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HomeMy WebLinkAbout04-0316 PETITION FOR PROBATE and GRANT OF LETTERS Estate of ETHEL V. LARKIN, No. ~ ~ - ~ -~_"~ also known as To: Register of Wills for the Deceased County of Cumberland in the SocialSecurityNo. 124-42-9012 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner is 18 years of age or older and the Executor named in the last will of the above decedent, dated November 25, 1992, and codicil(s) dated [none]. Decedent was domiciled at death in Cumberland County, Penns~ylvania, with her last family or principal residence at 2120 Longs Gap Road, North Middleton Township, Pennsylvania. Decedent, then 93 years of age, died February 18, 2004, at 2120 Longs Gap Road, North Middleton Township, Cumberland County, Pennsylvania. Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted al2er execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: [none] Decedent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ 90,000.00 (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ 0.00 situated as follows: n/a WH R '' E EFORE, petitioner respect fully requests the probate of the last v~l~ 11 ,Snd co~li~il(s) pr.egented herewith and the grant of letters testamentary thereon. ~1~_? "~tephen L. Bloom 2100 Longs Gap Road~ Carlisle, PA 17013 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ) : SS. COUNTY OF CUMBERLAND ) The petitioner above-named swears or affirms that the statements in the foregoing petition are true and correct to the bes/t of the knowledge and belief of petitioner and that as personal representative of the above decede, n,t;_petitioner will well and truly administer the esr. ate ac/cfl~ng t~9_~w. Sworn to or affirmed and suvscnbed before me thisQ~-'~"l '~'' ' day of Stephen L. Bloom ~ . ., 2064. No. 21- Oq -,3 lie Estate of ETHEL V. LARKIN, Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW, _(~3, J~[. _,--~, , 2004, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated November 25, 1992, and described therein be admitted to probate and filed of record as the last will of Ethel V. Larkin and Letters Testamentary are hereby granted to Stephen L. Bloom. Will Book # ~ Page ~, - Register 5~¢v~lls FEES Stephen L. Bloom, Esquire Probate, Letters, Etc. $ ,703. o.2 Sup. Ct. I.D. No. 49811 Short Certificates (4) $ ] ~7 .oo 2100 Longs Gap Road ~,ml~f;m~ ~ $ to.oc~ Carlisle, PA 17013 ,.~OOo $ it'). c.~'% (717) 249-7717 TOTAL Filed ~ 105.805 REV 9/86 This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copyby PhOtostat or photograph. F~e for this CertifiCate; $2.00 P 10159222 No. ~ Date H10~143~ ~? COMMONWEALTH OF PENNSYLVANIA · DEPARTMENTOF HEALTH ' VITAL RECORDS CERTIFICATE OF DEATH pERMANEh-~ NAMEOFDECEOENTIF~I, MR~IJe, L~I} SEX [S~IALSE~R[TYNUMBER J~TEO ~TH(MO~ ~.Y. · ~c.~ Ethe~ V. LarkZn z F~ma~e ~ 124 - 42 - 9012 v~ /2 7/1,910 ~: o~ ~,~ PA 17013, I~,~"'~"~ *~ : I~o. ~. ~(s~) -, ~I~fTY2004 ~nger C~emato~y Mt. Ho~y Spring~ PA 17065 ~ . LAST WILL AND TESTAMENT I, ETI-I~I. V. LARKIN, of West Pennsboro Township, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking any and ~t ~orme~Vills ,~r~ Codicils by me made. ~..r~ _. ::; ~..., o. I direct that all my just debts, funeral expenses, testamentary expenses and'all,, inh~ritanc~2 ~' · ' ' ;" ~ shaft~°-- taxes (whether such taxes may be payable by my estate or by any recipient of any. pmpe~) be paid from my residuary estate as soon as practicable after my decease and as part of the administration of my estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not passing under this Will. 2. I give, devise and bequeath all of my estate, both real and personal property, in equal shares, unto my daughters, JOAN I~. LARKIN, of West Faimouth, Maine, and MARY L. BLOOM, of Carlisle, Pennsylvania; provided, however, the issue of any deceased beneficiary shall take, per stiles, the share of their deceased ancestor. 3. All of my insurance policies which provide indemnity for the loss of or damage to any of my personal or real property by fire, windstorm or other similar casualty (including any claim for the loss of or damage to any such property which I might have at the time of my death against any insurance company), I give and bequeath, respectively, to those persons who shall become the owners of such properties by reason of my death, whether such ownership be acquired under the provisions of this Will or by other means. 4. I nominate, constitute and appoint my grandson, STEPHEN L. BLOOM, of Carlisle, Pennsylvania, as Executor of my estate. In the event he shall be unable or unwilling to serve IE.V.L. Page 1 of 3 Pages in such capacity, then ! appoint my daughter, MARY L. BLOOM, to act in such capacity. 5. I direct that my Executor or Executrix shall not be required to file a bond to secure the faithful performance of his or her duties in any jursdicfion. 