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HomeMy WebLinkAbout04-0195 STATUS REPORT UNDER RULE 6.12 Name of Decedent: xq~/~c~c~Rc~/ ~er~ ~'~O~ ~- Date of Death: /- &~ Pursuant to Rule 6.12 of the Supreme Cou~ O~hans' Co~ Rules, I repo~ the following with respect to completion of the adminis~ation of the above-captioned estate: 1. State~ther administration of the estate is complete: Yes No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final accost with the CouP? Yes ( No b. The separate O~hans' Cou~ No. (if any) for the personal representative's account is: c. Did the personal repEesentative state an account info~llY to t~ parties in interest? Yes c. Copies of receipts, releases, joinders and approval 'of fo~a~r info,al accounts may be filed with the Clerk of the O~han~' Cou~ and may be aRached to this repo~. Date: lo ~ ~ q - o ~. /~gnamre Name Address ~- [ Telephone No. Capaci~: ~rsonal Representative ~ Counsel for personal representative PETITION FOR GRANT OF LETTERS OF ADMINISTRATION also known as To: Register of Wills for the Deceased. County of in the Social Security No. o2 / 0.- z/cO -- L9 ~ ,~ Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl i ¢- ~ for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) . the above decedent. ~ t~/'r?~ ~' r~/c7 ~ ~ Decendent was domiciled at death in ~~ ...... Qo~t~, ~enn~vania, with h t~ last family or principal residence at 5 ~ /'~]~ [~'' Dec~n~nt~ th~n H ye~s.of ale, died ~,/(~ P ~ ~ ;~ ~ , Decendent at death owned property with estimated values as folllows: ~, c~ / O (If domiciled in Pa.) All personal property $ ' (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: Petitioner.__ after a proper search ha__ ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Relationship Residence THEREFORE, petitianer(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. ..~© ~° OATH OF PERSONAL REPRESENTATIVE COUNTyCOMMONWEALTHoF ~OF PENNSYLVANIA } ss The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me this tx"~/,n'l~ day of Est~e O ~'~ 4f: ~ , Deceased G~NT OF LETTERS OF ADMINIST~TION AND NOW ~_.~,laa3 t~n. ta ~ _Y~ , in consideration of the petition on the reverse side hereof, satis~ctor~ proof having been presented before me, IT IS. DECREED that is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to in the estate of ~'~.~ ~C~,~__.~_ FEES Letters of Administration ..... $~'~ Short Certificates( ) .......... $~,,.,~:~ ^TrORNE¥ (Sup. Ct. I.D. No.) Renunciation ................ $. ~,~ ~,~0 ~~ ADDRESS TOTAL __ Filed F~{t~.. ~ ......... A.D..~~~ PHONE 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. P 9 8 2 5 7 6 6 ~~~ ~-~.,.~. ~ ~,~,,~,,,, No. ~ (// ~ Dante .lo~ :-*:;~e~ :sz COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF HEALTH * VITAL RECORDS CERTIFICATE OF DEATH .L*CK~.K ~ Bradford Kent Strock, Jr. Dau hin I~. I~. I ~1~ ~ ~. ~~ ~ ~'~ Manufacturing Sharon L. Foose ~2~ West Main 8troet Shkemanstown, ~enns~l~ania ~70~ Cumbodand ~* .~.~~ Shimmanston ~, . Dr. ~radford Kont Strock ,~. Marian filhson ~. ~haron L ~trocK ~. 121 West Main Street Shlremanstown, Pa 17011 ~.,m~ ~<s~ ~[ Jan 29 20~ [ Conolite Cremato~ Schaefferstown Pa. 17088 V OFFICIAL USE'ONLY ~ COMMONWEALTH OF REV-1500 ~ PENNSYLVANIA ,~2~~:~. DEPARTMENT OF REVENUE FILE NUMBER ~'~,'~,~! DEPT. 280601INHERITANCE TAX RETURN HARRISBURG, PA 17128-0601 RESIDENT DECEDENT DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER ~DATE OF DEATH (MM-BD-YEA~) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~Q~. ~q ~O~ ~ O'~- D~--/~ REGISTER OF WILLS (IF APPL CABLE) SUR~I~ING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER ~ 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (~ate o~death prior to 12-13-82) ~ 4. Limited Estate ~ 4a. Future Interest Compromise (date of death a~r ,2-12-~2) ~ 5. Federal Estate Tax Return Required ~ 6. Decedent Died Testate (A~ch copy of wi,) ~ 7. Decedent Maintained a Living Trust (AUach copy of Trust) 8. Total Number of Safe Deposit Boxes ~ 9. Litigation Proceeds Re~ived ~ 10. Spousal Povedy Credit (date of death be~een ~2-3~-9~ and ~-~-9S) ~ 11. Election to tax under Sec. 9113(A)(A~ach Sch O) NAME COMPLETE MAILING ADDRESS FIRM NAME (IfAppli~bie) TELEPHONE NUMBER ~, Real Estate (ScheduleA) (1) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Modgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5)  (Schedule E) ,~ 6. Jointly Owned Property (Schedule F) (6) r~ Separate Billing Requested ;~) 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) I-" (Schedule G or L) ,~ 8. Total Gross Assets (total Lines 1-7) (8) O I,Li 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule l) (10) (total Lines 9 & 10) (11) 11. Total Beductions 12. Net Value of Estate (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 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) x .0 __ (15) 16. Amount of Line 14 taxable at lineal rate x .0 __ (16) 17. Amount of Line 14 taxable at sibling rate x .12 (17) 18. Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) Decedent's Complete Address: ISTREET ADDRESS STATE p,/,.~, Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 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 InterestJPenalty ( 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. (SA) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (bB) 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 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 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. S.~..~URE OF PERSO~ RESPONSIBLE FOR FILING RETURN DATE ' ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. {9116 (a)(1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. {9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax 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 decadent'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 an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX * (1-97) ~ SCHEDULE E COMMONW~LTH O~PENNSYLVAN,A CASH, BANK DEPOSITS, & MISC. ,NHER~TANCE ~ "~U,N ~S'~N~ ~C~N~ PERSONAL PROPERTY ESTATE OF FILE NUMBER Include the pro~s of litigation and the date the p~ds were m~iv~ by ~e es~te. All pmpe~ joint¥o~ ~ the right of suw~omhip must ~ disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF D~TH TOTAL (Also enter on line 5, Recapitulation) $ 0, ~ ~ o'~, I I (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER · - Debts of dec/edent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A.1. FUNERAL EXPENSES: ,~, ,~3/ /~?'--'7 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personat Representative(s) Street Address City State __ Zip Year(s) Commission Paid: 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ "~2 /"-'~ '7. ~ (If more space is needed, insed additional sheets of the same size) Inventory of the real and personal estate of !.-z'~_P-C~_'~Or2~ .~.~'n'Jc ~-~p__oc,~,.),Jo, deceased l~7.:Ld g-~dV ~). COMMONWEALTH OF PENNSYLVANIA '~ ss: COUNTY OF CUMBERLAND ~ being duly according fo law, deposes and says that he of the Estate of late of ..... Cumberland Gounty, Pa., deceased and that the within is an inventory made by , the said of the entire estate of said decedent, consisting of all the personal property and real estate, except real estate outside the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value as of the date of decedenf's death. and subscribed before me, Executor - Acfm;n;sfrafor 19 Address Date of Death Day Month Year INSTRUCTIONS I. An inventory must be filed within three months after appolntmenf of personal represenfaflve. 2. A supplement inventory must be filed wifhln fhlrfy days of discovery of addlflonal assets. 3. Additional sheets may be attached as fo personalty or realty 4. See Article IV, Fiduciaries Act of 1949. , WWR#3629885 FORM 93-O.C. DIVISION IN THE COURT OF COMMON PLEAS of CUMBERLAND, REGISTER OF WILLS, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE:ESTATE OF No. N/A Brad K Strock Deceased C5~//- 0 ¢-1/O2~ For a credit card with Bank of America, N.A., Account No. 4024134000084575 CLAIM To the Clerk of Orphans' Court Division: Index and make proper entry in your official records of the claim of Bank of America, N.A. c/o Weltman, Weinberg & Reis Co., L.P.A., 323 West Lakeside Avenue, Suite #200, Cleveland, Ohio 44113-1099 (Claimant) in the amount of $10,270.32 against the estate of the above named decedent. This claim is filed under Section 3532 (b) (2) of the Probate, Estates and Fiduciaries Code. The said decedent, who resided at 121 W Main St. Shiremanstown PA 17011 , died on 01/27/04 (Address) ' Written notice of this claim was given to Sharon Strock, Admin on (Personal representative, if any, or counsel) 121 W Main Street Shiremanstown, PA 17011 & Address or Personal Representative, if any, or counsel (Clammnt) Veda Flowers, Agent for the Claimant c/o Weltman, Weinberg, & Reis Co., L.P.A. ~ ~57~.~ ~. I~.~ 323 W. Lakeside Ave., Suite200 "~ '~ Cleveland, Ohio 44113 (Claimant's Address) CONNONNEALTH OF PENNSYLVANIA ~ BUREAU OF INDIVIDUAL TAXES DEPARTHENT OF REVENUE INHERITANCE TAX DZY/SZON DEPT. Z80601 HARR/SBURG, PA 171Z8-060! NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLO#ANCE OR DZSALLONANCE OF DEDUCTIONS AND ASSESSHENT OF TAX REV-lSd7 EX &FP C01-05) DATE 05-17-Z00~ ESTATE OF STROCK JR BRADFORD K DATE OF DEATH 01-Z7-ZO0~ FILE NUNBER 21 0~-0195 SHARON L STROCK '0~ i'i,'~'~' '~/.