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Home My WebLink About01-0815 Estate of ROBERT E. HOLLER also known as N/A, Deceased. PETITION FOR PROBATE and GRANT LETTERS No. c2J - 0 J -? IS To: Social Security No. 726-10-1075 Register of Wills for the County of CUMBERLAND in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner, who is 18 years of age or older an the executRIX named in the last will of the above decedent, dated 2 March 2001 and codicil dated N/A. Decendent was domiciled at death in OAKLAND County, MICHIGAN, with his last family or principal residence at 29606 Moran Street, Farmington Hills, Michigan 48336. Decendent, then 69 years of age, died 11 March 2001 at Detroit, Michigan. Except as follows. decendent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: N/A/. Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County $ $ $8,000.00 Value of real estate in Pennsylvania situated as follows: none WHEREFORE. petitioner respectfully request the probate of the last will and codicil presented herewith and the grant of letters testamentary thereon. ~/U.J ~~ Barbara ( ~ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND The petitioner above-named swears or affirms that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner and that as personal representat:ve of the above decedent petitioner will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me this 2~th day of August 2001 'IY)r1JU1 c.,. 'r& 1t ~ /2J.-. PB.\) r'~ I Registe " r / 7 -'I - 10 ~ ':j(~ Barbara . ~~I~r i( 'I9f::r ~ ~ No. 21-01-815 Estate of ROBERT E. HOLLER, Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW AUGUST 31,2001 , 2001, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREEED that the instrument dated 03f4.02-2001 described therein be admitted to probate and filed of record as the last will of ROBERT E. HOLLER, Deceased, and Letters testamentary are hereby granted to BARB_~RA Y'! ~C?}-LER. K~ 'Fn,." &, e.. t I ,..;~ jft,.f};, ~ r'\ R gistef' of Will . FEES Probate, Letters, Etc. ..................$ 40.00 Short Certificates (5 ) ................$ 15.00 Renunciation ..............................$ :3 88 x-pages $ . JCP . 5 00 TOTAL_..$ 63.00 Filed............ h.Q~U~r.. .:U,( ~QQJ,...... ........ ............ Samuel L. Andes, Esquire Supreme Court 10 # 17225 525 North 12th Street Lemoyne, PA 17043 (717) 761-5361 20CC LF 629 ~' ~ 21-01-815 STATE OF MICHIGAN DEPARTMENT OF COMMUNITY HEALTH STATE FILE NUMBER CERTIFICATE OF DEATH 1890733 TYPE/PRINT IN PERMANENT BLAClI INK CF DECEDENT'S NAME (F"s!. M,ddle, Last) ROBERT E. IDLER DATE OF DEATH (Mont/!, Day, Year) March 11, 2001 4a AGE - Last BIrthday (Years) Oakland OF BIRTH (Mont/! Day, Year) OF DEATH 4c. UNDER I DAY HOURS I MINUTES I 68 May 22, 1932 70. LOCATION OF DEATH (Ente, place officially p,onounced dead in 70, 7b, 7c) HOSPtTAl OR OTHER INSTITUTION - Name (If not In e,thf>f. give street and number) Huron Valley Hospital 7b IF HOSP OR INST Inpat,.nl.. Op /Eme, Room. DOA (Spec,fy) Inpatient CITY, VILLAGE, OR TOWNSHIP OF DEATH Conmerce Twp. 8 SOCIAL SECURITY NUMBER 90. USUAL OCCUPATION (G,~ kind of work done during most of working life. Do not use retired) Architectural Engineer 9b KIND OF BUSINESS OR INDUSTRY 726-10-1075 Design Develo nt IOd STREET AND NUMBER z o ;:: OJ l- t; '1; ~~ ~z Oc ~o Uiii ~> O~ u..> 0"' '" ~~ ~~ lOa CURRENT RESIDENCE - lOb. COUNTY STATE ' 'lOc. LOCALITY (Check one box and sp<<'fy) Iil INSIDE CITY OR VILLAGE OF o TWP. OF Farmin ton Hills Nuran, 29606 Michian .' 10e ZIP CODE Oakland II BIRTHPLACE (C,ty and H State if {ore/In Country) arr~sDurg, Pennsylvania 12 MARITAL STATUS - Marroed. 13 SURVIVING SPOUSE Never Mamed. Widowed. (If wife. gIve name before 'lfsf marned) DIVorced (Specify) Married 14 WAS DECEDENT EVER IN US ARMED FORCES? (Specify Yes or No) 48336 Barbara K. Kennedy 17, DECEDENT'S EDUCATION (Specify only higt>est srade completed) Elementary /Secondary (0-12) College (1-4 Of 5 + ) Yes 15. ANCESTRY - MeXican, Puerto Rican, Cuban, Central or South American, Chicano. other Hispanic, Afro-American. Arab, English. F,ench, FInnish. etc. (Specify below) German 16 RACE - American Indian, Black, WhIte, etc If ASian, give nationality I.e., Chinese, FIlipino, ASian Indian, etc (Specify below) White 1 18 FATHER'S NAME (F,,'t. MIddle, Last) 19 MOTHER'S NAME (Flfsf. Middle. Surname before Ilfsf mamed) Albert Holler Pearl G. Roush I' . 