6. I authorize and empower my personal representative, in his or her sole and absolute discretion, to purchase or otherwise acquire and retain any investments of which I die seized or any real or personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of or grant options in regard to any or all property of any kind forming a part of my estate for such terms and such prices as they may deem advisable; to borrow money for any puq~oses connected with the protection and preservation of my estate; to mortgage or pledge any real or personal property forming a part of my estate or to join in or secure the partition of same; to compromise any claims or demands of my estate against others or of others against my estate; to make distribution in kind and to cause any share to be composed of cash, property or undivided fractional shares in property different in kind from any other share; and to execute and deliver such instruments as may be necessary to carry out any of these powers. IN WITNESS WI-I~REOF I have hereunto set my hand and seal this ,Th~ day of ~"/~o ~, 1992. Ethel V. Larkin SIGNED, SEALED, PUBLISI-Ig~D AND DECLARED by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who at her request, have hereunto subscribed our names as witnesses thereto, in the presence of the said Testatrix and of each other. Page 2 of 3 Pages COMMONWEALTH OF PENNSYLVANIA ) : SS. COUNTY OF CUlVlBERLAND ) I, Ethel V. Larkin, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Ethel V. Larkin Sworn or affmned to and acknowledged before me by Ethel V. Larkin, the Testatrix, this ~ day of ~,,,~ 1992. Notary Public ~otarial Ceeir~ L Myem, Notay Pul31b COIVIIVIONWEALTH OF PENNSYLYANIA r_~is~eaoro, Cu~berandCou~ SS. My Commission Ex,res May 22,1995 . COUNTY OF CUMBERLAND Member, Penr~vana~of No~es the witness~es whose names are signe~o the attached or foregoin§ instrument, being duly qualified according to law, do depose and say that we were present and saw Ethel V. Larkin, the Testatrix, sign and execute the instrument as her Last Will; that the Testatrix signed willingly and that the Testatrix executed it as her free and voluntary act for the purposes therein expressed; that each of us, in the hearing and sight of the Testatrix, signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. ^al&ess Sworn or to and subscribed before me this day of 1992~ Notary ~blic , J ~ L Myer, ~ ~c I ~ ~ ~on F~r~ May ~, 1~5 Page 3 of 3 Pages Mem~r, P~nsylv~a~a~on of No~ COMMONWEALTH OF PENNSYLVANIA REV-11 62 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 003951 BLOOM STEPHEN L 2100 LONGS GAP ROAD CARLISLE, PA 17013 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold .......... - ....... 101 $3,400.00 ESTATE INFORMATION: SSN: 124-42-9012 FILE NUMBER: 2104-031 6 DECEDENT NAME: LARKIN ETHEL V DATE OF PAYMENT: 05/18/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 02/18/2004 TOTAL AMOUNT PAID: $3,400.00 REMARKS: CHECK# 2 INITIALS: JA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: ETHEL V. LARKIN Date of Death: February 18, 2004 File No. 2004-00316; PA File No. 21-04-0316 To the Register: I certify that Notice of Beneficial Interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above estate on May 12, 2004: Name Address Mary L. Bloom 2120 Longs Gap Road, Carlisle, PA 17013 Joan E. Larkin 86 Brook Road, West Falmouth, ME 04105 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: N/A Date: May 12, 2004 ~~ ~ Stephen L. Bloom ,.z4.' 2100 Longs Gap Road c._ Carlisle, PA 17013 ~ (717) 249-7717 Capacity: Personal Representative C:\Office - Estate Administration\7828.2cert.not.doc PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD OO4645 BLOOM ',STEPHEN L 2100 L(~NGS GAP ROAD CARLISL~E, PA 17013 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 $56.17 ESTATE INFORMATION: SSN: 124-429012 FILE NUMBE~: 2104-031 6 DECEDENT NAME: LARKIN ETHEL V DATE OF PA~/MENT: 11 / 18/2004 POSTMARK [bATE: 11 /18/2004 COUNTY: CUMBERLAND DATE OF DEATH: 02/18/2004 TOTAL AMOUNT PAID: $56.17 REMARKS: S BLOOM CHECK//9 INITIALS: VZ SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of Larkin, Ethel V. No. 21 - 04 - 00316 also known as Date of Death 2/18/2004 , Deceased Social Security No. 124-42-90t2 Stephen L. Bloom The PerSonal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory 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 relating ~ unsworn falsification to authorities. Persona, Representative~ ~'~:~ _. Attorney; Stephen L. Bloom Signature:-- ~ .... / ~ Stephen L. Bloom I.D. No.: 49811 Signature: Signature: Address: 2100 Longs Gap Road Address: 2 I00 Longs Gap Road Carlisle, PA 17013 Carlisle, PA 17013 Telephone: 717/24%7717 Telephone: 717-249-7717 Dated: / ~ Personal Property - Brokerage Cash Reserves #5AD-083260 - Jacqueline L. Powell & Associates, Inc. 1,694.90 Cinergy Corp - Common Stock - 490 Shares @ $38.92 19,070.80 Exelon Corp - Common Stock - 1,000 Shares ~ $66.86 66,860.00 Final Payment - E I Du Pont de Nemours & Co Inc Retirement Plan 95.50 Refund Overpayment - Carlisle Regional Medical Center 74.22 Savings Account # 15004200910550 - M&T Bank 387.42 Total Personal Property $88,182.84 (Attach additional sheets if necessary) Total Personal Property and Real Estate $88,182.84 ............... REV-1500 OO"MONWE*LT, O~PE..SV~V*N,A INHERITANCE TAX RETURN ~E~ ...... RESIDENT DECEDENT ~ I 04 003 I 6 Larkin, Ethel V. 124 42-9012 z~ DATE O~ D~ATH {MM.DD-YEAR) DATE OF 81RTH (MM-DD YEAR) ~ 02/t 8/2004 i 04/27/]910 REGISTER OF WILLS ~ (IF APPLICABLE) SURvIVIN~ ~OLJ~'S NAME ( LAST, FIRS+ AND M ~DL~ INITIAL) SOCIAL SECURITY NUMBER [] 1~ O~iginal Return [] 2 Supplemental Return [] 3 Remainder Return(date of de'Ih prier to 12 3-82) ~ B '~ ~° [] 4. Linited Estate [] 4a 12Future1282)Interest Compromise (date of death after [] 5 Federal Estate Tax Return Required o [ m [] 6of Decedentwilll Died Testate (Attach copy [] 7 copyDeCedentof Trust)Maintained a Living Trust (Attach 0 8 Total Number of Safe Deposit Boxes '~ [] 9 Litigation Proceeds Received [] 10 Spousal Poverty Credit (date of de~lh between [] 11 Election to tax under Sec 9113(A) (Attach Sch O) ~z~ S~ephe~ L. Bloom ii ~IRMNAME'fapplicable) ! Stephet~ b Bloom, Esquire 2]00 Lon~s Gap Road ~TELEPHONE NUMBER Carlisle, PA t7013 ?17/249-7717 1. Real; Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 87,625.70 3, Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5 Cash, Bank Deposits & Miscellaneous Personal Property {5) 557. t 4 (Schedule E) 6 Jointly Owned Property (Schedule F) (6) ? 