HomeMy WebLinkAbout04-0389Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Romaine S. Shaub No. ,,'~)..~-0,4~' ~?
, Deceased Social Security No. 209- 28- 9470
Shaub and Elmer W. Shaub
Estate of
also known as
Jack M.
Petitioner(s), who is/are 18 years of age or older, apply(les) for:
(COMPLETE 'A' or 'B' BELOW:)
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut ors
the Decedent, dated 05/04/1994 and codicil(s) dated None
N/A
named in the last Will of
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents
offered for probate; was not the victim of a killing and was never adjudicated incompetent:
N/A
B. Grant of Letters of Administration
(c.t.a.; d.b.n.c.ta; pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and
heirs:
I Name Relationship ~ ~-~'Resid er~
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland
or principal residence at 700 Walnut Bottom Road, Borou~;h of
Decedent, then 87 years of age, died 04/08/2004
County, Pennsylvania with his/,l~tj last family
Carlisle, Carlisle, PA 17013
(list street, number, and municipality)
at Forest Park Health Center, PA
Decedent 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
(Location)
3,000.00
situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of
letters in the appropriate form to the undersigned:
Si~lnature
Typedorprintednameandresidence
Jack M. Shaub
6204 Wallin~ford Way, Mechanicsburs, PA 17050
Elmer W. Shaub
39 Western Road, Dillsbur~, PA 17019
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSystems, Inc. Form RW-1 (1991)
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
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 Decedent, Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed
before me thi~.~v day of /~~ ~_/
/~.~9~ ) / , ~4'2 ~7/ ~lmer W. Shaub
Estate of Romaine S. Shaub
Deceased
Social Security No: 209- 28- 9470 Date of Death: 04/08/2004
AND NOW,
, __, i .r~l~.ideration
of the Petition on the reverse side hereon, satisfactory proof having been presented before me, r:7 · '.
DECREED that Letters IXI Testamentary J I Of Administration ~' :~
IT
IS
(c.t.a.; d.b.n.c.t.a.; pendente lit~ durante al~ntia; durante minoritate)
Jack M. Shaub and Elmer W. Shaub :~
are hereby granted to
in the above estate and that the instrument(s) dated 05/04/1994
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Letters ........... $
Sho~ Ce~ificate(s) .....
Renunciation ........
Affidavits ( ) ....
Extra Pages( ) ....
$
$
$
$
Codicil ........... $
JCP Fee .......... $
Inventory .......... $
Other ........... $
TOTAL ......... $
Prepared by the Pennsylvania Bar Association
Attorney: Jennifer B. Hipp, Esquire
I.D. No: Pa. f/86556
Address: One West Main Street
Shiremanstown, PA 17011
Telephone: 717/737-8761
Copyrlg ht (c) 1996 form software only CPSystems, Inc.
Form RW-1 (1991)
Register of Wills of Cumberland
OATH OF SUBSCRIBING
County, Pennsylvania
WITNESS
Estate of Romaine S. Shaub
also known as
, Deceased
No.
James D. Bo~ar, Esquire
(each) a subscribing witness to the r'~ codicil(s) ~'~ will(s) presented herewith, (each) being duly qualified according to law
depose(s) and say(s) that she/he/they was/were present and saw the above Testator(rix) sign the same and that she/he/they signed as
a witness at the request of Testator(rix) in his/her/their presence and r-~ in the presence of each other ~ in the presence of the
other subscribing witness(es).
(Signature)
(Address)
(Signature)
(Address)
"'-"'O~e (~;e sD~ ~tre2t '
Shiremanstown, PA 17011
Sworn to or affirmed and subscribed
before me this
of
Notary Public
My Commission Expires:
(Signature and seal of Notary or other official
qualified to administer oaths. Show date of
expiration of Notary's commission.)
day
o~o o q
/ BONNIE L. WILLIAMS, NOTA~ ~BLIC I
~SH~EaA,STOW" BO~O. CU~,~"~ CO.~
NOTE: To be taken by officer authorized to administer oaths.
Please have present the original or copy of instrument(s)
at time of notarization.
