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HomeMy WebLinkAbout04-0035PETITION FOR PROBATE & GRANT OF LETTERS Estate of ADAM R. HEBERLIG also known as Social Security No. 172-26-9276 , decease~ No. 21-04-~,~,,.~ To: Register of Wills for the County of Cumberland Commonwealth of Pennsylvania The Petition of the undersigned respectfully represents that: Your Petitioner, who is 18 years of age or older and the Executrix named in the Last Will of the above decedent dated Mamh 9, 1990 , and codicils dated none . The Executor named none died . Renunciations for none attached hereto. Decedent was domiciled at death in Cumberland County, Pennsylvania, with his last family or principal residence at 5 Darrin Avenue, Newbur.q, Hopewell Township Decedent, then 81 years of age, died December 14 ,2003, at Thornwald Home, Carlisle Borou.qh, Cumberland County, Pennsylvania Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the Will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property (If not domiciled in PA) Personal property in PA (If not domiciled in PA) Personal property in County Value of real estate in Pennsylvania, situated as follows: $15,000.00 $ $ $ WHEREFORE, Petitioners respectfully requests the probate of the Last Will and Codicil(s) presented herewith and the grant of letters testamentary thereon. Signature(s) and Residence(s) of Petitioner(s): Amy L~ He-b6rli.q /' 5 Darrin Avenue Newburq, PA 17240 717-423-5407 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA · · SS COUNTY OF CUMBERLAND ' The Petitioner(s) above named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that as personal representative of the above decedent, petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribe(J , before me this//,~~7''~/ day of January, 2004. Amy L. Heberliq ,,,/' //~j ister No. 21-04~-~ Estate of ADAM R. HEBERLIG , deceased. DECREE OF PROBATE & GRANT OF LETTERS AND NOW, January /,.~ , 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 March 9, 1990 described therein be admitted to probate and filed of record as the Last Will of Adam R. Heberliq ; and Letters Testamentary are hereby granted to Amy L. Heberliq FEES Probate, Letters, Etc ........ $ 50.00 Short Certificates(-2- ) .... $ 6.00 Renunciation(s) ........... $ JCP .................... $10.00 Other Will Paqes (-3-) .... $ 9.00 TOTAL: .... $ 75.00 Filed ............................ II:~¥~IN & McKNIGH% Roqer B,,,'F',r~vin. Esquire (06282) ATTOF~IEJ(Sup. Ct. liD. No.) 60 West Pomfret St., Carlisle, PA 17013 ADDRESS 717-249-2353 PHONE his 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 copy by photostat or~ ~.--~///ph°t°gra~ ~ P 9450795 No. Registrar ""'/cai .'r't.---rI 'Da/t. TYPE/PRINT PERMANENT BLACK INK H105.143 Rev. 2/87 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH STATE F~LE NUMBER / NAME OF DECEDENT (First. Middle, Last} SEX I SOCIAL SECURITY NUMBER DA/T~F DEATH (Month, D.y, Year) I 1. Adam R. Heberliq , . 12. Male 13. 172 -- 26 -- 9276 ~]AGE(LasI~;i~;,G.y) [ UNDER1YEAR UNDERIDAY DATE OF B~RTH BIRTHPLACE(City.nd PLACE OF DEATH CheCkonl~one-seensl~ctionsonoh~r~d~  Mo~ths Days HoursMinutes Month, Day, Year) State Or Foreign Country) I HOSPFL~. I OTHER s. 8 1 Yrs. I Oanberland Co., I ,.~.~,~ [] EU,~,.,~., r'-I bOA ~ I. ' N COUNTY OF DEATH CITY, BORO, TWP OF DEATH FACILITY NAME (if not institution, give s~-eel and number WAS DECEDENT OF HISPANIC ORIGIN? [ RACE - American Indian Black White -'r-~_ / ,, , No [] Ye, [] ,.~, a~.,~ Cuba., I (S~ea~) ab. Cumberland ac. Carlisle se. ~/-.474[f~lJ0.j.