HomeMy WebLinkAbout95-00655
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tNHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONWfA\TH O. PfNNlVIVANIA (TO BE FILED IN DUPLICATE
Df'''''"MfNT Of REVENUf )
HA'''S~J:6. ~~O~:"~601 WITH REGISTER OF WILLS COUNTY CODE
DEClDIN '. HAMill.' .'" . AND MIOOH lNI tALI D(CfOIN"~ (OMPUI( AOD~U'
G
REV. 1500 EX. 11.9'1
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'OR OATIS OF DIATH AmR 12/31/91 CHICK HIRI
I' A SPOUSAL
POVIRTY CRIDIT IS CLAIMID 0
'Ill NUMBIR
YEAR q 5
fpSS-
NUMBER
Iii
III
III
C>
G1PE MARY K.
'OCIAl $(CUIUn HUMIU
Cumberland County Nursing Horne
.Al' Of ""H 375 Claremont Drive
Feb. 24, 1899 co&;;; rlislc PA 17013 Cumberland
SOCIAL neURlfY HUM'U AMOUNT .((UVEO ISlE INSllIUCTlON51
205-09-1396
l!!
..:!5l:1
IlllE..
:lCC>9
u~..
[id 1. Original R.furn
Remainder R,turn
(for dOl., of death prior to 12.13.821
Fed.ral eliot, To.. R,'urn Required
o 2. Supplemental Return
03.
05.
..!LO.
04.
06.
limited Eata'.
o "0. future Inf.,.., Compromls.
(for do'.. of death oft., 12.12.82)
o 7. Oeceden' Molnlalnad a living Trult
(Anoch copy of Trult)
bENTIAl>1: N . JlON\S QULDllIE U1EClJEQ'.TOI
COM'UIE MAILING II
5 South Hanover Street
Carlisle, PA 17013
D.c.d.n' Di.d T ..101.
fAlloch copy of WillI
Total Numb., of Sa', a,polu Box..
:1l1ii
00c>
00..
82
1'-, '1"-' -- ,--,r;..",~r.<,-
"\",~~..1,: .': .J!.b~.:....~~'.
'"
~.. ...~.:"'T.~,_.,u.~ il.r1if'J{i!&:,! "Itr~;..'f~'lf
\.<.....__~....'.t. L.tt.h.~:,;...:..L11i/.t.:.L'''l-
Frey and Tiley
nUPHONE HUMIU
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i
III
00
I. R.al E.lal. (Sch.dul. AI f 1 )
2. Slock. and 80nd.(Sch.dul. 0) f 2 I
3. Clollly H.ld SlockIPartn...hlp Inl''''I(Sch.dul. c) f 3 )
... Mortgage. and NollI Receivable (Schedule 0) ( 4 J
5. Ca.h, Bonlc D'POIIII & Mllullan.ou. Penonol Prope,ly ( 5 )
(Sch.dul. EI
6. Jointly Own.d Prop.rty (Sch.dul. fl f 6 )
7. Tran"... (Sch.dul. GI(Sch.dul. LI (7 )
8. Total Grall A..... (toloIUn., 1.7)
9. Funeral ExpeRt.., Admlnllrrotlvl COlli, Mlle.lIaneoul ( 9 )
Explnl.. (Sch.dul. HJ
10. O.blt, Mortgao. Uablllll.., U... (Sch.dul. II (101
11. Tolal O.dudlon. (Iolollln.. 9 & 10)
12. Nt. Value of Eslal. (lIn. 8 mlnul line 11)
13. Charitable and Governmental aeque," (Schedule JI
lA. Net Value Sub ectto Tax (lIna 12 mlnu. lIna 13)
15. Spoulal Tran.fen (for dole. of death after 6.30.9"1
See In.lrudlon. for Applicable Percenlage an Reverse (15)
Side. (Include value. from Schedule K or Schedule M.I
16. Amount of line I.. laxoble 01 6% rot. (16)
(Indud. valu.. from Sch.dul. K or Schedula M.)
17. Amount of lIn. 1.c taxabl. at 15% rat. (17)
(Indud. valu.. from Sch.dul. K or 5ch.dule M.)
