HomeMy WebLinkAbout02-0013PETITION FOR PROBATE and GRANT OF LETTERS
Estateof Dorothy L. Anderson
also known as To:
No: O t--aO t g
~ , Deceased.
Social Security Nb.74- 2 O- 1537
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the execut
in the last will of the above decedent, dated '
and codicil(s) dated
Register of Wills for the
County of Cumberland
Commonwealth of Pennsylvania
or
in the
February '21
N/A
named
,19 89
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in C u m b e r 1 ~ n d County, Pennsylvania, with
last family or principal residence at Church' of Cod Hem~, 80! 'North Hanover
// (list street, number and muncipality)
Decendent, then 81 ·. years of age, died December 29, 2901 ,~c~< ,
at ~+. .... ~. ~c (~-'~.~ Home, Car!io!c PA 17013
Exce~'a~'f~l~w~,~de~e~gnt did not marry, was not ~ivorced 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:
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 $ .... -~J-
(If not domiciled in Pa.) Personal property in County $ - 0- '
Value of real estate in Pennsylvania $ -0-
situated as follows':
St,
WHEREFORE, petitioner(s) respectfully request(s) the probate 6f the last will and codicil(s)
presented herewith find the grant of letters T e s t am e n t a r y
(testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
theron.
Ronald L. Lebo
304 Glmnn Avonl~o
Boiling Springs. PA 17007
befoph me this . ? ~ day of
~ ' ~ , Re'gister~'
1"7- .31-/i
OATH OF' PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~ ss
COUNTY OF CUHBERLAND J
The petitioner(s) ab0ve-namcd swear(s) or affirm(s) that the statements in the foregoing petition are
truc and correct to thc best o,f/thc knowledge and belief of petitioner(s) and that as personal rcprcsen-
tativc(s) of thc above decedent petitioner(s) will well and truly administer the estate according to law.
Sworn :-to or affirmed and subscribed ~9~ ffd/Oz~~°'~y.'~ _0 ,~C~'P-~thO
Ronald.,T.. T.ebo
'L
.21-02-0013
Estate of ' Dorothy L. Anderson , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW JANUARY 7th 1~ 2002, in consideration of the petition.on
the .reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated Feb r u a r y 2 1. 1 9 8 9
described therein be admitted to probate and filed of record as the last will of Dorothy L. Anderson
and Letters Testamentary
are hereby granted'to Ronald L.
Lebo
FEES
Probaie, Letters, Etc .......... $ 80.00
Short Certificates(2) .......... $ 6.00
Renunciation ................ $
JCP $ 5.00
TOTAL ~ $ 91.00
Filed .J..A~..U.4R..Y..7.t.h.,..2.0.0.2 ..............
CALLED ATTORNEy JANUARY 7, 2002
Register of Wills
Dale. F. Shughart,- Jr.. 19373
ATTORNEY (Sup.' Ci. I.D. No.)
35 E. High St.}. Suite~ 203, Carlisle,
(.717)
ADDRESS P A 17013
?/41-/4311
PHONE
25 .'f
o
z
o C~'
~ .F~
.21-02-0013
REGISTER OF WILLS oF .. COUNTY'
OATH OF SUBSCRIBING WITNESS ' ~
'codicil ' . ~ ' '
(each) a subscribing witness..to the will presented herewith, (each) being dulY~ed according to
present and saw
law, depose(s) and say(s) that / ,
the testat : ~ ; sign the same and that _J signed as a witness at the
request of testat in h presence and (in the pr/~e of each other) (in the presence of the
other subscribing Witness(es)).. · ~ .
Sworn to or affirmed and subscribed before.~ ' . ___
me this L.. ,Q_ __d.~f (Name)
~ ' "~ ~_/9~ (Address).
Register. (Name)
(Address)
REGISTER OF. WILLS OF CUMBERS,AND COUNTY
OATH OF NON-SUBSCRIBING WITNESS
Dale F. Shughart, Jr. a'nd Ronald L. Lebo
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and saY(s) that
they are familiar with the signature of Dorothy L. Anderson,
testat~-~- of ffo~"x~f~i~:~Rl~j:bj~v3gx:~(t~'Rxt:q) the will presented herewith and
that e a c h believes the signature on the will is in the handwriting of
Dorothy L. Anderson
to the best.of .-~k~e~,~, knowledge and belief.
~.'. ~'~ .) ' . .- . -'. ,,..?'~
Sworn to-qr:affirmed and '~ubs'cribed before
me this' , ~,.,~cday of
Register
(Name)
35~Eas_t Hkg~ Street,
Ronald L. Lebo ~
Suite 203, Carlisle,
PA 17013
(Name)
304 Glenn Avenue, Boilin~
(Address)
Springs
PA 17007
105.805 REV 9~86
LAST WILL AND TESTAMENT
OF
DOROTHY L. ANDERSON
21-02-0013
I, DOROTHY L. ANDERSON, widow, of Middlesex Township (mailing
address: 15 Chestnut Drive, Carlisle, Pennsylvania 17013), Cumber-
land County, Pennsylvania, being of sound and disposing mind, memory
and understanding, do hereby make, publish and declare this as and for
my Last Will and Testament hereby revoking and making void any and all
Wills by me at anytime heretofore made.
1. I direct my'hereinafter named ExecUtor to pay~all of my just
debts and funeral expenses as soon after'my death as may be found con-
venient to do so.. - I direct .t.hat~ m~ ~f-un~rallser~ices be conducted by
Hoffman-Roth Funeral Home, 219 North Hanover street, Carlisle, Penn-
sylvania, and that my body be interred on my burial lot located in
Cumberland Valley Memorial Gardens along Governor Ritner Highwgy near
the Borough of Carlisle, Pennsylvania.
2. Ail of the rest, residue and remainder of my estate, real,
personal and mixed, and wheresoever the same may be situate, I give,
devise and bequeath to my son, Ronald L. Lebo, his heirs and assigns,
provided he shall survive me by a period of ninety (90) days, but
should he fail to so survive me then to such of his issue as shall
survive me by a period of ninety (90) days, per stirpes. At the
present time the issue of my son, Ronald L. Lebo, is his two sons,
Ronald L. Lebo, Jr., and Randall Lebo.
3. I hereby nominate, constitute and appoint my said son, Ronald
L. Lebo, as Executor of this my Last Will and Testament but should he
pre-decease me or fail to qualify or cease serving as such, then in
such event I nominate, constitute' and appoint Farmers Trust Company
and its successors, One West High Street, Carlisle, Pennsylvania, as
alternate or successor Executor, and I further direct that neither of
them shall be required to post any bond to secure the faithful perfor-
mance of his or its duties in the Commonwealth of Pennsylvania or in
any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this
my Last Will and Testament writteh on one (1) page this 21st day of
February , 1989.
Dorothy' L~Ander'so~ ' -' -.
(SEAL)
'Sig~e~d,'- sealed, publish~-d and= declared :by DOROTHY- L. ANDERSON,
the Testatrix above named, as and for her Last Will and Testament, in
our presence, who, in her presence, at her request, and in the
presence of each other, have hereunto subscribed our names as
attesting witnesses. ~. ....
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: Dorothy L. Anderson
Date of Death: December 29, 2001 ~
Estate No. 21-02-0013
To the Register:
I certify that notice of estate administration 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
January , 2002.
Name
Ronald L. Lebo..
2. Ronald L. Lebo, Jr.
3. Randall B. Lebo '
Address
304 Glenn Avenue
Boiling Springs, .PA 17007
471'Winding Brook Road
Biglerville,. PA 17.307
701 Baltimore Pike
Gardners, PA 17324
Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except None
Date: January< 2002
capacity:
35 East High Street, Suite 203
Carlisle, PA 17013 ~ ·
Teleph6ne (717)~ 241-{~1
- _ _
~ounsel for Personal~Repre~nta{~i~ve
Ronald L. Lebo '~
IMPORTANT NOTICE·
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE DOES NOT MEAN THAT YOU WILL
RECEIVE ANY MONEY OR PROPERTY FROM
THIS ESTATE OR OTHERWI. SE
Whether you will receive any money-or property will be
determined wholly or partly by the decedent's will. If the
decedent died without a will, whether you will receive any money
or property will be determined by the intestacy laws of
Pennsylvania.
