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Home My WebLink About04-0291 state of also known as Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS ° R[~, Deceased*- ..... ~'/~'~tlIS Social Security No 204-68-2979 Crystal L. Morris Pe~oner(s), who ~s/are 18 years of age or older, apply(~es) for (COMPLETE 'A' or 'B' BELOW ) '04 M~R 25 M2'06 A Probate and Grant of Letters Testamentary and aver that Pe~il~fler(s) ~s/are the exec~u~t~. the Decedent, dated and codicil(s) dated ,Ctllnb(~rI~.r~(J C,~ PA named ~n the last Will of State relevant circumstances, e g, renunciation, death of executor, etc Except as follows, Decedent did not marry, was not d~vorced, and d~d not have a child born or adopted after execution of the documents offered for probate, was not the wct~m of a killing and was never adjudicated ~ncornpetent r~ B Grant of Letters of Administration (c t a, d b n c t a, pendenta I~e, duranta absent,a, durante mlnor~ate) Pet~oner(s) after a proper search has/have ascertained that Decedent left no W~II and was survived by the following spouse (~f any) and he~rs Name Relationship Remdence David H. Morris, II Father ~0055 West Perry St., Enola, PA 17025 Crystal L. Morris Mother West Perry St., Enola, PA 17025 (COMPLETE IN ALL CASES ) Attach additional sheets # necessary Decedent was dorn~c~led at death ~n Cumberland County, Pennsylvania with his/her last farmb/ or pr~nc~palres~denceat 505 West Perry Street, East Pennsboro Township, Enola, PA (hst street, number, and munlclpabty) Decedent, then 19 years of age, d~ed 11/21/2003 at 1-81, N/B M/P 50.5, PA (Location) Decedent at death owned property w~th estimated values as follows (If domiciled ~n PA) Ail personal property (If not domiciled ~n PA) Personal property in Pennsylvania (If not domiciled tn PA) Personal property rn County Value of real estate ~n Pennsylvania 17025 $ 5,500.00 s~uatad as follows Wherefore, Pet~oner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented w~h thru Peri,on and the grant of letters in the appropr~ata form to the undermined Sl~lnature Typedorpr~ntednameandremdence Crystal L. Morris 505 West Perry Street, Enola, PA 17025 Prepared by t he Pennsylvamla Bar Association Copyright (c) 1996 form software ortly CPSystems, Inc Form RW-'~ (1991) Oath of Personal Representative before me this ¢~),~J~ day of Commonwealth of Pennsylvama County of Cumberland Recoraea 04,'i~ce of The Per,loner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true Re~tS[~[ Of WI~$ and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent. Per,boner(s) wilt welt and truly administer the estate according to law Sworn to or affirmed and subscnbed C No Cumberland Co., PA Estateof CHELSEY L. MORRIS Deceased Social Security No 204-68-2979 Date of Death 11/21/2003 , In consideration of the Pet~lon on the reverse side hereon, sabsfactory proof hawng been presented before me, IT iS DECREED that Letters [] Testamentary [] Of Adm~nmtrat~on (c t a, d b n c t a, pendente hte, durante absent,a, durante mlnontate) are hereby granted to Crystal L Morris In the above estate and that the ~nstrument(s) dated descnbed ~n the Pet~bon be admitted to probate and filed of record as the last Will of Decedent FEES Letters $ /"~0 ' (~ · Short Certificate(s) ~ $ icao 0 0 Renunclatmn I $ ~,, 0 0 Regmter of Wdls Attorney She[[,/ J. Kunkel, Esquire Affidavits ( ) $ ID No Extra Pages ( ) $ Address 64485 Skarlatos & Zonarich LLP 204 State Street Codicil S Harrisburs, PA 17101 JCP Fee $ /0.00 Telephone 717/233-1000 Inventory $ Other $ TOTA , Prepared by the Pennsylvania Bar ~soc~atlon Copyright (c) 1~6 form software only CPSystems, I~ Form RW-1 (1991) Register of Wills of Cumberland County, Pennsylvania Estate of CHELSEY L. MORRIS aJso known as RENUNCIATION , Deceased The undermgned, Father of (Relationship) (Capacity) the above Decedent, hereby renounce(s) the nght to administer the estate and respectfully request(s) that Letters be msued to Crystal L. Morris WITNESS ~r~ y hand,his /'~ dayo, ~}z~., ,~//)t")/~ / (S~gnature) David H. Morris, II 505 West Perry Street Enola, PA 17025 (Address) (S,gnature) (Address) (Signature) (Address) Sworn to or afffirmed and subscnbed before rne this /~' day My Commission Expires (SIgnature and seal of Notary or other official qualified to administer oat hs Show date of expiration of N ol~lry s commission ) Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc Ctty of Harrtsburg, Dauphin County ] My Comnusmon Expare~ Sept 6, 2004 [ ~iembe r, Pennsylvama AssocJatlon ot Notanes NOTE Renunciations executed outside the Off[ce of Register of Wills In some counties are required to be notarized Form #RW-4 {1991) CERTIFICATION OF NOTICE UNDER RULE 5.6 (a) Name of Decedent: CHELSEY L. MORRIS Date of Death: November 21, 2003 Will No. 2004-00291 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 April 19, 2004: Name DAVID H. MORRIS, II CRYSTAL L. MORRIS Address 505 West Perry Street Enola, PA 17025 505 West Perry Street Enola, PA 17025 Notice has been given to all persons entitled thereto under Rule 5.6(a). Dated: April 19, 2004 Signature Name: Address: ~lephone: ~%apacit y: Shelly J. Kunkel, Esquire Skarlatos & Zonarich LLP 204 State Street Harrisburg, PA 17101 {717)233-1000 Counsel for Personal Representative SKARLATOS & ZONARICH LLP John B. Zonarich, Esq. 204 State Street Harrisburg, Pennsylvania 17101 (717) 233 - 1000 Telephone (717) 233 - 6740 Facsimile Attorney for Petitioners ESTATE OF CHELSEY L. MORRIS, Deceased. 04 ,JJii 1~:: ';~:i~ : IN THE COURT OF.COMMON PLEAS · CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION : : ESTATENO. 2004-00291 PETITION TO SETTLE WRONGFUL DEATH AND SURVIVAL ACTION~ AND NOW comes David H. Morris, II, individually, and Crystal L. Morris, individually and as the Administratrix of the Estate of Chelsey L. Morris, deceased, by and through their counsel, Skarlatos & Zonarich LI~P, to petition this Honorable Court for settlement of wrongful death and survival actions pursuant to Pennsylvania Rule of Civil Procedure 2206, and in support thereof, respectfully represent: 1. Petitioners, David H. Morris, II and Crystal L. Morris, are the parents and natural guardians of the decedent who was nineteen (19) year old at the time of her passing. 2. On March 25, 2004, Petitioner David H. Morris, II renounced his right to administer the estate and requested that Letters be issued to Petitioner Crystal L. Morris. A copy of the Renunciation is attached as Exhibit "1". -1- 3. Petitioner Crystal L. Morris was appointed the Administratrix of the Estate of Chelsey L. Morris, Deceased, on March 25, 2004, by the Register of Wills of Cumberland County. A copy of the Certificate of Grant of Letters of Administration is attached as Exhibit 4. On November 21, 2003, the decedent was involved in a fatal automobile accident on State Route 81, Cumberland County, Pennsylvania and was pronounced dead at the scene of the accident by Cumberland County Coroner Michael L. Norris. A certificate of death is attached hereto as Exhibit "3". 5. The decedent died intestate. 6. On or around March 18, 2004, Petitioners engaged the services of Skarlatos & Zonarich LI~P to open an estate and resolve issues surrounding the death of the decedent. 7. The name, relationship, address and share of each beneficiary that is entitled to share in the proceeds of the survivorship claim is as follows: Relationship Fractional Share Name to Decedent Address to which Entitled David H. Morris, II Father 505 West Perry Street ½ Enola, Pennsylvania 17025 Crystal L. Morris Mother 505 West Perry Street ½ Enola, Pennsylvania 17025 -2- 8. The name, relationship, address and share of each person entitled to share in the proceeds of the wrongful death claim is as follows: Relationship Fractional Share Name to Decedent Address to which Entitled David H. Morris, II Father 505 West Perry Street ½ Enola, Pennsylvania 17025 Crystal L. Morris Mother 505 West Perry Street ½ Enola, Pennsylvania 17025 9. Petitioners have entered into an agreement with the Petitioners' automobile insurance carrier, State Farm, to settle the survival and wrongful death claims, subject to this court's approval pursuant to 20 Pa.C.S.A. {}3323. 10. The proposed settlement is for the uninsured policy limits of Petitioners' automobile insurance. 11. The total amount of the proposed settlement is forty-five thousand dollars ($45,000.00). The terms of the proposed settlement state that ninety percent (90%) of the settlement would be apportioned to the wrongful death claim and the remaining ten percent (10%) of the settlement would be apportioned to the survivorship claim. 