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HomeMy WebLinkAbout10-26-07 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA. ORPHANS' COURT DIVISION FILE NO. 21-06-0420 FIRST AND FINAL ACCOUNT OF ALBERTA LOUISE COOK, a.k.a. ALBERTA L. COOK, Executrix For ESTATE OF ROY EARLE COOK, a.k.a. ROY E. COOK Date of Death: Date ofIncapacity, if any: Date of Executor's Appointment: Date of First Complete Advertisement: Accounting for the period: 5/9/2006 None 5/16/2006 7/7/2006 5/16/06 7/30/07 PURPOSE OF ACCOUNT: The Executrix offers this Account to acquaint interested parties with the transactions that have occurred during the Administration. It is important that the Account be carefully examined. Requests for additional information, questions or objections can be discussed with: Charles E. Shields III 6 Clouser Road Mechanicsburg, Pennsylvania 17055 Phone Number: (717) 766-0209 Supreme Court I.D. No. 38513 f"'-.'} ,. -.~ " .. J (- ", " -1 r') (~~ " . I r,) \.D 1 4 SUMMARY OF ACCOUNT PRINCIP AL RECEIPTS PAGES Real Estate 3 $ 0.00 Common Stocks 3 0.00 Personal Effects (Business - Sole Proprietor) 3-4 2,355.00 Bank Accounts 4 14,267.41 Commission Payments 4-5 16.919.74 $ 33,542.15 Less Disbursements: Administration Expenses 6-7 $ 3,726.28 Fees and Commissions 7 6,797.22 Family Exemption 7 3,500.00 Funeral Expenses 7 9,645.33 Payments Prior to DOD 7 3.221.37 Sub- Total Disbursements 7 $ 26,890.20 INCOME Receipts of Income 8-9 $ 597.80 Less Disbursements 9 $ -0- Income Balance on Hand 9 $ 597.80 COMBINED BALANCE ON HAND 9 $ 7,249.75 Debts of Decedent / Proposed Distribution $88,511.04 $ 7,249.75 BALANCE AFTER PAYMENT OF APPORTIONED NON-PRIORITY DEBTS $ -0- 2 PRINCIP AL RECEIPTS Real Estate None Common Stocks None $ 0.00 $ 0.00 Personal Effects (BUSINESS RELATED PERSONALTY OWNED BY DECEDENT AS SOLE PROPRIETOR OF AN INSURANCE OFFICE) (* INFORMATIONAL NOTE: The figures below are updated and slightly different from those originally reported on the Inheritance Tax Return in that they include additional after discovered items and reflect price adjustments for items which have since actually been sold on the open market.) Business Computer sold to Linda Willis Metal Desk with Simulated Walnut Top 2nd Metal Desk with Simulated Walnut Top Gray Metal Desk Four (4) Small Metal "Duty Desks" @ $20.00 each Old Gray Metal Desk Metal Conference Table, Simulated Walnut Top Office Table, Simulated Walnut Top Old 5 - Drawer Metal Filing Cabinet Four (4) Old 6-Drawer Metal Filing Cabinets @ $35.00 each Two (2) 4-Drawer Metal Filing Cabinets @ $30.00 each Two (2) 2-Drawer Metal Filing cabinets @ $15.00 each 2 Drawer Metal Filing Cabinet Old 4-Drawer Metal Filing Cabinet Old Black Leather Swivel Chair Old Brown Leather Swivel Chair Old Leather Swivel Chair Two (2) Small Chairs with Green Leather seat - sold to Liberty Tax Fifteen (15) Peach Colored Straight Back Chairs sold to Liberty Tax Gray Metal Copier Cabinet Printer Stand / Cabinet Printer Stand on Wheels Small Folding Table on Wheels Metal Computer Desk 3 $ 360.00 $ 60.00 $ 60.00 $ 50.00 $ 80.00 $ 25.00 $ 35.00 $ 15.00 $ 20.00 $ 140.00 $ 60.00 $ 30.00 $ 15.00 $ 10.00 $ 50.00 $ 25.00 $ 10.00 $ 15.00 $ 100.00 $ 25.00 $ 25.00 $ 15.00 $ 10.00 $ 25.00 -- I Index Card Cabinet Three (3) Metal Filing Cabinets Sold to Boyd Myers Desk and Water Cooler Sold to Andrew Devitt Desk and Index Filing Cabinet sold to Mr. Drumheiser Computer sold to Mr. Drumheiser Merlin phone system sold to Liberty Tax Two (2) Computers @ $150 each Monitor and printer sold to John Andrews Old copier Gunk