HomeMy WebLinkAbout96-01023
PETITION I:OI{ PIWIlATE nnd GRANT or u~rnms
E\lII/I' III _.Ocrll!(IJ.Jllpp)o--------- Nil. __~H)~=-_J9~.p--
al,\/1 k"II"'" a, .__.__ ___.__.____...____.__ Tu:
__,,__ _...____ _.__ ___ __ _ ,___ ________________. I{cgil'tcr III Will> lur Ihc
_____ __ __ _.___. OI'('I'a.\l''', Cuuuty III ._CI1~j}ER~J.\~P_ in Ihc
SIIdal S,""lfil,l' Nil, ___ 208-24-3932------.- Conllnunwcllllh III I'cnnl'ylvllllill
Thc pctililln ul Ihc '"l1lc"igncd rCl'llCClllllly Icprcl'cnll' thlll:
Yllur pClitiuIICI(I'), who il'/arc IN YCllrl' ul IIgc ur Illdcr IIn Ihc CXCCllt..J:I.X
in Ihc hII'I will III Ihc IIbuvc dcccdcnl, dmcd l'ebruuryJE,
IInd cmlicil(I') dlllcd __-'19I1e
nllmcd
,IYJL.
(\HUl' IclC\i1111 ,ir~IUmIiUlf.:I",l'.Il., rc:nund:lliull,lIl'iUh uf C\l'~'lIlur,I'I~.)
Dccclldcnt Will' domicilcd m dClllh in Cumberlund CounlY, I'cnnsylvllnia, wilh
h is IIII'I IlIlllily ur principlll rcsidcncc III ~k..R.olld, Carlisle, P A 17013
WfST l1>-Ir-/'?t',(RJ flv,)
(Ii,. !\Ifl"!:l. lIumhcr nnd l11ulldpalily)
Dcccndent,lhen 62 yellrs of age, died November 18, ,19 96
lit .-16.M..lieWYille..Rolld, CArlisle, Pu.
Excepllls follows, decedent did not marry, was nol divorced and did not have a child born or adopted
aller execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent: -DOJ!Xccptions
Dccendcnt al demh owned property with estimaled values as lollows:
(II domicil cd inl'a,) All personal properlY $ unestimated
(II not domiciled in Pa.) Personal properlY in Pcnnsylvania $
(II nOI domiciled in Pa.) Personal properlY in County $
Value 01 real estate in Pcnnsylvania $ non"
situated as lollows:
WHEREFORE, pctitioner(s) respectfully
presented herewith and Ihe grant 01 letters
request(s) Ihe probale of the last will and eodicil(s)
testamentAry
(1C'llamcntary; admini\.rmiul1 c.I.a.; adminiMralion d.b.n.c.l.a.)
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Donna ae Hipp e
1202 Creek Road
Carlisle, PA 17013
OATH 01<' PERSONAL REPRESENT A TIVE
COMMONWEALTH 0... PENNSYLVANIA }'S
COUNTY 0... CUMBERLAND S
The pelitillner(s) abovc.named swear(s) or arlirm(s) Ihat the statements inlhe loregoing pClilion arc
rrue lInd corrccl to thc besl of the knowlcdge and belie I 01 petilioner(s) and that as personal represen-
tative(s) 01 the above decedcnt petilioner(s) will wcll and truly administer the cstale according to law.
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Sworn 10 or arrirmed and
before me Ihis 5TH
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ary C. L~
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LAST WILL AND TI':STAMI;:NT (n'
(:lmALD ,J. 1111'1'1.1':
I, (:I':HAI.D ,I, 1111'1'1.1':, of WI',;I I',.nnsbnl'o Township, (H, D. II '1,
Carlls)C'), ('lImill'I'land ('ollnl,\', I'I'nn",\'lvania, bl'in,~ of sOllnd and di;;posin/-(
mind, nH'mOI',\' and IIlulC'I'slandin/-(, do bl'I'ph\' mal\(', pllblisb and dC'dal'(' this
as and fOl' my lasl Will and Teslanll'nl, hl'I'pb,v 1'C'vol,in/-( a till mal,inl.( void any
and all Wills by ml' at any timl' hC'I'l'loforp madC'.
I, I dil'C'('( 111,1' IWI'pinaf"'I' nallled I-:x('"ull'ix 10 pay all of lilY jllSt dehts and
funeral expenseH as soon aftel' m~' dl'ath as may he found ('onvenienttu do so.
2. All the rest, reHidue and I'emainder of my estatp, I'pal, personal and
mixed. and whereHoevel' the same may he situate, I/-(ivl', devise and bequeath
to my wife, Donna Mae Ilipple, her heirs and assi/-(ns, to the exelusion of my
children, born and unborn, provided my said wife, Donna Mac IIipple, shall
survive me by a period of Ninety (DO) days.
:L Should my said wife, Donna Mac IIipple, pre-decease me or fail to
survive me hy the aforesaid pel'iod of Ninety (nO) days, then in such event all
the rest, residue and remainder of my estate, real, personal and mixed, and
wheresoever the same may be situate, I/-(i ve, deviHe and bequeath as follows:
(a) In equal shares to any childl'en of mine who may survive me. At the
present time I am not the father of any children.
(b) If no child of mine or the issue of any child of mine Hurvives me then
all household goods and furnishings. inclnding dishes, tahleware, cooking
utens'ils, etc. to m~' wife's hl'other, Ronald I':. Wilson, and the rC'maindel'
in equal shares to the children of my wife's hrolher, Ronald I':. Wilson. At
the pl'esenl lime my wife'H hrotl1l'I', Ronald 1-:. Wilson is Ihe father of 0111'
child, Honald I~, Wilson, II.
4. Should any person leHS than 21 ~'eal's of agf' 1)(' l'nlitled to distrihution
from my estate, then I nominalf', l'onslitute and appoint FarmerH TruHt
Company and its SUf'('essors, 1 West High Street, Carlisle, Pennsylvania, as
Guardian of the estate of each slIch person and I authori7.e and direct said
Guardian to invest the same and to pay the income arising therefrom together
2 1 - 96 - Ion
REGISTER OF WILLS <n: r.lH4I\ElnIlNIl COUNTY
OATH 01' SUnSCIUlUNG WITNESS
LIIURII II BISTLINE
-_._..__._~--_.__..~-_._----~._-
X&YJI~I
ltK:l\Jlil a subscribing witnm 10 the will prc>entcd herewith, {tlb'(;K) heing duly qualified according 10
law, depose(s) and say(s) thai SHE WIIS present and saw
GERIILD J HIPPLE
the leslat OR , sign the same and thai SHE signed as a wilness Dtthe
request of teslal~ in hl.?- presencc nnd (inlhe prcscncc 01' ench olhcr) (inlhc presence of the
other subscribing witncss(es)).
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c::kLLU <:I /0, \ I ,,?Lf "A I C
Sworn to or affirmed and subscribed bcl'orc
me this 9TH day of
DE MBER n'l 1 &--~L -
Rellisler (f
(Name)
( Address)
(Name)
(Address)
REGISTER OF WILLS OF COUNTY
OATH OF NON-SUBSCRIBING WITNESS
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(each) a subs;;'iller hereto, (each) being duly qualified according to ~~se(s) and say(s) tha;
fnmiliar wilh Ihe signature of, /
codicil
teslat_ of (one of the subscribing wilnesses _ to) the will presented herewith and
. '. codicil
that /_be~es Ihe signature on Ihe will is in the handwriting of
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to the best of
knowledge nnd belief.
Sworn 10 or affirmeu and subscrihed before
/
me this / day of
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(Name)
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RelliSlCf
(Name)
(Address)
NOTICE OF BENEFICI"1. I NTEIl EST IN I.:STATE
IlEFOHE Tim HEGISTlm OF WILI.Ii, COUNTY OF CUMBEHLANll,l'ENNSYI.VANIA
In re: Eslnll' of GEHALD J. 1I11'I'LE, 1II'l:I'nSI'd,
No. 1996 . 0102:1
I'A File No.: 2196 - 102:~
TO: Donnn Mac lIipple
1202 Crcek Homl
Cartisle, I'A 1701:1
Pleuse Inke nOlicc of Ihe denlh of dcccdcnl and thc gmnl of leuers 10 the personul
representulive(s) nnmed below. Vou may have a beneficinl intcrl'sl in Ihe eslnte as fullows:
Sole Ileneficiary
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Nume of decedenl:
Gerald J. lIipple
Lasl known address:
1202 Creek Hond
Cnrtisle, PA 17013
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Dale of dealh:
Novcmber 18, 1996
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Placc of dealh:
1694 Newville Hond
Carlisle, PA 17013
Counly of gran I of originallellers: Cumbl'rlmul
Decedcnl dicd X Icstale inleslntc
A copy of the will -X- is _ is nol aunched.
Nmne(s), address(es) nnd Ielephone nnmhl'r(s) of all pl'rsonall'cprcsl'nlalives appointcd:
Donnn Mne lIipple
1202 Crcek Homl
Cnrtislc,I'A 1701:l
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NIIIlIC(~), IIddrc~~(c~) 1II\lllelcphollc IlIllllhcr(~) or 1111 COUllscl:
SlIIllucl W, ~lilkcs, Esq.
JACOBSEN & MILKES
52 Ellsl High Slrccl
Cllrli81c, PA 17013
(717) 249-6427
Atlorllcy No. 33130
Addiliolllll illronnllliou IlII1Y hc ohlllillcd rrllln Ihc undcrsigncd.
Dille: )ff.~~7
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BY: SlIllIuel'li . Milkc~. Esq.
JACOBSEN & MILKES
52 Ellsl High Slrccl
Cllrli~lc. PA 17013
(717) 249-6427
Atlomcy No. 33130
Cllpllcity: _ Pcrsolllll Rcprcscnllllivc
...x..... COllllsel ror Pcrsolllll
Rcprcscllllllivc
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PRAECIPE
GERALD J. IIIPPLE,
DECEASED
IN TilE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PA
ORPHANS COURT DIVISION
NO. 21-96-01023
IN RE: ESTATE OF
To Mary C. Lewis, Register of Wllls:
Please show the undersigned as having withdrawn as counsel for the Executrix of the
above Estate, Donna Mae Hipple, as she has discharged me and retained Samuel W. Milkes,
Esquire, as her counsel.
