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HomeMy WebLinkAbout02-0413 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION ~ Estate of r :z...o y CA Jv1. blVen also known as No. To: ~/- 6" "' - 'I, 3 Register of ~illS for the County of I LlmbeJ /al1.d in the Commonwealth of Pennsylvania Deceased. Social Security No. ~ 0 J - f b - '-/ ~ 7 i The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl /e5 for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in C. LLm be r I an cA County, Pennsylvania, with h eV' last family or principal residence at CoOOO HI.lJ1'\W1 i'~_h{ld. .hv-t ve,. M~('haf1.[cshl1.lJi (list s t, number and municipality) ~amJdetf Tw p.] Decendent, then years of age, died d ~ , y(.d-..QOJ, at 0 If rl'v Qrl/C Decendent at death owned property with estimated values as folllows: (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: $ 7,rlSO J 00 , $ $ $ PetitionerS- after a proper search ha.\Lc:- ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Na THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. 3~ ~ xU~J.~~ ~3 <L> .... P:::~ 19 x4~19~ *~.-'YY} . q. 11 () ~o <;j = 00 Vi y tJ~Au {!. E)J'~ ~ 0~ NI1~~/~:L[Jd- ~riV~ M (}fllC Uf' A 1IJ50 / 7 - ~q 'I OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND ~,: 'p2 i~l'h 24 ''"^' The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. ice: t Sworn to or affirmed and subscribed xjl-tn~~ ~~ JJ~ before this, ~ day of ~ ~ egister No. 21-02-413 Estate of IZORA M. DIVEN Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW APRIL 26, ~ 2002 in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that VERONICA I. SHELLENBERGER AND WILHELMINA C. DIVEN is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to VRR(~T(:A T RHRT.T.F.NRF.RGF.R AND WTT.HF.T,MTNA C . DTVRN In the estate of T 7.()R A M _ T) T V F.N FEES Letters of Administration ..... $ 40.00 Short Certificates(1) .......... $ 3.00 Renunciation ........... ~.... $ 5.00 JCP $ 5.00 TOTAL $ 53.00 Filed APRIL..26th , , , , .. , , A,D. ~ 2002 Regi~~ter of Wills AT"TORNE'P (Sup. Ct. LD. No.) ADDRESS ]'HONE MAILED LETTERS AND ORDERS TO ADMINISTRATRIX WILHELMINA Hl0'l)~()" RFV 9iHf, 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. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 8227402 No. ITEM # .~o.4 SHOULD READ:'U.~ c..~~ SS .J4r.. 3/;)./ IDa.. .__. .--..... t i '" ! g 0 L~ t '" 0 r-- 1,: .-< <l; ! '" . i 0 ~ " ~ .~ E-< i ~ :I c: " "0 0. III Ii! o o I:! ~ ~ ~ " ;~ i~ Ilio ow ;S~ ~~ ~u. !l!~ ~~ ... o Ii: ,. ~ ' o f s ..:l I U') 'i ~ ~ ~ ~ ~ ~ i ~ 0 ~ M ~ b i ~ N ~ "'t h.ce~. ~.. U....I '" 5 is:: ~-I' 14-~ I'tl 0", :;; ~I ~ 5 0_. ~ o - t E~ ~ .~ ~ Ii ~ ~h ~ o ~ . q ~ '; i: " ~ ~ ~ > 0 > ili "~ ~ b j Cl "0 ~ ~ u 0 >< 113 j :3o;'"2~ g' ~ ~ i f~ 5 '''ill><I'ai,Bf !'~lU~P~ I gfil~~.~o~ ~ ~iCJ)p~ I :!!:::~~~~ ~ , IKU :B;: ~.~ ~ _Ii n ~> ~i H n ~ f .l t~ ~ ~! ':\ g~ ~ ~ !11 JV ..~ " ~h r; ~ <" ". -.---- -- ! - > ~ g ~! j o.~ i ~ [ ~ cd I ~ ~ ~ w ::E? "v ~ ~ f 1 d,'-2 ~ j M' ~8 Ml , ;t , ~ ~ .. E 8 , ?: i\ i\ ~~ ~ ~ I ~ tJ < ; ie ~ a k~~'1f'~<J cal Regi 'I~~A'tiA~) L....._ ~ - - " o z o , " ;000 o i j J ~ ~ ~~~ D ~ ~ ~~~ _____ ~Wf:~ ~~~~ ~~8~ o o ~! ~~ ~1 000 , 1i f f j ~ 1" f j ~i ~~ ~.'i o' oj gl i g a..ll ~ o ~ o 181 o 03sn S\I1W rl IUD o. ..~!~" ~l!! .01:) j:1i ~8 I~i.; ~. J~" I; ti!jH' d =3~H v. ill' ,let. VJ.<J 2. r ~, ~, u' " ~ I li ~ . ~ : ~ ~ ~ : ~ ~ ~ : ~; "0 I @; ~ ' BE ~ : I~ ~ ,t ~ 2~ ~ ~ .~ ~ i ~ t~ ~~ ~ ~ "g ~ ~~ g ~ {! ;~ ..c:;:I ..81; ~j li ~~ ~~ '-'"0 Z fO Ii ~l ~ g f g nn z~ ffia; ~j Uj U 0 00 ~~ ~~ ~i ~~ ~] g] i=.. z.. ffi= g= p~ ~~ Date !i ~ ~ Cl~ ~ :;;:::~ Ul (l) " E.w 113 .... 6 C ~N .' ~ : . ' € ' o , ~, ~, u , . ~: 'ii' u' o , .' ., ", ~. : €, ., '" . ' , , ~ ' €' . , ~, 8': :S I ~, I: J: I: ~ , ~' o:~ ' wo' ~: I 0:0' ~l : wE, i=l ~o~ w.!!lIi -' "; ~~! w,sii :&c5e IN303830 ,0 3VM1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG. PA 17128-0601 R E V- 1 5 0 0 I INHERITANCE TAX R TURN 02 RESIDENT DECEDENT 0413 DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I-- Diven, Izora M. 201-16-4273 Z DA'rE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) ~ THIS RETURN MUST BE RLED IN DUPLICATE WITH THE LU 03/20/2002 t09/14/1925 REGISTER OF WILLS !11 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ILl I- z lu r~ Z 0 h lU 0 0 [] 1. Original Retum [] 2. Supplemental Retum [] 3. Remainder Return (dato of ~ ~to 12-13..82) [] 4. Umitnd Estate [] 4a. Futura Interest Compromise (dm of de~ after 12-12~) [] 5. Federal Estate Tax Retom Required r~6. Decedent Died Testate (A~h copy of wa) [] 7. Decedent Maintained a Living Trust (Aaech ~ of Trna) __ 8. Total Number of Safe Deposit Boxes [] 9. LitigetionProceeds Recelvnd [] 10. SpouselPovertyCredit(datoofdeBthbehveef112-31-9, and,-1-95) [] 11. Elecfion to tax under Sec. 9113(A)(AUKhSchO) ~m SEC~ON ~ ~~~ AL~ ~s~~ A.O C~ TAX C~ECTm ~ NNME COMPLETE MNLING ADDRESS Wilhelmina C. Diven 6000 Hummingbird Drive RRM NAME 0f,~i~me) Mechanicsburg, PA 17050 TELEPHONE NUMBER (717) 697-5090 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Propdetorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointiy Owned Property (Schedule F) (6) 6,500.00 [] ,~lmmta Billing Requited 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Prppert, j (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) (8) 9. Funeral Expenses &Administrative Costs (Schedule H) (9) 8,616.80 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)(10) 154.00 11. Total Deductions (total Lines 9 & 10) (11) 12. Net Value of F..