6 I . 30 ~ [] Separate Billing Requested ,~ 7, Inter,Vivos Transfers & Miscellaneous Non-Probate Properly (7) ~o n ~ (Schedule G or L) <~ 8. Total Gross Assets (total Lines 1-7) (8) 88,944. 14 ~ 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 6 ,'74 [. 48 10. Debtb of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) | ,356.55 ~ 11. Total Deductions (total Lines 9 & 10) (11 ) 8,098.03 i 12. Net Yalue of Estate (Line 8 minus Line 11) (12) 80,846, t 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net ~'alue Subject to Tax (Line 12 minus Line 13) (14) 80,846. I l SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec 9116(a)(1.2) ~ 16.Amo~lnt of Line 14 taxable at lineal rate 80,846. ! I x .045 (16) 3,638.07 ~ i 17.Amo[lntofLine14taxableatsiblingrate x .12 (17) ~ 18 Amount of Line 14 taxable at collateral rate ~ x .15 (18) 19 Tax Due (19) 3,638.07 .... I - >> ~E SU -RE ~I~W~ ^L~LTQU~[STION$ oN REVER$£ SIDE AND REcBEcK MATH ~ Copyright 2000 for~ software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 2120 Longs Gap Road CITY ' Carlisle STATE PA zip 17013 Tax Pa~,ments and Credits: 1. Tax~ue Page 1 Line 19) (1) 3,638.07 2. Credlts/Pa,'ments A Soousal Povert, Credit B Prior Pat n~enls 3,400.00 lC Discount 181.90 Tota Credits (A + B + C) (2) 3,5 8 1.9 0 3. nterest/Penalty if applicable D n[erest E Penalt, Total InterestJPenalty (D + E) (3) 0.00 4 t Linb 2 is greater man L~ne 1 - Line 3. enter the d~fterence. This is the OVERPAYMENT (4) Check box on Page I Line 20 to request a refund 5. IfLinel+une3rsgreatermanLine2, enter the difference ThislstheTAXDUE (5) 56.17 A Enter the interest on me tax cue. (5A) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) 5 6 · ] 7 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Eiio aeceaent make a transfer and Yes No b. retain ine ngn[ [o oes~gnate WhO sna use the properly transferred or i s ncome; ................. retain a reverslonan, meres~ or .............................................................................. Id. receive the prom se o eoe her paymen s, benef sorcare? ........................................................ 2, Ifldeath occurred after December 12, 1982 did decedent transfer properly within one year of death without e!ce v ng adequa e cons dera on9 [] [] 3. Dtd decedent own an "in trust for" or payable upon death bank account or security at his or her death? [] [] 4. Did decedent own an Indiwdual Retirement Account. annu ty, or other non-probate property which c0ntains a beneflcmry des gna on? [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. S GNATURE OF PEF~SON RE NS LE FO NG RETURN ADDRESS DATE Stephen L. B · 2100 Lones Gap Road , - Carlisle, FA 17013 i'///~/~ ~RN ADDRESS / DATE Stephen Carlisle, ~fi~ 1701~ surviving spous4 is 3% [72 P S §9116 (a) (1.1/(i)] [72 P S §9116 (~) (1 1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure parent an adoptive parent, or a stepparent of the ch d is 0% 72 PS §9116 (a) (1.2/1. 1 2)[72 PS. §9'~16 (a) (1)] The tax rate imp~)sed on the net value of transfers to or for the use of the decedent's sibl ngs is 12% [72 P S §9116 (a) (1 3)]. A slbhng is defined, i.~p SCHEDULE B I STOCKS & BONDS ESTATE OF arkin, Ethel V. FILE NUMBER 21 -04-00316 All property jointl -owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER ; DESCRIPTION UNIT VALUE VALUE AT DATE OF ~ DEATH i BrOkerage Cash Reserves #5AD-083260 - Jacqueline L. Powell & Associates, Inc. 1 2 Ci~ergy Corp - Common Stock - 490 Shares ~ $38.92 19,070.80 3 Ex(Ion Corp - Common Stock - 1,000 Shares @ $66.86 66,86O.0O TOTAL (Also enter on line 2, Recapitulation) 87,625.70 SCHEDULE E CASH, BANK DEPOSITS, & MISC. ESTATE OF FILE NUMBER l~arkin. Ethel V. ! ; 21-04-00316 Include the procbeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship mlust be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH I Fm~al Payment - E I Du Pont de Nemours & Co Inc Retirement Plan 95.50 2 RefUnd Overpayment - Carlisle Regional Medical Center 74.22 3 Sa'&ngs Account #15004200910550 - M&T Bank 387.42 TOTAL (Also enter on Line 5, Recapitulation) 557.14 SCHEDULE F COMMONW ALTH OF PENNSYLVANIA ,~,~.c~ ~^× ~. JOINTLY-OWNED PROPERTY BESlDENT DECEDENT ESTATE OF Larkin, Ethel V. FILE NUMBER ; 21 -04-00316 If an asset was ~nade joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVIN~ JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A Mary L. Bloom 2120 Longs Gap Road Daughter Carlisle, PA 17013 JOINTLY OWNED PROPERTY: " DESCRIPTION OF PROPERTY % OF ; DATE OF