~ "/q0/77_~ ~,.x,can. F'uen0mcan. e,c. DECEDENT'S USUAL OCCUPATION KIND OF BUSINESS / INDUSTRY Dairy Farmer ~bSelf-employed 5 Darrin Avenue IRESlDENCE Newburg, PA 17240 I on other ~de) L~ATION - Ci~own, State, Zip C~e Cumberland County, 2ld. Newville~ PA 17244 20~.5 Darrin Avenue, Newburg, PA 17240 PLACE OF DISPOSITION- Na~ ~ Ce~t~, Cm~t~ FA~ ER'S NAME (Fbi, Middio, Last) John S. Heberliq INFORMANTS NAME ('rypelPdnt) 20a.]~.my L. Heberlig METHOD OF DISPOSITION Donation [] Burial [] Cremation [~ ..... If rom Stele [] r-1 i~1 Elam enia~y/S~ndary C~lege Divorced (~) · ~3. Married ~' ~V L. Hoover Fennsyivan~a Did 17c. ~ Y~, d~ent li~ in HoD.well 17b. ~ Cumberland ~n~ip? 17d.~ No, ~ll~d ~e. A. Ethel Kumler ~ ~. 12/18/2003 ~ 21a. . Other(Spe~ 21c. Newville Cemetery SIG O FUNER~c =. ~g NSE ERSON ACTING AS SUCH LICENSE NUMBER I NAME AND ADDRESS OF FACILI'~' ~ %.omp~te~ems23a-coofywhencertJtying ' ] To the best of my knowtedge death occurred at he me. daeandpacesteted. I LICENSE NUMBER DATESIGNED / certify cause of death, t ' ~ (Monthly, Year) ( ,,.. ....... ~.~ terns 24?6 must be c~mpleted by I TIME~O[ ~E~T,H .~,~ a ~ !/,~ 2 [ DA'['E P.J~OUNCE D DEAD (M~n h, Day, Year) person WhO pronounces death. ' ~[ f ' ., . 'E. /¥, F,. Ye,• IMMEDIATE CAUSE (Final.[ b ~ ~"~'(-;'-'~ ~ ; onsel disease or condition cause.if any, leadingEnter UNDERLYINGt° immediate / ii ou~ TO (O. ^S ^ CO.SEOUE.CE O~): I OF •EAT.? [] Y. [] .o [] Y.sD .otCl Su~da [] cou~.o,,e~.te..i..d ~13°"' I'O~. M. I~oc. 28b. 29. r 13oe. To th, he,t of my knowledge, d,th ..... d du, ,o th ...... (,),nd ....... teted~ .............................................................. ®:- To the heat of my Imovdeclge, death ...... d at the time, date, and pi ..... nd due to th ....... (a) and .......... ted ...................... I I 31c. On the b.~ls of examination and/a~ Investigation, In my opthten, de.Ih occurred a~ the time, dale, and place, and due to the cau~e~(~) and (Item 27) Type o~ manrmr as stated ............... . .................... ~-r S'GNA RE A"D .UMSER ............................................................ ' .DATE F,LEO(M th. =P.. I, ADAM R. HEBERLIG, of Hopewell Township, Cumberland County, Pennsylvania, declare this instrument to be my last will and testament, hereby expressly revoking all wills and codicils heretofore made by me. 1. I direct my executrix to pay all of my debts, funeral and administrative expenses as soon as may be done conveniently after my decease. owned either I authorize and empower my executrix to sell any realty by me at my death and not specifically devised herein, at public or private sale, and to give good and sufficient deeds therefor, in fee simple, as I could do if living. 3. I devise and bequeath all of my estate of every nature and wherever situate to my wife, Amy L. Heberlig, providing she shall survive me by sixty days. 4. Should the gift in Paragraph No. 3 not take effect, I devise and bequeath all of my estate of every nature and wherever situate as follows: (a) I give the sum of One Thousand ($1,000.00) Dollars to Zion Lutheran Church of Newville, Pennsylvania; (b) fo 11 ows: All the rest, residue and remainder thereof as (1) 1/3rd to Blevens Zinn, (2) 1/6th to Beatrice E. Myers, (3) 1/6th to Vivian G. Plasterer, (4) 1/6th to George H. Davidson, and (5) 1/6th to the Women's Auxiliary of the nursing home I may be a resident of at the time of my death. If ! am not living in a nursing home at the time of my death, this 1/6th shall go to the University Hospital, Rehabilitation Center for Children and Adults, 1451 S. Market Street, Elizabethtown, Pennsylvania. (6) If any of the above individuals living at the time of my death, their share shall be between their children, share and share alike. are not divided 5. I nominate and appoint Amy L. Heberlig to be the executrix of this my last will and testament; she is to serve as such without bond. Should she die before my death, renounce or refuse to serve for any reason, or die leaving any of my estate unadministered, I nominate and appoint George H. Davidson, as substitute executor, also to serve as such without bond, with the same powers as are given herein to my executrix. 