~tate (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) mede (Schedule J) 14. NM Value Subjeof to Tax (Line 12 minus Line 13) (14) :::::: ' 6,500.00 8,770.80 -2,270.80 -2,270.80 15. SEE INSTRUCTIONS ON REVERSE SIDE FOR APPUCABLE RATES Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (8)(1.2) x .0_ (15) 16. Amount of Une 14 taxable at lineal rate ........................ x .0_ (16) 17. Amount of Line 14 taxable at sibling rote x .12 (17) 18. Amount of Une 14 taxable at collateral rata ....................... x .15 (18) 19. Tax Due (19) Decedent's Complete Address: STREET N:)DRESS 6000 Hummingbird Drive CITY Mechanicsburg I STATEpA Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) Total Credits ( A + B + C ) (2) 3. Interest/Penalty if applicable D. Intarest E. Penalty Total Interest/Penalty ( D + E ) (3) 4. ff Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT, Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. IZIP 17050 A. Enter the interest on the tax due. (5) (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; .......................................................................................... [] [] b. retain the dght to designate who shall use the property tmnsfen'ed or its income; ............................................ [] [] c. retain a reversionary interest; or .......................................................................................................................... [] [] d. receive the promise for life of either payments, benefits or cam? ...................................................................... [] [] 2. If death occurred after December 12, 1982, did decedent lmnsfer property within one year of death without receiving adequate consideration? .............................................................................................................. [] [] 3. Did decedent own an "in trust for" or payable upon death bank account or secudty at his or her death? .............. [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designalion? ........................................................................................................................ [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Unde' penalties of pefiu~y, I dedare Ihat I have examined this return, induding accompanying sd~edules and stotornants, and to Ihe best of my knowledge and belief, it is tree, r, amct and complete. Declaration of pref~rer o~er ~an ~he personal representative is based on all iofom~alion of ~nich prepan~r has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RET-URN DATE ADDI~ §000 Hummingbird Drive, Mechanicsburg, PA 17050 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS DATE For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 FS. §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 RS. §9116 (a) (1.1) (ii)]. The statute does not exem_ot a transfer to a sun, iving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are slJll applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July I, 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 stepparant of the child is 0% [72 RS. §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 RS. §9116(1.2) [72 RS. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decadent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1509 EX+ (6-98) COMMONV~=ALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Izora M. Diven SCHEDULB F JOINTLY-OWNED PROPERTY FILE NUMBER 21-02-0413 If an asset was made Joint within one year of the decedent's date of death, It must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Wilhelmina C. Diven 6000 Hummingbird Drive Mechanicsburg, PA 17050 Daughter JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % Of: DATE OF DEATH ITEM FOR JOtN1 MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUt~-R. ATTACH DEED FOR JOiNTlY-HELD REN. ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 07/1988 1989 - 28' x 60' Redman Eaton Park Mobile Home $13,000.00 50% $6,500.0( TOTAL (Also enter on line 6, Recapitulation)$ 6,500.0( (If more space is needed, insert additional sheets of the same size) :' N &DA Appraisal Guides - Get a Value - Page 1 of I The Recognized Authority Since 1933 Home I Buy a Guide I Site Map I FAQ I Contact Us Yeur D~l~nattgm for Free V~t~t~ InfO~matio~ Free Finance Quote J Free Insurance Quote I Lemon Check ~ Warran~ I Consumer Tips I Vehicle Histo~ J Give Us Your Feedback www. NADAguides.com Manufactured Housing Pricing 1974-2000 For a free retail price, simply provide the following information: Enter Manufacturer Name Enter Trade/Model Name I.