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Home My WebLink About04-0334 Cumberland Register of Wills of County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Eleanor K. Anderson also known as o¢'-' Petitioner(s) who is/are 18 years of age or older apply(les) for . :(COMPLETE "A" OR "B" BELOW:) ' , Deceased Social Security No. 171-28-6711 ~ -'A, Prbbate and Grant of Letters Testamentary and aver that PetitiOner(s) is/are lhe eXecute)rs named in the last Will of the decedent, dated 2 / 22 / 88 -- and codicil(s) dated .... ( State relevant circUmstances, e.g. renunciation, death of executor, otc.) 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 ... (d.b.n.c.ta.; penclente lite; dura~,ie abser,[~,,; durante minoritate) 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 (COMPLETE IN ALL CASES:) Attach additional sheets if necessary Decedent was domiciled at death in Cu______mberland Count, Penns~ania, with his/her last family orprincipat residence at 16____29. Main St., Lisburt[r Mechanicsburg, E. Pennsboro Twp. (list street, number, and municipality) Decedent, then 69 years of age, died March 28 2004 , at Holy Spirit Hospital Decedent at death owned property with estimated values as follows; (Location) (If domiciled in PA) All personal property $ 40,000.00 : (If not domiciled in PA) Personal property in Pennsylvania $ -- (If not domiciled in PA) Personal property in County $ Value of Real Estate in Pennsylvania $ ICI f) r f~ f~ 0 _ f~ 0 situated as foliows: 1629 Main St., LIsburn, Mechanicsburg, PA Wherefore, Petitione¢(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 pdnted name and residence t x , .j,MiChael C. Anderson AJ/~_R °~~br.~ K.A. Batley~_ Kurtz ~ e t~a~-~eey S. Anderson Oath of Personal Representative Commonwealth of Pennsylvania County of York 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 or Petitioner(s) and that, as personal representative(s) of the Decedent, Petition(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed ..... ~/ da- of Michael C. Anderson _ _ .De~re me mis -/ Y ~-' -- - ; ~dle¢S~ Anderson No. Estate of Eleanor Social Security No.: I 71 Ke Anderson -g8 -6711 Deceased Date of Death: 3 / 2 8 / :2 0 0 4 AND NOW; .~,/./~7~; / ' ~' of the Petition on the reverse side hereon, satisfactory proof having been presented before me, ,20~2_/~__, in consideration IT iS DECREED that Letters [~ Testamentary [~ Of Administration d.b.n.c.ta.; pendente lite; durante absentia; durante minodtate are hereby granted to Bradley S. Anderson in the above estate and that the instrument(s) dated Feb. 2 2, 1 9 8 8 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters ........ .... $__ c~/~'-~, ~ Short Certificate(s)...$__ RenunCiation ....... $ Affidavits ( ) ....... $ Extra Pages ( ): .... $_~ Codicil ............ $ JCP Fee ........... $ /(~), inventory ........... $ Automation Fee ..... $ Other .............. TOTAL ........ $ ~/' Jan M. Wiley, ~E__s~qui,r/_ . ~ A~: 130 W, Church St., Suite 10~ Dillsburg, PA 17019 Telephone: 71 7 - 4 3 ~. - 9 6 6 6 ~nace?v~llsPetGr~ntL~/2001 t05 112 REV. 8/88 (FEE FOR THIS CERTIFICATE $2.00) WARNING: IT IS ILLEGAL TO ALTER THIS COPY OR TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS LOCAL REGISTRAR'S CERTIFICATION OF DEATH CERT. NO. T 5606473 200 Date of Issue of This Certification Name of Decedent F. 1 eanor [( o First Middle Anderson Last PA Date of Death March E. Pennsboro Twp. 28, 2004 Pennsylvania Sex Female Social Security No. 171-28-6711 March 10, 1934 Lewisberry, Date of Birth Ho i y $ p i r i ~: Birthplace Place of Death Hospital '- Cumberland Facility Name County City Borough or Township White Homemaker Race Occupation 162 ~ M a i n S t ~ e e ~,rm~ Fs~' (Yes or No) Marital Status Widowed Decedent's Mailing Address Mechanicsburg, PA 170.55-5944 Number Street City or Town Informant Bradley Anderson Funeral Director Louis C. Sibula Name and Address of Funeral Establishment Beaver grich Funeral Home, ]:nc., 30.5 W. Front St,, Immediate Cause (a) (b) (c) Part h Pneumonia Sepsis (d) Part I1: Other Significant Conditions I No State Lewisberry, PA 1733~ Interval Between Onset and Death Manner of Death Natural x[~ Accident [] Suicide [] Homicide Pending Investigation Could not be Determined Describe how injury occurred: Name and Title of Certfier Robert D. Kusztos, M. D. Address 207 House Ave. Camp Hill, PA 17011 (M.D., D.O., Coroner, M.E.) 