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Home My WebLink About03-0417PETITION FOR PROBATE and GRANT OF LETTERS also known as To: Deceased. Social Security No. 10,3, ~ ~ ~c~ 'z. 3 Register of Wills for the County of Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age_or older an the executor in the last will of the above decedent, dated ~-_~ and codicil(s) dated in the named ,19 (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in last family or principal residence at (list street, number and muncipality) Decendent, then --~c~ years of age, died ~'~0.~ 0~? ~-U_..~_),j? ~ 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: ~/~ ~_ Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ ~ (21C)(~) ~ 0(:2) (If not domiciled in Pa.) Personal property in Pennsylvania $ / (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: WHEREFORE, petitioner(s) respectfully presented herewith and the grant of letters theron. request(s) the probate of the last will and codicil(s) (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) OATH OF' PERSONAL REPRESENTATIVE COMMONWE~,LTH OF PENNSYLVANIA . COUNTY OF (~ tl ~.~oc~ ~ [~ ~ ~ . f 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 represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or ~ffirmed and subscribed before me this~ ~ ~-i% day of (J Re~ter Estate Of --~ ~_ c.c ~ 7.~ I~ ~ ,~ ~ , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW '~'~C0._{ ~ ~ C~ ',~OO~, in consideration of the petition.on the .reverse side hereof, satisfactory proof having be~en presented before me, IT IS DECREED that the instrument(s) dated ~')<~C~y~r~v- 'o~ "3~ ]c[~c~ described therein be ad~tted to probate ~filed of record as the last w~l of ~d Letters ~e_$ ~ ~ ~r~ he =byg .n ed o FEES Probate, Letters, Etc .......... Short Certificates(T) .......... Renunciation ................ TOTAL Filed . · ~ ~,. ~.~.. ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE RENUNCIATION In Re Estate of deceased. To the Register of Wills of County, Pennsylvania. The undersigned ~ ~__ VD ~ ,- r (~x.~ ~)~ c~ 0 ~ ~ - of the above d~edent, hereby renounce(s) the right to admi~ster the estate ~d resp~tfully ~k(s) that Letters beissuedto ~'~~~ ~ ~' ~ WITNESS hand this day of ,19. (Signature) ,(Address) c~ r--I('"~ (Signature) (Addr~s) (Signature) (Address) LAST WILL AND TESTAMENT OF REBECC~ ~ON I, REBECCA SALAMON, of Mechanicsburg, Cumberland County, Pennsylvania, make, publish and declare this as and for my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. FIRS?: I bequeath such of my tangible personal prop- erty as is set forth'in a separate dated and signed Memorandum, which dated and signed Memorandum shall be placed with or at- tached to this, my Last Will and Testament, to the individuals designated therein. It is my intent that the last dated and signed Memorandum shall control. If there is no Memorandum, it is my intent that all of my tangible personal property shall be and become a part of my residuary estate. SECOND: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, in · ~equal shares, to my children, THERESA H. SALAMON, HANNAH ADKINS and REBECCA PESOLA, provided that should any of my children predecease me, I give and bequeath such child's share unto her issue per stirpes by representation, and if there be a failure of same, then I give and bequeath such deceased child's share to my surviving children as provided herein. THIRD: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all proper- ty, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivi- sion, improvement, zoning or management of real estate and to impose or extinguish restrictions on real estate. (C) To compromise any claim or controversy and to abandon any property which is of little or no value. (D) To invest in all forms of property, including stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privilege given by the Federal and other tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named benefici- aries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever manner they consider advisable. (J) To make immediate payment for the support and maintenance of my children or child to said children or child directly or to his or her Guardian or Guardians as are deemed to 2 be in the best interest of said child or children. FOURTH: I direct that all inheritance, estate, trans- fer, succession and death taxes, of any kind whatsoever, which may be payable by reason of my death, whether or not with respect to property passing under this Will, shall be paid out of the principal of my residuary estate. FIFTH: All interests hereunder, whether principal or income, which are undistributed and in the possession of the fiduciaries acting hereunder, even though vested or distribut- able, shall not be subject to attachment, execution or sequestra- tion for any debt, contract, obligation or liability of any beneficiary, and furthermore, shall not be subject to pledge, assignment, conveyance or anticipation. SIXTH: I nominate and appoint my daughters, HANNAH ADKINS and REBECCA PESOLA, Co-Executrixes of this, my Last Will and Testament. I direct that my Executrix or Executor , as the case may be, and their successors, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this/~-~a.