Loading...
HomeMy WebLinkAbout09-29-08r , -,, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA. ORPHANS' COURT DIVISION FILE NO: 21-08-0080 FIRST AND FINAL ACCOUNT OF George W. Ely, Jr. For ESTATE OF GEORGE W. ELY, A.K.A. GEORGE W. ELY, SR. LAW OFFICES SNELBAKER EC BRENNEMAN. P.C. Social Security #: Tax ID #: Date of Death: Date of Incapacity, if any: Date of Executor Appointment: Date of First Complete Advertisement: Accounting for the period: 178-16-0189 83-6083030 January 16, 2008 None January 23, 2008 January 30, 2008 January 16, 2008 to September 8, 2008 Purpose of Account: George W. Ely, Jr., Executor, offers this Account to acquaint interested parties with the transactions that have occurred during his Administration. It is important that the Account be carefully examined. Requests for additional information, questions or objections can be discussed with: Keith O. Brenneman Snelbaker & Brenneman, P.C. 44 West Main Street Mechanicsburg, PA 17055 Phone #: 717-697-8528 Supreme Court I.D. No: 47077 Page 1 F.J CJ c _'i c~a E-> O cr' .-~ ~ cn ~~=v ~ ,, -v -- _ -- c~ .._ ~.o _ -~ - ; ~ _ i v W SUMMARY OF ACCOUNT PRINCIPAL PAGE Receipts Net Loss on Sales or Disposition Less Disbursements: Debts of Decedent Funeral Expenses Administration Expenses Family Exemption Federal, State & Local Taxes Fees and Commissions Balance before Distributions Distributions to Beneficiaries Principal Balance on Hand For Information: Investments Made Changes in Holdings 3 $809,944.20 3 -23,715.25 $ 786,228.95 3 $ 4,088.70 3 5,160.00 3 & 4 13,063.11 4 0.00 4 46,050.30 4 2,627.50 70,989.61 $ 715,239.34 4 100, 000.00 $ 615,239.34 5 5 INCOME LAW OFFICES SNELBAKER SC BRENNEMAN, P.C. Receipts 5 $ 20,580.14 Less Disbursements 5 $ 108.48 Balance before Distributions $ 20,471.66 Distributions to Beneficiaries 5 $0.00 Income Balance on Hand $ 20,471.66 COMBINED BALANCE ON HAND $ 635,711.00 Listing of unpaid creditors and beneficiaries 6 Proposed distribution to beneficiaries 7 Verification 8 Page 2 PRINCIPAL RECEIPTS Assets Listed on Inventory per copy of attached: $815,579.57 (Valued as of Date of Death) ADJUSTMENTS TO INVENTORY -6,500.49 Merrill Lynch Account #872-86953, all proceeds were distributed to designated beneficiaries SUBSEQUENT RECEIPTS 1/30/2008 MetLife Investor, annuity payment to Merrill Lynch #872-57477 306.53 6/6/2008 Funds received in Merrill Lynch account #872-10177 385.27 6/30/2008 Cash in Lieu of stock for various stocks from April 2008 to June 2008 73.58 on Merrill Lynch Investment account #872-10177 9/8/2008 Commonwealth of Pennsylvania, refund on Inheritance Tax 99.74 TOTAL PRINCIPAL RECEIPTS $809,944.20 PRINCIPAL GAINS OR LOSSES ON SALES OR OTHER DISPOSITIONS GAIN LOSS Merrill Lynch Investment Account #872-10177 $ - $ 21,283.86 net loss on sale of stocks Merrill Lynch Investment Account #872-57793 2,431.39 net loss on sale of stocks TOTAL LOSSES NET LOSS TRANSFERRED TO SUMMARY DISBURSEMENTS OF PRINCIPAL DEBTS OF DECEDENT 1/23/2008 Visa payment paid from Merrill Lynch account 1/18/2008 Ashbury Community paid from Merrill Lynch account 1/28/2008 Merrill Lynch Investment account, #872-57477, Nationwide 3/3/2008 West Shore EMS-ALS, payment on account 3/3/2008 Bethany Village, payment on account 3/7/2008 Bonnie K. Miller, Tax Collector, per capita tax due 3/8!2008 East Pennsboro Ambulance Service, payment on account FUNERAL EXPENSES 3/3/2008 Hollinger Funeral Home & Crematory, Inc. ADMINISTRATION EXPENSES 2/1/2008 Merrill Lynch, consultant fees #872-57793 3/3/2008 American Cancer Society, reimburse annuity overpayment 3/5/2008 MetLife, reimburse annuity overpayment 5/1/2008 Merrill Lynch, account fees on #872-10177 5/5/2008 Register