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 wilt be forwarded to the State Vital Records Office for permanent ~'~'~~~ ~ 61~,625 fill nc~,r"~ . ~ March 29, 2004 13~.~t~,~ve, DallastownO~t~ot~.A 17313 Date Received by Local Registrar Street Address City, Borough, Township of ELEANOR K. ANDERSON BE IT REMEMBERED, that I, ELEANOR K. ANDERSON, of 1629 Main Street, Lisburn, Mechanicsburg, Cumberland County, Pennsyl- vania, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me, at any time heretofore made. ITEM 1: I direct that all my just debts and funeral expenses be paid as soon after my demise as may be convenient. ITEM 2: I give, devise and bequeath all my personal property set forth on the attached list to my children, MICHAEL C. ANDERSON, DEBRA K. A. BATLEY and BRADLEY S. ANDERSON, provided they survive me. ITEM 3: All the rest, residue and remainder of my Estate, of whatsoever nature and wheresoever situate, whether it be real, personal or mixed, including property over which I have a power of appointment, I give, devise and bequeath unto my children, MICHAEL C. ANDERSON, DEBRA K. A. BATLEY and BRADLEY S. ANDERSON, in equal shares per stirpes. ITEM 4: I direct my Co-Executors to pay all inheritance, estate, succession and legacy taxes of whatsoever nature and kind, to which my Estate or the transfer of any property passing hereunder or otherwise passing by reason of my demise, may be subject and to charge such taxes against my residuary estate, it being my intention that none of the aforesaid taxes, either federal or state, on any property required to be WITNESS: ~-~ ,'~ < .. ELEANOR K. ANDERSON included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my Estate to whom such property is or may be transferred or to whom any benefit accrues. ITEM 5: I appoint my children, MICHAEL C. ANDERSON, DEBRA K. A. BATLEY and BRADLEY S. ANDERSON, as Co-Executors of this my Last Will and Testament. ITEM 6: I direct that my Co-Executors, guardians and their successors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS THEREOF, I have hereunto set my hand and seal this ,/~.-//~'~ day of ~- ,~,~. ~ ~y.~. L~< '/~- , 1988. WITNESS: ,k. ~4.~t'~. ~×.'(SEAL) ELEANOR K. ANDERSON COMMONWEALTH OF PENNSYLVANIA : SS COUNTY OF YO,~ /~ : ~ ~ / . a~~'~[L ~', ./~'~ the and sses -z-[~ ~f~ , T~statrix the witne respectively, whose names are signed to the attached or fore- going instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and Testament and that she had signed willingly (or willingly directed another to sign for her), 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 this Last Will and Testament as witness and that to the best of their knowledge, the Testatrix was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. ~ITNESS / / S~o~n to and subscribed to before My Commission Expires: CERTIFICATION OF NOTICE UNDER RULE 5.6 (a) Name of Decedent: Eleanor K. Anderson Date of Death: March 28, 2004 Estate Number: 21-04-00334 To the Register: I certify that notice of beneficial interest required by Rule 5.6 (a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on April 8, 2004: Name Address Michael C. Anderson Debra K.A. Batley Kurtz Bradley s. Anderson 103 E. 6th St., Lansdale, PA 19446 404 Lily's Way, Winchester, VA 22602 1728 Main St., Mechanicsburg, PA 17055 Notice has now been given to all persons entitled thereto under Rule 5.~ (a) except N/A. Date: April 8,2004 ?ignature v - -/// (/ Name: Jan M. Wiley, Esquire Address: 130 W. Church St., Suite 100 Dillsburg, PA 17019 Telephone: (717) 432-9666 Capacity: Counsel for personal Rep. Jan M. Wiley David J. Lenox Timothy J. Colgan Christopher J. Marzzacco December 29, 2004 THE XVILEY GROUP Attorneys at Law Wilo¥, konox, Colgan & Marzzacco, P.C. David E. Hershey Diana Woodside Bradley A. Winnick Thomas M. Clark Ari D. Weitzman Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 In Re: Estate of Eleanor K. Anderson, deceased File Number 21-04-00334 Dear Register: Enclosed for filing please find an Inventory, the inheritance tax retum in duplicate, and the status report with regard to the above captioned estate. Also enclosed is a check in the amount of $5,991.69 representing the tax due, and a check in the amount of $25.00 representing the filing fee. Please