DEATH OR ~IoINLET~TER MADEDATE Include name of financial institution and bank account number DATE OF DEATH DECD'S VALUE OF ITEM NUMBER ,IFTENANTT JOINT estate°r similar identifying number- Attach deed foriointly-held real VALUE OFASSET INTEREST DECEDENT'S INTEREST I A Checking Account # 1143107 - M&T Bank 1,522.591 50% 761.30 TOTAL (Also enter on line 6, Recapitulation) 761.30 ESTATE OF Larkin, Ethel V. FILE NUMBER ~ 21 - 04- 00316 Debts et decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FI~NERAL EXPENSES: I Hollinger Funeral Home & Crematory, Inc. 1,159.00 2 F}tmily Memorial Dinner - Platte 35.3.72 3 Filmily Memorial Reception - Caterer & Miscellaneous Beverages/Foods 559.96 4 EFerlasting Memorials - Grave Marker 720.80 5 Elistford Sand & Stone - Burial Fee 75.00 B. A~MINISTRATIVE COSTS: 1 Pbrsonal Representative's Commissions S~Ocial Security Number(s//EtN Number of Personal Representative(s}: S]reet Address C!ty State -- Zip Y,~ar(s) Commission paid 2 A~torney's Fees 3 F~mily Exemption: (If decedent's address is not the same as claimant's, attach explanation) 3,500.00 Claimant Mary L. Bloom Street Address 2120 Longs Gap Road City Carlisle State PA Zip 17013 Relationship of Claimant to Decedent Daughter 4 Prpbate Fees Register of Wills of Cumberland County 228.00 5. Adcountant's Fees 6 TaXx Return Preparer's Fees Mentzer & Company, P.C, 145,00 7 Ot~er Administrative Costs TOTAL (Also enter on line 9, Recapitulation) 6,741.48 SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ~ FILE NUMBER ESTATE OF [~arkin, Ethel V. 21 - 04- 00316 ITEM NUMBER DESCRIPTION AMOUNT I BF~tI'RA In Home Care - Final Invoice 685.50 2 BE~I'RA In Home Care - Interim Invoice 259.00 3 Podiatrist Invoice 15.73 4 Crqsscare Medical - Hospital Bed Rental 180,76 5 Cu~nberland County' Office of Aging - Homemaker Serv ce i09.56 6 Co~nmonwealth of Pennsylvania -2003 State Income 'Fax Due 106.00 TOTAL (Also enter on Line 10, Recapitulation) 1,356.55 REV-1515 EX+ (9-00) ~ SCHEDULE J COMMON~fEALT, O~ PE'NS~LV^N~^ BENEFICIARIES INHE ITANCE TAX RETURN ESTATE OF ~arkin, Ethel V. FILE NUMBER 21 - 04- 00316 RELATIONSHIP TO NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT AMOUNT OR SHARE DO NOt List Trustee(s) OF ESTATE I. T~XABLE DISTRIBUTIONS (include outright spousal distributions) I Jdan E. Larkin Daughter 50% of Estate 8~ Brook Road ~cst Fa mouth. ME 04105 2 iVI~ ry L. Bloom Daughter 50% of Estate 21120 Longs Gap Road Carhsle, PA 17013 Ente dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet NOb-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. C(4AR/TABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET LAST WILL AND TESTAMENT I, ETHI~.I.V. LARKIN, of West Pennsboro Township, Cumberland County, Peru sylvania, being of sound and disposing mind and memory, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking any and ail former Wills or Codicils by me made. 1. I direct that all my just debts, funeral expenses, testamentary expenses and ail inheritance taxe~ (whether such taxes may be payable by my estate or by any recipient of any property) shall be ~aid from my residuary estate as soon as practicable after my decease and as part of the admlnistration of my estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not @assing under this Will. ! I give, devise and bequeath all of my estate, both real and personal property, in equal shar~s, unto my daughters, JOAN E. LARKIN, of West Falmouth, Maine, and MARY L. BLOOM, of Carlisle, Pennsylvania; provided, however, the issue of any deceased beneficiary shai~ take, per stirpes, the share of their deceased ancestor. 3. All of my insurance policies which provide indemnity for the loss of or damage to any of m y personai or real property by fire, windstorm or other similar casualty (including any claim for l he loss of or damage to any such property which I might have at the time of my death agai~ tst any insurance company), I give and bequeath, respectively, to those persons who shall beco me the owners of such properties by reason of my death, whether such ownership be acqu ired under the provisions of this Will or by other means. 4. I nominate, constitute and appoint my grandson, STEPHF_.N L. BLOOM, of Carlisle, Pent sylvania, as Executor of my estate. In the event he shall be unable or unwilling to serve E.V.L. Page 1 of 3 Pages in s~ch capacity, then I appoint my daughter, MARY L. BLOOM, to act in such capacity. 5. I direct that my Executor or Executrix shall not be required to f'fle a bond to secure the fald ful performance of his or her duties in any jurisdiction. 6. I authorize and empower my personal representative, in his or her sole and absolute disc etion, to purchase or otherwise acquire and retain any investments of which I die seized or any real or personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, disp~, se of or grant options in regard to any or all property of any kind forming a part of my esta~ e for such terms and such prices as they may deem advisable; to borrow money for any pur[oses connected with the protection and preservation of my estate; to mortgage or pledge any real or personal property forming a part of my estate or to join in or secure the partition of sara :; to compromise any claims or demands of my estate against others or of others against my esta~ e; to make distribution in kind and to cause any share to be composed of cash, property or undi vided fractional shares in property different in kind from any other share; and to execute and deliver such instruments as may be necessary to carry out any of these powers. IN WITNESS WHEREOF I have hereunto set my hand and seal this ,76~/~ day of '7~? ~L**' 7~.