HomeMy WebLinkAbout03-0799JERRY R. DUFFIE
RICHARD XV STEWART
C, ROY WEIDNER, JR.
EDMUND G. MYERS
DAVID W. DELUCE
RALPH H. WRIGHT, JR.
DAVID J. LANZA
MARK C, DUFFIE
MELISSA PEEL GREEVY
MICHAEL J. CASSIDY
ROBERT M. WALKER
LAW OFFICES
JOHNSON, DUFFLE, STEWART & WEIDNER
A Professional Corporation
301 MARKET STREET
P. O. BOX 109
LEMOYNE, PENNSYLVANIA 17043-0109
WEBSITE: www.jdsw, com
TELEPHONE 717-761-4540
FACSIMILE 717-761-3015
E-MAIL mailOjdsw, com
HORACE A. JOHNSON
COUNSEL TO THE FIRM
WRITER'S EXT. NO. 114
E-MAIL dlw@jdsw.com
October 1, 2003
Register of Wills Office
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Re~
Estate of Paul D. Campbell
SSN: 180-01-5883
Date of Death: September 9, 2003
Dear Register:
Enclosed for filing please find the Estate Information Sheet. The above referenced Estate
was probated on September 30, 2003 by Hank Johnson. This form is to be included with those
probate documents. Should you have any questions, please do not hesitate to contact our office.
Thank you for you assistance in this matter.
Very truly yours,
#219088
JOHNSON, DUFFIE, STEWART & WEIDNER
Legal Assistant
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of Paul D. Campbell
also known as To:
.Deceased.
Social Security No. 180-01-5883'
No. o -
Register of Wills for the
County'of Ch~mbo_rla r),d
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 rix
in the last wilt of the above decedent, dated J'~mmry 19
and codicil(s) dated
in the
named
, l~r 2000
h
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in O~mhorl and County, Pennsylvania, with
last family or principal residence at 514 Susan Roadr East Penn.~boro
(list street, number and muncipality)
Decendent, then 86 years of age, died September 9
at ~rod~r~ cksburg, V-A ·
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(If domiciled i.n Pa.) All personal property · $
(If not domiciled in Pa.)' "Peisonal 'lSt~I~¢rty in Pennsylvania $
(If not domiciled in Pa.) personal prope, rty in County $
Value of real estate in Pennsylvania $
situated as folloWs: 514 Susan Rcxad.. Camp Hill. Pennsylvania
(Eas~ Pennsboro Township)
200rOOO
135,000
WHEREFORE, petitioner(s) respectfully
pre~ented herewith and the,grant of letters
theron.
request(s) the probate of the last will and codicil(s)
testamentary
(testamentary; administration c.t,a.; administration d.b.n.c.t.a.)
I Juc~t-h Tlono Brov~k
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNS3~LVANIA ~
COUNTY OF (l~~/)~ aY,,., j 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 kfiowledge and belief of petitioner(s) and that as person~ represen-
tative(s) of the above decedent petitioner(s) wi~ ~1 and truly administer the estate according to law.
/I .~,~
Sworn to or ~firmed and subscribed ~-~'~~ ~~
be~m~this c~O ~ day of ~ I- ___~_ ~
,,2 l- 03-' qq
DECREE OF PROBATE AND GRANT OF LETTERS
,Deceased
AND NOW
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated ] ~
.xle~ibed therein be ad~mitted to probate and filed of record as the last will of
and Letters ~_t~u- c~_e~,,~ ~Clk,u ~..
are hereby granted to ~.~. ,_-~ .~ ~
, in consideration of the petition on
FEES
Probate, Letters, Etc .......... $~C)~ CD&
Short Certificates( ) ..........
~ $/o. oo
TOTAL . $ ~Sq. o o
Filed .... ~..0. 7. '~' .'-..0....._~. .................
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
OPY A
FOR DIVISION OF
VITAL RECORDS
DEPARTMENT OF HEALTH - DIVISION OF VITAL RECORDS - RICHMOND
DECEDENT
t. FULL NAME (first)
OF DECEDENT
Paul
3.DEATH DATE OF (mo.) (day) (year) 4. AGE
September 9, 2003 86
PLACE OF 7. NAME OF HOSPITAL OR INSTITUTION OF DEATH (~ m3ne, so state)
DEATH
Hughes Home, Inc.
