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REV-1737-1 EX + (9-00) .
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
MONUSIDIIIT DICIDIMI
AFfIDAVII OF DOMICIL.
This affidavit must be completed and sworn to by a person having personal knowledge of these
facts, preferably by a surviving spouse or member of the decedent's family.
Name of Decedent Date of Death
Richard W. Haldeman 07/16/2006
Legal Address at Time of Death:
Street Address
5203 17th Street
FL
Zip Code
33540
City/Borough
Zephyrhills
State
The following information is submitted in support of the statement that the above individual was
not domiciled in the Commonwealth of Pennsylvania at the date of death.
1. NIlIltI and addre.... of the decedent'. .urvlvlng .pouse and members of hlslher Immediate family:
Name and relationship to decedent
Janet Haldeman (spouse)
Street Address
5203 17th Street
Name and relationship to decedent
Jeffery T Haldeman (Son)
Street Address
555 Belle Rive Acres
Name and relationship to decedent
See Attached
Street Address
CitylBorough
Zephyrhills
State
FL
Zip Code
33540
City/Borough
St. Louis
Stete
MO
Zip Code
63121
CitylBorough
State
Zip Code
JiG Vel
o No
2. Did the dectdent ever live In Pennsylvania?
.lfye~,~urillg\Nt1~tJ)I~!iQd~?
1941-1976
3. Old the cIecedent.pend time InPennsJjVlnll'dul'lngthtftVtye.rI precedlngdllih? . Vel
Ify~~~..~~~~g.~~.!!e!ricl<l~.!~.l1,t...~~!..~~~~?........ .., .......... .
Decedent visited on various dates with his son and daughters who resided in Carlisle, PA.
o No
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C..:;J
=
.......,
" ,;;5,~ ~ f;:
4. What wa the n8tUn. of ctlc:8dellt'lI PJlIC4lllofmld81lte durinG the . fiV. yellrllimmtdlllttlypn.c.dlnGd8ath?.... ... ..... .... . .'" oj::; S . . .'" ... '
Indicate whether decede~t resided in a house or apartment and Whether it was rented or owned by the decedent, and/or wh!l~A@lident r~ed in ~
hotel or the home of !'8lati~ orfrklllds, ' ,-',
Decedent resided in residence which he owned in Zephyrhills, FlOrida.' ~3 (,:; :s
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Q
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""[:i"'yu"'" II No
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5. '~;s~st~*~;gl~~U~":I\1~~~~Sre~p~lng death?
m';i
o
\.0
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;-'-1
6. Old the decedent leave 1 will? II .. Vu 0 No
If yes, state the court which admitted the will to probate, the date admitted, and attach a copy, including all codicils, and a certificate of issuance of
1~!t~~t~"tl,I,Il1!II~!Y'" . .
Cumberland County Orphans' Court, Carlisle, PA
7 .ifthtdtctdellt'didlloti.av.a;jl~hIlIln"~;;;iniltr8fOrofhilHtlltta;;Illppoilltld?miJYuiJ "No ..... ........ ..... .. .... ....... .'. ..........
If yes! state the court. which appoint~.~ adl\1inistrat()r, the dat~of appointrnttnt!~lId ~chac:erti~teof thei~uanc:e of letters of administration.
m ".~...~ ,.~. ~
8. At Iny time during the list five years did the decedent execute a will, a codicil, trust Indenture, deed, mortgage, lease or any other document In which
the cIecedent was described as a r61dent of Pennsylvania? 0 Ves II No
If Y~~,~~~.~lIc11.. ~~ll1!lIt,
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NONRESIDENT AFFIDAVIT OF DOMICILE
ATTACHMENT TO ITEM 1
Additional family members and relationships
Michael R. Haldeman (Son), 901 Long's Gap Road, Carlisle, PA 17013
Molly J. Ressler (Daughter), 1009 Trindle Road, Carlisle, PA 17013
Julie A. March (Daughter), 5 Primrose Lane, Carlisle, PA 17015
.~ .
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NON.IIIDINT DICIDINT A..IDAVIT O' DOMICILI (continued) Page 2
9. Had the dtcedtnt paid . tax on Incom. or on Intanglbl. property to .ny .tate, county, or municipality during the Int five ye.rs?
If yes, where and when was it paid? C Yes .. No
10. To what regional office of the Intem.1 Revenue Service did the decedent forward his Federal Income Tax return. during the Int five years
preceding de.th?
Atlanta, GA
11. At the time of death, did the cltctdtnt own, Individually or jointly, any Interest In real property, Including Ie.ae-hold. or tangible personal property
located In Pennaytvanll? 1'1 Yea 0 No
If yes, describe the property in detail. .
51.5 acres in North Middleton Township, Cumberland County, PA, known as Tax Parcel No. 29-05-0427-139
.32 acres in South Middleton Township, Cumberland County, PA, known as Tax Parcel No. 40-22-0485-0228
12. In what buII"",lCtIvttI.. WII the dtctdent enaaaecI durl~ the lilt fIv. ye.ra preceding death?
Indicate whether decedent WIS employed or otherwTai engaged In buaineaa, and state the names and the addreaaes of the persons, firms or corporations
with which the decedent had auch business affiliations. ( Except for employer listed in #5 )
None, Decedent was retired.
13. What I. the tltlmated fIt'OII value of the cItc:edtnt'. estate, whtrtlOtVtl' situated, exclusive of re.l property and tangible property located outaIdt
of PennayIvanI.?
$ 205,405.80
14. At the time of cItath, did the dtctcItnt own or operate an .utomobft.?
If ves, in which state was it rtAistered? . .
Decedent owned,:tWo vehicles and both were registered in Florida.
15. At the time of death, WII the dtctdtnt. member of . church or any other organization? C
If yes, provide the name and address of the church or any other organization.
. Yes
o No
Ves. No
....
18. Stat. the purpose or re.son the decedent owned re.l property In Pennsylvania.
,
Decedent owned property in Pennsylvania, prior to his retirement to Florida. Continued to maintain property for
distribution to his children under the terms of his Will
17. Include any other Information you wI.h to .ubmlt In .upport oftht contention that the Individual was not domiciled In Penn.ylvanl. at the time
of death. If more space is needed. insert additional sheets of same size.
,.
Name of person completing allidavit
Ivo V. Otto III
Relationship to decedent
Attorney
Street Address
Carlisle
City
Carlisle
State
PA
Zip Code
17013
Under penalties of perjury, I declare that based on my personal knowledge of the decedent, the
info ation provided on this form Is true, correct and complete.
Signature of person pleting ffj Date
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