HomeMy WebLinkAbout03-0828 Register of Wills of Dauphin County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of Theresa ~ Potami No.
also known as
, Deceased Social Security No.
Pe[it~¢meHs). who is/ere 18 years of age ot older, apply(ies) roi
(COMPLETE "A" OR "B" BELOW:)
[~ A. Probate and Grant of Letters and aver that Petitioner(s) is/are the ri×
execut
named
in
the
Last
Will
of
the
Decedent, dated 12/5/1989 and codicil(s) dated
Stale ~eleva~t c~cums~a~ces eg, lenunc~elion, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered
for probate; was not the victim of a killing and was never adjudicated incompetent:
B. Grant of Letters of Administration
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse
(if any) and heirs:
Name Relationship Residence t
I
(COMPLETE IN ALL CASES:) Attach additional heetsif necessary.
Decedent was domiciled at death in Cumins_fiend County, Pennsylvania, with his/l~r last family or principal
residenceat West Shor~ F~_m]f-.h mnel Reh~h OAnfpr; Ra~f PAnn~horn ~nwn~h~n_ DA
Decedent, then 91 years of age, died October 6, ,20 03. at West Shore Health &Rehab ~enter
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property .............................. $ 35 t 000
(If not domiciled in PA) Personal property in Pennsylvania ......................
(If not domiciled irt PA) Personal property in County ..........................
Value of real estate in Pennsylvania ...............................................
Total
Real Estate situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of letters in the
appropriate form to the undersigned:
~ Signature Typed or printed name and residence
I
/~m Z ~
.w-7
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Dauphin
The Petitioner(s) above-named swear(s) and 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(s) of the Decedent,
Petitioner(s) will well and truly administer the estate according to law.
Sworn to and affirmed and subscribed
before me this /'~..~ ~ day of
~~~ 20~
DECREE OF REGISTER
Estate o~~-2__,~_.,,/ ~~ Deceased NO.
also kndwn as
Social Security No: /2¢:~-Z::Q/- Date of Death:
~~.,,/ /~---~ 20Z>~ . in consideration of the Petition
AND
NOW,
on the reverse side hereon, satisJactory proof having been presented before me,
IT IS DECREED that Letters [~estamentary [] of Administration
are hereby granted to ~
/ t' /
in the above estate and that the instrument(s), if any, dated
described in the Petition be admitted to probate and filed of record as the t:¢st Will of Decedent.
FEES
Letters ........................... $~ ,~~_~ ~ O~_-~
Short Certificate(s) .......... $ z"~, ~:D~:)
Renunciation .................. $
Affidavit ( ) ................. $
Extra Pages ( ) ............ $ /..3_. 4:Do
Codicil ..........................
JCP Fee ........................ $ /O.~::x~ Attorney: Eli~.abetb A, HoCk=man
Inventory & Tax Forms... $ I.D. No: 71000
Other ............................ $ Address: 106 walnut Street
Harrisburg, PA 17101
TOTAL ................ $ _~.~_~ Telephone: 71 7-2_q6-2956
DATE FILED: October 13, 2003
~l~-7a
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 copy by photostat or photograph. ~.
Fee for this certificate, $2.00
No. '~ ' - Date
HIOS :43 FI~ ~/~7 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
· I ' I ; I~eb 9,1912 INew ~ven, Co~[~ J~
~rl~d ~t Pe~ro ~ u. ~8t Shore Health & Re~b. err. ,~'~" ,,~ite
,,. l,,12 "'~
321 S. ~venth St. ~
,~t~lton, PA 17113 ~ ,~
~c~s ~ ¢,~,~ ,,~ffalla ~chiele
~i~inia R. ~qnelii I~=='*~~~
[~221 S. 31st St., ~rri~h,,rg, PA 17109
DiSc. 8, 2~3
0 ~..~ ~~ ......... ~.~
"""~"~'~"~""'"" ....................................................................................... .0,,,,,, ~~~~_~ ~ o xm ~r~.e~~,/~/~~ '
LAST WILL AND TESTAIViENT
OF
THERESA POTAMI
I, THERESA POTAMI, of the Borough of Steelton, County
of Dauphin, Comonwealth of Pennsylvania, do make, publish
and declare this my Last Will and Testament, hereby revoking
all wills by me at any time heretofore made.
ITI~JI 1. I direct my Executrix, hereinafter named, to pay
all of my just debts, funeral expenses and costs of
administration of my estate as soon after my decease as
conveniently may be done.
IT~vl 2. I bequeath the sum of four thousand ($4,000.00)
dollars to my sister, VIRGINIA R. M~I3NELLI, Harrisburg, Pennsyl-
vania, if living at the time of my death.
IT,d 3. I bequeath the sum of two thousand ($2,000.00)
dollars to my brother, JOSEPH POT~dI, Harrisburg, Pennsylvania,
if living at the time of my death.
IT,d 4. I bequeath the sum of two thousand ($2,000.00)
dollars to iny brother, S~MUEL POTAMI, Steelton, Pennsylvania,
if living at the time of my death.
ITE.WI 5. I bequeath the sum of two thousand ($2,000.00) dollars
to my sister, ANGELA PINIZZOTTO, Steelton, Pennsylvania, if
living at the time of my death.
IT~,A 6. I bequeath the sum of two thousand ($2,000.00) dollars
to my sister, BLANCHE BOWIE, Steelton, Pennsylvania, if living
at the time of my death.
ITEIVI 7. I bequeath the sum of two thousand ($2,000.00) dollars
to my sister, LUCY CUNKO, Steelton, Pennsylvania, if living
at the time of my death.
ITEIM 8. I bequeath the sum of two thousand ($2,000.00} dollars
to my sister GENEVIEVE McKINLEY McLean Virginia if living
' ' ' '
at the time of my death.
ITI~i 9. I bequeath the sum of five hundred ($500.00) dollars
to my mephew and godchild DONALD R. BOWIE, Steelton, Pennsyl-
vania, if living at the time of my death.
ITI~4 10. I bequeath the sum of five hundred ($500.00) dollars
to my nephew and godchild SAMUEL POT~MI, Steelton, Pennsyl-
i: vania, if living at the time of my death.
ITEM 11. I bequeath the sum of five hundred ($500.00) dollars
to my niece and godchild ELIZABETH EDMISTON, Orlando, Florida,
if living at the time of my death.
2
ITeM 12. All of the rest, residue and remainder of my estate,
real, personal or mixed, wheresoever situate and of every
kind and description whether now owned by me or hereafter
acquired I give, devise and bequeath unto my sister, MARY
PINIZZOTTO, and her husband, ANTHONY PINIZZOTTO in equal shares.
In the event either predecease the other, his or her share
shall go to the survivor.
