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Home My WebLink About01-0601Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of James R. Smith also known as ,Deceased James W Smith No. ZI - d I - (ad ~ Social Security No. j ~ ~ , O 3 - .5' f $ ? Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' or 'B' BELOW:) QX A. Probate and Grant of letters Testamentary and aver that Petitioner(s) is/are the execut or named in the last tMll of the Decedent, dated 12/06/78 and codicil(s) dated None Primary named Executrix, Anna G. Smith, deceased State relevant circumstances, e.g., renunciation, death of executor, etc. Except as folows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: B. Grant of Letters of Administration (c.t.a.; d.b.n.c.t.a; pendente life; durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Witt and was survived by the following spouse ('rf any) and heirs: Name (COMPLETE IN ALL CASES:) Attach additional sheets if necessary: Decedent was domicibd at death in Cuumberland County, Pennsylvania wkh his/her last family or principal residence at Church of God Home, 801 N. Hanover St, Carlisle Borough (list street, number, and municipality) Decedent, tt-en 9f years of age, died 06/20 , t9 Ol, at Church of God Home, Carlisle, PA (Location) Decedent at deatlt owned property with sstirrtated values as folbws: (If domiciled in PA) All personal property S 50 , 000.00 (If not domiciled in PA) Personal property in Pennsylvania S (If not domiciled to PA) Personal property in County Z Value of real estate in Pennsylvania S situated as follows: Wherefore, Petitoner(s) respectfuNy request(s) the probate of the last Wdl and CodiciKs) presented with this Petition and the grant of letters in the a ro riate form to the unders' nsd: Si nature T ed or rinted name and residence .. James W Smith Q/. 140 Peak View Road, York S rin s, PA 17372 Prepared try the PenneylvaMa Bar Asaoclatlon Copyright (e)1996 form software only CPSystems, Ine. Form RW-1 (1991) Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according~t~o i/aw. ~ l,,-~ Sworn to or affirmed and subscribed ~ • ~~'~`~" `-r~-- James W Smith before me this~day of ~`T Estate of James R. Smith Deceased Social Security No: 185-0 3-Sl ss7 Date of Death: 06/20/01 AND NOW, ~ (,( ~ (E ~y~ } ~ (~ ~ ~ , 19 _, in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters []X Testamentary ~ Of Administration (c.t.a.; d.b.n.c.t.a.; pendente lite~; durante absentia; durante minoritate) are hereby granted to James W Smith in the above estate and that the instrument(s) dated 12/06/78 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES ~ ~y T ~ ~U~ Letters . . . . . . . . . . $ ~ • U i1 Short Certificate(s). $ j ~ ' ~ ~ Renunciation. .. $ Affidavits ( ) S ~~~ 22 r Extra Pages ( ) . S '~.l - ~ ~l Codicil. $ JCP Fee . . Inventory. . Other ........ S ~' L~ l.~ Re'gistter of Wills it Attorney: J M. Wile Es uire ` 1.D. No: 6298 The Wiley Group Address: One S . Baltimore St . Dillsburg, PA 17019 Telephone: X 7/432 - 9666 -7 I L- r V ~ ~~~ . TOTAL. S C Vs3 ~ V~ Prepared try the Pennsylvania Bar Association Coovriaht (c) 96 form software only CPSystems, Inc. Form RW-1 (1991) No. z~-or-o~y~ r~n5 o~5 n.-`. .~/c~ This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be. forwarded to the State Vital Records Offtce for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 7402546 No. N t 05.: U Rav. 7/E7 VT NT K Local Registrar JUN 2 2 Zoa~ Date COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH FnF VUUeER NAME OF DECEDENT (F xU. MitoN, ial SEK SOCIAL SECURItt NUMBER DATE OF OEATM iMCM^. Day,'T•r) ,. James R. SmitY: ,.Male ,. 185 -0~ - 5157 ._ 6/20/01 AOE IUe Bxeway) UNDER t YEAR UNDER t DAY DATE OF BIR1N BtFRHPt.,CE ;C.ry arA PLACE OF DEATNlCnecw orxy"ro-- .ee ~naxu<IAnamomv axMl ~- MoMM r Day rle.xa . MhWN '.Mmn. Day '4trl SNN«F<rtgn CauMlYl PA b 1 ^ ° 1 ~ OTHER: r~ HOSPITAL' «•~M U a N it r C r 11 u / 2 7 / 1910 D ° YM DDA ^ EFiIOMpar;tM mp•IitM r ar M L`7 R•aCarlu ~ SFeCpyl ^ . • COUNtt OF t~ATN CTTY. BORO. TWPOF DEATH FACILfTY NAME pl nM mmturan, q~.s sweet ant M,moer~ WAS DECEDENT OF NISPANK; ORIGIN? S~PetEM~ mancan IMian, BLCt, W1M•. Uc. "R~ ""^"'"' '°•`"`c"°'" ' ' North Middleton church of God Home M.';tar,•w.r,°R'°'"•"° ~Thite Curtberland • , ~ ~ ~ . OECEDEM'S USUAL OCCUPQION KIND Of SU H $lINDU$TRY NRS DECEDENT EYERM OECEDENT'$EDVCATION MARrtAL STATUS~Manitt SURVtY1HG SPOUSE ARMED FORCE37 Nawr ManiW, W;A)e'tt. Ip'axt, grvt maMn Mmtl U.S . {GM NM d+.«k eM7 dtxq racer a rorkinE w+: a nq ua• raGrea) ^ fltrMM+ry/S•cOM+ry C"Ngt ONOrctt rsve~p'n construction `"' ''~ ID,zj Ita«5.1 Cor strection ~ ~~ , ,,. , ,,. DECEDENT A I SS ISvew. Cpy~TO'an, $,ar•, ZO COOeI DECEDENT'S ActuAL n4 s,+,. Dia ,Te.(~ra. a<aaMp•te in NOr th Middleton rY,P. 801 IQort;1 Hanover St RESIDENCE a.t.e.M IStt xwrutlroru Yyt n t ~~ C a r l i s l e P A 1 7 0 1 3 °" """ aaj ""niMp4 tia.^ .~.~n.~.a~`~I ern a ety~ere. ,RI. FQNER'$ NAME IF'xx, Math. Leap MOTHER'S NAME IF(N. M;ttlp, Maltl•n Swnams) ,E Harr L. Smith ,.. INFORMANT'S NAME RyPaIPIW) I NFORMANT'S MAILING ADDRESS (SK•tI. Cirylfo«n. SWa, Zp Coal ~ y METNOOOF dSPOS1TION DATE OF dSPO51TK7N PUCE OF dSP05RK)N•N•nMaCtm•Itry, Cnmalory .S IoCot• ewlM C}~ cr.m";on ^ Rtrrlox" hom S1"• ^ • 'M°n"', o.x Y•"' «OI^U Plact Gardners P A ~•^^ u^"rse.