[.~ ~-, 1992. ,, ?~', ~. ~, (SF. AL) Ethel V. Larkin 5IGNED, SEALED, PUBLISI-I~D AND DECLARED by the above-named Testatrix, as and for ~er Last Will and Testament, in the presence of us, who at her request, have hereunto sub.' eribed our names as witnesses thereto, in the presence of the said Testatrix and of each other. / E 4~,.(_ ~_ ~..~ ,t~t / Page 2 of 3 Pages CO} IMONWEALTH OF PENNSYLVANIA ) : SS. COl INTY OF CUMBERLAND ) :, Ethel V. Larkin, Testatrix, whose name is signed to the attached or foregoing instrument, havi ag been duly qualified according to law, do hereby acknowledge that I signed and executed the nstrument as my Last Will; that I signed it willingly; and that I signed it as my free and voh atary act for the purposes therein expressed. Ethel V. Larkin Sworn or affirmed to and acknowledged before me by Ethel V. Larkin, the Testatrix, this ~ ~ day of '7')-OZ~L, 1992. [ Notary bnc dj I Notaflal Seal Ctmino L. Myer, Notary Pub~ [ CO} [IVlONrWEALTH OF PENNSYLVANIA CadisleBom, Cumbe~a~Co~nly I SS. My Commission F~p*res May 22, 1995 C01[ [N'rY OF CI,.J-IV~~ Meml:)er, Pemsy~vana~n of Naiades the ~itness~s whose names are signerd../~o the attached or foregoing instrument, being duly qual .fled according to law, do depose and say that we were present and saw Ethel V. Larkin, the restatrix, sign and execute the instrument as her Last Will; that the Testatrix signed willi ngly and that the Testatrix executed it as her free and voluntary act for the purposes therein expi ~ssed; that each of us, in the hearing and sight of the Testatrix, signed the Will as witnesses; and :hat to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sour mind and under no constraint or undue influence. Sworn or affirmed to and subscribed before me this o70-7~ day of 19% N~m~ ~blic ['" ~ / ~e L. Myem, NOU, p~ Cadi~ ~ro Cum~dar~ Page 3 of 3 ~ges Me.r, P~nsylv~-~n of JACQUELI ' or)WELL & ASSOCIATES, INC, 43A BROOKVVOOD AVENUE, SUITE 6, CARLISLE, PA 17013 PHONE (717) 258-075 I; FAX (717) 258-973 I www.jpowellassoc.com May 5, 2004 Stephen Bloom 2100 Longs Gap Road Carlisle, PA 17013 Re: Date of Death Values tbr 5AD-083260, Ethel Larkin Dear Steve, Please find below the date of death values for Ethel Larkin's individual account with our firm: As of 02/18/2004 Brokerage Cash Reserves 8173999 1,694.900 $I .00 $1,694.90 Cinergy Corp Com CIN 490.000 $38.92 $19,070.80 Exelon Corp Corn EXC 1,000.000 $66.86 $66,860.00 TOTAL: $87,625.70 Please do not hesitate to contact me should you have any questions. My office number is (717) 258-0751 and my email address is tracee~jpowellassoc.com. I Registered Sales ~.~Jitrafint Securities offered through Financial Network Investment Corporation. Member SIPC. Registered Broker/Dealer lacqueline L. Powell & Associates, Inc and Financial Network are not affiliated, j~STATE STREET P.O. BOX 550868 JACKSONVILLE, FL 32255-0868 ETHEL LARKIN 2120 LQNGS GAP RD CARLISgE PA 17013-9379 ACCOUNT ID F UPONT--DPQIO PERIOD EEGINNING: PLAN NAME E DUPONTDENEMOURS&COiNCRETIREMENTPlANS PERIOD ENDING: ~ PAYEE INFORMATION CHECK NO. T-~'-'~'~-EE soc. SEC. NO. I NE'~T PAYMENT FEBRUARY 27, 2004 330308697 124-42-**** 95 50 · PAYMENT DETAIL PAYMENT ~ ~ Curr'~'--'---~nt ~ Year-To-Date DEDUCTIONS '-'~-~urrent~ ~ ~ -- T43.00/ 286., MEDICAL ~ 95.00,  ~ TOTAL DEDUCTIONS~_ I CATE 02/27/200 PLAN NAME E I DU PONT DE NEMOURS & CO INC RETIREMENT PLANS CHECK NO. 330308697 PAY NINETY-F VE DOLLARS 50 CENTS TO THE ORDEROF ETHEL V LAHKIN 2120 TONGS GAP RD '° $********95 50 CARLISLE PA 17013-9379 ' NOT VALID AFTER 180 DAYS HEALTH MANAGEMENT ASSOCIATES, INC. .,,c=o~u, ~,ar.,, .~ VOID AFTER 90 DAYS CARL£SLE REG. MED CTR ~s, ~ 246' P~R STREET ~ ~ ~LI~LE, PA 17013 0045153 PA~ SEVEN~Y-FOUR&2~100 ~~ ~. DATE ~ AMOUNT ' ~'04/12/20041 [~*******'74.22 TO ~KIN, ETHEL V OF ~ ~ISLE, PA 17013- 0 "'OOh5 ~5 5,' ~:O~ ~ ~O ? 5 ~ 5~: ~OqOOO 8&O ~h,, HEALTH MANAGEMENT ASSOCIATES, INC, INVOICE DATE INVOICE NUMBER DESCRIPTION COMMENT DISCOUNT AMOUNT PAID 03/25/2~4 7325278 ~ 74.22 M&TBank 499 Mitchell SWeet, Millsboro, DE 19966 May 19, 2004 Stephen L Bloom Attorney and Counsellor At Law 2100 Longs Gap Road Carlisle, PA 17013 RE: Estate of Ethel V. Larktn Date of Death: Febr~ary 18, 2004 Social Security Number: 124-42-0012 Dear Mr. Bloom: In response to your request, please be advised that at the t/me of death, the above- named decedent had on deposit with this bank the following accounts. 1. Account Type ........................... Checking Account Account Number. ...................... 1143107 Ownership {Names of) ..............Mary L. Bloom, Ethel V. Larkin Opening Date ........................... 06/20/92 {account closed 05/11/04) Balance on Date of Death_ .........$1,522.59 Accrued Interest $ 0.00 Total. ...................................... $1,522.59 2. Account Type ........................... Savings Account AcceuntNumber. ...................... 