ITEM 13. Should both my sister, MARY PINIZZOTTO and her husband,
ANTHONY PINIZZOTTO, predecease me or should we die as the
result of a corrrnon disaster, I devise and bequeath the residue
of my estate of every nature and wherever situate, whether
now owned by me or hereafter acquired, to my niece VICTORIA
A. O' LEARY.
ITEM 14. I direct that all that be assessed
taxes
may
in
consequence of my death, of whatever nature and by whatever
jurisdiction imposed, shall be paid from my residuary estate.
ITeM 15. I nominate, constitute and appoint my sister, VIRGINIA
R. IVIAGNELLI, Executrix of this my Last Will and Testament.
IT~vi 16. I direct that whosoever acts in the capacity of
Executor of this my Last Will and Testament shall not be required
to give bond for the faithful performance of his duties in
any jurisdiction.
IN WITNESS VvHEREOF, I have hereunto set my hand
and affixed my seal this -~.~-~. day of Z~'~e.~q.,~.~-~---" , 1989.
THERESA POTAMI
The preceding instrument, consisting of this and
three other typewritten pages identified by the signature
of the Testatrix, was on the day and date thereof signed,
sealed, published and declared by Theresa Potami, the
Testatrix therein named as and for her Last Will and Testament,
in the presence of us, who at her request, in her presence
and in the presence of each other have subscribed our names
as witnesses hereto.
id /l~'"'~t_ Vx. ~.~.V..~. of 104 Walnut Street
FRANK R. NtAGNELLI~ Harrisburg, PA
v ~ ~ ~', -'-- of 104 Walnut Street
ROBERT N. TARMAN Harrisburg, PA
4
II
COMMONWEALTH OF PENNSYLVANIA :
: SS
CE)LINTY OF DAUPHIN :
We, Theresa Potami, Frank R. N~gnelli and Robert N.
Tarman the Testatrix and Witnesses respectively, whose names are
signed to the attached or foregoing instrument, being duly sworn,
do hereby declare to the undersigned authority that the
Testatrix signed and executed the instrument as her Last Will and
that she had signed willingly, and that she executed it as her
free and voluntary act for the purposes therein expressed, and
that each of the witnesses, in the presence and hearing of the
Testatrix signed the Will as witnesses and that to the best of
their knowledge, the Testatrix was at that time eighteen years of
age or older, of sound mind and under no constraint or undue
influence.
THERESA POTAM I
,
F~ R. ~LLI
ROBOT N. T~
Subscribed, sworn to and acknowledged before me
by Theresa Potami, the Testatrix, and subscribed and sworn
to before me by Frank R. Magnelli_and Robgrt N. Tarman
Witnesses, the ~_, day of ~~ , 1989.
[] Notary ?ubl~c : ~
I ~mMA R. MAGN~, .~Y ~ I
LAST WlLL ANDTESTAI~NT
OF
THERESA POTAMI
FRANK R. MAGNELLI
ATIORNEY AT LAW
104 WALNUT STREET
HARRISBURG, PENNSYLVANIA 17101
CERTIFICATION OF NOTICE UNDER RULE 5.6(a}
Name of Decedent: Theresa Potami
Date of Death: 1 0 / 6 / 2 0 0 3
Will No. 2 0 0 3 - 0 0 8 2B Admin. No.
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on 2 / 4 / 0 4 :
Nmne Address
Lucy Cunko 314 S. 2nd Street, Steelton, PA 17113
Genevieve McKinley 5806 Barnsley Drive, Harrisburg, PA 17111
Donald Bowie 604 Park Hills Drive, Mechanicsburg, PA 17055
Samuel Potami 104 N. 2nd Street, Steelton, PA 17113
Elizabeth Edmiston 13826 Osprey Nest Lane #12, Orlando, FL 32837
Mary Pinizzatto 321 S. 7th Street, Steelton, PA 17113
Victoria O'Leary 578 Pine Street, Steelton, PA 17113
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Joseph Potami,
Samuel Potami, Angela Pinizza~to and Anthony Pinizzatto who predeceased
Datte:he Decedent~/~ ~ ~,..~_ _
Signature~J -
Name Elizabeth Hoffman, Esquire
Address 106 Walnut Street
Harrisburg, PA 17101
Telephone (71 7 236- 2956
Capacity: __ Personal Representative
X Counsel for personal representative
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Dec~ent: Theresa Potami
Da~ of D~ath: 1 0/6/2003
Will No. 2 0 0 3 - 0 0 8 2 Admin. No.
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on 2 / 4 / 0 4 :
Ad,ess
Lucy Cunko 314 S. 2nd Street, Steelton, PA 17113
Genevieve McKinley 5806 Barnsley Drive, Harrisburg, PA 17111
Donald Bowie 604 Park Hills Drive, Mechanicsburg, PA 17055
Samuel Potami 104 N. 2nd Street, Steelton, PA 17113
Elizabeth Edmiston 13826 Osprey Nest Lane #12, Orlando, FL 32837
Mary Pinizzatto 321 S. 7th Street, Steelton, PA 17113
Victoria O'Leary 578 Pine Street, Steelton, PA 17113
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Joseph Potami t
Samuel Potami, Angela Pinizza~to and Anthony Pinizzatto who predeceased
Datte:he Decedent~/~ ~ ~...~ _
Signatu2 '
Name Elizabeth Hoffman, E~quire
Address 106 Walnut Street
Harrisburg, PA 17101
Telephone(717 236-2956
Capacity: __ Personal Representative
X Counsel for personal representative
CONNONWEALTH OF PENNSYLVANIA
BUREAU OF 'rNDTV/DUAL TAXES DEPARTHENT OF REVENUE
INHERITAHCE TAX DIVISION
DEPT. 280601 NOTTCE OF INHERITANCE TAX
HARRISBURG, PA 171ZB-0601 APPRATSEHENT. ALLO#ANCE OR DTSALLOHANCE
OF DEDUCTTOHS, AND ASSESSHEHT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
~ DATE 0~-05-2004
R~{'.~ ~ ESTATE OF POTAHI' THERESA M
~ ' ~- DATE OF DEATH lO-06-ZO0~
FILE NUNBER 21 03-0828
COUNTY CUHBERLAHD
MARY H PINIZZ~O APR -5 P ~ :05 SSN/DC 180-01-4647
~' ACN 04104657
SZ1 S 7TH ST Amoun~ Rem/~ed
STEE LTON ~A~. 1711 $
HAKE CHECK PAYABLE AND RENZT PAYNENT TO:
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LINE ~* RETAIN LONER PORTION FOR YOUR RECORDS *~
REV-15~8 EX AFP (01-03)
NOTICE OF INHERITANCE TAX APPRAISENENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSNENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 04-05-2004
ESTATE OF POTAH! THERESA H DATE OF DEATH 10-06-200~ COUNTY CUHBERLAND
FILE NO. 21 0~-0828 S.S/D.C. NO. 180-01-4647 ACN 04104657
TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED
JOINT OR TRUST ASSET INFORNATZON
FINANCIAL INSTITUTION: SUN BANK ACCOUNT NO. 112011460
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST ()0 TTHE CERTIFICATE
DATE ESTABLISHED 10-07-1985
Accoun~c Balance 1,007.75 NOTE: TO INSURE PROPER CREDIT TO
PePcen~ Taxable X 1.000 YOUR ACCOUNT, SUBHIT THE
Amoun* Sub,ecSc ~o Tax 1,007.75 UPPER PORTION OF THIS NOTICE
Deb~cs and Deductions - .00 WITH YOUR TAX PAYHENT TO THE
Taxable Amount 1,007.75 REGISTER OF WILLS AT THE
Tax Rate ~ .15 ABOVE ADDRESS. HAKE CHECK
Tax Due 151.16 OR HONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
TAX CRED/TS:
PAYHENT RECEIPT DISCOUNT (+) AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID
PAYHENT HUST BE HADE BY 07-07-Z004~. TOTAL TAX CREDIT J .00
BALANCE OF TAX DUEl 151.16
INTEREST AND PEN. .00
TOTAL DUE 151.16
IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
ZF TOTAL DUE ZS LESS THAN $1, NO PAYHENT 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.
