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No, 21-81
PETITION FOR PROBATE OF WILL AND LETTERS TESTAMENTARY
"t' ,,',
In the Estate of Marie Atcheson Henry, also known as l-larie A, Henry
, deceased.
To Register of Wills for the County of cumberland, in the Commonwealth of Pennsylvania,
PetltlDner(s)liX (are) the executors
named In the Last Will and Testament of
Marie Atcheson Henry dated May 22. 1973 and Codicil dated ~1arch ,31, 1975,
Decedent was a citizen of the United States and a resident of Lem:lvne
lOOOOOOQI: (Borough), Cumberland County, Commonwealth of Pennsylvania,
Decedent died on
County of CUmberland , State ol'ennsy 1 vania at the age of 22-- years,
Decedentlla6 (has not) been married and:l:ms (has not) had children born toiIim (her) since the ex.
ecution of the above described Will.
Decedent was possessed of personal property to the value of $10,000.00
and of real estate to the val ue of $25 , 000. 00
ItJnday
the
15th day of
June
A,D, 19~, In the
as near as can be ascertained; said real estate situated as follows 281 Clark Street, Lerroyne,
CUmberland County , Pennsylvania
TherefQ,t\lt'\YP,\l)j,~~rloner(S) respectfully applyliDl for the probate of the said Last Will and Testa.
mentja'iicl'1orLellers Testamentary theron.
Dated
June 22. 1981
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N,m""' ,dd"" 'If)( /" \ 7'/( 4-<' clA-
of Petltioner(s)' ".J6n F, 'LaFaver, sqtUre
317 Third St., Box 101, NEW CUmberland, PA 17070
r:?,,"<L--f:~,
'IfrUCe t. 'fu
2049 Sheridan St., illiamsport, PA 17701
COMMONWEALTH OF PENNSYLVANIA t
COUNTY OF CUMBERLAND I ss
.J~Faver, Esciuire and Bruce E, Henry
_ Sw:>rn,__ and subscribed before
me, Ju~e 22__.__,1981_
.?lij4A<7f-1l ~--~/~
tI ~~ter
according to law say(s) that the
their , knowledge and beilef.
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named in above application, being duly sworn
statements set forth in this petition are true to the best of
,
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/)70
Filed:
June 23. 1981
Attorney Jon F. LaFaver
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JON F. LA-FAVER
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LAST WILL AND TESTAMENT
OF
MARIE ATCHESON HENRY
i:
I, MARIE ATCHESON lillNRY, of Lemoyne, Cumberland County, Penn-
sylvania, being of sound mind, memory and understanding, do hereby make,
publish and declare this as and for my Last Will and Testament hereby revoking
and making void any and all other wills by me at any time heretofore made.
I.
I direct that my Coexecutors hereinafter named shall pay all my
just debts and funeral expenses as soon as conveniently may be done after my
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decease.
II.
I hereby give and bequeath all my furniture, household equipment,
clothing and jewelry unto my hereinafter named Coexecutors for further dis-
my specific desire that any cost of making this distribution
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including mailing!
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tribution by them as they have been directed or as they may see fit.
It is
and moving be borne by my estate.
III.
I hereby give and bequeath the sum of two thousand ($2,000.00)
dollars unto my sister, ADELINE I. SHICK, if she survives me.
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($750.00)\
IV.
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I hereby give and bequeath the sum of seven hundred fifty
dollars unto JEANE LEWIS ATCHESON.
V.
All the rest, residue and remainder or my estate, whether real,
personal or mixed, and wheresoever situate, I hereby give, devise and bequeat~
as follows:
A. One-sixth (1/6) unto my niece, ALICE ATCHESON THOMPSON.
B. One-sixth (1/6) unto my niece, ANABEL ATCHESON KASE.
C. One-sixth (1/6) unto my nephew, W. FRED ATCHESON.
D. One-sixth (1/6) unto my late husband's nephew, BRUCE E.HENRY.
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CODICIL TO THE IAST WILL AND TESTAMENT
OF
MARIE ATCHESON HENRY
I, MARIE ATCHESON HENRY, of Lemoyne, Cumberland County,
Pennsylvania, being of sound mind, memory and understanding, do hereby make,
publish and declare this as and for a Codicil to my Last Will and Testament
dated May 22, 1973.
