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No. 21.80 231
PETITION FOR, PROBATE OF WILL AND LETTERS TESTAMENTARY
in the Estate of JAMES CLIFFORD KOLLI~R, a/k/a J. CLIFFORD KOLLER , deceased.
To Harold B. McLane, Deputy , Register of Wills for the County
of Cumberland, in the Commonwealth of Pennsylvania.
is
Petitioner(s)~the executrix named in the Last Will and
Testament of JAMES CLIF'F'ORD KOLLER a/k/a dated October q, 1970.
D d . J. CLIFFORD KDLLER d S d 'd f
ece ent was a CItizen ot the Unite tates an 0 resl ent 0
~~PX)()(
Borough, Cumberland County, Commonwealth
M,,<,himi<,~bur.g
of Pennsylvania.
Decedent died on MQnd3~' the 19th
A. D. 19~, in the County of Cumberland
P"nn~)'l,,"n; " at the age of 87 years.
m ~ x1m1l
Decedent has not been married and has not had children born to "nirrl
since the execution of the above described Will.
Decedent was possessed of personal property to the value of
pn.nnn nn and of real estate to the value of
day of
March
, State of
$1'i,nno.nn
as near as can be ascertained; said real
estate situated as follows "rwn ~!"nry hrirk hn"o" o;!"""!",, ;n !"h" Hm'" "f
Mechanicsburg, Cumberland County, Pennsylvania,
~~
Therefore, your petitioner(s) respectfully applies for the probate
of the said Last Will and Testament and for Letters Testamentary thereon.
Dated April 2, 1980 I. / 1i~
1 .-;11;W. /Vi:!t, , LI \L, ~~y:t'
MRS. HELEN A. O'GOREK
Name and address
of Petitioner(s)
406 East Keller St.
Mp('hnn; ("'c:hl1"'g~ PA 1?nS5
COMMONWEALTH OF PENNSYLVANIA f
ss
COUNTY OF CUMBERLAND
MRS. HELEN A. O'(',()REl<
named in above application, being duly sworn according to law
say(s) that the statements set forth in this petition are true to the
best of her
knowledge and belief,
SHQRN and subscribed before
me April 2 19-BU_
~~tl< ""'n-j ~~(j"".s)" Deputy
Register
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J., ,j,," /I..~r/" I / <~->t~:~_.",~~;".:-/.,
. MRS. HELEN A. O'GOREK .
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Filed: April 7, 1980
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Attorne( JAN M. WILEY, ESQUIRE (,C~70 .
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OATH OF SUBSCRIBING WITNESS
COMMONWEALTH OF PENNSYLVANIA 1 ss:
COUNTY OF CUMBERLAND \
This,...... ,:/?!l\F.,.. ,......':'18, d.... ....,.., ..,..", ,....,.. ........,.. day of..,.., ....l':IiJy",........,..,......".........."..".. ......' A,D" 19,80,..,
Harold B. McLane, Deputy .
before me ftkl,,,. d EJ, ".1.88F8on, IWgister for the Probate of Wills and granting letters of Administration
in and for said County of Cumberland. in the Commonwealth of Pennsylvania, personally came ..............
"""",.""",.""", .)',., ,Rolx:r.t;. .St:.auf.f~x""", ,<;1 o~'" 9..t"""""""""""""",..""""""""",."""",."",,""""",...,"""",...
the subscribing witnesses to the foregoing instrument of writing purporting to be the last Will and
Testament of ....,Jaroes..Clif.f.o.rd,KDller..a/.k/.a ,,j.. ..CI.iEEo.rd ,Koller...... Dated ....Octooor, ..9.,..,1,9,70,....,..
lateof..........,..,The..Bar.oAgb.,of"Mechani.csbur.g".....................,.."......,..', Cumberland County Pa" deceased
who being duly .......swor.n..........,............... according to law, depose and say, that ..,..he...............................
present, and saw and heard the testa,tor..............,....,..,.." J,~~,:..~~~~~~~?..~(y~..~,:...~,~,~.~,~~~~..~~g~!...
sign, seal, publish, pronounce and declare the said instrument of writing as and for h,i.s;..........., Testament
and Last Will, and at the time of so doing ........,~,~......,..........,..............,....was of sound and disposing mind
memory and understanding, to the best of ......his....,...............,......,......knowledge, observation and belief.
