HomeMy WebLinkAbout97-00719
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U~e oS, limited ellote ; IJO fUlUrft lntere\! (omprOml11l
!29 (for dot., ot death after 12.12.02)
Utm '~6. Decede"t Died ToUale ~; 7 Decedent Moinlllined a living Tru\!
<( IAttach copy 01 Will) IAlloc' copy of l,ulll
----.-.. I ALL CORRUPONDINCB AND CONFIDINTlAL TAX INFCii-MATION SHOULD li'iiiilICTIDTO;-----
I ~ i NAME" -- -, ICO/,IfllErE ":-1.\ILlNG ADOHSS
$I ~ _ I (; 9 7 ,/.-'~ 5T"'''''/' K~J;>
.. z l, 'R"".d~f:P___?M/1tfN.5--_;...cQ" #J(I;;'~f!!c.o& : c .J..a_~"'''',.du-<'C ~ r-::1""/
8 2 ,rtrtffioNf NUMldl i /T'''''"/~''~ - /..-1 r
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, I. Roal EIlo'.ISc,odulo A) I I)
2, S.ockl and Bond. (Sc,odulo B) I 21 ....---------------
3, Clo..ly Hold SlocklPar'ne"hip In..,o" (Sc,odulo q I 31
4, Mcrtgag.. and Nato. R.c.i,ablo ISc,.dulo D) ( 4)
5, Casn, Banlc Deposits & Miscellaneous Personal Property! 5)
(Sch.dulo E)
6, Jain.ly Own,d Praporty ISc,odulo FI
7, T rcn.I." ISc,.dul. GIISchodul. LI
8. TOlal Gran Au.ts (totalllM1 1.71
9, Funeral Exp.nllS, Adminiltrative CaUl, Milcellaneous I Q)
E .p.nt.' ISchodul. HI
10, D.bll, Mcrtgago LiQbili'i.., Lio" ISc,.dulo II
11. T ctcl D.duction, I,atallin.. 9 & , 0)
12, N.t VQlu. of E,la', Ilin. 8 minu.lino II) ,""
rolf ;f".)~'^.tt,) r.:> S<.<A tN'. I'" ~ c./,-""'"",WO - Sd..# c>
13, Charitabl. and Goy.rnln.nlal aequelll (Schedule Jj
14, Ne' Value Subject to To. (Une 12 minulline 131
15, AlJount of Une 14 ta~abl. at 6% rol.
Ilnclud. valu.. from Sch.dul. K or Sc,.dul. M,!
16, Amount 01 line 14 tOXQbl. 01 1 S% ral.
Ilnclud. ..Iu.. Ircm Sch.dul. K or Se,.dul. M,I
17, PrincipQI tax due (Add to. from Ii no 15 and Ircm Ii no 16,1
18, Credits Prlor Paymentl Dittounl
['9' If 1i~8 i. gr.a'., ,hcn lin:17,+on':;.~'. dill.,one. on lin. 19, ~i' I. th~ OVUrAYMINT,
[0, If lint! 1711 gr.a'er than Itn. 18, enler Ih. difference on lin. 20, This is the TAX DUE,
A, Enter lh. inllr.,' on th. balance due on line 20A,
8, Ent.r I" 'atal 01 lin. 20 and 20A on lino 208, Thi, i, ,h. IALANCE DUE,
Mako Ch.ck PQyabl. ,., Regl.,., Qf Will" Ag.n'
- ..IIIURI '0 ANSWIR ALL QUlmoNS ON RIVIUISIDI AND TO IICMICIt MATH..
Under penalti.1 of perjury, 1 dlCla,. ,hat 1 ha.... ..amined thil re'urn, including accompanying schodul.. and .tatem.nfl, and to Ihe b..s' of my knowledge and belie"
It is truI, (orrect and comple'e, I d.clore thot all rial "loll h01 been report.d 01 IrvI mark.t valul, Oeclaralion of preportr olher than the penonal repr..entatlve IS
baled on allln'ormation of which preporer hOI any knowledge,
$lONAlURf Of PUSON Rf~PONS'.ll fOil: PIlING AElurn----"'o'fiiEss - DAle
'lll NUMB"
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".- ,..
INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
(EAR
;A,1-'Ql-119
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III
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.iMMutIWfAlIH Of I'Hm~Vl\//ltIIA
iifP...."IMHiI (1' ~fyENlJt
t,q~t ,)fIlCE BOX Rl(7
I.IA~RI~!HJII~I.~~~ ,~l1~~_,~.?,('., ___ _ "_ _no.
()tc'ffITTif- $ .,',.'M( ~flli~;r--:\i;()!".iii}mTiTi'.-n;:;(i'
"..4dtfA1?
SO-&~Ct)Il.I'V ~HiM8E1l
i)A1E 0' lll!<lH
:)IP.jTv ~nN
~.
, ---- -----.. - --., ~.-
- ~~---r:T(rcTti i. ,M .._ ':':'lllTiT:\f;-i':~. [<; ~ .-.-.----------
9'-v", t.V;fr",,,,r ~?"""-?' 'j?",,,O;'
C:'.A'A'''- ,>/0' r# ,1?~,13
:L/)A
'bj.,f(-I..')ffifA'll
9 -.:>.)/- oJ
"""",, C"J "..,~('-,"C/,1A/~..
,J RemCllnd"r RAlur"
{IOf dOI"s ot dealh prior 10 12.13.821'
.5. Fndllfnj estate Tal(
Return Required
..._, B T 0101 Number of Safe Depo'ut BOIllI
1;1"-V-~~
,,:?i!_7: P~<2~o-;;'l
oX I 0"9,nal R"urn
: 2
Suppio!tmenlol Return
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161______
I 7)
I $!
""<:: /87. iPO
110)
III)
II~!
1131
1141
5"''7 /~()
( -'l'7'/37.~_
a
liS!
. ,06 =
1161
. ,15 =
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117)
Inttr."
lIal
(19)
Chl'(k hl'I(' .f you ore '1''1\l(HII(19 (I refund of your oVl"fpnyment
(201
(20A)
12081
.,,',-'
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.-- "
-.{' , '.._'I ~ f/~-,),',,-'i 1~.J'--J:7f.;;i' rW~"c'l~ ''7:.,,-
'U (I J) 17L5!ff ,-I j ../ '1-;
I
~WAlUIJ O'.J'p",U,f.'IHV IHAM '~PlmNI'\'VI ',.. ,'~D'IS', "i / ' , "
':'_"-~'-' l(' .-->J- ,- ......-- --:-'--'''-1- (','-'_ ?l, ,,-.,-' __" f',,' ,t'-.
~,). ~-(_.(...J.,;&..j A'<l '-("1., (' (' t"~, / , l j .', I ,', .,,(', (
,
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:'Y'"01Ih ill'" '*
r:OMMONWUl1H Of "NN~nV"NI"
INHllIiIUN(! U~ lfYVIlN
_ _~.~!IOI~! DI.C.~Df~'
ISTATIOji . ----.--...,
;.ii.INliM'IIl"'C~=~~==~-"'~=~
SCHEDULE A
REAL ESTATE
(;;;party lal.i~:;':d "'~"RI,C';s:.~~~IP mull ba dl"lo.a. o. S.ho.ul. " All ,aal I;tat. ;h;.'ldb;;;;'a-,'~d ;;,~i;-';;;k;I-;;j;'
whl.h I. dall.ad a. tho p,l.. at whl.h p,aparty wa.ld b. u.ha.,.d batwa.n a wlllin, buya, an. a willi., ..11." .aith.. bal., ..mpolla.
t. b.y a, .all. b.th hay'., ..a..nabla ~.awlad," olth. 'allyant la.t., ,,_ , ,._ .__.