9. C;TY OR TOWN OF DEATH
Fredericksburq
PERSONAL
DECEDENT
CAUSE oP
PHYSI~AN:
c~ies m ~ner~
(middle) (last) 2. SEX male female
D Campbell ~ []
__ 6 WAS DECEDENT
IF UNDER 1 YEAR ! IF UNDER 1 DAY { 5. DATE OF (mo.)(day)(year)EVER IN U.S.yes no
, -~'- 7 - -~r~- -F -~ur,- T -~rn~e~ -1 B,RTH ARMED ~ORCES?:I~
y ....... July 17:1917 []
mill DCA[] EmerOUt[]Pat'Rm Inpatient[:~ 8. COUNTY OF DEATH (if independent c~ty, leave blank)
ins~dese city or town Ii,cite? 10. STREET ADDRESS OR RT. NO. OF PLACE OF DEATH
[] [] 100 Caroline Street
RESIDENcEUSUAL tl. STATE (OR FOREIGN COUNTRY) OF DECEDENT'S RESIDENCE 12. COUNTY OF DECEDENT'S RESIDENCE (if independent city, leave blank)
OF DECEDENT Pennsy 1 vania Cumber 1 and
13. CITY OR TOWN OF RESIDENCE inside city or town timits? ] 14. STREET ADDRESS OR RT. NO. OF REStDENCE I ZIP CODE
Yes f~] 514 SUSan Road '
Camp Hill [] :17011
15. NAME OF DECEDENT'S FATHER 16. MALDEN NAME OF DECEDENT'S MOTHER
James A. Campbell Clara Stipe
17. RACE OF DECEDENT 18. OF HISPANIC ORIGIN? It yes, sp~city Cuban, Mexican, 19. EDUCATION (Specify only highest grade completad)
Caucasian P...o R .....tO. ~ no [] Yes Elemer~a~/Seconda~ (~,2) 12 CO,,~. (,-~ or s +)
20. CITIZEN OF WHAT COUNTRY 21. BIRTHPLACE (state or country) 22. NEVER MARRIED r--I DIVORCED r-~ 23. IF MARRIED OR WIDOWED, NAME OF SPOUSE
I--.J [--J (if divoeced leave blank)
USA Pennsylvania MARR,ED [] W,DOWED:I~: Ellen Campbell
24. SOCIAL SECURITY NUMBER 2~.~ LA(;,,~..i.~CUPATION 26. KIND OF BUSINESS OR iNDUSTRY 27. iNFORMANT-OR SOURCE OF INFORMATION
180-01-5883 Su~-rvisor U.S. Government Family
28. PART I. Enter the diseases, injuries, or complications that caused the dealh. Do n~ enler the mode of dying, such.as cardiac or respiratory arrest, shock, or head feilu~e.
List o~ly one cause of~ each line.
'MED,.TE C.USE,F,.St di .....
condition resulting in death) ~, (Al _
DUE TO (OR AS A CONSEQUENCE OF):
SequantiaUy list conditions, if any, leading
to immediate cause. Ent~ UNDERLYING
CAUSE (Disease o~ injury that initiated
evants resulting in death) lAST
(Bi
DUE TO (OR AS A CONSEQUENCE OF):
{ct
INI~RVAL BETWEEN
ONSET AND DEA~-I
PART II. Other significant cor~ditions contributing to death but not resulting in the underlying cause given in Pa~t I.
28a. AUTOPSY? yes rio
AUTHORIZED BY: [] ~
NOTE: if
"Pending ' must
be indicated, so
state in per~ 1
and notify
FUNERAL
28b. IF FEMALE, WAS THERE A PREGNANCY 128C. IF EXTERNAL CAUSE, IT WAS 128d. DESCR BE HOW INJURY RELATING TO DEATH OCCURRED
IN PAST 3 MONTHS? I PRIMARY 0 O~ CONTRIBUTING E] I
,.o nod un,no..O I ~ ....... I
28e. TIME OF INJURY (mo.) (day)(year) 128f. INJURY OCCURRED 128g. PLACE OF INJURY (home. farm, 128h. (city or town)(counh') (statet
/'; I I ~,ory, .~ om~. ~;dg., ate.) ; .....
"To,h..,ofm~no~'~tho~r~ot i~'//~P.M (am,(pm,onthedateand.ptaceand~.~ ,hecauso(s, atated
IS~NATURE · ', '
, ........ -
,~E OF A'.'E.D~ P.¥B,C,A. ,'r,.p. ,..,',*,,, / - - ........ i~D'-.~s~ ~ ~'-.~,.G'-.~Y'~,C,A".-4-9-0-6 i:' l-ai"~- -~,a~- ........
. J. /~'L=,en. M.D.
Freder!cksbur9. VA 2240:
BURIAL REMOVAL CREMATION PLACE (name of cem~ or cremato~) (city of county) (state)
OF BURIAL,
REMOVAL'ETCmRolling Green Memorial Park, Camp Hill, Pennsylvanie
NAME OF FUNERAII~I 111 -; n ~
HOMEA.D '- ....... & ~'"~omE::>SO~ Funeral Se~,
~RESS: Fredericksburg, Virginia 22401
DIRECTOR
[] [] []
REGIST~
RESERVED FOR
REGISTRAR'S'USE
This is to certify that. this is a true and correct reproduction of the original record
filed with the Fredericksburg Department of Health, Fredericksburg, Virginia.
Date Issued
(SEAL)
VOID IF ALTERED OR DOES NOT
BEAR IMPRESSED SEAL OR REGISTRAR
VS 17A-2/78
011215-O000111.18.00/HAJ/RAP/128480.1
laul C mpbdl
I, PAUL D. CAMPBELL, of 514 Susan Road, Camp Hill, Cumberland County,
Pennsylvania 17011, declare this to be my Last Will and revoke any Will previously made
by me.
ITEM I: DEBTS.
I direct that all my debts and funeral expenses, including my gravemarker and all
expenses of my last illness, that my estate is obligated to pay shall be paid from my
residuary estate as a part of the expense of the administration of my estate.
ITEM II: TANGIBLE PERSONAL PROPERTY.
2.1. I give my automobiles and personal effects, my household goods and other
tangible personal property of like nature (not including cash or securities), together with
existing insurance thereon to my daughter, JUDITH ILENE BREVIK, should she survive
me.
2.2. While this bequest is absolute, it is my wish that any memorandum I may
leave addressed to my personal representative indicating my desire with respect to the
disposal of my tangible personal property shall be regarded.
0'11215-00001/1.18.00/HA J/RAP/128480.1
ITEM III: REST, RESIDUE AND REMAINDER IF MY WIFE
SURVIVES:
I give, devise and bequeath all the rest, residue and remainder of my estate to
my daughter, JUDITH ILENE BREVIK, of Fredricsburg, Virginia, per stirpes.