of Wills, filing fee for Inheritance Tax Return and Inventory 5!21/2008 Register of Wills, additional probate fee 5/21/2008 Snelbaker & Brenneman, P.C., costs advanced: LAw o~ices a. Register of Wills, additional probate fee 108.00 SNELBAKER & b. Cumberland Law Journal, advertise notice 75.00 BRENNEMAN, P.C. c. Certified mail 5.21 $ - $ 23,715.25 tLS, / 15.Lb) 16.88 2,986.55 136.52 823.02 82.93 9.80 33.00 $ 4,088.70 $ 5,160.00 $ 5,160.00 $ 1,169.76 78.34 306.53 1, 704.42 30.00 580.00 188.21 Page 3 5/22/2008 Nationwide Insurance, auto insurance 13.16 6/10/2008 Merrill Lynch, fee to purchase Cemex stock 818.11 To be paid upon confirmation of Account *" Snelbaker & Brenneman, P.C., costs advanced: 174.58 a. The Sentinel, advertise notice 174.58 "" Reserve for filing fees, accountant fees, attorney fees, and 2,500.00 other costs associated with the administration of the Decedent's estate `* Reserve for potential 2006 IRS tax liability 5,500.00 $ 13,063.11 FAMILY EXEMPTION NONE 0.00 FEDERAL. STATE & LOCAL TAXES 3/8/2008 Register of Wills, Agent, PA Inheritance Tax $ 37,900.00 5/5/2008 Register of Wills, Agent, PA Inheritance Tax 231.14 7/21/2008 Pennsylvania Department of Revenue, 2007 Income Tax 1,268.00 7/21/2008 Internal Revenue Service, 2007 Income Tax 6,651.16 $ 46,050.30 FEES AND COMMISSIONS 5/21/2008 Snelbaker & Brenneman, P.C., partial payment $ 2,187.50 on attorney services 7/21/2008 Smith, Elliot and Kearns, accountant fees 440.00 $ 2,627.50 TOTAL DISBURSEMENTS OF PRINCIPAL $ 70,989.61 DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES LAW OFFICES SNELBAKER EC BRENNEMAN, P.C. 5!612008 TO: Julie V. Ely $ 100,000.00 May 6, 2008, advance distribution $ 100,000.00 TOTAL DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES $ 100,000.00 PRINCIPAL BALANCE ON HAND FIDUCIARY VALUE AT ACQUISITION 9/8/2008 VALUE Cash 1995 Chevy S10 Pickup Miscellaneous furniture, furnishings & personalty "' Less items listed to be paid subsequent to confirmation of accounting as listed on page four TOTAL PRINCIPAL BALANCE ON HAND $ 641,730.58 $ 806,924.08 1,655.00 1,655.00 500.00 500.00 (8,174.58) $ 635,711.00 $ 809,079.08 Page 4 INFORMATION SCHEDULES PRINCIPAL INVESTMENTS MADE NONE CHANGES IN PRINCIPAL HOLDINGS NONE RECEIPTS OF INCOME 2/7/2008 Merrill Lynch Investment Account, #872-57792, dividends/interest to 2/7/08 $ 4,921.83 2/15/2008 Merrill Lynch Investment Account, #872-57793, dividends/interest to 2/15/08 666.28 2/29/2008 Merrill Lynch Investment Account, #872-57477, dividends/interest to 2/29/08 3,925.47 9/8/2008 Merrill Lynch Investment Account, #872-10177, dividends to 918/08 10,741.56 9/8/2008 Merrill Lynch Investment Account, #872-10177, principal payments/dividends 325.00 to 9/8/08 TOTAL RECEIPTS OF INCOME $ 20,580.14 DISBURSEMENTS OF INCOME 6/30/2008 Merrill Lynch Investment Account, #872-10177, foreign dividend tax $ 108.48 to June 2008 TOTAL DISBURSEMENTS OF INCOME $ 108.48 DISBURSEMENTS OF INCOME TO BENEFICIARIES NONE $0.00 TOTAL DISBURSEMENTS OF INCOME TO BENEFICIARIES $0.00 LAW OFFICES SNELBAKER Ef BRENNEMAN. P.C. Page 5 UNPAID CREDITORS: PERSONS INTERESTED IN DISTRIBUTION OF ESTATE: LAW OFFICES SNELBAKER SC BRENNEMAN, F.C. 1. George W. Ely, Jr. 11 Brenely Lane Mount Holly Springs, PA 17065 2. Julie V. Ely 1612 Red Hill Road Dauphin, PA 17018 3. Carol Weidler 107 Meadow View Lane Landsdale, PA 19446 4. Barbara Speece 1740 Hallman Drive Blue Bell, PA 19422 5. Virginia Brown 755 Lee Lane Enola, PA 17025 6. Frances Howard 4346 Campus Avenue Unit 202 San Diego, CA 92103 7. St. Timothy Evangelic Lutheran Church 4200 Carlisle Pike Camp Hill, PA 17011 8. University of Pennsylvania Office of Alumni Relations 3533 Locust