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Home My WebLink About03-0991 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of Ann Marie Williams No. ~ I--0 ~ ~ also known as To: Register of Wills for the Deceased. County of ~rland in the SociaISecurit.v No. 195-26-8243 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(~), who is/a~ ! 8 years of age or older, appl_Ces~ for letters of administration on the estate of (d.b.n.; pendeme lile; durante absentia; durante minorilate) the above decedent. Decedent was domiciled at death in Cumberland County, Pennsylvania, with h er last family or principai residence at 309 Fieldstone Road, Camp Hill, PA (list street, number, Twp. or Bore.) Decedent, then 67 years of age, died 13 Septonztber 2003 1a) at Harrisburg Hospital, Harrisb{{rg, PA ' ' Decedent at death owned property with estimated values as follows: (If donficiled in Pa.) Ali personal property $ 22,000. O0 (If not domiciled in Pa.) Personal property in Pennsylvania $ 0 (If not domiciled in Pa.) Personal property in County $ 0 Value of real estate in Pennsylvania $ 0 situated as follows: Petitioner after a proper search has ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name Relationship Residence Donald G. Williams hu.~band 309 Fieldstone Rd, Camp Hill PA Elizabeth Paul daughter 309 Fieldstone Rd, Camp Hill,PA Michael Williams son THEREFORE, petitioner(~9 respectfully request(s) the grant of letters of administration 'in the appropriate form to the undersigned. ~" l~d G~. ~iiliams ~ o 309 Fieldstone Road Camp Hill, PA 17011 ._~ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF c~mmp~n~ The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. ] /? / " ' firmed and subscribed ~worn io or af before me this 26th da~0~f3 / ~ Novembe!~ ..... · .~ 1~_ J -- Uonna M. Otto, 1st Depuny! R~Zer No. 21-2003-991 Estate of ~ MARTF, WTT,T,TAMS , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW ~ecember 1st, ~ 200~ in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that DONbZD G. ~'FT,T,T~:'[_~ is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to DONgI_D G. WTT,LLAYJS in the estate of ~ V~R~?. WTT,T,T~VL~. Register of Wills Donna M. Otto, 1st Deputy FEES Letters of Administration ..... $ 60.00 _ ATTORNEY (Sup. Ct. I.D. No.) 17225 Short Certificates(4) .......... $__L2~00-~ :' v ' .~. ~ · JCP ........... $~ Samuel L. Andes $ ADDRESS TOTAL , $ 82.00 525 N. 12th Street Filed D~cembe~.ls.t,200~ A.D. ~ Lemoyne, PA 17043 Mailed letters to attorney on 12/01/03. PHONE 717-761-5361 H105.805 REV 9/86 This is rD 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 Viral Records O£fice for permanent filing. WARNING: It is illegal to duplicate this cop}, blt photostat or photograph. '~'- ~ '"~'~'~2~ Local Registrar 9507906 SL'P 1 9 Dare Rev w87 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH ,. Ann Marie Williams female ,. 195 -- 26 -- 8243 67 ~.. J ~ I Nov. 22, [ [. ~ ~. Dauphin J. Harrisburg [. Harrisburg Hospital 1=.~,~__9~.~''~' ~CE~m'S USUAL ~U~ . J" 1,0. White ,,.. Homemaker · Do .... ~ ' '-~ ~ ' -,z ' --" ~ ' ~' - ' ' ' '" I"- ~ [ I'". married l,,Oonald G. Williams /*GIUL lZ.. ~. Pennsylvania . 309 Fieldstone Road "~mm~ ~ ,~.~.~.. Lo,er Allen ,,. Camp Hill, PA 17011 ~ ,,. Paul Vincent Kane [.omE.'s.~.~.~..~o~.~ I~OP~t:T'S~V~,;,~ ,e. Grace Elizabeth Schennenberger z~. Donald G. Williamm ~. 309 Fieldstone Road~ Camp Hill, PA 17011 .~,--u ~ Sl~eptember 22, 2003 [Rolling Green Memorial Par Lower Allen ~p. PA 17011 ,"'. .,,. , ~, ~ ..~,...,~.,~ ~ ~ ~ '"~'~'"~'"~'~"m'"~"~'~'"'~'"~""""'~ .... ~.~.~ ........ ,.,. .......... Q ~,~. ~D ~1770 0 ~,.. ~e ~m~6~ I ~ · %'~ 3,.. ' ........................................... ( ) ~ 2~ 7 ~/c'~ )~ 21-2003-991 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Ann Marie Williams Date of Death: 18 September 2003 Will No. Admin. No. 21-03-0991 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 17 December 2003. Name Address Donald G. Williams 309 Fieldstone Road Camp Hill, PA 17011 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Signature Name: Samuel L. Andes Address: 525 N. 12th Street Lemoyne, PA 17043 Telephone # 717-761-5361 Capacity: Personal Representative ~z- Counsel for Personal Representative PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN F,LE.UMBE. 21 - 03 0 9 9 1 HARRISBURG, PA 17128-0601 RESIDENT DECEDENT co . c®E DECEDE. S NAME (LAST. F,RST, AND M DDLE ,NmAL) SOCIAL SECURITY NUMBER z Williams, Ann Marie 195 - 26 - 8243 I"'! DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPUCATE WITH T ., 09-18-2003 REGISTER OF WILLS UJ (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURrrY NUMBER c~ Williams, Donald G. - - u.I [] 1. Original Return [] 2. Supplemental Return I~ 3. Remainder Return (date of death p~ to t2-13-S2) ,,~ =. ~'~' =: '"' r--] 4. Limited Estate ~ 4a. Future Interest Compromise (date of death after 12-12-a2) r--I 5. Federal Estate Tax Return Required o ,, aa I~1 6. Decedent Died Testate (Attec~ ~ of Wa) ~ 7. Decedent Maintained a Living Trust (At~c~ copy o~T~t) 8. Total Number of Safe Deposit Boxes < I-~ 9. utiga~on Proceeds Received r--] 10, Spousa~ Pove~ Cred, (~ ~d,~.,,~ ~-~-~ ,~..,~) m NAME COMPLETE MAILING ADDRESS z Samuel T,. A~es o e~ FIRM NAME (If,N~icaae) 525 North 12th Street ~ Lemoyne, PA 17043 ~ TELEPHONE NUMBER o u (717) 761-5361 1. Real Estate (Schedule A) (1) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole.-Pmprietorship (3) ~ 4. Mortgages & Notes Receivable (Schedule D) (4) ~. , ', 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 6,684.02 (Schedule E) '!:;; ' ' ~ 6. Jointly Owned Property (Schedule F) (6) [] Separate Billing Requested 19,607.46 ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) "'~i I-- (Schedule G or L) ! · '~ - ~, 26,291.~ ~ 8. Total 6rose Assets (total Lines 1-7) (8) 1,1,1 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 19,302.98 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 1,936.00 11. Total Deductions (total Unes 9 & 10) (11) 21,238.98 12. Net Value of Estate (Line 8 minus Line 11) (12) 5,052.50 13. Charitable and Governmental Sequests/Sec 9113 Trusts for which an election to tax has not been (13) 6~684.02 made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) (1,631.52) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE PATES 15. Amount of Line 14 taxable at ~e spousal tax ~.~ rate, or transfers under Sec. 9116 (a)(1.2) $0.00 x .0 (15) $0.00 16, Amount of Line 14 taxable at lineal rate x .0 . (16) 17. Amount of Line 14 taxable at sibling rate x .12 (17) t,,.) 18. Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) 'Decedent's Complete Address: STREET ADDRESS 309 Fieldstone Road C~TY Camp Hill ISTATE PA Iz'P 17011 Tax Payments and Credits: 1. Tax Due (Page l Line19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A * B + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) O O o Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PI.ACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; .............................. [] [] b. retain the right to designate who shall use the property transferred or its income; ............................................ [] [] c. retain a reversionary interest; or ......... . ..... [] [] d. receive the promise for life of either payments, benefits or care? .............................................................. [] [] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. [] [] 3. Did decedent own an "in trust for" or payable upon death bank account or secudty at his or her death? .............. [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ~ [] IF T~E ANSWER TO/I,'f~OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, Under l;nalUes of ~'~,1 de're I~have examined this return, including accompanying schedules and statements, and to the best of my knowledge and be ef, it is true, correct and complete. Decla~lJon of prejfarej~other titan tyJ~/~onal representaUve is based on all information of which preparer has any knowledge. SIG~I,~URF..~'~/E~S~N I~'~l~l~E,i~OR FILING RETURN DAT5~ · -~R~--~'~/- '~ . ,,v v v ~- ~ ,__.'/,_?/_/_n r ~ ~ 309 ~'ield~one Road, Camp Hill, PA 17011 / 5:25 lqoz't_h. 12th Street, T,a-ao1~e, i~A 17043 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 Janua~ 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 impesed 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 RS. {}9116(1.2) [72 RS. §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. REV4.508 E~ * (1-97) ~ SCHEDULE E COMMONWEALTH'~~OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATEOF Ann Marie Williams FILE NUMaER 21-03-0991 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 disclc~sed on Schedule ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1999 Dodge Stratus ES Sedan automobile (see Kelley Blue Book $5,620.00 report attached) 2. Checking account # 950797324 with M&T Bank (see bank letter $564.02 attached) 3. Miscellaneous items of clothing and personal effects $500.00 TOTAL (Also enter on line 5, Recapitulation) $ 6,684.02 (If more space is needed, insert additional sheets of the same size) Kelley Blue Book Used Car Values Page 1 of 2 j J!ey Blue Book E :RUSTED RESOU~RCE SPECIAL YEARLY REPORTS: 2004 Auto Show Debuts N ! rCarPricln aalad a C: ir Blue Book Private Party Repo z~ Pennsylvania · DeCember 29, 2003 ~hip~ Hyb~v~ 1999 Dodge Stratus ES Sedan 4D ~._~r ~,! Buy a New Car ~~~ Buy a Used Car ~ ~r List Your Car For Sale Online ~~ Free Lemon Check ~~ . Auto Loans from 3.99% APR ~um,~ Engine: V6 2.5 Liter insurance Quote ~~k Trans: Automatic Print "For Sale" Sign ........................................ Drive: Front Wheel Drive ~r ~ Payment Calculator ~r~ Mileage: 80,000 . ~~ Sell your car on eBay Motors ~i~ Equipment ~ Air Conditioning Cruise Control Power Seat ~~~~ Power Steering AM/FM Stereo Sliding Sun Roof ~j~ Power Windows DVD System Alloy Wheels ~ Power Door Locks Dual Front Air Bags Tilt Wheel ABS (4-Wheel) Consumer Rated Condition: Good "Good" condition means that the vehicle is free of any major defects. The paint, body and interior have only minor (if any) blemishes, and there are no major mechanical problems, in states where rust is a problem, this should be ve~ minimal, and a deduction should be made to correct it. The tires match and have substantial tread wear left. A clean title histo~ is assumed. A "good" vehicle will need some reconditioning to be sold at retail; however major reconditioning should be deducted from the value. Most recent model cars owned by consumers fall into this catego~. Private Pa y Value $ ,620 Private Pa~y value represents what you might expect to pay for a used car when purchasing' from a private pa~. It may also represent the value you might expect to receive when selling your own used car to another private party. Get a Used Car Trade-In Value Get Invoice & MSRP on New Cars Get a Person to Person Auto Loan http://www.kbb.com/kb/ki.dll/kw.kc.ur?kbb. PA;969040;P ~041 & 17011 ;sed+p;&722;Dodge... 12/29/03 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Phone (302) 934-2774 F ax (302) 934-2955 January 12, 2004 Samuel L. Andes Attorney At Law 525 North Twelfth Street P O Box 168 Lemoyne, PA 17043 Re: Estate of Ann M. Williams Social Security: 195-26-8243 Date of Death: September 18, 2003 Dear Mr. Samuel L. Andes: Per your inquiry dated December 17, 2003, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 90440072 Ownership (Names oJ) Ann M Williams Donald G Williams Opening Date 08/28/64 Balance on Date of Death $26, 698. 29 Accrued Interest $ .22 Total $26,968.51 Page 2 Re: Estate qf Ann M. Williams Social Security: 195-26-8243 Date of Death: September ]8, 2003 2. Type of Account Checking Account Account Number 950797324 Ownership (Names of) Ann M Williams Opening Date 05/09/01 Balance on Date of Death $564.02 Accrued Interest $ .00 Total $564.02 3. Type of Account Home Equity Loan Account Number 20000000070529 Ownership (Names oJ) Donald G Williams Ann M Williams Opening Date 10/08/99 Balance on Date of Death $24,842.39 For further account information, closures and/or reimbursement of funds please call the Highland Park Office at # 717-737-3322. Sincerely, Nancy Clagett Records Management (302) 934-2774 .~*,S,OE~-,,-.~ ~ SCHEDULE G INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATEOF Ann Marie Williams FIEENUMBER 21-03-0991 Thb schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY % OF ITEM ~.CLUD~ THE NAME OF THE TRA/~FEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VAI. L ATTACH A COPY OF THE DEED FOR REN. ESTATE. NUMBER VALUE OF ASSET INTEREST iIF AP,UCC_E) 1. Individual retirement account #41G-81138 with $19,607.46 100% none $19,607.46 Merrill Lynch Pierce Fenner & Smith, Inc. (see copies of payout checks issued from account which are attached). TOTAL (Also enter on line 7. Recapitulation) $ 19,607.46 (If more space is needed, insert additional sheets of the same size) The SHF Group Benjamin B. Shankroff, CFM Vice President Senior Financial Advisor John J. Hallahan Senior Financial Advisor Merrill Lynch v. Fo,ter, cFM Financial Advisor March 12, 2004 Tracey Keel Client Associate Global Private Client Group Mr. Donald Williams 214 Senate Avenue, Suite 501 309 Fieldstone Road P.O. Box 0810 Camp Hill, PA 17011-8445 Camp Hill, Pennsylvania 17011 717 975 4609 Direct 800 937 0735 Toll Free RE: Date of Death Values for the Ann M. Williams IRA FAX 717 975 4663 Dear Mr. Williams: Here is the following information you requested: Date-of-Death Values For the Ann M. Williams IRA As of September 18, 2003 Average* Quantity Security Description Cusip Number Price Per Share Total Value 12 Equity Residential REIT 29476L107 $29.235 $ 350.82 412.5960 Alliance Bernstein Premier 01877C200 15.03 6,201.32 Growth Fund Class B 389.5480 Merrill