ITEM IV. PAYMENT OF TAXES:
Federal, state and other taxes payable because of my death, with respect to
property forming my gross estate for tax purposes, whether or not passing under this Will,
including any interest or penalty imposed in connection with such tax, shall be considered a
part of the expense of the administration of my estate and shall be paid from that part of my
residuary estate passing pursuant to ITEM III hereof without apportionment or right of
reimbursement. All such taxes on present or future interest shall be paid at such time or
times that my personal representative may think proper, regardless of whether such taxes are
then due.
ITEM V. MISCELLANEOUS:
Distributions for Minors. Where under the provisions of this Will my
Personal Representative is authorized to distribute or expend the income or principal of any
fund to, or for the benefit of, a person who is a minor, the Personal Representative may
distribute such income or principal directly to such minor, to the person having custody of
him or her, to the guardian of his or her estate, to the guardian of his or her person or to a
custodian for such minor under any applicable Uniform Gilts (or Transfers) to Minors Act,
whether previously appointed or appointed by the Personal Representative for the purpose
011215-00001/1.18.00/HA J/RAP/128480.1
of receiving such distribution, all without liability on the part of the Personal Representative
to see to the application thereof and without required bond or surety.
ITEM VI: POWERS OF PERSONAL REPRESENTATIVE.
6.1. Administrative Powers of Personal Representative. In the administration
and management of my estate, my Personal Representative shall have and may exercise
(subject to any other provision of this Will limiting or qualifying in any way any power,
authority or discretion of my Personal Representative) full power, authority and discretion
without the necessity of obtaining the order of any court to do all acts, to execute,
acknowledge and deliver all writings and to exercise for the benefit of all persons who may
be or become beneficiaries under the provisions of this Will any and all powers, authorities
and discretions given to or vested my Personal Representative by the provisions of this Will
or by law. By way of illustration but not limitation, my Personal Representative shall have
and may exercise the following powers:
1. To retain property in the form and character in which the same shall be
received;
2. To sell, convey, mortgage, lease for any term whatever, transfer, exchange
and dispose of, either publicly or privately, the whole or any part of the estate;
3. To grant options for such period as my Personal Representative shall
deem advisable for the sale, conveyance, lease, transfer, exchange or other
disposition of the whole or any part of the estate and to exercise any option at any
time held as part of the estate;
011215-00001/1.18.00/HA J/RAP/128480.1
4. To invest and reinvest the whole or any part of the estate in any kind of
property, real, personal or mixed, or undivided or part interests therein, including
stocks, bonds, notes, securities, minerals and other natural resources, limited
partnerships, common trust funds, interest beating accounts and other property of
whatsoever character, located in the United States or abroad, all statutory and other
limitations as to the investment of funds, now or hereafter enacted or in force, being
hereby waived and without obligation to diversify the same and without liability for
any decline in the value thereof;
5. To compromise and settle claims;
6. To carry any property in the name of a nominee, including a clearing
corporation or depository or in book entry form or unregistered or in such other form
as will pass by delivery;
7. To vote shares of stock, in person or by proxy, in favor of or against
management and shareholder proposals and to join in or dissent from and oppose the
reorganization, recapitalization, consolidation, merger, liquidation, or sale of
corporations or properties;
8. To employ accountants, agents, attorneys, brokers, employees, investment
counselors and other representatives to perform any act of administration (whether or
not discretionary), to act without independent investigation upon their
recommendations and to determine and pay their compensation and expenses out of
the estate;
4
011215-O000111.18.00/HAJ/RAP/128480.1
9. To distribute, without the necessity of filing a judicial accounting or
obtaining judicial approval, the whole or any part of the estate upon the receipt and
release of the beneficiary entitled to receive such distribution, in which event my
Personal Representative shall be relieved of all further liability with respect to the
property so distributed with like effect as if such distribution had been made pursuant
to an order of court;
10. To borrow money from any person in such amounts and upon such terms
as my Personal Representative shall determine and to pledge all or any part of the
assets of the Trust estate to secure such borrowing;
11. To permit any beneficiary to occupy any real property forming part of
the estate without rent or upon such other terms and conditions as my Personal
Representative shall determine;
12. To make any distribution or division of the estate either in cash or in
kind, or partly in cash and partly in kind and to allot different kinds of, or interests in,
property to different shares, all as my Personal Representative, shall determine to be
equitable to effect such distribution or division.
13. To allocate receipts and expenses to principal or income or partly to
each as my Personal Representative from time to time think proper.
6.2. Exercise of Discretionary. Powers. Each and every power, authority and
discretion given to or vested in my Personal Representative by the provisions of this Will or
by law, whatever may be the nature or extent thereof, shall be freely exercisable by my
011215-00001/1.18.00/HA J/RAP/128480.1
Personal Representative at any time and from time to time in the Personal Representatives
sole and absolute discretion.
6.3. Disclaimer By Personal Representative. I authorize my Personal
Representative to disclaim in whole or in part any property or interest therein passing to me
or to my estate by reason of a testamentary or inter vivos transfer or an intestate disposition
or by any other means.
6.4. Option with Respect to Expenses. In the event any expense of
administration of my estate shall, at the option of my Personal Representative, be deductible
either in computing any federal income tax payable during the administration of my estate
or in computing the federal estate tax payable with respect to my estate, my Personal
Representative shall exercise such option as my Personal Representative shall deem to be in
the best interests of my estate and the beneficiaries thereof. In the event any such expense is
deducted for federal income tax purposes, my Personal Representative may, but shall not be
required to, transfer from income to principal an amount equal to the additional federal
estate tax which my estate may be required to pay by reason of the failure to claim any such
expense as a deduction for federal estate tax purposes.