Walk Philadelphia, PA 19104 9. The Rails-To-Trails Conservancy Northeast Regional Office 2131 Market Street, Suite 222 Camp Hill, PA 17011 NONE Page 6 PROPOSED DISTRIBUTION TO BENEFICIARIES George W. Ely, Jr., Executor and Accountant herein, proposes to distribute the balance of the Estate of George W. Ely, a.k.a., George W. Ely, Sr. Deceased to wit: $ 635,711.00 in accordance with the Last Will and Testament of said Decedent as follows: $ 338,427.06 1. George W. Ely, Jr. 46% of residue as per Article Five A of Will Household goods, retained In-Kind $ 250.00 Cash $ 338,177.06 I LAW OFFICES SNELBAKER 8C BRENNEMAN. P.C. 2. Julie V. Ely 46% of residue as per Article Five B of Will Household goods, retained In-Kind 1995 Chevrolet S10 pickup truck, In-Kind Cash Cash advance May, 6, 2008 in the amount of $100,000.00 3. Carol Weidler 2% of residue as per Article Five C of Will 4. Barbara Speece 2% of residue as per Article Five D of Will 5. The Rails-To-Trails Conservancy 1 % of residue as per Article Five E of Will 6. University of Pennsylvania 1 % of residue as per Article Five F of Will 7. St. Timothy Evangelic Lutheran Church 1 % of residue as per Article Five G of Will 8. Virginia Brown .5% of residue as per Article Five H of Will 9. Frances Howard .5% of residue as per Article Five I of Will TOTAL DISTRIBUTION: $ 238,427.05 $ 250.00 $ 1,655.00 $ 236,522.05 $ 14,714.22 $ 14,714.22 $ 14,714.22 $ 14,714.22 $ 7,357.11 $ 7,357.11 $ 7,357.11 $ 7,357.11 $ 7,357.11 $ 7,357.11 $ 3,678.56 $ 3,678.56 $ 3,678.56 $ 3,678.56 $ 635,711.00 Page 7 VERIFICATION GEORGE W. ELY, JR., Executor under the Last Will and Testament of GEORGE W. ELY A.K.A. GEORGE W. ELY, SR., Deceased hereby declares under oath that he has fully and faithfully discharged the duties of his office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the Estate have been paid in full; to his knowledge, there are no claims outstanding against the Estate; that all taxes presently due from the Estate have been paid; and that the grant of Letters Testamentary and the first complete advertisement thereof occurred more than four months before the filing of the foregoing First and Final Account. This statement is made subject to penaltigs` of y8 pa. C.S.A. Section 4904 relating to unsworn falsification to authorities. rge V~I.j~i, Jr., Executor Dated: 9 ~ ~j Ov Subscribed and sworn to by GEORGE W. ELY, JR. before me this ~~'? day of Se° ~i /~ 008 Notary Public fldl §~ad ~:~_~i Rr4~91idttlli~ ~r ~~ _~_f~iFflflil~fl € i~ ftldv: ~4,;~11 YiY ~f, FFW ' +iiifl{ii i8ral LAW OFFICES SNELBAKER EC BRENNEMAN. P.C. Page 8 DECEDENT'S ESTATE COURT OF COMMON PLEAS OF Cumberland COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF George W. Ely, Sr. , DECEASEI~~~ ~~ _ , ; ,_, ~> - No. 21-08-0080 - ~ r ~.~` rv -- ~, _f PETITION FOR ADJUDICATION / -. , =~ ':r'' STATEMENT OF PROPOSED DISTRIBUTION ~ ~, PURSUANT TO Pa. O.C. Rule 6.9 This form may be used in all cases involving the Audit of the Account of a Decedent's Estate. If space is insuffrcient, riders may be attached. Attach the spouse's election, if any; the papers required under items 8-19 inclusive; and any instrument pertinent to the adjudication. INCL UDE ATTACHMENTS AT THE BACK OF THIS FORM. Name of Counsel: Keith O. Brenneman Supreme Court I.D. No.: 47077 Name of Law Firm: Snelbaker & Brenneman P.C. Address: 44 West Main Street, Mechanicsburg, PA 17055 Telephone: 717-697-8528 Fax: 717-697-7681 Formoc-o~ re~~. l0.