Lynch Large Cap 59021R739 9.54 3,716.29 Core Fund Class B 314.7340 Oppenheimer Main Street 68380D801 29.57 9,306.68 Fund Class B 32.13 Merrill Lynch Bank USA 1.00 32.13 RASP (Money Fund) .22 Cash .22 Total Value as of 09/18/2003 $19,607.46 *Average price is calculated be using high and low prices from attached historical pricing information as of September 18, 2003 If you have any questions, please do not hesitate to contact me at 717-975-4609. Sincerely, enc: Merrill Lynch September 2003 Statement for 41G-81138 & Historical Pricing Information \Ve are providing the above information as requested. The information set lbrth herein was obtained from sources which we believe reliable, but we do not guarantee its accuracy. Historical Pricing Inquiry EQR - EQUITY RESIDENTIAL Cusip: 29476L107 Date High Price Low Price Close Price Volume og/18/2003 29.440 29.030 29.250 1687500 APGBX - ALLIANCEBERNSTEIN PREMIER GR Cusip: 01877C200 Date Bid Price Offer Price 09/18/2003 15.030 15.030 MBLRX - MERRILL LYNCH LARGE CAP SER Cusip: 59021R739 Date Bid Price Offer Price 09/18/2003 9.540 9.540 OMSBX - OPPENHEIMER MAIN STR FDS INC Cusip: 68380D801 Date Bid Price Offer Price 09/18/2003 29.570 29.570 The information has been obtained from sources we believe to be reliable but we do not guarantee its accuracy. Past performance is not indicative of future performance. RETIREMENT ACCOUNT Total Account Value As Of 09~30~2003 $18,815.38 YOUR FINANCIAL ADVISOR: Your Merrill Lynch Office: ~LPF& S CUST FPO SHF GROUP 214 SENATE AVE, STE 501 MRS ANN M WILLIAMS IRA FBO MRS ANN M WILLIAMS (717) 975-4600 CAMP HILL PA 17011 309 FIELDSTONE RD CAMP HILL PA 17011-8445 FOR CUSTOMER SERVICE QUESTIONS: Review Your Statement Online at: 1-800-MERRILL (1-800-637-7455) www. mlol.ml.com Monthly Portfolio Summary Income Summary Asset 08/29/03 Value % 09/30/03 Value % This Statement Year-to-Date Cash/Money Accounts 32 * 32 * Fund Dividends CD's/Equivalents Interest Income CorporateGovernment Bonds Securities Total Dividend Income 10.38 Municipal Bonds 10.38 Equities 348 2 35z 2 Items for Attention Mutual Funds 18,590 98 18,431 98 Options Other Security Message Date · -Less than 1% No Items For Attention Long Market Value 18,971 18,815 Short Market Value Estimated Accrued Interest Debit Balance Net Portfolio Value 18,971 18,815 NEWS Financial Market Indicators Make managing your finances easier and check your account This Statement Last Statement Previous Year-End anytime with Merrill Lynch OnLine (SM). We've introduced several S&P 500 995.97 1008.03 879.82 new enhancements, including the ability to reorder checks and Three-Month Treasury Bills .94% .97-% 1.19-% view and print images of cancelled checks. Long-Term Treasury Bonds 4.88 % 5.21.% 4.78.% One-Month LIBOR 1.12% 1.12% 1.38% NASDAQ 1786.94 1810.58 1335.51 FBO MRS ANN M WILLIAMS + Page Statement Period Account No. 14 of 29 08130/03 TO 09/30103 41G-81138 o~oo6 8204 RETIREMENT ACCOUNT Cash Flow Summary Activity Summary This Statement Year-to-Date Credits This Statement Year-to-Date Debits This Statement Year-to-Date Opening Balance Sales Purchases Cash & Money Income 10.38 Withdrawals Accounts 32.35 Funds Received Electronic Tfrs Electronic Tfrs Other Net Credits Other & Debits 10.38 Closing Balance Cash & Money Accounts 32.3 5 Total Credits 10.38 Total Debits Current Portfolio Adjust/Unit Total Estimated Estimated Unrealized Estimated Estimated Current Date Cost Cost Market Market Gain or Accrued Annual Yield Quantity Security Description Acquired Basis Basis Price Value (Loss) Interest Income % Cash and Money Accounts 32 ML BANK USA RASP 1. oo 32 1. oo 32 .30 Equity Weighting by Economic Sector * A - Health Care 0% D - Consumer D;sc,utionary 0% G - Financials 100% J - Energy 0% B - Consumer Staples 0% E - Industrials 0% H - Telecommunications Services 0% K - Unassigned 0% C- Information Technology 0% F - Materials 0% I - Utilities 0% · Economic sectors conform to the Global Industry Classification Standard. See statement backer. Current Portfolio Adjust/Unit Total Estimated Estimated Unrealized Estimated Current Date Cost Cost Market Market Gain or Annual Yield Quantity Security Description Symbol Sector Acquired Basis Basis Price Value (Loss) Income % Equities 12 ** EQUITY RESIDENTIAL EQR (G) N/A N/A N/A 29.28 351 N/A 20 5 90 REIT . Total Equities 351 20 5.91 FBO MRS ANN M WILLIAMS + Page Statement Period Account No. 15 of 29 08130/03 TO 09/30/03 41G-81138 01~006 6204 RETIREMENT ACCOUNT Current Portfolio Total Cumulative Total Estimated Estimated Unrealized Estimated Current Client Investment Cost Market Market Gain or Annual Yield Quantity Security Description Investment Return Basis Price Value (Loss) Income % Mutual Funds and Defined Asset Funds Equity Funds 412 ALLIANCEBERNSTEIN $10,423 ($4,556) 12,220 14.24 5,866 N/A PREMIER GROWTH FD CL B (.5960 FRACTIONAL SHARE) N/A 14.24 8 N/A INITIAL PURCHASE: 02/12/99 389 ML LARGE CAP CORE $5,000 ($1,440) 5,124 9.15 3,559 N/A FUND CL B (. 