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Home My WebLink About03-1056COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 I OFFICIAL USE ONLY REV-1 500 INHERITANCE TAX RETURN RESIDENT DECEDENT I.U LU Z o U.I o DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) BLoo,% El~g-[.. YA/ "~g~Ll CK DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 171 - ,~o - 73~3 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER .,~1. Odginat Return I~l 2. Supplemental Return [~I 4. Limited Estate [] 4a. Future Interest Compromise (date of death after 12-12-82) [] 6. Decedent Died Testate (A~ach copy of will) I----I 7. Decedent Maintained a Living Trust (^ttach copy of Trust) Z g. Litigation Proceeds Received i-~ 10. Spousal Poverty Credit (dat~ of death between 12-31-91 and 1-1-95) NAME ~/flF ~L ES E. ,Sl-il~ LD5 ~ FIRM NAME (If Applicable) TELEPHONE NUMBER [~]3. Remainder Return (date of death prior to 12-13-82) [~5. Federal Estate Tax Return Required ~) 8. Total Number of Safe Deposit Boxes [--'~ 11. Election to tax under Sec. 9113(A) (Attach SCh O) COMPLETE MAILING ADDRESS 1705'.5' 14. 1. Real Estate (Schedule A) (1) ~ ~ -- 2. Stocks and Bonds (Schedule B) (2) ~ ~ -- 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) ~ g:~ "" 4. Mortgages & Notes Receivable (Schedule D) (4) ~ 0 ~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) ~ ,,,.~ ~). ~ (Schedule E) 6. Jointly Owned Property(Schedule F) (6) ~'/~! _~/4~. ~-~ --]Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) "-" C) ~ (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) ~' 9. Funeral Expenses & Administrative Costs (Schedule H) (9) /'/! /-] ~ ~"o ,,~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule l) (10) ~ // ~ ~'~ ~" 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. 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) (8) /~/cF/B/ (11). (12) (13) (14) OFFICIAL USE ONLY 15. SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Amount of Line 14 taxable at the spousal tax -- ~ _ rate, or transfers under Sec. 9116 (aS(1.2) x .0 ~) (15) ~&, ~.~0.0! .0~ (16) 16. Amount of Line 14 taxable at lineal rate x 17. Amount of Line 14 taxable at sibling rate ~ O -- x .12 (17) 18. Amount of Line 14 taxable at collateral rate ~ O -- x .15 (18) 19. Tax Due (19) 20. ~ Decedent's Complete Address: STREET ADDRESS / / '7 ,5'. /ff,4-~,~' 7' $'T: CITY /'~//~"~'~/"~/~/'/~:~ '~"~/~'/~ I STATE ,~,,,~ ZIP Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Pdor Payments C. Discount Interest/Penalty if applicable D. Interest E. Penalty (1) Total Credits ( A + B + C ) (2) Total Interest/Penalty ( D + E ) 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) If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX BUR. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) IF THE ANSWER (3) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; .......................................................................................... [] ,~ b. retain the right to designate who shall use the property transferred or its income; ............................................ [] b. 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 decadent 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? ........................................................................................................................ [] TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties o)'l~rjury, I declare that I have examined this re,~, including accompanying schedules and statements, and to [he best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than t.~personal representative t b~sed or~ informatio~ which preparer has any knowledge. SIGNATURI~,~I~: ~DEt:~,SO.N ~SF~NSIBI~""FOR I~¢qG R~T.URN I~ DATE ADDRESS ~'Z~/-,~'Z., /~/ X"e'/V-/../,,v' ;Z),,~'.,, ~..~,~z./5'/-~ ,~,4 /7a/$ DATE -~ ~ -~..~ 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 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 decedenrs siblings is 12% [72 RS. §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. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ~/..~D,"/'f, ~'//'~F/,1'/1,/ /~'8~ZCK FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. /-,/,~) ,~/-,~ TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) SCHEDULE F JOINTLY-OWNED PROPERTY REV-1509 EX + (1-97) j~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ,,~/- g)(~/)l/ ~-'J/~"L J/,~/ ,,'~,~ ~-t'~/-~' FILE NUMBER ~ an ass~ ~s made joint ~hin one year of the decedent's da~ of death, ~ must ~ m~ded on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RE~TIONSHIP TO DECEDENT ~/t~,~,v~,,fS',, W/¢ / 7.= z q JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed for joinfiy-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTERES' 1. A. ~..z=.~ Ct'r'/c~/v$ Z~/zK cJC~'c~,w ,~t¢,~ # ~ ~, 7.2.0. 