..............Swor.n.............,....,.... and subscribed before
~-<)I In ,. ~~ j
...,..J,~,..B?..,'~~.l~!b,o.y~~..,.~,~!?.'::~?:
Kkl.lcud. E. AAAn~, Register "
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..................................................................................
AFFIDAVIT OF DEATH
COMMONWEALTH OF PENNSYLVANIA t ss:
COUNTY OF CUMBERLAND \
,.."..,',."..,",....,.~?:".J:!I!:~EN A:"Q,:~9~..",..".,..,.,"""""",.,..,""",....,"",..."""",.",."""",...."...."....being duly
.............,Swm:u..,...................., says that as nearly as can be ascertained the said decedent ....Jame&.GU.f,ford
..."...." ..fjl.1f,I,~, ,.].", ,C,UJford" Koller.,..\..."..""""""""..""".."",.",..,....""""""""',..,"",.,',.,....,.."..,..,,.. ,died on
,...........Mond.1!{,....,............".." the ..........~,?,~~"..,.........,day of ......,~,:,~~..,......,....,..,................... A,D" 1#..9"..,
at or about .....,8,;,4.5,............................ o'clock, a.M.
..............~~~~....,.......................,and subscribed this
..............?~....,........................ day of ..~p.~~,~..........,..
19, .......SO>efore
..."...~t\.\:;~~{~,\;.)~~:,(,h,c~~,~~X
RldlUld E. Aud~lo:JVUI Regl~te~. ~
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""..",.,,),1..,,....,,,....,,.......,...,,, ../.",.,.. .......",.....f...(I,..
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HRS. HELEN A. 0 I GOREl<
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA}
COUNTY OF CUMBERLAND SS:
. Before me, the Register for the Probate of Wills and granting of Letters of Administration in and for
the County of Cumberland. personally came ..,t':Ir!1,'" H~h~n,.I;\,..9.~,GoJ;'!!l(:.....,..,..,..,........,....,..,.......................
who, being duly ....,..,!1WRm,........., do ~,L.., depose amI say that as..,ji:XEC!JflUX,..................,..,..........,........,
of the last Will and Testament of ...,..Jfl!w.R..njJf.9.r,Q,..(llJ$L.<;l..,J,.,..r;),Ht;9.l::ct.J.\9.u.~X..,....,..............,deceased
....,......,....~):l,E;!.... ,will well and truly administer the goods and chattels, rights and credits of said deceased
according to law, And also will diligently comply with the provisions of the law relating to Transfer
Inheritances, ..,..RWRm..,.......... and subscribed
before me,
......'....'TA.j;>x'u..~......,..........,......., A, D" 19..,S'O......
~1fh~J~,.:B:TIJ~:,~~=:::,'~,~~,~~y
R:.cl....~d ~. ~4&A~dmBOn, Register
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DECREE
Be it remembered that on the ,....?~!.\..,......,.. day of .......A.p.EiL..........,....,..,.........., A. D" 19 .?,Q...,' there
was probated and recorded the last Will and 'restament of ..Jf..t10...~!tXf.f.Q@...~.!.~t.~..,~.:..,q;'.u:'f.Q!w...KQkhf;R
late of ....,~S~)).~S.~!?~Eg..~Rr.R............................,......, Cumberland County, Pennsylvania, Deceased, Letters
....,...........:r~~~il~!)~?:r.Y...,...,..".... were granted to "',..,',J:W.,~.:"Hf::)J;N"l:!..".Q:,@~....,',....,......,',..............,.....
