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Home My WebLink About03-0643 PETITION FOR PROBATE and GRANT OF LETTERS Estate of ' ~k~.~ wc- ~-I-.~a' ~--,-, . ~:¥-.~__~,~ a~J No. 0 3 - 3 also known as To: Register of Wills for the Deceased. County of ~ ~~ in the Social Security No. I ~ ~ ~ ~ ~ ~ Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut in the last wilt of the above decedent, dated ~ ~ ~ O~ and codicil(s) dated (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Ox3_~~~ County, Pennsylvania, with ~ last family, or principal residenc~t ' M :R ~ ~ (list street, number and muncipality) Decendent, then ~ years of age, died ~=~y ]'~ Z~I9. ., Except as follows, decedent did not marry, was not divorce~ and dM not have a child born or adopted after execution of the will offered for probate; was not the victim of a killin~ and was never adjudicated incompetent: ~- ~ [ ~ Decendent at death owned property with estimated values as follows: (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: &[~ ~ ~ ~l ~ ~~ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters ~ ~'~ ~ ~.~ (testamentary; administration e.t.a.; administration d.b.n.c.t.a.) theron. ~ , _ OATH OF' PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA -I COUNTY OF ~ ~~,.~_~,~,.~x> f 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 represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed c ~ ~~ ~~ ~ bef, yre me this 31st day of / / - ' ' ~' dtto, 1st Npu~ Re~ter~ ~ NO. ~ 2i-2003-64~ Estate Of ARDV. Lr,A C. PETERSON , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW August 6th ~9 2003, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated Octob~r ?q~-h: lqq0 described therein be admitted to probate and filed of record as the last will of A~della C. Peterson ; and Letters Te$~nent ary_ are hereby granted to Glenn E. Petarson FEES Probate, Letters, Etc .......... $ 235.00 David P. Perkins 34342 Short Certificates(~) .......... $ 6.00 A'YTORNEY (Sup. Ct. I.D. No.) Renunciation ~.1) ............ $ 5.00 4 Jen~es Circle, Shippensburg, PA 17257 x-Pages (4) $ 12.00 ADDRESS JCP TOTAL_ $ 268.00 Phone # (717) 532-9537 Filed .A.u. gx3..s.t..6.~.h,..2003 ................ PHONE Maile~letters to Attorney on 8-6-03. RENUNCIATION 21-2003-643 (Addtms) 1105805 REX,' 9/86 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 Gr permanent filing. WARNING: It is illegal to duplicate this copy by photosta~ , Fee for this certificate, $2.00 ~/~~ 21-2003-643 H105.;~3 Rev 2/87 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH * VITAL RECORDS ~V,~,...T CERTIFICATE OF DEATH Bt. ACXINK "- Ardella C. Peterson .Female *. 185 -- 03 -- 8780 Cumberland Co. , ~O*.E,~ s. 98 Y~' ] ,.09/15/1904 [?Leesburg, PA I~. ~,~I~..~ ~ Cumberland ~. Shippensburg M. 435 East King Street ,~'~"'~ ,.. White ,,.. Seamstress 11~ Penn Pants Co. ha. I~a. 6 I ,,. Widowed CE~NT'S Pennsylvania ~.~ ~ 435 E. King Street ~s~ ~ ,i. Shippensburg, PA 17257 ~} ,~.~ C~berland ~? ,7~ ~ Shippensburq ,.. Elizabeth McKni~ht ~. Glenn E. Peterson ~. 435 E. Kin~ Street~ Shippensburg, PA 17257 : ~ c,~,$ ~,.$ J~.~,.--, I~,~.~,~.c,~ ~-~.~..~ I I ~ C~berland Valley I C~berland County, ~ ~ ~ ,,b 07/17/2003 J,,*. Memorial Gardens la,~. W. Pennsboro ~p. , PA I~. 012984-L ~ ~]~-~ F.H., ~ ~ 3~, ~~ PA 17257 ' --"- .......... '"'--'- /4 I-'% / d ~mlER ~ ~y ~) ' S~N~U~ ~T~ ~ ~RT~R LAST WILL AND TESTAMENT ~/'O~'~ I, ARDELLA C. PETERSON, of 435 East King Street, Shippensburg, Cumberland County, Pennsylvania, being of sound mind, memory and disposition, do hereby make, publish and declare this my Last Will and Testament, hereby revoking and making void all wills by me at any time heretofore made. FIRST. I order and direct the payment of all my just debts and funeral expenses as soon as may be convenient after my decease. SECOND. I give and bequeath my square china closet to my son, ROSS E. PETERSON, SR. THIRD. I give and bequeath my Tiffany table lamp and my white and green leaded table lamp to my son, GLENN E. PETERSON. FOURTH. I give and bequeath my Lane cedar chest to my son, DANA L. PETERSON. FIFTH. I give and bequeath my brass single bed, my drop leaf table, and all of my personal effects, such as clothing and jewelry, to my daughter, ZELDA M. LLOYD. SIXTH. I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, whatsoever and wheresoever situate, in equal shares, as follows: A. ONE SHARE to ZELDA M. LLOYD. In the event the said Zelda M. Lloyd should predecease me or is not living on the sixtieth (60th) day following my death, I then give, devise and bequeath her share to her issue, on a per stirpes distribution basis; (SEAL) MARK, WEIGLE AND PERKINS - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA. 17257 B. ONE SHARE to GLENN E. PETERSON. In the event the said Glenn E. Peterson should predecease me or is not living on the sixtieth (60th) day following