII~I.;: /I ,:, IUi(;~1 1(1 AI.IIII IIII~; (III.', 1111
TO DlJl'lll:AI/ IIV PII,HUl:, AI 1)11 "110 I ()(oIIAI>II.
COMMONWEAI.Tft OF PEIlN9Y1.'IANIA
OEPARrMENl OF HEAI.Ttt VITAL Rf,COROS
LOCAL REGISTRAR'S CERTIFICATION OF Of.ATH
CERT, NO, 1968774
12-26-1993
. '--'-(,;rr;'Q1Tilii'ili,rf;iij'{;..i1ifi(~iiiiii~--.
Name of Decedent _.
Fiona
rU'1
._/01...._
-- ~t':ldl,;'
Bl o~~er
-~. -~_. -- ..., ---~T:ili-'---.~_...__..__._-
SeK -__EarnlL_.soclal Security No,.___..JJ9::~4::~1Q3.. .... ... '._ ...0010 of DelllhJf.:.l2-199.~__.___
Dnle of Birth k~2.1945_.___...__. Blrlhplnco._ _.. ... . .$C:otlqnd. . ..__.... ""____", ... _______.__.
Place of DealtUni vers 1 ty of Pi tts.burgh ~Q~~LQflnt~r ... ___~J J!l\J~Ql'",-----_.._fJ.tt~Qur,g~",_f'!l[1IJ~\'f!DlJ!.
rl\Clhlt tl.mG (;'1",,1/ {:,t~ lI)'Ul!Ut, 0' r(j~"lllip
Whit!;)___.. Ocoupation ._..QJJ::rlc. _H _. _'_'" ...... . Armed Forcoo? (Yos or No) J'P.._.......__.__._
Decedent's
Marital Statuo Marrie.<1._. m_. Mailing Address96f1<MilrctSt.__.~OQJp.L~fk_11Q.22.._...._._ __ __________
Ij IOlt"" !d"'1J1 1>1'( U' IVIII! ~I.\ll}
Informant Jack I ,Blo...??,gL____....___ FUlleml Dirootor_An.tb9nt_~.M~SJ.OO.nDQL~r..._ _n.__________._._
Name and Address of
Funeral Establishment Anthonl~.MuSlffiQO.o .F.H.. .. 700 . 7th St. JtJ<.~1i.R~.K~.fa_.__J5J36 _.....__.____
: Interval Between
: Onset and Death
I
(a) __.._ Mul t 1 p J.~_ QrgQ[l..sY.?.t:~nJilJJI.l.~__ ...... ...---n---...-.._...____L.__.
I
(b) Pancreat jt1.L___.___._....._ ...-.--.---.-..__._m._______.___:.._________.
I
(cL___~nd Sta@..l,,J VeLQ1 S~gSe_ _no. '-'_'__ ..-.--.-....---------.-....L
I
(d)_ Hepat1t1s 9----..-...-.___._.,._...._____.---'-_._L_.:___~___
Part II: Other Slgnlfloant Conditions
Race
Part I: Immediate Cause
--
Manner of Death:
Natural l!O
Aocldent 0
Suicide 0
_.__..__._~._-~-~-----_.~...~_.__.~-_.__..._--------._----
Homlcldl' 0
Pending Invostlgatlon 0
Could not be Determined 0
Desorlbe how Injury Ooourred:
---------.--.-'.------..----.---
-----.---..---0-,.-.-----.--- ___._.___
Namo and Title of Certifier -.-----..--.--J.8!I.t]gOO?_IM...Q.~____...__.____..__. ._.____..___....___________.
(M,D., 0,0., Coroner, M.E.)
Address ----l.QQ.Jot.t1.t:9P.3.t-'---____._~m.?QtJrglll.ea.L...lS..2.1J. -......_..m.... .__.._______.__.