6. I hereby suggest that my personal representative retain the services of Irwin, Irwin & McKnight, as attorneys in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this q'~ day of March, 1990. ADAM 1~. HEBERL~G Signed, sealed, published and declared by Adam R. Heberlig, the above named testator, as and for his last will and testament, in the presence of us, who at his request, in his presence and in the presence of each other have subscribed our names as witnesses hereto. ACKNOWLEDGEMENT AND AFFIDAVIT WE, ADAM R. HEBERLIG, BETZI A. MORRISON and SHARON L. SCHWALM, the testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his Last Will and that he had signed willingly, and that he executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in their presence and hearing of the testator, signed the Will as a witness and that to the best of their knowledge the testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ADAl~ R~ HEBERLIG//x SHARON L. 'SCHWALM - '~ COMMONWEALTH OF PENNSYLVANIA: : SS. COUNTY OF CUMBERLAND : Subscribed, sworn to and acknowledged before me by ADAM R. HEBERLIG, the testator, and subscribed and sworn to before me by BETZI A. MORRISON and SHARON L. SCHWALM, witnesses, this ~ day of March, 1990. J R(~ER lB. i ,R~iN. NOT^~y PUBLIC l JCARLtSLE BOROUuH, CU~.~BE~LAND COUNTYJ 3, / Mernb~t. Pennr;,?.~k~ ~_ ¢..,dr..t,',n ot No,ar!es CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Date of Death: Estate No.: ADAM R. HEBERLIG DECEMBER 14, 2003 21-04-0035 To the Register: I certify that notice of the beneficial interest required by Rule 5.6(a) of the Orphan's Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on February 10, 2004 . Nanle Address Amy L. Heberlig 5 Darrin Avenue, Newburg, PA 17240 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: 02/10/04 Capacity: none . Si a r;' IRWINX&-M'cKNIGHT Name Ro~er B. Irwin, Esquire Address 60 West Pomfret Street Carlisle, PA 17013 Telephone ~717) 249-2353 ~ Personal Representative X Counsel for Personal Representative EV- 1500 EX + (6-00) REV-1500 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN DEPARTMENT OF REVENUE DEPT. 280601 RESIDENT DECEDENT HARRISBURG, PA 17128-0601 cAPB HpRL EpIO cRAC KoTK ES Co. TILE NUMBER OFFICIAL USE ONLY 21~04-0035 COU NTT CODE YEAR N U MB ER 172-26-9276 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE SOCIAL SEcuRm~ NUMREREGIsTER OF WILLS 4. Limited Estate 4a. Future Interest Compromise (date of death after ~ .... prior to 12-13-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 12-12~82) L__J s. Federal Estate Tax ~eturn R~qJ~re~~ (Attach copy of Will) (Attach copy of Trust) ~ 8. Total Number of Safe Deposit Boxes J~9. Litigation Proceeds Received [~ 10. SpousaI Poverty Credit (date of death between 12-31-91 and 1-1-95) NAME ;er B. Irwin Es_q_. Fl RM NAM E (I f Applicable) IRWIN & McKNIGHT TELEPHONE NUMBER [~] 11. Election to tax under Sec. 9113(A) (Attach ScL O) AILING ADDRESS 60 West Pomfret Street West Pomfret Professional Bldg. Carlisle, PA 17013 R E C A P I T U L A T I O N C O M xl T I O N 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or (3) Sole -Proprietorship 4. Mortgages 8, 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) Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, 8, Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 8,4867,~? Npn~,e None None None 12,268.60 None OFFICIAL U.