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSystems, Inc. Form #RW-2 (1991)
R~GISTER OF WILLS OF COUNTY -
OATH OF SUBSCRII~ING V~TTNESS
codicil
(each) a subscribing wimess to the will pre~ented here,with, (each) being dMy quaLified ac:ording to
law, depose(s) and say(s) that pr~ent and saw
the te-~tat , si=ma the same and that signed a~ a withes at the
reque=t of testat in h pr=enc: and (in the pre.~enc: of each other) (in the pre~ence of the
other subscribing wime~s(e$)).
Sworn to or afl'ri'meal and subscribed before
me this day of
2O
(Name)
tAddrezs)
(Name)
(Address)
Reg~rer
REGISTER OF WILLS OF CI_lVIBERI_~ND COUNTY
OATH OF NON-SUBSCtLIBING WITNESS
Jack M. Shaub and Elmer W. Shaub
(each) a subscriber hereto, (each) being duly qu~-i~'fied acc=rding to law, degose',XK sd say~ ~at
they famJH~ with the si¢-a ..... 0f R~a~e S. S~ub
Romaine S. Shaub
to the bes; of their knowied~e and belief.
Sworn to or affirmed and subscribed befcr-*
me this og-~/e.O/ da'/ of
J~k M. SHaub
6204 Wall~gfor~Ye)
Mechanicsbur.q, PA 17050
39 Western Road (Name)
Dillsbur9, PA 17019
his 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.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
No.
Local Registrar
Date
;,-J
Ur''
COMMONWEALTH OF PENNSYLVANIA o DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
,. Romaine E. Shaub ,. femaleJ,. 209 __
8,
2004
~. Cu~verland ~. Carlisle I~ Forest Park Health Center I~''b",~°~.~- m. white
,,.. Home~ker [,,. Domestic ,a. ~ p,a
~CE~NT'S MAmI~ A~RE SS ~r~. C~n. ~m. Z~ C~e) ~CEDENT'S 14. widowed ,,.
ACTU*~ ,,. s,~,, Pennsylvania ~ ,~,.~
700 Allen Road ~s,oeuc, ~.,
,,.Carlisle, PA 17013 .o,,.,,~ ,m.c~ Cumberland '0~"~*~ ,~,.~ ~'~
~,,~ ..... ~,. o, Car lis le
~,. E~mer Sunday ,,. ~ary Irene Danner
~ Jack ~. Shaub ~. 620~ ~all~n~ford
I
~[~ Apr~l 1~ 200~ ~o11~ng Green ~emor~al Park Lower Allen
' · I~.
Sm~G-- L SER~C' ~ENSEE ffi PERSON ACT,~ AS SUCH lUtE.SE NUMBER {NAUt ~mORE~FAC'L'" Par themore FH &, C Inc.
=' 5~ ~. FD 012 848 L ,,~.P.O. Box 431, New Cumberland ~ 17070-0431
TO me ~lt ol my k~w~ge, dena ~cufr~ due lo the cause(s) I~ manor am Ilal~ ..................................................... 0 ] lb
, ,,..-,,.,,-,,,,- ....................................................................................... . o '"
IJAST WILL AND TESTAMENT
OP
ROI~ZNE S. SHAUB
I, ROMAINE S SHAUB, of Upper Allen Township, ~umber~.~
land County, Pennsylvania, make, publish and declare thi~as
for my Last Will and Testament, hereby revoking all othe~Wills
and Codicils heretofore made by me.
FIRST: I devise and bequeath all the rest, re dueiaad
remainder of my estate of whatever nature and wherever s~uate,
including any property over which I hold power of appointment and
together with any insurance policies thereon, as follows:
(A) One-fourth (1/4) thereof to my son, LEWIS D.
SHAUB, JR., or should he predecease me, to his issue per stirpes
by representation.
(B) One-fourth (1/4) thereof to my son, ELMER W.
SHAUB, or should he predecease me, to his issue per stirpes by
representation.
(C) One-fourth (1/4) thereof to my son, JACK M. SHAUB,
or should he predecease me, to his issue per stirpes by represen-
tation.
(D) One-eighth (1/8) to my granddaughter, DEBRA C.
BOWLES, or should she predecease me, to her issue per stirpes by
representation.