<^^ ^ 6/25/01 t Victory Cemetery ,. ETa, ae• z,t. _ 9KiNATURE 9f FAIN L SER E LICFN E qi PERSON ACTUK; AS $IICN ~"~ LICENSE NUMBER ' ~~[~E ~ e },'' it era 1 H o ~ T ~ . B a 1 t i - • „•. D 13895 L ,nk ire Ave Cenplat pam• 27tc only.Mn anpyinq t r MK .Yawn..,,;m."aam b b IM Ma d my knewMOp+, ann anKrtd M tM Pmt. !rat afW daa uWta. LICENSE NUMBER DATE SIGNED (Menn. Dw. n•r~ ,S;pMa,rt Wa r / n ,) J °-~ 3 -~ v r ~ tAruly ulrt"t.a^. ~~ . z ze~ J •-1 ~o j J a~ a o (,J2_ /c.~a.' Q~ pane 24p$mwlwcomp"w oY TIME OF DEATN `a DATE PRONOUNCED DEAD (MOnm, D+y. )trarj WASCASE REfER • tMr+tn.M prenOUrrt+a.n. ~~/~ I ~ RED TO MEDICAL £)UMtNERK:ORON 1 Y1a^ Nora-- O{.y M. P M ! M . . . ,T. MRT I: EMb,M nMtYa, upwi+s« <emPl;<•,;OM vAtic^ uuato lM o•a,h. Do ne, eMtI,M 1 tying, loch tl <uGac u reaenabry urtM, anxk «Man bilw•. I Appoaimal• ~ inl•MI MM•tn PART R: dMr signdtcanl taapiar mrtri0ulKq 10 0•at^, bR nd mupvq n IM urWrlyirq pWt EMn n PART I. LiW only aM uuaa on sUA pM. r orr" ant aan IYMEdATf CAUSE (FmY. I lt....«<entexn 12E--NAB Fr~t~~~tE, A4cmna ~TN1~~tES" ryl~cLl ~t.L~ - ...wxlo n aanl ~ .. ou£ ro roR As AcDN$EOVEf+cE oFl: r ~ Eytt ENT/ f'} Spwn"My p" wntpaM ' pony, Aattirlq m x«nwrt o. oUE ro (OR AS A CONE WENCE OF1: 1 _ calpt. EMU UMOERIYMlG ~ CAUfEIUarr «~nary • nr •rttlat e.~rw c , D~Eroroa ASACON$£OISENCE Oft: I rsswnp nlrnl IAfT e. YIA$AN AUTOPSY MERE AUTOPSY FINdNG9 MANNER OF DEATN DATE OF INJURY TIME OF INJURY INJVRY AT WORK7 DESCRIBE NOW INJURY OCCURRED. taERFORMEDI AMVLABLE PRM7R TD IMOnn. O+y, 1lUI OFM~pMION OF CAVE r-~~' Na,wM l7 N°mk0• ^ Yat ^ NO^ AccitaM ^ Pontine MvsHgarbn ^ M. ,tt .M ^ ~ yM ^ rp ^ Su;Cat ^ DOUIO n« M aNrminad ^ PULE OL INJURY. AI romt, rum, s,rem, r+erory, opk+ LOCATION rsnsw. Cay/,own, Sunl a.tane. "c.,so.<m, ,w. ,w. n. ,a. ,a. CERTIf1ER ICtv<A OrpyoMl $KiNATU A ,TIt E TIFIER ~~ 'CER7IFYINO-NYSKIAN IPIryrcranctnAyinq<a.ntdCeunw^an aMp,"PnvLCanlmgor,ounta0 otan aM Cm~p"eo Item 771 ~ ~ ~__-._,' UU !( re,M ata, lr my kMarNtgt, aan octumet !w a na e+uaHal Int manner N •lalb ..................................................... „0. - ml l P d • LICENSE N/U`MBEfR y ( ` DATE SKiNEDIMOr~. DaY'h"1 ~ ~ f ' ~ - ~2 ~Q( yxg NCSUet ^yxun°om°ronouncup dean anG <tm cea PIgNOUNCINO ANDCERTIfY1N0-NYlICIAMI ^ •rd ow Ie,M ewst,a) aru) Mannar as a,s1•t .......................... aan etewret at rM INna ta,a ant Platt " Tt IM o•tl el my AMwlatea Y T/~•4r 21 r 4 L 5`+% lam ,1. `./ i . , , , . NAME AND AOORES$OF PERSON WNO COMPLETEDCAUSE ATN ~ ~ Olem 2'n Tyja. ar lrlM W~~1 KA~t ~MI~N,NAP ~ 'MEDICAL ExAMINER/CORONER ant la< nt lw lotto ewat(:>an0 ti ta t I i i n taM yLrl (2G flit ~q~LS ~J ~I`' a, • me, p on,lnr xcurre < t, On lhtGtah ortnminalon+nt/or lnysa g+nun, n my oD n ? ,,.. (l D j3 n. CA-K-~i~St,E P1 REGISTRAR'S SIGNATURE AND NU A• w..cS~ ~ a ». DATE FILED IMMn. Day. '!t", c1y.~e ~F~~ ,.. ~~~t ilk ~trtd t~es~trrrettt v~ JAMS R. SMITH B~ IT R~M~MB~R~~, ~ha~ I, JAMS R. SMITH, ab R. ~. #l, yatcFt Sp1ri.ng~, La~.i,mane Tawvushi.~, Adams Cauwty, Penv~y2van-ia., be~.ng a~ daund mtind, mematcy and unde~~and.Lng, da maFze, ~ub2.i~sh and dec,2atce ~h.%a ad and ban my Labs (U.%P~. and Te~~a- mev~t hviceby nevafung and maFii.ng nu.22 and va,%d any and a,2.e. UJ.c.2Z6 and Te~s~amen~s and wncti..ng~s ~.n the na~une ~heneab by me a~ any ~.ime heh.etabone made. ITEM 1: I d.i~r.ect ~ha~ a.P.e my ~u~s~ debt and bunerca.2 ex~ehae~s be ~a~,d as ~saan ab~etr. my dem,cse ass may be canvev~i,ev~t. ITEM 2: A2.e the ne~~, ne~s~.due and nema.bnden ab my ea~ate, ab wha~saeve~c. ncrtujce and when.e~saeven ~s-itua~e, whe~hen .it be neat, ~e~ana~ an m,i,xed, ~.nceud~.ng pna~en.~y aver, which T have a ~awe~c ab appa~,n~rnev~t, I g~.ve, dev-ibe and bequeath uv~ta my w%be, Anna G. Sm,%th, abaa.~u~e.~y, ~nav.ided ehe 6u~cv~,veb me ban a ~e~c,%ad ab ~hv~y (3O) days. ITEM 3: Shau~.d my w~.be, Anna G. Sm.i~h, pnedeceabe me, ba.%Q ~a ~sunv~.ve me bax a ~etcfad ab zh,v~y (30) days, an ~shau2d we d~,e d.cmu,P.taneau,62y, I then g~.ve, dev,use and bequeath my ewtvice he~s~:duan.y eus~e uv~to my d,b4ue, tin equa.2 ~shahe~, etc ~~~~ . ITEM 4: I ap}~a~.wt the Adams Cauwty Na~,c.ana~ 13an~t, ass guand~.an avers any ~rc.a~en~y wh,%ch ~a~sae~ e-ithen unde~c ~h~s (O,i.~E'. an a~he~uu%be ~a a m~,nan and uzith ne~s~eet ~a whi:ch T am authatc,ized ~a a~~a-LrLt a guandtian and have nab a~henuzi~e ~s~ee,%b~.ca.P.2y dane ~a, y~nav~.ded ~ha~ ~h.i~ a~~a.~n~rnev~t ab a guatrd.ian bha.P.,2 nab ~u}ae~caede the fright a ~ any b~,due.cate y ~.n ~s d.irs e~ceti.a n ~a d-us~tr,%bu~e a b bane where padd.ib2e ~a the m~,nan an ~a ana~hetr. ban the m~.nan'~s beneb,%t. Such guakdtian bha~ have the pawetc ~a wse ~tr,%nc,i~a2. a~ we.~2 cus ~;neame, beam dime ~a dime ban the m~.natc'b ~su~~ar~t and educa~%an, TN~ss: `. ~ ~~~~~ ~ j , ~ ~?(S~AL) Jai (~.nc.2ud~.ng ea.22ege eduea~%an, bath gnadua~e and unde~rgnadua~eJ , w~.thau~ regard ~a h-is an hen panevLt'~s ab.c.et~y ~a pnav~.de ban ~ueh ~suppant and eduea~c.an, on ~a maf~e paymev-,t bvn ~he~ e putcpa~ e~, w.ithau~ butc~hen ne~s paws~,b.c,~,ity ~a the m.Lnan' ~ panev~t an ~a any pews a n ~aFi%ng carte a ~ the m.inan. ITBM 5: T d.vicect my Bxeeu~u.x ~a pay a.?.2 ~.nheni.