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA
In re Estate of Dorothy A. Anderson, deceased
Estate NO. 21-02-0013
TO:
Ronald L. Lebo
304 Glenn Avenue
Boiling Springs, PA
17007
Please t~ke notice of the death of decedent and the grant of
letters to the personal representative(s) named below.
The Decedent Dorothy L. Anderson, died on the 29th day of
December, 2001, at Carlisle, Cumberland County, Pennsylvania.
The Decedent died testate.
The personal representatives of the Decedent is:
Ronald L. Lebo
304 Glenn Avenue
Boiling Springs, PA
(717) 249-1245
17007
The will has been filed with the Office of the Register 'of
Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA
17013. Phone No. 717-240-6345.
A copy of the Will or Petition may be obtained by contacting
the Register'~o·f Wills and paying the charges~or duplication.
Date: January ~, 2002
bale F. S~g~rt, J/r.
Attorney Supreme Court I.D. #19373
35 East High Street, Suite 203
Carlisle, PA 17'013
Telephone (717) 241-4311.
Capacity: Counsel for Personal Representative
Ronald L. Lebo
'IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE'DOES NOT MEAN THAT YOU WILL
RECEIVE ANY MONEY OR PROPERTY FROM
THIS ESTATE OR OTHERWISE
Whether you will receive any money or property will be
determined wholly or partly by the decedent's will. If the
decedent died without a will, whether you will receive any money
or property will be determined by the intestacy laws of
Pennsylvania.
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA
In re EState of Dorothy A. Anderson, deceased
Estate No. 21-02-0013
TO: Ronald L. Lebo, Jr.
471 Winding Brook Road
Biglerville, PA 17307
Please take notice of the death of decedent and the grant of
letters to the personal representative(s) named below.
The Decedent Dorothy L. Anderson, died on the 29th day of
.December, 2001, at Carlisle, Cumberland County, Pennsylvania.
The Decedent died testate.
The personal representatives of the Decedent is:
Ronald L. Lebo
304 Glenn Avenue
Boiling Springs, PA
(717) 249-1245
17007
The will has been filed with the Office of the Register of
Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA
17013. Phone No. 717-240-6345.
A copy of the Will or Petition may be obtained by contacting
the Register of Wills and paying the c~arges f9~ duplication.
Date: January 2002
v ~ale Ff Shugh~k~t//Jr.
. Attorney Suprem~ Court I.D. #19373
35 East'High Street, Suite 203
Carlisle, PA 17013
Telephone (717) 241-4311
gapacity: Counsel for Personal Representative
Ronald L. Lebo
IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE DOES NOT MEAN THAT YOU WILL
RECEIVE ANY MONEY OR PROPERTY FROM
THIS ESTATE OR OTHERWISE
Whether you will receive any money or property will be
determined wholly or partly by the decedent's will. If the
decedent died without a will, whether you will receive any money
or property will be determined by the intestacy laws of
Pennsylvania.
BEFORE THE REGISTER OF WILLS, COUNTY .OF CUMBERLAND, PENNSYLVANIA
In re Estate of Dorothy A. Anderson, deceased
Estate NO. 21-02-0013
TO:
Randall B. Lebo
701 Baltimore Pike
Gardners, PA 17324
Please take notice of the' death of decedent and the grant of
letters to the personal representative(s) named below.
The Decedent 'Dorothy L. Anderson, died on the 29th day of
December, 2001, at Carlisle, Cumberland County, Pennsylvania.
The Decedent died testate.
The personal representatives of the Decedent is:
Ronald L..Lebo
304 Glenn Avenue
Boiling Springs, PA
(717) 249-1245
17007
The will has been filed with the Office of the Register of
Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA
17013..Phone No. 717-240-6345.
A copy of the Will or Petition may be obtained by contacting
the Register of Wills and paying the charges for .d~plication.
Date: Januar , 2002
ale F..Sh~ghart, Jr/
Attorney Supreme CoUrt I.Di #19373
35 East High Street, Suite 203
Carlisle, PA 17013
Telephone (717) 241-4311
Capacity: Counsel for Personal Representative
Ronald L. Lebo
IN RE: ESTATE oF
DOROTHY L. ANDERSON, deceaSed
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND~COUNTY, PENNSYLVANIA
: ORPHANS' COURT.DIVISION
: ESTATE NO. 21-02-0013
To:
PRAECIPE
Register of Wills
I, Ronald L. Lebo, Executor Of
the Estate
of Dorothy L.
Anderson,~ have decided to proceed with the administration of the
Estate without legal counsel. I therefOre request~that Dale F.
Shughart, Jr., Esquire, withdraw from representation as my attorney
in regard to'this matter. ·
Date: February ~, 2002 ~-'~_~7~~ /.~~
~o~ald L. Lebb, ~xecutor
Estate of Dorothy L. Anderson,
Deceased
Date:
Upon the.above request of Ronald L. Anderson, Executor of the
Estate of Dorothy L. Anderson, I hereby withdraw as his attorney in
regard to the above ~aptioned matter.
February', 2002 ~~ ~3 ~.
D~le F. Shugharf, Jr.
Supreme Court I.D. 19373
35 East High Street, Suite 203
Carlisle, PA 17013
0
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-1162 EX(11-96)
CD 000984
LEBO RONALD L
304 GLENN AVENUE
BOILING SPRINGS, PA
17007
........ fold
ESTATE INFORMATION: SSN: 174-20-1537
FILE NUMBER: 2102-001 3
DECEDENT NAME: ANDERSON DOROTHY L
DATE OF PAYMENT: 03/21/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUM BERLAN D
DATE OF DEATH: 12/29/2001
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101
$21,000.00
TOTAL AMOUNT PAID'
$21,000.00
REMARKS: RONALD LLEBO
SEAL
CHECK//105
INITIALS: CW
RECEIVED BY:
MARY C. LEWIS
REGISTER OF WILLS
REGISTER OF WILLS
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
31- II
FILE NUMBER
,¢..1
COUNTY CODE YEAR . NUMBER
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Z
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Z
ILl
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(.,3
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(..1
X
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
ANDERSON, DOROTHY L ESTATE 174-20-1537
DATE OF DEATH (MM-OD-YEAR) DATE OF BIRTH (MM-DO-YEAR) THIS RETURN MUST BE FILED mN'DUPLICATE wi'TH THE
12/29/2001 02/04/1920 REGISTER OF WILLS
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
[] 1. Original Return
[] 4. Limited Estate
[] 6. Decedent Died Testate (At~ach copy of Will)
[] 9. Litigation Proceeds Received
[] 2. Supplemental Return
] 43. Future Interest Compromise (date of death alter 12-12-82)
[] 7. Decedent Maintained a Living Trust (Attach copy of Trust)
[] 10. Spousal Poverty Credit (date of death between12-31-91 andl.l.95)
] 3. Remainder Retum (date of death prior to 12-13-82)
[] 5. Federal Estate Tax Return Required
__ 8. Total Number of Safe Deposit Boxes
[] 11. Election to tax under Sec. 9113(A) (~ach Sch O)
:THIS SEq~ION~MUST BE COM PEE~EDJ AL, E;CORRESp~ONDEN~CE AND CONFIDENT ~A E~T~ INFORMATION SHOIJED~BE{DIRECTED,TO ~
~ME
ARLENE GRAVER
FIRM NME (If Appli~ble) '-
J P HASSLER
TELEPHONE NUMBER
717-243-2536
COMPL~E ~ILING ADDRESS
236 SOUTH HANOVER STREET
CARLISLE PA 17013
1. Real Estate (Schedule A) (1) ~'.'-::
2. Stocks and Bonds (Schedule B) (2) 161,838 ~i'38
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) ;" -
4. Mortgages & Notes Receivable (Schedule D) (4) *~-':? '
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 2 8 8,8 6 2 .,18
(Schedule E) ~.:.