~ ONLY (8) 8,486.92 12. Net Value of Estate (Line 8 minus Line 11) (11)~ (la) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13)_ made (Schedule J) _ 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(aX1.2) (3,781.68) X .0 0 16. Amount of Line 14 taxable at lineal rate X .0 45 17. Amount of Line 14 taxable at siblin~ rate X .1-"~- 18. Amount of Line 14 taxable at collateral rate 19. Tax Due X .15 (14) 12,268.60 (3,781.68) J3,781.68) (lS) O. O0 (16)- O. O0 (17) O. O0 (18L o. oo (is) O. 00- Copyright (c) ?000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) "EV-1503 EX+ O~97) J J J SCHEDULE B COMMONWEA,TH O~PENNS~,VAN~A STOCKS & BONDS INHERITANCE TAX RETURN FILE NUMBER Adam R. Heberl~_f~_~_~S# 172-26-9276 12 1~_~2003 21-04-0035 All property jointly-owned with right of survivorship must be disclosed on Schedule F. NUMB] DESCRIPTION i 512 shares Cumberland Valley Co-Operative _ membership stock 2 82 shares Prudential Financial Inc. UNIT VALUE 10.00 41.06 VALUE AT DATE OF DEATH 5,120.00 3,366.92 TOTAL (Also enter on line 2, Rec~ (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. 8,486.92 Form REV-1503 EX (Rev. ~-97) REV-1511 EX ESTATE OF Adam R. Heberl~s# 172-26-9276 Debts°fdecedentmustberepo~edonSchedulel. 12/1_.~/2003 FILE NUMBER 21-04-0035 NUM, A. FUNERAL EXPENSES: DESCRIPTION Fogelsanger-Bricker Funeral Home ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address c~7 State Year(s) Commission Paid: Zip Attorney's Fees IRWIN & McKNIGHT Family Exemption: (if decedent's address is not the same as claimant's, attach explanation) Claimant ~ L. Heberlifz- Street Address 5 Darrin Avenue City Newbur_~. State PA Zip 17240 Relationship of Claimant to Decedent _ Spouse - Probate Fees Register of Wills Accountant's Fees Tax Return Preparer's Fees Other Administrative Costs Register of Wills filing fee AMOUNT 7,933,60 750.00 3,500.00 75.00 !0.00 TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev, 1-97) REV-~5~3 EX+(g-00/ I j J SCHEDULE J I COUUO.WE^LTH OF PENNS~LV^N~^ / BENEFICIARIES INHERITANCE TAX RETURN | ~~~f., I .............. Ad~ R. ~ebe~l: ~S~/ 172-26-9276 12~2003 FILE NUMBER NUMBER I. 1 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a~1.2)] Amy L. Heberlig 5 Darrin Avenue Newburg, PA 17240 II. Do Not List Trustee(s) 21-04-0035 OF ESTATE Spouse remainder DOLLAR AMTS. --OR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIA NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ON REV 1500 COVER SHEET TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) 0.00 Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1513 EX (Rev. 9-00) I, ADAM R. HEBERLIG, of Hopewell Township, Cumberland County, Penmsylvania, declare this instrument to be my last will and testament, hereby expressly revoking all wills and codicils heretofore made by me. 1. I direct my executrix to pay all of my debts, funeral and administrative expenses as soon as may be done conveniently after my decease. 2. I authorize and empower my executrix to sell any realty owned by me at my death and not specifically devised herein, at either' public or private sale, and to give good and sufficient deeds therefor, in fee simple, as I could do if living. 3. I devise and bequeath all of my estate of every nature and wherever situate to my wife, Amy L. Heberlig, providing she shall survive me by sixty days. 4. Should the gift in Paragraph No. 3 not take effect, I devise and bequeath all of my estate of every nature and wherever situate as follows: (a) I give the sum of One Thousand ($!,000.00) Dollars to Zion Lutheran Church of Newville, Pennsylvania; follows: (b) All the rest, residue and remainder thereof as {1) !