~.~9~...?ark * Enter State Located In Enter Year of Manufacturer Enter Width Enter Length * Values will not be affected by these criteria. These fields are for N.A.D.A.Guides demographic purposes only. ** Required fields Information about the home can be found on the HUD Compliance Certificate. This is located inside the home, generally on or near the main electrical breaker box or underneath the kitchen sink. [ Home I FAQ I Contact Us I Privacy Policy I Recommended Browsers ] [ Buy Trade Guides I Copyright Information I Advertising InformaUon I Become an Affiliate l About NADA Guides I Survey ] ¢)Copyright 2002 NADA Appraisal Guides, Inc. All Rights Reserved http://www.nadaguides.com~alueManufHousing.asp?UserlD=061463A388C&DID=37341 &GCode=Mh 3/26/200 : NADA Appraisal Guides - Get a Value - Manufactured Housing Page 1 of The Recognized Authority Since 1933 Home J Buy a Guide J Site Map J FAO J .Contact Us Year 0e~lil~tUe~t ~ ::::;:::::::; ;;; Free Finance Quote I Free Insurance Quote I Lemon Check I Warranty I Consumer Tips I Vehicle History I Give Us Your Feedback www. NADAguides.com Selected Construction Category: Standard Width: 28 Length: 60 State: PA Year of Manufacture: 1989 Low Retail: $13,017 Average Retail: $18,865 High Retail: $20,374 NOTE: This is a general valuation based on construction quality for the home only excluding optional equipment, accessories and site location. The value listed is derived from the N.A.D.A. Manufactured Housing Appraisal Guide "Supplemental Value Section" and is based on a general construction category chosen by the Website User. More :Information on Manufactured Homes Low Retail: This home would have signs of deterioration due to climate and/or deferred maintenance. May have some structural deterioration that is repairable. Components may need to be replaced. Accessories would be worn or may not have been added. Will need paint, new carpet, possible structural repair, etc. Less attractive to the eye than a most homes, but still useful. Commonly known in site built structures as a "fixer-upper". Average Retail: Home shows normal wear and tear due to climate, but is generally well maintained. Home is assumed to be a marketable product with no structural damage. Windows; doors, and cabinets open and close freely. A fresh coat of paint and new carpet may be all this home needs With the addition of a few accessories. The wear and tear is in relation to the age of the home. Obviously useful. http://www~nadaguides~c~m/Va~ueManu~-I~usingRep~rt.asp?UserID=~6 ~ 463A388C&D~D=3734 ~ &GC~d 3/26/200 ~ NADA Appraisal Guides - Get a Value - Manufactured Housing Page 2 of High Retail: Home is like new with no signs of deterioration. This home is obviously well maintained and very desirable. May have new paint, carpet, etc. Accessories are in excellent condition. Commonly known as "turn-key". ¢)C, opyright 2002 NADA Appraisal Guides,/nc. Afl Rights Resented The information in this report was obtained from NADAguides. com and is intended for the personal use of the customer only and may not be sold or transmitted to another party. We assume no responsibility for errors or omissions. http//www nadagmdes com/ValueManufHous~n Re oft as 9UserID 061463A388 : ' ' · ' g P · P. -- C&DID=37341&GCo(... 3/26/200 REV-1511 EX+ (12-99) COMMONWF_ALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Izora M. Diven SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21-02-0413 Debts of decedent must be reported on Schedule [. ITEM NUMBER DESCRIPTION AMOUNT 5. 6. 7. FUNERAL EXPENSES: Cocklin Funeral Home, Inc. - Services and Equipment 30 North Chestnut Street P. O. Box 424 Dillsburg, PA 17019 Gingrich Memorials - Headstone 5243 Simpson Ferry Road Mechanicsburg, PA 17055 Bmlflers Family Dining -- Room Rental Fee for Get-Togelher After Service Rt. 15 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State __ Zip Year(s) Commission Paid: Attomey Fees Family Exemption: (If desadent's address is not the same as claimant's, attach explanation) Claimant Street Address City State __ Zip Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees $6,794.00 $1,706.80 $50.00 66.00 TOTAL (Also enter on line 9, Recapitulation) $ 8,616.80 (if more space is needed, insert additional sheets of the same size) OPEN FO0~ CHECK COMP CHECK TOTAL .. C~© CASH .00 ~ALAN/'E ._ ,~:. :'~.~ ORDER FORM =James R. MEMORIALS aA Tribu~e to 5243 Simpson Feny ROad, Mechanicsburg, PA 17055 · (717) 766-5622 Phone(H) (~OJ"'J ' S DcJ O (w) Order 27754 Supplier Ack. # Date Rec'd Foand. ordered Position verified Date of Order ,,.