12. Petitioners concur in the proposed settlement distribution and desire that the gross settlement be allocated in the amount of forty thousand five hundred dollars ($40,500.00 (90%)) -3- to plaintiff's decedent's statutory beneficiaries as "wrongful death" damages and four thousand five hundred dollars ($4,500.00 (10%)) to plaintiff's decedent's estate as "survival" damages. 13. Attached hereto as Exhibit "4" is a letter from the Pennsylvania Department of Revenue authorizing the apportionment of damages of ninety percent (90%) to the wrongful death claim and the remaining ten percent (10%) to the survivorship claim. 14. Because the decedent was under the age of twenty-one (21) and the transfer of property herein is from the decedent to her natural parents, there is no inheritance tax pursuant to 72 P.S. §9116(a)(1.2). 15. The sum of four thousand five hundred dollars ($4,500.00) is sufficient to protect the estate, the interests of the beneficiaries named in paragraph seven above, the lienholders, other creditors and the taxing authorities. 16. The fees and expenses incurred by Skarlatos & Zonarich LI~P on behalf of the Petitioners are being paid by Petitioners on an hourly basis and are therefore not claimed herein. 17. Due to the uncertainties of litigation, the proposed compromise is in the best interests of the Estate. -4- 18. All of those parties named in paragraphs seven and eight believe that the proposed allocation is fair and reasonable and their consent is attached as Exhibit "5". 19. If this petition is granted, the settlement proceeds will be distributed as follows: SURVIVAL CLAIM (a) To the Estate of Chelsey L. Morris, the sum of four thousand five hundred dollars ($4,500.00) to be divided as follows: (1) ½ to David H. Morris, II; and, (2) ½ to Crystal L. Morris. II. WRONGFUL DEATH CLAIM (a) To the statutory beneficiaries of Chelsey L. Morris, the sum of forty thousand five hundred dollars ($40,500.00) to be divided as follows: (1) $20,250.00 to David H. Morris, II; and, (2) $20,250.00 to Crystal L. Morris. 20. Petitioners retained Skarlatos & Zonarich I~I~P as counsel to open an estate, investigate the case and take appropriate steps to prosecute the survival and wrongful death actions. Petitioners and counsel recommend the proposed distribution as set forth above. The statement of John B. Zonarich, Esquire, for Skarlatos & Zonarich I~I~P, is attached as Exhibit "6". -5- WHEREFORE, Petitioners request that an order be entered approving the proposed settlement of the wrongful death and survivorship actions, and authorizing the Administratrix to execute all necessary releases, endorse all checks and to make appropriate distribution. Dated: June 14, 2004 By: Respectfully submitted, S~,IOS' ZONARICH LLP Joh~l~.l;~a {~h, Esquire Ide~tif~fion ~o. 79989 204 Stat~Stn ~t~. Harrisburg, Pennsylvania 17101 (717) 233-1000 Attorney for Petitioners -6- VERIFICATION We, David H. Morris, II and Crystal L. Morris, hereby certify that the facts set forth in the following Petition are based upon information which we have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on our behalf in this matter. The language in the Petition is that of counsel and not our own. We have read the Petition, and to the extent it is based upon information that we have given to counsel, it is tree and correct to the best of our knowledge, information and belief. To the extent that the content of the Petition is that of counsel, we have relied upon counsel in making this Verification. We hereby acknowledge that the facts set forth in the aforesaid Petition are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unswom falsification to authorities. Dated: Dated: David H. Morris, II Crystal IL. Morris, Individually and the Administratrix of the Estate of Chelsey L. Morris, deceased EXHIBIT Register of Wills of Cumberland Estateof CHELSEY L. MORRIS also known as RENUNCIATION County, Pennsylvania No. , Deceased The undersigned, Father of (Relationship) (Capacity) the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters be issued to Crystal L. Morris ~ y hand this. / ~ day of _~)z~_. ~_.~ WITNESS / (S~nature) David H. Morris, II 505 West Perry Street Enola, PA 17025 (Address) (Signature) (Address) (Signature) (Address) Sworn to or affirmed and subscribed before me this /~J~ day My Co~n Expires: (SIg~tum a~ ~1 of No~ or other official q~llfl~ to ~nl~er ~ths. Show date of ex~ratl~ of No~'s comml~lon.) Notarial Seal Sharon K, Sbaffer. Not-;, Public City of Harrisburg, Dauphin County My Commission ttxpirea Sept. 6. 2004J Member, Pennsylvania Association Ot Notaries NOTE: Renunciations executed outside the Office of Register of Wills in some counties are required to be notarized. Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form #RW-4 (t~S 1) EXHIBIT REGISTER OF WILLS CUMBERLAND County, Pennsylvania CERTIFICATE OF GRANT OF LETTERS No. 2004- 00291 Estate Of: MORRIS CHELSEY L fLast, Fi, st, Middle) _PA No. 21- 04- 0291 Late Of: EAST PENNSBORO TOWNSHIP CUMBERLAND COUNTY Deceased Social Security No: 204-68-2879 WHEREAS, MORRIS CHELSEY L (last, First, Middle/ C07~BERLAND COUNTY died on the 21st day of November 2003 and, WHEREAS, the grant of Letters of Administration is required for the administration of the estate. ~ THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, have this day granted Letters of Administration to: MORRIS CRYSTAL L who has duly qualified as ADMINISTRATOR(RIX) of the estate of the above named decedent and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 25th day of March 2004. late of EAST PENNSBORO TOWNSHIP **NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE) EXHIBIT H105.905 P~,V.(01/03) This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953. WARNING: It is illegal to duplicate this copy by photostat or photograph. 3145700 No. Charles Hardester State Registrar 0 1 200q Date .10S.l,~R~v. ,~ICOP,-R~CTED IT]~'[(S): 3 TYI~JPHINT PERMANENT PER: FD DATE: 1-6-04 b as COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH 1 9-149 (Coroner) Chelse" L -- . J~F.X q SO.Al ~CURiTy NUM~,~q . [ DATE OF DEATH (Mon~, Day, Year y morrzs 2. Fema£e [2.208 64 2979 . [4 November 21, 2003 H ' C~be~la~d I ~ddleaex I [-81. ~/S ~/~ 50 5 ~ ~.~,~c~. I~) White' .Tj~..-~?usu~u~ I ~..~.~s~.~n~ I~.~.~mE~m~l ~C~'S~C~ ' ~ ~US ~ ' PC' --- 505 west Pe~ Street In~a~NCE . ~ Enola PA 17025 ~ ,~, ~._._._.~ m,e,'s ~e e~. ~. ~) David H. Mords II ]<~e,.s ~e(F.~.~.. ,.~S~i L. Jack~n ~'~' ~ 0 m~ ~,~0 ~P~remation Socie~ of PA ~ ~ 2~3 HaMsbu~, PA' 17110 0 1 1 825-L I Funeral Home 2~ Map~ Avenue Ma~vil~, PA 17053 12:45 ~ve~er 21, 2003 ~ ,.~o,~~~ - ~. . ...... ~,~.~ , Hultt le Traumatic In urtes ~ ] ~,.~ b. Motor Vehicle Crash i ] ...... ''~'~~')~~ ..................................................... ~ a~b. ~ Coroner ~m~~'~~,~,~,~~,)~-~ .......................... ~ ~. ]a,~ November 24,2003 ~~ ~'~"" ~"~'~ ~"~"~,~,~ ~,~~,)~ .............................................................................. ~. Mechantcsburg, Pa 17050 EXHIBIT 6/3/2004 John B Zonarich, Esquire Skarlatos & Zonarich 204 State Street Harrisburg, PA 17101 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 717-783-0972 Dear Mr. Zonarich: Re: Estate ofChelsey L Moms File Number: 2104-0291 Date of Death: November 21, 2003 Court Number: Cumberland-orphans'-No. 2004-00291 The Department of Revenue received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It was forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 19-year-old-decedent died as a result of a motor vehicle accident. The heirs to the decedent's estate are her parents. Therefore, any proceeds paid to settle the survival action would pass to the decedent's parents and would be subject to a zero percent inheritance tax rate. 72 P.S. §9116(a)(1.2). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 40,500.00 to the wrongful death claim and $ 4,500.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death / survival action. Sincerely, ~ ~ ~~ ~~Manager Inheritance Tax Division Bureau of Individual Taxes EXHIBIT ESTATE OF CHELSEY L. MORRIS, Deceased. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : ORPHANS' COURT DIVISION : : ESTATENO. 2004-00291 CERTIFICATE OF CONSENT We, David H. Morris, II and Crystal L. Morris, do hereby certify that we have reviewed the attached PETITION TO SETTLE WRONGFUL DEATH AND SURVIVAL ACTIONS, concur therewith, and join in this petition and pray that this court approve the proposed settlement and apportionment. Dated: Dated: David H. Morris, II Crysta~ L. Morris, Individually and as the Administratrix of the Estate of Chelsey L. Morals, deceased EXHIBIT ESTATE OF CHELSEY L. MORRIS, Deceased. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : ORPHANS' COURT DIVISION : : ESTATENO. 2004-00291 STATEMENT OF COUNSEL As attorney on behalf of the above named Petitioners and Administratrix, I, John B. Zonarich, Esquire, recommend to the Court the approved settlement in the amount of forty-five thousand dollars ($45,000.00) to be apportioned as follows: ninety percent (90%) to the wrongful death claim and the remaining ten percent (10%) to the survivorship claim. This is a fair settlement under the circumstances set forth in the Petition. Further, it would be in the best interest of the estate to settle this claim in the amount set forth above. By: Dated: June ~, 2004 jo l )n N( Esquire 79989 ~)NAPdCH LLP Attorney for Petitioners ESTATE OF CHELSEY L. MORRIS, Deceased. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE NO. 2004-00291 CERTIFICATE OF SERVICE I, Sherry L. Devlin, an employee with the law firm of Skarlatos & Zonarich LLP, hereby certify that I this day served a copy of the foregoing Petition to Settle Wrongful Death and Survivorship Actions upon the person(s) indicated below by depositing a copy of the same in the United States Mail, postage prepaid, at Harrisburg, Pennsylvania, and addressed as follows: George H. Eager, Esquire Eager, Reinaker & Spinello 1347 Fmitville Pike Lancaster, Pennsylvania 17601 Dated: June 14, 2004 Devlid/ ' _ _ L. SKARLATOS & Y~0NARICH LLP Estate of Josephine M. Zimmcrman SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS File Number 21-4)4-0060 ITEM NUMBER DESCRIPTION FUNERAL EXPENSES: Prepaid ADMINISTRATIVE COSTS: Personal Representative Commissions Harry D. Priest 570 "F" Street Carlisle, PA 17013 Year Commission Paid: 2004 Attorney Fees Landis & Black, estimated Family Exemption: Probate Fees Landis & Black, advanced Accountant's Fccs Tax ~ Preparer's Fees Reserve for Closing TOTAL (Also enter on line 9, Recapitulation) AMOUNT $500.00 $1,750.00 $230.85 $300.00 $2,780.85 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT, 280601 HARRISBURG, PA 171280601 REV-1500 INHERITANCE TAX RETURN I- Z u.I UJ [-- Z I~l [:3 Z LU o RESIDENT DECEDENT DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) Zin~erman, Josephine M. DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) 01-11-2004 I 03-26-1917 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAl_) N/A r~2. Supplemental Retum J~4a. Fulum Interest Compromise (date o~ death a~er 12-12-82) [~7. Decedent Maintained a Living Trust (Alta~ c~ of Trust) [~10. Spousal Poverty Credit (date of death be~een 12-3f-91 a~ ~j~l. Original Retum [---~ 4. Umited Estate r--~ 6. Decedent Died Testate (Aa~ch c~oy of Win) -'-]9, Litigation Proceeds Received NAME Robert R. Black, Esquire FIRM NAI~A~a~,e) & Black TELEPHONE NUMBER (717) 243-3727 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnemhip or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. J~.~tly Owned Property (Schedule F) (6) L._J Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Adminisl~alive Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions {total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an eleclion to tax has not been made (Schedule J) Net Value Subject to Tax (Une 12 minus Line t3) FILE NUMBER SEE INSTRUCTIONS ON REVERSE SIDE FOR APPUCABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or Iransfers under Sec. 9116 (a)(1.2) x .0 , (15) 16. Amount of Line 14 taxable at lineal rate x .0 . (16) 17. Amount of Line 14 taxable al sibling rate x .12 (17) 18. Amount of Line 14 taxable at collateral rate x .15 (18) 19, Tax Due.~., (19) COMPLETE MAILING ADDRESS R~bert R. Black, Esquire Landis & Black 36 South Hanover Street Carlisle, PA 17013 THIS RETURN MUST BE FILED IN DUPUCATE WITH TI- REGISTER OF WILLS SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER 204 - 03 - 2678 (14) [~3. Remainder Retum (da· o~ pc~to 1243.82) [----~ 5. Federal Estate Tax Retum Required __ 8. Total Number of Safe Deposit Boxes ]'~11. EleclJon to tax under Sec. 9113(A) (A~ach Sd~ O) (S) 2,780.85 18,465.76 0.00 0.00 0.00 0.00 17,190.22 0.00 0.00 OFFiCiAL USE 17,190.22 (11) 21,246.61 (12) ( 4,056.39 ) (13) 0.00 0.00 0.00 14. 21 - 04 0060 Decedent's Complete Address: ADDRESS 50 Bonnybrook Road Lot 15 CITY Carlisle ISTATE PA IZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) -0- 3. Interest/Penalty if applicable Total Credits ( A + B + C ) (2) D. Interest E. Penalty Total InterestJPenalty ( D + E ) (3) 4. If Line 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 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. A. Enter the interest on the tax due. (5) (5A) (58) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. -o- 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 right to designate who shall use the property transferred or its income; ............................................ [] [] c. retain a revemionary interest; or ....... . . [] [] d. receive the promise for life of either payments, benefits or care? ...................................................................... [] [] 2. If death occurred alter December 12, 1982, did decedent transfer property within one year of death w thout receiving adequate consideration? .............................................................................................................. [] [] 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? ........................................................................................................................ [] [] 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 stalemants, and to the best of my knowledge and bdief, it is line, correct and complete. Dedarat;,on of preparer other than the personal,[eiPresentative is based on all information of which preparer has any tmowledge. ~/~ %/, /~,~6/ Harr~ D. Priest ADDRESS // ~70 "F" Street, Carlisle, PA 17013 36 South Hanover Street, Carlisle, PA 17013 For dates of death on or alter July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% 72 P.S. {}9116 (a) (1.1) (i)]. :or dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. {}9116 (a) (1.1) (ii) [he statute does not exemot 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 he surviving spouse is the only beneficiary. =or dates of death on or alter July 1, 2000: rhe tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive paran )r a stepparent of the child is 0% [72 RS. §9116(a)(1.2)]. .the tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefidades is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 RS. §9116(a)(1)]. "he tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under SeclJon 9102, as a xlividual who has at least one parent in common with the decedent, whether by blood or adoplion. Estate of Josephin~ M. Zimmerman SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY File Number 21-04-0060 Include the ' m~.eeds of litigation and the date the proceeds were received by the estate. (Ali property jointly-owned with Right of Survivorshl ) must be disclosed on Schedule F.) Item Number 1. 2. 3. 4. 5. 6. Description M&T Bank, checking accost 0734217. See attached letter. M&T Bank, savings account #15004204155061. See attached letter. Proceeds from sale of 1981 Sylvan mobile home, VIN #08L16489. See attached title. Refund, Capital Blue Cross. Refund, mobile home insurance. Proceeds, Attorney-in-Fact account. TOTAL (also enter on line 5, Recapitul~ion) Value at Date of Doath $6,745.72 $122.50 $5,000.00 $195.00 $127.00 $5,000.00 $17,190.22 ITEM NUMBER Ao o SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Josephine M. Zimmerman File Number 21-04-0060 DESCRIPTION FUNERAL EXPENSES: ADMINISTRATIVE COSTS: Personal Representative Commissions Harry D. Priest SSN: 184-26-2593 570 "F" Street Carlisle, PA 17013 Year Commission Paid: 2004 Attorney Fees Landis & Black, estimated Family Exemption- Probate Fee~ Landis & Black, advanced Accountant's F~s Tax Return Preparer's Fees Reserve for Closing TOTAL (Also enter on line 9, Recap~!a_ti_'on) AMOUNT $500.00 $1,750.00 $230.85 $300.00 $2,780.85 Estate of Item Number 1. 2. 3. 4. 5. 6. 7. 