-.ITeM--;--'--_.P---~-~--'_.._---..P_' -'''--.''.---.'. VALUE AT DATE
NUMBER I DESCRIPTION or DEATH
-_.~.. ______._..M__._._~__."_.__n.. __. _~"_"m.. ...... ...___.._..... .. _________.H"____ _..____,____._~_._.
I.
<:)
"
TOTAL (AI.. a.to, o. Ii.. I, Raca 1I.latlo. S
(II..... Ipa.a I. neodarI, IItMtf addlHanal _II 01 la... oJ...,
\ " -,-,tT?j;~,~r.P':'t'
Co,
.
~eV"~03 IX+ 1...61
,
ISTATlO'
'*
COMMOHWUlTH 0' 'INNl'l'lVANIA
INloIllllANCI TAX ReTURN
aUIDINT DECeDeNT
---
r~t9
SCHEDULE B
STOCKS AND BONDS
PILI NUMIIR
/.::
~tf".,;it ,<J.r;.
(All prop.rly lolntly-own.d with RI,h' of SUli/lvorohlp mu.' b. dl.cIQ..d on Schedul. F.l
ITEM
NUMBER
l.
-
DESCRIPTION
TOTAL 1,1,110 tint.. Qn line 2, Rica ltuloHoft
IIf ...,. lfIOca ,. ~, In..rI oddlHonollhatll 0' .- ....,
yt-'_:;;'~JP~~"1'IfC""
VALUE AT DATE
OF DEATH
C)
$
-
MV.lIG1 U + (','1\
.
COMMONWEALTH OF PENNSVLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE "E"
CASH AND MISCEllANEOUS
PERSONAL PROPERTY
-".-.--.
ESTATE OF
I/?,4 /: ~A'A',;()s.
tAil PfOP.M", olntl"'oOw~~ tn. Algh' of SurvlVOtlhlp mun b5 dllClo.td on StlUdul. "F")
ITEM OESCRIPTION
NUMBER
1.
C'll I'f Nr' '~r~ "'7 POI,#",':', r - /'/e//.>,d ot&""-<JK
...-91"-... rP';> - ...,5- 0 If!'"
Su~:Jeif T() P,'.!><!.I-,,'-'f""...e
FILE NUMOER
VALUE AT
DATE OF DEATH
+,7/17. ...
TOTAL IAlIO en'lf on lint &, RlClpltulltlonl .
,.. __ __ .. ....... 1.-.: NIIIhtoMt .... of w. .....
HV1\ll H. 1"11"1
~'!-oI
,.~ If;J.,'(Ii.
. tW-....
COMMUNW(;.,L1ti Of ~ENN!iYl~;.,NI'"
lNHUll,uiCf t,,~ RETURN
i\UIDIN' DfCEOHH
iSTATE'OF'. .
II?'-') e: A'~"""-<J';;
"--~--r-'.'---'--'----
ITlM I
NUMBER
A.
SCHEDULE H
FUNERAL EXPENSES.
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
-..---....-.-- T-
_. _ . __~~_~!lnl_!!r Tn!.
f1UNUMIIR
I ,
DESCRIPTION
AMOUNT
Funeral IMpenl."
N~
l.
B. Admlnlltrallve Co.t..
1. Perlonal Repralanlative Commlulcn,
Social Security Number cf Perianal Repre..nlatiye, -~
Vear Ccmmi..lon. paid
2, A"crnay fae.
3, family exemptlcn
Claimant Relallcn.hlp
Addr.u of Clalmanl 01 d.cad.nl', daalh
Slraat Addra..
City Slale Zip Cod.
4, PrQbale f...
C. MI.c.lIoneoul Exp.nlell
1.
TOTAL (AIIO enler <<;In IIn. 'I, Racapllulotlonl S
llf more apac. I. n.....d, In..rt a....ltleaaallh..11 of 10m. 11..1
{a'st )1~H1 ,nt~ mC~diutntltt
of
IDA E. KEARNS
I, Ida E. Keurns. of the Township of Frank11n, County
of 'iork and COllSllonwealth of Pennsylvsn1a, being sound of mind,
memory and understanding, do make, publish and declare this to be
my last Will. and Testament, hereby revoking any and all Wills and
Codicils by 8.e heretofore made,
ITEM 1. I direct thst all my just debts and fureral
expenses be paid by my hereinafter named Executors as soon after
my decease as may be convenient to the proper and complete admini- '
stration of my estste.
ITEM 2, I give, devise snd bequeath my entire estate
remaining after payment of debts end expenses, whether such estate
be composed of property real, peraonal or mixed, and wheresoever
lame may be situeted, unto my husband, James Walter Kearns, if he
be living at the time of my death,
ITEM 3. In the event my said husband shall predecease
me, I then give, devise and bequeath my entire estate remaining af-
ter payment of debts and expenses, whether such estate be composed
of property real, personal or mixed, and wheresoever same may be
situated, unto my children, to be divided equs11y between them per
stirpes.
lTEM 4, I nominate, constitute and appoint my husband,
James Walter Kearns, Executor of this, my last Will and Testament.
In the event my said husband shall predecease me, I then appoint
-2-
\ \
\
I
"
WARNING: IT IS IllEGAL TO ALTER nus COP V OR
TU DUPLICATE BY PHOTOSTAT OR 1'llOTOGRAPH,
COMMONWEAL HI Of .ENNSYI ,^NI^
DEPAATMf;:NY OF ttf:Al TH VIT ^llll:CnlHJ!:;
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
CERT, NO, 3 3 0 1 ~ 18
Dee 6 1996
t'"fiiiifT~W;~"5111Ii~I;g~-~'
Name qf Decedent_'_____._~~-. [:..:~e<1rns
rll"
Sex ...____F'ema~.~,,_.soclal Security No_.,.., 'm__?~7-n3-0303__ Date of Death ___...__~?:~_~.!._~~9.~...
Date of Birth ____..~:.~.:~!~4....19ltJ1rthplace .__.-Pe~n~Yl van i a___.._..____.______________,
Place of Death Manor Care Nurslnq Cent8l" Cumherlancl Co. Carlisle Boro. Penns Ivanla
". .,.- ~"clllt\' N.01f1 ---,...~...------~---.Go;i;;iy ........,.---.--.-..- -..., ,. ...... -"~-r.'7I71iQ-,~;;-;ghOf r(,.~~,f1iiT-----......--.--...~' Jil!._ """,-.-.,
Race ._.._.__.W~:~__ occupallon--_-.--.~-ai-t'~::Ss/~O-~~ ,Armoej Foroes? (Yes or No) ___.._u~.~_____
Marital Status _,____..~~I,:r_i:lei ~:~I~~;~~dress __u...__9_1(J~a 1 nu t , Bottom Rei. Ca~.l~sl e~. P~_...2!~1.3. ..___
N"'hOIl' ~lf,)~1 C,lf or 1 nWI; - - !illt~ ---
Informant ~____~ nn!.~r~_ S. _~(:~r.:r::._____ __ Funeral Director
Name and Address of
Funeral Establishment __.._.._ COCKLI~,!~.NE R~L__~.~~~.D_lll s hu r g, r a
~""1:1I;'
- ~----~~-"~~--..~-~-TiI~I-~~.-~...."..~~-r-OT.........-"---.,.----'
Scott D. Brenneman, F.D.