Witness my hand and official seal the day and year aforesaid. l
',- .~~ c.~,Hl(~r~J.! ,~.'-- .c\0~~:~.~~.~.:Y
. L, J<<!gls~r.
COMMONWEALTH OF PENNSYLVANIA I.
COUNTY OF CUMBERLAND' Yo i/ It:- J
__________fig:,Y'-N--L',,-9' GQ8F,:K
55:
--~_._---_._-. -._-.-.--"-'. .---.-------'---'
being duly __---5WQl~IL_--- according to law, deposes and says that she _is-:the
____ExeGUtl'-ix-------.---------- of the Estate of JAMES CLIFFORD KOLLER a/k/a
lato of 124 E. Simson st.. tlechanicsburq , Cumberland Co~nt~~~:.Of.>c:.~~,p:!nd that tho
within is an invontory made by __.HELEN-A.--D-'-GOflF:K ____ -., the said JXP,"lItri x
of the ontire estate of said decedent, consisting of all the personal prop.rty and real estate, except real estate outside
the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory rcpresent it', hir value
as of the dato of decedent's death,
Sworn
_~ {j ([Jk/~
El(ocutor & )~;it)(lA~t<~iX
HELEN AD' GOFili'1<' - -- -- - -
4QfiJh..Ke.ller st..
tlechanicsburg, PA 170.55
and subscribed before me,
December ,-) rP1 19 80.
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Date of Death
March
D.y
19
Addreu
1980
Month
Yur
INSTRUCTIONS
I. An inventory must bo filed within three months after appointment of personal representative.
2. A supplement inventory must bo filed within thirty days of discovery of additional assots.
3. Additional sheets may be attached as to personalty or realty
4. See Article IV, Fiduciaries Act of 1949.
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COMMONWEAL TN OF rENNIYLVANIA
DEPARTMENT OF REV(tWE
BUREAU OF CDUtHY COLLECTIONS
APPLICATION FOR AND CONSENT 1\ I
TO TRANSFER SECURITIES 1(; !.....
REGISTERED IN TilE NAME I " ~r;$.., (\
OF A RESIDENT DECEDENT '
_____ ______.__,__.__...______._. _.'h_____" ____~- . _____.
APPLICATION (MUST BE FILED IN TRIPLICATE) DATE. '1.?Wl1d/:;-Iff/
TO THE PENNSYLVANIA DEPARTMENT OF REVENUE:
Application is hereby made lor cmsent to the transfer of the fallowing securities 01 a Pennsylvania
Corporotion or 0 National Banking Association located in Pennsylvania:
(a) 864 shares (b) COllUlDnwealth Ilational Ba.l2L___(c)CQilm;>n...s.1;Qck
(NOTE: In describing securities enter in (a), ab ",e, either the number of shares of stack or the face amount 01
registered bonds, in (b), the name of the issuing company and in (c) the class of stock or the stated interest rate
and maturity date of registered bonds.)
February 12, 1971&
ISSUED ON Malx:h_;>.6,_197-3_, and having a TOTAL MARKET VAtUE OF $_~~,192.00
(Do'.)
f h d f d h f h d d Jarres C. Koller
as ate ote 0 cat 0 ,~e ece ent,
, on
3/19/80
(Nome of Decedent)
(Dole of death)
who was late 01 124 E. Simpson st., Mechanicsburg Bora, PA 17055 Cumberland Co.
(Street and Number)
(Post Office)
(County)
(Sta'.)
The securities ore registered os lollows: JAMES C. KOLbER
(Nome or names in which cCfliflcoles ore registered)
Ar'f.wvr,K~JV1rs. Helen A. OIGorek
EXECUTOR) (Name)
406 E. Keller st., Mechani.csburg, PA 17055
(Address)
JAN M. LEY, ESQUIRE
NAME OF APPLICANT
COUNTY FILE NUMBE~-::{//0.:/' q /ADDRESS OF APPLICANT
288" Dills~..EL-
.
