HomeMy WebLinkAbout03-0379PETITION FOR PROBATE and GRANT OF LETTERS
also known as
No. c~_/- t'~ ~-
Social Security No. / '7 ~- bltt~--' ~9'~e~ed'
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age_or older a.n the execut tOff-
in the last wilt of the above decedent, dated
and codicil(s) dated
To:
Register of Wills for. the
County of &/Jd~/~n the
Commonwealth of Pennsylvania
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
D~ecendent was domiciled at death in c///~/]')~}?_~/~f) _~ _ Col~ntv.~eansvlvania with
h i b last family or principal residence at ~2~-~./~. Offf.~')ff_~J~ ']~__/f,~' ' . ,. !
(list street, number atnd muncipality)
Decendent. then ~.'-'-'/ ,,ear o1~ age, died
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 in Pa.) All personal property $
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows:
WHEREFORE, petitioner(s) respectfully
presented herewith and the grant of letters
theron.
PlY
~ 0
request(s) the probate of the last will and codicil(s)
(testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF~ ss
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and t~tgt as personal represen-
tative(s) of the above decedent petitioner(s) will well a])d~truly adngiaigter~state according to law.
Sworn to or affirmed and subscribed
before me_this a.~ day of ! _
~~d~f~_~~egiste~' L
No. ~,/-,o¢-,.ff_-~ ?
Estate0f /T]~o~,,,~I f~_ Z~r~tc~le ,Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW
the .reverse side hereof, satisfactory proof having l~n presented before me,
IT IS DECREED that the instrument(s) dated ~--~ ~T
described therein be admitted to probate and filed of record as the last will of
and Letters '-~"~'~T
are hereby granted to
~, in consideration of the petition.on
FEES
S~rt ~'~rtificates( )...' .......
ation ................ $.
TOTAL
Filed ../~ >2.....~~ ...........
A'I'rORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
IEF ~L'R T~S
WARNING: IT IS ILLEGAL TO ALTER THIS COPY OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
CO~IMONWEALTH OF PENNSYLVANIA
DEPA~TfCENT OF HEALTH VITAL RECORDS
LOCAl. REGISTRAR'S CERTIFICATION OF DEATH
CERT. NO. T 5380089
- I~ate of Issue-of This-C~rtCCication
Name of Decedent ""*r-),t_~/. Jt '-"-~-'~ .,i~,~t~ ~~t~'4~J ~/
Sex ~ {~ Soo,~ Se~.~ ~o. / 7~ - ~ - ~g~ ~e o~ ~e~, C~ ~]~/, ~
Date of Birth). ~J. ~, /~1 Birthplace ~ ~ , ~~, J ~
Place of Death ~J~ ~ 2,.~, ~ ~. _. J~ ~.~,, ~..~ennsylvania
City. Borough or Township ' ~ ' - ~
Race. ~ ~ _Occupation --~' ~ /* ~ ~] Armed Forces? (Yes or No) ~
. Deced~nt's ...... . -
[nforman~,~ ~.~[~,~. ~,~ Funeral Director ~- ~Z~.~- ~ --~ /
~ameandAddressot . ~ ~. d - / . ~ '~ ' ' -- - ....
Funeral Establishme~~/~j~,~_, ~, ~,~',~, ~ ~, ~. ~ ~ ~ ~,~ ~ /~ ~
Part I: Immediate Cause Inte~al Between
Onset and Death
(b) ~
(c) ,
(d)
Part I1' Other Sign~fi/cant Conditions
Manner of Death
Natural ~ Homicide []
Accident [~ Pending Investigation []
Suicide ~ Could not be Determined []
Describe how injury occurred:
Name and Title of Certfier ~'~_~L ,, L)~.: .~_~,..k-~ ; ~.._,)¢ E ~L..~.~.e~;.,
~(M.D., D.O., ~roner, M.E.)
Address_ ~37~/~~, ....... j~). /~ .'.~)~/~~ ~_ ~~
This is to certify that the information here given is correctly copied from an original certificate
of death duly filed with me as Local Registrar. The original certificate will be forwarded to the
State Vital Records Office for permanent filing~
~~ ~ ' ~0¢ Registra~it,I Records '~ -- - District NO
Loca~ ReCstrcr / Street Add .... -- - / - ' / City, B~rough. To~nshi~
SlI!AA .~o
OF
MICHAEL A. FORNICOLA
I, MICHAEL A. FORNICOLA, declare this to be my Last Will and Testament and hereby
revoke all prior wills and codicils made by me.
FIRST: My Executor shall pay from the residue of my estate all my debts, funeral and
administration expenses and all estate, inheritance, succession and transfer taxes imposed by the United
States or any state, territory or possession which shall become payable by reason of my death. It shall
not be necessary to file any claims therefor, nor to have them allowed by any court.
SECOND: I give and bequeath my guns to my brother, THOMAS E. FORNICOLA, provided
he survives me.
THIRD: I give and bequeath my grandfather's watch to my sister, PATRICIA E.
BACKENSTOE, provided she survives me, with the stipulation that she never sell the watch, but
instead pass it on through the family.
FOURTH: I give and bequeath my tools, in equal shares, to my brothers, THOMAS E.
FORNICOLA and JOHN C. FORNICOLA, or the survivor thereof, as they select.
FIFTH: I bequeath all remaining tangible personal property (except motor vehicles, cash and
securities) to my brothers and sister, JOHN C. FORNICOLA, THOMAS E. FORNICOLA and
PATRICIA E. BACKENSTOE, living at the time of my death as they may select in as nearly equal
shares as is practical. If there is any disagreement as to distribution, I direct my Executor to make such
LAST WILL AND TESTAMENT
OF
MICHAEL A. FORNICOLA
distribution. The decision of my Executor shall be final and binding. Any items not selected may be
distributed in the sole discretion of my Executor and, if sold, the net proceeds therefrom shall be added
to the residue of my estate.
SIXTH: I give and devise the residue o£my estate, real, personal and mixed, of whatever kind
and nature, and wherever situate at the time of my death, unto my brothers and sister, JOHN C.
FORNICOLA, THOMAS E. FORNICOLA and PATRICIA E. BACKENSTOE, and my daughter,
ALESHA M. FORNICOLA, in the following proportions:
Fifteen (15%) percent to my brother, JOHN C. FORNICOLA, if he survives
survives me.
D.
survives me.
Forty (40%) percent to my brother, THIOMAS E. FORNICOLA, if he survives
Fifteen (15%) percent to my sister, PATRICIA E. BACKENSTOE, if she
Thirty (30%) percent to my daughter, ALESItA M. FORNICOLA, if she
If any of my above-named beneficiaries predecease me, I direct that his or her share shall be
distributed to his or her issue, per stirpes, and in default of any such then living issue, such share shall
be divided into equal shares and added to the share or shares for my other beneficiary or beneficiaries.
2
LAST WILL AND TESTAMENT
OF
MICHAEL A. FORNICOLA
SEVENTH: I have knowingly and intentionally omitted my ex-wife and son as beneficiaries of
my estate.
EIGHTH: I nominate, constitute and appoint my brother, TItOMAS E. FORNICOLA,
Executor of this my Last Will and Testament, to serve without bond or security, and to make
distribution of my estate in cash or in kind, or partly in cash and partly in kind, and in such manner as
he may determine. I authorize, empower and direct him to sell, and convey, by good and sufficient deed,
in fee simple estate, any and all of my real estate, at public or private sale, for such price or prices, upon
such terms and conditions, as in his judgment is best for my estate, and to that end to sign, seal, execute,
acknowledge and deliver all deeds or other instruments necessary therefor, as effectively as ! could do
if I were personally present.
In the event such person does not survive me, or refuses to act as Executor or does not complete
the duties of Executor, then I nominate, constitute and appoint my daughter, ALESItA M.
FORNICOLA, as the alternate Executrix, to serve without bond or security. My alternate Executrix
shall have all of the powers, privileges, duties and immunities granted to my Executor as provided
herein.
NINTH: No beneficiary shall have the power to anticipate, encumber or transfer his or her
interest in my estate or any trust created herein in any manner other than by the valid exercise of a Power
of Appointment. No part of any trust or my estate shall be liable for or charged with any debts,
3
LAST WILL AND TESTAMENT
OF
MICHAEL A. FORNICOLA
contracts, liabilities or torts of a beneficiary or subject to seizure or other process by any creditor of a
beneficiary.
TENTH: Except as otherwise provided herein, should any distributee of my estate be a minor,
or, in the opinion of my Executor, be mentally or physically incapacitated, my Executor may pay his or
her share of my estate to the parent or guardian of the distributee, or to any person taking care of the
distributee, or, in the case of a minor, may deposit the share in a savings account, made payable to the
minor upon attaining majority, which I define as twenty-one (21) years of age.
IN WITNESS WHEREOF, I, MICHAEL A. FORNICOLA, the Testator, have to this my
Last Will and Testament, set my hand and seal this ~ day of ~"~~ ,1999.
