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Home My WebLink About04-0079PETITION FOR PROBATE and GRANT OF LETTERS Estate of Miriam H. Goudy also known as Deceased. Social Security No. 190-26-6599 TO: Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania. The petition of the undersigned respectfully represents that: Your Petitioner is 18 years of age or older and the executor named in the last will of the above decedent, dated 5 December 2000 and codicil(s) dated n/a. Decedent was domiciled at death in Cumberland County, Pennsylvania, with her last family or principal residence at 13 Creek Road, Camp Hill, Pennsylvania. ' Decedent, then 77 years of age, died on 7 January 2004 at Holy Spirit Hospital, Camp Hill, Cumberland County, Pennsylvania. 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: n/a Decedent at death owned property with estimated values as follows: (if domiciled in Pa.) All personal property (if not domiciled in Pa.) All personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania Situated as follows: 13 Creek Road, Camp Hill, PA WHEREFORE, Petitioner(s) respectfully request the probate of the last will and codicil(s) presented herewith and the grant of letters testamentary. Signature and residences of Petitioner(s): r------~. ~ ~ ~.. Sa-'~m~i L. ~,nd~s~ - "~'~ 525 North 12th Street Lemoyne, PA 17043 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) The petitioner above-named swears or affirms that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner and that as personal representative of the above decedent petitioner will well and truly administer the estate according to law. Sworn to or affirmed and subscribed ~ II before me this 27th day of San~uel L.-And~%J/ - ' I: 5anuary , 2004. 525 North 1 2th Street /~//~ ~ -~ j~../_. , ] Lemoyne, PA 17043 Glez Ia Farner Strasbaugh egister .... -/'~ _ R6 Fil No. 21-2004-0079 Estate of Miriam H. Goudy, Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW, January 27th , 2004 , in consideration of the Petition for Probate and Grant of Letters, satisfactory proof having been presented to me, IT IS DECREED that the instrument dated 5 December 2000 described therein be admitted to probate and filed of record as the last will of Miriam H. Goudy and Letters Testamentary are hereby granted to Samuel L. Andes. 'Re-ister of Wills' ~~ ~ Glenda Farner Strasbaugh ..... -'""~ '~7-- ~ FEES Probate, Letters, Etc ............ $ 235.00 Short Certificates ( 4 ) ..........$ 12.00 lunciation ....................... x-Pages (3) $CP Fee ~I~x ~Fot~ d January 27th, 2004 9.00 i0.00 266.00 Samuel L. Andes Attorney-at-Law (I.D. No. 17225) 525 North 1 2th Street Lemoyne, PA 17043 (717) 761-5361 Nailed Letters to attorney on 01-27-04 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 P 9813522 No. Local Registrar JAN 0 9 20C4 Date H105 143 Rev. 2/87 NAME OF DECEDENT (Fi~t, Middle. Last) t. AGE (Last Bkl~day) 77 v~. COUNTY OF DEATH ,b.Cumberland DECEDENT'S USUAL OCCUPATION ~.egistered nurse 13 Creek Rd. ~s.Camp Hill,PA 17011 FATHER'S NAME (Fiat. Middle, Last) COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH ° VITAL RECORDS CERTIFICATE OF DEATH STATE FILE N~JMBER · . ~SEX ! SOCIAL SECURITY NUMBER I DATE OF DEATH (Month, Day, Year) I '"l~'r lam 'H ' DAC~EUo¢~RTH ' B, RTHPLAOE ~ .~le l].90 --26 --6599 a~.,,c~-~-..I 'M ..... I - . ( 'tyand IPLACEOFDEATHtChec~onlvone-seeinstruclionsonot~s~lel · us l Uinutes~L t ~,uay,'fearj / Utale~Fo~elgnCountry) IHOS~ITAL: IOTHER: I . BORO. TWP OF DEATH [ FACILITY NAME (If nol inStllution, fl~va $1teet and numbe¢) ]WAS. DECEDENT OF HISPANIC ORIGIN? KIND OF BUSINESS I INDUSTRY · ," I ' IVVAS DECEDENT EVER IN ~ DECEDENT'S EDUCATION ~ MARITAL STATUS - Mal~ied. ~ SURVIVING SPOUSE ~ U.S. ARMEDFO~CES? I {Sl)eC~mlyN~e~l~'adec4~3~ted} I NevarMamed Widowed, I bnever DECEDENT'S t?a. S=~a Permsylvania C~d ~T=. [~ Y., ~=.~,~-C Allen : RESIDENCE decedent twp (See instructions live in a o, omer~e} ~7~. cou~y Cumberland township? 17d. FI No, decadent#veal MOTHER'S NAME (Firal, Midde, Maiden Surname IN~F~ORMANTS M.AILING ADDRESS (Street, Cil~/fown, Slate, Zip Code) i=a,~ Creel< Rd.,Camp Hill~PA 17011 [] [] (~.~71't'~2004 I,ggn-O-Lite Crematory .~:/~:~,=r.~ao~,m~l'7088 E (Type/P~nt) John R. Goudy Lorraine C. Hughes physician la m~ available at t~me of death to (Signature and Title) certif-/cause of death. 23a. Ileal 24-26 mum be compleled by 3-L time, date and plac~ slated TIME OF DEATH (Month, Day, Year) .[NAME ~ND ADDRESS OF FACILITY person who pro~nmJncas death. d--'M'EDiATECAUSE'"n',,,--on 0o¢ resu~t~)g in death) ~ a. I CAUSE (Disease (x'i~ju~ c. resuRing on death ) LAST d. COMPLETIoNW~RE AUTOPSY FINDINGS PERFORMED? AVAILABLE PRIOR TO OF CAUSE Natural ~I Homicide OF DEATH? Accidenl[] Perldi~g InvestigatE)n Yes []No [~ Yes [] No [] icide [] Could not I~e determined 28a. 2~b. . CERTIFIER (Check only ' ~.o ~u "__c.'_"?_A.."2 _C~.~ FY'~"~..".VS,C,A. (Phobia. ~o~, ,,o~,~.