20a. INFORMANT'S NAME (Type/Print) Barbara K. Holler 20b. MAILING ADDRESS (Street and Number or Rural Route Number, City or Village, State, lIP Code) .D. 4 Box 120 Newport, Penns Ivania 17074 220. PLACE OF DISPOSITION (Mune of Cemetery. Crematory, 22b. LOCATION - CIty 0' VIllage, State or other place) 21. METHOD OF DISPOSITION - Bu,ial, C,emation, Removal. Donahon. Other (specify) Removal I Burial ,~N_ewpot:t Penns lvania New crt Cemeter LICENSEE 24. LICENSE NUMBER (of Licensee) 25 NAME AND ADDRESS OF FACILITY David M. Myers Funeral Home Second & Walnut St., Newport, PA 17074 006916 PART I. Enter the diseases, InJunes. or complications that caused the death Do NOT enter the mode of dYing. such as cardIac or respiratory arrest. shock, or heart failure. list only one cause on each hne. - I f,ft~~~=:m:~~ween I Onset and Death I JH(}J", I I I I I IMMEDIATE CAUSE (Fonal dlsease or condition ~ resulting In death) ~V\C/\.R.a.....J"i L. ~c.etV DUE TO (OR AS A CONSEQUENCE OF) Sequentially hst conditions. { ~ leading to Immediate ~nter UNDERLYING CAUSE (Dtsease or Injury that Initiated events resultmg tn death) lAST d. PART II, Other slgnlhcant conditIons contnbutlng to death 27b WERE AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETION OF CAUSE OF DEATH? (Yes Of NO) DUE TO (OR AS A CONSEQUENCE OF). DUE TO (OR AS A CONSEQUENCE OF) 27. WAS AN AUTOPSY PERFORMED? (Yes or No) but not resultmg In the underlymg cause given In Part t No 28 ACTUAL PLACE OF DEATH (Home. NurSIng ,.~ome. ij01P't~ Ambulance) (Specify) ttOSp1LaJ. 31;Check 0 ~~~) 0 29. WAS CASE REFERRED TO MEDICAL EXAMINE~8peCdY Yes or No) The case reviewed and determined not to be a medical examiner's case. On the basis of examination and of investigation, '" my optrllon death occurred at the time, date and place and due to the cause(s) and manner stated. "z '1;", ~Q i=~ ~&: ~a: c'" UZ B:i "'c :;~ 31d PRONOUNCED DEAD (Mo, D.y Yr) 31e TIME OF DEATH ON (s" f14Jtvrt and TItle) ~ 31b DATE SIGNED (Mo. Day. Yr) 31c CASE NUMBER 2:. - /':2. - O} 12:25 AM 30e NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Prrnt) 32a NAME AND ADDRESS OF PERSON WHO, COMPLETED CAUSE OF DEATH (ITEM 26) (Type or Print) 48334 ton Hills MI 32b LICENSE NUMBER 4301'<075S'l TIME OF INJURY 33d DESCRIBE HOW INJURY OCCURRED M 33g LOCATION - SI'eel 0' R F 0 No City, Village Ot Twp DCH - 0483 10/98 (Formerly 8-36) JUSTIBE REID 34b. DATE FILED (Month, Day, Year) HAllCH 15. 2001 STATE OF MICHIGAN "\. S8 COUNTY OF OAKLAND j . . I, G.' William Cnddell, County Clerk for the County of Oakland, Clerk of the Circuit Court thereof, the same being a court of Record, and having a Seal, do. hereby certify that the .foregoing is a copy of the record now remaining in my ,office. this , In Testimony, Whereof, 15TH day of I have hereunto set' my hand and affixed the seal of said Court MARCH , A.D. 2001 G. WILLIAM CADDELL,-County Clerk-Register of Deeds By, gf~ ~J D'epu,", Clerk C-51 (II.98l M State ,." ~ LAST WILL AND TESTAMENT OF ROBERT E. HOLLER I, ROBERT E. HOLLER, of the City of Farmington Hills, County of Oakland, and State of Michigan, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore by me made. FIRST: I direct that all of my just debts enforceable against me during my lifetime and duly allowed in the administration of my estate, the expenses of my last illness and funeral, including the cost of a suitable monument at my grave, the costs of administration of my estate, together with all of the estate, inheritance, succession or similar taxes which shall become payable in respect of any property or interest therein which I may own at the time of my death, and which is properly includable in my gross estate for any such taxation purposes, shall be charged to and