~':~ Location Complete Center Over J Graves Lot # Approx. Date of Completion ~' J ~ we;e.J{~c~ :y Lett.e_ring IC"J $ '~ ~DfOW;~5 C 'J~ · sEPT 114 $ iA ~ Material Type o-f Memorial Size ~'0~' X 0 ID" X Finish Base ~'~" X t'[' X 0'~' Finish Misc. Design 3 ~e~ C~ ~ ~C~ O~ Location: [] Vase [] Corner Posts AgreementLA 50% deposit is required prior to commencement of work. Agree to pay stated balance upon erection regardless of labor troubles or shipments or any other good reasons. This order or contact cannot be cancelled by customer unless agreed by both parties. The article herein mentioned shall remain the properly of Jamea R. Gingrich Memorlala until ~aid in full and they reserve the rigtlt to remove the same is not paid as stated. I agree to ca refully proofread all names and dates for accuracy and accept full responsibility for any errors or emissions. THE R E WILL BE A N ADDITIONAL CHARGE FOR ANY LETFERING ADDED TO THIS MEMORIAL AFTER ERECTED ON THE CEMETERY. further agree to pay the balance stated for the work performed under this contract within thirly (30) day'~ of receipt of the final invoice and further agree thal interest shall accrue at the rate of one and one-halt percent (1 ~%) per month on the unpaid balance owed to James R. Gingrich Memorials not paid within t hilly (30) days of the invoice date. In addition thereto. I agree it it becomes necessary for James R. Gingrich to institute legal proceeding to collect any funds due from me for my account being past due thirty (30) days, to pay all court costs and attorneys fees incurred by James R. Gingrich Memorials to collect the same. WH ITE/Office Salesman Type of Sale YELLOW/Production Price FOundation $ $..Sso. - TOTAL DEPOSIT ¢~Li~~ · Balance Due Upon Completion $ i ~ ~. ~t3 (I further agree that the above names, spelling, and dates are correct) Date Entered ' / ,;-,, ~' . ~ PINK/Customer GOLDENROD/Branch ' * RECEIPT FOR MISC. INCOME Cumberland_County - Register Of Wills Hanover and Hiqh Street Carlisle, PA I7013 Receipt Date 4/24/2002 Receipt Time 10:21:01 Receipt No. 1029121 HOUSE ACCOUNT File Number 2002-99999 Remarks 3 PHOTO COPIES Transaction Description MISC. INCOME Cash Total Received ......... Distribution Of Receipt Payment Amount 1.50 .50 Payee Name CUMBERLAND COUNTY GENERAL FUND RECEIPT FOR PAYMENT Cumberland County - Register Of Wills Hanover and Hiqh Stree5 Carlisle, PA I7013 Receipt Date Receipt Time Receipt No. 4/26/2002 09:15:44 1029145 DIVEN IZORA M File Number Remarks 2002-00413 VERONICA I SHELLENBERGER CW Transaction Description PETITION LTRS ADM SHORT CERTIFICATE RENUNCIATION HEIRS JCP FEE Distribution Of Receipt ........................ Payment Amount Payee Name 40.00 3.00 5.00 5.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D Check# 448 ~53.00 Total Received ......... 53 00 RECEIPT FOR PAYMENT Cumberland_County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Receipt Date Receip~ Time Receipu No. 8/05/2002 08:39:20 1030130 DIVEN IZORA M File Number Remarks 2002-00413 PHOTO COPY JA Transaction Description COPIES Distribution Of Receipt Payment Amount Payee Name .50 CUMBERLAND COUNTY GENERAL FUN Cash ~.50 Total Received ......... 50 RECEIPT FOR PAYMENT Cumberland_County - Register Of Wills Hanover and Hiqh Street Carlisle, PA I7013 Receip~ Date Receipt Time Receipt No. 8/05/2002 08:56:44 1030131 DIVEN IZORA M File Number Remarks 2002-00413 WILHELMINA C DIVEN JA Transaction Description INVENTORY COPIES Distribution Of Receipt Payment Amount Payee Name 10.00 CUMBERLAND COUNTY GENERAL FUN 1.00 CUMBERLAND COUNTY GENERAL FUN Cash ~11.00 Total Received ......... 11 00 REV-1512 EX+ (6-98) I SCHEDULE I I cc~.~,~TH o~ ~NS~VA.~ DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE UABILmES, & UENS RESIDENT DGCEOENT ESTATE OF FILE NUMBER Izora M, Diven 21-02-0413 Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, Bowmansdale Family Practice - Medicare Copayment 1 Kacey Court, Suite 101 Mechanicsburg, PA 17055 Heritage (Cannot locate statement for this but it was not covered by Medicare or Supplemental Insurance) TOTAL (Nso enter o~ line 10, Recapitulation) $ $100.00 $54.00 154.00 (if mom space is needed, insert additional sheets of the same size) 2140 FISHER ROAD MECHANICSBURG, PA 17055 (717) 766-1795 [] Joseph ,~. Cincotta, M.D. LIC~ MD-O18341-E (PA) [] Janet F. Cincotta, M.D. LIC~ MD-017634-E (PA) [] Gary M, Schwartz, M.D. LIC# MD-O39532-E (PA) [] Alison H. Skurcenski, M.D. LIC# MD-O6856~L (PA) [] Elizabeth A. Alwine, C.R.N.P. LIC# VP..OD1525-B (PA) I KACEY COURT, SUITE 101 MECHANICSBURG, PA 17055 (717) 591-0961 .[aig-...Shrift,M.D, LIC# MD-043530-E (PA) J~eck-ln ~ "'i Appt. Time:~ Room,:__ · I · NF~.~_~.~23-2933075 1 KACEy COURT, SUITE 101 MECHANICSBURG, PA 17055 _.~71,~) 591-0961 I~Geoffrey M. James, M.D. LIC# MD-O22884-E (PA) [] W. Scott Setzer, M.D. LIC# MD-O62206-L (PA) [] Terrl L. Johnson, PA..