my death, I then give, devise and bequeath his share to his issue, on a per stirpes distribution basis; C. ONE SHARE to DANA L. PETERSON. In the event the said Dana L. Peterson should predecease me or is not living on the sixtieth (60th) day following my death, I then give, devise and bequeath his share to the following named individuals who survive me: ZELDA M. LLOYD, GLENN E. PETERSON and ROSS E. PETERSON, SR.; and D. ONE SHARE to ROSS E. PETERSON, SR. In the event the said Ross E. Peterson, Sr., should predecease me or is not living on the sixtieth (60th) day following my death, I then give, devise and bequeath his share to the following named individuals who survive me: ZELDA M. LLOYD, GLENN E. PETERSON, and DANA L. PETERSON~ on a per stirpes distribution basis. SEVENTH. I nominate, constitute and appoint ZELDA M. LLOYD, GLENN E. PETERSON, DANA L. PETERSON, and ROSS E. PETERSON, SR., to be the Co-Executors of this my Last Will and Testament. EIGHTH. I direct that my personal representatives shall not be required to give bond for the faithful performance of their duties in any jurisdiction. NINTH. I direct my Co-Executors to retain the services of DAVID P. PERKINS, ESQUIRE, with respect to the settlement of my estate due to his familiarity with my affairs. ~Y~'~/~~ ~-~ ~~'-~-/-Z (SEAL) --2-- MARK. WEIGLE ~,ND PERKINS - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257 IN WITNESS WHEREOF, I, ARDELLA C. PETERSON, have hereunto set my hand and seal to this my Last Will and Testament, written on three pages, the first two pages signed for identification only, this 29th day of October, 1990. This instrument was by the Testatrix, ARDELLA C. PETERSON, on the date hereof, signed, published and declared by her to be her Last Will and Testament, in our presence, who at her request and in her presence and in the presence of each other, we believing her to be of sound and disposing mind and memory, have hereunto subscribed our names as witnesses. -3- MARK, WEIGLE AND PERKINS - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSI3URG, PA 17257 COMMONWEALTH OF PENNSYLVANIA : : SS. COUNTY OF CIRtBERLAND : I, ARDELLA C. PETERSON, the Testatrix 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; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me by ARDELLA C. PETERSON, the Testatrix, this 29th day of October, 1990. Notarial Seal David P. Perkins, Notary Public Shippensburg Bo~o, Cumberland County My Commission Expires Oct. 28, 1993 Member, Pennsylvania AssodatJon of Notaries MARK, WEIGLE AND PERKINS ATTORNEYS AT LAW 126 EAST KING STREET - SHIPPENSBLJRG, PA 1 7257 COMMONWEALTH OF PENNSYLVANIA : : SS. COUNTY OF CUMBERLAND : We, .~~~ ~~TL~. and ~ ~ ~ ~~ , the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix, ARDELLA C. PETERSON, sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the will as witnesses; and that to the best of our knowledge the Testatrix was at the time eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. Sworn or aff~r~d to and subscribed before~me and ~~ '~ . ~~/ , witnesses, this 29th day of October, 1990. David R Perkins, Notary Public Shippensburg Boro, Cumberland County My Oommission Expires Oct. 28, 1993 Member, Pennsylvania Association of Not~es MARK, WEIGLE AND PERKINS - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 ~ HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 003051 PERKINS DAVID P ESQUIRE 126 E KING STREET SHIPPENSBURG, PA 17257 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold 101 $8,000.00 ESTATE INFORMATION: SSN: 185-03-8780 FILE NUMBER: 2103-0643 DECEDENT NAME: PETERSON ARDELLA C DATE OF PAYMENT: 09/23/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/12/2003 TOTAL AMOUNT PAID: $8,000.00 REMARKS: GLENN E PETERSON SR C/O DAVID P PERKINS ESQUIRE CHECK# 112 INITIALS: JA SEAL RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS November 20, 2003 Donna M. Otto Deputy Register of Wills MEMO: RE: Estate of PETERSON, ARDELLA C File Number: 2003 - 00643 David P. Perkins, counsel for the decedent, is hospitalized at this time and is unable to complete certification of notice to the beneficiaries. Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717)240-6345 Date: 11/13/2003 PERKINS DAVID P 4 JA2~ES CIRCLE SHIPPENSBURG, PA 17257 RE: Estate of PETERSON ARDELLA C t File Number: 2003-00643 Dear Sir/Madam: It has come to my attention that you have not filed the Certification of Notice Under Rule 5.7 (a) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within ten (10) days after giving proper notice to the beneficiaries and intestate heirs as required by subdivision (a) of Rule 5.7, shall file with the Register of Wills or Clerk of the Orphans' Court his/her Certification of Notice. This filing will become delinquent on 11/16/2003 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, DONNA M. OTTO DEPUTY REGISTER OF WILLS cc: File Personal Representative(s) Judge CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Oate of Oem: ,I ,~ l. I'~ Q 0 0 B Will No. 