PURPOSE OF
NOTICE: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of ZOO0. (72 P.S.
Section 9140).
PAYNENT: Detach the top portion of this Notice and submit eith your payment to the Register of Nills printed on the
rsvarsB side.
-- Hake check or money order payable to: REGISTER OF NILES, AGENT.
REFUND (CR): 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 [nharitanca and Estate Tax" (REV-1313). Applications are available at the Office of
the Register of NJlls, any of the 23 Revenue District Offices or by calling the special Z4-hour answering service
for forms ordering: 1-800-362-2050; services for taxpayers #ith special hearing and or speaking needs:
1-B00-~47-3020 iTT onZy).
OBJECT/DNS: 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 may 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
--electing to have the matter determined at the audit of the account of the personal representative, OR
--appeal to the Orphans' Court
ADHIN-
ISTRATIVE
CORRECTIONS: Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Indivldual Taxes, ATTN: Post Assessment Review Unit, DEPT. 280601, Harrisburg, PA 17128-0601
Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanation of administratively correctable errors.
DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (52)
discount of the tax paid is allowed.
PENALTY: The 157. 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 tho 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 would appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day
from tho date of death, to the date of payment. Taxes which became delinquent before January 1, 1982
bear interest at the rate of six (62) percent per annum calculated at a daily rate of .00016~.
All taxes which became delinquent on or after January 1, 198Z 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 appllcable
interest rates for 198Z through Z004 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1982 207. .000548 1988-1991 117. .000301 2001 97. .000247
1983 162 .000438 1992 92 .000247 ZOOZ 67. .000219
1984 112 .000301 1993-1994 72 .000192 2003 52 .000137
1985 137. .000356 1995-1998 9Z .000247 Z004 4Z .000110
1986 lOZ .000274 1999 77. .000192
1987 9Z .000247 ZOO0 8Z .000219
--Interest is calculated as follows:
ZNTEREST= BALANCE OF TAX UNPAZD X NUNBER OF DAYS DELZNQUENT X DAZEY ZNTEREST FACTOR
--Any Notice issued after tho 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.
COHHONNEALTH OF PENNSYLVANIA
BUREAU OF INDIVIDUAL TAXES DEPARTHENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601 NOTICE OF INHERITANCE TAX
HARRISBURGj PA 17128-0601
APPRAXSEHENT, ALLO#ANCE OR DXSALLO#ANCE
OF DEDUCTXONS, AND ASSESSHENT OF TAX ON
JOXNTL¥ HELD OR TRUST ASSETS R£V-X;48£XAFP(Ol-O$)
R~¢:' ~ DATE 0~-05-2004
~:: i~i!~ ESTATE OF POTAHZ THERESA H
DATE OF DEATH 10-06-Z003
FILE NUHBER 21 05-0828
COUNTY CUHBERLAND
PINIZZOTT'~u''' APR -5 P3:05 SSN/DC 180-01-46~7
HARY
H
ACN 0~10~636
321 S 7TH ST I Amoun~ Rmmi~ed
STEELTON PA ~i13
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
REGISTER OF HILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOgER PORTION FOR YOUR RECORDS
REV-15&8 EX AFP (01-03)
NOTICE OF INHERITANCE TAX APPRAISEHENT~ ALLOgANCE OR DZSALLOgANCE OF
DEDUCTIONS~ AND ASSESSHENT OF TAX ON dO/NTLY HELD OR TRUST ASSETS
DATE 0~-05-200~
ESTATE OF POTAHI THERESA H DATE OF DEATH 10-06-2003 COUNTY CUHBERLAND
FILE NO. 21 03-0828 S.S/D.C. NO. 180-01-46~7 ACN 0~10~636
TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED
JO'rNT OR TRUST ASSET 'rNFORNATION
FINANCIAL INSTITUTION: SUN BANK ACCOUNT NO. 112011383
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST ()0 TIHE CERTIFICATE
DATE ESTABLISHED 08-26-1985
Accoun~ Balance 5,038.66 NOTE: TO INSURE PROPER CREDIT TO
Percent Taxable X 0.500 YOUR ACCOUNT, SUBHIT THE
Amoun~ Subject to Tax Z,519.33 UPPER PORTION OF THIS NOTICE
Debts and Deductions - .00 HITH YOUR TAX PAYHEHT TO THE
Taxable Amoun~ Z,519.$$ REGISTER OF HILLS AT THE
Tax Ra'l:e X .15 ABOVE ADDRESS. HAKE CHECK
Tax Due :577.90 OR HONEY ORDER PAYABLE TO:
"REGISTER OF HILLS, AGENT."
TAX CREDTTS:
PAYHENT RECEIPT DISCOUNT (+) AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID
PAYHENT HUST BE HADE BY 07-07-Z00~. TOTAL TAX CREDIT [ .00
~ALANCE OF TAX DUEl 577.90
INTEREST AND PEN. .00
TOTAL DUE 377.90
ZF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ~
ZF TOTAL DUE ZS LESS THAN $1, NO PAYNENT ZS REQUIRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORN FOR INSTRUCTIONS. )
PURPOSE OF
NOTICE: To fulfill the requirements of Section 21q0 of the Inheritance and Estate Tax Act, Act 13 of ZOO0. (71 P.S.
Section 91q0)o
PAYHENT: Detach the top portion of this Notice and submit mith your payment to the Register of #i115 printed on the
reverse side.