~anee, ea~ate, ~sueee~~s~.an and .2egaey ~axe~s ab whaxisaevet~. na~euce and Find, ~a wh.Lch my Ba~ate on the ~canabetc. ab any pnapetrty pa~s~s~,ng heh.eundetc an a~henw,use pabd~,ng by reason ab my dem.c~se, may be ~subfect and ~a change ~ueh ~a.xed aga~,vus~ my ne~s~.duany e6~ate, .ct be~,ng my ~.hten~%an ~ha~ Wane ab the abane~sa~,d ~a.xe~s, e.i~heh. bedena2 an a~cite, on any pnapetrty ner~ui~ced ~a be ~,ne,2uded ,i,n my gno~s~s e~s~a~e, under the ~nav-ib~,av~ ab any date an ~edena2 taw raw ~.n bance an heneabze~c enacted, ~sha22 be pnana~ed among the ~e~r~sana -iv~ene~~ed ~.n my B~s~a~e ~a wham ~ueh pnapex~y .us an may be ~cav~abeJVCed an ~a wham any bench-ct acc~cue~5 . ITEM 6_:_ I appa~:wt my w~.be, Anna C. Sm-cth, a.a ~xeeu~ri.x ab ~hi~s my La~s~ tV,i;2.2 and Te~~amevLt. Shau2d my w~.be, Anna G. Smc~h, pnedeeeaae me, ba.%2 ~a qua2,%by, eea~se ~a yet an nenaunce pnaba~e, T then appa~.v~t my don Jamey GJ. Sm.%th, a~ the a.P,te~cna~e ~xeceatan a~ ~~ my La~s~ tV-i.P.2 and Te~s~amev~t. I~ my don, James tU. Smcth, pnedeeea~e me, b~ ~a qua.P.t;by, eea~se ~a oat an nenaunce pnaFia~e, I then appativ~t my daugGiten, Janet ~. Beam, ass the ~secand a,?.tetcw.a~e Bxeeu~1~i,x ab ~h~ my La~~ tU,%Q,2 and Te~,~amewt. ITBM 7: T d.ucect ~ha~ my Bxecu~,%x, guand.%an, an the-vr. ~aueee~sdatus ~sha.P.2 nab be nequ.uced ~a g~:ve band ban the ba.ithbu.2 penbanmanee ab ~he-uc du#,i,e~ ~.n any j c,v~,us d,Lct.%a n. IN UJITNBSS tUffBRBt)~, T have heneuv~ta ~se~ my hand and .aea.~ ~h~ ~ fh day ab ~~.:e,N,~b~~ iR78. ~, ~., The pneeed.i..ng tivv5~lcument, eavvs.v5~%ng ab ~h,~,a and one (1) when ~ype~;utu.#~en page wcvs an the day and dcite ~heneab ~stigned, ~ea~ed, pub2,ushed and dee.2eviced by IAMBS R. SMTTH, the 7e~s~atan heh.e~:n named, ass and ban h-id Labs UI,L2,e and Te6~amev~, ~.n the pne~s ence a b ws , who, a~ hip ner~ues~, ~:n hus peed ence and .Ln the prey ence a b each when, have ~sub~elubed awc name3 ass w,%tne~s~se~ hene~a ; ~~~ ~ ~ o~ ~I-DI-(~(~0! REGISTER OF WILLS OF Cum~2r la.n ~. COUNTY OATH OF NON-SUBSCRIBING WITNESS ~a me.s W • Sm ~ -1-h _ , (~so~r} a subscriber hereto, ~) being duly qualified according to law, depose(s) and say(s) that h~ i~ familiaz with the signature of _To-r~n~s ~. S~ i -l-h testa ct!'_ of ( o) the will presented herewith and ceditil that h~ - believes the signature on the will is in the handwriting of to the best of his knowledge and belief. _ Sworn to or affirmed and subscribed before me this ~ ~+ day of (Nam2) d. S, ~ i'{' (Address) l'l 'l a. R ist (Name) (Address) Register of Wills of Cumberland County, Pennsylvania OATH OF SUBSCRIBING WITNESS Estate of James R. Smith also known as ,Deceased No. ~ l" l,/ I r V lSi D, Jan M. Wiley (each) a subscribing witness to the ~ codicil(s) QX will(s) presented herewith, (each) being duly qual'rfied according to law depose(s) and say(s) that she/ he/ they was/ were present and saw the above Testator(rix) sign the same and that she/he/they signed as a witness at the request of Testator(rix) in his/her/their presence and ~ in the presence of each other X^ in the presence of the other subscribing witness(es). t,.,,J S. Baltimore St. lsbur>;, PA 17019 (Address) -. (Signature) (Address) Sworn to or affirmed ands-u.~blscribed fl , before me this ~Q day of p~ (~ ~E , 1 Z~ ~' ' s: (Signatwe and seal of Notary or other official N To be taken by officer authorized to administer oaths. gwlified to administer oaths. Show date of Please have present the original or copy of instrument(s) expiration of Notsry's commission.) at time of notarization. Prepared by the Psnnsyhrsnla Bar Asaoclatlon Copyright (e)1996 fo-m aoftwaro only CPSystems, Inc. Fo-m iRf~W-2 (1991) Name of Decedent: James R. Smith Date of Death: June 20, 2001 Estate Number: ~ /-0 ~ - D ~ D ~ 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 JUl1r 5, X00/ James W. Smith 140 Peak View Rd., York Springs, PA 17372 Doris L. Baughman 751 Baltimore Pike, Gardners, PA 17324 Janet E. Beam 1183 Myerstown Rd., Gardners, PA 17324 Notice has now been given to all persons entitle ther to under Rule 5.6 (a) except N/A. Date: 7/S/d/ ~ ~ ~~ ~ (~-~ r. Name: Jan M. Wiley, Esquire Address: One S. Baltimore St. Dillsburg, PA 17019 Telephone: (717) 432-9666 Capacity: Counsel for personal Rep. ~ o ~. o ~ ~^ s _~ "~+ ~ ~ ~ ~' • ~ ~~ ~ m ?~ o ro ~ o ~ O ~~ ~ ' n b .~ .~ .• is .r ~~ ;J D .~ t~ :..• ~ O -~~~~°h ~ n y .,~".~ Vl ~ ~ :.- ~_ fD n 'e ^~ O ..'"'-- :.- ... :...- ..-- :r ..-- ;..- ~r ~,,... i~ ~w• ~' +. '~w.~..s~ '. ~+ ~' THE WILEY GROUP September 17, 2001 ~tt~>rney5 .~t Law Wiley • Lenox • Colgan •Marzzacco • P.C. Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 In Re: Estate of James R. Smith Number 21-01-0601 Dear Register: Enclosed please find a check from the Estate of James R. Smith in the amount of $1,282.50 for prepayment of inheritance tax. This payment is being made on an estimated estate as follows: $30,000.00 @ 4.5% for a total tax of $1,350.00 less the 5% discount of $67.50 equals the payment of 1,282.50. Please return a receipt to my office in the envelope provided. Thank you for your assistance. Sincerely, c CX~ /vl ~ ~~ SC%i~ AN M. WILEY, ESQ JMW/sdg encl. )an M. Wiley • David ). Lenox • Timothy J. Colgan • Christopher ). Marzzacco • Christine ). Taylor 1 South Baltimore Street • Dillsburg, PA 17019 • Phone: (717) 432-9666 • (800) 682-4250 • Fax: (717) 432-0426 Offices in Harrisburg • York • Carbondale COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: WILEY JAN M 1 S BALTIMORE STREET DILLSBURG, PA 17019 fold ESTATE INFORMATION: ssN: X85-03-5757 FILE NUMBER: 21-2001- 0601 DECEDENT NAME: SMITH JAMES R DATE OF PAYMENT: 09/18/2001 POSTMARK DATE: 09/17/2001 COUNTY: CUMBERLAND DATE OF DEATH: 06/20/2001 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX~11-961 NO. CD 000273 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ S 1, 282.50 TOTAL AMOUNT PAID: REMARKS: JAMES W SMITH C/O JAN M WILEY ESQUIRE CHECK# 21 INITIALS: PB S 1,282.50 SEAL RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS REGISTER OF WILLS 1 do o~ 6~~~ ~~~~ ~•~~ ,.d ~ ,~ C1 9 0 ~ ,~ r ~. ~~~'a ------- ___-- ~ L `.. ,,; ,~-, ~~~ ~ .~ ~t -; s ~a~ ~'~~ ~ ~'~ ~ 1 "ti' ~ x ~ `~ ~ 't ~ ~., ~1 ~ ~ ~ ~ ', ,. ~ ~ ~i d-~f~ ~ F p °~" ,4µ ~ ~ ~ ~ ~• ~ ~ ~`~ O ~ti. ~ ~ t. '~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ z ~ ~ ~s ~ ~- ^r ~ ~ ~ ~ •. v ~ ~ ~ :~ :r t C' November 19, .2001 '~'~-iE WII.EY GROUP Attorneys at Law tNiley • Lenox « Colgan .Marzzacco • P.C. Register of Wills CumberlandCounty Courthouse One Courthouse Square Carlisle, PA 17013 In Re: Estate of James W. Smith; deceased File Number 2101-0601 Dear Register: Enclosed for filing please find an Inventory, the inheritance tax return in duplicate, and the status report with regard to the above captioned estate. Also enclosed is a check in the amount of $287.22 representing the tax due, and a check in the amount of $25.00 representing the filing fee. Please return the recording receipts to my attention in the enclosed envelope. Thank you for your cooperation. . Sincerely, /~~~ _ Dawn Gla fetter/Assi nt ~ ~' ~p /dg ~ ~~ ~ ~ ~ encl. ~ cY;:. .:,' .... N t" ~. ~ , D ~; N ~' ~, ~,- ~ Jan M. Wiley • David j. Lenox • Timothy j. Caigan • Christopher j. Marzzacco • Christine j. Taylor 1 South Baltimore Street • Dil(sburg, PA 17019 • Phone: (7i 7} 432-9666 • (800} 682-4250 • Fax: (7i7) 432-0426 Offices in Harrisburg • York • Carbondale i~ -a~~ - 8. Total Gross Assets (total Lines 1-7) (8) 50, 509.34 9. Funeral Expenses & Administrative Costs (schedule H)(9) 12, 763.18 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 1, 363 .41 11. Total Deductions (total Lines s & 10) (11) 14 126.59 12. Net Value of Estate (Line 8 minus Line 11) (12) 36, 382.75 13. Charitable and Governmental Bequests/Sec 8113 Trusts for which an election to tax (13) None has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) ( 36,382.75 REV-1500 EX + (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-~G00 DEPARTMENT OF REVENUE DEPT. 28060, INHERITANCE TAX RETURN FILE NUMBER HARRISBURG, PA 1712s-osol RESIDENT DECEDENT 21 0l 0601 COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER DECE Smith James R. 185-03-5157 - DENT DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE 06 20 O1 05 27 1910 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 3. Remainder Return CHECK 1. Original Return 2. Supplemental Return (date of death prior to 12-13-82) APPRO- 4. Limited Estate 4a. Future Interest Compromise ( e ) 5. Federal Estate Tax Return Re wired q PRIATE 6. Decedent Died Testate (Attacn copy of will) 7. Decedent MainWined a Living Trust (Attach a copy of Trust) 0 8. Total Number of Safe Deposit Boxes BLOCKS 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death between ~ 11. Election to tax under Sec. 9113(A) 12-31-91 and 1-1-96) (Attach Sch 0) NAME COMPLETE MAILING ADDRESS coR- Jan M. Wile a One S. Baltimore St. RE- SPON FIRM NAME (If Applicable) D111S PA 17019 DENT The Wile Gr0 TELEPHONE NUMBER 717-432-9666 1. Real Estate (Schedule A) (1) NOrie OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) i ~ 3. Closely Held Corporation, Partnership orSale -Proprietorship (3) ~ ~ ~ ~ t1] 4. Mortgages & Notes Receivable (Schedule D) (4) N ~ ~.!"T '~ 5. Cash, Bank Deposits & Miscellaneous Personal = ~ ~ Property (Schedule E) (5) 50, 509;;34 ,., , c ~"'~'`` 6. Joint) Owned Pro a y p rry (Schedule F) '-'~ N , Separate Billing Requested (6) N ,~ ' ' ._ , RECA- ~ ; ~ ` -tJ r , N rr"s (,,, PITULA- 7. Inter-Vivos Transfers & Miscellaneous °,.`I . : ; -+•• TION Non-Probate Property (Schedule G or L) (7) N nye-' ,,, ~ TAX COMPU- TATION SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Line i4 taxable at the spousal tax rate, or transfers under Sec. 9116 (aH1.2) X .0 (15) 16. Amount of Line t4 taxable at lineal rate 36, 382.75 x .0 45 (16) 1, 637.22 17. Amount of Line 14 taxable at sibling rate 0.00 X .12 (17) Q, QQ 18. Amount of Line 14 taxable at collateral rate Q. 00 x .15 (1$) 0 ~ 00 19. Tax Due (1s) 1, 637.22 Q ..... ........................... .#~~(3~~'F#T~ ~E)FfEF#~t'~. C]F ~s1;~YER~?