Date: March 18, 1997
terz-c."vf - J.. . ?t~
Robert M. Frey
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In re: Estate of GERALD J, HIPPLE
No, 1996.01023
PA File No.: 2196. 1023
PETITION FOH APPHOV AI. OF SETfLEMF.NT
Donna Mae Hipple, having qualil1ed and been duly appointed Executrix of the Estate
of Gerald J. Hipple, deceased, by and through her Allomcys, Samuel W, Milkes, Jacobsen
& Milkes, petitions this Court for approval of selllemenl of a claim, respectfully representing
that:
1. Gerald J. Hipple, age 63, of 1202 Creek Road, Carlisle, Cumberland County,
Pennsylvania, died on November 18, 1996, as the result of severe head lruuma sustained in
an automobile accident.
2. Said accident occurred on November 18, 1996, on SR 641 Newville Road,
approximately one half mile east of McAlister Church Hood, in West Pcnnsboro Township,
Cumberland County, Pennsylvania when a GMC vehicle owned and driven by Defendant
Jackie Ray Campbell crossed into the eastbound lane, where it collided almost head on with
the Hippies' Chevrolet Van.
3, As a result of said accident, Gerald J. Hipple died on impact or shortly thereafter,
4. Dcfcndnnt Jnckie Hny Cnmphell hns nulomohile Iinbility insurnuce through Erie
Insurnncc Company.
5, Thc pnrties 10 this nction hnve ngreed, conlingent on this Honoruhle Court's
approval, to a partial rcsolution of this mnttcr. Erie Insurllnce Compnny hns offercd thc
policy limit of S100,OOO ns n st,ttlcmcnt to thc Estnte of Cernld J. llipple. In return, Donna
Mae Hipple has agreed 10 rclense Erie Insurllnce Company from further liability in this
matter. A letter reflecting approvnl of this release is attnched.
6, Plaintiff respectfully requesls thnt this Honorable Court approve the proffered
settlement of S100,OOO from the Erie Insurance Company as fair and rensonable under all
circumstances,
7. A rclease is attached hercto, rcflccting Ihe documcnt which the Excculrix and Erie
Insurance Company are prcpared to execute, upon approval of this Court.
8. This settlemcnt docs not rcquirc Court approval but Eric Insurnnce Company has
requested that approval be obtaincd.
9. There have bccn no claims or licns filed against this estale and the Executrix is
unaware of any basis for the filing of any claims.
10. Under the Lust Will and Tcstament of the decedcnt, Donna Mac Hipple, wife of
the decedent, is the sole bcncficiury and is nnmcd as thc Executrix of thc Estate. Therc
were no childrcn of the dcccdcnl.
WHEREFORE,thc Exccutrix rcspcelfully rcqucsts Ihis Houurnhlc Court opprove the
settlcment os proposed ohove,
Dote:
nespeetfully suhmitted,
I, Donna Mac Hipple, Executrix of thc ahovc estate, verify that the statements
made in this Petition are true and correct, I understand that false statements herein
are made subject to the penaltieB of 18 Pa.C.S. ~ 4904, relating to unsworn falsification
to authoritieB.
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Date: '~~A;'~it~ipp~~4 )~na
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PARTIAL RELEASE OF CLAIM
I, Donna Mae Hipple, as Executrix, and on behalf of the Estate
of Gerald Hipple ("Releasor"), for an in consideration of the
payment of One Hundred Thousand ($100,000) Dollars by or on behalf
of Jack R. Campbell ("Releasee"), receipt of which is acknowledged,
for myself and my heirs, executors, administrators, and assigns, do
hereby and forever release, acquit and discharge, but only to the
extent of the consideration paid hereunder, Releasee and Releasee's
successorS and assigns, officers, directors, agents, employees, and
his heirs, representatives, successors, and assigns, of and from
liability, but only to the extent of the consideration paid
hereunder, arising from any causes of action, claims, demands,
damages, costs, loss of services, expenses, compensation and
consequential damages arising out of all known and unknown personal
injuries, death or property damage resulting or to result from an
accident which occurred on or about November 18, 1996 in the
vicinity of the Newville Road and McCallister Church Road,
Cumberland County, Pennsylvania. It is understood that this is
only a Partial Release of Releasor's claim against Releasee,
releasing Relessee only to the extent of the amount of the
consideration paid and that to the extent the full value of
Releasor's claims are not compensated by this amount, Releasor's
claims shall survive this Partial Release of claim.
It is further understood and agreed that this Partial Release
shall not discharge nor reduce the liability of any other persons
and/or organizations from whom Releasor seeks recovery unless it is
acknowledged or adjudicated that such other persons and/or
organizations are joint tortfeasors with Releasee. In the event
that any such persons and/or organizations are determined to be
joint tortfeasors with Releasee, it is understood and agreed that
the damages recoverable by Releasor from such other persons and/or
organizations shall be reduced to the extent of the dollar amount
of the consideration paid for under this Partial Release. It is
understood that the effect of this Partial Release is to provide a
single credit to Releasee and any other persons or organizations
acknowledged or adjudicated to be joint tortfeasors with Releasee
in the amount of the total consideration paid hereunder, against
the full value of Releasor's claim against Releasee and any
adjudicated or acknowledged joint tortfeasors.
If it should appear to be adjudicated in any litigation,
however, that Releasee and others were guilty of joint negligence
which caused the injuries to the Estate of Gerald Hipple, and the
losses or damages arising therefrom, in order to save Releasee
harmless, Releasor, as further consideration, will satisfy any
decree, judgment or award in which there is such finding or
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1
IN RE: Estate of GERALD J. HIPPLE
No.: 1996-01023
PA File No,: 2196 - 1023
, 1998, upon review of the Petition
rix of the Estate of Gerald J. Hipple, and
The settlement is in the best interest of the Estate and all those entitled to share
under the Wrongful Death Act for this accident and is approved as being fair and reasonable
under all the circumstances.
2. The prior Order entered in this maller, regarding a prior version of the Release
(dated November 7, 1997), is hereby rescinded and vacated.
3. The Executrix for herself and all wrongful death beneficiaries is directed, upon
payment of the selllement amount by Erie Insurance Exchange, to execute the Pro Rata Joint
Tortfeasor Release appended to the Petition,
4. The $100,000 to be paid out on this claim is allocated One Hundred (100%)
percent to wrongful death for inheritance tax purposes.
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IN RE: Estate of GERALD J. HIPPLE
No.: 1996 - 01023
PA File No.: 2196 -1023
STIPULATION AND PETITION FOR APPROVAL OF SETTLEMENT
I
Donna Mae Hipple, having qualified and been duly appointed Executrix of the Estate of
Gerald J. Hipple, deceased, and as wrongful death beneficiary representative, by and through
her attorne~':: :, ; ,: W. Milkes, Jacobsen & Milkes, and Erie Insurance Exchange, through
its COUl. , , "'1: ' ,,-I(. Esquire, Thomas, Thomas & Hafer, LLP, petition this Court for
approva, (" _",'~"rnent Oi i,,'l:. :~spectfully representing that:
1. Gerald J. Hippie, age 63, of 1202 Creek Road, Carlisle, Cumberland County,
Pennsylvania, died on November 18,1996 as the result of severe head trauma sustained in an
automobile accident.
2. Said accident occurred on November 18, 1996 on SR 641 Newville Road,
approximately one-half mile east of McAlister Church Road, in West Pennsboro Township,
Cumberland County. Pennsylvania when a GMC vehicle owned and driven by Defendant,
Jack R. Campbell, crossed into the eastbound lane, where it collided almost head on with the
Hippies' Chevrolet Van.
3. As a result of said accident, Gerald J. Hipple died after impact.
4. Jack R. Campbell had automobile liability insurance through Erie Insurance
Exchange at times relevant to this wrongful death and survivor claim.
5. The parties to this action have agreed, contingent on this Honorable Court's
approval, to the following resolution of this matter: Erie Insurance Exchange has offered,
without prejudice, its policy limit of $100,000 as a settlement, of all claims of the wrongful
death beneficiaries and the Estate of Gerald J. Hipple, against Erie or anyone for whom it
could be liable including insureds, Jack R. Campbell. In return, Donna Mae Hipple, who has
previously qualified as Executrix of the Estate and who represents all those entilled to share
under the Wrongful Death Act, has agreed to a Pro Rata Release of Jack R. Campbell and
Erie Insurance Exchange from further liability in this matter; Erie Insurance Exchange is joining
in this Stipulation, requesting the entry of an Order of approval of the Pro Rata Release, and
the setllement.
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6. Plaintiff respectfully requests that this Honorable Court approve the proffered
settlement of $100,000 from the Erie Insurance Exchange as fair and reasonable under all
circumstances.
7. The Pro Rata Release is attached hereto,
8. Although this settlement may not require Court approval, the parties have
agreed to seek Court approval.
9. There have been no claims or liens filed against this estate and the Executrix is
unaware of any basis for the filing of any claims or liens.
10. Under the Last Will and Testament of the decedent, Donna Mae Hipple, wife of
the decedent, is the sole beneficiary and is named as the Executrix of the Estate. There were
no children of the decedent. She is the only wrongful death beneficiary. She qualified as
Executrix in this County on ~(~""~~. See attached.
11. As Executrix, Donna Mae Hipple, requests of this Honorable Court that it
approve a percentage allocation of the claim, One Hundred (100%) percent allocated to
wrongful death and Zero (0%) percent allocated to survivor benefits for inheritance tax
purposes. After a full review of the circumstances surrounding the death of her husband, she
believes this to be a fair and adequate distribution. The Department of Revenue has orally
advised Hipple's attorney that such a division will be approved.
12. This Honorable Court, through President Judge Harold E. Sheely, previously
approved the authorization of a settlement of this case, by Order dated November 7, 1997 (a
copy of which is attached). The Executrix asks that the previous Order be rescinded and the
new Order executed for two reasons: (1) After further review of the Release approved in the
prior Order, the parties are not in agreement that the prior Release was acceptable but do now
agree that the new agreed upon Release be approved: (2) the prior Order did not provide for
an allocation of wrongful death and survivor benefits: the attached proposed Order now does.