17019
__~___L.._UHT_'__._~~~__r_....---~~-------"..-'<'-~----.
Part I:
Immediate Cause
(e)' Metastatic
--_.._~.---_.
(b)
Interval Between
: Onset and Death
Carcinoma of the Pancreas
__._~~_.,._._____.~__~___ ____u._. .--.--".~+_~.__._____.~-.------+--.__,_....__~._._..__~_.___.__.._~_~__~-......
__~~~____.~___~___..__.... ."_.________.~_~.........___,~__......._."'- "....._____~..___________t.~
,
,
,
-_.._.~-----..,..........._~.~...;..._"._,--~"".-.----:-~~~_._.~-_._--~.--......-..~-_.._--------_._~-
,
,
,
_ ..._.__.~__~__r__'-_________'__"____~... ._.__".~~~~c_..........-.;.....I-~---~.-.~-~-~--.
(c).
(d)..
Part II: Other Significant Con(illlons
,__~.N__.__~_____.......___'_~~.."_._~.._______._"__...._.__."._....+--------_.~._.._.._._____________+__~_'n_"~_~___~__._~
Manner of Death:
o XX
Accident 0
Suicide [J
DescribE' tlOW Injury occurred:
Natural
Homicide
Pending Investigation
Could not be Determined
o
o
o
,~______.._~__..__RO_.._______~, __.___._ -----
~-~~._-_._...-.,-.,--~-~_.....----- -----------------_._.._--~~.,
Name and Tille of Certifier __._.~.._D.QJ:LL....J.l1:.illJ.h,l'_.,-M.,D_..
Add Shermans !1a'le Fallli Iy Practice., Sh"e, rrr,l,a,ns
ress ,_.._~..______'_____' ......-.. ,-- ---"."
,.----- -----------(M, D~-6o., Corc'-iiEjr',--M~E.)
[J~ le, 1'1\
.< ~_____.____._.~_..__.____~_.........._.T____._NM
This Is to certify that theinformallon here given is correctly oopled from an original certificate of
death dUly flied with me 89 Local Registrar, The original cOltilicate will be forwarded to Ule State
Vital Records Office for permanent filing, (, / , ,'- " ,.' -t" "", , ",J ,;'
);I.&,,~( (.t;" l_Ltl'..,'cc__ .4L..t..f.J.L
(T, (",,"1110'1\1,,118' "I VIIIlI HIlI,tHdl 9\ /J.d _~' 9'lIl:' No
~/i:f./. /rrlfdl'" {II~ /Lvdl;"'f'f1;{H,' ".L",~.., . LZtL:.' 1'.
!j",..tAiII)rft&/l l;Il)'_r'OJ.IOh.TlWflllhIP--
____, Dec. 6 1996.-,
OIl' flecel1ltd by lOOllI~lIfIlllrlf
eOMM"WULlH Of' PEtMVLVAMla
lIl'ARTMl"I Of ""..._
_AU Of INDIVIDUAL IAnl
IIl~T. 1'0" I
HARRlllURG, PA 17121-0'01
'*'
INFORMATION NOTICE
AND
TAX PAVER RESPONSE
EST, OF IDA E KEARNS
5.5, NO, 207-03-0303
DATE OF DEATH 12-04-96
COUNTY CUMBERLAND
FILE NO. 21
ACN 97102589
DATI 01-20-97
TVPE OF ACCOUNT
o SAVIMDI
o CHECKIMD
o TRUST
00 CERTlF.
t.''1ld II'" II-m
RONALD S KEARNS
6S7 PINE STUMP RD
CHAMBERSIURG PA 17201
REHIT 'AVHEMT AND FDRN5 TO,
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE. PA 17013
HELLON ""1 1'111 prolllded tht Dlfllrt..nt ",Uti thl In,or..Uon I tlt,d balow which 1'1.. b..n uud In cllcuUtlnl t~
potanUal taM due, Their 'MDrd. t~icat. that at tha d..th of the above dleadant, you wa,.. , joint o..n.r/b'MHc.l.r~ of thll IcCOunt.
If YOU f..l ttlll in'oruUon II .lnoo,.,'.ot, ph.1I obhl" wrlUan catrletlon fro. thl flnancl.l In.Ututlonl attach' copy to this for.
and r.turn It to the 8IboVI ""t.... This IKICount it t,lCol, In IICcordllnoa lIflth thl Inhetitlncl hI( I.a... of thl Co..~.1th of P~n,Ylv."l..
CkN.l:UI,. ...,... ..lti....'...., u., .l.....iI'1I ;:11) ,,~,-ItS,',
COMPLETE PART 1 IELOW ~
AcCQunl 1Ic>, 00098424
~ . SEE REVERSE SIDE FOR
0.1. 02-03-95
E.hblllh.d
FILING AND PAVMENT INSTRUCTIONS
ACCQUIlI 1.1_. 47.187.00
r.rcenl T ..ebl. K 50 ,on 0
AMQunl Subject to To. 23.593,50
TaM R.I. M .15
Polentl.l T.. Duo 3.539.03
PART TAXPAYER RESPONSE
COI PAILORI TO RISPOND WILL RESULT IN AN OPP~CIAL TAX ASSISSNINT lASED ON THIS NOTICI I
.,
To In.ur. prop.r credit to your account, two
(Z) copl.. of thil noUo. aUlt .ccO...."V your
plVlllnt to thl fill.l"., of Will.. "Aka en.ell
pIVlbl, tal "/ilI"lthr of Wl11lj "Itnt",
HOTEl If h)C ply..ntl .r. ..d_ within thr..
e]} lIonthl of thl dlcldant'. data of dlOth,
you .IY deduct. Si: dllc""",t of thl '1M clu..
Any Inheritance tlM dlJI will bleo.' allnqulnt
nln. (,) 1I0nth. aftar thl data of dllth.
[CHECK ]
ONE
BLOCK
ONLY
o Th. above lnfor..tlon and tllC due I, corract.
1. Vou ..y choat. to re.1t pay..nt to thl A..htar of Will. with two copl.. of thil MUC' to obtain
. discount or avoid Intar..t, or you ..y chick bOM "... and raturn thlt noUce tl>> tM RIghtt,. of
WUh ,-"d In offIcial ......lIMn, wUI ba I..uld by the P. Dap.rt..nt of hVlnue,
I. 0 TM libov_ ....t h.. bien or 11I111 bl reported -.nd UI( ""lid .,Un the P.nn."l....nl. tnhlirH~. TII( return
to b. fHed bV thl deudent" rilpr..ent.U"e.
C, 0 Th. .boye l"for..Uon lWnoorrect .nd/o~.bh e"d dlductlJ'" "Ir. peld by YOU,
Vou MU.t caplete PART ~ end/or PART l!J belolil.
If wou indi~,t. , different t.. rate, pl.... .t.tl wour
relation.hip to d.c.dlntl
OFFICIAL USE ONLY 0 AAF
PA DEPARTNENT OF REVENUE
rART
[!]