return the recording receipts to my attention in the enclosed envelope. Thank you for your cooperation. Sincerely, /dg encl. 130 W. Church Street, Suite 100 · Dillsburg, PA 17019 · Phone: (717) 432-9666 · (800) 682-4250 · Fax: (717) 432-0426 Offices in Harrisburg · York · Carbondale www. wileygrouplaw, com 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. CD REV-1162 EX(11-96) 004800 ANDERSON BRADLEY S 1728 MAIN STREET MECHANICSBURG, PA 17055 ESTATE INFORMATION: SSN: 171-28-6711 FILE NUMBER: 2104-0334 DECEDENT NAME: ANDERSON ELEANOR K DATE OF PAYMENT: 01/06/2005 POSTMARK DATE: 1 2/30/2004 COUNTY: CUMBERLAND DATE OF DEATH: 03/28/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $5,991.69 TOTAL AMOUNT PAID: $5,991.69 REMARKS: ESTATE CHECK SEAL CHECK#1024 INITIALS' RSK RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONVVEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER 21 COUNTY CODE 04 00334 YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Anderson, Eleanor K. 171-28-671 l ~ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) '" THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ,,,u 03/28/2004 03/10/1934 REGISTER OF WILLS IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER uJ mu,,u n..' -I [] 1. Original Return [] 2. Supplemental Return 4. Limited Estate [] 4a. Future Interest Compromise (date of death after 12-12-82) [] 6. Decedent Died Testate (Attach copy [] 7. Decedent Maintained a Living Trust (Attach of Will) copy of Trust) [] 9. Litigation Proceeds Received [] 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95} ~AME Jan M. Wiley, Esq. :IRM NAME (If applicable) The Wiley Group tELEPHONE NUMBER 717/432-9666 1. Real Estate (Schedule A) (1) O0 10. 11. 13. 14. ] 3. Remainder Return (date of death pdor to 12~13-82) [] 5. Federal Estate Tax Return Required SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15.Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) 16.Amount of Line 14 taxable at lineal rate ] 3 3, ! 05.12 17.Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20. [] 130 W. Church St. Dillsburg, PA 17019 Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) Net Value Subject to Tax (Line 12 minus Line 13) Stocks and Bonds (Schedule B) (2) Closely Held Corporation, Partnership or Sole-Proprietorship (3) Mortgages & Notes Receivable (Schedule D) (4) Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) Jointly Owned Property (Schedule F) (6) [] Separate Billing Requested Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) Total Gross Assets (total Lines 1-7) Funeral Expenses & Administrative Costs (Schedule H) (9) Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) Total Deductions (total Lines 9 & 10) Net Value of Estate (Line 8 minus Line 11) 129,568.09 None None 36,401.87 6,772.87 None 29,092.75 58,522.65 10,207.81 (8) 201,835.58 (11) 68,730.46 (12) 133,105.12 (13) (14) 133,105.12 Copyright 2000 form software only The Lackner Group, Inc. Form REV-IS00 EX (Rev. 6-00) x .00 (15) x .045 (16) 5,989.73 x .12 (17) x .15 (18) (19) 5,989.73 8. Total Number of Safe Deposit Boxes [] 11. Election to tax under Sec. 9113(A) (Attach Sch O) COMPLETE MAILING ADDRESS *Decedent's Complete Address: ISTREET ADDRESS CITY Mechanicsburg STATE PA ZIP 17055 1629 Main Street, Lisbum Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Interest/Penalty if applicable D. Interest E. Penalty 1.96 (1) Total Credits (A + B + C) (2) Total Interest/Penalty (D + E) (3) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Line 20 to request a refund If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 5,989.73 0.00 1.96 5,991.69 5,991.69 (4) (5) (SA) (5B) 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 prom se for fe of ether 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 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 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 pest 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 ADDRESS 103 E. 6th St. DATE Michael C. Anderson ~ C. ~ Lansdale, PA 19446 SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS Debra ILA. Batley Kurtz _ ~ , ' ' 404 Lily s Way ~"x\ ~,,,~:)/~'/~/z/'/~~/~¢,g~-~j,/ Winchester, V)k 22602 Sl'.~ NAA~'{ORE.~ OF/5 RE R~,K'E R O.7'H ER .T~[AI~I~EPRESEN[PRESEN/~J,V~ ~/'~'~DDRESS .......... aa~l~JWiley, Esq. ~, - X~t _ . .