~ '~ 4~OUNTY CUHBERLAND ACN 101 121 t,/ HAIN ST SHZRENANSTOt,/N PA 1701,1 · Amoun'l: RemJ.~'l:od HAKE CHECK PAYABLE AND RENTT FAYNENT TO: REGISTER OF k/ILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 1701:5 CUT ALONG THIS LINE ~ RETAIN LOllER PORTION FOR YOUR RECORDS REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLO#ANCE OR DZSALLO#ANCE OF DEDUCTIONS AND ASSESSNENT OF TAX ESTATE OF STROCK dR BRADFORD K FILE NO. 21 0~-0195 ACN 101 DATE 05-17-200~ TAX RETURN #AS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Es~a~e (Schedule A) (1) . O0 NOTE: To /nsure proper 2. S~:ocks and Bonds (Schedule B) (2) . O0 credit: ~o your account:, 3. Closely Held S~:ock/Par:tnership Tn~eres* (Schedule C) ($) . O0 submi~ ~ho upper portion q. Hor~gages/No~es Receivable (Schedule D) (~) . O0 of :khis form wi~:h your S. Cash/Bank Deposi:ks/Hisc. Personal Proper~y (Schedule E) (5) 2;682.11 ~ax payment:. 6. Join*ly Owned Proper~y (Schedule F) (6) . O0 7. Transfers (Schedule G) (7) .00 8. To,al Asse~:s (8) 2,682.11 APPROVED DEDUCTZONS AND EXENPTZONS: :5,157.00 9. Funeral Exponses/Adm. Cos~:s/Hisc. Expenses (Schedule H) (9) 10. Dob~s/Nor~gago Liabi11:tios/Lians (Schodulo I) (10) . O0 11. To'al Deductions (11) :3. 157. 12. Ne~: Value of Tax Ro~urn (12) ~7~.89- 13. Chari~ablo/Governmon~al Bequests; Non-elected 911:5 Trusts (Schedule J) (13) . O0 1~. No~: Value of Es*a~e Sub~ec~ ~o Tax (1~) ~7~.89- NOTE= Zf an assessment was issued previously, lines 1~, 15 and/or 16, 17, 18 and 19 reflect figures that include the total of ALL returns assessed to date. ASSESSNENT OF TAX= 15. Amoun~ of L/no 1~ a~: Spousal ra~e (15) .00 X O0 = . O0 16. Amoun* of LAne 1~ ~axable e~: Lineal/Class A ra~e (16) . O0 X 0~5 = . O0 17. Amoun~ of L/no 1~ a* Sibling ra*e (17) . O0 X 12 = . O0 18. Amoun* of Line 1~ *exablo a~ Collar:oral/Class B ra~e (18) . O0 X 15 = . O0 19. Principal Tax Due (19)= .00 TAX CREDZTSc PAYHENT / R~CEIPT DT$COUNT DATE I NUNBER /NTEREST/PEN PA]mD (-) ANOUNT PAZD TOTAL TAX CREDZT .00 BALANCE OF TAX DUEI . O0 ZNTEREST AN]) PEN. I .00 TOTAL DUE I . O0 ~ ~F PAZD AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE ZS LESS THAN $1, NO PAYNENT ZS RE~U];RED. FOR CALCULATZON OF ADDITZONAL INTEREST. ZF TOTAL DUE IS REFLECTED AS A "CREDZT" (CR)~ YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORN FOR ZNSTRUCTZONS. RESERVATION: Estates of decadents dying on or before December lZ, [982 -- if any futura interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawfu! Class B [collateral) rata on any such futura interest. PURPOSE OF NOTICE: To fulfill tho requirements of Section Z[~O of tho Inheritance and Estate Tax Act, Act 25 of ZOO0. (?Z P.S. Section 91~0). PAYNENT: Detach the top portion of this Notice and submit with your payment to the Register of Nills printed on tho reverse side. --Hake check or money order payable to: REG/STER OF #XLLSj AGENT REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may ba requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1513}. Applications ara available at the Office of the Register of Nills, any of the Z$ Revenue District Offices, or by calling the special Z~-hour answering service for forms ordering: 1-800-36Z-Z050~ services for taxpayers with special hearing and ! or spanking needs: 1-800-4~7-30Z0 (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 sho~n on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Ravenuo~ Board of Appeals, Dept. Z810Z1, Harrisburg, PA I?IZB-IOZ1, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADH/N- ISTRATIVE CORRECTIONS: Factual errors discovered on this assessment should bo addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment ReviaN Unit, Dept. Z80601, Harrisburg, PA 171ZB-0601 Phone (717) 787-6505. Sea page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-150I) for an explanation of administratively correctable errors. DISCOUNT: If any tax due is paid within three (3) calendar months after the dacadent's death, a five percent (BI) 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 same manner and in the the same time period as you would appeal the tax and interest that has bean 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 data of death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rata of six (6X) percent per annum calculated at a daily rata of .00016~. All taxes which became delinquent on and after January 1, 1982 will bear interest at a rata ~hich will vary frei calendar year to calendar year with that rata announced by the 