'aO03 -- O0{_~q B admin. No. = I - ~-- 0 ~q~ To the Register: I ce~fy ~at notice of (~nefiei~ inte~0 ~mte a~Mstration r~uired by Rule 5.6(a) of the ~hans' Cou~ Rules was se~ed on or m~led to the following beneficiaries of the above-captioned estate on N~uZm~ ~ ~ ~O ~: Nme Ad.ess Notice has now been given to all persons entitled thereto under Rule 5.6(a) except ~ ~ m ~ ~3 Z O~ Signature Name ' [_"~ t~..ot J P. Address q ~htp ?=.~_rbcc~ ~ P,q 17~X7 Teleph°ne(ll-/) Capacity: __ Personal Representative X Counsel for personal representative STATUS REPORT UNDER RULE 6.12 - Name of Decedent: Charles C.. Chronister Date of Death: July 11, 2003 Will No.: 21-03-00649 Admin. No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: 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 _XX 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 [-"] c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this relp~~ Date: March 17, 2004 Signature Keith O. Brenneman Name ~ ' .: Mechanicsburg, PA 17055 eq : Address ~ .!5 (717) 697-8528 Capacity: [--] Personal Representative ~ Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDiViDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 003828 PERKINS DAVID P 4 JAMES CIRCLE SHIPPENSBURG, PA 17257 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold ' 101 81,141.31 ESTATE INFORMATION: SSN: 185-03-8780 FILE NUMBER: 2103-0643 DECEDENT NAME: PETERSON ARDELLA C DATE OF PAYMENT: 04/15/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/12/2003 · TOTAL AMOUNT PAID: 81 141.31 REMARKS' :: ~ CHECK# 121 ....... INITIALS: JA ...... SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH 'i:: REGISTER OF WILLS REGISTER OF WILLS ~,,,~o~,~.v,~ INHERITANCE TAX RETURN DEPARTMENT ~ ~NUE ~-.~ RESIDENT DECEDENT 2 ] 03 00643 ~, PA 171~1 COU~ C~E ~R NUMBER DECEDE~S ~ME (~, FIR~, AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER = P~o~ ~dclla C. ] 85-03-8780 DA~ OF D~TH (MM~D-~R) DATE OF BIRTH (MM-DD-~R) ~IS ~ MUST BE RLED IN DUP~TE ~ ~E 07/]2/2003 09/15/]904 REGISTER OF WILLS IF APPLICABLE) SURVIVING SPOUSE'S ~ME ( ~ST, FIRST AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER ~ 1. Original R~m ~ 2. Supple~n~l Return D 3. R~ Ream (d~e ~ d~ ~ to 12-1~2) D 4. Lim~Esmte D 4a. F~*lm--tCom~(date~d--~12_12~2) ~ 5. F~emIE--T~R~um n 6. ~ent Di~ T~ (A~ ~ D 7. ~e~ ~i~in~ a Living Trust (A~ 8. T~I Numar ~ Sa~ ~s~ ~x~ ~ ~) ~ ~ TraM) ~ 9. L~gafionP~sR~iv~ ~ 10. S~u~lPove~C~R(~tedd~n ~ 11.El~onto~un~r~.9113(A)(A~O) 12~1-91 ~ 1-1-95) ~ ~ ~T ~ C~. ~ ~E ~ ~T~ ~~ ~ ~ ~ TO: ~ME COMPLE~ MAILING ADDRE~ David P. Per~ :IRM ~ME (ff ~i~) David P. Pcr~s, AEomcy at Law 4 J~cs C~clc Shippcnsb~g, PA ]7257-2]65 *ELEPHONE NUMBER 717/658-6531 1. Real Estate (Schedule A) (1) 62,000.00 2. Sto~s and Bonds (Schedule B) (2) None 3. Closely Held Co~oration, Pa~nemhip or Sol~Proprietomhip (3) Non~ 4. Moagages & Notes R~ivable (S~edule D) (4) Non~T ' 5. Cash, Bank ~si~ & Mis~llan~us Pemonal Pro~ (5) 188,987.5 (Schedule E) .., 6. Jointly ~n~ P~ (Schedule F) (6) None ~ Separate Billing R~uested 7. Inter-~wos Tmnsfem & Mis~llaneous Non-Probate Pm~ (7) None (Sch~u~ G or L) ,.. 8. T~ ~s ~ (~o~a~ Un~s ~-7) -~ 9. Funeral E~n~s & Administmt~e Cos~ (S~ule H) (9) ~ ~, 801.0 ~ 10. ~b~ of ~ent, Mo~age Liabil~s, & L~ns (S~u~ I) (10) 2,6 ~ 9.4 ~ 11. T~I ~uctions (total Lines 9 & 10) (11) 3 8,4 90.51 12. Net Value ~ Es~ (Line 8 minus Line 11) (12) 212,496.99 13. Cha~ble and Governmental ~ues~/Sec 9113 Trusts for ~ich an ele~ion to tax has not ~n (13) made (Sch~u~ J) 14. Net Val~ Subje~ to T~ (Line 12 minus Line 13) (14) 2 12,496.99 SEE INS~UCTIONS ON REVERSE SIDE FOR APPMC~LE 15.Amount of Line 14 t~able at the s~usal t~ rate, x .~ (15) or transom under Sec. 9116(a)(1.2) 16. Amount of Line 14 t~able at Ii,al ~te 212,496.99 x .045 (16) 9,562.36 17. Amount of Line 14 t~ab~ at sibling rote x .12 (1~ 18. ~ount of Line 14 ~able at ~llateral rate x .1~ (18) 19. Tax Due (19) 9,562.36 ~0. D 20~ ~ s~m on~ T~ ~ck~r Group, Inc. Fo~ REV-I~0 ~ (Rev. 6~) Decedent's Complete Address: ISTREET ADDRESS 435 East King Street CITY Shippensburg STATE PA Zn' 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 9,562.36 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 8,000.00 C. Discount 421.05 Total Credits (A +B+C) (2) 8,421.05 3. Interest/Penalty if applicable D. Interest 0.00 E. Penalty Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line I + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page I Line 20 to request a refund 5. If Line l + Line 3 is greater than Line 2, enter the differenca. This is the TAX DUE. (5) 1,141.31 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 1,14 !.31 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 cons derat