-, 130W. ChurchSt. , . / f ~ ~ ~ ~ Dillsburg, PA 17019 .~Tdea;i~';; ;;;tier Ju;~, ;--i';~4 and b-;;0re JanU;~, i995, the tax rate i~;;;ed 0;';~-;-~~~s~-~he 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 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. {}9115 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 an individual who has at least one parent in common with the decedent, whether by blood or adoption. ADDITIONAL Personal Representatives Anderson, Eleanor K. SS# 171-28-6711 3~28~2004 Under penalties of perjury, the undersigned declare that they have examined this return, including accompanying schedules and statements, and to the best of their knowledge and belief, it is true, correct and complete. 3 Signature Name Address 17~8 Main St. 4 City, State, Zip Date Signature Name Address: Mechanicsburg PA 17055 City, State, Zip Date Signature Name Address: City, State, Zip Date 6 Signature Name Address: City, State, Zip Date 7 Signature Name Address: City, State, Zip Date of ELEAMOR K. ANDERSON BE IT REMEMBERED, that I, ELEANOR K. AJ~DERSON, of 1629 Main Street, Lisburn, Mechanicsbur§, Cumberland County, Pennsyl- vania, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me, at any time heretofore made. ITEM 1: I direct that all my just debts and funeral expenses be paid as soon after my demise as ~ay be convenient. ITEM 2: I give, devise and bequeath ali_ my personal property set forth on the attached list to my children, MICHAEL C. ANDERSON, DEBRA K. A. BATLEY and BRADLEY S. ANDERSON, provided they survive me. ITEM 3: All the rest, residue and remainder of my Estate, of whatsoever nature and wheresoever situate, whether it be real, personal or mixed, including property over which I have a power of appointment, I give, devise and bequeath unto my children, MICHAEL C. ANDERSON, DEBRA K. A. BATLEY and BRADLEY S. ANDERSON, in equal shares per stirpes. ITEM 4: I direct my Co-Executors to pay all inheritance, estate, succession and legacy taxes of whatsoever nature and kind, to which my Estate or the transfer of any property passing hereunder or otherwise passing by reason of my demise, may be subject and to charge such taxes against my residuary estate, it being my intention that none of the aforesaid taxes, either federal or state, on any property required to be ,] ELEANOR K. ANDERSON included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my Estate to whom such property is or may be transferred or to whom any benefit accrues. ITEM 5: I appoint my children, MICHAEL C. ANDERSON, DEBRA K. A. BATLEY and BRADLEY S. ANDERSON, as Co-Executors of this my Last Will and Testament. ITEM 6: I direct that my Co-Executors, guardians and their successors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS THEREOF, I have hereunto set my hand and seal this ~ day of -',ii . .,~ ?.~,,~, i, · 1988. WITNESS: (! ELEANOR K. ANDERSON COMMONWEALTH OF PENNSYLVANIA : : SS COUNTY OF YO~. : /'/ . .- . /7/ ," / ' ~.. / ,,. / ~ ./- / '/:::' 'f' "'"" 'f '/ i '- '~ ~ 2' ~ "~ f.," '~ ' W.e ('/ ~"~>tA.',:'Z' ;~ ~x:>:'~?~7~d,~. ~ ..... ' ?'' ~.' ~ ''~ '"" ~'?~'~' ..... ~'~ and /., ~', .,/7 z, ~ '- the Testatrix and the witnesses respectively, whose names are signed to the attached or fore- going instrument, bein~ first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and Testament and that she had si~ned willingly (or willingly directed another to sign for her), 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 this Last Will and Testament as witness and that to the best of their knowledge, the Testatrix was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. ELEANOR K. ANDERSON WITNESS ~i~TNESS · Sworn to and subscribed to before me this "~'Y' ~ day of ~ ' /,' '~' '~ ' 1988. Notary ~lic ~' /' My Commission Expires: COMMONWEALTH OF PENNSYLVANIA INHERFFANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Anderson, Eleanor K. SCHEDULE A REAL ESTATE FILE NUMBER 21 - 04 - 00334 All real prope .rty owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which proper~ would be exchanged between a w Ing buyer and a willing seller, neither being compelled to buy or sell both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on schedule F. ITEM NUMBER 1 2 DESCRIPTION Sale of real estate situate at 1629 Main St., Mechanicsburg, PA: Tax Proration due estate from sale of real estate: TOTAL (Also enter on Line l, Recapitulation) VALUE At DATE Of DEATH 129,000.00 568.09 129,568.09 COMMONVVEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Anderson, Eleanor K. SCHEDULE D MORTGAGES & NOTES RECEIVABLE FILE NUMBER 21 - 04 - 00334 All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION M&T Bank Installment Loan - (Debra K.A. Batley, Borrower): TOTAL (Also enter on Line 4, Recapitulation) VALUE AT DATE OF DEATH 36,401.87 36,401.87 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Anderson, Eleanor K. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21 - 04 - 00334 Include the ,~roceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivomh~p must be disclosed on schedule F. ITEM NUMBER 1 2 3 4 5 6 7 8 DESCRIPTION M&T Checking Account: Sale of Pontiac: US Treasury (Federal tax refund): Commonwealth of PA (tax rebate): Peoples Benefit Services (refund): Yard Sale: Personal Property purchased by Brad Anderson: Gordon Gaines (refund): TOTAL (Also enter on Line 5, Recapitulation) VALUE AT DATE OF DEATH 1,243.52 3,900.00 172.00 130.09 18.26 389.00 910.00 10.00 6,772.87 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Anderson, Eleanor K. FILE NUMBER 21 - 04 - 00334 ITEM NUMBER This schedule must be completed and filed if the answer to any of questions 1 throuql~ 4 on page 2 is yes. DESCRIPTION OF PROPERTY Include the name of the transferee, their relationship to decedent and the date of transfer. DATE OF DEATH % OF Attach a copy of the deed for real estate. VALUE OF ASSET DECD'S EXCLUSION TAXABLE VALUE INTEREST IF APPLICABLE) New York Life Annuity 58 217 119: 29,092.75 100% 29,092.75 TOTAL (Also enter on line 7, Recapitulation) 29,092.75 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Anderson, Eleanor K. FILE NUMBER 21 - 04 - 00334 Debts of decedent must be reported on Schedule I. ITEM AMOUNT NUMBER I DESCRIPTION FUNERAL EXPENSES: 1 Michael Anderson (reimbursement for funeral payment): 2 Gingrich Memorials: ADMINISTRATIVE COSTS: Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid Attorney's Fees The Wiley Group: Family Exemption: (If decedenrs address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent Probate Fees Register of Wills State ~ Zip Accountant's Fees Tax Return Preparer's Fees Other Administrative Costs Real Estate Closing: M&T Bank Payoff: Total of Continuation Schedule(s) TOTAL (Also enter on line 9, Recapitulation) 10,839.40 95.00 10,000.00 281.00 19.50 36,401.87 885.88 58,522.65 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Schedub H Funa-a & ESTATE OF ~FILE NUMBER Anderson, Eleanor K. ~ 21 04 - 00334 4 5 6 7 Cumberland Law Journal (advertise): The Sentinel (advertise): Register of Wills (filing fee): M&T Bank (check fee): Tyco (reimbursement of overpayment): 75.00 143.15 25.00 17.75 624.98 Page 2 of Schedule H SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONVVEALTH OF PENNSYLVANIA iNHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Anderson, Eleanor K. FILE NUMBER 21 - 04 - 00334 Include unreimbumed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 2 3 4 5 6 7 8 9 10 Kilmore Eye Associates: AT&T Wireless: Verizon: JJ Skelton (oil): M&T Bank (credit card): PP&L (electric bill): Capital Blue Cross: NGM (car insurance): Bonnie K. Miller (Tax collector): Bankcard Services (credit card): TOTAL (Also enter on Line 10, Recapitulation) 20.00 235.77 45.35 443.71 1,400.00 104.06 367.32 84.20 1,397.40 6,110.00 10,207.81 REV-1513 EX+ '(9-00) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF 'FILE NUMBER Anderson, Eleanor K. 21 - 04- 00334 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY AMOUNT OR SHARE OF ESTATE II. TAXABLE DISTRIBUTIONS (include outright spousal distributions) Michael C. Anderson 103 E. 6th St. Lansdale, PA 19446 Debra K.A. Barley Kurtz 404 Lily's Way Winchester, VA 22602 Bradley S. Anderson 1728 Main St. Mechanicsburg, PA 17055 RELATIONSHIP TO DECEDENT Do Not asr Trustee(s) son daughter son 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS one -third one-third one-third TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET~ OMB NO. 2502-0265 '*' '~'~ B. TYPE OF LOAN: ................. II [J.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT 1.r-]FHA 2. E]FmHA 3. [~CONV. UNINS. 