•~3'i('IY~fi~C;.: 0 PA15o01 NTF 29755 Copyright2000 Greatland/Nalco LP-Farms Software Only Estate of: James R. Smith SUMMARY OF ALLOCATIONS TO BENEFICIARIES Taxable at lineal rate James W. Smith 12,127.59 Doris L. Baughm-u1 12,127.58 Janet E. Beam 12,127.58 36,382.75 21-01-0601 PA REV-1500 EX (6-00) Page 2 Decedent's Com late Address: STREET ADDRESS church of God HoYlte 801 N. Hanover St. CITY STATE ZI P Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line i9) (~) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments 1, 282.50 C. Discount 67.50 Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable p, Interest. 0.00 E. Penalty 0.00 Total Interest/PenaiTy (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page i Llne 20 to request a refund (4) 5. if Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) Make Check Payable to: REGISTER OF WILLS, AGENT 1,637.22 1,350.00 0.00 287.22 0.00 287.22 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BL 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : .......................... . ........... . b. retain the right to designate who shall use the property transferred or its income : ................ . c, retain a reversionary interest; or ....................................................... . d. receive the promise for life of either payments, benefits or care? ............................. . 2. If death occurred attar December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .... . .............................................. 8 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .. . 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................ Q IF THE ANSWER TO ANY OF THE ABOVE GIUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that [have examined this return including accompanying schedules and statements, and to the best of my knowledge and belief, it 1s true, correct and complete. Declaration o~ preparer other than the personal representative is based on information of SIGNATUR,~ ~JF PERSON RESP01~616LE~OR FIL#NCz Rj~l'URN DATE ADDRE /~/ 1,~ /~ ~ See edule attached THAN REPRESENTATIVE S. Baltimore St. PA 17019 J _... or dates of death on ar after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value o trans ors o or or t e use o e surviving spouse is [72 P.S. i 9116 (a)(1.1}(i)]. For dates of death on or after January 1, 1995, the tax rata is imposed on the not value of transfers to or for the use of the surviving spouse is 0%[72 P.S. b 9176 (a) (1.1)(ii}]. Tha statute doe_ not exemr,t a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July t, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to orforthe use of a natural parent, an adoptive parent, orastepparentofthechildis0% 172 P.S.g9116(a)(1.2}]. The tax rate imposed on the net value of transfers to orforthe use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72. P.S. g 9176(1.2) [72 P.S, g 9116(aX1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 % [72 P.S. !3 8116(a)(1.3)]. A sibling is defined, under Sactinn 9102, as an individual who has at Least one parent in common with the decedent, whether by blood or adoption. 0 PA1501)2 NTF 29758 Copyright 2000 Greatland/Nalco LP -Farms Software Only Fjstate of : James R. Smith 21-01-0601 The following person(s) are signing the return as representative(s) of the estate: James W. Smith 140 Peak View Road York Springs, PA 17372 }~ittst tll t~dr (~.esttmieltE o~ JAMES R. SMITH BE TT REMEMBERED, xFeeit T, JAMES R. SMIT#f, os R. 9. ~1, York. Spfiinga, La~imone Township, Adams Caurity, Pennay.Cvania, 6e.i.ng os bound mLnd, memany and unde~es~anding, da make, pub.P,iah and dee~ane Shia ab and bon my Labs UI~ and Teaxa.- menZ hereby neuak.i.ng and matting nu.P,~, and void any and ate. Ult,eC6 and Tes~amewts and wniti.ngb .tn .the na~une ~h.¢Jc¢.as by me az any dime he~ce~asone made. TTEM 1: i d~.ect ~hctt a.GL my~ just debts and Sunena,E expenses be pa,i.d as baon as~e~c my demise as may be eonveni.en~. I7FM 2: A.F~..the nest, nea.cdue and nemasnden ob my ea~ate, as wh.a~aoeven na~une and whelcedaeven b,itua~e, whether .t~ be neat, peJCa4na,~ an. mixed, .cneEudi.ng pnapen~y oven wh,ieh T have a power qs appo.in~me-tit, T give, dev-c.ae and bequeath. un~ my wise, Anna G. Smith, ab4a.eute.Cy, pnovcd.ed she auhv.ives me San a peni,od os .thihty (301 days. ITEM 3: Shoa2d my wi.~e, Anna G. Sm~ctlt, pn.edeeeabe me, Sa.i,f. #o bunvive me San a pehiad os ~hi~ty (301 Jaya, an shau.Cd we die b.cmu.2taneau.s.Cy, T .th.en give, L dev.cde and .bequeath. my en~,ih.e. nea.iduany eazette unto my .ibbue, .tn equal bhtvrea, pen b.tucpea . -:;~ ' IT1=M'4: I appo.ittit the Adams Caun~y Natiana,C Bank, a~b guaaefi.an oven. any property wh.%eh. passes either under ~hi~a fU.t,P~ on othenuyi.se to a mtinan and with nespe~t to wh~:eh T am au#hon.%zed to appo.i:rtit a guardian and have nod othe~uu,iae bpeai.S,c.eaCEy dare ba, pnav.cded xhat this appo.%wtment as a gucurd can. bha~X nat bupenaede the nigh as any S.uluci.any .in .its d.iache#,can ~o dia~iu.6u~e a bhwre where po.ba.ib.Ze ~a the mi,,aon an to anaxhen Son the m-in.on'b 6enesct. Such. guanclian bhaZC have the power ~a ube pn.ina%pae. as wed ab .cneome, Snam dime to ~im~, Son the m.i,rtan'b buppont and education, t'Y,~1 ~ ~~ ..