on? ....................................................................................................................... [] [] 3. Did decedent own an "in trust for" or payable upon death bank account or secudty at his or her death? ......... [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designat on? ...................................................................................................................... [] [] 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 pequry, 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 infom,,at~on of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE ~~ ,~. Shippensburg, PA 17257 DA S ..,~. RE ~F PERSON RESPONSIBLE FOR FILING RETURN ADDRESS c- S~G~ ~ ~ OF PREP^RER OT~ER T~N RE~R~SENTA¥~¥E ADDRESS DATE ~ David P. Perkins 4 James Circle Shippensburg, PA 17257-2165 For dates of death on or after July 1, 1994 and before danuary 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 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. ,~ SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF FILE NUMBER Peterson, Ardella C. 21 - 03 - 00643 All rea! prope _fly owned solely or as a tenant in comm. on must.be ~ported at fair ma.rket value. Fair ma .rket value is defined as the price at which propert~ would be exchanged between a willing buyer ano a wimng seller, neither oeing compelled to ouy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE OF NUMBER DESCRIPTION DEATH 1 435 East King Street, Borough of Shippensburg, Cumberland County, Pennsylvania 62,000.00 TOTAL (Also enter on Line 1, Recapitulation) 62,000.00 SCHEDULE E ! CASH, BANK DEPOSITS, & MISC. ~,~,,~, o, ~,,,~.v,,~ PERSONAL PROPERTY INHER~TANCE TAX RETURN 1~810~qT DECEDENT ESTATE OF FILE NUMBER Pete~o~ ~della C. 21 - 03 - 00~3 In~uda tha ~m~ods of litiOat~n and th~ ~ate thR pro~e~s w~ro re~iv~ by tho estate. All pm~ ]ointl~wn~ ~th tha fight of au~ivomhlp muat ~ dlaal~d on aona~ula ~. ITEM VALOE AT DATE OF NOMBER DESCRIPTION D~TH ~to~ B~ Chec~g Accost No. 57~96 - p~cipal ~d accrued ~terest 14,677.71 1 ~sto~ B~ Ce~ficate of De,sit Accost No. 4000001223 - p~cipal ~d accrued hterest 45,403.49 2 ~to~ B~ Ce~ificate of Deposit Accost No. 5020059751 - p~cipal ~d accrued ~terest 11,599.30 3 ~to~ B~ CeRificate of Deposit Accost No. 502061714 - p~cipal ~d accrued ~terest 8,002.68 4 ~to~ B~ Cenificme of Deposit Accost No. 5020065432- p~cipal ~d ac~ed ~terest 17,528.57 5 ~to~ B~ CeRificate of Deposit Accost No. 5020070711- p~cipal ~d accrued ~terest ~,456.82 6 ~ B~ CeRificate of Deposit Accost No. 5020070712 - p~cipal ~d acc~ed ~terest 47,023.19 7 Blue Cross~lue Shield - premi~ re~d 295.74 TOTAL (Also enter on Line 5, Recapitulation) 188,987.50 COMMONWE/U.~I OF PENNSYLVANIA INHERITANCE TAX RETURN A~t~aII~TNE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Ardella C. 21 - 03 - 00643 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Fogelsanger Bricker Funeral Home 6,600.00 B. ADMINISTRATIVE COSTS: 12,549.38 1. Personal Representative's Commissions Glenn E. Peterson tr r of Personal Representative(s): eet City Shippensburg State PA Zip 17257 Year(s) Commission paid 2004 2. Attomey's Fees David P. Perkins, Esquire 12,549.38 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 3,500.00 Claimant Glenn E. Peterson Street Address 435 East King Street City Shippensburg State PA Zip 17257 Relationship of Claimant to Decedent son 4. Probate Fees Register of Wills-petition for probate, renunciation and short certificate 268.00 Register of Wills-short certificate- 9/23/2003 6.00 Register of Wills- inh tax, inventory, release 58.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 Sallhamer Real Estate, Inc.- real estate valuation 100.00 2 The Sentinel ~ advertising letters 95.27 Total of Continuation Schedule(s) 75.00 TOTAL (Also enter on line 9, Recapitulation) 35,801.03 INHERITANCE T~ RE~RN ~ ~ ~ RESIDE~ DECEDE~ ESTATE OF FILE NUMBER Pete~on, ~della C. 21 03 - 00~3 3 C~berl~d Law Jo~l - adve~is~g le~e~ 75.00 Page 2 of Schedule H SCHEDULE I DEBTS OF DECEDENT, MORTGAGE co..~..o.~.~v~.. LIABILITIES, & LIENS INHERITANCE TAX RET~I~N ESTATE OF FILE ~UMBER Petemon, ~della C. 21 - 03 - 00~3 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT ] Beverly Enterpises, lnc-medical expense 3 8. ! 5 2 Lisa Helm, Tax Collector- 2003-2004 School real estate taxes 602.77 3 Nationwide Mutual Homeowners Insurance Co. - homeowners insurance 308.00 4 Baxter Drew Wellman, MD - medical expense 47.18 5 West Shore EMS - paramedic medical expense 534.38 6 Cumberland County Recorder of Deeds - deed recdording fee 42.00 7 Eby Granite Works- grave marker 1,117.00 TOTAL (Also enter on Line 10, Recapitulation) 2,689.48 REV-I$1$ EX+ (9-00) dlL.,..,~ "' ~ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES ,.HmT^.CE T*X RESIDENT DECEDENT ESTATE OF 'FILE NUMBER Pctcrson, Ardclla C. 21 - 03 - 00643 RELATIONSHIP TO AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPER'FY DECEDENT OF ESTATE I~) N~t U~t Tru~tll~.s.