18. Prlnclpallax due (Add lax from lInel 15, 16 and 17.)
19. Credlll Spaulal Poverty Credll Prior Payment' Di,caunl
Inlorllt
5,456.84
21,766.03
( 01
5,456.84
21,766.03
(16,3U9.1llL
(11)
(121
(131
(141
IH1,309.19J
)(._CI
)( .06.
)( .15 a
(10)
+
+
(19)
120)
20. If line 191, greoler than line 18. ent.r the dlKeren,e on Line 20. Thl'I' th. OVERPAYMENT.
m O..rnr:I!'II....n_I_....I._.II...I.I.I'I~'III.,.......lmm.-:'l_....I.,_.......U!1...IIIUII
21.
(21)
121AI
1218)
j
(
. .
Act '48 of 1994 provld.. for the reduction of the tax rat.. Impo.ed on the nit valu. of trand.,. to or for
the u.. of the .pou... Th. rat.. a. prl.crlbld by the datut. will b.:
. 3% (.03) will b. appllcabl. for ..tat.1 of d.c.d.nll dying on or aftlr 7/1/94 and b.for. 1/1/96
. 2% (.02) wIll b. appllcabl. for ..tat.1 of d.c.d.nll dying on or aftlr 1/1/96 and blfora 1/1/97
. 1% (.01) will b. appllcabl. for ..tat.1 of d.c.d.nt. dying on or aft.T 1/1/97 and blfor. 1/1/98
. Spou.al trand.,. occurring on or aft.r 1/1/98 will b. .xempt from Inh.rltanc. tax.
PLEASE ANSWER THE FOLLOWING QUESTIONS
BY PLACING A CHECK MARK (....) IN THE APPROPRIATE BLOCKS.
YES NO
1. Old d.c.d.nt make 0 transf.r ond:
a. rltaln th. us. or Incom. of th. prop.rty tronsf.rr.d, .......................................................
b. r.taln th. right to d.slgnat. who shall us. th. prop.rty transf.rr.d or Its incom., ...............
x
x
c. retaIn a reversionary interest; or .,.................................................................................
x
X
d. r.c.lv. the promise for Iif. of .lth.r paym.n.s, b.n.fits or car.' .......................................
2. If d.a.h occurr.d on or b.for. D.c.mb.r 12, 1982, did dlc.d.nt within two y.ars pr.c.ding
d.ath transf.r prop.rty without r.c.lvlng od.quo.. conlid.ration' If d.ath occurr.d alt.r
Dlc.mb.r 12, 1982, did d.c.d.nt 'ransf.r prop.rty within ani y.ar of dlo.h without rlc.lvlng
adlquat. consid.rallon'.......... ....... ............... ...... ......... .................. ..................................
X
X
X
3. Old d.c.d.nt own on 'in 'rust for' bank occount at his or h.r d.ath"'....................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YESr
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
"
1l1~ISOIllf rut)
'*'
SCl'rIEDULE E
CASH, BANK DEPOSITS AND
MISCELLANEOUS
PERSONAL PROPERTY
Plea.e Print or l .
.
FILE NUMBER
COMMONWfALTH OF PfNNSYlVANIA
IHHIIJTANCI 'AX .m'N
1.IIDIN' DICIDIHT
ESTATE OF
MARY K. 01PE
CAli proJMrfy lolntlr-own,d with the Right o' SUfvlvonhlp mu" be dlnl...d on Schedule PI
ITEM
NUMBER
DESCRIPTION
VAWE AT
DATE OF DEATH
3,636.81
1,629.23
190.80
1.
Bal. Farmers Trust Company burial account 111-395904
Bal. patient account, Cumberland County NursIng Home
Blue CraBB/Blue Shield check
2.
3.
TOTAL AI.o enler on line 5, Reea lIulatlan S
5,456.84
IAttoch additional 8W' )C II" ,hUll If mor. 'pOCI It n..d.d.)
OFF/CI/.\L CHE~/
VJy
May 30.