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 ~ 20Z ~ ~)'~'8-1991 llX ~000501 ~ 9Z .000247 1963 16Z .000~38 [992 9Z .000247 ZOO2 6Z .000164 [984 llZ .000301 1993-1994 7Z .000192 2003 SZ .000137 1985 132 .0003S6 1995-1998 9X .O00Z~7 2004 4Z .000110 1986 10X .00027~ 1999 72 .O00XgZ 1987 IOZ .000274 ZOO0 7X .OOO19Z --Interest is calculated as follows: XNTERBST= BALANCE OF TAX UNPA/D X NUNBER OF DAYS DEL/NQUENT X DAXLY XNTEREST FACTOR --Any Notice issued after the tax becomes delinquent Hill reflect an interest calculation to fifteen (15) days beyond the date of the assessment. Xf payment is made after the interest computation data sho~n on tho Notice, additional interest must ba calculated. CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: ./~3~r~_r,/~L"o/~cL .,/~,~--/- ~_~-xt--/~O(- k i xJt~ · Date of Death: /- 0_.~7 - ~) ~. To the Register: I ceffi~ ~at notice of (beneficial intent) estate ad~Mstration required by Rule 5.6(a) of the O~h~s' Cou~ Rules w~ served on or mailed to the following beneficiaries of the above-captioned estate on C//~/~ O O 'e. : N~e Ad&ess Notice has now been given to all persons entitled thereto under Rule 5.6(a) except //Signature Name ~ CL/~O'Z) Address gineman , 17oll Telephone Capacity: ~ Personal Representative ~.Counsel for personal representative FORM 93 - O. C. DIVISION IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLV~A ORPHANS' COURT DIVISION IN RE: ESTATE } OF } No. 21 0~ 195 of 2004 } BRADFORD K STROCK JR } (Deceased) CLAIM To the Clerk of Orphans court Division: Index and make proper entry in your official records of the claim of OMNIUM WORLDWIDE, INC. for ROYAL BANK OF SCOTLAND POST CHARGE-OFF (Clammnt), account # 4388340105253953, in the amount of $3,893.31 against the estate of the above named decedent. This claim is filed under Section 732 (b) (2) of the Fiduciaries Act of 1949 as amended. The said decedent, who resided at 121 W MAIN ST, CAMP HILL, PA 17011-6329, died on January 27, 2004. Written notice of this claim was given to,,, (Personal representative, if any, or counsel). Sharon Strock 121 W Strock Camp Hill PA 17011 October 21 , 2004 f -- ~ (Claimant) ~] OMNIUM WORLDWIDE, INC. 7171 MERCY RD, SUITE 400 PO BOX 6618 OMAHA, NE 68106 800-999-3778 (Claimant's Address) ARS-A~RC 25 ~COVERY M~INT~N~NCE RECDSP 7:26:35 10/21/2004 CLI~T: RBS POST CHARGE-OFF CREDIT CARDS CLI ~F#: 4388340105253953 ACCOONT: 95710691 STATUS: ACTIVE STATUS I~A~ON: 42-CLAIM FILED PACKET: More... ~ ~: P~CON ~: ENGLSH ~D~SS ~: P~HOM PH~ ~: HOMPHN P~IX: ~SP: P~RSP S~T: 121 W ~ ST ~ ~E: ~ FI~T ~: ~ P~IX: 761 · DD~ ~: K CI~: C~P HILL ~: ~ ~T ~: ~ STA~: PA ~T~SION: ~0000 ~: ZIP C~E: ~ 6329 ~ ~E: -- ~X: S~: 210400838 C~Y: US ~L CODE: ~IL ~ ~E: CALL I ~sl I ~=S] L ~s~s] L ~s] [ ~cc~s~ms~zcs] ~ ~: 3893.31000 ~s~ ~: 0.00000 L~ST~G ~: 3893.31000 P~SD PA~S: 0.00000 ~CIP~ PA~S: 0.00000 ~ LISTING ~: 0.00000 ~e... COMMONWEALTH OF PENNSYLVANIA COURT OF COMMON PLEAS CUMBERLAND COUNTY ORPHANS' COURT DIVISION NOTICE OF CLAIM In Re: The Estate of: BRAD K STROCK Deceased Court File No: 21-04-195 TO: THE CLERK OF THE ORPHANS' COURT DIVISION: Notice of claim by creditor, Pursuant to Section 3532(b)(2) of the Probate, Estates, and Fiduciaries Code, 20 PA.C.S.A. !j3532(b)(2). 1) Claimant's name: CITICORP CREDIT SERVICES, INC C/O Balogh Becker, Ltd. 4150 Olson Memorial Highway, Suite 200 Minneapolis, MN 55422-4811 3) Creditor listed below is the owner and holder of a claim in the amount of $15233.02 2) Claimant's address: 4) The facts upon which this claim is based is an account for credit evidenced by the attached Affidavit of Account Stated. 5) Decedent's address: 121 W MAIN ST SHIREMANSTOWN, PA 17011 6) Date of Death: 1/27/2004 7) That the claim arose prior to the death of the decedent on or about 8) That the claim is secured by On behalf of the claimant, I do solemnly declare and affirm under the penalties of perjury that the Inf rmation and representations made h in are true and correct to the best of y k wledge, information and belief. Dated: Chelsea . hitley/Angela M. Horn/ Chad Bolinske/Thersia Lee, Attorney-in-Fact for Claimant Written notice of claim was given to Personal Representative and/or his/her counsel as stated below: See attached Affidavit of Mailing " w uA IN RE ESTATE OF: BRAD K STROCK AFFIDAVIT OF ACCOUNT The undersigned, being first duly sworn deposes and states the follows: 1. Your Affiant is authorized by the Claimant as its Attorney-In-Fact to make this Affidavit. 2. Your Affiant has reviewed the account records of the Claimant with respect to the decedent. Your Affiant is familiar with these records and accounts and reviews them as a regular part of his/her duties. 