~ death ~ ~, ..... , de.,,) On the basil ~ exa~nafl~ a~or lnveltlg~lon. In my opinion, death occu~ed at the tl~, date, I~ place, and due to the ci~ea{I and ILICENSE NUMBER IDATE SIGNED I(.onth, D?, v,~) 23b. · 1 234:. WAS CASE REFERRED TO ~. ME~DAL E~IIN~I~/C~_ ~ONER? DATE OF INJURY I TIME OF INJURYI [] 30 ~Oc. --TION~(Stree130d'. Ci~o~n. Slate) LICENSE NUMBER I ~IE SIGNED (M~. Day, Y~r) NAME AND AD~ESS ~ PERSON ~O ~MPLETED ~USE ~ DEATH DATE gtLE~(M~th, Day, Year) WILL OF MIRIAM H. GOUDY I, MIRIAM H. GOUDY, of Lower Allen Township, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. ITEM I. I direct that all my just debts and funeral expenses, including my gravemarker and all expenses of my last illness, and any and all taxes and assessments imposed by any governmental body as a result of my death, whether on property passing under this will or otherwise, shall be paid from my residuary estate as soon as practicable after my decease as a part of the expense of the administration of my estate. ITEM II. I give, devise, and bequeath all of my possessions and estate of every nature and wherever situate as follows: A. Twenty (20%) percent thereof to my friend, LORRAINE HUGHES, provided she survive my death by sixty (60) days and, if she does not so survive my death, to such of her issue, per stirpes, as survive my death by sixty (60) days. B. Fifty (50%) percent thereof to the GRACE LUTHERAN CHURCH of Lower Allen Township, Cumberland County, Pennsylvania, or its corporate successor. C. Twenty (20%) percent thereof to the PINNACLE HEALTH HOSPICE of Harrisburg, Pennsylvania, or its corporate successor. D. Ten (10%) percent thereof to the AMERICAN LUNG ASSOCIATION or its corporate successor. ITEM III. I appoint SAMUEL L. ANDES executor of this my last will. ITEM IV. All of the interests of the beneficiaries hereunder shall not be subject to anticipation or to voluntary or involuntary alienation nor shall they be subject to any execution or attachment. Page 1 of 4 ITEM V. In addition to the other powers and authorities granted to my personal representative by Pennsylvania Law and by the other terms and provisions of this will, I hereby give to my personal representative the following powers and authorities effective without court approval and until actual distribution of all property: to compromise any claim or controversy; to make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as my personal representative may determine and at valuations finally to be fixed by them; to invest in all forms of property, including any stock or other securities in any corporate fiduciary or its successor without restriction to investments authorized for Pennsylvania fiduciaries, as my personal representative deems proper, without regard to any principle of risk or diversification; to retain any or all assets of my estate, real or personal, without regard to any principle of risk or diversification; to sell at public or private sale, to exchange, 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 or conditions as my personal representative deems proper; and to allocate receipts and expenses to principal or income or partly to each as my personal representatives deem proper in their sole discretion. ITEM VI. I direct that my personal representatives and fiduciaries shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand this ,5''~ day of MIRI'AM H. GOUDY Pa~3e 2 of 4 The preceding instrument, consisting of this and TWO other typewritten pages, each identified by the signature of the testatrix was on the date thereof signed, published, and declared by MIRIAM H. GOUDY, the testatrix therein named, as and for her last will, in the presence of us, who at her request, in her presence, and in the presence of each other, have subscribed our names as witnesses hereto. ~ngs Amy H~lkins- - Page 3 of 4 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ) ( SS.: ) The undersigned, being the testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, does hereby acknowledge that I signed and executed the foregoing instrument as my last will, that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me by the testatrix named above this ~+~' day of t~e_~e~w[~,/~ , Zooo . Iv~RI,~'M H. GOUDY [ NOTARIAL SEAL' I i:1-~ill EHRENFELD, NOTARY PUBLIC I LEMOYNE BORO., CUMBERLAND CO. I MY COMMISSION EXPIRES AUG. ]7, 2004 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ) ( SS.: ) WE, MICHAEL L. BANGS and AMY HARKINS, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the testatrix sign and execute the instrument as her last will; that she signed it willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testatrix signed the will as witnesses; 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 or affirmed to and acknowledged before me this ~- Cf.. day of ~)eCe~rr- , Zoo~ . ~'my Ha~ins Notary ~~ N~SEAL LYNN EHRENFELD, NOTARY PUBUC | LEMOYNE BORO., CUMBERLAND CO. ! [MY COMMI$$10N Page 4 of 4 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Miriam H. Goudy Date of Death: 7 January 2004 Will No. Admin. No. 21-04-0079 To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on 29 January 2004: TO: Lorraine Hughes, 11 Creek Road, Camp Hill, PA 17011 Grace Lutheran Church, 1610 Carlisle Road, Camp Hill, PA 17011 Pinnacle Health Hospice, 3705 Elmwood Drive, Harrisburg, PA 17110 American Lung Association, 3001 Old Gettysburg Road, Camp Hill, PA 17011 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Date: 29 January 2004 Samuel L. Andes Attorney-at-Law 525 North 12th Street Lemoyne, PA 17043 (717) 761-5361 Personal Representative S~,~UF.L L. ANDES ATTOI:~N~Y AT LAW