8. SCHEDULE I DEBTS OF DECEDENT MORTGAGE LIABILITIF~$ & LI~NS Josephine M. Zimmcnnan File Number Description Claremont Nursing & Rehabilitation, nursing services Carlisle Regional Medical Center, invoice Central Pennsylvania Medical Group Emergency, invoice Carlisle Pathology Associates, invoice Andorra Radiology Associates, PC, invoice Lancaster HMA Physicians Management Center, invoice Yellow Breeches EMS, invoice Carlisle Hospitalists TOTAL (Also enter on line 10, Recapitulation) 21-04-0060 Amount $16,907.50 $840.00 $28.40 $30.17 $418.58 $69.83 $117.69 $53.59 $18,465.76 SCHEDULE J BENEFICIARIES Eslate of File Numbe~ Josephine M. Zimmerman 21-O4-0060 RelaUonship to Decedent Amount or Sham Number Name and Address of Person(s) Receiving Property Do Not Ust Trustee(s) of Estate I. TAXABLE DISTRIBUTIONS (include oubight spousal distributions) 1. Harry D. Priest Son 100% 570 "F" Street Carlisle, pa, 17013 $SN: 184-26-2593 ENTER DOU. N~ AMOUNTS FOR DIS'rRISU/'4)NS SHOWN ALCOVE ON LtNES 15 T~ 17. AS APPROeR~TE, O# REV 1500 COVER SHEE.r II. NON-TAXABLE DISTRIBUTIONS A. Spousal ~ 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 Une 13 of REV 1500 Cover Sheet $0.00 LAST WILL AND TESTAMENT OF JOSEPHINE M. ~.IMMERMAN I, JOSEPHINE M. ZIMMERMAN, of South Middleton Township, Cumberland County, Pennsylvania, make this Will, revoking all my former wills and codicils. ,ITEM I: I direct that all my just debts, funeral expenses, and administration expenses, including my grave marker, shall be paid from the assets of my estate as soon as practicable after my decease. ITEM II: I devise and bequeath all of the residue of my estate, of every nature and wherever situate, to my son, HARRY D. PRIEST, or his issue per stirpes. ITEM III: I direct that all taxes which may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. ITEM IV: I appoint my son, HARRY D. PRIEST, Executor of this, my Last Will. ITEM V: I direct that neither my Executor, Guardian, Trustee, nor their successors shall be required to give bond for the faithful performance of their duties in any jurisdiction. wg~ IN WITHRSS WHE~-OF~ I have day of ~~h4~ hereunto set my hand this '" , 1993 . ~t~OS~p~IN~'M. ~I~l~ ~EAL) The preceding instrument, consisting of this and other typewritten pages, each identified by the signature of the Testatrix, JOSEPHINE M. ZIMMERMAN, was, on the day and date thereof, signed, published, and declared by JOSEPHINE M. ZIMMERMAN, the Testatrix therein named, as and for her Last Will, in the presence of us, who, at her request, in her presence and in the presence of each other, have subscribed our names as witnesses thereto. COMMONWEALTH OF PENNSYLVANIA ) : COUNTY OF CUMBERLAND ) ~ We, Josephine M. Zimmerman, Robert R. Black, and /~ ~. ~D~ , the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will, and that she had signed willingly (or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness, and that to the best of their knowledge the Testatrix was at the time eighteen years of age or older, of sound mind and under no constraint or undue influence. atrix Josephine. ' ~.immerma~ ' ---~ Witness Robert R. Black Witness Subscribed, sworn to and acknowledged before me by Josephine M. Zimmerman, Testatrix, and subscribed and sworn to befor9 m~ by Robert R. Black a~ ~/~ ~. f~D~( , witnesses, this ~ day of ~ 1993. ' Notary ,Public .... ~ I mM Bank 499 Mitchell Road, Millsboro, DE 19966 Mail Code 501-120 Landis & Black Attorneys At Law 36 South Hanover Street Carlisle, PA 17013 Re: Estate of Josephine M Zimmerman Social Security: 204-03-2678 Date of Death: January 11,2004 Phone 002) 934-2909 F ax 002) 934-2955 Mmw~h 30, 2004 deposit with this bank the following: 1. Type of Account Account Number Ownership (Names oJ) Opening Date Balance on Date of Death Accrued lnterest Total Type of Account Accoum Number tnmership (Names q) Opening Date Balance on Date of Death A ccnted Interest Total Checking Account 734217 Jo Zimmerman Harry D Priest, POA 09/01/67 $6,745.72 $ 0.00 $6,745.72 Savings Account 15004204155061 $o Zimmerman Harry D Priest, POA 02/10/03 $122.50 $ 0.00 $122.50 For further account information, closures and/or reimbursement of funds please call the Stonehedge Office at g717-240-4524. We were unable to locate any safe deposit box for the above-mentioned decedent. Dear Sir or Madam: Per your inquiry _do_md March 22, 2004, please be advised that at the time of death, the above-named decedent had on CERTIFICATE OF TITLE TO A MOTOR VEHICLE OR TR~i[.~I~? m accm'ciance ~v~th Sectmn 1105 DJ the Vehicle Co~e, Title 7.~, Penns'~l~ania Consoliciared Statutes ALBERT L g JOSEPH[NE M ZIMMERMAN SO BONNYBROOK RD CARLISLE PA 17013 ACCOUNT CONTROL NUMBER 8 013441001626-"-6& CODE LEGEND A = ANTIQUE VEIflCLE C = CLASSIC VEHICLE: E = ELECTRIC VEHICLE F ----* OUT OF STATE VEHICLE P= FORMERLY A POUCE VEHICLE SECOI~O LIEN FAVOR OF:. LIEN RELEASED DATE LIEN HOLDER BY ALFI'HORIZED REPR~EIq'TA'I"I V £ ei ci~ ~ ESTATE OF CHELSEY L. MORRIS, Deceased. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : ORPHANS' COURT DIVISION : : ESTATE NO. 2004-00291 ORDER AND NOW, this ~d~ay of ~ ., 2004, upon consideration of the Petition to Settle Wrongful Death and Survival Actions, it is hereby ORDERED and DECREED that the settlement in the above referenced matter in the amount of forty-five thousand dollars ($45,000.00) is hereby APPROVED. It is further ORDERED that the apportionment of said settlement be as follows: four thousand five hundred dollars ($4,500.00) to the Estate of Chelsey L. Morris and forty thousand five hundred dollars ($40,500.00) to the statutory beneficiaries of Chelsey L. Morris, as set forth in the Petition. The Administratrix is authorized to execute all necessary releases, endorse all checks arid to make appropriate distribution. By the Court Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of MORRIS, CHELSEY L. No. 21 - 04 - 00291 a~so known as Date of Death 11/21/2003 , Deceased Social Security No. 208-64-2979 Crystal L. Morris The Personal RepreSentative(s) of th~above Estate, deceased, verify that the items appearin~ in the f011owi~g inven{ery include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S, Section 4904 re[ating to unsworn falsification to authorities. Attorney: Shelly J. Kunkel I.D. No,: 64485 Address: 204 State Street Harrisburg, PA 17101 Personal Representative , Signature: ~]~ ~ ~ ~tr ~ fd~Lg~'[~2~ Crystal [}. Morris Signature: Signature: Address: 505 West Perry Street Enola. PA 17025 Telephone: 717/233-1000 Personal Property Telephone: 717/732-2445 Survival claim under Order dated June 28, 2004 (attached hereto as Schedule E) 4,500.00 Total Personal Property $4,500.00 (Attach additional sheets if necessary) Total Personal Property and Real Estate $4,500.00 .......... ,4, , REV-1500 OOMMO.~'L*.O~.~..SVLV*~,A INHERITANCE TAX RETURN DEPARTMENT OF REVENUE DEPT 2~0~0, RESIDENT DECEDENT HARRISBURG PA 17128 0601 DECEeENT;~ NAbl~ (LA~i FIRST AND MIDDLE INITIAL} MORRIS, CHELSEY L. ,.o, 11/21/2003 09/27/1984 ~ '(IF APPLICABLEi ~[JRviVi~G SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) FILE NUMBER 21 04 00291 COUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER 208-64-2979 REGISTER OF WILLS SOCfAL SECURITY NUMBER [] i OriginaIReturn [] 2 SupplementalRetum [] 3 RemainderRetum(dateofdeathpaorto12-13-82) ~c~:< m [] 4. Limited Estate [] 4a. 121282)Future Interest Compromise{date of death after [] 5 Federal Estate Tax Return Required e:.a [] 6 Decedent Died Testate (Attach c~py [] 7 DecedentMaintainedaLivingTrust(Attach 8. TotalNumberofSafeDepositBoxes O ~ co of WiJl) copy of Trust} < [] 9. Litigation Proceeds Received [] 10 Spousal Poverty Credit {date of dea[h between [] 11 Election to tax under Sec 9113(A) (Attach Sch O) 12 31 91 and 1 1-95) 'THIS SECTION MU~T EE COMPLETED. ALL cORREsPONDENCE AND CONF DENT AL TAX NFORM~TION sHOULD BE D RECTED TO ~AME I COMPLETE MAILING ADDRESS , ~- Shelly J, Kunkel ~ Q ~IRM NAME (If applicable) OD Skarlatos & Zonarich LLP fTELEPHONE NUMBER 717/23%1000 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5, Cash, Bank Deposits & Miscellaneous Personal Property (5) (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) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule i) (9) (10) 11 Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 204 State Street Harrisburg, PA 17101 None None None 4,500.00 1,273.18 None 5,981.20 x .00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14 Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES I 15.Amount of Line 14 taxable at the spousal tax rate. ! or transfers under Sec 9116(a)(1 2) _o 16.Amount of Line 14 taxable at lineal rate x .045 · ¢' 17 Amount of Line14 taxable at sibling rate x ,12 O ~ 18. Amount of Line 14 taxable at collateral rate x .15 (8) -'5,773.18 (11) 5,981.20 19. Tax Due (12) insolvent (13) (14) (15) (16) (17) (18) (19) Copyright 2000 form soft~vare only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 505 West Perw Street Enola STATE PA ZIP 17025 Tax Payments and Credits: I Tax Due (Page 1 Line 19) 2 Credits/Payments A. Spousal Poverty Credit B Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) Total hiteres*JPenalty (D + E) 4 If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line l + Line 3 is greater than Line 2, enter the difference This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A This is the BALANCE DUE Make Check Payable to: REGISTER OF WILLS, AGENT (1) (2) 0.00 (3) 0.00 (4) o.o0 (5) (SA) (5B) 0.00 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 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 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 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? [] [] 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 sad to the best of my knowledge and beiief il is iru~ correct and complete Dec~araiion of prepare{ othe~ than the personal represen!ative !