I
This Is to certify that tho Informallon hero glvon Is correctly coploct trom an orlgillal cortiflcate of
death duly filed with mo liS Local RoglslrRr. Tho, f.' IOlnal OOlIIfIO? will bo tarwo/'dod to the State
Vital Records Office for pormanent filing, If" {::'(I .-::
--11, 13,J9)3 1;' ~::r!:;~:~ks~a. '5~f;''-:,iC
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1~~~~'_';~'~~-4045-7460 1~';;~'~;9'~!
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3424,42 '/2.00!\
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JACK I BLOSSER
rIONA M BLOSSER
98 HOWARD ST
ENOLA PA 17025-2817
A 1'&, l' I/nlwrstil Cm'll
1';0,0601 9999
Colllmbll., GA 31997.0001
. ATa.T
Duplicate
Statement
A18!f Uni,'ersal Card'
I", 'II", ".,.,., I"
I Ii! III 1:\ 1'"',,,,'1.1,
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PAGE 1
I '''~~~~' ~"'~LOSSER
! ~~'9'~'~;'i'~'0-4045-7460 I
'$"'4~~'~ I ,,,d '$" 'S7'~ I
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12/14/93
AT&T Universal MasterCard
Ill"!, /.' Ih,' rlupl/('all'
,stlltl'nIl,'ml'CJlI
I'I'I{III','I<''':
Tranuotions
Post. Description T.:anulotion D.tll Mount
Dat.l'
IIlll PAYMENT RECEIVEO - TllIIlII< YOll l1/Jl 60,00 PY
II III .fINA.NCE CHARGE- CI\91f I\DVl\flC': FEE lllll 3,76
IIlll CONVENIENCE CHECR 1001 11/1l 150,47
Il/OI REDWOOD INN PITT98llRGR PA 11/19 83.50
Il/Ol ANIHllLIA III\ILEY In Il/OJ 793,00
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~'illl~11
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881.S5 1..'11, I"",.
1. 3250 I '.' "",
15,90 II. I,
11. 76 [
J, 761 '
17.4 I
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OL/OB/94 !'"" "1')1"0'[ 1
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2415,97
60,00
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876,50
150,47
41.48
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1\,I,,,I.IIIII!,,,rhtll:'
111I:IIILlllill\'!
1"1,101,, ,i"
19S9.S2
1.3250
15.90
25,96
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72,00
,00
72,00
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Tho AT&i Unlversol Cs,d 19 Iss~'ocl hy Unlvo"nl Blink, Columbus, Goornln
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STATEMENT
This bill Is lor sorvlces rondored by your phynlclnn, Sopnrnlo
bllln for related hospllal and modlcal sorvlcon mny bo forth-
coming,
B101mer, Fiona M.
, , .
SEE RevERSE SIDE FOR INSURANCE INFORMATION
_.., .....___....' __... ._On __ ._.~ ".,. ~- -- .' ." --.." . . .' -
._n.._..~__...___.. ....-.---..----~--.---..
05/16/94
5863999
.__.__._....~_4._'_.'.
TltlSIS" 5TAl'EMfNl OF6fIlVICf!lll( IWIIHIlIl'f
, PIlYSICIAPIS WUO.vI[ MLMO Il~ Of .
Fiona M. Blosser
9B Howard Street
Enola, pJ\ 17025
Johns Hopkins Universi~y
c/o Frank R. Shaulis
p, O. Box 1300
Glen Burnie, Maryland 21060
.. .n. .,.a........ .."
. . , "-II:~. 'Of:6CmPlION Qp,aenVlCE .. . .
A PLEASE REMOVE AND RETURN THIS PORTION WITH YOUR PAYMENT A
AMOUNT
09/24/91
09/25/91
09/26/91
Hsp Care Comprehen
Subsquent Hospital Care, Each Day Brief
Hospital Discharge Day Mgt
250.00 .
60.00
150.00
\ 05/16/94
'PAYMENTS RECEIVED AFTEfl THIS DATE
WILL APPEAR ON YOUR NEXT STATEMENT
l
Fi;~:":'~"'~.!OSS~E__~ L ~~;;~"~0
PAV TillS AMOUNT ..[
460.00
)
MAKE CHECK
PAYAOLE TO:
IMPORTANT MESSAGE REGARDING.'YOUR ACCOUNT .