~/~ay of , 1999. ~E B~CcA SALAM~N Signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. Address / ~ Address MEMORANDUM In accordance with the provisions of Clause of my Last Will and Testament, dated DecemberS, 1999, I direct that the following described personal property be given outright to those individuals so designated: Date: REBECCA SALAMON (SEAL) 4 Z£:Zci 9~ ~l~ £0. > Z x~m z 0 0 0 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 2806O1 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003727 ADKINS HANNAH 351 STUMPSTOWN RD MECHANICSBURG, PA 17055 ESTATE INFORMATION: SSN: 102-14-8823 FILE NUMBER: 2103-0417 DECEDENT NAME: SALAMON REBECCA 'DATE OF PAYMENT: 03/29/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 05/09/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $1,256.31 iR~EMARKS: SEAL HANNAH ADKINS CHECK#0996 TOTAL AMOUNT PAID: $1,256.31 INITIALS: VZ RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-O601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003728 ADKINS HANNAH 351 STUMPSTOWN RD MECHANICSBURG, PA 17055 ........ fold .ESTATE INFORMATION: SSN: 102-14-8823 FILE NUMBER: 2103-041 7 DECEDENT NAME: SALAMON REBECCA DATE OF PAYMENT: 03/29/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 05/09/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $879.69 REMARKS: i - SEAL HANNAH ADKINS CHECK# 2109 TOTAL AMOUNT PAID: $879.69 INITIALS: VZ RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS Name of Decedent: Date of Death: Will No. CERTIFICATION OF NOTICE UNDER RULE 5.6(a) To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the~O~8~s' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on ,-,~][ ~ ' t / Name Address 55i Notice has now been g~ven to all persons entitled thereto under Rule 5.6(a) except Date: Capacity: __ Signature Name Address Telephone (7/)7 &9 7-s'-/o / Personal Representative Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIWDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003727 ADKINS HANNAH 351 STUMPSTOWN RD MECHANICSBURG, PA 17055 ........ fold ESTATE INFORMATION: SSN: 102-14-8823 :ILE NUMBER: 2103-041 7 DECEDENT NAME: SALAMON REBECCA DATE OF PAYMENT: 03/29/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 05/09/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $1,256.31 !REMARKS: r .... SEAL HANNAH ADKINS CHECK#0996 TOTAL AMOUNT PAID: $1,256.31 INITIALS: VZ RECEIVED BY' GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003728 ADKINS HANNAH 351 STUMPSTOWN RD MECHANICSBURG, PA 17055 -ESTATE INFORMATION: SSN: 102-14-8823 FILE NUMBER: 2103-0417 DECEDENT NAME: SALAMON REBECCA DATE OF PAYMENT: 03/29/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 05/09/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $879.69 REMARKS: HANNAH ADKINS CHECK# 2109 SEAL TOTAL AMOUNT PAID: $879.69 INITIALS: VZ RECEIVED BY' GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV- ]500 EX (6-0O) OFFICIAL USE ONLY 041 PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FI,E.UMBER DEPT. 280601 HARRISBURG,PA 1712&0601RESIDENT DECEDENT z- I _ 0 3 7_ c~-&--A Yr~ ~R DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Z Salamon, Rebecca 102.14.8823 1fi3 DATE OF DEATH (MIWDD-YEAR) DATE OF BIRTH (M~DD-YEAR) THIS RETURN MUST BE FILED IN DUPUCATE ~MTH THE (.3 0 5 . 0 9 . 0 3 10 · 2 6 · 19 2 3 REGISTER OF VVILLS III (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INiTIAL) SOCIAL SECURITY NUMBER F- Z LU Z o n,' n,' o o Z UJ n~ [] 1. Original Return [] 4. Umited Estate [] 6. Decedent Died Testate (^ttad~ copy of Wil) [] 9. Utiga~on Proceeds Received [] 2. Supplemental Return [] 4a. Future Interest Compromise (date of death Aa' 12-12-82) [] 7. Decedent Maintained a Uving Trust (Ntachcopy of Trust) [] 10. Spousal Povedy Credit (dale a death be~een 12-31-91 and 1-1-95) [] 3. RemainderRelurn(meo~dea~hpm~lo~2-13-82) [] 5. Federal Estate Tax Return Required __ 8. Totat Number of Safe Deposit Boxes [] 11. Election totax under Sec. 9113(A) (^ttachSchO) NAME Frank H. Kelly, EA FIRMNAME0fA~icalY, e) Kelly Financial Services, Inc. TELEPHONENU~ER 717.774.7536 COMPLETE MAILING ADDRE~ Kelly Financial Services, Inc. 400 Brid~e Street, Suite #4 New Cumberland, PA 17070 1. Real Estate(ScheduleA) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Cerpora~on, Partnership or Sole-Propdelorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Pemonat Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) [] Separate rating Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Propate Property (7) (~ule G or L) 8. To~ai Gross Assets (total Lines 1 - 7) 9. Funeral F__~penses & Adrninistralive Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate(Line 8 minus Une 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Ne~ Value Subject to Tax (Une 12 minus Une 13) 6 ,i253 48, ;~58 (8) 6,841 294 (11) (12) (13) (14) OFFICIAL USE ONLY 54,611 7,135 47,476 47,476 SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Une 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Une 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Une 14 taxable at co~lateral rate 19. Tax Due 47,476 x.0 45 x .12 X .15 (15) (16) (17) (18) (19) 2,136 2,136 STF PA42021F.1 Decedent's Complete Address: ISTREET ADDRESS 504 Boston Court c~Y I Mechanicsburg, Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount I STATEpA (1) Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line I + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page '1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) (5A) 17055 A. Enter the interest on the tax due. 2,136 0 2,136 B. Enter the total of Une 5 + 5A. This is the BALANCE DUE. (513) 2,1 3 6 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income d the property transferred; ........................................ [] [] b. retain the dght to designate who shall use the property transferred or its income; ................... [] [] c. retain a reversionary interest; or ....................................................... [] [] d. receive the premise for life of either payments, benefits or care? ............................... [] [] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................. [] [] 3. Did decedent own an "in trust for" or payable upon death bank account or secudty at his or her death? ..... [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................... [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND RLE IT AS PART OF THE RETURN. Under penalties of pe~y, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is flue, CaTect and complete. Declaration of preparer other than the personal representative is based on alt information of which preparer has ar~y knowledge. SIGNATUR~ O,E, PERSON RESPONSIBLE FOR FILING RETURN ADDRESS 351 Stumps~wn Road, Mechanicsburg, PA 17055 S IGNA/T~E~OF P~ARER OTHER THAN REPRESENTATIVE DAT, E ~ DATE 17070 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(aX1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. STF PA42021F 2 REV-1502 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE A REAL ESTATE FILE NUMBER 21.03. 0417 All real property owned solely or as a tenant in common must be refxxted a~ fair market value. Fair market value is defined as the pdce at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant fads. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. VALUE AT DATE DESCRIPTION OF DEATH None TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) STF PA42021F.3 REV-1503 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE B STOCKS & BONDS I FILE NUMBER 21.03. 0417 NI property jointly-owned with the dght of survivorship must be disclosed o~ Schedule F. ITEM NUMBER None DESCRIPTION TOTAL (Also enter on line 2, Recapitulation) VALUE AT DATE OF DEATH (If more space is needed, insert additional sheets of the same size) STF PA42021F.4 REV-1504 EX + (1-97)(I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP or SOLE-PROPRIETORSHIP FILE NUMBER 21.03. 0417 Schedule C-1 or C-2 (Including all supporting infon'nation) must be attached for each closely-held corporation/partnership interest of ~ decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER 1. DESCRIPTION None TOTAL (Also enter on line 3, Recapitulation) VALUE AT DATE OF DEATH (If more space is needed, insert additional sheets of the same size) STF PA42021F.5 REV-1505 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT FILE NUMBER 21.03. 