3. The Decedent purchased merchandise in the amount of $15233.02 evidenced by account number 5424180379371476 4. The unpaid balance does not include any post-death late payment charges, accrued interest, collection costs or attorney's fees. Further your affiant sayeth not By: Attorney-in-Fact for claim Chelsea A. Whitley _ Angela M. Horn _ Michael D. Johnson Mary Ellen Weeman_ Thersia O. Lee Chad J. Bolinske 4150 Olson Memorial Highway, Suite 200 Minneapolis, MN 55422-4811 Subscribed and sworn before me This 1 day of ~,20oF k" SEND ALL WRITTEN REPLIES TO: ARIZONA OFFICE: 64 E. BROADWAY ROAD SUITE 175 TEMPE, AI. 85282 DIANA THEOS - AZ, CO SANDRA TANG - AI., CA JAMES A. BALOGH - MN GARY W. BeCKER - DC, FL, IL, MN, WI- .CREDITOR'S RIGHTS SPECIALIST AMERICAN BOARD OF CERTIFICATION CHELSEA A. WHinEY - MN, WI ANGELA M. HORN - MN MICHAEL D. JOHNSON - MN MARY ELLEN WEEMAN - KS, MN, MO THERSIA O. LEE - MN CHAD J. BOUNSKE - MN STEVEN M. TOMS - MN JOHN E. OLCHEFSKE - MN JASON R. FOSTER - MN MEAGAN M. PROBST - MN MICHAEL J. DOUGHERTY - MN MICHAEL D. BOUNISKE - MN, OR JILL M. GEMlO - MN EMilY L. FINGER - MN ANOREW S. MillER - MN BALOGH BECKER, LTD. ATTORNEYS AT LAw 4150 OLSON MEMORIAL HIGHWAY, SUITE 200 MINNEAPOLIS, MINNESOTA 55422-4811 TELEPHONE 763-852-8440 FAX 763-852-8499 TOll-FREE 888-762-9997 OF COUNSEL: LITOW LAw OFFICES, P.C. (IOWA) lUSTIG, GlASER & WILSON, P.C. (MAsSACHUSETTS) December 30, 2004 REGISTER OF WILLS CUMBERLAND COUNTY COURTHOUSE 1 COURTHOUSE SQUARE, #102 CARLISLE, PA 17013 Re: In the Estate of Probate Case No. Social Security No: Last known residence: Our Client: Account Number: Amount of Debt: BRAD K STROCK 21-04-195 121 W MAIN ST SHIRETOWN, PA CITICORP CREDIT SERVICES, INC 5424180379371476 15233.02 Dear Sir or Madam: Enclosed please find a Creditor's claim to be filed in the record with the above-referenced Estate. Please return a file stamped copy of the claim in the enclosed self-addressed, stamped envelope. Thank you for your assistance. If you have any questions or if this is a duplicate claim, please call our firm toll free at 1-888-762-9997. Cordially, Balogh Becker, Ltd. Attorney-in-Fact for Claimant Enclosures If applicable, a check for the filing fee cc: Attorney for Estate Personal Representative CHARLES E. SHIELDS, III ATTORNEY-AT-LAW 6 CLOUSER ROAD Corner of Trindle and Clouser Ruads MECHANICSBURG, PA 17055 GEORGE M. HOUCK (1912-1991) Register of Wills Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013 TELEPHONE (717) 766-0209 FAX (717) 795-7473 January 21, 2010 Re: Estate of Bradford K. Strock, Jr. No. 21-04-0195 Dear Register of Wills: Please find enclosed for filing~l copies of the Supplem~tal Inheritance Tax Ret~ for the Bradford K. Strock, Jr. Estate as well as Check No. 5398, m the amount of $15.00 for the filing fee. Thank you for your kind attention to this matter. Very truly yours, CES/mjj Enclosures Charles E. Shields III n d , Attorney-At-Law ~ '. _..rJ' Y 1 ~I ~ 1 - Y ! I r ~1 ~ c , N ,n = , r'~~ ~~ , ~ =: " = _ ~ o -. w REV-1508 EX.1137) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RESIDENT DECEDENT RN PERSONAL PROPERTY ESTATE OF FILE NUMBER ~~ii2pt:k•, ~3t~~~-aD K,, ~R. a /-o ~-~ 1 q5 Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointiyowned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION _t OF DEATH 1. SWVIY~ ~jop Ot~~DCae,~~Di» l ~tvt ~JDfv~~l{J"GGftt) ~ nd- ~rOCf!.Gl~S ~irem '~tt Cid~~ i~~on ~~Su.if ~~e~! b Sharos7 1.. $drock, cPeCGolu~tts wida~v a~rtd -~ I~tn in isT~u~ix e~ !~i s es~~r a.~al,~nst dG~amon, M •D.,~ a-I. (S~e Cover /~fftr uaa~ enclosure o~'Ja~. 6, 2a/d ~l~irssed ~ Sharoy L . Sfibc~K ,7~»~i /I~atrifsky, D/soi~ { G>rlis~lcs,~;, Lc P , s; yam' by ti;~o% C, o/sca, ar;~ac~ct/ ~i~~~ (~s~ als o DI~Dt7? ~ ~ s' G7ec. , ZoOq S ;, n ~d 6y TuafS-e ~. G .,~'~t, ~~~ fan ~~ ~~; b,t . ~ ~~~ ~~3, ~f35 ~! TOTAL (Also enter on line 5 Recapitulation) I $ os .3, yc3$, ~ (If more space is needed, insert additional sheets of the same size) NAVITSKY, OLSON & WISNESKI LLP A T T O R N E Y S A T L A W January 6, 2010 Via Certified Mail, Return Receipt Requested Mrs. Sharon L. Stroclc 305 Antilles Court Mechanicsburg, PA 17050 In Re: Estate of Bradford Strock. Jr. Deai- Sharon: Enclosed please find your settlement check in the amount of $234,359.77, which includes $5.63 in interest earnings. It was an honor representing your family over the last few years. I sincerely wish you and your family the very best of health alid success in the future. My best wishes to your family always. Remember to contact Attorney Charlie Shields