$ based on a!l information of which preparer hasany ~nowledge SI A~R~F ~RS~ ~E~PbN~iBLE F6~ FIEI~G RETURN ADORing DATE SIGN~E OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS D~E Shelly nkc! , ~' ~ ~ _ Harrisburg, PA 17101 For dates of death on or a~er July 1, 1994 and before Januaw 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the su~iving spouse ~s 3% I72 P.S. ~9116 (a) (1.1) 0)]. For dates of death on or a~er Janua~ 1, 1995. the tax rate imposed on the net value of transfers to or for the use of the Su~iving spouoe is 0% [72 P.S. ~9116 (a) (1 1) (ii)]. The statute does not exempt a transfer to a su~wmg spouse from tax, and the statuto~ requirements for disclosure of assets and filing a tax return are still applicable even if the sullying spouse is the only beneficiaw. For dates of death on or after July 1, 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 or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 PS. $9116 (a) (1 2)] The tax rate imposed on the net value of transfers to or for the use of the decede~rs lineal beneficiaries is 45%, except as noted in 72 P.S. ~9116 1.2) [72 P.S ~9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 PS ~9116 (a) (1.3)]. A sibling is defined, under Section 9102, as an mdMdual who has at least one parent in common with the decedent, whether by blood or adoption. SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH O F PEN NSYLVANIA PERSONAL PROPERTY ESTATE OF MORRIS, CHELSEY L. FILE NUMBER 21 - 04- 00291 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER 1 DESCRIPTION Survival claim under Order dated June 28, 2004 (attached hereto as Schedule E) VALUE AT DATE OF DEATH 4,500.00 TOTAL (Also enter on Line 5, Recapitulation) 4,500.00 SCHEDULE F COMMONWEALTH OF RENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MORRIS, CHELSEY L. If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME A Crystal Morris B Jeri Morris ADDRESS 505 West Perry Street Enola, PA 17025 FILE NUMBER 21 - 04- 00291 RELATIONSHIP TO DECEDENT Mother Aunt JOINTLY OWNED PROPERTY: DESCRIPTION OF PROPERTY % OF ; DATE OF DEATH LETTER DATE Include name of financial institution and bank account number DATE QF DEATH DECD'S ! VALUE OF NUMBERITEM FORTENANTJOINT JOINTMADE estate.Dr similar identifying number. Attach deed for jointly-held real i VALUE OF ASSET INTERESTI DECEDENT'S INTEREST 1 A : 02/2 l/1997 Members 1 st Regular Savings Acconnt No. 1,145.54 50% 572.77 166163-00 (per verification attached hereto as Schedule F) 2 A 02/21/1997 Members 1 st Regular Savings Account No. 0.68 50% 0.34 166163-00 (accrued interest to DOD per verification ' attached herreto as Schedule F) 3 B 04/06/I 992 4 B 04/06/1992 PNC Bank Savings Account No. 5130120345 (per verification attached hereto as Schedule F) PNC Bank Savings Account No. 5130120345 (accrued interest to DOD per verification attached hereto as Schedule F) 1,399.95 50% 699.98 0.18 50% 0.09 TOTAL (Also enter on line 6, Recapitulation) 1,273.18 CO~ONWEALTH OF PENNSYLVANIA INHERITANCE TM RETURN RESIDENT DECEDENT ESTATE OF MORPd$, CHELSEY L. Debts of decedent must be reported on Schedule I. ~TEM NUMBER DESCRIPTION A. ~LINERAL EXPENSES: 1 Michael J. Shalonis Funeral Home SCHEDULE H FUNERAL EX]:~_NSES & ADMINISTRATIVE COSTS 2 Two (2) Ministers 3 Organist 4 Vocalist 5 Studio Technician 6 Sound & Video Technician FILE NUMBER 21 - 04- 00291 AMOUNT B. ADMINISTRATIVE COSTS: 1 Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid Attorney's Fees Skarlatos & Zonarich LLP Family Exemption: (If decedent's address is not the same as claimant's, attach expranation) Claimant Street Address City Relationship of Claimant to Decedent Probate Fees Register of Wills State Zip 1,761.20 200.00 100.00 100.00 100.00 100.00 3,500.00 67.00 5 Accountant's Fees Tax Return Preparer's Fees Other Administrative Costs Cumberland Coun~ Orphans' Court - Filing fee for Petition to Settle Wrongful Death Register of Wills - inheritance Tax Return Filing Fee 33.00 20.00 TOTAL (Also enter on line 9, Recapitulation) 5,981.20 ESTATE OF MORRIS, CHELSEY L. NUMBER I. 1 SCHEDULE J BENEFICIARIES NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) David H. Morris 505 West Perry Street Enola, PA 17025 2 Cwstal L, Morris 505 West Perry Street Enola, PA 17025 FILE NUMBER 21 - 04 - 00291 RELATIONSHIP TO AMOUNT OR SHARE DECEDENT OF ESTATE DoJNotL[st Trustee(s) Father Mother II. 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 ESTATE OF CHELSEY I,. MORRIS FILE NO. 21 -04 - 00291 INHERITANCE TAX RETURN SCHEDULE E IN RE: ESTATE OF CHELSEY L. MORRIS, Deceased. 1N TIlE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE NO. 2004-00291 ORDER AND NOW, this,no, r5 day of ',J-b(.ixJ ~ , 2004, upon consideration of the Petition to Settle Wrongful Death and Survival Actions, it is hereby ORDERED and DECREED that the settlement in the above referenced matter in the amount of tbrty-five thousand dollars ($45,000.00) is hereby APPROVED. It is further ORDERED that the apportionment of said settlmnent be as follows: tbur thousand five hundred dollars ($4,500.00) to the Estate of Chelsey L. Morris and forty thousand five hundred dollars ($40,500.00) to the statutoO' beneficiaries of Chelsey L. Morris. as set forth in the Petition. Thc Administratrix is authorized to execute all necessaps' releases, endorse all checks and to make appropriate distribution. A TRUE COPY FROM RECORD In Testimony whorof, ~ hereunto set my hand and tho seal of said Court at Carlisle, PA ~.~ .This Z~/ day of~.C._~L~20 ,? Cterk of the Orphans Cour~/,~_ Cumberland County By the Court ESTATE OF CHELSEY L. MORRIS FILE NO. 21 04- 00291 INHERITANCE TAX RETURN - SCHEDULE F PNCBAN<. July 26, 2004 Shelly J. Kunk¢l 204 State Street Harrisburg, PA 17101 Estate of Chelsey L. Moms, deceased SSN: 204-68-2979 (we have 208-64-2979) DOD: 11/21/2003 Dear Ms. Kunkel: In response to your request for Date of Death balances for the customer noted above, our records show the following: Savi~gsAccount Account #5130120345 CHELSEY MORRIS JERI MORRIS DOD balance: $1,399.95 + $.18 accrued interest Interes~ Paid 1/1/2003 - 11/21/2003 - $3.15 Established 04/06/1992 Please note that this office only provides date of death balances for deposit accounts (IRAs, CDs, Checking and Sav2gs accounts), We do not process any financial transactions or provide statements. If you need assistance with any of these items, please call 1-888-PNOBANK (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, Rachelle Wells 1-800-762-1775 PT-PFSC-04-F 500 fir*t Ave, Pittsburgh PA 15219 Member FDIC TOTAL P.O1 MEMBERS 1" FEDERAL CREDI1 LNION REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established 166163 -00 02/21/1997 $1,145.54 $.68 $1,146.22 Crystal Morris 02/21/1997 /~/,~BERS 1sT FEDERAL CREDIT UNION · D~nise A. Wolfe ~' Insurance Supervi§Or May 20, 2004 Estate of: CHELSEY L. MORRIS Date of Death: 11/21/2003 Social Security Number: 208-64-2979 50(t0 Louise Drive · PC). Box 4(/ · MechaIucsburg, l~clmsylx;tl~ia t7(~55 · (7]7) 097 1161 · SY~JAT~ & ZONARICH LLP 17 S. SECOND STREET, 6TH FLOOR HARRISBURG, PENNSYLVANIA 17101 Cumberland County Register of Wills Orphans Court Division Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 TOS &ZONAI CH LkP ATTORNEYS AT LAW SKARLATOS & ZONARICH BUILDING 17 SOUTH SECOND STREET, 6TM FLOOR HARRISBURG, PENNSYLVANIA 17101-2039 (717) 233-1OOO TELEFAX (717} 233-6740 WWW.S KAR LATOSZONAR ICH ,CO M October 18, 2004 shamn@skarlatoszonarich.