/3rd to B!evens Zinn, (2) 1/6th to Beatrice E, Myers, (3) 1/6th to Vivian G. Plasterer, (4) 1/6th to George H. Davidson, and (5) 1/6th to the Women's Auxiliary of the nursing home I may be a resident of at the time of my death. If I am not living in a nursing home a~ the time of my death, this 1/6th shal! go to the University Hospital, Rehabilitation Center for Children and Adults, 1451 S. Market Street, Elizabethtown, Pennsylvania. (6) If any of the above- individuals living at the time of my death, their share shall be between their children, share and share alike. are not divided 5. I nominate and appoint Amy [. Heberlig to be the executrix of this my last will and testament; she is to serve as such without bond. Should she die before my death, renounce or refuse to serve for any reason, or die leaving an7 of my estate n. UdVlUSO~, as substitute executor, also to serve as such without bond, with the same powers as are given herein ~o my executrix. the 6. I hereby suggest that my personal services of Irwin, Irwin & McKnight, representative retain as attorneys in the settlement of my stat~. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ':~ day of March, 1990. Signed, sealed, published and declared by Adam R. Heberlig, the above named testator, as and for his last will and testament,. in the presence of us, who at his request, in his presence and in the presence of each other have subscribed our names as witnesses hereto.. STATUS REPORT UNDER RULE 6.12 ADAM R. HEBERLIG DECEMBER 14, 2003 Name of Decedent: Date of Death: No. 21-04-0035 Pursuant to Rule 6.12 of the 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: X Yes ~ 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: a. Did the personal representative file a final account with the Court? Yes X No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? X Yes No Date: 5/18/04 Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of Orphan's Court and may be attached to this report. Si~nawt~cKNiGHT Roger B. Irwin, Esquire Name (please type or print) 60 West Pomfret Street Address Carlisle, PA 17013 City, State, Zip (717) 249-2353 Telephone Number Capacity: X Personal Representative Counsel for Personal Representative BUREAU OF INDIVIDUAL TAXES /NHER:TTANCE TAX DXV/STOH DEPT. 280601 HARRISBURG, PA 17128-0601 COHNONWEALTH OF PENNSYLVANIA DEPARTHENT OF REVENUE NOT/CE OF ZNHER/TANCE TAX APPRAISEMENT, ALLO#ANCE OR DISALLO#ANCE OF DEDUCT/ONS AND ASSESSMENT OF TAX REV-liq7 EX AFP ROGER B IRWIN IRWIH B HCKNIGHT 60 W POHFRET CARLISLE ~'), ~, .PA 17015 DATE ESTATE OF DATE OF DEATH FILE NUHBER COUNTY ACN 05-17-Z00q HEBERLI$ 12-1q-2005 21 0~-0055 CUMBERLAND 101 Aeoun~ Rom'i ~ted ADAH R HAKE CHECK PAYABLE AND REH/T PAYNENT TO: REGISTER OF WILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 1701S CUT ALONG THIS LINE I1~ RETAIN LOWER PORT/ON FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03) NOTXCE OF XNHERZTANCE TAX APPRAZSENENT, ALLOWANCE OR D]:SALLOWANCE OF DEDUCTXONS AND ASSESSNENT OF TAX ESTATE OF HEBERLIG ADAH R FILE NO. 21 0~-0055 ACN 101 DATE 05-17-200q TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERN/NG FUTURE ZNTAREST - SEE REVERSE APPRA/SED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Roe1 Estate {Schedule 2. S~ocks end Bonds {Schedule B) 3. Closely Held Stock/Partnership Znteros~ (Schedule C) (3) q. Mortgages/Notes Receivable (Schedule D) (q) $. Cash/Bank Deposits/Misc. Personal Property (Schedule E) ($) 6. Joln~ly Owned Property (Schedule F) (6). 7. Transfers (Schedule G) (7) 8. Total Assets APPROVED DEDUCTXONS AND EXENPTXONS: 9. Funeral Expanses/Ada. Costs/Hisc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 11. To'al Deductions 12. Nat Value of Tax Return 15. 1~. Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) Net Value of Estate Subject to Tax .00 8~86.92 .00 .00 .00 .00 .00 (8) 12,268.60 .00 (11) (12) (15) (lq) NOTE: ASSESSHENT OF TAX: 15. Amount of Line lq a~ Spousal rate 16. Amount of L/ne 1~ taxable a~ Lineal/Class A ra~o 17. Aaoun~ of Line 1~ at Sibling rate 18. Amount of Line lq taxable at Collateral/Class B rata 19. Principal Tax Duo TAX CREDITS: -- PAYMENT R~C~ZPT D/SCOUNT DATE NUMBER INTEREST/PEN PAID (-) ]:f an assessment Nas issued previously, lines 14, 15 and/or 16, 17, reflect flgures 'chat include the total of ALL returns assessed to date. (~), .00 x O0 = (16) .00 x Oq5= (17) .00 x 12 = (lB) .00 x 15 = (19)= AMOUNT PAID IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. NOTE: To insure proper credit to your account, submi~ the upper portion of ~his for. with your tax payment. 8,q86.92 $,781.68- .00 $,781.68- 18 and 19 will .00 .00 .00 .00 .00 TOTAL TAX CREDIT J .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ( IF TOTAL DUE ZS LESS THAN $1, NO PAYMENT IS REQUIRED. ZF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) RESERVATION: PURPOSE OF NOTICE: PAYHENT: REFUND (CR): OBJECTIONS: ADMIN- ISTRAT/VE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 1Z, 19BZ -- if any future interest in the estate is transferred in possession or enjoyment tn Class B (collateral) beneficiaries of the decadent 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 ~ulfi11 the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of ZOO0. (72 P.S. Section 9140). Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side. --Make check or money order payable to: REGZSTER OF N/LLS, AGENT A refund of a tax credit, which was not requested on the Tax Return, may ba requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications ara available at the Office of the Register of Mills, any of the 23 Revenue District Offices, or by calling the special 24-hour ansaering service for forms ordering: Z-800-362-2050~ services for taxpayers aith special hearing and / or speaking needs: 1-BOO-447-30ZO (TT only). Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object eithin sixty (60) days of receipt of this Notice by: --arittan protest to the PA Department of Revenue, Board of Appeals, Dept. 2810Z1, Harrisburg, PA 17128-10Z1, 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 Reviee Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 7B7-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-IS01) for an explanation of administratively correctable errors. If any tax due is paid aithin three (3) calendar months after the decadant's death, a five percent (52) discount of the tax paid is allowed. The 15X tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you mould appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes ~hich became delinquent before January 1, 1982 bear interest at the rate of six (6X) percent per annum calculated at a daily rate of .000164. All taxes ehich became delinquent on and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year eith that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2004 are: Interest Daily Interest Daily Interest DaiIy Year Rate Factor Year Rate Factor Year Rate Factor ~ ZOZ .0005q8 ~'~'~ - 1991 X1Z .000501 ~ 92 .000247 1985 162 .000438 1992 92 .000247 2002 62 .000164 1984 112 .000301 1993-1994 72 .000192 2003 52 .000137 1985 132 .000556 1995-1998 92 .000247 2004 42 . O00llO 1986 102 .000274 1999 72 .000192 1987 102 .000274 ZOO0 7Z .000192 --Interest is calculated as foZlows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELTNQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent mill reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date sheen on the Notice, additional interest must be calculated.