6. Jointly Owned Property (Schedule F) (6)
[] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1 - 7) (8)
9. Funeral Expenses & Administrative Costs (Schedule H) (9) 8, 4 9 8.1 5
10. Debts of Decedent, Modgage Liabilities, & Liens (Schedule I) (10) 7,7 6 2.2 7
11. Total Deductions (total Lines 9 & 10) (11)
12. Net Value of Estate (Line 8 minus Line 11) (12)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14)
' ~OFFIC!~Li~SE ONLY
450,700.56
16,260.42
434,440.14
434,440.14
SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1:2) × .0 (15)
16. Amount of Line14 taxable at lineal rate 434,440.14 x .o 45 (16)
17. Amount of Line 14 taxable at sibling rate × .12 (17)
18. Amount of Line 14 taxable at collateral rate × .15 (18)
19. Tax Due
19,549.81
'19,549.81
(19)
SURE TO,ANS~RAi2L QUESTIONS ON REVERSE S DE AND RECHECK MArrH ,<'A';;;. .......: -;. ; , ,;-'/, :¢.; j
STF PA42021F.1
Dece~lent's Complete Address:
STREET ADDRESS
304 Glenn Ave ....
cn'Y CARLISLE I STATE PA Iz'P 17007
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
21,000.00
984.72
Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C) (2)
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difterence. This is the OVERPAYMENT.
Check box on Page I Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
(1) 19,549.81
(3)
(4)
(5)
(5A)
(5B)
21,984.72
2,434.91
0.00
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 0.0 0
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ........................................ [] []
b. retain the dght 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 after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .................................................. [] []
3. Did decedent own an "in trust for" or payable upon death bank account or secudty at his or her death? ..... [] []
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................... [] []
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
DATE
SIGNAT, b'RI~ OF.,?[PREPAR..EE.QT[;tE-I~ THAN REPRESENTATIVE
('...~..~ ~- ~ (/~,~.~.,_.,,/ JOHN P. H~S[~ P~ DATE
ADDRESS ' /
238 SOUTH HANOVER
For dates of death on or alter July 1, 1994 and be~re Janua~ 1, 1995, the t~ rate impos~ on the net value of transfers to or for the use of the suwiving spouse is 3%
[72 P.S. }9116 (a) (1.1)(i)].
For dates of d~th on or after Janua~ 1, 1995, the t~ rate impos~ on the net value of tmnsfem to or for the use of the suwiving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)].
The statute does not exempt a transfer to a suwiving spouse ~om t~, and the statuto~ r~uirements for disclosure of assets and ~ling a t~ return are still applicable even
if the suwiving spouse is the only beneficial.
For dates of d~th on or after July 1, 2000:
The t~ rate impos~ on the net value of transfers from a d~as~ child ~en~-one years of age or younger at d~th to pi for the use of a natural paint, an adoptive
parent, or a steppamnt of the child is 0% [72 P.S. ~9116(a)(1.2)].
The t~ rate impos~ on the net value of transfers to or for the use of the d~ent's lineal beneficiaries is 4.5%, except as not~ in 72 RS. ~9116(1.2) [72 P.S. ~9116(a)(1)].
The t~ rote impos~ on the net value of transfem to or for the use of the d~enrs siblings is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is define, under S~tion 9102, as an
individual who has at least one parent in common with the d~ent, whether by blood or adoption.
STF PA42021F.2
REV-15~)3 EX + (1-97) (I)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DOROTHY L ANDERSON 21-02-0013
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
SCUDDER PREMIUM RESERVE MONEY MARKET
SCUDDER TOTAL RETURN FUND A
CUMBERLAND VALLEY COOPERATIVE ASSN
SHARES
158,069.83
2,528.55
1,240.00
TOTAL (Also enter on line 2, Recapitulation) $ 161, 838.38
(if more space is needed, insert additional sheets of the same size)
STF PA42021F.4
'RE~/-15'08 EX + (1-97) (I)
· COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
· DOROTHY L ANDERSON
FILE NUMBER
21-02-0013
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the dght of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION ~ OF DEATH
2
3
4
5
6
7
8
9
M&T BANK CHECKING ACCT # 400602
M&T BANK SAVINGS ACCT # 15004198190793
THE CHURCH OF GOD HOME INC. REFUND
M&T BANK X-MAS CLUB ACCT # 25004920035688
HOFFMAN-ROTH PREPAID FUNERAL ARRANGEMENTS
PENNSYLVANIA DEPT OF REV 2001 PERSONAL TAX REFUND
HARTFORD LIFE & ACCIDENT REFUNDED
HARTFORD LIFE & ACCIDENT REFUNDED
HARTFORD LIFE & ACCIDENT REFUNDED
24,541 83
258,260 70
2,068 44
160 12
3,551 02
113 00
6 43
31 24
129 40
TOTAL (Also enter on line 5, Recapitulation) $ 2 8 8,8 6 2. 1 8
(If more space is needed, insert additional sheets of the same size)
STF PA42021F.9
REV-1511 EX + (1-97) (I)
'COMMONVVEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
DOROTHY L ANDERSON
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
I
FILE NUMBER
21-02-0013
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A.
5.
6.
7.
FUNERAL EXPENSES:
HOFFMAN-ROTH FUNERAL HOME,
MAXIME BISHOP FUNERAL EXP'.
GRACE UNITED CHURCH
GLENVALE CHURCH
INC.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Sodal Security Number(s) / ElM Number of Personal Representative(s)
Street Address
City State
Year(s) Commission Paid:
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach e~lanation)
Claimant
Zip
Stree~ Address
City State Zip
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
THE SENTINAL EXECUTOR'S NOTICE LETTERS TESTAMENT
J P MORGON
TOTAL (Also enter on line 9, Recapitulation)
3,666.30
93.19
-100.00
100.00
1,422.75
91.00
2,500.00
400.00
64.67
60.24
8,498.15
(If more space is needed, insert additional sheets of the same size)
STF PA42021F.12
REV-1512 EX + (1-97) (I)
'COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
DOROTHY L ANDERSON
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES,& LIENS
FILENUMBER
21-02-0013
Include unreimbursed medical expenses.
iTEM
NUMBER
2
3
4
5
6
7
DESCRIPTION
BROCKIE PHARMATECH
J P HASSLER PERSONAL INCOME TAX PREP
INTERNAL REV PERSONAL 2001 INCOME TAX
BROCKIE PHARMATECH
THREE SPRINGS PRACTICE
CHURCH OF GOD HOME
THREE SPRINGS PRACTICE
AMOUNT
63 05
332 00
6,886 00
12 00
12 86
418 69
37 67
TOTAL (Also enter on line 10, Recapitulation) $ 7, 7 6 2.2 7
(If more space is needed, insert additional sheets of the same size)
STF PA42021 F. 13
· 'RE'~-15'~ 3 EX + (9-00)
"COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
DOROTHY L ANDERSON
SCHEDULE J
BENEFICIARIES
FILE NUMBER
21-02-0013
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I.
TAXABLEDISTRIBUTIONS[includeoutdghtspousaldistdbutions, andtmn~
underS~.9116(a)(1.2)]
RONALD L LEBO
304 GLEN AVE.
BOILING SPRINGS PA. 17007
SON
100%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insed additional sheets of the same size)
STF PA42021 F. 14
STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
MARY C. LEWIS
Register for the Probate of Wills and Granting
Letters of Administration &c. in and for said
County of CUMBERLAND do hereby certify that on
the 7th day of January A.D.,
Two Thousand and Two,
Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
estate of ANDERSON DOROTHY L
(]_~t~'l', ~'1~'1', MI~)
, late of NORTH MIDDLETON TOWNSHIP
in said county,' deceased, to
LEBO RONALD L
(~aS'c, ~'~'~', M±~)
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of said office at CARLISLE, PENNSYLVANIA, this 31st day of January
A.D., Two Thousand and Two.