15004200910550 Ownership {Names of) ..............Ethel V. Lark~n Opening Date ........................... 07/22/92 (account closed 05/11/04) Balance on Date of Death_ .........$387.11 Accrued Interest $ 0.09 Total ....................................... $387.20 Sincerely, Charlene Warrington, Records Management 1-888-502-4349 Hollinger Funeral Home & Crematory, Inc. Eric L. Hollinger, Supervisor Februar~ 24, 2004 Mary BI )om 2120 Lo~ gs Gap Road Carlisle, 'A 17013 The Fane ral Service for Ethel V. Larkin We since 'ely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free' o contact us if you have any questions in regard to this statement. THE FOLI OWING IS AN ITEMIZED STATEMENT OF THE SERVICES. FACILITIES, AUTOMOTIVE EQUIPMENT. AND MEI~ CHANDISE THAT YOU SELECTED WltEN MAKING THE FUNERAL ARRANGEMENTS. AT THE T ME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERIS ~ tS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. C. SPECI S,L CHARGES Direct Cre~ nation ........................ $895.00 CASH Al] VANCES Newspape~ Notices - Out-of-town ................... $244.00 Certified 12 >pies of the Death Certificate ................. $20.00 OTAL CASH ADVANCES AND SPECIAL CHARGES ........ $1159.~ IONTRACT PRICE ................... ~ ~'~ ~TAL AMOUNT DUE ................. ( ~ 501 NOI~TH BALTIMORE AVENUE .. MOUNT HOLLY SPRINGS. PENNSYLVANIA 17065 · (? 17) 486-3433 · FAX (717) 486-3215 www.hollingerfuneralhome.com G ? CATEI~ERS INC. n¥o | 139 RIVER]SIDE DRIVE THOMPSON, CT 06277 DATE INVOICE # 15/19/20042531 BILL T(~ Ph°~l~ixViile P.O. NO. i TERMS DUE DATE i 5/19/2004 DESCRIPTION QTY RATE AMOUNT Garden Salad, Pasta Salad, Potato 45 6.95 312.75T Salad, A~, sorted Finger Rolls, Pickles, i Chips, C,)ffee Chicken 'Fenders with Sauce 45 1.25 56.25T 1/2 Brownies 1 20.00 20.00T Ct. Sales ]Tax 6.00% 23.34 Total $412.34 We appreciate your prompt pavment. I ~9,3 4~ ¢ ~ ~7 $CHWP [ON WTR 1L 139 xT ' BOIfLE DEPOSIT 0.08 SCHWP BOTTLE DEPOSIT 0.05 SOHWP TON WTR 1L 1.39 BOTTLE DEPOSIT SCHWP 10N WTR 1L BOTTLE DEPOSZT 0.05  SCHWP TON WTR 1L 1.39 ~T 80FTLE DEPOSII 0.05 S&S PLASTIC CUP 1.39 [ S&S PLASTIC CUP 1.39 f SgS PLASTIC CUP 1 39 T All The Ingredients SSS PLASTIC CUP 1,39 T 101 1,45 lb ~ $0.99/ lib A BETTER PLACE TO SAVE LO w NAVEL ORNGE 1.44 STOP g SHOP #672 4 ~ 2 fo~ $1.00 DAYVILLE, CT. LIMES 2.00 860-779-2070 BIN CAN1ALOUPE 2.99 Stop WELCOME i'M JEFFf 2:qdpm 5/20/04 Price with your card 2.49 Iran 81541Termina! 4 Cashier 00146 LARGE HONEYDEW 3.99 S&S CLR PLST CUP 1.39 f Total $0,00 HN FLEX STRAW G,99 T Customer Card Number 1098083612 RIPE CR PINEAPPL 3.99 JCYJCE APPLE 12P 299 ~ S&S CLR PLSE CUP 1.39 T GLD DRWSTRNGTRSH 5.69 T S&S CLR PLST CUP 1.39 T HUG RIBEER ]2PK 4,69 *T SSS CLR PLST CUP 1.39 f Stop & Shop Card Sawngs -1.19 ~T SCS CLR PLST CUP 1.39 T Price with your card 350 JUMBO LEMONS 0.69 BOTTLE DEPOSI! 0.60 ~ SSS CLR PLST CUP 1.39 T PEPSI 12.12Z CAN 4.69 ~[ FO1 !.03 lb ~ $2.49/ lib Stop & Shop Card Savings -1.19 *T RED SDLESS GRAPE 2.56 Price with your card 3,50 lotal $91.42 BOTTLE DEPOSIT 0.60 ~ Cash $100.00 BRWNY BOX NAPKIN 3.99 f Total before savings $97.96 C/F DT PEPSi 4,59 *T 'Four Total Savings $10,12 Stop & Shop Card Savings -1.19 ~f Total after savings $87.84 Price with your card 3.50 Tax paid $3.58 BOTTLE DEPOSI1 0.60 * Total $91.42 SCHWP BT GNG12PK 4.69 =T loZal tender $100.00 S~op & Shop Card Savings -1.19 ~T Change $8.58 Price with your card 3.~0 BOTTLE DEPOSIT 0.60 ~ DR PEPPR 12PK12Z 4.69 *T YOUR SAVZNC~S SUMMARY Stop & Shop Card Savings -1.19 ~T Stop & Shop Card Savings $10.12 Price with your card 3,50 ToIaI Stop ~ Shop Card SavingS10.12 BOTTLE DEPOSIT 0.60 * Your Total Sawngs $10.12 MD LIVE WIRE 12P 4.39 TI Stop & Shop Card Savings -0.89 ~T ~*YEAR-fO-DATE SAVINGS*** $23.70 BOT1LE DEPOSIT 0.60 * SLICE ORNGE 12PK 4.69 ~T Stop & Shop Card Savings -1.19 *T THANK YOU FOR SHOPPING AT STOP & SHOP, Price with your card 3.50 WE'VE ENJOYED SERVING YOU, AND WE BOTTLE DEPOSIT 0,60 x LOOK FORWARD TO SERVING ALL YOUR BOUNTY TOWEL 1.29 f FUTURE SHOPPING NEEDS. SSS HVYDTY SPOON 1.39 Stop & Shop Card Savings -0.40 T RALPH DANIS STORE MGR, 779-2070 Price with your' card 0.99 SCHWP TON WTR 1L 1.39 ~f STOP ~ SHOP #672 BOTTLE DEPOSIT 0.05 ~ LIP/N BRISK 12PK 4.69 ~ All The Ingredients A BETTER PLACE TO SAVE STOP g SHOP #672 DAYVILLE, CT. 860-779-2070 WELCOME Z M LISA! 2:36pm 5/21/04 Tran 81753 Ter'mmal 4 Cashler 00143 MINI FRENCH BRD 1.29 ~ MINI FRENCH BRD 1,29 * SCS ARUGULA SALA 2.99 * S&S ARUGULA SALA 2,99 ~ FW gL POL CRKSCR 5.99 T 2 ~ 2 for $3.00 BLACK AVOCADO 3.00 · PINT GRAPE TOMAT 2.99 ~ PIN[ GRAPE TOMAT 2.99 * 1LB STRAWBERRIES 3.49 ~ 1LB SFRAWBERRIES 3.49 ~ IBLE WTR CRACKER 2,79 ~ CRRS ASST BZSCUT 3,99 · BTNI FM PSTO SCE 5.99 * BTNI CLB CHS TRf 5.99 * RUBSCHLGN WP GR 1.69 ~ MARIES SUPER BLU 3.99 * Total $56,37 Customer Card Number 10~9900001 Electromc Coupon Recap MINI FRENCH BRD EC -0.30 ~ MINI FRENCH BRD EC -0.30 · S&S ARUGULA SALA EC -O.4B ~ SCS ARUGULA SALA EC -0.49 · PINT GRAPE TONAl EC -2.99 ~ 1LB STRAWBERRIES EC -1.99 * IL8 SIRAWBERRZES EC -1.99 x Total $47.82 PHIL CPM CHEESaZ 2.19 · PHIL CPM CHEESBL 2.19 * Total $52,20 Cash $52.20 Fotal before savfngs $6033 Your Totai Savings $855 fotal atter savlmgs $51.78 [ax pa~d $0.42 lota! $52.20 Tota! tender $52.20 Change $0.00 YOUR SAVINGS SUMMARY Stop & Shop Card Savings $855 lotal