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Inventory of the reol ond personol e.tote of
Lisa Ann Adams
deceased.
1972 Opel Automobile - sold December 15, 1980
Checl< 1/32624 - 1he Golden N. Co., Inc.
Checl< //002744 - STB CoPp., Western SizzHn Steak House
ACCOW1t #9-26280 - FarnJer I s 1'rust Company, to close accoW1t
Insurance refund, automobile
Insurance Policy No. 58P574-180
Nationwide Mutual Insurance Company
Cash, sale of bed (by Dane Watson)
Cash, sale of toaster, camera, flatware, miscellaneous clothir~
Kinney Shoe COl'poration salary: Check No. 55195
Check No. 56031
Kinney Shoe Copporation Group Life Insurance proceeds
State of Pennsylvania 1980 Tax RefW1d
Tota 1
~$ 500 00
59 03
11 55
60 '72
35 00
I
20 100
45 100
90 159
16 22
6,000 100
45 124
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6,B83 35
COMMONWEALTH OF PENNSYLVANIA I
COUNTY OF CUMBERLAND J
55:
_.________.__n_____n_ _ _J!aj1e.L.HatsoJ'l __._____n_____________.___ ---
b.ing duly sworn_ m. ___ according 10 law, depose. and .ays Ihal he ____Qime L.L-_WA.til.on..._. --------
_.__P~rSOl1!!Lreprg!?l:lntfl,tiye__. _ n. 01 Ihe Eslate 01 Lisa Ann Adams
lal. 01 BorourrJl of CArll 51 e , Cumberland Counly, Pa" dec....d and that the
within is an inv.nlory mad. by. _ _ Dane L..Watson_..__. __nO _____._.___, Ih. said_persnm1 t'epresentativ
ollh. entire .slale 01 said dec.d.nt, consi.ting 01 all the personal proporty and r.al .state, exc.pt r.al .state outside
Ih. Commonw.alth 01 P.nnsylvania, and that Ihe figures opposite each it.m 01 the Inventory r.pr.sent it', fair value
as 01 the date of d.cedent's death.
Sworn
and subscribed before me,
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SHARON A. MOSER, NIllIIy PlIbl1c
Carlisle. flA. Cumberland County
My Convnlsslon expires Jan. 1~, 1985
19 81
executor. Administrator
j
Dane L. \~atson
5.Q5G So!l_th jlest Stl~"et
Carlisle, FA 17013
Addr."
D.y
Month
1980
Yur
Oat. of D.ath _________J!!..._______________~tober
INSTRUCTIONS
I. An inv.ntory must b. fiI.d within three months alter appointment 01 personal representaHve.
2. A supplem.nt inventory must be Iiled within thirty day. 01 discovery of additional a..ets.
3. Additional sheets may b. attach.d a. to personalty or really
4. S.. Articl. IV, Fiduciaries Act of 1949.
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BENEFICIARIES
------- ~.
RELATIONSHIP
TO DECEDENT
SURVIVED
DECEDENT
STATE YES
OR NO
AGE OF LIFE
TENANTS OR
ANNUITANTS
AT DEATH OF
~~CEDENT
INTEREST OF
BENEFICIARY
IN ESTATE
BENEFICIARIES AND ADDRESSES
(Stote lull names and addrM'OJ 01 All who hitI/o an intormt
either vustod, contingent 0' uther inltltustl
_---- trrrr-int'rln
Jacee Leearul ~~.?Ins_____________._.._____(tl\!1:htcr__-
Yes'
100%
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INFORMATION
PLACE FOR fiLING .._ The relUrn is 10 be iiled in duplicate with the Regisler oi Wills 01 the county wherein the decedent resided.
TIME FOR FILING __ The return is due nine months afler the decedent's death, unless an extension lor liIing has been applied for and granted
bV the Secretary 01 Revenue within the nine.montb period,
FAILURE TO FILE RETURN __ Section 791 of the 1961 Statute provide> that ", ' ,any person who willlully fails to liIe a ,eturn or
other report required of him. . SI1311 he personally liable, . . to a penalty 01 25% of ti,e tax ultimately found to be nue or $1,000
whichever is Ihe lesser 10 be recovered by tho Department oi Revenue as debts 01 like amourot are ,".cove,able by law."