4. E]VA 5. E]CONV. INS. 6. FILE NUMBER: I 7. LOAN NUMBER: SETTLEMENT STATEMENT AND358-04I 10590396 8. MORTGAGE INS CASE NUMBER: C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "[POC]" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. 1.0 3/98 (AND358-O4.PFDIANO358-~415) D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER: BRADLEY ANDERSON THE ESTATE OF ELEANOR K. ANDERSON M & T MORTGAGE CORPORATION 1728 MAIN STREET 1629 MAIN STREET ONE FOUNTAIN PLAZA MECHANICSBURG, PA 17055 MECHANICSBURG, PA 17055 BUFFALO, NY 14203 G. PROPERTY LOCATION: H. SETTLEMENT AGENT: I. SETTLEMENT DATE: 1629 MAIN STREET JAN M. WILEY, ESQ. MECHANICSBURG, PA 17055 December 8, 2004 CUMBERLAND County, Pennsylvania PLACE OF SETTLEMENT 130 W. CHURCH STREET, SUITE 100 DILLSBURG, PA 17019 J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contract Sales Price 129,000.00 401. Contract Sales Price 129,000.00 102. Personal Property 402. Personal Property 103. Settlement Charges to Borrower (Line 1400) 3,169.07 403. 104. 404. 105. 405. Adjustments For Items Paid By Seller in advance Adjustments For Items Paid By Seller in advance 106. City/TownTaxes 12/08/04 to 01/01/05 29.42 406. City/TownTaxes 12/08/04 to 01/01/05 29.42 107. County Taxes to 407. County Taxes to 108. SCHOOLTAX 12/08/04 to 07/01/05 519.54 408. SCHOOLTAX 12/08/04 to 07/01/05 519.54 109. SEWER AND TRASH BILL 12/08/04 to 01/01/05 19.13 409. SEWER AND TRASH BILL 12/08/04 to 01/01/05 19.13 110. 410. 111. ~ 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER 132,737.16 420. GROSS AMOUNT DUE TO SELLER 129,568.09 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. Deposit or earnest money 501. Excess Deposit (See Instructions) 202. Principal Amount of New Loan(s) 116,000.00 502, Settlement Charges to Seller (Line 1400) 19.50 203. Existing loan(s) taken subject to 503. Existing roan(s) taken subiect to 204. 504. Payoff of first Mortgage to M&T BANK/~100019268671 36,401.87 205. 505. Pa}off of second Mortgage 206. 506. 207. 507. 208. 508. 209. 509. Adjustments For Items Unpaid By Seller Adjustments For Items Unpaid By Seller 210. City/Town Taxes to 510. City/Town Taxes to 211. County Taxes to 511. County Taxes to 212. SCHOOL TAX to 512. SCHOOLTAX to 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220. TOTAL PAID BY/FOR BORROWER 116,000.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 36,421.37 300. CASH AT SETTLEMENT FROM/TO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER: 301. Gross Amount Due From Borrower (Line 120) 132,737.16 601. Gross Amount Due To Seller (Line 420) 129,568.09 302. Less Amount Paid By/For Borrower (Line 220) ( 116,000.00 602. Less Reductions Due Seller (Line 520) 36,421.37 303. CASH( X FROM) ( TO)BORROWER 16,737.16 603. CASH( X TO)( FROM)SELLER 93,146.72 The undersigned hereby acknowledge receipt of a completed copy of pages 1&2 of this statement & any attachments referred to herein. I HAVE CAREFULLY REVIEWED THE HUD-1 SETTLEMENT STATEMENT AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS A TRUE AND ACCURATE STATEMENT OF ALL RECEIPTS AND DISBURSEMENTS MADE ON MY ACCOUNT OR BY ME IN THIS TRANSACTION. I FURTHER CERTIFY THAT I HAVE RECEIVED A COPY OF THE HUD-1 SETTLEMENT STATEMENT. Borrower ,/ ~' ~) /~ .- Seller ./~__~ ~ THE ESTATE OF ELEANOR K. ANDERSON [3LEY RSON . ~ ..~ _T9 T_H_E BEST OF M/Y KNC~!..EDGE, THE HUD-1 SETTLEMENT STATEMENT WHICH I HAVE PRE~AREb r~ A'~F~E-AND *~;~CI~URATE~A~COUNT OF THE PUNL)$ WHICH WF~RE RECEIVED AND HAVE BEEN OI~/VILL BE DISBURSED BY THE UNDERSIGNED AS PART OF THE SETTLEMENT OF THIS TRANSACTION. ~'-..//O"'"~..~ t,"~, , I ~ J ~ _S,ET,~NT OFFICER * / ~...Jtlement Agent WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE: TITLE 18 U,S. CODE SECTION 1001 & SECTION 1010. · . L. SETTLEMENT CHARGES ",;'~0'~.' TOTAL C~:)MMiSSION Based on Price $ (~ % PAID FROM PAID FROM Division of Commission (line 700) as Follows: BORROWER'S SELLER'S 701. $ to FUNDS AT FUNDS AT 702. $ to SETTLEMENT SETTLEMENT 703. Commission Paid at Settlement 704. TRANSACTION FEE to 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Origination Fee % to 802. Loan Discount % to 803. Appraisal Fee to M & T MORTGAGE CORPORATION POC: $300.001 30.00 804. Credit Report to 805. Lender's Inspection,Fee to 806. Mortgage Ins. App. Fee to 807. Assumption Fee to 808. PROCESSING FEE to M&TMORTGAGECORPORATION 195.00 809. APPLICATION FEE M & T MORTGAGE CORPORATION POC: $100.00 810. TAX SERVICE FEE to M & T MORTGAGE CORPORATION 82.00 811. FLOOD CERTIFICATION FEE to M & T MORTGAGE CORPORATION 12.00 812. DOCUMENT PREPARATION FEE to M & T MORTGAGE CORPORATION 385.00 813. 