~. UC~ MA-0O0739-L (PA) B 51232 ~7:$4AM NEW OFFICE VISITS ESTABLISHED 99050 After Houm 99211 Nume 99201 Limited 99212 Umited 99202 Intermed 99213 ,ntermed 99204 Con~rehen __ S0610 GYN (US) S0612 GYN (US) []US r-199088 Emerg __ G0101 GYN (MC) Q0091 C&H (MC) NEW PREVENTIVE ESTABLISHED W9630 Gen Med (MA) __ EPSDT 99381 Under 1 yr. 99391 Under 1 yr, 99382 1-4 yrs. 99392 1-4 yrs. 99383 5-11 yin. 99393 5-11 yrs, 99384 12-17 yrs. 99394 12-17 yrs, 99385 18-39 yrs. 99395 18-39 yrs, 99386 40-64 yrs. 99396 40-64 yrs. 99387 65 & over 99397 65 & over HOSPITAL SERVICES: ( ) HSH, Camp Hill ( ) HUG lisp Dales: / / To ~/ / 9943_ NB_ 9943 NB_ 99238 Discharge __ NURSING HOME/HOUSE CALLS: INJECTIONS: 95115 Allergy [] 1 95117 Allergy [] 2 [] 3 [] 4 86580 Mantoux 86585 Tine Test Meds I DME: go782 Adm. Fee Abdominal Pain/Loc Abnormal PAP 795.0 Acne 706.1 ADD(T) 314.00 / ADHD(T) 314.01 Allergic Reaction to Allergic Rhinitis 477.9 Anxiety(T) · 300.00 Asthma 493.90 / AE 493.92 Back Pain 724.5 Bronchitis - Acute 466.0 Bronchitis - Chronic 491.21 Cellulitis/Loc Cerumen Impaction 380.4 Cervical Strain 847.0 IMMUNIZATIONS: 90471 Adm. Fee [] 1 __ 90472 Adm. Fes r-12 []3 []4 90748 HIS/Hep B 90700 DTaP 90713 [] IPV 90712 [] TOPV 90707 MMR 90744 Hep B .5 (0-19 yrs) 90746 Hep B 1.0 (>20 yrs) g0720 DPT. f NIB 90665 Lyme 90733 Mer~ingocoocal 90716 Vad~ella 90718 [] crt 90702 [] Ped 90658 Influenza 90732 Pneumo. 90669 [] Ped Pneumo __ PROCEDURES: THER: 92552 Audiomet~y 92567 Tympanometry 160__ Bum Tx .__.° / Loc 57454 Coipo 58100 Endo Asp *17__ Destructi~ X __ 69210 Ear Lavage 93OOO EKG with Interp. 11__ Excision cm /.Loc.__ 82270 Hemoccult II x 3 · 10060I & D-Sin'~le 10061 Comp/mult · 20__ InjecUon-Joint/Ligament/Tendon 1105__ Padng/Cumttement X 94664 Pulmoneide ,120__ Repair-Laceration cm /Loc 113__ Shave Excision cm /Loc 45330 Sigmoid-Flex. · 11200Skin Tags X __ Chest Pain 786.50 CAD 414.9 CHF 428.0 COPD 496 Conjunctivitis 372.00 Coumadin Therapy V58.61 Counseling(T) V65.40 n('r) 296.20 · ~s.maet&fis-'-~-~ 692.9 'D~rmatitis, Plant 692.6 Diarrhea 787.91 Dizziness 780.4 Dys. Utedne Bleeding 626.8 [] ,..CHECK # / I'-I CARD PATIENT INITIAi~ PERFORMED BY: [] HMG [ [] HMC [] OMEGA *DX Nr~DED 80048 Basic Metabolic ~...__~/' 84703 P, CG ~ QL 80076 Hepatic Profile  85610 ProTime/1NR 84153 PSA 84450 AST 85651 Sed. Rate, Wester 85024 CBC~iff/Pit. Ct, 84439 T4, Free 82465 Cholesterol 84443 TSH 82947 Glucose 82043 Urine Micro Nbumle [] Bill patient les for send, ce ' PATHOLOGY TO: [] HSH [] Quest [] HMC 87797 Gen Prbbe[] OMEGA [] PINfl 88150 PAP 88142,.-: .Thin Prep PAP T~sue ~r or heel stick ( 85018 Hemoglo~n %,~_._.~1025 Pregnancy - Udne 87220 KOH Prep. 87210 Saline 87880 Rapid Strept 81003 [] UA 81001 [] UA w/Micro *DX NEEDED --]CONSULT APPT. W/IN: ONLY '-~ CONSULT & TREAT '-~ SPEC SERV -'l DIAGNOSTIC STUDIES ~ SCREENING MAMMOGRAM '-1 DIAGNOSTIC MAMMOGRAM LAB PT ED -1 MRR DM Type ~ Type 2 Controlled 250.0'1 _2'~. Uncontrolled 250.03~"250.02~ Neuro 250.61 ~ Ophthalmic 250.51 250.50 Renal 250.41 250.40 Fatigue 780.79 Gastritis 535.00 Gastroenteritis - Viral 008.8 GE Reflux 530.81 Headache 784.0 Headache, Migraine 346.00 Hemorrhoids, Int 455.0 Hemorrhoids, Ext 455.3 94010 Spiromotry 94060 w/broncho 401.1 402.10 CAD/CHF 402.11 Renal 403.10 CAD/Renal 404.10 Jigh Risk M~.e.d V58.69 ~--I~j~m.~ 272.4 :ly'p'StWy~idism 244,9 Influenza 487.1 lBS 564.1 Insect Bite/Loc Labyrinthitis 386.30 Menopausal 627.2 LIMITATIONS INSTRUCTIONS: RETURN UNIT DAYS: WEEKS: , MONTHS: REASON DAY Menorrhagia 626.2 Obesity 278.00 Osteoporosis 733.00 Otitis Media 382.00 Otitis Extema 380.10 Pneumonia 486 Rectal Bleeding 569.3 Shortness of Breath 786.05 Sinusitis - Acute 461.9 Sinusitis - Chronic 473.9 Situational Stress(T) 308.0 Smoker 305.1 Sore Throat 462 Strap Thro~t 034.0 URI 465.9 UTI 599.0 Vaginitis 616.10 Vaginitis, Candidal 112.1 Viral Syndrome 079.99 Warts 078.10 Routine Gyn V72.3 Routine Gyn (MC) V76.2 AduWAdolesPE V70.0 Infant/Child PE V20.2 Family HX: DM V18.0 ~ Prostate CA V16.42 CAD V17.3 Colon CA V16.0 Screen Colon CA V76.51 / /__ thru __/__/__ Mo. Day Yr~ Mo. Day Yr. OK to retum to ( ) Work ( ) School /__/__ MO. D LIMITATIONS: P!ea,~..!,nform,.us o. ,n.~ day in a,dvan~e if ~ou .a!e un.a,.b,le to k,,.eep, yo. ur ap ,pointment. Missing an appointm.e.nt, wi/I.r.esult in_a. noE_.;e _char_ge:_. 10, 15, 25, 40 Yr. REV-1513 EX+ (9-00) COMMONWEALTH 0/: PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Izora M. Diven SCHEDULE J BENEFICIARIES FILE NUMBER 21-02-0413 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Sylvester B. Diven 4 Old Garrett Court White Hall, MD 21161 Veronica I. Diven 465 Garden Drive Mechanicsburg, PA 17055 Wilhelmina C. Diven 6000 Hummingbird Drive Mechanicsburg, PA 17050 Kevin P. Diven 3940 Longhill Station Road Williamsburg, VA 23188 Son Daughter Daughter Son ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 25% 25% 25% 25% (If more space is needed, insert additional sheets of the same size) Register of Wills of CUMBERLAND County, Pennsylvania Certificate of Grant of Letters No. 2002-00413 PA No. 21-02-0413 ESTATE OF DIVEN IZORA M (~'l', ~'l~S'z, m±uu~) WHEREAS, DIVEN IZORA M , late of /MBERLAND COUNTY , died on the 20th day of id WHEREAS, the grant of letters of administration required for the administration of the