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 have hereunto subscribed our names at his request, as witnesses
hereto, in the presence of the said Testator, and of each other. The preceding document consists of this
and three (3) other consecutively numbered typewritten pages.
residing at
4
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA )
) SS.:
COUNTY
I, MICHAEL A. FORNICOLA, the Testator whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act
for the purposes therein expressed.
Testator, this ~ day of~.-~9~ ~ ,1999.
No~ary Public
or
Attorney-at-Law
NOTARIAL SEAL
ANN MARIE BONAWtTZ; Notary Public
City of Harnsburg, Dauphin County
My Commission Expires Dec. 9, 1999
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA )
) SS.:
COUNTY
OF ~._~ fx~ ~/,~w~. )
witnesses whose names are signed t~' the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw the Testator sign and execute the
instrument as his Last Will; that the Testator signed willingly and executed it as his free and voluntary
act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the
Testator signed the Will as a witness; and that to the best of our knowledge the Testator was at that time
18 or more years of age, of sound mind and under no constraint or undue influence.
Sworn to~affirmed ar~d.su~,gt~ibed to before me by C~#d~z~J[OA {) ~.~OT/4t~_
Witness
- No'ta'~'btibli:
or
Attorney-at-Law
.(SEAL)
NOTARIAL SEAL
ANN MARIE BONAWlTZ, Notary Public
City of Harrisburg, Dauphin County
My Commission Expires Dec. 9, 1999
REV-1500 EX + (6-00)
COMMONWEALTH Of
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 210601
HARRISBURG, PA 17128-0601
M.I
Z
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Fornicola, Michael A.
DATE OF DEATH (MM-DD-Year) I DATE OF BIRTH (MM-DD-Year)
04/21/2003 I 09/2911951
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL).
OFFICIAL USE ONLY
FILE NUMBER
2 1 -0 3 0 3 7 9
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
1 7 4-4 0-8 0 8 0
THIS RETURN MUST BE FILED IN DUPLICATE WFrN THE
REGISTER OF WILLS
SOClALSECURITYNUMBER
[] 1. Original Retum
E~]4. Limited Estate
[~6. Decedent Died Testate (Attach copyofWill)
[] 9. Litigation Proceeds Received
r'-~ 2. Supplemental Retum
[~4a. Future Interest Compromise (da~ of death after 12-12-82)
r--~ 7. Decedent Maintained a Living Trust (,~ach copy of Trust)
[~ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1.1-95)
[~3. Remainder Return (date of death prior to 12-13-82)
~'15. Federal Estate Tax Retum Required
m 8. Total Number of Safe Deposit Boxes
[~ 11. Election to tax under Sec. 9113(A) (A~ach Sch O)
NAME
Thomas E. Fornicola
FIRM NAME (If Applicable)
Executor of the Estate of Michael A. Fornicola
TELEPHONE NUMBER
814-383-4519
COMPLETE MAILING ADDRESS
866 Forest Avenue
Bellefonte, PA 16823
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property {5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
[~] 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. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
OFFICIAL USE ONLY
(8)
137,535.37
137,535.37
9,920.25
338.54
(11)
10,258.79
127,276.58
(12)
(13)
(14) 127,276.58
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Bue
X (15)
38,182.97 X .045 (16) 1,718.23
89,093.61 X .12 (17) 10,691.23
X .15 (18) 0.00
(19) 12,409.46
REV-1508~ EX + (1-97) f~~
COMMONWEAl_IH OF P£NNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Fgrni~l~, Michael A. 21 03
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorshi
ITEM
NUMBER DESCRIPTION
1. Capital Growth Account with First Union National Bank, Account #3014087344756
10.
11.
12.
13.
14.
15.
16.
First Union High Performance Money Market Account with First Union Bank,
Account #101004941992
DDCU Account with First Union National Bank, Account #1100630137653
Local 520 U.A. Federal Credit Union Account, Account #1405-01
Cash available
Unemployment Compensation income to estate (total of 2 checks of equal amount)
Refund check from Local 520 U.A. (Union dues)
Vehicle insurance reimbursement to estate
Personal property sold
Local 520 U.A. Health and Welfare Account (burial benefit)
Local 520 U.A. death benefit account
Local 520 U.A. pre-retirement death pension
Local 520 M.A. pension benefit
996 Ford F-150 Truck, VIN #1FTEF14Y8TLB51472
;oins found in Safe Deposit Box
Firearms, Mossberg 9200 Shotgun
TOTAL (Also enter on line 5, Recapitulation
0379
must be disclosed on Schedule F.
VALUE AT DATE
OF DEATH
11,036.71
5O,953.79
2,359.24
2,267.93
343.00
860.00
50.00
348.60
290.00
1,900.00
5,000.00
27,000.00
27,946.20
5,930.00
89.90
200.00
$ 137,535.37
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
Fdrnicola, Michael A. 21 03
Pa§e 1
Schedule E - Cash, Bank Deposits, & Misc. Personal Property
0379
ITEM VALUE AT DATE
NUMBER DESCRIPTION OFDEATH
17. Firearms, Winchester 70 Stainless Steel Classic with Scope 450.00
18.
19.
Pocket watch w/chain
Miscellaneous personal property
SUBTOTAL SCHEDULE E
GRAND TOTAL SCHEDULE E
175.00
335.00
960.00
$ 137,535.37
REV-1511EX * (1-97)~ ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Fornicola. Michael A.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21 Q~
ITEM
NUMBER
1.
2.
3.
8.
9
10.
12.
DESCRIPTION AMOUNT
FUNERAL EXPENSES:
Wetzler Funeral Home
Mayes Memorial - headstone
Funeral luncheon (church donation)
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Secudty Number(s) / EIN Number of Personal Representative(s)
Street Address
City State
Year(s) Commission Paid:
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Zip
Street Address
City State Zip.
Relationship of Claimant to Decedent
Probate Fees Cumberland County Register of Wills
Accountant's Fees
TaxRetum PreparefsFees H&R Block
Preparation of Inheritance Tax Return to H&R Block
Estate publication fees to The Sentinel
Vehicle transfer costs
Trash removal to James Maran
Facsmile fee to McLanahan's
7,195.00
1,640.00
200.00
365.00
200.00
150.00
74.75
60.50
15.00
20.00
TOTAL (Also enter on line 9, Recapitulation) $ 9,920.25
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (1-97) ~,~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES~& LIENS
ESTATE OF
Fornicola. Michael A.
Include unreimbursed medical expenses.
FILE NUMBER
21 0;)
0879
ITEM
NUMBER DESCRIPTION
1. James Maran, Jr. - apartment rent
PP&L - electrical power
Verizon - telephone
Central Fill, Inc. - prescriptions
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
AMOUNT
175.00
98.12
35.42
30.00
338.54
REV-1513 EX + 11-97) ~
1
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Fornicol~
NUMBER
II.
Michael A.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Thomas E. Fornicola
866 Forest Avenue
Bellefonte, PA 16823
John C. Fornicola
846 Green Pond Road
Rockaway, NJ 07866
Patricia E. Fornicola
130 Collins Avenue
Bellefonte, PA 16823
Alesha M. (Fornicola) Hollinger
446 Pleasant Valley Drive
Conshohocken, PA 19428
FILE NUMBER
21 03
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Brother
Brother
Sister
Daughter
O379
AMOUNT OR SHARE
OF ESTATE
4O%
5%
5%
30%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE ON REV 1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - 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)
OF
MICHAEL A. FORNICOLA
I, MICHAEL A. FORNICOLA, declare this to be my Last Will and Testament and hereby
revoke all prior wills and codicils made by me.
FIRST: My Executor shall pay from the residue of my estate all my debts, funeral and
administration expenses and all estate, inheritance, succession and transfer taxes imposed by the United
States or any state, territory or possession which shall become payable by reason of my death. It shall
not be necessary to file any claims therefor, nor to have them allowed by any court.
SECOND: I give and bequeath my guns to my brother, THOMAS E. FORNICOLA, provided
he survives me.
THIRD: I give and bequeath my grandfather's watch to my sister, PATRICIA E.
BACKENSTOE, provided she survives me, with the stipulation that she never sell the watch, but
instead pass it on through the family.
FOURTH: I give and bequeath my tools, in equal shares, to my brothers, TItOMAS E.
FORNICOLA and JOHN C. FORNICOLA, or the survivor thereof, as they select.
Fi~I'H: I bequeath all remaining tangible personal property (ex,pt motor vehicles, cash and
securities) to my brothers and sister, JOHN C. FORNICOLA, THOMAS E. FORNICOLA and
PATRICIA E. BACKENSTOE, living at the time of my death as they may select in as nearly equal
shares as is practical. If there is any disagreement as to distribution, I direct my Executor to make such
LAST WILL AND TESTAMF_,NT
OF
MICHAEL A. FORNICOLA
distribution. The decision of my Executor shall be final and binding. Any items not selected may be
distributed in the sole discretion of my Executor and, if sold, the net proceeds therefrom shall be added
to the residue of my estate.