T~)t
LIME
U,.lIRN - C(lMPll"~."!'''' OF
1. D.t. E.tebll.h.d 1
2. Aeoount I.lanoe 2
5. ,"aroent la.ula S
~. Aeounl Subj.cl IQ T.. "
I. D.bt. ond D.ducIIQn. 5
.. AlIOunl T.....I. .
7. T.. R.to 7
a. Ta. Due e.
'T:I.X I)~~ ,tl)!N'!'''TPI_1!tT IV"~~I-'~I,,!,! rAt
1
2
x 3
4
5
,
x 7
I 8
DEITS AND DEDUCTIONS CLAIHED
rAil
!!l
DATE
PAID
PAVEE
DESCRIPTI ON
AMOUNT P A I D
I
TOTAL CEnter on line S of Tlx Co~put,tion)
j
.
-
Undlr pan.lti.. of Plrjury, I dlclar_ th,t tn. ilct. I hi'" reportld Mboye Ire truI, corrlct and
00MP1.tl to the be.t of .y kno.lldgl Ind blli.f,
HOME: (
WORK (
TELEPHONE
)
)
NUMBER
DATE
TAXPAYER SIGNATURE
...............
. II I
IN THE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT OF
PENNSYLV ANIA
Cumberland County Branch
: Estate of James W. Kearns,
Deceased
Orphans Court Division
O. C, No.
DISCLAIMER
Whereas; James W. and Ida E, Kearns entered into a Residency Agreement with
J..eTilrt Manor Churches of God, Inc, on April 20, 1992, for the occllpancy of Apartment
# 303 at 801 North Hanover Street, Carlisle, Pennsylvania for a deposit of $ 63,500.00,
Said Residency Agreement had refund provision of the original entrance fee less one
percent (1 %) per month from the date of occupancy to up to 60 months of occupancy.
Whereas; James W, Kearns was admitted to the Churches of God, Inc. Nursing
Home on May 26, 1994 and Ida E. Kearns was admitted to the Churches of God, Inc.
Nursing Home on November 14, 1994 and subsequently, tenninated their Residency
agreement on January 7, 1995. As a result of terminating the Residency Agreement, the
Churches of God, Inc. refunded $ 42,766,16 of their residency fee.
Whereas; I, Ronald S. Kearns, acting as all Attorney-In-Fact for my father and
mother, James W. and Ida E. Kearns, deposited the refund of $ 42,766,16 with Mellon
Bank in a Certificate of Deposit Account # 98424. The representative of the bank
suggested the account be opened under the joint account in the name of Ida E. Kearns or
Ronald S. Kearns for the convenience of the bank,
Whereas; the account remained intact on December 4, 1996 whereupon; at the
death of Ida E, Kearns the account balance was $ 47,187.00,
Whereas; On December 16, 1996, the account # 98424 at Mellon Bank in the
amount of $ 47,248.63 was closed and deposited to account N 100-005-0144 for the benefit
of James W, Kearns. The account was opened under the name of Ronald S, Kearns or
James W. Kearns as suggested by the bank for their convenience.
Therefore, I Ronald S. Kearns attest the account # 98424 at Mellon Bank in the
amount of $ 47,187,00 at the death oflda E. Kearns on December 4, 1996 was registered
in the names of Ida E. Kearns or Ronald S. Kearns for convenience only; the funds in the
account were assets of James W, and Ida E, Kearns and were intended to be used for their
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LeTORT MANOR
RESIDBNCYAGREEXBNT
THIS AGIU:EMENT, made this J..D day of ,t1J;J,QI'- , 19~
between THE CHURCH OF GOD HOME, INC. OF EAST PENNSYLVANIA
CONFERENCE, a Pennsylvania non-profit corporation, located at 801
North Hanover street, Car lis le , pennsy 1 vania, (called
.colDIDunity.) and Jft/1J~ ,J! /lJ4 A(EAAA/5
(together or sinqular ly called "Resident") for admission of
Resident to LeTort Manor for occupancy of Apartment Number ~;rO~
located at LeTort Manor, 825 North Hanover street, carl!9Ili;-
Pennsylvania.
RECITALS I
WHEREAS, the Community operates a continuing-care retirement
community consisting of nursing beds and personal care rooms
(together called the "Health Care center"), and independent
~iving apartment units;
WHEREAS, Resident has applied for admission to the
independent living apartment units known as LeTort Manor;
WHEREAS, Community has reviewed and accepted Resident's
application subject to the execution of this Agreement;
NOW I THEREFORE, in consideration of the mutual promises
herein, and intending to be legally bound, Community and Resident
agree as follows:
seCTION 1: LIVING ACCOMMODATIONS
A. Living AOaolllD1odation and Te1'lll
COlDIDunity will provide Resident with the apartment unit,
common facilities and services specified in this Agreement,
beginning on the Designated or Extended occupancy Oat., and
continuing until the termination of this Agreement.
B. Furnishinq!
cODllllunity will provide and lease to Resident an apartment
unit according to the plans ll.Ild specifications shown on Exhibit
.~. (attached), featuring an electric rll,nge, wall to wall
carpeting, custom draperies, washer and dryer and refrigerator.
c. Ol:Itional Appliana../J'Urnillh1Dq.
cOlDIDunity will provide at additional cost optional or
additional furnishings:
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Dish....asher
Shades
Garbage Disposal
Full Length Mirrors
Other
300,oq
/5t) . (It'
The cost of optional appliances/furnishings must be paid prior to
aoquisition and is in addition to the Entrance Fee. upon
installation, all optional appliances/furnishings immed..iately
Deoome the property of the Community and must remain in the
apartment unit after termination of Resident's occupancy and this
Agrlltement.
D. structural Change. and Redecoration
Any structural or physical change of any kind or
redecoration within the apartment unit may be made only after
approval by the COll\lllunity. The cost of any redecoration or
structural change requested by Resident, and restoration to
original condition, shall be borne by Resident unless otherwise
agreed in writing by Community. Selection of a contractor for
structural changes shall be made by Community. Resident shall be
responsible for maintenance of any approved structural changes or
redecoration.
E. CODon Facilities
Resident may use in common ....ith others the activity areas
and other facilities provided by Community for all residents,
1ncl ucHng the chapel, acti vi ty room and lounges, when programs
involving such facilities are specifically scheduled for
residents of LeTort Manor by the Activity Department or Chaplain.
'F. Designated Occupancy Date
COlll:lunity anticipates (but does not guarantee) that the
apartment unit will be ready for occupancy on or about
5-;J.5- 9:?. (Le. the "'Designated occupanoy Date"').
The Designated occupancy Date may be extendeel for a period
not to exceeel nine (9) months (1. e. the "'Extended Occupancy
Date"). Resident shall be provided notice of any extension of
the Designateel Occupancy Date by certif ied mail, addressed to the
address of Resident as reflecteel in Section 20. If, however, the
apartment unit is not reaely for occupancy by the Designateel or
Extendeel Occupancy Date, and such delay is due to strikes, fire,
unusual delay in construction, act of God or any other cause
beyond the control of community, then the date of occupancy shall
be furtller extended for such reasonable period of time as is
needed to ready the apartment unit for occupancy, as is mutually
agreed. Resident shall take possession on the above Designated
occupancy Date or Extendeel occupancy Date, whichever applies. In
the event that Resident fails to take possession on the
Designated occupancy Date 01" Extendeel Occupancy Date, then the
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Communi ty in its Bole and absolute discretion may elect to
teninate this Agreement in acoordance with the termination and
retund provisions herein.