~;11~.._~~~? (SEAL 1 .J ~ / '(h. sal n......~ .-i e.~1e~).... (.c.nc,P.rcding eo.llege education, bath graduate and undengraduatej, w~,tfwut regard to hi,a on her parent'e ab.i,lity to provide Son such suppant and education, or to maize payment fan .these. purpoeea, withau~ ~unthen neapona.Lb,i,P.i ty ~o the m~i.non'b pane-Lt an ~a any person taFring cane ab the m~.non. ' I7EM 5: I dNrect my Sxeec~tiaix to pay aP,l .cnherita.nee, estate, sueeess.can and .legacy taxes o~ whatsoever nature and fund, to which my Sstate an the t~cans~en a~ any property pase.cng hereunder on athe~uuiae pass.cng 6y reason os my demise, may be subject and to change eueh taxes against my nes.iduany estate, .ct 6ezng my .cntenti.an that none os the a~anesaid .taxes, ecther bederal an state, on any property requ.i~ced to be .cne.fuded ~,n my gross estate, under the prov.cs.cons o~ any state on 6edenal .law now ~.n 4oree on hereafter enacted, shad be. prorated among .the persona .e.nterested .cn. my ~atate to whom such pnvpeaty .c,s ar may be trana~exned an to wham any 6eneb.it acc~cues . Ir~1'6: I appa.i,nt my wi~'e,Anna G. Smith, as ~xeeutr.i.x ob this. my Last GJ.cl,l and Testament. Shvu.ed .my wi.~e, ~ Anna G. Smith, pnedeeecwe me, Sai.C to .4~~y, cease to ae~ on renounce probate, I then appo.i.nt my eon lames W. Sm~cth, as the aCternate Exeeutpn o~ thi6 my Laet W.i;IZ and Testament. Ig my eon, Tames tV. Sm.ctfc, predecease me, bail to qua.P.c:by; cease to set on renounce probate, ~' then appo.cnt my daughter, Tanet E. Seam, ab the .second alternate ~xecutiux o~ tfii,a my Last Gli,~,l and Testament. ` 'TT~fp.7: T dirieet that my Fzeeu,Uu,x, gua~u~Lutn, on Rhein eucceadanb abaci not be nequ.vred to give bond ~'an .the ~aithgul penbo~rmanee a~ the~in dwtiea .cn any f un.isdi.exi.on. IN G/ITNESS UINEREO~', I have kereunta set my hand and seal this ~'~T da.y a~ ~ ~~;.,'(;~~ 1978. ~~~SEAL ) The preceding .tnetnument, eana.ca~:ing o this and one t 1) ath.en. typewritten was on .the day and date #heneo$ s.cgned, sewed; pub,liahed and deeCwced by JAMbS R 9e SAiTTN, .the. Testator here.%n. named, as and ~'or fii,6 Ladt W.%Q,C, and Testament, .cn. the presence og ua, who, at hi,a request, .cn hca presence and .i:at the presence a~ each v ,have aubsaube~ our namee ae w~,trcessea hereto; OF ~ ..~..~...oJ(i+,~.ti. '~ G. REV-1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER James R. SYnith 21-O1-0601 Include proceeds of litigation & date proceeds were received by the estate. All r0 olntl -owned with ri ht of survivorshl must be disclosed on Sch. F. ITEM VALUE AT NO. DESCRIPTION DATE OF DEATH 1 Adams County National Bank Checking Account #191-136-8: 2 Bank of Hanover Account #9112197: 3 Misc. Refund• 4 Church of God Home (refund): 5 Building Trades Health & Welfare Fund: __ TOTAL (Also enter on line 5 Recapftul (If more space is needed, insert additional sheets of the same size) 7 CPA81 NTF 70908 Copyright Forms Software Only, 1997 Nelco, tnc. 2,971.45 41,569.21 116.22 4,931.74 920.72 S 50,509.34 ~~~~ GovNZy NATIONAL BANK 3uly 7, 2001 The Wiley Group Attorneys at Law 1 South Baltimore Street Dillsburg, PA 17019 Re: Estate of James R Smith To Whom It May Concern: The fallowing information is being provided as per your request: Account Type Account Number Acct Balance Acc. Interest Ownership Date On D.O.D to D.O.D Opened Checking 191-13b-8 $2,97Q.43 $1.02 Individual 8-8-97 If you need any additional information, please feel free to contact me. Sincerely, !n4 ~ , ~ t--vr'~2 Lois A. Kime Certificate of Deposit Coordinator .. BANKOFHANOVER ~.. August 12, 2001 The Wiley Group 1 S. Baltimore St. Dillsburg, Pa. 17019 Attn: Jan M. Wiley Re: Estate of James R. Smith Date of Death: June 20, 2001 25 Carlisle Street Hanover, PA 17331 717 - 637 - 2201 Dear Mr. Wiley: As of the date of death, our Bank had 1 account for the above-named decedent. The Personal Index Fund Account #9112197 was opened December 30, 1998 in the name of James R. Smith. The balance as of the date of death is $41,542.00 and the accrued interest as of the date of death is $27.21. Interest paid from January 1, 2001 to the date of death is $1,082.53. If I can be of any further assistance, please contact me at 735-5806. Sincerely, 1 ~arbara F. Bayer ~% ~/ Deposit. Services Support Manager MEMBER FDIC }'~ Equa! Housing Lender e EBTe~i.T~ 'v~ Jr4iYi~,S i~s , ~iiiTn s dc:: i i i tai: vl~tvau:uw~ F~c~y i 8 ~~s i307oe3 . L HL-1l..e:l. l.'S -'3•~:.'• 1 # iJiT's.~"!~-,M.1.rk 1t31V' ~1•!~1~..~2~2~ 1.,2'14.! LL L'!'1 VL VVL f"lVtwl.G ;L ~1 ~~~:~1 tl,,ji4 ~'YIt1 V C1~:2 ~}~~~Ji / 4 n tL! It P.~r U!`4 LJ iJU.C #1923-A REV-1511 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER James R. Smith 21-O1-0601 Debts of decedent must be r orted on Schedule i. ITEM NO. DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See Schedule attached Total from continuation page(s) 7,436.27 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 2, 500.00 Name of Personal Representative(s) James W. Smith Social Security Number(s)/EIN No. of Personal Representative(s) 164-36-5056 Stree Address 140 Peak V1eW ROad city York Springs state PA zip 17372 Year(s) Commission Paid: 2001 2. Attorney Fees Name: Jan M. Wiley, F-~~ire 2,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 0.00 Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 103.