(E) One-eighth (1/8) to my grandson, SAMUEL R. SINGER,
or should he predecease me, I devise and bequeath his share under
this, my Last Will and Testament, to my granddaughter, DEBRA C.
BOWLES.
SECOI~D: In addition to all powers granted to them by
law and by other provisions of this Will, I give the fiduciaries
acting hereunder the following powers, applicable to all proper-
ty, exercisable without court approval and effective until actual
distribution of all property:
(A) To sell at public or private sale, or to lease,
for any period of time, any real or personal property and to give
options for sales, exchanges or leases, for such prices and upon
such terms (including credit, with or without security) or
conditions as are deemed proper. This includes the power to give
legally sufficient instruments for transfer of the property and
to receive the proceeds of any disposition of it.
(B) To partition, subdivide, or improve real estate
and to enter into agreements concerning the partition, subdivi-
sion, improvement, zoning or management of real estate and to
impose or extinguish restrictions on real estate.
(C) To compromise any claim or controversy and to
abandon any property which is of little or no value.
(D) To invest in all forms of property, including
stocks, common trust funds and mortgage investment funds, without
restriction to investments authorized for Pennsylvania fiduci-
aries, as are deemed proper, without regard to any principle of
diversification, risk or productivity.
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments.
(F) To exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, gift and estate or inheritance tax
laws.
(G) To make distributions to my herein named benefici-
aries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in order
to pay debts, taxes, or estate or trust administration expenses,
to protect or improve any property held under my will, and for
investment purposes.
(I) To select a mode of payment under any qualified
retirement plan (pension plan, profit sharing plan, employee
stock ownership plan, or any other type of qualified plan) to the
extent the plan or the law permits them to do so, and to exercise
any other rights which they may have under the plan, in whatever
manner they consider advisable.
THIRD: I direct that all inheritance, estate, trans-
fer, succession and death taxes, of any kind whatsoever, which
may be payable by reason of my death, whether or not with respect
to property passing under this Will, shall be paid out of the
principal of my residuary estate.
FOURTH: I nominate and appoint, JACK M. SHAUB and
ELMER W. SHAUB, Co-Executors of this, my Last Will and Testament.
I direct that my Co-Executors, and their successors, shall not be
required to post security or a bond for the performance of their
duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal to this, my Last Will and Testament, this q~ day of
, 1994.
ROMAINE S. SHAUB
Signed, sealed, published and declared by the above-
named Testatrix as and for her Last Will and Testament in our
presence, who, at her request, in her presence and in the
presence of each other, have hereunto subscribed our names as
attesting witnesses.
Address
Address
3
CERTIFICATION OF NOTICE UNDER RULE 5.6 (a)
Name of Decedent: Romaine E. Shaub
Date of Death: April 8, 2004
Will No. 21-04-0389 Admin. No.
To the Register:
I certify that notice of estate administration 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
April 29, 2004:
Name Address
Jack M. Shaub
Elmer W. Shaub
Lewis D. Shaub, Jr.
Debra C. Lowe (formerly
Debra C. Bowles)
Samuel R. Singer
5204 Wallingford Way
Mechanicsburg, PA 17050
39 Western Road
Dillsburg, PA 17019
10755 Xavier Court
Goodyear, AZ 85338
154 Juniata Parkway E
Newport, PA 17074
154 Juniata Parkway E
Newport, PA 17074
Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except:
Date:
None
Capacity:
J B. Hipp, Esquire
One W~st Main Street
Shiremanstown, PA 17011
(717) 737-8761
Personal Representative
X Counsel for Personal
Representative
REV-1500
INHERITANCE TAX RETUR
RESIDENT DECEDENT
ED / OECEDENT'SNAME LAST. FIRST ANDMIBOLEiNiTiALishaub Romaine E.>1916
C
D 04/08/2004 06/04
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COMMONWEALTH 0FPENNSYLVANiA
DE?ARTMENTOFREVENUE
OEPT Z80601
HARRiSBURG.PA17128-0601
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OFFICIAL USE ONLY
FILE NUMBER
21-04-0389
COUNTYCOOE YEAR NUMBER
SOCIAL SECURITY NUMBER
209-28-9470
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOO;AL S ECUJAITy NUMBER
[~9. LitigatfonProceedsRecefved [~10. SpausaIPovertyCredit 11.Election o axunde Sec 9
THIS SECTION MUST BE COMPLEi~=D, ALL CORRESPONDENCE & CONFIDENTIAL TAX;INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETEMAIL[NGADDRESS
James D. Bo~ar Esquire
TELEPHONENUMBER Shiremanstown, PA 17011
, 717/737-8761
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. CloseJ¥ Held Corporation. Partnership or
Sole Proprietorship
4. Mortgages & Notes Receivable (ScheduJe B) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
] Separate Billing Requested
?. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent. Mortgage Liabilities. & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate/Line 8 minus Line 11~
13,
14.