or another attoniey of your choosing to help with any estate questions you may have. If you have any other questions, please do not hesitate to contact me. NCO/les Enclosure 2040 Linglestown Road • Suite 303 • Harrisburg, PA 17110 Phone: (7 ] 7) 541-9205 Fax: (717) 54 ] -9206 Toll Free: ] -800-515-9608 ww.nowllp.com NAVITSKY. OLSON & WISNESKI 'LLP A T T O R N E Y S A T L A W DISTRIBUTION SHEET Sharon Strock as Administratrix of the Estate of Bradfford Strock v. deRamon, M.D., et al. TOTAL AMOUNT OF SETTLEMENT $425,000.00 Less Attorney's Fees (Pursuant to Court Order - 40% of $425,000.00) -$170,000.00 Subtotal $255,000.00 Less NOW LLP Expenses -$ 20,645.86 Net settlement proceeds $234,354.14 Wrongful Death Allocation (90%) of net settlement proceeds ---~ $210,918.72 Survival Action Allocation (10%) of net settlement procee s~IrC.~ ~ - $ 23,435.41 ~ O-- f.~:ivrL+~ f FO ~' Total cash distribution to Sharon Strock °~ $210,918.72 - . ~~~ AND NOW, this 'day of '~2~~~' 2009, I acknowledge that 1 bare read, understood, approved aid obtained a copy of this Distribution Sheet. I Further acl<no~~ l~d~~e that the above balance constitutes my total reimbursement for medical expenses, wage loss, pain and suffering and other losses sustained or clai:~ns resulting from the death of Bradford Strock. 1 waiTant that if there are any outstanding medical bills or claims other than as set forth above, they will be my responsibility. I further ~~-arrant that I will pay any outstanding medical subrogation liens or expenses not noted above. s' ~ '~ Sharon Strock ~\ .~ Jan 14 10 01:52p NOW LLP 7175419206 p,l NAVITSKY, ULSON & WISNESI~I LLP A T T O R N E Y S A T L A W FAX COVER SHEET To: Charles Shields, Esquire Date: January 14, 2010 Firm/Company: City/State: Mechanicsburg, PA Fax Number: (717} 795-7473 From: Michael Navitsky, Esquire Comments: Charlie: Attached please find the signed Order in the Strock case, along with a copy of paragraph 16 as stated in the Order. I am also attaching a copy of the letter that we received from the Department of Revenue approving the settlement. Should you need anything further, please don't hesitate to call. Mike This fax transmission consists of 4 pages, including this page. If you do not receive all of the pages indicated, have any questions or require assistance, please call Lois Stauffer at 717/541-9205. Confidentiality Notice: The contents of this facsimile message are attorney privileged and highly confidential, directed to the above named person. Therefore, distribution, utilization ar copying of this information by anyone other than the designated recipient is strictly prohibited. If you have erroneously received this transmission, please notify us by telephone at once. 2040 Linglestown Road • Suite 303 • Harrisburg, PA 17110 Phonc: (717) 541-9205 Fax: (717) 541-9206 Toll Free: I-800-818-9608 www.nowl]p.corn Jan 14 10 01:52p NOW LLP 7175419206 p.2 SHARON L. STROCK, Individually and as Administratrix of the ESTATE~OF BRADFORD K. STROCK, JR., Plaintiff IN THE COURT OF COMMON PLEAS CUIviBERLAND CO., PENNSYLVANI.A NO. 06-090 Civil v. CIVIL ACTION -MEDICAL PROFESSIONAL LIABILITY CLAIM RICHARD A. de RAMON, M.D., and De RAMON PLASTIC SURGERY INSTITUTE, P.C. Defendants JURY TRIAL DEMANDED ORDER AND NOW, this _ 1 ~'E`--day of ~~~ n,,., ~, £,Q , 2009, upon consideration of the attached Petition for Approval of Decedent's Compromise Settlement and Distribution of Proceeds, IT IS HEREBY ORDERED THAT: 1) Settlement of the above-captioned action by Sharon L. Strock, Individually and as Administratrix of the Estate of Bradford K. Strock, Jr., in accordance with the terms of the Petition, is hereby ratified and approved. Sharon L. Strock is authorized to execute the Release in this matter and mark the above-captioned action settled, discontinued and ended as to Defendants. 2) All proceeds will be allocated as set forth in paragraph 16 of Plaintiff's Petition for Approval of Decedent's Compromise Settlement and Distribution of Proceeds. 3) Pursuant to the Release language at paragraph 10, this Petition for Court Approval of Decedent's Compromise Settlement and Distribution of Proceeds and Order are hereby sealed. BY THE COURT: 7. Jan 14 10 01:52p IVOW LLP 7175419206 p.3 13. By reason of the death of the decedent, .Bradford K. Strock, Jr., two causes of action arose against Richard A. deRamon, M.D. and DeRamon Plastic Surgery Institute, P.C.: one under the Wrongful Death Act for the benefit of decedent's beneficiaries, and one under the Survival Act for the benefit of decedent's Estate. 