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REV.484 EX+ (WO'
INHERITANCE TAX SUMMARY SHEET
(BUREAU USE ONLY)
File Humber
21-81-0554
Estate Hame
Lisa Ann Adams
Date af Death
October 14, 1980
Social Securi ty Humber
205-52-5897
REPORT OF IHHERITAHCE TAX APPRAISER
(i] Originol
o Supplemental
o Remainder
I, th. und.nlgned duly appoint.d Inheritance Tax Appralur In and lor the County 01 Cumberland
Penn.ylvonlo, do ",.pectfully report that Illave opproiud the real and personal ProP.~710' report.d In th. foregoing
return at the valu.. lOt lorth oppo.lte each item In th.lo.t column to e fht In Sc;.o)"le. "A", "B", "C", and "E"
Dot.d: October 16, 1981 - ,-,,'" h7~, ~
INH~"ITANCE TAX APP, ER
INVENTORY
YALUE AS APPRAISED
caDE
ADJUSTMEHTS
(HARRISBURG USE OHLY)
R.ol Prop.rty (Schedule A)
Person01 Property (Schedule B)
Jolnt.Held Property (Schedule E)
T..n.I..1 (Schedule C)
TOTAL GROSS ASSETS
s NONE aa+
6 883 35 10+
NONE 2lH
30+
~,883 35
40.
Len Debts end Oeductlons
(SCHEDULE F)
CLEAR YALUE OF ESTATE
OLlie Ellate
o Annuity
~
FACTOR
PRINCIPLE
FOR USE OF REGISTER OHL Y
Tax on $
~
6%
Tax on $
15%
Tax on $
Tax on $
Tox on $
eumptlc.n,
Total Estate
TOTAl. TAX
IIlTEREST FROM
BALANCE
TO
l..u Credlh
OATE OF PAYMENT
INTEREn
S
AMOUNT PAID
DISCOUNT
s
+ S
+
BALANCE
TO
S
REMAIHDER APPRAISEMEH1' CODE
'2+
13-
VALUE CODE
-\
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COMPUTATION OF TAX
$
$
$
$_
$
$
$
$
TAX CREDIT
.
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,
ESTATE OF LISA ANN ADMIS,
Deccnsed Oc tober 14, J 9RO
Formerly of the Ilorough of
Carlisle, Cumberland Coun ty, PA
Hi TilE COUnT OF CONIION PLEAS OF
CUNIlERLAND COUNTY, PENNSYLVAN1A
ORPIIAN'S COllRT D1VISlON
NO., ..., '/ ~_ crilL !.C'FlElll 1981
0<, -0 I - ~-.f.-LI
DECREE OF DISTRIBUTION OF SHALL ESTATE UNDEIl PIWIlATE
ESTATES AND FlDUCIAlllES CODE OF 1972
AND NOW, this
-
r,.w-
I .> . -day of ~, 1981, the Estate of Lisa
Ann Adams, deceased, composed as set forth in the Petition attached hereto,
is B\;arded and distribution is as follo\ls:
Ruby D. Weeks, Esquire - 5%
$ 305.00
$ 200.00
$ 130.28
$ 507.00
$ 850.00
$ 595.00
$2,000.00
$2,296.07
$6,883.35
Reserve to finalize Estate Administration
Common"ealth of Pennsylvania - 6% Inheritance Tax
Cumberland Valley Nemorial Gardens, grave marker
Samuel }~0nry, reimbursement for payment to Ewing
Ilrothers Funeral Home balance
Clayton II. Uatson. reimbursement for paymen t to
E"ing Ilrothers Funeral 1I0me balance
Jacee Leeann Adams, fami 1y exemption (Exhibi t "AIO)
To the Estate of Narlin C. Adams, Jr.
Total Debts of Estate
Further, Dane L. \,atson, as personal representative of the Estate of
Lisa Ann Adams, is hereby authorized to establish a checking account and
endorse checks to effect said disbursementa.