5480 FRACTIONAL SHARE) N/A 9.15 5 N/A INITIAL PURCHASE: 01/26/99 314 OPPENHEIMER MAIN STREET $10,350 ($1,379) 12,169 28 57 8,970 N/A FD CL B ' ( . 7340 FRACTIONAL SHARE) N/A 28.57 20 N/A INITIAL PURCHASE: 02/12/99 Total Equity Funds ($7,375) 29,514 18,431 Total Funds ($7,375) 29,514 18,431 TOTAL CLIENTINVESTMENT: Cost of shares directly purchased and still held. UNREALIZEDGAIN or (LOSS): Estimated Market Value minus Total Cost Basis. Does not include shares purchased through reinvestment. Provided for Tax Planning purposes only and is not applicable to retirement accounts "denoted by N/A". CUMULATIVEINVESTMENTRETURN: Estimated Market Value minus Total Client INITIAL PURCHASE: Date of your initial investment in this fund. Investment. Cumulative Investment Return is the capital appreciation (depreciation) of all shares purchased, including shares purchased through reinvestment. Total of Long Portfolio 29,546* 18,815 * 20 · - Excludes N/A Items · Customer Service For information about your account, please call 1-800-MERRILL (1-800-637-7455). When Requested, enter your Access Code 19-414-81138. FBO MRS ANN M WILLIAMS + Page Statement Period Account No. 16 of 29 08130/03 TO 09/30/03 41G-81138 0~o0~ a2o4 RETIREMENT ACCOUNT Retirement Money Accounts Summary Money Account Balances Dividends Description Opening Closing This Statement Year to Date ML Bank USA P~ASP $32.13 $32.13 $.00 $.00 Retirement Account Plan Summary Account Type: IRA Plan Number: 7700700 Year-End Plan Value as of December 31, 2002 $16,574.18 Contributions after December 30, 2002 for 2002 $.00 FBO MRS ANN M WILLIAMS *** END OF STATEMENT *** + Page Statement Period Account No. 17 of 29 08130/03 TO 09130/03 41 G-81138 o1~oo6 6204 REV-1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN AD/VtlNI5TRATIVE ¢O5T5 RESIDENT DECEDENT ESTATE OF Ann Marie Williams FILE NUMBER 21-03-0991 Debts of decedent must be reported on Schedule ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Parthemore Funeral Home $9,522.12 Rolling Green Cemetary (burial lot) $2,465.00 James R. Gingrich Memorials (headstone) $1,470.00 Pealer's Flowers $970.91 Catalano's Restaurant (refreshments/food for after funeral) $2,347.88 B. ADMINISTRATIVE COSTS: 1. 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: 2. Attorney Fees Samuel L. Andes $1,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Donald G. Williams Street Address 309 Fieldstone Road City Camp Hill State PA Zip 17011 Relationship of Claimant to Decedent Spouse 4. Probate Fees Register of Wills $97.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. The Sentinel (legal advertising) $88.43 Cumberland Law Journal (legal advertising) $75.00 Payments to Chrysler Financial on auto loan (4 payments of $316.66) $1,266.64 TOTAL (Also enter on line 9, Recapitulation) $ 19,302.98 (If more space is needed, insert additional sheets of the same size) 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 004115 WILLIAMS DONALD G 309 FIELDSTONE ROAD CAMP HILL, PA 17011 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold 101 $227.81 ESTATE INFORMATION: SSN.. 195-26-8243 FILE NUMBER: 2103-0991 DECEDENT NAME: WILLIAMS ANN MARIE DATE OF PAYMENT: 07/02/2004 POSTMARK DATE: 07/02/2004 COUNTY: CUMBERLAND DATE OF DEATH: 09/18/2003 TOTAL AMOUNT PAID' $227.81 REMARKS: DONALD G WILLIAMS CHECK# 5825 INITIALS: MW SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA ~"BUI~EAv~f OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280&01 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV*]S47 EX RFP DATE 06-21-2004 ESTATE OF WILLIAMS ANN M DATE OF DEATH 09-18-2005 FZLE NUMBER 21 05-0991 COUNTY CUMBERLAND SAMUEL L ANDES ACN 101 525 N 12TH ST LEMOYNE PA 17045 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUNBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS REV-1547 EX RFP C01-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF WILLIAMS ANN M FILE NO. 21 05-0991 ACN IO1 DATE 06-21-200~ TAX RETURN WAS: C ) ACCEPTED AS FILED C X) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN I. Real Estate CSchedule A) CI) .00 NOTE: To insure proper 2. Stocks and Bonds CSchedule B) C2} .00 credit to your account, S. Closely Held Stock/Partnership Interest CSchedule C) CS) .00 submit the upper POrt/on 4. Mortgages/Motes Receivable CSchedule D) C4) .00 of this form w/th your 5. Cash/Bank Deposits/Misc. Personal Property CSchedule E) C5) 6~84.02 tax payment. 