paid from my residuary estate. My Personal Representative shall not seek recovery or reimbl,Jrsement from or apportionment between or among the recipients of any such property or interest. SECOND: I give and bequeath to my wife, BARBARA K. HOLLER, all of my estate, of which I may die seized or possessed or to which I or my estate may then or thereafter be in any way entitled, real, personal or mixed, and wheresoever situated, including all property over which I may have a power of appointment. If my wife, BARBARA K. HOLLER, does not survive me by thirty (30) days, then I give and bequeath to my daughter, SHARON K. TOMPFORD, all of my estate, of which I may die seized or possessed or to which I or my estate may then or thereafter be in any way entitled, real, personal or mixed, and wheresoever situated, including all property over which I may have a power of appointment. THIRD: The principle of my estate and the income resulting therefrom, while in the hands of my Personal Representative, shall not be subject to any conveyance, transfer or assignment or be pledged as security for any debt of any beneficiary thereof and shall not be subject to any claim of any creditor of any such beneficiary through legal process or otherwise. Any attempted sale, anticipation, assignment or pledge of any of the principle income held in the estate by such beneficiaries or any of them shall be null and void, and shall not be recognized by my Personal Representative. It is my intention to place the absolute title to the property held in my estate and the income therefrom in my Personal Representative, with power and authority to payout the same only as authorized hereby. FOURTH: I am well aware that I have made no bequest herein for the benefit of my sister, ELGIE HALL, for the reason that she is well able to take care of herself. c:> ~~... en ::;~ L.0 .c- .:::- # , ~.. . l' FIFTH: I hereby nominate and appoint my wife, BARBARA K. HOLLER, of Newport, Pennsylvania, Personal Representative of this my Last Will and Testament. In the event that my wife, BARBARA K. HOLLER, is unable or unwilling to serve as my Personal Representative, then I nominate and appoint my daughter, SHARON K. TOMPFORD, my Personal Representative of this my Last Will and Testament. No Personal Representative shall give bond unless required by law or court rule. I, ROBERT E. HOLLER, the testator, sign my name to this document on March 2, 2001. I have taken an oath, administered by the officer whose signature and seal appear on this document, swearing that the statements in this document are true. I declare to that officer that this document is my will; that I sign it willingly, that I execute it as my voluntary act for the purposes expressed in this will; and that I am 18 years of age or older, of sound mind, and under no constraint or undue influence. &fC3~ ROBERT E. HOLLER We, Allan W. Ben and Williamtl. Scarlet, the witnesses, sign our names to this document and have taken an oath, administered by the officer whose signature and seal appear on this document, to swear that all of the following statements are true: the individual signing this document as the testator executes the document as his will, signs it willingly, and executes it as his voluntary act for the purposes expressed in this will; each of us, in the testator's presence, signs this will as witness to the testator's signing; and to the best of our knowledge, the testator is 18 years of age or 01 e , sound mind, and under no constraint or undue influence. (J,1/IJ '. Allan W. Ben '~~~hL~ William" Scarlet STATE OF MICHIGAN ) ) SS. COUNTY OF OAKLAND ) Sworn to and signed in my presence by Robert E. Holler, the testator, and sworn to and signed in my presence by Allan W. Ben and Williamf;;J. 