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WHEReFOAE. ".,. l!xtC\llrbc respect!u!\y reqo,:8sts thlt Honolllllle COUrt ~ the
,t\Uvmer'lt lIS ~ .bOVt,
Olted: .5:1 ~ \q 55
By: R~~
C Samuel IN, Milk... Elqullll
JACOBSEN & MILI<ES
52 E. High SlIeet
C:l1flSle. PA 17013
A\ttJmey No. 30130
CCllnsel fer Elteort'lX
Sy:
Tlmo'" \.', . Esquire
fJ.:,omey I. . 0, 2nSB
~C5 Nor.:!, Street
P.O. Bo~'399
Harr'sb'.:r;. PA ~71ce
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Counsel ~e! lE.r.e InsUfan~ Eltchange
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In reI Estate of GERALD J. HIPPLE
No. 1996 - 01023
PA File No.: 2196 . 1023
ORDER OF' COURT
IN RE: PETliION FOR APPROVAL OF' SETILEMENT
AND NOW, this
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day of /)1.........>",,1,')..<......
. 199.. upon review
of the Petition for Approval of Settleme:ll. .,ubmitted by the E.(ceutrix 'Jf the E:Hate of Gc:r:tld
J. Hipple. :ic:eking approval 01 :ieniement of claim a :iUDlllilt.:J by the E.;tate again:;t Erie
In:iur:tnce Company. the Executrix i:; hereby :tuthorized to enter into the propo:ied rele:lSe.
attached to the Petition fiied in [hi::: :natter. ;lI1d the Eo'ie In:imanc<= Croup j,; authorized to
mi.lk~ paytll~nt to th~ ~:::t;lt~. U:~I':C:' ::~c tC:-:l:~ =c~ :'IJr~:l ;n :hi: 8dr:a::,!.
By the Court:
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l'IW-ltAT,\ ,lOll'll' TOIn'FEASOIt IU~l.E,\SI~
\(J"lOW ALL MEN BY THESE PRESENTS. that I. DONNA MAE IIIPPLE. Executrix of
the Estate of Gerald Hipple ;md as Representative of all those entitled to share under the Wrongful
Death Statute on account of the death of the decedent. for and in consideration of the payment by
JACK R. CAMPBELL. of 1126 East Grand ,\venue. Tower. City. Pennsylvania and ERIE
INSURANCE COMPANY. insurer. and anyone on whose behalf they could be liable. and all and
each of their agents. representati\'l.:s. cmployccs. allOnlCYS. their predeccssors and succcssors.
present. fonner and subsequcnt subsidiaries. and their prescnt. fonncr and subsequent assigns.
officers. dircctors. insurers. allonlCYS. age11ls. represcntatives and employees of any of thcsc cntities
and all and cach of their heirs. cxccutors ami administrators (any and all of whom arc hcreinaftcr
eollcetively referred to as "Payors") of One Hundred Thousand Dollars (SIOO.OOO.OOl and other
good and valuablc considenttion at lhc timc of sealing and delivcry hereof. the receipt and
sufticiency of which is hcrcby acknowledged. d'l Illr myself. my heirs. executors. adminislratl1\"s.
successors and assigns. hereby remise. release. and forever dischargc complelely and absolutely thc
said Payors from any and all actions. causcs of action. suits. claims. damages and demands of evcry
kind. namc or naturc whatsOcvcr known or unknown whclhcr in law or in cquity. which I or anyonc
claiming through mc in any way may ha\'c I1\" will claim or could claim againsl thc ab'1\'c-namctl
payors for any and all medical. physical or mcntal claims. damages. losses or Icgal injurics of any
type whatsoever based upon or in any way arising out of. related to or resulting from or to result
from a certain incident which oceurrcd on or about Novembcr 18. 1996 in thc vicinity of thc
Ne\willc Road and McCallistcr Church Road. Cumbcrland County. Pcnnsylvania. which havc bccn
.I.
asserted by me and through my counsel and any and all claims which I. my heirs. successors.
assigns have made or could have made. whether accrued or not. whelher know or unknown.
whether anticipated or unanticipated and whether or not herelofore asserted by me or others in any
lawsuit.
I illlend that this Release shall be complete and shall not be subject to any e1aim of mislake
of fact, or of law and that it expresses a full and complete senlemelll of liability claimed and denied
by the above-named Payors. and. regardless of Ihe adequacy or inadequ.ley of the amount paid. this
Release is intended to avoid this and future litigation against the above-namcd I'ayors rdeased
herein and to be linal and eomplelc. The payment referred to hercin is in compromise of a doubtlill
and disputcd claim and such paymcnt is nnt to bc construcd as an admission of liability on bchalfof
the Payors or anyone on their behalf: to thc contrary. Pa~'llrs. expressly dcny any liability: and I
realizc that the paymcnt madc to me is upon my express warrallly thaI I ha\'\~ not recci\'cd
hcn~tolllrc any eonsidcration whatcvcr ','r nnr havc I rcccivcd any considcration \\hatcvcr from nor
ha\'e I madc any scnlcmclll with or prcvinusly givcn any rdcasc to any person. linn. associmion.
corporation or cntity lor any Iiabilily claim arising out of the aforesaid incident or series of
incidents.
I. thc undcrsigned. expressly rescr,c thc right to make any and all claims against any and
every othcr person. linllor cntity other than the I'ayors aod reser,c thc right to claim that such othcr
persons. lim1s or entities. and not the Payors. arc solely or otherwise liable to me lor my injuries,
losses or damage.
~
.I
Furthcr, 1 agrcc that any elaim. judgmcnt or uhimatc rccovcry (may obtain against any and
cvcry othcr pcrson, Iiml or cntity shall bc rcduccd to thc cxtcnt of thc pro-rala or pcrccntagc sharc
of causalncgligcncc, or pro rata or pcrccntagc sharc of comparativc causation fuult of Payors so
that thcre can bc no right of contribution or indcmnilication by such othcr non-scttling pcrson. !inns
or entities against Payors under any conccivablc theory. By executing this Rclease it is my
intention to enter into a !inal settlcmcnt with Payors and to insurc Payors have no furthcr obligation
of payment to me or any nonscttling party. It is my intcntion and Payors that this Pro-Rata Joint
Tortfeasor Releasc bc construcd. intcrprctcd and in compliancc with thc 1987 Pennsylvania
Supreme Court case of Charlcs V$, GianI Eal!le Markets VS. Stanlcv Macic Door. Inc.. 513 Pa. -17-1.
522 A.2d I. No matter how this Releasc is titled or worded. the intention of both parties is that i(
shall be construcd as to have exactly the samc legal elTect as the release mcntioncd on page live of
thc Giant Eagle dccision and given thc samc legal effect on all parties. including preclusion of the
non-settling parties to rights agains( I';I~WS fllr colllriblllion allll/or indemnity under a vcrdict or
judgmcnt or othcrwise.
Further, should it appear or be adjudicated in any lawsuit or any other action or procceding
of any kind or nature. whether or not now pending. arising out of the aforesaid incident or series of
incidents. that said Payors and others not being released by the temlS nf this Release (nonsettling
parties) were guilly of joint and conCUITelll negligence nr jointly or severally liable under any
theory, or that said Payors arc liable over lor indemnity or contribution to nonsettling parties who
causcd thc damages. losses herein concerned and morc particularly the injurics and damages
3
.
.I
incurred by me, then in order to save the I'ayors hannless and to indemnify them, I, binding my
heirs. executors, administrators, successors or assigns, and as further consideration for said
payment, will satisfy on I'ayors' behalf any verdict, decree, judgment or award in which there is
such finding or adjudication involving said Payors, and to the extent of the liability of the I'ayors
for contribution and/or indemnity and for such judgment against Payors for contribution and/or
indemnity under the law; further, I, my heirs. executors, administrators. successors and assigns will
indemnify and save forever hannless the said Payers for any judgments arising out of any and all
further claims. suits. demands or actions. including. but not limited to those for subrogation.
indemnity. and/or contribution made by non-settling parties on account of or rclated to. resulting
from. or arising out of the incident. series of incidents or litigation referred to above.
I turther certify. state. acknowledge. warrant and declare that each and every person.
attorney. carrier. entity or association. including any underinsured motorist carrier. any ERISA
entity or worker's compensation carrier ami any welfare or gOl'ernmcmal emity including but not
limited to Medicare which e1aims to have a Iicn on the procceds of this scttlemcnt arising out of this
incident or threatened litigation is aware of this Release and Settlement Agreemem and its tenns
and have consented and authorized me to execute this Rclease and Settlemem Al.!reemelll on its or
. ~
their behall: waiving any and all subrogation and I understand that said I'ayors and released parties
hercunder arc relying expressly upon this unconditional express warranty in making payment
hercunder; if any person. attorney. carrier. entity or association. including but not limited to any
ERISA entity or welfare agency or governmental emity. including but not limited to Medicarc. has
4
..
made known to me or my legal representatives that a lien on the proceeds of the scttlement is
claimed or asserted. I will provide to the parties released hereunder copies of any such documents
which indicate approval of the settlement and this Release and consent to and authorize me to
execute the same on my or its behall:
I. further certify. state. declare and acknowledge that I have had my own legal
representation throughout these proceedings and have been advised by my own counsel in all
matters pertaining hereto and I admit that no representation of f:lct or opinion has bcen made by
said Payors or anyone aeting on their behalf to induee this compromise or payment or release: I
have rdied wholly upon my 0\\11 judgment. belief :1I1d knowledge of my injuries and realize that
my injuries. including mental condition. arc or may be pennanent and/or as yet unknown or
unmanifested and that recovery therefrom is uncertain and indelinite but there have been no
statements or representations by Payors conccming these matters. In making this settlement. I
certiry. state. declare and acknowledge that I haw not relied on any stalements lIr representation or
either of the extent of Iinancial rcsponsibility or extent or legal responsibility of the Payws and that
it is my intention that this Release be complele and shall cover all losses. damages and injuries
knO\\11 or unknown insolar as they relate to Payors: I further certify. state. declare and acknowledge
Ihall alll over eightecn (18) ye:lrs of age. have read the Illregoing Release which has been explaincd
to me by my 0\\11 counsel: I am of sound mind. and under no constraint. undue inlluence. mental
reservation. lack of mental capacity or impainnent of heahh or mental ((Iculties or capabilities and
that I fully know. understand and comprehend the nature or and the ellcct or the Release and
5
A
settlement which I have signed. and that I have signed the same as my own free act and deed.
intending to be legally bound thereby.