File No.
PA File No.
Date of Death
s.s. #
2002-00013
21-02-0013
12/29/2001
174-20-1537
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
'DOROTHY C"AHDERSON
I, DOROTHY L. ANDERsoN,' widow, of Middlesex Township (mailinq
address: 15 Chestnut Drive, Carlisle, Pehnsylvania 17013), Cumber
la~d Co~unt.y, ~.Pennsy~!v.ania., being of sound and disposing mind, memory
anc~ unaerstan(]l'ng, ao hereby make, publish and declare this as and for
my Last Will and Testament hereby revoking and making void any and all
Wills by me at anytime heretofore made.
1. I direct my hereinafter named Executor to pay all of my just
debts and funeral expenses as soon after my death as may be found con-
veni~nt to do so. I direct that my funeral services be conducted by
Hoffman'R6th Funeral Home, 219 North Hanover Street, Carlisle, Penn-
sylvania, and that my body be interred on my burial lot located in
Cumberland Valley Memorial .Gardens along Governor Ritner Highway near
the Borough of Carlisle, Pennsylvania.
2. Ail of the rest, residue and remainder of my estate, real,
personal and mixed, and wheresoever the same may be situate, I give,
devise and bequeath to my son, Ronald L. Lebo, his heirs and assigns,
provided he shall survive me by a period of ninety (90) days, but
should he fail to so survive me then to such of his issue as shall
survive me by a period of ninety (90) days, per stirpes. At the
present time the issue of my son, Ronald L. Lebo, is his two sons,
Ronald L. Lebo, Jr., and Randall Lebo.
3. I hereby nominate, constitute and appoint my said son, Ronald
L. Lebo, as Executor of this my Last Will and Testament but should he
pre-decease me or fail to qualify or cease serving as such, then in
such event I nominate, constitute and appoint Farmers Trust Company
and its successors, One West High Street, Carlisle, Pennsylvania, 'as
alternate or successor Executor, and I further direct that neither of
them shall be required to post any bond to.secure the faithful perfor-
mance of his or its duties in the Commonwealth of Pennsylvania or in
any other jurisdiction. -
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this
my Last Will and Testament written on one (1) page this 21st day of
February , 1989.
Dorothy' L~Ander'soh '-
(SEAL)
Signed, soa].ed, published and ~eclared by DOROTHY L. ANDERSON,
the Testatrix above named, as and for her Last Will and Testament, in
our presence, who, in her presence, at her request, and in the'
presence of each other, have hereunto subscribed our names as
attesting witnesses.
DEPARTMENT OF THE TREASURY
INTERNAL REVENUE SERVICE
OGDEN UT 8q201
DATE.OF THIS NOTICE: 01-31-2002
NUMBER OF THIS NOTICE: CP 575 B
EMPLOYER IDENTIFICATION NUMBER:
FORM: SS-I
0511303108 B
26-6009769
DOROTHY L ANDERSON ESTATE
LEBO RONALD L
301 GLENN AVE
BOILING SPRINGS PA 17007
FOR ASSISTANCE CALL US AT:
1-800-829-1010
OR WRITE TO THE ADDRESS
SHOWN AT THE TOP LEFT.
IF YOU WRITE, ATTACH THE
STUB OF THIS NOTICE.
WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER (EIN)
...... Thank you fo~ .your-Form SS=ii .Applicat-ion_for: Employer__!dentification_Number'.
(EIN). We assigned you EIN 26-6009769. This number will identify your estate or
trust. If you are not the applicant, please contact the individual who is handling the
estate or trust for you. Please keep this notice in your permanent records.
Use your complete name and EIN shown above on all federal tax forms, payments and
related correspondence. If you use any variation in your name or EIN, it may cause
a delay in processing and incorrect information in your account. It also could cause
you to be assigned more than one EIN.
Based on the information shown on your Form SS-i, you must file the following
forms(s) by the date we show.
Form 10ql 0q/15/2003
Your assigned tax classification is based on information obtained from your Form
SS-i. It is not a legal determination of your tax classification and is not binding
on the IRS. If you want a determination on your tax classification, you may seek a
private letter ruling from the IRS under the procedures set forth in Rev. Proc. 98-01,
1998-11.R.B. 7 (or the superceding revenue procedure for the year at issue).
If you need help in determining what your tax year is, You can get Publication
538, Accounting Periods and Methods, at your local IRS office.
If you have.questions about the forms shown or the date they are due, you may
call us at 1-800-829-1010 or write to us at the address shown above.
88922~1105 II & T FTRST
O0 0 043~4N NH 017
AUG..O8-SEP.06,2002 I OF 1
ESTATE OF DOROTHY L ANDERSON
$0~, GLENN AVE
BOTLTNG SPRTNGS PA 17007
SPRZNG'G~RDEH
ACCOUNT SUMMARY
NO.I ANOUNT NO.I AHOUNT No.I AHOUNT
$5,, 6.6~. 06 0 O. O0 0 O. O0 0 O. O0 0. O0 $~, ,, 6F,5.06
ACCOUNT ACTZVZTY
08-08-.02 BEG/NNZNG,BALANCE SSS,65S.06
ENDZNG BALANCE
$55,655.06
REFER A FRZEND TO H&T BANK AND GET A FREE GZFT!
NOW, #H~N YOU ASK A FRZEND TO OPEN A CHECKZNG ACCOUNT'WZTH MST, NOT. ONLY #ZLL
YOU GET A FREE GZFT - SO HZLL YOUR FRZEND. STOP BY ANY NgT BRANCH OR CALL NgT'S
TELEPHONE BANKING CENTER AT 1-800-72q-2qqO TO GET A REFER-A-FRIEND COUPON.
HURRYj GZFT QUANTZTZES ARE LINITED. FREE GZFT PROVZDED AT TZHE OFACCOUNT'
OPENZNG.
L008A (12/93)
Follo~ these steps to bring your checP, bool~ balance into agreement with this statement.
[ STEP l: ]
[ STEP 2:
ADD
(a)
(b)
SUBTRACT
(a)
(b)
(c)
Beginning with the first item on this statement place a checkmark (,,-) beside each item that has a corresponding entry in*your
checkbook register. (Place the checkmark next to each item in your checkbook register and on this statement.)
TO DETERMINE YOUR CURRENT CHECKBOOK BALANCE:
to the balance shown in your checkbook register by writing in the amount of:
Any deposits and other additions shown on this statement which you have not already added; and
Any interest this statement shows as credited to your checking account, if it is an interest earning account.
from that total by writing in your checkbook register the amount of:
Any checks or other subtractions shown on this statement which you did n~)t enter into your register; and
Any automatic VISA or loan payments or other electronic transfers shown on this statement which you have not already
subtracted; and
Any service charges shown on this statement which you have not already subtracted.
Complete STEPS 3 through 8 to determine the current balance in your checking account.
[ STEP 3: ] List any outstanding checks (written but not yet paid by M&T Bank) and other subtractions not appearing on your statement in
the spaces provided below.
CHECKS OUTSTANDING AND OTHER SUBTRACTIONS
NUMBER AMOUNT
$
TOTAL AMOUNT OF
CHECKS OUTSTANDING
AND OTHER SUBTRACTIONS $
STEP 4: I Enter on this line the Ending Balance shown
on the front of this statement.
I Enter the total of any deposits or other additions
STEP
5:
shown in your checkbook register which are not shown on this
statement.
STEP 6: I Add the amounts in STEPS 4 and 51 enter the
total here.
I Enter the total of "Checks Outstanding and
STEP
7:
Other Subtractions" (from STEP 3) here.