SIXT[I: I give and devise the residue of my estate, real, personal and mixed, of whatever kind
and nature, and wherever situate at'the time of my .death, unto my brothers and sister, JOHN C.
FORNICOLA, T[IOMAS E. FORNICOLA and PATRICIA E. BACKENSTOE, and my daughter,
ALES[IA M. FORNICOLA, in the following proportions:
A. Fitteen (15%) percent to my brother, JO[IN C. FORNICOLA, if he survives
me.
Forty (40%) percent to my brother, THOMAS E. FORNICOLA, if he survives
me.
Fifteen (15%) percent to my sister, PATRICIA E. BACKENSTOE, if she
survives me.
D.
Thirty (30%) percent to my daughter, ALES[IA M. FORNICOLA, if she
survives me.
ff any of my above-named beneficiaries predecease me, I direct that his or her share shall be
distributed to his or her issue, per stirpes, and in default of any such then living issue, such share shall
be divided into equal shares and added to the share or shares for my other beneficiary or beneficiaries.
LAST WILL AND TESTAMENT
OF
MICHAEL A. FORNiCOLA
SEVENTH: I have knowingly and intentionally omitted my ex-wife and son as beneficiaries of
my estate.
EIG[IT//: I nominate, constitute and appoint my brother, TI/OMAS E. FORNICOLA,
Executor of this my Last Will and Testament, to serve without bond or security, and to make
distribution of my estate in cash or in kind, or partly in cash and partly in kind, and in such manner as
he may determine. I authorize, empower and direct him to sell, and convey, by good and sufficient deed,
in fee simple estate, any and all of my real estate, at public or private sale, for such price or prices, upon
such terms and conditions, as in his judgment is best for my estate, and to that end to sign, seal, execute,
acknowledge and deliver all deeds or other instruments necessary therefor, as effectively as I could do
ifI were personally present.
In the event such person does not survive me, or refuses to act as Executor or does not complete
the duties of Executor, then I nominate, constitute and appoint my daughter, ALE$1~A M.
FORNICOI~, as the alternate Executrix, to serve without bond or security. My alternate Executrix
shall have all of the powers, privileges, duties and immunities granted to my Executor as provided
herein.
NINTIt: No beneficiary shall have the power to anticipate, encumber or transfer his or her
interest in my estate or any trust created herein in any manner other than by the valid exercise of a Power
of Appointment. No part of any trust or my estate shall be liable for or charged with any debts,
LAST WILL AND TESTAMENT
OF
MICHAEL A. FORNICOLA
contracts, liabilities or torts of a beneficiary or subject to seizure or other process by any creditor of a
beneficiary.
TENTIt: Except as otherwise provided herein, should any distributee of my estate be a minor,
or, in the opinion of my Executor, be mentally or physically incapacitated, my Executor may pay his or
her share of my estate to the parent or guardian of the distributee, or to any person taking care of the
distributee, or, in the case of a minor, may deposit the share in a savings account, made payable to the
minor upon attaining majority, which I define as twenty-one (21) years of age.
h~ WITNESS WHEREOF, I, MICHAEL A. FORNICOLA, the Testator, have to this my
Last W'fll and Testament, set my hand and seal this ~ day of ~'~~ , 1999.
( 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 have hereunto subscribed our names at his request, as witnesses
hereto, in the presence of the said Testator, and of each other. The preceding document consists of this
and three (3) other consecutively numbered typewritten pages.
residing at
AFFIDAVIT
COIvlMONWEALTH OF PENNSYLVANIA )
) ss..
cot ,'
witnesses whose names are signed to/the attached o~: foregoing instrument, being · y qualified
according to law, do depose and say that we were present and saw the Testator sign and execute the
instrument as his Last W'fll; that the Testator signed willingly and executed it as his flee and voluntary
act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the
Testator signed the Will as a witness; and that to the best of our knowledge the Testator was at that time
18 or more years of age, of sound mind and under no constraint or undue influence.
1999.
Witness
Nomad'S'Public ...... ~ --
or
Attorney-at-Law
ANN MARIE BONAWITZ,:Notm~ Publlo I
NOTARIAL SEAL
City o~ Ham~uq], Dauphin County
My Oomml~,,ton Expim~ Deo. 9, 19~0
ACKNOWLEDG ,MENT
COMMONWEALTH OF PENNSYLVANIA )
) SS.'
COU~X',' OV ~.~.,{-)/,~..& )
I, MICHAEL A. FORNICOLA, the TestatOr whose name is signed to the attached or foregoing
instmment, having been duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last W'fll; and that I signed it willingly and as my free and voluntary act
tbr 'the purposes thereto expressed.
Sworn to or affirmed and~~ed~kbefOre me by MICHAEL A. FORNICOLA, the
Testator, this ~,day of ' ,1999.
Notiu'y Public
or
Attorney-at-Law
ANN MARIE BONAWIff'~'No#~'Y PuI~I~ !
NOTARIAL SEAL
My Commission Expires Dee. g, lg99
LETTERS TESTANENTARY
ESTATE OF
MICHAEL A FORNICOLA
-LATE OF
LOWERALLEN TOWNSHIP
CUMBERLAND COUNTY
PENNSYLVANIA
LETTERS ISSUED: 05-02-2003
NUMBER: 21-03-379
REGISTER OF WILLS &
CLERK OF THE ORPHANS' COURT
Cumberland County Courthouse
Carlisle, Pennsylvania 17013
Register of Wills of CUMBERLAND County, Pennsylvania
Certificate of Grant of Letters
WHEREAS, on the 2nd
dated September 20th 1999
No. 2003-00379 PA No. 21-03-0379
ESTATE OF FORNICOLA MICHAEL A
(Las'r, ~'i~'i', ~i~)
Late of LOWER ALLEN TOWNSHIP
Deceased
Social Security No. 174-40-8080
day of May 2003 an instrument
was admitted to probate as the last will of FORNICOLA MICHAEL A
late of LOWER ALLEN TOWNSHIP , CUMBERLAND County, who died on the
21st day of April 2003 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, DONNA M. OTTO , Register of Wills in and for
the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify
that I have this day granted Letters TESTAMENTARY
to FORNICOLA THOMAS E
who has duly qualified as Executor(rix)
and has agreed to administer the estate according to law, all of which fully
appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my Office the 2nd day of May 2003.
~glsEer 0~- Wli£S' -
**NOTE** ALL 5IAMES ABOVE APPEAR (LAST, FIRST, MIDDLE)
~ .... ' DATES OF SERVICE EXCLUDED REMARKS ALLOWED PAID BY PERCENT REMARKs AMOUNT
EFIT FROM-THRU CHARGE AMOUNT CODE AMOUNT DEDUCTIBLE OTHERS PAY CODE PAYABLE
fe 4/21/2003 $5,000.00 $1000.00 .%,000.00
Federal
Income
Tax
3ELO¥
REMARKS
Claim Benefits: Active Death Benefits
Remarks Codes: Michael Fornicola
Thomas Fornicola- executor 207-44-0664
Participant:
Patient=
Invoice:
Provider:
Claim ~:
Check #:
Michael Fornicola
Thomas Fornicola-executor
52682 Check Date: 7/14/2003
~ ~gh Performance Money Mark~'t ~:: . ' . :' · . ~' ~ ~
01 1010049419492 752 30 u 10 '.)0,7~(" ; m,....
00009625 .............. SNGLP
h,,Ihlh,h,h,,hh,lhh,h,,hh,,Ihhh,lh,,Ih,,,hU
MICHAEL A FORNICOLA
C/O THOMAS FORNICOLA
866 FOREST AVE
BELLEFONTE PA 16823
PB
High Performance Money Market
Account number: 1010049419492
Account holder(s): MICHAEL A FORNICOLA
Account Summary
Opening balance 4/16 $50,953.79
Interest paid 46.84 ~.-
Other withdrawals and smvice fees
51,000.63.
Closing balance 5/15
$0.00
Deposits and Other Credits
Date Amount Description
5/12 46.<34 INTEREST FROM 04/16/2003 'i HROUGH 05/1~2003
Total $46.84
4/16/2003 thru 5/15/2003
Interest
Number of days this statementperiod
Annual percentage yield earned
Interest earned this statement period
Interest paid this statement period
Interest paid this year
Other Withdrawals and Service Fees
Date Amount Description
5112
Total
26
1.30%
$46.84
$46.84
$264.91
51,000.63 DEBITTO CLOSE ACCOUNT
$51,00,0.63
AS YOU REQUESTED YOUR ACCOUNT IS NOW CLOSED, lIND THIS IS THE
FINAL STATEMENT. IF YOU HAVE ANY QUFSTIONS OR WI,~;H TO REOPEN
THIS ACCOUNT, CALL US AT 1-800-275-3862, OR CONTACT YOUR LOCAL
FINANCIAL CENTER. WE APPRECIATE YOUR BUS/NESS.
Moving? Relocating into a new home is enough of a c~ore.