It is further understood and agreed and made a part hereof that neither I nor my heirs.
executors, administrators. successors or assigns nor my attomeys or other representatives. will in
any way publicize in any news or communications media. ineluding but not limited to newspapers.
magazines. journals, trade or professional publications. radio or television. the facts of or tcnns and
conditions of this settlement agreement. All parties to this agreement expressly agree to keep all
aspects of this settlement totally conlidential and shall decline comment on any aspect of this
settlement to any member of the news media and/or public in general: notwithstanding the
foregoing. it is neither my intention nor Payors that this Rclease be kept secret or eonlidential from
the Court or nonsettling parties. and to that end 1 have authorized my counsel to execute a
Stipulation of Counsel to pennit the Payors to plead the Release as a full defense to any pleadings
tiled by me or any nonsettling party, This pamgraph is intended to become part of thc
consideration for settlement ofthc claims.
This special Relcase contains thc entire agreemcnt and undcrstanding bctween the parties
hereto and there are no \\Titten or oral understandings or agrecments dircetly or indirectly connected
with this Release and settlcmcnt that arc not ineorporatcd herein save only the Stipulation of
Counsel referrcd to above and thc tcnns Ill' this Rclease arc contractual and binding and this Release
is given under and pursuant to thc law of Pcnnsylvania including the Comparative Negligence Act
of 1976, as amended. the Unifoml Contribution I\mong Tortlcasors Act of the Commonwealth of
6
" .
.
I'IW-RA T A .JOINT TORTFEASOR RELEASE
KNOW ALL MEN BY THESE PRESENTS. that I, DONNA MAE HIPPLE, an adult
individual. for and in consideration of the payment by JACK R. CAMPBELL. of 1126 East Grand
Avenue. Tower City. Pennsylvania. and ERIE INSURANCE COMPANY. insurer. and anyone on
whose behalf they could be liable. and all and each of their agents. representatives. employees.
attorneys. their predecessors and successors. present. fonner and subsequent subsidiaries. and their
preselll. fonner and subsequclll assigns. olliccrs. dircctors. insurcrs. Ultorneys. agents.
rcprcscntatives and cmployecs of any of thesc cntities and all and cach of thcir hcirs. executors and
administrators (any and all of whom are hereinafter collcctivcly rcli:rred to us "Payors") of One
Hundred Thousand Dollars ($ 100.000.00) and other good and vuluablc consideration atthc timc of
sealing and delivery hereof, the receipt and sutliciency of which is hereby acknowledged. do for
mysclt: my heirs. executors. administrators. successors und assigns. hcrcby rcmise. rclcasc. :md
Illrcver discharge completely and ubsolutely thc said l'u~'Ors from any und all actions. causes of
action. suits. claims. damages and demands of every kind. numc or nature whatsocvcr known or
unknown whether in law or in cquity. which I or anyone claiming lhrough mc in uny way may have
or will claim or could claim against the abovc-namcd I'ayors lilr any and ullmcdieul. physical or
mcnlul claims. damages. losses or legal injurics of ,my typc whatsoever based upon or in any way
arising out at: related to or resulting trom or to resultlrom a certain ineidcnt which occurred on or
about November 18. 1996 in the vicinity of the Ncwville Road and McCallister Church Road.
Cumberland County. Pennsylvania. which have bcen asserted by me and through my counsel and
any and all claims which I. my heirs. succcssors. assigns have made or could have made. whether
, 0,
every other person. firnl or entity shall be reduced to the extent of the pro-rata or percentage share
of causal negligence. or pro rata or percentage share of compamtive causation fault of Payors so
thattherc can be no right of contribution or indemnification by such other non-settling person. finns
or entities against Payors under any conceivable theory. By executing this Release it is my
intention to enter into a final settlement with Payors and to insure Payors have no further obligation
of payment to me or any nonsettling party. It is my intention and Payors that this Pro-Rata Joint
Tortfeasor Release 01: construed. interpreted and in compliance with the 1987 Pennsylvania
Supreme Court case of Charles I'S. Giant Eal.!le Markets vs. Stanlev Mal.!ic Door. Inc., 513 Pa. 474.
5:!:! A.2d I. No matter how this Release is titled or worded. the intention of both parties is that it
shall be construed as to have exactly the same legal effect as the rclease mentioned on page live of
the Giant Eal.!le decision and given the same legal elTect on all parties. including preclusion of the
non-settling parties to rights against Payors for contribution and/or indemnity under a verdict or
judgment or otherwise.
Further. should it appear or be adjudicated in any lawsuit or any other action or proceeding
of any kind or nature. whether or not now pending. arising out of the aloresaid incident or serics of
incidents. that said Payors and others not being released by the terms of this Release (nonsettling
parties) were guilty of joint and concurrent negligence or jointly or se\'erally liable under any
theory. or that said Payors arc liable over for indemnity or contribution to nonseuling parties who
caused the damages. losses herein concerned and more particularly the injuries and damages
3
. .
, ..,
incurred by me, then in order to save the Payors hannless and to indemnify them, I, binding my
heirs, executors, administrators, successors or assigns, and as further consideration for said
payment, will satisfy on Payors' bchalf any verdict, decree, judgment or award in which there is
such finding or adjudication involving said Payors, and to the extent of the liability of the Payors
for contribution and/or indemnity and for such judgment against Payors for contribution and/or
indemnity under the law; further, I, my heirs, executors, administrators, successors and assigns will
indemnify and save forever hannless the said Payors for any judgments arising out of any and all
further claims, suits, demands or actions, including, but not limited to those lor subrogation,
indemnity, and/or contribution made by non-settling parties on account of or related to, resulting
from. or arising out of the incident, series ofincidellls or litigation relcrred to above.
( further certify, state, acknowledge. warrant, and declare that each and every person,
attorney. carrier, entity or association, including any underinsured motorist carrier. any ERISA
entity or worker's compensation carrier and any welfare or govemmelllal entity including bLll not
limited to Medicare which claims to have a lien on the proceeds of this settlement arising out of this
incident or threatened litigation is aware of this Release and Scttlcmcnt Agreement and its terms
and have consented and authorized me to execute this Release and Senlement on its or their behalf.
waiving any and all subrogation and I understand that said Payors and releascd parties hereunder
are relying expressly upon this unconditional express warranty in making payment hereunder: if
any person, attorney, carrier, entity or association, including but not limited to any ERISA entity or
4
. ,",
-
.
welfare ageney or govemmelllal entity. including but not limited to Medicare. has made known to
me or my legal representatives that a lien on the proceeds of the selllement is claimed or asserted, I
will provide to the parties released hereunder copies of any such documents which indicate
approval of the selllement and this Release and consent to and authorize me to execute the same on
my or its behal/:
I, further certify, state. declare and acknowledge that I have had my own legal
representation throughout these proceedings and have been advised by my 01111 counsel in all
mallers pertaining hereto and I admit that no representation of fact or opinion has been made by
said Payors or anyone acting on their behalf to induce this compromise or payment or release; I
haw relied wholly upon my own judgmelll, belief and knowledge of my injuries and realize that
my injuries. including mental condition, are or may be permanent and/or as yet unknown or
unmanifested and that recovery therefrom is uncertain and indefinite but there have been no
stUlements or represelllations by Paynrs concerning these malters. In making this scttlcmcnt. I
ccrtify. statc. dcclare and acknowledge that I have not relied on any statcmcnts or representation of
either of the extent of tinancial responsibility or extent of legal responsibility of the Payors and that
it is my intention that this Release be complete and shall cover all losses. damages and injuries
knOI\l1 or unknO\lll insofar as they relate to Payors; [ further certifY. slate. declare and acknowledge
that I am over eighteen (18) years of age. have read the foregoing Release which has been explained
to me by my own counsel; I am of sound mind, and under no constraint. undue int1uence, mental
5
. .,
.
reservation, lack of mental capacity or impaimlent of health or mentallhculties or capabilities and
that I fully know, understand and comprehend the nature of and the el1cct of the Release and
settlement which ( have signed, and that I have signed the same as my own free act and deed,
intending to be legally bound thereby.
It is further understood and agreed and made a part hereof that neither I nor my heirs,
executors, administrators, successors or assigns nor my attorneys or other representatives, will in
any way publicize in any news or communications media. including but not limited to newspapers,
magazines, journals. trade or professional publications. radio or television. the lacts of or tenns and
conditions of this settlement agreement. All parties to this agreement exprcssly agree to keep all
aspects of this settlement totally conlidential and shall decline conUlIent on any aspect of this
settlement to any member of the news media and/or public in general: notwithstanding the
foregoing. it is neither my intention nor Payors that this Release be kept secret or conlidential from
thc Co un or nonscttling panics. and to that cnd I havc authorizcd my counsel to cxccutc a
Stipulation of Counsel to pennit the Payors to plcad the Releasc as a full delense to any plcadings
tiled by me or any nonsettling party. This paragraph is intcnded to become pan of the
consideration for settlement of the claims.
This special Release contains the entire agreemcnt and understanding between the panies
hereto and there are no written or oral understandings or agreements directly or indirectly connected
with this Release and settlement that arc not incorporated herein save only the Stipulation of
6
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CQMI.IONWEALlillll
PEfINSYI\WIIA
OEPAHlI.IENI OF REVUIUI.
OEPI ;'1.8,111
HAHHISBUHG I'A HllR I'tilll
REV-1500
15"- / tj 7 - 7
FILE NUMnER
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
,D,CEDCtH 5 liM.'( ill,'.) T I ,ri=, T ~~;D I.t!i~~l t :',:' "": !
trIP O\~d I Gcw.\\., "3.
DAlE 0\ D~\TH\"HJDD'Y["RI i [J:"! ClHilWt ,I,ll.' DLn!J,I~'
_~LI\~\~b . 10<"6 1\"\"7;)
(IF APPlI~ABlEI SUR','IW~G SPOuSE S ~~AI,'E ILA5i FI4S1 t.".D "\iD~i.[ illiTI~ I
:,()('A\ ~H,UI~Ih' !jUI.IO(l1
,;/k:G 1'--1 "3crs1
. 1I11S RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
-'-'-'-'._--~-"--' -
:,lfA'. :J CURITY NUl,leER
~C - 51 .
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o 4 limited Estate
o 6 Decedent Died TC$ta!e ,~~...~ ,.,.,;,
o 9 litigation Proceed$ Rece,ved
! --]2 SII,'plcm"rllal RetiJ'r\
1_.
[] ~J Future Inlc!e~t ComVGm,~c ',',. ':" -"~" ':'.-.
