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Home My WebLink About04-0082COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003787 SHADE WAYNE F 53 WEST POMFRET ST CARLISLE, PA 17013 ........ fold ESTATE INFORMATION: SSN. 182-40-5409 FILE NUMBER: 2104-0082 DECEDENT NAME: DAVIS VIOLET R DATE OF PAYMENT: 04/08/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 01/15/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $10,000.00 ;REMARKS: .... SEAL CHECK# 2025 TOTAL AMOUNT PAID: $10,000.00 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD REV-1162 EX(11-96) OO41 2 3 SHADE WAYNE F 53 WEST POMFRET ST CARLISLE, PA 17013 ........ fold ESTATE INFORMATION: SSN: 182-40-5409 FILE NUMBER: 21 04-0082 DECEDENT NAME: DAVIS VIOLET R DATE OF PAYMENT: 07/06/2004 POSTMARK DATE: 07/06/2004 COUNTY: CUMBERLAND DATE OF DEATH: 01/15/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $971.00 TOTAL AMOUNT PAID: $971.00 REMARKS: SHADE WAYNE F SEAL CHECK#2126 INITIALS: SK RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV-15OO EX + (6-00) UJ UJ ~oo n I-.- Z O O. UJ O Z UJ Z 0 0 X COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENT'S NAME (LAST1 FIRST, AND MIDDLE INITIAL) Davis~ Violet R. CATE OF DEATH (MM-DD-Year) [ DAT ~ OF BIRTH (MM-DD-Year) 01/15/2004 J 04/11/1914 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) OFFICIAL USE ONLY FILE NUMBER 2 I -0 4 0 0 8 COUNTy CODE YEAR NUMBER SOCIAL SECURITY NUMBER 1 8 2-4 0- 5 4 0 9 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER [-~1. Original Return r--j4 Limited Estate ~-16 Decedent Died Testate (Ntach cop¥ofWill) E~9 Litigation Proceeds Received --]2 Supplemental Return E~ 4~. Future InterestCompromise(dateofdeatha~er12.12_82) E~7 Decedent Maintained a Living Trust (Attach ¢op¥ofTrusl) E~ 1 ) Spousal Poverty Credit (date of death between 12-31-91 end 1-1-95) [~3 Remainder Return (date of death prior to 12-13-82) '--]5. Federal Estate Tax Return Required 0 8. Total Number of Safe Deposil Boxes E~]l 1 Election to tax under Sec. 9113(A) (Attach Sch O) NAME Wayne F. Shade~ Esquire FIRM NAME (If Apptcable) TELEPHONE NUMBER 717-243-0220 1 Real Estate (Schedule A) (1) 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 Properly (5) (Schedule E) 6 Joinlly Owned Property (Schedule F) (6) ] Separate Billing Requested 7 Inter-Vivos Transfers & Miscellaneous Non-Probate Prop( rly (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10 Debts of Decedent, Modgage Liabililies, & Liens (Schedule I) (10) 11 Total Deductions (total Lines 9 & 10) 12 Net Value of Estate (Line 8 minus Line 11) ~ON~IDE~I~ TAX t~FORMATION S~LD ~,,~REC¥~O,TO: , COMPLETE MAILING ADDRESS 53 West Pomfret Street Carlisle 283z001.87 PA 17013 OFFICIAL USE ONLY t (8) 283~001.87 (11) (12) (13) 207526.69 67979.43 27~506.12 255~495.75 (14) 255~495.75 13. Charitable and Governmental Bequests/Sec 9113 Trusts br which an election to tax has not been made (Schedule J) 14 Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15 Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16 Amount of Line 14 taxable at lineal rate 17 Amount of Line 14 taxable at sibling rate 18 Amount of Line 14 taxable at collateral rate 19 Tax Due x (15) 2557495.75 x .045 (16) x 12 (17) X 15 (18) 11~497.31 (19) l 1,497.31 Decedent's Complete Address: STREET ADDRESS 1000 West South Street CITY Carlisle I STATE PA I zip 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A Spousal Poverty Credit B. Prior Payments C. Discount 10,00o.00 52~.31 3. Interest/Penalty if applicable D. Interest E. Penalty 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 5. 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. (1) Total Credits ( A + B + C ) (2) Total Interest/Penalty ( D + E ) (3) (4) (5) (5A) (5B) 11,497.31 10,526.31 0.00 971.00 971.