But changing your address can be a breeze.
Just use Address Express. It's quick, easy, convenien~;
and FREE. Simply call 1-800-430-4418 to order your
Address Express kit, or go to wachovia.com/adclres=~,xpress
FIRST UNION NATIONAL BANK, MECHANICSBURG page 1 of 2
, 01 '.:':' ':, 97::4.:~': 56 752 $C 0 1(I 48,437 ,
PB
Capital Growth ccount
Account number: 3014[~37344756
Account qolder(s): :dI[:;H:~EL h FORNICOLA
Accottnt SummaL,,-3(- ......
Opening aalance 4_..__~/16 $11,036.71
Interest j~aid .......... 0.97 +
Othe~ wimdrawals and s~,vic~, i~e~. 11,037.68 -
Closing balance 5/15
$0.00
Deposits and Other C r'cdits
Date Anl~ ~Jnt ~ ~u.. crip, ion
5/02 ,? 97 1,1'~ :_Rl:.$'r FROM 04/16/2003 THROUGH 05/02/'~_003
4/16/2003 thru 5/15/2003
Interest
Number of days this state,,ne~t F ~m ~d
Annual percentage yield ~ar~ e~:l
Interest earned this stater,~ent p~.ri~;d
Interest paid this statement p~rk,d
Interest paid this year
Other Withdraw~ds am~ Service Fees
Date Amc, ~nt I e~ .:rip,~on
5/02
16
0.20%
$0.96
$0.97
$8.75
11,037 68 [:,E;AIT 're OLOSE ACCOUNT
$11~037 ~
AS YOU ~tr.:)t.i!i:k rED YOUR ACCOUNT IS NOW CLOSED, AND THIS IS THE
FINAL 'J"; 'A 7 E/vJEJVT. IF YOU HA YE ANY QUESTIONS OR WISH TO REOPEN
THIS ACi ~£),IJN /; , ~At L US AT 1-800-275-3862, OR CONTAC T YOUR LOCAL
FINANCI,~L ,3[:?.~TF.R. WE APPRECIATE YOUR BUSINESS.
Moving ? ~elocidi/~il in~o a new home is enough of a chore.
But chan./ir,~/ )'~ ut adoress can be a breeze.
Just usu -%~le,~.s ~;~pcess It's quick, easy, convenient,
and FRE,.~. ?;~m~ fly carl 1-800-430-4418 to order you/
Address ?.xt;ras ; ~t, or go to wachovia, com/addressexpress
~i~ FIRST UNION NATIONAL t:IANK, MECHANICSBURG
page 1 of 2
CDI2 A330054 TCCP5470
Sei
MICHAEL A FORNICOLA
2225 B ORCHARD RD
CAMF HILL PA 17011
Customer Detail Inquiry
040815651 CZlll901 05/02/03
11:51
MORE: +
Tax Id: S174408080
Customer Assets
$ 64349.74+
Customer Liabilities
$ 0.00+
S-Org-Serv-Account Number/Ma5 Date-Prod-J/S-St Date .... Cmt-Balance ...... ~-I
075 DDA 1010049419492 HPMM S OP 02222002 Y 50953.79+~
075 DDA 1100630137653 DDCU S OP 07171992 N 2359.24+
075 SAV 3014087344756 SCGP S OP 04011995 N 11036.71+
075 SDB 07585398A0003
075 CDA 247412041472583
075 CDA 247412030563352
075 CDA 247412030726040
~)~5 CDA ~4741204097i592
075 CDA 247412041304655
~75 CDA 247412046057306
BALANCE INQUIRY COMPLETED
SDB S OP 05231994 N
204 S CL 02222002 N
203 S PG 06151999 N
203 S PG 11151999 N
204 S PG 08152000 N
204 S PG 02202001 N
204 S PG 04201998 N
PRESS F9 FOR BALANCE
Command:
Fl~=Help F3=Ext F4=Nxt F5=Sold F6=Add Lead F7=Bkwd F8=Fwd F10=Lt Fll=Rt F24=CSEL
5;o u. 41
FEDERAL CREDIT UNION ~
7]87 donestown Road · Harrisburg, PA 17112
Phone (717) 545-9329
MICHAEL A FORNICOLA
22258 ORCHARD ROAD
CAMP HILL PA 17011
00
your right to dispute errors on your
ACCOUNT NUMBER: 1405
YTD DIV RECEIVED~ 4.90
PAGE Nt~ER~ 1
YOU CAN NOW WITHDRAW FUNDS FROM
YOUR SHARE ACCT. WITHOUT CA~.LING
THE CREDIT UNION. CALL FOR INFO.
SUFFIX 01 REGULAR SHARES
STATEMENT PERIOD 04/01/03 - 06/30/03
BEGINNING BALANCE 1,045.84
DEPOSITS 2 1,222.09
WITHDRAWALS 1 2,267.93
ENDING BALANCE .00
DIVIDEND YEAR-TO-DATE
DIVIDEND THIS PERIOD
AVERAG~ DAILY BALANCE
DAYS DIVIDEND EARNED
SUMMARY OF YOUR ACCOUNTS
4.90
.00
88~. S4
91
SUFFIX 01 REGULAR SHARES
HISTORY
DATE DESCRIPTION TRANSACTION AMOUNT ACCOUNT BAL~CE
4/25/03 BATTA/MAR 03 176.25 1,222.09
5/16/03 LIFE SAVINGS 1,045.84 2,267.93
5/29/03 MEMBER DECEASED 2,267.93- .00
/lief 3om~'bl°wn P' a~'
phone [/17) ,54h 9329
Time: 9:53:49
~-an Oes~
........ {405-01 ~GSHR ~ LIFE SAVINGS
Teller: 04
1045.84
Receipt No: 32685
2267.93
Signature:
MICHAEL A FORNICOLA
22258 ORCHARD ROAD
CAMP HILL PA 17011
Cash In:
Checks In:
Cash Out:
Remember to include your member number
and applicable account with all payments
Plumbers and Pipefitters Union
7193 JONESTOWN ROAD ® HARRISBURG, PA 17112
TELEPHONE: (717) 652-3135 · FAX: (717) 541-8908
Business Manager
JOSEPH A. CROWN II
Businesa Agents
JAMES G. CARPENTER
J. STEVE HOFFMAN
Business Agents
TERRY E. PECK
GEORGE VON NIEDA
Financial Secretary
RANDALL N. DIPALO
June 10,2003
Mr. Thomas Fornicola
2225-B Orchard Road
Camp Hill, PA 17011-1243
Dear Mr. Fornicola:
Please find enclosed check number 60608 in the amount of $1,900.00.
This check is the amount due you from the United Association for burial
expenses.
Also, please find enclosed check number 19787 in the amount of $50.00,
which represents dues paid in advance.
If we can help you in any way, please don't hesitate to call.
Sincerely,
LOCAL 520, PLUMBERS & PIPEFITTERS
Randall N. DiPalo
Financial Secretary
R N D/taj
This State~nent issued in lieu of a Form 1099-Misc. Miscellaneous Income.
United Association of JAPPI
, 901 Massachusetts Ave., N.W.
Washington, DC 2001
EIN:53-0159020
UA Member: MICHAEL A. FORNICOLA
Beneficiary Name:
Address:
The Estate Of
MICHAEL A. FORNICOLA
2225B ORCHARD RD
CAMP HILL, PA 17011
1099 -MISC Burial Benefit Payment
Box 3 Other Income
For Calendar Year
2003
Taxpayer ID Number
174-40-8080
Benefit Amount
$1,900.00
Instructions for Recipient - Form 1099-MISC:
Both individuals and estates should report the taxable amounts on this form on the line for "Other Income"
on form 1040 or form 1041 and identify the type of income received.
This is important tax information and is being furnished to the Internal Revenue Service. If you are required to
file a return, a negligence penalty or other sanctions may be imposed on you if this income is taxable and IRS
determines that it has not been reported.
LOCAL 520, PLUMBERS & PIPEFITTERS
RND/taj
Randall N. DiPalo
Financial Secretary
[0/I~/9 q~eea lo e~ea
I I I I
S qV&O& ~&V~ O~
~SH~ O0'O09'iZ O0'O0~g O0'O00~Z~
00'009'I~ O0'O0~'g O0'O00'lZ
RELIANCE TRUST COMPANY DETACH BEFORE DEPOSmNG
PLAN NO. 158426
PLUMBERS & PIPEFrR'ERS 520
PARTICIPANT ESTATE OF MICHAEL FORICOLA
No. 383475
LUMP SUM DISTR-FULLY VESTED TO
Payable Date NET AMOUNT
09/16/2003 $22,356.96
CURRENT YEAR-TO-DATE
GROSS $27,946.20 $27,946.20
FED WTH $5,589.24 $5,589.24
STATE WTH
TPA FEE
RELIANCE FEE '"-
REMOVE CHECK ALONG THIS PERFORATION ;'
~ ,,".' .,,". ~,,". .,,". .,,". ~,,'. .,,"' ~,,"' ~i," ~i," ~i,"
. ~ ~.. ¢, .'.~ , .'.~ , '.~ ~;~... .,~ '. ~;~".