Stop & Shop Card Saving $8,55 Your Total Savings $8.55 THANK YOU FOR SHOPPING Al STOP 8 SHOP. WE'VE ENJOYED SERVING YOU, AND WE LOOK FORWARD l0 SERVING ALL YOUR PUTURE SHOPPING NEEDS RALPH DANIS STORE MGR 779-2U70 STOP 8 SHOP #672 Builders orr Fine Hemorials 'r~LE..o.E DATi=' JUNE 10, 2004 MARY BLOOM 2120 LONGS GAP ROAD CARLISE, PA 17013 BARRE GRANITE MARKER, SPECIAL SHAPE COMPLETE --- $595.00 FOUNDATION --- 85.00 TOTAL 680.00 SALES TAX 40.80 TOTAL $720.80 THANK YOU DELIVERY OFF HIGHWAY AT BUYERS RISK OF DAMAGE BY TRUCKS 'E~A~,-G~ ,~,,~u & ~,,IE Route ~98, Eastford, Connecticut 06242 e~ ~Phone (203) 974-0790 GRAVEL STONE SAND Gravel B/R [] 2" ~ A (Brick) Processed ~ I 1/4" ~ B (Concrete) Fill ~ 1" ~ Sand 3/4" Loam ~ 1/2" Screened Loam [; 3/8" 1/4" ~,~ /~ Delive~ At: Weight Truck Delive~ By: Weight P.O. ~ Net Cubic Truck ¢ Yards In consideration of your making deliveW off the highway, the a~ve sign~ agr~s to responsible for all damage d~e 1o sidewalks, driveways, grounds or othe~ise RECEIPT FOR PAYMENT Curgoezland County - Re~ister Of Wills Receipt Date: 4/02/2004 Hano¥~r and Hiqh Stree[ CarliSle, PA ~7013 ReceSpt Time: 14:44:54 Receipt No.: 1036159 L~RKIN ETHEL V EstateI File No.: 2004-00316 Paid B% Remarks: STEPHEN L BLOOM~ESQ JA ................. Receipt Distribution Fee/Tap: Description Payment Amount Payee Name PBTITI(N FOR PROBA EXTRA ~AGES 200.00 CUMBERLAND COUNTY GENERAL FUN 6.00 CIIMBERLAND COUNTY GENERAL FUN SHORT (ERTIFICATE 12 00 JCP FE~ · CUMBERLAND COUNTY GENERAL FUN 10.00 BUREAU OF RECEIPTS & CNTR M.D Check# oo32 ....... Check# 003297 Total Received ......... $~.00 .00 Me tzer & .C. ompany, P.C. Certified Public Accountant 35 Et High Street, Suite 104 Carlisle, PA 17013-3052 Invoice BIL TO DATEINVOICE # Ethel ¥. Larkin 2/11/2004 5128 21201 ~ongs Gap Road Carlis e, PA 17013 I DUE DATE ', 3/12/2004 ~SCRiPTION AMOUNT Preparfit{( ofaPpii~abl~ Federal, giaie and/Or Local InCome Tax Returns fOr 4 the year en ted December 31, 2003. 145.00 To avoid tim nce charges, payment must be received by the due date above. A fin ance charge of 1 1/2% per month or 18% per annum will be Tote I $145.00 charged on a 1 amounts outstanding after that date. WE GREAT LY APPRECIATE YOUR BUSINESS AND WELCOME YOURREFERRALS!! Phone (717) 249-6327 BE RA In Home Care Invoice 1026 ~Ritner Highway DATE INVOICE# CarliHe, PA 17013 3/1/2004 1546 BI[.L TO Eth¢ Larkin 212( Longs Gap Road Carl sle, Pa. 17013 PATIEI~ T NAME DESCRIPTION HOURS RATE SERVICED AMOUNT HOME HEALTH AIDE 2 18.50 2/2/2004 37.00 HOME HEALTH AIDE 2 18.50 2/7/2004 37.00 HOME HEALTH AIDE 2 18.50 2/9/2004 37.00 NURSFqG VISIT 60.00 2/10/2004 60.00 HOME HEALTH AIDE 7.5 18.50 2/10/2004 138.75 HOME fEALTH AIDE 3.5 18.50 2/13/2004 64.75 HOME -IEALTH AIDE 2 18.50 2/14/2004 37.00 HOME 4EALTH AIDE 2 18.50 2/15/2004 37.00 HOME HEALTH AIDE 2 18.50 2/16/2004 37.00 AIDE: ;~VE/WEEKEND 10 20.00 2/16/2004 200.00 Your bt siness is greatly appreciated. Please pay' upon Total f/ $685.50/ receipt )f statement. Thank you. BETRA l.n Home Care Invoice 1026 I~itner H~ghway DATE INVOICE# Carlidle, PA 17013 2/2/2004 1509 BiL_ TO Ethel Larkin 2120 Longs Gap Road CarliSle, Pa. 17013 PATIEN' NAME DESCRIPTION HOURS RATE SERVICED AMOUNT HOME [EALTH AIDE 2 18.50 1/5/2004 37.00 HOME [EALTH AIDE 2 18.50 1/7/2004 37.00 HOME [EALTH AIDE 2 18.50 1/12/2004 37.00 HOME [EALTH AIDE 2 18.50 1/14/2004 37.00 HOME EALTH AIDE 2 18.50 1/19/2004 37.00 HOME I-iEALTH AIDE 2 18.50 1/21/2004 37.00 HOMEI~ EALTH AIDE 2 18.50 1/28/2004 37.00 Bills pay4ble within 30 days THANK yOU Total $259.00 ?.THEL V. LARKIN (12969.0! 12969.0) 12/02/03 )EBRIDE MYCOTIC NAILS I 60.00 12/23/03 Ins Pmt-MEDICARE 28.66 12/23/03 Adjustment 24.18 01/13/04 Reject-AETNA DUPONT C~AIM T/NIT 0.00 7.1 12/02/03 12/02/03! ?ARING/CUTTING LESION; 2-4 47.00 12/23/03 Ins Pmt-MEI)ICARE 34.30 12/23/03 Adjustment 4.13 01/13/04 Reject-AETNA DUPONT CLAIM UNIT 0.00 8.5 12/02/03 T)TAL FOR ETHEL V. LARKIN 15.73 BALANCE )LTE BEFORE 03/04/04** IF NO PAYMENT RECIEVED %%~ ~ A $5.00 ~ROCESSING FEE WILL BE A)DED TO BALANCE IF YOU I{~ 15.7 15.73 0.00 J0.00 0~00 0.00 ~ PAY THIS ; AMOUNT == Acti~ ~ Fo: V. : -LARIiE tl/10/03 '12/ BgD SEMi S&D 6gDO02 25.19 PR -PATIENT 30 DAYS: ' i 60 DAYS: . 90 DAYS: ~ ~ >CAKE /4EDZCAL ~,-227-Bi82 SL~Lem~L [}~Le: ~4 '-= AuLi~ Fu[ V. - LARKE 12/10/03 SEMi S&D: BED~02 25.19 PR -PATIENT RESPONSiBi 30 DAYS: . 60 DAYS: . 90 DAYS: .OO + / '~ FLoill: CR~S ;CARE MEDICAL 866-227-8i~2 *= AcLi~ ! FoL' V. -LARKE 01/10/04 ,~z~ SEMI S&D BED002 105.19 .0~ '* , DED -ANNUAL DEDUCTABLE ) 30 DAYS: - ~ ~ 60 DAYS: · ~ 90 DAYS: YT.D. FIN CHG .0~ ~i~sfe ~aty ~y .~ + = . i~5.i9 F~eom: CR~SSCARE ~EDiCAL 866-227-8182 St~tem~[~L D~te: == AcLiv Fu[ E ¥, -LARKE ~2/i0/Q4 )ED SEMi S&DiBEDOQ2 25.19 fiNS -NO LONGER HAS LiST ED iNSURANCE ~ 30 DAYS: 60 DAYS: . O 90 DAYS: ~':~.~ii: CRi!]S >CANE MEDICAL 866-227-~i~2 SL~bemenL D~Le: ~5/~3/'~4 (gumberlani ~~ ~ 16 West High Street, Carlisle, PA 17013 ~ 17171 240-6110 or 697-0371, Ext. 6110 ~[avtc~s ~u~co~nG 532-7286, Ext. 6110 Fax: 240-6118 Ill'being g~ gg~l~gg I website:www.ccpa.net/aging '~ ~ ~'~ .......... ~ I e-maih aging~ccpa.net ~thel V Larkin ~? ,Lo~g~ ?ap Road ' Richard L Rovegto ~rli~ PA 17013 I~voice Number:03-3173 Ipvoice Date: 02/12/2004  RVICE PROVIDED: .OHENAKER SERVICE NTH OF SffRVlCE: DEC '03 A~UAL COST PER HOUR YOUR REDUCED SLIDING FEE SCALE RATE PER HOUR I 9.13 TOTAL HOUR OF SERVICE YOU RECEIVED ] 12 PLEASE PAY THIS AMOUNT [ 109.56 ayment Due Upon Receipt of Invoice ayment Is Delinquent if not paid by March 8, 2004, Contact CCOA if any issues. Make Checks Payable To: CUMBERLAND COUNTY OFFICE OF AGING Please keep this copy for your records COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIV:itl.