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SIOTION 2: SZRVICB8
A. otilitiel and Allelement.
COllUllunity will provide heat, air oonditioning, hot and cold
water, electr ici ty, sewer, trash removal anel grounds li1hting.
Relident will be responsible for the payment ot any other
utilitie., charges and assessments, inoluding but not limited to,
telephone service and connection oharges, cable television
service and connection charges, and real estate or other taxes on
a pro-rated basis if such taxes are at some future time assesled
against the Community (assessments for real estate taxes will be
added to the Monthly Fee), and Sllch other utilities, oharges and
aSllllllments are not included in the Monthly Fee. PaYlDent of Il
pro-rata portion of any real estate tax assessment does not give
Relident any interest in the land, improvements, or real estate
of the community. If phone service is desired, it shall be
provided by Community.
B. Maintenanoe and Repair
COlDInuni ty wi 11 provide groundskeeping, elevator servioe,
lawn oare, snow remova 1, and necessary repj'irs, maintenance and
replaoement of Community property, equipment and applianoes.
Repairs, maintenance, and replacement of Resident's property and
furnishings will be the responsibility of Resident. Redecoration
will be at the discretion of Community and will be implemented al
part of COMunity'1 preventive maintenance program. Hanging of
all items on walle/doors must be done by the maintenance staff.
Items attached to doors/windows must remain as permanent fixtures
of the unit at the time of vacancy.
C. Pood and Heala
.
1. Community will provide Resident with the noon meal
eaoh day (this meal is included in the Monthly Fee), to be served
in the cUning room within the LeTort Manor apartment building.
Additional meals and guest meals will be available at an
additional charge and at rates determined by COllllllunity. Meals
will not be served to guests unless Resident accompanies queet to
the dininq room and is present for the meal. If Resident is
abient from the aputment unit for more than one conseoutive
week, and Resident provides one week advanoe notice to Community,
Resident shall receive a credit against the next due Monthly Fee.
2. Tray Service - Meal delivery service will be provided
at additional cost to Resident in the event of illness or other
extenuating circul1wtances for no more than thirty (30)
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oon..cutive days. After fifteen (15) days, Resident must provide
Community with a physician's order justifying the need for tray
..rvice or community may discontinue the tray service.
3. Menu Choice - Community will provide optional menu
ahoice in advance but will not be able to provide individualized
IIpecia1 diets.
D. Bou..oleaning and Laundry
Community will provide bi-week1y cleaning services. Laundry
and extensive housecleaning service are available at an
additional charge and are. not included in the Monthly .'es.
I. Agtivith.
Recreational, educational, social and religious programs,
including sunday worship service and chaplain services will be
offered. Activity areas will be available for Resident use in
LeTort Manor and include: lounges, hobby/craft rooms, and social
rooms. Certain special activities and outings will be available
at an additional charge and are not included in the Monthly Fee.
P. Extra p..tu~e.
Community will provide security features which will include
a 24-hour emergency call system, fire alarm and sprinkler system,
daily well-being check and an entranco phone system. Periodic
fire drills will be conducted.
CJ. parking
One parking space will be provided and made available to
each apartment unit. However, in order to obtain a reserved
parldng space, Resident must register an automobile with
cOUllllunity and provide proof of liability insurance ooverage.
R. storaqe
One storage bin will be provided each apartment unit which
will be located on the ground floor. The access door to the
storaqe area must be looked by Resident after accessing the
.torage area. Resident must provide a personal lock for the
ResieSent's storage bin at Resident's expense, and provide a
duplicate access key to community.
I. Ph~De Servic.
If Resident desires phone service in the apartment unit,
cOUllllunity shall arrange for and provide it. Community has
oontracted with a phone service company to provide phone service,
including long distance telephone service. Resident will be
billed month~y by Cornmun i ty for the phone service. Phones may be
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rented or purchased from Community. Only II'touoh-tone" phones are
oompatible with the Community's telephone system. Not all pUsh-
button phones are touch-tone.
J. TranlPortatiol!
Some scheduled transportation will be provided by Community.
Inoluded will be one (1) weekly trip to a local mall.
Transportation to medical appointments is the responsibility ot
Resident.
I. othe..L!..erviaes
Other servioes, such as beauty and barber services, are
available at an additional charge and are not included in the
Monthly Fee.
L. Chanqu In a.~viael!
Community reserves the right to provide additional services
or delete existing services in its sole and absolute disoretion,
and to assess additional charges for any additional servicss.
Thirty (30) days advance notice of any such ohanges in services
will be provided.
81OTION 31 HEALTH CARE~RVICES
A. The Health Care Center
Community intends to operate fully approved nursing (semi-
privats aooommodations) and personal oare facilities in the
Health Care Center licensed by the Commonwealth of Pennsylvania.
Residents at Community will be oftered priority access as defined
in this Agreement to the Health Care Center for temporary or
permanent illne~ses.
TBDI WILL BE AN ADDITIONAL CHARGE rOR SOCH HEALTH CUI
SIIRVIOI8. RISIDENTS MOST MEET THE REQUIRBlU!NTS POR .l\bXI88ION '1'0
TBI P1R80J.IIAL OR NURSING CARl J'ACILt'1'IBS, 8IGN All .l\bMI88IOJf
ACJRIIIIDT, AND PAY THE DAILY CBARGE rOR SUCK BIALTK OUI
.IIVIOI.. HIRI I8 NO GUJUUUfTII THAT SPACI WILL BI AVAILULB III
'1'IIB BUlLTB CARE CIN'l'IlR AT aUCH TIKI A8 '1'HI!l RISIDmrT DI.IRI8 TO
'1'HAIISPIR '1'0 EITIIR PERSONAL OR NURSING CARl OR AT 8UCK TIU AS
HI .1.IDlIIl'1' IS NO LONGIR CAPABLI or LIVING IIlDIPUDIDI'l'LY. Ir
PLaOIllD'1' IL8BWIrlRI XI NBCI8SARY, TBI TRAI!8PIIRRID .18IDIN'l' WILL
BI OrrDBI) PRIORITY RETtJIUl .l\bHISSION CONSIDllUI.TlON COIfSISTIDl'l'
WITB 'I'D DUIIlITIOIl or PRIORITY ACCI.. B..IU.
B. Temporary Nursinq S.rvice.
Community will not provide or make available temporary
nursing services or oompanion services in the apartment unit.
The UBe of private duty nurses or oompanions must be approved in
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writin9 by Community. All private duty nuraoa or companions IIlUst:
provide Community with an appropriate rolease and indemnifioation
aqreement as II concUtion of Community's .'\pproval. Resident must
make all arrangements and is responsible to pay the costs for
luch .ervices. To the extent required by law, Resident s,hall be
required to provide worket"' s compensation insurance. Community
relerves the right to disapprove all nurses and companions and to
prohibit the Use of such services, particularly in the event that
R.lident is suffering from an illness or medical condition that
limit. the ability of Resident to live independently for more
than thirty (30) days.
C. ".rg.ncy Hurlinq 8er~
Emergency nursing intervention or initial nursing assessment
in the event of an aooident/emergency will be prov,i.ded at no
additional charge.
D. Bl!erq.noX_Intor.!!!ation
Resident shall complete a medical history form which must be
kept in a container supplied by COlTUllunity and storad in
Relident's refrigerator for purpose of emergency intervention by
COlDlllunity. It is the Resident's responsibility to keep this
information current.
