HomeMy WebLinkAbout04-0390PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of /~'/~9~o.~ C~ ~ /b,J
also known as ~7~ ~ c~ ~,~,x/
To:
Register of Wills for the
Deceased. County of a ~a ~ ~k~¢~-~,././.~ in the
Commonwealth of Pennsylvania
Social Security
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl
(d.b.n.; pendente lite; durante absentia; durante minoritate)
for le~fk~e~:of administration
~ ,: on ~e estat~T.~
the above decedent. ~::, '~::' !77,
Decendent was domiciled at death in ~c~.,,~ ~,r~ County, Penns~,vania, with
h / 5 last family or principal re~dence at ~/7 5~ ~/~ ~- ~A~,c~ ~ ~.
h ,~&, ~ ~ · · ~ ~
~ ~ ~ ~ (hst street, number and mumc~pahty~
Decendent, then ~ ~ ye~s of age, died ~~ ~ ~ ,~~ ~-,,
at ~~ ~-~/ ~~ ' ~ ....
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:
Petitioner after a proper search ha
the following spouse (if any) and heirs:
Name
ascertained that decedent left no will and was survived by
Relationship
Residence
THEREFORE,
appropriate form to the undersigned.
~ 0
petitioner(s) respectfully request(s) the grant of letters of administration in the
RENUNCIATION
deceased.
To the Register of Wills of County, Pennsylvania.
The undersigned "-~ y /];.'~ ~-~Ct~_~ ~O~C~"~ ~ ~O'~..V- of
the above decedent, hereby renounce(s) the right to administer thc estate and respectfully ask(s) that Letters
be issued to ~'~' ,~' '---/
WITNESS hand this day of ,20
(Address)
(Signature)
(Address)
(Signature)
(Address)
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 c ~te-i~$2.00 . : ~ ~ ....
~ Local Registrar
'04 ,qPR22 74:12
- .rl'! OtV
{~fi't [2 c.,: :. c_ ::,._ ~~~ Date
H106.144 Rev. 1/91 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH * VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
· ..~ ~ ~ BI~H BIRTHP~E (C~ ~ I P~CE ~ ~H (~k ~V ~_ ~ ~ ~ ~ ~ I '
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29 ~. I · E ·
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~ ~n ~ ~' m-~ ~ Her h ....... r-'-~ ..... ~ ....~,cm=,~ i~=.~,,~.~.=.
.. ~k l,b, Restaur~t '% '- -- '?. ~ ~ ('"~S+)l ..Never ~i~
917 Scottish Court
,~chanicsburg, PA 17055
17l. State PA Did 17c.[~ ~, d~ liwd iff
1 ?d.[']~ wtt hl~ ~c~u~l Nmi~ of Mechan i c'-~,'-,~lrcj =;.~
I
MOTHER'S NAME (F~rK.
~. Kevin Ox:ran I~. ~hvll~9
~. Kevin ~ ~ 60 Walnut Strut, ~rlisle, Pa 17013
~ ~ ~ ~RVCE ~EE~rE.~ ~ ~ 8~H t~ENSE NUMAR
oz~man-Ro[h ?une~al ~ome
' '' ~*-~' 9:16 p.m. ~rch 27~ '2~
~=~ ~ltiple tra~tic inj~ies ,
__ n . ~ m ~ ~ ffi ,~,~ 8l~. ' I2'~' ~'"',: I.. '-- I ~n~nt
~d~'~"h~"~--~ ........ ..: :.':;2::T2:TZ" ... n ~'[ /~ ~rl~ Crv
........................ f~x .... //.4//r } ~/~A4
~.1271
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 08/02/2004
COGAN KEVIN J
560 WALNUT STREET
CARLISLE, PA 17013
RE: Estate of COGAN TIMOTHY S
File Number: 2004-00390
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES,
NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on
or after July 1, 1992, the personal representative or his
counsel, within ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of Wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 08/02/2004
Your prompt attention to this matter will be appreciated.
Thank You.