~'. c. (C'=!:"F C.f INHERITANCE nx DI i. ~r','"::.:'~-, '..../1 I ,\...1--. ,.:: PO BOX Z80601 ":1_1..11. ',,'.' " HARRISBURG PA 17128- 6'0"1 .,.' -J NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX 2CQ5 Jill! Ilf Pi': 3: 14 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN CLERK Of- OR~PL1V,1"~~ (>",,111';'1" h roo,:". '.) '.."\.., v' I STEPHU/I\LBl: 110M ,. , 2100 LONGS GAP RD CARLISLE PA 17013 01-17-2005 LARKIN 02-18-2004 21 04-0316 CUMBERLAND 101 '*' REY-lS41 EK tFP 112-0~l ETHEL V "..aunt R...i H:ed MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ~rV :m""lic"'A~p"rll1":6!')"'~iiT"fcl''l:il!'1:NHliiY'l'AN'cE'YA'x'7ipj5IlA''islM'iNT:"A'LLiiwANCi.o'R"'....,.,.... ." DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF LARKIN ETHEL V FILE NO. 21 04-0316 ACN 101 DATE 01-17-2005 TAX RETURN WAS: (X I ACCEPTED AS FILED I CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. stocks and Bonds (Schedule Bl 3. Closely Held stock/Partnership Interest (Schedule CJ 4. Mortgages/Notes Receivable (Schedule DJ 5. Cash/Bank Deposits/Misc. Personal Property (Schedule EJ 6. 401ntly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets III 121 (31 (41 [51 (61 (71 .00 87.625.70 .00 .00 557.14 761.30 .00 (BI APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governaental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax I~ an assessment was issued previously. lines 14. 15 and/or 16. 17. 18 and 19 will re~lect ~igures that include the total o~ Abh returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rat. (17) 18. Amount of Line 14 taxable at Collateral/Class Brat. (18) 19. Principal Tax Due X C ITS: (91 1101 NOTE: 6,741.48 1.356.55 (111 1121 1131 1141 .00 X DO = 80,846.11 X 045 = .00 X 12 = .00 X 15 = 1191= + NUMBER CD003951 CDo04645 INTEREST/PEN PAID (-I 178.95 .00 DATE 05-18-2004 11-18-2004 AMOUNT PAID 3,400.00 56.17 INTEREST IS CHARGED THROUGH 02-01-2005 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax pay.ant. 88,944.14 8.098 03 80,846.11 .00 80,846.11 .00 3,638.07 .00 .00 3,638.07 3,635.12 2.95 .04 2.99 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $~, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YOU MAY BE DUE 'L A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. I ~'> COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11~96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BLOOM STEPHEN L 2100 LONGS GAP ROAD CARLISLE, PA 17013 _nn___ fold ESTATE INFORMATION: SSN: 124-42-9012 FILE NUMBER: 2104-0316 DECEDENT NAME: LARKIN ETHEL V DATE OF PAYMENT: 01/27/2005 POSTMARK DATE: 01/27/2005 COUNTY: CUMBERLAND DATE OF DEATH: 02/18/2004 NO. CD 004888 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $2.99 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK#12 SEAL INITIALS: CCP RECEIVED BY: REGISTER OF WILLS $2.99 GLENDA FARNER STRASBAUGH REGISTER OF WILLS BUREAU OF INDIVIDUAl.,~-TAX1;~V-- INHERITANCE TAX DIVISION PO BOX Z806Dl HARRISBURG PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REY-1607 EX AFP 112-041 ! I ,~ u , DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 03-14-2005 LARKIN 02-18-2004 21 04-0316 CUMBERLAND 101 ETHEL v ('" (.....'."'--- STEPHEN lrB-LOOM 2100 LONGS GAP RD CARLISLE PA 17013 Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ~~:r&~~.!5r.i'~..rG1~.~!1........;..;rA~!~e1r~11r.i'l1f!~.b~.1~l:6D~...ii...................... ESTATE OF LARKIN ETHEL V FILE NO.21 04-0316 ACN 101 DATE 03-14-2005 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT DR RECORD ADJUSTMENT: 01-17-2005 PRINCIPAL TAX DUE:, 3,638.07 PAYMENTS (TAX CREDITS): 4, PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-18-2004 CD003951 178.95 3,400.00 11-18-2004 CD004645 ,DO 56.17 01-27-2005 CD004888 .02- 2.99 TOTAL TAX CREDIT 3,638.09 BALANCE OF TAX DUE .02CR INTEREST AND PEN. .00 IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .02CR . SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRl, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. l Name of Decedent: Date of Death: File No. : Social Security No. : REGISTER OF WILLS OF CUMBERLAND COUNTY STATUS REPORT UNDER RULE 6.12 (For Resident Decedents Dying After July 1, 1992) ETHEL V. LARKIN February 18, 2004 21-04-0316 124-42-9012 Pursuant to Rule 6.12 ofthe Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes x No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: M o f. - : 'b. a. Did the personal representative file a final account with the Court? Yes No~ The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes~ No C~) <0." Copies of receipts, releases, joinders and approvals offormal or informal accounts may befiledwith the Clerk of the Orphans' Court and may be attached to this report. ~ ~phen L. Bloom 2100 Longs Gap Road Carlisle, PA 17013 (717) 249-7717 Personal Representative Signature: Name: Address: C:\Office - Estate Administration\7828.2status.l.doc Date: October 25, 2005 \/L'