6. Jointly Owned Property CSchedule F) C6) .00 7. Transfers CSchedule G) C7) 19r607.46 8. Total Assets C8) 26,291.48 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses CSchedule H) C9) 10. Debts/Mortgage Liabilities/Liens CSchedule I) C10) 11. Total Deductions Cll) 12. Net Value of Tax Return C12) 5,0~2.~0 IS. Char/table/Governmental Bequests; Non-elected 9115 Trusts CSchedule J) C15) .00 14. Net Value of Estate Subject to Tax (14) 5~052.50 NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) .00 X O0 = .00 16. Amount of Line 14 taxable at Lineal/Class A rate C16) 5~052.50 X 045 = 227.56 17. Amount of Line 14 at Sibling rate C17) ~0~ X 1~ = "' .00 18. Amount of L/ne 14 taxable at Collateral/Class B rate (18) '~00 X 1~' = .00 19. Principal Tax Due C~_~)= 227.56 TAX CREDITS: PAYMENT I RECEIPT DISCOUNT (+) DATE NUMBER INTEREST/PEN PAID C-] AMOUNT PAID INTEREST IS CHARGED THROUGH 07-06-2004 TOTAL TAX CREDIT I .00 AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUEl 227.56 REVERSE SIDE OF THIS FORM INTEREST AND PEN. TOTAL DUE 227.81 * IF PAID AFTER DATE INDICATED, SEE REVERSE C IF TOTAL DUE IS LESS THAN ~l, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE I A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) RESERVATION= Estates of decedents dying on or before December 12, 1982 -- if any future /ntarest /n the estate Ks transferred in possess/on or enjoyment to Class 8 (collateral) beneficiaries of the decedent after the expirat/on of any estate for life or For years, the Commonwealth hereby expressly reserves the right to appra/se and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future /nterest. PURPOSE OF NOTICE= To fulfill the requirements of Section 2140 of the Inher/tance and Estate Tax Act, Act 23 of 2000. (72 P.S. Section 9140). PAYHEHT= Detach the top portion of th/s Notice and submit with your payment to the Rea/star of Wills printed on the reverse s/de° --Hake check or money order payable to= REGZS~I~ OF #ILLS, AGENT REFUND (CR)= A refund of a tax credit, wh/ch was not requasted on the Tax Return, may be requested by complet/ng an °°Appl/cation for Refund of Pennsylvania Inher/tance and Estate Tax" (REV-1313). Appl/cat/ons are available at the Off/ca of the Register of W/lls, any of the 23 Revenue D/str/ct Off/cas, or bY call/ne the special 24-hour answer/ne service for forms ordering= 1-800-362-2050; serv/ces for taxpayers with spec/al hear/ne and ! or speak/ne needs= 1-800-447-3020 (TT OBJECTIONS= Any party in interest not satisfied w/th the appraisement, allowance, or disallowance of deduct/ons, or assessment of tax (includ/ng d/scount or /nterest} as shown on th/s Not/ce must object w/thln sixty (60) days of race/pt of this Notice --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harr/sburg, PA 17128-1021, OR -oelect/on to have the matter determ/ned at aud/t of the account of the personal representer/ye, OR --appeal to the Orphans' Court. ADHIN- ISTRATIVE CORRECTIONS= Factual errors d/scovered on th/s assessment should be addressed /n writing to= PA Departaent of Revenue, Bureau of Ind/vidua! Taxes, ATTH= Post Assessment Rev/aw Un/t, Dept. 280601, Harr/sburg, PA 17128-0601 Phona (717) 787-6505. See page 5 of the booklet "Instruct/ohs for lnhar/tance Tax Return for a Resident Decedent" (REV-1501) for an explanat/on of admin/strat/valy corractable errors. DISCOUNT= If any tax due Ks paid w/th/n three (S} calendar months after the decadent's death, a f/ye percent (5~} discount of the tax paid Ks allo~ed. PENALTY~ The 15~ tax amnesty non-partic/pation penalty is computed on the total of the tax and interest assessed, and not paid before JanuamJ 18, 1996, the first day after the end of the tax amnesty per/od. This non-part/c/pat/on penalty Ks appealable in the same manner and in the the same time per/od as you would appeal the tax and interest that has been assessed as /ndicated on this not/ce. INTEREST= Interest Ks charged beg/nning w/th first day of delinquency, or nlne (9) months and one (1) day from the date of death, to the date of payment. Taxes wh/ch became del/nquent before January 1, 1982 bear /nterest at the rate of s/x (6~) percent per annum calculated at a da/ly rate of .000164. All taxes wh/ch became del/nquent on and after January 1, 1982 w/l! bear /nterest at a rate wh/ch w/ll vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2004 are= Interest Daily