BY THE COllllT,
/~~ .(E~
enOK 108 rAC1 ~7
.,
.'
items at the listed valuiltions:
(a) 1972 Opel automobile, sold December 15, 1980 $ 500.00
(b) Salary, Check 1/32624, Tht, Golden N. Co. , Inc. $ 59.03
(c) Salary, Check 11002744, STn Corporation,
Western Sizzlin Steak lIouse $ 11.55
(d) Balance, Account No. 9-26280, Lisa Ann Adams,
Farmer's Trust Company $ 60.72
(e) :nsurance refund, Nation"ide ~futual Insurance
Company, Au tomobile Insurance Policy
1158P574-180
$
35.00
(f) (1) Cash, sa Ie 0 f bed
(2) Cash, sale of household items
$
$
20.00
45.00
(g) Hetropolitan Life Insurance Company Group
Policy No. 5534, Certif. No. 179549581
$6,000.00
(h) Salary, Kinney Shoe Corporation
Check 1155195
Check 1156031
$
$
90.59
16.22
(i) State of Pennsylvania, State Income Tax Refund
not yet received, "ould be payable to the
Estate of Narlin C. Adams, Jr. .1nd then to
Jacee Leeann Adams, sole surviving infant
daughter of both deceased parents
$
45.24
Total Assets
$6,883.35
9. (a) The minor child, Jacet' Leeann Adams, has a Gu.1rdian by a Petition
for Appointment of Commonwealth National Ilank as Guardian of the assets of the
minor filed in this Court, docketed to No. 292, Orphan's Court 1981 on April
28, 1981. Ilowever, her eustodio1l1S. Jack and Sharon Il1ack, have also consented
and join in this Petition.
(b) All other p.,rties an' slli jlld s.
10. (a) All parties in interest in the proceeding as distributees,
he-irs, or crl'ditorfi, who are sui juris, havp consent<>d to the filing of this
BOOt: 108 rACE G80
p(~ti.ti.on and join in its pnlyer. The wr"ittl'11 l'OnHl'nts of the parties in
interest who consent art" Llttached hereto as Exhi.bi ts "n" through "gll.
(b) Jacee LeC<111n Adams, WilD l.:1cl(s capacity as averred in paragral>11
6 hereof, has not consented to the filing of thiH Petition except through her
Guardian of her assets, Commonwealth Nationa] Bank, and her legal c.lIstodi.anH,
Jack aud Sharon Black.
11. No on(~ has received 01" retailH-'eJ any property of decedent as payment
of "ages or acaued pensions undcr ~ 2 of tilt! P.E.F.C. Code of June 30, 1972,
P.L. 508, as amended, 20 Pa. C.B.A. 9 3101 or other"ise.
12. On September 10, 1981, a sch"duJe of assets and deductions for
inheritance tax purposes "as filed with the Register of Hills of Cumberland
Coun ty. An i nhet"i tance tax asses I-itnen t 0 f $
W.IS made. The inllQri. tance
tax as afHH'sscd has not been paid as yet. lIowevl1r, funds are allocated
belo" for payment of this tax in full. A copy of the inventory and appraisement
and of thl1 tax vOllclwr are attached hereto as Exhibits IIF", "e", and 1111".
WIIEREFORE, tIll' Pet it ioner requps ts the Court, pu rsuan t to S". t ion 2 of
the Probate, Estates, and Fiduciaries Act of June 30, 1972, P.L. 50H, as
um~11ljed 20 Fa. C.S.A. g ]i02, to award distribution of the Estate as follows:
JacC'c Leeann Adams, family pxpmptlon (Exhibit IIAII)
Commonwp.a]th of Pennsylvania, ]nlll'ritancl~ Taxes
Iluby D. Wl'('ks, Esqui,.e - 5%
$2,000.00
$ 130.28
305.00
aodtl 108 ritl GBl
Reserved for expenses of Administration
Samuel Henry, reimbursemen t for payment to E"ing
Brothers Funeral Home
$ 200.00
$ 507.00
$ 850.00
$ 595.00
$2,296.07
$6,883.35
Cumberland Valley Hemorial Gardens, grave marker
Clayton H. IVatson, reimbursement for payment to
E"ing Brothers Funeral Home
To the Estate of Harlin C. Adams, Jr. (deceased
husband of Lisa Ann Adams)
Total Debts of Estate
Further, Dane L. l~atson, as personal representative of the Estate of
Lisa Ann Adams, is hereby authorized to establish a checking account and to
endorse checks to effect said distribution as set out above.