BUREAU FILE NUMBER SIGNATURE OF APPLlCAN
NOTICE: IF YOU FAIL TO PROpERLY FILL IN ANY PORTION OF THIS PPLI
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU OR
- '--~.
ION, IT WILL NOT ~
PLETION.
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE .
CONSENT TO TRANSFER SECURITIES /) /II. I.
DATELM/~~ Iln
I hereby consent to the transler of the above securities now registered in the name 01 JYl aforesqfll
Decedent and waive the Iiling 01 a certificote certifying to the payment of the transler inheritance tax to which
the property 01 said Decedent is made subject pursuant to the provisions 01 the Act 01 June 20, 1919, P.L. 521,
os amended and the Act 01 June 15, 1961, P.L. 373, as amended. This is also in accordance with the provisions
01 the Act 01 April 9, 1929, P.L. 343.
This Consent t~ Transler the herein described property operotes only in relerence to the estate 01 the
above.named Decedent.
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Signed lor the Secretory 01 Revenue
/A/ ~;J.
By~ ~ . U/-C.
4 S19' reI ~'
F#;#~ LJ. Il~d~
?,.) (Cau,'y)
COMMONWEAL Tli OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUtny COLLECTIONS
APPLlCt.TION FOR AND COt~SENT A ~ \
TO TRANSFER SECURITIES ...;q,:y.dJ .\
REGISTERED IN THE NAME . 'JfuW01l.~\
OF A RESIDENT DECEDENT '''o--h::,.,r:;'/.' I
'_____.________________ ._____.____ ____,____ __.___ .___,_ _____--.---. _.______ ._~Qt.-.-' _.__.,__.' ____,_J
,PPLlCATION (MUIT BE FlLEO IN TRIPLICATE) DAT~"'''''y.d~jff/
TO THE PENNSYLVANIA DEPARTMENT OF REVENUE:
Applicolion is hereby mode lor coosent to Ihe tronsler ollhe lollowing securities 01 0 Pennsylvania
Corporulion or 0 Nolionol Bonking Association located in Pennsylvunio:
(01_._50 shar~.b;)~I'!Q!illSVI1JLI::~~l'ro:-l!\L BANK___----(c),~on ---
(NOTE: In describing securities enter in (0), ob ",e, either Ihe number 01 shores of slack or the luce ulllounl 01
regislered bonds, in (b), the nome 01 Ihe issuing company and in (c) the closs of stock or the slated interest role
and molurity dote 01 regislered bonds.)
ISSUED ON
Jan. 28,~_, and having 0 TOTAL MARKET VA'lUE OF $~OOO.OO_
(Dote)
OS 01 the dote 01 death 01 the decedent,
JAMES C. K01JloER
March 19, 1980
, on
(Dcle of death)
who was late 01 124 E. Simpson st., Mechanicsburg Bore, CLm1berland Co" PA 17055
(Name of Oucodant)
(Street and Nl.lmber)
(Post Oflico)
(County)
(State)
The securilies ore registered os lollows:
JAMES C. KOLLER
(Nome or names In which certiflcales arc registered)
1WM'~'M;oo.b~
EXECUTOR )
MRS _ J-Wt F:N-A.'-o!,GOHEK-,_406-E...-Kellec-St..,.MecbaOicSburg,~055
(Nome) (Address)
NAME OF APPLICANT JAN M. WILEY, ESQUIRE
COUNTY FILE NUMBER<-;?/" ?j'{)-;J,.,1/ ADDRESS OF APPLICANT Dillsburg,
BUREAU FILE NUMBER_ SIGNA TURE OF APPL\CAN
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THI
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU'
~
COMMONWEALTH OF PENNSYLVANIA - DEP ARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES
DATE
I hereby cons en I 10 the lronsler 01 the above securilies now registered in Ihe nome 01 e oloreso
pecedent and waive the filing of 0 certilicote cerlilying to Ihe payment 01 Ihe transfer inheritance tax 10 which
Ihe properly 01 said Decedenl is mode subject pursuant 10 the provisions 01 the Act 01 June 20, 1919, P.l. 521,
os amended and the Act 01 June 15, 1961, P.l. 373, os amended. This is also in accordance with the provisions
01 the Acl 01 April 9, 1929, P.L. 343.