value) Old fax machine Gunk value) $ 20.00 $ 100.00 $ 50.00 $ 100.00 $ 150.00 $ 250.00 $ 300.00 $ 125.00 $ -0- $ -0- $ 2,355.00 BANK ACCOUNTS PNC Bank Account #50-7002-7084 (sub nom. Roy E. Cook Associates, Diversified Enterprises, Sole Proprietorship) $ 7,535.81 PNC Bank Account #50-0429-0466 (sub nom. Roy E. Cook D/B/A Roy E. Cook Associates, Sole Proprietorship) $ 2,930.03 Interest Accrued thereon to D.O.D. $ 1.99 PNC Bank Account #50-0353-5679 (sub nom. Roy E. Cook Agency, Insurance, Notary and Investment Services, Sole Proprietorship) Adjusted balance after automatic deduction and transfer of premiums from account per standard and automatic operating procedure of this reservoir / fiduciary account.) $ 3,570.85 Escrowed funds from Premium Account now available $ 228.73 $ 14,267.41 INFORMATIONAL NOTE: Decedent maintained another account at PNC Bank Account # 50-0353-5695 (sub nom. "Roy E. Cook Associates, Nationwide Escrow Account" was an escrow account in which premiums paid on insurance policies were deposited and were then swept out by Nationwide Insurance Company. Decedent had no ownership interest in these funds). COMMISSION PAYMENTS Nationwide Insurance Co. Commission Payment Nationwide Insurance Co. Commission Payment Nationwide Insurance Co. Commission Payment Nationwide Insurance Co. Commission Payment Nationwide Insurance Co. Commission Payment $ 7,236.05 $ 8,166.72 $ 90.15 $ 228.30 $ 51.45 4 i - Nationwide Insurance Co. Commission Payment ACH CREDIT PAYROLL/COMMISSIONS PAYMENTS ACH Credit Payroll Assurity Life Insurance 126 H-I $ Corporate ACH Commission $ ACH Credit Payroll Assurity Life Insurance 126 H - 1. $ ACH Credit Payroll Assurity Life Insurance 126 H - I $ ACH Credit Payroll Assurity Life Insurance 126 H - I $ ACH Credit Commission: CHCS (Nationwide Life Insurance) $ ACH Credit Payroll Assurity Life Insurance 126 H - I $ ACH Credit Payroll Assurity Life Insurance 126 H - I $ ACH Credit Payroll Assurity Life Insurance 126 H - I $ ACH Credit Payroll Assurity Life Insurance 126 H - I $ ACH Credit Commission Payment Chcs Svcs FBO Na. 95215R $ ACH Credit Payroll Assurity Life Insurance 126 H - I $ $ MISCELLANEOUS REFUNDS. COMMISSIONS AND CREDITS: Refund for Pitney Bowes Machine $ Refund for negative balance/Chase VISA $ Refund for REC Health Insur./Capital Blue Cross $ Refund for REC Prescription Plan/Capital Blue Cross $ Refund from Chase (negative credit card balance) $ Refund for REC cell phone overpayment/V erizon Wireless $ Mobile - REC Commission $ $ TOTAL PRINCIPAL RECEIPTS 5 $ 306.38 $ 16,079.05 11.87 50.71 51.73 6.83 7.75 31.43 5.27 2.89 19.52 2.84 33.74 3.07 227.65 172.02 16.74 178.28 114.00 28.08 56.22 47.70 613.04 $ 33,542.15 DISBURSEMENTS OF PRINCIPAL INFORMATIONAL NOTE: ESTATE IS INSOLVENT. FOR CONVENIENCE OF YOUR HONORABLE COURT AND CREDITORS, DISBURSEMENTS ARE SET FORTH HEREINBELOW ACCORDING TO LEGAL PRIORITIES OF PAYMENT, AS FOLLOWS: COSTS OF ADMINISTRATION GENERAL: Probate fees and original issue of short certificates Additional probate fees Filing Fee to Register of Wills for Inheritance Tax Return Filing Fee for Accounting with Orphans' Court Photocopies, certified mailings to creditors, etc. (estim.) Advertising in Cumberland Law Journal Advertising in Carlisle Sentinel Additional Short Certificates COSTS OF ADMINISTRATION IN CONNECTION WITH WINDING UP OF SOLE PROPRIETORSHIP BUSINESS: Balance owed from Commission Funds to John Andrews, Sub-Agent for commissions earned within 6 mos. ofD.O.D. and for work in connection with winding up of business Pitney Bowes - supplies for