1.
I hereby amend Item V in my Last Will and Testament
aforesaid to read as follows:
A. One-fifth (115) unto my niece, ALICE ATCHESON
THOMPSON.
B. One-fifth (115) unto my niece, ANABEL ATCHESON KASE.
C. One-fifth (115) unto my late husband's nephew,
BRUCE E. HENRY,
D. One-fifth (115) unto my late husband's niece,
DORIS HENRY KIMBLE.
E. One-fifth (115) unto my late husband's nephew,
R. IARUE HENRY.
II.
All other parts of my aforesaid Last Will and Testament
are to remain in full force and effect, and unchanged by this Codicil.
IN WITNESS WHEREOF, I, Marie Atcheson Henry, have unto
this Codicil set my hand and sea 1 this 3/;!:!;" day of March, A. D., 1975.
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Page one of two Pages
LAW O"leUI
JON-F. LAFAVER
al7 THIRD stRUT
MEW CUlolSEIIlLAND, "'A.
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CODICIL
CUMBERLAND COUNTY, ss:
This
22nd
81
A,D,,19_,
June
day or
berore me Mary C. Lewis, Register ror the Probate of Wills and granting leHers of Administration in and ror said
County of Cumberland, in the Commonwealth or Pennsylvania, personally came Jon F. LaFaver
the subscribing witnessx~ to the foregoing instrument or writing purporting to be a
codicil to the last Will and Testament of
Marie Atcheson Henry, a/k/a Marie A. Henry
Dated 3/31/75 late or
Lemoyne
Cumberland County, Penna"
deceased who being duly sworn according to law, depose and say, that
he was
present,
saw and heard the testa tr; Y, Marie Atcheson Henry, a/k/a sign, seal, publish, pronounce
Mar:te A. Henry
and declare the said instrument of writing as and for a _ codicil to h er Testament and
Last Will, and at the time or so doing
she
was of sound and disposing mind, memory and un-
derstanding, to the best or her
knowledge, observation and belief.
I ~'~~~~L~
sworn
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and subscribed before
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RE V_UQ ( l-nOl
COMMONWEAL TH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIOENT OECEOENT
AFFIDAVIT OF
FIDUCIARY
(Instructions on Revorsc Side)
*
:' ~:lt",jJ,~ . Atche~)Oll 1 lorry J a/ i/",
Estate of ,'.::n:l(~ !'. ~,,-':J."l.r':
'-
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Dote of Death
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LosI Address~!li~l~~_______
Social Security No.
J,o:(wn,eJ 'fl/\ llCi...i
(CITYI (STATE)
Bureau FileNo.
(ZIP)
County File No,
!l-,l-3;,'j
1. Decedenl died:
Inteslal. (without 0 will)
Teslote (leaving 0 lasl will--copy ottached)
2. Is Ihe filing of 0 Federal Eslate Tax Return required for this estote?
Yes_ No "
3.
Execu 10 r/E1<eo<Jfrl~
) Administrator/Administralrix
Name
.Tell:-". 4~1.:'21\':'l~.
. ',-;.~", L-~,}:,~..L.:::YllC:: (: j ~. :',
Address
!,li' T.-i~..l '~~:'i_:_ i'
.c.,.; L~':"~\L": LJi ;.__, ,
l.i'J'/;..
(CITY)
(STATE)
{ZIP}
4. All correspondence should be mailed to ( ) Attorney
) Fiduci ory,
5. If an attorney is representing Ihe eSlute, indicate:
Name .1011 ::-\ IaFavl:'l'
Address Jll 'ulir(l ';Cr'Ll ,;
- , '
)..::.:~.~ L'..l'lLr.,::rl~L>.,
1'/ !I\J
(CITY)
(",TATE)
{ZIP}
Lisl all safe deposil boxes regislered in the decedent's individual namel or jointly with, or as an ageol or depuly
of onolher, or in decedenl's individual nome with righl of occess by onotner as ogenl or depuly. Include Ihe nome
and oddress of Ihe bonk or olher institution where the safe deposil box is locoted, Ihe name (s) in which Ihe box
is registered and Ihe relolionship of the joinl holders 10 Ihe decedenl.