Interest Da/ly Interest Daily Year Rate Factor Year Rate Factor Yea~ Rate Factor ~ 20~ .000545' ~'~'~'8-1991 11~ .000501 ~'~ 9~ .000247 1985 16~ .000438 1992 9~ .000247 2002 ~ .0001&4 1984 11~ .000301 1995-1994 7~ .000192 2003 S~ .000157 1985 13~ .000356 1995-1998 9~ .000247 2004 4~ .000110 198~ 10~ .000274 1999 7~ .000192 1987 10~ .000274 2000 7X .000192 --Interest is calculated as follows= XNTEREST = BALANCE OF TAX UNPAXD X NURBER OF DAYS DELXN~UENT X DAXLY XNTEREST FAC'rOE --Any Notice issued after the tax becomes del/nquent ~ill reflect an interest calculation to fifteen (15) days beyond the date of the assessment. Zf payment Ks made after the /nterest computation date sho~n on the Notlce, add/t/oriel interest must be calculated. REV- 1470 EX~6-88) INHERITANCE TAX EXPLANATION COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE OF CHANGES BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG~ PA 17128-0601 DECEDEN'PS NAME Ann M. Williams FILE NUMBER 2103-0991 REVIEWED BY Bill Lyons ACE 101 ITEM SCHEDULE NO. EXPLANATION OF CHANGES J I1-1 There is no provision for a charitable deduction or a trust within the return. ORIGINAL Page 1 COMMONWEALTH OF PENNSYLVANIA BUREAU OF ~NDIVIDUAL TAXES DEPARTMENT OF REVENUE [NHE~ZZANCE TAX DEPT: 280601 ~RRISBURG, PA 17128-0~01 HOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX R~-1547 ~AFP DATE 06-21-2004 ESTATE OF WILLIAHS ANN M DATE OF DEATH 09-18-2005 FILE NUMBER 21 05-0991 COUNTY CUHBERLAND SAMUEL I ANDES ACH 101 525 N 12TH ST Amount Remitted LEMOYNE PA 17045 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS ~-v-: ~.~-7- - ;~(- -~ ~:~,- - ~ ~i---~ ~5- -~ ~T-~-~ ;:- -o-~ - -~-N-~ ;~ ~-g - T~ - ~ ~ ~ T~- ~ [~ ~-g - ~- ................. DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF WILLIAMS ANN M FILE NO. 21 05-0991 ACN 101 DATE 06-21-2004 TAX RETURN NAS: C } ACCEPTED AS FILED C X) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON= ORIGINAL RETURN 1. Real Estate (Schedule A) (1) O0 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) C2) O0 credit to your account, 5. Closely Held Stock/Partnership Interest (Schedule C) C$) O0 submit the upper portion ~. Mortgages/Notes Receivable (Schedule D) C~ 00 of this form ~ith your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E] C5~ ~84 02 tax payment. 6. Jointly O~ned Property (Schedule F~ C&~ 00 7. Transfers CSchedule G) C7) 19~&07.46 8. Total Assets C8) 26,291.48 APPROVED DEDUCTIONS AND EXEHPTIONS: 19,502.98 9. Funeral Expenses/Adm. Costs/Ntsc. Expenses (Schedule H~ 10. Debts/Mortgage Liabilities/Liens (Schedule I} C10) 11. Total Deductions CI1) ~] 12. Net Value of Tax Return C12} -~,052.50 15. Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J:) (15:) 1~,. Net Value of Estate Sub3ect to Tax C1~,~) 5,052.50 NOTE,' If an assessment t~as issued previously, lines 14, 15 and/or 16, 17, 18 and 19 ~ill reflect figures that inc/ude the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of L/ne 1~ at Spousal rate C[5) ,00 X O0 = ,00 16. Amount of L/ne 1~ taxable at Lineal/Class A rate C16} 5,052.50 x 045 = 227.56 17. Amount of L/ne lq at Sibling rate C17} ;-00 X ]'~:~= .00 18. Amount of Line 1~ taxable at Collateral/Class B rate C18} :~ X l~>''~>' .00 19. Principal Tax Due C~}= 227 TAX CREDITS= PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID C-} INTEREST IS CHARGED THROUGH 07-06-2004 TOTAL TAX CREDIT I .00 AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUEl 227.56 REVERSE SIDE OF THIS FORM INTEREST AND PEN. TOTAL DUE 227.81 * IF PAID AFTER DATE INDICATED, SEE REVERSE C IF TOTAL DUE IS LESS THAN 91, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR}, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR [NSTRUCTIONS.} RESERVATION= Estates of decedents dYing on or before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class 8 ¢collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth herQby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawfui Class 8 (coiiaterai) rate on any such future interest. PURPOSE OF NOTICE= To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 25 of 2000. (72 P.S. Section 9140). PAYHENT= Detach the top portion of this Notice and submit with your payment to the Register of Wills printed on the reverse side. --Hake check or money order payable to= REGISTE~ OF NZLLS, AGENT REFUND (CR)= A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" CREV-1SI$). Applications are available at the Office of the Register of Wills, any of the 25 Revenue District Offices, or by calling the special 24-hour answering service fop forms ordering= 1-800-$62-2050; services