'Scarlet, witnesses, on March 2, 2001. C:\clients\holler\last will and testament2.wpd Subscribed and sworn to before ~~ d~arch, 2001. - ~~- JAMIE A. BACHMANN, NOTARY PUBLIC MACOMB COUNTY, MI Acting in Oakland County, MI My commission expires: 11/27/01 .. e: --- CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Robert E. Holler Date of Death: 11 March 2001 Will No. Admin. No. 21-01-0815 To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on 11 October 2001 . Name Address Barbara K. Holler R.D. 4, Box 120 Newport, PA 17074 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Date: ~~~ Attorney-at-Law 525 North 12th Street Lemoyne, PA 17043 (717) 761-5361 Counsel for personal representative ~ .. NOTICE OF BENEFICIAL INTEREST IN ESTATE BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, CARLISLE, PA IN RE: Estate of Robert E. Holler, deceased Estate No.: 21-01-0815 TO: Mrs. Barbara A. Holler R.D. 4, Box 120 Newport, PA 17074 Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. You may have a beneficial interest in the estate as follows: Name of Decedent: Robert E. Holler Last Known Address of Decedent: 29606 Moran Street, Farmington Hills, MI 48336 Date of Death: 3/11/01 Place of Death: Oakland County, Michigan Count of grant of original letters: Cumberland County, Pennsylvania Decedent died ~ testate intestate A copy of the will is Lis not attached. Names, addresses, and telephone numbers of all personal representatives appointed: Barbara A. Holler, R.D. 4, Box 120, Newport, PA 17074 Name, address and telephone number of all counsel: Samuel L. Andes, 525 N. 12th Street, Lemoyne, PA 17043 (717) 761-5361 Additional information may be obtained from the undersigned: Date: /Df,/ t>/ ~~ Sa el L. Andes Attorney-at-Law 525 North 12th Street Lemoyne, PA 17043 (717) 761-5361 Counsel for personal representative .. e;v- Name of Decedent: STATUS REPORT UNDER RULE 6.12 f<ob~ E, Holt, 3 IIl/ol , Date of Death: Will No.: Admin. No.: ;2D'DI- (Jo8 / ~ Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State. whether administration of the estate is complete: Yes.~ No 0 2. Ifthe answer is No, state when the personal representative reasonably believes that the administration will be complete: tv / It , 3. Ifthe answer to No.1 is Yes, state the following: a. Did the personal ~esentative file a final account with the Court? Yes _ No M b. The separate Orphans' Court No. (if any) for the personal representative's account is: ~ c. Did the personal~resentative state an account informally to the parties in interest? Y es ~ No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and maybe attached to thiS.~ ~ Date:~2/(]3 __~ Sl . e SA fY\ Vl a L. A f'-J De J Name 52-S tV ( 2.. 1i-.. S~ Le r>A 1:J'1 fJe. PA nOil Address "111 ,\.. ( 5 JbJ Telephone No. Capacity: 0 Personal Representative ~ Counsel for personal representative ; . Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 Date: 2/07/2003 HOLLER BARBARA K R.D.4 BOX 120 NEWPORT, PA 17074 RE: Estate of HOLLER ROBERT E File Number: 2001-00815 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July I, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 3/11/2003 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, DONNA M. OTTO DEPUTY REGISTER OF WILLS cc: ;!File Counsel Judge BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX OIVISION PO BOX 280601 HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRkl.s~IiNT. ALLOWANCE OR DISALLOWANCE OF -DEDUCTIONS AND ASSESSMENT OF TAX '* REV-1547 EX AFP (06-05) DATE 02-19-2007 ESTATE OF HOLLER ROBERT E DATE OF DEATH 03-11-2001 FILE NUMBER 21 01-0815 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 04-20-2007 ( See reverse side under Objections) Amount Remittedl I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WIllS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS +- ------------------------------------------------------------------------------------------- REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HOLLER ROBERT E FILE NO. 21 01-0815 ACN 101 DATE 02-19-2007 """"] ,... ~ UU !- f.B 23 PH !: I 5 SAMUEL l ANDES 525 N 12TH ST LEMOYNE OF,C Ct'. PA 17043 TAX RETURN WAS: ) ACCEPTED AS FILED x) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule DJ 5. Cash/Bank Deposits/Misc. Personal Property (Schedule EJ 6. Jointly Owned Property (Schedule FJ 7. Transfers (Schedule GJ (lJ (2J (3) (4) (5) (6J (7J .00 .00 .00 .00 .00 .00 .00 (8) NOTE: To insure proper credit to your account. submit the upper portion of this form with your tax payment. 