Respectfully Submitted,
\
\...J.u.t& LJnJ2.d-
Ruby D. Weeks, Esquire
Attorney for Petitioner
We join in the above Petition and aver the facts therein are true and correct
to the hest of our information, knowledge, and belief.
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Dane L. \~atsoil, personal repre-
sentative, Estate of Lisa Ann
Adams, and natural parent of
Lisa Ann Adams, deceased herein
~/~
!1ar in i2-. A',hms. Sr., Administra-
tor of the Estate of Harlin C.
Adams, Jr.
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74d1; .I (/vc {
Sharon L. Black, natural parent
of Li sa Ann Adams, dec(>ased
herein, and custodian of Jacec
LeClann Adams t minor eh i 1 d IH">re i n
haron L.
BOOR 108 rACE6~
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CO~'1t\~O:'!h'EJ\LTll OF '''E:-Jf.1:3YLVf,l:J f\
ss
COUNTY OF CUI.1BERL^NIJ
Pcrsonally appear'cd before me, a liotary Pub] ic in and for
the CommonHealth and County afo,..csaid, the lJnder-sir,ned, beine
duly SHorn accordine; to 1m;, deposes and says that t.he fact.s set
forth in the foregoinr, Petition at'e tl"lJC and correct.
_"7~ A ~__ /_~_
~l~, Sr.
Swor'l1 and subscr'i bed to
befol"e me this
.;2/$.L
day of -1ul;r . 198/
~14EzL_O, 7JJ~
Notary Public
SHARON A. MOSER. Notary Mile
Carlisle. PA. Cum!Jer1and Counly
My CommiSSion Expires Jan. 14. 1985
80r.K 108 FACt 684
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RE: Es tate 0 f Lisa Ann Adams
To Whom It Hay Concern:
On behalf of Jacee Leeann Adams, daughter of Lisa Ann Adams, deceased,
she li.ved in the same household as the deceased, her mother, from date of
birth, November 8, 1979, until her death, October 14, 1980. From October 1,
1980 to date of death, they resided at Carl"ynne Hanor Apartments, Carlisle,
Cumberland County, Pennsylvania. 1 hereby request payment of the family
exemption allo"ance to "hich she is entitled under 20 Pa. C.o.A. 3121, and
I have retained I,ersonal property in the value of ~2,OOO.00 for this purpose
on her behalf.
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IVitness my hand and seal this
ot-l.- 0. f
I day of !.fV_:, 1981.
JJd/vtr,. ~. OdL{Lc1
Guardian 0, ..1(~ 1,Cl':~Gn :lJ1(
Sworn and subscribed to
Cl tJ.
before me this I
day of O-(J,J ,1981.
.---:.....1 j,(J ,en ,a rY) "'" "".
'Notary Public
..C)'f"....v ,.ulJUQ
., f,ooI~ Wk"'{'~htd',i. ,'Ii, !'-;~~/'J
Exhihit lIAu
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Inventory of 1he reol and per~onQI C!io'ate of
L:i :J(l r~Jm hd:.U!;S
decoased.
_.__.~-,----- --. -. .- --- "-'".
__'_+M._'___"'_"__"" .-.-.....,...
1972 Opel AutolI"KJbile - sold DcCClnbcp 15, 1980
CI I JI"''"''6')11 fHl G 1:1- J" C "
lCCr~ 1t){..(..'1 - .u1C JO ldl 'j, O. ,Inc.