CC:
File
Counsel
Judge
Sincerely,
Clerk of the Orphans' Court
CERTIFICATION OF NOTICE UNDER RULE 5.6(al
of Death: . oOff
Will No. ~
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the O~phans' Court Rules was
served on or mailed to the following beneficiaries Of the above-captioned estate on :
Address
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
Telephone( ~/ ~) ~t~
Capacity: //Personal Representative
__Counsel for personal representative
Glenda Farner Strasbaugh
Register of Wills
and
Clerk of Orphans' Court
Ma~orie A. Wevodau
First Deputy
Kirk S. Sohonage, Esq
Solicitor
Register of Wills and Clerk of the Orphans' Court
County of Cumberland
One Courthouse Square
Carlisle, PA 17013
(717) 240-6345
FAX (717)240-7797
INVOICE
Bill To:
InvoiceNo:
Invoice Date:
Estate of:
Estate No:
263
3/22/2005
TIMOlHY S CCX:;AN
21-2004-0390
KEVIN J CCX:;AN
560 WALNUT S1REET
vz
CARLISLE, PA 17013
Qty
1
Fee Description
Additional Probate
Fee Total
7.00 $7.00
Total:
$7.00
Cl1ecks should be made payable to the Register of Wills. Terms: Net 30.
Please return one copy of this invoice with your payment. Thank you.
~
W'1500EXI6-DOI'
NO ~L, PMBAr& F-~(: [>Ub
REV -1 50 0 OFFICIAL USE ONLY
INHERITANCE TAX RETURN FILENUMBERO<1
1- I -
RESIDENT DECEDENT
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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YEAR
NUMBER
SOCIAL SECURITY NUMBER
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
C'06A,J -r;~O+( S
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
03 - 27-';;ooy /1- 22- /77'-1
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
pol //1
TELEPHONE NUMBER ...-
7/7 - "0 -77~
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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14. Net Value Subject to Tax (Line 12 minus Line 13)
3S'5'9
~ 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12.12.82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
o 3. Remainder Return (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11, Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
COMPLETE MAILING ADDRESS
aD w/Jt..,vtJ I $ r
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(2)
(3)
(4)
(5)
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OFFICIAL USE ONLY
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(10)
(11)
(12)
(13)
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SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
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15. Amount of Line 14 taxable at the spousal tax ~,fJ/? o. ~
rate, or transfers under Sec. 9116 (a)(1.2) x.O_ (15)
16. Amount of Line 14 taxable at lineal rate 6).00 x.O_ (16) 0- c.~
17. Amount of Line 14 taxable at sibling rate 0. ~ x .12 (17) en~. 0-0
18. Amount of Line 14 taxable at collateral rate ([?.. <90 x .15 (18) e::> _ ere>
19. Tax Due (19) O. OC>
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
. REV-l508 EX. rl-~7)
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate, All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1,
DESCRIPTION
2.
1.
~ble t- '-I c:l"I4I~~
C L. 0"17-l,.-l 6-
VALUE AT DATE
OF DEATH
,S7:J. 0>.:.>
/.s.0 . c::ro
<f' {)O , 0-0
:l. St' ' ~
pJ cJY-A-
't.
/ 9 9 C{ rf/ ~s~ flU' CiL.
(-,1.-.L...... ....; c:.... I, ~ r ~ ~~ tJoo ~ y< -i/.. f" veL. . zk)
rV/ '.sc- t' //+r~s I'~~,.r># I i-k....sl Lvr'* teJ,J ;-v,'Iv4-~ 6 (}-C)lcs)
C-/15/-1/,6.4..J /L J4c-q)(.I-1 TS
J,
TOTAL (Also enter on line 5, Recapitulation) $ I 2 So I t70
(If more space is needed, insert additional sheets of the same size)
REV-'S.11 EX+ (12-99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF .~ _ LI
/ / ~ ,,1fWr
S. COG~
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
;I~..f..r,'VI;::Jr - /2elf-t.... FJrI e"'l/) I ~ ~
~,.z. i.-{ r L.e r A
/
13 ISO.
)
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B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
K e;/ I".J ::r
,
C c:> G,q,J
JS"7-vZ-Y J S '2-
D -0-0
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address ~~ Z> U/ IlL ttJ (/ ..,- sr
City Cfl-t2. U SI.. €-
State PI1 Zip 1701..5
Year(s) Commission Paid:
(() . 00
2.
Attorney Fees
o.~
3.
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant /< e.1/ ,,.J ;:r. c- e (, A ..J
.
Street Address .s- (gc? (,J "1'2.-,..) oj -r $,
31 StJV.
v,o
City
C~, :S .... e....
State P,4 Zip i ?~/3
Relationship of Claimant to Decedent
.r/.l~
4.
Probate Fees
'-/ 9" c.:ro
5. Accountant's Fees
6.