14. Petitioner's counsel has received confirmation from the Department of Revenue to allocate 90% of the settlement proceeds to the Wrongful Death Action and 10% of the settlement proceeds to the Survival Action. See, letter from the Department of Revenue attached hereto as Exhibit "F". 15. There are sufficient assets in decedent's Estate to satisfy any outstanding debts, of which there are none. 16. Your Petitioner believes that, in accordance with the terms of the Power of Attorney and Fee Agreement and the Department of Revenue's acknowledgement letter, a fair, just, and equitable distribution of all settlement proceeds would be as follows: a) The Estate of Bradford Strock Survival Action allocation (10% of the net settlement proceeds of $234,354.14 $ 23,435.41 b) Sharon Strock's Wrongful Death Claim Allocation (90% of net settlement proceeds) $210,918.73 c) Navitsky, Olson &Wisneski LLP legal fees $170,000.00 (40% of $425,000) d) Navitsky, Olson &Wisneski LLP $ 20.645.86 reimbursement of expenses TOTAL $425,000.00 17. An Affidavit signed by the Petitioner requesting court approval in accordance with the terms of this Petition is attached hereto as Exhibit "G". 3 Jan 14 10 01:52p NOW LLP 7175419206 p.4 ~~:: ~~~ pennsylvania ~• . DEPARTMENT OF REVENUE November 24, 2009 Michael J. Navitsky ' Navitsky Olson & Wisneski, LLP 2040 Linglesto~vn Road, Suite 303 •• Harrisburg, PA 17110 Re: Estate of Bradford Strock, Jr. File Number 2104-0195 Court of Common Pleas Cumberland County Dear Mr. Navitsky: The Department of Revenue has received your correspondence dated November 6, 2009. Attached was the petition to approve a compromise settlement to be filed on behalf of the above-referenced estate in regard to a wrongful death and survival action. ~It was sent to this office for the Commonwealth's approval of the allocation to the proceeds paid to settle the actions. According to the Petition, the 54 year old decedent died as a result of medical negligence. Decedent:is survived by his spouse and. one adult child. i . ,. Pursuant to the Supreme Court of Pennsylvania, damages recoverable under a survival action include those for future earnings, even,where those earnings may be difficult to quantify. Kiser v. Schulte, 538 Pa:..., 219, 648 A.2d 1 (1994).:.This is supported by the Conmionwealth Court. Roberts v. Duncan, 574 A.2d 1193 . (Cmwlth. Ct. 1990). A portion of the subject recovery, absent any facts to the contrary, therefore must be allocated to the survival action as compensation for the decedents lost earnings. Please be advised that based upon these facts and case law, the Department disagrees to the proposed allocation of a 100/0 split between wrongful death and survival action. However, for inheritance tax purpose only, this Department would not object to the allocation of the net proceeds of this action, $230,758.04 to the wrongful death claim and $25,639.78 to the survival claim. This is equal to a 90/10 split. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pemnsylvania inheritance tax. 42 Pa.C.S.A. §8302, 72 P.S. §9106, 9107. I trust that this letter is a sufficient representation of the Department's position on this matter. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Sin /rely, C~'1~.~.~~~ lam. ~`----. . ha~on~•E. Baker ~ ... • ° ' • Trust Vdluation Specialist ~ ~ _ ' ". Inheritance Tax•Division• • Bureau of Individual Taxes ~.: ~ ~. Bureau of Individual Taxes ~ PO Box 280601 ~ Harrisburg, PA 17128 ~ 717.783.5824 ~ shabaker@state.pa.us REV-1511 EX+ (10-06) SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COST'S RESIDENT DECEDENT ESTATE OF STi~O~f ~iei~/~~ ~. ~TiP FILE NUMBER "`~~ ~9S Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTfON AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Represent~altive(1s,) .SiYi¢aIZOyV ,(, S7XOL-/l lt9Q! UGq~ Street Address v~~ /7A7 /~~C~f (;p/,l~+t' City /ylechan~r^sdKra State~Zip _/7aSo Year(s) Commission Paid: ~/,e~ z• Attorney Fees l~W.f IP.~$ ~ SCI/P~aS ~ ~ ~S~ . CP~{im.~ ~3 ~Q~ ~p 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant S'HA/1pA/ L. $T~cfC ~3~SQ0. o a Street Address ~~] /¢//fif/C,$ (.ONr~' / ~ ~f o , ~ I-~~- a~ Lrl~f Shisr~yew•r~~s~~, p1l'~ hd„~ city ~P~(~d.>? ~ cs ~k!^q state P~' zip ~7oSti Relationship of Claimant to Decedent ~(/,hy/ {~i/t ~~ D/PJ. 4• Probate Fees ~ OP! 4 -11 ~ I S g UC 6•~ ~1(91't C ~i )~~4L~$ ~3~' oO 5• Accountant's Fees 0 6• Tax Return Preparer's Fees ~. ~'!; 1 n heri>~nnce 7`~ ~c~urn lsf 1~'n~e. ~S, 00 . cl 9.J"j/i~ S~ppl. ~I~rl~rvnce ~ %e~urn P~ l~: DD /D• ~ r lJ -over dedu~{~'6/e ~/x~ses ~o~ ~'%n9 0~ /s~ ~ 1,er/~t,u Tnx /Pefurh ~f7~, ~'9 (If more space is needed, insert additional sheets of the same size) TOTAL (Also enter on line 9, Recapitulation) I $ ~/ yyd„ 89 REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ~ l~C~' ~~~~~ K, ~~ FILE HUNKER ~ a/- o~-~~~s Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~,~r/»a~S'ona/ NOt : 77,~e t~~J ~roo~ o><' Cla~rn ~vr ~~riot~S d ~bfis w ~ d-i'leu~ a~Z in St ~ es rc,~ 7~e o '{~i ~e of f~ ~, o erne s race `{~sc c>~P.