(1) None
(2) 1,606.15
(3) None
None
3,002.99
None
None
1,422.22
85,879.37
Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
Net Value Subject to Tax (Line 12 minus Line 13)
(11)
(12)
(14)
OFFICIAL USE ONLY
4,609.14
87,301.59
(82,692.45)
(82,692.45)
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)(12)
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
X 0 0 (15)
(82,692.45) X .0 45 (16)
X .12 (17)
X 15 (18)
0.00
0.00
0.90
0.00
19. Tax Due (19) O, O0
20. ~-~ I CHEC~ HEREiE ~0~ ARE BEQUEST NG~ REFUND oF AN OVERpAyMEN~
: ~; BE SuRE T0 ANSWER AiL QUESTIONS ON REVERSE
Copyright (c: 2000 form software only The Lackner Group, rnc. Form REV-1500 EX (Rev
Decedent's Complete Address:
STREET ADDRESS
700 Allen Road
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
Z. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
Total Credits ( A + B + C ) (2)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total interest/Penalty ( B + E ) (3)
4. if Line 2 is greater than Line 1 + Line 3. enter the difference. This is the OVERPAYMENT.
Check box on Page I 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 {SA)
E. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (SB)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
0.00
0.00
0.00
0.00
0.00
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
b. retain the right to designate who shall use the proper'b/transferred or its income:
c. retain a reversionary interest; or ...............................
d. receive the promise for life of either payments, benefits or care7 ............
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 security at his
or her death? [] []
4. Did decedent own an Individual Retirement Account. annuity, or other non-probate property
which contains a beneficiary designation? ....................... [] []
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
SIGNATURE CF PERSON RESPONSISLEFORF[LINGRETURN
Jack M. Shaub DATE
_6~2_ 9_4_ _¥_~_~ 1 ~_ _~_s_~_o_ r_d- _~_~y_ .........................
Mechaniosbur~;, PA 17050
James D. EDgar Esquire DA~E
One West Main Street
Shiremanst own, PA 17011
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
surwving spouse is 3% [72 PS. 9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
(72 PS. 9116 (a) (1,1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax. and the statutory requirements for disclosure of assets
and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 9116 (a) (1,2)],
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4,5%, except as noted in 72 PS. 9116(1.2)
[72 P.S. 9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(a)(1.3)]. A sibling fs defined, under
Section 9102. as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
ADDITIONAL Personal Representatives
Estate of Romaine E. Shaub SS{~ 209-28-9470 04/08/2004
Under penalties of perjury, the undersigned declare that they
have examined this return, including accompanying schedules and
statements, and to the best of their knowledge and belief, it is
true, correct and complete.
Signature
Marne
Address Line 1
Address Line 2
City, State, Zip
Date
Elmer W. Shaub
39 Western Road
Dillsburg, PA 17019
REV-1503EX
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE T,~X RETURN
RESIDENTDECEDENT
ESTATE OF
Romaine E. Shaub SS~ 209-28-9470
SCHEDULE B
STOCKS & BONDS
04/08/2004
FILE NUMBER
21-04-0389
All property jointly-owned with right of survivorship must be c~isclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE
NUMBER OFDEATH
1 35 Prudential Financial, Inc. - 35 shares stock 45.89 1,606.15
TOTAL(Alsoenteronline2, Recapitu[ation) 1,606.15
(If more space is needed, insert additional sheets of the same size)
Copyright (c} 1996 form software only CPSystems, Inc. Form REV- 1503 EX Rev. ! -97)
REV 1508 EX ;{1-97)
SCHEDULE E
CASH, BANK DEPOSITS,& MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
RESIOENTDECEDENT
ESTATE OF FILE NUMEER
Romaine g. Shaub SS~ 209-28-9470 04/08/2004 21-04-0389
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
i 3,002.99
Commerce Bank - Checking Account No. 536054315, date of death
balance $3,002.81, accrued interest $0.18
TOTAL (Also enter on line 5, Recapitulation) $ 3 , 002.99
(If more space is needed, insert additional sheets of the same size)
Commerce
CBank,.