. ... "..-. ....,..-.-.....--.-..----.-..--
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c.._____,___.
_. ....._._....._. ...~______._.___.___.~'_._.4__ ...
STATEMENT
This bill Is for servloes rendered by your physician, Separate
bills lor related hospllal and medloal servloes may be forth-
coming,
, ,
.SEIf'REVEFfsE' SiDE' 'FOR INS!lll~M(C-'.UI':!F.QI!MA'JQ~
05/16/94
.._._____...._...__.__.4.__.__ _
. . nnSIRA8'1'ATIMfNTOr&fnVICnnINOfIlHIIJ'l'
. , . ptlY51Ct NSWtlOAnE M[Mn(nSO~ '
Fiona M. Blosser
98 Howard Street
Enola, PA 17025
Johns Hopkins University
c/o Frank R. Shaulis
P. O. Box 1300
Glen Burnie, Maryland 21060
._--~._..._.-- -.-.--.-.---.
~.._.... ...~_..... ..-..- .--_.~-'
. PLEASE REMOVE AND RETURN THIS PORTION WITH YOUR PAYMENT .
DESCRIPTION OF 8!nVtCI!: I " ."...
02/24/92
02/24/92
Off/out Visit Est Pt, Level 5
Muscle Testing-Total Evaluation of Body: Includ Hands
_._u__._ _.. ._.__ _.... ....__...... .. _..__.n...._..__.._...
l 05/16/94 J l F:~~:.~':"~losser - ___J l__;~"~;:~~___J PAY TIllS AMOUNT .[
~ PAYMENTS RECEIVED AFTER TillS DATE MAKE CHECK
WILL APPEAR ON YOUR NEXT STATEMENT PAYAIlIE TU
AMOUNT
250.00
40.00
290.00
)
"
IMPORTANT MESSAGE REGARDING' YOUR' ACCOUNT .
--.---.--. ..---.-.-. -. ..--.-.-.
.....____~ ._.___._.____.__._.__..... .... . __. ._n.___
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STATEMENT
This bill Is tor services rendered by your physician. Soparnte
bills for related hospllal and medical servloes may bo forth-
coming.
I"!o._. .. ._.._._ .... 0" ,. . . .. . . p.. -.. . .h. .- ....
SEE RF.VERSE SIDE. FOR !~SUR~~.9JU~(;mMB.:r.19~.
Blosser
. ,
05/16/94
5864006
TUlS 18 A !ifATrMENT or S(hVICr5 m'tlOrnro nl'
, . PIIYSIC1M4! WtlOAnE M[MnrIlS or
Fiona M. Blosser
9B HCMard street
Enola, PA 17025
Johns Hopkins University
c/o Frank R. Shaulis
P. 0, Box 1300
Glen Burnie, Maryland 21060
f"!GI','il.(l
DESCRIPTION OP DEnVICE ' .
. PLEASE REMOVE AND RETURN THIS PORTION WITH YOUR PAYMENT ..
AMOUNT '
06/22/92
Hospital Discharge Day Management
150.00
I'
._._-_._-_.._-,._-_._.~..__._----_.--_._--
O^Tr
P^V TIllS ^MOUNT. ...r--
""l '150.00
)
l C :I.1n;lI..1,.,'1 ~ 1-- .1MM'llIn.m
05/16/94 J __ Fion~_.~~I}J.Q~_s.~~_ ._..__) l.__.?_8_6.~_9!>.6.uJ
~ PAYMENTS RECEIVED AFTER THIS DATE MME CHECK
WILL APPEAR ON YOUR NEXT STATEMENT PAYAOLE TO:
"
IMPORTANT MESSIiGE REGARDING YOUR ACCOUNT
1
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CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
I ;~ i .' :11 'j I
Name of Decedent I Fiona M, Blosser
(,l
Date of Deathl Dlcmter 12, 1993 CLI'
Will No, Admin, No, 1994-00220
-
,"
To the Registerl
I certify that notice of beneficial interest required by
Ru Ie 5,6 (a) of the Orphans' Court Hules waR served on or mailed to
the (ollowing bentfiCiaries of the above-captioned estate on
/lLd.' /1 'J.-:. I
~'J, '
Na~ Address
Jock I. Blosser
. ~ lbIard Street, Eoola PA 17025
2400 Mlrl<et Street ~rtrrent B-83 Harrisburg, PA
SooiJn I. Shap I ro
Notice has now been given to all persons entitled thereto under
Rule 5,6(11) except
Oatel {[US, ] I /991
.,
'i1f>!/.'!(l'/
S gnature
....