~bts wP.rz. r n G,crre,ar ~a~' a-word%"J ~, f Pu 1~,5 u.a.l cu~sfvw~~p8~, c~'ed~ f curd co ~,an %r•.s alrrd as ~0 ,b ~n emllet~ le TOTAL (Also enter on line 10, Recapitulation) $ I °- Q ~-- (lf more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCFIEDtILE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER STizock, t3~~o~ K., ~n• a/-o~- /qs RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Llst Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ' ~ Sharon L . sh^otk 305' ,~¢r,f.'!/eS Court, ~ ISt 3o,oao'pD s~G('.~1ati'll C'$bu,rG ~ 1~A' 17a Sa W ~.brs~ J pl ~.s ~z ~s~d~ce a. II ,B,hQct~?br~ ~ s~''1DC~ !~% ~o S!u'cro•7 L . Sfr»~ ~D.S' ~~~~i!S (~ur~'I /1'I,P.~.1?aj2ic.5~iwrg, f~~ / 7o Sa ~~ 1Z -~SiC~ue . 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 II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size) Pa. O.C. Rule 6.12 STATUS REPORT REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Name of Decedent: BRADFORD K. STROCK, JR. Date of Death: 1/27/2004 File Number: 21-04-0195 Pursuant to Pa. O.C. Rule 6.12, 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 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is YES, state the following: a. Did the personal representative file a final account with the Court? ....... ®Yes ~No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the,personal representative state an account informally to the parties in interest? ............................... Yes ^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 May 14, 2010 ~ Signature of Person Filing this Form ~:. ~ ..~ . ..]" ~..~.: ~_ `_ ~ ~ ~ [l. u-O~) L~~ . _I rte. -... ~ rf ~."r rte <;_ ~ ~-- . L --t `"~ CC " UC~~.'," '~ ~ •' _. ~ (~ O N V Form RW-10 rev. 10.13.06 Capacity: ®Personal Representative Counsel Charles E. Shields, III Name of Person Filing Phis Form 6 Clouser Road Address Mechanicsburg, PA 17055 (717) 766-0209 Telephone NOTI,~CE 0~ INHERITANCE TAX pennsy van~a ~ BUREAU OF INDIVIDUAL TAXES ~f~~ ~1LOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION -;-fgF ;D~EDU.Cf~®I~'S AND ASSESSMENT OF TAX REV-1547 EX AFP C12-09) PO BOX 280601 "~~` 11 r-~~` HARRISBURG PA 17128-0601 ~~~~~~~ _~ Q~'~: 07 DATE 05-03-2010 ESTATE OF STROCK JR BRADFORD K C~~K ~~ DATE OF DEATH 01-27-2004 0~~~~,~ ~~~~,~ F I L E NUMBER 21 0 4- 019 5 ~! ~~ ~~D' ~°` ~ ~~'~~'~ ~ ~~ ` COUNTY CUMBERLAND ,, . _ , CHARLES E SHIELDS I~ t~ " ACN 501 6 CLOUSER ROAD APPEAL DATE: 07-0 2-2010 M E C H AN I C S B U R G P A 17 0 5 5- 9 7 3 5 (See reverse side under Objections Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE----- ~ --RETAIN-LOWER PORTION FOR YOUR RECORDS ~ -- ------------------- ---- ------ ----------------------------------- ----------------- REV-15 47 EX AFP C12-09~ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: STROCK JR BRADFORD KFILE N0 .:21 04-0195 ACN: 501 DATE: 05-03-2010 TAX RETURN WAS: CX) ACCEPTE D AS FILED C ) CHANGED APPRAISED VALUE OF RETURN BASED ON: LITIGATION RETURN 1. Real Estate (Schedule A) C1) •0 0 NOTE: To ensure proper 2. Stocks and Bonds (Schedule B) C2) .O 0 credit to your account, 0 0 submit the upper portion 3. Closely Held Stock/Partnership Interest (Schedule . C) C3) of this form with your 4. Mortgages/Notes Receivable (Schedule D) C4) •0 0 tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) 23,435.41 6. Jointly Owned Property (Schedule F) (6) .0 0 7. Transfers (Schedule G) (7) .0 0 8. Total Assets c8) 23 , 435.41 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9) 4.4 4 2.8 9 10. Debts/Mortgage Liabilities/Liens (Schedule I) C10) .0 0 11. Total Deductions C11) 4,442.89 12. Net Value of Tax Return C12) 18, 992.52 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) .0 0 14. Net Value of Estate Subject to Tax C14) 18, 992.52 NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) 18, 992.52 X 00 = . 00 16. Amount of Line 14 taxable at Lineal/Class A rate C16) _0 0 x 0 4 5 = .0 0 17. Amount of Line 14 at Sibling rate C17) .0 0 X 12 = .0 0 18. Amount of Line 14 taxable at Collateral/Class B rate C18) .0 0 X 15 = .0 0 19. Principal Tax Due (19)= .0 0 TAX CREDITS: PAYMENT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST/PEN PAID C-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~f~ ~