This Consent 10 Transfer the herein described property operoles only in relerence 10 the estole of the
above-named Decedenl.
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Signe~the Secretory 01. Revenue
B;jjy / ~~!~~:~
. _ ~.~ __~~d~A-L'd#'.AL
tIe) (County)
,
COMMONWEALTH Or: PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF EXAMINATION
OFFICIAL NOTICE OF
INHERITANCE TAX
ASSESSMENT
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COUNTY FILE NO:
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DAT~
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ESTATE
FILE NO,
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COUNTY
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DATE OF DEATH "/'>.i ,.:1. //: / /(,.1
Appraised Value of Estato:
Real Estate
$
',-1'::-(~: /'-(1
Personal Property
..../
+ /;1" ".."/;'/ (/,
/
Jointly Held PropertylTransfers
+ :.::/ /!~ --'./ :,.,./
Clear Value of Estate
$ /I v, " .:J .;.... ~;
,
/
- , , / /i .'Y:> ,r; /
/
$ (! ;) '1/ 1/
",
I
Total Gross Estate
Total Approved Deductions
less: Approved Charitable Exemptions
Clear Value of Estate Subject to Tax
$ It ;,..;11')
/
Amount Taxable @ 6% Rate
$
tax due
$
Amount Taxable @ '5% Rate
/' /." ,j '7,')
. t. /,1.1 '-/- J
, 1-
tax due
j,/ ./ I;;, 1()
/
$ 1'/ ,/ 1;/ 7 t!
/
TOTAL PENNSYLVANIA INHERITANCE TAX DUE
.. .. .. .. .. .. A five percent discount totaling $
will be granted if the Inheritance Tax is paid by
Less Credits:
DATE OF PAYMENT
AMOUNT PAID
DISCOUNT
INTEREST
TAX CREDIT
j'"
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1'/ .;'(l
$ /L/ ,j/,-'/ <", +
, ('
$
$
=
$ /~/ "jl..}
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+
=
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Interest accrues at the rate of six (6) percont per
on the unpaid balance of Inheritanco Tax from
to date of payment. Interest due if paid by
annum
BALANCE OF PENNSYLVANIA INHERITANCE TAX DUE
$'/''/ , h ///(./l...-
" I, .'),
/,~. ,ft.'A/...d.1.' -
Assessed by: " / / /l -i'" I (t':,' ~ '7:~'(>;'" A~' .,)
. . Agent tot th' Ccim;:WtI111h v -
See Informal Ion on Reverse Side .' "
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is
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COMMn"WEAL TH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
'TRANSFER INHERITANCE TAX
RESIOENT DECEDENT
SCHEDULE "F"
STATEMENT OF DEBTS
AND DEDUCTIONS
~~\
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--_._.-....-::..;:...o-.,...._-_._.._._~__.____ ____=~~ ' -
Estate of -lAlIlES-CLII'~a/k/", 1_r.1 wr.(mn Date of Death3/19/BO
WHEN CLAIMING THE FAMILY EXEMPTION. COMPLETE THE FOLLOWING:
Claimant
_ Relationship to Decedent.
Claimant's ,L\ddress
, I
File No, /!