ADri! 29, 280%
James D Bcgar
Attorney At Law
i W Hain S~
Sh±remanstewx, PA
17111
Estate of: Romaine E Shaub
Social Security ~: 209-28-9470
Date of ~e==h. Act!! 8, 2004
in reference to zhe ieuter_~===~_~e~=~,s~ -e~__.~ above menzioned
's like inform you of the informazion tha~
Esua~e, we woui~ uo
we have researched axd found.
T~ppe: Checking
Accounl ~: 536~543!5
Date O~ened: 12,/21/02
Primary Owner: Romaine E Shaub
Rep Payee: Jask H Shaub
Da2e of Deazh 8a!ance: S3,002.81
Accrued In~eres~: S.!3
if ~here are any cuesuions or additional information ~hat
is needed, clease feel free ~o con~act me au {717} 795-7118
ext. 3151.
Wanda ,7. Herris
Team Leader
Commerce Bank / Harrisburg, N.A.
RO, Box 8599
100 Senate Avenue
Camp Hiil. Pennsylvania 17001-8599
.E¥-I~I! ~×*11-97/ SCHEDULE H
FUNERAL EXPENSES &
CCMMONWEALTH OF PENNSYLVANIA
INHERITANCETAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF
Romaine E. Shaub SS~) 209-28-9470 04/08/2004
FILE NUMBER
21-04-0389
Debts of decedent must be reported on ScheduJe I.
ITEM
NUMBER DESCRIPTION AMOUNT
FUNERAL EXPENSES:
Marianne Winkowski - Funeral Luncheon
Parthemore Funeral Home - Balance Due-Funeral
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) / EIN Number of Persona[ Representative{s)
Street Address
City State
Zip
Year(s) Commission Paid:
Attorneys Fees James D. Bogar Esquire
Family Exemption: (If decedent's address is not the same as cJaimant s. attach explanation)
CIaimant
Street Address
City State Zip
Relationship of Claimant to Decedent
Probate Fees Regisl:er of
Accountant's Fees
Tax Return Preparer's Fees
Other Administrative Costs
Register of Wills - Filing Fee-Pa. Inheritance Tax Return
145.00
104.22
1,110.00
53.00
10.00
TOTAL (Also enter on line 9. Recapitulation)
1,422.22
(If more space is needed, insert additional sheets of the same size)
F~EV-1512 EX +(1 97)
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
COMMONWEALTH OF PENNSYLVANIA
[NHERFTANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Romaine E. Shaub SS*~ 209-28-9470 04/08/2004 21-04-0389
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
i 85,130.62
Department of Public Welfare - Claim for restitution of medical
assistance per attached letter
Forest Park Health Center - Final Bill
TOTAL (Also enter on line 10. Recapitulation)
748.75
85,879.37
(If more space is needed, insert additional sheets of the same size)
J3PIES 8 8QGAR ESQUIRE
J~2{ES 8 8OGAR ESQ
QPTE WEST HA~N ST
SH i REM3}TSTOWN PA i~0!i
Hay 11, 2004
SiS ~: -'-50!5829%
SS}T: 239-28-9470
Dear Ptr. 3ogar:
Please b~ = .... d chat ' ~
claim ix the amount cf $85,130.62 against the ~' ~ ......
claim is for res~iEution cf medical assisEance granted en behalf of the
decedenE for which ehe Probate Es~a~e is now reseenslble to reimburse 5he
Desartmen5 accordinc to Act 4~, 62 ~ S. ~ '~ ~=~-,~ =
amended bv Ac: ~ = ~- .... s
.... c~;e June 30, 1995. Enclosed is the Depa
~.~ _scrtlen of -' -~nl= medical expense, =-~.=m~_f~' $28,015.75, was incurred
during Eke lose slx mcnnhs cf the decedenu's life; therefore, 15 ~s a Class 3
Code, 20 Pa. C.S.A. 3392(3}. The balance of tee c~__m, namely $57,114.8,, is
en_er=c ~r ..... ? Class 6 claim agains~ the e~ate.