postage meter (ink cartridge) Secure RX - Prescription Plan Premium for Employees AT&T, telephone and fax bills PNC Bank Account Service Charge PNC Bank Account, Line of Credit for Business, Interest Executive Image Solutions, Copier toner cartridge Park Financial Services - Accounting, bookkeeping aid AT&T, Telephone and fax bills PNC Bank Account Service Charge Verizon Computer modem costs AT&T, Telephone and fax bills Verizon Computer modem costs PNC Bank Account, Line of Credit for Business, Interest Park Financial Services, Accounting, bookkeeping aid AT&T, Telephone and fax bills Verizon Computer Modem costs PNC Bank Account Line of Credit for Business, Interest Tri-State Shredding Corp. - Shredding files for disposal 6 $ $ $ $ $ $ $ $ $ 84.00 90.00 15.00 130.00 62.50 75.00 107.99 8.00 572.49 $ 859.09 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 56.69 342.00 309.32 5.00 123.96 74.20 45.00 50.35 5.00 3.47 222.72 16.17 131.75 64.00 216.35 14.83 126.68 83.52 AT&T, Telephone and fax bills PNC Bank Account, Line of Credit for Business, Interest Verizon Computer Modem costs Stop Payment on check charge for lost check to M&T FEES AND COMMISSIONS Alberta L. Cook, Executrix Charles E. Shields III, attorney's fees Robert Park, Park Financial Services, Accountant F AMIL Y EXEMPTION Family Exemption claimed by decedent's widow, Alberta L. Cook FUNERAL EXPENSES AND MEDICAL SERVICE EXPENSES WITHIN SIX (6) MONTHS OF DEATH Myers Funeral Home of Mechanicsburg Funeral Luncheon at Masonic Lodge Hall, Food obtained from Giant Supermarket Paper Cups, Plates, Coffee, etc., from B.J's for funeral meal West Shore Ambulance Services PAYMENTS MADE BY DECEDENT BEFORE D.O.D. WHICH CLEARED PAYMENT FROM PNC ACCOUNTS AFTER D.O.D. PNC Bank - Business Line of Credit - Interest Expense Diner's Club Card - Business Ritters' Hardware - Supplies Park Financial Services - April Payroll and Quarterly Tax PPL - Electric for offices Susquehanna Oil $ 217.95 $ 139.77 $ 14.97 $ 31.00 $ 3,153.79 $ 2,547.22 $ 3,750.00 $ 500.00 $ 6,797.22 $ 3.500.00 $ 3,500.00 $ 8,705.70 $ 228.84 $ 23.05 $ 687.74 $ 9,645.33 $ 123.11 $ 1,654.01 $ 83.41 $ 210.00 $ 250.34 $ 900.50 $ 3,221.37 SUBTOTAL OF ALL PRIORITY AND PRE-DEATH PAYMENTS $ 26,890.20 7 RECEIPTS OF INCOME * INFORMATIONAL NOTE: Unless otherwise noted the income figures hereinbelow reflect automatic tax withholding at the source of payment or by the Executrix at the rate of 29.52% upon advice of her Tax Accountant to provide for taxes due on the income to the I.R.S., Commonwealth of Pennsylvania, etc. Deposits of Income in the form of Refunds or Commissions credited to PNC Account No. 50-7002-7084 February 2007 - Flood Insurance Commissions July 2007 - Commonwealth of Pennsylvania Tax Refund Deposits of Interest to PNC Account No. 50-0429-0466 May June July August September October November December January February March April May June July 2006 2006 2006 2006 2006 2006 2006 2006 2007 2007 2007 2007 2007 2007 2007 Interest earned on Estate Checking Account No. 50-0487-6504 at PNC: July August September October November December 2006 2006 2006 2006 2006 2006 8 $ $ $ 108.15 20.44 128.59 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 2.31 3.91 4.37 4.39 2.96 2.86 2.68 2.59 2.96 2.50 2.64 2.73 2.73 2.55 2.82 45.00 $ $ $ $ $ $ $ 0.71 2.23 3.62 2.82 0.56 0.45 10.39 Additional Miscellaneous Items of Income: December 2006 VFIS Insurance Co. Commissions and/or Refunds for overpayment of premium 2007 Refund from American Express Travel 2006 through July 2007 Additional Sales Commissions January