NAME AND ADDRESS OF BANK OR OlllER INSTITUTION
IN WHICH DECEDENT MAINTAINED A SAFE DEPOSIT BOX
NAME OR NAMES IN WHiCH
SAFE DEPOSIT BOX IS RECISTERED
RELATIONSHIP OF JOINT
HOLDERS TO DECEDENT
Under penalties of perjury, I declare that I hove exomined this return, including accomponying schedules and
SlDlements, and to the besl of my knowledge ond belief it is true, correcI and compi.le.
r31< <Co', ;;.. ~/it''11AAl
-rR.ATURE aF,FIDucIARY
/d-/-~I
DATE
, REV.451 EX+ (3.80)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "6"
PERSONALPROPERTV
(Instructions on Reverse Side)
Estate of -,'Ll.r:i~ !\tCla-$On ric.rrt"r a 1:./;'. \1l"iG 1\. HiEtt'!
ITEM
NO,
1.
2.
DESCRIPTION
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3. ~. .\:,.,-,..:...~j fn-,,( .~j,:;:l.:.~ OIC ~':(.:rsu.;..~J.. ;:::O.:'L"rt? (~lOUS0~.01-.~~
. .~J.~ :::. ,i'u.1l"'s)
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. :(!l:C. G1::" '.J~:). , J),)L:,
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7.
UNIT
VALUE
ESTI MATE D
MARKET
VALUE
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TOTAL THIS PAGE
32, 77~. Ji
.
OEPARTMENT
VALUATION
(OFFICIAL USE ONL Y!
CCCC~LE3
CONS BANK. NA.
MAIN OFFICE 331 BRIDGE STREET NEW CUMBERlAND, PENNSYLVANIA 17070
BANK (717) 774.7000 DlflECT
Dnto July III, 1901
TO: Jon F. LaFaver
317 Third Street
New Cumberland. PA 17070
P.E: Estate of I.larie A. Henry
Name of Decedcnt
The following is a complete record of the above decedent's accounts
as of
June 15. 1981
Date of Death
NO~I TJ"Pc of Account
Ba.lance on uat.e of DQH.1.h
Principa: Accrue~ In".
i:OJUCS on Account
(1\11 'CwnU:'~8)
Da:te oi' ':r~a,t 'i,':I1",
of Joint
()r/m'.!rflh~_
Checking $ 3,957.93 llone
Savings $ 2.848.08 $22.96
Cert. of Deposit $ 6,000.00 $45.92
Cert. of Deposit $15.000.00 $35.96
Mllrie A. Henry
Mnrie A. Henry
Mllrie A. Henry
Marie A. Henry
ill
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AUl:1.II.',rizcd Sir,r.o.turc
QUESTIONS CONCERNING PROPERTY TRMSFERS
1. Did decedent, within two years of death, make any lransfel of any Inalorial pr1l1 of his eslate /lllIlout receiving
valuahle and adequate consideration? (Answer "Yes" or "No".) _u_
2, Did decedent, within two years of dealh, transfer property from hilnseW hersdl to himself/herself and [mother pmty
or parties (including a spouse) in joint ownership? (AIISWIH "Yes" or "No".) --
3. If the answer to aile 01 two <lhove is "Yes" <lnd the lr<lllslcrs ,lfe claimed to he nont<lxable, provide the following
information:
a, Age of decedent at time of tmnsfer. --
b. Copy of death certificate.
c, Affidavit by the attending physici<lll indicating tile ,l<lte of decedent's hOillll1 ill lill1e of tmnsfer,
d. All other infolllwtion supporting nonlax<lbifiiy of frauslor,
4, Did decedent, in his/her lifetime, make any transfer of property without receiving it v<lluable or <IdeQu<lte consideration
therefor which was to take effect in possession or enjoYlnent at or aftelhis/her de<lth? (Answer "Yes" or "No",)
a, Was there any possibility thatlhe property transferred might return to lransferor or his/her estate or be subject
to his/her power of disposition? (Answer "Yes" or "No" ,)
b, What was the transferee's <lge at time of decedent's death?