. "/
. J.~)
.- - -
ITEM OATE NAME OF PAYEE REMARKS AMOUNT
NO,
1. 4/14/8C Register of Wills, CL:'"nb. Co. Probate Will 78.00
2. 4/15/8C Patriot News Advertise Estate 53.01
3. 4/15/80 Cumbo Law Journal Advertise Estate 18.00
4. 4/15/80 Comronweal th National Bank L=k Box inventory 5.00
5. 4/14/80 Mechanicsburg Oil Oil 221.31
6. 4/14/80 Mechanicsburg Bora Sewer 39.80
7. 4/14/80 PP [, L Electric 5.14
8. 4/9/80 IRS Income tax 250.00
9. 5/6/80 Myers Funeral Home Funeral Bill 1599.00
10. 5/9/80 Mechanicsburg Oil Oil 77.92
11. 5/9/80 R. Hers Repairs ... 15.96
12. 5/24/80 Mechanicsbury Oil Oil 64.94
-
13. 5/15/80 PP [, L Electric 2.64
14. 5/21/80 Gingrich Tombstone 30.00
15. 5/21/80 Mechanicsburg Bora Water 19.22
, 16. 5/21/80 PP [, L electric 2.66
17. 6/6/80 Holy Spirit Hospital Last Illness 93.00
18. 6/16/80 Community Physicians Last Illness 30.00 .
19. 7/16/80 PP [, L electric 2.66
.
20. 7/25/80 Jack Gaughen Realtor Real tor's Comnission 3,850.00
21. 7/25/80 Notary Public notarize deed 1.50
22. 7/25/80 Recorder of Deeds Transfer stamps 550.00
23. 7/25/80 Ray Anderson School Taxes 409.37
TOTAL THIS PAGE I 7 419.13
I hereby certify that to the best of my knowledge and belief the foregoing is a just and true statement of debts. funeral
expenses and expenses of administration submitted to the eslate as deductions for Inheritance Tax purp ses, I,J /.J/(C
HELEN A. O'GOREK / ' .
SIGN^TUr~E Of AT OHNFYjFIOlJCIAnV
OFFICIAL USE ONLY
DEBTS AND DEDUCTIONS ARE ALLOWED IN THE SUM OF S. /~ d t3.3 /
DATE
AT
15--'
PERCENT,
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~.""C!V~4ti5.'EXt poliO)'
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
.. TRANSFER INHERITANCE TAX
RESIOENT OECEOENT
SCHEDULE "F"
STATEMENT OF DEBTS
AND DEDUCTIONS
-
..=-.-_ -.-..--.=;:;...,.--,e.......--"'.coa..--O.. o:::~~,"
Estate of JAMES CLIFFORD KOLLER a/k/a J. CLIFFOl1fbatc of Denth-.!.'1arct:'..,!:..~.1:.(IQ\1, No,___
WHEN CLAIMING THE FAMILY EXEMPTION, COMPLETE THE FOLLOWING:
Claimant
Claimant's .L\ddress
ITEM DATE NAME OF PAYEE
NO,
24 7/25/BO Mechanicsburg Boro
25. B/5/BO PP " L
26. B/5/BO Mechanicsburg Boro
27. 12/BO Register of Wills
2B. 12/BO Register of Wills
29. 12/BO Register of Wills
30. 12/BO Notary Public
31. 12/BO Helen A. O'Gorek
32. 12/BO Wiley " Benn
Relationship to Decedent _
REMARKS
AMOUNT
Sewage " refuse
Final Electric BIll
Water bill
filing debts " deductions
filing inventory
filing release
Notary fees
Executrixes' fee
Attorneys' fees
39.BO
3.03
16.B5
6.00
6.00
27.50
25.00
5,770.00
5,770.00
TOTAL THIS PAGE $11.664.1B
I hereby certify that to the best 01, my knowledge and belief the foregoing is il just ilnd true statement of debts, funeral
expenses and expenses of administration submilled to the estate as deductions for Inheritance TilX purpo~ /~/J~1c
HELEN A. 0' GOI1EK / d1 . I AJ
, /r7f-A~, tZ.- w J.>F/~
:,I(;NI\"UI~E OF I\TTOIlNr-Y/FfDUC[/\HY DATE
OFFICIAL USE ONLY
DEBTS AND DEDUCTIONS ARE ALLOWED IN THE SUM OF 5__ If () i J'..JLAT __8--
PERCENT,
,./-"'; ..,)
1}1 . /1) ,
, /,/1,' I s;:,. ,.- V L'~.:/.1
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GENERAL INHERITANCE TAX INFORMATION
,
Unsatisfied liabilities incurred by the decedent prior to his/her death are deductible against his/her taxable estate.