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 7 Ctm~berland Law Journal (advertise) : 75.00 8 The Sentinel (advertise): 100.31 9 US Postal Service (stamps): 13.60 10 Register of Wills (filing fee); 25.00 11 Notary Fee: 10.00 7 CPAt1 NTF 10971 Copyright Forms Software Only, 1997 Neleo, Inc. TOTAL (Also enter on line 9 Recapitul (If more space is needed, insert additional sheets of the same size) 12,763.18 Page 2 Estate of: James R.-Smith 21-01-0601 SQ~ULE H, PART A -- Funeral Expel'kses Item No. Description Amotmt 1 Wilson Hollinger Funeral Home, Inc.: 6,270.00 2 The Whimsical Poppy (flowers): 82.15 3 Wayne Noss Flowers (flowers): 106.00 4 James W. Smitih (reimbursement for funeral dinner): 789.26 5 Jack E. Beam (reimbursement for cleaning bill & shirt): 63.86 6 Codori Memorials (date on stone): 125.00 TaTAL.(Car2y forward to main schedule) 7,436.27 ' •REV-1 X12 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF James R. Smith SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-01-0601 Include unreimbursed medical expenses. ITEM NO. DESCRIPTION AMOUNT 1 BroGkie Pharntiatech: 72.09 2 Shermansdale Family Practice: 122.33 3 Mobile X-Ray Imaging, Inc.: 66.84 4 Carlisle Regional Medical Center: 815.57 5 Carlisle Imaging Assoc.: 5.73 6 Spring Road Family Practice: 164.27 7 Church of God Home: 86.28 8 ItN1C Corp. (medical services): 30.30 TOTAL (Also enter on line i0, Recapitulation) ~$ 1, 363.41 7 CPA12 NTF 10912 (If more space is needed, insert additional sheets of the same size) Copyright Forms Software Only, 1997 Netco, Ina COMMONWEALTH OF PENNSYLVANIA l ss: COUNTY OF ¢~~g~ID ~~ James W. Smith being duly sworn according to law, deposes and says that he is Executor of the Estate of JameG R _ Smith late of -Ca~1-is~.e--Borough -~- Cumberland County, Pa., deceased end that the within is an inventory made by James W. Smith - ., the said Executor of the entire estate of said decedent, consisting of all the personal proparty end real estate, except reel estate outside the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value as of the date of decedent's death . Sworn to and subscribed before me, ~~ • Executor - Administrator 140 Peak View Rd., York Springsr PA 17372 ' Notarial Seal S. Dawn Qrgladtelter, Notary rPriuybl' M C Domm~issfon~F.xp~ ire Nlay X17, Y 1~Aember, Perxisylvania Aseoaation of Notaries Date of Death 20 June Day Month Addns: 2001 Yser INSTRUCTIONS I. An inventory must be filed within three months after appointment of personal representative. 2. A supplement inventory must be filed within thirty days of discovery of additional assets. :7 C', 3. Additional sheets may be attached as to personalty or realty '' ~ o ~ ~:_ .~. 4. See Article IV, Fiduciaries Act of 1949. ~' `'... r~ . t::~,. N .. r..., c_'; ..0 LL ~ :' N , `* ~ ~ _..+ . tJl 0 lp 0 0 i 0 0 N Z Q f~ W Z ~ ~ W a F W ~ W 1-- ~ J LL LL ~ Q O O Z ~ O o Z W Q o_ -,1 E N (d f] is ~. O O N m -~ U O .~ a -o m a d V m 0 a~ C O U c A m v M e ~C3 ~ ~^~ t~ uy r~i _~. a W O ~ "/'~ a oW ' ~ 3 2 •• ~ inventory of the real and personal estate of James R. Smith deceased Adams County National Bank Checking #191-136-8: Bank of Hanover Account #9112197: Misc. Refund: Church of God Home (refund): Building Trades Health & Welfare Fund: 2,971 .45 41,569.21 116.22 4,931 .74 920.72 TOTAL: ~~$50, 509.34 C STATUS REPORT UNDER RULE 6.12 Name of Decedent: James R. S m~t-~-~l Date of Death: ~Cc ~ ~..o ~ O I Will No. ~,.1 - d (- Oi'e O ~ Admin. No. 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 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No ~_. b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes ~_ No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: ~ < < 5 f ~~ ~- .-. N .~~ w.~ ;; .: y o °~'~~ ,- ~ ' ~w ~ ~~ _ o ~ ~ c~ 1 ~ . _ d~1~r~or--e. ~-~ Address ~'~ -~ burg ~ ~(~ (-7019 Tel. No. Capacity: Personal Representative X Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: WILEY JAN M 1 S BALTIMORE STREET DILLSBURG, PA 17019 fold ESTATE INFORMATION: ssrv: ~ s5-o3-5157 FILE NUMBER: 21-2001- 0601 DECEDENT NAME: SMITH JAMES R DATE OF PAYMENT: 1 1 /21 /2001 POSTMARK DATE: 1 1 /20/2001 COUNTY: CUMBERLAND DATE OF DEATH: 06/20/2001 REMARKS: JAN M WILEY SEAL CHECK# 4856 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT AMOUNT ACN ASSESSMENT CONTROL NUMBER 101 ~ $287.22 TOTAL AMOUNT PAID: INITIALS: PB RECEIVED BY: MARY C. LEWIS $287.22 REGISTER OF WILLS REGISTER OF WILLS REV-1162 EX111-961 NO. CD 000547 /~- a~~ 7 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 2806D1 HARRISBURG, PA 17128-0601 JAN M WILEY ESQ WILEY GROUP 1 S BALTIMORE DILLSBURG COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX RE;C;t~ `~ DP~E f~~,i_ , ' ~3TATE OF - DATE OF DEATH FILE NUMBER '~2 JtiN 25 P ~gc~tt~TY REY-1547 E% ~FP (1Y-00] 01-21-2002 SMITH JAMES R 06-20-2001 21 01-0601 CUMBERLAND 101 ST _ Amount Remitted t ~~(+~ . . PA 17019 ~111n~~~, ~..: MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ ---------------------------------------------------------------------------------------------------------------- REV-1547 EX AFP (12-00) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SMITH JAMES R FILE N0. 