[J 1 Decedent ~.'.l'nt.l'f1c(l a l"o'l'lg Tru~l ~~,' .;.., "-"
LJ 10 S~~:)115a: Po\CrT, Cree: l~b ,-~,~.. t,'A'" ,;~..' .,- ~' ','
: } RNTI,I 'aler Relu'n . :.... ..' ~.~ r'" I,; ,~ t!~..,
J 5 Fl'ri!'f,ll blalfJ Tal Return Required
a To~al r~'J'T1tel 01 Safe DepoM BOJcs
[J 11 ElfJct0'110 l.I' U''\d~f See 9113(Al ,A~.I'f,5,~OI
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THIS SECnON MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENnAL TAX INFORMAnON SHOULD BE DIRECTED TO:~
NAI,lJ>- . \ ,", 1\.... \\. _ c... ' COl,lPlETE MAILING ADDRESS ,
~g,ro-\L~~~_\~\L\\.t':::::..,--'-''S.~l~--- \/0 ~" \\-\ \\ ~ t"l\1C-..
FI AME ,;'k'u,"' ~ ~'~I) , '. <=-
TElEPHONE NUMBER ~I'\ c....'- L' - C/ G:..\~\.e I Q\\ \IO\~
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III __-::LQ_,~~n
121 0
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ISI___'2 \_<9_0_0
Q
Ed
Of-! ICt/\L USE ONl.Y
1. Real E$tate lSthedule Al
2 Stocks and Bonds (Schedule Bl
3 Closely Held Corporal,on. Partnership or So~e.Propf,etor$h-p
III
4 Morlgages & Noles Rece:vab1c (S(',hedu'c OJ
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5 Ca$h, Bank Deposits & Mlscetlanwus Pel3Qnal ProperT)'
(SChedule EI
6 JOintly Owned Properly (Schedule FJ
o Separate Billing Requested
1&1
i1I
7. Inter,Vlvos Transfers & Miscellaneous Non.Probate Property
(SChedule G or LI
c; \ .a::c>
8. Total Gron Assets llotalllflcs 1.7)
161
191 ---\~, ::J-Scg-~
(101 0
\\~
::,~~ ~
::J3 2tt \
9 Funeral EJpenses & Mmlnistrahve Costs (SOledule H)
10. Debts of Decedent. Mortgage llab,h{,es. & liens ISchcdule I)
11. Total Deductionl (lotallmes 9 & 10l
12. Net Value ofEltate llmo 8 minus line 11)
(111
il21
1131
13. Chant.1ble and Governmental Bequcsts-See 9113 Tru$ts for ..'ohlch an elecl,on 10 t,ll ha$ not been
made (SChedule JI
14 Nel Value Subject to Tax (llno 12 m~nus lme 131
1141
SEE INSTRUCTIDNS ON REVERSE SIDE FOR APPLICABLE RATES
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11.
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15. Amount or ltne 14 taJable at the $pousaltal
rate, or transfers under Sec. 9116 (au' 2l
,0_ ilSI
16 Amount 01 line 14 lalable at lineal rate
---------.-----------
. 0 ___ (16)
17. Amount ollme t" la.able at Sibling fatc
--~.._.~-~---_._~---------
l 12 (171
.'5 pal
18 Amount ollme 14 t.1K3ble at coNatcral rate
___0
19 Tax Due
(191
200
,BIW;,~'."; ;".;;;;,'., ,;_, > > BE SURE TO ANSWER ALL QUESnONS ON REVERSE SIDE AND RECHECK MATH <<~;;: ,;i;;i".(.'i'J'~~:l1<~f.~.1j
Decedent's Complete Address:
~'REE'~OO~E~S~.. \t(}p~ . c,~
CITY -.,.,
Tax Payments and Credits:
1, To. Ouo (Paga I line 19)
2, CrOOllslPaymenls
A Spousal Povorly CIOOII
B PIIOI Paymonls
C, Dlscounl
II)
0-
3,
Telal Crodlls (A' B . C )
o
12)
InlolOsUPenally If applicable
O,lnlolosl
E, Penally
o
4,
TolallnlmesUPonally I 0 . E )
I' Une 2 is g,ealer Ihan Uno 1 + Une 3, enlor Ihe difference. ThIS IS IlIe OVERPAYMENT.
Check box on Page 1 Llna 20 to request a refund
(3)
(4)
15)
(SA)
15BI
o
5, If Une I + Une 3 is grealel than Line 2, enlerlhe dlffelenco, ThiS is Ille TAX OUE,
o
A, Enlellhe Inleresl on Ihe la. duo,
B, Enle, Iho t01a1 of Line 5 + SA, This is Ihe BALANCE DUE.
Make Check Payable 10: REGISTER OF WILLS, AGENT
~::;:}f(-
, , -. ,-" -:.:c :'-~~': --.:;7'S'.~;~~!:':2;:Yr:fl~~
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Old decedenl make a ll.nsfer .nd: Ves
., 'elain the use 0' income of Ihe property Ir.nsferred:,... ........,............,., ...............,.........., 0
b, relaln Ihe ligllllo design.le who sh.1I use Ihe property Ir.nsferred 01 ils income;.. ............,.,..... ........,.......... 0
c. relain a reversionary interest; Of. ,......_........................'''............... 0
d, leceive the promise for life of ellher p.ymenls, benefits or care' ,............., .....,...................., 0
2, If de.lh occurred afler Decembel12, 1982, did decedent Iransfel property w,lh,n one ye.r 0' dealh
wilhout receiving adequ.le considel.l,on? ......,.,....................., ........,......,......., ,."....." .. .................... ........,..., 0
3, Did decedenl own .n .,n lIusl 'or. or pay.ble upon de.lh bank accounl 01 secullty.1 hIS or her death?, 0
4, Did docedenl own .n Individu.1 Reliremenl Accounl. annully, or olllel non.probale property which
contains. benefiCiary design.lion? ,......,....,..., .. . ..... .........................,..,...........,...,
No
81
~
!Xl:
!8t
~
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penaf\.es 01 pef/lJry I ded.1'! lhat I h.l"l! e.arr..nt>d Ill,S relum. If'dud;r.g ilCCOIT'pa",'i"9 sthedJlt>s a'ld s:ale'f>en!~ ,l~ 10 I~ bt>sl o! my ~f1Ol'oje<lgl! and bel el. II IS true, COITetl and ~plele
OedaratJon 01 ptepa'el Qtheor l/Ian U',e personal reprMentatrV9 IS based on a11n1omtilhon of \Io11-C!l plepJ'er has c1~y ~r.wledge
SIG~p~PO~TURN ~ ~
~.~\IP\ \l.l. ~\ c:....
ADDRfSS .... ~ \;') \ .
\ ~ Co..\l~ \\\ r-~ \Ie (" C' 1'-\\.,,\("> S>~
SIGN~~~REPRESENTAnVE' .
ADDRESS
DATE
\o\k\O?
\
\')a\~
DATE
p__,._....:.."'. ....u...,.':........
~..!~ -
For dales of de.lh on or after July 1, 1994 .nd befo,e J.nuary I, 1995, Ihe I.. rale imposed on tile net value ollransfers 10 or fOlthe use of the surviving spouse is 3%
172 PS ~9116 (al (l.1ll,}J.
For dales of dealh on 01 .f1el January I, 1995, IlIe la. rale imposed on Ihe nel v.lue 0' Iransfers 10 0' 'or Ihe use of Ihe survi~ng spouse is 0% (72 P,S, ~91161.) (1.1) (ii)).
The slalule does nol e.emot a t,ansfer to a survIVing spouse from ta., and Ihe slalulory lequiremenls for disdosure of .ssels and filing a I.. relum are slill applicable even if
Ihe survi~ng spouse is the only benefiCiary
For dales of de.th on 0' afler July I, 2000:
Tho Ia' r.le imposOO on Ihe net v.lue of lransfers from a dece.sed child Iwenly-one ye.rs of age or younger .1 death 10 or fOI the use of a naJural parenl. .n adoptive pa,ent,
or. stepp.lOnt of the child is 0% 172 PS ~9116(aIl12}J
The Ia' rale imposOO on Ihe net value of Iransfers to or fOllhe use ollhe dotedenl's lineal benefiCia"es is 4,5%, e.copl as noled in 72 P,S, ~9116(1.2) 172 P,S. ~9116(.)(1)).
The tal 1.le imposOO on Ihe nel value of tr.nslers to 01 for the use 0' the decodenl's s.blings is 12% 172 P,S, ~91161.)(1.3)). A Sibling is definOO, under Section 9102. .s.n
individu.1 who has atleasl one parent in common w,lh the decodenl. whelhe, by blood or .doption.
~..""'.""'.
COl.l~OfM'[Al TU or P[tmSYlVAPil~
INItERlTAPlC[ TAX RfWHN
Rf lorNT orC:WfNt
SCHEDULE C.1
CLOSEL Y.HELD CORPORATE
STOCK INFORMATION REPORT
1. Namo 01 CorpotallOl1 51010 of InCOlpOtaliOl1
Addross Dolo of IncorporaliOl1
Clly Slale lip Codo Total Number 01 Sharoholdors
2, Fedoral Employer 10 Number Business Repot1ing Yoar
3. Type 01 Business ProducUServlce
4,
STOCK
TVPE
VOMgl Non,Vohng
TOTAL NUMBER OF
SHARES OUTSTANDING
PAR VALUE
NUMBER OF SHARES
OWNED BV THE DECEDENT
VALUE OF THE
DECEDENT'S STOCK
Common
s
s
Proferred
Provide all nghls and reslhcllons pertaining 10 each class of slock,
5, Was Iho decedont employed by Ihe COIjlOralion? 0 Ves o No
If yos, Posllion Annual Salary S Tlmo Dovoled 10 Businoss
6, Was tho Corporallon indebled 10 Iho decedenl? 0 Ves o No
If yos, provide amounl 01 indebledness S
7, Was Ihere Ille Insurance payable 10 Ihe corporalion upon Ihe dealh of the decedenl? 0 Ves 0 No
If yes, Cash Surrender Value S Nel proceeds payable S
OiIner of Ihe policy
8, Old Ihe decedenl sell or transfer Slock ollhls company wilhin OI1e year prior 10 dealh or wllhin two years if Ihe dale of dealh was phorto 12.31-82?
o Ves 0 No If yes, 0 Transfer 0 Sale Number of Shares
Transferee or Purchaser
Attflch a separate sheet for addtbOnal transfers and/or sales
Considerallon S
Dale
g. Was Ihere a wnnen shareholders agreemenl in effecl allhe lime of Ihe decedent's dealh?
If yes, provide a copy ollhe agreement
10, Was Ihe decedent's slock sold' 0 Ves 0 No
If yes, provide a copy of the agreemenl of sale, elc.