ITEM VII: PERSONAL REPRESENTATIVE.
I hereby nominate, constitute and appoint my daughter, JUDITH ILENE BREVIK,
Executrix of this my Last Will and Testament. In the event my daughter, JUDITH ILENE
BREVIK, fails to qualify or ceases to so act, I name, constitute and appoint my grandson,
GREGORY SCOTT BREVIK, Executor of this my Last Will and Testament.
6
011215-00001/1.18.00/HA J/RAP/128480.1
ITEM VIII: BOND.
No fiduciary acting hereunder shall be required to post bond or enter security in any
jurisdiction.
IN WITNESS WHEREOF, I hereunto set my hand and seal this
January, 2000.
/~day of
PAUL D. CAMI~ELL
(SEAL)
Signed, sealed, published and declared by the above-named Testator, as and for his
Last Will and Testament, in the presence of us, who, at his request, in his presence and in
the presence of each other have hereunto sub~
itnesses.
7
011215-00001/1.18.00/HA J/RAP/128480.1
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA:
· ' SS.
COUNTY OF CUMBERLAND :
We, PAUL D. CAMPBELL, ~,-.~.~ ,~,. ~ and
~N-'~ ~ %. c,.,.x~..~.~, the Testator and the witness~, respectively, whose
names are signed to~e attached o~f~)regoing instrument, being first duly sworn, to hereby
declare to the undersigned authority that the Testator signed and executed the instrument as
his Last Will and that he had signed willingly and that he executed it as his free and
voluntary act for the purposes therein expressed, and that each of the wimesses, in the
presence and hearing of the Testator, signed the Will as wimess and that to the best of
his/her knowledge the Testator was at that time eighteen years of age or older, of sound
mind and under no constraint or undue influence.
Wimess(// '
Sworn to or affirmed to and subscribed to before me by PAUL D. CAMPBELL,
Testator, and x",,,~,2,.~ C~,. ~ and xcxx~~. ~
and ., witnesses, th~ ~ ~x x.~ da~
of January, 2000.
Notary Public
8
NOTARIAL SEAL
DIANNE LENIG, Notary Public
Lemoyne Borough Cumberland Co.
=My Commission Expires Dec. 21, 2001
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of Paul D. Campbell
also known as To:
.Deceased.
Social Security No. 180-01-5883'
Register of Wills for the
County' of Ch~mbarland
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 rix
in the last will of the above decedent, dated · Jam~ary 19
and codicil(s) dated
in the
named
14k 2000
h
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in C~arahorl and County, Pennsylvania, with
last family or principal residence at 514 Susan Road, East Pannsboro Township
(list street, number and muncipatit¥)
Decendent, then 86 years of age, died Saptambar 9 ,:4~~,
at wrodar4 cksburg, VA
Except as follows, decedent did not marry, was not divorced and did not have a child horn or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(If domiciled i.n Pa.) Ail personal property · $
(If not domiciled in Pa.)' "' Peisonal 'Ibr~p'erty in Pennsylvania $
(If not domiciled in Pa.) personal property in County $
Value of reaI estate in Pent'sylvania $
situated, as follows: 514 Susan Road, Camp_ Hill. Pennsylvania
(East Pannsboro Tawnship )
200~000
135,000
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
pre~ented herewith and the,grant of letters testamentary
(testamentary; administration c.t.a.; administration d.b.n.e.t.a.)
theron.
t ,-rnrt~ th T1 ~n~ Rrov~ k
OATH OF PERSONAL REPRESENTATIVE
COMMONWEAl,TH OF PENNSYLVANIA
COUNTY ov d,_ 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 kfiowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will w.~ll and truly administer the estate according to law.
Sworn to or ~firmed and subscribed
begiak~e me this c"'~)L)'v-k~ day of [ I .... / / o~'
No. ,,2 t- 03--;qcl
DECREE OF PROBATE AND GRANT OF LETTERS
,Deceased
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated
.~: ribed therein be ad~mitted to probate and filed of record as the last will of
and Letters "X'~._~-c~.x-y-~-~,~ ~:),.~ ~..
are hereby granted to ~.k_, . ._Y ~A~c, ~
, in consideration of the petition on
FEES
Probate, Letters, Etc ..........
Short Certificates( ) ..........
~ $,/,o. oo
TOTAL . $ .~Sq. o o
Filed .... i..O. ?..~..--..o.~..Z~. .................
Io-~.- o,~
ADDRESS
PHONE
OF
PAUL Do CAI~PBELL
JOHNSON, DUFFIi~, STEWART
& WEiDNER
ATTORNEYS AT LAW
LEMOYNE, PENNSYLVANIA
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent:
Date of Death:
Will No.:
PAUL D. CAMPBELL
September 9, 2003
2003-00799
Admin. No.:
To the Register:
I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above-captioned estate on
October 9, 2003.
Name Address
JUDITH ILENE BREVIK 200 Gerber Drive
Fredericksburg, VA 22408
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except None.
Date: October 9, 2003
Name)~ ),RACE A. JOHNSON
Johns~r/D,Duffle, Stewart & Weidner
Addre~,' 301 Market St.