Tax Return Preparer's Fees
o~cv
7. ~ E>y?~f, ~~ J;,~ 5+e-. ~ 3. j)~ct?,)ct,.d WA$"
4,.1 I~(/Jf b4t,-~~ 50.4; ~ 2-~ "",4 rVI4,;rlh/~eJ
h 1$ OtV r i1tl ~~J1e~c ..e.. d
TOTAL (Also enter on line 9, Recapitulation) $ r;, J b '1 r c:ro
(If more space is needed, insert additional sheets of the same size)
ESTATE OF
-r;Iv)O~ 5. C- 0 G,~
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
REV-1512 EX' (1-97)
1..
1 .
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7 '
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
DESCRIPTION
AMOUNT
12, 6~-o. <.rO
It,. '17
? ~,,;>hQ.! Lan,J
,.,., of- 'I 13;IhJ k
~ tA~'
c-~~d 4c:.GocJrJ+
c-~.!...f- GO"1..~D~~O~
/ 0 22,ff
I
c;.,f'I P /TbL O;-l€.-
P15 /f&I2s~ ;vJr;d to-JJ/ ~fe<<, - (/VnoJWJA ~
{).)es+ sfvt;/J.A.I C/to, B~ 1'fI~'-41 $e4v/c.e S
11e/Jd,..,y fl1ee!,;"", Ce)fe,re Ih'$'€'A'.Js ~f'
C/ I (,;J A /-J.-ePL. 7'1-1 c~
Z 711.2'"
,;
~ 11.. " '-10
i II It) 9. 90
I, G 2(0 . c:N)
TOTAL (AlsO enter on line 10, Recapitulation) $ /1, /03,92-
(If more space is needed, insert additional sheets of the same size)
REV.'?13 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE O. Y J! .., . .. _ I
'/r^".:J'~l 5. {[;(:;>/lrJ
FILE NUMBER
NUMBER
I
AMOUNT OR SHARE
OF ESTATE
II
RELATIONSHIP TO DECEDENT
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s)
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
{( e Vi,-J ;T. c. 0 G"d'~
5'1 0 u/Ai..~ j/ r sr4f2.e-1
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Clf-rJ--i.- i$" P PA , 7 .:> 13
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M ., 14 Jt..
3.1
114/er ?~<.-(,.I eft-$' ,.
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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
- - . IJ
,;,j;;."i I')'> tJ.,;~
1.
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
,~....~
TOTAL OF PART II - ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, Insert additional sheets of the same size)
ACCOUNT NO.
fl!M&f
9835749566
FREE CHECKING
JUN.18-JUL.16,2004
1 OF 1
00 0 0610'" NH 017
1637
TIMOTHY S COGAN
917 SCOTTISH CT
MECHANICSBURG PA 17050
HAHPDEN
ACCOUNT SUMMARY
BEGINNING DEPOSITS & OTHER CURRENT ENDING
BALANCE OTHER ADDITIONS CHECKS PAID SUBTRACTIONS INTERESTPD ... BALANCE
NO. I AHOUNT NO. I AHOUNT NO. I A~T
16.77- 01 0.00 01 0.00 o I 0.00 0.00 16.77-
ACCOUNT ACTIVITY
POSTING DEPOSITS, INTEREST CHECKS & OTHER DAILY
DATE TRANSACTION DESCRIPTION & OTHER ADDITIONS SUBTRACTIONS BALANCE
06-18-04 BEGINNING BA.LANCE $16.77-
ENDING BALANCE $16.77-
EFFECTIVE AUGUST 20, 2004, IF THE AHOUNT OF A WITHDRAWAL, TRANSFER OR OTHER TRANSACTION HADE OR
ATTEHPTED TO BE HADE BY ANY HEANS EXCEEDS THE BALANCE AVAILABLE FOR WITHDRAWAL WHEN THE WITHDRAWAL,
TRANSFER OR OTHER TRANSACTION IS CHARGED OR ATTEHPTED TO BE CHARGED AGAINST YOUR ACCOUNT, A $32
INSUFFICIENT FUNDS FEE WILL BE ASSESSED TO YOUR ACCOUNT UNLESS THE EXCESS IS LENT UNDER A LINE OF
CREDIT ACCOUNT OR HADE AVAILABLE FROH ANOTHER DEPOSIT ACCOUNT YOU HAVE WITH US THAT IS LINKED TO YOUR
ACCOUNT AS PART OF AN OVERDRAFT ARRANGEHENT. IF YOU HAVE ANY QUESTIONS, CALL THE H&T TELEPHONE BANKING
CENTER AT 1-800-724-2440.