-- Hake check or money order payable to: REGISTER OF RILLS, AGENT.
REFUND (CR): A refund of a tax credit, ehJch mas not requested on the tax return, may ba requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office of
the Register of #i115, any of the 23 Revenue District Offices or by calling the special Z~-hour ansmering service
for forms ordering: 1-800-36Z-Z050; services for taxpayers with special hearing and or speaking needs:
1-B00-~7-3010 (TT only).
OBJECTIONS: Any party in interest not satisfied aith the appraisement, alloaance, or disalZoaance of deductions or assessment
of tax (including discount or interest) as sheen on this Notice may object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 281011, Harrisburg, PA 17128-1011, OR
--electing to have the matter determined at the audit of the account of the personal reprasmntmtive, OR
--appeal to the Orphans' Court
ADNIN-
ISTRATIVE
CORRECTIONS: 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. 180601, Harrisburg, PA 17128-0601
Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanation of administratively correctable errors.
DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (51)
discount of the tax paid is alloaed.
PENALTY: The 151 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 tiao period as you would appeal tho tax and interest
that has been assessed as indicated on this notice.
INTEREST: Interest is charged beginning aith 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, 19BI
bear interest at the rate of six (67.) percent per annum calculated at a daily rate of .00016q.
All taxes which became delinquent an or after January 1, 1981 will bear interest at a rate which will vary from
calendar year to calendar year with that rata announced by the PA nepartmant of Revenue. The applicable
interest rates for 1982 through 200q are:
Interest Daily Xnterest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1981 ZOZ .0005~8 1988-1991 117. .000301 Z001 91 .OOOZ~7
1983 162 . O 00~38 1991 91 . OOOZ~7 ZOOZ 61 .000219
198q 111 .000301 1993-199~ 71 . OOOlgZ 2003 51 .000137
1985 137. .000356 1995-1998 92 . OOOZ~7 200~ ~.X .000110
1986 IOZ .00017~ 1999 71 .O00Zgz
1987 91 . O00Zq7 ZOOO BZ .000119
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUMBER OF DAYS DELINQUENT 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 shown on the
Notice, additionaX interest must ba calculated.
ELIZABETH A. HOFFMAN
A~-rORNEY AT LAW
106 WALNUT STREET
HARRISBURG, PA 17101
717-236-2956 717-232-2559 FAX
May 7, 2004
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013-3387
In re: Estate of Theresa Potami, File No. 2103-0828
Dear Jackie:
Enclosed please find check in the amount of $15.00 to pay for the filing of the
Inheritance Tax Form which I filed along with the money for the taxes due today. I am also
enclosing an envelope to send me stamped copies of the form.
If you have any questions, please do not hesitate to contact me. Thank you for your
assistance in this matter.
Very truly yours,
~ PENNSYLVANIA
~~~ DEPARTMENT OF REVENUE
~~~ DEPT. 280601
INHERITANCE TAX RETURN
RESIDENT
DECEDENT
COUNTY CODE YEAR NUMBER
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
1 O- 6- 2003 2 - 9 - 1 91 2 REGISTER OF WILLS
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER
~ 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death priorto 12-13-82)
~ 4. Limited Estate ~ 4a. Future Interest Compromise (date of death after 12-12-82) ~ 5. Federal Estate Tax Return Required
~ 6. Decedent Died Testate (A~ch copy of Will) ~ 7. Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Deposit Boxes
~ 9. Litigation Proceeds Received ~ 10. Spousa~ Povedy Credit (date of death baleen 12-31-91 and 1-1-95) ~ 11. Ejection to tax uRder Sec. 9113(A)(A~ach Sch O)
NAME
COMPLETE MAILING ADDRESS
g~&zabeth A. Bo~man~ gsqu&~e
FIRM NAME (IfAppli~ble)
106 Walnut Street
~aw O~lces
TELEPHONE NUMBER
(717) 236-2956
1. Real Estate (Schedule A) (1) ~"" ~' OFFICIAL USE ONLY
2. Stocks and Bonds (Schedule B) (2) ~ ~ ~, .~.~
3. Closely Held Corporation, Padnemhip or Sole-Proprietorship (3)
4. Uodgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Properly (5) A 1 ~ ~ 270 ' O 0
(Schedule E) '
6. Jointly Owned Prope~y (Schedule F) (6) 1 6,9 6 3.81 ?"~
~ Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7) (8) 3 0 ~ 2 3 3 81
'
9. Funeral Expenses & Administrative Costs (Schedule H) (9) 8 ~ 7 8 2.5 0
10. Debts of Decedent, Modgage Liabilities, & Liens (Schedule I) (10) I 7 ~: ~ ~
11. Total Deductions (total Lines 9 & 10) (11)
12. Net Value of Estate (Line 8 minus Line11) (12) 21 ~ 277.75
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 (Line12 minus Line13) (14) 21 ~ 277.75
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE ~TES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2) x .0 ~ (15)
16. Amount of Line 14 taxable at linea~ rate x .0 (16)
17. Amount of Line 14 taxable at sibling rate 19 ~ 777.75 x .12 (17) 2 ~ 373.33
18. Amount of Line 14 taxable at collateral rate 1 ~ 500. O0 x .15 (18) 225. O0
19. TaxDue (19) 2 598 33
Decedent's Complete Address:
STREET ADDRESS
West Shore Health & Rehab Center
STATE ZIP
CITY East Pennsboro q~own~h~ ? PA 1 7022
Tax Payments and Credits:
1. Tex Due (Page l Line19) (1) 2,598.33
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount 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 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 2 ~ 5 9 8.3 3
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; .......................................................................................... [] []
b. retain the right to designate who shall use the property transferred or its income; ............................................ [] []
c. retain a reversionary interest; or .......................................................................................................................... [] []
d. receive the promise for life of either payments, benefits or care? ...................................................................... [] []
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. [] []
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. [] []
4. Did dece'dent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ [] []
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FiLiNG RETURN DATE
ADDRESS
ADDRESS "-' (.// ' ° ' ;"
106 Walnut Street Harrisburg, PA 17101
For dates of death on or after July 1, 1994 and before January i, 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 return are still applicable even
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 paren
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(a)(1.3)]. A sibling is defined, under Section 9102, as a
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX + (1-9~)
~-~ SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN
RES,~ENT DECEDENT PERSONAL PROPERTY
ESTATE OF FILE NUMBER
THERESA M. POTAMI
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorshi must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Sunbank, 51 S. Front Street, Steelton, PA 17113
#1 621 55223 $3,755.00
#40407421 2,568.00
2. Wiedeman Funeral Home, Inc. 6,947.00
357 S. 2nd Street
Steelton, PA 17113
TOTAL (Also enter on line 5, Recapitulation) $ 1 3,2 7 0 · 0 0
(If more space is needed, insert additional sheets of the same size)
SCHEDULE F
CO..ONW , , ENNS¥,V^NI^ JOINTLY-OWNED PROPER'D'
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Virginia R. Magnelli 221 S. 31st Street, Harrisburg, PA
1 71 09 Sister
B. Virginia R. Magnelli Same as above Sister
C. Mary M. Pinizzoto 321 S. 7th Street, Steelton, PA 17113 Sister
JOINTLY-OWNED PROPERTY:
LEI I I:R DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH
rrEM FOR JOINT MADE Include name of financial institution and bank account number ot similar identifying number. Attach DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT deed for jointiy-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTERES
1. A. Sunbank, 51 S. Front St., Steelton,
Pa.