\-1rrt-Name Ilruce Bratton, ESQ,
f
,
~'(
Address tv'artsolf & Bratton
2515 N. Front St. P.O, Ibx 12106 Harrisburg, PA 17100-
2106
Telephone (717 )236-4241
Capacityl_____ Personal Representative
X Counsel for personal
representative
Blosser, FICX1a M.
1;~;2!~~ NUM:~~n_=~--1;~E1~~;;ATH ~~;;~R H
rn 1. Original Relurn [] 2, Supplem.r.tal ~elurn
[I 4, llmllod E,'a'e [] 40, Fulure InlerOlI Campraml..
Ifar dale. 01 dealh ah.r 12.12.82)
[] 6, Oe"denl Died Te,'ale [] 7, Oecedenl Malnralned a living Trull
lAllach copy of Willi IMach _~py of Tru.11 _
ALL CORRISPONDINCe AND CONPlDINTIAL TAX IN.ORMATION SHOULD III DIRIClID TOI
M JOM'lilE MAIIINO AODR!5S
J~~~,;..~ulDiils~r________._______________ 98 fb../ard St. Erola, PA
d!;PHONr= N Me II
tl1Z, - J 7}2-9765. 'n n I"
I. Real E.lal. ISchodule AI I 1) _________. _m__.....____
2. Slackl and Bondi (Schedule B, I 21_..___......___....____
3, Clalely Held Stack/Partno"hlp InlerOlllSchedule CJ I 31 ___.m'__ . . __..__.___
4, Marlgag.. and Nale. Receivable ISchedule D) ( 41 ._______......___...___._
5, Calh, 8ank Dopallll & MllCellaneaul Perianal Praperly( 51 _1J~~lZ,QJ_____
(Schodul. E)
6, Jolnlly Owned Properly ISchedule FI ( 6) ______~__
7, Tranlle" ISchodule G) ISchedule LJ ( 7) _..._..______.....____.__
8, Talal Grall Allellllalalllnel 1.71
9, Funeral ExpenlOl, Admlnhlrallve COlli, MI"ellaneau. I 9) _~l~_.QO_..
Expen.e. ISchedule H)
lD. Oebll, Morlgage llablllll... lien. ISchedule II 110)25J5J..flA~______
11. T 0101 Oeducllonl Ilalalllnel 9 & 10)
12, Nel Value of Ellale IlIne 8 mlnulllne 11)
13, Charllable and Goveromenlal aequelll ISchedule J)
14, Nol Voluo Sub eel 10 To, IlIne 12 mlnulllne 13)
15, Amaunl of line 14 la,able 01 6% role
(Include volUOl from Schedule K or Schodule M.)
16. Amaunl of line 14 laxablo 01 15% ralo
Ilnclude value, Iram Sch.dule K or Schedule M,I
17, Principal 10' due {Add lodrom line 15 and from line 16,1
18, Credlll SpaulOl Paverly Credit Prior Paymonll Ol"ounl InlerOlI
....---.-.-.---.---- + ..---.---.--...- +----- - ------.
19, If IIno 18 Ilgroolor Ihon line 17, enlor Ihe dlllerenco an line 19, Thh Illhe OVERPAYMENT.