5, Did decedent in his/her lifetime m<lke <lny transfer wi thout receiving <I valu<lble <lnd adequ<lte consideration therefor
under which transferor expressly or impliedly reserves for his/her life or rmy peried which does in fact end before his/her
death:
a, The possession or enjoyment of or the right to income from the properly transferred? (Answer "Yes" or "No".) -
b, The right to designate the persons who shall possess or enjoy the property transferred or income therefrom?
(Answer "Yes" or "No".)
G, If the answer to five b, above is "Yes," state whether the right \Vas reserved in decedent alone or others,
7. Did decedent in his/herlifetimo make a transfer, the consideration for which was transferee's promise to pay income
to or for the benefit or care of transferor? (Answer "Yes" or "No".)
8, Did decedent, at any time, transfer properly, the bmeficial enjoyment of which was subject to chaoge, because of
a reserved power to al ter, amend, or revoke, or which could revert to decedent under terms of transfer Dr by operation of
law? (Answer "Yes" or "No".)
9. If the answer to eight above is "Yes," was the power to alter, amend 01 revoke the interest of the beneficiary reserved
in the decedent alone or the decedent and others? (Answer "Yes" or "No".)
REY.4~J ~Xi' (J.l\ol
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIOENT DECEOENT
SCHEDULE "D"
BENEFICIARIES
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Estate of 'tide AtellL,son Hellry, <I/;'.!:! ".Irit! /'., 1"~lr"
BENEFICIARIES AND ADDRESSES
RELATIONSHIP
SUBV'iV'E'D
DECEDENT
DA T[ OF
BIHTH
INTEREST OF IlENEFICIARY
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The above beneficiaries are living at this time except for the following:
NAME
DATE OF DEATH
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
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55:
Jon F. LaFaver and B,roce E. H~_,______
being duly ffioXlm according to law, doposes and says that they_ Are
EXecutors of the Estate of H'l'rif' At-"hf'~nn HPnry, "/k/,, M<l,.i" A Henry
late of the_~,Q\lgb,pf.J:..Em;lyne___,__ , Cumbarland County, Pa" deceased and that the
within is an inventory made by Jon F~~aruiJl~e_ E....lIeru:y " tha said Executors
of tha entire estate of said decedent, consisting of all the persona' property and real estate, except raal estate oulside
the Commonwealth of Pennsylvania. and that the figuras opposita each itam of the Inventory raprasant it's fair value
as of the date of decedent's death. '
SlIDm
and subscribed before me,
19 Ji
Suzrr"':l ~.... k~'/r!le, "!-:ti~iY Public
M\' (to!\Il,i:;:(..~ b..:"ft\ hr:. 23. 1983
I':IW 'umber:~ll~. PA Cu,I1~c.rland Counly
317 Third Street
New Clm1ber1and, PA 17070
Addr.n
Data of Death
15th clAY of
Day
.Ttmp
Month
lqRl
VOir
INSTRUCTIONS
I, An inventory must be filed within three months after appointment of personal represanhtiva.
2. A supplement inventory must be filed within thirty days of discovery of additional assets. "
nr
3. Additional sheels may be attached as to personalty or realty ~~
4. See Article IV, Fiduciaries Act of 1949. ~;,
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GENERAL I.NHERITANCE TAX INFORMATION
Unsatisfied Ilebllltles 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, tombstone 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 domiciled 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, I n 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 fam i1y exemption is
allowable only against assets which pass by a wiil 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,
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OEV.1162 EX
COMMONWEALTH OF PENNSYLVANIA
NO LOI06'1 OEPARTMENT OF REVENUE
)2.' "'tJI!FICIAL RECEIPT. PENNSYLVANIA INHERITANCE AND ESTATE TAX
'v,
G
M!i
m AMOUNT
Assessment Control No.