Savings Account #100002062 $23,839.64 50% $11,919.82
2. B. ~/26/~ 5 Sunbank
CD #12/01/1382 5,049.32 50% 2,524.66
3. C. ~/26/~ 5 Sunbank
CD #12/01/1383 5,038.66 50% 2,519.33
TOTALs(Als0 enter on ne 6 Recapitulation) $ 1 6,963.81
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX * (1-97)
~ SCHEDULE G
COMMONWEALTH~OF PENNSYLVANIA INTER-VIVOS TRANSFERS &
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
THERESA M. POTAMI
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.~ND THE DATE OF TRANSFER.
NUMBER ATrACHACOPYOFTHEDEEDFORREN. ESTATE. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
VALUE OF ASSET INTEREST (IF APFI.ICABLE)
1. Sunbank, 51 S. Front St., Steelton,PA
CD #12/01/1460-iTF Virginia
Pinizzotto(niece) $1,000.00 -0- -0-
TOTAL (Also enter on line 7, Recapitulation) $ 0
/,f .... ~r~M ~ .... .~A.j, insert additional sheets of the same size)
REV-1511 EX+ (12-99)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURNADMINISTRATIVECOSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
THERESA M. POTAMI
Debts of decedent must be reported on Schedule
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
Wiedeman Funeral Home, Inc. $6,947.00
Luncheon 700.00
Rental of Hall 75.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) Virci"i n'i a R, MaQ'nelli
S°cia' Security Number(s)/EIN Number °f Pers°nal Representative(s/
Street Address 221 S. 31st Street
City Harrisburo State PA Zip 1 71 09
Year(s) Commission Paid: 8 5 0.0 0
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address ~ '
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 1 1 0.0 0
5. Accountant's Fees
6, Tax Return Preparer's Fees
7. Advertise Estate-Dauphin County Reporter, Paxton Heral.d 100.50
TOTAL (Aisc enter on tine 9. Recapitulation) $ 8,782.50
(If more space is needed, insert additional sheets of the same size)
SCHEDULE I
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHER'TANCE TAX RETURN
RES'OENTDECEDENT MORTGAGE LIABILITIES, & LIENS
ESTATE OF
THERESA M. POTAMI FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1, Pharmercia
$58.00
2. West Shore Health & Rehab 103.56
3. Estate Checking Account 12.00
TOTAL (Also enter on line 10, Recapitulation $
!73.56
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
THERESA M. POTAMI
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Bo Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Virginia Magnelli, 221 S. 31st St.,
Harrisburg,. PA 17109 Sister $4,000.00
2 3amuel Potami, 104 N. 2nd St., Steelton
Pa. 17113 Nephew 500.00
3 5ucy Cunko, 314 S. 2nd St., Steelton,
Pa. 17113 Sister 2,000.00
4 Genevieve McKinley, 5806 Barnsley Dr.,
Harrisburg, Pa. 17111 Sister 2,000.00
5 Donald R. Bowie, 604 Park Hills Dr.,
Mechanicsburg, Pa. 17055 Nephew 500 00
6. Elizabeth Edmiston, 13826 Osprey Nest '
Lane, #12, Orlando FL 32837 Niece 500.00
7.Estate of Blanche Bowie (d.10/21/03)-
Personal Representative-Donald
Bowie Sister 2,000.00
(Address above)
8. 4ary Pinizzotto, 321 S. 7th St.,
Steelton, Pa. 17113 Sister Residue
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART I!- 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)
COMMONWEALTH Of PENNSYLVANIA REV-1162 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 003914
HOFFMAN ELIZABETH A
106 WALNUT STREET
HARRISBURG, PA 17109
ACH
ASSESSMENT AMOUNT
CONTROL
NUMBER
........ fold
101 92,598.33
ESTATE INFORMATION: SSN: 180-01-4647
FILE NUMBER: 2103-0828
DECEDENT NAME: POTAMI THERESA
DATE OF PAYMENT: 05/07/2004
POSTMARK DATE: 00/00/0000
COUNTY: CUM BERLAN D
DATE OF DEATH: 1 0/06/2003
-' ' TOTAL AMOUNT PAID: 92,598.33
REMARKS:
CHECK# 1315
INITIALS: JA
· SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
COHHONWEALTH OF pENNSYLVANIA
~ DEPARTHENT OF REVENUE
BUI~AU OF /ND/V/DUAL TAXES
~HHERITANCE TAX D~VISIOH NOTZCE OF /NHER/TANCE TAX
DEPT. 280601 REV-1547 EX ~FP (01-03)
HARR~SSURG, PA 17128-0601 APPRA/SEMENT, ALLO#ANCE OR D/SALLO#ANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE 07-05-ZOOq THERESA
ESTATE OF POTAMI
DATE OF DEATH
FILE NUMBER 21 03-0828
.COUNTY CUMBERLAND
~: .ACN 101
ELIZABETH A HOFFMAN ESQ
E A HOFFMAN LAW OFCS
106 WALNUT ST
HBG PA 17101~
'' HAKE CHECK PAYABLE AND REM/T PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
WER PORT/ON FOR YOUR RECORDS ~ ......................
RETAZN LO ................ '~C~-~E OR
ESTATE OF POTAMI THERESA M F/LE HO. 21 03-0828 ACN
TAX RETURN HAS: ( ) ACCEPTED AS F/LED (X) CHANGED SEE ATTACHED NOTICE
ED ON: ORIGINAL RETURN .00 NOTE: To insure proper
RESERVATION CONCERNING FUTURE INTEREST ' SEE REVERSE (1) .00_ cred/t to your account,
1. Reel Estate (Schedule A) (2)
2. Stocks end Bonds (Schedule B) O0 sube/t the upper portion
$. Closely Held Stock/Partnersh/p /nterest (Schedule C) ($) ' --
(q} .00~ of this form w/th your
q. Mortgages/Notes Receivable (Schedule D) 15;270.00 tax payment.