.. Ambulance/AL8 Service.
Resident is required to purchase an annual membership in the
Community ALS/Ambulance services. The fee for this service is an
additional Charge and is not inoluded in the Monthly Fee.
.. Bo.pit.lilatio~
Communi ty does not provide hospi ta 1 or acute care.
Community will assist, if requested, in arranging for the prompt,
non-emerqency transfer of Resident to a hospital on the order of
a physician. The costs of transportation for transfer toa
hospital or other aoute care provider and the costs of such
hospitalization and acute care are not included in this Agreement
and shall be the responsibility of Resident.
G. Ment.l I~e.l, Conta;ioul or Dangerou. Di......
The Health Care Center is not designed to, and the Community
does not have the oapabilities to oare for persons who are
afflicted with mental illness, dangerously contagious diseases or
who require speoialized psyohiatrio care or require services not
authorized or permitted under the personal or nursing oare
licensure rClqulations. 1f Community determines that Resident's
mental or physioal condition is such that Resident's continued
presence in the Community is eithel- dangerous or detrimental tc
the life, health, safety or peace of RAsident or other residents,
the Community may terminate this Agreement: and transfer Resident
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to an appropriate facility sele,ot.ed by community. Suoh
determination must be made in writinq and !:Iigned by the Medical
Oirector ~nd Administrator of the community. If the transfer is
for a tempol'ary period, then the\ I\llI:\idClnt Bhall oontinue to pay
the Monthly Fee for the lIpartment unit "nel also shall be
re.ponsible for the coot of Resident's care in such other
facility. If the transfer is to be permanent., then the
termination provislol\s of this Agreement ahall apply, except that
only .uch notice of termination as ia reasonable under the
circumstances shall be given in any situation where Resident ie a
danger to himself/herself or othera, or to the health, safety or
peace of the community.
B. hclusionll tN.ot covered by MO!!thly 1'..)
The cost of health care services, including, but not limited
to therapist or rehabilitation services, physician services,
diagno~tic services, personal care or nursing care in the
COll\lllunity'll Health Care center or in another faoility shall be
the responsibility of Resident and are not includ~d in the
Monthly Fee or covered by this Agreement.
I. Services Not Available
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Community does not provide private duty nurses, including
temporary nursing services il. the apartment unit, or companions,
specialized treatment, dialysis, refractions, eyeglasses, hearing
~ids, dentistry, dentures, inlays, therapy for psychiatric
disorders, or any other hea 1 th or med ica 1 serv ioe not
speel.fieally set forth in this Agreement. However I some
servie.., suoh as podiatry, preecription medication, drugs, and
orthopedic appliances may be provided by outside providers at the
community, and such nervioes may be arranged at Resident's
request by community.
J. Third Party Re~urc.. and Insurance
In the event of transfer to the Health Care Center,
community expects that some of the cost of medicines, medical or
surgioal service or equipment provided Resident may be paid by
pre.ent or future federal, state, munioipal, or private plans or
programs of medical/surgical insurance I including, without
limitation, the benefits avtoilable through sooial security
programs (commonly known as "Medicare A and B"). Resi,dent is
required to carry the coverage known as "Medicare A and B", or an
equivalent policy, and at least one supplemental co-pay health
insurance policy. If proceeds from Medicare and the co-pay
health in.uranc. policies are allowable for nurlinCJ oar. or
related care, those prooeeds shall be paid to COll\lllunity direotly
if billed directly by community. Proof of such insurance must be
provided at the time of signing this Agreement.
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(b) An Amortized Part equal to sixty (60%) percent
of the Entrance Fee which will be amortized at
the rate of one (1%) percent per month from the
date of occupancy for a period of sixty (60)
months.
4. After the execution of this Agreement and the initial
payment, there will be no increases in the Entrance Fee prior to
ocoupancy.
5. The entire Entrance Fae shall be used by Community for
any corporate purpose and in any manner deemed appropriate by
Community in its sole and absolute discretion consistent with
la..... The Entrance Fee is not held in trust for the benefit of
Resident, and community assUlIIes no fiduciary obligations with
respect to the Entrance Fee.
B. pee for optional rurnishiD~s
for optional
must be paid before the
wi thin ten (10) dayS of
The fee of $
appliancesl furnishings, if applicable,
acqt1isition of t,he opt.ional items and
request by the community.
C. MonthlY ree
1. Resident shall pay to community a Monthly Fee of
$ '-60.00 I in advance each month. payment of the first
Monthly Fee is due thirty (30) days prior to the Oesiqnated or
Extended occupancy Date. All subsequent payments are due on the
first day of each month thereafter immediately upon receipt of a
monthly invoice from community.
2. community will provide a monthly invoice which. shall
sho.... the amount due for the Month.ly Fee and any other sums which
are chargeable to Resident. If any Monthly Fee or charge is not
paid ....ithin thirty (30) days of delivery of the invoice, then
community may terlllinate this Agreement and require Resident to
surrender the apartment unit.
3. The Monthly Fee may be increased or adjusted from time
to time. cOlDlllunity will give at least thirty (30) days advanc.
writt.n not,ice of any ch.anges or inoreas.S in the MonthlY F...
Resident should anticipate at a minimum increases in the Monthly
F.. oomparable to annual increases in the united States Consum.r
prioe Index (CPI) published by the U. S. Department of Labor,
Bureau of Labor statistiCS. Fee increases in any year may exoe.d
increase. in the CPI and may occur more frequently than on an
annual basis.
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ot a oopy
to executing
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E. Resident acknowledges receipt
Community's Annual Disclosure Statement prior
Ag~eement .
F. community reserves the right to modify this Aqreeltt~,':
to contorm to changes in law or regulation.
G. The Entrance ~'ee may be used and applied by Commun~~y
tor any proper corporate purpose, and Community assumes :'.0
tiduciary obligations to Resident with respect to any amou.-::s
paid tor admission or continued occupancy of the apartment uni~,
K. Th.is Agreement shall bind and serve to benetit -:'::'e
successors and assigns of Community, and the heirs, executc:-"
administrators and assigns ot Resident.
I. This Agreement shall be interpreted according to o;.,:e
laws of the Commonwealth of Pennsylvania.
J. Res ident hereby acknowledges having read t::~s
Agreement in its entirety and understanding i tSl provis ions, ~-.:i
having have been provided an opportunity to consult with perso:'.ll
advisors, including legal counsel, regarding the terms of 0;.,:1
Agreement.
IN WITNESS WHEREOF, The Church of God Home, Inc .of Eas':
Pennsylvania Conference has caused this Agreement to be signed:y
its authorized representative, and the Resident has hereu.::~o
affixed his/her/their signature(s), the day and year tirst abc71
written.
Attll.t:
THE CHURCH OF GOD HOME, INC.
OF EAST PENNSYLVANIA CONFERENCE
~
By #" ~~.. ,i-
~.uc." Cl41/f/'IIId:weW
Title
"
;/1.
~ "
/,,;/) "vP'
(A'
I .' NcIdI SIll
, S~E. OlImIl\Sl'"NolIlyNllc
Nl:rlf1..M.~. ___mTM).,~,t.~.d~
MvCcmMloOn '"-~ 17, 1885
':Jd..~J <,_-n07d'''''/YI,~sea:)
pR:sident
~'~" ~ /1''..JZ.~~' (sea:;
Resldent '
3:13:92
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., ~ "" ,
IDA KEARNS . EQUITY RETURN
LETORT MANOR, APARTMENT ~
From: Lynne C. Madeira, LL.C.