11[J
20. If line 17 II grealer Ihon line 18, enler Ihe dlller.nce an line 20, Thlllllhe TAX DUE,
A. Enler Ihe Inferell an Iho balance due an line 2DA,
B, Enler Iho lalal 01 line 2D and 2DA an line 2DB, Thll II the IIALANCE DUE.
. Make Choc~ Payoblo tOI ..!logl.t" 0' WillI, ARont
.-.IIE SURITO ANSWIR ALL QUISTIONS ON RIVIRII SmE AND TO RICHICK MATH....
Under Plnaltl.. of perlury, I declare tholl have eKomlned Ihlt relurn, Including accompanying Iche'dulel and 'talemenll, and to the bllt of my knowledge and belief,
It I, lrue, ,orred and ~omplel., I declare Ihat all real IUlale hat bun reporled at trUlt markel value, Dodarallon of preparer olher than the perlonal repreltntatlve I,
~~lIln'or tlon of hich reparer hal any knowledge,
A 0 R ffAE sl- ORfIlINORllITR'fl~~~~ St~-~1~~-~^-17~25----------- DAl/; lr-i
!1 ,m; 0 -Tft~~1l\i( -~--------'DoHss-------'--------'-""------"-----'~-"-'---- DATE - -
- ilP,.. _._ c:' lU.tb.L<'_!-~:iL~5_1:_~_~~_~!:....!:?~_~~_~2~~__~~~~rg,_~ l~lOO- 'i/.3h4
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R!V.1500 IK+ 111.911
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INHERITANCE TAX RETURN
REiSIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
'OIDATlSO'DIA'HAnlI12131/91 CHICK HIli
lP A IPOU.AL , "1
POVlllY CIIDI' I~ CLAIMID c..J
'ILl NUMI..
00220-1994
'\
"~"~0t
",~j I,ll'
,..,':,!/..
COMMONWEAlTH Of PlNNSYlVANIA
DE~ARTMENT Of REVENUE
DEP!. 280601
HARRISBURG, PA 11128,0601
CEDENT'S NAMf IlAST, FIR-ST, "-ND.MIDD~E iNITIAl)
COUNTY CODE 21
T'S COMPLETE A[JORESS .
~EAR 1994
00220
NUMBER
98 lbiard St, Erola" PA 17025
County
Cl.l1ffirlard
[J 3,
Remolnder Relurn
(far dole. of dealh prior 10 12,13,82)
[J 5, Federal Ellale To,
Relurn Required
_ 8, Tolol Number of Safo Oepolll BOKo,
17025
(8) 11,317.00
(11)
(12)
(13)
(14)
28,622.00
-17,305.00
(151__Q.00
K ,D6..
0,00
0.00
(16) _____~..
K ,15 ..
(171
1181
1191----
Check tWIC if you ClIlt 'l'Clul'\llnH U H,lund of vour oVUlflClVlllent
120)
(20A)
120B) _
0,00
,
" , . .
'lIV-ll11I1:'I'.1I1
~~
COMMONWEAltH 0' 'ENNIYlVANIA
INHERITANCE TAX mURN
REIIOEN! DECEDENT
1 SCHEDULE H ~
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
. MISCELLANEOUS EXPENSES
PI.a.. Print or T .
nw
Fiala M. Blosser
ITEM
NUMBER
A. Funeral bp.n....
1.
1994-00220
DESCRIPTION
AMOUNT
B. Admlnl.tratlv. Co.t..
1. P.nonal Repre.entallve Commlulon.
Social Security Number of Personal ReprtleRtallvtl
Year Commlulon, paid
2, Attorney FII. Bruce F. Bratton, Esq. (717) 236-4241 $ 7CX),(Xl
MARTSOLF & BRA TTllJ
2515 N. Front Street, P.O.Box 12106 Harrisburg, PA 17100-2106
3, Family Exempllon
. .