NORTH T~ELFTH STRI~.ET P. O. ~X 168 LE~OYN~, PENNSYLVAN~ 17043 25 March 2004 Register of Wills Cumberland County Court House I Courthouse Square Carlisle, PA 17013 RE: Estate of Miriam H. Goudy ,~.2/- Ladies: Enclosed is my check for $10,000.00 with which I make a deposit against the Pennsylvania inheritance tax that will be owed on the above estate. Thank you for your attention to this matter. Sincerely, la Enclosure -~" ~, '~" · COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BL~EAU OF INDIVIDUAL TAXES DEPT. 2,80601 H~RRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD O03715 ANDES SAMUEL L 525N 12THST LEMOYNE, PA 17043 ..... '-- fold ESTATE INFORMATION: SSN: 190~26-6599 FILE NUMBER: 2104-0079 DECEDENT NAME: GOUDY MIRIAM H DATE OF PAYMENT: 03/25/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 01/07/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $ 10,000.00 REMARKS: ..... SEAL SAMUEL L ANDES CHECK# 5027 TOTAL AMOUNT PAID: $10,000.00 INITIALS: SK RECEIVED BY.' GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 C~?FJCL~,L ~ ...... FILE NUMBER 21-04 OO7 17, Amount of Line 14 taxable at sibling rate x .12 (17) 18. Amount of Line 14 taxable at collateral rate 66,165.51 x .15 (is) 9,924.83 19. Tax Bue (19) 9,924.83 20. '[~ F~I. Odginal Return [~4. Limited Estate ~m6. Decedent Died Testate (Attach copy of W'd~) [~9. Litigation Proceeds Received E~]2. Supplemental Return ~'-~ 4a. Future Interest Compromise (date of death after 12.12-82) r---~ 7. Decedent Maintained a Living Trust (^~ch copy of Tr~st) [~]10. Spousal Poverty Credit {date of death between 12-31-91 a~ 1-1.95) NAME Samuel L. Andes FIRM NAME TELEPHONE NUMBER (717) 761-5361 F-'I. Remainder Return (date of death prior to 12-13-82) F']5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes r'~ 11. Election to tax under Sec. 9113(A) (Atmch S~ ( COMPLETE MAILING ADDRESS 525 North 12th Street Lemoyne, PA 17043 14. 1. Real Estate (Schedule A) (1) 1 17,420.00 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) 176,413.92 (Schedule E) 6. Jointly Owned Property (Schedule F) (6) [--~ Separate Billin~ Requested 86,505.80 7. inter-Vivos Transfers & Miscellaneous Non-Probata Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses &Administrative Costs (Schedule H) (9) 48,873.65 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule l) (10) 638.53 t1~ Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. 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) OFFICIAL USE ONLY 380,339.72 (8) (11) 49,512.18 (12) 330,827.54 (13) 264,662.03 (80% of net estate) 66,165.51 (14) 15. SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Amount of Une 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) (15) 16. Amount of Line 14 taxable at lineal rate x .0_ (16) U,J -,-oo < 9 COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER z Goudy, Miriam H. 190 - 26 - 6599 ~ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR THIS RETURN MUST BE FILED IN DUPLICATE WITH T tu 01-07-2004 02-04-1926 REGISTER OF WILLS LI, J (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ¢3 None - - Decedent's Complete Address: STREET ADDRESS 13 Creek Road CITY Camp Hill STATE PA I z~P 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount $10,000.00 $500.00 (1) 9,924.83 Total Credits (A+ B + C) (2) $10,500.00 (3) (4) 3. Interest/Penalty if applicable D. Interest E. Penalty 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + SA, This is the BALANCE DUE. Total Interest/Penalty ( D + E ) (5) (5A) (59) 575.17 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 transferred or its income; ............................................ [] [] c. retain a reversionary interest; or .......................................................................................................................... [] [] d. receive the promise for life of either payments, benefits or care? ...................................................................... [] [] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. [] [] 3. Did decedent own an "in trust for" or payable upon death bank account or 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? .._S...E..E.....S..C....H...E....D...U....L...E...G. ........................................................................... [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is mJe, correct and complete. Declaration of preparer,.¢h.&.~an the personal representative is based on all information of which preparer has any knowledge, SIGNATURE OF P S~_ RES PONSI~.O~F~LING ~j,4 ~ ADDRESS ~ - - ~",J' - -- - 525 North 12th Street, Lemoyne, PA 17043 DATE SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 525 North 12th Street, Lemoyne, PA 17043 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S, §9116 (a) (1.1) (i)]. For dates of death on or after 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 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S, §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. {}9116(1,2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption, COMMONWEALTH OF PENNSYLVANIA iNHERiTANCE TAX RETURN RESIDENT DECEDENT SCHEDULEA REAL ESTATE ESTATE OF FILE NUMBER Miriam H. Goudy 21-04-0079 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as bhe