Please :~k~ow]=d~~ r .... at of this letter and aavLse-
~om,,,on.~_a .... claim Ls admitted and ween pai~menn may be expected.
:~ .... = is complene, please ~ "~ If
estate .... u ...... g .
rea! estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sharon E.~m._n~
lPL Program Investigator
717-772 6397
717 772-6553 F~{
May 11,2004
STATEMENT OF CLAIM SUMMARY
NAME Estate of SHAUB, ROMAINE
ID 450 158 294
MEDICAL CLASS 3 CLASS 6 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 23.00 23.00
LONG TERM CARE 22,156.66 48,605.01 70,761.67
DRUG 5,859.09 8,486.86 14,345.95
REIMBURSEMENT TO DPW 28,015.75 57,114.87 85,130.62
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EiN- 23-8003113
REV 1513 EX * ¢9
COMMONWEALTH OF PENNSYLVANIA
[NH ERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Romaine E. Shaub SS~ 209-28-9470
SCHEDULE J
BENEFICIARIES
04/08/2004
FILE NUMBER
21-04-0389
NUMBER
II.
NAME AND AODRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal dfstrfbutioms, ann
transfers under Sec 9116<ai(12)]
Debra C. Lowe (Bowles)
154 Juniata Parkway E.
Newport, PA 17074
Elmer W. Shaub
39 Western Road
Diilsburg, PA 17019
Jack M. Shaub
6204 Wa!lingford Way
Mechanicsburg, 17050
Lewis D. Shaub, Jr.
10755 Xavier Court
Goodyear, AZ 85338
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
;randdaughter
;on
Son
Son
AMOUNT OR SHARE
OF ESTATE
One eighth
(1/8) of rest,
residue and
remainder
One fourth
(1/4) of rest,
residue and
remainder
One fourth
(1/4) of rest,
residue and
remainder
One fourth
(1/4) of rest,
residue and
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18. AS APPROPRIATE, ON REV 1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET
0.00
(If more space is needed, insert additional sheets of the same size)
Estate of: Romaine E. Shaub
Soc Sec ~: 209-28-9470
Date of Death: 04/08/200~
Continuation of Schedule J,
(Taxable Bequests)
Item Name and Address of Beneficiary
Part I
Relationship
Share of Estate
Samuel R. Singer
154 Juniata Parkway E.
Newport, PA 17074
One eighth
(1/8) of rest,
residue and
remainder
I AST WILL A_ND TESTA_¥IENT
OF
ROMAINE S. SZIAUB
I, ROMAINE S. SHAUB, cf Upper Allen Township, Cumber-
land County, Pennsylvania, make, publish and declare this as and
for my Last Will and Testament, hereby revoking all other Wills
and Codicils heretofore made by me.
FIRST: I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
including any proper~y over which I hold power of appointment and
together with any insurance policies thereon, as follows:
(A) One-fourth (1/4) thereof to my son, LEWIS D.
SP~UB, JR., or should he predecease me, to his issue per stirpes
by representation.
(B) One-fourth (1/4) thereof to my son, ELMER W.
SF~UB, or should ke predecease me, to his issue per stirpes by
representation.
(C) One-fourth (1/4) thereof to my son, JACK M. S~AUB,
or should he predecease me, to his issue per stirpes by represen-
tation.
(D) One-eighth (1/8) to my granddaughter, DEBkA C.
BOWLES, or should she predecease me, to her issue per stirpes by
representation.
(E) One-eighth (1/8) to my grandson, S~k~'EL R. SINGER,
or should he predecease me, I devise and bequeath his share under
this, my Last Will and Testament, to my granddaughter, DEBRA C.