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L008A (1/03)
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. . 111111111111 1I1lllRII 11111 11111 11111 11111111
3 EXECUTIVE CAMPUS
SUITE 400
CHERRY HILL, NJ 08002-4103
RETURN ADDRESS
IF PAYING BY MASTERCARD, VISA OR AMERICAN EXPRESS. FILL"OU~~OW.
CHECK CARD USING FOR PAYMENT
.0 11Il1~OO]O _0
MASTERCARD -. VISA .. ArvlERtCI-'\N eXPRESS
CARD NUMBER I CVV2 COOE*
I
SIGNATURE iEXPCWio ---."
I
CLT ACCT # MRS ACCT # I AMOUNT DUE
I
5178052247356666 5023383 $1,060.84
I
RE: CAPITAL ONE
--j
RETURN SERVICE REQUESTED
--i
November 5, 2004
6525i1A
ADDRESSEE:
1",111",111"""11"11",11,,11,,,,1,11,1,,,11,,11,""I,ll
TIMOTHY S COGAN
560 WALNUT ST
CARLISLE, PA 17013-3629
PAYMENT / REPLY TO:
111",1"1,11"111"",1,1,1"1",1111",,,11,11,,,11,""I,ll
M.R.S. ASSOCIATES, INC.
3 EXECUTIVE CAMPUS, SUITE 400
CHERRY HILL, NJ 08002-4103
f-
17823-S603*1DEOUFFR0022892 589
* See back lor details
1..111111I18.1..111111
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
RE: CAPITAL ONE
CLT ACCT #: 5178052247356666
MRS ACCT #: 5023383
AMOUNT DUE: $1,060.84 (Interest may accrue on unpaid balances)
Dear Timothy S Cogan,
Office Hours:
Mon Thurs 8am-9pm EST
Fri 8arn-5pm EST
Sat 8arn-12pm EST
Sun 9am-12pm EST
This letter is to inform you of a special offer to resolve your overdue account with our client. We recognize that a possible
hardship or pitfall may have prevented you from satisfYing your obligation. It is with this in mind that we would like to offer
you a limited time offer opportunity to satisfy your outstanding debt. Weare presenting four options that will enable you to
avoid further collection activity being taken against you.
OPTION I: A settlement of 50 % OFF of your current balance, SO YOU ONLY PAY $530.42 in ONE PAYMENT
that must be received in this office on or before Nov 15th.
OPTION 2: A settlement of 40 % OFF of your current balance, SO YOU ONLY PAY $636.50 in ONE PAYMENT
that must be received in this office on or before Nov 26th.
OPTION 3: A settlement of30 % OFF of your current balance, SO YOU ONLY PAY $742.59 in TWO PAYMENTS.
The first payment must be received in this office on or before Nov 26th and the second by Dee 28th.
OPTION 4: Monthly payment plan on full balance (Interest may accrue on unpaid balances).
If you are interested in taking advantage of one of these terrific opportunities or if you have any questions, you MUST
contact our office as soon as possible at (877) 774 - 7992 (toll free). When you call, please let our representative know that
you have received the (CAPITAL ONE) Option Letter and tell us whether you would like to take advantage of the
SETTLEMENT OPTION or the PAYMENT OPTION.
Ifwe do not hear from you, we are forced to assume that you do not intend to resolve your obligation on a voluntary basis
and we will recommend that our client proceed with further collection activity.
If you pay your balance in full, your credit will be amended by our client.
Sincerely,
B. Simone
Director of Operations
(877) 774 - 7992
Office Handlin!:! Your Account:
M.R.S. ASSOCIATES, INC.
3 EXECUTIVE CAMPUS, SUITE 400
CHERRY HILL, NJ 08002-4103
This is an attempt to collect a debt and any information obtained will be used for that purpose.
This communication is from a debt collection agency.
PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION.