price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, bot~ having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Single-family residence at 13 Creek Road, Lower Allen Township, Cumberland County, Pennsylvania. This property was sold during the administration of the estate. Attached is a copy of the settlement statement for that sale, which reflects the gross value of the real estate to be: $117,420.00 TOTAL (Also enter on line 1, Recapitulation) $ 117,420.00 (If more space is needed, insert additional sheets of the same size) A. Settlement Statement u.s. Department of Housin¢:l and Urban Development ~ -ir' OMB No. 2502~0265 B. Type gl~ Loan 1. [] FHA 2. [] FmHA 3. [] Conv. Unins File Number Loan Number J Mortgage Insurance Case Number 4. [] VA 5. [] Conv. Ins. 26206--= '/33-02574 C. NOTE:This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "p.o.c" were paid outside of closing; they are shown here for informational purposes and are not included in the totals. D. NAME AND ADDRESS OF BORROWER: RUSSELL J. FINLEY, JR. 1129 COLUMBUS AVENUE APT#7, LEMOYN'E, E. NAME AND ADDRESS OF SELLER: THE ESTATE OF MIRIAM H. GOUDY 13 CREEK ROAD, CAMP HILL, PA 17011 KERENSA C. FINLEY 129 COLUMBUS A VENUE APT #7, LEMOYNE, F. NAME AND ADDRESS OF LENDER: SUPERIOR HOME MORTGAGE CORPORATION , PA G. PROPERTY 13 CREEK ROAD LOCATION: CAMP HILL, PA 17011 H. SETTLEMENT AGENT: PLACE OF SETTLEMENT: TIN: 23-2133165 I. SETTLEMENT DATE: 04/21/2004 J. SUMMARY OF BORROWER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: lol. Contracl Sales Price CEDAR CLIFF ABSTRACT AGENCY, INC. 414 BRIDGE STREET, NEW CUMBERLAND, PA 17070 ~117f420.00 102. Personal Properly 103. Settlements charges to borrower: ([rom line 1400) $4,539.40 104. 105. ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: 106. City/~own taxes to 107. County Taxes 04/21/2004 to 01/01/2005 $348.16 108. Assessments04/21/2004 to 07/01/2004 $218.16 RESCISSION DATE: K. SUMMARY OF SELLER'S TRANSACTION 400. GROSS AMOUNT DUE TO SELLER: 401. Contract Sales Price 402. Personal property 403, 404. 405. ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: 406. City/town Taxes to $117¢420. O0 407. CountyTaxes04/21/2004 to 01/01/2005 $348.16 408. Assessments04/21/2004 to 07/01/2004 $218.16 109. 409. 110. S=w~'~/TRASH -=RORATION-4/21/O4T06/3 $56.70 410. SEWER/TRASH PRORATION-4/21/O4T06/3 $56.70 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER: $122,582.42 420. GROSS AMOUNT DUE TO SELLER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 501. Excess deposit (see instructions) 502. Settlement charges to seller (line 1400) 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 201. Deposit or earnest money $1,000. O0 $118,043.02 202. Principal amount o1 new loan(s) $93,956, O0 $8,679.60 203. Existing loan(s) taken subject 1o 503. Existing loan(s) taken subject to 204. 504. Payoff of first mortgage loan 205. 206. SELLER 14ELP $3,385.80 207. PRO~,'~'~'I)S FROM 2ND MTG $22,824.10 208. $121,145.90 209. ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: 210. City/Iown taxes to 211. County taxes to 212. Assessments Io 213. 214. 215. 216, 217, 218. 219. 505. Payoff of second mortgage loan 506. SEL~ J'D~.T.~ $3,385.80 507. 508. 509. ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: 510. City/town taxes to 511. County taxes to 513. 514. 515. 516. 517. 518. 519. 520. TOTAL REDUCTIONS IN AMOUNT DUE TO SELLER: $12,065.40 600. CASH AT SETTLEMENT TO/FROM SELLER 601. Gross amount due to seller (line 420) $118,043.02 602. Less reductions in amt. due seller (line 520) $12,065.40 603. CASH ( [-] FROM ) ( ~3 TO ) SELLER: $105,977.62 220. TOTAL PAID BY/FOR BORROWER: 300. CASH AT SETTLEMENT FROM/TO BORROWER: 301. Gross amount due I~rom borrower (line 120) I $122,582.4.2. 302. Less amount paid by/[or borrower (line 220) I $121,145.9~ 3O3. CASH ( ~]FROM ) ( ~-~ TO ) BORROWER: $1,436.52 HUD-1 (3-86) - RESPA, HB 4305.2 PAGE 1 HUD-1 (Rev. 3186} OMB No 2502-0255 L. S~- ~ ~ LEMENT CHARGES 700. TOTAL SALES/BROKER'S COMMISSION PAID FROM PAID FROM BASEDONPRICE $114,000.00 ~ 6 %= $6,840.00 BORROWER'S SELLER'S DIVISION OF COMMISSION (LINE 700) AS FOLLOWS: FUNDS FUNDS 701. ID AT AT 702. $6¢ 840.00 to ERA-NRT~ ZNC. SETTLEMENT SETTLEMENT to 703. $0. O0 704. $0. O0 705. Commission paid al settlement 706. $6,840.00 '900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE: $25. O0 805. Lender's inspection fee muz~5~IOR HOME MORTGAGE CORPORATION $150. O0 $98. O0 $i 7. O0 $150. O0 901. Intarest from 04/21/2004 Io 05/01/2004 ~ $15. 441day $154.40 902. Mortgage insurance premium for mos. to 903. Hazard insurance premium for yrs. to ERIE INSURANCE 904, Flood insurance premium th~' yrs to $250. O0 905. DOCUMENT PREP-S~4 1000. RESERVES DEPOSITED WITH LENDER: 1001. H=za, d insurance 4.00 mOnlhs @ $27.42 per month $109.68 1002. Mortgage insurance months ~ per monlh 1003. City property taxes months ~ per month 1004. County property taxes 4.. 00 months {[~ $40. 67 per month $1 62. 