Home*************************************** '
. -lrARM!!flS ~MM'
.. rfl~-M~
M""OIIlEMlnEll' for ,burial of Mary K. GlpQ
SSN: 205 09 1396,' clostngPBt-395904
.-I7<""''''E_''T~A''''''l_ '",-_. .
f>wl~...... "._. HA.,-...eo:;;;.;.......".EI9I"';""'Co!orJ40
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n 0
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.....
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5 ~
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OJ ~:i'g
ID I-' J: ":]
..... !" ~ a;
~ a; p
n .... ~ C't
1I> ID' 0'
. 0 "l
~ .... ~ ~
~ ~ 18'~
-mmu
I .
FARMERS .
", TROST. '
, ,ClrfllJr. rcnns)'I~.nl. f7QU
m
PAY~O'r:OF Lininger-Fries Funeral
-I
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I OJ~
.!i so n
.....0
. 5
C't
fit fit
61-357369020
19..2L MiA
1$ 3,636.81******
s
DOLLARS
~~
nQ d:.l> ~n".l~~ :>::
~~lI>..nll>P""""~lI>~o~lI>~lI>
C't1D~lI>OS ~oo~ ~1I>~1I>C't
C't <; t: II> 0 ID P ~ .... <1' 0 'C ~0Il II>
~~~on<"1D ID~~~ID ~.....
P 'C.... ;:T P> 'C ~ P> .. ...."'l II> ~ ~ .. I
llIlns .....;:TID~..~ ~P><I><1'''
;:TlDn.. P>.....~~<I>..~<1'~<I>1D
~P>plDlI>......... p>0~'C~~"~1D
p>~~a~~C't..pp ~ao'C .....
<1'llIl 1I> <: 0 I 1I> (,Q p> n II> l:l II> 0' ID
lI>~P>C'tI-"S"~~""'lI>"'lC't 'CO~
"pll>n ID<S ~ Oll>llIO
OI~'1l1>li?;P>~IDIDC'tO p'1ll;'n
P:.I "l ~.....nPPt-'.....~~ ~ ID
ID.... 1D'111>1I>C't~"" 1I> ::SID"
S"lIDIDP"~'" ~""<lll>onll;'
o np~I-" ~Uln"""l:lC'tll;'lI>
P:':~~ ::sn <:C'tIl>O~O'~P<t
~n..... ....llIlO ~1D<1'~lI>lDnO~
aQ~o..... p lI>....lI>lI>"'l~llI~S
1D~C't<tol:Iln ~.... ~a .......<1> ~
P ID ~;:T~ 0 ~ ~ n.. 0 . <I> a ;.0
C't'lI>lI>lI>SlI> P"D" PP ~o ::l
. .. '1 ~ ID <t (,Q 1I> 'C ~llQ OIl ~ ~l;l.
. . c>> '1 ...... . a....
....n.... ID < 1I>::<: III ID
~P>t:< p...... II> P.....
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CD' CD ~ 01 C1" ~
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ID ID C't P 11>.....
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11'1111111. (1"1J
SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
Pllall Print or T I
'*
COMMONWU.LrH 0' P!NNSYLYANIA
INHUITANC! TAX UTURN
RlIID!NT D!CtDtNT
MARY K. OIPE
ITEM
NUMBER
DESCRIPTION
AMOUNT
A.
Funeral Explnll"
Lininger-Fries Funeral Home, funeral services
3,925.00
1.
B. Admlnllfrall... Calhl
1. Porsonal Reprollntatlve Camml..lanl
sadal slcurlty Number of Porsonal Rlp..llntotlve,
Vlar Comml..lan. paid
2. Attorney Fo.. - minimum
3. family EXlmpllan
Claimant Rllatlan.hlp
Addro.. of Claimant at dlcedent'. dlath
Street Addro..
City State Zip Code
... Probate Fo..
C. Mllclllanlou. Expln.I.1
1. Register of Wills, flllng Inheritance Tax Return
2. PA Department of Public Welfare, claim
3.
...
5.
6.
7.
8.