PLEASE MAKE CHECKS PAYABLE TO:
'~S HERSHEY MEDICAL CENTER D. dE D. STATEMENT OF HOSPITAL ACCOUNT
PO BOX 643291 CARDiI AMr. ~~l';~~ ( )
PITTSBURGH PA 15264-3291 AMOUNT PAID
SIGNATURE EXP. DATE
ACCOUNT NO. ADMISSION DATE DISCHARGE DATE STATEMENT DATE
4252513 03/26/04 03/27 /04 11/19/04
0000000042525130326041119040000271126
MS HERSHEY MEDICAL CENTER
PO BOX 643291
PITTSBURGH PA 15264-3291
*************AUTO**3-DIGIT 170
00000048 1 AT 0.292 01
TIMOTHY COGAN
560 WALNUT 5T
CARLISLE PA 17013-3629
1...11.1.1.,.1,1,11..,1,.1..11...1.11,1..".111.1.....111,..11
1...111...111,.....11..11.,.11..11,.,,1.11.1.,.11,.11.....1.11
IMPORTANT: PLEASE DETACH AND RETURN THE TOP PORTION OF THIS STATEMENT WITH YOUR REMITTANCE TO ASSURE PROPER CREDIT. PLEASE WRITE ACCOUNT NUMBER ON THE CHECK.
INPATIENT
OX 80135
TRAUMA
'10/28/04
**BALANCE FORWARO**
2711.26
We not i fi ed you prev i OU$ 1 y th.a t your i nsu rance
company has not paid your claim in full. You
responsible for any amounts not covered by t
insurance carrier. Do not delay taking care of
this matter any Tonger. Please send your payment
for the full amount.
...
-
....>......... .".... ......... ................ ...
--
......i.............................
-
__ 0.00)
(AMOUNTS BILlED TOYO\JR INSURANCE COMPANY)
)
0.00 )
0.00 )
2711.2b)
Patient Inquiry Representatives are available
Monday through Wednesday 8:00 A.M. - 5:30 P.M.
Thursday through Friday 8:00 A.M. - 4:30 P.M.
717-531-5069 1-800-254-2619
FM 46 (REV. 6/01)
-
2711.26 J
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: ~? 1,- 7 J -5--:{~'
WEST SHORE EMS - ALS
205GRANDVIEWAVE ~~-~)
SUITE 211
CA.MP HiLL PA 17011
Phone #: (800) 367-0:512 IN~ II.-f.ed~~.d Tax 10: 23-2463002 WFST SHORE
v Ul(;~ EMERGENCY MEDICAL SERVICES
3021368A
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
233ti9
M\!.A.D
PATIENT NAME: T!I\i10TH\' CO.3.AN
302 '1 808.A.
fl..JC)NE
INSURANCE:
03i25i2004
BEr'H CREEf-< Bi....VD
LIFE LION
TIMOTHY COGAN
9.11 SCOTTISH CT
MECHANICSBURG. PA 17050
REASON(S)
FOR
TRANSPORT
fl/lulti-System Trauma
Unresponsrv'e Patient
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
F'.A.R.A.MEDiC !i".JTERCEF'T .A.tJQ99 '\.0 488.08 488.08
A.f'.j G I OCATH ('14-24) A0394 3.0 4.75 14.25
Ef'.JDOTRC)L ET TUBE A0422 '1.0 34.4'1 344'1
5CC/10\:::C SYF<:li~GE A0394 1.0 3,92 3.92
OF' SITE .A.O 3 94 2.0 4 .""T 8.94
.,l
Rlj'.JGERS LA.CTATE 1000C:C .A.0394 20 3.82 7.54
'10GTITUBiNG .A. 0 394 20 '71=.'-;' '15.-15
{ ,._"_1
otal Charges 572.40
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT ..... $512..40
COGAN. TlMOTH'i S
23369
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
ft7? .to
PATIENT NAME:
PATIENT NUMBER:
CALL NUMBER
BILLING DATE:
3021868A
04!22J2004
".Je were unable to obtain sufficient Insurance infomution.
Therefore, we are requesting that you forward this inovice
to your automobile insurance carner in accordance with
Section 1797 of PA C.S. Chapter 17 of the MVfRL
~ VISA l-~I
~ AND
MASTER CARD
ACCEPTED
WEST SHORE EMS -ALS 205 GRANOVIEW AVE CAMP HILL, PA 17011
)ENNSTATE
!!! The Milton S. Hershey Medical Center
. The College of Medicmc
TIMOTHY SEAN COGAN
560 WALNUT ST
CARLISLE PA 17013-3629
4 of .