68 1000. Annual assessments months ~ per monlh 1006. Fiood insurance months I~ per month 1007. SCHOOL TAXES 12. O0 months ~ $90.91 per month $1,090.92 1008. mOnlhs ~ per month 1009. Aggregate Accounting Escrow Adjustment 1100. TITLE CHARGES: ($431.36) 1101. Settlement or closing fee to 1102. Abstract or U~le search to 1103. Title examination to 1104. Tltie insurance binder to 1105. Document preparation to 1106. Notaly fees toCASH $15. O0 1107. Aeorney*s fees to (includes above items Numbers: 1108. Titleinsuranceto CE~ CLIF~ ABSTRACT AGENCY, INC. (inOudes above items Numbers: TITLE INS-PJE-ISSUE ) 1109. Leader's coverage ( $93,936.00 ) 1110. Owr~el's coverage 11~1. END-lO0,300,8.1 1112. INSURED CLOSING 1113. 1200, GOVERNMENT RECORDING AND TRANSFER CHARGES: 1201. Recording fees:Deed $38.50 ; Mortgage $56.50 ; Retease$ 1202. City/county tax/stamps: Deed $2,348.40; MOrtDage 1203. State tax/stamps; Deed ; Mo~lgage 1204. 1205. 1300. ADDITIONAL SETTLEMENT CHARGES: $853.88I $150.00I $35.00 $95.00I $1,174.20 $4.00 1301. Sunmy Io 1302. Pest inspection to 1303. LOW~ ALLEN ~-g~W~/TRASH-4/1/O4T06/30/04 1304. 2"RANSACTION ~EE-ERA-AE~T, INC. 1305. 2004 CO TAXES-BONNIE MILLER 1306. FED-EX/WIRE-SLS 1307. 1400. TOTAL SETTLEMENT CHARGES $73.35 $I00.00 $i00.00 $488.05 $40.00 $4,539.40 $8,679.60 I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate slatement o[ all receipts and disbursements made on my account or by me in this transaction. I further certify that I have received a copy of the HUD-1 Seglement Statement. ~U SELLJ. FINLEY, JR. ~ ' THEESTATE~FM~LAMH. GOUD~ ' k~RENSA C. FINLE~ ~ Date: The HUD-~ Samemam Stamment which ~ have preparad is a tree and accurate accoum o~ ~his transaction. I have c~~ with this statement, the funds lo be disbursed ia accordance Saltl .... I Agen,: Date: WARNING: , ................................................... DA(VID ~O~E Da, Dale: Date:Z( SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY REV-150~ EX * (t-97) ~ COMMONWF_.ALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATEOF Miriam H. Goudy FILENUMBER 21-04-0079 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 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. o o Household furnishings and tangible personal property. These items were sold at auction and a copy of the auction receipt is attached. Assorted silver coins. These coins were sold to a coin collector for: 1990 Dodge Sedan in fair condition Certificate of Deposit # 1066263539 with Waypoint Bank. Date of death value (see letter attached) Certificate of Deposit # 31003913919072 with M&T Bank. Date of death value (see letter attached) Checking Account # 10139184 with M&T Bank. Date of death value (see letter attached) U.S. Treasury - income tax refund for tax year 2003 Refund of overpaid cable bill from Comcast Cable Cash $3,270.50 $1,232.00 $625.00 $100,112.78 $10,000.96 $60,799.91 $189.00 $43.77 $140.00 TOTAL (Also enter on line S, Recapitulation) $ 176,413.92 (if more space is needed, insert additional sheets of the same size) BRICKERS AUCTION Complete Auction Service Auction - Wednesday Evenings 766-5785 Chuck Bricker, Auctioneer TOTAL SALE COMM. CLEAR " / /'') 7~. ~'~) / Wag LOOK FOR US. WE'LL GET YOU THERE. 3/2/2004 SAMUEL L ANDES 525 N TWELFTH ST PO BOX 168 LEMOYNE PA 17043 Account Number Class of Account Date Opened Principal Balance Accrued Interest Balance at Date of Death The information which you requested on the account(s) of MIRIAM H GOUDY (Social Security Number 190-26-6599) is/are as follows: 1066263539 CERTIFICATE 022795 100000.00 112.78 100112.78 Account Ownership SOLE Name of Joint Owner, if any Date Ownership 022795 Was Established Account Number Class of Account Date Opened Principal Balance Accrued Interest Balance at Date of Death Account Ownership Name of Joint Owner, if any Date Ownership Was Established Additional Information Requested 'nc ely,, -ERIN WATTS SENIOR SERVICES REP. P.O. Box 171 I. HARRISBURG, PENNSYLVANIA 17105-1711 Toll Fr~61-866-WAYPOINT (I-866-9;~9-7646) · IN YORK AR~A 717/815-4500 · www. wagpointbank.com m M&TBank 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Samuel L Andes Attorney At Law 525 North Twelfth Street PO Box 168 Lemoyne, PA 17043 Phone (888) 5024349 F ax (302) 934-2955 February 13, 2004 Re: Estate of Miriam H Goudy Social Security: ! 90-26-6599 Date of Death: January 7, 2004 Dear Sir or Madam: Per your inquiry dated February 6, 2004, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Account Number Ownership (Names oJ) Opening Date Balance on Date of Death Accrued Interest Total Type of Account Account iX/umber Ownership (Names oJ) Opening Date Balance on Date of Death Accrued Interest Certificate of Deposit 31003913919072 Miriam H Goudy Lorraine C Hughes, POA 08/30/00 $10,000.00 $ .96 $10,000.96 Checking A ccotmt 10139184 Miriam H Goudy Lorraine C Hughes, POA 02/04/92 $60,797.62 $ 2.29 $60,799.91 For further account information, closures and/or reimbursement of fimds please call the llighland Park Office at #71%737-3322. Please be advised, there was no safe deposit box fmmd for the above decedent. Records Management COMMOI',h~/EALTH OF PENNSYLVANIA tNHERITANCE TAX RETURN. RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Miriam H. Goudy 21-04-0079 This schedule must be completed and filed if the answer to any of questions 1 through 4 on ~e reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY % OF ITEM iNCLUDE THE NAME OF ?HE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TR~,NSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VAL ATTACH A COPY OF THE DEED FOR REAL ESTATE. NUMBER VALUE OF ASSET