~ Io TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 Dana L. Peterson son onc-£ourth 4 Koscr Road Shippensburg, PA 17257 2 Glenn E. Peterson son one fourth 435 East King Street Shippensburg, PA 17257 3 Ross E. Peterson, Sr. son one fourth 11757 Lower Horse Valley Road Upper Strasburg, PA 17265 4 Zelda M. Lloyd daughter one fourth 123 Marco Circle Shippensburg, PA 17257 Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II. 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 II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Register of Wills of Cumberland County, Pennsylvania INVENTORY' Estate of Peterson, Ardella C. No. 21 - 03 - 00643 also known as Date of Death 7/12/2003 , Deceased Social Security No. 185-03-8780 Glenn E. Peterson The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/VVe verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unswom falsification to authorities. Personal Representative Attorney: David P. Perkins Signature: ~ ~1. /0z~__~,~n~ Gl~n~ E. Peterson I.D. No.: 34342 Signature: Signature: ;"~" Address: 4 James Circle Address: 435 East King S~ct Shippensburg, PA 17257-2165 Shippensburg, PA 17257 Telephone: 717/658-6531 Telephone: 717 532-5167 --~ ~ . Dated: Personal Property Orrstown Bank Checking Account No. 570496 - principal and accrued interest 14,677.71 Orrstown Bank Certificate of Deposit Account No. 4000001223 - principal and accrued 45,403.49 interest Orrstown Bank Certificate of Deposit Account No. 5020059751 - principal and accrued 11,599.30 interest Orrstown Bank Certificate of Deposit Account No. 502061714 - principal and accrued interest 8,002.68 Orrstown Bank Certificate of Deposit Account No. 5020065432- principal and accrued 17,528.57 interest Orrstown Bank Certificate of Deposit Account No. 5020070711- principal and accrued 44,456.82 interest Orrstown Bank Certificate of Deposit Account No. 5020070712 - principal and accrued 47,023.19 interest (Attach additional sheets if necessary) Total Personal Property and Real Estate $250,987.50 Register of Wills of Cumberland County, Pennsylvania INVENTORY continued Estate of Peterson, Ardella C. No. 21 - 03 - 00643 also known as Date of Death 7/12/2003 , Deceased Social Security No. 185-03-8780 Blue Cross/Blue Shield - premium refund 295.74 Total Personal Property $188,987.50 2 . ' Register of Wills of Cumberland County, Pennsylvania INVENTORY continued Estate of Pctcrson, Ardcl]a C. No. 2] - 03 - 00645 also known as Date of Death ?/12/2003 , Deceased Social Secudty No. ] 85-03-8?80 Real Estate 435 ]~ast King Street, Borough of Sbippcnsburg, Cumberland Coumy, Pcrmsylv~ia 62,000.00 Total Real Estate $62,000.00 COMNONNEALTH OF PENNSYLVANIA .~)~,, BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE /NHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHER/TANCE TAX APPRAISEMENT, ALLONANCE OR DISALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-IS47EXAFP[B1-05) :. DATE 05-31-200q ESTATE OF PETERSON ARDELLA C DATE OF DEATH 07-12-2003 FILE NUHBER 21 03-06q3 DAVID P PERKINS ATTY '0~ l, ll~ ~ ~y CUMBERLAND ACN 101 q JAMES CIR I Amount Remitted L SHIPPENSBURG PA 17257 ~ HAKE CHECK PAYABLE AND REHZT PAYHENT TO: REGISTER OF MILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE I~ RETA/N LONER PORTION FOR YOUR RECORDS ~ REV-15~7 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLONANCE OR DZSALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF PETERSON ARDELLA C FILE NO. 21 03-06q3 ACN 101 DATE 05-31-200~ TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) 62~000.00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) .00 cred/t to your account, $. Closely Held Stock/Partnership Interest (Schedule C) ($) .00 submit the upper portion ~. Hortgagas/Notes Receivable (Schedule D) (~) .00 of ~his form wi~h your S. Cash/Bank Deposits/Misc. Personal Propar~y (Schedule E) (5) 188~987.50 ~ax payment. 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedula G) (7) .00 8. Total Assats (8) 250,987.50 APPROVED DEDUCTIONS AND EXEHPTZONS: 35,801.05 9. Funeral Expenses/Adm. Cos~s/Nisc. Expansas (Schedule H) (9) 10. Dabts/Nortgage Liabilities/Liens (Schedule I) (10) Z~689.~8 11. Total Deductions (11) ~B.GgO.5! 12. Na~ Value of Tax Return (12) Z12,~96.99 15. Charitable~Governmental Bequests; Non-alactad 9113 Trusts (Schedule J) (13) .00 1~. Nat Valua of Estate Subject to Tax (1~) Z12,q96.99 NOTE: Z~ an assessment was issued previously, lines 1~, 15 and/or 16, 17, 18 and 19 wlll re~lect ~igures that lnclude the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 1~ at Spousal ra~a (15) .00 X O0 = .00 16. Amount of Line 1~ taxable a* Lineal/Class A rata (163 212,~96.99 X 0~5 = 9,562.36 17. Amount of LAne 1~ at Sibling ra~a (17) .00 x 12 = .00 18. Amount of Line 1~ *axable at Collateral/Class B rata (18) .00 X 15 = .00 19. Principal Tax Due (19)= 9,562.36 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 09-23-Z003 CD003051 q21.05 8,000.00 Oq-15-ZOOq CD003828 .00 1,1q1.