In addition to debts incurred by the decedent or estate.. other items are claimable including the cost of administration,
attorney fees, fiduciary fees, funeral and burial expenses including the cost of a burial lot. tomb~tone or grave marker.
All debts being claimed against an estate are subject to the approval of the Register of Wills with whom the
Inheritance Tax Return is filed, Evidence to support the decedent's or the estate's liability for the debts being claimed
should be attached to this schedule,
A family exemption of $2,000 may be claimed by a spouse of a decedent who died domiciied in Pennsylvania.
If there is no spouse, or if the spouse has forfeited his/her rights, then any child of the decedent who is a member of
the same household can claim the exemption, In the event there is no such spouse or child, the exemption can be
claimed by a parent or parents who are members of the same household as the decedent, The family exemption is
allowable only against assets which pass by a will or by the Pennsylvania Intestate Laws.
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INSTRUCTIONS FOR COMPLETING SCHEDULE "F"
1. If the family exemption is being claimed, indicate the claimant's name, address and his/her relationship to the
decedent. Enter "family exemption" in the remarks column and the amount claimed in the amount column.
2. Assign consecutive numbers to each item listed,
3. Enter the date on which each debt was incurred and/or paid,
4, Enter the names of each payee,
5. Provide a brief explanation in the remarks column for each debt claimed,
6, Enter the amount of each debt being claimed,
7. The form must be signed by the person who has assumed the responsibility for paying the debts,
REV~451.EX:+ (3.80).
COMMONWEALTH OF PENNSVLVANIA
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
Estate of
ITEM
NO.
SCHEDULE "B"
PERSONALPROPERTV
(Instructions 011 Reverse Side)
JAMES CLIFFOHD KOLLER alkla J. CLIFFORD KOLLER
DESCRIPTION
1.
2.
commonwealth National Bank checking AIC 142 10369,1
Commonwealth National Bank Savings AIC 14 0007634 3
(Interest to date of death)
50 shares Bendersville National Bank Stock
at $60.00 per share
864 shares Commonwealth National Bank stock
at $28.00 per share
Tax proration on sale of real estate
proceeds of Series E Bonds in name of Decedent
see list from attached safe deposit box inventory
proceeds of public sale of personal property
TOTAL PERSONAL PROPERTY
3.
4.
5.
6.
7.
~^
-~
ESTIMATED DEPARTMENT
UNIT MARKET VALUATION
VALUE VALUE (OFFICIAL USE ONL Yi
919.30
18,708.87
144.24
3,000.00
24,192.00
461.87
(5,623.14) ~-(,o,2... 17
3,544.70
G56,594.12)
TOTAL THIS PAGE ~56,594.12)
nr5'"7.3.IC
.Il~.
.1., Did decedent, within Iwo yems of dealh, make any tlansfel 01 any mateliill pari of his eslilte wi 1110111 receiving
villuable ilnd mlequilte consideration1 (Answer IOYes" 01 IONo",)-IlO--
. 2. Did decedenl, wilhin Iwo yeals or dealh, I"lnsler property frOIll himsel f' 11OIselllo hi1l1Sel f!hersel f and another party
or parties (including ,I spouse) in joinl ownership? (Answer "Yes" or IONolO,) ..no_.