Check #00271j4 - SID CoPp., I'icstcm Slzzlin ~;tcal( Jlouse
r'CCOllllt 119-26280 - Fanner's 11'llst COl!~xmy, to clo:;c, iJCCOllllt
In:JIJrance )'efwld, 8utol1"KJbll e
InsurHnce Pollcy No. 58P574-J80
liatIonwide j'Jutual Insumnce Company
Cash, sale of bed (by Dane \'latson)
Cash, sale of toastep, camera, flatware, mJscel1nneous clothing
Kinney Shoe CopporatIon salary: Check j~o. 55195
Check No. 56031
Kinney Shoe COlj.loration Group Life Insumnce ppoc-ceds
State of Pennsy1 vania 1980 Tax Refund
Tot31
EXIIIBIT "F"
q' 500 00
,-
59 o~
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11 55
60 72
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II 35 00
11 20 :00
II 45 ,00
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il 90 '59
II 16 122
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COMMONWEALTH OF PEIHlSYLVANIA
COUNT\' OF CUMBERLAND
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55:
Dane L. I'iatson
being dulys\~or'l1 _ ilccording to low. depo,.' ilnd ,.,y. that he DaJ1e__L. .Viatson,.
_ _ __.P<3.r:>9!18.1peprC:,\CI)\;ative 01 the ",lote 01 .1.,-1.80. Ann Adallls_.____
late of ~~\1E~}_o.L Cr"r:.J.t."J..El_______ __ .,__._..-.-. .., Curnberl,,"d County. Pa., decea..d and that the
within i. an invenlory m.,de by Danc L. Hatson . -., the .aid personall'C:Pj,esentntivl'
01 theenti,e "tate of 'ilid deceden\' con';lling 01 ,,\I thr' perlo",,1 properly "nd real cllole. except r..1 ,,,late outlide "
the Commonwealth of Pennlylv,,,,;a, ond th"t Ihe 1;'Jure, oppel;te pach item of Ihe Inventory reprelent it'. I.,ir v"lu.
a. 01 the date of decedonl'. deolh.
2,\-J01"'I1
...,_._ and 5ub!lcribcd bdorc me, \
_19 ~\
- \
'CJ~9/;f~-
[,,,clllor . Adminhhalor
D:mc T" I'JfJ;son
JO~~G .~.(Iut.b ;'~est Str.'C!2t.
__---4jJJ..,~--.J-~~. ------..--
_____pdl1~--{L-?1'l~~------
:1i1ARON A. MOSER. Mol~l'1 Public
Callisle, PA. Clllnhcr1and CQuntv
My Commls5;nn l'piles .Jon, I'. 19B5
Cal'lis1e, FA 1'1013
..---.- .---~ ..-,.---...-- .~-_.__.- - . .
,L.ddre..
Dale 01 Death
e'2tc-bc:r
14
.1960
Year
l..lc.n\h
C^Y
I. An invenlory Illu.t be liled v. ithin th",e month. oller .-.pro'nlment 01 penor,al repcc,entoHve.
2. A supplement invenlory m'JIi be filed within Ihidy d yl ,,! .'i',,,, cry d ,.-(1dilion,1 ,;lsd..
'3. Additional 5~l;eh may b~ uti,jc'hcd <H i'o f'(,ncr",1iy or rc-alty
4. See Article IV, Fiduciarie. Act 011949.
Il,STRUCTIONS
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I Jacee LCCiU1l1 Adams
;_.________..___.~._____.u_ .. _._
IJENEFICIARI ES
-rREI.A~-IONS!t1P
TO O~CEDENT
.OClJEFICIAIlIES AND AIlDOfSSES
{Stiltu full n:lInl'S ;md nrlrlrll~~('!. 01 all who h~~'(' ;trl inlt!II'st
citlwl VI!",,'d, cUnlill(/l'tlt or olher inll'Hlotl
SUnVIVED
OECEDt:NT
STATE YES
on NO
INTEREST OF'
R!'NEFICIARY
IN [SlATE
AGE OF LIFE
TENANTS OR
ANflSUITAN1S
AT DEATH OF
nrCCOCNT
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