11. Was Ihe corporallon dissolved or liquidaled afterthe decedent's dealh? 0 Ves 0 No
II yos, provide a breakdown of dislnbulions received by Ihe eSlalo, including dales and amounls received
o Ves 0 No
12, Did tho corporalion have an inlereslin olher corporalions or partnerships? 0 Ves 0 No
If yes, report Iho necessary InformaliOl1 on a separale sheel, including a Schedule C.1 or C.2 for each inlerest.
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A, Delailed calculaliOl1s used in the valualion of Ihe decedent's slock,
B. Complele copies of financial slalemenls or Federal Corporale Income Tax relurns (Form 1120) for the year 01 dealh and 4 preceding years,
C, If Ihe COIpOtallOl1 owned real estale, submit a list showing Ihe complele address/es and eSllmated lair markel valuels II real eslale appraisals have been
secured, affach copies
0, Ust of phnClpal stockholders allhe dale of dealh, number 01 shares held and Iheir relalionship 10 Iho decedenl
E, LiSI of officers, Ihelr salahes, bonuses and any olher benefils receivP.d from Ihe corporalion
F, Slalemenl of dIVidends paid each year, Lisllllose declared and unpaid
G, Any olher informaliOl1 relaling to the valualiOl1 of the decedent's Slock
<l-V'~"lt~'
t\*~ ~.
If- " ~""
~
ESTA~OF ~
.,.e.rc.. \
SCHEDULE C.2
PARTNERSHIP
INFORMATION REPORT
~- \\1 ~~'e
_\.')n et:.
Dalo Businoss Commenced
Business Reponing Year
CO...UONWf.,AlTHcr PEM.:;'I'lVMjIA
INtlERlTMIC( T...'( RETURN
Rf. IrF~T ora fH
FILE NUMBER (., 'J.. <-.
1J..\-C1 ~ 0\0
1.
Name of Partnership
Address
City
Fodeial EmployerlD, Number
Type of Business
Decedent was a 0 General
ProductlSClVice
o Umllod panner, If decedent was a Iimlled partner, provide imlial investmenl S
Slale
Zip Codo
~
3,
4,
5.
PERCENT OF
INCOME
PERCENT OF
OWNERSHIP
BALANCE OF
CAPITAL ACCOUNT
PARTNER NAME
A,
B.
C,
0,
6. Value of the decedent's interest S
7. Was Ihe Partnership indebled to Ihe decedenl? 0 Yes 0 No
If yes, provide amount of indebtedness S
8, Was there life insurance payable to the partnership upon Ihe dealh oflhe decedent? 0 Yes 0 No
If yes, Cash Surrender Value S Nel proceeds payable S
Owner of the policy
9, Did the decedent sell or transfer an Interest in Ihis partnership Wlthin one year pnor 10 death or Wlthin IWO years if the dale of death was pnorto 12.31-821
o Yes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold
Transferee or Purchaser Consideralion S Dale
Attach a separate sheet for adclltional transfers and/or sales.
10, \Vas Ihere a written partnership agreement in effect at the time of tho decedents death?
If yes, provide a copy of the agreement.
DYes 0 No
o Yes 0 No
10. Was the decedent's partnership interest sold?
If yes, proVide a copy of Ihe agreement of sale, ete,
11. Was Ihe partnership dissolved or liQuidaled a"erlhe deceden!'s dealh? 0 Yes 0 No
If yes, provide a breakdown of dislnbulions received by Ihe estale, Including dales and amounts received,
12 Was tho decedent reialed 10 any of Ihe panners?
DYes 0 No If yes. explalll
13. Did the partnership have an inlerest in olher corporations or partnerships? 0 Yes 0 No
If yes. report the necessary Informanon on a separate sheet. including a Schedule C.1 or C.2 for each interest
, THEFOLLOWlNG ,lNFORMAnON MUST ImSUBMITTED WlTHTHl8 SCHEDULE, .
A, Detailed calculations used in Ihe valualion of Ihe deceden!'s Dartnershlp Inlerest.
B. Complele COpies of financ:a1 slalemenls or Federal Partnership Incomo Tax relums lForm 1065) for Ihe year of death and 4 preceding years,
C, If tho partnershiD owned real estate, submit a list show1llg Ihe complete address/es and estimated fair mar1<el value/s, If real estate appraisals have been
secured, allach copies,
0, Any other Information reiatlllg 10 Ihe valualion of Ihe deceden!'s partnershlo Interest.
,
Ifv'''''I''I,,1'1 C)~.
.11
SCHEDULE F
JOINTLY.OWNED PROPERTY
CO\tUOtMtAlTH or PE.MIS' LVMM
ItlllERllAtlCE 1M R(tURt.
R: lPH CH)[M
If In m.t WlI mid. jolnl wtthln onl yur olthl dICId.nt'l dill 01 dtllh, ~ mUlt be roportld on Schldull 0,
R(l).tlONSHIP lOOlCE[}EUT
"[){)HESS
SURVMUG JOtU! TU/AUTlSlllAt.ll:
A,
Wo<'e.
B,
c,
LETTER OATE DESCR~TION Of PROPERTY "Of DATE Of OEATIi
nEU FORJOlUT t.WlE Irdude """" rJ!tIlrO~ ""luOOl\ lJlll b3lk """" n'- or....... """1y>r9 0<ll1'l>e! Am DAlE OF DEATH DECDS VAlUE OF
NUMBER TENANT J()IHT deed lor joinUy-held real Mtate VAlUE Of ASSET INTEREST DECEDENTS IUTERESl
1, A,
TOTAL (AlSO enter on line 6, Recapilulation) S
JOINTLy.oWNED PROPERTY:
(II more space is needed. insert additional sheels ollhe same size)
..,"''',.,,'''.
COM~()fMtAL1HOf ,,..N,j$"lVAtlIA
ItjH[R1lANCE '^. R[1UIH4
R IOPH ' '"
SCHEDULE G
INTER.VIVOS TRANSFERS &
Mise, NON.PROBA TE PROPERTY
EST A T}.QF ro... \\ -r-. .
~~-~ ~- \\\~~~-
FILE NUMBER
:9.. \- ({b ~n\o'l-~
Th~ Idledulo mu,t bo complohldond flied ,f Itle an,werto eny 01 que,llOIl'lltlroogh 4 on Itlerave"" '~e olllle REV,I!>OO COVER SMEET ~ yo,
DESCRIPTION Of PROPERTY II Of
ITEM IIfCtI.<< "41\1,\I( r-. ll'lllR.l'tVI"fL l!OI.>Il~ll_!o,,,,~r'i)IHll,,-,,IIHJ'101 (.;01'11.' ''''''''".JIM DATE OF OEATH ?;"~~~, EXCLUSION TAXABLE VALUE
N"MB"R '''A(HICt.,.(~ '''' ~1l:1''''''''''U''lt VAlli" "" A<<"T 1m R T ..IJ"'MAAI\
1. ~O~
TOTAL (Atso enter on line 7. Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
.;..,,-.. ~ ....
,l_k
CO?,WON'h[Al HI or F'W!jSY'tVAfrl.
:mtl'ltllAflCE ,",x R[lUr\~l
~[SIO[tll OfCfl)Hll
J1t~l,.Jt..t' .'1
ESTATGe<a.\\ ~
SCHEDULE I
DEBTS OF DECEDENT,
MO~_lGAGE L1ABlldIIESj & L1E~~. .
FilE NUMBER
\\"\ ~~e ~\::.96-('J \ 01~
>'t..","r-
Includo unrelmbursed medical expenses,
ITEM
NUMBER
1,
DESCRIPTlOII
AMOUIIT
~Ol'e
TOTAL (Also enler on lint 10, Recapllulalion) S
(If more space IS needed, insen addllional sheets of Ihe same size)
-
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
~~ 19lcck Box 4 on R2t"1500 Covcr Shcct _~~~_~.,~.."~_~,,,
ESTATE OF FILE NUMBER
__G;,~\\. __ _~_~QP"e._____n.___ _n________~\c~lh=-O-\Q2:?2--_
This schedule IS 10 be used for all sln~e~,ie, JOint or successive life eslate and term cerlaln calculations For dates of death
prior 10 5-1-89, actuarial factors for single life calculahons can be oblalned from Ihe Department of Revenue, SpeCialty Tax Unit
Actuarial faclors can be found In IRS Publication 1457, Acluarlal Values, Alpha Volume for dates of death on or after 5 -1.89
Indicate the lype of Instrument which created the future Interesl below and anach a copy to lhe tax return
o Will [J Inlervlvos Deed of Trust 0 Other
-. - -_. ... -. ----- ----.--. .
i.iFE ESTATE INTEREST CALCULATION
NEAREST AGE AT
DATE OF DEATH
. ~.
........,.'.
l~k
,.\IV"lj^1 A( ''',11'1',',;". ,.P,I,A
'j!'i 4,11.', f ','.' ;ii' ;,'t,
i':l ~, i .. '.' ~ 'i t i i '. .
NAMt(S) OF
LIFE TENANT S
DATE OF BIRTH
1 Value of fund from which life estate is payable
2 Actuarial factor per appropriate table
Interest table rate - 031/2% 06% 0 10% 0 Variable Rate %
3, Value of life estate (Line 1 multiplied by Line 2)
ANNUITY INTEREST CALCULATION
NAME(SIOF NEAREST AGE AT
ANNUITANT S DATE OF BIRTH DATE OF DEATH
s
1, Value of fund from which annuity is payable
2, Check appropriale block below and enter corresponding (number)
Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26)
o Quarterly (4l 0 Semi-annually (2) 0 Annually (1)
3 Amount of payout per period
4 Aggregate annual payment, Line 2 mulliplied by Line 3
5, Annuity Factor (see instructions)
Interesltable rate 031/2% 06% [] 10% 0 Variable Rate
6 Adjustment Factor (see instructions)
7 Value of annuity .If using 3 1/2%, 6%, 10%, Dr If vanable rate and period payoulls at end of period,
calculation is Line 4 x Line 5 x Line 6
If using vanable rate and period payout IS at beginning of period calculation IS
(Line 4 x Line 5 x Line 61 + Line 3
D Monthly (12)
[J Other ( )
%
TERM OF YEARS LIFE ESTATE IS
PAYABLE
o Llfc or 0 Tcrm of Years_
o Life or rJ Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
s
s
TERM OF YEARS
ANNUITY IS PAY ABLE
o Life Dr 0 Term of Years _
o Life or 0 Term of Years
o Life or 0 Term of Years _
o Life Dr 0 Tcrm of Years _
s
s
=-~--<=;-".--_.
s
NOTE: The values of the funds which create the above future Interests musl be reponed as part of tile estate assets an
Schedules A through G of thiS tax return The resulhng life or annUity Interesllsl Should be reported at the approprla!e lax rale on
._ Lines !1.15_16an~ IT ___ _ _____ .____._____ ... _._ _n _ . _ _ .__.. _ ._ _ .