STEP 8: I Subtract total of STEP 7 from STEP 6 and
enter the difference here. This amount should be you~ '~'
current checking account balance.
HAVE YOU MOVED? If so, please contact QuickLine at (716) 626-1900 or (800) 724-2440
outside of the Buffalo area or.contact your local branch of M&T Bank or write to:
M&T BANK
AlrN: QUICKLINE
P.O. BOX 767
BUFFALO, NEW YORK 14240-0767
CALL (716) 626-1900 OR (800) 724-2440 OUTSIDE OFTHE BUFFALO AREATO DETERMINE IFANY SCHEDULED DIRECT DEPOSIT OR PREAUTHORIZED TRANSFER
TO YOUR ACCOUNT HAS OCCURRED.
Telephone us at (716) 626-1900 or (800) 724-2440 outside of the Buffalo area or write us at: M&T BANK
A'I-FN: QUICKLINE
PO BOX 767
BUFFALO, NY 14240-0767
as soon as you 'can,' if you think your statement or receipt is wrong or if you need more information about a transfer on the statement or receipt.
We must hear from you no later than 60 days after we sent you the FIRST statement on which the error or problem appeared.
(1) Tell us your name and account number (if any).
(2) Describe the error or the transfer you are unsure about, and explain as clearly as you can why you believe there is an error or why you need.
more information.
(3) Tell us the dollar amount of the suspected error.
We will investigate your complaint and will correct any error promptly. If we take more than 10 business days to do this, we will recredit your
account for the amount you think is in error, so that you will have use of the money during the time it takes us to complete our investigation.
1993 Manufacturers and Traders Trust Company LOO8A (12~93)
February 12, 2002
~: Estate Search
The Estate of: DOROT~ L ~DERSON
Date of Death (D.O.D.) 12/29/01
To Whom It May Concern:
Identified below is the account information requested.
1. M&T Bank accounts in which the decedent's name appears:
Account Account Number Account Title Opening Branch
Type
CHK 400602
SAV 15004198190793
DOROTHY L ANDERSON 4344
DOROTHY L ANDERSON 4344
RONALD L LEBO, POA
X-MAS 25004920035688 DOROTHY L ANDERSON 4344 $160.12 $.12
CLUB
D.O.D. Accrued Interest
Balances
(Includes Accr.
Int.)
$24,541.83 $2.08 .
$258,260.70 $53.20
2. Loans, Mortgages, or other obligations titled in the decedent's name
Account Number Amount Owed Account Description
NO Safe Deposit Box titled in the Decedent's name existed at our office.
If you have any questions about the information provided, please contact our Records Department at (716) 635-4010 or 1-800-724-
2440 outside of the Buffalo, NY calling area. Ihank you.
Sincerely,
M&T BANK CORPORATION
Authorized Signature
DATE: &~ [ '2, ~0 2--
Manufacturers and Traders Trust Compan~ · 1100 Wehrle Drive, RO. Box 767, Buffalo, NY 14240-0767
$EP-24-~2 t ! :~5 AM GI~B
Account Statement
January, I March 31, 2002
F IhlAt~C I AL
SERVICES
24 9
P.~4
SCUDDER
INVESTMENT5
Pagr 3 of 4
Premium Reserve MM Shares
Fund-Actount~ 97 - $8§$ { ~2 -0
Oivldand Summery
Ceteger~ Year..To- Dote
Taxable
Ordinary Income' $111.16
This amount Includes taxable int~mm dividends and taxable short-term capitul gain dividends,
Account Activity
Date Description
Market Value as oj7 12/.51/01
01/11/02 From Tot Ret-A 3855090
01/15/02 Strafes Redeemed
01/15/02 Income Div Cash
· 01/15/02 Ca.~h Dividend Reinvested
01/15/02 Redemption Cancellation
01/23/02 'l'runsfer To 660373
Market Value as of 03/31/02
Dollar Amount 4, Shore Prka s Shares
$158,069.g3 $1.00
2,767.35 1.00 2,767.350
160,837. I8 1,00 160,837.180
111.16
111,16 1,00 111.160
160,837.18 1.00 160,837.180
0.00 160,948,340
$0.00 $ ~.00
Shores Owned
i5$,069,830
160,8:17,180
0,000
0.000
111.160
i 60,948.:340
0,000
0,000
Fund Performance:
All yields are annualized for the peri(x{ ending 03/26/02. Please s~e the reverse side for mc~re inFormattor~.
The 7-~)ay Average Simple Yield: 1,35%; the 7-Day Average Compound Yield: 1,36%.
· N1 HAI~,, OVER .$TI~L~,,;
'*' PAY,
GLENN AVENUE
17~7
EST
u~ bu~uinz .~o~ ~Ci~l~: ~~i Register No29343
~.~l~liz ACCT $ um~'i~li~l~ AMOUNT
CHURCH OF
GOD HOME
11201 A/R-PRiV PAY
z~oo 44
g1923-A
January 28, 2002
Ronald L. Lebo
304 glen Ave.
Boiling Springs, PA
17007
Hoffman-Roth Funeral HOme, Inc.
219 North Hanover Street
Carlisle, PA. 1.7013
(717)243-4511
The Funeral Service for Dorothy L. Anderson
13665-268
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
(A) OUR SERVICE:
TRADITIONAL FUNERAL SERVICE PACKAGE $3490.00
FUNERAL HOME SERVICE CItARGES ............ $3490.00
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED
$3490.00
Cash Advances
Certified Copies of Death Certificates .................. $12.00
Flowers ...... $164.30
TOTAL CASH ADVANCES AND SPECIAL CHARGES ........ $176.30
Total
Total Cost
$3666.30
History
01/28/2002 Microdata Systems, Ine ................... ~ C~
TOTAL AMOUNT DUE .................. / k.~.$1!5.28 ) x,~l i~4,.
Please return this portion with your Remittance
Amount Enclosed
Service ID # 13665-268
Dorothy L. Anderson
PLEASE
DO NOT USE YOUR
LABEL
0100115195
2001
PA-40
PAGE 1 OF 2
174-20-1537
ANDERSON
304 GLENN AVE
BOILING SPRIN
lA
2
5
8
11
.00
133.00
.00
.00
3109.00
PA
17007
DOROTHY
lB .00
3 2976.00
6 .00
9 3109.00
12 87.00
1C
4
7
10
EX
A
FY
XX
SC
PN
0 RS R
0 FS D
0
21110
717-249-1245
.00
.00
.00
.00
PLEASE FOLD PAGE ALONG THIS LINE
Local Information. Enter where you lived as of 12/31/2001
School District: Carlisle Area
School Code: 21110
County: Cumberland
Municipality: CARLISLE BORO
Residency Status. (Mark the Correct Space)
R X Pennsylvania Resident
NR Nonresident
P Part Year Resident
From:
To:
Extension, (Mark This Space)
Amended Return, (Mark This Space)
Fiscal Year Filer, (Mark This Space)
Type Filer. (Fill in only one circle)
S Single
J Married, Filing Jointly
M Married, Filing Separately
F Final Return. Indicate Reason:
D X Deceased
Date of Death 12/29/01
la Gross Compensation. See the instructions la
1 b Unreimbursed Employee Business Expenses. See the instructions lb
lc Net Compensation. Subtract Line lb from Line la. lc
2 Interest Income. Complete and submit PA Schedule A, if over $2,500. 2
3 Dividend Income. Complete and submit PA Schedule B, if over $2,500.. .................................... 3
4 Net Income or Loss from the Operation of a Business, Profession, or Farm. 4
5 Net Gain or Loss from the Sale, Exchange, or Disposition of Property. 5
6 Net Income or Loss from Rents, Royalties, Patents, or Copyrights. 6
7 Estate or Trust Income. Complete and enclose PA Schedule J. 7
8 Gambling and Lottery Winnings.. ....................................................................... 8
9 Total PA Taxable Income. Add only the positive income amounts from Lines lc, 2, 3, 4, 5, 6, 7, and 8.
DO NOT ADD any losses reported on Lines 4, 5, or 6. 9
10 Deduct payments to Medical Savings Account ........................................................ 10
.00
00
00
133 00
2976 00
00
00
00
00
00
3109.00
.00
11 Adjusted PA Taxable Income. Subtract Line 10 from Line 9. 11
3109.00
12
PA Tax Liability. Multiply Line 11 by 2.8% (0.028). Also enter on Line 13, Side 2.