INTEREST I~F^mJC~LE) 4. Proceeds of individual retirement accounts held with Fulton Bank. Immediately prior to her death, Decedent owned three individual retirement accounts with Fulton Bank. Her agent, operating under a Power of Attorney, closed those three accounts on 2 January 2004. The check for the total proceeds of those accounts, in the total amount of $ 86,505.80, had not yet been delivered on the date of Decedent's death. It arrived the day after her death and was deposited into the Decedenrs account at M&T Bank. However, because the deposit was made after the date of Decedent's death, the amount of that deposit is not included in the date of death value in the account as listed on Schedule E. Nevertheless, the taxable amount of these proceeds was: $86,505.80 100 % None $86,505.80 TOTAL (Also enter on line 7, Recapitulation) $ 86,505.80 (If more space is needed, insert additional sheets of the same size) P.O. BOX 1189 ~ HARRISBURG, PA 17108 LISTENING. www. fultonbank.com 1 ~800-FULTON-4 February 2, 2004 Samuel L Andes Attorney At Law 525 North Twelfth Street P.O. Box 168 Lemoyne, Pa 17043 Dear Mr. Andes, I have received your letter pertaining to Miriam Goudy's IRA accounts here at Fulton Bank. We have three (3) IRA's with Miriam, #390-1956049, #390-1905565, and #390- 1956006. Each one of these was closed out on 1-02-04 with a check cut on 1-05-04. The checks are in the amount of$9,113.71 for account # 390-1956049, $76,706.26 for account # 390-1905565 and $685.83 for account # 390-1956006. On all three (3) IRA's the beneficiary is Estate of Miriam Goudy. If you have any further questions regarding this please call me at 255-7674. Sincerely, ,, Sandy Lee I Customer Service Representative West Shore Office Page 1 of I CASHIER'S CHECK Dlio~[~l iAX& D&'~I~N · GIL~? VJ~.Lt~ DZ'~'t~ID:~ FUT_ ¥.fitl~ · 90915£ DATE JANUARY ~, 2004 IRA OZSB 390-190'5565, 390'-1956049 & 0 q & rt"' i,"[3r3 Q8 r-, 5, D 5 SD.,' Posting Date Research Seq # Account fl Check/Store # DB/CR Dollar Amount Bank # Deposit Acct it 2004 Jan 08 5542775442 90000919 909152 DB $86,505.80 999 10139184 firstmd com/]nqmry/servlet/zn ut 9CONTEXT http://pc-ncrwebl. - ' - ' q 'ry. ~printlogging&ACTION... 3/16/2004 REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Miriam H. Goudy SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 -O4-OO79 Debts of decedent must be reported on Schedule [. ITEM NUMBER DESCRIPTION AMOUNT FUNERAL EXPENSES: Musselman's Funeral Home (cremation and related expenses) ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) n/a Social Secudty Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: Attorney Fees Samuel L. Andes Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant n/a Street Address City State__Zip Relationship of Claimant to Decedent Probate Fees Register of Wills Accountant's Fees Tax Return Preparer's Fees Cumberland Law Journal - advertising The Sentinel- advertising Chuck Bricker, Auctioneer - commission for sale of household property Mary Haring - cleaning of house and disposal of discarded items Expenses incurred in sale of real estate (see attached schedule) Federal income tax on individual retirement account distribution TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) $1,458.50 Waived $17,000.00 $290.00 $75.00 $102.11 $1,070.50 $676.00 $10,900.54 $17,301.00 $ 48,873.65 Schedule Attached to Schedule H of Inheritance Tax Return Miriam H. Goudy File No. 21-04-0079 List of expenses incurred in sale of real estate: 1. ERA-NRT, Inc. - real estate sales commission $6,080.00 2. Recorder of Deeds of Cumberland County - realty transfer $1,174.20 tax 3. Cash - notary fee $4.00 4. Lower Allen Township - trash fee (less refund from $16.65 purchaser) 5. Bonnie Miller, Tax Collector - real estate taxes (less refund $139.89 from purchaser) 6. ERA-NRT, Inc. - transaction fee charged at settlement .$100.00 7. Russell J. Finley and Kerensa Finley - contribution to $3,385.80 purchaser's settlement costs Total Costs $10,900.54 COMMONWEALTH OF PENNSYLVANIA h',IHERt'FANCE TAX RETURN RESIDENT OECEDENT SCHEDULE ! DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATEOF Miriam H. Goudy FILENUMBER 21-04-0079 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. Internists of Central Penna. PP&L - utility bills Verizon - phone bills PAWC - water bill UGI - utility bills Timothy Clark, M.D. - medical expense Bonnie K. Miller - Tax Collector (final personal tax bill) $23.81 $64.57 $8.45 $80.33 $375.38 $76.19 $9.80 TOTAL (Also enter on line I0, Recapitulation) $ 638.53 (If more spac6 is needed, insert additional sheets of the same size) SCHEDULE J BENEFICIARIES REV-1S13 EX * (1-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATEOF Miriam H. Goudy FILE NUMBER 21-04-0079 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE II. TAXABLE DISTRIBUTIONS (include outright spousal distributions) Lorraine C. Hughes 11 Creek Road Camp Hill, PA 17011 None (friend and neighbor) 20 % ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEE'~ NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE None B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS Grace Lutheran Church, 1610 Carlisle Road, Camp Hill, PA 17011 Pinnacle Health Hospice, 3705 Elmwood Drive, Harrisburg, PA 17110 American Lung