~3.06 Page 1 of 10 Estate of George W. Ely, Sr. 1. Name(s) and address(es) of Petitioner(s): Nome: George W. Ely, Jr. Address: 11 Brenely Lane Mount Holly Springs, PA 17065 Deceased Identify any executors or administrators who have not joined in the Petition for Adjudication and Statement of Proposed Distribution and state reason: N/A Is this the first accounting by this fiduciary? ..................... ~ Yes ~ No If not, identify prior accountings, the accounting periods covered, and the date of adjudication of the prior accounting. 2. Decedent died on January 16, 2008 Letters Testamentary or ~ Letters of Administration were granted to Petitioner(s) on Januarv 23.2008 Date of Will (if applicable): July 1, 2004 Date(s) of Codicil(s) (if applicable): N/A Date of probate (if different from date Letters granted) : same as above Was a bond required? ~JYes ~ No If yes, state amount: Are proofs of advertising of the grant of Letters attached? ......... ~ Yes No Dates of advertising of the grant of Letters: The Sentinel -January 30, February 6, 13 2008 and Cumberland Law Journal -February 8, 15, 22, 2008 FormOC-01 rev. !0./3.06 Page 2 of 10 PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Troy 4Vhitesel, Classified Sales Manager, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13t1~,1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s) Tanuary 30, February 6 & 13, 2008. COPY OF NOTICE OF PUBLICATION EXECUTOR'S NOTICE Letters Testamentary on the`Estate of GEORGE W. ' ELY, also knownras GEORGE W."ELY, SR.; late of Upper Allen Township, Cumberlarid County, Pennsylvania, have been granted to the undersigned. ` All persons knowing themselves to be mdebtedYo ' said Estate will make payment immediately, antl those<heving claims wilC.present them:for settlement ta: George W. Ely, Jr., Executor: 11 BrenelyLane Mauht Holly Springs, PA A 7065 Keith O.Brennemah, Esquire Snelbaker & Brenneman, P:C. 44 W: Main St P.O.-.Box 318 Mechanicsburg,,PA 17055 _ Attorneys far Executor Affiant further deposes that he/she is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of public`~ation are true. ~1 -,... Sworn to and subscribed before me this 13th. day of February, 2008. 'lGL.3 Notary Pub i My commission expires: ~l~ ~~ COMMONWEALTH OF PENNSYLVANIA Notarial Seal Christina L. Wolfe, Notary Public Carlisle Boro, Cumberiafx7 County My Commission Expires Sept 1,2008 Member, Pennsylvania Association Of Notaries PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: February 8 February 15 and February 22, 2008 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. -...,, ~,~ Lida Marie Coyn~, Editor .~' SWORN TO AND SUBSCRIBED before me this 22 day of February, 2008 Notary Ely, George W. a/k/a George W. Ely, 3r., deed. Late of Upper Allen Township. Executor: George W. Ely, Jr., i i Brenely Lane, Mount Holly Springs, PA 17065. Attorneys: Keith O. Brenneman, Esquire, Snelbaker & Brenneman, P. C., 44 W. Main Street, P.O. Box 318, Mechanicsburg, PA 17055. NOTAR----SEA DEBORAH A COLLINS Notary Public CARLISLE BORO, CUMBERLAND COUNTY My Commission Expires Apr 28, 2010 Estate of George W. Ely, Sr. ,Deceased 3. Was decedent survived by a spouse? ............................. Yes ~ No If yes, name of the surviving spouse: 4. Has the surviving spouse filed to take an elective share? ............. Yes ~ No (See Section 2201 et sic. of the Probate, Estates and Fiduciaries Code) If yes, date of election: 5. In the case of an intestacy, state the names of the decedent's surviving children or surviving issue of deceased children (if none, so state): N/A 6. Did decedent marry after execution of Will or Codicil(s)? ........... Yes ~ No Were any children born to decedent after execution of Will or Codicil(s)? ........................................... ~ Yes ~ No If yes, give names and dates of birth: Name: Date of Birth: 7. If required by the Medical Assistance Estate Recovery Act, 62 P.S. § 1412, was a request for a statement of claim sent to the Department of Public Welfare? .............................. Yes ~ No FormOC-OI rev. io.