EC
0100115195
12
FC
0100115195
-87.00
· mmm~ 0100215193
2001
PA-40
PAGE 2 OF 2
ANDERSON
DOROTHY
13 87.00 14 .00 15
16 157.00 17 .00 18
19 200.00 20A 00 20B
21 .00 22 .00 23
24 .00 25 .00 26
27 200.00 28 .00 29
30 113.00 31 .00 32
33 .00 34 .00 35
36 .00
L 174-20-1537
43.00
.00
00
.00
.00
113.00
.00
.00
13 Total PA Tax Liability.
Enter your PA Tax Liability from Line 12 on Side 1 ........................................... 13
14 Total PA Tax Withheld. See the instructions 14
15 ' Credit from your 2000 PA Income Tax Return. 15
16 2001 Estimated Installment Payments.. ............................................................. 16
17 2001 Extension Payment. 17
18 Nonresident Tax Withheld on your PA Schedule(s) NRK-1. (Nonresidents only) 18
19 Total Estimated Payments and Credits. Add Lines 15, 16, 17, and 18. 19
TAX BACK/Tax Forgiveness Credit. Complete lines 20a, 20b, 21, and 22. Read instructions
20a Filing Status: Unmarried or Separated Married Deceased
20a
20b Dependents, Part B, Line 2 PA Schedule SP. 20b
21 Total Eligibility Income, Part C, Line 11, PA Sc~'e'c~l~' S~.' ................ · ............................. 21
22 TAX BACK/Tax Forc~iveness Credit from Part D~ Line 16~ PA Schedule SP ................. 22
23 Total Credit for Taxes Paid to Other States or Countries. Submit your PA Schedule G or RK-1. 23
24 PA Employment Incentive Payments Credit. Submit your PA Schedule W, RK-1 .or NRK-1. 24
25 PA Jobs Creation Tax Credit. Submit your certification or PA Schedule RK-1 or NRK-1. 25
26 'PA Research and Development Tax Credit. Submit your certification on PA Schedule RK-1 or NRK-1. 26
27 Total Payments and Credits. Add lines 14 and 19 and 22 through 26. 27
28 TAX DUE. If Line 13 is more than Line 27, enter the difference here. 28
29 OVERPAYMENT. If Line 27 is more than Line 13, enter the difference here. 29
The total of Lines 30 through 36 must equal Line 29.
30 Refund - Amount of Line 29 you want as a check mailed to you. Refund 30
31 Credit - Amount of Line 29 you want as a credit to your 2002 estimated tax account. 31
32 Donation - Amount of Line 29 you want to donate to the Wild Resource Conservation Fund. 32
33 Donation - Amount of Line 29 you want to donate to the United States Olympic Committee. 33
34 Donation - Amount of Line 29 you want to donate to the Governor Robert P. Casey Memorial
Organ and Tissue Donation Awareness Trust Fund. 34
35 Donation - Amount of Line 29 you want to donate to the Korea/Vietnam Memorial, Inc. 35
36 Donation - Amount of Line 29 you want to donate to the Breast and Cervical Cancer Research Fund. 36
87.00
.00
43.00
157.00
.00
.00
200.00
00
00
00
00
00
00
200 00
00
113 00
113.00
.00
.00
.00
.00
.00
.00
Under penalties of perjury, I (we) declare that I (we) have examined this return, including all accompanying schedules and statements,
and to the bes~f my (our) belief they are truer correctr and complete.
Your Sig~-=~. j,.)j~ J~.~,~ / ~), Date: Your Occupation:
/~3 ,'/-/'/z~ . RETIRED
Spouse's Signature, if filing jointly: Date: Spouse's Occupation:
Preparer or Company Name~ other than taxpayer(s)~ based on all information of which the preparer has any knowledge
Preparer or Company Name (Please Print): I Date: I Telephone Number:
JOHN P. HASSLER PC 717-243-7743
Signature (Optional):
0100215193 0100215193
PA Schedule I
, .~ PA I (09-01)
Name(s) as shown on your PA tax return:
D%D3515%93
Federal Amounts for Reporting on PA PIT Returns
20 01
SSN/EIN
DOROTHY L. ANDERSON
174-20-1537
DO NOT USE THIS SCHEDULE IF YOU ARE A PARTNER OR SHAREHOLDER IN A PA S CORPORATION.
Read all instructions for each income class in the PA instruction booklet. Do you maintain separate books and records exclusively for PA
purposes? Do you use a different depreciation method for PA purposes? Do you take additional expenses that PA allows, but federal law does not
allow? Do you take expenses or credits that federal rules allow, but PA law does not permit? If you answer at least one of these questions YES, you
may not use this schedule, and you must submit the required PA schedule with your PA-40.
Line lb. Allowable Employee Business Expenses. Use this part only if all your Form 2106 expenses are also allowable for PA purposes.
OCaution. The amount from your Form 2106 must not include expenses on Line 4. If you are claiming such expenses, you must file PA Schedule UE.
Enter the Form 2106 or Form 2106EZ amount here and on Line lb of your PA-40 ...........
Line 2. PA Taxable Interest Income. Use this part to report the taxable interest income that you report on your federal return.
OCaution. If you must make any adjustments for PA purposes, fill out PA Schedule A. Do Not Use This Schedule.
You do not have to attach Federal Schedule B, if the PA taxable amount is under $2,500.
Enter your Federal Schedule Bp Line 2p amount here and on Line 2 of your PA-40. 13 3
Line 3. PA Taxable Dividend Income. Use this part to report the same taxable dividend income that you report on your federal return.
~Caution. If you must make any adjustments for PA purposes, fill out PA Schedule B. Do Not Use This Schedule.
You do not have to attach Federal Schedule B, if the PA taxable amount is under $2,500.
Enter your Federal Schedule Bp Line 6, amount here and on Line 3 of your PA-40 .................................... 2,976
Line 4. PA Net Profit or Loss from the Operation of a Business, Profession, or Farm. Use this part to report the same amount from each Federal
Schedule C or F you filed with your federal return. Do not include income or loss from a partnership or PA S corporation. You must classify such income.
~Caution. If you must make any adjustments for PA purposes to your federal schedules, fill out the necessary PA Schedule C or F or C-F Reconciliation.
Do Not Use This Schedule.
A. Enter the Federal Identification Number of each business, profession, or farm.
B. Indicate the federal schedule you submitted with your federal return. Schedule C Schedule F Schedule C Schedule F
FI FI F1 FI
C. Enter your PA Sales Tax License Number, if you have one for your business. I
D. Total individual net income or loss. If realizing income or loss from separately owned businesses, enter your amounts separately.
If married and you each have separate business or farm schedules, fill in the aPpropriate oval. H UJ w U H U w U
LOSS LOSS
Include your federal profit or loss on Line 4 of your PA-40.
Line 6. PA Net Income or Loss from Rents, Royalties, Patents, or Copyrights. Use this part to report the same amount from Part I of each Federal
Schedule E you filed with your federal return. Do not include income or loss from a partnership or PA S corporation. You must classify such income.
· Caution. If you must make any adjustments for PA purposes, fill out PA Schedule E. Do Not Use This Schedule.
A. Enter the type of income or loss: Rents, Royalties, Patents, or Copyrights.
B. Describe the address or source of the income. For example: mineral rights, patent, house at 555 Main St. Anywhere PA 55555.