Association, 3001 Old Gettysburg Road, Camp Hill, PA 17011 TOTAL OF PART I! - 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) 5O % 2O % 10% ~.,,,j_ ~,,_%\~, BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DTVIS1'OH DEPT. Z80601 HARRISBURG, PA 17128-0601 SAMUEL L ANDES 515 N 12TH ST LEMOYNE PA 170q$ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF /NHERITANCE TAX APPRAISEMENT, ALLO#ANCE OR DZSALLOHANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE 09-20-200q ESTATE OF GOUDY DATE OF DEATH 01-07-200q FZLE NUMBER 21 0q-0079 COUNTY CUMBERLAND ACN 101 Aeoun~ Remi~ed REV-IEq7 EX AFP (01-05) MIRIAM H MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECO~-' ~. REV-1547 EX AFP (01-03) ~ZC~ ~ ~H~-~N~' ~-)~ A~PR~fgE~ERY~* '-_A~R~'~-~ ........... DZSALLOWANCE OF DEDUCTIONS AND ASSESSMENT~F TAX ESTATE OF GOUDY MIRIAM H FILE NO. Z1 0q-0079 ACM 101~ TAX RETURN HAS: (X) ACCEPTED AS FTLED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN I Real Es~a~e (Schedule A) 2 S~ocks and Bonds (Schedule B) $ Closely Held S~ock/Par~narship Zn~ares~ (Schedule C) Mortgages/No,es Reca~vabZe (Schedule D) 5 Cash/Bank Deposi:ks/Misc. Personal Proper~y (Schedule E) 6 Jointly Owned Proper~y (Schedule F) 7 Transfers (Schedule g) 8. To,al Asse~s APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expanses/Adm. Cos:ks/Misc. Expenses (Schedule H) 10. Debts/Mortgage Ltabili~ies/L~ens (Schedule I) 11. To~:al Deduc~:ions 12. Na~ Value of Tax Ra~urn DATE: 09-20-200q (1) 1177120. O0 ~ NOTE::~T.o;ii!nsure proper (2) O0 ~:~ credit: ~:o your account:, (3) (~) (;) 1761q15 (6) O0 submi~ ~ha upper portion O0 of *his fore wi*h your ~ax payment, 92 O0 (7) 86z505 80 (8) q8,875.65 13. lq. NOTE: (9) (10) 638.53 Char/~able/Govarneen~al Beques*s; Non-elected 9115 Trus*s (Schedule J) (15) Na~ Value of Es*a~a Sub,ac* ~o Tax (lq) $80,359.72 (11) ~g.512.]8 (11) $$0,827.5q 26q,662.05 66,165.51 Zf an assessment was issued prevLously, 11nas 1~, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amoun~ of Line lq a~ Spousal ra~a 16. Amoun~ of Line 1~ ~axabla a~ Lineal/Class A ra~e 17. Aeoun~ of Line 1~ a~ Sibling ra~e 18. Amoun~ of Line lq ~axabla a~ Colla:~eral/Class B ra~e 19. Principal Tax Due TAX CRED]:TS: PAYMENT RECETpT DISCOUNT DATE NUMBER INTEREST/PEN pAID (-) 03-25-200q CD005715 q96.Zq IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. (15) .00 x O0 = .00 (16) .00 x Oq5= .00 (17) . O0 x 12 = . O0 (18) 66,165.51 x 15 = 9,92q.85 (19)= 9,92q .8:5 AMOUNT PAID I 10,000.00 TOTAL TAX CREDIT 10,q96.Zq BALANCE OF TAX DUEI 571.~1CR INTEREST AND PEN. I .00 TOTAL DUE { 571.q1CR ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUZRED. ZF TOTAL DUE ZS REFLECTED AS A "CREDZT" (CR), YOU NAY BE DUE '' A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) RESERVATION: PURPOSE OF NOTICE: PAYHENT: REFUND (CR): OBJECTIONS: ADNIN- ISTRATIVE CORRECTIONS: DISCDUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of tho decedent after the expiration of any estate for lifo or for years, tho Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at tho lawful Class B (collateral) rate on any such futura interest. To fulfill the requirements of Section 21q0 of tho Inheritance and Estate Tax Act, Act 23 of ZOO0. (72 P.S. Section 91~0). Detach tho top portion of this Notice and submit with your payment to the Register of Hills printed on tho reverse side. --Hake check or money order payable to: REGISTER OF HILLS, AGENT A refund of a tax credit, which was not requested on tho Tax Return, say bo requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office of tho ~{egister of Hills, any of tho 23 Revenue District Offices, or by calling the special 2~-hour answering service for forms ordering= I-BOO-36Z-ZOSO; services for taxpayers with special hearing and ! or speaking needs: 1-800-~7-3020 (TT only). Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, er assessment of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to tho PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to tho Orphans' Court. Factual errors discovered on this assessment should bo addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. If any tax duo is paid within three (5) calendar months after the decadant's death, a five percent (SX) discount of tho tax paid is allowed. Tho 152 tax amnesty non-participation penalty is computed on the total of tho tax and interest assessed, and not paid before January 18, 1996, the first day after tho 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 tho date of payment. Taxes which became delinquent before January l, 19BI bear interest at tho rate of six (62) percent per annum calculated at a daily rata of .00016~. All taxes which became delinquent on and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates far 1982 through 200q are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor ~ ZOZ .0005~8 ~'~-1991 Ill .O0030X ~'~ 92 .O00Z~? 