L"r"',ye~;',kf' ",:"f,,:,!n.l r,...".. l~l. .nj "....~..."....-.~1'...,:"
llV.lb4.t (It. PUI
1l~'J~:9~
-.?li...,.,.
COMMONWEALTH Of PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE "L"
REMAINDER PREPAYMENT OR INVASION
OF TRUST PRINCIPAL
FIlE NUMBER
?-'\~Qi!3
I,
(Finl Nom.) (Middle Inillal)
Thll Ichedule Is appropriate only for e.tate. of decedentl dying on or before December 12, 1982.
Thi, Ichedule ilto bo uled lor 011 remainder returnl whon on election to prepay hal been filed vnder the pravilionl
olSecllon 714 of the Inheritance and Eltat. Tax Act of 1961 or 10 report thelnyollan 01 trult principal.
-..\
Estat' of
II.
Remainder Prepayment:
A. Election to prepoy filed wilh Iho Regllter 01 Willi on
(attach copy 01 eloction)
B. Namo(l) of lIle T enont(l) Dato 01 Birth
or Annultant(l)
(Dolo)
~o+
~~~~~::'e
or annuily I, payable
Ago on dote
of election
C. Allell: Camplote Schodulo l.1
1. Roal Eltato 5
2. Stackl and Bondi 5
3. Clo,ely Hold Stock/Partnenhip 5
4. Mortgage, and Note, 5
5. Ca,h/Milt. Pellonal Proporty 5
6. T otollrom 5chedulo l.1 5
O. Credits: Complete Schodulo l.2
1. Unpaid liabilitie,
2. Unpaid Boquo,"
3. Valuo 01 Unincludablo AllolI
4. Total from Schedulo l.2
E. Total yalue of tru,t allell (line C.6 minu, lino 0.4)
F. Remaindor faclor (,eo Table I or T ablo 11 In In,truction Booklal)
G, T a"abla Remainder yaluo (lino E " lino f)
Also ontor on line 7. Reca itulation
5
5
5
s
s
s
III,
Invasion of Corpus:
A. Inya,ion of corpu,
(Month, Day. Year)
B. Nama(,) of Lifo T onant(') Dolo of Birth
or Annuilont(')
Ago on dote
corpus consumed
Term 01 yeall income
or annuity is payable
C, Corpu, con,umed
0, Romainder foetor (,eo Table I or Table 11 in In,truction Bookie I)
E. T a"oble yaluo of corpu, cOnlumed (lino C " lino D)
(AI,o onlor on lino 7, Recapilulation)
5
5
5
IlV,'6Ab [U I1U) \
COM~ONWEAL~NNSnVANIA
INHERITANCE TAX RETURN
RUIDENT DECEDENT
.-- -,.--....
INHERITANCE TAX
SCHEDULE L-2,
REMAINDER PREPAYMENT ELECTION
.CREDITS-
----'-------\--
~fhL \<\
\ "'."",,, ,&\.n.,hc0r::;g.3,
~uD.D"~
.__~~I~-U~.IJ-
-~
I, blate 01
If,nl ~n~_~l .~~=-=-.~:~-:=---J~ddj;j;.~
Do"riptlon Amount
---.------.- -..-- -.-----.--,------
A. Unpaid Liebititio, Cloimod oguin't Ori9,nlll E,luln, end payebto from ano"
roportod on Schodulo l.' (plo",e li,l)
~O~~
II. Item No,
--.------.------. --
S
T 0101 unpaid liuuililicll
.,,~,Ji~~~~?~ on. S"tlion lI~t~n~ O:l_,,~~.cho-~ulo l) - .-
a. Unpaid aoquo," payoblo Irom onel' reported on Schodule l.l (ploo,e li,t)
--... .~._..--~"-'-
~O(\-e..
TOIOI unpaid boquo," S
_ . _=.!~~~~.-"~,;e.c~i."~~~-~i'.'-,,R:~."."-~chodulo-!l
C. Valuo 01 onat' reportod on Schedule l.l (other Ihan unpaid boquo," li,ted under
"a" above) that ore not included lor 10' purpo,o, or Ihol do not lorm a port
01 tha tru,1.
Computation 0> 10110"'''
~O\\e..
._~-_.-_.._._---_. .--.-.,---.- -..-------------- ---.---.--.-
.. ---- ------.- .--".-.--
S
---~_.--_..._.
10to1 unincludoblc O!l~et!l
(include on Section II, line 0.3 on Scheduloll
_____.b__---
--------- - ----_..__._-_._--~
---_._~-- -... --.---.------
...----c----.-- .-.----- - --
-----. .---"-' .-- -..-'
III.
TOTA~~"-..n'-"r,o-"S.~cti,,n II, line 0,4 on Schodulel)
(11 moro 'pace j, needed, olloch additional BY, · 1 \ ,heol',)
SCHEDULE N
SPOUSAL POVERTY CREDIT
IH.... '~~ft L' (I 'I~I
'i>,.//~,,- ~
"".WJj 'C'
-.' .'-
COMMONWEALtH Of PENN5YlAtUA
INHERITANCE lAX OlVI510N (AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91)
ESTATE ot;:~-,-O-<~ -:So ~"\~D\~-"-._"--"-"- ...-..-----rl~~~..(,~<9\C---P
Ihi, schedule must be completed and fi~d '" you chuckod tho spousul povorty credit box on the cover shoD!.
. .
,
I
I
l--~-----------"
I
:',\
I. Toxoblo Anoh 10101 from line 8 (cover sheel)
2, Insurance Proceeds on life of Decedent.. . 2
3, Retirement Bcnclih... ... ........... ....... 3
I
4, Joint Ancl\ with Spouso ...., ....... IA. I
! i
5. PA lollcry Winning' . .. . . . . . . . . . . . . 15 I
t" _.l.._
i
60. Other Nontaxable Anols: Us, (AlIoch schedule if ncwumy).. 60.
!6b
,
;6c,
I
,
\6d.
6, SUBTOTAL (Line. 60, b, c, d)....,
............. ...... ....
7, T 0101 Gran Anet. (Add line. 1 thru 6)..
.............,.......
.......................
B. Tolal Aclualliabililics ........................................,........ ...................., 8.
Q, Net Value of E'tolO (Subtract line B from line 7),.,...............................,...,......................... Q,
" line 9 i$ greoler ,hon 5200,000 . STOP. The eslote j, nol eliglbfe to dorm 'he credit H nol, conlmue to Pari II.
. . . ..
,-- --~.__._~-----
----.-------
2, TAX YEAR: 19 3. TAX YEAR: lQ
_..-- -------------------~--_..-~._---
1201 3.0 ..__..~d_
l2b,
, 1
12<1
12d:
I .
I .
12e!
. I
121:
Income:
Q. Spouse...................... Je:r
b. Decedent................... .lb,i
c, loinl........................., \1.C'\! .
d. TOK EKcmpllncomc...,. ,ld.___
c. Other Incomo not \'
lisled above ...,.......lc,
JJ.!'!9L,.,..."",...,..,....""".1f.!
4. Average Joinl Exemption Income Calculation
40. Add Joinl Exemption Income from above:
(II)
+ (21)
+ (311
::\_~d
,
. 3d 1
\3.\~
: i
.~ 31 :
=
1+ 3)
4b. Average Joinl Exemplion Income ........................ ....".... ........ ....... =
II liRe A(b} is greoler 'han SAO,OOO. STOP. The Dslate is nol elIgible 10 claim the credit. " not, continue 10 Potf III.
. . .., .
1. Insert amounl of laxable transfen 10 spouse or S'OO,OOO, whichever i\ len....
2. Multiply by credit percentage (\ee imlruclion,).. . . .._."'" . . 2 '
3. Thi\ i\ the amount ollhe Re,idenl Spou,ol Poverly Credit Include thi\ figure
in the calculolion of tolol credih on line 18 of Ihe cover ..heet 3.
4. For Nonre,idenh, enter the rolio ollhe decedcnt'\ gron e,tolc in PA 10 the \loluc of the
decedent', gro\\ o'lolc.... ,. ... ................._ ." . .' . .1
5. Multiply Ii no 3 by line 4 and enle, the 10101 here Thi\ is the omounl of the Nonrc..idenl Spou\ol
Poverly Credit. 'ndude this finure in the calculation of lolollledih on line 18 of the CO\ler sheel. .5
',/16-- 1"1'7- 7
I BUREAU DF INDIVIDUAL TAXES
IHIIlRITANC[ TAX DIVISION
OCP'. 180bOl
ItARRISBUPC, PI. I1l11l-0601
'*
COMHONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NDTICE OF INHERITANCE TAX
APPRAISEMENT. ALLOWANCE OR D'SALLDWANCE
DF DEDUCTIDNS AND ASSESSMENT DF TAX
II'.U" II lI' 111.111
SAMUEL W MILKES ESQ
JACOBSEN 8 MILKES
16 CAVE HILL DR
CARLISLE PA 17013
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
11-19-2002
HIPPLE
11-18-1996
21 96-1023
CUMBERLAND
101
Allount Rani Had
GERALD
J
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE. PA 17013
CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~
iiEv:is4i-Ex-AFi'--l'oFozY-iloYicE--oF-YNHEiiiTANcE-YAx-A-ppRiiisEHEilT-;-Ai'LowANcE-oR"m-----n-------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF HIPPLE GERALD J FILE NO.21 96-1023 ACN 101 DATE 11-19-2002
TAX RETURN WAS: I X I ACCLPTED AS FILED
I CHANGED
RESERVATION CONCERNING FUTURE INTEREST - ~EE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Reel Estete (Schedule AI
2. stocks and Bonds ISchedule B)
3. Closely Hald Stock/Partn.~ship Inte~.5t (Schedule C)
4. Mo~tgagas/Not.s Receivable (Schedula D)
5. Cash/Bank Daposits/Misc. Pe~50n8l Prop.~ty (Schadule E)
6. Jointly Owned P~op.~ty (Schadule F)
7. Tr.nsfa~s (Schedule GJ
8. Total Assets
NOTE: To insure prope~
c~.dlt to your account,
subnit the uppa~ portion
of this forn with you~
tax paYIIBnt.