C. If realizing income or loss from separately owned properties, enter your amounts separately, or if from jointly owned properties, use Your column.
Remember. Spouses may not offset their income and losses with each other.
Type of income or loss B. Description: Your income or loss I Spouse's income or loss
Spouses may not offset income or loss.
LOSS LOSS
Include your federal income or loss on Line 6 of your PA-40. U U
Remember. Spouses may not offset their income and losses with each other.
Line 8. Gambling and Lottery Winnings. Use this part to report the gambling and lottery winnings that you reported on your federal return.
OCaution. If you are not reporting the same amount as on your federal return, you must submit a detailed schedule of the sources and amounts
of your winnings. Do Not Use This Schedule.~ Important. Do not include winnings from the Pennsylvania Lottery, if won on or after July 21,
1983. You must include lottery winnings from another state or country. If you and your spouse have separate winnings to report, you enter
your winnings separately.
Your total winnings. Spouse's total winnings.
Include your federal gambling and lottery winnings on Line 8 of your PA-40.
You may photocopy this schedule or make your own schedule in this format.
0103515193 0103515193
PA SCHEDULE A & B
Interest and Dividend Income
PA-40 A/BlUE-1 (09-01)
Name as shown first on the PA tax return:
DOROTHY L. ANDERSON
2001
0101215192
OFFICIAL USE ONLY
If yOU need more space, you may photocopy these schedules or prepare your own schedules in these formats.
ISocial Security Number:
3.74-20-3.53?
Caution. Federal and PA rules for taxable interest and dividend income are different. Read the instructions. If either your taxable interest or dividend income is $2,500 or
ess you must report the income, but you do not need to submit any schedule. If either your interest income or dividendincome is more than $2,50~you must submit a schedule.
If you must adjustyour federal income enter your federal amount on Line 1, and make your corrections and explain them in the space under Fihng uption 3.
F ling opt ons 1_. Su.bmit a cgpy' of your federal schedule - you .do n. ot need thi.s PA sch.edu!e
z. ~-nter your reoera/taxable interest and/or divioeno income - oo not suomi~ your I-eoeral ~cneoule
3. Otherwise~ list the name of each payer and the amount of PA taxable interest and dividend income you received in 2001.
PA Schedule A - PA Taxable Interest Income
Filing option 2. Enter the amount from your Federal Schedule B (Form 1040) or Schedule I (Form 1040A).
Filing] option 3. PA Taxable Interest Income. Read the instructions.
Total PA Taxable Interest Income. Add the amounts, & include the total on Line 2 of your PA tax return.
IMPORTANT. Capital ~lain distributions are dividend income for PA purposes.
PA Schedule B - PA Taxable Dividend Income
$
$
$
$
$
$
$
2. $
Filing] option 2. Enter the amount from your Federal Schedule B (Form 1040) or Schedule I (Form 1040A).
Filing option 3. PA Taxable Dividend Income. Read the instructions.
2. Total PA Taxable Dividend Income. Add the amounts, & include the total on Line 3 of your PA tax return. 2.
PA-40A/B/UE-1 (09/01) PA SCHEDULE UE-1 Allowable Employee Business Expenses
Name of taxpayer claiming expenses: IMPORTANT. You must submit a PA Schedule UE-I or UE for each job - see the instr.
2,976
2,976
2001
SSN of taxpayer claiming expenses
Employer's name and address:
Employer's Federal EIN:
Describe the duties of the job in which you I Employer's telephone
incurred these exoenses:
I
number;
You may not combine expenses for more than one job or profession. Spouses may not file joint PA Schedule s) UE-1.
Mileage. Use either Option (a) or Option (b) - not both.
1 a) Enter your total business miles , & multiply by the federal standard mileage rate $0.345; OR
b) Enter your amount from your Form 2106 or Form 2106-EZ. 1 $
2 Parking fees, tolls and transportation. Enter the amount from your Form 2106 or Form 2106-EZ. 2 $
3 Away from home overnight. Enter the amount from your Form 2106 or Form 2106-EZ. 3 $
4 Meals and entertainment expenses. Enter the amount from your Form 2106 or Form 2106-EZ. 4 $
Union Dues. List union name(s) and amount(s) paid. Enter total. Attach additional sheets, if needed.
5 Name of union(s) and amount(s). 5 $
Work Clothes and Uniforms, Required as a condition of your employment & not suitable for everyday use.
6 Description: 6 $
Small Tools and Supplies. Required as a condition of your employment & not provided by your employer.
7 Description: 7 $
8 Total Allowable PA Employee Business Expenses. Add Lines 1 through 7. 8 $
9 Reimbursements. Enter amounts that your employer DID NOT report on your Form W-2. 9 $
.1.0.. N.et Expense or.Reimbursement Subtract Line 9 from Line 8. 10 $
; 9, include your excess expenses on Line lb, Unreimbursed Employee Business Expenses.
If Line 9 is MORE than Line 8, include your excess reimbursement on Line la, Gross PA Compensation.
0101215192
0101215192
BUREAU OF INDIVIDUAL TAXES
ZNHERTTANCE TAX DZVZSTON
DEPT. Z80601
HARRISBURg, PA 171Z8-0601
ARLENE GRAVER
J P HASSLER
256 S HANOVER ST
CARLISLE
COMMONWEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOTZCE OF INHERITANCE TAX
APPRAISEMENT, ALLO#ANCE OR DZSALLONANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
R~:: ........ :.-,, "'~
.... ESTATE OF
DATE OF DEATH
FILE NUMBER
NOV -8 Pi'""
·~O. DUNTY
ACH
PA 17015'U;~'''~':~ '~' '~*; .i~,;%,
11-11-2002
ANDERSON
12-29-2001
21 02-001~
CUMBERLAND
101
Amount Remi~ad
DOROTHY L
HAKE CHECK PAYABLE AND RENZT PAYMENT TO:
REGTSTER OF WILLS
CUHSERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS -~
REV-15~7 EX AFP (01-02) NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX
ESTATE OF ANDERSON DOROTHY L FILE NO. ZZ 02-0015 ACN 101 DATE 11-11-2002
TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Es~a~a (Schedule A) (1)
2. S~ocks and Bonds (Schedule B) (2)
$. Closely Held S~ock/Par*nership Interest (Schedule C) ($)
~. Not,gages/No,es Receivable (Schedule D) (~)
5. Cash/Bank Deposits~Misc. Personal Proper~y (Schedule E) ($)
6. Joln~ly O~ned Proper~y (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. To~al Asse~s
APPROVED DEDUCTIONS AND EXEHPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9)
10. Deb~s/Nor~gaga Liabilities/Liens (Schedule I) (10)
11. To~al Deductions
12. Ne~ Value of Tax Re~urn
.00
161~8~8.$8
.00
.00
288~862.18
.00
.00
(8)
8,~98.15
NOTE: To insure proper
credi~ ~o your account,
submi~ ~he upper portion
of ~his form with your
~ax payment.
15.
NOTE:
q50,700.56
7~762.27
(11) ]6.2~0.q2
(12) q3q,qqO.lq
Chari~able/govarnmen~al Bequests; Non-elected 9115 Trusts (Schedule J) (15)
Ne~ Value of Es~a~e Sub5ec~ ~o Tax (lq)
.00
qSq,qqO.lq
If an~assessment ~as issued previously, lines lq, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL retUrns assessed to date.