21 01-0601 ACN 101 DATE 01-21-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ( )CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estat• (Schedule A) (1] .00 NOTE: To insure proper 2. Stocks end Bonds (Schedule B) (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) .00 of this form with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 50,509.34 tax payment. 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .00 8. Totai assets (g) 50,509.34 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 12,763.18 (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 1.36 3.41 11. Total Deductions (ll) 14. 6. 9 12. Net Value of Tax Return (l2) 36,382.75 13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts [Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 36,382.75 NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) •00 X 00 _ .00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 36,382.75 X 045. 1,637.22 17. Amount of Line 14 at Sibling rate (17) •00 X 12 - .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 1 5 - .00 19. Principal Tax Due (lq). 1,637.22 TAY CRFf1TTC~ YME DATE CEIP NUMBER D SCOUNT (+) INTEREST/PEN PAID (-) AMOUNT PAID 09-17-2001 CD000273 67.50 1,282.50 11-20-2001 CD000547 .00 287.22 TOTAL TAX CREDIT 1,637.22 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ^ IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) RESERVATION: Estates of decedents dying on or before Decewber 12, 1982 -- if any future interest in the estate is transferred in possession or enjoywent to Class B (collateral) beneficiaries of the decadent after the expiration of any estate for life or for years, the Cowwonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. ' PURPOSE OF NOTICE: To fulfill the requirewents of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of 2000. C72 P.S. Section 9140). PAYMENT: Detach the top portion of this Notice and subwit with your paywent to the Register of Nills printed on the reverse side. --Make check or Honey order payable to: REGISTER OF NILLS, AGENT REFUND CCR): A refund of a tax credit, which was not requested on the Tax Return, way be requested by cowpleting an ^Application for Refund of Pennsylvania Inheritance and Estate Tax° (REV-1313). Applications are available at the Office of the Register of Nills, any of the 23 Revenue District Offices, or by calling the special 24-hour answering service for forws ordering: 1-800-362-2050; services for taxpayers with special hearing and / or speaking needs: 1-800-447-3020 (TT only). 08JECTIONS: Any party in interest not satisfied with the appraisewent, allowance, or disallowance of deductions, or assesswent of tax (including discount or interest) as shown on this Notice wust object within sixty C6D) days of receipt of this Notice by: --written protest to the PA Departwent of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the wetter deterwined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS: Factual errors discovered on this assesswent should he addressed in writing to: PA Departwent of Revenue, Bureau of Individual Taxes, ATTN: Post Assesswent Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet ^Instructions for Inheritance Tax Return for a Resident Decedent^ (REV-1501) far an explanation of adwinistratively correctable errors. DISCOUNT: If any tax due is paid within three f3) calendar wonths after the decedent's death, a five percent (5%) discount of the tax paid is allowed. PENALTY: The 15% tax asnesty non-participation penalty is cowputed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax awnesty period. This Han-participation penalty is appealable in the sane wanner and in the the sane tine period as you would appeal the tax and interest that has bean assessed as indicated on this notice. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) wonths and one (1) day frog the date of death, to the date of paywent. Taxes which bacawe delinquent before January 1, 1982 bear interest at the rate of six (6%) percent per annuw calculated at a daily rate of .000164. All taxes which becawe delinquent on and after January 1, 1982 will bear interest at a rate which will vary frow calendar year to calendar year with that rate announced by the PA Oepartwent of Revenue. The applicable interest rates for 1982 through 2002 are: Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor 1982 20% .000548 1992 9% .000247 1983 16% .000438 1993-1994 7% .000192 1984 11% .000301 1995-1998 9% .000247 1985 13% .000356 1999 7% .000192 1986 10% .000274 2000 8% .000219 1987 9% .000247 2001 9% .000247 1988-1991 11% .000301 2002 6% .000164 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUMBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becowes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assesswent. If paywent is wade after the interest cowputaticn date shown on the Notice, additional interest wust be calculated.