8. Total Assets .00 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule HJ 10. Debts/Mortgage Liabilities/Liens (Schedule IJ 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) .00 .00 (llJ (l2J (l3J (14) .00 .00 .00 .00 NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, lS and 19 will reflect figures that include the total of Ab.b. returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (l5J .00 X 00 .00 16. Amount of Line 14 taxable at Lineal/Class A rate (l6J .00 X 045 = .00 17. Amount of Line 14 at Sibling rate (l7J .00 X 12 .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 .00 19. Principal Tax Due (19)= .00 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-J TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1. NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU MAY BE DUE _ ) A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) ~~ . .. REV-1470 EX (6-8&) . '* INHERITANCE TAX EXPLANATION OF CHANGES COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG PA 17128-0601 DECEDENTS NAME ROBERT HOLLER FILE NUMBER Department of Revenue I TERESA SEIDERS ACN 2101-0815 101 REVIEWED BY ITEM SCHEDULE NO. EXPLANATION OF CHANGES Efforts to file an Inheritance tax return have been exhausted in the above referenced estate. Therefore, the filing requirements have been waived. The Department however, reserves the right to assess any assets that may be recovered at a future time. ROW Paqe 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX ~P~,SfMIiNT, ALLOWANCE OR DISALLOWANCE g~ DEDUCTIONS AND ASSESSMENT OF TAX *' DATE 02-19-2007 ESTATE OF HOLLER ROBERT E DATE OF DEATH 03-11-2001 FILE NUMBER 21 01-0815 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 04-20-2007 ( See reverse side under Objections) Amount Remittedl I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS +-- REY:is47-EX-AFP-C03:0Sj-NOTicE-OF-iNHERiTANCE-TAX-APPRAisEMENT:-ALLOWANCE-OR--------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HOLLER ROBERT E FILE NO. 21 01-0815 ACN 101 DATE 02-19-2007 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 2B0601 HARRISBURG PA 17128-0601 ~ ,~ -)- - zaD7 FES 23 pr! I: /5 SAMUEL LANDES 525 N 12TH ST LEMOYNE (:i P:'11.I'< n,C: , ~-' ., \.jj GPD /"'"'' .'_. '1"..-1 cu," .', ... ,', PA 17043 REV-1547 EX AFP (06-05) TAX RETURN WAS: ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. 3. 4. 5. 6. 7. S. Stocks and Bonds (Schedule B) (ll (2) (3) (4) (S) (6) (7) .00 .00 .00 .00 .00 .00 .00 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. Closely Held Stock/Partnership Interest (Schedule C) Mortgages/Notes Receivable (Schedule D) Cash/Bank Deposits/Misc. Personal Property (Schedule E) Jointly Owned Property (Schedule F) Transfers (Schedule G) Total Assets .00 (S) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax .00 .00 (ll) (l2) (l3) (l4) (9) (l0) .00 .00 .00 .00 NOTE: If an assessment was issued previouslY, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of 6ll. returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (lS) .00 X 00 .00 16. Amount of Line 14 taxable at Lineal/Class A rate (l6) .00 X 045 = .00 17. Amount of Line 14 at Sibling rate (l7) .00 X 12 = .00 IS. Amount of Line 14 taxable at Collateral/Class B rate (lS) .00 X 15 = .00 19. Principal Tax Due (l9)= .00 TAX CR~DITS: l'AYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) ~ REV-1470 EX (6-88) '* INHERITANCE TAX EXPLANATION OF CHANGES COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG PA 17128-0601 DECEDENT'S NAME ROBERT HOLLER FILE NUMBER Department of Revenue I TERESA SEIDERS ACN 2101-0815 101 REVIEWED BY ITEM SCHEDULE NO. EXPLANATION OF CHANGES Efforts to file an Inheritance tax return have been exhausted in the above referenced estate. Therefore, the filing requirements have been waived. The Department however, reserves the right to assess any assets that may be recovered at a future time. ROW PaQe 1