P. O. Box 109
Lemoyne, PA 17043-0109
Telephone (717) 76!-4540
Capacity:
Counsel for personal representative
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 003827
BREVIK JUDITH ILENE
200 GERBER DRIVE
FREDRICKSBURG, VA
22408
........ fold
ESTATE INFORMATION: SSN: 180-01-5883
FILE NUMBER: 2103-0799
DECEDENT NAME: CAMPBELL PAUL D
DATE OF PAYMENT: 04/15/2004
POSTMARK DATE: 04/1 5/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 09/09/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $13,828.49
~: REMARKS:
CHECK//5108
SEAL
TOTAL AMOUNT PAID'
$13,828.49
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
der 1500 tX (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
FILE NUMBER
D.~ - 03' '-1 qq~
COUNTY CODE '~-YEAR ~UMBE~
I--
Z
I.IJ
Z
o
U.I
o
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
~j~,.,,,~h~ll ~'t~,_[ !:3.
DAT~: OF BEACH (MM-dD-;CEA~R) DATE OF BIRTH (MM-DB-YEAR)
¢~' Oq' ~ ~ ~. I~' I~ /?
SOCIAL SECURITY NUMBER
18o - ~t
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
~,/~ - ~,1~-
2' 1. Original Return
F-J4. Limited Estate
--]6. Decedent Died Testate (Attach copy of Will)
[~9. Litigation Proceeds Received
E~2. Supplemental Return
E~4a. Future Interest Compromise (date of death after 12-12-82)
--]7. Decedent Maintained a Living Trust (Attach copy of Trust)
~----~ 10, Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
E~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)
FIRM NAME (If Applicable)
TELEPHONE NUMBER
COMPLETE MAILING ADDRESS
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) _ L
4. Mortgages & Notes Receivable (Schedule D) (4) '-'-'-'
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
(6) ~
6. Jointly Owned Property (Schedule F)
[-'-~ Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (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, Mortgage Liabilities, & Liens (Schedule I) (10)
11.' Total Deductions (total Lines 9 ~.10)
12. Net Value of Estate (Line 8 minus Line 11)
13.
14.
· I
(2)
(5) ~. !14);!b4).
OFFICIAL USE ONLY
Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax ha§ not been
made (Schedule J)
Net Value Subject to Tax (Line 12 minus Line 13)
(11)
(12) ,~ ,.:,4~ 7. ~-'/'¢. TM
- !
(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 ~ A~')'~I~°
17, Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.
x .12
x .15
(15)
(17)
(18)
Decedent's Complete Address:
ISTREET ADDRESS
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Interest/Penalty if applicable
D. Interest
E. Penalty
. (1)
Total Credits ( A + B + C ) (2)
Total Interest/Penalty ( D + E ) (3)
B. Enter the. total of Line 5 + SA. This is the BALANCE.DUE.
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)'/~
A. Enter the interest on the tax due. : (5A)
(5B)
Make Check'PaYable th: REGISTER OF WILLS, AGENT
IF THE ANSWER
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 premise for life of either payd~ents, benefits or care? ...................................................................... [] ~
If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....i ............... ~ ......... i ................................................................................ [] '~
Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ..............[] ~
Did decedent own an Individual RetirementAccounL annu~ty,.or other non-probate property which
contains a beneficiary designation? ............... '. .................... ' .................................................................................... [] []
TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE 6 AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
d DATE
ADDRESS
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after. January 1, 19~5, the tax rate imposed on the net value of transfers to or fo~: the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii)i
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
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 paren~
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 a~
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV.-1502 EX+ (6-98~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF FILE NUMBER
All real property ownea so e y or as a Tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a wil~ing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
TOTAL (Also enter on line 1, Recapitulation)
VALUE AT DATE
OF DEATH
$141 ooo.-
(If more space is needed, insert additional sheets of the same size)
RE"~-1503 EX+ (6-98)~j~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
TOTAL (Also enter on line 2, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
RE~/-1504 EX+ (1-97~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
FILE NUMBER
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM NUMBER VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
TOTAL (Also enter on line 3, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
p.~-v.~sc~_x'.(~-97) ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE C-1
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
'FILE NUMBER
Name of Corporation
Address
City
2. Federal Employer I.D. Number
3. Type of Business
State Zip Code
Product/Service
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK VoUng / Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common
Preferred $
5. Was the decedent employed by the Corporation?
If yes, Position
6. Was the Corporation indebted to the decedent?
If yes, previde amount of indebtedness $
Provide all rights and restrictions pertaining to each class of stock.
[] Yes [] No
Annual Salary $ Time Devoted to Business
[] Yes [] No
7. Was there life insurance payable to the corporation upon the death of the decedent? [] Yes [] No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
8. Did the decedent sell or transfer stock of this company within one year pdor to death or within two years if the date of death was prior to 12-31-827
[] Yes [] No If yes, [] Transfer [] Sale Number of Shares
Transferee or Purehaser Consideration $ Date
Attach a separate sheet for additional transfers and/or sales.
9. Was there a written shareholder's agreement in effect at the time of the decedent's death? [] Yes [] No
If yes, previde a copy of the agreement.
10. Was the decedent's stock sold? [] Yes [] No
If yes, provide a copy of the agreement of sale, etc.
11. Was the corporation dissolved or liquidated after the decedent's death? [] Yes [] No
If yes, previde a breakdown of distributions received by the estate, including dates and amounts received.
12. Did the corporation have an interest in other corporations or partnerships? [] Yes [] No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years.
C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been
secured, attach copies.
D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent.
E. List of officers, their salaries, bonuses and any other benefits received from the corporation.
F. Statement of dividends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
REV-'1506 EX+ (9-00a~a'
'~'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
ESTATE OF FILE NUMBER
1.
3.
4.
5.
Name of Partnership Date Business Commenced
Address Business Reporting Year
City State__ Zip Code
Federal Employer I.D. Number
Type of Business Product/Service
Decedent was a [] General [] Limited partner. If decedent was a limited partner, provide initial investment $
A,
B.