500.00
15.00
17 ,326.03
TOTAL (Alia enler an line 9, Recapllulallan)
(If mare 'pacI I. nlldld, Inllrt additIonal .hllt. of .aml .1.1.1
s
21,766.03
.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION. CASUAL TV UNIT
P.O. BOX 8400
HARRISBURG, PA 17105
July 24, 1995
ROBERT M FREY ESg
5 SOUTH HANOVER STREET
CARLISLE PA 17013
Estate of. Gipe, Mary
C/R. 21-0071101
Date of Birth. 1-24-1S99
Social Security" 205-09-1396
Dear Attorney Frey,
Please be advised the Department of Public Welfare maintains a claim in
the amount of $17,326.03, aqainst the above-mentioned estate. This claim is
for restitution of medical assistance qranted on behalf of the decedent for
which the Probate Estate is now responsible to rsimburse the Department
according to Act 49, 62 P.S. 1412, effective Auqust 15, 1994. Enclosed is the
Department's itemizsd Statement of Claim.
A portion of this medical expenso, namely $12,705.52, was incurred
during the last six months of the decedent's lifel therefore, it is a Class 3
olaim pursuant to section 3392 of the Decedents, Estatee, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the Claim, namely $4,620.51, is
to be entered as a priority Class 6 claim aqainst the estate.
Please acknowledqe receipt of this letter and adviee whether the
Commonwea1th's claim is admitted and when payment may be expected.
Thomas H Gar lic
Claims Inveetiqation Aqent
(717) 772-6725
Enclosure. Statement of Claim
i5 - ,/&' .'.J
R!V-1547 !X AFP (12-94*
CDHttONWEAL TIt OF P[NHSYLYANIA
DEPARTMENT Of' REY[NlJ[
IURfAU Of INDIVIDUAL TAXfl
DEPT. lIO'O I
HARRISBURG, PA 171"-0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT. ALLOWANCE OR DISALLOWANCE
Of OEDUCTIONS ANO ASSESSHENT Of TAX
ACN 101
DAT! 12-18-95
o FIL! NO.
DAT! OF D!ATH 05-11-95 COUNTY CUMBERLAND
NOTE. TO INSURE PROPER CREOIT TO YOUR ACCOUNT. SUIHIT THE UPPER PORTION Of THIS fORH WITN YOUR TAX
PAYHENT TO TNE REOISTER Of WILLS. HAXE CHECK PAYABLE TO "REOISTER OF WILLS. AGENT"
REMIT PAYMENT TO:
FREV & Tl LEY
5 S HANOVER ST
CARLISLE
PA 17013
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
A.ount R..itt.d
CUT ALONG THIS LIN! ~ R!TAIN LOll!R PORTION FOR YOUR R!CORDS ~
iiilj:is4i-iif-APji-nZ":94Y-iiifficiuo"-YNHiiiifANCE-YAX-iipjiitiiisEifiiir-;-.U.'LoiiANCE-ijli-----------------
DISALLOllANC! OF D!DUCTIONS AND ASS!SSM!NT OF TAX
!STAT! OF GIPE MARY K FIL! NO. 21 95-0655 ACN 101 DAT! 12-18-95
TAX RETURN WAS. I X I ACCEPTED AS fILED
R!S!RVATION CONC!RNING FUTUR! INT!R!ST - S!! R!V!RS!
APPRAIS!D VALUE OF R!TURN BAS!D ONI ORIGINAL RETURN
1. R..l E.t.t. (Schedule A) (1)
2. stock. and BondI ISchedule IJ 12)
S. Clo..1~ Held stock/Partner.hip Int.r..t (Schedule C) IS)
~. Hortgag..IHot.. Receivable (Schedule DJ (~)
5. C..h/lank Depoaita/Hilo. Perlonal Property (Schedul. EJ (5)
6. Jointly Owned Property (Schedul. fJ (6)
7. Tranafer. (Schedul. OJ (7)
8. Tot.l A...t.
I CHANGED
.00
.00
.00
.00
5.456.84
.00
.00
(al
5.456.84
APPROV!D D!DUCTIONS AND EXEMPTIONS:
21,766.03
9. Funeral EMP.n.../A~. Coat./H1.c. E~p.nle. (Sch.dul. H) (,)
10. Dobt./HortGooo Llobllltlo./Llon. (Schodulo II (101 .00
11. Totol Doductlcn. (11)
12. N.t Value of T.~ Return (12)
15. Char1t.bla/Gov.r~ant.1 aaqu..t. (Schedul. J) (15)
1~. Not Voluo cf E.toto Subjoct to Tox 11~)
NOT!I If an aBBBBlmBnt waB 1BBuad prBv1auBly, 11neB 14, 15 and/or 16, 17 and 18
reflect f1gureB that 1ncludB thB total of ~ rBturne aBBBBBed tD dBte.