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Chec/: Payab/e to: REGISTEt~ 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 ~ ansferred; ......................................................................... [] [] b. retain the right to designate who shall usE, the property t~ansferred 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, Cid decedent transfer property within one year of death without receiving adequate consideratinn? .......................................................................................... [] [] 3. Did decedent own an "in lrust fo~' or payable upon death bank account or security at his or her death2 ............... [] [] 4. Did decedent own an Individual Retirement ,~ccount, 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, [ decbre that l have examined tl?s ?et, urn, in, cbdi,n,g ,acco n. panyi, ng,~c,hedubs an~d sta_t_e..r~,_n_t.s.:2~n_d,.to the pest of my knowbdge and pelef, it is true, correct and compbte. Declaration of preparer other than the personal representatl~ is oaseo on all in]orm.i[ion o! wnlcn preparer nas ~ny DATE SIGNATURE~/,~I~'..~-"~OF"~PERSON RESPONSIBLE~ F~ ADDRESS 320 Hickory Road PA 17013 Carlisle SIGNATURE OF PREPARER OTHER T.,~.~.,,REPRESENTATIVE DATE ADDRESS 53~West Pomfret Street Carlisle PA 17013 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 impcsed 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 l~ansfer 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 lransfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. {}9116(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-1$08 EX * (l-g?) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Davis, Violet R. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21 04 0082 Include the proceeds of litigation and the date the proceeds were ~eceived by the estate All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION Adams County National Bank, checking account #197-697-4 Adams County National Bank, saviags account #96-1350-1 Sprint, telephone service refund Capital Blue Cross, refund of health insurance premium Proceeds of sale of 71.6385 acres in Huntingdon Township, Adams County, Pennsylvania Pennsylvania Department of Reven~e, income tax refund PNC Bank, checking account #5004220011 PNC Bank, savings account #5004086887 VALUE AT DATE OF DEATH 756.34 12,612.75 3.72 195.00 79,458.11 1,450.00 3,865.92 184,660.03 TOTAL (Also enter on line (If more sp~ce is needed, insert additional sheets of the same size) 2837001.8 / NATIONAL BANK February 4, 2004 Wayne F. Shade Attorney at Law 53 West Pomfret Street Carlisle, PA 17013 Re: Estate of Violet R. Davis Dear Mr. Shade: The following information is being provided as per your request: Acct. Type Account Account' Accrued Ownership Date Account No. Principal on Interest to Opened D.O.D. D.O.D. Checking 1976974 $756.34 $0.00 Individual 4-1-71 Savings 9613501 $12,612.16 $.59 Individual 4-1-71 **A check is enclosed for the proceeds of these two accounts. Inquiries concerning ACNB Corporation stock information should be directed to the Registrar and Transfer Company at 1-800-368-5948. If you need any additional information,. · please feel free to contact me at (717) 338-2171. Sincerely, Lois Kime Deposit Services JUM-iJ-z~4 iU:ii HNCW~NP 412 ?68 3458 P.01×01 PN CBAI March22, 2004 Wayne F. Shade Attorney at Law 53 West Pomfret Street Carlisle, PA 17013 Estate of Violet R. Davis, deceased SSN: 182-40-5409 DOD: 1/15/2004 Dear Mr. Shade: In response to your request for Date of Death balances for the customer noted above, our records show the followiag: Checklug Account Account #5004220011 VIOLET R DAVIS DOD balance: $3,865,5:: + $.40 accrued interest Interest Paid 1/1/2004 - 1/15/2004 - $0.00 Established 05/27/2003 Savings Account Account #5004086887 VIOLET R DAVIS DOD balance: $184,572.51 + $87.52 accrued interest Interest Paid 1/1/2004 - 1/15/2004. $0.00 Established 05/27/2003 Please note that this office only provides elate of death balances for deposit accounts (IRAs, CDs, Checking ~md Savings accounts). We do not process any fiuancial tl~nsaetioes or provide statements. If you need assistance with any of these items, please call 1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, 1-800-762-1775 P7-PFSC-04-F 500 fi~st Ave. Pittsburgh PA 15219 Member FDIC TOTAL P.O1 OMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER Davis. Violet R. Debts of decedent must be reported on Schedule I. 21 04 ITEM NUMBER 8. 9. 10. 11. 12. DESCRIPTION FUNERAL EXPENSES: Carlisle Memorial Service, Inc., gravemarker lettering ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (.~) Nancy M. Bennett Social Security Number(s) / EIN Nul'~ber of Personal Representative(s) Street Address 320 Hickory Road City Carlisle State PA Year(s) Commission Paid: Attorney Fees Wayne F. Shade, Esr uire Family Exemption: (If decedent's address is n 9t the same as claimanrs, attach explanation) Claimant 182-32-4152 Zip 17013 Street Address City Relationship of Claimant to Deceder:t State Zip Probate Fees Register of Wills of Cumberland Count5' Accountant's Fees Tax Return Preparer's Fees Cumberland Law Journal, advert ise Letters Testamentary The Sentinel, advertise Letters Testamentary Tanya S. Thomas, C.P.A., preparation of income tax returns Miller Insurance Associates, Inc, liability insurance Register of Wills, filing Inherita]lce Tax Return Register of Wills, reserve for fili~g Account, etc. TOTAL (Also enter on line 9, Recapitulation) 0082 AMOUNT 155.00 12,000.00 7,500.00 301.00 75.00 98.69 120.00 12.00 15.00 250.00 (If more space s needed, insert additional sheets of the same size) 20~526.69 REV-1512 EX + (~-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULEI DEBTS OFDECEDENT, MORTGAGELIABILITIES,& LIENS FILE NUMBER Davis. Violet R. Include unreimbursed medical expenses. O4 0082 ITEM NUMBER DESCRIPTION 1. Pharmerica, unreimbursed pharmaceuticals Nancy M Bennett, reimbursement for personal expenses of decedent United Church of Christ Homes, nub'sing home expenses Pharmerica, unreimbursed pharmaceuticals TOTAL (Also enter on line 10, AMOUNT 129.25 3,792.09 2,993.79 64.30 (If more sp~ce s needed, insert additional sheets of the same size) 6~979.43 REV-1513 EX + (g.nm COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAXRETURN RESIDENT DECEDENT ESTATE OF Davis, V ~let R. NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. SCHEDULE J BENEFICIARIES TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)J Nancy M. Bennett 320 Hickory Road Carlisle, PA 17013 Charles W. Davis 335 Greenbrier Road York Springs, PA 17372 Samuel E. Davis 7652 Carlisle Pike York Springs, PA 17372 John M. Davis 66301 Oak Road Lakeville. IN 46536 FILE NUMBER 21 04 0082 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE Daughter Son Son Son One-fourth One-fourth One-fourth One-fourth 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 TOTAL OF PART Il - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more si:ace is needed, insert additional sheets of the same size) WAYNE F. SHADE Attorney at Law 53 West Pornfret Street Carlisle, Pennsylvania 17013 LAST WILL AND TESTAMENT I, VIOLET R. DAVIS, of the Township of Huntington, County of Adams, Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at anytime heretofore made. FIRST. I order and direct that all my just debts and funeral expenses be paid by my personal representative or representatives, hereinafter named, as soon as conveniently may be done after my decease. I further authorize my personal representative to expend funds from my Estate in such amounts as my personal representative shall consider appropriate, for the disposition and memorial of my remains. SECOND. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, I give, devise and bequeath unto my husband, CHARLES F. DAVIS, if he survives me. THIRD. For the purposes of this my Last Will and Testament, a person shall not be deemed to have survived me unless he or she shall have survived me by more than ninety (90) days. FOURTH. Should my husband, CHARLES F. DAVIS, fail to survive me, I give, devise and bequeath the said residue of my Estate unto my children, CHARLES W. DAVIS, NANCY M. BENNETT, JOHN M. DAVIS and SAMUEL E. DAVIS, in equal WAYNE F. SHADE Atlorney at Law 53 West Pomffet Street C~rlisl¢, Pennsylvania 17013 shares. If any of my said children should fail to survive me, I give, devise and bequeath his or her share unto such of my said children who shall survive me, in equal shares. If all of my said children should fail to survive me, I give, devise and bequeath the said residue of my Estate unto such of my issue who shall survive me, in equal shares by representation and not per capita. FIFTH. I order and direct that any estate, inheritance or similar tax due as a result of my death with respect to any property passing as a result of my death, shall be paid from the residue of my Estate before its division into shares and prior to distribution as an expense of