5. Cash/Bank Depos/~s/M/sc. personal Property (Schedule E) (S)_ --
(6)_ 16z963'81~
6. Jo/ntlY Owned property (Schedule F) (7)_ llO00.O0
-- 31,233.81
7. Transfers (Schedule G) (8)
8. Total Assets 8,782.50
APPROVED DEDUCTZONS AND EXEMPTZONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9)_
10. Debts/Mortgage Liabilities/Liens (Schedule /) (10)
(11) R.95~.06
-- 22,277.7~
11. Total Deduct/OhS (12) .04
12. Net Value of Tax Return (13) _
15. Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) 22,277.75~
lq. Ne~ Value of Estate Subject ~o Tax
NOTE: Zf an assessment Nas Sssued prev$ousZy, 1Shes 1~, ~5 and/or ~6, 17, 18 and
re~Zect ~igures that incZude the to/aZ of AL_L_~Lreturns assessed to date. .00
.O~x oo ~ --
ASSESSMENT OF TAX: (ts) 00
15. Amount of Line lq a~ Spousal re~e -- .00 X Oq5 = ' --
16. Amount of L/ne lq taxable e~ L/neal/Class k rate (16)__ -- -- Z,$73.$~
17 Aeount of Line lq et S/bl/ng rate (17)__ 19,777.7~ X 12 ~ 375.00
~8. Aeoun~ of Line ~q ~exeble at Collateral/Class B rate (~a}__ Z ·500 · 0~ X 15 =~ --
19. Principal Tax Due
~ NUMBER /NTEREST/PEN PA/D (-)
~ DATE
REVERSE SIDE OF THIS FORM TOTAL DUE J
~ /F PA/D AFTER DATE /ND/CATED, SEE REVERSE ( /F TOTAL DUE /S LESS THAN $1· NO pAYMENT /S RE~U/RED.
FOR CALCULAT/ON OF ADD/T/ONAL /NTEREST. /F TOTAL DUE /S REFLECTED AS A "CRED/T" (CR), YOU MAY BE DUI
A REFUND. SEE REVERSE S/DE OF TH/S FORM FOR iNSTRUCTIONS-)
RESERVATION: Estates of decedents dying on or before December ZZ, 2982 -- if any futura 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
PURPOSE OF at the lawful Class B (collateral) rate on any such future interest.
NOTICE: To fulfill the requirements of Section 2iqO of the Inheritance and Estate Tax Act, Act Z$ of 2000. (72 P.S.
Section 91~0).
PAYHENT= Detach the top portion of this Notice and submit with Your Payment to the Register of Nills Printed on tho reverse side.
--Hake check or money order PaYable to: REGISTER OF NIECE, AGENT
REFUND (CR)= A refund of a tax credit, which was not requested on tho Tax Return, may be requested by completing an "APPlication
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-IllS). APplications ara available at the Office
of the Register of NJlls, any of the 23 Revenue District Offices, or by calling the special 24-hour
answering service for forms ordering= 1-B00-362-2050; services for taxpayers with special hearing and / or
speaking needs: 1-800-447-3020 (TT only).
OBJECTIONS: 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
ADHIN- --appeal to the Orphans' Court.
ISTRATIVE
CORRECTIONS: 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 I7128-060I
Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-1501) for an explanation of administratively correctable errors.
DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five Percent (52) discount of
the tax paid is allowed.
PENALTY: The ISZ 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 seam manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (l) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 19BI bear interest at the rate of
six (62) Percent Par annua calculated at a daily rata of .000164. Ail taxes which bscaaa delinquent on and after
January 1, 1982 will bear interest at a rata which will vary from calendar year to calendar Year with that rata
announced by ths PA Department of Revenue. The applicable interest rates for 1982 through 2004 ara:
Interest Daily
Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1983 162 .000438 1992 92 ,000247 2002 62 ,000164
1984 112 .OOO3O! 1993-1994 72 ,000192 2003 52 .000137
1985 132 .000356 1995-1998 92 .000247 2004 42 .000110
1986 IOZ -000274 1999 72 .000192
1987 IOZ .000274 ZOO0 72 .O00lgz
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT
--Any Notice issued after the tax becomes delinquent will reflect an interest X DAILY INTEREST FACTOR
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 bm calculated.
,~v-~470 ~× ~6-,8~ iNHERITANCE TAX
~ EXPLANATION
coMMONWEALTH OF PENNSYLVANIA OF CHANGES
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2so60~ ~MBER 2103-0828
~R~S~U~G PA ~7~2s-0so~ ~
POTAMI,THERESA M ~
~NAU~ ~ ~ACN 10~
~aY Kath~n Harbilas
EXPLANATION OF CHANGES allowed, see Section
SCHEDULE =Or" accoun~ are fully taxable with no 000 exclusion
G 2~07(c) (7) of the Inheri~nce Tax Act of 199~.
Page
ROW
CONHONNEALTH OF PENNSYLVANIA
DU~AU OF INDIVIDUAL TAXES DEPARTHENT OF REVENUE
ZNHER/TANCE TAX D/V/SION
DEPT. 180601
HARRISBURG, PA 1711D-0601 NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLONANCE OR DZSALLONANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX RE¥-Z647EXAFP(01-O$)
DATE 07-05-ZOOR
ESTATE OF POTAH! THERESA H
DATE OF DEATH 10-06-2005
FZLE NUMBER 21 05-0828
'~'~, ir .COUNTY CUHBERLAND
ELIZABETH A HOFFHAN ESQ ....... ~ -'?~-* ' '~CN 101
E A HOFFHAN LAN OFCS Aeoun~ Ramified
106 NALNUT ST
HBG PA 17101:'
HAKE CHECK PAYABLE AND REMIT PAYHENT TO:
REGISTER OF MILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS
REV-15&7 EX AFP (01-03} NOTICE OF INHERITANCE TAX APPRAZSENENT~ ALLONANCE OR DISALLONANCE OF DEDUCTZONS AND ASSESSMENT OF TAX
ESTATE OF POTAH! THERESA HFZLE NO. 21 05-0828 ACM 101 DATE 07-05-200~
TAX RETURN NAS: ( ) ACCEPTED AS FILED (X) CHANGED SEE ATTACHED NOTICE
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Es~a~a (Schedule A) (1) 00 NOTE: To insure proper
2. S~ocks end Bonds (Schedule B) (2) O0 cradi~ ~o your account,
$. Closely Held S~ock/Par~narship Zn~aras~ (Schedule C) ($) O0 subei~ ~ha upper portion
q. Mor~gagas/No~as Receivable (Schedule D) (q) O0 of ~his fore wi~h your
S. Cash/Bank Daposi~s/Misc. Personal Propar~y (Schedule E) ($) ~;~70.00 ~ax payean~.
6. Jointly Owned Proper~y (Schedule F) (6} ~6196~.8~
7. Transfers (Schedule G) (7) ~000.00
8. To~el AssaYs (G)
APPROVED DEDUCTIONS AND EXEHPTIONS: 8,782.50
9. Funeral Expenses/Adm. Cos~s/Hisc. Expanses (Schedule H) (9)
10. Dab~s/Nor~gaga Liabilities/Liens (Schedule I) (10) 175.56
11. To,al Deductions (11)
12. Na~ Value of Tax Ra~urn (12) 22,277.75
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00
lq. Ne~ Value of Es~a~e Sub~ec~ ~o Tax (1~) 22,277.75
NOTE: I~ an assessment ~as issued previously, lines 1~, 15 and/or 16, 17, 18 and 19 ~ill
reflect figures that include the total of ALL returns assessed to date.