0417 Name of Corporation None Address City 2. Federal Employer I.D. Number 3. Typo of Business State Zip Cede Preduct/Sen/ice State of Incorporation Date of Incorporation Total Number of Shareholders Business Repoding Yea' TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK young / Non-Vdang SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? If yes, Position 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness $ [~Yes [~]No Annual Salary $ E-]yes E~]No '~me Devoted to Business 7. Was there life insurance payable to the corporation upon the death of the decedent? [] Yes [] No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year pdor to death or within two years if the date of death was pdor to 12-31-827 r-~Yes i-]No If yes, E-~Transfer E~]Sale Number of Shares Transferee or Pumhaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a wdtten shareholder's agreement in effect at the time of the decedent's death? [] Yes [] No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? [] Yes [] No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? [] Yes [] No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? [] Yes [] No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. STF PA42021F.6 REV-1506 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT FILE NUMBER 21.03. 0417 Name of Partnership None Address City 2. Federal Employer I.D. Number 3. Type of Business 4. Decedent was a [] General State Zip Code Date Business Commenced Business Reporting Year Product/Service [] Limited partner. If decedent was a limited partner, provide initial investment $ PERCENT OF PERCENT OF BALANCE OF PARTNER NAME INCOME OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? [] Yes [] No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? [] Yes If yes, Cash Surrender Value $. Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-827 []Yes [] No If yes, []Transfer []Sale Percentage transferred/sold · Transferee or Pumhaser Consideration $ Date Attach a separate shee{ for additional ffansfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedenrs death? [] Yes [] No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? []Yes [] No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedenrs death? [] Yes [] No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent retated to any of the partners? [] Yes [] No If yes, explain 14. Did the padnership have an interest in other corporations or partnerships? [] Yes [] No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's padnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. STF PA42021F.7 REV-1507 EX + (%97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE D MORTGAGES & NOTES RECEIVABLE FILE NUMBER 21.03. 0417 All property jointly-owned with the right of survivorship must he disclosed on Schedule F. ITEM NUMBER None DESCRIPTION TOTAL (Also enter on line 4, Recapitulation) VALUE AT DATE OF DEATH (If more space is needed, insert additional sheets of the same size) STF PA42021F.8 REV-1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21.03. 0417 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of smvivorship must be disct_ _,'~:,d_ _ on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Citizens Bank Account #610087.506.7 2. Citizens Bank Account #6140.269881 3. Personal Property - sold at auction TOTAL (Also enter on Fine 5, Recapitulation) 285 3,897 2,071 6,253 (If more space is needed, insed additional sheets of the same size) STF PA42021F.9 REV-1509 EX + (1-97)(I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE F JOINTLY-OWNED PROPERTY I FILE NUMBER 21.03. 0417 If an asse~ was made joint within one year of the decedent's da~e of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. JOINTLY-OWNED PROPERTY: LEI-rER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institulion and bank accou~ nu~ or similar ide~fying rubber. DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT Attach deed for join6y-he~l real estate. VALUE OFASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) STF PA42021F,10 REV-1510 EX + COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER.VIVOS TRANSFERS & MlSC, NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Rebecca Salamon 21.03.0417 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY % OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER OF TRANSFER. ATTACH A COPY OF TIE DEED FOR ~ ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE 1. AIG Annuity Contract#U9800283 48,358 100 48,35~ TOTAL (Also enter on line 7, Recapitulation) $ 4 8, 3 5 R (If more space is needed, insed additional sheets of the same size) STF PA42021 F11 REV-1511 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21.03. 0417 Debts of decedent must be reported on ~ule I. ITEM NUMBER DESCRIPTION 5. 6. 