~.,. . .~, , . , '~' , .~, , -~, , ~ , ~ ., ,. · .
. .........
01354
RICHAEL A FORNICOLA
866 FOREST AVE
BELEFONTE
PA 16823-8215
HICHAEL A FORNICOLA
866 FOREST AVE
BELEFONTE
PA 16823-8215
Policy Number: 5837c 661607
Refund Amount: $ ****348.60
Check Number: 58245982
Check Issued: 05-20-2003
This refund was issued for the following reason(s):
CANCELLATION CREDIT REFUND.
If you have any questions, please contact your Nationwide representative.
Agent Name: /q FERSTER BS
Agent Phone Number: 717-243-6877
Agent Number: 0008509
Detach Stub Before Cashing And Keep For Your Record
CHECK NUMBER
00843114
BENEFIT CHECK
SEQ. NUMBER
009935
Claimant's Name
MICHAEL A FORNICOLA
Soc, Sec. Acct. No.
174-40-8080
INSTRUCTIONS
This is your unemployment compensation check for the benefit week(s)
indicated on the check and above. If you are entitled to this check as
defined by the PA Unemployment Compensation Law, carefully detach it
at the perforations and cash promptly, ff you feel you are not entitled to
this check or the check is for an improper amount, please mail it to the
office address shown at the right, do not cash it.
Week 1 Amount
04-19-03 387.00
Week 2
Amount Office PGM
0996 TEUC
Federal~thholdlngT~$43.00 I CumulativeT~Withheld$258.00
OFFICEADDRESS
LANCASTER UC SERVICE CENTER
60 W. WALNUT STREET
LANCASTER PA 17603-3015
DIRECT DEPOSIT SAVES TIME
If you have a checking or savings account, you can have your unemployment compensation (UC) benefits electronically
deposited into a separate or joint account in your name. Direct deposit will get your benefits to you at least one day
sooner than the traditional paper check method-in some Instances, 3 to 5 days sooner! If you have direct deposit and
you file for your benefits by close of business on Wednesday, in most cases, you will have your benefits directly
deposited into your account before the weekend!
Sign up for direct deposit and receive your UC benefits faster. Mall your direct deposit application today. If you need a
form, please visit us online through the PA PowerPort at www.state.pa.us, PA Keyword: "unemployment" to request that
one be sent to you or contact your UC Service Center. If you already have submitted an authorization form for direct
deposit, please do not submit a duplicate form.
Internet service hours for filing claims: Sunday through Friday 6:00 a.m. to 9:00 p.m.
PAT service hours for filing claims: Sunday through Friday 5:00 a.m. to 9:00 p.m.
I CHECK NUMBER
00843113
BENEFIT CHECK
SEQ. NUMBER
009934
Claimant's Name
.~ICHAEL A FORNICOLA
Soc. Sec. Acct. No.
174-40-8080
INSTRUCTIONS
This is your unemployment compensation check for the benefit week(s)
indicated on the check and above. If you are entitled to this check as
defined by the PA Unemployment Compensation Law, carefully detach it
at the perforations and cash promptly. If you feel you are not entitled to
this check or the check is for an improper amount, please mail it to the
office address shown at the right, do not cash it.
Week 1 Amount
04-12-03 387.00
Week 2
Federal Withholding Tax
$43.00
AmountI Office PGM
0996 TEUC
CumulativeTax Withheld
$215.00
OFFICEADDRESS
LANCASTER UC SERVICE CENTER
60 W. WALNUT STREET
LANCASTER PA 17603-3015
DIRECT DEPOSIT SAVES TIME
If you have a checking or savings account, you can have your unemployment compensation (UC) benefits electronically
deposited into a separate or joint account in your name. Direct deposit will get your benefits to you at least one day
sooner than the traditional paper check method-in some instances, 3 to 5 days sooner! If you have direct deposit and
you file for your benefits by close of business on Wednesday, in most cases, you will have your benefits directly
deposited into your account before the weekend!
Sign up for direct deposit and receive your UC benefits faster. Mall your direct deposit application today. If you need a
form, please visit us online through the PA PowerPort at www.state.pa, us, PA Keyword: "unemployment" to request that
one be sent to you or contact your UC Service Center. If you already have submitted an authorization form for direct
deposit, please do not submit a duplicate form.
Internet service hours for filing claims: Sunday through Friday 6:00 a.m. to 9:00 p.m.
PAT service hours for filing claims: Sunday through Friday 5:00 a.m. to 9:00 p.m.
REV-485 EX+ (9-00) ~
COMMONWEALTH OF PENNSYLVANIA
,DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT· 280601
HARRISBURG, PA 17128-0601
SAFE DEPOSIT BOX
INVENTORY
Please Print or Type
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS
COUNTY CODEp/ |~'~ FILE~.~.~NUMBER(.~ 3 '7 ~ !~'~ SOClAL/~SECURI~o~ ~ oOR DEATH CERTIFICATE NUMBER
DECEDENT'S NAME (~ST, FIRST, MIDDLE) ~ DATE OF DEATH
ADDRESS OF DECEDENT (STREE~ (CI~) (STATE) (ZIP CODE)
~r~ NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
(NAME)
(STREET NAME) (CITY) (STATE) (ZIP CODE)
NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING
(NAME~. (F~ELATIONSHIP)
(STREET NAME) (Cl~) (STATE) (ZIP CODE)
b. (NAME) (RELATIONSHIP)
(STREET NAME) . (CITY) (STATE) (ZIP CODE)
c. (NAME) (RELATIONSHIP)
(STREET NAME) (CITY) (STATE) (ZIP CODE)
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
(STREET NAME) (CITY) (STATE) (ZIP CODE)
~[1~ NAME OF PERSON MAKING LAST ENTRY
DATE O[ CO~T~ ~ RENT BOX IB] NUMBER OF BOX i~
NAM~ AND ADDreSS O~ PG~SON(8) HAVING AOOGSS ~0 BOX
· W DATE AND TIME OF LAST ENTRY
TITLE UNO. ER W~IICH ~ IS REQUESTED
a. (NAME)
(STREET ADDRESS)
· (CITY) (STATE) (ZIP CODE)
NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY
b. (NAME)
(STREET ADDRESS)
(CITY) (STATE) (ZIP CODE)
m WAS A WILL IN THE BOX? [] YES [~NO If yes, a. Date of will:
b. Name and address of personal representative, if named in the will
(NAME)
(STREET NAME) (CITY) (STATE) (ZIP CODE)
c. Name and address of attorney, if any
(NAME)
(STREET NAME) (CITY) (STATE (ZIP CODE)
SAFE DEPOSIT BOX INVENTORY Page of~
!NSTRUCTIONS
(1) Cash: Report total only.
(2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be
designated by name of company, certificate number, date of certificate, name in which stock is registered, and
number of shares and class of stock.
(3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and
type of ownership, 'i.e., jbintly held, payable on death, etc.
(4) Bonds: Designate by name, amount, serial number, or other des, ignation. (Bearer Bonds)
(5) Bank and Savings and 'Loan Passbooks: State name of depositor, number of book, last date 'appea~ing in book,
name of bank and branch, and balance.
(6) Jewelry, Coins,' Stamps, Manuscripts, etc: List an~d describe as fully as possible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully
as possible.
(8) All other contents.
ITEM
NO. ' ITEM DESCRIPTION
I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF
CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY:
PRINT TITLE DATE CHECK APPROPRIATE BOX:
.____ ~__. ~~d~~~ ~~ ~ .... tot{trix) ~ Administrator(trix)
~ Estate Representative ~ Joint owner of safe de~s~t box
NOTE: Attach additional 8%" x 11" sheet(s) if necessary or use duplicates of this page of form.
Karcn Bonanno DeHaas, P.G., F.G.A.
Certified Master Gemologist
Gem & Jewelry ~lppraisals ~ Sales + Consultations + Gemology lnstt~tction
P.O. Box 263
Warriors Mark, PA 16877
July 11, 2003
(814) 632-3077
t~x (814) 632-6331
Email kbdehaas~aol.com
Miss Patty Fornicola
130 Collins Avenue
Bellefonte, PA 16823
Re: Jewelry Appraisal for the
Estate of Michael A.
Fornicola, deceased
I have this day examined and appraised a 14K gold-filled, "25 year Warranted",
open face, "Elgin" pocket watch that measures approx. 50 mm in diameter by 15 mm
deep. The watch is engraved on the back with the initials "MAF".
The watch case (#1903159) contains a 15 jewelled, safety pinion, 14 "O" size
movement by Elgin National Watch Company, serial #13744801. This watch has a white
porcelain dial and it is fully numbered with black Arabic numerals. It has gunmetal blue
hands and a sweep second hand.