ACCOUNT #
367242
STATEMENT
DATE: 07/29/04
LAST STATEMENT
DATE: 06/24/04
FED TAX ID # 251857035
CHARGE PAYMeNTI GUARANH
ADJUSTMENT BALANCE
i IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES
DATE PROCEDURE DIAG QTY DESCRIPTION INS
CODE CODE
HE HAVE tilT RECEIVED YOUR PAYMENT IN FULL. YOUR ACCDlNr IS PAST
DUE. PLEASE SEND PAYMENT Ift1EDIATELY. IF PAYMENT HAS BEEN
MADE, THAt<<. YOO AND DISREGARD THIS BILL.
PLEASE NOTE: TO KEEP YOUR ACCClM CURRENT, OUR POLICY IS TO
APPLY YOUR PAYMENT TO THE OLDEST OUTSTANDING BALANCE.
THAN<. YOU FOR USING HSHI1C PHYSICIANS GROUP FOR YOUR PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE
CONTACT US AT 717-531-5069 OR~-254-26~llETNEEN 8:00AM AND
5:30PM tOIlAY THROUGH MEDNESDAY OR BETWEEN 8:00AM AND 4:30PM
THURSDAY AND FRIDAY.
BALANCE SlJt1ARY
RESPONSIBLE PARTY
CIS CIGNA
*** GUARANTOR RESPlH)IBILITY
POLICY I
096623589*3172120
TOTAL
$ 8576.10
t 11109.90
.___________________________jl_~~Q~_t~~_tlr_~~~~_~~{r}l~ltll~9_~_~ry~~_'~rr~~~Q~JJ~~_QJ'-~_t~r_~~_~~r_~U[~_!9_~~_e}l!~{~_t_jl_________________________.
STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMI
07/29/04 $ 11109.90 $ 11109.9
BF6.
MSHMC PHYSICIANS GROUP
BILLING SERVICES
POBOX 854
HERSHEY PA 17033.0854
00000367242 UP
0000000001110990072904
1...11.1.1...1.1.11.111111..11.111111..111111111111..11.11.1.1
Md MSHMC PHYSICIANS GROUP
To:
PO BOX 643313
PITTSBURGH PA 15264-3313
11,111111.111,1111111..1111.111.111,1.1.111111.11..111,,1.1.11
00003055 1 AT 0.292 04
TIMOTHY SEAN COGAN
560 WALNUT ST
CARLISLE PA 17013-3629
FFICE USE ONt y
.; CHECK ONE
FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW
-iC : F6BO
_M/C
_VISA
367242
EXP DATE
08/19/04
CARDHOLDER NAME (PRINT)
Decedent's Complete Address:
STREET ADDRESS
CITY
STATE ? A
ZIP /7 ~ ..so
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2, Credits/Payments
A, Spousal Poverty Credit
8, Prior Payments
C, Discount
(1 )
cD. <.>-c>
3, InteresUPenalty if applicable
0, Interest
E, Penalty
(!) .~"r()
Total Credits ( A + 8 + C ) (2)
TotallnteresUPenalty ( D + E ) (3)
4, If Line 2 is greater than Line 1 + Line 3, enter the difference, This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
6) .00
5, If Line 1 + Line 3 is greater than Line 2, enter the difference, This is the TAX DUE. (5)
t) . tf1J
A. Enter the interest on the tax due,
(5A)
8, Enter the total of Line 5 + 5A, This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
6) . o5"D
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
No
~
[Xl
~
~
['ZJ
!'8l
~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
1, Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;,...........,............,..............................................................., 0
b, retain the right to designate who shall use the property transferred or its income; ..........................................., 0
c, retain a reversionary interest; or",. """."",."",.."".. ",'...",.."",.."" ..", "."""""""""."""."",."""..", ,,'" ""."",.., 0
d, receive the promise for life of either payments, benefits or care? ..................................................................,.., 0
2, If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ..""""",.""..""".""."""."",.""".""",..".""""""'.."""""."",."""."",,, 0
3, Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0
4, Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? "",..... ..... .......,."",."",.."".."",..""."""."",.""""",.""".""""""."""""".""", 0
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 true, correct
and complete,
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
DATE
~ 2.-1 Zoo~.-
ADDR
..s""GD WJk..,.J v r S~ ~'--l SG ~ . ,Q?/J-
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE '
I 2013
DATE
ADDRESS
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 exemot 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,
06-20-2005
COGAN
03-27-2004
21 04-0390
CUMBERLAND
101