BOWLES.
SECOND: In addition to all powers granted to them by
law and by other provisions of this Will, I give the fiduciaries
acting hereunder the following powers, applicable to all proper-
ty, exercisable without court approval and effective until actual
distribution of all property:
(A) To sell at public or private sale, or to lease,
for any period of time, any real or personal property and to give
options for sales, exchanges or leases, for such prices and upon
such terms (including credit, with or without security) or
conditions as are deemed proper. This includes the 'power to give
legally sufficient instruments for transfer of the property and
to receive the proceeds of any disposition of it.
(B) To partition, subdivide, or improve real estate
and to enter into agreements concerning the partition, subdivi-
sion, improvement, zoning cr management of real estate and to
impose or extinguish restrictions on real estate.
abandon
(C) To compromise any claim or controversy and to
any property which is of little or no value.
(D) To invest in all forms of property, including
common trust funds and mortgage investment funds, without
stocks,
restriction to investments authorized for Pennsylvania fiduci-
aries, as are deemed proper, without regard to any principle of
diversification, risk or productivity.
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments.
(F) To exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, gift and estate or inheritance tax
laws.
(G) To make distributions to my herein named benefici-
aries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in order
to pay debts, taxes, or estate or trust administration expenses,
to protect or improve any property held under my will, and for
investment purposes.
(I) To select a mode of payment under any qualified
retirement plan (pension plan, profit sharing plan, employee
stock ownership plan, or any other type of qualified plan) to the
extent the plan or the law permits them to do so, and to exercise
any other rights which they may have under the plan, in whatever
2
manner they consider advisable.
THIRD: I direct that all inheritance, estate, trans-
fer, succession and death taxes, of any kind whatsoever, which
may be payable by reason of my death, whether or not'with respect
to property passing under this Will, shall be paid out of the
principal of my residuary estate.
FOURTH: I nominate and appoint, JACK M. SF~UB and
ELMER W. SHAUB, Co-Executors of this, my Last Will and Testament.
I direct that my Co-Executors, and their successors, shall not be
required to post security or a bond for the performance of their
duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal to this, my Last Will and Testament, this ~r', day of
'~ ' 1994
ROMAINE S. SHAUB
Signed, sealed, published and declared by the above-
named Testatrix as and for her Last Will and Testament in our
presence, who, at her request, in her presence and in the
subscribed our names as
presence of each other, have hereunto
attesting witnesses.
Address
Address
STATUS REPORT UNDER RULE 6. 12
Romaine E. shaub
Name of Decedent:_
Date of Death: April B, 2004 Admin. No._
21-04-0389 '
will No._ pursuant to Rule 6.12 of the Supreme court Orphans
Court RuleS, I report the following with respect to completion of
the administration of the above-captioned estate:
1. state whether administration of the estate is complete:
YesX___~ No~
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:_ state the following:
3. If the answer to No. 1 is Yes,
a Did the personal representative file a final
· No~__~_~·
account with the Court? Yes~
b. The separate orphans' court No. (if any) for
the personal representative'S account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes ~__~__ No~
d. copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
cerk of the orphans' court and may be attached to this report.
~, Esquire __
~e. ty~ or print)
"~ ~est Mazn ou. 17011
shiremanstown, PA
Address
~ 737-8761
Tel. No.
Personal Representative
Capacity: ------
x counsel for personal
-------representative
(MAH:rmf/AM3)
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMHONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAZSEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REV-1547 EX AFP (DI-O$)
JAHES D ~OGAR ESQ
i W HAIN ST
SHIREHANSTOWN
PA 17011
DATE 09-20-200q
ESTATE OF SHAUB
DATE OF DEATH 0q-08-200~
FILE NUHBER 21 0~-0589
COUNTY CUMBERLAND
ACN 101
Amount Remitted
ROMAINE S
HAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LINE ~m~ RETAIN LOWER PORTION FOR YOUR RECORDS
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT .O~AX
'~
ESTATE OF SHAUB ROMAINE S FILE NO. 21 0R-0589 ACN~ .~01 ~C~DATE
TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGE c~ .~ .'_
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Reel Estate (Schedule A} (1)
2. Stocks and Bonds (Schedule B) (2)
:5. Closely Held Stock/Partnership Interest (Schedule C) (3)
q. Mortgages/Notes Receivable (Schedule D) (q)
$. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (.~)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
APPROVED DEDUCTTONS AND EXEHPTTONS:
9. Funeral Expenses/Adm. Costs/Hisc. Expanses (Schedule H) (9)
10. Debts/Hortgaga L1abilltlas/Liens (Schedule I) (10)
11. Total Deduct ions
12. Nat Value of Tax Return
· 00 NOTE: To insure proper
ll606.15 ~edit t:d Your account,
"00 ~ubm~t ~he!i.~ppar port/on
~';00 ~ ~his form wi~h your
$1002.99 tax payment.