7. FUNERAL~PENSES: Myers Funeral Flowers Home, Inc. ADMINISTRATIVE COSTS: Personal Reprasenta~ve's Commissions Name of Personal Represer~ative(s) Social Secudty Numba'(s) / EIN Number d Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant SEeet Address City RelalJonship of Claiman{ to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees State Zip TOTAL (Also enter on line 9, Recapitulation) AMOUNT 5,480 212 58 956 135 6,841 (If more space is needed, insert additional sheets of the same size) STF PA42021F.12 REV-1512 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21.03.0417 IncJude unreimbursed medical expenses. ITEM NUMBER Verizon PPL DESCRIPTION TOTAL (Also enter on line 10, Recapitulation) AMOUNT 9 285 294 (If more space is needed, insert additional sheets of the same size) STF PA42021F. 13 REV-1513 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE J BENEFICIARIES FILE NUMBER 21.03. 0417 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE [. o o o o TAXABLEDISTRIBUTlONS[includeout~ghts~usaldi~dbuti~s,~dtmnsf~ und~Sec. 9116(a)(l.2~ Tim Adkins 100 Blair Mountian Road Dillsburg, PA Sheena Adkins 351 Stumpstown Road Mechanicsburg, PA 17055 Alexis Adkins 351 Stumpstown Road Mechanicsburg, PA 17055 Jarrett Pesola 5184 Ridge Trail South Clarkson, MI 48348 Katelym Marie Pesola 5184 Ridge Trail South Clarkston, MI 48348 Theresa Salamon Hanna Adkins 351 Stumpstown Road Mechanicsburg, PA 17055 E~ERDOLLARAMOUNTSFORDISTRIBUTIONSSHOWNABOVEONLINEI Grandson Garanddaughter Granddaughter Grandson Granddaughter Daughter Daughter 9,859 9,859 9,859 9,859 9,859 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDERSECTION 9113 FOR WHICH AN ELECTIONTO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART I! - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ STF PA42021 F14 (If more space is needed, insert additional sheets of the same size) REV-1514 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Box 4 on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER Rebecca Salamon 21.03.0417 This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-$9, actuarial factors for single life calculations can be obtained from the Depadment of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax retum. J--]Will r--~lntervivos Deed of Trust E]~r NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE E~ Life or [-~Term of Years__ [] Life or [] Term of Years__ []Life or F']Term of Yea~~ []Life or [--]Term of Years__ 1. Value of fund from which life estate is payable $ 2. Actuarial factor per appropriate table Interest table rate - [] 3 1/2% [] 6% [] 10% [] Variable Rate % 3. Value of life estate (Line I multiplied by Line 2) $ NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE [] Ufe or E~] Term of Years__ [~]Ufe or []Tefra of Years__ []Ufe or E]Term of Years__ [] Life or E~] Terrn of Years__ 1. Value of fund from which annuity is payable 2. Check appropriate block below and enter corresponding (number) Frequency of payout - [] Weekly (52) [] Bi-weekly (26) [~Quarterly (4) [] Semi-annually (2) []Annually (1) 3. Amount of payout per period 4. Aggregate annual payment, Line 2 multiplied by Line 3 5. Annuity Factor (see instructions) Interest table rate I--]3 1/2% I-~6% [] 10% Adjustment Factor (see instructions) $ [] Monthly (12) [] Other ( ) []Variable Rate % Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 × Line 5 × Line 6 $ If using variable rate and period payout is at beginning of pedod, calculation is: (Line4 × Line5 × Line 6) + Line3 $ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15, 16 and 17. (If more space is needed, insert additional sheets of the same size) STF PA42021 F 15 REV-164? EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box 4a on Rev-1500 Cover Sheet) ES'rATE OF FILE NUMBER Rebecca Salamon 21.03.0417 This schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. [] Will [] Trust [] Other Beneficiaries ¸3. NAME OF BENEFICIARY RELATIONSHIP AGE TO DATE OF BIRTH NEAREST BIRTHDAY For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a dght of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. [] Unlimited dghtofwithdrawal [] Limited dghtofwithdrawal Explanation of Compromise Offer: Summary of Compromise Offer: 1. Amount of Future Interest .................................................................... $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Une 13 of Cover Sheet) ........... $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One I-~6%, []3%, []0% .......................... $ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One []6%, [~]4.5% ................................. $ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 Taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ........... $ 6. Value of Line 1 Taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ........... $ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ................................ $ (If more space is needed, insert additional sheets of the same size) STF PA42021F. 16 REV-1649 EX + (1-97)(I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rebecca Salamon SCHEDULE 0 ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) FILE NUMBER 21. 