To: Sue Keener, B.O.M.
Date of Contract Signing: 4/20/92
Date of Apartment Reoccupation: 1/7/95
Original Entrance Fee: $63,500.00
Amount of Return: $42,766.16
Calculations are Based on Contract Date to Reoccupation Date:
1. ~te perJ2.!l
$20.88
l(
Number of Days
993 Days
=
Deduction
$20,733.84
2. Entrance Fee
$63,500.00
Deduction
$20,733.84
.
Retained Equi ty
$42,766.16
Check Should be Sent to: Mr. Ronald S. Kearns
687 Pine Stump Road
ChambersbufCj, FA 1 '7201
Home Phone: 717-263-9697
Work Phone: 717-263-3910
~ l ... ,
MellolIBanll, N.A.. ~ldlR'"
1\1...1
,......11I.... p_....v....(..) 1)p1
06,01110 8,20 Growth
M.t<,ilY Do"
05/03/98
0IIlUI0I1I M_
0(l(l8lI424
IUI
NlA
_Do"
C1J/~
Ptlad..I-"
"2,7...1'
1._, PoyMlIllnq....,
MOtmlL V FROM ISSUE DT
~P
JOlNT-OTHER
ate.ut.....,
Automallo8lly Renewed
noli
IDA E KEARNS."OR RONALD S KEARNS............................
IDA B J(E.ARNS OR
~ONALD S KEARNS
6f{1 pINE S'I'UMP RD
CHAMBBRSBURO PA 17201
e......, Mo, \Inl(~ Mo,
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" ylL'AoIfA.AlahA:
--.., --
Bilk A.ol.bcIulloR
H...Mr~; HoITrdllmtlI
nlIlI ,-n_Iio. 01 1"""'--' optl<>l
104 II'" nq......,..-.......
...... ........ .., .... . . . .... . . - . . . ., .. . ., . . . . (i>oliM'ui.) . ., .. . ., ..... . . . . . . ., ., . .... . . . . . ...... . .... . .
AutomlUe Renewal
U\lICII OIberw\le speclflcd. your Certllleale of DepDIll will aulomalleally renew whencwr II malure. for the IBmc period u Ita origlnallerm al
the Inlerat rale In elfCCl on eacI1 malurity date lor the Bank's Certll1cale. 01 Depotll of the IIIme type, lerm ood omount. II will renew for the
IIIDlC laccllllOUnl, or lor lhalsmounl plUS accrued Inlercalllln,elOl,lI added 10 the Certll\c8te 01 Depot\l 81111 malurity, ......n If the omounl
",ncwcd illNI \hill the minimum depDIll required 10 catahlllh a new certll\c8le 01 Depot\t ollhe IIIme Iype and term. your Certllleale of
Depot\l will aUlomalka1ly ",new u staled abaYll wheocycr II malUIOl unleU: \) you requeal or I\lMl rcqUClled that the certll\c8le 01 Depot\t
110I ",new aU\Olll8tlcal1y; 2) II II redeemed by you; 3) we send WIlllen notice to you statlnllhat the Certll\c8lo of Depollt will 110I renew
aulomatlcally; or, 4) lhe orIJln81lerma ollhe Certllkate 01 Depoelt you purchale call for ronewallnto ft dllfe",nl term. You may wllhdraw
your lunda lrol'IIlD aUlomatlcally ",newable Certll\c810 01 Depotlt wlthoul penalty up to \0 ealendar dayloller each malurity dale; If you do,
InlClOII will DOl be camed allor \bO malurity dale. II we send you notice lhal your Certll\c8te 01 Depotll will 110I ",new aulomallcally, It will
slOp camlnllnlCrat aller II maturca.
. . .. . .. . .. . .. . .. .. .. . .. . .. " '! ,. .,~..:Ii:. '," '" .... ...'., .. .. ..
............. ~ oi."(p~,a6."U'~l""""." ....,.. .. ...... .. 0..
4.'1':.'';'.'';.' ..4"........." -..." 01
8M, Ill) IUY,(9,94) I.C 7194 Lll9/1>4
/5dC(}" /
lURE AU OF IMDIIlIDUAL lAKES
INHERITANCE lAM DIVISION
bEP1. 21UOl
HARRIS'URO, PA 1112*-0601
COMMONWEALTH OF PENNSVLVANIA
DEPARTMENT OF REVENUE
c
*'
MOTICE OF IMHERITAMCE TAM
APrRAISEHENT, ALLOWANCE OM DISALLOIlAMCE
OF DEDUCTIDM5 AMD ASSESSNEMl OF 7AX
"v-I..,..m II'.",
RONALD S KEARNS
687 PIKE STUMP RD
CHAMBERS BURG PA
DATI
ISTATI OF
DATI OF DIATH
FILE NUMBER
COUNTY
ACN
IDA
12-08-97
KEARNS
12-04-96
21 97-0719
CUMBERLAND
101
Allcunt R.III tt.d
[
J
17201
MAKE CHECK PAVABLE AND REHIT P~VMENT TOI
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE. PA 17013
CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS ..
ii'iy: ii~"'-ix--AF;'. -m-:i7)" -ilciiriciuop-INHEiii i ANCf TAX - APPRA"i iiMEilr; -Ai.iiiwANc i"iili - - - - --- - -- - - - - -.-
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
IITATI OF KEARNS IDA E FILE NO. 21 97-0719 ACN 101 DATI 12'08-97
TAX RnURM liAS. I X I ACCEPTED AS FILED
RlSIRVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN lASED ONI ORIGINAL RETURN
1. R..l E.t.t. 15ch.dul. Al
2. Stock. end aood. ISchedul. 81
S. Clo..ly Held Stock/r.rtn.r.hip Int....t (Sch.dul. CI
~. "artl..../Not.. Rlcl!Ylbl. eSchedull D)
5. C..h/llnk Oapoatt,'Hilc, Perlonal Propert, (Schedule E)
6. Jointly Pwnad rrQP.rty ISch.dul. FI
7. Tr~.f.r. (Schedule G)
.. Total A...t.
I I CHANGED
.00
.00
.00
.00
47.187.00
,00
.00
lal
111
121
151
I~I
1&1
161
(7l
NOTE I To in.ure proper
crldit to your IccOunt,
lubait the upper portion
of thAI forM with your
tax p.y..nt.
47.187,00
APPROVED DEDUCTIONS AND EXEMPTIONS I
9. Funeral Expan.../A.. COlta/Hila. Expan... (Schedul. H) f')
10. D.bh/HQrt.... UebU1U../U.n. (Sch.dul. II 1101 .00
11. TQt.l D.ductlQn. 1111
12. Hat V.lue Qf T.. R.turn (12)
15. Ch.r1tebla/GQ..rnll.ntel I.quula, Mon-.l.clad 9115 Tru.to ISch.dul. .II (15)
14. Met lI.lu. of E.t.t. Subj.ct tQ T.. 1141
NOTEI If.n ......m.nt w.. 1..u.d pr.v1ou.ly, 11n.. 14, 15 .nd/or 16, 17 .nd II
refl.ot f1gur.. th.t 1nclud. the tot.l o~ ~ r.turn. .......d to d.t..