$1 TOTAL TAX CREDIT [ 9,562.36 BALANCE OF TAX DUEl .00 ]:NTEREST AND PEN. .38 TOTAL DUE . :58 ]:F PA/D AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE TS LESS THAN $1, NO PAYMENT IS REI~U/RED. FOR CALCULATION OF ADDTTIONAL /NTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR)~ YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) RESERVATION: Estates of decadents dying on or before December 12) 1982 -- if any future 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 lawful Class B (collateral) rate on any such future interest. PURPOSE OF NOT[CE: To fulfilt the requirements of Section 1140 of the Inheritance and Estate Tax Act) Act 15 of ZOO0. (71 P.S. Section 9140). PAYHENT: 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: RESISTER OF NZLLS, 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-ISIS). Applications ara available at the Office of the Register of Hills, any of the Z5 Revenue District Offices, or by calling the special 2~-hour answering service for forms ordering: 1-800-561-1050~ services for taxpayers aith special hearing and / or speaking needs: 1-80O-~4?-SOZO [TT only). OBJECTIONS: Any party in interest not satisfied aith the appraisement, allowance, or disalloaance of deductions) or assessment of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 181011, Harrisburg, PA 17128-1011, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS: Factual errors discovered on this assessment should be addressed in ariting to: PA Department of Revenue) Bureau of Individual Taxes, ATTH: Post Assessment Revise Unit, Dept. Z80601, Harrisburg, PA 17118-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-IS01) for an explanation of administratively correctabIe errors. DISCOUNT: If any tax due is paid within three (S) calendar months after the decadent's death, a five percent (51) discount of the tax paid is allowod. PENALTY: The 151 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in tho the same tiaa period as you would appeal the tax and interest that has been assessed as indicated on this notice. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the data of death, to the date of payment. Taxes which be:aaa delinquent before January 1, 1981 bear interest at the rate of six (61) percent per annum calculated at a daily rata of .000164. All taxes which became delinquent on and after January 1, 1981 will bear interest at a rate 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 Z004 ara: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rote Factor ~ ZOZ .0005~8 1988-1991 III .DOOSO1 ~ 9X .000247 1983 16Z .000438 1992 91 .0002~7 2002 6Z .000164 1984 111 .000301 1995-1994 7Z .000192 2003 51 .000137 1985 I3Z .000356 1995-1998 9Z .000247 2004 4Z .000110 1986 IOZ .O0027~ 1999 7Z .O00IgZ 1987 lOZ .000Z74 ZOO0 71 .000192 --[nterast is calculated as folloas: /NTEREST = BALANCE OF TAX UNPA/D X NUNBER OF DAYS DEL/NQUENT X DAXLY /NTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (IS) days beyond the date of the assessment. If payment is made after the interest computation date sheen on the Notice, additional interest must be calculated. COMMO.WEA'THO. PE.NSYLVA"'A INHERITANCE TAX RETURN FILE"UMBER DEPARTMENT OF REVENUE 21 03 00643 DE..~o, RESIDENT DECEDENT HARRISBURG, PA 17128-0~01 COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Peterson, Ardella C. 18 5 - 03 - 8 7 8 0 mz DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE "q 07/12/2003 09/15/1904 REGISTER OF WILLS C3 IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER [] 1. Original Return [] 2. Supplemental Return [] 3. Remainder Return (date of death priorto 12-13-82) uJ Future Interest Compromise (date of death '~ u~ [] 4. Limited Estate [] 4a. after 12-12-82) [] 5. Federal Estate Tax Return Required ~-oo tv ~ [] 6. Decedent Died Testate (Attach copy [] 7. Decedent Maintained a Living Trust (Attach 8. Total Number of Safe Deposit Boxes ~o a. ~ of Will) copy of Trust) -- < [] 9. Litigation Proceeds Received [] 10. Spousal Poverty Credit (date of death belween [] 11.Election to tax under Sec. 9113(A) (Attach Sch O) 12-31-91 and 1-1-95) ~IAME COMPLETE MAILING ADDRESS David P. Perkins i FIRM NAME (If applicable) David P. Perkins, Attorney at Law 4 James Circle Shippensburg, PA 17257-2165 tELEPHONE NUMBER 717/658-6531 1. Real Estate (Schedule A) (1) None 2. Stocks and Bonds (Schedule B) (2) None 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) None 4. Mortgages & Notes Receivable (Schedule D) (4) None 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 16,545.55 ' -n ~ ,_ --ri (Schedule E) 6. Jointly Owned Property (Schedule F) (6) None :~'"~ ~ [] Separate Billing Requested :r-,- e.,O-T~ .