estate. Late of HAMPDEN TOWNSHIP , ~UM~.L~L~ ~UU~'I'Z, Deceased Social Security No. 201-16-4273 HAMPDEN TOWNSHIP March 2002; THEREFORE, I, MARY C. LEWIS , Register of Wills and for the County of CUMBERLAND , in the' )mmonwealth of Pennsylvania, have this day granted Letters of Administration to SHELLENBERGER VERONICA I and (~-~'z, ~'±~'i', m±mu~) DIVEN WILHELMINA C have duly qualified as administrator(rix) of the estate the above named decedent and have agreed to administer the estate according law, all of which fully appears of record in my Office at CUMBERLAND )UNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal my Office on the 26th day of April 2002. # -- ~gls~er.o~ ~i±1~ ''f **NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE) BUREAU OF ZNDZV/DUAL TAXES TNHERTTANCE TAX D/VIS/ON DEPT. 280601 HARRTSBURG, PA 17128-0601 COMMONNEALTH OF PENNSYLVANZA DEPARTMENT OF REVENUE NOTICE OF /NHERITANCE TAX APPRA/SEMENT, ALLOWANCE OR D/SALLOWANCE OF DEDUCT/ONS AND ASSESSMENT OF TAX REV-15~i7 EX AFP COl-OS) WILHELMINA C DIVEN 6000 HUMMINGBIRD DR MECHANICSBURG PA 17050 DATE 05-O$-ZOOq ESTATE OF DTVEN DATE OF DEATH O$-ZO-200Z F]~LE NUMBER 21 02-0q15 COUNTY CUHBERLAND ACN 10 ! I Amount Remitted IZORA M MAKE CHECK PAYABLE AND REMZT PAYMENT TO: REGTSTER OF NTLLS CUMBERLAND CO COURT HOUSE CARLTSLE, PA 17015 CUT ALONG THZS LZNE ~ RETAZN LONER PORTZON FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03) NOTZCE OF ZNHERZTANCE TAX APPRAZSEMENT, ALLONANCE OR DZSALLONANCE OF DEDUCTZONS AND ASSESSMENT OF TAX ESTATE OF DTVEN ZZORA M FZLE NO. 21 02-0q15 ACN 101 DATE 05-05-ZOOq TAX RETURN WAS: { X) ACCEPTED AS FZLED ( ) CHANGED RESERVATZON CONCERNZNG FUTURE ZNTEREST - SEE REVERSE APPRA/SED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) $. Closely Held Stock/Partnership Interest (Schedule C) ($) q. Mortgages/Notes Receivable (Schedule D) (q) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets APPROVED DEDUCTZONS AND EXEMPTZONS: 9. Funeral Expanses/Ada. Costs/M/sc. Expanses (Schedule H) (9) 10. Debts/Hortgage L/ab/litias/Lians (Schedule Z) (10) 11. Total Deductions 12. Nat Value of Tax Return .00 NOTE: To /nsura proper .00 crad/t to your account, .00 submit the upper port/on .00 of this form with your .00 tax payment. 6~500.00 .00 (8) 8,616.80 15q.00 6,500.00 (11) 8.770-~]0 (12) 2,270.80- 15. lq. NOTE: ASSESSMENT OF TAX: 15. Amount of L/ne lfi mt Spousal rata 16. Amount of L/nm lq taxable mt Lineal/Class A rata 17. Amount of L/ne lq mt S/bl/ng rata 18. Amount of L/ne lq taxable at Collateral/Class B rata 19. Princi)al Tax Due TAX CREDZTS PAYMENT RECEZPT OZSCOUNT (+) DATE NUMBER INTEREST/PEN PAZD (-) Char/table/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (13) Nat Value of Estate Subject to Tax (lq) Zf an =ssessment was issued previously, lines 14, 15 and/or 16, 17, reflect figures that include the total of ALL returns assessed to date. (15) (16) (17) (18) · O0 x O0 = · O0 x 0~5 = .o~,~:. lZ =. · ~x 15~ ~"' (19)= AMOUNT PA1D TOTAL TAX CREDZT I I BALANCE OF TAX DUE ZNTEREST AND PEN. TOTAL DUE ZF PAZD AFTER DATE ZNDZCATED, SEE REVERSE FOR CALCULATION OF ADDZTIONAL ~NTEREST. .00 2,270.80- 18 and 19 will .00 .00 ,~ . O0 ? ~: . o o " .00 .00 .00 .00 .00 ( ZF TOTAL DUE 1S LESS THAN $1, NO PAYMENT ZS RE~UZRED. 1F TOTAL DUE 1S REFLECTED AS A 'CREDZT' (CR), YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THZS FORM FOR ZNSTRUCTZONS.) RESERVATION: PURPOSE OF NOTICE: PAYNENT: REFURD (CR): OBJECTIONS: ADH/N- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 12, 1982 -- if any futura [nterest in the estate as transferred an possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for lifo or for years, the CoamonNaalth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the laaful Class B (collateral) rate on any such future interest. To Tulfill the requirements of Section Z140 of the Inheritance and Estate Tax Act, Act 25 of lOgO. (7Z P.S. Sec[ton 91q0). Detach the top port[on of this Not[ce and submit with your payment to the Regis[ar of Rills printed on the reverse sade. --Make check or money order payable to: REGXSTER OF MILLS, AGENT A refund of a tax credit, which was not requested on the Tax Return, may ba requested by completing an "Application for Refund of Pannsylvan[a Inheritance and Estate Tax" (REV-1515). Applications ara ava[labia at the Office of the Register of Rills, any of the Z$ Revenue District Offices, or by calling the special Z4-hour answering service for forms ordering: 1-800-S6Z-Z050~ services for taxpayers ~ith special hearing and / or speaking needs: 1-800-4q7-sogo (TT only). Any party in interest not satisfied ~ith the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as sho~n on this Notice must object ~ithin sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Oep[. g810Z1, Harrisburg, PA 171Z8-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors d[scovered an this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Ravtaw Un[t, Bapt. 