October TOTAL RECEIPTS OF INCOME DISBURSEMENTS OF INCOME RECAPITULATION PRINCIPAL BALANCE DISBURSEMENTS FROM PRINCIPAL BALANCE OF PRINCIPAL ON HAND INCOME BALANCE ON HAND COMBINED BALANCE ON HAND 9 $ 190.30 $ 26.68 $ 196.84 $ 413.82 $ 597.80 $ -0- $ 33,542.15 $ 26,890.20 $ 6,651.95 $ 597.80 $ 7,249.75 CLAIMS OF PRIVATE NON-GOVERNMENTAL AND NON-SECURED CRREDITORS FOR DEBTS OF DECEDENT [These are to be paid at the rate of $0.081908 on the dollar. This is based on the percentage of funds left versus face amount of these debts which follow. The face amounts are given in the first column and the proposed payment amounts are given in the second column in brackets.] PNC Bank - Single name Credit Line $17,123.11 [$ 1,402.51 ] $14,571.31 [$ 1,193.50] $32,000.00 [$ 2,621.06] $21,052.62 [$ 1,724.38] $ 3,764.00 [$ 308.30] $88,511.04 [$ 7,249.75] Chase Manhattan Bank Chase Bank USA Citi-Bank, South Dakota, N.A. Diner's Club International TOTAL CLAIMS / PROPOSED DISTRIBUTION ~L/~'r~:7; ~EAL) AL ERT A LOUIS COOK, x~tor of the Will of Roy Earle Cook, a.ka. Roy E. Cook, Deceased ~/~ a.k.a. ALBERTA L. COOK (SEAL) 10 VERIFICATION ALBERTA LOUISE COOK, a.k.a. ALBERTA L. COOK, Executrix of the Will of Roy Earle Cook, a.k.a. Roy E. Cook, deceased, hereby declares under oath that she has fully and faithfully discharged the duties of her office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the Estate have been paid in full; that, to her knowledge, there are no claims outstanding against the Estate; that all taxes presently due from the Estate have been paid; and that the grant of Letters Testamentary and the first complete advertisement thereof occurred more than four months before the filing of the foregoing First and Final Account. This statement is made subject to penalties of 18 Pa. C.S.A. Section 4904 relating to unsworn falsification to authorities. ~ c1f'~~I) ALBERTA LOUISE COOK ~/~ a.k.a. ALBERTA L. COOK (Seal) Dated: /,,/z,~/~ r , , 11 DECEDENT'S ESTATE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS' COURT DIVISION ESTATE OF Roy Earle Cook, a.k.a. Roy E. Cook , DECEASED No. 21-06-0420 PETITION FOR ADJUDICATION / STATEMENT OF PROPOSED DISTRIBUTION PURSUANT TO Pa. O.C. Rule 6.9 This form may be used in all cases involving the Audit of the Account of a Decedent's Estate. If space is insufficient, riders may be attached Attach the spouse's election, if any; the papers required under items 8-19 inclusive; and any instrument pertinent to the adjudication. .--....., C C) -.j INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM. . --'\ h' e., , I Name of Counsel: Charles E. Shields, III c..) a , ; Supreme Court I.D. No.: 38513 Name of Law Firm: 6 Clouser Road Address: Telephone: Fax: (717) 766-0209 (717) 795-7473 Form OC-OJ rev. JO.13.06 Page 1 of 10 , Estate of Roy Earle Cook, a.k.a. Roy E. Cook , Deceased 1. Name(s) and addressees) ofPetitioner(s): Name: Alberta L. Cook Address: 109 Winston Drive Mechanicsburg, PA 17055 Identify any executors or administrators who have not joined in the Petition for Adjudication and Statement of Proposed Distribution and state reason: Is this the first accounting by this fiduciary? . . . . . . . . . . . . . . . . . . . . . IZI Yes 0 No If not, identify prior accountings, the accounting periods covered, and the date of adjudication of the prior accounting. 2. Decedent died on May 9, 2006 IZI Letters Testamentary or DLetters of Administration were granted to Petitioner(s) on Mav 16. 