administration and that no part of the taxes should be prorated or apportioned among the persons or beneficiaries receiving the taxable property. It is my express intention that all inheritance taxes imposed as a result of my death be paid from the residue of my Estate whether or not the property passes under my Last Will and Testament. My personal representative shall have full power and authority to pay, compromise or settle any such taxes at anytime whether with respect to present or future interests. SIXTH. Any and all decisions, determinations or actions made or taken by a personal representative or Trustee hereunder, if made in good faith, shall be final and conclusive on all persons who are or may become interested in my Estate. No fiduciary acting under this my Last Will and Testament shall be liable for any error in judgment or for any depreciation or reduction in value of any Estate or Trust assets at anytime, in the absence of willful default. -2- WAYNE F. SHADE Attorney at Law 53 West Pomfret Sueet Carlisle, Pennsylvania 17013 SEVENTH. I order and direct that, upon my death, my body be interred in my burial plot and not cremated. LASTLY. I nominate, constitute and appoint my husband, CHARLES F. DAVIS, to be the Executor of this my Last Will and Testament, but if, for any reason, he should fail to qualify as such Executor or decline or cease so to serve, I nominate, constitute and appoint my daughter, NANCY M. BENNETT, and my sons, CHARLES W. DAVIS, JOHN M. DAVIS and SAMUEL E. DAVIS, as successive alternate personal representatives hereof, all to serve without bond. IN WITNESS WHEREOF, I, VIOLET R. DAVIS, have hereunto set my hand and seal to this my Last Will and Testament which consists of five (5) typewritten pages to each of which I have affixed my signature, this 27th day of March , A.D. One Thousand Nine Hundred Ninety-Eight (1998). V~ol~t~1{. ~Savis ' The preceding instrument, consisting of this and four (4) other typewritten pages, each identified by the signature of the Testatrix, was on the date thereof signed, sealed, published and declared by VIOLET R. DAVIS, the Testatrix therein named, as her Last -3- WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle, Pennsylvania 17013 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. Acknowledgment COMMONWEALTH OF PENNSYLVANIA ) ) SS: COUNTY OF CUMBERLAND ) I, VIOLET R. DAVIS, the person whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by VIOLET R. DAVIS, this 27th dayof March ., 1998. Violet R. Davis Notary Pubic ~ Notarial Seal I Connie J. Tritt, Notary Public Carlisle, Cumberland County ~ ~J{Y Commission Expires Oct. 5, 2000 -4- Affidavit COMMONWEALTH OF PENNSYLVANIA ) ) COUNTY OF CUMBERLAND ) SS: We,_Wayne F. Shade and Karen F. Byers , the witnesses whose names are signed hereto, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the instrument as her Last Will and Testament; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Will as a witness; and that, to the best of our knowledge, the Testatrix was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. and 1998. Sworn to or affirmed and subscribed to before me by _ Wayne F. Shade Karen F. Byers , witnesses, this_27th day of March Notary Public/ Notarial Seal Connie j. Trill, Nolary Public Carlisle, Cumberland Count My Commission Expires Oct. 5, ~000 F. SHADE ~ at Law ~rnfret Street ermsylvania 013 -5- BUREAU OF INDTVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 171Z8-060! WAYNE F SHADE ESQ 53 W POHFRET ST CARLISLE COHHONWEALTH OF PENNSYLVANIA DEPARTHENT OF REVENUE PA 17013 NOT/CE OF /NHERZTANCE TAX APPRATSEHENT, ALLOWANCE OR DTSALLOWANCE OF DEDUCTTONS AND ASSESSHENT OF TAX REV-1547 EX &FP DATE ESTATE OF DATE OF DEATH FILE NUHBER COUNTY ACN 08-30-ZOOq DA~'~ _..:. VIOLET 01'~200~ 'I ~i~ 21 ~q'OOSZ :"~. .... CU,.ER'A.D ~ HAKE CHECK PAYABLe:AND Rli~I~T PAY~NT TO: REGISTER OF WILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV-15~7 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT~ ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX ESTATE OF DAVIS VIOLET R FZLE NO. 21 Oq-OO8Z ACN 101 DATE 08-30-Z00~ TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Rea/ Es~a~a (Schedule A) 2. S~ocks and Bonds (Schedule B) {2) $. Closely Held S*ock/Partnership Interest (Schedule C) q. Hot,gages/No,es Receivable (Schedule D) (q) S. Cash/Bank Deposi~cs/NAsc. Personal Proper~y (Schedule E) (S) 6. Jointly Owned Propar~y (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. To,al Asse~s APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expensas/Adm. Cos~:s/Misc. Expenses (Schedule H) (9) 10. Debts/Her*gage Llabili*las/Liens (Schedule 1) (10) 11. To*al Daduc*ions 12. Ne~: Value of Tax Re~urn 283~001.87 .00 .00 NOTE: To insure proper .00 credi~ *o your account, .00 subei~ ~he upper por~ion .00 of ~h~s fore w~h your ~ax payment. .00 (8) 20,526.69 283,001.87 6~979.q3 (11) 27.