for taxpayers with special hearing and / or speaking needs= 1-800-447-$020 CTT only)o OBJECTIONS= Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest} as shown on this Notice must ob§act within sixty (60) days of receipt of this Notice --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADNIN- ISTRATIVE CORRECTIONS= Factual errors discovered on this assessment should be addressed in writing to= PA Department of Revenue, Bureau of Individual Taxes, ATTN= Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for e Resident Decedent" CREV-1501) for an explanation of administratively correctable errors. DISCOUNT= If any tax due is paid within three ¢$) calendar months after the decedent's death, a five percent (SZ) discount of the tax paid is allo~ed. PENALTY= The 15Z 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 the the same time 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 date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (6X) percent pen annum calculated at a daily rate of .000164. All taxes ~hich became delinquent on and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2004 are= Interest Daily Interest Daily Interest DaiIy Year Rate Factor Year Rate Factor Year Rate Factor 1982 20Z .000548 ~'~'~'8-1991 11Z .000501 ~ 9Z .000247 1983 16Z .000458 1992 9Z .000247 2002 6Z .000164 1984 llZ .000501 1995-1994 7Z .000192 2005 5Z .000157 1985 13Z .000356 1995-1998 9Z .000247 2004 4Z .000110 1986 IOZ .000274 1999 7Z .000192 1987 10~ .000274 2000 7~ .000192 --Interest is calculated as INTEREST = BALANCE OF TAX UNPAXD X NUKBBR OF DAYS DELXNqUENT X DAXLY XNTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest caZculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date sho~n on the Notice, additional interest must be calculated. REV-1470 EX (6-88) INHERITANCE TAX EXPLANATION COMMONWEALTH OF PENNSYLVANIA DEP^RTMENT OF REVENUE OF CHANGES BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 IFILE NUMBER DECEDENT'S NAME Ann M. Williams 2103-099t ACN REVIEVVED BY Bill Lyons 101 ITEM EXPLANATION OF CHANGES SCHEDULE NO. J I1-1 There is no provision for a charitable deduction or a trust within the return. ROW Page 1 BUREAU OF ZNDZVTDUAL TAXES DEPT. Z80601 HARRISBURG, PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEHENT OF ACCOUNT REV-i~D7 EX &FP (01-05) SAMUEL L ANDES 5Z5 N 1ZTH ST LEMOYNE PA 170q$ DATE 08-16-200q ESTATE OF WILLIAMS DATE OF DEATH 09-18-2005 FILE NUMBER 21 03-099! COUNTY CUMBERLAND ACN 101 Aeoun~ Remi'l:'l:ed ANN M MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper crmdi~ ~o your account, subei~ ~he upper portion of ~his form wi~h your ~ax payment:. CUT ALONG TH'rS LINE ~ RETA'rN LOWER PORTION FOR YOUR RECORDS ~ REV-1607 EX AFP (01-03) ESTATE OF WILLIAMS #~ INHERITANCE TAX STATEMENT OF ACCOUNT ~-~ ANN M FILE N0.21 03-0991 ACH 101 DATE 08-16-200q THIS STATEMENT 1S PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELO# ZSA SUMMARY OF THE PRINCIPAL TAX DUE, APPLZCAT/ON OF ALL PAYMENTS, THE CURRENT BALANCE, AND, ZF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-21-Z00q PRINCIPAL TAX DUE: ........................................................................................................................................................................................................................... 227.36 PAYMENTS (TAX CREDITS): PAYMENT DATE 07-OZ-ZOOq RECEIPT NUMBER CDOOqll5 DISCOUNT (+) INTEREST/PEN PAID (-) .35- ZF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCT/ONS. ) AMOUNT PAID 227.81 TOTAL TAX CREDIT 227.q6 BALANCE OF TAX DUE .1OCR INTEREST AND PEN. .00 TOTAL DUE .1OCR STATUS REPORT UNDER RULE 6.17 Name of Decedent: Ann Marie Williams Date of Death: 09-18-2003 Wilt No. Admin. No. 21-03-0991 To the Register: 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 2. If the answer is No, state when the persona[ representative reasonably believes that the administration wi[[ be complete: 3. If the answer to No. 1 is Yes, state the fo[towing: A. Did the persona[ representative file a final account with the Court? Yes No Y B. The separate Orphans' Court No. (if any) for the persona[ representative's account is: C. Did the persona[ representative state an account informally to the parties in interest? Yes ~' No D. Copies of receipts, re[eases, joinders and approvals of formal or informal accounts may be fi[ed with the Clerk of the Orphans' Court and may be attached to this report. , Name: Samuel L. Andes ~: '.' Address: 525 N. 12th Street :=: Lemoyne, PA 17043 Telephone # 717 761-5361 : Capacity: · ~ Counsel for Personal Representative