2006 Date of Will (if applicable): March 10, 2005 Date(s) ofCodicil(s) (if applicable): N/A Date of probate (if different from date Letters granted): Same Was a bond required? oY es IZI No If yes, state amount: Are proofs of advertising of the grant of Letters attached? ......... 0 Yes IZI No Dates of advertising ofthe grant of Letters: Cumberland Law Journal: June 23,30 and July 7, 2006; Carlisle Sentinel: June 14,21 and 28, 2006 Form OC-OJ rev. JO.13.06 Page 2 of 10 Estate of Roy Earle Cook, aka. Roy E. Cook , Deceased 3. Was decedent survived by a spouse? . . . . . . . . . . . . . . . . . . . . . . . . . . . " IZIYes D No If yes, name of the surviving spouse: Alberta L. Cook 4. Has the surviving spouse filed to take an elective share? ............ . DYes IZI No (See Section 2201 et seq. of the Probate, Estates and Fiduciaries Code) If yes, date of election: 5. In the case of an intestacy, state the names of the decedent's surviving children or surviving issue of deceased children (if none, so state): N/A 6. Did decedent marry after execution of Will or Codicil(s)? . . . . . . . . . " DYes IZI No Were any children born to decedent after execution of Will or Codicil(s)? . . .. . . .. .. . ... " .. . . .. ... .. . . ... . .. .. .. .. . . DYes IZI No If yes, give names and dates of birth: Name: Date of Birth: 7. If required by the Medical Assistance Estate Recovery Act, 62 P.S. ~ 1412, was a request for a statement of claim sent to the Department of Public Welfare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. IZIYes D No Form DC-OJ rev. JO.13.06 Page 3 of! 0 Estate of Roy Earle Cook, aka. Roy E. Cook , Deceased 8. Written notice ofthe Audit as required by Pa. a.c. Rules 6.3, 6.7 and 6.8 has been or will be given to all parties in interest listed in item 9 below, all unpaid creditors and all claimants listed in item 10 below. In addition, notice of any questions requiring Adjudication as discussed in item 14 below has been or will be given to all persons affected thereby. A. If Notice has been given, attach a copy of the Notice as well as a list of the names and addresses ofthe parties receiving such Notice. B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice shall be submitted at the Audit together with a statement executed by a Petitioner or counsel certifying that such notice has been given. C. Ifany person entitled to Notice is not suijuris (e.g., minors or incapacitated persons), Notice of the Audit has been or will be given to the appropriate representative on such party's behalf as required by Pa. a.c. Rule 5.2. D. If any charitable interest is involved, Notice of the Audit has been or will also be given to the Attorney General as required under Pa. a.c. Rule 5.5. In addition, the Attorney General's clearance certificate (or proof of service of Notice and a copy of such Notice) must be submitted herewith or at the Audit. 9. List all parties (charitable and non-charitable) of whom Petitioner(s) haslhave notice or knowledge, having or claiming any interest in the estate as beneficiaries under the Will or Codicil(s) or as intestate heirs ifthere is a complete or partial intestacy: A. State each party's relationship to the decedent and the nature of each party's interest(s): Name and Address of Each Party in Interest Relationship and Comments, if any Interest Alberta L. Cook 109 Winston Drive Mechanicsburg, PA 17055 Widow 100% Form OC-OI rev. 10.13.06 Page 4 of 10 Estate of Roy Earle Cook, a.k.a. Roy E. Cook , Deceased Name and Address of Each Party in Interest RelationshiD and Comments, if anv Interest B. Identify each party who is not suijuris (e.g., minors or incapacitated persons). For each