~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) None = (Schedule G or L) I- · . 8. Total Gross Assets (total Lines 1-7) (8) 16,545.55 < ,9, 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) (11) 12. Net Value of Estate (Line 8 minus Line 11) (12) ! 6,545.55 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not (13) been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 16,545.55 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, x o00 (15) or transfers under Sec. 9116(a)(1.2) z 16,545.55 .045 (16) 744.55 _(2 16. Amount of Line 14 taxable at lineal rate x ~= 17. Amount of Line 14 taxable at sibling rate x .12 (17) O ~ 18. Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) 744.55 Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: J STREET ADDRESS 435 East King Street ICITY Shippensburg STATE ZIP PA 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 744.55 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. InterestJPenalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page '1 Line 20 to request a refund 5. If Line1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 744.55 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 744,5:~ 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 rece v ng adequate cons derat on? ................................................................................................................ [] [] 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 benefic ary des gnat on? 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 thai I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS Glenn E. Peterson, Sr. DATE 16 West Green Street /g~ .d~ /O~~,e_ Shiremanstown, eA 17011 David P. Perkins ATE 4 James Circle Shippensburg, PA 17257-2165 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 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. SCHEDULE E CASH. BANK DEPOSITS, & MISC. ooMMo,wEA.., o, ,E,,sY.w.l~ P E RS O N A L PRO P E RTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Ardella C. 21 - 03 - 00643 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 Certificate of Deposit Account No. 4000000714 - principal and accrued interest 16,503.19 Orrstown Bank P. O. Box 250 Shippensburg, PA 17257 2 Beverly Enterprises- medical expense refund 38.15 3 Adams Electric Cooperative - member dividend 4.21 TOTAL (Also enter on Line 5, Recapitulation) 16,545.55 REV-1513 EX+ (9-00) .~ ,~ ],, ' SCHEDULE J coMMo.w~.m oF PE..s¥.v^.,^ BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Peterson, Ardella C. 21 - 03 - 00643 RELATIONSHIP TO AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE Do Not Mst Trusteeis) [o TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 Dana L. Peterson son one fourth 4 Koser Road Shippensburg, PA 17257 2 Glenn E. Peterson son one fourth 16 West Green Street Shiremanstown, PA 17011 3 Ross E. Peterson son one fourth I 1757 Lower Horse Valley Road Upper Strasburg, PA 17265 4 Zelda M. Lloyd daughter one fourth 123 Marco Circle Shippensburg, PA 17257 Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover she( t II. 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 II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER sHEET COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE REV~1162 EX(11-96) BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004741 PETERSON GLENN E 435 EAST KING STREET SHIPPENSBURG, PA 17257 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold 101 $744.55 ESTATE INFORMATION: SSN: 185-03-8780 FILE NUMBER: 2103-0643 DECEDENT NAME: PETERSON ARDELLA C DATE OF PAYMENT: 12/15/2004 POSTMARK DATE: 12/15/2004 COUNTY: CUMBERLAND DATF OF DEATH' 07/12/2003 TOTAL AMOUNT PAID' $744.55 REMARKS: CHECK# 139 INITIALS: CCP SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE 8UREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(1 1-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT PERKINS DAVID P 4 JAMES CIRCLE SHIPPENSBURG, PA 17257 - fold ESTATE INFORMATION: SSN: 185-03-8780 FILE NUMBER: 2103-0643 DECEDENT NAME: PETERSON ARDELLA C DATE OF PAYMENT: 03/02/2005 POSTMARK DATE: 03/02/2005 COUNTY: CUMBERLAND DATE OF DEATH: 07/12/2003 NO. CD 005010 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $29.13 I I I I I I I I TOTAL AMOUNT PAID: $29.13 REMARKS: CHECK# 257 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS x ;I> " ... 00'" 0 >c:m "'3:0) % ,..."'.... ... ...."'''' 0 "''''.... " ,...,...m "U I "'>'" - :z: ;I> I t:lQ < I "'II -n ;I> 'N I J>O lit I r- , Q Ol: . .... ... ..f) ....0 ,... ...,Q ,... ;I> . coc: '" Z ....'" tJ "'.... '" LJ :<: ... Q X c: ... '" .... m ... ;I> < X ... Z .... .... Cl .. ",...t:l :<: J> ....<-< "'II>.... "'113:t:l "'''' :Z:"'"'II '" "'0"'11 c:....m "''''''' 0) "" .... :z: '" J> :j <'.J "'II J> .... ..., N U1 ..., , , ;I> 0 "II",...tJ 00..;1>0;1> ZCr-............ Z......J>... .... .... <ZO... C"II itJ~ ...... ",;I> .... % =- a ....ONc""OCI 5 Q~""'-...Im~ ........a:tICI.!..;;N "'(,o&N;:O..... ;:tJ I I en I r-ONON ;::'O\C>>ZQ Z...O 0 OUolt.\! U1 if s ... ... ... l x-a... QI pOZc: ~tlJi'i ::0 "'Olllll'l'l ~)(~ ~ C::NP c: i!'I~l!io 'O~m .,., po....;! 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II '-' L 1II " . ~ .elll.l:.f .!~:5,,", .~~ l......lDlU o U It C 0 c.... 0'" 0 lU 01.... 1= c:. coo _muu ~. ~ '0 ~ . 1fl.~:5l1Q ~ C . C III .. \II . .. 1:11..1...... II 0 III U U . 1II C "'.... '0 0 , ~"~ \to III 0 .J: o III .... ta . ~ . . " GI III 0 GII 1ij&G1:S ~ ~ III c....... \I.l.......m ~ M l< ~ "' ~ il! COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE '* :'~j :'~':'''''';'.-''' :---',: ....,:'n-r-. NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX REY-1547 EX AFP 112-141 BUREAU OF INDIVIDUAL.:rAxESu. INHERITANCE TAX DIVISION. -- PO BOX Z806Dl HARRISBURG PA 171Z8-0601 r.., DAVID PPERKINS ATTY 4 JAMES CIR SHIPPENSBURG PA 17257 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 02-21-2005 PETERSON 07-12-2003 21 03-0643 CUMBERLAND 101 ARDELLA C Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ R1V :1!\"'.i;c-.AFp..C~1.:6J')..NOT.icE.'bF.iNHER.ITlil'ce:.TA;c-A.P"RA.isEii€N'~..ALtOWANCE.OR.............. ... DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF PETERSON ARDELLA C FILE NO. 21 03-0643 ACN 101 DATE 02-21-2005 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Stock/Partnership Interest (Schedule C) (3) 4. tIortgagas/Notes Receivable (Schedule D) (4) 5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets NO. 01 .00 .00 .00 .00 16,545.55 .00 .00 (8) NOTE: To insure proper credit to your account, submit the upper portion of this fOri! with your tax paYllent. 16,545.55 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) (9) 10. Debts/Hortgaga Liabilities/Liens (Schedule I) (10) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllenta1 Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax .00 .00 (11) (12) (13) (14) 00 16,545.55 .00 229,042.54 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: 1S. AIIount of Line 14 at Spousal rate (lS) 16. AlIOunt of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due NOTE: .00 229,042.54 .00 .00 X 00 = X 045 = X 12 = X 15 = (19)= .00 10,306.91 .00 .00 10.306.91 TAX CREDITS: ............ l1'J AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) 09-23-2003 , CD003051 421.05 8,000.00 04-15-2004 CD003828 .00 1.141.31 12-15-2004 ......... CD004741 .00 744.55 BALANCE OF UNPAID INTEREST/PENALTY AS OF 12-16-2004 TOTAL TAX CREDIT 10,306.91 BALANCE OF TAX DUE .00 INTEREST AND PEN. 20.60 TOTAL DUE 20.60 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) . ~.... BUREAU OF INDIVIDUAL1'AXt:!S -- INHERITANCE TAX DIVISION - - - PO BOX Z80601 HARRISBURG PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT '* REV-1607 EX AFP (03-05) : :33 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04-04-2005 PETERSON 07-12-2003 21 03-0643 CUMBERLAND 101 ARDELLA C DAVID P PERKINS ATTY 4 JAMES CIR SHIPPENSBURG PA 17257 Allount Relli tted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 NOTE: To insure proper credit to your account. subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ................................................................................................................ REV-1607 EX AFP (03-05) ~~~ INHERITANCE TAX STATEMENT OF ACCOUNT ... ESTATE OF PETERSON ARDELLA C FILE NO.21 03-0643 ACN 101 DATE 04-04-2005 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE. APPLICATION OF ALL PAYMENTS. THE CURRENT BALANCE. AND. IF APPLICABLE. A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 02-21-2005 PRINCIPAL TAX DUE: 10.306.91 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 09-23-2003 CD003051 421.05 8.000.00 04-15-2004 CD003828 .00 1.141.31 12-15-2004 CD004741 .00 744.55 03-02-2005 CD005010 20.60- 29.13 TOTAL TAX CREDIT 10.315.44 BALANCE OF TAX DUE 8.53CR INTEREST AND PEN. .00 IF PAID AFTER THIS DATE. SEE REVERSE TOTAL DUE 8.53CR . 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" (CRJ. YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J _c~ - " {, . Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name of Decedent: Ardella C. Peterson Date of Death: July 12, 2003 E N 2003 -00643 state 0.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes ~ No 0 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. I is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No I!l 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 III No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: April 25, 2005 ~~O~C~ Signature David Patrick Perkins Name 4hJames Circle S ~ppensburg, PA 17257-2165 Address ,..--- , C-.. (717) 532--6629 Telephone No. Capacity: o Personal Representative I!l Counsel for personal representative o