280601, Harrisburg, PA 171Z8-0601 Phone (717) 787-6505. Sam 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 is paid w[th[n three (3) calendar months after the dacedant's death, a five percent (SI) discount of the tax paid as alloNad. The lSZ tax amnesty non-participstion penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty par[od. This non-participation penalty is appealable in the same manner and in the the same time period as you ~ould appeal the tax and interest that has been assessed as indicated on this notice. Interest as charged beginning a[th 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 rata of slx [6Z) percent par annum calculated at a dally rate of .000164. All taxes which became delinquent on and after January 1, 198Z will bear interest at a rate Nhich will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOO4 ara: Interest Daily Interest Daily Interest Daily Year Rata Factor Year Rate Factor Year Rate Factor ~ 20X .OOOSq8 ~)'~'& - 1991 llX .000301 ~ 9Z .ooogq7 1985 167. .000q38 1992 97. .000Z47 ZOOZ 62 .000164 1984 llZ .000301 1993-1994 7Z .O0019Z Z003 5Z .0001~7 1985 13Z .000356 1995-1998 9Z .000Z47 ZOO4 4X .000110 1986 107. .000274 1999 7Z .00019Z 1987 ZOZ .000Z74 logo 7Z .00019Z --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NURBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent Hill reflect an interest calculation to fifteen (IS) days beyond the date of the assessment. If payment is made after the interest computation date shown on the No[ica, additional interest must bo calculated. RENUNCIATION In Re Estate of r ~O(Ct f'/\. DiVu> deceased. To the Register of Wills of (11 lYY\lw Rl >=:\ (I) County, Pennsylvania. The undersigned QJ,\ \J;qell of the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters C)~ R Oln I n I F,T RATI n n VerOnica. I.S;'hc:/JcnbcrycJ 0l\c1 W if It dm illa C I J)/vOJ be issued to WITNESS hand this day of ,19_. -2I~~ . (Signature) J-j ()/cJ r;a~ ~ tv.Lt / 1-/<<: ~ /1 '0 .j.../ / b / (A dress) (",I Z () (? f2--- ! ~ \ /j,.<-&y"...! I. . _t~<L-y0 (Signature) ~9'/() [0I\j'\7 II 5h-h'cJf\ R-C<ic) UJ t /ljQm5bu(Cj [lit Z ~)88 -(Address) ....c ("-.I (Signature) "I P ~ ,- '.r... ..#.~ (Address) <....... CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: "I -:2..0 (0.. M. D I \I el) Date of Death: Mafch dO, ~Od-. Will No. Admin. No. o~ - Ll t3 To the Register: I certify that notice of (beneficial interest) 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 l\e.vl Y\ P. Diven Address 4- old Gllf"rett.. Court: W hHe Ha.ll, M b d.-l t ~ , L\-loS GQ.rde.i\ ~f'"1"~ tv1echO'f\{csblA.... PA I1D5 (0000 }-{ urnm J rl brrd... {) ri \I~ M echon t<:.sbuR I PA 11050 3't!fa LOYl,g~\I1 stat&Ot'l ~()ad v,.lII(jatV.~blLr1' VA ::2.3188 Name 5'fh/e.o*er ~.' bj"~t1 V eret'\' Co.... I. Sn e 1 len ber ef" W i lh~\rn /no. C. 1 i \/e.1\ Notice has now been given to all persons entitled thereto under Rule S.6(a) except Date: Signature Name uJ11i~~ c. ~~ Address Co 000 f.J. u. m JY1 fl]J ill'rd JJ r i V t: Me. c..n Q () f t s b u (J I \)A 1'7 D 5 0 Telephone (1 1>1 !p q 7- So q D Capacity: ~ Personal Representative _Counsel for personal representative ..!J (: COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND I J 55: ~\il~e.lrn'fl,^ C. ]Jive" being duly 5"'-lnrn according to law, deposes and says that $11e Ad ml(H~f.("o...+or of the Estate of Iz..ora. M. jJ jVC'n late of ~--J.!~~de-o_ -=rCJJ.)nsh i~_________ I Cumberland County. Pa., deceased and that the within is an inventory made by W."l--tdrY\lt'\d c... :l'JNe" -,the said AdfTnMs+ret+or of the entire estate of said decedent, consisting of all the personal property and real estate, except real estate outside the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value as of the date of decedent's death. 19 w~c.k)~ Executor. Administrator and subscribed before me, Address Date of Death ~o Day MQ("c~ Month 01.00.;;1. Year 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. >- cl -0 a> rY) I- w ~I '" ~ 0::: I- ttl - W -< CII ':;t- a.. l- v 0 V'I ~I CII a> 0 w w 0 01 >- , 0::: 'II a> \6 l- I a.. LL Q,. c Z I- .....I ttl .. 0 .....I -< 0 ~I a.. 0 I LL :s: I w 0 -< w E .;. , > 0::: I -< - Ii z csJ .... 'l) Z 0 d c 0 :J 0 V'I Z bi -:::L 0 0::: U z I w < ~I - a.. -0 c Hi ttl I - &: 0 CII ..Q "tl ~ I CII E .... a> 0 ::I 0 I ttl U i.i: I .....I co ij '" / ] u' ~nventory of the real and personal estate of I Z-Dra. M. j)(\Ien deceased , I. P>SE L LJ CJ1 ec.Kl ~ A C COLtfrt ci54 ~~ ~. 19 gq R~dma" E.O-ton ....po.r Ie( M Dhll~ ~CfYle.. .3. ~(QPC:(+~ To:xf ~<:(l+ ~~bo..fe. ~500 00 500 OQ COMMONWEALTH OF PENNSYLVANIA DEF'ARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG. PA 17128-0601 REV-1162 EX(11-961 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT DIVEN WILHELMINA C 6000 HUMMINGBIRD DRIVE MECHANICSBURG, PA 17050 __nun fold ESTATE INFORMATION: SSN: 201-16-4273 FILE INUMBER: 2102-0413 DECE:DENT NAME: DIVEN IZORA M DATE OF PAYMENT: 01/24/2003 POSTMARK DATE: 01/23/2003 COUNTY: CUMBERLAND DATE OF DEATH: 03/20/2002 NO. CD 002080 ACN ASSESSMENT CONTROL NUMBER AMOUNT 02120759 I $10.11 I I I I I I I I TOTAL AMOUNT PAID: $10.11 REMARKS: WILHELMINA C DIVEN CHECK# 268 SEAL INITIALS: VZ RECEIVED BY: REGISTER OF WILLS DONNA M. OTTO DEPUTY REGISTER OF WILLS /?