such party, give date of birth, the name of each Guardian and how each Guardian was appointed. If no Guardian has been appointed, identify the next of kin of such party, giving the name, address and relationship of each. None. C. State why a Petition for Guardianffrustee Ad Litem has or has not been filed for this Audit (~ee Pa. o.c. Rule 12.4). N/A D. If distribution is to be made to the personal representative of a deceased party, state date of death, date and place of grant of Letters and type of Letters granted. N/A Form OC-OI rev. 10.13.06 Page 5 of 10 Estate of Roy Earle Cook, aka. Roy E. Cook , Deceased 10. Other than the claim for the family exemption, list the names of all known claimants and the amount of their claims and state whether each claim is admitted. Name and Address of Each Claimant Amount of Claim Claim Will Claim Admitted? Be Paid In Full? Patricia McLachlan, PNC Bank, N.A. $17,123.11 IZIVes DVes Consumer Loan Center DNo IZINo 2730 Liberty A venue Pittsburgh, PA 15222 Chase Manhattan Bank, a.k.a. J.P. $14,571.31 IZIVes DVes Morgan Chase Bank, N.A. DNo IZINo c/o Phillips & Cohen Associates, Lt. 258 Chapman Road, Suite 205 Newark. DE 19702 Chase Bank, USA $32,000.00 IZIVes DVes c/o Omnium Worldwide, Inc. DNo IZINo PO Box 956842 St. Louis, MO 63195 Citi-Bank, South Dakota, N.A. $21,052.62 IZIVes DVes c/o Balogh Becker, Ltd. DNo IZINo 4150 Olson Memorial Hwy, Suite 200 Minneapolis, MN 55422-4811 Ifthe estate is insolvent, attach a schedule setting forth the order of preference under 20 Pa.C.S. ~ 3392 and the proposed payments. 11. Was family exemption claimed? ............................... . IZIVes DNo IZIVes DNo Was family exemption allowed? ............................... . Family exemption claimant's name and relationship: Name: Alberta L. Cook Relationship: Widow Form DC-OJ rev. 10.13.06 Page 6 of 10 Estate of Roy Earle Cook, a.k.a. Roy E. Cook , Deceased 10. Other than the claim for the family exemption, list the names of all known claimants and the amount of their claims and state whether each claim is admitted. Name and Address of Each Claimant Amount of Claim Claim Will Claim Admitted? Be Paid In Full? Diner's Club International $3,764.00 (ZIYes DYes a.k.a. Citibank (South Dakota) N.A. DNo (ZINo c/o Balough Becker, Ltd. 4150 Olson Memorial Hwy, Suite 200 Minneapolis, MN 55422-4811 DYes DYes DNo DNo DYes DYes DNo DNo DYes DYes DNo DNo If the estate is insolvent, attach a schedule setting forth the order of preference under 20 Pa.C.S. S 3392 and the proposed payments. 11. Was family exemption claimed? ............................... . DYes DNo DYes DNo Was family exemption allowed? ............................... . Family exemption claimant's name and relationship: Name: Relationship: Form OC-OJ rev. 10.13.06 Page 6 of 10 Estate of Roy Earle Cook, aka. Roy E. Cook , Deceased 12. The amount of Pennsylvania Transfer Inheritance Tax and additional Pennsylvania Estate Tax paid, the date(s) ofpayment(s), and the interest(s) upon which paid, are as follows: Date Payment Interest The Department waived any claims to collection of any tax by zero balance sheet. 13. On the date of death, was the decedent a fiduciary (personal representative, trustee, guardian, agent under power of attorney) or surety on the bond ofa fiduciary? . . . . . . . . . . . . . . . . . .. DYes IZI No If yes, provide the name of the estate, indicate whether an account has been filed and confirmed absolutely and all awards performed, or, in the alternative, how the decedent's estate will be discharged for the decedent's fiduciary administration of the estate. 