~§6.]2 (12) 255,q95.75 15. lq. NOTE: reflect f/gures that include the total of ALL returns assessed to date. Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15) . O0 Na~: Value of Es~:a~e Sub~ec~: ~:o Tax (lq) 255,q95.75 Zf an assess;ent was issued previously, lines 1~, 15 and/or 16, 17, 18 and 19 ~111 ZF PATD AFTER DATE TNDTCATED~ SEE REVERSE FOR CALCULATTON OF ADDTT/ONAL TNTEREST. (z;) .00 x O0 = .00 (16) 255,q95.75 x Off5: 11,q97.31 (17) . O0 x 12 = . O0 (~8) .00 x 15 = .00 (19)= 11, q97.31 ANOUNT PAID 10,000.00 971.00 TOTAL TAX CREDIT I 11,q97.32 BALANCE OF TAX DUEI .OICR ZNTEREST AND PEN. I .00 TOTAL DUE I .01CR ( TF TOTAL DUE TS LESS THAN $1, NO PAYHENT TS RE~UTRED. TF TOTAL DUE TS REFLECTED AS A "CREDTT- (CR]~ YOU NAY BE DUE A REFUND. SEE REVERSE S/DE OF THTS FORN FOR TNSTRUCTTONS.] ASSESSHENT OF TAX: 15. Amoun~ of Line lq at Spousal ra~a 16. Amoun~ of L/ne lq ~axablo a~ Lineal/Class A ra~o 17. Aeoun~ of Line lq a~ Sibling ra~e 18. Amoun~ of Line lq ~axable a~ Collateral/Class B ra~e 19. Principal Tax Due TAX CREDITS: PAYMENT RECEZPT DZSCOUNT {+) DATE NUNBER TNTEREST/PEN PAID (-) 0q-08-200q CD003787 526.32 07-06-200q CD00q123 .00 RESERVATION: Estates of decedents dying on or before December 1Z, 198Z -- if any futura interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commoneealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. PURPOSE OF HOTICE: PAYNENT: REFUND (CR): OBJECTIONS: ADNIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act Z$ of 2000. (72 P.S. Section 9140). Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side. --Hake check or money order payable to: REGISTER OF NILES) AGENT A refund of a tax credit, which ems not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1315). Applications are available at the Office of the Register of Nills, any of the Z$ Revenue District Offices, or by calling the special Z4-hour anseering service for forms ordering: I-BOO-36Z-ZO50; services for taxpayers with special hearing and / or speaking needs: 1-800-447-50Z0 (TT only). Any party in interest not satisfied eith the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as sheen on this Notice must object aithin 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 parsons! representative, OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Revise Unit, Dept. ZBOSO1, Harrisburg, PA 171Z8-0601 Phone (717) 787-6505. Sea page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" [REV-iS01) for an explanation of administratively correctable errors. If any tax due is paid within three (2) calendar months after the decadent's death, a five percent (SI) discount of the tax paid is alloaed. The 15Z tax amnesty non-participation penalty is computed on the totaI 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 eouId appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of detinqusncy, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became deIinquent before January 1, 1982 bear interest at the rate of six (SI) percent per annum calculated at a deity rate of .000164. A11 taxes which became delinquent on and after January 1, 198Z ail1 bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 19BI through ZOO4 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor ~ 20Z .OOOS4B ~'8-1991 11Z .000501 ~ 9Z .000247 1982 16Z .000458 1992 9Z .000247 ZOOZ 62 .000164 1964 112 .000301 1992-1994 72 .00019Z 2002 5Z .000157 1985 132 .000556 1995-1998 92 .000247 2004 4Z .000110 1986 102 .000274 1999 7Z .000192 1987 102 .000274 ZOO0 72 .00019Z --Interest is calculated as folloes: INTEREST = BALANCE OF TAX UNPA/D X NUHBER OF DAYS DELZNQUENT X DATLY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle, Pennsylvania IN RE: ESTATE OF : 1N THE COURT OF COMMON PLEAS OF VIOLET R. DAVIS, : CUMBERLAND COUNTY, PENNSYLVANIA Deceased, Late of the : ORPHANS' COURT DIVISION Borough of Carlisle, : Cumberland County, Pennsylvania : NO. 21-04-82 FIRST AND FINAL ACCOUNT OF NANCY M. BENNETT, E}(ECUTR!