-r:,.~-?- 7 \ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRIS8URG. PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE '* NOTICE OF INHERITANCE TAX APPRAISEKENT~ ALLONANCE OR DISALLONANCE OF DEDUCTION~J AND ASSESSKENT OF TAX ON JOINTLY HELD OR TRUST ASSETS REV-1548 EX AFP (01-03) WILHELMIN C DIVEN 6000 HUMMINGBIRD DR 17 MECHANICSBURG PA 17~5D-2040 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY SSN/DC ACN 03-24-2003 DIVEN 03-20-2002 21 02-0413 CUMBERLAND 201-16-4273 02120759 IZORA M Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~ ---------------------------------------------------------------------------------------------------------------- REV-1548 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 03-24-2003 ESTATE OF DIVEN IZORA M DATE OF DEATH 03-20-2002 COUNTY CUMBERLAND FILE NO. 21 02-0413 TAX RETURN WAS: S.S/D.C. NO. 201-16-4273 (X) ACCEPTED AS FILED () CHANGED JOINT OR TRUST ASSET INFORMATION ACN 02120759 FINANCIAL INSTITUTION: PSECU ACCOUNT NO. 0201164273 TYPE OF ACCOUNT: DATE ESTABLISHED ()() SAVINGS ( ) CHECKING ( ) TRUST ( ) TIME CERTIFICATE 01-23-1986 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due X 449.47 0.500 224.74 .00 224.74 .45 10.11 NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." X TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 01-23-2003 CD002080 .00 10.11 TOTAL TAX CREDIT 10.11 BALANCE OF TAX DUE .00 INTEREST AND PEN. .05 - TOTAL DUE .05 * IF PAID AFTER THIS DATE. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. * ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CRJ, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J ., ~)\\0 COM"ONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 *' INFORMATION NOTICE AND TAXPAYER RESPONSE FILE NO. ACN DATE 21 - O~- Y-f3 02120759 05-02-2002 REV-1545 EX AFP lD9-UUl EST. OF IZORA M DIVEN S.S. NO. 201-16-4273 DATE OF DEATH 03-20-2002 "r COUNTY CUMBERLAND TYPE OF ACCOUNT IX] SAVINGS D CHECKING D TRUST D CERTIF. WILHELMIN C DIVEN 6000 HUMMINGBIRD DR 17 MECHANICSBURG PA 17050~2040 REHIT PAYHENT AND FORHS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Thair racords indicata that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with tha Inheritance Tax Laws of the Commonwealth of F'..nn..ylvani... Questions may b.. ans....rad by c&lllnll l7ln 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0201164273 Date 01-23-1986 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 449.47 50.000 224.74 .045 10.11 TAXPAYER RESPONSE To insure propar credit to your account, two (2) copi..s of this notice must accompany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". x NOTE: If tax payments are made within three (3) months of the decedent.s date of death, you may deduct a 5% discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. Tax PART [!] A. [ CHECK ] ONE BLOCK B. ONLY c. ua(The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you may check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. [J The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the decedent's representativa. [J The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. TAX ON JOINT/TRUST ACCOUNTS If you indicate a different tax rate, please state your relationship to decedent: PART ~ TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF 1 2 3 4 5 6 7 8 x x PART @] DATE PAID DEBTS AND DEDUCTIONS CLAIMED PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on Line 5 of Tax Computation) I $ Under penalties of perjury, I declare that the facts I complete to the best of my knowledge and belief. TW~Rr'~~ have reported above are true, correct HOME ('1' 1 ) lDQ'1- SO 'to WORK ( '7 I? ) 17 A - 78 Lf I TELEPHONE NUMBER and I-J.;l-o 3 DATE Name of Decedent: Date of Death: W~ll No.: STATUS RBPORT UNDBR RULB 6.1.2. '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 adminis~ation of the estate is complete: Yes[~ No[-] 2. I/the answer is No, state when the personal representative reasonably believes that the adra~n~tration will be complete: 3. If the answer to No. 1 is Yes, state the following: Did the personal representative file a final account with the Court? Yes _ No ~ b. The sepazate Orphans' Court No. (if any) for the personal representative's account is: __ c. Did the personal representative state an accouut informally to the parties in interest? Yes [~ No' ['-] Date: Copies of receipts, r~leases, joinders and approval of formal or informal accounts may be filed with the Clerk of the. Orphans' Court and may be attached to th~ report. Signature 6o~ H~m~,n~bi~ ~fivc M~an i c%~r~ PA ~q05O Ad~ss' (qlq) 6qfl-SoflO T~l~hon~ No. CapaoiW: ~P~rson~ R~pr~s:ntadv~ ~ Co~sel for person~ r=pr~senta~w