, RECEIVED FROM:
I -Jo11-F,.-LaFavel'-y.-zeq..-,_,,_______1
--3l-?--'Rhird-,Stl'eet ,-- . ..... .. ____.,,'_.._.___,
--JI..O_Box-10L,.,__...._.,... _ .___ ,_,.......... ...__
_N.'LCWIIbe:dand,,_l"a._l.'lllJ_Q ...__'"_
L ~
P:rehatte
&€7 . 68
ESTATE INFORMATION:
FILE NUMBER
NAME OF DECEDENT
DATE OF PAYMENT
la
POSTMARK DATE
COUNT'I
DATE OF DEATH
("nm'hAt-1A"~
RECEIVED BY
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REMARKS
[i]TOTAL AMOUNT PAID
567.68
SEAL
as
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6-30-81
7- 2-81
7- 6-81
7-22-81
7-23-81
8-21-81
8-28-81
9- 8-81
11- 4-81
11-18-81
12- 1-81
12- 9-81
12-16-81
12-21-81
12-24-81
1-25-82
2-23-82
3- 9-82
3-29-82
3-30-82
7- 1-81
7- 6-81
LAW O'I'ICE8
JON F. LAFAVER
317 nllllll STRUT
NEW CUMIlI:IlLAHD,PA.
FIRST AND F'INAL AGCOUNT
OF
JON F. l.9.FAVER and BRUCE E. HENRY
Executors of the Estate of Marie Atcheson Henry, also kn= as Marie A, Henry
late of the Borough of Lanoyne, cUmberland County,
permsylvania, deceased,
RECEIPI'S
Your accountants charge thanselves with receipt of the following items:
Cash
Glose CCNB Checking Account No. 385 440 3
Proceeds from Prudential Insurance Policy No. 01 760 030
Proceeds fran sale of personal property .
Proceeds from sale of coin
CCNB - Interest on G/D #1830018
Forest Park Nursing llane - Refund
Capital Blue Cross - Refund
CCNB - Interest on G/D 110019260
CCNB - Interest on G/D #1830018
Close GCNB Savings Account No. 003-000181-2
Redemption of CCNB G/D No. 0019260
Redemption of CCNB G/D No. 1830018
CaimJnwealth of PA - 1980 Property Tax Rebate
CCNB - Interest on C/D #1830018
Net proceeds fran sale of real estate
ComrtJnwealth of PA - 1980 Inflati.on Dividend Check
Nedicare - Glaim payrrent
PA Blue Shield 65 Special - Claim Payment
CCNB - Interest on NOW Estate Checking Account
CCNB - Interest on NaIl Estate Checking Account
CCNB - Interest on NOW Estate Checking Account
Redemption of CCNB Estate C/D No. 36597
Carrnonwea.1th of Permsylvania - Property Tax Rebate
CCNB - Interest on NCM Estate Checking Account to date
$ 44.83
3,675.96
706.31
1,030.01
116.36
179.79
578.02
8.25
108.75
179.79
2,875,71
6,036,24
15,000.00
92.13
179. 79
30,137.83
15.00
287.46
71.86
77.92
157.24
143. 04
17,280.08
100.00 ,
220.74
$ 79,303.11
Total
DISBURsEl1ENrS
I Your accDlIDtants credit themselves with payrrent of the following items:
i
I Register of Hills - Letters and Certificates
UGI - (',as Service
I Lerroyne Borough - Sewer & Trash Service
MJo1 Pharrracy - Prescriptions
Barbara Rodgers - Reimbursement for costs advanced
$
49.00
6.72
16.00
121.92
6,98
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7- 8-81
7-10-81
7-21-81
7-22-81
7-23-81
7-24-81
8-28-81
9- 8-81
9- 9-81
9-28-81
11-18-81
12- 1-81
12-22-81
1- 4-82
3-15-82
4- 2-82
LAW O..,.ItU
JON F. LAFAVEA
111 'rHlIlD ITIlUT
Nr.W Cl,IM.UIL...HD.P....