C.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted to the decedent? ................................. [] Yes
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? ..... [] Yes
If yes, Cash Surrender Value $. Net proceeds payable $
Owner of the policy
[] No
[] No
Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-827
[] Yes [] No If yes, [] Transfer [] Sate Percentage transferred/sold
Transferee or Purchaser Consideration $ Date
Attach a separate sheet for additional transfers and/or sales.
10. Was there a wdtten partnership agreement in effect at the time of the decedenrs death? ...... [] Yes [] No
If yes, provide a copy of the agreement.
11. Was the decedenrs partnership interest sold? ....................................... [] Yes [] No
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedent's death? ................... [] Yes [] No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any of the partners? .................................... [] Yes [] No
If yes, explain
14. Did the partnership have an interest in other corporations or partnerships? .............. [] Yes [] No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
A. Detailed calculations used in the valuation of the decedent's partnership interest.
B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
RE~-1507 EX+ (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
TOTAL (Also enter on line 4, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX -~(1-97) ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF.Lc''~ , 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
NUMBER DESCRIPTION
1.
TOTAL (Also enter on line 5, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
VALUE AT DATE
OF DEATH
REV-1509 EX + (1-97) ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTAT~.~F
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SCHEDULE F
JOINTLY-OWNED PROPERTY
FILE NUMBER
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
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 JOtNT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
TOTAL (Also enter on line 6, Recapitulation) $ ~ ~ ~ ff ~ · ~
(If more space is needed, insert additional sheets of the same size)
REV-1510 E'X * (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
This schedule must be completed and flied if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET ~s/es,
DESCRIPTION OF PROPERTY % OF
ITEM ~NCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
ATTACH A COPY OF THE DEED FOR REAL ESTATE.
qUMBER VALUE OF ASSET INTEREST (~FA~CASLE)
TOTAL (Also enter on line 7, Recapitulation) $ ] ~ / ~ ~, *~
(If more space is needed, insert additional sheets of the same size)
REV-'1511 EX+ (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF :ILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
FUNERAL EXPENSES:
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative{s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State __ Zip
Year(s) Commission Paid:
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State__Zip
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
TOTAL (Also enter on line 9, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX · (1 9~')
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1.
TOTAL (Also enter on line 10, Recapitulation)
AMOUNT
(If more space is needed, insert additional sheets of the same size)
REV;1513 EX+ (9-00~
'.~'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
NUMBER
!
1.
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
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 [!- 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)
REV-1514 EX + (1-97) ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
(Check Box 4 on Rev.1500 Cover Sheet)
FILE NUMbeR
This schedule is to be used for all single life, joint or.successive life estate and term certain calculations. For dates of death
prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5 -1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
[] Will [] Intervivos Deed of Trust [] Other
UFE ESTATE INTEREST CALC JLATION
NAME(S) OF ...... ~EAREST AGE AT TERM OF YEARS LIFE ESTATE IS
LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE
[] Life or [] Term of Years ~
[] Life or [] Term of Years ~
[] Life or [] Term of Years ~
[] Life or [] Term of Years __
1. Value of fund from which life estate is payable $
2. Actuarial factor per appropriate table
Interest table rate- [] 3 1/2% [] 6% [] 10% [] Variable Rate %
3. Value of life estate (Line 1 multiplied by Line 2) $
, ANNUI~ tNTEREST CALCULATION
NAME(S) OF NEAREST AGE AT TERM OF YEARS
ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE
[] Life or [] Term of Years
[] Life or [] Term of Years
[] Life or [] Term of Years
[] Life or [] Term of Years
1. Value of fund from which annuity is payable $
2. Check appropriate block below and enter corresponding (number)
Frequency of payout- [] Weekly (52) [] Bi-weekly (26) [] Monthly (12)
[] Quarterly (4) [] Semi-annually (2) [] Annually (1) [] Other ( )
3. Amount of payout per period $
4. Aggregate annual payment, Line 2 multiplied by Line 3
5. Annuity Factor (see instructions)
Interest table rate []31/2% r-~6% []10% [--] Vadable Rate %
6. Adjustment Factor (see instructions)
7. Value of annuity - If using 3 1/2%, 6%, 10%, or if vadable rate and period payout is at end of pedod,
calculation is: Line 4 x Line 5 x Line 6 $
If using variable rate and pedod payout is at beginning of pedod, calculation is:
(Line 4 x Line 5 x Line 6) + Line 3 $
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on
Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on
Lines 13, 15, 16 and 17.
(If more space is needed, insert additional sheets of the same size)
~y Brevik
Gerber Dr.