(;om Cumberland County Register of Wills Orphans Court Division Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 RE: Estate of Chelsey L. Morris Estate No. 2004-00291 Dear Sir/Madam: Enclosed please find a check in the amount of $105.77 in payment of the additional inheritance tax owed on the above-referenced estate. Sincerely, Sharon K. Shaffer Estate Administrator Enclosure A MEMBER OF LAWPACTTM - AN INTERNATIONAL ASSOCIATION OF INDEPENDENT BUSINESS LAW FIRMS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INO~VIDUAL TAXES DEPT 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX(11-96) NO. CD 004532 KUNKEL SHELLY J 204 STATE STREET HARRISBURG, PA 17101 ESTATE INFORMATION: SSN: 204-68-2979 FILE NUMBER: 2104-0291 DECEDENT NAME: MORRIS CHELSEY L DATE OF PAYMENT: 10/22/2004 POSTMARK DATE: 10/21/2004 COUNTY: CUMBERLAND DATE OF DEATH: 11/21/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $105.77 TOTAL AMOUNT PAID: 9105.77 REMARKS: SEAL CHECK//3071 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS STATUS REPORT UNDER RULE 6.12 Name of Decedent: Date of Death: CHELSEY L. MORRIS NOVEMBER 21, 2003 Will No.: 2104-0291 Admin. No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report that following with respect to completion of the administration of the above-captioned estate: complete: State whether administration of the estate Yes X No is 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 X b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative account informally to the parties in interest? Yes X state an No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be file~/~th the Clerk of the Orphans' Court and may be attach-edeCo th/s r~ort. Date: Nov. 12, 2004 ~~~ ~ ~ohn R. Zonarich Name (Please type or print) Skarlatos & Zonarich LLP 204 State Street Harrisburg, PA 17101 Address (717)233-1000 Tel. No. Capacity: Counsel for Personal Representative BUREAU OF. INDIVIDUAL TAXES I'NHE~;TAHCE TAX DTVZSI'ON DEP"r. 280601 HARRISBURG, PA 171Z8-0601 CONNONgEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLONANCE OR DZSALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX RE¥-I~7 EX AFP (01-05) SHELLY J KUNKEL SKARLATOS & ZONARICH 20q STATE ST HBG PA 17101 DATE 10-11-200q ESTATE OF MORRIS DATE OF DEATH 11-21-2005 FILE NUMBER 21 0~-0291 COUNTY CUMBERLAND ACN 101 J Amount Remitted CHELSEY L HAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF gILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOgANCE OR DZSALLOgANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF NORRIS CHELSEY L FILE NO. 21 0~-0291 ACN 101 DATE 10-11-200~ TAX RETURN NAS: ( ) ACCEPTED AS FILED (X) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schadula A) (1) 2. Stocks and Bonds (Schadula B) (2) 3. Closely Hald Stock/Partnership Interest (Schedule C) (3) q. Mortgages/Notes Receivable (Schedule D) (q) E. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 6. Jointly Owned Proper~y (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9 10 11 12 15 Funeral Expenses/Ada. Costs/Misc. Expenses (Schedule H) Debts/Mortgage Liabilities/Liens (Schedule Z) Total Deductions Net Value of Tax Return (9) (10) Charitabla/Govarneental Bequests; Non-elected 9113 Trusts (Schedule J) Net Value of Estate Sub~ect to Tax ~zSO0.O0 1/273.18 .00 .00 NOTE: To insure proper .00 credit to your account, .00 submit the upper portion .00 of this for. with your tax payment. (8) 5,981.20 .00 NOTE: 5,773.18 (11) 5 .~)81.20 (12) 208.02- (13) . O0 (lq) 208.02- If an assessment was issued previously, llnes 14, 15 and/or 16, 17, reflect figures that include the total of ALL returns assessed to date. 18 and 19 will REVERSE SIDE OF THIS FORM INTEREST IS CHARGED THROUGH 10-26-200q AT THE RATES APPLICABLE AS OUTLINED ON THE .°°I 105.01 .76 105.77 ( IF TOTAL DUE TS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU NAY BE DUE ~ A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) ~? IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ASSESSMENT OF TAX: 15. Amount of Line lq at Spousal rata 16. Amount of Line lq taxable at Lineal/Class A rate 17. Amount of Line lq at Sibling rate 18. Aaount of Line lq taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: PAYMENT RECExP i DISCOUNT (+ j DATE NUMBER INTEREST/PEN PAID (- AMOUNT PAID TOTAL TAX CREDZT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE (15) .00 x O0 = .00 (16) :'~,OTD x 0q5 = ~' .00 (17) ':-'~00 X ~ = ::: .00 (18) 700¥'97 x 15 = ~' ~ 105. O1 CL9 ' (~.i)= 105.01 RESERVATION: PURPOSE OF NOT[CE: PAYMENT: REFUND (CR): OBJECT[OHS: ADHIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred in possession or enSoyaent to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for 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 Zl~O of the Inheritance and Estate Tax Act, Act 23 of ZOO0. (72 P.S. Section 91~01. Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side. --Hake chock or money order payable to: REGISTER OF NICESt AGENT A refund of a tax credit, which was not requested on the Tax Return, amy be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications ara available at the Office of the Register of Hills, any of the 23 Revenue District Offices, or by calling the special Z4-hour answering service far fores ordering: 1-800-362-2050; services for taxpayers eith special hearing and / or speaking needs: 1-800-qq7-3020 (TT only). Any party in interest not satisfied with tho 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. ZalOZ1, Harrisburg, PA 17128-1021, 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) 787-6505. See page 5 af the booklet "Instructions for Inheritance Tax Return for a Res[dent Decedent" (REV-IS01) for an explanation of administratively correctable errors. If any tax due is paid eithin three (3) calendar months after the decedant's death, a five percent (52) 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 nat paid before January 18, 1996, the first day after the and of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the saea time per[od 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 (11 day from the data of death, to the date of payment. Taxes which became delinquent before January 1, i982 bear interest at the rate of six [621 percent par annum calculated at a daily rats of .00016~. 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 ZO0~ ara: Interest Daily Interest Daily Year Rata Factor Year Rate Factor 1982 ZOZ .0005~.8 ~'~-8-1991 11Z .000501 1983 162 .000~38 1992 92 .0002~7 198~ llZ .000'~01 1993-199~ 72 .000192 1985 132 .000356 1995-1998 92 .OOOZ~7 1986 10Z . D0027~ 1999 7Z .000192 1987 102 .00027~ 2000 77. .000192 --Interest is calculated as fallows: INTEREST = BALANCE OF TAX UNPAID Interest Daily Year Rate Factor ~'~ 92 .0002q7 2002 82 .00016~ Z003 SZ .000137 ZO0~ ~Z .000110 X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent .ill reflect an interest calculation to fifteen (151 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, :EV-'1470 EX INHERITANCE TAX EXPLANATION COMMONVVEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE OF CHANGES BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG~ PA 17128-0601 FILE NUMBER DECEDENTS NAME Morris, Chelsey L. 2104-0291 ^CN REVIEWED BY Daniel Heck 101 ITEM EXPLANATION OF CHANGES SCHEDULE NO. Probate estate is insolvent. Jointly held assets are taxable to the survivors. No F 3,4 deductions can be claimed against joint property, as it was not the responsibility of the survivors to pay the debts. ROW Page 1 BUREAU OF TNDTVTDUAL TAXES TNHERTTANCE TAX DTVTSTON PO BOX 280601 HARRTSBURG, PA 171Z8-0601 COHHONWEALTH OF PENNSYLVAN'rA DEPARTNENT OF REVENUE ZNHERZTANCE TAX STATEHENT OF ACCOUNT REV-1607 EX AFP (09-04) SHELLY J KUNKEL SKARLATOS & ZONARTCH ZO~ STATE ST HB_q. PA 17101 DATE 12-06-200~ ESTATE OF MORRIS DATE OF DEATH 11-21-2005 F/LE NUNDER 21 0~-0291 COUNTY CUHBERLAND ACN 101 Amoun'l: R,~mi*~ed CHELSEY L HAKE CHECK PAYABLE AND REHZT PAYNENT TO: C~ON(~I'HZS ~ Ik'- RETATN LOWER PORTTON FOR YOUR RECORDS -Mil I~W-~I~I~Y :~' Yiqs'YIE~:'~I ...... '.'~' Yl:ih~ ! 'r'~:~' Y~' 'ff?AYg ilDl'f ' Z)Y '~:~'(~0hY ' ' ~;~ ..................... ESTATE OF HORRIS CHELSEY L F'rLE NO. 21 0~-0291 ACN 101 DATE 12-06-200~ THTS STATEHENT TS PROVTDED TO ADVTSE OF THE CURRENT STATUS OF THE STATED ACN TN THE NAHED ESTATE. SHOWN BELO# TS A SUHHARY OF THE PR/NC/PAL TAX DUE,, APPL'rCATTON OF ALL PAYHENTS~ THE CURRENT BALANCE,, AND., TF APPLTCABLE,, A PROJECTED TNTEREST FTOURE. DATE OF LAST ASSESSHENT OR RECORD ADJUSTHENT: 10-11-200q PR[NC[PAL TAX DUE: ........................................................................................ PAYNENTS CTAX CREDITS): 105.01 PAYMENT RECEIPT DISCOUNT (+) AHOUNT PAID DATE NUNBER INTEREST/PEN PAID (-) 10-21-200~ CD00~552 .70- 105.77 ZF PAID AFTER THZS DATE~ SEE REVERSE SZDE FOR CALCULATION OF ADDZTZONAL ZNTEREST. ( ZF TOTAL DUE IS LESS THAN $1~ NO PAYHENT IS RE~U/RED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" TOTAL TAX CREDZT 105.07 BALANCE OF TAX DUE .06CR ZNTEREST AND PEN. .00 TOTAL DUE .06CR YOU HAY BE DUE A REFUND. SEE REVERSE S/DE OF THTS FORH FOR TNSTRUCTTONS. , r, .. ~, 0= L;.5 IN RE: ESTATE OF CHELSEY L. MORRIS Deceased r....'-- ~, : r~'1 . . \ iN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE NO, 2004-00291 PETITION TO SETTLE WRONGFUL DEATH AND SURVIVAL ACTIONS AND NOW, comes David H. Morris, II, individually, and Crystal L. Morris, individually and as the Administratrix of the Estate of Chelsey L. Morris, deceased, by and through their attorneys, Eager, Spinello, Quinn & Stengel, and petition this Honorable Court for settlement of wrongful death and survival actions pursuant to Pennsylvania Rules of Civil Procedure 2206, and in support thereof, allege as follows: 1. Petitioners, David H. Morris, II and Crystal L. Morris, are the parents and natural guardians of the decedent who was nineteen (19) years old at the time of her passing. 2. On March 25, 2004, Petitioner David H. Morris, II renounced his right to administer the estate and requested that Letters be issued to Petitioner Crystal L. Morris. A copy of the Renunciation is attached as Exhibit "A". 3. Petitioner Crystal L. Morris was appointed as the Administratrix of the Estate of Chelsey L. Morris, deceased, on March 25, 2004, by the Register of Wills of Cumberland County. A copy of the Certificate of Grant of Letters of Administration is attached as Exhibit "B". 4. On November 21, 2003, the decedent was involved in a fatal automobile accident on State Route 81, Cumberland County, Pennsylvania and was pronounced dead at the scene of the accident by Cumberland County Coroner, Michael L. Norris. A certificate of death is attached hereto as Exhibit "C". 5. The decedent died intestate. ,~. A 6. The name, relationship, address and share of each beneficiary that is entitled to share in the proceeds of the survivorship claim is as follows: NAME RELA TlONSHIP TO ADDRESS FRACTIONAL SHARE DECEDENT TO WHICH ENTITLED David H. Morris, II Father 505 West Perry Street ~ Enola, PA 17025 ~ Crystal L. Morris Mother 505 West Perry Street Enola, PA 17025 7. The name, relationship, address and share of each person entitled to share in the proceeds of the wrongful death claim is as follows: NAME RELA TlONSHIP TO ADDRESS FRACTIONAL SHARE DECEDENT TO WHICH ENTITLED David H. Morris, II Father 505 West Perry Street ~ Enola, PA 17025 ~ Crystal L. Morris Mother 505 West Perry Street Enola, PA 17025 8. Petitioners have entered into an agreement with the Petitioners' automobile insurance carrier, State Farm, to settle the survival and wrongful death claims, subject to this Court's approval pursuant to 20 Pa.C.S.A.S3323. 9. The proposed settlement is for the uninsured policy limits of Petitioners' automobile insurance. Attached as Exhibit "0" is a copy of a Certificate of Coverage issued by State Farm Mutual Automobile Insurance Company. 3 10. Previously, by Order dated June 28, 2004, this Court approved a settlement in the amount of $45,000.00. That amount was based on there being a total of $45,000.00 of insurance coverage available. 11. Since this claim involves uninsured motorist benefits that there is an additional $15,000.00 in insurance coverage available. 12. The total amount of the proposed settlement is $15,000.00. The terms of the proposed settlement provided that ninety percent (90%) be apportioned to the wrongful death claim and the remaining ten percent (10%) of the settlement would be apportioned to the survivorship claim. 13. Petitioners concur in the proposed settlement distribution and desire that the gross settlement be allocated in the amount of thirteen thousand five hundred dollars ($13,500.00 (90%)) to Plaintiffs' decedent's statutory beneficiaries as "wrongful death" damages and one thousand five hundred dollars ($1,500.00 (10%)) to Plaintiffs' decedent's estate as "survival" damages. 14. Attached hereto as Exhibit "E" is a letter from the Pennsylvania Department of Revenue authorizing the apportionment of damages of ninety percent (90%) to the wrongful death claim and the remaining ten percent (10%) to the survivorship claim. 15. Because the decedent was under the age of twenty-one (21) and the transfer of property herein is from the decedent to her natural parents, there is no inheritance tax pursuant to 72 P.S.s9116(a)(1.2). 15. The sum of one thousand five hundred dollars ($1,500.00) is sufficient to protect the estate, the interests of the beneficiaries named in paragraph six above, the lienholders, other creditors and the taxing authorities. 4 16. The expenses incurred Eager, Spinello, Quinn & Stengel on behalf of the Petitioners are being paid by State Farm Insurance Company on an hourly basis and are therefore not claimed herein. 17. Due to the uncertainties of litigation, the proposed compromise is in the best interests of the Estate. 18. All of those parties named in paragraphs six and seven believe that the proposed allocation is fair and reasonable and their consent is attached as Exhibit "F". 19. If this Petition is granted, the settlement proceeds will be distributed as follows: I. SURVIVAL CLAIM (a) To the Estate of Chelsey L. Morris, the sum of one thousand five dollars ($1,500.00) to be divided as follows: (1) Y2 to David H. Morris, II (2) Y2 to Crystal L. Morris II. WRONGFUL DEATH CLAIM (a) To the statutory beneficiaries of Chelsey L. Morris, the sum of thirteen thousand five hundred dollars ($13,500.00) to be divided as follows: (1) $6,750.00 to David H. Morris, II (2) $6,750.00 to Crystal L. Morris 20. Petitioners and counsel recommend the proposed distribution as set forth above. The statement of George H. Eager for Eager, Spinello, Quinn & Stengel is attached as Exhibit "G". 5 WHEREFORE, Petitioners request that an Order be entered approving the proposed settlement of the wrongful death and survivorship actions, and authorizing the Administratrix to execute all necessary releases, endorse all checks and to make appropriate distribution. EAGER, SPINELLO, QUINN & STENGEL DATE: BY: George H. Eag ,Esquire Attorneys for etitioners 1347 Fruitville Pike Lancaster, PA 17601 (717) 290-7971 Atty. 1.0. No. 27740 6 VERI FICA TION We, David H. Morris, II and Crystal L. Morris, hereby certify that the facts set forth in the foregoing Petition are based upon information which we have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on our behalf in this matter. The language in the Petition is that of counsel and not our own. We have read the Petition, and to the extent it is based upon information that we have given to counsel, it is true and correct to the best of our knowledge, information and belief. To the extent that the content of the Petition is that of counsel, we have relied upon counsel in making this Verification. We hereby acknowledge that the facts set forth in the aforesaid Petition are made subject to the penalties of 18 Pa.C.S.A.94904 relating to unsworn falsification to authorities. Dated: 5,/:2IJb/o Dated: ,S):)llv~ () 41 'J{ &-Vu~ CRYS L L. MORRIS, individually and the Administratrix of the Estate of Chelsey L. Morris, deceased BXlllBl'T A \. Register of Wills of Cumberland County, Pennsylvania RENUNCIATION Estate of CHELSEY L. MORRIS No. also known as . Deceased The undersigned. Father of (Relationship) (Capacity) the above Decedent. hereby renounce(s) the right to administer the estate and respectfully request{s) that Letters be issued to Crystal L. Morris WITNESS \../Y"r) Y hand this J7f/L , day of '~4?LIL ,~(') f (Signature) 6~t;,~7J: David H. Morris, II 505 West Perry Street Enola, PA 17025 \0 { ~" ' (Address) IJ\ N ~ ::s: (Signature) '- 'j,) (1' ".. ci~ '<:.:j p (Address) - ... r .. -- .~.._"" (Signature) (Address) Sworn to or affirmed and subscribed before me this /~ day m 7?J(!/JflJu . &J04 @Ii!~ Notarial Scal ~haron K. Shaffer. Nor ~~' Public City of Harrisburg, Dauphin County My Commission Expires Sept. 6. 