~_~.? Date of Death: January 15, 2004 Letters Testamentary Granted: January 28, 2004 First Complete Advertisement of Grant of Letters: February 13, 2004 Account Stated to August 19, 2004 PRINCIPAL RECEIPTS 2/ 2/04 2/ 4/04 2/ 4/04 2/ 4/04 2/ 4/04 2/ 4/04 2/11/04 5/14/04 Sprint, telephone service refund Proceeds of sale of 71.6385 acres in Huntington Township, Adams County, Pennsylvania Adams County National Bank, checking account #197-697-4 Adams County National Bank~ sa~ngs account #96- 1350-1 PNC Bank, checking account #5004220011 PNC Bank, savings account #5004086887 Capital Blue Cross, refund of health insurance premium Pennsylvania Department of Revenue, income tax refund TOTAL PRINCIPAL RECEIPTS $3.72 79,458.11 756.34 12,612.16 3,865.52 184,572.51 195.00 1.450,00 $282,913.36 A~lomey at Law 53 West Pomfret Street Carlisle, Pennsylvania 1/20/04 2/ 6/04 2/ 6/04 2/ 6/04 2/ 6/04 2/ 6/04 2/18/04 2/19/04 3/ 1/04 4/ 6/04 6/29/04 6/29/04 8/19/04 8/19/04 8/19/04 9/19/04 PRINCIPAL DISBURSEMENTS Checks cleared after date of death Pharmerica, pharmaceuticals 129.25 Wayne F. Shade, Esquire, reimbursement for: Register of Wills, probate 301.00 Cumberland Law Journal, advertise Letters Testamentary 75.00 Carlisle Memorial Service, Inc., cemetery lettering United Church of Christ Homes, nursing home expenses Nancy M. Bennett, reimbursement for personal expenses of decedent Miller Insurance Associates, Inc., liability insurance Pharmerica, pharmaceuticals The Sentinel, advertise Letters Testamentary Tanya S Thomas, C.P.A., preparation of income tax returns Register of Wills, estimated inheritance tax Register of Wills, Inheritance Tax Register of Wills, file Inheritance Tax Return Nancy M. Bennett, Executrix' fee Wayne F. Shade, attorney fees Tanya S. Thomas, CPA, reserve for preparation of fiduciary income tax returns Register of Wills, reserve for filing Account, etc. TOTAL PRINCIPAL DISBURSEMENTS -2- $129.25 376.00 155.00 2,993.79 3,792.09 12.00 64.30 98.69 120.00 10,000.00 971.00 15.00 12,000.00 7,500.00 750.00 250.00 $39,227.12 WAYNE F. SHADE Carlisle, Pennsylvania 2/ 4/04 8/19/04 8/19/04 8/19/04 8/19/04 INCOME RECEIPTS Adams County National Bank, savings account #96- 1350-1 PNC Bank, checking account #5004220011, interest less tax withholding PNC Bank, savings account #5004086887, interest less tax withholding Orrstown Bank, savings account #108210493, interest Orrstown Bank, checking account # 108210493, interest TOTAL INCOME RECEIPTS INCOME DISBURSEMENTS None TOTAL 1NCOME DISBURSEMENTS -3- $6.73 3.14 437.92 758.73 321.27 $1,527.79 $0.00 $0.00 WAYNE F. SHADE Attorney at Law 53 West Pomfrel Street Carlisle, Pennsylvania Receipts Less Disbursements Principal Balance Remaining Receipts Less Disbursements Income Balance Remaining RECAPITULATION PRINCIPAL $282,913.36 39.227.12 INCOME $1,527.79 0.00 COMBINED BALANCE REMAINING -4- $243,686.24 1.527.79 $245,214.03 I, NANCY M. BENNETT, Executrix of the Estate of Violet R. Davis, Deceased, hereby declare under penalty of perjury that I have fully and faithfully discharged the duties of my office; that the foregoing First and Final Account is true and correct and fully discloses all signilicant transactions occurring during the accounting period; that all known claims against the Estate have been paid in full; that, to my knowledge, there are no claims now outstanding against the Estate; and that all taxes presently due from the Estate have been paid. Date: September 7, 2004 Nancy M. Bennett WAYNEF. SHADE[[ 53 ~etts;r~;YmgeLtastWreet ti Carlisle, Pennsylvania WAYNE F. SHAD[ Attorney at kaw 53 West Poml?et Street Carlisle, Pennsylvania 17013 IN RE: ESTATE OF VIOLET R. DAVIS, Deceased, Late of the Borough of Carlisle, Cumberland County, Pennsylvania : 1N THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION : : NO. 21-04-82 STATEMENT OF PROPOSED DISTRIBUTION The Executrix proposes to distribute the entire balance of the Estate