30 .b'-~ ¢1, $6o. TOTAL (Also enter on line 6, R~apitulation) $ / ~t ~ / ~. ~G tit ......... (If more space ~s needed, insert additional sheets of the same size) CITIZENS BANK 525 William Penn Place Suite 153-2510 Pittsburgh, PA 15219 November 20, 2003 CHARLES E SHIELDS, ATTORNEY AT LAW 6 CLOUSER ROAD CORNER OF TRINDLE & CLOUSER ROADS MECHANICSBURG, PA 17055 Estate of EVELYN REBUCK BLOOM Date of Death: Dec 19, 2002 SSN: 171-30-7343 Dear Sir/Madam: In accordance with your request, the attached information sheet has been provided in the above decedent's name as of his/her date of death. For IL or LC accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 412.867.3815. Sincerely, Ann Rhodes Operations Services CITIZENS BANK Account Number 6100699854 Account Title EVELYN F BLOOM OR SANDRA K MILLER Date Opened 4/23/84 Account Type Checking Principal Balance as of DOD $2720.30 Interest from Last Posting to DOD Account Balance as of DOD $ .00 $2720.30 YTD Interest to DOD $ .00 CITIZENS BANK Account Number 6140168740 Account Title EVELYN F BLOOM OR SANDRA K MILLER Date Opened 5/12/86 Account Type Savings Principal Balance as of DOD $10283.19 Interest from Last Posting to DOD $1.34 Account Balance as of DOD $10284.53 YTD Interest to DOD $23.24 CITIZENS BANK Account Number 6140884039 Account Title EVELYN F BLOOM OR RONALD E REBUCK Date Opened 11/12/90 Account Type Time Deposits Principal Balance as of DOD $12010.00 Interest from Last Posting to DOD $14.31 Account Balance as of DOD $12024.31 YTD Interest to DOD $171.47 EV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF /~/_~j~/ ~-~'//~"/~/~/ SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER ITEM NUMBER 5. 6. 7. Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) ~2~/i~--/..~ ~ ~'~.,~' Social Security Number(s)/EIN Number of Personal Representative Street Address /~--// /~'/V-L//I/ "~'. City ~4t-~'~./G~..-~- State ~/~t' Zip /70/,..~' Year(s) Commission Paid: Attorney Fees ~/~t ~/_.~-.r.~ ~.. ~..~/¢/~_--"Z~)..~' ~ Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent Probate Fees A)07' //~°///c.~/'4ff Accountant's Fees ~vO ~ Tax Return Preparer's Fees State Zip TOTAL (Aisc enter on line 9, Recapitulation) (If more space is needed, insed additional sheets of the same size) AMOUNT ~'/¢ 5'". oo $ ,/, REV-1512 EX *~(1-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT OECEDENT SCHEDULE ! DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ~'~.~/¢/f/ ,~¢-/,,',~"z',/,/.,/f,/' /~,~",~¢'/L~,(" FILE NUMBER Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (1-97) ~ _.~ ~;~ · ' ~ SCHEDULEJ COMMONWEALTH OFPENNSYLVAN,A BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER NUMBER II. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) /9'/ Id~-N -L//v .b,~.. Ett,~.z./~z ~, p,,i /7o/3 17~$5'" ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINEI RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE ,V3 15 THROUGH 17, 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 ]]- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) Ms. Ann Capozzi Office of the Register-of Wills Cumberland Co. Court House 1 Court Square Carlisle, PA 17013 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-O601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD REV-1162 EX(11-96) OO3373 SHIELDS CHARLES E III 6 CLOUSER ROAD MECHANICSBURG, PA 17055 ........ fold ESTATE INFORMATION: SSN: 171-30-7343 FILE NUMBER: 2103- 1056 DECEDENT NAME: BLOOM EVELYN REBUCK DATE OF PAYMENT: 12/23/2003 POSTMARK DATE: 12/19~2003 COUNTY: CUMBERLAND DATE OF DEATH: 12/19/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $284.85 TOTAL AMOUNT PAID: $284.85 REMARKS: RONALD E REBUCK C/O CHARLES E SHIELDS III ESQ SEAL CHECK//1022 INITIALS' AC RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXES TNHERZTANCE TAX DTVTSTON DEPT. Z80601 HARRTSBURG, PA 171Z8-060! COHHONgEALTH OF PENNSYLVANIA DEPARTHENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX REV-I;d7 EX AFP (01-03) CHARLES E SHIELDS II~O~ APR 13 All :44 6 CLOUSER RD HECHANICS]~URG DATE ESTATE OF DATE OF DEATH FILE NUHBER COUNTY ACN 0Z-16-200~ ltL00H EVELYN 12-19-2002 21 0:3-1056 CUHSERLAND 101 ~'~Am°un~ Rimi~ed I HAKE CHECK PAYAZ~LE AND REH'rT PAYHENT TO.' REGISTER OF gILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 1701:5 CUT ALONG THIS LINE ~ RETAIN LOgER PORT'rON FOR YOUR RECORDS ~ .................... II! ........................... IIIIII! .......... I.III ........ IIlI ...... IIIIlIIll ............. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003806 SHIELDS CHARLES E III 6 CLOUSER ROAD MECHANICSBURG, PA 17055 ........ fold ESTATE INFORMATION: SSN.' 171-30-7343 FILE NUMBER: 2103- 1056 DECEDENT NAME: BLOOM EVELYN REBUCK DATE OF PAYMENT: 04/13/2004 POSTMARK DATE: 04/12/2004 COUNTY: CUMBERLAND DATE OF DEATH: 12/19/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $3.55 REMARKS: .... SEAL :: CHECK#1028 TOTAL AMOUNT PAID: 83.55 INITIALS: JA RECEIVED BY-' GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS RESERVATTON: Estates of decedents dying on or before December [Z, 198Z -- if any future interest in the estate is transferred Charles E. Shields III Attorney-At-Law 6 Clouser Road Mechanicsburg, PA 17055 BUREAU OF INDZVTDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG,, PA 17128-0601 COMMONWEALTH OF PENNSYLVAN'rA DEPARTMENT OF REVENUE 'rNHERTTANCE TAX STATEMENT OF ACCOUNT REV-I~07 EX AFP (01-03) 'O4 CHARLES E SHIELDS 6 CLOUSER RD MECHANICSBURG PA 17,,055 Jui --7 DATE 05-2q-ZOOq ESTATE OF BLOOM DATE OF DEATH 12-19-2002 FILE NUMBER 21 03-1056 COUNTY CUMBERLAND ACN 101 Amoun'l: Rem'i'Ll:ed EVELYN R HAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 NOTE: To insure proper credi~c ~o your account, submi'c 'the upper portion of ~his form wi~h your ~:ax payment. CUT ALONG THZS LZNE ~'~ RETAZN LOWER PORTZON FOR YOUR RECORDS '~ REV-1607 EX AFP (01-03) ~## ZNHER'rTANCE TAX STATEMENT OF ACCOUNT ~ ESTATE OF BLOOM EVELYN R F'rLE NO. 21 05-1056 ACN 101 DATE 05-Zq-ZOOq THIS STATEMENT ZS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN ZN THE NAMED ESTATE. SHONN BELON ZSA SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, ZF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: OZ-16-200q PRINCIPAL TAX DUE: ........................................................................................................................................................................................................................... PAYMENTS (TAX CREDITS): 28~.85 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 12-19-2005 Oq-lZ-200q CD005575 CD005806 .00 $.55- 28q.85 5.55 IF PAID AFTER THIS DATE, SEE REVERSE SIDE 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), TOTAL TAX CREDTT 28q.85 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. PAYMENT: Detach the top portion of this Notice and submit with your payment made payable to the name and address printed on the reverse side. -- If RESIDENT DECEDENT make check or money order payable to: REGISTER OF N/LLS, AGENT. -- Zf NON-RESIDENT DECEDENT make check or money order payable to: COMMONNEALTN OF PENNSYLVANIA. REFUND [CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-13[5). ApplicaUons ara available at the Office of the Register of Nil[s, any of the Z3 Revenue District Offices or from the Department's gq-hour answering service for forms ordering: [-800-36g-gOSO; services for taxpayers with special hearing and / or speaking needs: [-80O-qqT-3OgO (TT on[y). REPLY TO: Ouastions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. Z8060[, Harrisburg, PA IT1ZS-060[, phone (7[7) 787-6SOS. DZSCOUNT: If any tax due is paid within three (5) calendar months after the decedent's death, a five percent (SI) discount of the tax paid is allowed. PENALTY: The lex tax amnesty non-participation penalty is computed on the total cf the tax and interest assessed, and not paid before January 18, 1996, the first day after the and of the tax amnesty period. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (i) day from the date of death, to the date of payment. Taxes which became delinquent before January l, 198g bear intsrest at the rate of six (6Z) percent per annum calculated at a daily rata of .00016q. Ali taxes which became delinquent on and after January l, 198g will bear interest at a rata which will vary fram calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through gOOq are: Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year 1982 2OZ .000548 1988-1991 llZ .000301 gOD1 [985 [6g .000q38 1992 9Z .0002q7 ZOOZ 198q llZ .000301 1995-199q 7Z .OO019Z 2003 1985 15Z .000356 1995-1998 9Z .O00Zq7 ZOOq 1986 102 .O00Z7q 1999 7Z .O0019Z 1987 9Z .O00Zq7 ZOO0 8Z .OOOZ19 Interest Daily Rate Factor 9Z .O00Zq7 6Z .00016q 5Z .000137 qg .O00110 --Interest is caZculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DATLy INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional lntersst must be calculated. STATUS REPORT UNDER RULE 6.12 Name of Decedent: Evel_vn R. Date of Death: 12-19-02 Will No. Admin. No. 21-03-1056 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 ~ether 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: account with the Court? Did the personal representative file a final Yes No b. The separate Orphans' Court No. (if any) the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes y No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. Date: 07-20-04 _ for Signature Name (Please type or print) 6 Clouser Road, Mechanicsburg, PA 17055 Address ~17 )766-0209 Tel. No. (MAH: rmf/AM3 ) Capacity: __Personal Representative _~Counsel for personal representative