ASSESSHENT OF TAX:
15. Aeoun~ of Line 1~ a~ Spousal ra~e (15) .00 X O0 = .00
16. Amoun~ of Line lq ~axabla a~ Lineal/Class A ra~a (16) .00 X 0~5 = .00
17. Amoun~ of Line 1R a~ Sibling ra~a (17) 19,777.75 x 12 = 2,~75.$$
18. Amoun~ of Line 1~ ~axable e~ Collateral/Class B ra~e (18) 2,500.00 X 15 = ~75.00
19. Principal Tax Due (19)= Z, 7~8.
TAX CREDITS:
PAYMENT RECEIPT D/SCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
05-07-200~ CD00591~ .00 2,598.33
TNTEREST TS CHARGED THROUGH 07-ZO-ZO0~ TOTAL TAX CREDIT Z,598.$$
AT THE RATES APPLTCABLE AS OUTLTNED ON THE ~ALANCE OF TAX DUEI 150.00
REVERSE STDE OF TH]:S FORH INTEREST AND 'PEN. .Z$
TOTAL DUE 150.2:5
~ I'F pAI'D AFTER DATE INDICATED, SEE REVERSE ( I'F TOTAL DUE IS LESS THAN $1, NO PAYHENT TS RE{~UZRED.
FOR CALCULAT:]:ON OF ADDI'T/ONAL I'NTEREST. I'F TOTAL DUE TS REFLECTED AS A "CREDI'T" (CR), YOU NAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR ZNSTRUCTTONS.) ~
RESERVATION: Estates of decedents dying on or before December 12, 198Z -- if any future interest in the estate is transferred
in possession or enjoyment to Class S (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 D (collateral) rate an any such futura interest.
PURPOSE OF
NOTICE: To ~ulfill the requirements of Section Z140 of tho Inheritance and Estate Tax Act, Act Z3 of ZOO0. (72 P.S.
Section 9140).
PAYNENT: Detach the top portion of this Notice and submit ~ith your payment to the Register of Nills printed on the reverse side.
--Hake check or money order payable to: REGISTER OF #ILLS, AGENT
REFUND (CR): A refund of a tax credit, ehich ems nat requested an the Tax Return, may ba requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office
of the Register of Nills, any of the Z3 Revenue District Offices, or by calling the special Z4-haur
ansaering service for forms ordering: 1-800-362-2050; services for taxpayers with special hearing and ! or
speaking needs: 1-DOO-447-30ZO (TT only).
OBJECTIONS: 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 abject eithin sixty (60) days cf receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. ZDIOZ1, Harrisburg, PA 17liD-lOll, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
ADMIN-
ISTRATIVE
CORRECTIONS: 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 171ZD-O&01
Phone (717) 787-6505. See page 5 of the booklet "Instructions far Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanation of administratively correctable errors.
DISCOUNT: If any tax due is paid within three (3) calendar months after the decedant's death, a five percent (SI) discount of
the tax paid is allowed.
PENALTY: The 1SI 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 would appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST: 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 calculated at a daily rate of .000164. All taxes which became delinquent on and after
January l, 1982 Hill bear interest at a rate which mill vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through ZOO4 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
~ 20Z .000548 ~)'~'8-X991 IXZ .00030! ~ 9Z .000247
1983 16X .000438 1992 9Z .000Z47 ZOO2 6Z .000164
1984 IIX .000301 1993-1994 7Z .O00lGZ ZOO3 5Z .000157
1985 13Z .000556 1995-1998 92 .000247 ZOO4 42 .000110
1986 XOZ .000274 1999 7Z .O0019Z
1987 lOX .000274 ZOO0 72 .O0019Z
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY 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 tho interest computation date shown on tho
Notice, additional interest must be calculated.
~EV-I ¢70 EX (6~88)
INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT. 28O601
HARRISBURGi PA 17128-0601
[3ECEDENT'S NAME FILE NUMBER
POTAMI,THERESA M 2103-0828
ACN
I~EVIEWED BY Kathryn Harbilas 101
ITEM
SCHEDULE NO, EXPLANATION OF CHANGES
"In Trust For" accounts are fully taxable with no $3,000 exclusion allowed, see Section
G 1
2107(c) (7) of the Inheritance Tax Act of 1991.
Row Page 1
ELIZABETH A. HOFFMAN
ATTORNEY AT LAW
106 WALNUT STREET
HARRISBURG, PA 17101
717-236-2956 717-232-2559 FAX
July 9, 2004
Register of Wills
Cumberland County Courthouse
! Courthouse Square
Carlisle, PA 17013-3387
In re: Estate of Theresa Potami, File No. 2103-0828
To the Register of Wills:
Enclosed please find the following: (1) 4 copies of a Notice of Inheritance Tax
Appraisement, (2) my check in the amount of one hundred fifty dollars and twenty-three cents
($150.23), and a stamped, self-addressed envelope to return to me stamped copies of the
Notice.
If you have any questions, please do not hesitate to contact me.
Very truly yours,
enc
COMMONWEALTH OF PENNSYLVANIA
BUREA~ OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT, ZB06Ol
HARRISBURG, PA 17128-0601 NOTTCE OF /NHERTTANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTTONS AND ASSESSMENT OF TAX
DATE 07-05-2006`
ESTATE OF POTAMI THERESA M
DATE OF DEATH 10-06-2003
FILE NUHBER 21 05-0828
L,,.~ ,~--C00~Y ;: ;~!.*!:; CUMBERLAND
ELTZABETH A HOFFMAN ESQ ACN 101
E A HOFFMAN LAW OFCS
106 WALNUT ST , Aaoun~ RaaA~ed
HBG PA 17101 ' : ~
MAKE CHECK PAYABLE AND REMTT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LXNE I~ RETAIN LOWER PORTION FOR YOUR RECORDS
REV-1547 EX AFP (01-03) NOTICE OF ZNHERTTANCE TAX APPRA/SENENT, ALLOWANCE OR
DTSALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF POTAMI THERESA MFZLE NO. 21 03-0828 ACM 101 DATE 07-05-ZOOq
TAX RETURN NAS: ( ) ACCEPTED AS FTLED (X) CHANGED SEE ATTACHED NOTICE
RESERVATION CONCERNING FUTURE zN~REST - SEE REVERSK
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Es~a*e (Schedule A) (1) . O0 NOTE: To Ansure proper