1983 162 .000q38 1992 92 .0002~7 ZOOZ 62 .00016~ 198~ llZ .000301 1993-199~ 7X .000192 2005 52 .000137 1985 132 .000356 1995-1998 9Z .0002~7 ZO0~ ~Z .000110 1986 XOZ .00a27~ 1999 7Z .OOOl9Z 1987 lOZ .00027~ ZOO0 72 .O00lgz --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUHBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR --Any Notice issued after tho tax becomes delinquent will reflect an interest calculation to fifteen [15) days beyond the date cf the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. BUREAU OF ZNDTVTDUAL TAXES THHERITAHCE TAX nTVZSTOH DEPT. Z80601 HARRTSBUR~, PA 171Z8-0601 COHHONNEALTH OF PENNSYLVAN*rA DEPARTHENT OF REVENUE ZNHERZTANCE TAX STATEHENT OF ACCOUNT SAHUEL L ANDES 525 N 12TH ST LEHOYNE PA 17045 DATE ESTATE OF DATE OF DEATH FILE NUHBER COUNTY ACN ll-O1-200R GOUDY MIRIAM 01-07-2004 21 0~-0079 CUMBERLAND 101 Amoun~ Rmmi4:4:~ HAKE CHECK PAYABLE AND RI~ZT PAYHENT TO: REGISTER OF NILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17015 H NOTE: To insure proper crmdi~ ~co your mccoun~c, submi~ ~he upper portion of ~hLs form w'/:~h your ~aX payment. CUT ALONG TH*rS LINE ~ RETAIN LONER PORT*rON FOR YOUR RECORDS REV-1607 EX AFP (01-03) #~ ZNHERZTANCE TAX STATEHENT OF ACCOUNT ESTATE OF GOUDY HIRIAH H FILE NO. 21 04-0079 ACN 101 DATE ll-O1-200q THTS STATEHENT 1S PROV'rDED TO ADV/SE OF THE CURRENT STATUS OF THE STATED ACN *rN THE NANED ESTATE. SHONN BELON 'rs A SUNNARY OF THE PR'rNCIPAL TAX DUE, APPL'rCAT'rON OF ALL PAYHENTS, THE CURRENT BALANCE, AND, 'rF APPLTCABLE, A PROJECTED 'rNTEREST F'rGURE. DATE OF LAST ASSESSHENT OR RECORD ADJUSTHENT: 09-15-200~ PRINCIPAL TAX DUE: ........................................................................................................................................................................................................................... PAYHENTS (TAX CREDITS): 9,92~.85 PAYNENT RECEIPT DISCOUNT (+) AHOUNT PAID DATE NUNBER INTEREST/PEN PAID (-) q96.2q 05-25-200~ 10-12-2004 CD00~715 REFUND .00 10,000.00 571.~1- 'rF PA'rD AFTER TH'rS DATE, SEE REVERSE S'rDE FOR CALCULAT'rON OF ADDZT'rONAL 'rNTEREST. ( 'rF TOTAL DUE 'rS LESS THAN $1, NO PAYNENT 1S REQU'rRED. 'rF TOTAL DUE 'rS REFLECTED AS A -CRED/T' (CR), TOTAL TAX CREDIT 9,92~.85 BALANCE OF TAX DUE .00 *rNTEREST AND PEN. .00 TOTAL DUE .00 YOU HAY BE DUE A REFUND. SEE REVERSE S'rDE OF TH'rS FORN FOR 'rNSTRUCTTONS. ) PAYMENT: Detach the top portion of this Notice and submit with your payment made payable to the name and address printed on the reverse side. -- If RESIDENT DECEDENT make check ar money order payable to: REGISTER OF N[LLS, AGENT. -- If NON-RESIDENT DECEDENT make check or money order payable to: COMMONNEALTH OF PENNSYLVANIA. REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications ara available at the Office of the Register of Hills, any of the 25 Revenue District Offices or fram the Department's Zq-haur answering service for farms ordering: 1-BOO-56Z-Z050; services for taxpayers with special hearing and / or speaking needs: 1-BOO-qq7-5020 (TT only). REPLY TO: Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. ZB0601, Harrisburg, PA 171ZS-060I, phone (717) 787-6S05. DISCOUNT: If any tax due is paid within throe (5) calendar months after the dacedent's death, a five percent (SI) discount of the tax paid is allowed. PENALTY: The 15Z tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. INTEREST: Interest is charged baginn[ng with first day of delinquency, ar nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January l, 198Z bear interest at the rate of six (BZ) percent per annum caIculatad at a daily rate of .OOO16q. All taxes which became deIinquant on and after January 1, 19aZ wiIZ 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 198Z through ZOOq ara: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 1982 20Z .O005qB 1988-1991 llZ .000501 gOOl 9Z .OOOZq7 1985 16Z .000q58 199Z 9Z .O00Zq7 ZOOZ 6Z .000164 1984 llZ .000501 1995-1994 72 .O00IgZ 2003 5Z .000157 1985 152 .000556 1995-1998 92 .000247 ZOO4 42 .000110 1986 XOZ .000274 1999 7Z .O0019Z 1987 9Z .000247 ZOO0 8Z .O00Z19 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUllBER 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 Notice, additional interest must ba calculated. ~ A~~ ~~. ~~ ~ ""_._---!_."-_... .-C'"r';l1l_ _.en__._.,'__~,---..3 ,,_~.,~.!}-.,- Jl."...c:g!~IlIt.ll.. 0.11. 'if'" ...JlJl~ iUlJL \L,.UJlR...Uit;:.Il. .Il.dHIUL vV\Uj.JJ.JJ.il.J STATUS REPORT UNDER RULE 6.12 Name of Decedent: Mlf\o..(\I\ H. GOvtD; Date of Death: 1 1"a rJ fA. a 11 2- DaY Estate No.: Z \ - 0 t.-( - 0 0 tCf . Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes ~ No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. lfthe answer to No.1 is Yes, state the following: a. Did the personal representative file a fmal account with the Court? Yes 0 No fgl 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 Kl No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. 0 ~ Date:~ ~P"\.'XJ~\q) o ~., en 5~M\Ae' t..., {+ woe.> Name 52-5 (\1. 12- ~ 5~ ~~y~~ fA Ilo~3 Address ..a: IL ,....-. - v:> -:_< (.,f) dtt.t c:.. 0"-) o I~ I 1(" l 5>(,\ Telephone No. u w c.:::::; I~!"":" C:;::. = ,-1 Capacity: ~ Personal Representative o Co;,.msel for personal representative w Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 12/06/2005 ANDES SAMUEL L 525 NORTH 12TH STREET LEMOYNE, PA 17043 RE: Estate of GOUDY MIRIAM H File Number: 2004-00079 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 1/07/2006 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ,I:;At,~l; : :~:.;j _~~L~~_# ~"M"_ .A' ~, >4P~ i._" GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge ~~