ASSESSMENT OF TAXI
11. A.ount Qf Lln. 14 .t Spou..l
16, AMOUnt Qf Lln. 1~ t...bl. .t
17. AMOunt Qf Lln. 14 t...bl. .t
11. Prlnclp.l To. Qua
TAX CRIDnS I
rAYHEMT
DATE
,00
nn
47.187.00
.00
47.187.00
will
r.t.
Lin..l/Ch.. A ,...t.
Col1.t.ral/Cl... I rat.
47 . 187 , 00 M ' 0 O.
.00 M .06.
.00M.15.
l1al
.00
.00
.00
:00
I1S1
1161
1171
RECElrT
MUI1.ER
DISCDUMT 1+1
IMTEREST IPEH rAID I - I
AHDUMT rAID
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUI
.00
.00
.00
.00
. IF rAID AFTER DATE IMDICATED. SEE REVERSE
FOR CALCULATIDM OF ADDITIDMAL IMTEREST.
IF TOTAL DUE IS LESSTHAM U. MD rAYHEMT IS REQUIMED.
IF 7DT AL DUE IS REFlECTED AS A "CREDIT" I CR I. YOU HAY IE DUE
A REFUND. SEE REVERSE SIDE OF TNIS FDRH FOR INSTRUCTlOMS.I
E
o
OUERVATlON, E.t.t.. of d...donll d.l.... .n or b,'or. D.......r 12. 1.12 .. 11 On. MUrI Int....t In the ..t.t. \I tron.',""
in po.....lon or enJoy.."t to C1... . (ooll.t,r,U bentfloll,rI.. of the dludef\t .ftlr tn. IMPintlon ofanv ..tate for
11f. or for y..r., the COINonw..1th h.f.by .~pr'''1Y rl.irY.. thl rhtM to .pprahl Illnd ...... tr.,,~flr Inherltlncl h)ll'
at thl l..,ful Cl." . (Clolhterel) rfllt. on .n'l .ueh ,utur. lnt.rut,
PURPOSE Of
NOTICE I
To fulfill thl raqulrlll1ntl af hOUO" ZlltD of thl Inn-rUlno. and E.te'_ Tax Aot, Act Z1 of 1995. (12 P.S.
SloUon '9140).
O.tacn tnl top portion of thl. Nottoe and sub,lt wUh your PIYIIlI"t to thl Rt\1htl' of ~Hl1. prlntad on the r.Vlr.' tiele.
..Hak. chick or 10nlY order payable tal 'REGISTER OF tlILLS_ AGENT
PA"'tENT I
REFUND (CA)1
A r.fund of I tllC cr.dlt, which .... nut raquut'id on thl TalC Aeturn, ..y bl ,.quuted by co.pl,ttnll In "AppllelUon
for Refund of p.nnnl\l.nie Inhu 1 hnce end Estat. hx" (REV-UU). APplications ar. .\lIJ llbl. .t the Office
cf thl Rlllhter of wUlt, eny of thll :!3 R_\l.nU. Dlstrlct Offlc'" or by calling the .plelal 24-hour
tn....rinll IIr...lcl nUllblr. for for.. ord.r!ngl In p.n"'yi....nl. l~aOO-S62-20S0, outside P.nn.yl....nl. .nd
within local Harrl.burg .r.. (117) 167-8094, TOOl (717) 172-2252 (HI.rlng I.p.ired Only).
AnY p.rty In Int.r..t not .athfl.d ~Uh thl appra,....nt, allowanol or dl..11cwenol' of d.ductlon., or ........nt
of tlM (including dheount or InUra.U a. .hown on this Notice IIU.t objlet within .Ilo:ty ('Ol deyt of rlcllpt of
thit NoUc. by;
-"written prot..t to the PA D.part..nt of R.venua, loard of App.el., O.pt. 261021, HlrrltburQ, PA
uIllctlon to hlv. thl ..Ulr dltlrlllnld at audit of the Iceount of the p.r.on.l r.prl..nt.Uv.,
--IIPP..l to thl Orphen.' Court.
Hlll"lOll,
DR
DR
OBJECTIONS;
AD"IN
ISTflATlYE
CORRECTIOK$I
Fletu.l .rrorl dltcov.rid on thlt ........nt Ihould be Ilddr....d In wrlUng tOI PA D.p.rt.lnt of R.yInUI,
Iurllu of tndlvldu.l TUII, AllN; POlt A.......nt A.vl... Unit, n.pt. 2110601, ttarrhburlJ, PA 11121-0601
PhOne (7171 717-6505, SI. pIlI ~ of the bookl.t "In.tructlunl for tnh.~ltanc. T.M Rlturn for e R..ldent
Olc~t" (REV"ISO}) for In Ixpllnltlon of Idllnl.tr.tly.ly corrlctlbl. .rror..
If any taM du. 11 p.ld wlthln thr.. ()} eel.ndar ""thl aft.r the d.c.d.nt'. dllth, I fi..,. p.rclnt (Sin discount of
the tllX paid I. .1lOWld,
Th. ISi( t.M Hne.t)ll non-p.rtlc1peticm p.nltty 1. celPutld on tha tuta1 of the tall and Intar..t .......d, .nd not
p.ld beforl Jlnulu'y II, 1996, tt1. Ur.t d.y aft.r tha Ind of the laM .an..ty ".rlad, Thl. non-parUclplUon
p.na1 ty II app.ahbll In tha .... .annar .nd In thl lhl ",.a t 1.. p.r led iI' you weuid .pp..l lh. t.M and Inter..t
thlt h.1 bllln ....n.d II Ind'ca'"d en thl, noUca,
tnt.r..t I. chlr..d b..lnnlng Hlth flr.t day of dllinquency, or nil'll (9) aonth. and ona (I) dlY froa thl data of
death, to thl dlt. of ply..nt. Taltu which b.e"" d.llnquant b.for. J.nu.ry 1, 1982 b..r Int.rut .t tha r.t. of
,Ix (6i() plrelnt par annUl Ulcl.llBtld at a dally r.t. of ,000164, 'll tlMII Which b.c... dellnqu.nt on and aftar
J."u.ry L 1912 will blar InUr..t at a ratl which will vary frol cllhndar ~..r to cal.ndar yl.r with that r.ta
announced by the PA DIPlrt..nt of Ravlnu., Thl appllclb1. Intara.t rlt.. fol' 1962 through 1991 al'.l
U!t Int.ra.t Ratl !!!!..lLA n t.r. I t faotor !!!r Intera.t Rlt. O,lll/ Intar..t ".otor
1912 20X .00aS41 1911 OX .000247
1915 16k .000431 1911-'''1 11;( .ooonl
19.. llX ,000501 1"2 .k .000247
1915 11;( .0001S6 I"S-199(, 7% ,000192
1916 lOX .000274 1995-1997 .y, ,000241
--Intar..t I. u1cul.ted .. follewtl
IMTEREIT . BALANCE OF TAX UNPAID X MUHIER OF DAYI DELIMQUENT X DAILY INTERElT FACTOR
nAny NOUCI hluad Iftlr thl taM bleea.. d.lInqll.nt will r.Uact an Int.r..t calcu1a\lon to flfta.n OS) d.y.
b.vond tha dlt. of thl ........nt. If ply.ent I. ,Il.d. aftar the Int.rut Clo.putaHon dltl lhaMn on thl
NoUeI, .ddltlonll Intlr..t lIU,t b. 0I1cl.lllt.d,
DtSCOUNT I
PENALTY I
INTEREST :