.00
.O0
(8)
1,q22.22
q,609.1q
1:5.
lq.
NOTE:
ASSESSMENT OF TAX:
1.;. Amount of Line lq at Spousal rata
16. Amount of LLne lfi taxable at Lineal/Class A ra~e
17. Amount of Line lq at Sibling rate
18. Amount of Line lq taxable at Collateral/Class B rata
19. Principal Tax Due
TAX CREDITS:
PAYMENT RECETpT OT$COUNT
DATE NUMBER INTEREST/PEN PAID (-)
85~879.$7
(11) B7.301.Sg
(12) 82,692.fi5-
Charitable/Governmental Bequests; Non-elected 911:5 Trusts (Schedule J) (15} . O0
Nat Value of Estate Sub,act to Tax (lq) 82,692.q5-
Tf an assessment ~as issued previously, lines la, 15 and/er 16, 17, 18 and 19
reflect flgures that lnclude the total of ALL returns assessed to date.
(1~) .00 x O0 = .00
(16) .00 x OqS= .00
(17) . O0 x 12 = . O0
(la) .00 x 15 = .00
(19)= . O0
AMOUNT PAID
IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
.00
.00
.00
.00
( IF TOTAL DUE ZS LESS THAN $1, NO PAYMENT IS RE&)UIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
RESERVATION:
Estates of decedents dying on or before December Il, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class S (collateral) beneficiaries of the decedent after tho expiration of any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such futura interest.
PURPOSE OF
NOTICE:
PAYHENT:
REFUND (CR):
OBJECTIONS:
ADHZN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act Z$ of ZOO0. (7Z P.S.
Section 9140).
Detach tho top portion of this Notice and submit with your payment to the Register of #ills printed on the reverse side.
--Hake check ar 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-IBIS). Applications ara available at tho Office
of the Register of Rills, any of the 23 Revenue District Offices, or by calling t~e special Z4-hour
ans#ering service for forms ordering: 1-BOO-56Z-ZOSO~ services for taxpayers eith special hearing and / or
speaking needs: 1-BOO-447-50ZO (TT only).
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 object within sixty (60} days of receipt af
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals) Dept. ZBlOZ1, Harrisburg) PA 171Z&-10Z1, OR
--election to have the matter determined at audit of the account of the personal representative) OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should ba addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit) Dept. lDO601, Harrisburg) PA 17liD-0601
Phone (717) 787-6505. Sea page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-lBO1) for an explanation of administratively correctable errors.
If any tax due is paid within three (5) 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 18, 1996) the first day after the and of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January I, 198Z bear interest at the rate of
six (BI) percent par annum calculated at a daily rate of .000164. All taxes which became delinquent an and after
January l, 19BI will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by tho PA Department of Revenue. The applicable interest rates for 198Z through ZOO4 ara:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
~ ZOZ .0005~8 ~'8-1991 llZ .000301 ~ 9Z .000247
1983 16Z .000458 1992 9Z .000247 ZOOZ 6Z .000164
1964 Ill .000301 1993-1994 72 .O00lgZ 2003 52 .000157
1985 15Z .000556 1995-199& 92 .000247 2004 42 .O001ZO
1986 lOZ .000Z74 1999 7Z .O0019Z
1987 lOX .000Z74 ZOO0 7X .00019Z
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUHBER OF DAYS DELINQUENT 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
Natlce, additional interest must be calculated.