3. If the answer to one or two ahove is IOYes" and the tr,1Ilsfers arc claimed to he nontilxable, provide the following
information:
a, Age of decedent at time of tli1nster.
b. Copy 01 death certi ficate,
c. Affidavit by the attending physician indicaling Ihe state of decedenl's heal III altime of Iransfer,
d. All other information supporting non(axabilily of tra/lster,
4, Did decedent, in his/her lifetime, IIwke any trmlsfer 01 properly without receiving <1 villllilble or <1dequate considemtion
therefor which was to take effect in possession or clljoymellt at or alter his/her de<1th1 (Answer "Yes" or "No'hq,no
a. Was there any possibility thatlhe property Ili1nslerred might return to Iransferor 01 his/her estate or be subject
to his/her power of disposition? (Answer IOYes" or "No",) no
b, What was the tmnsferee's age allime of decedent's dealh1
5. Did decedent in his/her liletillle make any tli1l1sfer withoul receiving a v<1luilble and mlequate consideration therefor
under which transferor expressly 01 impliedly reserves 101 his/her Ii fe or ilny period which tloes in Iact end before his/her
death:
a, The possession or enjoyment of or the right to income frolll the property trmJSferrerl1 (Answer IOYes" or "No" ,) ~
b, The right to designate the persons who shall possess or enjoy the property transferred or income Iherefrom?
(Answer "Yes" or IONo",) no
6. If the answer to five b, above is "Yes," slate whether the light W<1S reserved in decedenl alone or others,
QUESTIONS CONCERNING PROPERTY THANSfERS
7, Did decedent in his/her lifetime make <1 transfer, Ihe consideration for wl1ich was transferee's promise 10 pay income
to or for Il1e benefit or care 01 t13nsferor1 (Answer "Yes" or "No" ,) no
8, D:d decedent, at any time, Iransler property, tile baleficial enioymp.n\ 01 which was subject 10 change, because of
a reserved power to alter, amen(\, or revolle, 01 whicl1 could revert 10 decedent under terms of tmnsfer or by operation of
law? (Answer "Yes" or "No" ,) nn
3, If the answer 10 eight above is "Yes," was tile power to aller, amend 01 revoke Ihe interest of the beneficimy reserved
in the decedent <1lone or Il1e decedent and others'! (Answer "Yes" or "No" ,) no
REV:.t5G EX+ (J.aol
COMMONWEALTH OF PENNSYLVANIA
, OEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT OECEOENT
SCHEDULE "0"
BENEFICIARIES
&JLA
~.'~.'...~.
~~~,~
(Instructions on Reverse Side)
Estate of JAMES CLIFFORD KOLLER a/k/a J. CLIFFORD KOLLER
-.
RELATIONSHIP SURVIVED DATE OF INTEREST OF BENEFICIARY
BENEFICIARIES AND ADDRESSES DECEDENT BIRTH
- -
416 Valley st.
er yes ega .00
Herbert R. j;ep Wi'lndsoIL- . $1.,.000... nn
416 W. Valley st.
Olive Lauck Striejewsk friend yes legal 500.00
Helen A. O'Gorek niece yes legal entire residuary
es a e
The above beneficiaries are living at this time except for the following:
NAME
DATE OF DEATH
INSTRUCTIONS FOR COMPLETING SCHEDULE "E"
Schedule "E" must incli.lde all property. real and personal, owned by the decedent jointly with another
party or parties as joint tenants with right of survivorship, 80th tangible and intangible property ore 10 be
included, List real estate first.
1. Describe all real property as indicated in the instructions for Schedule" A", Describe allllorsonul propllrty
as indicated in the instructions for Schedule "8", Include the name, address and relationship to tho
decedent of the co-owner (sl and the date the joint ownership was established,
2. Indicate the total market value of the jointly owned property,
3, Indicate the percentage of the decedent's interest,
4. Indicate the market value of the decedent's interest,
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