70.000.00
.00
.00
.00
21,000.00
.00
.00
181
III
121
131
(41
151
1&1
17l
91,000.00
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funa~.l Expansas/Ad.. Costs/Misc. Expenses (Schedule H)
10. Debts/Hoctgege LI.bllitles/Llens ISchodule 11
11. Total Deductions
12, H.t Value of Tax Return
13. Charit.bla/Gova~nllanta1 Bequests; Hon-.lBct.d 9113 T~usts
14. Net Va1ua of Est.te Subject to Tax
191
1101
11,758.54
.00
1111
1121
1131
1141
11 .71;9 DO
79,241. 00
.00
79,241. 00
I Schedule J J
If an assessment was issued previoUSlY, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ~ returns assessed to date.
ASSESSMENT OF TAX:
15. A"ount of Line 14 at Spousal rate (15)
16. Anount of Line 14 taxabla at Lin.al/Class A ~8t. 116J
17. Amount of Line 14 .t Sibling cete 1171
18. Anount of Lina 14 taxable at Col1.ta~.l/Cl.s5 Brat. (18)
19, P~inclp.1 Tax Due
NOTE:
79,241.00 X 00 =
.00 X 06 =
.00 X 00 =
.00 X 15 =
.00
.00
.00
.00
.00
1191=
NUMBER
=0
INTEREST/PEN PAID I-I
AMDUNT PAID
DATE
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
.00
.00
.00
.00
,
IF PAID AFTER DATE INDICATED, SEE REVERSE
'OR CALCULATION DF ADDITIONAL INTEREST.
I IF TDTAL DUE IS LESS THAN $1. ND PAYHENT IS REQUIRED.
IF TDTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YDU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FDRH FDR INSTRUCTIDNS.1
RESERVATION: E.tate. of decedent. dying on or before Daca.bar 12, 1982 -- If .ny future Intera.t In the astate Is tran.ferrad
In po.se..lon or .nJoyaant to Cia.. 8 (collataral) banaflclarlas of tha dacedant after the axplratlon of any as tat. for
II'. or for y.ar., the Co..anw..lth h.r.by axpr...ly r...rv.s the right to apprals. and ..sess transfer Inherltanca Taxes
at the lawful Class B (collateral) rat. on any such future Int.r.st.
PURPOSE OF
NOTICE:
To fulfill the r.qulre..nt. of Section 21~0 of the Inharltanc. and Estute T.. Act, Act 23 of 2000. r72 P.S.
Section 9UOJ.
PAYMENT:
D.t.ch the top portion of this Notlca and sub.lt with your pays.nt to the Register of Will. printed on the ravars. sid..
--Hak. check or .onay order paYabla tal REGISTER OF MILLS, AGENT
REFUND (CRlI
A refund of e t.. cr.dlt, which was not r.qua.ted on the T.. R.turn, .ay be requasted by coapl.tlng an "Appllc.tlon
for R.fund of Pennsylvania Inh.rlt.nce and Est.te Tax" IREV-1313J. Applications ar. .vallabl. at the Dfflc.
of th. Raglstar of Wills, any of tha 23 Ravanue District OfflcDS, or by c.lllng the special 2~-hour
answering .ervlc. for for.. ordering: I-BOO-162-2050J sarvlces for taxpayers with specl.1 ha.rlng and I or
spaaklng naeds: 1-800-~~7-3020 ITT onlyJ.
OBJECTIONS:
Any party In Interest not satlsflad with the appralses.nt, allowance, or disallowance of deductions, or ass.ss.ent
of ta. (Including discount or Int.rast) as shown on this Notlc. .ust object within sixty (60) days of r.calpt of
this Notlc. by:
--written protest to th. PA Capartsant of Ravenue, Board of App.als, Dept. 281021, f1.rrhburg, PA
--.I.ctlon to have the ..tt.r d.ter.lnad at audit of the .ccount of the personal represantatlv.,
.-appeal to the Orphans' Court.
DR
17128-1021,
DR
ADMIN-
ISTRATIVE
CORRECTIONS:
Factual errors discovered on thl. .ssess..nt should be addrassed In writing to: PA Dep.rt.ent of Revenue,
Bur..u of Indlvldu.1 Ta.es, ATTN: Post Asse.seent Review Unit, Dept. 280601, Harrisburg, PA 17128-0601
Phon. (717) 787-6505. 5.. p.ge 5 of the booklet "Instruction. for Inherlt.nce Tax Return for a Re.ldent
D.cedent" (REV-1501) for an ..plan.tlon of ad.lnlstratlvely corractable error..
DISCOUNT:
If any ta. due I. p.ld within thraa (1) c.lond.r sonths after the decedent.s death, a flv. p.rcant e5~) discount of
the ta. paid Is allowed.
PENALTY:
Th. 15~ ta. sanesty non-p.rtlclp.tlon penalty Is cosputad on the tat.l of the t.. and Intar.st assassed, and not
p.ld b.fore January 18, 1996, the flr.t d.y aft.r the .nd of the tax a.n.sty p.rlod. This non-partlclp.tlon
p.nalty I, appe.l.bl. In the sa.. sann.r and In the the .... tl.. period as YOU would appeal the ta. and Int.r.st
that has b.en ....,s.d a. Indlcat.d on this natlc.,
INTEREST:
Int.r.st I, ch.rgad beginning with first day of d.llnquency, or nln. t9J .onths and one (1) d.y fras the date of
d..th, to tha d.t. of p.y..nt. T.... which b.c... d.1Inqu.nt before J.nuary 1, 1982 bear Intere.t .t the r.t. of
,1M 16~) perc.nt par annus calculated at a dally r.te of .00016~. All tax.s which b.ca.e da1lnqu.nt on and .fter
January 1, 1982 will b.ar Int.re.t at a rate which will vary fro. cal.nd.r year to cal.ndar ye.r with that r.t.
announc.d by tho PA D.p.rt.ent of Revenu.. Th. applicable Int.r.st rat.s for 1982 through 2002 ar.:
Vear Interest Rat. Dally Interast F.ctor Vear Int.rut Rate D.lly Int.rnt fIIctor
1982 20~ .0005~8 1992 OX .000241
1981 16~ .000418 1993-1994 7X ,000]92
1984 1J~ .0003DI 1995-1998 OX .000247
1985 1l~ .000356 19lJ9 7X .000192
1986 10~ ,000274 2000 oX .000219
1987 OX .000247 2001 OX ,OO02~7
1988-1991 1J~ .000301 2002 OX .000164
nlnterest Is calculat.d o. follow.:
INTEREST = BALANCE DF TAX UNPAID X NUNDER DF DAYS DELINQUENT X DAILY INTEREST FACTOR
.-Any Notlc. Issued aft.r the t.. b.co..s d.llnquent will r.fl.ct an 1nt.r.st c.lcul.tlon to flfte.n liS) days
bayond the date of the .ss.SI.ent. If paysent Is .ade after the Int.rest co.putatlon d.t. shown on the
Notlc., additional Inter..t .ust be c.lculat.d.
In re: Estate of GERALD J. HIPPLE
No. 1996.01023
PA File No.: 2196 - 1023
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Gerald J. Hipple
Date of Death: November 18, 1996
Will No: 1996-01023
Administration No. 21-1996-01023
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:
,
1. State whether administration of the estate is complet~
2. If the answer is No, state when the personal representative
reasonably believes that the administration will be complete: Within
the next ~ months.
~:t If~r }~er to No.1 is Yes, sta~ollOWing: N;::pplicable.
Dat~:'3(~";>' .~
'.' '.' I '..' BY S I W M'lk
,; , 0:: ': : amue . 1 es
g~: ~~: JACOBSEN & MILKES
8 'gl .2.g 52 E. High Street
~a: ~ ~8 Carlisle. PA 17013
(717) 249-6427
(717) 249-8427 - Fax
Attorney No. 30130
Counsel for Personal Representative
STATUS REPOltT UNDER RULE 6,12
Name of Decedent: Gerald ,}, l-liPJlle
Date of Death:
November 1H, 1!lDli
Will No.
21.1!J!)(j.() 1023
Admin. No.
Pursuant to Rule G12 of the Supreme COlll't Orphans' CO\ll't Rules, I report
the following with respect to completion of the administration of the above.
captioned estate:
1.
State whether adxinistration of the estate is complete:
Yes _ No
2. If the answer is No, state when the personal representative
responsibility believes that the administration will be complete:
on 01' about January 1. 2001
3. If the answer to No.1 is Yes, state the following:
a.
Court?
Did the personal representative lile a final account with the
Yes_ No..A-
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
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 01'
informal accounts may be liled with the Clerk of the Orphans' COlll't and may
be attached to this report.
..
Date: \o\:~\... y-D
. -
. '
amuel W. MtI es, Esq.
JACOBSEN & l\IlLKES
52 East High Street
Carlisle, PA 17013
(717) 24!l-G427
~
,-
- ~
''';~
Capacity: _ Personal Representative
X Counsel for personal
Representative
(MAII:l.II.fIAl\I:11
STATUS REPORT UNDER IWLE 6,12
Name of Decedent: Gerald J. Hipple
Date of Death:
November 18, l!l!l(j
Will No. HJ!l(j.Ol023
Admin. No. 21.1!l!)(i-01023
Pursuant to Rule 612 of the Supreme Court Orphans' Court Rules. I report
the following with respect to completion of the administration of the above.
captioned estate:
1. State whether administration of the estate is complete:
Yes_X_ No_
2. If the answer is No, state when the pel'sOlllllrepresentative
l'esponsibility believes that the administration will be complete:
3. If the answer to No. 1 is Yes, state the following:
a.
Court?
Did the personal representative file a linal account with the
Yes_ No_X_
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
c. Did the personal representative state an account informally to
the parties in interest? Yes_X_ No_
d. Copies of receipts, releases, joinders and approvals of formal or
informal accounts may be filed with the Clerk of the Orphans' CouJ't nnd may
be attached to this report. /...........~<~... -./
6:,~;V ~,-
Date: &'/5/" I _,c??1/ /' ,;>
Samul!'1 W. Milkes, Esq.
JACOBSEN & MILKES
52 East High Street
Carlisle, PA 17013
(717) 249.6427
Cllpllcily: _ Person III Hepresentlllive
..l Counsel for persolllll
Hepresenllllive