~burg, VA 22408
U.S. POSTAGE
PAID
AMOUNT FREDERICKSBURG VA
22~01
OOOO ' 17013
h,,III,,,III,,,.,IMI, M,I
; IEI. IVEllY CONFIIlMA TION -
I
0303 2460 0002 1975 8439
BUREAU OF ZNDXVZDUAL TAXES
CONNONHEALTH OF PENNSYLVAN
SEPARTNENT OF REVENUE ZA
NOTZCE OF INHERXTANCE TAX
APPRAZSEHENT, ALLONANCE OR DZSALLiYdANCE
OF DEDUCTZONS AND ASSESSHENT OF TAX
~Fi:~:~ ! ~i3 ESTATE OF CANPBELL PAUL D
SATE OF DEATH 09-09-2005
FZLE NU~ER 2~
JUSZTH ~ SREVZK '04 gEP -2 Al] :~NTY CUHSERLAHS
200 SERBER DR ACN
FREDER~CKSBuR$ VA 22~08~i~ii:L
NAKE CHECK PAYABLE ANS REHZT PAYNENT TO:
REGISTER OF H~LLS
CUN~ERLAHS CO COURT HUUS;
CUT ALU~; TNZS CZp~_ ...... .~,~__~.F~}~_,.~~p_,_~_,ORTZON CARliSLe, PA
FOR YOUR RECORDS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENTOFREVENUE
BUREAU OFINDIV~DUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 004337
BREVIK JUDITH ILENE
200 GERBER DRIVE
FREDRICKSBURG, VA 22408
fold
ESTATE INFORMATION: SSN: 180-01-5883
FILE NUMBER: 2103-0799
DECEDENT NAME: CAMPBELL PAUL D
DATE OF PAYMENT: 09/02/2004
POSTMARK DATE: 08/30/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 09/09/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $2,217.31
REMARKS:
TOTAL AMOUNT PAID:
$2,217.31
SEAL
CHECK# 5120
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
200 Gerb~ Dr.
Fr~o'~cIcsbor~ VA 22408
..... ':~": J"'JlJ"'lJl"-i,Jl-lJ.,JJ,,,jl.,jdidJ,hl,,lij.j,j.j
BL~ZAU O~= ZNDZVZDUAL TAXES
TNHER'rTANCE TAX DI'VZSZON
DEPT. 280601
HARRISBURG, PA 17128-0601
JUDZTH ! BREVIK
ZOO GERBER DR
FREDERZCKSBURG
CONNONNEALTH OF PENNSYLVANZA
DEPARTNENT OF REVENUE
NOTZCE OF ZNHERZTANCE TAX
APPRAZSEHENT, ALLONANCE OR DZSALLOgANCE
OF DEDUCTZONS AND ASSESSNENT OF TAX
VA ZZ~,08
DATE
ESTATE OF
DATE OF DEATH
FZLE NUNBER
COUNTY
ACN
08-$0-200q
CAMPBELL PAUL
09-09-2005
MAKE CHECK PAYABLE AND Rr~ZT PAYNENT TO:
CUNBERLAND CG;:COURT~OUSE
CARLZSLE, PA 17013
D
CUT ALONG THZS LZNE ~ RETAZN LONER PORTZON FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03) NOTZCE OF ZNHERZTANCE TAX APPRAZSENENT, ALLONANCE OR
DZSALLONANCE OF DEDUCTZONS AND ASSESSMENT OF TAX
ESTATE OF CANPBELL PAUL D FZLE NO. 21 03-0799 ACN 101 DATE 08-30-200q
TAX RETURN gAS: ( ) ACCEPTED AS FZLED (X) CHANGED SEE ATTACHED NOTZCE
RESERVATZON CONCERNZNG FUTURE ZNTEREST - SEE REVERSE
APPRAZSED VALUE OF RETURN BASED ON: ORTGTNAL RETURN
1. Real Es~e~e (Schedule A) (1)
2. S~ocks and Bonds (Schedule B) (2)
:5. ClosmZy Held S~ock/Per~nershlp Zn~ceres'c (Schedule C) (:5)
4. Not,gages/No,es Receivable (Schedule D) (~)
S. Cash/Bank Deposi~:s/N1sc. Personal Propar~:y (Schedule E) ($)
6. Jointly Owned Proper~y (Schedule F) (6)
7. Transfers (Schedule G} (7)
8. To,el Asse~s
APPROVED DEDUCTZONS AND EXENPTTONS:
9
lO
11
12
1:5
Funeral Expenses/Ada. Cos~s/Hisc. Expenses (Schedule H)
Debts/Nor*gage Liabi11~ies/Liens (Schedule Z)
To*al Deductions
Ne~ Value of Tax Re~urn
(9)
(10)
Charitable/governmental Bequests; Non-elected 9113 Trusts (Schedule J)
Ne~ Value of Es~e~e Sub~ec~ ~o Tax
1~1~000.00
.00
.00
.00
110;160.79
37z516.Zq
67;375.99
(8)
NOTE: To insure proper
credi~ ~o your account,
submi~ ~he upper portion
of ~h~s form w~h your
~ex payment.
356,053. OZ
.00
.00
(11) .00
(12) 356,053.02
(1:5) . O0
(1~,) 356,053.02
NOTE:
Xf an assessment was issued previously, 11nas 14, 15 and/or 16, 17, 18 and 19 will
re~lect ~lgures that include the total o~ ALL returns assessed to date.
ASSESSNENT OF TAX:
15. Aaoun~ of L/ne 1~ a~ Spousal ra~:e
16. Aaoun~ of L~ne Zq ~axab~e a~ L~neal/Class A ra~e
17. Aaoun~ of L~ne l~t a~ S~bl~ng ra~e
18. Aaoun~ of L~ne l~t ~axable e~ Colla~eraZ/Class B ra~cm
19. PrSnc~=aZ Tax Due
TAX CREDTTS
PAYHENT RECEZPT D/SCOUNT
DATE NUHBER /NTEREST/PEN PAZD (-)
0~-15-200~ CD005817 .00
(:LS). .00 X O0 = .00
(16). 356,053.02 x Oq5= 16,022.39
(17). .00 x 12 = .00
(18), .00 x 15 = .00
(19)= 16,022.39
ANOUNT PAZD
13,828.~9
TOTAL TAX CREDXT
BALANCE OF TAX DUEI
ZNTEREST AND PEN.