ClalmaRt Jack I. Blosser . Relollon.hlp Slrose 2000.00
Add"u of Claimant at deceden". death
5trll' Addreu ffi fboIard Street
City Erola 5la'e PA_ Zip Code 17025
4, Probote FII. Letters of Jldnj nl straUal 154.00
srort Certificate \3l' ~th Certificate
C. MI.etllan.ou. .g".Im~~r of W I s Fi ling Fee .
1. Emest E. fnlsh,CPA E.I.# 23 2226539 . 250.00 .
2166 SardhlIl Road
2. . I1lrshey, PA 17033
3.
4,
5,
6.. "
7.
8. .
TOTAL (AI.o eRler on line 9, Recapllulbllonl S 3104.00
(II mar. .pae. I. n"d.d, Inltrt additional .hltt. of .am. "11.1
. ,I,. .
. I
Estate of Flooa M. Blosser
File ~r 1994-00220
11CM~ OE.,C;CRIPTIOO tmM'
-
7. to'edlcal Expense: $ 40.00
l.l1lverslty SUrgical Associates
Box 4lXm) W
PlttS:f1I. PA 15268
Account M199-34-9103
8. Presb~rlan l.l1lverslty fbspltal 2.25
P.O. x 360479-M
Pittsburgh, PA 15250-6479
Account H 02745127-3318
,9, to'edlcal Expense: 427.00
PERF- Presbyterian
P.O. Box 371790M
Pittsburgh. PA 15251-lXXll
Acount # 45518
10.' . to'edlcal Expense PsllltJursam 650.00
Possible lNerpa}lTelTt by
Capital Bile Cross
Claim H 9332616194500 & 9405419059500
\, Psferred to Collections Manager
c/o: Greg:lry J. Walclllan
Capital Blue Cross
Harrisburg. PA 17177
11., PA Irdlvldual Incare Tax ,877.00
Final Pstum
Social Security t{nmr: 199-34-9103
,.1 I
" , 1 "
12. Federal Irdlvldual Incare Tax " 8936.00
" . , Final Pstum
Social Security ttlltler: 199-34-910~
I- "
,
. TOTAL $25;518;00
, "
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Worley Motors, Inc.
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Susquehanna Avenue. Enola Road' Enola, PA 17026 · Phone (717) 732.2061
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~ RIY-ll1,.? EX APP 110-93'*
C_AL TIt OF PENlnYlVINl1
PEPI.I...N! OF R'VUU
IUIII'IU OF INOIVIDUIL lllEI
IlEPI. /U601
ttARMIIIlMQ, PA I,UI'UOl
/(/G
J;
NOTICE OF INHERITANCE TAX
APPRAISEHENT, AI.LOWANCE DR DISALLOWANCE
OF DEDUCTIONS, AND ASSESSHENT OF TAX
ACN
101
DATE 10-18-94
FILE NO.
DATI OF DEATH 12-12-93 COUNTY CUMBERLAND
NOTe I 1'0 INSUN! PROPER CREDIT TO YOUR ACCOUNT, SUBHIT THE UPPER PORTION OF THIS FDRH WITH YOUR TAX
PAYHENT Tn THE REGISTER OF WILLS. HAKE CHECK PAYABLE TO "REGISTER OF WILLS, AGENT"
REMIT PAYMENT TO:
JACK I BLOSSER
98 HOWARD S T
ENOLA PA 17025
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
~nount Rlnlttld
CUT ALONG THIS LINE ~ RI!TAIN LOIIER PORTION FOR YOUR RECORDS ....