for distribution under the provisions of Item Fourth of the Last Will and Testament of the decedent, as follows: 1. Nancy M. Bennett $61,303.50 2. Charles W. Davis 61,303.51 3. Samuel E. Davis 61,303.51 4. John M. Davis TOTAL 61.303.51 $2214.03 I, NANCY M. BENNETT, Executrix of the Estate of ViOlet R. ~hvis, :~ De'&ased, hereby declare under penalty of perjury that the foregoing Statement of Proposed Distribution is tree and correct to the best of my knowledge, information and belief. Date: September 7, 2004 Nancy M. Bennett STATUS REPORT UNDER RULE 6.12 Name of Decedent: Violet R. Davis Date of Death: January 15,2004 Social Security No.: 182-40-5409 File No.: 21-04-82 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: 3. If the answer to No.1 is Yes, state the following: (a) Did the personal representative file a final account with the Court? Yes --X- No (b) The separate Orphans' Court No. (if any) for the personal representative's account is: (c) Did the personal representative state an account informally to the parties in interest? 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: April 4, 2005 r".,') , ~~~~ Wayne F. Shade, Esquire Supreme Court No. 15712 53 West Pomfret Street Carlisle, Pennsylvania 17013 Telephone: 717-243-0220 I,}I \,...-') -n r...) (J'~ -...J Counsel for personal representative J WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carl isle, Pennsylvania 17013 IN RE: ESTATE OF VIOLET R. DAVIS, Deceased, Late of the Borough of Carlisle, Cumberland County, Pennsylvania : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION : NO. 21-04-82 RELEASE KNOW ALL PERSONS BY THESE PRESENTS, That I, JOHN M. DAVIS, being one of the heirs of Violet R. Davis, Deceased, late of the Borough of Carlisle, Cumberland County, Pennsylvania, do hereby acknowledge that I have this date had and received of and from Nancy M. Bennett, Executrix of the Estate of the said Violet R. Davis, the sum of Sixty-One Thousand Three Hundred Three and 511100 ($61,303.51) Dollars in full satisfaction and payment of all such sum or sums of money, legacies, bequests, intestate shares and family exemptions to which I am entitled by Will or as an heir-at-law and to which I am entitled from the Estate of said Decedent. NOW, THEREFORE, I do hereby remise, release, quitclaim and forever discharge the said Nancy M. Bennett, Executrix of said Estate, her heirs, executors, administrators and assigns, of and from the said legacy or legacies and other shares in said Estate and of and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever, for and by reason thereof, or of any other act, matter, cause or thing whatsoever, from the beginning of the world to the date of these presents. IN WITNESS "'HEREOF, I have hereunto set my hand and seal, this / <-j day of 0,- +- , 2004. WI~ (SEAL) ~D!(~~ I verify that the statements made in the foregoing Release are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904, relating to unsworn falsification to authorities. Date: ~rC2 ~~_ hn M. DaVIS IU-I'-r-oy WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle. Pennsylvania 17013 IN RE: ESTATE OF VIOLET R. DAVIS, Deceased, Late of the Borough of Carlisle, Cumberland County, Pennsylvania : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL VANIA : ORPHANS' COURT DIVISION : NO. 21-04-82 RELEASE KNOW ALL PERSONS BY THESE PRESENTS, That I, SAMUEL E. DAVIS, being one of the heirs of Violet R. Davis, Deceased, late of the Borough of Carlisle, Cumberland County, Pennsylvania, do hereby acknowledge that I have this date had and received of and from Nancy M. Bennett, Executrix of the Estate of the said Violet R. Davis, the sum of Sixty-One Thousand Three Hundred Three and 51/100 ($61,303.51) Dollars in full satisfaction and payment of all such sum or sums of money, legacies, bequests, intestate shares and family exemptions to which I am entitled by Will or as an heir-at-law and to which I am entitled from the Estate of said Decedent. . NOW, THEREFORE, I do hereby remise, release, quitclaim and forever discharge the said Nancy M. Bennett, Executrix of said Estate, her heirs, executors, administrators and assigns, of and from the said legacy or legacies and other shares in said Estate and of