~3.06 Page 3 of 10 Estate of George W. Ely, Sr. Deceased Written notice of the Audit as required by Pa. O.C. Rules 6.3, 6.7 and 6.8 has been or will be given to all parties in interest listed in item 9 below, all unpaid creditors and all claimants listed in item 10 below. In addition, notice of any questions requiring Adjudication as discussed in item 14 below has been or will be given to all persons affected thereby. A. If Notice has been given, attach a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice. B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice shall be submitted at the Audit together with a statement executed by a Petitioner or counsel certifying that such notice has been given. C. If any person entitled to Notice is not sui juris (e.g., minors or incapacitated persons), Notice of the Audit has been or will be given to the appropriate representative on such party's behalf as required by Pa. O.C. Rule 5.2. I). If any charitable interest is involved, Notice of the Audit has been or will also be given to the Attorney General as required under Pa. O.C. Rule 5.5. In addition, the Attorney General's clearance certificate (or proof of service of Notice and a copy of such Notice) must be submitted herewith or at the Audit. List all parties (charitable and non-charitable) of whom Petitioner(s) has/have notice or knowledge, having or claiming any interest in the estate as beneficiaries under the Will or Codicil(s) or as intestate heirs if there is a complete or partial intestacy: A. State each party's relationship to the decedent and the nature of each party's interest(s): Form OC-01 rev. 10.13.06 Page 4 Of I0 Estate of George W. Ely, Sr. Deceased B. Identify each party who is not sui juris (e.g., minors or incapacitated persons). For each such party, give date of birth, the name of each Guardian and how each Guardian was appointed. If no Guardian has been appointed, identify the next of kin of such party, giving the name, address and relationship of each. N/A C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed for this Audit (see Pa. O.C. Rule 12.4). N/A D. If distribution is to be made to the personal representative of a deceased party, state date of death, date and place of grant of Letters and type of Letters granted. N/A Form oc-o~ ren. ro.13.06 Page 5 of 10 Estate of George W. Ely, Sr. ,Deceased 10. Other than the claim for the family exemption, list the names of all known claimants and the amount of their claims and state whether each claim is admitted. Name and Address of Each Claimant Amount of Claim Claim Will Claim Admitted? Be Paid /n Fu[l? None Yes Yes ~No ~ No Yes ~ Yes No ®No Yes ~ Yes ~No ~ No Yes ^ Yes No No If the estate is insolvent, attach a schedule setting forth the order of preference under 20 Pa.C.S. § 3392 and the proposed payments. 11. Was family exemption claimed? ................................ Yes No Was family exemption allowed? ................................ Yes ~No family exemption claimant's name and relationship: Name: Relationship: Form OC-01 rev. 10.13.06 Page 6 Of 10 Estate of George W. Ely, Sr. Deceased 12. The amount of Pennsylvania Transfer Inheritance Tax and additional Pennsylvania Estate Tax paid, the date(s) of payment(s), and the interest(s) upon which paid, are as follows: Date Payment Interest 4/10/2008 5/8/2008 37,900.00 231.14 13. On the date of death, was the decedent a fiduciary (personal representative, trustee, guardian, agent under power of attorney) or surety on the bond of a fiduciary? ................... Yes ~ No If yes, provide the name of the estate, indicate whether an account has been filed and confirmed absolutely and all awards performed, or, in the alternative, how the decedent's estate will be discharged for the decedent's fiduciary administration of the estate. 