iiEV: iS47 - iii - Aj:p- i 1 ii :m-- iloYici" -OF - "iNil Biiff ilNCE --fAx - jfpPRXi sEifENT ~- -At roiiiliicE - iili - - - - -- - ---- - - - - --
DISALLOIIANCE OP DEDUCTIONS AND ASSESSMENT OF TAX
IITATI! OF BLOSSER FIONA M FILE NO. 21 94-0220 ACN 101 DATE 10-1S-94
TAX RETURN WAS I (X) ACCEPTED AS FILED
( ) CHANGED
RiiiRiATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ONI ORIGINAL RETURN
1. Rod E.tlll (Sonldull A) 11)
2, Stookl ond Rondl (Sonldulo B) (2)
S, Clouh Hlld slook/Plrtnlrlnlp Inllrllt ISonldul1 Cl (3)
~, ""rt"~II../Notll Rloll.lbll (Sonldull D) (~)
&, C.on/Bonk Dlpoo1to/Hho, Plrlonll ProPlrty ISonldul. E) (&)
6. Jointly ewnld Proplrty (Sohldull f) (6)
7, Tronlfor. ISonldul1 G) 17)
I. Totol AlIOto
,00
.00
,00
.00
11,317.00
.00
.00
II)
11,317,00
APPROYED DEDUCTIONS AND EXEMPTIONS:
9. Funlrll EMpln.u/AdollnhtrIU.1 Co.hl
HIIOlllonloul ENplnll1 (S.nldull H) 19)__
10, Dobto/Horta_ Lllbllltlll/Lllnl ISohldul1 Xl liD)
ll, TolIl Dlductlonl
12, NIt VduI of TIN Rlturn
IS. Cnlrllobll/Do.lrnaontll Blqul.tl (Sonldull J)
14, NIt 'lIt.. of Eltotl Subjlot to ToN
3,104,00
25,518.80
(11)
(12)
I1S)
(14)
28,622.80
17,305.80-
.00
.00
If In a.....M.nt wa. i..u.d pr.viou.ly, line. 1,., 15 and/or 16 and 17 will
r.flaat figur'l that inalud. th. total of ALL r.turn. a.....ed to datI.
A881!88MENT OF TAXI -
11. Aoaunt of L1no 14 t...bl. It 6% rltl 11&)
16, Aoaunt of Llnl 14 toN1lb1o It 1&% rlt. (16)
17, Prlnolpll TIN Duo
TAlC CREDITS I
PAYHENT
DATE
NOTE I
,DO
,DO
X .06 .
X,l& .
(17)
.00
,DO
.00
RECEIPT
NutlBER
DISCOUNT I')
INTEREST 1-)
ANOUNT PAID
TOTAL TAlC CREDIT
BALANCE OF TAlC DUE
INTEREST
TOTAL DUE
.00
,DO
.00
.00
J
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN II, NO PAYHENT IS REQUIRED,
IF TOTAL DUE IS REFLECTED AS A "CREon" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
RESl:R'lATlOH,
Pt.llPOSEOF
HOlICEI
PAVIENr.,
REFUND (CRI'
DBJECTlDHS I
.ADltIN
ISTAATlYE
CDRREClIDHS ,
DISCDlJNT'
INTEREST,
..~
"
.,
'.
,;'
Eltlt" of dIcIldlnh dYSng on or before OftHblr 12, 1912 ..... If any future intlr..' In thl IItltl 11 trenlflrrld
In po.....lon,or ."joVHnt to ell.. I (coUI,.r.U bln,flai.rl.. of ,thl dlcldlnt Ift.r thl Ixplr.Uon of eny ..tll, for
Uf. or for yur., the Ca.onwe.1th hlrebv ,)Cpr.lIly r".,vII the rllht to Ippr.h, BOd I"'" trlnl'It' Inh.,ltancl Tlx"
It the llWful Cll111 I (COUlt"IO 'rat. on _'IV luch future lntsrl.t.
To fulfill thl r,qulre..ntt of Station ~140 of thl Inh.rltancl end E,tlt. riM Aot, Act 2Z of 1991. 12 P,S.
Slatton 2140.