and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever, for and by reason thereof, or of any other act, matter, cause or thing whatsoever, from the beginning of the world to the date of these presents. IN WITNESS "''HEREOF, I have hereunto set my hand and seal, this J i-o:/- day of (:) ~ ,2004. WITNESS: ~~VSLJ~ ~t{!jjaJJ~ Samuel E. Davis (SEAL) I verifY that the statements made in the foregoing Release are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904, relating to unsworn falsification to authorities. Date: \ ( l.o l'-{ O~ ~~ {O 8,~/~ Samuel E. Davis WAYNEF.SHADE Attorney at Law 53 West Pomfret Street Carlisle, Pennsylvania 17013 IN RE: ESTATE OF VIOLET R. DAVIS, Deceased, Late of the Borough of Carlisle, Cumberland County, Pennsylvania : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION : NO. 21-04-82 RELEASE KNOW ALL PERSONS BY THESE PRESENTS, That I, CHARLES W. DAVIS, being one of the heirs of Violet R. Davis, Deceased, late of the Borough of Carlisle, Cumberland County, Pennsylvania, do hereby acknowledge that I have this date had and received of and from Nancy M. Bennett, Executrix of the Estate ofthe said Violet R. Davis, the sum of Sixty-One Thousand Three Hundred Three and 51/100 ($61,303.51) Dollars in full satisfaction and payment of all such sum or sums of money, legacies, bequests, intestate shares and family exemptions to which I am entitled by Will or as an heir-at-law and to which I am entitled from the Estate of said Decedent. NOW, THEREFORE, I do hereby remise, release, quitclaim and forever discharge the said Nancy M. Bennett, Executrix of said Estate, her heirs, executors, administrators and assigns, of and from the said legacy or legacies and other shares in said Estate and of and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever, for and by reason thereof, or of any other act, matter, cause or thing whatsoever, from the beginning of the world to the date ofthese presents. IN ~SS ~lIEREOF, I have hereunto set my hand and seal, this day of . (i/;eR- ,2004. /<j~ ~~ " " .~..~ '" . _ .. _ _ .. ." tii:/[V/~ ~1~{~lrt'1~(SEAL) Charles W. Davis I verify that the statements made in the foregoing Release are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904, relating to unsworn falsification to authorities. Date: /b'-/8-t>Y. ~h !Jd(/CU Charles W. Davis NOTARIAL SEAL' CHESTE~ E. CHRONISTER, Notary Public Huntingdon Twp., Adams County My Commission Expires May 21, 2005 Member, Pennsylvania Association of Notaries .. WA YNE F. SHADE Attorney at Law 53 West Pomfret Street CalClisle, Pennsylvania 17013 IN RE: ESTATE OF VIOLET R. DAVIS, Deceased, Late of the Borough of Carlisle, Cumberland County, Pennsylvania : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL VANIA : ORPHANS' COURT DIVISION : NO. 21-04-82 RELEASE KNOW ALL PERSONS BY THESE PRESENTS, That I, NANCY M. BENNETT, being one of the heirs of Violet R. Davis, Deceased, late of the Borough of Carlisle, Cumberland County, Pennsylvania, do hereby acknowledge that I have this date had and received of and from Nancy M. Bennett, Executrix of the Estate of the said Violet R. Davis, the sum of Sixty-One Thousand Three Hundred Three and 50/100 ($61,303.50) Dollars in full satisfaction and payment of all such sum or sums of money, legacies, bequests, intestate shares and family exemptions to which I am entitled by Will or as an heir-at-law and to which I am entitled from the Estate of said Decedent. NOW, THEREFORE, I do hereby remise, release, quitclaim and forever discharge the said Nancy M. Bennett, Executrix of said Estate, her heirs, executors, administrators and assigns, of and from the said legacy or legacies and other shares in said Estate and of and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever, for and by reason thereof, or of any other act, matter, cause or thing whatsoever, from the beginning of the world to the date of these presents. IN WITNESS \\'HEREOF, I have hereunto set my hand and seal, this / fA day of Oc:::(,;~ ,2004. WITNESS: ?t/r ~ o ~~ P7 &~~ (SEAL) Nancy M. Bennett I verifY that the statements made in the foregoing Release are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. e.s. 94904, relating to unsworn falsification to authorities. Date: O~ /<(-2005' i = ~~"Yn.~ Nancy M. Bennett