The watch is attached to a 14K YELLOW GOLD watch chain that measures
approx. 4 mm wide by 22 ~A inches long, including the watch swivel and spring-ring
The chain has a solid curb link construction. It is decorated with an additional spring-
ring and a buttonhole "toggle". Attached to this chain is a gold-filled pocketknife in
excellent condition; the knife is decorated with engine-turned engraving and a rectangular
engraving plate on each side. Also attached to this chain, in a silver bezel type coin
frame, is an 1899, Liberty Head SILVER DOLLAR in FINE condition.
In my opinion, this pocket watch with the chain and attachments has a fair
ESTATE appraised valuation of $175.00 (one hundred seventy-five dollars).
(Watch = $25, chain = $110, pocketknife = $22, silver dollar = $18)
This report was prepared by:
Karen Bonanno DeHaas, P.G., F.G.A.
Certified Master Gemologist
INVOICE
Sold To:
PORT'S SPORTS EMPORIUM
1848 ZION ROAD
BELLEFONTE, PA 16823
814-355-4933
FEDERAL I.D. #25-1199417
/
7-'z.A- o'5
QUANTITY DESCRIPTION UNIT PRICE TOTAL
S U 8-101~k
' SALES T~
TOTAL
Bob's Coins
122 West Bishop Street
Belle£onte, Pennsylvania
(814)355-3015
Appraisal
/0
~ ,oo
~ ,O 0~
i~lley Blue Book Used Car Values
Page I of 2
Kelley Blue Bo k
Enter your email to get the la,test
L_~e
1996 Ford F150 Long Bed
Engine: 6-Cyl. 4.9 Liter
Trans: 5 Speed Manual
Drive: 4 Wheel Drive
Mileage: 65,000
Equipment
XL
Air Conditioning
Power Steering
AM/FM Stereo
B_Uy a New Car
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ABS (4-Wheel)
Pickup Shell/Cap
Custom Bumper
Optional Fuel Tank
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 very minimal, and a
deduction should be made to correct iL. The tires match and have
substantial tread wear left. A clean title history is assumed. A "good"
vehicle will need some reconditioning Lo be sold at retail; however
major reconditioning should be deducted from the value. Most
recent model cars owned by consumers fall into this category.
Private Party Value $5,930
Private Party value represents what you might expect to pay for a
used car when purchasing from a private party. It may also
represent the value you might expect to receive when selling your
own used car to another private party.
RECEIPT FOR PAYMENT
Cumberland County - Reqistez Of Wills
Hanover and Hiqh Street
Carlisle, PA %7013
Receipt Date
Receipt Time
Receipt No.
5/02/2003
12:50:37
1032717
FORNICOLA MICHAEL A
File Number
Remarks
2003-00379
ALESHA M FORNICOLA
AC
Transaction Description
PETITION FOR PROBA
EXTRA PAGES
SHORT CERTIFICATE
JCP FEE
Check# 1249
Total Received .........
Distribution Of Receipt ...........................
Payment Amount Payee Name
200.00
15.00
30.00
10.00
CUMBERLAND COUNTY GENERAL PUN
CUMBERLAIgD COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
$55.00
55 O0
ACTIVITY REPORT
TIME
NAME
FAX
TEL
SER. #
88/29/2883 15:44
MCLANAHAN'S
18142387552
8142345888
BROK1J675287
',NO. DATE TIME FAX NO./NAME DURATION PAGE(S) RESULT COMMENT
#858 88/28 16:36 2387552 88 88 BUSY TX
~851 88/28 16:39 2387552 88 88 BUSY TX
~852 88/28 16:45 2387552 88 88 BUSY TX
#855 88/28 16:57 2787562 48 81 OK TX
~856 88/28 17:88 2787562 41 81 OK TX
#854 88/28 17:11 2387552 88 88 BUSY TX
88/29 88:12 231 5557 19 81 OK RX
88/29 88:39 814 364 2353 33 81 OK RX ECM
#857 88/29 88:58 MCANENY 82:31 84 OK TX ECM
88/29 89:48 21 81 OK RX ECM
88/29 89:52 81:18 81 OK RX ECM
88/29 18:88 28 81 OK RX ECM
88/29 18:38 18148672492 14 81 OK R× EOM
88/29 18:44 28 81 OK RX ECM
88/29 18:44 814 238 7439 26 81 OK RX ECM
88/29 18:54 21 81 OK RX ECM
88/29 11:39 28 81 OK RX ECM
#858 88/29 11:43 17813413646 27 81 OK TX
88/29 12:87 39532843 82:39' 85 OK RX ECM
#859 88/29 13:24 18664486455 18 81 OK TX ECM
88/29 14:81 21 81 OK RX ECM
#868 88/29 14:51 17874288641 49 83 OK TX ECM
~861 88/29 15:38 17176714937 84:58 28 OK TX ECM
BUSY:
NG
CV
POL
RET
PC
BUSY/NO RESPONSE
POOR LINE CONDITION / OUT OF MEMORY
COVERPAGE
POLLING
RETRIEVAL
PC-FAX
Messenger Service Receipt
Pa Auto License Brokers Invoice,
6483 Carlisle Pike Suite 104 ::~
Mechanicsburg, Pa 17050
717-691-6720
For: Aiesha M Hoilinger
446 Pieasantvalley Dr
Conshohocken Pa 19428
610-567-0332
Clerks~i
~, File~
Title # or Date of Birth: 49669780401
VIN or Driver's Number : 1FTEF14Y8TLB51472
Tag Number or Eye Color : YKC7208
--Year-Make or Soc. Sec.# : 96FORD
Transaction : Transfer Deal
Odometer : 0
Comments:
This item will be Mailed to you.
WARNING: Bureau regulation require that any
item left in our office for 60 days be
returned to the Bureau of Motor Vehicles as
unclaimed.
Title Fee ........ ~..{~
Encumbrance Fee..~.
Tag~,Transfer...~.
Reglstration..~'~
Dui
Replacement
Tax-On $0.
Total,,ist~te
Check# .......
Commonwealth'of
22~.~50
I/We swear that I/we have applied for the
above item(s).
Sworn & subscribed to before me on 05/12/03.
Notary
Seal
Dc
CheCk
Servi
Paid~
Nofar~
EIN 25-1641815 If this is a bill you MUST
credit. Ail accounts, must be paid by the 15th of
will be granted. Partial payments are not acceptab i'Wei~
for work that is not processed by PennDOT. HAVE AiiNICE DAY!!
OZLu
.IJJZ
CR
PFI
S-7 PA
4218 FUNERAL PURCHASE CONTRACT
(STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED)
(Charges are only for those items that you selected or that are required. If we are required by law or
by a cemetery or crematory to use any items, we will explain the reasons in writing below.)
Secbon 13 204 of the Rules and Regulations of the Pennsylvania State Board of Funera~ Directors reauires this contract
to be s~ned by the person or persons arranging for the funeral serviCe and by the funeral director
UJ
(A) OUR SERVICE: --
BASIC SERVICE OF FUNERAL DIRECTOR & SfAFF ........
EMBALMING ...................................
If you selected a lunerat which requires embalming such as a
funeral with viewing, you may have to pay for embalming You
do not have to pay for embalming you did not approve if you
selected arrangements such as a direct cremation or
immediate burial. If we charge you for embalming, we wilt
explain why be/ow.
REASON FOR EMBALMING:
Public Visitation
OTHER PREPARATION OF THE BODY .................. $
USE OF FACILITIES, STAFF & EQUIPMENT:
Funeral Ceremony (conducted at Funeral Home) ..........
Visitation/Viewing (conducted at Funeral Home) ........... $
Memorial Service (conducted at Funeral Home) ...........
USE OF STAFF & EQUIPMENT:
Funeral Ceremony (Conducted at another facility) ..........
Visitation/Viewing (Conducted at another facility) ...........
: Memorial Service (Conducted at another facility) ...........
Graveside Service .............................. $
TRANSFER OF REMAINS TO FUNERAL HOME ............ $
( 90 Miles Transported)
AUTOMOTIVE EQUIPMENT:
Casket Coach (Hearse) ..........................
Lead Car / Clergy Car ...........................
Flower Car
MISCELLANEOUS MERCHANDISE:
Acknowledgment Cards ......................... $
Visitors Register ...............................
Memorial Folders/Pray Cards ......................
Flowers ........
CASKET Jersey
20 ga. Steel Rosetan Crepe
OUTER BURIAL CONTAINER (As Selected)
Deluxe Reinforced Concrete
Receptacle (other than casket)
Wearing Apparel
1295.00
525.00
175.00
300.00
375 00
250 00
272 50
175 O0
150 O0
95 O0
25,00
40,00
50,00
FORWARDING OF REMAINS TO ANOTHER FUNERAL HOME ...................
RECEIVING OF REMAINS FROM ANOTHER FUNERAL HOME ...................
DIRECT CREMATION las Selected) ....................................
IMMEDIATE BURIAL (As Selected) ....................................