ASSESSMENT OF TAX:
15. Amoun~ of Line lq at Spousal ra~e (15)
16. Amoun~ of Line lq ~axable a~ Lineal/CZass A ra~e (16)
17. Amoun~'of Line lq a~ Sibling ra~e (17)
18. Amoun~ of Line lq ~axable a~ Colla~ceral/Class B ra~e (18)
~al Tax Due
DISCOUNT
INTEREST/PEN PAID (-)
977.q9
· O0 X O0 = . O0
qSq,qqO.lq X Oq5= 19,5q9.81
· O0 X 12 = . O0
· O0 x 15 = . O0
(19)= 19,5q9.81
19. Prinoi
TAX CREDITS
PAYMENT
DATE
O$-Zl-ZOOZ
RECEIPT
NUMBER
AMOUNT PAID
21,000.00
TOTAL TAX CREDZT 21,977.q9
BALANCE OF TAX DUE] Z,qZ7.68CR
INTEREST AND PEN. ] .00
.,, TOTAL DUE I 2, q27.68CR
CDOOO98q
IF PAXD AFTER DATE XNDXCATED, SEE REVERSE ( IF TOTAL DUE XS LESS THAN $1, NO PAYMENT IS REQUIRED.
FOR CALCULATION OF ADDXTXONAL INTEREST. XF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
RESERVATION=
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADMIN-
ISTRATIVE
CORRECTZONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December 1Z, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral3 beneficiaries of the decedent after the expiration of any estate for
life or far years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
To fulfill the requirements of Section ZlfiO of the Inheritance and Estate Tax Act, Act 23 of 2000. (72 P.S.
Section 91q03.
Detach the tap portion of this Notice and submit aith your payment to the Register of Nills printed on the reverse side.
--Make check or money order payable to: REGISTER OF NILES, AGENT
A refund of a tax credit, which was not requested on the Tax Return, may be requested bY completing an "Application
for Refund of Pennsylvania [nhmritance and Estate Tax" (REV-1313}. Applications ara available at the Office
of the Register of Nills, any of the 23 Revenue District Offices, or by calling the special Zq-heur
answering service for forms ordering: 1-800-36Z-ZOSO; services for taxpayers with special hearing and ~ or
speaking needs: 1-800-qfiT-30ZO iTT only}. .-
Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest} as shown on this Notice must object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17lIB-lOll, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in writing to: PA DePartment of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601
Phone (717) 787-6SOS. Sea page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-lEO1} for an explanation of administratively correctable errors.
If any tax due is paid within three (53 calendar months after the decedent's death, a five percent (52) discount of
the tax paid is allowed.
The 1SI tax amnesty non-participation penalty is computed 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 amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (62) percent per annum calculated at a daily rate of .O0016q. All taxes which became delinquent on and after
'January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are:
Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor
1982 207. . 000548 1992 9Z , 000247 ·
1985 162 -' · .000438 1993-1994 72 .000192 -
1984 llZ . 000301 1995-1998 92 . 000247
1985 152 · 000556 1999 77. · 000192
1986 102 . 000274 ZOO0 82 . 000219
1987 97. .000247 2001 92 .000247
1988-1991 117. .000301 2002 67. .000164
--Interest is calculatad as follo~s:
TNTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an lntarest calculation to fiftaan (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
BUREAU OF ZNDTVZDUAL TAXES
ZNHERTTANCE TAX DZVZSTOH
DEPT. 280601
HARRTSBURG,, PA 17128-0601
COMMONWEALTH OF PENNSYLVANZA
DEPARTNENT OF REVENUE
ZNHERZTANCE TAX
STATEHENT OF ACCOUNT
REV-IS07 EX AFP (01-02)
ARLENE GRAVER
J P HASSLER
236 S HANOVER ST
CARLISLE
'02 [JE. 20. FI2:02
DATE 11-25-2002
ESTATE OF ANDERSON
DATE OF DEATH 12-29-2001
FILE NUMBER 21 02-0013
COUNTY CUMBERLAND
ACN 101
Amoun~ Remi~ed
DOROTHY .L
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credi~ ~o your account, subm/~ ~:h'e upper portion of ~his form Wi(h your ~ax payment.
CUT ALONG THIS LINE ~'- RETAIN LOWER POR'~ZON FOR YOUR RECORDS *~
REV-1607 EX AFP (01-02) ~ 'rNHER'rTANCE TAX STATEMENT OF ACCOUNT ~
ESTATE OF ANDERSON DOROTHY L FILE NO. 21 02-0013 ACN 101 .DATE 11-25-2002
TH/S STATEHENT TS PROVIDED TO ADVTSE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHONN BELO#
TS A SUHHARY OF THE PR/NC/PAL TAX DUE, APPLICAT'rON OF ALL PAYHENTS, THE CURRENT BALANCE, AND., IF APPLICABLE.,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT:. 11-04-2002
PRINCIPAL TAX DUE: ..........................................................................................................................................................................................................................
PAYMENTS' (TAX CREDITS):
19,549.81
PAYMENT
DATE
03-21-2002
11-06-2002
RECEIPT
NUHBER
CD000984
REFUND
ZF PAID AFTER THIS DATE, SEE*REVERSE
SIDE FOR CALCULATION OF ADDITIONAL ZNTEREST.
( ZF TOTAL DUE ZS LESS THAN $1,
NO PAYHENT ZS REQUIRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDIT" (CR),
DISCOUNT (+)
INTEREST/PEN PAID (-)
977.49
.00
AMOUNT PAID.
21,000.00
2,427.68-
TOTAL TAX CREDIT 19,549.81
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. )
PAYNENT:
Detach the top portion of this Notice and submit .ith your payment made payable to the name and address
printed on the reverse side.
-- If RES[DENT DECEDENT make check or money order payable to: REGISTER OF NILLS, AGENT.
-- If NON-RESIDENT 'DECEDENT make check or money order payable tO: CONHON#EALTH OF PENNSYLVANIA.
REFUND (CR): A refund of a tax credit, which mas not requested on the Tax Return, may be requested by completing an
"Application for Refund of Pennsylvania inheritance and Estate Tax" (REV-1313). Applications are available at
the Office of the Register of Nills, any of the Z$ Revenue District Off~ces or from the Department's Z~-hour
. answering service for forms ordering: 1-800-36Z-ZO50; services for taxpayers with special hearing and / or -
speaking needs: 1-800-q~7-30ZO (TT only).
REPLY TO:
Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Sureau
of [ndividua! Taxes, ATTN: Post Assessment Reviem Unit, Dept. ze0601, Harrisburg, PA 17lie'0601, phone
(717) 787-6505,
DISCOUNT:
PENALTY:
INTEREST:
If any tax due is paid within three (3) calendar oonths after the decedent's death, a five percent (SZ) discount
of the tax paid is allowed.
The 15Z tax amnesty non-participation penalty is computed 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 amnesty period.
Interest is charged beginning with first day of delinquency, or nine [9) month~ and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of
six (6Z) percent per annum calculated at a daily rate of .00016fi. All taxes w~ich became delinquent on and after
January 1, I98Z will bear interest at a rate which will vary from calendar year to calendar year with that rata
announced bylthe PA Department of Revenue. The applicable interest rates far 198Z through ZOOZ are:
Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor
19az ~o~ .ooo5~8
198~ llZ .ooo~ol
1986 lO~ .o0027~
1987 9Z .O00Z~7
1988-1991' 11Z ~OOO~OX
199Z 9Z
1993-199fi 7Z
1995-1998 . _gl_
1999 7Z
zooo sZ
ZOO1 9X
ZOOZ 62
.O00Z~7
.O0019Z
.O00Z~7
.00019Z
.000Z19
.000Z47
.00016~
--Interest is calculated as folloms:
INTEREST = BALANCE OF TAX UNPAID X NUMBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent mill reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
STATUS REPORT UNDER RULE 6.12
NameofDecedent: ,/~lr'o ,7'~ ~ . , __ .
Date of Death: ,/~',
Will No.: "' tqm/5 Admin. No.:
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the
followin/g with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes ~ No [-'1
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:
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 [-]
Date: t'/~ 17- ,~.,~
Copies of receipts, releases, joinders and approval of formal or
informal accounts may be filed with the Clerk of the Orphans' Court
and may be attached to thi~~.,,~) ~'~/~~
Name
Capacity: [] Personal Representative
[--1 Counsel for personal representative