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,I Bell of PA - Telephone service
'll>Iunnt s Diamond ('ullery Ltd. - Ring appraisals
U. S. Post Office - postage to mail rings
i I11sselman F\mera1 !lane - F\meral Expenses
'I Wormleysburg Fire Co. Ambulance - Ambulance service
The Patriot-News Co. - Legal Advertising
i Joseph McGraw, Inc, - Real Estate Appraisal
I Belvedere Medical Corp. - Professional services
! PP&L - Electric service
i Nick Diorio - U1Wll maintenance
i CUmberland U1W Journal - Legal advertising
I'Rcweo - Water service
UGI - Gas service
I PP&L - Electric service
I Rayroond e. Grandon, M. D, - Professional services
\ Register of Wills - Payment on account of PA Inheritance Tax
eCNB Bank, N. A. - Purchase of e(D #1836597 (Temporary investment)
I' Nick Diorio - U1Wll rraintenance
UGI - Gas service
I PP&L - Electric service
RCHeO - Water service
l.aInyne Borough - Sewer & Trash service
Register of Wills - Filing Fees
. RCWeO - Water service
I, PP&L - Electric service
I UGI - Gas service
Nationwide Mutual Fire Ins. Co. - Balance of premiun due
Register of Hills - Balance of PA Inheritance Tax Due
Jon F. LaFaver - Legal Fee
I Bruce E. Henrv - Executor I s Fee
Jon F. LaFaver - Executor t s Fee
Register of Wills - Filing Account
Recorder of Deeds - Filing Releases
I
iTotal
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RECAPITUlATION
Total Receipts $ 79, 303 .11
Total Disbursements 35,218.04
Balance for Distribution $ 44,085. 07
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384
$ 3.08 I
20.00 I
11.70
2,542.90
55.00
21. 63
125,00
14,00
5.07
25,00
18.00
9.43
12.64
4.77
490.00
6,900.00
16,000.00
45.00
14.11
12,11
9.47
16.80
15.00
5.37
5.56
2,78
10.00
567,68
3,965.16
1,982.58
1,982.58
75.00
50.00
$ 35,218.04
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INFORMATION
This document is the Notice required to be given under Section 709 of the Inheritance and Estate Tax Act
of 1961 (72 P.S. section 24851,
If the tax is paid within three (3) months after the decedent's death, a discount of 5% of the tax paid is allowed.
Inheritance Tax becomes delinquent nine (9) months after the decedent's dealth. Interest is charged at the
rate of six (6) percent per annum on the amount of unpaid tax. (SEE EXAMPLE 8ELOW)
EXAMPLE: If a balance of tax due of $2,000.00 is in a delinquent status from 3-3-80, and payment is made
on 5-23-80. the interest is calculated as indicated below:
STEP 1
Determine the rate of
interest from the table below.
STEP 2
Multiply the balance of
tax due by the rate of
interest.
STEP 3
Add the interest
to the balance of
tax due.
Interest from 3-30-80 to 5-23-80
Results in:
Balance of tax due
Rate of interest
INTEREST
$2,000.00
x .01335
$ 26.70
Salance of tax due $2.000.00
Plus Interest to
Date of Payment (+) $26,70
TOTAL tax and
interest to Date
of Payment $2,026.70
.010
= + .00335
.01335
2 Months =
20 Oays
Rate of interest
=
---------------------------------------------------------------------
1 month .005 4 months .020 7 months ,035 10 months .050
2 months .010 5 months .025 8 months .040 11 months ,055
3 months ,015 6 months .030 9 months ,045 12 months ,060
1 day ,00017 11 days .00186 21 days .00352
2 days .00034 12 days .00203 22 days .00369
3 days .00051 13 days ,00220 23 days .00386
4 days .00068 14 days .00237 24 days ,00403
5 days .00085 15 days .00250 25 days .00420
6 days ,00101 16 days .00267 26 days .00437
7 days .00118 17 days ,00284 27 days ,00454
8 days ,00135 18 days .00301 28 days .00471
9 days .00152 19 days .00318 29 days .00488
10 days .00169 20 days ,00335 30 days ,00500
---------------------------------------------------------------------
Any party in interest, including the Commonwealth and the personal representative, not satisfied with the
appraiserrent and assessment may object within sixty (60l days after receipt of this Notice as provided by
Section 1001 of the Inheritance and Estate Tax Act of 1961 172 P.S, sec. 2485 - 1001),
MAKE CHECK OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT"
DETACH THE TOP PORTION OF THIS FORM AND SU8MIT WITH YOUR PAYMENT TO THE REGISTER OF WILLS FOR
THE COUNTY SHOWN ON THE REVERSE. SEE THE INHERITANCE TAX INSTRUCTION 800K FOR ADORESS.
m:.v.!:iOO ex ~ (9.iH)
OUREAU OF EXAMINATION
PENNSYLVANIA OEPARTMEN1' OF REVENUE
p,O, OOX 8327
HARRISBURG. PA t7105
//-d6f- !