14. A. Describe in detail any questions requiring adjudication and state the position of the Petitioner(s) as to each question: N/A B. Has notice of the question requiring adjudication been given to the parties identified in Paragraph 9 above? .................. ~ Yes ~ No 15. If Petitioner(s) has/have knowledge that a share has been assigned, renounced, disclaimed or attached, provide a copy of the assignment, renunciation, disclaimer or attachment, together with any relevant supporting documentation. Form oc-ol rev. 10.13.06 Page 7 of 10 Estate of George W. Ely, Sr. Deceased 16. Had the decedent been adjudicated an incapacitated person? .......... ~ Yes ~ No If yes, attach a copy of the Order if available; otherwise state the Court, term, number, date, and name of Hearing Judge. 17. A. List or attach a separate list of additional receipts and disbursements since the closing date of the Account. N/A B. Has notice of the additional receipts and disbursements been given to the parties identified in Paragraph 9 above? ............. DYes ~ No 18. If a reserve is requested, state amount and purpose. 8,000.00 Amount: nu,pose: Reserve for filing fees, accountant fees, attorney fees and other costs associated with the administration of the Decedent's estate. In addticsn; we are holding a reserve amount for potential 2006 IRS tax liability II~ a reserve is requested for counsel fees, has notice of the amount of fees to be paid from the reserve been given to the parties in interest? ........................................ QYes ~No If so, attach a copy of the notice. 19. Is the Court being asked to direct the filing of a Schedule of Distribution? .......................... DYes ~No As to real estate only? ........................................ DYes ®/ No Form OC-01 rev. IOJ3.06 Page $ Of 1 ~ Estate of George W. Ely, Sr. Deceased Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties entitled and suggest(s) that the distributive shares of income and principal (residuary shares being stated in proportions, not amounts) are as follows: A. Income: Proposed Distributee(s) Amount/Proportion See Accounting B. Principal: Proposed Dtstributee(s) Amount/Proportion See Accounting Submitted By: (All petitioners must sign. Add additigrlZY~ lines if necessary): ame of Haiti Ely, Jr. Name of Petitioner: Form OC-01 rev. !0.13.06 Page 9 of 10 Estate of George W. Ely, Sr. Verification of Petitioner (Verification must be by at least one petitioner.) Deceased The undersigned hereby verifies * [that heishe he is rime Executor of the above-named name of corporation Estate of George W. Ely, Sr. and] that the facts set forth in the foregoing Petition for Adjudication /Statement of Proposed Distribution which are within the personal knowledge of the Petitioner are true, and as to facts based on the information of others, the Petitioner, after diligent inquiry, believes them to be true; and that any false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities). * Corporate petitioners must complete bracketed information. Certification of Counsel The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/ Statement of Proposed Distribution is a true and accurate reproduction of the form Petition authorized by the Supreme Court, and that no changes to the form have been made beyond the responses herein. I~ Signature of Counsel for Petitioner Form OC-Ol rev. /0.!3.06 Page 10 of 10