APPEAL DATE: 08-19-2005
( See reverse side under Objections)
Amount Remitted I I
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 -
REY:is47-Ex-AFp-co3:osi-NOTICE-OF-INHERITANCE-TAX-APPRAIsEMENT:-ALLowANCE-OR---------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
TIMOTHY S FILE NO. 21 04-0390 ACN 101
BUREAU OF INDIVIDUAL TAXES,
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
,.APPRAISEMENT, ALLOWANCE OR DISALLOIIANCE
'DF DEDUCTIONS AND ASSESSMENT OF TAX
i-I
\: 55
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
,-
r ii
O~-" '--"
~A.J~-,.z~:: '-'"
.!>i 1 ..,.,.,
KEVIN J COG~n,T"
560 WALNUT ST
CARLISLE
PA 17013
ESTATE OF
COGAN
TAX RETURN liAS: I
) ACCEPTED AS FILED
I X) CHANGED
SEE
I~ an assessaent was issued previously, lines 14, 15 and/or 16, 17, 18 and
reflect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
IS. AlIOunt of Line 14 at Spousal rat. (15)
16. Amount of Line 14 taxable .t Lineal/Class A rat. (16)
17. Amount of Line 14 at Sibling rat. (17)
18. AROUnt of Line 14 taxable at Coll.teral/Class Brat. (18)
19. Principal Tax Due
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held stock/Partnership Interest (Schedule Cl
4. Hortgages/Notes Receivable (Schedule DJ
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule FJ
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
IS)
(6)
(7)
.00
.00
.00
.00
1.250.00
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Ad.. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governuental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
3,199.00
17 .058.92
Ill)
(12)
(13)
(14)
NOTE:
.00 X
.00 X
.00 X
.00 X
'*
REV-1547 EX AFP (06-05)
TIMOTHY
S
DATE 06-20-2005
ATTACHED NOTICE
NOTE: To insure proper
credit to your account I
sub.it the upper portion
of this for. with your
tax pay_nt.
1,250.00
;>0,;>1;7 9;>
19,007.92-
.00
19,007.92-
19 will
00 =
045 =
12 =
15 =
.00
.00
.00
.00
.00
(19)=
TAX CREDITS,
.."..r. II ,+, AMDUNT PAID
DATE NUM8ER INTEREST/PEN PAID 1-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
~
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FDR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YDU HAY 8E DUE
A REFUND. SEE REVERSE SIDE DF THIS FORM FOR INSTRUCTIONS.)
RIV-l,410EX(8-e8)
'*'
INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENTS NAME
Timothy S Cogan
FILE NUMBER
REVIEWED BY
Deborah Washington
ACN
2104-0390
101
ITEM
SCHEDULE NO.
EXPLANATION OF CHANGES
H B-3 The claim for the family exemption has been disallowed. The claimant must be a
spouse or if no spouse, a parent or child living in the same household as the decedent as
of the date of death.
I 1 The deduction claimed for reimbursement has been disallowed. No evidence of a
written contract of indebtedness between decedent and claimant was submitted.
,
"
':~
.~
\
ROW
Page 1
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of /~'/~9~o.~ C~ ~ /b,J
also known as ~7~ ~ c~ ~,~,x/
To:
Register of Wills for the
Deceased. County of a ~a ~ ~k~¢~-~,././.~ in the
Commonwealth of Pennsylvania
Social Security
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl
(d.b.n.; pendente lite; durante absentia; durante minoritate)
for le~fk~e~:of administration
~ ,: on ~e estat~T.~
the above decedent. ~::, '~::' !77,
Decendent was domiciled at death in ~c~.,,~ ~,r~ County, Penns~,vania, with
h / 5 last family or principal re~dence at ~/7 5~ ~/~ ~- ~A~,c~ ~ ~.
h ,~&, ~ ~ · · ~ ~
~ ~ ~ ~ (hst street, number and mumc~pahty~
Decendent, then ~ ~ ye~s of age, died ~~ ~ ~ ,~~ ~-,,
at ~~ ~-~/ ~~ ' ~ ....
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:
Petitioner after a proper search ha
the following spouse (if any) and heirs:
Name
ascertained that decedent left no will and was survived by
Relationship
Residence
THEREFORE,
appropriate form to the undersigned.
~ 0
petitioner(s) respectfully request(s) the grant of letters of administration in the
RENUNCIATION
deceased.