3727.50
1385.00
895.00
FRANK L WETZLER, Supervisor-Director
206 North Spring Street - P.O. Box #7
BELLEFONTE, PENNSYLVANI,~ 16823
Phone (814) 355-4261
Fax (814) 355-2898
Full l~ame of deceased Michael A. Fornicola
Dat~ of Death ____April 21
(B) CASH ADVANCE ITEMS:
Open and Close Grave ........................... $
Certified Copies ................................ $
Death Notices ..................................
Clergyman ....................................
Phone Calls ................................... $
Tent & Accessories
Organist .......
Flowers .......
Grave Space .......
No, 5103
(C) OTHER ITEMS:
(Please PRINT Name!
2C 3 Deceased is Father
{Grve Relationship)
Total (A) Forward $
350.00
30.00
177.00
50.00
75.00
20.00
185.50
300.00
2O
_Age 5__1__. _
of p¢,-son arrangin~ -~ervl;:~..!
6007.50
Total (B) $ 1187.50 ~ -~195,,' 00
....... $ Total (A) & (Bj~
Total (C) ~ 0. O0 ~ 7195.00
Total (A) (B) & (ti
LESS: Preneed Adjustment/Allowance
Payment $
Other (Specify) $ (
Balance $ 7195,00
LEGAL, CEMETERY, CREMATORY OR OTHER REQUIREMENTS COMPELLING THE PURCHASE OF ANY ITEMS LISTED
ABOVE: Cemetery Requirement VAULT
The unders~ned purchaser(s) hereby attest to the following (1) I/We did {X~did not ( ) authorize embalming of the above named deceased
(2) i/We were shown a Casket Price List and an Outer Buria! Container Price List before the showing of caskets and outer burial containers
I/We were given/offered for retention a General Price List upon the beginning of a discussion of funeral arrangements and/or selectlor~
serv~cas and merchandise.
TERMS: NET 30 DAYS
I, or we, having read the above, accept and approve same, and jointi~ and severally promise to make tull payment therefor Each purchase
understands that this promise to jointly and severally make/full payment means the Funeral Home has the right to collect the entire amount frorr
anyone or more of the purchasers without resort to any :~J~im against any other purchasers This right exists regardless of whether or nor one el
more of the purchasers have agreed among theraselv, e~r.bow much each wfll contribute to make full payment Receipt of a copy of this conhac
, ,~- . /- - ~-- .... ,~,~t~ Fleasan! Valley urlve
S~Jnature of Purchaser(s) . Street Address
~:)'~:~--4/~--~9 _~ ~_~ ~ Conshohocken PA 19428
s.s No. C~y State Zip Code
S~gnature of Purchaser(s) Street Address City and State Z~p Code
Signature of Purchasffr(s)
We agree to provide the service & merchandise indiCated above
Street Address
~O~-,¢'~,,.,-~' ~'/~ O~ty and State Zip Code
A~COUNF RECEIVABLES FILE
CASE # 5103
BILL or PAYMENT?[ p ]
SVC FEE Y/N?[ ]
DECEASED: Michael A. Fornicola DEATHDATE: 04/21/2003
BILL TO: Ms. Alesha M. Hollinger
ADDRESS: 446 Pleasant Valley Drive
Conshohocken, PA 19428
PHONE: 610-567-0332
**PAID**
--CURRENT----I
OVER 30~---OVER 60--~VER 90
COST OF FUNERAL:
ADDITIONAL ITEMS:
PAYMENTS RECEIVED:
YTD SVC FEE:
7195.00
0.00
7195.00
BALANCE DUE: 0.00
LAST TRANSACTION DATE: 05/14/2
CURRENT SERVICE FEE:
#DAYS SINCE SERVICE:
PAYMENT/ RECEIVED FROM
SVC FEE
0.00
7195.00 Thomas Fornicola
DATE
04/21/2
o5/14/2
--ADDITIONAL ITEMS ORDERED LATER
.TOTAL:
0.00
AUTHORIZED ROCK OF AGES DEALER
PURCHASE AGREEMENT
MAYES MEMORIALS, INC.
~" P.O. Box 295
9 l0 Pike Street
Lemont, PA ! 6851
SERVING CENTRAL PA SINCE 1880
Date ~'(' ~-'~ ~'~,0 _~ No.
hereinafter "Customer"
Street ~.'~,~ ~ f*~'~ ~ /~'~
Ci~ t:.~F~/,, ~'~-:'-:-~ State /'~
(814) 237-2352 · Fax: (8]4) 235-1235 Phone (~) _~'~.~ - .Z_7/57'~/
Customer agrees to purchase the following, as specified herein, for the sum of ~"~; '"~c-,~m- ,.r- ~ /
($ /[~f/D, ) Dollars. Memorial to be erected ~ / Se~ices to be pedormed D in .Z/ )~5;:
Cemete~, subject to the rules and regulations of said Cemete~.
MONUMENT ~ DBL. MARKER ~ SINGLE-~./ ~/''~ ~" ~ALES AMOUNT
' MARKER ~
CORNER MARKERS ~
VASE ~_
OTHER ~- ~ ~O .
Material, dimensions, finish, design and levering of the memorial are to be substantially as follows: ~'~z/~.,Z
Marker ...... .__ X - .... X .... - ...... Material Finish
inscriptions, levering, dates, and other data Delow are as they are to appear on the work ordered. Unless othe~ise noted, arrangement and
size of inscriptions, levering, dates, and other engraving will be adjusted to lit memorial size and space as needed by Mayes designer or
layout person. Any adificial color added per agreement (i.e. color etching, cawing, levering, etc.) is not guaranteed. Name placement on
the memorial is correct as show and corresponds with grave locations unless othe~ise noted.
Payment to be made as follows: $ ~".~, ~ D (~, .~..
' on signing this Agreement; $
.... ; $ ..... representing the remaining balance due hereunder within ten (10) days
after erection of the memorial. This Agreement is subject to the terms and ~nditions sta~ on the back hereof.
This agreempn~ ~ay be withdrawn by Mayes Memorials, In~ if not Dcpepted wi~ ~- days.
Date .~,'~)./~,; Accepted by ~oUr Signatur~~~~
Date .... /Z '/~' Mayes Memorials, Inc. by
This Agreement is subject to the terms and conditions stated on the back hereof and is subject to acceptance of above owner and is not subject
to cancellation a~er acceptance. Please check spelling, dates, etc. If changes are necessa~, make them as needed on this agreement, sign,
and send original with your payment to Mayes Memorials, Inc. Thank You.
DATE
7/23/03
for M-~i ch~l
$1640.00I
Completion of memorial
St. Michael's Cemetery
MAYES MEMORIALS
CREDITS ! BALANCE
A. Forni
$820.00
ck. 103
cola in
$820.00
PAY LAST AMOUNT
If*! THIS COL UMN
RETAIN THIS PORTION FOR YOUR RECORD~
REMITTANCE ADDRESS BILL TO
THE SENTINEL - LEGAL THOMAS E FORNICOLA
P.O. BOX 130, CARLISLE, PA 17013 '
AD NUMBER ~ CLASS SALESPERSOI~ BILLING DATE LINES
' ' 243084I 10 PUBLIC NOTICES c32 05/21/03 20
AD DESCRIPTION .,, START DATE STOP DATE
ESTATE NOTICE LETTERS TESTAMENTARY 05/06/03 05/20/03
PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT
3 THE SENTINEL - LEGAL 3 LGL 68.40
TOTAL AD CHARGE 68 . 40
3 PROOF OF PUBLICATION 01PRF 6.35
PREVIOUSLY PAID -74.75
DAYS RUN
PURCHASE ORDER
Michaei Yornicoia PAY THIS AMOUNT . oD . oo*
* AFTER 06/20/03
MESSAGE:
Thank you for advertising with The Sentinel.
Deadlines for in-column legal advertisements: Monday is Friday at
11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon;
Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 Noon; Sunday
is Thursday at 12 Noon.
If you have any questions regarding your Legal bill please call
Lori Saylor 243-2611 ext. 201
Fax your legals to 243-3754, attention Lori Saylor
You can also EMAIL your legal to Classified ads: ads@cumberlink.com.
Please send a cover letter including your name and address as an attachment
DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
THE SENTINEL - LEGAL
P.O. BOX 130, CARLISLE PA 17013 Michael Fornicola
AD NUMBER CLASS0 START DATE STOP DATE
243084 PUBLIC NOTICES 05/06/03 05/20/03
AD DESCRIPTION BILLING DATE TELEPHONE NUMBER
ESTATE NOTICE LETTERS TESTAMENTARY 05/21/03 814-383-4519
GROSS AMOUNT OF
.OO
DUE AFTER 06/20/03
THOMAS E. FORNICOLA
866 FOREST AVENUE
BELLEFONTE, PA
16823
20200000002430840000000000000000000000000000007
TOTAL AMOUNT DUE
.00
ENTER AMOUNT ENCLOSED
State of Pennsylvania,
County of Cumberland.