TOTAL DUE
ZNTEREST ZS CHARGED THROUGH 09-1~-200~
AT THE RATES APPLZCABLE AS OUTLZNED ON THE
REVERSE SZDE OF THXS FORM
ZF PAZD AFTER DATE ZNDZCATED, SEE REVERSE
FOR CALCULATZON OF ADDXTZONAL XNTEREST.
13,828.~9
2,193.90
23.ql
2,217
( IF TOTAL DUE IS LESS THAN $1~ NO PAYNENT IS RE{)UZRED.
IF TOTAL DUE IS REFLECTED AS A 'CREDZT' (CR), YOU NAY BE DUE,[~/ .
A REFUND. SEE REVERSE SZDE OF THZS FORH FOR ZNSTRUCTZONS.)
RESERVATION:
PURPOSE OF
NOT[CE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADMIN-
ISTRATIVE
CORRECTIONS:
DZSCOUNT:
PENALTY:
INTEREST:
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 Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the 1aclu1 Class B (collateral) rate on any such futura interest.
To fulfill the requirements of Section 21q0 of the Inheritance and Estate Tax Act, Act Z5 of ZOO0. (7Z P.S.
Section 91qO).
Detach the top portion of this Notice and submit with your payment to the Register of #ills printed on the reverse side.
--Make check or money order payable to: REGISTER OF HILLS, AGENT
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-1515}. Applications are available at the Office
of the Register of Nills, any of the Z5 Revenue District Offices, or by calling the special Zq-hour
answering service for forms ordering: 1-800-262-2050; services for taxpayers with special hearing and / or
speaking needs: [-BO0-q~7-5OZO (TT only).
Any party in interest not satisfied with the appraisementj allowance, or disallowance of deductionsj or assessment
of tax (including discount or interest) as shown on this Notice must ob[act within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of AppeaZs~ Dept. ZalOZ[, Harrisburg, PA 17ZZB-IOZ1, OR
--election to have the matter determined at audit of the account of the personal 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 Review Unit, Dept. ZB0601, Harrisburg~ PA 171ZB-0601
Phone (717) 787-6505. Sea page S of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-150I) for an explanation of administratively correctable errors.
If any tax due is paid within three (2) calendar months after the dacedent's death, a five percent (SI) discount of
the tax paid is allowed.
The 1SI tax amnesty non-participation penalty is computed on the to[at 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 the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death~ to the date of payment. Taxes which became delinquent before January l, 198Z bear interest at the rate of
six (6X) percent per annum calculated et a daily rate of .O0016q. A11 taxes which became delinquent on and after
January 1, 198Z wi1! bear interest at a rate which w111 vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through ZOOfi are:
Interest gaily Interest Daily Interest
Year Rate Factor Year Rate Factor
~ ZOZ .O00Sq& 1988-1991 llX .000501
1985 16X .000q58 1992 9Z .o00gq7
198q IIX .000301 1993-199~ 7Z .OOOleg
1985 122 .000556 1995=1998 9Z .O00Zq7
1986 lOX .O00Z7~ 1999 7Z .O0019Z
1987 IOZ .O00ZTq ZOO0 7Z .00019Z
--Xntarest is calculated as follows:
ZNTEREST= BALANCE OF TAX UNPAZD
Daily
Year Rate Factor
LrB'd~ 9x .0o0zq7
200z 6Z .00016~
2003 SZ .00fl157
ZOOq qZ .O001lO
X NUNBER OF DAYS DELINQUENT X DALLY ZNTEREST 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 bm calculated.
REV-1470 EX (8-88)
INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG~ PA 17128-0601
DECEDENT'S NAME FILE NUMBER
Paul D Campbell 2103-0799
REVIEWED BY ACN
Deborah Washington 101
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
G I Annuities are fully taxable with no exclusion.
Row Page 1
Cumberland County - Register Of wills
One Courthouse Square
Carlisle, PA 17013
phone: (717) 240-6345
Date: 8/15/2005
JOHNSON HORACE A
3RD & MARKET STREETS
P. O. BOX 109
LEMOYNE, PA 17043
RE: Estate of CAMPBELL PAUL D
File Number: 2003-00799
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by:
9/09/2005
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
&,,"L'- ~~
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
cc: File
Personal Representative(s)
Judge
~
, .
,
Register of Wills of Cumberland County
STATUS REPORT UNDER RULE 6.12
Name of Decedent: --.:,' . 'PA U I
"'"JI' - __I
D. C A-m pbe l}
9}~3
Date of Death: '-C:;Q-ptvm~
Estate No.: &ID3 - D'199
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.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes 0 No~
b. The separate Orphans' Court No. (if any) for the personal representative's
account is: ~ ID ~ ~ 0 i'1 't
c. Did the personal representative state an account informally to the parties in
interest? Yes 0 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 report.
6L,{)O
Address
~~
Telephone No.
Capacity: gPersonal Representative
o Counsel for personal representative
Date: ~ . cl. - OS
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In Re: Estate of
MCMANUELS PAUL D S
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 2003-00790
NOTICE OF FAILURE TO FILE STATUS REPORT
Personal Representative: MCMANUELS TERRY WAYNE
Counsel for Personal Representative:
Date of Decedent's Death: 9/19/2003
The Orphans' Court record indicates that neither the above named personal representative
nor the above named counsel for the personal representative have filed with the Register of Wills
or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme
Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court
Orphans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Report.
If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of
such delinquency and the undersigned will requests that a Court conduct a hearing to determine
whether sanctions should be imposed upon the delinquent personal representative or counsel for
the delinquent personal representative.
Date:
10/9/2006
Distribution: Personal Representative
Counsel for Personal Representative
Estate File
~
G~=~
Clerk of .1. -
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