ASS!SSM!NT OF TAXI
lS. A.ount of Line 14 at Spou.al rata (15)
16. A.aunt of Lin. 14 ta~ab1. .t Lina.l/Cl... A r.t. (16)
17. Aaount of L1n. 14 t.~.b1. at Co1l.tara1/Cl... 8 rata (17)
1a. Principal TaM Du.
TAX CR!DITSI
PAYHENT
DATE
1'1 . U~ 03
16.309.19-
.00
16.309.19-
will
.00
.00
.00
X. DO.
X .06.
X .15.
IlII
.00
.00
.00
.00
RECEIPT
HUHIER
DISCOUNT C.)
INTEREST I-I
~ PAID
TOTAL TAX CR!DIT
BALANCE OF TAX DUE
INT!R!ST
TOTAL DU!
.00
.00
.00
.00
. IF PAID AFTER DATE INDICATED. SEE REVERSE
fOR CALCULATION OF ADDITIONAL INTEREST.
If TOTAL DUE IS LESS THAN '1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS RE'UCTED AS A "CREDIT" ICRI, YDU HAY IE OUE
A REFUND. SEE REVERSE SIDE Of THIS FORH FOR INSTRUCTIONS. I
~',) ()
I'!,
RESERVATION, E.t.t.. 0' ~c~t. dying on or be'or. Dec.-ber Il, 191' -- I' any 'utur' Int.r..t In the ..t.t. I.' tren.'.rrad
In po.....lon or enJovlent to Cia.. . (collat.r.l) b*"-'Iclarl.. 0' the ~c~t .ft., the .~plr.tlon 0' anv ..t.t. for
II" or 'or v..r., thl C~.lth h.raby a~Pt...ly t...rv.. the right to appr.I.. ~ ...... tran.'ar Inharltenc. T.~..
.t the IIM'ul CI... I (coll.t.r.l) r.ta on an1 .uch 'utur. Int.r..t.
PUIPOSE OF
HOTICE, To 'ulflll the raqult.-.nt. of S.ctlon 21~0 0' tha Inharltine. and E.tat. Tax Act, Act 22 of 1991. 72 P.I.
bctlon lIU.
PAMHT1 Detach the top portion of this Notice and .ubalt with your paVlant to the Reght.r of NUll printed on the r.v.,.a side.
u"lIk. check or MJftIV order pavable tal REGISTER OF MILLS, AGENT
All p.yaant. rlcllved shall flr.t bl appllad to any Intlr..t which .av be due with anv ra'.lndar applied to the tax.
RfF1.Ml (CA)I A r.fund 0' . t.x credlt, which WII not r~.t.d on the T.x R.-urn, IIY be r.que.t... by cc*plltlna .... ....ppllcatlon
for R.fund of Penn.vlvanl. Inherltanc. and E.t.t. T.x" (REV-ISIS). Application. .r. av.II~I. at the Dfflc.
of the RI,I.t.r of Will., any of the 25 R.v~ DI.trlct Offlc.., or by clllln, the .p.cl.l 24.hour
.....werlna ,.rvlc. nuabar. for for.. ordlrlna' In Penn,ylvanll I-IOD-S62-2D50, out.ldl Penn,ylvanl. ~
within loc.l H.rrl.bUr, .r.. (717) 717-Ia", TDDI (717) 772-2252 (H..rlna 1~.lr'" Only).