PROOF OF PUBLICATION
Lori Saylor, Classified Advertising Manager of THE SENTINEL,
of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of
general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th,
1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice
or publication attached hereto is exactly the same as was printed and published in the regular editions and
issues of THE SENTINEL on the following dates, viz
Copy of Notice of Publication
ESTATE NOTICE
Letters Testamentary on
:~ the Estate of MICHAEL
A, FORNICOLA, late of
the Lower Allen ~ ·
~':'! Township of Camp Hill,'
/ Cumberland County,
Pennsylvania, deceased,
i~ have been granted to
~ the u0dersi?ned;
All parsons kl~owing them-
ili selvo~ to be ndebled to
~ ~said Estate will make
~: payment !mmedtatelyl
and those haying claims
, will present them for set-
- · tlelnentto?~ ~:" '
i~i'h0mas EilFornicola
i'~ 866 Forest Avenue
BellefonIe~ PA ! 6823
May_ 6, 13 & 20, 2003
Affiant further deposes that he is not interested in
the subject matter of the aforesaid notice or
advertisement, and that all allegations in the
foregoing statement as to time, place and character
of publication are true.
May 21,2003
Sworn to and subscribed before me this 21st
day of May ,2003.
Notary Public
My commission expires:
NOTARIAL SEAl.
SHIRLEY O. DURNIN, Notary Public
,.C.~lisle B, or,o., C_umbertand Co{mN
~y ~,ommtss~on ~:xpires Aug. 9
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
being duly ~:~o. ?~),"~'z-~,~ according fo law, deposes and says that he
~-X,~.~_~.~,~- of the Estate of .~~1 ~_ F~,~I~
I~fe of ~ __~~S( . , Cumberland County, Pa., deceased ~nd fhef the
within is an inventory m~de by~O~$ ~. ~O~,~ , the s~id.. ~x~O~
of the entire estate of said decedent, consisting of ell +he personal property and real estate, except real estate oufslde
the CommonweeHh of Pennsylvania, end that the figures opposite each item of the Inventory represent it's fair value
as of +he date of decedenf's death.
and subscribed before me,
19
Adminlstrafor
Date of Death
Day Month
INSTRUCTIONS
I. An inventory must be filed within three months after appointment of personal representative.
2. A supplement inventory must be filed within thirty days of discovery of additional assets.
3. Additional sheets may be attached as to personalty or realty
4. See Article IV, Fiduciaries Act of 1949.
O ~
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 003290
FORNICOLA THOMAS E
866 FOREST AVENUE
BELLEFONTE, PA 16823
fold
ESTATE INFORMATION: SSN: 174-40-8080
FILE NUMBER: 2103-0379
DECEDENT NAME: FORNICOLA MICHAEL A
DATE OF PAYMENT: 12/01/2003
POSTMARK DATE: 11/25/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 04/21/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $12,409.46
TOTAL AMOUNT PAID'
$12,409.46
REMARKS: THOMAS E FORNICOLA
SEAL
CHECK# 109
INITIALS: AC
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
MICHAEL A. FORNICOLA
THE LAW FIRM OF
KILLIAN & GEPHART
El8 PINE STREET
P O. BOX 886
HARRISBURG, PENNSYLVANIA 17108-0886
0000
17013
U.S. P(
PHIl
BELLEFONI
1682
NOV 25,
RMOUF
$1
00011
Name of Decedent:
STATUS REPORT UNDER RULE 6.12
Date of Death:
Will No.: ~ 003
Admin. No.: o~! -DB - 037c~
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 ['-I
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:
ao
Did the personal representative file a final account with the Court?
Yes _ No ~]
b. The separate Orphans' Court No. (if any) for the personal representative's
accoUnt is: tqO
c. Did the personal representative state an account informally to the parties
in interest? Yes [~ No ["]
Co
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.
Signature
Address
,: ~,. C,a,,aca,,:
Telephone No.
[~ Personal Representative
['-I Counsel for personal representative
BUREAU OF /ND/V/DUAL TAXES
TNHERTTANCE TAX DTVTSXON
DEPT. 180601
HARRISBURG,, PA 17118-0601
THOHAS E FORNICOLA
866 FOREST AVE
BELLEFONTE
COHHONWEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLO#ANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REV-1E~i? EX AFP (Dl-nS)
PA 16825
DATE 01-02-2004
ESTATE OF FORNICOLA
DATE OF DEATH 04-21-2005
FILE NUHBER 21 05-0579
:COUNTY CUHBERLAND
ACN 101
J Amount Remitted
MICHAEL A
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THZS LINE ~ RETA'rH LOWER PORTION FOR YOUR RECORDS *~
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLOWANCE OR DZSALLOWANCE OF DEDUCTZONS AND ASSESSHENT OF TAX
ESTATE OF FORNICOLA MICHAEL AFZLE NO. 21 05-0579 ACN 101 DATE 02-02-2004
TAX RETURN gAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATZON CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
5. Closely Held Stock/Partnership Interest (Schedule C) ($)
q. Hortgeges/Notas Receivable (Schedule D) (q)
5. Cash/Bank Daposits/Hisc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
APPROVED BEDUCTZONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expanses (Schedule H) (9)
10. Debts/Hortgage Liabilltles/Liens (Schedule I) (10)
11. Tote1 Deductions
12. Net Value of Tax Return
O0
O0
O0
O0
157~555 57
O0
O0
(8)
9,920.25
358.54
NOTE: To insure proper
credLt ~o your account,
submit the upper portion
of this form wi~h your
tax payment.
13.
1~.
NOTE:
157,535.57
(11) ]0.258.79
(12) 127,276.58
Charitable/governmental Bequests; Non-eXacted 9113 Trusts (Schedule J) (15) .00
Net Value of Estate Subject to Tax (1~) 127,276.58
Zf an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 w111
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 1~ at Spousal rate
16. Amount of Line 1~ taxable at Lineal/Class A ra~e
17. Amount of Line 1~ at Sibling rate
18. Amount of Line lq taxable mt Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
PAYHENT K~C~/PT DISCOUNT
DATE NUHBER INTEREST/PEN PAID (-)
11-25-2005 CD005290 .00
(15) .00 X O0 = .00
(16) 58,182.97 X 045= 1,718.25
(17) 89,095.61 x 12 = 10,691.25
(18) .00 X 15 = .00
(19)= 12,409.46
ZF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
AHOUNT PAID
12,409
TOTAL TAX CREDIT 12,409.46
BALANCE OF TAX DUEI .00
XNTEREST AND PEN. .00
TOTAL DUE .00
( ZF TOTAL DUE XS LESS THAN $1, NO PAYHENT IS REQUIRED.
ZF TOTAL DUE XS REFLECTED AS A 'CREDXT' (CR), YOU NAY BE DUE
A REFUND. SEE REVERSE SXDE OF THIS FORH FOR XNSTRUCTIONS.)
RESERVATION:
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADMIN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December 1Z, 1982 -- if any future interest in the estate is transferred
in possession ar enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class 8 (collateral) rate on any such future interest.
To fulfill the requirements of Section Zl~O of the Inheritance and Estate Tax Act, Act 23 of ZOO0. (72 P.S.
Section 91~0).
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 #ILLS, 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-1313). Applications are available at the Office
of the Register of Mills, any of the ES Revenue District Offices, or by calling the special Z4-hour
answering service for fores ordering: 1-800-362-2050~ services for taxpayers with special hearing end / or
speaking needs: 1-800-qqT-30ZO (TT only).
Any party in interest not satisfied with the appraisement, allowance) or disallowance of deductions, or assessment
of tax (incIuding discount or interest) as shown on this Notice must object within sixty (60) days of receipt of
this Notice by;
--written protest to the PA Department of Revenuer Board of Appeals) Dept. 181021) Harrisburg, PA 17118-1021,
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
OR
Factual errors discovered on this assessment should be addressed in eriting to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 180601) Harrisburg, PA 17118-0601
Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-1501) for an explanation of administratively correctable errors.
If any tax due ls paid within three (3) calendar months after the decedent's death) a five percent (5Z) discount of
the tax paid is allowed.
The 151 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed) and not
paid before January lA, 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 (93 months and one (1) day from the date of
death, to the date of payment. Taxes which became deIinquent before January 1, 1981 bear interest at the rate of
six (61) percent per annum calculated at a daily rate of .00016q. All taxes which became delinquent on end after
January 1, 198Z 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 1981 through Z003 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1982 ZOZ . 0005~,8 1987 9Z · 000Z6,7 1999 7Z . 00019Z
1983 162 . OOO~i. 38 1988-1991 112 .000301 2:000 8Z .0002:19
198~, llZ . 000301 1992 9Z · O00Zr~7 ZOO1 92 . O00Zq7
1985 132 .000356 1993-199q 71 .000192: 2:002 67. .00016~,
1986 102 . O0027~, 1995-1998 9Z . O00Z~7 ZOO3 57. .000137
--Interest is calculated es follows:
'rNTERBST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELTNQUBNT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen [15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.