2004 Member, Pennsylvania Association otNotaries My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills in some counties are required to be notarized- l Prepared by the Pennsylvania Bar Association Copyrlghl (c) 1996 form soflware only CPSyslems, Inc. Form ilRW-4 (1991) EXHIBIT B \ REGISTER OF WILLS . CUMBERLAND County, Pennsylvania CERTIFICATE OF GRANT OF LETTERS No. 2004- 00291 PA No. 21- 04- 0291 Es ta te Of: MORRIS CHELSEY L ILast, First, Middle! Late Of: EAST PENNSBORO TOWNSHIP CUMBERLAND COUNTY Deceased Social Securi ty No: 204-68-2979 WHEREAS, MORRIS CHELSEY L (Last. First, Middle! late of EAST PENNSBORO TOWNSHIP CUMBERLAND COUNTY died on the 21st day of November 2003 and, WHEREAS, the grant of Letters of Administration is required for the administration of the estate. THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, have this day granted Letters of Administration to: MORRIS CRYSTAL L who has duly qualified as ADMINISTRATOR(RIX) of the estate of the above named decedent and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 25th day of March 2004. / * *NOTE* * ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE) --------------- . -~-_.~----~._---~_.__._---_.,_.__..__._..._--_._--_. --. ..- BX1l1B11 C This- is to certifY that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records In accordance with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~ !I~J Charles Hardester State Registrar 3145700 APR 0 1 200lt Date Hl05,...Aev'I9,CORRECTED lTEM(S):3 PER:FD DATE:I-6-04 bas COMMONWEALTH OF PENNSYLlfANIA . DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (Coroner) 118785 TYPE/PRINT .. PE....ANENT BLACK INK ~ L Morris sex .. Female &WE FILE NUMBeR SCQAI "~cunfTY NUJoIP~1:\ ..208 64 2979 DATE OF DEATH (Month. Day. '1baf\ .. November 21, 2003 UNDER' DAY Hours MinuteS ORE OF BIRTH (Month. Day. '!'ear) BIRTHPlACE (CCy and State 01' Foreign Counlry) Harrisburg. PA ""'eo !vi' (SpecilYJp-.... CITY. RACE -Americal'ltndian. Black, While,ate (SpoOl,) White ,.. MARJ'TAL STATUS. Married Neyer Merrltd. Widowed, N~ SURVIVING SPOUSE (II wile, give maiden name) Cumberland Did _m Mlna 1oWnIhip? 17d.D ~==Ol "OTHEA'SNAME(F"'.M_''''''''"~rystall. Jackson 18. 'NFOA"-5(ffl'W~~'~~ 17025 !wp. 17b.CO Iboro. 011825-L LOCATION. Cltyf1Own, Stt.\e. Zip Code Harrisburg, PA 17110 o w Ul :> Ul '" ::J '" 21c. b. Multi Ie Traumatic In uries DUE 10 (OR AS A CONSEQUENCE OF): Motor Vehicle Crash DUE 10 (OR AS A CONSEQUENCE OF): .... \'\MCASE REFERRE01O:~ 'f. l~e PART": : "*'-I between !~anddNth NoD .... TIME OF DEATH Ap rx . DATE PRONOUNCED DEAD ~MonIh. Day, 'Mer) 2.. 12:45 P. ... 25. November 21, 2003 27. MAT I: Enlerlhe......, Infurlellorcornplic8tioMwhiChcaueedthe d8lath. Do notenler the mode of dying, euchuc:ardl&cOl' ~M'eSt. shDckOl'tleafltallure. l.. onty one ca... on each line. conditionll con1rlbU1ing 10 death. but In the undortying cause given In PART I. DUE 10 (OR AS A CONSEQUENCE OF) d. WERE ,WTOPSY FfN[HNGS MIlABLE PAIOA '1U COMPLETION OF CAUSE OF DE.<fH? ""~NoD ""~ NoD ZIII. lib. CERTFIER (Cheek only 008) -caR11F'f1MG PHYSICWt (Physician certJtying c:atM 01 de8Ih when another physician has pronounced death and completed Item 23) To...lleetof.,knowIIdfe.......occ:un.d.....tD....~.)....__.............................................. ............... A_ Pendlnglnvesl:lgatlOn D Nov.21,2003 D . J2:45 P ~ o PLACEOFINJUAY.A1hofM,~8lreet.tactofy.offtoe ~..,.(S_ Highway S\GNRURE AND 'T D ..>. LICENSE N SEA TIME Of tNJURY Aprx. PA MANNER OF DERH ORE OF INJURY (Month. Day. 'IIaar) INJURY IU:.WORK'1 0ESCAl9E HOH tNJUHY OCCURRED Belted operator, auto vs. tractor trailer Nol..., D ~ o -- SuIcIde ... Could not ~ dehmni,.d Coroner i ~ c ... c w ,. '" z -==:'~~~~=;:~=~toc;:.~':,~C:"eIMed...... .................... 0 .MEDfCALEXAMW~EA On the...... of.umlnlldon lMdIor ~.ln my opInIon., dnth oceun'ed M the time, date. MCI paIlce, and due to the CMlIM(.) and .....,..tltated.. ............ .'........................ ............... ............................... ............. '1.. REG' rs;o,4,51~ BXlllBlT D . State Farm Insurance Companies STATE FARM .. I NSURANC E '" CERTIFICATE OF COVERAGE State Farm Insurance Companies 555 Southpointe Blvd, 4th Floor Canonsburg, PA 15317 Claim Number: 3 8 - K3 2 7 - 2 8 3 The undersigned is a Claim Team Manager for: ___State Farm County Mutual Insurance Company of Texas ___State Farm Lloyds, Inc. ___State Farm Indemnity Company ~State Farm Mutual Automobile Insurance Company ___State Farm Fire and Casualty Company This certifies that policy number 6622-331-38P Car 004/ covering a 2001 Toyota Camry, was issued to Crystal L & David H II Morris and was in effect on the accident date of November 21/ 2003. The coverages and limits of liability for this policy on that date were: A 100/300/50/C2 10/000/D100/G500/R1 80%/1000/U 15/30/W 15/30/F 2/500/21 This policy provides Full Tors.-~ . /Z / (/l.~it# YJ[~ Dennis R Jack Claim Team Manager State of Pennsylvania )ss. County of Washinqton Subscribed and sworn to before me this 9tt (, . day of \j?[4Ui:,Ci:r_:r" (Year) l/d. ()tJ ?:;> V l; /"J / K.1A/t.-A, i/~ / . 'otary Public :Z-iL'7"'0J(j My Insurance Company State HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 BXll1Bl1' B ~ . WEB ADDRESS www.state.oa.us BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO Box 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE May 8, 2006 Vincent J. Quinn, Esq. Eager, Spinello, Quinn & Stengel 1347 Fruitville Pk. Lancaster, PA 17601 Re: Estate of Chelsey L. Morris File Number: 2104-0291 Date of Death: 11/21/03 Court Number: CCP Cumberland Co. No. 2004-00291 Dear Mr. Quinn: The Department of Revenue received a petition concerning the approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It was forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the petition, the 19-year-old-decedent died as a result of a motor vehicle accident. The heirs to the decedent's estate are her parents. Therefore, any proceeds paid to settle the survival action would pass to the decedent's parents and would be subject to a zero percent inheritance tax rate. 72 P.S. 99116(a)(1.2). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 13,500 to the wrongful death claim and $ 1,500 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa. C.S.A. 98302; 72 P.S. 999106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. !n re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death/survival action. Sincerely, A I {\ f\ ri'., (' --t,. '" ~)X ~ v .,\.\_,,-)<V\i\\S~'CL_ Holly A. McClintock Trust Valuation Specialist PHONE: 717-787-1794 . FAX: 717-783-3467 . EMAIL: hmcclintoc@state.Da.U5 I _ B)(1l1Bl1' f . IN RE: ESTATE OF CHELSEY L. MORRIS Deceased IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE NO. 2004-00291 CERTIFICATE OF CONSENT We, David H. Morris, II and Crystal L. Morris, do hereby certify that we have reviewed the attached PETITION TO SETTLE WRONGFUL DEATH AND SURVIVAL ACTIONS, concur therewith, and join in this Petition and pray that this Court approve the proposed settlement and apportionment. Dated: 7. /3- 0 6 O~~/~1C DAVID H. MORRIS, II Dated:~ iJ ~ /Yk9vw CRYS L L. MORRIS, individually and the Administratrix of the Estate of Chelsey L. Morris, deceased B)(1l1B1T G . .' . IN RE: ESTATE OF CHELSEY L. MORRIS Deceased IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE NO. 2004-00291 STATEMENT OF COUNSEL As attorney on behalf of the above-named Petitioners and Administratrix, I, George H. Eager, Esquire, recommend to the Court the approved settlement in the amount of thirteen thousand five hundred dollars ($13,500.00) to be apportioned as follows: ninety percent (90%) to the wrongful death claim and the remaining ten percent (10%) to the survivorship claim. This is a fair settlement under the circumstances set forth in the Petition. Further, it would be in the best interest of the Estate to settle this claim in the amount set forth above. DATE: EAGER, SPINELLO, QUINN & STENGEL BY: Geor. H. Ea Attorneys for ioners 1347 Fruitville Pike Lancaster, PA 17601 (717) 290-7971 Atty. 1.0. No. 27740 J JUt 2 1 2ao~ IN RE: ESTATE OF CHELSEY L. MORRIS Deceased IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE NO. 2004-00291 ORDER AND NOW, this~!'day of ->> ' 2006, upon consideration of the Petition to Settle Wrongful Death and Survival Actions, it is hereby ORDERED and DECREED that the settlement in the above-referenced matter in the amount of fifteen thousand dollars ($15,000.00) is hereby APPROVED. It is further ORDERED that the apportionment of said settlement be as follows: one thousand five hundred dollars ($1,500.00) to the Estate of Chelsey L. Morris and thirteen thousand five hundred dollars ($13,500.00) to the statutory beneficiaries of Chelsey L. Morris, as set forth in the Petition. The Administratrix is authorized to execute all necessary releases, endorse all checks and to make appropriate distribution. _ . ',..,-~ ..-'",-0- c:';/? , \ i I I " ,.T-H'E'- .: C) 1'-.",..' ---:-~-~ ) J. ~,c: .-) f"',--..') Wi ",J 1'.....) u-, \>-