To the Register of Wills of County, Pennsylvania.
The undersigned "-~ y /];.'~ ~-~Ct~_~ ~O~C~"~ ~ ~O'~..V- of
the above decedent, hereby renounce(s) the right to administer thc estate and respectfully ask(s) that Letters
be issued to ~'~' ,~' '---/
WITNESS hand this day of ,20
(Address)
(Signature)
(Address)
(Signature)
(Address)
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 c ~te-i~$2.00 . : ~ ~ ....
~ Local Registrar
'04 ,qPR22 74:12
- .rl'! OtV
{~fi't [2 c.,: :. c_ ::,._ ~~~ Date
H106.144 Rev. 1/91 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH * VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
· ..~ ~ ~ BI~H BIRTHP~E (C~ ~ I P~CE ~ ~H (~k ~V ~_ ~ ~ ~ ~ ~ I '
I
29 ~. I · E ·
I
~ ~n ~ ~' m-~ ~ Her h ....... r-'-~ ..... ~ ....~,cm=,~ i~=.~,,~.~.=.
.. ~k l,b, Restaur~t '% '- -- '?. ~ ~ ('"~S+)l ..Never ~i~
917 Scottish Court
,~chanicsburg, PA 17055
17l. State PA Did 17c.[~ ~, d~ liwd iff
1 ?d.[']~ wtt hl~ ~c~u~l Nmi~ of Mechan i c'-~,'-,~lrcj =;.~
I
MOTHER'S NAME (F~rK.
~. Kevin Ox:ran I~. ~hvll~9
~. Kevin ~ ~ 60 Walnut Strut, ~rlisle, Pa 17013
~ ~ ~ ~RVCE ~EE~rE.~ ~ ~ 8~H t~ENSE NUMAR
oz~man-Ro[h ?une~al ~ome
' '' ~*-~' 9:16 p.m. ~rch 27~ '2~
~=~ ~ltiple tra~tic inj~ies ,
__ n . ~ m ~ ~ ffi ,~,~ 8l~. ' I2'~' ~'"',: I.. '-- I ~n~nt
~d~'~"h~"~--~ ........ ..: :.':;2::T2:TZ" ... n ~'[ /~ ~rl~ Crv
........................ f~x .... //.4//r } ~/~A4
~.1271
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 08/02/2004
COGAN KEVIN J
560 WALNUT STREET
CARLISLE, PA 17013
RE: Estate of COGAN TIMOTHY S
File Number: 2004-00390
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES,
NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on
or after July 1, 1992, the personal representative or his
counsel, within ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of Wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 08/02/2004
Your prompt attention to this matter will be appreciated.
Thank You.
CC:
File
Counsel
Judge
Sincerely,
Clerk of the Orphans' Court
CERTIFICATION OF NOTICE UNDER RULE 5.6(al
of Death: . oOff
Will No. ~
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the O~phans' Court Rules was
served on or mailed to the following beneficiaries Of the above-captioned estate on :
Address
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
Telephone( ~/ ~) ~t~
Capacity: //Personal Representative
__Counsel for personal representative
"
'"
Register of Wills of Cumberland County
Name of Decedent:
STATUS REPORT UNDER RULE 6.12
~~D~Vf-1 S. C~
(
Date of Death: /'JJ 4'rz 2 ~ ZOo <-I
, ,
Estate No.:
o '-( - D :Jj>O
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 ad~stration of the estate is complete:
Yes 0 No rc:i
2. If the answer is No, state when the personal representative reasonably believes that
the administration will be complete: r..el> 107
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes 0 No 0
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 0 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.
Date: U 2~
~cJ~
SIgnature
J~et/irJ :r-: Cx~
t?'
2. tN-' c..
Name
..s&c> t.RalrJJl S-/ C~(.-/Jl~
Address
('.
,'7 J . (>
- '" fl..)
. , ~..j
&/7) 9&O--99d-0
Telephone No.
f.. -,
./ .::: /''''
Capacity:
B'Personal Representative
o Counsel for personal representative
/r:-"1
I ';Y/
tJJ' \) ,.
r-, " /
\ '
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 2/17/2006
COGAN KEVIN J
560 WALNUT STREET
CARLISLE, PA 17013
RE: Estate of COGAN TIMOTHY S
File Number: 2004-00390
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO.1, 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:
3/27/2006
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
sr~~
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
~k'