03. 0417 Do not complete this schedule unless the estate is making the election to tax assets under Section 9113 (A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113 (A), and: a. The trust or similar arrangement is listed on Schedule O, end b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule O, then the transferor's personal representative may specifically identify the trust (all or a fractional podion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule O, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedenrs surviving spouse under a Section 9113 (A) trust or similar arrangement. DESCRIPTION VALUE Part A Total $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. DESCRIPTION Part B Total $ (If more space is needed, insert additional sheets of the same s~ze) STF PA42021 F17 VALUE BUREAU OF INDIVIDUAL TAXES TNHERI'TAHCE TAX DTVZSI'0N DEPT. 280601 HARRXSBURG, PA 17128-0601 COHHONWEALTH OF PENNSYLVANIA DEPARTHENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLO#ANCE OR DZSALLO#ANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-lDO7 EX AFP FRANK H KELLY '04 lii;iY 14 KELLY FINANCIAL SERVS ~00 BRTDGE ST STE q NEW CUHBERLAND PA 1707g,,~.i._~,~ DATE 05-17-200~ ESTATE OF SALAHON DATE OF DEATH 05-09-200:5 FILE NUHBER 21 0:5-0~17 ~ :~OUNTY CUHBERLAND ''~ 'KCN 101 Amount Remitted REBECCA HAKE CHECK PAYABLE AND RENZT PAYHENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLTSLE, PA 1701:5 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV-1517 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX ESTATE OF SALAHON REBECCA FILE NO. 21 0:5-0~17 ACN 101 DATE 05-17-Z00~ TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: 0RZ$INAL RETURN 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) $. Closely Held Stock/Partnership Zn~eres~ (Schedule C) (3) q. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Proper~y (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8, To,al Assa~s APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expansas/Adm. Costs/Misc. Expanses (Schedule H) (9) 10. Deb~s/Hortgage Liabilities/Liens (Schedule Z) (10) 11. To,al Deductions 12. Nat Value of Tax Return O0 O0 O0 O0 6zZ5:5.00 O0 ~8z:558 00 (8) 6,8~1.00 29~.00 (11) NOTE: To insure proper credit to your account, submit the upper portion of this form with your ~ax payment. 5~,611.00 7.135.00 ~7,~76.00 13. NOTE: Charitable/governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15) Ne~ Value of Estate Subject to Tax (lq) If an assessment Nas issued previously, lines Ii, 15 and/or 16, 17, .00 R7,~76.00 18 and 19 Nil1 reflect figures that include the total of ALL returns assessed to date. ASSESSHENT OF TAX: 15. Amoun~ of Line lq at Spousal rate 16. Amount of L/ne lq ~axable a~ Lineal/Class A rate 17. Amount of Line lq at Sibling rate 18. Amount of Line lq ~axable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: PAYMENT KECE/PI DISCOUNT DATE NUMBER INTEREST/PEN PAID (- 0:5-29-200~ CD00:5727 . O0 0:5-29-200~ CD00:5728 . O0 (1.5) .00 X O0 = .00 (161 ~,7,~76.00 X 0~5 = 2,1:56.00 (17). .00 x 12 = .00 (18), .00 x 15 = . O0 (19)= 2,136. O0 AMOUNT PAID 1,256.:51 879.69 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE BALANCE OF UNPAID INTEREST/PENALTY AS OF 0:5-:50-Z001 IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. 2,136.00 .00 11.51 11.51 ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT ZS REQUIRED. ZF TOTAL DUE ZS REFLECTED AS A 'CREDIT' (CR), YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) RESERVATION: PURPOSE OF NOTICE: PAYHENT: REFUND (CR): OBJECTIONS: ADHZN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 11, 19BI -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act Z$ of ZOO0. (72 P.S. Section 91qO). Detach the top portion of this Notice and submit with your payment to the Register of gills printed on the reverse side. --Hake check or money order payable to: REGISTER OF HILLS) AGENT A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an '*Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1515). Applications are available at the Office of the Register of Hills, any of the 25 Revenue District Offices, or by calling the special Iq-hour answering service for fores ordering: 1-B00-562-Z050~ services for taxpayers with special hearing and / or speaking needs: 1-B00-~47-5020 (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 within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans* Court. Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6S05. Sea page S of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-150X) for an explanation of administratively correctable errors. Xf any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5Z) discount of the tax paid is allowed. The 152 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 and 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 which became delinquent before January 1, 1982 bear interest at the rate of six (6Z) percent per annum calculatmd at a daily rata of .00016~. Al! taxes which became delinquent on and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through ZOOq are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 1982 202 .O005qO ~'8-1991 112 .000301 ~ 9Z .OOOZ~7 1983 X6X .000q38 1992 92 .0002q7 2002 6X .00016~ 198q 112 .000301 1993-199q 7X .000192 2003 52 .000137 1985 132 .000356 1995-1998 9Z .O00Zq7 ZO0¢ qZ .000110 1986 IOZ .00027~ 1999 71 .000192 1987 10Z .00027~ 2000 72 .000192 --Interest is caIculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DATLY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. COMMONWEALTH OF PENNSYLVANIA ' DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 2806O1 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 004096 ADKINS HANNAH 351 STUMPSTOWN RD MECHANICSBURG, PA 17055 ........ fold ESTATE INFORMATION: SSN: 102-14-8823 FILE NUMBER: 2103-041 7 DECEDENT NAME: SALAMON REBECCA DATE OF PAYMENT: 06/29/2004 POSTMARK DATE: 06/28/2004 COUNTY: CUM BERLAN D DATE OF DEATH: 05/09/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 ~11.51 REMARKS' TOTAL AMOUNT PAID: ~11.51 SEAL CHECK#2540 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS · ,el OF TNDTV'rDUAL TAXES ~U~II~iTAHCE TAX D~VTSTOH ,.~T. Z80601 HARRI*SBURG, PA 17128-0601 · COM.oN#EALTHOF PENNSYLVANIA ~ '~ DEPARTHENT OF REVENUE i~ ' NOTICE OFINHERZTANCE TAX APPRA/SEHENT, ALLONANCE OR DZSALLO#ANCE OF DEDUCTIONS AND ASSESSHENT OF TAX REV-15~i? El( &FP FRANK H KELLY KELLY FINANCIAL SERVS 400 BRIDGE ST STE 4 NEH CUHBERLAND ~" CUT ALONG THIS LZNE! PA 17070 DATE 05-17-2004 ESTATE OF SALAMOH REBECCA DATE OF DEATH 05-09-2003 FXLE NUHBER 21 05-0417 *0( Ju~i 2~)COUNT~i~ CUMBERLAND *'ACN' " 101 Amoun~ Remi~ed HAKE CHECK PAYABLE AND REHZT PAYHENT TO: REGISTER OF HILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 RETAIN LOHER PORTION FOR YOUR RECORDS DUREAU OF INDIVIDUAL TAXES TNHERITANCE TAX DTV/STON DEPT. 280601 HARRISBURG, PA 171Z8-0601 CONNONNEALTH OF PENNSYLVANZA DEPARTNENT OF REVENUE ZNHERZTANCE TAX STATEMENT OF ACCOUNT REV-]~07 EX AFP FRANK H KELLY '04 ~U~ 17 P1:14 KELLY FTNANCl'AL SERVS qO0 BRIDGE ST ~T~-~ , i::~::,ji'~ NEW CUMBERLANDCui,~_~O ii,L, PA DATE 08-02-Z00q ESTATE OF SALAHON DATE OF DEATH 05-09-Z005 FZLE NUMBER 21 05-0~17 COUNTY CUHBERLAND ACN 101 Amoun~ REBECCA HAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGTSTER OF WILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17015 NOTE: To insure proper credA~: ~o your account, submi~c ~he upper por~ton of ~hJs fore wi~:h your ~ax payment:. CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS *~ REV-1607 EX AFP (01-03) #~# INHERITANCE TAX STATEMENT OF ACCOUNT ESTATE OF SALAMON REBECCA F'rLE NO. 21 05-0~17 ACN 101 DATE 08-02-200q THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHONN DELOI./ TS A SUNHARY OF THE pRTNC'rpAL TAX DUE, APpLI'CATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSHENT OR RECORD ADJUSTHENT: 05-17-Z00~ PRINCIPAL TAX DUE: ........................................................................................................................................................................................................................... PAYHENTS (TAX CREDITS): Z,156.00 PAYMENT RECEIPT DISCOUNT (+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID .00 O$-Z9-200q O$-Z9-200q 06-28-Z00~ CD005727 CD005728 COOOq096 .00 11.51- 1,256.$1 879.69 11.51 IF PAID AFTER THIS DATE, SEE REVERSE SZDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), TOTAL TAX CREDIT 2,136.00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 YOU HAY DE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 () . ) Name of Decedent: ~weco.. 'S.1 QmDtl Date of Death: yY\ CU1 q) J-OO 3 Estate No.: dO) 3 - ooL/ I 7 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 whpher administration of the estate is complete: Yes 0' No 0 2. lfthe answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. lfthe answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No 1)(1 b. The separate Orphans' Court No. (if any) for the personal representative's account is: N 11\ / c. Did the person~representative state an account informally to the parties in interest? Yes bU No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: j -/8-05 \f~~ ~~ Signature ' \-\(\V\\1~ ~V~d'€.f Name 3S t Stvy~ ~'IDuJ'J ~ Address {/1 097- ~lfG{ Yltecl'} (,4 I 'loSS 7 ' Telephone No. ~ersonal Representative o Counsel for personal representative Capacity: uJ