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COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
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RESIDENT DECEDENT
COUNTY OF Cumberland
IMPORTANT:
This return must be completed in detail and filed in duplicate, with all attached, with the Register of Wills of the
County where decedent resided; Return is due within nine months after date of death, unless an extension is granted
hy the Secretary of Re1l:enue. (Section 703 of the Inheritance and Estate Tax Act of 1961.)
IN TilE MATTER 0.. THE ESTATE OF
} AFFIDA VlT OF
EXECUTOR
ADMINISTRA TOR
.___gI"P~~S:_. Kline
(STATE FULL NAME OF DECEDENTI
Late of
Cumberland
County
State of Pennsylvania
) 55:
County of _~~1!1~erland_
Kenneth R. Kline
Administrator ----------;;f- the ;state of the above-named decedent being duly sworn, depose S
Executor
and sayS
Decedent di ed AuguS t
(MONTH)
Name and address of attorney or }
other authorized repres,entative to whom
nIl ~0,.,.~",;pondeflce should be moiled.
22
, 19-ZL{~cstate leaving a last will, copy of which is hereto attached. }
(YEAR) rm"""'Cl"te>
(DAY)
William A. Yocum. Esquire
_P. O. Box_ ~4.ILg~!IlE_Hig_L_~ennsylvania
17011
That as such Executor deponent is familiar with the affairs of said estate and the property constituting
( EXECUTOR-ADMINISTRATOR)
the assets thereof and their fair market value.
That at the time of dea th there was no safe deposi t box regi s tered in decedent's indi vidual name, or jointly wi th, or
as agent or deputy of another, or in decedent's individual name, with right of access by another as agent or deputy, with the
t::\ception of the following: -
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION THIS SAFE DEPOSIT BOX R EN TED RELATIONSHIP OF JOINT
IN WHICH DECEDENT R EN TED A SAFE DEPOSIT BOX IN NAME OR NAMES OF HOLDERS TO DECEDENT
-'.-.--- -- -
_~uphil!~2~~t Bank and Trust Company Orpha C. Kline and Kenneth son
R. Kline --
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That the contents of said safe deposit box or boxes are itemized under Schedules n/a of this return,
with the exception of the following, for the reasons hereinafter set forth: (Will was kept in safe deposit box.)
Tlta [ Schedule A attached hereto and made part hereof sets forth fully and in detai I all the real property
In the Commonwealth of Pennsylvania of which decedent died having an interest therein. It also sets forth the
mortgage encumbrances upon each parcel of real property at the date of death, giving the amount still due at
death, name of mortgagee, date, rate of interest, and book and page of record thereof. It also sets forth in the
columns provided therefore the assessed valuation of each of said parcels, the estimated market value thereof
as of date of death of decedent.
That Schedule B attached hereto and made part hereof sets forth fully and in detail all personal property
wheresover situated owned by the decedent at the time of death; all moneys left by the decedent at the time of
death, whether in decedent's immediate possession, standing to decedent's credit in banks of deposit, savings
banks, trust companies, or other institutions, whether individually, or in trust for any other person or persons
giving also separately the accrued interest thereon, if any, down to the last interest day pri@T to decedent's
death in the case of savings banks, and to the date of decedent's death in all other cases; all bonds, postal
sav ings, treasury certificates or notes and other evidence of indebtedness of the United States to the de-
cedent; all obligations, whether by statute or agreement they are designated as tax free, of the United States,
or any state, or political subdivision thereof, or of any foreign country, which are owned at the tim(;, of de'lth;
all wearing apparel, jewelry, silverware, pictures, books, works of art, household furniture, horses, earri:lges,
automol>ilcs, "oals, and any and all other personal chattels of whatsoever. kind or nature, left by decedent,
together with llic rairly estimated market value thereof; all bonds and mortgages held by decedent and of all
claims due and owing decedent at the time of death, and all promissory notes or other instruments in writing
for the payment of money of which decedent died possessed, of whatsoever nature, with interest thereon, if
any, giving the race value and estimated fair market value thereof, and if such estimated fair market value be
less than the face vallie, it sets forth briefly the reasons for such depreciation as to each item; all moneys
pay,-,bic 10 lhe c.state from life insurance policies carried by decedent; all annuity and endowment contracts
1 he pr"cced:.; of whieh were payable upon the death of the decedent; all and the corporate stocks and dividends
dlle 111,'1('"'' "Tld unpdid as of the date of death, bonds and accrued interest thereon to the date of decedent's
de ", i, ,,,,,I "11".'r i 11\<:,:"; lment securi tics owned by the decedent at the time of death, wi th the market value there-
nf ~11 "uch til~~\'.
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