2. S~ocks and Bonds (Schedule B) (2) . O0 credit: ~:o your account:,
3. Closely HeZd S~ock/Par~nersh/p Zn~eres~: (Schedule C) (:5) . O0 subai~: ~cha upper pore/on
q. Mor~kgages/No~es ReceAvable (Schedule D) (q) .00 of ~:his fora wASh your
5. Cash/Bank Daposi~cs/MAsc. Personal Proper~y (Schedule E) (S) 13;~70.00 ~ax payaen~.
6. Join*ly Owned Proper~:y (Schedule F) (6)., 16 r 963.81
7. Transfers (Schedule G) (7) 1;000. O0
8. To*al Asse*s (8) 31,233.81
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Ada. Cosmos/Misc. Expenses (Schedule H) (9) 8,78~.50
10. Debts/Mortgage Liabi1A~:Aes/LAens (Schedule z) (10) 173.56
11. To*al Deduc~Aons (11)
12. Ns'i: Value of Tax Re~urn (12) 22,277.75
15. Chari~cable/Governaen~al Bequest:s; Non-elected 911:5 Trusts (Schedule J) (15) . O0
1~. Ne~ Value of Es~a~:e Sub3ec~: ~o Tax (lq) 22,277.75
NOTE: /:f an assess;ent ~as issued previously, l~nes 14, 15 and/or 16, 17, 18 and 19
re~Zect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Aaoun~ of LAne lq a~ Spousal ra~e (1.G) . O0 X O0 = . O0
16. Aaoun* of Line lq ~:axable a~ LAneal/Class A ra*e (16) . O0 X 06'5 = . O0
17. Aaoun* of LAne 1~ a~ Sibllng ra~e (17) 19,777.75 x 12 = 2,373.33
18. Aaoun~ of L/ne Zfi ~:axable a~: Colla~:eral/Class B ra~e (18) 7,500. O0 X 15 = 375. O0
19. Principal Tax Due
TAX CREDITS: (19)= 2,76`8.33
PAYMENT J RECETpT DISCOUNT
DATE / NUMBER INTEREST/PEN PAID (-) AMOUNT PA/D
05-07-2006` CDOO$91q . O0 2,598.33
INTEREST IS CHARGED THROUGH 07-20-2006` TOTAL TAX CREDIT / 2,598.33
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE/ 150.00
REVERSE SIDE OF THIS FORM INTEREST AND PEN. .2:5
TOTAL DUE 150.23
~ TF PATD AFTER DATE ZNDTCATED, SEE REVERSE ( ZF TOTAL DUE TS LESS THAN $1, NO PAYMENT TS REi~UZRED.
FOR CALCULATTON OF ADDTTZONAL TNTEREST. TF TOTAL DUE TS REFLECTED AS A "CREDTT" (CA), YOU MAY BE DUE
A REFUND. SEE REVERSE STDE OF THIS FORM FOR TNSTRUCTTONS. )
RE71470 E~((6-88)
INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT, 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME FILE NUMBER
POTAMI,THERESA M 2103-0828
REVIEWED BY ACN
Kathryn Harbilas 101
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
G 1 "In Trust For" accounts are fully taxable with no $3,000 exclusion allowed, see Section
2107(c) (7) of the Inheritance Tax Act of 1991.
ORIGINAL Page 1
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE REV-1162 EX(11-96)
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 0041 52
HOFFMAN ELIZABETH A
106 WALNUT STREET
HARRISBURG, PA 17109
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
........ ford
101 $150.25
ESTATE INFORMATION: SSN: 180-01-4647
FILE NUMBER: 2103-0828
DECEDENT NAME: POTAMI THERESA
DATE OF PAYMENT: 07/12/2004
POSTMARK DATE: 07/09/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 10/06/2003
TOTAL AMOUNT PAID: $150.25
REMARKS:
CHECK# 1323
INITIALS: JA
· SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
ELIZABETH A. HOFFMAN ,.
ATTORNEY AT LAW
106 Walnut Street .
Harrisburg, PA 17101 , '-
Register of Wills
Cumberland County Courthouse
I Courthouse Square
Carlisle, PA 17013-3387
COMMONWEALTH OF PENNSYLVANIA REV-1162 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 004156
HOFFMAN ELIZABETH A
106 WALNUT STREET
HARRISBURG, PA 17109
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
........ fold ..........
101 $150.23
ESTATE INFORMATION: SSN: 180-01-4647
FILE NUMBER: 2103-0828
DECEDENT NAME: POTAMI THERESA
DATE OF PAYMENT: 07/12/2004
POSTMARK DATE: 07/09/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 10/06/2003
TOTAL AMOUNT PAID' $150.23
REMARKS:
CHECK# 1323
INITIALS: JA
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
ELIZABETH A. HOFFMAN
A'FrORNEY AT LAW
106 WALNUT STREET
HARRISBURG, PA 17101
717-236-2956 717-232-2559 FAX
October 29, 2004
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013-3387
In re: Estate of Theresa Potami, File No. 2103-0828
To the Register of Wills:
Enclosed please find for filing one original and three copies of the "Status Report"
pursuant to Rule 6.12. Kindly return two of the copies to me in the enclosed stamped, self-
addressed envelope.
If you have any questions please do not hesitate to contact me.
Very truly yours,
PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF
THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY
UNTIL COMPLETION
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Tho_ro~.q~ M_ Pc~trami
Date of Death: 1 0 / 6 / 2003
Estate No.: 21 03-0828
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:
Yes x No
2. If the answer is No, state when the personal representative reasonably believes
that the administration will be complete:
(date)
3. If the answer to No. 1 is yes, state the following:
A. Did the personal representative file a final account with the court?
Yes No x
B. The separate Orphans' Court No. (if any) for the personal representative's
account is: 2003- 00828 (Not Applicable in Dauphin County)
C. Did the personal representative state an account informally to the parties in
interest? Yes x No
D. Copies of receipts, releases, joinders and approvals of formal or informal
accounts may be filed with the Clerk of the Orphans' Court and may be attached
to this report.
Date:
Signature
· .~. ~ Elizabeth A. Hoffman
c:._ Name (Please type or print)
106 Walnut Street
'-~ Address
:~! Harrisburg, PA 17101
(MAH:rmt/AM3) ~'~ Telephone No. 717-236-2956
Capacity: __ __ Personal Representative
x Counsel for Personal Representative
{~.W. - 5/)