OBJECTIONS, Any p.rty In Intlr..t not 'Itl.flad with the IPPr.I...-nt, allowencl or dl..llowancl of ~tlon', or .....lIent
of t.~ (Includln, dl.count or Int.rl.t) a. shown on thl. Notlcl au.t obJlct within .I~ty (60) d.y. of r.c.lpt 0'
thh Notice by,
--written prot..t to the PA D.p.rt..nt 0' R.v.nue, lo.rd of App..I., D.pt. 211021, H.rrl.bUrl, PA 17121-IOZ1, OR
--allctlon to h.v. tM .att.,. d.t.nlnld at INdlt of tha ICCount of tha p.tlOMI tlprllant.tlv., OR
--."..1 to the Orphan,' Court.
ADttIN
ISTRAlIVE
CORRECTIONSI
INTEREST.
F.ctu.l Irrar. dl.coy.r.d on this """lInt .hould b. .ddr....d In writing tal PA DIP.rt.ant of R.venue,
lutlau of Indlvldu.1 Ta~.., ATTNI Pa.t A......."t Ravllw Unit, Dept. ZlUOl, Harrlsbur., PA 17121-0601
Phon. (717) 717.6501. S.e pegs ) of the bookl.t "In.tructlon. for Inherltanc. T.x R.turn for I A..ld~t
Oecldent" CAtV-ISOI) for an .~pl..,atlon of ~1"htr.t1v.lill carr.ctlbla erratl.
I' any t.x dUe I. p.ld within thr.e (5) c.lend.r lanth. aftar the dlCedant'. d..th, . flv. parcant CS~) dl.count 0'
thl tax p.ld hallowed.
Int.r..t I. ch.r.ed b.alnnlng with flr.t day of dellnqu.ncy, or nln. (9) lonth. and one (1) d.y fru. thl dati of
de.th, to thl del. of p.veant. Ta... which bee... d.llnquent befara J~ry 1, 19.2 ba.r Int.r..t at thl rlt. of
.1. (6X) p.reant p.r annua c.lculat.d .t . dallr rat. of .00aI64. All ta~a. which bac... d.llnquent on and .ft.r
Janu.r~ I, 19.2 will bear Int.r..t .t . ,.at. which will vary fral c.lendar v..r to caland.r ya.r with thlt r.t.
announced bV the PA O.p.rt.-nt of R.vanua. Tha appllcabl. Int.r..t r.ta. far 1912 through 1995 .rel
DIICDUHT I
'!!!r Inter..t Rat. D.llY Int.r..t Factor ~ Int.re.t Rat. D.lly Intar..t Factor
1912 .n .0U54' 1917 n . Ual47
191) lOX .OUU' 1"1-1991 IIX .DaUOI
1914 lU .aUnl 1992 'X .0aOl47
1911 ISX .00U16 199).1994 7X .0Danz
I'" lOX .Oa0274 I99S n .UOl47
--Int"..t I. calculated .. 'oUaw.1
INTEREST. IALANCE OF TAll UNPAID X HVHIER OF DAYI DELINQUENT X DAILY IIlTEIIEST FACTOR
--Anv Matlc. 1,.Uld a,t.r the t.. blC~. delinquent wIll r,'I.ct an Int.r..t c.louletlon to '1ft"" (IS) d.w.
b.yond the det. of the ......lInt. If payeant I. .~. .,t.r thl Int.r..l cu.put.tlon det. .hown on thl
Notlc., additional Int.r..t .u.t bl calcul.tad.
STATUS REPORT UNDER RULF. 6.12
Name of Decedent I MARY K. OlPE
Date of Deathl May 11, 1995
will No.
Admin. No.
21-95-0655
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate I
1. State whether administration of the estate is complete I
Yes X No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete I
3. If the answer to No. 1 is Yes, state the followingl
a. Did the personal representative file a final
account with the Court? Yes No There was no personal representative.
The estate was Insolvent.
b. The separate Orphans' Court No. (if any) for
the personal representative's account iSI
c. Did the personal representative state an
account informally to the parties in interest? Yes No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
:(1
~'-ht, 11
Signature ~
Robert M.Frev
Name (Please type or print)
5 S. Hanover St.. Carlisle. PA 17013
Address
Date I February 29, 1996
I " .
'.. : '
I 717) 243-5838
Tel. No.
CapacitYI
Personal Representative
X Counsel for personal
representative
(MAHlrmf/AM3)