14. A. Describe in detail any questions requiring adjudication and state the position of the Petitioner(s) as to each question: B. Has notice of the question requiring adjudication been given to the parties identified in Paragraph 9 above? .................. D Yes D No 15. IfPetitioner(s) haslhave knowledge that a share has been assigned, renounced, disclaimed or attached, provide a copy ofthe assignment, renunciation, disclaimer or attachment, together with any relevant supporting documentation. Form DC-OJ rev. 10./3.06 Page 7 of 10 Estate of Roy Earle Cook, a.k.a. Roy E. Cook , Deceased 16. Had the decedent been adjudicated an incapacitated person? . . . . . . . . . . DYes lZI No If yes, attach a copy ofthe Order if available; otherwise state the Court, term, number, date, and name of Hearing Judge. 17. A. List or attach a separate list of additional receipts and disbursements since the closing date of the Account. None as of this date. B. Has notice of the additional receipts and disbursements been given to the parties identified in Paragraph 9 above? ............. DYes D No 18. If a reserve is requested, state amount and purpose. Amount: Purpose: Mr. Cook's widow is holding sufficient funds to pay the balance due the creditors to pay proportional amounts of debt from an insolvent Estate. If a reserve is requested for counsel fees, has notice of the amount of fees to be paid from the reserve been given to the parties in interest? ........................................ DYes lZINo If so, attach a copy of the notice. 19. Is the Court being asked to direct the filing of a Schedule of Distribution? ......................... . DYes lZINo As to real estate only? ....................................... . DYes IZ'I No Form OC-OJ rev. JO.13.06 Page 8 of 10 Estate of Roy Earle Cook, a.k.a. Roy E. Cook . Deceased Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties entitled and suggest(s) that the distributive shares of income and principal (residuary shares being stated in proportions, not amounts) are as follows: A. Income: Proposed Distributee(s) Amount/Proportion Alberta L. Cook o - Insolvent B. Principal: Proposed Distributee(s) Amount/Proportion Alberta L. Cook o - Insolvent Submitted By: (All petitioners must sign. Add additional lines ifnecessary): aBdL~ Name of Petitioner: Alberta L. Cook Name of Petitioner: Form OC-OI rev. 10.13.06 Page 9 of 10 1 Estate of Roy Earle Cook, aka. Roy E. Cook , Deceased Verification of Petitioner (Verification must be by at least one petitioner.) The undersigned hereby verifies * [that he/she she of the above-named name of corporation Estate is title Executrix and] that the facts set forth in the foregoing Petition for Adjudication / Statement of Proposed Distribution which are within the personal knowledge of the Petitioner are true, and as to facts based on the information of others, the Petitioner, after diligent inquiry, believes them to be true; and that any false statements herein are made subject to the penalties of 18 Pa. C.S. g 4904 (relating to unsworn falsification to authorities). ~,1~ Signature of Petitioner * Corporate petitioners must complete bracketed information. Certification of Counsel The undersigned counsel hereby certifies that the foregoing Petition for Adjudication! Statement of Proposed Distribution is a true and accurate reproduction ofthe form Petition authorized by the Supreme Court, and that no changes to the form have been made beyond the responses herein. ~u~~~ Form OC-OI rev. 10.13.06 Page 10 of 10