Detlch the top portion of thl, Hotlel and subllt with your plv..nt to thl RIgI.t,r of Willi printed on thl r.ver'l ,Ide.
nHollI chock or oonlV ordlr pIvlIIIl1 '0' REalSTElI OF NILLS, AaENT
All Plytttnh rtcllvad ,hlU flr.t be tppUtd to Iny lnttrllt which ..y b. due with any r...lndtr applied to the tllC,
A rlfund of I tllC crldlt, which wal not rlqueltld on thl TalC Rlturn, lay bl r.qullted by eOlplltlng an "Applloltlon
for Rlfund of PIM.ylvanla Inh,rJtano. and Eltat. TalC" (AEV-UU)' Appllcatlon. ar. aVIU,bl. at the Offlol
of the Alght.r of NUll, .ny of ,the 2S AIVlnue Olltrlot Offloll, or by tailing thl IPlclal Z4-hOur
anlwerlng .ervl01 nu.blr, for for., ordlrlngl In Plnnlylvanll 1.800~~62-2050, outlJdl Pennlvlvanll and
wUhln locII Hlrrllburo Ir.' (717) 787-a09It, TOO. (717) 772-U52 (Hllrlng 1~,lr1d Onh),
Anv party In Inter..t not ..tltflld wUh th. appralu'tnt, 11Iowanol or dlllllow.no. of deduction" or a.....nnt
of tllC (Including dltoOUflt Dr I"tarllt) II .hown (In thll Notle. IU,t objlct within 11Mb (60) day, of reollpt of
thlt Notice bYI
~RwrIU.n protllt to thl PA Dlplrt.lnt of Revlnul, loard of APPllh, DEPT. 281021, Harrhburg, PA 1712a-l0t1', OR
....ll<ltlon to hlVI thl I.tter d.ter.IMd at audit of thl tocount of tht p.rlonll r."rtltntltlv., OR
"'eppall to the Orphan,' Court.
Faotu.l arrOrl dl.oov.red on thlt .........,t lhould b. addre...d In wrttlng tOI PA o.par tllnt 0' A.v.nue,
aur.au of Individual TaICII, ATTNI Po.t A.......nt A.vllw Unit, DEPT. 210601, Hlrrt'bUrg, PA 1112a-0'0\
Phone (117) 7'7-6505. SH plgl 5 of the bookllt "lnl,rucUon. for Inherlt.nol h)( Alturn for I Allldlnt
Dle.dent" (REV-lsOt) for an IMpllnatlon of Id.lnl,tratlv.lY corrlotabll .rror.,
If any tI)I due It plld wltnln thrH (5) cahndlr lanthl aftlr the d.c.d.nt'l d..th, I 11\/. Plrcent (5:0 dltclKA1t of
thl tllC plid II tllowed.
Intlr..' II chtrgld beglMlno with flret d.v of d.lInquency, or nlnl (9) aonth. and OM (1) dlV fra thl dltl of
death, to thl (lIt. of P......"t. TllClI which blc... dlllnquent blfore JlnUlry 1, 1912 b.llr Intlrllt It thtl ratl of
,tlK (6iO Plrcent per annul cllcullted at I d.lly ratl of .OD016~. All tl.1I which biOI" dlllnquent on and Iftlr
Januarv 1, 1912 wUl bllr Intlrut It . ret. which wll1 v.ry frol cehndar Yllr to c.lender nar with thlt ret,
~uncld by thl pa DIPlrt.lnt of Alvlnu.. ThI appllclbll Intlr.ot r.tl' for 1982 through 1994 Irll
Vllr Intlrut A.tl nlllY Intlr.,t Faotor ~ Int.rl.t Alt. DIUv Intlrut Flctor
-
1912 m ,00ml 1916 lOX ,000214
I9IS 16X .omsa 1911 9X ,000211
1914 m .DOOSOI 1911-1991 IIX ,000501
1915 m ,000SS6 1992 9% ,000211
1995-1994 IX ,000192
uIntlrallt 11 ollCUlatld II follow'l
INTEREST 0 SALANCE OF TAX UNPAID X NU"IER OF DAYS DELINQUENT X DAlLY INTEREST FACTOR
R-Any Hottel 1.lued .ft.r thl talC blCo." d,llnquent will r'fl.ct an tntlr.., clloulltlon to flftl,n (1&) dlV'
blvond thl detl 0' the ........nt. If pIYllnt It ..dl Iftlr thl Intlrtlt OOlputetlon dati .hown on the
Not~C', Iddltlonll In',rl,t au.t be cllcullttd.