814. 815. 816. 817. 818. 819. 820. 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901.Interest From 12/08104 to 01101/05 @ $ 19.068493/day ( 24 days %) 457.64 902. Mortgage Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 ,/ears to DILLSBURG AGENCY POC: $574.00 904. 905. 1000. RESERVES DEPOSITED WiTH LENDER 1001. Hazard Insurance 3.000 months ~ $ 47.83 per month 143.49 1002. Mort~a~elnsurance months (~ $ per month 1003. City/Town Taxes months {~ $ per month 1,004. County Taxes 11,000 months ~ $ 37.39 per month 411.29 1005. SCHOOLTAX 7.000 months @ $ 77.09 per month 539.6; 1006. months (~ $ per month 1007. months ~ $ per month 1008. AGGREGATE ESCROW ADJUSTMEI months ~'~ $ per month -532.23 1100. TITLE CHARGES 1101. Settlement or CIosin~l Fee to 1102. CLOSING PROTECTION LETTER to FIRST AMERICAN TITLE INSURANCE COMPANY 35.00 1103. 60 YEAR SEARCH to TRI-COUNTY ABSTRACT SERVICE 125.00 1104. Title Insurance Binder to 1105. Document Preparation to 1106. Notary Fees to CASH 10.00 1107. Attorney's Fees to JAN M. WILEY, ESQ. 571.5(~ (includes above item numbers: 1108. Title Insurance to TRI-COUNTY ABSTRACT SERVICE, AGENT 432.25 (includes above item numbers: ) 1109. Lender's Coverage $ 116,000.00 103094236 1110. Owner's Coverage $ 129,000.00 432.25 103133262 1111. ENDORSEMENTS to TRI-COUNTY ABSTRACT SERVICE 100, 300, 8.1 150.0(~ 1112. 1113. 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recording Fees: Deed $ 40.50; Mortgage $ 66.50; Releases $ 107.0(~ 1202. City/County Tax/Stamps: Deed ; Mortgage 1203. State Tax/Stamps: Revenue Stamps ; Mortga~e 1204. 1205. OVERNIGHT/COURIER FEES to TRI-COUNTY ABSTRACT SERVICE 14.5(~ 14.50 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Survey to 1302. Pest Inspection to 1303. TAX CERT FEE to TRI-COUNTY ABSTRACT SERVICE 5.00 1304. 1305. 1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Section K) 3,169.07 19.50 Certified to be a true copy. SETTLEMENT OFFICER Settlement Agent (AND358~41AND3.58-O417) MaT Bank April l3,2004 The Wiley Group Attorneys At Law Wiley, Lenox, Colgan & Marzzacco, P.C. 130 W. Church Street, Suite 100 Dillsburg, PA 17019 499 Mitchell Street, Millsboro, DE 19966 Dear Ms. Wiley: Estate of Eleanor K. Anderson Date of Death: March 28, 2004 Social Security Number: 171-28-6711 In response to your request, please be advised that at the time of death, the above- named decedent had on deposit with this bank the following accounts. 1. Account Type ........................... Checking Account Account Number. ...................... 10970592 Ownership (Names of) .............. Eleanor K. Anderson. Opening Date ........................... 08/28/64 Balance on Date of Deattt .........$1,243.51 Accrued Interest $ 0.01 Total ...................................... $1,243.52 Account Type ........................... Installment Loan Account Number. ...................... 10000192686710001 Ownership (Names of) ..............Eleanor K. Anderson (coborrower) Debra K.A. Barley (borrower) Opening Date ........................... 05/30/02 on Date of Death. ......... $42,608.52 Balance Sincerely, Charlene Warrmgton, Rec~rd~~agement 1-888-502-4349 Jan M. Wiley David J. Lenox Timothy J. Colgan Christopher J. Marzzacco The Company You Keep~ www.newyorklife.com Gerald L. Sweger, LUTCF Agent New Yod( Life Insurance Company 259 W. Middlesex Drive Carlisle, PA 17013 Bus. 717 249-1846 Res, 717 249-1846 Registered Representative for NYMFE Sm:udties Inc. 3401 N. Front Street. Suite 100 Harrisburg, PA 17110 717 232-2555 ! %X, rILEY GROUP Attorneys at Law lox, Colgan & Marzzacco, P.C. In Re: Eleanor K. AndersOn, DeceaSed Policy Number: 58 217 119 David E. Hershey Diana Woodside Bradley A. Winnick Jennifer L. Frechette Dear Mr. Sweger: Please be advised that I represent the estate of Eleanor K. Anderson, who died on March 28, 2004. At the time of her death, she was the owner of the above captioned annuity. I would appreciate if you would provide me with the following, at your earliest convenience: A. ' Current date of death value; ~' '~-2~-o~ · -- £q,o~,z. 7'5 B: Current surrender value, and if different, the annuity value; C. Current beneficiary status, f/1,do,d; Pebr~ tc~. ~/~, D~ In addition, please advise if this annuity is in the deferral stage, or has it been annuitized? If so, under what payout option? In either case, please advise us as to ownership annuitant options upon Mrs. Anderson's demise. [J~,rt~-~ le b ~ Finally, please send the necessary paperwork to my office to enable the beneficiaries to redeem this account. Thank you for your aSsistance in this matter. Sincerely, JMW/sdg Encl. Death certificate, Authorization signed by the co-executors) 130 W. Church Street, Suite 100 · Dillsburg, PA 1 7019 · Phone: (717) 432-9666 ° (800) 682-4250 · Fax: (717) 432-0426 Offices in Harrisburg · York · Carbondale www. wileygrou plaw. com Register of Wills of Cumberland County, INVENTORY Estate of Anderson, Eleanor K. also known as Pennsylvania No. 21 - 04-00334 Date of Death 3/28/2004 , Deceased Social Security No. 171-28-6711 Michael C. Anderson Debra K.A. Barley Kurtz Bradley S. Anderson The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities. Attorney: Jan M. Wiley, Esq. I.D. No.: 06298 Address: 130 W. Church St. Dillsburg, PA 17019 Telephone: 717/432-9666 Lansdale, PA 19446 Telephone: 215-368-4012 Dated: Personal Representative Signature: Signature: Debr,~ K.A~. BO]ey~,uz~z Signature:~~ Address: St. · Personal Property M&T Bank Installment Loan - (Debra K.A. Batley, Borrower): 36,401.87 M&T Checking Account: 1,243.52 Sale of Pontiac: 3,900.00 US Treasury (Federal tax refund): 172.00 Commonwealth of PA (tax rebate): 130.09 Peoples Benefit Services (refund): 18.26 Yard Sale: 389.00 Personal Property purchased by Brad Anderson: 910.00 Gordon Gaines (refund): 10.00 Total Personal Property $43,174.74 (Attach additional sheets if necessary) Total Personal Property and Real Estate $172,742.83 STATUS REPORT UNDER RULE 6.12 Name of Decedent: ~'~ Date of Death: I wi, No. Admin. No. 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 ~ No administration will be complete: If the answer to No. 1 is Yes, state the following: --,~ r-n a. Did the personal representative file a' final account with the C Yes No ~ b. If the answer is No, state when the personal representative reasonably believ¢~ The separate Orphans' Court No. (if any) for the personal representative's account that the c. Did the Personal representative state an acCount informally to the parties in interest? Yes v" 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: Name (Please type'~r prir~ Tel. No. Capacity: Personal Representative Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE *' BUREAU OF INDIVIDU~:(T~::i~} INHERITANCE TAX DIVISION"'" '/_" PO BOX 280601 HARRISBURG PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX REY-1547 EX .FP 112-D4> CLERK O.r\n.t! '\ 1'. tre" rirru:,\t\l,.) JAN M W:Ot~~F'f~~L., WILEY GROUP 130 W CHURCH ST DILLSBURG PA 17019 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 03-21-2005 ANDERSON 03-28-2004 21 04-0334 CUMBERLAND 101 ELEANOR K !8 II: lIS Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ R'Ev=r!W-ix--AFP--CftT--6J'--Nol-ici-o"F-i:'N'HiitifAN-cf-Yu-APjSRA-isiM€N'~-A[tOQANCE-OR------------- - --- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF ANDERSON ELEANOR K FILE NO. 21 04-0334 ACN 101 DATE 03-21-2005 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Hortgages/Notes Receivable (Schedule D)' S. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (,5) (6) (7) 129.568.09 .00 .00 36.401.87 6.772.87 .00 29.092.75 (8) NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 201.835.58 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adn. Costs/Hisc. Expenses (Schedule H) 10. Debts/Hortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) 58.522.65 10.207.81 (11) (12) (13) (14) 68.730 46 133.105.12 .00 133.105.12 I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will r~lect ~igures that include the total o~ ~ returns assessed to date. ASSESSMENT OF TAX: IS. Allount of Line 14 at Spousal rate (IS) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TA C D TS: NOTE: .00 X 133.105.12 X .00 X .00 X 00 = 045 = 12 = 15 = (19)= .00 5,989.73 .00 .00 5.989.73 DATE 12-30-2004 NUMBER CD004800 + INTEREST/PEN PAID (-) 1. 32- AMOUNT PAID 5.991.69 ~. TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 5.990.37 .64CR .00 .64CR IF PAID AFTER DATE INDICATED. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)