INHERITANCE TAX RETURN
RESIDENT DECEDENT
t::::Ai Y
Decedent's Neme (Lest, First, Ind Mid,dlo Initiel!.1 I Oecedonl's Address
~...: /,',. /tn/lit' ~N .;<f'/ C?/;:t,,:.e J;f:
Sociel Securit Number Dlte 01 Oeeth /'
(JC." /'f=J'/ "J.t:'IA"jlvt'J ril, i70<!~
1, Driginll Return ~ 2, Supplemental Return 0 3, Remaindor Return 0
DECEASED
CHECK
Filo Numb.r
,;, 1 ~ (/'1- I) Ii ;;'6
4, Lifl Estlte 0 5, Federal Estete Tex 0
Return Required,
6, Oecedlnt dild tlStltl r.:71 7. Oecodent mlintlined a living 0 8, Numbor 01 safe deposit 0
(Attlch copy of Willi lC:::I- trust (Attach copy of trust! boxes inventoried
All correspondencelnd confidentilltex informetion should bl directed to:
Computation of Tax
15. Amount of line 14 tlxlble at 6% rIte (15)
(include VIIUIS from Schedule K)
16, Amount olline 14 laxlbl..t 15% rIte (16) rr'.nl; I If';, i 7
linelude velulS from Schedule K)
17. Principal tax due (Idd tax from line 15 plus tax from IIno 16)
18, Totll Prior plyments:
(I) Amount Plid
(b) Pl.s Discount
(c) Minus Interest (18)
19. 8111nce Duelllne 17 minus line 18)
Mike Check PlyablltO: Ragister of Wills. Agent
. . . PLE~SE RECHECK MATH' . .
APPRO.
PRIATE
BLOCKS
CORRE.
SPONOENT Noma
Telephone No.
RECAPIT.
ULATION
RlClpit.lotiln
1. Rell EStltl (Schedule A)
2. Stocks Ind Bonds (Schldull 8)
3, Closely Held Stock/Plrtnll1hip Interest (Schedule C)
4, Mortgages end Notes (Schedull D)
5, Cash & Miscelleneous Pmonel Property (Schedulo E)
6, Jointlv Owned Proportv (Schedule F)
7. Transfel11Schedule G)
8. Totel Gross Assets (totel lines 1-7)
9. Funerll Expensls Administrative Cosu/Miscellaneous
Expenses (Schedule H)
10. Debts/Mortgages/Liens (Schedule Il
11, Total Deductions hotel line, 9 & 10)
12. Net Value 01 EStltl (1101 8 minus line 11)
13. Chariteble Beque<ts (Schedul. J)
14. Net Velue subject to tex Uine 12 minus line 13)
AND
TAX
CALCU,
LATION
Address
City
State
ZI
( 1)
( 21
( 3)
( 4)
( 5)
( 6)
( 7)
.11. rjtJtJ,O'O
.
,J,2, '/7,'1 <"I
( 9)
(10)
/~ </ &':1, til
( 8) It 7 t1J: t'i
,
(11) .~tlH,84
(12) .J.t>l / ./1
(13)
(14) .r.7. I '? 1/ , /1
x,06=
x.15= 7.$.??.lJ
,
(171 /j g02'!.I)
(19)
"
Under penalties of perjury, I decl...thltI hlVI eXlminld this return, including eccompanying schedules end stltements, Ind to the best of my knowledgo
end belief, it is true, corract, Ind complete, Deellration of preperer other thin the personel representative is blsed on ell inlormllion 01 which preparer has
any knowledge.
SIGNATURE OF PERSONAL REPRESENTATIVEIS)
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
ADDRESS
DATE
ADDRESS
DATE